ID

22628

Description

Form from HIS OpenVista

Keywords

Versions (2)
  1. 3/9/12 3/9/12 -
  2. 6/8/17 6/8/17 - Martin Dugas
Uploaded on

June 8, 2017

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License

Creative Commons BY-NC 3.0
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SOCIAL SERVICES PSYCHOSOCIAL ASSESSMENT NOTE

German English

HIS

1 forms  
  1. StudyEvent: HIS
    1. HIS
Psychosocial Assessment
Description

Psychosocial Assessment

Alias
UMLS CUI-1
C1455743
INFORMANT
Description

INFORMANT

Data type

text

Alias
UMLS CUI [1]
C1550484
PRIMARY CONTACT/RELATIONSHIP/TELEPHONE
Description

PRIMARY CONTACT

Data type

text

Alias
UMLS CUI [1]
C3476398
LANGUAGE/COMMUNICATION BARRIER
Description

COMMUNICATION BARRIER

Data type

boolean

Alias
UMLS CUI [1]
C0009454
Spoken Language
Description

Primary Language

Data type

string

Alias
UMLS CUI 2011AA
C0424919
SNOMED CT 2011_0131
161139007
PHYSICIAN
Description

PHYSICIAN

Data type

string

Diagnose
Description

CURRENT DIAGNOSIS

Data type

string

Alias
UMLS CUI 2011AA
C0011900
SNOMED CT 2011_0131
439401001
LOINC Version 232
MTHU008876
Anamnese
Description

RELEVANT HISTORY

Data type

string

Alias
UMLS CUI 2011AA
C0262926
SNOMED CT 2011_0131
417662000
LOINC Version 232
MTHU027722
DISCUSSED ADVANCE DIRECTIVE WITH PATIENT
Description

Advance directive discussed with patient

Data type

boolean

Alias
UMLS CUI [1]
C0587821
PATIENT HAS EXECUTED AN ADVANCE DIRECTIVE
Description

PATIENT HAS EXECUTED AN ADVANCE DIRECTIVE

Data type

boolean

Alias
UMLS CUI [1]
C0001683
IS ADVANCE DIRECTIVE FORM IN THE ELECTRONIC RECORD?
Description

ADVANCE DIRECTIVE FORM IN THE ELECTRONIC RECORD

Data type

boolean

Alias
UMLS CUI [1,1]
C0001683
UMLS CUI [1,2]
C2362543
NOTES regarding Advance Directive
Description

Advance Directive NOTES

Data type

text

Alias
UMLS CUI [1,1]
C0001683
UMLS CUI [1,2]
C1317574
Therapien
Description

Therapien

Alias
UMLS CUI-1
C0087111
HBO
Description

Hyperbaric oxygenation therapy

Data type

boolean

Alias
UMLS CUI [1]
C0020431
Occupational Therapy
Description

Occupational Therapy

Data type

boolean

Alias
UMLS CUI [1]
C1318464
Physical Therapy
Description

Physical Therapy

Data type

boolean

Alias
UMLS CUI [1]
C0949766
Phototherapy
Description

Phototherapy

Data type

boolean

Alias
UMLS CUI [1]
C0031765
Radiation / Chemotherapy
Description

Radiation / Chemotherapy

Data type

boolean

Alias
UMLS CUI 2011AA
C1522449
SNOMED CT 2011_0131
302505005
UMLS CUI 2011AA
C0392920
SNOMED CT 2011_0131
150415003
Atemtherapie
Description

Respiratory Therapy

Data type

boolean

Alias
UMLS CUI 2011AA
C0035239
SNOMED CT 2011_0131
53950000
MedDRA 14.1
10059828
LOINC Version 232
MTHU015440
ICD-9-CM Version 2011
93.9
Speech Therapy
Description

