ID

15894

Description

Report/Protocol collecting patient and treatment information like the circumstances of the accident and initial ER treatment. http://klinikum.uni-muenster.de/

Link

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

Keywords

Versions (3)
  1. 6/17/16 6/17/16 -
  2. 6/18/16 6/18/16 -
  3. 7/3/16 7/3/16 -
Uploaded on

June 17, 2016

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Emergency Room Point B in Time Part 2: Emergency Room Report UKM

German English

Emergency Room Point B in Time Part 2: Emergency Room Report UKM

1 forms  
Patient information
Description

Patient information

Alias
UMLS CUI-1
C1955348
Nachname
Description

Last name

Data type

text

Alias
UMLS CUI [1]
C0421448
Vorname
Description

First name

Data type

text

Alias
UMLS CUI [1]
C1443235
Geburtsdatum
Description

Date of birth

Data type

date

Alias
UMLS CUI [1]
C0421451
Index
Description

Index

Data type

text

Alias
UMLS CUI [1]
C1300638
Untersuchungsbefund
Description

Untersuchungsbefund

ATLS
Description

ATLS

Alias
UMLS CUI-1
C3494237
A-Problem (Airway)
Description

A-Problem (Airway)

Data type

boolean

Alias
UMLS CUI [1,1]
C0458827
UMLS CUI [1,2]
C0033213
B-Problem (Breathing)
Description

B-Problem (Breathing)

Data type

boolean

Alias
UMLS CUI [1,1]
C0035203
UMLS CUI [1,2]
C0033213
C-Problem (Circulation)
Description

C-Problem (Circulation)

Data type

boolean

Alias
UMLS CUI [1,1]
C0005775
UMLS CUI [1,2]
C0033213
D-Problem (Disability)
Description

D-Problem (Disability)

Data type

boolean

Alias
UMLS CUI [1,1]
C0231170
UMLS CUI [1,2]
C0033213
E-Problem (Hypothermie)
Description

E-Problem (Hypothermia)

Data type

boolean

Alias
UMLS CUI [1,1]
C0020672
UMLS CUI [1,2]
C0033213
Peripherer Neurologischer Status
Description

Peripherer Neurologischer Status

Alias
UMLS CUI-1
C0027853
Motorik
Description

motor function

Data type

integer

Alias
UMLS CUI [1]
C0234130
Sesibilität
Description

sensitivity

Data type

integer

Alias
UMLS CUI [1]
C1522640
Reflexe
Description

reflexes

Data type

integer

Alias
UMLS CUI [1]
C0436145
Babinski
Description

Babinski Reflex

Data type

boolean

Alias
UMLS CUI [1]
C0034935
Sphinktertonus
Description

sphincter tone

Data type

boolean

Alias
UMLS CUI [1]
C0516792
Sonstiges
Description

other neurological finding

Data type

text

Alias
UMLS CUI [1]
C0438194
Gefäßstatus
Description

Gefäßstatus

Alias
UMLS CUI-1
C0005847
UMLS CUI-2
C0438105
rechte A. carotis tastbar
Description

right A. carotis palpable

Data type

boolean

Alias
UMLS CUI [1,1]
C0517385
UMLS CUI [1,2]
C0007272
UMLS CUI [1,3]
C0444532
UMLS CUI [2,1]
C0162481
UMLS CUI [2,2]
C0007272
UMLS CUI [2,3]
C0444532
linke A. carotis tastbar
Description

left A. carotis palpable

Data type

boolean

Alias
UMLS CUI [1,1]
C0517385
UMLS CUI [1,2]
C0007272
UMLS CUI [1,3]
C0162481
UMLS CUI [1,4]
C0007272
UMLS CUI [1,5]
C0443246
rechte A. radialis tastbar
Description

right A. radialis palpable

Data type

boolean

Alias
UMLS CUI [1,1]
C0232142
UMLS CUI [1,2]
C0444532
UMLS CUI [2,1]
C0162481
UMLS CUI [2,2]
C0162857
UMLS CUI [2,3]
C0444532
linke A. radialis tastbar
Description

