ID

11672

Description

ODM form derived from [DAST Aufnahme PSYCH UKM]. Used as a routine documentation by the University Hospital Muenster, Germany.

Keywords

  1. 7/20/15 7/20/15 -
  2. 7/20/15 7/20/15 -
  3. 7/21/15 7/21/15 -
  4. 7/21/15 7/21/15 -
  5. 7/26/15 7/26/15 -
  6. 7/26/15 7/26/15 -
Uploaded on

July 26, 2015

DOI

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License

Creative Commons BY-NC 3.0 Legacy

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DAST - Basic documentation - Patient Admission Form

DAST - Basic documentation - Patient Admission Form

Patient Demographics
Description

Patient Demographics

Alias
UMLS CUI-1
C1955348
Patient Name
Description

Patient Name

Data type

integer

Alias
UMLS CUI-1
C1299487
Date of admission
Description

Date of admission

Data type

date

Alias
UMLS CUI-1
C1302393
Date of birth
Description

Date of birth

Data type

date

Alias
UMLS CUI-1
C0421451
Entry date
Description

Entry date

Data type

date

Alias
UMLS CUI-1
C1978797
Attending physician
Description

Physician attending and documenting the patient`s admission

Data type

text

Alias
UMLS CUI-1
C1320929
Gender
Description

Gender

Alias
UMLS CUI-1
C0079399
Patient Gender
Description

Patient Gender

Data type

integer

Alias
UMLS CUI-1
C0079399
Patient age
Description

Patient age

Patient age
Description

Patient age

Data type

integer

Marital status
Description

Marital status

Marital status
Description

Marital status

Data type

text

Alias
UMLS CUI-1
C0024819
Offspring
Description

Offspring

How many children do you have?
Description

How many children do you have?

Data type

integer

Alias
UMLS CUI-1
C2229974
Sharde household
Description

Sharde household

How many children live with you in your household?
Description

How many children live with you in your household?

Data type

integer

Alias
UMLS CUI-1
C1518468
How many adults live with you in your household?
Description

How many adults live with you in your household?

Data type

integer

Alias
UMLS CUI-1
C0557510
UMLS CUI-2
C0557510
Total amount of people living in your household
Description

Total amount of people living with patient in household

Data type

integer

Alias
UMLS CUI-1
C0682277
Descent
Description

Descent

Country of birth?
Description

Where was the patient born?

Data type

text

Alias
UMLS CUI-1
C1300001
Years in Germany
Description

Years in Germany

In case you where not born in Germany, how many years have you lived in Germany for?
Description

In case you where not born in Germany, how many years have you lived in Germany for?

Data type

text

Alias
UMLS CUI-1
C0017480
UMLS CUI-2
C0682130
UMLS CUI-3
C0946385
Patient's parents country of birth
Description

Patient's parents country of birth

Where was your mother born?
Description

Where was your mother born?

Data type

text

Alias
UMLS CUI-1
C1300001
UMLS CUI-2
C0026591
Where was your father born?
Description

Where was your father born?

Data type

text

Alias
UMLS CUI-1
C1300001
UMLS CUI-2
C0015671
School leaving certificate
Description

School leaving certificate

What is your highest achieved level of education?
Description

What is your highest achieved level of education?

Data type

text

Alias
UMLS CUI-1
C2030935
Number of school years
Description

Number of school years

How many years of schooling have you completed?
Description

How many years of schooling have you completed?

Data type

integer

Alias
UMLS CUI-1
C2360044
Training qualification / Professional education
Description

Training qualification / Professional education

What is your highest level of vocational training
Description

What is your highest level of vocational training

Data type

text

Alias
UMLS CUI-1
C0204116
UMLS CUI-2
C2030935
Current employment situation
Description

Current employment situation

What is your current employment situation?
Description

What is your current employment situation?

Data type

text

Alias
UMLS CUI-1
C3261398
Family history of psychiatric disease
Description

Family history of psychiatric disease

Has any of your first-degree relatives suffered from a mental disorder?
Description

Has any of your first-degree relatives suffered from a psychiatric disease?

Data type

text

Alias
UMLS CUI-1
C0004936
UMLS CUI-2
C1518469
In case mental disorders have occured in your family: Who has been affected and by which mental disorder specifically? (Mother, Father, Brother, Sister, Aunt, Uncle, Grandfather, Grandmother, others)
Description

In case mental disorders have occured in your family: Who has been affected and by which mental disorder specifically?

