ID

21454

Description

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

Keywords

Versions (1)
  1. 4/22/17 4/22/17 -
Uploaded on

April 22, 2017

DOI

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License

Creative Commons BY-NC 3.0
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Gastroenterology activity recording, University Hospital Cologne

German

Gastroenterology activity recording, University Hospital Cologne

1 forms  
Leistungserfassung Gastroenterologie
Description

Leistungserfassung Gastroenterologie

Alias
UMLS CUI-1
C0587581
Patient
Description

Patient name

Data type

text

Alias
UMLS CUI [1]
C1299487
Geburtsdatum
Description

Birth Date

Data type

date

Measurement units
  • dd.mm.yyyy
Alias
UMLS CUI [1]
C0421451
dd.mm.yyyy
Auftragsnummer
Description

Order ID

Data type

integer

Alias
UMLS CUI [1,1]
C1300638
UMLS CUI [1,2]
C1705175
Leistende Stelle
Description

Department performing procedure

Data type

text

Alias
UMLS CUI [1,1]
C2986180
UMLS CUI [1,2]
C0019961
UMLS CUI [1,3]
C0587581
Leistungsdatum
Description

Date of procedure

Data type

date

Measurement units
  • dd.mm.yyyy
Alias
UMLS CUI [1,1]
C2584899
UMLS CUI [1,2]
C0587581
dd.mm.yyyy
Bereitschaftsdienst
Description

Emergency medical service

Data type

boolean

Alias
UMLS CUI [1]
C0013961
Dokumentiert von
Description

Documented by

Data type

text

Measurement units
  • Name
Alias
UMLS CUI [1]
C2361125
Name
Leistungsanforderer
Description

Department ordering procedure

Data type

text

Alias
UMLS CUI [1,1]
C1705175
UMLS CUI [1,2]
C0587581
UMLS CUI [1,3]
C1550369
UMLS CUI [1,4]
C0019961
Fachabteilung
Description

Medical specialty

Data type

text

Alias
UMLS CUI [1]
C0037778
Sitzungszahl
Description

Session quantity

Data type

integer

Alias
UMLS CUI [1,1]
C1883017
UMLS CUI [1,2]
C1265611
Leistungsdauer
Description

Duration of procedure

Data type

integer

Measurement units
  • min
Alias
UMLS CUI [1,1]
C0449238
UMLS CUI [1,2]
C2700391
UMLS CUI [1,3]
C0587581
min
Neuvorstellung
Description

Neuvorstellung

Alias
UMLS CUI-1
C1313868
Beratung/a. Tel. - Kassenpat.
Description

Counseling

Data type

boolean

Alias
UMLS CUI [1]
C0010210
Ganzkörperstatus/Dokument.
Description

Physical examination

Data type

boolean

Alias
UMLS CUI [1]
C0031809
Blutentnahme aus der Vene
Description

Blood sample taken

Data type

boolean

Alias
UMLS CUI [1]
C1277698
Wiedervorstellung
Description

Wiedervorstellung

Alias
UMLS CUI-1
C0589121
Beratung/a. Tel. - Kassenpat.
Description

Counseling

Data type

boolean

Alias
UMLS CUI [1]
C0010210
Symptombezogene Untersuchung
Description

Physical examination (symptom oriented)

Data type

boolean

Alias
UMLS CUI [1,1]
C0031809
UMLS CUI [1,2]
C1457887
Ausführlicher Befundbericht
Description

Report

Data type

boolean

Alias
UMLS CUI [1]
C0684224
Blutentnahme aus der Vene
Description

Blood sample taken

Data type

boolean

Alias
UMLS CUI [1]
C1277698
Abschluss
Description

Abschluss

Alias
UMLS CUI-1
C0871548
Beratung/a. Tel. - Kassenpat.
Description

Counseling

Data type

boolean

Alias
UMLS CUI [1]
C0010210
Symptombezogene Untersuchung
Description

Physical examination (symptom oriented)

Data type

boolean

Alias
UMLS CUI [1,1]
C0031809
UMLS CUI [1,2]
C1457887
Ausführlicher Befundbericht
Description

Report

Data type

boolean

Alias
UMLS CUI [1]
C0684224
Blutentnahme aus der Vene
Description

Blood sample taken

Data type

boolean

Alias
UMLS CUI [1]
C1277698
Chemotherapie
Description

Chemotherapie

Alias
UMLS CUI-1
C3665472
Chemother.Beh.-/Nachsorgeplan
Description

Chemotherapy/Aftercare plan

Data type

boolean

Alias
UMLS CUI [1,1]
C3665472
UMLS CUI [1,2]
C0599880
UMLS CUI [2,1]
C0001758
UMLS CUI [2,2]
C0599880
Zusatzpausch. Beh.Systemerkrankung
Description