Speech Therapy

Data type

boolean

Alias
UMLS CUI [1]
C0037831
Wound Care
Description

Wound Care

Data type

boolean

Alias
UMLS CUI [1]
C0886052
None
Description

None

Data type

boolean

Alias
UMLS CUI [1]
C0549184
Time of Patient's condition
Description

Time of Patient's condition

Alias
UMLS CUI-1
C0040223
THE FOLLOWING ASSESSMENT REFLECTS THE PATIENTS' CONDITION
Description

Time

Data type

text

Alias
UMLS CUI [1]
C0040223
Patient Status
Description

Patient Status

Alias
UMLS CUI-1
C0449437
Alert
Description

Alert

Data type

boolean

Alias
UMLS CUI [1]
C0239110
Disoriented
Description

Disoriented

Data type

boolean

Alias
UMLS CUI [1]
C0233407
Comatose
Description

Comatose

Data type

boolean

Alias
UMLS CUI [1]
C0009421
Speech impairment
Description

Speech impairment

Data type

boolean

Alias
UMLS CUI [1]
C0233715
Vision impairment
Description

Vision impairment

Data type

boolean

Alias
UMLS CUI [1]
C1456582
Hearing impairment
Description

Hearing impairment

Data type

boolean

Alias
UMLS CUI [1]
C1384666
Notes
Description

Notes

Data type

text

Alias
UMLS CUI [1]
C0947611
Living Situation
Description

Living Situation

Alias
UMLS CUI-1
C2184149
Lives with family
Description

Lives with family

Data type

boolean

Alias
UMLS CUI [1]
C0557130
Lives with spouse
Description

Lives with spouse

Data type

boolean

Alias
UMLS CUI [1]
C2184147
Pflegeheim
Description

Nursing home

Data type

boolean

Alias
UMLS CUI 2011AA
C0028688
SNOMED CT 2011_0131
42665001
LOINC Version 232
MTHU015917
HL7 V3 2006_05
N
Foster home
Description

