ID

240

Description

Form from HIS OpenVista

Mots-clés

  1. 09/03/2012 09/03/2012 -
  2. 08/06/2017 08/06/2017 - Martin Dugas
Téléchargé le

9 mars 2012

DOI

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Licence

Creative Commons BY-NC 3.0

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HIS SOCIAL SERVICES PSYCHOSOCIAL ASSESSMENT NOTE

  1. StudyEvent: HIS
    1. HIS
Psychosocial Assessment
Description

Psychosocial Assessment

INFORMANT
Description

INFORMANT

Type de données

string

PRIMARY CONTACT/RELATIONSHIP/TELEPHONE
Description

PRIMARY CONTACT/RELATIONSHIP/TELEPHONE

Type de données

string

LANGUAGE/COMMUNICATION BARRIER
Description

LANGUAGE/COMMUNICATION BARRIER

Type de données

boolean

Spoken Language
Description

Primary Language

Type de données

string

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

PHYSICIAN

Type de données

string

Diagnose
Description

CURRENT DIAGNOSIS

Type de données

string

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

RELEVANT HISTORY

Type de données

string

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

DISCUSSED ADVANCE DIRECTIVE WITH PATIENT

Type de données

boolean

PATIENT HAS EXECUTED AN ADVANCE DIRECTIVE
Description

PATIENT HAS EXECUTED AN ADVANCE DIRECTIVE

Type de données

boolean

IS ADVANCE DIRECTIVE FORM IN THE ELECTRONIC RECORD?
Description

IS ADVANCE DIRECTIVE FORM IN THE ELECTRONIC RECORD?

