ID

15793

Beschreibung

Report/Protocol collecting patient and treatment information like the circumstances of the accident and initial ER treatment. Documentation in traum room. ODM derived from EHR form: MS Schockraumprotokoll 2 by University Hospital Muenster http://klinikum.uni-muenster.de/

Link

http://klinikum.uni-muenster.de/

Stichworte

Versionen (1)
  1. 13.06.16 13.06.16 -
Hochgeladen am

13. Juni 2016

DOI

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Creative Commons BY-NC 3.0
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Preclinical Point A in Time: Trauma Protocol UKM

Deutsch Englisch

Preclinical Point A in Time: Emergency Room Report UKM

1 Formulare  
General Information
Beschreibung

General Information

Time of Alarm
Beschreibung

Time of Alarm

Datentyp

time

Alias
UMLS CUI [1]
C0040223
Arrival of A&E doctor
Beschreibung

Arrival of A&E doctor in ER

Datentyp

time

Alias
UMLS CUI [1,1]
C0583237
UMLS CUI [1,2]
C0040223
time of ED leaving site of accident
Beschreibung

time of departure

Datentyp

time

Alias
UMLS CUI [1]
C2735126
Transport mode to hospital
Beschreibung

Transport mode to hospital

Datentyp

integer

Control center
Beschreibung

Control center

Datentyp

text

fax AE doctor
Beschreibung

fax AE doctor

Datentyp

text

Alias
UMLS CUI [1,1]
C1549619
UMLS CUI [1,2]
C0586803
medical report to A&E doctor
Beschreibung

medical report to A&E doctor

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0451617
UMLS CUI [1,2]
C0586803
NACA-Score
Beschreibung

NACA-Score

Datentyp

integer

Alias
UMLS CUI [1,1]
C0449820
UMLS CUI [1,2]
C3263723
UMLS CUI [1,3]
C0012634
UMLS CUI [1,4]
C0032343
Vital signs
Beschreibung

Vital signs

Alias
UMLS CUI-1
C0518766
Blood pressure systolic
Beschreibung

Blood pressure systolic

Datentyp

integer

Maßeinheiten
  • mmHg
Alias
UMLS CUI [1]
C0871470
mmHg
Heart rate
Beschreibung

Heart rate

Datentyp

integer

Maßeinheiten
  • bpm
Alias
UMLS CUI [1]
C0018810
bpm
respiratory rate
Beschreibung

respiratory rate

Datentyp

integer

Maßeinheiten
  • /minute
Alias
UMLS CUI [1]
C0231832
/minute
SpO2
Beschreibung

SpO2

Datentyp

integer

Maßeinheiten
  • %
Alias
UMLS CUI [1]
C0428179
%
GCS Score
Beschreibung

GCS Score

Datentyp

integer

Alias
UMLS CUI [1]
C1271007
Size of right pupil
Beschreibung

Size of right pupil

Datentyp

integer

Alias
UMLS CUI [1,1]
C0517965
UMLS CUI [1,2]
C0444532
Size of left pupil
Beschreibung

Size of left pupil

Datentyp

integer

Alias
UMLS CUI [1,1]
C0517965
UMLS CUI [1,2]
C0443246
right pupil reaction to light
Beschreibung

right pupil reaction to light

Datentyp

integer

Alias
UMLS CUI [1,1]
C0234671
UMLS CUI [1,2]
C0444532
left pupil reaction to light
Beschreibung

left pupil reaction to light

Datentyp

integer

Alias
UMLS CUI [1,1]
C0234671
UMLS CUI [1,2]
C0443246
Therapy (til Intensive Care)
Beschreibung

Therapy (til Intensive Care)

Alias
UMLS CUI-1
C0087111
electrolytes
Beschreibung

Administration of electrolytes

Datentyp

integer

Maßeinheiten
  • ml
Alias
UMLS CUI [1]
C0199796
ml
Administration of colloids
Beschreibung

Administration of colloids

Datentyp

integer

Maßeinheiten
  • ml
Alias
UMLS CUI [1]
C3267204
ml
hyperosmolar infusion
Beschreibung

hyperosmolar infusion

Datentyp

integer

Maßeinheiten
  • ml
Alias
UMLS CUI [1,1]
C0259752
UMLS CUI [1,2]
C0087111
ml
Intubation
Beschreibung

