ID

14968

Description

https://www.hope-clara.de/ The HOPE Hospice and Palliative Care Recording standard documentation is used for documentation of palliative care and as an instrument for quality assurance in pallatiave wards, hospices and oncological wards as well as in ambulatory services and palliative teams.

Link

https://www.hope-clara.de/

Keywords

Versions (1)
  1. 5/10/16 5/10/16 -
Copyright Holder

CC BY-NC 3.0

Uploaded on

May 10, 2016

DOI

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License

Creative Commons BY-NC 3.0
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Palliative and Hospice Care Thrombosis Prophylaxsis

German English

Palliative and Hospice Care Thrombose Prophylaxsis

1 forms  
Form Information
Description

Form Information

Form number
Description

Form number

Data type

integer

Alias
UMLS CUI [1]
C0237753
Staff member filling out the form
Description

Staff member filling out the form

Data type

integer

Alias
UMLS CUI [1,1]
C1552089
UMLS CUI [1,2]
C3273494
other staff
Description

other staff

Data type

text

Alias
UMLS CUI [1,1]
C0851286
UMLS CUI [1,2]
C0205394
doctor specialization
Description

doctor specialization

Data type

integer

Alias
UMLS CUI [1,1]
C0031831
UMLS CUI [1,2]
C0237888
other specialization
Description

other specialization

Data type

text

Alias
UMLS CUI [1,1]
C0031831
UMLS CUI [1,2]
C0237888
UMLS CUI [1,3]
C0205394
Medication
Description

Medication

Alias
UMLS CUI-1
C0013227
anticoagulant drug
Description

anticoagulant drug

Data type

integer

Alias
UMLS CUI [1]
C0003280
heparin low-molecular
Description

heparin low-molecular

Data type

integer

Alias
UMLS CUI [1]
C0019139
unfractionated heparin
Description

unfractionated heparin

Data type

integer

Alias
UMLS CUI [1]
C2825026
heparinoids, other thrombin inhibitors
Description

heparinoids, other thrombin inhibitors

Data type

integer

Alias
UMLS CUI [1,1]
C0019142
UMLS CUI [1,2]
C0003440
ASS
Description

ASS

Data type

integer

Alias
UMLS CUI [1]
C0004057
oral vitamin k antagonist (e.g. phenprocoumon / marcumar)
Description

oral vitamin k antagonist

Data type

boolean

Alias
UMLS CUI [1]
C1096489
laboratory frequency
Description

laboratory frequency

Data type

integer

Alias
UMLS CUI [1,1]
C0022885
UMLS CUI [1,2]
C0439603
other anticoagulants, please specify
Description

other anticoagulants

Data type

text

Alias
UMLS CUI [1,1]
C0003280
UMLS CUI [1,2]
C0205394
Indication
Description

Indication

Alias
UMLS CUI-1
C3146298
so far no thromboembolism, now thrombophilic risk factors and therefore primary prophylaxis
Description

primary prophylaxis due to risk factors

Data type

boolean

Alias
UMLS CUI [1,1]
C0040038
UMLS CUI [1,2]
C0035648
UMLS CUI [2]
C0199242
prior deep vein thrombosis, now continued secondary prophylaxis
Description

prior deep vein thrombosis

Data type

boolean

Alias
UMLS CUI [1,1]
C0149871
UMLS CUI [1,2]
C0332152
UMLS CUI [2]
C0199176
prior pulmonary embolism, now continued secondary prophylaxis
Description

prior lung artery embolism

Data type

boolean

Alias
UMLS CUI [1,1]
C0034065
UMLS CUI [1,2]
C0332152
UMLS CUI [2]
C0199176
current deep vein thrombosis, therefore new therapy
Description

current deep vein thrombosis, therefore new therapy

Data type

boolean

Alias
UMLS CUI [1,1]
C0149871
UMLS CUI [1,2]
C0521116
UMLS CUI [2]
C3242274
diagnostic procedure for deep vein thrombosis
Description

diagnostic procedure for deep vein thrombosis

Data type

integer

Alias
UMLS CUI [1,1]
C0430022
UMLS CUI [1,2]
C0149871
current pulmonary artery embolism therefore new therapy
Description

current pulmonary artery embolism therefore new therapy

Data type

boolean

Alias
UMLS CUI [1,1]
C0034065
UMLS CUI [1,2]
C0521116
UMLS CUI [2]
C3242274
diagnostic procedure for pulmonary embolism
Description

