ID

14633

Description

Item used as routine documentation by Clinic Bremen-Mitte, Urology Department, Kidney transplant. ODM derived from form “Anmdeldebogen- NTx” Number TPLF006, Version 3, Transplant Center Bremen, Clinic Bremen-Mitte gGmbH 28177 Bremen. Investigations before registering for kidney transplant (Application with medical report and Epicrisis) 1. Obligatory examinations 1.1. Imaging techniques - Chest X-ray in two planes (Finding and image) - X- ray pelvis overview (without gonad protection in females) (Finding and image) - Abdominal ultrasonography (liver, gall bladder, kidney own, aorta) 1.2. Consultation and additional examinations - Ophthalmologist - Gynecologist - Dermatologist - Otolaryngologist - Dentist - Urologist: Uroflow (rest precipitation> 500 mL / d), residual urine, sediment, urine culture, Prostate palpation and PSA determination aged 30 and older - Cardiologist: ECG (Original / Copy) 1.3. Laboratory tests Blood count, electrolytes, urea, creatinine, uric acid, iPTH, inorg. Phosphate, alkaline phosphatase, GGT, ALT, AST, LDH, total Bilirubin, total Protein, fasting blood sugar level, basal C-peptide and HbA1c (In all diabetics), triglycerides, cholesterol, BSG, BM-Test Colon albumin (3x), 55 years and older colonoscopy (according to current guideline) 1.4. Virology - Hepatitis (HBsAg, HBcAK, HBsAK, HCV antibodies) - HIV (1 and 2), CMV, EBV, VZV 1.5. Hepatitis B vaccination (with antibody detection) 2. Selective indicated examinations 2.1. Imaging tests - Abdominal CT by cystic kidneys, tumors in the History, Analgesic nephropathy - Coronary angiography by cardiac risk, by diabetics - Arterial angiography by PAD, pelvic vascular sclerosis in pelvic x- ray - Colonoscopy / Colon contrast enema with diverticulosis - CT abdomen on spec diverticulitis - Voiding cystourethrogram (VCUG) at Pyelonephritis-, urinary tract infection or stone in the urinary tract , unclear etiology of renal insufficiency - Urethro cystoscopy, retrograde Urethrography left/ right and Bladder irrigation left/ right Analgesic nephropathy or hematuria - Kidney bladder overview by medical history of kidney stone 2.2. Other examinations - Echocardiography, exercise ECG by aged 50 and older and by all diabetics - Gastroscopy at ulcer anamnesis - Lung function tests only if indicated (all smokers) - Carotid Doppler by flow noise or cerebral circulatory disorder

Keywords

Versions (2)
  1. 4/24/16 4/24/16 -
  2. 9/20/21 9/20/21 -
Uploaded on

April 24, 2016

DOI

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License

Creative Commons BY-NC 3.0
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Registration Form Kidney Transplant Urology Department Transplant Center Clinic Bremen-Mitte

German English

Registration Form Kidney Transplant

1 forms  
Personal Information
Description

Personal Information

Alias
UMLS CUI-1
C2983694
Patient's address
Description

Patient address

Data type

text

Alias
UMLS CUI [1]
C0421449
Patient's occupatioin
Description

occupation

Data type

text

Alias
UMLS CUI [1]
C0028811
Employer
Description

Employer

Data type

text

Alias
UMLS CUI [1]
C1274022
Telephone number
Description

Telephone number

Data type

integer

Alias
UMLS CUI [1]
C0039457
Health insurance
Description

Please include a copy of insurance card with every registration, otherwise registration at Euro transplant is not possible!

