ID
5512
Beschreibung
Form from HIS OpenVistA
Stichworte
Versionen (4)
- 23.02.12 23.02.12 -
- 07.08.14 07.08.14 - Martin Dugas
- 07.08.14 07.08.14 - Martin Dugas
- 26.06.15 26.06.15 - Martin Dugas
Hochgeladen am
7. August 2014
DOI
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HIS H and P or consult specialty
HIS
- StudyEvent: HIS
Beschreibung
HISTORY OF PRESENT ILLNESS
Beschreibung
HISTORY OF PRESENT ILLNESS (HPI, include location, quality, severity, duration, timing, context, modifying factors & associated signs/symptoms)
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0262512
- LOINC Version 232
- MTHU001399
Beschreibung
SOURCE(S) OF HISTORY
Datentyp
integer
Beschreibung
SOURCE(S) OF HISTORY comment
Datentyp
string
Beschreibung
REVIEW OF SYSTEMS
Beschreibung
PAST HISTORY
Beschreibung
Adult Illness
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0277562
- SNOMED CT 2011_0131
- 64342008
Beschreibung
History of childhood diseases
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0489532
- LOINC Version 232
- MTHU001066
Beschreibung
Surgeries
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0455610
- SNOMED CT 2011_0131
- 161615003
Beschreibung
Injury
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0175677
- SNOMED CT 2011_0131
- 417746004
- MedDRA 14.1
- 10022116
- ICD-10-CM Version 2010
- T14.9
Beschreibung
Female Specific History
Beschreibung
Date of last menstrual period
Datentyp
date
Alias
- UMLS CUI 2011AA
- C0425932
- SNOMED CT 2011_0131
- 21840007
- LOINC Version 232
- MTHU024536
Beschreibung
Date of last PAP
Datentyp
date
Beschreibung
last PAP Results
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0079104
- MedDRA 14.1
- 10041205
Beschreibung
Date of last MMG
Datentyp
date
Beschreibung
last MMG Results
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0024671
- SNOMED CT 2011_0131
- 71651007
- MedDRA 14.1
- 10026735
Beschreibung
Age at menarche
Datentyp
integer
Alias
- UMLS CUI 2011AA
- C1314691
- SNOMED CT 2011_0131
- 398700009
- LOINC Version 232
- MTHU018825
Beschreibung
Describe Menses
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0025344
- SNOMED CT 2011_0131
- 248957007
Beschreibung
Birth Control
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0700589
- SNOMED CT 2011_0131
- 146680009
- MedDRA 14.1
- 10010808
Beschreibung
Pregnancies
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0032961
- SNOMED CT 2011_0131
- 289908002
- MedDRA 14.1
- 10036556
- LOINC Version 232
- MTHU035048
Beschreibung
Abortions
Datentyp
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
Beschreibung
Number of full term pregnancies
Datentyp
integer
Beschreibung
Number of spontaneous abortions
Datentyp
integer
Beschreibung
Number of therapeutic abortions
Datentyp
integer
Beschreibung
Number of other types Abortions
Datentyp
integer
Beschreibung
Age at first pregnancy
Datentyp
integer
Beschreibung
FAMILY HISTORY
Beschreibung
SOCIAL HISTORY
Beschreibung
ALLERGIES
Beschreibung
MEDICATIONS
Beschreibung
Inpatient medications
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0013227
Beschreibung
Active medications
Datentyp
string
Alias
- UMLS CUI 2011AA
- C1553892
Beschreibung
Home medications
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0013227
Beschreibung
PHYSICAL EXAM - General
Beschreibung
VITALS
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0518766
- SNOMED CT 2011_0131
- 46680005
- LOINC Version 232
- MTHU024540
Beschreibung
TEMPERATURE
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0039476
- SNOMED CT 2011_0131
- 246508008
- LOINC Version 232
- MTHU009008
Beschreibung
PULSE
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0232117
- SNOMED CT 2011_0131