diagnostic procedure for pulmonary embolism

Data type

integer

Alias
UMLS CUI [1,1]
C0430022
UMLS CUI [1,2]
C0034065
arterial circulatory disorder
Description

arterial circulatory disorder

Data type

boolean

Alias
UMLS CUI [1,1]
C0728936
UMLS CUI [1,2]
C0221464
coronary heart disease
Description

coronary heart disease

Data type

boolean

Alias
UMLS CUI [1]
C0010068
peripheral arterial disease
Description

peripheral arterial disease

Data type

boolean

Alias
UMLS CUI [1]
C1704436
cerebrovascular disorder
Description

cerebrovascular disorder

Data type

boolean

Alias
UMLS CUI [1]
C0007820
other indication please specify
Description

other indication

Data type

text

Alias
UMLS CUI [1,1]
C3146298
UMLS CUI [1,2]
C0205394
Risk factors for thromboembolism
Description

Risk factors for thromboembolism

neoplastic disease / advanced internal disease
Description

neoplastic disease / advanced internal disease

Data type

boolean

Alias
UMLS CUI [1,1]
C1709160
UMLS CUI [1,2]
C0012634
UMLS CUI [2]
C0679246
medication increasing thromboembolic risk (e.g. current chemotherapy, hormone therapy)
Description

medication increasing thromboembolic risk

Data type

boolean

Alias
UMLS CUI [1,1]
C0013227
UMLS CUI [1,2]
C0040038
UMLS CUI [1,3]
C0035647
immobility (e.g. Karnofsky <40 / ECOG >3)
Description

immobility

Data type

boolean

Alias
UMLS CUI [1]
C0231441
paresis / plegia of one or more limb
Description

paresis / plegia of one or more limb

Data type

boolean

Alias
UMLS CUI [1]
C0030552
UMLS CUI [2]
C0522224
post surgery <30 days
Description

post surgery

Data type

boolean

Alias
UMLS CUI [1]
C0032790
port or other catheter system <30 days old
Description

port or other catheter system <30 days old

Data type

boolean

Alias
UMLS CUI [1]
C1608324
UMLS CUI [2]
C0085590
port or other catheter system >30 days old
Description

port or other catheter system >30 days old

Data type

boolean

Alias
UMLS CUI [1]
C1608324
UMLS CUI [2]
C0085590
other risk factors, please specify
Description

other risk factors

Data type

text

Alias
UMLS CUI [1,1]
C0035648
UMLS CUI [1,2]
C0205394
Standard procedures for palliative patients regarding anticoagulation
Description

Standard procedures for palliative patients regarding anticoagulation

are there written standards in your facility regarding anticoagulation?
Description

written standards regarding anticoagulation

Data type

integer

Alias
UMLS CUI [1,1]
C0449867
UMLS CUI [1,2]
C0237893
With what subjective success was anticoagulation performed?
Description

With what subjective success was anticoagulation performed?

no thromboembolism / no further thromboembolism
Description

no thromboembolism / no further thromboembolism

Data type

boolean

Alias
UMLS CUI [1]
C0040038
for current symptomatic thromboembolism
Description

current thromboembolism

Data type

integer

Alias
UMLS CUI [1,1]
C0040038
UMLS CUI [1,2]
C0521116
side effects
Description

side effects

Data type

boolean

Alias
UMLS CUI [1]
C0041755
what side effects?
Description

what side effects

Data type

text

Alias
UMLS CUI [1]
C0041755
no success (thromboembolic event despite prophylactic anticoagulation or worsening of pre-existing thromboembolism-associated conditions despite therapeutic anticoagulation)
Description

no success

Data type

boolean

Alias
UMLS CUI [1]
C1272703
was there a discontinuation of an anticoagulant drug during the documentation period?
Description

was there a discontinuation of an anticoagulant drug during the documentation period?

