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ID
10048
Description
Documentation form for quality assurance in German Health Care by the institute forapplied quality Improvement and Research in Health Care (Aqua), https://www.aqua-institut.de/en/home. Internal Aqua form version: HEP-B Specification 2015 V02
Link
https://www.aqua-institut.de/en/home
Keywords
Versions (3)
- 11/23/14 11/23/14 - Julian Varghese
- 3/21/15 3/21/15 - Sarah Schulze Sünninghausen
- 9/5/19 9/5/19 - Julian Varghese
Uploaded on
March 21, 2015
DOI
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License
Creative Commons BY-NC 3.0 Legacy
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Quality assurance Hip Replacement - Basic (AQUA)
Quality assurance Hip Replacement - Basic (AQUA)
- StudyEvent: SE
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Quality assurance Hip Replacement - Basic (AQUA)
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Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
eGK-Versichertennummer
Item
Patient insurance ID
text
C1548070 (UMLS CUI-1)
Institutionskennzeichen
Item
Healthcare Facility Identifier
integer
C2986045 (UMLS CUI-1)
entlassender Standort ([0-9]{2})
Item
Zip Code of Discharge
text
C1521842 (UMLS CUI-1)
Betriebsstätten-Nummer
Item
Facility's Section Identifier
text
C1547540 (UMLS CUI-1)
CL Item
internal medicine (0100)
CL Item
internal medicine: geriatrics (0102)
CL Item
internal medicine: cardiology (0103)
CL Item
internal medicine: nephrology (0104)
CL Item
internal medicine: hematology and internal oncology (0105)
CL Item
internal medicine: endocrinology (0106)
CL Item
internal medicine: gastroenterology (0107)
CL Item
internal medicine: pneumonology (0108)
CL Item
internal medicine: rheumatology (0109)
CL Item
internal medicine: pulmonology (0114)
CL Item
internal medicine: tumor research (0150)
CL Item
internal medicine: coloproctology (0151)
CL Item
internal medicine: infectiology (0152)
CL Item
internal medicine: diabetes (0153)
CL Item
internal medicine: naturopathy (0154)
CL Item
internal medicine: stroke unit (0156)
CL Item
internal medicine (0190)
CL Item
geriatry (0200)
CL Item
geriatry: gynecology (0224)
CL Item
geriatry: day unit (for semi-residential care) (0260)
CL Item
geriaty: night unit (for semi-residential care) (0261)
CL Item
geriatry (0290)
CL Item
cardiology (0300)
CL Item
nephrology (0400)
CL Item
nephrology: pediatrics (0410)
CL Item
nephrology: intensive care (0436)
CL Item
nephrology (0490)
CL Item
hematology and internal oncology (0500)
CL Item
hematology and internal oncology: pediatrics (0510)
CL Item
hematology and internal oncology: gynacology (0524)
CL Item
hematology and internal oncology: radiation therapy (0533)
CL Item
hematology and internal oncology (0590)
CL Item
endocrinology (0600)
CL Item
endicrinology: gastroenterology (0607)
CL Item
endocrinology: pediatrics (0610)
CL Item
endocrinology (0690)
CL Item
gastroenterology (0700)
CL Item
gastroenterology: endocrinology (0706)
CL Item
gastroenterology: pediatrics (0710)
CL Item
gastroenterology (0790)
CL Item
pneumology (0800)
CL Item
rheumatology (0900)
CL Item
rheumatology: pediatrics (0910)
CL Item
rheumatology (0990)
CL Item
pediatrics (1000)
CL Item
pediatrics: nephrology (1004)
CL Item
pediatrics: hematology and internal oncology (1005)
CL Item
pediatrics: endocrinology (1006)
CL Item
pediatrics: gastroenterology (1007)
CL Item
pediatrics: rheumatology (1009)
CL Item
pediatrics: pediatric cardiology (1011)
CL Item
pediatrics: nephrology (1012)
CL Item
pediatrics: pulmonology (1014)
CL Item
pediatrics: pediatric neurology (1028)
CL Item
pediatrics: perinatal medicine (1050)
