ID

5507

Beschrijving

Form from HIS OpenVistA

Trefwoorden

Versies (5)
  1. 24-02-12 24-02-12 -
  2. 29-02-12 29-02-12 -
  3. 07-08-14 07-08-14 - Martin Dugas
  4. 09-08-14 09-08-14 - Martin Dugas
  5. 26-06-15 26-06-15 - Martin Dugas
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7 augustus 2014

DOI

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HIS INTERVENTIONAL RADIOLOGY

Duits Engels

HIS

1 Formulieren  
  1. StudyEvent: HIS
    1. HIS
General Info
Beschrijving

General Info

Alter
Beschrijving

Age

Datatype

integer

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

Gender

Datatype

integer

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

Race

Datatype

string

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

Height

Datatype

integer

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

Weight

Datatype

integer

Alias
UMLS
C0005910
SNOMED CT 2011_0131
107647005
MedDRA 14.1
10047890
LOINC Version 232
LP18015-5
Hauptbeschwerden
Beschrijving

CHIEF COMPLAINT

Datatype

string

Alias
UMLS CUI 2011AA
C0277786
SNOMED CT 2011_0131
33962009
LOINC Version 232
MTHU001077
Anamnese der aktuellen Erkrankung
Beschrijving

PRESENT ILLNESS

Datatype

string

Alias
UMLS CUI 2011AA
C0262512
LOINC Version 232
MTHU001399
Prior Health History
Beschrijving

Prior Health History

Anamnese
Beschrijving

Medical Illness

Datatype

string

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

Surgery

Datatype

string

Alias
UMLS CUI 2011AA
C0455610
SNOMED CT 2011_0131
161615003
aktuelle Medikation
Beschrijving

DETAILED ACTIVE MEDS

Datatype

string

Alias
UMLS CUI 2011AA
C1553892
Allergien
Beschrijving

Allergies

Datatype

string

Alias
UMLS CUI 2011AA
C0020517
SNOMED CT 2011_0131
257550005
ICD-10-CM Version 2010
T78.40
Anamnese der Organsysteme
Beschrijving

REVIEW OF SYSTEMS(Positive findings)

Datatype

string

Alias
UMLS CUI 2011AA
C0489633
SNOMED CT 2011_0131
415300000
LOINC Version 232
MTHU001422
Familienanamnese
Beschrijving

FAMILY HISTORY

Datatype

string

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

SOCIAL HISTORY

Datatype

string

Alias
UMLS CUI 2011AA
C0424945
SNOMED CT 2011_0131
160476009
LOINC Version 232
MTHU014081
Impfung
Beschrijving

IMMUNIZATIONS

Datatype

string

Alias
UMLS CUI 2011AA
C0020971
SNOMED CT 2011_0131
127785005
MedDRA 14.1
10021431
Physical Exam
Beschrijving

Physical Exam

Temperatur
Beschrijving

Temperature

Datatype

string

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

Pulse

Datatype

integer

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

Respiration rate

Datatype

integer

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

Blood pressure

Datatype

string

Alias
UMLS CUI 2011AA
C0005823
SNOMED CT 2011_0131
75367002
LOINC Version 232
MTHU008342
Schmerz
Beschrijving

Pain

Datatype

string

Alias
UMLS CUI 2011AA
C0030193
SNOMED CT 2011_0131
22253000
MedDRA 14.1
10033371
LOINC Version 232
MTHU029813
ICD-10-CM Version 2010
R52
ICD-9-CM Version 2011
338-338.9
CTCAE 1105E
E11167
Allgemeinzustand
Beschrijving

GENERAL APPEARANCE

Datatype

string

Alias
UMLS CUI 2011AA
C1148438
LOINC Version 232
MTHU015040
Head, Ears, Eyes, Nose and Throat
Beschrijving

