German English

Palliative and Hospice Care Emergency Form

1 forms  
Informationen über den Patienten
Description

Informationen über den Patienten

Alias
UMLS CUI-1
C1955348
Name
Description

Name

Data type

text

Alias
UMLS CUI [1]
C0027365
Geburtsdatum
Description

Date of birth

Data type

date

Alias
UMLS CUI [1]
C0421451
Adresse
Description

Address

Data type

text

Alias
UMLS CUI [1]
C0421449
Diagnosen
Description

Diagnoses

Data type

text

Alias
UMLS CUI [1]
C0011900
Aktuelle Probleme
Description

Current issues

Data type

text

Alias
UMLS CUI [1,1]
C0033213
UMLS CUI [1,2]
C0521116
Besonderheiten
Description

Peculiarities

Data type

text

Alias
UMLS CUI [1]
C1704258
WICHTIGE Kontaktpersonen / Telefonnummern
Description

WICHTIGE Kontaktpersonen / Telefonnummern

Nächster Angehöriger
Description

closest relative

Data type

text

Alias
UMLS CUI [1]
C0080103
Bevollmächtigter:
Description

authorized person

Data type

boolean

Name
Description

name

Data type

text

Alias
UMLS CUI [1]
C0027365
Geburtsdatum
Description

date of birth

Data type

text

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C0027361
UMLS CUI [1,3]
C0005615
Adresse
Description

address

Data type

text

Alias
UMLS CUI [1]
C1442065
Palliativteam Telefonnummer
Description

palliative team phone number

Data type

integer

Alias
UMLS CUI [1,1]
C0030231
UMLS CUI [1,2]
C0086390
UMLS CUI [1,3]
C0237753
UMLS CUI [1,4]
C0039457
Hausarzt Telefonnummer
Description

general practitioner phone number

Data type

integer

Alias
UMLS CUI [1,1]
C0017319
UMLS CUI [1,2]
C0237753
UMLS CUI [1,3]
C0039457
Pflegedienst Telefonnummer
Description

nursing care service phone number

Data type

integer

Alias
UMLS CUI [1,1]
C0019855
UMLS CUI [1,2]
C0237753
UMLS CUI [1,3]
C0039457
Kassenärztl. Notdienst Telefonnummer
Description

association of shi physicians emergency service phone number

Data type

integer

Alias
UMLS CUI [1,1]
C0013961
UMLS CUI [1,2]
C0237753
UMLS CUI [1,3]
C0039457
Notarzt Telefonnummer
Description

emergency physician

Data type

integer

Alias
UMLS CUI [1]
C2065341
Seelsorge Telefonnummer
Description

pastoral care phone number

Data type

integer

Alias
UMLS CUI [1,1]
C0030643
UMLS CUI [1,2]
C0237753
UMLS CUI [1,3]
C0039457
Hospiz Telefonnummer
Description

hospice phone number

Data type

integer

Alias
UMLS CUI [1,1]
C0085555
UMLS CUI [1,2]
C0237753
UMLS CUI [1,3]
C0039457
Erwünschte Maßnahmen
Description

Erwünschte Maßnahmen

Herz-Lungen-Wiederbelebung gewünscht?
Description

heart lung rescucitation requested

Data type

boolean

Alias
UMLS CUI [1,1]
C0035273
UMLS CUI [1,2]
C1272683
Krankenhauseinweisung gewünscht?
Description

hospital admission requested

Data type

boolean

Alias
UMLS CUI [1,1]
C0184666
UMLS CUI [1,2]
C1272683
Aufklärung des Patienten über Prognose/Diagnose?
Description

information about the diagnosis/prognosis for the patient?

Data type

boolean

Alias
UMLS CUI [1,1]
C0011900
UMLS CUI [1,2]
C0033325
UMLS CUI [1,3]
C1533716
UMLS CUI [1,4]
C0030705
Aufklärung der Angehörigen über Prognose/Diagnose?
Description

information about the diagnosis/prognosis for the relatives?

