ID
15907
Description
Report/Protocol collecting patient and treatment information like the circumstances of the accident and initial ER treatment. Documentation in traum room. ODM derived from EHR form: MS Schockraumprotokoll 2 by University Hospital Muenster http://klinikum.uni-muenster.de/
Link
http://klinikum.uni-muenster.de/
Keywords
Versions (3)
- 6/17/16 6/17/16 -
- 6/18/16 6/18/16 -
- 7/3/16 7/3/16 -
Uploaded on
June 18, 2016
DOI
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License
Creative Commons BY-NC 3.0
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Emergency Room Point B in Time Part 2: Trauma Protocol UKM
Emergency Room Point B in Time Part 2: Emergency Room Report UKM
- StudyEvent: ODM
Description
Physical examination result
Description
ATLS
Alias
- UMLS CUI-1
- C3494237
Description
A-Problem (Airway)
Data type
boolean
Alias
- UMLS CUI [1,1]
- C0458827
- UMLS CUI [1,2]
- C0033213
Description
B-Problem (Breathing)
Data type
boolean
Alias
- UMLS CUI [1,1]
- C0035203
- UMLS CUI [1,2]
- C0033213
Description
C-Problem (Circulation)
Data type
boolean
Alias
- UMLS CUI [1,1]
- C0005775
- UMLS CUI [1,2]
- C0033213
Description
D-Problem (Disability)
Data type
boolean
Alias
- UMLS CUI [1,1]
- C0231170
- UMLS CUI [1,2]
- C0033213
Description
E-Problem (Hypothermia)
Data type
boolean
Alias
- UMLS CUI [1,1]
- C0020672
- UMLS CUI [1,2]
- C0033213
Description
Peripheral neurological status
Alias
- UMLS CUI-1
- C0027853
Description
motor function
Data type
integer
Alias
- UMLS CUI [1]
- C0234130
Description
sensitivity
Data type
integer
Alias
- UMLS CUI [1]
- C1522640
Description
reflexes
Data type
integer
Alias
- UMLS CUI [1]
- C0436145
Description
Babinski Reflex
Data type
boolean
Alias
- UMLS CUI [1]
- C0034935
Description
sphincter tone
Data type
boolean
Alias
- UMLS CUI [1]
- C0516792
Description
other neurological finding
Data type
text
Alias
- UMLS CUI [1]
- C0438194
Description
Vascular examination
Alias
- UMLS CUI-1
- C0005847
- UMLS CUI-2
- C0438105
Description
right A. carotis palpable
Data type
boolean
Alias
- UMLS CUI [1,1]
- C0517385
- UMLS CUI [1,2]
- C0007272
- UMLS CUI [1,3]
- C0444532
- UMLS CUI [2,1]
- C0162481
- UMLS CUI [2,2]
- C0007272
- UMLS CUI [2,3]
- C0444532
Description
left A. carotis palpable
Data type
boolean
Alias
- UMLS CUI [1,1]
- C0517385
- UMLS CUI [1,2]
- C0007272
- UMLS CUI [1,3]
- C0162481
- UMLS CUI [1,4]
- C0007272
- UMLS CUI [1,5]
- C0443246
Description
right A. radialis palpable
Data type
boolean
Alias
- UMLS CUI [1,1]
- C0232142
- UMLS CUI [1,2]
- C0444532
- UMLS CUI [2,1]
- C0162481
- UMLS CUI [2,2]
- C0162857
- UMLS CUI [2,3]
- C0444532
Description
left A. radialis palpable
Data type
boolean
Alias
- UMLS CUI [1,1]
- C0232142
- UMLS CUI [1,2]
- C0443246
- UMLS CUI [2,1]
- C0162481
- UMLS CUI [2,2]
- C0162857
- UMLS CUI [2,3]
- C0443246
Description
right A. femoralis palpable
Data type
boolean
Alias
- UMLS CUI [1,1]