Systemic disease treatment

Data type

boolean

Alias
UMLS CUI [1,1]
C0442893
UMLS CUI [1,2]
C0039798
Administration
Description

Administration

Alias
UMLS CUI-1
C1533734
Administration
Description

Administration

Data type

integer

Alias
UMLS CUI [1]
C1533734
Zuschläge
Description

Additional fees

Data type

integer

Alias
UMLS CUI [1,1]
C1524062
UMLS CUI [1,2]
C0015754
Beratung
Description

Beratung

Alias
UMLS CUI-1
C0010210
Beratung/a. Tel. - Kassenpat.
Description

Counseling

Data type

boolean

Alias
UMLS CUI [1]
C0010210
Eingehende Beratung
Description

Extensive counseling

Data type

boolean

Alias
UMLS CUI [1]
C0545100
Erört/Plan.gez.therap.Maßn.
Description

Treatment plan

Data type

boolean

Alias
UMLS CUI [1]
C0599880
Konsil.Eröt.zwisch.2 o.mehr Ärzte
Description

Consultation

Data type

boolean

Alias
UMLS CUI [1]
C0009818
Diagnostik
Description

Diagnostik

Alias
UMLS CUI-1
C0430022
Symptombez. Untersuchung
Description

Physical examination (symptom oriented)

Data type

boolean

Alias
UMLS CUI [1,1]
C0031809
UMLS CUI [1,2]
C1457887
Ganzkörperstatus/Dokument.
Description

Full body physical examination

Data type

boolean

Alias
UMLS CUI [1,1]
C0031809
UMLS CUI [1,2]
C0444584
Funktion
Description

Funktion

Alias
UMLS CUI-1
C2700391
Funktion
Description

Procedure

Data type

integer

Alias
UMLS CUI [1]
C0455713
Chemotherapie
Description

Chemotherapie

Alias
UMLS CUI-1
C3665472
Chemotherapie
Description

Chemotherapy

Data type

integer

Alias
UMLS CUI [1]
C3665472
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Similar models