Foster home

Data type

boolean

Alias
UMLS CUI [1]
C0599761
Home alone
Description

Home alone

Data type

boolean

Alias
UMLS CUI [1]
C0439044
Notes
Description

Notes

Data type

text

Alias
UMLS CUI [1]
C0947611
FINANCIAL INFORMATION
Description

FINANCIAL INFORMATION

Alias
UMLS CUI-1
C3242467
employed
Description

employed

Data type

boolean

Alias
UMLS CUI [1]
C0557351
unemployed
Description

unemployed

Data type

boolean

Alias
UMLS CUI [1]
C0041674
commercial insurance
Description

commercial insurance

Data type

boolean

Alias
UMLS CUI [1]
C3530230
MEDICAID
Description

MEDICAID

Data type

boolean

Alias
UMLS CUI [1]
C0596896
MEDICARE
Description

MEDICARE

Data type

boolean

Alias
UMLS CUI [1]
C0018717
SS
Description

SS

Data type

boolean

Alias
UMLS CUI [1]
C3846158
SSD
Description

SSD

Data type

boolean

Alias
UMLS CUI [1]
C0585391
SSI
Description

SSI

Data type

boolean

Alias
UMLS CUI [1]
C3846158
AFDC
Description

AFDC

Data type

boolean

Alias
UMLS CUI [1]
C0001843
CSHCN
Description

CSHCN

Data type

boolean

Alias
UMLS CUI [1]
C3846158
CHIP
Description

CHIP

Data type

boolean

Alias
UMLS CUI [1]
C3846158
MCHD
Description

MCHD

Data type

boolean

Alias
UMLS CUI [1]
C3846158
VA
Description

VA

Data type

boolean

Alias
UMLS CUI [1]
C3846158
No Income
Description

No Income

Data type

boolean

Alias
UMLS CUI [1]
C1827386
Notes
Description

Notes

Data type

text

Alias
UMLS CUI [1]
C0947611
SUPPORT SYSTEM
Description

SUPPORT SYSTEM

Alias
UMLS CUI-1
C0748877
Spouse/Family
Description

Spouse

Data type

boolean

Alias
UMLS CUI [1]
C0162409
Church
Description

Church

Data type

boolean

Alias
UMLS CUI [1]
C3810853
Agency
Description

Agency

Data type

boolean

Alias
UMLS CUI [1]
C0237463
None
Description

None

Data type

boolean

Alias
UMLS CUI [1]
C0549184
Notes
Description

Notes

Data type

text

Alias
UMLS CUI [1]
C0947611
CAREGIVER
Description

CAREGIVER

Alias
UMLS CUI-1
C0085537
Self
Description

Self

Data type

boolean

Alias
UMLS CUI [1]
C0036588
Spouse/Family
Description

Spouse

Data type

boolean

Alias
UMLS CUI [1]
C0162409
Friend
Description

Friend

Data type

boolean

Alias
UMLS CUI [1]
C0079382
Agency personnel
Description

Agency personnel

Data type

boolean

Alias
UMLS CUI [1]
C4035527
Community Clinic
Description

Community Clinic

Data type

boolean

Alias
UMLS CUI [1]
C0587907
Notes
Description

Notes

Data type

text

Alias
UMLS CUI [1]
C0947611
SKILLED NEEDS
Description

SKILLED NEEDS

Alias
UMLS CUI-1
C0871403
intravenöse Therapie
Description

IV Therapy

Data type

boolean

Alias
UMLS CUI 2011AA
C1411942
Foley Catheter Care
Description

Foley Catheter Care

Data type

boolean

Alias
UMLS CUI [1]
C3649076
Ostomy Care
Description

Ostomy Care

Data type

boolean

Alias
UMLS CUI [1]
C1955856
Wound Care
Description

Wound Care

Data type

boolean

Alias
UMLS CUI [1]
C0886052
Feeding Tube Care
Description

Feeding Tube Care

Data type

boolean

Alias
UMLS CUI [1]
C2094398
Dialysis
Description

Dialysis

Data type

boolean

Alias
UMLS CUI [1]
C0011946
Drain Care
Description

Drain Care

Data type

boolean

Alias
UMLS CUI [1]
C2224139
Ventilator
Description

Ventilator

Data type

boolean

Alias
UMLS CUI [1]
C0087153
None
Description

None

Data type

boolean

Alias
UMLS CUI [1]
C0549184
Notes
Description

Notes

Data type

text

Alias
UMLS CUI [1]
C0947611
CURRENT ASSISTIVE DEVICES EQUIPMENT NEEDS
Description

CURRENT ASSISTIVE DEVICES EQUIPMENT NEEDS

Wheelchair
Description

Wheelchair

Data type

boolean

Crutches
Description

Crutches

Data type

boolean

Walker
Description

Walker

Data type

boolean

Cane
Description

Cane

Data type

boolean

Hospital Bed/Rails
Description

Hospital Bed/Rails

Data type

boolean

Hoyer lift/Trapeze
Description

Hoyer lift/Trapeze

Data type

boolean

Oxygen
Description

Oxygen

Data type

boolean

Apnea Monitor
Description

Apnea Monitor

Data type

boolean

Carseat
Description

Carseat

Data type

boolean

Crib
Description

Crib

Data type

boolean

None
Description

None

Data type

boolean

Notes
Description

Notes

Data type

string

DAILY LIVING ACTIVITY
Description

DAILY LIVING ACTIVITY

Wheelchair
Description

Wheelchair

Data type

boolean

Bedbound
Description

Bedbound

Data type

boolean

Inkontinenz
Description

Incontinence

Data type

boolean

Alias
UMLS CUI 2011AA
C0021167
SNOMED CT 2011_0131
48340000
MedDRA 14.1
10021639
Hygiene preparation
Description

Hygiene preparation

Data type

boolean

Meal preparation
Description

Meal preparation

Data type

boolean

Ernährung über Sonde
Description

Feeding tube

Data type

boolean

Alias
UMLS CUI 2011AA
C0041281
SNOMED CT 2011_0131
61420007
MedDRA 14.1
10053095
Grooming / Dressing
Description

