ID

43560

Beschreibung

Form from HIS OpenVista

Stichworte

  1. 09.03.12 09.03.12 -
  2. 08.06.17 08.06.17 - Martin Dugas
  3. 20.09.21 20.09.21 -
Hochgeladen am

20. September 2021

DOI

Für eine Beantragung loggen Sie sich ein.

Lizenz

Creative Commons BY-NC 3.0

Modell Kommentare :

Hier können Sie das Modell kommentieren. Über die Sprechblasen an den Itemgruppen und Items können Sie diese spezifisch kommentieren.

Itemgroup Kommentare für :

Item Kommentare für :

Um Formulare herunterzuladen müssen Sie angemeldet sein. Bitte loggen Sie sich ein oder registrieren Sie sich kostenlos.

NURSING ASSESSMENT (pedi)

  1. StudyEvent: HIS
    1. HIS
Child Nursing Assessment
Beschreibung

Child Nursing Assessment

Alias
UMLS CUI-1
C0028680
UMLS CUI-2
C0008059
see initial Admission Assessment
Beschreibung

initial Assessment

Datentyp

boolean

Alias
UMLS CUI [1]
C0150637
DONE ON
Beschreibung

assessment date

Datentyp

date

Alias
UMLS CUI [1]
C2985720
ADMISSION TEXT
Beschreibung

ADMISSION

Datentyp

text

Alias
UMLS CUI [1]
C0030673
POST OP DAY
Beschreibung

POST OP DAY

Datentyp

integer

Alias
UMLS CUI [1]
C0032790
Neuro / Psychosocial
Beschreibung

Neuro / Psychosocial

Alias
UMLS CUI-1
C0027853
Normal Baseline: Alert, appropriate verbalization, response appropriate for age, pupils equal and reactive, sensation intact.
Beschreibung

Neurological examination normal

Datentyp

boolean

Alias
UMLS CUI [1]
C1112287
Narrative: Abnormal Findings
Beschreibung

Abnormal Findings

Datentyp

text

Alias
UMLS CUI [1]
C1704258
GLASGOW COMA SCALE ADULT
Beschreibung

GLASGOW COMA SCALE ADULT

Alias
UMLS CUI-1
C1271007
EYES OPEN
Beschreibung

Eyes open

Datentyp

integer

Alias
UMLS CUI [1]
C3648956
BEST VERBAL RESPONSE
Beschreibung

BEST VERBAL RESPONSE

Datentyp

integer

Alias
UMLS CUI [1]
C3648957
BEST MOTOR RESPONSE
Beschreibung

BEST MOTOR RESPONSE

Datentyp

integer

Alias
UMLS CUI [1]
C3648958
GLASCOW COMA SCALE SCORE ADULT
Beschreibung

GLASCOW COMA SCALE SCORE

Datentyp

integer

Alias
UMLS CUI [1]
C1271007
Pupillen
Beschreibung

Pupillen

Alias
UMLS CUI-1
C0034121
Right Size [mm]
Beschreibung

Right Pupil Size

Datentyp

integer

Maßeinheiten
  • mm
Alias
UMLS CUI [1,1]
C0517965
UMLS CUI [1,2]
C0205090
mm
Right Reaction
Beschreibung

Right Pupil Reaction

Datentyp

text

Alias
UMLS CUI [1,1]
C0234671
UMLS CUI [1,2]
C0444532
Left Size [mm]
Beschreibung

Left Pupil Size

Datentyp

integer

Maßeinheiten
  • mm
Alias
UMLS CUI [1,1]
C0517965
UMLS CUI [1,2]
C0205091
mm
Left Reaction
Beschreibung

Left Pupil Reaction

Datentyp

text

Alias
UMLS CUI [1,1]
C0234671
UMLS CUI [1,2]
C0443246
GLASGOW COMA SCALE CHILD
Beschreibung

GLASGOW COMA SCALE CHILD

Alias
UMLS CUI-1
C0017594
UMLS CUI-2
C0008059
EYES OPEN
Beschreibung

EYES OPEN

Datentyp

integer

Alias
UMLS CUI [1]
C3648956
BEST VERBAL RESPONSE
Beschreibung

BEST VERBAL RESPONSE

Datentyp

integer

BEST MOTOR RESPONSE
Beschreibung

BEST MOTOR RESPONSE

Datentyp

integer

Alias
UMLS CUI [1]
C3648958
GLASCOW COMA SCALE SCORE CHILD
Beschreibung

GLASCOW COMA SCALE SCORE CHILD

Datentyp

integer

ORIENTATION
Beschreibung

ORIENTATION

Alias
UMLS CUI-1
C0029266
Orientierung
Beschreibung

ORIENTATION

Datentyp

string

Alias
UMLS CUI 2011AA
C0029266
SNOMED CT 2011_0131
43173001
HX OF SEIZURE ACTIVITY
Beschreibung

History of SEIZURE ACTIVITY

Datentyp

text

Alias
UMLS CUI [1]
C1148156
Affekt
Beschreibung

AFFECT

Datentyp

string

Alias
UMLS CUI 2011AA
C0001721
SNOMED CT 2011_0131
4065008
Sprache
Beschreibung

SPEECH

Datentyp

string

Alias
UMLS CUI 2011AA
C0037817
SNOMED CT 2011_0131
87335007
LOINC Version 232
MTHU021528
NUMBNESS OR TINGLING PRESENT
Beschreibung

NUMBNESS OR TINGLING

Datentyp

text

Alias
UMLS CUI [1]
C3842982
Kardiovaskuläres System
Beschreibung

Kardiovaskuläres System

Alias
UMLS CUI-1
C0007226
Normal Baseline: Regular rate and rhythm, no edema, capillary refill less than 2 seconds, pink nailbeds, warm extemities, peripheral pulses strong and regular.
Beschreibung

Cardiovascular System Normal

Datentyp

boolean

Alias
UMLS CUI [1]
C0577867
Narrative: Abnormal Findings
Beschreibung

Abnormal Findings

Datentyp

text

Alias
UMLS CUI [1]
C1704258
TEDS ON
Beschreibung

Antithromboembolic stockings

Datentyp

boolean

Alias
UMLS CUI [1]
C0419312
SCDS ON
Beschreibung

Vascular Sequential Compression Devices

Datentyp

boolean

Alias
UMLS CUI [1]
C0180062
Herztöne
Beschreibung

HEART SOUNDS

Datentyp

string

Alias
UMLS CUI 2011AA
C0018820
SNOMED CT 2011_0131
23472005
Radial pulse (L/R)
Beschreibung

Radial pulse (L/R)

Datentyp

string

Alias
UMLS CUI 2011AA
C0232142
SNOMED CT 2011_0131
65452004
MedDRA 14.1
10053935
Pedal pulse (L/R)
Beschreibung

Pedal pulse

Datentyp

text

Alias
UMLS CUI [1]
C0232157
Tibialis posterior-Puls (L/R)
Beschreibung

Pos-Tibial Pulse

Datentyp

text

Alias
SNOMED CT 2011_0131
421568004
UMLS CUI [1]
C1720310
Popliteal-Puls (L/R)
Beschreibung

Popliteal Pulse (L/R)

Datentyp

string

Alias
UMLS CUI 2011AA
C0232151
SNOMED CT 2011_0131
74828005
MedDRA 14.1
10053938
Brachialis-Puls (L/R)
Beschreibung

Brachial Pulse (L/R)

Datentyp

string

Alias
UMLS CUI 2011AA
C1096531
MedDRA 14.1
10053929
Karotis-Puls (L/R)
Beschreibung

Carotid Pulse (L/R)

Datentyp

string

Alias
UMLS CUI 2011AA
C1096529
MedDRA 14.1
10053926
AV SHUNT/GRAFT
Beschreibung

AV SHUNT

Datentyp

text

Alias
UMLS CUI [1]
C1456474
SHUNT/GRAFT LOCATION
Beschreibung

SHUNT LOCATION

Datentyp

text

Alias
UMLS CUI [1,1]
C1442858
UMLS CUI [1,2]
C0450429
BRUIT
Beschreibung

BRUIT

Datentyp

text

Alias
UMLS CUI [1]
C0006318
SHUNT/GRAFT BRUITS
Beschreibung

SHUNT BRUIT

Datentyp

text

Alias
UMLS CUI [1]
C0232112
THRILL PALPATED
Beschreibung

THRILL

Datentyp

text

Alias
UMLS CUI [1]
C2678517
CAPILLARY REFILL
Beschreibung

CAPILLARY REFILL

Datentyp

text

Alias
UMLS CUI [1]
C0425716
NAIL BED COLOR
Beschreibung

NAIL BED COLOR

Datentyp

text

Alias
UMLS CUI [1]
C0574757
Ödem
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
Heart RHYTHM
Beschreibung

Heart RHYTHM

Datentyp

text

Alias
UMLS CUI [1]
C0232187
(künstlicher) Herzschrittmacher
Beschreibung

PACEMAKER PRESENT

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0030163
SNOMED CT 2011_0131
14106009
LOINC Version 232
MTHU024521
Eyes Ear Nose & Throat
Beschreibung

Eyes Ear Nose & Throat

Alias
UMLS CUI-1
C3494720
Normal Baseline EYES: Without drainage, sclera white.
Beschreibung

EYES NORMAL

Datentyp

boolean

Alias
UMLS CUI [1]
C4230579
Normal Baseline EARS: No complaint of pain.
Beschreibung

Normal Ears

Datentyp

boolean

Alias
UMLS CUI [1]
C0576927
Normal Baseline NOSE: No drainage or congestion.
Beschreibung

Normal Nose

Datentyp

boolean

Alias
UMLS CUI [1]
C0577884
Normal Baseline THROAT: No complaint of pain.
Beschreibung

Normal Throat

Datentyp

boolean

Alias
UMLS CUI [1]
C0577002
NARRATIVE: Abnormal Findings
Beschreibung

Abnormal Findings

Datentyp

text

Alias
UMLS CUI [1]
C1704258
Augen
Beschreibung

Augen

Alias
UMLS CUI-1
C0015392
Pupil Right Size [mm]
Beschreibung

Right Pupil Size

Datentyp

integer

Maßeinheiten
  • mm
Alias
UMLS CUI [1,1]
C0517965
UMLS CUI [1,2]
C0205090
mm
Pupil Right Reaction
Beschreibung

Right Pupil Reaction

Datentyp

text

Alias
UMLS CUI [1,1]
C0234671
UMLS CUI [1,2]
C0444532
Pupil Left Size [mm]
Beschreibung

Left Pupil Size

Datentyp

integer

Maßeinheiten
  • mm
Alias
UMLS CUI [1,1]
C0517965
UMLS CUI [1,2]
C0205091
mm
Pupil Left Reaction
Beschreibung