Gastroenterology activity recording, University Hospital Cologne

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Leistungserfassung Gastroenterologie
C0587581 (UMLS CUI-1)
Patient name
Item
Patient
text
C1299487 (UMLS CUI [1])
Birth Date
Item
Geburtsdatum
date
C0421451 (UMLS CUI [1])
Order ID
Item
Auftragsnummer
integer
C1300638 (UMLS CUI [1,1])
C1705175 (UMLS CUI [1,2])
Department performing procedure
Item
Leistende Stelle
text
C2986180 (UMLS CUI [1,1])
C0019961 (UMLS CUI [1,2])
C0587581 (UMLS CUI [1,3])
Date of procedure
Item
Leistungsdatum
date
C2584899 (UMLS CUI [1,1])
C0587581 (UMLS CUI [1,2])
Emergency medical service
Item
Bereitschaftsdienst
boolean
C0013961 (UMLS CUI [1])
Documented by
Item
Dokumentiert von
text
C2361125 (UMLS CUI [1])
Department ordering procedure
Item
Leistungsanforderer
text
C1705175 (UMLS CUI [1,1])
C0587581 (UMLS CUI [1,2])
C1550369 (UMLS CUI [1,3])
C0019961 (UMLS CUI [1,4])
Medical specialty
Item
Fachabteilung
text
C0037778 (UMLS CUI [1])
Session quantity
Item
Sitzungszahl
integer
C1883017 (UMLS CUI [1,1])
C1265611 (UMLS CUI [1,2])
Duration of procedure
Item
Leistungsdauer
integer
C0449238 (UMLS CUI [1,1])
C2700391 (UMLS CUI [1,2])
C0587581 (UMLS CUI [1,3])
Item Group
Neuvorstellung
C1313868 (UMLS CUI-1)
Counseling
Item
Beratung/a. Tel. - Kassenpat.
boolean
C0010210 (UMLS CUI [1])
Physical examination
Item
Ganzkörperstatus/Dokument.
boolean
C0031809 (UMLS CUI [1])
Blood sample taken
Item
Blutentnahme aus der Vene
boolean
C1277698 (UMLS CUI [1])
Item Group
Wiedervorstellung
C0589121 (UMLS CUI-1)
Counseling
Item
Beratung/a. Tel. - Kassenpat.
boolean
C0010210 (UMLS CUI [1])
Physical examination (symptom oriented)
Item
Symptombezogene Untersuchung
boolean
C0031809 (UMLS CUI [1,1])
C1457887 (UMLS CUI [1,2])
Report
Item
Ausführlicher Befundbericht
boolean
C0684224 (UMLS CUI [1])
Blood sample taken
Item
Blutentnahme aus der Vene
boolean
C1277698 (UMLS CUI [1])
Item Group
Abschluss
C0871548 (UMLS CUI-1)
Counseling
Item
Beratung/a. Tel. - Kassenpat.
boolean
C0010210 (UMLS CUI [1])
Physical examination (symptom oriented)
Item
Symptombezogene Untersuchung
boolean
C0031809 (UMLS CUI [1,1])
C1457887 (UMLS CUI [1,2])
Report
Item
Ausführlicher Befundbericht
boolean
C0684224 (UMLS CUI [1])
Blood sample taken
Item
Blutentnahme aus der Vene
boolean
C1277698 (UMLS CUI [1])
Item Group
Chemotherapie
C3665472 (UMLS CUI-1)
Chemotherapy/Aftercare plan
Item
Chemother.Beh.-/Nachsorgeplan
boolean
C3665472 (UMLS CUI [1,1])
C0599880 (UMLS CUI [1,2])
C0001758 (UMLS CUI [2,1])
C0599880 (UMLS CUI [2,2])
Systemic disease treatment
Item
Zusatzpausch. Beh.Systemerkrankung
boolean
C0442893 (UMLS CUI [1,1])
C0039798 (UMLS CUI [1,2])
Item Group
Administration
C1533734 (UMLS CUI-1)
Item
Administration
integer
C1533734 (UMLS CUI [1])
Administration
Code List
Administration
CL Item
Patient nicht erschienen/nicht behandelt (1)
CL Item
Achtung: §116b-Fall (2)
CL Item
Verwal.Komp._Rezept_Bef.Übermittl.v.Pers. (3)
CL Item
Kurzer ärtzl. Bericht (4)
CL Item
Kurze Bescheinigung (5)
CL Item
Ausführlicher Befundbericht (6)
CL Item
Gebühr Mehranfertigung Bericht an Hausarzt (7)
CL Item
Schrift. Diätplan_ indiv. angef. (8)
CL Item
Kopie_ EDV-technische Abschrift (9)
CL Item
Versand.p.Brief b.20g Porto (0_55Euro) (10)
CL Item
Versand.p.Brief b.50g Porto (0_90Euro) (11)
Item
Zuschläge
integer
C1524062 (UMLS CUI [1,1])
C0015754 (UMLS CUI [1,2])
Additional fees
Code List
Zuschläge
CL Item
Zusatzpausch. Gastroenterologe onkolog. Pat. (1)
CL Item
Zuschl. allg. Internist Grundvers. (2)
Item Group
Beratung
C0010210 (UMLS CUI-1)
Counseling
Item
Beratung/a. Tel. - Kassenpat.
boolean
C0010210 (UMLS CUI [1])
Extensive counseling
Item
Eingehende Beratung
boolean
C0545100 (UMLS CUI [1])
Treatment plan
Item
Erört/Plan.gez.therap.Maßn.
boolean
C0599880 (UMLS CUI [1])
Consultation
Item
Konsil.Eröt.zwisch.2 o.mehr Ärzte
boolean
C0009818 (UMLS CUI [1])
Item Group
Diagnostik
C0430022 (UMLS CUI-1)
Physical examination (symptom oriented)
Item
Symptombez. Untersuchung
boolean
C0031809 (UMLS CUI [1,1])
C1457887 (UMLS CUI [1,2])
Full body physical examination
Item
Ganzkörperstatus/Dokument.
boolean
C0031809 (UMLS CUI [1,1])
C0444584 (UMLS CUI [1,2])
Item Group
Funktion
C2700391 (UMLS CUI-1)
Item
Funktion
integer
C0455713 (UMLS CUI [1])
Procedure
Code List
Funktion
CL Item
Verband (1)
CL Item
Blutentnahme aus der Vene (2)
CL Item
Injektion s.c. (3)
CL Item
Injektion i.m. (4)
CL Item
Injektion i.v. (5)
CL Item
Portpunktion_Anstechen_Spülung (6)
CL Item
Infusion i.v. <30 Min (7)
CL Item
Infusion i.v. >30 Min (8)
CL Item
Transfusion 1 Blutkonverse (9)
CL Item
Transf.j.weit.Blutkons.n.EBM (10)
CL Item
Aderlass Vene/Art./Ent. 200ml Blut (11)
Item Group
Chemotherapie
C3665472 (UMLS CUI-1)
Item
Chemotherapie
integer
C3665472 (UMLS CUI [1])
Chemotherapy
Code List
Chemotherapie
CL Item
Betr./Beob.Pat.: Transp./kons.Krankh.>2St. (1)
CL Item
Betr./Beob.Pat.: Transp./kons.Krankh.>4St. (2)
CL Item
Chemother.Beh-/Nachsorgeplan (3)
CL Item
Infusion Zytost. b. Malignom/HIV >90 Min (4)
CL Item
Zusatzpausch. Beh. Systemerkrankung (5)
CL Item
Zusatzpausch. Nachbetr. n. Stammzelltransplantationen (6)
CL Item
Zusatzpausch. Aplasieinduz. Behandlung (7)
CL Item
Tumorerkrankung unter parent. tumorspez. Behandl. oder progr. Malignome (8)
CL Item
Orale u. parenterale Chemother. bei Tu.-Pat. einschließlich Hormonanaloga usw. (9)
CL Item
Therapie des M. Crohn mit Infliximab (10)
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