ID

10046

Descrição

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

Palavras-chave

  1. 23/11/2014 23/11/2014 - Julian Varghese
  2. 21/03/2015 21/03/2015 - Sarah Schulze Sünninghausen
Transferido a

21 de março de 2015

DOI

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Licença

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
Descrição

Test

Anamnesis / diagnosis
Descrição

Anamnesis / diagnosis

ASA classification
Descrição

ASA classification

Tipo de dados

integer

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

Wound contamination classifcation of procedure

Tipo de dados

integer

Alias
UMLS CUI-1
C1629491
fracture localization
Descrição

fracture localization

Tipo de dados

integer

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

femoral fracture near hip - classification by garden

Tipo de dados

integer

Alias
UMLS CUI-1
C0441821
pre-existing coxarthrosis
Descrição

pre-existing coxarthrosis

Tipo de dados

boolean

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

Patient was admitted with antithrombotic Extended therapy

Tipo de dados

boolean

Type of medication
Descrição

Type of medication

Tipo de dados

integer

Alias
UMLS CUI-1
C1704311
Operation
Descrição

Operation

Surgical operation date
Descrição

Surgical operation date

Tipo de dados

date

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

Time starting surgery (hh:mm)

Tipo de dados

text

Alias
UMLS CUI-1
C0944781
Operation
Descrição

Operation

Tipo de dados

integer

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

Procedure Duration (in minutes)

Tipo de dados

integer

Unidades de medida
  • Minuten
Alias
UMLS CUI-1
C1442476
Minuten
perioperative antibiotic prophylaxis
Descrição

perioperative antibiotic prophylaxis

Tipo de dados

integer

Alias
UMLS CUI-1
C0282638
Operative procedures
Descrição

Operative procedures

Tipo de dados

integer

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

Intra- and postoperative course

postoperative plain x-ray a/p
Descrição

postoperative plain x-ray a/p

Tipo de dados

boolean

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

postoperative radiograph axially or Lauenstein

Tipo de dados

boolean

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

requiring treatment intra- / postoperative surgical complication (s)

Tipo de dados

boolean

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

Implant malposition

Tipo de dados

integer

Alias
UMLS CUI-1
C0333042
implant dislocation
Descrição

implant dislocation

Tipo de dados

integer

Alias
UMLS CUI-1
C2183848
Wound hematoma / rebleedinghemorrhage
Descrição

Wound hematoma / rebleedinghemorrhage

Tipo de dados

integer

Alias
UMLS CUI-1
C0281860
vascular lesion
Descrição

vascular lesion

Tipo de dados

integer

Alias
UMLS CUI-1
C1402315
Nerve injury
Descrição

Nerve injury

Tipo de dados

integer

Alias
UMLS CUI-1
C0161479
fracture
Descrição

fracture

Tipo de dados

integer

Alias
UMLS CUI-1
C0016658
other
Descrição

other

Tipo de dados

integer

postoperative wound infection
Descrição

postoperative wound infection

Tipo de dados

boolean

Alias
UMLS CUI-1
C1629491
CDC-classification
Descrição

CDC-classification

Tipo de dados

integer

Required repeat Surgery because of complication (s)
Descrição

Required repeat Surgery because of complication (s)

Tipo de dados

boolean

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

general postoperative complication (s) needed of treatment

Tipo de dados

boolean

Alias
UMLS CUI-1
C0032787
Pneumonia
Descrição

Pneumonia

Tipo de dados

integer

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

cardiovascular complication (s)

Tipo de dados

integer

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

deep leg/pelvic vein thrombosis<

Tipo de dados

integer

Alias
UMLS CUI-1
C0149871
pulmonary embolism
Descrição

pulmonary embolism

Tipo de dados

integer

Alias
UMLS CUI-1
C0034065
other
Descrição

other

Tipo de dados

integer

Discharge
Descrição

Discharge

independent walking possible at discharge
Descrição

independent walking possible at discharge

Tipo de dados

boolean

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

Walking independently prior to the fracture?

Tipo de dados

boolean

self care in the daily hygiene possible at discharge
Descrição

self care in the daily hygiene possible at discharge

Tipo de dados

boolean

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

independently in daily hygiene prior to fracture?

Tipo de dados

boolean

Hostpital discharge date (DD.MM.YYYY)
Descrição

Hostpital discharge date (DD.MM.YYYY)

Tipo de dados

date

Alias
UMLS CUI-1
C2710998
Discharge diagnoses
Descrição

Discharge diagnoses

Tipo de dados

integer

Alias
UMLS CUI-1
C0011900
Reason for Discharge
Descrição

Reason for Discharge

Tipo de dados

integer

Alias
UMLS CUI-1
C3164834

Similar models

Quality assurance Hip Fracture with Osteosynthesis (AQUA)

Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de dados
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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