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ID
14645
Description
https://www.hope-clara.de/ The HOPE Hospice and Palliative Care Recording standard documentation is used for documentation of palliative care and as an instrument for quality assurance in pallatiave wards, hospices and oncological wards as well as in ambulatory services and palliative teams.
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Keywords
Versions (1)
- 4/25/16 4/25/16 -
Copyright Holder
CC BY-NC 3.0
Uploaded on
April 25, 2016
DOI
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License
Creative Commons BY-NC 3.0
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Palliative and Hospice Care Baseline Form
Palliative and Hospice Care Baseline Form
- StudyEvent: ODM
Similar models
Palliative and Hospice Care Baseline Form
- StudyEvent: ODM
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Baseline form number
Item
Baseline form number
integer
C0237753 (UMLS CUI [1])
Date of birth
Item
Date of birth
date
C0421451 (UMLS CUI [1])
Date of admission
Item
Date of admission
date
C1302393 (UMLS CUI [1])
CL Item
female (1)
CL Item
male (2)
CL Item
alone (1)
CL Item
with relatives/friends (2)
CL Item
nursing home (3)
CL Item
other, please specify: (4)
Other housing situation
Item
Other housing situation
text
C0020056 (UMLS CUI [1])
Item
specialized ambulatory palliative care request
integer
Code List
specialized ambulatory palliative care request
CL Item
consultation (1)
CL Item
coordination (2)
CL Item
additional partial care (3)
CL Item
full care (4)
Item
Agreement and submitted form
integer
C0680240 (UMLS CUI [1,1])
C1515023 (UMLS CUI [1,2])
C1515023 (UMLS CUI [1,2])
CL Item
living will (1)
CL Item
health care proxy (2)
CL Item
caregiver document (3)
CL Item
none (1)
CL Item
applied for (2)
CL Item
level 0 (3)
CL Item
level 1 (4)
CL Item
level 2 (5)
CL Item
level 3 (6)
CL Item
level 3+ (7)
Main diagnosis and other diagnoses or problems
Item
Main diagnosis and other diagnoses or problems with ICD-10 Code
integer
C0332137 (UMLS CUI [1])
C0011900 (UMLS CUI [2])
C0870733 (UMLS CUI [3])
C0011900 (UMLS CUI [2])
C0870733 (UMLS CUI [3])
Main diagnosis and other diagnoses/problems
Item
Main diagnosis and other diagnoses/problems
text
C0332137 (UMLS CUI [1])
C0011900 (UMLS CUI [2])
C0011900 (UMLS CUI [2])
Date of diagnosis
Item
Date of diagnosis (approximately)
date
C2316983 (UMLS CUI [1])
CL Item
Brain (1)
CL Item
Lung (2)
CL Item
Liver (3)
CL Item
Bone (4)
CL Item
Other location, please specify: (5)
Other location of metastases
Item
Other location of metastases
text
C0027627 (UMLS CUI [1,1])
C0450429 (UMLS CUI [1,2])
C0205394 (UMLS CUI [1,3])
C0450429 (UMLS CUI [1,2])
C0205394 (UMLS CUI [1,3])
Item
Previous treatment / assistance
integer
C0039798 (UMLS CUI [1,1])
C0025070 (UMLS CUI [1,2])
C0205156 (UMLS CUI [1,3])
C0025070 (UMLS CUI [1,2])
C0205156 (UMLS CUI [1,3])
CL Item
palliative ward (1)
CL Item
hospice (inpatient) (2)
CL Item
hospital (other ward) (3)
CL Item
ambulance (4)
CL Item
consulting service (5)
CL Item
general practitioner (6)
CL Item
outpatient care (7)
CL Item
doctor for palliative care (8)
CL Item
palliative care (9)
