ID

15368

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. 5/28/16 5/28/16 -
Copyright Holder

CC BY-NC 3.0

Uploaded on

May 28, 2016

DOI

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License

Creative Commons BY-NC 3.0
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Palliative and Hospice Care Emergency Form

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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