German English

Palliative and Hospice Care Emergency Form

1 forms  
Patient information
Description

Patient information

Alias
UMLS CUI-1
C1955348
Name
Description

Name

Data type

text

Alias
UMLS CUI [1]
C0027365
Date of birth
Description

Date of birth

Data type

date

Alias
UMLS CUI [1]
C0421451
Address
Description

Address

Data type

text

Alias
UMLS CUI [1]
C0421449
Diagnoses
Description

Diagnoses

Data type

text

Alias
UMLS CUI [1]
C0011900
Current issues
Description

Current issues

Data type

text

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

Peculiarities

Data type

text

Alias
UMLS CUI [1]
C1704258
IMPORTANT contact persons / phone numbers
Description

IMPORTANT contact persons / phone numbers

closest relative
Description

closest relative

Data type

text

Alias
UMLS CUI [1]
C0080103
authorized person
Description

this authorized person has been appointed to implement my will that is determined in this instruction according to §1896 passage 2 BGB)

Data type

boolean

name
Description

name

Data type

text

Alias
UMLS CUI [1]
C0027365
date of birth
Description

date of birth

Data type

text

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

address

Data type

text

Alias
UMLS CUI [1]
C1442065
palliative team phone number
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
general practitioner phone number
Description

general practitioner phone number

Data type

integer

Alias
UMLS CUI [1,1]
C0017319
UMLS CUI [1,2]
C0237753
UMLS CUI [1,3]
C0039457
nursing care service phone number
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
association of shi physicians emergency service phone number
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
emergency physician
Description

emergency physician

Data type

integer

Alias
UMLS CUI [1]
C2065341
pastoral care phone number
Description

pastoral care phone number

Data type

integer

Alias
UMLS CUI [1,1]
C0030643
UMLS CUI [1,2]
C0237753
UMLS CUI [1,3]
C0039457
hospice phone number
Description

hospice phone number

Data type

integer

Alias
UMLS CUI [1,1]
C0085555
UMLS CUI [1,2]
C0237753
UMLS CUI [1,3]
C0039457
Requested procedures
Description

Requested procedures

heart lung rescucitation requested
Description

heart lung rescucitation requested

Data type

boolean

Alias
UMLS CUI [1,1]
C0035273
UMLS CUI [1,2]
C1272683
hospital admission requested
Description

hospital admission requested

Data type

boolean

Alias
UMLS CUI [1,1]
C0184666
UMLS CUI [1,2]
C1272683
information about the diagnosis/prognosis for the patient?
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
information about the diagnosis/prognosis for the relatives?
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
living will
Description

living will

Data type

boolean

Alias
UMLS CUI [1]
C0023914
health care proxy
Description

health care proxy

Data type

boolean

Alias
UMLS CUI [1]
C2029796
deposition of documents
Description

(for updates please see the back of the page; this emergency form accords to the existing law regarding living wills §1901a passage 1-5 BGB)

Data type

text

Alias
UMLS CUI [1]
C1301746
date
Description

date

Data type

date

Alias
UMLS CUI [1]
C0011008
name
Description

name

Data type

text

Alias
UMLS CUI [1]
C0027365
patient/representative signature
Description

patient/representative signature

Data type

text

Alias
UMLS CUI [1,1]
C1519316
UMLS CUI [1,2]
C0030705
UMLS CUI [1,3]
C0030701
Further procedures
Description

Further procedures

refusal of further procedures
Description

(Possible consequences that result from refusing medical procedures were explained to the patient; during the issue of this document the patient was fully capable of understanding and agreeing)

