ID

11669

Beschreibung

Form from HIS OpenVistA

Stichworte

  1. 25.02.12 25.02.12 -
  2. 25.07.15 25.07.15 - Martin Dugas
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25. Juli 2015

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SPEECH THERAPY CONSULT RESULTS

SPEECH THERAPY CONSULT RESULTS

General Info
Beschreibung

General Info

Diagnose
Beschreibung

Medical Diagnosis

Datentyp

string

Alias
UMLS CUI 2011AA
C0011900
SNOMED CT 2011_0131
439401001
LOINC Version 232
MTHU008876
Treatment Diagnosis
Beschreibung

Treatment Diagnosis

Datentyp

string

Grund für Überweisung
Beschreibung

Reason for referral

Datentyp

string

Alias
UMLS CUI 2011AA
C1547731
LOINC Version 232
MTHU019076
Prior level of function/Previous S.T. treatments
Beschreibung

Prior level of function/Previous S.T. treatments

Datentyp

string

Severity Rating Scale (1. Within Normal Limits| 2. Mild| 3. Moderate| 4. Severe)
Beschreibung

Severity Rating Scale

Datentyp

string

Alias
UMLS CUI 2011AA
CL425496
SPEECH-LANGUAGE TESTING
Beschreibung

SPEECH-LANGUAGE TESTING

AUDITORY COMPREHENSION
Beschreibung

AUDITORY COMPREHENSION

Datentyp

string

READING COMPREHENSION
Beschreibung

READING COMPREHENSION

Datentyp

string

VERBAL EXPRESSION
Beschreibung

VERBAL EXPRESSION

Datentyp

string

WRITTEN EXPRESSION
Beschreibung

WRITTEN EXPRESSION

Datentyp

string

PRAGMATICS
Beschreibung

PRAGMATICS

Datentyp

string

Kognition
Beschreibung

COGNITION

Datentyp

string

Alias
UMLS CUI 2011AA
C0009240
SUMMARY
Beschreibung

SUMMARY

Datentyp

string

Severity Rating Scale (1. Within Normal Limits| 2. Mild| 3. Moderate| 4. Severe)
Beschreibung

Severity Rating Scale

Datentyp

string

Alias
UMLS CUI 2011AA
CL425496
SPEECH THERAPY CONSULT RESULTS
Beschreibung

SPEECH THERAPY CONSULT RESULTS

Pflegeplanung
Beschreibung

PLAN OF CARE

Datentyp

string

Alias
UMLS CUI 2011AA
C0028683
Diagnose
Beschreibung

DIAGNOSIS

Datentyp

string

Alias
UMLS CUI 2011AA
C0011900
SNOMED CT 2011_0131
439401001
LOINC Version 232
MTHU008876
Anamnese der aktuellen Erkrankung
Beschreibung

MEDICAL HISTORY/ONSET

Datentyp

string

Alias
UMLS CUI 2011AA
C0262512
LOINC Version 232
MTHU001399
Alter
Beschreibung

Age

Datentyp

integer

Maßeinheiten
  • years
Alias
SNOMED CT 2011_0131
397669002
UMLS CUI-1
C0001779
years
Geschlecht
Beschreibung

Gender

Datentyp

text

Alias
SNOMED CT 2011_0131
263495000
LOINC Version 232
MTHU002975
UMLS CUI-1
C0079399
Ethnizität
Beschreibung

ETHNICITY

Datentyp

string

Alias
UMLS CUI 2011AA
C0015031
SNOMED CT 2011_0131
397731000
LOINC Version 232
MTHU010275
ADMITTED WITH
Beschreibung

ADMITTED WITH

Datentyp

string

Aufnahmedatum
Beschreibung

DATE

Datentyp

date

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

PREVIOUS MEDICAL HISTORY (SYMPTOMS/DIAGNOSIS)

Datentyp

string

Alias
UMLS CUI 2011AA
C0262926
SNOMED CT 2011_0131
417662000
LOINC Version 232
MTHU027722
S.T. ORDER
Beschreibung

S.T. ORDER

Datentyp

string

Frühere Operationen
Beschreibung

SURGERY

Datentyp

string

Alias
UMLS CUI 2011AA
C0455610
SNOMED CT 2011_0131
161615003
PRECAUTIONS
Beschreibung

