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5508

Description

Form from HIS OpenVista

Keywords

Versions (6)
  1. 3/7/12 3/7/12 -
  2. 8/7/14 8/7/14 - Martin Dugas
  3. 8/9/14 8/9/14 - Martin Dugas
  4. 12/23/14 12/23/14 - Martin Dugas
  5. 6/25/15 6/25/15 - Martin Dugas
  6. 9/27/21 9/27/21 -
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August 7, 2014

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Creative Commons BY-NC 3.0 Legacy
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    HIS SHORT STAY RECORD ID NOTE-ENDO

    German English

    HIS

    1 forms  
    1. StudyEvent: HIS
      1. HIS
    SHORT STAY RECORD ID NOTE-ENDO
    Description

    SHORT STAY RECORD ID NOTE-ENDO

    Age
    Description

    Age

    Data type

    integer

    Alias
    UMLS CUI 2011AA
    C0001779
    SNOMED CT 2011_0131
    397669002
    Sex
    Description

    Sex

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C0079399
    SNOMED CT 2011_0131
    263495000
    LOINC Version 232
    MTHU002975
    Racial group
    Description

    Race

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C0034510
    SNOMED CT 2011_0131
    103579009
    LOINC Version 232
    MTHU009923
    Height
    Description

    Height

    Data type

    integer

    Alias
    UMLS CUI 2011AA
    C0489786
    LOINC Version 232
    MTHU005354
    Weight
    Description

    Weight

    Data type

    float

    Alias
    UMLS
    C0005910
    SNOMED CT 2011_0131
    107647005
    MedDRA 14.1
    10047890
    LOINC Version 232
    LP18015-5
    Hypersensitivity
    Description

    Allergies

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C0020517
    SNOMED CT 2011_0131
    257550005
    Chief complaint (CC)
    Description

    Chief complaint (CC)

    Abnormal GI Xray
    Description

    Abnormal GI Xray

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C0521362
    LOINC Version 232
    MTHU031867
    UMLS CUI 2011AA
    C0000766
    MedDRA 14.1
    10048065
    Abdominal Pain
    Description

    Abdominal Pain

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C0000737
    SNOMED CT 2011_0131
    21522001
    MedDRA 14.1
    10000081
    LOINC Version 232
    MTHU013636
    ICD-10-CM Version 2010
    R10.9
    ICD-9-CM Version 2011
    789.0
    CTCAE 1105E
    E10460
    Abnormal weight loss (finding)
    Description

    Abnormal Weight Loss

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C0936227
    SNOMED CT 2011_0131
    267024001
    MedDRA 14.1
    10000159
    ICD-10-CM Version 2010
    R63.4
    Achalasia
    Description

    Achalasia

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C1321756
    SNOMED CT 2011_0131
    48531003
    MedDRA 14.1
    10000420
    ICD-10-CM Version 2010
    K22.0
    Anaemia
    Description

    Anemia

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C0002871
    SNOMED CT 2011_0131
    271737000
    MedDRA 14.1
    10002034
    LOINC Version 232
    MTHU020823
    ICD-10-CM Version 2010
    D64.9
    ICD-9-CM Version 2011
    285.9
    CTCAE 1105E
    E10010
    Ascites
    Description

    Ascites

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C0003962
    SNOMED CT 2011_0131
    389026000
    MedDRA 14.1
    10003445
    ICD-10-CM Version 2010
    R18
    ICD-9-CM Version 2011
    789.5
    CTCAE 1105E
    E10502
    Irregular bowel habits
    Description

    Change in Bowel Habits

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C2919545
    SNOMED CT 2011_0131
    444702007
    Liver Cirrhosis
    Description

    Hepatic Cirrhosis

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C0023890
    SNOMED CT 2011_0131
    19943007
    MedDRA 14.1
    10019641
    ICD-10-CM Version 2010
    K74.60
    Screening for Colorectal Cancer
    Description

    Colorectal Cancer Screening

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C0281185
    Common Bile Duct Leak
    Description

    Common Bile Duct Leak

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C0009437
    SNOMED CT 2011_0131
    79741001
    LOINC Version 232
    MTHU011879
    UMLS CUI 2011AA
    CL382906
    Common Bile Duct Stone
    Description

    Common Bile Duct Stone

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C0009437
    SNOMED CT 2011_0131
    79741001
    LOINC Version 232
    MTHU011879
    UMLS CUI 2011AA
    C0006736
    SNOMED CT 2011_0131
    56381008
    LOINC Version 232
    MTHU003416
    Constipation
    Description

    Constipation

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C0009806
    SNOMED CT 2011_0131
    14760008
    MedDRA 14.1
    10010774
    LOINC Version 232
    MTHU020768
    ICD-10-CM Version 2010
    K59.0
    ICD-9-CM Version 2011
    564.0
    CTCAE 1105E
    E10562
    Diarrhea
    Description

    Diarrhea

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C0011991
    SNOMED CT 2011_0131
    62315008
    MedDRA 14.1
    10012735
    LOINC Version 232
    MTHU013347
    ICD-10-CM Version 2010
    R19.7
    ICD-9-CM Version 2011
    787.91
    CTCAE 1105E
    E10572
    Indigestion
    Description

    Dyspepsia

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C0013395
    SNOMED CT 2011_0131
    162031009
    MedDRA 14.1
    10013946
    ICD-10-CM Version 2010
    R10.13, K30
    CTCAE 1105E
    E10617
    Deglutition Disorders
    Description