- 78564009
- MedDRA 14.1
- 10037485
Beschreibung
RESPIRATION rate
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0231832
- SNOMED CT 2011_0131
- 86290005
- MedDRA 14.1
- 10038709
- LOINC Version 232
- MTHU008344
Beschreibung
BLOOD PRESSURE
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0005823
- SNOMED CT 2011_0131
- 75367002
- LOINC Version 232
- MTHU008342
Beschreibung
Pain
Datentyp
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
Beschreibung
Weight
Datentyp
integer
Alias
- UMLS
- C0005910
- SNOMED CT 2011_0131
- 107647005
- MedDRA 14.1
- 10047890
- LOINC Version 232
- LP18015-5
Beschreibung
GENERAL
Datentyp
string
Beschreibung
PHYSICAL EXAM - HEAD
Beschreibung
PHYSICAL EXAM - EYES
Beschreibung
EYES
Datentyp
boolean
Alias
- UMLS CUI 2011AA
- C0015392
- SNOMED CT 2011_0131
- 81745001
- LOINC Version 232
- MTHU000064
Beschreibung
Pupils
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0034121
- SNOMED CT 2011_0131
- 392406005
- LOINC Version 232
- MTHU015063
Beschreibung
Conjunctivae
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0009758
- SNOMED CT 2011_0131
- 29445007
- LOINC Version 232
- MTHU009301
Beschreibung
Sclerae
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0036410
- SNOMED CT 2011_0131
- 18619003
- LOINC Version 232
- MTHU015068
Beschreibung
EOM
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0028863
- SNOMED CT 2011_0131
- 67833000
- LOINC Version 232
- MTHU015037
Beschreibung
Funduscopic
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0029090
- SNOMED CT 2011_0131
- 274798009
- MedDRA 14.1
- 10017519
Beschreibung
Physical Exam - Ears, Nose, Throat
Beschreibung
Ear canals patent. TM's intact. Nares patent and pink without epistaxis. Mucosa pink. No pharyngitis. Natural dentition.
Datentyp
boolean
Beschreibung
EAR R ext canal
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0013444
- SNOMED CT 2011_0131
- 84301002
- LOINC Version 232
- MTHU015034
Beschreibung
EAR R tympanic membrane (TM)
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0041445
- SNOMED CT 2011_0131
- 42859004
- LOINC Version 232
- MTHU014731
Beschreibung
EAR L ext canal
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0013444
- SNOMED CT 2011_0131
- 84301002
- LOINC Version 232
- MTHU015034
Beschreibung
EAR L tympanic membrane (TM)
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0041445
- SNOMED CT 2011_0131
- 42859004
- LOINC Version 232
- MTHU014731
Beschreibung
NOSE Septum
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0027432
- SNOMED CT 2011_0131
- 68426009
- LOINC Version 232
- MTHU015054
Beschreibung
Nose Mucosa
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0027428
- SNOMED CT 2011_0131
- 34508005
Beschreibung
Nose R Nares
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0595944
- SNOMED CT 2011_0131
- 1797002
- LOINC Version 232
- MTHU015056
Beschreibung
Nose L Nares
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0595944
- SNOMED CT 2011_0131
- 1797002
- LOINC Version 232
- MTHU015056
Beschreibung
Throat: Mouth mucosa
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0026639
- SNOMED CT 2011_0131
- 113277000
Beschreibung
Pharynx
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0031354
- SNOMED CT 2011_0131
- 54066008
- LOINC Version 232
- MTHU015061
Beschreibung
Tonsils
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0836921
- LOINC Version 232
- MTHU015077
Beschreibung
Dentition
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0011443
- SNOMED CT 2011_0131
- 245543004
- LOINC Version 232
- MTHU014794
Beschreibung
Physical Exam - Neck
Beschreibung
supple, no JVD, no carotid bruits, trachea midline, no thyromegaly, no adenopathy
Datentyp
boolean
