ID

5521

Description

Form from HIS OpenVistA

Keywords

  1. 2/16/12 2/16/12 -
  2. 8/8/14 8/8/14 - Martin Dugas
Uploaded on

August 8, 2014

DOI

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License

Creative Commons BY-NC 3.0 Legacy

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HIS ENDOSCOPY PROCEDURE RECORD

  1. StudyEvent: HIS
    1. HIS
SCOPE INSTRUMENT USED
Description

SCOPE INSTRUMENT USED

COLONOSCOPE
Description

COLONOSCOPE

Data type

text

EGD SCOPE
Description

EGD SCOPE

Data type

text

FLEX SIGMOID SCOPE
Description

FLEX SIGMOID SCOPE

Data type

text

ERCP SCOPE
Description

ERCP SCOPE

Data type

text

ENTEROSCOPE
Description

ENTEROSCOPE

Data type

text

DB CHANNEL SCOPE
Description

DB CHANNEL SCOPE

Data type

text

LOANER SCOPE
Description

LOANER SCOPE

Data type

text

VIDEO CAMERA
Description

VIDEO CAMERA

Data type

text

General Info
Description

General Info

HISTORY & PHYSICAL COMPLETED?
Description

HISTORY & PHYSICAL COMPLETED?

Data type

boolean

IV START
Description

IV START

Data type

text

IV PUNCTURE SITE
Description

IV PUNCTURE SITE

Data type

text

IV GAUGE
Description

IV GAUGE

Data type

text

IV FLUID
Description

IV FLUID

Data type

text

AMOUNT
Description

AMOUNT

Data type

text

IV RATE [ml/hr]
Description

IV RATE [ml/hr]

Data type

text

TIME STARTED
Description

TIME STARTED

Data type

time

IV INSERTED BY
Description

IV INSERTED BY

Data type

text

NOTES
Description

NOTES

Data type

text

ENDOSCOPY START
Description

ENDOSCOPY START

Data type

text

ENDOSCOPY ROOM
Description

ENDOSCOPY ROOM

Data type

text

TIME OUT TAKEN FOR PROCEDURE VERIFICATION
Description

TIME OUT TAKEN FOR PROCEDURE VERIFICATION

Data type

boolean

VERIFICATION PROCESS
Description

VERIFICATION PROCESS

Data type

text

Finding of American Society of Anesthesiologists physical status classification
Description

ASA SCORE

Data type

string

Alias
UMLS CUI 2011AA
C1531480
SNOMED CT 2011_0131
413347006
OXYGEN DELIVERY METHOD
Description

OXYGEN DELIVERY METHOD

Data type

text

PROCEDURE
Description

PROCEDURE

Data type

text

Alias
UMLS CUI 2011AA
C0087111
PROCEDURE START
Description

PROCEDURE START

Data type

time

PROCEDURE STOP
Description

PROCEDURE STOP

Data type

time

ANESTHESIA START
Description

ANESTHESIA START

Data type

time

ANESTHESIA STOP
Description

ANESTHESIA STOP

Data type

time

Vitalzeichen
Description

VITALS SIGNS

Data type

string

Alias
UMLS CUI 2011AA
C0518766
SNOMED CT 2011_0131
46680005
LOINC Version 232
MTHU024540
IV MEDICATIONS
Description

IV MEDICATIONS

Data type

text

COMMENTS
Description

COMMENTS

Data type

text

COLD BIOPSY
Description

COLD BIOPSY

Data type

text

HOT BIOPSY
Description

HOT BIOPSY

Data type

text

SNARE POLYPECTOMY
Description

SNARE POLYPECTOMY

Data type

text

Alias
UMLS CUI 2011AA
C0940840
CYTOLOGY BRUSHINGS
Description

CYTOLOGY BRUSHINGS

Data type

text

Alias
UMLS CUI 2011AA
C1305671
POST CASE
Description

POST CASE

Data type

text

PATIENT TOLERATED PROCEDURE WELL
Description

PATIENT TOLERATED PROCEDURE WELL

Data type

boolean

POST-OP CONDITION
Description

POST-OP CONDITION

Data type

text

Postoperative Diagnose
Description

Post-op diagnosis

Data type

string

Alias
UMLS CUI 2011AA
C1318969
SNOMED CT 2011_0131
406521002
OTHER
Description

OTHER

Data type

string

ERCP OMNIPAQUE CONTRAST MEDIUM [ml]
Description

ERCP OMNIPAQUE CONTRAST MEDIUM [ml]

Data type

text

FLUOROSCOPY TIME [minutes]
Description

FLUOROSCOPY TIME [minutes]

Data type

text

ESU
Description

ESU

Data type

text

SETTINGS
Description

SETTINGS

Data type

text

PLACEMENT OF GROUNDING PAD
Description

PLACEMENT OF GROUNDING PAD

Data type

text

TEXT
Description

TEXT

Data type

string

SKIN CLEAR & INTACT BENEATH SITE OF GROUNDING PAD
Description

SKIN CLEAR & INTACT BENEATH SITE OF GROUNDING PAD

Data type

text

DISCHARGE
Description

DISCHARGE

Data type

text

IV DISCONTINUED
Description

IV DISCONTINUED

Data type

time

AMOUNT OF SOLUTION GIVEN [ml]
Description

AMOUNT OF SOLUTION GIVEN [ml]

Data type

integer

CONDITION AT DISCHARGE
Description

CONDITION AT DISCHARGE

Data type

string

Alias
UMLS CUI 2011AA
C0586514
Discharge disposition
Description

DISPOSITION

Data type

string

Alias
UMLS CUI 2011AA
C1550390
LOINC Version 232
MTHU021441
ACCOMPANIED BY
Description

ACCOMPANIED BY

Data type

text

DISCHARGE INSTRUCTIONS GIVEN TO
Description

DISCHARGE INSTRUCTIONS GIVEN TO

Data type

text

TIME OF DISCHARGE
Description

TIME OF DISCHARGE

Data type

time

PROCEDURE REPORT GIVEN TO STAFF NURSE
Description

PROCEDURE REPORT GIVEN TO STAFF NURSE

Data type

text

Patient able to
Description

Patient able to

Data type

text

ALDRETE SCORE
Description

ALDRETE SCORE

ACTIVITY (2= all 4 extremities move voluntarily or on command, 1= 2 extremities move voluntarily or on command, 0= cannot move extremities)
Description

ACTIVITY

Data type

integer

RESPIRATORY (2= able to deep breath, cough freely, 1= dyspnea or limited breathing, 0= apnea or SAO2 <90%)
Description

RESPIRATORY

Data type

integer

BLOOD PRESSURE (2= BP +/- 20% of pre-procedure level, 1= BP +/- 21-49% pre-procedure level, 0= BP +/- 50% pre-procedure level)
Description

Blood pressure

Data type

integer

Alias
UMLS
C0005823
SNOMED CT 2011_0131
386534000
Bewusstseinslage
Description

LEVEL OF CONSCIOUSNESS

Data type

integer

Alias
UMLS CUI 2011AA
C0234421
SNOMED CT 2011_0131
106167005
EVALUATION OF SKIN CONDITION AND COLOR (2=Skin is pink-warm- dry, 1= Skin is pale-dusky-blotchy- jaundice, 0= Patient is cyanotic)
Description

EVALUATION OF SKIN CONDITION AND COLOR

Data type

integer

Alias
UMLS CUI 2011AA
C1719933
SNOMED CT 2011_0131
422000003
LOINC Version 232
MTHU034830
ALDRETE TOTAL SCORE
Description