HEENT

Datatype

text

Alias
UMLS CUI 2011AA
C1512338
Hals
Beschrijving

NECK

Datatype

string

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

CHEST

Datatype

string

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

BREAST

Datatype

string

Alias
UMLS CUI 2011AA
C0006141
SNOMED CT 2011_0131
76752008
LOINC Version 232
MTHU011382
Herz
Beschrijving

HEART

Datatype

string

Alias
UMLS CUI 2011AA
C0018787
SNOMED CT 2011_0131
80891009
LOINC Version 232
MTHU001067
Abdomen
Beschrijving

ABDOMEN

Datatype

string

Alias
UMLS CUI 2011AA
C0000726
SNOMED CT 2011_0131
113345001
LOINC Version 232
MTHU001425
Lymphknoten
Beschrijving

LYMPH NODES

Datatype

string

Alias
UMLS CUI 2011AA
C0024204
SNOMED CT 2011_0131
59441001
LOINC Version 232
MTHU015050
Genitalorgane/Rektal
Beschrijving

GENITALIA/RECTAL

Datatype

string

Alias
UMLS CUI 2011AA
C0017420, C0205052
SNOMED CT 2011_0131
255582007
LOINC Version 232
MTHU002681
Extremitäten
Beschrijving

EXTREMITIES

Datatype

string

Alias
UMLS CUI 2011AA
C0015385
SNOMED CT 2011_0131
66019005
LOINC Version 232
MTHU001429
Haut
Beschrijving

SKIN

Datatype

string

Alias
UMLS CUI 2011AA
C1123023
SNOMED CT 2011_0131
39937001
LOINC Version 232
MTHU001414
Nervensystem
Beschrijving

NEUROLOGICAL

Datatype

string

Alias
UMLS CUI 2011AA
C0027763
SNOMED CT 2011_0131
25087005
LOINC Version 232
MTHU001437
summary, conclusion
Beschrijving

IMPRESSION

Datatype

string

Alias
UMLS CUI 2011AA
CL386604
Planung
Beschrijving

PLAN

Datatype

string

Alias
UMLS CUI 2011AA
C1301732
SNOMED CT 2011_0131
397943006
ASA Status
Beschrijving

ASA SCORE

Datatype

string

Alias
UMLS CUI 2011AA
C1531480
SNOMED CT 2011_0131
413347006
AIRWAY ASSESSMENT FOR PATIENTS RECEIVING MODERATE SEDATION
Beschrijving

AIRWAY ASSESSMENT FOR PATIENTS RECEIVING MODERATE SEDATION

Datatype

text

Zähne
Beschrijving

Teeth

Datatype

string

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

MALLAMPATI AIRWAY SCORE

Datatype

string

Alias
UMLS CUI 2011AA
C0451276
SNOMED CT 2011_0131
273585005
Neck Extension (normal/RESTRICTED/NO MOBILITY)
Beschrijving

Neck Extension

Datatype

text

Alias
UMLS CUI 2011AA
C0027530, C0231448
SNOMED CT 2011_0131
45048000, 255536004
LOINC Version 232
MTHU002688, MTHU010348
Behandelnder Arzt
Beschrijving

Physician

Datatype

string

Alias
UMLS CUI 2011AA
C1710470
Procedure
Beschrijving

Procedure

Datum der Prozedur
Beschrijving

DATE OF PROCEDURE

Datatype

string

Alias
UMLS CUI 2011AA
C2584899
SNOMED CT 2011_0131
439272007
präoperative Diagnose
Beschrijving

PRE-OP DIAGNOSIS

Datatype

string

Alias
UMLS CUI 2011AA
C1318968
SNOMED CT 2011_0131
406520001
Postoperative Diagnose
Beschrijving

POST-OP DIAGNOSIS

Datatype

string

Alias
UMLS CUI 2011AA
C1318969
SNOMED CT 2011_0131
406521002
Erster Operateur
Beschrijving

PRIMARY SURGEON

Datatype

string

Alias
UMLS CUI 2011AA
C0808118
LOINC Version 232
MTHU010488
HL7 V3 2006_05
PRISURG
first assistant surgeon
Beschrijving

