ID

28805

Description

Routine documentation for Central Retinal Vein Occlusion. 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 1 Discharge Letter CRVO

English

Example 1 Discharge Letter CRVO

1 forms  
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 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
Past medical history
Description

past medical history

Data type

text

Alias
UMLS CUI [1]
C3661816
Date medical history
Description

date medical history

Data type

date

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C3661816
Visual Acuity
Description

Visual Acuity

Alias
UMLS CUI-1
C0042812
Visual Acuity
Description

Visual Acuity

Data type

text

Alias
UMLS CUI [1]
C0042812
Autorefraction
Description

Autorefraction

Data type

text

Alias
UMLS CUI [1]
C2070116
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
Pupil
Description

Pupil

Data type

text

Alias
UMLS CUI [1]
C0034121
Cataract
Description

Cataract

Data type

boolean

Alias
UMLS CUI [1]
C0086543
Corneal scars and opacities
Description

Corneal scars and opacities

Data type

boolean

Alias
UMLS CUI [1]
C0155098
Ophthalmoscopy Right eye
Description

Ophthalmoscopy Right eye

Alias
UMLS CUI-1
C0029090
UMLS CUI-2
C0229089
In Mydriasis ?
Description

Mydriasis

Data type

boolean

Alias
UMLS CUI [1]
C0026961
Optic disc- Confluent drusen
Description

Optic disc finding- Confluent drusen

Data type

boolean

Alias
UMLS CUI [1,1]
C0423451
UMLS CUI [1,2]
C1720180
Optic disc vascular anomaly
Description

Optic disc vascular anomaly

Data type

boolean

Alias
UMLS CUI [1]
C0423459
Retinal dot hemorrhage
Description

Retinal dot hemorrhage

Data type

boolean

Alias
UMLS CUI [1]
C0474358
Sectorial hypoplasia of optic disc
Description

Sectorial hypoplasia of optic disc

Data type

boolean

Alias
UMLS CUI [1]
C0338501
proliferative retinopathy pan-retinal ablation performed
Description

proliferative retinopathy pan-retinal ablation performed

Data type

boolean

Alias
UMLS CUI [1]
C2114790
Ophthalmoscopy Left eye
Description

Ophthalmoscopy Left eye

Alias
UMLS CUI-1
C0029090
UMLS CUI-2
C0229090
In Mydriasis ?
Description

Mydriasis

Data type

boolean

Alias
UMLS CUI [1]
C0026961
Optic disc- vital, sharp margin?
Description

Optic disc finding vital sharp margin

Data type

boolean

Alias
UMLS CUI [1,1]
C0423451
UMLS CUI [1,2]
C0442732
UMLS CUI [1,3]
C2963144
Optic cupping
Description

Optic cupping

Data type

text

Alias
UMLS CUI [1]
C0344298
SD- OCT Right eye
Description

SD- OCT Right eye

Alias
UMLS CUI-1
C3876157
UMLS CUI-2
C0229089
Atrophic retina
Description

Atrophic retina

Data type

boolean

Alias
UMLS CUI [1]
C0521694
Macula edema
Description

Macula edema

Data type

boolean

Alias
UMLS CUI [1]
C1403471
Macular holes
Description

Macular holes

Data type

boolean

Alias
UMLS CUI [1]
C0024441
SD- OCT Left eye
Description

SD- OCT Left eye

Alias
UMLS CUI-1
C3876157
UMLS CUI-2
C0229090
Foveal depression?
Description

Foveal depression

Data type

boolean

Alias
UMLS CUI [1]
C2013325
Central retina area thickness
Description

Central retina area thickness

Data type

text

Alias
UMLS CUI [1,1]
C0459678
UMLS CUI [1,2]
C1280412
Retinal fovea Edema
Description

Retinal fovea Edema

Data type

boolean

Alias
UMLS CUI [1,1]
C0877659
UMLS CUI [1,2]
C0013604
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
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Similar models

