ID

235

Beschreibung

Form from HIS OpenVista

Stichworte

Versionen (6)
  1. 07.03.12 07.03.12 -
  2. 07.08.14 07.08.14 - Martin Dugas
  3. 09.08.14 09.08.14 - Martin Dugas
  4. 23.12.14 23.12.14 - Martin Dugas
  5. 25.06.15 25.06.15 - Martin Dugas
  6. 27.09.21 27.09.21 -
Hochgeladen am

7. März 2012

DOI

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HIS SHORT STAY RECORD ID NOTE-ENDO

Deutsch Englisch

HIS

1 Formulare  
  1. StudyEvent: HIS
    1. HIS
SHORT STAY RECORD ID NOTE-ENDO
Beschreibung

SHORT STAY RECORD ID NOTE-ENDO

Age
Beschreibung

Age

Datentyp

integer

Alias
UMLS CUI 2011AA
C0001779
SNOMED CT 2011_0131
397669002
Sex
Beschreibung

Sex

Datentyp

string

Alias
UMLS CUI 2011AA
C0079399
SNOMED CT 2011_0131
263495000
LOINC Version 232
MTHU002975
Racial group
Beschreibung

Race

Datentyp

string

Alias
UMLS CUI 2011AA
C0034510
SNOMED CT 2011_0131
103579009
LOINC Version 232
MTHU009923
Height
Beschreibung

Height

Datentyp

integer

Alias
UMLS CUI 2011AA
C0489786
LOINC Version 232
MTHU005354
Weight
Beschreibung

Weight

Datentyp

float

Alias
UMLS CUI 2011AA
C1305866
SNOMED CT 2011_0131
107647005
MedDRA 14.1
10047890
LOINC Version 232
LP18015-5
Hypersensitivity
Beschreibung

Allergies

Datentyp

string

Alias
UMLS CUI 2011AA
C0020517
SNOMED CT 2011_0131
257550005
Chief complaint (CC)
Beschreibung

Chief complaint (CC)

Abnormal GI Xray
Beschreibung

Abnormal GI Xray

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0521362
LOINC Version 232
MTHU031867
UMLS CUI 2011AA
C0000766
MedDRA 14.1
10048065
Abdominal Pain
Beschreibung

Abdominal Pain

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0000737
SNOMED CT 2011_0131
21522001
MedDRA 14.1
10000081
LOINC Version 232
MTHU013636
ICD-10-CM Version 2010
R10.9
ICD-9-CM Version 2011
789.0
CTCAE 1105E
E10460
Abnormal weight loss (finding)
Beschreibung

Abnormal Weight Loss

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0936227
SNOMED CT 2011_0131
267024001
MedDRA 14.1
10000159
ICD-10-CM Version 2010
R63.4
Achalasia
Beschreibung

Achalasia

Datentyp

boolean

Alias
UMLS CUI 2011AA
C1321756
SNOMED CT 2011_0131
48531003
MedDRA 14.1
10000420
ICD-10-CM Version 2010
K22.0
Anaemia
Beschreibung

Anemia

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0002871
SNOMED CT 2011_0131
271737000
MedDRA 14.1
10002034
LOINC Version 232
MTHU020823
ICD-10-CM Version 2010
D64.9
ICD-9-CM Version 2011
285.9
CTCAE 1105E
E10010
Ascites
Beschreibung

Ascites

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0003962
SNOMED CT 2011_0131
389026000
MedDRA 14.1
10003445
ICD-10-CM Version 2010
R18
ICD-9-CM Version 2011
789.5
CTCAE 1105E
E10502
Irregular bowel habits
Beschreibung

Change in Bowel Habits

Datentyp

boolean

Alias
UMLS CUI 2011AA
C2919545
SNOMED CT 2011_0131
444702007
Liver Cirrhosis
Beschreibung

Hepatic Cirrhosis

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0023890
SNOMED CT 2011_0131
19943007
MedDRA 14.1
10019641
ICD-10-CM Version 2010
K74.60
Screening for Colorectal Cancer
Beschreibung

Colorectal Cancer Screening

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0281185
Common Bile Duct Leak
Beschreibung

Common Bile Duct Leak

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0009437
SNOMED CT 2011_0131
79741001
LOINC Version 232
MTHU011879
UMLS CUI 2011AA
CL382906
Common Bile Duct Stone
Beschreibung

Common Bile Duct Stone

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0009437
SNOMED CT 2011_0131
79741001
LOINC Version 232
MTHU011879
UMLS CUI 2011AA
C0006736
SNOMED CT 2011_0131
56381008
LOINC Version 232
MTHU003416
Constipation
Beschreibung

Constipation

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0009806
SNOMED CT 2011_0131
14760008
MedDRA 14.1
10010774
LOINC Version 232
MTHU020768
ICD-10-CM Version 2010
K59.0
ICD-9-CM Version 2011
564.0
CTCAE 1105E
E10562
Diarrhea
Beschreibung

Diarrhea

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0011991
SNOMED CT 2011_0131
62315008
MedDRA 14.1
10012735
LOINC Version 232
MTHU013347
ICD-10-CM Version 2010
R19.7
ICD-9-CM Version 2011
787.91
CTCAE 1105E
E10572
Indigestion
Beschreibung

