ID

15307

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 (2)
  1. 26.05.16 26.05.16 -
  2. 20.09.21 20.09.21 -
Rechteinhaber

CC BY-NC 3.0

Hochgeladen am

26. Mai 2016

DOI

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Creative Commons BY-NC 3.0
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Palliative and Hospice Care Liverpool Care Pathway Short Version

Deutsch Englisch

Palliative and Hospice Care Liverpool Care Pathway Short Version

1 Formulare  
Main diagnosis
Beschreibung

Main diagnosis

Alias
UMLS CUI-1
C0011900
Main diagnosis
Beschreibung

Main diagnosis

Datentyp

text

Alias
UMLS CUI [1]
C0011900
Initial status
Beschreibung

Initial status

Current medication has been reviewed, not necessarily required medication has been stopped
Beschreibung

current medication

Datentyp

boolean

Alias
UMLS CUI [1]
C1553892
subcutaneous medication for the following symptoms has been prescribed if needed according to the existing guidelines
Beschreibung

medication if needed

Datentyp

boolean

Alias
UMLS CUI [1]
C0013227
pain - analgesics
Beschreibung

pain - analgesics

Datentyp

boolean

Alias
UMLS CUI [1]
C0030193
UMLS CUI [2]
C0002771
nausea and emesis - antiemetics
Beschreibung

nausea and emesis - antiemetics

Datentyp

boolean

Alias
UMLS CUI [1]
C0042963
UMLS CUI [2]
C0027497
UMLS CUI [3]
C0003297
agitation - tranquilizers
Beschreibung

agitation - tranquilizers

Datentyp

boolean

Alias
UMLS CUI [1]
C0085631
UMLS CUI [2]
C0040614
bronchial secretion - anticholinergics
Beschreibung

bronchial secretion - anticholinergics

Datentyp

boolean

Alias
UMLS CUI [1]
C1511332
UMLS CUI [2]
C0242896
dyspnea - opioids, anxiolytics
Beschreibung

dyspnea - opioids, anxiolytics

Datentyp

boolean

Alias
UMLS CUI [1]
C0013404
UMLS CUI [2]
C0242402
UMLS CUI [3]
C0040616
the following unnecessary medical procedures were stopped:
Beschreibung

unnecessary procedures

Datentyp

boolean

Alias
UMLS CUI [1]
C0376708
blood withdrawal
Beschreibung

blood withdrawal

Datentyp

integer

Alias
UMLS CUI [1]
C0005834
antibiotics
Beschreibung

antibiotics

Datentyp

integer

Alias
UMLS CUI [1]
C0003232
intravenous (liquids/medications)
Beschreibung

intravenous

Datentyp

integer

Alias
UMLS CUI [1]
C0348016
cardiopulmonary resuscitation
Beschreibung

cardiopulmonary resuscitation

Datentyp

boolean

Alias
UMLS CUI [1]
C0007203
unnecessary nursing procedures were stopped
Beschreibung

unnecessary nursing procedures

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0376708
UMLS CUI [1,2]
C0204636
subcutaneous syringe pump was started 4 hours at most after doctor's instruction
Beschreibung

subcutaneous syringe pump

Datentyp

integer

Alias
UMLS CUI [1,1]
C0181332
UMLS CUI [1,2]
C0443315
UMLS CUI [2]
C0040223
Psychological insight
Beschreibung

Psychological insight

the patient's ability to communicate in German was assessed as adequate
Beschreibung

adequate communication in German

Datentyp

integer

Alias
UMLS CUI [1,1]
C0017477
UMLS CUI [1,2]
C0009452
UMLS CUI [1,3]
C0205411
the patient's family's / other people's ability to communicate in German was assessed as adequate
Beschreibung

family's ability to communicate in German

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0017477
UMLS CUI [1,2]
C0009452
UMLS CUI [1,3]
C0205411
patient awareness of the diagnosis
Beschreibung

patient awareness of the diagnosis

Datentyp

integer

Alias
UMLS CUI [1,1]
C0004448
UMLS CUI [1,2]
C0011900
UMLS CUI [1,3]
C0030705
family/other awareness of the diagnosis
Beschreibung

family/other awareness of the diagnosis

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0004448
UMLS CUI [1,2]
C0011900
UMLS CUI [1,3]
C0015576
patient awareness of dying
Beschreibung

patient awareness of dying

Datentyp

integer

Alias
UMLS CUI [1,1]
C0004448
UMLS CUI [1,2]
C0184532
UMLS CUI [1,3]
C0030705
family/other awareness of dying
Beschreibung

family/other awareness of dying

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0004448
UMLS CUI [1,2]
C0184532
UMLS CUI [1,3]
C0015576
Religious/spiritual assistance
Beschreibung