Data type

text

Alias
UMLS CUI [1]
C1548070
Status
Description

Gender

Data type

text

Alias
UMLS CUI [1]
C0079399
Membership number
Description

health insurance

Data type

integer

Alias
UMLS CUI [1]
C1548070
Dialysis Center
Description

Dialysis Center

Data type

text

Alias
UMLS CUI [1]
C1707735
Telephone number
Description

Telephone

Data type

integer

Alias
UMLS CUI [1]
C1515258
Attending physician
Description

attending physician

Data type

text

Alias
UMLS CUI [1]
C1320929
Telephone number
Description

Telephone

Data type

integer

Alias
UMLS CUI [1]
C1515258
Transplant type
Description

Please attach a summary of medical report about medical history, previous illnesses, current health status, and current treatment.

Data type

text

Alias
UMLS CUI [1]
C0022671
Kidney transplant
Description

Kidney transplant

Data type

text

Alias
UMLS CUI [1]
C0022671
Date of registration
Description

date of registration

Data type

date

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C0030705
UMLS CUI [1,3]
C1514821
Diagnosis
Description

Diagnosis

Alias
UMLS CUI-1
C0011900
Primary kidney disease
Description

kidney disease

Data type

text

Alias
UMLS CUI [1]
C0022658
Histological confirmation
Description

please enclose a copy of findings

Data type

boolean

Alias
UMLS CUI [1,1]
C0019638
UMLS CUI [1,2]
C0022658
Date of diagnosis
Description

diagnosis date

Data type

date

Alias
UMLS CUI [1]
C2316983
Further diagnosis
Description

diagnosis

Data type

text

Alias
UMLS CUI [1]
C0011900
Therapy
Description

Therapy

Alias
UMLS CUI-1
C0087111
Date of first dialysis
Description

dialysis date

Data type

date

Alias
UMLS CUI [1]
C3262256
Type of dialysis
Description

dialysis Hemodialysis Hemofiltration continuous ambulatory peritoneal dialysis

Data type

text

Alias
UMLS CUI [1,1]
C0011946
UMLS CUI [1,2]
C0019004
UMLS CUI [1,3]
C0019014
UMLS CUI [1,4]
C0031140
Therapy duration
Description

therapy duration

Data type

text

Alias
UMLS CUI [1]
C0444917
Dialysis days
Description

dialysis days

Data type

text

Alias
UMLS CUI [1,1]
C0011946
UMLS CUI [1,2]
C0439228
Shunt
Description

shunt

Data type

text

Alias
UMLS CUI [1]
C0542331
Shunt complications
Description

medical complication shunt

Data type

text

Alias
UMLS CUI [1,1]
C0221791
UMLS CUI [1,2]
C0542331
Residual diuresis
Description

diuresis

Data type

float

Measurement units
  • ml/24 h
Alias
UMLS CUI [1]
C0012797
ml/24 h
Dry weight
Description

dry weight

Data type

float

Measurement units
  • kg
Alias
UMLS CUI [1]
C1439839
kg
Body Height
Description

body height

Data type

float

Measurement units
  • cm
Alias
UMLS CUI [1]
C0005890
cm
Dialysis specific issues
Description

Dialysis issue

Data type

text

Alias
UMLS CUI [1,1]
C0011946
UMLS CUI [1,2]
C0033213
Medications
Description

medications

Data type

text

Alias
UMLS CUI [1]
C0013227
Anamnesis
Description

Anamnesis

Alias
UMLS CUI-1
C0021055
Medical history (FA, EA, kidney disease, high pressure, cardiopulmonary, gastrointestinal, endocrine complications, vascular-cerebral complications, infectious diseases, surgeries, etc.)
Description

Anamnesis

Data type

text

Alias
UMLS CUI [1]
C0021055
Allergies
Description

hypersensitivity

Data type

text

Alias
UMLS CUI [1]
C0020517
Social and psychological history (Mental overall situation, willingness to cooperate, marital status, children, socio-occupational situation, etc.)
Description

social history; psychological history

Data type

text

Alias
UMLS CUI [1]
C0945165
UMLS CUI [2]
C0679832
Nicotine consumption
Description

nicotine consumption

Data type

integer

Measurement units
  • /d
Alias
UMLS CUI [1]
C1519386
/d
Alcohol / drug abuse
Description

