ID

20016

Description

Documentation form for quality assurance in German Health Care by the institute forapplied quality Improvement and Research in Health Care (Aqua), https://www.aqua-institut.de/en/home. Internal Aqua form version: 16-1-K Specification 2015 V02

Link

https://www.aqua-institut.de/en/home

Keywords

Versions (3)
  1. 11/23/14 11/23/14 - Julian Varghese
  2. 2/24/15 2/24/15 - Sarah Schulze Sünninghausen
  3. 2/3/17 2/3/17 - Martin Dugas
Uploaded on

February 3, 2017

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Quality assurance Obstetrics - Child (AQUA)

German English

Quality assurance Obstetrics - Child (AQUA)

1 forms  
Basic documentation - child
Description

Basic documentation - child

Date of birth of the child (dd.mm.yyyy)
Description

Geburtsdatum des Kindes

Data type

date

Alias
UMLS CUI-1
C0421451
Time of Birth (hh:mm)
Description

Uhrzeit der Geburt

Data type

text

Alias
UMLS CUI-1
C2736116
Birth diagnosis child
Description

Geburtsdiagnose Kind

Data type

integer

Alias
UMLS CUI-1
C0011900
further combined birth diagnosis child
Description

weitere kombinierte Geburtsdiagnose Kind

Data type

integer

Gender of the child
Description

Geschlecht des Kindes

Data type

integer

Alias
UMLS CUI-1
C0079399
APGAR
Description

APGAR

Data type

integer

Alias
UMLS CUI-1
C0003533
APGAR
Description

APGAR

Data type

integer

APGAR
Description

APGAR

Data type

integer

Child's body weight (in g)
Description

Gewicht des Kindes

Data type

integer

Measurement units
  • g
Alias
UMLS CUI-1
C0005910
g
Length of the child (in cm)
Description

Länge des Kindes

Data type

integer

Measurement units
  • cm
Alias
UMLS CUI-1
C0005890
cm
Head circumference of the child (in cm)
Description

Kopfumfang des Kindes

Data type

integer

Measurement units
  • cm
Alias
UMLS CUI-1
C0262499
cm
Umbilical artery blood gas analysis
Description

Blutgasanalyse Nabelschnurarterie

Data type

boolean

Alias
UMLS CUI-1
C0005800
Base excess blood gas analysis umbilical artery (in mmol / l)
Description

Base Excess Blutgasanalyse Nabelschnurarterie (in mmol / l)

Data type

integer

Measurement units
  • mmol/l
Alias
UMLS CUI-1
C0201985
mmol/l
pH of blood gas analysis umbilical artery
Description

pH-Wert Blutgasanalyse Nabelschnurarterie

Data type

text

Alias
UMLS CUI-1
C1304686
pulse oximetry
Description

Pulsoxymetrie

Data type

boolean

Alias
UMLS CUI-1
C0034108
Intubation
Description

Intubation

Data type

boolean

Alias
UMLS CUI-1
C0021925
substitution volume
Description

Volumensubstitution

Data type

boolean

Alias
UMLS CUI-1
C0521302
buffering
Description

Pufferung

Data type

boolean

mask ventilation
Description

Maskenbeatmung

Data type

boolean

Alias
UMLS CUI-1
C1960845
O2 enrichment
Description

O2-Anreicherung

Data type

boolean

Alias
UMLS CUI-1
C0523807
U2 performed at children's medical examination
Description

U2 durchgeführt bei kinderärztlicher Untersuchung

Data type

boolean

Congenital Abnormality present
Description

Fehlbildung vorhanden

Data type

boolean

Alias
UMLS CUI-1
C0000768
Malformation diagnosed prenatally
Description

Fehlbildung pränatal diagnostiziert

Data type

integer

Alias
UMLS CUI-1
C0033053
Morbidity diagnosis of the child
Description

Diagnose Morbidität des Kindes

Data type

integer

Alias
UMLS CUI-1
C0848898
In stillbirth
Description

In stillbirth

Stillbirth
Description

Totgeburt

Data type

boolean

Alias
UMLS CUI-1
C0595939
Death before hospital admission in stillbirth
Description

Tod vor Klinikaufnahme bei Totgeburt

Data type

boolean

Time of death in stillborn
Description

Todeszeitpunkt bei Totgeburt

Data type

integer

Alias
UMLS CUI-1
C1301931
Discharge / Transfer
Description

Discharge / Transfer

Child transferred to Children's Hospital
Description

Kind in Kinderklinik verlegt

Data type

boolean

Alias
UMLS CUI-1
C0020017
Children's Hospital number at Transfer of the child
Description

