SHORT STAY RECORD ID NOTE-ENDO

Form from HIS OpenVista

  1. StudyEvent: HIS
    1. HIS
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
SHORT STAY RECORD ID NOTE-ENDO
Age
Item
Age
integer
397669002 (SNOMED CT 2011_0131)
C0001779 (UMLS CUI-1)
Item
Sex
text
263495000 (SNOMED CT 2011_0131)
MTHU002975 (LOINC Version 232)
C0079399 (UMLS CUI-1)
Code List
Sex
CL Item
male (1)
248153007 (SNOMED CT 2011_0131)
M (HL7 V3 2006_05)
C0086582 (UMLS CUI-1)
CL Item
female (2)
248152002 (SNOMED CT 2011_0131)
F (HL7 V3 2006_05)
C0086287 (UMLS CUI-1)
Race
Item
Racial group
text
103579009 (SNOMED CT 2011_0131)
MTHU009923 (LOINC Version 232)
C0034510 (UMLS CUI-1)
Height
Item
Height
float
MTHU005354 (LOINC Version 232)
C0005890 (UMLS CUI-1)
Weight
Item
Weight
float
107647005 (SNOMED CT 2011_0131)
10047890 (MedDRA 14.1)
LP18015-5 (LOINC Version 232)
C0005910 (UMLS CUI-1)
Allergies
Item
Hypersensitivity
string
C0020517 (UMLS CUI 2011AA)
257550005 (SNOMED CT 2011_0131)
Item Group
Chief complaint (CC)
Abnormal GI Xray
Item
Abnormal GI Xray
boolean
C0521362 (UMLS CUI 2011AA)
MTHU031867 (LOINC Version 232)
C0000766 (UMLS CUI 2011AA)
10048065 (MedDRA 14.1)
Abdominal Pain
Item
Abdominal Pain
boolean
C0000737 (UMLS CUI 2011AA)
21522001 (SNOMED CT 2011_0131)
10000081 (MedDRA 14.1)
MTHU013636 (LOINC Version 232)
R10.9 (ICD-10-CM Version 2010)
789.0 (ICD-9-CM Version 2011)
E10460 (CTCAE 1105E)
Abnormal Weight Loss
Item
Abnormal weight loss (finding)
boolean
C0936227 (UMLS CUI 2011AA)
267024001 (SNOMED CT 2011_0131)
10000159 (MedDRA 14.1)
R63.4 (ICD-10-CM Version 2010)
Achalasia
Item
Achalasia
boolean
C1321756 (UMLS CUI 2011AA)
48531003 (SNOMED CT 2011_0131)
10000420 (MedDRA 14.1)
K22.0 (ICD-10-CM Version 2010)
Anemia
Item
Anaemia
boolean
C0002871 (UMLS CUI 2011AA)
271737000 (SNOMED CT 2011_0131)
10002034 (MedDRA 14.1)
MTHU020823 (LOINC Version 232)
D64.9 (ICD-10-CM Version 2010)
285.9 (ICD-9-CM Version 2011)
E10010 (CTCAE 1105E)
Ascites
Item
Ascites
boolean
C0003962 (UMLS CUI 2011AA)
389026000 (SNOMED CT 2011_0131)
10003445 (MedDRA 14.1)
R18 (ICD-10-CM Version 2010)
789.5 (ICD-9-CM Version 2011)
E10502 (CTCAE 1105E)
Change in Bowel Habits
Item
Irregular bowel habits
boolean
C2919545 (UMLS CUI 2011AA)
444702007 (SNOMED CT 2011_0131)
Hepatic Cirrhosis
Item
Liver Cirrhosis
boolean
C0023890 (UMLS CUI 2011AA)
19943007 (SNOMED CT 2011_0131)
10019641 (MedDRA 14.1)
K74.60 (ICD-10-CM Version 2010)
Colorectal Cancer Screening
Item
Screening for Colorectal Cancer
boolean
C0281185 (UMLS CUI 2011AA)
Common Bile Duct Leak
Item
Common Bile Duct Leak
boolean
79741001 (SNOMED CT 2011_0131)
MTHU011879 (LOINC Version 232)
C0400998 (UMLS CUI-1)
Common Bile Duct Stone
Item
Common Bile Duct Stone
boolean
C0009437 (UMLS CUI 2011AA)
79741001 (SNOMED CT 2011_0131)
MTHU011879 (LOINC Version 232)
C0006736 (UMLS CUI 2011AA)
56381008 (SNOMED CT 2011_0131)
MTHU003416 (LOINC Version 232)
Constipation
Item
Constipation
boolean
