ID
43560
Beschreibung
Form from HIS OpenVista
Stichworte
Versionen (3)
- 09.03.12 09.03.12 -
- 08.06.17 08.06.17 - Martin Dugas
- 20.09.21 20.09.21 -
Hochgeladen am
20. September 2021
DOI
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Lizenz
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NURSING ASSESSMENT (pedi)
HIS
- StudyEvent: HIS
Beschreibung
Neuro / Psychosocial
Alias
- UMLS CUI-1
- C0027853
Beschreibung
GLASGOW COMA SCALE ADULT
Alias
- UMLS CUI-1
- C1271007
Beschreibung
Eyes open
Datentyp
integer
Alias
- UMLS CUI [1]
- C3648956
Beschreibung
BEST VERBAL RESPONSE
Datentyp
integer
Alias
- UMLS CUI [1]
- C3648957
Beschreibung
BEST MOTOR RESPONSE
Datentyp
integer
Alias
- UMLS CUI [1]
- C3648958
Beschreibung
GLASCOW COMA SCALE SCORE
Datentyp
integer
Alias
- UMLS CUI [1]
- C1271007
Beschreibung
Pupillen
Alias
- UMLS CUI-1
- C0034121
Beschreibung
Right Pupil Size
Datentyp
integer
Maßeinheiten
- mm
Alias
- UMLS CUI [1,1]
- C0517965
- UMLS CUI [1,2]
- C0205090
Beschreibung
Right Pupil Reaction
Datentyp
text
Alias
- UMLS CUI [1,1]
- C0234671
- UMLS CUI [1,2]
- C0444532
Beschreibung
Left Pupil Size
Datentyp
integer
Maßeinheiten
- mm
Alias
- UMLS CUI [1,1]
- C0517965
- UMLS CUI [1,2]
- C0205091
Beschreibung
Left Pupil Reaction
Datentyp
text
Alias
- UMLS CUI [1,1]
- C0234671
- UMLS CUI [1,2]
- C0443246
Beschreibung
GLASGOW COMA SCALE CHILD
Alias
- UMLS CUI-1
- C0017594
- UMLS CUI-2
- C0008059
Beschreibung
EYES OPEN
Datentyp
integer
Alias
- UMLS CUI [1]
- C3648956
Beschreibung
BEST VERBAL RESPONSE
Datentyp
integer
Beschreibung
BEST MOTOR RESPONSE
Datentyp
integer
Alias
- UMLS CUI [1]
- C3648958
Beschreibung
GLASCOW COMA SCALE SCORE CHILD
Datentyp
integer
Beschreibung
ORIENTATION
Alias
- UMLS CUI-1
- C0029266
Beschreibung
ORIENTATION
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0029266
- SNOMED CT 2011_0131
- 43173001
Beschreibung
History of SEIZURE ACTIVITY
Datentyp
text
Alias
- UMLS CUI [1]
- C1148156
Beschreibung
AFFECT
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0001721
- SNOMED CT 2011_0131
- 4065008
Beschreibung
SPEECH
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0037817
- SNOMED CT 2011_0131
- 87335007
- LOINC Version 232
- MTHU021528
Beschreibung
NUMBNESS OR TINGLING
Datentyp
text
Alias
- UMLS CUI [1]
- C3842982
Beschreibung
Kardiovaskuläres System
Alias
- UMLS CUI-1
- C0007226
Beschreibung
Cardiovascular System Normal
Datentyp
boolean
Alias
- UMLS CUI [1]
- C0577867
Beschreibung
Abnormal Findings
Datentyp
text
Alias
- UMLS CUI [1]
- C1704258
Beschreibung
Antithromboembolic stockings
Datentyp
boolean
Alias
- UMLS CUI [1]
- C0419312
Beschreibung
Vascular Sequential Compression Devices
Datentyp
boolean
Alias
- UMLS CUI [1]
- C0180062
Beschreibung
HEART SOUNDS
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0018820
- SNOMED CT 2011_0131
- 23472005
Beschreibung
Radial pulse (L/R)
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0232142
- SNOMED CT 2011_0131
- 65452004
- MedDRA 14.1
- 10053935
Beschreibung
Pedal pulse
Datentyp
text
Alias
- UMLS CUI [1]
- C0232157
Beschreibung
Pos-Tibial Pulse
Datentyp
text
Alias
- SNOMED CT 2011_0131
- 421568004
- UMLS CUI [1]
- C1720310
Beschreibung
Popliteal Pulse (L/R)
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0232151
- SNOMED CT 2011_0131
- 74828005
- MedDRA 14.1
- 10053938
Beschreibung
Brachial Pulse (L/R)
Datentyp
string
Alias
- UMLS CUI 2011AA
- C1096531
- MedDRA 14.1
- 10053929
Beschreibung
Carotid Pulse (L/R)
Datentyp
string
Alias
- UMLS CUI 2011AA
