ID
22323
Description
Routine documentation in German hospitals. Source file name: SD070109_Geburtenbogen. Examplary forms provided by DMI (http://www.dmi.de/)
Link
Keywords
Versions (5)
- 5/29/17 5/29/17 -
- 5/29/17 5/29/17 -
- 6/6/17 6/6/17 -
- 6/6/17 6/6/17 -
- 7/30/17 7/30/17 -
Uploaded on
May 29, 2017
DOI
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License
Creative Commons BY-NC 3.0
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Birth sheet Routine documentation in German hospitals DMI
Birth sheet Routine documentation in German hospitals DMI
- StudyEvent: ODM
Description
Gynecology - Midwifery: Admission
Description
Beginning of labor
Description
Rupture of membranes (ROM)
Description
Birth I
Description
Birth II
Description
Type of birth
Description
Placental expulsion
Description
Day
Data type
text
Description
Month
Data type
text
Description
Time
Data type
time
Description
Spontaneous placental expulsion
Data type
boolean
Description
Cord-traction
Data type
boolean
Description
Nachtastung
Data type
boolean
Description
Manual placenta removal
Data type
boolean
Description
Curettage
Data type
boolean
Description
Placenta
Description
Complete placenta
Data type
boolean
Description
Incomplete placenta
Data type
boolean
Description
Infarcts
Data type
boolean
Description
Calcareous incrustation
Data type
boolean
Description
Placenta histology
Data type
boolean
Description
Amniotic membranes
Description
Umbilical cord and blood loss
Description
Umbilical cord, normal insertion
Data type
boolean
Description
Umbilical cord: Insertion
Data type
text
Description
True umbilical cord knot
Data type
boolean
Description
Nuchal cord
Data type
boolean
Description
Blood loss
Data type
integer
Measurement units
- ml
Description
Perineum and vagina
Description
Intact perineum and vagina
Data type
boolean
Description
Perineal tear
Data type
boolean
Description
Grade of perineal tear
Data type
integer
Description
Cervical tear
Data type
boolean
Description
Episiotomy
Data type
boolean
Description
Vaginal-labial tear
Data type
boolean
Description
Combined lesions
Data type
boolean
Description
Suture
Data type
boolean
Description
Suture, site
Data type
text
Description
Anesthesia
Data type
text
Description
Further information
Description
Child no. 1
Description
Sex
Data type
text
Description
Weight
Data type
integer
Measurement units
- g
Description
Length
Data type
float
Measurement units
- cm
Description
Head circumference
Data type
float
Measurement units
- cm
Description
Shoulder circumference
Data type
float
Measurement units
- cm
Description
Blennorrhoea prevention
Data type
text
Description
Konakion
Data type
boolean
Description
Child no. 2
Description
Sex
Data type
text
Description
Weight
Data type
integer
Measurement units
- g
Description
Length
Data type
integer
Measurement units
- cm
Description
Head circumference
Data type
integer
Measurement units
- cm
Description
Shoulder circumference
Data type
integer
Measurement units
- cm
Description
Blennorrhoea prevention
Data type
text
Description
Konakion
Data type
boolean
Description
Maturity
Description
Fingernails
Data type
text
Description
Vernix
Data type
text
Description
Lanugo
Data type
text
Description
Testicles
Data type
text
Description
Vulva
Data type
text
Description
Peeling skin
Data type
text
Description
Wrinkled hands and feet
Data type
text
Description
Apgar score
Description
Analysis of umbilical cord blood
Description
Further procedures
Description
Suctioning
Data type
boolean
Description
Pediatrician present at birth
Data type
boolean
Description
Presentation at pediatrician
Data type
boolean
Description
Presentation at pediatrician, reason
Data type
text
Description
Transfer to pediatric clinic
Data type
boolean
Description
Transfer to pediatric clinic, reason
Data type
text
Description
Oxygen mask
Data type
boolean
Description
Intubation
Data type
boolean
Description
Child development
Description
Medical history
Description
Course of pregnancy
Description
Normal course
Data type
text
Description
Severe vomiting
Data type
text
Description
Edemas, protein, hypertension
Data type
text
Description
Fever (also viral disease)
Data type
text
Description
Urinary tract infection
Data type
text
Description
Bleeding during pregnancy
Data type
text
Description
Anemia
Data type
text
Description
Surgery
Data type
text
Description
