ID

11250

Beschrijving

Form from HIS OpenVistA

Trefwoorden

Versies (2)
  1. 26-02-12 26-02-12 -
  2. 26-06-15 26-06-15 - Martin Dugas
Geüploaded op

26 juni 2015

DOI

Voor een aanvraag inloggen.

Licentie

Creative Commons BY-NC 3.0 Legacy
Model Commentaren :

Hier kunt u commentaar leveren op het model. U kunt de tekstballonnen bij de itemgroepen en items gebruiken om er specifiek commentaar op te geven.

Terug naar het model Commentaren
Itemgroep Commentaren voor :

Item Commentaren voor :

U moet ingelogd zijn om formulieren te downloaden. AUB inloggen of schrijf u gratis in.

TRANSFER ASSESSMENT INTERDISCIPLINARY NOTE

Duits Engels

HIS

1 Formulieren  
  1. StudyEvent: HIS
    1. HIS
Transfer assessment
Beschrijving

Transfer assessment

Aufnahmediagnose
Beschrijving

ADMITTING DIAGNOSIS

Datatype

string

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

DOCTOR

Datatype

string

Alias
UMLS CUI 2011AA
C1710470
Aufnahmedatum
Beschrijving

Admission Date

Datatype

date

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

FAMILY NOTIFIED

Datatype

boolean

BELONGINGS WITH PATIENT
Beschrijving

BELONGINGS WITH PATIENT

Datatype

boolean

MEDICATIONS WITH PATIENT
Beschrijving

MEDICATIONS WITH PATIENT

Datatype

boolean

IV MEDICATIONS WITH PATIENT
Beschrijving

IV MEDICATIONS WITH PATIENT

Datatype

boolean

PENDING LABS
Beschrijving

PENDING LABS

Datatype

string

Temperatur
Beschrijving

Temperature

Datatype

float

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

Pulse Rate

Datatype

integer

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

Respiratory rate

Datatype

integer

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

Blood Pressure

Datatype

integer

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

DATE OF SURGERY

Datatype

date

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

CODE STATUS

Datatype

string

DATE CODE STATUS ORDERED
Beschrijving

DATE CODE STATUS ORDERED

Datatype

date

REASON FOR TRANSFER
Beschrijving

REASON FOR TRANSFER

Datatype

string

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

MODE OF TRANSFER

Datatype

string

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

LEVEL OF FUNCTION

Datatype

string

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

Mental Status

Datatype

string

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

Level of Activity

Datatype

string

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

Activities of Daily Living

Datatype

string

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

DIET

Datatype

string

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

Tube Feeding via @ with @ strength of @

Datatype

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 @
Beschrijving

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

Datatype

string

IV Therapy
Beschrijving

IV Therapy

Alias
UMLS CUI-1
C1411942
intravenöse Therapie
Beschrijving

IV THERAPY

Datatype

string

Alias
UMLS CUI 2011AA
C1411942
Katheter-Größe
Beschrijving

Catheter Size

Datatype

string

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

LOCATION

Datatype

string

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

IV Fluid

Datatype

string

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

LEFT TO COUNT [ml]

Datatype

integer

Rate: @ ml/hr
Beschrijving

Rate: @ ml/hr

Datatype

integer

IV Site APPEARANCE
Beschrijving

IV Site APPEARANCE

Datatype

string

Zentralvenöser Katheter (ZVK)
Beschrijving

CENTRAL LINE PORT

Datatype

string

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

IV Fluid

Datatype

string

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

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

Datatype

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
Beschrijving

IV Site APPEARANCE

Datatype

string

SITE CHANGE DUE
Beschrijving

SITE CHANGE DUE

Datatype

date

IV REASSESSMENT
Beschrijving

IV REASSESSMENT

Datatype

string

IV Site APPEARANCE
Beschrijving

IV Site APPEARANCE

Datatype

string

NARRATIVE
Beschrijving

NARRATIVE

Datatype

string

Wound
Beschrijving

Wound

Alias
UMLS CUI-1
C0043250
WOUND CARE
Beschrijving

WOUND CARE

Datatype

string

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

SITE: LAST DRESSING CHANGE

Datatype

string

ELIMINATION
Beschrijving

ELIMINATION

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

Date of last bowel movement

Datatype

date

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

Is the patient incontinent of stool?

Datatype

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?
Beschrijving

Is the patient incontinent of urine?

Datatype

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
Beschrijving

OTHER CARE

Sauerstoff
Beschrijving

OXYGEN

Datatype

string

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

DRAINS

Datatype

string

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

PAIN MANAGEMENT

Datatype

string

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

MED RT

Datatype

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
Beschrijving

LAST TIME PATIENT WAS MEDICATED

Datatype

time

Isolation
Beschrijving

ISOLATION

Datatype

string

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

TYPE OF ISOLATION

Datatype

string

DAILY WEIGHTS
Beschrijving

DAILY WEIGHTS

Datatype

boolean

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

AT RISK FOR FALLS

Datatype

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
Beschrijving

AT RISK FOR SKIN BREAKDOWN

Datatype

string

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

RESTRAINTS

Datatype

string

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

Date/Time of Restraints order:

Datatype

date

Vorsichtsmaßnahmen
Beschrijving

SPECIAL PRECAUTIONS

Datatype

string

Alias
UMLS CUI 2011AA
C1882442
Terug naar het begin van de pagina

Similar models

HIS

1 Formulieren
  1. StudyEvent: HIS
    1. HIS
Name
Type
Description | Question | Decode (Coded Value)
Datatype
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)
Terug naar het begin van de pagina 

Contact

Gebruik dit formulier voor feedback, vragen en verbeteringsvoorstellen.

Velden gemarkeerd met een * zijn verplicht.

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