Alias
- UMLS CUI 2011AA
- C0027530
- SNOMED CT 2011_0131
- 45048000
- LOINC Version 232
- MTHU002688
Beschreibung
Adenopathy
Datentyp
string
Alias
- UMLS CUI 2011AA
- C1706304
- ICD-10-CM Version 2010
- R59
Beschreibung
Carotid bruit
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0007280
- SNOMED CT 2011_0131
- 419642000
- MedDRA 14.1
- 10048777
Beschreibung
JVD
Datentyp
string
Alias
- UMLS CUI 2011AA
- C1719935
- SNOMED CT 2011_0131
- 422008005
Beschreibung
Thyroid gland
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0040132
- SNOMED CT 2011_0131
- 69748006
- LOINC Version 232
- MTHU007792
Beschreibung
Trachea
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0040578
- SNOMED CT 2011_0131
- 44567001
- LOINC Version 232
- MTHU009117
Beschreibung
Physical Exam - BREAST
Beschreibung
symmetric without masses
Datentyp
boolean
Alias
- UMLS CUI 2011AA
- C0006141
- SNOMED CT 2011_0131
- 76752008
- LOINC Version 232
- MTHU011382
Beschreibung
inspection: Right breast
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0006141
- SNOMED CT 2011_0131
- 76752008
- LOINC Version 232
- MTHU011382
Beschreibung
inspection: Right nipple
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0028109
- SNOMED CT 2011_0131
- 24142002
Beschreibung
inspection: Left breast
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0006141
- SNOMED CT 2011_0131
- 76752008
- LOINC Version 232
- MTHU011382
Beschreibung
inspection: Left nipple
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0028109
- SNOMED CT 2011_0131
- 24142002
Beschreibung
palpation: Right breast
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0006141
- SNOMED CT 2011_0131
- 76752008
- LOINC Version 232
- MTHU011382
Beschreibung
palpation: Right nipple
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0028109
- SNOMED CT 2011_0131
- 24142002
Beschreibung
palpation: Left breast
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0006141
- SNOMED CT 2011_0131
- 76752008
- LOINC Version 232
- MTHU011382
Beschreibung
palpation: Left nipple
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0028109
- SNOMED CT 2011_0131
- 24142002
Beschreibung
Physical Exam - CHEST
Beschreibung
normal for inspection, percussion, palpation, and auscultation of the lungs.
Datentyp
boolean
Beschreibung
Chest significant for:
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0817096
- SNOMED CT 2011_0131
- 51185008
Beschreibung
Location
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0450429
- SNOMED CT 2011_0131
- 246267002
Beschreibung
Additional lung sounds
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0035234
- SNOMED CT 2011_0131
- 52653008
- MedDRA 14.1
- 10064779
Beschreibung
Location
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0450429
- SNOMED CT 2011_0131
- 246267002
Beschreibung
Physical Exam - HEART
Beschreibung
PMI at 5th intercostal space, mid clavicular line, normal S1,S2 without murmur or gallop
Datentyp
boolean
Alias
- UMLS CUI 2011AA
- C0018787
- SNOMED CT 2011_0131
- 80891009
- LOINC Version 232
- MTHU001067
Beschreibung
Palpation: PMI is
Datentyp
string
Beschreibung
Rhythm
Datentyp
string
Beschreibung
Heart Sounds: S1 is , S2 is, S3 is, S4 is
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0018820
- SNOMED CT 2011_0131
- 23472005
Beschreibung
PE HEART RUB TEXT
Datentyp
string
Beschreibung
PE HEART OTHER SOUNDS TEXT
Datentyp
string
Beschreibung
Murmur: grade
Datentyp
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
Beschreibung
Murmur heard best at
Datentyp
string
Beschreibung
Murmur radiates
Datentyp
string
Beschreibung
Heart - OTHER1
Datentyp
string
Beschreibung
Physical Exam - VASCULAR
Beschreibung
Pulses present and equal bilat.
