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ID

11306

Description

Items used as routine documentation by the university hospital muenster. Derived from original form "DAST Aufnahme PSYCH MS", converted to ODM format.

Keywords

  1. 6/28/15 6/28/15 -
  2. 6/28/15 6/28/15 -
Uploaded on

June 28, 2015

DOI

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License

Creative Commons BY-NC 3.0 Legacy

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    DAST Basic Documentation_Admission

    DAST Basic Documentation_Admission

    Patient informations
    Description

    Patient informations

    Alias
    UMLS CUI-1
    C1955348
    Name of the patient:
    Description

    Patient's name

    Data type

    text

    Alias
    UMLS CUI-1
    C1299487
    Date of birth:
    Description

    Date of birth

    Data type

    date

    Alias
    UMLS CUI-1
    C0421451
    Date of admission:
    Description

    Date of admission

    Data type

    date

    Alias
    UMLS CUI-1
    C0011008
    UMLS CUI-2
    C0019994
    UMLS CUI-3
    C0809949
    Document date:
    Description

    Document date

    Data type

    date

    Alias
    UMLS CUI-1
    C1978797
    Gender:
    Description

    Gender

    Data type

    text

    Alias
    UMLS CUI-1
    C0079399
    Age in years:
    Description

    Age

    Data type

    integer

    Alias
    UMLS CUI-1
    C0001779
    Marital status:
    Description

    Marital status

    Data type

    text

    Alias
    UMLS CUI-1
    C0024819
    How many children do you have?
    Description

    Number of children

    Data type

    integer

    Alias
    UMLS CUI-1
    C2229974
    How many people live in your house? Please enter as follow: Number of children, number of adults and total number of people living in your house.
    Description

    Number of people in household

    Data type

    text

    Name of the country you were born in:
    Description

    Birth country

    Data type

    text

    Alias
    UMLS CUI-1
    C1300001
    If you were not born in Germany, for how long are you living in Germany?
    Description

    Number of years in Germany

    Data type

    text

    Alias
    UMLS CUI-1
    C0439234
    UMLS CUI-2
    C0017480
    Birth country of your parents, please mention the birth country for both of your parents:
    Description

    Birth country of parents

    Data type

    text

    Alias
    UMLS CUI-1
    C1300001
    UMLS CUI-2
    C0030551
    What is your highest school-leaving qualification?
    Description

    School-leaving qualification

    Data type

    text

    Alias
    UMLS CUI-1
    C1522410
    UMLS CUI-2
    C0036375
    UMLS CUI-3
    C1711333
    How many years did you go to school?
    Description

    Number of years in school

    Data type

    integer

    Alias
    UMLS CUI-1
    C0237753
    UMLS CUI-2
    C0439234
    UMLS CUI-3
    C0036375
    What is your highest vocational qualification?
    Description

    Highest vocational qualification

    Data type

    text

    Alias
    UMLS CUI-1
    C0042933
    What is your present profession?
    Description

    Profession

    Data type

    text

    Alias
    UMLS CUI-1
    C0028811
    Do you have any first-degree relative who suffers from psychiatric disorder? If yes, please mention the person's relation to you and the type of psychiatric disorder he has.
    Description

    Psychiatric disorders in first-degree relatives

    Data type

    text

    Alias
    UMLS CUI-1
    C0004936
    UMLS CUI-2
    C1517194
    Pretreatments in the last 8 weeks before the present admission
    Description

    Pretreatments in the last 8 weeks before the present admission

    None
    Description

    None

    Data type

    boolean

    Alias
    UMLS CUI-1
    C0549184
    Did you undergo antidepressive therapy? If yes please mention the drug generic, dose and therapy duration:
    Description

    Antidepressive therapy

    Data type

    text

    Alias
    UMLS CUI-1
    C0003289
    UMLS CUI-2
    C0087111
    Did you undergo electroconvulsive therapy, ECT? If yes, please state the number of single stimulations you recieved.
    Description