    Dysphagia

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C0011168
    SNOMED CT 2011_0131
    40739000
    MedDRA 14.1
    10013950
    LOINC Version 232
    MTHU029874
    ICD-10-CM Version 2010
    R13
    ICD-9-CM Version 2011
    787.2
    CTCAE 1105E
    E10621
    Elevated Liver Function Tests
    Description

    Elevated Liver Function Tests

    Data type

    boolean

    Oesophageal Varices
    Description

    Esophageal Varices

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C0014867
    SNOMED CT 2011_0131
    28670008
    MedDRA 14.1
    10030209
    ICD-10-CM Version 2010
    I85
    Family History of Colon Cancer
    Description

    Family History of Colon Cancer

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C0241889
    SNOMED CT 2011_0131
    57177007
    UMLS CUI 2011AA
    C0699790
    SNOMED CT 2011_0131
    269533000
    MedDRA 14.1
    10009957
    Family History of Polyps
    Description

    Family History of Polyps

    Data type

    boolean

    Family History of Polyposis
    Description

    Family History of Polyposis

    Data type

    boolean

    Foreign Body in Colon
    Description

    Foreign Body in Colon

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C0016542
    SNOMED CT 2011_0131
    125670008
    MedDRA 14.1
    10070245
    UMLS CUI 2011AA
    C0009368
    SNOMED CT 2011_0131
    71854001
    LOINC Version 232
    MTHU003023
    Foreign Body in Esophagus
    Description

    Foreign Body in Esophagus

    Data type

    boolean

    Foreign Body in Stomach
    Description

    Foreign Body in Stomach

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C0016542
    SNOMED CT 2011_0131
    125670008
    MedDRA 14.1
    10070245
    UMLS CUI 2011AA
    C0038351
    SNOMED CT 2011_0131
    69695003
    LOINC Version 232
    MTHU003059
    Peptic Ulcer
    Description

    Gastric Ulcer

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C0030920
    SNOMED CT 2011_0131
    13200003
    MedDRA 14.1
    10034341
    ICD-10-CM Version 2010
    K27
    Gastroesophageal reflux disease (GERD)
    Description

    GERD

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C0017168
    SNOMED CT 2011_0131
    235595009
    MedDRA 14.1
    10017885
    ICD-10-CM Version 2010
    K21
    ICD-9-CM Version 2011
    530.81
    CTCAE 1105E
    E10739
    Gastrointestinal Hemorrhage
    Description

    GI Bleeding

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C0017181
    SNOMED CT 2011_0131
    74474003
    MedDRA 14.1
    10017955
    ICD-10-CM Version 2010
    K92.2
    ICD-9-CM Version 2011
    578
    Haematemesis
    Description

    Hematemesis

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C0018926
    SNOMED CT 2011_0131
    8765009
    MedDRA 14.1
    10018830
    ICD-10-CM Version 2010
    K92.0
    ICD-9-CM Version 2011
    578.0
    History of Barrett's
    Description

    History of Barrett's

    Data type

    boolean

    History of Cholangiocarcinoma
    Description

    History of Cholangiocarcinoma

    Data type

    boolean

    History of Colon Cancer
    Description

    History of Colon Cancer

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C0262926
    SNOMED CT 2011_0131
    417662000
    LOINC Version 232
    MTHU027722
    UMLS CUI 2011AA
    C0699790
    SNOMED CT 2011_0131
    269533000
    MedDRA 14.1
    10009957
    History of Crohn's Disease
    Description

    History of Crohn's Disease

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C0262926
    SNOMED CT 2011_0131
    417662000
    LOINC Version 232
    MTHU027722
    UMLS CUI 2011AA
    C0010346
    SNOMED CT 2011_0131
    34000006
    MedDRA 14.1
    10011401
    ICD-10-CM Version 2010
    K50.9
    History of Diverticulosis
    Description

    History of Diverticulosis

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C0262926
    SNOMED CT 2011_0131
    417662000
    LOINC Version 232
    MTHU027722
    UMLS CUI 2011AA
    C1510475
    SNOMED CT 2011_0131
    397881000
    MedDRA 14.1
    10013559
    ICD-10-CM Version 2010
    K57
    ICD-9-CM Version 2011
    562
    History of Esophageal Cancer
    Description

    History of Esophageal Cancer

    Data type

    boolean

    History of Esophageal/ Gastric Varicies
    Description

    History of Esophageal/ Gastric Varicies

    Data type

    boolean

    History of Gastric Cancer
    Description

    History of Gastric Cancer

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C0262926
    SNOMED CT 2011_0131
    417662000
    LOINC Version 232
    MTHU027722
    UMLS CUI 2011AA
    C0024623
    SNOMED CT 2011_0131
    363349007
    MedDRA 14.1
    10017758
    ICD-10-CM Version 2010
    C16
    ICD-9-CM Version 2011
    151
    History of Pancreatic Cancer
    Description

    History of Pancreatic Cancer

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C0262926
    SNOMED CT 2011_0131
    417662000
    LOINC Version 232
    MTHU027722
    UMLS CUI 2011AA
    C0346647
    SNOMED CT 2011_0131
    363418001
    MedDRA 14.1
    10033604
    ICD-10-CM Version 2010
    C25
    ICD-9-CM Version 2011
    157
    History of Peptic Ulcer Disease
    Description

    History of Peptic Ulcer Disease

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C0262926
    SNOMED CT 2011_0131
    417662000
    LOINC Version 232
    MTHU027722
    UMLS CUI 2011AA
    C0030920
    SNOMED CT 2011_0131
    13200003
    MedDRA 14.1
    10034341
    ICD-10-CM Version 2010
    K27
    ICD-9-CM Version 2011
    533
    History of Polyps
    Description

