ID

16163

Beschreibung

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/

Stichworte

Körperliche Untersuchung

Emergency protocol

Hochgeladen am

3. Juli 2016

DOI

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Lizenz

Creative Commons BY-NC 3.0

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

Modell
Details

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

1 Formulare

StudyEvent: ODM
1. Emergency Room Point B in Time Part 2: Emergency Room Report UKM

Name

Typ

Description | Question | Decode (Coded Value)

Datentyp

Alias

Patient information

Item Group

Patient information

C1955348 (UMLS CUI-1)

Last name

Item

Last name

text

C0421448 (UMLS CUI [1])

First name

Item

First name

text

C1443235 (UMLS CUI [1])

Date of birth

Item

Date of birth

date

C0421451 (UMLS CUI [1])

Index

Item

text

C1300638 (UMLS CUI [1])

Physical examination result

Item Group

ATLS

Item Group

C3494237 (UMLS CUI-1)

A-Problem (Airway)

Item

boolean

C0458827 (UMLS CUI [1,1])
C0033213 (UMLS CUI [1,2])

B-Problem (Breathing)

Item

boolean

C0035203 (UMLS CUI [1,1])
C0033213 (UMLS CUI [1,2])

C-Problem (Circulation)

Item

boolean

C0005775 (UMLS CUI [1,1])
C0033213 (UMLS CUI [1,2])

D-Problem (Disability)

Item

boolean

C0231170 (UMLS CUI [1,1])
C0033213 (UMLS CUI [1,2])

E-Problem (Hypothermia)

Item

boolean

C0020672 (UMLS CUI [1,1])
C0033213 (UMLS CUI [1,2])

Peripheral neurological status

Item Group

C0027853 (UMLS CUI-1)

motor function

Item

integer

C0234130 (UMLS CUI [1])

motor function

Code List

motor function

CL Item

(1)

CL Item

(2)

CL Item

(3)

CL Item

(4)

sensitivity

Item

integer

C1522640 (UMLS CUI [1])

sensitivity

Code List

sensitivity

CL Item

(1)

CL Item

(2)

CL Item

(3)

reflexes

Item

integer

C0436145 (UMLS CUI [1])

reflexes

Code List

reflexes

CL Item

(1)

CL Item

(2)

Babinski Reflex

Item

boolean

C0034935 (UMLS CUI [1])

sphincter tone

Item

boolean

C0426763 (UMLS CUI [1])

other neurological finding

Item

text

C0438194 (UMLS CUI [1])

Vascular examination

Item Group

C0005847 (UMLS CUI-1)
C0438105 (UMLS CUI-2)

right A. carotis palpable

Item

boolean

C0517385 (UMLS CUI [1,1])
C0226086 (UMLS CUI [1,2])
C0162481 (UMLS CUI [2,1])
C0226086 (UMLS CUI [2,2])

left A. carotis palpable

Item

boolean

C0517385 (UMLS CUI [1,1])
C0226087 (UMLS CUI [1,2])
C0162481 (UMLS CUI [2,1])
C0226087 (UMLS CUI [2,2])

right A. radialis palpable

Item

boolean

C0232142 (UMLS CUI [1,1])
C0444532 (UMLS CUI [1,2])
C0162481 (UMLS CUI [2,1])
C0226438 (UMLS CUI [2,2])

left A. radialis palpable

Item

boolean

C0232142 (UMLS CUI [1,1])
C0443246 (UMLS CUI [1,2])
C0162481 (UMLS CUI [2,1])
C0226439 (UMLS CUI [2,2])

right A. femoralis palpable

Item

boolean

C0517385 (UMLS CUI [1,1])
C0226447 (UMLS CUI [1,2])
C0162481 (UMLS CUI [2,1])
C0226447 (UMLS CUI [2,2])

left A. femoralis palpable

Item

boolean

C0517385 (UMLS CUI [1,1])
C0226448 (UMLS CUI [1,2])
C0162481 (UMLS CUI [2,1])
C0226448 (UMLS CUI [2,2])

right A. poplitea palpable

Item

boolean

C0232151 (UMLS CUI [1,1])
C0444532 (UMLS CUI [1,2])
C0162481 (UMLS CUI [2,1])
C0226462 (UMLS CUI [2,2])

left A. poplitea palpable

Item

boolean

C0232151 (UMLS CUI [1,1])
C0443246 (UMLS CUI [1,2])
C0162481 (UMLS CUI [2,1])
C0226463 (UMLS CUI [2,2])