    Electroconvulsive therapy

    Data type

    text

    Alias
    UMLS CUI-1
    C0013806
    Did you undergo a therapy for sleep deprivation?
    Description

    Sleep deprivation

    Data type

    boolean

    Alias
    UMLS CUI-1
    C0037316
    Did you undergo light therapy?
    Description

    Light therapy

    Data type

    boolean

    Alias
    UMLS CUI-1
    C0031765
    Did you receive any individual psychotherapy session?
    Description

    Psychotherapy

    Data type

    boolean

    Alias
    UMLS CUI-1
    C0033968
    Did you receive any group psychotherapy session?
    Description

    Psychotherapy

    Data type

    boolean

    Others:
    Description

    Others

    Data type

    text

    Alias
    UMLS CUI-1
    C0205394
    Diagnoses
    Description

    Diagnoses

    Alias
    UMLS CUI-1
    C0011900
    Main diagnosis according to DSM-IV
    Description

    Main diagnosis

    Data type

    text

    Alias
    UMLS CUI-1
    C0332137
    Secondary diagnoses according to DSM-IV:
    Description

    Secondary diagnosis

    Data type

    text

    Alias
    UMLS CUI-1
    C0332138
    Body height (in centimetres):
    Description

    Body height

    Data type

    float

    Alias
    UMLS CUI-1
    C0005890
    Weight (in kilograms):
    Description

    Weight

    Data type

    float

    Alias
    UMLS CUI-1
    C0005910
    Electrocardiogram, QTC- Interval (in seconds):
    Description

    Electrocardiogram, QTC- time

    Data type

    float

    Alias
    UMLS CUI-1
    C1623258
    When did you have your first depressive episode?
    Description

    Depressive episode

    Data type

    text

    Alias
    UMLS CUI-1
    C0349217
    Number of previous depressive episodes:
    Description

    Depressive episode

    Data type

    integer

    Alias
    UMLS CUI-1
    C0349217
    Number of previous stationary psychiatric hospitalizations:
    Description

    stationary psychiatric hospitalization

    Data type

    integer

    Clinical global impression (Severity of illness), please evaluate only for the period of last week.
    Description

    Clinical global impression

    Data type

    text

    Please select the score range based on the Global Assessment of Functioning (GAF) Scale. The evaluation of the GAF scale should relate to the period of last week before admission:
    Description

    Global Assessment of Functioning (GAF) Scale

    Data type

    text

    Alias
    UMLS CUI-1
    C0561904
    Patient's actual score:
    Description

    Score

    Data type

    float

    Alias
    UMLS CUI-1
    C0030705
    UMLS CUI-2
    C0018684
    UMLS CUI-3
    C0449820
    Assessment Form for admission
    Description

    Assessment Form for admission

    Beck Depression Inventory, BDI:
    Description

    Beck Depression Inventory

    Data type

    text

    Alias
    UMLS CUI-1
    C0451022
    Hamilton Anxiety Rating Scale, HAM-A:
    Description

    Hamilton Anxiety Rating Scale

    Data type

    text

    Young Mania Rating Scale, YMRS:
    Description

    Young Mania Rating Scale

    Data type

    text

    Others:
    Description

    Others

    Data type

    text

    Alias
    UMLS CUI-1
    C0205394

    Similar models

    DAST Basic Documentation_Admission

    Name
    Type
    Description | Question | Decode (Coded Value)
    Data type
    Alias
    Item Group
    Patient informations
    C1955348 (UMLS CUI-1)
    Patient's name
    Item
    Name of the patient:
    text
    C1299487 (UMLS CUI-1)
    Date of birth
    Item
    Date of birth:
    date
    C0421451 (UMLS CUI-1)
    Date of admission
    Item
    Date of admission:
    date
    C0011008 (UMLS CUI-1)
    C0019994 (UMLS CUI-2)
    C0809949 (UMLS CUI-3)
    Document date
    Item
    Document date:
    date
    C1978797 (UMLS CUI-1)
    Item
    Gender:
    text
    C0079399 (UMLS CUI-1)
    Code List
    Gender:
    CL Item
    Male (1)
    CL Item
    Female (2)
    Age
    Item
    Age in years:
    integer
    C0001779 (UMLS CUI-1)
    Item
    Marital status:
    text
    C0024819 (UMLS CUI-1)
    Code List
    Marital status:
    CL Item
    Married (1)
    CL Item
    Single (2)
    CL Item
    Widowed (3)
    CL Item
    Separated/ Divorced (4)
    CL Item
    Fixed partnership (5)
    Number of children
    Item
    How many children do you have?
    integer
    C2229974 (UMLS CUI-1)
    Number of people in household
    Item
    How many people live in your house? Please enter as follow: Number of children, number of adults and total number of people living in your house.
    text
    Birth country
    Item
    Name of the country you were born in:
    text
    C1300001 (UMLS CUI-1)
    Number of years in Germany
    Item
    If you were not born in Germany, for how long are you living in Germany?
    text
    C0439234 (UMLS CUI-1)
    C0017480 (UMLS CUI-2)
    Birth country of parents
    Item
    Birth country of your parents, please mention the birth country for both of your parents:
    text
    C1300001 (UMLS CUI-1)
    C0030551 (UMLS CUI-2)
    Item
    What is your highest school-leaving qualification?
    text
    C1522410 (UMLS CUI-1)
    C0036375 (UMLS CUI-2)
    C1711333 (UMLS CUI-3)
    Code List
    What is your highest school-leaving qualification?
    CL Item
    Without graduation (1)
    CL Item
    Primary school (2)
    CL Item
    Secondary school (3)
    CL Item
    University (4)
    CL Item
    University of applied science (5)
    CL Item
    Others (6)
    Number of years in school
    Item
    How many years did you go to school?
    integer
    C0237753 (UMLS CUI-1)
    C0439234 (UMLS CUI-2)
    C0036375 (UMLS CUI-3)
    Highest vocational qualification
    Item
    What is your highest vocational qualification?
    text
    C0042933 (UMLS CUI-1)
    Item
    What is your present profession?
    text
    C0028811 (UMLS CUI-1)
    Code List
    What is your present profession?
    CL Item
    Unemployed (1)
    CL Item
    Employed (2)
    CL Item
    Self-employed (3)
    CL Item
    Free-lancer (4)
    CL Item
    Craftsman (5)
    CL Item
    Skilled worker (6)
    CL Item
    Employee (7)
    Psychiatric disorders in first-degree relatives
    Item
    Do you have any first-degree relative who suffers from psychiatric disorder? If yes, please mention the person's relation to you and the type of psychiatric disorder he has.
    text
    C0004936 (UMLS CUI-1)
    C1517194 (UMLS CUI-2)
    Item Group
    Pretreatments in the last 8 weeks before the present admission
    None
    Item
    None
    boolean
    C0549184 (UMLS CUI-1)
    Antidepressive therapy
    Item
    Did you undergo antidepressive therapy? If yes please mention the drug generic, dose and therapy duration:
    text
    C0003289 (UMLS CUI-1)
    C0087111 (UMLS CUI-2)
    Electroconvulsive therapy
    Item
    Did you undergo electroconvulsive therapy, ECT? If yes, please state the number of single stimulations you recieved.
    text
    C0013806 (UMLS CUI-1)
    Sleep deprivation
    Item
    Did you undergo a therapy for sleep deprivation?