Datentyp
boolean
Beschreibung
Aorta
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0003483
- SNOMED CT 2011_0131
- 15825003
- LOINC Version 232
- MTHU003021
Beschreibung
Pulses R/L: carotid
Datentyp
string
Alias
- UMLS CUI 2011AA
- C1096529
- MedDRA 14.1
- 10053926
Beschreibung
Pulses R/L: brachial
Datentyp
string
Alias
- UMLS CUI 2011AA
- C1096531
- MedDRA 14.1
- 10053929
Beschreibung
Pulses R/L: radial
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0232142
- SNOMED CT 2011_0131
- 65452004
- MedDRA 14.1
- 10053935
Beschreibung
Pulses R/L: femoral
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0232148
- SNOMED CT 2011_0131
- 67316000
- MedDRA 14.1
- 10053932
Beschreibung
Pulses R/L: popliteal
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0232151
- SNOMED CT 2011_0131
- 74828005
- MedDRA 14.1
- 10053938
Beschreibung
Pulses R/L: posterior tibial
Datentyp
string
Alias
- UMLS CUI 2011AA
- C1720310
- SNOMED CT 2011_0131
- 421568004
Beschreibung
Pulses R/L: dorsalis pedis
Datentyp
string
Alias
- UMLS CUI 2011AA
- C1706488
- SNOMED CT 2011_0131
- 421811005
Beschreibung
Physical Exam - ABDOMEN
Beschreibung
soft, flat, nontender with normal bowel sounds. no organomegaly, no ascites, no palpable mass, no hernia.
Datentyp
boolean
Alias
- UMLS CUI 2011AA
- C0000726
- SNOMED CT 2011_0131
- 113345001
- LOINC Version 232
- MTHU001425
Beschreibung
Appearance
Datentyp
string
Beschreibung
Bowel sounds
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0232693
- SNOMED CT 2011_0131
- 87042004
- MedDRA 14.1
- 10006023
Beschreibung
Midepigastric bruit
Datentyp
string
Beschreibung
Abdominal tenderness
Datentyp
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
Beschreibung
Rebound
Datentyp
string
Beschreibung
Liver
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0023884
- SNOMED CT 2011_0131
- 10200004
- LOINC Version 232
- MTHU002039
Beschreibung
Spleen
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0037993
- SNOMED CT 2011_0131
- 78961009
- LOINC Version 232
- MTHU012104
Beschreibung
Hernia
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0019270
- SNOMED CT 2011_0131
- 414403008
- MedDRA 14.1
- 10019909
- ICD-10-CM Version 2010
- K40-K46
Beschreibung
Physical Exam - GENITOURINARY/RECTAL: MALE
Beschreibung
GU Assessment
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0042066
- SNOMED CT 2011_0131
- 21514008
- LOINC Version 232
- MTHU013232
Beschreibung
Urine appears
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0042036
- SNOMED CT 2011_0131
- 78014005
- LOINC Version 232
- MTHU001343
Beschreibung
Urine is adequate
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0042036
- SNOMED CT 2011_0131
- 78014005
- LOINC Version 232
- MTHU001343
Beschreibung
Urine Output [ml]
Datentyp
integer
Alias
- UMLS CUI 2011AA
- C1287298
- SNOMED CT 2011_0131
- 365678000
- MedDRA 14.1
- 10059894
- LOINC Version 232
- MTHU024573
Beschreibung
Foley catheter
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0179804
- MedDRA 14.1
- 10016892
Beschreibung
Suprapubic catheter
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0150798
- SNOMED CT 2011_0131
- 286861005
Beschreibung
scrotal contents
Datentyp
string
Beschreibung
Penis
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0030851
- SNOMED CT 2011_0131
- 18911002
- LOINC Version 232
- MTHU004206
Beschreibung
rectal: sphincter tone
Datentyp
string
Beschreibung
hemorrhoids
Datentyp
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
Beschreibung
Prostate
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0033572
- SNOMED CT 2011_0131
- 41216001
- LOINC Version 232
- MTHU004957
Beschreibung
mass
Datentyp
string
Beschreibung
Physical Exam - GENITOURINARY/RECTAL: FEMALE
Beschreibung
GU Assessment FEMALE
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0042066
- SNOMED CT 2011_0131
- 21514008
- LOINC Version 232
- MTHU013232
Beschreibung
Urine appears
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0042036