discontinuation of anticoagulant drug because of terminal stage
Description

discontinuation of anticoagulant drug because of terminal stage

Data type

boolean

Alias
UMLS CUI [1,1]
C0003280
UMLS CUI [1,2]
C0457454
UMLS CUI [2]
C0205088
discontinuation of anticoagulant drug because of new risk-benefit-analysis due to progress of disease
Description

discontinuation of anticoagulant drug because of new risk-benefit-analysis

Data type

boolean

Alias
UMLS CUI [1,1]
C0003280
UMLS CUI [1,2]
C0457454
UMLS CUI [2]
C0524785
discontinuation of anticoagulant drug because of increased risk of hemorrhage
Description

discontinuation of anticoagulant drug because of increased risk of hemorrhage

Data type

integer

Alias
UMLS CUI [1,1]
C0003280
UMLS CUI [1,2]
C0457454
UMLS CUI [2]
C3251812
platelets or quick value
Description

platelets or quick value

Data type

integer

Alias
UMLS CUI [1]
C0005821
UMLS CUI [2]
C0483455
discontinuation of anticoagulant drug because of hemorrhages (please specify the localization)
Description

discontinuation of anticoagulant drug because of hemorrhages (please specify the location)

Data type

boolean

Alias
UMLS CUI [1,1]
C0003280
UMLS CUI [1,2]
C0457454
UMLS CUI [2]
C0019080
hemorrhage localization
Description

hemorrhage localization

Data type

text

Alias
UMLS CUI [1,1]
C0019080
UMLS CUI [1,2]
C0475264
discontinuation of anticoagulant drug because of patient wish / refusal
Description

discontinuation of anticoagulant drug because of patient wish / refusal

Data type

boolean

Alias
UMLS CUI [1,1]
C0003280
UMLS CUI [1,2]
C0457454
UMLS CUI [2]
C0747309
discontinuation of anticoagulant drug because of other reasons (please specify)
Description

discontinuation of anticoagulant drug because of other reasons

Data type

text

Alias
UMLS CUI [1,1]
C0003280
UMLS CUI [1,2]
C0457454
UMLS CUI [2]
C3840932
no discontinuation of anticoagulant drug
Description

no discontinuation of anticoagulant drug

Data type

boolean

Alias
UMLS CUI [1,1]
C0003280
UMLS CUI [1,2]
C0457454
no anticoagulant applied
Description

no anticoagulant applied

Data type

boolean

Alias
UMLS CUI [1]
C0003280
comments
Description

comments

Data type

text

Alias
UMLS CUI [1]
C0947611
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Similar models

