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

Time of Alarm
Beschrijving

Time of Alarm

Datatype

time

Alias
UMLS CUI [1]
C0040223
Arrival of A&E doctor
Beschrijving

Arrival of A&E doctor in ER

Datatype

time

Alias
UMLS CUI [1,1]
C0583237
UMLS CUI [1,2]
C0040223
time of ED leaving site of accident
Beschrijving

time of departure

Datatype

time

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

Transport mode to hospital

Datatype

integer

Control center
Beschrijving

Control center

Datatype

text

fax AE doctor
Beschrijving

fax AE doctor

Datatype

text

Alias
UMLS CUI [1,1]
C1549619
UMLS CUI [1,2]
C0586803
medical report to A&E doctor
Beschrijving

medical report to A&E doctor

Datatype

boolean

Alias
UMLS CUI [1,1]
C0451617
UMLS CUI [1,2]
C0586803
NACA-Score
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
Vital signs
Beschrijving

Vital signs

Alias
UMLS CUI-1
C0518766
Blood pressure systolic
Beschrijving

Blood pressure systolic

Datatype

integer

Maateenheden
  • mmHg
Alias
UMLS CUI [1]
C0871470
mmHg
Heart rate
Beschrijving

Heart rate

Datatype

integer

Maateenheden
  • bpm
Alias
UMLS CUI [1]
C0018810
bpm
respiratory rate
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
Size of right pupil
Beschrijving

Size of right pupil

Datatype

integer

Alias
UMLS CUI [1,1]
C0517965
UMLS CUI [1,2]
C0444532
Size of left pupil
Beschrijving

Size of left pupil

Datatype

integer

Alias
UMLS CUI [1,1]
C0517965
UMLS CUI [1,2]
C0443246
right pupil reaction to light
Beschrijving

right pupil reaction to light

Datatype

integer

Alias
UMLS CUI [1,1]
C0234671
UMLS CUI [1,2]
C0444532
left pupil reaction to light
Beschrijving

left pupil reaction to light

Datatype

integer

Alias
UMLS CUI [1,1]
C0234671
UMLS CUI [1,2]
C0443246
Therapy (til Intensive Care)
Beschrijving

Therapy (til Intensive Care)

Alias
UMLS CUI-1
C0087111
electrolytes
Beschrijving

Administration of electrolytes

Datatype

integer

Maateenheden
  • ml
Alias
UMLS CUI [1]
C0199796
ml
Administration of colloids
Beschrijving

Administration of colloids

Datatype

integer

Maateenheden
  • ml
Alias
UMLS CUI [1]
C3267204
ml
hyperosmolar infusion
Beschrijving

hyperosmolar infusion

Datatype

integer

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

Intubation

Datatype

boolean

Alias
UMLS CUI [1]
C0021925
Analgosedation
Beschrijving

Analgosedation

Datatype

boolean

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

Resuscitation

Datatype

boolean

Alias
UMLS CUI [1]
C0007203
Catecholamine therapy
Beschrijving

Catecholamine therapy

Datatype

boolean

Alias
UMLS CUI [1]
C0007412
External fixation device (outside of OR)
Beschrijving

External cervical fixation device

Datatype

boolean

Alias
UMLS CUI [1,1]
C0079321
UMLS CUI [1,2]
C0238943
chest tube
Beschrijving

chest tube

Datatype

boolean

Alias
UMLS CUI [1]
C0008034
peripheral venous catheter
Beschrijving

peripheral venous catheter

Datatype

integer

Alias
UMLS CUI [1]
C2985513
central catheter
Beschrijving

central catheter

Datatype

integer

Alias
UMLS CUI [1]
C1145640
capnography
Beschrijving

capnography

Datatype

boolean

Alias
UMLS CUI [1]
C0376529
Lap belt
Beschrijving

Lap belt

Datatype

boolean

Alias
UMLS CUI [1]
C0553557
Injuries
Beschrijving

Injuries

Alias
UMLS CUI-1
C3263723
craniocerebral
Beschrijving

craniocerebral trauma

Datatype

integer

Alias
UMLS CUI [1]
C0018674
face
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
spine
Beschrijving