Substance Use Disorder

Data type

text

Alias
UMLS CUI [1]
C0038586
Clinical evaluation
Description

Clinical evaluation

Alias
UMLS CUI-1
C1261322
General condition
Description

General condition

Data type

text

Alias
UMLS CUI [1]
C1142435
Blood pressure
Description

Blood pressure

Data type

text

Measurement units
  • mmHg
Alias
UMLS CUI [1]
C0005823
mmHg
Heart rate
Description

Heart rate

Data type

integer

Measurement units
  • /min
Alias
UMLS CUI [1]
C0018810
/min
Heart Rhythm
Description

heart rhythm

Data type

text

Alias
UMLS CUI [1]
C0232187
Percussion and auscultation of the lungs and thorax
Description

Chest percussion; auscultation chest

Data type

text

Alias
UMLS CUI [1]
C1285807
UMLS CUI [2]
C0577960
Percussion and auscultation of Abdomen
Description

auscultation abdomen; Percussion abdomen

Data type

text

Alias
UMLS CUI [1]
C2089447
UMLS CUI [2]
C0437020
First BM Test Colon
Description

BM Test Colon

Data type

text

Second BM Test Colon
Description

BM Test Colon

Data type

text

Third BM Test Colon (55 years and older instead gets colonoscopy, according to the current guidline)
Description

BM Test Colon

Data type

text

Palpation and auscultation carotid artery (right)
Description

Palpation carotid artery right

Data type

text

Alias
UMLS CUI [1]
C0488805
Palpation and auscultation carotid artery (left)
Description

Palpation carotid artery left

Data type

text

Alias
UMLS CUI [1]
C0488804
Palpation and auscultation femoral artery (right)
Description

Palpation femoral artery right

Data type

text

Alias
UMLS CUI [1]
C0488809
Palpation and auscultation femoral artery (left)
Description

palpation femoral artery left

Data type

text

Alias
UMLS CUI [1]
C0488808
Palpation and auscultation popliteal artery (right)
Description

palpation popliteal artery right

Data type

text

Alias
UMLS CUI [1]
C0488811
Palpation and auscultation popliteal artery (left)
Description

palpation popliteal artery left

Data type

text

Alias
UMLS CUI [1]
C0488810
Palpation and auscultation tibial artery (right)
Description

palpation tibial artery right

Data type

text

Alias
UMLS CUI [1]
C0488812
Palpation and auscultation tibial artery (left)
Description

palpation tibial artery left

Data type

text

Alias
UMLS CUI [1]
C0488813
Palpation and auscultation dorsalis pedis artery (right)
Description

palpation Right dorsalis pedis artery

Data type

text

Alias
UMLS CUI [1,1]
C0030247
UMLS CUI [1,2]
C0834665
Palpation and auscultation dorsalis pedis artery (left)
Description

palpation Left dorsalis pedis artery

Data type

text

Alias
UMLS CUI [1,1]
C0030247
UMLS CUI [1,2]
C0834666
Immunological data
Description

Immunological data

Alias
UMLS CUI-1
C1533716
UMLS CUI-2
C0205470
Blood group
Description

(Please submit the blood group certificate)

Data type

text

Alias
UMLS CUI [1]
C0005810
Blood Transfusions
Description

blood transfusions

Data type

text

Alias
UMLS CUI [1]
C0005841
Blood transfusions period
Description

Blood Transfusions period

Data type

text

Alias
UMLS CUI [1,1]
C0005841
UMLS CUI [1,2]
C1948053
Number of blood transfusions
Description