Grooming / Dressing

Data type

boolean

Shopping
Description

Shopping

Data type

boolean

Alias
UMLS CUI [1]
C0150768
Laundry
Description

Laundry

Data type

boolean

Alias
UMLS CUI [1]
C1830412
Cleaning
Description

Cleaning

Data type

boolean

Total independence
Description

Total independence

Data type

boolean

Mobility impaired
Description

Mobility impaired

Data type

boolean

Alias
UMLS CUI [1]
C0518456
No assistance required
Description

No assistance needed

Data type

boolean

Alias
UMLS CUI [1]
C2599886
Notes
Description

Notes

Data type

string

PSYCHOSOCIAL ASSESSMENT
Description

PSYCHOSOCIAL ASSESSMENT

PATIENT'S/FAMILY'S PERCEPTION OF ILLNESS/ADMISSION
Description

PATIENT'S/FAMILY'S PERCEPTION OF ILLNESS/ADMISSION

Data type

string

COPING STRENGTHS
Description

COPING STRENGTHS

Data type

string

Coping WEAKNESSES
Description

Coping WEAKNESSES

Data type

string

NOTED COGNITIVE/BEHAVIORAL/BONDING/FUNCTIONAL PROBLEMS
Description

NOTED COGNITIVE/BEHAVIORAL/BONDING/FUNCTIONAL PROBLEMS

Data type

string

EXPLANATION OF FAMILY DYNAMICS/PATIENT INVOLVEMENT/PEDI/SPOUSE/BOYFRIEND INVOLVEMENT
Description

EXPLANATION OF FAMILY DYNAMICS/PATIENT INVOLVEMENT/PEDI/SPOUSE/BOYFRIEND INVOLVEMENT

Data type

string

RELIGIOUS/CULTURAL PREFERENCE
Description

RELIGIOUS/CULTURAL PREFERENCE

RELIGIOUS/CULTURAL PREFERENCE
Description

RELIGIOUS/CULTURAL PREFERENCE

Data type

string

POSSIBLE NEEDS
Description

POSSIBLE NEEDS

No Needs evident
Description

No Needs evident

Data type

boolean

Adoption
Description

Adoption

Data type

boolean

Alias
UMLS CUI [1]
C0237459
Adult protective Services
Description

Adult protective Services

Data type

boolean

Assistance ADL's
Description

Assistance ADL's

Data type

boolean

Child protective Services
Description

Child protective Services

Data type

boolean

Counseling / Therapy
Description

Counseling / Therapy

Data type

boolean

Ausbildung
Description

Education

Data type

boolean

Alias
UMLS CUI [1]
C0013631
Equipment
Description

Equipment

Data type

boolean

Alias
UMLS CUI [1]
C0014672
Financial Resources
Description

Financial Resources

Data type

boolean

Alias
UMLS CUI [1]
C0516918
Food / Clothing
Description

Food / Clothing

Data type

boolean

Home health
Description

Home health

Data type

boolean

Alias
UMLS CUI [1]
C0019855
Hospice
Description

Hospice

Data type

boolean

Alias
UMLS CUI [1]
C0085555
Housing
Description

Housing

Data type

boolean

Lifeline / ERS
Description

Lifeline / ERS

Data type

boolean

LTAC
Description

LTAC

Data type

boolean

Medication / Supplies
Description

Medication / Supplies

Data type

boolean

PBCCMHMR
Description

PBCCMHMR

Data type

boolean

Meals on Wheels
Description

Meals on Wheels

Data type

boolean

Nursing facility placement
Description

Nursing facility placement

Data type

boolean

Other hospital
Description

Other hospital

Data type

boolean

Alias
UMLS CUI [1]
C4035586
Rehabilitation
Description

Rehabilitation

Data type

boolean

Alias
UMLS CUI 2011AA
C0034991
SNOMED CT 2011_0131
52052004
MedDRA 14.1
10057374
Safe Place
Description

