ID

17843

Beschrijving

Standardized Discharge Summary used in France since March 2016, released by ATIH (Agence technique de l'information sur l'hospitalisation). Provided for MDM portal by Prof. Dr. Jean Marie RODRIGUES, Université Jean Monnet Saint Etienne/Lyon. Le résumé de sortie standardisé (RSS) groupé format 117, applicable à compter du 1er mars 2016, créé par l'Agence technique de l'information sur l'hospitalisation (ATIH). Fourni de Prof. Dr. Jean Marie RODRIGUES pour le MDM portal. http://www.atih.sante.fr/

Link

http://www.atih.sante.fr/

Trefwoorden

Versies (1)
  1. 05-10-16 05-10-16 -
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5 oktober 2016

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Creative Commons BY-NC 3.0
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Standardized Discharge Summary March 2016 Format 117 ATIH France

Engels Frans

Standardized Discharge Summary March 2016 Format 117 ATIH France

1 Formulieren  
RSS format grouped 117
Beschrijving

RSS format grouped 117

DRG Version
Beschrijving

DRG Version

Datatype

integer

Alias
UMLS CUI [1,1]
C0333052
UMLS CUI [1,2]
C0011928
Major Diagnostic Category
Beschrijving

Major Diagnostic Category

Datatype

integer

Alias
UMLS CUI [1]
C1550395
DRG ID
Beschrijving

DRG ID

Datatype

text

Alias
UMLS CUI [1]
C0011928
Filler
Beschrijving

NA / space

Datatype

text

RSS Version Format
Beschrijving

RSS Version Format

Datatype

text

Wrong Code
Beschrijving

Wrong Code

Datatype

integer

Alias
UMLS CUI [1,1]
C3827420
UMLS CUI [1,2]
C0011928
FINESS-Number of registration ePMSI
Beschrijving

Means the number of health facility in the national health and social facilities (FINESS) file. It must be registered in the RUM:-number FINESS of the legal entity for public health institutions -the number of FINESS of the geographical entity for private healthcare facilities.

Datatype

text

Version of the RUM format
Beschrijving

The description of computer formats of summaries of activity and information of medical units file is available on the website of the ATIH. Are also indicated the dates from which these formats are required, as well as their validity period. Healthcare facilities should ensure strict compliance with these standards and formats, otherwise data could not be taken into account in the various treatments.

Datatype

integer

RSS Number
Beschrijving

Left/space

Datatype

text

Administrative Local Identifier of stay
Beschrijving

Left/space

Datatype

text

Alias
UMLS CUI [1,1]
C0600091
UMLS CUI [1,2]
C0184666
RUM No.
Beschrijving

Left/space

Datatype

text

Date of birth
Beschrijving

Date of Birth

Datatype

date

Alias
UMLS CUI [1]
C0421451
Sex
Beschrijving

Gender

Datatype

integer

Alias
UMLS CUI [1]
C0079399
Medical unit ID
Beschrijving

Left/space

Datatype

text

Alias
UMLS CUI [1,1]
C1555565
UMLS CUI [1,2]
C0019988
Authorization of type of bed
Beschrijving

Right/Zero

Datatype

integer

Alias
UMLS CUI [1,1]
C1547328
UMLS CUI [1,2]
C0004916
Date of admission to medical unit
Beschrijving

Admission Date Medical Unit

Datatype

date

Alias
UMLS CUI [1]
C1302393
Admission type to the medical unit
Beschrijving

Admission Type

Datatype

integer

Alias
UMLS CUI [1]
C1550330
Previous Medical Unit (if entry mode transfer, transfer or home)
Beschrijving

Previous Medical Unit

Datatype

integer

Alias
UMLS CUI [1,1]
C0205156
UMLS CUI [1,2]
C0019988
Discharge Date
Beschrijving

Discharge Date

Datatype

date

Alias
UMLS CUI [1]
C2361123
Discharge Type
Beschrijving

Discharge Type

Datatype

integer

Alias
UMLS CUI [1]
C0586514
Destination (if Discharge Type transfer, transfer or home)
Beschrijving

Destination

Datatype

integer

Alias
UMLS CUI [1]
C0079220
Postal code of residence (or 99 followed code of the oversea country for patients living outside France)
Beschrijving

Right/Zero

Datatype

integer

Alias
UMLS CUI [1]
C0421454
Weight of the newborn at admission date to the medical unit (in grams)
Beschrijving

