ID

17834

Descripción

Standardized Discharge Summary used in France since March 2016, released by ATIH (Agence technique de l'information sur l'hospitalisation). Provided for MDM portal by Prof. Dr. Jean Marie RODRIGUES, Université Jean Monnet Saint Etienne/Lyon. Le résumé de sortie standardisés (RSS) non groupé format 017, applicable à compter du 1er mars 2016, créé par l'Agence technique de l'information sur l'hospitalisation (ATIH). Fourni de Prof. Dr. Jean Marie RODRIGUES pour le MDM portal. http://www.atih.sante.fr/

Link

http://www.atih.sante.fr/

Palabras clave

Versiones (1)
  1. 4/10/16 4/10/16 -
Subido en

4 de octubre de 2016

DOI

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Licencia

Creative Commons BY-NC 3.0
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Standardized Discharge Summary March 2016 Format 017 ATIH France

Inglés Francés

Standardized Discharge Summary March 2016 ATIH France

1 formularios  
RSS format not grouped 017
Descripción

RSS format not grouped 017

FINESS-Number of registration ePMSI
Descripción

Means the number of health facility in the national health and social facilities (FINESS) file. It must be registered in the RUM:-number FINESS of the legal entity for public health institutions -the number of FINESS of the geographical entity for private healthcare facilities.

Tipo de datos

text

Version of the RUM format
Descripción

The description of computer formats of summaries of activity and information of medical units file is available on the website of the ATIH. Are also indicated the dates from which these formats are required, as well as their validity period. Healthcare facilities should ensure strict compliance with these standards and formats, otherwise data could not be taken into account in the various treatments.

Tipo de datos

integer

RSS Number
Descripción

Left/space

Tipo de datos

text

Administrative Local Identifier of stay
Descripción

Left/space

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0600091
UMLS CUI [1,2]
C0184666
RUM No.
Descripción

Left/space

Tipo de datos

text

Date of birth
Descripción

Date of Birth

Tipo de datos

date

Alias
UMLS CUI [1]
C0421451
Sex
Descripción

Gender

Tipo de datos

integer

Alias
UMLS CUI [1]
C0079399
Medical unit ID
Descripción

Left/space

Tipo de datos

text

Alias
UMLS CUI [1,1]
C1555565
UMLS CUI [1,2]
C0019988
Authorization of type of bed
Descripción

Right/Zero

Tipo de datos

integer

Alias
UMLS CUI [1,1]
C1547328
UMLS CUI [1,2]
C0004916
Date of admission to medical unit
Descripción

Admission Date Medical Unit

Tipo de datos

date

Alias
UMLS CUI [1]
C1302393
Admission type to the medical unit
Descripción

Admission Type

Tipo de datos

integer

Alias
UMLS CUI [1]
C1550330
Previous Medical Unit (if entry mode transfer, transfer or home)
Descripción

Previous Medical Unit

Tipo de datos

integer

Alias
UMLS CUI [1,1]
C0205156
UMLS CUI [1,2]
C0019988
Discharge Date
Descripción

Discharge Date

Tipo de datos

date

Alias
UMLS CUI [1]
C2361123
Discharge Type
Descripción

Discharge Type

Tipo de datos

integer

Alias
UMLS CUI [1]
C0586514
Destination (if Discharge Type transfer, transfer or home)
Descripción

Destination

Tipo de datos

integer

Alias
UMLS CUI [1]
C0079220
Postal code of residence (or 99 followed code of the oversea country for patients living outside France)
Descripción

Right/Zero

Tipo de datos

integer

Alias
UMLS CUI [1]
C0421454
Weight of the newborn at admission date to the medical unit (in grams)
Descripción

Right/Zero

Tipo de datos

integer

Unidades de medida
  • g
Alias
UMLS CUI [1]
C2712830
g
Gestational age
Descripción

Right/Zero

Tipo de datos

integer

Alias
UMLS CUI [1]
C0017504
Date of your last period
Descripción

Date Last Menstrual Period

Tipo de datos

date

Alias
UMLS CUI [1]
C0425932
Number of Visits
Descripción

Right/Zero

Tipo de datos

integer

Alias
UMLS CUI [1,1]
C0449788
UMLS CUI [1,2]
C0545082
Number of associated diagnoses (nDA) in this RUM
Descripción