ALDRETE TOTAL SCORE

Data type

integer

Similar models

  1. StudyEvent: HIS
    1. HIS
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
COLONOSCOPE
Item
COLONOSCOPE
text
EGD SCOPE
Item
EGD SCOPE
text
FLEX SIGMOID SCOPE
Item
FLEX SIGMOID SCOPE
text
ERCP SCOPE
Item
ERCP SCOPE
text
ENTEROSCOPE
Item
ENTEROSCOPE
text
DB CHANNEL SCOPE
Item
DB CHANNEL SCOPE
text
LOANER SCOPE
Item
LOANER SCOPE
text
VIDEO CAMERA
Item
VIDEO CAMERA
text
Item Group
HISTORY & PHYSICAL COMPLETED?
Item
HISTORY & PHYSICAL COMPLETED?
boolean
IV START
Item
IV START
text
IV PUNCTURE SITE
Item
IV PUNCTURE SITE
text
IV GAUGE
Item
IV GAUGE
text
IV FLUID
Item
IV FLUID
text
AMOUNT
Item
AMOUNT
text
IV RATE [ml/hr]
Item
IV RATE [ml/hr]
text
TIME STARTED
Item
TIME STARTED
time
IV INSERTED BY
Item
IV INSERTED BY
text
NOTES
Item
NOTES
text
ENDOSCOPY START
Item
ENDOSCOPY START
text
ENDOSCOPY ROOM
Item
ENDOSCOPY ROOM
text
TIME OUT TAKEN FOR PROCEDURE VERIFICATION
Item
TIME OUT TAKEN FOR PROCEDURE VERIFICATION
boolean
VERIFICATION PROCESS
Item
VERIFICATION PROCESS
text
ASA SCORE
Item
Finding of American Society of Anesthesiologists physical status classification
string
C1531480 (UMLS CUI 2011AA)
413347006 (SNOMED CT 2011_0131)
OXYGEN DELIVERY METHOD
Item
OXYGEN DELIVERY METHOD
text
PROCEDURE
Item
PROCEDURE
text
C0087111 (UMLS CUI 2011AA)
PROCEDURE START
Item
PROCEDURE START
time
PROCEDURE STOP
Item
PROCEDURE STOP
time
ANESTHESIA START
Item
ANESTHESIA START
time
ANESTHESIA STOP
Item
ANESTHESIA STOP
time
VITALS SIGNS
Item
Vitalzeichen
string
C0518766 (UMLS CUI 2011AA)
46680005 (SNOMED CT 2011_0131)
MTHU024540 (LOINC Version 232)
IV MEDICATIONS
Item
IV MEDICATIONS
text
COMMENTS
Item
COMMENTS
text
COLD BIOPSY
Item
COLD BIOPSY
text
HOT BIOPSY
Item
HOT BIOPSY
text
SNARE POLYPECTOMY
Item
SNARE POLYPECTOMY
text
C0940840 (UMLS CUI 2011AA)
CYTOLOGY BRUSHINGS
Item
CYTOLOGY BRUSHINGS
text
C1305671 (UMLS CUI 2011AA)
POST CASE
Item
POST CASE
text
PATIENT TOLERATED PROCEDURE WELL
Item
PATIENT TOLERATED PROCEDURE WELL
boolean
POST-OP CONDITION
Item
POST-OP CONDITION
text
Post-op diagnosis
Item
Postoperative Diagnose
string
C1318969 (UMLS CUI 2011AA)
406521002 (SNOMED CT 2011_0131)
OTHER
Item
OTHER
string
ERCP OMNIPAQUE CONTRAST MEDIUM [ml]
Item
ERCP OMNIPAQUE CONTRAST MEDIUM [ml]
text
FLUOROSCOPY TIME [minutes]
Item
FLUOROSCOPY TIME [minutes]
text
ESU
Item
ESU
text
SETTINGS
Item
SETTINGS
text
PLACEMENT OF GROUNDING PAD
Item
PLACEMENT OF GROUNDING PAD
text
TEXT
Item
TEXT
string
SKIN CLEAR & INTACT BENEATH SITE OF GROUNDING PAD
Item
SKIN CLEAR & INTACT BENEATH SITE OF GROUNDING PAD
text
DISCHARGE
Item
DISCHARGE
text
IV DISCONTINUED
Item
IV DISCONTINUED
time
AMOUNT OF SOLUTION GIVEN [ml]
Item
AMOUNT OF SOLUTION GIVEN [ml]
integer
CONDITION AT DISCHARGE
Item
CONDITION AT DISCHARGE
string
C0586514 (UMLS CUI 2011AA)
DISPOSITION
Item
Discharge disposition
string
C1550390 (UMLS CUI 2011AA)
MTHU021441 (LOINC Version 232)
ACCOMPANIED BY
Item
ACCOMPANIED BY
text
DISCHARGE INSTRUCTIONS GIVEN TO
Item
DISCHARGE INSTRUCTIONS GIVEN TO
text
TIME OF DISCHARGE
Item
TIME OF DISCHARGE
time
PROCEDURE REPORT GIVEN TO STAFF NURSE
Item
PROCEDURE REPORT GIVEN TO STAFF NURSE
text
Patient able to
Item
Patient able to
text
Item Group
ACTIVITY
Item
ACTIVITY (2= all 4 extremities move voluntarily or on command, 1= 2 extremities move voluntarily or on command, 0= cannot move extremities)
integer
RESPIRATORY
Item
RESPIRATORY (2= able to deep breath, cough freely, 1= dyspnea or limited breathing, 0= apnea or SAO2 <90%)
integer
Blood pressure
Item
BLOOD PRESSURE (2= BP +/- 20% of pre-procedure level, 1= BP +/- 21-49% pre-procedure level, 0= BP +/- 50% pre-procedure level)
integer
C0005823 (UMLS)
386534000 (SNOMED CT 2011_0131)
LEVEL OF CONSCIOUSNESS
Item
Bewusstseinslage
integer
C0234421 (UMLS CUI 2011AA)
106167005 (SNOMED CT 2011_0131)
EVALUATION OF SKIN CONDITION AND COLOR
Item
EVALUATION OF SKIN CONDITION AND COLOR (2=Skin is pink-warm- dry, 1= Skin is pale-dusky-blotchy- jaundice, 0= Patient is cyanotic)
integer
C1719933 (UMLS CUI 2011AA)
422000003 (SNOMED CT 2011_0131)
MTHU034830 (LOINC Version 232)
ALDRETE TOTAL SCORE
Item
ALDRETE TOTAL SCORE
integer

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