ID

12501

Description

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)

Keywords

Versions (1)
  1. 11/24/15 11/24/15 -
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November 24, 2015

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Creative Commons BY-NC 3.0
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Emergency background: Emergency Physicians protocol DIVI

English

Emergency background and medical history

1 forms  
Emergency background
Description

Emergency background

General condition before emergency
Description

General condition before emergency

Data type

text

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

first aid (layman)

Data type

text

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

Emergency responder at the site

Data type

boolean

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

Time of arrival of emergency responder

Data type

time

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

Please describe emergency situation

Data type

text

Alias
UMLS CUI [1]
C0013956
Medical history
Description

Medical history

Data type

text

Alias
UMLS CUI [1]
C0262926
Prior medication
Description

Prior medication

Data type

text

Alias
UMLS CUI [1]
C0013227
Prior treatment
Description

Prior treatment

Data type

text

Alias
UMLS CUI [1]
C1514463
emergency preliminary evaluation
Description

emergency preliminary evaluation

Data type

text

Alias
UMLS CUI [1]
C0199206
Colonization with MRSA
Description

Colonization with MRSA

Data type

text

Alias
UMLS CUI [1]
C0343401
Neurological preliminary assessment
Description

Neurological preliminary assessment

Time of neurological assessment
Description

Time of neurological assessment

Data type

time

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

normal assessment finding

Data type

boolean

Alias
UMLS CUI [1]
C1873497
GCS Eye opening
Description

GCS best response

Data type

integer

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

best verbal response

Data type

integer

Alias
UMLS CUI [1]
C0559291
Best motor response
Description

Best motor response

Data type

integer

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

best motor response left arm

Data type

integer

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

best motor response left leg

Data type

integer

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

best motor response right arm

Data type

integer

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

best motor response right leg

Data type

integer

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

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

Data type

integer

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

Use of Extremities, right arm

Data type

text

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

Use of extremities, right leg

Data type

text

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

Use of extremities, left arm

Data type

text

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

Use of extremities, left leg

Data type

text

Alias
UMLS CUI [1]
C0015385
Awareness
Description

Awareness

state of consciousness
Description

state of consciousness

Data type

text

Alias
UMLS CUI [1]
C0517960
Neurological Abnormality
Description

Neurological Abnormality

Neurological examination findings
Description

Neurological examination findings

Data type

text

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

Size of right Pupil

Data type

text

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

Size of left Pupil

Data type

text

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

Pupil reaction to light (left)

Data type

text

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

Pupil reaction to light (right)

Data type

text

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

Initial vital signs

Have vital signs been taken?
Description

Vital signs

Data type

boolean

Alias
UMLS CUI [1]
C0518766
Pain scale
Description

Pain scale

Data type

text

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

Blood Pressure

Data type

integer

Measurement units
  • mmHg
Alias
UMLS CUI [1]
C0005823
mmHg
Heart rate (in bpm):
Description

Heart Rate

Data type

integer

Measurement units
  • bpm
Alias
UMLS CUI [1]
C0018810
bpm
Cardiac rhythm type
Description

Cardiac rhythm type

Data type

text

Alias
UMLS CUI [1]
C0232187
Blood Glucose
Description

Blood Glucose

Data type

float

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

Unit used for measuring blood glucose

Data type

text

Alias
UMLS CUI [1]
C0202042
Respiratory Rate
Description

Respiratory rate

Data type

integer

Measurement units
  • /min
Alias
UMLS CUI [1]
C0231832
/min
Oxygen saturation
Description

OxygenSaturation

Data type

float

Measurement units
  • SaO2
Alias
UMLS CUI [1]
C0237753
SaO2
SaO2
Description

SaO2

Data type

text

Alias
UMLS CUI [1]
C0523807
Body Temperature
Description

Body Temperature

Data type

float

Measurement units
  • °C
Alias
UMLS CUI [1]
C0005903
°C
etCO2
Description

etCO2

Data type

float

Alias
UMLS CUI [1]
C0428658
ECG
Description

ECG

Data type

boolean

Alias
UMLS CUI [1]
C1623258
ECG findings
Description

ECG findings

Data type

text

Alias
UMLS CUI [1]
C0438154
Respiratory pattern
Description

Respiratory pattern

Data type

text

Alias
UMLS CUI [1]
C0517967
Skin status
Description

Skin status

Data type

text

Alias
UMLS CUI [1]
C1123023
psychiatric evaluation
Description

psychiatric evaluation

Data type

text

Alias
UMLS CUI [1]
C0846574
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Similar models

Emergency background and medical history

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Emergency background
Item
General condition before emergency
text
C0424449 (UMLS CUI [1])
General condition before emergency
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])
first aid (layman)
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])
Colonization with MRSA
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])
GCS Eye opening
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])
GCS best verbal response
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])
BEST MOTOR RESPONSE
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])
Use of Extremities, right arm
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])
Use of extremities, right leg
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])
Use of extremities, left arm
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])
Use of extremities, left leg
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])
state of consciousness
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])
Neurological examination findings
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])
Size of right Pupil
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])
Size of left Pupil
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])
Pupil reaction to light left
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])
Pupil reaction to light right eye
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])
Pain scale
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])
Cardiac rhythm type
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])
Unit used for measuring blood glucose
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])
SaO2
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])
ECG findings
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])
Respiratory pattern
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])
Skin status
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])
psychiatric evaluation
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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