left A. radialis palpable

Data type

boolean

Alias
UMLS CUI [1,1]
C0232142
UMLS CUI [1,2]
C0443246
UMLS CUI [2,1]
C0162481
UMLS CUI [2,2]
C0162857
UMLS CUI [2,3]
C0443246
rechte A. femoralis tastbar
Description

right A. femoralis palpable

Data type

boolean

Alias
UMLS CUI [1,1]
C0517385
UMLS CUI [1,2]
C0015801
UMLS CUI [1,3]
C0444532
UMLS CUI [2,1]
C0162481
UMLS CUI [2,2]
C0015801
UMLS CUI [2,3]
C0444532
linke A. femoralis tastbar
Description

left A. femoralis palpable

Data type

boolean

Alias
UMLS CUI [1,1]
C0517385
UMLS CUI [1,2]
C0015801
UMLS CUI [1,3]
C0443246
UMLS CUI [2,1]
C0162481
UMLS CUI [2,2]
C0015801
UMLS CUI [2,3]
C0443246
rechte A. poplitea tastbar
Description

right A. poplitea palpable

Data type

boolean

Alias
UMLS CUI [1,1]
C0232151
UMLS CUI [1,2]
C0444532
UMLS CUI [2,1]
C0162481
UMLS CUI [2,2]
C0032649
UMLS CUI [2,3]
C0444532
linke A. poplitea tastbar
Description

left A. poplitea palpable

Data type

boolean

Alias
UMLS CUI [1,1]
C0232151
UMLS CUI [1,2]
C0162481
UMLS CUI [1,3]
C0032649
UMLS CUI [1,4]
C0443246
rechte A. dors. ped. tastbar
Description

right A. dors. ped. palpable

Data type

boolean

Alias
UMLS CUI [1,1]
C0517385
UMLS CUI [1,2]
C0226492
UMLS CUI [1,3]
C0444532
UMLS CUI [2,1]
C0162481
UMLS CUI [2,2]
C0226492
UMLS CUI [2,3]
C0444532
linke A. dors. ped. tastbar
Description

left A. dors. ped. palpable

Data type

boolean

Alias
UMLS CUI [1,1]
C0517385
UMLS CUI [1,2]
C0226492
UMLS CUI [1,3]
C0443246
UMLS CUI [2,1]
C0162481
UMLS CUI [2,2]
C0226492
UMLS CUI [2,3]
C0443246
rechte A. tib. post. tastbar
Description

right A. tib. post. palpable

Data type

boolean

Alias
UMLS CUI [1,1]
C0517385
UMLS CUI [1,2]
C0086835
UMLS CUI [1,3]
C0444532
UMLS CUI [2,1]
C0162481
UMLS CUI [2,2]
C0086835
UMLS CUI [2,3]
C0444532
linke A. tib. post. tastbar
Description

left A. tib. post. palpable

Data type

boolean

Alias
UMLS CUI [1,1]
C0517385
UMLS CUI [1,2]
C0086835
UMLS CUI [1,3]
C0443246
UMLS CUI [2,1]
C0162481
UMLS CUI [2,2]
C0086835
UMLS CUI [2,3]
C0443246
Kopf/Hals
Description

