ID
5505
Description
Form from HIS OpenVistA
Mots-clés
Versions (4)
- 23/02/2012 23/02/2012 -
- 07/08/2014 07/08/2014 - Martin Dugas
- 07/08/2014 07/08/2014 - Martin Dugas
- 26/06/2015 26/06/2015 - Martin Dugas
Téléchargé le
7 août 2014
DOI
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Licence
Creative Commons BY-NC 3.0 Legacy
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HIS H and P or consult specialty
HIS
- StudyEvent: HIS
Description
HISTORY OF PRESENT ILLNESS
Description
HISTORY OF PRESENT ILLNESS (HPI, include location, quality, severity, duration, timing, context, modifying factors & associated signs/symptoms)
Type de données
string
Alias
- UMLS CUI 2011AA
- C0262512
- LOINC Version 232
- MTHU001399
Description
SOURCE(S) OF HISTORY
Type de données
integer
Description
SOURCE(S) OF HISTORY comment
Type de données
string
Description
REVIEW OF SYSTEMS
Description
PAST HISTORY
Description
Adult Illness
Type de données
string
Alias
- UMLS CUI 2011AA
- C0277562
- SNOMED CT 2011_0131
- 64342008
Description
History of childhood diseases
Type de données
string
Alias
- UMLS CUI 2011AA
- C0489532
- LOINC Version 232
- MTHU001066
Description
Surgeries
Type de données
string
Alias
- UMLS CUI 2011AA
- C0455610
- SNOMED CT 2011_0131
- 161615003
Description
Injury
Type de données
string
Alias
- UMLS CUI 2011AA
- C0175677
- SNOMED CT 2011_0131
- 417746004
- MedDRA 14.1
- 10022116
- ICD-10-CM Version 2010
- T14.9
Description
Female Specific History
Description
Date of last menstrual period
Type de données
date
Alias
- UMLS CUI 2011AA
- C0425932
- SNOMED CT 2011_0131
- 21840007
- LOINC Version 232
- MTHU024536
Description
Date of last PAP
Type de données
date
Description
last PAP Results
Type de données
string
Alias
- UMLS CUI 2011AA
- C0079104
- MedDRA 14.1
- 10041205
Description
Date of last MMG
Type de données
date
Description
last MMG Results
Type de données
string
Alias
- UMLS CUI 2011AA
- C0024671
- SNOMED CT 2011_0131
- 71651007
- MedDRA 14.1
- 10026735
Description
Age at menarche
Type de données
integer
Alias
- UMLS CUI 2011AA
- C1314691
- SNOMED CT 2011_0131
- 398700009
- LOINC Version 232
- MTHU018825
Description
Describe Menses
Type de données
string
Alias
- UMLS CUI 2011AA
- C0025344
- SNOMED CT 2011_0131
- 248957007
Description
Birth Control
Type de données
string
Alias
- UMLS CUI 2011AA
- C0700589
- SNOMED CT 2011_0131
- 146680009
- MedDRA 14.1
- 10010808
Description
Pregnancies
Type de données
string
Alias
- UMLS CUI 2011AA
- C0032961
- SNOMED CT 2011_0131
- 289908002
- MedDRA 14.1
- 10036556
- LOINC Version 232
- MTHU035048
Description
Abortions
Type de données
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
Description
Number of full term pregnancies
Type de données
integer
Description
Number of spontaneous abortions
Type de données
integer
Description
Number of therapeutic abortions
Type de données
integer
Description
Number of other types Abortions
Type de données
integer
Description
Age at first pregnancy
Type de données
integer
Description
FAMILY HISTORY
Description
SOCIAL HISTORY
Description
ALLERGIES
Description
MEDICATIONS
Description
Inpatient medications
Type de données
string
Alias
- UMLS CUI 2011AA
- C0013227
Description
Active medications
Type de données
string
Alias
- UMLS CUI 2011AA
- C1553892
Description
Home medications
Type de données
string
Alias
- UMLS CUI 2011AA
- C0013227
Description
PHYSICAL EXAM - General
Description
VITALS
Type de données
string
Alias
- UMLS CUI 2011AA
- C0518766
- SNOMED CT 2011_0131
- 46680005
- LOINC Version 232
- MTHU024540
Description
TEMPERATURE
Type de données
string
Alias
- UMLS CUI 2011AA
- C0039476
- SNOMED CT 2011_0131
- 246508008
- LOINC Version 232
- MTHU009008
Description
PULSE
Type de données
string
Alias
- UMLS CUI 2011AA
- C0232117
- SNOMED CT 2011_0131
- 78564009
- MedDRA 14.1
- 10037485
Description
RESPIRATION rate
Type de données
string
Alias
- UMLS CUI 2011AA
- C0231832
- SNOMED CT 2011_0131
- 86290005
- MedDRA 14.1
- 10038709
- LOINC Version 232
- MTHU008344
Description
BLOOD PRESSURE
Type de données
string
Alias
- UMLS CUI 2011AA
- C0005823
- SNOMED CT 2011_0131
- 75367002
- LOINC Version 232
- MTHU008342
Description
Pain
Type de données
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
Description
WEIGHT
Type de données
integer
Alias
- UMLS CUI 2011AA
- C1305866
- SNOMED CT 2011_0131
- 107647005
- MedDRA 14.1
- 10047890
- LOINC Version 232
- LP18015-5
Description
GENERAL
Type de données
string
Description
PHYSICAL EXAM - HEAD
Description
PHYSICAL EXAM - EYES
Description
EYES
Type de données
boolean
Alias
- UMLS CUI 2011AA
- C0015392
- SNOMED CT 2011_0131
- 81745001
- LOINC Version 232
- MTHU000064
Description
Pupils
Type de données
string
Alias
- UMLS CUI 2011AA
- C0034121
- SNOMED CT 2011_0131
- 392406005
- LOINC Version 232
- MTHU015063
Description
Conjunctivae
Type de données
string
Alias
- UMLS CUI 2011AA
- C0009758
- SNOMED CT 2011_0131
- 29445007
- LOINC Version 232
- MTHU009301
Description
Sclerae
Type de données
string
Alias
- UMLS CUI 2011AA
- C0036410
- SNOMED CT 2011_0131
- 18619003
- LOINC Version 232
- MTHU015068
Description
EOM
Type de données
string
Alias
- UMLS CUI 2011AA
- C0028863
- SNOMED CT 2011_0131
- 67833000
- LOINC Version 232
- MTHU015037
Description
Funduscopic
Type de données
string
Alias
- UMLS CUI 2011AA
- C0029090
- SNOMED CT 2011_0131
- 274798009
- MedDRA 14.1
- 10017519
Description
Physical Exam - Ears, Nose, Throat
Description
Ear canals patent. TM's intact. Nares patent and pink without epistaxis. Mucosa pink. No pharyngitis. Natural dentition.
Type de données
boolean
Description
EAR R ext canal
Type de données
string
Alias
- UMLS CUI 2011AA
- C0013444
- SNOMED CT 2011_0131
- 84301002
- LOINC Version 232
- MTHU015034
Description
EAR R tympanic membrane (TM)
Type de données
string
Alias
- UMLS CUI 2011AA
- C0041445
- SNOMED CT 2011_0131
- 42859004
- LOINC Version 232
- MTHU014731
Description
EAR L ext canal
Type de données
string
Alias
- UMLS CUI 2011AA
- C0013444
- SNOMED CT 2011_0131
- 84301002
- LOINC Version 232
- MTHU015034
Description
EAR L tympanic membrane (TM)
Type de données
string
Alias
- UMLS CUI 2011AA
- C0041445
- SNOMED CT 2011_0131
- 42859004
- LOINC Version 232
- MTHU014731
Description
NOSE Septum
Type de données
string
Alias
- UMLS CUI 2011AA
- C0027432
- SNOMED CT 2011_0131
- 68426009
- LOINC Version 232
- MTHU015054
Description
Nose Mucosa
Type de données
string
Alias
- UMLS CUI 2011AA
- C0027428
- SNOMED CT 2011_0131
- 34508005
Description
Nose R Nares
Type de données
string
Alias
- UMLS CUI 2011AA
- C0595944
- SNOMED CT 2011_0131
- 1797002
- LOINC Version 232
- MTHU015056
Description
Nose L Nares
Type de données
string
Alias
- UMLS CUI 2011AA
- C0595944
- SNOMED CT 2011_0131
- 1797002
- LOINC Version 232
- MTHU015056
Description
Throat: Mouth mucosa
Type de données
string
Alias
- UMLS CUI 2011AA
- C0026639
- SNOMED CT 2011_0131
- 113277000
Description
Pharynx
Type de données
string
Alias
- UMLS CUI 2011AA
- C0031354
- SNOMED CT 2011_0131
- 54066008
- LOINC Version 232
- MTHU015061
Description
Tonsils
Type de données
string
Alias
- UMLS CUI 2011AA
- C0836921
- LOINC Version 232
- MTHU015077
Description
Dentition
Type de données
string
Alias
- UMLS CUI 2011AA
- C0011443
- SNOMED CT 2011_0131
- 245543004
- LOINC Version 232
- MTHU014794
Description
Physical Exam - Neck
Description
supple, no JVD, no carotid bruits, trachea midline, no thyromegaly, no adenopathy
Type de données
boolean
Alias
- UMLS CUI 2011AA
- C0027530
- SNOMED CT 2011_0131
- 45048000
- LOINC Version 232
- MTHU002688
Description
Adenopathy
Type de données
string
Alias
- UMLS CUI 2011AA
- C1706304
- ICD-10-CM Version 2010
- R59
Description
Carotid bruit
Type de données
string
Alias
- UMLS CUI 2011AA
- C0007280
- SNOMED CT 2011_0131
- 419642000
- MedDRA 14.1
- 10048777
Description
JVD
Type de données
string
Alias
- UMLS CUI 2011AA
- C1719935
- SNOMED CT 2011_0131
- 422008005
Description
Thyroid gland
Type de données
string
Alias
- UMLS CUI 2011AA
- C0040132
- SNOMED CT 2011_0131
- 69748006
- LOINC Version 232
- MTHU007792
Description
Trachea
Type de données
string
Alias
- UMLS CUI 2011AA
- C0040578
- SNOMED CT 2011_0131
- 44567001
- LOINC Version 232
- MTHU009117
Description
Physical Exam - BREAST
Description
symmetric without masses
Type de données
boolean
Alias
- UMLS CUI 2011AA
- C0006141
- SNOMED CT 2011_0131
- 76752008
- LOINC Version 232
- MTHU011382
Description
inspection: Right breast
Type de données
string
Alias
- UMLS CUI 2011AA
- C0006141
- SNOMED CT 2011_0131
- 76752008
- LOINC Version 232
- MTHU011382
Description
inspection: Right nipple
Type de données
string
Alias
- UMLS CUI 2011AA
- C0028109
- SNOMED CT 2011_0131
- 24142002
Description
inspection: Left breast
Type de données
string
Alias
- UMLS CUI 2011AA
- C0006141
- SNOMED CT 2011_0131
- 76752008
- LOINC Version 232
- MTHU011382
Description
inspection: Left nipple
Type de données
string
Alias
- UMLS CUI 2011AA
- C0028109
- SNOMED CT 2011_0131
- 24142002
Description
palpation: Right breast
Type de données
string
Alias
- UMLS CUI 2011AA
- C0006141
- SNOMED CT 2011_0131
- 76752008
- LOINC Version 232
- MTHU011382
Description
palpation: Right nipple
Type de données
string
Alias
- UMLS CUI 2011AA
- C0028109
- SNOMED CT 2011_0131
- 24142002
Description
palpation: Left breast
Type de données
string
Alias
- UMLS CUI 2011AA
- C0006141
- SNOMED CT 2011_0131
- 76752008
- LOINC Version 232
- MTHU011382
Description
palpation: Left nipple
Type de données
string
Alias
- UMLS CUI 2011AA
- C0028109
- SNOMED CT 2011_0131
- 24142002
Description
Physical Exam - CHEST
Description
normal for inspection, percussion, palpation, and auscultation of the lungs.
Type de données
boolean
Description
Chest significant for:
Type de données
string
Alias
- UMLS CUI 2011AA
- C0817096
- SNOMED CT 2011_0131
- 51185008
Description
Location
Type de données
string
Alias
- UMLS CUI 2011AA
- C0450429
- SNOMED CT 2011_0131
- 246267002
Description
Additional lung sounds
Type de données
string
Alias
- UMLS CUI 2011AA
- C0035234
- SNOMED CT 2011_0131
- 52653008
- MedDRA 14.1
- 10064779
Description
Location
Type de données
string
Alias
- UMLS CUI 2011AA
- C0450429
- SNOMED CT 2011_0131
- 246267002
Description
Physical Exam - HEART
Description
PMI at 5th intercostal space, mid clavicular line, normal S1,S2 without murmur or gallop
Type de données
boolean
Alias
- UMLS CUI 2011AA
- C0018787
- SNOMED CT 2011_0131
- 80891009
- LOINC Version 232
- MTHU001067
Description
Palpation: PMI is
Type de données
string
Description
Rhythm
Type de données
string
Description
Heart Sounds: S1 is , S2 is, S3 is, S4 is
Type de données
string
Alias
- UMLS CUI 2011AA
- C0018820
- SNOMED CT 2011_0131
- 23472005
Description
PE HEART RUB TEXT
Type de données
string
Description
PE HEART OTHER SOUNDS TEXT
Type de données
string
Description
Murmur: grade
Type de données
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
Description
Murmur heard best at
Type de données
string
Description
Murmur radiates
Type de données
string
Description
Heart - OTHER1
Type de données
string
Description
Physical Exam - VASCULAR
Description
Pulses present and equal bilat.
Type de données
boolean
Description
Aorta
Type de données
string
Alias
- UMLS CUI 2011AA
- C0003483
- SNOMED CT 2011_0131
- 15825003
- LOINC Version 232
- MTHU003021
Description
Pulses R/L: carotid
Type de données
string
Alias
- UMLS CUI 2011AA
- C1096529
- MedDRA 14.1
- 10053926
Description
Pulses R/L: brachial
Type de données
string
Alias
- UMLS CUI 2011AA
- C1096531
- MedDRA 14.1
- 10053929
Description
Pulses R/L: radial
Type de données
string
Alias
- UMLS CUI 2011AA
- C0232142
- SNOMED CT 2011_0131
- 65452004
- MedDRA 14.1
- 10053935
Description
Pulses R/L: femoral
Type de données
string
Alias
- UMLS CUI 2011AA
- C0232148
- SNOMED CT 2011_0131
- 67316000
- MedDRA 14.1
- 10053932
Description
Pulses R/L: popliteal
Type de données
string
Alias
- UMLS CUI 2011AA
- C0232151
- SNOMED CT 2011_0131
- 74828005
- MedDRA 14.1
- 10053938
Description
Pulses R/L: posterior tibial
Type de données
string
Alias
- UMLS CUI 2011AA
- C1720310
- SNOMED CT 2011_0131
- 421568004
Description
Pulses R/L: dorsalis pedis
Type de données
string
Alias
- UMLS CUI 2011AA
- C1706488
- SNOMED CT 2011_0131
- 421811005
Description
Physical Exam - ABDOMEN
Description
soft, flat, nontender with normal bowel sounds. no organomegaly, no ascites, no palpable mass, no hernia.
Type de données
boolean
Alias
- UMLS CUI 2011AA
- C0000726
- SNOMED CT 2011_0131
- 113345001
- LOINC Version 232
- MTHU001425
Description
Appearance
Type de données
string
Description
Bowel sounds
Type de données
string
Alias
- UMLS CUI 2011AA
- C0232693
- SNOMED CT 2011_0131
- 87042004
- MedDRA 14.1
- 10006023
Description
Midepigastric bruit
Type de données
string
Description
Abdominal tenderness
Type de données
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
Description
Rebound
Type de données
string
Description
Liver
Type de données
string
Alias
- UMLS CUI 2011AA
- C0023884
- SNOMED CT 2011_0131
- 10200004
- LOINC Version 232
- MTHU002039
Description
Spleen
Type de données
string
Alias
- UMLS CUI 2011AA
- C0037993
- SNOMED CT 2011_0131
- 78961009
- LOINC Version 232
- MTHU012104
Description
Hernia
Type de données
string
Alias
- UMLS CUI 2011AA
- C0019270
- SNOMED CT 2011_0131
- 414403008
- MedDRA 14.1
- 10019909
- ICD-10-CM Version 2010
- K40-K46
Description
Physical Exam - GENITOURINARY/RECTAL: MALE
Description
GU Assessment
Type de données
string
Alias
- UMLS CUI 2011AA
- C0042066
- SNOMED CT 2011_0131
- 21514008
- LOINC Version 232
- MTHU013232
Description
Urine appears
Type de données
string
Alias
- UMLS CUI 2011AA
- C0042036
- SNOMED CT 2011_0131
- 78014005
- LOINC Version 232
- MTHU001343
Description
Urine is adequate
Type de données
string
Alias
- UMLS CUI 2011AA
- C0042036
- SNOMED CT 2011_0131
- 78014005
- LOINC Version 232
- MTHU001343
Description
Urine Output [ml]
Type de données
integer
Alias
- UMLS CUI 2011AA
- C1287298
- SNOMED CT 2011_0131
- 365678000
- MedDRA 14.1
- 10059894
- LOINC Version 232
- MTHU024573
Description
Foley catheter
Type de données
string
Alias
- UMLS CUI 2011AA
- C0179804
- MedDRA 14.1
- 10016892
Description
Suprapubic catheter
Type de données
string
Alias
- UMLS CUI 2011AA
- C0150798
- SNOMED CT 2011_0131
- 286861005
Description
scrotal contents
Type de données
string
Description
Penis
Type de données
string
Alias
- UMLS CUI 2011AA
- C0030851
- SNOMED CT 2011_0131
- 18911002
- LOINC Version 232
- MTHU004206
Description
rectal: sphincter tone
Type de données
string
Description
hemorrhoids
Type de données
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
Description
Prostate
Type de données
string
Alias
- UMLS CUI 2011AA
- C0033572
- SNOMED CT 2011_0131
- 41216001
- LOINC Version 232
- MTHU004957
Description
mass
Type de données
string
Description
Physical Exam - GENITOURINARY/RECTAL: FEMALE
Description
GU Assessment FEMALE
Type de données
string
Alias
- UMLS CUI 2011AA
- C0042066
- SNOMED CT 2011_0131
- 21514008
- LOINC Version 232
- MTHU013232
Description
Urine appears
Type de données
string
Alias
- UMLS CUI 2011AA
- C0042036
- SNOMED CT 2011_0131
- 78014005
- LOINC Version 232
- MTHU001343
Description
Urine is adequate
Type de données
string
Alias
- UMLS CUI 2011AA
- C0042036
- SNOMED CT 2011_0131
- 78014005
- LOINC Version 232
- MTHU001343
Description
Urine Output [ml]
Type de données
integer
Alias
- UMLS CUI 2011AA
- C1287298
- SNOMED CT 2011_0131
- 365678000
- MedDRA 14.1
- 10059894
- LOINC Version 232
- MTHU024573
Description
Foley catheter
Type de données
string
Alias
- UMLS CUI 2011AA
- C0179804
- MedDRA 14.1
- 10016892
Description
Suprapubic catheter
Type de données
string
Alias
- UMLS CUI 2011AA
- C0150798
- SNOMED CT 2011_0131
- 286861005
Description
External genitalia
Type de données
string
Alias
- UMLS CUI 2011AA
- C0227605
- SNOMED CT 2011_0131
- 77142006
Description
Urethra
Type de données
string
Alias
- UMLS CUI 2011AA
- C0041967
- SNOMED CT 2011_0131
- 264255005
- LOINC Version 232
- MTHU001321
Description
Vagina
Type de données
string
Alias
- UMLS CUI 2011AA
- C0042232
- SNOMED CT 2011_0131
- 76784001
- LOINC Version 232
- MTHU014732
Description
Bladder
Type de données
string
Alias
- UMLS CUI 2011AA
- C0005682
- SNOMED CT 2011_0131
- 89837001
- LOINC Version 232
- MTHU002918
Description
Cervix
Type de données
string
Alias
- UMLS CUI 2011AA
- C0007874
- SNOMED CT 2011_0131
- 71252005
- LOINC Version 232
- MTHU001800
Description
Uterus
Type de données
string
Alias
- UMLS CUI 2011AA
- C0042149
- SNOMED CT 2011_0131
- 35039007
- LOINC Version 232
- MTHU002943
Description
adnexa
Type de données
string
Alias
- UMLS CUI 2011AA
- C0001575
- SNOMED CT 2011_0131
- 23043003
- LOINC Version 232
- MTHU015033
Description
rectal: sphincter tone
Type de données
string
Description
hemorrhoids
Type de données
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
Description
mass
Type de données
string
Description
Physical Exam -MUSCULOSKELETAL
Description
MUSCULOSKELETAL
Type de données
string
Alias
- UMLS CUI 2011AA
- C0026860
- SNOMED CT 2011_0131
- 26107004
- LOINC Version 232
- MTHU001411
Description
Gait
Type de données
string
Alias
- UMLS CUI 2011AA
- C0016928
- SNOMED CT 2011_0131
- 63448001
- LOINC Version 232
- MTHU015039
Description
Station
Type de données
string
Description
Digits
Type de données
string
Alias
- UMLS CUI 2011AA
- C0582802
- SNOMED CT 2011_0131
- 82680008
- LOINC Version 232
- MTHU015035
Description
Nails
Type de données
string
Alias
- UMLS CUI 2011AA
- C0027342
- SNOMED CT 2011_0131
- 72651009
- LOINC Version 232
- MTHU002041
Description
Joints, Bones, Muscles
Type de données
string
Alias
- UMLS CUI 2011AA
- C0022417, C0262950, C0026845
- SNOMED CT 2011_0131
- 39352004, 272673000, 71616004
Description
Head & Neck
Type de données
string
Alias
- UMLS CUI 2011AA
- C0018670, C0027530
- SNOMED CT 2011_0131
- 69536005, 45048000
Description
Spine/Ribs/Pelvis
Type de données
string
Description
Right Shoulder
Type de données
string
Alias
- UMLS CUI 2011AA
- C0037004
- SNOMED CT 2011_0131
- 16982005
- LOINC Version 232
- MTHU002689
Description
Right Elbow
Type de données
string
Alias
- UMLS CUI 2011AA
- C0013769
- SNOMED CT 2011_0131
- 127949000
- LOINC Version 232
- MTHU002674
Description
Right Wrist
Type de données
string
Alias
- UMLS CUI 2011AA
- C0043262
- SNOMED CT 2011_0131
- 8205005
- LOINC Version 232
- MTHU002691
Description
Left Shoulder
Type de données
string
Alias
- UMLS CUI 2011AA
- C0037004
- SNOMED CT 2011_0131
- 16982005
- LOINC Version 232
- MTHU002689
Description
Left Elbow
Type de données
string
Alias
- UMLS CUI 2011AA
- C0013769
- SNOMED CT 2011_0131
- 127949000
- LOINC Version 232
- MTHU002674
Description
Left Wrist
Type de données
string
Alias
- UMLS CUI 2011AA
- C0043262
- SNOMED CT 2011_0131
- 8205005
- LOINC Version 232
- MTHU002691
Description
Right Hip
Type de données
string
Alias
- UMLS CUI 2011AA
- C0019552
- SNOMED CT 2011_0131
- 24136001
- LOINC Version 232
- MTHU002686
Description
Right Knee
Type de données
string
Alias
- UMLS CUI 2011AA
- C0022742
- SNOMED CT 2011_0131
- 304679005
- LOINC Version 232
- MTHU002687
Description
Right Ankle
Type de données
string
Alias
- UMLS CUI 2011AA
- C0003086
- SNOMED CT 2011_0131
- 344001
Description
Left Hip
Type de données
string
Alias
- UMLS CUI 2011AA
- C0019552
- SNOMED CT 2011_0131
- 24136001
- LOINC Version 232
- MTHU002686
Description
Left Knee
Type de données
string
Alias
- UMLS CUI 2011AA
- C0022742
- SNOMED CT 2011_0131
- 304679005
- LOINC Version 232
- MTHU002687
Description
Left Ankle
Type de données
string
Alias
- UMLS CUI 2011AA
- C0003086
- SNOMED CT 2011_0131
- 344001
Description
Physical Exam - EXTREMITIES
Description
Significant for:
Type de données
string
Description
pitting edema
Type de données
string
Alias
- UMLS CUI 2011AA
- C0333243
- SNOMED CT 2011_0131
- 139248000
Description
pretibial: R / L
Type de données
string
Description
ankle: R / L
Type de données
string
Alias
- UMLS CUI 2011AA
- C0003086
- SNOMED CT 2011_0131
- 344001
Description
foot: R / L
Type de données
string
Alias
- UMLS CUI 2011AA
- C0016504
- SNOMED CT 2011_0131
- 56459004
- LOINC Version 232
- MTHU002679
Description
Pulses R/L: posterior tibial
Type de données
string
Alias
- UMLS CUI 2011AA
- C1720310
- SNOMED CT 2011_0131
- 421568004
Description
Pulses R/L: dorsalis pedis
Type de données
string
Alias
- UMLS CUI 2011AA
- C1706488
- SNOMED CT 2011_0131
- 421811005
Description
capillary fill time R/L
Type de données
string
Description
sensation by monofilament test R/L
Type de données
string
Description
toenails
Type de données
string
Description
skin
Type de données
string
Alias
- UMLS CUI 2011AA
- C1123023
- SNOMED CT 2011_0131
- 39937001
- LOINC Version 232
- MTHU001414
Description
Physical Exam - LYMPHATIC
Description
no adenopathy
Type de données
boolean
Description
adenopathy
Type de données
string
Alias
- UMLS CUI 2011AA
- C1706304
Description
neck
Type de données
string
Alias
- UMLS CUI 2011AA
- C0027530
- SNOMED CT 2011_0131
- 45048000
- LOINC Version 232
- MTHU002688
Description
Axilla
Type de données
string
Alias
- UMLS CUI 2011AA
- C0004454
- SNOMED CT 2011_0131
- 91470000
- LOINC Version 232
- MTHU002668
Description
groin
Type de données
string
Alias
- UMLS CUI 2011AA
- C0018246
- SNOMED CT 2011_0131
- 26893007
- LOINC Version 232
- MTHU002684
Description
other
Type de données
string
Description
Physical Exam - SKIN
Description
Inspection and palpation of skin and subcutaneous tissue reveals no acute rashes, lesions, or induration.
Type de données
boolean
Alias
- UMLS CUI 2011AA
- C1123023
- SNOMED CT 2011_0131
- 39937001
- LOINC Version 232
- MTHU001414
Description
inspection
Type de données
string
Alias
- UMLS CUI 2011AA
- C0199219
- SNOMED CT 2011_0131
- 32750006
Description
Palpation
Type de données
string
Alias
- UMLS CUI 2011AA
- C0030247
- SNOMED CT 2011_0131
- 113011001
Description
Physical Exam - Wound and Incision Care
Description
WOUND #
Type de données
string
Alias
- UMLS CUI 2011AA
- C0043250
- SNOMED CT 2011_0131
- 13924000
- MedDRA 14.1
- 10052428
- LOINC Version 232
- MTHU001326
Description
WOUND LOCATION
Type de données
string
Description
WOUND MEASUREMENT (Length, Width, Depth [cm])
Type de données
string
Description
UNDERMINING Wound
Type de données
boolean
Description
TUNNELING Wound
Type de données
boolean
Description
SURROUNDING SKIN: WOUND BASE
Type de données
string
Description
SENSATION
Type de données
string
Alias
- UMLS CUI 2011AA
- C0036658
- SNOMED CT 2011_0131
- 373713005
- LOINC Version 232
- MTHU017277
Description
EXUDATE
Type de données
string
Alias
- UMLS CUI 2011AA
- C0015388
- SNOMED CT 2011_0131
- 247450001
- LOINC Version 232
- MTHU025016
Description
COLOR OF DRAINAGE
Type de données
string
Description
ODOR: Before Cleaning
Type de données
boolean
Description
ODOR: After Cleaning
Type de données
boolean
Description
CLEANSED WITH/IRRIGATED WITH
Type de données
string
Description
WOUND MED applied
Type de données
string
Description
FILLED WITH
Type de données
string
Description
COVERED WITH
Type de données
string
Description
SECURED WITH
Type de données
string
Description
PRESSURE RELIEF
Type de données
string
Description
COMMENTS
Type de données
string
Description
PHOTOGRAPH DATE
Type de données
date
Description
NARRATIVE
Type de données
string
Alias
- UMLS CUI 2011AA
- C1135957
Description
INCISION #
Type de données
string
Alias
- UMLS CUI 2011AA
- C0184898
- SNOMED CT 2011_0131
- 34896006
Description
LOCATION
Type de données
string
Alias
- UMLS CUI 2011AA
- C0450429
- SNOMED CT 2011_0131
- 246267002
Description
CLOSURE TYPE
Type de données
string
Description
DRESSING TYPE
Type de données
string
Description
DRESSING APPEARANCE
Type de données
string
Description
DRAINS
Type de données
string
Alias
- UMLS CUI 2011AA
- C0180499
- SNOMED CT 2011_0131
- 32712000
- LOINC Version 232
- MTHU022515
Description
NARRATIVE
Type de données
string
Alias
- UMLS CUI 2011AA
- C1135957
Description
Physical Exam - NEUROLOGIC
Description
Oriented x 3, cranial nerves 2-12 intact, no gross sensory or motor deficits, reflexes symmetric, no cerebellar signs, no involuntary movements
Type de données
boolean
Alias
- UMLS CUI 2011AA
- C0027763
- SNOMED CT 2011_0131
- 25087005
- LOINC Version 232
- MTHU001437
Description
Conciousness
Type de données
string
Alias
- UMLS CUI 2011AA
- C0234421
- SNOMED CT 2011_0131
- 106167005
Description
Responsive to
Type de données
string
Description
Orientation
Type de données
string
Alias
- UMLS CUI 2011AA
- C0029266
- SNOMED CT 2011_0131
- 43173001
Description
Proverb
Type de données
string
Description
Writing
Type de données
string
Alias
- UMLS CUI 2011AA
- C2584304
- SNOMED CT 2011_0131
- 12261009
Description
Reading
Type de données
string
Alias
- UMLS CUI 2011AA
- C0034754
- SNOMED CT 2011_0131
- 50360004
Description
Memory
Type de données
string
Alias
- UMLS CUI 2011AA
- C0025260
- SNOMED CT 2011_0131
- 303116000
- LOINC Version 232
- MTHU021129
Description
Registration
Type de données
string
Description
Naming Intact
Type de données
string
Description
Speech
Type de données
string
Alias
- UMLS CUI 2011AA
- C0037817
- SNOMED CT 2011_0131
- 87335007
- LOINC Version 232
- MTHU021528
Description
OTHER
Type de données
string
Description
Score normal
Type de données
boolean
Description
Concentration normal
Type de données
boolean
Description
Cranial nerves normal
Type de données
boolean
Description
Comment
Type de données
string
Description
Motor tone
Type de données
string
Alias
- UMLS CUI 2011AA
- C0026841
- MedDRA 14.1
- 10070541
- LOINC Version 232
- MTHU015024
Description
Motor strength R/L
Type de données
string
Alias
- UMLS CUI 2011AA
- C0517349
Description
Grip R/L
Type de données
string
Alias
- UMLS CUI 2011AA
- C0220843
Description
Biceps R/L
Type de données
string
Alias
- UMLS CUI 2011AA
- C0559499
- SNOMED CT 2011_0131
- 16225001
- LOINC Version 232
- MTHU014778
Description
Triceps R/L
Type de données
string
Alias
- UMLS CUI 2011AA
- C0559502
- SNOMED CT 2011_0131
- 40284004
- LOINC Version 232
- MTHU014783
Description
Quadriceps R/L
Type de données
string
Alias
- UMLS CUI 2011AA
- C0224440
- SNOMED CT 2011_0131
- 21989003
Description
Hip Extensors R/L
Type de données
string
Description
Dorsiflexion R/L
Type de données
string
Description
Plantarflexion R/L
Type de données
string
Description
Sensation
Type de données
string
Alias
- UMLS CUI 2011AA
- C0036658
- SNOMED CT 2011_0131
- 373713005
- LOINC Version 232
- MTHU017277
Description
Pin prick
Type de données
string
Alias
- UMLS CUI 2011AA
- C0423557
- SNOMED CT 2011_0131
- 247315008
Description
Comment
Type de données
string
Description
Light touch
Type de données
string
Description
Vibration
Type de données
string
Alias
- UMLS CUI 2011AA
- C0459800
- SNOMED CT 2011_0131
- 33679000
- LOINC Version 232
- MTHU021537
Description
Comment
Type de données
string
Description
Position Sense
Type de données
string
Alias
- UMLS CUI 2011AA
- C0234219
- SNOMED CT 2011_0131
- 73535003
Description
Temperature
Type de données
string
Alias
- UMLS CUI 2011AA
- C0039476
- SNOMED CT 2011_0131
- 246508008
- LOINC Version 232
- MTHU009008
Description
Stereognosis
Type de données
string
Alias
- UMLS CUI 2011AA
- C0038263
- SNOMED CT 2011_0131
- 22382001
Description
Deep Tendon Reflexes Biceps R/L
Type de données
string
Alias
- UMLS CUI 2011AA
- C0234151
- SNOMED CT 2011_0131
- 30901003
Description
Deep Tendon Reflexes Triceps R/L
Type de données
string
Alias
- UMLS CUI 2011AA
- C0422908
- SNOMED CT 2011_0131
- 271716008
Description
Deep Tendon Reflexes Brachioradialis R/L
Type de données
string
Description
Deep Tendon Reflexes Patellar R/L
Type de données
string
Alias
- UMLS CUI 2011AA
- C0234147
- SNOMED CT 2011_0131
- 271714006
Description
Deep Tendon Reflexes Achilles R/L
Type de données
string
Description
Abnormal reflexes
Type de données
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
Description
Involuntary Movements
Type de données
string
Alias
- UMLS CUI 2011AA
- C0427086
- SNOMED CT 2011_0131
- 267078001
- MedDRA 14.1
- 10028042
- CTCAE 1105E
- E12728
Description
Cerebellar Signs
Type de données
string
Alias
- UMLS CUI 2011AA
- C0742038
Description
Gait
Type de données
string
Alias
- UMLS CUI 2011AA
- C0016928
- SNOMED CT 2011_0131
- 63448001
- LOINC Version 232
- MTHU015039
Description
Comment
Type de données
string
Description
Station
Type de données
string
Description
PSYCHIATRIC
Description
Alert, oriented to person, place, and time, judgement and insight good, recent and remote memory intact, normal mood and affect.
Type de données
boolean
Description
Judgement & Insight
Type de données
string
Alias
- UMLS CUI 2011AA
- C0022423, C0233820
- SNOMED CT 2011_0131
- 61254005, 27026000
Description
Orientation
Type de données
string
Alias
- UMLS CUI 2011AA
- C0029266
- SNOMED CT 2011_0131
- 43173001
Description
Recent Memory
Type de données
string
Alias
- UMLS CUI 2011AA
- C0233792
- SNOMED CT 2011_0131
- 69063000
Description
Remote Memory
Type de données
string
Alias
- UMLS CUI 2011AA
- C0233793
- SNOMED CT 2011_0131
- 81964002
Description
Mood/Affect
Type de données
string
Alias
- UMLS CUI 2011AA
- C0026516, C0001721
- SNOMED CT 2011_0131
- 85256008, 4065008
- LOINC Version 232
- MTHU031584
Description
Laboratory Results
Description
Radiology Results
Description
ASSESSMENT
Description
acceptable for surgery
Type de données
boolean
Description
progressing well
Type de données
boolean
Description
stable medically
Type de données
boolean
Alias
- UMLS CUI 2011AA
- C0205360
- SNOMED CT 2011_0131
- 58158008
- LOINC Version 232
- MTHU015276
Description
Active Problems
Type de données
string
Alias
- UMLS CUI 2011AA
- C0552582
- LOINC Version 232
- LP73189-0
Description
Other
Type de données
string
Description
PLAN
Description
Continue Home Regimen
Type de données
boolean
Description
Continue Home Meds
Type de données
boolean
Description
Continue Chemotherapy
Type de données
boolean
Description
Continue IV Antibiotics
Type de données
boolean
Description
Continue PO Antibiotics
Type de données
boolean
Description
DVT Prophylaxis
Type de données
boolean
Alias
- UMLS CUI 2011AA
- C0853245
- MedDRA 14.1
- 10013880
Description
O2 Protocol
Type de données
boolean
Description
Follow Up X-Rays
Type de données
boolean
Description
UTI treatment
Type de données
boolean
Alias
- UMLS CUI 2011AA
- C0042029
- SNOMED CT 2011_0131
- 68566005
- MedDRA 14.1
- 10046577
Description
Monitor Blood Pressure and Heart Rate
Type de données
boolean
Description
Monitor Diabetes Mellitus
Type de données
boolean
Description
Accuchecks AC & HS
Type de données
boolean
Description
Accuchecks Q6H
Type de données
boolean
Description
Sliding Scale Regular Insulin
Type de données
boolean
Alias
- UMLS CUI 2011AA
- C0021641
- SNOMED CT 2011_0131
- 67866001
- LOINC Version 232
- MTHU019392
Description
Check Follow Up Labs
Type de données
boolean
Description
Appreciate following patient with you
Type de données
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)