ID

42644

Beschreibung

Routine documentation for Diabetic Retinopathy. Eye clinic, University Clinic of Muenster.

Stichworte

Versionen (2)
  1. 05.02.18 05.02.18 -
  2. 17.09.21 17.09.21 -
Rechteinhaber

Eye Clinic UKM

Hochgeladen am

17. September 2021

DOI

Für eine Beantragung loggen Sie sich ein.

Lizenz

Creative Commons BY-NC 3.0
Modell Kommentare :

Hier können Sie das Modell kommentieren. Über die Sprechblasen an den Itemgruppen und Items können Sie diese spezifisch kommentieren.

Zurück zu Modell Kommentaren
Itemgroup Kommentare für :

Item Kommentare für :

  • Neueste
  • Älteste
  • Beliebt
  • Neueste
    • Neueste
    • Älteste
    • Beliebt

Keine Kommentare

Um Formulare herunterzuladen müssen Sie angemeldet sein. Bitte loggen Sie sich ein oder registrieren Sie sich kostenlos.

Example 1 Discharge Letter Diabetic Retinopathy

Englisch

Example 1

2 Formulare  
  1. StudyEvent: ODM
    1. Example 1
    2. Example 2
Administrative data
Beschreibung

Administrative data

Alias
UMLS CUI-1
C1320722
Patient Name
Beschreibung

Patient Name

Datentyp

text

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

Patient date of birth

Datentyp

date

Alias
UMLS CUI [1]
C0421451
Patient address
Beschreibung

Patient address

Datentyp

text

Alias
UMLS CUI [1]
C0421449
Visit Date
Beschreibung

Visit Date

Datentyp

date

Alias
UMLS CUI [1]
C1320303
Type of care
Beschreibung

Type of care

Datentyp

text

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

Reason for patient visit

Datentyp

text

Alias
UMLS CUI [1]
C1704447
Attending physician name
Beschreibung

Attending physician name

Datentyp

text

Alias
UMLS CUI [1]
C2361125
Recipient
Beschreibung

Recipient

Datentyp

text

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

Recipient address

Datentyp

text

Alias
UMLS CUI [1,1]
C1709854
UMLS CUI [1,2]
C1442065
Diagnosis Right eye
Beschreibung

Diagnosis Right eye

Alias
UMLS CUI-1
C0011900
UMLS CUI-2
C0229089
Present diagnosis
Beschreibung

diagnosis present

Datentyp

text

Alias
UMLS CUI [1,1]
C0011900
UMLS CUI [1,2]
C0150312
Diagnosis Left eye
Beschreibung

Diagnosis Left eye

Alias
UMLS CUI-1
C0011900
UMLS CUI-2
C0229090
Present diagnosis
Beschreibung

diagnosis present

Datentyp

text

Alias
UMLS CUI [1,1]
C0011900
UMLS CUI [1,2]
C0150312
Date of procedure
Beschreibung

date of procedure

Datentyp

date

Alias
UMLS CUI [1]
C2584899
Vision
Beschreibung

Vision

Alias
UMLS CUI-1
C0042789
Vision Right eye
Beschreibung

Vision Right eye

Datentyp

text

Alias
UMLS CUI [1,1]
C0042789
UMLS CUI [1,2]
C0229089
Vision Left eye
Beschreibung

Vision Left eye

Datentyp

text

Alias
UMLS CUI [1,1]
C0042789
UMLS CUI [1,2]
C0229090
Intraocular pressure
Beschreibung

Intraocular pressure

Alias
UMLS CUI-1
C0578862
Intraocular pressure Right eye
Beschreibung

Intraocular pressure Right eye

Datentyp

text

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

Intraocular pressure Left eye

Datentyp

text

Maßeinheiten
  • mmHg
Alias
UMLS CUI [1,1]
C0578862
UMLS CUI [1,2]
C0229090
mmHg
Slit lamp biomicroscopy Right eye
Beschreibung

Slit lamp biomicroscopy Right eye

Alias
UMLS CUI-1
C0419360
UMLS CUI-2
C0229089
Anterior segment of eye- Irritation?
Beschreibung

Anterior segment of eye Eye irritation

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0003153
UMLS CUI [1,2]
C0235266
Cataracta corticonuclearis
Beschreibung

Cataract

Datentyp

boolean

Alias
UMLS CUI [1]
C0086543
Rubeosis
Beschreibung

Rubeosis

Datentyp

boolean

Alias
UMLS CUI [1]
C0154916
Pupil
Beschreibung

Pupil

Datentyp

text

Alias
UMLS CUI [1]
C0034121
Slit lamp biomicroscopy Left eye
Beschreibung

Slit lamp biomicroscopy Left eye

Alias
UMLS CUI-1
C0419360
UMLS CUI-2
C0229090
Deposition of cornea "Eisenlinie"
Beschreibung

deposition; cornea

Datentyp

boolean

Alias
UMLS CUI [1]
C1386913
Ophthalmoscopy Right eye
Beschreibung

Ophthalmoscopy Right eye

Alias
UMLS CUI-1
C0029090
UMLS CUI-2
C0229089
Optic disc- vital, sharp margin?
Beschreibung

