ID

43960

Description

Hospital Routine Documentation Subform at the University Hospital Muenster. Original Form name: Pädiatrische Anamnese

Keywords

  1. 10/27/16 10/27/16 -
  2. 9/20/21 9/20/21 -
Uploaded on

September 20, 2021

DOI

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License

Creative Commons BY-NC 3.0

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Pediatric medical history MS University Hospital Muenster (UKM) Subform

Pädiatrische Anamnese MS University Hospital Muenster (UKM) Subform

Allgemeine Angaben
Description

Allgemeine Angaben

Aufnahmeart
Description

Type of admission

Data type

integer

Alias
UMLS CUI [1]
C1550330
Erhoben von
Description

Medical history taken by

Data type

text

Alias
UMLS CUI [1,1]
C0025084
UMLS CUI [1,2]
C0680379
Erhoben am
Description

Date medical history taken

Data type

date

Alias
UMLS CUI [1,1]
C0025084
UMLS CUI [1,2]
C0011008
Erhebungsmodus
Description

Type of medical history taking

Data type

integer

Alias
UMLS CUI [1,1]
C0025084
UMLS CUI [1,2]
C0332307
Erhebungsmodus: Fremdanamnese
Description

Type of medical history taking

Data type

integer

Alias
UMLS CUI [1,1]
C0025084
UMLS CUI [1,2]
C0332307
Erhebungsmodus: Fremdanamnese andere
Description

Type of medical history taking

Data type

text

Alias
UMLS CUI [1,1]
C0025084
UMLS CUI [1,2]
C0332307
Erhebungsmodus: Sonstiges
Description

Type of medical history taking

Data type

text

Alias
UMLS CUI [1,1]
C0025084
UMLS CUI [1,2]
C0332307
Aktuelle Anamnese
Description

Aktuelle Anamnese

Aktuelle Anamnese
Description

Current medical history

Data type

text

Alias
UMLS CUI [1,1]
C0262926
UMLS CUI [1,2]
C0521116
Aktuelle Medikation
Description

Dauermedikation für die aktuelle Behandlung erfassen. Die Anordnung von Medikamenten muss über die Fieberkurve erfolgen.

Data type

text

Alias
UMLS CUI [1]
C1553892
Kommentar zur Medikation:
Description

Current medication comment

Data type

text

Alias
UMLS CUI [1,1]
C1553892
UMLS CUI [1,2]
C0947611
Vorgeschichte
Description

Vorgeschichte

Allgemeine Anamnese
Description

General medical history

Data type

text

Alias
UMLS CUI [1]
C0262926
Impfstatus
Description

Immunization status

Data type

text

Alias
UMLS CUI [1]
C0552506
Allergien/Unverträglichkeiten
Description

Hypersensitivities

Data type

text

Alias
UMLS CUI [1]
C0020517
Geburtsanamnese
Description

Geburtsanamnese

Geburtsanamnese
Description

Peripartum history

Data type

text

Alias
UMLS CUI [1]
C2053583
Geschwisterfolge:
Description

Birth Order

Data type

text

Alias
UMLS CUI [1]
C0005607
Gestationsalter
Description

zSSW[Gan SSW + zTage[Gan Tage

Data type

integer

Alias
UMLS CUI [1]
C0017504
Geburtsklinik:
Description

Birth clinic

Data type

text

Alias
UMLS CUI [1]
C1552420
Geburtsmodus
Description

Mode of delivery

Data type

text

Alias
UMLS CUI [1]
C1555567
Geschlecht
Description

Gender

Data type

text

Alias
UMLS CUI [1]
C0079399
Geburtsgewicht
Description

Birth weight

Data type

integer

Measurement units
  • grams
Alias
UMLS CUI [1]
C0005612
grams
Geburtslänge
Description

Birth length

Data type

integer

Measurement units
  • cm
Alias
UMLS CUI [1]
C0419415
cm
APGAR
Description

APGAR

Data type

integer

Alias
UMLS CUI [1]
C0003533
Nabelschnur-pH
Description

Umbilical cord pH

Data type

integer

Alias
UMLS CUI [1]
C4067152
Geburtskopfumfang
Description

Head circumference

Data type

float

Measurement units
  • cm
Alias
UMLS CUI [1]
C0262499
cm
Schwangerschaftsverlauf
Description

Pregnancy course

Data type

text

Alias
UMLS CUI [1,1]
C0032961
UMLS CUI [1,2]
C0750729
Perinatalperiode
Description

