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5521
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Form from HIS OpenVistA
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- 16-02-12 16-02-12 -
- 08-08-14 08-08-14 - Martin Dugas
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8 augustus 2014
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Creative Commons BY-NC 3.0 Legacy
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HIS ENDOSCOPY PROCEDURE RECORD
Similar models
HIS
- StudyEvent: HIS
Name
Type
Description | Question | Decode (Coded Value)
Datatype
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
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)
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
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)
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
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
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)
386534000 (SNOMED CT 2011_0131)
LEVEL OF CONSCIOUSNESS
Item
Bewusstseinslage
integer
C0234421 (UMLS CUI 2011AA)
106167005 (SNOMED CT 2011_0131)
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
ALDRETE TOTAL SCORE
Item
ALDRETE TOTAL SCORE
integer