ID
5512
Beschrijving
Form from HIS OpenVistA
Trefwoorden
Versies (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
Geüploaded op
7 augustus 2014
DOI
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Licentie
Creative Commons BY-NC 3.0 Legacy
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HIS H and P or consult specialty
HIS
- StudyEvent: HIS
Beschrijving
HISTORY OF PRESENT ILLNESS
Beschrijving
HISTORY OF PRESENT ILLNESS (HPI, include location, quality, severity, duration, timing, context, modifying factors & associated signs/symptoms)
Datatype
string
Alias
- UMLS CUI 2011AA
- C0262512
- LOINC Version 232
- MTHU001399
Beschrijving
SOURCE(S) OF HISTORY
Datatype
integer
Beschrijving
SOURCE(S) OF HISTORY comment
Datatype
string
Beschrijving
REVIEW OF SYSTEMS
Beschrijving
PAST HISTORY
Beschrijving
Adult Illness
Datatype
string
Alias
- UMLS CUI 2011AA
- C0277562
- SNOMED CT 2011_0131
- 64342008
Beschrijving
History of childhood diseases
Datatype
string
Alias
- UMLS CUI 2011AA
- C0489532
- LOINC Version 232
- MTHU001066
Beschrijving
Surgeries
Datatype
string
Alias
- UMLS CUI 2011AA
- C0455610
- SNOMED CT 2011_0131
- 161615003
Beschrijving
Injury
Datatype
string
Alias
- UMLS CUI 2011AA
- C0175677
- SNOMED CT 2011_0131
- 417746004
- MedDRA 14.1
- 10022116
- ICD-10-CM Version 2010
- T14.9
Beschrijving
Female Specific History
Beschrijving
Date of last menstrual period
Datatype
date
Alias
- UMLS CUI 2011AA
- C0425932
- SNOMED CT 2011_0131
- 21840007
- LOINC Version 232
- MTHU024536
Beschrijving
Date of last PAP
Datatype
date
Beschrijving
last PAP Results
Datatype
string
Alias
- UMLS CUI 2011AA
- C0079104
- MedDRA 14.1
- 10041205
Beschrijving
Date of last MMG
Datatype
date
Beschrijving
last MMG Results
Datatype
string
Alias
- UMLS CUI 2011AA
- C0024671
- SNOMED CT 2011_0131
- 71651007
- MedDRA 14.1
- 10026735
Beschrijving
Age at menarche
Datatype
integer
Alias
- UMLS CUI 2011AA
- C1314691
- SNOMED CT 2011_0131
- 398700009
- LOINC Version 232
- MTHU018825
Beschrijving
Describe Menses
Datatype
string
Alias
- UMLS CUI 2011AA
- C0025344
- SNOMED CT 2011_0131
- 248957007
Beschrijving
Birth Control
Datatype
string
Alias
- UMLS CUI 2011AA
- C0700589
- SNOMED CT 2011_0131
- 146680009
- MedDRA 14.1
- 10010808
Beschrijving
Pregnancies
Datatype
string
Alias
- UMLS CUI 2011AA
- C0032961
- SNOMED CT 2011_0131
- 289908002
- MedDRA 14.1
- 10036556
- LOINC Version 232
- MTHU035048
Beschrijving
Abortions
Datatype
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
Beschrijving
Number of full term pregnancies
Datatype
integer
Beschrijving
Number of spontaneous abortions
Datatype
integer
Beschrijving
Number of therapeutic abortions
Datatype
integer
Beschrijving
Number of other types Abortions
Datatype
integer
Beschrijving
Age at first pregnancy
Datatype
integer
Beschrijving
FAMILY HISTORY
Beschrijving
SOCIAL HISTORY
Beschrijving
ALLERGIES
Beschrijving
MEDICATIONS
Beschrijving
Inpatient medications
Datatype
string
Alias
- UMLS CUI 2011AA
- C0013227
Beschrijving
Active medications
Datatype
string
Alias
- UMLS CUI 2011AA
- C1553892
Beschrijving
Home medications
Datatype
string
Alias
- UMLS CUI 2011AA
- C0013227
Beschrijving
PHYSICAL EXAM - General
Beschrijving
VITALS
Datatype
string
Alias
- UMLS CUI 2011AA
- C0518766
- SNOMED CT 2011_0131
- 46680005
- LOINC Version 232
- MTHU024540
Beschrijving
TEMPERATURE
Datatype
string
Alias
- UMLS CUI 2011AA
- C0039476
- SNOMED CT 2011_0131
- 246508008
- LOINC Version 232
- MTHU009008
Beschrijving
PULSE
Datatype
string
Alias
- UMLS CUI 2011AA
- C0232117
