ID

15368

Beschrijving

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/

Trefwoorden

Versies (1)
  1. 28-05-16 28-05-16 -
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CC BY-NC 3.0

Geüploaded op

28 mei 2016

DOI

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Licentie

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

Duits Engels

Palliative and Hospice Care Emergency Form

1 Formulieren  
Patient information
Beschrijving

Patient information

Alias
UMLS CUI-1
C1955348
Name
Beschrijving

Name

Datatype

text

Alias
UMLS CUI [1]
C0027365
Date of birth
Beschrijving

Date of birth

Datatype

date

Alias
UMLS CUI [1]
C0421451
Address
Beschrijving

Address

Datatype

text

Alias
UMLS CUI [1]
C0421449
Diagnoses
Beschrijving

Diagnoses

Datatype

text

Alias
UMLS CUI [1]
C0011900
Current issues
Beschrijving

Current issues

Datatype

text

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

Peculiarities

Datatype

text

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

IMPORTANT contact persons / phone numbers

closest relative
Beschrijving

closest relative

Datatype

text

Alias
UMLS CUI [1]
C0080103
authorized person
Beschrijving

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

Datatype

boolean

name
Beschrijving

name

Datatype

text

Alias
UMLS CUI [1]
C0027365
date of birth
Beschrijving

date of birth

Datatype

text

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

address

Datatype

text

Alias
UMLS CUI [1]
C1442065
palliative team phone number
Beschrijving

palliative team phone number

Datatype

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
Beschrijving

general practitioner phone number

Datatype

integer

Alias
UMLS CUI [1,1]
C0017319
UMLS CUI [1,2]
C0237753
UMLS CUI [1,3]
C0039457
nursing care service phone number
Beschrijving

nursing care service phone number

Datatype

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
Beschrijving

association of shi physicians emergency service phone number

Datatype

integer

Alias
UMLS CUI [1,1]
C0013961
UMLS CUI [1,2]
C0237753
UMLS CUI [1,3]
C0039457
emergency physician
Beschrijving

emergency physician

Datatype

integer

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

pastoral care phone number

Datatype

integer

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

hospice phone number

Datatype

integer

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

Requested procedures

heart lung rescucitation requested
Beschrijving

heart lung rescucitation requested

Datatype

boolean

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

hospital admission requested

Datatype

boolean

Alias
UMLS CUI [1,1]
C0184666
UMLS CUI [1,2]
C1272683
information about the diagnosis/prognosis for the patient?
Beschrijving

information about the diagnosis/prognosis for the patient?

Datatype

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?
Beschrijving

information about the diagnosis/prognosis for the relatives?

Datatype

boolean

Alias
UMLS CUI [1,1]
C0011900
UMLS CUI [1,2]
C0033325
UMLS CUI [1,3]
C1533716
UMLS CUI [1,4]
C0080103
living will
Beschrijving

living will

Datatype

boolean

Alias
UMLS CUI [1]
C0023914
health care proxy
Beschrijving

health care proxy

Datatype

boolean

Alias
UMLS CUI [1]
C2029796
deposition of documents
Beschrijving

(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)

Datatype

text

Alias
UMLS CUI [1]
C1301746
date
Beschrijving

date

Datatype

date

Alias
UMLS CUI [1]
C0011008
name
Beschrijving

name

Datatype

text

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

patient/representative signature

Datatype

text

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

Further procedures

refusal of further procedures
Beschrijving

(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)

Datatype

text

Alias
UMLS CUI [1]
C0040809
last hospital stay
Beschrijving

last hospital stay

Datatype

text

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

hospital / facility

Datatype

text

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

date

Datatype

date

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

information provided by

Datatype

text

Alias
UMLS CUI [1,1]
C0031831
UMLS CUI [1,2]
C0027365
signature
Beschrijving

signature

Datatype

text

Alias
UMLS CUI [1]
C1519316
Terug naar het begin van de pagina

Similar models

Palliative and Hospice Care Emergency Form

1 Formulieren
Name
Type
Description | Question | Decode (Coded Value)
Datatype
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])
Terug naar het begin van de pagina 

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