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ID

10128

Description

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: KEP-PROZ Specification 2015 V02

Link

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

Keywords

Versions (4)
  1. 11/23/14 11/23/14 - Julian Varghese
  2. 4/1/15 4/1/15 - Julian Varghese
  3. 4/8/15 4/8/15 - Julian Varghese
  4. 4/11/15 4/11/15 - Sarah Schulze Sünninghausen
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April 11, 2015

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Creative Commons BY-NC 3.0 Legacy
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    Quality assurance Knee Replacement - Procedure (AQUA)

    German English

    Quality assurance Knee Replacement - Procedure (AQUA)

    1 forms  
    ProzedurEingriff
    Description

    ProzedurEingriff

    Number of endoprothetic procedure during this stay?
    Description

    Number of endoprothetic procedure during this stay?

    Data type

    integer

    Alias
    UMLS CUI-1
    C2114712
    side of surgery
    Description

    side of surgery

    Data type

    integer

    Alias
    UMLS CUI-1
    C0441987
    Preoperative state
    Description

    Preoperative state

    Gonarthrosis
    Description

    Gonarthrosis

    Data type

    integer

    Alias
    UMLS CUI-1
    C0877389
    Deformity of knee joint
    Description

    Deformity of knee joint

    Data type

    integer

    Alias
    UMLS CUI-1
    C0576091
    ASA classification
    Description

    ASA classification

    Data type

    integer

    Alias
    UMLS CUI-1
    C1531480
    Wound contamination classifcation
    Description

    Wound contamination classifcation

    Data type

    integer

    Alias
    UMLS CUI-1
    C1629491
    Surgery
    Description

    Surgery

    Type of procedure
    Description

    Type of procedure

    Data type

    integer

    Alias
    UMLS CUI-1
    C1550373
    perioperative antibiotic prophylaxis
    Description

    perioperative antibiotic prophylaxis

    Data type

    integer

    Alias
    UMLS CUI-1
    C0282638
    Date of procedure (dd.mm.yyyy)
    Description

    Date of procedure (dd.mm.yyyy)

    Data type

    date

    Alias
    UMLS CUI-1
    C3258210
    Prozedur(en)
    Description

    Prozedur(en)

    Data type

    integer

    Intra- and postoperative course of procedure
    Description

    Intra- and postoperative course of procedure

    Were there specific needs treatment intra- and / or postoperative complications?
    Description

    Were there specific needs treatment intra- and / or postoperative complications?

    Data type

    boolean

    Alias
    UMLS CUI-1
    C0021890
    UMLS CUI-2
    C0032787
    primary implant malposition
    Description

    primary implant malposition

    Data type

    integer

    Alias
    UMLS CUI-1
    C0333042
    Secondary implant dislocation
    Description

    Secondary implant dislocation

    Data type

    integer

    postoperative dislocation of the artificial joint
    Description

    postoperative dislocation of the artificial joint

    Data type

    integer

    Alias
    UMLS CUI-1
    C0012691
    Deformity of patella
    Description

    Deformity of patella

    Data type

    integer

    Alias
    UMLS CUI-1
    C0343295
    wound hematoma/hemorrhage requiring OP or intervention
    Description

    wound hematoma/hemorrhage requiring OP or intervention

    Data type

    integer

    Alias
    UMLS CUI-1
    C0281860
    Surgical or interventional needed vascular lesion
    Description

    Surgical or interventional needed vascular lesion

    Data type

    integer

    Alias
    UMLS CUI-1
    C1402315
    persistent at discharge, motor nerve damage
    Description

    persistent at discharge, motor nerve damage

    Data type

    integer

    Alias
    UMLS CUI-1
    C0161479
    Periprosthetic Fractures
    Description

    Periprosthetic Fractures

    Data type

    integer

    Alias
    UMLS CUI-1
    C2609162
    postoperative wound infection (according to CDC definition)
    Description

    postoperative wound infection (according to CDC definition)

    Data type

    integer

    Alias
    UMLS CUI-1
    C0038941
    Wound dehiscence requiring reoperations
    Description

    Wound dehiscence requiring reoperations

    Data type

    integer

    Alias
    UMLS CUI-1
    C0259768
    Operational require secondary necrosis of the wound edges
    Description

