ID

5629

Beschreibung

Form from HIS OpenVista

Stichworte

Versionen (5)
  1. 09.03.12 09.03.12 -
  2. 07.08.14 07.08.14 - Martin Dugas
  3. 09.08.14 09.08.14 - Martin Dugas
  4. 11.08.14 11.08.14 - Martin Dugas
  5. 26.06.15 26.06.15 - Martin Dugas
Hochgeladen am

11. August 2014

DOI

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HIS PHYSICAL THERAPY INITIAL EVALUATION

Deutsch Englisch

HIS

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

General Info

PHYSICAL THERAPY ORDER
Beschreibung

PHYSICAL THERAPY ORDER

Datentyp

string

operative procedures
Beschreibung

SURGERY

Datentyp

string

Alias
UMLS CUI 2011AA
C0038895
HISTORY OF PRESENT ILLNESS WITH ONSET DATE
Beschreibung

HISTORY OF PRESENT ILLNESS WITH ONSET DATE

Datentyp

string

Alias
UMLS CUI 2011AA
C0262512
LOINC Version 232
MTHU001399
UMLS CUI 2011AA
C0332162
SNOMED CT 2011_0131
77374008
SOCIAL/HEALTH HABITS(PAST & CURRENT)
Beschreibung

SOCIAL/HEALTH HABITS(PAST & CURRENT)

Alkohol-Abusus
Beschreibung

Alcohol

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0085762
SNOMED CT 2011_0131
15167005
MedDRA 14.1
10001584
LOINC Version 232
LP36309-0
ICD-10-CM Version 2010
F10.1
ICD-9-CM Version 2011
305.0
Raucher
Beschreibung

Smoking

Datentyp

boolean

Alias
UMLS CUI-1
C1519386
Living Situation, Dwelling
Beschreibung

Living Situation, Dwelling

Assisted Living, Residential Care
Beschreibung

Assisted Living

Datentyp

boolean

Alias
UMLS CUI 2011AA
C1456630
Home (Lives Alone)
Beschreibung

Home (Lives Alone)

Datentyp

boolean

Home with parent(s)
Beschreibung

Home with parent(s)

Datentyp

boolean

Home w/Significant Other
Beschreibung

Home w/Significant Other

Datentyp

boolean

Home w/Spouse
Beschreibung

Home w/Spouse

Datentyp

boolean

Home w/Family (Children)
Beschreibung

Home w/Family (Children)

Datentyp

boolean

Home w/Friend (Caretaker)
Beschreibung

Home w/Friend (Caretaker)

Datentyp

boolean

Dependent in ADLs
Beschreibung

Dependent in ADLs

Datentyp

boolean

Independent in ADLs
Beschreibung

Independent in ADLs

Datentyp

boolean

Pflegeheim
Beschreibung

Nursing Home

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0028688
SNOMED CT 2011_0131
42665001
LOINC Version 232
MTHU015917
HL7 V3 2006_05
N
Altersheim
Beschreibung

Retirement Center/ Assisted Living Facility

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0872103
HL7 V3 2006_05
310400000X
Requires Assistance with ADLs
Beschreibung

Requires Assistance with ADLs

Datentyp

boolean

Other
Beschreibung

Other

Datentyp

boolean

Stairs to enter
Beschreibung

Stairs to enter

Datentyp

boolean

Stairs indoors
Beschreibung

Stairs indoors

Datentyp

boolean

REMAIN ON FIRST FLOOR
Beschreibung

REMAIN ON FIRST FLOOR

Datentyp

boolean

OTHER OBSTACLES OF CONCERN
Beschreibung

OTHER OBSTACLES OF CONCERN

Datentyp

string

Anamnese
Beschreibung

Anamnese

Alias
UMLS CUI-1
C0262926
PREMORBID FUNCTIONAL STATUS
Beschreibung

PREMORBID FUNCTIONAL STATUS

Datentyp

string

Familienanamnese
Beschreibung

Family history

Datentyp

text

Alias
SNOMED CT 2011_0131
57177007
UMLS CUI-1
C0241889
MEDICAL/SURGICAL HISTORY
Beschreibung