Perinatal period

Data type

text

Alias
UMLS CUI [1]
C0178795
Vitamin D Prophylaxe
Description

Vitamin D prophylaxis

Data type

text

Alias
UMLS CUI [1]
C0420176
Ernährung
Description

Infant feeding method

Data type

text

Alias
UMLS CUI [1]
C0420979
Meilensteine d. Entwicklung
Description

Meilensteine d. Entwicklung

Kindergarten:
Description

Kindergarten

Data type

text

Alias
UMLS CUI [1]
C0876933
Schulform
Description

School type

Data type

text

Alias
UMLS CUI [1]
C1547791
Klasse
Description

School Grade

Data type

integer

Alias
UMLS CUI [1]
C3244287
Schulleistungen
Description

Achievements in school

Data type

text

Alias
UMLS CUI [1]
C0700132
Frühere Krankenhausaufenthalte und Operationen
Description

Frühere Krankenhausaufenthalte und Operationen

Monat/Jahr
Description

Month/year of hospital admission

Data type

partialDate

Alias
UMLS CUI [1,1]
C0184666
UMLS CUI [1,2]
C0680185
Welches Krankenhaus
Description

Hospital

Data type

text

Alias
UMLS CUI [1]
C0019994
Indikation
Description

Indication

Data type

text

Alias
UMLS CUI [1]
C3146298
Art der Operation
Description

Type of surgery

Data type

text

Alias
UMLS CUI [1]
C0543467
Kinderkrankheiten
Description

Childhood diseases

Data type

text

Alias
UMLS CUI [1]
C0489532
Familien Sozialanamnese
Description

Familien Sozialanamnese

Geburtsjahr Mutter
Description

Mother´s year of birth

Data type

integer

Alias
UMLS CUI [1]
C2319404
Beruf der Mutter
Description

Mother´s occupation

Data type

text

Alias
UMLS CUI [1,1]
C0028811
UMLS CUI [1,2]
C0026591
Krankheiten der Mutter
Description

Medical history mother

Data type

text

Alias
UMLS CUI [1,1]
C0241889
UMLS CUI [1,2]
C0026591
Geburtsjahr Vater
Description

Father´s year of birth

Data type

integer

Alias
UMLS CUI [1]
C2136977
Beruf des Vaters
Description

Father´s occupation

Data type

text

Alias
UMLS CUI [1,1]
C0028811
UMLS CUI [1,2]
C0015671
Krankheiten des Vaters
Description

Medical history of father

Data type

text

Alias
UMLS CUI [1,1]
C0241889
UMLS CUI [1,2]
C0015671
Geschwister
Description

Siblings

Data type

text

Alias
UMLS CUI [1]
C0037047
Sonstiges
Description

other

Data type

text

Alias
UMLS CUI [1]
C0205394
Untersuchung
Description

Untersuchung

Vitalparameter in Fieberkurve übertragen
Description

VITALS

Data type

text

Alias
UMLS CUI [1]
C0518766
Körpergröße
Description

Body Height

Data type

integer

Measurement units
  • cm
Alias
UMLS CUI [1]
C0005890
cm
Körpergewicht
Description

Body weight

Data type

float

Measurement units
  • kg
Alias
UMLS CUI [1]
C0005910
kg
Kopfumfang
Description

Head circumference

Data type

integer

Measurement units
  • cm
cm
Körpertemperatur
Description

Body temperature

Data type

float

Measurement units
  • °C
Alias
UMLS CUI [1]
C0005903
°C
Herzfrequenz
Description

Heart rate

Data type

integer

Measurement units
  • /min
Alias
UMLS CUI [1]
C0018810
/min
Blutdruck systolisch
Description

Systolic bloodpressure

Data type

integer

Measurement units
  • mmHg
Alias
UMLS CUI [1]
C0871470
mmHg
Diastolischer Blutdruck
Description

Diastolic blood pressure

Data type

integer

Measurement units
  • mmHg
Alias
UMLS CUI [1]
C0428883
mmHg
MAD
Description

MAP

Data type

integer

Measurement units
  • mmHg
Alias
UMLS CUI [1]
C0428886
mmHg
Atemfrequenz
Description

Respiratory rate

Data type

integer

Measurement units
  • /minute
Alias
UMLS CUI [1]
C0231832
/minute
Sauerstoffsättigung:
Description

