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ID
22628
Beschreibung
Form from HIS OpenVista
Stichworte
Versionen (2)
- 09.03.12 09.03.12 -
- 08.06.17 08.06.17 - Martin Dugas
Hochgeladen am
8. Juni 2017
DOI
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SOCIAL SERVICES PSYCHOSOCIAL ASSESSMENT NOTE
Ähnliche Modelle
HIS
- StudyEvent: HIS
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
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)
161139007 (SNOMED CT 2011_0131)
PHYSICIAN
Item
PHYSICIAN
string
CURRENT DIAGNOSIS
Item
Diagnose
string
RELEVANT HISTORY
Item
Anamnese
string
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])
C2362543 (UMLS CUI [1,2])
Advance Directive NOTES
Item
NOTES regarding Advance Directive
text
C0001683 (UMLS CUI [1,1])
C1317574 (UMLS CUI [1,2])
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)
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)
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])
Code List
THE FOLLOWING ASSESSMENT REFLECTS THE PATIENTS' CONDITION
CL Item
Prior to hospitalization (1)
C0019993 (UMLS CUI-1)
C0332152 (UMLS CUI-2)
C0332152 (UMLS CUI-2)
CL Item
At current level (2)
C1948052 (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])
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)
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])
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])
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])
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])
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])
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
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)
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)
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
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
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)
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)
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
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)
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])