Medical/surgical history

Datentyp

text

Alias
SNOMED CT 2011_0131
417662000
LOINC Version 232
MTHU027722
SNOMED CT 2011_0131
161615003
UMLS CUI-1
C0262926
UMLS CUI-2
C0455610
MEDICATIONS REVIEWED
Beschreibung

MEDICATIONS REVIEWED

Datentyp

boolean

PERTINENT MEDICATIONS AFFECTING THERAPY
Beschreibung

PERTINENT MEDICATIONS AFFECTING THERAPY

Datentyp

string

CLINICAL TESTS
Beschreibung

CLINICAL TESTS

Datentyp

string

I.D. VERIFIED BY
Beschreibung

I.D. VERIFIED BY

Datentyp

string

I.D. VERIFICATION
Beschreibung

I.D. VERIFICATION

Datentyp

string

Anamnese der Organsysteme
Beschreibung

Anamnese der Organsysteme

Größe
Beschreibung

Height

Datentyp

integer

Alias
UMLS CUI-1
C0005890
LOINC Version 232
MTHU005354
Gewicht
Beschreibung

Weight

Datentyp

float

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

Pulse

Datentyp

integer

Alias
UMLS CUI 2011AA
C0232117
SNOMED CT 2011_0131
78564009
MedDRA 14.1
10037485
Atemfrequenz
Beschreibung

Respiration

Datentyp

integer

Alias
UMLS CUI 2011AA
C0231832
SNOMED CT 2011_0131
86290005
MedDRA 14.1
10038709
LOINC Version 232
MTHU008344
Blutdruck
Beschreibung

Blood Pressure

Datentyp

string

Alias
UMLS CUI 2011AA
C0005823
SNOMED CT 2011_0131
75367002
LOINC Version 232
MTHU008342
Ödem
Beschreibung

Edema

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0013604
SNOMED CT 2011_0131
423666004
MedDRA 14.1
10030095
LOINC Version 232
MTHU019803
ICD-10-CM Version 2010
R60.9
ICD-9-CM Version 2011
782.3
Ankle Edema (L/R)
Beschreibung

Ankle Edema (L/R)

Datentyp

string

Alias
UMLS CUI 2011AA
C0003086
SNOMED CT 2011_0131
344001
UMLS CUI 2011AA
C0013604
SNOMED CT 2011_0131
423666004
MedDRA 14.1
10030095
LOINC Version 232
MTHU019803
ICD-10-CM Version 2010
R60.9
ICD-9-CM Version 2011
782.3
Foot Edema (L/R)
Beschreibung

Foot Edema (L/R)

Datentyp

string

Alias
UMLS CUI 2011AA
C0016504
SNOMED CT 2011_0131
56459004
LOINC Version 232
MTHU002679
UMLS CUI 2011AA
C0013604
SNOMED CT 2011_0131
423666004
MedDRA 14.1
10030095
LOINC Version 232
MTHU019803
ICD-10-CM Version 2010
R60.9
ICD-9-CM Version 2011
782.3
Hand Edema (L/R)
Beschreibung

Hand Edema (L/R)

Datentyp

string

Knee Edema (L/R)
Beschreibung

Knee Edema (L/R)

Datentyp

string

Beinödeme
Beschreibung

Leg Edema (L/R)

Datentyp

string

Alias
UMLS CUI 2011AA
C0235886
SNOMED CT 2011_0131
102574007
MedDRA 14.1
10024127
INTEGUMENTARY within normal limits
Beschreibung

INTEGUMENTARY WNL

Datentyp

boolean

Haut
Beschreibung

Integument

Datentyp

string

Alias
UMLS CUI 2011AA
C1123023
SNOMED CT 2011_0131
39937001
LOINC Version 232
MTHU001414
MUSCULOSKELETAL WNL
Beschreibung

MUSCULOSKELETAL WNL

Datentyp

boolean

Muskuloskeletales System
Beschreibung

Musculoskeletal

Datentyp

string

Alias
UMLS CUI 2011AA
C0026860
SNOMED CT 2011_0131
26107004
LOINC Version 232
MTHU001411
ROM/STRENGTH
Beschreibung

ROM/STRENGTH

Datentyp

string

NEUROMUSCULAR WNL
Beschreibung

NEUROMUSCULAR WNL

Datentyp

boolean

Neuromuscular
Beschreibung

Neuromuscular

Datentyp

string

Gang
Beschreibung

GAIT

Datentyp

string

Alias
UMLS CUI 2011AA
C0016928
SNOMED CT 2011_0131
63448001
LOINC Version 232
MTHU015039
BALANCE
Beschreibung

