1. StudyEvent: HIS
    1. HIS
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
General Info
C1508263 (UMLS CUI-1)
PHYSICAL THERAPY ORDER
Item
PHYSICAL THERAPY ORDER
text
C0949766 (UMLS CUI-1)
SURGERY
Item
operative procedures
string
C0038895 (UMLS CUI 2011AA)
HISTORY OF PRESENT ILLNESS WITH ONSET DATE
Item
HISTORY OF PRESENT ILLNESS WITH ONSET DATE
string
C0262512 (UMLS CUI 2011AA)
MTHU001399 (LOINC Version 232)
C0332162 (UMLS CUI 2011AA)
77374008 (SNOMED CT 2011_0131)
Item Group
SOCIAL/HEALTH HABITS(PAST & CURRENT)
Alcohol
Item
Alcohol abuse
boolean
C0085762 (UMLS CUI 2011AA)
15167005 (SNOMED CT 2011_0131)
10001584 (MedDRA 14.1)
LP36309-0 (LOINC Version 232)
F10.1 (ICD-10-CM Version 2010)
305.0 (ICD-9-CM Version 2011)
Smoking
Item
Smoker
boolean
C1519386 (UMLS CUI-1)
Item Group
Living Situation, Dwelling
Assisted Living
Item
Assisted Living, Residential Care
boolean
C1456630 (UMLS CUI 2011AA)
Home (Lives Alone)
Item
Home (Lives Alone)
boolean
Home with parent(s)
Item
Home with parent(s)
boolean
Home w/Significant Other
Item
Home w/Significant Other
boolean
Home w/Spouse
Item
Home w/Spouse
boolean
Home w/Family (Children)
Item
Home w/Family (Children)
boolean
Home w/Friend (Caretaker)
Item
Home w/Friend (Caretaker)
boolean
Dependent in ADLs
Item
Dependent in ADLs
boolean
Independent in ADLs
Item
Independent in ADLs
boolean
Nursing Home
Item
Nursing Home (NH)
boolean
C0028688 (UMLS CUI 2011AA)
42665001 (SNOMED CT 2011_0131)
MTHU015917 (LOINC Version 232)
N (HL7 V3 2006_05)
Retirement Center/ Assisted Living Facility
Item
Assisted Living Facility, Retirement Center
boolean
C0872103 (UMLS CUI 2011AA)
310400000X (HL7 V3 2006_05)
Requires Assistance with ADLs
Item
Requires Assistance with ADLs
boolean
Other
Item
Other
boolean
Stairs to enter
Item
Stairs to enter
boolean
Stairs indoors
Item
Stairs indoors
boolean
REMAIN ON FIRST FLOOR
Item
REMAIN ON FIRST FLOOR
boolean
OTHER OBSTACLES OF CONCERN
Item
OTHER OBSTACLES OF CONCERN
string
Item Group
Medical history
C0262926 (UMLS CUI-1)
PREMORBID FUNCTIONAL STATUS
Item
PREMORBID FUNCTIONAL STATUS
string
Family history
Item
Family history (FH)
text
57177007 (SNOMED CT 2011_0131)
C0241889 (UMLS CUI-1)
Medical/surgical history
Item
Medical/surgical history
text
417662000 (SNOMED CT 2011_0131)
MTHU027722 (LOINC Version 232)
161615003 (SNOMED CT 2011_0131)
C0262926 (UMLS CUI-1)
C0455610 (UMLS CUI-2)
MEDICATIONS REVIEWED
Item
MEDICATIONS REVIEWED
boolean
PERTINENT MEDICATIONS AFFECTING THERAPY
Item
PERTINENT MEDICATIONS AFFECTING THERAPY
string
CLINICAL TESTS
Item
CLINICAL TESTS
string
I.D. VERIFIED BY
Item
I.D. VERIFIED BY
string
I.D. VERIFICATION
Item
I.D. VERIFICATION
string
Item Group
Review of systems
C0489633 (UMLS CUI-1)
Height
Item
Height
float
MTHU005354 (LOINC Version 232)
C0005890 (UMLS CUI-1)
Weight
Item
Body weight
float
107647005 (SNOMED CT 2011_0131)
10047890 (MedDRA 14.1)
LP18015-5 (LOINC Version 232)
C0005910 (UMLS CUI-1)
Pulse Rate
Item
Pulse
integer
78564009 (SNOMED CT 2011_0131)
10037485 (MedDRA 14.1)
C0232117 (UMLS CUI-1)
Respiration Rate
Item
Respiration rate, Breathing rate (BR)
integer
86290005 (SNOMED CT 2011_0131)
10038709 (MedDRA 14.1)
MTHU008344 (LOINC Version 232)
C0231832 (UMLS CUI-1)
Blood Pressure
Item
Blood pressure (BP)
integer
75367002 (SNOMED CT 2011_0131)
MTHU008342 (LOINC Version 232)
C0005823 (UMLS CUI-1)
Edema
Item
Edema
boolean
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)
Item
Ankle Edema
text
344001 (SNOMED CT 2011_0131)
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)
C0235439 (UMLS CUI-1)
Code List
Ankle Edema
CL Item
left (L)
C0205091 (UMLS CUI-1)
CL Item
right (R)
C0205090 (UMLS CUI-1)
Item
Foot Edema
text
56459004 (SNOMED CT 2011_0131)
MTHU002679 (LOINC Version 232)
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)
C0574002 (UMLS CUI-1)
Code List
Foot Edema
CL Item
left (L)
C0205091 (UMLS CUI-1)
CL Item
right (R)
C0205090 (UMLS CUI-1)
Item
Hand Edema
text
C0239819 (UMLS CUI-1)
Code List
Hand Edema
CL Item
left (L)
C0205091 (UMLS CUI-1)
CL Item
right (R)
C0205090 (UMLS CUI-1)
Item
Knee Edema
text
C0522045 (UMLS CUI-1)
Code List
Knee Edema
CL Item
left (L)
C0205091 (UMLS CUI-1)
CL Item
right (R)
C0205090 (UMLS CUI-1)
Item
Leg oedema, Edema of leg
text
102574007 (SNOMED CT 2011_0131)
10024127 (MedDRA 14.1)
C0235886 (UMLS CUI-1)
Code List
Leg oedema, Edema of leg
CL Item
left (L)
C0205091 (UMLS CUI-1)
CL Item
right (R)
C0205090 (UMLS CUI-1)
INTEGUMENTARY WNL
Item
INTEGUMENTARY within normal limits
boolean
C0558145 (UMLS CUI-1)
Integument
Item
Integument
string
C1123023 (UMLS CUI 2011AA)
39937001 (SNOMED CT 2011_0131)
MTHU001414 (LOINC Version 232)
MUSCULOSKELETAL WNL
Item
MUSCULOSKELETAL WNL
boolean
C0430745 (UMLS CUI-1)
Musculoskeletal
Item
Musculoskeletal System, Musculo-skeletal system
text
26107004 (SNOMED CT 2011_0131)
MTHU001411 (LOINC Version 232)
C0026860 (UMLS CUI-1)
ROM/STRENGTH
Item
ROM/STRENGTH
string
NEUROMUSCULAR WNL
Item
NEUROMUSCULAR WNL
boolean
Neuromuscular
Item
Neuromuscular
text
C1979768 (UMLS CUI-1)
GAIT
Item
Gait, Manner of walking
text
63448001 (SNOMED CT 2011_0131)
MTHU015039 (LOINC Version 232)
C0016928 (UMLS CUI-1)
BALANCE
Item
BALANCE
text
C0560184 (UMLS CUI-1)
MOTOR CONTROL
Item
MOTOR CONTROL
text
C0517961 (UMLS CUI-1)
COMMUNICATION WNL
Item
COMMUNICATION WNL
boolean
COMMUNICATION
Item
COMMUNICATION
text
C0009452 (UMLS CUI-1)
LANGUAGE
Item
language ability, verbal ability
string
C1145677 (UMLS CUI 2011AA)
Item
Orientation as to time, place and people
string
C0029266 (UMLS CUI 2011AA)
43173001 (SNOMED CT 2011_0131)
Code List
Orientation as to time, place and people
CL Item
Oriented (1)
CL Item
Disoriented (2)
Item
Memory loss, Loss of memory
string
C0751295 (UMLS CUI 2011AA)
10027176 (MedDRA 14.1)
MTHU013522 (LOINC Version 232)
780.93 (ICD-9-CM Version 2011)
Code List
Memory loss, Loss of memory
CL Item
no memory loss (1)
CL Item
Long term memory loss (2)
CL Item
Recent memory loss (3)
EMOTIONAL/BEHAVIORAL RESPONSES WNL
Item
EMOTIONAL/BEHAVIORAL RESPONSES WNL
boolean
Emotional / Behavioral responses
Item
Emotional / Behavioral responses
string
LEARNING BARRIERS
Item
LEARNING BARRIERS
boolean
Hearing impaired
Item
Hearing impaired
boolean
C1384666 (UMLS CUI-1)
Language/Needs interpreter
Item
Language/Needs interpreter
boolean
unable to read
Item
unable to read
boolean
C0586741 (UMLS CUI-1)
Vision impaired
Item
Vision impaired
boolean
C3665347 (UMLS CUI-1)
EDUCATION NEEDS
Item
EDUCATION NEEDS
boolean
Education ADLs
Item
Education ADLs
boolean
129025006 (SNOMED CT 2011_0131)
C0013622 (UMLS CUI-1)
