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ID
11851
Beschreibung
Documentation form for quality assurance in German Health Care by the Institute for Applied Quality Improvement and Research in Health Care (Aqua), https://www.aqua-institut.de/en/home. Internal Aqua form version: 21-3-B Specification 2015 V02
Link
https://www.aqua-institut.de/en/home
Stichworte
Versionen (3)
- 22.12.14 22.12.14 - Julian Varghese
- 19.01.15 19.01.15 - Sarah Schulze Sünninghausen
- 12.08.15 12.08.15 - Julian Varghese
Hochgeladen am
12. August 2015
DOI
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Lizenz
Creative Commons BY-NC 3.0
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Quality Assurance Coronary Angiography and Percuteanous Intervention (PCI) - Basic (AQUA)
Quality assurance Coronary Angiography and Percuteanous Intervention (PCI) - Basic (AQUA)
Ähnliche Modelle
Quality assurance Coronary Angiography and Percuteanous Intervention (PCI) - Basic (AQUA)
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Institutionskennzeichen
Item
Healthcare Facility Identifier
integer
C2986045 (UMLS CUI-1)
Entlassender Standort
Item
Zip Code of Discharge
string
C1521842 (UMLS CUI-1)
Betriebsstätten-Nummer
Item
Facility's Section Identifier
string
C1547540 (UMLS CUI-1)
Aufnahmedatum Krankenhaus
Item
Hospital admission date (DD.MM.YYYY)
date
C1302393 (UMLS CUI-1)
CL Item
internal medicine (0100)
CL Item
internal medicine: geriatrics (0102)
CL Item
internal medicine: cardiology (0103)
CL Item
internal medicine: nephrology (0104)
CL Item
internal medicine: hematology and internal oncology (0105)
CL Item
internal medicine: endocrinology (0106)
CL Item
internal medicine: gastroenterology (0107)
CL Item
internal medicine: pneumonology (0108)
CL Item
internal medicine: rheumatology (0109)
CL Item
internal medicine: pulmonology (0114)
CL Item
internal medicine: tumor research (0150)
CL Item
internal medicine: coloproctology (0151)
CL Item
internal medicine: infectiology (0152)
CL Item
internal medicine: diabetes (0153)
CL Item
internal medicine: naturopathy (0154)
CL Item
internal medicine: stroke unit (0156)
CL Item
internal medicine (0190)
CL Item
geriatry (0200)
CL Item
geriatry: gynecology (0224)
CL Item
geriatry: day unit (for semi-residential care) (0260)
CL Item
geriaty: night unit (for semi-residential care) (0261)
CL Item
geriatry (0290)
CL Item
cardiology (0300)
CL Item
nephrology (0400)
CL Item
nephrology: pediatrics (0410)
CL Item
nephrology: intensive care (0436)
CL Item
nephrology (0490)
CL Item
hematology and internal oncology (0500)
CL Item
hematology and internal oncology: pediatrics (0510)
CL Item
hematology and internal oncology: gynacology (0524)
CL Item
hematology and internal oncology: radiation therapy (0533)
CL Item
hematology and internal oncology (0590)
CL Item
endocrinology (0600)
CL Item
endicrinology: gastroenterology (0607)
CL Item
endocrinology: pediatrics (0610)
CL Item
endocrinology (0690)
CL Item
gastroenterology (0700)
CL Item
gastroenterology: endocrinology (0706)
CL Item
gastroenterology: pediatrics (0710)
CL Item
gastroenterology (0790)
CL Item
pneumology (0800)
CL Item
rheumatology (0900)
CL Item
rheumatology: pediatrics (0910)
CL Item
rheumatology (0990)
CL Item
pediatrics (1000)
CL Item
pediatrics: nephrology (1004)
CL Item
pediatrics: hematology and internal oncology (1005)
CL Item
pediatrics: endocrinology (1006)
CL Item
pediatrics: gastroenterology (1007)
CL Item
pediatrics: rheumatology (1009)
CL Item
pediatrics: pediatric cardiology (1011)
CL Item
pediatrics: nephrology (1012)
CL Item