BALANCE

Datentyp

string

MOTOR CONTROL
Beschreibung

MOTOR CONTROL

Datentyp

string

COMMUNICATION WNL
Beschreibung

COMMUNICATION WNL

Datentyp

boolean

COMMUNICATION
Beschreibung

COMMUNICATION

Datentyp

string

language ability, verbal ability
Beschreibung

LANGUAGE

Datentyp

string

Alias
UMLS CUI 2011AA
C1145677
Orientierung
Beschreibung

ORIENTATION

Datentyp

string

Alias
UMLS CUI 2011AA
C0029266
SNOMED CT 2011_0131
43173001
Gedächtnisverlust
Beschreibung

Memory loss

Datentyp

string

Alias
UMLS CUI 2011AA
C0751295
MedDRA 14.1
10027176
LOINC Version 232
MTHU013522
ICD-9-CM Version 2011
780.93
EMOTIONAL/BEHAVIORAL RESPONSES WNL
Beschreibung

EMOTIONAL/BEHAVIORAL RESPONSES WNL

Datentyp

boolean

Emotional / Behavioral responses
Beschreibung

Emotional / Behavioral responses

Datentyp

string

LEARNING BARRIERS
Beschreibung

LEARNING BARRIERS

Datentyp

boolean

Hearing impaired
Beschreibung

Hearing impaired

Datentyp

boolean

Language/Needs interpreter
Beschreibung

Language/Needs interpreter

Datentyp

boolean

unable to read
Beschreibung

unable to read

Datentyp

boolean

Vision impaired
Beschreibung

Vision impaired

Datentyp

boolean

EDUCATION NEEDS
Beschreibung

EDUCATION NEEDS

Datentyp

boolean

Education ADLs
Beschreibung

Education ADLs

Datentyp

boolean

Alias
UMLS CUI 2011AA
CL357394
UMLS CUI 2011AA
C0001288
SNOMED CT 2011_0131
129025006
Education Disease
Beschreibung

Education Disease

Datentyp

boolean

Alias
UMLS CUI 2011AA
CL357394
UMLS CUI 2011AA
C0012634
SNOMED CT 2011_0131
64572001
Education Equipment
Beschreibung

Education Equipment

Datentyp

boolean

Education Exercise Program
Beschreibung

Education Exercise Program

Datentyp

boolean

Education Safety
Beschreibung

Education Safety

Datentyp

boolean

Education Transfers
Beschreibung

Education Transfers

Datentyp

boolean

other Education needs
Beschreibung

other Education needs

Datentyp

string

KEYS TO TEST AND MEASURES
Beschreibung

KEYS TO TEST AND MEASURES

AEROBIC CAPACITY/ENDURANCE
Beschreibung

AEROBIC CAPACITY/ENDURANCE

Datentyp

string

AROUSAL, ATTENTION, AND COGNITION
Beschreibung

AROUSAL, ATTENTION, AND COGNITION

Datentyp

string

ASSISTIVE AND ADAPTIVE EQUIPMENT
Beschreibung

ASSISTIVE AND ADAPTIVE EQUIPMENT

Datentyp

string

CIRCULATION
Beschreibung

CIRCULATION

Datentyp

string

GAIT, LOCOMOTION, AND BALANCE
Beschreibung

GAIT, LOCOMOTION, AND BALANCE

Datentyp

string

INTEGUMENTARY INTEGRITY
Beschreibung

INTEGUMENTARY INTEGRITY

Datentyp

string

MOTOR FUNCTION (MOTOR CONTROL AND MOTOR LEARNING)
Beschreibung

MOTOR FUNCTION (MOTOR CONTROL AND MOTOR LEARNING)

Datentyp

string

MUSCLE PERFORMANCE (STRENGTH,POWER,AND ENDURANCE)
Beschreibung

MUSCLE PERFORMANCE (STRENGTH,POWER,AND ENDURANCE)