ASSISTANT

Datatype

string

Alias
UMLS CUI 2011AA
C1550491
HL7 V3 2006_05
FASST
Anästhesist
Beschrijving

ANESTHESIA PROVIDER

Datatype

string

Alias
UMLS CUI 2011AA
C1550495
HL7 V3 2006_05
ANEST
ANESTHESIA/SEDATION
Beschrijving

ANESTHESIA/SEDATION

Datatype

string

Alias
UMLS CUI 2011AA
C0002903, C0344106
SNOMED CT 2011_0131
399097000, 72641008
MedDRA 14.1
10002091, 10059283
LOINC Version 232
MTHU035920
Medication
Beschrijving

Medication

ANTIBIOTIC: Ancef
Beschrijving

ANTIBIOTIC: Ancef

Datatype

boolean

Alias
UMLS CUI 2011AA
C0003232
SNOMED CT 2011_0131
255631004
ANTIBIOTIC: Rocephin
Beschrijving

ANTIBIOTIC: Rocephin

Datatype

boolean

Alias
UMLS CUI 2011AA
C0003232
SNOMED CT 2011_0131
255631004
ANTIBIOTIC: Levaquin
Beschrijving

ANTIBIOTIC: Levaquin

Datatype

boolean

Alias
UMLS CUI 2011AA
C0003232
SNOMED CT 2011_0131
255631004
ANTIBIOTIC: Other
Beschrijving

ANTIBIOTIC: Other

Datatype

string

Alias
UMLS CUI 2011AA
C0003232
SNOMED CT 2011_0131
255631004
OTHER MEDS GIVEN
Beschrijving

OTHER MEDS GIVEN

Datatype

string

Alias
UMLS CUI 2011AA
C0013227
TECHNICAL PROCEDURE
Beschrijving

TECHNICAL PROCEDURE

Abszess-Drainage
Beschrijving

Abscess drainage

Datatype

boolean

Alias
UMLS CUI 2011AA
C0344096
SNOMED CT 2011_0131
118442004
MedDRA 14.1
10000279
Aortographie
Beschrijving

Aortogram

Datatype

boolean

Alias
UMLS CUI 2011AA
C0003515
SNOMED CT 2011_0131
54640009
MedDRA 14.1
10057775
ICD-9-CM Version 2011
88.42
Aortogram and Runoff
Beschrijving

Aortogram and Runoff

Datatype

boolean

AV Fistulagram
Beschrijving

AV Fistulagram

Datatype

boolean

Alias
UMLS CUI 2011AA
C0412315
SNOMED CT 2011_0131
241275007
Biliäre Drainage
Beschrijving

Biliary Drain

Datatype

boolean

Alias
UMLS CUI 2011AA
C0489793
LOINC Version 232
MTHU001297
Carotis-Angiographie
Beschrijving

Carotid Angiogram

Datatype

boolean

Alias
UMLS CUI 2011AA
C0202896
SNOMED CT 2011_0131
420171008
MedDRA 14.1
10003194
ICD-9-CM Version 2011
88.41
Cerebrale Angiographie
Beschrijving

Cerebral Angiogram

Datatype

boolean

Alias
UMLS CUI 2011AA
C0948923
SNOMED CT 2011_0131
419364000
MedDRA 14.1
10052905
Thoraxdrainage
Beschrijving

Chest tube

Datatype

boolean

Alias
UMLS CUI 2011AA
C0008034
SNOMED CT 2011_0131
258643002
LOINC Version 232
MTHU001287
Chest tube/Empyema
Beschrijving

Chest tube/Empyema

Datatype

boolean

Alias
UMLS CUI 2011AA
C0008034,C0014009
SNOMED CT 2011_0131
258643002, 66696
MedDRA 14.1
10014568
LOINC Version 232
MTHU001287
ICD-9-CM Version 2011
510
Zentralvenöser Katheter (ZVK)
Beschrijving

