ID

19097

Description

Hospital Routine Documentation Subform at the University Hospital Muenster. Original Form name: Entlassbericht Hamburg Sub.

Keywords

Versions (2)
  1. 11/18/16 11/18/16 -
  2. 12/5/16 12/5/16 -
Uploaded on

December 5, 2016

DOI

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License

Creative Commons BY-NC 3.0
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Entlassbericht Hamburg Sub University Hospital Muenster (UKM) Subform

German

Entlassbericht Hamburg Sub University Hospital Muenster (UKM) Subform

1 forms  
Aktuelle Vitalzeichen / letzte Medikation
Description

Aktuelle Vitalzeichen / letzte Medikation

Alias
UMLS CUI-1
C0518766
UMLS CUI-2
C0013227
UMLS CUI-3
C0030685
Blutdruck
Description

Blood pressure

Data type

text

Measurement units
  • mmHg
Alias
UMLS CUI [1]
C0005823
mmHg
Blutzucker
Description

Blood sugar

Data type

text

Alias
UMLS CUI [1]
C0392201
Temperatur
Description

Temperature

Data type

float

Measurement units
  • °C
Alias
UMLS CUI [1]
C0005903
°C
Puls
Description

Pulse

Data type

text

Alias
UMLS CUI [1]
C0232117
Atmung
Description

Respiration

Data type

text

Alias
UMLS CUI [1]
C0035203
Letzte Medikation
Description

Latest medication

Data type

text

Alias
UMLS CUI [1]
C0013227
Bewusstsein / Orientierung
Description

Bewusstsein / Orientierung

Alias
UMLS CUI-1
C0234421
UMLS CUI-2
C0029266
UMLS CUI-3
C0030685
wach
Description

Alertness

Data type

boolean

Alias
UMLS CUI [1]
C0239110
somnolent
Description

Somnolence

Data type

boolean

Alias
UMLS CUI [1]
C2830004
desorientiert
Description

Desorientation

Data type

boolean

Alias
UMLS CUI [1,1]
C0233407
UMLS CUI [1,2]
C0009676
komatös
Description

Coma

Data type

boolean

Alias
UMLS CUI [1]
C0009421
zur Person
Description

Orientation to person

Data type

boolean

Alias
UMLS CUI [1,1]
C0029266
UMLS CUI [1,2]
C2371003
örtlich
Description

Orientation to place

Data type

boolean

Alias
UMLS CUI [1,1]
C0029266
UMLS CUI [1,2]
C2370999
situativ
Description

Orientation to situation

Data type

boolean

Alias
UMLS CUI [1]
C0029266
Weglauftendenz
Description

Tendency to run away

Data type

boolean

Alias
UMLS CUI [1]
C0029266
sonstiges
Description

Other

Data type

boolean

Alias
UMLS CUI [1,1]
C0205394
UMLS CUI [1,2]
C0234421
UMLS CUI [1,3]
C0029266
Wenn sonstiges, bitte beschreiben
Description

Other (specification)

Data type

text

Alias
UMLS CUI [1,1]
C0205394
UMLS CUI [1,2]
C0234421
UMLS CUI [1,3]
C0029266
Mobilität (körperlich)
Description

Mobilität (körperlich)

Alias
UMLS CUI-1
C0030685
UMLS CUI-2
C0449580
selbständig
Description

Independently mobile

Data type

boolean

Alias
UMLS CUI [1,1]
C0429979
UMLS CUI [1,2]
C0449580
Rollstuhl
Description

Wheelchair

Data type

boolean

Alias
UMLS CUI [1,1]
C0449580
UMLS CUI [1,2]
C0043143
Gehhilfe
Description

Walking aid

Data type

boolean

Alias
UMLS CUI [1,1]
C0449580
UMLS CUI [1,2]
C0557834
eingeschränkt
Description

Reduced mobility

Data type

boolean

Alias
UMLS CUI [1]
C0700572
Bettlägerigkeit
Description

Bedriddenness

Data type

boolean

Alias
UMLS CUI [1,1]
C0425251
UMLS CUI [1,2]
C0449580
Essen / Trinken
Description