Safe Place

Data type

boolean

Skilled Nursing Facility
Description

Skilled Nursing Facility

Data type

boolean

Substance abuse treatment
Description

Substance abuse treatment

Data type

boolean

Alias
UMLS CUI 2011AA
C0740858
SNOMED CT 2011_0131
66214007
MedDRA 14.1
10066169
LOINC Version 232
MTHU019364
UMLS CUI 2011AA
C0039798
Support Group
Description

Support Group

Data type

boolean

Transportation
Description

Transportation

Data type

boolean

Alias
UMLS CUI [1]
C0040757
WIC
Description

WIC

Data type

boolean

Other
Description

Other

Data type

boolean

INITIAL ASSESSMENT NOTE
Description

INITIAL ASSESSMENT NOTE

Data type

string

AT THIS TIME CONTINUED INTERVENTION IS
Description

CONTINUE Therapy

Data type

text

Alias
UMLS CUI [1]
C0584669
PLANNED DISPOSITION
Description

PLANNED DISPOSITION

Data type

string

Alias
UMLS CUI 2011AA
C1301732
SNOMED CT 2011_0131
397943006
UMLS CUI 2011AA
C1550390
LOINC Version 232
MTHU021441
ANTICIPATED DATE OF PLANNED DISPOSITION
Description

PLANNED DISCHARGE DATE

Data type

date

Alias
UMLS CUI [1]
C3841770
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Similar models

