ID

22558

Description

Form from HIS OpenVista

Mots-clés

  1. 09/03/2012 09/03/2012 -
  2. 08/06/2017 08/06/2017 - Martin Dugas
Téléchargé le

8 juin 2017

DOI

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Licence

Creative Commons BY-NC 3.0

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NURSING ASSESSMENT (adult)

  1. StudyEvent: HIS
    1. HIS
Adult Nursing Assessment
Description

Adult Nursing Assessment

Alias
UMLS CUI-1
C0028680
see initial Admission Assessment
Description

initial assessment

Type de données

boolean

Alias
UMLS CUI [1]
C0150637
DONE ON
Description

assessment date

Type de données

date

Alias
UMLS CUI [1]
C2985720
ADMISSION TEXT
Description

ADMISSION

Type de données

text

Alias
UMLS CUI [1]
C0030673
POST OP DAY
Description

postoperative day

Type de données

integer

Alias
UMLS CUI [1]
C0032790
Neuro / Psychosocial
Description

Neuro / Psychosocial

Alias
UMLS CUI-1
C0746866
Normal Baseline: Alert, responsive to stimuli, sensation intact, speech clear and appropriate, PERRLA, hand grips equal, can follow directions, oriented X4, cooperative with treatment plan, hygiene and grooming adequate, maintains eye contact, poses no danger to self or to others, normal affect.
Description

Neurological examination normal

Type de données

boolean

Alias
UMLS CUI [1]
C1112287
Narrative: Abnormal Findings
Description

Abnormal Findings

Type de données

text

Alias
UMLS CUI [1]
C1704258
GLASGOW COMA SCALE ADULT
Description

GLASGOW COMA SCALE ADULT

Alias
UMLS CUI-1
C1271007
EYES OPEN
Description

Eyes open

Type de données

integer

Alias
UMLS CUI [1]
C3648956
BEST VERBAL RESPONSE
Description

BEST VERBAL RESPONSE

Type de données

integer

Alias
UMLS CUI [1]
C3648957
BEST MOTOR RESPONSE
Description

BEST MOTOR RESPONSE

Type de données

integer

Alias
UMLS CUI [1]
C3648958
GLASCOW COMA SCALE SCORE ADULT
Description

GLASCOW COMA SCALE SCORE

Type de données

integer

Alias
UMLS CUI [1]
C1271007
Pupillen
Description

Pupillen

Alias
UMLS CUI-1
C0034121
Right Size [mm]
Description

Right Pupil Size

Type de données

integer

Unités de mesure
  • mm
Alias
UMLS CUI [1,1]
C0517965
UMLS CUI [1,2]
C0205090
mm
Right Reaction
Description

Right Pupil Reaction

Type de données

text

Alias
UMLS CUI [1,1]
C0234671
UMLS CUI [1,2]
C0444532
Left Size [mm]
Description

Left Pupil Size

Type de données

integer

Unités de mesure
  • mm
Alias
UMLS CUI [1,1]
C0517965
UMLS CUI [1,2]
C0205091
mm
Left Reaction
Description

Left Pupil Reaction

Type de données

text

Alias
UMLS CUI [1,1]
C0234671
UMLS CUI [1,2]
C0443246
ORIENTATION
Description

ORIENTATION

Alias
UMLS CUI-1
C0029266
Orientierung
Description

ORIENTATION

Type de données

string

Alias
UMLS CUI 2011AA
C0029266
SNOMED CT 2011_0131
43173001
HX OF SEIZURE ACTIVITY
Description

History of SEIZURE ACTIVITY

Type de données

text

Alias
UMLS CUI [1]
C1148156
Affekt
Description

AFFECT

Type de données

string

Alias
UMLS CUI 2011AA
C0001721
SNOMED CT 2011_0131
4065008
Sprache
Description

SPEECH

Type de données

string

Alias
UMLS CUI 2011AA
C0037817
SNOMED CT 2011_0131
87335007
LOINC Version 232
MTHU021528
NUMBNESS OR TINGLING PRESENT
Description

NUMBNESS OR TINGLING

Type de données

text

Alias
UMLS CUI [1]
C3842982
Kardiovaskuläres System
Description

Kardiovaskuläres System

Alias
UMLS CUI-1
C0007226
NORMAL BASELINE: Regular rate and rhythm, no edema, capillary refill less than 3 seconds, rate: 60-100 per minute, BP normotensive.
Description

Cardiovascular system normal

Type de données

boolean

Alias
UMLS CUI [1]
C0577867
Narrative: Abnormal Findings
Description

Abnormal Findings

Type de données

text

Alias
UMLS CUI [1]
C1704258
TEDS ON
Description

Antithromboembolic stockings

Type de données

boolean

Alias
UMLS CUI [1]
C0419312
SCDS ON
Description

Vascular Sequential Compression Devices

Type de données

boolean

Alias
UMLS CUI [1]
C0180062
Herztöne
Description

HEART SOUNDS

Type de données

string

Alias
UMLS CUI 2011AA
C0018820
SNOMED CT 2011_0131
23472005
Radial pulse (L/R)
Description

Radial pulse (L/R)

Type de données

string

Alias
UMLS CUI 2011AA
C0232142
SNOMED CT 2011_0131
65452004
MedDRA 14.1
10053935
Pedal pulse (L/R)
Description

Pedal pulse

Type de données

text

Alias
UMLS CUI [1]
C0232157
Tibialis posterior-Puls (L/R)
Description

Pos-Tibial Pulse (L/R)

Type de données

string

Alias
UMLS CUI 2011AA
C1720310
SNOMED CT 2011_0131
421568004
Popliteal-Puls (L/R)
Description

Popliteal Pulse (L/R)

Type de données

string

Alias
UMLS CUI 2011AA
C0232151
SNOMED CT 2011_0131
74828005
MedDRA 14.1
10053938
Brachialis-Puls (L/R)
Description

Brachial Pulse (L/R)

Type de données

string

Alias
UMLS CUI 2011AA
C1096531
MedDRA 14.1
10053929
Karotis-Puls (L/R)
Description

Carotid Pulse (L/R)

Type de données

string

Alias
UMLS CUI 2011AA
C1096529
MedDRA 14.1
10053926
AV SHUNT/GRAFT
Description

AV SHUNT

Type de données

text

Alias
UMLS CUI [1]
C1456474
BRUIT
Description

BRUIT

Type de données

text

Alias
UMLS CUI [1]
C0006318
SHUNT/GRAFT BRUITS
Description

SHUNT BRUIT

Type de données

text

Alias
UMLS CUI [1]
C0232112
THRILL PALPATED
Description

THRILL

Type de données

text

Alias
UMLS CUI [1]
C2678517
CAPILLARY REFILL
Description

CAPILLARY REFILL

Type de données

text

Alias
UMLS CUI [1]
C0425716
NAIL BED COLOR
Description

NAIL BED COLOR

Type de données

text

Alias
UMLS CUI [1]
C0574757
Ödem
Description

Edema

Type de données

string

Alias
UMLS CUI 2011AA
C0013604
SNOMED CT 2011_0131
423666004
MedDRA 14.1
10030095
LOINC Version 232
MTHU019803
ICD-10-CM Version 2010
R60.9
ICD-9-CM Version 2011
782.3
Heart RHYTHM
Description

Heart RHYTHM

Type de données

text

Alias
UMLS CUI [1]
C0232187
(künstlicher) Herzschrittmacher
Description

PACEMAKER PRESENT

Type de données

boolean

Alias
UMLS CUI 2011AA
C0030163
SNOMED CT 2011_0131
14106009
LOINC Version 232
MTHU024521
Eyes Ear Nose & Throat
Description

Eyes Ear Nose & Throat

Normal Baseline EYES: Without drainage, sclera white.
Description

NORMAL BASELINE EYES

Type de données

boolean

Normal Baseline EARS: No complaint of pain.
Description

Normal Baseline Ears

Type de données

boolean

Normal Baseline NOSE: No drainage or congestion.
Description

Normal Baseline Nose

Type de données

boolean

Normal Baseline THROAT: No complaint of pain.
Description

Normal Baseline Throat

Type de données

boolean

NARRATIVE: Abnormal Findings
Description

NARRATIVE: Abnormal Findings

Type de données

string

Augen
Description

Augen

Pupil Right Size [mm]
Description

Pupil Right Size [mm]

Type de données

integer

Pupil Right Reaction
Description

Pupil Right Reaction

Type de données

string

Pupil Left Size [mm]
Description

Pupil Left Size [mm]

Type de données

integer

Pupil Left Reaction
Description

Pupil Left Reaction

Type de données

string

Eye Complains
Description

Eye Complains

Type de données

string

Right Sclera
Description

Right Sclera

Type de données

string

Left Sclera
Description

Left Sclera

Type de données

string

Drainage
Description

Drainage

Type de données

boolean

Drainage Color
Description

Drainage Color

Type de données

string

Ohren
Description

Ohren

EARS(EXTERNAL CANAL)
Description

EARS(EXTERNAL CANAL)

Type de données

string

C/O Pain
Description

C/O Pain

Type de données

boolean

Trommelfell
Description

Tempanic Membranes

Type de données

string

Alias
UMLS CUI 2011AA
C0041445
SNOMED CT 2011_0131
42859004
LOINC Version 232
MTHU014731
Tubes
Description

Tubes

Type de données

string

Hard of Hearing
Description

Hard of Hearing

Type de données

boolean

Hearing Loss
Description

Hearing Loss

Type de données

boolean

Deafness
Description

Deafness

Type de données

boolean

Hearing Aids
Description

Hearing Aids

Type de données

string

Patent
Description

Patent

Type de données

boolean

Schwindel
Description

Dizziness

Type de données

boolean

Alias
UMLS CUI 2011AA
C0012833
SNOMED CT 2011_0131
404640003
MedDRA 14.1
10013573
CTCAE 1105E
E12631
Tinnitus
Description

Tinnitus

Type de données

boolean

Alias
UMLS CUI 2011AA
C0040264
SNOMED CT 2011_0131
60862001
MedDRA 14.1
10043882
ICD-10-CM Version 2010
H93.1
ICD-9-CM Version 2011
388.3
CTCAE 1105E
E10287
Drainage
Description

Drainage

Type de données

boolean

Alias
UMLS CUI 2011AA
C0180499
SNOMED CT 2011_0131
32712000
LOINC Version 232
MTHU022515
Color of Ear Drainage
Description

Color of Ear Drainage

Type de données

string

Nase
Description

Nase

Nares patent
Description

Nares patent

Type de données

boolean

Nares Drainage
Description

Nares Drainage

Type de données

boolean

Nasenseptum
Description

Septum

Type de données

string

Alias
UMLS CUI 2011AA
C0027432
SNOMED CT 2011_0131
68426009
LOINC Version 232
MTHU015054
Pharynx
Description