Data type

text

Alias
UMLS CUI [1]
C0040809
last hospital stay
Description

last hospital stay

Data type

text

Alias
UMLS CUI [1,1]
C3489408
UMLS CUI [1,2]
C1517741
hospital / facility
Description

hospital / facility

Data type

text

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

date

Data type

date

Alias
UMLS CUI [1]
C0011008
doctor's name
Description

information provided by

Data type

text

Alias
UMLS CUI [1,1]
C0031831
UMLS CUI [1,2]
C0027365
signature
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
Patient information
C1955348 (UMLS CUI-1)
Name
Item
Name
text
C0027365 (UMLS CUI [1])
Date of birth
Item
Date of birth
date
C0421451 (UMLS CUI [1])
Address
Item
Address
text
C0421449 (UMLS CUI [1])
Diagnoses
Item
Diagnoses
text
C0011900 (UMLS CUI [1])
Current issues
Item
Current issues
text
C0033213 (UMLS CUI [1,1])
C0521116 (UMLS CUI [1,2])
Peculiarities
Item
Peculiarities
text
C1704258 (UMLS CUI [1])
Item Group
IMPORTANT contact persons / phone numbers
closest relative
Item
closest relative
text
C0080103 (UMLS CUI [1])
authorized person
Item
authorized person
boolean
name
Item
name
text
C0027365 (UMLS CUI [1])
date of birth
Item
date of birth
text
C0011008 (UMLS CUI [1,1])
C0027361 (UMLS CUI [1,2])
C0005615 (UMLS CUI [1,3])
address
Item
address
text
C1442065 (UMLS CUI [1])
palliative team phone number
Item
palliative team phone number
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
general practitioner phone number
integer
C0017319 (UMLS CUI [1,1])
C0237753 (UMLS CUI [1,2])
C0039457 (UMLS CUI [1,3])
nursing care service phone number
Item
nursing care service phone number
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
association of shi physicians emergency service phone number
integer
C0013961 (UMLS CUI [1,1])
C0237753 (UMLS CUI [1,2])
C0039457 (UMLS CUI [1,3])
Item
emergency physician
integer
C2065341 (UMLS CUI [1])
emergency physician
Code List
emergency physician
CL Item
112 (1)
pastoral care phone number
Item
pastoral care phone number
integer
C0030643 (UMLS CUI [1,1])
C0237753 (UMLS CUI [1,2])
C0039457 (UMLS CUI [1,3])
hospice phone number
Item
hospice phone number
integer
C0085555 (UMLS CUI [1,1])
C0237753 (UMLS CUI [1,2])
C0039457 (UMLS CUI [1,3])
Item Group
Requested procedures
heart lung rescucitation requested
Item
heart lung rescucitation requested
boolean
C0035273 (UMLS CUI [1,1])
C1272683 (UMLS CUI [1,2])
hospital admission requested
Item
hospital admission requested
boolean
C0184666 (UMLS CUI [1,1])
C1272683 (UMLS CUI [1,2])
information about the diagnosis/prognosis for the patient?
Item
information about the diagnosis/prognosis for the patient?
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
information about the diagnosis/prognosis for the relatives?
boolean
C0011900 (UMLS CUI [1,1])
C0033325 (UMLS CUI [1,2])
C1533716 (UMLS CUI [1,3])
C0080103 (UMLS CUI [1,4])
living will
Item
living will
boolean
C0023914 (UMLS CUI [1])
health care proxy
Item
health care proxy
boolean
C2029796 (UMLS CUI [1])
deposition of documents
Item
deposition of documents
text
C1301746 (UMLS CUI [1])
date
Item
date
date
C0011008 (UMLS CUI [1])
name
Item
name
text
C0027365 (UMLS CUI [1])
patient/representative signature
Item
patient/representative signature
text
C1519316 (UMLS CUI [1,1])
C0030705 (UMLS CUI [1,2])
C0030701 (UMLS CUI [1,3])
Item Group
Further procedures
refusal of further procedures
Item
refusal of further procedures
text
C0040809 (UMLS CUI [1])
last hospital stay
Item
last hospital stay
text
C3489408 (UMLS CUI [1,1])
C1517741 (UMLS CUI [1,2])
hospital / facility
Item
hospital / facility
text
C0019994 (UMLS CUI [1])
C0018704 (UMLS CUI [2])
date
Item
date
date
C0011008 (UMLS CUI [1])
doctor name
Item
doctor's name
text
C0031831 (UMLS CUI [1,1])
C0027365 (UMLS CUI [1,2])
signature
Item
signature
text
C1519316 (UMLS CUI [1])
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