ID

28806

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 2 Discharge Letter CRVO

English

Example 2 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
Description

Diagnosis

Alias
UMLS CUI-1
C0011900
Eye
Description

Eye

Data type

text

Alias
UMLS CUI [1]
C0015392
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
Objective refraction
Description

Objective refraction

Data type

text

Alias
UMLS CUI [1]
C1301317
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
Description

Slit lamp biomicroscopy

Alias
UMLS CUI-1
C0419360
Eye
Description

Eye

Data type

text

Alias
UMLS CUI [1]
C0015392
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
SD- OCT Left eye
Description

SD- OCT Left eye

Alias
UMLS CUI-1
C3876157
UMLS CUI-2
C0229090
Macula edema
Description

Macula edema

Data type

boolean

Alias
UMLS CUI [1]
C1403471
Recurrence
Description

Recurrence

Data type

text

Alias
UMLS CUI [1]
C0034897
SD- OCT Right eye
Description

SD- OCT Right eye

Alias
UMLS CUI-1
C3876157
UMLS CUI-2
C0229089
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
Posterior Vitreous Detachment
Description

Posterior Vitreous Detachment

Data type

boolean

Alias
UMLS CUI [1]
C0423361
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
Comment for health insurance
Description

Comment

Data type

text

Alias
UMLS CUI [1]
C0947611
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Similar models

Example 2 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
C0011900 (UMLS CUI-1)
Item
Eye
text
C0015392 (UMLS CUI [1])
Eye
Code List
Eye
CL Item
Right Eye (Right Eye)
C0229089 (UMLS CUI-1)
(Comment:en)
CL Item
Left Eye (Left Eye)
C0229090 (UMLS CUI-1)
(Comment:en)
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)
CL Item
Eylea injection (Eylea injection)
C4060241 (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])
Objective refraction
Item
Objective refraction
text
C1301317 (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
C0419360 (UMLS CUI-1)
Item
Eye
text
C0015392 (UMLS CUI [1])
Eye
Code List
Eye
CL Item
Right eye (Right eye)
C0229089 (UMLS CUI-1)
(Comment:en)
CL Item
Left eye (Left eye)
C0229090 (UMLS CUI-1)
(Comment:en)
CL Item
Both eyes (Both eyes)
C0229118 (UMLS CUI-1)
(Comment:en)
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])
Item Group
SD- OCT Left eye
C3876157 (UMLS CUI-1)
C0229090 (UMLS CUI-2)
Macula edema
Item
Macula edema
boolean
C1403471 (UMLS CUI [1])
Recurrence
Item
Recurrence
text
C0034897 (UMLS CUI [1])
Item Group
SD- OCT Right eye
C3876157 (UMLS CUI-1)
C0229089 (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])
Posterior Vitreous Detachment
Item
Posterior Vitreous Detachment
boolean
C0423361 (UMLS CUI [1])
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
Intravitreal injections (Intravitreal injections)
C1554888 (UMLS CUI-1)
(Comment:en)
CL Item
Eylea injection (Eylea injection)
C4060241 (UMLS CUI-1)
(Comment:en)
CL Item
Follow- up (Follow- up)
C1522577 (UMLS CUI-1)
(Comment:en)
Comment
Item
Comment for health insurance
text
C0947611 (UMLS CUI [1])
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