ID

5521

Descripción

Form from HIS OpenVistA

Palabras clave

Versiones (2)
  1. 16/2/12 16/2/12 -
  2. 8/8/14 8/8/14 - Martin Dugas
Subido en

8 de agosto de 2014

DOI

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Licencia

Creative Commons BY-NC 3.0 Legacy
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HIS ENDOSCOPY PROCEDURE RECORD

Alemán Inglés

HIS

1 formularios  
  1. StudyEvent: HIS
    1. HIS
SCOPE INSTRUMENT USED
Descripción

SCOPE INSTRUMENT USED

COLONOSCOPE
Descripción

COLONOSCOPE

Tipo de datos

text

EGD SCOPE
Descripción

EGD SCOPE

Tipo de datos

text

FLEX SIGMOID SCOPE
Descripción

FLEX SIGMOID SCOPE

Tipo de datos

text

ERCP SCOPE
Descripción

ERCP SCOPE

Tipo de datos

text

ENTEROSCOPE
Descripción

ENTEROSCOPE

Tipo de datos

text

DB CHANNEL SCOPE
Descripción

DB CHANNEL SCOPE

Tipo de datos

text

LOANER SCOPE
Descripción

LOANER SCOPE

Tipo de datos

text

VIDEO CAMERA
Descripción

VIDEO CAMERA

Tipo de datos

text

General Info
Descripción

General Info

HISTORY & PHYSICAL COMPLETED?
Descripción

HISTORY & PHYSICAL COMPLETED?

Tipo de datos

boolean

IV START
Descripción

IV START

Tipo de datos

text

IV PUNCTURE SITE
Descripción

IV PUNCTURE SITE

Tipo de datos

text

IV GAUGE
Descripción

IV GAUGE

Tipo de datos

text

IV FLUID
Descripción

IV FLUID

Tipo de datos

text

AMOUNT
Descripción

AMOUNT

Tipo de datos

text

IV RATE [ml/hr]
Descripción

IV RATE [ml/hr]

Tipo de datos

text

TIME STARTED
Descripción

TIME STARTED

Tipo de datos

time

IV INSERTED BY
Descripción

IV INSERTED BY

Tipo de datos

text

NOTES
Descripción

NOTES

Tipo de datos

text

ENDOSCOPY START
Descripción

ENDOSCOPY START

Tipo de datos

text

ENDOSCOPY ROOM
Descripción

ENDOSCOPY ROOM

Tipo de datos

text

TIME OUT TAKEN FOR PROCEDURE VERIFICATION
Descripción

TIME OUT TAKEN FOR PROCEDURE VERIFICATION

Tipo de datos

boolean

VERIFICATION PROCESS
Descripción

VERIFICATION PROCESS

Tipo de datos

text

Finding of American Society of Anesthesiologists physical status classification
Descripción

ASA SCORE

Tipo de datos

string

Alias
UMLS CUI 2011AA
C1531480
SNOMED CT 2011_0131
413347006
OXYGEN DELIVERY METHOD
Descripción

OXYGEN DELIVERY METHOD

Tipo de datos

text

PROCEDURE
Descripción

PROCEDURE

Tipo de datos

text

Alias
UMLS CUI 2011AA
C0087111
PROCEDURE START
Descripción

PROCEDURE START

Tipo de datos

time

PROCEDURE STOP
Descripción

PROCEDURE STOP

Tipo de datos

time

ANESTHESIA START
Descripción

ANESTHESIA START

Tipo de datos

time

ANESTHESIA STOP
Descripción

ANESTHESIA STOP

Tipo de datos

time

Vitalzeichen
Descripción

VITALS SIGNS

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0518766
SNOMED CT 2011_0131
46680005
LOINC Version 232
MTHU024540
IV MEDICATIONS
Descripción

IV MEDICATIONS

Tipo de datos

text

COMMENTS
Descripción

COMMENTS

Tipo de datos

text

COLD BIOPSY
Descripción

COLD BIOPSY

Tipo de datos

text

HOT BIOPSY
Descripción

HOT BIOPSY

Tipo de datos

text

SNARE POLYPECTOMY
Descripción

SNARE POLYPECTOMY

Tipo de datos

text

Alias
UMLS CUI 2011AA
C0940840
CYTOLOGY BRUSHINGS
Descripción

CYTOLOGY BRUSHINGS

Tipo de datos

text

Alias
UMLS CUI 2011AA
C1305671
POST CASE
Descripción

POST CASE

Tipo de datos

text

PATIENT TOLERATED PROCEDURE WELL
Descripción

PATIENT TOLERATED PROCEDURE WELL

Tipo de datos

boolean

POST-OP CONDITION
Descripción

POST-OP CONDITION

Tipo de datos

text

Postoperative Diagnose
Descripción

Post-op diagnosis

Tipo de datos

string

Alias
UMLS CUI 2011AA
C1318969
SNOMED CT 2011_0131
406521002
OTHER
Descripción

OTHER

Tipo de datos

string

ERCP OMNIPAQUE CONTRAST MEDIUM [ml]
Descripción

ERCP OMNIPAQUE CONTRAST MEDIUM [ml]