Left Pupil Reaction

Datentyp

text

Alias
UMLS CUI [1,1]
C0234671
UMLS CUI [1,2]
C0443246
Eye Complains
Beschreibung

Eye symptom

Datentyp

text

Alias
UMLS CUI [1]
C0848690
Right Sclera
Beschreibung

Right Sclera

Datentyp

text

Alias
UMLS CUI [1]
C0929516
Left Sclera
Beschreibung

Left Sclera

Datentyp

text

Alias
UMLS CUI [1]
C0934600
Drainage
Beschreibung

Drainage

Datentyp

boolean

Alias
UMLS CUI [1]
C0012621
Drainage Color
Beschreibung

Drainage Color

Datentyp

text

Alias
UMLS CUI [1,1]
C0012621
UMLS CUI [1,2]
C0009393
Ohren
Beschreibung

Ohren

Alias
UMLS CUI-1
C0013443
EARS(EXTERNAL CANAL)
Beschreibung

EXTERNAL CANAL

Datentyp

text

Alias
UMLS CUI [1]
C1517034
C/O Pain
Beschreibung

C/O Pain

Datentyp

boolean

Alias
UMLS CUI [1]
C0436561
Trommelfell
Beschreibung

Tympanic Membranes

Datentyp

text

Alias
SNOMED CT 2011_0131
42859004
LOINC Version 232
MTHU014731
UMLS CUI [1]
C0041445
Tubes
Beschreibung

Tubes

Datentyp

text

Alias
UMLS CUI [1]
C0015183
Hard of Hearing
Beschreibung

Hard of Hearing

Datentyp

boolean

Alias
UMLS CUI [1]
C1384666
Hearing Loss
Beschreibung

Hearing Loss

Datentyp

boolean

Alias
UMLS CUI [1]
C3887873
Deafness
Beschreibung

Deafness

Datentyp

boolean

Alias
UMLS CUI [1]
C0011053
Hearing Aids
Beschreibung

Hearing Aids

Datentyp

text

Alias
UMLS CUI [1]
C0018768
Patent
Beschreibung

Patent

Datentyp

boolean

Alias
UMLS CUI [1]
C0175566
Schwindel
Beschreibung

Dizziness

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0012833
SNOMED CT 2011_0131
404640003
MedDRA 14.1
10013573
CTCAE 1105E
E12631
Tinnitus
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
Drainage
Beschreibung

Drainage

Datentyp

boolean

Alias
SNOMED CT 2011_0131
32712000
LOINC Version 232
MTHU022515
UMLS CUI [1]
C0012621
Color of Ear Drainage
Beschreibung

Color of Ear Drainage

Datentyp

text

Alias
UMLS CUI [1,1]
C0012621
UMLS CUI [1,2]
C0009393
Nase
Beschreibung

Nase

Alias
UMLS CUI-1
C0028429
Nares patent
Beschreibung

Nares patent

Datentyp

boolean

Alias
UMLS CUI [1,1]
C1456808
UMLS CUI [1,2]
C0175566
Nares Drainage
Beschreibung

Nares Drainage

Datentyp

boolean

Alias
UMLS CUI [1]
C0746759
Nasenseptum
Beschreibung

Septum

Datentyp

string

Alias
UMLS CUI 2011AA
C0027432
SNOMED CT 2011_0131
68426009
LOINC Version 232
MTHU015054
Pharynx
Beschreibung

Pharynx

Alias
UMLS CUI-1
C0031354
Sore throat, Pain in throat, Pharyngeal pain
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
Mouth Sores
Beschreibung

Mouth Sores

Datentyp

boolean

Alias
UMLS CUI [1]
C0149745
Appearance of Throat
Beschreibung

Appearance of Throat

Datentyp

text

Alias
UMLS CUI [1]
C0426505
Mucous Membranes
Beschreibung

Mucous Membranes

Datentyp

text

Alias
UMLS CUI [1]
C0026724
Respiratory
Beschreibung

Respiratory

Alias
UMLS CUI-1
C0035237
Normal Baseline Respiratory: Unlabored respirations, BBS clear, chest rise symmetrical, pink mucous membranes.
Beschreibung

Respiratory NORMAL

Datentyp

boolean

Alias
UMLS CUI [1]
C0231795
NARRATIVE: Abnormal Findings
Beschreibung

Abnormal Findings

Datentyp

text

Alias
UMLS CUI [1]
C1704258
Atemgeräusch
Beschreibung

BREATH SOUNDS

Datentyp

string

Alias
UMLS CUI 2011AA
C0035234
SNOMED CT 2011_0131
52653008
MedDRA 14.1
10064779
RESPIRATORY EFFORT
Beschreibung

RESPIRATORY EFFORT

Datentyp

text

Alias
UMLS CUI [1]
C0425466
CHEST EXPANSION
Beschreibung

CHEST EXPANSION

Datentyp

text

Alias
UMLS CUI [1]
C0231902
INCENTIVE SPIROMETRY DONE
Beschreibung

INCENTIVE SPIROMETRY

Datentyp

boolean

Alias
UMLS CUI [1]
C0454512
OXYGEN DELIVERY METHOD
Beschreibung

oxygen delivery system

Datentyp

text

Alias
UMLS CUI [1]
C0809836
Pulse Oximeter present with alarms set
Beschreibung

Pulse Oximeter

Datentyp

boolean

Alias
UMLS CUI [1]
C0182109
Cardio-Respriratory Monitor present with alarms set
Beschreibung

Cardio-Respiratory Monitoring

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0150496
UMLS CUI [1,2]
C0199438
Husten
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
Sputum
Beschreibung

Sputum

Datentyp

text

Alias
SNOMED CT 2011_0131
45710003
MedDRA 14.1
10041802
LOINC Version 232
MTHU001309
UMLS CUI [1]
C0038056
CHEST TUBE PRESENT
Beschreibung

CHEST TUBE

Datentyp

boolean

Alias
UMLS CUI [1]
C0008034
CHEST TUBE LOCATION
Beschreibung

Chest tube site

Datentyp

boolean

Alias
UMLS CUI [1]
C0489468
Chest Tube Suction Setting
Beschreibung

Chest Tube Suction Setting

Datentyp

text

Alias
UMLS CUI [1,1]
C0008034
UMLS CUI [1,2]
C1306323
Air Leak
Beschreibung

Air Leak

Datentyp

text

Alias
UMLS CUI [1]
C2242512
Gastrointestinal
Beschreibung

Gastrointestinal

Normal Baseline GI: Abdomen soft, nondistended, bowel sounds normoactive in all quadrants.
Beschreibung

NORMAL BASELINE GI

Datentyp

boolean

Last Bowel Movement
Beschreibung

Last BM

Datentyp

date

NARRATIVE: Abnormal Findings
Beschreibung

NARRATIVE: Abnormal Findings

Datentyp

string

Abdomen
Beschreibung

ABDOMINAL DESCRIPTION

Datentyp

string

Alias
UMLS CUI 2011AA
C0000726
SNOMED CT 2011_0131
113345001
LOINC Version 232
MTHU001425
Darmgeräusche
Beschreibung

BOWEL SOUNDS

Datentyp

string

Alias
UMLS CUI 2011AA
C0232693
SNOMED CT 2011_0131
87042004
MedDRA 14.1
10006023
FLATUS
Beschreibung

FLATUS

Datentyp

boolean

Inkontinenz
Beschreibung

incontinence

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0021167
SNOMED CT 2011_0131
48340000
MedDRA 14.1
10021639
GASTRIC SYMPTOMS
Beschreibung

GASTRIC SYMPTOMS

Datentyp

string

Nasogastric Tube Type
Beschreibung

NG TUBE TYPE

Datentyp

string

NG placement checked
Beschreibung

NG placement checked

Datentyp

boolean

Suction Setting
Beschreibung

Suction Setting

Datentyp

string

Gastric Content Color
Beschreibung

Gastric Content Color

Datentyp

string

NGT irrigated (with # ML's of #)
Beschreibung

NGT irrigated

Datentyp

string

Ernährung über Sonde
Beschreibung

FEEDING TUBE PRESENT

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0041281
SNOMED CT 2011_0131
61420007
MedDRA 14.1
10053095
Feeding Tube Type
Beschreibung

Feeding Tube Type

Datentyp

string

Formula (# strength @ # ml's/hour via kangaroo pump)
Beschreibung

Formula

Datentyp

string

OSTOMY TYPE
Beschreibung

OSTOMY TYPE

Datentyp

string

RECTAL BAG PRESENT
Beschreibung

RECTAL BAG PRESENT

Datentyp

boolean

Urogenitales System
Beschreibung

Urogenitales System

Normal Baseline Genitourinary: Voids without pain or hesitation, no suprapubic distention.
Beschreibung

NORMAL BASELINE Genitourinary

Datentyp

boolean

NARRATIVE: Abnormal Findings
Beschreibung

NARRATIVE: Abnormal Findings

Datentyp

string

Geschlecht
Beschreibung

Sex

Datentyp

string

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

INCONTINENT

Datentyp

boolean

VOIDS SUFFICIENT QUANITY
Beschreibung

VOIDS SUFFICIENT QUANITY

Datentyp

boolean

IS PATIENT RECEIVING DIALYSIS
Beschreibung

IS PATIENT RECEIVING DIALYSIS

Datentyp

boolean

ODOR PRESENT
Beschreibung

ODOR PRESENT

Datentyp

boolean

Katheter
Beschreibung

CATHETER PRESENT

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0085590
SNOMED CT 2011_0131
19923001
Katheter-Größe
Beschreibung

CATHETER SIZE

Datentyp

string

Alias
UMLS CUI 2011AA
C0449963
SNOMED CT 2011_0131
260967009
Date of insertion
Beschreibung

Date of insertion

Datentyp

date

Urine color
Beschreibung

Urine color

Datentyp

string

URINARY SYMPTOMS
Beschreibung

URINARY SYMPTOMS

Datentyp

string

SEXUALLY ACTIVE
Beschreibung

SEXUALLY ACTIVE

Datentyp

boolean

CURRENTLY ON MENSES
Beschreibung

CURRENTLY ON MENSES

Datentyp

boolean

Ausfluss
Beschreibung

DISCHARGE PRESENT

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0012621
SNOMED CT 2011_0131
75823008
Discharge color
Beschreibung