Palliative and Hospice Care Thrombose Prophylaxsis

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Form Information
Form number
Item
Form number
integer
C0237753 (UMLS CUI [1])
Item
Staff member filling out the form
integer
C1552089 (UMLS CUI [1,1])
C3273494 (UMLS CUI [1,2])
Staff member filling out the form
Code List
Staff member filling out the form
CL Item
doctor (1)
CL Item
nursing staff (2)
CL Item
other staff: (3)
other staff
Item
other staff
text
C0851286 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
Item
doctor specialization
integer
C0031831 (UMLS CUI [1,1])
C0237888 (UMLS CUI [1,2])
doctor specialization
Code List
doctor specialization
CL Item
anaesthesia (1)
CL Item
general internal medicine (2)
CL Item
hematology/oncology (3)
CL Item
other specialization (4)
other specialization
Item
other specialization
text
C0031831 (UMLS CUI [1,1])
C0237888 (UMLS CUI [1,2])
C0205394 (UMLS CUI [1,3])
Item Group
Medication
C0013227 (UMLS CUI-1)
Item
anticoagulant drug
integer
C0003280 (UMLS CUI [1])
anticoagulant drugs
Code List
anticoagulant drug
CL Item
none (1)
CL Item
continued (2)
CL Item
modified (3)
CL Item
newly applied (4)
CL Item
discontinued (5)
Item
heparin low-molecular
integer
C0019139 (UMLS CUI [1])
heparin low-molecular
Code List
heparin low-molecular
CL Item
prophylactic dosage (e.g. Enoxaparin 1x 40mg s.c.) (1)
CL Item
therapeutic dosage (e.g. Enoxaparin 2x 80 mg weight-adapted) (2)
Item
unfractionated heparin
integer
C2825026 (UMLS CUI [1])
unfractionized heparin
Code List
unfractionated heparin
CL Item
prophylactic dosage (e.g. Heparin 2x 7500 IE s.c.) (1)
CL Item
therapeutic dosage (perfusor, aPTT-adapted) (2)
Item
heparinoids, other thrombin inhibitors
integer
C0019142 (UMLS CUI [1,1])
C0003440 (UMLS CUI [1,2])
heparinoids, other thrombin inhibitors
Code List
heparinoids, other thrombin inhibitors
CL Item
prophylactic dosage (1)
CL Item
therapeutic dosage (2)
Item
ASS
integer
C0004057 (UMLS CUI [1])
ASS
Code List
ASS
CL Item
100 mg pills (1)
CL Item
300 mg pills (2)
oral vitamin k antagonist
Item
oral vitamin k antagonist (e.g. phenprocoumon / marcumar)
boolean
C1096489 (UMLS CUI [1])
Item
laboratory frequency
integer
C0022885 (UMLS CUI [1,1])
C0439603 (UMLS CUI [1,2])
laboratory frequency
Code List
laboratory frequency
CL Item
more than once per week (1)
CL Item
once per week or less (2)
other anticoagulants
Item
other anticoagulants, please specify
text
C0003280 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
Item Group
Indication
C3146298 (UMLS CUI-1)
primary prophylaxis due to risk factors
Item
so far no thromboembolism, now thrombophilic risk factors and therefore primary prophylaxis
boolean
C0040038 (UMLS CUI [1,1])
C0035648 (UMLS CUI [1,2])
C0199242 (UMLS CUI [2])
prior deep vein thrombosis
Item
prior deep vein thrombosis, now continued secondary prophylaxis
boolean
C0149871 (UMLS CUI [1,1])
C0332152 (UMLS CUI [1,2])
C0199176 (UMLS CUI [2])
prior lung artery embolism
Item
prior pulmonary embolism, now continued secondary prophylaxis
boolean
C0034065 (UMLS CUI [1,1])
C0332152 (UMLS CUI [1,2])
C0199176 (UMLS CUI [2])
current deep vein thrombosis, therefore new therapy
Item
current deep vein thrombosis, therefore new therapy
boolean
C0149871 (UMLS CUI [1,1])
C0521116 (UMLS CUI [1,2])
C3242274 (UMLS CUI [2])
Item
diagnostic procedure for deep vein thrombosis
integer
C0430022 (UMLS CUI [1,1])
C0149871 (UMLS CUI [1,2])
diagnostic procedure for deep vein thrombosis
Code List
diagnostic procedure for deep vein thrombosis
CL Item
duplex ultrasound (1)
CL Item
display via venous contrast medium (2)
CL Item
computer tomography (3)
CL Item
suspected diagnosis due to clinical criteria (4)
current pulmonary artery embolism therefore new therapy
Item
current pulmonary artery embolism therefore new therapy
boolean
C0034065 (UMLS CUI [1,1])
C0521116 (UMLS CUI [1,2])
C3242274 (UMLS CUI [2])
Item
diagnostic procedure for pulmonary embolism
integer
C0430022 (UMLS CUI [1,1])
C0034065 (UMLS CUI [1,2])
diagnostic procedure for pulmonary embolism
Code List
diagnostic procedure for pulmonary embolism
CL Item
computer tomography (1)
CL Item
V/Q radio imaging (2)
CL Item
angiography of arteria pulmonalis (3)
CL Item
suspected diagnosis due to clinical criteria (4)
arterial circulatory disorder
Item
arterial circulatory disorder
boolean
C0728936 (UMLS CUI [1,1])
C0221464 (UMLS CUI [1,2])
coronary heart disease
Item
coronary heart disease
boolean
C0010068 (UMLS CUI [1])
peripheral arterial disease
Item
peripheral arterial disease
boolean
C1704436 (UMLS CUI [1])
cerebrovascular disorder
Item
cerebrovascular disorder
boolean
C0007820 (UMLS CUI [1])
other indication
Item
other indication please specify
text
C3146298 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
Item Group
Risk factors for thromboembolism
