ID

235

Description

Form from HIS OpenVista

Mots-clés

Versions (6)
  1. 07/03/2012 07/03/2012 -
  2. 07/08/2014 07/08/2014 - Martin Dugas
  3. 09/08/2014 09/08/2014 - Martin Dugas
  4. 23/12/2014 23/12/2014 - Martin Dugas
  5. 25/06/2015 25/06/2015 - Martin Dugas
  6. 27/09/2021 27/09/2021 -
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7 mars 2012

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HIS SHORT STAY RECORD ID NOTE-ENDO

Allemand Anglais

HIS

1 Formulaires  
  1. StudyEvent: HIS
    1. HIS
SHORT STAY RECORD ID NOTE-ENDO
Description

SHORT STAY RECORD ID NOTE-ENDO

Alter
Description

Age

Type de données

integer

Alias
UMLS CUI 2011AA
C0001779
SNOMED CT 2011_0131
397669002
Geschlecht
Description

Sex

Type de données

string

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

Race

Type de données

string

Alias
UMLS CUI 2011AA
C0034510
SNOMED CT 2011_0131
103579009
LOINC Version 232
MTHU009923
Größe
Description

Height

Type de données

integer

Alias
UMLS CUI 2011AA
C0489786
LOINC Version 232
MTHU005354
Gewicht
Description

Weight

Type de données

float

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

Allergies

Type de données

string

Alias
UMLS CUI 2011AA
C0020517
SNOMED CT 2011_0131
257550005
Hauptbeschwerden
Description

Hauptbeschwerden

Abnormal GI Xray
Description

Abnormal GI Xray

Type de données

boolean

Alias
UMLS CUI 2011AA
C0521362
LOINC Version 232
MTHU031867
UMLS CUI 2011AA
C0000766
MedDRA 14.1
10048065
Bauchschmerzen
Description

Abdominal Pain

Type de données

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
abnormaler Gewichtsverlust
Description

Abnormal Weight Loss

Type de données

boolean

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

Achalasia

Type de données

boolean

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

Anemia

Type de données

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
Aszites
Description

Ascites

Type de données

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
Description

Change in Bowel Habits

Type de données

boolean

Alias
UMLS CUI 2011AA
C2919545
SNOMED CT 2011_0131
444702007
Leberzirrhose
Description

Hepatic Cirrhosis

Type de données

boolean

Alias
UMLS CUI 2011AA
C0023890
SNOMED CT 2011_0131
19943007
MedDRA 14.1
10019641
ICD-10-CM Version 2010
K74.60
Screening für Kolonkarzinom
Description

Colorectal Cancer Screening

Type de données

boolean

Alias
UMLS CUI 2011AA
C0281185
Common Bile Duct Leak
Description

Common Bile Duct Leak

Type de données

boolean

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

Common Bile Duct Stone

Type de données

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
Verstopfung
Description

Constipation

Type de données

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
Diarrhö
Description

Diarrhea

Type de données

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
Dyspepsie
Description

Dyspepsia

Type de données

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
Dysphagie
Description

Dysphagia

Type de données

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
Description

Elevated Liver Function Tests

Type de données

boolean

Ösophagusvarizen
Description

Esophageal Varices

Type de données

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
Description

Family History of Colon Cancer

Type de données

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
Description

Family History of Polyps

Type de données

boolean

Family History of Polyposis
Description

Family History of Polyposis

Type de données

boolean

Foreign Body in Colon
Description

Foreign Body in Colon

Type de données

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
Description

Foreign Body in Esophagus

Type de données

boolean

Foreign Body in Stomach
Description

Foreign Body in Stomach

Type de données

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
Description

Gastric Ulcer

Type de données

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)
Description

GERD

Type de données

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
Gastrointestinale Blutung
Description

GI Bleeding

Type de données

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
Hämatemesis
Description

Hematemesis

Type de données

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
Description

History of Barrett's

Type de données

boolean

History of Cholangiocarcinoma
Description

History of Cholangiocarcinoma

Type de données

boolean

History of Colon Cancer
Description

History of Colon Cancer

Type de données

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
Description

History of Crohn's Disease

Type de données

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
Description

History of Diverticulosis

Type de données

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
Description

History of Esophageal Cancer

Type de données

boolean

History of Esophageal/ Gastric Varicies
Description

History of Esophageal/ Gastric Varicies

Type de données

boolean

History of Gastric Cancer
Description

History of Gastric Cancer

Type de données

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
Description

History of Pancreatic Cancer

Type de données

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
Description

History of Peptic Ulcer Disease

Type de données

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
Description

History of Polyps

Type de données

boolean

History of Ulcerative Colitis
Description

History of Ulcerative Colitis

Type de données

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
Blut im Stuhl
Description

Hematochezia

Type de données

boolean

Alias
UMLS CUI 2011AA
C0018932
SNOMED CT 2011_0131
405729008
MedDRA 14.1
10018836
ICD-9-CM Version 2011
578.1
Eisenmangelanämie
Description

Iron Deficiency Anemia

Type de données

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
Ikterus
Description

Jaundice

Type de données

boolean

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

Melena

Type de données

boolean

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

Nausea

Type de données

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
Erbrechen
Description

Vomiting

Type de données

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
Description

Occult/Guaiac Positive Stool

Type de données

boolean

Alias
UMLS CUI 2011AA
C0201811
SNOMED CT 2011_0131
104435004
MedDRA 14.1
10016297
Pankreatitis
Description

Pancreatitis

Type de données

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
Portale Hypertension
Description

Portal Hypertension

Type de données

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
Description

Gastroesophageal Reflux

Type de données

boolean

Alias
UMLS CUI 2011AA
C0558176
SNOMED CT 2011_0131
225587003
abnormaler Gewichtsverlust
Description

Weight Loss

Type de données

boolean

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

Other

Type de données

string

Anamnese der aktuellen Erkrankung
Description

HISTORY OF PRESENT ILLNESS

Type de données

string

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

HOME MEDICATIONS

Type de données

string

Alias
UMLS CUI 2011AA
C0013227
Körperliche Untersuchung
Description

Körperliche Untersuchung

Temperatur
Description

Temperature

Type de données

float

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

Pulse

Type de données

string

Alias
UMLS CUI 2011AA
C0232117
SNOMED CT 2011_0131
78564009
MedDRA 14.1
10037485
Atemfrequenz
Description

Respiration Rate

Type de données

string

Alias
UMLS CUI 2011AA
C0231832
SNOMED CT 2011_0131
86290005
MedDRA 14.1
10038709
LOINC Version 232
MTHU008344
Blutdruck
Description

Blood Pressure

Type de données

string

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

General Apperance unremarkable

Type de données

boolean

Alias
UMLS CUI 2011AA
C1148438
LOINC Version 232
MTHU015040
UMLS CUI 2011AA
C0205307
SNOMED CT 2011_0131
17621005
Allgemeinzustand
Description

General Apperance text

Type de données

string

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

HEENT within normal limits

Type de données

boolean

Head, Ears, Eyes, Nose and Throat
Description

HEENT text

Type de données

string

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

Neck supple, no jugular vein distention

Type de données

boolean

Hals
Description

Neck text

Type de données

string

Alias
UMLS CUI 2011AA
C0027530
SNOMED CT 2011_0131
45048000
LOINC Version 232
MTHU002688
Thorax
Description

Chest

Type de données

string

Alias
UMLS CUI 2011AA
C0817096
SNOMED CT 2011_0131
51185008
Brust
Description

Breast

Type de données

string

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

Heart S1 S2 present, Regular rhythm and rate

Type de données

boolean

Herz
Description

Heart text

Type de données

string

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

Abdomen Soft, (+) Bowel sounds, Normal tone

Type de données

boolean

Abdomen
Description

Abdomen text

Type de données

string

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

Lymph Nodes not palpable

Type de données

boolean

Lymphknoten
Description

Lymph Nodes text

Type de données

string

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

GENITALIA/RECTAL

Type de données

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
Description

Extremities No clubbing, cyanosis or edema

Type de données

boolean

Extremitäten
Description

Extremities text

Type de données

string

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

Skin: No abnormalities detected

Type de données

boolean

Haut
Description

Skin text

Type de données

string

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

Neurological: No abnormalities detected

Type de données

boolean

Nervensystem
Description

Neurological text

Type de données

string

Alias
UMLS CUI 2011AA
C0027763
SNOMED CT 2011_0131
25087005
LOINC Version 232
MTHU001437
Aufnahmediagnose
Description

ADMITTING DIAGNOSIS

Type de données

string

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

PLAN: Endoscopy

Type de données

string

ASA Status
Description

ASA SCORE

Type de données

string

Alias
UMLS CUI 2011AA
C1531480
SNOMED CT 2011_0131
413347006
Zähne
Description

TEETH

Type de données

string

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

MALLAMPATI AIRWAY SCORE

Type de données

string

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

NECK EXTENSION

Type de données

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
Frühere Anamnese
Description

Frühere Anamnese

Frühere Anamnese
Description

Medical History

Type de données

string

Alias
UMLS CUI 2011AA
C0262926
SNOMED CT 2011_0131
417662000
LOINC Version 232
MTHU027722
Frühere Operationen
Description

Prior Surgeries

Type de données

string

Alias
UMLS CUI 2011AA
C0455610
SNOMED CT 2011_0131
161615003
Familienanamnese
Description

Family history

Type de données

string

Alias
UMLS CUI 2011AA
C0241889
SNOMED CT 2011_0131
57177007
Sozialanamnese
Description

Social history

Type de données

string

Alias
UMLS CUI 2011AA
C0424945
SNOMED CT 2011_0131
160476009
LOINC Version 232
MTHU014081
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Similar models

HIS

1 Formulaires
  1. StudyEvent: HIS
    1. HIS
Name
Type
Description | Question | Decode (Coded Value)
Type de données
Alias
Item Group
SHORT STAY RECORD ID NOTE-ENDO
Age
Item
Alter
integer
C0001779 (UMLS CUI 2011AA)
397669002 (SNOMED CT 2011_0131)
Item
Geschlecht
string
C0079399 (UMLS CUI 2011AA)
263495000 (SNOMED CT 2011_0131)
MTHU002975 (LOINC Version 232)
Sex
Code List
Geschlecht
CL Item
männlich (1)
C0024554 (UMLS CUI 2011AA)
248153007 (SNOMED CT 2011_0131)
M (HL7 V3 2006_05)
CL Item
weiblich (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
Größe
integer
C0489786 (UMLS CUI 2011AA)
MTHU005354 (LOINC Version 232)
Weight
Item
Gewicht
float
C1305866 (UMLS CUI 2011AA)
107647005 (SNOMED CT 2011_0131)
10047890 (MedDRA 14.1)
LP18015-5 (LOINC Version 232)
Allergies
Item
Allergie
string
C0020517 (UMLS CUI 2011AA)
257550005 (SNOMED CT 2011_0131)
Item Group
Hauptbeschwerden
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
Bauchschmerzen
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
abnormaler Gewichtsverlust
boolean
C0936227 (UMLS CUI 2011AA)
267024001 (SNOMED CT 2011_0131)
10000159 (MedDRA 14.1)
R63.4 (ICD-10-CM Version 2010)
Achalasia
Item
Achalasie
boolean
C1321756 (UMLS CUI 2011AA)
48531003 (SNOMED CT 2011_0131)
10000420 (MedDRA 14.1)
K22.0 (ICD-10-CM Version 2010)
Anemia
Item
Anämie
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
Aszites
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
Leberzirrhose
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 für Kolonkarzinom
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
Verstopfung
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
Diarrhö
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
Dyspepsie
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
Dysphagie
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
Ösophagusvarizen
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
Gastrointestinale Blutung
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
Hämatemesis
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
Blut im Stuhl