Kopf/Hals

Alias
UMLS CUI-1
C0031809
UMLS CUI-2
C0460004
o.B.
Description

without finding

Data type

boolean

Alias
UMLS CUI [1,1]
C0332288
UMLS CUI [1,2]
C0243095
Hämatom
Description

hematoma

Data type

boolean

Alias
UMLS CUI [1]
C0018944
Orbitalhämatom
Description

hematoma of orbita

Data type

boolean

Alias
UMLS CUI [1]
C0520723
Gehörgangsblutung
Description

bleeding of auditory canal

Data type

boolean

Alias
UMLS CUI [1,1]
C0019080
UMLS CUI [1,2]
C0013444
Liquorrhoe
Description

liquorrhea

Data type

boolean

Alias
UMLS CUI [1]
C0860578
Platzwunde
Description

laceration

Data type

boolean

Alias
UMLS CUI [1]
C0856548
Mittelgesichtsinstabilität
Description

facial instabilty

Data type

boolean

Alias
UMLS CUI [1]
C0024953
Unterkieferfraktur
Description

fracture of mandibula

Data type

boolean

Alias
UMLS CUI [1]
C0024692
Augenverletzung
Description

injury of eye

Data type

boolean

Alias
UMLS CUI [1]
C0015408
Sonstige:
Description

ohter injuries of head

Data type

text

Alias
UMLS CUI [1]
C0178671
Thorax
Description

Thorax

Alias
UMLS CUI-1
C0031809
UMLS CUI-2
C0817096
o.B.
Description

without finding

Data type

boolean

Alias
UMLS CUI [1,1]
C0332288
UMLS CUI [1,2]
C0243095
Prellmarken
Description

contusion of chest

Data type

boolean

Alias
UMLS CUI [1]
C0160925
Hämatom
Description

hematoma

Data type

boolean

Alias
UMLS CUI [1]
C4049192
Hautemphysem
Description

skin emphysema

Data type

boolean

Alias
UMLS CUI [1]
C0038536
Instabilität
Description

thoracal instability

Data type

boolean

Alias
UMLS CUI [1,1]
C0231433
UMLS CUI [1,2]
C0817096
atemabh. Schmerz
Description

chest pain on breathing

Data type

boolean

Alias
UMLS CUI [1]
C0423729
Kompressionsschmerz
Description

chest pain on compression

Data type

boolean

Alias
UMLS CUI [1,1]
C0008031
UMLS CUI [1,2]
C0728907
offene Verletzung
Description

open wound

Data type

boolean

Alias
UMLS CUI [1]
C0478235
Halsvenenstauung
Description

jugular vein congestion

Data type

boolean

Alias
UMLS CUI [1,1]
C0700148
UMLS CUI [1,2]
C0022427
path. Auskultationsbefund
Description

pathological auscultation of chest

Data type

boolean

Alias
UMLS CUI [1]
C0577960
Thoraxdrainage
Description

chest tube

Data type

boolean

Alias
UMLS CUI [1]
C0008034
Sonstige:
Description

other chest pain

Data type

text

Alias
UMLS CUI [1]
C0039980
Abdomen und Urogenitaltrakt
Description

Abdomen und Urogenitaltrakt

Alias
UMLS CUI-1
C0031809
UMLS CUI-2
C0000726
UMLS CUI-3
C0042066
o.B.
Description

without finding

Data type

boolean

Alias
UMLS CUI [1,1]
C0332288
UMLS CUI [1,2]
C0243095
Prellmarken
Description

contusion

Data type

boolean

Alias
UMLS CUI [1]
C1439271
UMLS CUI [2]
C1389458
Hämatom
Description

Hematoma

Data type

boolean

Alias
UMLS CUI [1]
C0018944
aufgetrieben
Description

Abdomen distended

Data type

boolean

Alias
UMLS CUI [1]
C0000731
Druckschmerz
Description

pressure pain

Data type

boolean

Alias
UMLS CUI [1]
C3647129
Abwehrspannung
Description

muscular guarding

Data type

boolean

Alias
UMLS CUI [1]
C0238547
offene Verletzung
Description

open injury

Data type

boolean

Alias
UMLS CUI [1]
C0559870
Verletzung Anogenitaltrakt
Description

anogenital injury

Data type

boolean

Alias
UMLS CUI [1,1]
C3263723
UMLS CUI [1,2]
C0031066
path. rekt. digit. Befund
Description