Discharge color

Datentyp

string

Discharge odor
Beschreibung

Discharge odor

Datentyp

string

Discharge consistency
Beschreibung

Discharge consistency

Datentyp

string

ABNORMAL GENITALIA DESCRIPTION
Beschreibung

ABNORMAL GENITALIA DESCRIPTION

Datentyp

string

Muskuloskeletales System
Beschreibung

Muskuloskeletales System

Normal Baseline Musculoskeletal: Full ROM, no muscle weakness, bones intact, gait steady or age appropriate.
Beschreibung

NORMAL BASELINE Musculoskeletal

Datentyp

boolean

NARRATIVE: Abnormal Findings
Beschreibung

NARRATIVE: Abnormal Findings

Datentyp

string

GENERALIZED WEAKNESS
Beschreibung

GENERALIZED WEAKNESS

Datentyp

boolean

LIMITED ROM
Beschreibung

LIMITED ROM

Datentyp

boolean

LIMITED MOBILITY
Beschreibung

LIMITED MOBILITY

Datentyp

boolean

PARALYSIS TYPE
Beschreibung

PARALYSIS TYPE

Datentyp

string

Hemiplegia Side
Beschreibung

Hemiplegia Side

Datentyp

string

FRACTURE(S) LOCATION
Beschreibung

FRACTURE(S) LOCATION

Datentyp

string

FINGER DIGITS
Beschreibung

FINGER DIGITS

Datentyp

string

TOE DIGITS
Beschreibung

TOE DIGITS

Datentyp

string

LEFT UPPER EXTREMITIES
Beschreibung

LEFT UPPER EXTREMITIES

Datentyp

string

RIGHT UPPER EXTREMITIES
Beschreibung

RIGHT UPPER EXTREMITIES

Datentyp

string

GRIPS EQUAL
Beschreibung

GRIPS EQUAL

Datentyp

boolean

LEFT LOWER EXTREMITIES
Beschreibung

LEFT LOWER EXTREMITIES

Datentyp

string

RIGHT LOWER EXTREMITIES
Beschreibung

RIGHT LOWER EXTREMITIES

Datentyp

string

UNSTEADY GAIT
Beschreibung

UNSTEADY GAIT

Datentyp

boolean

Haut
Beschreibung

Haut

Normal Baseline Skin: Warm, pink, dry, elastic, intact, moist mucous membranes.
Beschreibung

NORMAL BASELINE Skin

Datentyp

boolean

NARRATIVE: Abnormal Findings
Beschreibung

NARRATIVE: Abnormal Findings

Datentyp

string

Temperatur
Beschreibung

TEMPERATURE

Datentyp

float

Alias
UMLS CUI 2011AA
C0039476
SNOMED CT 2011_0131
246508008
LOINC Version 232
MTHU009008
SKIN COLOR
Beschreibung

SKIN COLOR

Datentyp

string

MOIST
Beschreibung

MOIST

Datentyp

boolean

SKIN TURGOR
Beschreibung

SKIN TURGOR

Datentyp

string

Inzision
Beschreibung

Inzision

Inzision
Beschreibung

Incision #:

Datentyp

string

Alias
UMLS CUI 2011AA
C0184898
SNOMED CT 2011_0131
34896006
MID WOUND#
Beschreibung

MID WOUND#

Datentyp

string

Site
Beschreibung

Site

Datentyp

string

Closure Type
Beschreibung

Closure Type

Datentyp

string

Incision Appearance
Beschreibung

Incision Appearance

Datentyp

string

Dressing Changed
Beschreibung

Dressing Changed

Datentyp

boolean

Date Dressing Changed
Beschreibung

Date Dressing Changed

Datentyp

date

Dressing Type
Beschreibung

Dressing Type

Datentyp

string

Dressing Appearance
Beschreibung

Dressing Appearance

Datentyp

string

Drainage
Beschreibung

Drains

Datentyp

string

Alias
UMLS CUI 2011AA
C0180499
SNOMED CT 2011_0131
32712000
LOINC Version 232
MTHU022515
Wunde
Beschreibung

Wunde

Wunde
Beschreibung

WOUND #

Datentyp

string

Alias
UMLS CUI 2011AA
C0043250
SNOMED CT 2011_0131
13924000
MedDRA 14.1
10052428
LOINC Version 232
MTHU001326
MID WOUND#
Beschreibung

MID WOUND#

Datentyp

string

Wound Location
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
Length (cm, mm)
Beschreibung

Length (cm, mm)

Datentyp

string

Width (cm, mm)
Beschreibung

Width (cm, mm)

Datentyp

string

Depth (cm, mm)
Beschreibung

Depth (cm, mm)

Datentyp

string

Undermining
Beschreibung

Undermining

Datentyp

boolean

Tunneling
Beschreibung

Tunneling

Datentyp

boolean

Surrounding Skin
Beschreibung

Surrounding Skin

Datentyp

string

Wound Base
Beschreibung

Wound Base

Datentyp

string

Exsudat
Beschreibung

Exudate

Datentyp

string

Alias
UMLS CUI 2011AA
C0015388
SNOMED CT 2011_0131
247450001
LOINC Version 232
MTHU025016
Exudate Color
Beschreibung

Exudate Color

Datentyp

string

Sensation
Beschreibung

Sensation

Datentyp

string

Alias
UMLS CUI 2011AA
C0036658
SNOMED CT 2011_0131
373713005
LOINC Version 232
MTHU017277
Odor: Before Cleaning
Beschreibung

Odor: Before Cleaning

Datentyp

boolean

Odor: After Cleaning
Beschreibung

Odor: After Cleaning

Datentyp

boolean

Cleansed with/irrigated with
Beschreibung

Cleansed with/irrigated with

Datentyp

string

Wound Medication Applied
Beschreibung

Wound Medication Applied

Datentyp

string

Wound Filled with
Beschreibung

Wound Filled with

Datentyp

string

Wound covered with
Beschreibung

Wound covered with

Datentyp

string

Wound secured with
Beschreibung

Wound secured with

Datentyp

string

Wound Pressure Relief
Beschreibung

Wound Pressure Relief

Datentyp

string

Comments
Beschreibung

Comments

Datentyp

string

Photograph Date
Beschreibung

Photograph Date

Datentyp

date

RASH LOCATION
Beschreibung

RASH LOCATION

Datentyp

string

RASH DESCRIPTION
Beschreibung

RASH DESCRIPTION

Datentyp

string

TATTOO'S/PIERCINGS
Beschreibung

TATTOO'S/PIERCINGS

Datentyp

string

SKIN TEARS, LOCATION/ Description
Beschreibung

SKIN TEARS, LOCATION/ Description

Datentyp

string

SPECIALTY BEDS
Beschreibung

SPECIALTY BEDS

Datentyp

string

Nutrition
Beschreibung

Nutrition

Diät
Beschreibung

Current Diet

Datentyp

string

Alias
UMLS CUI 2011AA
C0012155
SNOMED CT 2011_0131
41829006
NPO
Beschreibung

NPO

Datentyp

boolean

Ernährung über Sonde
Beschreibung

FEEDING TUBE PRESENT

Datentyp

boolean

Alias
UMLS CUI 2011AA
C0041281
SNOMED CT 2011_0131
61420007
MedDRA 14.1
10053095
Feeding Tube Type
Beschreibung

Feeding Tube Type

Datentyp

string

Formula: # strength @ # cc's/hour via kangaroo pump
Beschreibung

Formula

Datentyp

string

RESIDUALS CHECKED: AMOUNT # CC
Beschreibung

RESIDUALS CHECKED

Datentyp

string

BREAKFAST
Beschreibung

BREAKFAST

Datentyp

string

Breakfast: Amount taken
Beschreibung

Breakfast: Amount taken

Datentyp

string

Breakfast: Patient fed by
Beschreibung

Breakfast: Patient fed by

Datentyp

string

LUNCH
Beschreibung

LUNCH

Datentyp

string

Lunch: Amount taken
Beschreibung

Lunch: Amount taken

Datentyp

string

Lunch: Patient fed by
Beschreibung

Lunch: Patient fed by

Datentyp

string

SUPPER
Beschreibung

SUPPER

Datentyp

string

Supper: Amount taken
Beschreibung

Supper: Amount taken

Datentyp

string

Supper: Patient fed by
Beschreibung

Supper: Patient fed by

Datentyp

string

Supper: Amount taken
Beschreibung

Supper: Amount taken

Datentyp

string

intravenöse Therapie
Beschreibung

intravenöse Therapie

NARRATIVE: IV Therapy
Beschreibung

NARRATIVE: IV Therapy

Datentyp

string

IV HEPLOCKED
Beschreibung

IV HEPLOCKED

Datentyp

boolean

IV Site APPEARANCE
Beschreibung

IV Site APPEARANCE

Datentyp

string

IV DISCONTINUED
Beschreibung

IV DISCONTINUED

Datentyp

boolean

CATHETER INTACT
Beschreibung

CATHETER INTACT

Datentyp

boolean

IV Catheter Size
Beschreibung

IV Catheter Size

Datentyp

string

IV Site Location
Beschreibung

IV Site Location

Datentyp

string

Zentralvenöser Katheter (ZVK)
Beschreibung

CENTRAL LINE PORT

Datentyp

string

Alias
UMLS CUI 2011AA
C1145640
SNOMED CT 2011_0131
52124006
Infusion
Beschreibung

IV FLUIDS

Datentyp

string

Alias
UMLS CUI 2011AA
C1289919
SNOMED CT 2011_0131
118431008
MedDRA 14.1
10067708
Left to count:
Beschreibung

Left to count:

Datentyp

string

IV Fluid Rate: @ ml/hr
Beschreibung

IV Fluid Rate: @ ml/hr

Datentyp

integer

TPN/LIPIDS: TPN @ ml/hr and Lipids @ ml/hr
Beschreibung

TPN/LIPIDS: TPN @ ml/hr and Lipids @ ml/hr

Datentyp

string

PCA PUMP: at @ cc's/hr
Beschreibung

PCA PUMP: at @ cc's/hr

Datentyp

string

IV Site APPEARANCE
Beschreibung

IV Site APPEARANCE

Datentyp

string

INSERTION DATE
Beschreibung

INSERTION DATE

Datentyp

date

DRESSING CHANGE DUE
Beschreibung

DRESSING CHANGE DUE

Datentyp

date

SITE CHANGE DUE
Beschreibung

SITE CHANGE DUE

Datentyp

date

PLACED ON IMED
Beschreibung

PLACED ON IMED

Datentyp

boolean

Patientensicherheit
Beschreibung

Patientensicherheit

SIDE RAILS UP
Beschreibung

SIDE RAILS UP

Datentyp

boolean

IN LOW POSTION
Beschreibung

IN LOW POSTION

Datentyp

boolean

BED/CRIB
Beschreibung

BED/CRIB

Datentyp

string

CALL BELL WITHIN REACH
Beschreibung

CALL BELL WITHIN REACH

Datentyp

boolean

ALLERGY BAND ON
Beschreibung

ALLERGY BAND ON

Datentyp

boolean

NAME BAND ON
Beschreibung

NAME BAND ON

Datentyp

boolean

BLOOD BAND ON
Beschreibung

BLOOD BAND ON

Datentyp

boolean

FALL BAND ON
Beschreibung

FALL BAND ON

Datentyp

boolean

BED SAFETY
Beschreibung

BED SAFETY

Datentyp

string

Pediatric Fall Risk Assessment
Beschreibung

Pediatric Fall Risk Assessment

Unable to assess fall risk status at this time due to patient is:
Beschreibung

Unable to assess fall risk status at this time due to patient is:

Datentyp

string

Geschlecht
Beschreibung

gender

Datentyp

string

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

LEVEL OF CONSCIOUS

Datentyp

string

Alias
UMLS CUI 2011AA
C0234421
SNOMED CT 2011_0131
106167005
Seizures/Previous history of falls
Beschreibung

Seizures/Previous history of falls

Datentyp

string

MEDICATION/EQUIPMENT
Beschreibung

MEDICATION/EQUIPMENT

Datentyp

string

Verweildauer
Beschreibung

LENGTH OF STAY

Datentyp

string

Alias
UMLS CUI 2011AA
C0023303
ELIMINATION
Beschreibung

ELIMINATION

Datentyp

string

GET UP AND GO TEST: "RISING FROM A CHAIR"
Beschreibung

GET UP AND GO TEST: "RISING FROM A CHAIR"

Datentyp

string

FINAL RISK SCORE (Pediatric Fall Risk Assessment)
Beschreibung

FINAL RISK SCORE

Datentyp

integer

INTERVENTIONS
Beschreibung

INTERVENTIONS

Assist with Ambulation
Beschreibung

Assist with Ambulation

Datentyp

boolean

Reorient Q2H or Less
Beschreibung

Reorient Q2H or Less

Datentyp

boolean

Gait Belt
Beschreibung

Gait Belt

Datentyp

boolean

ID Patient at Risk
Beschreibung

ID Patient at Risk

Datentyp

boolean

Restraints (see policy)
Beschreibung

Restraints (see policy)

Datentyp

boolean

Multi-personnel Transfer
Beschreibung

Multi-personnel Transfer

Datentyp

boolean

Close Observation
Beschreibung

Close Observation

Datentyp

boolean

Non-slip Footwear
Beschreibung

Non-slip Footwear

Datentyp

boolean

Bed in lowest position
Beschreibung

Bed in lowest position

Datentyp

boolean

Lock wheels of vehicles of conveyance during transfer
Beschreibung

Lock wheels of vehicles of conveyance during transfer

Datentyp

boolean

Upper siderails raised
Beschreibung

Upper siderails raised

Datentyp

boolean

Call light in reach
Beschreibung

Call light in reach

Datentyp

boolean

Offer toileting at least every 2 hours
Beschreibung

Offer toileting at least every 2 hours

Datentyp

boolean

Offer fluid/nutrition every 2 hours
Beschreibung

Offer fluid/nutrition every 2 hours

Datentyp

boolean

Place frequently used objects within reach
Beschreibung

Place frequently used objects within reach

Datentyp

boolean

Provide adequate lighting
Beschreibung

Provide adequate lighting

Datentyp

boolean

Provide sensory impairment/orientation devices (clocks,etc)
Beschreibung

Provide sensory impairment/orientation devices (clocks,etc)

Datentyp

boolean

Provide adequate rest periods
Beschreibung

Provide adequate rest periods

Datentyp

boolean

Use age appropriate distractions for confusion/disorientation
Beschreibung

Use age appropriate distractions for confusion/disorientation

Datentyp

boolean

Remove harmful hazards
Beschreibung

Remove harmful hazards

Datentyp

boolean

Provide appropriate and least restrictive patient supervision/surveillance
Beschreibung

Provide appropriate and least restrictive patient supervision/surveillance

Datentyp

boolean

Communicate information about fall risk to caregivers
Beschreibung

Communicate information about fall risk to caregivers

Datentyp

boolean

Encourage family/support system to participate in care
Beschreibung

Encourage family/support system to participate in care

Datentyp

boolean

Teach/educate family/support system Fall Prevention information
Beschreibung

Teach/educate family/support system Fall Prevention information

Datentyp

boolean

Implement Fall Prevention Protocol for Hendrich II Score>5
Beschreibung

Implement Fall Prevention Protocol for Hendrich II Score>5

Datentyp

boolean

IMPAIRED MOBILITY RISK
Beschreibung

IMPAIRED MOBILITY RISK

Implement Universal Fall Prevention Intervention
Beschreibung

Implement Universal Fall Prevention Intervention

Datentyp

boolean

Monitor transfers to/from bed/chair(etc.)
Beschreibung

Monitor transfers to/from bed/chair(etc.)

Datentyp

boolean

Use appropriate assistance for transfers to/from bed/chair
Beschreibung

Use appropriate assistance for transfers to/from bed/chair

Datentyp

boolean

Use chairs with armrests and of proper height for transfers
Beschreibung

Use chairs with armrests and of proper height for transfers

Datentyp

boolean

Implement progressive ambulation(unless contraindicated by condition/orders)
Beschreibung

Implement progressive ambulation(unless contraindicated by condition/orders)

Datentyp

boolean

Encourage/Provide self-care assistance
Beschreibung

Encourage/Provide self-care assistance

Datentyp

boolean

Remain in attendance during toileting/ADL's
Beschreibung

Remain in attendance during toileting/ADL's

Datentyp

boolean

Provide assistive devices for ambulation (canes/walkers/etc.)
Beschreibung

Provide assistive devices for ambulation (canes/walkers/etc.)

Datentyp

boolean

Gait Belt during transport/ambulation
Beschreibung

Gait Belt during transport/ambulation

Datentyp

boolean

Teach patient/family to call for help and WAIT for help before
Beschreibung

Teach patient/family to call for help and WAIT for help before

Datentyp

boolean

attempting any transfer/ambulation
Beschreibung

attempting any transfer/ambulation

Datentyp

boolean

ALTERED ELIMINATION
Beschreibung

ALTERED ELIMINATION

Implement Universal Fall Prevention Interventions
Beschreibung

Implement Universal Fall Prevention Interventions

Datentyp

boolean

Remain in attendance during toileting/ADL's
Beschreibung

Remain in attendance during toileting/ADL's

Datentyp

boolean

Assist with post-elimination hygiene
Beschreibung

Assist with post-elimination hygiene

Datentyp

boolean

Remove non-essential clothing
Beschreibung

Remove non-essential clothing

Datentyp

boolean

Instruct patient on importance of toileting when offered by staff
Beschreibung

Instruct patient on importance of toileting when offered by staff

Datentyp

boolean

Monitor for 'patient's normal' bladder/bowel habits
Beschreibung

Monitor for 'patient's normal' bladder/bowel habits

Datentyp

boolean

Monitor for causes of incontinence (diuretics,cathartics,etc.)
Beschreibung

Monitor for causes of incontinence (diuretics,cathartics,etc.)

Datentyp

boolean

Monitor skin integrity
Beschreibung

Monitor skin integrity

Datentyp

boolean

HIGH RISK FALL MEDICATIONS (ANTIEPILEPTICS & BENZODIAZEPINES)
Beschreibung

HIGH RISK FALL MEDICATIONS (ANTIEPILEPTICS & BENZODIAZEPINES)

Implement Universal Fall Prevention Interventions
Beschreibung

Implement Universal Fall Prevention Interventions

Datentyp

boolean

Monitor drug dosages
Beschreibung

Monitor drug dosages

Datentyp

boolean

Evaluate sensory functions
Beschreibung

Evaluate sensory functions

Datentyp

boolean

Monitor/Assess for drug overdose
Beschreibung

Monitor/Assess for drug overdose

Datentyp

boolean

Monitor response to exercise
Beschreibung

Monitor response to exercise

Datentyp

boolean

Educate patient/support system about drug classification, side effects,
Beschreibung

Educate patient/support system about drug classification, side effects,

Datentyp

boolean

precautions, toxic symptoms of overdose.
Beschreibung

precautions, toxic symptoms of overdose.

Datentyp

boolean

Hendrich II Fall Risk Assessment
Beschreibung

Hendrich II Fall Risk Assessment

Unable to assess fall risk status at this time due to patient is:
Beschreibung

Unable to assess fall risk status at this time due to patient is:

Datentyp

string

HENDRICH CALCULATION
Beschreibung

HENDRICH CALCULATION

Datentyp

string

ONN Unit specific
Beschreibung

ONN Unit specific

AFFECTED SITE
Beschreibung

AFFECTED SITE

Datentyp

string

CIRCULATORY STATUS
Beschreibung

CIRCULATORY STATUS

Datentyp

string

SKIN COLOR
Beschreibung

SKIN COLOR

Datentyp

string

SENSATION
Beschreibung

SENSATION

Datentyp

string

MOVEMENT
Beschreibung

MOVEMENT

Datentyp

string

Temperatur
Beschreibung

TEMPERATURE

Datentyp

string

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

SKIN CONDITION

Datentyp

string

Alias
UMLS CUI 2011AA
C1719933
SNOMED CT 2011_0131
422000003
LOINC Version 232
MTHU034830
PULSE(s) SITE(s)
Beschreibung

PULSE(s) SITE(s)

Datentyp

string

RESPONSE
Beschreibung

RESPONSE

Datentyp

string

POSITION OF LIMB
Beschreibung

POSITION OF LIMB

Datentyp

string

ORTHOPEDIC DEVICE IN USE
Beschreibung

ORTHOPEDIC DEVICE IN USE

Datentyp

string

CONTINUOUS PASSIVE MOTION
Beschreibung

CONTINUOUS PASSIVE MOTION

Datentyp

string

POUNDS
Beschreibung

POUNDS

Datentyp

string

CERVICAL COLLARS
Beschreibung

CERVICAL COLLARS

Datentyp

string

AFO BRACE: Foot/Feet (LEFT-RIGHT-BILATERAL)
Beschreibung

AFO BRACE: Foot/Feet

Datentyp

string

SWELLING
Beschreibung

SWELLING

Datentyp

string

PIN SITES
Beschreibung

PIN SITES

Datentyp

string

CLEANED WITH
Beschreibung

CLEANED WITH

Datentyp

string

NARRATIVE
Beschreibung

NARRATIVE

Datentyp

string

Post Surgical
Beschreibung

Post Surgical

Patient activity
Beschreibung

General Activity

Datentyp

string

Alias
UMLS CUI 2011AA
C0451369
SNOMED CT 2011_0131
273688003
Vaginal Packing
Beschreibung

Vaginal Packing

Datentyp

string

Equipment/Devices
Beschreibung

Equipment/Devices

Datentyp

string

EQUIPMENT/DEVICES
Beschreibung

EQUIPMENT/DEVICES

Datentyp

string

ADOLESCENT INTERACTION
Beschreibung

ADOLESCENT INTERACTION

Prepared for treatment/procedure as soon as possible.
Beschreibung

Prepared for treatment/procedure as soon as possible.