Oxygen saturation

Data type

float

Measurement units
  • %
Alias
UMLS CUI [1]
C2237091
%
Untersuchungsbefund
Description

Clinical findings

Data type

text

Alias
UMLS CUI [1]
C0455712
Untersucher
Description

Examiner

Data type

text

Alias
UMLS CUI [1]
C0025082
Allgemeiner Eindruck
Description

General medical impression

Data type

text

Alias
UMLS CUI [1]
C2973287
Haut
Description

Topogramm Hautbefunde aufrufen

Data type

text

Alias
UMLS CUI [1]
C0437750
HNO-Inspektion
Description

ENT examination

Data type

text

Alias
UMLS CUI [1]
C0278350
Lymphknotenstatus
Description

Lymph node status

Data type

text

Alias
UMLS CUI [1]
C0024204
Herz
Description

Heart examination

Data type

text

Alias
UMLS CUI [1,1]
C0018787
UMLS CUI [1,2]
C0031809
Kreislauf
Description

Circulatory system examination

Data type

text

Alias
UMLS CUI [1,1]
C0007226
UMLS CUI [1,2]
C0031809
Lunge und Atmung
Description

Respiratory system examination

Data type

text

Alias
UMLS CUI [1,1]
C0035237
UMLS CUI [1,2]
C0031809
Abdomen
Description

Abdomen examination

Data type

text

Alias
UMLS CUI [1]
C0562238
Neurologie
Description

Neurological exam

Data type

text

Alias
UMLS CUI [1]
C0027853
Bewegungsapparat
Description

Musculoskeletal system examination

Data type

text

Alias
UMLS CUI [1,1]
C0026860
UMLS CUI [1,2]
C0031809
Fontanelle
Description

Fontanelle

Data type

text

Alias
UMLS CUI [1]
C0224548
Genitale und Pubertätsstadien
Description

Puberty and genitalia

Data type

text

Alias
UMLS CUI [1,1]
C0429595
UMLS CUI [1,2]
C0017420
Behandlungsplan
Description

Behandlungsplan

Aufnahme Diagnose(n)
Description

Admission Diagnosis

Data type

text

Alias
UMLS CUI [1]
C1628992
Aufnahmegrund
Description

Reason for admission

Data type

text

Alias
UMLS CUI [1,1]
C0184666
UMLS CUI [1,2]
C0392360
Mitaufnahme Begleitperson
Description

Accompanying person

Data type

boolean

Alias
UMLS CUI [1]
C0868649
Anordnungen Fieberkurve
Description

Anordnungen Fieberkurve

Ärztliche Kurzanordnung (KAO)
Description

Physician orders

Data type

text

Alias
UMLS CUI [1]
C1546491
Medikation aufrufen
Description

Medication review

Data type

text

Alias
UMLS CUI [1]
C0560023
Dokumentation initiale Diagnostik und Anordnungen
Description

Documentation initial exams and orders

Data type

text

Alias
UMLS CUI [1,1]
C0920316
UMLS CUI [1,2]
C2729337
Differentialdiagnosen
Description

Differential diagnosis

Data type

text

Alias
UMLS CUI [1]
C0011906
Probleme und Behandlungsziele definieren
Description

Medical problems and treatment goals definition

Data type

text

Alias
UMLS CUI [1,1]
C0025104
UMLS CUI [1,2]
C0677092
Verlauf anlegen
Description

