ID

17834

Beskrivning

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/

Länk

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

Nyckelord

Versioner (1)
  1. 2016-10-04 2016-10-04 -
Uppladdad den

4 oktober 2016

DOI

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Licens

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

Engelsk Franska

Standardized Discharge Summary March 2016 ATIH France

1 Formulär  
RSS format not grouped 017
Beskrivning

RSS format not grouped 017

FINESS-Number of registration ePMSI
Beskrivning

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.

Datatyp

text

Version of the RUM format
Beskrivning

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.

Datatyp

integer

RSS Number
Beskrivning

Left/space

Datatyp

text

Administrative Local Identifier of stay
Beskrivning

Left/space

Datatyp

text

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

Left/space

Datatyp

text

Date of birth
Beskrivning

Date of Birth

Datatyp

date

Alias
UMLS CUI [1]
C0421451
Sex
Beskrivning

Gender

Datatyp

integer

Alias
UMLS CUI [1]
C0079399
Medical unit ID
Beskrivning

Left/space

Datatyp

text

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

Right/Zero

Datatyp

integer

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

Admission Date Medical Unit

Datatyp

date

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

Admission Type

Datatyp

integer

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

Previous Medical Unit

Datatyp

integer

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

Discharge Date

Datatyp

date

Alias
UMLS CUI [1]
C2361123
Discharge Type
Beskrivning

Discharge Type

Datatyp

integer

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

Destination

Datatyp

integer

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

Right/Zero

Datatyp

integer

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

Right/Zero

Datatyp

integer

Måttenheter
  • g
Alias
UMLS CUI [1]
C2712830
g
Gestational age
Beskrivning

Right/Zero

Datatyp

integer

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

Date Last Menstrual Period

Datatyp

date

Alias
UMLS CUI [1]
C0425932
Number of Visits
Beskrivning

Right/Zero

Datatyp

integer

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

Right/Zero

Datatyp

integer

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

Right/Zero

Datatyp

integer

Number of procedures (nZA) in this RUM
Beskrivning

Right/Zero

Datatyp

integer

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

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').

Datatyp

text

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

Left/space

Datatyp

text

Alias
UMLS CUI [1]
C0243087
SAPS II
Beskrivning

Right/Zero Simplified severity index

Datatyp

integer

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

Confirmation of RSS Code

Datatyp

integer

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

Radiotherapy Device

Datatyp

integer

Alias
UMLS CUI [1]
C0302617
Type of dosimetry
Beskrivning

Type of Dosimetry

Datatyp

integer

Alias
UMLS CUI [1]
C0034603
Study Participation ID
Beskrivning

Left/space

Datatyp

text

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

Right/Zero

Datatyp

integer

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

Right/Zero

Datatyp

integer

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

NA / space

Datatyp

text

Number of previous live births
Beskrivning

Right/Zero

Datatyp

integer

Alias
UMLS CUI [1]
C2114488
Reserved Space
Beskrivning

NA / space

Datatyp

integer

Diagnosis associated with
Beskrivning

Diagnosis associated with

Concomitant Diagnosis n° nDA
Beskrivning

Left/space Diagnosis associated with

Datatyp

text

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

Further Data

Further Data n° nDAD
Beskrivning

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.

Datatyp

text

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

Procedures

Date of Procedure performed
Beskrivning

Date of Procedure

Datatyp

date

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

Common classification of medical procedures.

Datatyp

text

Alias
UMLS CUI [1]
C1140148
Extension PMSI
Beskrivning

Medicalization of information systems program

Datatyp

text

Phase
Beskrivning

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

Datatyp

integer

Alias
UMLS CUI [1]
C0205390
Activity
Beskrivning

authorized activities

Datatyp

text

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

Further Documentation

Datatyp

text

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

Left/space

Datatyp

text

Exceptional Reimbursement
Beskrivning

Exceptional Reimbursement

Datatyp

text

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

Combination of Procedures

Datatyp

text

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

Right/Zero

Datatyp

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 Formulär
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
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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