Datentyp

string

Provided detailed information about events/procedures/treatments.
Beschreibung

Provided detailed information about events/procedures/treatments.

Datentyp

string

Allowed contact with peer group.
Beschreibung

Allowed contact with peer group.

Datentyp

string

NARRATIVE
Beschreibung

NARRATIVE

Datentyp

string

GERIATRIC INTERVENTION (65+)
Beschreibung

GERIATRIC INTERVENTION (65+)

Involved in decision process regarding pain control/medication/care decisions
Beschreibung

Involved in decision process regarding pain control/medication/care decisions

Datentyp

string

Encouraged family/S.O.to visit
Beschreibung

Encouraged family/S.O.to visit

Datentyp

string

Independence promoted.
Beschreibung

Independence promoted.

Datentyp

string

NARRATIVE
Beschreibung

NARRATIVE

Datentyp

string

Ähnliche Modelle

  1. StudyEvent: HIS
    1. HIS
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
Child Nursing Assessment
C0028680 (UMLS CUI-1)
C0008059 (UMLS CUI-2)
initial Assessment
Item
see initial Admission Assessment
boolean
C0150637 (UMLS CUI [1])
assessment date
Item
DONE ON
date
C2985720 (UMLS CUI [1])
ADMISSION
Item
ADMISSION TEXT
text
C0030673 (UMLS CUI [1])
POST OP DAY
Item
POST OP DAY
integer
C0032790 (UMLS CUI [1])
Item Group
Neuro / Psychosocial
C0027853 (UMLS CUI-1)
Neurological examination normal
Item
Normal Baseline: Alert, appropriate verbalization, response appropriate for age, pupils equal and reactive, sensation intact.
boolean
C1112287 (UMLS CUI [1])
Abnormal Findings
Item
Narrative: Abnormal Findings
text
C1704258 (UMLS CUI [1])
Item Group
GLASGOW COMA SCALE ADULT
C1271007 (UMLS CUI-1)
Item
EYES OPEN
integer
C3648956 (UMLS CUI [1])
Code List
EYES OPEN
CL Item
Spontaneously (4)
C2012046 (UMLS CUI-1)
CL Item
To speech (3)
C2012048 (UMLS CUI-1)
CL Item
To pain (2)
C2012047 (UMLS CUI-1)
CL Item
None (1)
C2012045 (UMLS CUI-1)
Item
BEST VERBAL RESPONSE
integer
C3648957 (UMLS CUI [1])
Code List
BEST VERBAL RESPONSE
CL Item
Oriented (5)
C2012059 (UMLS CUI-1)
CL Item
Confused (4)
C2012056 (UMLS CUI-1)
CL Item
Inappropriate words (3)
C2012058 (UMLS CUI-1)
CL Item
Incomprehensible words (2)
C2012057 (UMLS CUI-1)
CL Item
None (1)
C2012060 (UMLS CUI-1)
Item
BEST MOTOR RESPONSE
integer
C3648958 (UMLS CUI [1])
Code List
BEST MOTOR RESPONSE
CL Item
Obeys command (6)
C2012055 (UMLS CUI-1)
CL Item
Localize to pain (5)
C2012053 (UMLS CUI-1)
CL Item
Withdraws (4)
C2012052 (UMLS CUI-1)
CL Item
Flexion to pain (3)
C2012051 (UMLS CUI-1)
CL Item
Extension to pain (2)
C2012050 (UMLS CUI-1)
CL Item
None (1)
C2012054 (UMLS CUI-1)
GLASCOW COMA SCALE SCORE
Item
GLASCOW COMA SCALE SCORE ADULT
integer
C1271007 (UMLS CUI [1])
Item Group
Pupillen
C0034121 (UMLS CUI-1)
Right Pupil Size
Item
Right Size [mm]
integer
C0517965 (UMLS CUI [1,1])
C0205090 (UMLS CUI [1,2])
Right Pupil Reaction
Item
Right Reaction
text
C0234671 (UMLS CUI [1,1])
C0444532 (UMLS CUI [1,2])
Left Pupil Size
Item
Left Size [mm]
integer
C0517965 (UMLS CUI [1,1])
C0205091 (UMLS CUI [1,2])
Left Pupil Reaction
Item
Left Reaction
text
C0234671 (UMLS CUI [1,1])
C0443246 (UMLS CUI [1,2])
Item Group
GLASGOW COMA SCALE CHILD
C0017594 (UMLS CUI-1)
C0008059 (UMLS CUI-2)
Item
EYES OPEN
integer
C3648956 (UMLS CUI [1])
Code List
EYES OPEN
CL Item
Spontaneously (4)
C2012046 (UMLS CUI-1)
CL Item
To speech (3)
C2012048 (UMLS CUI-1)
CL Item
To pain (2)
C2012047 (UMLS CUI-1)
CL Item
None (1)
C2012045 (UMLS CUI-1)
Item
BEST VERBAL RESPONSE
integer
Code List
BEST VERBAL RESPONSE
CL Item
Coos and babbles (5)
C0517058 (UMLS CUI-1)
CL Item
Irritable, cries (4)
C0010399 (UMLS CUI-1)
CL Item
Cries in response to pain (3)
C1698479 (UMLS CUI-1)
CL Item
Moans in response to pain (2)
C2071460 (UMLS CUI-1)
CL Item
None (1)
C2012060 (UMLS CUI-1)
Item
BEST MOTOR RESPONSE
integer
C3648958 (UMLS CUI [1])
Code List
BEST MOTOR RESPONSE
CL Item
Moves spontaneously and purposely (6)
C2012055 (UMLS CUI-1)
CL Item
Withdraws in response to touch (5)
C2012053 (UMLS CUI-1)
CL Item
Withdraws in response to pain (4)
C2012052 (UMLS CUI-1)
CL Item
Decorticate posturing (abnormal flexion) in response to pain (3)
C2012051 (UMLS CUI-1)
CL Item
Decerebrate posturing (abnormal extension) in response to pain (2)
C2012050 (UMLS CUI-1)
CL Item
None (1)
C2012054 (UMLS CUI-1)
GLASCOW COMA SCALE SCORE CHILD
Item
GLASCOW COMA SCALE SCORE CHILD
integer
Item Group
ORIENTATION
C0029266 (UMLS CUI-1)
ORIENTATION
Item
Orientierung
string
C0029266 (UMLS CUI 2011AA)
43173001 (SNOMED CT 2011_0131)
History of SEIZURE ACTIVITY
Item
HX OF SEIZURE ACTIVITY
text
C1148156 (UMLS CUI [1])
AFFECT
Item
Affekt
string
C0001721 (UMLS CUI 2011AA)
4065008 (SNOMED CT 2011_0131)
SPEECH
Item
Sprache
string
C0037817 (UMLS CUI 2011AA)
87335007 (SNOMED CT 2011_0131)
MTHU021528 (LOINC Version 232)
NUMBNESS OR TINGLING
Item
NUMBNESS OR TINGLING PRESENT
text
C3842982 (UMLS CUI [1])
Item Group
Kardiovaskuläres System
C0007226 (UMLS CUI-1)
Cardiovascular System Normal
Item
Normal Baseline: Regular rate and rhythm, no edema, capillary refill less than 2 seconds, pink nailbeds, warm extemities, peripheral pulses strong and regular.
boolean
C0577867 (UMLS CUI [1])
Abnormal Findings
Item
Narrative: Abnormal Findings
text
C1704258 (UMLS CUI [1])
Antithromboembolic stockings
Item
TEDS ON
boolean
C0419312 (UMLS CUI [1])
Vascular Sequential Compression Devices
Item
SCDS ON
boolean
C0180062 (UMLS CUI [1])
HEART SOUNDS
Item
Herztöne
string
C0018820 (UMLS CUI 2011AA)
23472005 (SNOMED CT 2011_0131)
Radial pulse (L/R)
Item
Radial pulse (L/R)
string
C0232142 (UMLS CUI 2011AA)
65452004 (SNOMED CT 2011_0131)
10053935 (MedDRA 14.1)
Pedal pulse
Item
Pedal pulse (L/R)
text
C0232157 (UMLS CUI [1])
Pos-Tibial Pulse
Item
Tibialis posterior-Puls (L/R)
text
421568004 (SNOMED CT 2011_0131)
C1720310 (UMLS CUI [1])
Popliteal Pulse (L/R)
Item
Popliteal-Puls (L/R)
string
C0232151 (UMLS CUI 2011AA)
74828005 (SNOMED CT 2011_0131)
10053938 (MedDRA 14.1)
Brachial Pulse (L/R)
Item
Brachialis-Puls (L/R)
string
C1096531 (UMLS CUI 2011AA)
10053929 (MedDRA 14.1)
Carotid Pulse (L/R)
Item
Karotis-Puls (L/R)
string
C1096529 (UMLS CUI 2011AA)
10053926 (MedDRA 14.1)
AV SHUNT
Item
AV SHUNT/GRAFT
text
C1456474 (UMLS CUI [1])
SHUNT LOCATION
Item
SHUNT/GRAFT LOCATION
text
C1442858 (UMLS CUI [1,1])
C0450429 (UMLS CUI [1,2])
BRUIT
Item
BRUIT
text
C0006318 (UMLS CUI [1])
SHUNT BRUIT
Item
SHUNT/GRAFT BRUITS
text
C0232112 (UMLS CUI [1])
THRILL
Item
THRILL PALPATED
text
C2678517 (UMLS CUI [1])
CAPILLARY REFILL
Item
CAPILLARY REFILL
text
C0425716 (UMLS CUI [1])
NAIL BED COLOR
Item
NAIL BED COLOR
text
C0574757 (UMLS CUI [1])
Edema
Item
Ödem
string
C0013604 (UMLS CUI 2011AA)
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)
Heart RHYTHM
Item
Heart RHYTHM
text
C0232187 (UMLS CUI [1])
PACEMAKER PRESENT
Item
(künstlicher) Herzschrittmacher
boolean
C0030163 (UMLS CUI 2011AA)
14106009 (SNOMED CT 2011_0131)
MTHU024521 (LOINC Version 232)
Item Group
Eyes Ear Nose & Throat
C3494720 (UMLS CUI-1)
EYES NORMAL
Item
Normal Baseline EYES: Without drainage, sclera white.
boolean
C4230579 (UMLS CUI [1])
Normal Ears
Item
Normal Baseline EARS: No complaint of pain.
boolean
C0576927 (UMLS CUI [1])
Normal Nose
Item
Normal Baseline NOSE: No drainage or congestion.
boolean
C0577884 (UMLS CUI [1])
Normal Throat
Item
Normal Baseline THROAT: No complaint of pain.
boolean
C0577002 (UMLS CUI [1])
Abnormal Findings
Item
NARRATIVE: Abnormal Findings
text
C1704258 (UMLS CUI [1])
Item Group
Augen
C0015392 (UMLS CUI-1)
Right Pupil Size
Item
Pupil Right Size [mm]
integer
C0517965 (UMLS CUI [1,1])
C0205090 (UMLS CUI [1,2])
Right Pupil Reaction
Item
Pupil Right Reaction
text
C0234671 (UMLS CUI [1,1])
C0444532 (UMLS CUI [1,2])
Left Pupil Size
Item
Pupil Left Size [mm]
integer
C0517965 (UMLS CUI [1,1])
C0205091 (UMLS CUI [1,2])
Left Pupil Reaction
Item
Pupil Left Reaction
text
C0234671 (UMLS CUI [1,1])
C0443246 (UMLS CUI [1,2])
Eye symptom
Item
Eye Complains
text
C0848690 (UMLS CUI [1])
Right Sclera
Item
Right Sclera
text
C0929516 (UMLS CUI [1])
Left Sclera
Item
Left Sclera
text
C0934600 (UMLS CUI [1])
Drainage
Item
Drainage
boolean
C0012621 (UMLS CUI [1])
Drainage Color
Item
Drainage Color
text
C0012621 (UMLS CUI [1,1])
C0009393 (UMLS CUI [1,2])
Item Group
Ohren
C0013443 (UMLS CUI-1)
EXTERNAL CANAL
Item
EARS(EXTERNAL CANAL)
text
C1517034 (UMLS CUI [1])
C/O Pain
Item
C/O Pain
boolean
C0436561 (UMLS CUI [1])
Tympanic Membranes
Item
Trommelfell
text
42859004 (SNOMED CT 2011_0131)
MTHU014731 (LOINC Version 232)
C0041445 (UMLS CUI [1])
Tubes
Item
Tubes
text
C0015183 (UMLS CUI [1])
Hard of Hearing
Item
Hard of Hearing
boolean
C1384666 (UMLS CUI [1])
Hearing Loss
Item
Hearing Loss
boolean
C3887873 (UMLS CUI [1])
Deafness
Item
Deafness
boolean
C0011053 (UMLS CUI [1])
Item
Hearing Aids
text
C0018768 (UMLS CUI [1])
Code List
Hearing Aids
CL Item
RT (1)
C0444532 (UMLS CUI-1)
CL Item
LT (2)
C0443246 (UMLS CUI-1)
CL Item
bilateral (3)
C0238767 (UMLS CUI-1)
Patent
Item
Patent
boolean
C0175566 (UMLS CUI [1])
Dizziness
Item
Schwindel
boolean
C0012833 (UMLS CUI 2011AA)
404640003 (SNOMED CT 2011_0131)
10013573 (MedDRA 14.1)
E12631 (CTCAE 1105E)
Tinnitus
Item
Tinnitus
boolean
C0040264 (UMLS CUI 2011AA)
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)
Drainage
Item
Drainage
boolean
32712000 (SNOMED CT 2011_0131)
MTHU022515 (LOINC Version 232)
C0012621 (UMLS CUI [1])
Color of Ear Drainage
Item
Color of Ear Drainage
text
C0012621 (UMLS CUI [1,1])
C0009393 (UMLS CUI [1,2])
Item Group
Nase
C0028429 (UMLS CUI-1)
Nares patent
Item
Nares patent
boolean
C1456808 (UMLS CUI [1,1])
C0175566 (UMLS CUI [1,2])
Nares Drainage
Item
Nares Drainage
boolean
C0746759 (UMLS CUI [1])
Septum
Item
Nasenseptum
string
C0027432 (UMLS CUI 2011AA)
68426009 (SNOMED CT 2011_0131)
MTHU015054 (LOINC Version 232)
Item Group
Pharynx
C0031354 (UMLS CUI-1)
Throat Pain
Item
Sore throat, Pain in throat, Pharyngeal pain
boolean
C0242429 (UMLS CUI 2011AA)
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)
Mouth Sores
Item
Mouth Sores
boolean
C0149745 (UMLS CUI [1])
Appearance of Throat
Item
Appearance of Throat
text
C0426505 (UMLS CUI [1])
Mucous Membranes
Item
Mucous Membranes
text
C0026724 (UMLS CUI [1])
Item Group
Respiratory
C0035237 (UMLS CUI-1)
Respiratory NORMAL
Item
Normal Baseline Respiratory: Unlabored respirations, BBS clear, chest rise symmetrical, pink mucous membranes.
boolean
C0231795 (UMLS CUI [1])
Abnormal Findings
Item
NARRATIVE: Abnormal Findings
text
C1704258 (UMLS CUI [1])
BREATH SOUNDS
Item
Atemgeräusch
string
C0035234 (UMLS CUI 2011AA)
52653008 (SNOMED CT 2011_0131)
10064779 (MedDRA 14.1)
RESPIRATORY EFFORT
Item
RESPIRATORY EFFORT
text
C0425466 (UMLS CUI [1])
Item
CHEST EXPANSION
text
C0231902 (UMLS CUI [1])
Code List
CHEST EXPANSION
CL Item
symmetrical (1)
C0332516 (UMLS CUI-1)
CL Item
non-symmetrical (2)
C0332514 (UMLS CUI-1)
INCENTIVE SPIROMETRY
Item
INCENTIVE SPIROMETRY DONE
boolean
C0454512 (UMLS CUI [1])
oxygen delivery system
Item
OXYGEN DELIVERY METHOD
text
C0809836 (UMLS CUI [1])
Pulse Oximeter
Item
Pulse Oximeter present with alarms set
boolean
C0182109 (UMLS CUI [1])
Cardio-Respiratory Monitoring
Item
Cardio-Respriratory Monitor present with alarms set
boolean
C0150496 (UMLS CUI [1,1])
C0199438 (UMLS CUI [1,2])
COUGH TYPE
Item
Husten
string
C0010200 (UMLS CUI 2011AA)
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)
Sputum
Item
Sputum
text
45710003 (SNOMED CT 2011_0131)
10041802 (MedDRA 14.1)
MTHU001309 (LOINC Version 232)
C0038056 (UMLS CUI [1])
CHEST TUBE
Item
CHEST TUBE PRESENT
boolean
C0008034 (UMLS CUI [1])
Chest tube site
Item
CHEST TUBE LOCATION
boolean
C0489468 (UMLS CUI [1])
Chest Tube Suction Setting
Item
Chest Tube Suction Setting
text
C0008034 (UMLS CUI [1,1])
C1306323 (UMLS CUI [1,2])
Item
Air Leak
text
C2242512 (UMLS CUI [1])
Code List
Air Leak
CL Item
none (1)
C0549184 (UMLS CUI-1)
CL Item
small (2)
C0700321 (UMLS CUI-1)
CL Item
moderate (3)
C0205081 (UMLS CUI-1)
CL Item
large (4)
C0549177 (UMLS CUI-1)
Item Group
Gastrointestinal
NORMAL BASELINE GI
Item
Normal Baseline GI: Abdomen soft, nondistended, bowel sounds normoactive in all quadrants.
boolean
Last BM
Item
Last Bowel Movement
date
NARRATIVE: Abnormal Findings
Item
NARRATIVE: Abnormal Findings
string
ABDOMINAL DESCRIPTION
Item
Abdomen
string
C0000726 (UMLS CUI 2011AA)
113345001 (SNOMED CT 2011_0131)
MTHU001425 (LOINC Version 232)
BOWEL SOUNDS
Item
Darmgeräusche
string
C0232693 (UMLS CUI 2011AA)
87042004 (SNOMED CT 2011_0131)
10006023 (MedDRA 14.1)
FLATUS
Item
FLATUS
boolean
incontinence
Item
Inkontinenz
boolean
C0021167 (UMLS CUI 2011AA)
48340000 (SNOMED CT 2011_0131)
10021639 (MedDRA 14.1)
GASTRIC SYMPTOMS
Item
GASTRIC SYMPTOMS
string
NG TUBE TYPE
Item
Nasogastric Tube Type
string
NG placement checked
Item
NG placement checked
boolean
Suction Setting
Item
Suction Setting
string
Gastric Content Color
Item
Gastric Content Color
string
NGT irrigated
Item
NGT irrigated (with # ML's of #)
string
FEEDING TUBE PRESENT
Item
Ernährung über Sonde
boolean
C0041281 (UMLS CUI 2011AA)
61420007 (SNOMED CT 2011_0131)
10053095 (MedDRA 14.1)
Feeding Tube Type
Item
Feeding Tube Type
string
Formula
Item
Formula (# strength @ # ml's/hour via kangaroo pump)
string
OSTOMY TYPE
Item
OSTOMY TYPE
string
RECTAL BAG PRESENT
Item
RECTAL BAG PRESENT
boolean
Item Group
Urogenitales System
NORMAL BASELINE Genitourinary
Item
Normal Baseline Genitourinary: Voids without pain or hesitation, no suprapubic distention.
boolean
NARRATIVE: Abnormal Findings
Item
NARRATIVE: Abnormal Findings
string
Item
Geschlecht
string
C0079399 (UMLS CUI 2011AA)
263495000 (SNOMED CT 2011_0131)
MTHU002975 (LOINC Version 232)
Code List
Geschlecht
CL Item
Male (1)
CL Item
Female (2)
INCONTINENT
Item
INCONTINENT
boolean
VOIDS SUFFICIENT QUANITY
Item
VOIDS SUFFICIENT QUANITY
boolean
IS PATIENT RECEIVING DIALYSIS
Item
IS PATIENT RECEIVING DIALYSIS
boolean
ODOR PRESENT
Item
ODOR PRESENT
boolean
CATHETER PRESENT
Item
Katheter
boolean
C0085590 (UMLS CUI 2011AA)
19923001 (SNOMED CT 2011_0131)
CATHETER SIZE
Item
Katheter-Größe
string
C0449963 (UMLS CUI 2011AA)
260967009 (SNOMED CT 2011_0131)
Date of insertion
Item
Date of insertion
date
Urine color
Item
Urine color
string
URINARY SYMPTOMS
Item
URINARY SYMPTOMS
string
SEXUALLY ACTIVE
Item
SEXUALLY ACTIVE
boolean
CURRENTLY ON MENSES
Item
CURRENTLY ON MENSES
boolean
DISCHARGE PRESENT
Item
Ausfluss
boolean
C0012621 (UMLS CUI 2011AA)
75823008 (SNOMED CT 2011_0131)
Discharge color
Item
Discharge color
string
Discharge odor
Item
Discharge odor
string
Discharge consistency
Item
Discharge consistency
string
ABNORMAL GENITALIA DESCRIPTION
Item
ABNORMAL GENITALIA DESCRIPTION
string
Item Group
Muskuloskeletales System
NORMAL BASELINE Musculoskeletal
Item
Normal Baseline Musculoskeletal: Full ROM, no muscle weakness, bones intact, gait steady or age appropriate.
boolean
NARRATIVE: Abnormal Findings
Item
NARRATIVE: Abnormal Findings
string
GENERALIZED WEAKNESS
Item
GENERALIZED WEAKNESS
boolean
LIMITED ROM
Item
LIMITED ROM
boolean
LIMITED MOBILITY
Item
LIMITED MOBILITY
boolean
PARALYSIS TYPE
Item
PARALYSIS TYPE
string
Item
Hemiplegia Side
string
Code List
Hemiplegia Side
CL Item
left (1)
CL Item
right (2)
FRACTURE(S) LOCATION
Item
FRACTURE(S) LOCATION
string
FINGER DIGITS
Item
FINGER DIGITS
string
TOE DIGITS
Item
TOE DIGITS
string
LEFT UPPER EXTREMITIES
Item
LEFT UPPER EXTREMITIES
string
RIGHT UPPER EXTREMITIES
Item
RIGHT UPPER EXTREMITIES
string
GRIPS EQUAL
Item
GRIPS EQUAL
boolean
LEFT LOWER EXTREMITIES
Item
LEFT LOWER EXTREMITIES
string
RIGHT LOWER EXTREMITIES
Item
RIGHT LOWER EXTREMITIES
string
UNSTEADY GAIT
Item
UNSTEADY GAIT
boolean
Item Group
Haut
NORMAL BASELINE Skin
Item
Normal Baseline Skin: Warm, pink, dry, elastic, intact, moist mucous membranes.
boolean
NARRATIVE: Abnormal Findings
Item
NARRATIVE: Abnormal Findings
string
TEMPERATURE
Item
Temperatur
float
C0039476 (UMLS CUI 2011AA)
246508008 (SNOMED CT 2011_0131)
MTHU009008 (LOINC Version 232)
SKIN COLOR
Item
SKIN COLOR
string
MOIST
Item
MOIST
boolean
SKIN TURGOR
Item
SKIN TURGOR
string
Item Group
Inzision
Incision #:
Item
Inzision
string
C0184898 (UMLS CUI 2011AA)
34896006 (SNOMED CT 2011_0131)
MID WOUND#
Item
MID WOUND#
string
Site
Item
Site
string
Closure Type
Item
Closure Type
string
Incision Appearance
Item
Incision Appearance
string
Dressing Changed
Item
Dressing Changed
boolean
Date Dressing Changed
Item
Date Dressing Changed
date
Dressing Type
Item
Dressing Type
string
Dressing Appearance
Item
Dressing Appearance
string
Drains
Item
Drainage
string
C0180499 (UMLS CUI 2011AA)
32712000 (SNOMED CT 2011_0131)
MTHU022515 (LOINC Version 232)
Item Group
Wunde
WOUND #
Item
Wunde
string
C0043250 (UMLS CUI 2011AA)
13924000 (SNOMED CT 2011_0131)
10052428 (MedDRA 14.1)
MTHU001326 (LOINC Version 232)
MID WOUND#
Item
MID WOUND#
string
Wound Location
Item
Wound Location
string
C0043250 (UMLS CUI 2011AA)
13924000 (SNOMED CT 2011_0131)
10052428 (MedDRA 14.1)
MTHU001326 (LOINC Version 232)
C0450429 (UMLS CUI 2011AA-2)
246267002 (SNOMED CT 2011_0131-2)
Length (cm, mm)
Item
Length (cm, mm)
string
Width (cm, mm)
Item
Width (cm, mm)
string
Depth (cm, mm)
Item
Depth (cm, mm)
string
Undermining
Item
Undermining
boolean
Tunneling
Item
Tunneling
boolean
Surrounding Skin
Item
Surrounding Skin
string
Wound Base
Item
Wound Base
string
Exudate
Item
Exsudat
string
C0015388 (UMLS CUI 2011AA)
247450001 (SNOMED CT 2011_0131)
MTHU025016 (LOINC Version 232)
Exudate Color
Item
Exudate Color
string
Sensation
Item
Sensation
string
C0036658 (UMLS CUI 2011AA)
373713005 (SNOMED CT 2011_0131)
MTHU017277 (LOINC Version 232)
Odor: Before Cleaning
Item
Odor: Before Cleaning
boolean
Odor: After Cleaning
Item
Odor: After Cleaning
boolean
Cleansed with/irrigated with
Item
Cleansed with/irrigated with
string
Wound Medication Applied
Item
Wound Medication Applied
string
Wound Filled with
Item
Wound Filled with
string
Wound covered with
Item
Wound covered with
string
Wound secured with
Item
Wound secured with
string
Wound Pressure Relief
Item
Wound Pressure Relief
string
Comments
Item
Comments
string
Photograph Date
Item
Photograph Date
date
RASH LOCATION
Item
RASH LOCATION
string
RASH DESCRIPTION
Item
RASH DESCRIPTION
string
TATTOO'S/PIERCINGS
Item
TATTOO'S/PIERCINGS
string
SKIN TEARS, LOCATION/ Description
Item
SKIN TEARS, LOCATION/ Description
string
SPECIALTY BEDS
Item
SPECIALTY BEDS
string
Item Group
Nutrition
Current Diet
Item
Diät
string
C0012155 (UMLS CUI 2011AA)
41829006 (SNOMED CT 2011_0131)
NPO
Item
NPO
boolean
FEEDING TUBE PRESENT
Item
Ernährung über Sonde
boolean
C0041281 (UMLS CUI 2011AA)
61420007 (SNOMED CT 2011_0131)
10053095 (MedDRA 14.1)
Feeding Tube Type
Item
Feeding Tube Type
string
Formula
Item
Formula: # strength @ # cc's/hour via kangaroo pump
string
RESIDUALS CHECKED
Item
RESIDUALS CHECKED: AMOUNT # CC
string
BREAKFAST
Item
BREAKFAST
string
Breakfast: Amount taken
Item
Breakfast: Amount taken
string
Breakfast: Patient fed by
Item
Breakfast: Patient fed by
string
LUNCH
Item
LUNCH
string
Lunch: Amount taken
Item
Lunch: Amount taken
string
Lunch: Patient fed by
Item
Lunch: Patient fed by
string
SUPPER
Item
SUPPER
string
Supper: Amount taken
Item
Supper: Amount taken
string
Supper: Patient fed by
Item
Supper: Patient fed by
string
Supper: Amount taken
Item
Supper: Amount taken
string
Item Group
intravenöse Therapie
NARRATIVE: IV Therapy
Item
NARRATIVE: IV Therapy
string
IV HEPLOCKED
Item
IV HEPLOCKED
boolean
IV Site APPEARANCE
Item
IV Site APPEARANCE
string
IV DISCONTINUED
Item
IV DISCONTINUED
boolean
CATHETER INTACT
Item
CATHETER INTACT
boolean
IV Catheter Size
Item
IV Catheter Size
string
IV Site Location
Item
IV Site Location
string
CENTRAL LINE PORT
Item
Zentralvenöser Katheter (ZVK)
string
C1145640 (UMLS CUI 2011AA)
52124006 (SNOMED CT 2011_0131)
IV FLUIDS
Item
Infusion
string
C1289919 (UMLS CUI 2011AA)
118431008 (SNOMED CT 2011_0131)
10067708 (MedDRA 14.1)
Left to count:
Item
Left to count:
string
IV Fluid Rate: @ ml/hr
Item
IV Fluid Rate: @ ml/hr
integer
TPN/LIPIDS: TPN @ ml/hr and Lipids @ ml/hr
Item
TPN/LIPIDS: TPN @ ml/hr and Lipids @ ml/hr
string
PCA PUMP: at @ cc's/hr
Item
PCA PUMP: at @ cc's/hr
string
IV Site APPEARANCE
Item
IV Site APPEARANCE
string
INSERTION DATE
Item
INSERTION DATE
date
DRESSING CHANGE DUE
Item
DRESSING CHANGE DUE
date
SITE CHANGE DUE
Item
SITE CHANGE DUE
date
PLACED ON IMED
Item
PLACED ON IMED
boolean
Item Group
Patientensicherheit
SIDE RAILS UP
Item
SIDE RAILS UP
boolean
IN LOW POSTION
Item
IN LOW POSTION
boolean
BED/CRIB
Item
BED/CRIB
string
CALL BELL WITHIN REACH
Item
CALL BELL WITHIN REACH
boolean
ALLERGY BAND ON
Item
ALLERGY BAND ON
boolean
NAME BAND ON
Item
NAME BAND ON
boolean
BLOOD BAND ON
Item
BLOOD BAND ON
boolean
FALL BAND ON
Item
FALL BAND ON
boolean
BED SAFETY
Item
BED SAFETY
string
Item Group
Pediatric Fall Risk Assessment
Unable to assess fall risk status at this time due to patient is:
Item
Unable to assess fall risk status at this time due to patient is:
string
gender
Item
Geschlecht
string
C0079399 (UMLS CUI 2011AA)
263495000 (SNOMED CT 2011_0131)
MTHU002975 (LOINC Version 232)
Item
Bewusstseinslage
string
C0234421 (UMLS CUI 2011AA)
106167005 (SNOMED CT 2011_0131)
Code List
Bewusstseinslage
CL Item
Awake/Alert  (0)
CL Item
Drowsy/Medicated for pain/Seizures (1)
CL Item
Lethargic/Confused (2)
Item
Seizures/Previous history of falls
string
Code List
Seizures/Previous history of falls
CL Item
No significant medical history of falls/ (0)
CL Item
No difficulty in ambulation, Generalized weakness/Dizziness/Syncope/ (1)
CL Item
PT or OT Services, Altered mental status/Developmental Delay/ (2)
Item
MEDICATION/EQUIPMENT
string
Code List
MEDICATION/EQUIPMENT
CL Item
No prescribed medication that has been known to alter LOC. No IV or other equipment (IV, Pulse Oximeter) prescribed for the patient (0)
CL Item
Prescribed pain medication (oral), seizure medication (oral), continuous IV therapy requiring infusion device (1)
CL Item
Prescribed IV/IM pain medication, seizure medication/PCA pump, crutches, CR monitor (2)
Item
Verweildauer
string
C0023303 (UMLS CUI 2011AA)
Code List
Verweildauer
CL Item
Admission as inpatient 0-3 Days (0)
CL Item
Admission as inpatient 4-7 Days (1)
CL Item
Admission as inpatient greater than 7 Days (2)
Item
ELIMINATION
string
Code List
ELIMINATION
CL Item
Takes care of elimination needs independently with no assist/Infant in diapers (0)
CL Item
Independent with frequent trips to bathroom (1)
CL Item
Needs assist with toilet (2)
Item
GET UP AND GO TEST: "RISING FROM A CHAIR"
string
Code List
GET UP AND GO TEST: "RISING FROM A CHAIR"
CL Item
Ability to rise in single movement-No loss of balance with steps (0)
CL Item
Pushes up, successful in one attempt (1)
CL Item
Multiple attempts but successful (3)
CL Item
Unable to rise without assistance during test (OR if a medical order states the same and/or complete bed rest is ordered) (4)
FINAL RISK SCORE
Item
FINAL RISK SCORE (Pediatric Fall Risk Assessment)
integer
Item Group
INTERVENTIONS
Assist with Ambulation
Item
Assist with Ambulation
boolean
Reorient Q2H or Less
Item
Reorient Q2H or Less
boolean
Gait Belt
Item
Gait Belt
boolean
ID Patient at Risk
Item
ID Patient at Risk
boolean
Restraints (see policy)
Item
Restraints (see policy)
boolean
Multi-personnel Transfer
Item
Multi-personnel Transfer
boolean
Close Observation
Item
Close Observation
boolean
Non-slip Footwear
Item
Non-slip Footwear
boolean
Bed in lowest position
Item
Bed in lowest position
boolean
Lock wheels of vehicles of conveyance during transfer
Item
Lock wheels of vehicles of conveyance during transfer
boolean
Upper siderails raised
Item
Upper siderails raised
boolean
Call light in reach
Item
Call light in reach
boolean
Offer toileting at least every 2 hours
Item
Offer toileting at least every 2 hours
boolean
Offer fluid/nutrition every 2 hours
Item
Offer fluid/nutrition every 2 hours
boolean
Place frequently used objects within reach
Item
Place frequently used objects within reach
boolean
Provide adequate lighting
Item
Provide adequate lighting
boolean
Provide sensory impairment/orientation devices (clocks,etc)
Item
Provide sensory impairment/orientation devices (clocks,etc)
boolean
Provide adequate rest periods
Item
Provide adequate rest periods
boolean
Use age appropriate distractions for confusion/disorientation
Item
Use age appropriate distractions for confusion/disorientation
boolean
Remove harmful hazards
Item
Remove harmful hazards
boolean
Provide appropriate and least restrictive patient supervision/surveillance
Item
Provide appropriate and least restrictive patient supervision/surveillance
boolean
Communicate information about fall risk to caregivers
Item
Communicate information about fall risk to caregivers
boolean
Encourage family/support system to participate in care
Item
Encourage family/support system to participate in care
boolean
Teach/educate family/support system Fall Prevention information
Item
Teach/educate family/support system Fall Prevention information
boolean
Implement Fall Prevention Protocol for Hendrich II Score>5
Item
Implement Fall Prevention Protocol for Hendrich II Score>5
boolean
Item Group
IMPAIRED MOBILITY RISK
Implement Universal Fall Prevention Intervention
Item
Implement Universal Fall Prevention Intervention
boolean
Monitor transfers to/from bed/chair(etc.)
Item
Monitor transfers to/from bed/chair(etc.)
boolean
Use appropriate assistance for transfers to/from bed/chair
Item
Use appropriate assistance for transfers to/from bed/chair
boolean
Use chairs with armrests and of proper height for transfers
Item
Use chairs with armrests and of proper height for transfers
boolean
Implement progressive ambulation(unless contraindicated by condition/orders)
Item
Implement progressive ambulation(unless contraindicated by condition/orders)
boolean
Encourage/Provide self-care assistance
Item
Encourage/Provide self-care assistance
boolean
Remain in attendance during toileting/ADL's
Item
Remain in attendance during toileting/ADL's
boolean
Provide assistive devices for ambulation (canes/walkers/etc.)
Item
Provide assistive devices for ambulation (canes/walkers/etc.)
boolean
Gait Belt during transport/ambulation
Item
Gait Belt during transport/ambulation
boolean
Teach patient/family to call for help and WAIT for help before
Item
Teach patient/family to call for help and WAIT for help before
boolean
attempting any transfer/ambulation
Item
attempting any transfer/ambulation
boolean
Item Group
ALTERED ELIMINATION
Implement Universal Fall Prevention Interventions
Item
Implement Universal Fall Prevention Interventions
boolean
Remain in attendance during toileting/ADL's
Item
Remain in attendance during toileting/ADL's
boolean
Assist with post-elimination hygiene
Item
Assist with post-elimination hygiene
boolean
Remove non-essential clothing
Item
Remove non-essential clothing
boolean
Instruct patient on importance of toileting when offered by staff
Item
Instruct patient on importance of toileting when offered by staff
boolean
Monitor for 'patient's normal' bladder/bowel habits
Item
Monitor for 'patient's normal' bladder/bowel habits
boolean
Monitor for causes of incontinence (diuretics,cathartics,etc.)
Item
Monitor for causes of incontinence (diuretics,cathartics,etc.)
boolean
Monitor skin integrity
Item
Monitor skin integrity
boolean
Item Group
HIGH RISK FALL MEDICATIONS (ANTIEPILEPTICS & BENZODIAZEPINES)
Implement Universal Fall Prevention Interventions
Item
Implement Universal Fall Prevention Interventions
boolean
Monitor drug dosages
Item
Monitor drug dosages
boolean
Evaluate sensory functions
Item
Evaluate sensory functions
boolean
Monitor/Assess for drug overdose
Item
Monitor/Assess for drug overdose
boolean
Monitor response to exercise
Item
Monitor response to exercise
boolean
Educate patient/support system about drug classification, side effects,
Item
Educate patient/support system about drug classification, side effects,
boolean
precautions, toxic symptoms of overdose.
Item
precautions, toxic symptoms of overdose.
boolean
Item Group
Hendrich II Fall Risk Assessment
Unable to assess fall risk status at this time due to patient is:
Item
Unable to assess fall risk status at this time due to patient is:
string
HENDRICH CALCULATION
Item
HENDRICH CALCULATION
string
Item Group
ONN Unit specific
AFFECTED SITE
Item
AFFECTED SITE
string
CIRCULATORY STATUS
Item
CIRCULATORY STATUS
string
SKIN COLOR
Item
SKIN COLOR
string
SENSATION
Item
SENSATION
string
MOVEMENT
Item
MOVEMENT
string
TEMPERATURE
Item
Temperatur
string
C0039476 (UMLS CUI 2011AA)
246508008 (SNOMED CT 2011_0131)
MTHU009008 (LOINC Version 232)
SKIN CONDITION
Item
Hautzustand
string
C1719933 (UMLS CUI 2011AA)
422000003 (SNOMED CT 2011_0131)
MTHU034830 (LOINC Version 232)
PULSE(s) SITE(s)
Item
PULSE(s) SITE(s)
string
RESPONSE
Item
RESPONSE
string
POSITION OF LIMB
Item
POSITION OF LIMB
string
ORTHOPEDIC DEVICE IN USE
Item
ORTHOPEDIC DEVICE IN USE
string
CONTINUOUS PASSIVE MOTION
Item
CONTINUOUS PASSIVE MOTION
string
POUNDS
Item
POUNDS
string
CERVICAL COLLARS
Item
CERVICAL COLLARS
string
AFO BRACE: Foot/Feet
Item
AFO BRACE: Foot/Feet (LEFT-RIGHT-BILATERAL)
string
SWELLING
Item
SWELLING
string
PIN SITES
Item
PIN SITES
string
CLEANED WITH
Item
CLEANED WITH
string
NARRATIVE
Item
NARRATIVE
string
Item Group
Post Surgical
General Activity
Item
Patient activity
string
C0451369 (UMLS CUI 2011AA)
273688003 (SNOMED CT 2011_0131)
Vaginal Packing
Item
Vaginal Packing
string
Equipment/Devices
Item
Equipment/Devices
string
EQUIPMENT/DEVICES
Item
EQUIPMENT/DEVICES
string
Item Group
ADOLESCENT INTERACTION
Item
Prepared for treatment/procedure as soon as possible.
string
Code List
Prepared for treatment/procedure as soon as possible.
CL Item
Definitely Yes (1)
CL Item
Yes (2)
CL Item
No (3)
CL Item
not applicable (4)
Item
Provided detailed information about events/procedures/treatments.
string
Code List
Provided detailed information about events/procedures/treatments.
CL Item
Definitely Yes (1)
CL Item
Yes (2)
CL Item
No (3)
CL Item
NA (4)
Item
Allowed contact with peer group.
string
Code List
Allowed contact with peer group.
CL Item
Definitely Yes (1)
CL Item
Yes (2)
CL Item
No (3)
CL Item
NA (4)
NARRATIVE
Item
NARRATIVE
string
Item Group
GERIATRIC INTERVENTION (65+)
Item
Involved in decision process regarding pain control/medication/care decisions
string
Code List
Involved in decision process regarding pain control/medication/care decisions
CL Item
Def. Yes (1)
CL Item
Yes (2)
CL Item
No (3)
CL Item
NA (4)
Item
Encouraged family/S.O.to visit
string
Code List
Encouraged family/S.O.to visit
CL Item
Def. Yes (1)
CL Item
Yes (2)
CL Item
No (3)
CL Item
NA (4)
Item
Independence promoted.
string
Code List
Independence promoted.
CL Item
Def. Yes (1)
CL Item
Yes (2)
CL Item
No (3)
CL Item
NA (4)
NARRATIVE
Item
NARRATIVE
string

Benutzen Sie dieses Formular für Rückmeldungen, Fragen und Verbesserungsvorschläge.

Mit * gekennzeichnete Felder sind notwendig.

Benötigen Sie Hilfe bei der Suche? Um mehr Details zu erfahren und die Suche effektiver nutzen zu können schauen Sie sich doch das entsprechende Video auf unserer Tutorial Seite an.

Zum Video