Optic disc finding vital sharp margin

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0423451
UMLS CUI [1,2]
C0442732
UMLS CUI [1,3]
C2963144
Macula normal
Beschreibung

Macula

Datentyp

boolean

Alias
UMLS CUI [1]
C0450295
Diabetic retinal microaneurysm
Beschreibung

Diabetic retinal microaneurysm

Datentyp

boolean

Alias
UMLS CUI [1]
C0271064
Retinal Hemorrhage
Beschreibung

Retinal Hemorrhage

Datentyp

boolean

Alias
UMLS CUI [1]
C0035317
Ophthalmoscopy Left eye
Beschreibung

Ophthalmoscopy Left eye

Alias
UMLS CUI-1
C0029090
UMLS CUI-2
C0229090
Optic disc- vital, sharp margin?
Beschreibung

Optic disc finding vital sharp margin

Datentyp

boolean

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

Macula

Datentyp

text

Alias
UMLS CUI [1]
C0450295
Diabetic retinal microaneurysm
Beschreibung

Diabetic retinal microaneurysm

Datentyp

boolean

Alias
UMLS CUI [1]
C0271064
Retinal Hemorrhage
Beschreibung

Retinal Hemorrhage

Datentyp

boolean

Alias
UMLS CUI [1]
C0035317
SD- OCT Right eye
Beschreibung

SD- OCT Right eye

Alias
UMLS CUI-1
C3876157
UMLS CUI-2
C0229089
Foveal depression?
Beschreibung

Foveal depression

Datentyp

boolean

Alias
UMLS CUI [1]
C2013325
Foveal thickness right
Beschreibung

Foveal thickness right

Datentyp

boolean

Alias
UMLS CUI [1]
C4069287
SD- OCT Left eye
Beschreibung

SD- OCT Left eye

Alias
UMLS CUI-1
C3876157
UMLS CUI-2
C0229090
Diabetic retinal microaneurysm
Beschreibung

Diabetic retinal microaneurysm

Datentyp

boolean

Alias
UMLS CUI [1]
C0271064
Macula edema
Beschreibung

Macula edema

Datentyp

boolean

Alias
UMLS CUI [1]
C1403471
Macular exudation
Beschreibung

Macular exudation

Datentyp

boolean

Alias
UMLS CUI [1]
C1827223
Atrophic retina
Beschreibung

Atrophic retina

Datentyp

boolean

Alias
UMLS CUI [1]
C0521694
Fluorescein Angiography
Beschreibung

Fluorescein Angiography

Alias
UMLS CUI-1
C0016313
Hyperfluorescence with leaking and pooling Right eye
Beschreibung

hyperfluorescence with leaking and pooling Right eye

Datentyp

boolean

Alias
UMLS CUI [1,1]
C2062011
UMLS CUI [1,2]
C0229089
Hyperfluorescence with leaking and pooling Left eye
Beschreibung

hyperfluorescence with leaking and pooling Left eye

Datentyp

boolean

Alias
UMLS CUI [1,1]
C2062011
UMLS CUI [1,2]
C0229090
Intraretinal microvascular abnormality IRMA
Beschreibung