- C1096529
- MedDRA 14.1
- 10053926
Beschreibung
AV SHUNT
Datentyp
text
Alias
- UMLS CUI [1]
- C1456474
Beschreibung
SHUNT LOCATION
Datentyp
text
Alias
- UMLS CUI [1,1]
- C1442858
- UMLS CUI [1,2]
- C0450429
Beschreibung
BRUIT
Datentyp
text
Alias
- UMLS CUI [1]
- C0006318
Beschreibung
SHUNT BRUIT
Datentyp
text
Alias
- UMLS CUI [1]
- C0232112
Beschreibung
THRILL
Datentyp
text
Alias
- UMLS CUI [1]
- C2678517
Beschreibung
CAPILLARY REFILL
Datentyp
text
Alias
- UMLS CUI [1]
- C0425716
Beschreibung
NAIL BED COLOR
Datentyp
text
Alias
- UMLS CUI [1]
- C0574757
Beschreibung
Edema
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0013604
- SNOMED CT 2011_0131
- 423666004
- MedDRA 14.1
- 10030095
- LOINC Version 232
- MTHU019803
- ICD-10-CM Version 2010
- R60.9
- ICD-9-CM Version 2011
- 782.3
Beschreibung
Heart RHYTHM
Datentyp
text
Alias
- UMLS CUI [1]
- C0232187
Beschreibung
PACEMAKER PRESENT
Datentyp
boolean
Alias
- UMLS CUI 2011AA
- C0030163
- SNOMED CT 2011_0131
- 14106009
- LOINC Version 232
- MTHU024521
Beschreibung
Eyes Ear Nose & Throat
Alias
- UMLS CUI-1
- C3494720
Beschreibung
EYES NORMAL
Datentyp
boolean
Alias
- UMLS CUI [1]
- C4230579
Beschreibung
Normal Ears
Datentyp
boolean
Alias
- UMLS CUI [1]
- C0576927
Beschreibung
Normal Nose
Datentyp
boolean
Alias
- UMLS CUI [1]
- C0577884
Beschreibung
Normal Throat
Datentyp
boolean
Alias
- UMLS CUI [1]
- C0577002
Beschreibung
Abnormal Findings
Datentyp
text
Alias
- UMLS CUI [1]
- C1704258
Beschreibung
Augen
Alias
- UMLS CUI-1
- C0015392
Beschreibung
Right Pupil Size
Datentyp
integer
Maßeinheiten
- mm
Alias
- UMLS CUI [1,1]
- C0517965
- UMLS CUI [1,2]
- C0205090
Beschreibung
Right Pupil Reaction
Datentyp
text
Alias
- UMLS CUI [1,1]
- C0234671
- UMLS CUI [1,2]
- C0444532
Beschreibung
Left Pupil Size
Datentyp
integer
Maßeinheiten
- mm
Alias
- UMLS CUI [1,1]
- C0517965
- UMLS CUI [1,2]
- C0205091
Beschreibung
Left Pupil Reaction
Datentyp
text
Alias
- UMLS CUI [1,1]
- C0234671
- UMLS CUI [1,2]
- C0443246
Beschreibung
Eye symptom
Datentyp
text
Alias
- UMLS CUI [1]
- C0848690
Beschreibung
Right Sclera
Datentyp
text
Alias
- UMLS CUI [1]
- C0929516
Beschreibung
Left Sclera
Datentyp
text
Alias
- UMLS CUI [1]
- C0934600
Beschreibung
Drainage
Datentyp
boolean
Alias
- UMLS CUI [1]
- C0012621
Beschreibung
Drainage Color
Datentyp
text
Alias
- UMLS CUI [1,1]
- C0012621
- UMLS CUI [1,2]
- C0009393
Beschreibung
Ohren
Alias
- UMLS CUI-1
- C0013443
Beschreibung
EXTERNAL CANAL
Datentyp
text
Alias
- UMLS CUI [1]
- C1517034
Beschreibung
C/O Pain
Datentyp
boolean
Alias
- UMLS CUI [1]
- C0436561
Beschreibung
Tympanic Membranes
Datentyp
text
Alias
- SNOMED CT 2011_0131
- 42859004
- LOINC Version 232
- MTHU014731
- UMLS CUI [1]
- C0041445
Beschreibung
Tubes
Datentyp
text
Alias
- UMLS CUI [1]
- C0015183
Beschreibung
Hard of Hearing
Datentyp
boolean
Alias
- UMLS CUI [1]
- C1384666
Beschreibung
Hearing Loss
Datentyp
boolean
Alias
- UMLS CUI [1]
- C3887873
Beschreibung
Deafness
Datentyp
boolean
Alias
- UMLS CUI [1]
- C0011053
Beschreibung
Hearing Aids
Datentyp
text
Alias
- UMLS CUI [1]
- C0018768
Beschreibung
Patent
Datentyp
boolean
Alias
- UMLS CUI [1]
- C0175566
Beschreibung
Dizziness
Datentyp
boolean
Alias
- UMLS CUI 2011AA
- C0012833
- SNOMED CT 2011_0131
- 404640003
- MedDRA 14.1
- 10013573
- CTCAE 1105E
- E12631
Beschreibung
Tinnitus
Datentyp
boolean
Alias
- UMLS CUI 2011AA
- C0040264
- SNOMED CT 2011_0131
- 60862001
- MedDRA 14.1
- 10043882
- ICD-10-CM Version 2010
- H93.1
- ICD-9-CM Version 2011
- 388.3
