HIS

1 forms
  1. StudyEvent: HIS
    1. HIS
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Child Nursing Assessment
C0028680 (UMLS CUI-1)
C0008059 (UMLS CUI-2)
initial Assessment
Item
see initial Admission Assessment
boolean
C0150637 (UMLS CUI [1])
assessment date
Item
DONE ON
date
C2985720 (UMLS CUI [1])
ADMISSION
Item
ADMISSION TEXT
text
C0030673 (UMLS CUI [1])
POST OP DAY
Item
POST OP DAY
integer
C0032790 (UMLS CUI [1])
Item Group
Neuro / Psychosocial
C0027853 (UMLS CUI-1)
Neurological examination normal
Item
Normal Baseline: Alert, appropriate verbalization, response appropriate for age, pupils equal and reactive, sensation intact.
boolean
C1112287 (UMLS CUI [1])
Abnormal Findings
Item
Narrative: Abnormal Findings
text
C1704258 (UMLS CUI [1])
Item Group
GLASGOW COMA SCALE ADULT
C1271007 (UMLS CUI-1)
Item
EYES OPEN
integer
C3648956 (UMLS CUI [1])
EYES OPEN
Code List
EYES OPEN
CL Item
Eyes open spontaneously (4)
C2012046 (UMLS CUI-1)
CL Item
Eyes open to verbal stimuli (3)
C2012048 (UMLS CUI-1)
CL Item
Eyes open to pain stimuli (2)
C2012047 (UMLS CUI-1)
CL Item
Never open (1)
C2012045 (UMLS CUI-1)
Item
BEST VERBAL RESPONSE
integer
C3648957 (UMLS CUI [1])
BEST VERBAL RESPONSE
Code List
BEST VERBAL RESPONSE
CL Item
Oriented (5)
C2012059 (UMLS CUI-1)
CL Item
Confused (4)
C2012056 (UMLS CUI-1)
CL Item
Inappropriate words (3)
C2012058 (UMLS CUI-1)
CL Item
Incomprehensible words (2)
C2012057 (UMLS CUI-1)
CL Item
None (1)
C2012060 (UMLS CUI-1)
Item
BEST MOTOR RESPONSE
integer
C3648958 (UMLS CUI [1])
BEST MOTOR RESPONSE
Code List
BEST MOTOR RESPONSE
CL Item
Obeys command (6)
C2012055 (UMLS CUI-1)
CL Item
Localize to pain (5)
C2012053 (UMLS CUI-1)
CL Item
Withdraws (4)
C2012052 (UMLS CUI-1)
CL Item
Flexion to pain (3)
C2012051 (UMLS CUI-1)
CL Item
Extension to pain (2)
C2012050 (UMLS CUI-1)
CL Item
None (1)
C2012054 (UMLS CUI-1)
GLASCOW COMA SCALE SCORE
Item
GLASCOW COMA SCALE SCORE ADULT
integer
C1271007 (UMLS CUI [1])
Item Group
Pupils
C0034121 (UMLS CUI-1)
Right Pupil Size
Item
Right Size
integer
C0517965 (UMLS CUI [1,1])
C0205090 (UMLS CUI [1,2])
Right Pupil Reaction
Item
Right Reaction
text
C0234671 (UMLS CUI [1,1])
C0444532 (UMLS CUI [1,2])
Left Pupil Size
Item
Left Size
integer
C0517965 (UMLS CUI [1,1])
C0205091 (UMLS CUI [1,2])
Left Pupil Reaction
Item
Left Reaction
text
C0234671 (UMLS CUI [1,1])
C0443246 (UMLS CUI [1,2])
Item Group
GLASGOW COMA SCALE CHILD
C0017594 (UMLS CUI-1)
C0008059 (UMLS CUI-2)
Item
EYES OPEN
integer
C3648956 (UMLS CUI [1])
EYES OPEN
Code List
EYES OPEN
CL Item
Spontaneously (4)
C2012046 (UMLS CUI-1)
CL Item
To speech (3)
C2012048 (UMLS CUI-1)
CL Item
To pain (2)
C2012047 (UMLS CUI-1)
CL Item
None (1)
C2012045 (UMLS CUI-1)
Item
BEST VERBAL RESPONSE
integer
BEST VERBAL RESPONSE
Code List
BEST VERBAL RESPONSE
CL Item
Coos and babbles (5)
C0517058 (UMLS CUI-1)
CL Item
Irritable, cries (4)
C0010399 (UMLS CUI-1)
CL Item
Cries in response to pain (3)
C1698479 (UMLS CUI-1)
CL Item
Moans in response to pain (2)
C2071460 (UMLS CUI-1)
CL Item
None (1)
C2012060 (UMLS CUI-1)
Item
BEST MOTOR RESPONSE
integer
C3648958 (UMLS CUI [1])
BEST MOTOR RESPONSE
Code List
BEST MOTOR RESPONSE
CL Item
Moves spontaneously and purposely (6)
C2012055 (UMLS CUI-1)
CL Item
Withdraws in response to touch (5)
C2012053 (UMLS CUI-1)
CL Item
Withdraws in response to pain (4)
C2012052 (UMLS CUI-1)
CL Item
Decorticate posturing (abnormal flexion) in response to pain (3)
C2012051 (UMLS CUI-1)
CL Item
Decerebrate posturing (abnormal extension) in response to pain (2)
C2012050 (UMLS CUI-1)
CL Item
None (1)
C2012054 (UMLS CUI-1)
GLASCOW COMA SCALE SCORE CHILD
Item
GLASCOW COMA SCALE SCORE CHILD
integer
Item Group
ORIENTATION
C0029266 (UMLS CUI-1)
ORIENTATION
Item
ORIENTATION
string
C0029266 (UMLS CUI 2011AA)
43173001 (SNOMED CT 2011_0131)
History of SEIZURE ACTIVITY
Item
HX OF SEIZURE ACTIVITY
text
C1148156 (UMLS CUI [1])
AFFECT
Item
Affect
string
C0001721 (UMLS CUI 2011AA)
4065008 (SNOMED CT 2011_0131)
SPEECH
Item
Speech, Speaking, using verbal communication
string
C0037817 (UMLS CUI 2011AA)
87335007 (SNOMED CT 2011_0131)
MTHU021528 (LOINC Version 232)
NUMBNESS OR TINGLING
Item
NUMBNESS OR TINGLING PRESENT
text
C3842982 (UMLS CUI [1])
Item Group
Cardiovascular system
C0007226 (UMLS CUI-1)
Cardiovascular System Normal
Item
Normal Baseline: Regular rate and rhythm, no edema, capillary refill less than 2 seconds, pink nailbeds, warm extemities, peripheral pulses strong and regular.
