ID

11248

Description

Form from HIS OpenVistA

Keywords

Versions (5)
  1. 2/24/12 2/24/12 -
  2. 2/29/12 2/29/12 -
  3. 8/7/14 8/7/14 - Martin Dugas
  4. 8/9/14 8/9/14 - Martin Dugas
  5. 6/26/15 6/26/15 - Martin Dugas
Uploaded on

June 26, 2015

DOI

To request one please log in.

License

Creative Commons BY-NC 3.0 Legacy
Model comments :

You can comment on the data model here. Via the speech bubbles at the itemgroups and items you can add comments to those specificially.

Back to model comments
Itemgroup comments for :

Item comments for :

In order to download data models you must be logged in. Please log in or register for free.

INTERVENTIONAL RADIOLOGY

German English

HIS

1 forms  
  1. StudyEvent: HIS
    1. HIS
General Info
Description

General Info

Alias
UMLS CUI-1
C1508263
Age
Description

Age

Data type

integer

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

Gender

Data type

integer

Alias
UMLS CUI 2011AA
C0079399
SNOMED CT 2011_0131
263495000
LOINC Version 232
MTHU002975
Racial group
Description

Racial group

Data type

text

Alias
SNOMED CT 2011_0131
103579009
LOINC Version 232
MTHU009923
UMLS CUI-1
C0034510
Body height
Description

Body height

Data type

integer

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

Body weight

Data type

float

Measurement units
  • kg
Alias
SNOMED CT 2011_0131
107647005
MedDRA 14.1
10047890
LOINC Version 232
LP18015-5
UMLS CUI-1
C0005910
kg
Chief complaint (CC)
Description

CHIEF COMPLAINT

Data type

string

Alias
UMLS CUI 2011AA
C0277786
SNOMED CT 2011_0131
33962009
LOINC Version 232
MTHU001077
History of present illness
Description

PRESENT ILLNESS

Data type

string

Alias
UMLS CUI 2011AA
C0262512
LOINC Version 232
MTHU001399
Prior Health History
Description

Prior Health History

Alias
UMLS CUI-1
C0262926
Past medical history
Description

Medical Illness

Data type

string

Alias
UMLS CUI 2011AA
C0262926
SNOMED CT 2011_0131
417662000
LOINC Version 232
MTHU027722
Prior Surgery, History of (H/O) surgery, Past surgical history
Description

Surgery

Data type

string

Alias
UMLS CUI 2011AA
C0455610
SNOMED CT 2011_0131
161615003
current medication list, active medication
Description

DETAILED ACTIVE MEDS

Data type

string

Alias
UMLS CUI 2011AA
C1553892
Allergies
Description

Allergies

Data type

string

Alias
UMLS CUI 2011AA
C0020517
SNOMED CT 2011_0131
257550005
ICD-10-CM Version 2010
T78.40
Review of systems
Description

REVIEW OF SYSTEMS(Positive findings)

Data type

string

Alias
UMLS CUI 2011AA
C0489633
SNOMED CT 2011_0131
415300000
LOINC Version 232
MTHU001422
Family history (FH) of
Description

FAMILY HISTORY

Data type

string

Alias
UMLS CUI 2011AA
C0241889
SNOMED CT 2011_0131
57177007
Social and personal history, Social and personal circumstances
Description

SOCIAL HISTORY

Data type

string

Alias
UMLS CUI 2011AA
C0424945
SNOMED CT 2011_0131
160476009
LOINC Version 232
MTHU014081
Immunisation
Description

IMMUNIZATIONS

Data type

string

Alias
UMLS CUI 2011AA
C0020971
SNOMED CT 2011_0131
127785005
MedDRA 14.1
10021431
Physical Exam
Description

Physical Exam

Alias
UMLS CUI-1
C0031809
Temperature
Description

Temperature

Data type

float

Measurement units
  • °C
Alias
SNOMED CT 2011_0131
246508008
LOINC Version 232
MTHU009008
UMLS CUI-1
C0039476
°C
Pulse
Description

Pulse

Data type

integer

Measurement units
  • beats/min
Alias
SNOMED CT 2011_0131
78564009
MedDRA 14.1
10037485
UMLS CUI-1
C0232117
beats/min
Respiration rate, Breathing rate (BR)
Description

