ID

28804

Description

Routine documentation for Diabetic Retinopathy. Eye clinic, University Clinic of Muenster

Keywords

Versions (1)
  1. 2/5/18 2/5/18 -
Copyright Holder

Eye Clinic UKM

Uploaded on

February 5, 2018

DOI

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License

Creative Commons BY-NC 3.0
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Example 3 Discharge Letter Diabetic Retinopathy

English

Example 3

2 forms  
  1. StudyEvent: ODM
    1. Example 3
    2. Example 2
Administrative data
Description

Administrative data

Alias
UMLS CUI-1
C1320722
Patient Name
Description

Patient Name

Data type

text

Alias
UMLS CUI [1]
C1299487
Patient date of birth
Description

Patient date of birth

Data type

date

Alias
UMLS CUI [1]
C0421451
Patient address
Description

Patient address

Data type

text

Alias
UMLS CUI [1]
C0421449
Visit Date
Description

Visit Date

Data type

date

Alias
UMLS CUI [1]
C1320303
Type of care
Description

Type of care

Data type

text

Alias
UMLS CUI [1,1]
C0086388
UMLS CUI [1,2]
C0332307
Reason for patient visit
Description

Reason for patient visit

Data type

text

Alias
UMLS CUI [1]
C1704447
Attending physician name
Description

Attending physician name

Data type

text

Alias
UMLS CUI [1]
C2361125
Recipient
Description

Recipient

Data type

text

Alias
UMLS CUI [1]
C1709854
Recipient's address
Description

Recipient address

Data type

text

Alias
UMLS CUI [1,1]
C1709854
UMLS CUI [1,2]
C1442065
Diagnosis Both eyes
Description

Diagnosis Both eyes

Alias
UMLS CUI-1
C0011900
UMLS CUI-2
C0229118
Diagnosis Both eyes
Description

Diagnosis Both eyes

Data type

text

Alias
UMLS CUI [1,1]
C0011900
UMLS CUI [1,2]
C0229118
Diagnosis Right eye
Description

Diagnosis Right eye

Alias
UMLS CUI-1
C0011900
UMLS CUI-2
C0229089
Present diagnosis
Description

diagnosis present

Data type

text

Alias
UMLS CUI [1,1]
C0011900
UMLS CUI [1,2]
C0150312
Diagnosis Left eye
Description

Diagnosis Left eye

Alias
UMLS CUI-1
C0011900
UMLS CUI-2
C0229090
Present diagnosis
Description

diagnosis present

Data type

text

Alias
UMLS CUI [1,1]
C0011900
UMLS CUI [1,2]
C0150312
Date of procedure
Description

date of procedure

Data type

date

Alias
UMLS CUI [1]
C2584899
Vision
Description

Vision

Alias
UMLS CUI-1
C0042789
Vision Right eye
Description

Vision Right eye

Data type

text

Alias
UMLS CUI [1,1]
C0042789
UMLS CUI [1,2]
C0229089
Vision Left eye
Description

Vision Left eye

Data type

text

Alias
UMLS CUI [1,1]
C0042789
UMLS CUI [1,2]
C0229090
Intraocular pressure
Description

Intraocular pressure

Alias
UMLS CUI-1
C0578862
Intraocular pressure Right eye
Description

Intraocular pressure Right eye

Data type

text

Measurement units
  • mmHg
Alias
UMLS CUI [1,1]
C0578862
UMLS CUI [1,2]
C0229089
mmHg
Intraocular pressure Left eye
Description

Intraocular pressure Left eye

Data type

text

Measurement units
  • mmHg
Alias
UMLS CUI [1,1]
C0578862
UMLS CUI [1,2]
C0229090
mmHg
Slit lamp biomicroscopy Right eye
Description

Slit lamp biomicroscopy Right eye

Alias
UMLS CUI-1
C0419360
UMLS CUI-2
C0229089
Anterior segment of eye- Irritation?
Description

Anterior segment of eye Eye irritation

Data type

boolean

Alias
UMLS CUI [1,1]
C0003153
UMLS CUI [1,2]
C0235266
Cataract
Description

Cataract

Data type

boolean

Alias
UMLS CUI [1]
C0086543
Hyposphagma
Description

Hyposphagma

Data type

boolean

Alias
UMLS CUI [1]
C0271297
Slit lamp biomicroscopy Left eye
Description

Slit lamp biomicroscopy Left eye

Alias
UMLS CUI-1
C0419360
UMLS CUI-2
C0229090
Anterior segment of eye- Irritation?
Description

Anterior segment of eye Eye irritation

Data type

boolean

Alias
UMLS CUI [1,1]
C0003153
UMLS CUI [1,2]
C0235266
Hyposphagma
Description

Hyposphagma

Data type

boolean

Alias
UMLS CUI [1]
C0271297
Evaluation and Treatment
Description

Evaluation and Treatment

Alias
UMLS CUI-1
C0220825
UMLS CUI-2
C0087111
Diagnosis
Description

Diagnosis

Data type

text

Alias
UMLS CUI [1]
C0011900
Therapy
Description

Therapy

Data type

text

Alias
UMLS CUI [1]
C0087111
Next Visit Date
Description

Next visit date

Data type

date

Alias
UMLS CUI [1]
C2735342
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Similar models