- SNOMED CT 2011_0131
- 78014005
- LOINC Version 232
- MTHU001343
Beschreibung
Urine is adequate
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0042036
- SNOMED CT 2011_0131
- 78014005
- LOINC Version 232
- MTHU001343
Beschreibung
Urine Output [ml]
Datentyp
integer
Alias
- UMLS CUI 2011AA
- C1287298
- SNOMED CT 2011_0131
- 365678000
- MedDRA 14.1
- 10059894
- LOINC Version 232
- MTHU024573
Beschreibung
Foley catheter
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0179804
- MedDRA 14.1
- 10016892
Beschreibung
Suprapubic catheter
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0150798
- SNOMED CT 2011_0131
- 286861005
Beschreibung
External genitalia
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0227605
- SNOMED CT 2011_0131
- 77142006
Beschreibung
Urethra
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0041967
- SNOMED CT 2011_0131
- 264255005
- LOINC Version 232
- MTHU001321
Beschreibung
Vagina
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0042232
- SNOMED CT 2011_0131
- 76784001
- LOINC Version 232
- MTHU014732
Beschreibung
Bladder
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0005682
- SNOMED CT 2011_0131
- 89837001
- LOINC Version 232
- MTHU002918
Beschreibung
Cervix
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0007874
- SNOMED CT 2011_0131
- 71252005
- LOINC Version 232
- MTHU001800
Beschreibung
Uterus
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0042149
- SNOMED CT 2011_0131
- 35039007
- LOINC Version 232
- MTHU002943
Beschreibung
adnexa
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0001575
- SNOMED CT 2011_0131
- 23043003
- LOINC Version 232
- MTHU015033
Beschreibung
rectal: sphincter tone
Datentyp
string
Beschreibung
hemorrhoids
Datentyp
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
Beschreibung
mass
Datentyp
string
Beschreibung
Physical Exam -MUSCULOSKELETAL
Beschreibung
MUSCULOSKELETAL
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0026860
- SNOMED CT 2011_0131
- 26107004
- LOINC Version 232
- MTHU001411
Beschreibung
Gait
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0016928
- SNOMED CT 2011_0131
- 63448001
- LOINC Version 232
- MTHU015039
Beschreibung
Station
Datentyp
string
Beschreibung
Digits
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0582802
- SNOMED CT 2011_0131
- 82680008
- LOINC Version 232
- MTHU015035
Beschreibung
Nails
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0027342
- SNOMED CT 2011_0131
- 72651009
- LOINC Version 232
- MTHU002041
Beschreibung
Joints, Bones, Muscles
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0022417, C0262950, C0026845
- SNOMED CT 2011_0131
- 39352004, 272673000, 71616004
Beschreibung
Head & Neck
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0018670, C0027530
- SNOMED CT 2011_0131
- 69536005, 45048000
Beschreibung
Spine/Ribs/Pelvis
Datentyp
string
Beschreibung
Right Shoulder
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0037004
- SNOMED CT 2011_0131
- 16982005
- LOINC Version 232
- MTHU002689
Beschreibung
Right Elbow
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0013769
- SNOMED CT 2011_0131
- 127949000
- LOINC Version 232
- MTHU002674
Beschreibung
Right Wrist
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0043262
- SNOMED CT 2011_0131
- 8205005
- LOINC Version 232
- MTHU002691
Beschreibung
Left Shoulder
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0037004
- SNOMED CT 2011_0131
- 16982005
- LOINC Version 232
- MTHU002689
Beschreibung
Left Elbow
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0013769
- SNOMED CT 2011_0131
- 127949000
- LOINC Version 232
- MTHU002674
Beschreibung
Left Wrist
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0043262
- SNOMED CT 2011_0131
- 8205005
- LOINC Version 232
- MTHU002691
Beschreibung
Right Hip
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0019552
- SNOMED CT 2011_0131
- 24136001
- LOINC Version 232