Data type

boolean

Alias
UMLS CUI [1,1]
C0011900
UMLS CUI [1,2]
C0033325
UMLS CUI [1,3]
C1533716
UMLS CUI [1,4]
C0080103
Patientenverfügung:
Description

living will

Data type

boolean

Alias
UMLS CUI [1]
C0023914
Vorsorgevollmacht:
Description

health care proxy

Data type

boolean

Alias
UMLS CUI [1]
C2029796
Hinterlegung der Dokumente
Description

(Aktualisierungen siehe Rückseite, der Notfallbogen entspricht der gültigen Gesetzgebung zu Patientenverfügungen §1901a Abs. 1-5 BGB)

Data type

text

Alias
UMLS CUI [1]
C1301746
Datum
Description

date

Data type

date

Alias
UMLS CUI [1]
C0011008
Name
Description

name

Data type

text

Alias
UMLS CUI [1]
C0027365
Unterschrift Patient/Bevollmächtigter
Description

patient/representative signature

Data type

text

Alias
UMLS CUI [1,1]
C1519316
UMLS CUI [1,2]
C0030705
UMLS CUI [1,3]
C0030701
Weitere Maßnahmen
Description

Weitere Maßnahmen

Ablehnung weiterer Maßnahmen
Description

(mögliche Konsequenzen, die sich aus der Ablehnung medizinischer Maßnahmen ergeben, wurden dem Patienten erläutert; die volle Einsichts- und Einwilligungsfähigkeit des Patienten lag zum Zeitpunkt der Erstellung vor)

Data type

text

Alias
UMLS CUI [1]
C0040809
Letzter Klinikaufenthalt:
Description

last hospital stay

Data type

text

Alias
UMLS CUI [1,1]
C3489408
UMLS CUI [1,2]
C1517741
Klinik/Einrichtung:
Description

hospital / facility

Data type

text

Alias
UMLS CUI [1]
C0019994
UMLS CUI [2]
C0018704
Datum
Description

date

Data type

date

Alias
UMLS CUI [1]
C0011008
Name des Arztes
Description

Aufklärung bei Erstellung des Bogens durch:

Data type

text

Alias
UMLS CUI [1,1]
C0031831
UMLS CUI [1,2]
C0027365
Unterschrift
Description

signature

Data type

text

Alias
UMLS CUI [1]
C1519316
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Similar models