Right/Zero

Datatype

integer

Maateenheden
  • g
Alias
UMLS CUI [1]
C2712830
g
Gestational age
Beschrijving

Right/Zero

Datatype

integer

Alias
UMLS CUI [1]
C0017504
Date of your last period
Beschrijving

Date Last Menstrual Period

Datatype

date

Alias
UMLS CUI [1]
C0425932
Number of Visits
Beschrijving

Right/Zero

Datatype

integer

Alias
UMLS CUI [1,1]
C0449788
UMLS CUI [1,2]
C0545082
Number of associated diagnoses (nDA) in this RUM
Beschrijving

Right/Zero

Datatype

integer

Alias
UMLS CUI [1,1]
C0449788
UMLS CUI [1,2]
C0243087
Number of data (nDAD) documented in this RUM
Beschrijving

Right/Zero

Datatype

integer

Number of procedures (nZA) in this RUM
Beschrijving

Right/Zero

Datatype

integer

Alias
UMLS CUI [1,1]
C1265611
UMLS CUI [1,2]
C2700391
Main diagnosis (PD)
Beschrijving

Left/space The DP can be: -a disease, a syndrome, a symptom, a traumatic injury or poisoning classified in chapters I to XIX or XXII105F 1 of ICD-10 - or one of the entities classified in chapter XXI factors influencing health status and patterns of use of health services ('codes Z').

Datatype

text

Alias
UMLS CUI [1]
C0332137
Concomitant diagnosis (DR)
Beschrijving

Left/space

Datatype

text

Alias
UMLS CUI [1]
C0243087
SAPS II
Beschrijving

Right/Zero Simplified severity index

Datatype

integer

Alias
UMLS CUI [1]
C0451481
Confirmation of the coding of the RSS
Beschrijving

Confirmation of RSS Code

Datatype

integer

Alias
UMLS CUI [1,1]
C0521091
UMLS CUI [1,2]
C0009219
Type of Radiotherapy Device
Beschrijving

Radiotherapy Device

Datatype

integer

Alias
UMLS CUI [1]
C0302617
Type of dosimetry
Beschrijving

Type of Dosimetry

Datatype

integer

Alias
UMLS CUI [1]
C0034603
Study Participation ID
Beschrijving

Left/space

Datatype

text

Alias
UMLS CUI [1]
C2242969
Number of previous abortions
Beschrijving

Right/Zero

Datatype

integer

Alias
UMLS CUI [1,1]
C1265611
UMLS CUI [1,2]
C0392535
Year of latest abortion
Beschrijving

Right/Zero

Datatype

integer

Alias
UMLS CUI [1,1]
C0439234
UMLS CUI [1,2]
C0392535
Number of previous live births
Beschrijving

Right/Zero

Datatype

integer

Alias
UMLS CUI [1]
C2114488
Reserved Space
Beschrijving

NA / space

Datatype

integer

Filler
Beschrijving

NA / space

Datatype

text

Diagnosis associated with
Beschrijving

Diagnosis associated with

Concomitant Diagnosis n° nDA
Beschrijving

Left/space Diagnosis associated with

Datatype

text

Alias
UMLS CUI [1,1]
C2348235
UMLS CUI [1,2]
C0243087
Further Data
Beschrijving

Further Data

Further Data n° nDAD
Beschrijving

Left/space, max 8 A documentary aiming (DAD) data can be any kind of information: a Figure, a procedure code or diagnosis or natural language. If the BOMs of coding are used, they may be those of ISMP or any other. The DAD entry is optional. They do not affect the classification into homogeneous groups sick and are not included in the anonymous release Summary: instead of the diagnoses associated with (significant and conventional), they are therefore not passed on to the regional health agency.

Datatype

text

Alias
UMLS CUI [1,1]
C2348235
UMLS CUI [1,2]
C1511726
Procedures
Beschrijving

Procedures

Date of Procedure performed
Beschrijving

Date of Procedure

Datatype

date

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C2700391
Code Healthcare Common Procedure Coding System
Beschrijving

Common classification of medical procedures.

Datatype

text

Alias
UMLS CUI [1]
C1140148
Extension PMSI
Beschrijving

Medicalization of information systems program

Datatype

text

Phase
Beschrijving

almost always '0' (only a small number of acts are a realization in distinct phases)

Datatype

integer

Alias
UMLS CUI [1]
C0205390
Activity
Beschrijving

authorized activities

Datatype

text

Alias
UMLS CUI [1,1]
C1555472
UMLS CUI [1,2]
C2700391
Further Documentation
Beschrijving

Further Documentation

Datatype

text

Alias
UMLS CUI [1,1]
C1517331
UMLS CUI [1,2]
C0920316
Reimbursement Modifiers
Beschrijving

Left/space

Datatype

text

Exceptional Reimbursement
Beschrijving

Exceptional Reimbursement

Datatype

text

Alias
UMLS CUI [1,1]
C0035002
UMLS CUI [1,2]
C0750577
Combination of Procedures
Beschrijving

Combination of Procedures

Datatype

text

Alias
UMLS CUI [1,1]
C0205195
UMLS CUI [1,2]
C2700391
UMLS CUI [1,3]
C2700391
Times the procedure has been performed
Beschrijving

Right/Zero

Datatype

integer

Alias
UMLS CUI [1,1]
C1265611
UMLS CUI [1,2]
C2700391
UMLS CUI [1,3]
C0884358
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Similar models

Standardized Discharge Summary March 2016 Format 117 ATIH France

1 Formulieren
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
RSS format grouped 117
DRG Version
Item
DRG Version
integer
C0333052 (UMLS CUI [1,1])
C0011928 (UMLS CUI [1,2])
Major Diagnostic Category
Item
Major Diagnostic Category
integer
C1550395 (UMLS CUI [1])
DRG ID
Item
DRG ID
text
C0011928 (UMLS CUI [1])
Filler
Item
Filler
text
RSS Version Format
Item
RSS Version Format
text
Wrong Code
Item
Wrong Code
integer
C3827420 (UMLS CUI [1,1])
C0011928 (UMLS CUI [1,2])
FINESS number
Item
FINESS-Number of registration ePMSI
text
RUM format number
Item
Version of the RUM format
integer
RSS Number
Item
RSS Number
text
Hospital Admission Number
Item
Administrative Local Identifier of stay
text
C0600091 (UMLS CUI [1,1])
C0184666 (UMLS CUI [1,2])
RUM Number
Item
RUM No.
text
Date of Birth
Item
Date of birth
date
C0421451 (UMLS CUI [1])
Item
Sex
integer
C0079399 (UMLS CUI [1])
Gender
Code List
Sex
CL Item
male (1)
CL Item
female (2)
Medical Unit ID
Item
Medical unit ID
text
C1555565 (UMLS CUI [1,1])
C0019988 (UMLS CUI [1,2])
Authorization Type Bed
Item
Authorization of type of bed
integer
C1547328 (UMLS CUI [1,1])
C0004916 (UMLS CUI [1,2])
Admission Date Medical Unit
Item
Date of admission to medical unit
date
C1302393 (UMLS CUI [1])
Item
Admission type to the medical unit
integer
C1550330 (UMLS CUI [1])
Admission Type
Code List
Admission type to the medical unit
CL Item
Internal transfer (6)
CL Item
Permanent transfer (7)
CL Item
Temporary transfer (0)
CL Item
Home (8)
CL Item
Death (9)
Item
Previous Medical Unit (if entry mode transfer, transfer or home)
integer
C0205156 (UMLS CUI [1,1])
C0019988 (UMLS CUI [1,2])
Previous Medical Unit
Code List
Previous Medical Unit (if entry mode transfer, transfer or home)
CL Item
From a unit of Medicine, Surgery, Gynecology-Obstetrics, except intensive care unit (1)
CL Item
From a resuscitation unit (R)
CL Item
From a care and rehabilitation unit (2)
CL Item
From a long-term care unit (3)
CL Item
From a psychiatric unit (4)
CL Item
With passage through the emergency department  (5)
CL Item
From a hospital close to patient's home (6)
CL Item
From an assisted-living institution (7)
Discharge Date
Item
Discharge Date
date
C2361123 (UMLS CUI [1])
Item
Discharge Type
integer
C0586514 (UMLS CUI [1])
Admission Type
Code List
Discharge Type
CL Item
Internal transfer (6)
CL Item
Permanent transfer (7)
CL Item
Temporary transfer (0)
CL Item
Home (8)
CL Item
Death (9)
Item
Destination (if Discharge Type transfer, transfer or home)
integer
C0079220 (UMLS CUI [1])
Destination
Code List
Destination (if Discharge Type transfer, transfer or home)
CL Item
To a unit (Medicine, surgery, gynecology-obstetrics) (1)
CL Item
To a care and rehabilitation unit (2)
CL Item
To a long-term care unit  (3)
CL Item
To a psychiatric unit (4)
CL Item
To a hospital close to patient's home (6)
CL Item
To an assisted-living institution (7)
Postal Code
Item
Postal code of residence (or 99 followed code of the oversea country for patients living outside France)
integer
C0421454 (UMLS CUI [1])
Weight Newborn
Item