Intubation

Datentyp

boolean

Alias
UMLS CUI [1]
C0021925
Analgosedation
Beschreibung

Analgosedation

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0344106
UMLS CUI [1,2]
C0002766
Resuscitation
Beschreibung

Resuscitation

Datentyp

boolean

Alias
UMLS CUI [1]
C0007203
Catecholamine therapy
Beschreibung

Catecholamine therapy

Datentyp

boolean

Alias
UMLS CUI [1]
C0007412
External fixation device (outside of OR)
Beschreibung

External cervical fixation device

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0079321
UMLS CUI [1,2]
C0238943
chest tube
Beschreibung

chest tube

Datentyp

boolean

Alias
UMLS CUI [1]
C0008034
peripheral venous catheter
Beschreibung

peripheral venous catheter

Datentyp

integer

Alias
UMLS CUI [1]
C2985513
central catheter
Beschreibung

central catheter

Datentyp

integer

Alias
UMLS CUI [1]
C1145640
capnography
Beschreibung

capnography

Datentyp

boolean

Alias
UMLS CUI [1]
C0376529
Lap belt
Beschreibung

Lap belt

Datentyp

boolean

Alias
UMLS CUI [1]
C0553557
Injuries
Beschreibung

Injuries

Alias
UMLS CUI-1
C3263723
craniocerebral
Beschreibung

craniocerebral trauma

Datentyp

integer

Alias
UMLS CUI [1]
C0018674
face
Beschreibung

facial injury

Datentyp

integer

Alias
UMLS CUI [1]
C0015459
thorax
Beschreibung

thoracic injury

Datentyp

integer

Alias
UMLS CUI [1]
C0039980
abdomen
Beschreibung

abdominal injury

Datentyp

integer

Alias
UMLS CUI [1]
C0848377
spine
Beschreibung

injury of spine

Datentyp

integer

Alias
UMLS CUI [1]
C0037937
pelvis
Beschreibung

injury of pelvis

Datentyp

integer

Alias
UMLS CUI [1]
C0560636
upper limb
Beschreibung

injury of upper limb

Datentyp

integer

Alias
UMLS CUI [1]
C0003794
lower limb
Beschreibung

injuries of lower limb

Datentyp

integer

Alias
UMLS CUI [1]
C0023220
soft tissue
Beschreibung

injury of soft tissue

Datentyp

integer

Alias
UMLS CUI [1]
C0037578
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Ähnliche Modelle

