ID

21240

Description

Hospital Routine Documentation Subform at the University Hospital Cologne. Original Form name: Allgemeiner_Befund_Poliklinik

Keywords

Versions (1)
  1. 4/16/17 4/16/17 -
Uploaded on

April 16, 2017

DOI

To request one please log in.

License

Creative Commons BY-NC 3.0
Model comments :

You can comment on the data model here. Via the speech bubbles at the itemgroups and items you can add comments to those specificially.

Back to model comments
Itemgroup comments for :

Item comments for :

  • Newest
  • Oldest
  • Popular
  • Newest
    • Newest
    • Oldest
    • Popular

No comments

In order to download data models you must be logged in. Please log in or register for free.

Trauma surgery polyclinic, University Hospital Cologne

German

Trauma surgery polyclinic, University Hospital Cologne

1 forms  
Unfallchirurgie Poliklinik
Description

Unfallchirurgie Poliklinik

Alias
UMLS CUI-1
C0587530
UMLS CUI-2
C0557824
Auftragsstatus
Description

Order status

Data type

text

Alias
UMLS CUI [1,1]
C1550341
UMLS CUI [1,2]
C0587530
Auftragsnummer
Description

Request identification number

Data type

text

Alias
UMLS CUI [1,1]
C1300638
UMLS CUI [1,2]
C1272683
UMLS CUI [1,3]
C0587530
Dringlichkeit
Description

Urgency of request

Data type

text

Alias
UMLS CUI [1,1]
C0549179
UMLS CUI [1,2]
C1272683
UMLS CUI [1,3]
C0587530
Zielbenutzer
Description

Recipient

Data type

text

Alias
UMLS CUI [1,1]
C1709854
UMLS CUI [1,2]
C1706077
UMLS CUI [1,3]
C0587530
Rückweisungs-/Stornierungsgrund
Description

Justification for cancellation of request

Data type

text

Alias
UMLS CUI [1,1]
C0566251
UMLS CUI [1,2]
C1548226
UMLS CUI [1,3]
C0587530
Leistungsanforderer
Description

Department requesting service

Data type

text

Alias
UMLS CUI [1,1]
C1272683
UMLS CUI [1,2]
C1550369
UMLS CUI [1,3]
C0019961
Leistungserbringer
Description

Department performing service

Data type

text

Alias
UMLS CUI [1,1]
C0557854
UMLS CUI [1,2]
C1550369
UMLS CUI [1,3]
C0019961
Art des Befundes/Angeforderte Leistung
Description

Type of service requested

Data type

text

Alias
UMLS CUI [1,1]
C0332307
UMLS CUI [1,2]
C1272683
UMLS CUI [1,3]
C0557854
BG Fall Datenerfassung
Description

BG Fall Datenerfassung

Alias
UMLS CUI-1
C0021676
UMLS CUI-2
C0681104
UMLS CUI-3
C0000931
Unfallbetrieb
Description

Unfallbetrieb

Alias
UMLS CUI-1
C1274022
UMLS CUI-2
C0000931
Unfallbetrieb Name
Description

Name of corporation

Data type

text

Alias
UMLS CUI [1,1]
C0683758
UMLS CUI [1,2]
C0027365
Unfallbetrieb Adresse
Description

Address of corporation

Data type

text

Alias
UMLS CUI [1,1]
C0683758
UMLS CUI [1,2]
C1442065
Patient beschäftigt als
Description

Patient occupied as

Data type

text

Alias
UMLS CUI [1,1]
C0421456
UMLS CUI [1,2]
C0332307
Patient beschäftigt seit
Description

Patient occupied since

Data type

date

Measurement units
  • dd.mm.yyyy
Alias
UMLS CUI [1,1]
C0421456
UMLS CUI [1,2]
C0808070
dd.mm.yyyy
Unfall
Description

Unfall

Alias
UMLS CUI-1
C0000924
Unfallort
Description

Accident site

Data type

text

Alias
UMLS CUI [1]
C0337069
Unfalldatum
Description

Date of accident

Data type

date

Measurement units
  • dd.mm.yyyy
Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C0000924
dd.mm.yyyy
Arbeitszeit von
Description

Working hours start

Data type

time

Measurement units
  • hh:mm
Alias
UMLS CUI [1,1]
C0043227
UMLS CUI [1,2]
C1301880
hh:mm
Arbeitszeit bis
Description

Working hours end

Data type

time

Measurement units
  • hh:mm
Alias
UMLS CUI [1,1]
C0043227
UMLS CUI [1,2]
C1522314
hh:mm
Unfallunabhängige Beeinträchtigungen
Description

Prior impairments not caused by current accident

Data type

text

Alias
UMLS CUI [1,1]
C2347662
UMLS CUI [1,2]
C0221099
UMLS CUI [1,3]
C1314792
Alkohol/Drogen/Medikamente
Description

