ID

15793

Beschrijving

Report/Protocol collecting patient and treatment information like the circumstances of the accident and initial ER treatment. Documentation in traum room. ODM derived from EHR form: MS Schockraumprotokoll 2 by University Hospital Muenster http://klinikum.uni-muenster.de/

Link

http://klinikum.uni-muenster.de/

Trefwoorden

  1. 13-06-16 13-06-16 -
Geüploaded op

13 juni 2016

DOI

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Licentie

Creative Commons BY-NC 3.0

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Preclinical Point A in Time: Trauma Protocol UKM

Preclinical Point A in Time: Emergency Room Report UKM

General Information
Beschrijving

General Information

Alarm
Beschrijving

Time of Alarm

Datatype

time

Alias
UMLS CUI [1]
C0040223
Eintreffen des Notarztes im SR
Beschrijving

Arrival of A&E doctor in ER

Datatype

time

Alias
UMLS CUI [1,1]
C0583237
UMLS CUI [1,2]
C0040223
Abfahrt vom Unfallort
Beschrijving

time of departure

Datatype

time

Alias
UMLS CUI [1]
C2735126
Transport mode to hospital
Beschrijving

Transport mode to hospital

Datatype

integer

Leitstelle
Beschrijving

Control center

Datatype

text

Fax Notarzt
Beschrijving

fax AE doctor

Datatype

text

Alias
UMLS CUI [1,1]
C1549619
UMLS CUI [1,2]
C0586803
Brief an Notarzt
Beschrijving

medical report to A&E doctor

Datatype

boolean

Alias
UMLS CUI [1,1]
C0451617
UMLS CUI [1,2]
C0586803
NACA-Index
Beschrijving

NACA-Score

Datatype

integer

Alias
UMLS CUI [1,1]
C0449820
UMLS CUI [1,2]
C3263723
UMLS CUI [1,3]
C0012634
UMLS CUI [1,4]
C0032343
Vitalparameter am Unfallort
Beschrijving

Vitalparameter am Unfallort

Alias
UMLS CUI-1
C0518766
RRsys
Beschrijving

Blood pressure systolic

Datatype

integer

Maateenheden
  • mmHg
Alias
UMLS CUI [1]
C0871470
mmHg
Herzfrequenz
Beschrijving

Heart rate

Datatype

integer

Maateenheden
  • bpm
Alias
UMLS CUI [1]
C0018810
bpm
Atemfrequenz
Beschrijving

respiratory rate

Datatype

integer

Maateenheden
  • /minute
Alias
UMLS CUI [1]
C0231832
/minute
SpO2
Beschrijving

SpO2

Datatype

integer

Maateenheden
  • %
Alias
UMLS CUI [1]
C0428179
%
GCS Score
Beschrijving

GCS Score

Datatype

integer

Alias
UMLS CUI [1]
C1271007
Pupillengröße rechts
Beschrijving

Size of right pupil

Datatype

integer

Alias
UMLS CUI [1,1]
C0517965
UMLS CUI [1,2]
C0444532
Pupillengröße links
Beschrijving

Size of left pupil

Datatype

integer

Alias
UMLS CUI [1,1]
C0517965
UMLS CUI [1,2]
C0443246
Lichtreaktion rechts
Beschrijving

right pupil reaction to light

Datatype

integer

Alias
UMLS CUI [1,1]
C0234671
UMLS CUI [1,2]
C0444532
Lichtreaktion left
Beschrijving

left pupil reaction to light

Datatype

integer

Alias
UMLS CUI [1,1]
C0234671
UMLS CUI [1,2]
C0443246
Therapie
Beschrijving

Therapie

Alias
UMLS CUI-1
C0087111
Kristalloide
Beschrijving

Administration of electrolytes

Datatype

integer

Maateenheden
  • ml
Alias
UMLS CUI [1]
C0199796
ml
Kolloide
Beschrijving

Administration of colloids

Datatype

integer

Maateenheden
  • ml
Alias
UMLS CUI [1]
C3267204
ml
Hyperonk./Hyperosm. Lösung
Beschrijving

hyperosmolar infusion

Datatype

integer

Maateenheden
  • ml
Alias
UMLS CUI [1,1]
C0259752
UMLS CUI [1,2]
C0087111
ml
Alternative Atemwegssicherung
Beschrijving

Intubation

Datatype

boolean

Alias
UMLS CUI [1]
C0021925
Analgosedierung
Beschrijving

Analgosedation

Datatype

boolean

Alias
UMLS CUI [1,1]
C0344106
UMLS CUI [1,2]
C0002766
Herzdruckmassage
Beschrijving

