ID
5581
Beschreibung
Form from HIS OpenVistA
Stichworte
Versionen (3)
- 25.02.12 25.02.12 -
- 09.08.14 09.08.14 - Martin Dugas
- 25.06.15 25.06.15 - Martin Dugas
Hochgeladen am
9. August 2014
DOI
Für eine Beantragung loggen Sie sich ein.
Lizenz
Creative Commons BY-NC 3.0 Legacy
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.
HIS NUTRITION SCREENING CONSULT RESULTS MAIN
HIS
- StudyEvent: HIS
Beschreibung
COMMENTS
Beschreibung
Patient triggered for problem swallowing difficulty
Datentyp
boolean
Alias
- UMLS CUI 2011AA
- C0392678
- SNOMED CT 2011_0131
- 399122003
- MedDRA 14.1
- 10042647
- LOINC Version 232
- MTHU020878
Beschreibung
Patient states no problems with swallowing difficulty
Datentyp
boolean
Beschreibung
Swallow difficulty due to sore throat. Nursing Notified.
Datentyp
boolean
Alias
- UMLS CUI 2011AA
- C0242429
- SNOMED CT 2011_0131
- 267102003
- MedDRA 14.1
- 10041367
- ICD-10-CM Version 2010
- R07.0
- ICD-9-CM Version 2011
- 784.1
- CTCAE 1105E
- E13575
Beschreibung
Patient needs diet consistency change to diet.
Datentyp
boolean
Beschreibung
Patient needs special foods of appropriate consistency.
Datentyp
boolean
Beschreibung
other
Datentyp
string
Beschreibung
Patient triggered for poor po intake > 5 days.
Datentyp
boolean
Beschreibung
Patient requests oral supplements of
Datentyp
string
Beschreibung
Patient states no problems with po intake.
Datentyp
boolean
Beschreibung
Patient states po intake improved>50% at all meals.
Datentyp
boolean
Beschreibung
Patient states no appetite.
Datentyp
boolean
Alias
- UMLS CUI 2011AA
- C0232462
- SNOMED CT 2011_0131
- 64379006
- MedDRA 14.1
- 10061428
Beschreibung
Patient states unable to eat certain foods:
Datentyp
string
Beschreibung
Patient started on nutrition support
Datentyp
boolean
Beschreibung
other
Datentyp
string
Beschreibung
Patient triggered for unintentional weight loss of 10 pounds or more in 3 months.
Datentyp
boolean
Alias
- UMLS CUI 2011AA
- C0936227
- SNOMED CT 2011_0131
- 267024001
- MedDRA 14.1
- 10000159
- ICD-10-CM Version 2010
- R63.4
Beschreibung
Patient states no weight loss.
Datentyp
boolean
Beschreibung
Patient was on a diet, weight loss was intentional.
Datentyp
boolean
Alias
- UMLS CUI 2011AA
- C0012155
- SNOMED CT 2011_0131
- 41829006
Beschreibung
Patient states weight loss due to increased activity.
Datentyp
boolean
Beschreibung
other
Datentyp
string
Beschreibung
Patient triggered for food allergies
Datentyp
boolean
Alias
- UMLS CUI 2011AA
- C0016470
- SNOMED CT 2011_0131
- 414285001
- MedDRA 14.1
- 10016946
Beschreibung
Patient states they have no food allergies/intolerances.
Datentyp
boolean
Beschreibung
Patient has no food intolerances to
Datentyp
string
Beschreibung
All food allergies/intolerances were identified.
Datentyp
boolean
Beschreibung
other
Datentyp
string
Beschreibung
Patient triggered for being pregnant and less than 16 years old of age.
Datentyp
boolean
Beschreibung
Patient is greater than 16 years old of age.
Datentyp
boolean
Alias
- UMLS CUI 2011AA
- C0001779
- SNOMED CT 2011_0131
- 397669002
Beschreibung
Patient is not pregnant.
Datentyp
boolean
Alias
- UMLS CUI 2011AA
- C0232973
- SNOMED CT 2011_0131
- 60001007
Beschreibung
other
Datentyp
string
Beschreibung
Patient triggered for being pregnant and on special diet.
Datentyp
boolean
Beschreibung
Patient is not pregnant.
Datentyp
boolean
Alias
- UMLS CUI 2011AA
- C0232973
- SNOMED CT 2011_0131
- 60001007
Beschreibung
Patient is not on a special diet.
Datentyp
boolean
Beschreibung
Patient is on diet for
Datentyp
string
Alias
- UMLS CUI 2011AA
- C0012155
- SNOMED CT 2011_0131
- 41829006
Beschreibung
Patient understands special diet, does not need additional information.
Datentyp
boolean
Beschreibung
Patient does not understand special diet.
Datentyp
boolean
Beschreibung
Patient triggered for being below 10th percentile of Pediatric Growth Charts.
Datentyp
boolean
Beschreibung
Patient is at 50th percentile or greater on growth charts.
Datentyp
boolean
Beschreibung
Patient is between 25th and 50th percentile on growth charts.
Datentyp
boolean
Beschreibung
Patient seen due to extended length of stay in hospital.
Datentyp
boolean
Alias
- UMLS CUI 2011AA
- C0023303
Beschreibung
other
Datentyp
string
Beschreibung
GOALS
Beschreibung
Patient to resume po intake (if currently NPO).
Datentyp
boolean
Alias
- UMLS CUI 2011AA
- C1512806
Beschreibung
Patient to transition to solid foods (if on CL or FL diet).
Datentyp
boolean
Beschreibung
Patient to be provided foods of appropriate consistency to decrease swallowing difficulty.
Datentyp
boolean
Beschreibung
Patient to continue po intake>75% at meals/snacks.
Datentyp
boolean
Beschreibung
PO intake to be greater than 50% at all meals/snacks.
Datentyp
boolean
Beschreibung
Weight gain of 1-2 lbs per week.
Datentyp
boolean
Alias
- UMLS CUI 2011AA
- C0043094
- SNOMED CT 2011_0131
- 262286000
- MedDRA 14.1
- 10047899
- LOINC Version 232
- MTHU020882
- CTCAE 1105E
- E12224
Beschreibung
Patient will not receive foods that they have indicated as being allergic or intolerate to.
Datentyp
boolean
Beschreibung
Patient to understand diet currently ordered by physician.
Datentyp
boolean
Beschreibung
Patient to be seen by dietician due to:
Datentyp
string
Beschreibung
other
Datentyp
string
Beschreibung
LEVEL OF CARE
Beschreibung
PLAN
Beschreibung
Continue with diet as currently ordered.
Datentyp
boolean
Alias
- UMLS CUI 2011AA
- C0012155
- SNOMED CT 2011_0131
- 41829006
Beschreibung
Advance diet as tolerated.
Datentyp
boolean
Alias
- UMLS CUI 2011AA
- C0012155
- SNOMED CT 2011_0131
- 41829006
Beschreibung
Explain menu process. Encourage continued good intake > 50%.
Datentyp
boolean
Beschreibung
Encourage patient to mark menu selections.
Datentyp
boolean
Beschreibung
Obtain food preferences. Place in computer and notify kitchen.
Datentyp
boolean
Beschreibung
Discuss adding oral supplement with nursing or dietician.
Datentyp
boolean
Beschreibung
Provide snacks to increase po intake.
Datentyp
boolean
Beschreibung
Notify diet office of food allergens or intolerances via computer.
Datentyp
boolean
Beschreibung
Provided educational handout on diet. Give RD contact information for further questions.
Datentyp
boolean
Beschreibung
Inform dietician of need for extensive diet education on diet.
Datentyp
boolean
Beschreibung
Follow patient per protocol.
Datentyp
boolean
Beschreibung
Refer to dietician.
Datentyp
boolean
Alias
- UMLS CUI 2011AA
- C0237083
- SNOMED CT 2011_0131
- 159033005
Beschreibung
other
Datentyp
string
Ähnliche Modelle
HIS
- StudyEvent: HIS
397669002 (SNOMED CT 2011_0131)
107647005 (SNOMED CT 2011_0131)
10047890 (MedDRA 14.1)
LP18015-5 (LOINC Version 232)
41829006 (SNOMED CT 2011_0131)
399122003 (SNOMED CT 2011_0131)
10042647 (MedDRA 14.1)
MTHU020878 (LOINC Version 232)
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)
64379006 (SNOMED CT 2011_0131)
10061428 (MedDRA 14.1)
267024001 (SNOMED CT 2011_0131)
10000159 (MedDRA 14.1)
R63.4 (ICD-10-CM Version 2010)
41829006 (SNOMED CT 2011_0131)
414285001 (SNOMED CT 2011_0131)
10016946 (MedDRA 14.1)
397669002 (SNOMED CT 2011_0131)
60001007 (SNOMED CT 2011_0131)
60001007 (SNOMED CT 2011_0131)
41829006 (SNOMED CT 2011_0131)
262286000 (SNOMED CT 2011_0131)
10047899 (MedDRA 14.1)
MTHU020882 (LOINC Version 232)
E12224 (CTCAE 1105E)
41829006 (SNOMED CT 2011_0131)
41829006 (SNOMED CT 2011_0131)
159033005 (SNOMED CT 2011_0131)