Kinderkliniknummer bei Verlegung des Kindes

Data type

text

Medical specialty Children's Hospital at transfer the child
Description

Fachabteilung der Kinderklinik bei Verlegung des Kindes (§ 301-Vereinbarung)

Data type

integer

Alias
UMLS CUI-1
C0037778
Children's Hospital discharge/transfer date (DD.MM.YYYY)
Description

Entlassungs-/Verlegungsdatum aus der Geburtsklinik Kind

Data type

date

Alias
UMLS CUI-1
C2710998
Discharge / transfer time from the children´s hospital (hh: mm)
Description

Entlassungs-/Verlegungsuhrzeit aus der Geburtsklinik Kind

Data type

text

Alias
UMLS CUI-1
C1442476
Final discharge from / death / stationary in
Description

Endgültige Entlassung aus / Tod in / stationär in

Data type

integer

Discharge/transfer diagnosis from the maternity hospital child
Description

Entlassungs-/Verlegungsdiagnose aus der Geburtsklinik Kind

Data type

integer

Alias
UMLS CUI-1
C0011900
Reason for Discharge from the maternity hospital child
Description

Entlassungsgrund aus der Geburtsklinik Kind (§ 301-Vereinbarung)

Data type

integer

Alias
UMLS CUI-1
C3164834
Death of live-born child within the first 7 days
Description

Tod des lebendgeborenen Kindes innerhalb der ersten 7 Tage

Data type

boolean

Alias
UMLS CUI-1
C0524343
Cause of Death of live-born child
Description

Todesursache des lebendgeborenen Kindes

Data type

integer

Alias
UMLS CUI-1
C0007465
Date of death - live born child (dd.mm.yyyy)
Description

Datum des Todes - lebendgeborenes Kind

Data type

date

Alias
UMLS CUI-1
C1148348
Time of death - live born child (hh: mm)
Description

Uhrzeit des Todes - lebendgeborenes Kind

Data type

text

Alias
UMLS CUI-1
C1301931
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Similar models

Quality assurance Obstetrics - Child (AQUA)