CL Item
continuing care for children (1051)
CL Item
pediatrics (1090)
CL Item
pediatric cardiology (1100)
CL Item
pediatric cardiology: intensive care (1136)
CL Item
pediatric cardiology (1190)
CL Item
neonatology (1200)
CL Item
pediatric surgery (1300)
CL Item
pulmonology (1400)
CL Item
pulmonology: pediatrics (1410)
CL Item
pulmonology (1490)
CL Item
general surgery (1500)
CL Item
general surgery: pediatric surgery (1513)
CL Item
general surgery: trauma surgery (1516)
CL Item
general surgery: vascular surgery (1518)
CL Item
general surgery: plastic surgery (1519)
CL Item
general surgery: thoracic surgery (1520)
CL Item
general surgery: orthopedics (1523)
CL Item
general surgery: intensive care (1536)
CL Item
general surgery: abdominal- and vascular surgery (1550)
CL Item
Allgemeine Chirurgie: hand surgery (1551)
CL Item
general surgery (1590)
CL Item
trauma surgery (1600)
CL Item
neurosurgery (1700)
CL Item
vascular surgery (1800)
CL Item
plastic surgery (1900)
CL Item
thoracic surgery (2000)
CL Item
thoracic surgery: cardiac surgery (2021)
CL Item
thoracic surgery: intensive care (2036)
CL Item
thoracic surgery: cardiac surgery intensive care (2050)
CL Item
thoracic surgery (2090)
CL Item
cardiac surgery (2100)
CL Item
cardiac surgery: vascular surgery (2118)
CL Item
cardiac surgery: thoracic surgery (2120)
CL Item
cardiac surgery: intensive care (2136)
CL Item
cardiac surgery: thoracic surgery and intensive care (2150)
CL Item
cardiac surgery (2190)
CL Item
urology (2200)
CL Item
orthopedics (2300)
CL Item
orthopedics: rheumatology (2309)
CL Item
orthopedics: surgery (2315)
CL Item
orthopedics and trauma surgery (2316)
CL Item
orthopedics (2390)
CL Item
gynecology and obstetrics (2400)
CL Item
gynecology: geriatry (2402)
CL Item
gynecology: hematology and internal oncology (2405)
CL Item
gynecology: endocrinology (2406)
CL Item
gynecology (2425)
CL Item
gynecology and obstetrics (2490)
CL Item
obstetrics (2500)
CL Item
otolaryngology (2600)
CL Item
ophthalmology (2700)
CL Item
neurology: (2800)
CL Item
neurology: pediatrics (2810)
CL Item
neurology: stroke units (2856)
CL Item
neurology (2890)
CL Item
general psychiatry: (2900)
CL Item
general psychiatry: neurology (2928)
CL Item
general psychiatry: child and adolescent psychiatry (2930)
CL Item
general psychiatry: psychosomatics and psychotherapy (2931)
CL Item
general psychiatry: addiction treatment (2950)
CL Item
general psychiatry: geropsychiatry (2951)
CL Item
general psychiatry: forensic treatment (2952)
CL Item
general psychiatry: addiction treatment (day unit) (2953)
CL Item
general psychiatry: addiction treatment (night unit) (2954)
CL Item
general psychiatry: geropsychiatry (day unit) (2955)
CL Item
general psychiatry: geropsychiatry (night unit) (2956)
CL Item
general psychiatry: day unit (for semi-residential care) (2960)
CL Item
general psychiatry: night unit (for semi-residential care) (2961)
CL Item
general psychiatry (2990)
CL Item
child and adolescent psychiatry (3000)
CL Item
child and adolescent psychiatry: day unit (for semi-residential care) (3060)
CL Item
child and adolescent psychiatry: night unit (for semi-residential care) (3061)
CL Item
child and adolescent psychiatry (3090)
CL Item
psychosomatic/psychotherapy (3100)
CL Item
psychosomatic/psychotherapy: child and adolescent psychiatry (3110)
CL Item
psychosomatic/psychotherapy: day unit (for semi-residential care) (3160)
CL Item
psychosomatic/psychotherapy: night unit (for semi-residential care) (3161)
CL Item
psychosomatic/psychotherapy (3190)
CL Item
nuclear medicine (3200)
CL Item
nuclear medicine: radiation therapy (3233)
CL Item
nuclear medicine (3290)
CL Item
radiation therapy (3300)