    History of Polyps

    Data type

    boolean

    History of Ulcerative Colitis
    Description

    History of Ulcerative Colitis

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C0262926
    SNOMED CT 2011_0131
    417662000
    LOINC Version 232
    MTHU027722
    UMLS CUI 2011AA
    C0302596
    SNOMED CT 2011_0131
    64766004
    MedDRA 14.1
    10009900
    ICD-10-CM Version 2010
    K51
    ICD-9-CM Version 2011
    556
    Blood in Stool
    Description

    Hematochezia

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C0018932
    SNOMED CT 2011_0131
    405729008
    MedDRA 14.1
    10018836
    ICD-9-CM Version 2011
    578.1
    Iron Deficiency Anaemia
    Description

    Iron Deficiency Anemia

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C0162316
    SNOMED CT 2011_0131
    87522002
    MedDRA 14.1
    10022972
    ICD-10-CM Version 2010
    D50.0
    ICD-9-CM Version 2011
    280
    Icterus
    Description

    Jaundice

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C0022346
    SNOMED CT 2011_0131
    18165001
    MedDRA 14.1
    10023126
    ICD-10-CM Version 2010
    R17
    Melaena
    Description

    Melena

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C0025222
    SNOMED CT 2011_0131
    2901004
    MedDRA 14.1
    10027141
    ICD-10-CM Version 2010
    K92.1
    Nausea
    Description

    Nausea

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C0027497
    SNOMED CT 2011_0131
    422587007
    MedDRA 14.1
    10028813
    LOINC Version 232
    MTHU013524
    ICD-10-CM Version 2010
    R11.0
    CTCAE 1105E
    E10878
    Emesis
    Description

    Vomiting

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C0042963
    SNOMED CT 2011_0131
    249497008
    MedDRA 14.1
    10047700
    LOINC Version 232
    MTHU013530
    ICD-10-CM Version 2010
    R11.1
    CTCAE 1105E
    E11068
    Occult/Guaiac Positive Stool
    Description

    Occult/Guaiac Positive Stool

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C0201811
    SNOMED CT 2011_0131
    104435004
    MedDRA 14.1
    10016297
    Pancreatitis
    Description

    Pancreatitis

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C0030305
    SNOMED CT 2011_0131
    75694006
    MedDRA 14.1
    10033645
    ICD-10-CM Version 2010
    K85.9
    ICD-9-CM Version 2011
    577.0
    CTCAE 1105E
    E10930
    Portal Hypertension
    Description

    Portal Hypertension

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C0020541
    SNOMED CT 2011_0131
    34742003
    MedDRA 14.1
    10036200
    ICD-10-CM Version 2010
    K76.6
    ICD-9-CM Version 2011
    572.3
    CTCAE 1105E
    E11238
    gastric reflux
    Description

    Gastroesophageal Reflux

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C0558176
    SNOMED CT 2011_0131
    225587003
    Abnormal weight loss
    Description

    Weight Loss

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C0936227
    SNOMED CT 2011_0131
    267024001
    MedDRA 14.1
    10000159
    ICD-10-CM Version 2010
    R63.4
    Other
    Description

    Other

    Data type

    string

    History of present illness
    Description

    HISTORY OF PRESENT ILLNESS

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C0262512
    LOINC Version 232
    MTHU001399
    Home Medications
    Description

    HOME MEDICATIONS

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C0013227
    Physical examination
    Description

    Physical examination

    Temperature
    Description

    Temperature

    Data type

    float

    Alias
    UMLS CUI 2011AA
    C0039476
    SNOMED CT 2011_0131
    246508008
    LOINC Version 232
    MTHU009008
    Pulse Rate
    Description

    Pulse

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C0232117
    SNOMED CT 2011_0131
    78564009
    MedDRA 14.1
    10037485
    Respiration rate, Breathing rate (BR)
    Description

    Respiration Rate

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C0231832
    SNOMED CT 2011_0131
    86290005
    MedDRA 14.1
    10038709
    LOINC Version 232
    MTHU008344
    Blood pressure (BP)
    Description

    Blood Pressure

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C0005823
    SNOMED CT 2011_0131
    75367002
    LOINC Version 232
    MTHU008342
    General Apperance unremarkable
    Description

    General Apperance unremarkable

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C1148438
    LOINC Version 232
    MTHU015040
    UMLS CUI 2011AA
    C0205307
    SNOMED CT 2011_0131
    17621005
    general appearance
    Description

    General Apperance text

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C1148438
    LOINC Version 232
    MTHU015040
    HEENT within normal limits
    Description

    HEENT within normal limits

    Data type

    boolean

    Head, Ears, Eyes, Nose and Throat
    Description

    HEENT text

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C1512338
    Neck supple, no jugular vein distention
    Description

    Neck supple, no jugular vein distention

    Data type

    boolean

    Neck, Collum, Cervical
    Description

    Neck text

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C0027530
    SNOMED CT 2011_0131
    45048000
    LOINC Version 232
    MTHU002688
    Chest, Thorax
    Description

    Chest

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C0817096
    SNOMED CT 2011_0131
    51185008
    Mammary region
    Description

    Breast

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C0006141
    SNOMED CT 2011_0131
    76752008
    LOINC Version 232
    MTHU011382
    Heart S1 S2 present, Regular rhythm and rate
    Description

    Heart S1 S2 present, Regular rhythm and rate

    Data type

    boolean

    Heart
    Description

    Heart text

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C0018787
    SNOMED CT 2011_0131
    80891009
    LOINC Version 232
    MTHU001067
    Abdomen Soft, (+) Bowel sounds, Normal tone
    Description