Use of alcohol, drugs or pharmaceutical preparations

Data type

boolean

Alias
UMLS CUI [1,1]
C0237123
UMLS CUI [1,2]
C0240320
Blutentnahme durchgeführt
Description

Blood test performed

Data type

boolean

Alias
UMLS CUI [1]
C0005834
Zweifel/Bedenken an Arbeitsunfall
Description

Doubts or disbelief in casualty being an occupational accident

Data type

boolean

Alias
UMLS CUI [1,1]
C0000931
UMLS CUI [1,2]
C1547322
Art der Heilbehandlung
Description

Art der Heilbehandlung

Alias
UMLS CUI-1
C0039798
Art der Heilbehandlung
Description

Type of treatment

Data type

integer

Alias
UMLS CUI [1]
C0039798
Beurteilung der Arbeitsfähigkeit
Description

Beurteilung der Arbeitsfähigkeit

Alias
UMLS CUI-1
C0870486
UMLS CUI-2
C0220825
Beurteilung der Arbeitsfähigkeit
Description

Evaluation of working ability

Data type

integer

Alias
UMLS CUI [1,1]
C0870486
UMLS CUI [1,2]
C0220825
Konsilärzte
Description

Konsilärzte

Alias
UMLS CUI-1
C0034928
Ist die Zuziehung von Konsiliarärzten zur Klärung der Diagnose und/oder Mitbehandlung erforderlich?
Description

Is consultation of other specialties necessary regarding diagnosis and/or therapy?

Data type

boolean

Alias
UMLS CUI [1,1]
C0034928
UMLS CUI [1,2]
C0087111
UMLS CUI [2]
C1546898
Diagnose, Anamnese und Bildgebung
Description

Diagnose, Anamnese und Bildgebung

Alias
UMLS CUI-1
C0262926
UMLS CUI-2
C0011900
UMLS CUI-3
C0011923
UMLS CUI-4
C0587530
Diagnosen
Description

Diagnosis

Data type

text

Alias
UMLS CUI [1,1]
C0011900
UMLS CUI [1,2]
C0587530
Anamnese
Description

Medical history

Data type

text

Alias
UMLS CUI [1,1]
C0262926
UMLS CUI [1,2]
C0587530
Radiologie
Description

Radiology

Data type

text

Alias
UMLS CUI [1,1]
C0587500
UMLS CUI [1,2]
C0587530
Therapie
Description

Therapy

Data type

text

Alias
UMLS CUI [1,1]
C0087111
UMLS CUI [1,2]
C0587530
Prozedur / Konzept für den stationären Aufenthalt
Description

Procedure/concept for hospital stay

Data type

text

Alias
UMLS CUI [1,1]
C3489408
UMLS CUI [1,2]
C0178566
UMLS CUI [1,3]
C0587530
Befundungsdatum
Description

Date of evaluation

Data type

date

Measurement units
  • dd.mm.yyyy
Alias
UMLS CUI [1,1]
C1302584
UMLS CUI [1,2]
C0587530
dd.mm.yyyy
Unterschrift
Description

