H and P or consult specialty
Form from HIS OpenVistA

  1. StudyEvent: HIS
    1. HIS
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
H and P or consult specialty
Reason for visit
Item
Reason for visit
string
CHIEF COMPLAINT
Item
Chief complaint (CC)
string
C0277786 (UMLS CUI 2011AA)
33962009 (SNOMED CT 2011_0131)
MTHU001077 (LOINC Version 232)
Item Group
HISTORY OF PRESENT ILLNESS
HISTORY OF PRESENT ILLNESS (HPI, include location, quality, severity, duration, timing, context, modifying factors & associated signs/symptoms)
Item
History of present illness
string
C0262512 (UMLS CUI 2011AA)
MTHU001399 (LOINC Version 232)
SOURCE(S) OF HISTORY
Item
SOURCE(S) OF HISTORY (Patient, Family, Outside records, Unobtainable)
integer
SOURCE(S) OF HISTORY comment
Item
SOURCE(S) OF HISTORY comment
string
Item Group
REVIEW OF SYSTEMS
REVIEW OF SYSTEMS: see form Review of systems
Item
REVIEW OF SYSTEMS: see form Review of systems
string
Item Group
PAST HISTORY
Adult Illness
Item
Adult disease
string
C0277562 (UMLS CUI 2011AA)
64342008 (SNOMED CT 2011_0131)
History of childhood diseases
Item
Childhood Illness
string
C0489532 (UMLS CUI 2011AA)
MTHU001066 (LOINC Version 232)
Surgeries
Item
Prior Surgery, History of (H/O) surgery, Past surgical history
string
C0455610 (UMLS CUI 2011AA)
161615003 (SNOMED CT 2011_0131)
Injury
Item
Traumatic injury, trauma
string
C0175677 (UMLS CUI 2011AA)
417746004 (SNOMED CT 2011_0131)
10022116 (MedDRA 14.1)
T14.9 (ICD-10-CM Version 2010)
Item Group
Female Specific History
Date of last menstrual period
Item
Date of last menstrual period (LMP)
date
C0425932 (UMLS CUI 2011AA)
21840007 (SNOMED CT 2011_0131)
MTHU024536 (LOINC Version 232)
Date of last PAP
Item
Date of last Papanicolaou test (PAP)
date
last PAP Results
Item
Pap smear, smear cervix, vaginal smear, Papanicolaou Test
string
C0079104 (UMLS CUI 2011AA)
10041205 (MedDRA 14.1)
Date of last MMG
Item
Date of last mammogram (MMG)
date
last MMG Results
Item
Mammogram
string
C0024671 (UMLS CUI 2011AA)
71651007 (SNOMED CT 2011_0131)
10026735 (MedDRA 14.1)
Age at menarche
Item
Age at menarche
integer
C1314691 (UMLS CUI 2011AA)
398700009 (SNOMED CT 2011_0131)
MTHU018825 (LOINC Version 232)
Describe Menses
Item
Menstruation, Menses
string
C0025344 (UMLS CUI 2011AA)
248957007 (SNOMED CT 2011_0131)
Birth Control
Item
Contraception, Birth control
string
C0700589 (UMLS CUI 2011AA)
146680009 (SNOMED CT 2011_0131)
10010808 (MedDRA 14.1)
Pregnancies
Item
Pregnancy, Gestation
string
C0032961 (UMLS CUI 2011AA)
289908002 (SNOMED CT 2011_0131)
10036556 (MedDRA 14.1)
MTHU035048 (LOINC Version 232)
Abortions
Item
Abortion, Pregnancy with abortive outcome
string
C0156543 (UMLS CUI 2011AA)
70317007 (SNOMED CT 2011_0131)
10000210 (MedDRA 14.1)
MTHU002834 (LOINC Version 232)
O00-O08 (ICD-10-CM Version 2010)
637 (ICD-9-CM Version 2011)
Number of full term pregnancies
Item
Number of full term pregnancies
integer
Number of spontaneous abortions
Item
Number of spontaneous abortions
integer
Number of therapeutic abortions
Item
Number of therapeutic abortions
integer
Number of other types Abortions
Item
Number of other types Abortions
integer
Age at first pregnancy
Item
Age at first pregnancy
integer
Item Group
FAMILY HISTORY
Family history: see form Family Hx
Item
Family history (FH)
string
C0241889 (UMLS CUI 2011AA)
57177007 (SNOMED CT 2011_0131)
Item Group
SOCIAL HISTORY
Social history: see form 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)
Item Group
ALLERGIES
No Known Allergies
Item
No Known Allergies
boolean
Allergies text
Item
Hypersensitivity
string
C0020517 (UMLS CUI 2011AA)
257550005 (SNOMED CT 2011_0131)
Item Group
MEDICATIONS
Inpatient medications
Item
Inpatient Medications
string
C0013227 (UMLS CUI 2011AA)
Active medications
Item
current medication list, active medication
string
C1553892 (UMLS CUI 2011AA)