boolean
C0577867 (UMLS CUI [1])
Abnormal Findings
Item
Narrative: Abnormal Findings
text
C1704258 (UMLS CUI [1])
Antithromboembolic stockings
Item
TEDS ON
boolean
C0419312 (UMLS CUI [1])
Vascular Sequential Compression Devices
Item
SCDS ON
boolean
C0180062 (UMLS CUI [1])
HEART SOUNDS
Item
Heart sounds (HS), Cardiac Sounds
string
C0018820 (UMLS CUI 2011AA)
23472005 (SNOMED CT 2011_0131)
Radial pulse (L/R)
Item
Radial pulse (L/R)
string
C0232142 (UMLS CUI 2011AA)
65452004 (SNOMED CT 2011_0131)
10053935 (MedDRA 14.1)
Pedal pulse
Item
Pedal pulse (L/R)
text
C0232157 (UMLS CUI [1])
Pos-Tibial Pulse
Item
Posterior tibial pulse (L/R)
text
421568004 (SNOMED CT 2011_0131)
C1720310 (UMLS CUI [1])
Popliteal Pulse (L/R)
Item
Popliteal pulse (L/R)
string
C0232151 (UMLS CUI 2011AA)
74828005 (SNOMED CT 2011_0131)
10053938 (MedDRA 14.1)
Brachial Pulse (L/R)
Item
Brachial pulse (L/R)
string
C1096531 (UMLS CUI 2011AA)
10053929 (MedDRA 14.1)
Carotid Pulse (L/R)
Item
Carotid pulse (L/R)
string
C1096529 (UMLS CUI 2011AA)
10053926 (MedDRA 14.1)
AV SHUNT
Item
AV SHUNT/GRAFT
text
C1456474 (UMLS CUI [1])
SHUNT LOCATION
Item
SHUNT/GRAFT LOCATION
text
C1442858 (UMLS CUI [1,1])
C0450429 (UMLS CUI [1,2])
BRUIT
Item
BRUIT
text
C0006318 (UMLS CUI [1])
SHUNT BRUIT
Item
SHUNT/GRAFT BRUITS
text
C0232112 (UMLS CUI [1])
THRILL
Item
THRILL PALPATED
text
C2678517 (UMLS CUI [1])
CAPILLARY REFILL
Item
CAPILLARY REFILL
text
C0425716 (UMLS CUI [1])
NAIL BED COLOR
Item
NAIL BED COLOR
text
C0574757 (UMLS CUI [1])
Edema
Item
EDEMA DESCRIPTION (Grading, Location)
string
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)
Heart RHYTHM
Item
Heart RHYTHM
text
C0232187 (UMLS CUI [1])
PACEMAKER PRESENT
Item
Cardiac Pacemaker
boolean
C0030163 (UMLS CUI 2011AA)
14106009 (SNOMED CT 2011_0131)
MTHU024521 (LOINC Version 232)
Item Group
Eyes Ear Nose & Throat
C3494720 (UMLS CUI-1)
EYES NORMAL
Item
Normal Baseline EYES: Without drainage, sclera white.
boolean
C4230579 (UMLS CUI [1])
Normal Ears
Item
Normal Baseline EARS: No complaint of pain.
boolean
C0576927 (UMLS CUI [1])
Normal Nose
Item
Normal Baseline NOSE: No drainage or congestion.
boolean
C0577884 (UMLS CUI [1])
Normal Throat
Item
Normal Baseline THROAT: No complaint of pain.