    boolean
    C0037316 (UMLS CUI-1)
    Light therapy
    Item
    Did you undergo light therapy?
    boolean
    C0031765 (UMLS CUI-1)
    Psychotherapy
    Item
    Did you receive any individual psychotherapy session?
    boolean
    C0033968 (UMLS CUI-1)
    Psychotherapy
    Item
    Did you receive any group psychotherapy session?
    boolean
    Others
    Item
    Others:
    text
    C0205394 (UMLS CUI-1)
    Item Group
    Diagnoses
    C0011900 (UMLS CUI-1)
    Main diagnosis
    Item
    Main diagnosis according to DSM-IV
    text
    C0332137 (UMLS CUI-1)
    Secondary diagnosis
    Item
    Secondary diagnoses according to DSM-IV:
    text
    C0332138 (UMLS CUI-1)
    Body height
    Item
    Body height (in centimetres):
    float
    C0005890 (UMLS CUI-1)
    Weight
    Item
    Weight (in kilograms):
    float
    C0005910 (UMLS CUI-1)
    Electrocardiogram
    Item
    Electrocardiogram, QTC- Interval (in seconds):
    float
    C1623258 (UMLS CUI-1)
    Depressive episode
    Item
    When did you have your first depressive episode?
    text
    C0349217 (UMLS CUI-1)
    Depressive episode
    Item
    Number of previous depressive episodes:
    integer
    C0349217 (UMLS CUI-1)
    stationary psychiatric hospitalization
    Item
    Number of previous stationary psychiatric hospitalizations:
    integer
    Item
    Clinical global impression (Severity of illness), please evaluate only for the period of last week.
    text
    Code List
    Clinical global impression (Severity of illness), please evaluate only for the period of last week.
    CL Item
    0 Can not be assessed. (1)
    CL Item
    1 Patient is not ill. (2)
    CL Item
    2 Patient is a borderline case of psychiatric illness. (3)
    CL Item
    3 Patient is only slightly ill. (4)
    CL Item
    4 Patient is moderately ill. (5)
    CL Item
    5 Patient is clearly ill. (6)
    CL Item
    6 Patient is seriously ill. (7)
    Item
    Please select the score range based on the Global Assessment of Functioning (GAF) Scale. The evaluation of the GAF scale should relate to the period of last week before admission:
    text
    C0561904 (UMLS CUI-1)
    Code List
    Please select the score range based on the Global Assessment of Functioning (GAF) Scale. The evaluation of the GAF scale should relate to the period of last week before admission:
    CL Item
    100-91 Superior functioning in all areas. (1)
    CL Item
    90-81 Good functioning in all areas. (2)
    CL Item
    80-71 No more than slight impairment. (3)
    CL Item
    70-61 Some difficulty. (4)
    CL Item
    60-51 Moderate difficulty. (5)
    CL Item
    50-41 Serious impairment. (6)
    CL Item
    40-31 Major impairment in several areas. (7)
    CL Item
    30-21 Inability to function in almost all areas. (8)
    CL Item
    20-11 Some danger of hurting self or others. (9)
    CL Item
    10-1 Permanent risk or persistent inability.  (10)
    CL Item
    Inadequate information. (0)
    Score
    Item
    Patient's actual score:
    float
    C0030705 (UMLS CUI-1)
    C0018684 (UMLS CUI-2)
    C0449820 (UMLS CUI-3)
    Item Group
    Assessment Form for admission
    Item
    Beck Depression Inventory, BDI:
    text
    C0451022 (UMLS CUI-1)
    Code List
    Beck Depression Inventory, BDI:
    CL Item
    Not specified (1)
    CL Item
    Is available (2)
    CL Item
    Patient is severely ill. (3)
    CL Item
    Denied (4)
    CL Item
    Others (5)
    Item
    Hamilton Anxiety Rating Scale, HAM-A:
    text
    Code List
    Hamilton Anxiety Rating Scale, HAM-A:
    CL Item
    Not specified (1)
    CL Item
    Is available (2)
    CL Item
    Patient is severely ill. (3)
    CL Item
    Denied (4)
    CL Item
    Others (5)
    Item
    Young Mania Rating Scale, YMRS:
    text
    Code List
    Young Mania Rating Scale, YMRS:
    CL Item
    Not specified (1)
    CL Item
    Is available (2)
    CL Item
    Patient is severely ill. (3)
    CL Item
    Denied (4)
    CL Item
    Others (5)
    Others
    Item
    Others:
    text
    C0205394 (UMLS CUI-1)

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