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11669
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Form from HIS OpenVistA
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- 25-02-12 25-02-12 -
- 25-07-15 25-07-15 - Martin Dugas
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25 juli 2015
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Creative Commons BY-NC 3.0 Legacy
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SPEECH THERAPY CONSULT RESULTS
SPEECH THERAPY CONSULT RESULTS
- StudyEvent: HIS
Similar models
SPEECH THERAPY CONSULT RESULTS
- StudyEvent: HIS
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Medical Diagnosis
Item
Diagnose
string
Treatment Diagnosis
Item
Treatment Diagnosis
string
Reason for referral
Item
Grund für Überweisung
string
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
MEDICAL HISTORY/ONSET
Item
Anamnese der aktuellen Erkrankung
string
Age
Item
Alter
integer
397669002 (SNOMED CT 2011_0131)
C0001779 (UMLS CUI-1)
C0001779 (UMLS CUI-1)
Item
Geschlecht
text
CL Item
(M)
CL Item
(F)
ETHNICITY
Item
Ethnizität
string
ADMITTED WITH
Item
ADMITTED WITH
string
DATE
Item
Aufnahmedatum
date
PREVIOUS MEDICAL HISTORY (SYMPTOMS/DIAGNOSIS)
Item
Anamnese
string
S.T. ORDER
Item
S.T. ORDER
string
SURGERY
Item
Frühere Operationen
string
C0455610 (UMLS CUI 2011AA)
161615003 (SNOMED CT 2011_0131)
161615003 (SNOMED CT 2011_0131)
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)
191044006 (SNOMED CT 2011_0131)
DNR
Item
keine Reanimation
boolean
C0582114 (UMLS CUI 2011AA)
304253006 (SNOMED CT 2011_0131)
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)
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)
10029366 (MedDRA 14.1)
E12198 (CTCAE 1105E)
Other
Item
Other
string
FUNCTIONAL STATUS BEFORE ONSET
Item
FUNCTIONAL STATUS BEFORE ONSET
string
Orientation
Item
Orientierung
string
C0029266 (UMLS CUI 2011AA)
43173001 (SNOMED CT 2011_0131)
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)
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)
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)
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)
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)
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
DENTURES
Item
Zahnprothesen
string
C0011394 (UMLS CUI 2011AA)
8060009 (SNOMED CT 2011_0131)
8060009 (SNOMED CT 2011_0131)
REFLEXES
Item
Reflexe
string
C0034929 (UMLS CUI 2011AA)
87572000 (SNOMED CT 2011_0131)
87572000 (SNOMED CT 2011_0131)
VOICE QUALITY
Item
Voice quality, vocal quality
string
C0042943 (UMLS CUI 2011AA)
58102000 (SNOMED CT 2011_0131)
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)
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)
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
PROGNOSIS
Item
Prognose
string
C0033325 (UMLS CUI 2011AA)
20481000 (SNOMED CT 2011_0131)
20481000 (SNOMED CT 2011_0131)
S.T. PLAN
Item
S.T. PLAN
string
ESTIMATED DURATION
Item
Zeitdauer
string
FREQUENCY
Item
Häufigkeit
string
C0439603 (UMLS CUI 2011AA)
260864003 (SNOMED CT 2011_0131)
260864003 (SNOMED CT 2011_0131)