ID

5522

Beschreibung

Form from HIS OpenVistA

Stichworte

Versionen (6)
  1. 16.02.12 16.02.12 -
  2. 07.08.14 07.08.14 - Martin Dugas
  3. 07.08.14 07.08.14 - Martin Dugas
  4. 08.08.14 08.08.14 - Martin Dugas
  5. 09.08.14 09.08.14 - Martin Dugas
  6. 28.08.15 28.08.15 - Martin Dugas
Hochgeladen am

8. August 2014

DOI

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HIS ENDOSCOPY PRE PROCEDURE ID RECORD

Deutsch Englisch

HIS

1 Formulare  
  1. StudyEvent: HIS
    1. HIS
General Info
Beschreibung

General Info

TODAY'S DATE & TIME OF ARRIVAL
Beschreibung

TODAY'S DATE & TIME OF ARRIVAL

Datentyp

date

Allergie
Beschreibung

ALLERGIES

Datentyp

string

Alias
UMLS CUI 2011AA
C0020517
SNOMED CT 2011_0131
257550005
ICD-10-CM Version 2010
T78.40
Medikation
Beschreibung

CURRENT MEDICATIONS

Datentyp

string

Alias
UMLS CUI 2011AA
C0013227
PATIENT STATUS
Beschreibung

PATIENT STATUS

Datentyp

text

HOW ARRIVED
Beschreibung

HOW ARRIVED

Datentyp

text

ACCOMPANIED BY
Beschreibung

ACCOMPANIED BY

Datentyp

text

CONDITION UPON ARRIVAL (stable, unstable)
Beschreibung

CONDITION UPON ARRIVAL

Datentyp

integer

Bewusstseinslage
Beschreibung

LEVEL OF CONSCIOUSNESS

Datentyp

integer

Alias
UMLS CUI 2011AA
C0234421
SNOMED CT 2011_0131
106167005
CONSENT SIGNED BY
Beschreibung

CONSENT SIGNED BY

Datentyp

text

PATIENT ID BAND ON WITH CORRECT NAME, DOB AND PHYSICIAN
Beschreibung

PATIENT ID BAND ON WITH CORRECT NAME, DOB AND PHYSICIAN

Datentyp

boolean

NOTES Patient ID
Beschreibung

NOTES Patient ID

Datentyp

text

Behandelnder Arzt
Beschreibung

PHYSICIAN1

Datentyp

string

Alias
UMLS CUI 2011AA
C1710470
Behandelnder Arzt
Beschreibung

PHYSICIAN2

Datentyp

string

Alias
UMLS CUI 2011AA
C1710470
ASSISTED BY
Beschreibung

ASSISTED BY

Datentyp

text

ANESTHESIA BY
Beschreibung

ANESTHESIA BY

Datentyp

text

Anamnese
Beschreibung

MEDICAL/SURGICAL HISTORY

Datentyp

string

Alias
UMLS CUI 2011AA
C0262926
SNOMED CT 2011_0131
417662000
LOINC Version 232
MTHU027722
LANGUAGE BARRIER
Beschreibung

LANGUAGE BARRIER

Datentyp

boolean

TRANSLATOR (yes, N/A)
Beschreibung

TRANSLATOR

Datentyp

boolean

NOTES
Beschreibung

NOTES

Datentyp

text

PHYSICAL DISABILITIES
Beschreibung

PHYSICAL DISABILITIES

Datentyp

boolean

Körperliche Behinderung
Beschreibung

PHYSICAL DISABILITIES (Description)

Datentyp

string

Alias
UMLS CUI 2011AA
C0520817
SNOMED CT 2011_0131
32572006
MedDRA 14.1
10048624
Dental (Dentures, Partials, Own Intact)
Beschreibung

DENTAL

Datentyp

integer

Hearing (within normal limits (WNL), Decreased R, Decreased L)
Beschreibung

HEARING

Datentyp

integer

Alias
UMLS CUI 2011AA
C0018767
SNOMED CT 2011_0131
47078008
LOINC Version 232
MTHU015042
Visual (WNL,Glasses, Contacts)
Beschreibung

VISUAL

Datentyp

integer

Alias
UMLS CUI 2011AA
C0042789
SNOMED CT 2011_0131
281004000
LOINC Version 232
MTHU014733
NOTES
Beschreibung

NOTES

Datentyp

text

Vitalzeichen bei Aufnahme
Beschreibung

ADMISSION VITAL SIGNS

Datentyp

string

Alias
UMLS CUI 2011AA
C0518766
SNOMED CT 2011_0131
46680005
LOINC Version 232
MTHU024540
Oximetrie
Beschreibung