Resuscitation

Datatype

boolean

Alias
UMLS CUI [1]
C0007203
Katecholamine
Beschrijving

Catecholamine therapy

Datatype

boolean

Alias
UMLS CUI [1]
C0007412
Cervikalstütze
Beschrijving

External cervical fixation device

Datatype

boolean

Alias
UMLS CUI [1,1]
C0079321
UMLS CUI [1,2]
C0238943
Thoraxdrainage
Beschrijving

chest tube

Datatype

boolean

Alias
UMLS CUI [1]
C0008034
Peripherer Zugang Anzahl
Beschrijving

peripheral venous catheter

Datatype

integer

Alias
UMLS CUI [1]
C2985513
Zentral Zugang Anzahl
Beschrijving

central catheter

Datatype

integer

Alias
UMLS CUI [1]
C1145640
Kapnometrie
Beschrijving

capnography

Datatype

boolean

Alias
UMLS CUI [1]
C0376529
Beckengurt
Beschrijving

Lap belt

Datatype

boolean

Alias
UMLS CUI [1]
C0553557
Injuries
Beschrijving

Injuries

Alias
UMLS CUI-1
C3263723
SHT
Beschrijving

craniocerebral trauma

Datatype

integer

Alias
UMLS CUI [1]
C0018674
Gesicht
Beschrijving

facial injury

Datatype

integer

Alias
UMLS CUI [1]
C0015459
Thorax
Beschrijving

thoracic injury

Datatype

integer

Alias
UMLS CUI [1]
C0039980
Abdomen
Beschrijving

abdominal injury

Datatype

integer

Alias
UMLS CUI [1]
C0848377
Wirbelsäule
Beschrijving

injury of spine

Datatype

integer

Alias
UMLS CUI [1]
C0037937
Becken
Beschrijving

injury of pelvis

Datatype

integer

Alias
UMLS CUI [1]
C0560636
Obere Extr.
Beschrijving

injury of upper limb

Datatype

integer

Alias
UMLS CUI [1]
C0003794
Untere Extr.
Beschrijving

injuries of lower limb

Datatype

integer

Alias
UMLS CUI [1]
C0023220
Weichteile
Beschrijving

injury of soft tissue

Datatype

integer

Alias
UMLS CUI [1]
C0037578

Similar models

Preclinical Point A in Time: Emergency Room Report UKM

Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Time of Alarm
Item
Alarm
time
C0040223 (UMLS CUI [1])
Arrival of A&E doctor in ER
Item
Eintreffen des Notarztes im SR
time
C0583237 (UMLS CUI [1,1])
C0040223 (UMLS CUI [1,2])
time of departure
Item
Abfahrt vom Unfallort
time
C2735126 (UMLS CUI [1])
Item
Transport mode to hospital
integer
Code List
Transport mode to hospital
CL Item
RTH (1)
CL Item
NAW/NEF (2)
CL Item
RTW (3)
CL Item
selbst/privat (4)
Control center
Item
Leitstelle
text
fax AE doctor
Item
Fax Notarzt
text
C1549619 (UMLS CUI [1,1])
C0586803 (UMLS CUI [1,2])
medical report to A&E doctor
Item
Brief an Notarzt
boolean
C0451617 (UMLS CUI [1,1])
C0586803 (UMLS CUI [1,2])
NACA-Score
Item
NACA-Index
integer
C0449820 (UMLS CUI [1,1])
C3263723 (UMLS CUI [1,2])
C0012634 (UMLS CUI [1,3])
C0032343 (UMLS CUI [1,4])
Item Group
Vitalparameter am Unfallort
C0518766 (UMLS CUI-1)
Blood pressure systolic
Item
RRsys
integer
C0871470 (UMLS CUI [1])
Heart rate
Item
Herzfrequenz
integer
C0018810 (UMLS CUI [1])
respiratory rate
Item
Atemfrequenz
integer
C0231832 (UMLS CUI [1])
SpO2
Item
SpO2
integer
C0428179 (UMLS CUI [1])
GCS Score
Item
integer
C1271007 (UMLS CUI [1])
Item
Pupillengröße rechts
integer
C0517965 (UMLS CUI [1,1])
C0444532 (UMLS CUI [1,2])
Code List
Pupillengröße rechts
CL Item
eng (1)
CL Item
mittel (2)
CL Item
weit (3)