Respiration rate, Breathing rate (BR)

Data type

integer

Measurement units
  • /min
Alias
SNOMED CT 2011_0131
86290005
MedDRA 14.1
10038709
LOINC Version 232
MTHU008344
UMLS CUI-1
C0231832
/min
Blood pressure (BP)
Description

Blood pressure (BP)

Data type

integer

Measurement units
  • mmHg
Alias
SNOMED CT 2011_0131
75367002
LOINC Version 232
MTHU008342
UMLS CUI-1
C0005823
mmHg
Pain
Description

Pain

Data type

string

Alias
UMLS CUI 2011AA
C0030193
SNOMED CT 2011_0131
22253000
MedDRA 14.1
10033371
LOINC Version 232
MTHU029813
ICD-10-CM Version 2010
R52
ICD-9-CM Version 2011
338-338.9
CTCAE 1105E
E11167
general appearance
Description

GENERAL APPEARANCE

Data type

string

Alias
UMLS CUI 2011AA
C1148438
LOINC Version 232
MTHU015040
Head, Ears, Eyes, Nose and Throat
Description

HEENT

Data type

text

Alias
UMLS CUI 2011AA
C1512338
Neck, Collum, Cervical
Description

NECK

Data type

string

Alias
UMLS CUI 2011AA
C0027530
SNOMED CT 2011_0131
45048000
LOINC Version 232
MTHU002688
Chest, Thorax
Description

CHEST

Data type

string

Alias
UMLS CUI 2011AA
C0817096
SNOMED CT 2011_0131
51185008
Mammary region
Description

BREAST

Data type

string

Alias
UMLS CUI 2011AA
C0006141
SNOMED CT 2011_0131
76752008
LOINC Version 232
MTHU011382
Heart
Description

HEART

Data type

string

Alias
UMLS CUI 2011AA
C0018787
SNOMED CT 2011_0131
80891009
LOINC Version 232
MTHU001067
Abdomen
Description

ABDOMEN

Data type

string

Alias
UMLS CUI 2011AA
C0000726
SNOMED CT 2011_0131
113345001
LOINC Version 232
MTHU001425
lymph nodes
Description

LYMPH NODES

Data type

string

Alias
UMLS CUI 2011AA
C0024204
SNOMED CT 2011_0131
59441001
LOINC Version 232
MTHU015050
Genital Organs/Rectal
Description

Genital Organs/Rectal

Data type

text

Alias
SNOMED CT 2011_0131
255582007
LOINC Version 232
MTHU002681
UMLS CUI-1
C0017420
UMLS CUI-2
C0205052
Extremities, Limb structure
Description

EXTREMITIES

Data type

string

Alias
UMLS CUI 2011AA
C0015385
SNOMED CT 2011_0131
66019005
LOINC Version 232
MTHU001429
Integument
Description

SKIN

Data type

string

Alias
UMLS CUI 2011AA
C1123023
SNOMED CT 2011_0131
39937001
LOINC Version 232
MTHU001414
Neurologic system, Nervous system, Nervous system structure
Description

NEUROLOGICAL

Data type

string

Alias
UMLS CUI 2011AA
C0027763
SNOMED CT 2011_0131
25087005
LOINC Version 232
MTHU001437
summary, conclusion
Description

IMPRESSION

Data type

string

Alias
UMLS CUI 2011AA
CL386604
Plan
Description

PLAN

Data type

string

Alias
UMLS CUI 2011AA
C1301732
SNOMED CT 2011_0131
397943006
Finding of American Society of Anesthesiologists physical status classification
Description

ASA SCORE

Data type

string

Alias
UMLS CUI 2011AA
C1531480
SNOMED CT 2011_0131
413347006
AIRWAY ASSESSMENT FOR PATIENTS RECEIVING MODERATE SEDATION
Description

AIRWAY ASSESSMENT FOR PATIENTS RECEIVING MODERATE SEDATION

Data type

text

Teeth
Description

Teeth

Data type

string

Alias
UMLS CUI 2011AA
C0040426
SNOMED CT 2011_0131
245543004
LOINC Version 232
MTHU021292
Mallampati score
Description

MALLAMPATI AIRWAY SCORE

Data type

string

Alias
UMLS CUI 2011AA
C0451276
SNOMED CT 2011_0131
273585005
Neck Extension (normal/RESTRICTED/NO MOBILITY)
Description

Neck Extension (normal/RESTRICTED/NO MOBILITY)

Data type

text

Alias
SNOMED CT 2011_0131
45048000, 255536004
LOINC Version 232
MTHU002688, MTHU010348
UMLS CUI-1
C0027530
UMLS CUI-2
C0231448
Treating Physician
Description

Physician

Data type

string

Alias
UMLS CUI 2011AA
C1710470
Procedure
Description

Procedure

Alias
UMLS CUI-1
C0184661
Date of procedure
Description

DATE OF PROCEDURE

Data type

string

Alias
UMLS CUI 2011AA
C2584899
SNOMED CT 2011_0131
439272007
Preoperative diagnosis
Description

PRE-OP DIAGNOSIS

Data type

string

Alias
UMLS CUI 2011AA
C1318968
SNOMED CT 2011_0131
406520001
Post-operative diagnosis
Description

POST-OP DIAGNOSIS

Data type

string

Alias
UMLS CUI 2011AA
C1318969
SNOMED CT 2011_0131
406521002
Primary Surgeon
Description

PRIMARY SURGEON

Data type

string

Alias
UMLS CUI 2011AA
C0808118
LOINC Version 232
MTHU010488
HL7 V3 2006_05
PRISURG
first assistant surgeon
Description

ASSISTANT

Data type

string

Alias
UMLS CUI 2011AA
C1550491
HL7 V3 2006_05
FASST
anesthesist
Description

ANESTHESIA PROVIDER

Data type

string

Alias
UMLS CUI 2011AA
C1550495
HL7 V3 2006_05
ANEST
ANESTHESIA/SEDATION
Description

ANESTHESIA/SEDATION

Data type

text

Alias
SNOMED CT 2011_0131
399097000, 72641008
MedDRA 14.1
10002091, 10059283
LOINC Version 232
MTHU035920
UMLS CUI-1
C0002903
UMLS CUI-2
C0344106
Medication
Description

Medication

Alias
UMLS CUI-1
C0013227
ANTIBIOTIC: Ancef
Description

ANTIBIOTIC: Ancef

Data type

boolean

Alias
UMLS CUI 2011AA
C0003232
SNOMED CT 2011_0131
255631004
ANTIBIOTIC: Rocephin
Description

ANTIBIOTIC: Rocephin

Data type

boolean

Alias
UMLS CUI 2011AA
C0003232
SNOMED CT 2011_0131
255631004
ANTIBIOTIC: Levaquin
Description

ANTIBIOTIC: Levaquin

Data type

boolean

Alias
UMLS CUI 2011AA
C0003232
SNOMED CT 2011_0131
255631004
ANTIBIOTIC: Other
Description

ANTIBIOTIC: Other

Data type

string

Alias
UMLS CUI 2011AA
C0003232
SNOMED CT 2011_0131
255631004
OTHER MEDS GIVEN
Description

OTHER MEDS GIVEN

Data type

string

Alias
UMLS CUI 2011AA
C0013227
TECHNICAL PROCEDURE
Description

TECHNICAL PROCEDURE

Alias
UMLS CUI-1
C0946440
Drainage of abscess
Description

Abscess drainage

Data type

boolean

Alias
UMLS CUI 2011AA
C0344096
SNOMED CT 2011_0131
118442004
MedDRA 14.1
10000279
Aortography, Contrast aortogram
Description

Aortogram

Data type

boolean

Alias
UMLS CUI 2011AA
C0003515
SNOMED CT 2011_0131
54640009
MedDRA 14.1
10057775
ICD-9-CM Version 2011
88.42
Aortogram and Runoff
Description

Aortogram and Runoff

Data type

boolean

AV Fistulagram
Description

AV Fistulagram

Data type

boolean

Alias
UMLS CUI 2011AA
C0412315
SNOMED CT 2011_0131
241275007
Biliary Drain
Description

Biliary Drain

Data type

boolean

Alias
UMLS CUI 2011AA
C0489793
LOINC Version 232
MTHU001297
Angiogram carotid, Carotid angiography
Description

Carotid Angiogram

Data type

boolean

Alias
UMLS CUI 2011AA
C0202896
SNOMED CT 2011_0131
420171008
MedDRA 14.1
10003194
ICD-9-CM Version 2011
88.41
Cerebral angiogram, Angiogram cerebral, Fluoroscopic angiography of cerebral artery
Description

Cerebral Angiogram

Data type

boolean

Alias
UMLS CUI 2011AA
C0948923
SNOMED CT 2011_0131
419364000
MedDRA 14.1
10052905
Chest drain, chest tube, thoracic tube
Description

Chest tube

Data type

boolean

Alias
UMLS CUI 2011AA
C0008034
SNOMED CT 2011_0131
258643002
LOINC Version 232
MTHU001287
Chest tube/Empyema
Description

Chest tube/Empyema

Data type

boolean

Alias
SNOMED CT 2011_0131
258643002, 66696
MedDRA 14.1
10014568
LOINC Version 232
MTHU001287
ICD-9-CM Version 2011
510
UMLS CUI-1
C0008034
UMLS CUI-2
C0014009
Central venous catheter (CVC), Central venous line
Description

CVC

Data type

boolean

Alias
UMLS CUI 2011AA
C1145640
SNOMED CT 2011_0131
52124006
CVC/Port
Description

CVC/Port

Data type

boolean

Alias
SNOMED CT 2011_0131
52124006
UMLS CUI-1
C1145640
UMLS CUI-2
C1275732
CVC Temporary
Description

CVC Temporary

Data type

boolean

CVC Tunneled
Description

CVC Tunneled

Data type

boolean

Dialysis Access Declot
Description

Dialysis Access Declot

Data type

boolean

Endovenous laser treatment (ELT)
Description

EVLT

Data type

boolean

Alias
UMLS CUI 2011AA
C1998394
Extremity Angiogram
Description

Extremity Angiogram

Data type

boolean

Alias
SNOMED CT 2011_0131
77343006, 66019005
MedDRA 14.1
10050062
LOINC Version 232
MTHU001429
UMLS CUI-1
C0002978
UMLS CUI-2
C0015385
Balloon Vertebroplasty
Description

Kyphoplasty

Data type

boolean

Alias
UMLS CUI 2011AA
C1455863
MedDRA 14.1
10064702
ICD-9-CM Version 2011
81.66
Percutaneous insertion of nephrostomy tube
Description

Percutaneous Nephrostomy

Data type

boolean

Alias
UMLS CUI 2011AA
C0564457
SNOMED CT 2011_0131
313270001
Peripherally-Inserted Central Catheter (PICC), PICC line
Description

PICC

Data type

boolean

Alias
UMLS CUI 2011AA
C0179740
SNOMED CT 2011_0131
398176008
Pulmonary arteriogram, Pulmonary artery angiography
Description

Pulmonary Angiogram

Data type

boolean

Alias
UMLS CUI 2011AA
C0202910
SNOMED CT 2011_0131
84200003
MedDRA 14.1
10002440
ICD-9-CM Version 2011
88.43
radiofrequency ablation (RFA) procedure
Description

radiofrequency ablation (RFA) procedure

Data type

boolean

Alias
UMLS CUI-1
C1292442
transarterial chemoembolization
Description

transarterial chemoembolization

Data type

boolean

Alias
UMLS CUI-1
C3539919
Thrombolysis
Description

Thrombolysis

Data type

boolean

Alias
UMLS CUI 2011AA
C0520997
SNOMED CT 2011_0131
51308000
MedDRA 14.1
10043568
Embolisation of uterine artery
Description

Uterine Artery Embolization

Data type

boolean

Alias
UMLS CUI 2011AA
C0729536
SNOMED CT 2011_0131
312138002
Other procedure
Description

Other procedure

Data type

string

FINDINGS
Description

FINDINGS

Data type

integer

Alias
UMLS CUI-1
C0243095
Findings text
Description

Findings text

Data type

string

bleeding, blood loss, hemorrhage
Description

BLOOD LOSS

Data type

string

Alias
UMLS CUI 2011AA
C0019080
SNOMED CT 2011_0131
50960005
MedDRA 14.1
10055798
ICD-10-CM Version 2010
R58
ICD-9-CM Version 2011
459.0
Contrast medium, Contrast agent
Description

CONTRAST

Data type

string

Alias
UMLS CUI 2011AA
C0009924
SNOMED CT 2011_0131
385420005
FLUORO TIME
Description

FLUORO TIME

Data type

string

Alias
UMLS CUI 2011AA
C0016356
SNOMED CT 2011_0131
44491008
MedDRA 14.1
10064426
SPECIMEN(s)REMOVED (yes|no)
Description

SPECIMEN(s) REMOVED

Data type

boolean

Specimen
Description

SPECIMEN(s)

Data type

string

Alias
UMLS CUI 2011AA
C0370003
SNOMED CT 2011_0131
123038009
LOINC Version 232
MTHU010726
COMPLICATIONS: No immediate
Description

COMPLICATIONS: No immediate

Data type

boolean

Complications
Description

Complications text

Data type

string

Alias
UMLS CUI 2011AA
C0009566
SNOMED CT 2011_0131
116223007
LOINC Version 232
MTHU008883
Back to the top of the page

Similar models

HIS

1 forms
  1. StudyEvent: HIS
    1. HIS
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
General Info
C1508263 (UMLS CUI-1)
Age
Item
Age
integer
397669002 (SNOMED CT 2011_0131)
C0001779 (UMLS CUI-1)
Gender
Item
Sex
integer
C0079399 (UMLS CUI 2011AA)
263495000 (SNOMED CT 2011_0131)
MTHU002975 (LOINC Version 232)
Race
Item
Racial group
text
103579009 (SNOMED CT 2011_0131)
MTHU009923 (LOINC Version 232)
C0034510 (UMLS CUI-1)
Height
Item
Body height
integer
MTHU005354 (LOINC Version 232)
C0005890 (UMLS CUI-1)
Weight
Item
Body weight
float
107647005 (SNOMED CT 2011_0131)
10047890 (MedDRA 14.1)
LP18015-5 (LOINC Version 232)
C0005910 (UMLS CUI-1)
CHIEF COMPLAINT
Item
Chief complaint (CC)
string
C0277786 (UMLS CUI 2011AA)
33962009 (SNOMED CT 2011_0131)
MTHU001077 (LOINC Version 232)
PRESENT ILLNESS
Item
History of present illness
string
C0262512 (UMLS CUI 2011AA)
MTHU001399 (LOINC Version 232)
Item Group
Prior Health History
C0262926 (UMLS CUI-1)
Medical Illness
Item
Past medical history
string
C0262926 (UMLS CUI 2011AA)
417662000 (SNOMED CT 2011_0131)
MTHU027722 (LOINC Version 232)
Surgery
Item
Prior Surgery, History of (H/O) surgery, Past surgical history
string
C0455610 (UMLS CUI 2011AA)
161615003 (SNOMED CT 2011_0131)
DETAILED ACTIVE MEDS
Item
current medication list, active medication
string
C1553892 (UMLS CUI 2011AA)
Allergies
Item
Allergies
string
C0020517 (UMLS CUI 2011AA)
257550005 (SNOMED CT 2011_0131)
T78.40 (ICD-10-CM Version 2010)
REVIEW OF SYSTEMS(Positive findings)
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
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 Exam
C0031809 (UMLS CUI-1)
Temperature
Item
Temperature
float
246508008 (SNOMED CT 2011_0131)
MTHU009008 (LOINC Version 232)
C0039476 (UMLS CUI-1)
Pulse Rate
Item
Pulse
integer
78564009 (SNOMED CT 2011_0131)
10037485 (MedDRA 14.1)
C0232117 (UMLS CUI-1)
Respiration Rate
Item
Respiration rate, Breathing rate (BR)
integer
86290005 (SNOMED CT 2011_0131)
10038709 (MedDRA 14.1)
MTHU008344 (LOINC Version 232)
C0231832 (UMLS CUI-1)
Blood Pressure
Item
Blood pressure (BP)
integer
75367002 (SNOMED CT 2011_0131)
MTHU008342 (LOINC Version 232)
C0005823 (UMLS CUI-1)
Pain
Item
Pain
string
C0030193 (UMLS CUI 2011AA)
22253000 (SNOMED CT 2011_0131)
10033371 (MedDRA 14.1)
MTHU029813 (LOINC Version 232)
R52 (ICD-10-CM Version 2010)
338-338.9 (ICD-9-CM Version 2011)
E11167 (CTCAE 1105E)
GENERAL APPEARANCE
Item
general appearance
string
C1148438 (UMLS CUI 2011AA)
MTHU015040 (LOINC Version 232)
HEENT
Item
Head, Ears, Eyes, Nose and Throat
text
C1512338 (UMLS CUI 2011AA)
NECK
Item
Neck, Collum, Cervical
string
C0027530 (UMLS CUI 2011AA)
45048000 (SNOMED CT 2011_0131)
MTHU002688 (LOINC Version 232)
CHEST
Item
Chest, Thorax
string
C0817096 (UMLS CUI 2011AA)
51185008 (SNOMED CT 2011_0131)
BREAST
Item
Mammary region
string
C0006141 (UMLS CUI 2011AA)
76752008 (SNOMED CT 2011_0131)
MTHU011382 (LOINC Version 232)
HEART
Item
Heart
string
C0018787 (UMLS CUI 2011AA)
80891009 (SNOMED CT 2011_0131)
MTHU001067 (LOINC Version 232)
ABDOMEN
Item
Abdomen
string
C0000726 (UMLS CUI 2011AA)
113345001 (SNOMED CT 2011_0131)
MTHU001425 (LOINC Version 232)
LYMPH NODES
Item
lymph nodes
string
C0024204 (UMLS CUI 2011AA)
59441001 (SNOMED CT 2011_0131)
MTHU015050 (LOINC Version 232)
GENITALIA/RECTAL
Item
Genital Organs/Rectal
text
255582007 (SNOMED CT 2011_0131)
MTHU002681 (LOINC Version 232)
C0017420 (UMLS CUI-1)
C0205052 (UMLS CUI-2)
EXTREMITIES
Item
Extremities, Limb structure
string
C0015385 (UMLS CUI 2011AA)
66019005 (SNOMED CT 2011_0131)
MTHU001429 (LOINC Version 232)
SKIN
Item
Integument
string
C1123023 (UMLS CUI 2011AA)
39937001 (SNOMED CT 2011_0131)
MTHU001414 (LOINC Version 232)
NEUROLOGICAL
Item
Neurologic system, Nervous system, Nervous system structure
string
C0027763 (UMLS CUI 2011AA)
25087005 (SNOMED CT 2011_0131)
MTHU001437 (LOINC Version 232)
IMPRESSION
Item
summary, conclusion
string
CL386604 (UMLS CUI 2011AA)
PLAN
Item
Plan
string
C1301732 (UMLS CUI 2011AA)
397943006 (SNOMED CT 2011_0131)
ASA SCORE
Item
Finding of American Society of Anesthesiologists physical status classification
string
C1531480 (UMLS CUI 2011AA)
413347006 (SNOMED CT 2011_0131)
AIRWAY ASSESSMENT FOR PATIENTS RECEIVING MODERATE SEDATION
Item
AIRWAY ASSESSMENT FOR PATIENTS RECEIVING MODERATE SEDATION
text
Teeth
Item
Teeth
string
C0040426 (UMLS CUI 2011AA)
245543004 (SNOMED CT 2011_0131)
MTHU021292 (LOINC Version 232)
MALLAMPATI AIRWAY SCORE
Item
Mallampati score
string
C0451276 (UMLS CUI 2011AA)
273585005 (SNOMED CT 2011_0131)
Neck Extension
Item
Neck Extension (normal/RESTRICTED/NO MOBILITY)
text
45048000, 255536004 (SNOMED CT 2011_0131)
MTHU002688, MTHU010348 (LOINC Version 232)
C0027530 (UMLS CUI-1)
C0231448 (UMLS CUI-2)
Physician
Item
Treating Physician
string
C1710470 (UMLS CUI 2011AA)
Item Group
Procedure
C0184661 (UMLS CUI-1)
DATE OF PROCEDURE
Item
Date of procedure
string
C2584899 (UMLS CUI 2011AA)
439272007 (SNOMED CT 2011_0131)
PRE-OP DIAGNOSIS
Item
Preoperative diagnosis
string
C1318968 (UMLS CUI 2011AA)
406520001 (SNOMED CT 2011_0131)
POST-OP DIAGNOSIS
Item
Post-operative diagnosis
string
C1318969 (UMLS CUI 2011AA)
406521002 (SNOMED CT 2011_0131)
PRIMARY SURGEON
Item
Primary Surgeon
string
C0808118 (UMLS CUI 2011AA)
MTHU010488 (LOINC Version 232)
PRISURG (HL7 V3 2006_05)
ASSISTANT
Item
first assistant surgeon
string
C1550491 (UMLS CUI 2011AA)
FASST (HL7 V3 2006_05)
ANESTHESIA PROVIDER
Item
anesthesist
string
C1550495 (UMLS CUI 2011AA)
ANEST (HL7 V3 2006_05)
ANESTHESIA/SEDATION
Item
ANESTHESIA/SEDATION
text
399097000, 72641008 (SNOMED CT 2011_0131)
10002091, 10059283 (MedDRA 14.1)
MTHU035920 (LOINC Version 232)
C0002903 (UMLS CUI-1)
C0344106 (UMLS CUI-2)
Item Group
Medication
C0013227 (UMLS CUI-1)
ANTIBIOTIC: Ancef
Item
ANTIBIOTIC: Ancef
boolean
C0003232 (UMLS CUI 2011AA)
255631004 (SNOMED CT 2011_0131)
ANTIBIOTIC: Rocephin
Item
ANTIBIOTIC: Rocephin
boolean
C0003232 (UMLS CUI 2011AA)
255631004 (SNOMED CT 2011_0131)
ANTIBIOTIC: Levaquin
Item
ANTIBIOTIC: Levaquin
boolean
C0003232 (UMLS CUI 2011AA)
255631004 (SNOMED CT 2011_0131)
ANTIBIOTIC: Other
Item
ANTIBIOTIC: Other
string
C0003232 (UMLS CUI 2011AA)
255631004 (SNOMED CT 2011_0131)
OTHER MEDS GIVEN
Item
OTHER MEDS GIVEN
string
C0013227 (UMLS CUI 2011AA)
Item Group
TECHNICAL PROCEDURE
C0946440 (UMLS CUI-1)
Abscess drainage
Item
Drainage of abscess
boolean
C0344096 (UMLS CUI 2011AA)
118442004 (SNOMED CT 2011_0131)
10000279 (MedDRA 14.1)
Aortogram
Item
Aortography, Contrast aortogram
boolean
C0003515 (UMLS CUI 2011AA)
54640009 (SNOMED CT 2011_0131)
10057775 (MedDRA 14.1)
88.42 (ICD-9-CM Version 2011)
Aortogram and Runoff
Item
Aortogram and Runoff
boolean
AV Fistulagram
Item
AV Fistulagram
boolean
C0412315 (UMLS CUI 2011AA)
241275007 (SNOMED CT 2011_0131)
Biliary Drain
Item
Biliary Drain
boolean
C0489793 (UMLS CUI 2011AA)
MTHU001297 (LOINC Version 232)
Carotid Angiogram
Item
Angiogram carotid, Carotid angiography
boolean
C0202896 (UMLS CUI 2011AA)
420171008 (SNOMED CT 2011_0131)
10003194 (MedDRA 14.1)
88.41 (ICD-9-CM Version 2011)
Cerebral Angiogram
Item
Cerebral angiogram, Angiogram cerebral, Fluoroscopic angiography of cerebral artery
boolean
C0948923 (UMLS CUI 2011AA)
419364000 (SNOMED CT 2011_0131)
10052905 (MedDRA 14.1)
Chest tube
Item
Chest drain, chest tube, thoracic tube
boolean
C0008034 (UMLS CUI 2011AA)
258643002 (SNOMED CT 2011_0131)
MTHU001287 (LOINC Version 232)
Chest tube/Empyema
Item
Chest tube/Empyema
boolean
258643002, 66696 (SNOMED CT 2011_0131)
10014568 (MedDRA 14.1)
MTHU001287 (LOINC Version 232)
510 (ICD-9-CM Version 2011)
C0008034 (UMLS CUI-1)
C0014009 (UMLS CUI-2)
CVC
Item
Central venous catheter (CVC), Central venous line
boolean
C1145640 (UMLS CUI 2011AA)
52124006 (SNOMED CT 2011_0131)
