ID

15013

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

Versions (1)
  1. 5/11/16 5/11/16 -
Copyright Holder

CC BY-NC 3.0

Uploaded on

May 11, 2016

DOI

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License

Creative Commons BY-NC 3.0
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Palliative and Hospice Care Advanced Diagnostic Procedures

German English

Palliative and Hospice Care Advanced Diagnostic Procedures

1 forms  
Microbiological tests
Description

Microbiological tests

laboratory culture
Description

laboratory culture

Data type

boolean

Alias
UMLS CUI [1]
C0430400
material for laboratory culture
Description

material for laboratory culture

Data type

text

Alias
UMLS CUI [1,1]
C0520510
UMLS CUI [1,2]
C0430400
laboratory culture resistency testing
Description

laboratory culture resistency testing

Data type

boolean

Alias
UMLS CUI [1]
C3160797
UMLS CUI [2]
C0430400
smear test
Description

smear test

Data type

boolean

Alias
UMLS CUI [1]
C0444186
localization smear test
Description

localization smear test

Data type

text

Alias
UMLS CUI [1,1]
C0444186
UMLS CUI [1,2]
C0475264
smear test resistance test
Description

smear test resistance test

Data type

boolean

Alias
UMLS CUI [1]
C3160797
UMLS CUI [2]
C0444186
virological testing
Description

virological testing

Data type

boolean

Alias
UMLS CUI [1]
C0599616
type of virological testing and/or localization of sample
Description

type of virological testing and localization of sample

Data type

text

Alias
UMLS CUI [1,1]
C0599616
UMLS CUI [1,2]
C0475264
UMLS CUI [1,3]
C0332307
mycological tests
Description

mycological tests

Data type

boolean

Alias
UMLS CUI [1]
C0085127
type of mycological test and/or localization
Description

type of mycological test and localization

Data type

text

Alias
UMLS CUI [1,1]
C0085127
UMLS CUI [1,2]
C0475264
UMLS CUI [1,3]
C0332307
other laboratory procedures, e.g. DNA sequencing or PCR procedures
Description

other laboratory procedures

Data type

boolean

Alias
UMLS CUI [1,1]
C0022885
UMLS CUI [1,2]
C0205394
other laboratory procedures, e.g. DNA sequencing or PCR procedures, type of test and/or localization
Description

other laboratory procedures

Data type

text

Alias
UMLS CUI [1,1]
C0022885
UMLS CUI [1,2]
C0205394
technically-analytically usable result?
Description

usable result

Data type

boolean

Alias
UMLS CUI [1]
C1274040
Therapeutic consequences from laboratory result
Description

Therapeutic consequences from laboratory result

prescription of antibiotic
Description

prescription of antibiotic

Data type

boolean

Alias
UMLS CUI [1,1]
C0003232
UMLS CUI [1,2]
C0033080
name of antibiotic prescribed
Description

name of antibiotic prescribed

Data type

text

Alias
UMLS CUI [1,1]
C0003232
UMLS CUI [1,2]
C0033080
decision against use of antibiotic
Description

