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ID

5585

Description

Form from HIS OpenVistA

Keywords

  1. 2/24/12 2/24/12 -
  2. 2/29/12 2/29/12 -
  3. 8/7/14 8/7/14 - Martin Dugas
  4. 8/9/14 8/9/14 - Martin Dugas
  5. 6/26/15 6/26/15 - Martin Dugas
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August 9, 2014

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Creative Commons BY-NC 3.0 Legacy

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    HIS INTERVENTIONAL RADIOLOGY

    1. StudyEvent: HIS
      1. HIS
    General Info
    Description

    General Info

    Age
    Description

    Age

    Data type

    integer

    Alias
    UMLS CUI 2011AA
    C0001779
    SNOMED CT 2011_0131
    397669002
    Sex
    Description

    Gender

    Data type

    integer

    Alias
    UMLS CUI 2011AA
    C0079399
    SNOMED CT 2011_0131
    263495000
    LOINC Version 232
    MTHU002975
    Racial group
    Description

    Race

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C0034510
    SNOMED CT 2011_0131
    103579009
    LOINC Version 232
    MTHU009923
    Height
    Description

    Height

    Data type

    integer

    Alias
    UMLS CUI-1
    C0005890
    LOINC Version 232
    MTHU005354
    Weight
    Description

    Weight

    Data type

    integer

    Alias
    UMLS
    C0005910
    SNOMED CT 2011_0131
    107647005
    MedDRA 14.1
    10047890
    LOINC Version 232
    LP18015-5
    Chief complaint (CC)
    Description

    CHIEF COMPLAINT

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C0277786
    SNOMED CT 2011_0131
    33962009
    LOINC Version 232
    MTHU001077
    History of present illness
    Description

    PRESENT ILLNESS

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C0262512
    LOINC Version 232
    MTHU001399
    Prior Health History
    Description

    Prior Health History

    Past medical history
    Description

    Medical Illness

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C0262926
    SNOMED CT 2011_0131
    417662000
    LOINC Version 232
    MTHU027722
    Prior Surgery, History of (H/O) surgery, Past surgical history
    Description

    Surgery

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C0455610
    SNOMED CT 2011_0131
    161615003
    current medication list, active medication
    Description

    DETAILED ACTIVE MEDS

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C1553892
    Allergies
    Description

    Allergies

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C0020517
    SNOMED CT 2011_0131
    257550005
    ICD-10-CM Version 2010
    T78.40
    Review of systems
    Description

    REVIEW OF SYSTEMS(Positive findings)

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C0489633
    SNOMED CT 2011_0131
    415300000
    LOINC Version 232
    MTHU001422
    Family history (FH) of
    Description

    FAMILY HISTORY

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C0241889
    SNOMED CT 2011_0131
    57177007
    Social and personal history, Social and personal circumstances
    Description

    SOCIAL HISTORY

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C0424945
    SNOMED CT 2011_0131
    160476009
    LOINC Version 232
    MTHU014081
    Immunisation
    Description

    IMMUNIZATIONS

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C0020971
    SNOMED CT 2011_0131
    127785005
    MedDRA 14.1
    10021431
    Physical Exam
    Description

    Physical Exam

    Temperature
    Description

    Temperature

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C0039476
    SNOMED CT 2011_0131
    246508008
    LOINC Version 232
    MTHU009008
    Pulse Rate
    Description

    Pulse

    Data type

    integer

    Alias
    UMLS CUI 2011AA
    C0232117
    SNOMED CT 2011_0131
    78564009
    MedDRA 14.1
    10037485
    Respiration rate, Breathing rate (BR)
    Description

    Respiration rate

    Data type

    integer

    Alias
    UMLS CUI 2011AA
    C0231832
    SNOMED CT 2011_0131
    86290005
    MedDRA 14.1
    10038709
    LOINC Version 232
    MTHU008344
    Blood pressure (BP)
    Description

    Blood pressure

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C0005823
    SNOMED CT 2011_0131
    75367002
    LOINC Version 232
    MTHU008342
    Pain
    Description

    Pain

    Data type

    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
    general appearance
    Description

    GENERAL APPEARANCE

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C1148438
    LOINC Version 232
    MTHU015040
    Head, Ears, Eyes, Nose and Throat
    Description

    HEENT

    Data type

    text

    Alias
    UMLS CUI 2011AA
    C1512338
    Neck, Collum, Cervical
    Description

    NECK

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C0027530
    SNOMED CT 2011_0131
    45048000
    LOINC Version 232
    MTHU002688
    Chest, Thorax
    Description

    CHEST

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C0817096
    SNOMED CT 2011_0131
    51185008
    Mammary region
    Description

    BREAST

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C0006141
    SNOMED CT 2011_0131
    76752008
    LOINC Version 232
    MTHU011382
    Heart
    Description

    HEART

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C0018787
    SNOMED CT 2011_0131
    80891009
    LOINC Version 232
    MTHU001067
    Abdomen
    Description

    ABDOMEN

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C0000726
    SNOMED CT 2011_0131
    113345001
    LOINC Version 232
    MTHU001425
    lymph nodes
    Description

    LYMPH NODES

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C0024204
    SNOMED CT 2011_0131
    59441001
    LOINC Version 232
    MTHU015050
    Genital Organs/Rectal
    Description

    GENITALIA/RECTAL

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C0017420, C0205052
    SNOMED CT 2011_0131
    255582007
    LOINC Version 232
    MTHU002681
    Extremities, Limb structure
    Description

    EXTREMITIES

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C0015385
    SNOMED CT 2011_0131
    66019005
    LOINC Version 232
    MTHU001429
    Integument
    Description

    SKIN

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C1123023
    SNOMED CT 2011_0131
    39937001
    LOINC Version 232
    MTHU001414
    Neurologic system, Nervous system, Nervous system structure
    Description

    NEUROLOGICAL

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C0027763
    SNOMED CT 2011_0131
    25087005
    LOINC Version 232
    MTHU001437
    summary, conclusion
    Description

    IMPRESSION

    Data type

    string

    Alias
    UMLS CUI 2011AA
    CL386604
    Plan
    Description

    PLAN

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C1301732
    SNOMED CT 2011_0131
    397943006
    Finding of American Society of Anesthesiologists physical status classification
    Description

    ASA SCORE

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C1531480
    SNOMED CT 2011_0131
    413347006
    AIRWAY ASSESSMENT FOR PATIENTS RECEIVING MODERATE SEDATION
    Description

    AIRWAY ASSESSMENT FOR PATIENTS RECEIVING MODERATE SEDATION

    Data type

    text

    Teeth
    Description

    Teeth

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C0040426
    SNOMED CT 2011_0131
    245543004
    LOINC Version 232
    MTHU021292
    Mallampati score
    Description

    MALLAMPATI AIRWAY SCORE

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C0451276
    SNOMED CT 2011_0131
    273585005
    Neck Extension (normal/RESTRICTED/NO MOBILITY)
    Description

    Neck Extension

    Data type

    text

    Alias
    UMLS CUI 2011AA
    C0027530, C0231448
    SNOMED CT 2011_0131
    45048000, 255536004
    LOINC Version 232
    MTHU002688, MTHU010348
    Treating Physician
    Description

    Physician

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C1710470
    Procedure
    Description

    Procedure

    Date of procedure
    Description

    DATE OF PROCEDURE

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C2584899
    SNOMED CT 2011_0131
    439272007
    Preoperative diagnosis
    Description

    PRE-OP DIAGNOSIS

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C1318968
    SNOMED CT 2011_0131
    406520001
    Post-operative diagnosis
    Description

    POST-OP DIAGNOSIS

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C1318969
    SNOMED CT 2011_0131
    406521002
    Primary Surgeon
    Description

    PRIMARY SURGEON

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C0808118
    LOINC Version 232
    MTHU010488
    HL7 V3 2006_05
    PRISURG
    first assistant surgeon
    Description