- SNOMED CT 2011_0131
- 78564009
- MedDRA 14.1
- 10037485
Beschrijving
RESPIRATION rate
Datatype
string
Alias
- UMLS CUI 2011AA
- C0231832
- SNOMED CT 2011_0131
- 86290005
- MedDRA 14.1
- 10038709
- LOINC Version 232
- MTHU008344
Beschrijving
BLOOD PRESSURE
Datatype
string
Alias
- UMLS CUI 2011AA
- C0005823
- SNOMED CT 2011_0131
- 75367002
- LOINC Version 232
- MTHU008342
Beschrijving
Pain
Datatype
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
Beschrijving
Weight
Datatype
integer
Alias
- UMLS
- C0005910
- SNOMED CT 2011_0131
- 107647005
- MedDRA 14.1
- 10047890
- LOINC Version 232
- LP18015-5
Beschrijving
GENERAL
Datatype
string
Beschrijving
PHYSICAL EXAM - HEAD
Beschrijving
PHYSICAL EXAM - EYES
Beschrijving
EYES
Datatype
boolean
Alias
- UMLS CUI 2011AA
- C0015392
- SNOMED CT 2011_0131
- 81745001
- LOINC Version 232
- MTHU000064
Beschrijving
Pupils
Datatype
string
Alias
- UMLS CUI 2011AA
- C0034121
- SNOMED CT 2011_0131
- 392406005
- LOINC Version 232
- MTHU015063
Beschrijving
Conjunctivae
Datatype
string
Alias
- UMLS CUI 2011AA
- C0009758
- SNOMED CT 2011_0131
- 29445007
- LOINC Version 232
- MTHU009301
Beschrijving
Sclerae
Datatype
string
Alias
- UMLS CUI 2011AA
- C0036410
- SNOMED CT 2011_0131
- 18619003
- LOINC Version 232
- MTHU015068
Beschrijving
EOM
Datatype
string
Alias
- UMLS CUI 2011AA
- C0028863
- SNOMED CT 2011_0131
- 67833000
- LOINC Version 232
- MTHU015037
Beschrijving
Funduscopic
Datatype
string
Alias
- UMLS CUI 2011AA
- C0029090
- SNOMED CT 2011_0131
- 274798009
- MedDRA 14.1
- 10017519
Beschrijving
Physical Exam - Ears, Nose, Throat
Beschrijving
Ear canals patent. TM's intact. Nares patent and pink without epistaxis. Mucosa pink. No pharyngitis. Natural dentition.
Datatype
boolean
Beschrijving
EAR R ext canal
Datatype
string
Alias
- UMLS CUI 2011AA
- C0013444
- SNOMED CT 2011_0131
- 84301002
- LOINC Version 232
- MTHU015034
Beschrijving
EAR R tympanic membrane (TM)
Datatype
string
Alias
- UMLS CUI 2011AA
- C0041445
- SNOMED CT 2011_0131
- 42859004
- LOINC Version 232
- MTHU014731
Beschrijving
EAR L ext canal
Datatype
string
Alias
- UMLS CUI 2011AA
- C0013444
- SNOMED CT 2011_0131
- 84301002
- LOINC Version 232
- MTHU015034
Beschrijving
EAR L tympanic membrane (TM)
Datatype
string
Alias
- UMLS CUI 2011AA
- C0041445
- SNOMED CT 2011_0131
- 42859004
- LOINC Version 232
- MTHU014731
Beschrijving
NOSE Septum
Datatype
string
Alias
- UMLS CUI 2011AA
- C0027432
- SNOMED CT 2011_0131
- 68426009
- LOINC Version 232
- MTHU015054
Beschrijving
Nose Mucosa
Datatype
string
Alias
- UMLS CUI 2011AA
- C0027428
- SNOMED CT 2011_0131
- 34508005
Beschrijving
Nose R Nares
Datatype
string
Alias
- UMLS CUI 2011AA
- C0595944
- SNOMED CT 2011_0131
- 1797002
- LOINC Version 232
- MTHU015056
Beschrijving
Nose L Nares
Datatype
string
Alias
- UMLS CUI 2011AA
- C0595944
- SNOMED CT 2011_0131
- 1797002
- LOINC Version 232
- MTHU015056
Beschrijving
Throat: Mouth mucosa
Datatype
string
Alias
- UMLS CUI 2011AA
- C0026639
- SNOMED CT 2011_0131
- 113277000
Beschrijving
Pharynx
Datatype
string
Alias
- UMLS CUI 2011AA
- C0031354
- SNOMED CT 2011_0131
- 54066008
- LOINC Version 232
- MTHU015061
Beschrijving
Tonsils
Datatype
string
Alias
- UMLS CUI 2011AA
- C0836921
- LOINC Version 232
- MTHU015077
Beschrijving
Dentition
Datatype
string
Alias
- UMLS CUI 2011AA
- C0011443
- SNOMED CT 2011_0131
- 245543004
- LOINC Version 232
- MTHU014794
Beschrijving
Physical Exam - Neck
Beschrijving
supple, no JVD, no carotid bruits, trachea midline, no thyromegaly, no adenopathy
Datatype
boolean