pediatrics: pulmonology (1014)
CL Item
pediatrics: pediatric neurology (1028)
CL Item
pediatrics: perinatal medicine (1050)
CL Item
continuing care for children (1051)
CL Item
pediatrics (1090)
CL Item
pediatric cardiology (1100)
CL Item
pediatric cardiology: intensive care (1136)
CL Item
pediatric cardiology (1190)
CL Item
neonatology (1200)
CL Item
pediatric surgery (1300)
CL Item
pulmonology (1400)
CL Item
pulmonology: pediatrics (1410)
CL Item
pulmonology (1490)
CL Item
general surgery (1500)
CL Item
general surgery: pediatric surgery (1513)
CL Item
general surgery: trauma surgery (1516)
CL Item
general surgery: vascular surgery (1518)
CL Item
general surgery: plastic surgery (1519)
CL Item
general surgery: thoracic surgery (1520)
CL Item
general surgery: orthopedics (1523)
CL Item
general surgery: intensive care (1536)
CL Item
general surgery: abdominal- and vascular surgery (1550)
CL Item
Allgemeine Chirurgie: hand surgery (1551)
CL Item
general surgery (1590)
CL Item
trauma surgery (1600)
CL Item
neurosurgery (1700)
CL Item
vascular surgery (1800)
CL Item
plastic surgery (1900)
CL Item
thoracic surgery (2000)
CL Item
thoracic surgery: cardiac surgery (2021)
CL Item
thoracic surgery: intensive care (2036)
CL Item
thoracic surgery: cardiac surgery intensive care (2050)
CL Item
thoracic surgery (2090)
CL Item
cardiac surgery (2100)
CL Item
cardiac surgery: vascular surgery (2118)
CL Item
cardiac surgery: thoracic surgery (2120)
CL Item
cardiac surgery: intensive care (2136)
CL Item
cardiac surgery: thoracic surgery and intensive care (2150)
CL Item
cardiac surgery (2190)
CL Item
urology (2200)
CL Item
orthopedics (2300)
CL Item
orthopedics: rheumatology (2309)
CL Item
orthopedics: surgery (2315)
CL Item
orthopedics and trauma surgery (2316)
CL Item
orthopedics (2390)
CL Item
gynecology and obstetrics (2400)
CL Item
gynecology: geriatry (2402)
CL Item
gynecology: hematology and internal oncology (2405)
CL Item
gynecology: endocrinology (2406)
CL Item
gynecology (2425)
CL Item
gynecology and obstetrics (2490)
CL Item
obstetrics (2500)
CL Item
otolaryngology (2600)
CL Item
ophthalmology (2700)
CL Item
neurology: (2800)
CL Item
neurology: pediatrics (2810)
CL Item
neurology: stroke units (2856)
CL Item
neurology (2890)
CL Item
general psychiatry: (2900)
CL Item
general psychiatry: neurology (2928)
CL Item
general psychiatry: child and adolescent psychiatry (2930)
CL Item
general psychiatry: psychosomatics and psychotherapy (2931)
CL Item
general psychiatry: addiction treatment (2950)
CL Item
general psychiatry: geropsychiatry (2951)
CL Item
general psychiatry: forensic treatment (2952)
CL Item
general psychiatry: addiction treatment (day unit) (2953)
CL Item
general psychiatry: addiction treatment (night unit) (2954)
CL Item
general psychiatry: geropsychiatry (day unit) (2955)
CL Item
general psychiatry: geropsychiatry (night unit) (2956)
CL Item
general psychiatry: day unit (for semi-residential care) (2960)
CL Item
general psychiatry: night unit (for semi-residential care) (2961)
CL Item
general psychiatry (2990)
CL Item
child and adolescent psychiatry (3000)
CL Item
child and adolescent psychiatry: day unit (for semi-residential care) (3060)
CL Item
child and adolescent psychiatry: night unit (for semi-residential care) (3061)
CL Item
child and adolescent psychiatry (3090)
CL Item
psychosomatic/psychotherapy (3100)
CL Item
psychosomatic/psychotherapy: child and adolescent psychiatry (3110)
CL Item
psychosomatic/psychotherapy: day unit (for semi-residential care) (3160)
CL Item
psychosomatic/psychotherapy: night unit (for semi-residential care) (3161)