C0001288 (UMLS CUI-2)
Education Disease
Item
Education Disease
boolean
64572001 (SNOMED CT 2011_0131)
C0013622 (UMLS CUI-1)
C0012634 (UMLS CUI-2)
Education Equipment
Item
Education Equipment
boolean
Education Exercise Program
Item
Education Exercise Program
boolean
Education Safety
Item
Education Safety
boolean
Education Transfers
Item
Education Transfers
boolean
other Education needs
Item
other Education needs
string
Item Group
KEYS TO TEST AND MEASURES
AEROBIC CAPACITY/ENDURANCE
Item
AEROBIC CAPACITY/ENDURANCE
string
AROUSAL, ATTENTION, AND COGNITION
Item
AROUSAL, ATTENTION, AND COGNITION
string
ASSISTIVE AND ADAPTIVE EQUIPMENT
Item
ASSISTIVE AND ADAPTIVE EQUIPMENT
string
CIRCULATION
Item
CIRCULATION
string
GAIT, LOCOMOTION, AND BALANCE
Item
GAIT, LOCOMOTION, AND BALANCE
string
INTEGUMENTARY INTEGRITY
Item
INTEGUMENTARY INTEGRITY
string
MOTOR FUNCTION (MOTOR CONTROL AND MOTOR LEARNING)
Item
MOTOR FUNCTION (MOTOR CONTROL AND MOTOR LEARNING)
string
MUSCLE PERFORMANCE (STRENGTH,POWER,AND ENDURANCE)
Item
MUSCLE PERFORMANCE (STRENGTH,POWER,AND ENDURANCE)
string
NEUROMOTOR DEVELOPMENT AND SENSORY INTEGRATION
Item
NEUROMOTOR DEVELOPMENT AND SENSORY INTEGRATION
string
ORTHOTIC, PROTECTIVE, AND SUPPORTIVE DEVICES
Item
ORTHOTIC, PROTECTIVE, AND SUPPORTIVE DEVICES
string
PAIN
Item
Pain
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)
POSTURE
Item
POSTURE
text
C1262869 (UMLS CUI-1)
RANGE OF MOTION (INCLUDING MUSCLE LENGTH)
Item
RANGE OF MOTION (INCLUDING MUSCLE LENGTH)
string
REFLEX INTEGRITY
Item
REFLEX INTEGRITY
text
C0596002 (UMLS CUI-1)
SENSORY INTEGRITY
Item
SENSORY INTEGRITY
text
C2735300 (UMLS CUI-1)
SELF CARE AND HOME MANAGEMENT
Item
SELF CARE AND HOME MANAGEMENT
string
WORK REINTEGRATION
Item
WORK REINTEGRATION
string
EVALUATION
Item
EVALUATION
string
Item Group
Diagnosis
C0011900 (UMLS CUI-1)
Cardiovascular Pattern(s)
Item
Cardiovascular Pattern(s)
boolean
Integumentary Pattern(s)
Item
Integumentary Pattern(s)
boolean
Musculoskeletal Pattern(s)
Item
Musculoskeletal Pattern(s)
boolean
Neuromuscular Pattern(s)
Item
Neuromuscular Pattern(s)
boolean
Diagnosis text
Item
Diagnosis
string
C0011900 (UMLS CUI 2011AA)
439401001 (SNOMED CT 2011_0131)
MTHU008876 (LOINC Version 232)
Item Group
PROGNOSIS, Goals, Interventions, Plan
Prognosis
Item
Prognosis, prediction of outcome
string
C0033325 (UMLS CUI 2011AA)
20481000 (SNOMED CT 2011_0131)
Goals
Item
Goals, Objectives
string
C0018017 (UMLS CUI 2011AA)
410518001 (SNOMED CT 2011_0131)
MTHU036445 (LOINC Version 232)
Interventions
Item
Interventions
text
C0184661 (UMLS CUI-1)
TODAYS
Item
TODAYS
string
Educated - family
Item
Educated - family
boolean
Educated - patient
Item
Educated - patient
boolean
Educated - significant other
Item
Educated - significant other
boolean
Educated - returns Demonstration
Item
Educated - returns Demonstration
boolean
Educated - Verbalizes understanding
Item
Educated - Verbalizes understanding
boolean
DISCHARGE PLANS
Item
DISCHARGE PLANS
text
C2735970 (UMLS CUI-1)
DISCHARGE STATUS
Item
Discharge status
string
C0586514 (UMLS CUI 2011AA)
309039003 (SNOMED CT 2011_0131)
MTHU031549 (LOINC Version 232)
FREQUENCY OF VISITS/DURATION OF EPISODE OF CARE
Item
FREQUENCY OF VISITS/DURATION OF EPISODE OF CARE
string

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