Home medications
Item
Home Medications
string
C0013227 (UMLS CUI 2011AA)
Item Group
PHYSICAL EXAM - General
VITALS
Item
VITAL signs
string
C0518766 (UMLS CUI 2011AA)
46680005 (SNOMED CT 2011_0131)
MTHU024540 (LOINC Version 232)
Temperature
Item
Temperature
float
246508008 (SNOMED CT 2011_0131)
MTHU009008 (LOINC Version 232)
C0039476 (UMLS CUI-1)
Pulse Rate
Item
Pulse
integer
78564009 (SNOMED CT 2011_0131)
10037485 (MedDRA 14.1)
C0232117 (UMLS CUI-1)
Respiration Rate
Item
Respiration rate, Breathing rate (BR)
integer
86290005 (SNOMED CT 2011_0131)
10038709 (MedDRA 14.1)
MTHU008344 (LOINC Version 232)
C0231832 (UMLS CUI-1)
Blood Pressure
Item
Blood pressure (BP)
integer
75367002 (SNOMED CT 2011_0131)
MTHU008342 (LOINC Version 232)
C0005823 (UMLS CUI-1)
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)
Weight
Item
Body weight
float
107647005 (SNOMED CT 2011_0131)
10047890 (MedDRA 14.1)
LP18015-5 (LOINC Version 232)
C0005910 (UMLS CUI-1)
GENERAL
Item
GENERAL
text
C1148438 (UMLS CUI-1)
Item Group
PHYSICAL EXAM - HEAD
HEAD
Item
HEAD (Normocephalic, atraumatic)
boolean
Head text (significant for:)
Item
Head
string
C0018670 (UMLS CUI 2011AA)
69536005 (SNOMED CT 2011_0131)
MTHU001435 (LOINC Version 232)
Item Group
PHYSICAL EXAM - EYES
EYES
Item
EYES (Pupils are RRE and react to light and accomodation, Conjunctivae pink and moist, Extraocular muscles intact)
boolean
C0015392 (UMLS CUI 2011AA)
81745001 (SNOMED CT 2011_0131)
MTHU000064 (LOINC Version 232)
Pupils
Item
Pupil
string
C0034121 (UMLS CUI 2011AA)
392406005 (SNOMED CT 2011_0131)
MTHU015063 (LOINC Version 232)
Conjunctivae
Item
conjunctiva
string
C0009758 (UMLS CUI 2011AA)
29445007 (SNOMED CT 2011_0131)
MTHU009301 (LOINC Version 232)
Sclerae
Item
Sclera
string
C0036410 (UMLS CUI 2011AA)
18619003 (SNOMED CT 2011_0131)
MTHU015068 (LOINC Version 232)
EOM
Item
Extraocular muscles (EOM)
string
C0028863 (UMLS CUI 2011AA)
67833000 (SNOMED CT 2011_0131)
MTHU015037 (LOINC Version 232)
Funduscopic
Item
Fundoscopy
string
C0029090 (UMLS CUI 2011AA)
274798009 (SNOMED CT 2011_0131)
10017519 (MedDRA 14.1)
Item Group
Physical Exam - Ears, Nose, Throat
Ear canals patent. TM's intact. Nares patent and pink without epistaxis. Mucosa pink. No pharyngitis. Natural dentition.
Item
Ear canals patent. TM's intact. Nares patent and pink without epistaxis. Mucosa pink. No pharyngitis. Natural dentition.
boolean
EAR R ext canal
Item
EAR R ext canal
string
C0013444 (UMLS CUI 2011AA)
84301002 (SNOMED CT 2011_0131)
MTHU015034 (LOINC Version 232)
EAR R tympanic membrane (TM)
Item
EAR R tympanic membrane (TM)
string
C0041445 (UMLS CUI 2011AA)
42859004 (SNOMED CT 2011_0131)
MTHU014731 (LOINC Version 232)
EAR L ext canal
Item
EAR L ext canal
string
C0013444 (UMLS CUI 2011AA)
84301002 (SNOMED CT 2011_0131)
MTHU015034 (LOINC Version 232)
EAR L tympanic membrane (TM)
Item
EAR L tympanic membrane (TM)
string
C0041445 (UMLS CUI 2011AA)
42859004 (SNOMED CT 2011_0131)
MTHU014731 (LOINC Version 232)
NOSE Septum
Item
Nasal septum, Septum nasi
string
C0027432 (UMLS CUI 2011AA)
68426009 (SNOMED CT 2011_0131)
MTHU015054 (LOINC Version 232)
Nose Mucosa
Item
Nasal mucosa, Mucosa of nose
string
C0027428 (UMLS CUI 2011AA)
34508005 (SNOMED CT 2011_0131)
Nose R Nares
Item
Nose R Nares
string
C0595944 (UMLS CUI 2011AA)
1797002 (SNOMED CT 2011_0131)
MTHU015056 (LOINC Version 232)
Nose L Nares
Item
Nose L Nares
string
C0595944 (UMLS CUI 2011AA)
1797002 (SNOMED CT 2011_0131)
MTHU015056 (LOINC Version 232)
Throat: Mouth mucosa
Item
Mouth mucosa, Oral Mucosa
string
C0026639 (UMLS CUI 2011AA)
113277000 (SNOMED CT 2011_0131)
Pharynx
Item
Pharynx, Throat
string
C0031354 (UMLS CUI 2011AA)
54066008 (SNOMED CT 2011_0131)
MTHU015061 (LOINC Version 232)
Tonsils
Item
Tonsils
string
C0836921 (UMLS CUI 2011AA)
MTHU015077 (LOINC Version 232)
Dentition
Item
Dentition
string
C0011443 (UMLS CUI 2011AA)
