ID

15686

Description

Routine documentation in German hospitals. Source file name: VL160105_Pflegebericht/ Pflegebericht.107 and Pflegebericht.108 Examplary forms provided by DMI (http://www.dmi.de/)

Link

http://www.dmi.de/

Keywords

Versions (1)
  1. 6/8/16 6/8/16 -
Uploaded on

June 8, 2016

DOI

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License

Creative Commons BY-NC 3.0
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Proof of execution Nursing report Routine documentation in German hospitals DMI

German

Proof of execution Nursing report

1 forms  
Patienteninformation
Description

Patienteninformation

Alias
UMLS CUI-1
C1955348
Vorname
Description

Patient first name

Data type

text

Alias
UMLS CUI [1]
C1443235
Nachname des Patienten
Description

Patient Last Name

Data type

text

Alias
UMLS CUI [1]
C0421448
Körperpflege
Description

Körperpflege

Alias
UMLS CUI-1
C0036592
Datum/ Zeit
Description

Date and time

Data type

datetime

Alias
UMLS CUI [1]
C1264639
Selbstständig
Description

Independent for personal grooming

Data type

boolean

Alias
UMLS CUI [1]
C0429950
Hilfe bei überwiegend selbstständiger Körperpflege
Description

Independent for personal grooming

Data type

boolean

Alias
UMLS CUI [1]
C0429950
Stellen d. Wasch.Sch+ Waschutens + Nachb.
Description

washing

Data type

boolean

Mithilfe beim Waschen
Description

wash oneself

Data type

text

Alias
UMLS CUI [1]
C0441648
Hilfe beim
Description

bathing

Data type

text

Alias
UMLS CUI [1]
C0150141
Teilkörperpflege mit
Description

Body care

Data type

text

Alias
UMLS CUI [1]
C0036592
Hilfe bei Mundhygiene
Description

oral hygiene

Data type

boolean

Alias
UMLS CUI [1]
C0029164
Übernahme der Körperpflege
Description

Body care

Data type

boolean

Alias
UMLS CUI [1]
C0036592
Ganzwaschung
Description

Bathing

Data type

text

Alias
UMLS CUI [1]
C0150141
Ganzkörperpflege mit
Description

Body care

Data type

text

Alias
UMLS CUI [1]
C0036592
Mundhygiene mit
Description

oral hygiene

Data type

text

Alias
UMLS CUI [1]
C0029164
Gesichtrasur
Description

shaving face

Data type

boolean

Alias
UMLS CUI [1]
C2136539
Augenpflege mit
Description

eye care

Data type

text

Alias
UMLS CUI [1]
C0885957
Ernährung
Description

Ernährung

Alias
UMLS CUI-1
C0600072
Datum/ Zeit
Description

Date and time

Data type

datetime

Alias
UMLS CUI [1]
C1264639
Selbständig
Description

Independent feeding

Data type

boolean

Alias
UMLS CUI [1]
C0429947
Nahrungsaufbereitung
Description

Food preparation

Data type

boolean

Alias
UMLS CUI [1]
C0920297
Sondenernährung Dauertropf
Description

Tube feeding of patient

Data type

boolean

Alias
UMLS CUI [1]
C0041281
Sondenernährung portioniert
Description

Tube feeding of patient

Data type

boolean

Alias
UMLS CUI [1]
C0041281
Hilfe bei Nahrungsaufnahme
Description

food intake

Data type

boolean

Alias
UMLS CUI [1]
C0086311
Ausscheidung
Description

Ausscheidung

Alias
UMLS CUI-1
C0504085
Datum/ Zeit
Description

Date and time

Data type

datetime

Alias
UMLS CUI [1]
C1264639
Selbständig
Description

Independent in toilet

Data type

boolean

Alias
UMLS CUI [1]
C0429975
Ünterstützung zur kontrollierten Blasenentleerung
Description

urination

Data type

boolean

Alias
UMLS CUI [1]
C0042034
Begleitung zum WC
Description

Toilet dependency

Data type

boolean

Alias
UMLS CUI [1]
C0429972
Unterstützung zur kontrollierten Darmentleerung
Description