Type de données

boolean

NOTES regarding Advance Directive
Description

NOTES regarding Advance Directive

Type de données

string

Therapien
Description

Therapien

HBO
Description

HBO

Type de données

boolean

Occupational Therapy
Description

Occupational Therapy

Type de données

boolean

Physical Therapy
Description

Physical Therapy

Type de données

boolean

Phototherapy
Description

Phototherapy

Type de données

boolean

Radiation / Chemotherapy
Description

Radiation / Chemotherapy

Type de données

boolean

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

Respiratory Therapy

Type de données

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

Type de données

boolean

Wound Care
Description

Wound Care

Type de données

boolean

None
Description

None

Type de données

boolean

Time of Patient's condition
Description

Time of Patient's condition

THE FOLLOWING ASSESSMENT REFLECTS THE PATIENTS' CONDITION
Description

THE FOLLOWING ASSESSMENT REFLECTS THE PATIENTS' CONDITION

Type de données

string

Patient Status
Description

Patient Status

Alert
Description

Alert

Type de données

boolean

Disoriented
Description

Disoriented

Type de données

boolean

Comatose
Description

Comatose

Type de données

boolean

Speech impairment
Description

Speech impairment

Type de données

boolean

Vision impairment
Description

Vision impairment

Type de données

boolean

Hearing impairment
Description

Hearing impairment

Type de données

boolean

Notes
Description

Notes

Type de données

string

Living Situation
Description

Living Situation

Lives with family
Description

Lives with family

Type de données

boolean

Lives with spouse
Description

Lives with spouse

Type de données

boolean

Pflegeheim
Description

Nursing home

Type de données

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

Type de données

boolean

Home alone
Description

Home alone

Type de données

boolean

Notes
Description

Notes

Type de données

string

FINANCIAL INFORMATION
Description

FINANCIAL INFORMATION

employed
Description

employed

Type de données

boolean

unemployed
Description

unemployed

Type de données

boolean

commercial insurance
Description

commercial insurance

Type de données

boolean

MEDICAID
Description

MEDICAID

Type de données

boolean

MEDICARE
Description

MEDICARE

Type de données

boolean

SS
Description

SS

Type de données

boolean

SSD
Description

SSD

Type de données

boolean

SSI
Description

SSI

Type de données

boolean

AFDC
Description

AFDC

Type de données

boolean

CSHCN
Description

CSHCN

Type de données

boolean

CHIP
Description

CHIP

Type de données

boolean

MCHD
Description

MCHD

Type de données

boolean

VA
Description

VA

Type de données

boolean

No Income
Description

No Income

Type de données

boolean

Notes
Description

Notes

Type de données

string

SUPPORT SYSTEM
Description

SUPPORT SYSTEM

Spouse/Family
Description

Spouse/Family

Type de données

boolean

Church
Description

Church

Type de données

boolean

Agency
Description

Agency

Type de données

boolean

None
Description

None

Type de données

boolean

Notes
Description

Notes

Type de données

string

CAREGIVER
Description

CAREGIVER

Self
Description

Self

Type de données

boolean

Spouse/Family
Description

Spouse/Family

Type de données

boolean

Friend
Description

Friend

Type de données

boolean

Agency personnel
Description

Agency personnel

Type de données

boolean

Community Clinic
Description

Community Clinic

Type de données

boolean

Notes
Description

Notes

Type de données

string

SKILLED NEEDS
Description

SKILLED NEEDS

intravenöse Therapie
Description

IV Therapy

Type de données

boolean

Alias
UMLS CUI 2011AA
C1411942
Foley Catheter Care
Description

Foley Catheter Care

Type de données

boolean

Ostomy Care
Description

Ostomy Care

Type de données

boolean

Wound Care
Description

Wound Care

Type de données

boolean

Feeding Tube Care
Description

Feeding Tube Care

Type de données

boolean

Dialysis
Description

Dialysis

Type de données

boolean

Drain Care
Description

Drain Care

Type de données

boolean

Ventilator
Description

Ventilator

Type de données

boolean

None
Description

None

Type de données

boolean

Notes
Description

Notes

Type de données

string

CURRENT ASSISTIVE DEVICES EQUIPMENT NEEDS
Description

CURRENT ASSISTIVE DEVICES EQUIPMENT NEEDS

Wheelchair
Description

Wheelchair

Type de données

boolean

Crutches
Description

Crutches

Type de données

boolean

Walker
Description

Walker

Type de données

boolean

Cane
Description

Cane

Type de données

boolean

Hospital Bed/Rails
Description

Hospital Bed/Rails

Type de données

boolean

Hoyer lift/Trapeze
Description

Hoyer lift/Trapeze

Type de données

boolean

Oxygen
Description

Oxygen

Type de données

boolean

Apnea Monitor
Description

Apnea Monitor

Type de données

boolean

Carseat
Description

Carseat

Type de données

boolean

Crib
Description

Crib

Type de données

boolean

None
Description

None

Type de données

boolean

Notes
Description

Notes

Type de données

string

DAILY LIVING ACTIVITY
Description

DAILY LIVING ACTIVITY

Wheelchair
Description

Wheelchair

Type de données

boolean

Bedbound
Description

Bedbound

Type de données

boolean

Inkontinenz
Description

Incontinence

Type de données

boolean

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

Hygiene preparation

Type de données

boolean

Meal preparation
Description

Meal preparation

Type de données

boolean

Ernährung über Sonde
Description

Feeding tube

Type de données

boolean

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

Grooming / Dressing

Type de données

boolean

Shopping
Description

Shopping

Type de données

boolean

Laundry
Description

Laundry

Type de données

boolean

Cleaning
Description

Cleaning

Type de données

boolean

Total independence
Description

Total independence

Type de données

boolean

Mobility impaired
Description

Mobility impaired

Type de données

boolean

No assistance required
Description

No assistance required

Type de données

boolean

Notes
Description

Notes

Type de données

string

PSYCHOSOCIAL ASSESSMENT
Description

PSYCHOSOCIAL ASSESSMENT

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

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

Type de données

string

COPING STRENGTHS
Description

COPING STRENGTHS

Type de données

string

Coping WEAKNESSES
Description

Coping WEAKNESSES

Type de données

string

NOTED COGNITIVE/BEHAVIORAL/BONDING/FUNCTIONAL PROBLEMS
Description

NOTED COGNITIVE/BEHAVIORAL/BONDING/FUNCTIONAL PROBLEMS

Type de données

string

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

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

Type de données

string

RELIGIOUS/CULTURAL PREFERENCE
Description

RELIGIOUS/CULTURAL PREFERENCE

RELIGIOUS/CULTURAL PREFERENCE
Description

RELIGIOUS/CULTURAL PREFERENCE

Type de données

string

POSSIBLE NEEDS
Description

POSSIBLE NEEDS

No Needs evident
Description

No Needs evident

Type de données

boolean

Adoption
Description

Adoption

Type de données

boolean

Adult protective Services
Description

Adult protective Services

Type de données

boolean

Assistance ADL's
Description

Assistance ADL's

Type de données

boolean

Child protective Services
Description

Child protective Services

Type de données

boolean

Counseling / Therapy
Description

Counseling / Therapy

Type de données

boolean

Ausbildung
Description

Education

Type de données

boolean

Alias
UMLS CUI 2011AA
CL357394
Equipment
Description

Equipment

Type de données

boolean

Financial Resources
Description

Financial Resources

Type de données

boolean

Food / Clothing
Description

Food / Clothing

Type de données

boolean

Home health
Description

Home health

Type de données

boolean

Hospice
Description

Hospice

Type de données

boolean

Housing
Description

Housing

Type de données

boolean

Lifeline / ERS
Description

Lifeline / ERS

Type de données

boolean

LTAC
Description

LTAC

Type de données

boolean

Medication / Supplies
Description

Medication / Supplies

Type de données

boolean

PBCCMHMR
Description

PBCCMHMR

Type de données

boolean

Meals on Wheels
Description

Meals on Wheels

Type de données

boolean

Nursing facility placement
Description

Nursing facility placement

Type de données

boolean

Other hospital
Description

Other hospital

Type de données

boolean

Rehabilitation
Description

Rehabilitation

Type de données

boolean

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

Safe Place

Type de données

boolean

Skilled Nursing Facility
Description

Skilled Nursing Facility

Type de données

boolean

Substance abuse treatment
Description

Substance abuse treatment

Type de données

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

Type de données

boolean

Transportation
Description

Transportation

Type de données

boolean

WIC
Description

WIC

Type de données

boolean

Other
Description

Other

Type de données

boolean

INITIAL ASSESSMENT NOTE
Description

INITIAL ASSESSMENT NOTE

Type de données

string

AT THIS TIME CONTINUED INTERVENTION IS
Description

AT THIS TIME CONTINUED INTERVENTION IS

Type de données

string

PLANNED DISPOSITION
Description

PLANNED DISPOSITION

Type de données

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

ANTICIPATED DATE OF PLANNED DISPOSITION

Type de données

date

Similar models

  1. StudyEvent: HIS
    1. HIS
Name
Type
Description | Question | Decode (Coded Value)
Type de données
Alias
Item Group
Psychosocial Assessment
Item
INFORMANT
string
Code List
INFORMANT
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)
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)
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
Item Group
Therapien
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)
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
Wound Care
Item
Wound Care
boolean
None
Item
None
boolean
Item Group
Time of Patient's condition
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)
Item Group
Patient Status
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
Item Group
Living Situation
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)
Foster home
Item
Foster home
boolean
Home alone
Item
Home alone
boolean
Notes
Item
Notes
string
Item Group
FINANCIAL INFORMATION
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
Item Group
SUPPORT SYSTEM
Spouse/Family
Item
Spouse/Family
boolean
Church
Item
Church
boolean
Agency
Item
Agency
boolean
None
Item
None
boolean
Notes
Item
Notes
string
Item Group
CAREGIVER
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
Item Group
SKILLED NEEDS
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
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
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
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
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)
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
WIC
Item
WIC
boolean
Other
Item
Other
boolean
INITIAL ASSESSMENT NOTE
Item
INITIAL ASSESSMENT NOTE
string
Item
AT THIS TIME CONTINUED INTERVENTION IS
string
Code List
AT THIS TIME CONTINUED INTERVENTION IS
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)
ANTICIPATED DATE OF PLANNED DISPOSITION
Item
ANTICIPATED DATE OF PLANNED DISPOSITION
date

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