- MTHU002686
Beschreibung
Right Knee
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0022742
- SNOMED CT 2011_0131
- 304679005
- LOINC Version 232
- MTHU002687
Beschreibung
Right Ankle
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0003086
- SNOMED CT 2011_0131
- 344001
Beschreibung
Left Hip
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0019552
- SNOMED CT 2011_0131
- 24136001
- LOINC Version 232
- MTHU002686
Beschreibung
Left Knee
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0022742
- SNOMED CT 2011_0131
- 304679005
- LOINC Version 232
- MTHU002687
Beschreibung
Left Ankle
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0003086
- SNOMED CT 2011_0131
- 344001
Beschreibung
Physical Exam - EXTREMITIES
Beschreibung
Significant for:
Datentyp
string
Beschreibung
pitting edema
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0333243
- SNOMED CT 2011_0131
- 139248000
Beschreibung
pretibial: R / L
Datentyp
string
Beschreibung
ankle: R / L
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0003086
- SNOMED CT 2011_0131
- 344001
Beschreibung
foot: R / L
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0016504
- SNOMED CT 2011_0131
- 56459004
- LOINC Version 232
- MTHU002679
Beschreibung
Pulses R/L: posterior tibial
Datentyp
string
Alias
- UMLS CUI 2011AA
- C1720310
- SNOMED CT 2011_0131
- 421568004
Beschreibung
Pulses R/L: dorsalis pedis
Datentyp
string
Alias
- UMLS CUI 2011AA
- C1706488
- SNOMED CT 2011_0131
- 421811005
Beschreibung
capillary fill time R/L
Datentyp
string
Beschreibung
sensation by monofilament test R/L
Datentyp
string
Beschreibung
toenails
Datentyp
string
Beschreibung
skin
Datentyp
string
Alias
- UMLS CUI 2011AA
- C1123023
- SNOMED CT 2011_0131
- 39937001
- LOINC Version 232
- MTHU001414
Beschreibung
Physical Exam - LYMPHATIC
Beschreibung
no adenopathy
Datentyp
boolean
Beschreibung
adenopathy
Datentyp
string
Alias
- UMLS CUI 2011AA
- C1706304
Beschreibung
neck
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0027530
- SNOMED CT 2011_0131
- 45048000
- LOINC Version 232
- MTHU002688
Beschreibung
Axilla
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0004454
- SNOMED CT 2011_0131
- 91470000
- LOINC Version 232
- MTHU002668
Beschreibung
groin
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0018246
- SNOMED CT 2011_0131
- 26893007
- LOINC Version 232
- MTHU002684
Beschreibung
other
Datentyp
string
Beschreibung
Physical Exam - SKIN
Beschreibung
Inspection and palpation of skin and subcutaneous tissue reveals no acute rashes, lesions, or induration.
Datentyp
boolean
Alias
- UMLS CUI 2011AA
- C1123023
- SNOMED CT 2011_0131
- 39937001
- LOINC Version 232
- MTHU001414
Beschreibung
inspection
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0199219
- SNOMED CT 2011_0131
- 32750006
Beschreibung
Palpation
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0030247
- SNOMED CT 2011_0131
- 113011001
Beschreibung
Physical Exam - Wound and Incision Care
Beschreibung
WOUND #
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0043250
- SNOMED CT 2011_0131
- 13924000
- MedDRA 14.1
- 10052428
- LOINC Version 232
- MTHU001326
Beschreibung
WOUND LOCATION
Datentyp
string
Beschreibung
WOUND MEASUREMENT (Length, Width, Depth [cm])
Datentyp
string
Beschreibung
UNDERMINING Wound
Datentyp
boolean
Beschreibung
TUNNELING Wound
Datentyp
boolean
Beschreibung
SURROUNDING SKIN: WOUND BASE
Datentyp
string
Beschreibung
SENSATION
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0036658
- SNOMED CT 2011_0131
- 373713005
- LOINC Version 232
- MTHU017277
Beschreibung
EXUDATE
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0015388
- SNOMED CT 2011_0131
- 247450001
- LOINC Version 232
- MTHU025016
Beschreibung
COLOR OF DRAINAGE
Datentyp
string
Beschreibung
ODOR: Before Cleaning
Datentyp
boolean
Beschreibung
ODOR: After Cleaning
Datentyp
boolean
Beschreibung
CLEANSED WITH/IRRIGATED WITH
Datentyp
string
Beschreibung
WOUND MED applied
