ID

28807

Beskrivning

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

Nyckelord

Versioner (1)
  1. 2018-02-05 2018-02-05 -
Rättsinnehavare

Eye Clinic UKM

Uppladdad den

5 februari 2018

DOI

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Licens

Creative Commons BY-NC 3.0
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Example 3 Discharge Letter CRVO

Engelsk

Example 3 Discharge Letter CRVO

1 Formulär  
Administrative data
Beskrivning

Administrative data

Alias
UMLS CUI-1
C1320722
Patient Name
Beskrivning

Patient Name

Datatyp

text

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

Patient date of birth

Datatyp

date

Alias
UMLS CUI [1]
C0421451
Patient address
Beskrivning

Patient address

Datatyp

text

Alias
UMLS CUI [1]
C0421449
Visit Date
Beskrivning

Visit Date

Datatyp

date

Alias
UMLS CUI [1]
C1320303
Type of care
Beskrivning

Type of care

Datatyp

text

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

Reason for patient visit

Datatyp

text

Alias
UMLS CUI [1]
C1704447
Attending physician name
Beskrivning

Attending physician name

Datatyp

text

Alias
UMLS CUI [1]
C2361125
Recipient
Beskrivning

Recipient

Datatyp

text

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

Recipient address

Datatyp

text

Alias
UMLS CUI [1,1]
C1709854
UMLS CUI [1,2]
C1442065
Diagnosis
Beskrivning

Diagnosis

Alias
UMLS CUI-1
C0011900
Eye
Beskrivning

Eye

Datatyp

text

Alias
UMLS CUI [1]
C0015392
Present diagnosis
Beskrivning

diagnosis present

Datatyp

text

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

past medical history

Datatyp

text

Alias
UMLS CUI [1]
C3661816
Date medical history
Beskrivning

date medical history

Datatyp

date

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

Visual Acuity

Alias
UMLS CUI-1
C0042812
Eye
Beskrivning

Eye

Datatyp

text

Alias
UMLS CUI [1]
C0015392
Corrected visual acuity
Beskrivning

Corrected visual acuity

Datatyp

text

Alias
UMLS CUI [1]
C1275680
Intraocular pressure
Beskrivning

Intraocular pressure

Alias
UMLS CUI-1
C0578862
Intraocular pressure Right eye
Beskrivning

Intraocular pressure Right eye

Datatyp

text

Måttenheter
  • mmHg
Alias
UMLS CUI [1,1]
C0578862
UMLS CUI [1,2]
C0229089
mmHg
Intraocular pressure Left eye
Beskrivning

Intraocular pressure Left eye

Datatyp

text

Måttenheter
  • mmHg
Alias
UMLS CUI [1,1]
C0578862
UMLS CUI [1,2]
C0229090
mmHg
Slit lamp biomicroscopy
Beskrivning

Slit lamp biomicroscopy

Alias
UMLS CUI-1
C0419360
Eye
Beskrivning

Eye

Datatyp

text

Alias
UMLS CUI [1]
C0015392
Anterior segment of eye- Irritation?
Beskrivning

Anterior segment of eye Eye irritation

Datatyp

boolean

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

Cataract

Datatyp

boolean

Alias
UMLS CUI [1]
C0086543
Ophthalmoscopy
Beskrivning

Ophthalmoscopy

Alias
UMLS CUI-1
C0029090
In Miosis
Beskrivning

Miosis

Datatyp

boolean

Alias
UMLS CUI [1]
C0728710
Optic disc- vital, sharp margin?
Beskrivning

Optic disc finding vital sharp margin

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0423451
UMLS CUI [1,2]
C0442732
UMLS CUI [1,3]
C2963144
OCT Macula
Beskrivning

OCT Macula

Alias
UMLS CUI-1
C2013322
UMLS CUI-2
C0450295
Eye
Beskrivning

Eye

Datatyp

text

Alias
UMLS CUI [1]
C0015392
Macula edema
Beskrivning

Macula edema

Datatyp

boolean

Alias
UMLS CUI [1]
C1403471
Foveal depression?
Beskrivning

Foveal depression

Datatyp

boolean

Alias
UMLS CUI [1]
C2013325
Evaluation and Treatment
Beskrivning

Evaluation and Treatment

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

Diagnosis

Datatyp

text

Alias
UMLS CUI [1]
C0011900
Therapy
Beskrivning

Therapy

Datatyp

text

Alias
UMLS CUI [1]
C0087111
Date of start of therapy
Beskrivning

Date of start of therapy

Datatyp

date

Alias
UMLS CUI [1]
C3173309
Tillbaka till toppen

Similar models

Example 3 Discharge Letter CRVO

1 Formulär
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
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
Adjustment of glasses (Adjustment of glasses)
C0481759 (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)
CL Item
Both Eyes (Both Eyes)
C0229118 (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
Epiphora (Epiphora)
C1024522 (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
Macula edema (Macula edema)
C1403471 (UMLS CUI-1)
(Comment:en)
CL Item
Central retinal vein occlusion (Central retinal vein occlusion)
C0154841 (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)
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)
Corrected visual acuity
Item
Corrected visual acuity
text
C1275680 (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
Ophthalmoscopy
C0029090 (UMLS CUI-1)
Miosis
Item
In Miosis
boolean
C0728710 (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])
Item Group
OCT Macula
C2013322 (UMLS CUI-1)
C0450295 (UMLS CUI-2)
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)
Macula edema
Item
Macula edema
boolean
C1403471 (UMLS CUI [1])
Foveal depression
Item
Foveal depression?
boolean
C2013325 (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
Follow- up (Follow- up)
C1522577 (UMLS CUI-1)
(Comment:en)
CL Item
Cataract surgery (Cataract surgery)
C2939459 (UMLS CUI-1)
(Comment:en)
CL Item
Tear substitute (Tear substitute)
C0543462 (UMLS CUI-1)
(Comment:en)
Date of start of therapy
Item
Date of start of therapy
date
C3173309 (UMLS CUI [1])
Tillbaka till toppen 

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