Alias
- UMLS CUI 2011AA
- C0027530
- SNOMED CT 2011_0131
- 45048000
- LOINC Version 232
- MTHU002688
Beschrijving
Adenopathy
Datatype
string
Alias
- UMLS CUI 2011AA
- C1706304
- ICD-10-CM Version 2010
- R59
Beschrijving
Carotid bruit
Datatype
string
Alias
- UMLS CUI 2011AA
- C0007280
- SNOMED CT 2011_0131
- 419642000
- MedDRA 14.1
- 10048777
Beschrijving
JVD
Datatype
string
Alias
- UMLS CUI 2011AA
- C1719935
- SNOMED CT 2011_0131
- 422008005
Beschrijving
Thyroid gland
Datatype
string
Alias
- UMLS CUI 2011AA
- C0040132
- SNOMED CT 2011_0131
- 69748006
- LOINC Version 232
- MTHU007792
Beschrijving
Trachea
Datatype
string
Alias
- UMLS CUI 2011AA
- C0040578
- SNOMED CT 2011_0131
- 44567001
- LOINC Version 232
- MTHU009117
Beschrijving
Physical Exam - BREAST
Beschrijving
symmetric without masses
Datatype
boolean
Alias
- UMLS CUI 2011AA
- C0006141
- SNOMED CT 2011_0131
- 76752008
- LOINC Version 232
- MTHU011382
Beschrijving
inspection: Right breast
Datatype
string
Alias
- UMLS CUI 2011AA
- C0006141
- SNOMED CT 2011_0131
- 76752008
- LOINC Version 232
- MTHU011382
Beschrijving
inspection: Right nipple
Datatype
string
Alias
- UMLS CUI 2011AA
- C0028109
- SNOMED CT 2011_0131
- 24142002
Beschrijving
inspection: Left breast
Datatype
string
Alias
- UMLS CUI 2011AA
- C0006141
- SNOMED CT 2011_0131
- 76752008
- LOINC Version 232
- MTHU011382
Beschrijving
inspection: Left nipple
Datatype
string
Alias
- UMLS CUI 2011AA
- C0028109
- SNOMED CT 2011_0131
- 24142002
Beschrijving
palpation: Right breast
Datatype
string
Alias
- UMLS CUI 2011AA
- C0006141
- SNOMED CT 2011_0131
- 76752008
- LOINC Version 232
- MTHU011382
Beschrijving
palpation: Right nipple
Datatype
string
Alias
- UMLS CUI 2011AA
- C0028109
- SNOMED CT 2011_0131
- 24142002
Beschrijving
palpation: Left breast
Datatype
string
Alias
- UMLS CUI 2011AA
- C0006141
- SNOMED CT 2011_0131
- 76752008
- LOINC Version 232
- MTHU011382
Beschrijving
palpation: Left nipple
Datatype
string
Alias
- UMLS CUI 2011AA
- C0028109
- SNOMED CT 2011_0131
- 24142002
Beschrijving
Physical Exam - CHEST
Beschrijving
normal for inspection, percussion, palpation, and auscultation of the lungs.
Datatype
boolean
Beschrijving
Chest significant for:
Datatype
string
Alias
- UMLS CUI 2011AA
- C0817096
- SNOMED CT 2011_0131
- 51185008
Beschrijving
Location
Datatype
string
Alias
- UMLS CUI 2011AA
- C0450429
- SNOMED CT 2011_0131
- 246267002
Beschrijving
Additional lung sounds
Datatype
string
Alias
- UMLS CUI 2011AA
- C0035234
- SNOMED CT 2011_0131
- 52653008
- MedDRA 14.1
- 10064779
Beschrijving
Location
Datatype
string
Alias
- UMLS CUI 2011AA
- C0450429
- SNOMED CT 2011_0131
- 246267002
Beschrijving
Physical Exam - HEART
Beschrijving
PMI at 5th intercostal space, mid clavicular line, normal S1,S2 without murmur or gallop
Datatype
boolean
Alias
- UMLS CUI 2011AA
- C0018787
- SNOMED CT 2011_0131
- 80891009
- LOINC Version 232
- MTHU001067
Beschrijving
Palpation: PMI is
Datatype
string
Beschrijving
Rhythm
Datatype
string
Beschrijving
Heart Sounds: S1 is , S2 is, S3 is, S4 is
Datatype
string
Alias
- UMLS CUI 2011AA
- C0018820
- SNOMED CT 2011_0131
- 23472005
Beschrijving
PE HEART RUB TEXT
Datatype
string
Beschrijving
PE HEART OTHER SOUNDS TEXT
Datatype
string
Beschrijving
Murmur: grade
Datatype
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
Beschrijving
Murmur heard best at
Datatype
string
Beschrijving
Murmur radiates
Datatype
string
Beschrijving
Heart - OTHER1
Datatype
string
Beschrijving
Physical Exam - VASCULAR
Beschrijving
Pulses present and equal bilat.