right A. dors. ped. palpable

Item

boolean

C0517385 (UMLS CUI [1,1])
C0834665 (UMLS CUI [1,2])
C0162481 (UMLS CUI [2,1])
C0834665 (UMLS CUI [2,2])

left A. dors. ped. palpable

Item

boolean

C0517385 (UMLS CUI [1,1])
C0834666 (UMLS CUI [1,2])
C0162481 (UMLS CUI [2,1])
C0834666 (UMLS CUI [2,2])

right A. tib. post. palpable

Item

boolean

C0517385 (UMLS CUI [1,1])
C0226474 (UMLS CUI [1,2])
C0162481 (UMLS CUI [2,1])
C0226474 (UMLS CUI [2,2])

left A. tib. post. palpable

Item

boolean

C0517385 (UMLS CUI [1,1])
C0226475 (UMLS CUI [1,2])
C0162481 (UMLS CUI [2,1])
C0226475 (UMLS CUI [2,2])

Physical examination of head

Item Group

C0031809 (UMLS CUI-1)
C0460004 (UMLS CUI-2)

without finding

Item

boolean

C0332288 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])

hematoma

Item

boolean

C0018944 (UMLS CUI [1])

hematoma of orbita

Item

boolean

C0520723 (UMLS CUI [1])

bleeding of auditory canal

Item

boolean

C0019080 (UMLS CUI [1,1])
C0013444 (UMLS CUI [1,2])

liquorrhea

Item

boolean

C0860578 (UMLS CUI [1])

laceration

Item

boolean

C0856548 (UMLS CUI [1])

facial instabilty

Item

boolean

C0435321 (UMLS CUI [1])

fracture of mandibula

Item

boolean

C0024692 (UMLS CUI [1])

injury of eye

Item

boolean

C0015408 (UMLS CUI [1])

ohter injuries of head

Item

text

C0178671 (UMLS CUI [1])

Physical examination of thorax

Item Group

C0031809 (UMLS CUI-1)
C0817096 (UMLS CUI-2)

without finding

Item

boolean

C0332288 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])

contusion of chest

Item

boolean

C0160925 (UMLS CUI [1])

hematoma

Item

boolean

C4049192 (UMLS CUI [1])

skin emphysema

Item

boolean

C0038536 (UMLS CUI [1])

thoracal instability

Item

boolean

C0231433 (UMLS CUI [1,1])
C0817096 (UMLS CUI [1,2])

chest pain on breathing

Item

boolean

C0423729 (UMLS CUI [1])

chest pain on compression

Item

boolean

C0008031 (UMLS CUI [1,1])
C0728907 (UMLS CUI [1,2])

open wound

Item

boolean

C0478235 (UMLS CUI [1])

jugular vein congestion

Item

boolean

C0700148 (UMLS CUI [1,1])
C0022427 (UMLS CUI [1,2])

pathological auscultation of chest

Item

boolean

C0577960 (UMLS CUI [1])

chest tube

Item

boolean

C0008034 (UMLS CUI [1])

other chest pain

Item

text

C0039980 (UMLS CUI [1])

Physical examination of abdomen and genitourinary system

Item Group

C0031809 (UMLS CUI-1)
C0000726 (UMLS CUI-2)
C0042066 (UMLS CUI-3)

without finding

Item

boolean

C0332288 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])

contusion

Item

boolean

C1439271 (UMLS CUI [1])
C1389458 (UMLS CUI [2])

Hematoma

Item

boolean

C0018944 (UMLS CUI [1])

Abdomen distended

Item

boolean

C0000731 (UMLS CUI [1])

pressure pain

Item

boolean

C3647129 (UMLS CUI [1])

muscular guarding

Item

boolean

C0238547 (UMLS CUI [1])

open injury

Item

boolean

C0559870 (UMLS CUI [1])

anogenital injury

Item

boolean

C3263723 (UMLS CUI [1,1])
C0031066 (UMLS CUI [1,2])

pathological digital examination of the rectum

Item

boolean

C1384593 (UMLS CUI [1])

other injury of abdomen

Item

text

C1260446 (UMLS CUI [1])

Physical examination of pelvis

Item Group

C0031809 (UMLS CUI-1)
C0030797 (UMLS CUI-2)

without finding

Item

boolean

C0332288 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])

instability of pelvis

Item

boolean

C1389477 (UMLS CUI [1])

open wound

Item

boolean

C0559870 (UMLS CUI [1,1])
C0030797 (UMLS CUI [1,2])

other injury of pelvis

Item

text

C0560636 (UMLS CUI [1])