Medication/Hormones
Data type
text
Description
Other diseases/trouble
Data type
text
Description
Smoking, drugs, alcohol
Data type
text
Description
Contraceptives
Data type
text
Description
Mode of conception
Data type
text
Description
Rubella titer
Data type
text
Description
HBsAg
Data type
text
Description
Anti-D
Data type
text
Description
Breastfeeding
Data type
text
Description
Crédé desired
Data type
text
Description
Miscarriages
Description
Previous deliveries
Description
Date
Data type
date
Description
Type and place of delivery
Data type
text
Description
Duration of delivery
Data type
text
Description
Complications during delivery
Data type
text
Description
Sex of newborn
Data type
text
Description
Weight of newborn
Data type
text
Description
Specifics of newborn
Data type
text
Description
Fetal Doppler sonography: A. umbilicalis
Description
Fetal Doppler sonography: A. cerebri media
Description
Fetal Doppler sonography: A. uterina, right
Description
Fetal Doppler sonography: A. uterina, left
Description
Fetal Doppler sonography: Findings
Description
Date
Data type
date
Description
Week of gestation
Data type
integer
Description
Arteria umbilicalis
Data type
float
Description
Arteria cerebri media
Data type
float
Description
Ducuts venosus
Data type
text
Description
Right Arteria uterina
Data type
float
Description
Left Arteria uterina
Data type
float
Description
Physician name
Data type
text
Description
Fetal Doppler sonography: diagnostics
Description
weeks of gestation
Data type
text
Description
Findings
Data type
text
Description
Crown-rump length (CRL)
Data type
float
Measurement units
- cm
Description
Cerebellum
Data type
float
Measurement units
- cm
Description
Biparietal diameter/Occipitofrontal diameter
Data type
float
Measurement units
- cm
Description
Abdominal transverse diameter/Sagittal abdominal diameter
Data type
float
Measurement units
- cm
Description
Femur
Data type
float
Measurement units
- cm
Description
Fetal movements/cardiac activity
Data type
text
Description
Position
Data type
text
Description
Placental location
Data type
text
Description
Volume of amniotic fluid (AFI)
Data type
text
Description
Other
Data type
text
Description
Picture
Data type
text
Description
Date
Data type
date
Description
Physician name
Data type
text
Description
Obstetric sheet: General information
Description
Health insurance
Data type
text
Description
Referring physician
Data type
text
Description
Referring physician, telephone number
Data type
integer
Description
Medical specialist
Data type
text
Description
Medical specialist, telephone number
Data type
integer
Description
Medical history
Data type
text
Description
Person taking medical history
Data type
text
Description
Date
Data type
date
Description
Obstetric sheet: Medical history
Description
Family history
Data type
text
Description
Family history, specifics
Data type
boolean
Description
Social history
Data type
text
Description
Occupation of mother
Data type
text
Description
Occupation of father
Data type
text
Description
Personal medical history
Data type
text
Description
Allergy
Data type
text
Description
Medication
Data type
text
Description
Nicotine
Data type
text
Description
Alcohol
Data type
text
Description
Specifics
Data type
text
Description
Obstetric sheet: Medical exam
Description
Obstetric sheet: General findings
Description
Blood type
Data type
text
Description
Rh factor
Data type
text
Description
Antibodies
Data type
text
Description
Rubella titer
Data type
text
Description
HbsAG
Data type
text
Description
Height
Data type
text
Description
Weight
Data type
text
Description
Edemata
Data type
text
Description
Varices
Data type
text
Description
Urine test strip
Data type
text
Description
HIV
Data type
text
Description
Hepatitis C
Data type
text
Description
Obstetric sheet: Current pregnancy, anamnesis of menstrual cycle
Description
Obstetric sheet: Current pregnancy, complications
Description
Complications and diseases, current pregnancy
Data type
text
Description
In-patient treatment
Data type
text
Description
In-patient treatment, reason
Data type
text
Description
In-patient treatment, duration
Data type
date
Description
In-patient treatment, therapy
Data type
text
Description
Observations during birth
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Birth sheet Routine documentation in German hospitals DMI
- StudyEvent: ODM