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Basic documentation - child
Geburtsdatum des Kindes
Item
Date of birth of the child (dd.mm.yyyy)
date
C0421451 (UMLS CUI-1)
Uhrzeit der Geburt
Item
Time of Birth (hh:mm)
text
C2736116 (UMLS CUI-1)
Geburtsdiagnose Kind
Item
Birth diagnosis child
integer
C0011900 (UMLS CUI-1)
weitere kombinierte Geburtsdiagnose Kind
Item
further combined birth diagnosis child
integer
Item
Gender of the child
integer
C0079399 (UMLS CUI-1)
Geschlecht des Kindes
Code List
Gender of the child
CL Item
male (1)
CL Item
female (2)
CL Item
not determined (3)
Item
APGAR
integer
C0003533 (UMLS CUI-1)
APGAR
Code List
APGAR
CL Item
0 (0)
CL Item
1 (1)
CL Item
10 (10)
CL Item
2 (2)
CL Item
3 (3)
CL Item
4 (4)
CL Item
5 (5)
CL Item
6 (6)
CL Item
7 (7)
CL Item
8 (8)
CL Item
9 (9)
Item
integer
APGAR
Code List
APGAR
CL Item
 (0)
CL Item
 (1)
CL Item
 (10)
CL Item
 (2)
CL Item
 (3)
CL Item
 (4)
CL Item
 (5)
CL Item
 (6)
CL Item
 (7)
CL Item
 (8)
CL Item
 (9)
Item
integer
APGAR
Code List
APGAR
CL Item
 (0)
CL Item
 (1)
CL Item
 (10)
CL Item
 (2)
CL Item
 (3)
CL Item
 (4)
CL Item
 (5)
CL Item
 (6)
CL Item
 (7)
CL Item
 (8)
CL Item
 (9)
Gewicht des Kindes
Item
Child's body weight (in g)
integer
C0005910 (UMLS CUI-1)
Länge des Kindes
Item
Length of the child (in cm)
integer
C0005890 (UMLS CUI-1)
Kopfumfang des Kindes
Item
Head circumference of the child (in cm)
integer
C0262499 (UMLS CUI-1)
Blutgasanalyse Nabelschnurarterie
Item
Umbilical artery blood gas analysis
boolean
C0005800 (UMLS CUI-1)
Base Excess Blutgasanalyse Nabelschnurarterie (in mmol / l)
Item
Base excess blood gas analysis umbilical artery (in mmol / l)
integer
C0201985 (UMLS CUI-1)
pH-Wert Blutgasanalyse Nabelschnurarterie
Item
pH of blood gas analysis umbilical artery
text
C1304686 (UMLS CUI-1)
Pulsoxymetrie
Item
pulse oximetry
boolean
C0034108 (UMLS CUI-1)
Intubation
Item
Intubation
boolean
C0021925 (UMLS CUI-1)
Volumensubstitution
Item
substitution volume
boolean
C0521302 (UMLS CUI-1)
Pufferung
Item
buffering
boolean
Maskenbeatmung
Item
mask ventilation
boolean
C1960845 (UMLS CUI-1)
O2-Anreicherung
Item
O2 enrichment
boolean
C0523807 (UMLS CUI-1)
U2 durchgeführt bei kinderärztlicher Untersuchung
Item
U2 performed at children's medical examination
boolean
Fehlbildung vorhanden
Item
Congenital Abnormality present
boolean
C0000768 (UMLS CUI-1)
Item
Malformation diagnosed prenatally
integer
C0033053 (UMLS CUI-1)
Fehlbildung pränatal diagnostiziert
Code List
Malformation diagnosed prenatally
CL Item
no (0)
CL Item
yes (1)
CL Item
not determined (2)
Diagnose Morbidität des Kindes
Item
Morbidity diagnosis of the child
integer
C0848898 (UMLS CUI-1)
Item Group
In stillbirth
Totgeburt
Item
Stillbirth
boolean
C0595939 (UMLS CUI-1)
Tod vor Klinikaufnahme bei Totgeburt
Item
Death before hospital admission in stillbirth
boolean
Item
Time of death in stillborn
integer
C1301931 (UMLS CUI-1)
Todeszeitpunkt bei Totgeburt
Code List
Time of death in stillborn
CL Item
antepartum death (1 )
CL Item
death sub partu (2 )
CL Item
time of death unknown (3 )
Item Group
Discharge / Transfer
Kind in Kinderklinik verlegt
Item
Child transferred to Children's Hospital
boolean
C0020017 (UMLS CUI-1)
Kinderkliniknummer bei Verlegung des Kindes
Item
Children's Hospital number at Transfer of the child
text
Item
Medical specialty Children's Hospital at transfer the child
integer
C0037778 (UMLS CUI-1)
Fachabteilung der Kinderklinik bei Verlegung des Kindes
Code List
Medical specialty Children's Hospital at transfer the child
CL Item
internal medicine (0100)
CL Item
internal medicine: geriatrics (0102)
CL Item
internal medicine: cardiology (0103)
CL Item
internal medicine: nephrology (0104)
CL Item
internal medicine: hematology and internal oncology  (0105)
CL Item
internal medicine: endocrinology (0106)
CL Item
internal medicine: gastroenterology  (0107)
CL Item
internal medicine: pneumonology (0108)
CL Item
internal medicine: rheumatology (0109)
CL Item
internal medicine: pulmonology (0114)
CL Item
internal medicine: tumor research (0150)
CL Item
internal medicine: coloproctology (0151)
CL Item
internal medicine: infectiology (0152)
CL Item
internal medicine: diabetes (0153)
CL Item
internal medicine: naturopathy (0154)
CL Item
internal medicine: stroke unit (0156)
CL Item
internal medicine (0190)
CL Item
geriatry (0200)
CL Item
geriatry: gynecology  (0224)
CL Item
geriatry: day unit (for semi-residential care)  (0260)
CL Item
geriaty: night unit (for semi-residential care) (0261)
CL Item
