ID

16163

Beschrijving

Report/Protocol collecting patient and treatment information like the circumstances of the accident and initial ER treatment. http://klinikum.uni-muenster.de/

Link

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

Trefwoorden

Registries

Physical Examination

Emergency protocol

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3 juli 2016

DOI

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Creative Commons BY-NC 3.0

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Emergency Room Point B in Time Part 2: Emergency Room Report UKM

model
Details

Emergency Room Point B in Time Part 2: Emergency Room Report UKM

1 Formulieren

StudyEvent: ODM
1. Emergency Room Point B in Time Part 2: Emergency Room Report UKM

Name

Type

Description | Question | Decode (Coded Value)

Datatype

Alias

Patient information

Item Group

C1955348 (UMLS CUI-1)

Last name

Item

Nachname

text

C0421448 (UMLS CUI [1])

First name

Item

Vorname

text

C1443235 (UMLS CUI [1])

Date of birth

Item

Geburtsdatum

date

C0421451 (UMLS CUI [1])

Index

Item

Index

text

C1300638 (UMLS CUI [1])

Physical examination result

Item Group

Untersuchungsbefund

ATLS

Item Group

ATLS

C3494237 (UMLS CUI-1)

A-Problem (Airway)

Item

A-Problem (Airway)

boolean

C0458827 (UMLS CUI [1,1])
C0033213 (UMLS CUI [1,2])

B-Problem (Breathing)

Item

B-Problem (Breathing)

boolean

C0035203 (UMLS CUI [1,1])
C0033213 (UMLS CUI [1,2])

C-Problem (Circulation)

Item

C-Problem (Circulation)

boolean

C0005775 (UMLS CUI [1,1])
C0033213 (UMLS CUI [1,2])

D-Problem (Disability)

Item

D-Problem (Disability)

boolean

C0231170 (UMLS CUI [1,1])
C0033213 (UMLS CUI [1,2])

E-Problem (Hypothermia)

Item

E-Problem (Hypothermie)

boolean

C0020672 (UMLS CUI [1,1])
C0033213 (UMLS CUI [1,2])

Peripheral neurological status

Item Group

Peripherer Neurologischer Status

C0027853 (UMLS CUI-1)

motor function

Item

Motorik

integer

C0234130 (UMLS CUI [1])

motor function

Code List

Motorik

CL Item

spontan (1)

CL Item

seitengleich (2)

CL Item

abgeschwächt (3)

CL Item

keine (4)

sensitivity

Item

Sesibilität

integer

C1522640 (UMLS CUI [1])

sensitivity

Code List

Sesibilität

CL Item

o.B. (1)

CL Item

gestört (2)

CL Item

nicht eurierbar (3)

reflexes

Item

Reflexe

integer

C0436145 (UMLS CUI [1])

reflexes

Code List

Reflexe

CL Item

o.B. (1)

CL Item

path. (2)

Babinski Reflex

Item

Babinski

boolean

C0034935 (UMLS CUI [1])

sphincter tone

Item

Sphinktertonus

boolean

C0426763 (UMLS CUI [1])

other neurological finding

Item

Sonstiges

text

C0438194 (UMLS CUI [1])

Vascular examination

Item Group

Gefäßstatus

C0005847 (UMLS CUI-1)
C0438105 (UMLS CUI-2)

right A. carotis palpable

Item

rechte A. carotis tastbar

boolean

C0517385 (UMLS CUI [1,1])
C0226086 (UMLS CUI [1,2])
C0162481 (UMLS CUI [2,1])
C0226086 (UMLS CUI [2,2])

left A. carotis palpable

Item

linke A. carotis tastbar

boolean

C0517385 (UMLS CUI [1,1])
C0226087 (UMLS CUI [1,2])
C0162481 (UMLS CUI [2,1])
C0226087 (UMLS CUI [2,2])

right A. radialis palpable

Item

rechte A. radialis tastbar

boolean

C0232142 (UMLS CUI [1,1])
C0444532 (UMLS CUI [1,2])
C0162481 (UMLS CUI [2,1])
C0226438 (UMLS CUI [2,2])

left A. radialis palpable

Item

linke A. radialis tastbar

boolean

C0232142 (UMLS CUI [1,1])
C0443246 (UMLS CUI [1,2])
C0162481 (UMLS CUI [2,1])
C0226439 (UMLS CUI [2,2])

