HIS

1 forms
  1. StudyEvent: HIS
    1. HIS
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Allgemeine Informationen
C1508263 (UMLS CUI-1)
Arrival date and time
Item
Datum und Zeit des Eintreffens
date
C2215405 (UMLS CUI [1])
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
STATUS des Patienten
text
C0449437 (UMLS CUI [1])
HOW ARRIVED
Item
HOW ARRIVED
text
ACCOMPANIED BY
Item
ACCOMPANIED BY
text
Item
Zustand bei Ankunft
integer
C0348080 (UMLS CUI [1])
CONDITION UPON ARRIVAL
Code List
Zustand bei Ankunft
CL Item
stabil (1)
C0205360 (UMLS CUI-1)
CL Item
instabil (2)
C0443343 (UMLS CUI-1)
Item
Bewusstseinslage
integer
106167005 (SNOMED CT 2011_0131)
C0234425 (UMLS CUI [1])
LEVEL OF CONSCIOUSNESS
Code List
Bewusstseinslage
CL Item
wach (3)
C0239110 (UMLS CUI-1)
CL Item
lethargisch (2)
C0023380 (UMLS CUI-1)
CL Item
sediert (1)
C0235195 (UMLS CUI-1)
CL Item
stuporös (0)
C0085628 (UMLS CUI-1)
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
Anesthesist
Item
Anästhesist
text
C1550495 (UMLS CUI [1])
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)
Item
Zahnstatus
integer
C0226984 (UMLS CUI [1])
DENTAL
Code List
Zahnstatus
CL Item
Vollprothese (1)
C0011394 (UMLS CUI-1)
CL Item
Partielle Prothese (2)
C0011460 (UMLS CUI-1)
CL Item
Eigenes Gebiss intakt (3)
Item
Hören
text
47078008 (SNOMED CT 2011_0131)
MTHU015042 (LOINC Version 232)
C0018767 (UMLS CUI [1])
HEARING
Code List
Hören
CL Item
normal (WNL)
C0442816 (UMLS CUI-1)
CL Item
rechts vermindert (DR)
C0018772 (UMLS CUI-1)
C0205090 (UMLS CUI-2)
CL Item
links vermindert (DL)
C0018772 (UMLS CUI-1)
C0205091 (UMLS CUI-2)
Item
Visual (WNL,Glasses, Contacts)
integer
281004000 (SNOMED CT 2011_0131)
MTHU014733 (LOINC Version 232)
C0042789 (UMLS CUI [1])
VISUAL
Code List
Visual (WNL,Glasses, Contacts)
CL Item
normal (1)
C0442816 (UMLS CUI-1)
CL Item
Brille (2)
C0015421 (UMLS CUI-1)
CL Item
Kontaktlinsen (3)
C0009836 (UMLS CUI-1)
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
Item
Oximetrie
float
264598005 (SNOMED CT 2011_0131)
10033316 (MedDRA 14.1)
C0034108 (UMLS CUI [1])
Weight
Item
Gewicht
float
107647005 (SNOMED CT 2011_0131)
10047890 (MedDRA 14.1)
LP18015-5 (LOINC Version 232)
C0005910 (UMLS CUI [1])
Height
Item
Größe
float
MTHU005354 (LOINC Version 232)
C0005890 (UMLS CUI [1])
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
Item Group
Präoperative Diagnosen
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
Familienanamnese Kolonkarzinom
boolean
C0730200 (UMLS CUI [1])
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
Item
Aktivität
integer
C0026606 (UMLS CUI [1])
ACTIVITY
Code List
Aktivität
CL Item
all 4 extremities move voluntarily or on command (2)
CL Item
2 extremities move voluntarily or on command (1)
CL Item
cannot move extremities (0)
Item
Atmung
integer
C0035237 (UMLS CUI [1])
RESPIRATORY
Code List
Atmung
CL Item
able to deep breath, cough freely (2)
CL Item
dyspnea or limited breathing (1)
CL Item
apnea or SAO2 <90% (0)
Item
Blutdruck
integer
386534000 (SNOMED CT 2011_0131)
C0005823 (UMLS CUI [1])
Blood pressure
Code List
Blutdruck
CL Item
BP +/- 20% of pre-procedure level (2)
CL Item
BP +/- 21-49% pre-procedure level (1)
CL Item
BP +/- 50% pre-procedure level (0)
Item
Bewusstseinslage
integer
106167005 (SNOMED CT 2011_0131)
C0234421 (UMLS CUI [1])
LEVEL OF CONSCIOUSNESS
Code List
Bewusstseinslage
CL Item
Wach und reagiert adäquat (2)
CL Item
leicht erweckbar (1)
CL Item
nicht oder schwer erweckbar (0)
Item
Hautzustand
integer
422000003 (SNOMED CT 2011_0131)
MTHU034830 (LOINC Version 232)
C1719933 (UMLS CUI [1])
EVALUATION OF SKIN CONDITION AND COLOR
Code List
Hautzustand
CL Item
Skin is pink-warm- dry (2)
CL Item
Skin is pale-dusky-blotchy- jaundice (1)
CL Item
Patient is cyanotic (0)
ALDRETE TOTAL SCORE
Item
ALDRETE Gesamtscore
integer
C1821424 (UMLS CUI [1])
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