Datentyp

string

NEUROMOTOR DEVELOPMENT AND SENSORY INTEGRATION
Beschreibung

NEUROMOTOR DEVELOPMENT AND SENSORY INTEGRATION

Datentyp

string

ORTHOTIC, PROTECTIVE, AND SUPPORTIVE DEVICES
Beschreibung

ORTHOTIC, PROTECTIVE, AND SUPPORTIVE DEVICES

Datentyp

string

Schmerz
Beschreibung

PAIN

Datentyp

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
POSTURE
Beschreibung

POSTURE

Datentyp

string

RANGE OF MOTION (INCLUDING MUSCLE LENGTH)
Beschreibung

RANGE OF MOTION (INCLUDING MUSCLE LENGTH)

Datentyp

string

REFLEX INTEGRITY
Beschreibung

REFLEX INTEGRITY

Datentyp

string

SENSORY INTEGRITY
Beschreibung

SENSORY INTEGRITY

Datentyp

string

SELF CARE AND HOME MANAGEMENT
Beschreibung

SELF CARE AND HOME MANAGEMENT

Datentyp

string

WORK REINTEGRATION
Beschreibung

WORK REINTEGRATION

Datentyp

string

EVALUATION
Beschreibung

EVALUATION

Datentyp

string

Diagnose
Beschreibung

Diagnose

Cardiovascular Pattern(s)
Beschreibung

Cardiovascular Pattern(s)

Datentyp

boolean

Integumentary Pattern(s)
Beschreibung

Integumentary Pattern(s)

Datentyp

boolean

Musculoskeletal Pattern(s)
Beschreibung

Musculoskeletal Pattern(s)

Datentyp

boolean

Neuromuscular Pattern(s)
Beschreibung

Neuromuscular Pattern(s)

Datentyp

boolean

Diagnose
Beschreibung

Diagnosis text

Datentyp

string

Alias
UMLS CUI 2011AA
C0011900
SNOMED CT 2011_0131
439401001
LOINC Version 232
MTHU008876
PROGNOSIS, Goals, Interventions, Plan
Beschreibung

PROGNOSIS, Goals, Interventions, Plan

Prognose
Beschreibung

Prognosis

Datentyp

string

Alias
UMLS CUI 2011AA
C0033325
SNOMED CT 2011_0131
20481000
Ziele
Beschreibung

Goals

Datentyp

string

Alias
UMLS CUI 2011AA
C0018017
SNOMED CT 2011_0131
410518001
LOINC Version 232
MTHU036445
Interventions
Beschreibung

Interventions

Datentyp

string

TODAYS
Beschreibung

TODAYS

Datentyp

string

Educated - family
Beschreibung

Educated - family

Datentyp

boolean

Educated - patient
Beschreibung

Educated - patient

Datentyp

boolean

Educated - significant other
Beschreibung

Educated - significant other

Datentyp

boolean

Educated - returns Demonstration
Beschreibung

Educated - returns Demonstration

Datentyp

boolean

Educated - Verbalizes understanding
Beschreibung

Educated - Verbalizes understanding

Datentyp

boolean

DISCHARGE PLANS
Beschreibung

DISCHARGE PLANS

Datentyp

string

Discharge status
Beschreibung

DISCHARGE STATUS

Datentyp

string

Alias
UMLS CUI 2011AA
C0586514
SNOMED CT 2011_0131
309039003
LOINC Version 232
MTHU031549
FREQUENCY OF VISITS/DURATION OF EPISODE OF CARE
Beschreibung

