ID

11248

Beskrivning

Form from HIS OpenVistA

Nyckelord

Versioner (5)
  1. 2012-02-24 2012-02-24 -
  2. 2012-02-29 2012-02-29 -
  3. 2014-08-07 2014-08-07 - Martin Dugas
  4. 2014-08-09 2014-08-09 - Martin Dugas
  5. 2015-06-26 2015-06-26 - Martin Dugas
Uppladdad den

26 juni 2015

DOI

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Creative Commons BY-NC 3.0 Legacy
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INTERVENTIONAL RADIOLOGY

Tysk Engelsk

HIS

1 Formulär  
  1. StudyEvent: HIS
    1. HIS
General Info
Beskrivning

General Info

Alias
UMLS CUI-1
C1508263
Alter
Beskrivning

Age

Datatyp

integer

Måttenheter
  • years
Alias
SNOMED CT 2011_0131
397669002
UMLS CUI-1
C0001779
years
Geschlecht
Beskrivning

Gender

Datatyp

integer

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

Race

Datatyp

text

Alias
SNOMED CT 2011_0131
103579009
LOINC Version 232
MTHU009923
UMLS CUI-1
C0034510
Größe
Beskrivning

Height

Datatyp

integer

Måttenheter
  • cm
Alias
LOINC Version 232
MTHU005354
UMLS CUI-1
C0005890
cm
Gewicht
Beskrivning

Weight

Datatyp

float

Måttenheter
  • kg
Alias
SNOMED CT 2011_0131
107647005
MedDRA 14.1
10047890
LOINC Version 232
LP18015-5
UMLS CUI-1
C0005910
kg
Hauptbeschwerden
Beskrivning

CHIEF COMPLAINT

Datatyp

string

Alias
UMLS CUI 2011AA
C0277786
SNOMED CT 2011_0131
33962009
LOINC Version 232
MTHU001077
Anamnese der aktuellen Erkrankung
Beskrivning

PRESENT ILLNESS

Datatyp

string

Alias
UMLS CUI 2011AA
C0262512
LOINC Version 232
MTHU001399
Medical History
Beskrivning

Medical History

Alias
UMLS CUI-1
C0262926
Anamnese
Beskrivning

Medical Illness

Datatyp

string

Alias
UMLS CUI 2011AA
C0262926
SNOMED CT 2011_0131
417662000
LOINC Version 232
MTHU027722
Frühere Operationen
Beskrivning

Surgery

Datatyp

string

Alias
UMLS CUI 2011AA
C0455610
SNOMED CT 2011_0131
161615003
aktuelle Medikation
Beskrivning

DETAILED ACTIVE MEDS

Datatyp

string

Alias
UMLS CUI 2011AA
C1553892
Allergien
Beskrivning

Allergies

Datatyp

string

Alias
UMLS CUI 2011AA
C0020517
SNOMED CT 2011_0131
257550005
ICD-10-CM Version 2010
T78.40
Anamnese der Organsysteme
Beskrivning

REVIEW OF SYSTEMS(Positive findings)

Datatyp

string

Alias
UMLS CUI 2011AA
C0489633
SNOMED CT 2011_0131
415300000
LOINC Version 232
MTHU001422
Familienanamnese
Beskrivning

FAMILY HISTORY

Datatyp

string

Alias
UMLS CUI 2011AA
C0241889
SNOMED CT 2011_0131
57177007
Sozialanamnese
Beskrivning

SOCIAL HISTORY

Datatyp

string

Alias
UMLS CUI 2011AA
C0424945
SNOMED CT 2011_0131
160476009
LOINC Version 232
MTHU014081
Impfung
Beskrivning

IMMUNIZATIONS

Datatyp

string

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

Physical Exam

Alias
UMLS CUI-1
C0031809
Temperatur
Beskrivning

Temperature

Datatyp

float

Måttenheter
  • °C
Alias
SNOMED CT 2011_0131
246508008
LOINC Version 232
MTHU009008
UMLS CUI-1
C0039476
°C
Pulsfrequenz
Beskrivning

Pulse Rate

Datatyp

integer

Måttenheter
  • beats/min
Alias
SNOMED CT 2011_0131
78564009
MedDRA 14.1
10037485
UMLS CUI-1
C0232117
beats/min
Atemfrequenz
Beskrivning

Respiration Rate

Datatyp

integer

Måttenheter
  • /min
Alias
SNOMED CT 2011_0131
86290005
MedDRA 14.1
10038709
LOINC Version 232
MTHU008344
UMLS CUI-1
C0231832
/min
Blutdruck
Beskrivning

Blood Pressure

Datatyp

integer

Måttenheter
  • mmHg
Alias
SNOMED CT 2011_0131
75367002
LOINC Version 232
MTHU008342
UMLS CUI-1
C0005823
mmHg
Schmerz
Beskrivning

Pain

Datatyp

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
Allgemeinzustand
Beskrivning

GENERAL APPEARANCE

Datatyp

string

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

HEENT

Datatyp

text

Alias
UMLS CUI 2011AA
C1512338
Hals
Beskrivning

NECK

Datatyp

string

Alias
UMLS CUI 2011AA
C0027530
SNOMED CT 2011_0131
45048000
LOINC Version 232
MTHU002688
Thorax
Beskrivning

CHEST

Datatyp

string

Alias
UMLS CUI 2011AA
C0817096
SNOMED CT 2011_0131
51185008
Brust
Beskrivning

BREAST

Datatyp

string

Alias
UMLS CUI 2011AA
C0006141
SNOMED CT 2011_0131
76752008
LOINC Version 232
MTHU011382
Herz
Beskrivning

HEART

Datatyp

string

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

ABDOMEN

Datatyp

string

Alias
UMLS CUI 2011AA
C0000726
SNOMED CT 2011_0131
113345001
LOINC Version 232
MTHU001425
Lymphknoten
Beskrivning

LYMPH NODES

Datatyp

string

Alias
UMLS CUI 2011AA
C0024204
SNOMED CT 2011_0131
59441001
LOINC Version 232
MTHU015050
Genitalorgane/Rektal
Beskrivning

GENITALIA/RECTAL

Datatyp

text

Alias
SNOMED CT 2011_0131
255582007
LOINC Version 232
MTHU002681
UMLS CUI-1
C0017420
UMLS CUI-2
C0205052
Extremitäten
Beskrivning

EXTREMITIES

Datatyp

string

Alias
UMLS CUI 2011AA
C0015385
SNOMED CT 2011_0131
66019005
LOINC Version 232
MTHU001429
Haut
Beskrivning

SKIN

Datatyp

string

Alias
UMLS CUI 2011AA
C1123023
SNOMED CT 2011_0131
39937001
LOINC Version 232
MTHU001414
Nervensystem
Beskrivning

NEUROLOGICAL

Datatyp

string

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

IMPRESSION

Datatyp

string

Alias
UMLS CUI 2011AA
CL386604
Planung
Beskrivning

PLAN

Datatyp

string

Alias
UMLS CUI 2011AA
C1301732
SNOMED CT 2011_0131
397943006
ASA Status
Beskrivning

ASA SCORE

Datatyp

string

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

AIRWAY ASSESSMENT FOR PATIENTS RECEIVING MODERATE SEDATION

Datatyp

text

Zähne
Beskrivning

Teeth

Datatyp

string

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

MALLAMPATI AIRWAY SCORE

Datatyp

string

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

Neck Extension

Datatyp

text

Alias
SNOMED CT 2011_0131
45048000, 255536004
LOINC Version 232
MTHU002688, MTHU010348
UMLS CUI-1
C0027530
UMLS CUI-2
C0231448
Behandelnder Arzt
Beskrivning

Physician

Datatyp

string

Alias
UMLS CUI 2011AA
C1710470
Procedure
Beskrivning

Procedure

Alias
UMLS CUI-1
C0184661
Datum der Prozedur
Beskrivning

DATE OF PROCEDURE

Datatyp

string

Alias
UMLS CUI 2011AA
C2584899
SNOMED CT 2011_0131
439272007
präoperative Diagnose
Beskrivning

PRE-OP DIAGNOSIS

Datatyp

string

Alias
UMLS CUI 2011AA
C1318968
SNOMED CT 2011_0131
406520001
Postoperative Diagnose
Beskrivning

POST-OP DIAGNOSIS

Datatyp

string

Alias
UMLS CUI 2011AA
C1318969
SNOMED CT 2011_0131
406521002
Erster Operateur
Beskrivning

PRIMARY SURGEON

Datatyp

string

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

ASSISTANT

Datatyp

string

Alias
UMLS CUI 2011AA
C1550491
HL7 V3 2006_05
FASST
Anästhesist
Beskrivning

ANESTHESIA PROVIDER

Datatyp

string

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

ANESTHESIA/SEDATION

Datatyp

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
Beskrivning

Medication

Alias
UMLS CUI-1
C0013227
ANTIBIOTIC: Ancef
Beskrivning

ANTIBIOTIC: Ancef

Datatyp

boolean

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

ANTIBIOTIC: Rocephin

Datatyp

boolean

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

ANTIBIOTIC: Levaquin

Datatyp

boolean

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

ANTIBIOTIC: Other

Datatyp

string

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

OTHER MEDS GIVEN

Datatyp

string

Alias
UMLS CUI 2011AA
C0013227
TECHNICAL PROCEDURE
Beskrivning

TECHNICAL PROCEDURE

Alias
UMLS CUI-1
C0946440
Abszess-Drainage
Beskrivning

Abscess drainage

Datatyp

boolean

Alias
UMLS CUI 2011AA
C0344096
SNOMED CT 2011_0131
118442004
MedDRA 14.1
10000279
Aortographie
Beskrivning

Aortogram

Datatyp

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
Beskrivning

Aortogram and Runoff

Datatyp

boolean

AV Fistulagram
Beskrivning

AV Fistulagram

Datatyp

boolean

Alias
UMLS CUI 2011AA
C0412315
SNOMED CT 2011_0131
241275007
Biliäre Drainage
Beskrivning

Biliary Drain

Datatyp

boolean

Alias
UMLS CUI 2011AA
C0489793
LOINC Version 232
MTHU001297
Carotis-Angiographie
Beskrivning

Carotid Angiogram

Datatyp

boolean

Alias
UMLS CUI 2011AA
C0202896
SNOMED CT 2011_0131
420171008
MedDRA 14.1
10003194
ICD-9-CM Version 2011
88.41
Cerebrale Angiographie
Beskrivning

Cerebral Angiogram

Datatyp

boolean

Alias
UMLS CUI 2011AA
C0948923
SNOMED CT 2011_0131
419364000
MedDRA 14.1
10052905
Thoraxdrainage
Beskrivning

Chest tube

Datatyp

boolean

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

Chest tube/Empyema

Datatyp

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
Zentralvenöser Katheter (ZVK)
Beskrivning

CVC

Datatyp

boolean

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

CVC/Port

Datatyp

boolean

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

CVC Temporary

Datatyp

boolean

CVC Tunneled
Beskrivning

CVC Tunneled

Datatyp

boolean

Dialysis Access Declot
Beskrivning

Dialysis Access Declot

Datatyp

boolean

Endovenous laser treatment (ELT)
Beskrivning

EVLT

Datatyp

boolean

Alias
UMLS CUI 2011AA
C1998394
Extremity Angiogram
Beskrivning

Extremity Angiogram

Datatyp

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
Beskrivning

Kyphoplasty

Datatyp

boolean

Alias
UMLS CUI 2011AA
C1455863
MedDRA 14.1
10064702
ICD-9-CM Version 2011
81.66
Perkutane Nephrostomie
Beskrivning

Percutaneous Nephrostomy

Datatyp

boolean

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

PICC

Datatyp

boolean

Alias
UMLS CUI 2011AA
C0179740
SNOMED CT 2011_0131
398176008
Pulmonale Angiographie
Beskrivning

Pulmonary Angiogram

Datatyp

boolean

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

RF-Ablation

Datatyp

boolean

Alias
UMLS CUI-1
C1292442
transarterial chemoembolization
Beskrivning

TACE

Datatyp

boolean

Alias
UMLS CUI-1
C3539919
Thrombolysis
Beskrivning

Thrombolysis

Datatyp

boolean

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

Uterine Artery Embolization

Datatyp

boolean

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

Other procedure

Datatyp

string

FINDINGS (None|Same|N/A|Successful|Unsuccessful)
Beskrivning

FINDINGS

Datatyp

integer

Alias
UMLS CUI-1
C0243095
Findings text
Beskrivning

Findings text

Datatyp

string

bleeding, blood loss, hemorrhage
Beskrivning

BLOOD LOSS

Datatyp

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
Kontrastmittel
Beskrivning

CONTRAST

Datatyp

string

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

FLUORO TIME

Datatyp

string

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

SPECIMEN(s) REMOVED

Datatyp

boolean

Specimen
Beskrivning

SPECIMEN(s)

Datatyp

string

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

COMPLICATIONS: No immediate

Datatyp

boolean

Komplikationen
Beskrivning

Complications text

Datatyp

string

Alias
UMLS CUI 2011AA
C0009566
SNOMED CT 2011_0131
116223007
LOINC Version 232
MTHU008883
Tillbaka till toppen

Similar models

HIS

1 Formulär
  1. StudyEvent: HIS
    1. HIS
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
Alias
Item Group
C1508263 (UMLS CUI-1)
Age
Item
Alter
integer
397669002 (SNOMED CT 2011_0131)
C0001779 (UMLS CUI-1)
Gender
Item
Geschlecht
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
Größe
integer
MTHU005354 (LOINC Version 232)
C0005890 (UMLS CUI-1)
Weight
Item
Gewicht
float
107647005 (SNOMED CT 2011_0131)
10047890 (MedDRA 14.1)
LP18015-5 (LOINC Version 232)
C0005910 (UMLS CUI-1)
CHIEF COMPLAINT
Item
Hauptbeschwerden
string
C0277786 (UMLS CUI 2011AA)
33962009 (SNOMED CT 2011_0131)
MTHU001077 (LOINC Version 232)
PRESENT ILLNESS
Item
Anamnese der aktuellen Erkrankung
string
C0262512 (UMLS CUI 2011AA)
MTHU001399 (LOINC Version 232)
Item Group
C0262926 (UMLS CUI-1)
Medical Illness
Item
Anamnese
string
C0262926 (UMLS CUI 2011AA)
417662000 (SNOMED CT 2011_0131)
MTHU027722 (LOINC Version 232)
Surgery
Item
Frühere Operationen
string
C0455610 (UMLS CUI 2011AA)
161615003 (SNOMED CT 2011_0131)
DETAILED ACTIVE MEDS
Item
aktuelle Medikation
string
C1553892 (UMLS CUI 2011AA)
Allergies
Item
Allergien
string
C0020517 (UMLS CUI 2011AA)
257550005 (SNOMED CT 2011_0131)
T78.40 (ICD-10-CM Version 2010)
REVIEW OF SYSTEMS(Positive findings)
Item
Anamnese der Organsysteme
string
C0489633 (UMLS CUI 2011AA)
415300000 (SNOMED CT 2011_0131)
MTHU001422 (LOINC Version 232)
FAMILY HISTORY
Item
Familienanamnese
string
C0241889 (UMLS CUI 2011AA)
57177007 (SNOMED CT 2011_0131)
SOCIAL HISTORY
Item
Sozialanamnese
string
C0424945 (UMLS CUI 2011AA)
160476009 (SNOMED CT 2011_0131)
MTHU014081 (LOINC Version 232)
IMMUNIZATIONS
Item
Impfung
string
C0020971 (UMLS CUI 2011AA)
127785005 (SNOMED CT 2011_0131)
10021431 (MedDRA 14.1)
Item Group
C0031809 (UMLS CUI-1)
Temperature
Item
Temperatur
float
246508008 (SNOMED CT 2011_0131)
MTHU009008 (LOINC Version 232)
C0039476 (UMLS CUI-1)
Pulse Rate
Item
Pulsfrequenz
integer
78564009 (SNOMED CT 2011_0131)
10037485 (MedDRA 14.1)
C0232117 (UMLS CUI-1)
Respiration Rate
Item
Atemfrequenz
integer
86290005 (SNOMED CT 2011_0131)
10038709 (MedDRA 14.1)
MTHU008344 (LOINC Version 232)
C0231832 (UMLS CUI-1)
Blood Pressure
Item
Blutdruck
integer
75367002 (SNOMED CT 2011_0131)
MTHU008342 (LOINC Version 232)
C0005823 (UMLS CUI-1)
Pain
Item
Schmerz
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
Allgemeinzustand
string
C1148438 (UMLS CUI 2011AA)
MTHU015040 (LOINC Version 232)
HEENT
Item
Head, Ears, Eyes, Nose and Throat
text
C1512338 (UMLS CUI 2011AA)
NECK
Item
Hals
string
C0027530 (UMLS CUI 2011AA)
45048000 (SNOMED CT 2011_0131)
MTHU002688 (LOINC Version 232)
CHEST
Item
Thorax
string
C0817096 (UMLS CUI 2011AA)
51185008 (SNOMED CT 2011_0131)
BREAST
Item
Brust
string
C0006141 (UMLS CUI 2011AA)
76752008 (SNOMED CT 2011_0131)
MTHU011382 (LOINC Version 232)
HEART
Item
Herz
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
Lymphknoten
string
C0024204 (UMLS CUI 2011AA)
59441001 (SNOMED CT 2011_0131)
MTHU015050 (LOINC Version 232)
GENITALIA/RECTAL
Item
Genitalorgane/Rektal
text
255582007 (SNOMED CT 2011_0131)
MTHU002681 (LOINC Version 232)
C0017420 (UMLS CUI-1)
C0205052 (UMLS CUI-2)
EXTREMITIES
Item
Extremitäten
string
C0015385 (UMLS CUI 2011AA)
66019005 (SNOMED CT 2011_0131)
MTHU001429 (LOINC Version 232)
SKIN
Item
Haut
string
C1123023 (UMLS CUI 2011AA)
39937001 (SNOMED CT 2011_0131)
MTHU001414 (LOINC Version 232)
NEUROLOGICAL
Item
Nervensystem
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
Planung
string
C1301732 (UMLS CUI 2011AA)
397943006 (SNOMED CT 2011_0131)
ASA SCORE
Item
ASA Status
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
Zähne
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
Behandelnder Arzt
string
C1710470 (UMLS CUI 2011AA)
Item Group
C0184661 (UMLS CUI-1)
DATE OF PROCEDURE
Item
Datum der Prozedur
string
C2584899 (UMLS CUI 2011AA)
439272007 (SNOMED CT 2011_0131)
PRE-OP DIAGNOSIS
Item
präoperative Diagnose
string
C1318968 (UMLS CUI 2011AA)
406520001 (SNOMED CT 2011_0131)
POST-OP DIAGNOSIS
Item
Postoperative Diagnose
string
C1318969 (UMLS CUI 2011AA)
406521002 (SNOMED CT 2011_0131)
PRIMARY SURGEON
Item
Erster Operateur
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
Anästhesist
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
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
C0946440 (UMLS CUI-1)
Abscess drainage
Item
Abszess-Drainage
boolean
C0344096 (UMLS CUI 2011AA)
118442004 (SNOMED CT 2011_0131)
10000279 (MedDRA 14.1)
Aortogram
Item
Aortographie
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
Biliäre Drainage
boolean
C0489793 (UMLS CUI 2011AA)
MTHU001297 (LOINC Version 232)
Carotid Angiogram
Item
Carotis-Angiographie
boolean
C0202896 (UMLS CUI 2011AA)
420171008 (SNOMED CT 2011_0131)
10003194 (MedDRA 14.1)
88.41 (ICD-9-CM Version 2011)
Cerebral Angiogram
Item
Cerebrale Angiographie
boolean
C0948923 (UMLS CUI 2011AA)
419364000 (SNOMED CT 2011_0131)
10052905 (MedDRA 14.1)
Chest tube
Item
Thoraxdrainage
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
Zentralvenöser Katheter (ZVK)
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
Perkutane Nephrostomie
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
Pulmonale Angiographie
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 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 (None|Same|N/A|Successful|Unsuccessful)
integer
C0243095 (UMLS CUI-1)
FINDINGS
Code List
FINDINGS (None|Same|N/A|Successful|Unsuccessful)
CL Item
 (1)
CL Item
 (2)
CL Item
 (3)
CL Item
 (4)
CL Item
 (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
Kontrastmittel
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
Komplikationen
string
C0009566 (UMLS CUI 2011AA)
116223007 (SNOMED CT 2011_0131)
MTHU008883 (LOINC Version 232)
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