- C0517385
- UMLS CUI [1,2]
- C0015801
- UMLS CUI [1,3]
- C0444532
- UMLS CUI [2,1]
- C0162481
- UMLS CUI [2,2]
- C0015801
- UMLS CUI [2,3]
- C0444532
Description
left A. femoralis palpable
Data type
boolean
Alias
- UMLS CUI [1,1]
- C0517385
- UMLS CUI [1,2]
- C0015801
- UMLS CUI [1,3]
- C0443246
- UMLS CUI [2,1]
- C0162481
- UMLS CUI [2,2]
- C0015801
- UMLS CUI [2,3]
- C0443246
Description
right A. poplitea palpable
Data type
boolean
Alias
- UMLS CUI [1,1]
- C0232151
- UMLS CUI [1,2]
- C0444532
- UMLS CUI [2,1]
- C0162481
- UMLS CUI [2,2]
- C0032649
- UMLS CUI [2,3]
- C0444532
Description
left A. poplitea palpable
Data type
boolean
Alias
- UMLS CUI [1,1]
- C0232151
- UMLS CUI [1,2]
- C0162481
- UMLS CUI [1,3]
- C0032649
- UMLS CUI [1,4]
- C0443246
Description
right A. dors. ped. palpable
Data type
boolean
Alias
- UMLS CUI [1,1]
- C0517385
- UMLS CUI [1,2]
- C0226492
- UMLS CUI [1,3]
- C0444532
- UMLS CUI [2,1]
- C0162481
- UMLS CUI [2,2]
- C0226492
- UMLS CUI [2,3]
- C0444532
Description
left A. dors. ped. palpable
Data type
boolean
Alias
- UMLS CUI [1,1]
- C0517385
- UMLS CUI [1,2]
- C0226492
- UMLS CUI [1,3]
- C0443246
- UMLS CUI [2,1]
- C0162481
- UMLS CUI [2,2]
- C0226492
- UMLS CUI [2,3]
- C0443246
Description
right A. tib. post. palpable
Data type
boolean
Alias
- UMLS CUI [1,1]
- C0517385
- UMLS CUI [1,2]
- C0086835
- UMLS CUI [1,3]
- C0444532
- UMLS CUI [2,1]
- C0162481
- UMLS CUI [2,2]
- C0086835
- UMLS CUI [2,3]
- C0444532
Description
left A. tib. post. palpable
Data type
boolean
Alias
- UMLS CUI [1,1]
- C0517385
- UMLS CUI [1,2]
- C0086835
- UMLS CUI [1,3]
- C0443246
- UMLS CUI [2,1]
- C0162481
- UMLS CUI [2,2]
- C0086835
- UMLS CUI [2,3]
- C0443246
Description
Physical examination of head
Alias
- UMLS CUI-1
- C0031809
- UMLS CUI-2
- C0460004
Description
without finding
Data type
boolean
Alias
- UMLS CUI [1,1]
- C0332288
- UMLS CUI [1,2]
- C0243095
Description
hematoma
Data type
boolean
Alias
- UMLS CUI [1]
- C0018944
Description
hematoma of orbita
Data type
boolean
Alias
- UMLS CUI [1]
- C0520723
Description
bleeding of auditory canal
Data type
boolean
Alias
- UMLS CUI [1,1]
- C0019080
- UMLS CUI [1,2]
- C0013444
Description
liquorrhea
Data type
boolean
Alias
- UMLS CUI [1]
- C0860578
Description
laceration
Data type
boolean
Alias
- UMLS CUI [1]
- C0856548
Description
facial instabilty
Data type
boolean
Alias
- UMLS CUI [1]
- C0024953
Description
fracture of mandibula
Data type
boolean
Alias
- UMLS CUI [1]
- C0024692
Description
injury of eye
Data type
boolean
Alias
- UMLS CUI [1]
- C0015408
Description
ohter injuries of head
Data type
text
Alias
- UMLS CUI [1]
- C0178671
Description
Physical examination of thorax
Alias
- UMLS CUI-1
- C0031809
- UMLS CUI-2
- C0817096
Description
without finding
Data type
boolean
Alias
- UMLS CUI [1,1]
- C0332288
- UMLS CUI [1,2]
- C0243095
Description
contusion of chest
Data type
boolean
Alias
- UMLS CUI [1]
- C0160925