Pharynx

Sore throat, Pain in throat, Pharyngeal pain
Description

Throat Pain

Type de données

boolean

Alias
UMLS CUI 2011AA
C0242429
SNOMED CT 2011_0131
267102003
MedDRA 14.1
10041367
ICD-10-CM Version 2010
R07.0
ICD-9-CM Version 2011
784.1
CTCAE 1105E
E13575
Mouth Sores
Description

Mouth Sores

Type de données

boolean

Appearance of Throat
Description

Appearance of Throat

Type de données

string

Mucous Membranes
Description

Mucous Membranes

Type de données

string

Respiratory
Description

Respiratory

Normal Baseline: Regular, unlabored, symmetrical, no accessory muscles used, no abnormal breathsounds, rate 12-20 per minute.
Description

NORMAL BASELINE

Type de données

boolean

NARRATIVE: Abnormal Findings
Description

NARRATIVE: Abnormal Findings

Type de données

string

Atemgeräusch
Description

BREATH SOUNDS

Type de données

string

Alias
UMLS CUI 2011AA
C0035234
SNOMED CT 2011_0131
52653008
MedDRA 14.1
10064779
RESPIRATORY EFFORT
Description

RESPIRATORY EFFORT

Type de données

string

CHEST EXPANSION
Description

CHEST EXPANSION

Type de données

string

INCENTIVE SPIROMETRY DONE
Description

INCENTIVE SPIROMETRY DONE

Type de données

boolean

OXYGEN DELIVERY METHOD
Description

OXYGEN DELIVERY METHOD

Type de données

string

Pulse Oximeter present with alarms set
Description

Pulse Oximeter present with alarms set

Type de données

boolean

Cardio-Respriratory Monitor present with alarms set
Description

Cardio-Respriratory Monitor present with alarms set

Type de données

boolean

Husten
Description

COUGH TYPE

Type de données

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
Sputum
Description

Sputum (incl. Quantity)

Type de données

string

Alias
UMLS CUI 2011AA
C0038056
SNOMED CT 2011_0131
45710003
MedDRA 14.1
10041802
LOINC Version 232
MTHU001309
CHEST TUBE PRESENT
Description

CHEST TUBE PRESENT

Type de données

boolean

CHEST TUBE LOCATION
Description

CHEST TUBE LOCATION

Type de données

boolean

Chest Tube Suction Setting
Description

Chest Tube Suction Setting

Type de données

string

Air Leak
Description

Air Leak

Type de données

string

Gastrointestinal
Description

Gastrointestinal

Normal Baseline GI: Abdomen soft, non-distended, bowel tones present X4, continent, stool soft, brown and formed, states regular bowel movements.
Description

NORMAL BASELINE GI

Type de données

boolean

Last Bowel Movement
Description

Last BM

Type de données

date

NARRATIVE: Abnormal Findings
Description

NARRATIVE: Abnormal Findings

Type de données

string

Abdomen
Description

ABDOMINAL DESCRIPTION

Type de données

string

Alias
UMLS CUI 2011AA
C0000726
SNOMED CT 2011_0131
113345001
LOINC Version 232
MTHU001425
Darmgeräusche
Description

BOWEL SOUNDS

Type de données

string

Alias
UMLS CUI 2011AA
C0232693
SNOMED CT 2011_0131
87042004
MedDRA 14.1
10006023
FLATUS
Description

FLATUS

Type de données

boolean

GASTRIC SYMPTOMS
Description

GASTRIC SYMPTOMS

Type de données

string

NARES
Description

NARES

Type de données

string

Nasogastric Tube Type
Description

NG TUBE TYPE

Type de données

string

NG placement checked
Description

NG placement checked

Type de données

boolean

Suction Setting
Description

Suction Setting

Type de données

string

Gastric Content Color
Description

Gastric Content Color

Type de données

string

NGT irrigated (with # ML's of #)
Description

NGT irrigated

Type de données

string

OSTOMY TYPE
Description

OSTOMY TYPE

Type de données

string

RECTAL BAG PRESENT
Description

RECTAL BAG PRESENT

Type de données

boolean

Urogenitales System
Description

Urogenitales System

Normal Baseline Genitourinary: Voids without pain, burning, or hesitation, urine clear, no strong odor, no distention, continent.
Description

NORMAL BASELINE

Type de données

boolean

NARRATIVE: Abnormal Findings
Description

NARRATIVE: Abnormal Findings

Type de données

string

Geschlecht
Description

Sex

Type de données

string

Alias
UMLS CUI 2011AA
C0079399
SNOMED CT 2011_0131
263495000
LOINC Version 232
MTHU002975
INCONTINENT
Description

INCONTINENT

Type de données

boolean

VOIDS SUFFICIENT QUANITY
Description

VOIDS SUFFICIENT QUANITY

Type de données

boolean

IS PATIENT RECEIVING DIALYSIS
Description

IS PATIENT RECEIVING DIALYSIS

Type de données

boolean

ODOR PRESENT
Description

ODOR PRESENT

Type de données

boolean

URINE COLOR
Description

URINE COLOR

Type de données

string

Katheter
Description

CATHETER PRESENT

Type de données

boolean

Alias
UMLS CUI 2011AA
C0085590
SNOMED CT 2011_0131
19923001
Katheter-Größe
Description

CATHETER SIZE

Type de données

string

Alias
UMLS CUI 2011AA
C0449963
SNOMED CT 2011_0131
260967009
Date of insertion
Description

Date of insertion

Type de données

date

Urine color
Description

Urine color

Type de données

string

URINARY SYMPTOMS
Description

URINARY SYMPTOMS

Type de données

string

SEXUALLY ACTIVE
Description

SEXUALLY ACTIVE

Type de données

boolean

CURRENTLY ON MENSES
Description

CURRENTLY ON MENSES

Type de données

boolean

Ausfluss
Description

DISCHARGE PRESENT

Type de données

boolean

Alias
UMLS CUI 2011AA
C0012621
SNOMED CT 2011_0131
75823008
Discharge color
Description

Discharge color

Type de données

string

Discharge odor
Description

Discharge odor

Type de données

string

Discharge consistency
Description

Discharge consistency

Type de données

string

ABNORMAL GENITALIA DESCRIPTION
Description

ABNORMAL GENITALIA DESCRIPTION

Type de données

string

Muskuloskeletales System
Description

Muskuloskeletales System

Normal Baseline Musculoskeletal: Full ROM, no muscle weakness, long bones intact, gait steady.
Description

NORMAL BASELINE

Type de données

boolean

NARRATIVE: Abnormal Findings
Description

NARRATIVE: Abnormal Findings

Type de données

string

GENERALIZED WEAKNESS
Description

GENERALIZED WEAKNESS

Type de données

boolean

LIMITED ROM
Description

LIMITED ROM

Type de données

boolean

LIMITED MOBILITY
Description

LIMITED MOBILITY

Type de données

boolean

CONTRACTURES
Description

CONTRACTURES

Type de données

boolean

FRACTURE(S) LOCATION
Description

FRACTURE(S) LOCATION

Type de données

string

FINGER DIGITS
Description

FINGER DIGITS

Type de données

string

TOE DIGITS
Description

TOE DIGITS

Type de données

string

PARALYSIS TYPE
Description

PARALYSIS TYPE

Type de données

string

Hemiplegia Side
Description

Hemiplegia Side

Type de données

string

LEFT UPPER EXTREMITIES
Description

LEFT UPPER EXTREMITIES

Type de données

string

RIGHT UPPER EXTREMITIES
Description

RIGHT UPPER EXTREMITIES

Type de données

string

GRIPS EQUAL
Description

GRIPS EQUAL

Type de données

boolean

LEFT LOWER EXTREMITIES
Description

LEFT LOWER EXTREMITIES

Type de données

string

RIGHT LOWER EXTREMITIES
Description

RIGHT LOWER EXTREMITIES

Type de données

string

UNSTEADY GAIT
Description

UNSTEADY GAIT

Type de données

boolean

Haut
Description

Haut

NORMAL BASELINE: Warm, dry, turgor elastic, pink undertone to skin or mucosa, no lesions, skin smooth and intact, moist mucous membranes.
Description

NORMAL BASELINE

Type de données

boolean

NARRATIVE: Abnormal Findings
Description

NARRATIVE: Abnormal Findings

Type de données

string

SKIN COLOR
Description

SKIN COLOR

Type de données

string

Temperatur
Description

TEMPERATURE

Type de données

string

Alias
UMLS CUI 2011AA
C0039476
SNOMED CT 2011_0131
246508008
LOINC Version 232
MTHU009008
MOIST
Description

MOIST

Type de données

boolean

SKIN TURGOR
Description

SKIN TURGOR

Type de données

string

RASH LOCATION
Description

RASH LOCATION

Type de données

string

RASH DESCRIPTION
Description

RASH DESCRIPTION

Type de données

string

TATTOO'S/PIERCINGS
Description

TATTOO'S/PIERCINGS

Type de données

string

SKIN TEARS, LOCATION/ Description
Description

SKIN TEARS, LOCATION/ Description

Type de données

string

PRESSURE ULCER ASSESSMENT
Description

PRESSURE ULCER ASSESSMENT

Bony Prominences Assessed
Description

Bony Prominences Assessed

Type de données

boolean

At risk for skin breakdown
Description

At risk for skin breakdown

Type de données

boolean

Braden Score 18 or less
Description

Braden Score 18 or less

Type de données

boolean

Pressure ulcer(s) present
Description

Pressure ulcer(s) present

Type de données

boolean

ULCER #
Description

ULCER #

Type de données

string

Ulcer LOCATION
Description

Ulcer LOCATION

Type de données

string

ULCER STAGE
Description

ULCER STAGE

Type de données

string

Ulcer Length
Description

Ulcer Length

Type de données

string

Ulcer Width
Description

Ulcer Width

Type de données

string

Ulcer Depth
Description

Ulcer Depth

Type de données

string

Wunde
Description

Wunde

Wunde
Description

WOUND #

Type de données

string

Alias
UMLS CUI 2011AA
C0043250
SNOMED CT 2011_0131
13924000
MedDRA 14.1
10052428
LOINC Version 232
MTHU001326
Wound healed
Description

Wound healed

Type de données

boolean

Wound Location
Description

Wound Location

Type de données

string

Alias
UMLS CUI 2011AA
C0043250
SNOMED CT 2011_0131
13924000
MedDRA 14.1
10052428
LOINC Version 232
MTHU001326
UMLS CUI 2011AA
C0450429
SNOMED CT 2011_0131
246267002
Length (cm, mm)
Description

Length (cm, mm)

Type de données

string

Width (cm, mm)
Description

Width (cm, mm)

Type de données

string

Depth (cm, mm)
Description

Depth (cm, mm)