    Abdomen Soft, (+) Bowel sounds, Normal tone

    Data type

    boolean

    Abdomen
    Description

    Abdomen text

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C0000726
    SNOMED CT 2011_0131
    113345001
    LOINC Version 232
    MTHU001425
    Lymph Nodes not palpable
    Description

    Lymph Nodes not palpable

    Data type

    boolean

    lymph nodes
    Description

    Lymph Nodes text

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C0024204
    SNOMED CT 2011_0131
    59441001
    LOINC Version 232
    MTHU015050
    GENITALIA/RECTAL
    Description

    GENITALIA/RECTAL

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C0017420
    LOINC Version 232
    MTHU002681
    UMLS CUI 2011AA
    C0205052
    SNOMED CT 2011_0131
    255582007
    Extremities No clubbing, cyanosis or edema
    Description

    Extremities No clubbing, cyanosis or edema

    Data type

    boolean

    Extremities, Limb structure
    Description

    Extremities text

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C0015385
    SNOMED CT 2011_0131
    66019005
    LOINC Version 232
    MTHU001429
    Skin: No abnormalities detected
    Description

    Skin: No abnormalities detected

    Data type

    boolean

    Integument
    Description

    Skin text

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C1123023
    SNOMED CT 2011_0131
    39937001
    LOINC Version 232
    MTHU001414
    Neurological: No abnormalities detected
    Description

    Neurological: No abnormalities detected

    Data type

    boolean

    Neurologic system, Nervous system, Nervous system structure
    Description

    Neurological text

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C0027763
    SNOMED CT 2011_0131
    25087005
    LOINC Version 232
    MTHU001437
    ADMITTING DIAGNOSIS (AD)
    Description

    ADMITTING DIAGNOSIS

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C0332133
    SNOMED CT 2011_0131
    52870002
    PLAN: Endoscopy
    Description

    PLAN: Endoscopy

    Data type

    string

    ASA score, Finding of American Society of Anesthesiologists physical status classification
    Description

    ASA SCORE

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C1531480
    SNOMED CT 2011_0131
    413347006
    Teeth
    Description

    TEETH

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C0040426
    SNOMED CT 2011_0131
    245543004
    LOINC Version 232
    MTHU021292
    Mallampati score
    Description

    MALLAMPATI AIRWAY SCORE

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C0451276
    SNOMED CT 2011_0131
    273585005
    NECK EXTENSION
    Description

    NECK EXTENSION

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C0027530
    SNOMED CT 2011_0131
    45048000
    LOINC Version 232
    MTHU002688
    UMLS CUI 2011AA
    C0231448
    SNOMED CT 2011_0131
    255536004
    LOINC Version 232
    MTHU010348
    past medical History, prior medical History
    Description

    past medical History, prior medical History

    past medical History, prior medical History
    Description

    Medical History

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C0262926
    SNOMED CT 2011_0131
    417662000
    LOINC Version 232
    MTHU027722
    Prior Surgery, History of (H/O) surgery, Past surgical history
    Description

    Prior Surgeries

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C0455610
    SNOMED CT 2011_0131
    161615003
    Family history (FH)
    Description

    Family history

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C0241889
    SNOMED CT 2011_0131
    57177007
    Social and personal history, Social and personal circumstances
    Description

    Social history

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C0424945
    SNOMED CT 2011_0131
    160476009
    LOINC Version 232
    MTHU014081
    Back to the top of the page