CL Item
specialized ambulatory pallitiave care team (10)
CL Item
other, please specify: (11)
CL Item
0 Fully active, able to carry on all pre-disease performance without restriction (1)
CL Item
1 Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work (2)
CL Item
2 Ambulatory and capable of all selfcare but unable to carry out any work activities; up and about more than 50% of waking hours (3)
CL Item
3 Capable of only limited selfcare; confined to bed or chair more than 50% of waking hours (4)
CL Item
4 Completely disabled; cannot carry on any selfcare; totally confined to bed or chair (5)
Barthel Index
Item
Barthel Index
integer
C0451019 (UMLS CUI [1])
Date of collection of the patient's medical issues
Item
Date of collection of the patient's medical issues
date
C1516698 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
C0033213 (UMLS CUI [2,1])
C0205476 (UMLS CUI [2,2])
C0011008 (UMLS CUI [1,2])
C0033213 (UMLS CUI [2,1])
C0205476 (UMLS CUI [2,2])
CL Item
none (1)
CL Item
mild (2)
CL Item
moderate (3)
CL Item
severe (4)
CL Item
none (1)
CL Item
mild (2)
CL Item
moderate (3)
CL Item
severe (4)
CL Item
none (1)
CL Item
mild (2)
CL Item
moderate (3)
CL Item
severe (4)
CL Item
None (1)
CL Item
Mild (2)
CL Item
Moderate (3)
CL Item
Severe (4)
CL Item
None (1)
CL Item
mild (2)
CL Item
Moderate (3)
CL Item
Severe (4)
CL Item
None (1)
CL Item
Mild (2)
CL Item
Moderate (3)
CL Item
Severe (4)
CL Item
None (1)
CL Item
Mild (2)
CL Item
Moderate (3)
CL Item
Severe (4)
CL Item
None (1)
CL Item
Mild (2)
CL Item
Moderate (3)
CL Item
Severe (4)
Item
Care issues due to lesions/pressure ulcers
integer
C0017313 (UMLS CUI [1,1])
C0033213 (UMLS CUI [1,2])
C0221198 (UMLS CUI [2])
C0011127 (UMLS CUI [3])
C0033213 (UMLS CUI [1,2])
C0221198 (UMLS CUI [2])
C0011127 (UMLS CUI [3])
CL Item
None (1)
CL Item
Mild (2)
CL Item
Moderate (3)
CL Item
Severe (4)
Item
Need for assistance for activities of daily living
integer
C0476651 (UMLS CUI [1,1])
C0001288 (UMLS CUI [1,2])
C0001288 (UMLS CUI [1,2])
Code List
Need for assistance for activities of daily living
CL Item
None (1)
CL Item
mild (2)
CL Item
moderate (3)
CL Item
severe (4)
CL Item
none (1)
CL Item
mild (2)
CL Item
moderate (3)
CL Item
severe (4)
CL Item
None (1)
CL Item
Mild (2)
CL Item
Moderate (3)
CL Item
Severe (4)
CL Item
none (1)
CL Item
mild (2)
CL Item
moderate (3)
CL Item
severe (4)
Item
Disorientation, confusion
integer
C0233407 (UMLS CUI [1])
C0009676 (UMLS CUI [2])
C0009676 (UMLS CUI [2])
CL Item
none (1)
CL Item
mild (2)
CL Item
moderate (3)
CL Item
severe (4)
Item
Issues organizing care
integer
C0033213 (UMLS CUI [1,1])
C1822380 (UMLS CUI [1,2])
C1822380 (UMLS CUI [1,2])
CL Item
none (1)
CL Item
mild (2)
CL Item
moderate (3)
CL Item
severe (4)
CL Item
None (1)
CL Item
Mild (2)
CL Item
Moderate (3)
CL Item
Severe (4)
Other issues
Item
Other issues
text
C0033213 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
C0205394 (UMLS CUI [1,2])
CL Item
none (1)
CL Item
mild (2)
CL Item
moderate (3)
CL Item
severe (4)
Comments
Item
Comments
text
C0947611 (UMLS CUI [1])
Reason for visit, treatment goal
Item
What is the reason for the visit, what is the aim of this treatment?