Preclinical Point A in Time: Emergency Room Report UKM

1 Formulare
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
General Information
Time of Alarm
Item
Time of Alarm
time
C0040223 (UMLS CUI [1])
Arrival of A&E doctor in ER
Item
Arrival of A&E doctor
time
C0583237 (UMLS CUI [1,1])
C0040223 (UMLS CUI [1,2])
time of departure
Item
time of ED leaving site of accident
time
C2735126 (UMLS CUI [1])
Item
Transport mode to hospital
integer
Transport mode to hospital
Code List
Transport mode to hospital
CL Item
ambulance; with physician attendance (1)
CL Item
ambulance; without physician attendance (2)
CL Item
SAR helicopter  (3)
CL Item
private (4)
Control center
Item
text
fax AE doctor
Item
text
C1549619 (UMLS CUI [1,1])
C0586803 (UMLS CUI [1,2])
medical report to A&E doctor
Item
boolean
C0451617 (UMLS CUI [1,1])
C0586803 (UMLS CUI [1,2])
NACA-Score
Item
integer
C0449820 (UMLS CUI [1,1])
C3263723 (UMLS CUI [1,2])
C0012634 (UMLS CUI [1,3])
C0032343 (UMLS CUI [1,4])
Item Group
C0518766 (UMLS CUI-1)
Blood pressure systolic
Item
integer
C0871470 (UMLS CUI [1])
Heart rate
Item
integer
C0018810 (UMLS CUI [1])
respiratory rate
Item
integer
C0231832 (UMLS CUI [1])
SpO2
Item
integer
C0428179 (UMLS CUI [1])
GCS Score
Item
integer
C1271007 (UMLS CUI [1])
Item
integer
C0517965 (UMLS CUI [1,1])
C0444532 (UMLS CUI [1,2])
Size of right pupil
Code List
Size of right pupil
CL Item
 (1)
CL Item
 (2)
CL Item
 (3)
CL Item
 (4)
Item
integer
C0517965 (UMLS CUI [1,1])
C0443246 (UMLS CUI [1,2])
Size of right pupil
Code List
Size of left pupil
CL Item
 (1)
CL Item
 (2)
CL Item
 (3)
CL Item
 (4)
Item
integer
C0234671 (UMLS CUI [1,1])
C0444532 (UMLS CUI [1,2])
right pupil reaction to light
Code List
right pupil reaction to light
CL Item
 (1)
CL Item
 (2)
CL Item
 (3)
CL Item
 (4)
Item
integer
C0234671 (UMLS CUI [1,1])
C0443246 (UMLS CUI [1,2])
right pupil reaction to light
Code List
left pupil reaction to light
CL Item
 (1)
CL Item
 (2)
CL Item
 (3)
CL Item
 (4)
Item Group
Therapy (til Intensive Care)
C0087111 (UMLS CUI-1)
Administration of electrolytes
Item
electrolytes
integer
C0199796 (UMLS CUI [1])
Administration of colloids
Item
Administration of colloids
integer
C3267204 (UMLS CUI [1])
hyperosmolar infusion
Item
hyperosmolar infusion
integer
C0259752 (UMLS CUI [1,1])
C0087111 (UMLS CUI [1,2])
Intubation
Item
Intubation
boolean
C0021925 (UMLS CUI [1])
Analgosedation
Item
boolean
C0344106 (UMLS CUI [1,1])
C0002766 (UMLS CUI [1,2])
Resuscitation
Item
Resuscitation
boolean
C0007203 (UMLS CUI [1])
Catecholamine therapy
Item
Catecholamine therapy
boolean
C0007412 (UMLS CUI [1])
External cervical fixation device
Item
External fixation device (outside of OR)
boolean
C0079321 (UMLS CUI [1,1])
C0238943 (UMLS CUI [1,2])
chest tube
Item
chest tube
boolean
C0008034 (UMLS CUI [1])
peripheral venous catheter
Item
integer
C2985513 (UMLS CUI [1])
central catheter
Item
integer
C1145640 (UMLS CUI [1])
capnography
Item
boolean
C0376529 (UMLS CUI [1])
Lap belt
Item
boolean
C0553557 (UMLS CUI [1])
Item Group
Injuries
C3263723 (UMLS CUI-1)
Item
craniocerebral
integer
C0018674 (UMLS CUI [1])
craniocerebral trauma
Code List
craniocerebral
CL Item
none (1)
CL Item
light (2)
CL Item
moderate (3)
CL Item
severe (4)
Item
face
integer
C0015459 (UMLS CUI [1])
facial injury
Code List
face
CL Item
none (1)
CL Item
light (2)
CL Item
moderate (3)
CL Item
severe (4)
Item
thorax
integer
C0039980 (UMLS CUI [1])
thoracic injury
Code List
thorax
CL Item
none (1)
CL Item
light (2)
CL Item
moderate (3)
CL Item
severe (4)
Item
abdomen
integer
C0848377 (UMLS CUI [1])
abdominal injury
Code List
abdomen
CL Item
none (1)
CL Item
light (2)
CL Item
moderate (3)
CL Item
severe (4)
Item
spine
integer
C0037937 (UMLS CUI [1])
injury of spine
Code List
spine
CL Item
none (1)
CL Item
light (2)
CL Item
moderate (3)
CL Item
severe (4)
Item
pelvis
integer
C0560636 (UMLS CUI [1])
injury of pelvis
Code List
pelvis
CL Item
none (1)
CL Item
light (2)
CL Item
moderate (3)
CL Item
severe (4)
Item
upper limb
integer
C0003794 (UMLS CUI [1])
injury of upper limb
Code List
upper limb
CL Item
none (1)
CL Item
light (2)
CL Item
moderate (3)
CL Item
severe (4)
Item
lower limb
integer
C0023220 (UMLS CUI [1])
injuries of lower limb
Code List
lower limb
CL Item
none (1)
CL Item
light (2)
CL Item
moderate (3)
CL Item
severe (4)
Item
soft tissue
integer
C0037578 (UMLS CUI [1])
injury of soft tissue
Code List
soft tissue
CL Item
none (1)
CL Item
light (2)
CL Item
moderate (3)
CL Item
severe (4)
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