Informationen:
Fehler:
ID
11319
Beschreibung
Items used as routine documentation by the university hospital muenster. Derived from original form "DAST Entlassung PSYCH MS", converted to ODM format.
Stichworte
Versionen (2)
- 30.06.15 30.06.15 -
- 30.06.15 30.06.15 -
Hochgeladen am
30. Juni 2015
DOI
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Creative Commons BY-NC 3.0 Legacy
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DAST Basic Documentation_Discharge
DAST Basic Documentation_Discharge
- StudyEvent: ODM
Ähnliche Modelle
DAST Basic Documentation_Discharge
- StudyEvent: ODM
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Patient's name
Item
Name of the patient:
text
C1299487 (UMLS CUI-1)
Date of birth
Item
Date of birth:
date
C0421451 (UMLS CUI-1)
Date of admission
Item
Date of admission:
date
C0011008 (UMLS CUI-1)
C0019994 (UMLS CUI-2)
C0809949 (UMLS CUI-3)
C0019994 (UMLS CUI-2)
C0809949 (UMLS CUI-3)
Date of entry
Item
Date of entry:
date
C0807937 (UMLS CUI-1)
Pharmacotherapy
Item
Pharmacotherapy:
boolean
C0013216 (UMLS CUI-1)
Electroconvulsive therapy
Item
Electroconvulsive therapy:
boolean
C0013806 (UMLS CUI-1)
Sleep deprivation
Item
Sleep deprivation:
boolean
C0037316 (UMLS CUI-1)
Light therapy
Item
Light therapy:
boolean
C0031765 (UMLS CUI-1)
None
Item
None:
boolean
C0549184 (UMLS CUI-1)
Others
Item
Others:
boolean
C0205394 (UMLS CUI-1)
None
Item
None:
boolean
C0549184 (UMLS CUI-1)
Individual sessions
Item
Number of individual sessions less than 30 minutes:
integer
Individual sessions
Item
Number of individual sessions more than 30 minutes:
integer
Group sessions
Item
Number of sessions in group:
integer
No psychotherapy
Item
No psychotherapy:
boolean
C1298908 (UMLS CUI-1)
C0033968 (UMLS CUI-2)
C0033968 (UMLS CUI-2)
Supportive psychotherapy
Item
Supportive psychotherapy:
boolean
C0221295 (UMLS CUI-1)
Psychodynamic Therapy
Item
Psychodynamic therapy:
boolean
C0599237 (UMLS CUI-1)
Cognitive behavioral therapy
Item
Cognitive behavioral therapy :
boolean
C0579049 (UMLS CUI-1)
C1998288 (UMLS CUI-2)
C1998288 (UMLS CUI-2)
Person-centered therapy
Item
Roger's Person-centered therapy/ Client-centered therapy :
boolean
C0028302 (UMLS CUI-1)
Interpersonal psychotherapy
Item
Interpersonal psychotherapy:
boolean
C0871787 (UMLS CUI-1)
Psychodynamic- interactional group therapy
Item
Psychodynamic- interactional group therapy:
boolean
Others
Item
Others:
boolean
C0205394 (UMLS CUI-1)
Unknown
Item
Unknown:
boolean
C0439673 (UMLS CUI-1)
None
Item
None:
boolean
C0549184 (UMLS CUI-1)
Psychoeducation
Item
Psychoeducation (Individual/ Group):
boolean
Cognitive Training
Item
Cognitive training (Individual/ Group):
boolean
C1868940 (UMLS CUI-1)
Relaxation training
Item
Relaxation training (Individual/ Group):
boolean
C0282333 (UMLS CUI-1)
Social skills training
Item
Social skills training (Group):
boolean
C0150777 (UMLS CUI-1)
Symptom Management Training
Item
Symptom management training (Group/ Individual):
boolean
Behavioral therapy group members
Item
Behavioral therapy group members:
boolean
Others
Item
Others:
boolean
C0205394 (UMLS CUI-1)
Item Group
Medication, ECG and Weight
C0013227 (UMLS CUI-1)
C0013798 (UMLS CUI-2)
C0043100 (UMLS CUI-3)
C0013798 (UMLS CUI-2)
C0043100 (UMLS CUI-3)
Medication name
Item
Medication name (prescribed due to somatic indications):
text
C2360065 (UMLS CUI-1)
Medication dose
Item
Medication dose (prescribed due to somatic indications in mg or ml):
text
C3174092 (UMLS CUI-1)
Medication name
Item
Medication name (prescribed due to psychiatric indications):
text
C2360065 (UMLS CUI-1)
Medication dose
Item
Medication dose (prescribed due to psychiatric indications in mg or ml):
text
C3174092 (UMLS CUI-1)
Electrocardiogram
Item
QTC- Interval in electrocardiogram (in seconds):
float
C1623258 (UMLS CUI-1)
Weight
Item
Weight (in kg):
float
C0005910 (UMLS CUI-1)
Item Group
Problems in the psychotherapy
C0033968 (UMLS CUI-1)
C0033213 (UMLS CUI-2)
C0033213 (UMLS CUI-2)
None
Item
None:
boolean
C0549184 (UMLS CUI-1)
Motivational change
Item
Lack of change in motivation:
boolean
C0456814 (UMLS CUI-1)
C0026605 (UMLS CUI-2)
C1705241 (UMLS CUI-3)
C0026605 (UMLS CUI-2)
C1705241 (UMLS CUI-3)
Symptom worsening
Item
Worsening of symptoms:
boolean
Therapy termination
Item
Therapy termination (by the therapist) for other reasons. Please mention the reason:
text
C0087111 (UMLS CUI-1)
C1283212 (UMLS CUI-2)
C1283212 (UMLS CUI-2)
Others
Item
Others, please mention specifically:
text
C0205394 (UMLS CUI-1)
Unknown
Item
Unknown/ Undecided:
boolean
C0439673 (UMLS CUI-1)
Day-care hospital
Item
Day-care hospital:
boolean
C0587439 (UMLS CUI-1)
C0420529 (UMLS CUI-2)
C0420529 (UMLS CUI-2)
Ambulatory treatment
Item
Ambulatory treatment:
boolean
C0002423 (UMLS CUI-1)
Psychiatric clinic
Item
Other psychiatric clinics:
boolean
C0205487 (UMLS CUI-1)
C0442592 (UMLS CUI-2)
C0442592 (UMLS CUI-2)
Psychotherapeutic or Somatic clinics
Item
Psychotherapeutic or Somatic clinics:
boolean
C0033968 (UMLS CUI-1)
C2986476 (UMLS CUI-2)
C0442592 (UMLS CUI-3)
C2986476 (UMLS CUI-2)
C0442592 (UMLS CUI-3)
Addict hospitalization
Item
Hospitalization for addicts:
boolean
C0858354 (UMLS CUI-1)
C0019993 (UMLS CUI-2)
C0019993 (UMLS CUI-2)
Others
Item
Others
boolean
C0205394 (UMLS CUI-1)
Item Group
Ambulatory aftercare services and Follow-up care services
C0002423 (UMLS CUI-1)
C0001758 (UMLS CUI-2)
C0001758 (UMLS CUI-2)
None
Item
None:
boolean
C0549184 (UMLS CUI-1)
CL Item
No (1)
CL Item
Yes, contacted (2)
CL Item
Yes, not contacted (3)
CL Item
No (1)
CL Item
Yes, contacted (2)
CL Item
Yes, not contacted (3)
CL Item
No (1)
CL Item
Yes, contacted (2)
CL Item
Yes, not contacted (3)
CL Item
No (1)
CL Item
Yes, contacted (2)
CL Item
Yes, not contacted (3)
Item
Other psychiatric outpatient departments:
text
C0205394 (UMLS CUI-1)
C0205487 (UMLS CUI-2)
C0557824 (UMLS CUI-3)
C0205487 (UMLS CUI-2)
C0557824 (UMLS CUI-3)
CL Item
No (1)
CL Item
Yes, contacted (2)
CL Item
Yes, not contacted (3)
CL Item
No (1)
CL Item
Yes, contacted (2)
CL Item
Yes, not contacted (3)
CL Item
No (1)
CL Item
Yes, contacted (2)
CL Item
Yes, not contacted (3)
Self-help group
Item
Self-help group:
boolean
C0424946 (UMLS CUI-1)
Ambulatory care nursing
Item
Ambulatory care nursing:
boolean
Vocational Rehabilitation
Item
Vocational rehabilitation:
boolean
C0034996 (UMLS CUI-1)
Assisted living residence
Item
Assisted living residence:
boolean
Forensics
Item
Forensics:
boolean
Day- care
Item
Day- care:
boolean
C0175952 (UMLS CUI-1)
Others
Item
Others:
boolean
C0205394 (UMLS CUI-1)
Unknown
Item
Unknown:
boolean
C0439673 (UMLS CUI-1)
Psychiatric diagnosis
Item
Psychiatric diagnosis according to ICD-10:
text
C0376338 (UMLS CUI-1)
Psychiatric diagnosis
Item
Psychiatric diagnosis according to DSM- IV:
text
C0376338 (UMLS CUI-1)
Somatic diagnosis
Item
Somatic diagnosis:
text
C2986476 (UMLS CUI-1)
C0011900 (UMLS CUI-2)
C0011900 (UMLS CUI-2)
Item
Clinical Global Impression (Severity of illness), please consider the patient's condition only from the last week:
text
C0521117 (UMLS CUI-1)
Code List
Clinical Global Impression (Severity of illness), please consider the patient's condition only from the last week:
CL Item
0 Can not be assessed. (1)
CL Item
1 Patient is not ill. (2)
CL Item
2 Patient is a borderline case of psychiatric disease. (3)
CL Item
3 Patient is mildly ill. (4)
CL Item
4 Patient is moderately ill. (5)
CL Item
5 Patient is clearly ill. (6)
CL Item
6 Patient is severly ill. (7)
Item
Clinical Global Impression Scale of Change (CGI-C), please consider the overall change in patient's condition between the last time's and the present visit:
text
Code List
Clinical Global Impression Scale of Change (CGI-C), please consider the overall change in patient's condition between the last time's and the present visit:
CL Item
0 Condition can not be assessed. (1)
CL Item
1 Condition is very good. (2)
CL Item
2 Condition is much better. (3)
CL Item
3 Condition is little better. (4)
CL Item
4 Condition is unchanged. (5)
CL Item
5 Condition is slightly worse. (6)
CL Item
6 Condition is much worse. (7)
Item
Therapeutic effectiveness (desired drug effects):
text
C0087113 (UMLS CUI-1)
Code List
Therapeutic effectiveness (desired drug effects):
CL Item
0 Can not be assessed. (1)
CL Item
1 Very good- extensive recovery, complete or nearly complete remission of all symptoms. (2)
CL Item
2 Moderate- clear recovery, partial remission of symptoms. (3)
CL Item
3 Low- slight recovery, a further treatment is required. (4)
CL Item
4 Condition unchanged or worsened. (5)
Item
Adverse effects (therapeutic risk):
text
C0879626 (UMLS CUI-1)
CL Item
0 Can not be assessed. (1)
CL Item
1 None. (2)
CL Item
2 No significant effects on patient. (3)
CL Item
3 Significant effects on patient. (4)
CL Item
4 Outweighs the therapeutic efficacy. (5)
Item Group
Global Assessment of Functioning (GAF) Scale
C0561904 (UMLS CUI-1)
Item
Please select the score range based on the Global Assessment of Functioning (GAF) Scale. The evaluation of the GAF scale should relate to the period of last week before admission:
text
C0561904 (UMLS CUI-1)
Code List
Please select the score range based on the Global Assessment of Functioning (GAF) Scale. The evaluation of the GAF scale should relate to the period of last week before admission:
CL Item
100-91 Superior functioning in all areas. (1)
CL Item
90-81 Good functioning in all areas. (2)
CL Item
80-71 No more than slight impairment. (3)
CL Item
70-61 Some difficulty. (4)
CL Item
60-51 Moderate difficulty. (5)
CL Item
50-41 Serious impairment. (6)
CL Item
40-31 Major impairment in several areas. (7)
CL Item
30-21 Inability to function in almost all areas. (8)
CL Item
20-11 Some danger of hurting self or others. (9)
CL Item
10-1 Permanent risk or persistent inability. (10)
CL Item
0 Inadequate information. (11)
Score
Item
Patient's score:
float
C0030705 (UMLS CUI-1)
C0018684 (UMLS CUI-2)
C0449820 (UMLS CUI-3)
C0018684 (UMLS CUI-2)
C0449820 (UMLS CUI-3)
CL Item
Not specified (1)
CL Item
Is available (2)
CL Item
Patient is severely ill. (3)
CL Item
Denied (4)
CL Item
Others (5)
CL Item
Not specified (1)
CL Item
Is available (2)
CL Item
Patient is severely ill. (3)
CL Item
Denied (4)
CL Item
Others (5)
CL Item
Not specified (1)
CL Item
Is available (2)
CL Item
Patient is severely ill. (3)
CL Item
Denied (4)
CL Item
Others (5)
Others
Item
Others:
text
C0205394 (UMLS CUI-1)