ID

20945

Description

Hospital Routine Documentation Subform at the University Hospital Cologne Original Form name: BE UCH LSTM Sub.pdf

Keywords

Versions (1)
  1. 3/30/17 3/30/17 -
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March 30, 2017

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Creative Commons BY-NC 3.0
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Trauma surgery LSTM Subform, University Hospital Cologne

German

Trauma surgery LSTM Subform, University Hospital Cologne

1 forms  
BG Fall Datenerfassung
Description

BG Fall Datenerfassung

Alias
UMLS CUI-1
C0021676
UMLS CUI-2
C0681104
UMLS CUI-3
C0000931
Unfallbetrieb
Description

Unfallbetrieb

Alias
UMLS CUI-1
C1274022
UMLS CUI-2
C0000931
Unfallbetrieb Name
Description

Name of corporation

Data type

text

Alias
UMLS CUI [1,1]
C0683758
UMLS CUI [1,2]
C0027365
Unfallbetrieb Adresse
Description

Address of corporation

Data type

text

Alias
UMLS CUI [1,1]
C0683758
UMLS CUI [1,2]
C1442065
Patient beschäftigt als
Description

Patient occupied as

Data type

text

Alias
UMLS CUI [1]
C0421456
Patient beschäftigt seit
Description

Patient occupied since

Data type

date

Measurement units
  • dd.mm.yyyy
Alias
UMLS CUI [1,1]
C0421456
UMLS CUI [1,2]
C0808070
dd.mm.yyyy
Unfall
Description

Unfall

Alias
UMLS CUI-1
C0000924
Unfallort
Description

Accident site

Data type

text

Alias
UMLS CUI [1]
C0337069
Unfalldatum
Description

Date of accident

Data type

date

Measurement units
  • dd.mm.yyyy
Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C0000924
dd.mm.yyyy
Arbeitszeit von
Description

Working hours start

Data type

time

Measurement units
  • hh:mm
Alias
UMLS CUI [1,1]
C0043227
UMLS CUI [1,2]
C1301880
hh:mm
Arbeitszeit bis
Description

Working hours end

Data type

time

Measurement units
  • hh:mm
Alias
UMLS CUI [1,1]
C0043227
UMLS CUI [1,2]
C1522314
hh:mm
Unfallunabhängige Beeinträchtigungen
Description

Prior impairments not caused by current accident

Data type

text

Alias
UMLS CUI [1,1]
C2347662
UMLS CUI [1,2]
C0221099
UMLS CUI [1,3]
C1314792
Alkohol/Drogen/Medikamente
Description

Use of alcohol, drugs or pharmaceutical preparations

Data type

boolean

Alias
UMLS CUI [1]
C0237123
UMLS CUI [2]
C0240320
Blutentnahme durchgeführt
Description

Blood test performed

Data type

boolean

Alias
UMLS CUI [1]
C0005834
Zweifel/Bedenken an Arbeitsunfall
Description

Doubts or disbelief in casualty being an occupational accident

Data type

boolean

Alias
UMLS CUI [1,1]
C0000931
UMLS CUI [1,2]
C1547322
Art der Heilbehandlung
Description

Art der Heilbehandlung

Alias
UMLS CUI-1
C0039798
Allgemeine Heilbehandlung
Description

General treatment

Data type

integer

Alias
UMLS CUI [1]
C0199174
Besondere Heilbehandlung
Description

Special treatment

Data type

integer

Alias
UMLS CUI [1]
C1719237
Liegt eine Verletzung nach dem Verletzungsarten-/Schwerstverletzungsartenverfahren vor?
Description

Severe accident

Data type

integer

Alias
UMLS CUI [1,1]
C0000924
UMLS CUI [1,2]
C0205082
Es wird keine Heilbehandlung zu Lasten der Unfallversicherung durchgeführt, weil...
Description

Justification for treatment not being covered by accident insurance

Data type

text

Alias
UMLS CUI [1,1]
C0021680
UMLS CUI [1,2]
C1555522
Beurteilung der Arbeitsfähigkeit
Description

Beurteilung der Arbeitsfähigkeit

Alias
UMLS CUI-1
C0870486
UMLS CUI-2
C0220825
Arbeitsfähigkeit
Description

Working ability

Data type

integer

Alias
UMLS CUI [1]
C0870486
Falls arbeitsunfähig: Arbeitsunfähigkeit ab
Description

Working ability impaired since

Data type

date

Measurement units
  • dd.mm.yyyy
Alias
UMLS CUI [1,1]
C3843202
UMLS CUI [1,2]
C0808070
dd.mm.yyyy
Falls arbeitsunfähig: Voraussichtlich wieder arbeitsfähig ab
Description

Expected date of regained working ability

Data type

date

Measurement units
  • dd.mm.yyyy
Alias
UMLS CUI [1,1]
C3843202
UMLS CUI [1,2]
C0806020
dd.mm.yyyy
Falls arbeitsunfähig: Voraussichtlich länger als 6 Monate arbeitsunfähig
Description

Working ability expected to be impaired for longer than 6 months

Data type

boolean

Alias
UMLS CUI [1,1]
C3843202
UMLS CUI [1,2]
C0449238
Konsilärzte
Description

Konsilärzte

Alias
UMLS CUI-1
C0034928
Ist die Zuziehung von Konsiliarärzten zur Klärung der Diagnose und/oder Mitbehandlung erforderlich?
Description

Is consultation of other specialties necessary regarding diagnosis and/or therapy?

Data type

boolean

Alias
UMLS CUI [1,1]
C0034928
UMLS CUI [1,2]
C0087111
UMLS CUI [2]
C1546898
Falls ja, welche Konsilärzte wurden hinzugezogen?
Description

If yes, please specify consultated specialty:

Data type

text

Alias
UMLS CUI [1,1]
C0009818
UMLS CUI [1,2]
C0037778
Diagnose, Anamnese und Untersuchung
Description

Diagnose, Anamnese und Untersuchung

Alias
UMLS CUI-1
C0150618
UMLS CUI-2
C0011900
Diagnosen
Description

Diagnosis

Data type

text

Alias
UMLS CUI [1]
C0011900
Anamnese
Description

Medical history

Data type

text

Alias
UMLS CUI [1]
C0262926
Untersuchungsbefund
Description

Examination findings

Data type

text

Alias
UMLS CUI [1,1]
C0243095
UMLS CUI [1,2]
C0582103
Bildgebung
Description

Bildgebung

Alias
UMLS CUI-1
C0011923
Radiologie
Description

Radiology report

Data type

text

Alias
UMLS CUI [1]
C1299496
Therapie
Description

Therapy

Data type

text

Alias
UMLS CUI [1]
C0087111
Prozedur / Konzept für den stationären Aufenthalt
Description

Procedure/concept for hospital stay

Data type

text

Alias
UMLS CUI [1,1]
C3489408
UMLS CUI [1,2]
C0178566
Befund
Description

Finding

Data type

text

Alias
UMLS CUI [1]
C0243095
Beurteilung
Description

Evaluation

Data type

text

Alias
UMLS CUI [1]
C0220825
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Similar models

Trauma surgery LSTM Subform, University Hospital Cologne

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
BG Fall Datenerfassung
C0021676 (UMLS CUI-1)
C0681104 (UMLS CUI-2)
C0000931 (UMLS CUI-3)
Item Group
Unfallbetrieb
C1274022 (UMLS CUI-1)
C0000931 (UMLS CUI-2)
Name of corporation
Item
Unfallbetrieb Name
text
C0683758 (UMLS CUI [1,1])
C0027365 (UMLS CUI [1,2])
Address of corporation
Item
Unfallbetrieb Adresse
text
C0683758 (UMLS CUI [1,1])
C1442065 (UMLS CUI [1,2])
Patient occupied as
Item
Patient beschäftigt als
text
C0421456 (UMLS CUI [1])
Patient occupied since
Item
Patient beschäftigt seit
date
C0421456 (UMLS CUI [1,1])
C0808070 (UMLS CUI [1,2])
Item Group
Unfall
C0000924 (UMLS CUI-1)
Accident site
Item
Unfallort
text
C0337069 (UMLS CUI [1])
Date of accident
Item
Unfalldatum
date
C0011008 (UMLS CUI [1,1])
C0000924 (UMLS CUI [1,2])
Working hours start
Item
Arbeitszeit von
time
C0043227 (UMLS CUI [1,1])
C1301880 (UMLS CUI [1,2])
Working hours end
Item
Arbeitszeit bis
time
C0043227 (UMLS CUI [1,1])
C1522314 (UMLS CUI [1,2])
Prior impairments not caused by current accident
Item
Unfallunabhängige Beeinträchtigungen
text
C2347662 (UMLS CUI [1,1])
C0221099 (UMLS CUI [1,2])
C1314792 (UMLS CUI [1,3])
Use of alcohol, drugs or pharmaceutical preparations
Item
Alkohol/Drogen/Medikamente
boolean
C0237123 (UMLS CUI [1])
C0240320 (UMLS CUI [2])
Blood test performed
Item
Blutentnahme durchgeführt
boolean
C0005834 (UMLS CUI [1])
Doubts or disbelief in casualty being an occupational accident
Item
Zweifel/Bedenken an Arbeitsunfall
boolean
C0000931 (UMLS CUI [1,1])
C1547322 (UMLS CUI [1,2])
Item Group
Art der Heilbehandlung
C0039798 (UMLS CUI-1)
Item
Allgemeine Heilbehandlung
integer
C0199174 (UMLS CUI [1])
General treatment
Code List
Allgemeine Heilbehandlung
CL Item
durch mich (1)
CL Item
durch anderen Arzt (2)
Item
Besondere Heilbehandlung
integer
C1719237 (UMLS CUI [1])
Special treatment
Code List
Besondere Heilbehandlung
CL Item
stationär (1)
CL Item
ambulant (2)
Item
Liegt eine Verletzung nach dem Verletzungsarten-/Schwerstverletzungsartenverfahren vor?
integer
C0000924 (UMLS CUI [1,1])
C0205082 (UMLS CUI [1,2])
undefined item
Code List
Liegt eine Verletzung nach dem Verletzungsarten-/Schwerstverletzungsartenverfahren vor?
CL Item
nein (1)
CL Item
ja, SAV nach Ziffer 4.2 (2)
Justification for treatment not being covered by accident insurance
Item
Es wird keine Heilbehandlung zu Lasten der Unfallversicherung durchgeführt, weil...
text
C0021680 (UMLS CUI [1,1])
C1555522 (UMLS CUI [1,2])
Item Group
Beurteilung der Arbeitsfähigkeit
C0870486 (UMLS CUI-1)
C0220825 (UMLS CUI-2)
Item
Arbeitsfähigkeit
integer
C0870486 (UMLS CUI [1])
Working ability
Code List
Arbeitsfähigkeit
CL Item
arbeitsfähig (1)
CL Item
arbeitsunfähig (2)
Working ability impaired since
Item
Falls arbeitsunfähig: Arbeitsunfähigkeit ab
date
C3843202 (UMLS CUI [1,1])
C0808070 (UMLS CUI [1,2])
Expected date of regained working ability
Item
Falls arbeitsunfähig: Voraussichtlich wieder arbeitsfähig ab
date
C3843202 (UMLS CUI [1,1])
C0806020 (UMLS CUI [1,2])
Working ability expected to be impaired for longer than 6 months
Item
Falls arbeitsunfähig: Voraussichtlich länger als 6 Monate arbeitsunfähig
boolean
C3843202 (UMLS CUI [1,1])
C0449238 (UMLS CUI [1,2])
Item Group
Konsilärzte
C0034928 (UMLS CUI-1)
Is consultation of other specialties necessary regarding diagnosis and/or therapy?
Item
Ist die Zuziehung von Konsiliarärzten zur Klärung der Diagnose und/oder Mitbehandlung erforderlich?
boolean
C0034928 (UMLS CUI [1,1])
C0087111 (UMLS CUI [1,2])
C1546898 (UMLS CUI [2])
If yes, please specify consultated specialty:
Item
Falls ja, welche Konsilärzte wurden hinzugezogen?
text
C0009818 (UMLS CUI [1,1])
C0037778 (UMLS CUI [1,2])
Item Group
Diagnose, Anamnese und Untersuchung
C0150618 (UMLS CUI-1)
C0011900 (UMLS CUI-2)
Diagnosis
Item
Diagnosen
text
C0011900 (UMLS CUI [1])
Medical history
Item
Anamnese
text
C0262926 (UMLS CUI [1])
Examination findings
Item
Untersuchungsbefund
text
C0243095 (UMLS CUI [1,1])
C0582103 (UMLS CUI [1,2])
Item Group
Bildgebung
C0011923 (UMLS CUI-1)
Radiology report
Item
Radiologie
text
C1299496 (UMLS CUI [1])
Therapy
Item
Therapie
text
C0087111 (UMLS CUI [1])
Procedure/concept for hospital stay
Item
Prozedur / Konzept für den stationären Aufenthalt
text
C3489408 (UMLS CUI [1,1])
C0178566 (UMLS CUI [1,2])
Finding
Item
Befund
text
C0243095 (UMLS CUI [1])
Evaluation
Item
Beurteilung
text
C0220825 (UMLS CUI [1])
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