Essen / Trinken

Alias
UMLS CUI-1
C0392209
UMLS CUI-2
C0600072
UMLS CUI-3
C0030685
Diät
Description

Diet

Data type

boolean

Alias
UMLS CUI [1]
C0012155
wenn Diät, bitte beschreiben
Description

Diet (specification)

Data type

text

Alias
UMLS CUI [1,1]
C0012155
UMLS CUI [1,2]
C2348235
Schluckstörung
Description

Dysphagia

Data type

boolean

Alias
UMLS CUI [1]
C0011168
Ernährungssonde
Description

Feeding tube

Data type

boolean

Alias
UMLS CUI [1]
C0041281
Pat. trinkt ausreichend?
Description

Sufficient drinking

Data type

boolean

Alias
UMLS CUI [1,1]
C0429791
UMLS CUI [1,2]
C0205410
Pat. isst ausreichend?
Description

Sufficient eating

Data type

boolean

Alias
UMLS CUI [1,1]
C0013470
UMLS CUI [1,2]
C0205410
Ausscheidung
Description

Ausscheidung

Alias
UMLS CUI-1
C0221102
UMLS CUI-2
C0030685
Harninkontinenz
Description

Aconuresis

Data type

boolean

Alias
UMLS CUI [1,1]
C0542565
UMLS CUI [1,2]
C0042024
Pat. hat abgeführt
Description

Purging

Data type

boolean

Alias
UMLS CUI [1]
C0855227
Pat. hat abgeführt am
Description

Date of purging

Data type

date

Alias
UMLS CUI [1,1]
C0855227
UMLS CUI [1,2]
C0011008
Stuhlregulierung
Description

Fecal regulation

Data type

boolean

Alias
UMLS CUI [1,1]
C1290944
UMLS CUI [1,2]
C0015733
Stuhlregulierung durch
Description

Method of fecal regulation

Data type

text

Alias
UMLS CUI [1,1]
C0025663
UMLS CUI [1,2]
C1290944
UMLS CUI [1,3]
C0015733
Blasenkatheter
Description

Urinary catheter

Data type

boolean

Alias
UMLS CUI [1]
C0042019
Blasenkatheter am
Description

Date of urinary catheter

Data type

date

Alias
UMLS CUI [1,1]
C0042019
UMLS CUI [1,2]
C0011008
Anus praeter
Description

Artificial anus

Data type

boolean

Alias
UMLS CUI [1]
C1611169
Versorgung Anus praeter
Description

Care of artificial anus

Data type

text

Alias
UMLS CUI [1,1]
C1611169
UMLS CUI [1,2]
C1947933
UMLS CUI [1,3]
C0024501
Schlaf / spezielle Pflegehinweise
Description

Schlaf / spezielle Pflegehinweise

Alias
UMLS CUI-1
C0037313
UMLS CUI-2
C0017313
UMLS CUI-3
C0947611
UMLS CUI-4
C0030685
Schlafgewohnheiten
Description

Sleeping habits

Data type

text

Alias
UMLS CUI [1,1]
C0037313
UMLS CUI [1,2]
C0018464
Spezielle pflegerische Hinweise
Description

z.B. Schmerzen, Dekubitus, Therapie, fachärztl. Behandlung

Data type

text

Alias
UMLS CUI [1,1]
C0017313
UMLS CUI [1,2]
C2348235
UMLS CUI [1,3]
C0947611
Hilfsmittel
Description

Hilfsmittel

Alias
UMLS CUI-1
C0036605
UMLS CUI-2
C0030685
Brille
Description

Glasses

Data type

boolean

Alias
UMLS CUI [1,1]
C0015421
UMLS CUI [1,2]
C0042813
Hörgerät
Description

Hearing aid

Data type

boolean

Alias
UMLS CUI [1]
C0018768
Zahnprothese
Description

Denture

Data type

boolean

Alias
UMLS CUI [1]
C0011394
Zahnprothese oben
Description

Denture upper jaw

Data type

boolean

Alias
UMLS CUI [1]
C0011394
Zahnprothese unten
Description

Denture lower jaw

Data type

boolean

Alias
UMLS CUI [1]
C0011394
Sonstiges
Description

Other

Data type

boolean

Alias
UMLS CUI [1,1]
C0036605
UMLS CUI [1,2]
C0205394
Wenn sonstiges, bitte beschreiben
Description

Other (specification)

Data type

text

Alias
UMLS CUI [1,1]
C0036605
UMLS CUI [1,2]
C0205394
Patient benötigt Unterstützung beim
Description

Patient benötigt Unterstützung beim

Alias
UMLS CUI-1
C1521721
UMLS CUI-2
C0030685
Essen
Description

Eating

Data type

text

Alias
UMLS CUI [1,1]
C1521721
UMLS CUI [1,2]
C0013470
Trinken
Description

Drinking

Data type

text

Alias
UMLS CUI [1,1]
C1521721
UMLS CUI [1,2]
C0429791
Aufstehen
Description

Getting up

Data type

text

Alias
UMLS CUI [1,1]
C1521721
UMLS CUI [1,2]
C0449580
An-/Auskleiden
Description

Dressing/Undressing

Data type

text

Alias
UMLS CUI [1,1]
C1521721
UMLS CUI [1,2]
C0518459
Waschen
Description

Washing

Data type

text

Alias
UMLS CUI [1,1]
C1521721
UMLS CUI [1,2]
C0564673
UMLS CUI [1,3]
C0441648
Toilettengang
Description

Going to the toilet

Data type

text

Alias
UMLS CUI [1,1]
C1521721
UMLS CUI [1,2]
C1718402
Weitere Informationen
Description

Weitere Informationen

Alias
UMLS CUI-1
C0030685
UMLS CUI-2
C1533716
Datum
Description

Date

Data type

date

Alias
UMLS CUI [1]
C0011008
Pflegekraft
Description

Nurse

Data type

text

Alias
UMLS CUI [1]
C0028661
Station
Description

Bei weiteren Fragen wenden Sie sich bitte an das Team der Station

Data type

text

Alias
UMLS CUI [1,1]
C1305702
UMLS CUI [1,2]
C1704729
Telefon
Description

Telephone

Data type

text

Alias
UMLS CUI [1]
C1515258
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Similar models

Entlassbericht Hamburg Sub University Hospital Muenster (UKM) Subform

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Aktuelle Vitalzeichen / letzte Medikation
C0518766 (UMLS CUI-1)
C0013227 (UMLS CUI-2)
C0030685 (UMLS CUI-3)
Blood pressure
Item
Blutdruck
text
C0005823 (UMLS CUI [1])
Blood sugar
Item
Blutzucker
text
C0392201 (UMLS CUI [1])
Temperature
Item
Temperatur
float
C0005903 (UMLS CUI [1])
Pulse
Item
Puls
text
C0232117 (UMLS CUI [1])
Respiration
Item
Atmung
text
C0035203 (UMLS CUI [1])
Latest medication
Item
Letzte Medikation
text
C0013227 (UMLS CUI [1])
Item Group
Bewusstsein / Orientierung
C0234421 (UMLS CUI-1)
C0029266 (UMLS CUI-2)
C0030685 (UMLS CUI-3)
Alertness
Item
wach
boolean
C0239110 (UMLS CUI [1])
Somnolence
Item
somnolent
boolean
C2830004 (UMLS CUI [1])
Desorientation
Item
desorientiert
boolean
C0233407 (UMLS CUI [1,1])
C0009676 (UMLS CUI [1,2])
Coma
Item
komatös
boolean
C0009421 (UMLS CUI [1])
Orientation to person
Item
zur Person
boolean
C0029266 (UMLS CUI [1,1])
C2371003 (UMLS CUI [1,2])
Orientation to place
Item
örtlich
boolean
C0029266 (UMLS CUI [1,1])
C2370999 (UMLS CUI [1,2])
Orientation to situation
Item
situativ
boolean
C0029266 (UMLS CUI [1])
Tendency to run away
Item
Weglauftendenz
boolean
C0029266 (UMLS CUI [1])
Other
Item
sonstiges
boolean
C0205394 (UMLS CUI [1,1])
C0234421 (UMLS CUI [1,2])
C0029266 (UMLS CUI [1,3])
Other (specification)
Item
Wenn sonstiges, bitte beschreiben
text
C0205394 (UMLS CUI [1,1])
C0234421 (UMLS CUI [1,2])
C0029266 (UMLS CUI [1,3])
Item Group
Mobilität (körperlich)
C0030685 (UMLS CUI-1)
C0449580 (UMLS CUI-2)
Independently mobile
Item
selbständig
boolean
C0429979 (UMLS CUI [1,1])
C0449580 (UMLS CUI [1,2])
Wheelchair
Item
Rollstuhl
boolean
C0449580 (UMLS CUI [1,1])
C0043143 (UMLS CUI [1,2])
Walking aid
Item
Gehhilfe
boolean
C0449580 (UMLS CUI [1,1])
C0557834 (UMLS CUI [1,2])
Reduced mobility
Item
eingeschränkt
boolean
C0700572 (UMLS CUI [1])
Bedriddenness
Item
Bettlägerigkeit
boolean
C0425251 (UMLS CUI [1,1])
C0449580 (UMLS CUI [1,2])
Item Group
Essen / Trinken
C0392209 (UMLS CUI-1)
C0600072 (UMLS CUI-2)
C0030685 (UMLS CUI-3)
Diet
Item
Diät
boolean
C0012155 (UMLS CUI [1])
Diet (specification)
Item
wenn Diät, bitte beschreiben
text
C0012155 (UMLS CUI [1,1])
C2348235 (UMLS CUI [1,2])
Dysphagia
Item
Schluckstörung
boolean
C0011168 (UMLS CUI [1])
Feeding tube
Item
Ernährungssonde
boolean
C0041281 (UMLS CUI [1])
Sufficient drinking
Item
Pat. trinkt ausreichend?
boolean
C0429791 (UMLS CUI [1,1])
C0205410 (UMLS CUI [1,2])
Sufficient eating
Item
Pat. isst ausreichend?
boolean
C0013470 (UMLS CUI [1,1])
C0205410 (UMLS CUI [1,2])
Item Group
Ausscheidung
C0221102 (UMLS CUI-1)
C0030685 (UMLS CUI-2)
Aconuresis
Item
Harninkontinenz
boolean
C0542565 (UMLS CUI [1,1])
C0042024 (UMLS CUI [1,2])
Purging
Item
Pat. hat abgeführt
boolean
C0855227 (UMLS CUI [1])
Date of purging
Item
Pat. hat abgeführt am
date
C0855227 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Fecal regulation
Item
Stuhlregulierung
boolean
C1290944 (UMLS CUI [1,1])
C0015733 (UMLS CUI [1,2])
Method of fecal regulation
Item
Stuhlregulierung durch
text
C0025663 (UMLS CUI [1,1])
C1290944 (UMLS CUI [1,2])
C0015733 (UMLS CUI [1,3])
Urinary catheter
Item
Blasenkatheter
boolean
C0042019 (UMLS CUI [1])
Date of urinary catheter
Item
Blasenkatheter am
date
C0042019 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Artificial anus
Item
Anus praeter
boolean
C1611169 (UMLS CUI [1])
Item
Versorgung Anus praeter
text
C1611169 (UMLS CUI [1,1])
C1947933 (UMLS CUI [1,2])
C0024501 (UMLS CUI [1,3])
Care of artificial anus
Code List
Versorgung Anus praeter
CL Item
mit Hilfe (mit Hilfe)
CL Item
Versorgung selbständig (Versorgung selbständig)
Item Group
Schlaf / spezielle Pflegehinweise
C0037313 (UMLS CUI-1)
C0017313 (UMLS CUI-2)
C0947611 (UMLS CUI-3)
C0030685 (UMLS CUI-4)
Sleeping habits
Item
Schlafgewohnheiten
text
C0037313 (UMLS CUI [1,1])
C0018464 (UMLS CUI [1,2])
Nursing specifics
Item
Spezielle pflegerische Hinweise
text
C0017313 (UMLS CUI [1,1])
C2348235 (UMLS CUI [1,2])
C0947611 (UMLS CUI [1,3])
Item Group
Hilfsmittel
C0036605 (UMLS CUI-1)
C0030685 (UMLS CUI-2)
Glasses
Item
Brille
boolean
C0015421 (UMLS CUI [1,1])
C0042813 (UMLS CUI [1,2])
Hearing aid
Item
Hörgerät
boolean
C0018768 (UMLS CUI [1])
Denture
Item
Zahnprothese
boolean
C0011394 (UMLS CUI [1])
Denture upper jaw
Item
Zahnprothese oben
boolean
C0011394 (UMLS CUI [1])
Denture lower jaw
Item
Zahnprothese unten
boolean
C0011394 (UMLS CUI [1])
Other
Item
Sonstiges
boolean
C0036605 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
Other (specification)
Item
Wenn sonstiges, bitte beschreiben
text
C0036605 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
Item Group
Patient benötigt Unterstützung beim
C1521721 (UMLS CUI-1)
C0030685 (UMLS CUI-2)
Item
Essen
text
C1521721 (UMLS CUI [1,1])
C0013470 (UMLS CUI [1,2])
Eating
Code List
Essen
CL Item
ganz (ganz)
CL Item
teilweise (teilweise)
CL Item
ohne (ohne)
Item
Trinken
text
C1521721 (UMLS CUI [1,1])
C0429791 (UMLS CUI [1,2])
Eating
Code List
Trinken
CL Item
ganz (ganz)
CL Item
teilweise (teilweise)
CL Item
ohne (ohne)
Item
Aufstehen
text
C1521721 (UMLS CUI [1,1])
C0449580 (UMLS CUI [1,2])
Eating
Code List
Aufstehen
CL Item
ganz (ganz)
CL Item
teilweise (teilweise)
CL Item
ohne (ohne)
Item
An-/Auskleiden
text
C1521721 (UMLS CUI [1,1])
C0518459 (UMLS CUI [1,2])
Eating
Code List
An-/Auskleiden
CL Item
ganz (ganz)
CL Item
teilweise (teilweise)
CL Item
ohne (ohne)
Item
Waschen
text
C1521721 (UMLS CUI [1,1])
C0564673 (UMLS CUI [1,2])
C0441648 (UMLS CUI [1,3])
Eating
Code List
Waschen
CL Item
ganz (ganz)
CL Item
teilweise (teilweise)
CL Item
ohne (ohne)
Item
Toilettengang
text
C1521721 (UMLS CUI [1,1])
C1718402 (UMLS CUI [1,2])
Eating
Code List
Toilettengang
CL Item
ganz (ganz)
CL Item
teilweise (teilweise)
CL Item
ohne (ohne)
Item Group
Weitere Informationen
C0030685 (UMLS CUI-1)
C1533716 (UMLS CUI-2)
Date
Item
Datum
date
C0011008 (UMLS CUI [1])
Nurse
Item
Pflegekraft
text
C0028661 (UMLS CUI [1])
ward
Item
Station
text
C1305702 (UMLS CUI [1,1])
C1704729 (UMLS CUI [1,2])
Telephone
Item
Telefon
text
C1515258 (UMLS CUI [1])
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