    Operational require secondary necrosis of the wound edges

    Data type

    integer

    Alias
    UMLS CUI-1
    C0406828
    postoperative mechanical complication of the artificial joint
    Description

    postoperative mechanical complication of the artificial joint

    Data type

    integer

    Alias
    UMLS CUI-1
    C0451898
    Rupture of the quadriceps tendon/patellar ligament
    Description

    Rupture of the quadriceps tendon/patellar ligament

    Data type

    integer

    Alias
    UMLS CUI-1
    C0263968
    UMLS CUI-2
    C0435122
    Fracture of the patella
    Description

    Fracture of the patella

    Data type

    integer

    Alias
    UMLS CUI-1
    C0159849
    Other specific complications requiring treatment
    Description

    Other specific complications requiring treatment

    Data type

    integer

    Alias
    UMLS CUI-1
    C0009566
    unplanned sequence-OP due to complications
    Description

    unplanned sequence-OP due to complications

    Data type

    integer

    Other procedures
    Description

    Other procedures

    Were more endoprosthetic operative procedures performed at this stay?
    Description

    Were more endoprosthetic operative procedures performed at this stay?

    Data type

    boolean

    Alias
    UMLS CUI-1
    C0543467
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    Similar models

    Quality assurance Knee Replacement - Procedure (AQUA)

    1 forms
    Name
    Type
    Description | Question | Decode (Coded Value)
    Data type
    Alias
    NumberProcedure?
    Item
    Number of endoprothetic procedure during this stay?
    integer
    C2114712 (UMLS CUI-1)
    Item
    side of surgery
    integer
    C0441987 (UMLS CUI-1)
    zu operierende Seite
    Code List
    side of surgery
    CL Item
    right (1)
    CL Item
    left (2)
    Item Group
    Preoperative state
    Item
    Gonarthrosis
    integer
    C0877389 (UMLS CUI-1)
    Liegt eine Gonarthrose vor?
    Code List
    Gonarthrosis
    CL Item
    no (0)
    CL Item
    primary gonarthrosis (1)
    CL Item
    secondary osteoarthritis of the knee (2)
    Item
    Deformity of knee joint
    integer
    C0576091 (UMLS CUI-1)
    Liegen Fehlstellungen des Knies vor?
    Code List
    Deformity of knee joint
    CL Item
    no (0)
    CL Item
    severe valgus knee (1)
    CL Item
    severe varus knee (2)
    Item
    ASA classification
    integer
    C1531480 (UMLS CUI-1)
    Einstufung nach ASA-Klassifikation
    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
    integer
    C1629491 (UMLS CUI-1)
    Wundkontaminationsklassifikation
    Code List
    Wound contamination classifcation
    CL Item
    aseptic procedure (1)
    CL Item
    partially aseptic procedure (2)
    CL Item
    procedure with contamination (3)
    CL Item
    septic procedure (4)
    Item Group
    Surgery
    Item
    Type of procedure
    integer
    C1550373 (UMLS CUI-1)
    Art des Eingriffs
    Code List
    Type of procedure
    CL Item
    elective knee endoprosthesis primary implantation (1)
    CL Item
    one-stage exchange or replacing components (2)
    CL Item
    rhyme plantations as part of a two-stage change or change components (3)
    Item
    perioperative antibiotic prophylaxis
    integer
    C0282638 (UMLS CUI-1)
    perioperative Antibiotikaprophylaxe
    Code List
    perioperative antibiotic prophylaxis
    CL Item
    no (0)
    CL Item
    single shot (1)
    CL Item
    second shot (2)
    CL Item
    often (3)
    Datum des Eingriffs (TT.MM.JJJJ)
    Item
    Date of procedure (dd.mm.yyyy)
    date
    C3258210 (UMLS CUI-1)
    Prozedur(en)
    Item
    integer
    Item Group
    Intra- and postoperative course of procedure
    Gab es spezifische behandlungsbedürftige intra- und/oder postoperative Komplikationen?
    Item
    Were there specific needs treatment intra- and / or postoperative complications?
    boolean
    C0021890 (UMLS CUI-1)
    C0032787 (UMLS CUI-2)
    Item
    primary implant malposition
    integer
    C0333042 (UMLS CUI-1)
    primäre Implantatfehllage
    Code List
    primary implant malposition
    CL Item
    femoral component (1)
    CL Item
    tibial component (2)
    Item
    Secondary implant dislocation
    integer
    sekundäre Implantatdislokalisation
    Code List
    Secondary implant dislocation
    CL Item
    yes (1)
    Item
    postoperative dislocation of the artificial joint
    integer
    C0012691 (UMLS CUI-1)
    postoperative Luxation des künstlichen Gelenkes
    Code List
    postoperative dislocation of the artificial joint
    CL Item
    yes (1)
    Item
    Deformity of patella
    integer
    C0343295 (UMLS CUI-1)
    Patellafehlstellung
    Code List
    Deformity of patella
    CL Item
    yes (1)
    Item
    wound hematoma/hemorrhage requiring OP or intervention
    integer
    C0281860 (UMLS CUI-1)
    OP-, oder interventionsbedürftige(s) Wundhämatom/Nachblutung
    Code List
    wound hematoma/hemorrhage requiring OP or intervention
    CL Item
    yes (1)
    Item
    Surgical or interventional needed vascular lesion
    integer
    C1402315 (UMLS CUI-1)
    OP-, oder interventionsbedürftige Gefäßläsion
    Code List
    Surgical or interventional needed vascular lesion
    CL Item
    Yes, no pain catheter-related (1)
    CL Item
    Yes, pain catheter-related (2)
    Item
    persistent at discharge, motor nerve damage
    integer
    C0161479 (UMLS CUI-1)
    bei Entlassung persistierender, motorischer Nervenschaden
    Code List
    persistent at discharge, motor nerve damage
    CL Item
    Yes, no pain catheter-related (1)
    CL Item
    Yes, pain catheter-related (2)
    Item
    Periprosthetic Fractures
    integer
    C2609162 (UMLS CUI-1)
    periprothetische Fraktur
    Code List
    Periprosthetic Fractures
    CL Item
    yes (1)
    Item
    postoperative wound infection (according to CDC definition)
    integer
    C0038941 (UMLS CUI-1)
    postoperative Wundinfektion (nach CDC Definition)
    Code List
    postoperative wound infection (according to CDC definition)
    CL Item
    CDC A1 (superficial infection) (1)
    CL Item
    CDC A2 (postoperative deep infection) (2)
    CL Item
    CDC A3 (Organs/body cavity in the surgical area) (3)
    Item
    Wound dehiscence requiring reoperations
    integer
    C0259768 (UMLS CUI-1)
    reoperationspflichtige Wunddehiszenz
    Code List
    Wound dehiscence requiring reoperations
    CL Item
    yes (1)
    Item
    Operational require secondary necrosis of the wound edges
    integer
    C0406828 (UMLS CUI-1)
    reoperationspflichtige sekundäre Nekrose der Wundränder
    Code List
    Operational require secondary necrosis of the wound edges
    CL Item
    yes (1)
    Item
    postoperative mechanical complication of the artificial joint
    integer
    C0451898 (UMLS CUI-1)
    postoperative mechanische Komplikation des künstlichen Gelenkes
    Code List
    postoperative mechanical complication of the artificial joint
    CL Item
    yes (1)
    Item
    Rupture of the quadriceps tendon/patellar ligament
    integer
    C0263968 (UMLS CUI-1)
    C0435122 (UMLS CUI-2)
    Ruptur der Quadrizepssehne/Ligamentum patellae
    Code List
    Rupture of the quadriceps tendon/patellar ligament
    CL Item
    yes (1)
    Item
    Fracture of the patella
    integer
    C0159849 (UMLS CUI-1)
    Fraktur der Patella
    Code List
    Fracture of the patella
    CL Item
    yes (1)
    Item
    Other specific complications requiring treatment
    integer
    C0009566 (UMLS CUI-1)
    sonstige spezifische behandlungsbedürftige Komplikationen
    Code List
    Other specific complications requiring treatment
    CL Item
    yes (1)
    Item
    unplanned sequence-OP due to complications
    integer
    ungeplante Folge-OP aufgrund von Komplikationen
    Code List
    unplanned sequence-OP due to complications
    CL Item
    yes (1)
    Item Group
    Other procedures
    Wurden weitere endoprothetische operative Prozeduren in diesem stationären Aufenthalt durchgeführt?
    Item
    Were more endoprosthetic operative procedures performed at this stay?
    boolean
    C0543467 (UMLS CUI-1)
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