Right/Zero

Tipo de datos

integer

Alias
UMLS CUI [1,1]
C0449788
UMLS CUI [1,2]
C0243087
Number of data (nDAD) documented in this RUM
Descripción

Right/Zero

Tipo de datos

integer

Number of procedures (nZA) in this RUM
Descripción

Right/Zero

Tipo de datos

integer

Alias
UMLS CUI [1,1]
C1265611
UMLS CUI [1,2]
C2700391
Main diagnosis (PD)
Descripción

Left/space The DP can be: -a disease, a syndrome, a symptom, a traumatic injury or poisoning classified in chapters I to XIX or XXII105F 1 of ICD-10 - or one of the entities classified in chapter XXI factors influencing health status and patterns of use of health services ('codes Z').

Tipo de datos

text

Alias
UMLS CUI [1]
C0332137
Concomitant diagnosis (DR)
Descripción

Left/space

Tipo de datos

text

Alias
UMLS CUI [1]
C0243087
SAPS II
Descripción

Right/Zero Simplified severity index

Tipo de datos

integer

Alias
UMLS CUI [1]
C0451481
Confirmation of the coding of the RSS
Descripción

Confirmation of RSS Code

Tipo de datos

integer

Alias
UMLS CUI [1,1]
C0521091
UMLS CUI [1,2]
C0009219
Type of Radiotherapy Device
Descripción

Radiotherapy Device

Tipo de datos

integer

Alias
UMLS CUI [1]
C0302617
Type of dosimetry
Descripción

Type of Dosimetry

Tipo de datos

integer

Alias
UMLS CUI [1]
C0034603
Study Participation ID
Descripción

Left/space

Tipo de datos

text

Alias
UMLS CUI [1]
C2242969
Number of previous abortions
Descripción

Right/Zero

Tipo de datos

integer

Alias
UMLS CUI [1,1]
C1265611
UMLS CUI [1,2]
C0392535
Year of latest abortion
Descripción

Right/Zero

Tipo de datos

integer

Alias
UMLS CUI [1,1]
C0439234
UMLS CUI [1,2]
C0392535
Filler
Descripción

NA / space

Tipo de datos

text

Number of previous live births
Descripción

Right/Zero

Tipo de datos

integer

Alias
UMLS CUI [1]
C2114488
Reserved Space
Descripción

NA / space

Tipo de datos

integer

Diagnosis associated with
Descripción

Diagnosis associated with

Concomitant Diagnosis n° nDA
Descripción

Left/space Diagnosis associated with

Tipo de datos

text

Alias
UMLS CUI [1,1]
C2348235
UMLS CUI [1,2]
C0243087
Further Data
Descripción

Further Data

Further Data n° nDAD
Descripción

Left/space, max 8 A documentary aiming (DAD) data can be any kind of information: a Figure, a procedure code or diagnosis or natural language. If the BOMs of coding are used, they may be those of ISMP or any other. The DAD entry is optional. They do not affect the classification into homogeneous groups sick and are not included in the anonymous release Summary: instead of the diagnoses associated with (significant and conventional), they are therefore not passed on to the regional health agency.

Tipo de datos

text

Alias
UMLS CUI [1,1]
C2348235
UMLS CUI [1,2]
C1511726
Procedures
Descripción

Procedures

Date of Procedure performed
Descripción

Date of Procedure

Tipo de datos

date

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C2700391
Code Healthcare Common Procedure Coding System
Descripción

Common classification of medical procedures.

Tipo de datos

text

Alias
UMLS CUI [1]
C1140148
Extension PMSI
Descripción

Medicalization of information systems program

Tipo de datos

text

Phase
Descripción

almost always '0' (only a small number of acts are a realization in distinct phases)

Tipo de datos

integer

Alias
UMLS CUI [1]
C0205390
Activity
Descripción

authorized activities

Tipo de datos

text

Alias
UMLS CUI [1,1]
C1555472
UMLS CUI [1,2]
C2700391
Further Documentation
Descripción

Further Documentation

Tipo de datos

text

Alias
UMLS CUI [1,1]
C1517331
UMLS CUI [1,2]
C0920316
Reimbursement Modifiers
Descripción

Left/space

Tipo de datos

text

Exceptional Reimbursement
Descripción

Exceptional Reimbursement

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0035002
UMLS CUI [1,2]
C0750577
Combination of Procedures
Descripción

Combination of Procedures

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0205195
UMLS CUI [1,2]
C2700391
UMLS CUI [1,3]
C2700391
Times the procedure has been performed
Descripción

Right/Zero

Tipo de datos

integer

Alias
UMLS CUI [1,1]
C1265611
UMLS CUI [1,2]
C2700391
UMLS CUI [1,3]
C0884358
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Similar models

Standardized Discharge Summary March 2016 ATIH France

1 formularios
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
Alias
Item Group
RSS format not grouped 017
FINESS number
Item
FINESS-Number of registration ePMSI
text
RUM format number
Item
Version of the RUM format
integer
RSS Number
Item
RSS Number
text
Hospital Admission Number
Item
Administrative Local Identifier of stay
text
C0600091 (UMLS CUI [1,1])
C0184666 (UMLS CUI [1,2])
RUM Number
Item
RUM No.
text
Date of Birth
Item
Date of birth
date
C0421451 (UMLS CUI [1])
Item
Sex
integer
C0079399 (UMLS CUI [1])
Gender
Code List
Sex
CL Item
male (1)
CL Item
female (2)
Medical Unit ID
Item
Medical unit ID
text
C1555565 (UMLS CUI [1,1])
C0019988 (UMLS CUI [1,2])
Authorization Type Bed
Item
Authorization of type of bed
integer
C1547328 (UMLS CUI [1,1])
C0004916 (UMLS CUI [1,2])
Admission Date Medical Unit
Item
Date of admission to medical unit
date
C1302393 (UMLS CUI [1])
Item
Admission type to the medical unit
integer
C1550330 (UMLS CUI [1])
Admission Type
Code List
Admission type to the medical unit
CL Item
Internal transfer (6)
CL Item
Permanent transfer (7)
CL Item
Temporary transfer (0)
CL Item
Home (8)
CL Item
Death (9)
Item
Previous Medical Unit (if entry mode transfer, transfer or home)
integer
C0205156 (UMLS CUI [1,1])
C0019988 (UMLS CUI [1,2])
Previous Medical Unit
Code List
Previous Medical Unit (if entry mode transfer, transfer or home)
CL Item
From a unit of Medicine, Surgery, Gynecology-Obstetrics, except intensive care unit (1)
CL Item
From a resuscitation unit (R)
CL Item
From a care and rehabilitation unit (2)
CL Item
From a long-term care unit (3)
CL Item
From a psychiatric unit (4)
CL Item
With passage through the emergency department  (5)
CL Item
From a hospital close to patient's home (6)
CL Item
From an assisted-living institution (7)
Discharge Date
Item
Discharge Date
date
C2361123 (UMLS CUI [1])
Item
Discharge Type
integer
C0586514 (UMLS CUI [1])
Admission Type
Code List
Discharge Type
CL Item
Internal transfer (6)
CL Item
Permanent transfer (7)
CL Item
Temporary transfer (0)
CL Item
Home (8)
CL Item
Death (9)
Item
Destination (if Discharge Type transfer, transfer or home)
integer
C0079220 (UMLS CUI [1])
Destination
Code List
Destination (if Discharge Type transfer, transfer or home)
CL Item
To a unit (Medicine, surgery, gynecology-obstetrics) (1)
CL Item
To a care and rehabilitation unit (2)
CL Item
To a long-term care unit  (3)
CL Item
To a psychiatric unit (4)
CL Item
To a hospital close to patient's home (6)
CL Item
To an assisted-living institution (7)
Postal Code
Item
Postal code of residence (or 99 followed code of the oversea country for patients living outside France)
integer
C0421454 (UMLS CUI [1])
Weight Newborn
Item
Weight of the newborn at admission date to the medical unit (in grams)
integer
C2712830 (UMLS CUI [1])
Gestational Age
Item
Gestational age
integer
C0017504 (UMLS CUI [1])
