ID

28805

Description

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

Mots-clés

Versions (1)
  1. 05/02/2018 05/02/2018 -
Détendeur de droits

Eye Clinic UKM

Téléchargé le

5 février 2018

DOI

Pour une demande vous connecter.

Licence

Creative Commons BY-NC 3.0
Modèle Commentaires :

Ici, vous pouvez faire des commentaires sur le modèle. À partir des bulles de texte, vous pouvez laisser des commentaires spécifiques sur les groupes Item et les Item.

Retour au modèle Commentaires
Groupe Item commentaires pour :

Item commentaires pour :

Vous devez être connecté pour pouvoir télécharger des formulaires. Veuillez vous connecter ou s’inscrire gratuitement.

Example 1 Discharge Letter CRVO

Anglais

Example 1 Discharge Letter CRVO

1 Formulaires  
Administrative data
Description

Administrative data

Alias
UMLS CUI-1
C1320722
Patient Name
Description

Patient Name

Type de données

text

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

Patient date of birth

Type de données

date

Alias
UMLS CUI [1]
C0421451
Patient address
Description

Patient address

Type de données

text

Alias
UMLS CUI [1]
C0421449
Visit Date
Description

Visit Date

Type de données

date

Alias
UMLS CUI [1]
C1320303
Type of care
Description

Type of care

Type de données

text

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

Reason for patient visit

Type de données

text

Alias
UMLS CUI [1]
C1704447
Attending physician name
Description

Attending physician name

Type de données

text

Alias
UMLS CUI [1]
C2361125
Recipient
Description

Recipient

Type de données

text

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

Recipient address

Type de données

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

Type de données

text

Alias
UMLS CUI [1,1]
C0011900
UMLS CUI [1,2]
C0150312
Past medical history
Description

past medical history

Type de données

text

Alias
UMLS CUI [1]
C3661816
Date medical history
Description

date medical history

Type de données

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

Type de données

text

Alias
UMLS CUI [1]
C0042812
Autorefraction
Description

Autorefraction

Type de données

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

Type de données

text

Unités de mesure
  • mmHg
Alias
UMLS CUI [1,1]
C0578862
UMLS CUI [1,2]
C0229089
mmHg
Intraocular pressure Left eye
Description

Intraocular pressure Left eye

Type de données

text

Unités de mesure
  • 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

Type de données

boolean

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

Pupil

Type de données

text

Alias
UMLS CUI [1]
C0034121
Cataract
Description

Cataract

Type de données

boolean

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

Corneal scars and opacities

Type de données

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

Type de données

boolean

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

Optic disc finding- Confluent drusen

Type de données

boolean

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

Optic disc vascular anomaly

Type de données

boolean

Alias
UMLS CUI [1]
C0423459
Retinal dot hemorrhage
Description

Retinal dot hemorrhage

Type de données

boolean

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

Sectorial hypoplasia of optic disc

Type de données

boolean

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

proliferative retinopathy pan-retinal ablation performed

Type de données

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

Type de données

boolean

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

Optic disc finding vital sharp margin

Type de données

boolean

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

Optic cupping

Type de données

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

Type de données

boolean

Alias
UMLS CUI [1]
C0521694
Macula edema
Description

Macula edema

Type de données

boolean

Alias
UMLS CUI [1]
C1403471
Macular holes
Description

Macular holes

Type de données

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

Type de données

boolean

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

Central retina area thickness

Type de données

text

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

Retinal fovea Edema

Type de données

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

Type de données

text

Alias
UMLS CUI [1]
C0011900
Therapy
Description

Therapy

Type de données

text

Alias
UMLS CUI [1]
C0087111
Retour au début de la page

Similar models

Example 1 Discharge Letter CRVO

1 Formulaires
Name
Type
Description | Question | Decode (Coded Value)
Type de données
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)
Retour au début de la page 

Contact

Utilisez ce formulaire pour les retours, les questions et les améliorations suggérées.

Les champs marqués d’un * sont obligatoires.

Aide

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial