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11250

Beschreibung

Form from HIS OpenVistA

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Versionen (2)
  1. 26.02.12 26.02.12 -
  2. 26.06.15 26.06.15 - Martin Dugas
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26. Juni 2015

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TRANSFER ASSESSMENT INTERDISCIPLINARY NOTE

Deutsch Englisch

HIS

1 Formulare  
  1. StudyEvent: HIS
    1. HIS
Transfer assessment
Beschreibung

Transfer assessment

Aufnahmediagnose
Beschreibung

ADMITTING DIAGNOSIS

Datentyp

string

Alias
UMLS CUI 2011AA
C0332133
SNOMED CT 2011_0131
52870002
Behandelnder Arzt
Beschreibung

DOCTOR

Datentyp

string

Alias
UMLS CUI 2011AA
C1710470
Aufnahmedatum
Beschreibung

Admission Date

Datentyp

date

Alias
UMLS CUI 2011AA
C1302393
SNOMED CT 2011_0131
399423000
LOINC Version 232
MTHU029790
FAMILY NOTIFIED
Beschreibung

FAMILY NOTIFIED

Datentyp

boolean

BELONGINGS WITH PATIENT
Beschreibung

BELONGINGS WITH PATIENT

Datentyp

boolean

MEDICATIONS WITH PATIENT
Beschreibung

MEDICATIONS WITH PATIENT

Datentyp

boolean

IV MEDICATIONS WITH PATIENT
Beschreibung

IV MEDICATIONS WITH PATIENT

Datentyp

boolean

PENDING LABS
Beschreibung

PENDING LABS

Datentyp

string

Temperatur
Beschreibung

Temperature

Datentyp

float

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

Pulse Rate

Datentyp

integer

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

Respiratory rate

Datentyp

integer

Alias
SNOMED CT 2011_0131
86290005
MedDRA 14.1
10038709
LOINC Version 232
MTHU008344
UMLS CUI-1
C0231832
Blutdruck
Beschreibung

Blood Pressure

Datentyp

integer

Maßeinheiten
  • mmHg
Alias
SNOMED CT 2011_0131
75367002
LOINC Version 232
MTHU008342
UMLS CUI-1
C0005823
mmHg
OP-Datum
Beschreibung

DATE OF SURGERY

Datentyp

date

Alias
LOINC Version 232
MTHU019327
UMLS CUI-1
C1628561
CODE STATUS
Beschreibung

CODE STATUS

Datentyp

string

DATE CODE STATUS ORDERED
Beschreibung

DATE CODE STATUS ORDERED

Datentyp

date

REASON FOR TRANSFER
Beschreibung

REASON FOR TRANSFER

Datentyp

string

Alias
UMLS CUI 2011AA
C1547731
LOINC Version 232
MTHU019076
Mode of transfer
Beschreibung

MODE OF TRANSFER

Datentyp

string

Alias
UMLS CUI 2011AA
C1718076
LOINC Version 232
MTHU021155
Functional Status, Level of function
Beschreibung

LEVEL OF FUNCTION

Datentyp

string

Alias
UMLS CUI 2011AA
C0598463
LOINC Version 232
MTHU027728
Mental Status, Mental State
Beschreibung

Mental Status

Datentyp

string

Alias
UMLS CUI 2011AA
C0278060
SNOMED CT 2011_0131
36456004
LOINC Version 232
MTHU001424
CTCAE 1105E
MTHU117157
Patient activity
Beschreibung

Level of Activity

Datentyp

string

Alias
UMLS CUI 2011AA
C0451369
SNOMED CT 2011_0131
273688003
Aktivitäten des täglichen Lebens (ATL)
Beschreibung

Activities of Daily Living

Datentyp

string

Alias
UMLS CUI 2011AA
C0001288
SNOMED CT 2011_0131
129025006
Diät
Beschreibung

DIET

Datentyp

string

Alias
UMLS CUI 2011AA
C0012155
SNOMED CT 2011_0131
41829006
Tube Feeding via @ with @ strength of @
Beschreibung

Tube Feeding via @ with @ strength of @

Datentyp

string

Alias
UMLS CUI 2011AA
C0041281
SNOMED CT 2011_0131
61420007
MedDRA 14.1
10053095
Last residual amount was @ CC'S and it was checked at @
Beschreibung

Last residual amount was @ CC'S and it was checked at @

Datentyp

string

IV Therapy
Beschreibung

IV Therapy

Alias
UMLS CUI-1
C1411942
intravenöse Therapie
Beschreibung

IV THERAPY

Datentyp

string

Alias
UMLS CUI 2011AA
C1411942
Katheter-Größe
Beschreibung

Catheter Size

Datentyp

string

Alias
UMLS CUI 2011AA
C0449963
SNOMED CT 2011_0131
260967009
Lokalisation
Beschreibung

LOCATION

Datentyp

string

Alias
UMLS CUI 2011AA
C0450429
SNOMED CT 2011_0131
246267002
Infusion
Beschreibung

IV Fluid

Datentyp

string

Alias
UMLS CUI 2011AA
C1289919
SNOMED CT 2011_0131
118431008
MedDRA 14.1
10067708
LEFT TO COUNT [ml]
Beschreibung

LEFT TO COUNT [ml]

Datentyp

integer

Rate: @ ml/hr
Beschreibung

Rate: @ ml/hr

Datentyp

integer

IV Site APPEARANCE
Beschreibung

IV Site APPEARANCE

Datentyp

string

Zentralvenöser Katheter (ZVK)
Beschreibung

CENTRAL LINE PORT

Datentyp

string

Alias
UMLS CUI 2011AA
C1145640
SNOMED CT 2011_0131
52124006
Infusion
Beschreibung

IV Fluid

Datentyp

string

Alias
UMLS CUI 2011AA
C1289919
SNOMED CT 2011_0131
118431008
MedDRA 14.1
10067708
TPN/LIPIDS: TPN @ ml/hr and Lipids @ ml/hr
Beschreibung

TPN/LIPIDS: TPN @ ml/hr and Lipids @ ml/hr

Datentyp

string

Alias
UMLS CUI 2011AA
C0030548, C0023779
SNOMED CT 2011_0131
225372007, 70106000
MedDRA 14.1
10044107
LOINC Version 232
MTHU014331, MTHU003688
ICD-9-CM Version 2011
99.15
IV Site APPEARANCE
Beschreibung

IV Site APPEARANCE

Datentyp

string

SITE CHANGE DUE
Beschreibung

SITE CHANGE DUE

Datentyp

date

IV REASSESSMENT
Beschreibung

IV REASSESSMENT

Datentyp

string

IV Site APPEARANCE
Beschreibung

IV Site APPEARANCE

Datentyp

string

NARRATIVE
Beschreibung

NARRATIVE

Datentyp

string

Wound
Beschreibung

Wound

Alias
UMLS CUI-1
C0043250
WOUND CARE
Beschreibung

WOUND CARE

Datentyp

string

Alias
UMLS CUI 2011AA
C0043250
SNOMED CT 2011_0131
13924000
MedDRA 14.1
10052428
LOINC Version 232
MTHU001326
SITE: LAST DRESSING CHANGE
Beschreibung

SITE: LAST DRESSING CHANGE

Datentyp

string

ELIMINATION
Beschreibung

ELIMINATION

Alias
UMLS CUI-1
C0221102
Date of last bowel movement
Beschreibung

Date of last bowel movement

Datentyp

date

Alias
UMLS CUI 2011AA
C0011135
SNOMED CT 2011_0131
39211005
Is the patient incontinent of stool?
Beschreibung

Is the patient incontinent of stool?

Datentyp

string

Alias
UMLS CUI 2011AA
C0015732
SNOMED CT 2011_0131
72042002
MedDRA 14.1
10016092
LOINC Version 232
MTHU013375
ICD-10-CM Version 2010
R15
ICD-9-CM Version 2011
787.6
CTCAE 1105E
E10693
Is the patient incontinent of urine?
Beschreibung

Is the patient incontinent of urine?

Datentyp

string

Alias
UMLS CUI 2011AA
C0042024
SNOMED CT 2011_0131
165232002
MedDRA 14.1
10046543
ICD-10-CM Version 2010
R32
ICD-9-CM Version 2011
788.3
CTCAE 1105E
E13042
OTHER CARE
Beschreibung

OTHER CARE

Sauerstoff
Beschreibung

OXYGEN

Datentyp

string

Alias
UMLS CUI 2011AA
C0030054
SNOMED CT 2011_0131
24099007
LOINC Version 232
MTHU002757
Drainage
Beschreibung

DRAINS

Datentyp

string

Alias
UMLS CUI 2011AA
C0180499
SNOMED CT 2011_0131
32712000
LOINC Version 232
MTHU022515
Schmerztherapie
Beschreibung

PAIN MANAGEMENT

Datentyp

string

Alias
UMLS CUI 2011AA
C0002766
SNOMED CT 2011_0131
278414003
MedDRA 14.1
10056350
LOINC Version 232
MTHU031888
Atemtherapie
Beschreibung

MED RT

Datentyp

string

Alias
UMLS CUI 2011AA
C0035239
SNOMED CT 2011_0131
53950000
MedDRA 14.1
10059828
LOINC Version 232
MTHU015440
ICD-9-CM Version 2011
93.9
LAST TIME PATIENT WAS MEDICATED
Beschreibung

LAST TIME PATIENT WAS MEDICATED

Datentyp

time

Isolation
Beschreibung

ISOLATION

Datentyp

string

Alias
UMLS CUI 2011AA
C0205409
SNOMED CT 2011_0131
46651001
TYPE OF ISOLATION
Beschreibung

TYPE OF ISOLATION

Datentyp

string

DAILY WEIGHTS
Beschreibung

DAILY WEIGHTS

Datentyp

boolean

Alias
UMLS CUI 2011AA
C1305866
SNOMED CT 2011_0131
107647005
MedDRA 14.1
10047890
LOINC Version 232
LP18015-5
Sturzgefährdung
Beschreibung

AT RISK FOR FALLS

Datentyp

boolean

Alias
UMLS CUI 2011AA
C1268740
SNOMED CT 2011_0131
129839007
ICD-10-CM Version 2010
Z91.81
ICD-9-CM Version 2011
V15.88
AT RISK FOR SKIN BREAKDOWN
Beschreibung

AT RISK FOR SKIN BREAKDOWN

Datentyp

string

Alias
UMLS CUI 2011AA
C0150077
SNOMED CT 2011_0131
247442005
MedDRA 14.1
10050204
LOINC Version 232
MTHU013438
Haltegurte
Beschreibung

RESTRAINTS

Datentyp

string

Alias
UMLS CUI 2011AA
C0337184
SNOMED CT 2011_0131
57395004
LOINC Version 232
MTHU032305
Date/Time of Restraints order:
Beschreibung

Date/Time of Restraints order:

Datentyp

date

Vorsichtsmaßnahmen
Beschreibung

SPECIAL PRECAUTIONS

Datentyp

string

Alias
UMLS CUI 2011AA
C1882442
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Ähnliche Modelle

HIS

1 Formulare
  1. StudyEvent: HIS
    1. HIS
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
ADMITTING DIAGNOSIS
Item
Aufnahmediagnose
string
C0332133 (UMLS CUI 2011AA)
52870002 (SNOMED CT 2011_0131)
DOCTOR
Item
Behandelnder Arzt
string
C1710470 (UMLS CUI 2011AA)
Admission Date
Item
Aufnahmedatum
date
C1302393 (UMLS CUI 2011AA)
399423000 (SNOMED CT 2011_0131)
MTHU029790 (LOINC Version 232)
FAMILY NOTIFIED
Item
FAMILY NOTIFIED
boolean
BELONGINGS WITH PATIENT
Item
BELONGINGS WITH PATIENT
boolean
MEDICATIONS WITH PATIENT
Item
MEDICATIONS WITH PATIENT
boolean
IV MEDICATIONS WITH PATIENT
Item
IV MEDICATIONS WITH PATIENT
boolean
PENDING LABS
Item
PENDING LABS
string
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)
Respiratory 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)
DATE OF SURGERY
Item
OP-Datum
date
MTHU019327 (LOINC Version 232)
C1628561 (UMLS CUI-1)
CODE STATUS
Item
CODE STATUS
string
DATE CODE STATUS ORDERED
Item
DATE CODE STATUS ORDERED
date
REASON FOR TRANSFER
Item
REASON FOR TRANSFER
string
C1547731 (UMLS CUI 2011AA)
MTHU019076 (LOINC Version 232)
MODE OF TRANSFER
Item
Mode of transfer
string
C1718076 (UMLS CUI 2011AA)
MTHU021155 (LOINC Version 232)
LEVEL OF FUNCTION
Item
Functional Status, Level of function
string
C0598463 (UMLS CUI 2011AA)
MTHU027728 (LOINC Version 232)
Mental Status
Item
Mental Status, Mental State
string
C0278060 (UMLS CUI 2011AA)
36456004 (SNOMED CT 2011_0131)
MTHU001424 (LOINC Version 232)
MTHU117157 (CTCAE 1105E)
Level of Activity
Item
Patient activity
string
C0451369 (UMLS CUI 2011AA)
273688003 (SNOMED CT 2011_0131)
Activities of Daily Living
Item
Aktivitäten des täglichen Lebens (ATL)
string
C0001288 (UMLS CUI 2011AA)
129025006 (SNOMED CT 2011_0131)
DIET
Item
Diät
string
C0012155 (UMLS CUI 2011AA)
41829006 (SNOMED CT 2011_0131)
Tube Feeding via @ with @ strength of @
Item
Tube Feeding via @ with @ strength of @
string
C0041281 (UMLS CUI 2011AA)
61420007 (SNOMED CT 2011_0131)
10053095 (MedDRA 14.1)
Last residual amount was @ CC'S and it was checked at @
Item
Last residual amount was @ CC'S and it was checked at @
string
Item Group
C1411942 (UMLS CUI-1)
IV THERAPY
Item
intravenöse Therapie
string
C1411942 (UMLS CUI 2011AA)
Catheter Size
Item
Katheter-Größe
string
C0449963 (UMLS CUI 2011AA)
260967009 (SNOMED CT 2011_0131)
LOCATION
Item
Lokalisation
string
C0450429 (UMLS CUI 2011AA)
246267002 (SNOMED CT 2011_0131)
IV Fluid
Item
Infusion
string
C1289919 (UMLS CUI 2011AA)
118431008 (SNOMED CT 2011_0131)
10067708 (MedDRA 14.1)
LEFT TO COUNT [ml]
Item
LEFT TO COUNT [ml]
integer
Rate: @ ml/hr
Item
Rate: @ ml/hr
integer
IV Site APPEARANCE
Item
IV Site APPEARANCE
string
CENTRAL LINE PORT
Item
Zentralvenöser Katheter (ZVK)
string
C1145640 (UMLS CUI 2011AA)
52124006 (SNOMED CT 2011_0131)
IV Fluid
Item
Infusion
string
C1289919 (UMLS CUI 2011AA)
118431008 (SNOMED CT 2011_0131)
10067708 (MedDRA 14.1)
TPN/LIPIDS: TPN @ ml/hr and Lipids @ ml/hr
Item
TPN/LIPIDS: TPN @ ml/hr and Lipids @ ml/hr
string
C0030548, C0023779 (UMLS CUI 2011AA)
225372007, 70106000 (SNOMED CT 2011_0131)
10044107 (MedDRA 14.1)
MTHU014331, MTHU003688 (LOINC Version 232)
99.15 (ICD-9-CM Version 2011)
IV Site APPEARANCE
Item
IV Site APPEARANCE
string
SITE CHANGE DUE
Item
SITE CHANGE DUE
date
IV REASSESSMENT
Item
IV REASSESSMENT
string
IV Site APPEARANCE
Item
IV Site APPEARANCE
string
NARRATIVE
Item
NARRATIVE
string
Item Group
C0043250 (UMLS CUI-1)
WOUND CARE
Item
WOUND CARE
string
C0043250 (UMLS CUI 2011AA)
13924000 (SNOMED CT 2011_0131)
10052428 (MedDRA 14.1)
MTHU001326 (LOINC Version 232)
SITE: LAST DRESSING CHANGE
Item
SITE: LAST DRESSING CHANGE
string
Item Group
C0221102 (UMLS CUI-1)
Date of last bowel movement
Item
Date of last bowel movement
date
C0011135 (UMLS CUI 2011AA)
39211005 (SNOMED CT 2011_0131)
Is the patient incontinent of stool?
Item
Is the patient incontinent of stool?
string
C0015732 (UMLS CUI 2011AA)
72042002 (SNOMED CT 2011_0131)
10016092 (MedDRA 14.1)
MTHU013375 (LOINC Version 232)
R15 (ICD-10-CM Version 2010)
787.6 (ICD-9-CM Version 2011)
E10693 (CTCAE 1105E)
Is the patient incontinent of urine?
Item
Is the patient incontinent of urine?
string
C0042024 (UMLS CUI 2011AA)
165232002 (SNOMED CT 2011_0131)
10046543 (MedDRA 14.1)
R32 (ICD-10-CM Version 2010)
788.3 (ICD-9-CM Version 2011)
E13042 (CTCAE 1105E)
Item Group
OXYGEN
Item
Sauerstoff
string
C0030054 (UMLS CUI 2011AA)
24099007 (SNOMED CT 2011_0131)
MTHU002757 (LOINC Version 232)
DRAINS
Item
Drainage
string
C0180499 (UMLS CUI 2011AA)
32712000 (SNOMED CT 2011_0131)
MTHU022515 (LOINC Version 232)
PAIN MANAGEMENT
Item
Schmerztherapie
string
C0002766 (UMLS CUI 2011AA)
278414003 (SNOMED CT 2011_0131)
10056350 (MedDRA 14.1)
MTHU031888 (LOINC Version 232)
MED RT
Item
Atemtherapie
string
C0035239 (UMLS CUI 2011AA)
53950000 (SNOMED CT 2011_0131)
10059828 (MedDRA 14.1)
MTHU015440 (LOINC Version 232)
93.9 (ICD-9-CM Version 2011)
LAST TIME PATIENT WAS MEDICATED
Item
LAST TIME PATIENT WAS MEDICATED
time
ISOLATION
Item
Isolation
string
C0205409 (UMLS CUI 2011AA)
46651001 (SNOMED CT 2011_0131)
TYPE OF ISOLATION
Item
TYPE OF ISOLATION
string
DAILY WEIGHTS
Item
DAILY WEIGHTS
boolean
C1305866 (UMLS CUI 2011AA)
107647005 (SNOMED CT 2011_0131)
10047890 (MedDRA 14.1)
LP18015-5 (LOINC Version 232)
AT RISK FOR FALLS
Item
Sturzgefährdung
boolean
C1268740 (UMLS CUI 2011AA)
129839007 (SNOMED CT 2011_0131)
Z91.81 (ICD-10-CM Version 2010)
V15.88 (ICD-9-CM Version 2011)
AT RISK FOR SKIN BREAKDOWN
Item
AT RISK FOR SKIN BREAKDOWN
string
C0150077 (UMLS CUI 2011AA)
247442005 (SNOMED CT 2011_0131)
10050204 (MedDRA 14.1)
MTHU013438 (LOINC Version 232)
RESTRAINTS
Item
Haltegurte
string
C0337184 (UMLS CUI 2011AA)
57395004 (SNOMED CT 2011_0131)
MTHU032305 (LOINC Version 232)
Date/Time of Restraints order:
Item
Date/Time of Restraints order:
date
SPECIAL PRECAUTIONS
Item
Vorsichtsmaßnahmen
string
C1882442 (UMLS CUI 2011AA)
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