ID

15870

Beschrijving

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/

Trefwoorden

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17 juni 2016

DOI

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Licentie

Creative Commons BY-NC 3.0

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Emergency Room Point B in Time Part 1: Trauma Protocol UKM

model
Details

Emergency Room Point B in Time Part 1: Emergency Room Report UKM

1 Formulieren

StudyEvent: ODM
1. Emergency Room Point B in Time Part 1: Emergency Room Report UKM

Name

Type

Description | Question | Decode (Coded Value)

Datatype

Alias

Patient information

Item Group

Patient information

C1955348 (UMLS CUI-1)

Last name

Item

Last name

text

C0421448 (UMLS CUI [1])

First name

Item

First name

text

C1443235 (UMLS CUI [1])

Date of birth

Item

Date of birth

date

C0421451 (UMLS CUI [1])

Index

Item

text

C1300638 (UMLS CUI [1])

Time of arrival

Item

datetime

C3263562 (UMLS CUI [1])

Relatives informed

Item

boolean

C0080103 (UMLS CUI [1,1])
C1522154 (UMLS CUI [1,2])

Emergency Room Team

Item Group

C0562508 (UMLS CUI-1)
C0086390 (UMLS CUI-2)

casualty surgeon

Item

boolean

C0586908 (UMLS CUI [1])

general surgeon

Item

boolean

C0334885 (UMLS CUI [1])

anesthesist

Item

boolean

C1550495 (UMLS CUI [1])

neurosurgeon

Item

boolean

C0237427 (UMLS CUI [1])

radiologist

Item

boolean

C0260194 (UMLS CUI [1])

Nurses

Item

boolean

C0028661 (UMLS CUI [1])

OMS

Item

boolean

C0260272 (UMLS CUI [1])

ENT surgeon

Item

boolean

C0586894 (UMLS CUI [1])

Eye surgeon

Item

boolean

C1517083 (UMLS CUI [1])

other medical specialist

Item

boolean

C0920580 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])

Medical history

Item Group

C0262926 (UMLS CUI-1)

Pre-existing illness/Premedication

Item

integer

C0521987 (UMLS CUI [1])
C0033045 (UMLS CUI [2])

Pre-existing illness/Premedication

Code List

Pre-existing illness/Premedication

CL Item

(1)

CL Item

(2)

please specify

Item

text

C0521987 (UMLS CUI [1])
C0033045 (UMLS CUI [2])

tetanus vaccination

Item

integer

C0199807 (UMLS CUI [1])

tetanus vaccination

Code List

tetanus vaccination

CL Item

(1)

CL Item

(2)

Vital signs

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])

intubated at arrival

Item

boolean

C3844652 (UMLS CUI [1])

FiO2

Item

float

C2370852 (UMLS CUI [1])

Partial pressure of Oxygen

Item

float

C0391840 (UMLS CUI [1])

end tidal co2

Item

integer

C0428658 (UMLS CUI [1])

oral airway right position

Item

boolean

C0457430 (UMLS CUI [1])

Surgical interventions until admission in ICU

Item Group

First surgical intervention

C2216322 (UMLS CUI-1)

intracranial pressure measurement

Item

boolean

C0394279 (UMLS CUI [1])

Cranioectomy

Item

Craniotomy

boolean

C0195897 (UMLS CUI [1])

Thoracotomy

Item

Thoracotomy

boolean

C0039991 (UMLS CUI [1])

laparotomy

Item

laparotomy

boolean

C0023038 (UMLS CUI [1])

revascularization

Item

revascularization

boolean

C0581603 (UMLS CUI [1])

embolization

Item

embolization

boolean

C0013931 (UMLS CUI [1])

stabilization pelvis

Item

stabilization pelvis

boolean

C1293130 (UMLS CUI [1,1])
C0030797 (UMLS CUI [1,2])

stabilization of limb

Item

stabilization of limb

boolean

C1293130 (UMLS CUI [1,1])
C0015385 (UMLS CUI [1,2])

Beginning of surgical procedure

Item

Beginning of surgical procedure

time

C0439659 (UMLS CUI [1,1])
C0543467 (UMLS CUI [1,2])

Diagnostics until admission in ICU

Item Group

Diagnostics

C0430022 (UMLS CUI-1)

Sono abdomen

Item

Abdominal sonography

boolean

C0041618 (UMLS CUI [1,1])
C0000726 (UMLS CUI [1,2])

time of procedure

Item

Time of abdominal sonography

time

C0087111 (UMLS CUI [1,1])
C1547403 (UMLS CUI [1,2])

x-ray thorax

Item

X-Ray of chest

boolean

C0039985 (UMLS CUI [1])

time of procedure

Item

Time of chest X-Ray

time

C0087111 (UMLS CUI [1,1])
C1547403 (UMLS CUI [1,2])

x-ray pelvis

Item

X-Ray of pelvis

boolean

C0554740 (UMLS CUI [1])

Time of procedure

Item

Time of pelvis X-ray

time

C0087111 (UMLS CUI [1,1])
C1547403 (UMLS CUI [1,2])

x-ray spine

Item

X-ray of spine

boolean

C0203139 (UMLS CUI [1])

Time of procedure

Item

Time of X-Ray of spine

time

C0087111 (UMLS CUI [1,1])
C1547403 (UMLS CUI [1,2])

x ray upper spine

Item

boolean

C0203145 (UMLS CUI [1])

x ray upper spine time

Item

time

C0040223 (UMLS CUI [1,1])
C0203145 (UMLS CUI [1,2])

x-ray limb

Item

boolean

C0853222 (UMLS CUI [1])

x-ray limb time

Item

time

C0040223 (UMLS CUI [1,1])
C0853222 (UMLS CUI [1,2])

Item

CCT

boolean

C0040405 (UMLS CUI [1])

Time of procedure

Item

Time of CCT

time

C0087111 (UMLS CUI [1,1])
C1547403 (UMLS CUI [1,2])

whole-body computed tomography

Item

Whole-body CT

boolean

C0412583 (UMLS CUI [1])

Time of procedure

Item

Time of whole-body CT

time

C0087111 (UMLS CUI [1,1])
C1547403 (UMLS CUI [1,2])

MRI

Item

boolean

C0024485 (UMLS CUI [1])

Time of MRI

Item

time

C0040223 (UMLS CUI [1,1])
C0024485 (UMLS CUI [1,2])

Rotem/Rotec

Item

Rotem/Rotec

boolean

C0032173 (UMLS CUI [1,1])
C0039593 (UMLS CUI [1,2])

Time of procedure

Item

Time of Rotem/Rotec

time

C0087111 (UMLS CUI [1,1])
C1547403 (UMLS CUI [1,2])

Neurological examination

Item Group

Glasgow Coma Scale

C0027853 (UMLS CUI-1)

eye opening response

Item

eye opening response

integer

C0559289 (UMLS CUI [1])

eye opening response

Code List

eye opening response

CL Item

None (1)

CL Item

Opens to pain, not applied to face (2)

CL Item

Opens to verbal command, speech, or shout (3)

CL Item

Spontaneous (4)

best verbal response

Item

best verbal response

integer

C3648957 (UMLS CUI [1])

best verbal response

Code List

best verbal response

CL Item

None (1)

CL Item

Incomprehensible speech (2)

CL Item

Inappropriate Responses, words discernible (3)

CL Item

Confused conversation, but able to answer questions (4)

CL Item

Oriented (5)

best motor response

Item

best motor response

integer

C3648958 (UMLS CUI [1])

best motor response

Code List

best motor response

CL Item

None (1)

CL Item

Extensor (rigid) Response, decerebrate posture (2)

CL Item

Abnormal (spastic) flexion, decorticate posture (3)

CL Item

With draws from pain (4)

CL Item

Purposeful movement to painful Stimulus (5)

CL Item

Obeys commands for movement (6)

total score

Item

total score

integer

C0578785 (UMLS CUI [1])

Size of left pupil

Item

integer

C0517965 (UMLS CUI [1,1])
C0443246 (UMLS CUI [1,2])

Size of left pupil

Code List

Size of left pupil

CL Item

(1)

CL Item

(2)

CL Item

(3)

CL Item

(4)

Size of right pupil

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)

Pupil reaction to light left

Item

integer

C1287558 (UMLS CUI [1,1])
C0205091 (UMLS CUI [1,2])

Pupil reaction to light left

Code List

Pupil reaction to light left

CL Item

(1)

CL Item

(2)

CL Item

(3)

CL Item

(4)

Pupil reaction to light right

Item

integer

C1287558 (UMLS CUI [1,1])
C0205090 (UMLS CUI [1,2])

Pupil reaction to light right

Code List

Pupil reaction to light right

CL Item

(1)

CL Item

(2)

CL Item

(3)

CL Item

(4)

Blood test

Item Group

Blood test

C0018941 (UMLS CUI-1)

Item

Hb-Value

float

C0518015 (UMLS CUI [1])

Platelet

Item

Platelet count

float

C0032181 (UMLS CUI [1])

Quick

Item

Quick

float

C0483455 (UMLS CUI [1])

PTT

Item

PTT

float

C0030605 (UMLS CUI [1])

Alcohol concentration

Item

float

C0542492 (UMLS CUI [1])

Item

float

C0202165 (UMLS CUI [1])

Base Excess

Item

Base Excess

float

C0201985 (UMLS CUI [1])

Calcium measurement

Item

float

C0201925 (UMLS CUI [1])

Temperature

Item

Temperature

float

C0005903 (UMLS CUI [1])

INR

Item

INR

float

C0525032 (UMLS CUI [1])

Fibrinogen

Item

float

C0016006 (UMLS CUI [1])

Clinical course

Item Group

C0449259 (UMLS CUI-1)

worst hemoglobin

Item

float

C0518015 (UMLS CUI [1,1])
C1522166 (UMLS CUI [1,2])

worst quick

Item

float

C0483455 (UMLS CUI [1,1])
C1522166 (UMLS CUI [1,2])

worst be

Item

float

C0201985 (UMLS CUI [1,1])
C1522166 (UMLS CUI [1,2])

ASA

Item Group

C1531480 (UMLS CUI-1)

ASA

Item

integer

C1531480 (UMLS CUI [1])

ASA

Code List

ASA

CL Item

(1)

CL Item

(2)

CL Item

(3)

CL Item

(4)

coagulopathy

Item

boolean

C0005779 (UMLS CUI [1])

Therapy

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])

FFP

Item

integer

C0016709 (UMLS CUI [1])

Blood

Item

integer

C0086252 (UMLS CUI [1])

time of first blood transfusion

Item

time

C1547403 (UMLS CUI [1,1])
C0086252 (UMLS CUI [1,2])

Platelets

Item

integer

C0086818 (UMLS CUI [1])

Intubation

Item

Intubation

boolean

C0021925 (UMLS CUI [1])

Resuscitation

Item

Resuscitation

boolean

C0007203 (UMLS CUI [1])

Catecholamine therapy

Item

Catecholamine therapy

boolean

C0007412 (UMLS CUI [1])

chest tube

Item

chest tube

boolean

C0008034 (UMLS CUI [1])

Lap belt

Item

boolean

C0553557 (UMLS CUI [1])

External fixation device (outside of OR)

Item

External fixation device (outside of OR)

boolean

C0079321 (UMLS CUI [1])

Hemostasis Therapy

Item Group

Hemostasis Therapy

C0740166 (UMLS CUI-1)

rfVIIa

Item

rfVIIa

boolean

C0534191 (UMLS CUI [1])

count of rfVIIa transfusions

Item

integer

C0085430 (UMLS CUI [1,1])
C0534191 (UMLS CUI [1,2])
C0449788 (UMLS CUI [1,3])

count of red cell concentrate

Item

integer

C0085430 (UMLS CUI [1,1])
C0086252 (UMLS CUI [1,2])
C0449788 (UMLS CUI [1,3])

cumulative dose rfVIIa

Item

float

C2986497 (UMLS CUI [1,1])
C0534191 (UMLS CUI [1,2])

beginning of hemostasis therapy

Item

time

C0740166 (UMLS CUI [1,1])
C1547403 (UMLS CUI [1,2])

PPSB

Item

ppsb

boolean

C0072434 (UMLS CUI [1])

Tranexamic Acid

Item

boolean

C0040613 (UMLS CUI [1])

Fibrinogen

Item

Fibrinogen

boolean

C0016006 (UMLS CUI [1])

other hemostatic agents

Item

other hemostatic agents

boolean

C0019120 (UMLS CUI [1])

Further treatment

Item Group

Further treatment

emergency room

Item

ER Diagnostics completed

boolean

C0086143 (UMLS CUI [1,1])
C0205197 (UMLS CUI [1,2])
C0562508 (UMLS CUI [1,3])

patient transfer

Item

if yes, Patient transfered to:

integer

C0030704 (UMLS CUI [1])

patient transfer

Code List

if yes, Patient transfered to:

CL Item

OR (1)

CL Item

Intensive Care Ward (2)

CL Item

other (3)

CL Item

(4)

CL Item

(5)

Time of transfer

Item

Time of transfer

time

C0030704 (UMLS CUI [1,1])
C0040223 (UMLS CUI [1,2])

termination of diagnostics

Item

if no, Termination of diagnostics because:

integer

C2746065 (UMLS CUI [1,1])
C0348026 (UMLS CUI [1,2])

termination of diagnostics

Code List

if no, Termination of diagnostics because:

CL Item

Emergency OR (1)

CL Item

Other (2)

time

Item

Termination time

time

C2746065 (UMLS CUI [1,1])
C0040223 (UMLS CUI [1,2])

diagnostics completed before ICU

Item

diagnostics completed before ICU

boolean

C0086143 (UMLS CUI [1,1])
C1556116 (UMLS CUI [1,2])

Urinary diversion

Item Group

C0042020 (UMLS CUI-1)

Urinary diversion

Item

integer

C0042020 (UMLS CUI [1])

Urinary diversion

Code List

Urinary diversion

CL Item

(1)

CL Item

(2)

CL Item

(3)

Urine

Item

integer

C0042036 (UMLS CUI [1])

Urine

Code List

Urine

CL Item

(1)

CL Item

(2)

PTS

Item Group

C0026771 (UMLS CUI-1)
C0449820 (UMLS CUI-2)

head

Item

integer

C0018670 (UMLS CUI [1,1])
C0451547 (UMLS CUI [1,2])

head

Code List

head

CL Item

(2)

CL Item

(4)

CL Item

(16)

CL Item

(1)

limbs

Item

integer

C0015385 (UMLS CUI [1,1])
C0451547 (UMLS CUI [1,2])

head

Code List

limbs

CL Item

(2)

CL Item

(4)

CL Item

(1)

CL Item

(8)

CL Item

(6)

CL Item

(5)

CL Item

(3)

age

Item

integer

C0001779 (UMLS CUI [1,1])
C0451547 (UMLS CUI [1,2])

head

Code List

age

CL Item

(2)

CL Item

(4)

CL Item

(1)

CL Item

(3)

CL Item

(5)

CL Item

(6)

CL Item

(7)

Abdomen

Item

integer

C0000726 (UMLS CUI [1,1])
C0451547 (UMLS CUI [1,2])

Abdomen

Code List

Abdomen

CL Item

(5)

CL Item

(8)

CL Item

(10)

CL Item

(2)

Thorax

Item

integer

C0817096 (UMLS CUI [1,1])
C0451547 (UMLS CUI [1,2])

Thorax

Code List

Thorax

CL Item

(1)

CL Item

(4)

CL Item

(10)

CL Item

(2)

CL Item

(3)

CL Item

(5)

CL Item

(16)

pelvis

Item

integer

C0030797 (UMLS CUI [1,1])
C0451547 (UMLS CUI [1,2])

pelvis

Code List

pelvis

CL Item

(2)

CL Item

(5)

CL Item

(8)

CL Item

(12)

base deficiancy

Item

integer

C0030797 (UMLS CUI [1,1])
C0451547 (UMLS CUI [1,2])

base deficiancy

Code List

base deficiancy

CL Item

(26)

CL Item

(20)

CL Item

(14)

CL Item

(9)

CL Item

(5)

CL Item

(3)

CL Item

(1)

CL Item

(0)

paO2/FiO2 quotient

Item

integer

C0391840 (UMLS CUI [1,1])
C0428648 (UMLS CUI [1,2])
C0451547 (UMLS CUI [1,3])

paO2/FiO2 quotient

Code List

paO2/FiO2 quotient

CL Item

(22)

CL Item

(12)

CL Item

(8)

CL Item

(5)

CL Item

(3)

CL Item

(1)

CL Item

(0)

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Model Commentaren :

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Item Commentaren voor :

Emergency Room Point B in Time Part 1: Trauma Protocol UKM

Emergency Room Point B in Time Part 1: Emergency Room Report UKM

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