C0009806 (UMLS CUI 2011AA)
14760008 (SNOMED CT 2011_0131)
10010774 (MedDRA 14.1)
MTHU020768 (LOINC Version 232)
K59.0 (ICD-10-CM Version 2010)
564.0 (ICD-9-CM Version 2011)
E10562 (CTCAE 1105E)
Diarrhea
Item
Diarrhea
boolean
C0011991 (UMLS CUI 2011AA)
62315008 (SNOMED CT 2011_0131)
10012735 (MedDRA 14.1)
MTHU013347 (LOINC Version 232)
R19.7 (ICD-10-CM Version 2010)
787.91 (ICD-9-CM Version 2011)
E10572 (CTCAE 1105E)
Dyspepsia
Item
Indigestion
boolean
C0013395 (UMLS CUI 2011AA)
162031009 (SNOMED CT 2011_0131)
10013946 (MedDRA 14.1)
R10.13, K30 (ICD-10-CM Version 2010)
E10617 (CTCAE 1105E)
Dysphagia
Item
Deglutition Disorders
boolean
C0011168 (UMLS CUI 2011AA)
40739000 (SNOMED CT 2011_0131)
10013950 (MedDRA 14.1)
MTHU029874 (LOINC Version 232)
R13 (ICD-10-CM Version 2010)
787.2 (ICD-9-CM Version 2011)
E10621 (CTCAE 1105E)
Elevated Liver Function Tests
Item
Elevated Liver Function Tests
boolean
Esophageal Varices
Item
Oesophageal Varices
boolean
C0014867 (UMLS CUI 2011AA)
28670008 (SNOMED CT 2011_0131)
10030209 (MedDRA 14.1)
I85 (ICD-10-CM Version 2010)
Family History of Colon Cancer
Item
Family History of Colon Cancer
boolean
C0241889 (UMLS CUI 2011AA)
57177007 (SNOMED CT 2011_0131)
C0699790 (UMLS CUI 2011AA)
269533000 (SNOMED CT 2011_0131)
10009957 (MedDRA 14.1)
Family History of Polyps
Item
Family History of Polyps
boolean
Family History of Polyposis
Item
Family History of Polyposis
boolean
Foreign Body in Colon
Item
Foreign Body in Colon
boolean
C0016542 (UMLS CUI 2011AA)
125670008 (SNOMED CT 2011_0131)
10070245 (MedDRA 14.1)
C0009368 (UMLS CUI 2011AA)
71854001 (SNOMED CT 2011_0131)
MTHU003023 (LOINC Version 232)
Foreign Body in Esophagus
Item
Foreign Body in Esophagus
boolean
Foreign Body in Stomach
Item
Foreign Body in Stomach
boolean
C0016542 (UMLS CUI 2011AA)
125670008 (SNOMED CT 2011_0131)
10070245 (MedDRA 14.1)
C0038351 (UMLS CUI 2011AA)
69695003 (SNOMED CT 2011_0131)
MTHU003059 (LOINC Version 232)
Gastric Ulcer
Item
Peptic Ulcer
boolean
C0030920 (UMLS CUI 2011AA)
13200003 (SNOMED CT 2011_0131)
10034341 (MedDRA 14.1)
K27 (ICD-10-CM Version 2010)
GERD
Item
Gastroesophageal reflux disease (GERD)
boolean
C0017168 (UMLS CUI 2011AA)
235595009 (SNOMED CT 2011_0131)
10017885 (MedDRA 14.1)
K21 (ICD-10-CM Version 2010)
530.81 (ICD-9-CM Version 2011)
E10739 (CTCAE 1105E)
GI Bleeding
Item
Gastrointestinal Hemorrhage
boolean
C0017181 (UMLS CUI 2011AA)
74474003 (SNOMED CT 2011_0131)
10017955 (MedDRA 14.1)
K92.2 (ICD-10-CM Version 2010)
578 (ICD-9-CM Version 2011)
Hematemesis
Item
Haematemesis
boolean
C0018926 (UMLS CUI 2011AA)
8765009 (SNOMED CT 2011_0131)
10018830 (MedDRA 14.1)
K92.0 (ICD-10-CM Version 2010)
578.0 (ICD-9-CM Version 2011)
History of Barrett's
Item
History of Barrett's
boolean
History of Cholangiocarcinoma
Item
History of Cholangiocarcinoma
boolean
History of Colon Cancer
Item
History of Colon Cancer
boolean
C0262926 (UMLS CUI 2011AA)
417662000 (SNOMED CT 2011_0131)
MTHU027722 (LOINC Version 232)
C0699790 (UMLS CUI 2011AA)
269533000 (SNOMED CT 2011_0131)
10009957 (MedDRA 14.1)
History of Crohn's Disease
Item
History of Crohn's Disease
boolean
C0262926 (UMLS CUI 2011AA)
417662000 (SNOMED CT 2011_0131)
MTHU027722 (LOINC Version 232)
C0010346 (UMLS CUI 2011AA)
34000006 (SNOMED CT 2011_0131)
10011401 (MedDRA 14.1)
K50.9 (ICD-10-CM Version 2010)
History of Diverticulosis
Item
History of Diverticulosis
boolean
C0262926 (UMLS CUI 2011AA)
417662000 (SNOMED CT 2011_0131)
MTHU027722 (LOINC Version 232)
C1510475 (UMLS CUI 2011AA)
397881000 (SNOMED CT 2011_0131)
10013559 (MedDRA 14.1)
K57 (ICD-10-CM Version 2010)
562 (ICD-9-CM Version 2011)
History of Esophageal Cancer
Item
History of Esophageal Cancer
boolean
History of Esophageal/ Gastric Varicies
Item
History of Esophageal/ Gastric Varicies
boolean
History of Gastric Cancer
Item
History of Gastric Cancer
boolean
C0262926 (UMLS CUI 2011AA)
417662000 (SNOMED CT 2011_0131)
MTHU027722 (LOINC Version 232)
C0024623 (UMLS CUI 2011AA)
363349007 (SNOMED CT 2011_0131)
10017758 (MedDRA 14.1)
C16 (ICD-10-CM Version 2010)
151 (ICD-9-CM Version 2011)
History of Pancreatic Cancer
Item
History of Pancreatic Cancer
boolean
C0262926 (UMLS CUI 2011AA)
417662000 (SNOMED CT 2011_0131)
MTHU027722 (LOINC Version 232)
C0346647 (UMLS CUI 2011AA)
363418001 (SNOMED CT 2011_0131)
10033604 (MedDRA 14.1)
C25 (ICD-10-CM Version 2010)
157 (ICD-9-CM Version 2011)
History of Peptic Ulcer Disease
Item
History of Peptic Ulcer Disease
boolean
C0262926 (UMLS CUI 2011AA)
417662000 (SNOMED CT 2011_0131)
MTHU027722 (LOINC Version 232)
C0030920 (UMLS CUI 2011AA)
13200003 (SNOMED CT 2011_0131)
10034341 (MedDRA 14.1)
K27 (ICD-10-CM Version 2010)
533 (ICD-9-CM Version 2011)
History of Polyps
Item
History of Polyps
boolean
History of Ulcerative Colitis
Item
History of Ulcerative Colitis
boolean
C0262926 (UMLS CUI 2011AA)
417662000 (SNOMED CT 2011_0131)
MTHU027722 (LOINC Version 232)
C0302596 (UMLS CUI 2011AA)
64766004 (SNOMED CT 2011_0131)
10009900 (MedDRA 14.1)
K51 (ICD-10-CM Version 2010)
556 (ICD-9-CM Version 2011)
Hematochezia
Item
Blood in Stool
boolean
C0018932 (UMLS CUI 2011AA)
405729008 (SNOMED CT 2011_0131)
10018836 (MedDRA 14.1)
578.1 (ICD-9-CM Version 2011)
Iron Deficiency Anemia
Item
Iron Deficiency Anaemia
boolean
C0162316 (UMLS CUI 2011AA)
87522002 (SNOMED CT 2011_0131)
10022972 (MedDRA 14.1)
D50.0 (ICD-10-CM Version 2010)
280 (ICD-9-CM Version 2011)
Jaundice
Item
Icterus
boolean
C0022346 (UMLS CUI 2011AA)
18165001 (SNOMED CT 2011_0131)
10023126 (MedDRA 14.1)
R17 (ICD-10-CM Version 2010)
Melena
Item
Melaena
boolean
C0025222 (UMLS CUI 2011AA)
2901004 (SNOMED CT 2011_0131)
10027141 (MedDRA 14.1)
K92.1 (ICD-10-CM Version 2010)
Nausea
Item
Nausea
boolean
C0027497 (UMLS CUI 2011AA)
422587007 (SNOMED CT 2011_0131)
10028813 (MedDRA 14.1)
MTHU013524 (LOINC Version 232)
R11.0 (ICD-10-CM Version 2010)
E10878 (CTCAE 1105E)
Vomiting
Item
Emesis
boolean
C0042963 (UMLS CUI 2011AA)
249497008 (SNOMED CT 2011_0131)
10047700 (MedDRA 14.1)
MTHU013530 (LOINC Version 232)
R11.1 (ICD-10-CM Version 2010)
E11068 (CTCAE 1105E)
Occult/Guaiac Positive Stool
Item
Occult/Guaiac Positive Stool
boolean
C0201811 (UMLS CUI 2011AA)
104435004 (SNOMED CT 2011_0131)
10016297 (MedDRA 14.1)
Pancreatitis
Item
Pancreatitis
boolean
C0030305 (UMLS CUI 2011AA)
75694006 (SNOMED CT 2011_0131)
10033645 (MedDRA 14.1)
K85.9 (ICD-10-CM Version 2010)
577.0 (ICD-9-CM Version 2011)
E10930 (CTCAE 1105E)
Portal Hypertension
Item
Portal Hypertension
boolean
C0020541 (UMLS CUI 2011AA)
34742003 (SNOMED CT 2011_0131)
10036200 (MedDRA 14.1)
K76.6 (ICD-10-CM Version 2010)
572.3 (ICD-9-CM Version 2011)
E11238 (CTCAE 1105E)
Gastroesophageal Reflux
Item
gastric reflux
boolean
C0558176 (UMLS CUI 2011AA)
225587003 (SNOMED CT 2011_0131)
Weight Loss
Item
Abnormal weight loss
boolean
C0936227 (UMLS CUI 2011AA)
267024001 (SNOMED CT 2011_0131)
10000159 (MedDRA 14.1)
R63.4 (ICD-10-CM Version 2010)
Other
Item
Other
string
HISTORY OF PRESENT ILLNESS
Item
History of present illness
string
C0262512 (UMLS CUI 2011AA)
MTHU001399 (LOINC Version 232)
HOME MEDICATIONS
Item
Home Medications
string
C0013227 (UMLS CUI 2011AA)
Item Group
Physical examination
Temperature
Item
Temperature
float
246508008 (SNOMED CT 2011_0131)
MTHU009008 (LOINC Version 232)
C0039476 (UMLS CUI-1)
Pulse
Item
Pulse Rate
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)
General Apperance unremarkable
Item
General Apperance unremarkable
boolean
C1148438 (UMLS CUI 2011AA)
MTHU015040 (LOINC Version 232)
C0205307 (UMLS CUI 2011AA)
17621005 (SNOMED CT 2011_0131)
General Apperance text
Item
general appearance
string
C1148438 (UMLS CUI 2011AA)
MTHU015040 (LOINC Version 232)
HEENT within normal limits
Item
HEENT within normal limits
boolean
HEENT text
Item
Head, Ears, Eyes, Nose and Throat
string
C1512338 (UMLS CUI 2011AA)
Neck supple, no jugular vein distention
Item
Neck supple, no jugular vein distention
boolean
Neck text
Item
Neck, Collum, Cervical
string
C0027530 (UMLS CUI 2011AA)
45048000 (SNOMED CT 2011_0131)
MTHU002688 (LOINC Version 232)
Chest
Item
Chest, Thorax
string
C0817096 (UMLS CUI 2011AA)
51185008 (SNOMED CT 2011_0131)
Breast
Item
Mammary region
string
C0006141 (UMLS CUI 2011AA)
76752008 (SNOMED CT 2011_0131)
MTHU011382 (LOINC Version 232)
Heart S1 S2 present, Regular rhythm and rate
Item
Heart S1 S2 present, Regular rhythm and rate
boolean
Heart text
Item
Heart
string
C0018787 (UMLS CUI 2011AA)
80891009 (SNOMED CT 2011_0131)
MTHU001067 (LOINC Version 232)
Abdomen Soft, (+) Bowel sounds, Normal tone
Item
Abdomen Soft, (+) Bowel sounds, Normal tone
boolean
Abdomen text
Item
Abdomen
string
C0000726 (UMLS CUI 2011AA)
113345001 (SNOMED CT 2011_0131)
MTHU001425 (LOINC Version 232)
Lymph Nodes not palpable
Item
Lymph Nodes not palpable
boolean
Lymph Nodes text
Item
lymph nodes
string
C0024204 (UMLS CUI 2011AA)
59441001 (SNOMED CT 2011_0131)
MTHU015050 (LOINC Version 232)
GENITALIA/RECTAL
Item
GENITALIA/RECTAL
string
C0017420 (UMLS CUI 2011AA)
MTHU002681 (LOINC Version 232)
C0205052 (UMLS CUI 2011AA)
255582007 (SNOMED CT 2011_0131)
Extremities No clubbing, cyanosis or edema
Item
Extremities No clubbing, cyanosis or edema
boolean
Extremities text
Item
Extremities, Limb structure
string
C0015385 (UMLS CUI 2011AA)
66019005 (SNOMED CT 2011_0131)
MTHU001429 (LOINC Version 232)
Skin: No abnormalities detected
Item
Skin: No abnormalities detected
boolean
Skin text
Item
Integument
string
C1123023 (UMLS CUI 2011AA)
39937001 (SNOMED CT 2011_0131)
MTHU001414 (LOINC Version 232)
Neurological: No abnormalities detected
Item
Neurological: No abnormalities detected
boolean
Neurological text
Item
Neurologic system, Nervous system, Nervous system structure
string
C0027763 (UMLS CUI 2011AA)
25087005 (SNOMED CT 2011_0131)
MTHU001437 (LOINC Version 232)
ADMITTING DIAGNOSIS
Item
ADMITTING DIAGNOSIS (AD)
string
C0332133 (UMLS CUI 2011AA)
52870002 (SNOMED CT 2011_0131)
PLAN: Endoscopy
Item
PLAN: Endoscopy
string
ASA SCORE
Item
ASA score, Finding of American Society of Anesthesiologists physical status classification
integer
413347006 (SNOMED CT 2011_0131)
C1531480 (UMLS CUI-1)
Item
Teeth
text
245543004 (SNOMED CT 2011_0131)
MTHU021292 (LOINC Version 232)
C0040426 (UMLS CUI-1)
Code List
Teeth
CL Item
Normal (1)
17621005 (SNOMED CT 2011_0131)
C0205307 (UMLS CUI-1)
CL Item
Loose Teeth (2)
C0600028 (UMLS CUI-1)
CL Item
Dental Prosthesis(es) (3)
8060009 (SNOMED CT 2011_0131)
C0011394 (UMLS CUI-1)
CL Item
Co-Existing Dental Abnormalities (4)
C0262444 (UMLS CUI-1)
Item
Mallampati score
string
C0451276 (UMLS CUI 2011AA)
273585005 (SNOMED CT 2011_0131)
Code List
Mallampati score
CL Item
The soft palate, uvula, fauces, and pillars are visible (Class 1)
CL Item
The soft palate, uvula and fauces are visible (Class 2)
CL Item
The soft palate and base of uvula are visible (Class 3)
CL Item
The hard palate only is visible (Class 4)
NECK EXTENSION
Item
NECK EXTENSION
text
45048000 (SNOMED CT 2011_0131)
MTHU002688 (LOINC Version 232)
255536004 (SNOMED CT 2011_0131)
MTHU010348 (LOINC Version 232)
C0027530 (UMLS CUI-1)
C0231448 (UMLS CUI-2)
Item Group
past medical History, prior medical History
Medical History
Item
past medical History, prior medical History
string
C0262926 (UMLS CUI 2011AA)
417662000 (SNOMED CT 2011_0131)
MTHU027722 (LOINC Version 232)
Prior Surgeries
Item
Prior Surgery, History of (H/O) surgery, Past surgical history
string
C0455610 (UMLS CUI 2011AA)
161615003 (SNOMED CT 2011_0131)
Family history
Item
Family history (FH)
string
C0241889 (UMLS CUI 2011AA)
57177007 (SNOMED CT 2011_0131)
Social history
Item
Social and personal history, Social and personal circumstances
string
C0424945 (UMLS CUI 2011AA)
160476009 (SNOMED CT 2011_0131)
MTHU014081 (LOINC Version 232)

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