Type de données

string

Undermining
Description

Undermining

Type de données

boolean

Tunneling
Description

Tunneling

Type de données

boolean

Surrounding Skin
Description

Surrounding Skin

Type de données

string

Wound Base
Description

Wound Base

Type de données

string

Exsudat
Description

Exudate

Type de données

string

Alias
UMLS CUI 2011AA
C0015388
SNOMED CT 2011_0131
247450001
LOINC Version 232
MTHU025016
Exudate Color
Description

Exudate Color

Type de données

string

Sensation
Description

Sensation

Type de données

string

Alias
UMLS CUI 2011AA
C0036658
SNOMED CT 2011_0131
373713005
LOINC Version 232
MTHU017277
Odor: Before Cleaning
Description

Odor: Before Cleaning

Type de données

boolean

Odor: After Cleaning
Description

Odor: After Cleaning

Type de données

boolean

Cleansed with/irrigated with
Description

Cleansed with/irrigated with

Type de données

string

Hemostasis Achieved with
Description

Hemostasis Achieved with

Type de données

string

Wound Medication Applied
Description

Wound Medication Applied

Type de données

string

Wound Filled with
Description

Wound Filled with

Type de données

string

Wound covered with
Description

Wound covered with

Type de données

string

Wound secured with
Description

Wound secured with

Type de données

string

Wound Pressure Relief
Description

Wound Pressure Relief

Type de données

string

Comments
Description

Comments

Type de données

string

Photograph Date
Description

Photograph Date

Type de données

date

Inzision
Description

Inzision

Inzision
Description

Incision #:

Type de données

string

Alias
UMLS CUI 2011AA
C0184898
SNOMED CT 2011_0131
34896006
MID WOUND#
Description

MID WOUND#

Type de données

string

Site
Description

Site

Type de données

string

Closure Type
Description

Closure Type

Type de données

string

Incision Appearance
Description

Incision Appearance

Type de données

string

Dressing Changed
Description

Dressing Changed

Type de données

boolean

Date Dressing Changed
Description

Date Dressing Changed

Type de données

date

Dressing Type
Description

Dressing Type

Type de données

string

Dressing Appearance
Description

Dressing Appearance

Type de données

string

Drainage
Description

Drains

Type de données

string

Alias
UMLS CUI 2011AA
C0180499
SNOMED CT 2011_0131
32712000
LOINC Version 232
MTHU022515
Nutrition
Description

Nutrition

Diät
Description

Current Diet

Type de données

string

Alias
UMLS CUI 2011AA
C0012155
SNOMED CT 2011_0131
41829006
Ernährung über Sonde
Description

FEEDING TUBE PRESENT

Type de données

boolean

Alias
UMLS CUI 2011AA
C0041281
SNOMED CT 2011_0131
61420007
MedDRA 14.1
10053095
Feeding Tube Type
Description

Feeding Tube Type

Type de données

string

Formula: # strength @ # cc's/hour via kangaroo pump
Description

Formula

Type de données

string

RESIDUALS CHECKED: AMOUNT # CC
Description

RESIDUALS CHECKED

Type de données

string

NPO
Description

NPO

Type de données

boolean

BREAKFAST
Description

BREAKFAST

Type de données

string

Breakfast: Amount taken
Description

Breakfast: Amount taken

Type de données

string

Breakfast: Patient fed by
Description

Breakfast: Patient fed by

Type de données

string

LUNCH
Description

LUNCH

Type de données

string

Lunch: Amount taken
Description

Lunch: Amount taken

Type de données

string

Lunch: Patient fed by
Description

Lunch: Patient fed by

Type de données

string

SUPPER
Description

SUPPER

Type de données

string

Supper: Amount taken
Description

Supper: Amount taken

Type de données

string

Supper: Patient fed by
Description

Supper: Patient fed by

Type de données

string

Supper: Amount taken
Description

Supper: Amount taken

Type de données

string

intravenöse Therapie
Description

intravenöse Therapie

NARRATIVE: IV Therapy
Description

NARRATIVE: IV Therapy

Type de données

string

IV HEPLOCKED
Description

IV HEPLOCKED

Type de données

boolean

IV Site APPEARANCE
Description

IV Site APPEARANCE

Type de données

string

IV DISCONTINUED
Description

IV DISCONTINUED

Type de données

boolean

CATHETER INTACT
Description

CATHETER INTACT

Type de données

boolean

IV Catheter Size
Description

IV Catheter Size

Type de données

string

IV Site Location
Description

IV Site Location

Type de données

string

Zentralvenöser Katheter (ZVK)
Description

CENTRAL LINE PORT

Type de données

string

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

IV FLUIDS

Type de données

string

Alias
UMLS CUI 2011AA
C1289919
SNOMED CT 2011_0131
118431008
MedDRA 14.1
10067708
Left to count:
Description

Left to count:

Type de données

string

IV Fluid Rate: @ ml/hr
Description

IV Fluid Rate: @ ml/hr

Type de données

integer

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

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

Type de données

string

PCA PUMP: at @ cc's/hr
Description

PCA PUMP: at @ cc's/hr

Type de données

string

IV Site APPEARANCE
Description

IV Site APPEARANCE

Type de données

string

INSERTION DATE
Description

INSERTION DATE

Type de données

date

DRESSING CHANGE DUE
Description

DRESSING CHANGE DUE

Type de données

date

SITE CHANGE DUE
Description

SITE CHANGE DUE

Type de données

date

PLACED ON IMED
Description

PLACED ON IMED

Type de données

boolean

Patientensicherheit
Description

Patientensicherheit

SIDE RAILS UP
Description

SIDE RAILS UP

Type de données

boolean

IN LOW POSTION
Description

IN LOW POSTION

Type de données

boolean

BED/CRIB
Description

BED/CRIB

Type de données

string

CALL BELL WITHIN REACH
Description

CALL BELL WITHIN REACH

Type de données

boolean

ALLERGY BAND ON
Description

ALLERGY BAND ON

Type de données

boolean

NAME BAND ON
Description

NAME BAND ON

Type de données

boolean

BLOOD BAND ON
Description

BLOOD BAND ON

Type de données

boolean

BED SAFETY
Description

BED SAFETY

Type de données

string

Hendrich II Fall Risk Assessment
Description

Hendrich II Fall Risk Assessment

Unable to assess fall risk status at this time due to patient is:
Description

Unable to assess fall risk status at this time due to patient is:

Type de données

string

Confusion/Disorientation/Impulsivity +4
Description

Confusion/Disorientation/Impulsivity +4

Type de données

boolean

Symptomatic Depression +2
Description

Symptomatic Depression +2

Type de données

boolean

Altered Elimination +1
Description

Altered Elimination +1

Type de données

boolean

Dizziness/Vertigo +1
Description

Dizziness/Vertigo +1

Type de données

boolean

Gender (male) +1
Description

Gender (male) +1

Type de données

boolean

Any Administered Antiepileptics (Anticonvulsants) +2
Description

Any Administered Antiepileptics (Anticonvulsants) +2

Type de données

boolean

Any Administered Benzodiazepines +1
Description

Any Administered Benzodiazepines +1

Type de données

boolean

GET UP AND GO TEST: RISING FROM A CHAIR
Description

GET UP AND GO TEST: RISING FROM A CHAIR

Type de données

integer

FINAL Hendrich II RISK SCORE
Description

FINAL Hendrich II RISK SCORE

Type de données

integer

INTERVENTIONS
Description

INTERVENTIONS

Assist with Ambulation
Description

Assist with Ambulation

Type de données

boolean

Reorient Q2H or Less
Description

Reorient Q2H or Less

Type de données

boolean

Gait Belt
Description

Gait Belt

Type de données

boolean

ID Patient at Risk
Description

ID Patient at Risk

Type de données

boolean

Restraints (see policy)
Description

Restraints (see policy)

Type de données

boolean

Multi-personnel Transfer
Description

Multi-personnel Transfer

Type de données

boolean

Close Observation
Description

Close Observation

Type de données

boolean

Non-slip Footwear
Description

Non-slip Footwear

Type de données

boolean

Bed in lowest position
Description

Bed in lowest position

Type de données

boolean

Lock wheels of vehicles of conveyance during transfer
Description

Lock wheels of vehicles of conveyance during transfer

Type de données

boolean

Upper siderails raised
Description

Upper siderails raised

Type de données

boolean

Call light in reach
Description

Call light in reach

Type de données

boolean

Assist with ambulation
Description

Assist with ambulation

Type de données

boolean

Offer toileting at least every 2 hours
Description

Offer toileting at least every 2 hours

Type de données

boolean

Offer fluid/nutrition every 2 hours
Description

Offer fluid/nutrition every 2 hours

Type de données

boolean

Place frequently used objects within reach
Description

Place frequently used objects within reach

Type de données

boolean

Provide adequate lighting
Description

Provide adequate lighting

Type de données

boolean

Provide sensory impairment/orientation devices (clocks,etc)
Description

Provide sensory impairment/orientation devices (clocks,etc)

Type de données

boolean

Provide adequate rest periods
Description

Provide adequate rest periods

Type de données

boolean

Use age appropriate distractions for confusion/disorientation
Description

Use age appropriate distractions for confusion/disorientation

Type de données

boolean

Remove harmful hazards
Description

Remove harmful hazards

Type de données

boolean

Provide appropriate and least restrictive patient supervision/surveillance
Description

Provide appropriate and least restrictive patient supervision/surveillance

Type de données

boolean

Communicate information about fall risk to caregivers
Description

Communicate information about fall risk to caregivers

Type de données

boolean

Encourage family/support system to participate in care
Description

Encourage family/support system to participate in care

Type de données

boolean

Teach/educate family/support system Fall Prevention information
Description

Teach/educate family/support system Fall Prevention information

Type de données

boolean

Implement Fall Prevention Protocol for Hendrich II Score>5
Description

Implement Fall Prevention Protocol for Hendrich II Score>5

Type de données

boolean

IMPAIRED MOBILITY RISK
Description

IMPAIRED MOBILITY RISK

Implement Universal Fall Prevention Intervention
Description

Implement Universal Fall Prevention Intervention

Type de données

boolean

Monitor transfers to/from bed/chair(etc.)
Description

Monitor transfers to/from bed/chair(etc.)

Type de données

boolean

Use appropriate assistance for transfers to/from bed/chair
Description

Use appropriate assistance for transfers to/from bed/chair

Type de données

boolean

Use chairs with armrests and of proper height for transfers
Description

Use chairs with armrests and of proper height for transfers

Type de données

boolean

Implement progressive ambulation(unless contraindicated by condition/orders)
Description

Implement progressive ambulation(unless contraindicated by condition/orders)

Type de données

boolean

Encourage/Provide self-care assistance
Description

Encourage/Provide self-care assistance

Type de données

boolean

Remain in attendance during toileting/ADL's
Description

Remain in attendance during toileting/ADL's

Type de données

boolean

Provide assistive devices for ambulation (canes/walkers/etc.)
Description

Provide assistive devices for ambulation (canes/walkers/etc.)