PRECAUTIONS

Airborne
Beschreibung

Airborne

Datentyp

boolean

Cardiac
Beschreibung

Cardiac

Datentyp

boolean

Alias
UMLS CUI 2011AA
C1522601
Contact
Beschreibung

Contact

Datentyp

boolean

Diabetic
Beschreibung

Diabetic

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0011849
SNOMED CT 2011_0131
191044006
keine Reanimation
Beschreibung

DNR

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0582114
SNOMED CT 2011_0131
304253006
Sturzgefährdung
Beschreibung

Fall Risk

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
Neutropenie
Beschreibung

Neutropenic

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0853697
MedDRA 14.1
10029366
CTCAE 1105E
E12198
Other
Beschreibung

Other

Datentyp

string

FUNCTIONAL STATUS BEFORE ONSET
Beschreibung

FUNCTIONAL STATUS BEFORE ONSET

FUNCTIONAL STATUS BEFORE ONSET
Beschreibung

FUNCTIONAL STATUS BEFORE ONSET

Datentyp

string

Alias
UMLS CUI 2011AA
C0598463
LOINC Version 232
MTHU027728
SUBJECTIVE
Beschreibung

SUBJECTIVE

Orientierung
Beschreibung

Orientation

Datentyp

string

Alias
UMLS CUI 2011AA
C0029266
SNOMED CT 2011_0131
43173001
Schmerz
Beschreibung

PAIN: LEVEL

Datentyp

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
OBJECTIVE
Beschreibung

OBJECTIVE

SPEECH PRODUCTION
Beschreibung

SPEECH PRODUCTION

Datentyp

string

SPEECH INTELLIGIBILITY
Beschreibung

SPEECH INTELLIGIBILITY

Datentyp

string

Alias
UMLS CUI 2011AA
C0037824
ORAL MOTOR FUNCTION
Beschreibung

ORAL MOTOR FUNCTION

Datentyp

string

language ability, verbal ability
Beschreibung

LANGUAGE SKILLS

Datentyp

string

Alias
UMLS CUI 2011AA
C1145677
Broca-Aphasie, motorische Aphasie
Beschreibung

EXPRESSIVE APHASIA

Datentyp

string

Alias
UMLS CUI 2011AA
C0917814
SNOMED CT 2011_0131
229665008
MedDRA 14.1
10015713
Wernicke-Aphasie, sensorische Aphasie
Beschreibung

RECEPTIVE APHASIA

Datentyp

string

Alias
UMLS CUI 2011AA
C0454578
SNOMED CT 2011_0131
329676006
MedDRA 14.1
10038008
Aphasie
Beschreibung

MIXED EXPRESSIVE & RECEPTIVE APHASIA

Datentyp

string

Alias
UMLS CUI 2011AA
C0003537
SNOMED CT 2011_0131
87486003
MedDRA 14.1
10002948
LOINC Version 232
MTHU020799
ICD-10-CM Version 2010
R47.01
ICD-9-CM Version 2011
784.3
Stimme
Beschreibung

VOICE

Datentyp

string

Alias
UMLS CUI 2011AA
C0042939
BEDSIDE DYSPHAGIA EVALUATION
Beschreibung

BEDSIDE DYSPHAGIA EVALUATION

ORAL MOTOR FUNCTION
Beschreibung

ORAL MOTOR FUNCTION

Datentyp

string

Gebiss
Beschreibung

DENTITION

Datentyp

string

Alias
UMLS CUI 2011AA
C0011443
SNOMED CT 2011_0131
245543004
LOINC Version 232
MTHU014794
Zahnprothesen
Beschreibung

DENTURES

Datentyp

string

Alias
UMLS CUI 2011AA
C0011394
SNOMED CT 2011_0131
8060009
Reflexe
Beschreibung

REFLEXES

Datentyp

string

Alias
UMLS CUI 2011AA
C0034929
SNOMED CT 2011_0131
87572000
Voice quality, vocal quality
Beschreibung

VOICE QUALITY

Datentyp

string

Alias
UMLS CUI 2011AA
C0042943
SNOMED CT 2011_0131
58102000
Husten
Beschreibung

COUGH

Datentyp

string

Alias
UMLS CUI 2011AA
C0010200
SNOMED CT 2011_0131
49727002
MedDRA 14.1
10011224
ICD-10-CM Version 2010
R05
ICD-9-CM Version 2011
786.2
CTCAE 1105E
E13364
TRIAL SWALLOW
Beschreibung

TRIAL SWALLOW

Datentyp

text

Palpation
Beschreibung

PALPATION

Datentyp

string

Alias
UMLS CUI 2011AA
C0030247
SNOMED CT 2011_0131
113011001
Untersuchung
Beschreibung

ASSESSMENT

Datentyp

string

Alias
UMLS CUI 2011AA
C1516048
Speech Therapy GOALS
Beschreibung

Speech Therapy GOALS

Patient will increase speed and accuracy of 4/10 exercises.
Beschreibung

Patient will increase speed and accuracy of 4/10 exercises.

Datentyp

string

Patient will practice slow,exaggerated speech with an accuracy of
Beschreibung

Patient will practice slow,exaggerated speech with an accuracy of

Datentyp

string

Patient will vary stress and inotation if words and sentences with an accuracy of
Beschreibung

Patient will vary stress and inotation if words and sentences with an accuracy of

Datentyp

string

Patient will perform confrontational naming with
Beschreibung

Patient will perform confrontational naming with

Datentyp

string

Patient will perform word retrieval tasks with
Beschreibung

Patient will perform word retrieval tasks with

Datentyp

string

Patient will describe sequence of activities using complete sentences with
Beschreibung

Patient will describe sequence of activities using complete sentences with

Datentyp

string

Patient will be able to carry on an appropriate conversation with
Beschreibung

Patient will be able to carry on an appropriate conversation with

Datentyp

string

Patient will follow 1 to 2 stop commands with
Beschreibung

Patient will follow 1 to 2 stop commands with

Datentyp

string

Patient will demonstrate function of objects with
Beschreibung

Patient will demonstrate function of objects with

Datentyp

string

Patient will match pictures to objects with
Beschreibung

Patient will match pictures to objects with

Datentyp

string

Patient will practice diaphragmatic breathing with
Beschreibung

Patient will practice diaphragmatic breathing with

Datentyp

string

Patient will practice relaxation exercises with
Beschreibung

Patient will practice relaxation exercises with

Datentyp

string

PROGNOSIS
Beschreibung

PROGNOSIS

Alias
UMLS CUI-1
C0033325
Prognose
Beschreibung

PROGNOSIS

Datentyp

string

Alias
UMLS CUI 2011AA
C0033325
SNOMED CT 2011_0131
20481000
S.T. PLAN
Beschreibung

S.T. PLAN

S.T. PLAN
Beschreibung

S.T. PLAN

Datentyp

string

Zeitdauer
Beschreibung

ESTIMATED DURATION

Datentyp

string

Alias
UMLS CUI 2011AA
C0449238
SNOMED CT 2011_0131
103335007
LOINC Version 232
MTHU001938
Häufigkeit
Beschreibung

FREQUENCY

Datentyp

string

Alias
UMLS CUI 2011AA
C0439603
SNOMED CT 2011_0131
260864003

Ähnliche Modelle

SPEECH THERAPY CONSULT RESULTS

Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
Medical Diagnosis
Item
Diagnose
string
C0011900 (UMLS CUI 2011AA)
439401001 (SNOMED CT 2011_0131)
MTHU008876 (LOINC Version 232)
Treatment Diagnosis
Item
Treatment Diagnosis
string
Reason for referral
Item
Grund für Überweisung
string
C1547731 (UMLS CUI 2011AA)
MTHU019076 (LOINC Version 232)
Prior level of function/Previous S.T. treatments
Item
Prior level of function/Previous S.T. treatments
string
Severity Rating Scale
Item
Severity Rating Scale (1. Within Normal Limits| 2. Mild| 3. Moderate| 4. Severe)
string
CL425496 (UMLS CUI 2011AA)
AUDITORY COMPREHENSION
Item
AUDITORY COMPREHENSION
string
READING COMPREHENSION
Item
READING COMPREHENSION
string
VERBAL EXPRESSION
Item
VERBAL EXPRESSION
string
WRITTEN EXPRESSION
Item
WRITTEN EXPRESSION
string
PRAGMATICS
Item
PRAGMATICS
string
COGNITION
Item
Kognition
string
C0009240 (UMLS CUI 2011AA)
SUMMARY
Item
SUMMARY
string
Severity Rating Scale
Item
Severity Rating Scale (1. Within Normal Limits| 2. Mild| 3. Moderate| 4. Severe)
string
CL425496 (UMLS CUI 2011AA)
PLAN OF CARE
Item
Pflegeplanung
string
C0028683 (UMLS CUI 2011AA)
DIAGNOSIS
Item
Diagnose
string
C0011900 (UMLS CUI 2011AA)
439401001 (SNOMED CT 2011_0131)
MTHU008876 (LOINC Version 232)
MEDICAL HISTORY/ONSET
Item
Anamnese der aktuellen Erkrankung
string
C0262512 (UMLS CUI 2011AA)
MTHU001399 (LOINC Version 232)
Age
Item
Alter
integer
397669002 (SNOMED CT 2011_0131)
C0001779 (UMLS CUI-1)
Item
Geschlecht
text
263495000 (SNOMED CT 2011_0131)
MTHU002975 (LOINC Version 232)
C0079399 (UMLS CUI-1)
Code List
Geschlecht
CL Item
 (M)
CL Item
 (F)
ETHNICITY
Item
Ethnizität
string
C0015031 (UMLS CUI 2011AA)
397731000 (SNOMED CT 2011_0131)
MTHU010275 (LOINC Version 232)
ADMITTED WITH
Item
ADMITTED WITH
string
DATE
Item
Aufnahmedatum
date
C1302393 (UMLS CUI 2011AA)
399423000 (SNOMED CT 2011_0131)
MTHU029790 (LOINC Version 232)
PREVIOUS MEDICAL HISTORY (SYMPTOMS/DIAGNOSIS)
Item
Anamnese
string
C0262926 (UMLS CUI 2011AA)
417662000 (SNOMED CT 2011_0131)
MTHU027722 (LOINC Version 232)
S.T. ORDER
Item
S.T. ORDER
string
SURGERY
Item
Frühere Operationen
string
C0455610 (UMLS CUI 2011AA)
161615003 (SNOMED CT 2011_0131)
Item Group
Airborne
Item
Airborne
boolean
Cardiac
Item
Cardiac
boolean
C1522601 (UMLS CUI 2011AA)
Contact
Item
Contact
boolean
Diabetic
Item
Diabetic
boolean
C0011849 (UMLS CUI 2011AA)
191044006 (SNOMED CT 2011_0131)
DNR
Item
keine Reanimation
boolean
C0582114 (UMLS CUI 2011AA)
304253006 (SNOMED CT 2011_0131)
Fall Risk
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)
Neutropenic
Item
Neutropenie
boolean
C0853697 (UMLS CUI 2011AA)
10029366 (MedDRA 14.1)
E12198 (CTCAE 1105E)
Other
Item
Other
string
FUNCTIONAL STATUS BEFORE ONSET
Item
FUNCTIONAL STATUS BEFORE ONSET
string
C0598463 (UMLS CUI 2011AA)
MTHU027728 (LOINC Version 232)
Item Group
Orientation
Item
Orientierung
string
C0029266 (UMLS CUI 2011AA)
43173001 (SNOMED CT 2011_0131)
PAIN: LEVEL
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)
Item Group
SPEECH PRODUCTION
Item
SPEECH PRODUCTION
string
SPEECH INTELLIGIBILITY
Item
SPEECH INTELLIGIBILITY
string
C0037824 (UMLS CUI 2011AA)
ORAL MOTOR FUNCTION
Item
ORAL MOTOR FUNCTION
string
LANGUAGE SKILLS
Item
language ability, verbal ability
string