Tipo de datos

text

FLUOROSCOPY TIME [minutes]
Descripción

FLUOROSCOPY TIME [minutes]

Tipo de datos

text

ESU
Descripción

ESU

Tipo de datos

text

SETTINGS
Descripción

SETTINGS

Tipo de datos

text

PLACEMENT OF GROUNDING PAD
Descripción

PLACEMENT OF GROUNDING PAD

Tipo de datos

text

TEXT
Descripción

TEXT

Tipo de datos

string

SKIN CLEAR & INTACT BENEATH SITE OF GROUNDING PAD
Descripción

SKIN CLEAR & INTACT BENEATH SITE OF GROUNDING PAD

Tipo de datos

text

DISCHARGE
Descripción

DISCHARGE

Tipo de datos

text

IV DISCONTINUED
Descripción

IV DISCONTINUED

Tipo de datos

time

AMOUNT OF SOLUTION GIVEN [ml]
Descripción

AMOUNT OF SOLUTION GIVEN [ml]

Tipo de datos

integer

CONDITION AT DISCHARGE
Descripción

CONDITION AT DISCHARGE

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0586514
Discharge disposition
Descripción

DISPOSITION

Tipo de datos

string

Alias
UMLS CUI 2011AA
C1550390
LOINC Version 232
MTHU021441
ACCOMPANIED BY
Descripción

ACCOMPANIED BY

Tipo de datos

text

DISCHARGE INSTRUCTIONS GIVEN TO
Descripción

DISCHARGE INSTRUCTIONS GIVEN TO

Tipo de datos

text

TIME OF DISCHARGE
Descripción

TIME OF DISCHARGE

Tipo de datos

time

PROCEDURE REPORT GIVEN TO STAFF NURSE
Descripción

PROCEDURE REPORT GIVEN TO STAFF NURSE

Tipo de datos

text

Patient able to
Descripción

Patient able to

Tipo de datos

text

ALDRETE SCORE
Descripción

ALDRETE SCORE

ACTIVITY (2= all 4 extremities move voluntarily or on command, 1= 2 extremities move voluntarily or on command, 0= cannot move extremities)
Descripción

ACTIVITY

Tipo de datos

integer

RESPIRATORY (2= able to deep breath, cough freely, 1= dyspnea or limited breathing, 0= apnea or SAO2 <90%)
Descripción

RESPIRATORY

Tipo de datos

integer

BLOOD PRESSURE (2= BP +/- 20% of pre-procedure level, 1= BP +/- 21-49% pre-procedure level, 0= BP +/- 50% pre-procedure level)
Descripción

Blood pressure

Tipo de datos

integer

Alias
UMLS
C0005823
SNOMED CT 2011_0131
386534000
Bewusstseinslage
Descripción

LEVEL OF CONSCIOUSNESS

Tipo de datos

integer

Alias
UMLS CUI 2011AA
C0234421
SNOMED CT 2011_0131
106167005
EVALUATION OF SKIN CONDITION AND COLOR (2=Skin is pink-warm- dry, 1= Skin is pale-dusky-blotchy- jaundice, 0= Patient is cyanotic)
Descripción

EVALUATION OF SKIN CONDITION AND COLOR

Tipo de datos

integer

Alias
UMLS CUI 2011AA
C1719933
SNOMED CT 2011_0131
422000003
LOINC Version 232
MTHU034830
ALDRETE TOTAL SCORE
Descripción