    ASSISTANT

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C1550491
    HL7 V3 2006_05
    FASST
    anesthesist
    Description

    ANESTHESIA PROVIDER

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C1550495
    HL7 V3 2006_05
    ANEST
    ANESTHESIA/SEDATION
    Description

    ANESTHESIA/SEDATION

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C0002903, C0344106
    SNOMED CT 2011_0131
    399097000, 72641008
    MedDRA 14.1
    10002091, 10059283
    LOINC Version 232
    MTHU035920
    Medication
    Description

    Medication

    ANTIBIOTIC: Ancef
    Description

    ANTIBIOTIC: Ancef

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C0003232
    SNOMED CT 2011_0131
    255631004
    ANTIBIOTIC: Rocephin
    Description

    ANTIBIOTIC: Rocephin

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C0003232
    SNOMED CT 2011_0131
    255631004
    ANTIBIOTIC: Levaquin
    Description

    ANTIBIOTIC: Levaquin

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C0003232
    SNOMED CT 2011_0131
    255631004
    ANTIBIOTIC: Other
    Description

    ANTIBIOTIC: Other

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C0003232
    SNOMED CT 2011_0131
    255631004
    OTHER MEDS GIVEN
    Description

    OTHER MEDS GIVEN

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C0013227
    TECHNICAL PROCEDURE
    Description

    TECHNICAL PROCEDURE

    Drainage of abscess
    Description

    Abscess drainage

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C0344096
    SNOMED CT 2011_0131
    118442004
    MedDRA 14.1
    10000279
    Aortography, Contrast aortogram
    Description

    Aortogram

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C0003515
    SNOMED CT 2011_0131
    54640009
    MedDRA 14.1
    10057775
    ICD-9-CM Version 2011
    88.42
    Aortogram and Runoff
    Description

    Aortogram and Runoff

    Data type

    boolean

    AV Fistulagram
    Description

    AV Fistulagram

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C0412315
    SNOMED CT 2011_0131
    241275007
    Biliary Drain
    Description

    Biliary Drain

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C0489793
    LOINC Version 232
    MTHU001297
    Angiogram carotid, Carotid angiography
    Description

    Carotid Angiogram

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C0202896
    SNOMED CT 2011_0131
    420171008
    MedDRA 14.1
    10003194
    ICD-9-CM Version 2011
    88.41
    Cerebral angiogram, Angiogram cerebral, Fluoroscopic angiography of cerebral artery
    Description

    Cerebral Angiogram

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C0948923
    SNOMED CT 2011_0131
    419364000
    MedDRA 14.1
    10052905
    Chest drain, chest tube, thoracic tube
    Description

    Chest tube

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C0008034
    SNOMED CT 2011_0131
    258643002
    LOINC Version 232
    MTHU001287
    Chest tube/Empyema
    Description

    Chest tube/Empyema

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C0008034,C0014009
    SNOMED CT 2011_0131
    258643002, 66696
    MedDRA 14.1
    10014568
    LOINC Version 232
    MTHU001287
    ICD-9-CM Version 2011
    510
    Central venous catheter (CVC), Central venous line
    Description

    CVC

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C1145640
    SNOMED CT 2011_0131
    52124006
    CVC/Port
    Description

    CVC/Port

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C1145640, C0179694
    SNOMED CT 2011_0131
    52124006
    CVC Temporary
    Description

    CVC Temporary

    Data type

    boolean

    CVC Tunneled
    Description

    CVC Tunneled

    Data type

    boolean

    Dialysis Access Declot
    Description

    Dialysis Access Declot

    Data type

    boolean

    Endovenous laser treatment (ELT)
    Description

    EVLT

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C1998394
    Extremity Angiogram
    Description

    Extremity Angiogram

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    CL378222, C0015385
    SNOMED CT 2011_0131
    77343006, 66019005
    MedDRA 14.1
    10050062
    LOINC Version 232
    MTHU001429
    Balloon Vertebroplasty
    Description

    Kyphoplasty

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C1455863
    MedDRA 14.1
    10064702
    ICD-9-CM Version 2011
    81.66
    Percutaneous insertion of nephrostomy tube
    Description

    Percutaneous Nephrostomy

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C0564457
    SNOMED CT 2011_0131
    313270001
    Peripherally-Inserted Central Catheter (PICC), PICC line
    Description

    PICC

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C0179740
    SNOMED CT 2011_0131
    398176008
    Pulmonary arteriogram, Pulmonary artery angiography
    Description

    Pulmonary Angiogram

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C0202910
    SNOMED CT 2011_0131
    84200003
    MedDRA 14.1
    10002440
    ICD-9-CM Version 2011
    88.43
    radiofrequency ablation procedure
    Description

    RFA (RF-Ablation)

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    CL382653
    transarterial chemoembolization
    Description

    TACE

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    CL388501
    Thrombolysis
    Description

    Thrombolysis

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C0520997
    SNOMED CT 2011_0131
    51308000
    MedDRA 14.1
    10043568
    Embolisation of uterine artery
    Description

    Uterine Artery Embolization

    Data type

    boolean

    Alias
    UMLS CUI 2011AA
    C0729536
    SNOMED CT 2011_0131
    312138002
    Other procedure
    Description

    Other procedure

    Data type

    string

    FINDINGS (None|Same|N/A|Successful|Unsuccessful)
    Description

    FINDINGS

    Data type

    integer

    Findings text
    Description

    Findings text

    Data type

    string

    bleeding, blood loss, hemorrhage
    Description

    BLOOD LOSS

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C0019080
    SNOMED CT 2011_0131
    50960005
    MedDRA 14.1
    10055798
    ICD-10-CM Version 2010
    R58
    ICD-9-CM Version 2011
    459.0
    Contrast medium, Contrast agent
    Description

    CONTRAST

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C0009924
    SNOMED CT 2011_0131
    385420005
    FLUORO TIME
    Description

    FLUORO TIME

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C0016356
    SNOMED CT 2011_0131
    44491008
    MedDRA 14.1
    10064426
    SPECIMEN(s)REMOVED (yes|no)
    Description

    SPECIMEN(s) REMOVED

    Data type

    boolean

    Specimen
    Description

    SPECIMEN(s)

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C0370003
    SNOMED CT 2011_0131
    123038009
    LOINC Version 232
    MTHU010726
    COMPLICATIONS: No immediate
    Description

    COMPLICATIONS: No immediate

    Data type

    boolean

    Complications
    Description

    Complications text

    Data type

    string

    Alias
    UMLS CUI 2011AA
    C0009566
    SNOMED CT 2011_0131
    116223007
    LOINC Version 232
    MTHU008883

    Similar models

    1. StudyEvent: HIS
      1. HIS
    Name
    Type
    Description | Question | Decode (Coded Value)
    Data type
    Alias
    Item Group
    General Info
    Age
    Item
    Age
    integer
    C0001779 (UMLS CUI 2011AA)
    397669002 (SNOMED CT 2011_0131)
    Gender
    Item
    Sex
    integer
    C0079399 (UMLS CUI 2011AA)
    263495000 (SNOMED CT 2011_0131)
    MTHU002975 (LOINC Version 232)
    Race
    Item
    Racial group
    string
    C0034510 (UMLS CUI 2011AA)
    103579009 (SNOMED CT 2011_0131)
    MTHU009923 (LOINC Version 232)
    Height
    Item
    Height
    integer
    C0005890 (UMLS CUI-1)
    MTHU005354 (LOINC Version 232)
    Weight
    Item
    Weight
    integer
    C0005910 (UMLS)
    107647005 (SNOMED CT 2011_0131)
    10047890 (MedDRA 14.1)
    LP18015-5 (LOINC Version 232)
    CHIEF COMPLAINT
    Item
    Chief complaint (CC)
    string
    C0277786 (UMLS CUI 2011AA)
    33962009 (SNOMED CT 2011_0131)
    MTHU001077 (LOINC Version 232)
    PRESENT ILLNESS
    Item
    History of present illness
    string
    C0262512 (UMLS CUI 2011AA)
    MTHU001399 (LOINC Version 232)
    Item Group
    Prior Health History
    Medical Illness
    Item
    Past medical history
    string
    C0262926 (UMLS CUI 2011AA)
    417662000 (SNOMED CT 2011_0131)
    MTHU027722 (LOINC Version 232)
    Surgery
    Item
    Prior Surgery, History of (H/O) surgery, Past surgical history
    string
    C0455610 (UMLS CUI 2011AA)
    161615003 (SNOMED CT 2011_0131)
    DETAILED ACTIVE MEDS
    Item
    current medication list, active medication
    string
    C1553892 (UMLS CUI 2011AA)
    Allergies
    Item
    Allergies
    string
    C0020517 (UMLS CUI 2011AA)
    257550005 (SNOMED CT 2011_0131)
    T78.40 (ICD-10-CM Version 2010)
    REVIEW OF SYSTEMS(Positive findings)
    Item
    Review of systems
    string
    C0489633 (UMLS CUI 2011AA)
    415300000 (SNOMED CT 2011_0131)
    MTHU001422 (LOINC Version 232)
    FAMILY HISTORY
    Item
    Family history (FH) of
    string
    C0241889 (UMLS CUI 2011AA)
    57177007 (SNOMED CT 2011_0131)
    SOCIAL HISTORY
    Item
    Social and personal history, Social and personal circumstances
    string
    C0424945 (UMLS CUI 2011AA)
    160476009 (SNOMED CT 2011_0131)
    MTHU014081 (LOINC Version 232)
    IMMUNIZATIONS
    Item
    Immunisation
    string
    C0020971 (UMLS CUI 2011AA)
    127785005 (SNOMED CT 2011_0131)
    10021431 (MedDRA 14.1)
    Item Group
    Physical Exam
    Temperature
    Item
    Temperature
    string
    C0039476 (UMLS CUI 2011AA)
    246508008 (SNOMED CT 2011_0131)
    MTHU009008 (LOINC Version 232)
    Pulse
    Item
    Pulse Rate
    integer
    C0232117 (UMLS CUI 2011AA)
    78564009 (SNOMED CT 2011_0131)
    10037485 (MedDRA 14.1)
    Respiration rate
    Item
    Respiration rate, Breathing rate (BR)
    integer
    C0231832 (UMLS CUI 2011AA)
    86290005 (SNOMED CT 2011_0131)
    10038709 (MedDRA 14.1)
    MTHU008344 (LOINC Version 232)
    Blood pressure
    Item
    Blood pressure (BP)
    string
    C0005823 (UMLS CUI 2011AA)
    75367002 (SNOMED CT 2011_0131)
    MTHU008342 (LOINC Version 232)
    Pain
    Item
    Pain
    string
    C0030193 (UMLS CUI 2011AA)
    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)
    GENERAL APPEARANCE
    Item
    general appearance
    string
    C1148438 (UMLS CUI 2011AA)
    MTHU015040 (LOINC Version 232)
    HEENT
    Item
    Head, Ears, Eyes, Nose and Throat
    text
    C1512338 (UMLS CUI 2011AA)
    NECK
    Item
    Neck, Collum, Cervical
    string
    C0027530 (UMLS CUI 2011AA)
    45048000 (SNOMED CT 2011_0131)
    MTHU002688 (LOINC Version 232)
    CHEST
    Item
    Chest, Thorax
    string
    C0817096 (UMLS CUI 2011AA)
    51185008 (SNOMED CT 2011_0131)
    BREAST
    Item
    Mammary region
    string
    C0006141 (UMLS CUI 2011AA)
    76752008 (SNOMED CT 2011_0131)
    MTHU011382 (LOINC Version 232)
    HEART
    Item
    Heart
    string
    C0018787 (UMLS CUI 2011AA)
    80891009 (SNOMED CT 2011_0131)
    MTHU001067 (LOINC Version 232)
    ABDOMEN
    Item
    Abdomen
    string
    C0000726 (UMLS CUI 2011AA)
    113345001 (SNOMED CT 2011_0131)
    MTHU001425 (LOINC Version 232)
    LYMPH NODES
    Item
    lymph nodes
    string
    C0024204 (UMLS CUI 2011AA)
    59441001 (SNOMED CT 2011_0131)
    MTHU015050 (LOINC Version 232)
    GENITALIA/RECTAL
    Item
    Genital Organs/Rectal
    string
    C0017420, C0205052 (UMLS CUI 2011AA)
    255582007 (SNOMED CT 2011_0131)
    MTHU002681 (LOINC Version 232)
    EXTREMITIES
    Item
    Extremities, Limb structure
    string
    C0015385 (UMLS CUI 2011AA)
    66019005 (SNOMED CT 2011_0131)
    MTHU001429 (LOINC Version 232)
    SKIN
    Item
    Integument
    string
    C1123023 (UMLS CUI 2011AA)
    39937001 (SNOMED CT 2011_0131)
    MTHU001414 (LOINC Version 232)
    NEUROLOGICAL
    Item
    Neurologic system, Nervous system, Nervous system structure
    string
    C0027763 (UMLS CUI 2011AA)
    25087005 (SNOMED CT 2011_0131)
    MTHU001437 (LOINC Version 232)
    IMPRESSION
    Item
    summary, conclusion
    string
    CL386604 (UMLS CUI 2011AA)
    PLAN
    Item
    Plan
    string
    C1301732 (UMLS CUI 2011AA)
    397943006 (SNOMED CT 2011_0131)
    ASA SCORE
    Item
    Finding of American Society of Anesthesiologists physical status classification
    string
    C1531480 (UMLS CUI 2011AA)
    413347006 (SNOMED CT 2011_0131)
    AIRWAY ASSESSMENT FOR PATIENTS RECEIVING MODERATE SEDATION
    Item
    AIRWAY ASSESSMENT FOR PATIENTS RECEIVING MODERATE SEDATION
    text
    Teeth
    Item
    Teeth
    string
    C0040426 (UMLS CUI 2011AA)
    245543004 (SNOMED CT 2011_0131)
    MTHU021292 (LOINC Version 232)
    MALLAMPATI AIRWAY SCORE
    Item
    Mallampati score
    string
    C0451276 (UMLS CUI 2011AA)
    273585005 (SNOMED CT 2011_0131)
    Neck Extension
    Item
    Neck Extension (normal/RESTRICTED/NO MOBILITY)
    text
    C0027530, C0231448 (UMLS CUI 2011AA)
    45048000, 255536004 (SNOMED CT 2011_0131)
    MTHU002688, MTHU010348 (LOINC Version 232)
    Physician
    Item
    Treating Physician
    string
    C1710470 (UMLS CUI 2011AA)
    Item Group
    Procedure
    DATE OF PROCEDURE
    Item
    Date of procedure
    string
    C2584899 (UMLS CUI 2011AA)
    439272007 (SNOMED CT 2011_0131)
    PRE-OP DIAGNOSIS
    Item
    Preoperative diagnosis
    string
    C1318968 (UMLS CUI 2011AA)
    406520001 (SNOMED CT 2011_0131)
    POST-OP DIAGNOSIS
    Item
    Post-operative diagnosis
    string
    C1318969 (UMLS CUI 2011AA)
    406521002 (SNOMED CT 2011_0131)
    PRIMARY SURGEON
    Item
    Primary Surgeon
    string
    C0808118 (UMLS CUI 2011AA)
    MTHU010488 (LOINC Version 232)
    PRISURG (HL7 V3 2006_05)
    ASSISTANT
    Item
    first assistant surgeon
    string
    C1550491 (UMLS CUI 2011AA)
    FASST (HL7 V3 2006_05)
    ANESTHESIA PROVIDER
    Item
    anesthesist
    string
    C1550495 (UMLS CUI 2011AA)
    ANEST (HL7 V3 2006_05)
    ANESTHESIA/SEDATION
    Item
    ANESTHESIA/SEDATION
    string
    C0002903, C0344106 (UMLS CUI 2011AA)
    399097000, 72641008 (SNOMED CT 2011_0131)
    10002091, 10059283 (MedDRA 14.1)
    MTHU035920 (LOINC Version 232)
    Item Group
    Medication
    ANTIBIOTIC: Ancef
    Item
    ANTIBIOTIC: Ancef
    boolean
    C0003232 (UMLS CUI 2011AA)
    255631004 (SNOMED CT 2011_0131)
    ANTIBIOTIC: Rocephin
    Item
    ANTIBIOTIC: Rocephin
    boolean
    C0003232 (UMLS CUI 2011AA)
    255631004 (SNOMED CT 2011_0131)
    ANTIBIOTIC: Levaquin
    Item
    ANTIBIOTIC: Levaquin
    boolean
    C0003232 (UMLS CUI 2011AA)
    255631004 (SNOMED CT 2011_0131)
    ANTIBIOTIC: Other
    Item
    ANTIBIOTIC: Other
    string
    C0003232 (UMLS CUI 2011AA)
    255631004 (SNOMED CT 2011_0131)
    OTHER MEDS GIVEN
    Item
    OTHER MEDS GIVEN
    string
    C0013227 (UMLS CUI 2011AA)
    Item Group
    TECHNICAL PROCEDURE
    Abscess drainage
    Item
    Drainage of abscess
    boolean
    C0344096 (UMLS CUI 2011AA)
    118442004 (SNOMED CT 2011_0131)
    10000279 (MedDRA 14.1)
    Aortogram
    Item
    Aortography, Contrast aortogram
    boolean
    C0003515 (UMLS CUI 2011AA)
    54640009 (SNOMED CT 2011_0131)
    10057775 (MedDRA 14.1)
    88.42 (ICD-9-CM Version 2011)
    Aortogram and Runoff
    Item
    Aortogram and Runoff
    boolean
    AV Fistulagram
    Item
    AV Fistulagram
    boolean
    C0412315 (UMLS CUI 2011AA)
    241275007 (SNOMED CT 2011_0131)
    Biliary Drain
    Item
    Biliary Drain
    boolean
    C0489793 (UMLS CUI 2011AA)
    MTHU001297 (LOINC Version 232)
    Carotid Angiogram
    Item
    Angiogram carotid, Carotid angiography
    boolean
    C0202896 (UMLS CUI 2011AA)
    420171008 (SNOMED CT 2011_0131)
    10003194 (MedDRA 14.1)
    88.41 (ICD-9-CM Version 2011)
    Cerebral Angiogram
    Item
    Cerebral angiogram, Angiogram cerebral, Fluoroscopic angiography of cerebral artery
    boolean
    C0948923 (UMLS CUI 2011AA)
    419364000 (SNOMED CT 2011_0131)
    10052905 (MedDRA 14.1)
    Chest tube
    Item
    Chest drain, chest tube, thoracic tube
    boolean
    C0008034 (UMLS CUI 2011AA)
    258643002 (SNOMED CT 2011_0131)
    MTHU001287 (LOINC Version 232)
    Chest tube/Empyema
    Item
    Chest tube/Empyema
    boolean
    C0008034,C0014009 (UMLS CUI 2011AA)
    258643002, 66696 (SNOMED CT 2011_0131)
    10014568 (MedDRA 14.1)
    MTHU001287 (LOINC Version 232)
    510 (ICD-9-CM Version 2011)
    CVC
    Item
    Central venous catheter (CVC), Central venous line