pathological digital examination of the rectum

Data type

boolean

Alias
UMLS CUI [1]
C1384593
Sonstige:
Description

other injury of abdomen

Data type

text

Alias
UMLS CUI [1]
C1260446
Becken
Description

Becken

Alias
UMLS CUI-1
C0031809
UMLS CUI-2
C0030797
o.B.
Description

without finding

Data type

boolean

Alias
UMLS CUI [1,1]
C0332288
UMLS CUI [1,2]
C0243095
instabil
Description

instability of pelvis

Data type

boolean

Alias
UMLS CUI [1]
C1389477
offene Verletzung
Description

open wound

Data type

boolean

Alias
UMLS CUI [1,1]
C0559870
UMLS CUI [1,2]
C0030797
Sonstige:
Description

other injury of pelvis

Data type

text

Alias
UMLS CUI [1]
C0560636
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Similar models

Emergency Room Point B in Time Part 2: Emergency Room Report UKM

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
C1955348 (UMLS CUI-1)
Last name
Item
Nachname
text
C0421448 (UMLS CUI [1])
First name
Item
Vorname
text
C1443235 (UMLS CUI [1])
Date of birth
Item
Geburtsdatum
date
C0421451 (UMLS CUI [1])
Index
Item
Index
text
C1300638 (UMLS CUI [1])
Item Group
Untersuchungsbefund
Item Group
ATLS
C3494237 (UMLS CUI-1)
A-Problem (Airway)
Item
A-Problem (Airway)
boolean
C0458827 (UMLS CUI [1,1])
C0033213 (UMLS CUI [1,2])
B-Problem (Breathing)
Item
B-Problem (Breathing)
boolean
C0035203 (UMLS CUI [1,1])
C0033213 (UMLS CUI [1,2])
C-Problem (Circulation)
Item
C-Problem (Circulation)
boolean
C0005775 (UMLS CUI [1,1])
C0033213 (UMLS CUI [1,2])
D-Problem (Disability)
Item
D-Problem (Disability)
boolean
C0231170 (UMLS CUI [1,1])
C0033213 (UMLS CUI [1,2])
E-Problem (Hypothermia)
Item
E-Problem (Hypothermie)
boolean
C0020672 (UMLS CUI [1,1])
C0033213 (UMLS CUI [1,2])
Item Group
Peripherer Neurologischer Status
C0027853 (UMLS CUI-1)
Item
Motorik
integer
C0234130 (UMLS CUI [1])
motor function
Code List
Motorik
CL Item
spontan (1)
CL Item
seitengleich (2)
CL Item
abgeschwächt (3)
CL Item
keine (4)
Item
Sesibilität
integer
C1522640 (UMLS CUI [1])
sensitivity
Code List
Sesibilität
CL Item
o.B. (1)
CL Item
gestört (2)
CL Item
nicht eurierbar (3)
Item
Reflexe
integer
C0436145 (UMLS CUI [1])
reflexes
Code List
Reflexe
CL Item
o.B. (1)
CL Item
path. (2)
Babinski Reflex
Item
Babinski
boolean
C0034935 (UMLS CUI [1])
sphincter tone
Item
Sphinktertonus
boolean
C0516792 (UMLS CUI [1])
other neurological finding
Item
Sonstiges
text
C0438194 (UMLS CUI [1])
Item Group
Gefäßstatus
C0005847 (UMLS CUI-1)
C0438105 (UMLS CUI-2)
right A. carotis palpable
Item
rechte A. carotis tastbar
boolean
C0517385 (UMLS CUI [1,1])
C0007272 (UMLS CUI [1,2])
C0444532 (UMLS CUI [1,3])
C0162481 (UMLS CUI [2,1])
C0007272 (UMLS CUI [2,2])
C0444532 (UMLS CUI [2,3])
left A. carotis palpable
Item