Datatype
boolean
Beschrijving
Aorta
Datatype
string
Alias
- UMLS CUI 2011AA
- C0003483
- SNOMED CT 2011_0131
- 15825003
- LOINC Version 232
- MTHU003021
Beschrijving
Pulses R/L: carotid
Datatype
string
Alias
- UMLS CUI 2011AA
- C1096529
- MedDRA 14.1
- 10053926
Beschrijving
Pulses R/L: brachial
Datatype
string
Alias
- UMLS CUI 2011AA
- C1096531
- MedDRA 14.1
- 10053929
Beschrijving
Pulses R/L: radial
Datatype
string
Alias
- UMLS CUI 2011AA
- C0232142
- SNOMED CT 2011_0131
- 65452004
- MedDRA 14.1
- 10053935
Beschrijving
Pulses R/L: femoral
Datatype
string
Alias
- UMLS CUI 2011AA
- C0232148
- SNOMED CT 2011_0131
- 67316000
- MedDRA 14.1
- 10053932
Beschrijving
Pulses R/L: popliteal
Datatype
string
Alias
- UMLS CUI 2011AA
- C0232151
- SNOMED CT 2011_0131
- 74828005
- MedDRA 14.1
- 10053938
Beschrijving
Pulses R/L: posterior tibial
Datatype
string
Alias
- UMLS CUI 2011AA
- C1720310
- SNOMED CT 2011_0131
- 421568004
Beschrijving
Pulses R/L: dorsalis pedis
Datatype
string
Alias
- UMLS CUI 2011AA
- C1706488
- SNOMED CT 2011_0131
- 421811005
Beschrijving
Physical Exam - ABDOMEN
Beschrijving
soft, flat, nontender with normal bowel sounds. no organomegaly, no ascites, no palpable mass, no hernia.
Datatype
boolean
Alias
- UMLS CUI 2011AA
- C0000726
- SNOMED CT 2011_0131
- 113345001
- LOINC Version 232
- MTHU001425
Beschrijving
Appearance
Datatype
string
Beschrijving
Bowel sounds
Datatype
string
Alias
- UMLS CUI 2011AA
- C0232693
- SNOMED CT 2011_0131
- 87042004
- MedDRA 14.1
- 10006023
Beschrijving
Midepigastric bruit
Datatype
string
Beschrijving
Abdominal tenderness
Datatype
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
Beschrijving
Rebound
Datatype
string
Beschrijving
Liver
Datatype
string
Alias
- UMLS CUI 2011AA
- C0023884
- SNOMED CT 2011_0131
- 10200004
- LOINC Version 232
- MTHU002039
Beschrijving
Spleen
Datatype
string
Alias
- UMLS CUI 2011AA
- C0037993
- SNOMED CT 2011_0131
- 78961009
- LOINC Version 232
- MTHU012104
Beschrijving
Hernia
Datatype
string
Alias
- UMLS CUI 2011AA
- C0019270
- SNOMED CT 2011_0131
- 414403008
- MedDRA 14.1
- 10019909
- ICD-10-CM Version 2010
- K40-K46
Beschrijving
Physical Exam - GENITOURINARY/RECTAL: MALE
Beschrijving
GU Assessment
Datatype
string
Alias
- UMLS CUI 2011AA
- C0042066
- SNOMED CT 2011_0131
- 21514008
- LOINC Version 232
- MTHU013232
Beschrijving
Urine appears
Datatype
string
Alias
- UMLS CUI 2011AA
- C0042036
- SNOMED CT 2011_0131
- 78014005
- LOINC Version 232
- MTHU001343
Beschrijving
Urine is adequate
Datatype
string
Alias
- UMLS CUI 2011AA
- C0042036
- SNOMED CT 2011_0131
- 78014005
- LOINC Version 232
- MTHU001343
Beschrijving
Urine Output [ml]
Datatype
integer
Alias
- UMLS CUI 2011AA
- C1287298
- SNOMED CT 2011_0131
- 365678000
- MedDRA 14.1
- 10059894
- LOINC Version 232
- MTHU024573
Beschrijving
Foley catheter
Datatype
string
Alias
- UMLS CUI 2011AA
- C0179804
- MedDRA 14.1
- 10016892
Beschrijving
Suprapubic catheter
Datatype
string
Alias
- UMLS CUI 2011AA
- C0150798
- SNOMED CT 2011_0131
- 286861005
Beschrijving
scrotal contents
Datatype
string
Beschrijving
Penis
Datatype
string
Alias
- UMLS CUI 2011AA
- C0030851
- SNOMED CT 2011_0131
- 18911002
- LOINC Version 232
- MTHU004206
Beschrijving
rectal: sphincter tone
Datatype
string
Beschrijving
hemorrhoids
Datatype
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
Beschrijving
Prostate
Datatype
string
Alias
- UMLS CUI 2011AA
- C0033572
- SNOMED CT 2011_0131
- 41216001
- LOINC Version 232
- MTHU004957
Beschrijving
mass
Datatype
string
Beschrijving
Physical Exam - GENITOURINARY/RECTAL: FEMALE
Beschrijving
GU Assessment FEMALE
Datatype
string
Alias
- UMLS CUI 2011AA
- C0042066
- SNOMED CT 2011_0131
- 21514008
- LOINC Version 232
- MTHU013232
Beschrijving
Urine appears
Datatype
string
