ID

14791

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.

Link

https://www.hope-clara.de/

Keywords

  1. 4/28/16 4/28/16 -
Copyright Holder

CC BY-NC 3.0

Uploaded on

April 28, 2016

DOI

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License

Creative Commons BY-NC 3.0

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Palliative and Hospice Care Wound Treatment In Palliative Medicine

Palliative and Hospice Care Wound Treatment In Palliative Medicine

Form Information
Description

Form Information

Baseline Form Number
Description

Baseline Form Number

Data type

integer

Alias
UMLS CUI [1]
C0237753
Date
Description

Date

Data type

date

Alias
UMLS CUI [1]
C0011008
Who completes this form?
Description

Reporting person

Data type

integer

Alias
UMLS CUI [1,1]
C0027361
UMLS CUI [1,2]
C0700287
Doctor's specialty
Description

Doctor's specialty

Data type

text

Alias
UMLS CUI [1]
C0037778
Other staff (profession)
Description

Other staff (profession)

Data type

text

Alias
UMLS CUI [1,1]
C0851286
UMLS CUI [1,2]
C0205394
UMLS CUI [1,3]
C0028811
Wound history
Description

Wound history

Wound exists since:
Description

Wound exists since

Data type

text

Alias
UMLS CUI [1,1]
C0043250
UMLS CUI [1,2]
C2987476
previous therapy
Description

previous therapy

Data type

text

Alias
UMLS CUI [1]
C1514463
Type of wound
Description

Type of wound

Data type

integer

Alias
UMLS CUI [1]
C1276783
degree of decubitus ulcer
Description

degree of decubitus ulcer

Data type

text

Alias
UMLS CUI [1,1]
C0011127
UMLS CUI [1,2]
C0449286
other type of wound
Description

other type of wound

Data type

text

Alias
UMLS CUI [1,1]
C1276783
UMLS CUI [1,2]
C0205394
wound- or therapy-related handicap
Description

wound- or therapy-related handicap

Data type

integer

Alias
UMLS CUI [1,1]
C0231170
UMLS CUI [1,2]
C0043250
UMLS CUI [1,3]
C0039798
other wound- or therapy-related handicap
Description

other wound- or therapy-related handicap

Data type

text

Alias
UMLS CUI [1,1]
C0231170
UMLS CUI [1,2]
C0043250
UMLS CUI [1,3]
C0039798
UMLS CUI [1,4]
C0205394
Wound assessment
Description

Wound assessment

Alias
UMLS CUI-1
C0558033
Localization
Description

Localization

Data type

text

Alias
UMLS CUI [1]
C0475264
Size, length, maximum of cm long:
Description

Size, length

Data type

integer

Measurement units
  • cm
Alias
UMLS CUI [1,1]
C0456389
UMLS CUI [1,2]
C1444754
cm
Size, width, maximum of cm wide:
Description

Size, width

Data type

integer

Measurement units
  • cm
Alias
UMLS CUI [1,1]
C0456389
UMLS CUI [1,2]
C0487742
cm
Size, depth, maximum of cm deep:
Description

Size, depth

Data type

integer

Measurement units
  • cm
Alias
UMLS CUI [1,1]
C0456389
UMLS CUI [1,2]
C0205125
cm
Bottom of wound
Description

Bottom of wound

Data type

integer

Alias
UMLS CUI [1,1]
C1511276
UMLS CUI [1,2]
C0043250
Wound bottom body parts
Description

Wound bottom body parts

Data type

text

Alias
UMLS CUI [1,1]
C1511276
UMLS CUI [1,2]
C0043250
UMLS CUI [1,3]
C0229962
wound margin
Description

wound margin

Data type

integer

Alias
UMLS CUI [1]
C1545981
wound surrounding
Description

wound surrounding

Data type

integer

Alias
UMLS CUI [1]
C2116843
wound odor
Description

wound odor

Data type

integer

Alias
UMLS CUI [1]
C2721577
Exudate type
Description

Exudate type

Data type

integer

Alias
UMLS CUI [1,1]
C0015388
UMLS CUI [1,2]
C0332307
Exudate volume
Description

Exudate volume

Data type

integer

Alias
UMLS CUI [1,1]
C0015388
UMLS CUI [1,2]
C2700258
Wound surface film
Description

Wound surface film

Data type

integer

Alias
UMLS CUI [1,1]
C0043250
UMLS CUI [1,2]
C0205148
UMLS CUI [1,3]
C1561572
Inflammation
Description

Inflammation

Data type

integer

Alias
UMLS CUI [1]
C0021368
Pain
Description

Pain

Data type

integer

Alias
UMLS CUI [1]
C0030193
Bleeding type
Description

Bleeding type

Data type

integer

Alias
UMLS CUI [1,1]
C0019080
UMLS CUI [1,2]
C0332307
Bleeding extent
Description

Bleeding extent

Data type

integer

Alias
UMLS CUI [1,1]
C0019080
UMLS CUI [1,2]
C0439792
Comment
Description

Comment

Data type

text

Alias
UMLS CUI [1]
C0947611
Diagnostic procedures
Description

Diagnostic procedures

Alias
UMLS CUI-1
C0430022
wound smear test
Description

wound smear test

Data type

boolean

Alias
UMLS CUI [1]
C0444086
excision sample
Description

excision sample

Data type

boolean

Alias
UMLS CUI [1,1]
C0728940
UMLS CUI [1,2]
C0870078
other
Description

other

Data type

text

Alias
UMLS CUI [1]
C0205394
Photography documentation (with flash)
Description

Photography documentation

Data type

integer

Alias
UMLS CUI [1]
C0031749
UMLS CUI [2]
C0920316
Primary treatment goals
Description

Primary treatment goals

Basic goal
Description

Basic goal

Data type

integer

Alias
UMLS CUI [1,1]
C0018017
UMLS CUI [1,2]
C0178499
primary goals
Description

primary goals

Data type

integer

Alias
UMLS CUI [1,1]
C0018017
UMLS CUI [1,2]
C0205225
Comment
Description

Comment

Data type

text

Alias
UMLS CUI [1]
C0947611
Therapeutic procedures for wound management
Description

Therapeutic procedures for wound management

Therapeutic procedures for wound management
Description

Therapeutic procedures for wound management

Data type

integer

Alias
UMLS CUI [1,1]
C0087111
UMLS CUI [1,2]
C1272654
Other therapeutic procedures for wound management
Description

Other therapeutic procedures for wound management

Data type

text

Alias
UMLS CUI [1,1]
C0087111
UMLS CUI [1,2]
C1272654
UMLS CUI [1,3]
C0205394
Specific procedures in wound management
Description

Specific procedures in wound management

gentle removal of the bandage, wetting of the bandage with:
Description

gentle removal of the bandage

Data type

text

Alias
UMLS CUI [1,1]
C0004726
UMLS CUI [1,2]
C0015252
wound cleaning
Description

wound cleaning

Data type

integer

Alias
UMLS CUI [1]
C0455099
other wound cleaning
Description

other wound cleaning

Data type

text

Alias
UMLS CUI [1,1]
C0455099
UMLS CUI [1,2]
C0205394
wound rinses
Description

wound rinses

Data type

integer

Alias
UMLS CUI [1,1]
C0043250
UMLS CUI [1,2]
C1882955
other wound rinses
Description

other wound rinses

Data type

text

Alias
UMLS CUI [1,1]
C0043250
UMLS CUI [1,2]
C1882955
UMLS CUI [1,3]
C0205394
Wound therapy
Description

Wound therapy

Data type

integer

Alias
UMLS CUI [1]
C0886052
Wound overlays
Description

Wound overlays

Data type

integer

Alias
UMLS CUI [1,1]
C0043250
UMLS CUI [1,2]
C1706359
Other wound overlay
Description

Other wound overlay

Data type

text

Alias
UMLS CUI [1,1]
C0043250
UMLS CUI [1,2]
C1706359
UMLS CUI [1,3]
C0205394
Specific procedures for wound margin protection
Description