Dyspepsia

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0013395
SNOMED CT 2011_0131
162031009
MedDRA 14.1
10013946
ICD-10-CM Version 2010
R10.13, K30
CTCAE 1105E
E10617
Deglutition Disorders
Beschreibung

Dysphagia

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0011168
SNOMED CT 2011_0131
40739000
MedDRA 14.1
10013950
LOINC Version 232
MTHU029874
ICD-10-CM Version 2010
R13
ICD-9-CM Version 2011
787.2
CTCAE 1105E
E10621
Elevated Liver Function Tests
Beschreibung

Elevated Liver Function Tests

Datentyp

boolean

Oesophageal Varices
Beschreibung

Esophageal Varices

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0014867
SNOMED CT 2011_0131
28670008
MedDRA 14.1
10030209
ICD-10-CM Version 2010
I85
Family History of Colon Cancer
Beschreibung

Family History of Colon Cancer

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0241889
SNOMED CT 2011_0131
57177007
UMLS CUI 2011AA
C0699790
SNOMED CT 2011_0131
269533000
MedDRA 14.1
10009957
Family History of Polyps
Beschreibung

Family History of Polyps

Datentyp

boolean

Family History of Polyposis
Beschreibung

Family History of Polyposis

Datentyp

boolean

Foreign Body in Colon
Beschreibung

Foreign Body in Colon

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0016542
SNOMED CT 2011_0131
125670008
MedDRA 14.1
10070245
UMLS CUI 2011AA
C0009368
SNOMED CT 2011_0131
71854001
LOINC Version 232
MTHU003023
Foreign Body in Esophagus
Beschreibung

Foreign Body in Esophagus

Datentyp

boolean

Foreign Body in Stomach
Beschreibung

Foreign Body in Stomach

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0016542
SNOMED CT 2011_0131
125670008
MedDRA 14.1
10070245
UMLS CUI 2011AA
C0038351
SNOMED CT 2011_0131
69695003
LOINC Version 232
MTHU003059
Peptic Ulcer
Beschreibung

Gastric Ulcer

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0030920
SNOMED CT 2011_0131
13200003
MedDRA 14.1
10034341
ICD-10-CM Version 2010
K27
Gastroesophageal reflux disease (GERD)
Beschreibung

GERD

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0017168
SNOMED CT 2011_0131
235595009
MedDRA 14.1
10017885
ICD-10-CM Version 2010
K21
ICD-9-CM Version 2011
530.81
CTCAE 1105E
E10739
Gastrointestinal Hemorrhage
Beschreibung

GI Bleeding

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0017181
SNOMED CT 2011_0131
74474003
MedDRA 14.1
10017955
ICD-10-CM Version 2010
K92.2
ICD-9-CM Version 2011
578
Haematemesis
Beschreibung

Hematemesis

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0018926
SNOMED CT 2011_0131
8765009
MedDRA 14.1
10018830
ICD-10-CM Version 2010
K92.0
ICD-9-CM Version 2011
578.0
History of Barrett's
Beschreibung

History of Barrett's

Datentyp

boolean

History of Cholangiocarcinoma
Beschreibung

History of Cholangiocarcinoma

Datentyp

boolean

History of Colon Cancer
Beschreibung

History of Colon Cancer

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0262926
SNOMED CT 2011_0131
417662000
LOINC Version 232
MTHU027722
UMLS CUI 2011AA
C0699790
SNOMED CT 2011_0131
269533000
MedDRA 14.1
10009957
History of Crohn's Disease
Beschreibung

History of Crohn's Disease

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0262926
SNOMED CT 2011_0131
417662000
LOINC Version 232
MTHU027722
UMLS CUI 2011AA
C0010346
SNOMED CT 2011_0131
34000006
MedDRA 14.1
10011401
ICD-10-CM Version 2010
K50.9
History of Diverticulosis
Beschreibung

History of Diverticulosis

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0262926
SNOMED CT 2011_0131
417662000
LOINC Version 232
MTHU027722
UMLS CUI 2011AA
C1510475
SNOMED CT 2011_0131
397881000
MedDRA 14.1
10013559
ICD-10-CM Version 2010
K57
ICD-9-CM Version 2011
562
History of Esophageal Cancer
Beschreibung

History of Esophageal Cancer

Datentyp

boolean

History of Esophageal/ Gastric Varicies
Beschreibung

History of Esophageal/ Gastric Varicies

Datentyp

boolean

History of Gastric Cancer
Beschreibung

History of Gastric Cancer

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0262926
SNOMED CT 2011_0131
417662000
LOINC Version 232
MTHU027722
UMLS CUI 2011AA
C0024623
SNOMED CT 2011_0131
363349007
MedDRA 14.1
10017758
ICD-10-CM Version 2010
C16
ICD-9-CM Version 2011
151
History of Pancreatic Cancer
Beschreibung

History of Pancreatic Cancer

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0262926
SNOMED CT 2011_0131
417662000
LOINC Version 232
MTHU027722
UMLS CUI 2011AA
C0346647
SNOMED CT 2011_0131
363418001
MedDRA 14.1
10033604
ICD-10-CM Version 2010
C25
ICD-9-CM Version 2011
157
History of Peptic Ulcer Disease
Beschreibung

History of Peptic Ulcer Disease

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0262926
SNOMED CT 2011_0131
417662000
LOINC Version 232
MTHU027722
UMLS CUI 2011AA
C0030920
SNOMED CT 2011_0131
13200003
MedDRA 14.1
10034341
ICD-10-CM Version 2010
K27
ICD-9-CM Version 2011
533
History of Polyps
Beschreibung