C1145677 (UMLS CUI 2011AA)
EXPRESSIVE APHASIA
Item
Broca-Aphasie, motorische Aphasie
string
C0917814 (UMLS CUI 2011AA)
229665008 (SNOMED CT 2011_0131)
10015713 (MedDRA 14.1)
RECEPTIVE APHASIA
Item
Wernicke-Aphasie, sensorische Aphasie
string
C0454578 (UMLS CUI 2011AA)
329676006 (SNOMED CT 2011_0131)
10038008 (MedDRA 14.1)
MIXED EXPRESSIVE & RECEPTIVE APHASIA
Item
Aphasie
string
C0003537 (UMLS CUI 2011AA)
87486003 (SNOMED CT 2011_0131)
10002948 (MedDRA 14.1)
MTHU020799 (LOINC Version 232)
R47.01 (ICD-10-CM Version 2010)
784.3 (ICD-9-CM Version 2011)
VOICE
Item
Stimme
string
C0042939 (UMLS CUI 2011AA)
ORAL MOTOR FUNCTION
Item
ORAL MOTOR FUNCTION
string
DENTITION
Item
Gebiss
string
C0011443 (UMLS CUI 2011AA)
245543004 (SNOMED CT 2011_0131)
MTHU014794 (LOINC Version 232)
DENTURES
Item
Zahnprothesen
string
C0011394 (UMLS CUI 2011AA)
8060009 (SNOMED CT 2011_0131)
REFLEXES
Item
Reflexe
string
C0034929 (UMLS CUI 2011AA)
87572000 (SNOMED CT 2011_0131)
VOICE QUALITY
Item
Voice quality, vocal quality
string
C0042943 (UMLS CUI 2011AA)
58102000 (SNOMED CT 2011_0131)
COUGH
Item
Husten
string
C0010200 (UMLS CUI 2011AA)
49727002 (SNOMED CT 2011_0131)
10011224 (MedDRA 14.1)
R05 (ICD-10-CM Version 2010)
786.2 (ICD-9-CM Version 2011)
E13364 (CTCAE 1105E)
TRIAL SWALLOW
Item
TRIAL SWALLOW
text
PALPATION
Item
Palpation
string
C0030247 (UMLS CUI 2011AA)
113011001 (SNOMED CT 2011_0131)
ASSESSMENT
Item
Untersuchung
string
C1516048 (UMLS CUI 2011AA)
Patient will increase speed and accuracy of 4/10 exercises.
Item
Patient will increase speed and accuracy of 4/10 exercises.
string
Patient will practice slow,exaggerated speech with an accuracy of
Item
Patient will practice slow,exaggerated speech with an accuracy of
string
Patient will vary stress and inotation if words and sentences with an accuracy of
Item
Patient will vary stress and inotation if words and sentences with an accuracy of
string
Patient will perform confrontational naming with
Item
Patient will perform confrontational naming with
string
Patient will perform word retrieval tasks with
Item
Patient will perform word retrieval tasks with
string
Patient will describe sequence of activities using complete sentences with
Item
Patient will describe sequence of activities using complete sentences with
string
Patient will be able to carry on an appropriate conversation with
Item
Patient will be able to carry on an appropriate conversation with
string
Patient will follow 1 to 2 stop commands with
Item
Patient will follow 1 to 2 stop commands with
string
Patient will demonstrate function of objects with
Item
Patient will demonstrate function of objects with
string
Patient will match pictures to objects with
Item
Patient will match pictures to objects with
string
Patient will practice diaphragmatic breathing with
Item
Patient will practice diaphragmatic breathing with
string
Patient will practice relaxation exercises with
Item
Patient will practice relaxation exercises with
string
Item Group
C0033325 (UMLS CUI-1)
PROGNOSIS
Item
Prognose
string
C0033325 (UMLS CUI 2011AA)
20481000 (SNOMED CT 2011_0131)
Item Group
S.T. PLAN
Item
S.T. PLAN
string
ESTIMATED DURATION
Item
Zeitdauer
string
C0449238 (UMLS CUI 2011AA)
103335007 (SNOMED CT 2011_0131)
MTHU001938 (LOINC Version 232)
FREQUENCY
Item
Häufigkeit
string
C0439603 (UMLS CUI 2011AA)
260864003 (SNOMED CT 2011_0131)

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