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ID

19097

Description

Hospital Routine Documentation Subform at the University Hospital Muenster. Original Form name: Entlassbericht Hamburg Sub.

Keywords

Versions (2)
  1. 11/18/16 11/18/16 -
  2. 12/5/16 12/5/16 -
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December 5, 2016

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Creative Commons BY-NC 3.0
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    Entlassbericht Hamburg Sub University Hospital Muenster (UKM) Subform

    German

    Entlassbericht Hamburg Sub University Hospital Muenster (UKM) Subform

    1 forms  
    Aktuelle Vitalzeichen / letzte Medikation
    Description

    Aktuelle Vitalzeichen / letzte Medikation

    Alias
    UMLS CUI-1
    C0518766
    UMLS CUI-2
    C0013227
    UMLS CUI-3
    C0030685
    Blutdruck
    Description

    Blood pressure

    Data type

    text

    Measurement units
    • mmHg
    Alias
    UMLS CUI [1]
    C0005823
    mmHg
    Blutzucker
    Description

    Blood sugar

    Data type

    text

    Alias
    UMLS CUI [1]
    C0392201
    Temperatur
    Description

    Temperature

    Data type

    float

    Measurement units
    • °C
    Alias
    UMLS CUI [1]
    C0005903
    °C
    Puls
    Description

    Pulse

    Data type

    text

    Alias
    UMLS CUI [1]
    C0232117
    Atmung
    Description

    Respiration

    Data type

    text

    Alias
    UMLS CUI [1]
    C0035203
    Letzte Medikation
    Description

    Latest medication

    Data type

    text

    Alias
    UMLS CUI [1]
    C0013227
    Bewusstsein / Orientierung
    Description

    Bewusstsein / Orientierung

    Alias
    UMLS CUI-1
    C0234421
    UMLS CUI-2
    C0029266
    UMLS CUI-3
    C0030685
    wach
    Description

    Alertness

    Data type

    boolean

    Alias
    UMLS CUI [1]
    C0239110
    somnolent
    Description

    Somnolence

    Data type

    boolean

    Alias
    UMLS CUI [1]
    C2830004
    desorientiert
    Description

    Desorientation

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0233407
    UMLS CUI [1,2]
    C0009676
    komatös
    Description

    Coma

    Data type

    boolean

    Alias
    UMLS CUI [1]
    C0009421
    zur Person
    Description

    Orientation to person

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0029266
    UMLS CUI [1,2]
    C2371003
    örtlich
    Description

    Orientation to place

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0029266
    UMLS CUI [1,2]
    C2370999
    situativ
    Description

    Orientation to situation

    Data type

    boolean

    Alias
    UMLS CUI [1]
    C0029266
    Weglauftendenz
    Description

    Tendency to run away

    Data type

    boolean

    Alias
    UMLS CUI [1]
    C0029266
    sonstiges
    Description

    Other

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0205394
    UMLS CUI [1,2]
    C0234421
    UMLS CUI [1,3]
    C0029266
    Wenn sonstiges, bitte beschreiben
    Description

    Other (specification)

    Data type

    text

    Alias
    UMLS CUI [1,1]
    C0205394
    UMLS CUI [1,2]
    C0234421
    UMLS CUI [1,3]
    C0029266
    Mobilität (körperlich)
    Description

    Mobilität (körperlich)

    Alias
    UMLS CUI-1
    C0030685
    UMLS CUI-2
    C0449580
    selbständig
    Description

    Independently mobile

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0429979
    UMLS CUI [1,2]
    C0449580
    Rollstuhl
    Description

    Wheelchair

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0449580
    UMLS CUI [1,2]
    C0043143
    Gehhilfe
    Description

    Walking aid

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0449580
    UMLS CUI [1,2]
    C0557834
    eingeschränkt
    Description

    Reduced mobility

    Data type

    boolean

    Alias
    UMLS CUI [1]
    C0700572
    Bettlägerigkeit
    Description

    Bedriddenness

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0425251
    UMLS CUI [1,2]
    C0449580
    Essen / Trinken
    Description

    Essen / Trinken

    Alias
    UMLS CUI-1
    C0392209
    UMLS CUI-2
    C0600072
    UMLS CUI-3
    C0030685
    Diät
    Description

    Diet

    Data type

    boolean

    Alias
    UMLS CUI [1]
    C0012155
    wenn Diät, bitte beschreiben
    Description