Type de données

boolean

Gait Belt during transport/ambulation
Description

Gait Belt during transport/ambulation

Type de données

boolean

Teach patient/family to call for help and WAIT for help before
Description

Teach patient/family to call for help and WAIT for help before

Type de données

boolean

attempting any transfer/ambulation
Description

attempting any transfer/ambulation

Type de données

boolean

ALTERED ELIMINATION
Description

ALTERED ELIMINATION

Implement Universal Fall Prevention Interventions
Description

Implement Universal Fall Prevention Interventions

Type de données

boolean

Remain in attendance during toileting/ADL's
Description

Remain in attendance during toileting/ADL's

Type de données

boolean

Assist with post-elimination hygiene
Description

Assist with post-elimination hygiene

Type de données

boolean

Remove non-essential clothing
Description

Remove non-essential clothing

Type de données

boolean

Instruct patient on importance of toileting when offered by staff
Description

Instruct patient on importance of toileting when offered by staff

Type de données

boolean

Monitor for 'patient's normal' bladder/bowel habits
Description

Monitor for 'patient's normal' bladder/bowel habits

Type de données

boolean

Monitor for causes of incontinence (diuretics,cathartics,etc.)
Description

Monitor for causes of incontinence (diuretics,cathartics,etc.)

Type de données

boolean

Monitor skin integrity
Description

Monitor skin integrity

Type de données

boolean

HIGH RISK FALL MEDICATIONS (ANTIEPILEPTICS & BENZODIAZEPINES)
Description

HIGH RISK FALL MEDICATIONS (ANTIEPILEPTICS & BENZODIAZEPINES)

Implement Universal Fall Prevention Interventions
Description

Implement Universal Fall Prevention Interventions

Type de données

boolean

Monitor drug dosages
Description

Monitor drug dosages

Type de données

boolean

Evaluate sensory functions
Description

Evaluate sensory functions

Type de données

boolean

Monitor/Assess for drug overdose
Description

Monitor/Assess for drug overdose

Type de données

boolean

Monitor response to exercise
Description

Monitor response to exercise

Type de données

boolean

Educate patient/support system about drug classification, side effects,precautions, toxic symptoms of overdose.
Description

Educate patient/support system about drug classification, side effects,precautions, toxic symptoms of overdose.

Type de données

boolean

INTERVENTIONS (FOR ONCOLOGY USE ONLY)
Description

INTERVENTIONS (FOR ONCOLOGY USE ONLY)

UNIVERSAL FALL PRECAUTIONS
Description

UNIVERSAL FALL PRECAUTIONS

Type de données

boolean

Neutropenic Precautions taken.
Description

Neutropenic Precautions taken.

Type de données

boolean

Date of last chemotherapy cycle
Description

Date of last chemotherapy cycle

Type de données

date

Chemotherapy Agent/Dosage
Description

Chemotherapy Agent/Dosage

Type de données

string

day of chemotherapy
Description

day of chemotherapy

Type de données

integer

Chemotherapy ADVERSE EFFECTS
Description

Chemotherapy ADVERSE EFFECTS

Type de données

string

Radiation Safety Precautions taken.
Description

Radiation Safety Precautions taken.

Type de données

boolean

RADIATION INTERNAL
Description

RADIATION INTERNAL

Type de données

string

Radiation External: Location of Markings
Description

Radiation External: Location of Markings

Type de données

string

Radiation: Number of Fractions prescribed
Description

Radiation: Number of Fractions prescribed

Type de données

string

Remaining Radiations
Description

Remaining Radiations

Type de données

string

Radiation Adverse Effects
Description

Radiation Adverse Effects

Type de données

string

ONN Unit specific
Description

ONN Unit specific

AFFECTED SITE
Description

AFFECTED SITE

Type de données

string

CIRCULATORY STATUS
Description

CIRCULATORY STATUS

Type de données

string

SKIN COLOR
Description

SKIN COLOR

Type de données

string

Sensation
Description

SENSATION

Type de données

string

Alias
UMLS CUI 2011AA
C0036658
SNOMED CT 2011_0131
373713005
LOINC Version 232
MTHU017277
MOVEMENT
Description

MOVEMENT

Type de données

string

Temperatur
Description

TEMPERATURE

Type de données

string

Alias
UMLS CUI 2011AA
C0039476
SNOMED CT 2011_0131
246508008
LOINC Version 232
MTHU009008
Hautzustand
Description

SKIN CONDITION

Type de données

string

Alias
UMLS CUI 2011AA
C1719933
SNOMED CT 2011_0131
422000003
LOINC Version 232
MTHU034830
PULSE(s) SITE(s)
Description

PULSE(s) SITE(s)

Type de données

string

RESPONSE
Description

RESPONSE

Type de données

string

POSITION OF LIMB
Description

POSITION OF LIMB

Type de données

string

ORTHOPEDIC DEVICE IN USE
Description

ORTHOPEDIC DEVICE IN USE

Type de données

string

CONTINUOUS PASSIVE MOTION
Description

CONTINUOUS PASSIVE MOTION

Type de données

string

POUNDS
Description

POUNDS

Type de données

string

CERVICAL COLLARS
Description

CERVICAL COLLARS

Type de données

string

AFO BRACE: Foot/Feet (LEFT-RIGHT-BILATERAL)
Description

AFO BRACE: Foot/Feet

Type de données

string

SWELLING
Description

SWELLING

Type de données

string

PIN SITES
Description

PIN SITES

Type de données

string

CLEANED WITH
Description

CLEANED WITH

Type de données

string

NARRATIVE
Description

NARRATIVE

Type de données

string

Antepartum specific
Description

Antepartum specific

Gravida
Description

Gravida

Type de données

integer

Para
Description

Para

Type de données

integer

EDC
Description

EDC

Type de données

date

Weeks gestation
Description

Weeks gestation

Type de données

integer

Fetal movement
Description

Fetal movement

Type de données

boolean

FHR
Description

FHR

Type de données

string

Vision
Description

Vision

Type de données

string

Kopfschmerzen
Description

Headaches

Type de données

boolean

Alias
UMLS CUI 2011AA
C0018681
SNOMED CT 2011_0131
25064002
MedDRA 14.1
10019211
LOINC Version 232
MTHU020860
ICD-10-CM Version 2010
R51
ICD-9-CM Version 2011
784.0
CTCAE 1105E
E12678
Abdominal Cramps
Description

Abdominal Cramps

Type de données

boolean

Uterine Contraction
Description

Uterine Contraction

Type de données

boolean

Epigastric Pain
Description

Epigastric Pain

Type de données

boolean

Vaginal Discharge
Description

Vaginal Discharge

Type de données

boolean

Additional Findings
Description

Additional Findings

Type de données

string

Fundal Height
Description

Fundal Height

Type de données

integer

NARRATIVE: Antepartum
Description

NARRATIVE: Antepartum

Type de données

string

Post partum specific
Description

Post partum specific

Fundal Location
Description

Fundal Location

Type de données

string

LOCHIA
Description

LOCHIA

Type de données

string

Perineum
Description

Perineum

Type de données

string

Brust
Description

BREASTS

Type de données

string

Alias
UMLS CUI 2011AA
C0006141
SNOMED CT 2011_0131
76752008
LOINC Version 232
MTHU011382
Mamillen
Description

NIPPLES

Type de données

string

Alias
UMLS CUI 2011AA
C0028109
SNOMED CT 2011_0131
24142002
Mother/Baby Relationship
Description

Mother/Baby Relationship

Type de données

string

BONDING
Description

BONDING

Type de données

string

Feedings
Description

Feedings

Type de données

string

Hämorrhoiden
Description

Hemorrhoids

Type de données

string

Alias
UMLS CUI 2011AA
C0019112
SNOMED CT 2011_0131
70153002
MedDRA 14.1
10019022
LOINC Version 232
MTHU015043
ICD-10-CM Version 2010
I84
ICD-9-CM Version 2011
455
CTCAE 1105E
E10773
NARRATIVE: Post partum
Description

NARRATIVE: Post partum

Type de données

string

Post Surgical
Description

Post Surgical

Patient activity
Description

General Activity

Type de données

string

Alias
UMLS CUI 2011AA
C0451369
SNOMED CT 2011_0131
273688003
Vaginal Packing
Description

Vaginal Packing

Type de données

string

Equipment/Devices
Description

Equipment/Devices

Type de données

string

EQUIPMENT/DEVICES
Description

EQUIPMENT/DEVICES

Type de données

string

ADOLESCENT INTERACTION
Description

ADOLESCENT INTERACTION

Prepared for treatment/procedure as soon as possible.
Description

Prepared for treatment/procedure as soon as possible.

Type de données

string

Provided detailed information about events/procedures/treatments.
Description

Provided detailed information about events/procedures/treatments.

Type de données

string

Allowed contact with peer group.
Description

Allowed contact with peer group.

Type de données

string

NARRATIVE
Description

NARRATIVE

Type de données

string

GERIATRIC INTERVENTION (65+)
Description

GERIATRIC INTERVENTION (65+)

Involved in decision process regarding pain control/medication/care decisions
Description

Involved in decision process regarding pain control/medication/care decisions

Type de données

string

Encouraged family/S.O.to visit
Description

Encouraged family/S.O.to visit

Type de données

string

Independence promoted.
Description

Independence promoted.