    Similar models

    HIS

    1 forms
    1. StudyEvent: HIS
      1. HIS
    Name
    Type
    Description | Question | Decode (Coded Value)
    Data type
    Alias
    Item Group
    SHORT STAY RECORD ID NOTE-ENDO
    Age
    Item
    Age
    integer
    C0001779 (UMLS CUI 2011AA)
    397669002 (SNOMED CT 2011_0131)
    Item
    Sex
    string
    C0079399 (UMLS CUI 2011AA)
    263495000 (SNOMED CT 2011_0131)
    MTHU002975 (LOINC Version 232)
    Sex
    Code List
    Sex
    CL Item
    male (1)
    C0024554 (UMLS CUI 2011AA)
    248153007 (SNOMED CT 2011_0131)
    M (HL7 V3 2006_05)
    CL Item
    female (2)
    C0015780 (UMLS CUI 2011AA)
    248152002 (SNOMED CT 2011_0131)
    F (HL7 V3 2006_05)
    Race
    Item
    Racial group
    string
    C0034510 (UMLS CUI 2011AA)
    103579009 (SNOMED CT 2011_0131)
    MTHU009923 (LOINC Version 232)
    Height
    Item
    Height
    integer
    C0489786 (UMLS CUI 2011AA)
    MTHU005354 (LOINC Version 232)
    Weight
    Item
    Weight
    float
    C0005910 (UMLS)
    107647005 (SNOMED CT 2011_0131)
    10047890 (MedDRA 14.1)
    LP18015-5 (LOINC Version 232)
    Allergies
    Item
    Hypersensitivity
    string
    C0020517 (UMLS CUI 2011AA)
    257550005 (SNOMED CT 2011_0131)
    Item Group
    Chief complaint (CC)
    Abnormal GI Xray
    Item
    Abnormal GI Xray
    boolean
    C0521362 (UMLS CUI 2011AA)
    MTHU031867 (LOINC Version 232)
    C0000766 (UMLS CUI 2011AA)
    10048065 (MedDRA 14.1)
    Abdominal Pain
    Item
    Abdominal Pain
    boolean
    C0000737 (UMLS CUI 2011AA)
    21522001 (SNOMED CT 2011_0131)
    10000081 (MedDRA 14.1)
    MTHU013636 (LOINC Version 232)
    R10.9 (ICD-10-CM Version 2010)
    789.0 (ICD-9-CM Version 2011)
    E10460 (CTCAE 1105E)
    Abnormal Weight Loss
    Item
    Abnormal weight loss (finding)
    boolean
    C0936227 (UMLS CUI 2011AA)
    267024001 (SNOMED CT 2011_0131)
    10000159 (MedDRA 14.1)
    R63.4 (ICD-10-CM Version 2010)
    Achalasia
    Item
    Achalasia
    boolean
    C1321756 (UMLS CUI 2011AA)
    48531003 (SNOMED CT 2011_0131)
    10000420 (MedDRA 14.1)
    K22.0 (ICD-10-CM Version 2010)
    Anemia
    Item
    Anaemia
    boolean
    C0002871 (UMLS CUI 2011AA)
    271737000 (SNOMED CT 2011_0131)
    10002034 (MedDRA 14.1)
    MTHU020823 (LOINC Version 232)
    D64.9 (ICD-10-CM Version 2010)
    285.9 (ICD-9-CM Version 2011)
    E10010 (CTCAE 1105E)
    Ascites
    Item
    Ascites
    boolean
    C0003962 (UMLS CUI 2011AA)
    389026000 (SNOMED CT 2011_0131)
    10003445 (MedDRA 14.1)
    R18 (ICD-10-CM Version 2010)
    789.5 (ICD-9-CM Version 2011)
    E10502 (CTCAE 1105E)
    Change in Bowel Habits
    Item
    Irregular bowel habits
    boolean
    C2919545 (UMLS CUI 2011AA)
    444702007 (SNOMED CT 2011_0131)
    Hepatic Cirrhosis
    Item
    Liver Cirrhosis
    boolean
    C0023890 (UMLS CUI 2011AA)
    19943007 (SNOMED CT 2011_0131)
    10019641 (MedDRA 14.1)
    K74.60 (ICD-10-CM Version 2010)
    Colorectal Cancer Screening
    Item
    Screening for Colorectal Cancer
    boolean
    C0281185 (UMLS CUI 2011AA)
    Common Bile Duct Leak
    Item
    Common Bile Duct Leak
    boolean
    C0009437 (UMLS CUI 2011AA)
    79741001 (SNOMED CT 2011_0131)
    MTHU011879 (LOINC Version 232)
    CL382906 (UMLS CUI 2011AA)
    Common Bile Duct Stone
    Item
    Common Bile Duct Stone
    boolean
    C0009437 (UMLS CUI 2011AA)
    79741001 (SNOMED CT 2011_0131)
    MTHU011879 (LOINC Version 232)
    C0006736 (UMLS CUI 2011AA)
    56381008 (SNOMED CT 2011_0131)
    MTHU003416 (LOINC Version 232)
    Constipation
    Item
    Constipation
    boolean
    C0009806 (UMLS CUI 2011AA)
    14760008 (SNOMED CT 2011_0131)
    10010774 (MedDRA 14.1)
    MTHU020768 (LOINC Version 232)
    K59.0 (ICD-10-CM Version 2010)
    564.0 (ICD-9-CM Version 2011)
    E10562 (CTCAE 1105E)
    Diarrhea
    Item
    Diarrhea
    boolean
    C0011991 (UMLS CUI 2011AA)
    62315008 (SNOMED CT 2011_0131)
    10012735 (MedDRA 14.1)
    MTHU013347 (LOINC Version 232)
    R19.7 (ICD-10-CM Version 2010)
    787.91 (ICD-9-CM Version 2011)
    E10572 (CTCAE 1105E)
    Dyspepsia
    Item
    Indigestion
    boolean
    C0013395 (UMLS CUI 2011AA)
    162031009 (SNOMED CT 2011_0131)
    10013946 (MedDRA 14.1)
    R10.13, K30 (ICD-10-CM Version 2010)
    E10617 (CTCAE 1105E)
    Dysphagia
    Item
    Deglutition Disorders
    boolean
    C0011168 (UMLS CUI 2011AA)
    40739000 (SNOMED CT 2011_0131)
    10013950 (MedDRA 14.1)
    MTHU029874 (LOINC Version 232)
