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ID
240
Beschreibung
Form from HIS OpenVista
Stichworte
Versionen (2)
- 09.03.12 09.03.12 -
- 08.06.17 08.06.17 - Martin Dugas
Hochgeladen am
9. März 2012
DOI
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Creative Commons BY-NC 3.0
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HIS SOCIAL SERVICES PSYCHOSOCIAL ASSESSMENT NOTE
Ähnliche Modelle
HIS
- StudyEvent: HIS
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
CL Item
Family (1)
CL Item
Nurse (2)
CL Item
Patient (3)
CL Item
Physician (4)
CL Item
Therapist (5)
CL Item
Other (6)
PRIMARY CONTACT/RELATIONSHIP/TELEPHONE
Item
PRIMARY CONTACT/RELATIONSHIP/TELEPHONE
string
LANGUAGE/COMMUNICATION BARRIER
Item
LANGUAGE/COMMUNICATION BARRIER
boolean
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
DISCUSSED ADVANCE DIRECTIVE WITH PATIENT
Item
DISCUSSED ADVANCE DIRECTIVE WITH PATIENT
boolean
PATIENT HAS EXECUTED AN ADVANCE DIRECTIVE
Item
PATIENT HAS EXECUTED AN ADVANCE DIRECTIVE
boolean
IS ADVANCE DIRECTIVE FORM IN THE ELECTRONIC RECORD?
Item
IS ADVANCE DIRECTIVE FORM IN THE ELECTRONIC RECORD?
boolean
NOTES regarding Advance Directive
Item
NOTES regarding Advance Directive
string
HBO
Item
HBO
boolean
Occupational Therapy
Item
Occupational Therapy
boolean
Physical Therapy
Item
Physical Therapy
boolean
Phototherapy
Item
Phototherapy
boolean
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
Wound Care
Item
Wound Care
boolean
None
Item
None
boolean
Item
THE FOLLOWING ASSESSMENT REFLECTS THE PATIENTS' CONDITION
string
Code List
THE FOLLOWING ASSESSMENT REFLECTS THE PATIENTS' CONDITION
CL Item
Prior to hospitalization (1)
CL Item
At current level (2)
Alert
Item
Alert
boolean
Disoriented
Item
Disoriented
boolean
Comatose
Item
Comatose
boolean
Speech impairment
Item
Speech impairment
boolean
Vision impairment
Item
Vision impairment
boolean
Hearing impairment
Item
Hearing impairment
boolean
Notes
Item
Notes
string
Lives with family
Item
Lives with family
boolean
Lives with spouse
Item
Lives with spouse
boolean
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
Home alone
Item
Home alone
boolean
Notes
Item
Notes
string
employed
Item
employed
boolean
unemployed
Item
unemployed
boolean
commercial insurance
Item
commercial insurance
boolean
MEDICAID
Item
MEDICAID
boolean
MEDICARE
Item
MEDICARE
boolean
SS
Item
SS
boolean
SSD
Item
SSD
boolean
SSI
Item
SSI
boolean
AFDC
Item
AFDC
boolean
CSHCN
Item
CSHCN
boolean
CHIP
Item
CHIP
boolean
MCHD
Item
MCHD
boolean
VA
Item
VA
boolean
No Income
Item
No Income
boolean
Notes
Item
Notes
string
Spouse/Family
Item
Spouse/Family
boolean
Church
Item
Church
boolean
Agency
Item
Agency
boolean
None
Item
None
boolean
Notes
Item
Notes
string
Self
Item
Self
boolean
Spouse/Family
Item
Spouse/Family
boolean
Friend
Item
Friend
boolean
Agency personnel
Item
Agency personnel
boolean
Community Clinic
Item
Community Clinic
boolean
Notes
Item
Notes
string
IV Therapy
Item
intravenöse Therapie
boolean
C1411942 (UMLS CUI 2011AA)
Foley Catheter Care
Item
Foley Catheter Care
boolean
Ostomy Care
Item
Ostomy Care
boolean
Wound Care
Item
Wound Care
boolean
Feeding Tube Care
Item
Feeding Tube Care
boolean
Dialysis
Item
Dialysis
boolean
Drain Care
Item
Drain Care
boolean
Ventilator
Item
Ventilator
boolean
None
Item
None
boolean
Notes
Item
Notes
string
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
Laundry
Item
Laundry
boolean
Cleaning
Item
Cleaning
boolean
Total independence
Item
Total independence
boolean
Mobility impaired
Item
Mobility impaired
boolean
No assistance required
Item
No assistance required
boolean
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
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
CL357394 (UMLS CUI 2011AA)
Equipment
Item
Equipment
boolean
Financial Resources
Item
Financial Resources
boolean
Food / Clothing
Item
Food / Clothing
boolean
Home health
Item
Home health
boolean
Hospice
Item
Hospice
boolean
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
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
WIC
Item
WIC
boolean
Other
Item
Other
boolean
INITIAL ASSESSMENT NOTE
Item
INITIAL ASSESSMENT NOTE
string
CL Item
indicated (1)
CL Item
not indicated (2)
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)
ANTICIPATED DATE OF PLANNED DISPOSITION
Item
ANTICIPATED DATE OF PLANNED DISPOSITION
date