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Falhas:
ID
14968
Descrição
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.
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Palavras-chave
Versões (1)
- 10/05/2016 10/05/2016 -
Titular dos direitos
CC BY-NC 3.0
Transferido a
10 de maio de 2016
DOI
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Licença
Creative Commons BY-NC 3.0
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Palliative and Hospice Care Thrombosis Prophylaxsis
Palliative and Hospice Care Thrombose Prophylaxsis
- StudyEvent: ODM
Similar models
Palliative and Hospice Care Thrombose Prophylaxsis
- StudyEvent: ODM
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de dados
Alias
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])
C3273494 (UMLS CUI [1,2])
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])
C0205394 (UMLS CUI [1,2])
Item
doctor specialization
integer
C0031831 (UMLS CUI [1,1])
C0237888 (UMLS CUI [1,2])
C0237888 (UMLS CUI [1,2])
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])
C0237888 (UMLS CUI [1,2])
C0205394 (UMLS CUI [1,3])
CL Item
none (1)
CL Item
continued (2)
CL Item
modified (3)
CL Item
newly applied (4)
CL Item
discontinued (5)
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)
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])
C0003440 (UMLS CUI [1,2])
CL Item
prophylactic dosage (1)
CL Item
therapeutic dosage (2)
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])
C0439603 (UMLS CUI [1,2])
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])
C0205394 (UMLS CUI [1,2])
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])
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])
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])
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])
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])
C0149871 (UMLS CUI [1,2])
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])
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])
C0034065 (UMLS CUI [1,2])
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])
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])
C0205394 (UMLS CUI [1,2])
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])
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])
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])
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])
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])
C0085590 (UMLS CUI [2])
other risk factors
Item
other risk factors, please specify
text
C0035648 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
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])
C0237893 (UMLS CUI [1,2])
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])
C0521116 (UMLS CUI [1,2])
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])
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])
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])
C0457454 (UMLS CUI [1,2])
C3251812 (UMLS CUI [2])
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])
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])
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])
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])
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])
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])
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])