Specific procedures for wound margin protection

Data type

integer

Alias
UMLS CUI [1,1]
C1545981
UMLS CUI [1,2]
C1545588
UMLS CUI [1,3]
C0087111
UMLS CUI [1,4]
C0205369
specific therapeutic procedures for exudation
Description

specific therapeutic procedures for exudation

Data type

integer

Alias
UMLS CUI [1,1]
C0311437
UMLS CUI [1,2]
C0087111
UMLS CUI [1,3]
C0205369
Specific therapeutic procedure for exudation, vacuum therapy
Description

Specific therapeutic procedure for exudation, vacuum therapy

Data type

integer

Alias
UMLS CUI [1,1]
C0311437
UMLS CUI [1,2]
C0087111
UMLS CUI [1,3]
C0205369
UMLS CUI [1,4]
C1322784
Specific therapeutic procedures for bleeding wounds
Description

Specific therapeutic procedures for bleeding wounds

Data type

integer

Alias
UMLS CUI [1,1]
C0087111
UMLS CUI [1,2]
C0205369
UMLS CUI [1,3]
C0241742
Specific therapeutic procedures for malodorous wounds
Description

Specific therapeutic procedures for malodorous wounds

Data type

integer

Alias
UMLS CUI [1,1]
C0087111
UMLS CUI [1,2]
C0205369
UMLS CUI [1,3]
C2168496
pharmaceuticals
Description

pharmaceuticals

Data type

integer

Alias
UMLS CUI [1]
C0013227
other pharmaceuticals
Description

other pharmaceuticals

Data type

text

Alias
UMLS CUI [1,1]
C0013227
UMLS CUI [1,2]
C0205394
additional procedures
Description

additional procedures

Data type

integer

Alias
UMLS CUI [1]
C0940824
Please describe the localization of the wound and plot it in the drawing
Description

