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ID

12501

Descripción

DIVI-Protocol for documentation purposes of emergency medical response by emergency physicians (Version 5.1 2015) Deutsche interdisziplinaere Vereinigung fuer Intensiv und Notfallmedizin DIVI (German interdisciplinary association for intensive and emergeny medical care)

Palabras clave

  1. 24/11/15 24/11/15 -
Subido en

24 de noviembre de 2015

DOI

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Licencia

Creative Commons BY-NC 3.0

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    Emergency background: Emergency Physicians protocol DIVI

    Emergency background and medical history

    Emergency background
    Descripción

    Emergency background

    General condition before emergency
    Descripción

    General condition before emergency

    Tipo de datos

    text

    Alias
    UMLS CUI [1]
    C0424449
    first aid (layman)
    Descripción

    first aid (layman)

    Tipo de datos

    text

    Alias
    UMLS CUI [1]
    C0016143
    Emergency responder at the site
    Descripción

    Emergency responder at the site

    Tipo de datos

    boolean

    Alias
    UMLS CUI [1]
    C3178988
    Time of arrival of emergency responder (if applicable)
    Descripción

    Time of arrival of emergency responder

    Tipo de datos

    time

    Alias
    UMLS CUI [1]
    C1320531
    Please describe emergency situation
    Descripción

    Please describe emergency situation

    Tipo de datos

    text

    Alias
    UMLS CUI [1]
    C0013956
    Medical history
    Descripción

    Medical history

    Tipo de datos

    text

    Alias
    UMLS CUI [1]
    C0262926
    Prior medication
    Descripción

    Prior medication

    Tipo de datos

    text

    Alias
    UMLS CUI [1]
    C0013227
    Prior treatment
    Descripción

    Prior treatment

    Tipo de datos

    text

    Alias
    UMLS CUI [1]
    C1514463
    emergency preliminary evaluation
    Descripción

    emergency preliminary evaluation

    Tipo de datos

    text

    Alias
    UMLS CUI [1]
    C0199206
    Colonization with MRSA
    Descripción

    Colonization with MRSA

    Tipo de datos

    text

    Alias
    UMLS CUI [1]
    C0343401
    Neurological preliminary assessment
    Descripción

    Neurological preliminary assessment

    Time of neurological assessment
    Descripción

    Time of neurological assessment

    Tipo de datos

    time

    Alias
    UMLS CUI [1,1]
    C0040223
    UMLS CUI [1,2]
    C0027853
    Normal assessment finding
    Descripción

    normal assessment finding

    Tipo de datos

    boolean

    Alias
    UMLS CUI [1]
    C1873497
    GCS Eye opening
    Descripción

    GCS best response

    Tipo de datos

    integer

    Alias
    UMLS CUI [1]
    C0806221
    GCS best verbal response
    Descripción

    best verbal response

    Tipo de datos

    integer

    Alias
    UMLS CUI [1]
    C0559291
    Best motor response
    Descripción

    Best motor response

    Tipo de datos

    integer

    Alias
    UMLS CUI [1]
    C3648958
    best motor response left arm
    Descripción

    best motor response left arm

    Tipo de datos

    integer

    Alias
    UMLS CUI [1]
    C3648958
    best motor response left leg
    Descripción

    best motor response left leg

    Tipo de datos

    integer

    Alias
    UMLS CUI [1]
    C3648958
    best motor response right arm
    Descripción

    best motor response right arm

    Tipo de datos

    integer

    Alias
    UMLS CUI [1]
    C3648958
    best motor response right leg
    Descripción

    best motor response right leg

    Tipo de datos

    integer

    Alias
    UMLS CUI [1]
    C3648958
    Glasgow coma score total
    Descripción

    to sum up the total of GCS only take the score of that extremity with best motor response.