Religious/spiritual assistance

Patient defined religious/spiritual needs
Beschreibung

Patient defined religious/spiritual needs

Datentyp

integer

Alias
UMLS CUI [1,1]
C0027552
UMLS CUI [1,2]
C0150355
UMLS CUI [1,3]
C0030705
family/others defined religious/spiritual needs
Beschreibung

family/others defined religious/spiritual needs

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0027552
UMLS CUI [1,2]
C0150355
UMLS CUI [1,3]
C0015576
Communication between family/others and nursing team
Beschreibung

Communication between family/others and nursing team

it was settled how the family/other people close to the patient should be informed about the patient's death
Beschreibung

information about patient death

Datentyp

boolean

Alias
UMLS CUI [1,1]
C1306577
UMLS CUI [1,2]
C1533716
UMLS CUI [1,3]
C0015576
the family/other people close to the patient received information about the following matters: drive and parking, lodging, drinks, phone, lavatories and toilets, visiting hours, other important information
Beschreibung

information about important matters

Datentyp

boolean

Alias
UMLS CUI [1]
C1533716
UMLS CUI [2]
C0030566
UMLS CUI [3]
C1556029
UMLS CUI [4]
C0452428
UMLS CUI [5]
C0039457
UMLS CUI [6]
C0558278
UMLS CUI [7]
C0040364
UMLS CUI [8]
C1547409
general practitioner was informed about the patient's current state
Beschreibung

general practitioner informed about current state

Datentyp

boolean

Alias
UMLS CUI [1]
C0017319
UMLS CUI [2]
C3166194
UMLS CUI [3]
C1533716
the care plan was explained and discussed with the patient
Beschreibung

care plan explained to patient

Datentyp

integer

Alias
UMLS CUI [1,1]
C0178916
UMLS CUI [1,2]
C0681841
UMLS CUI [1,3]
C0030705
the care plan was explained and discussed with the family/other people
Beschreibung

care plan explained to family/other people

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0178916
UMLS CUI [1,2]
C0681841
UMLS CUI [1,3]
C0015576
the family/other people close to the patient confirmed that they understood the care plan
Beschreibung

family/other people confirmed understanding of care plan

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0015576
UMLS CUI [1,2]
C0750484
UMLS CUI [1,3]
C0162340
UMLS CUI [1,4]
C0178916
assistance after death
Beschreibung

assistance after death

general practitioner was informed about the patient's death
Beschreibung

general practitioner was informed about the patients death

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0017319
UMLS CUI [1,2]
C1522154
UMLS CUI [1,3]
C1306577
procedures for the laying-out were performed according to the in-house regulations
Beschreibung

laying-out procedures

Datentyp

boolean

Alias
UMLS CUI [1]
C2700391
procedures after death were discussed or performed
Beschreibung

procedures after death

Datentyp

boolean

Alias
UMLS CUI [1,1]
C2700391
UMLS CUI [1,2]
C1306577
patient suffered from an infectious disease
Beschreibung

infectious disease

Datentyp

boolean

Alias
UMLS CUI [1]
C0009450
patient had special needs regarding religious rituals
Beschreibung

special needs regarding religious rituals

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0871403
UMLS CUI [1,2]
C0237841
autopsy was clarified
Beschreibung

autopsy

Datentyp

boolean

Alias
UMLS CUI [1]
C0004398
family/other people close to the patient were informed about the procedures in the hospital
Beschreibung

information about procedures in hospital

Datentyp

boolean

Alias
UMLS CUI [1,1]
C2700391
UMLS CUI [1,2]
C0019994
UMLS CUI [2]
C1533716
UMLS CUI [3]
C0015576
hospital guidelines regarding articles of value and patient's belongings were followed
Beschreibung

articles of value and patient belongings

Datentyp

boolean

Alias
UMLS CUI [1]
C0162791
UMLS CUI [2]
C2347695
necessary documentation and references were passed on to the respective person
Beschreibung

documentation and references

Datentyp

boolean

Alias
UMLS CUI [1]
C0920316
UMLS CUI [2]
C0586393
brochure with information about grieving process was handed out
Beschreibung

brochure with information about grieving process

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0949917
UMLS CUI [1,2]
C0018235
Documentation
Beschreibung