boolean
C0577002 (UMLS CUI [1])
Abnormal Findings
Item
Narrative: Abnormal Findings
text
C1704258 (UMLS CUI [1])
Item Group
Eyes
C0015392 (UMLS CUI-1)
Right Pupil Size
Item
Pupil Right Size
integer
C0517965 (UMLS CUI [1,1])
C0205090 (UMLS CUI [1,2])
Right Pupil Reaction
Item
Pupil Right Reaction
text
C0234671 (UMLS CUI [1,1])
C0444532 (UMLS CUI [1,2])
Left Pupil Size
Item
Pupil Left Size
integer
C0517965 (UMLS CUI [1,1])
C0205091 (UMLS CUI [1,2])
Left Pupil Reaction
Item
Pupil Left Reaction
text
C0234671 (UMLS CUI [1,1])
C0443246 (UMLS CUI [1,2])
Eye symptom
Item
Eye Complaint
text
C0848690 (UMLS CUI [1])
Right Sclera
Item
Right Sclera
text
C0929516 (UMLS CUI [1])
Left Sclera
Item
Left Sclera
text
C0934600 (UMLS CUI [1])
Drainage
Item
Drainage
boolean
C0012621 (UMLS CUI [1])
Drainage Color
Item
Drainage Color
text
C0012621 (UMLS CUI [1,1])
C0009393 (UMLS CUI [1,2])
Item Group
EARS
C0013443 (UMLS CUI-1)
EXTERNAL CANAL
Item
EARS(EXTERNAL CANAL)
text
C1517034 (UMLS CUI [1])
C/O Pain
Item
C/O Pain
boolean
C0436561 (UMLS CUI [1])
Tympanic Membranes
Item
Tympanic Membranes (TM), eardrums
text
42859004 (SNOMED CT 2011_0131)
MTHU014731 (LOINC Version 232)
C0041445 (UMLS CUI [1])
Tubes
Item
Tubes
text
C0015183 (UMLS CUI [1])
Hard of Hearing
Item
Hard of Hearing
boolean
C1384666 (UMLS CUI [1])
Hearing Loss
Item
Hearing Loss
boolean
C3887873 (UMLS CUI [1])
Deafness
Item
Deafness
boolean
C0011053 (UMLS CUI [1])
Item
Hearing Aids
text
C0018768 (UMLS CUI [1])
Hearing Aids
Code List
Hearing Aids
CL Item
RT (1)
C0444532 (UMLS CUI-1)
CL Item
LT (2)
C0443246 (UMLS CUI-1)
CL Item
bilateral (3)
C0238767 (UMLS CUI-1)
Patent
Item
Patent
boolean
C0175566 (UMLS CUI [1])
Dizziness
Item
Dizziness
boolean
C0012833 (UMLS CUI 2011AA)
404640003 (SNOMED CT 2011_0131)
10013573 (MedDRA 14.1)
E12631 (CTCAE 1105E)
Tinnitus
Item
Tinnitus, Ear noises, Ear ringing
boolean
C0040264 (UMLS CUI 2011AA)
60862001 (SNOMED CT 2011_0131)
10043882 (MedDRA 14.1)
H93.1 (ICD-10-CM Version 2010)
388.3 (ICD-9-CM Version 2011)
E10287 (CTCAE 1105E)
Drainage
Item
Drainage
boolean
32712000 (SNOMED CT 2011_0131)
MTHU022515 (LOINC Version 232)
C0012621 (UMLS CUI [1])
Color of Ear Drainage
Item
Color of Ear Drainage
text
C0012621 (UMLS CUI [1,1])
C0009393 (UMLS CUI [1,2])
Item Group
Nose
C0028429 (UMLS CUI-1)
Nares patent
Item
Nares patent
boolean
C1456808 (UMLS CUI [1,1])
C0175566 (UMLS CUI [1,2])
Nares Drainage
Item
Nares Drainage
boolean
C0746759 (UMLS CUI [1])
Septum
Item
Nasal septum
string
C0027432 (UMLS CUI 2011AA)
68426009 (SNOMED CT 2011_0131)
MTHU015054 (LOINC Version 232)
Item Group
Pharynx, Throat
C0031354 (UMLS CUI-1)
Throat Pain
Item
Sore throat, Pain in throat, Pharyngeal pain
boolean
C0242429 (UMLS CUI 2011AA)
267102003 (SNOMED CT 2011_0131)
10041367 (MedDRA 14.1)
R07.0 (ICD-10-CM Version 2010)
784.1 (ICD-9-CM Version 2011)
E13575 (CTCAE 1105E)
Mouth Sores
Item
Mouth Sores
boolean
C0149745 (UMLS CUI [1])
Appearance of Throat
Item
Appearance of Throat
text
C0426505 (UMLS CUI [1])
Mucous Membranes
Item
Mucous Membranes
text
C0026724 (UMLS CUI [1])
Item Group
Respiratory
C0035237 (UMLS CUI-1)
Respiratory NORMAL
Item
Normal Baseline Respiratory: Unlabored respirations, BBS clear, chest rise symmetrical, pink mucous membranes.
