ID

15368

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. 5/28/16 5/28/16 -
Copyright Holder

CC BY-NC 3.0

Uploaded on

May 28, 2016

DOI

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License

Creative Commons BY-NC 3.0
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Palliative and Hospice Care Emergency Form

German English

Palliative and Hospice Care Emergency Form

1 forms  
Patient information
Description

Patient information

Alias
UMLS CUI-1
C1955348
Name
Description

Name

Data type

text

Alias
UMLS CUI [1]
C0027365
Date of birth
Description

Date of birth

Data type

date

Alias
UMLS CUI [1]
C0421451
Address
Description

Address

Data type

text

Alias
UMLS CUI [1]
C0421449
Diagnoses
Description

Diagnoses

Data type

text

Alias
UMLS CUI [1]
C0011900
Current issues
Description

Current issues

Data type

text

Alias
UMLS CUI [1,1]
C0033213
UMLS CUI [1,2]
C0521116
Peculiarities
Description

Peculiarities

Data type

text

Alias
UMLS CUI [1]
C1704258
IMPORTANT contact persons / phone numbers
Description

IMPORTANT contact persons / phone numbers

closest relative
Description

closest relative

Data type

text

Alias
UMLS CUI [1]
C0080103
authorized person
Description

this authorized person has been appointed to implement my will that is determined in this instruction according to §1896 passage 2 BGB)

Data type

boolean

name
Description

name

Data type

text

Alias
UMLS CUI [1]
C0027365
date of birth
Description

date of birth

Data type

text

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C0027361
UMLS CUI [1,3]
C0005615
address
Description

address

Data type

text

Alias
UMLS CUI [1]
C1442065
palliative team phone number
Description

palliative team phone number

Data type

integer

Alias
UMLS CUI [1,1]
C0030231
UMLS CUI [1,2]
C0086390
UMLS CUI [1,3]
C0237753
UMLS CUI [1,4]
C0039457
general practitioner phone number
Description

general practitioner phone number

Data type

integer

Alias
UMLS CUI [1,1]
C0017319
UMLS CUI [1,2]
C0237753
UMLS CUI [1,3]
C0039457
nursing care service phone number
Description

nursing care service phone number

Data type

integer

Alias
UMLS CUI [1,1]
C0019855
UMLS CUI [1,2]
C0237753
UMLS CUI [1,3]
C0039457
association of shi physicians emergency service phone number
Description

association of shi physicians emergency service phone number

Data type

integer

Alias
UMLS CUI [1,1]
C0013961
UMLS CUI [1,2]
C0237753
UMLS CUI [1,3]
C0039457
emergency physician
Description

emergency physician

Data type

integer

Alias
UMLS CUI [1]
C2065341
pastoral care phone number
Description

pastoral care phone number

Data type

integer

Alias
UMLS CUI [1,1]
C0030643
UMLS CUI [1,2]
C0237753
UMLS CUI [1,3]
C0039457
hospice phone number
Description

hospice phone number

Data type

integer

Alias
UMLS CUI [1,1]
C0085555
UMLS CUI [1,2]
C0237753
UMLS CUI [1,3]
C0039457
Requested procedures
Description

Requested procedures

heart lung rescucitation requested
Description

heart lung rescucitation requested

Data type

boolean

Alias
UMLS CUI [1,1]
C0035273
UMLS CUI [1,2]
C1272683
hospital admission requested
Description

hospital admission requested

Data type

boolean

Alias
UMLS CUI [1,1]
C0184666
UMLS CUI [1,2]
C1272683
information about the diagnosis/prognosis for the patient?
Description

information about the diagnosis/prognosis for the patient?

Data type

boolean

Alias
UMLS CUI [1,1]
C0011900
UMLS CUI [1,2]
C0033325
UMLS CUI [1,3]
C1533716
UMLS CUI [1,4]
C0030705
information about the diagnosis/prognosis for the relatives?
Description

information about the diagnosis/prognosis for the relatives?

Data type

boolean

Alias
UMLS CUI [1,1]
C0011900
UMLS CUI [1,2]
C0033325
UMLS CUI [1,3]
C1533716
UMLS CUI [1,4]
C0080103
living will
Description

living will

Data type

boolean

Alias
UMLS CUI [1]
C0023914
health care proxy
Description

health care proxy

Data type

boolean

Alias
UMLS CUI [1]
C2029796
deposition of documents
Description

(for updates please see the back of the page; this emergency form accords to the existing law regarding living wills §1901a passage 1-5 BGB)

Data type

text

Alias
UMLS CUI [1]
C1301746
date
Description

date

Data type

date

Alias
UMLS CUI [1]
C0011008
name
Description

name

Data type

text

Alias
UMLS CUI [1]
C0027365
patient/representative signature
Description

patient/representative signature

Data type

text

Alias
UMLS CUI [1,1]
C1519316
UMLS CUI [1,2]
C0030705
UMLS CUI [1,3]
C0030701
Further procedures
Description

Further procedures

refusal of further procedures
Description

(Possible consequences that result from refusing medical procedures were explained to the patient; during the issue of this document the patient was fully capable of understanding and agreeing)

Data type

text

Alias
UMLS CUI [1]
C0040809
last hospital stay
Description

last hospital stay

Data type

text

Alias
UMLS CUI [1,1]
C3489408
UMLS CUI [1,2]
C1517741
hospital / facility
Description

hospital / facility

Data type

text

Alias
UMLS CUI [1]
C0019994
UMLS CUI [2]
C0018704
date
Description

date

Data type

date

Alias
UMLS CUI [1]
C0011008
doctor's name
Description

information provided by

Data type

text

Alias
UMLS CUI [1,1]
C0031831
UMLS CUI [1,2]
C0027365
signature
Description

signature

Data type

text

Alias
UMLS CUI [1]
C1519316
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Similar models

Palliative and Hospice Care Emergency Form

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Patient information
C1955348 (UMLS CUI-1)
Name
Item
Name
text
C0027365 (UMLS CUI [1])
Date of birth
Item
Date of birth
date
C0421451 (UMLS CUI [1])
Address
Item
Address
text
C0421449 (UMLS CUI [1])
Diagnoses
Item
Diagnoses
text
C0011900 (UMLS CUI [1])
Current issues
Item
Current issues
text
C0033213 (UMLS CUI [1,1])
C0521116 (UMLS CUI [1,2])
Peculiarities
Item
Peculiarities
text
C1704258 (UMLS CUI [1])
Item Group
IMPORTANT contact persons / phone numbers
closest relative
Item
closest relative
text
C0080103 (UMLS CUI [1])
authorized person
Item
authorized person
boolean
name
Item
name
text
C0027365 (UMLS CUI [1])
date of birth
Item
date of birth
text
C0011008 (UMLS CUI [1,1])
C0027361 (UMLS CUI [1,2])
C0005615 (UMLS CUI [1,3])
address
Item
address
text
C1442065 (UMLS CUI [1])
palliative team phone number
Item
palliative team phone number
integer
C0030231 (UMLS CUI [1,1])
C0086390 (UMLS CUI [1,2])
C0237753 (UMLS CUI [1,3])
C0039457 (UMLS CUI [1,4])
general practitioner phone number
Item
general practitioner phone number
integer
C0017319 (UMLS CUI [1,1])
C0237753 (UMLS CUI [1,2])
C0039457 (UMLS CUI [1,3])
nursing care service phone number
Item
nursing care service phone number
integer
C0019855 (UMLS CUI [1,1])
C0237753 (UMLS CUI [1,2])
C0039457 (UMLS CUI [1,3])
association of shi physicians emergency service phone number
Item
association of shi physicians emergency service phone number
integer
C0013961 (UMLS CUI [1,1])
C0237753 (UMLS CUI [1,2])
C0039457 (UMLS CUI [1,3])
Item
emergency physician
integer
C2065341 (UMLS CUI [1])
emergency physician
Code List
emergency physician
CL Item
112 (1)
pastoral care phone number
Item
pastoral care phone number
integer
C0030643 (UMLS CUI [1,1])
C0237753 (UMLS CUI [1,2])
C0039457 (UMLS CUI [1,3])
hospice phone number
Item
hospice phone number
integer
C0085555 (UMLS CUI [1,1])
C0237753 (UMLS CUI [1,2])
C0039457 (UMLS CUI [1,3])
Item Group
Requested procedures
heart lung rescucitation requested
Item
heart lung rescucitation requested
boolean
C0035273 (UMLS CUI [1,1])
C1272683 (UMLS CUI [1,2])
hospital admission requested
Item
hospital admission requested
boolean
C0184666 (UMLS CUI [1,1])
C1272683 (UMLS CUI [1,2])
information about the diagnosis/prognosis for the patient?
Item
information about the diagnosis/prognosis for the patient?
boolean
C0011900 (UMLS CUI [1,1])
C0033325 (UMLS CUI [1,2])
C1533716 (UMLS CUI [1,3])
C0030705 (UMLS CUI [1,4])
information about the diagnosis/prognosis for the relatives?
Item
information about the diagnosis/prognosis for the relatives?
boolean
C0011900 (UMLS CUI [1,1])
C0033325 (UMLS CUI [1,2])
C1533716 (UMLS CUI [1,3])
C0080103 (UMLS CUI [1,4])
living will
Item
living will
boolean
C0023914 (UMLS CUI [1])
health care proxy
Item
health care proxy
boolean
C2029796 (UMLS CUI [1])
deposition of documents
Item
deposition of documents
text
C1301746 (UMLS CUI [1])
date
Item
date
date
C0011008 (UMLS CUI [1])
name
Item
name
text
C0027365 (UMLS CUI [1])
patient/representative signature
Item
patient/representative signature
text
C1519316 (UMLS CUI [1,1])
C0030705 (UMLS CUI [1,2])
C0030701 (UMLS CUI [1,3])
Item Group
Further procedures
refusal of further procedures
Item
refusal of further procedures
text
C0040809 (UMLS CUI [1])
last hospital stay
Item
last hospital stay
text
C3489408 (UMLS CUI [1,1])
C1517741 (UMLS CUI [1,2])
hospital / facility
Item
hospital / facility
text
C0019994 (UMLS CUI [1])
C0018704 (UMLS CUI [2])
date
Item
date
date
C0011008 (UMLS CUI [1])
doctor name
Item
doctor's name
text
C0031831 (UMLS CUI [1,1])
C0027365 (UMLS CUI [1,2])
signature
Item
signature
text
C1519316 (UMLS CUI [1])
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