245543004 (SNOMED CT 2011_0131)
MTHU014794 (LOINC Version 232)
Item Group
Physical Exam - Neck
supple, no JVD, no carotid bruits, trachea midline, no thyromegaly, no adenopathy
Item
Neck, Collum, Cervical
boolean
C0027530 (UMLS CUI 2011AA)
45048000 (SNOMED CT 2011_0131)
MTHU002688 (LOINC Version 232)
Adenopathy
Item
Adenopathy
string
C1706304 (UMLS CUI 2011AA)
R59 (ICD-10-CM Version 2010)
Carotid bruit
Item
Carotid bruit
string
C0007280 (UMLS CUI 2011AA)
419642000 (SNOMED CT 2011_0131)
10048777 (MedDRA 14.1)
JVD
Item
Jugular venous distension (JVD)
string
C1719935 (UMLS CUI 2011AA)
422008005 (SNOMED CT 2011_0131)
Thyroid gland
Item
Thyroid gland, Glandula thyroidea, thyroid
string
C0040132 (UMLS CUI 2011AA)
69748006 (SNOMED CT 2011_0131)
MTHU007792 (LOINC Version 232)
Trachea
Item
Trachea, windpipe
string
C0040578 (UMLS CUI 2011AA)
44567001 (SNOMED CT 2011_0131)
MTHU009117 (LOINC Version 232)
Item Group
Physical Exam - BREAST
symmetric without masses
Item
symmetric without masses
boolean
C0006141 (UMLS CUI 2011AA)
76752008 (SNOMED CT 2011_0131)
MTHU011382 (LOINC Version 232)
inspection: Right breast
Item
inspection: Right breast
string
C0006141 (UMLS CUI 2011AA)
76752008 (SNOMED CT 2011_0131)
MTHU011382 (LOINC Version 232)
inspection: Right nipple
Item
inspection: Right nipple
string
C0028109 (UMLS CUI 2011AA)
24142002 (SNOMED CT 2011_0131)
inspection: Left breast
Item
inspection: Left breast
string
C0006141 (UMLS CUI 2011AA)
76752008 (SNOMED CT 2011_0131)
MTHU011382 (LOINC Version 232)
inspection: Left nipple
Item
inspection: Left nipple
string
C0028109 (UMLS CUI 2011AA)
24142002 (SNOMED CT 2011_0131)
palpation: Right breast
Item
palpation: Right breast
string
C0006141 (UMLS CUI 2011AA)
76752008 (SNOMED CT 2011_0131)
MTHU011382 (LOINC Version 232)
palpation: Right nipple
Item
palpation: Right nipple
string
C0028109 (UMLS CUI 2011AA)
24142002 (SNOMED CT 2011_0131)
palpation: Left breast
Item
palpation: Left breast
string
C0006141 (UMLS CUI 2011AA)
76752008 (SNOMED CT 2011_0131)
MTHU011382 (LOINC Version 232)
palpation: Left nipple
Item
palpation: Left nipple
string
C0028109 (UMLS CUI 2011AA)
24142002 (SNOMED CT 2011_0131)
Item Group
Physical Exam - CHEST
normal for inspection, percussion, palpation, and auscultation of the lungs.
Item
normal for inspection, percussion, palpation, and auscultation of the lungs.
boolean
Chest significant for:
Item
Chest significant for:
string
C0817096 (UMLS CUI 2011AA)
51185008 (SNOMED CT 2011_0131)
Location
Item
Location
string
C0450429 (UMLS CUI 2011AA)
246267002 (SNOMED CT 2011_0131)
Additional lung sounds
Item
Additional lung sounds
string
C0035234 (UMLS CUI 2011AA)
52653008 (SNOMED CT 2011_0131)
10064779 (MedDRA 14.1)
Location
Item
Location
string
C0450429 (UMLS CUI 2011AA)
246267002 (SNOMED CT 2011_0131)
Item Group
Physical Exam - HEART
PMI at 5th intercostal space, mid clavicular line, normal S1,S2 without murmur or gallop
Item
PMI at 5th intercostal space, mid clavicular line, normal S1,S2 without murmur or gallop
boolean
C0018787 (UMLS CUI 2011AA)
80891009 (SNOMED CT 2011_0131)
MTHU001067 (LOINC Version 232)
Palpation: PMI is
Item
Palpation: PMI is
string
Rhythm
Item
Rhythm
string
Heart Sounds: S1 is , S2 is, S3 is, S4 is
Item
Heart Sounds: S1 is , S2 is, S3 is, S4 is
string
C0018820 (UMLS CUI 2011AA)
23472005 (SNOMED CT 2011_0131)
PE HEART RUB TEXT
Item
PE HEART RUB TEXT
string
PE HEART OTHER SOUNDS TEXT
Item
PE HEART OTHER SOUNDS TEXT
string
Murmur: grade
Item
Murmur: grade
string
C0018808 (UMLS CUI 2011AA)
421493004 (SNOMED CT 2011_0131)
10007586 (MedDRA 14.1)
R01.1 (ICD-10-CM Version 2010)
785.2 (ICD-9-CM Version 2011)
Murmur heard best at
Item
Murmur heard best at
string
Murmur radiates
Item
Murmur radiates
string
Heart - OTHER1
Item
Heart - OTHER1
string
Item Group
Physical Exam - VASCULAR
Pulses present and equal bilat.
