ID

22547

Beschrijving

Form from HIS OpenVistA

Trefwoorden

Versies (2)
  1. 25-02-12 25-02-12 -
  2. 07-06-17 07-06-17 - Martin Dugas
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7 juni 2017

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

Duits Engels

HIS

1 Formulieren  
  1. StudyEvent: HIS
    1. HIS
SHORT STAY RECORD-PAIN MANAGEMENT
Beschrijving

SHORT STAY RECORD-PAIN MANAGEMENT

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

CHIEF COMPLAINT

Datatype

string

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

HISTORY OF PRESENT ILLNESS

Datatype

string

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

PAST MEDICAL HISTORY

Datatype

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
Beschrijving

PRIOR SURGERIES

Datatype

string

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

ALLERGIES

Datatype

string

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

CURRENT MEDICATIONS

Datatype

string

Alias
UMLS CUI 2011AA
C1553892
Review of systems
Beschrijving

REVIEW OF SYSTEMS

Datatype

string

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

FAMILY HISTORY

Datatype

string

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

SOCIAL HISTORY

Datatype

string

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

Physical Exam

Alias
UMLS CUI-1
C0031809
general appearance
Beschrijving

GENERAL APPEARANCE

Datatype

string

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

HEENT

Datatype

string

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

NECK

Datatype

string

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

CHEST

Datatype

string

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

BREAST

Datatype

string

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

HEART

Datatype

string

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

ABDOMEN

Datatype

string

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

LYMPH NODES

Datatype

string

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

GENITALIA/RECTAL

Datatype

text

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

EXTREMITIES

Datatype

string

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

SKIN

Datatype

string

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

NEUROLOGICAL

Datatype

string

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

ADMITTING DIAGNOSIS

Datatype

string

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

PLAN: Surgery

Datatype

boolean

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

ASA SCORE

Datatype

string

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

HIS

1 Formulieren
  1. StudyEvent: HIS
    1. HIS
Name
Type
Description | Question | Decode (Coded Value)
Datatype
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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