Documentation

Alias
UMLS CUI-1
C0920316
Were the following symptoms frequently (meaning every 4 hours or at each patient contact) assessed?
Beschreibung

symptom assessment

Datentyp

boolean

Alias
UMLS CUI [1,1]
C3494437
UMLS CUI [1,2]
C0439603
pain
Beschreibung

pain

Datentyp

boolean

Alias
UMLS CUI [1]
C0030193
agitation
Beschreibung

agitation

Datentyp

boolean

Alias
UMLS CUI [1]
C0085631
bronchial secretion
Beschreibung

bronchial secretion

Datentyp

boolean

Alias
UMLS CUI [1]
C1511332
nausea / emesis
Beschreibung

nausea / emesis

Datentyp

boolean

Alias
UMLS CUI [1]
C0027497
UMLS CUI [2]
C0042963
dyspnea
Beschreibung

dyspnea

Datentyp

boolean

Alias
UMLS CUI [1]
C0013404
were the following medical or nursing procedures frequently (meaning every 4 hours or at every patient contact) performed or assessed?
Beschreibung

frequency of medical or nursing procedures

Datentyp

boolean

Alias
UMLS CUI [1]
C0199171
UMLS CUI [2]
C0204636
UMLS CUI [3]
C0439603
oral hygiene
Beschreibung

oral hygiene

Datentyp

boolean

Alias
UMLS CUI [1]
C0029164
urinary excretion
Beschreibung

urinary excretion

Datentyp

boolean

Alias
UMLS CUI [1]
C0042034
all medication was applied safely and precisely
Beschreibung

medication application

Datentyp

integer

Alias
UMLS CUI [1,1]
C0013227
UMLS CUI [1,2]
C0185125
subcutaneous syringe pump
Beschreibung

subcutaneous syringe pump

Datentyp

integer

Alias
UMLS CUI [1,1]
C0181332
UMLS CUI [1,2]
C0443315
defecation
Beschreibung

defecation

Datentyp

boolean

Alias
UMLS CUI [1]
C0011135
Comments
Beschreibung

Comments

Alias
UMLS CUI-1
C0947611
comments
Beschreibung

comments

Datentyp

text

Alias
UMLS CUI [1]
C0947611
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Ähnliche Modelle

Palliative and Hospice Care Liverpool Care Pathway Short Version

1 Formulare
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
Main diagnosis
C0011900 (UMLS CUI-1)
Main diagnosis
Item
Main diagnosis
text
C0011900 (UMLS CUI [1])
Item Group
Initial status
current medication
Item
Current medication has been reviewed, not necessarily required medication has been stopped
boolean
C1553892 (UMLS CUI [1])
medication if needed
Item
subcutaneous medication for the following symptoms has been prescribed if needed according to the existing guidelines
boolean
C0013227 (UMLS CUI [1])
pain - analgesics
Item
pain - analgesics
boolean
C0030193 (UMLS CUI [1])
C0002771 (UMLS CUI [2])
nausea and emesis - antiemetics
Item
nausea and emesis - antiemetics
boolean
C0042963 (UMLS CUI [1])
C0027497 (UMLS CUI [2])
C0003297 (UMLS CUI [3])
agitation - tranquilizers
Item
agitation - tranquilizers
boolean
C0085631 (UMLS CUI [1])
C0040614 (UMLS CUI [2])
bronchial secretion - anticholinergics
Item
bronchial secretion - anticholinergics
boolean
C1511332 (UMLS CUI [1])
C0242896 (UMLS CUI [2])
dyspnea - opioids, anxiolytics
Item
dyspnea - opioids, anxiolytics
boolean
C0013404 (UMLS CUI [1])
C0242402 (UMLS CUI [2])
C0040616 (UMLS CUI [3])
unnecessary procedures
Item
the following unnecessary medical procedures were stopped:
boolean
C0376708 (UMLS CUI [1])
Item
blood withdrawal
integer
C0005834 (UMLS CUI [1])
blood withdrawal
Code List
blood withdrawal
CL Item
not necessary (1)
CL Item
yes (2)
CL Item
no (3)
Item
antibiotics
integer
C0003232 (UMLS CUI [1])
blood withdrawal
Code List
antibiotics
CL Item
not necessary (1)
CL Item
yes (2)
CL Item
no (3)
Item
intravenous (liquids/medications)
integer
C0348016 (UMLS CUI [1])
blood withdrawal
Code List
intravenous (liquids/medications)
CL Item
not necessary (1)
CL Item
yes (2)
CL Item
no (3)
cardiopulmonary resuscitation
Item
cardiopulmonary resuscitation
boolean
C0007203 (UMLS CUI [1])
unnecessary nursing procedures
Item
unnecessary nursing procedures were stopped
boolean
C0376708 (UMLS CUI [1,1])
C0204636 (UMLS CUI [1,2])
Item
subcutaneous syringe pump was started 4 hours at most after doctor's instruction
integer
C0181332 (UMLS CUI [1,1])
C0443315 (UMLS CUI [1,2])
C0040223 (UMLS CUI [2])
blood withdrawal
Code List
subcutaneous syringe pump was started 4 hours at most after doctor's instruction
CL Item
not necessary (1)
CL Item
yes (2)
CL Item
no (3)
Item Group
Psychological insight
Item
the patient's ability to communicate in German was assessed as adequate
integer
C0017477 (UMLS CUI [1,1])
C0009452 (UMLS CUI [1,2])
C0205411 (UMLS CUI [1,3])
adequate communication in German
Code List
the patient's ability to communicate in German was assessed as adequate
CL Item
comatose (1)
CL Item
yes (2)
CL Item
no (3)
family's ability to communicate in German
Item
the patient's family's / other people's ability to communicate in German was assessed as adequate
boolean
C0017477 (UMLS CUI [1,1])
C0009452 (UMLS CUI [1,2])
C0205411 (UMLS CUI [1,3])
Item
patient awareness of the diagnosis
integer
C0004448 (UMLS CUI [1,1])
C0011900 (UMLS CUI [1,2])
C0030705 (UMLS CUI [1,3])
adequate communication in German
Code List
patient awareness of the diagnosis
CL Item
comatose (1)
CL Item
yes (2)
CL Item
no (3)
family/other awareness of the diagnosis
Item
family/other awareness of the diagnosis
boolean
C0004448 (UMLS CUI [1,1])
C0011900 (UMLS CUI [1,2])
C0015576 (UMLS CUI [1,3])
Item
patient awareness of dying
integer
C0004448 (UMLS CUI [1,1])
C0184532 (UMLS CUI [1,2])
C0030705 (UMLS CUI [1,3])
adequate communication in German
Code List
patient awareness of dying
CL Item
comatose (1)
CL Item
yes (2)
CL Item
no (3)
family/other awareness of dying
Item
family/other awareness of dying
boolean
C0004448 (UMLS CUI [1,1])
C0184532 (UMLS CUI [1,2])
C0015576 (UMLS CUI [1,3])
Item Group
Religious/spiritual assistance
Item
Patient defined religious/spiritual needs
integer
C0027552 (UMLS CUI [1,1])
C0150355 (UMLS CUI [1,2])
C0030705 (UMLS CUI [1,3])
adequate communication in German
Code List
Patient defined religious/spiritual needs
CL Item
comatose (1)
CL Item
yes (2)
CL Item
no (3)
family/others defined religious/spiritual needs
Item
family/others defined religious/spiritual needs
boolean
C0027552 (UMLS CUI [1,1])
C0150355 (UMLS CUI [1,2])
C0015576 (UMLS CUI [1,3])
Item Group
Communication between family/others and nursing team
information about patient death
Item
it was settled how the family/other people close to the patient should be informed about the patient's death
boolean
C1306577 (UMLS CUI [1,1])
C1533716 (UMLS CUI [1,2])
C0015576 (UMLS CUI [1,3])
information about important matters