Physical examination of limbs

Item Group

C0031809 (UMLS CUI-1)
C0015385 (UMLS CUI-2)

Lower limb

Item

text

C0031809 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C0023216 (UMLS CUI [1,3])

compartment syndrome lower limb

Item

boolean

C0009492 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])

Upper limb

Item

text

C0031809 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
C1140618 (UMLS CUI [1,3])

compartment syndrome of upper limb

Item

boolean

C0009492 (UMLS CUI [1,1])
C1140618 (UMLS CUI [1,2])

Diagnoses

Item Group

Diagnosis

Item

text

C0011900 (UMLS CUI [1])

Patient handover

Item Group

C3494290 (UMLS CUI-1)
C0586001 (UMLS CUI-3)

thrombosis prophylaxis

Item

text

C0199242 (UMLS CUI [1])

Antibiotics

Item

text

C0003232 (UMLS CUI [1])

analgesics

Item

text

C0002771 (UMLS CUI [1])

food

Item

text

C0016452 (UMLS CUI [1])

infusion

Item

text

C1289919 (UMLS CUI [1])

medication

Item

text

C0013227 (UMLS CUI [1])

positioning aids

Item

text

C0182347 (UMLS CUI [1])

control sono abdomen

Item

boolean

C0041618 (UMLS CUI [1,1])
C0000726 (UMLS CUI [1,2])

time of control sono abdomen

Item

time

C0041618 (UMLS CUI [1,1])
C0000726 (UMLS CUI [1,2])
C1547403 (UMLS CUI [1,3])

control CCT

Item

boolean

C3515744 (UMLS CUI [1])

time of control CCT

Item

time

C3515744 (UMLS CUI [1,1])
C1547403 (UMLS CUI [1,2])

control CT

Item

integer

C0040405 (UMLS CUI [1])

control CT

Code List

control CT

CL Item

(1)

CL Item

(2)

time of control CT

Item

time

C0040405 (UMLS CUI [1,1])
C1547403 (UMLS CUI [1,2])

hematologic tests

Item

boolean

C0018941 (UMLS CUI [1])

time of hematologic tests

Item

time

C0018941 (UMLS CUI [1,1])
C1547403 (UMLS CUI [1,2])

other arrangements

Item

text

C0586001 (UMLS CUI [1])

Work-related accident

Item Group

C0586557 (UMLS CUI-1)

confraternity

Item

text

C3841800 (UMLS CUI [1])

city

Item

text

C2316883 (UMLS CUI [1])

profession

Item

text

C0028811 (UMLS CUI [1])

engaged since

Item

date

C0028811 (UMLS CUI [1,1])
C0439659 (UMLS CUI [1,2])

beginning of workday

Item

time

C0680192 (UMLS CUI [1,1])
C0439659 (UMLS CUI [1,2])

Employer

Item

text

C1274022 (UMLS CUI [1])

posttraumatic behaviour

Item

text

initial treatment

Item

text

C2065349 (UMLS CUI [1])

Comorbidity

Item

text

C0009488 (UMLS CUI [1])

do accident circumstances fit employers insurance requirements

Item

integer

C0586557 (UMLS CUI [1])

do accident circumstances fit employers insurance requirements

Code List

do accident circumstances fit employers insurance requirements

CL Item

(1)

CL Item

(2)

CL Item

(3)

Further treatment

Item

boolean

C0087111 (UMLS CUI [1,1])
C1517331 (UMLS CUI [1,2])

fit for work

Item

date

C0578795 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])

sick leave certificate

Item

boolean

C0007836 (UMLS CUI [1,1])
C0242807 (UMLS CUI [1,2])

sick leave duration less than 3 days

Item

boolean

C0007836 (UMLS CUI [1,1])
C0439092 (UMLS CUI [1,2])
C1442459 (UMLS CUI [1,3])

sick leave duration

Item

text

C0007836 (UMLS CUI [1,1])
C0449238 (UMLS CUI [1,2])

general treatment by

Item

integer

C1710470 (UMLS CUI [1])

general treatment by

Code List

general treatment by

CL Item

(1)

CL Item

(2)

specify treating physician

Item

text

C1710470 (UMLS CUI [1])

special treatment

Item

integer

special treatment

Code List

special treatment

CL Item

(1)

CL Item

(2)

treating physician special treatment

Item

integer

special treatment

Code List

treating physician special treatment

CL Item

(1)

CL Item

(2)

treating physician special treatment

Item

text

employers insurance questionnaire

Item

boolean

C3841800 (UMLS CUI [1,1])
C0034394 (UMLS CUI [1,2])

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

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

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