- CTCAE 1105E
- E10287
Beschreibung
Drainage
Datentyp
boolean
Alias
- SNOMED CT 2011_0131
- 32712000
- LOINC Version 232
- MTHU022515
- UMLS CUI [1]
- C0012621
Beschreibung
Color of Ear Drainage
Datentyp
text
Alias
- UMLS CUI [1,1]
- C0012621
- UMLS CUI [1,2]
- C0009393
Beschreibung
Nase
Alias
- UMLS CUI-1
- C0028429
Beschreibung
Nares patent
Datentyp
boolean
Alias
- UMLS CUI [1,1]
- C1456808
- UMLS CUI [1,2]
- C0175566
Beschreibung
Nares Drainage
Datentyp
boolean
Alias
- UMLS CUI [1]
- C0746759
Beschreibung
Septum
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0027432
- SNOMED CT 2011_0131
- 68426009
- LOINC Version 232
- MTHU015054
Beschreibung
Pharynx
Alias
- UMLS CUI-1
- C0031354
Beschreibung
Throat Pain
Datentyp
boolean
Alias
- UMLS CUI 2011AA
- C0242429
- SNOMED CT 2011_0131
- 267102003
- MedDRA 14.1
- 10041367
- ICD-10-CM Version 2010
- R07.0
- ICD-9-CM Version 2011
- 784.1
- CTCAE 1105E
- E13575
Beschreibung
Mouth Sores
Datentyp
boolean
Alias
- UMLS CUI [1]
- C0149745
Beschreibung
Appearance of Throat
Datentyp
text
Alias
- UMLS CUI [1]
- C0426505
Beschreibung
Mucous Membranes
Datentyp
text
Alias
- UMLS CUI [1]
- C0026724
Beschreibung
Respiratory
Alias
- UMLS CUI-1
- C0035237
Beschreibung
Respiratory NORMAL
Datentyp
boolean
Alias
- UMLS CUI [1]
- C0231795
Beschreibung
Abnormal Findings
Datentyp
text
Alias
- UMLS CUI [1]
- C1704258
Beschreibung
BREATH SOUNDS
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0035234
- SNOMED CT 2011_0131
- 52653008
- MedDRA 14.1
- 10064779
Beschreibung
RESPIRATORY EFFORT
Datentyp
text
Alias
- UMLS CUI [1]
- C0425466
Beschreibung
CHEST EXPANSION
Datentyp
text
Alias
- UMLS CUI [1]
- C0231902
Beschreibung
INCENTIVE SPIROMETRY
Datentyp
boolean
Alias
- UMLS CUI [1]
- C0454512
Beschreibung
oxygen delivery system
Datentyp
text
Alias
- UMLS CUI [1]
- C0809836
Beschreibung
Pulse Oximeter
Datentyp
boolean
Alias
- UMLS CUI [1]
- C0182109
Beschreibung
Cardio-Respiratory Monitoring
Datentyp
boolean
Alias
- UMLS CUI [1,1]
- C0150496
- UMLS CUI [1,2]
- C0199438
Beschreibung
COUGH TYPE
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0010200
- SNOMED CT 2011_0131
- 49727002
- MedDRA 14.1
- 10011224
- ICD-10-CM Version 2010
- R05
- ICD-9-CM Version 2011
- 786.2
- CTCAE 1105E
- E13364
Beschreibung
Sputum
Datentyp
text
Alias
- SNOMED CT 2011_0131
- 45710003
- MedDRA 14.1
- 10041802
- LOINC Version 232
- MTHU001309
- UMLS CUI [1]
- C0038056
Beschreibung
CHEST TUBE
Datentyp
boolean
Alias
- UMLS CUI [1]
- C0008034
Beschreibung
Chest tube site
Datentyp
boolean
Alias
- UMLS CUI [1]
- C0489468
Beschreibung
Chest Tube Suction Setting
Datentyp
text
Alias
- UMLS CUI [1,1]
- C0008034
- UMLS CUI [1,2]
- C1306323
Beschreibung
Air Leak
Datentyp
text
Alias
- UMLS CUI [1]
- C2242512
Beschreibung
Gastrointestinal
Beschreibung
NORMAL BASELINE GI
Datentyp
boolean
Beschreibung
Last BM
Datentyp
date
Beschreibung
NARRATIVE: Abnormal Findings
Datentyp
string
Beschreibung
ABDOMINAL DESCRIPTION
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0000726
- SNOMED CT 2011_0131
- 113345001
- LOINC Version 232
- MTHU001425
Beschreibung
BOWEL SOUNDS
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0232693
- SNOMED CT 2011_0131
- 87042004
- MedDRA 14.1
- 10006023
Beschreibung
FLATUS
Datentyp
boolean
Beschreibung
incontinence
Datentyp
boolean
Alias
- UMLS CUI 2011AA
- C0021167
- SNOMED CT 2011_0131
- 48340000
- MedDRA 14.1
- 10021639
Beschreibung
GASTRIC SYMPTOMS
Datentyp
string
Beschreibung
NG TUBE TYPE
Datentyp
string
Beschreibung