HIS

1 forms
  1. StudyEvent: HIS
    1. HIS
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Psychosocial Assessment
C1455743 (UMLS CUI-1)
Item
INFORMANT
text
C1550484 (UMLS CUI [1])
INFORMANT
Code List
INFORMANT
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
Diagnose
string
C0011900 (UMLS CUI 2011AA)
439401001 (SNOMED CT 2011_0131)
MTHU008876 (LOINC Version 232)
RELEVANT HISTORY
Item
Anamnese
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])
Item Group
Therapien
C0087111 (UMLS CUI-1)
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
Atemtherapie
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 Group
Time of Patient's condition
C0040223 (UMLS CUI-1)
Item
THE FOLLOWING ASSESSMENT REFLECTS THE PATIENTS' CONDITION
text
C0040223 (UMLS CUI [1])
THE FOLLOWING ASSESSMENT REFLECTS THE PATIENTS' CONDITION
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)
Item Group
Patient Status
C0449437 (UMLS CUI-1)
Alert
Item
Alert
boolean
C0239110 (UMLS CUI [1])
Disoriented
Item
Disoriented
boolean
C0233407 (UMLS CUI [1])
Comatose
Item
Comatose
boolean
C0009421 (UMLS CUI [1])
Speech impairment
Item
Speech impairment
boolean
C0233715 (UMLS CUI [1])
Vision impairment
Item
Vision impairment
boolean
C1456582 (UMLS CUI [1])
Hearing impairment
Item
Hearing impairment
boolean
C1384666 (UMLS CUI [1])
Notes
Item
Notes
text
C0947611 (UMLS CUI [1])
Item Group
Living Situation
C2184149 (UMLS CUI-1)
Lives with family
Item
Lives with family
boolean
C0557130 (UMLS CUI [1])
Lives with spouse
Item
Lives with spouse
boolean
C2184147 (UMLS CUI [1])
Nursing home
Item
Pflegeheim
boolean
C0028688 (UMLS CUI 2011AA)
42665001 (SNOMED CT 2011_0131)
MTHU015917 (LOINC Version 232)
N (HL7 V3 2006_05)
Foster home
Item
Foster home
boolean
C0599761 (UMLS CUI [1])
Home alone
Item
Home alone
boolean
C0439044 (UMLS CUI [1])
Notes
Item
Notes
text
C0947611 (UMLS CUI [1])
Item Group
FINANCIAL INFORMATION
C3242467 (UMLS CUI-1)
employed
Item
employed
boolean
C0557351 (UMLS CUI [1])
unemployed
Item
unemployed
boolean
C0041674 (UMLS CUI [1])
commercial insurance
Item
commercial insurance
boolean
C3530230 (UMLS CUI [1])
MEDICAID
Item
MEDICAID
boolean
C0596896 (UMLS CUI [1])
MEDICARE
Item
MEDICARE
boolean
C0018717 (UMLS CUI [1])
SS
Item
SS
boolean
C3846158 (UMLS CUI [1])
SSD
Item
SSD
boolean
C0585391 (UMLS CUI [1])
SSI
Item
SSI
boolean
C3846158 (UMLS CUI [1])
AFDC
Item
AFDC
boolean
C0001843 (UMLS CUI [1])
CSHCN
Item
CSHCN
boolean
C3846158 (UMLS CUI [1])
CHIP
Item
CHIP
boolean
C3846158 (UMLS CUI [1])
MCHD
Item
MCHD
boolean
C3846158 (UMLS CUI [1])
VA
Item
VA
boolean
C3846158 (UMLS CUI [1])
No Income
Item
No Income
boolean
C1827386 (UMLS CUI [1])
Notes
Item
Notes
text
C0947611 (UMLS CUI [1])
Item Group
SUPPORT SYSTEM
C0748877 (UMLS CUI-1)
Spouse
Item
Spouse/Family
boolean
C0162409 (UMLS CUI [1])
Church
Item
Church
boolean
C3810853 (UMLS CUI [1])
Agency
Item
Agency
boolean
C0237463 (UMLS CUI [1])
None
Item
None
boolean
C0549184 (UMLS CUI [1])
Notes
Item
Notes
text
C0947611 (UMLS CUI [1])
Item Group
CAREGIVER
C0085537 (UMLS CUI-1)
Self
Item
Self
boolean
C0036588 (UMLS CUI [1])
Spouse
Item
Spouse/Family
boolean
C0162409 (UMLS CUI [1])
Friend
Item
Friend
boolean
C0079382 (UMLS CUI [1])
Agency personnel
Item
Agency personnel
boolean
C4035527 (UMLS CUI [1])
Community Clinic
Item
Community Clinic
boolean
C0587907 (UMLS CUI [1])
Notes
Item
Notes
text
C0947611 (UMLS CUI [1])
Item Group
SKILLED NEEDS
C0871403 (UMLS CUI-1)
IV Therapy
Item
intravenöse Therapie
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])
Item Group
CURRENT ASSISTIVE DEVICES EQUIPMENT NEEDS
Wheelchair
Item
Wheelchair
boolean
Crutches
Item
Crutches
boolean
Walker
Item
Walker
boolean
Cane
Item
Cane
boolean
Hospital Bed/Rails
Item
Hospital Bed/Rails
boolean
Hoyer lift/Trapeze
Item
Hoyer lift/Trapeze
boolean
Oxygen
Item
Oxygen
boolean
Apnea Monitor
Item
Apnea Monitor
boolean
Carseat
Item
Carseat
boolean
Crib
Item
Crib
boolean
None
Item
None
boolean
Notes
Item
Notes
string
Item Group
DAILY LIVING ACTIVITY
Wheelchair
Item
Wheelchair
boolean
Bedbound
Item
Bedbound
boolean
Incontinence
Item
Inkontinenz
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
Ernährung über Sonde
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])
Notes
Item
Notes
string
Item Group
PSYCHOSOCIAL ASSESSMENT
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
Item Group
RELIGIOUS/CULTURAL PREFERENCE
RELIGIOUS/CULTURAL PREFERENCE
Item
RELIGIOUS/CULTURAL PREFERENCE
string
Item Group
POSSIBLE NEEDS
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
Ausbildung
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
LTAC
Item
LTAC
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
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])
WIC
Item
WIC
boolean
Other
Item
Other
boolean
INITIAL ASSESSMENT NOTE
Item
INITIAL ASSESSMENT NOTE
string
Item
AT THIS TIME CONTINUED INTERVENTION IS
text
C0584669 (UMLS CUI [1])
AT THIS TIME CONTINUED INTERVENTION IS
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])
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