boolean
C0231795 (UMLS CUI [1])
Abnormal Findings
Item
Narrative: Abnormal Findings
text
C1704258 (UMLS CUI [1])
BREATH SOUNDS
Item
Breath Sounds (RUL, LUL, LLL, RLL)
string
C0035234 (UMLS CUI 2011AA)
52653008 (SNOMED CT 2011_0131)
10064779 (MedDRA 14.1)
RESPIRATORY EFFORT
Item
RESPIRATORY EFFORT
text
C0425466 (UMLS CUI [1])
Item
CHEST EXPANSION
text
C0231902 (UMLS CUI [1])
CHEST EXPANSION
Code List
CHEST EXPANSION
CL Item
symmetrical (1)
C0332516 (UMLS CUI-1)
CL Item
non-symmetrical (2)
C0332514 (UMLS CUI-1)
INCENTIVE SPIROMETRY
Item
INCENTIVE SPIROMETRY DONE
boolean
C0454512 (UMLS CUI [1])
oxygen delivery system
Item
OXYGEN DELIVERY METHOD
text
C0809836 (UMLS CUI [1])
Pulse Oximeter
Item
Pulse Oximeter present with alarms set
boolean
C0182109 (UMLS CUI [1])
Cardio-Respiratory Monitoring
Item
Cardio-Respiratory Monitor present with alarms set
boolean
C0150496 (UMLS CUI [1,1])
C0199438 (UMLS CUI [1,2])
COUGH TYPE
Item
COUGH TYPE
string
C0010200 (UMLS CUI 2011AA)
49727002 (SNOMED CT 2011_0131)
10011224 (MedDRA 14.1)
R05 (ICD-10-CM Version 2010)
786.2 (ICD-9-CM Version 2011)
E13364 (CTCAE 1105E)
Sputum
Item
Sputum, Expectoration (incl. Quantity)
text
45710003 (SNOMED CT 2011_0131)
10041802 (MedDRA 14.1)
MTHU001309 (LOINC Version 232)
C0038056 (UMLS CUI [1])
CHEST TUBE
Item
CHEST TUBE PRESENT
boolean
C0008034 (UMLS CUI [1])
Chest tube site
Item
CHEST TUBE LOCATION
boolean
C0489468 (UMLS CUI [1])
Chest Tube Suction Setting
Item
Chest Tube Suction Setting
text
C0008034 (UMLS CUI [1,1])
C1306323 (UMLS CUI [1,2])
Item
Air Leak
text
C2242512 (UMLS CUI [1])
Air Leak
Code List
Air Leak
CL Item
none (1)
C0549184 (UMLS CUI-1)
CL Item
small (2)
C0700321 (UMLS CUI-1)
CL Item
moderate (3)
C0205081 (UMLS CUI-1)
CL Item
large (4)
C0549177 (UMLS CUI-1)
Item Group
Gastrointestinal
NORMAL BASELINE GI
Item
Normal Baseline GI: Abdomen soft, nondistended, bowel sounds normoactive in all quadrants.
boolean
Last BM
Item
Last Bowel Movement
date
NARRATIVE: Abnormal Findings
Item
NARRATIVE: Abnormal Findings
string
ABDOMINAL DESCRIPTION
Item
Abdomen
string
C0000726 (UMLS CUI 2011AA)
113345001 (SNOMED CT 2011_0131)
MTHU001425 (LOINC Version 232)
BOWEL SOUNDS
Item
BOWEL SOUNDS (RUQ, LUQ, RLQ,LLQ)
string
C0232693 (UMLS CUI 2011AA)
87042004 (SNOMED CT 2011_0131)
10006023 (MedDRA 14.1)
FLATUS
Item
FLATUS
boolean
incontinence
Item
Incontinence
boolean
C0021167 (UMLS CUI 2011AA)
48340000 (SNOMED CT 2011_0131)
10021639 (MedDRA 14.1)
GASTRIC SYMPTOMS
Item
GASTRIC SYMPTOMS
string
NG TUBE TYPE
Item
Nasogastric Tube Type
string
NG placement checked
Item
NG placement checked
boolean
Suction Setting
Item
Suction Setting
string
Gastric Content Color
Item
Gastric Content Color
string
NGT irrigated
Item
NGT irrigated (with # ML's of #)
string
FEEDING TUBE PRESENT
Item
Tube feeding (TF), Enteral tube feeding
boolean
C0041281 (UMLS CUI 2011AA)
61420007 (SNOMED CT 2011_0131)
10053095 (MedDRA 14.1)
Feeding Tube Type
Item
Feeding Tube Type
string
Formula
Item
Formula (# strength @ # ml's/hour via kangaroo pump)
string
OSTOMY TYPE
Item
OSTOMY TYPE
string
RECTAL BAG PRESENT
Item
RECTAL BAG PRESENT
boolean
Item Group
Genitourinary system, Urogenital system
NORMAL BASELINE Genitourinary
Item
Normal Baseline Genitourinary: Voids without pain or hesitation, no suprapubic distention.
boolean
NARRATIVE: Abnormal Findings
Item
NARRATIVE: Abnormal Findings
string
Item
Sex
string
C0079399 (UMLS CUI 2011AA)
263495000 (SNOMED CT 2011_0131)
MTHU002975 (LOINC Version 232)
Sex
Code List
Sex
CL Item
Male (1)
CL Item
Female (2)
INCONTINENT
Item
INCONTINENT
boolean
VOIDS SUFFICIENT QUANITY
Item
VOIDS SUFFICIENT QUANITY
boolean
IS PATIENT RECEIVING DIALYSIS
Item
IS PATIENT RECEIVING DIALYSIS
boolean
ODOR PRESENT
Item
ODOR PRESENT
boolean
CATHETER PRESENT
Item
catheter present
boolean
C0085590 (UMLS CUI 2011AA)
19923001 (SNOMED CT 2011_0131)
CATHETER SIZE
Item
Size of catheter
string
C0449963 (UMLS CUI 2011AA)
260967009 (SNOMED CT 2011_0131)
Date of insertion
Item
Date of insertion
date
Urine color
Item
Urine color
string
URINARY SYMPTOMS
Item
URINARY SYMPTOMS
string
SEXUALLY ACTIVE
Item
SEXUALLY ACTIVE
boolean
CURRENTLY ON MENSES
Item
CURRENTLY ON MENSES
boolean
DISCHARGE PRESENT
Item
Discharge (Dx)
boolean
C0012621 (UMLS CUI 2011AA)
75823008 (SNOMED CT 2011_0131)
Discharge color
Item
Discharge color
string
Discharge odor
Item
Discharge odor
string
Discharge consistency
Item
Discharge consistency
string
ABNORMAL GENITALIA DESCRIPTION
Item
ABNORMAL GENITALIA DESCRIPTION
string
Item Group
Musculoskeletal System, Musculo-skeletal system
NORMAL BASELINE Musculoskeletal
Item
Normal Baseline Musculoskeletal: Full ROM, no muscle weakness, bones intact, gait steady or age appropriate.