Item
Pulses present and equal bilat.
boolean
Aorta
Item
Aorta
string
C0003483 (UMLS CUI 2011AA)
15825003 (SNOMED CT 2011_0131)
MTHU003021 (LOINC Version 232)
Pulses R/L: carotid
Item
Pulses R/L: carotid
string
C1096529 (UMLS CUI 2011AA)
10053926 (MedDRA 14.1)
Pulses R/L: brachial
Item
Pulses R/L: brachial
string
C1096531 (UMLS CUI 2011AA)
10053929 (MedDRA 14.1)
Pulses R/L: radial
Item
Pulses R/L: radial
string
C0232142 (UMLS CUI 2011AA)
65452004 (SNOMED CT 2011_0131)
10053935 (MedDRA 14.1)
Pulses R/L: femoral
Item
Pulses R/L: femoral
string
C0232148 (UMLS CUI 2011AA)
67316000 (SNOMED CT 2011_0131)
10053932 (MedDRA 14.1)
Pulses R/L: popliteal
Item
Pulses R/L: popliteal
string
C0232151 (UMLS CUI 2011AA)
74828005 (SNOMED CT 2011_0131)
10053938 (MedDRA 14.1)
Pulses R/L: posterior tibial
Item
Pulses R/L: posterior tibial
string
C1720310 (UMLS CUI 2011AA)
421568004 (SNOMED CT 2011_0131)
Pulses R/L: dorsalis pedis
Item
Pulses R/L: dorsalis pedis
string
C1706488 (UMLS CUI 2011AA)
421811005 (SNOMED CT 2011_0131)
Item Group
Physical Exam - ABDOMEN
soft, flat, nontender with normal bowel sounds. no organomegaly, no ascites, no palpable mass, no hernia.
Item
soft, flat, nontender with normal bowel sounds. no organomegaly, no ascites, no palpable mass, no hernia.
boolean
C0000726 (UMLS CUI 2011AA)
113345001 (SNOMED CT 2011_0131)
MTHU001425 (LOINC Version 232)
Appearance
Item
Appearance
string
Bowel sounds
Item
Bowel Sounds (BS), Borborygmi
string
C0232693 (UMLS CUI 2011AA)
87042004 (SNOMED CT 2011_0131)
10006023 (MedDRA 14.1)
Midepigastric bruit
Item
Midepigastric bruit
string
Abdominal tenderness
Item
Abdominal tenderness
string
C0232498 (UMLS CUI 2011AA)
43478001 (SNOMED CT 2011_0131)
10000097 (MedDRA 14.1)
R10.81 (ICD-10-CM Version 2010)
789.6 (ICD-9-CM Version 2011)
Rebound
Item
Rebound
string
Liver
Item
Liver, Hepar
string
C0023884 (UMLS CUI 2011AA)
10200004 (SNOMED CT 2011_0131)
MTHU002039 (LOINC Version 232)
Spleen
Item
Spleen
string
C0037993 (UMLS CUI 2011AA)
78961009 (SNOMED CT 2011_0131)
MTHU012104 (LOINC Version 232)
Hernia
Item
Hernia
string
C0019270 (UMLS CUI 2011AA)
414403008 (SNOMED CT 2011_0131)
10019909 (MedDRA 14.1)
K40-K46 (ICD-10-CM Version 2010)
Item Group
Physical Exam - GENITOURINARY/RECTAL: MALE
GU Assessment
Item
GU Assessment
string
C0042066 (UMLS CUI 2011AA)
21514008 (SNOMED CT 2011_0131)
MTHU013232 (LOINC Version 232)
Urine appears
Item
Urine appears
string
C0042036 (UMLS CUI 2011AA)
78014005 (SNOMED CT 2011_0131)
MTHU001343 (LOINC Version 232)
Urine is adequate
Item
Urine is adequate
string
C0042036 (UMLS CUI 2011AA)
78014005 (SNOMED CT 2011_0131)
MTHU001343 (LOINC Version 232)
Urine Output [ml]
Item
Urine output (UO), Urinary volume, Micturition volume
integer
C1287298 (UMLS CUI 2011AA)
365678000 (SNOMED CT 2011_0131)
10059894 (MedDRA 14.1)
MTHU024573 (LOINC Version 232)
Foley catheter
Item
Foley catheter
string
C0179804 (UMLS CUI 2011AA)
10016892 (MedDRA 14.1)
Suprapubic catheter
Item
Suprapubic catheter (SPC)
string
C0150798 (UMLS CUI 2011AA)
286861005 (SNOMED CT 2011_0131)
scrotal contents
Item
scrotal contents
string
Penis
Item
Penis
string
C0030851 (UMLS CUI 2011AA)
18911002 (SNOMED CT 2011_0131)
MTHU004206 (LOINC Version 232)
rectal: sphincter tone
Item
rectal: sphincter tone
string
hemorrhoids
Item
Haemorrhoids, Piles
string
C0019112 (UMLS CUI 2011AA)
70153002 (SNOMED CT 2011_0131)
10019022 (MedDRA 14.1)
MTHU015043 (LOINC Version 232)
I84 (ICD-10-CM Version 2010)
455 (ICD-9-CM Version 2011)
E10773 (CTCAE 1105E)
Prostate
Item
Prostate, Prostate Gland
string
C0033572 (UMLS CUI 2011AA)
41216001 (SNOMED CT 2011_0131)
MTHU004957 (LOINC Version 232)
mass
Item
mass
string
Item Group
Physical Exam - GENITOURINARY/RECTAL: FEMALE
GU Assessment FEMALE
Item
GU Assessment FEMALE
string
C0042066 (UMLS CUI 2011AA)
21514008 (SNOMED CT 2011_0131)
MTHU013232 (LOINC Version 232)
Urine appears
Item
Urine appears
string
C0042036 (UMLS CUI 2011AA)
78014005 (SNOMED CT 2011_0131)
MTHU001343 (LOINC Version 232)
Urine is adequate
Item
Urine is adequate
string