right A. femoralis palpable

Item

rechte A. femoralis tastbar

boolean

C0517385 (UMLS CUI [1,1])
C0226447 (UMLS CUI [1,2])
C0162481 (UMLS CUI [2,1])
C0226447 (UMLS CUI [2,2])

left A. femoralis palpable

Item

linke A. femoralis tastbar

boolean

C0517385 (UMLS CUI [1,1])
C0226448 (UMLS CUI [1,2])
C0162481 (UMLS CUI [2,1])
C0226448 (UMLS CUI [2,2])

right A. poplitea palpable

Item

rechte A. poplitea tastbar

boolean

C0232151 (UMLS CUI [1,1])
C0444532 (UMLS CUI [1,2])
C0162481 (UMLS CUI [2,1])
C0226462 (UMLS CUI [2,2])

left A. poplitea palpable

Item

linke A. poplitea tastbar

boolean

C0232151 (UMLS CUI [1,1])
C0443246 (UMLS CUI [1,2])
C0162481 (UMLS CUI [2,1])
C0226463 (UMLS CUI [2,2])

right A. dors. ped. palpable

Item

rechte A. dors. ped. tastbar

boolean

C0517385 (UMLS CUI [1,1])
C0834665 (UMLS CUI [1,2])
C0162481 (UMLS CUI [2,1])
C0834665 (UMLS CUI [2,2])

left A. dors. ped. palpable

Item

linke A. dors. ped. tastbar

boolean

C0517385 (UMLS CUI [1,1])
C0834666 (UMLS CUI [1,2])
C0162481 (UMLS CUI [2,1])
C0834666 (UMLS CUI [2,2])

right A. tib. post. palpable

Item

rechte A. tib. post. tastbar

boolean

C0517385 (UMLS CUI [1,1])
C0226474 (UMLS CUI [1,2])
C0162481 (UMLS CUI [2,1])
C0226474 (UMLS CUI [2,2])

left A. tib. post. palpable

Item

linke A. tib. post. tastbar

boolean

C0517385 (UMLS CUI [1,1])
C0226475 (UMLS CUI [1,2])
C0162481 (UMLS CUI [2,1])
C0226475 (UMLS CUI [2,2])

Physical examination of head

Item Group

Kopf/Hals

C0031809 (UMLS CUI-1)
C0460004 (UMLS CUI-2)

without finding

Item

o.B.

boolean

C0332288 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])

hematoma

Item

Hämatom

boolean

C0018944 (UMLS CUI [1])

hematoma of orbita

Item

Orbitalhämatom

boolean

C0520723 (UMLS CUI [1])

bleeding of auditory canal

Item

Gehörgangsblutung

boolean

C0019080 (UMLS CUI [1,1])
C0013444 (UMLS CUI [1,2])

liquorrhea

Item

Liquorrhoe

boolean

C0860578 (UMLS CUI [1])

laceration

Item

Platzwunde

boolean

C0856548 (UMLS CUI [1])

facial instabilty

Item

Mittelgesichtsinstabilität

boolean

C0435321 (UMLS CUI [1])

fracture of mandibula

Item

Unterkieferfraktur

boolean

C0024692 (UMLS CUI [1])

injury of eye

Item

Augenverletzung

boolean

C0015408 (UMLS CUI [1])

ohter injuries of head

Item

Sonstige:

text

C0178671 (UMLS CUI [1])

Physical examination of thorax

Item Group

Thorax

C0031809 (UMLS CUI-1)
C0817096 (UMLS CUI-2)

without finding

Item

o.B.

boolean

C0332288 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])

contusion of chest

Item

Prellmarken

boolean

C0160925 (UMLS CUI [1])

hematoma

Item

Hämatom

boolean

C4049192 (UMLS CUI [1])

skin emphysema

Item

Hautemphysem

boolean

C0038536 (UMLS CUI [1])

thoracal instability

Item

Instabilität

boolean

C0231433 (UMLS CUI [1,1])
C0817096 (UMLS CUI [1,2])

chest pain on breathing

Item

atemabh. Schmerz

boolean

C0423729 (UMLS CUI [1])

chest pain on compression

Item

Kompressionsschmerz

boolean

C0008031 (UMLS CUI [1,1])
C0728907 (UMLS CUI [1,2])

open wound

Item

offene Verletzung

boolean

C0478235 (UMLS CUI [1])

jugular vein congestion

Item

Halsvenenstauung

boolean

C0700148 (UMLS CUI [1,1])
C0022427 (UMLS CUI [1,2])

pathological auscultation of chest

Item

path. Auskultationsbefund

boolean

C0577960 (UMLS CUI [1])

chest tube

Item

Thoraxdrainage

boolean

C0008034 (UMLS CUI [1])

other chest pain

Item

Sonstige:

text

C0039980 (UMLS CUI [1])