text
C1704447 (UMLS CUI [1])
C0679840 (UMLS CUI [2])
C0679840 (UMLS CUI [2])
Non-opioids
Item
Non-opioids
boolean
C3863698 (UMLS CUI [1])
Opioids WHO level 2
Item
Opioids WHO level 2
boolean
C0242402 (UMLS CUI [1])
Opioids WHO level 3
Item
Opioids WHO level 3
boolean
C0242402 (UMLS CUI [1])
Adjuvant analgesics
Item
Adjuvant analgesics
boolean
C1510809 (UMLS CUI [1])
Corticosteroids
Item
Corticosteroids
boolean
C0001617 (UMLS CUI [1])
Antidepressants
Item
Antidepressants
boolean
C0003289 (UMLS CUI [1])
Antiemetics
Item
Antiemetics
boolean
C0003297 (UMLS CUI [1])
Neuroleptics
Item
Neuroleptics
boolean
C0040615 (UMLS CUI [1])
Sedatives / Anxiolytics
Item
Sedatives / Anxiolytics
boolean
C0036557 (UMLS CUI [1])
C0040616 (UMLS CUI [2])
C0040616 (UMLS CUI [2])
Stomach protector
Item
Stomach protector
boolean
C0038351 (UMLS CUI [1,1])
C0033613 (UMLS CUI [1,2])
C0033613 (UMLS CUI [1,2])
Laxatives
Item
Laxatives
boolean
C0282090 (UMLS CUI [1])
Antibiotics
Item
Antibiotics
boolean
C0003232 (UMLS CUI [1])
Diuretics
Item
Diuretics
boolean
C0012798 (UMLS CUI [1])
Cardiaca/Antihypertensive Agents
Item
Cardiaca/Antihypertensive Agents
boolean
C0007209 (UMLS CUI [1])
C0003364 (UMLS CUI [2])
C0003364 (UMLS CUI [2])
Other medication
Item
Other medication
boolean
C1115771 (UMLS CUI [1])
Other medication
Item
Other medication
text
C1115771 (UMLS CUI [1])
CL Item
p.o. (1)
CL Item
s.c. (2)
CL Item
i.v. (3)
Item
Palliative sedation
integer
C0344106 (UMLS CUI [1,1])
C1285530 (UMLS CUI [1,2])
C1285530 (UMLS CUI [1,2])
CL Item
intermittent (1)
CL Item
continuous (2)
CL Item
enteral (1)
CL Item
parenteral (2)
CL Item
feeding counseling (3)
Transfusions
Item
Transfusions
boolean
C1879316 (UMLS CUI [1])
CL Item
i.v. (1)
CL Item
s.c. (2)
Item
Puncture or drainage
integer
C0034117 (UMLS CUI [1])
C0013103 (UMLS CUI [2])
C0013103 (UMLS CUI [2])
CL Item
Ascites (1)
CL Item
Pleura (2)
Item
Application or change of
integer
C0185125 (UMLS CUI [1])
C0392747 (UMLS CUI [2])
C0392747 (UMLS CUI [2])
CL Item
Central venous catheter / port (1)
CL Item
tracheo-gastro-, uro-colo-stoma (2)
CL Item
permanent catheter / suprapubic permanent catheter / drainage tube (3)
CL Item
new (1)
CL Item
continued (2)
CL Item
radiological intervention (neurolysis, endoscopy etc.) (3)
CL Item
activating (1)
CL Item
assisting (2)
CL Item
special positioning (due to fractures etc.) (3)
CL Item
treatment of pressure ulcer (4)
CL Item
treatment of lesions (5)
CL Item
rectal abstergent treatment (6)
Item
Maintenance of catheters
integer
C0024501 (UMLS CUI [1,1])
C0085590 (UMLS CUI [1,2])
C0085590 (UMLS CUI [1,2])
CL Item
central venous catheter, port (1)
CL Item
tracheo,- gastro,- uro,- colo-stoma (2)
CL Item
irrigation of permanent catheter/drainage probe / suprapubic permanent catheter (3)
CL Item
new (1)
CL Item
continued (2)
CL Item
other pharmaceutical tumor therapy (p.o., i.th.) (3)
CL Item
mobilisation (1)
CL Item
heat/cold-treatment (2)
CL Item
edema treatment, manual lymphatic drainage (3)
CL Item
massages, embrocation (4)
CL Item
breathing therapy (5)
CL Item
intervention in a crisis (1)
CL Item
supportive short-time-therapy, training (2)
CL Item
creative procedures (art, music, writing etc.) (3)
CL Item
practicing procedures (relaxation, hypnosis...) (4)
CL Item
couple-/family-counseling (relatives/patient and relatives) (5)
Surgical procedure
Item
Surgical procedure (surgery, stenting, dilation etc.)
boolean
C0543467 (UMLS CUI [1])
Diagnostic procedures
Item
Diagnostic procedures (ct, mri, endoscopy etc.)
boolean
C0430022 (UMLS CUI [1])
CL Item
for organizing final arrangements (1)
CL Item
for living will, authorization (2)
CL Item
for mediation of community service (3)
CL Item
for request for public authorities, insurances etc. (4)
CL Item
for the suggestion of legal assistance (5)
Organization of following treatment
Item
Organization of following treatment
boolean
C0039798 (UMLS CUI [1,1])
C0332282 (UMLS CUI [1,2])
C1300196 (UMLS CUI [1,3])
C0332282 (UMLS CUI [1,2])
C1300196 (UMLS CUI [1,3])
assistance for (grieving) relatives
Item
assistance for (grieving) relatives
boolean
C0018896 (UMLS CUI [1,1])
C0080103 (UMLS CUI [1,2])
C0018235 (UMLS CUI [1,3])
C0080103 (UMLS CUI [1,2])
C0018235 (UMLS CUI [1,3])
CL Item
conversation (1)
CL Item
rites (2)
Other procedures
Item
Other procedures
text
C0393107 (UMLS CUI [1])
Which issue was solved especially well?