CL Item
psychosomatic/psychotherapy (3190)
CL Item
nuclear medicine (3200)
CL Item
nuclear medicine: radiation therapy (3233)
CL Item
nuclear medicine (3290)
CL Item
radiation therapy (3300)
CL Item
radiation therapy: hematology and internal oncology (3305)
CL Item
radiation therapy: radiology (3350)
CL Item
radiation therapy (3390)
CL Item
dermatology (3400)
CL Item
dermatology: day unit (for semi-residential care) (3460)
CL Item
dermatology (3490)
CL Item
dentistry, orthodontics, maxillofacial surgery (3500)
CL Item
intensive-care medicine (3600)
CL Item
intensive-care medicine: internal medicine (3601)
CL Item
intensive-care medicine: cardiology (3603)
CL Item
intensive-care medicine: pediatrics (3610)
CL Item
intensive-care medicine: neurosurgery (3617)
CL Item
intensive-care medicine: surgery (3618)
CL Item
intensive-care medicine: cardiac surgery (3621)
CL Item
intensive-care medicine: urology (3622)
CL Item
intensive-care medicine: gynecology and obstetrics (3624)
CL Item
intensive-care medicine: otolaryngology (3626)
CL Item
intensive-care medicine: neurology (3628)
CL Item
operative intensive-care medicine: surgery (3650)
CL Item
intensive-care medicine: thorax-heart surgery (3651)
CL Item
intensive-care medicine: heart-thorax surgery (3652)
CL Item
intensive-care medicine (3690)
CL Item
other medical specialty (3700)
CL Item
angiology (3750)
CL Item
radiology (3751)
CL Item
palliative care (3752)
CL Item
pain therapy (3753)
CL Item
section for alternative health practice (3754)
CL Item
spinal surgery (3755)
CL Item
addiction medicine (3756)
CL Item
visceral surgery (3757)
CL Item
other medical specialty (3790)
Verbringungsleistung (Die dokumentierende und die den Eingriff durchführende Einrichtung sind NICHT identisch)
Item
Healthcare facility is the provider of this procedure (The facility for documenting the procedure and the facility for providing the procedure are not identical)
boolean
Identifikationsnummer des Patienten
Item
Patient identification number
string
C1549734 (UMLS CUI-1)
Geburtsdatum
Item
Date of Birth (DD.MM.YYYY)
date
C0421451 (UMLS CUI-1)
CL Item
male (1)
CL Item
female (2)
Item
diagnostic coronary angiography before this stay
integer
C0085532 (UMLS CUI-1)
Code List
diagnostic coronary angiography before this stay
CL Item
no (0)
CL Item
yes (1)
CL Item
unknown (9)
Item
Catheteral intervention before this stay
integer
C1532338 (UMLS CUI-1)
CL Item
no (0)
CL Item
yes (1)
CL Item
unknown (9)
Item
Patient post coronary bypass operation
integer
C0010055 (UMLS CUI-1)
CL Item
no (0)
CL Item
yes (1)
CL Item
unknown (9)
Item
Left ventricular ejection fraction under 40%
integer
C0428772 (UMLS CUI [1])
CL Item
no (0)
CL Item
yes (1)
CL Item
questionable (2)
CL Item
unknown (9)
CL Item
no (0)
CL Item
yes, non-insulin-dependent (1)
CL Item
yes, insulin-dependent (2)
CL Item
unknown (9)
CL Item
no (0)
CL Item
yes, dependence on dialysis (1)
CL Item
yes, non-dependent on dialysis (2)
CL Item
unknown (9)
Item Group
Current cardiac medical history (before first procedure)
akutes Koronarsyndrom (ST-Hebungsinfarkt oder Infarkt ohne ST-Hebung, aber mit Markererhöhung oder instabile Angina pectoris (Ruheangina) innerhalb der letzten 48 Stunden)
Item
acute coronary syndrome (STEMI or NSTEMI, but with positive lab values or instable angina pectoris (rest angina))
boolean
C0948089 (UMLS CUI-1)
CL Item
nein (0)
CL Item
CCS I (angina only during strenuous physical activity) (1)
CL Item
CCS II (angina during ordinary activity ) (2)
CL Item
CCS III (angina during less-than-ordinary activity) (3)
Item