Type de données

string

NARRATIVE
Description

NARRATIVE

Type de données

string

Hendrich Fall Risk
Description

Hendrich Fall Risk

Confusion/Disorientation +3
Description

Confusion/Disorientation +3

Type de données

boolean

Depression +4
Description

Depression +4

Type de données

boolean

Alias
UMLS CUI 2011AA
C0011581
SNOMED CT 2011_0131
35489007
MedDRA 14.1
10012401
ICD-10-CM Version 2010
F32.9
Altered Elimination (incontinence, nocturia) +3
Description

Altered Elimination (incontinence, nocturia) +3

Type de données

boolean

Non-Adaptive Mobility/Generalized Weakness +2
Description

Non-Adaptive Mobility/Generalized Weakness +2

Type de données

boolean

Dizziness/Vertigo +3
Description

Dizziness/Vertigo +3

Type de données

boolean

Primary Cancer Diagnosis +3
Description

Primary Cancer Diagnosis +3

Type de données

boolean

Alias
UMLS CUI 2011AA
C0006826
SNOMED CT 2011_0131
363346000
MedDRA 14.1
10028997
LOINC Version 232
MTHU010328
ICD-10-CM Version 2010
C00-C96
RECENT HISTORY of FALLS +7
Description

RECENT HISTORY of FALLS +7

Type de données

boolean

FINAL Hendrich Fall RISK SCORE
Description

FINAL Hendrich Fall RISK SCORE

Type de données

integer

SUGGESTED INTERVENTIONS
Description

SUGGESTED INTERVENTIONS

Assist with Ambulation
Description

Assist with Ambulation

Type de données

string

Toileting Q2H
Description

Toileting Q2H

Type de données

string

Sensory Impairment Device
Description

Sensory Impairment Device

Type de données

string

Reorient Q2H or Less
Description

Reorient Q2H or Less

Type de données

string

Gait Belt
Description

Gait Belt

Type de données

string

ID Patient at Risk
Description

ID Patient at Risk

Type de données

string

Restraints (see policy)
Description

Restraints (see policy)