defecation

Data type

boolean

Alias
UMLS CUI [1]
C0011135
Entleeren von Katheterbeuteln
Description

Emptying catheter bag

Data type

boolean

Alias
UMLS CUI [1]
C0455031
Wechseln von Stomabeutel
Description

Colostomy bag changed

Data type

boolean

Alias
UMLS CUI [1]
C0438289
Versorgen bei häufigem Erbrechen
Description

Vomiting

Data type

boolean

Alias
UMLS CUI [1]
C0042963
Versorgen bei unkontrollierter Blasenentleerung
Description

urination

Data type

boolean

Alias
UMLS CUI [1]
C0042034
Versorgen bei unkontrollierter Blasenentleerung
Description

defecation

Data type

boolean

Alias
UMLS CUI [1]
C0011135
Bewegung und Lagerung
Description

Bewegung und Lagerung

Alias
UMLS CUI-1
C0026649
UMLS CUI-2
C1561964
Datum/ Zeit
Description

Date and time

Data type

datetime

Alias
UMLS CUI [1]
C1264639
Selbständig
Description

Independent walking

Data type

boolean

Alias
UMLS CUI [1]
C0429979
Hilfe beim Aufstehen
Description

Standing up

Data type

boolean

Alias
UMLS CUI [1]
C0444796
Hilfe beim Gehen
Description

walking

Data type

boolean

Alias
UMLS CUI [1]
C0080331
Einfaches Lagerung
Description

Positioning

Data type

boolean

Alias
UMLS CUI [1]
C1561964
Mobilisieren
Description

mobilise

Data type

boolean

Alias
UMLS CUI [1]
C0578131
Pneumonieprophylaxe
Description

prophylaxis pneumonia

Data type

boolean

Alias
UMLS CUI [1,1]
C0199176
UMLS CUI [1,2]
C0032285
Thromboseprophylaxe
Description

prophylaxis Thrombosis

Data type

boolean

Alias
UMLS CUI [1,1]
C0199176
UMLS CUI [1,2]
C0040053
Antithrombosestrümpfe Gr.
Description

antithrombosis stockings

Data type

text

Dekubitusprophylaxe
Description

prophylaxis decubitus

Data type

boolean

Alias
UMLS CUI [1,1]
C0199176
UMLS CUI [1,2]
C0011127
Häufiges Körperlagern (2-4 stündlich)
Description

positioning

Data type

boolean

Alias
UMLS CUI [1]
C1561964
Intensives Mobilisieren
Description

mobilise

Data type

boolean

Alias
UMLS CUI [1]
C0578131
Lagerung in Zusammenhang mit: OP, Invasiven Maßnahmen, akuten Krankheitsphasen
Description

Lagerung in Zusammenhang mit: OP, Invasiven Maßnahmen, akuten Krankheitsphasen

Alias
UMLS CUI-1
C0150305
Leistungen in Zusammenhang mit: OP- Invasiven Maßnahmen- akuten Krankheitsphasen
Description

Clinical Services Surgery Disease phases

Data type

boolean

Alias
UMLS CUI [1,1]
C1704289
UMLS CUI [1,2]
C0543467
UMLS CUI [1,3]
C0457338
RR, Puls & Temp. Kontrolle
Description

Blood pressure; pulse; Body Temperature

Data type

boolean

Alias
UMLS CUI [1]
C0005823
UMLS CUI [2]
C0034107
UMLS CUI [3]
C0005903
Beobachten des Patienten und Vitalzeichenkontrolle von mindestens zwei Parametern, 4-6 mal innerhalb 8 Std
Description

vital signs

Data type

boolean

Alias
UMLS CUI [1]
C0518766
Spontanurin
Description

urine

Data type

boolean

Alias
UMLS CUI [1]
C0042036
Nachblutungskontrolle
Description

After bleeding

Data type

boolean

Alias
UMLS CUI [1]
C3552928
Aufwendiges Versorgen von Ableitungs- u. Absaugsystem
Description

drainage system

Data type

boolean

Blasenkatheter
Description

urinary catheter

Data type

text

Alias
UMLS CUI [1]
C0042019