Alias
- UMLS CUI 2011AA
- C0042036
- SNOMED CT 2011_0131
- 78014005
- LOINC Version 232
- MTHU001343
Beschrijving
Urine is adequate
Datatype
string
Alias
- UMLS CUI 2011AA
- C0042036
- SNOMED CT 2011_0131
- 78014005
- LOINC Version 232
- MTHU001343
Beschrijving
Urine Output [ml]
Datatype
integer
Alias
- UMLS CUI 2011AA
- C1287298
- SNOMED CT 2011_0131
- 365678000
- MedDRA 14.1
- 10059894
- LOINC Version 232
- MTHU024573
Beschrijving
Foley catheter
Datatype
string
Alias
- UMLS CUI 2011AA
- C0179804
- MedDRA 14.1
- 10016892
Beschrijving
Suprapubic catheter
Datatype
string
Alias
- UMLS CUI 2011AA
- C0150798
- SNOMED CT 2011_0131
- 286861005
Beschrijving
External genitalia
Datatype
string
Alias
- UMLS CUI 2011AA
- C0227605
- SNOMED CT 2011_0131
- 77142006
Beschrijving
Urethra
Datatype
string
Alias
- UMLS CUI 2011AA
- C0041967
- SNOMED CT 2011_0131
- 264255005
- LOINC Version 232
- MTHU001321
Beschrijving
Vagina
Datatype
string
Alias
- UMLS CUI 2011AA
- C0042232
- SNOMED CT 2011_0131
- 76784001
- LOINC Version 232
- MTHU014732
Beschrijving
Bladder
Datatype
string
Alias
- UMLS CUI 2011AA
- C0005682
- SNOMED CT 2011_0131
- 89837001
- LOINC Version 232
- MTHU002918
Beschrijving
Cervix
Datatype
string
Alias
- UMLS CUI 2011AA
- C0007874
- SNOMED CT 2011_0131
- 71252005
- LOINC Version 232
- MTHU001800
Beschrijving
Uterus
Datatype
string
Alias
- UMLS CUI 2011AA
- C0042149
- SNOMED CT 2011_0131
- 35039007
- LOINC Version 232
- MTHU002943
Beschrijving
adnexa
Datatype
string
Alias
- UMLS CUI 2011AA
- C0001575
- SNOMED CT 2011_0131
- 23043003
- LOINC Version 232
- MTHU015033
Beschrijving
rectal: sphincter tone
Datatype
string
Beschrijving
hemorrhoids
Datatype
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
Beschrijving
mass
Datatype
string
Beschrijving
Physical Exam -MUSCULOSKELETAL
Beschrijving
MUSCULOSKELETAL
Datatype
string
Alias
- UMLS CUI 2011AA
- C0026860
- SNOMED CT 2011_0131
- 26107004
- LOINC Version 232
- MTHU001411
Beschrijving
Gait
Datatype
string
Alias
- UMLS CUI 2011AA
- C0016928
- SNOMED CT 2011_0131
- 63448001
- LOINC Version 232
- MTHU015039
Beschrijving
Station
Datatype
string
Beschrijving
Digits
Datatype
string
Alias
- UMLS CUI 2011AA
- C0582802
- SNOMED CT 2011_0131
- 82680008
- LOINC Version 232
- MTHU015035
Beschrijving
Nails
Datatype
string
Alias
- UMLS CUI 2011AA
- C0027342
- SNOMED CT 2011_0131
- 72651009
- LOINC Version 232
- MTHU002041
Beschrijving
Joints, Bones, Muscles
Datatype
string
Alias
- UMLS CUI 2011AA
- C0022417, C0262950, C0026845
- SNOMED CT 2011_0131
- 39352004, 272673000, 71616004
Beschrijving
Head & Neck
Datatype
string
Alias
- UMLS CUI 2011AA
- C0018670, C0027530
- SNOMED CT 2011_0131
- 69536005, 45048000
Beschrijving
Spine/Ribs/Pelvis
Datatype
string
Beschrijving
Right Shoulder
Datatype
string
Alias
- UMLS CUI 2011AA
- C0037004
- SNOMED CT 2011_0131
- 16982005
- LOINC Version 232
- MTHU002689
Beschrijving
Right Elbow
Datatype
string
Alias
- UMLS CUI 2011AA
- C0013769
- SNOMED CT 2011_0131
- 127949000
- LOINC Version 232
- MTHU002674
Beschrijving
Right Wrist
Datatype
string
Alias
- UMLS CUI 2011AA
- C0043262
- SNOMED CT 2011_0131
- 8205005
- LOINC Version 232
- MTHU002691
Beschrijving
Left Shoulder
Datatype
string
Alias
- UMLS CUI 2011AA
- C0037004
- SNOMED CT 2011_0131
- 16982005
- LOINC Version 232
- MTHU002689
Beschrijving
Left Elbow
Datatype
string
Alias
- UMLS CUI 2011AA
- C0013769
- SNOMED CT 2011_0131
- 127949000
- LOINC Version 232
- MTHU002674
Beschrijving
Left Wrist
Datatype
string
Alias
- UMLS CUI 2011AA
- C0043262
- SNOMED CT 2011_0131
- 8205005
- LOINC Version 232
- MTHU002691
Beschrijving
Right Hip
Datatype
string
Alias
- UMLS CUI 2011AA
- C0019552
- SNOMED CT 2011_0131
- 24136001
- LOINC Version 232
- MTHU002686
Beschrijving
Right Knee