Example 1 Discharge Letter CRVO

1 forms
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 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
Thrombosis of retinal vein (Thrombosis of retinal vein)
C1527411 (UMLS CUI-1)
(Comment:en)
Item
Past medical history
text
C3661816 (UMLS CUI [1])
past medical history
Code List
Past medical history
CL Item
Intravitreal injections (Intravitreal injections)
C1554888 (UMLS CUI-1)
(Comment:en)
CL Item
Argon laser (Argon laser)
C0392247 (UMLS CUI-1)
(Comment:en)
CL Item
Vitrectomy by pars plana approach (Vitrectomy by pars plana approach)
C0563537 (UMLS CUI-1)
(Comment:en)
CL Item
Membrane peeling (Membrane peeling)
C3524958 (UMLS CUI-1)
(Comment:en)
CL Item
Injection of gas/air into vitreous (Injection of gas/air into vitreous)
C0395598 (UMLS CUI-1)
(Comment:en)
date medical history
Item
Date medical history
date
C0011008 (UMLS CUI [1,1])
C3661816 (UMLS CUI [1,2])
Item Group
Visual Acuity
C0042812 (UMLS CUI-1)
Visual Acuity
Item
Visual Acuity
text
C0042812 (UMLS CUI [1])
Autorefraction
Item
Autorefraction
text
C2070116 (UMLS CUI [1])
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])
Item
Pupil
text
C0034121 (UMLS CUI [1])
Pupil
Code List
Pupil
CL Item
Round  (Round)
C0332490 (UMLS CUI-1)
(Comment:en)
CL Item
Reacts (Reacts)
C0423300 (UMLS CUI-1)
(Comment:en)
Cataract
Item
Cataract
boolean
C0086543 (UMLS CUI [1])
Corneal scars and opacities
Item
Corneal scars and opacities
boolean
C0155098 (UMLS CUI [1])
Item Group
Ophthalmoscopy Right eye
C0029090 (UMLS CUI-1)
C0229089 (UMLS CUI-2)
Mydriasis
Item
In Mydriasis ?
boolean
C0026961 (UMLS CUI [1])
Optic disc finding- Confluent drusen
Item
Optic disc- Confluent drusen
boolean
C0423451 (UMLS CUI [1,1])
C1720180 (UMLS CUI [1,2])
Optic disc vascular anomaly
Item
Optic disc vascular anomaly
boolean
C0423459 (UMLS CUI [1])
Retinal dot hemorrhage
Item
Retinal dot hemorrhage
boolean
C0474358 (UMLS CUI [1])
Sectorial hypoplasia of optic disc
Item
Sectorial hypoplasia of optic disc
boolean
C0338501 (UMLS CUI [1])
proliferative retinopathy pan-retinal ablation performed
Item
proliferative retinopathy pan-retinal ablation performed
boolean
C2114790 (UMLS CUI [1])
Item Group
Ophthalmoscopy Left eye
C0029090 (UMLS CUI-1)
C0229090 (UMLS CUI-2)
Mydriasis
Item
In Mydriasis ?
boolean
C0026961 (UMLS CUI [1])
Optic disc finding vital sharp margin
Item
Optic disc- vital, sharp margin?
boolean
C0423451 (UMLS CUI [1,1])
C0442732 (UMLS CUI [1,2])
C2963144 (UMLS CUI [1,3])
Optic cupping
Item
Optic cupping
text
C0344298 (UMLS CUI [1])
Item Group
SD- OCT Right eye
C3876157 (UMLS CUI-1)
C0229089 (UMLS CUI-2)
Atrophic retina
Item
Atrophic retina
boolean
C0521694 (UMLS CUI [1])
Macula edema
Item
Macula edema
boolean
C1403471 (UMLS CUI [1])
Macular holes
Item
Macular holes
boolean
C0024441 (UMLS CUI [1])
Item Group
SD- OCT Left eye
C3876157 (UMLS CUI-1)
C0229090 (UMLS CUI-2)
Foveal depression
Item
Foveal depression?
boolean
C2013325 (UMLS CUI [1])
Central retina area thickness
Item
Central retina area thickness
text
C0459678 (UMLS CUI [1,1])
C1280412 (UMLS CUI [1,2])
Retinal fovea Edema
Item
Retinal fovea Edema
boolean
C0877659 (UMLS CUI [1,1])
C0013604 (UMLS CUI [1,2])
Item Group
Evaluation and Treatment
C0220825 (UMLS CUI-1)
C0087111 (UMLS CUI-2)
Diagnosis
Item
Diagnosis
text
C0011900 (UMLS CUI [1])
Item
Therapy
text
C0087111 (UMLS CUI [1])
Therapy
Code List
Therapy
CL Item
Follo- up (Follo- up)
C1522577 (UMLS CUI-1)
(Comment:en)
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