Intraretinal microvascular abnormality

Datentyp

boolean

Alias
UMLS CUI [1]
C3714733
Retinal Neovascularization
Beschreibung

Retinal Neovascularization

Datentyp

boolean

Alias
UMLS CUI [1]
C0035320
Evaluation and Treatment
Beschreibung

Evaluation and Treatment

Alias
UMLS CUI-1
C0220825
UMLS CUI-3
C0087111
Diagnosis
Beschreibung

Diagnosis

Datentyp

text

Alias
UMLS CUI [1]
C0011900
Therapy
Beschreibung

Therapy

Datentyp

text

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

Date of start of therapy

Datentyp

date

Alias
UMLS CUI [1]
C3173309
Date of procedure
Beschreibung

Date of procedure

Datentyp

date

Alias
UMLS CUI [1]
C2584899
Next Visit Date
Beschreibung

Next visit date

Datentyp

date

Alias
UMLS CUI [1]
C2735342
Zum Seitenanfang zurückkehren

Ähnliche Modelle

Example 1

2 Formulare
  1. StudyEvent: ODM
    1. Example 1
    2. Example 2
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
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
Diabetic Retinopathy (Diabetic Retinopathy)
C0011884 (UMLS CUI-1)
(Comment:en)
Item Group
Diagnosis Left eye
C0011900 (UMLS CUI-1)
C0229090 (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
Intravitreal Injections Lucentis (Intravitreal Injections Lucentis)
C1554888 (UMLS CUI-1)
C3234800 (UMLS CUI-2)
(Comment:en)
CL Item
Diabetic Macula Edema ( Macula Edema Diabetic)
C2092759 (UMLS CUI-1)
(Comment:en)
date of procedure
Item
Date of procedure
date
C2584899 (UMLS CUI [1])
Item Group
Vision
C0042789 (UMLS CUI-1)
Vision Right eye
Item
Vision Right eye
text
C0042789 (UMLS CUI [1,1])
C0229089 (UMLS CUI [1,2])
Vision Left eye
Item
Vision Left eye
text
C0042789 (UMLS CUI [1,1])
C0229090 (UMLS CUI [1,2])
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])
Cataract
Item
Cataracta corticonuclearis
boolean
C0086543 (UMLS CUI [1])
Rubeosis
Item
Rubeosis
boolean
C0154916 (UMLS CUI [1])
Item
Pupil
text
C0034121 (UMLS CUI [1])
Optic Disk
Code List
Pupil
CL Item
Round (Round)
C0332490 (UMLS CUI-1)
(Comment:en)
CL Item
Reacts (Reacts)
C0423300 (UMLS CUI-1)
(Comment:en)
Item Group
Slit lamp biomicroscopy Left eye
C0419360 (UMLS CUI-1)
C0229090 (UMLS CUI-2)
deposition; cornea
Item
Deposition of cornea "Eisenlinie"
boolean
C1386913 (UMLS CUI [1])
Item Group
Ophthalmoscopy Right eye
C0029090 (UMLS CUI-1)
C0229089 (UMLS CUI-2)
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])
Macula
Item
Macula normal
boolean
C0450295 (UMLS CUI [1])
Diabetic retinal microaneurysm
Item
Diabetic retinal microaneurysm
boolean
C0271064 (UMLS CUI [1])
Retinal Hemorrhage
Item
Retinal Hemorrhage
boolean
C0035317 (UMLS CUI [1])
Item Group
Ophthalmoscopy Left eye
C0029090 (UMLS CUI-1)
C0229090 (UMLS CUI-2)
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
Macula
text
C0450295 (UMLS CUI [1])
Macula
Code List
Macula
CL Item
Macular exudation (Macular exudation)
C1827223 (UMLS CUI-1)
(Comment:en)
CL Item
macula edema (Macula edema)
C1403471 (UMLS CUI-1)
(Comment:en)
Diabetic retinal microaneurysm
Item
Diabetic retinal microaneurysm
boolean
C0271064 (UMLS CUI [1])
Retinal Hemorrhage
Item
Retinal Hemorrhage
boolean
C0035317 (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])
Foveal thickness right
Item
Foveal thickness right
boolean
C4069287 (UMLS CUI [1])
Item Group
SD- OCT Left eye
C3876157 (UMLS CUI-1)
C0229090 (UMLS CUI-2)
Diabetic retinal microaneurysm
Item
Diabetic retinal microaneurysm
boolean
C0271064 (UMLS CUI [1])
Macula edema
Item
Macula edema
boolean
C1403471 (UMLS CUI [1])
Macular exudation
Item
Macular exudation
boolean
C1827223 (UMLS CUI [1])
Atrophic retina
Item
Atrophic retina
boolean
C0521694 (UMLS CUI [1])
Item Group
Fluorescein Angiography
C0016313 (UMLS CUI-1)
hyperfluorescence with leaking and pooling Right eye
Item
Hyperfluorescence with leaking and pooling Right eye
boolean
C2062011 (UMLS CUI [1,1])
C0229089 (UMLS CUI [1,2])
hyperfluorescence with leaking and pooling Left eye
Item
Hyperfluorescence with leaking and pooling Left eye
boolean
C2062011 (UMLS CUI [1,1])
C0229090 (UMLS CUI [1,2])
Intraretinal microvascular abnormality
Item
Intraretinal microvascular abnormality IRMA
boolean
C3714733 (UMLS CUI [1])
Retinal Neovascularization
Item
Retinal Neovascularization
boolean
C0035320 (UMLS CUI [1])
Item Group
Evaluation and Treatment
C0220825 (UMLS CUI-1)
C0087111 (UMLS CUI-3)
Diagnosis
Item
Diagnosis
text
C0011900 (UMLS CUI [1])
Item
Therapy
text
C0087111 (UMLS CUI [1])
Therapy
Code List
Therapy
CL Item
Intravitreal Injections Lucentis (Intravitreal Injections Lucentis)
C1554888 (UMLS CUI-1)
C3234800 (UMLS CUI-2)
(Comment:en)
CL Item
OCT (Follow- up) (OCT (Follow- up))
C0920367 (UMLS CUI-1)
(Comment:en)
Date of start of therapy
Item
Date of start of therapy
date
C3173309 (UMLS CUI [1])
Date of procedure
Item
Date of procedure
date
C2584899 (UMLS CUI [1])
Next visit date
Item
Next Visit Date
date
C2735342 (UMLS CUI [1])
Zum Seitenanfang zurückkehren 

Kontakt

Benutzen Sie dieses Formular für Rückmeldungen, Fragen und Verbesserungsvorschläge.

Mit * gekennzeichnete Felder sind notwendig.

Hilfe

Benötigen Sie Hilfe bei der Suche? Um mehr Details zu erfahren und die Suche effektiver nutzen zu können schauen Sie sich doch das entsprechende Video auf unserer Tutorial Seite an.

Zum Video