ID

22547

Descripción

Form from HIS OpenVistA

Palabras clave

Versiones (2)
  1. 25/2/12 25/2/12 -
  2. 7/6/17 7/6/17 - Martin Dugas
Subido en

7 de junio de 2017

DOI

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Licencia

Creative Commons BY-NC 3.0
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SHORT STAY RECORD-PAIN MANAGEMENT

Alemán Inglés

HIS

1 formularios  
  1. StudyEvent: HIS
    1. HIS
SHORT STAY RECORD-PAIN MANAGEMENT
Descripción

SHORT STAY RECORD-PAIN MANAGEMENT

Alias
UMLS CUI-1
C0002766
Chief complaint (CC)
Descripción

CHIEF COMPLAINT

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0277786
SNOMED CT 2011_0131
33962009
LOINC Version 232
MTHU001077
History of present illness
Descripción

HISTORY OF PRESENT ILLNESS

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0262512
LOINC Version 232
MTHU001399
Past medical history
Descripción

PAST MEDICAL HISTORY

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0262926
SNOMED CT 2011_0131
417662000
LOINC Version 232
MTHU027722
Prior Surgery, History of (H/O) surgery, Past surgical history
Descripción

PRIOR SURGERIES

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0455610
SNOMED CT 2011_0131
161615003
Hypersensitivity
Descripción

ALLERGIES

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0020517
SNOMED CT 2011_0131
257550005
ICD-10-CM Version 2010
T78.40
current medication list, active medication
Descripción

CURRENT MEDICATIONS

Tipo de datos

string

Alias
UMLS CUI 2011AA
C1553892
Review of systems
Descripción

REVIEW OF SYSTEMS

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0489633
SNOMED CT 2011_0131
415300000
LOINC Version 232
MTHU001422
Family history (FH) of
Descripción

FAMILY HISTORY

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0241889
SNOMED CT 2011_0131
57177007
Social and personal history, Social and personal circumstances
Descripción

SOCIAL HISTORY

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0424945
SNOMED CT 2011_0131
160476009
LOINC Version 232
MTHU014081
Physical Exam
Descripción

Physical Exam

Alias
UMLS CUI-1
C0031809
general appearance
Descripción

GENERAL APPEARANCE

Tipo de datos

string

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

HEENT

Tipo de datos

string

Alias
UMLS CUI 2011AA
C1512338
Neck, Collum, Cervical
Descripción

NECK

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0027530
SNOMED CT 2011_0131
45048000
LOINC Version 232
MTHU002688
Chest, Thorax
Descripción

CHEST

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0817096
SNOMED CT 2011_0131
51185008
Mammary region
Descripción

BREAST

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0006141
SNOMED CT 2011_0131
76752008
LOINC Version 232
MTHU011382
Heart
Descripción

HEART

Tipo de datos

string

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

ABDOMEN

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0000726
SNOMED CT 2011_0131
113345001
LOINC Version 232
MTHU001425
lymph node
Descripción

LYMPH NODES

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0024204
SNOMED CT 2011_0131
59441001
LOINC Version 232
MTHU015050
GENITALIA/RECTAL
Descripción

GENITALIA/RECTAL

Tipo de datos

text

Alias
SNOMED CT 2011_0131
255582007
LOINC Version 232
MTHU002681
UMLS CUI [1,1]
C0017420
UMLS CUI [1,2]
C0205052
Extremities, Limb structure
Descripción

EXTREMITIES

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0015385
SNOMED CT 2011_0131
66019005
LOINC Version 232
MTHU001429
Integument
Descripción

SKIN

Tipo de datos

string

Alias
UMLS CUI 2011AA
C1123023
SNOMED CT 2011_0131
39937001
LOINC Version 232
MTHU001414
Neurologic system, Nervous system, Nervous system structure
Descripción

NEUROLOGICAL

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0027763
SNOMED CT 2011_0131
25087005
LOINC Version 232
MTHU001437
ADMITTING DIAGNOSIS (AD)
Descripción

ADMITTING DIAGNOSIS

Tipo de datos

string

Alias
UMLS CUI 2011AA
C0332133
SNOMED CT 2011_0131
52870002
PLAN: Surgery
Descripción

PLAN: Surgery

Tipo de datos

boolean

Alias
UMLS CUI 2011AA
C1301732
SNOMED CT 2011_0131
397943006
Finding of American Society of Anesthesiologists physical status classification
Descripción

ASA SCORE

Tipo de datos

string

Alias
UMLS CUI 2011AA
C1531480
SNOMED CT 2011_0131
413347006
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Similar models

