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ID

28805

Description

Routine documentation for Central Retinal Vein Occlusion. Eye clinic, University Clinic of Muenster.

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

Eye Clinic UKM

Uploaded on

February 5, 2018

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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)
    Back to the top of the page 

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