injury of spine

Datatype

integer

Alias
UMLS CUI [1]
C0037937
pelvis
Beschrijving

injury of pelvis

Datatype

integer

Alias
UMLS CUI [1]
C0560636
upper limb
Beschrijving

injury of upper limb

Datatype

integer

Alias
UMLS CUI [1]
C0003794
lower limb
Beschrijving

injuries of lower limb

Datatype

integer

Alias
UMLS CUI [1]
C0023220
soft tissue
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
Item Group
General Information
Time of Alarm
Item
Time of Alarm
time
C0040223 (UMLS CUI [1])
Arrival of A&E doctor in ER
Item
Arrival of A&E doctor
time
C0583237 (UMLS CUI [1,1])
C0040223 (UMLS CUI [1,2])
time of departure
Item
time of ED leaving site of accident
time
C2735126 (UMLS CUI [1])
Item
Transport mode to hospital
integer
Code List
Transport mode to hospital
CL Item
ambulance; with physician attendance (1)
CL Item
ambulance; without physician attendance (2)
CL Item
SAR helicopter  (3)
CL Item
private (4)
Control center
Item
text
fax AE doctor
Item
text
C1549619 (UMLS CUI [1,1])
C0586803 (UMLS CUI [1,2])
medical report to A&E doctor
Item
boolean
C0451617 (UMLS CUI [1,1])
C0586803 (UMLS CUI [1,2])
NACA-Score
Item
integer
C0449820 (UMLS CUI [1,1])
C3263723 (UMLS CUI [1,2])
C0012634 (UMLS CUI [1,3])
C0032343 (UMLS CUI [1,4])
Item Group
C0518766 (UMLS CUI-1)
Blood pressure systolic
Item
integer
C0871470 (UMLS CUI [1])
Heart rate
Item
integer
C0018810 (UMLS CUI [1])
respiratory rate
Item
integer
C0231832 (UMLS CUI [1])
SpO2
Item
integer
C0428179 (UMLS CUI [1])
GCS Score
Item
integer
C1271007 (UMLS CUI [1])
Item
integer
C0517965 (UMLS CUI [1,1])
C0444532 (UMLS CUI [1,2])
Code List
Size of right pupil
CL Item
 (1)
CL Item
 (2)
CL Item
 (3)
CL Item
 (4)
Item
integer
C0517965 (UMLS CUI [1,1])
C0443246 (UMLS CUI [1,2])
Code List
Size of left pupil
CL Item
 (1)
CL Item
 (2)
CL Item
 (3)
CL Item
 (4)
Item
integer
C0234671 (UMLS CUI [1,1])
C0444532 (UMLS CUI [1,2])
Code List
right pupil reaction to light
CL Item
 (1)
CL Item
 (2)
CL Item
 (3)
CL Item
 (4)
Item
integer
C0234671 (UMLS CUI [1,1])
C0443246 (UMLS CUI [1,2])
Code List
left pupil reaction to light
CL Item
 (1)
CL Item
 (2)
CL Item
 (3)
CL Item
 (4)
Item Group
Therapy (til Intensive Care)
C0087111 (UMLS CUI-1)
Administration of electrolytes
Item
electrolytes
integer
C0199796 (UMLS CUI [1])
Administration of colloids
Item
Administration of colloids
integer
C3267204 (UMLS CUI [1])
hyperosmolar infusion
Item
hyperosmolar infusion
integer
C0259752 (UMLS CUI [1,1])
C0087111 (UMLS CUI [1,2])
Intubation
Item
Intubation
boolean
C0021925 (UMLS CUI [1])
Analgosedation
Item
boolean
C0344106 (UMLS CUI [1,1])
C0002766 (UMLS CUI [1,2])
Resuscitation
Item
Resuscitation
boolean
C0007203 (UMLS CUI [1])
Catecholamine therapy
Item
Catecholamine therapy
boolean
C0007412 (UMLS CUI [1])
External cervical fixation device
Item
External fixation device (outside of OR)
boolean
C0079321 (UMLS CUI [1,1])
C0238943 (UMLS CUI [1,2])
chest tube
Item
chest tube
boolean
C0008034 (UMLS CUI [1])
peripheral venous catheter
Item
integer
C2985513 (UMLS CUI [1])
central catheter
Item
integer
C1145640 (UMLS CUI [1])
capnography
Item
boolean
C0376529 (UMLS CUI [1])
Lap belt
Item
boolean
C0553557 (UMLS CUI [1])
Item Group
Injuries
C3263723 (UMLS CUI-1)
Item
craniocerebral
integer
C0018674 (UMLS CUI [1])
Code List
craniocerebral
CL Item
none (1)
CL Item
light (2)
CL Item
moderate (3)
CL Item
severe (4)
Item
face
integer
C0015459 (UMLS CUI [1])
Code List
face
CL Item
none (1)
CL Item
light (2)
CL Item
moderate (3)
CL Item
severe (4)
Item
thorax
integer
C0039980 (UMLS CUI [1])
Code List
thorax
CL Item
none (1)
CL Item
light (2)
CL Item
moderate (3)
CL Item
severe (4)
Item
abdomen
integer
C0848377 (UMLS CUI [1])
Code List
abdomen
CL Item
none (1)
CL Item
light (2)
CL Item
moderate (3)
CL Item
severe (4)
Item
spine
integer
C0037937 (UMLS CUI [1])
Code List
spine
CL Item
none (1)
CL Item
light (2)
CL Item
moderate (3)
CL Item
severe (4)
Item
pelvis
integer
C0560636 (UMLS CUI [1])
Code List
pelvis
CL Item
none (1)
CL Item
light (2)
CL Item
moderate (3)
CL Item
severe (4)
Item
upper limb
integer
C0003794 (UMLS CUI [1])
Code List
upper limb
CL Item
none (1)
CL Item
light (2)
CL Item
moderate (3)
CL Item
severe (4)
Item
lower limb
integer
C0023220 (UMLS CUI [1])
Code List
lower limb
CL Item
none (1)
CL Item
light (2)
CL Item
moderate (3)
CL Item
severe (4)
Item
soft tissue
integer
C0037578 (UMLS CUI [1])
Code List
soft tissue
CL Item
none (1)
CL Item
light (2)
CL Item
moderate (3)
CL Item
severe (4)

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