    R13 (ICD-10-CM Version 2010)
    787.2 (ICD-9-CM Version 2011)
    E10621 (CTCAE 1105E)
    Elevated Liver Function Tests
    Item
    Elevated Liver Function Tests
    boolean
    Esophageal Varices
    Item
    Oesophageal Varices
    boolean
    C0014867 (UMLS CUI 2011AA)
    28670008 (SNOMED CT 2011_0131)
    10030209 (MedDRA 14.1)
    I85 (ICD-10-CM Version 2010)
    Family History of Colon Cancer
    Item
    Family History of Colon Cancer
    boolean
    C0241889 (UMLS CUI 2011AA)
    57177007 (SNOMED CT 2011_0131)
    C0699790 (UMLS CUI 2011AA)
    269533000 (SNOMED CT 2011_0131)
    10009957 (MedDRA 14.1)
    Family History of Polyps
    Item
    Family History of Polyps
    boolean
    Family History of Polyposis
    Item
    Family History of Polyposis
    boolean
    Foreign Body in Colon
    Item
    Foreign Body in Colon
    boolean
    C0016542 (UMLS CUI 2011AA)
    125670008 (SNOMED CT 2011_0131)
    10070245 (MedDRA 14.1)
    C0009368 (UMLS CUI 2011AA)
    71854001 (SNOMED CT 2011_0131)
    MTHU003023 (LOINC Version 232)
    Foreign Body in Esophagus
    Item
    Foreign Body in Esophagus
    boolean
    Foreign Body in Stomach
    Item
    Foreign Body in Stomach
    boolean
    C0016542 (UMLS CUI 2011AA)
    125670008 (SNOMED CT 2011_0131)
    10070245 (MedDRA 14.1)
    C0038351 (UMLS CUI 2011AA)
    69695003 (SNOMED CT 2011_0131)
    MTHU003059 (LOINC Version 232)
    Gastric Ulcer
    Item
    Peptic Ulcer
    boolean
    C0030920 (UMLS CUI 2011AA)
    13200003 (SNOMED CT 2011_0131)
    10034341 (MedDRA 14.1)
    K27 (ICD-10-CM Version 2010)
    GERD
    Item
    Gastroesophageal reflux disease (GERD)
    boolean
    C0017168 (UMLS CUI 2011AA)
    235595009 (SNOMED CT 2011_0131)
    10017885 (MedDRA 14.1)
    K21 (ICD-10-CM Version 2010)
    530.81 (ICD-9-CM Version 2011)
    E10739 (CTCAE 1105E)
    GI Bleeding
    Item
    Gastrointestinal Hemorrhage
    boolean
    C0017181 (UMLS CUI 2011AA)
    74474003 (SNOMED CT 2011_0131)
    10017955 (MedDRA 14.1)
    K92.2 (ICD-10-CM Version 2010)
    578 (ICD-9-CM Version 2011)
    Hematemesis
    Item
    Haematemesis
    boolean
    C0018926 (UMLS CUI 2011AA)
    8765009 (SNOMED CT 2011_0131)
    10018830 (MedDRA 14.1)
    K92.0 (ICD-10-CM Version 2010)
    578.0 (ICD-9-CM Version 2011)
    History of Barrett's
    Item
    History of Barrett's
    boolean
    History of Cholangiocarcinoma
    Item
    History of Cholangiocarcinoma
    boolean
    History of Colon Cancer
    Item
    History of Colon Cancer
    boolean
    C0262926 (UMLS CUI 2011AA)
    417662000 (SNOMED CT 2011_0131)
    MTHU027722 (LOINC Version 232)
    C0699790 (UMLS CUI 2011AA)
    269533000 (SNOMED CT 2011_0131)
    10009957 (MedDRA 14.1)
    History of Crohn's Disease
    Item
    History of Crohn's Disease
    boolean
    C0262926 (UMLS CUI 2011AA)
    417662000 (SNOMED CT 2011_0131)
    MTHU027722 (LOINC Version 232)
    C0010346 (UMLS CUI 2011AA)
    34000006 (SNOMED CT 2011_0131)
    10011401 (MedDRA 14.1)
    K50.9 (ICD-10-CM Version 2010)
    History of Diverticulosis
    Item
    History of Diverticulosis
    boolean
    C0262926 (UMLS CUI 2011AA)
    417662000 (SNOMED CT 2011_0131)
    MTHU027722 (LOINC Version 232)
    C1510475 (UMLS CUI 2011AA)
    397881000 (SNOMED CT 2011_0131)
    10013559 (MedDRA 14.1)
    K57 (ICD-10-CM Version 2010)
    562 (ICD-9-CM Version 2011)
    History of Esophageal Cancer
    Item
    History of Esophageal Cancer
    boolean
    History of Esophageal/ Gastric Varicies
    Item
    History of Esophageal/ Gastric Varicies
    boolean
    History of Gastric Cancer
    Item
    History of Gastric Cancer
    boolean
    C0262926 (UMLS CUI 2011AA)
    417662000 (SNOMED CT 2011_0131)
    MTHU027722 (LOINC Version 232)
    C0024623 (UMLS CUI 2011AA)
    363349007 (SNOMED CT 2011_0131)
    10017758 (MedDRA 14.1)
    C16 (ICD-10-CM Version 2010)
    151 (ICD-9-CM Version 2011)
    History of Pancreatic Cancer
    Item
    History of Pancreatic Cancer
    boolean
    C0262926 (UMLS CUI 2011AA)
    417662000 (SNOMED CT 2011_0131)
    MTHU027722 (LOINC Version 232)
    C0346647 (UMLS CUI 2011AA)
    363418001 (SNOMED CT 2011_0131)
    10033604 (MedDRA 14.1)
    C25 (ICD-10-CM Version 2010)
    157 (ICD-9-CM Version 2011)
    History of Peptic Ulcer Disease
    Item
    History of Peptic Ulcer Disease
    boolean
    C0262926 (UMLS CUI 2011AA)
    417662000 (SNOMED CT 2011_0131)
    MTHU027722 (LOINC Version 232)
    C0030920 (UMLS CUI 2011AA)