FREQUENCY OF VISITS/DURATION OF EPISODE OF CARE

Datentyp

string

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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
General Info
PHYSICAL THERAPY ORDER
Item
PHYSICAL THERAPY ORDER
string
SURGERY
Item
operative procedures
string
C0038895 (UMLS CUI 2011AA)
HISTORY OF PRESENT ILLNESS WITH ONSET DATE
Item
HISTORY OF PRESENT ILLNESS WITH ONSET DATE
string
C0262512 (UMLS CUI 2011AA)
MTHU001399 (LOINC Version 232)
C0332162 (UMLS CUI 2011AA)
77374008 (SNOMED CT 2011_0131)
Item Group
SOCIAL/HEALTH HABITS(PAST & CURRENT)
Alcohol
Item
Alkohol-Abusus
boolean
C0085762 (UMLS CUI 2011AA)
15167005 (SNOMED CT 2011_0131)
10001584 (MedDRA 14.1)
LP36309-0 (LOINC Version 232)
F10.1 (ICD-10-CM Version 2010)
305.0 (ICD-9-CM Version 2011)
Smoking
Item
Raucher
boolean
C1519386 (UMLS CUI-1)
Item Group
Living Situation, Dwelling
Assisted Living
Item
Assisted Living, Residential Care
boolean
C1456630 (UMLS CUI 2011AA)
Home (Lives Alone)
Item
Home (Lives Alone)
boolean
Home with parent(s)
Item
Home with parent(s)
boolean
Home w/Significant Other
Item
Home w/Significant Other
boolean
Home w/Spouse
Item
Home w/Spouse
boolean
Home w/Family (Children)
Item
Home w/Family (Children)
boolean
Home w/Friend (Caretaker)
Item
Home w/Friend (Caretaker)
boolean
Dependent in ADLs
Item
Dependent in ADLs
boolean
Independent in ADLs
Item
Independent in ADLs
boolean
Nursing Home
Item
Pflegeheim
boolean
C0028688 (UMLS CUI 2011AA)
42665001 (SNOMED CT 2011_0131)
MTHU015917 (LOINC Version 232)
N (HL7 V3 2006_05)
Retirement Center/ Assisted Living Facility
Item
Altersheim
boolean
C0872103 (UMLS CUI 2011AA)
310400000X (HL7 V3 2006_05)
Requires Assistance with ADLs
Item
Requires Assistance with ADLs
boolean
Other
Item
Other
boolean
Stairs to enter
Item
Stairs to enter
boolean
Stairs indoors
Item
Stairs indoors
boolean
REMAIN ON FIRST FLOOR
Item
REMAIN ON FIRST FLOOR
boolean
OTHER OBSTACLES OF CONCERN
Item
OTHER OBSTACLES OF CONCERN
string
Item Group
Anamnese
C0262926 (UMLS CUI-1)
PREMORBID FUNCTIONAL STATUS
Item
PREMORBID FUNCTIONAL STATUS
string
Family history
Item
Familienanamnese
text
57177007 (SNOMED CT 2011_0131)
C0241889 (UMLS CUI-1)
Medical/surgical history
Item
MEDICAL/SURGICAL HISTORY
text
417662000 (SNOMED CT 2011_0131)
MTHU027722 (LOINC Version 232)
161615003 (SNOMED CT 2011_0131)
C0262926 (UMLS CUI-1)
C0455610 (UMLS CUI-2)
MEDICATIONS REVIEWED
Item
MEDICATIONS REVIEWED
boolean
PERTINENT MEDICATIONS AFFECTING THERAPY
Item
PERTINENT MEDICATIONS AFFECTING THERAPY
string
CLINICAL TESTS
Item
CLINICAL TESTS
string
I.D. VERIFIED BY
Item
I.D. VERIFIED BY
string
I.D. VERIFICATION
Item
I.D. VERIFICATION
string
Item Group
Anamnese der Organsysteme
Height
Item
Größe
integer
C0005890 (UMLS CUI-1)
MTHU005354 (LOINC Version 232)
Weight
Item
Gewicht
float
C0005910 (UMLS)
107647005 (SNOMED CT 2011_0131)
10047890 (MedDRA 14.1)
LP18015-5 (LOINC Version 232)
Pulse
Item
Pulsfrequenz
integer
C0232117 (UMLS CUI 2011AA)
78564009 (SNOMED CT 2011_0131)
10037485 (MedDRA 14.1)
Respiration
Item
Atemfrequenz
integer
C0231832 (UMLS CUI 2011AA)
