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ID
22323
Description
Routine documentation in German hospitals. Source file name: SD070109_Geburtenbogen. Examplary forms provided by DMI (http://www.dmi.de/)
Link
Keywords
Versions (5)
- 5/29/17 5/29/17 -
- 5/29/17 5/29/17 -
- 6/6/17 6/6/17 -
- 6/6/17 6/6/17 -
- 7/30/17 7/30/17 -
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May 29, 2017
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License
Creative Commons BY-NC 3.0
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Birth sheet Routine documentation in German hospitals DMI
Birth sheet Routine documentation in German hospitals DMI
- StudyEvent: ODM
Similar models
Birth sheet Routine documentation in German hospitals DMI
- StudyEvent: ODM
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Gynäkologie - Geburtshilfe: Allgemeine Informationen
Specifics
Item
Besonderheiten
text
Health insurance
Item
Krankenkasse
text
Gynecologist
Item
Frauenarzt
text
Estimated due date (EDD)
Item
ET
date
Last period
Item
LP
text
Gravida
Item
Grav.
text
Para
Item
Para
text
Allergies
Item
Allergien
text
Blood type of mother
Item
Blutgruppe d. Mutter
text
Date of admission
Item
Aufn. am
date
Diagnosis
Item
Diagnose
text
Day
Item
Tag
text
Month
Item
Mon.
text
Time
Item
Uhrzeit
time
Labor, spontaneous
Item
spontan
boolean
Induction of labor
Item
Einleitung mit
text
Day
Item
Tag
text
Month
Item
Mon.
text
Time
Item
Uhrzeit
time
CL Item
vorz. (premature)
CL Item
frühz. (early)
CL Item
rechtz. (timely)
CL Item
spontan (spontaneous)
CL Item
instrumentell (artificial)
CL Item
klar (clear)
CL Item
grün (green)
CL Item
erbsbreiartig (similar to pea-soup)
CL Item
sanguin. (sanguineous)
Day
Item
Tag
text
Month
Item
Mon.
text
Time
Item
Uhrzeit
time
Birth I, fetal position
Item
aus:
text
CL Item
Lokal (local)
CL Item
Pudendus (pudendal nerve)
CL Item
PDA (PDA)
CL Item
ITN (endotracheal anesthesia)
Day
Item
Tag
text
Month
Item
Mon.
text
Time
Item
Uhrzeit
time
Birth II, fetal position
Item
aus:
text
CL Item
Lokal (local)
CL Item
Pudendus (pudendal nerve)
CL Item
PDA (PDA)
CL Item
ITN (endotracheal anesthesia)
CL Item
spontan (spontaneous)
CL Item
operativ (operative)
Operative birth, method
Item
operativ durch:
text
Surgeon
Item
Operateur
text
Indication
Item
Indikation
text
Day
Item
Tag
text
Month
Item
Mon.
text
Time
Item
Uhrzeit
time
Spontaneous placental expulsion
Item
spontan
boolean
Cord-traction
Item
Cord-traction
boolean
Nachtastung
Item
Nachtastung
boolean
Manual placenta removal
Item
Man. Lösung
boolean
Curettage
Item
Curettage
boolean
Complete placenta
Item
vollst.
boolean
Incomplete placenta
Item
unvollst.
boolean
Infarcts
Item
Infarkte
boolean
Calcareous incrustation
Item
Kalkinkrustationen
boolean
Placenta histology
Item
Placenta-Histologie
boolean
Complete amniotic membranes
Item
vollst.
boolean
Incomplete amniotic membranes
Item
fehlen z. T.
boolean
Oxytocin, intravenous
Item
3 IE Oxytocin i. v.
boolean
Methergin, intravenous
Item
0,2 mg Methergin i. v.
boolean
Umbilical cord, normal insertion
Item
Nabelschnur: Insertio normal
boolean
Umbilical cord: Insertion
Item
Nabelschnur: Insertio
text
True umbilical cord knot
Item
Echter Knoten
boolean
Nuchal cord
Item
Umschlingung
boolean
Blood loss
Item
Blutverlust
integer
Intact perineum and vagina
Item
intakt
boolean
Perineal tear
Item
DR
boolean
Grade of perineal tear
Item
Grad DR
integer
Cervical tear
Item
Cervix-Riss
boolean
Episiotomy
Item
Epi
boolean
Vaginal-labial tear
Item
Scheiden-Labien-Riss
boolean
Combined lesions
Item
Komb. Schäden
boolean
Suture
Item
Art der Versorgung: Naht
boolean
Suture, site
Item
Art der Versorgung: Naht in
text
Anesthesia
Item
Art der Versorgung: Narkose
text
Extraordinary incidents during birth
Item
Außergewöhnliche Geburtsereignisse
text
Physician in charge of birth
Item
Geburtsleitung
text
Midwife
Item
Hebamme
text
Sex
Item
Geschlecht
text
Weight
Item
Gewicht
integer
Length
Item
Länge
float
Head circumference
Item
Kopfumfang
float
Shoulder circumference
Item
Schulterumfang
float
CL Item
durchgeführt (executed)
CL Item
abgelehnt (refused)
Konakion
Item
2 mg Konakion oral
boolean
Sex
Item
Geschlecht
text
Weight
Item
Gewicht
integer
Length
Item
Länge
integer
Head circumference
Item
Kopfumfang
integer
Shoulder circumference
Item
Schulterumfang
integer
CL Item
durchgeführt (executed)
CL Item
abgelehnt (refused)
Konakion
Item
2 mg Konakion oral
boolean
CL Item
überragen (Extend beyond the fingertips)
CL Item
schließen ab (Reach the fingertips)
CL Item
schließen nicht ab (Do not reach the fingertips)
CL Item
O (O)
CL Item
+ (+)
CL Item
++ (++)
CL Item
O (O)
CL Item
+ (+)
CL Item
++ (++)
CL Item
descendiert (descended)
CL Item
nicht descendiert (undescended)
CL Item
geschlossen (closed)
CL Item
klafft (gaping)
CL Item
+ (+)
CL Item
O (O)
CL Item
+ (+)
CL Item
O (O)
CL Item
blau, weiß (0)
CL Item
Stamm rosig, Extremit. blau (1)
CL Item
rosig (2)
CL Item
keine (0)
CL Item
Schnappatm., unregelm. (1)
CL Item
regelmäßig, kräftig (2)
CL Item
schlaff (0)
CL Item
träge Flexionsbewegung (1)
CL Item
gute Spontanbewegung (2)
CL Item
keine (0)
CL Item
gering (1)
CL Item
lebhaft (2)
CL Item
absent (0)
CL Item
<100 (1)
CL Item
>100 (2)
Artery
Item
Art.
boolean
Vein
Item
Ven.
boolean
Suctioning
Item
Absaugen
boolean
Pediatrician present at birth
Item
Pädiater bei Geburt anwesend
boolean
Presentation at pediatrician
Item
Vorstellung beim Pädiater
boolean
Presentation at pediatrician, reason
Item
Vorstellung beim Pädiater wegen
text
Transfer to pediatric clinic
Item
Verlegung in Kikl.
boolean
Transfer to pediatric clinic, reason
Item
Verlegung in Kikl. wegen
text
Oxygen mask
Item
O2-Maske
boolean
Intubation
Item
Intubation
boolean
Normal child development
Item
Kindesentwicklung normal
boolean
Child development, description
Item
Kindesentwicklung:
text
Medical history
Item
Eigenanamnese
text
Surgery
Item
OP
text
Family history
Item
Familien-Anamnese
text
Normal course
Item
Ungestörter Verlauf
text
Severe vomiting
Item
Starkes Erbrechen
text
Edemas, protein, hypertension
Item
Oedeme, Eiweiß, Hochdruck
text
Fever (also viral disease)
Item
Fieber (auch Viruserkrankungen)
text
Urinary tract infection
Item
Harnwegsinfektion
text
Bleeding during pregnancy
Item
Blutungen in der Schwangerschaft
text
Anemia
Item
Anämie
text
Surgery
Item
Operationen
text
Medication/Hormones
Item
Medikamente/Hormone
text
Other diseases/trouble
Item
Andere Erkrankungen/Beschwerden
text
Smoking, drugs, alcohol
Item
Rauchen, Drogen, Alkohol
text
Contraceptives
Item
Antikonzeptiva
text
Mode of conception
Item
Konzeptionsmodus
text
Rubella titer
Item
Röteln Titer
text
HBsAg
Item
HBsAg
text
Anti-D
Item
Anti D
text
Breastfeeding
Item
Stillen
text
Crédé desired
Item
Crédé erwünscht
text
Date
Item
Datum
date
Menstruation
Item
mens
text
Curettage
Item
Nachräumung (wo)
text
Complications
Item
Komplikationen
text
Date
Item
Datum
date
Type and place of delivery
Item
Entbindung: Art und Ort
text
Duration of delivery
Item
Entbindung: Dauer
text
Complications during delivery
Item
Entbindung: Komplikationen
text
CL Item
männlich (male)
CL Item
weiblich (female)
Weight of newborn
Item
Kind: Gewicht
text
Specifics of newborn
Item
Kind: Besonderheiten
text
Weeks
Item
weeks
integer
Resistance Index (RI)
Item
RI
float
Weeks
Item
weeks
integer
Pulsatility Index (PI)
Item
PI
float
Weeks
Item
weeks
integer
Resistance Index (RI)
Item
RI
float
Weeks
Item
weeks
integer
Resistance Index (RI)
Item
RI
float
Date
Item
Datum
date
Week of gestation
Item
SSW
integer
Arteria umbilicalis
Item
UMB
float
Arteria cerebri media
Item
ACM
float
Ducuts venosus
Item
Duct. ven.