linke A. carotis tastbar
boolean
C0517385 (UMLS CUI [1,1])
C0007272 (UMLS CUI [1,2])
C0162481 (UMLS CUI [1,3])
C0007272 (UMLS CUI [1,4])
C0443246 (UMLS CUI [1,5])
right A. radialis palpable
Item
rechte A. radialis tastbar
boolean
C0232142 (UMLS CUI [1,1])
C0444532 (UMLS CUI [1,2])
C0162481 (UMLS CUI [2,1])
C0162857 (UMLS CUI [2,2])
C0444532 (UMLS CUI [2,3])
left A. radialis palpable
Item
linke A. radialis tastbar
boolean
C0232142 (UMLS CUI [1,1])
C0443246 (UMLS CUI [1,2])
C0162481 (UMLS CUI [2,1])
C0162857 (UMLS CUI [2,2])
C0443246 (UMLS CUI [2,3])
right A. femoralis palpable
Item
rechte A. femoralis tastbar
boolean
C0517385 (UMLS CUI [1,1])
C0015801 (UMLS CUI [1,2])
C0444532 (UMLS CUI [1,3])
C0162481 (UMLS CUI [2,1])
C0015801 (UMLS CUI [2,2])
C0444532 (UMLS CUI [2,3])
left A. femoralis palpable
Item
linke A. femoralis tastbar
boolean
C0517385 (UMLS CUI [1,1])
C0015801 (UMLS CUI [1,2])
C0443246 (UMLS CUI [1,3])
C0162481 (UMLS CUI [2,1])
C0015801 (UMLS CUI [2,2])
C0443246 (UMLS CUI [2,3])
right A. poplitea palpable
Item
rechte A. poplitea tastbar
boolean
C0232151 (UMLS CUI [1,1])
C0444532 (UMLS CUI [1,2])
C0162481 (UMLS CUI [2,1])
C0032649 (UMLS CUI [2,2])
C0444532 (UMLS CUI [2,3])
left A. poplitea palpable
Item
linke A. poplitea tastbar
boolean
C0232151 (UMLS CUI [1,1])
C0162481 (UMLS CUI [1,2])
C0032649 (UMLS CUI [1,3])
C0443246 (UMLS CUI [1,4])
right A. dors. ped. palpable
Item
rechte A. dors. ped. tastbar
boolean
C0517385 (UMLS CUI [1,1])
C0226492 (UMLS CUI [1,2])
C0444532 (UMLS CUI [1,3])
C0162481 (UMLS CUI [2,1])
C0226492 (UMLS CUI [2,2])
C0444532 (UMLS CUI [2,3])
left A. dors. ped. palpable
Item
linke A. dors. ped. tastbar
boolean
C0517385 (UMLS CUI [1,1])
C0226492 (UMLS CUI [1,2])
C0443246 (UMLS CUI [1,3])
C0162481 (UMLS CUI [2,1])
C0226492 (UMLS CUI [2,2])
C0443246 (UMLS CUI [2,3])
right A. tib. post. palpable
Item
rechte A. tib. post. tastbar
boolean
C0517385 (UMLS CUI [1,1])
C0086835 (UMLS CUI [1,2])
C0444532 (UMLS CUI [1,3])
C0162481 (UMLS CUI [2,1])
C0086835 (UMLS CUI [2,2])
C0444532 (UMLS CUI [2,3])
left A. tib. post. palpable
Item
linke A. tib. post. tastbar
boolean
C0517385 (UMLS CUI [1,1])
C0086835 (UMLS CUI [1,2])
C0443246 (UMLS CUI [1,3])
C0162481 (UMLS CUI [2,1])
C0086835 (UMLS CUI [2,2])
C0443246 (UMLS CUI [2,3])
Item Group
Kopf/Hals
C0031809 (UMLS CUI-1)
C0460004 (UMLS CUI-2)
without finding
Item
o.B.
boolean
C0332288 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
hematoma
Item
Hämatom
boolean
C0018944 (UMLS CUI [1])
hematoma of orbita
Item
Orbitalhämatom
boolean
C0520723 (UMLS CUI [1])
bleeding of auditory canal
Item
Gehörgangsblutung
boolean
C0019080 (UMLS CUI [1,1])
C0013444 (UMLS CUI [1,2])
liquorrhea
Item
Liquorrhoe
boolean
C0860578 (UMLS CUI [1])