History of Polyps

Datentyp

boolean

History of Ulcerative Colitis
Beschreibung

History of Ulcerative Colitis

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0262926
SNOMED CT 2011_0131
417662000
LOINC Version 232
MTHU027722
UMLS CUI 2011AA
C0302596
SNOMED CT 2011_0131
64766004
MedDRA 14.1
10009900
ICD-10-CM Version 2010
K51
ICD-9-CM Version 2011
556
Blood in Stool
Beschreibung

Hematochezia

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0018932
SNOMED CT 2011_0131
405729008
MedDRA 14.1
10018836
ICD-9-CM Version 2011
578.1
Iron Deficiency Anaemia
Beschreibung

Iron Deficiency Anemia

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0162316
SNOMED CT 2011_0131
87522002
MedDRA 14.1
10022972
ICD-10-CM Version 2010
D50.0
ICD-9-CM Version 2011
280
Icterus
Beschreibung

Jaundice

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0022346
SNOMED CT 2011_0131
18165001
MedDRA 14.1
10023126
ICD-10-CM Version 2010
R17
Melaena
Beschreibung

Melena

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0025222
SNOMED CT 2011_0131
2901004
MedDRA 14.1
10027141
ICD-10-CM Version 2010
K92.1
Nausea
Beschreibung

Nausea

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0027497
SNOMED CT 2011_0131
422587007
MedDRA 14.1
10028813
LOINC Version 232
MTHU013524
ICD-10-CM Version 2010
R11.0
CTCAE 1105E
E10878
Emesis
Beschreibung

Vomiting

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0042963
SNOMED CT 2011_0131
249497008
MedDRA 14.1
10047700
LOINC Version 232
MTHU013530
ICD-10-CM Version 2010
R11.1
CTCAE 1105E
E11068
Occult/Guaiac Positive Stool
Beschreibung

Occult/Guaiac Positive Stool

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0201811
SNOMED CT 2011_0131
104435004
MedDRA 14.1
10016297
Pancreatitis
Beschreibung

Pancreatitis

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0030305
SNOMED CT 2011_0131
75694006
MedDRA 14.1
10033645
ICD-10-CM Version 2010
K85.9
ICD-9-CM Version 2011
577.0
CTCAE 1105E
E10930
Portal Hypertension
Beschreibung

Portal Hypertension

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0020541
SNOMED CT 2011_0131
34742003
MedDRA 14.1
10036200
ICD-10-CM Version 2010
K76.6
ICD-9-CM Version 2011
572.3
CTCAE 1105E
E11238
gastric reflux
Beschreibung

Gastroesophageal Reflux

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0558176
SNOMED CT 2011_0131
225587003
Abnormal weight loss
Beschreibung

Weight Loss

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0936227
SNOMED CT 2011_0131
267024001
MedDRA 14.1
10000159
ICD-10-CM Version 2010
R63.4
Other
Beschreibung

Other

Datentyp

string

History of present illness
Beschreibung

HISTORY OF PRESENT ILLNESS

Datentyp

string

Alias
UMLS CUI 2011AA
C0262512
LOINC Version 232
MTHU001399
Home Medications
Beschreibung

HOME MEDICATIONS

Datentyp

string

Alias
UMLS CUI 2011AA
C0013227
Physical examination
Beschreibung

Physical examination

Temperature
Beschreibung

Temperature

Datentyp

float

Alias
UMLS CUI 2011AA
C0039476
SNOMED CT 2011_0131
246508008
LOINC Version 232
MTHU009008
Pulse Rate
Beschreibung

Pulse

Datentyp

string

Alias
UMLS CUI 2011AA
C0232117
SNOMED CT 2011_0131
78564009
MedDRA 14.1
10037485
Respiration rate, Breathing rate (BR)
Beschreibung

Respiration Rate

Datentyp

string

Alias
UMLS CUI 2011AA
C0231832
SNOMED CT 2011_0131
86290005
MedDRA 14.1
10038709
LOINC Version 232
MTHU008344
Blood pressure (BP)
Beschreibung

Blood Pressure

Datentyp

string

Alias
UMLS CUI 2011AA
C0005823
SNOMED CT 2011_0131
75367002
LOINC Version 232
MTHU008342
General Apperance unremarkable
Beschreibung

General Apperance unremarkable

Datentyp

boolean

Alias
UMLS CUI 2011AA
C1148438
LOINC Version 232
MTHU015040
UMLS CUI 2011AA
C0205307
SNOMED CT 2011_0131
17621005
general appearance
Beschreibung

General Apperance text

Datentyp

string

Alias
UMLS CUI 2011AA
C1148438
LOINC Version 232
MTHU015040
HEENT within normal limits
Beschreibung

HEENT within normal limits

Datentyp

boolean

Head, Ears, Eyes, Nose and Throat
Beschreibung

HEENT text

Datentyp

string

Alias
UMLS CUI 2011AA
C1512338
Neck supple, no jugular vein distention
Beschreibung

Neck supple, no jugular vein distention

Datentyp

boolean

Neck, Collum, Cervical
Beschreibung

Neck text

Datentyp

string

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

Chest

Datentyp

string

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

Breast

Datentyp

string

Alias
UMLS CUI 2011AA
C0006141
SNOMED CT 2011_0131
76752008
LOINC Version 232
MTHU011382
Heart S1 S2 present, Regular rhythm and rate
Beschreibung

Heart S1 S2 present, Regular rhythm and rate

Datentyp

boolean

Heart
Beschreibung

Heart text

Datentyp

string

Alias
UMLS CUI 2011AA
C0018787
SNOMED CT 2011_0131
80891009
LOINC Version 232
MTHU001067
Abdomen Soft, (+) Bowel sounds, Normal tone
Beschreibung

Abdomen Soft, (+) Bowel sounds, Normal tone

Datentyp

boolean

Abdomen
Beschreibung

Abdomen text

Datentyp

string

Alias
UMLS CUI 2011AA
C0000726
SNOMED CT 2011_0131
113345001
LOINC Version 232
MTHU001425
Lymph Nodes not palpable
Beschreibung

Lymph Nodes not palpable

Datentyp

boolean

lymph nodes
Beschreibung

Lymph Nodes text

Datentyp

string

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

GENITALIA/RECTAL

Datentyp

string

Alias
UMLS CUI 2011AA
C0017420
LOINC Version 232
MTHU002681
UMLS CUI 2011AA
C0205052
SNOMED CT 2011_0131
255582007
Extremities No clubbing, cyanosis or edema
Beschreibung

Extremities No clubbing, cyanosis or edema

Datentyp

boolean

Extremities, Limb structure
Beschreibung

Extremities text

Datentyp

string

Alias
UMLS CUI 2011AA
C0015385
SNOMED CT 2011_0131
66019005
LOINC Version 232
MTHU001429
Skin: No abnormalities detected
Beschreibung

Skin: No abnormalities detected

Datentyp

boolean

Integument
Beschreibung

Skin text

Datentyp

string

Alias
UMLS CUI 2011AA
C1123023
SNOMED CT 2011_0131
39937001
LOINC Version 232
MTHU001414
Neurological: No abnormalities detected
Beschreibung

Neurological: No abnormalities detected

Datentyp

boolean

Neurologic system, Nervous system, Nervous system structure
Beschreibung

Neurological text

Datentyp

string

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

ADMITTING DIAGNOSIS

Datentyp

string

Alias
UMLS CUI 2011AA
C0332133
SNOMED CT 2011_0131
52870002
PLAN: Endoscopy
Beschreibung

PLAN: Endoscopy

Datentyp

string

ASA score, Finding of American Society of Anesthesiologists physical status classification
Beschreibung

ASA SCORE

Datentyp

string

Alias
UMLS CUI 2011AA
C1531480
SNOMED CT 2011_0131
413347006
Teeth
Beschreibung

TEETH

Datentyp

string

Alias
UMLS CUI 2011AA
C0040426
SNOMED CT 2011_0131
245543004
LOINC Version 232
MTHU021292
Mallampati score
Beschreibung

MALLAMPATI AIRWAY SCORE

Datentyp

string

Alias
UMLS CUI 2011AA
C0451276
SNOMED CT 2011_0131
273585005
NECK EXTENSION
Beschreibung

NECK EXTENSION

Datentyp

string

Alias
UMLS CUI 2011AA
C0027530
SNOMED CT 2011_0131
45048000
LOINC Version 232
MTHU002688
UMLS CUI 2011AA
C0231448
SNOMED CT 2011_0131
255536004
LOINC Version 232
MTHU010348
past medical History, prior medical History
Beschreibung

past medical History, prior medical History

past medical History, prior medical History
Beschreibung

Medical History

Datentyp

string

Alias
UMLS CUI 2011AA
C0262926
SNOMED CT 2011_0131
417662000
LOINC Version 232
MTHU027722
Prior Surgery, History of (H/O) surgery, Past surgical history
Beschreibung

Prior Surgeries

Datentyp

string

Alias
UMLS CUI 2011AA
C0455610
SNOMED CT 2011_0131
161615003
Family history (FH)
Beschreibung

Family history

Datentyp

string

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

Social history

Datentyp

string

Alias
UMLS CUI 2011AA
C0424945
SNOMED CT 2011_0131
160476009
LOINC Version 232
MTHU014081
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Ähnliche Modelle