Signature

Data type

text

Alias
UMLS CUI [1]
C1519316
Back to the top of the page

Similar models

Trauma surgery polyclinic, University Hospital Cologne

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Unfallchirurgie Poliklinik
C0587530 (UMLS CUI-1)
C0557824 (UMLS CUI-2)
Order status
Item
Auftragsstatus
text
C1550341 (UMLS CUI [1,1])
C0587530 (UMLS CUI [1,2])
Request identification number
Item
Auftragsnummer
text
C1300638 (UMLS CUI [1,1])
C1272683 (UMLS CUI [1,2])
C0587530 (UMLS CUI [1,3])
Urgency of request
Item
Dringlichkeit
text
C0549179 (UMLS CUI [1,1])
C1272683 (UMLS CUI [1,2])
C0587530 (UMLS CUI [1,3])
Recipient
Item
Zielbenutzer
text
C1709854 (UMLS CUI [1,1])
C1706077 (UMLS CUI [1,2])
C0587530 (UMLS CUI [1,3])
Justification for cancellation of request
Item
Rückweisungs-/Stornierungsgrund
text
C0566251 (UMLS CUI [1,1])
C1548226 (UMLS CUI [1,2])
C0587530 (UMLS CUI [1,3])
Department requesting service
Item
Leistungsanforderer
text
C1272683 (UMLS CUI [1,1])
C1550369 (UMLS CUI [1,2])
C0019961 (UMLS CUI [1,3])
Department performing service
Item
Leistungserbringer
text
C0557854 (UMLS CUI [1,1])
C1550369 (UMLS CUI [1,2])
C0019961 (UMLS CUI [1,3])
Type of service requested
Item
Art des Befundes/Angeforderte Leistung
text
C0332307 (UMLS CUI [1,1])
C1272683 (UMLS CUI [1,2])
C0557854 (UMLS CUI [1,3])
Item Group
BG Fall Datenerfassung
C0021676 (UMLS CUI-1)
C0681104 (UMLS CUI-2)
C0000931 (UMLS CUI-3)
Item Group
Unfallbetrieb
C1274022 (UMLS CUI-1)
C0000931 (UMLS CUI-2)
Name of corporation
Item
Unfallbetrieb Name
text
C0683758 (UMLS CUI [1,1])
C0027365 (UMLS CUI [1,2])
Address of corporation
Item
Unfallbetrieb Adresse
text
C0683758 (UMLS CUI [1,1])
C1442065 (UMLS CUI [1,2])
Patient occupied as
Item
Patient beschäftigt als
text
C0421456 (UMLS CUI [1,1])
C0332307 (UMLS CUI [1,2])
Patient occupied since
Item
Patient beschäftigt seit
date
C0421456 (UMLS CUI [1,1])
C0808070 (UMLS CUI [1,2])
Item Group
Unfall
C0000924 (UMLS CUI-1)
Accident site
Item
Unfallort
text
C0337069 (UMLS CUI [1])
Date of accident
Item
Unfalldatum
date
C0011008 (UMLS CUI [1,1])
C0000924 (UMLS CUI [1,2])
Working hours start
Item
Arbeitszeit von
time
C0043227 (UMLS CUI [1,1])
C1301880 (UMLS CUI [1,2])
Working hours end
Item
Arbeitszeit bis
time
C0043227 (UMLS CUI [1,1])
C1522314 (UMLS CUI [1,2])
Prior impairments not caused by current accident
Item
Unfallunabhängige Beeinträchtigungen
text
C2347662 (UMLS CUI [1,1])
C0221099 (UMLS CUI [1,2])
C1314792 (UMLS CUI [1,3])
Use of alcohol, drugs or pharmaceutical preparations
Item
Alkohol/Drogen/Medikamente
boolean
C0237123 (UMLS CUI [1,1])
C0240320 (UMLS CUI [1,2])
Blood test performed
Item
Blutentnahme durchgeführt
boolean
C0005834 (UMLS CUI [1])
Doubts or disbelief in casualty being an occupational accident
Item
Zweifel/Bedenken an Arbeitsunfall
boolean
C0000931 (UMLS CUI [1,1])
C1547322 (UMLS CUI [1,2])
Item Group
Art der Heilbehandlung
C0039798 (UMLS CUI-1)
Item
Art der Heilbehandlung
integer
C0039798 (UMLS CUI [1])
Type of treatment
Code List
Art der Heilbehandlung
CL Item
allgemeine Heilbehandlung (1)
CL Item
besondere Heilbehandlung (2)
CL Item
es wird keine Heilbehandlung zu Lasten der UV durchgeführt (3)
Item Group
Beurteilung der Arbeitsfähigkeit
C0870486 (UMLS CUI-1)
C0220825 (UMLS CUI-2)
Item
Beurteilung der Arbeitsfähigkeit
integer
C0870486 (UMLS CUI [1,1])
C0220825 (UMLS CUI [1,2])
Evaluation of working ability
Code List
Beurteilung der Arbeitsfähigkeit
CL Item
arbeitsfähig (1)
CL Item
arbeitsunfähig (2)
Item Group
Konsilärzte
C0034928 (UMLS CUI-1)
Is consultation of other specialties necessary regarding diagnosis and/or therapy?
Item
Ist die Zuziehung von Konsiliarärzten zur Klärung der Diagnose und/oder Mitbehandlung erforderlich?
boolean
C0034928 (UMLS CUI [1,1])
C0087111 (UMLS CUI [1,2])
C1546898 (UMLS CUI [2])
Item Group
Diagnose, Anamnese und Bildgebung
C0262926 (UMLS CUI-1)
C0011900 (UMLS CUI-2)
C0011923 (UMLS CUI-3)
C0587530 (UMLS CUI-4)
Diagnosis
Item
Diagnosen
text
C0011900 (UMLS CUI [1,1])
C0587530 (UMLS CUI [1,2])
Medical history
Item
Anamnese
text
C0262926 (UMLS CUI [1,1])
C0587530 (UMLS CUI [1,2])
Radiology
Item
Radiologie
text
C0587500 (UMLS CUI [1,1])
C0587530 (UMLS CUI [1,2])
Therapy
Item
Therapie
text
C0087111 (UMLS CUI [1,1])
C0587530 (UMLS CUI [1,2])
Procedure/concept for hospital stay
Item
Prozedur / Konzept für den stationären Aufenthalt
text
C3489408 (UMLS CUI [1,1])
C0178566 (UMLS CUI [1,2])
C0587530 (UMLS CUI [1,3])
Date of evaluation
Item
Befundungsdatum
date
C1302584 (UMLS CUI [1,1])
C0587530 (UMLS CUI [1,2])
Signature
Item
Unterschrift
text
C1519316 (UMLS CUI [1])
Back to the top of the page 

Help

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial