ID

14968

Beschreibung

https://www.hope-clara.de/ The HOPE Hospice and Palliative Care Recording standard documentation is used for documentation of palliative care and as an instrument for quality assurance in pallatiave wards, hospices and oncological wards as well as in ambulatory services and palliative teams.

Link

https://www.hope-clara.de/

Stichworte

Versionen (1)
  1. 10.05.16 10.05.16 -
Rechteinhaber

CC BY-NC 3.0

Hochgeladen am

10. Mai 2016

DOI

Für eine Beantragung loggen Sie sich ein.

Lizenz

Creative Commons BY-NC 3.0
Modell Kommentare :

Hier können Sie das Modell kommentieren. Über die Sprechblasen an den Itemgruppen und Items können Sie diese spezifisch kommentieren.

Zurück zu Modell Kommentaren
Itemgroup Kommentare für :

Item Kommentare für :

Um Formulare herunterzuladen müssen Sie angemeldet sein. Bitte loggen Sie sich ein oder registrieren Sie sich kostenlos.

Palliative and Hospice Care Thrombosis Prophylaxsis

Deutsch Englisch

Palliative and Hospice Care Thrombose Prophylaxsis

1 Formulare  
Form Information
Beschreibung

Form Information

Form number
Beschreibung

Form number

Datentyp

integer

Alias
UMLS CUI [1]
C0237753
Staff member filling out the form
Beschreibung

Staff member filling out the form

Datentyp

integer

Alias
UMLS CUI [1,1]
C1552089
UMLS CUI [1,2]
C3273494
other staff
Beschreibung

other staff

Datentyp

text

Alias
UMLS CUI [1,1]
C0851286
UMLS CUI [1,2]
C0205394
doctor specialization
Beschreibung

doctor specialization

Datentyp

integer

Alias
UMLS CUI [1,1]
C0031831
UMLS CUI [1,2]
C0237888
other specialization
Beschreibung

other specialization

Datentyp

text

Alias
UMLS CUI [1,1]
C0031831
UMLS CUI [1,2]
C0237888
UMLS CUI [1,3]
C0205394
Medication
Beschreibung

Medication

Alias
UMLS CUI-1
C0013227
anticoagulant drug
Beschreibung

anticoagulant drug

Datentyp

integer

Alias
UMLS CUI [1]
C0003280
heparin low-molecular
Beschreibung

heparin low-molecular

Datentyp

integer

Alias
UMLS CUI [1]
C0019139
unfractionated heparin
Beschreibung

unfractionated heparin

Datentyp

integer

Alias
UMLS CUI [1]
C2825026
heparinoids, other thrombin inhibitors
Beschreibung

heparinoids, other thrombin inhibitors

Datentyp

integer

Alias
UMLS CUI [1,1]
C0019142
UMLS CUI [1,2]
C0003440
ASS
Beschreibung

ASS

Datentyp

integer

Alias
UMLS CUI [1]
C0004057
oral vitamin k antagonist (e.g. phenprocoumon / marcumar)
Beschreibung

oral vitamin k antagonist

Datentyp

boolean

Alias
UMLS CUI [1]
C1096489
laboratory frequency
Beschreibung

laboratory frequency

Datentyp

integer

Alias
UMLS CUI [1,1]
C0022885
UMLS CUI [1,2]
C0439603
other anticoagulants, please specify
Beschreibung

other anticoagulants

Datentyp

text

Alias
UMLS CUI [1,1]
C0003280
UMLS CUI [1,2]
C0205394
Indication
Beschreibung

Indication

Alias
UMLS CUI-1
C3146298
so far no thromboembolism, now thrombophilic risk factors and therefore primary prophylaxis
Beschreibung

primary prophylaxis due to risk factors

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0040038
UMLS CUI [1,2]
C0035648
UMLS CUI [2]
C0199242
prior deep vein thrombosis, now continued secondary prophylaxis
Beschreibung

prior deep vein thrombosis

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0149871
UMLS CUI [1,2]
C0332152
UMLS CUI [2]
C0199176
prior pulmonary embolism, now continued secondary prophylaxis
Beschreibung

prior lung artery embolism

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0034065
UMLS CUI [1,2]
C0332152
UMLS CUI [2]
C0199176
current deep vein thrombosis, therefore new therapy
Beschreibung

current deep vein thrombosis, therefore new therapy

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0149871
UMLS CUI [1,2]
C0521116
UMLS CUI [2]
C3242274
diagnostic procedure for deep vein thrombosis
Beschreibung

diagnostic procedure for deep vein thrombosis

Datentyp

integer

Alias
UMLS CUI [1,1]
C0430022
UMLS CUI [1,2]
C0149871
current pulmonary artery embolism therefore new therapy
Beschreibung

current pulmonary artery embolism therefore new therapy

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0034065
UMLS CUI [1,2]
C0521116
UMLS CUI [2]
C3242274
diagnostic procedure for pulmonary embolism
Beschreibung

diagnostic procedure for pulmonary embolism

Datentyp

integer

Alias
UMLS CUI [1,1]
C0430022
UMLS CUI [1,2]
C0034065
arterial circulatory disorder
Beschreibung

arterial circulatory disorder

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0728936
UMLS CUI [1,2]
C0221464
coronary heart disease
Beschreibung

coronary heart disease

Datentyp

boolean

Alias
UMLS CUI [1]
C0010068
peripheral arterial disease
Beschreibung

peripheral arterial disease

Datentyp

boolean

Alias
UMLS CUI [1]
C1704436
cerebrovascular disorder
Beschreibung

cerebrovascular disorder

Datentyp

boolean

Alias
UMLS CUI [1]
C0007820
other indication please specify
Beschreibung

other indication

Datentyp

text

Alias
UMLS CUI [1,1]
C3146298
UMLS CUI [1,2]
C0205394
Risk factors for thromboembolism
Beschreibung

Risk factors for thromboembolism

neoplastic disease / advanced internal disease
Beschreibung

neoplastic disease / advanced internal disease

Datentyp

boolean

Alias
UMLS CUI [1,1]
C1709160
UMLS CUI [1,2]
C0012634
UMLS CUI [2]
C0679246
medication increasing thromboembolic risk (e.g. current chemotherapy, hormone therapy)
Beschreibung

medication increasing thromboembolic risk

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0013227
UMLS CUI [1,2]
C0040038
UMLS CUI [1,3]
C0035647
immobility (e.g. Karnofsky <40 / ECOG >3)
Beschreibung

immobility

Datentyp

boolean

Alias
UMLS CUI [1]
C0231441
paresis / plegia of one or more limb
Beschreibung

paresis / plegia of one or more limb

Datentyp

boolean

Alias
UMLS CUI [1]
C0030552
UMLS CUI [2]
C0522224
post surgery <30 days
Beschreibung

post surgery

Datentyp

boolean

Alias
UMLS CUI [1]
C0032790
port or other catheter system <30 days old
Beschreibung

port or other catheter system <30 days old

Datentyp

boolean

Alias
UMLS CUI [1]
C1608324
UMLS CUI [2]
C0085590
port or other catheter system >30 days old
Beschreibung

port or other catheter system >30 days old

Datentyp

boolean

Alias
UMLS CUI [1]
C1608324
UMLS CUI [2]
C0085590
other risk factors, please specify
Beschreibung

other risk factors

Datentyp

text

Alias
UMLS CUI [1,1]
C0035648
UMLS CUI [1,2]
C0205394
Standard procedures for palliative patients regarding anticoagulation
Beschreibung

Standard procedures for palliative patients regarding anticoagulation

are there written standards in your facility regarding anticoagulation?
Beschreibung

written standards regarding anticoagulation

Datentyp

integer

Alias
UMLS CUI [1,1]
C0449867
UMLS CUI [1,2]
C0237893
With what subjective success was anticoagulation performed?
Beschreibung

With what subjective success was anticoagulation performed?

no thromboembolism / no further thromboembolism
Beschreibung

no thromboembolism / no further thromboembolism

Datentyp

boolean

Alias
UMLS CUI [1]
C0040038
for current symptomatic thromboembolism
Beschreibung

current thromboembolism

Datentyp

integer

Alias
UMLS CUI [1,1]
C0040038
UMLS CUI [1,2]
C0521116
side effects
Beschreibung

side effects

Datentyp

boolean

Alias
UMLS CUI [1]
C0041755
what side effects?
Beschreibung

what side effects

Datentyp

text

Alias
UMLS CUI [1]
C0041755
no success (thromboembolic event despite prophylactic anticoagulation or worsening of pre-existing thromboembolism-associated conditions despite therapeutic anticoagulation)
Beschreibung

no success

Datentyp

boolean

Alias
UMLS CUI [1]
C1272703
was there a discontinuation of an anticoagulant drug during the documentation period?
Beschreibung

was there a discontinuation of an anticoagulant drug during the documentation period?

discontinuation of anticoagulant drug because of terminal stage
Beschreibung

discontinuation of anticoagulant drug because of terminal stage

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0003280
UMLS CUI [1,2]
C0457454
UMLS CUI [2]
C0205088
discontinuation of anticoagulant drug because of new risk-benefit-analysis due to progress of disease
Beschreibung

discontinuation of anticoagulant drug because of new risk-benefit-analysis

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0003280
UMLS CUI [1,2]
C0457454
UMLS CUI [2]
C0524785
discontinuation of anticoagulant drug because of increased risk of hemorrhage
Beschreibung

discontinuation of anticoagulant drug because of increased risk of hemorrhage

Datentyp

integer

Alias
UMLS CUI [1,1]
C0003280
UMLS CUI [1,2]
C0457454
UMLS CUI [2]
C3251812
platelets or quick value
Beschreibung

platelets or quick value

Datentyp

integer

Alias
UMLS CUI [1]
C0005821
UMLS CUI [2]
C0483455
discontinuation of anticoagulant drug because of hemorrhages (please specify the localization)
Beschreibung

discontinuation of anticoagulant drug because of hemorrhages (please specify the location)

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0003280
UMLS CUI [1,2]
C0457454
UMLS CUI [2]
C0019080
hemorrhage localization
Beschreibung

hemorrhage localization

Datentyp

text

Alias
UMLS CUI [1,1]
C0019080
UMLS CUI [1,2]
C0475264
discontinuation of anticoagulant drug because of patient wish / refusal
Beschreibung

discontinuation of anticoagulant drug because of patient wish / refusal

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0003280
UMLS CUI [1,2]
C0457454
UMLS CUI [2]
C0747309
discontinuation of anticoagulant drug because of other reasons (please specify)
Beschreibung

discontinuation of anticoagulant drug because of other reasons

Datentyp

text

Alias
UMLS CUI [1,1]
C0003280
UMLS CUI [1,2]
C0457454
UMLS CUI [2]
C3840932
no discontinuation of anticoagulant drug
Beschreibung

no discontinuation of anticoagulant drug

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0003280
UMLS CUI [1,2]
C0457454
no anticoagulant applied
Beschreibung

no anticoagulant applied

Datentyp

boolean

Alias
UMLS CUI [1]
C0003280
comments
Beschreibung

comments

Datentyp

text

Alias
UMLS CUI [1]
C0947611
Zum Seitenanfang zurückkehren

Ähnliche Modelle

Palliative and Hospice Care Thrombose Prophylaxsis

1 Formulare
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
Form Information
Form number
Item
Form number
integer
C0237753 (UMLS CUI [1])
Item
Staff member filling out the form
integer
C1552089 (UMLS CUI [1,1])
C3273494 (UMLS CUI [1,2])
Staff member filling out the form
Code List
Staff member filling out the form
CL Item
doctor (1)
CL Item
nursing staff (2)
CL Item
other staff: (3)
other staff
Item
other staff
text
C0851286 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
Item
doctor specialization
integer
C0031831 (UMLS CUI [1,1])
C0237888 (UMLS CUI [1,2])
doctor specialization
Code List
doctor specialization
CL Item
anaesthesia (1)
CL Item
general internal medicine (2)
CL Item
hematology/oncology (3)
CL Item
other specialization (4)
other specialization
Item
other specialization
text
C0031831 (UMLS CUI [1,1])
C0237888 (UMLS CUI [1,2])
C0205394 (UMLS CUI [1,3])
Item Group
Medication
C0013227 (UMLS CUI-1)
Item
anticoagulant drug
integer
C0003280 (UMLS CUI [1])
anticoagulant drugs
Code List
anticoagulant drug
CL Item
none (1)
CL Item
continued (2)
CL Item
modified (3)
CL Item
newly applied (4)
CL Item
discontinued (5)
Item
heparin low-molecular
integer
C0019139 (UMLS CUI [1])
heparin low-molecular
Code List
heparin low-molecular
CL Item
prophylactic dosage (e.g. Enoxaparin 1x 40mg s.c.) (1)
CL Item
therapeutic dosage (e.g. Enoxaparin 2x 80 mg weight-adapted) (2)
Item
unfractionated heparin
integer
C2825026 (UMLS CUI [1])
unfractionized heparin
Code List
unfractionated heparin
CL Item
prophylactic dosage (e.g. Heparin 2x 7500 IE s.c.) (1)
CL Item
therapeutic dosage (perfusor, aPTT-adapted) (2)
Item
heparinoids, other thrombin inhibitors
integer
C0019142 (UMLS CUI [1,1])
C0003440 (UMLS CUI [1,2])
heparinoids, other thrombin inhibitors
Code List
heparinoids, other thrombin inhibitors
CL Item
prophylactic dosage (1)
CL Item
therapeutic dosage (2)
Item
ASS
integer
C0004057 (UMLS CUI [1])
ASS
Code List
ASS
CL Item
100 mg pills (1)
CL Item
300 mg pills (2)
oral vitamin k antagonist
Item
oral vitamin k antagonist (e.g. phenprocoumon / marcumar)
boolean
C1096489 (UMLS CUI [1])
Item
laboratory frequency
integer
C0022885 (UMLS CUI [1,1])
C0439603 (UMLS CUI [1,2])
laboratory frequency
Code List
laboratory frequency
CL Item
more than once per week (1)
CL Item
once per week or less (2)
other anticoagulants
Item
other anticoagulants, please specify
text
C0003280 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
Item Group
Indication
C3146298 (UMLS CUI-1)
primary prophylaxis due to risk factors
Item
so far no thromboembolism, now thrombophilic risk factors and therefore primary prophylaxis
boolean
C0040038 (UMLS CUI [1,1])
C0035648 (UMLS CUI [1,2])
C0199242 (UMLS CUI [2])
prior deep vein thrombosis
Item
prior deep vein thrombosis, now continued secondary prophylaxis
boolean
C0149871 (UMLS CUI [1,1])
C0332152 (UMLS CUI [1,2])
C0199176 (UMLS CUI [2])
prior lung artery embolism
Item
prior pulmonary embolism, now continued secondary prophylaxis
boolean
C0034065 (UMLS CUI [1,1])
C0332152 (UMLS CUI [1,2])
C0199176 (UMLS CUI [2])
current deep vein thrombosis, therefore new therapy
Item
current deep vein thrombosis, therefore new therapy
boolean
C0149871 (UMLS CUI [1,1])
C0521116 (UMLS CUI [1,2])
C3242274 (UMLS CUI [2])
Item
diagnostic procedure for deep vein thrombosis
integer
C0430022 (UMLS CUI [1,1])
C0149871 (UMLS CUI [1,2])
diagnostic procedure for deep vein thrombosis
Code List
diagnostic procedure for deep vein thrombosis
CL Item
duplex ultrasound (1)
CL Item
display via venous contrast medium (2)
CL Item
computer tomography (3)
CL Item
suspected diagnosis due to clinical criteria (4)
current pulmonary artery embolism therefore new therapy
Item
current pulmonary artery embolism therefore new therapy
boolean
C0034065 (UMLS CUI [1,1])
C0521116 (UMLS CUI [1,2])
C3242274 (UMLS CUI [2])
Item
diagnostic procedure for pulmonary embolism
integer
C0430022 (UMLS CUI [1,1])
C0034065 (UMLS CUI [1,2])
diagnostic procedure for pulmonary embolism
Code List
diagnostic procedure for pulmonary embolism
CL Item
computer tomography (1)
CL Item
V/Q radio imaging (2)
CL Item
angiography of arteria pulmonalis (3)
CL Item
suspected diagnosis due to clinical criteria (4)
arterial circulatory disorder
Item
arterial circulatory disorder
boolean
C0728936 (UMLS CUI [1,1])
C0221464 (UMLS CUI [1,2])
coronary heart disease
Item
coronary heart disease
boolean
C0010068 (UMLS CUI [1])
peripheral arterial disease
Item
peripheral arterial disease
boolean
C1704436 (UMLS CUI [1])
cerebrovascular disorder
Item
cerebrovascular disorder
boolean
C0007820 (UMLS CUI [1])
other indication
Item
other indication please specify
text
C3146298 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
Item Group
Risk factors for thromboembolism
neoplastic disease / advanced internal disease
Item
neoplastic disease / advanced internal disease
boolean
C1709160 (UMLS CUI [1,1])
C0012634 (UMLS CUI [1,2])
C0679246 (UMLS CUI [2])
medication increasing thromboembolic risk
Item
medication increasing thromboembolic risk (e.g. current chemotherapy, hormone therapy)
boolean
C0013227 (UMLS CUI [1,1])
C0040038 (UMLS CUI [1,2])
C0035647 (UMLS CUI [1,3])
immobility
Item
immobility (e.g. Karnofsky <40 / ECOG >3)
boolean
C0231441 (UMLS CUI [1])
paresis / plegia of one or more limb
Item
paresis / plegia of one or more limb
boolean
C0030552 (UMLS CUI [1])
C0522224 (UMLS CUI [2])
post surgery
Item
post surgery <30 days
boolean
C0032790 (UMLS CUI [1])
port or other catheter system <30 days old
Item
port or other catheter system <30 days old
boolean
C1608324 (UMLS CUI [1])
C0085590 (UMLS CUI [2])
port or other catheter system >30 days old
Item
port or other catheter system >30 days old
boolean
C1608324 (UMLS CUI [1])
C0085590 (UMLS CUI [2])
other risk factors
Item
other risk factors, please specify
text
C0035648 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
Item Group
Standard procedures for palliative patients regarding anticoagulation
Item
are there written standards in your facility regarding anticoagulation?
integer
C0449867 (UMLS CUI [1,1])
C0237893 (UMLS CUI [1,2])
written standards regarding anticoagulation
Code List
are there written standards in your facility regarding anticoagulation?
CL Item
yes (1)
CL Item
no (2)
CL Item
unknown (3)
Item Group
With what subjective success was anticoagulation performed?
no thromboembolism / no further thromboembolism
Item
no thromboembolism / no further thromboembolism
boolean
C0040038 (UMLS CUI [1])
Item
for current symptomatic thromboembolism
integer
C0040038 (UMLS CUI [1,1])
C0521116 (UMLS CUI [1,2])
current thromboembolism
Code List
for current symptomatic thromboembolism
CL Item
detumescence of possible bulge (1)
CL Item
contribution to reduction of pain (2)
CL Item
contribution to treatment of dyspnea (3)
side effects
Item
side effects
boolean
C0041755 (UMLS CUI [1])
what side effects
Item
what side effects?
text
C0041755 (UMLS CUI [1])
no success
Item
no success (thromboembolic event despite prophylactic anticoagulation or worsening of pre-existing thromboembolism-associated conditions despite therapeutic anticoagulation)
boolean
C1272703 (UMLS CUI [1])
Item Group
was there a discontinuation of an anticoagulant drug during the documentation period?
discontinuation of anticoagulant drug because of terminal stage
Item
discontinuation of anticoagulant drug because of terminal stage
boolean
C0003280 (UMLS CUI [1,1])
C0457454 (UMLS CUI [1,2])
C0205088 (UMLS CUI [2])
discontinuation of anticoagulant drug because of new risk-benefit-analysis
Item
discontinuation of anticoagulant drug because of new risk-benefit-analysis due to progress of disease
boolean
C0003280 (UMLS CUI [1,1])
C0457454 (UMLS CUI [1,2])
C0524785 (UMLS CUI [2])
Item
discontinuation of anticoagulant drug because of increased risk of hemorrhage
integer
C0003280 (UMLS CUI [1,1])
C0457454 (UMLS CUI [1,2])
C3251812 (UMLS CUI [2])
discontinuation of anticoagulant drug because of increased risk of hemorrhage
Code List
discontinuation of anticoagulant drug because of increased risk of hemorrhage
CL Item
thrombocytopenia (please enter the value in the following item) (1)
CL Item
hepatic failure (please enter the Quick value in the following item) (2)
CL Item
exulcerating tumor (3)
platelets or quick value
Item
platelets or quick value
integer
C0005821 (UMLS CUI [1])
C0483455 (UMLS CUI [2])
discontinuation of anticoagulant drug because of hemorrhages (please specify the location)
Item
discontinuation of anticoagulant drug because of hemorrhages (please specify the localization)
boolean
C0003280 (UMLS CUI [1,1])
C0457454 (UMLS CUI [1,2])
C0019080 (UMLS CUI [2])
hemorrhage localization
Item
hemorrhage localization
text
C0019080 (UMLS CUI [1,1])
C0475264 (UMLS CUI [1,2])
discontinuation of anticoagulant drug because of patient wish / refusal
Item
discontinuation of anticoagulant drug because of patient wish / refusal
boolean
C0003280 (UMLS CUI [1,1])
C0457454 (UMLS CUI [1,2])
C0747309 (UMLS CUI [2])
discontinuation of anticoagulant drug because of other reasons
Item
discontinuation of anticoagulant drug because of other reasons (please specify)
text
C0003280 (UMLS CUI [1,1])
C0457454 (UMLS CUI [1,2])
C3840932 (UMLS CUI [2])
no discontinuation of anticoagulant drug
Item
no discontinuation of anticoagulant drug
boolean
C0003280 (UMLS CUI [1,1])
C0457454 (UMLS CUI [1,2])
no anticoagulant applied
Item
no anticoagulant applied
boolean
C0003280 (UMLS CUI [1])
comments
Item
comments
text
C0947611 (UMLS CUI [1])
Zum Seitenanfang zurückkehren 

Kontakt

Benutzen Sie dieses Formular für Rückmeldungen, Fragen und Verbesserungsvorschläge.

Mit * gekennzeichnete Felder sind notwendig.

Hilfe

Benötigen Sie Hilfe bei der Suche? Um mehr Details zu erfahren und die Suche effektiver nutzen zu können schauen Sie sich doch das entsprechende Video auf unserer Tutorial Seite an.

Zum Video