86290005 (SNOMED CT 2011_0131)
10038709 (MedDRA 14.1)
MTHU008344 (LOINC Version 232)
Blood Pressure
Item
Blutdruck
string
C0005823 (UMLS CUI 2011AA)
75367002 (SNOMED CT 2011_0131)
MTHU008342 (LOINC Version 232)
Edema
Item
Ödem
boolean
C0013604 (UMLS CUI 2011AA)
423666004 (SNOMED CT 2011_0131)
10030095 (MedDRA 14.1)
MTHU019803 (LOINC Version 232)
R60.9 (ICD-10-CM Version 2010)
782.3 (ICD-9-CM Version 2011)
Ankle Edema (L/R)
Item
Ankle Edema (L/R)
string
C0003086 (UMLS CUI 2011AA)
344001 (SNOMED CT 2011_0131)
C0013604 (UMLS CUI 2011AA)
423666004 (SNOMED CT 2011_0131)
10030095 (MedDRA 14.1)
MTHU019803 (LOINC Version 232)
R60.9 (ICD-10-CM Version 2010)
782.3 (ICD-9-CM Version 2011)
Foot Edema (L/R)
Item
Foot Edema (L/R)
string
C0016504 (UMLS CUI 2011AA)
56459004 (SNOMED CT 2011_0131)
MTHU002679 (LOINC Version 232)
C0013604 (UMLS CUI 2011AA)
423666004 (SNOMED CT 2011_0131)
10030095 (MedDRA 14.1)
MTHU019803 (LOINC Version 232)
R60.9 (ICD-10-CM Version 2010)
782.3 (ICD-9-CM Version 2011)
Hand Edema (L/R)
Item
Hand Edema (L/R)
string
Knee Edema (L/R)
Item
Knee Edema (L/R)
string
Leg Edema (L/R)
Item
Beinödeme
string
C0235886 (UMLS CUI 2011AA)
102574007 (SNOMED CT 2011_0131)
10024127 (MedDRA 14.1)
INTEGUMENTARY WNL
Item
INTEGUMENTARY within normal limits
boolean
Integument
Item
Haut
string
C1123023 (UMLS CUI 2011AA)
39937001 (SNOMED CT 2011_0131)
MTHU001414 (LOINC Version 232)
MUSCULOSKELETAL WNL
Item
MUSCULOSKELETAL WNL
boolean
Musculoskeletal
Item
Muskuloskeletales System
string
C0026860 (UMLS CUI 2011AA)
26107004 (SNOMED CT 2011_0131)
MTHU001411 (LOINC Version 232)
ROM/STRENGTH
Item
ROM/STRENGTH
string
NEUROMUSCULAR WNL
Item
NEUROMUSCULAR WNL
boolean
Neuromuscular
Item
Neuromuscular
string
GAIT
Item
Gang
string
C0016928 (UMLS CUI 2011AA)
63448001 (SNOMED CT 2011_0131)
MTHU015039 (LOINC Version 232)
BALANCE
Item
BALANCE
string
MOTOR CONTROL
Item
MOTOR CONTROL
string
COMMUNICATION WNL
Item
COMMUNICATION WNL
boolean
COMMUNICATION
Item
COMMUNICATION
string
LANGUAGE
Item
language ability, verbal ability
string
C1145677 (UMLS CUI 2011AA)
Item
Orientierung
string
C0029266 (UMLS CUI 2011AA)
43173001 (SNOMED CT 2011_0131)
ORIENTATION
Code List
Orientierung
CL Item
Oriented (1)
CL Item
Disoriented (2)
Item
Gedächtnisverlust
string
C0751295 (UMLS CUI 2011AA)
10027176 (MedDRA 14.1)
MTHU013522 (LOINC Version 232)
780.93 (ICD-9-CM Version 2011)
Memory loss
Code List
Gedächtnisverlust
CL Item
no memory loss (1)
CL Item
Long term memory loss (2)
CL Item
Recent memory loss (3)
EMOTIONAL/BEHAVIORAL RESPONSES WNL
Item
EMOTIONAL/BEHAVIORAL RESPONSES WNL
boolean
Emotional / Behavioral responses
Item
Emotional / Behavioral responses
string
LEARNING BARRIERS
Item
LEARNING BARRIERS
boolean
Hearing impaired
Item
Hearing impaired
boolean
Language/Needs interpreter
Item
Language/Needs interpreter
boolean
unable to read
Item
unable to read
boolean
Vision impaired
Item
Vision impaired
boolean
EDUCATION NEEDS
Item
EDUCATION NEEDS
boolean
Education ADLs
Item
Education ADLs
boolean
CL357394 (UMLS CUI 2011AA)
C0001288 (UMLS CUI 2011AA)
129025006 (SNOMED CT 2011_0131)
Education Disease
Item