CVC/Port
Item
CVC/Port
boolean
52124006 (SNOMED CT 2011_0131)
C1145640 (UMLS CUI-1)
C1275732 (UMLS CUI-2)
CVC Temporary
Item
CVC Temporary
boolean
CVC Tunneled
Item
CVC Tunneled
boolean
Dialysis Access Declot
Item
Dialysis Access Declot
boolean
EVLT
Item
Endovenous laser treatment (ELT)
boolean
C1998394 (UMLS CUI 2011AA)
Extremity Angiogram
Item
Extremity Angiogram
boolean
77343006, 66019005 (SNOMED CT 2011_0131)
10050062 (MedDRA 14.1)
MTHU001429 (LOINC Version 232)
C0002978 (UMLS CUI-1)
C0015385 (UMLS CUI-2)
Kyphoplasty
Item
Balloon Vertebroplasty
boolean
C1455863 (UMLS CUI 2011AA)
10064702 (MedDRA 14.1)
81.66 (ICD-9-CM Version 2011)
Percutaneous Nephrostomy
Item
Percutaneous insertion of nephrostomy tube
boolean
C0564457 (UMLS CUI 2011AA)
313270001 (SNOMED CT 2011_0131)
PICC
Item
Peripherally-Inserted Central Catheter (PICC), PICC line
boolean
C0179740 (UMLS CUI 2011AA)
398176008 (SNOMED CT 2011_0131)
Pulmonary Angiogram
Item
Pulmonary arteriogram, Pulmonary artery angiography
boolean
C0202910 (UMLS CUI 2011AA)
84200003 (SNOMED CT 2011_0131)
10002440 (MedDRA 14.1)
88.43 (ICD-9-CM Version 2011)
RF-Ablation
Item
radiofrequency ablation (RFA) procedure
boolean
C1292442 (UMLS CUI-1)
TACE
Item
transarterial chemoembolization
boolean
C3539919 (UMLS CUI-1)
Thrombolysis
Item
Thrombolysis
boolean
C0520997 (UMLS CUI 2011AA)
51308000 (SNOMED CT 2011_0131)
10043568 (MedDRA 14.1)
Uterine Artery Embolization
Item
Embolisation of uterine artery
boolean
C0729536 (UMLS CUI 2011AA)
312138002 (SNOMED CT 2011_0131)
Other procedure
Item
Other procedure
string
Item
FINDINGS
integer
C0243095 (UMLS CUI-1)
FINDINGS
Code List
FINDINGS
CL Item
None (1)
CL Item
Same (2)
CL Item
N/A (3)
CL Item
Successful (4)
CL Item
Unsuccessful (5)
Findings text
Item
Findings text
string
BLOOD LOSS
Item
bleeding, blood loss, hemorrhage
string
C0019080 (UMLS CUI 2011AA)
50960005 (SNOMED CT 2011_0131)
10055798 (MedDRA 14.1)
R58 (ICD-10-CM Version 2010)
459.0 (ICD-9-CM Version 2011)
CONTRAST
Item
Contrast medium, Contrast agent
string
C0009924 (UMLS CUI 2011AA)
385420005 (SNOMED CT 2011_0131)
FLUORO TIME
Item
FLUORO TIME
string
C0016356 (UMLS CUI 2011AA)
44491008 (SNOMED CT 2011_0131)
10064426 (MedDRA 14.1)
SPECIMEN(s) REMOVED
Item
SPECIMEN(s)REMOVED (yes|no)
boolean
SPECIMEN(s)
Item
Specimen
string
C0370003 (UMLS CUI 2011AA)
123038009 (SNOMED CT 2011_0131)
MTHU010726 (LOINC Version 232)
COMPLICATIONS: No immediate
Item
COMPLICATIONS: No immediate
boolean
Complications text
Item
Complications
string
C0009566 (UMLS CUI 2011AA)
116223007 (SNOMED CT 2011_0131)
MTHU008883 (LOINC Version 232)
Back to the top of the page 

Contact

Please use this form for feedback, questions and suggestions for improvements.

Fields marked with * are required.

Help

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial