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Falhas:
ID
43308
Descrição
EHR General report
Palavras-chave
Versões (3)
- 25/09/2014 25/09/2014 - Martin Dugas
- 28/09/2014 28/09/2014 - Martin Dugas
- 20/09/2021 20/09/2021 -
Transferido a
20 de setembro de 2021
DOI
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Licença
Creative Commons BY-NC 3.0 Legacy
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EHR General report
General report
- StudyEvent: Allgemeiner Bericht
Similar models
General report
- StudyEvent: Allgemeiner Bericht
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de dados
Alias
Creation date
Item
Creation date
date
C2347859 (UMLS CUI-1)
Medical date
Item
date
Priority
Item
text
C0549179 (UMLS CUI-1)
Report status
Item
text
C0586177 (UMLS CUI-1)
Receiver
Item
text
C1553422 (UMLS CUI-1)
Summary report
Item
text
C0242482 (UMLS CUI-1)
Attachment
Item
text
C1999228 (UMLS CUI-1)
Consciousness
Item
text
C0517960 (UMLS CUI-1)
Psyche
Item
text
C1277043 (UMLS CUI-1)
General physical condition
Item
text
C1142435 (UMLS CUI-1)
Nutritional status
Item
text
C0392209 (UMLS CUI-1)
Dyspnea
Item
text
C0013404 (UMLS CUI-1)
Cyanosis
Item
text
C0010520 (UMLS CUI-1)
Venous congestion
Item
text
C0042484 (UMLS CUI-1)
Skin turgor
Item
text
C0277937 (UMLS CUI-1)
Icterus
Item
text
C0022346 (UMLS CUI-1)
Edemas
Item
text
C0013604 (UMLS CUI-1)
Decubitus
Item
text
C0011127 (UMLS CUI-1)
Cutaneous signs of liver diseases
Item
text
Nail finding
Item
text
C0423800 (UMLS CUI-1)
Joint flexibility
Item
text
C0080078 (UMLS CUI-1)
Deformation of bone
Item
text
C0575133 (UMLS CUI-1)
Musculature
Item
text
C1995013 (UMLS CUI-1)
Mobility
Item
text
C0425245 (UMLS CUI-1)
Deformity of spine
Item
text
C0575157 (UMLS CUI-1)
Gelenke
Item
text
Pain in spine
Item
text
C0423673 (UMLS CUI-1)
Mobility of the spine
Item
text
calotte
Item
text
C0205950 (UMLS CUI-1)
Nerve exit points
Item
text
Tongue
Item
text
C0040408 (UMLS CUI-1)
Throat
Item
text
C0031354 (UMLS CUI-1)
Tonsil
Item
text
C0836921 (UMLS CUI-1)
Mucous Membrane
Item
text
C0026724 (UMLS CUI-1)
Thyroid Gland
Item
text
C0040132 (UMLS CUI-1)
Lymph nodes conspicuous
Item
boolean
KopfSonstiges
Item
text
Other lymph nodes (right)
Item
text
Other lymph nodes (left)
Item
text
Leg circumference
Item
text
Peripheral pulse
Item
text
C0232139 (UMLS CUI-1)
Varices
Item
text
C0042345 (UMLS CUI-1)
Thrombophlebitis
Item
text
C0040046 (UMLS CUI-1)
Breast
Item
text
C0006141 (UMLS CUI-1)
Percussion
Item
text
C0030987 (UMLS CUI-1)
blood pressure, systolic (right)
Item
integer
C0871470 (UMLS CUI-1)
C0205090 (UMLS CUI-2)
C0205090 (UMLS CUI-2)
blood pressure, diastolic (right)
Item
integer
C0428883 (UMLS CUI-1)
C0205090 (UMLS CUI-2)
C0205090 (UMLS CUI-2)
blood pressure, systolic (left)
Item
integer
C0871470 (UMLS CUI-1)
C0205091 (UMLS CUI-2)
C0205091 (UMLS CUI-2)
Cardiac rhythm type
Item
text
C0232187 (UMLS CUI-1)
Apex beat
Item
text
C0277909 (UMLS CUI-1)
Heart murmur
Item
text
C0018808 (UMLS CUI-1)
Heart Sounds
Item
text
C0018820 (UMLS CUI-1)
Carotid
Item
text
C0007272 (UMLS CUI-1)
Aorta
Item
text
C0003483 (UMLS CUI-1)
Abdominal wall
Item
text
C1269041 (UMLS CUI-1)
Hernia
Item
text
C0019270 (UMLS CUI-1)
Bowel sounds
Item
text
C0232693 (UMLS CUI-1)
External genitalia
Item
text
C0227605 (UMLS CUI-1)
Rectal examination
Item
text
C0199900 (UMLS CUI-1)
Wound or scar
Item
text
C0043250 (UMLS CUI-1)
C2004491 (UMLS CUI-2)
C2004491 (UMLS CUI-2)
Meteorism
Item
text
C1291077 (UMLS CUI-1)
pain pressure
Item
text
C3647129 (UMLS CUI-1)
Resistance
Item
text
Ascites
Item
text
C0003962 (UMLS CUI-1)
Liver
Item
text
C0023884 (UMLS CUI-1)
Gallbladder
Item
text
C0016976 (UMLS CUI-1)
Spleen
Item
text
C0037993 (UMLS CUI-1)
Renal bed
Item
text
Vigilance
Item
text
C0087156 (UMLS CUI-1)
Neck stiffness
Item
text
C0151315 (UMLS CUI-1)
Pupils
Item
text
C0034121 (UMLS CUI-1)
KonvReaktion
Item
text
Pupillenreaktion
Item
text
Finger-to-nose test
Item
text
C0278158 (UMLS CUI-1)
Heel-to-knee test
Item
text
C0278160 (UMLS CUI-1)
Tremor
Item
text
C0040822 (UMLS CUI-1)
Muscle Tonus
Item
text
C0026841 (UMLS CUI-1)
Muscle Strength
Item
text
C0517349 (UMLS CUI-1)
Sensibility
Item
text
C0439823 (UMLS CUI-1)
Motor behaviour
Item
text
C0026606 (UMLS CUI-1)
Diadochokinesia
Item
text
C0278157 (UMLS CUI-1)
Language
Item
text
C1145677 (UMLS CUI-1)
Position Sense
Item
text
C0234219 (UMLS CUI-1)
Biceps reflex finding
Item
text
C1287963 (UMLS CUI-1)
triceps tendon reflex
Item
text
C2146253 (UMLS CUI-1)
Radial reflex
Item
text
C0422909 (UMLS CUI-1)
Patella reflex
Item
text
C0234147 (UMLS CUI-1)
Achilles tendon reflex
Item
text
C0234171 (UMLS CUI-1)
Babinski Reflex
Item
text
C0034935 (UMLS CUI-1)
Neurological status
Item
text
C0746866 (UMLS CUI-1)
Clinic
Item
text
C0442592 (UMLS CUI-1)
Admission date
Item
date
C1302393 (UMLS CUI-1)
Discharge date
Item
date
C2361123 (UMLS CUI-1)
Person Initials
Item
text
C2986440 (UMLS CUI-1)
Signature
Item
text
C1519316 (UMLS CUI-1)