CL Item
radiation therapy: hematology and internal oncology (3305)
CL Item
radiation therapy: radiology (3350)
CL Item
radiation therapy (3390)
CL Item
dermatology (3400)
CL Item
dermatology: day unit (for semi-residential care) (3460)
CL Item
dermatology (3490)
CL Item
dentistry, orthodontics, maxillofacial surgery (3500)
CL Item
intensive-care medicine (3600)
CL Item
intensive-care medicine: internal medicine (3601)
CL Item
intensive-care medicine: cardiology (3603)
CL Item
intensive-care medicine: pediatrics (3610)
CL Item
intensive-care medicine: neurosurgery (3617)
CL Item
intensive-care medicine: surgery (3618)
CL Item
intensive-care medicine: cardiac surgery (3621)
CL Item
intensive-care medicine: urology (3622)
CL Item
intensive-care medicine: gynecology and obstetrics (3624)
CL Item
intensive-care medicine: otolaryngology (3626)
CL Item
intensive-care medicine: neurology (3628)
CL Item
operative intensive-care medicine: surgery (3650)
CL Item
intensive-care medicine: thorax-heart surgery (3651)
CL Item
intensive-care medicine: heart-thorax surgery (3652)
CL Item
intensive-care medicine (3690)
CL Item
other medical specialty (3700)
CL Item
angiology (3750)
CL Item
radiology (3751)
CL Item
palliative care (3752)
CL Item
pain therapy (3753)
CL Item
section for alternative health practice (3754)
CL Item
spinal surgery (3755)
CL Item
addiction medicine (3756)
CL Item
visceral surgery (3757)
CL Item
other medical specialty (3790)
einrichtungsinterne Identifikationsnummer des Patienten
Item
Patient identification number
text
C1549734 (UMLS CUI-1)
Aufnahmedatum (TT.MM.JJJJ)
Item
Hospital admission date (DD.MM.YYYY)
date
C1302393 (UMLS CUI-1)
Aufnahmeuhrzeit
Item
Admission time (hh:mm)
text
C2215405 (UMLS CUI-1)
CL Item
hospitalization, inpatient, normally (0101 )
CL Item
hospitalization, inpatient, accidents at work / occupational disease (11, para. 5 SGB V) (0102 )
CL Item
hospitalization, inpatient, traffic accident / sports accident / other accidents (eg 116 SGB X) (0103 )
CL Item
hospitalization, inpatient, reference to the action of external force (0104 )
CL Item
hospitalization, inpatient, free (0105 )
CL Item
hospitalization, inpatient, war-Cripples -suffering / BVG-suffering (0106 )
CL Item
hospitalization, inpatient, emergency (0107 )
CL Item
hospitalization, inpatient, normally, payers exchange (0121 )
CL Item
hospitalization, inpatient, accidents at work / occupational disease (11, para. 5 SGB V) cost carrier exchange (0122 )
CL Item
hospitalization, inpatient, traffic accident / sports accident / other accidents (eg 116 SGB X) Cost volume change (0123 )
CL Item
hospitalization, inpatient, reference to the action of external force, payers exchange (0124 )
CL Item
hospitalization, inpatient, free, payers exchange (0125 )
CL Item
hospitalization, inpatient, war wounded Cripples / BVG-suffering, payers exchange (0126 )
CL Item
hospitalization, inpatient, emergency, payers exchange (0127 )
CL Item
hospitalization, inpatient, normally, IV (0141 )
CL Item
hospitalization, inpatient, accidents at work / occupational disease (11, para. 5 SGB V), IV (0142 )
CL Item
hospitalization, inpatient, traffic accident / sports accident / other accidents (eg 116 SGB X), IV (0143 )
CL Item
hospitalization, inpatient, reference to the action of external force, by IV (0144 )
CL Item
hospitalization, inpatient, free, IV (0145 )
CL Item
hospitalization, inpatient, war wounded Cripples / BVG-suffering, IV (0146 )
CL Item
hospitalization, inpatient, emergency, IV (0147 )
CL Item
hospitalization, inpatient with prior pre-admission treatment, usually (0201 )
CL Item