text
Right Arteria uterina
Item
UT rechts
float
Left Arteria uterina
Item
UT links
float
Physician name
Item
Arzt
text
Calculated gestational age
Item
Rechnerisches Schwangerschaftsalter
text
Findings
Item
Befund
text
Crown-rump length (CRL)
Item
SSL
float
Cerebellum
Item
Zerebellum
float
Biparietal diameter/Occipitofrontal diameter
Item
BIP/FOD
float
Abdominal transverse diameter/Sagittal abdominal diameter
Item
ATD/ASD
float
Femur
Item
Femur
float
Fetal movements/cardiac activity
Item
Fetale Bewegung/Herzaktion
text
Position
Item
Lage/Stellung
text
Placental location
Item
Plazentasitz
text
Volume of amniotic fluid (AFI)
Item
Fruchtwassermenge (AFI)
text
Other
Item
Sonstiges
text
Picture
Item
Foto
text
Date
Item
Datum
date
Physician name
Item
Arzt
text
Health insurance
Item
Krankenkasse
text
Referring physician
Item
Einweisender Arzt
text
Referring physician, telephone number
Item
Tel.:
integer
Medical specialist
Item
Facharzt
text
Medical specialist, telephone number
Item
Tel.:
integer
Medical history
Item
Anamnese
text
Person taking medical history
Item
Erhoben von
text
Date
Item
Datum
date
Family history
Item
Familienanamnese
text
Family history, specifics
Item
keine Besonderheiten
boolean
Social history
Item
Sozialanamnese
text
Occupation of mother
Item
Beruf der Mutter
text
Occupation of father
Item
Beruf des Vaters
text
Personal medical history
Item
Eigene Anamnese
text
Allergy
Item
Allergie
text
Medication
Item
Medikamente
text
Nicotine
Item
Nikotin
text
Alcohol
Item
Alkohol
text
Specifics
Item
Besonderheiten
text
State at admission
Item
Aufnahmestatus
text
Heart
Item
Herz
text
Lungs
Item
Lunge
text
Abdomen
Item
Abdomen
text
Blood type
Item
Blutgruppe
text
Rh factor
Item
Rh Faktor
text
Antibodies
Item
Antikörper
text
Rubella titer
Item
Röteln-Titer
text
HbsAG
Item
HbsAG
text
Height
Item
Größe
text
Weight
Item
Gewicht
text
Edemata
Item
Ödeme
text
Varices
Item
Varizen
text
Urine test strip
Item
Urinstix
text
HIV
Item
HIV
text
Hepatitis C
Item
Hep C
text
Item Group
Jetzige Schwangerschaft Zyklusanamnese
Last period
Item
Letzte Periode
text
Estimated due date (EDD)
Item
ET
date
Date of conception based on ultrasound diagnostics
Item
Konz. Termin n. USD
date
Week of gestation
Item
SSW
text
Complications and diseases, current pregnancy
Item
Komplikationen + Krankheiten der jetzigen Schwangerschaft
text
In-patient treatment
Item
Stat. Behandlung
text
In-patient treatment, reason
Item
Warum?
text
In-patient treatment, duration
Item
Bis:
date
In-patient treatment, therapy
Item
Therapie
text
Date
Item
Datum
date
Time
Item
Uhrzeit
time
Observations
Item
Beobachtungen
text
Signature
Item
Unterschrift
text
Initials
Item
Handzeichen
text