neoplastic disease / advanced internal disease
Item
neoplastic disease / advanced internal disease
boolean
C1709160 (UMLS CUI [1,1])
C0012634 (UMLS CUI [1,2])
C0679246 (UMLS CUI [2])
medication increasing thromboembolic risk
Item
medication increasing thromboembolic risk (e.g. current chemotherapy, hormone therapy)
boolean
C0013227 (UMLS CUI [1,1])
C0040038 (UMLS CUI [1,2])
C0035647 (UMLS CUI [1,3])
immobility
Item
immobility (e.g. Karnofsky <40 / ECOG >3)
boolean
C0231441 (UMLS CUI [1])
paresis / plegia of one or more limb
Item
paresis / plegia of one or more limb
boolean
C0030552 (UMLS CUI [1])
C0522224 (UMLS CUI [2])
post surgery
Item
post surgery <30 days
boolean
C0032790 (UMLS CUI [1])
port or other catheter system <30 days old
Item
port or other catheter system <30 days old
boolean
C1608324 (UMLS CUI [1])
C0085590 (UMLS CUI [2])
port or other catheter system >30 days old
Item
port or other catheter system >30 days old
boolean
C1608324 (UMLS CUI [1])
C0085590 (UMLS CUI [2])
other risk factors
Item
other risk factors, please specify
text
C0035648 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
Item Group
Standard procedures for palliative patients regarding anticoagulation
Item
are there written standards in your facility regarding anticoagulation?
integer
C0449867 (UMLS CUI [1,1])
C0237893 (UMLS CUI [1,2])
written standards regarding anticoagulation
Code List
are there written standards in your facility regarding anticoagulation?
CL Item
yes (1)
CL Item
no (2)
CL Item
unknown (3)
Item Group
With what subjective success was anticoagulation performed?
no thromboembolism / no further thromboembolism
Item
no thromboembolism / no further thromboembolism
boolean
C0040038 (UMLS CUI [1])
Item
for current symptomatic thromboembolism
integer
C0040038 (UMLS CUI [1,1])
C0521116 (UMLS CUI [1,2])
current thromboembolism
Code List
for current symptomatic thromboembolism
CL Item
detumescence of possible bulge (1)
CL Item
contribution to reduction of pain (2)
CL Item
contribution to treatment of dyspnea (3)
side effects
Item
side effects
boolean
C0041755 (UMLS CUI [1])
what side effects
Item
what side effects?
text
C0041755 (UMLS CUI [1])
no success
Item
no success (thromboembolic event despite prophylactic anticoagulation or worsening of pre-existing thromboembolism-associated conditions despite therapeutic anticoagulation)
boolean
C1272703 (UMLS CUI [1])
Item Group
was there a discontinuation of an anticoagulant drug during the documentation period?
discontinuation of anticoagulant drug because of terminal stage
Item
discontinuation of anticoagulant drug because of terminal stage
boolean
C0003280 (UMLS CUI [1,1])
C0457454 (UMLS CUI [1,2])
C0205088 (UMLS CUI [2])
discontinuation of anticoagulant drug because of new risk-benefit-analysis
Item
discontinuation of anticoagulant drug because of new risk-benefit-analysis due to progress of disease
boolean
C0003280 (UMLS CUI [1,1])
C0457454 (UMLS CUI [1,2])
C0524785 (UMLS CUI [2])
Item
discontinuation of anticoagulant drug because of increased risk of hemorrhage
integer
C0003280 (UMLS CUI [1,1])
C0457454 (UMLS CUI [1,2])
C3251812 (UMLS CUI [2])
discontinuation of anticoagulant drug because of increased risk of hemorrhage
Code List
discontinuation of anticoagulant drug because of increased risk of hemorrhage
CL Item
thrombocytopenia (please enter the value in the following item) (1)
CL Item
hepatic failure (please enter the Quick value in the following item) (2)
CL Item
exulcerating tumor (3)
platelets or quick value
Item
platelets or quick value
integer
C0005821 (UMLS CUI [1])
C0483455 (UMLS CUI [2])
discontinuation of anticoagulant drug because of hemorrhages (please specify the location)
Item
discontinuation of anticoagulant drug because of hemorrhages (please specify the localization)
boolean
C0003280 (UMLS CUI [1,1])
C0457454 (UMLS CUI [1,2])
C0019080 (UMLS CUI [2])
hemorrhage localization
Item
hemorrhage localization
text
C0019080 (UMLS CUI [1,1])
C0475264 (UMLS CUI [1,2])
discontinuation of anticoagulant drug because of patient wish / refusal
Item
discontinuation of anticoagulant drug because of patient wish / refusal
boolean
C0003280 (UMLS CUI [1,1])
C0457454 (UMLS CUI [1,2])
C0747309 (UMLS CUI [2])
discontinuation of anticoagulant drug because of other reasons
Item
discontinuation of anticoagulant drug because of other reasons (please specify)
text
C0003280 (UMLS CUI [1,1])
C0457454 (UMLS CUI [1,2])
C3840932 (UMLS CUI [2])
no discontinuation of anticoagulant drug
Item
no discontinuation of anticoagulant drug
boolean
C0003280 (UMLS CUI [1,1])
C0457454 (UMLS CUI [1,2])
no anticoagulant applied
Item
no anticoagulant applied
boolean
C0003280 (UMLS CUI [1])
comments
Item
comments
text
C0947611 (UMLS CUI [1])
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