hospitalization, inpatient with prior pre-admission treatment, industrial injury / occupational disease (11, para. 5 SGB V) (0202 )
CL Item
hospitalization, inpatient with prior pre-admission treatment, traffic accident / sports accident / other accidents (eg 116 SGB X) (0203 )
CL Item
hospitalization, inpatient with prior pre-admission treatment, reference to the action of external force (0204 )
CL Item
hospitalization, inpatient with prior treatment pre-admission free (0205 )
CL Item
hospitalization, inpatient with prior treatment pre-admission, war wounded Cripples / BVG-suffering (0206 )
CL Item
hospitalization, inpatient with prior pre-admission care, emergency (0207 )
CL Item
hospitalization, inpatient with prior pre-admission treatment, normally, payers exchange (0221 )
CL Item
hospitalization, inpatient with prior pre-admission treatment, industrial injury / occupational disease (11, para. 5 SGB V), payers exchange (0222 )
CL Item
hospitalization, inpatient with prior pre-admission treatment, traffic accident / sports accident / other accidents (eg 116 SGB X), cost volume change (0223 )
CL Item
hospitalization, inpatient with prior pre-admission treatment, reference to the action of external force, payers exchange (0224 )
CL Item
hospitalization, inpatient with prior treatment pre-admission, free, payers exchange (0225 )
CL Item
hospitalization, inpatient with prior treatment pre-admission, war wounded Cripples / BVG-suffering, payers exchange (0226 )
CL Item
hospitalization, inpatient with prior pre-admission care, emergency, payers exchange (0227 )
CL Item
hospitalization, inpatient with prior pre-admission treatment, normally, IV (0241 )
CL Item
hospitalization, inpatient with prior pre-admission treatment, industrial injury / occupational disease (11, para. 5 SGB V), IV (0242 )
CL Item
hospitalization, inpatient with prior pre-admission treatment, traffic accident / sports accident / other accidents (eg 116 SGB X), IV (0243 )
CL Item
hospitalization, inpatient with prior pre-admission treatment, indication of the effect of external violence, IV (0244 )
CL Item
hospitalization, inpatient with prior treatment pre-admission, free, IV (0245 )
CL Item
hospitalization, inpatient with prior treatment pre-admission, war wounded Cripples / BVG-suffering, IV (0246 )
CL Item
hospitalization, inpatient with prior pre-admission care, emergency, IV (0247 )
CL Item
hospitalization, day patient, usually (0301 )
CL Item
hospitalization, day patient, accidents at work / occupational disease (11, para. 5 SGB V) (0302 )
CL Item
hospitalization, day patient, traffic accident / sports accident / other accidents (eg 116 SGB X) (0303 )
CL Item
hospitalization, day patient, regard to the action of external force (0304 )
CL Item
hospitalization, day patient, free (0305 )
CL Item
hospitalization, day patient, war wounded Cripples / BVG-suffering (0306 )
CL Item
hospital treatment, partial inpatient, emergency (0307 )
CL Item
hospitalization, day patient, normally, payers exchange (0321 )
CL Item
hospitalization, day patient, accidents at work / occupational disease (11, para. 5 SGB V), payers exchange (0322 )
CL Item
hospitalization, day patient, traffic accident / sports accident / other accidents (eg 116 SGB X), cost volume change (0323 )
CL Item
hospitalization, day patient, regard to the action of external force, payers exchange (0324 )
CL Item
hospitalization, day patient, free, payers exchange (0325 )
CL Item
hospitalization, day patient, war wounded Cripples / BVG-suffering, payers exchange (0326 )
CL Item
hospital treatment, partial inpatient, emergency, payers exchange (0327 )
CL Item
hospitalization, day patient, normally, IV (0341 )
CL Item
hospitalization, day patient, accidents at work / occupational disease (11, para. 5 SGB V), IV (0342 )
CL Item
hospitalization, day patient, traffic accident / sports accident / other accidents (eg 116 SGB X), IV (0343 )
CL Item
hospitalization, day patient, regard to the action of external force, by IV (0344 )
CL Item
hospitalization, day patient, free, IV (0345 )
CL Item
hospitalization, day patient, war wounded Cripples / BVG-suffering, IV (0346 )
CL Item
hospital treatment, partial inpatient, emergency, IV (0347 )
CL Item
pre-admission treatment without subsequent inpatient treatment, usually (0401 )
CL Item
pre-admission treatment without subsequent inpatient treatment, industrial injury / occupational disease (11, para. 5 SGB V) (0402 )
CL Item
pre-admission treatment without subsequent inpatient treatment, traffic accident / sports accident / other accidents (eg 116 SGB X) (0403 )
CL Item
pre-admission treatment without subsequent inpatient treatment, reference to the action of external force (0404 )
CL Item
pre-admission treatment without subsequent inpatient treatment, free (0405 )
CL Item
pre-admission treatment without subsequent inpatient treatment, War Cripples suffering / BVG-suffering (0406 )
CL Item
pre-admission treatment without subsequent inpatient care, emergency (0407 )
CL Item
pre-admission treatment without subsequent inpatient treatment, normally, payers exchange (0421 )
CL Item
pre-admission treatment without subsequent inpatient treatment, industrial injury / occupational disease (11, para. 5 SGB V), payers exchange (0422 )
CL Item
pre-admission treatment without subsequent inpatient treatment, traffic accident / sports accident / other accidents (eg 116 SGB X), cost volume change (0423 )
CL Item
pre-admission treatment without subsequent inpatient treatment, reference to the action of external force, payers exchange (0424 )
CL Item
pre-admission treatment without subsequent inpatient treatment, free, payers exchange (0425 )
CL Item
pre-admission treatment without subsequent inpatient treatment, War Cripples suffering / BVG-suffering, payers exchange (0426 )
CL Item
pre-admission treatment without subsequent inpatient care, emergency, payers exchange (0427 )
CL Item
pre-admission treatment without subsequent inpatient treatment, normally, IV (0441 )
CL Item
pre-admission treatment without subsequent inpatient treatment, industrial injury / occupational disease (11, para. 5 SGB V), IV (0442 )
CL Item
pre-admission treatment without subsequent inpatient treatment, traffic accident / sports accident / other accidents (eg 116 SGB X), IV (0443 )
CL Item
pre-admission treatment without subsequent inpatient treatment, indication of the effect of external violence, IV (0444 )
CL Item
pre-admission treatment without subsequent inpatient treatment, free, IV (0445 )
CL Item
pre-admission treatment without subsequent inpatient treatment, War Cripples suffering / BVG-suffering, IV (0446 )
CL Item
pre-admission treatment without subsequent inpatient care, emergency, IV (0447 )
CL Item
Stationary delivery, normally (0501 )
CL Item
Inpatient maternity, employment injury / occupational disease (11, para. 5 SGB V) (0502 )
CL Item
Inpatient maternity, accident / sports accident / other accidents (eg 116 SGB X) (0503 )
CL Item
Inpatient confinement regard to the action of external force (0504 )
CL Item
Stationary delivery, free (0505 )
CL Item
Stationary childbirth, war wounded suffering / BVG-suffering (0506 )
CL Item
Inpatient maternity, emergency (0507 )
CL Item
Stationary delivery, normally, payers exchange (0521 )
CL Item
Inpatient maternity, employment injury / occupational disease (11, para. 5 SGB V), payers exchange (0522 )
CL Item
Inpatient maternity, accident / sports accident / other accidents (eg 116 SGB X), cost volume change (0523 )
CL Item
Inpatient confinement regard to the action of external force, payers exchange (0524 )
CL Item
Inpatient confinement, free, payers exchange (0525 )
CL Item
Stationary childbirth, war wounded Cripples / BVG-suffering, payers exchange (0526 )
CL Item
Inpatient maternity, emergency, payers exchange (0527 )
CL Item
Stationary delivery, normally, IV (0541 )
CL Item
Inpatient maternity, employment injury / occupational disease (11, para. 5 SGB V), IV (0542 )
CL Item
Inpatient maternity, accident / sports accident / other accidents (eg 116 SGB X), IV (0543 )
CL Item
Inpatient confinement regard to the action of external force, by IV (0544 )
CL Item
Inpatient confinement, free, IV (0545 )
CL Item
Stationary childbirth, war wounded Cripples / BVG-suffering, IV (0546 )
CL Item
Inpatient maternity, emergency, IV (0547 )
CL Item
born, normally (0601 )
CL Item
birth, accidents at work / occupational disease (11, para. 5 SGB V) (0602 )
CL Item
born, traffic accident / sports accident / other accidents (eg 116 SGB X) (0603 )
CL Item
born, reference to the action of external force (0604 )
CL Item
born, free (0605 )
CL Item
born, war wounded suffering / BVG-suffering (0606 )
CL Item
born, emergency (0607 )
CL Item
born, normally, payers exchange (0621 )
CL Item
birth, accidents at work / occupational disease (11, para. 5 SGB V), payers exchange (0622 )
CL Item
born, traffic accident / sports accident / other accidents (eg 116 SGB X), cost volume change (0623 )
CL Item
born, reference to the action of external force, payers exchange (0624 )
CL Item
born, free, payers exchange (0625 )
CL Item
born, war wounded Cripples / BVG-suffering, payers exchange (0626 )
CL Item
born, emergency, payers exchange (0627 )
CL Item
born, normally, IV (0641 )
CL Item
birth, accidents at work / occupational disease (11, para. 5 SGB V), IV (0642 )
CL Item
born, traffic accident / sports accident / other accidents (eg 116 SGB X), IV (0643 )
CL Item
born, reference to the action of external force, by IV (0644 )
CL Item
born, free, IV (0645 )
CL Item
born, war wounded Cripples / BVG-suffering, IV (0646 )
CL Item
born, emergency, IV (0647 )
CL Item
recovery due to complications (flat rate) to KFPV 2003 normally (0701 )
CL Item
recovery due to complications (flat rate) to KFPV 2003 work injury / occupational disease (11, para. 5 SGB V) (0702 )
CL Item
recovery due to complications (flat rate) to KFPV 2003 traffic accident / sports accident / other accidents (eg 116 SGB X) (0703 )
CL Item
recovery due to complications (flat rate) to KFPV 2003 Note on the action of external force (0704 )
CL Item
recovery due to complications (flat rate) to KFPV 2003 free (0705 )
CL Item
recovery due to complications (flat rate) to KFPV 2003 War Cripples suffering / BVG-suffering (0706 )
CL Item
recovery due to complications (flat rate) to KFPV 2003 Emergency (0707 )
CL Item
recovery due to complications (flat rate) to KFPV 2003 Normally, payers exchange (0721 )
CL Item
recovery due to complications (flat rate) to KFPV 2003 work injury / occupational disease (11, para. 5 SGB V), payers exchange (0722 )
CL Item
recovery due to complications (flat rate) to KFPV 2003 traffic accident / sports accident / other accidents (eg 116 SGB X), cost volume change (0723 )
CL Item
recovery due to complications (flat rate) to KFPV 2003 Note on the action of external force, payers exchange (0724 )
CL Item
recovery due to complications (flat rate) to KFPV 2003 free, cost volume change (0725 )
CL Item