    Diet (specification)

    Data type

    text

    Alias
    UMLS CUI [1,1]
    C0012155
    UMLS CUI [1,2]
    C2348235
    Schluckstörung
    Description

    Dysphagia

    Data type

    boolean

    Alias
    UMLS CUI [1]
    C0011168
    Ernährungssonde
    Description

    Feeding tube

    Data type

    boolean

    Alias
    UMLS CUI [1]
    C0041281
    Pat. trinkt ausreichend?
    Description

    Sufficient drinking

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0429791
    UMLS CUI [1,2]
    C0205410
    Pat. isst ausreichend?
    Description

    Sufficient eating

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0013470
    UMLS CUI [1,2]
    C0205410
    Ausscheidung
    Description

    Ausscheidung

    Alias
    UMLS CUI-1
    C0221102
    UMLS CUI-2
    C0030685
    Harninkontinenz
    Description

    Aconuresis

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0542565
    UMLS CUI [1,2]
    C0042024
    Pat. hat abgeführt
    Description

    Purging

    Data type

    boolean

    Alias
    UMLS CUI [1]
    C0855227
    Pat. hat abgeführt am
    Description

    Date of purging

    Data type

    date

    Alias
    UMLS CUI [1,1]
    C0855227
    UMLS CUI [1,2]
    C0011008
    Stuhlregulierung
    Description

    Fecal regulation

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C1290944
    UMLS CUI [1,2]
    C0015733
    Stuhlregulierung durch
    Description

    Method of fecal regulation

    Data type

    text

    Alias
    UMLS CUI [1,1]
    C0025663
    UMLS CUI [1,2]
    C1290944
    UMLS CUI [1,3]
    C0015733
    Blasenkatheter
    Description

    Urinary catheter

    Data type

    boolean

    Alias
    UMLS CUI [1]
    C0042019
    Blasenkatheter am
    Description

    Date of urinary catheter

    Data type

    date

    Alias
    UMLS CUI [1,1]
    C0042019
    UMLS CUI [1,2]
    C0011008
    Anus praeter
    Description

    Artificial anus

    Data type

    boolean

    Alias
    UMLS CUI [1]
    C1611169
    Versorgung Anus praeter
    Description

    Care of artificial anus

    Data type

    text

    Alias
    UMLS CUI [1,1]
    C1611169
    UMLS CUI [1,2]
    C1947933
    UMLS CUI [1,3]
    C0024501
    Schlaf / spezielle Pflegehinweise
    Description

    Schlaf / spezielle Pflegehinweise

    Alias
    UMLS CUI-1
    C0037313
    UMLS CUI-2
    C0017313
    UMLS CUI-3
    C0947611
    UMLS CUI-4
    C0030685
    Schlafgewohnheiten
    Description

    Sleeping habits

    Data type

    text

    Alias
    UMLS CUI [1,1]
    C0037313
    UMLS CUI [1,2]
    C0018464
    Spezielle pflegerische Hinweise
    Description

    z.B. Schmerzen, Dekubitus, Therapie, fachärztl. Behandlung

    Data type

    text

    Alias
    UMLS CUI [1,1]
    C0017313
    UMLS CUI [1,2]
    C2348235
    UMLS CUI [1,3]
    C0947611
    Hilfsmittel
    Description

    Hilfsmittel

    Alias
    UMLS CUI-1
    C0036605
    UMLS CUI-2
    C0030685
    Brille
    Description

    Glasses

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0015421
    UMLS CUI [1,2]
    C0042813
    Hörgerät
    Description

    Hearing aid

    Data type

    boolean

    Alias
    UMLS CUI [1]
    C0018768
    Zahnprothese
    Description

    Denture

    Data type

    boolean

    Alias
    UMLS CUI [1]
    C0011394
    Zahnprothese oben
    Description

    Denture upper jaw

    Data type

    boolean

    Alias
    UMLS CUI [1]
    C0011394
    Zahnprothese unten
    Description

    Denture lower jaw

    Data type

    boolean

    Alias
    UMLS CUI [1]
    C0011394
    Sonstiges
    Description

    Other

    Data type

    boolean

    Alias
    UMLS CUI [1,1]
    C0036605
    UMLS CUI [1,2]
    C0205394
    Wenn sonstiges, bitte beschreiben
    Description

    Other (specification)

    Data type

    text

    Alias
    UMLS CUI [1,1]
    C0036605
    UMLS CUI [1,2]
    C0205394
    Patient benötigt Unterstützung beim
    Description

    Patient benötigt Unterstützung beim

    Alias
    UMLS CUI-1
    C1521721
    UMLS CUI-2
    C0030685
    Essen
    Description

    Eating

    Data type

    text

    Alias
    UMLS CUI [1,1]
    C1521721
    UMLS CUI [1,2]
    C0013470
    Trinken
    Description

    Drinking

    Data type

    text

    Alias
    UMLS CUI [1,1]
    C1521721
    UMLS CUI [1,2]
    C0429791
    Aufstehen
    Description

    Getting up

    Data type

    text

    Alias
    UMLS CUI [1,1]
    C1521721
    UMLS CUI [1,2]
    C0449580
    An-/Auskleiden
    Description

    Dressing/Undressing

    Data type

    text

    Alias
    UMLS CUI [1,1]
    C1521721
    UMLS CUI [1,2]
    C0518459
    Waschen
    Description

    Washing

    Data type

    text

    Alias
    UMLS CUI [1,1]
    C1521721
    UMLS CUI [1,2]
    C0564673
    UMLS CUI [1,3]
    C0441648
    Toilettengang
    Description

    Going to the toilet

    Data type

    text

    Alias
    UMLS CUI [1,1]
    C1521721
    UMLS CUI [1,2]
    C1718402
    Weitere Informationen
    Description

    Weitere Informationen

    Alias
    UMLS CUI-1
    C0030685
    UMLS CUI-2
    C1533716
    Datum
    Description

    Date

    Data type

    date

    Alias
    UMLS CUI [1]
    C0011008
    Pflegekraft
    Description

    Nurse

    Data type

    text

    Alias
    UMLS CUI [1]
    C0028661
    Station
    Description

    Bei weiteren Fragen wenden Sie sich bitte an das Team der Station

    Data type

    text

    Alias
    UMLS CUI [1,1]
    C1305702
    UMLS CUI [1,2]
    C1704729
    Telefon
    Description

    Telephone

    Data type

    text

    Alias
    UMLS CUI [1]
    C1515258
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    Similar models