Blood Transfusion

Data type

integer

Alias
UMLS CUI [1]
C0005841
Red cell concentrate
Description

red cell concentrate

Data type

boolean

Whole blood
Description

whole blood

Data type

boolean

Alias
UMLS CUI [1]
C0370231
Fresh frozen plasma FFP
Description

Fresh frozen plasma

Data type

boolean

Alias
UMLS CUI [1]
C0016709
Organ Transplantation
Description

organ transplantation

Data type

boolean

Alias
UMLS CUI [1]
C0029216
Organ Transplantation centre
Description

Organ Transplantation centre

Data type

text

Year of organ transplantation
Description

year Organ Transplantation

Data type

integer

Alias
UMLS CUI [1,1]
C0439234
UMLS CUI [1,2]
C0029216
ET-Number
Description

ET-Number

Data type

integer

Antibodies known?
Description

Antibodies

Data type

boolean

Alias
UMLS CUI [1]
C0003241
If yes, which?
Description

antibodies

Data type

text

Alias
UMLS CUI [1]
C0003241
Pregnancy
Description

Pregnancy

Data type

boolean

Alias
UMLS CUI [1]
C0032961
When was the pregnancy?
Description

pregnancy

Data type

text

Alias
UMLS CUI [1]
C0032961
Indications for the existence of an autoimmune disease
Description

autoimmune disease

Data type

boolean

Alias
UMLS CUI [1]
C0004364
If yes, which?
Description

autoimmune disease

Data type

text

Alias
UMLS CUI [1]
C0004364
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Similar models