    Tipo de datos

    integer

    Alias
    UMLS CUI [1]
    C0806223
    Use of Extremities,right arm
    Descripción

    Use of Extremities, right arm

    Tipo de datos

    text

    Alias
    UMLS CUI [1]
    C0015385
    Use of extremities,right leg
    Descripción

    Use of extremities, right leg

    Tipo de datos

    text

    Alias
    UMLS CUI [1]
    C0015385
    Use of extremities, left arm
    Descripción

    Use of extremities, left arm

    Tipo de datos

    text

    Alias
    UMLS CUI [1]
    C0015385
    Use of extremities, left leg
    Descripción

    Use of extremities, left leg

    Tipo de datos

    text

    Alias
    UMLS CUI [1]
    C0015385
    Awareness
    Descripción

    Awareness

    state of consciousness
    Descripción

    state of consciousness

    Tipo de datos

    text

    Alias
    UMLS CUI [1]
    C0517960
    Neurological Abnormality
    Descripción

    Neurological Abnormality

    Neurological examination findings
    Descripción

    Neurological examination findings

    Tipo de datos

    text

    Alias
    UMLS CUI [1]
    C0027853
    Size of right Pupil
    Descripción

    Size of right Pupil

    Tipo de datos

    text

    Alias
    UMLS CUI [1,1]
    C0517965
    UMLS CUI [1,2]
    C0205090
    Size of left Pupil
    Descripción

    Size of left Pupil

    Tipo de datos

    text

    Alias
    UMLS CUI [1,1]
    C0517965
    UMLS CUI [1,2]
    C0205091
    Pupil reaction to light (left)
    Descripción

    Pupil reaction to light (left)

    Tipo de datos

    text

    Alias
    UMLS CUI [1,1]
    C1287558
    UMLS CUI [1,2]
    C0205091
    Pupil reaction to light (right)
    Descripción

    Pupil reaction to light (right)

    Tipo de datos

    text

    Alias
    UMLS CUI [1,1]
    C1287558
    UMLS CUI [1,2]
    C0205090
    Initial vital signs
    Descripción

    Initial vital signs

    Have vital signs been taken?
    Descripción

    Vital signs

    Tipo de datos

    boolean

    Alias
    UMLS CUI [1]
    C0518766
    Pain scale
    Descripción

    Pain scale

    Tipo de datos

    text

    Alias
    UMLS CUI [1]
    C1504479
    Blood pressure (BP)
    Descripción

    Blood Pressure

    Tipo de datos

    integer

    Unidades de medida
    • mmHg
    Alias
    UMLS CUI [1]
    C0005823
    mmHg
    Heart rate (in bpm):
    Descripción

    Heart Rate

    Tipo de datos

    integer

    Unidades de medida
    • bpm
    Alias
    UMLS CUI [1]
    C0018810
    bpm
    Cardiac rhythm type
    Descripción

    Cardiac rhythm type

    Tipo de datos

    text

    Alias
    UMLS CUI [1]
    C0232187
    Blood Glucose
    Descripción

    Blood Glucose

    Tipo de datos

    float

    Alias
    UMLS CUI [1]
    C0202042
    Unit used for measuring blood glucose
    Descripción

    Unit used for measuring blood glucose

    Tipo de datos

    text

    Alias
    UMLS CUI [1]
    C0202042
    Respiratory Rate
    Descripción

    Respiratory rate

    Tipo de datos

    integer

    Unidades de medida
    • /min
    Alias
    UMLS CUI [1]
    C0231832
    /min
    Oxygen saturation
    Descripción

    OxygenSaturation

    Tipo de datos

    float

    Unidades de medida
    • SaO2
    Alias
    UMLS CUI [1]
    C0237753
    SaO2
    SaO2
    Descripción

    SaO2

    Tipo de datos

    text

    Alias
    UMLS CUI [1]
    C0523807
    Body Temperature
    Descripción

    Body Temperature

    Tipo de datos

    float

    Unidades de medida
    • °C
    Alias
    UMLS CUI [1]
    C0005903
    °C
    etCO2
    Descripción