Physical examination of abdomen and genitourinary system

Item Group

Abdomen und Urogenitaltrakt

C0031809 (UMLS CUI-1)
C0000726 (UMLS CUI-2)
C0042066 (UMLS CUI-3)

without finding

Item

o.B.

boolean

C0332288 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])

contusion

Item

Prellmarken

boolean

C1439271 (UMLS CUI [1])
C1389458 (UMLS CUI [2])

Hematoma

Item

Hämatom

boolean

C0018944 (UMLS CUI [1])

Abdomen distended

Item

aufgetrieben

boolean

C0000731 (UMLS CUI [1])

pressure pain

Item

Druckschmerz

boolean

C3647129 (UMLS CUI [1])

muscular guarding

Item

Abwehrspannung

boolean

C0238547 (UMLS CUI [1])

open injury

Item

offene Verletzung

boolean

C0559870 (UMLS CUI [1])

anogenital injury

Item

Verletzung Anogenitaltrakt

boolean

C3263723 (UMLS CUI [1,1])
C0031066 (UMLS CUI [1,2])

pathological digital examination of the rectum

Item

path. rekt. digit. Befund

boolean

C1384593 (UMLS CUI [1])

other injury of abdomen

Item

Sonstige:

text

C1260446 (UMLS CUI [1])

Physical examination of pelvis

Item Group

Becken

C0031809 (UMLS CUI-1)
C0030797 (UMLS CUI-2)

without finding

Item

o.B.

boolean

C0332288 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])

instability of pelvis

Item

instabil

boolean

C1389477 (UMLS CUI [1])

open wound

Item

offene Verletzung

boolean

C0559870 (UMLS CUI [1,1])
C0030797 (UMLS CUI [1,2])

other injury of pelvis

Item

Sonstige:

text

C0560636 (UMLS CUI [1])

Physical examination of limbs

Item Group

Obere/Untere Extremität

C0031809 (UMLS CUI-1)
C0015385 (UMLS CUI-2)

Lower limb

Item

Untere Extremität

text

C0031809 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0023216 (UMLS CUI [1,3])

compartment syndrome lower limb

Item

drohendes Kompartmentsyndrom

boolean

C0009492 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])

Upper limb

Item

Obere Extremität

text

C0031809 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C1140618 (UMLS CUI [1,3])

compartment syndrome of upper limb

Item

drohendes Kompartmentsyndrom

boolean

C0009492 (UMLS CUI [1,1])
C1140618 (UMLS CUI [1,2])

Diagnoses

Item Group

Diagnoses

Diagnosis

Item

Diagnose

text

C0011900 (UMLS CUI [1])

Patient handover

Item Group

Übergabeprotokoll / Anordnungen

C3494290 (UMLS CUI-1)
C0586001 (UMLS CUI-3)

thrombosis prophylaxis

Item

Thromboseprophylaxe

text

C0199242 (UMLS CUI [1])

Antibiotics

Item

Antibiotikatherapie

text

C0003232 (UMLS CUI [1])

analgesics

Item

Analgetika

text

C0002771 (UMLS CUI [1])

food

Item

Kost

text

C0016452 (UMLS CUI [1])

infusion

Item

Infusionen

text

C1289919 (UMLS CUI [1])

medication

Item

Medikamente

text

C0013227 (UMLS CUI [1])

positioning aids

Item

Lagerunshilfen

text

C0182347 (UMLS CUI [1])

control sono abdomen

Item

Kontroll Sono Abdomen

boolean

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

time of control sono abdomen

Item

Zeitpunkt Kontroll Sono Abdomen

time

C0041618 (UMLS CUI [1,1])
C0000726 (UMLS CUI [1,2])
C1547403 (UMLS CUI [1,3])

control CCT

Item

Kontroll CCT

boolean

C3515744 (UMLS CUI [1])

time of control CCT

Item

Zeitpunkt Kontroll CCT

time

C3515744 (UMLS CUI [1,1])
C1547403 (UMLS CUI [1,2])

control CT

Item

Kontroll CT

integer

C0040405 (UMLS CUI [1])

control CT

Code List

Kontroll CT

CL Item

Thorax (1)

CL Item

Abdomen (2)

time of control CT

Item

Zeitpunkt Kontroll CT

time

C0040405 (UMLS CUI [1,1])
C1547403 (UMLS CUI [1,2])

hematologic tests

Item

Labor

boolean

C0018941 (UMLS CUI [1])

time of hematologic tests

Item

Zeitpunkt Labor

time

C0018941 (UMLS CUI [1,1])
C1547403 (UMLS CUI [1,2])

other arrangements

Item

Sonstiges

text

C0586001 (UMLS CUI [1])

Work-related accident

Item Group

Bei Arbeitsunfällen (BG)

C0586557 (UMLS CUI-1)

confraternity

Item

Berufsgenossenschaft

text

C3841800 (UMLS CUI [1])

city

Item

Ort

text

C2316883 (UMLS CUI [1])

profession

Item

Beschäftigt als

text

C0028811 (UMLS CUI [1])

engaged since

Item

seit

date

C0028811 (UMLS CUI [1,1])
C0439659 (UMLS CUI [1,2])

beginning of workday

Item

Beginn der Arbeit

time

C0680192 (UMLS CUI [1,1])
C0439659 (UMLS CUI [1,2])

Employer

Item

Betrieb

text

C1274022 (UMLS CUI [1])

posttraumatic behaviour

Item

Verhalten nach Unfall

text

initial treatment

Item

Erstbehandlung durch

text

C2065349 (UMLS CUI [1])

Comorbidity

Item

Unfallunabhängige Krankheiten

text

C0009488 (UMLS CUI [1])

do accident circumstances fit employers insurance requirements

Item

Sprechen Hergang und Befund gegen eine AU

integer

C0586557 (UMLS CUI [1])

do accident circumstances fit employers insurance requirements

Code List

Sprechen Hergang und Befund gegen eine AU

CL Item

nein (1)

CL Item

ja (2)

CL Item

muss BG klären (3)

Further treatment

Item

Weitere Behandlung

boolean

C0087111 (UMLS CUI [1,1])
C1517331 (UMLS CUI [1,2])

fit for work

Item

arbeitsfähig ab

date

C0578795 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])

sick leave certificate

Item

AU - Bescheinigung ausgestellt

boolean

C0007836 (UMLS CUI [1,1])
C0242807 (UMLS CUI [1,2])

sick leave duration less than 3 days

Item

AU <3 Tage

boolean

C0007836 (UMLS CUI [1,1])
C0439092 (UMLS CUI [1,2])
C1442459 (UMLS CUI [1,3])

sick leave duration

Item

AU Dauer ca.

text

C0007836 (UMLS CUI [1,1])
C0449238 (UMLS CUI [1,2])

general treatment by

Item

allg. Behandlung durch

integer

C1710470 (UMLS CUI [1])

general treatment by

Code List

allg. Behandlung durch

CL Item

durch:_____ (1)

CL Item

durch mich (2)

specify treating physician

Item

allg. Behandlung durch (bitte spezifizieren)

text

C1710470 (UMLS CUI [1])

special treatment

Item

bes. Behandlung

integer

special treatment

Code List

bes. Behandlung

CL Item

stationär (1)

CL Item

ambulant (2)

treating physician special treatment

Item

bes. Behandlung durch

integer

special treatment

Code List

bes. Behandlung durch

CL Item

durch:______ (1)

CL Item

durch uns (2)

treating physician special treatment

Item

bes. Behandlung durch (bitte spezifizieren)

text

employers insurance questionnaire

Item

BG-Ergänzungsbogen ausgefüllt (SHT, Verbrennung, Hand, Finger, Knie)

boolean

C3841800 (UMLS CUI [1,1])
C0034394 (UMLS CUI [1,2])

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Model Commentaren :

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Item Commentaren voor :

Emergency Room Point B in Time Part 2: Emergency Room Report UKM

Emergency Room Point B in Time Part 2: Emergency Room Report UKM

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