Item
the family/other people close to the patient received information about the following matters: drive and parking, lodging, drinks, phone, lavatories and toilets, visiting hours, other important information
boolean
C1533716 (UMLS CUI [1])
C0030566 (UMLS CUI [2])
C1556029 (UMLS CUI [3])
C0452428 (UMLS CUI [4])
C0039457 (UMLS CUI [5])
C0558278 (UMLS CUI [6])
C0040364 (UMLS CUI [7])
C1547409 (UMLS CUI [8])
general practitioner informed about current state
Item
general practitioner was informed about the patient's current state
boolean
C0017319 (UMLS CUI [1])
C3166194 (UMLS CUI [2])
C1533716 (UMLS CUI [3])
Item
the care plan was explained and discussed with the patient
integer
C0178916 (UMLS CUI [1,1])
C0681841 (UMLS CUI [1,2])
C0030705 (UMLS CUI [1,3])
adequate communication in German
Code List
the care plan was explained and discussed with the patient
CL Item
comatose (1)
CL Item
yes (2)
CL Item
no (3)
care plan explained to family/other people
Item
the care plan was explained and discussed with the family/other people
boolean
C0178916 (UMLS CUI [1,1])
C0681841 (UMLS CUI [1,2])
C0015576 (UMLS CUI [1,3])
family/other people confirmed understanding of care plan
Item
the family/other people close to the patient confirmed that they understood the care plan
boolean
C0015576 (UMLS CUI [1,1])
C0750484 (UMLS CUI [1,2])
C0162340 (UMLS CUI [1,3])
C0178916 (UMLS CUI [1,4])
Item Group
assistance after death
general practitioner was informed about the patients death
Item
general practitioner was informed about the patient's death
boolean
C0017319 (UMLS CUI [1,1])
C1522154 (UMLS CUI [1,2])
C1306577 (UMLS CUI [1,3])
laying-out procedures
Item
procedures for the laying-out were performed according to the in-house regulations
boolean
C2700391 (UMLS CUI [1])
procedures after death
Item
procedures after death were discussed or performed
boolean
C2700391 (UMLS CUI [1,1])
C1306577 (UMLS CUI [1,2])
infectious disease
Item
patient suffered from an infectious disease
boolean
C0009450 (UMLS CUI [1])
special needs regarding religious rituals
Item
patient had special needs regarding religious rituals
boolean
C0871403 (UMLS CUI [1,1])
C0237841 (UMLS CUI [1,2])
autopsy
Item
autopsy was clarified
boolean
C0004398 (UMLS CUI [1])
information about procedures in hospital
Item
family/other people close to the patient were informed about the procedures in the hospital
boolean
C2700391 (UMLS CUI [1,1])
C0019994 (UMLS CUI [1,2])
C1533716 (UMLS CUI [2])
C0015576 (UMLS CUI [3])
articles of value and patient belongings
Item
hospital guidelines regarding articles of value and patient's belongings were followed
boolean
C0162791 (UMLS CUI [1])
C2347695 (UMLS CUI [2])
documentation and references
Item
necessary documentation and references were passed on to the respective person
boolean
C0920316 (UMLS CUI [1])
C0586393 (UMLS CUI [2])
brochure with information about grieving process
Item
brochure with information about grieving process was handed out
boolean
C0949917 (UMLS CUI [1,1])
C0018235 (UMLS CUI [1,2])
Item Group
Documentation
C0920316 (UMLS CUI-1)
symptom assessment
Item
Were the following symptoms frequently (meaning every 4 hours or at each patient contact) assessed?
boolean
C3494437 (UMLS CUI [1,1])
C0439603 (UMLS CUI [1,2])
pain
Item
pain
boolean
C0030193 (UMLS CUI [1])
agitation
Item
agitation
boolean
C0085631 (UMLS CUI [1])
bronchial secretion
Item
bronchial secretion
boolean
C1511332 (UMLS CUI [1])
nausea / emesis
Item
nausea / emesis
boolean
C0027497 (UMLS CUI [1])
C0042963 (UMLS CUI [2])
dyspnea
Item
dyspnea
boolean
C0013404 (UMLS CUI [1])
frequency of medical or nursing procedures
Item
were the following medical or nursing procedures frequently (meaning every 4 hours or at every patient contact) performed or assessed?
boolean
C0199171 (UMLS CUI [1])
C0204636 (UMLS CUI [2])
C0439603 (UMLS CUI [3])
oral hygiene
Item
oral hygiene
boolean
C0029164 (UMLS CUI [1])
urinary excretion
Item
urinary excretion
boolean
C0042034 (UMLS CUI [1])
Item
all medication was applied safely and precisely
integer
C0013227 (UMLS CUI [1,1])
C0185125 (UMLS CUI [1,2])
blood withdrawal
Code List
all medication was applied safely and precisely
CL Item
not necessary (1)
CL Item
yes (2)
CL Item
no (3)
Item
subcutaneous syringe pump
integer
C0181332 (UMLS CUI [1,1])
C0443315 (UMLS CUI [1,2])
blood withdrawal
Code List
subcutaneous syringe pump
CL Item
not necessary (1)
CL Item
yes (2)
CL Item
no (3)
defecation
Item
defecation
boolean
C0011135 (UMLS CUI [1])
Item Group
Comments
C0947611 (UMLS CUI-1)
comments
Item
comments
text
C0947611 (UMLS CUI [1])
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