Palliative and Hospice Care Emergency Form

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Informationen über den Patienten
C1955348 (UMLS CUI-1)
Name
Item
Name
text
C0027365 (UMLS CUI [1])
Date of birth
Item
Geburtsdatum
date
C0421451 (UMLS CUI [1])
Address
Item
Adresse
text
C0421449 (UMLS CUI [1])
Diagnoses
Item
Diagnosen
text
C0011900 (UMLS CUI [1])
Current issues
Item
Aktuelle Probleme
text
C0033213 (UMLS CUI [1,1])
C0521116 (UMLS CUI [1,2])
Peculiarities
Item
Besonderheiten
text
C1704258 (UMLS CUI [1])
Item Group
WICHTIGE Kontaktpersonen / Telefonnummern
closest relative
Item
Nächster Angehöriger
text
C0080103 (UMLS CUI [1])
authorized person
Item
Bevollmächtigter:
boolean
name
Item
Name
text
C0027365 (UMLS CUI [1])
date of birth
Item
Geburtsdatum
text
C0011008 (UMLS CUI [1,1])
C0027361 (UMLS CUI [1,2])
C0005615 (UMLS CUI [1,3])
address
Item
Adresse
text
C1442065 (UMLS CUI [1])
palliative team phone number
Item
Palliativteam Telefonnummer
integer
C0030231 (UMLS CUI [1,1])
C0086390 (UMLS CUI [1,2])
C0237753 (UMLS CUI [1,3])
C0039457 (UMLS CUI [1,4])
general practitioner phone number
Item
Hausarzt Telefonnummer
integer
C0017319 (UMLS CUI [1,1])
C0237753 (UMLS CUI [1,2])
C0039457 (UMLS CUI [1,3])
nursing care service phone number
Item
Pflegedienst Telefonnummer
integer
C0019855 (UMLS CUI [1,1])
C0237753 (UMLS CUI [1,2])
C0039457 (UMLS CUI [1,3])
association of shi physicians emergency service phone number
Item
Kassenärztl. Notdienst Telefonnummer
integer
C0013961 (UMLS CUI [1,1])
C0237753 (UMLS CUI [1,2])
C0039457 (UMLS CUI [1,3])
Item
Notarzt Telefonnummer
integer
C2065341 (UMLS CUI [1])
emergency physician
Code List
Notarzt Telefonnummer
CL Item
112 (1)
pastoral care phone number
Item
Seelsorge Telefonnummer
integer
C0030643 (UMLS CUI [1,1])
C0237753 (UMLS CUI [1,2])
C0039457 (UMLS CUI [1,3])
hospice phone number
Item
Hospiz Telefonnummer
integer
C0085555 (UMLS CUI [1,1])
C0237753 (UMLS CUI [1,2])
C0039457 (UMLS CUI [1,3])
Item Group
Erwünschte Maßnahmen
heart lung rescucitation requested
Item
Herz-Lungen-Wiederbelebung gewünscht?
boolean
C0035273 (UMLS CUI [1,1])
C1272683 (UMLS CUI [1,2])
hospital admission requested
Item
Krankenhauseinweisung gewünscht?
boolean
C0184666 (UMLS CUI [1,1])
C1272683 (UMLS CUI [1,2])
information about the diagnosis/prognosis for the patient?
Item
Aufklärung des Patienten über Prognose/Diagnose?
boolean
C0011900 (UMLS CUI [1,1])
C0033325 (UMLS CUI [1,2])
C1533716 (UMLS CUI [1,3])
C0030705 (UMLS CUI [1,4])
information about the diagnosis/prognosis for the relatives?
Item
Aufklärung der Angehörigen über Prognose/Diagnose?
boolean
C0011900 (UMLS CUI [1,1])
C0033325 (UMLS CUI [1,2])
C1533716 (UMLS CUI [1,3])
C0080103 (UMLS CUI [1,4])
living will
Item
Patientenverfügung:
boolean
C0023914 (UMLS CUI [1])
health care proxy
Item
Vorsorgevollmacht:
boolean
C2029796 (UMLS CUI [1])
deposition of documents
Item
Hinterlegung der Dokumente
text
C1301746 (UMLS CUI [1])
date
Item
Datum
date
C0011008 (UMLS CUI [1])
name
Item
Name
text
C0027365 (UMLS CUI [1])
patient/representative signature
Item
Unterschrift Patient/Bevollmächtigter
text
C1519316 (UMLS CUI [1,1])
C0030705 (UMLS CUI [1,2])
C0030701 (UMLS CUI [1,3])
Item Group
Weitere Maßnahmen
refusal of further procedures
Item
Ablehnung weiterer Maßnahmen
text
C0040809 (UMLS CUI [1])
last hospital stay
Item
Letzter Klinikaufenthalt:
text
C3489408 (UMLS CUI [1,1])
C1517741 (UMLS CUI [1,2])
hospital / facility
Item
Klinik/Einrichtung:
text
C0019994 (UMLS CUI [1])
C0018704 (UMLS CUI [2])
date
Item
Datum
date
C0011008 (UMLS CUI [1])
doctor name
Item
Name des Arztes
text
C0031831 (UMLS CUI [1,1])
C0027365 (UMLS CUI [1,2])
signature
Item
Unterschrift
text
C1519316 (UMLS CUI [1])
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