Item
Which issue was solved especially well?
text
C0033213 (UMLS CUI [1])
Which issue could not be solved sufficiently?
Item
Which issue could not be solved sufficiently?
text
C0033213 (UMLS CUI [1])
CL Item
nurse (1)
CL Item
doctor (2)
CL Item
ambulatory hospice (3)
CL Item
psychologic department (4)
CL Item
social worker (5)
CL Item
other: (6)
Other, who filled out the form
Item
Other, who filled out the form
text
C3273494 (UMLS CUI [1])
Date of discharge/change in assistance/death
Item
Date of discharge/change in assistance/death
date
C2361123 (UMLS CUI [1])
C0011008 (UMLS CUI [2,1])
C0443172 (UMLS CUI [2,2])
C0025070 (UMLS CUI [2,3])
C1148348 (UMLS CUI [3])
C0011008 (UMLS CUI [2,1])
C0443172 (UMLS CUI [2,2])
C0025070 (UMLS CUI [2,3])
C1148348 (UMLS CUI [3])
CL Item
passed away (1)
CL Item
transfer/discharge (2)
CL Item
end of documentation (3)
CL Item
other (4)
Other end of therapy
Item
Other end of therapy
text
C0087111 (UMLS CUI [1,1])
C0444930 (UMLS CUI [1,2])
C0205394 (UMLS CUI [1,3])
C0444930 (UMLS CUI [1,2])
C0205394 (UMLS CUI [1,3])
Item
Discharge to/ treatment ongoing in
integer
C0030685 (UMLS CUI [1])
C0087111 (UMLS CUI [2,1])
C0549178 (UMLS CUI [2,2])
C0087111 (UMLS CUI [2,1])
C0549178 (UMLS CUI [2,2])
CL Item
palliative ward (1)
CL Item
hospice (inpatient) (2)
CL Item
hospital (other ward) (3)
CL Item
ambulance (4)
CL Item
consultation service (5)
CL Item
GP (6)
CL Item
ambulatory care (7)
CL Item
doctor for palliative care (8)
CL Item
palliative care service (9)
CL Item
palliative care team (10)
CL Item
other (11)
Other discharge to / ongoing treatment in
Item
Other discharge to / ongoing treatment in
text
C0030685 (UMLS CUI [1])
C0087111 (UMLS CUI [2,1])
C0549178 (UMLS CUI [2,2])
C0087111 (UMLS CUI [2,1])
C0549178 (UMLS CUI [2,2])
CL Item
home (1)
CL Item
nursing home (2)
CL Item
hospice (3)
CL Item
palliative ward (4)
CL Item
hospital (5)
CL Item
unknown (6)
Item
final evaluation of the team's satisfaction with the medical assistance for the entire treatment
integer
C0220825 (UMLS CUI [1])
C0242428 (UMLS CUI [2])
C0087111 (UMLS CUI [3,1])
C0439751 (UMLS CUI [3,2])
C0242428 (UMLS CUI [2])
C0087111 (UMLS CUI [3,1])
C0439751 (UMLS CUI [3,2])
Code List
final evaluation of the team's satisfaction with the medical assistance for the entire treatment
CL Item
very bad (1)
CL Item
bad (2)
CL Item
medium (3)
CL Item
good (4)
CL Item
very good (5)
Item
final evaluation of the team's satisfaction with the medical assistance for the final stage (for patients who passed away)
integer
C0220825 (UMLS CUI [1])
C0242428 (UMLS CUI [2])
C0205088 (UMLS CUI [3])
C0242428 (UMLS CUI [2])
C0205088 (UMLS CUI [3])
Code List
final evaluation of the team's satisfaction with the medical assistance for the final stage (for patients who passed away)
CL Item
very bad (1)
CL Item
bad (2)
CL Item
medium (3)
CL Item
good (4)
CL Item
very good (5)