HIS

1 forms
  1. StudyEvent: HIS
    1. HIS
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
C1508263 (UMLS CUI-1)
Age
Item
Alter
integer
397669002 (SNOMED CT 2011_0131)
C0001779 (UMLS CUI-1)
Gender
Item
Geschlecht
integer
C0079399 (UMLS CUI 2011AA)
263495000 (SNOMED CT 2011_0131)
MTHU002975 (LOINC Version 232)
Race
Item
Racial group
text
103579009 (SNOMED CT 2011_0131)
MTHU009923 (LOINC Version 232)
C0034510 (UMLS CUI-1)
Height
Item
Größe
integer
MTHU005354 (LOINC Version 232)
C0005890 (UMLS CUI-1)
Weight
Item
Gewicht
float
107647005 (SNOMED CT 2011_0131)
10047890 (MedDRA 14.1)
LP18015-5 (LOINC Version 232)
C0005910 (UMLS CUI-1)
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)
Item Group
C0262926 (UMLS CUI-1)
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
C0031809 (UMLS CUI-1)
Temperature
Item
Temperatur
float
246508008 (SNOMED CT 2011_0131)
MTHU009008 (LOINC Version 232)
C0039476 (UMLS CUI-1)
Pulse Rate
Item
Pulsfrequenz
integer
78564009 (SNOMED CT 2011_0131)
10037485 (MedDRA 14.1)
C0232117 (UMLS CUI-1)
Respiration Rate
Item
Atemfrequenz
integer
86290005 (SNOMED CT 2011_0131)
10038709 (MedDRA 14.1)
MTHU008344 (LOINC Version 232)
C0231832 (UMLS CUI-1)
Blood Pressure
Item
Blutdruck
integer
75367002 (SNOMED CT 2011_0131)
MTHU008342 (LOINC Version 232)
C0005823 (UMLS CUI-1)
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
text
255582007 (SNOMED CT 2011_0131)
MTHU002681 (LOINC Version 232)
C0017420 (UMLS CUI-1)
C0205052 (UMLS CUI-2)
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
45048000, 255536004 (SNOMED CT 2011_0131)
MTHU002688, MTHU010348 (LOINC Version 232)
C0027530 (UMLS CUI-1)
C0231448 (UMLS CUI-2)
Physician
Item
Behandelnder Arzt
string
C1710470 (UMLS CUI 2011AA)
Item Group
C0184661 (UMLS CUI-1)
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
text
399097000, 72641008 (SNOMED CT 2011_0131)
10002091, 10059283 (MedDRA 14.1)
MTHU035920 (LOINC Version 232)
C0002903 (UMLS CUI-1)
C0344106 (UMLS CUI-2)
Item Group
C0013227 (UMLS CUI-1)
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)
Item Group
C0946440 (UMLS CUI-1)
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
258643002, 66696 (SNOMED CT 2011_0131)
10014568 (MedDRA 14.1)
MTHU001287 (LOINC Version 232)
510 (ICD-9-CM Version 2011)
C0008034 (UMLS CUI-1)
C0014009 (UMLS CUI-2)
CVC
Item
Zentralvenöser Katheter (ZVK)
boolean
C1145640 (UMLS CUI 2011AA)
52124006 (SNOMED CT 2011_0131)
CVC/Port
Item
CVC/Port
boolean
52124006 (SNOMED CT 2011_0131)
C1145640 (UMLS CUI-1)
C1275732 (UMLS CUI-2)
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
77343006, 66019005 (SNOMED CT 2011_0131)
10050062 (MedDRA 14.1)
MTHU001429 (LOINC Version 232)
C0002978 (UMLS CUI-1)
C0015385 (UMLS CUI-2)
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)
RF-Ablation
Item
radiofrequency ablation procedure
boolean
C1292442 (UMLS CUI-1)
TACE
Item
transarterial chemoembolization
boolean
C3539919 (UMLS CUI-1)
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
Item
FINDINGS (None|Same|N/A|Successful|Unsuccessful)
integer
C0243095 (UMLS CUI-1)
FINDINGS
Code List
FINDINGS (None|Same|N/A|Successful|Unsuccessful)
CL Item
 (1)
CL Item
 (2)
CL Item
 (3)
CL Item
 (4)
CL Item
 (5)
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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