recovery due to complications (flat rate) to KFPV 2003 War Cripples suffering / BVG-suffering, payers exchange (0726 )
CL Item
recovery due to complications (flat rate) to KFPV 2003 emergency, payers exchange (0727 )
CL Item
recovery due to complications (flat rate) to KFPV 2003 Normally, IV (0741 )
CL Item
recovery due to complications (flat rate) to KFPV 2003 work injury / occupational disease (11, para. 5 SGB V), IV (0742 )
CL Item
recovery due to complications (flat rate) to KFPV 2003 traffic accident / sports accident / other accidents (eg 116 SGB X), IV (0743 )
CL Item
recovery due to complications (flat rate) to KFPV 2003 Note on the action of external force, by IV (0744 )
CL Item
recovery due to complications (flat rate) to KFPV 2003 free, IV (0745 )
CL Item
recovery due to complications (flat rate) to KFPV 2003 War Cripples suffering / BVG-suffering, IV (0746 )
CL Item
recovery due to complications (flat rate) to KFPV 2003 emergency, IV (0747 )
CL Item
Hospitalisation for organ removal, normally (0801 )
CL Item
Hospitalisation for organ removal, accidents at work / occupational disease (11, para. 5 SGB V) (0802 )
CL Item
Hospitalisation for organ removal, traffic accident / sports accident / other accidents (eg 116 SGB X) (0803 )
CL Item
Hospitalisation for organ removal, reference to the action of external force (0804 )
CL Item
Hospitalisation for organ removal, free (0805 )
CL Item
Hospitalisation for organ removal, war wounded suffering / BVG-suffering (0806 )
CL Item
Hospitalisation for organ removal, emergency (0807 )
CL Item
Hospitalisation for organ removal, normally, payers exchange (0821 )
CL Item
Hospitalisation for organ removal, accidents at work / occupational disease (11, para. 5 SGB V), payers exchange (0822 )
CL Item
Hospitalisation for organ removal, traffic accident / sports accident / other accidents (eg 116 SGB X), cost volume change (0823 )
CL Item
Hospitalisation for organ removal, reference to the action of external force, payers exchange (0824 )
CL Item
Hospitalisation for organ removal, free, payers exchange (0825 )
CL Item
Hospitalisation for organ removal, war wounded suffering / BVG-suffering, payers exchange (0826 )
CL Item
Hospitalisation for organ removal, emergency, payers exchange (0827 )
CL Item
Hospitalisation for organ removal, normally, IV (0841 )
CL Item
Hospitalisation for organ removal, accidents at work / occupational disease (11, para. 5 SGB V), IV (0842 )
CL Item
Hospitalisation for organ removal, traffic accident / sports accident / other accidents (eg 116 SGB X), IV (0843 )
CL Item
Hospitalisation for organ removal, reference to the action of external force, by IV (0844 )
CL Item
Hospitalisation for organ removal, free, IV (0845 )
CL Item
Hospitalisation for organ removal, war wounded suffering / BVG-suffering, IV (0846 )
CL Item
Hospitalisation for organ removal, emergency, IV (0847 )
Geburtsdatum (TT.MM.JJJJ)
Item
Date of Birth (DD.MM.YYYY)
date
C0421451 (UMLS CUI-1)
CL Item
male (1)
CL Item
female (2)
Item
Walking aids (at admission or prior to fracture)
integer
C0557834 (UMLS CUI-1)
Code List
Walking aids (at admission or prior to fracture)
CL Item
no (0)
CL Item
Crutches (1)
CL Item
rollator / walker (2)
CL Item
wheelchair (3)
CL Item
bedridden (4)
Item
Walking distance (at admission or prior to fracture)
integer
C0429886 (UMLS CUI-1)
Code List
Walking distance (at admission or prior to fracture)
CL Item
unlimited (1)
CL Item
go straight possible to 500m (2)
CL Item
at the station level mobile (walking distance: 50m) (3)
CL Item
in-room mobile (4)
CL Item
immobile (5)
Item Group
Basic documentation intra- and postoperative course
Gab es allgemeine behandlungsbedürftige Komplikationen?