objective (apparatus-based) signs of ischemia - exercise ecg or other non-invasive tests
integer
C0151744 (UMLS CUI-1)
Code List
objective (apparatus-based) signs of ischemia - exercise ecg or other non-invasive tests
CL Item
no (0)
CL Item
yes (1)
CL Item
questionable (2)
CL Item
unknown (9)
Item
postprocedural myocardial infarction
integer
C0027051 (UMLS CUI-1)
CL Item
no (0)
CL Item
yes, until 36 hours after the previous procedure (1)
CL Item
yes, more than 36 hours after the previous procedure (until discharge from the hospital) (2)
Item
postprocedural TIA/Stroke
integer
C0007787 (UMLS CUI-1)
C0038454 (UMLS CUI-2)
C0038454 (UMLS CUI-2)
CL Item
no (0)
CL Item
yes, until 36 hours after the previous procedure (1)
CL Item
yes, more than 36 hours after the previous procedure (until discharge from the hospital) (2)
Item
postprocedural Emergency-PCI at the same vessel
integer
C1532338 (UMLS CUI-1)
Code List
postprocedural Emergency-PCI at the same vessel
CL Item
no (0)
CL Item
yes, until 36 hours after the previous procedure (1)
CL Item
yes, more than 36 hours after the previous procedure (until discharge from the hospital) (2)
Item
postprocedural transferral or admission to emergency CABG surgery
integer
C0010055 (UMLS CUI-1)
Code List
postprocedural transferral or admission to emergency CABG surgery
CL Item
no (0)
CL Item
yes, until 36 hours after the previous procedure (1)
CL Item
yes, more than 36 hours after the previous procedure (until discharge from the hospital) (2)
Item
Severe hemorrhage at puncture site
integer
C0919883 (UMLS CUI-1)
Code List
Severe hemorrhage at puncture site
CL Item
no (0)
CL Item
yes, until 36 hours after the previous procedure (1)
CL Item
yes, more than 36 hours after the previous procedure (until discharge from the hospital) (2)
Item
Therapy of hemarrage at puncture site
integer
C1522326 (UMLS CUI-1)
C0919883 (UMLS CUI-2)
C0919883 (UMLS CUI-2)
CL Item
injection of thrombin (1)
CL Item
transfusion (2)
CL Item
surgical intervention at the puncture site (3)
Item
Vascular thrombosis (close to punction site)
integer
C2938969 (UMLS CUI-1)
CL Item
no (0)
CL Item
yes, until 36 hours after the previous procedure (1)
CL Item
yes, more than 36 hours after the previous procedure (until discharge from the hospital) (2)
Item
Pseudoaneurysm with new compression (at site of punctutre)
integer
C1510412 (UMLS CUI-1)
Code List
Pseudoaneurysm with new compression (at site of punctutre)
CL Item
no (0)
CL Item
yes, until 36 hours after the previous procedure (1)
CL Item
yes, more than 36 hours after the previous procedure (until discharge from the hospital) (2)
Item
other postprocedural events - e.g. Sepsis
integer
Code List
other postprocedural events - e.g. Sepsis
CL Item
no (0)
CL Item
yes, until 36 hours after the previous procedure (1)
CL Item
yes, more than 36 hours after the previous procedure (until discharge from the hospital) (2)
Code List
Death - every Deathcase independent from cause
CL Item
no (0)
CL Item
yes, until 36 hours after the previous procedure (1)
CL Item
yes, more than 36 hours after the previous procedure (until discharge from the hospital) (2)
Lag der Patient in der Herzchirurgie oder wurde er elektiv dorthin verlegt/überwiesen?
Item
Did the patient stay at heart surgery or has he/she been transferred there for elective purposes ?
boolean
Entlassungsdatum Krankenhaus
Item
Hostpital discharge date (DD.MM.YYYY)
date
C2710998 (UMLS CUI-1)
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)
Entlassungsdiagnose(n) (stationär) ICD-10-GM
Item
Discharge diagnoses - ICD codes
integer
C0011900 (UMLS CUI-1)