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15307
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 (2)
- 5/26/16 5/26/16 -
- 9/20/21 9/20/21 -
Copyright Holder
CC BY-NC 3.0
Uploaded on
May 26, 2016
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License
Creative Commons BY-NC 3.0
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Palliative and Hospice Care Liverpool Care Pathway Short Version
Palliative and Hospice Care Liverpool Care Pathway Short Version
- StudyEvent: ODM
Similar models
Palliative and Hospice Care Liverpool Care Pathway Short Version
- StudyEvent: ODM
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Main diagnosis
Item
Main diagnosis
text
C0011900 (UMLS CUI [1])
current medication
Item
Current medication has been reviewed, not necessarily required medication has been stopped
boolean
C1553892 (UMLS CUI [1])
medication if needed
Item
subcutaneous medication for the following symptoms has been prescribed if needed according to the existing guidelines
boolean
C0013227 (UMLS CUI [1])
pain - analgesics
Item
pain - analgesics
boolean
C0030193 (UMLS CUI [1])
C0002771 (UMLS CUI [2])
C0002771 (UMLS CUI [2])
nausea and emesis - antiemetics
Item
nausea and emesis - antiemetics
boolean
C0042963 (UMLS CUI [1])
C0027497 (UMLS CUI [2])
C0003297 (UMLS CUI [3])
C0027497 (UMLS CUI [2])
C0003297 (UMLS CUI [3])
agitation - tranquilizers
Item
agitation - tranquilizers
boolean
C0085631 (UMLS CUI [1])
C0040614 (UMLS CUI [2])
C0040614 (UMLS CUI [2])
bronchial secretion - anticholinergics
Item
bronchial secretion - anticholinergics
boolean
C1511332 (UMLS CUI [1])
C0242896 (UMLS CUI [2])
C0242896 (UMLS CUI [2])
dyspnea - opioids, anxiolytics
Item
dyspnea - opioids, anxiolytics
boolean
C0013404 (UMLS CUI [1])
C0242402 (UMLS CUI [2])
C0040616 (UMLS CUI [3])
C0242402 (UMLS CUI [2])
C0040616 (UMLS CUI [3])
unnecessary procedures
Item
the following unnecessary medical procedures were stopped:
boolean
C0376708 (UMLS CUI [1])
CL Item
not necessary (1)
CL Item
yes (2)
CL Item
no (3)
CL Item
not necessary (1)
CL Item
yes (2)
CL Item
no (3)
CL Item
not necessary (1)
CL Item
yes (2)
CL Item
no (3)
cardiopulmonary resuscitation
Item
cardiopulmonary resuscitation
boolean
C0007203 (UMLS CUI [1])
unnecessary nursing procedures
Item
unnecessary nursing procedures were stopped
boolean
C0376708 (UMLS CUI [1,1])
C0204636 (UMLS CUI [1,2])
C0204636 (UMLS CUI [1,2])
Item
subcutaneous syringe pump was started 4 hours at most after doctor's instruction
integer
C0181332 (UMLS CUI [1,1])
C0443315 (UMLS CUI [1,2])
C0040223 (UMLS CUI [2])
C0443315 (UMLS CUI [1,2])
C0040223 (UMLS CUI [2])
Code List
subcutaneous syringe pump was started 4 hours at most after doctor's instruction
CL Item
not necessary (1)
CL Item
yes (2)
CL Item
no (3)
Item
the patient's ability to communicate in German was assessed as adequate
integer
C0017477 (UMLS CUI [1,1])
C0009452 (UMLS CUI [1,2])
C0205411 (UMLS CUI [1,3])
C0009452 (UMLS CUI [1,2])
C0205411 (UMLS CUI [1,3])
Code List
the patient's ability to communicate in German was assessed as adequate
CL Item
comatose (1)
CL Item
yes (2)
CL Item
no (3)
family's ability to communicate in German
Item
the patient's family's / other people's ability to communicate in German was assessed as adequate
boolean
C0017477 (UMLS CUI [1,1])
C0009452 (UMLS CUI [1,2])
C0205411 (UMLS CUI [1,3])
C0009452 (UMLS CUI [1,2])
C0205411 (UMLS CUI [1,3])
Item
patient awareness of the diagnosis
integer
C0004448 (UMLS CUI [1,1])
C0011900 (UMLS CUI [1,2])
C0030705 (UMLS CUI [1,3])
C0011900 (UMLS CUI [1,2])
C0030705 (UMLS CUI [1,3])
CL Item
comatose (1)
CL Item
yes (2)
CL Item
no (3)
family/other awareness of the diagnosis
Item
family/other awareness of the diagnosis
boolean
C0004448 (UMLS CUI [1,1])
C0011900 (UMLS CUI [1,2])
C0015576 (UMLS CUI [1,3])
C0011900 (UMLS CUI [1,2])
C0015576 (UMLS CUI [1,3])
Item
patient awareness of dying
integer
C0004448 (UMLS CUI [1,1])
C0184532 (UMLS CUI [1,2])
C0030705 (UMLS CUI [1,3])
C0184532 (UMLS CUI [1,2])
C0030705 (UMLS CUI [1,3])
CL Item
comatose (1)
CL Item
yes (2)
CL Item
no (3)
family/other awareness of dying
Item
family/other awareness of dying
boolean
C0004448 (UMLS CUI [1,1])
C0184532 (UMLS CUI [1,2])
C0015576 (UMLS CUI [1,3])
C0184532 (UMLS CUI [1,2])
C0015576 (UMLS CUI [1,3])
Item
Patient defined religious/spiritual needs
integer
C0027552 (UMLS CUI [1,1])
C0150355 (UMLS CUI [1,2])
C0030705 (UMLS CUI [1,3])
C0150355 (UMLS CUI [1,2])
C0030705 (UMLS CUI [1,3])
CL Item
comatose (1)
CL Item
yes (2)
CL Item
no (3)
family/others defined religious/spiritual needs
Item
family/others defined religious/spiritual needs
boolean
C0027552 (UMLS CUI [1,1])
C0150355 (UMLS CUI [1,2])
C0015576 (UMLS CUI [1,3])
C0150355 (UMLS CUI [1,2])
C0015576 (UMLS CUI [1,3])
Item Group
Communication between family/others and nursing team
information about patient death
Item
it was settled how the family/other people close to the patient should be informed about the patient's death
boolean
C1306577 (UMLS CUI [1,1])
C1533716 (UMLS CUI [1,2])
C0015576 (UMLS CUI [1,3])
C1533716 (UMLS CUI [1,2])
C0015576 (UMLS CUI [1,3])
information about important matters
Item
the family/other people close to the patient received information about the following matters: drive and parking, lodging, drinks, phone, lavatories and toilets, visiting hours, other important information
boolean
C1533716 (UMLS CUI [1])
C0030566 (UMLS CUI [2])
C1556029 (UMLS CUI [3])
C0452428 (UMLS CUI [4])
C0039457 (UMLS CUI [5])
C0558278 (UMLS CUI [6])
C0040364 (UMLS CUI [7])
C1547409 (UMLS CUI [8])
C0030566 (UMLS CUI [2])
C1556029 (UMLS CUI [3])
C0452428 (UMLS CUI [4])
C0039457 (UMLS CUI [5])
C0558278 (UMLS CUI [6])
C0040364 (UMLS CUI [7])
C1547409 (UMLS CUI [8])
general practitioner informed about current state
Item
general practitioner was informed about the patient's current state
boolean
C0017319 (UMLS CUI [1])
C3166194 (UMLS CUI [2])
C1533716 (UMLS CUI [3])
C3166194 (UMLS CUI [2])
C1533716 (UMLS CUI [3])
Item
the care plan was explained and discussed with the patient
integer
C0178916 (UMLS CUI [1,1])
C0681841 (UMLS CUI [1,2])
C0030705 (UMLS CUI [1,3])
C0681841 (UMLS CUI [1,2])
C0030705 (UMLS CUI [1,3])
Code List
the care plan was explained and discussed with the patient
CL Item
comatose (1)
CL Item
yes (2)
CL Item
no (3)
care plan explained to family/other people
Item
the care plan was explained and discussed with the family/other people
boolean
C0178916 (UMLS CUI [1,1])
C0681841 (UMLS CUI [1,2])
C0015576 (UMLS CUI [1,3])
C0681841 (UMLS CUI [1,2])
C0015576 (UMLS CUI [1,3])
family/other people confirmed understanding of care plan
Item
the family/other people close to the patient confirmed that they understood the care plan
boolean
C0015576 (UMLS CUI [1,1])
C0750484 (UMLS CUI [1,2])
C0162340 (UMLS CUI [1,3])
C0178916 (UMLS CUI [1,4])
C0750484 (UMLS CUI [1,2])
C0162340 (UMLS CUI [1,3])
C0178916 (UMLS CUI [1,4])
general practitioner was informed about the patients death
Item
general practitioner was informed about the patient's death
boolean
C0017319 (UMLS CUI [1,1])
C1522154 (UMLS CUI [1,2])
C1306577 (UMLS CUI [1,3])
C1522154 (UMLS CUI [1,2])
C1306577 (UMLS CUI [1,3])
laying-out procedures
Item
procedures for the laying-out were performed according to the in-house regulations
boolean
C2700391 (UMLS CUI [1])
procedures after death
Item
procedures after death were discussed or performed
boolean
C2700391 (UMLS CUI [1,1])
C1306577 (UMLS CUI [1,2])
C1306577 (UMLS CUI [1,2])
infectious disease
Item
patient suffered from an infectious disease
boolean
C0009450 (UMLS CUI [1])
special needs regarding religious rituals
Item
patient had special needs regarding religious rituals
boolean
C0871403 (UMLS CUI [1,1])
C0237841 (UMLS CUI [1,2])
C0237841 (UMLS CUI [1,2])
autopsy
Item
autopsy was clarified
boolean
C0004398 (UMLS CUI [1])
information about procedures in hospital
Item
family/other people close to the patient were informed about the procedures in the hospital
boolean
C2700391 (UMLS CUI [1,1])
C0019994 (UMLS CUI [1,2])
C1533716 (UMLS CUI [2])
C0015576 (UMLS CUI [3])
C0019994 (UMLS CUI [1,2])
C1533716 (UMLS CUI [2])
C0015576 (UMLS CUI [3])
articles of value and patient belongings
Item
hospital guidelines regarding articles of value and patient's belongings were followed
boolean
C0162791 (UMLS CUI [1])
C2347695 (UMLS CUI [2])
C2347695 (UMLS CUI [2])
documentation and references
Item
necessary documentation and references were passed on to the respective person
boolean
C0920316 (UMLS CUI [1])
C0586393 (UMLS CUI [2])
C0586393 (UMLS CUI [2])
brochure with information about grieving process
Item
brochure with information about grieving process was handed out
boolean
C0949917 (UMLS CUI [1,1])
C0018235 (UMLS CUI [1,2])
C0018235 (UMLS CUI [1,2])
symptom assessment
Item
Were the following symptoms frequently (meaning every 4 hours or at each patient contact) assessed?
boolean
C3494437 (UMLS CUI [1,1])
C0439603 (UMLS CUI [1,2])
C0439603 (UMLS CUI [1,2])
pain
Item
pain
boolean
C0030193 (UMLS CUI [1])
agitation
Item
agitation
boolean
C0085631 (UMLS CUI [1])
bronchial secretion
Item
bronchial secretion
boolean
C1511332 (UMLS CUI [1])
nausea / emesis
Item
nausea / emesis
boolean
C0027497 (UMLS CUI [1])
C0042963 (UMLS CUI [2])
C0042963 (UMLS CUI [2])
dyspnea
Item
dyspnea
boolean
C0013404 (UMLS CUI [1])
frequency of medical or nursing procedures
Item
were the following medical or nursing procedures frequently (meaning every 4 hours or at every patient contact) performed or assessed?
boolean
C0199171 (UMLS CUI [1])
C0204636 (UMLS CUI [2])
C0439603 (UMLS CUI [3])
C0204636 (UMLS CUI [2])
C0439603 (UMLS CUI [3])
oral hygiene
Item
oral hygiene
boolean
C0029164 (UMLS CUI [1])
urinary excretion
Item
urinary excretion
boolean
C0042034 (UMLS CUI [1])
Item
all medication was applied safely and precisely
integer
C0013227 (UMLS CUI [1,1])
C0185125 (UMLS CUI [1,2])
C0185125 (UMLS CUI [1,2])
CL Item
not necessary (1)
CL Item
yes (2)
CL Item
no (3)
Item
subcutaneous syringe pump
integer
C0181332 (UMLS CUI [1,1])
C0443315 (UMLS CUI [1,2])
C0443315 (UMLS CUI [1,2])
CL Item
not necessary (1)
CL Item
yes (2)
CL Item
no (3)
defecation
Item
defecation
boolean
C0011135 (UMLS CUI [1])
comments
Item
comments
text
C0947611 (UMLS CUI [1])