HIS

1 Formulare
  1. StudyEvent: HIS
    1. HIS
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
SHORT STAY RECORD ID NOTE-ENDO
Age
Item
Age
integer
C0001779 (UMLS CUI 2011AA)
397669002 (SNOMED CT 2011_0131)
Item
Sex
string
C0079399 (UMLS CUI 2011AA)
263495000 (SNOMED CT 2011_0131)
MTHU002975 (LOINC Version 232)
Sex
Code List
Sex
CL Item
male (1)
C0024554 (UMLS CUI 2011AA)
248153007 (SNOMED CT 2011_0131)
M (HL7 V3 2006_05)
CL Item
female (2)
C0015780 (UMLS CUI 2011AA)
248152002 (SNOMED CT 2011_0131)
F (HL7 V3 2006_05)
Race
Item
Racial group
string
C0034510 (UMLS CUI 2011AA)
103579009 (SNOMED CT 2011_0131)
MTHU009923 (LOINC Version 232)
Height
Item
Height
integer
C0489786 (UMLS CUI 2011AA)
MTHU005354 (LOINC Version 232)
Weight
Item
Weight
float
C1305866 (UMLS CUI 2011AA)
107647005 (SNOMED CT 2011_0131)
10047890 (MedDRA 14.1)
LP18015-5 (LOINC Version 232)
Allergies
Item
Hypersensitivity
string
C0020517 (UMLS CUI 2011AA)
257550005 (SNOMED CT 2011_0131)
Item Group
Chief complaint (CC)
Abnormal GI Xray
Item
Abnormal GI Xray
boolean
C0521362 (UMLS CUI 2011AA)
MTHU031867 (LOINC Version 232)
C0000766 (UMLS CUI 2011AA)
10048065 (MedDRA 14.1)
Abdominal Pain
Item
Abdominal Pain
boolean
C0000737 (UMLS CUI 2011AA)
21522001 (SNOMED CT 2011_0131)
10000081 (MedDRA 14.1)
MTHU013636 (LOINC Version 232)
R10.9 (ICD-10-CM Version 2010)
789.0 (ICD-9-CM Version 2011)
E10460 (CTCAE 1105E)
Abnormal Weight Loss
Item
Abnormal weight loss (finding)
boolean
C0936227 (UMLS CUI 2011AA)
267024001 (SNOMED CT 2011_0131)
10000159 (MedDRA 14.1)
R63.4 (ICD-10-CM Version 2010)
Achalasia
Item
Achalasia
boolean
C1321756 (UMLS CUI 2011AA)
48531003 (SNOMED CT 2011_0131)
10000420 (MedDRA 14.1)
K22.0 (ICD-10-CM Version 2010)
Anemia
Item
Anaemia
boolean
C0002871 (UMLS CUI 2011AA)
271737000 (SNOMED CT 2011_0131)
10002034 (MedDRA 14.1)
MTHU020823 (LOINC Version 232)
D64.9 (ICD-10-CM Version 2010)
285.9 (ICD-9-CM Version 2011)
E10010 (CTCAE 1105E)
Ascites
Item
Ascites
boolean
C0003962 (UMLS CUI 2011AA)
389026000 (SNOMED CT 2011_0131)
10003445 (MedDRA 14.1)
R18 (ICD-10-CM Version 2010)
789.5 (ICD-9-CM Version 2011)
E10502 (CTCAE 1105E)
Change in Bowel Habits
Item
Irregular bowel habits
boolean
C2919545 (UMLS CUI 2011AA)
444702007 (SNOMED CT 2011_0131)
Hepatic Cirrhosis
Item
Liver Cirrhosis
boolean
C0023890 (UMLS CUI 2011AA)
19943007 (SNOMED CT 2011_0131)
10019641 (MedDRA 14.1)
K74.60 (ICD-10-CM Version 2010)
Colorectal Cancer Screening
Item
Screening for Colorectal Cancer
boolean
C0281185 (UMLS CUI 2011AA)
Common Bile Duct Leak
Item
Common Bile Duct Leak
boolean
C0009437 (UMLS CUI 2011AA)
79741001 (SNOMED CT 2011_0131)
MTHU011879 (LOINC Version 232)
CL382906 (UMLS CUI 2011AA)
Common Bile Duct Stone
Item
Common Bile Duct Stone
boolean
C0009437 (UMLS CUI 2011AA)
79741001 (SNOMED CT 2011_0131)
MTHU011879 (LOINC Version 232)
C0006736 (UMLS CUI 2011AA)
56381008 (SNOMED CT 2011_0131)
MTHU003416 (LOINC Version 232)
Constipation
Item
Constipation
boolean
C0009806 (UMLS CUI 2011AA)
14760008 (SNOMED CT 2011_0131)
10010774 (MedDRA 14.1)
MTHU020768 (LOINC Version 232)
K59.0 (ICD-10-CM Version 2010)
564.0 (ICD-9-CM Version 2011)
E10562 (CTCAE 1105E)
Diarrhea
Item
Diarrhea
boolean
C0011991 (UMLS CUI 2011AA)
62315008 (SNOMED CT 2011_0131)
10012735 (MedDRA 14.1)
MTHU013347 (LOINC Version 232)
R19.7 (ICD-10-CM Version 2010)
787.91 (ICD-9-CM Version 2011)
E10572 (CTCAE 1105E)
Dyspepsia
Item
Indigestion
boolean
C0013395 (UMLS CUI 2011AA)
162031009 (SNOMED CT 2011_0131)
10013946 (MedDRA 14.1)
R10.13, K30 (ICD-10-CM Version 2010)
E10617 (CTCAE 1105E)
Dysphagia
Item
Deglutition Disorders
boolean
C0011168 (UMLS CUI 2011AA)
40739000 (SNOMED CT 2011_0131)
10013950 (MedDRA 14.1)
MTHU029874 (LOINC Version 232)
R13 (ICD-10-CM Version 2010)
787.2 (ICD-9-CM Version 2011)