CL Item
nicht feststellbar (4)
Item
Pupillengröße links
integer
C0517965 (UMLS CUI [1,1])
C0443246 (UMLS CUI [1,2])
Code List
Pupillengröße links
CL Item
eng (1)
CL Item
mittel (2)
CL Item
weit (3)
CL Item
nicht feststellbar (4)
Item
Lichtreaktion rechts
integer
C0234671 (UMLS CUI [1,1])
C0444532 (UMLS CUI [1,2])
Code List
Lichtreaktion rechts
CL Item
prompt (1)
CL Item
träge (2)
CL Item
keine (3)
CL Item
nicht feststellbar (4)
Item
Lichtreaktion left
integer
C0234671 (UMLS CUI [1,1])
C0443246 (UMLS CUI [1,2])
Code List
Lichtreaktion left
CL Item
prompt (1)
CL Item
träge (2)
CL Item
keine (3)
CL Item
nicht feststellbar (4)
Item Group
Therapie
C0087111 (UMLS CUI-1)
Administration of electrolytes
Item
Kristalloide
integer
C0199796 (UMLS CUI [1])
Administration of colloids
Item
Kolloide
integer
C3267204 (UMLS CUI [1])
hyperosmolar infusion
Item
Hyperonk./Hyperosm. Lösung
integer
C0259752 (UMLS CUI [1,1])
C0087111 (UMLS CUI [1,2])
Intubation
Item
Alternative Atemwegssicherung
boolean
C0021925 (UMLS CUI [1])
Analgosedation
Item
Analgosedierung
boolean
C0344106 (UMLS CUI [1,1])
C0002766 (UMLS CUI [1,2])
Resuscitation
Item
Herzdruckmassage
boolean
C0007203 (UMLS CUI [1])
Catecholamine therapy
Item
Katecholamine
boolean
C0007412 (UMLS CUI [1])
External cervical fixation device
Item
Cervikalstütze
boolean
C0079321 (UMLS CUI [1,1])
C0238943 (UMLS CUI [1,2])
chest tube
Item
Thoraxdrainage
boolean
C0008034 (UMLS CUI [1])
peripheral venous catheter
Item
Peripherer Zugang Anzahl
integer
C2985513 (UMLS CUI [1])
central catheter
Item
Zentral Zugang Anzahl
integer
C1145640 (UMLS CUI [1])
capnography
Item
Kapnometrie
boolean
C0376529 (UMLS CUI [1])
Lap belt
Item
Beckengurt
boolean
C0553557 (UMLS CUI [1])
Item Group
C3263723 (UMLS CUI-1)
Item
SHT
integer
C0018674 (UMLS CUI [1])
CL Item
keine (1)
CL Item
leicht  (2)
CL Item
mittel (3)
CL Item
schwer (4)
Item
Gesicht
integer
C0015459 (UMLS CUI [1])
Code List
Gesicht
CL Item
keine (1)
CL Item
leicht  (2)
CL Item
mittel (3)
CL Item
schwer (4)
Item
Thorax
integer
C0039980 (UMLS CUI [1])
Code List
Thorax
CL Item
keine (1)
CL Item
leicht  (2)
CL Item
mittel (3)
CL Item
schwer (4)
Item
Abdomen
integer
C0848377 (UMLS CUI [1])
Code List
Abdomen
CL Item
keine (1)
CL Item
leicht  (2)
CL Item
mittel (3)
CL Item
schwer (4)
Item
Wirbelsäule
integer
C0037937 (UMLS CUI [1])
Code List
Wirbelsäule
CL Item
keine (1)
CL Item
leicht  (2)
CL Item
mittel (3)
CL Item
schwer (4)
Item
Becken
integer
C0560636 (UMLS CUI [1])
Code List
Becken
CL Item
keine (1)
CL Item
leicht  (2)
CL Item
mittel (3)
CL Item
schwer (4)
Item
Obere Extr.
integer
C0003794 (UMLS CUI [1])
Code List
Obere Extr.
CL Item
keine (1)
CL Item
leicht  (2)
CL Item
mittel (3)
CL Item
schwer (4)
Item
Untere Extr.
integer
C0023220 (UMLS CUI [1])
Code List
Untere Extr.
CL Item
keine (1)
CL Item
leicht  (2)
CL Item
mittel (3)
CL Item
schwer (4)
Item
Weichteile
integer
C0037578 (UMLS CUI [1])
Code List
Weichteile
CL Item
keine (1)
CL Item
leicht  (2)
CL Item
mittel (3)
CL Item
schwer (4)

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