C0042036 (UMLS CUI 2011AA)
78014005 (SNOMED CT 2011_0131)
MTHU001343 (LOINC Version 232)
Urine Output [ml]
Item
Urine Output [ml]
integer
C1287298 (UMLS CUI 2011AA)
365678000 (SNOMED CT 2011_0131)
10059894 (MedDRA 14.1)
MTHU024573 (LOINC Version 232)
Foley catheter
Item
Foley catheter
string
C0179804 (UMLS CUI 2011AA)
10016892 (MedDRA 14.1)
Suprapubic catheter
Item
Suprapubic catheter (SPC)
string
C0150798 (UMLS CUI 2011AA)
286861005 (SNOMED CT 2011_0131)
External genitalia
Item
External genitalia
string
C0227605 (UMLS CUI 2011AA)
77142006 (SNOMED CT 2011_0131)
Urethra
Item
Urethra
string
C0041967 (UMLS CUI 2011AA)
264255005 (SNOMED CT 2011_0131)
MTHU001321 (LOINC Version 232)
Vagina
Item
Vagina
string
C0042232 (UMLS CUI 2011AA)
76784001 (SNOMED CT 2011_0131)
MTHU014732 (LOINC Version 232)
Bladder
Item
Urinary Bladder
string
C0005682 (UMLS CUI 2011AA)
89837001 (SNOMED CT 2011_0131)
MTHU002918 (LOINC Version 232)
Cervix
Item
Cervix uteri
string
C0007874 (UMLS CUI 2011AA)
71252005 (SNOMED CT 2011_0131)
MTHU001800 (LOINC Version 232)
Uterus
Item
Uterus
string
C0042149 (UMLS CUI 2011AA)
35039007 (SNOMED CT 2011_0131)
MTHU002943 (LOINC Version 232)
adnexa
Item
Uterine adnexa
string
C0001575 (UMLS CUI 2011AA)
23043003 (SNOMED CT 2011_0131)
MTHU015033 (LOINC Version 232)
rectal: sphincter tone
Item
rectal: sphincter tone
string
hemorrhoids
Item
Haemorrhoids, Piles
string
C0019112 (UMLS CUI 2011AA)
70153002 (SNOMED CT 2011_0131)
10019022 (MedDRA 14.1)
MTHU015043 (LOINC Version 232)
I84 (ICD-10-CM Version 2010)
455 (ICD-9-CM Version 2011)
E10773 (CTCAE 1105E)
mass
Item
mass
string
Item Group
Physical Exam -MUSCULOSKELETAL
MUSCULOSKELETAL
Item
Musculoskeletal System, Musculo-skeletal system
string
C0026860 (UMLS CUI 2011AA)
26107004 (SNOMED CT 2011_0131)
MTHU001411 (LOINC Version 232)
Gait
Item
Gait, Manner of walking
string
C0016928 (UMLS CUI 2011AA)
63448001 (SNOMED CT 2011_0131)
MTHU015039 (LOINC Version 232)
Station
Item
Station
string
Digits
Item
Digits
string
C0582802 (UMLS CUI 2011AA)
82680008 (SNOMED CT 2011_0131)
MTHU015035 (LOINC Version 232)
Nails
Item
Nails
string
C0027342 (UMLS CUI 2011AA)
72651009 (SNOMED CT 2011_0131)
MTHU002041 (LOINC Version 232)
Joints, Bones, Muscles
Item
Joints, Bones, Muscles
text
39352004, 272673000, 71616004 (SNOMED CT 2011_0131)
C0022417 (UMLS CUI-1)
C0262950 (UMLS CUI-2)
C0026845 (UMLS CUI-3)
Head and Neck
Item
Head & Neck (inspection & palpation, ROM, stability, muscle strength, tone)
text
69536005, 45048000 (SNOMED CT 2011_0131)
C0018670 (UMLS CUI-1)
C0027530 (UMLS CUI-2)
Spine/Ribs/Pelvis
Item
Spine/Ribs/Pelvis (inspection & palpation, ROM, stability, muscle strength, tone)
string
Right Shoulder
Item
Right Shoulder (inspection & palpation, ROM, stability, muscle strength, tone)
string
C0037004 (UMLS CUI 2011AA)
16982005 (SNOMED CT 2011_0131)
MTHU002689 (LOINC Version 232)
Right Elbow
Item
Right Elbow (inspection & palpation, ROM, stability, muscle strength, tone)
string
C0013769 (UMLS CUI 2011AA)
127949000 (SNOMED CT 2011_0131)
MTHU002674 (LOINC Version 232)
Right Wrist
Item
Right Wrist (inspection & palpation, ROM, stability, muscle strength, tone)
string
C0043262 (UMLS CUI 2011AA)
8205005 (SNOMED CT 2011_0131)
MTHU002691 (LOINC Version 232)
Left Shoulder
Item
Left Shoulder (inspection & palpation, ROM, stability, muscle strength, tone)
string
C0037004 (UMLS CUI 2011AA)
16982005 (SNOMED CT 2011_0131)
MTHU002689 (LOINC Version 232)
Left Elbow
Item
Left Elbow (inspection & palpation, ROM, stability, muscle strength, tone)
string
C0013769 (UMLS CUI 2011AA)
127949000 (SNOMED CT 2011_0131)
MTHU002674 (LOINC Version 232)
Left Wrist
Item
Left Wrist (inspection & palpation, ROM, stability, muscle strength, tone)
string
C0043262 (UMLS CUI 2011AA)
8205005 (SNOMED CT 2011_0131)
MTHU002691 (LOINC Version 232)
Right Hip
Item
Right Hip (inspection & palpation, ROM, stability, muscle strength, tone)
string
C0019552 (UMLS CUI 2011AA)
24136001 (SNOMED CT 2011_0131)
MTHU002686 (LOINC Version 232)
Right Knee
Item
Right Knee (inspection & palpation, ROM, stability, muscle strength, tone)