CVC

Datatype

boolean

Alias
UMLS CUI 2011AA
C1145640
SNOMED CT 2011_0131
52124006
CVC/Port
Beschrijving

CVC/Port

Datatype

boolean

Alias
UMLS CUI 2011AA
C1145640, C0179694
SNOMED CT 2011_0131
52124006
CVC Temporary
Beschrijving

CVC Temporary

Datatype

boolean

CVC Tunneled
Beschrijving

CVC Tunneled

Datatype

boolean

Dialysis Access Declot
Beschrijving

Dialysis Access Declot

Datatype

boolean

Endovenous laser treatment (ELT)
Beschrijving

EVLT

Datatype

boolean

Alias
UMLS CUI 2011AA
C1998394
Extremity Angiogram
Beschrijving

Extremity Angiogram

Datatype

boolean

Alias
UMLS CUI 2011AA
CL378222, C0015385
SNOMED CT 2011_0131
77343006, 66019005
MedDRA 14.1
10050062
LOINC Version 232
MTHU001429
Balloon Vertebroplasty
Beschrijving

Kyphoplasty

Datatype

boolean

Alias
UMLS CUI 2011AA
C1455863
MedDRA 14.1
10064702
ICD-9-CM Version 2011
81.66
Perkutane Nephrostomie
Beschrijving

Percutaneous Nephrostomy

Datatype

boolean

Alias
UMLS CUI 2011AA
C0564457
SNOMED CT 2011_0131
313270001
Peripherally-Inserted Central Catheter (PICC), PICC line
Beschrijving

PICC

Datatype

boolean

Alias
UMLS CUI 2011AA
C0179740
SNOMED CT 2011_0131
398176008
Pulmonale Angiographie
Beschrijving

Pulmonary Angiogram

Datatype

boolean

Alias
UMLS CUI 2011AA
C0202910
SNOMED CT 2011_0131
84200003
MedDRA 14.1
10002440
ICD-9-CM Version 2011
88.43
radiofrequency ablation procedure
Beschrijving

RFA (RF-Ablation)

Datatype

boolean

Alias
UMLS CUI 2011AA
CL382653
transarterial chemoembolization
Beschrijving

TACE

Datatype

boolean

Alias
UMLS CUI 2011AA
CL388501
Thrombolysis
Beschrijving

Thrombolysis

Datatype

boolean

Alias
UMLS CUI 2011AA
C0520997
SNOMED CT 2011_0131
51308000
MedDRA 14.1
10043568
Embolisation of uterine artery
Beschrijving

Uterine Artery Embolization

Datatype

boolean

Alias
UMLS CUI 2011AA
C0729536
SNOMED CT 2011_0131
312138002
Other procedure
Beschrijving

Other procedure

Datatype

string

FINDINGS (None|Same|N/A|Successful|Unsuccessful)
Beschrijving

FINDINGS

Datatype

integer

Findings text
Beschrijving

Findings text

Datatype

string

bleeding, blood loss, hemorrhage
Beschrijving

BLOOD LOSS

Datatype

string

Alias
UMLS CUI 2011AA
C0019080
SNOMED CT 2011_0131
50960005
MedDRA 14.1
10055798
ICD-10-CM Version 2010
R58
ICD-9-CM Version 2011
459.0
Kontrastmittel
Beschrijving

CONTRAST

Datatype

string

Alias
UMLS CUI 2011AA
C0009924
SNOMED CT 2011_0131
385420005
FLUORO TIME
Beschrijving

FLUORO TIME

Datatype

string

Alias
UMLS CUI 2011AA
C0016356
SNOMED CT 2011_0131
44491008
MedDRA 14.1
10064426
SPECIMEN(s)REMOVED (yes|no)
Beschrijving

SPECIMEN(s) REMOVED

Datatype

boolean

Specimen
Beschrijving

SPECIMEN(s)

Datatype

string

Alias
UMLS CUI 2011AA
C0370003
SNOMED CT 2011_0131
123038009
LOINC Version 232
MTHU010726
COMPLICATIONS: No immediate
Beschrijving