    Entlassbericht Hamburg Sub University Hospital Muenster (UKM) Subform

    1 forms
    Name
    Type
    Description | Question | Decode (Coded Value)
    Data type
    Alias
    Item Group
    Aktuelle Vitalzeichen / letzte Medikation
    C0518766 (UMLS CUI-1)
    C0013227 (UMLS CUI-2)
    C0030685 (UMLS CUI-3)
    Blood pressure
    Item
    Blutdruck
    text
    C0005823 (UMLS CUI [1])
    Blood sugar
    Item
    Blutzucker
    text
    C0392201 (UMLS CUI [1])
    Temperature
    Item
    Temperatur
    float
    C0005903 (UMLS CUI [1])
    Pulse
    Item
    Puls
    text
    C0232117 (UMLS CUI [1])
    Respiration
    Item
    Atmung
    text
    C0035203 (UMLS CUI [1])
    Latest medication
    Item
    Letzte Medikation
    text
    C0013227 (UMLS CUI [1])
    Item Group
    Bewusstsein / Orientierung
    C0234421 (UMLS CUI-1)
    C0029266 (UMLS CUI-2)
    C0030685 (UMLS CUI-3)
    Alertness
    Item
    wach
    boolean
    C0239110 (UMLS CUI [1])
    Somnolence
    Item
    somnolent
    boolean
    C2830004 (UMLS CUI [1])
    Desorientation
    Item
    desorientiert
    boolean
    C0233407 (UMLS CUI [1,1])
    C0009676 (UMLS CUI [1,2])
    Coma
    Item
    komatös
    boolean
    C0009421 (UMLS CUI [1])
    Orientation to person
    Item
    zur Person
    boolean
    C0029266 (UMLS CUI [1,1])
    C2371003 (UMLS CUI [1,2])
    Orientation to place
    Item
    örtlich
    boolean
    C0029266 (UMLS CUI [1,1])
    C2370999 (UMLS CUI [1,2])
    Orientation to situation
    Item
    situativ
    boolean
    C0029266 (UMLS CUI [1])
    Tendency to run away
    Item
    Weglauftendenz
    boolean
    C0029266 (UMLS CUI [1])
    Other
    Item
    sonstiges
    boolean
    C0205394 (UMLS CUI [1,1])
    C0234421 (UMLS CUI [1,2])
    C0029266 (UMLS CUI [1,3])
    Other (specification)
    Item
    Wenn sonstiges, bitte beschreiben
    text
    C0205394 (UMLS CUI [1,1])
    C0234421 (UMLS CUI [1,2])
    C0029266 (UMLS CUI [1,3])
    Item Group
    Mobilität (körperlich)
    C0030685 (UMLS CUI-1)
    C0449580 (UMLS CUI-2)
    Independently mobile
    Item
    selbständig
    boolean
    C0429979 (UMLS CUI [1,1])
    C0449580 (UMLS CUI [1,2])
    Wheelchair
    Item
    Rollstuhl
    boolean
    C0449580 (UMLS CUI [1,1])
    C0043143 (UMLS CUI [1,2])
    Walking aid
    Item
    Gehhilfe
    boolean
    C0449580 (UMLS CUI [1,1])
    C0557834 (UMLS CUI [1,2])
    Reduced mobility
    Item
    eingeschränkt
    boolean
    C0700572 (UMLS CUI [1])
    Bedriddenness
    Item
    Bettlägerigkeit
    boolean
    C0425251 (UMLS CUI [1,1])
    C0449580 (UMLS CUI [1,2])
    Item Group
    Essen / Trinken
    C0392209 (UMLS CUI-1)
    C0600072 (UMLS CUI-2)
    C0030685 (UMLS CUI-3)
    Diet
    Item
    Diät
    boolean
    C0012155 (UMLS CUI [1])
    Diet (specification)
    Item
    wenn Diät, bitte beschreiben
    text
    C0012155 (UMLS CUI [1,1])
    C2348235 (UMLS CUI [1,2])
    Dysphagia
    Item
    Schluckstörung
    boolean
    C0011168 (UMLS CUI [1])
    Feeding tube
    Item
    Ernährungssonde
    boolean
    C0041281 (UMLS CUI [1])
    Sufficient drinking
    Item
    Pat. trinkt ausreichend?
    boolean
    C0429791 (UMLS CUI [1,1])
    C0205410 (UMLS CUI [1,2])
    Sufficient eating
    Item
    Pat. isst ausreichend?
    boolean
    C0013470 (UMLS CUI [1,1])
    C0205410 (UMLS CUI [1,2])
    Item Group
    Ausscheidung
    C0221102 (UMLS CUI-1)
    C0030685 (UMLS CUI-2)
    Aconuresis
    Item
    Harninkontinenz
    boolean
    C0542565 (UMLS CUI [1,1])
    C0042024 (UMLS CUI [1,2])
    Purging
    Item
    Pat. hat abgeführt
    boolean
    C0855227 (UMLS CUI [1])
    Date of purging
    Item
    Pat. hat abgeführt am
    date
    C0855227 (UMLS CUI [1,1])
    C0011008 (UMLS CUI [1,2])
    Fecal regulation
    Item
    Stuhlregulierung
    boolean
    C1290944 (UMLS CUI [1,1])
    C0015733 (UMLS CUI [1,2])
    Method of fecal regulation
    Item
    Stuhlregulierung durch
    text
    C0025663 (UMLS CUI [1,1])
    C1290944 (UMLS CUI [1,2])
    C0015733 (UMLS CUI [1,3])
    Urinary catheter
    Item
    Blasenkatheter
    boolean
    C0042019 (UMLS CUI [1])
    Date of urinary catheter
    Item
    Blasenkatheter am
    date
    C0042019 (UMLS CUI [1,1])
    C0011008 (UMLS CUI [1,2])
    Artificial anus
    Item
    Anus praeter
    boolean
    C1611169 (UMLS CUI [1])
    Item
    Versorgung Anus praeter
    text
    C1611169 (UMLS CUI [1,1])
    C1947933 (UMLS CUI [1,2])
    C0024501 (UMLS CUI [1,3])
    Care of artificial anus
    Code List
    Versorgung Anus praeter
    CL Item
    mit Hilfe (mit Hilfe)
    CL Item
    Versorgung selbständig (Versorgung selbständig)
    Item Group
    Schlaf / spezielle Pflegehinweise
    C0037313 (UMLS CUI-1)
    C0017313 (UMLS CUI-2)
    C0947611 (UMLS CUI-3)
    C0030685 (UMLS CUI-4)
    Sleeping habits
    Item
    Schlafgewohnheiten
    text
    C0037313 (UMLS CUI [1,1])
    C0018464 (UMLS CUI [1,2])
    Nursing specifics
    Item
    Spezielle pflegerische Hinweise
    text
    C0017313 (UMLS CUI [1,1])
    C2348235 (UMLS CUI [1,2])
    C0947611 (UMLS CUI [1,3])
    Item Group
    Hilfsmittel
    C0036605 (UMLS CUI-1)
    C0030685 (UMLS CUI-2)
    Glasses
    Item
    Brille
    boolean
    C0015421 (UMLS CUI [1,1])
    C0042813 (UMLS CUI [1,2])
    Hearing aid
    Item
    Hörgerät
    boolean
    C0018768 (UMLS CUI [1])
    Denture
    Item
    Zahnprothese
    boolean
    C0011394 (UMLS CUI [1])
    Denture upper jaw
    Item
    Zahnprothese oben
    boolean
    C0011394 (UMLS CUI [1])
    Denture lower jaw
    Item
    Zahnprothese unten
    boolean
    C0011394 (UMLS CUI [1])
    Other
    Item
    Sonstiges
    boolean
    C0036605 (UMLS CUI [1,1])
    C0205394 (UMLS CUI [1,2])
    Other (specification)
    Item
    Wenn sonstiges, bitte beschreiben
    text
    C0036605 (UMLS CUI [1,1])
    C0205394 (UMLS CUI [1,2])
    Item Group
    Patient benötigt Unterstützung beim
    C1521721 (UMLS CUI-1)
    C0030685 (UMLS CUI-2)
    Item
    Essen
    text
    C1521721 (UMLS CUI [1,1])
    C0013470 (UMLS CUI [1,2])
    Eating
    Code List
    Essen
    CL Item
    ganz (ganz)
    CL Item
    teilweise (teilweise)
    CL Item
    ohne (ohne)
    Item
    Trinken
    text
    C1521721 (UMLS CUI [1,1])
    C0429791 (UMLS CUI [1,2])
    Eating
    Code List
    Trinken
    CL Item
    ganz (ganz)
    CL Item
    teilweise (teilweise)
    CL Item
    ohne (ohne)
    Item
    Aufstehen
    text
    C1521721 (UMLS CUI [1,1])
    C0449580 (UMLS CUI [1,2])
    Eating
    Code List
    Aufstehen
    CL Item
    ganz (ganz)
    CL Item
    teilweise (teilweise)
    CL Item
    ohne (ohne)
    Item
    An-/Auskleiden
    text
    C1521721 (UMLS CUI [1,1])
    C0518459 (UMLS CUI [1,2])
    Eating
    Code List
    An-/Auskleiden
    CL Item
    ganz (ganz)
    CL Item
    teilweise (teilweise)
    CL Item
    ohne (ohne)
    Item
    Waschen
    text
    C1521721 (UMLS CUI [1,1])
    C0564673 (UMLS CUI [1,2])
    C0441648 (UMLS CUI [1,3])
    Eating
    Code List
    Waschen
    CL Item
    ganz (ganz)
    CL Item
    teilweise (teilweise)
    CL Item
    ohne (ohne)
    Item
    Toilettengang
    text
    C1521721 (UMLS CUI [1,1])
    C1718402 (UMLS CUI [1,2])
    Eating
    Code List
    Toilettengang
    CL Item
    ganz (ganz)
    CL Item
    teilweise (teilweise)
    CL Item
    ohne (ohne)
    Item Group
    Weitere Informationen
    C0030685 (UMLS CUI-1)
    C1533716 (UMLS CUI-2)
    Date
    Item
    Datum
    date
    C0011008 (UMLS CUI [1])
    Nurse
    Item
    Pflegekraft
    text
    C0028661 (UMLS CUI [1])
    ward
    Item
    Station
    text
    C1305702 (UMLS CUI [1,1])
    C1704729 (UMLS CUI [1,2])
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    Item
    Telefon
    text
    C1515258 (UMLS CUI [1])
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