Datatype
string
Alias
- UMLS CUI 2011AA
- C0022742
- SNOMED CT 2011_0131
- 304679005
- LOINC Version 232
- MTHU002687
Beschrijving
Right Ankle
Datatype
string
Alias
- UMLS CUI 2011AA
- C0003086
- SNOMED CT 2011_0131
- 344001
Beschrijving
Left Hip
Datatype
string
Alias
- UMLS CUI 2011AA
- C0019552
- SNOMED CT 2011_0131
- 24136001
- LOINC Version 232
- MTHU002686
Beschrijving
Left Knee
Datatype
string
Alias
- UMLS CUI 2011AA
- C0022742
- SNOMED CT 2011_0131
- 304679005
- LOINC Version 232
- MTHU002687
Beschrijving
Left Ankle
Datatype
string
Alias
- UMLS CUI 2011AA
- C0003086
- SNOMED CT 2011_0131
- 344001
Beschrijving
Physical Exam - EXTREMITIES
Beschrijving
Significant for:
Datatype
string
Beschrijving
pitting edema
Datatype
string
Alias
- UMLS CUI 2011AA
- C0333243
- SNOMED CT 2011_0131
- 139248000
Beschrijving
pretibial: R / L
Datatype
string
Beschrijving
ankle: R / L
Datatype
string
Alias
- UMLS CUI 2011AA
- C0003086
- SNOMED CT 2011_0131
- 344001
Beschrijving
foot: R / L
Datatype
string
Alias
- UMLS CUI 2011AA
- C0016504
- SNOMED CT 2011_0131
- 56459004
- LOINC Version 232
- MTHU002679
Beschrijving
Pulses R/L: posterior tibial
Datatype
string
Alias
- UMLS CUI 2011AA
- C1720310
- SNOMED CT 2011_0131
- 421568004
Beschrijving
Pulses R/L: dorsalis pedis
Datatype
string
Alias
- UMLS CUI 2011AA
- C1706488
- SNOMED CT 2011_0131
- 421811005
Beschrijving
capillary fill time R/L
Datatype
string
Beschrijving
sensation by monofilament test R/L
Datatype
string
Beschrijving
toenails
Datatype
string
Beschrijving
skin
Datatype
string
Alias
- UMLS CUI 2011AA
- C1123023
- SNOMED CT 2011_0131
- 39937001
- LOINC Version 232
- MTHU001414
Beschrijving
Physical Exam - LYMPHATIC
Beschrijving
no adenopathy
Datatype
boolean
Beschrijving
adenopathy
Datatype
string
Alias
- UMLS CUI 2011AA
- C1706304
Beschrijving
neck
Datatype
string
Alias
- UMLS CUI 2011AA
- C0027530
- SNOMED CT 2011_0131
- 45048000
- LOINC Version 232
- MTHU002688
Beschrijving
Axilla
Datatype
string
Alias
- UMLS CUI 2011AA
- C0004454
- SNOMED CT 2011_0131
- 91470000
- LOINC Version 232
- MTHU002668
Beschrijving
groin
Datatype
string
Alias
- UMLS CUI 2011AA
- C0018246
- SNOMED CT 2011_0131
- 26893007
- LOINC Version 232
- MTHU002684
Beschrijving
other
Datatype
string
Beschrijving
Physical Exam - SKIN
Beschrijving
Inspection and palpation of skin and subcutaneous tissue reveals no acute rashes, lesions, or induration.
Datatype
boolean
Alias
- UMLS CUI 2011AA
- C1123023
- SNOMED CT 2011_0131
- 39937001
- LOINC Version 232
- MTHU001414
Beschrijving
inspection
Datatype
string
Alias
- UMLS CUI 2011AA
- C0199219
- SNOMED CT 2011_0131
- 32750006
Beschrijving
Palpation
Datatype
string
Alias
- UMLS CUI 2011AA
- C0030247
- SNOMED CT 2011_0131
- 113011001
Beschrijving
Physical Exam - Wound and Incision Care
Beschrijving
WOUND #
Datatype
string
Alias
- UMLS CUI 2011AA
- C0043250
- SNOMED CT 2011_0131
- 13924000
- MedDRA 14.1
- 10052428
- LOINC Version 232
- MTHU001326
Beschrijving
WOUND LOCATION
Datatype
string
Beschrijving
WOUND MEASUREMENT (Length, Width, Depth [cm])
Datatype
string
Beschrijving
UNDERMINING Wound
Datatype
boolean
Beschrijving
TUNNELING Wound
Datatype
boolean
Beschrijving
SURROUNDING SKIN: WOUND BASE
Datatype
string
Beschrijving
SENSATION
Datatype
string
Alias
- UMLS CUI 2011AA
- C0036658
- SNOMED CT 2011_0131
- 373713005
- LOINC Version 232
- MTHU017277
Beschrijving
EXUDATE
Datatype
string
Alias
- UMLS CUI 2011AA
- C0015388
- SNOMED CT 2011_0131
- 247450001
- LOINC Version 232
- MTHU025016
Beschrijving
COLOR OF DRAINAGE
Datatype
string
Beschrijving
ODOR: Before Cleaning
Datatype
boolean
Beschrijving
ODOR: After Cleaning
Datatype
boolean
Beschrijving
CLEANSED WITH/IRRIGATED WITH
Datatype
string
Beschrijving
WOUND MED applied
Datatype
string