Type de données

string

Multi-personnel Transfer
Description

Multi-personnel Transfer

Type de données

string

Close Observation
Description

Close Observation

Type de données

string

Non-slip Footwear
Description

Non-slip Footwear

Type de données

string

Similar models

  1. StudyEvent: HIS
    1. HIS
Name
Type
Description | Question | Decode (Coded Value)
Type de données
Alias
Item Group
Adult Nursing Assessment
C0028680 (UMLS CUI-1)
initial assessment
Item
see initial Admission Assessment
boolean
C0150637 (UMLS CUI [1])
assessment date
Item
DONE ON
date
C2985720 (UMLS CUI [1])
ADMISSION
Item
ADMISSION TEXT
text
C0030673 (UMLS CUI [1])
postoperative day
Item
POST OP DAY
integer
C0032790 (UMLS CUI [1])
Item Group
Neuro / Psychosocial
C0746866 (UMLS CUI-1)
Neurological examination normal
Item
Normal Baseline: Alert, responsive to stimuli, sensation intact, speech clear and appropriate, PERRLA, hand grips equal, can follow directions, oriented X4, cooperative with treatment plan, hygiene and grooming adequate, maintains eye contact, poses no danger to self or to others, normal affect.
boolean
C1112287 (UMLS CUI [1])
Abnormal Findings
Item
Narrative: Abnormal Findings
text
C1704258 (UMLS CUI [1])
Item Group
GLASGOW COMA SCALE ADULT
C1271007 (UMLS CUI-1)
Item
EYES OPEN
integer
C3648956 (UMLS CUI [1])
Code List
EYES OPEN
CL Item
Spontaneously (4)
C2012046 (UMLS CUI-1)
CL Item
To speech (3)
C2012048 (UMLS CUI-1)
CL Item
To pain (2)
C2012047 (UMLS CUI-1)
CL Item
None (1)
C2012045 (UMLS CUI-1)
Item
BEST VERBAL RESPONSE
integer
C3648957 (UMLS CUI [1])
Code List
BEST VERBAL RESPONSE
CL Item
Oriented (5)
C2012059 (UMLS CUI-1)
CL Item
Confused (4)
C2012056 (UMLS CUI-1)
CL Item
Inappropriate words (3)
C2012058 (UMLS CUI-1)
CL Item
Incomprehensible words (2)
C2012057 (UMLS CUI-1)
CL Item
None (1)
C2012060 (UMLS CUI-1)
Item
BEST MOTOR RESPONSE
integer
C3648958 (UMLS CUI [1])
Code List
BEST MOTOR RESPONSE
CL Item
Obeys command (6)
C2012055 (UMLS CUI-1)
CL Item
Localize to pain (5)
C2012053 (UMLS CUI-1)
CL Item
Withdraws (4)
C2012052 (UMLS CUI-1)
CL Item
Flexion to pain (3)
C2012051 (UMLS CUI-1)
CL Item
Extension to pain (2)
C2012050 (UMLS CUI-1)
CL Item
None (1)
C2012054 (UMLS CUI-1)
GLASCOW COMA SCALE SCORE
Item
GLASCOW COMA SCALE SCORE ADULT
integer
C1271007 (UMLS CUI [1])
Item Group
Pupillen
C0034121 (UMLS CUI-1)
Right Pupil Size
Item
Right Size [mm]
integer
C0517965 (UMLS CUI [1,1])
C0205090 (UMLS CUI [1,2])
Right Pupil Reaction
Item
Right Reaction
text
C0234671 (UMLS CUI [1,1])
C0444532 (UMLS CUI [1,2])
Left Pupil Size
Item
Left Size [mm]
integer
C0517965 (UMLS CUI [1,1])
C0205091 (UMLS CUI [1,2])
Left Pupil Reaction
Item
Left Reaction
text
C0234671 (UMLS CUI [1,1])
C0443246 (UMLS CUI [1,2])
Item Group
ORIENTATION
C0029266 (UMLS CUI-1)
ORIENTATION
Item
Orientierung
string
C0029266 (UMLS CUI 2011AA)
43173001 (SNOMED CT 2011_0131)
History of SEIZURE ACTIVITY
Item
HX OF SEIZURE ACTIVITY
text
C1148156 (UMLS CUI [1])
AFFECT
Item
Affekt
string
C0001721 (UMLS CUI 2011AA)
4065008 (SNOMED CT 2011_0131)
SPEECH
Item
Sprache
string
C0037817 (UMLS CUI 2011AA)
87335007 (SNOMED CT 2011_0131)
MTHU021528 (LOINC Version 232)
NUMBNESS OR TINGLING
Item
NUMBNESS OR TINGLING PRESENT
text
C3842982 (UMLS CUI [1])
Item Group
Kardiovaskuläres System
C0007226 (UMLS CUI-1)
Cardiovascular system normal
Item
NORMAL BASELINE: Regular rate and rhythm, no edema, capillary refill less than 3 seconds, rate: 60-100 per minute, BP normotensive.
boolean
C0577867 (UMLS CUI [1])
Abnormal Findings
Item
Narrative: Abnormal Findings
text
C1704258 (UMLS CUI [1])
Antithromboembolic stockings
Item
TEDS ON
boolean
C0419312 (UMLS CUI [1])
Vascular Sequential Compression Devices
Item
SCDS ON
boolean
C0180062 (UMLS CUI [1])
HEART SOUNDS
Item
Herztöne
string
C0018820 (UMLS CUI 2011AA)
23472005 (SNOMED CT 2011_0131)
Radial pulse (L/R)
Item
Radial pulse (L/R)
string
C0232142 (UMLS CUI 2011AA)
65452004 (SNOMED CT 2011_0131)
10053935 (MedDRA 14.1)
Pedal pulse
Item
Pedal pulse (L/R)
text
C0232157 (UMLS CUI [1])
Pos-Tibial Pulse (L/R)
Item
Tibialis posterior-Puls (L/R)
string
C1720310 (UMLS CUI 2011AA)
421568004 (SNOMED CT 2011_0131)
Popliteal Pulse (L/R)
Item
Popliteal-Puls (L/R)
string
C0232151 (UMLS CUI 2011AA)
74828005 (SNOMED CT 2011_0131)
10053938 (MedDRA 14.1)
Brachial Pulse (L/R)
Item
Brachialis-Puls (L/R)
string
C1096531 (UMLS CUI 2011AA)
10053929 (MedDRA 14.1)
Carotid Pulse (L/R)
Item
Karotis-Puls (L/R)
string
C1096529 (UMLS CUI 2011AA)
10053926 (MedDRA 14.1)
AV SHUNT
Item
AV SHUNT/GRAFT
text
C1456474 (UMLS CUI [1])
BRUIT
Item
BRUIT
text
C0006318 (UMLS CUI [1])
SHUNT BRUIT
Item
SHUNT/GRAFT BRUITS
text
C0232112 (UMLS CUI [1])
THRILL
Item
THRILL PALPATED
text
C2678517 (UMLS CUI [1])
CAPILLARY REFILL
Item
CAPILLARY REFILL
text
C0425716 (UMLS CUI [1])
NAIL BED COLOR
Item
NAIL BED COLOR
text
C0574757 (UMLS CUI [1])
Edema
Item
Ödem
string
C0013604 (UMLS CUI 2011AA)
423666004 (SNOMED CT 2011_0131)
10030095 (MedDRA 14.1)
MTHU019803 (LOINC Version 232)
R60.9 (ICD-10-CM Version 2010)
782.3 (ICD-9-CM Version 2011)
Heart RHYTHM
Item
Heart RHYTHM
text
C0232187 (UMLS CUI [1])
PACEMAKER PRESENT
Item
(künstlicher) Herzschrittmacher
boolean
C0030163 (UMLS CUI 2011AA)
14106009 (SNOMED CT 2011_0131)
MTHU024521 (LOINC Version 232)
Item Group
Eyes Ear Nose & Throat
NORMAL BASELINE EYES
Item
Normal Baseline EYES: Without drainage, sclera white.
boolean
Normal Baseline Ears
Item
Normal Baseline EARS: No complaint of pain.
boolean
Normal Baseline Nose
Item
Normal Baseline NOSE: No drainage or congestion.
boolean
Normal Baseline Throat
Item
Normal Baseline THROAT: No complaint of pain.
boolean
NARRATIVE: Abnormal Findings
Item
NARRATIVE: Abnormal Findings
string
Item Group
Augen
Pupil Right Size [mm]
Item
Pupil Right Size [mm]
integer
Pupil Right Reaction
Item
Pupil Right Reaction
string
Pupil Left Size [mm]
Item
Pupil Left Size [mm]
integer
Pupil Left Reaction
Item
Pupil Left Reaction
string
Eye Complains
Item
Eye Complains
string
Right Sclera
Item
Right Sclera
string
Left Sclera
Item
Left Sclera
string
Drainage
Item
Drainage
boolean
Drainage Color
Item
Drainage Color
string
Item Group
Ohren
EARS(EXTERNAL CANAL)
Item
EARS(EXTERNAL CANAL)
string
C/O Pain
Item
C/O Pain
boolean
Tempanic Membranes
Item
Trommelfell
string
C0041445 (UMLS CUI 2011AA)
42859004 (SNOMED CT 2011_0131)
MTHU014731 (LOINC Version 232)
Tubes
Item
Tubes
string
Hard of Hearing
Item
Hard of Hearing
boolean
Hearing Loss
Item
Hearing Loss
boolean
Deafness
Item
Deafness
boolean
Item
Hearing Aids
string
Code List
Hearing Aids
CL Item
RT (1)
CL Item
LT (2)
CL Item
bilateral (3)
Patent
Item
Patent
boolean
Dizziness
Item
Schwindel
boolean
C0012833 (UMLS CUI 2011AA)
404640003 (SNOMED CT 2011_0131)
10013573 (MedDRA 14.1)
E12631 (CTCAE 1105E)
Tinnitus
Item
Tinnitus
boolean
C0040264 (UMLS CUI 2011AA)
60862001 (SNOMED CT 2011_0131)
10043882 (MedDRA 14.1)
H93.1 (ICD-10-CM Version 2010)
388.3 (ICD-9-CM Version 2011)
E10287 (CTCAE 1105E)
Drainage
Item
Drainage
boolean
C0180499 (UMLS CUI 2011AA)
32712000 (SNOMED CT 2011_0131)
MTHU022515 (LOINC Version 232)
Color of Ear Drainage
Item
Color of Ear Drainage
string
Item Group
Nase
Nares patent
Item
Nares patent
boolean
Nares Drainage
Item
Nares Drainage
boolean
Septum
Item
Nasenseptum
string
C0027432 (UMLS CUI 2011AA)
68426009 (SNOMED CT 2011_0131)
MTHU015054 (LOINC Version 232)
Item Group
Pharynx
Throat Pain
Item
Sore throat, Pain in throat, Pharyngeal pain
boolean
C0242429 (UMLS CUI 2011AA)
267102003 (SNOMED CT 2011_0131)
10041367 (MedDRA 14.1)
R07.0 (ICD-10-CM Version 2010)
784.1 (ICD-9-CM Version 2011)
E13575 (CTCAE 1105E)
Mouth Sores
Item
Mouth Sores
boolean
Appearance of Throat
Item
Appearance of Throat
string
Mucous Membranes
Item
Mucous Membranes
string
Item Group
Respiratory
NORMAL BASELINE
Item
Normal Baseline: Regular, unlabored, symmetrical, no accessory muscles used, no abnormal breathsounds, rate 12-20 per minute.
boolean
NARRATIVE: Abnormal Findings
Item
NARRATIVE: Abnormal Findings
string
BREATH SOUNDS
Item
Atemgeräusch
string
C0035234 (UMLS CUI 2011AA)
52653008 (SNOMED CT 2011_0131)
10064779 (MedDRA 14.1)
RESPIRATORY EFFORT
Item
RESPIRATORY EFFORT
string
Item
CHEST EXPANSION
string
Code List
CHEST EXPANSION
CL Item
symmetrical (1)
CL Item
non-symmetrical (2)
INCENTIVE SPIROMETRY DONE
Item
INCENTIVE SPIROMETRY DONE
boolean
OXYGEN DELIVERY METHOD
Item
OXYGEN DELIVERY METHOD
string
Pulse Oximeter present with alarms set
Item
Pulse Oximeter present with alarms set
boolean
Cardio-Respriratory Monitor present with alarms set
Item
Cardio-Respriratory Monitor present with alarms set
boolean
COUGH TYPE
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)
Sputum (incl. Quantity)
Item
Sputum
string
C0038056 (UMLS CUI 2011AA)
45710003 (SNOMED CT 2011_0131)
10041802 (MedDRA 14.1)
MTHU001309 (LOINC Version 232)
CHEST TUBE PRESENT
Item
CHEST TUBE PRESENT
boolean
CHEST TUBE LOCATION
Item
CHEST TUBE LOCATION
boolean
Chest Tube Suction Setting
Item
Chest Tube Suction Setting
string
Item
Air Leak
string
Code List
Air Leak
CL Item
none (1)
CL Item
small (2)
CL Item
moderate (3)
CL Item
large (4)
Item Group
Gastrointestinal
NORMAL BASELINE GI
Item
Normal Baseline GI: Abdomen soft, non-distended, bowel tones present X4, continent, stool soft, brown and formed, states regular bowel movements.
boolean
Last BM
Item
Last Bowel Movement
date
NARRATIVE: Abnormal Findings
Item
NARRATIVE: Abnormal Findings
string
ABDOMINAL DESCRIPTION
Item
Abdomen
string
C0000726 (UMLS CUI 2011AA)
113345001 (SNOMED CT 2011_0131)
MTHU001425 (LOINC Version 232)
BOWEL SOUNDS
Item
Darmgeräusche
string
C0232693 (UMLS CUI 2011AA)
87042004 (SNOMED CT 2011_0131)
10006023 (MedDRA 14.1)
FLATUS
Item
FLATUS
boolean
GASTRIC SYMPTOMS
Item
GASTRIC SYMPTOMS
string
NARES
Item
NARES
string
NG TUBE TYPE
Item
Nasogastric Tube Type
string
NG placement checked
Item
NG placement checked
boolean
Suction Setting
Item
Suction Setting
string
Gastric Content Color
Item
Gastric Content Color
string
NGT irrigated
Item
NGT irrigated (with # ML's of #)
string
OSTOMY TYPE
Item
OSTOMY TYPE
string
RECTAL BAG PRESENT
Item
RECTAL BAG PRESENT
boolean
Item Group
Urogenitales System
NORMAL BASELINE
Item
Normal Baseline Genitourinary: Voids without pain, burning, or hesitation, urine clear, no strong odor, no distention, continent.
boolean
NARRATIVE: Abnormal Findings
Item
NARRATIVE: Abnormal Findings
string
Item
Geschlecht
string
C0079399 (UMLS CUI 2011AA)
263495000 (SNOMED CT 2011_0131)
MTHU002975 (LOINC Version 232)
Code List
Geschlecht
CL Item
Male (1)
CL Item
Female (2)
INCONTINENT
Item
INCONTINENT
boolean
VOIDS SUFFICIENT QUANITY
Item
VOIDS SUFFICIENT QUANITY
boolean
IS PATIENT RECEIVING DIALYSIS
Item
IS PATIENT RECEIVING DIALYSIS
boolean