description of localization

Data type

text

Alias
UMLS CUI [1,1]
C0475264
UMLS CUI [1,2]
C0678257

Similar models

Palliative and Hospice Care Wound Treatment In Palliative Medicine

Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Form Information
Baseline Form Number
Item
Baseline Form Number
integer
C0237753 (UMLS CUI [1])
Date
Item
Date
date
C0011008 (UMLS CUI [1])
Item
Who completes this form?
integer
C0027361 (UMLS CUI [1,1])
C0700287 (UMLS CUI [1,2])
Code List
Who completes this form?
CL Item
Doctor (1)
CL Item
Doctor's specialty (2)
CL Item
Nurse (3)
CL Item
Other staff (profession) (4)
Doctor's specialty
Item
Doctor's specialty
text
C0037778 (UMLS CUI [1])
Other staff (profession)
Item
Other staff (profession)
text
C0851286 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
C0028811 (UMLS CUI [1,3])
Item Group
Wound history
Wound exists since
Item
Wound exists since:
text
C0043250 (UMLS CUI [1,1])
C2987476 (UMLS CUI [1,2])
previous therapy
Item
previous therapy
text
C1514463 (UMLS CUI [1])
Item
Type of wound
integer
C1276783 (UMLS CUI [1])
Code List
Type of wound
CL Item
exulcerating tumor wound (1)
CL Item
decubitus ulcer, degree: (2)
CL Item
radiotherapy wound (3)
CL Item
other: (4)
degree of decubitus ulcer
Item
degree of decubitus ulcer
text
C0011127 (UMLS CUI [1,1])
C0449286 (UMLS CUI [1,2])
other type of wound
Item
other type of wound
text
C1276783 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
Item
wound- or therapy-related handicap
integer
C0231170 (UMLS CUI [1,1])
C0043250 (UMLS CUI [1,2])
C0039798 (UMLS CUI [1,3])
Code List
wound- or therapy-related handicap
CL Item
odor (1)
CL Item
pain (2)
CL Item
pruritus (3)
CL Item
exudation (4)
CL Item
bleeding (5)
CL Item
issues eating, drinking, vision, hearing etc. (6)
CL Item
sleep disturbance (7)
CL Item
social isolation (8)
CL Item
body image (9)
other wound- or therapy-related handicap
Item
other wound- or therapy-related handicap
text
C0231170 (UMLS CUI [1,1])
C0043250 (UMLS CUI [1,2])
C0039798 (UMLS CUI [1,3])
C0205394 (UMLS CUI [1,4])
Item Group
Wound assessment
C0558033 (UMLS CUI-1)
Localization
Item
Localization
text
C0475264 (UMLS CUI [1])
Size, length
Item
Size, length, maximum of cm long:
integer
C0456389 (UMLS CUI [1,1])
C1444754 (UMLS CUI [1,2])
Size, width
Item
Size, width, maximum of cm wide:
integer
C0456389 (UMLS CUI [1,1])
C0487742 (UMLS CUI [1,2])
Size, depth
Item
Size, depth, maximum of cm deep:
integer
C0456389 (UMLS CUI [1,1])
C0205125 (UMLS CUI [1,2])
Item
Bottom of wound
integer
C1511276 (UMLS CUI [1,1])
C0043250 (UMLS CUI [1,2])
Code List
Bottom of wound
CL Item
granulation tissue (1)
CL Item
fibrin film (2)
CL Item
epithelial layer (3)
CL Item
dry necrosis (4)
CL Item
wet necrosis (5)
CL Item
body structures such as muscles, fibers: (6)
Wound bottom body parts
Item
Wound bottom body parts
text
C1511276 (UMLS CUI [1,1])
C0043250 (UMLS CUI [1,2])
C0229962 (UMLS CUI [1,3])
Item
wound margin
integer
C1545981 (UMLS CUI [1])
Code List
wound margin
CL Item
intact (1)
CL Item
diffuse (2)
CL Item
ragged (3)
CL Item
undermined (4)
CL Item
dry (5)
CL Item
macerated (6)
CL Item
edematous (7)
CL Item
reddened (8)
Item
wound surrounding
integer
C2116843 (UMLS CUI [1])
Code List
wound surrounding
CL Item
intact (1)
CL Item
hardened (2)
CL Item
scaly (3)
CL Item
swollen (4)
CL Item
dry (5)
CL Item
macerated (6)
Item
wound odor
integer
C2721577 (UMLS CUI [1])
Code List
wound odor
CL Item
none (1)
CL Item
faint (2)
CL Item
medium (3)
CL Item
strong (4)
Item
Exudate type
integer
C0015388 (UMLS CUI [1,1])
C0332307 (UMLS CUI [1,2])
Code List
Exudate type
CL Item
none (1)
CL Item
viscous (2)
CL Item
liquid (3)
CL Item
bloody (4)
Item
Exudate volume
integer
C0015388 (UMLS CUI [1,1])
C2700258 (UMLS CUI [1,2])
Code List
Exudate volume
CL Item
none (1)
CL Item
small (2)
CL Item
medium (3)
CL Item
large (4)
Item
Wound surface film
integer
C0043250 (UMLS CUI [1,1])
C0205148 (UMLS CUI [1,2])
C1561572 (UMLS CUI [1,3])
Code List
Wound surface film
CL Item
yellow solid (1)
CL Item
yellow soft (2)
CL Item
greenish (3)
CL Item
gray/black (4)
Item
Inflammation
integer
C0021368 (UMLS CUI [1])
Code List
Inflammation
CL Item
reddening (1)
CL Item
tumor (2)
CL Item
hyperthermia (3)
CL Item
functional disability (4)
Item
Pain
integer
C0030193 (UMLS CUI [1])
Code List
Pain
CL Item
none (1)
CL Item
continuous (2)
CL Item
only during change of bandages (3)
Item
Bleeding type
integer
C0019080 (UMLS CUI [1,1])
C0332307 (UMLS CUI [1,2])
Code List
Bleeding type
CL Item
on contact (1)
CL Item
spontaneous (2)
Item
Bleeding extent
integer
C0019080 (UMLS CUI [1,1])
C0439792 (UMLS CUI [1,2])
Code List
Bleeding extent
CL Item
none (1)
CL Item
mild (2)
CL Item
moderate (3)
CL Item
severe (4)
Comment
Item
Comment
text
C0947611 (UMLS CUI [1])
Item Group
Diagnostic procedures
C0430022 (UMLS CUI-1)
wound smear test
Item
wound smear test
boolean
C0444086 (UMLS CUI [1])
excision sample
Item
excision sample
boolean
C0728940 (UMLS CUI [1,1])
C0870078 (UMLS CUI [1,2])
other
Item
other
text
C0205394 (UMLS CUI [1])
Item
Photography documentation (with flash)
integer
C0031749 (UMLS CUI [1])
C0920316 (UMLS CUI [2])
Code List
Photography documentation (with flash)
CL Item
patient agreed to photo documentation (1)
Item Group
Primary treatment goals
Item
Basic goal
integer
C0018017 (UMLS CUI [1,1])
C0178499 (UMLS CUI [1,2])
Code List
Basic goal
CL Item
palliative (1)
CL Item
curative (2)
Item
primary goals
integer
C0018017 (UMLS CUI [1,1])
C0205225 (UMLS CUI [1,2])
Code List
primary goals
CL Item
protection of surrounding skin (1)
CL Item
reduction of odor (2)
CL Item
size reduction of the wound (3)
CL Item
atraumatic change of bandage (4)
CL Item
reduction/absorption of secretion (5)
CL Item
containment of bleeding (6)
CL Item
pain reduction (7)
CL Item
cosmetically acceptable bandage (8)
CL Item
assistance with the experience and the challenges (9)
Comment
Item
Comment
text
C0947611 (UMLS CUI [1])
Item Group
Therapeutic procedures for wound management
Item
Therapeutic procedures for wound management
integer
C0087111 (UMLS CUI [1,1])
C1272654 (UMLS CUI [1,2])
Code List
Therapeutic procedures for wound management
CL Item
wound cleaning (1)
CL Item
wound purging solvent (2)
CL Item
wound therapeutics (3)
CL Item
wound overlay (4)
CL Item
wound margin protection (5)
CL Item
therapy for exudate (6)
CL Item
procedures against bleedings (7)
CL Item
procedures against odor (8)
CL Item
pharmaceutic procedures (9)
CL Item
additional procedures (10)
CL Item
other (11)
Other therapeutic procedures for wound management
Item
Other therapeutic procedures for wound management
text
C0087111 (UMLS CUI [1,1])
C1272654 (UMLS CUI [1,2])
C0205394 (UMLS CUI [1,3])
Item Group
Specific procedures in wound management
gentle removal of the bandage
Item
gentle removal of the bandage, wetting of the bandage with:
text
C0004726 (UMLS CUI [1,1])
C0015252 (UMLS CUI [1,2])
Item
wound cleaning
integer
C0455099 (UMLS CUI [1])
Code List
wound cleaning
CL Item
no cleaning (1)
CL Item
surgical cleaning (2)
CL Item
autolysis (3)
CL Item
enzymatic cleaning (4)
CL Item
biosurgical (maggots) (5)
CL Item
ultrasound (6)
CL Item
other: (7)
other wound cleaning
Item
other wound cleaning
text
C0455099 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
Item
wound rinses
integer
C0043250 (UMLS CUI [1,1])