Beschrijving
FILLED WITH
Datatype
string
Beschrijving
COVERED WITH
Datatype
string
Beschrijving
SECURED WITH
Datatype
string
Beschrijving
PRESSURE RELIEF
Datatype
string
Beschrijving
COMMENTS
Datatype
string
Beschrijving
PHOTOGRAPH DATE
Datatype
date
Beschrijving
NARRATIVE
Datatype
string
Alias
- UMLS CUI 2011AA
- C1135957
Beschrijving
INCISION #
Datatype
string
Alias
- UMLS CUI 2011AA
- C0184898
- SNOMED CT 2011_0131
- 34896006
Beschrijving
LOCATION
Datatype
string
Alias
- UMLS CUI 2011AA
- C0450429
- SNOMED CT 2011_0131
- 246267002
Beschrijving
CLOSURE TYPE
Datatype
string
Beschrijving
DRESSING TYPE
Datatype
string
Beschrijving
DRESSING APPEARANCE
Datatype
string
Beschrijving
DRAINS
Datatype
string
Alias
- UMLS CUI 2011AA
- C0180499
- SNOMED CT 2011_0131
- 32712000
- LOINC Version 232
- MTHU022515
Beschrijving
NARRATIVE
Datatype
string
Alias
- UMLS CUI 2011AA
- C1135957
Beschrijving
Physical Exam - NEUROLOGIC
Beschrijving
Oriented x 3, cranial nerves 2-12 intact, no gross sensory or motor deficits, reflexes symmetric, no cerebellar signs, no involuntary movements
Datatype
boolean
Alias
- UMLS CUI 2011AA
- C0027763
- SNOMED CT 2011_0131
- 25087005
- LOINC Version 232
- MTHU001437
Beschrijving
Conciousness
Datatype
string
Alias
- UMLS CUI 2011AA
- C0234421
- SNOMED CT 2011_0131
- 106167005
Beschrijving
Responsive to
Datatype
string
Beschrijving
Orientation
Datatype
string
Alias
- UMLS CUI 2011AA
- C0029266
- SNOMED CT 2011_0131
- 43173001
Beschrijving
Proverb
Datatype
string
Beschrijving
Writing
Datatype
string
Alias
- UMLS CUI 2011AA
- C2584304
- SNOMED CT 2011_0131
- 12261009
Beschrijving
Reading
Datatype
string
Alias
- UMLS CUI 2011AA
- C0034754
- SNOMED CT 2011_0131
- 50360004
Beschrijving
Memory
Datatype
string
Alias
- UMLS CUI 2011AA
- C0025260
- SNOMED CT 2011_0131
- 303116000
- LOINC Version 232
- MTHU021129
Beschrijving
Registration
Datatype
string
Beschrijving
Naming Intact
Datatype
string
Beschrijving
Speech
Datatype
string
Alias
- UMLS CUI 2011AA
- C0037817
- SNOMED CT 2011_0131
- 87335007
- LOINC Version 232
- MTHU021528
Beschrijving
OTHER
Datatype
string
Beschrijving
Score normal
Datatype
boolean
Beschrijving
Concentration normal
Datatype
boolean
Beschrijving
Cranial nerves normal
Datatype
boolean
Beschrijving
Comment
Datatype
string
Beschrijving
Motor tone
Datatype
string
Alias
- UMLS CUI 2011AA
- C0026841
- MedDRA 14.1
- 10070541
- LOINC Version 232
- MTHU015024
Beschrijving
Motor strength R/L
Datatype
string
Alias
- UMLS CUI 2011AA
- C0517349
Beschrijving
Grip R/L
Datatype
string
Alias
- UMLS CUI 2011AA
- C0220843
Beschrijving
Biceps R/L
Datatype
string
Alias
- UMLS CUI 2011AA
- C0559499
- SNOMED CT 2011_0131
- 16225001
- LOINC Version 232
- MTHU014778
Beschrijving
Triceps R/L
Datatype
string
Alias
- UMLS CUI 2011AA
- C0559502
- SNOMED CT 2011_0131
- 40284004
- LOINC Version 232
- MTHU014783
Beschrijving
Quadriceps R/L
Datatype
string
Alias
- UMLS CUI 2011AA
- C0224440
- SNOMED CT 2011_0131
- 21989003
Beschrijving
Hip Extensors R/L
Datatype
string
Beschrijving
Dorsiflexion R/L
Datatype
string
Beschrijving
Plantarflexion R/L
Datatype
string
Beschrijving
Sensation
Datatype
string
Alias
- UMLS CUI 2011AA
- C0036658
- SNOMED CT 2011_0131
- 373713005
- LOINC Version 232
- MTHU017277
Beschrijving
Pin prick
Datatype
string
Alias
- UMLS CUI 2011AA
- C0423557
- SNOMED CT 2011_0131
- 247315008
Beschrijving
Comment
Datatype
string
Beschrijving
Light touch
Datatype
string
Beschrijving
Vibration
Datatype
string
Alias
- UMLS CUI 2011AA
- C0459800
- SNOMED CT 2011_0131
- 33679000
- LOINC Version 232
- MTHU021537
Beschrijving
Comment
Datatype
string
Beschrijving
Position Sense
Datatype
string
Alias
- UMLS CUI 2011AA
- C0234219
- SNOMED CT 2011_0131
- 73535003
Beschrijving
Temperature