boolean
NARRATIVE: Abnormal Findings
Item
NARRATIVE: Abnormal Findings
string
GENERALIZED WEAKNESS
Item
GENERALIZED WEAKNESS
boolean
LIMITED ROM
Item
LIMITED ROM
boolean
LIMITED MOBILITY
Item
LIMITED MOBILITY
boolean
PARALYSIS TYPE
Item
PARALYSIS TYPE
string
Item
Hemiplegia Side
string
Hemiplegia Side
Code List
Hemiplegia Side
CL Item
left (1)
CL Item
right (2)
FRACTURE(S) LOCATION
Item
FRACTURE(S) LOCATION
string
FINGER DIGITS
Item
FINGER DIGITS
string
TOE DIGITS
Item
TOE DIGITS
string
LEFT UPPER EXTREMITIES
Item
LEFT UPPER EXTREMITIES
string
RIGHT UPPER EXTREMITIES
Item
RIGHT UPPER EXTREMITIES
string
GRIPS EQUAL
Item
GRIPS EQUAL
boolean
LEFT LOWER EXTREMITIES
Item
LEFT LOWER EXTREMITIES
string
RIGHT LOWER EXTREMITIES
Item
RIGHT LOWER EXTREMITIES
string
UNSTEADY GAIT
Item
UNSTEADY GAIT
boolean
Item Group
Integument
NORMAL BASELINE Skin
Item
Normal Baseline Skin: Warm, pink, dry, elastic, intact, moist mucous membranes.
boolean
NARRATIVE: Abnormal Findings
Item
NARRATIVE: Abnormal Findings
string
TEMPERATURE
Item
Temperature
float
C0039476 (UMLS CUI 2011AA)
246508008 (SNOMED CT 2011_0131)
MTHU009008 (LOINC Version 232)
SKIN COLOR
Item
SKIN COLOR
string
MOIST
Item
MOIST
boolean
SKIN TURGOR
Item
SKIN TURGOR
string
Item Group
Surgical incision
Incision #:
Item
Surgical incision
string
C0184898 (UMLS CUI 2011AA)
34896006 (SNOMED CT 2011_0131)
MID WOUND#
Item
MID WOUND#
string
Site
Item
Site
string
Closure Type
Item
Closure Type
string
Incision Appearance
Item
Incision Appearance
string
Dressing Changed
Item
Dressing Changed
boolean
Date Dressing Changed
Item
Date Dressing Changed
date
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)
Item Group
Wound
WOUND #
Item
Wound
string
C0043250 (UMLS CUI 2011AA)
13924000 (SNOMED CT 2011_0131)
10052428 (MedDRA 14.1)
MTHU001326 (LOINC Version 232)
MID WOUND#
Item
MID WOUND#
string
Wound Location
Item
Wound Location
string
C0043250 (UMLS CUI 2011AA)
13924000 (SNOMED CT 2011_0131)
10052428 (MedDRA 14.1)
MTHU001326 (LOINC Version 232)
C0450429 (UMLS CUI 2011AA-2)
246267002 (SNOMED CT 2011_0131-2)
Length (cm, mm)
Item
Length (cm, mm)
string
Width (cm, mm)
Item
Width (cm, mm)
string
Depth (cm, mm)
Item
Depth (cm, mm)
string
Undermining
Item
Undermining
boolean
Tunneling
Item
Tunneling
boolean
Surrounding Skin
Item
Surrounding Skin
string
Wound Base
Item
Wound Base
string
Exudate
Item
EXUDATE
string
C0015388 (UMLS CUI 2011AA)
247450001 (SNOMED CT 2011_0131)
MTHU025016 (LOINC Version 232)
Exudate Color
Item
Exudate Color
string
Sensation
Item
Sensation
string
C0036658 (UMLS CUI 2011AA)
373713005 (SNOMED CT 2011_0131)
MTHU017277 (LOINC Version 232)
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 Medication Applied
Item
Wound Medication Applied
string
Wound Filled with
Item
Wound Filled with
string
Wound covered with
Item
Wound covered with
string
Wound secured with
Item
Wound secured with
string
Wound Pressure Relief
Item
Wound Pressure Relief
string
Comments
Item
Comments
string
Photograph Date
Item
Photograph Date
date
RASH LOCATION
Item
RASH LOCATION
string
RASH DESCRIPTION
Item
RASH DESCRIPTION
string
TATTOO'S/PIERCINGS
Item
TATTOO'S/PIERCINGS
string
SKIN TEARS, LOCATION/ Description
Item
SKIN TEARS, LOCATION/ Description
string
SPECIALTY BEDS
Item
SPECIALTY BEDS
string
Item Group
Nutrition
Current Diet
Item
Current Diet
string
C0012155 (UMLS CUI 2011AA)
41829006 (SNOMED CT 2011_0131)
NPO
Item
NPO
boolean
FEEDING TUBE PRESENT
Item
Tube feeding (TF)
boolean
C0041281 (UMLS CUI 2011AA)
61420007 (SNOMED CT 2011_0131)
10053095 (MedDRA 14.1)
Feeding Tube Type
Item
Feeding Tube Type
string
Formula
Item
Formula: # strength @ # cc's/hour via kangaroo pump
string
RESIDUALS CHECKED
Item
RESIDUALS CHECKED: AMOUNT # CC
string
BREAKFAST
Item
BREAKFAST
string
Breakfast: Amount taken
Item
Breakfast: Amount taken
string
Breakfast: Patient fed by
Item
Breakfast: Patient fed by
string
LUNCH
Item
LUNCH
string
Lunch: Amount taken
Item
Lunch: Amount taken
string
Lunch: Patient fed by
Item
Lunch: Patient fed by
string
SUPPER
Item
SUPPER
string
Supper: Amount taken
Item
Supper: Amount taken
string
Supper: Patient fed by
Item
Supper: Patient fed by
string
Supper: Amount taken
Item
Supper: Amount taken
string
Item Group
intravenous therapy
NARRATIVE: IV Therapy
Item
NARRATIVE: IV Therapy
string
IV HEPLOCKED
Item
IV HEPLOCKED
boolean
IV Site APPEARANCE
Item
IV Site APPEARANCE
string
IV DISCONTINUED
Item
IV DISCONTINUED
boolean
CATHETER INTACT
Item
CATHETER INTACT
boolean
IV Catheter Size
Item
IV Catheter Size
string
IV Site Location
Item
IV Site Location
string
CENTRAL LINE PORT
Item
Central venous catheter (CVC), Central venous line
string
C1145640 (UMLS CUI 2011AA)
52124006 (SNOMED CT 2011_0131)
IV FLUIDS
Item
Intravenous fluid, Fluid for intravenous administration
string
C1289919 (UMLS CUI 2011AA)
118431008 (SNOMED CT 2011_0131)
10067708 (MedDRA 14.1)
Left to count:
Item
Left to count:
string
IV Fluid Rate: @ ml/hr
Item
IV Fluid Rate: @ ml/hr
integer
TPN/LIPIDS: TPN @ ml/hr and Lipids @ ml/hr
Item
TPN/LIPIDS: TPN @ ml/hr and Lipids @ ml/hr
string
PCA PUMP: at @ cc's/hr
Item
PCA PUMP: at @ cc's/hr
string
IV Site APPEARANCE
Item
IV Site APPEARANCE
string
INSERTION DATE
Item
INSERTION DATE
date
DRESSING CHANGE DUE
Item
DRESSING CHANGE DUE
date
SITE CHANGE DUE
Item
SITE CHANGE DUE
date
PLACED ON IMED
Item
PLACED ON IMED
boolean
Item Group
patient safety
SIDE RAILS UP
Item
SIDE RAILS UP
boolean
IN LOW POSTION
Item
IN LOW POSTION
boolean
BED/CRIB
Item
BED/CRIB
string
CALL BELL WITHIN REACH
Item
CALL BELL WITHIN REACH
boolean
ALLERGY BAND ON
Item
ALLERGY BAND ON
boolean
NAME BAND ON
Item
NAME BAND ON
boolean
BLOOD BAND ON
Item
BLOOD BAND ON
boolean
FALL BAND ON
Item
FALL BAND ON
boolean
BED SAFETY
Item
BED SAFETY
string
Item Group
Pediatric Fall Risk Assessment
Unable to assess fall risk status at this time due to patient is:
Item
Unable to assess fall risk status at this time due to patient is:
string
gender
Item
Sex
string
C0079399 (UMLS CUI 2011AA)
263495000 (SNOMED CT 2011_0131)
MTHU002975 (LOINC Version 232)
Item
LEVEL OF CONSCIOUS
string
C0234421 (UMLS CUI 2011AA)
106167005 (SNOMED CT 2011_0131)
LEVEL OF CONSCIOUS
Code List
LEVEL OF CONSCIOUS
CL Item
Awake/Alert  (0)
CL Item
Drowsy/Medicated for pain/Seizures (1)
CL Item
Lethargic/Confused (2)
Item
Seizures/Previous history of falls
string
Seizures/Previous history of falls
Code List
Seizures/Previous history of falls
CL Item
No significant medical history of falls/ (0)
CL Item
No difficulty in ambulation, Generalized weakness/Dizziness/Syncope/ (1)
CL Item
PT or OT Services, Altered mental status/Developmental Delay/ (2)
Item
MEDICATION/EQUIPMENT
string
MEDICATION/EQUIPMENT
Code List
MEDICATION/EQUIPMENT
CL Item
No prescribed medication that has been known to alter LOC. No IV or other equipment (IV, Pulse Oximeter) prescribed for the patient (0)
CL Item
Prescribed pain medication (oral), seizure medication (oral), continuous IV therapy requiring infusion device (1)
CL Item
Prescribed IV/IM pain medication, seizure medication/PCA pump, crutches, CR monitor (2)
Item
LENGTH OF STAY
string
C0023303 (UMLS CUI 2011AA)
LENGTH OF STAY
Code List
LENGTH OF STAY
CL Item
Admission as inpatient 0-3 Days (0)
CL Item
Admission as inpatient 4-7 Days (1)
CL Item
Admission as inpatient greater than 7 Days (2)
Item
ELIMINATION
string
ELIMINATION
Code List
ELIMINATION
CL Item
Takes care of elimination needs independently with no assist/Infant in diapers (0)
CL Item
Independent with frequent trips to bathroom (1)
CL Item
Needs assist with toilet (2)
Item
GET UP AND GO TEST: "RISING FROM A CHAIR"
string
GET UP AND GO TEST: "RISING FROM A CHAIR"
Code List
GET UP AND GO TEST: "RISING FROM A CHAIR"
CL Item
Ability to rise in single movement-No loss of balance with steps (0)
CL Item
Pushes up, successful in one attempt (1)
CL Item
Multiple attempts but successful (3)
CL Item
Unable to rise without assistance during test (OR if a medical order states the same and/or complete bed rest is ordered) (4)
FINAL RISK SCORE
Item
FINAL RISK SCORE (Pediatric Fall Risk Assessment)
integer
Item Group
INTERVENTIONS
Assist with Ambulation
Item
Assist with Ambulation
boolean
Reorient Q2H or Less
Item