    etCO2

    Tipo de datos

    float

    Alias
    UMLS CUI [1]
    C0428658
    ECG
    Descripción

    ECG

    Tipo de datos

    boolean

    Alias
    UMLS CUI [1]
    C1623258
    ECG findings
    Descripción

    ECG findings

    Tipo de datos

    text

    Alias
    UMLS CUI [1]
    C0438154
    Respiratory pattern
    Descripción

    Respiratory pattern

    Tipo de datos

    text

    Alias
    UMLS CUI [1]
    C0517967
    Skin status
    Descripción

    Skin status

    Tipo de datos

    text

    Alias
    UMLS CUI [1]
    C1123023
    psychiatric evaluation
    Descripción

    psychiatric evaluation

    Tipo de datos

    text

    Alias
    UMLS CUI [1]
    C0846574

    Similar models

    Emergency background and medical history

    Name
    Tipo
    Description | Question | Decode (Coded Value)
    Tipo de datos
    Alias
    Item Group
    Emergency background
    Item
    General condition before emergency
    text
    C0424449 (UMLS CUI [1])
    Code List
    General condition before emergency
    CL Item
    healthy (1)
    CL Item
    ill, not impaired (2)
    CL Item
    slightly impaired (3)
    CL Item
    severely impaired (4)
    CL Item
    life threatening illness (5)
    CL Item
    unknown (6)
    Item
    first aid (layman)
    text
    C0016143 (UMLS CUI [1])
    Code List
    first aid (layman)
    CL Item
    sufficient (1)
    CL Item
    insufficient (2)
    CL Item
    none (3)
    Emergency responder at the site
    Item
    Emergency responder at the site
    boolean
    C3178988 (UMLS CUI [1])
    Time of arrival of emergency responder
    Item
    Time of arrival of emergency responder (if applicable)
    time
    C1320531 (UMLS CUI [1])
    Please describe emergency situation
    Item
    Please describe emergency situation
    text
    C0013956 (UMLS CUI [1])
    Medical history
    Item
    Medical history
    text
    C0262926 (UMLS CUI [1])
    Prior medication
    Item
    Prior medication
    text
    C0013227 (UMLS CUI [1])
    Prior treatment
    Item
    Prior treatment
    text
    C1514463 (UMLS CUI [1])
    emergency preliminary evaluation
    Item
    emergency preliminary evaluation
    text
    C0199206 (UMLS CUI [1])
    Item
    Colonization with MRSA
    text
    C0343401 (UMLS CUI [1])
    Code List
    Colonization with MRSA
    CL Item
    yes (yes)
    CL Item
    no (no)
    CL Item
    open (1)
    CL Item
    covered (2)
    Item Group
    Neurological preliminary assessment
    Time of neurological assessment
    Item
    Time of neurological assessment
    time
    C0040223 (UMLS CUI [1,1])
    C0027853 (UMLS CUI [1,2])
    normal assessment finding
    Item
    Normal assessment finding
    boolean
    C1873497 (UMLS CUI [1])
    Item
    GCS Eye opening
    integer
    C0806221 (UMLS CUI [1])
    Code List
    GCS Eye opening
    CL Item
    spontaneously (4)
    CL Item
    on request (3)
    CL Item
    on pain stimulus (2)
    CL Item
    no reaction (1)
    Item
    GCS best verbal response
    integer
    C0559291 (UMLS CUI [1])
    Code List
    GCS best verbal response
    CL Item
    conversational oriented (5)
    CL Item
    conversational confused (4)
    CL Item
    inadequate utterance (3)
    CL Item
    incomprehensible sounds (2)
    CL Item
    no verbal response (1)
    Item
    Best motor response
    integer
    C3648958 (UMLS CUI [1])
    Code List
    Best motor response
    CL Item
    Obeys command (6)
    CL Item
    Localize to pain (5)
    CL Item
    Withdraws (4)
    CL Item
    Flexion to pain (3)
    CL Item
    Extension to pain (2)
    CL Item
    None (1)
    best motor response left arm