E10621 (CTCAE 1105E)
Elevated Liver Function Tests
Item
Elevated Liver Function Tests
boolean
Esophageal Varices
Item
Oesophageal Varices
boolean
C0014867 (UMLS CUI 2011AA)
28670008 (SNOMED CT 2011_0131)
10030209 (MedDRA 14.1)
I85 (ICD-10-CM Version 2010)
Family History of Colon Cancer
Item
Family History of Colon Cancer
boolean
C0241889 (UMLS CUI 2011AA)
57177007 (SNOMED CT 2011_0131)
C0699790 (UMLS CUI 2011AA)
269533000 (SNOMED CT 2011_0131)
10009957 (MedDRA 14.1)
Family History of Polyps
Item
Family History of Polyps
boolean
Family History of Polyposis
Item
Family History of Polyposis
boolean
Foreign Body in Colon
Item
Foreign Body in Colon
boolean
C0016542 (UMLS CUI 2011AA)
125670008 (SNOMED CT 2011_0131)
10070245 (MedDRA 14.1)
C0009368 (UMLS CUI 2011AA)
71854001 (SNOMED CT 2011_0131)
MTHU003023 (LOINC Version 232)
Foreign Body in Esophagus
Item
Foreign Body in Esophagus
boolean
Foreign Body in Stomach
Item
Foreign Body in Stomach
boolean
C0016542 (UMLS CUI 2011AA)
125670008 (SNOMED CT 2011_0131)
10070245 (MedDRA 14.1)
C0038351 (UMLS CUI 2011AA)
69695003 (SNOMED CT 2011_0131)
MTHU003059 (LOINC Version 232)
Gastric Ulcer
Item
Peptic Ulcer
boolean
C0030920 (UMLS CUI 2011AA)
13200003 (SNOMED CT 2011_0131)
10034341 (MedDRA 14.1)
K27 (ICD-10-CM Version 2010)
GERD
Item
Gastroesophageal reflux disease (GERD)
boolean
C0017168 (UMLS CUI 2011AA)
235595009 (SNOMED CT 2011_0131)
10017885 (MedDRA 14.1)
K21 (ICD-10-CM Version 2010)
530.81 (ICD-9-CM Version 2011)
E10739 (CTCAE 1105E)
GI Bleeding
Item
Gastrointestinal Hemorrhage
boolean
C0017181 (UMLS CUI 2011AA)
74474003 (SNOMED CT 2011_0131)
10017955 (MedDRA 14.1)
K92.2 (ICD-10-CM Version 2010)
578 (ICD-9-CM Version 2011)
Hematemesis
Item
Haematemesis
boolean
C0018926 (UMLS CUI 2011AA)
8765009 (SNOMED CT 2011_0131)
10018830 (MedDRA 14.1)
K92.0 (ICD-10-CM Version 2010)
578.0 (ICD-9-CM Version 2011)
History of Barrett's
Item
History of Barrett's
boolean
History of Cholangiocarcinoma
Item
History of Cholangiocarcinoma
boolean
History of Colon Cancer
Item
History of Colon Cancer
boolean
C0262926 (UMLS CUI 2011AA)
417662000 (SNOMED CT 2011_0131)
MTHU027722 (LOINC Version 232)
C0699790 (UMLS CUI 2011AA)
269533000 (SNOMED CT 2011_0131)
10009957 (MedDRA 14.1)
History of Crohn's Disease
Item
History of Crohn's Disease
boolean
C0262926 (UMLS CUI 2011AA)
417662000 (SNOMED CT 2011_0131)
MTHU027722 (LOINC Version 232)
C0010346 (UMLS CUI 2011AA)
34000006 (SNOMED CT 2011_0131)
10011401 (MedDRA 14.1)
K50.9 (ICD-10-CM Version 2010)
History of Diverticulosis
Item
History of Diverticulosis
boolean
C0262926 (UMLS CUI 2011AA)
417662000 (SNOMED CT 2011_0131)
MTHU027722 (LOINC Version 232)
C1510475 (UMLS CUI 2011AA)
397881000 (SNOMED CT 2011_0131)
10013559 (MedDRA 14.1)
K57 (ICD-10-CM Version 2010)
562 (ICD-9-CM Version 2011)
History of Esophageal Cancer
Item
History of Esophageal Cancer
boolean
History of Esophageal/ Gastric Varicies
Item
History of Esophageal/ Gastric Varicies
boolean
History of Gastric Cancer
Item
History of Gastric Cancer
boolean
C0262926 (UMLS CUI 2011AA)
417662000 (SNOMED CT 2011_0131)
MTHU027722 (LOINC Version 232)
C0024623 (UMLS CUI 2011AA)
363349007 (SNOMED CT 2011_0131)
10017758 (MedDRA 14.1)
C16 (ICD-10-CM Version 2010)
151 (ICD-9-CM Version 2011)
History of Pancreatic Cancer
Item
History of Pancreatic Cancer
boolean
C0262926 (UMLS CUI 2011AA)
417662000 (SNOMED CT 2011_0131)
MTHU027722 (LOINC Version 232)
C0346647 (UMLS CUI 2011AA)
363418001 (SNOMED CT 2011_0131)
10033604 (MedDRA 14.1)
C25 (ICD-10-CM Version 2010)
157 (ICD-9-CM Version 2011)
History of Peptic Ulcer Disease
Item
History of Peptic Ulcer Disease
boolean
C0262926 (UMLS CUI 2011AA)
417662000 (SNOMED CT 2011_0131)
MTHU027722 (LOINC Version 232)
C0030920 (UMLS CUI 2011AA)
13200003 (SNOMED CT 2011_0131)