Reorient Q2H or Less
boolean
Gait Belt
Item
Gait Belt
boolean
ID Patient at Risk
Item
ID Patient at Risk
boolean
Restraints (see policy)
Item
Restraints (see policy)
boolean
Multi-personnel Transfer
Item
Multi-personnel Transfer
boolean
Close Observation
Item
Close Observation
boolean
Non-slip Footwear
Item
Non-slip Footwear
boolean
Bed in lowest position
Item
Bed in lowest position
boolean
Lock wheels of vehicles of conveyance during transfer
Item
Lock wheels of vehicles of conveyance during transfer
boolean
Upper siderails raised
Item
Upper siderails raised
boolean
Call light in reach
Item
Call light in reach
boolean
Offer toileting at least every 2 hours
Item
Offer toileting at least every 2 hours
boolean
Offer fluid/nutrition every 2 hours
Item
Offer fluid/nutrition every 2 hours
boolean
Place frequently used objects within reach
Item
Place frequently used objects within reach
boolean
Provide adequate lighting
Item
Provide adequate lighting
boolean
Provide sensory impairment/orientation devices (clocks,etc)
Item
Provide sensory impairment/orientation devices (clocks,etc)
boolean
Provide adequate rest periods
Item
Provide adequate rest periods
boolean
Use age appropriate distractions for confusion/disorientation
Item
Use age appropriate distractions for confusion/disorientation
boolean
Remove harmful hazards
Item
Remove harmful hazards
boolean
Provide appropriate and least restrictive patient supervision/surveillance
Item
Provide appropriate and least restrictive patient supervision/surveillance
boolean
Communicate information about fall risk to caregivers
Item
Communicate information about fall risk to caregivers
boolean
Encourage family/support system to participate in care
Item
Encourage family/support system to participate in care
boolean
Teach/educate family/support system Fall Prevention information
Item
Teach/educate family/support system Fall Prevention information
boolean
Implement Fall Prevention Protocol for Hendrich II Score>5
Item
Implement Fall Prevention Protocol for Hendrich II Score>5
boolean
Item Group
IMPAIRED MOBILITY RISK
Implement Universal Fall Prevention Intervention
Item
Implement Universal Fall Prevention Intervention
boolean
Monitor transfers to/from bed/chair(etc.)
Item
Monitor transfers to/from bed/chair(etc.)
boolean
Use appropriate assistance for transfers to/from bed/chair
Item
Use appropriate assistance for transfers to/from bed/chair
boolean
Use chairs with armrests and of proper height for transfers
Item
Use chairs with armrests and of proper height for transfers
boolean
Implement progressive ambulation(unless contraindicated by condition/orders)
Item
Implement progressive ambulation(unless contraindicated by condition/orders)
boolean
Encourage/Provide self-care assistance
Item
Encourage/Provide self-care assistance
boolean
Remain in attendance during toileting/ADL's
Item
Remain in attendance during toileting/ADL's
boolean
Provide assistive devices for ambulation (canes/walkers/etc.)
Item
Provide assistive devices for ambulation (canes/walkers/etc.)
boolean
Gait Belt during transport/ambulation
Item
Gait Belt during transport/ambulation
boolean
Teach patient/family to call for help and WAIT for help before
Item
Teach patient/family to call for help and WAIT for help before
boolean
attempting any transfer/ambulation
Item
attempting any transfer/ambulation
boolean
Item Group
ALTERED ELIMINATION
Implement Universal Fall Prevention Interventions
Item
Implement Universal Fall Prevention Interventions
boolean
Remain in attendance during toileting/ADL's
Item
Remain in attendance during toileting/ADL's
boolean
Assist with post-elimination hygiene
Item
Assist with post-elimination hygiene
boolean
Remove non-essential clothing
Item
Remove non-essential clothing
boolean
Instruct patient on importance of toileting when offered by staff
Item
Instruct patient on importance of toileting when offered by staff
boolean
Monitor for 'patient's normal' bladder/bowel habits
Item
Monitor for 'patient's normal' bladder/bowel habits
boolean
Monitor for causes of incontinence (diuretics,cathartics,etc.)