Registration Form Kidney Transplant

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Personal Information
C2983694 (UMLS CUI-1)
Patient address
Item
Patient's address
text
C0421449 (UMLS CUI [1])
occupation
Item
Patient's occupatioin
text
C0028811 (UMLS CUI [1])
Employer
Item
Employer
text
C1274022 (UMLS CUI [1])
Telephone number
Item
Telephone number
integer
C0039457 (UMLS CUI [1])
health insurance
Item
Health insurance
text
C1548070 (UMLS CUI [1])
Item
Status
text
C0079399 (UMLS CUI [1])
Gender
Code List
Status
CL Item
M (1)
CL Item
F (2)
CL Item
R (3)
health insurance
Item
Membership number
integer
C1548070 (UMLS CUI [1])
Dialysis Center
Item
Dialysis Center
text
C1707735 (UMLS CUI [1])
Telephone
Item
Telephone number
integer
C1515258 (UMLS CUI [1])
attending physician
Item
Attending physician
text
C1320929 (UMLS CUI [1])
Telephone
Item
Telephone number
integer
C1515258 (UMLS CUI [1])
Item
Transplant type
text
C0022671 (UMLS CUI [1])
kidney transplant
Code List
Transplant type
CL Item
deceased Kidney transplant (1)
CL Item
live transplant (2)
Item
Kidney transplant
text
C0022671 (UMLS CUI [1])
Kidney transplant
Code List
Kidney transplant
CL Item
1. Tx (1)
CL Item
2. Tx (2)
date of registration
Item
Date of registration
date
C0011008 (UMLS CUI [1,1])
C0030705 (UMLS CUI [1,2])
C1514821 (UMLS CUI [1,3])
Item Group
Diagnosis
C0011900 (UMLS CUI-1)
kidney disease
Item
Primary kidney disease
text
C0022658 (UMLS CUI [1])
histology kidney disease
Item
Histological confirmation
boolean
C0019638 (UMLS CUI [1,1])
C0022658 (UMLS CUI [1,2])
diagnosis date
Item
Date of diagnosis
date
C2316983 (UMLS CUI [1])
diagnosis
Item
Further diagnosis
text
C0011900 (UMLS CUI [1])
Item Group
Therapy
C0087111 (UMLS CUI-1)
dialysis date
Item
Date of first dialysis
date
C3262256 (UMLS CUI [1])
Item
Type of dialysis
text
C0011946 (UMLS CUI [1,1])
C0019004 (UMLS CUI [1,2])
C0019014 (UMLS CUI [1,3])
C0031140 (UMLS CUI [1,4])
dialysis Hemodialysis Hemofiltration continuous ambulatory peritoneal dialysis
Code List
Type of dialysis
CL Item
acetate haemodialysis (1)
CL Item
bicarbonate hemodialysis (2)
CL Item
hemofiltration (3)
CL Item
continuous ambulatory peritoneal dialysis (4)
therapy duration
Item
Therapy duration
text
C0444917 (UMLS CUI [1])
dialysis days
Item
Dialysis days
text
C0011946 (UMLS CUI [1,1])
C0439228 (UMLS CUI [1,2])
shunt
Item
Shunt
text
C0542331 (UMLS CUI [1])
medical complication shunt
Item
Shunt complications
text
C0221791 (UMLS CUI [1,1])
C0542331 (UMLS CUI [1,2])
diuresis
Item
Residual diuresis
float
C0012797 (UMLS CUI [1])
dry weight
Item
Dry weight
float
C1439839 (UMLS CUI [1])
body height
Item
Body Height
float
C0005890 (UMLS CUI [1])
Dialysis issue
Item
Dialysis specific issues
text
C0011946 (UMLS CUI [1,1])
C0033213 (UMLS CUI [1,2])
medications
Item
Medications
text
C0013227 (UMLS CUI [1])
Item Group
Anamnesis
C0021055 (UMLS CUI-1)
Anamnesis
Item
Medical history (FA, EA, kidney disease, high pressure, cardiopulmonary, gastrointestinal, endocrine complications, vascular-cerebral complications, infectious diseases, surgeries, etc.)
text
C0021055 (UMLS CUI [1])
hypersensitivity
Item
Allergies
text
C0020517 (UMLS CUI [1])
social history; psychological history
Item
Social and psychological history (Mental overall situation, willingness to cooperate, marital status, children, socio-occupational situation, etc.)
text
C0945165 (UMLS CUI [1])
C0679832 (UMLS CUI [2])
nicotine consumption
Item
Nicotine consumption
integer
C1519386 (UMLS CUI [1])
Substance Use Disorder
Item
Alcohol / drug abuse
text
C0038586 (UMLS CUI [1])
Item Group
Clinical evaluation
C1261322 (UMLS CUI-1)
General condition
Item
General condition
text
C1142435 (UMLS CUI [1])
Blood pressure
Item
Blood pressure
text
C0005823 (UMLS CUI [1])
Heart rate
Item
Heart rate
integer
C0018810 (UMLS CUI [1])
heart rhythm
Item
Heart Rhythm
text
C0232187 (UMLS CUI [1])
Chest percussion; auscultation chest
Item
Percussion and auscultation of the lungs and thorax
text
C1285807 (UMLS CUI [1])
C0577960 (UMLS CUI [2])
auscultation abdomen; Percussion abdomen
Item
Percussion and auscultation of Abdomen
text
C2089447 (UMLS CUI [1])
C0437020 (UMLS CUI [2])
Item
First BM Test Colon
text
BM Test Colon
Code List
First BM Test Colon
CL Item
positive (1)
CL Item
negative (2)
Item
Second BM Test Colon
text
BM Test Colon
Code List
Second BM Test Colon
CL Item
positive (1)
CL Item
negative (2)
Item
Third BM Test Colon (55 years and older instead gets colonoscopy, according to the current guidline)
text
BM Test Colon
Code List
Third BM Test Colon (55 years and older instead gets colonoscopy, according to the current guidline)
CL Item
positive (1)
CL Item
negative (2)
Item
Palpation and auscultation carotid artery (right)
text
C0488805 (UMLS CUI [1])
BM Test Colon
Code List
Palpation and auscultation carotid artery (right)
CL Item
positive (1)
CL Item
negative (2)
Item
Palpation and auscultation carotid artery (left)
text
C0488804 (UMLS CUI [1])
BM Test Colon
Code List
Palpation and auscultation carotid artery (left)
CL Item
positive (1)
CL Item
negative (2)
Item
Palpation and auscultation femoral artery (right)
text
C0488809 (UMLS CUI [1])
BM Test Colon
Code List
Palpation and auscultation femoral artery (right)
CL Item
positive (1)
CL Item
negative (2)
Item
Palpation and auscultation femoral artery (left)
text
C0488808 (UMLS CUI [1])
BM Test Colon
Code List
Palpation and auscultation femoral artery (left)
CL Item
positive (1)
CL Item
negative (2)
Item
Palpation and auscultation popliteal artery (right)
text
C0488811 (UMLS CUI [1])
BM Test Colon
Code List
Palpation and auscultation popliteal artery (right)
CL Item
positive (1)
CL Item
negative (2)
Item
Palpation and auscultation popliteal artery (left)
text
C0488810 (UMLS CUI [1])
BM Test Colon
Code List
Palpation and auscultation popliteal artery (left)
CL Item
positive (1)
CL Item
negative (2)
Item
Palpation and auscultation tibial artery (right)
text
C0488812 (UMLS CUI [1])
BM Test Colon
Code List
Palpation and auscultation tibial artery (right)
CL Item
positive (1)
CL Item
negative (2)
Item
Palpation and auscultation tibial artery (left)
text
C0488813 (UMLS CUI [1])
BM Test Colon
Code List
Palpation and auscultation tibial artery (left)
CL Item
positive (1)
CL Item
negative (2)
Item
Palpation and auscultation dorsalis pedis artery (right)
text
C0030247 (UMLS CUI [1,1])
C0834665 (UMLS CUI [1,2])
BM Test Colon
Code List
Palpation and auscultation dorsalis pedis artery (right)
CL Item
positive (1)
CL Item
negative (2)
Item
Palpation and auscultation dorsalis pedis artery (left)
text
C0030247 (UMLS CUI [1,1])
C0834666 (UMLS CUI [1,2])
BM Test Colon
Code List
Palpation and auscultation dorsalis pedis artery (left)
CL Item
positive (1)
CL Item
negative (2)
Item Group
Immunological data
C1533716 (UMLS CUI-1)
C0205470 (UMLS CUI-2)
Blood group
Item
Blood group
text
C0005810 (UMLS CUI [1])
blood transfusions
Item
Blood Transfusions
text
C0005841 (UMLS CUI [1])
Blood Transfusions period
Item
Blood transfusions period
text
C0005841 (UMLS CUI [1,1])
C1948053 (UMLS CUI [1,2])
Blood Transfusion
Item
Number of blood transfusions
integer
C0005841 (UMLS CUI [1])
red cell concentrate
Item
Red cell concentrate
boolean
whole blood
Item
Whole blood
boolean
C0370231 (UMLS CUI [1])
Fresh frozen plasma
Item
Fresh frozen plasma FFP
boolean
C0016709 (UMLS CUI [1])
organ transplantation
Item
Organ Transplantation
boolean
C0029216 (UMLS CUI [1])
Organ Transplantation centre
Item
Organ Transplantation centre
text
year Organ Transplantation
Item
Year of organ transplantation
integer
C0439234 (UMLS CUI [1,1])
C0029216 (UMLS CUI [1,2])
ET-Number
Item
ET-Number
integer
Antibodies
Item
Antibodies known?
boolean
C0003241 (UMLS CUI [1])
antibodies
Item
If yes, which?
text
C0003241 (UMLS CUI [1])
Pregnancy
Item
Pregnancy
boolean
C0032961 (UMLS CUI [1])
pregnancy
Item
When was the pregnancy?
text
C0032961 (UMLS CUI [1])
autoimmune disease
Item
Indications for the existence of an autoimmune disease
boolean
C0004364 (UMLS CUI [1])
autoimmune disease
Item
If yes, which?
text
C0004364 (UMLS CUI [1])
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