Item
INFORMANT
text
C1550484 (UMLS CUI [1])
CL Item
Family (1)
C0015576 (UMLS CUI-1)
CL Item
Nurse (2)
C0028661 (UMLS CUI-1)
CL Item
Patient (3)
C0030705 (UMLS CUI-1)
CL Item
Physician (4)
C0031831 (UMLS CUI-1)
CL Item
Therapist (5)
C0871525 (UMLS CUI-1)
CL Item
Other (6)
C0205394 (UMLS CUI-1)
PRIMARY CONTACT
Item
PRIMARY CONTACT/RELATIONSHIP/TELEPHONE
text
C3476398 (UMLS CUI [1])
COMMUNICATION BARRIER
Item
LANGUAGE/COMMUNICATION BARRIER
boolean
C0009454 (UMLS CUI [1])
Primary Language
Item
Spoken Language
string
C0424919 (UMLS CUI 2011AA)
161139007 (SNOMED CT 2011_0131)
PHYSICIAN
Item
PHYSICIAN
string
CURRENT DIAGNOSIS
Item
Diagnosis
string
C0011900 (UMLS CUI 2011AA)
439401001 (SNOMED CT 2011_0131)
MTHU008876 (LOINC Version 232)
RELEVANT HISTORY
Item
Medical history
string
C0262926 (UMLS CUI 2011AA)
417662000 (SNOMED CT 2011_0131)
MTHU027722 (LOINC Version 232)
Advance directive discussed with patient
Item
DISCUSSED ADVANCE DIRECTIVE WITH PATIENT
boolean
C0587821 (UMLS CUI [1])
PATIENT HAS EXECUTED AN ADVANCE DIRECTIVE
Item
PATIENT HAS EXECUTED AN ADVANCE DIRECTIVE
boolean
C0001683 (UMLS CUI [1])
ADVANCE DIRECTIVE FORM IN THE ELECTRONIC RECORD
Item
IS ADVANCE DIRECTIVE FORM IN THE ELECTRONIC RECORD?
boolean
C0001683 (UMLS CUI [1,1])
C2362543 (UMLS CUI [1,2])
Advance Directive NOTES
Item
NOTES regarding Advance Directive
text
C0001683 (UMLS CUI [1,1])
C1317574 (UMLS CUI [1,2])
Hyperbaric oxygenation therapy
Item
HBO
boolean
C0020431 (UMLS CUI [1])
Occupational Therapy
Item
Occupational Therapy
boolean
C1318464 (UMLS CUI [1])
Physical Therapy
Item
Physical Therapy
boolean
C0949766 (UMLS CUI [1])
Phototherapy
Item
Phototherapy
boolean
C0031765 (UMLS CUI [1])
Radiation / Chemotherapy
Item
Radiation / Chemotherapy
boolean
C1522449 (UMLS CUI 2011AA)
302505005 (SNOMED CT 2011_0131)
C0392920 (UMLS CUI 2011AA)
150415003 (SNOMED CT 2011_0131)
Respiratory Therapy
Item
Respiratory Therapy (RT), Respiratory care
boolean
C0035239 (UMLS CUI 2011AA)
53950000 (SNOMED CT 2011_0131)
10059828 (MedDRA 14.1)
MTHU015440 (LOINC Version 232)
93.9 (ICD-9-CM Version 2011)
Speech Therapy
Item
Speech Therapy
boolean
C0037831 (UMLS CUI [1])
Wound Care
Item
Wound Care
boolean
C0886052 (UMLS CUI [1])
None
Item
None
boolean
C0549184 (UMLS CUI [1])
Item
THE FOLLOWING ASSESSMENT REFLECTS THE PATIENTS' CONDITION
text
C0040223 (UMLS CUI [1])
Code List
THE FOLLOWING ASSESSMENT REFLECTS THE PATIENTS' CONDITION
CL Item
Prior to hospitalization (1)
C0019993 (UMLS CUI-1)
C0332152 (UMLS CUI-2)
CL Item
At current level (2)
C1948052 (UMLS CUI-1)
IV Therapy
Item
intravenous therapy
boolean
C1411942 (UMLS CUI 2011AA)
Foley Catheter Care
Item
Foley Catheter Care
boolean
C3649076 (UMLS CUI [1])
Ostomy Care
Item
Ostomy Care
boolean
C1955856 (UMLS CUI [1])
Wound Care
Item
Wound Care
boolean
C0886052 (UMLS CUI [1])
Feeding Tube Care
Item
Feeding Tube Care
boolean
C2094398 (UMLS CUI [1])
Dialysis
Item
Dialysis
boolean
C0011946 (UMLS CUI [1])
Drain Care
Item
Drain Care
boolean
C2224139 (UMLS CUI [1])
Ventilator
Item
Ventilator
boolean
C0087153 (UMLS CUI [1])
None
Item
None
boolean
C0549184 (UMLS CUI [1])
Notes
Item
Notes
text
C0947611 (UMLS CUI [1])
Wheelchair
Item
Wheelchair
boolean
Bedbound
Item
Bedbound
boolean
Incontinence
Item
Incontinence
boolean
C0021167 (UMLS CUI 2011AA)
48340000 (SNOMED CT 2011_0131)
10021639 (MedDRA 14.1)
Hygiene preparation
Item
Hygiene preparation
boolean
Meal preparation
Item
Meal preparation
boolean
Feeding tube
Item
Tube feeding (TF), Enteral tube feeding, Gavage
boolean
C0041281 (UMLS CUI 2011AA)
61420007 (SNOMED CT 2011_0131)
10053095 (MedDRA 14.1)
Grooming / Dressing
Item
Grooming / Dressing
boolean
Shopping
Item
Shopping
boolean
C0150768 (UMLS CUI [1])
Laundry
Item
Laundry
boolean
C1830412 (UMLS CUI [1])
Cleaning
Item
Cleaning
boolean
Total independence
Item
Total independence
boolean
Mobility impaired
Item
Mobility impaired
boolean
C0518456 (UMLS CUI [1])
No assistance needed
Item
No assistance required
boolean
C2599886 (UMLS CUI [1])
PATIENT'S/FAMILY'S PERCEPTION OF ILLNESS/ADMISSION
Item
PATIENT'S/FAMILY'S PERCEPTION OF ILLNESS/ADMISSION
string
COPING STRENGTHS
Item
COPING STRENGTHS
string
Coping WEAKNESSES
Item
Coping WEAKNESSES
string
NOTED COGNITIVE/BEHAVIORAL/BONDING/FUNCTIONAL PROBLEMS
Item
NOTED COGNITIVE/BEHAVIORAL/BONDING/FUNCTIONAL PROBLEMS
string
EXPLANATION OF FAMILY DYNAMICS/PATIENT INVOLVEMENT/PEDI/SPOUSE/BOYFRIEND INVOLVEMENT
Item
EXPLANATION OF FAMILY DYNAMICS/PATIENT INVOLVEMENT/PEDI/SPOUSE/BOYFRIEND INVOLVEMENT
string
RELIGIOUS/CULTURAL PREFERENCE
Item
RELIGIOUS/CULTURAL PREFERENCE
string
No Needs evident
Item
No Needs evident
boolean
Adoption
Item
Adoption
boolean
C0237459 (UMLS CUI [1])
Adult protective Services
Item
Adult protective Services
boolean
Assistance ADL's
Item
Assistance ADL's
boolean
Child protective Services
Item
Child protective Services
boolean
Counseling / Therapy
Item
Counseling / Therapy
boolean
Education
Item
Education
boolean
C0013631 (UMLS CUI [1])
Equipment
Item
Equipment
boolean
C0014672 (UMLS CUI [1])
Financial Resources
Item
Financial Resources
boolean
C0516918 (UMLS CUI [1])
Food / Clothing
Item
Food / Clothing
boolean
Home health
Item
Home health
boolean
C0019855 (UMLS CUI [1])
Hospice
Item
Hospice
boolean
C0085555 (UMLS CUI [1])
Housing
Item
Housing
boolean
Lifeline / ERS
Item
Lifeline / ERS
boolean
Medication / Supplies
Item
Medication / Supplies
boolean
PBCCMHMR
Item
PBCCMHMR
boolean
Meals on Wheels
Item
Meals on Wheels
boolean
Nursing facility placement
Item
Nursing facility placement
boolean
Other hospital
Item
Other hospital
boolean
C4035586 (UMLS CUI [1])
Rehabilitation
Item
Rehabilitation, Rehabilitation therapy
boolean
C0034991 (UMLS CUI 2011AA)
52052004 (SNOMED CT 2011_0131)
10057374 (MedDRA 14.1)
Safe Place
Item
Safe Place
boolean
Skilled Nursing Facility
Item
Skilled Nursing Facility
boolean
Substance abuse treatment
Item
Substance abuse treatment
boolean
C0740858 (UMLS CUI 2011AA)
66214007 (SNOMED CT 2011_0131)
10066169 (MedDRA 14.1)
MTHU019364 (LOINC Version 232)
C0039798 (UMLS CUI 2011AA)
Support Group
Item
Support Group
boolean
Transportation
Item
Transportation
boolean
C0040757 (UMLS CUI [1])
INITIAL ASSESSMENT NOTE
Item
INITIAL ASSESSMENT NOTE
string
Item
AT THIS TIME CONTINUED INTERVENTION IS
text
C0584669 (UMLS CUI [1])
Code List
AT THIS TIME CONTINUED INTERVENTION IS
CL Item
indicated (1)
C1444656 (UMLS CUI-1)
CL Item
not indicated (2)
C1444655 (UMLS CUI-1)
PLANNED DISPOSITION
Item
PLANNED DISPOSITION
string
C1301732 (UMLS CUI 2011AA)
397943006 (SNOMED CT 2011_0131)
C1550390 (UMLS CUI 2011AA)
MTHU021441 (LOINC Version 232)
PLANNED DISCHARGE DATE
Item
ANTICIPATED DATE OF PLANNED DISPOSITION
date
C3841770 (UMLS CUI [1])