Datatype
string
Alias
- UMLS CUI 2011AA
- C0039476
- SNOMED CT 2011_0131
- 246508008
- LOINC Version 232
- MTHU009008
Beschrijving
Stereognosis
Datatype
string
Alias
- UMLS CUI 2011AA
- C0038263
- SNOMED CT 2011_0131
- 22382001
Beschrijving
Deep Tendon Reflexes Biceps R/L
Datatype
string
Alias
- UMLS CUI 2011AA
- C0234151
- SNOMED CT 2011_0131
- 30901003
Beschrijving
Deep Tendon Reflexes Triceps R/L
Datatype
string
Alias
- UMLS CUI 2011AA
- C0422908
- SNOMED CT 2011_0131
- 271716008
Beschrijving
Deep Tendon Reflexes Brachioradialis R/L
Datatype
string
Beschrijving
Deep Tendon Reflexes Patellar R/L
Datatype
string
Alias
- UMLS CUI 2011AA
- C0234147
- SNOMED CT 2011_0131
- 271714006
Beschrijving
Deep Tendon Reflexes Achilles R/L
Datatype
string
Beschrijving
Abnormal reflexes
Datatype
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
Beschrijving
Involuntary Movements
Datatype
string
Alias
- UMLS CUI 2011AA
- C0427086
- SNOMED CT 2011_0131
- 267078001
- MedDRA 14.1
- 10028042
- CTCAE 1105E
- E12728
Beschrijving
Cerebellar Signs
Datatype
string
Alias
- UMLS CUI 2011AA
- C0742038
Beschrijving
Gait
Datatype
string
Alias
- UMLS CUI 2011AA
- C0016928
- SNOMED CT 2011_0131
- 63448001
- LOINC Version 232
- MTHU015039
Beschrijving
Comment
Datatype
string
Beschrijving
Station
Datatype
string
Beschrijving
PSYCHIATRIC
Beschrijving
Alert, oriented to person, place, and time, judgement and insight good, recent and remote memory intact, normal mood and affect.
Datatype
boolean
Beschrijving
Judgement & Insight
Datatype
string
Alias
- UMLS CUI 2011AA
- C0022423, C0233820
- SNOMED CT 2011_0131
- 61254005, 27026000
Beschrijving
Orientation
Datatype
string
Alias
- UMLS CUI 2011AA
- C0029266
- SNOMED CT 2011_0131
- 43173001
Beschrijving
Recent Memory
Datatype
string
Alias
- UMLS CUI 2011AA
- C0233792
- SNOMED CT 2011_0131
- 69063000
Beschrijving
Remote Memory
Datatype
string
Alias
- UMLS CUI 2011AA
- C0233793
- SNOMED CT 2011_0131
- 81964002
Beschrijving
Mood/Affect
Datatype
string
Alias
- UMLS CUI 2011AA
- C0026516, C0001721
- SNOMED CT 2011_0131
- 85256008, 4065008
- LOINC Version 232
- MTHU031584
Beschrijving
Laboratory Results
Beschrijving
Radiology Results
Beschrijving
ASSESSMENT
Beschrijving
acceptable for surgery
Datatype
boolean
Beschrijving
progressing well
Datatype
boolean
Beschrijving
stable medically
Datatype
boolean
Alias
- UMLS CUI 2011AA
- C0205360
- SNOMED CT 2011_0131
- 58158008
- LOINC Version 232
- MTHU015276
Beschrijving
Active Problems
Datatype
string
Alias
- UMLS CUI 2011AA
- C0552582
- LOINC Version 232
- LP73189-0
Beschrijving
Other
Datatype
string
Beschrijving
PLAN
Beschrijving
Continue Home Regimen
Datatype
boolean
Beschrijving
Continue Home Meds
Datatype
boolean
Beschrijving
Continue Chemotherapy
Datatype
boolean
Beschrijving
Continue IV Antibiotics
Datatype
boolean
Beschrijving
Continue PO Antibiotics
Datatype
boolean
Beschrijving
DVT Prophylaxis
Datatype
boolean
Alias
- UMLS CUI 2011AA
- C0853245
- MedDRA 14.1
- 10013880
Beschrijving
O2 Protocol
Datatype
boolean
Beschrijving
Follow Up X-Rays
Datatype
boolean
Beschrijving
UTI treatment
Datatype
boolean
Alias
- UMLS CUI 2011AA
- C0042029
- SNOMED CT 2011_0131
- 68566005
- MedDRA 14.1
- 10046577
Beschrijving
Monitor Blood Pressure and Heart Rate
Datatype
boolean
Beschrijving
Monitor Diabetes Mellitus
Datatype
boolean
Beschrijving
Accuchecks AC & HS
Datatype
boolean
Beschrijving
Accuchecks Q6H
Datatype
boolean
Beschrijving
Sliding Scale Regular Insulin
Datatype
boolean
Alias
- UMLS CUI 2011AA
- C0021641
- SNOMED CT 2011_0131
- 67866001
- LOINC Version 232
- MTHU019392
Beschrijving
Check Follow Up Labs
Datatype
boolean
Beschrijving
Appreciate following patient with you
Datatype
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)