Example 3

2 forms
  1. StudyEvent: ODM
    1. Example 3
    2. Example 2
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Administrative data
C1320722 (UMLS CUI-1)
Patient Name
Item
Patient Name
text
C1299487 (UMLS CUI [1])
Patient date of birth
Item
Patient date of birth
date
C0421451 (UMLS CUI [1])
Patient address
Item
Patient address
text
C0421449 (UMLS CUI [1])
Visit Date
Item
Visit Date
date
C1320303 (UMLS CUI [1])
Item
Type of care
text
C0086388 (UMLS CUI [1,1])
C0332307 (UMLS CUI [1,2])
Type of care
Code List
Type of care
CL Item
Inpatient (Inpatient)
C0021562 (UMLS CUI-1)
(Comment:en)
CL Item
Outpatients (Outpatients)
C0029921 (UMLS CUI-1)
(Comment:en)
Item
Reason for patient visit
text
C1704447 (UMLS CUI [1])
Reason for patient visit
Code List
Reason for patient visit
CL Item
First consultation (First consultation)
C3826021 (UMLS CUI-1)
(Comment:en)
CL Item
Follow- up (Follow- up)
C0589121 (UMLS CUI-1)
(Comment:en)
Attending physician name
Item
Attending physician name
text
C2361125 (UMLS CUI [1])
Recipient
Item
Recipient
text
C1709854 (UMLS CUI [1])
Recipient address
Item
Recipient's address
text
C1709854 (UMLS CUI [1,1])
C1442065 (UMLS CUI [1,2])
Item Group
Diagnosis Both eyes
C0011900 (UMLS CUI-1)
C0229118 (UMLS CUI-2)
Item
Diagnosis Both eyes
text
C0011900 (UMLS CUI [1,1])
C0229118 (UMLS CUI [1,2])
Diagnosis Both eyes
Code List
Diagnosis Both eyes
CL Item
Nonproliferative diabetic retinopathy (Nonproliferative diabetic retinopathy)
C0004606 (UMLS CUI-1)
(Comment:en)
Item Group
Diagnosis Right eye
C0011900 (UMLS CUI-1)
C0229089 (UMLS CUI-2)
Item
Present diagnosis
text
C0011900 (UMLS CUI [1,1])
C0150312 (UMLS CUI [1,2])
diagnosis present
Code List
Present diagnosis
CL Item
Diabetic Macula Edema (Diabetic Macula Edema)
C2092759 (UMLS CUI-1)
(Comment:en)
CL Item
Intravitreal Injections (Intravitreal Injections)
C1554888 (UMLS CUI-1)
(Comment:en)
Item Group
Diagnosis Left eye
C0011900 (UMLS CUI-1)
C0229090 (UMLS CUI-2)
Item
Present diagnosis
text
C0011900 (UMLS CUI [1,1])
C0150312 (UMLS CUI [1,2])
diagnosis present
Code List
Present diagnosis
CL Item
Intravitreal Injections (Intravitreal Injections)
C1554888 (UMLS CUI-1)
(Comment:en)
CL Item
Diabetic Macula Edema (Macula Edema Diabetic)
C2092759 (UMLS CUI-1)
(Comment:en)
CL Item
Focal laser photocoagulation (Focal laser photocoagulation)
C0948675 (UMLS CUI-1)
(Comment:en)
date of procedure
Item
Date of procedure
date
C2584899 (UMLS CUI [1])
Item Group
Vision
C0042789 (UMLS CUI-1)
Vision Right eye
Item
Vision Right eye
text
C0042789 (UMLS CUI [1,1])
C0229089 (UMLS CUI [1,2])
Vision Left eye
Item
Vision Left eye
text
C0042789 (UMLS CUI [1,1])
C0229090 (UMLS CUI [1,2])
Item Group
Intraocular pressure
C0578862 (UMLS CUI-1)
Intraocular pressure Right eye
Item
Intraocular pressure Right eye
text
C0578862 (UMLS CUI [1,1])
C0229089 (UMLS CUI [1,2])
Intraocular pressure Left eye
Item
Intraocular pressure Left eye
text
C0578862 (UMLS CUI [1,1])
C0229090 (UMLS CUI [1,2])
Item Group
Slit lamp biomicroscopy Right eye
C0419360 (UMLS CUI-1)
C0229089 (UMLS CUI-2)
Anterior segment of eye Eye irritation
Item
Anterior segment of eye- Irritation?
boolean
C0003153 (UMLS CUI [1,1])
C0235266 (UMLS CUI [1,2])
Cataract
Item
Cataract
boolean
C0086543 (UMLS CUI [1])
Hyposphagma
Item
Hyposphagma
boolean
C0271297 (UMLS CUI [1])
Item Group
Slit lamp biomicroscopy Left eye
C0419360 (UMLS CUI-1)
C0229090 (UMLS CUI-2)
Anterior segment of eye Eye irritation
Item
Anterior segment of eye- Irritation?
boolean
C0003153 (UMLS CUI [1,1])
C0235266 (UMLS CUI [1,2])
Hyposphagma
Item
Hyposphagma
boolean
C0271297 (UMLS CUI [1])
Item Group
Evaluation and Treatment
C0220825 (UMLS CUI-1)
C0087111 (UMLS CUI-2)
Item
Diagnosis
text
C0011900 (UMLS CUI [1])
Diagnosis
Code List
Diagnosis
CL Item
Post-op diagnosis (Post-op diagnosis)
C1318969 (UMLS CUI-1)
(Comment:en)
Item
Therapy
text
C0087111 (UMLS CUI [1])
Therapy
Code List
Therapy
CL Item
Intravitreal Injections Lucentis (Intravitreal Injections Lucentis)
C1554888 (UMLS CUI-1)
C3234800 (UMLS CUI-2)
(Comment:en)
CL Item
Follow up (Follow up)
C1522577 (UMLS CUI-1)
(Comment:en)
Next visit date
Item
Next Visit Date
date
C2735342 (UMLS CUI [1])
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