decision against use of antibiotic

Data type

boolean

Alias
UMLS CUI [1]
C0003232
new evaluation of the general prognosis
Description

new evaluation

Data type

boolean

Alias
UMLS CUI [1,1]
C0220825
UMLS CUI [1,2]
C0205314
no consequence
Description

no consequence

Data type

boolean

Alias
UMLS CUI [1]
C1547646
other consequences
Description

other consequences

Data type

text

Alias
UMLS CUI [1,1]
C1547646
UMLS CUI [1,2]
C0205394
Ultrasound
Description

Ultrasound

Alias
UMLS CUI-1
C0041618
b-mode
Description

b-mode

Data type

boolean

Alias
UMLS CUI [1]
C1302166
duplex
Description

duplex

Data type

boolean

Alias
UMLS CUI [1]
C0242845
abdomen
Description

abdomen

Data type

boolean

Alias
UMLS CUI [1]
C0000726
bladder
Description

bladder

Data type

boolean

Alias
UMLS CUI [1]
C0005682
pleura
Description

pleura

Data type

boolean

Alias
UMLS CUI [1]
C0032225
vessels
Description

vessels

Data type

boolean

Alias
UMLS CUI [1]
C0005847
other
Description

other

Data type

text

Alias
UMLS CUI [1]
C0205394
technically-analytically usable result?
Description

usable result

Data type

boolean

Alias
UMLS CUI [1]
C1274040
X-ray
Description

X-ray

Alias
UMLS CUI-1
C0043309
thorax
Description

thorax

Data type

boolean

Alias
UMLS CUI [1]
C1269614
abdomen
Description

abdomen

Data type

boolean

Alias
UMLS CUI [1]
C0000726
gastrointestinal passage
Description

gastrointestinal passage

Data type

boolean

Alias
UMLS CUI [1,1]
C0521362
UMLS CUI [1,2]
C0011135
extremities
Description

extremities

Data type

boolean

Alias
UMLS CUI [1]
C0015385
other
Description

other

Data type

text

Alias
UMLS CUI [1]
C0205394
technically-analytically usable result?
Description

usable result

Data type

boolean

Alias
UMLS CUI [1]
C1274040
CT / MRI
Description

CT / MRI

neck
Description

neck

Data type

boolean

Alias
UMLS CUI [1]
C0027530
thorax
Description

thorax

Data type

boolean

Alias
UMLS CUI [1]
C1269614
abdomen
Description

abdomen

Data type

boolean

Alias
UMLS CUI [1]
C0000726
pelvis
Description

pelvis

Data type

boolean

Alias
UMLS CUI [1]
C0030797
other
Description

other

Data type

text

Alias
UMLS CUI [1]
C0205394
technically-analytically usable result?
Description

usable result

Data type

boolean

Alias
UMLS CUI [1]
C1274040
radio imaging
Description

radio imaging

radionuclide imaging
Description

radionuclide imaging

Data type

boolean

Alias
UMLS CUI [1]
C0034606
radionuclide imaging of the skeleton
Description

radionuclide imaging of the skeleton

Data type

boolean

Alias
UMLS CUI [1,1]
C0034606
UMLS CUI [1,2]
C0816871
other radionuclide imaging
Description

other radionuclide imaging

Data type

boolean

Alias
UMLS CUI [1,1]
C0034606
UMLS CUI [1,2]
C0205394
PET
Description

PET

Data type

boolean

Alias
UMLS CUI [1]
C0032743
other diagnostic procedure
Description

other diagnostic procedure

Data type

text

Alias
UMLS CUI [1,1]
C0430022
UMLS CUI [1,2]
C0205394
technically-analytically usable result?
Description

usable result

Data type

boolean

Alias
UMLS CUI [1]
C1274040
Issues during diagnostic imaging
Description

Issues during diagnostic imaging

pain due to the examination
Description

pain due to the examination

Data type

boolean

Alias
UMLS CUI [1,1]
C0030193
UMLS CUI [1,2]
C0582103
issues during transportation or positioning
Description

issues during transportation or positioning

Data type

boolean

Alias
UMLS CUI [1,1]
C1948143
UMLS CUI [1,2]
C1561964
patient need for rest
Description

patient need for rest

Data type

boolean

Alias
UMLS CUI [1,1]
C0686904
UMLS CUI [1,2]
C0035253
issues with enteral contrast medium
Description

issues with enteral contrast medium

Data type

boolean

Alias
UMLS CUI [1,1]
C0009924
UMLS CUI [1,2]
C1304890
contraindication for intravenous contrast medium
Description

contraindication for intravenous contrast medium

Data type

boolean

Alias
UMLS CUI [1,1]
C1301624
UMLS CUI [1,2]
C0009924
UMLS CUI [1,3]
C0348016
other issues
Description

other issues

Data type

text

Alias
UMLS CUI [1,1]
C0033213
UMLS CUI [1,2]
C0205394
what issues occured during the evaluation?
Description

issues during evluation

Data type

integer

Alias
UMLS CUI [1,1]
C0033213
UMLS CUI [1,2]
C0220825
other issues during evaluation
Description

other issues during evaluation

Data type

text

Alias
UMLS CUI [1,1]
C0033213
UMLS CUI [1,2]
C0205394
UMLS CUI [1,3]
C0220825
Therapeutic consequences from diagnostic imaging
Description

Therapeutic consequences from diagnostic imaging

invasive procedure (puncture, endoscopy, urinary catheter...) as a consequence
Description

invasive procedure

Data type

boolean

Alias
UMLS CUI [1]
C1548804
non-invasive procedure (laxation, therapy of ileus, diuretics, antibiotics...) as a consequence
Description

non-invasive procedure

Data type

boolean

Alias
UMLS CUI [1,1]
C0087111
UMLS CUI [1,2]
C0205303
new evaluation of the general prognosis
Description

new evaluation

Data type

boolean

Alias
UMLS CUI [1,1]
C0220825
UMLS CUI [1,2]
C0205314
no consequence
Description

no consequence

Data type

boolean

Alias
UMLS CUI [1]
C0686907
other consequences
Description

other consequences

Data type

text

Alias
UMLS CUI [1,1]
C0686907
UMLS CUI [1,2]
C0205394
Form Information
Description

Form Information

who fills out the form?
Description

who fills out the form?

Data type

integer

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Similar models

Palliative and Hospice Care Advanced Diagnostic Procedures

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Microbiological tests
laboratory culture
Item
laboratory culture
boolean
C0430400 (UMLS CUI [1])
material for laboratory culture
Item
material for laboratory culture
text
C0520510 (UMLS CUI [1,1])
C0430400 (UMLS CUI [1,2])
laboratory culture resistency testing
Item
laboratory culture resistency testing
boolean
C3160797 (UMLS CUI [1])
C0430400 (UMLS CUI [2])
smear test
Item
smear test
boolean
C0444186 (UMLS CUI [1])
localization smear test
Item
localization smear test
text
C0444186 (UMLS CUI [1,1])
C0475264 (UMLS CUI [1,2])
smear test resistance test
Item
smear test resistance test
boolean
C3160797 (UMLS CUI [1])
C0444186 (UMLS CUI [2])
virological testing
Item
virological testing
boolean
C0599616 (UMLS CUI [1])
type of virological testing and localization of sample
Item
type of virological testing and/or localization of sample
text
C0599616 (UMLS CUI [1,1])
C0475264 (UMLS CUI [1,2])
C0332307 (UMLS CUI [1,3])
mycological tests
Item
mycological tests
boolean
C0085127 (UMLS CUI [1])
type of mycological test and localization
Item
type of mycological test and/or localization
text
C0085127 (UMLS CUI [1,1])
C0475264 (UMLS CUI [1,2])
C0332307 (UMLS CUI [1,3])
other laboratory procedures
Item
other laboratory procedures, e.g. DNA sequencing or PCR procedures
boolean
C0022885 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
other laboratory procedures
Item
other laboratory procedures, e.g. DNA sequencing or PCR procedures, type of test and/or localization
text
C0022885 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
usable result
Item
technically-analytically usable result?
boolean
C1274040 (UMLS CUI [1])
Item Group
Therapeutic consequences from laboratory result
prescription of antibiotic
Item
prescription of antibiotic
boolean
C0003232 (UMLS CUI [1,1])
C0033080 (UMLS CUI [1,2])
name of antibiotic prescribed
Item
name of antibiotic prescribed
text
C0003232 (UMLS CUI [1,1])
C0033080 (UMLS CUI [1,2])
decision against use of antibiotic
Item
decision against use of antibiotic
boolean
C0003232 (UMLS CUI [1])
new evaluation
Item
new evaluation of the general prognosis
boolean
C0220825 (UMLS CUI [1,1])
C0205314 (UMLS CUI [1,2])
no consequence
Item
no consequence
boolean
C1547646 (UMLS CUI [1])
other consequences
Item
other consequences
text
C1547646 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
Item Group
Ultrasound
C0041618 (UMLS CUI-1)
b-mode
Item
b-mode
boolean
C1302166 (UMLS CUI [1])
duplex
Item
duplex
boolean
C0242845 (UMLS CUI [1])
abdomen
Item
abdomen
boolean
C0000726 (UMLS CUI [1])
bladder
Item
bladder
boolean
C0005682 (UMLS CUI [1])
pleura
Item
pleura
boolean
C0032225 (UMLS CUI [1])
vessels
Item
vessels
boolean
C0005847 (UMLS CUI [1])
other
Item
other
text
C0205394 (UMLS CUI [1])
usable result
Item
technically-analytically usable result?
boolean
C1274040 (UMLS CUI [1])
Item Group
X-ray
C0043309 (UMLS CUI-1)
thorax
Item
thorax
boolean
C1269614 (UMLS CUI [1])
abdomen
Item
abdomen
boolean
C0000726 (UMLS CUI [1])
gastrointestinal passage
Item
gastrointestinal passage
boolean
C0521362 (UMLS CUI [1,1])
C0011135 (UMLS CUI [1,2])
extremities
Item
extremities
boolean
C0015385 (UMLS CUI [1])
other
Item
other
text
C0205394 (UMLS CUI [1])
usable result
Item
technically-analytically usable result?
boolean
C1274040 (UMLS CUI [1])
Item Group
CT / MRI
neck
Item
neck
boolean
C0027530 (UMLS CUI [1])
thorax
Item
thorax
boolean
C1269614 (UMLS CUI [1])
abdomen
Item
abdomen
boolean
C0000726 (UMLS CUI [1])
pelvis
Item
pelvis
boolean
C0030797 (UMLS CUI [1])
other
Item
other
text
C0205394 (UMLS CUI [1])
usable result
Item
technically-analytically usable result?
boolean
C1274040 (UMLS CUI [1])
Item Group
radio imaging
radionuclide imaging
Item
radionuclide imaging
boolean
C0034606 (UMLS CUI [1])
radionuclide imaging of the skeleton
Item
radionuclide imaging of the skeleton
boolean
C0034606 (UMLS CUI [1,1])
C0816871 (UMLS CUI [1,2])
other radionuclide imaging
Item
other radionuclide imaging
boolean
C0034606 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
PET
Item
PET
boolean
C0032743 (UMLS CUI [1])
other diagnostic procedure
Item
other diagnostic procedure
text
C0430022 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
usable result
Item
technically-analytically usable result?
boolean
C1274040 (UMLS CUI [1])
Item Group
Issues during diagnostic imaging
pain due to the examination
Item
pain due to the examination
boolean
C0030193 (UMLS CUI [1,1])
C0582103 (UMLS CUI [1,2])
issues during transportation or positioning
Item
issues during transportation or positioning
boolean
C1948143 (UMLS CUI [1,1])
C1561964 (UMLS CUI [1,2])
patient need for rest
Item
patient need for rest
boolean
C0686904 (UMLS CUI [1,1])
C0035253 (UMLS CUI [1,2])
issues with enteral contrast medium
Item
issues with enteral contrast medium
boolean
C0009924 (UMLS CUI [1,1])
C1304890 (UMLS CUI [1,2])
contraindication for intravenous contrast medium
Item
contraindication for intravenous contrast medium
boolean
C1301624 (UMLS CUI [1,1])
C0009924 (UMLS CUI [1,2])
C0348016 (UMLS CUI [1,3])
other issues
Item
other issues
text
C0033213 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
Item
what issues occured during the evaluation?
integer
C0033213 (UMLS CUI [1,1])
C0220825 (UMLS CUI [1,2])
issues during evluation
Code List
what issues occured during the evaluation?
CL Item
meteorism (1)
CL Item
adipositas (2)
CL Item
other issues (3)
other issues during evaluation
Item
other issues during evaluation
text
C0033213 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
C0220825 (UMLS CUI [1,3])
Item Group
Therapeutic consequences from diagnostic imaging
invasive procedure
Item
invasive procedure (puncture, endoscopy, urinary catheter...) as a consequence
boolean
C1548804 (UMLS CUI [1])
non-invasive procedure
Item
non-invasive procedure (laxation, therapy of ileus, diuretics, antibiotics...) as a consequence
boolean
C0087111 (UMLS CUI [1,1])
C0205303 (UMLS CUI [1,2])
new evaluation
Item
new evaluation of the general prognosis
boolean
C0220825 (UMLS CUI [1,1])
C0205314 (UMLS CUI [1,2])
no consequence
Item
no consequence
boolean
C0686907 (UMLS CUI [1])
other consequences
Item
other consequences
text
C0686907 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
Item Group
Form Information
Item
who fills out the form?
integer
who fills out the form?
Code List
who fills out the form?
CL Item
doctor (1)
CL Item
nursing staff (2)
CL Item
other staff (3)
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