PULSE OXIMETRY (OXYGEN SATURATION)

Datentyp

string

Alias
UMLS CUI 2011AA
C0523807
SNOMED CT 2011_0131
264598005
MedDRA 14.1
10033316
Gewicht
Beschreibung

Weight

Datentyp

string

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

HEIGHT

Datentyp

string

Alias
UMLS CUI 2011AA
C0489786
LOINC Version 232
MTHU005354
NPO SINCE
Beschreibung

NPO SINCE

Datentyp

time

Prep (Fleet Enema, Fleet Prep Kit, Golytely, Half-Lightly, MAG Citrate, MOVI Prep, Nulytely, OSMO Prep)
Beschreibung

PREP

Datentyp

integer

PREP COMMENTS
Beschreibung

PREP COMMENTS

Datentyp

text

PRE-OP DIAGNOSIS
Beschreibung

PRE-OP DIAGNOSIS

Abnormal GI Xray
Beschreibung

Abnormal GI Xray

Datentyp

boolean

Bauchschmerzen
Beschreibung

Abdominal Pain

Datentyp

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
abnormaler Gewichtsverlust
Beschreibung

Abnormal Weight Loss

Datentyp

boolean

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

Achalasia

Datentyp

boolean

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

Anemia

Datentyp

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
Aszites
Beschreibung

Ascites

Datentyp

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
Beschreibung

Change in Bowel Habits

Datentyp

boolean

Alias
UMLS CUI 2011AA
C2919545
SNOMED CT 2011_0131
444702007
Leberzirrhose
Beschreibung

Hepatic Cirrhosis

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0023890
SNOMED CT 2011_0131
19943007
MedDRA 14.1
10019641
ICD-10-CM Version 2010
K74.60
Screening für Kolonkarzinom
Beschreibung

Colorectal Cancer Screening

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0281185
Common Bile Duct Leak
Beschreibung

Common Bile Duct Leak

Datentyp

boolean

Common Bile Duct Stone
Beschreibung

Common Bile Duct Stone

Datentyp

boolean

Verstopfung
Beschreibung

Constipation

Datentyp

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
Diarrhö
Beschreibung

Diarrhea

Datentyp

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
Dyspepsie
Beschreibung

Dyspepsia

Datentyp

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
Dysphagie
Beschreibung

Dysphagia

Datentyp

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
Beschreibung

Elevated Liver Function Tests

Datentyp

boolean

Ösophagusvarizen
Beschreibung

Esophageal Varices

Datentyp

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
Beschreibung

Family History of Colon Cancer

Datentyp

boolean

Family History of Polyps
Beschreibung

Family History of Polyps

Datentyp

boolean

Family History of Polyposis
Beschreibung

Family History of Polyposis

Datentyp

boolean

Foreign Body in Colon
Beschreibung

Foreign Body in Colon

Datentyp

boolean

Foreign Body in Esophagus
Beschreibung

Foreign Body in Esophagus

Datentyp

boolean

Foreign Body in Stomach
Beschreibung

Foreign Body in Stomach

Datentyp

boolean

Peptic Ulcer
Beschreibung

Gastric Ulcer

Datentyp

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)
Beschreibung

GERD

Datentyp

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
Gastrointestinale Blutung
Beschreibung

GI Bleeding

Datentyp

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
Hämatemesis
Beschreibung

Hematemesis

Datentyp

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
Beschreibung

History of Barrett's

Datentyp

boolean

History of Cholangiocarcinoma
Beschreibung

History of Cholangiocarcinoma

Datentyp

boolean

History of Colon Cancer
Beschreibung

History of Colon Cancer

Datentyp

boolean

History of Crohn's Disease
Beschreibung

History of Crohn's Disease

Datentyp

boolean

History of Diverticulosis
Beschreibung

History of Diverticulosis

Datentyp

boolean

History of Esophageal Cancer
Beschreibung

History of Esophageal Cancer

Datentyp

boolean

History of Esophageal/ Gastric Varicies
Beschreibung

History of Esophageal/ Gastric Varicies

Datentyp

boolean

History of Gastric Cancer
Beschreibung

History of Gastric Cancer

Datentyp

boolean

History of Pancreatic Cancer
Beschreibung

History of Pancreatic Cancer

Datentyp

boolean

History of Peptic Ulcer Disease
Beschreibung

History of Peptic Ulcer Disease

Datentyp

boolean

History of Polyps
Beschreibung

History of Polyps

Datentyp

boolean

History of Ulcerative Colitis
Beschreibung

History of Ulcerative Colitis

Datentyp

boolean

Blut im Stuhl
Beschreibung

Hematochezia

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0018932
SNOMED CT 2011_0131
405729008
MedDRA 14.1
10018836
ICD-9-CM Version 2011
578.1
Eisenmangelanämie
Beschreibung

Iron Deficiency Anemia

Datentyp

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
Ikterus
Beschreibung

Jaundice

Datentyp

boolean

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

Melena

Datentyp

boolean

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

Nausea

Datentyp

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
Erbrechen
Beschreibung

Vomiting

Datentyp

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
Beschreibung

Occult/Guaiac Positive Stool

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0201811
SNOMED CT 2011_0131
104435004
MedDRA 14.1
10016297
Pankreatitis
Beschreibung

Pancreatitis

Datentyp

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
Portale Hypertension
Beschreibung

Portal Hypertension

Datentyp

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
Beschreibung

Gastroesophageal Reflux

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0558176
SNOMED CT 2011_0131
225587003
abnormaler Gewichtsverlust
Beschreibung

Weight Loss

Datentyp

boolean

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

Other

Datentyp

text

PRE-PROCEDURE ALDRETE SCORE
Beschreibung

PRE-PROCEDURE ALDRETE SCORE

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

ACTIVITY

Datentyp

integer

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

RESPIRATORY

Datentyp

text

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

Blood pressure

Datentyp

text

Alias
UMLS
C0005823
SNOMED CT 2011_0131
386534000
Bewusstseinslage
Beschreibung

LEVEL OF CONSCIOUSNESS

Datentyp

text

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)
Beschreibung

EVALUATION OF SKIN CONDITION AND COLOR

Datentyp

text

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

ALDRETE TOTAL SCORE

Datentyp

integer

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Ähnliche Modelle

HIS

1 Formulare
  1. StudyEvent: HIS
    1. HIS
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
TODAY'S DATE & TIME OF ARRIVAL
Item
TODAY'S DATE & TIME OF ARRIVAL
date
ALLERGIES
Item
Allergie
string
C0020517 (UMLS CUI 2011AA)
257550005 (SNOMED CT 2011_0131)
T78.40 (ICD-10-CM Version 2010)
CURRENT MEDICATIONS
Item
Medikation
string
C0013227 (UMLS CUI 2011AA)
PATIENT STATUS
Item
PATIENT STATUS
text
HOW ARRIVED
Item
HOW ARRIVED
text
ACCOMPANIED BY
Item
ACCOMPANIED BY
text
CONDITION UPON ARRIVAL
Item
CONDITION UPON ARRIVAL (stable, unstable)
integer
LEVEL OF CONSCIOUSNESS
Item
Bewusstseinslage
integer
C0234421 (UMLS CUI 2011AA)
106167005 (SNOMED CT 2011_0131)
CONSENT SIGNED BY
Item
CONSENT SIGNED BY
text
PATIENT ID BAND ON WITH CORRECT NAME, DOB AND PHYSICIAN
Item
PATIENT ID BAND ON WITH CORRECT NAME, DOB AND PHYSICIAN
boolean
NOTES Patient ID
Item
NOTES Patient ID
text
PHYSICIAN1
Item
Behandelnder Arzt
string
C1710470 (UMLS CUI 2011AA)
PHYSICIAN2
Item
Behandelnder Arzt
string
C1710470 (UMLS CUI 2011AA)
ASSISTED BY
Item
ASSISTED BY
text
ANESTHESIA BY
Item
ANESTHESIA BY
text
MEDICAL/SURGICAL HISTORY
Item
Anamnese
string
C0262926 (UMLS CUI 2011AA)
417662000 (SNOMED CT 2011_0131)
MTHU027722 (LOINC Version 232)
LANGUAGE BARRIER
Item
LANGUAGE BARRIER
boolean
TRANSLATOR
Item
TRANSLATOR (yes, N/A)
boolean
NOTES
Item
NOTES
text
PHYSICAL DISABILITIES
Item
PHYSICAL DISABILITIES
boolean
PHYSICAL DISABILITIES (Description)
Item
Körperliche Behinderung
string
C0520817 (UMLS CUI 2011AA)
32572006 (SNOMED CT 2011_0131)
10048624 (MedDRA 14.1)
DENTAL
Item
Dental (Dentures, Partials, Own Intact)
integer
HEARING
Item
Hearing (within normal limits (WNL), Decreased R, Decreased L)
integer
C0018767 (UMLS CUI 2011AA)
47078008 (SNOMED CT 2011_0131)
MTHU015042 (LOINC Version 232)
VISUAL
Item
Visual (WNL,Glasses, Contacts)
integer
C0042789 (UMLS CUI 2011AA)
281004000 (SNOMED CT 2011_0131)
MTHU014733 (LOINC Version 232)
NOTES
Item
NOTES
text
ADMISSION VITAL SIGNS
Item
Vitalzeichen bei Aufnahme
string