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
Eisenmangelanämie
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
Ikterus
boolean
C0022346 (UMLS CUI 2011AA)
18165001 (SNOMED CT 2011_0131)
10023126 (MedDRA 14.1)
R17 (ICD-10-CM Version 2010)
Melena
Item
Teerstuhl
boolean
C0025222 (UMLS CUI 2011AA)
2901004 (SNOMED CT 2011_0131)
10027141 (MedDRA 14.1)
K92.1 (ICD-10-CM Version 2010)
Nausea
Item
Übelkeit
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
Erbrechen
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
Pankreatitis
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
Portale 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
abnormaler Gewichtsverlust
boolean
C0936227 (UMLS CUI 2011AA)
267024001 (SNOMED CT 2011_0131)
10000159 (MedDRA 14.1)
R63.4 (ICD-10-CM Version 2010)
Other
Item
Sonstig
string
HISTORY OF PRESENT ILLNESS
Item
Anamnese der aktuellen Erkrankung
string
C0262512 (UMLS CUI 2011AA)
MTHU001399 (LOINC Version 232)
HOME MEDICATIONS
Item
Home Medications
string
C0013227 (UMLS CUI 2011AA)
Item Group
Körperliche Untersuchung
Temperature
Item
Temperatur
float
C0039476 (UMLS CUI 2011AA)
246508008 (SNOMED CT 2011_0131)
MTHU009008 (LOINC Version 232)
Pulse
Item
Pulsfrequenz
string
C0232117 (UMLS CUI 2011AA)
78564009 (SNOMED CT 2011_0131)
10037485 (MedDRA 14.1)
Respiration Rate
Item
Atemfrequenz
string
C0231832 (UMLS CUI 2011AA)
86290005 (SNOMED CT 2011_0131)
10038709 (MedDRA 14.1)
MTHU008344 (LOINC Version 232)
Blood Pressure
Item
Blutdruck
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
Allgemeinzustand
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
Hals
string
C0027530 (UMLS CUI 2011AA)
45048000 (SNOMED CT 2011_0131)
MTHU002688 (LOINC Version 232)
Chest
Item
Thorax
string
C0817096 (UMLS CUI 2011AA)
51185008 (SNOMED CT 2011_0131)
Breast
Item
Brust
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
Herz
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
Lymphknoten
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
Extremitäten
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
Haut
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
Nervensystem
string
C0027763 (UMLS CUI 2011AA)
25087005 (SNOMED CT 2011_0131)
MTHU001437 (LOINC Version 232)
ADMITTING DIAGNOSIS
Item
Aufnahmediagnose
string
C0332133 (UMLS CUI 2011AA)
52870002 (SNOMED CT 2011_0131)
PLAN: Endoscopy
Item
PLAN: Endoscopy
string
ASA SCORE
Item
ASA Status
string
C1531480 (UMLS CUI 2011AA)
413347006 (SNOMED CT 2011_0131)
Item
Zähne
string
C0040426 (UMLS CUI 2011AA)
245543004 (SNOMED CT 2011_0131)
MTHU021292 (LOINC Version 232)
TEETH
Code List
Zähne
CL Item
normal (1)
C0205307 (UMLS CUI 2011AA)
17621005 (SNOMED CT 2011_0131)
CL Item
Loose Teeth (2)
CL Item
Zahnprothese(n) (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
Frühere Anamnese
Medical History
Item
Frühere Anamnese
string
C0262926 (UMLS CUI 2011AA)
417662000 (SNOMED CT 2011_0131)
MTHU027722 (LOINC Version 232)
Prior Surgeries
Item
Frühere Operationen
string
C0455610 (UMLS CUI 2011AA)
161615003 (SNOMED CT 2011_0131)
Family history
Item
Familienanamnese
string
C0241889 (UMLS CUI 2011AA)
57177007 (SNOMED CT 2011_0131)
Social history
Item
Sozialanamnese
string
C0424945 (UMLS CUI 2011AA)
160476009 (SNOMED CT 2011_0131)
MTHU014081 (LOINC Version 232)
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