ODOR PRESENT
Item
ODOR PRESENT
boolean
URINE COLOR
Item
URINE COLOR
string
CATHETER PRESENT
Item
Katheter
boolean
C0085590 (UMLS CUI 2011AA)
19923001 (SNOMED CT 2011_0131)
CATHETER SIZE
Item
Katheter-Größe
string
C0449963 (UMLS CUI 2011AA)
260967009 (SNOMED CT 2011_0131)
Date of insertion
Item
Date of insertion
date
Urine color
Item
Urine color
string
URINARY SYMPTOMS
Item
URINARY SYMPTOMS
string
SEXUALLY ACTIVE
Item
SEXUALLY ACTIVE
boolean
CURRENTLY ON MENSES
Item
CURRENTLY ON MENSES
boolean
DISCHARGE PRESENT
Item
Ausfluss
boolean
C0012621 (UMLS CUI 2011AA)
75823008 (SNOMED CT 2011_0131)
Discharge color
Item
Discharge color
string
Discharge odor
Item
Discharge odor
string
Discharge consistency
Item
Discharge consistency
string
ABNORMAL GENITALIA DESCRIPTION
Item
ABNORMAL GENITALIA DESCRIPTION
string
Item Group
Muskuloskeletales System
NORMAL BASELINE
Item
Normal Baseline Musculoskeletal: Full ROM, no muscle weakness, long bones intact, gait steady.
boolean
NARRATIVE: Abnormal Findings
Item
NARRATIVE: Abnormal Findings
string
GENERALIZED WEAKNESS
Item
GENERALIZED WEAKNESS
boolean
LIMITED ROM
Item
LIMITED ROM
boolean
LIMITED MOBILITY
Item
LIMITED MOBILITY
boolean
CONTRACTURES
Item
CONTRACTURES
boolean
FRACTURE(S) LOCATION
Item
FRACTURE(S) LOCATION
string
FINGER DIGITS
Item
FINGER DIGITS
string
TOE DIGITS
Item
TOE DIGITS
string
PARALYSIS TYPE
Item
PARALYSIS TYPE
string
Item
Hemiplegia Side
string
Code List
Hemiplegia Side
CL Item
left (1)
CL Item
right (2)
LEFT UPPER EXTREMITIES
Item
LEFT UPPER EXTREMITIES
string
RIGHT UPPER EXTREMITIES
Item
RIGHT UPPER EXTREMITIES
string
GRIPS EQUAL
Item
GRIPS EQUAL
boolean
LEFT LOWER EXTREMITIES
Item
LEFT LOWER EXTREMITIES
string
RIGHT LOWER EXTREMITIES
Item
RIGHT LOWER EXTREMITIES
string
UNSTEADY GAIT
Item
UNSTEADY GAIT
boolean
Item Group
Haut
NORMAL BASELINE
Item
NORMAL BASELINE: Warm, dry, turgor elastic, pink undertone to skin or mucosa, no lesions, skin smooth and intact, moist mucous membranes.
boolean
NARRATIVE: Abnormal Findings
Item
NARRATIVE: Abnormal Findings
string
SKIN COLOR
Item
SKIN COLOR
string
TEMPERATURE
Item
Temperatur
string
C0039476 (UMLS CUI 2011AA)
246508008 (SNOMED CT 2011_0131)
MTHU009008 (LOINC Version 232)
MOIST
Item
MOIST
boolean
SKIN TURGOR
Item
SKIN TURGOR
string
RASH LOCATION
Item
RASH LOCATION
string
RASH DESCRIPTION
Item
RASH DESCRIPTION
string
TATTOO'S/PIERCINGS
Item
TATTOO'S/PIERCINGS
string
SKIN TEARS, LOCATION/ Description
Item
SKIN TEARS, LOCATION/ Description
string
Item Group
PRESSURE ULCER ASSESSMENT
Bony Prominences Assessed
Item
Bony Prominences Assessed
boolean
At risk for skin breakdown
Item
At risk for skin breakdown
boolean
Braden Score 18 or less
Item
Braden Score 18 or less
boolean
Pressure ulcer(s) present
Item
Pressure ulcer(s) present
boolean
ULCER #
Item
ULCER #
string
Ulcer LOCATION
Item
Ulcer LOCATION
string
ULCER STAGE
Item
ULCER STAGE
string
Ulcer Length
Item
Ulcer Length
string
Ulcer Width
Item
Ulcer Width
string
Ulcer Depth
Item
Ulcer Depth
string
Item Group
Wunde
WOUND #
Item
Wunde
string
C0043250 (UMLS CUI 2011AA)
13924000 (SNOMED CT 2011_0131)
10052428 (MedDRA 14.1)
MTHU001326 (LOINC Version 232)
Wound healed
Item
Wound healed
boolean
Wound Location
Item
Wound Location
string
C0043250 (UMLS CUI 2011AA)
13924000 (SNOMED CT 2011_0131)
10052428 (MedDRA 14.1)
MTHU001326 (LOINC Version 232)
C0450429 (UMLS CUI 2011AA)
246267002 (SNOMED CT 2011_0131)
Length (cm, mm)
Item
Length (cm, mm)
string
Width (cm, mm)
Item
Width (cm, mm)
string
Depth (cm, mm)
Item
Depth (cm, mm)
string
Undermining
Item
Undermining
boolean
Tunneling
Item
Tunneling
boolean
Surrounding Skin
Item
Surrounding Skin
string
Wound Base
Item
Wound Base
string
Exudate
Item
Exsudat
string
C0015388 (UMLS CUI 2011AA)
247450001 (SNOMED CT 2011_0131)
MTHU025016 (LOINC Version 232)
Exudate Color
Item
Exudate Color
string
Sensation
Item
Sensation
string
C0036658 (UMLS CUI 2011AA)
373713005 (SNOMED CT 2011_0131)
MTHU017277 (LOINC Version 232)
Odor: Before Cleaning
Item
Odor: Before Cleaning
boolean
Odor: After Cleaning
Item
Odor: After Cleaning
boolean
Cleansed with/irrigated with
Item
Cleansed with/irrigated with
string
Hemostasis Achieved with
Item
Hemostasis Achieved with
string
Wound Medication Applied
Item
Wound Medication Applied
string
Wound Filled with
Item
Wound Filled with
string
Wound covered with
Item
Wound covered with
string
Wound secured with
Item
Wound secured with
string
Wound Pressure Relief
Item
Wound Pressure Relief
string
Comments
Item
Comments
string
Photograph Date
Item
Photograph Date
date
Item Group
Inzision
Incision #:
Item
Inzision
string
C0184898 (UMLS CUI 2011AA)
34896006 (SNOMED CT 2011_0131)
MID WOUND#
Item
MID WOUND#
string
Site
Item
Site
string
Closure Type
Item
Closure Type
string
Incision Appearance
Item
Incision Appearance
string
Dressing Changed
Item
Dressing Changed
boolean
Date Dressing Changed
Item
Date Dressing Changed
date
Dressing Type
Item
Dressing Type
string
Dressing Appearance
Item
Dressing Appearance
string
Drains
Item
Drainage
string
C0180499 (UMLS CUI 2011AA)
32712000 (SNOMED CT 2011_0131)
MTHU022515 (LOINC Version 232)
Item Group
Nutrition
Current Diet
Item
Diät
string
C0012155 (UMLS CUI 2011AA)
41829006 (SNOMED CT 2011_0131)
FEEDING TUBE PRESENT
Item
Ernährung über Sonde
boolean
C0041281 (UMLS CUI 2011AA)
61420007 (SNOMED CT 2011_0131)
10053095 (MedDRA 14.1)
Feeding Tube Type
Item
Feeding Tube Type
string
Formula
Item
Formula: # strength @ # cc's/hour via kangaroo pump
string
RESIDUALS CHECKED
Item
RESIDUALS CHECKED: AMOUNT # CC
string
NPO
Item
NPO
boolean
BREAKFAST
Item
BREAKFAST
string
Breakfast: Amount taken
Item
Breakfast: Amount taken
string
Breakfast: Patient fed by
Item
Breakfast: Patient fed by
string
LUNCH
Item
LUNCH
string
Lunch: Amount taken
Item
Lunch: Amount taken
string
Lunch: Patient fed by
Item
Lunch: Patient fed by
string
SUPPER
Item
SUPPER
string
Supper: Amount taken
Item
Supper: Amount taken
string
Supper: Patient fed by
Item
Supper: Patient fed by
string
Supper: Amount taken
Item
Supper: Amount taken
string
Item Group
intravenöse Therapie
NARRATIVE: IV Therapy
Item
NARRATIVE: IV Therapy
string
IV HEPLOCKED
Item
IV HEPLOCKED
boolean
IV Site APPEARANCE
Item
IV Site APPEARANCE
string
IV DISCONTINUED
Item
IV DISCONTINUED
boolean
CATHETER INTACT
Item
CATHETER INTACT
boolean
IV Catheter Size
Item
IV Catheter Size
string
IV Site Location
Item
IV Site Location
string
CENTRAL LINE PORT
Item
Zentralvenöser Katheter (ZVK)
string
C1145640 (UMLS CUI 2011AA)
52124006 (SNOMED CT 2011_0131)
IV FLUIDS
Item
Infusion
string
C1289919 (UMLS CUI 2011AA)
118431008 (SNOMED CT 2011_0131)
10067708 (MedDRA 14.1)
Left to count:
Item
Left to count:
string
IV Fluid Rate: @ ml/hr
Item
IV Fluid Rate: @ ml/hr
integer
TPN/LIPIDS: TPN @ ml/hr and Lipids @ ml/hr
Item
TPN/LIPIDS: TPN @ ml/hr and Lipids @ ml/hr
string
PCA PUMP: at @ cc's/hr
Item
PCA PUMP: at @ cc's/hr
string
IV Site APPEARANCE
Item
IV Site APPEARANCE
string
INSERTION DATE
Item
INSERTION DATE
date
DRESSING CHANGE DUE
Item
DRESSING CHANGE DUE
date
SITE CHANGE DUE
Item
SITE CHANGE DUE
date
PLACED ON IMED
Item
PLACED ON IMED
boolean
Item Group
Patientensicherheit
SIDE RAILS UP
Item
SIDE RAILS UP
boolean
IN LOW POSTION
Item
IN LOW POSTION
boolean
BED/CRIB
Item
BED/CRIB
string
CALL BELL WITHIN REACH
Item
CALL BELL WITHIN REACH
boolean
ALLERGY BAND ON
Item
ALLERGY BAND ON
boolean
NAME BAND ON
Item
NAME BAND ON
boolean
BLOOD BAND ON
Item
BLOOD BAND ON
boolean
BED SAFETY
Item
BED SAFETY
string
Item Group
Hendrich II Fall Risk Assessment
Unable to assess fall risk status at this time due to patient is:
Item
Unable to assess fall risk status at this time due to patient is:
string
Confusion/Disorientation/Impulsivity +4
Item
Confusion/Disorientation/Impulsivity +4
boolean
Symptomatic Depression +2
Item
Symptomatic Depression +2
boolean
Altered Elimination +1
Item
Altered Elimination +1
boolean
Dizziness/Vertigo +1
Item
Dizziness/Vertigo +1
boolean
Gender (male) +1
Item
Gender (male) +1
boolean
Any Administered Antiepileptics (Anticonvulsants) +2
Item
Any Administered Antiepileptics (Anticonvulsants) +2
boolean
Any Administered Benzodiazepines +1
Item
Any Administered Benzodiazepines +1
boolean
Item
GET UP AND GO TEST: RISING FROM A CHAIR
integer
Code List
GET UP AND GO TEST: RISING FROM A CHAIR
CL Item
Ability to rise in single movement-No loss of balance with steps +0 (Ability to rise in single movement-No loss of balance with steps +0)
CL Item
Pushes up, successful in one attempt +1 (Pushes up, successful in one attempt +1)
CL Item
Multiple attempts but successful +3 (Multiple attempts but successful +3)
CL Item
Unable to rise without assistance during test (OR if a medical order states the same and/or complete bed rest is ordered) +4 (Unable to rise without assistance during test (OR if a medical order states the same and/or complete bed rest is ordered) +4)
FINAL Hendrich II RISK SCORE
Item
FINAL Hendrich II RISK SCORE
integer
Item Group
INTERVENTIONS
Assist with Ambulation
Item
Assist with Ambulation
boolean
Reorient Q2H or Less
Item
Reorient Q2H or Less
boolean
Gait Belt
Item
Gait Belt
boolean
ID Patient at Risk
Item
ID Patient at Risk
boolean
Restraints (see policy)
Item
Restraints (see policy)
boolean
Multi-personnel Transfer
Item
Multi-personnel Transfer
boolean
Close Observation
Item
Close Observation
boolean
Non-slip Footwear
Item
Non-slip Footwear
boolean
Bed in lowest position
Item
Bed in lowest position
boolean
Lock wheels of vehicles of conveyance during transfer
Item
Lock wheels of vehicles of conveyance during transfer
boolean
Upper siderails raised
Item
Upper siderails raised
boolean
Call light in reach
Item
Call light in reach
boolean
Assist with ambulation
Item
Assist with ambulation
boolean
Offer toileting at least every 2 hours
Item
Offer toileting at least every 2 hours
boolean
Offer fluid/nutrition every 2 hours
Item
Offer fluid/nutrition every 2 hours
boolean
Place frequently used objects within reach
Item
Place frequently used objects within reach
boolean
Provide adequate lighting
Item
Provide adequate lighting
boolean
Provide sensory impairment/orientation devices (clocks,etc)
Item
Provide sensory impairment/orientation devices (clocks,etc)
boolean
Provide adequate rest periods
Item
Provide adequate rest periods
boolean
Use age appropriate distractions for confusion/disorientation
Item
Use age appropriate distractions for confusion/disorientation
boolean
Remove harmful hazards
Item
Remove harmful hazards
boolean
Provide appropriate and least restrictive patient supervision/surveillance
Item
Provide appropriate and least restrictive patient supervision/surveillance
boolean
Communicate information about fall risk to caregivers
Item