NG placement checked
Datentyp
boolean
Beschreibung
Suction Setting
Datentyp
string
Beschreibung
Gastric Content Color
Datentyp
string
Beschreibung
NGT irrigated
Datentyp
string
Beschreibung
FEEDING TUBE PRESENT
Datentyp
boolean
Alias
- UMLS CUI 2011AA
- C0041281
- SNOMED CT 2011_0131
- 61420007
- MedDRA 14.1
- 10053095
Beschreibung
Feeding Tube Type
Datentyp
string
Beschreibung
Formula
Datentyp
string
Beschreibung
OSTOMY TYPE
Datentyp
string
Beschreibung
RECTAL BAG PRESENT
Datentyp
boolean
Beschreibung
Urogenitales System
Beschreibung
NORMAL BASELINE Genitourinary
Datentyp
boolean
Beschreibung
NARRATIVE: Abnormal Findings
Datentyp
string
Beschreibung
Sex
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0079399
- SNOMED CT 2011_0131
- 263495000
- LOINC Version 232
- MTHU002975
Beschreibung
INCONTINENT
Datentyp
boolean
Beschreibung
VOIDS SUFFICIENT QUANITY
Datentyp
boolean
Beschreibung
IS PATIENT RECEIVING DIALYSIS
Datentyp
boolean
Beschreibung
ODOR PRESENT
Datentyp
boolean
Beschreibung
CATHETER PRESENT
Datentyp
boolean
Alias
- UMLS CUI 2011AA
- C0085590
- SNOMED CT 2011_0131
- 19923001
Beschreibung
CATHETER SIZE
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0449963
- SNOMED CT 2011_0131
- 260967009
Beschreibung
Date of insertion
Datentyp
date
Beschreibung
Urine color
Datentyp
string
Beschreibung
URINARY SYMPTOMS
Datentyp
string
Beschreibung
SEXUALLY ACTIVE
Datentyp
boolean
Beschreibung
CURRENTLY ON MENSES
Datentyp
boolean
Beschreibung
DISCHARGE PRESENT
Datentyp
boolean
Alias
- UMLS CUI 2011AA
- C0012621
- SNOMED CT 2011_0131
- 75823008
Beschreibung
Discharge color
Datentyp
string
Beschreibung
Discharge odor
Datentyp
string
Beschreibung
Discharge consistency
Datentyp
string
Beschreibung
ABNORMAL GENITALIA DESCRIPTION
Datentyp
string
Beschreibung
Muskuloskeletales System
Beschreibung
NORMAL BASELINE Musculoskeletal
Datentyp
boolean
Beschreibung
NARRATIVE: Abnormal Findings
Datentyp
string
Beschreibung
GENERALIZED WEAKNESS
Datentyp
boolean
Beschreibung
LIMITED ROM
Datentyp
boolean
Beschreibung
LIMITED MOBILITY
Datentyp
boolean
Beschreibung
PARALYSIS TYPE
Datentyp
string
Beschreibung
Hemiplegia Side
Datentyp
string
Beschreibung
FRACTURE(S) LOCATION
Datentyp
string
Beschreibung
FINGER DIGITS
Datentyp
string
Beschreibung
TOE DIGITS
Datentyp
string
Beschreibung
LEFT UPPER EXTREMITIES
Datentyp
string
Beschreibung
RIGHT UPPER EXTREMITIES
Datentyp
string
Beschreibung
GRIPS EQUAL
Datentyp
boolean
Beschreibung
LEFT LOWER EXTREMITIES
Datentyp
string
Beschreibung
RIGHT LOWER EXTREMITIES
Datentyp
string
Beschreibung
UNSTEADY GAIT
Datentyp
boolean
Beschreibung
Haut
Beschreibung
NORMAL BASELINE Skin
Datentyp
boolean
Beschreibung
NARRATIVE: Abnormal Findings
Datentyp
string
Beschreibung
TEMPERATURE
Datentyp
float
Alias
- UMLS CUI 2011AA
- C0039476
- SNOMED CT 2011_0131
- 246508008
- LOINC Version 232
- MTHU009008
Beschreibung
SKIN COLOR
Datentyp
string
Beschreibung
MOIST
Datentyp
boolean
Beschreibung
SKIN TURGOR
Datentyp
string
Beschreibung
Inzision
Beschreibung
Incision #:
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0184898
- SNOMED CT 2011_0131
- 34896006
Beschreibung
MID WOUND#
Datentyp
string
Beschreibung
Site
Datentyp
string
Beschreibung
Closure Type
Datentyp
string
Beschreibung
Incision Appearance
Datentyp
string
Beschreibung
Dressing Changed
Datentyp
boolean
Beschreibung
Date Dressing Changed
Datentyp
date
Beschreibung
Dressing Type
Datentyp
string
Beschreibung
Dressing Appearance
Datentyp
string
Beschreibung
Drains
