ID

15211

Description

Routine documentation in German hospitals. Source file name: AM170105_Qualitätssicherungsbogen/ Qualitätssicherung.021 Examplary forms provided by DMI (http://www.dmi.de/)

Link

http://www.dmi.de/

Keywords

  1. 5/22/16 5/22/16 -
Uploaded on

May 22, 2016

DOI

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License

Creative Commons BY-NC 3.0

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Quality assurance gall bladders and bile duct diseases Quality assurance sheet Routine documentation in German hospitals DMI

Quality assurance gall bladders and bile duct diseases Quality assurance sheet

Medical history
Description

Medical history

Alias
UMLS CUI-1
C0262926
Anamnesis
Description

medical history

Data type

text

Alias
UMLS CUI [1]
C0262926
Colics
Description

colics

Data type

boolean

Alias
UMLS CUI [1]
C0232488
Pain in the right upper abdomen
Description

abdominal pain

Data type

boolean

Alias
UMLS CUI [1]
C0000737
Cholestasis
Description

cholestasis

Data type

boolean

Alias
UMLS CUI [1]
C0008370
Diagnostic
Description

Diagnostic

Alias
UMLS CUI-1
C0086143
Gallstone detection confirmed?
Description

Gallstones

Data type

boolean

Alias
UMLS CUI [1]
C0008350
When yes, confirmed through
Description

specify

Data type

text

X- ray
Description

X- ray

Data type

boolean

Alias
UMLS CUI [1]
C0034571
Ultrasonography
Description

Ultrasonography

Data type

boolean

Alias
UMLS CUI [1]
C0041618
MRCP
Description

Cholangiopancreatography, Magnetic Resonance MRCP

Data type

boolean

Alias
UMLS CUI [1]
C0994163
CT
Description

CT

Data type

boolean

Alias
UMLS CUI [1]
C0040405
ERCP
Description

ERCP Endoscopic Retrograde Cholangiopancreatography

Data type

boolean

Alias
UMLS CUI [1]
C0008310
If ERCP was performed, Biliary Stone Extraction?
Description

Biliary Stone Extraction

Data type

boolean

Alias
UMLS CUI [1]
C1548824
Other
Description

Other

Data type

boolean

Alias
UMLS CUI [1]
C0205394
Acute inflammation
Description

Acute inflammation

Alias
UMLS CUI-1
C0333361
Acute inflammation
Description

Acute inflammation

Data type

boolean

Alias
UMLS CUI [1]
C0333361
If yes, confirmed through:
Description

Specify

Data type

text

Clinical findings
Description

clinical findings

Data type

boolean

Alias
UMLS CUI [1]
C0037088
Leukocytes > 12000 cells/ mm^2
Description

Leukocytes

Data type

boolean

Alias
UMLS CUI [1]
C0023508
CRP
Description

CRP

Data type

boolean

Alias
UMLS CUI [1]
C0201657
Body temperature (> 38° rectal)
Description

Body temperature

Data type

boolean

Alias
UMLS CUI [1]
C0005903
Ultrasonography
Description

Ultrasonography

Data type

boolean

Alias
UMLS CUI [1]
C0041618
Extrahepatic cholestasis
Description

Extrahepatic cholestasis

Alias
UMLS CUI-1
C0005398
Extrahepatic cholestasis
Description

Extrahepatic cholestasis

Data type

boolean

Alias
UMLS CUI [1]
C0005398
Confirmed through x- ray
Description

x- ray

Data type

boolean

Alias
UMLS CUI [1]
C0034571
Confirmed through ultrasonography?
Description

ultrasonography

Data type

boolean

Alias
UMLS CUI [1]
C0041618
Confirmed through ERCP?
Description

ERCP

Data type

boolean

Alias
UMLS CUI [1]
C0008310
Confirmed through MRCP?
Description

MRCP

Data type

boolean

Alias
UMLS CUI [1]
C0994163
Confirmed through CT?
Description

CT

Data type

boolean

Alias
UMLS CUI [1]
C0040405
Other
Description

Other

Data type

boolean

Alias
UMLS CUI [1]
C0205394
Information for quality assurance completely collected?
Description

Documentation

Data type

boolean

Alias
UMLS CUI [1]
C0920316
Date of documentaion
Description

date documentaion

Data type

date

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C0920316

Similar models

Quality assurance gall bladders and bile duct diseases Quality assurance sheet

Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Medical history
C0262926 (UMLS CUI-1)
medical history
Item
Anamnesis
text
C0262926 (UMLS CUI [1])
colics
Item
Colics
boolean
C0232488 (UMLS CUI [1])
abdominal pain
Item
Pain in the right upper abdomen
boolean
C0000737 (UMLS CUI [1])
cholestasis
Item
Cholestasis
boolean
C0008370 (UMLS CUI [1])
Item Group
Diagnostic
C0086143 (UMLS CUI-1)
Gallstones
Item
Gallstone detection confirmed?
boolean
C0008350 (UMLS CUI [1])
specify
Item
When yes, confirmed through
text
X- ray
Item
X- ray
boolean
C0034571 (UMLS CUI [1])
Ultrasonography
Item
Ultrasonography
boolean
C0041618 (UMLS CUI [1])
Cholangiopancreatography, Magnetic Resonance MRCP
Item
MRCP
boolean
C0994163 (UMLS CUI [1])
CT
Item
CT
boolean
C0040405 (UMLS CUI [1])
ERCP Endoscopic Retrograde Cholangiopancreatography
Item
ERCP
boolean
C0008310 (UMLS CUI [1])
Biliary Stone Extraction
Item
If ERCP was performed, Biliary Stone Extraction?
boolean
C1548824 (UMLS CUI [1])
Other
Item
Other
boolean
C0205394 (UMLS CUI [1])
Item Group
Acute inflammation
C0333361 (UMLS CUI-1)
Acute inflammation
Item
Acute inflammation
boolean
C0333361 (UMLS CUI [1])
Specify
Item
If yes, confirmed through:
text
clinical findings
Item
Clinical findings
boolean
C0037088 (UMLS CUI [1])
Leukocytes
Item
Leukocytes > 12000 cells/ mm^2
boolean
C0023508 (UMLS CUI [1])
CRP
Item
CRP
boolean
C0201657 (UMLS CUI [1])
Body temperature
Item
Body temperature (> 38° rectal)
boolean
C0005903 (UMLS CUI [1])
Ultrasonography
Item
Ultrasonography
boolean
C0041618 (UMLS CUI [1])
Item Group
Extrahepatic cholestasis
C0005398 (UMLS CUI-1)
Extrahepatic cholestasis
Item
Extrahepatic cholestasis
boolean
C0005398 (UMLS CUI [1])
x- ray
Item
Confirmed through x- ray
boolean
C0034571 (UMLS CUI [1])
ultrasonography
Item
Confirmed through ultrasonography?
boolean
C0041618 (UMLS CUI [1])
ERCP
Item
Confirmed through ERCP?
boolean
C0008310 (UMLS CUI [1])
MRCP
Item
Confirmed through MRCP?
boolean
C0994163 (UMLS CUI [1])
CT
Item
Confirmed through CT?
boolean
C0040405 (UMLS CUI [1])
Other
Item
Other
boolean
C0205394 (UMLS CUI [1])
Documentation
Item
Information for quality assurance completely collected?
boolean
C0920316 (UMLS CUI [1])
date documentaion
Item
Date of documentaion
date
C0011008 (UMLS CUI [1,1])
C0920316 (UMLS CUI [1,2])

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