string
C0022742 (UMLS CUI 2011AA)
304679005 (SNOMED CT 2011_0131)
MTHU002687 (LOINC Version 232)
Right Ankle
Item
Right Ankle (inspection & palpation, ROM, stability, muscle strength, tone)
string
C0003086 (UMLS CUI 2011AA)
344001 (SNOMED CT 2011_0131)
Left Hip
Item
Left Hip (inspection & palpation, ROM, stability, muscle strength, tone)
string
C0019552 (UMLS CUI 2011AA)
24136001 (SNOMED CT 2011_0131)
MTHU002686 (LOINC Version 232)
Left Knee
Item
Left Knee (inspection & palpation, ROM, stability, muscle strength, tone)
string
C0022742 (UMLS CUI 2011AA)
304679005 (SNOMED CT 2011_0131)
MTHU002687 (LOINC Version 232)
Left Ankle
Item
Left Ankle (inspection & palpation, ROM, stability, muscle strength, tone)
string
C0003086 (UMLS CUI 2011AA)
344001 (SNOMED CT 2011_0131)
Item Group
Physical Exam - EXTREMITIES
Significant for:
Item
Significant for:
string
pitting edema
Item
Pitting edema
string
C0333243 (UMLS CUI 2011AA)
139248000 (SNOMED CT 2011_0131)
pretibial: R / L
Item
pretibial: R / L
string
ankle: R / L
Item
ankle: R / L
string
C0003086 (UMLS CUI 2011AA)
344001 (SNOMED CT 2011_0131)
foot: R / L
Item
foot: R / L
string
C0016504 (UMLS CUI 2011AA)
56459004 (SNOMED CT 2011_0131)
MTHU002679 (LOINC Version 232)
Pulses R/L: posterior tibial
Item
Posterior tibial pulse R/L
string
C1720310 (UMLS CUI 2011AA)
421568004 (SNOMED CT 2011_0131)
Pulses R/L: dorsalis pedis
Item
Pulses R/L: dorsalis pedis
string
C1706488 (UMLS CUI 2011AA)
421811005 (SNOMED CT 2011_0131)
capillary fill time R/L
Item
capillary fill time R/L
string
sensation by monofilament test R/L
Item
sensation by monofilament test R/L
string
toenails
Item
toenails
string
skin
Item
skin
string
C1123023 (UMLS CUI 2011AA)
39937001 (SNOMED CT 2011_0131)
MTHU001414 (LOINC Version 232)
Item Group
Physical Exam - LYMPHATIC
no adenopathy
Item
no adenopathy
boolean
adenopathy
Item
adenopathy (generalized, localized)
string
C1706304 (UMLS CUI 2011AA)
neck
Item
Neck, Collum, Cervical
string
C0027530 (UMLS CUI 2011AA)
45048000 (SNOMED CT 2011_0131)
MTHU002688 (LOINC Version 232)
Axilla
Item
Axilla, axillary region
string
C0004454 (UMLS CUI 2011AA)
91470000 (SNOMED CT 2011_0131)
MTHU002668 (LOINC Version 232)
groin
Item
Inguinal region
string
C0018246 (UMLS CUI 2011AA)
26893007 (SNOMED CT 2011_0131)
MTHU002684 (LOINC Version 232)
other
Item
other
string
Item Group
Physical Exam - SKIN
Inspection and palpation of skin and subcutaneous tissue reveals no acute rashes, lesions, or induration.
Item
Inspection and palpation of skin and subcutaneous tissue reveals no acute rashes, lesions, or induration.
boolean
C1123023 (UMLS CUI 2011AA)
39937001 (SNOMED CT 2011_0131)
MTHU001414 (LOINC Version 232)
inspection
Item
inspection, visual examination
string
C0199219 (UMLS CUI 2011AA)
32750006 (SNOMED CT 2011_0131)
Palpation
Item
Palpation
string
C0030247 (UMLS CUI 2011AA)
113011001 (SNOMED CT 2011_0131)
Item Group
Physical Exam - Wound and Incision Care
WOUND #
Item
Wound
string
C0043250 (UMLS CUI 2011AA)
13924000 (SNOMED CT 2011_0131)
10052428 (MedDRA 14.1)
MTHU001326 (LOINC Version 232)
WOUND LOCATION
Item
WOUND LOCATION
string
WOUND MEASUREMENT (Length, Width, Depth [cm])
Item
WOUND MEASUREMENT (Length, Width, Depth [cm])
string
UNDERMINING Wound
Item
UNDERMINING Wound
boolean
TUNNELING Wound
Item
TUNNELING Wound
boolean
SURROUNDING SKIN: WOUND BASE
Item
SURROUNDING SKIN: WOUND BASE
string
SENSATION
Item
Sensation, Esthesia, Sensory function, Sensory perception
string
C0036658 (UMLS CUI 2011AA)
373713005 (SNOMED CT 2011_0131)
MTHU017277 (LOINC Version 232)
EXUDATE
Item
EXUDATE
string
C0015388 (UMLS CUI 2011AA)
247450001 (SNOMED CT 2011_0131)
MTHU025016 (LOINC Version 232)
COLOR OF DRAINAGE
Item
COLOR OF DRAINAGE
string
ODOR: Before Cleaning
Item
ODOR: Before Cleaning
boolean
ODOR: After Cleaning
Item
ODOR: After Cleaning
boolean
CLEANSED WITH/IRRIGATED WITH
Item
CLEANSED WITH/IRRIGATED WITH
string
WOUND MED applied
Item
WOUND MED applied
string
FILLED WITH
Item
FILLED WITH
string
COVERED WITH
Item
COVERED WITH
string