Education Disease
boolean
CL357394 (UMLS CUI 2011AA)
C0012634 (UMLS CUI 2011AA)
64572001 (SNOMED CT 2011_0131)
Education Equipment
Item
Education Equipment
boolean
Education Exercise Program
Item
Education Exercise Program
boolean
Education Safety
Item
Education Safety
boolean
Education Transfers
Item
Education Transfers
boolean
other Education needs
Item
other Education needs
string
Item Group
KEYS TO TEST AND MEASURES
AEROBIC CAPACITY/ENDURANCE
Item
AEROBIC CAPACITY/ENDURANCE
string
AROUSAL, ATTENTION, AND COGNITION
Item
AROUSAL, ATTENTION, AND COGNITION
string
ASSISTIVE AND ADAPTIVE EQUIPMENT
Item
ASSISTIVE AND ADAPTIVE EQUIPMENT
string
CIRCULATION
Item
CIRCULATION
string
GAIT, LOCOMOTION, AND BALANCE
Item
GAIT, LOCOMOTION, AND BALANCE
string
INTEGUMENTARY INTEGRITY
Item
INTEGUMENTARY INTEGRITY
string
MOTOR FUNCTION (MOTOR CONTROL AND MOTOR LEARNING)
Item
MOTOR FUNCTION (MOTOR CONTROL AND MOTOR LEARNING)
string
MUSCLE PERFORMANCE (STRENGTH,POWER,AND ENDURANCE)
Item
MUSCLE PERFORMANCE (STRENGTH,POWER,AND ENDURANCE)
string
NEUROMOTOR DEVELOPMENT AND SENSORY INTEGRATION
Item
NEUROMOTOR DEVELOPMENT AND SENSORY INTEGRATION
string
ORTHOTIC, PROTECTIVE, AND SUPPORTIVE DEVICES
Item
ORTHOTIC, PROTECTIVE, AND SUPPORTIVE DEVICES
string
PAIN
Item
Schmerz
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)
POSTURE
Item
POSTURE
string
RANGE OF MOTION (INCLUDING MUSCLE LENGTH)
Item
RANGE OF MOTION (INCLUDING MUSCLE LENGTH)
string
REFLEX INTEGRITY
Item
REFLEX INTEGRITY
string
SENSORY INTEGRITY
Item
SENSORY INTEGRITY
string
SELF CARE AND HOME MANAGEMENT
Item
SELF CARE AND HOME MANAGEMENT
string
WORK REINTEGRATION
Item
WORK REINTEGRATION
string
EVALUATION
Item
EVALUATION
string
Item Group
Diagnose
Cardiovascular Pattern(s)
Item
Cardiovascular Pattern(s)
boolean
Integumentary Pattern(s)
Item
Integumentary Pattern(s)
boolean
Musculoskeletal Pattern(s)
Item
Musculoskeletal Pattern(s)
boolean
Neuromuscular Pattern(s)
Item
Neuromuscular Pattern(s)
boolean
Diagnosis text
Item
Diagnose
string
C0011900 (UMLS CUI 2011AA)
439401001 (SNOMED CT 2011_0131)
MTHU008876 (LOINC Version 232)
Item Group
PROGNOSIS, Goals, Interventions, Plan
Prognosis
Item
Prognose
string
C0033325 (UMLS CUI 2011AA)
20481000 (SNOMED CT 2011_0131)
Goals
Item
Ziele
string
C0018017 (UMLS CUI 2011AA)
410518001 (SNOMED CT 2011_0131)
MTHU036445 (LOINC Version 232)
Interventions
Item
Interventions
string
TODAYS
Item
TODAYS
string
Educated - family
Item
Educated - family
boolean
Educated - patient
Item
Educated - patient
boolean
Educated - significant other
Item
Educated - significant other
boolean
Educated - returns Demonstration
Item
Educated - returns Demonstration
boolean
Educated - Verbalizes understanding
Item
Educated - Verbalizes understanding
boolean
DISCHARGE PLANS
Item
DISCHARGE PLANS
string
DISCHARGE STATUS
Item
Discharge status
string
C0586514 (UMLS CUI 2011AA)
309039003 (SNOMED CT 2011_0131)
MTHU031549 (LOINC Version 232)
FREQUENCY OF VISITS/DURATION OF EPISODE OF CARE
Item
FREQUENCY OF VISITS/DURATION OF EPISODE OF CARE
string
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