CARDIAC REHAB CONSULT RESULTS INTERDISCIPLINARY NOTE

Form from HIS OpenVistA

  1. StudyEvent: HIS
    1. HIS
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Date, Diagnosis, BMI
DATE REFERRAL RECEIVED
Item
DATE REFERRAL RECEIVED
date
ADMISSION DATE TO CARDIAC REHABILITATION
Item
ADMISSION DATE TO CARDIAC REHABILITATION
date
Diagnosis
Item
Diagnosis
string
C0011900 (UMLS CUI)
439401001 (SNOMED CT 2010_0731)
MTHU008876 (LOINC Version 232)
Current Weight
Item
Weight
text
107647005 (SNOMED CT 2010_0731)
10047890 (MedDRA 13.1)
LP18015-5 (LOINC Version 232)
C0005910 (UMLS CUI [1])
Current Height
Item
Height
float
MTHU005354 (LOINC Version 232)
C0489786 (UMLS CUI [1])
BMI
Item
Body Mass Index
float
140075008 (SNOMED CT 2010_0731)
10005894 (MedDRA 13.1)
LP35925-4 (LOINC Version 232)
C1305855 (UMLS CUI [1])
Item Group
SYMPTOM(S) ON ADMISSION
C1457887 (UMLS CUI-1)
SYMPTOMS ON ADMISSION
Item
SYMPTOM(S) ON ADMISSION
text
C1457887 (UMLS CUI [1,1])
C0457453 (UMLS CUI [1,2])
Item Group
PAST CARDIAC HISTORY
C0559157 (UMLS CUI-1)
PAST CARDIAC HISTORY
Item
PAST CARDIAC HISTORY
text
C0559157 (UMLS CUI [1])
Item Group
PAST Medical HISTORY
C0262926 (UMLS CUI-1)
ARF/Dialysis
Item
Acute Renal Failure/Dialysis
string
Arthritis
Item
Arthritis
string
C0003864 (UMLS CUI)
3723001 (SNOMED CT 2010_0731)
10003246 (MedDRA 13.1)
MTHU020793 (LOINC Version 232)
M19.90 (ICD-10-CM Version 2010)
716.9 (ICD-9-CM Version 2011)
E12378 (CTCAE Version 4.03)
Asthma
Item
Asthma
string
C0004096 (UMLS CUI)
195967001 (SNOMED CT 2010_0731)
10003553 (MedDRA 13.1)
MTHU020815 (LOINC Version 232)
J45 (ICD-10-CM Version 2010)
493 (ICD-9-CM Version 2011)
Cancer
Item
Malignant Neoplasms
string
C0006826 (UMLS CUI)
363346000 (SNOMED CT 2010_0731)
10028997 (MedDRA 13.1)
MTHU010328 (LOINC Version 232)
C00-C96 (ICD-10-CM Version 2010)
COPD
Item
Chronic Obstructive Pulmonary Disease
string
C0024117 (UMLS CUI)
13645005 (SNOMED CT 2010_0731)
10009033 (MedDRA 13.1)
J44.9 (ICD-10-CM Version 2010)
496 (ICD-9-CM Version 2011)
Depression
Item
Depression
string
C0011581 (UMLS CUI)
35489007 (SNOMED CT 2010_0731)
10012401 (MedDRA 13.1)
F32.9 (ICD-10-CM Version 2010)
Orthopedic Limitation
Item
Orthopedic Limitation
string
Thyroid Disorder
Item
Thyroid Disease
string
C0040128 (UMLS CUI)
14304000 (SNOMED CT 2010_0731)
10043709 (MedDRA 13.1)
E00-E07 (ICD-10-CM Version 2010)
240-246.99 (ICD-9-CM Version 2011)
Other
Item
Other
string
History of Hypertension
Item
History of Hypertension
text
C0455527 (UMLS CUI [1])
History of Diabetes
Item
History of Diabetes
string
Cholesterol History
Item
Cholesterol History
string
LIPID VALUES THIS ADMISSION
Item
LIPID VALUES THIS ADMISSION
string
Physical Activity
Item
Physical activity
string
C0026606 (UMLS CUI)
68130003 (SNOMED CT 2010_0731)
MTHU017278 (LOINC Version 232)
Item Group
PERTINENT SOCIAL HISTORY
Family Status
Item
Family Status
text
C0682315 (UMLS CUI-1)
PATIENT LIVES
Item
PATIENT LIVES
string
Employment Status
Item
Employment status
string
C0242271 (UMLS CUI)
224362002 (SNOMED CT 2010_0731)
Family History
Item
Family history (FH) of
string
C0241889 (UMLS CUI)
57177007 (SNOMED CT 2010_0731)
Stress/ Psychological Concerns
Item
Stress
string
C0038435 (UMLS CUI)
262188008 (SNOMED CT 2010_0731)
10042209 (MedDRA 13.1)
PATIENT APPEARS (Behavior)
Item
PATIENT APPEARS (Behavior)
string
Item Group
Smoking History
C1519384 (UMLS CUI-1)
Uses tobacco products
Item
Smoker
text
C0543414 (UMLS CUI-1)
HOW MUCH Smoking
Item
HOW MUCH Smoking
text
C1822491 (UMLS CUI-1)
Quit at time of hospitalization
Item