Item
Were there any general complications requiring treatment?
boolean
C0032787 (UMLS CUI-1)
CL Item
yes (1)
Item
cardiovascular complication (s)
integer
C0032963 (UMLS CUI-1)
CL Item
yes (1)
CL Item
yes (1)
CL Item
yes (1)
Item
postoperative catheter-associated urinary tract infection
integer
C3838785 (UMLS CUI-1)
C0403709 (UMLS CUI-2)
C0403709 (UMLS CUI-2)
Code List
postoperative catheter-associated urinary tract infection
CL Item
yes (1)
CL Item
yes (1)
Item
Acute gastrointestinal hemorrhage
integer
C0266807 (UMLS CUI-1)
CL Item
yes (1)
CL Item
yes (1)
CL Item
yes (1)
Item
other general complications requiring treatment
integer
Code List
other general complications requiring treatment
CL Item
yes (1)
Ist eine systematische Erfassung der individuellen Sturzrisikofaktoren des Patienten erfolgt?
Item
systematic collection of individual fall risk factors of the patient
boolean
C1532976 (UMLS CUI-1)
Wurden Präventionsmaßnahmen ergriffen? (s. auch Pflegedokumentation)
Item
Were taken preventive measures? (s. also nursing documentation)
boolean
C0518064 (UMLS CUI-1)
Item
Patient has received gait training
integer
C0085673 (UMLS CUI-1)
CL Item
yes (1)
Item
Patient has received aids (eg walking aids) and their application has been trained
integer
C0184009 (UMLS CUI-1)
Code List
Patient has received aids (eg walking aids) and their application has been trained
CL Item
yes (1)
Item
Medication the patient was checked and adjusted if necessary
integer
Code List
Medication the patient was checked and adjusted if necessary
CL Item
yes (1)
Item
Patient and/or family members were informed about the individual patients fall risk, of potential hazards in the home and of possible measures to Fall Prevention
integer
C0030688 (UMLS CUI-1)
Code List
Patient and/or family members were informed about the individual patients fall risk, of potential hazards in the home and of possible measures to Fall Prevention
CL Item
yes (1)
Bewegungsausmaß passiv mit Neutral-Null-Methode bestimmt (betroffene Seite)
Item
Passive range of motion with neutral zero method is determined (affected side)
boolean
C0079991 (UMLS CUI-1)
Extension/Flexion 1 bei Entlassung (in Grad)
Item
Extension/flexion 1 at discharge (in degrees)
integer
C0522009 (UMLS CUI-1)
C0231452 (UMLS CUI-2)
C0231452 (UMLS CUI-2)
Extension/Flexion 2 bei Entlassung
Item
Extension/flexion 2 at discharge (in degrees)
integer
Extension/Flexion 3 bei Entlassung
Item
Extension/flexion 3 at discharge (in degrees)
integer
CL Item
unlimited (1)
CL Item
go straight possible to 500m (2)
CL Item
at the station level mobile (walking distance: 50m) (3)
CL Item
in-room mobile (4)
CL Item
immobile (5)
CL Item
no (0)
CL Item
Crutches (1)
CL Item
rollator / walker (2)
CL Item
wheelchair (3)
CL Item
bedridden (4)
Entlassungsdatum (TT.MM.JJJJ)
Item
Hostpital discharge date (DD.MM.YYYY)
date
C2710998 (UMLS CUI-1)
CL Item
treatment finished as planned (1)
CL Item
transferral to nursing facility (10)
CL Item
discharge to hospice (11)
CL Item
external transferral to psychiatric treatment (13)
CL Item
treatment finished because of other reasons, postdischarge treatment is planned (14)
CL Item
treatment aborted against medical advice, postdischarge treatment is planned (15)
CL Item
internal transferral with change of DRG payment areas (17)
CL Item
treatment finished as planned, postdischarge treatment is planned (2)
CL Item
case termination (internal transferral) with change between full- and partial stationary care (22)
CL Item
discharge at the end of the year with admission in previous year (25)
CL Item
treatment finished because of other reasons (3)
CL Item
treatment aborted against medical advice (4)
CL Item
change of jurisdiction of insurer or other payer (5)
CL Item
transferral to another hospital (6)
CL Item
death (7)
CL Item
transferral to another hospital within cooperative and governmental policies (8)
CL Item
transferral to rehabilitation facility (9)
Entlassungsdiagnosen (ICD-10-GM)
Item
Discharge diagnosis
integer
C0011900 (UMLS CUI-1)