SECURED WITH
Item
SECURED WITH
string
PRESSURE RELIEF
Item
PRESSURE RELIEF
string
COMMENTS
Item
COMMENTS
string
PHOTOGRAPH DATE
Item
PHOTOGRAPH DATE
date
NARRATIVE
Item
NARRATIVE
string
C1135957 (UMLS CUI 2011AA)
INCISION #
Item
Surgical incision
string
C0184898 (UMLS CUI 2011AA)
34896006 (SNOMED CT 2011_0131)
LOCATION
Item
Location
string
C0450429 (UMLS CUI 2011AA)
246267002 (SNOMED CT 2011_0131)
CLOSURE TYPE
Item
CLOSURE TYPE
string
DRESSING TYPE
Item
DRESSING TYPE
string
DRESSING APPEARANCE
Item
DRESSING APPEARANCE
string
DRAINS
Item
Drains, Drain device
string
C0180499 (UMLS CUI 2011AA)
32712000 (SNOMED CT 2011_0131)
MTHU022515 (LOINC Version 232)
NARRATIVE
Item
NARRATIVE
string
C1135957 (UMLS CUI 2011AA)
Item Group
Physical Exam - NEUROLOGIC
Oriented x 3, cranial nerves 2-12 intact, no gross sensory or motor deficits, reflexes symmetric, no cerebellar signs, no involuntary movements
Item
Oriented x 3, cranial nerves 2-12 intact, no gross sensory or motor deficits, reflexes symmetric, no cerebellar signs, no involuntary movements
boolean
C0027763 (UMLS CUI 2011AA)
25087005 (SNOMED CT 2011_0131)
MTHU001437 (LOINC Version 232)
Conciousness
Item
Consciousness related finding
string
C0234421 (UMLS CUI 2011AA)
106167005 (SNOMED CT 2011_0131)
Responsive to
Item
Responsive to
string
Orientation
Item
Orientation as to time, place and people
string
C0029266 (UMLS CUI 2011AA)
43173001 (SNOMED CT 2011_0131)
Proverb
Item
Proverb
string
Writing
Item
Writing
string
C2584304 (UMLS CUI 2011AA)
12261009 (SNOMED CT 2011_0131)
Reading
Item
Reading (activity)
string
C0034754 (UMLS CUI 2011AA)
50360004 (SNOMED CT 2011_0131)
Memory
Item
Memory function
string
C0025260 (UMLS CUI 2011AA)
303116000 (SNOMED CT 2011_0131)
MTHU021129 (LOINC Version 232)
Registration
Item
Registration
string
Naming Intact
Item
Naming Intact
string
Speech
Item
Speech, Speaking, using verbal communication
string
C0037817 (UMLS CUI 2011AA)
87335007 (SNOMED CT 2011_0131)
MTHU021528 (LOINC Version 232)
OTHER
Item
OTHER
string
Score normal
Item
Score normal
boolean
Concentration normal
Item
Concentration normal
boolean
Cranial nerves normal
Item
Cranial nerves normal
boolean
Comment
Item
Comment
string
Motor tone
Item
Muscle Tonus, Muscle tone, Muscle tension
string
C0026841 (UMLS CUI 2011AA)
10070541 (MedDRA 14.1)
MTHU015024 (LOINC Version 232)
Motor strength R/L
Item
Muscle Strength R/L
string
C0517349 (UMLS CUI 2011AA)
Grip R/L
Item
Grip R/L
string
C0220843 (UMLS CUI 2011AA)
Biceps R/L
Item
Biceps brachii, Biceps brachii muscle
string
C0559499 (UMLS CUI 2011AA)
16225001 (SNOMED CT 2011_0131)
MTHU014778 (LOINC Version 232)
Triceps R/L
Item
Triceps brachii muscle, Triceps brachii
string
C0559502 (UMLS CUI 2011AA)
40284004 (SNOMED CT 2011_0131)
MTHU014783 (LOINC Version 232)
Quadriceps R/L
Item
Quadriceps femoris muscle, Quadriceps femoris
string
C0224440 (UMLS CUI 2011AA)
21989003 (SNOMED CT 2011_0131)
Hip Extensors R/L
Item
Hip Extensors R/L
string
Dorsiflexion R/L
Item
Dorsiflexion R/L
string
Plantarflexion R/L
Item
Plantarflexion R/L
string
Sensation
Item
Sensation, Esthesia, Sensory function, Sensory perception
string
C0036658 (UMLS CUI 2011AA)
373713005 (SNOMED CT 2011_0131)
MTHU017277 (LOINC Version 232)
Pin prick
Item
Pin prick sensation, Discrimination between sharp and blunt
string
C0423557 (UMLS CUI 2011AA)
247315008 (SNOMED CT 2011_0131)
Comment
Item
Comment
string
Light touch
Item
Light touch
string
Vibration
Item
Vibration
string
C0459800 (UMLS CUI 2011AA)
33679000 (SNOMED CT 2011_0131)
MTHU021537 (LOINC Version 232)
Comment
Item
Comment
string
Position Sense
Item
Position Sense, Position sensation, Postural sense
string
C0234219 (UMLS CUI 2011AA)
73535003 (SNOMED CT 2011_0131)
Temperature
Item
Temperature
string
C0039476 (UMLS CUI 2011AA)
246508008 (SNOMED CT 2011_0131)
MTHU009008 (LOINC Version 232)
Stereognosis
Item
Stereognosis, Stereognostic perception, Touch discrimination
string
C0038263 (UMLS CUI 2011AA)
22382001 (SNOMED CT 2011_0131)
Deep Tendon Reflexes Biceps R/L
Item
Biceps reflex R/L
string