HIS

1 formularios
  1. StudyEvent: HIS
    1. HIS
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
Alias
Item Group
SHORT STAY RECORD-PAIN MANAGEMENT
C0002766 (UMLS CUI-1)
CHIEF COMPLAINT
Item
Chief complaint (CC)
string
C0277786 (UMLS CUI 2011AA)
33962009 (SNOMED CT 2011_0131)
MTHU001077 (LOINC Version 232)
HISTORY OF PRESENT ILLNESS
Item
History of present illness
string
C0262512 (UMLS CUI 2011AA)
MTHU001399 (LOINC Version 232)
PAST MEDICAL HISTORY
Item
Past medical history
string
C0262926 (UMLS CUI 2011AA)
417662000 (SNOMED CT 2011_0131)
MTHU027722 (LOINC Version 232)
PRIOR SURGERIES
Item
Prior Surgery, History of (H/O) surgery, Past surgical history
string
C0455610 (UMLS CUI 2011AA)
161615003 (SNOMED CT 2011_0131)
ALLERGIES
Item
Hypersensitivity
string
C0020517 (UMLS CUI 2011AA)
257550005 (SNOMED CT 2011_0131)
T78.40 (ICD-10-CM Version 2010)
CURRENT MEDICATIONS
Item
current medication list, active medication
string
C1553892 (UMLS CUI 2011AA)
REVIEW OF SYSTEMS
Item
Review of systems
string
C0489633 (UMLS CUI 2011AA)
415300000 (SNOMED CT 2011_0131)
MTHU001422 (LOINC Version 232)
FAMILY HISTORY
Item
Family history (FH) of
string
C0241889 (UMLS CUI 2011AA)
57177007 (SNOMED CT 2011_0131)
SOCIAL HISTORY
Item
Social and personal history, Social and personal circumstances
string
C0424945 (UMLS CUI 2011AA)
160476009 (SNOMED CT 2011_0131)
MTHU014081 (LOINC Version 232)
Item Group
Physical Exam
C0031809 (UMLS CUI-1)
GENERAL APPEARANCE
Item
general appearance
string
C1148438 (UMLS CUI 2011AA)
MTHU015040 (LOINC Version 232)
HEENT
Item
Head, Ears, Eyes, Nose and Throat
string
C1512338 (UMLS CUI 2011AA)
NECK
Item
Neck, Collum, Cervical
string
C0027530 (UMLS CUI 2011AA)
45048000 (SNOMED CT 2011_0131)
MTHU002688 (LOINC Version 232)
CHEST
Item
Chest, Thorax
string
C0817096 (UMLS CUI 2011AA)
51185008 (SNOMED CT 2011_0131)
BREAST
Item
Mammary region
string
C0006141 (UMLS CUI 2011AA)
76752008 (SNOMED CT 2011_0131)
MTHU011382 (LOINC Version 232)
HEART
Item
Heart
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
lymph node
string
C0024204 (UMLS CUI 2011AA)
59441001 (SNOMED CT 2011_0131)
MTHU015050 (LOINC Version 232)
GENITALIA/RECTAL
Item
GENITALIA/RECTAL
text
255582007 (SNOMED CT 2011_0131)
MTHU002681 (LOINC Version 232)
C0017420 (UMLS CUI [1,1])
C0205052 (UMLS CUI [1,2])
EXTREMITIES
Item
Extremities, Limb structure
string
C0015385 (UMLS CUI 2011AA)
66019005 (SNOMED CT 2011_0131)
MTHU001429 (LOINC Version 232)
SKIN
Item
Integument
string
C1123023 (UMLS CUI 2011AA)
39937001 (SNOMED CT 2011_0131)
MTHU001414 (LOINC Version 232)
NEUROLOGICAL
Item
Neurologic system, Nervous system, Nervous system structure
string
C0027763 (UMLS CUI 2011AA)
25087005 (SNOMED CT 2011_0131)
MTHU001437 (LOINC Version 232)
ADMITTING DIAGNOSIS
Item
ADMITTING DIAGNOSIS (AD)
string
C0332133 (UMLS CUI 2011AA)
52870002 (SNOMED CT 2011_0131)
PLAN: Surgery
Item
PLAN: Surgery
boolean
C1301732 (UMLS CUI 2011AA)
397943006 (SNOMED CT 2011_0131)
ASA SCORE
Item
Finding of American Society of Anesthesiologists physical status classification
string
C1531480 (UMLS CUI 2011AA)
413347006 (SNOMED CT 2011_0131)
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