ALDRETE TOTAL SCORE

Tipo de datos

integer

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Similar models

HIS

1 formularios
  1. StudyEvent: HIS
    1. HIS
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
Alias
COLONOSCOPE
Item
COLONOSCOPE
text
EGD SCOPE
Item
EGD SCOPE
text
FLEX SIGMOID SCOPE
Item
FLEX SIGMOID SCOPE
text
ERCP SCOPE
Item
ERCP SCOPE
text
ENTEROSCOPE
Item
ENTEROSCOPE
text
DB CHANNEL SCOPE
Item
DB CHANNEL SCOPE
text
LOANER SCOPE
Item
LOANER SCOPE
text
VIDEO CAMERA
Item
VIDEO CAMERA
text
Item Group
HISTORY & PHYSICAL COMPLETED?
Item
HISTORY & PHYSICAL COMPLETED?
boolean
IV START
Item
IV START
text
IV PUNCTURE SITE
Item
IV PUNCTURE SITE
text
IV GAUGE
Item
IV GAUGE
text
IV FLUID
Item
IV FLUID
text
AMOUNT
Item
AMOUNT
text
IV RATE [ml/hr]
Item
IV RATE [ml/hr]
text
TIME STARTED
Item
TIME STARTED
time
IV INSERTED BY
Item
IV INSERTED BY
text
NOTES
Item
NOTES
text
ENDOSCOPY START
Item
ENDOSCOPY START
text
ENDOSCOPY ROOM
Item
ENDOSCOPY ROOM
text
TIME OUT TAKEN FOR PROCEDURE VERIFICATION
Item
TIME OUT TAKEN FOR PROCEDURE VERIFICATION
boolean
VERIFICATION PROCESS
Item
VERIFICATION PROCESS
text
ASA SCORE
Item
Finding of American Society of Anesthesiologists physical status classification
string
C1531480 (UMLS CUI 2011AA)
413347006 (SNOMED CT 2011_0131)
OXYGEN DELIVERY METHOD
Item
OXYGEN DELIVERY METHOD
text
PROCEDURE
Item
PROCEDURE
text
C0087111 (UMLS CUI 2011AA)
PROCEDURE START
Item
PROCEDURE START
time
PROCEDURE STOP
Item
PROCEDURE STOP
time
ANESTHESIA START
Item
ANESTHESIA START
time
ANESTHESIA STOP
Item
ANESTHESIA STOP
time
VITALS SIGNS
Item
Vitalzeichen
string
C0518766 (UMLS CUI 2011AA)
46680005 (SNOMED CT 2011_0131)
MTHU024540 (LOINC Version 232)
IV MEDICATIONS
Item
IV MEDICATIONS
text
COMMENTS
Item
COMMENTS
text
COLD BIOPSY
Item
COLD BIOPSY
text
HOT BIOPSY
Item
HOT BIOPSY
text
SNARE POLYPECTOMY
Item
SNARE POLYPECTOMY
text
C0940840 (UMLS CUI 2011AA)
CYTOLOGY BRUSHINGS
Item
CYTOLOGY BRUSHINGS
text
C1305671 (UMLS CUI 2011AA)
POST CASE
Item
POST CASE
text
PATIENT TOLERATED PROCEDURE WELL
Item
PATIENT TOLERATED PROCEDURE WELL
boolean
POST-OP CONDITION
Item
POST-OP CONDITION
text
Post-op diagnosis
Item
Postoperative Diagnose
string
C1318969 (UMLS CUI 2011AA)
406521002 (SNOMED CT 2011_0131)
OTHER
Item
OTHER
string
ERCP OMNIPAQUE CONTRAST MEDIUM [ml]
Item
ERCP OMNIPAQUE CONTRAST MEDIUM [ml]
text
FLUOROSCOPY TIME [minutes]
Item
FLUOROSCOPY TIME [minutes]
text
ESU
Item
ESU
text
SETTINGS
Item
SETTINGS
text
PLACEMENT OF GROUNDING PAD
Item
PLACEMENT OF GROUNDING PAD
text
TEXT
Item
TEXT
string
SKIN CLEAR & INTACT BENEATH SITE OF GROUNDING PAD
Item
SKIN CLEAR & INTACT BENEATH SITE OF GROUNDING PAD
text
DISCHARGE
Item
DISCHARGE
text
IV DISCONTINUED
Item
IV DISCONTINUED
time
AMOUNT OF SOLUTION GIVEN [ml]
Item
AMOUNT OF SOLUTION GIVEN [ml]
integer
CONDITION AT DISCHARGE
Item
CONDITION AT DISCHARGE
string
C0586514 (UMLS CUI 2011AA)
DISPOSITION
Item
Discharge disposition
string
C1550390 (UMLS CUI 2011AA)
MTHU021441 (LOINC Version 232)
ACCOMPANIED BY
Item
ACCOMPANIED BY
text
DISCHARGE INSTRUCTIONS GIVEN TO
Item
DISCHARGE INSTRUCTIONS GIVEN TO
text
TIME OF DISCHARGE
Item
TIME OF DISCHARGE
time
PROCEDURE REPORT GIVEN TO STAFF NURSE
Item
PROCEDURE REPORT GIVEN TO STAFF NURSE
text
Patient able to
Item
Patient able to
text
Item Group
ACTIVITY
Item
ACTIVITY (2= all 4 extremities move voluntarily or on command, 1= 2 extremities move voluntarily or on command, 0= cannot move extremities)
integer
RESPIRATORY
Item
RESPIRATORY (2= able to deep breath, cough freely, 1= dyspnea or limited breathing, 0= apnea or SAO2 <90%)
integer
Blood pressure
Item
BLOOD PRESSURE (2= BP +/- 20% of pre-procedure level, 1= BP +/- 21-49% pre-procedure level, 0= BP +/- 50% pre-procedure level)
integer
C0005823 (UMLS)
386534000 (SNOMED CT 2011_0131)
LEVEL OF CONSCIOUSNESS
Item
Bewusstseinslage
integer
C0234421 (UMLS CUI 2011AA)
106167005 (SNOMED CT 2011_0131)
EVALUATION OF SKIN CONDITION AND COLOR
Item
EVALUATION OF SKIN CONDITION AND COLOR (2=Skin is pink-warm- dry, 1= Skin is pale-dusky-blotchy- jaundice, 0= Patient is cyanotic)
integer
C1719933 (UMLS CUI 2011AA)
422000003 (SNOMED CT 2011_0131)
MTHU034830 (LOINC Version 232)
ALDRETE TOTAL SCORE
Item
ALDRETE TOTAL SCORE
integer
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