Item
Monitor for causes of incontinence (diuretics,cathartics,etc.)
boolean
Monitor skin integrity
Item
Monitor skin integrity
boolean
Item Group
HIGH RISK FALL MEDICATIONS (ANTIEPILEPTICS & BENZODIAZEPINES)
Implement Universal Fall Prevention Interventions
Item
Implement Universal Fall Prevention Interventions
boolean
Monitor drug dosages
Item
Monitor drug dosages
boolean
Evaluate sensory functions
Item
Evaluate sensory functions
boolean
Monitor/Assess for drug overdose
Item
Monitor/Assess for drug overdose
boolean
Monitor response to exercise
Item
Monitor response to exercise
boolean
Educate patient/support system about drug classification, side effects,
Item
Educate patient/support system about drug classification, side effects,
boolean
precautions, toxic symptoms of overdose.
Item
precautions, toxic symptoms of overdose.
boolean
Item Group
Hendrich II Fall Risk Assessment
Unable to assess fall risk status at this time due to patient is:
Item
Unable to assess fall risk status at this time due to patient is:
string
HENDRICH CALCULATION
Item
HENDRICH CALCULATION
string
Item Group
ONN Unit specific
AFFECTED SITE
Item
AFFECTED SITE
string
CIRCULATORY STATUS
Item
CIRCULATORY STATUS
string
SKIN COLOR
Item
SKIN COLOR
string
SENSATION
Item
SENSATION
string
MOVEMENT
Item
MOVEMENT
string
TEMPERATURE
Item
Temperature
string
C0039476 (UMLS CUI 2011AA)
246508008 (SNOMED CT 2011_0131)
MTHU009008 (LOINC Version 232)
SKIN CONDITION
Item
Integumentary status
string
C1719933 (UMLS CUI 2011AA)
422000003 (SNOMED CT 2011_0131)
MTHU034830 (LOINC Version 232)
PULSE(s) SITE(s)
Item
PULSE(s) SITE(s)
string
RESPONSE
Item
RESPONSE
string
POSITION OF LIMB
Item
POSITION OF LIMB
string
ORTHOPEDIC DEVICE IN USE
Item
ORTHOPEDIC DEVICE IN USE
string
CONTINUOUS PASSIVE MOTION
Item
CONTINUOUS PASSIVE MOTION
string
POUNDS
Item
POUNDS
string
CERVICAL COLLARS
Item
CERVICAL COLLARS
string
AFO BRACE: Foot/Feet
Item
AFO BRACE: Foot/Feet (LEFT-RIGHT-BILATERAL)
string
SWELLING
Item
SWELLING
string
PIN SITES
Item
PIN SITES
string
CLEANED WITH
Item
CLEANED WITH
string
NARRATIVE
Item
NARRATIVE
string
Item Group
Post Surgical
General Activity
Item
Patient activity
string
C0451369 (UMLS CUI 2011AA)
273688003 (SNOMED CT 2011_0131)
Vaginal Packing
Item
Vaginal Packing
string
Equipment/Devices
Item
Equipment/Devices
string
EQUIPMENT/DEVICES
Item
EQUIPMENT/DEVICES
string
Item Group
ADOLESCENT INTERACTION
Item
Prepared for treatment/procedure as soon as possible.
string
Prepared for treatment/procedure as soon as possible.
Code List
Prepared for treatment/procedure as soon as possible.
CL Item
Definitely Yes (1)
CL Item
Yes (2)
CL Item
No (3)
CL Item
not applicable (4)
Item
Provided detailed information about events/procedures/treatments.
string
Provided detailed information about events/procedures/treatments.
Code List
Provided detailed information about events/procedures/treatments.
CL Item
Definitely Yes (1)
CL Item
Yes (2)
CL Item
No (3)
CL Item
NA (4)
Item
Allowed contact with peer group.
string
Allowed contact with peer group.
Code List
Allowed contact with peer group.
CL Item
Definitely Yes (1)
CL Item
Yes (2)
CL Item
No (3)
CL Item
NA (4)
NARRATIVE
Item
NARRATIVE
string
Item Group
GERIATRIC INTERVENTION (65+)
Item
Involved in decision process regarding pain control/medication/care decisions
string
Involved in decision process regarding pain control/medication/care decisions
Code List
Involved in decision process regarding pain control/medication/care decisions
CL Item
Def. Yes (1)
CL Item
Yes (2)
CL Item
No (3)
CL Item
NA (4)
Item
Encouraged family/S.O.to visit
string
Encouraged family/S.O.to visit
Code List
Encouraged family/S.O.to visit
CL Item
Def. Yes (1)
CL Item
Yes (2)
CL Item
No (3)
CL Item
NA (4)
Item
Independence promoted.
string
Independence promoted.
Code List
Independence promoted.
CL Item
Def. Yes (1)
CL Item
Yes (2)
CL Item
No (3)
CL Item
NA (4)
NARRATIVE
Item
NARRATIVE
string
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