ID

11213

Description

Form from HIS OpenVistA

Keywords

  1. 2/25/12 2/25/12 -
  2. 8/9/14 8/9/14 - Martin Dugas
  3. 6/25/15 6/25/15 - Martin Dugas
Uploaded on

June 25, 2015

DOI

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License

Creative Commons BY-NC 3.0 Legacy

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NUTRITION SCREENING CONSULT RESULTS MAIN

  1. StudyEvent: HIS
    1. HIS
BASIC EVALUATION
Description

BASIC EVALUATION

Age
Description

Age

Data type

integer

Measurement units
  • years
Alias
SNOMED CT 2011_0131
397669002
UMLS CUI-1
C0001779
years
Patient sex
Description

Patient sex

Data type

integer

Alias
SNOMED CT 2011_0131
263495000
LOINC Version 232
MTHU002975
UMLS CUI-1
C0079399
Height
Description

Height

Data type

float

Measurement units
  • cm
Alias
LOINC Version 232
MTHU005354
UMLS CUI-1
C0005890
cm
Weight
Description

Current Weight

Data type

integer

Alias
UMLS CUI 2011AA
C1305866
SNOMED CT 2011_0131
107647005
MedDRA 14.1
10047890
LOINC Version 232
LP18015-5
Weight change (increase|decrease| stable)
Description

Weight change

Data type

integer

Alias
UMLS CUI 2011AA
C0005911
SNOMED CT 2011_0131
248346009
LOINC Version 232
MTHU021183
Ideal Body Weight (IBW) +/-10%
Description

IBW

Data type

integer

Alias
UMLS CUI 2011AA
C0421272
SNOMED CT 2011_0131
170804003
LOINC Version 232
MTHU031532
Weight status (underweight| normal| overweight| obese)
Description

Weight status

Data type

integer

Diet
Description

Diet

Data type

text

Alias
SNOMED CT 2011_0131
41829006
UMLS CUI-1
C0012155
PO intake
Description

PO intake

Data type

string

COMMENTS
Description

COMMENTS

Patient triggered for problem swallowing difficulty
Description

Patient triggered for problem swallowing difficulty

Data type

boolean

Alias
UMLS CUI 2011AA
C0392678
SNOMED CT 2011_0131
399122003
MedDRA 14.1
10042647
LOINC Version 232
MTHU020878
Patient states no problems with swallowing difficulty
Description

Patient states no problems with swallowing difficulty

Data type

boolean

Swallow difficulty due to sore throat. Nursing Notified.
Description

Swallow difficulty due to sore throat. Nursing Notified.

Data type

boolean

Alias
UMLS CUI 2011AA
C0242429
SNOMED CT 2011_0131
267102003
MedDRA 14.1
10041367
ICD-10-CM Version 2010
R07.0
ICD-9-CM Version 2011
784.1
CTCAE 1105E
E13575
Patient needs diet consistency change to diet.
Description

Patient needs diet consistency change to diet.

Data type

boolean

Patient needs special foods of appropriate consistency.
Description

Patient needs special foods of appropriate consistency.

Data type

boolean

other
Description

other

Data type

string

Patient triggered for poor po intake > 5 days.
Description

Patient triggered for poor po intake > 5 days.

Data type

boolean

Patient requests oral supplements of
Description

Patient requests oral supplements of

Data type

string

Patient states no problems with po intake.
Description

Patient states no problems with po intake.

Data type

boolean

Patient states po intake improved>50% at all meals.
Description

Patient states po intake improved>50% at all meals.

Data type

boolean

Patient states no appetite.
Description

Patient states no appetite.

Data type

boolean

Alias
UMLS CUI 2011AA
C0232462
SNOMED CT 2011_0131
64379006
MedDRA 14.1
10061428
Patient states unable to eat certain foods:
Description

Patient states unable to eat certain foods:

Data type

string

Patient started on nutrition support
Description

Patient started on nutrition support

Data type

boolean

other
Description

other

Data type

string

Patient triggered for unintentional weight loss of 10 pounds or more in 3 months.
Description

Patient triggered for unintentional weight loss of 10 pounds or more in 3 months.

Data type

boolean

Alias
UMLS CUI 2011AA
C0936227
SNOMED CT 2011_0131
267024001
MedDRA 14.1
10000159
ICD-10-CM Version 2010
R63.4
Patient states no weight loss.
Description

Patient states no weight loss.

Data type

boolean

Patient was on a diet, weight loss was intentional.
Description

Patient was on a diet, weight loss was intentional.

Data type

boolean

Alias
UMLS CUI 2011AA
C0012155
SNOMED CT 2011_0131
41829006
Patient states weight loss due to increased activity.
Description

Patient states weight loss due to increased activity.

Data type

boolean

other
Description

other

Data type

string

Patient triggered for food allergies
Description

Patient triggered for food allergies

Data type

boolean

Alias
UMLS CUI 2011AA
C0016470
SNOMED CT 2011_0131
414285001
MedDRA 14.1
10016946
Patient states they have no food allergies/intolerances.
Description

Patient states they have no food allergies/intolerances.

Data type

boolean

Patient has no food intolerances to
Description

Patient has no food intolerances to

Data type

string

All food allergies/intolerances were identified.
Description

All food allergies/intolerances were identified.

Data type

boolean

other
Description

other

Data type

string

Patient triggered for being pregnant and less than 16 years old of age.
Description

Patient triggered for being pregnant and less than 16 years old of age.

Data type

boolean

Patient is greater than 16 years old of age.
Description

Patient is greater than 16 years old of age.

Data type

boolean

Alias
UMLS CUI 2011AA
C0001779
SNOMED CT 2011_0131
397669002
Patient is not pregnant.
Description

Patient is not pregnant.

Data type

boolean

Alias
UMLS CUI 2011AA
C0232973
SNOMED CT 2011_0131
60001007
other
Description

other

Data type

string

Patient triggered for being pregnant and on special diet.
Description

Patient triggered for being pregnant and on special diet.

Data type

boolean

Patient is not pregnant.
Description

Patient is not pregnant.

Data type

boolean

Alias
UMLS CUI 2011AA
C0232973
SNOMED CT 2011_0131
60001007
Patient is not on a special diet.
Description

Patient is not on a special diet.

Data type

boolean

Patient is on diet for
Description

Patient is on diet for

Data type

string

Alias
UMLS CUI 2011AA
C0012155
SNOMED CT 2011_0131
41829006
Patient understands special diet, does not need additional information.
Description

Patient understands special diet, does not need additional information.

Data type

boolean

Patient does not understand special diet.
Description

Patient does not understand special diet.

Data type

boolean

Patient triggered for being below 10th percentile of Pediatric Growth Charts.
Description

Patient triggered for being below 10th percentile of Pediatric Growth Charts.

Data type

boolean

Patient is at 50th percentile or greater on growth charts.
Description

Patient is at 50th percentile or greater on growth charts.

Data type

boolean

Patient is between 25th and 50th percentile on growth charts.
Description

Patient is between 25th and 50th percentile on growth charts.

Data type

boolean

Patient seen due to extended length of stay in hospital.
Description

Patient seen due to extended length of stay in hospital.

Data type

boolean

Alias
UMLS CUI 2011AA
C0023303
other
Description

other

Data type

string

GOALS
Description

GOALS

Patient to resume po intake (if currently NPO).
Description

Patient to resume po intake (if currently NPO).

Data type

boolean

Alias
UMLS CUI 2011AA
C1512806
Patient to transition to solid foods (if on CL or FL diet).
Description

Patient to transition to solid foods (if on CL or FL diet).

Data type

boolean

Patient to be provided foods of appropriate consistency to decrease swallowing difficulty.
Description

Patient to be provided foods of appropriate consistency to decrease swallowing difficulty.

Data type

boolean

Patient to continue po intake>75% at meals/snacks.
Description

Patient to continue po intake>75% at meals/snacks.

Data type

boolean

PO intake to be greater than 50% at all meals/snacks.
Description

PO intake to be greater than 50% at all meals/snacks.

Data type

boolean

Weight gain of 1-2 lbs per week.
Description

Weight gain of 1-2 lbs per week.

Data type

boolean

Alias
UMLS CUI 2011AA
C0043094
SNOMED CT 2011_0131
262286000
MedDRA 14.1
10047899
LOINC Version 232
MTHU020882
CTCAE 1105E
E12224
Patient will not receive foods that they have indicated as being allergic or intolerate to.
Description

Patient will not receive foods that they have indicated as being allergic or intolerate to.

Data type

boolean

Patient to understand diet currently ordered by physician.
Description

Patient to understand diet currently ordered by physician.

Data type

boolean

Patient to be seen by dietician due to:
Description

Patient to be seen by dietician due to:

Data type

string

other
Description

other

Data type

string

LEVEL OF CARE
Description

LEVEL OF CARE

Level of care, HCPCS Level II National Modifiers
Description

Level of care

Data type

string

Alias
UMLS CUI 2011AA
C0851273
PLAN
Description

PLAN

Continue with diet as currently ordered.
Description

Continue with diet as currently ordered.

Data type

boolean

Alias
UMLS CUI 2011AA
C0012155
SNOMED CT 2011_0131
41829006
Advance diet as tolerated.
Description

Advance diet as tolerated.

Data type

boolean

Alias
UMLS CUI 2011AA
C0012155
SNOMED CT 2011_0131
41829006
Explain menu process. Encourage continued good intake > 50%.
Description

Explain menu process. Encourage continued good intake > 50%.

Data type

boolean

Encourage patient to mark menu selections.
Description

Encourage patient to mark menu selections.

Data type

boolean

Obtain food preferences. Place in computer and notify kitchen.
Description

Obtain food preferences. Place in computer and notify kitchen.

Data type

boolean

Discuss adding oral supplement with nursing or dietician.
Description

Discuss adding oral supplement with nursing or dietician.

Data type

boolean

Provide snacks to increase po intake.
Description

Provide snacks to increase po intake.

Data type

boolean

Notify diet office of food allergens or intolerances via computer.
Description

Notify diet office of food allergens or intolerances via computer.

Data type

boolean

Provided educational handout on diet. Give RD contact information for further questions.
Description

Provided educational handout on diet. Give RD contact information for further questions.

Data type

boolean

Inform dietician of need for extensive diet education on diet.
Description

Inform dietician of need for extensive diet education on diet.

Data type

boolean

Follow patient per protocol.
Description

Follow patient per protocol.

Data type

boolean

Refer to dietician
Description

Refer to dietician

Data type

boolean

Alias
SNOMED CT 2011_0131
159033005
UMLS CUI-1
C0237083
other
Description

other

Data type

string

Similar models

  1. StudyEvent: HIS
    1. HIS
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
BASIC EVALUATION
Age
Item
Age
integer
397669002 (SNOMED CT 2011_0131)
C0001779 (UMLS CUI-1)
Item
Patient sex
integer
263495000 (SNOMED CT 2011_0131)
MTHU002975 (LOINC Version 232)
C0079399 (UMLS CUI-1)
Code List
Patient sex
CL Item
Female (1)
CL Item
Male (2)
CL Item
Unknown (3)
Height
Item
Height
float
MTHU005354 (LOINC Version 232)
C0005890 (UMLS CUI-1)
Current Weight
Item
Weight
integer
C1305866 (UMLS CUI 2011AA)
107647005 (SNOMED CT 2011_0131)
10047890 (MedDRA 14.1)
LP18015-5 (LOINC Version 232)
Weight change
Item
Weight change (increase|decrease| stable)
integer
C0005911 (UMLS CUI 2011AA)
248346009 (SNOMED CT 2011_0131)
MTHU021183 (LOINC Version 232)
IBW
Item
Ideal Body Weight (IBW) +/-10%
integer
C0421272 (UMLS CUI 2011AA)
170804003 (SNOMED CT 2011_0131)
MTHU031532 (LOINC Version 232)
Weight status
Item
Weight status (underweight| normal| overweight| obese)
integer
Diet
Item
Diet
text
41829006 (SNOMED CT 2011_0131)
C0012155 (UMLS CUI-1)
PO intake
Item
PO intake
string
Item Group
COMMENTS
Patient triggered for problem swallowing difficulty
Item
Patient triggered for problem swallowing difficulty
boolean
C0392678 (UMLS CUI 2011AA)
399122003 (SNOMED CT 2011_0131)
10042647 (MedDRA 14.1)
MTHU020878 (LOINC Version 232)
Patient states no problems with swallowing difficulty
Item
Patient states no problems with swallowing difficulty
boolean
Swallow difficulty due to sore throat. Nursing Notified.
Item
Swallow difficulty due to sore throat. Nursing Notified.
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)
Patient needs diet consistency change to diet.
Item
Patient needs diet consistency change to diet.
boolean
Patient needs special foods of appropriate consistency.
Item
Patient needs special foods of appropriate consistency.
boolean
other
Item
other
string
Patient triggered for poor po intake > 5 days.
Item
Patient triggered for poor po intake > 5 days.
boolean
Patient requests oral supplements of
Item
Patient requests oral supplements of
string
Patient states no problems with po intake.
Item
Patient states no problems with po intake.
boolean
Patient states po intake improved>50% at all meals.
Item
Patient states po intake improved>50% at all meals.
boolean
Patient states no appetite.
Item
Patient states no appetite.
boolean
C0232462 (UMLS CUI 2011AA)
64379006 (SNOMED CT 2011_0131)
10061428 (MedDRA 14.1)
Patient states unable to eat certain foods:
Item
Patient states unable to eat certain foods:
string
Patient started on nutrition support
Item
Patient started on nutrition support
boolean
other
Item
other
string
Patient triggered for unintentional weight loss of 10 pounds or more in 3 months.
Item
Patient triggered for unintentional weight loss of 10 pounds or more in 3 months.
boolean
C0936227 (UMLS CUI 2011AA)
267024001 (SNOMED CT 2011_0131)
10000159 (MedDRA 14.1)
R63.4 (ICD-10-CM Version 2010)
Patient states no weight loss.
Item
Patient states no weight loss.
boolean
Patient was on a diet, weight loss was intentional.
Item
Patient was on a diet, weight loss was intentional.
boolean
C0012155 (UMLS CUI 2011AA)
41829006 (SNOMED CT 2011_0131)
Patient states weight loss due to increased activity.
Item
Patient states weight loss due to increased activity.
boolean
other
Item
other
string
Patient triggered for food allergies
Item
Patient triggered for food allergies
boolean
C0016470 (UMLS CUI 2011AA)
414285001 (SNOMED CT 2011_0131)
10016946 (MedDRA 14.1)
Patient states they have no food allergies/intolerances.
Item
Patient states they have no food allergies/intolerances.
boolean
Patient has no food intolerances to
Item
Patient has no food intolerances to
string
All food allergies/intolerances were identified.
Item
All food allergies/intolerances were identified.
boolean
other
Item
other
string
Patient triggered for being pregnant and less than 16 years old of age.
Item
Patient triggered for being pregnant and less than 16 years old of age.
boolean
Patient is greater than 16 years old of age.
Item
Patient is greater than 16 years old of age.
boolean
C0001779 (UMLS CUI 2011AA)
397669002 (SNOMED CT 2011_0131)
Patient is not pregnant.
Item
Patient is not pregnant.
boolean
C0232973 (UMLS CUI 2011AA)