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0180499
- SNOMED CT 2011_0131
- 32712000
- LOINC Version 232
- MTHU022515
Beschreibung
Wunde
Beschreibung
WOUND #
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0043250
- SNOMED CT 2011_0131
- 13924000
- MedDRA 14.1
- 10052428
- LOINC Version 232
- MTHU001326
Beschreibung
MID WOUND#
Datentyp
string
Beschreibung
Wound Location
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0043250
- SNOMED CT 2011_0131
- 13924000
- MedDRA 14.1
- 10052428
- LOINC Version 232
- MTHU001326
- UMLS CUI 2011AA-2
- C0450429
- SNOMED CT 2011_0131-2
- 246267002
Beschreibung
Length (cm, mm)
Datentyp
string
Beschreibung
Width (cm, mm)
Datentyp
string
Beschreibung
Depth (cm, mm)
Datentyp
string
Beschreibung
Undermining
Datentyp
boolean
Beschreibung
Tunneling
Datentyp
boolean
Beschreibung
Surrounding Skin
Datentyp
string
Beschreibung
Wound Base
Datentyp
string
Beschreibung
Exudate
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0015388
- SNOMED CT 2011_0131
- 247450001
- LOINC Version 232
- MTHU025016
Beschreibung
Exudate Color
Datentyp
string
Beschreibung
Sensation
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0036658
- SNOMED CT 2011_0131
- 373713005
- LOINC Version 232
- MTHU017277
Beschreibung
Odor: Before Cleaning
Datentyp
boolean
Beschreibung
Odor: After Cleaning
Datentyp
boolean
Beschreibung
Cleansed with/irrigated with
Datentyp
string
Beschreibung
Wound Medication Applied
Datentyp
string
Beschreibung
Wound Filled with
Datentyp
string
Beschreibung
Wound covered with
Datentyp
string
Beschreibung
Wound secured with
Datentyp
string
Beschreibung
Wound Pressure Relief
Datentyp
string
Beschreibung
Comments
Datentyp
string
Beschreibung
Photograph Date
Datentyp
date
Beschreibung
RASH LOCATION
Datentyp
string
Beschreibung
RASH DESCRIPTION
Datentyp
string
Beschreibung
TATTOO'S/PIERCINGS
Datentyp
string
Beschreibung
SKIN TEARS, LOCATION/ Description
Datentyp
string
Beschreibung
SPECIALTY BEDS
Datentyp
string
Beschreibung
Nutrition
Beschreibung
Current Diet
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0012155
- SNOMED CT 2011_0131
- 41829006
Beschreibung
NPO
Datentyp
boolean
Beschreibung
FEEDING TUBE PRESENT
Datentyp
boolean
Alias
- UMLS CUI 2011AA
- C0041281
- SNOMED CT 2011_0131
- 61420007
- MedDRA 14.1
- 10053095
Beschreibung
Feeding Tube Type
Datentyp
string
Beschreibung
Formula
Datentyp
string
Beschreibung
RESIDUALS CHECKED
Datentyp
string
Beschreibung
BREAKFAST
Datentyp
string
Beschreibung
Breakfast: Amount taken
Datentyp
string
Beschreibung
Breakfast: Patient fed by
Datentyp
string
Beschreibung
LUNCH
Datentyp
string
Beschreibung
Lunch: Amount taken
Datentyp
string
Beschreibung
Lunch: Patient fed by
Datentyp
string
Beschreibung
SUPPER
Datentyp
string
Beschreibung
Supper: Amount taken
Datentyp
string
Beschreibung
Supper: Patient fed by
Datentyp
string
Beschreibung
Supper: Amount taken
Datentyp
string
Beschreibung
intravenöse Therapie
Beschreibung
NARRATIVE: IV Therapy
Datentyp
string
Beschreibung
IV HEPLOCKED
Datentyp
boolean
Beschreibung
IV Site APPEARANCE
Datentyp
string
Beschreibung
IV DISCONTINUED
Datentyp
boolean
Beschreibung
CATHETER INTACT
Datentyp
boolean
Beschreibung
IV Catheter Size
Datentyp
string
Beschreibung
IV Site Location
Datentyp
string
Beschreibung
CENTRAL LINE PORT
Datentyp
string
Alias
- UMLS CUI 2011AA
- C1145640
- SNOMED CT 2011_0131
- 52124006
Beschreibung
IV FLUIDS
Datentyp
string
Alias
- UMLS CUI 2011AA
- C1289919
- SNOMED CT 2011_0131
- 118431008
- MedDRA 14.1
- 10067708