Quit at time of hospitalization
string
Former smoker(not smoked more than 6 months)
Item
Former smoker(not smoked more than 6 months)
string
Quit smoking in
Item
Quit smoking in
date
Never Smoked
Item
Never Smoked
string
NARRATIVE
Item
NARRATIVE
string
Item Group
Procedure Date and Results
CARDIAC CATHETERIZATION
Item
Heart catheterization
string
C0018795 (UMLS CUI)
41976001 (SNOMED CT 2010_0731)
10007815 (MedDRA 13.1)
37.21 (ICD-9-CM Version 2011)
CARDIAC CATHETERIZATION DATE
Item
CARDIAC CATHETERIZATION DATE
string
Ejection Fraction
Item
Cardiac ejection fraction
string
C0232174 (UMLS CUI)
70822001 (SNOMED CT 2010_0731)
LV FUNCTION
Item
LV FUNCTION
string
MARK WITH % OCCLUSIONS
Item
MARK WITH % OCCLUSIONS
string
LM
Item
LM
string
LAD
Item
LAD
string
DIAGONAL
Item
DIAGONAL
string
CX
Item
CX
string
ADDITIONAL COMMENTS
Item
ADDITIONAL COMMENTS
string
PTCI / STENT
Item
PTCI / STENT
string
PTCI DATE
Item
PTCI DATE
string
PTCA
Item
PTCA
text
C2936173 (UMLS CUI-1)
STENT
Item
STENT
text
C0038257 (UMLS CUI-1)
ATHERECTOMY
Item
ATHERECTOMY
string
IIB/IIA INHIBITOR
Item
IIB/IIA INHIBITOR
string
MARK WITH APPROPRIATE LETTER: PTCA-(P), STENT-(S), ATHERECTOMY-(A)
Item
MARK WITH APPROPRIATE LETTER: PTCA-(P), STENT-(S), ATHERECTOMY-(A)
string
LM
Item
LM
string
LAD
Item
LAD
text
C0226032 (UMLS CUI-1)
DIAGONAL
Item
DIAGONAL
string
CX
Item
CX
string
ADDITIONAL COMMENTS
Item
ADDITIONAL COMMENTS
string
SURGERY
Item
SURGERY
string
CABG
Item
Coronary Artery Bypass Surgery
string
C0010055 (UMLS CUI)
232717009 (SNOMED CT 2010_0731)
10011077 (MedDRA 13.1)
36.10 (ICD-9-CM Version 2011)
DATE CABG
Item
DATE CABG
date
MIDCAB
Item
MIDCAB
string
AVR
Item
AVR
string
MVR
Item
MVR
string
OTHER PROCEDURES
Item
OTHER PROCEDURES
string
CARDIOVASCULAR RISK FACTOR
Item
CARDIOVASCULAR RISK FACTOR
string
CORRELATE A NUMBER WITH GRAFT ORIGIN SITE
Item
CORRELATE A NUMBER WITH GRAFT ORIGIN SITE
string
DONOR AREA TO
Item
DONOR AREA TO
string
LIMA
Item
LIMA
string
RIMA
Item
RIMA
string
RADIAL
Item
RADIAL
string
SVG
Item
SVG
string
RPD
Item
RPD
string
Item Group
PATIENT/FAMILY EDUCATION
BOOKLET(S) GIVEN
Item
BOOKLET(S) GIVEN
string
DATE BOOKLET(S) given
Item
DATE BOOKLET(S) given
date
BOOKLET VERSIONS
Item
BOOKLET VERSIONS
string
VIDEO(S) SHOWN
Item
VIDEO(S) SHOWN
string
DATE VIDEO(S) shown
Item
DATE VIDEO(S) shown
string
VIDEO VERSION
Item
VIDEO VERSION
string
LEARNER
Item
LEARNER
string
PATIENT'S PHYSICAL READINESS TO LEARN
Item
PATIENT'S PHYSICAL READINESS TO LEARN
string
PSYCHOLOGICALLY WILLING TO LEARN
Item
PSYCHOLOGICALLY WILLING TO LEARN
string
EDUCATIONAL TOPICS Heart Disease
Item
EDUCATIONAL TOPICS: 1.Description of Cardiac Catheterization and site care, 2.Heart structure and function, 3.Myocardial Infarction symptoms and interventions, 4.Unstable Angina symptoms and interventons, 5.Congestive Heart Failure and importance of daily weights, 6.PTCI (Angioplasty,Stent), 7.Open Heart Surgery
string
EDUCATIONAL TOPICS CORONARY RISK AND MODIFICATION
Item
EDUCATIONAL TOPICS CORONARY RISK AND MODIFICATION: 1.Tobacco Cessation, 2.Exercise guidelines, aerobic exercise for minimum of 30 minutes, 3.Dietary Modifications, 4.Stress Management, 5.Cholesterol and Triglycerides, 6.Diabetes Management, 7.Obesity, 8.Medication, 9.Hypertension
string
DISCHARGE SPECIFIC INSTRUCTIONS
Item
DISCHARGE SPECIFIC INSTRUCTIONS: 1.Activity, 2.Site / Incision care, 3.Daily Weight, 4.Returning to work, 5.Driving, 6.Recurrent Chest Pain, 7.Psychosocial, 8.Coumadin, 9.Sex
string
CARDIAC REHAB NARRATIVE
Item
CARDIAC REHAB NARRATIVE
string