    Item
    best motor response left arm
    integer
    C3648958 (UMLS CUI [1])
    best motor response left leg
    Item
    best motor response left leg
    integer
    C3648958 (UMLS CUI [1])
    best motor response right arm
    Item
    best motor response right arm
    integer
    C3648958 (UMLS CUI [1])
    best motor response right leg
    Item
    best motor response right leg
    integer
    C3648958 (UMLS CUI [1])
    Glasgow coma score total
    Item
    Glasgow coma score total
    integer
    C0806223 (UMLS CUI [1])
    Item
    Use of Extremities,right arm
    text
    C0015385 (UMLS CUI [1])
    Code List
    Use of Extremities,right arm
    CL Item
    normal (1)
    CL Item
    slightly reduced movements (2)
    CL Item
    severely reduced movement (3)
    Item
    Use of extremities,right leg
    text
    C0015385 (UMLS CUI [1])
    Code List
    Use of extremities,right leg
    CL Item
    normal (1)
    CL Item
    slightly reduced movement (2)
    CL Item
    severely reduced movement (3)
    Item
    Use of extremities, left arm
    text
    C0015385 (UMLS CUI [1])
    Code List
    Use of extremities, left arm
    CL Item
    normal (1)
    CL Item
    slightly reduced movement (2)
    CL Item
    severely reduced movement (3)
    Item
    Use of extremities, left leg
    text
    C0015385 (UMLS CUI [1])
    Code List
    Use of extremities, left leg
    CL Item
    normal (1)
    CL Item
    slightly reduced movement (2)
    CL Item
    severely reduced movement (3)
    Item Group
    Awareness
    Item
    state of consciousness
    text
    C0517960 (UMLS CUI [1])
    Code List
    state of consciousness
    CL Item
    alert (1)
    CL Item
    sleepy (2)
    CL Item
    unconscious (3)
    CL Item
    response to verbal stimulus (4)
    CL Item
    response to pain stimulus (5)
    CL Item
    anesthetized (6)
    CL Item
    can not be assessed (7)
    Item Group
    Neurological Abnormality
    Item
    Neurological examination findings
    text
    C0027853 (UMLS CUI [1])
    Code List
    Neurological examination findings
    CL Item
    normal (0)
    CL Item
    can not be assessed (1)
    CL Item
    hemiplegic symptoms (2)
    CL Item
    no smiling (3)
    CL Item
    blurred vision (4)
    CL Item
    paraplegia (5)
    CL Item
    babinski sign positive (6)
    CL Item
    disturbance of speech (7)
    CL Item
    dementia (8)
    CL Item
    meningism (9)
    CL Item
    prior known neurological deficit (10)
    CL Item
    other (11)
    Item
    Size of right Pupil
    text
    C0517965 (UMLS CUI [1,1])
    C0205090 (UMLS CUI [1,2])
    Code List
    Size of right Pupil
    CL Item
    small (1)
    CL Item
    medium (2)
    CL Item
    large (3)
    CL Item
    irregular (4)
    Item
    Size of left Pupil
    text
    C0517965 (UMLS CUI [1,1])
    C0205091 (UMLS CUI [1,2])
    Code List
    Size of left Pupil
    CL Item
    small (1)
    CL Item
    medium (2)
    CL Item
    large (3)
    CL Item
    irregular (4)
    Item
    Pupil reaction to light (left)
    text
    C1287558 (UMLS CUI [1,1])
    C0205091 (UMLS CUI [1,2])
    Code List
    Pupil reaction to light (left)
    CL Item
    prompt (1)
    CL Item
    indolent (2)
    CL Item
    none (3)
    Item
    Pupil reaction to light (right)
    text
    C1287558 (UMLS CUI [1,1])
    C0205090 (UMLS CUI [1,2])
    Code List
    Pupil reaction to light (right)
    CL Item
    prompt (1)
    CL Item
    indolent (2)
    CL Item
    none (3)
    Item Group
    Initial vital signs
    Vital signs
    Item
    Have vital signs been taken?
    boolean
    C0518766 (UMLS CUI [1])
    Item
    Pain scale
    text
    C1504479 (UMLS CUI [1])
    Code List
    Pain scale
    CL Item
    0 no pain at all (0)
    CL Item
    1 (1)
    CL Item
    2 (2)
    CL Item
    3 (3)
    CL Item
    4 (4)
    CL Item
    5 (5)
    CL Item
    6 (6)
    CL Item
    7 (7)
    CL Item
    8 (8)
    CL Item
    9 (9)
    CL Item
    10 unbearable pain (10)
    Blood Pressure
    Item
    Blood pressure (BP)
    integer
    C0005823 (UMLS CUI [1])
    Heart Rate
    Item
    Heart rate (in bpm):
    integer
    C0018810 (UMLS CUI [1])
    Item
    Cardiac rhythm type
    text
    C0232187 (UMLS CUI [1])
    Code List
    Cardiac rhythm type
    CL Item
    rhythmical (1)
    CL Item
    arrhythmical (2)
    Blood Glucose
    Item
    Blood Glucose
    float
    C0202042 (UMLS CUI [1])
    Item
    Unit used for measuring blood glucose
    text
    C0202042 (UMLS CUI [1])
    Code List
    Unit used for measuring blood glucose
    CL Item
    mg/dl (1)
    CL Item
    mmol/l (2)
    Respiratory rate
    Item
    Respiratory Rate
    integer
    C0231832 (UMLS CUI [1])
    OxygenSaturation
    Item
    Oxygen saturation
    float
    C0237753 (UMLS CUI [1])
    Item
    SaO2
    text
    C0523807 (UMLS CUI [1])
    Code List
    SaO2
    CL Item
    at room air (1)
    CL Item
    with oxygen insufflation (2)
    Body Temperature
    Item
    Body Temperature
    float
    C0005903 (UMLS CUI [1])
    etCO2
    Item
    etCO2
    float
    C0428658 (UMLS CUI [1])
    ECG
    Item
    ECG
    boolean
    C1623258 (UMLS CUI [1])
    Item
    ECG findings
    text
    C0438154 (UMLS CUI [1])
    Code List
    ECG findings
    CL Item
    sinus rhthm (1)
    CL Item
    arrhythmia absoluta (2)
    CL Item
    AV-block II° (3)
    CL Item
    AV-block III° (4)
    CL Item
    pacemaker (5)
    CL Item
    artrial fibrillation (6)
    CL Item
    electro-mechanical dissociation (7)
    CL Item
    asystole (8)
    CL Item
    STEMI (9)
    CL Item
    small complex tachycardia (10)
    CL Item
    wide complex tachycardia (11)
    CL Item
    SVES/VES monomorph (12)
    CL Item
    VES polymorph (13)
    Item
    Respiratory pattern
    text
    C0517967 (UMLS CUI [1])
    Code List
    Respiratory pattern
    CL Item
    not examined (0)
    CL Item
    without pathological finding (1)
    CL Item
    Dyspnea (2)
    CL Item
    gasping (3)
    CL Item
    Apnea (4)
    CL Item
    artificial ventilation (5)
    CL Item
    other pathological breathing pattern (6)
    CL Item
    stridor (7)
    CL Item
    cyanosis (8)
    CL Item
    spasticity (9)
    CL Item
    hyperventilation (10)
    CL Item
    choking (11)
    CL Item
    rattling sound (12)
    Item
    Skin status
    text
    C1123023 (UMLS CUI [1])
    Code List
    Skin status
    CL Item
    not examined (0)
    CL Item
    normal (1)
    CL Item
    abnormal (2)
    CL Item
    dehydrated (standing skin fold) (3)
    CL Item
    bedsore (4)
    CL Item
    exanthema (5)
    CL Item
    edema (6)
    CL Item
    cold and clammy (7)
    Item
    psychiatric evaluation
    text
    C0846574 (UMLS CUI [1])
    Code List
    psychiatric evaluation
    CL Item
    not examined (0)
    CL Item
    without pathological finding (1)
    CL Item
    can not be assessed (2)
    CL Item
    delusional (3)
    CL Item
    agitated (4)
    CL Item
    depressed (5)
    CL Item
    confused (6)
    CL Item
    aggressiv (7)
    CL Item
    anxious (8)
    CL Item
    suicidal (9)
    CL Item
    retarded/stuporous (10)
    CL Item
    euphorical (11)
    CL Item
    motorical restless (12)

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