10034341 (MedDRA 14.1)
K27 (ICD-10-CM Version 2010)
533 (ICD-9-CM Version 2011)
History of Polyps
Item
History of Polyps
boolean
History of Ulcerative Colitis
Item
History of Ulcerative Colitis
boolean
C0262926 (UMLS CUI 2011AA)
417662000 (SNOMED CT 2011_0131)
MTHU027722 (LOINC Version 232)
C0302596 (UMLS CUI 2011AA)
64766004 (SNOMED CT 2011_0131)
10009900 (MedDRA 14.1)
K51 (ICD-10-CM Version 2010)
556 (ICD-9-CM Version 2011)
Hematochezia
Item
Blood in Stool
boolean
C0018932 (UMLS CUI 2011AA)
405729008 (SNOMED CT 2011_0131)
10018836 (MedDRA 14.1)
578.1 (ICD-9-CM Version 2011)
Iron Deficiency Anemia
Item
Iron Deficiency Anaemia
boolean
C0162316 (UMLS CUI 2011AA)
87522002 (SNOMED CT 2011_0131)
10022972 (MedDRA 14.1)
D50.0 (ICD-10-CM Version 2010)
280 (ICD-9-CM Version 2011)
Jaundice
Item
Icterus
boolean
C0022346 (UMLS CUI 2011AA)
18165001 (SNOMED CT 2011_0131)
10023126 (MedDRA 14.1)
R17 (ICD-10-CM Version 2010)
Melena
Item
Melaena
boolean
C0025222 (UMLS CUI 2011AA)
2901004 (SNOMED CT 2011_0131)
10027141 (MedDRA 14.1)
K92.1 (ICD-10-CM Version 2010)
Nausea
Item
Nausea
boolean
C0027497 (UMLS CUI 2011AA)
422587007 (SNOMED CT 2011_0131)
10028813 (MedDRA 14.1)
MTHU013524 (LOINC Version 232)
R11.0 (ICD-10-CM Version 2010)
E10878 (CTCAE 1105E)
Vomiting
Item
Emesis
boolean
C0042963 (UMLS CUI 2011AA)
249497008 (SNOMED CT 2011_0131)
10047700 (MedDRA 14.1)
MTHU013530 (LOINC Version 232)
R11.1 (ICD-10-CM Version 2010)
E11068 (CTCAE 1105E)
Occult/Guaiac Positive Stool
Item
Occult/Guaiac Positive Stool
boolean
C0201811 (UMLS CUI 2011AA)
104435004 (SNOMED CT 2011_0131)
10016297 (MedDRA 14.1)
Pancreatitis
Item
Pancreatitis
boolean
C0030305 (UMLS CUI 2011AA)
75694006 (SNOMED CT 2011_0131)
10033645 (MedDRA 14.1)
K85.9 (ICD-10-CM Version 2010)
577.0 (ICD-9-CM Version 2011)
E10930 (CTCAE 1105E)
Portal Hypertension
Item
Portal Hypertension
boolean
C0020541 (UMLS CUI 2011AA)
34742003 (SNOMED CT 2011_0131)
10036200 (MedDRA 14.1)
K76.6 (ICD-10-CM Version 2010)
572.3 (ICD-9-CM Version 2011)
E11238 (CTCAE 1105E)
Gastroesophageal Reflux
Item
gastric reflux
boolean
C0558176 (UMLS CUI 2011AA)
225587003 (SNOMED CT 2011_0131)
Weight Loss
Item
Abnormal weight loss
boolean
C0936227 (UMLS CUI 2011AA)
267024001 (SNOMED CT 2011_0131)
10000159 (MedDRA 14.1)
R63.4 (ICD-10-CM Version 2010)
Other
Item
Other
string
HISTORY OF PRESENT ILLNESS
Item
History of present illness
string
C0262512 (UMLS CUI 2011AA)
MTHU001399 (LOINC Version 232)
HOME MEDICATIONS
Item
Home Medications
string
C0013227 (UMLS CUI 2011AA)
Item Group
Physical examination
Temperature
Item
Temperature
float
C0039476 (UMLS CUI 2011AA)
246508008 (SNOMED CT 2011_0131)
MTHU009008 (LOINC Version 232)
Pulse
Item
Pulse Rate
string
C0232117 (UMLS CUI 2011AA)
78564009 (SNOMED CT 2011_0131)
10037485 (MedDRA 14.1)
Respiration Rate
Item
Respiration rate, Breathing rate (BR)
string
C0231832 (UMLS CUI 2011AA)
86290005 (SNOMED CT 2011_0131)
10038709 (MedDRA 14.1)
MTHU008344 (LOINC Version 232)
Blood Pressure
Item
Blood pressure (BP)
string
C0005823 (UMLS CUI 2011AA)
75367002 (SNOMED CT 2011_0131)
MTHU008342 (LOINC Version 232)
General Apperance unremarkable
Item
General Apperance unremarkable
boolean
C1148438 (UMLS CUI 2011AA)
MTHU015040 (LOINC Version 232)
C0205307 (UMLS CUI 2011AA)
17621005 (SNOMED CT 2011_0131)
General Apperance text
Item
general appearance
string
C1148438 (UMLS CUI 2011AA)
MTHU015040 (LOINC Version 232)
HEENT within normal limits
Item
HEENT within normal limits
boolean
HEENT text
Item
Head, Ears, Eyes, Nose and Throat
string
C1512338 (UMLS CUI 2011AA)
Neck supple, no jugular vein distention
Item
Neck supple, no jugular vein distention
boolean
Neck text
Item
Neck, Collum, Cervical
string
C0027530 (UMLS CUI 2011AA)
45048000 (SNOMED CT 2011_0131)
