Informações:
Falhas:
ID
11213
Descrição
Form from HIS OpenVistA
Palavras-chave
Versões (3)
- 25/02/2012 25/02/2012 -
- 09/08/2014 09/08/2014 - Martin Dugas
- 25/06/2015 25/06/2015 - Martin Dugas
Transferido a
25 de junho de 2015
DOI
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Licença
Creative Commons BY-NC 3.0 Legacy
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NUTRITION SCREENING CONSULT RESULTS MAIN
Similar models
HIS
- StudyEvent: HIS
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de dados
Alias
Age
Item
Alter
integer
397669002 (SNOMED CT 2011_0131)
C0001779 (UMLS CUI-1)
C0001779 (UMLS CUI-1)
Item
Geschlecht
integer
CL Item
(1)
CL Item
(2)
CL Item
(3)
Current Weight
Item
Gewicht
integer
C1305866 (UMLS CUI 2011AA)
107647005 (SNOMED CT 2011_0131)
10047890 (MedDRA 14.1)
LP18015-5 (LOINC Version 232)
107647005 (SNOMED CT 2011_0131)
10047890 (MedDRA 14.1)
LP18015-5 (LOINC Version 232)
Weight change
Item
Gewichtsänderung
integer
IBW
Item
Idealgewicht
integer
Weight status
Item
Weight status (underweight| normal| overweight| obese)
integer
Diet
Item
Diät
text
41829006 (SNOMED CT 2011_0131)
C0012155 (UMLS CUI-1)
C0012155 (UMLS CUI-1)
PO intake
Item
PO intake
string
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)
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)
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)
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)
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)
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)
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)
397669002 (SNOMED CT 2011_0131)
Patient is not pregnant.
Item
Patient is not pregnant.
boolean
C0232973 (UMLS CUI 2011AA)
60001007 (SNOMED CT 2011_0131)
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)
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)
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
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)
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
Level of care
Item
Pflegestufe
string
C0851273 (UMLS CUI 2011AA)
Continue with diet as currently ordered.
Item
Continue with diet as currently ordered.
boolean
C0012155 (UMLS CUI 2011AA)
41829006 (SNOMED CT 2011_0131)
41829006 (SNOMED CT 2011_0131)
Advance diet as tolerated.
Item
Advance diet as tolerated.
boolean
C0012155 (UMLS CUI 2011AA)
41829006 (SNOMED CT 2011_0131)
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)
C0237083 (UMLS CUI-1)
other
Item
other
string