geriatry (0290)
CL Item
cardiology (0300)
CL Item
nephrology (0400)
CL Item
nephrology: pediatrics (0410)
CL Item
nephrology: intensive care (0436)
CL Item
nephrology (0490)
CL Item
hematology and internal oncology  (0500)
CL Item
hematology and internal oncology: pediatrics (0510)
CL Item
hematology and internal oncology: gynacology (0524)
CL Item
hematology and internal oncology: radiation therapy (0533)
CL Item
hematology and internal oncology  (0590)
CL Item
endocrinology (0600)
CL Item
endicrinology: gastroenterology (0607)
CL Item
endocrinology: pediatrics (0610)
CL Item
endocrinology (0690)
CL Item
gastroenterology (0700)
CL Item
gastroenterology: endocrinology (0706)
CL Item
gastroenterology: pediatrics (0710)
CL Item
gastroenterology (0790)
CL Item
pneumology (0800)
CL Item
rheumatology (0900)
CL Item
rheumatology: pediatrics (0910)
CL Item
rheumatology (0990)
CL Item
pediatrics (1000)
CL Item
pediatrics: nephrology (1004)
CL Item
pediatrics: hematology and internal oncology  (1005)
CL Item
pediatrics: endocrinology (1006)
CL Item
pediatrics: gastroenterology (1007)
CL Item
pediatrics: rheumatology (1009)
CL Item
pediatrics: pediatric cardiology (1011)
CL Item
pediatrics: nephrology (1012)
CL Item
pediatrics: pulmonology (1014)
CL Item
pediatrics: pediatric neurology (1028)
CL Item
pediatrics: perinatal medicine (1050)
CL Item
continuing care for children (1051)
CL Item
pediatrics (1090)
CL Item
pediatric cardiology (1100)
CL Item
pediatric cardiology: intensive care (1136)
CL Item
pediatric cardiology (1190)
CL Item
neonatology (1200)
CL Item
pediatric surgery (1300)
CL Item
pulmonology (1400)
CL Item
pulmonology: pediatrics (1410)
CL Item
pulmonology (1490)
CL Item
general surgery (1500)
CL Item
general surgery: pediatric surgery (1513)
CL Item
general surgery: trauma surgery (1516)
CL Item
general surgery: vascular surgery (1518)
CL Item
general surgery: plastic surgery (1519)
CL Item
general surgery: thoracic surgery (1520)
CL Item
general surgery: orthopedics (1523)
CL Item
general surgery: intensive care (1536)
CL Item
general surgery: abdominal- and vascular surgery (1550)
CL Item
Allgemeine Chirurgie: hand surgery (1551)
CL Item
general surgery (1590)
CL Item
trauma surgery (1600)
CL Item
neurosurgery (1700)
CL Item
vascular surgery (1800)
CL Item
plastic surgery (1900)
CL Item
thoracic surgery (2000)
CL Item
thoracic surgery: cardiac surgery (2021)
CL Item
thoracic surgery: intensive care (2036)
CL Item
thoracic surgery: cardiac surgery intensive care (2050)
CL Item
thoracic surgery (2090)
CL Item
cardiac surgery (2100)
CL Item
cardiac surgery: vascular surgery (2118)
CL Item
cardiac surgery: thoracic surgery (2120)
CL Item
cardiac surgery: intensive care (2136)
CL Item
cardiac surgery: thoracic surgery and intensive care (2150)
CL Item
cardiac surgery (2190)
CL Item
urology (2200)
CL Item
orthopedics (2300)
CL Item
orthopedics: rheumatology (2309)
CL Item
orthopedics: surgery (2315)
CL Item
orthopedics and trauma surgery (2316)
CL Item
orthopedics (2390)
CL Item
gynecology and obstetrics (2400)
CL Item
gynecology: geriatry (2402)
CL Item
gynecology: hematology and internal oncology  (2405)
CL Item
gynecology: endocrinology (2406)
CL Item
gynecology (2425)
CL Item
gynecology and obstetrics (2490)
CL Item
obstetrics (2500)
CL Item
otolaryngology (2600)
CL Item
ophthalmology (2700)
CL Item
neurology: (2800)
CL Item
neurology: pediatrics (2810)
CL Item
neurology: stroke units (2856)
CL Item
neurology (2890)
CL Item
general psychiatry: (2900)
CL Item
general psychiatry: neurology (2928)
CL Item
general psychiatry: child and adolescent psychiatry (2930)
CL Item
general psychiatry: psychosomatics and psychotherapy (2931)
CL Item
general psychiatry: addiction treatment (2950)
CL Item
general psychiatry: geropsychiatry (2951)
CL Item
general psychiatry: forensic treatment (2952)
CL Item
general psychiatry: addiction treatment (day unit) (2953)
CL Item
general psychiatry: addiction treatment (night unit) (2954)
CL Item
general psychiatry: geropsychiatry (day unit) (2955)
CL Item
general psychiatry: geropsychiatry (night unit) (2956)
CL Item
general psychiatry: day unit (for semi-residential care) (2960)
CL Item
general psychiatry: night unit (for semi-residential care) (2961)
CL Item
general psychiatry (2990)
CL Item
child and adolescent psychiatry (3000)
CL Item
child and adolescent psychiatry: day unit (for semi-residential care) (3060)
CL Item
child and adolescent psychiatry: night unit (for semi-residential care) (3061)