Hospital course

Data type

text

Alias
UMLS CUI [1]
C0489547
Arbeitsliste-Dekurs anlegen
Description

Work-flow

Data type

text

Alias
UMLS CUI [1]
C1710679

Similar models

Pädiatrische Anamnese MS University Hospital Muenster (UKM) Subform

Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Allgemeine Angaben
Item
Aufnahmeart
integer
C1550330 (UMLS CUI [1])
Code List
Aufnahmeart
CL Item
stationäre Aufnahme (1)
CL Item
ambulante Vorstellung (2)
Medical history taken by
Item
Erhoben von
text
C0025084 (UMLS CUI [1,1])
C0680379 (UMLS CUI [1,2])
Date medical history taken
Item
Erhoben am
date
C0025084 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Item
Erhebungsmodus
integer
C0025084 (UMLS CUI [1,1])
C0332307 (UMLS CUI [1,2])
Code List
Erhebungsmodus
CL Item
Eigenanamnese (1)
CL Item
Fremdanamnese (2)
CL Item
Sonstiges (3)
Item
Erhebungsmodus: Fremdanamnese
integer
C0025084 (UMLS CUI [1,1])
C0332307 (UMLS CUI [1,2])
Code List
Erhebungsmodus: Fremdanamnese
CL Item
erhoben zusammen mit Mutter (1)
CL Item
erhoben zusammen mit Vater (2)
CL Item
erhoben zusammen mit andere (3)
Type of medical history taking
Item
Erhebungsmodus: Fremdanamnese andere
text
C0025084 (UMLS CUI [1,1])
C0332307 (UMLS CUI [1,2])
Type of medical history taking
Item
Erhebungsmodus: Sonstiges
text
C0025084 (UMLS CUI [1,1])
C0332307 (UMLS CUI [1,2])
Item Group
Aktuelle Anamnese
Current medical history
Item
Aktuelle Anamnese
text
C0262926 (UMLS CUI [1,1])
C0521116 (UMLS CUI [1,2])
Current medication
Item
Aktuelle Medikation
text
C1553892 (UMLS CUI [1])
Current medication comment
Item
Kommentar zur Medikation:
text
C1553892 (UMLS CUI [1,1])
C0947611 (UMLS CUI [1,2])
Item Group
Vorgeschichte
General medical history
Item
Allgemeine Anamnese
text
C0262926 (UMLS CUI [1])
Immunization status
Item
Impfstatus
text
C0552506 (UMLS CUI [1])
Hypersensitivities
Item
Allergien/Unverträglichkeiten
text
C0020517 (UMLS CUI [1])
Item Group
Geburtsanamnese
Peripartum history
Item
Geburtsanamnese
text
C2053583 (UMLS CUI [1])
Birth Order
Item
Geschwisterfolge:
text
C0005607 (UMLS CUI [1])
Gestational age
Item
Gestationsalter
integer
C0017504 (UMLS CUI [1])
Birth clinic
Item
Geburtsklinik:
text
C1552420 (UMLS CUI [1])
Mode of delivery
Item
Geburtsmodus
text
C1555567 (UMLS CUI [1])
Gender
Item
Geschlecht
text
C0079399 (UMLS CUI [1])
Birth weight
Item
Geburtsgewicht
integer
C0005612 (UMLS CUI [1])
Birth length
Item
Geburtslänge
integer
C0419415 (UMLS CUI [1])
APGAR
Item
APGAR
integer
C0003533 (UMLS CUI [1])
Umbilical cord pH
Item
Nabelschnur-pH
integer
C4067152 (UMLS CUI [1])
Head circumference
Item
Geburtskopfumfang
float
C0262499 (UMLS CUI [1])
Pregnancy course
Item
Schwangerschaftsverlauf
text
C0032961 (UMLS CUI [1,1])
C0750729 (UMLS CUI [1,2])
Perinatal period
Item
Perinatalperiode
text
C0178795 (UMLS CUI [1])
Vitamin D prophylaxis
Item
Vitamin D Prophylaxe
text
C0420176 (UMLS CUI [1])
Infant feeding method
Item
Ernährung
text
C0420979 (UMLS CUI [1])
Item Group
Meilensteine d. Entwicklung
Kindergarten
Item
Kindergarten:
text
C0876933 (UMLS CUI [1])
School type
Item
Schulform
text
C1547791 (UMLS CUI [1])
School Grade
Item
Klasse
integer
C3244287 (UMLS CUI [1])
Achievements in school
Item
Schulleistungen
text
C0700132 (UMLS CUI [1])
Item Group
Frühere Krankenhausaufenthalte und Operationen
Month/year of hospital admission
Item
Monat/Jahr
partialDate
C0184666 (UMLS CUI [1,1])
C0680185 (UMLS CUI [1,2])
Hospital
Item
Welches Krankenhaus
text
C0019994 (UMLS CUI [1])
Indication
Item
Indikation
text
C3146298 (UMLS CUI [1])
Type of surgery
Item
Art der Operation
text
C0543467 (UMLS CUI [1])
Childhood diseases
Item
Kinderkrankheiten
text
C0489532 (UMLS CUI [1])
Item Group
Familien Sozialanamnese
Mother´s year of birth
Item
Geburtsjahr Mutter
integer
C2319404 (UMLS CUI [1])
Mother´s occupation
Item
Beruf der Mutter
text
C0028811 (UMLS CUI [1,1])
C0026591 (UMLS CUI [1,2])
Medical history mother
Item
Krankheiten der Mutter
text
C0241889 (UMLS CUI [1,1])
C0026591 (UMLS CUI [1,2])
Father´s year of birth
Item
Geburtsjahr Vater
integer
C2136977 (UMLS CUI [1])
Father´s occupation
Item
Beruf des Vaters
text
C0028811 (UMLS CUI [1,1])
C0015671 (UMLS CUI [1,2])
Medical history of father
Item
Krankheiten des Vaters
text
C0241889 (UMLS CUI [1,1])
C0015671 (UMLS CUI [1,2])
Siblings
Item
Geschwister
text
C0037047 (UMLS CUI [1])
other
Item
Sonstiges
text
C0205394 (UMLS CUI [1])
Item Group
Untersuchung
VITALS
Item
Vitalparameter in Fieberkurve übertragen
text
C0518766 (UMLS CUI [1])
Body Height
Item
Körpergröße
integer
C0005890 (UMLS CUI [1])
Body weight
Item
Körpergewicht
float
C0005910 (UMLS CUI [1])
Head circumference
Item
Kopfumfang
integer
Body temperature
Item
Körpertemperatur
float
C0005903 (UMLS CUI [1])
Heart rate
Item
Herzfrequenz
integer
C0018810 (UMLS CUI [1])
Systolic bloodpressure
Item
Blutdruck systolisch
integer
C0871470 (UMLS CUI [1])
Diastolic blood pressure
Item
Diastolischer Blutdruck
integer
C0428883 (UMLS CUI [1])
MAP
Item
MAD
integer
C0428886 (UMLS CUI [1])
Respiratory rate
Item
Atemfrequenz
integer
C0231832 (UMLS CUI [1])
Oxygen saturation
Item
Sauerstoffsättigung:
float
C2237091 (UMLS CUI [1])
Clinical findings
Item
Untersuchungsbefund
text
C0455712 (UMLS CUI [1])
Examiner
Item
Untersucher
text
C0025082 (UMLS CUI [1])
General medical impression
Item
Allgemeiner Eindruck
text
C2973287 (UMLS CUI [1])
SKIN
Item
Haut
text
C0437750 (UMLS CUI [1])
ENT examination
Item
HNO-Inspektion
text
C0278350 (UMLS CUI [1])
Lymph node status
Item
Lymphknotenstatus
text
C0024204 (UMLS CUI [1])
Heart examination
Item
Herz
text
C0018787 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])
Circulatory system examination
Item
Kreislauf
text
C0007226 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])
Respiratory system examination
Item
Lunge und Atmung
text
C0035237 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])
Abdomen examination
Item
Abdomen
text
C0562238 (UMLS CUI [1])
Neurological exam
Item
Neurologie
text
C0027853 (UMLS CUI [1])
Musculoskeletal system examination
Item
Bewegungsapparat
text
C0026860 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])
Fontanelle
Item
Fontanelle
text
C0224548 (UMLS CUI [1])
Puberty and genitalia
Item
Genitale und Pubertätsstadien
text
C0429595 (UMLS CUI [1,1])
C0017420 (UMLS CUI [1,2])
Item Group
Behandlungsplan
Admission Diagnosis
Item
Aufnahme Diagnose(n)
text
C1628992 (UMLS CUI [1])
Reason for admission
Item
Aufnahmegrund
text
C0184666 (UMLS CUI [1,1])
C0392360 (UMLS CUI [1,2])
Accompanying person
Item
Mitaufnahme Begleitperson
boolean
C0868649 (UMLS CUI [1])
Item Group
Anordnungen Fieberkurve
Physician orders
Item
Ärztliche Kurzanordnung (KAO)
text
C1546491 (UMLS CUI [1])
Medication review
Item
Medikation aufrufen
text
C0560023 (UMLS CUI [1])
Documentation initial exams and orders
Item
Dokumentation initiale Diagnostik und Anordnungen
text
C0920316 (UMLS CUI [1,1])
C2729337 (UMLS CUI [1,2])
Differential diagnosis
Item
Differentialdiagnosen
text
C0011906 (UMLS CUI [1])
Medical problems and treatment goals definition
Item
Probleme und Behandlungsziele definieren
text
C0025104 (UMLS CUI [1,1])
C0677092 (UMLS CUI [1,2])
Hospital course
Item
Verlauf anlegen
text
C0489547 (UMLS CUI [1])
Work-flow
Item
Arbeitsliste-Dekurs anlegen
text
C1710679 (UMLS CUI [1])

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