MTHU002688 (LOINC Version 232)
Chest
Item
Chest, Thorax
string
C0817096 (UMLS CUI 2011AA)
51185008 (SNOMED CT 2011_0131)
Breast
Item
Mammary region
string
C0006141 (UMLS CUI 2011AA)
76752008 (SNOMED CT 2011_0131)
MTHU011382 (LOINC Version 232)
Heart S1 S2 present, Regular rhythm and rate
Item
Heart S1 S2 present, Regular rhythm and rate
boolean
Heart text
Item
Heart
string
C0018787 (UMLS CUI 2011AA)
80891009 (SNOMED CT 2011_0131)
MTHU001067 (LOINC Version 232)
Abdomen Soft, (+) Bowel sounds, Normal tone
Item
Abdomen Soft, (+) Bowel sounds, Normal tone
boolean
Abdomen text
Item
Abdomen
string
C0000726 (UMLS CUI 2011AA)
113345001 (SNOMED CT 2011_0131)
MTHU001425 (LOINC Version 232)
Lymph Nodes not palpable
Item
Lymph Nodes not palpable
boolean
Lymph Nodes text
Item
lymph nodes
string
C0024204 (UMLS CUI 2011AA)
59441001 (SNOMED CT 2011_0131)
MTHU015050 (LOINC Version 232)
GENITALIA/RECTAL
Item
GENITALIA/RECTAL
string
C0017420 (UMLS CUI 2011AA)
MTHU002681 (LOINC Version 232)
C0205052 (UMLS CUI 2011AA)
255582007 (SNOMED CT 2011_0131)
Extremities No clubbing, cyanosis or edema
Item
Extremities No clubbing, cyanosis or edema
boolean
Extremities text
Item
Extremities, Limb structure
string
C0015385 (UMLS CUI 2011AA)
66019005 (SNOMED CT 2011_0131)
MTHU001429 (LOINC Version 232)
Skin: No abnormalities detected
Item
Skin: No abnormalities detected
boolean
Skin text
Item
Integument
string
C1123023 (UMLS CUI 2011AA)
39937001 (SNOMED CT 2011_0131)
MTHU001414 (LOINC Version 232)
Neurological: No abnormalities detected
Item
Neurological: No abnormalities detected
boolean
Neurological text
Item
Neurologic system, Nervous system, Nervous system structure
string
C0027763 (UMLS CUI 2011AA)
25087005 (SNOMED CT 2011_0131)
MTHU001437 (LOINC Version 232)
ADMITTING DIAGNOSIS
Item
ADMITTING DIAGNOSIS (AD)
string
C0332133 (UMLS CUI 2011AA)
52870002 (SNOMED CT 2011_0131)
PLAN: Endoscopy
Item
PLAN: Endoscopy
string
ASA SCORE
Item
ASA score, Finding of American Society of Anesthesiologists physical status classification
string
C1531480 (UMLS CUI 2011AA)
413347006 (SNOMED CT 2011_0131)
Item
Teeth
string
C0040426 (UMLS CUI 2011AA)
245543004 (SNOMED CT 2011_0131)
MTHU021292 (LOINC Version 232)
TEETH
Code List
Teeth
CL Item
Normal (1)
C0205307 (UMLS CUI 2011AA)
17621005 (SNOMED CT 2011_0131)
CL Item
Loose Teeth (2)
CL Item
Dental Prosthesis(es) (3)
C0011394 (UMLS CUI 2011AA)
8060009 (SNOMED CT 2011_0131)
CL Item
Co-Existing Dental Abnormalities (4)
Item
Mallampati score
string
C0451276 (UMLS CUI 2011AA)
273585005 (SNOMED CT 2011_0131)
MALLAMPATI AIRWAY SCORE
Code List
Mallampati score
CL Item
The soft palate, uvula, fauces, and pillars are visible (Class 1)
CL Item
The soft palate, uvula and fauces are visible (Class 2)
CL Item
The soft palate and base of uvula are visible (Class 3)
CL Item
The hard palate only is visible (Class 4)
NECK EXTENSION
Item
NECK EXTENSION
string
C0027530 (UMLS CUI 2011AA)
45048000 (SNOMED CT 2011_0131)
MTHU002688 (LOINC Version 232)
C0231448 (UMLS CUI 2011AA)
255536004 (SNOMED CT 2011_0131)
MTHU010348 (LOINC Version 232)
Item Group
past medical History, prior medical History
Medical History
Item
past medical History, prior medical History
string
C0262926 (UMLS CUI 2011AA)
417662000 (SNOMED CT 2011_0131)
MTHU027722 (LOINC Version 232)
Prior Surgeries
Item
Prior Surgery, History of (H/O) surgery, Past surgical history
string
C0455610 (UMLS CUI 2011AA)
161615003 (SNOMED CT 2011_0131)
Family history
Item
Family history (FH)
string
C0241889 (UMLS CUI 2011AA)
57177007 (SNOMED CT 2011_0131)
Social history
Item
Social and personal history, Social and personal circumstances
string
C0424945 (UMLS CUI 2011AA)
160476009 (SNOMED CT 2011_0131)
MTHU014081 (LOINC Version 232)
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