Beschreibung
Left to count:
Datentyp
string
Beschreibung
IV Fluid Rate: @ ml/hr
Datentyp
integer
Beschreibung
TPN/LIPIDS: TPN @ ml/hr and Lipids @ ml/hr
Datentyp
string
Beschreibung
PCA PUMP: at @ cc's/hr
Datentyp
string
Beschreibung
IV Site APPEARANCE
Datentyp
string
Beschreibung
INSERTION DATE
Datentyp
date
Beschreibung
DRESSING CHANGE DUE
Datentyp
date
Beschreibung
SITE CHANGE DUE
Datentyp
date
Beschreibung
PLACED ON IMED
Datentyp
boolean
Beschreibung
Patientensicherheit
Beschreibung
SIDE RAILS UP
Datentyp
boolean
Beschreibung
IN LOW POSTION
Datentyp
boolean
Beschreibung
BED/CRIB
Datentyp
string
Beschreibung
CALL BELL WITHIN REACH
Datentyp
boolean
Beschreibung
ALLERGY BAND ON
Datentyp
boolean
Beschreibung
NAME BAND ON
Datentyp
boolean
Beschreibung
BLOOD BAND ON
Datentyp
boolean
Beschreibung
FALL BAND ON
Datentyp
boolean
Beschreibung
BED SAFETY
Datentyp
string
Beschreibung
Pediatric Fall Risk Assessment
Beschreibung
Unable to assess fall risk status at this time due to patient is:
Datentyp
string
Beschreibung
gender
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0079399
- SNOMED CT 2011_0131
- 263495000
- LOINC Version 232
- MTHU002975
Beschreibung
LEVEL OF CONSCIOUS
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0234421
- SNOMED CT 2011_0131
- 106167005
Beschreibung
Seizures/Previous history of falls
Datentyp
string
Beschreibung
MEDICATION/EQUIPMENT
Datentyp
string
Beschreibung
LENGTH OF STAY
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0023303
Beschreibung
ELIMINATION
Datentyp
string
Beschreibung
GET UP AND GO TEST: "RISING FROM A CHAIR"
Datentyp
string
Beschreibung
FINAL RISK SCORE
Datentyp
integer
Beschreibung
INTERVENTIONS
Beschreibung
Assist with Ambulation
Datentyp
boolean
Beschreibung
Reorient Q2H or Less
Datentyp
boolean
Beschreibung
Gait Belt
Datentyp
boolean
Beschreibung
ID Patient at Risk
Datentyp
boolean
Beschreibung
Restraints (see policy)
Datentyp
boolean
Beschreibung
Multi-personnel Transfer
Datentyp
boolean
Beschreibung
Close Observation
Datentyp
boolean
Beschreibung
Non-slip Footwear
Datentyp
boolean
Beschreibung
Bed in lowest position
Datentyp
boolean
Beschreibung
Lock wheels of vehicles of conveyance during transfer
Datentyp
boolean
Beschreibung
Upper siderails raised
Datentyp
boolean
Beschreibung
Call light in reach
Datentyp
boolean
Beschreibung
Offer toileting at least every 2 hours
Datentyp
boolean
Beschreibung
Offer fluid/nutrition every 2 hours
Datentyp
boolean
Beschreibung
Place frequently used objects within reach
Datentyp
boolean
Beschreibung
Provide adequate lighting
Datentyp
boolean
Beschreibung
Provide sensory impairment/orientation devices (clocks,etc)
Datentyp
boolean
Beschreibung
Provide adequate rest periods
Datentyp
boolean
Beschreibung
Use age appropriate distractions for confusion/disorientation
Datentyp
boolean
Beschreibung
Remove harmful hazards
Datentyp
boolean
Beschreibung
Provide appropriate and least restrictive patient supervision/surveillance
Datentyp
boolean
Beschreibung
Communicate information about fall risk to caregivers
Datentyp
boolean
Beschreibung
Encourage family/support system to participate in care
Datentyp
boolean
Beschreibung
Teach/educate family/support system Fall Prevention information
Datentyp
boolean
Beschreibung
Implement Fall Prevention Protocol for Hendrich II Score>5
Datentyp
boolean
Beschreibung
IMPAIRED MOBILITY RISK
Beschreibung
Implement Universal Fall Prevention Intervention
Datentyp
boolean
Beschreibung
Monitor transfers to/from bed/chair(etc.)
Datentyp
boolean
Beschreibung
Use appropriate assistance for transfers to/from bed/chair
Datentyp
boolean
Beschreibung
Use chairs with armrests and of proper height for transfers
Datentyp
boolean
Beschreibung
Implement progressive ambulation(unless contraindicated by condition/orders)
Datentyp
boolean
Beschreibung
Encourage/Provide self-care assistance
Datentyp
boolean
Beschreibung
Remain in attendance during toileting/ADL's
Datentyp
boolean
Beschreibung
Provide assistive devices for ambulation (canes/walkers/etc.)
Datentyp
boolean
Beschreibung
Gait Belt during transport/ambulation
Datentyp
boolean
Beschreibung
Teach patient/family to call for help and WAIT for help before
Datentyp
boolean
Beschreibung
attempting any transfer/ambulation
Datentyp
boolean
Beschreibung
ALTERED ELIMINATION
Beschreibung
Implement Universal Fall Prevention Interventions
Datentyp
boolean
Beschreibung
Remain in attendance during toileting/ADL's
Datentyp
boolean
Beschreibung
Assist with post-elimination hygiene
Datentyp
boolean
Beschreibung
Remove non-essential clothing
Datentyp
boolean
Beschreibung
Instruct patient on importance of toileting when offered by staff
Datentyp
boolean
Beschreibung
Monitor for 'patient's normal' bladder/bowel habits
Datentyp
boolean
Beschreibung
Monitor for causes of incontinence (diuretics,cathartics,etc.)
Datentyp
boolean
Beschreibung
Monitor skin integrity
Datentyp
boolean
Beschreibung
HIGH RISK FALL MEDICATIONS (ANTIEPILEPTICS & BENZODIAZEPINES)
Beschreibung
Implement Universal Fall Prevention Interventions
Datentyp
boolean
Beschreibung
Monitor drug dosages
Datentyp
boolean
Beschreibung
Evaluate sensory functions
Datentyp
boolean
Beschreibung
Monitor/Assess for drug overdose
Datentyp
boolean
Beschreibung
Monitor response to exercise
Datentyp
boolean
Beschreibung
Educate patient/support system about drug classification, side effects,
Datentyp
boolean
Beschreibung
precautions, toxic symptoms of overdose.
Datentyp
boolean
Beschreibung
Hendrich II Fall Risk Assessment
Beschreibung
ONN Unit specific
Beschreibung
AFFECTED SITE
Datentyp
string
Beschreibung
CIRCULATORY STATUS
Datentyp
string
Beschreibung
SKIN COLOR
Datentyp
string
Beschreibung
SENSATION
Datentyp
string
Beschreibung
MOVEMENT
Datentyp
string
Beschreibung
TEMPERATURE
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0039476
- SNOMED CT 2011_0131
- 246508008
- LOINC Version 232
- MTHU009008
Beschreibung
SKIN CONDITION
Datentyp
string
Alias
- UMLS CUI 2011AA
- C1719933
- SNOMED CT 2011_0131
- 422000003
- LOINC Version 232
- MTHU034830
Beschreibung
PULSE(s) SITE(s)
Datentyp
string
Beschreibung
RESPONSE
Datentyp
string
Beschreibung
POSITION OF LIMB
Datentyp
string
Beschreibung
ORTHOPEDIC DEVICE IN USE
Datentyp
string
Beschreibung
CONTINUOUS PASSIVE MOTION
Datentyp
string
Beschreibung
POUNDS
Datentyp
string
Beschreibung
CERVICAL COLLARS
Datentyp
string
Beschreibung
AFO BRACE: Foot/Feet
Datentyp
string
Beschreibung
SWELLING
Datentyp
string
Beschreibung
PIN SITES
Datentyp
string
Beschreibung
CLEANED WITH
Datentyp
string
Beschreibung
NARRATIVE
Datentyp
string
Beschreibung
Post Surgical
Beschreibung
General Activity
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0451369
- SNOMED CT 2011_0131
- 273688003
Beschreibung
Vaginal Packing
Datentyp
string
Beschreibung
Equipment/Devices
Datentyp
string
Beschreibung
EQUIPMENT/DEVICES
Datentyp
string
Beschreibung
ADOLESCENT INTERACTION
Beschreibung
Prepared for treatment/procedure as soon as possible.
Datentyp
string
Beschreibung
Provided detailed information about events/procedures/treatments.
Datentyp
string
Beschreibung
Allowed contact with peer group.
Datentyp
string
Beschreibung
NARRATIVE
Datentyp
string
Beschreibung
GERIATRIC INTERVENTION (65+)
Beschreibung
Involved in decision process regarding pain control/medication/care decisions
Datentyp
string
Beschreibung
Encouraged family/S.O.to visit
Datentyp
string
Beschreibung
Independence promoted.
Datentyp
string
Beschreibung
NARRATIVE
Datentyp
string
Ähnliche Modelle
HIS
- StudyEvent: HIS
C0008059 (UMLS CUI-2)
C0205090 (UMLS CUI [1,2])
C0444532 (UMLS CUI [1,2])
C0205091 (UMLS CUI [1,2])
C0443246 (UMLS CUI [1,2])
C0008059 (UMLS CUI-2)
43173001 (SNOMED CT 2011_0131)
4065008 (SNOMED CT 2011_0131)
23472005 (SNOMED CT 2011_0131)
65452004 (SNOMED CT 2011_0131)
10053935 (MedDRA 14.1)
C1720310 (UMLS CUI [1])
74828005 (SNOMED CT 2011_0131)
10053938 (MedDRA 14.1)
10053929 (MedDRA 14.1)
10053926 (MedDRA 14.1)
C0450429 (UMLS CUI [1,2])
423666004 (SNOMED CT 2011_0131)
10030095 (MedDRA 14.1)
MTHU019803 (LOINC Version 232)
R60.9 (ICD-10-CM Version 2010)
782.3 (ICD-9-CM Version 2011)
C0205090 (UMLS CUI [1,2])
C0444532 (UMLS CUI [1,2])
C0205091 (UMLS CUI [1,2])
C0443246 (UMLS CUI [1,2])
C0009393 (UMLS CUI [1,2])
404640003 (SNOMED CT 2011_0131)
10013573 (MedDRA 14.1)
E12631 (CTCAE 1105E)
60862001 (SNOMED CT 2011_0131)
10043882 (MedDRA 14.1)
H93.1 (ICD-10-CM Version 2010)
388.3 (ICD-9-CM Version 2011)
E10287 (CTCAE 1105E)
C0009393 (UMLS CUI [1,2])
C0175566 (UMLS CUI [1,2])
267102003 (SNOMED CT 2011_0131)
10041367 (MedDRA 14.1)
R07.0 (ICD-10-CM Version 2010)
784.1 (ICD-9-CM Version 2011)
E13575 (CTCAE 1105E)
52653008 (SNOMED CT 2011_0131)
10064779 (MedDRA 14.1)
C0199438 (UMLS CUI [1,2])
49727002 (SNOMED CT 2011_0131)
10011224 (MedDRA 14.1)
R05 (ICD-10-CM Version 2010)
786.2 (ICD-9-CM Version 2011)
E13364 (CTCAE 1105E)
10041802 (MedDRA 14.1)
MTHU001309 (LOINC Version 232)
C0038056 (UMLS CUI [1])
C1306323 (UMLS CUI [1,2])
87042004 (SNOMED CT 2011_0131)
10006023 (MedDRA 14.1)
48340000 (SNOMED CT 2011_0131)
10021639 (MedDRA 14.1)
61420007 (SNOMED CT 2011_0131)
10053095 (MedDRA 14.1)
19923001 (SNOMED CT 2011_0131)
260967009 (SNOMED CT 2011_0131)
75823008 (SNOMED CT 2011_0131)
34896006 (SNOMED CT 2011_0131)
13924000 (SNOMED CT 2011_0131)
10052428 (MedDRA 14.1)
MTHU001326 (LOINC Version 232)
13924000 (SNOMED CT 2011_0131)
10052428 (MedDRA 14.1)
MTHU001326 (LOINC Version 232)
C0450429 (UMLS CUI 2011AA-2)
246267002 (SNOMED CT 2011_0131-2)
41829006 (SNOMED CT 2011_0131)
61420007 (SNOMED CT 2011_0131)
10053095 (MedDRA 14.1)
52124006 (SNOMED CT 2011_0131)
118431008 (SNOMED CT 2011_0131)
10067708 (MedDRA 14.1)
106167005 (SNOMED CT 2011_0131)
273688003 (SNOMED CT 2011_0131)