CL Item
child and adolescent psychiatry (3090)
CL Item
psychosomatic/psychotherapy (3100)
CL Item
psychosomatic/psychotherapy: child and adolescent psychiatry (3110)
CL Item
psychosomatic/psychotherapy: day unit (for semi-residential care) (3160)
CL Item
psychosomatic/psychotherapy: night unit (for semi-residential care) (3161)
CL Item
psychosomatic/psychotherapy (3190)
CL Item
nuclear medicine (3200)
CL Item
nuclear medicine: radiation therapy (3233)
CL Item
nuclear medicine (3290)
CL Item
radiation therapy (3300)
CL Item
radiation therapy: hematology and internal oncology  (3305)
CL Item
radiation therapy: radiology (3350)
CL Item
radiation therapy (3390)
CL Item
dermatology (3400)
CL Item
dermatology: day unit (for semi-residential care) (3460)
CL Item
dermatology (3490)
CL Item
dentistry, orthodontics, maxillofacial surgery (3500)
CL Item
intensive-care medicine (3600)
CL Item
intensive-care medicine: internal medicine (3601)
CL Item
intensive-care medicine: cardiology (3603)
CL Item
intensive-care medicine: pediatrics (3610)
CL Item
intensive-care medicine: neurosurgery (3617)
CL Item
intensive-care medicine: surgery (3618)
CL Item
intensive-care medicine: cardiac surgery (3621)
CL Item
intensive-care medicine: urology (3622)
CL Item
intensive-care medicine: gynecology and obstetrics (3624)
CL Item
intensive-care medicine: otolaryngology  (3626)
CL Item
intensive-care medicine: neurology (3628)
CL Item
operative intensive-care medicine: surgery (3650)
CL Item
intensive-care medicine: thorax-heart surgery (3651)
CL Item
intensive-care medicine: heart-thorax surgery (3652)
CL Item
intensive-care medicine (3690)
CL Item
other medical specialty (3700)
CL Item
angiology (3750)
CL Item
radiology (3751)
CL Item
palliative care (3752)
CL Item
pain therapy (3753)
CL Item
section for alternative health practice (3754)
CL Item
spinal surgery (3755)
CL Item
addiction medicine (3756)
CL Item
visceral surgery (3757)
CL Item
other medical specialty (3790)
Entlassungs-/Verlegungsdatum aus der Geburtsklinik Kind
Item
Children's Hospital discharge/transfer date (DD.MM.YYYY)
date
C2710998 (UMLS CUI-1)
Entlassungs-/Verlegungsuhrzeit aus der Geburtsklinik Kind
Item
Discharge / transfer time from the children´s hospital (hh: mm)
text
C1442476 (UMLS CUI-1)
Item
Final discharge from / death / stationary in
integer
Endgültige Entlassung aus / Tod in / stationär in
Code List
Final discharge from / death / stationary in
CL Item
maternity hospital (1)
C0020010 (UMLS CUI-1)
CL Item
children's Hospital (2)
C0020017 (UMLS CUI-1)
Entlassungs-/Verlegungsdiagnose aus der Geburtsklinik Kind
Item
Discharge/transfer diagnosis from the maternity hospital child
integer
C0011900 (UMLS CUI-1)
Item
Reason for Discharge from the maternity hospital child
integer
C3164834 (UMLS CUI-1)
Entlassungsgrund aus der Geburtsklinik Kind
Code List
Reason for Discharge from the maternity hospital child
CL Item
treatment finished as planned (1)
CL Item
transferral to nursing facility (10)
CL Item
discharge to hospice (11)
CL Item
external transferral to psychiatric treatment (13)
CL Item
treatment finished because of other reasons, postdischarge treatment is planned (14)
CL Item
treatment aborted against medical advice, postdischarge treatment is planned (15)
CL Item
internal transferral with change of DRG payment areas (17)
CL Item
treatment finished as planned, postdischarge treatment is planned (2)
CL Item
case termination (internal transferral) with change between full- and partial stationary care (22)
CL Item
treatment finished because of other reasons (3)
CL Item
treatment aborted against medical advice (4)
CL Item
change of jurisdiction of insurer or other payer (5)
CL Item
transferral to another hospital (6)
CL Item
death (7)
CL Item
transferral to another hospital within cooperative and governmental policies  (8)
CL Item
transferral to rehabilitation facility (9)
CL Item
discharge at the end of the year with admission in previous year (25)
Tod des lebendgeborenen Kindes innerhalb der ersten 7 Tage
Item
Death of live-born child within the first 7 days
boolean
C0524343 (UMLS CUI-1)
Todesursache des lebendgeborenen Kindes
Item
Cause of Death of live-born child
integer
C0007465 (UMLS CUI-1)
Datum des Todes - lebendgeborenes Kind
Item
Date of death - live born child (dd.mm.yyyy)
date
C1148348 (UMLS CUI-1)
Uhrzeit des Todes - lebendgeborenes Kind
Item
Time of death - live born child (hh: mm)
text
C1301931 (UMLS CUI-1)
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