SHORT STAY RECORD-ORTHO SURGICARE

Form from HIS OpenVistA

  1. StudyEvent: HIS
    1. HIS
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Medical History
C0262926 (UMLS CUI-1)
CHIEF COMPLAINT
Item
Chief complaint (CC)
string
C0277786 (UMLS CUI 2011AA)
33962009 (SNOMED CT 2011_0131)
MTHU001077 (LOINC Version 232)
HISTORY OF PRESENT ILLNESS
Item
History of present illness
string
C0262512 (UMLS CUI 2011AA)
MTHU001399 (LOINC Version 232)
Past Medical History
Item
Medical history
string
C0262926 (UMLS CUI 2011AA)
417662000 (SNOMED CT 2011_0131)
MTHU027722 (LOINC Version 232)
PRIOR SURGERIES
Item
Prior Surgery, History of (H/O) surgery, Past surgical history
string
C0455610 (UMLS CUI 2011AA)
161615003 (SNOMED CT 2011_0131)
ALLERGY
Item
Hypersensitivity
string
C0020517 (UMLS CUI 2011AA)
257550005 (SNOMED CT 2011_0131)
T78.40 (ICD-10-CM Version 2010)
CURRENT MEDICATIONS
Item
current medication list
string
C1553892 (UMLS CUI 2011AA)
CURMEDLIST (HL7 V3 2006_05)
REVIEW OF SYSTEMS
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 (SH)
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 Examination
C0031809 (UMLS CUI-1)
GENERAL APPEARANCE
Item
GENERAL APPEARANCE (normal: well developed, well nourished)
string
C1148438 (UMLS CUI 2011AA)
MTHU015040 (LOINC Version 232)
HEENT
Item
Head, Ears, Eyes, Nose and Throat (HEENT)
string
C1512338 (UMLS CUI 2011AA)
NECK
Item
Neck (normal: Supple. No jugular vein distention)
string
C0027530 (UMLS CUI 2011AA)
45048000 (SNOMED CT 2011_0131)
MTHU002688 (LOINC Version 232)
CHEST
Item
Chest (normal: clear anteriorly and posteriorly)
string
C0817096 (UMLS CUI 2011AA)
51185008 (SNOMED CT 2011_0131)
BREAST
Item
Breast (default: deferred)
string
C0006141 (UMLS CUI 2011AA)
76752008 (SNOMED CT 2011_0131)
MTHU011382 (LOINC Version 232)
HEART
Item
Heart (normal: Regular rate and rhythm without murmur)
string
C0018787 (UMLS CUI 2011AA)
80891009 (SNOMED CT 2011_0131)
MTHU001067 (LOINC Version 232)
ABDOMEN
Item
Abdomen (normal: Soft, (+) Bowel sounds, Normal tone)
string
C0000726 (UMLS CUI 2011AA)
113345001 (SNOMED CT 2011_0131)
MTHU001425 (LOINC Version 232)
LYMPH NODES
Item
Lymph nodes (normal: not palpable)
string
C0024204 (UMLS CUI 2011AA)
59441001 (SNOMED CT 2011_0131)
MTHU015050 (LOINC Version 232)
GENITALIA/RECTAL
Item
Genitalia/Rectal (default: deferred)
text
255582007 (SNOMED CT 2011_0131)
MTHU002681 (LOINC Version 232)
C0017420 (UMLS CUI [1,1])
C0205052 (UMLS CUI [1,2])
EXTREMITIES
Item
Extremities, Limb structure
string
C0015385 (UMLS CUI 2011AA)
66019005 (SNOMED CT 2011_0131)
MTHU001429 (LOINC Version 232)
SKIN
Item
Skin (default: no abnormalities detected)
string
C1123023 (UMLS CUI 2011AA)
39937001 (SNOMED CT 2011_0131)
MTHU001414 (LOINC Version 232)
Neurological examination normal
Item
NEUROLOGICAL: intact
boolean
C0027853 (UMLS CUI [1,1])
C0205307 (UMLS CUI [1,2])
Neurological assessment
Item
Neurological: intact except
text
225398001 (SNOMED CT 2011_0131)
10050318 (MedDRA 14.1)
89.13 (ICD-9-CM Version 2011)
C0027853 (UMLS CUI [1])
Item Group
Diagnosis and Plan
C0011900 (UMLS CUI-1)
C0599880 (UMLS CUI-2)
ADMITTING DIAGNOSIS
Item
ADMITTING DIAGNOSIS (AD)
string
C0332133 (UMLS CUI 2011AA)
52870002 (SNOMED CT 2011_0131)
PLAN: Surgery
Item
Planned
string
C1301732 (UMLS CUI 2011AA)
397943006 (SNOMED CT 2011_0131)
Item
ASA SCORE
integer
413347006 (SNOMED CT 2011_0131)
C1531480 (UMLS CUI [1])
Code List
ASA SCORE
CL Item
ASA 1 (1)
CL Item
ASA 2 (2)
CL Item
ASA 3 (3)
CL Item
ASA 4 (4)