ID
5505
Beskrivning
Form from HIS OpenVistA
Nyckelord
Versioner (4)
- 2012-02-23 2012-02-23 -
- 2014-08-07 2014-08-07 - Martin Dugas
- 2014-08-07 2014-08-07 - Martin Dugas
- 2015-06-26 2015-06-26 - Martin Dugas
Uppladdad den
7 augusti 2014
DOI
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Licens
Creative Commons BY-NC 3.0 Legacy
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HIS H and P or consult specialty
HIS
- StudyEvent: HIS
Beskrivning
HISTORY OF PRESENT ILLNESS
Beskrivning
HISTORY OF PRESENT ILLNESS (HPI, include location, quality, severity, duration, timing, context, modifying factors & associated signs/symptoms)
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0262512
- LOINC Version 232
- MTHU001399
Beskrivning
SOURCE(S) OF HISTORY
Datatyp
integer
Beskrivning
SOURCE(S) OF HISTORY comment
Datatyp
string
Beskrivning
REVIEW OF SYSTEMS
Beskrivning
PAST HISTORY
Beskrivning
Adult Illness
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0277562
- SNOMED CT 2011_0131
- 64342008
Beskrivning
History of childhood diseases
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0489532
- LOINC Version 232
- MTHU001066
Beskrivning
Surgeries
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0455610
- SNOMED CT 2011_0131
- 161615003
Beskrivning
Injury
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0175677
- SNOMED CT 2011_0131
- 417746004
- MedDRA 14.1
- 10022116
- ICD-10-CM Version 2010
- T14.9
Beskrivning
Female Specific History
Beskrivning
Date of last menstrual period
Datatyp
date
Alias
- UMLS CUI 2011AA
- C0425932
- SNOMED CT 2011_0131
- 21840007
- LOINC Version 232
- MTHU024536
Beskrivning
Date of last PAP
Datatyp
date
Beskrivning
last PAP Results
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0079104
- MedDRA 14.1
- 10041205
Beskrivning
Date of last MMG
Datatyp
date
Beskrivning
last MMG Results
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0024671
- SNOMED CT 2011_0131
- 71651007
- MedDRA 14.1
- 10026735
Beskrivning
Age at menarche
Datatyp
integer
Alias
- UMLS CUI 2011AA
- C1314691
- SNOMED CT 2011_0131
- 398700009
- LOINC Version 232
- MTHU018825
Beskrivning
Describe Menses
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0025344
- SNOMED CT 2011_0131
- 248957007
Beskrivning
Birth Control
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0700589
- SNOMED CT 2011_0131
- 146680009
- MedDRA 14.1
- 10010808
Beskrivning
Pregnancies
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0032961
- SNOMED CT 2011_0131
- 289908002
- MedDRA 14.1
- 10036556
- LOINC Version 232
- MTHU035048
Beskrivning
Abortions
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0156543
- SNOMED CT 2011_0131
- 70317007
- MedDRA 14.1
- 10000210
- LOINC Version 232
- MTHU002834
- ICD-10-CM Version 2010
- O00-O08
- ICD-9-CM Version 2011
- 637
Beskrivning
Number of full term pregnancies
Datatyp
integer
Beskrivning
Number of spontaneous abortions
Datatyp
integer
Beskrivning
Number of therapeutic abortions
Datatyp
integer
Beskrivning
Number of other types Abortions
Datatyp
integer
Beskrivning
Age at first pregnancy
Datatyp
integer
Beskrivning
FAMILY HISTORY
Beskrivning
SOCIAL HISTORY
Beskrivning
ALLERGIES
Beskrivning
MEDICATIONS
Beskrivning
PHYSICAL EXAM - General
Beskrivning
VITALS
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0518766
- SNOMED CT 2011_0131
- 46680005
- LOINC Version 232
- MTHU024540
Beskrivning
TEMPERATURE
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0039476
- SNOMED CT 2011_0131
- 246508008
- LOINC Version 232
- MTHU009008
Beskrivning
PULSE
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0232117
- SNOMED CT 2011_0131
- 78564009
- MedDRA 14.1
- 10037485
Beskrivning
RESPIRATION rate
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0231832
- SNOMED CT 2011_0131
- 86290005
- MedDRA 14.1
- 10038709
- LOINC Version 232
- MTHU008344
Beskrivning
BLOOD PRESSURE
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0005823
- SNOMED CT 2011_0131
- 75367002
- LOINC Version 232
- MTHU008342
Beskrivning
Pain
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0030193
- SNOMED CT 2011_0131
- 22253000
- MedDRA 14.1
- 10033371
- LOINC Version 232
- MTHU029813
- ICD-10-CM Version 2010
- R52
- ICD-9-CM Version 2011
- 338-338.9
- CTCAE 1105E
- E11167
Beskrivning
WEIGHT
Datatyp
integer
Alias
- UMLS CUI 2011AA
- C1305866
- SNOMED CT 2011_0131
- 107647005
- MedDRA 14.1
- 10047890
- LOINC Version 232
- LP18015-5
Beskrivning
GENERAL
Datatyp
string
Beskrivning
PHYSICAL EXAM - HEAD
Beskrivning
PHYSICAL EXAM - EYES
Beskrivning
EYES
Datatyp
boolean
Alias
- UMLS CUI 2011AA
- C0015392
- SNOMED CT 2011_0131
- 81745001
- LOINC Version 232
- MTHU000064
Beskrivning
Pupils
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0034121
- SNOMED CT 2011_0131
- 392406005
- LOINC Version 232
- MTHU015063
Beskrivning
Conjunctivae
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0009758
- SNOMED CT 2011_0131
- 29445007
- LOINC Version 232
- MTHU009301
Beskrivning
Sclerae
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0036410
- SNOMED CT 2011_0131
- 18619003
- LOINC Version 232
- MTHU015068
Beskrivning
EOM
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0028863
- SNOMED CT 2011_0131
- 67833000
- LOINC Version 232
- MTHU015037
Beskrivning
Funduscopic
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0029090
- SNOMED CT 2011_0131
- 274798009
- MedDRA 14.1
- 10017519
Beskrivning
Physical Exam - Ears, Nose, Throat
Beskrivning
Ear canals patent. TM's intact. Nares patent and pink without epistaxis. Mucosa pink. No pharyngitis. Natural dentition.
Datatyp
boolean
Beskrivning
EAR R ext canal
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0013444
- SNOMED CT 2011_0131
- 84301002
- LOINC Version 232
- MTHU015034
Beskrivning
EAR R tympanic membrane (TM)
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0041445
- SNOMED CT 2011_0131
- 42859004
- LOINC Version 232
- MTHU014731
Beskrivning
EAR L ext canal
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0013444
- SNOMED CT 2011_0131
- 84301002
- LOINC Version 232
- MTHU015034
Beskrivning
EAR L tympanic membrane (TM)
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0041445
- SNOMED CT 2011_0131
- 42859004
- LOINC Version 232
- MTHU014731
Beskrivning
NOSE Septum
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0027432
- SNOMED CT 2011_0131
- 68426009
- LOINC Version 232
- MTHU015054
Beskrivning
Nose Mucosa
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0027428
- SNOMED CT 2011_0131
- 34508005
Beskrivning
Nose R Nares
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0595944
- SNOMED CT 2011_0131
- 1797002
- LOINC Version 232
- MTHU015056
Beskrivning
Nose L Nares
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0595944
- SNOMED CT 2011_0131
- 1797002
- LOINC Version 232
- MTHU015056
Beskrivning
Throat: Mouth mucosa
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0026639
- SNOMED CT 2011_0131
- 113277000
Beskrivning
Pharynx
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0031354
- SNOMED CT 2011_0131
- 54066008
- LOINC Version 232
- MTHU015061
Beskrivning
Tonsils
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0836921
- LOINC Version 232
- MTHU015077
Beskrivning
Dentition
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0011443
- SNOMED CT 2011_0131
- 245543004
- LOINC Version 232
- MTHU014794
Beskrivning
Physical Exam - Neck
Beskrivning
supple, no JVD, no carotid bruits, trachea midline, no thyromegaly, no adenopathy
Datatyp
boolean
Alias
- UMLS CUI 2011AA
- C0027530
- SNOMED CT 2011_0131
- 45048000
- LOINC Version 232
- MTHU002688
Beskrivning
Adenopathy
Datatyp
string
Alias
- UMLS CUI 2011AA
- C1706304
- ICD-10-CM Version 2010
- R59
Beskrivning
Carotid bruit
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0007280
- SNOMED CT 2011_0131
- 419642000
- MedDRA 14.1
- 10048777
Beskrivning
JVD
Datatyp
string
Alias
- UMLS CUI 2011AA
- C1719935
- SNOMED CT 2011_0131
- 422008005
Beskrivning
Thyroid gland
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0040132
- SNOMED CT 2011_0131
- 69748006
- LOINC Version 232
- MTHU007792
Beskrivning
Trachea
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0040578
- SNOMED CT 2011_0131
- 44567001
- LOINC Version 232
- MTHU009117
Beskrivning
Physical Exam - BREAST
Beskrivning
symmetric without masses
Datatyp
boolean
Alias
- UMLS CUI 2011AA
- C0006141
- SNOMED CT 2011_0131
- 76752008
- LOINC Version 232
- MTHU011382
Beskrivning
inspection: Right breast
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0006141
- SNOMED CT 2011_0131
- 76752008
- LOINC Version 232
- MTHU011382
Beskrivning
inspection: Right nipple
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0028109
- SNOMED CT 2011_0131
- 24142002
Beskrivning
inspection: Left breast
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0006141
- SNOMED CT 2011_0131
- 76752008
- LOINC Version 232
- MTHU011382
Beskrivning
inspection: Left nipple
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0028109
- SNOMED CT 2011_0131
- 24142002
Beskrivning
palpation: Right breast
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0006141
- SNOMED CT 2011_0131
- 76752008
- LOINC Version 232
- MTHU011382
Beskrivning
palpation: Right nipple
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0028109
- SNOMED CT 2011_0131
- 24142002
Beskrivning
palpation: Left breast
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0006141
- SNOMED CT 2011_0131
- 76752008
- LOINC Version 232
- MTHU011382
Beskrivning
palpation: Left nipple
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0028109
- SNOMED CT 2011_0131
- 24142002
Beskrivning
Physical Exam - CHEST
Beskrivning
normal for inspection, percussion, palpation, and auscultation of the lungs.
Datatyp
boolean
Beskrivning
Chest significant for:
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0817096
- SNOMED CT 2011_0131
- 51185008
Beskrivning
Location
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0450429
- SNOMED CT 2011_0131
- 246267002
Beskrivning
Additional lung sounds
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0035234
- SNOMED CT 2011_0131
- 52653008
- MedDRA 14.1
- 10064779
Beskrivning
Location
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0450429
- SNOMED CT 2011_0131
- 246267002
Beskrivning
Physical Exam - HEART
Beskrivning
PMI at 5th intercostal space, mid clavicular line, normal S1,S2 without murmur or gallop
Datatyp
boolean
Alias
- UMLS CUI 2011AA
- C0018787
- SNOMED CT 2011_0131
- 80891009
- LOINC Version 232
- MTHU001067
Beskrivning
Palpation: PMI is
Datatyp
string
Beskrivning
Rhythm
Datatyp
string
Beskrivning
Heart Sounds: S1 is , S2 is, S3 is, S4 is
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0018820
- SNOMED CT 2011_0131
- 23472005
Beskrivning
PE HEART RUB TEXT
Datatyp
string
Beskrivning
PE HEART OTHER SOUNDS TEXT
Datatyp
string
Beskrivning
Murmur: grade
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0018808
- SNOMED CT 2011_0131
- 421493004
- MedDRA 14.1
- 10007586
- ICD-10-CM Version 2010
- R01.1
- ICD-9-CM Version 2011
- 785.2
Beskrivning
Murmur heard best at
Datatyp
string
Beskrivning
Murmur radiates
Datatyp
string
Beskrivning
Heart - OTHER1
Datatyp
string
Beskrivning
Physical Exam - VASCULAR
Beskrivning
Pulses present and equal bilat.
Datatyp
boolean
Beskrivning
Aorta
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0003483
- SNOMED CT 2011_0131
- 15825003
- LOINC Version 232
- MTHU003021
Beskrivning
Pulses R/L: carotid
Datatyp
string
Alias
- UMLS CUI 2011AA
- C1096529
- MedDRA 14.1
- 10053926
Beskrivning
Pulses R/L: brachial
Datatyp
string
Alias
- UMLS CUI 2011AA
- C1096531
- MedDRA 14.1
- 10053929
Beskrivning
Pulses R/L: radial
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0232142
- SNOMED CT 2011_0131
- 65452004
- MedDRA 14.1
- 10053935
Beskrivning
Pulses R/L: femoral
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0232148
- SNOMED CT 2011_0131
- 67316000
- MedDRA 14.1
- 10053932
Beskrivning
Pulses R/L: popliteal
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0232151
- SNOMED CT 2011_0131
- 74828005
- MedDRA 14.1
- 10053938
Beskrivning
Pulses R/L: posterior tibial
Datatyp
string
Alias
- UMLS CUI 2011AA
- C1720310
- SNOMED CT 2011_0131
- 421568004
Beskrivning
Pulses R/L: dorsalis pedis
Datatyp
string
Alias
- UMLS CUI 2011AA
- C1706488
- SNOMED CT 2011_0131
- 421811005
Beskrivning
Physical Exam - ABDOMEN
Beskrivning
soft, flat, nontender with normal bowel sounds. no organomegaly, no ascites, no palpable mass, no hernia.
Datatyp
boolean
Alias
- UMLS CUI 2011AA
- C0000726
- SNOMED CT 2011_0131
- 113345001
- LOINC Version 232
- MTHU001425
Beskrivning
Appearance
Datatyp
string
Beskrivning
Bowel sounds
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0232693
- SNOMED CT 2011_0131
- 87042004
- MedDRA 14.1
- 10006023
Beskrivning
Midepigastric bruit
Datatyp
string
Beskrivning
Abdominal tenderness
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0232498
- SNOMED CT 2011_0131
- 43478001
- MedDRA 14.1
- 10000097
- ICD-10-CM Version 2010
- R10.81
- ICD-9-CM Version 2011
- 789.6
Beskrivning
Rebound
Datatyp
string
Beskrivning
Liver
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0023884
- SNOMED CT 2011_0131
- 10200004
- LOINC Version 232
- MTHU002039
Beskrivning
Spleen
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0037993
- SNOMED CT 2011_0131
- 78961009
- LOINC Version 232
- MTHU012104
Beskrivning
Hernia
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0019270
- SNOMED CT 2011_0131
- 414403008
- MedDRA 14.1
- 10019909
- ICD-10-CM Version 2010
- K40-K46
Beskrivning
Physical Exam - GENITOURINARY/RECTAL: MALE
Beskrivning
GU Assessment
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0042066
- SNOMED CT 2011_0131
- 21514008
- LOINC Version 232
- MTHU013232
Beskrivning
Urine appears
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0042036
- SNOMED CT 2011_0131
- 78014005
- LOINC Version 232
- MTHU001343
Beskrivning
Urine is adequate
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0042036
- SNOMED CT 2011_0131
- 78014005
- LOINC Version 232
- MTHU001343
Beskrivning
Urine Output [ml]
Datatyp
integer
Alias
- UMLS CUI 2011AA
- C1287298
- SNOMED CT 2011_0131
- 365678000
- MedDRA 14.1
- 10059894
- LOINC Version 232
- MTHU024573
Beskrivning
Foley catheter
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0179804
- MedDRA 14.1
- 10016892
Beskrivning
Suprapubic catheter
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0150798
- SNOMED CT 2011_0131
- 286861005
Beskrivning
scrotal contents
Datatyp
string
Beskrivning
Penis
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0030851
- SNOMED CT 2011_0131
- 18911002
- LOINC Version 232
- MTHU004206
Beskrivning
rectal: sphincter tone
Datatyp
string
Beskrivning
hemorrhoids
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0019112
- SNOMED CT 2011_0131
- 70153002
- MedDRA 14.1
- 10019022
- LOINC Version 232
- MTHU015043
- ICD-10-CM Version 2010
- I84
- ICD-9-CM Version 2011
- 455
- CTCAE 1105E
- E10773
Beskrivning
Prostate
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0033572
- SNOMED CT 2011_0131
- 41216001
- LOINC Version 232
- MTHU004957
Beskrivning
mass
Datatyp
string
Beskrivning
Physical Exam - GENITOURINARY/RECTAL: FEMALE
Beskrivning
GU Assessment FEMALE
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0042066
- SNOMED CT 2011_0131
- 21514008
- LOINC Version 232
- MTHU013232
Beskrivning
Urine appears
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0042036
- SNOMED CT 2011_0131
- 78014005
- LOINC Version 232
- MTHU001343
Beskrivning
Urine is adequate
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0042036
- SNOMED CT 2011_0131
- 78014005
- LOINC Version 232
- MTHU001343
Beskrivning
Urine Output [ml]
Datatyp
integer
Alias
- UMLS CUI 2011AA
- C1287298
- SNOMED CT 2011_0131
- 365678000
- MedDRA 14.1
- 10059894
- LOINC Version 232
- MTHU024573
Beskrivning
Foley catheter
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0179804
- MedDRA 14.1
- 10016892
Beskrivning
Suprapubic catheter
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0150798
- SNOMED CT 2011_0131
- 286861005
Beskrivning
External genitalia
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0227605
- SNOMED CT 2011_0131
- 77142006
Beskrivning
Urethra
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0041967
- SNOMED CT 2011_0131
- 264255005
- LOINC Version 232
- MTHU001321
Beskrivning
Vagina
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0042232
- SNOMED CT 2011_0131
- 76784001
- LOINC Version 232
- MTHU014732
Beskrivning
Bladder
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0005682
- SNOMED CT 2011_0131
- 89837001
- LOINC Version 232
- MTHU002918
Beskrivning
Cervix
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0007874
- SNOMED CT 2011_0131
- 71252005
- LOINC Version 232
- MTHU001800
Beskrivning
Uterus
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0042149
- SNOMED CT 2011_0131
- 35039007
- LOINC Version 232
- MTHU002943
Beskrivning
adnexa
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0001575
- SNOMED CT 2011_0131
- 23043003
- LOINC Version 232
- MTHU015033
Beskrivning
rectal: sphincter tone
Datatyp
string
Beskrivning
hemorrhoids
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0019112
- SNOMED CT 2011_0131
- 70153002
- MedDRA 14.1
- 10019022
- LOINC Version 232
- MTHU015043
- ICD-10-CM Version 2010
- I84
- ICD-9-CM Version 2011
- 455
- CTCAE 1105E
- E10773
Beskrivning
mass
Datatyp
string
Beskrivning
Physical Exam -MUSCULOSKELETAL
Beskrivning
MUSCULOSKELETAL
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0026860
- SNOMED CT 2011_0131
- 26107004
- LOINC Version 232
- MTHU001411
Beskrivning
Gait
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0016928
- SNOMED CT 2011_0131
- 63448001
- LOINC Version 232
- MTHU015039
Beskrivning
Station
Datatyp
string
Beskrivning
Digits
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0582802
- SNOMED CT 2011_0131
- 82680008
- LOINC Version 232
- MTHU015035
Beskrivning
Nails
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0027342
- SNOMED CT 2011_0131
- 72651009
- LOINC Version 232
- MTHU002041
Beskrivning
Joints, Bones, Muscles
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0022417, C0262950, C0026845
- SNOMED CT 2011_0131
- 39352004, 272673000, 71616004
Beskrivning
Head & Neck
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0018670, C0027530
- SNOMED CT 2011_0131
- 69536005, 45048000
Beskrivning
Spine/Ribs/Pelvis
Datatyp
string
Beskrivning
Right Shoulder
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0037004
- SNOMED CT 2011_0131
- 16982005
- LOINC Version 232
- MTHU002689
Beskrivning
Right Elbow
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0013769
- SNOMED CT 2011_0131
- 127949000
- LOINC Version 232
- MTHU002674
Beskrivning
Right Wrist
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0043262
- SNOMED CT 2011_0131
- 8205005
- LOINC Version 232
- MTHU002691
Beskrivning
Left Shoulder
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0037004
- SNOMED CT 2011_0131
- 16982005
- LOINC Version 232
- MTHU002689
Beskrivning
Left Elbow
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0013769
- SNOMED CT 2011_0131
- 127949000
- LOINC Version 232
- MTHU002674
Beskrivning
Left Wrist
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0043262
- SNOMED CT 2011_0131
- 8205005
- LOINC Version 232
- MTHU002691
Beskrivning
Right Hip
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0019552
- SNOMED CT 2011_0131
- 24136001
- LOINC Version 232
- MTHU002686
Beskrivning
Right Knee
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0022742
- SNOMED CT 2011_0131
- 304679005
- LOINC Version 232
- MTHU002687
Beskrivning
Right Ankle
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0003086
- SNOMED CT 2011_0131
- 344001
Beskrivning
Left Hip
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0019552
- SNOMED CT 2011_0131
- 24136001
- LOINC Version 232
- MTHU002686
Beskrivning
Left Knee
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0022742
- SNOMED CT 2011_0131
- 304679005
- LOINC Version 232
- MTHU002687
Beskrivning
Left Ankle
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0003086
- SNOMED CT 2011_0131
- 344001
Beskrivning
Physical Exam - EXTREMITIES
Beskrivning
Significant for:
Datatyp
string
Beskrivning
pitting edema
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0333243
- SNOMED CT 2011_0131
- 139248000
Beskrivning
pretibial: R / L
Datatyp
string
Beskrivning
ankle: R / L
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0003086
- SNOMED CT 2011_0131
- 344001
Beskrivning
foot: R / L
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0016504
- SNOMED CT 2011_0131
- 56459004
- LOINC Version 232
- MTHU002679
Beskrivning
Pulses R/L: posterior tibial
Datatyp
string
Alias
- UMLS CUI 2011AA
- C1720310
- SNOMED CT 2011_0131
- 421568004
Beskrivning
Pulses R/L: dorsalis pedis
Datatyp
string
Alias
- UMLS CUI 2011AA
- C1706488
- SNOMED CT 2011_0131
- 421811005
Beskrivning
capillary fill time R/L
Datatyp
string
Beskrivning
sensation by monofilament test R/L
Datatyp
string
Beskrivning
toenails
Datatyp
string
Beskrivning
skin
Datatyp
string
Alias
- UMLS CUI 2011AA
- C1123023
- SNOMED CT 2011_0131
- 39937001
- LOINC Version 232
- MTHU001414
Beskrivning
Physical Exam - LYMPHATIC
Beskrivning
no adenopathy
Datatyp
boolean
Beskrivning
adenopathy
Datatyp
string
Alias
- UMLS CUI 2011AA
- C1706304
Beskrivning
neck
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0027530
- SNOMED CT 2011_0131
- 45048000
- LOINC Version 232
- MTHU002688
Beskrivning
Axilla
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0004454
- SNOMED CT 2011_0131
- 91470000
- LOINC Version 232
- MTHU002668
Beskrivning
groin
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0018246
- SNOMED CT 2011_0131
- 26893007
- LOINC Version 232
- MTHU002684
Beskrivning
other
Datatyp
string
Beskrivning
Physical Exam - SKIN
Beskrivning
Inspection and palpation of skin and subcutaneous tissue reveals no acute rashes, lesions, or induration.
Datatyp
boolean
Alias
- UMLS CUI 2011AA
- C1123023
- SNOMED CT 2011_0131
- 39937001
- LOINC Version 232
- MTHU001414
Beskrivning
inspection
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0199219
- SNOMED CT 2011_0131
- 32750006
Beskrivning
Palpation
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0030247
- SNOMED CT 2011_0131
- 113011001
Beskrivning
Physical Exam - Wound and Incision Care
Beskrivning
WOUND #
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0043250
- SNOMED CT 2011_0131
- 13924000
- MedDRA 14.1
- 10052428
- LOINC Version 232
- MTHU001326
Beskrivning
WOUND LOCATION
Datatyp
string
Beskrivning
WOUND MEASUREMENT (Length, Width, Depth [cm])
Datatyp
string
Beskrivning
UNDERMINING Wound
Datatyp
boolean
Beskrivning
TUNNELING Wound
Datatyp
boolean
Beskrivning
SURROUNDING SKIN: WOUND BASE
Datatyp
string
Beskrivning
SENSATION
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0036658
- SNOMED CT 2011_0131
- 373713005
- LOINC Version 232
- MTHU017277
Beskrivning
EXUDATE
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0015388
- SNOMED CT 2011_0131
- 247450001
- LOINC Version 232
- MTHU025016
Beskrivning
COLOR OF DRAINAGE
Datatyp
string
Beskrivning
ODOR: Before Cleaning
Datatyp
boolean
Beskrivning
ODOR: After Cleaning
Datatyp
boolean
Beskrivning
CLEANSED WITH/IRRIGATED WITH
Datatyp
string
Beskrivning
WOUND MED applied
Datatyp
string
Beskrivning
FILLED WITH
Datatyp
string
Beskrivning
COVERED WITH
Datatyp
string
Beskrivning
SECURED WITH
Datatyp
string
Beskrivning
PRESSURE RELIEF
Datatyp
string
Beskrivning
COMMENTS
Datatyp
string
Beskrivning
PHOTOGRAPH DATE
Datatyp
date
Beskrivning
NARRATIVE
Datatyp
string
Alias
- UMLS CUI 2011AA
- C1135957
Beskrivning
INCISION #
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0184898
- SNOMED CT 2011_0131
- 34896006
Beskrivning
LOCATION
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0450429
- SNOMED CT 2011_0131
- 246267002
Beskrivning
CLOSURE TYPE
Datatyp
string
Beskrivning
DRESSING TYPE
Datatyp
string
Beskrivning
DRESSING APPEARANCE
Datatyp
string
Beskrivning
DRAINS
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0180499
- SNOMED CT 2011_0131
- 32712000
- LOINC Version 232
- MTHU022515
Beskrivning
NARRATIVE
Datatyp
string
Alias
- UMLS CUI 2011AA
- C1135957
Beskrivning
Physical Exam - NEUROLOGIC
Beskrivning
Oriented x 3, cranial nerves 2-12 intact, no gross sensory or motor deficits, reflexes symmetric, no cerebellar signs, no involuntary movements
Datatyp
boolean
Alias
- UMLS CUI 2011AA
- C0027763
- SNOMED CT 2011_0131
- 25087005
- LOINC Version 232
- MTHU001437
Beskrivning
Conciousness
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0234421
- SNOMED CT 2011_0131
- 106167005
Beskrivning
Responsive to
Datatyp
string
Beskrivning
Orientation
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0029266
- SNOMED CT 2011_0131
- 43173001
Beskrivning
Proverb
Datatyp
string
Beskrivning
Writing
Datatyp
string
Alias
- UMLS CUI 2011AA
- C2584304
- SNOMED CT 2011_0131
- 12261009
Beskrivning
Reading
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0034754
- SNOMED CT 2011_0131
- 50360004
Beskrivning
Memory
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0025260
- SNOMED CT 2011_0131
- 303116000
- LOINC Version 232
- MTHU021129
Beskrivning
Registration
Datatyp
string
Beskrivning
Naming Intact
Datatyp
string
Beskrivning
Speech
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0037817
- SNOMED CT 2011_0131
- 87335007
- LOINC Version 232
- MTHU021528
Beskrivning
OTHER
Datatyp
string
Beskrivning
Score normal
Datatyp
boolean
Beskrivning
Concentration normal
Datatyp
boolean
Beskrivning
Cranial nerves normal
Datatyp
boolean
Beskrivning
Comment
Datatyp
string
Beskrivning
Motor tone
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0026841
- MedDRA 14.1
- 10070541
- LOINC Version 232
- MTHU015024
Beskrivning
Motor strength R/L
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0517349
Beskrivning
Grip R/L
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0220843
Beskrivning
Biceps R/L
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0559499
- SNOMED CT 2011_0131
- 16225001
- LOINC Version 232
- MTHU014778
Beskrivning
Triceps R/L
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0559502
- SNOMED CT 2011_0131
- 40284004
- LOINC Version 232
- MTHU014783
Beskrivning
Quadriceps R/L
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0224440
- SNOMED CT 2011_0131
- 21989003
Beskrivning
Hip Extensors R/L
Datatyp
string
Beskrivning
Dorsiflexion R/L
Datatyp
string
Beskrivning
Plantarflexion R/L
Datatyp
string
Beskrivning
Sensation
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0036658
- SNOMED CT 2011_0131
- 373713005
- LOINC Version 232
- MTHU017277
Beskrivning
Pin prick
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0423557
- SNOMED CT 2011_0131
- 247315008
Beskrivning
Comment
Datatyp
string
Beskrivning
Light touch
Datatyp
string
Beskrivning
Vibration
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0459800
- SNOMED CT 2011_0131
- 33679000
- LOINC Version 232
- MTHU021537
Beskrivning
Comment
Datatyp
string
Beskrivning
Position Sense
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0234219
- SNOMED CT 2011_0131
- 73535003
Beskrivning
Temperature
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0039476
- SNOMED CT 2011_0131
- 246508008
- LOINC Version 232
- MTHU009008
Beskrivning
Stereognosis
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0038263
- SNOMED CT 2011_0131
- 22382001
Beskrivning
Deep Tendon Reflexes Biceps R/L
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0234151
- SNOMED CT 2011_0131
- 30901003
Beskrivning
Deep Tendon Reflexes Triceps R/L
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0422908
- SNOMED CT 2011_0131
- 271716008
Beskrivning
Deep Tendon Reflexes Brachioradialis R/L
Datatyp
string
Beskrivning
Deep Tendon Reflexes Patellar R/L
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0234147
- SNOMED CT 2011_0131
- 271714006
Beskrivning
Deep Tendon Reflexes Achilles R/L
Datatyp
string
Beskrivning
Abnormal reflexes
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0034933
- SNOMED CT 2011_0131
- 46670006
- MedDRA 14.1
- 10000171
- ICD-10-CM Version 2010
- R29.2
- ICD-9-CM Version 2011
- 796.1
Beskrivning
Involuntary Movements
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0427086
- SNOMED CT 2011_0131
- 267078001
- MedDRA 14.1
- 10028042
- CTCAE 1105E
- E12728
Beskrivning
Cerebellar Signs
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0742038
Beskrivning
Gait
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0016928
- SNOMED CT 2011_0131
- 63448001
- LOINC Version 232
- MTHU015039
Beskrivning
Comment
Datatyp
string
Beskrivning
Station
Datatyp
string
Beskrivning
PSYCHIATRIC
Beskrivning
Alert, oriented to person, place, and time, judgement and insight good, recent and remote memory intact, normal mood and affect.
Datatyp
boolean
Beskrivning
Judgement & Insight
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0022423, C0233820
- SNOMED CT 2011_0131
- 61254005, 27026000
Beskrivning
Orientation
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0029266
- SNOMED CT 2011_0131
- 43173001
Beskrivning
Recent Memory
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0233792
- SNOMED CT 2011_0131
- 69063000
Beskrivning
Remote Memory
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0233793
- SNOMED CT 2011_0131
- 81964002
Beskrivning
Mood/Affect
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0026516, C0001721
- SNOMED CT 2011_0131
- 85256008, 4065008
- LOINC Version 232
- MTHU031584
Beskrivning
Laboratory Results
Beskrivning
Radiology Results
Beskrivning
ASSESSMENT
Beskrivning
acceptable for surgery
Datatyp
boolean
Beskrivning
progressing well
Datatyp
boolean
Beskrivning
stable medically
Datatyp
boolean
Alias
- UMLS CUI 2011AA
- C0205360
- SNOMED CT 2011_0131
- 58158008
- LOINC Version 232
- MTHU015276
Beskrivning
Active Problems
Datatyp
string
Alias
- UMLS CUI 2011AA
- C0552582
- LOINC Version 232
- LP73189-0
Beskrivning
Other
Datatyp
string
Beskrivning
PLAN
Beskrivning
Continue Home Regimen
Datatyp
boolean
Beskrivning
Continue Home Meds
Datatyp
boolean
Beskrivning
Continue Chemotherapy
Datatyp
boolean
Beskrivning
Continue IV Antibiotics
Datatyp
boolean
Beskrivning
Continue PO Antibiotics
Datatyp
boolean
Beskrivning
DVT Prophylaxis
Datatyp
boolean
Alias
- UMLS CUI 2011AA
- C0853245
- MedDRA 14.1
- 10013880
Beskrivning
O2 Protocol
Datatyp
boolean
Beskrivning
Follow Up X-Rays
Datatyp
boolean
Beskrivning
UTI treatment
Datatyp
boolean
Alias
- UMLS CUI 2011AA
- C0042029
- SNOMED CT 2011_0131
- 68566005
- MedDRA 14.1
- 10046577
Beskrivning
Monitor Blood Pressure and Heart Rate
Datatyp
boolean
Beskrivning
Monitor Diabetes Mellitus
Datatyp
boolean
Beskrivning
Accuchecks AC & HS
Datatyp
boolean
Beskrivning
Accuchecks Q6H
Datatyp
boolean
Beskrivning
Sliding Scale Regular Insulin
Datatyp
boolean
Alias
- UMLS CUI 2011AA
- C0021641
- SNOMED CT 2011_0131
- 67866001
- LOINC Version 232
- MTHU019392
Beskrivning
Check Follow Up Labs
Datatyp
boolean
Beskrivning
Appreciate following patient with you
Datatyp
boolean
Similar models
HIS
- StudyEvent: HIS
64342008 (SNOMED CT 2011_0131)
161615003 (SNOMED CT 2011_0131)
417746004 (SNOMED CT 2011_0131)
10022116 (MedDRA 14.1)
T14.9 (ICD-10-CM Version 2010)
10041205 (MedDRA 14.1)
71651007 (SNOMED CT 2011_0131)
10026735 (MedDRA 14.1)
248957007 (SNOMED CT 2011_0131)
146680009 (SNOMED CT 2011_0131)
10010808 (MedDRA 14.1)
289908002 (SNOMED CT 2011_0131)
10036556 (MedDRA 14.1)
MTHU035048 (LOINC Version 232)
70317007 (SNOMED CT 2011_0131)
10000210 (MedDRA 14.1)
MTHU002834 (LOINC Version 232)
O00-O08 (ICD-10-CM Version 2010)
637 (ICD-9-CM Version 2011)
57177007 (SNOMED CT 2011_0131)
257550005 (SNOMED CT 2011_0131)
78564009 (SNOMED CT 2011_0131)
10037485 (MedDRA 14.1)
86290005 (SNOMED CT 2011_0131)
10038709 (MedDRA 14.1)
MTHU008344 (LOINC Version 232)
22253000 (SNOMED CT 2011_0131)
10033371 (MedDRA 14.1)
MTHU029813 (LOINC Version 232)
R52 (ICD-10-CM Version 2010)
338-338.9 (ICD-9-CM Version 2011)
E11167 (CTCAE 1105E)
107647005 (SNOMED CT 2011_0131)
10047890 (MedDRA 14.1)
LP18015-5 (LOINC Version 232)
274798009 (SNOMED CT 2011_0131)
10017519 (MedDRA 14.1)
34508005 (SNOMED CT 2011_0131)
113277000 (SNOMED CT 2011_0131)
R59 (ICD-10-CM Version 2010)
419642000 (SNOMED CT 2011_0131)
10048777 (MedDRA 14.1)
422008005 (SNOMED CT 2011_0131)
24142002 (SNOMED CT 2011_0131)
24142002 (SNOMED CT 2011_0131)
24142002 (SNOMED CT 2011_0131)
24142002 (SNOMED CT 2011_0131)
51185008 (SNOMED CT 2011_0131)
246267002 (SNOMED CT 2011_0131)
52653008 (SNOMED CT 2011_0131)
10064779 (MedDRA 14.1)
246267002 (SNOMED CT 2011_0131)
23472005 (SNOMED CT 2011_0131)
421493004 (SNOMED CT 2011_0131)
10007586 (MedDRA 14.1)
R01.1 (ICD-10-CM Version 2010)
785.2 (ICD-9-CM Version 2011)
10053926 (MedDRA 14.1)
10053929 (MedDRA 14.1)
65452004 (SNOMED CT 2011_0131)
10053935 (MedDRA 14.1)
67316000 (SNOMED CT 2011_0131)
10053932 (MedDRA 14.1)
74828005 (SNOMED CT 2011_0131)
10053938 (MedDRA 14.1)
421568004 (SNOMED CT 2011_0131)
421811005 (SNOMED CT 2011_0131)
87042004 (SNOMED CT 2011_0131)
10006023 (MedDRA 14.1)
43478001 (SNOMED CT 2011_0131)
10000097 (MedDRA 14.1)
R10.81 (ICD-10-CM Version 2010)
789.6 (ICD-9-CM Version 2011)
414403008 (SNOMED CT 2011_0131)
10019909 (MedDRA 14.1)
K40-K46 (ICD-10-CM Version 2010)
365678000 (SNOMED CT 2011_0131)
10059894 (MedDRA 14.1)
MTHU024573 (LOINC Version 232)
10016892 (MedDRA 14.1)
286861005 (SNOMED CT 2011_0131)
70153002 (SNOMED CT 2011_0131)
10019022 (MedDRA 14.1)
MTHU015043 (LOINC Version 232)
I84 (ICD-10-CM Version 2010)
455 (ICD-9-CM Version 2011)
E10773 (CTCAE 1105E)
365678000 (SNOMED CT 2011_0131)
10059894 (MedDRA 14.1)
MTHU024573 (LOINC Version 232)
10016892 (MedDRA 14.1)
286861005 (SNOMED CT 2011_0131)
77142006 (SNOMED CT 2011_0131)
70153002 (SNOMED CT 2011_0131)
10019022 (MedDRA 14.1)
MTHU015043 (LOINC Version 232)
I84 (ICD-10-CM Version 2010)
455 (ICD-9-CM Version 2011)
E10773 (CTCAE 1105E)
39352004, 272673000, 71616004 (SNOMED CT 2011_0131)
69536005, 45048000 (SNOMED CT 2011_0131)
344001 (SNOMED CT 2011_0131)
344001 (SNOMED CT 2011_0131)
139248000 (SNOMED CT 2011_0131)
344001 (SNOMED CT 2011_0131)
421568004 (SNOMED CT 2011_0131)
421811005 (SNOMED CT 2011_0131)
32750006 (SNOMED CT 2011_0131)
113011001 (SNOMED CT 2011_0131)
13924000 (SNOMED CT 2011_0131)
10052428 (MedDRA 14.1)
MTHU001326 (LOINC Version 232)
34896006 (SNOMED CT 2011_0131)
246267002 (SNOMED CT 2011_0131)
106167005 (SNOMED CT 2011_0131)
43173001 (SNOMED CT 2011_0131)
12261009 (SNOMED CT 2011_0131)
50360004 (SNOMED CT 2011_0131)
21989003 (SNOMED CT 2011_0131)
247315008 (SNOMED CT 2011_0131)
73535003 (SNOMED CT 2011_0131)
22382001 (SNOMED CT 2011_0131)
30901003 (SNOMED CT 2011_0131)
271716008 (SNOMED CT 2011_0131)
271714006 (SNOMED CT 2011_0131)
46670006 (SNOMED CT 2011_0131)
10000171 (MedDRA 14.1)
R29.2 (ICD-10-CM Version 2010)
796.1 (ICD-9-CM Version 2011)
267078001 (SNOMED CT 2011_0131)
10028042 (MedDRA 14.1)
E12728 (CTCAE 1105E)
61254005, 27026000 (SNOMED CT 2011_0131)
43173001 (SNOMED CT 2011_0131)
69063000 (SNOMED CT 2011_0131)
81964002 (SNOMED CT 2011_0131)
85256008, 4065008 (SNOMED CT 2011_0131)
MTHU031584 (LOINC Version 232)
118246004 (SNOMED CT 2011_0131)
371527006 (SNOMED CT 2011_0131)
10013880 (MedDRA 14.1)
68566005 (SNOMED CT 2011_0131)
10046577 (MedDRA 14.1)