Data type

text

Alias
UMLS CUI-1
C0455379
Treatment prior to admission
Description

Treatment prior to admission

Treatment received in the last 8 weeks prior to current admission
Description

Treatment received in the last 8 weeks prior to current admission

Data type

integer

Alias
UMLS CUI-1
C1514463
Admission diagnosis
Description

Admission diagnosis

Primary mental disorder admission diagnosis (DSM-IV)
Description

Primary mental disorder admission diagnosis (DSM-IV)

Data type

text

Alias
UMLS CUI-1
C1628992
Relevant secondary diagnosis
Description

Relevant secondary diagnosis

Data type

text

Vital status
Description

Vital status

Patient height
Description

Patient height

Data type

integer

Measurement units
  • cm
Alias
UMLS CUI-1
C0489786
cm
Patient weight
Description

Patient weight

Data type

integer

Measurement units
  • kg
Alias
UMLS CUI-1
C0005910
kg
Electrocardiography
Description

Electrocardiography

Corrected QT Interval (QTc)
Description

Corrected QT Interval (QTc)

Data type

integer

Measurement units
  • sec
sec
Major depressive disorder
Description

Major depressive disorder

Occurrence first major depressive episode
Description

Occurrence first major depressive episode

Data type

date

Alias
UMLS CUI-1
C0024517
Number of major depressive episodes
Description

Number of major depressive episodes

Data type

integer

Alias
UMLS CUI-1
C0024517
UMLS CUI-2
C0449788
Number of times patient was hospitalized a psychiatric clinic
Description

Number of times patient was hospitalized a psychiatric clinic

Data type

integer

Alias
UMLS CUI-1
C0019993
UMLS CUI-2
C0871167
Clinical Global Impression (Degrees of severity)
Description

Clinical Global Impression (Degrees of severity)

Severity Score
Description

Severity Score

Data type

integer

Global Assessment of Functioning (GAF) Scale
Description

Global Assessment of Functioning (GAF) Scale

Evaluation of GAF shall refer to the last 8 weeks prior to admission
Description

intermediary values i.e 45,68,72 shall be entered

Data type

integer

Alias
UMLS CUI-1
C0017644
Rating sheet / Evaluation sheet at admission
Description

Rating sheet / Evaluation sheet at admission

Beck Depression Inventory
Description

Beck Depression Inventory

Data type

integer

Alias
UMLS CUI-1
C0451022
Hamilton Depression Scale (HAMD)
Description

Hamilton Depression Scale (HAMD)

Data type

text

Alias
UMLS CUI-1
C0451203
Young's Mania Rating Scale (YMRS-C)
Description

Young's Mania Rating Scale (YMRS-C)