Date Last Menstrual Period
Item
Date of your last period
date
C0425932 (UMLS CUI [1])
Number of Visits
Item
Number of Visits
integer
C0449788 (UMLS CUI [1,1])
C0545082 (UMLS CUI [1,2])
Number of Concomitant Diseases
Item
Number of associated diagnoses (nDA) in this RUM
integer
C0449788 (UMLS CUI [1,1])
C0243087 (UMLS CUI [1,2])
Number of documented data
Item
Number of data (nDAD) documented in this RUM
integer
Number of Procedures
Item
Number of procedures (nZA) in this RUM
integer
C1265611 (UMLS CUI [1,1])
C2700391 (UMLS CUI [1,2])
Main Diagnosis
Item
Main diagnosis (PD)
text
C0332137 (UMLS CUI [1])
Concomitant Diagnosis
Item
Concomitant diagnosis (DR)
text
C0243087 (UMLS CUI [1])
SAPS II
Item
SAPS II
integer
C0451481 (UMLS CUI [1])
Item
Confirmation of the coding of the RSS
integer
C0521091 (UMLS CUI [1,1])
C0009219 (UMLS CUI [1,2])
Confirmation of RSS Code
Code List
Confirmation of the coding of the RSS
CL Item
Yes (1)
CL Item
No (2)
Item
Type of Radiotherapy Device
integer
C0302617 (UMLS CUI [1])
Radiotherapy Device
Code List
Type of Radiotherapy Device
CL Item
Tomotherapy®, Novalis®, Cyberknife® or proton therapy (1)
CL Item
Device equipped with portal imaging, MLC, recording and control system with repositioning patient module (2)
CL Item
Device equipped with portal imaging, MLC, recording and control system without repositioning patient module (3)
CL Item
Device not equipped with portal imaging, MLC or recording and control system (4)
Item
Type of dosimetry
integer
C0034603 (UMLS CUI [1])
Type of Dosimetry
Code List
Type of dosimetry
CL Item
IMRT dosimetry (1 )
CL Item
three-dimensional with HDV on target volume and organ at risk (2 )
CL Item
three-dimensional without HDV on target volume and organ at risk (3 )
CL Item
another type of dosimetry (4 )
Study Number
Item
Study Participation ID
text
C2242969 (UMLS CUI [1])
Number of Previous Abortions
Item
Number of previous abortions
integer
C1265611 (UMLS CUI [1,1])
C0392535 (UMLS CUI [1,2])
Year Previous Abortion
Item
Year of latest abortion
integer
C0439234 (UMLS CUI [1,1])
C0392535 (UMLS CUI [1,2])
Filler
Item
Filler
text
Number of Live Births
Item
Number of previous live births
integer
C2114488 (UMLS CUI [1])
Reserved Space
Item
Reserved Space
integer
Item Group
Diagnosis associated with
Concomitant Diagnosis n° nDA
Item
Concomitant Diagnosis n° nDA
text
C2348235 (UMLS CUI [1,1])
C0243087 (UMLS CUI [1,2])
Item Group
Further Data
Further Data n° nDAD
Item
Further Data n° nDAD
text
C2348235 (UMLS CUI [1,1])
C1511726 (UMLS CUI [1,2])
Item Group
Procedures
Date of Procedure
Item
Date of Procedure performed
date
C0011008 (UMLS CUI [1,1])
C2700391 (UMLS CUI [1,2])
CCAM Code
Item
Code Healthcare Common Procedure Coding System
text
C1140148 (UMLS CUI [1])
Extension PMSI
Item
Extension PMSI
text
Phase
Item
Phase
integer
C0205390 (UMLS CUI [1])
Activity
Item
Activity
text
C1555472 (UMLS CUI [1,1])
C2700391 (UMLS CUI [1,2])
Further Documentation
Item
Further Documentation
text
C1517331 (UMLS CUI [1,1])
C0920316 (UMLS CUI [1,2])
Modifier
Item
Reimbursement Modifiers
text
Exceptional Reimbursement
Item
Exceptional Reimbursement
text
C0035002 (UMLS CUI [1,1])
C0750577 (UMLS CUI [1,2])
Combination of Procedures
Item
Combination of Procedures
text
C0205195 (UMLS CUI [1,1])
C2700391 (UMLS CUI [1,2])
C2700391 (UMLS CUI [1,3])
Times Procedure Performed
Item
Times the procedure has been performed
integer
C1265611 (UMLS CUI [1,1])
C2700391 (UMLS CUI [1,2])
C0884358 (UMLS CUI [1,3])
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