    13200003 (SNOMED CT 2011_0131)
    10034341 (MedDRA 14.1)
    K27 (ICD-10-CM Version 2010)
    533 (ICD-9-CM Version 2011)
    History of Polyps
    Item
    History of Polyps
    boolean
    History of Ulcerative Colitis
    Item
    History of Ulcerative Colitis
    boolean
    C0262926 (UMLS CUI 2011AA)
    417662000 (SNOMED CT 2011_0131)
    MTHU027722 (LOINC Version 232)
    C0302596 (UMLS CUI 2011AA)
    64766004 (SNOMED CT 2011_0131)
    10009900 (MedDRA 14.1)
    K51 (ICD-10-CM Version 2010)
    556 (ICD-9-CM Version 2011)
    Hematochezia
    Item
    Blood in Stool
    boolean
    C0018932 (UMLS CUI 2011AA)
    405729008 (SNOMED CT 2011_0131)
    10018836 (MedDRA 14.1)
    578.1 (ICD-9-CM Version 2011)
    Iron Deficiency Anemia
    Item
    Iron Deficiency Anaemia
    boolean
    C0162316 (UMLS CUI 2011AA)
    87522002 (SNOMED CT 2011_0131)
    10022972 (MedDRA 14.1)
    D50.0 (ICD-10-CM Version 2010)
    280 (ICD-9-CM Version 2011)
    Jaundice
    Item
    Icterus
    boolean
    C0022346 (UMLS CUI 2011AA)
    18165001 (SNOMED CT 2011_0131)
    10023126 (MedDRA 14.1)
    R17 (ICD-10-CM Version 2010)
    Melena
    Item
    Melaena
    boolean
    C0025222 (UMLS CUI 2011AA)
    2901004 (SNOMED CT 2011_0131)
    10027141 (MedDRA 14.1)
    K92.1 (ICD-10-CM Version 2010)
    Nausea
    Item
    Nausea
    boolean
    C0027497 (UMLS CUI 2011AA)
    422587007 (SNOMED CT 2011_0131)
    10028813 (MedDRA 14.1)
    MTHU013524 (LOINC Version 232)
    R11.0 (ICD-10-CM Version 2010)
    E10878 (CTCAE 1105E)
    Vomiting
    Item
    Emesis
    boolean
    C0042963 (UMLS CUI 2011AA)
    249497008 (SNOMED CT 2011_0131)
    10047700 (MedDRA 14.1)
    MTHU013530 (LOINC Version 232)
    R11.1 (ICD-10-CM Version 2010)
    E11068 (CTCAE 1105E)
    Occult/Guaiac Positive Stool
    Item
    Occult/Guaiac Positive Stool
    boolean
    C0201811 (UMLS CUI 2011AA)
    104435004 (SNOMED CT 2011_0131)
    10016297 (MedDRA 14.1)
    Pancreatitis
    Item
    Pancreatitis
    boolean
    C0030305 (UMLS CUI 2011AA)
    75694006 (SNOMED CT 2011_0131)
    10033645 (MedDRA 14.1)
    K85.9 (ICD-10-CM Version 2010)
    577.0 (ICD-9-CM Version 2011)
    E10930 (CTCAE 1105E)
    Portal Hypertension
    Item
    Portal Hypertension
    boolean
    C0020541 (UMLS CUI 2011AA)
    34742003 (SNOMED CT 2011_0131)
    10036200 (MedDRA 14.1)
    K76.6 (ICD-10-CM Version 2010)
    572.3 (ICD-9-CM Version 2011)
    E11238 (CTCAE 1105E)
    Gastroesophageal Reflux
    Item
    gastric reflux
    boolean
    C0558176 (UMLS CUI 2011AA)
    225587003 (SNOMED CT 2011_0131)
    Weight Loss
    Item
    Abnormal weight loss
    boolean
    C0936227 (UMLS CUI 2011AA)
    267024001 (SNOMED CT 2011_0131)
    10000159 (MedDRA 14.1)
    R63.4 (ICD-10-CM Version 2010)
    Other
    Item
    Other
    string
    HISTORY OF PRESENT ILLNESS
    Item
    History of present illness
    string
    C0262512 (UMLS CUI 2011AA)
    MTHU001399 (LOINC Version 232)
    HOME MEDICATIONS
    Item
    Home Medications
    string
    C0013227 (UMLS CUI 2011AA)
    Item Group
    Physical examination
    Temperature
    Item
    Temperature
    float
    C0039476 (UMLS CUI 2011AA)
    246508008 (SNOMED CT 2011_0131)
    MTHU009008 (LOINC Version 232)
    Pulse
    Item
    Pulse Rate
    string
    C0232117 (UMLS CUI 2011AA)
    78564009 (SNOMED CT 2011_0131)
    10037485 (MedDRA 14.1)
    Respiration Rate
    Item
    Respiration rate, Breathing rate (BR)
    string
    C0231832 (UMLS CUI 2011AA)
    86290005 (SNOMED CT 2011_0131)
    10038709 (MedDRA 14.1)
    MTHU008344 (LOINC Version 232)
    Blood Pressure
    Item
    Blood pressure (BP)
    string
    C0005823 (UMLS CUI 2011AA)
    75367002 (SNOMED CT 2011_0131)
    MTHU008342 (LOINC Version 232)
    General Apperance unremarkable
    Item
    General Apperance unremarkable
    boolean
    C1148438 (UMLS CUI 2011AA)
    MTHU015040 (LOINC Version 232)
    C0205307 (UMLS CUI 2011AA)
    17621005 (SNOMED CT 2011_0131)
    General Apperance text
    Item
    general appearance
    string
    C1148438 (UMLS CUI 2011AA)
    MTHU015040 (LOINC Version 232)
    HEENT within normal limits
    Item
    HEENT within normal limits
    boolean
    HEENT text
    Item
    Head, Ears, Eyes, Nose and Throat
    string
    C1512338 (UMLS CUI 2011AA)
    Neck supple, no jugular vein distention
    Item
    Neck supple, no jugular vein distention
    boolean
    Neck text
    Item
    Neck, Collum, Cervical
    string
    C0027530 (UMLS CUI 2011AA)