Data type

text

Alias
UMLS CUI-1
C3640523
Other
Description

Other

Data type

text

Similar models

DAST - Basic documentation - Patient Admission Form

Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Patient Demographics
C1955348 (UMLS CUI-1)
Patient Name
Item
Patient Name
integer
C1299487 (UMLS CUI-1)
Date of admission
Item
Date of admission
date
C1302393 (UMLS CUI-1)
Date of birth
Item
Date of birth
date
C0421451 (UMLS CUI-1)
Entry date
Item
Entry date
date
C1978797 (UMLS CUI-1)
Attending physician
Item
Attending physician
text
C1320929 (UMLS CUI-1)
Item Group
Gender
C0079399 (UMLS CUI-1)
Item
Patient Gender
integer
C0079399 (UMLS CUI-1)
Code List
Patient Gender
CL Item
male (1)
CL Item
female (2)
Item Group
Patient age
Patient age
Item
Patient age
integer
Item Group
Marital status
Marital status
Item
Marital status
text
C0024819 (UMLS CUI-1)
Item Group
Offspring
How many children do you have?
Item
How many children do you have?
integer
C2229974 (UMLS CUI-1)
Item Group
Sharde household
Number of Children in Household
Item
How many children live with you in your household?
integer
C1518468 (UMLS CUI-1)
Number of Adults in Household
Item
How many adults live with you in your household?
integer
C0557510 (UMLS CUI-1)
C0557510 (UMLS CUI-2)
Total number of persons in your household
Item
Total amount of people living in your household
integer
C0682277 (UMLS CUI-1)
Country of birth
Item
Country of birth?
text
C1300001 (UMLS CUI-1)
Item Group
Years in Germany
In case you where not born in Germany, how many years have you lived in Germany for?
Item
In case you where not born in Germany, how many years have you lived in Germany for?
text
C0017480 (UMLS CUI-1)
C0682130 (UMLS CUI-2)
C0946385 (UMLS CUI-3)
Item Group
Patient's parents country of birth
Where was your mother born?
Item
Where was your mother born?
text
C1300001 (UMLS CUI-1)
C0026591 (UMLS CUI-2)
Where was your father born?
Item
Where was your father born?
text
C1300001 (UMLS CUI-1)
C0015671 (UMLS CUI-2)
Item Group
School leaving certificate
What is your highest achieved level of education?
Item
What is your highest achieved level of education?
text
C2030935 (UMLS CUI-1)
Item Group
Number of school years
How many years of schooling have you completed?
Item
How many years of schooling have you completed?
integer
C2360044 (UMLS CUI-1)
Item Group
Training qualification / Professional education
What is your highest level of vocational training
Item
What is your highest level of vocational training
text
C0204116 (UMLS CUI-1)
C2030935 (UMLS CUI-2)
Item Group
Current employment situation
What is your current employment situation?
Item
What is your current employment situation?
text
C3261398 (UMLS CUI-1)
Item Group
Family history of psychiatric disease
Has any of your first-degree relatives suffered from a psychiatric disease?
Item
Has any of your first-degree relatives suffered from a mental disorder?
text
C0004936 (UMLS CUI-1)
C1518469 (UMLS CUI-2)
In case mental disorders have occured in your family
Item
In case mental disorders have occured in your family: Who has been affected and by which mental disorder specifically? (Mother, Father, Brother, Sister, Aunt, Uncle, Grandfather, Grandmother, others)
text
C0455379 (UMLS CUI-1)
Item Group
Treatment prior to admission
Item
Treatment received in the last 8 weeks prior to current admission
integer
C1514463 (UMLS CUI-1)
Code List
Treatment received in the last 8 weeks prior to current admission
CL Item
None (1)
CL Item
Antidepressive Agents (generic name, mg/d, Duration) (2)
CL Item
Electroconvulsive therapy: Number of single stimulations  (3)
CL Item
Sleep deprivation (4)
CL Item
Phototherapy (5)
CL Item
Psychotherapy: individual therapy (6)
CL Item
Psychotherapy: group therapy (7)
CL Item
Other: (8)
Item Group
Admission diagnosis
Primary mental disorder admission diagnosis (DSM-IV)
Item
Primary mental disorder admission diagnosis (DSM-IV)
text
C1628992 (UMLS CUI-1)
Relevant secondary diagnosis
Item
Relevant secondary diagnosis
text
Item Group
Vital status
Patient height
Item
Patient height
integer
C0489786 (UMLS CUI-1)
Patient weight
Item
Patient weight
integer
C0005910 (UMLS CUI-1)
Item Group
Electrocardiography
Corrected QT Interval (QTc)
Item
Corrected QT Interval (QTc)
integer
Item Group
Major depressive disorder
Major depressive disorder
Item
Occurrence first major depressive episode
date
C0024517 (UMLS CUI-1)
Number of major depressive episodes
Item
Number of major depressive episodes
integer
C0024517 (UMLS CUI-1)
C0449788 (UMLS CUI-2)
Number of times patient was hospitalized a psychiatric clinic
Item
Number of times patient was hospitalized a psychiatric clinic
integer
C0019993 (UMLS CUI-1)
C0871167 (UMLS CUI-2)
Item Group
Clinical Global Impression (Degrees of severity)
Item
Severity Score
integer
Code List
Severity Score
CL Item
cannot be assessed (0)
CL Item
normal, not at all ill (1)
CL Item
borderline mentally ill (2)
CL Item
mildly ill (3)
CL Item
moderately ill (4)
CL Item
markedly ill (5)
CL Item
severely ill (6)
CL Item
extremely ill (7)
Item Group
Global Assessment of Functioning (GAF) Scale
Item
Evaluation of GAF shall refer to the last 8 weeks prior to admission
integer
C0017644 (UMLS CUI-1)
Code List
Evaluation of GAF shall refer to the last 8 weeks prior to admission
CL Item
Inadequate information (0 )
CL Item
No symptoms (100-91 )
CL Item
Absent or minimal symptoms  (90-81 )
CL Item
If symptoms are present, they are transient and expectable reactions to psychosocial stressors  (80-71 )
CL Item
Some mild symptomss. (70-61 )
CL Item
Moderate symptoms (60-51 )
CL Item
Serious symptoms (50-41 )
CL Item
Some impairment  (40-31 )
CL Item
Behavior is considerably influenced by delusions or hallucinations or serious impairment (30-21 )
CL Item
Some danger of hurting self or others (20-11 )
CL Item
Persistent danger of severely hurting self or others (10-1 )
Item Group
Rating sheet / Evaluation sheet at admission
Item
Beck Depression Inventory
integer
C0451022 (UMLS CUI-1)
Code List
Beck Depression Inventory
CL Item
available (1)
CL Item
patient too sick (2)
CL Item
refused (3)
CL Item
other (4)
CL Item
not specified (5)
Item
Hamilton Depression Scale (HAMD)
text
C0451203 (UMLS CUI-1)
Code List
Hamilton Depression Scale (HAMD)
CL Item
available (1)
CL Item
patient too sick (2)
CL Item
refused (3)
CL Item
other (4)
CL Item
not specified (5)
Item
Young's Mania Rating Scale (YMRS-C)
text
C3640523 (UMLS CUI-1)
Code List
Young's Mania Rating Scale (YMRS-C)
CL Item
available (1)
CL Item
patient too sick (2)
CL Item
refused (3)
CL Item
other (4)
CL Item
not specified (5)
Other
Item
Other
text

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