C1882955 (UMLS CUI [1,2])
Code List
wound rinses
CL Item
clary tea (1)
CL Item
aseptic water (2)
CL Item
ringer solution (3)
CL Item
NaCl 0,9% (4)
CL Item
local antibiotic (5)
CL Item
antiseptic (6)
CL Item
other (7)
other wound rinses
Item
other wound rinses
text
C0043250 (UMLS CUI [1,1])
C1882955 (UMLS CUI [1,2])
C0205394 (UMLS CUI [1,3])
Item
Wound therapy
integer
C0886052 (UMLS CUI [1])
Code List
Wound therapy
CL Item
silverhydrate wound overlay (1)
CL Item
alginate (2)
CL Item
morphine gel (3)
CL Item
antiseptic gel (4)
CL Item
hydrofibres (5)
CL Item
hydrogel (6)
CL Item
sterile honey (7)
Item
Wound overlays
integer
C0043250 (UMLS CUI [1,1])
C1706359 (UMLS CUI [1,2])
Code List
Wound overlays
CL Item
wound distance grid (1)
CL Item
coal containing wound overlay (2)
CL Item
foam bandage (3)
CL Item
suction compression (4)
CL Item
super absorber (5)
CL Item
sterile compression (6)
CL Item
fixation mat (7)
CL Item
silicon coated fixation bandage (8)
CL Item
other (9)
Other wound overlay
Item
Other wound overlay
text
C0043250 (UMLS CUI [1,1])
C1706359 (UMLS CUI [1,2])
C0205394 (UMLS CUI [1,3])
Item
Specific procedures for wound margin protection
integer
C1545981 (UMLS CUI [1,1])
C1545588 (UMLS CUI [1,2])
C0087111 (UMLS CUI [1,3])
C0205369 (UMLS CUI [1,4])
Code List
Specific procedures for wound margin protection
CL Item
zinc lotion (1)
CL Item
silicone oil (2)
CL Item
urea cream (3)
CL Item
dexpanthenol lotion (4)
Item
specific therapeutic procedures for exudation
integer
C0311437 (UMLS CUI [1,1])
C0087111 (UMLS CUI [1,2])
C0205369 (UMLS CUI [1,3])
Code List
specific therapeutic procedures for exudation
CL Item
drainage, stoma material (1)
Item
Specific therapeutic procedure for exudation, vacuum therapy
integer
C0311437 (UMLS CUI [1,1])
C0087111 (UMLS CUI [1,2])
C0205369 (UMLS CUI [1,3])
C1322784 (UMLS CUI [1,4])
Code List
Specific therapeutic procedure for exudation, vacuum therapy
CL Item
black sponge (1)
CL Item
white sponge (2)
Item
Specific therapeutic procedures for bleeding wounds
integer
C0087111 (UMLS CUI [1,1])
C0205369 (UMLS CUI [1,2])
C0241742 (UMLS CUI [1,3])
Code List
Specific therapeutic procedures for bleeding wounds
CL Item
compression of the wound (1)
CL Item
sympathomimetic agent (e.g. suprarenin) (2)
CL Item
NaCl 0,9% ice cubes on capillary bleedings (3)
CL Item
application of sucralfat suspension (4)
CL Item
local absorbable hemostyptic agent (5)
CL Item
local non-absorbable hemostyptic agent (6)
Item
Specific therapeutic procedures for malodorous wounds
integer
C0087111 (UMLS CUI [1,1])
C0205369 (UMLS CUI [1,2])
C2168496 (UMLS CUI [1,3])
Code List
Specific therapeutic procedures for malodorous wounds
CL Item
compressions soaked with antiseptic agent (1)
CL Item
compressions soaked with antibiotic agent (2)
CL Item
compressions soaked with chlorophyll 0,25% (3)
Item
pharmaceuticals
integer
C0013227 (UMLS CUI [1])
Code List
pharmaceuticals
CL Item
painkillers (1)
CL Item
antibiotics (2)
CL Item
sedatives (for wounds close to blood vessels) (3)
CL Item
other (4)
other pharmaceuticals
Item
other pharmaceuticals
text
C0013227 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
Item
additional procedures
integer
C0940824 (UMLS CUI [1])
Code List
additional procedures
CL Item
lymphatic drainage (1)
CL Item
physiotherapy (2)
CL Item
counseling on stoma therapy (3)
CL Item
compression bandage (4)
CL Item
fragrance lamp (5)
CL Item
odor binding synthetic (6)
description of localization
Item
Please describe the localization of the wound and plot it in the drawing
text
C0475264 (UMLS CUI [1,1])
C0678257 (UMLS CUI [1,2])

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