Description
hematoma
Data type
boolean
Alias
- UMLS CUI [1]
- C4049192
Description
skin emphysema
Data type
boolean
Alias
- UMLS CUI [1]
- C0038536
Description
thoracal instability
Data type
boolean
Alias
- UMLS CUI [1,1]
- C0231433
- UMLS CUI [1,2]
- C0817096
Description
chest pain on breathing
Data type
boolean
Alias
- UMLS CUI [1]
- C0423729
Description
chest pain on compression
Data type
boolean
Alias
- UMLS CUI [1,1]
- C0008031
- UMLS CUI [1,2]
- C0728907
Description
open wound
Data type
boolean
Alias
- UMLS CUI [1]
- C0478235
Description
jugular vein congestion
Data type
boolean
Alias
- UMLS CUI [1,1]
- C0700148
- UMLS CUI [1,2]
- C0022427
Description
pathological auscultation of chest
Data type
boolean
Alias
- UMLS CUI [1]
- C0577960
Description
chest tube
Data type
boolean
Alias
- UMLS CUI [1]
- C0008034
Description
other chest pain
Data type
text
Alias
- UMLS CUI [1]
- C0039980
Description
Physical examination of abdomen and genitourinary system
Alias
- UMLS CUI-1
- C0031809
- UMLS CUI-2
- C0000726
- UMLS CUI-3
- C0042066
Description
without finding
Data type
boolean
Alias
- UMLS CUI [1,1]
- C0332288
- UMLS CUI [1,2]
- C0243095
Description
contusion
Data type
boolean
Alias
- UMLS CUI [1]
- C1439271
- UMLS CUI [2]
- C1389458
Description
Hematoma
Data type
boolean
Alias
- UMLS CUI [1]
- C0018944
Description
Abdomen distended
Data type
boolean
Alias
- UMLS CUI [1]
- C0000731
Description
pressure pain
Data type
boolean
Alias
- UMLS CUI [1]
- C3647129
Description
muscular guarding
Data type
boolean
Alias
- UMLS CUI [1]
- C0238547
Description
open injury
Data type
boolean
Alias
- UMLS CUI [1]
- C0559870
Description
anogenital injury
Data type
boolean
Alias
- UMLS CUI [1,1]
- C3263723
- UMLS CUI [1,2]
- C0031066
Description
pathological digital examination of the rectum
Data type
boolean
Alias
- UMLS CUI [1]
- C1384593
Description
other injury of abdomen
Data type
text
Alias
- UMLS CUI [1]
- C1260446
Description
Physical examination of pelvis
Alias
- UMLS CUI-1
- C0031809
- UMLS CUI-2
- C0030797
Description
without finding
Data type
boolean
Alias
- UMLS CUI [1,1]
- C0332288
- UMLS CUI [1,2]
- C0243095
Description
instability of pelvis
Data type
boolean
Alias
- UMLS CUI [1]
- C1389477
Description
open wound
Data type
boolean
Alias
- UMLS CUI [1,1]
- C0559870
- UMLS CUI [1,2]
- C0030797
Description
other injury of pelvis
Data type
text
Alias
- UMLS CUI [1]
- C0560636
Description
Physical examination of limbs
Alias
- UMLS CUI-1
- C0031809
- UMLS CUI-2
- C0015385
Description
Lower limb
Data type
text
Alias
- UMLS CUI [1,1]
- C0031809
- UMLS CUI [1,2]
- C0243095
- UMLS CUI [1,3]
- C0023216
Description
compartment syndrome lower limb
Data type
boolean
Alias
- UMLS CUI [1,1]
- C0009492
- UMLS CUI [1,2]
- C0031809
Description
Upper limb
Data type
text
Alias
- UMLS CUI [1,1]
- C0031809
- UMLS CUI [1,2]
- C0243095
- UMLS CUI [1,3]
- C1140618
Description
compartment syndrome of upper limb
Data type
boolean
Alias
- UMLS CUI [1,1]
- C0009492
- UMLS CUI [1,2]
- C1140618
Description
Diagnoses
Description
Patient handover
Alias
- UMLS CUI-1
- C3494290
- UMLS CUI-3
- C0586001
Description
thrombosis prophylaxis
Data type
text
Alias
- UMLS CUI [1]
- C0199242
Description
Antibiotics
Data type
text
Alias
- UMLS CUI [1]
- C0003232
Description
analgesics
Data type
text
Alias
- UMLS CUI [1]
- C0002771
Description
food
Data type
text
Alias
- UMLS CUI [1]
- C0016452
Description
infusion
Data type
text
Alias
- UMLS CUI [1]
- C1289919
Description
medication
Data type
text
Alias
- UMLS CUI [1]
- C0013227
Description
positioning aids
Data type
text
Alias
- UMLS CUI [1]
- C0182347
Description
control sono abdomen
Data type
boolean
Alias
- UMLS CUI [1,1]
- C0041618
- UMLS CUI [1,2]
- C0000726
Description
time of control sono abdomen
Data type
time
Alias
- UMLS CUI [1,1]
- C0041618
- UMLS CUI [1,2]
- C0000726
- UMLS CUI [1,3]
- C1547403
Description
control CCT
Data type
boolean
Alias
- UMLS CUI [1]
- C3515744
Description
time of control CCT
Data type
time
Alias
- UMLS CUI [1,1]
- C3515744
- UMLS CUI [1,2]
- C1547403
Description
control CT
Data type
integer
Alias
- UMLS CUI [1]
- C0040405
Description
time of control CT
Data type
time
Alias
- UMLS CUI [1,1]
- C0040405
- UMLS CUI [1,2]
- C1547403
Description
hematologic tests
Data type
boolean
Alias
- UMLS CUI [1]
- C0018941
Description
time of hematologic tests
Data type
time
Alias
- UMLS CUI [1,1]
- C0018941
- UMLS CUI [1,2]
- C1547403
Description
other arrangements
Data type
text
Alias
- UMLS CUI [1]
- C0586001
Description
Work-related accident
Alias
- UMLS CUI-1
- C0586557
Description
confraternity
Data type
text
Alias
- UMLS CUI [1]
- C3841800
Description
city
Data type
text
Alias
- UMLS CUI [1]
- C2316883
Description
profession
Data type
text
Alias
- UMLS CUI [1]
- C0028811
Description
engaged since
Data type
date
Alias
- UMLS CUI [1,1]
- C0028811
- UMLS CUI [1,2]
- C0439659
Description
beginning of workday
Data type
time
Alias
- UMLS CUI [1,1]
- C0680192
- UMLS CUI [1,2]
- C0439659
Description
Employer
Data type
text
Alias
- UMLS CUI [1]
- C1274022
Description
behaviour after accident
Data type
text
Description
initial treatment
Data type
text
Alias
- UMLS CUI [1]
- C2065349
Description
Comorbidity
Data type
text
Alias
- UMLS CUI [1]
- C0009488
Description
do accident circumstances fit employers insurance requirements
Data type
integer
Alias
- UMLS CUI [1]
- C0586557
Description
Further treatment
Data type
boolean
Alias
- UMLS CUI [1,1]
- C0087111
- UMLS CUI [1,2]
- C1517331
Description
fit for work
Data type
date
Alias
- UMLS CUI [1,1]
- C0578795
- UMLS CUI [1,2]
- C0011008
Description
sick leave certificate
Data type
boolean
Alias
- UMLS CUI [1,1]
- C0007836
- UMLS CUI [1,2]
- C0242807
Description
sick leave duration less than 3 days
Data type
boolean
Alias
- UMLS CUI [1,1]
- C0007836
- UMLS CUI [1,2]
- C0439092
- UMLS CUI [1,3]
- C1442459
Description
sick leave duration
Data type
text
Alias
- UMLS CUI [1,1]
- C0007836
- UMLS CUI [1,2]
- C0449238
Description
general treatment by
Data type
text
Alias
- UMLS CUI [1]
- C1710470
Description
special treatment
Data type
text
Description
employers insurance questionnaire
Data type
boolean
Alias
- UMLS CUI [1,1]
- C3841800
- UMLS CUI [1,2]
- C0034394
Similar models
Emergency Room Point B in Time Part 2: Emergency Room Report UKM
- StudyEvent: ODM
C0033213 (UMLS CUI [1,2])
C0033213 (UMLS CUI [1,2])
C0033213 (UMLS CUI [1,2])
C0033213 (UMLS CUI [1,2])
C0033213 (UMLS CUI [1,2])
C0007272 (UMLS CUI [1,2])
C0444532 (UMLS CUI [1,3])
C0162481 (UMLS CUI [2,1])
C0007272 (UMLS CUI [2,2])
C0444532 (UMLS CUI [2,3])
C0007272 (UMLS CUI [1,2])
C0162481 (UMLS CUI [1,3])
C0007272 (UMLS CUI [1,4])
C0443246 (UMLS CUI [1,5])
C0444532 (UMLS CUI [1,2])
C0162481 (UMLS CUI [2,1])
C0162857 (UMLS CUI [2,2])
C0444532 (UMLS CUI [2,3])
C0443246 (UMLS CUI [1,2])
C0162481 (UMLS CUI [2,1])
C0162857 (UMLS CUI [2,2])
C0443246 (UMLS CUI [2,3])
C0015801 (UMLS CUI [1,2])
C0444532 (UMLS CUI [1,3])
C0162481 (UMLS CUI [2,1])
C0015801 (UMLS CUI [2,2])
C0444532 (UMLS CUI [2,3])
C0015801 (UMLS CUI [1,2])
C0443246 (UMLS CUI [1,3])
C0162481 (UMLS CUI [2,1])
C0015801 (UMLS CUI [2,2])
C0443246 (UMLS CUI [2,3])
C0444532 (UMLS CUI [1,2])
C0162481 (UMLS CUI [2,1])
C0032649 (UMLS CUI [2,2])
C0444532 (UMLS CUI [2,3])
C0162481 (UMLS CUI [1,2])
C0032649 (UMLS CUI [1,3])
C0443246 (UMLS CUI [1,4])
C0226492 (UMLS CUI [1,2])
C0444532 (UMLS CUI [1,3])
C0162481 (UMLS CUI [2,1])
C0226492 (UMLS CUI [2,2])
C0444532 (UMLS CUI [2,3])
C0226492 (UMLS CUI [1,2])
C0443246 (UMLS CUI [1,3])
C0162481 (UMLS CUI [2,1])
C0226492 (UMLS CUI [2,2])
C0443246 (UMLS CUI [2,3])
C0086835 (UMLS CUI [1,2])
C0444532 (UMLS CUI [1,3])
C0162481 (UMLS CUI [2,1])
C0086835 (UMLS CUI [2,2])
C0444532 (UMLS CUI [2,3])
C0086835 (UMLS CUI [1,2])
C0443246 (UMLS CUI [1,3])
C0162481 (UMLS CUI [2,1])
C0086835 (UMLS CUI [2,2])
C0443246 (UMLS CUI [2,3])
C0243095 (UMLS CUI [1,2])
C0013444 (UMLS CUI [1,2])
C0243095 (UMLS CUI [1,2])
C0817096 (UMLS CUI [1,2])
C0728907 (UMLS CUI [1,2])
C0022427 (UMLS CUI [1,2])
C0000726 (UMLS CUI-2)
C0042066 (UMLS CUI-3)
C0243095 (UMLS CUI [1,2])
C1389458 (UMLS CUI [2])
C0031066 (UMLS CUI [1,2])
C0243095 (UMLS CUI [1,2])
C0030797 (UMLS CUI [1,2])
C0243095 (UMLS CUI [1,2])
C0023216 (UMLS CUI [1,3])
C0031809 (UMLS CUI [1,2])
C0243095 (UMLS CUI [1,2])
C1140618 (UMLS CUI [1,3])
C1140618 (UMLS CUI [1,2])
C0000726 (UMLS CUI [1,2])
C0000726 (UMLS CUI [1,2])
C1547403 (UMLS CUI [1,3])
C1547403 (UMLS CUI [1,2])
C1547403 (UMLS CUI [1,2])
C1547403 (UMLS CUI [1,2])
C0439659 (UMLS CUI [1,2])
C0439659 (UMLS CUI [1,2])
C1517331 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,2])
C0242807 (UMLS CUI [1,2])
C0439092 (UMLS CUI [1,2])
C1442459 (UMLS CUI [1,3])
C0449238 (UMLS CUI [1,2])
C0034394 (UMLS CUI [1,2])