Communicate information about fall risk to caregivers
boolean
Encourage family/support system to participate in care
Item
Encourage family/support system to participate in care
boolean
Teach/educate family/support system Fall Prevention information
Item
Teach/educate family/support system Fall Prevention information
boolean
Implement Fall Prevention Protocol for Hendrich II Score>5
Item
Implement Fall Prevention Protocol for Hendrich II Score>5
boolean
Item Group
IMPAIRED MOBILITY RISK
Implement Universal Fall Prevention Intervention
Item
Implement Universal Fall Prevention Intervention
boolean
Monitor transfers to/from bed/chair(etc.)
Item
Monitor transfers to/from bed/chair(etc.)
boolean
Use appropriate assistance for transfers to/from bed/chair
Item
Use appropriate assistance for transfers to/from bed/chair
boolean
Use chairs with armrests and of proper height for transfers
Item
Use chairs with armrests and of proper height for transfers
boolean
Implement progressive ambulation(unless contraindicated by condition/orders)
Item
Implement progressive ambulation(unless contraindicated by condition/orders)
boolean
Encourage/Provide self-care assistance
Item
Encourage/Provide self-care assistance
boolean
Remain in attendance during toileting/ADL's
Item
Remain in attendance during toileting/ADL's
boolean
Provide assistive devices for ambulation (canes/walkers/etc.)
Item
Provide assistive devices for ambulation (canes/walkers/etc.)
boolean
Gait Belt during transport/ambulation
Item
Gait Belt during transport/ambulation
boolean
Teach patient/family to call for help and WAIT for help before
Item
Teach patient/family to call for help and WAIT for help before
boolean
attempting any transfer/ambulation
Item
attempting any transfer/ambulation
boolean
Item Group
ALTERED ELIMINATION
Implement Universal Fall Prevention Interventions
Item
Implement Universal Fall Prevention Interventions
boolean
Remain in attendance during toileting/ADL's
Item
Remain in attendance during toileting/ADL's
boolean
Assist with post-elimination hygiene
Item
Assist with post-elimination hygiene
boolean
Remove non-essential clothing
Item
Remove non-essential clothing
boolean
Instruct patient on importance of toileting when offered by staff
Item
Instruct patient on importance of toileting when offered by staff
boolean
Monitor for 'patient's normal' bladder/bowel habits
Item
Monitor for 'patient's normal' bladder/bowel habits
boolean
Monitor for causes of incontinence (diuretics,cathartics,etc.)
Item
Monitor for causes of incontinence (diuretics,cathartics,etc.)
boolean
Monitor skin integrity
Item
Monitor skin integrity
boolean
Item Group
HIGH RISK FALL MEDICATIONS (ANTIEPILEPTICS & BENZODIAZEPINES)
Implement Universal Fall Prevention Interventions
Item
Implement Universal Fall Prevention Interventions
boolean
Monitor drug dosages
Item
Monitor drug dosages
boolean
Evaluate sensory functions
Item
Evaluate sensory functions
boolean
Monitor/Assess for drug overdose
Item
Monitor/Assess for drug overdose
boolean
Monitor response to exercise
Item
Monitor response to exercise
boolean
Educate patient/support system about drug classification, side effects,precautions, toxic symptoms of overdose.
Item
Educate patient/support system about drug classification, side effects,precautions, toxic symptoms of overdose.
boolean
Item Group
INTERVENTIONS (FOR ONCOLOGY USE ONLY)
UNIVERSAL FALL PRECAUTIONS
Item
UNIVERSAL FALL PRECAUTIONS
boolean
Neutropenic Precautions taken.
Item
Neutropenic Precautions taken.
boolean
Date of last chemotherapy cycle
Item
Date of last chemotherapy cycle
date
Chemotherapy Agent/Dosage
Item
Chemotherapy Agent/Dosage
string
day of chemotherapy
Item
day of chemotherapy
integer
Chemotherapy ADVERSE EFFECTS
Item
Chemotherapy ADVERSE EFFECTS
string
Radiation Safety Precautions taken.
Item
Radiation Safety Precautions taken.
boolean
RADIATION INTERNAL
Item
RADIATION INTERNAL
string
Radiation External: Location of Markings
Item
Radiation External: Location of Markings
string
Radiation: Number of Fractions prescribed
Item
Radiation: Number of Fractions prescribed
string
Remaining Radiations
Item
Remaining Radiations
string
Radiation Adverse Effects
Item
Radiation Adverse Effects
string
Item Group
ONN Unit specific
AFFECTED SITE
Item
AFFECTED SITE
string
CIRCULATORY STATUS
Item
CIRCULATORY STATUS
string
SKIN COLOR
Item
SKIN COLOR
string
SENSATION
Item
Sensation
string
C0036658 (UMLS CUI 2011AA)
373713005 (SNOMED CT 2011_0131)
MTHU017277 (LOINC Version 232)
MOVEMENT
Item
MOVEMENT
string
TEMPERATURE
Item
Temperatur
string
C0039476 (UMLS CUI 2011AA)
246508008 (SNOMED CT 2011_0131)
MTHU009008 (LOINC Version 232)
SKIN CONDITION
Item
Hautzustand
string
C1719933 (UMLS CUI 2011AA)
422000003 (SNOMED CT 2011_0131)
MTHU034830 (LOINC Version 232)
PULSE(s) SITE(s)
Item
PULSE(s) SITE(s)
string
RESPONSE
Item
RESPONSE
string
POSITION OF LIMB
Item
POSITION OF LIMB
string
ORTHOPEDIC DEVICE IN USE
Item
ORTHOPEDIC DEVICE IN USE
string
CONTINUOUS PASSIVE MOTION
Item
CONTINUOUS PASSIVE MOTION
string
POUNDS
Item
POUNDS
string
CERVICAL COLLARS
Item
CERVICAL COLLARS
string
AFO BRACE: Foot/Feet
Item
AFO BRACE: Foot/Feet (LEFT-RIGHT-BILATERAL)
string
SWELLING
Item
SWELLING
string
PIN SITES
Item
PIN SITES
string
CLEANED WITH
Item
CLEANED WITH
string
NARRATIVE
Item
NARRATIVE
string
Item Group
Antepartum specific
Gravida
Item
Gravida
integer
Para
Item
Para
integer
EDC
Item
EDC
date
Weeks gestation
Item
Weeks gestation
integer
Fetal movement
Item
Fetal movement
boolean
FHR
Item
FHR
string
Vision
Item
Vision
string
Headaches
Item
Kopfschmerzen
boolean
C0018681 (UMLS CUI 2011AA)
25064002 (SNOMED CT 2011_0131)
10019211 (MedDRA 14.1)
MTHU020860 (LOINC Version 232)
R51 (ICD-10-CM Version 2010)
784.0 (ICD-9-CM Version 2011)
E12678 (CTCAE 1105E)
Abdominal Cramps
Item
Abdominal Cramps
boolean
Uterine Contraction
Item
Uterine Contraction
boolean
Epigastric Pain
Item
Epigastric Pain
boolean
Vaginal Discharge
Item
Vaginal Discharge
boolean
Additional Findings
Item
Additional Findings
string
Fundal Height
Item
Fundal Height
integer
NARRATIVE: Antepartum
Item
NARRATIVE: Antepartum
string
Item Group
Post partum specific
Fundal Location
Item
Fundal Location
string
LOCHIA
Item
LOCHIA
string
Perineum
Item
Perineum
string
BREASTS
Item
Brust
string
C0006141 (UMLS CUI 2011AA)
76752008 (SNOMED CT 2011_0131)
MTHU011382 (LOINC Version 232)
NIPPLES
Item
Mamillen
string
C0028109 (UMLS CUI 2011AA)
24142002 (SNOMED CT 2011_0131)
Mother/Baby Relationship
Item
Mother/Baby Relationship
string
BONDING
Item
BONDING
string
Feedings
Item
Feedings
string
Hemorrhoids
Item
Hämorrhoiden
string
C0019112 (UMLS CUI 2011AA)
70153002 (SNOMED CT 2011_0131)
10019022 (MedDRA 14.1)
MTHU015043 (LOINC Version 232)
I84 (ICD-10-CM Version 2010)
455 (ICD-9-CM Version 2011)
E10773 (CTCAE 1105E)
NARRATIVE: Post partum
Item
NARRATIVE: Post partum
string
Item Group
Post Surgical
General Activity
Item
Patient activity
string
C0451369 (UMLS CUI 2011AA)
273688003 (SNOMED CT 2011_0131)
Vaginal Packing
Item
Vaginal Packing
string
Equipment/Devices
Item
Equipment/Devices
string
EQUIPMENT/DEVICES
Item
EQUIPMENT/DEVICES
string
Item Group
ADOLESCENT INTERACTION
Item
Prepared for treatment/procedure as soon as possible.
string
Code List
Prepared for treatment/procedure as soon as possible.
CL Item
Definitely Yes (1)
CL Item
Yes (2)
CL Item
No (3)
CL Item
not applicable (4)
Item
Provided detailed information about events/procedures/treatments.
string
Code List
Provided detailed information about events/procedures/treatments.
CL Item
Definitely Yes (1)
CL Item
Yes (2)
CL Item
No (3)
CL Item
NA (4)
Item
Allowed contact with peer group.
string
Code List
Allowed contact with peer group.
CL Item
Definitely Yes (1)
CL Item
Yes (2)
CL Item
No (3)
CL Item
NA (4)
NARRATIVE
Item
NARRATIVE
string
Item Group
GERIATRIC INTERVENTION (65+)
Item
Involved in decision process regarding pain control/medication/care decisions
string
Code List
Involved in decision process regarding pain control/medication/care decisions
CL Item
Def. Yes (1)
CL Item
Yes (2)
CL Item
No (3)
CL Item
NA (4)
Item
Encouraged family/S.O.to visit
string
Code List
Encouraged family/S.O.to visit
CL Item
Def. Yes (1)
CL Item
Yes (2)
CL Item
No (3)
CL Item
NA (4)
Item
Independence promoted.
string
Code List
Independence promoted.
CL Item
Def. Yes (1)
CL Item
Yes (2)
CL Item
No (3)
CL Item
NA (4)
NARRATIVE
Item
NARRATIVE
string
Item Group
Hendrich Fall Risk
Confusion/Disorientation +3
Item
Confusion/Disorientation +3
boolean
Depression +4
Item
Depression +4
boolean
C0011581 (UMLS CUI 2011AA)
35489007 (SNOMED CT 2011_0131)
10012401 (MedDRA 14.1)
F32.9 (ICD-10-CM Version 2010)
Altered Elimination (incontinence, nocturia) +3
Item
Altered Elimination (incontinence, nocturia) +3
boolean
Non-Adaptive Mobility/Generalized Weakness +2
Item
Non-Adaptive Mobility/Generalized Weakness +2
boolean
Dizziness/Vertigo +3
Item
Dizziness/Vertigo +3
boolean
Primary Cancer Diagnosis +3
Item
Primary Cancer Diagnosis +3
boolean
C0006826 (UMLS CUI 2011AA)
363346000 (SNOMED CT 2011_0131)
10028997 (MedDRA 14.1)
MTHU010328 (LOINC Version 232)
C00-C96 (ICD-10-CM Version 2010)
RECENT HISTORY of FALLS +7
Item
RECENT HISTORY of FALLS +7
boolean
FINAL Hendrich Fall RISK SCORE
Item
FINAL Hendrich Fall RISK SCORE
integer
Item Group
SUGGESTED INTERVENTIONS
Item
Assist with Ambulation
string
Code List
Assist with Ambulation
CL Item
Definitely Yes (1)
CL Item
Yes (2)
CL Item
No (3)
CL Item
NA (4)
Item
Toileting Q2H
string
Code List
Toileting Q2H
CL Item
Definitely Yes (1)
CL Item
Yes (2)
CL Item
No (3)
CL Item
NA (4)
Item
Sensory Impairment Device
string
Code List
Sensory Impairment Device
CL Item
Definitely Yes (1)
CL Item
Yes (2)
CL Item
No (3)
CL Item
NA (4)
Item
Reorient Q2H or Less
string
Code List
Reorient Q2H or Less
CL Item
Definitely Yes (1)
CL Item
Yes (2)
CL Item
No (3)
CL Item
NA (4)
Item
Gait Belt
string
Code List
Gait Belt
CL Item
Definitely Yes (1)
CL Item
Yes (2)
CL Item
No (3)
CL Item
NA (4)
Item
ID Patient at Risk
string
Code List
ID Patient at Risk
CL Item
Definitely Yes (1)
CL Item
Yes (2)
CL Item
No (3)
CL Item
NA (4)
Item
Restraints (see policy)
string
Code List
Restraints (see policy)
CL Item
Definitely Yes (1)
CL Item
Yes (2)
CL Item
No (3)
CL Item
NA (4)
Item
Multi-personnel Transfer
string
Code List
Multi-personnel Transfer
CL Item
Definitely Yes (1)
CL Item
Yes (2)
CL Item
No (3)
CL Item
NA (4)
Item
Close Observation
string
Code List
Close Observation
CL Item
Definitely Yes (1)
CL Item
Yes (2)
CL Item
No (3)
CL Item
NA (4)
Item
Non-slip Footwear
string
Code List
Non-slip Footwear
CL Item
Definitely Yes (1)
CL Item
Yes (2)
CL Item
No (3)
CL Item
NA (4)

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