    45048000 (SNOMED CT 2011_0131)
    MTHU002688 (LOINC Version 232)
    Chest
    Item
    Chest, Thorax
    string
    C0817096 (UMLS CUI 2011AA)
    51185008 (SNOMED CT 2011_0131)
    Breast
    Item
    Mammary region
    string
    C0006141 (UMLS CUI 2011AA)
    76752008 (SNOMED CT 2011_0131)
    MTHU011382 (LOINC Version 232)
    Heart S1 S2 present, Regular rhythm and rate
    Item
    Heart S1 S2 present, Regular rhythm and rate
    boolean
    Heart text
    Item
    Heart
    string
    C0018787 (UMLS CUI 2011AA)
    80891009 (SNOMED CT 2011_0131)
    MTHU001067 (LOINC Version 232)
    Abdomen Soft, (+) Bowel sounds, Normal tone
    Item
    Abdomen Soft, (+) Bowel sounds, Normal tone
    boolean
    Abdomen text
    Item
    Abdomen
    string
    C0000726 (UMLS CUI 2011AA)
    113345001 (SNOMED CT 2011_0131)
    MTHU001425 (LOINC Version 232)
    Lymph Nodes not palpable
    Item
    Lymph Nodes not palpable
    boolean
    Lymph Nodes text
    Item
    lymph nodes
    string
    C0024204 (UMLS CUI 2011AA)
    59441001 (SNOMED CT 2011_0131)
    MTHU015050 (LOINC Version 232)
    GENITALIA/RECTAL
    Item
    GENITALIA/RECTAL
    string
    C0017420 (UMLS CUI 2011AA)
    MTHU002681 (LOINC Version 232)
    C0205052 (UMLS CUI 2011AA)
    255582007 (SNOMED CT 2011_0131)
    Extremities No clubbing, cyanosis or edema
    Item
    Extremities No clubbing, cyanosis or edema
    boolean
    Extremities text
    Item
    Extremities, Limb structure
    string
    C0015385 (UMLS CUI 2011AA)
    66019005 (SNOMED CT 2011_0131)
    MTHU001429 (LOINC Version 232)
    Skin: No abnormalities detected
    Item
    Skin: No abnormalities detected
    boolean
    Skin text
    Item
    Integument
    string
    C1123023 (UMLS CUI 2011AA)
    39937001 (SNOMED CT 2011_0131)
    MTHU001414 (LOINC Version 232)
    Neurological: No abnormalities detected
    Item
    Neurological: No abnormalities detected
    boolean
    Neurological text
    Item
    Neurologic system, Nervous system, Nervous system structure
    string
    C0027763 (UMLS CUI 2011AA)
    25087005 (SNOMED CT 2011_0131)
    MTHU001437 (LOINC Version 232)
    ADMITTING DIAGNOSIS
    Item
    ADMITTING DIAGNOSIS (AD)
    string
    C0332133 (UMLS CUI 2011AA)
    52870002 (SNOMED CT 2011_0131)
    PLAN: Endoscopy
    Item
    PLAN: Endoscopy
    string
    ASA SCORE
    Item
    ASA score, Finding of American Society of Anesthesiologists physical status classification
    string
    C1531480 (UMLS CUI 2011AA)
    413347006 (SNOMED CT 2011_0131)
    Item
    Teeth
    string
    C0040426 (UMLS CUI 2011AA)
    245543004 (SNOMED CT 2011_0131)
    MTHU021292 (LOINC Version 232)
    TEETH
    Code List
    Teeth
    CL Item
    Normal (1)
    C0205307 (UMLS CUI 2011AA)
    17621005 (SNOMED CT 2011_0131)
    CL Item
    Loose Teeth (2)
    CL Item
    Dental Prosthesis(es) (3)
    C0011394 (UMLS CUI 2011AA)
    8060009 (SNOMED CT 2011_0131)
    CL Item
    Co-Existing Dental Abnormalities (4)
    Item
    Mallampati score
    string
    C0451276 (UMLS CUI 2011AA)
    273585005 (SNOMED CT 2011_0131)
    MALLAMPATI AIRWAY SCORE
    Code List
    Mallampati score
    CL Item
    The soft palate, uvula, fauces, and pillars are visible (Class 1)
    CL Item
    The soft palate, uvula and fauces are visible (Class 2)
    CL Item
    The soft palate and base of uvula are visible (Class 3)
    CL Item
    The hard palate only is visible (Class 4)
    NECK EXTENSION
    Item
    NECK EXTENSION
    string
    C0027530 (UMLS CUI 2011AA)
    45048000 (SNOMED CT 2011_0131)
    MTHU002688 (LOINC Version 232)
    C0231448 (UMLS CUI 2011AA)
    255536004 (SNOMED CT 2011_0131)
    MTHU010348 (LOINC Version 232)
    Item Group
    past medical History, prior medical History
    Medical History
    Item
    past medical History, prior medical History
    string
    C0262926 (UMLS CUI 2011AA)
    417662000 (SNOMED CT 2011_0131)
    MTHU027722 (LOINC Version 232)
    Prior Surgeries
    Item
    Prior Surgery, History of (H/O) surgery, Past surgical history
    string
    C0455610 (UMLS CUI 2011AA)
    161615003 (SNOMED CT 2011_0131)
    Family history
    Item
    Family history (FH)
    string
    C0241889 (UMLS CUI 2011AA)
    57177007 (SNOMED CT 2011_0131)
    Social history
    Item
    Social and personal history, Social and personal circumstances
    string
    C0424945 (UMLS CUI 2011AA)
    160476009 (SNOMED CT 2011_0131)
    MTHU014081 (LOINC Version 232)
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