C0234151 (UMLS CUI 2011AA)
30901003 (SNOMED CT 2011_0131)
Deep Tendon Reflexes Triceps R/L
Item
Triceps reflex R/L
string
C0422908 (UMLS CUI 2011AA)
271716008 (SNOMED CT 2011_0131)
Deep Tendon Reflexes Brachioradialis R/L
Item
Deep Tendon Reflexes Brachioradialis R/L
string
Deep Tendon Reflexes Patellar R/L
Item
Patellar reflex, Knee reflex, Quadriceps reflex, Knee jerk (KJ) R/L
string
C0234147 (UMLS CUI 2011AA)
271714006 (SNOMED CT 2011_0131)
Deep Tendon Reflexes Achilles R/L
Item
Deep Tendon Reflexes Achilles R/L
string
Abnormal reflexes
Item
Abnormal reflexes
string
C0034933 (UMLS CUI 2011AA)
46670006 (SNOMED CT 2011_0131)
10000171 (MedDRA 14.1)
R29.2 (ICD-10-CM Version 2010)
796.1 (ICD-9-CM Version 2011)
Involuntary Movements
Item
Involuntary Movements
string
C0427086 (UMLS CUI 2011AA)
267078001 (SNOMED CT 2011_0131)
10028042 (MedDRA 14.1)
E12728 (CTCAE 1105E)
Cerebellar Signs
Item
Cerebellar Signs
string
C0742038 (UMLS CUI 2011AA)
Gait
Item
Gait, Manner of walking
string
C0016928 (UMLS CUI 2011AA)
63448001 (SNOMED CT 2011_0131)
MTHU015039 (LOINC Version 232)
Comment
Item
Comment
string
Station
Item
Station
string
Item Group
PSYCHIATRIC
Alert, oriented to person, place, and time, judgement and insight good, recent and remote memory intact, normal mood and affect.
Item
Alert, oriented to person, place, and time, judgement and insight good, recent and remote memory intact, normal mood and affect.
boolean
Judgement and Insight
Item
Judgement & Insight
text
61254005, 27026000 (SNOMED CT 2011_0131)
C0022423 (UMLS CUI-1)
C0233820 (UMLS CUI-2)
Orientation
Item
Orientation as to time, place and people
string
C0029266 (UMLS CUI 2011AA)
43173001 (SNOMED CT 2011_0131)
Recent Memory
Item
Recent Memory
string
C0233792 (UMLS CUI 2011AA)
69063000 (SNOMED CT 2011_0131)
Remote Memory
Item
Remote Memory, Palinmnesis
string
C0233793 (UMLS CUI 2011AA)
81964002 (SNOMED CT 2011_0131)
Mood/Affect
Item
Mood/Affect
text
85256008, 4065008 (SNOMED CT 2011_0131)
MTHU031584 (LOINC Version 232)
C0026516 (UMLS CUI-1)
C0001721 (UMLS CUI-2)
Item Group
Laboratory Results
Laboratory results reviewed
Item
Laboratory results reviewed
boolean
Prior 24 hour labs
Item
Prior 24 hour labs
string
C0587081 (UMLS CUI 2011AA)
118246004 (SNOMED CT 2011_0131)
Other
Item
Other
string
Item Group
Radiology Results
Radiology results reviewed
Item
Radiology results reviewed
boolean
radiology findings
Item
Radiology report
string
C1299496 (UMLS CUI 2011AA)
371527006 (SNOMED CT 2011_0131)
Item Group
ASSESSMENT
acceptable for surgery
Item
acceptable for surgery
boolean
progressing well
Item
progressing well
boolean
stable medically
Item
stable medically
boolean
C0205360 (UMLS CUI 2011AA)
58158008 (SNOMED CT 2011_0131)
MTHU015276 (LOINC Version 232)
Active Problems
Item
Active Problems
string
C0552582 (UMLS CUI 2011AA)
LP73189-0 (LOINC Version 232)
Other
Item
Other
string
Item Group
PLAN
Continue Home Regimen
Item
Continue Home Regimen
boolean
Continue Home Meds
Item
Continue Home Meds
boolean
Continue Chemotherapy
Item
Continue Chemotherapy
boolean
Continue IV Antibiotics
Item
Continue IV Antibiotics
boolean
Continue PO Antibiotics
Item
Continue PO Antibiotics
boolean
DVT Prophylaxis
Item
Deep venous thrombosis prophylaxis
boolean
C0853245 (UMLS CUI 2011AA)
10013880 (MedDRA 14.1)
O2 Protocol
Item
O2 Protocol
boolean
Follow Up X-Rays
Item
Follow Up X-Rays
boolean
UTI treatment
Item
UTI treatment
boolean
C0042029 (UMLS CUI 2011AA)
68566005 (SNOMED CT 2011_0131)
10046577 (MedDRA 14.1)
Monitor Blood Pressure and Heart Rate
Item
Monitor Blood Pressure and Heart Rate
boolean
Monitor Diabetes Mellitus
Item
Monitor Diabetes Mellitus
boolean
Accuchecks AC & HS
Item
Accuchecks AC & HS
boolean
Accuchecks Q6H
Item
Accuchecks Q6H
boolean
Sliding Scale Regular Insulin
Item
Sliding Scale Regular Insulin
boolean
C0021641 (UMLS CUI 2011AA)
67866001 (SNOMED CT 2011_0131)
MTHU019392 (LOINC Version 232)
Check Follow Up Labs
Item
Check Follow Up Labs
boolean
Appreciate following patient with you
Item
Appreciate following patient with you
boolean