COMPLICATIONS: No immediate

Datatype

boolean

Komplikationen
Beschrijving

Complications text

Datatype

string

Alias
UMLS CUI 2011AA
C0009566
SNOMED CT 2011_0131
116223007
LOINC Version 232
MTHU008883
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Similar models

HIS

1 Formulieren
  1. StudyEvent: HIS
    1. HIS
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
Age
Item
Alter
integer
C0001779 (UMLS CUI 2011AA)
397669002 (SNOMED CT 2011_0131)
Gender
Item
Geschlecht
integer
C0079399 (UMLS CUI 2011AA)
263495000 (SNOMED CT 2011_0131)
MTHU002975 (LOINC Version 232)
Race
Item
Racial group
string
C0034510 (UMLS CUI 2011AA)
103579009 (SNOMED CT 2011_0131)
MTHU009923 (LOINC Version 232)
Height
Item
Größe
integer
C0489786 (UMLS CUI 2011AA)
MTHU005354 (LOINC Version 232)
Weight
Item
Gewicht
integer
C0005910 (UMLS)
107647005 (SNOMED CT 2011_0131)
10047890 (MedDRA 14.1)
LP18015-5 (LOINC Version 232)
CHIEF COMPLAINT
Item
Hauptbeschwerden
string
C0277786 (UMLS CUI 2011AA)
33962009 (SNOMED CT 2011_0131)
MTHU001077 (LOINC Version 232)
PRESENT ILLNESS
Item
Anamnese der aktuellen Erkrankung
string
C0262512 (UMLS CUI 2011AA)
MTHU001399 (LOINC Version 232)
Medical Illness
Item
Anamnese
string
C0262926 (UMLS CUI 2011AA)
417662000 (SNOMED CT 2011_0131)
MTHU027722 (LOINC Version 232)
Surgery
Item
Frühere Operationen
string
C0455610 (UMLS CUI 2011AA)
161615003 (SNOMED CT 2011_0131)
DETAILED ACTIVE MEDS
Item
aktuelle Medikation
string
C1553892 (UMLS CUI 2011AA)
Allergies
Item
Allergien
string
C0020517 (UMLS CUI 2011AA)
257550005 (SNOMED CT 2011_0131)
T78.40 (ICD-10-CM Version 2010)
REVIEW OF SYSTEMS(Positive findings)
Item
Anamnese der Organsysteme
string
C0489633 (UMLS CUI 2011AA)
415300000 (SNOMED CT 2011_0131)
MTHU001422 (LOINC Version 232)
FAMILY HISTORY
Item
Familienanamnese
string
C0241889 (UMLS CUI 2011AA)
57177007 (SNOMED CT 2011_0131)
SOCIAL HISTORY
Item
Sozialanamnese
string
C0424945 (UMLS CUI 2011AA)
160476009 (SNOMED CT 2011_0131)
MTHU014081 (LOINC Version 232)
IMMUNIZATIONS
Item
Impfung
string
C0020971 (UMLS CUI 2011AA)
127785005 (SNOMED CT 2011_0131)
10021431 (MedDRA 14.1)
Item Group
Temperature
Item
Temperatur
string
C0039476 (UMLS CUI 2011AA)
246508008 (SNOMED CT 2011_0131)
MTHU009008 (LOINC Version 232)
Pulse
Item
Pulsfrequenz
integer
C0232117 (UMLS CUI 2011AA)
78564009 (SNOMED CT 2011_0131)
10037485 (MedDRA 14.1)
Respiration rate
Item
Atemfrequenz
integer
C0231832 (UMLS CUI 2011AA)
86290005 (SNOMED CT 2011_0131)
10038709 (MedDRA 14.1)
MTHU008344 (LOINC Version 232)
Blood pressure
Item
Blutdruck
string