60001007 (SNOMED CT 2011_0131)
other
Item
other
string
Patient triggered for being pregnant and on special diet.
Item
Patient triggered for being pregnant and on special diet.
boolean
Patient is not pregnant.
Item
Patient is not pregnant.
boolean
C0232973 (UMLS CUI 2011AA)
60001007 (SNOMED CT 2011_0131)
Patient is not on a special diet.
Item
Patient is not on a special diet.
boolean
Patient is on diet for
Item
Patient is on diet for
string
C0012155 (UMLS CUI 2011AA)
41829006 (SNOMED CT 2011_0131)
Patient understands special diet, does not need additional information.
Item
Patient understands special diet, does not need additional information.
boolean
Patient does not understand special diet.
Item
Patient does not understand special diet.
boolean
Patient triggered for being below 10th percentile of Pediatric Growth Charts.
Item
Patient triggered for being below 10th percentile of Pediatric Growth Charts.
boolean
Patient is at 50th percentile or greater on growth charts.
Item
Patient is at 50th percentile or greater on growth charts.
boolean
Patient is between 25th and 50th percentile on growth charts.
Item
Patient is between 25th and 50th percentile on growth charts.
boolean
Patient seen due to extended length of stay in hospital.
Item
Patient seen due to extended length of stay in hospital.
boolean
C0023303 (UMLS CUI 2011AA)
other
Item
other
string
Item Group
GOALS
Patient to resume po intake (if currently NPO).
Item
Patient to resume po intake (if currently NPO).
boolean
C1512806 (UMLS CUI 2011AA)
Patient to transition to solid foods (if on CL or FL diet).
Item
Patient to transition to solid foods (if on CL or FL diet).
boolean
Patient to be provided foods of appropriate consistency to decrease swallowing difficulty.
Item
Patient to be provided foods of appropriate consistency to decrease swallowing difficulty.
boolean
Patient to continue po intake>75% at meals/snacks.
Item
Patient to continue po intake>75% at meals/snacks.
boolean
PO intake to be greater than 50% at all meals/snacks.
Item
PO intake to be greater than 50% at all meals/snacks.
boolean
Weight gain of 1-2 lbs per week.
Item
Weight gain of 1-2 lbs per week.
boolean
C0043094 (UMLS CUI 2011AA)
262286000 (SNOMED CT 2011_0131)
10047899 (MedDRA 14.1)
MTHU020882 (LOINC Version 232)
E12224 (CTCAE 1105E)
Patient will not receive foods that they have indicated as being allergic or intolerate to.
Item
Patient will not receive foods that they have indicated as being allergic or intolerate to.
boolean
Patient to understand diet currently ordered by physician.
Item
Patient to understand diet currently ordered by physician.
boolean
Patient to be seen by dietician due to:
Item
Patient to be seen by dietician due to:
string
other
Item
other
string
Item Group
LEVEL OF CARE
Level of care
Item
Level of care, HCPCS Level II National Modifiers
string
C0851273 (UMLS CUI 2011AA)
Item Group
PLAN
Continue with diet as currently ordered.
Item
Continue with diet as currently ordered.
boolean
C0012155 (UMLS CUI 2011AA)
41829006 (SNOMED CT 2011_0131)
Advance diet as tolerated.
Item
Advance diet as tolerated.
boolean
C0012155 (UMLS CUI 2011AA)
41829006 (SNOMED CT 2011_0131)
Explain menu process. Encourage continued good intake > 50%.
Item
Explain menu process. Encourage continued good intake > 50%.
boolean
Encourage patient to mark menu selections.
Item
Encourage patient to mark menu selections.
boolean
Obtain food preferences. Place in computer and notify kitchen.
Item
Obtain food preferences. Place in computer and notify kitchen.
boolean
Discuss adding oral supplement with nursing or dietician.
Item
Discuss adding oral supplement with nursing or dietician.
boolean
Provide snacks to increase po intake.
Item
Provide snacks to increase po intake.
boolean
Notify diet office of food allergens or intolerances via computer.
Item
Notify diet office of food allergens or intolerances via computer.
boolean
Provided educational handout on diet. Give RD contact information for further questions.
Item
Provided educational handout on diet. Give RD contact information for further questions.
boolean
Inform dietician of need for extensive diet education on diet.
Item
Inform dietician of need for extensive diet education on diet.
boolean
Follow patient per protocol.
Item
Follow patient per protocol.
boolean
Refer to dietician
Item
Refer to dietician
boolean
159033005 (SNOMED CT 2011_0131)
C0237083 (UMLS CUI-1)
other
Item
other
string

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