ID

10046

Beschrijving

Documentation form for quality assurance in German Health Care by the institute forapplied quality Improvement and Research in Health Care (Aqua), https://www.aqua-institut.de/en/home. Internal Aqua form version: 17-1 Specification 2015 V02

Link

https://www.aqua-institut.de/en/home

Trefwoorden

  1. 23-11-14 23-11-14 - Julian Varghese
  2. 21-03-15 21-03-15 - Sarah Schulze Sünninghausen
Geüploaded op

21 maart 2015

DOI

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Licentie

Creative Commons BY-NC 3.0 Legacy

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Quality assurance Hip Fracture with Osteosynthesis (AQUA)

Quality assurance Hip Fracture with Osteosynthesis (AQUA)

Test
Beschrijving

Test

Anamnesis / diagnosis
Beschrijving

Anamnesis / diagnosis

ASA classification
Beschrijving

ASA classification

Datatype

integer

Alias
UMLS CUI-1
C1531480
Wound contamination classifcation of procedure
Beschrijving

Wound contamination classifcation of procedure

Datatype

integer

Alias
UMLS CUI-1
C1629491
fracture localization
Beschrijving

fracture localization

Datatype

integer

Alias
UMLS CUI-1
C0475264
femoral fracture near hip - classification by garden
Beschrijving

femoral fracture near hip - classification by garden

Datatype

integer

Alias
UMLS CUI-1
C0441821
pre-existing coxarthrosis
Beschrijving

pre-existing coxarthrosis

Datatype

boolean

Alias
UMLS CUI-1
C0029410
Patient was admitted with antithrombotic Extended therapy
Beschrijving

Patient was admitted with antithrombotic Extended therapy

Datatype

boolean

Type of medication
Beschrijving

Type of medication

Datatype

integer

Alias
UMLS CUI-1
C1704311
Operation
Beschrijving

Operation

Surgical operation date
Beschrijving

Surgical operation date

Datatype

date

Alias
UMLS CUI-1
C3258210
Time starting surgery (hh:mm)
Beschrijving

Time starting surgery (hh:mm)

Datatype

text

Alias
UMLS CUI-1
C0944781
Operation
Beschrijving

Operation

Datatype

integer

Alias
UMLS CUI-1
C0543467
Procedure Duration (in minutes)
Beschrijving

Procedure Duration (in minutes)

Datatype

integer

Maateenheden
  • Minuten
Alias
UMLS CUI-1
C1442476
Minuten
perioperative antibiotic prophylaxis
Beschrijving

perioperative antibiotic prophylaxis

Datatype

integer

Alias
UMLS CUI-1
C0282638
Operative procedures
Beschrijving

Operative procedures

Datatype

integer

Alias
UMLS CUI-1
C1550373
Intra- and postoperative course
Beschrijving

Intra- and postoperative course

postoperative plain x-ray a/p
Beschrijving

postoperative plain x-ray a/p

Datatype

boolean

Alias
UMLS CUI-1
C1306645
postoperative radiograph axially or Lauenstein
Beschrijving

postoperative radiograph axially or Lauenstein

Datatype

boolean

Alias
UMLS CUI-1
C0442269
UMLS CUI-2
C1302237
requiring treatment intra- / postoperative surgical complication (s)
Beschrijving

requiring treatment intra- / postoperative surgical complication (s)

Datatype

boolean

Alias
UMLS CUI-1
C0021890
UMLS CUI-2
C0032787
Implant malposition
Beschrijving

Implant malposition

Datatype

integer

Alias
UMLS CUI-1
C0333042
implant dislocation
Beschrijving

implant dislocation

Datatype

integer

Alias
UMLS CUI-1
C2183848
Wound hematoma / rebleedinghemorrhage
Beschrijving

Wound hematoma / rebleedinghemorrhage

Datatype

integer

Alias
UMLS CUI-1
C0281860
vascular lesion
Beschrijving

vascular lesion

Datatype

integer

Alias
UMLS CUI-1
C1402315
Nerve injury
Beschrijving

Nerve injury

Datatype

integer

Alias
UMLS CUI-1
C0161479
fracture
Beschrijving

fracture

Datatype

integer

Alias
UMLS CUI-1
C0016658
other
Beschrijving

other

Datatype

integer

postoperative wound infection
Beschrijving

postoperative wound infection

Datatype

boolean

Alias
UMLS CUI-1
C1629491
CDC-classification
Beschrijving

CDC-classification

Datatype

integer

Required repeat Surgery because of complication (s)
Beschrijving

Required repeat Surgery because of complication (s)

Datatype

boolean

Alias
UMLS CUI-1
C0035110
general postoperative complication (s) needed of treatment
Beschrijving

general postoperative complication (s) needed of treatment

Datatype

boolean

Alias
UMLS CUI-1
C0032787
Pneumonia
Beschrijving

Pneumonia

Datatype

integer

Alias
UMLS CUI-1
C0032285
cardiovascular complication (s)
Beschrijving

cardiovascular complication (s)

Datatype

integer

Alias
UMLS CUI-1
C0032963
deep leg/pelvic vein thrombosis
Beschrijving

deep leg/pelvic vein thrombosis<

Datatype

integer

Alias
UMLS CUI-1
C0149871
pulmonary embolism
Beschrijving

pulmonary embolism

Datatype

integer

Alias
UMLS CUI-1
C0034065
other
Beschrijving

other

Datatype

integer

Discharge
Beschrijving

Discharge

independent walking possible at discharge
Beschrijving

independent walking possible at discharge

Datatype

boolean

Alias
UMLS CUI-1
C0429979
Walking independently prior to the fracture?
Beschrijving

Walking independently prior to the fracture?

Datatype

boolean

self care in the daily hygiene possible at discharge
Beschrijving

self care in the daily hygiene possible at discharge

Datatype

boolean

Alias
UMLS CUI-1
C0518462
independently in daily hygiene prior to fracture?
Beschrijving

independently in daily hygiene prior to fracture?

Datatype

boolean

Hostpital discharge date (DD.MM.YYYY)
Beschrijving

Hostpital discharge date (DD.MM.YYYY)

Datatype

date

Alias
UMLS CUI-1
C2710998
Discharge diagnoses
Beschrijving

Discharge diagnoses

Datatype

integer

Alias
UMLS CUI-1
C0011900
Reason for Discharge
Beschrijving

Reason for Discharge

Datatype

integer

Alias
UMLS CUI-1
C3164834

Similar models

Quality assurance Hip Fracture with Osteosynthesis (AQUA)

Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
Item Group
Anamnesis / diagnosis
Item
ASA classification
integer
C1531480 (UMLS CUI-1)
Code List
ASA classification
CL Item
normal healthy patient (1)
CL Item
patient with mild systemic disease (2)
CL Item
patient with severe systemic disease (3)
CL Item
patient with severe systemic disease that is a constant threat to life (4)
CL Item
moribund patient who is not expected to survive without the operation (5)
Item
Wound contamination classifcation of procedure
integer
C1629491 (UMLS CUI-1)
Code List
Wound contamination classifcation of procedure
CL Item
aseptic procedure (1)
CL Item
partially aseptic procedure (2)
CL Item
procedure with contamination (3)
CL Item
septic procedure (4)
Item
fracture localization
integer
C0475264 (UMLS CUI-1)
Code List
fracture localization
CL Item
medial (1)
CL Item
lateral (2)
CL Item
pertrochantär (3)
CL Item
other (9)
Item
femoral fracture near hip - classification by garden
integer
C0441821 (UMLS CUI-1)
Code List
femoral fracture near hip - classification by garden
CL Item
abduction fracture (1)
CL Item
unshifted (2)
CL Item
shifted (3)
CL Item
completely shifted (4)
vorbestehende Koxarthrose
Item
pre-existing coxarthrosis
boolean
C0029410 (UMLS CUI-1)
Patient wurde mit antithrombotischer Dauertherapie aufgenommen
Item
Patient was admitted with antithrombotic Extended therapy
boolean
Item
Type of medication
integer
C1704311 (UMLS CUI-1)
Code List
Type of medication
CL Item
vitamin K antagonists (eg phenprocoumon, warfarin) (1)
CL Item
acetylsalicylic acid (2)
CL Item
other antiplatelet agents (eg clopidogrel, prasugrel, ticagrelor, cilostazol) (3)
CL Item
direct thrombin inhibitors (eg argatroban, dabigatran) (4)
CL Item
other (eg rivaroxaban, fondaparinux) (9)
Item Group
Operation
OP-Datum (TT.MM.JJJJ)
Item
Surgical operation date
date
C3258210 (UMLS CUI-1)
Uhrzeit OP-Beginn
Item
Time starting surgery (hh:mm)
text
C0944781 (UMLS CUI-1)
Operation
Item
Operation
integer
C0543467 (UMLS CUI-1)
Dauer des Eingriffs
Item
Procedure Duration (in minutes)
integer
C1442476 (UMLS CUI-1)
Item
perioperative antibiotic prophylaxis
integer
C0282638 (UMLS CUI-1)
Code List
perioperative antibiotic prophylaxis
CL Item
no (0)
CL Item
single shot (1)
CL Item
second dose (2)
CL Item
more often (3)
Item
Operative procedures
integer
C1550373 (UMLS CUI-1)
Code List
Operative procedures
CL Item
DHS, angle plate (1)
CL Item
intramedullary stabilization (eg, PFN, gamma nail) (2)
CL Item
Tightening (3)
CL Item
other (9)
Item Group
Intra- and postoperative course
postoperatives Röntgenbild a/p
Item
postoperative plain x-ray a/p
boolean
C1306645 (UMLS CUI-1)
postoperatives Röntgenbild axial oder Lauenstein
Item
postoperative radiograph axially or Lauenstein
boolean
C0442269 (UMLS CUI-1)
C1302237 (UMLS CUI-2)
behandlungsbedürftige intra-/postoperative chirurgische Komplikation(en)
Item
requiring treatment intra- / postoperative surgical complication (s)
boolean
C0021890 (UMLS CUI-1)
C0032787 (UMLS CUI-2)
Item
Implant malposition
integer
C0333042 (UMLS CUI-1)
Code List
Implant malposition
CL Item
yes (1)
Item
implant dislocation
integer
C2183848 (UMLS CUI-1)
Code List
implant dislocation
CL Item
yes (1)
Item
Wound hematoma / rebleedinghemorrhage
integer
C0281860 (UMLS CUI-1)
Code List
Wound hematoma / rebleedinghemorrhage
CL Item
yes (1)
Item
vascular lesion
integer
C1402315 (UMLS CUI-1)
Code List
vascular lesion
CL Item
yes (1)
Item
Nerve injury
integer
C0161479 (UMLS CUI-1)
Code List
Nerve injury
CL Item
yes (1)
Item
fracture
integer
C0016658 (UMLS CUI-1)
Code List
fracture
CL Item
yes (1)
Item
other
integer
Code List
other
CL Item
yes (1)
postoperative Wundinfektion
Item
postoperative wound infection
boolean
C1629491 (UMLS CUI-1)
Item
CDC-classification
integer
Code List
CDC-classification
CL Item
A1 (superficial infection) (1)
CL Item
A2 (deep infection) (2)
CL Item
A3 (cavitas/organ) (3)
Reoperation wegen Komplikation(en) erforderlich
Item
Required repeat Surgery because of complication (s)
boolean
C0035110 (UMLS CUI-1)
allgemeine behandlungsbedürftige postoperative Komplikation(en)
Item
general postoperative complication (s) needed of treatment
boolean
C0032787 (UMLS CUI-1)
Item
Pneumonia
integer
C0032285 (UMLS CUI-1)
Code List
Pneumonia
CL Item
yes (1)
Item
cardiovascular complication (s)
integer
C0032963 (UMLS CUI-1)
Code List
cardiovascular complication (s)
CL Item
yes (1)
Item
deep leg/pelvic vein thrombosis
integer
C0149871 (UMLS CUI-1)
Code List
deep leg/pelvic vein thrombosis
CL Item
yes (1)
Item
pulmonary embolism
integer
C0034065 (UMLS CUI-1)
Code List
pulmonary embolism
CL Item
yes (1)
Item
other
integer
Code List
other
CL Item
yes (1)
Item Group
Discharge
selbstständiges Gehen bei Entlassung möglich
Item
independent walking possible at discharge
boolean
C0429979 (UMLS CUI-1)
War der Patient vor der Fraktur selbstständig gehfähig?
Item
Walking independently prior to the fracture?
boolean
selbstständige Versorgung in der täglichen Hygiene bei Entlassung möglich
Item
self care in the daily hygiene possible at discharge
boolean
C0518462 (UMLS CUI-1)
War der Patient vor der Fraktur selbstständig in der täglichen Hygiene?
Item
independently in daily hygiene prior to fracture?
boolean
Entlassungsdatum Krankenhaus
Item
Hostpital discharge date (DD.MM.YYYY)
date
C2710998 (UMLS CUI-1)
Entlassungsdiagnose(n)
Item
Discharge diagnoses
integer
C0011900 (UMLS CUI-1)
Item
Reason for Discharge
integer
C3164834 (UMLS CUI-1)
Code List
Reason for Discharge
CL Item
treatment finished as planned (1)
CL Item
transferral to nursing facility (10)
CL Item
discharge to hospice (11)
CL Item
external transferral to psychiatric treatment (13)
CL Item
treatment finished because of other reasons, postdischarge treatment is planned (14)
CL Item
treatment aborted against medical advice, postdischarge treatment is planned (15)
CL Item
internal transferral with change of DRG payment areas (17)
CL Item
treatment finished as planned, postdischarge treatment is planned (2)
CL Item
case termination (internal transferral) with change between full- and partial stationary care (22)
CL Item
discharge at the end of the year with admission in previous year (25)
CL Item
treatment finished because of other reasons (3)
CL Item
treatment aborted against medical advice (4)
CL Item
change of jurisdiction of insurer or other payer (5)
CL Item
transferral to another hospital (6)
CL Item
death (7)
CL Item
transferral to another hospital within cooperative and governmental policies  (8)
CL Item
transferral to rehabilitation facility (9)

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