C0518766 (UMLS CUI 2011AA)
46680005 (SNOMED CT 2011_0131)
MTHU024540 (LOINC Version 232)
PULSE OXIMETRY (OXYGEN SATURATION)
Item
Oximetrie
string
C0523807 (UMLS CUI 2011AA)
264598005 (SNOMED CT 2011_0131)
10033316 (MedDRA 14.1)
Weight
Item
Gewicht
string
C0005910 (UMLS)
107647005 (SNOMED CT 2011_0131)
10047890 (MedDRA 14.1)
LP18015-5 (LOINC Version 232)
HEIGHT
Item
Größe
string
C0489786 (UMLS CUI 2011AA)
MTHU005354 (LOINC Version 232)
NPO SINCE
Item
NPO SINCE
time
PREP
Item
Prep (Fleet Enema, Fleet Prep Kit, Golytely, Half-Lightly, MAG Citrate, MOVI Prep, Nulytely, OSMO Prep)
integer
PREP COMMENTS
Item
PREP COMMENTS
text
Abnormal GI Xray
Item
Abnormal GI Xray
boolean
Abdominal Pain
Item
Bauchschmerzen
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
abnormaler Gewichtsverlust
boolean
C0936227 (UMLS CUI 2011AA)
267024001 (SNOMED CT 2011_0131)
10000159 (MedDRA 14.1)
R63.4 (ICD-10-CM Version 2010)
Achalasia
Item
Achalasie
boolean
C1321756 (UMLS CUI 2011AA)
48531003 (SNOMED CT 2011_0131)
10000420 (MedDRA 14.1)
K22.0 (ICD-10-CM Version 2010)
Anemia
Item
Anämie
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
Aszites
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
Leberzirrhose
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 für Kolonkarzinom
boolean
C0281185 (UMLS CUI 2011AA)
Common Bile Duct Leak
Item
Common Bile Duct Leak
boolean
Common Bile Duct Stone
Item
Common Bile Duct Stone
boolean
Constipation
Item
Verstopfung
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
Diarrhö
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
Dyspepsie
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
Dysphagie
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
Ösophagusvarizen
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
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
Foreign Body in Esophagus
Item
Foreign Body in Esophagus
boolean
Foreign Body in Stomach
Item
Foreign Body in Stomach
boolean
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
Gastrointestinale Blutung
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
Hämatemesis
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
History of Crohn's Disease
Item
History of Crohn's Disease
boolean
History of Diverticulosis
Item
History of Diverticulosis
boolean
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
History of Pancreatic Cancer
Item
History of Pancreatic Cancer
boolean
History of Peptic Ulcer Disease
Item
History of Peptic Ulcer Disease
boolean
History of Polyps
Item
History of Polyps
boolean
History of Ulcerative Colitis
Item
History of Ulcerative Colitis
boolean
Hematochezia
Item
Blut im Stuhl
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
Eisenmangelanämie
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
Ikterus
boolean
C0022346 (UMLS CUI 2011AA)
18165001 (SNOMED CT 2011_0131)
10023126 (MedDRA 14.1)
R17 (ICD-10-CM Version 2010)
Melena
Item
Teerstuhl
boolean
C0025222 (UMLS CUI 2011AA)
2901004 (SNOMED CT 2011_0131)
10027141 (MedDRA 14.1)
K92.1 (ICD-10-CM Version 2010)
Nausea
Item
Übelkeit
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
Erbrechen
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
Pankreatitis
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
Portale 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
abnormaler Gewichtsverlust
boolean
C0936227 (UMLS CUI 2011AA)
267024001 (SNOMED CT 2011_0131)
10000159 (MedDRA 14.1)
R63.4 (ICD-10-CM Version 2010)
Other
Item
Sonstig
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%)
text
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)
text
C0005823 (UMLS)
386534000 (SNOMED CT 2011_0131)
LEVEL OF CONSCIOUSNESS
Item
Bewusstseinslage
text
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)
text
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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