C0005823 (UMLS CUI 2011AA)
75367002 (SNOMED CT 2011_0131)
MTHU008342 (LOINC Version 232)
Pain
Item
Schmerz
string
C0030193 (UMLS CUI 2011AA)
22253000 (SNOMED CT 2011_0131)
10033371 (MedDRA 14.1)
MTHU029813 (LOINC Version 232)
R52 (ICD-10-CM Version 2010)
338-338.9 (ICD-9-CM Version 2011)
E11167 (CTCAE 1105E)
GENERAL APPEARANCE
Item
Allgemeinzustand
string
C1148438 (UMLS CUI 2011AA)
MTHU015040 (LOINC Version 232)
HEENT
Item
Head, Ears, Eyes, Nose and Throat
text
C1512338 (UMLS CUI 2011AA)
NECK
Item
Hals
string
C0027530 (UMLS CUI 2011AA)
45048000 (SNOMED CT 2011_0131)
MTHU002688 (LOINC Version 232)
CHEST
Item
Thorax
string
C0817096 (UMLS CUI 2011AA)
51185008 (SNOMED CT 2011_0131)
BREAST
Item
Brust
string
C0006141 (UMLS CUI 2011AA)
76752008 (SNOMED CT 2011_0131)
MTHU011382 (LOINC Version 232)
HEART
Item
Herz
string
C0018787 (UMLS CUI 2011AA)
80891009 (SNOMED CT 2011_0131)
MTHU001067 (LOINC Version 232)
ABDOMEN
Item
Abdomen
string
C0000726 (UMLS CUI 2011AA)
113345001 (SNOMED CT 2011_0131)
MTHU001425 (LOINC Version 232)
LYMPH NODES
Item
Lymphknoten
string
C0024204 (UMLS CUI 2011AA)
59441001 (SNOMED CT 2011_0131)
MTHU015050 (LOINC Version 232)
GENITALIA/RECTAL
Item
Genitalorgane/Rektal
string
C0017420, C0205052 (UMLS CUI 2011AA)
255582007 (SNOMED CT 2011_0131)
MTHU002681 (LOINC Version 232)
EXTREMITIES
Item
Extremitäten
string
C0015385 (UMLS CUI 2011AA)
66019005 (SNOMED CT 2011_0131)
MTHU001429 (LOINC Version 232)
SKIN
Item
Haut
string
C1123023 (UMLS CUI 2011AA)
39937001 (SNOMED CT 2011_0131)
MTHU001414 (LOINC Version 232)
NEUROLOGICAL
Item
Nervensystem
string
C0027763 (UMLS CUI 2011AA)
25087005 (SNOMED CT 2011_0131)
MTHU001437 (LOINC Version 232)
IMPRESSION
Item
summary, conclusion
string
CL386604 (UMLS CUI 2011AA)
PLAN
Item
Planung
string
C1301732 (UMLS CUI 2011AA)
397943006 (SNOMED CT 2011_0131)
ASA SCORE
Item
ASA Status
string
C1531480 (UMLS CUI 2011AA)
413347006 (SNOMED CT 2011_0131)
AIRWAY ASSESSMENT FOR PATIENTS RECEIVING MODERATE SEDATION
Item
AIRWAY ASSESSMENT FOR PATIENTS RECEIVING MODERATE SEDATION
text
Teeth
Item
Zähne
string
C0040426 (UMLS CUI 2011AA)
245543004 (SNOMED CT 2011_0131)
MTHU021292 (LOINC Version 232)
MALLAMPATI AIRWAY SCORE
Item
Mallampati score
string
C0451276 (UMLS CUI 2011AA)
273585005 (SNOMED CT 2011_0131)
Neck Extension
Item
Neck Extension (normal/RESTRICTED/NO MOBILITY)
text
C0027530, C0231448 (UMLS CUI 2011AA)
45048000, 255536004 (SNOMED CT 2011_0131)
MTHU002688, MTHU010348 (LOINC Version 232)
Physician
Item
Behandelnder Arzt
string
C1710470 (UMLS CUI 2011AA)
Item Group
DATE OF PROCEDURE
Item
Datum der Prozedur
string
C2584899 (UMLS CUI 2011AA)
439272007 (SNOMED CT 2011_0131)
PRE-OP DIAGNOSIS
Item
präoperative Diagnose
string
C1318968 (UMLS CUI 2011AA)
406520001 (SNOMED CT 2011_0131)
POST-OP DIAGNOSIS
Item
Postoperative Diagnose
string
C1318969 (UMLS CUI 2011AA)
406521002 (SNOMED CT 2011_0131)
PRIMARY SURGEON
Item
Erster Operateur
string
C0808118 (UMLS CUI 2011AA)
MTHU010488 (LOINC Version 232)
PRISURG (HL7 V3 2006_05)
ASSISTANT
Item
first assistant surgeon
string
C1550491 (UMLS CUI 2011AA)
FASST (HL7 V3 2006_05)
ANESTHESIA PROVIDER
Item
Anästhesist
string
C1550495 (UMLS CUI 2011AA)
ANEST (HL7 V3 2006_05)
ANESTHESIA/SEDATION
Item
ANESTHESIA/SEDATION
string
C0002903, C0344106 (UMLS CUI 2011AA)
399097000, 72641008 (SNOMED CT 2011_0131)
10002091, 10059283 (MedDRA 14.1)
MTHU035920 (LOINC Version 232)
Item Group
ANTIBIOTIC: Ancef
Item
ANTIBIOTIC: Ancef
boolean
C0003232 (UMLS CUI 2011AA)
255631004 (SNOMED CT 2011_0131)
ANTIBIOTIC: Rocephin
Item
ANTIBIOTIC: Rocephin
boolean
C0003232 (UMLS CUI 2011AA)
255631004 (SNOMED CT 2011_0131)
ANTIBIOTIC: Levaquin
Item
ANTIBIOTIC: Levaquin
boolean
C0003232 (UMLS CUI 2011AA)
255631004 (SNOMED CT 2011_0131)
ANTIBIOTIC: Other
Item
ANTIBIOTIC: Other
string
C0003232 (UMLS CUI 2011AA)
255631004 (SNOMED CT 2011_0131)
OTHER MEDS GIVEN
Item
OTHER MEDS GIVEN
string
C0013227 (UMLS CUI 2011AA)
Abscess drainage
Item
Abszess-Drainage
boolean
C0344096 (UMLS CUI 2011AA)
118442004 (SNOMED CT 2011_0131)
10000279 (MedDRA 14.1)
Aortogram
Item
Aortographie
boolean
C0003515 (UMLS CUI 2011AA)
54640009 (SNOMED CT 2011_0131)
10057775 (MedDRA 14.1)
88.42 (ICD-9-CM Version 2011)
Aortogram and Runoff
Item
Aortogram and Runoff
boolean
AV Fistulagram
Item
AV Fistulagram
boolean
C0412315 (UMLS CUI 2011AA)
241275007 (SNOMED CT 2011_0131)
Biliary Drain
Item
Biliäre Drainage
boolean
C0489793 (UMLS CUI 2011AA)
MTHU001297 (LOINC Version 232)
Carotid Angiogram
Item
Carotis-Angiographie
boolean
C0202896 (UMLS CUI 2011AA)
420171008 (SNOMED CT 2011_0131)
10003194 (MedDRA 14.1)
88.41 (ICD-9-CM Version 2011)
Cerebral Angiogram
Item
Cerebrale Angiographie
boolean
C0948923 (UMLS CUI 2011AA)
419364000 (SNOMED CT 2011_0131)
10052905 (MedDRA 14.1)
Chest tube
Item
Thoraxdrainage
boolean
C0008034 (UMLS CUI 2011AA)
258643002 (SNOMED CT 2011_0131)
MTHU001287 (LOINC Version 232)
Chest tube/Empyema
Item
Chest tube/Empyema
boolean
C0008034,C0014009 (UMLS CUI 2011AA)
258643002, 66696 (SNOMED CT 2011_0131)
10014568 (MedDRA 14.1)
MTHU001287 (LOINC Version 232)
510 (ICD-9-CM Version 2011)
CVC
Item
Zentralvenöser Katheter (ZVK)
boolean
C1145640 (UMLS CUI 2011AA)
52124006 (SNOMED CT 2011_0131)
CVC/Port
Item
CVC/Port
boolean
C1145640, C0179694 (UMLS CUI 2011AA)
52124006 (SNOMED CT 2011_0131)
CVC Temporary
Item
CVC Temporary
boolean
CVC Tunneled
Item
CVC Tunneled
boolean
Dialysis Access Declot
Item
Dialysis Access Declot
boolean
EVLT
Item
Endovenous laser treatment (ELT)
boolean
C1998394 (UMLS CUI 2011AA)
Extremity Angiogram
Item
Extremity Angiogram
boolean
CL378222, C0015385 (UMLS CUI 2011AA)
77343006, 66019005 (SNOMED CT 2011_0131)
10050062 (MedDRA 14.1)
MTHU001429 (LOINC Version 232)
Kyphoplasty
Item
Balloon Vertebroplasty
boolean
C1455863 (UMLS CUI 2011AA)
10064702 (MedDRA 14.1)
81.66 (ICD-9-CM Version 2011)
Percutaneous Nephrostomy
Item
Perkutane Nephrostomie
boolean
C0564457 (UMLS CUI 2011AA)
313270001 (SNOMED CT 2011_0131)
PICC
Item
Peripherally-Inserted Central Catheter (PICC), PICC line
boolean
C0179740 (UMLS CUI 2011AA)
398176008 (SNOMED CT 2011_0131)
Pulmonary Angiogram
Item
Pulmonale Angiographie
boolean
C0202910 (UMLS CUI 2011AA)
84200003 (SNOMED CT 2011_0131)
10002440 (MedDRA 14.1)
88.43 (ICD-9-CM Version 2011)
RFA (RF-Ablation)
Item
radiofrequency ablation procedure
boolean
CL382653 (UMLS CUI 2011AA)
TACE
Item
transarterial chemoembolization
boolean
CL388501 (UMLS CUI 2011AA)
Thrombolysis
Item
Thrombolysis
boolean
C0520997 (UMLS CUI 2011AA)
51308000 (SNOMED CT 2011_0131)
10043568 (MedDRA 14.1)
Uterine Artery Embolization
Item
Embolisation of uterine artery
boolean
C0729536 (UMLS CUI 2011AA)
312138002 (SNOMED CT 2011_0131)
Other procedure
Item
Other procedure
string
FINDINGS
Item
FINDINGS (None|Same|N/A|Successful|Unsuccessful)
integer
Findings text
Item
Findings text
string
BLOOD LOSS
Item
bleeding, blood loss, hemorrhage
string
C0019080 (UMLS CUI 2011AA)
50960005 (SNOMED CT 2011_0131)
10055798 (MedDRA 14.1)
R58 (ICD-10-CM Version 2010)
459.0 (ICD-9-CM Version 2011)
CONTRAST
Item
Kontrastmittel
string
C0009924 (UMLS CUI 2011AA)
385420005 (SNOMED CT 2011_0131)
FLUORO TIME
Item
FLUORO TIME
string
C0016356 (UMLS CUI 2011AA)
44491008 (SNOMED CT 2011_0131)
10064426 (MedDRA 14.1)
SPECIMEN(s) REMOVED
Item
SPECIMEN(s)REMOVED (yes|no)
boolean
SPECIMEN(s)
Item
Specimen
string
C0370003 (UMLS CUI 2011AA)
123038009 (SNOMED CT 2011_0131)
MTHU010726 (LOINC Version 232)
COMPLICATIONS: No immediate
Item
COMPLICATIONS: No immediate
boolean
Complications text
Item
Komplikationen
string
C0009566 (UMLS CUI 2011AA)
116223007 (SNOMED CT 2011_0131)
MTHU008883 (LOINC Version 232)
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