Weight of the newborn at admission date to the medical unit (in grams)
integer
C2712830 (UMLS CUI [1])
Gestational Age
Item
Gestational age
integer
C0017504 (UMLS CUI [1])
Date Last Menstrual Period
Item
Date of your last period
date
C0425932 (UMLS CUI [1])
Number of Visits
Item
Number of Visits
integer
C0449788 (UMLS CUI [1,1])
C0545082 (UMLS CUI [1,2])
Number of Concomitant Diseases
Item
Number of associated diagnoses (nDA) in this RUM
integer
C0449788 (UMLS CUI [1,1])
C0243087 (UMLS CUI [1,2])
Number of documented data
Item
Number of data (nDAD) documented in this RUM
integer
Number of Procedures
Item
Number of procedures (nZA) in this RUM
integer
C1265611 (UMLS CUI [1,1])
C2700391 (UMLS CUI [1,2])
Main Diagnosis
Item
Main diagnosis (PD)
text
C0332137 (UMLS CUI [1])
Concomitant Diagnosis
Item
Concomitant diagnosis (DR)
text
C0243087 (UMLS CUI [1])
SAPS II
Item
SAPS II
integer
C0451481 (UMLS CUI [1])
Item
Confirmation of the coding of the RSS
integer
C0521091 (UMLS CUI [1,1])
C0009219 (UMLS CUI [1,2])
Confirmation of RSS Code
Code List
Confirmation of the coding of the RSS
CL Item
Yes (1)
CL Item
No (2)
Item
Type of Radiotherapy Device
integer
C0302617 (UMLS CUI [1])
Radiotherapy Device
Code List
Type of Radiotherapy Device
CL Item
Tomotherapy®, Novalis®, Cyberknife® or proton therapy (1)
CL Item
Device equipped with portal imaging, MLC, recording and control system with repositioning patient module (2)
CL Item
Device equipped with portal imaging, MLC, recording and control system without repositioning patient module (3)
CL Item
Device not equipped with portal imaging, MLC or recording and control system (4)
Item
Type of dosimetry
integer
C0034603 (UMLS CUI [1])
Type of Dosimetry
Code List
Type of dosimetry
CL Item
IMRT dosimetry (1 )
CL Item
three-dimensional with HDV on target volume and organ at risk (2 )
CL Item
three-dimensional without HDV on target volume and organ at risk (3 )
CL Item
another type of dosimetry (4 )
Study Number
Item
Study Participation ID
text
C2242969 (UMLS CUI [1])
Number of Previous Abortions
Item
Number of previous abortions
integer
C1265611 (UMLS CUI [1,1])
C0392535 (UMLS CUI [1,2])
Year Previous Abortion
Item
Year of latest abortion
integer
C0439234 (UMLS CUI [1,1])
C0392535 (UMLS CUI [1,2])
Number of Live Births
Item
Number of previous live births
integer
C2114488 (UMLS CUI [1])
Reserved Space
Item
Reserved Space
integer
Filler
Item
Filler
text
Item Group
Diagnosis associated with
Concomitant Diagnosis n° nDA
Item
Concomitant Diagnosis n° nDA
text
C2348235 (UMLS CUI [1,1])
C0243087 (UMLS CUI [1,2])
Item Group
Further Data
Further Data n° nDAD
Item
Further Data n° nDAD
text
C2348235 (UMLS CUI [1,1])
C1511726 (UMLS CUI [1,2])
Item Group
Procedures
Date of Procedure
Item
Date of Procedure performed
date
C0011008 (UMLS CUI [1,1])
C2700391 (UMLS CUI [1,2])
CCAM Code
Item
Code Healthcare Common Procedure Coding System
text
C1140148 (UMLS CUI [1])
Extension PMSI
Item
Extension PMSI
text
Phase
Item
Phase
integer
C0205390 (UMLS CUI [1])
Activity
Item
Activity
text
C1555472 (UMLS CUI [1,1])
C2700391 (UMLS CUI [1,2])
Further Documentation
Item
Further Documentation
text
C1517331 (UMLS CUI [1,1])
C0920316 (UMLS CUI [1,2])
Modifier
Item
Reimbursement Modifiers
text
Exceptional Reimbursement
Item
Exceptional Reimbursement
text
C0035002 (UMLS CUI [1,1])
C0750577 (UMLS CUI [1,2])
Combination of Procedures
Item
Combination of Procedures
text
C0205195 (UMLS CUI [1,1])
C2700391 (UMLS CUI [1,2])
C2700391 (UMLS CUI [1,3])
Times Procedure Performed
Item
Times the procedure has been performed
integer
C1265611 (UMLS CUI [1,1])
C2700391 (UMLS CUI [1,2])
C0884358 (UMLS CUI [1,3])
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