    boolean
    C1145640 (UMLS CUI 2011AA)
    52124006 (SNOMED CT 2011_0131)
    CVC/Port
    Item
    CVC/Port
    boolean
    C1145640, C0179694 (UMLS CUI 2011AA)
    52124006 (SNOMED CT 2011_0131)
    CVC Temporary
    Item
    CVC Temporary
    boolean
    CVC Tunneled
    Item
    CVC Tunneled
    boolean
    Dialysis Access Declot
    Item
    Dialysis Access Declot
    boolean
    EVLT
    Item
    Endovenous laser treatment (ELT)
    boolean
    C1998394 (UMLS CUI 2011AA)
    Extremity Angiogram
    Item
    Extremity Angiogram
    boolean
    CL378222, C0015385 (UMLS CUI 2011AA)
    77343006, 66019005 (SNOMED CT 2011_0131)
    10050062 (MedDRA 14.1)
    MTHU001429 (LOINC Version 232)
    Kyphoplasty
    Item
    Balloon Vertebroplasty
    boolean
    C1455863 (UMLS CUI 2011AA)
    10064702 (MedDRA 14.1)
    81.66 (ICD-9-CM Version 2011)
    Percutaneous Nephrostomy
    Item
    Percutaneous insertion of nephrostomy tube
    boolean
    C0564457 (UMLS CUI 2011AA)
    313270001 (SNOMED CT 2011_0131)
    PICC
    Item
    Peripherally-Inserted Central Catheter (PICC), PICC line
    boolean
    C0179740 (UMLS CUI 2011AA)
    398176008 (SNOMED CT 2011_0131)
    Pulmonary Angiogram
    Item
    Pulmonary arteriogram, Pulmonary artery angiography
    boolean
    C0202910 (UMLS CUI 2011AA)
    84200003 (SNOMED CT 2011_0131)
    10002440 (MedDRA 14.1)
    88.43 (ICD-9-CM Version 2011)
    RFA (RF-Ablation)
    Item
    radiofrequency ablation procedure
    boolean
    CL382653 (UMLS CUI 2011AA)
    TACE
    Item
    transarterial chemoembolization
    boolean
    CL388501 (UMLS CUI 2011AA)
    Thrombolysis
    Item
    Thrombolysis
    boolean
    C0520997 (UMLS CUI 2011AA)
    51308000 (SNOMED CT 2011_0131)
    10043568 (MedDRA 14.1)
    Uterine Artery Embolization
    Item
    Embolisation of uterine artery
    boolean
    C0729536 (UMLS CUI 2011AA)
    312138002 (SNOMED CT 2011_0131)
    Other procedure
    Item
    Other procedure
    string
    FINDINGS
    Item
    FINDINGS (None|Same|N/A|Successful|Unsuccessful)
    integer
    Findings text
    Item
    Findings text
    string
    BLOOD LOSS
    Item
    bleeding, blood loss, hemorrhage
    string
    C0019080 (UMLS CUI 2011AA)
    50960005 (SNOMED CT 2011_0131)
    10055798 (MedDRA 14.1)
    R58 (ICD-10-CM Version 2010)
    459.0 (ICD-9-CM Version 2011)
    CONTRAST
    Item
    Contrast medium, Contrast agent
    string
    C0009924 (UMLS CUI 2011AA)
    385420005 (SNOMED CT 2011_0131)
    FLUORO TIME
    Item
    FLUORO TIME
    string
    C0016356 (UMLS CUI 2011AA)
    44491008 (SNOMED CT 2011_0131)
    10064426 (MedDRA 14.1)
    SPECIMEN(s) REMOVED
    Item
    SPECIMEN(s)REMOVED (yes|no)
    boolean
    SPECIMEN(s)
    Item
    Specimen
    string
    C0370003 (UMLS CUI 2011AA)
    123038009 (SNOMED CT 2011_0131)
    MTHU010726 (LOINC Version 232)
    COMPLICATIONS: No immediate
    Item
    COMPLICATIONS: No immediate
    boolean
    Complications text
    Item
    Complications
    string
    C0009566 (UMLS CUI 2011AA)
    116223007 (SNOMED CT 2011_0131)
    MTHU008883 (LOINC Version 232)

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