laceration
Item
Platzwunde
boolean
C0856548 (UMLS CUI [1])
facial instabilty
Item
Mittelgesichtsinstabilität
boolean
C0024953 (UMLS CUI [1])
fracture of mandibula
Item
Unterkieferfraktur
boolean
C0024692 (UMLS CUI [1])
injury of eye
Item
Augenverletzung
boolean
C0015408 (UMLS CUI [1])
ohter injuries of head
Item
Sonstige:
text
C0178671 (UMLS CUI [1])
Item Group
Thorax
C0031809 (UMLS CUI-1)
C0817096 (UMLS CUI-2)
without finding
Item
o.B.
boolean
C0332288 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
contusion of chest
Item
Prellmarken
boolean
C0160925 (UMLS CUI [1])
hematoma
Item
Hämatom
boolean
C4049192 (UMLS CUI [1])
skin emphysema
Item
Hautemphysem
boolean
C0038536 (UMLS CUI [1])
thoracal instability
Item
Instabilität
boolean
C0231433 (UMLS CUI [1,1])
C0817096 (UMLS CUI [1,2])
chest pain on breathing
Item
atemabh. Schmerz
boolean
C0423729 (UMLS CUI [1])
chest pain on compression
Item
Kompressionsschmerz
boolean
C0008031 (UMLS CUI [1,1])
C0728907 (UMLS CUI [1,2])
open wound
Item
offene Verletzung
boolean
C0478235 (UMLS CUI [1])
jugular vein congestion
Item
Halsvenenstauung
boolean
C0700148 (UMLS CUI [1,1])
C0022427 (UMLS CUI [1,2])
pathological auscultation of chest
Item
path. Auskultationsbefund
boolean
C0577960 (UMLS CUI [1])
chest tube
Item
Thoraxdrainage
boolean
C0008034 (UMLS CUI [1])
other chest pain
Item
Sonstige:
text
C0039980 (UMLS CUI [1])
Item Group
Abdomen und Urogenitaltrakt
C0031809 (UMLS CUI-1)
C0000726 (UMLS CUI-2)
C0042066 (UMLS CUI-3)
without finding
Item
o.B.
boolean
C0332288 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
contusion
Item
Prellmarken
boolean
C1439271 (UMLS CUI [1])
C1389458 (UMLS CUI [2])
Hematoma
Item
Hämatom
boolean
C0018944 (UMLS CUI [1])
Abdomen distended
Item
aufgetrieben
boolean
C0000731 (UMLS CUI [1])
pressure pain
Item
Druckschmerz
boolean
C3647129 (UMLS CUI [1])
muscular guarding
Item
Abwehrspannung
boolean
C0238547 (UMLS CUI [1])
open injury
Item
offene Verletzung
boolean
C0559870 (UMLS CUI [1])
anogenital injury
Item
Verletzung Anogenitaltrakt
boolean
C3263723 (UMLS CUI [1,1])
C0031066 (UMLS CUI [1,2])
pathological digital examination of the rectum
Item
path. rekt. digit. Befund
boolean
C1384593 (UMLS CUI [1])
other injury of abdomen
Item
Sonstige:
text
C1260446 (UMLS CUI [1])
Item Group
Becken
C0031809 (UMLS CUI-1)
C0030797 (UMLS CUI-2)
without finding
Item
o.B.
boolean
C0332288 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
instability of pelvis
Item
instabil
boolean
C1389477 (UMLS CUI [1])
open wound
Item
offene Verletzung
boolean
C0559870 (UMLS CUI [1,1])
C0030797 (UMLS CUI [1,2])
other injury of pelvis
Item
Sonstige:
text
C0560636 (UMLS CUI [1])
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