Datentyp
string
Beschreibung
FILLED WITH
Datentyp
string
Beschreibung
COVERED WITH
Datentyp
string
Beschreibung
SECURED WITH
Datentyp
string
Beschreibung
PRESSURE RELIEF
Datentyp
string
Beschreibung
COMMENTS
Datentyp
string
Beschreibung
PHOTOGRAPH DATE
Datentyp
date
Beschreibung
NARRATIVE
Datentyp
string
Alias
- UMLS CUI 2011AA
- C1135957
Beschreibung
INCISION #
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0184898
- SNOMED CT 2011_0131
- 34896006
Beschreibung
LOCATION
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0450429
- SNOMED CT 2011_0131
- 246267002
Beschreibung
CLOSURE TYPE
Datentyp
string
Beschreibung
DRESSING TYPE
Datentyp
string
Beschreibung
DRESSING APPEARANCE
Datentyp
string
Beschreibung
DRAINS
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0180499
- SNOMED CT 2011_0131
- 32712000
- LOINC Version 232
- MTHU022515
Beschreibung
NARRATIVE
Datentyp
string
Alias
- UMLS CUI 2011AA
- C1135957
Beschreibung
Physical Exam - NEUROLOGIC
Beschreibung
Oriented x 3, cranial nerves 2-12 intact, no gross sensory or motor deficits, reflexes symmetric, no cerebellar signs, no involuntary movements
Datentyp
boolean
Alias
- UMLS CUI 2011AA
- C0027763
- SNOMED CT 2011_0131
- 25087005
- LOINC Version 232
- MTHU001437
Beschreibung
Conciousness
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0234421
- SNOMED CT 2011_0131
- 106167005
Beschreibung
Responsive to
Datentyp
string
Beschreibung
Orientation
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0029266
- SNOMED CT 2011_0131
- 43173001
Beschreibung
Proverb
Datentyp
string
Beschreibung
Writing
Datentyp
string
Alias
- UMLS CUI 2011AA
- C2584304
- SNOMED CT 2011_0131
- 12261009
Beschreibung
Reading
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0034754
- SNOMED CT 2011_0131
- 50360004
Beschreibung
Memory
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0025260
- SNOMED CT 2011_0131
- 303116000
- LOINC Version 232
- MTHU021129
Beschreibung
Registration
Datentyp
string
Beschreibung
Naming Intact
Datentyp
string
Beschreibung
Speech
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0037817
- SNOMED CT 2011_0131
- 87335007
- LOINC Version 232
- MTHU021528
Beschreibung
OTHER
Datentyp
string
Beschreibung
Score normal
Datentyp
boolean
Beschreibung
Concentration normal
Datentyp
boolean
Beschreibung
Cranial nerves normal
Datentyp
boolean
Beschreibung
Comment
Datentyp
string
Beschreibung
Motor tone
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0026841
- MedDRA 14.1
- 10070541
- LOINC Version 232
- MTHU015024
Beschreibung
Motor strength R/L
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0517349
Beschreibung
Grip R/L
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0220843
Beschreibung
Biceps R/L
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0559499
- SNOMED CT 2011_0131
- 16225001
- LOINC Version 232
- MTHU014778
Beschreibung
Triceps R/L
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0559502
- SNOMED CT 2011_0131
- 40284004
- LOINC Version 232
- MTHU014783
Beschreibung
Quadriceps R/L
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0224440
- SNOMED CT 2011_0131
- 21989003
Beschreibung
Hip Extensors R/L
Datentyp
string
Beschreibung
Dorsiflexion R/L
Datentyp
string
Beschreibung
Plantarflexion R/L
Datentyp
string
Beschreibung
Sensation
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0036658
- SNOMED CT 2011_0131
- 373713005
- LOINC Version 232
- MTHU017277
Beschreibung
Pin prick
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0423557
- SNOMED CT 2011_0131
- 247315008
Beschreibung
Comment
Datentyp
string
Beschreibung
Light touch
Datentyp
string
Beschreibung
Vibration
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0459800
- SNOMED CT 2011_0131
- 33679000
- LOINC Version 232
- MTHU021537
Beschreibung
Comment
Datentyp
string
Beschreibung
Position Sense
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0234219
- SNOMED CT 2011_0131
- 73535003
Beschreibung
Temperature
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0039476
- SNOMED CT 2011_0131
- 246508008
- LOINC Version 232
- MTHU009008
Beschreibung
Stereognosis
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0038263
- SNOMED CT 2011_0131
- 22382001
Beschreibung
Deep Tendon Reflexes Biceps R/L
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0234151
- SNOMED CT 2011_0131
- 30901003
Beschreibung
Deep Tendon Reflexes Triceps R/L
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0422908
- SNOMED CT 2011_0131
- 271716008
Beschreibung
Deep Tendon Reflexes Brachioradialis R/L
Datentyp
string
Beschreibung
Deep Tendon Reflexes Patellar R/L
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0234147
- SNOMED CT 2011_0131
- 271714006
Beschreibung
Deep Tendon Reflexes Achilles R/L
Datentyp
string
Beschreibung
Abnormal reflexes
Datentyp
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
Beschreibung
Involuntary Movements
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0427086
- SNOMED CT 2011_0131
- 267078001
- MedDRA 14.1
- 10028042
- CTCAE 1105E
- E12728
Beschreibung
Cerebellar Signs
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0742038
Beschreibung
Gait
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0016928
- SNOMED CT 2011_0131
- 63448001
- LOINC Version 232
- MTHU015039
Beschreibung
Comment
Datentyp
string
Beschreibung
Station
Datentyp
string
Beschreibung
PSYCHIATRIC
Beschreibung
Alert, oriented to person, place, and time, judgement and insight good, recent and remote memory intact, normal mood and affect.
Datentyp
boolean
Beschreibung
Judgement & Insight
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0022423, C0233820
- SNOMED CT 2011_0131
- 61254005, 27026000
Beschreibung
Orientation
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0029266
- SNOMED CT 2011_0131
- 43173001
Beschreibung
Recent Memory
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0233792
- SNOMED CT 2011_0131
- 69063000
Beschreibung
Remote Memory
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0233793
- SNOMED CT 2011_0131
- 81964002
Beschreibung
Mood/Affect
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0026516, C0001721
- SNOMED CT 2011_0131
- 85256008, 4065008
- LOINC Version 232
- MTHU031584
Beschreibung
Laboratory Results
Beschreibung
Radiology Results
Beschreibung
ASSESSMENT
Beschreibung
acceptable for surgery
Datentyp
boolean
Beschreibung
progressing well
Datentyp
boolean
Beschreibung
stable medically
Datentyp
boolean
Alias
- UMLS CUI 2011AA
- C0205360
- SNOMED CT 2011_0131
- 58158008
- LOINC Version 232
- MTHU015276
Beschreibung
Active Problems
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0552582
- LOINC Version 232
- LP73189-0
Beschreibung
Other
Datentyp
string
Beschreibung
PLAN
Beschreibung
Continue Home Regimen
Datentyp
boolean
Beschreibung
Continue Home Meds
Datentyp
boolean
Beschreibung
Continue Chemotherapy
Datentyp
boolean
Beschreibung
Continue IV Antibiotics
Datentyp
boolean
Beschreibung
Continue PO Antibiotics
Datentyp
boolean
Beschreibung
DVT Prophylaxis
Datentyp
boolean
Alias
- UMLS CUI 2011AA
- C0853245
- MedDRA 14.1
- 10013880
Beschreibung
O2 Protocol
Datentyp
boolean
Beschreibung
Follow Up X-Rays
Datentyp
boolean
Beschreibung
UTI treatment
Datentyp
boolean
Alias
- UMLS CUI 2011AA
- C0042029
- SNOMED CT 2011_0131
- 68566005
- MedDRA 14.1
- 10046577
Beschreibung
Monitor Blood Pressure and Heart Rate
Datentyp
boolean
Beschreibung
Monitor Diabetes Mellitus
Datentyp
boolean
Beschreibung
Accuchecks AC & HS
Datentyp
boolean
Beschreibung
Accuchecks Q6H
Datentyp
boolean
Beschreibung
Sliding Scale Regular Insulin
Datentyp
boolean
Alias
- UMLS CUI 2011AA
- C0021641
- SNOMED CT 2011_0131
- 67866001
- LOINC Version 232
- MTHU019392
Beschreibung
Check Follow Up Labs
Datentyp
boolean
Beschreibung
Appreciate following patient with you
Datentyp
boolean
Ähnliche Modelle
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)