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ID
22323
Beschreibung
Routine documentation in German hospitals. Source file name: SD070109_Geburtenbogen. Examplary forms provided by DMI (http://www.dmi.de/)
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Stichworte
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- 29.05.17 29.05.17 -
- 29.05.17 29.05.17 -
- 06.06.17 06.06.17 -
- 06.06.17 06.06.17 -
- 30.07.17 30.07.17 -
Hochgeladen am
29. Mai 2017
DOI
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Creative Commons BY-NC 3.0
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Birth sheet Routine documentation in German hospitals DMI
Birth sheet Routine documentation in German hospitals DMI
- StudyEvent: ODM
Ähnliche Modelle
Birth sheet Routine documentation in German hospitals DMI
- StudyEvent: ODM
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Specifics
Item
Specifics
text
Health insurance
Item
Health insurance
text
Gynecologist
Item
Gynecologist
text
Estimated due date (EDD)
Item
EDD
date
Last period
Item
Last period
text
Gravida
Item
Grav.
text
Para
Item
Para
text
Allergies
Item
Allergies
text
Blood type of mother
Item
Blood type of mother
text
Date of admission
Item
Date of admission
date
Diagnosis
Item
Diagnosis
text
Day
Item
Day
text
Month
Item
Month
text
Time
Item
Time
time
Labor, spontaneous
Item
Spontaneous
boolean
Induction of labor
Item
Induction with
text
Day
Item
Day
text
Month
Item
Month
text
Time
Item
Time
time
CL Item
premature (premature)
CL Item
early (early)
CL Item
timely (timely)
CL Item
spontaneous (spontaneous)
CL Item
artificial (artificial)
CL Item
clear (clear)
CL Item
green (green)
CL Item
similar to pea-soup (similar to pea-soup)
CL Item
sanguineous (sanguineous)
Day
Item
Day
text
Month
Item
Month
text
Time
Item
Time
time
Birth I, fetal position
Item
From:
text
CL Item
local (local)
CL Item
pudendal nerve (pudendal nerve)
CL Item
PDA (PDA)
CL Item
endotracheal anesthesia (endotracheal anesthesia)
Day
Item
Day
text
Month
Item
Month
text
Time
Item
Time
time
Birth II, fetal position
Item
From:
text
CL Item
local (local)
CL Item
pudendal nerve (pudendal nerve)
CL Item
PDA (PDA)
CL Item
endotracheal anesthesia (endotracheal anesthesia)
CL Item
spontaneous (spontaneous)
CL Item
operative (operative)
Operative birth, method
Item
Operative by:
text
Surgeon
Item
Surgeon
text
Indication
Item
Indication
text
Day
Item
Day
text
Month
Item
Month
text
Time
Item
Time
time
Spontaneous placental expulsion
Item
Spontaneous
boolean
Cord-traction
Item
Cord-traction
boolean
Nachtastung
Item
Nachtastung
boolean
Manual placenta removal
Item
Manual placenta removal
boolean
Curettage
Item
Curettage
boolean
Complete placenta
Item
Complete placenta
boolean
Incomplete placenta
Item
Incomplete
boolean
Infarcts
Item
Infarcts
boolean
Calcareous incrustation
Item
Calcareous incrustation
boolean
Placenta histology
Item
Placenta histology
boolean
Complete amniotic membranes
Item
Complete
boolean
Incomplete amniotic membranes
Item
Incomplete
boolean
Oxytocin, intravenous
Item
3 IE Oxytocin IV
boolean
Methergin, intravenous
Item
0,2 mg Methergin IV
boolean
Umbilical cord, normal insertion
Item
Umbilical cord: Normal insertion
boolean
Umbilical cord: Insertion
Item
Umbilical cord: Insertion
text
True umbilical cord knot
Item
True umbilical cord knot
boolean
Nuchal cord
Item
Nuchal cord
boolean
Blood loss
Item
Blood loss
integer
Intact perineum and vagina
Item
Intact
boolean
Perineal tear
Item
Perineal tear
boolean
Grade of perineal tear
Item
Grade of perineal tear
integer
Cervical tear
Item
Cervical tear
boolean
Episiotomy
Item
Episiotomy
boolean
Vaginal-labial tear
Item
Vaginal-labial tear
boolean
Combined lesions
Item
Combined lesions
boolean
Suture
Item
Type of treatment: Suture
boolean
Suture, site
Item
Type of treatment: Suture in
text
Anesthesia
Item
Type of treatment: Anesthesia
text
Extraordinary incidents during birth
Item
Extraordinary incidents during birth
text
Physician in charge of birth
Item
Physician in charge
text
Midwife
Item
Midwife
text
Sex
Item
Sex
text
Weight
Item
Weight
integer
Length
Item
Length
float
Head circumference
Item
Head circumference
float
Shoulder circumference
Item
Shoulder circumference
float
CL Item
executed (executed)
CL Item
refused (refused)
Konakion
Item
2 mg Konakion oral
boolean
Sex
Item
Sex
text
Weight
Item
Weight
integer
Length
Item
Length
integer
Head circumference
Item
Head circumference
integer
Shoulder circumference
Item
Shoulder circumference
integer
CL Item
executed (executed)
CL Item
refused (refused)
Konakion
Item
2 mg Konakion oral
boolean
CL Item
Extend beyond the fingertips (Extend beyond the fingertips)
CL Item
Reach the fingertips (Reach the fingertips)
CL Item
Do not reach the fingertips (Do not reach the fingertips)
CL Item
O (O)
CL Item
+ (+)
CL Item
++ (++)
CL Item
O (O)
CL Item
+ (+)
CL Item
++ (++)
CL Item
descended (descended)
CL Item
undescended (undescended)
CL Item
closed (closed)
CL Item
gaping (gaping)
CL Item
+ (+)
CL Item
O (O)
CL Item
+ (+)
CL Item
O (O)
CL Item
blue or pale (0)
CL Item
blue at extremities, body pink (1)
CL Item
pink (2)
CL Item
absent (0)
CL Item
weak, irregular, gasping (1)
CL Item
strong, robust cry (2)
CL Item
none (0)
CL Item
some flexion (1)
CL Item
active motion (2)
CL Item
no response (0)
CL Item
grimacing (1)
CL Item
crying (2)
CL Item
absent (0)
CL Item
<100 (1)
CL Item
>100 (2)
Artery
Item
Art.
boolean
Vein
Item
Vein
boolean
Suctioning
Item
Suctioning
boolean
Pediatrician present at birth
Item
Pediatrician present at birth
boolean
Presentation at pediatrician
Item
Presentation at pediatrician
boolean
Presentation at pediatrician, reason
Item
Presentation at pediatrician because of
text
Transfer to pediatric clinic
Item
Transfer to pediatric clinic
boolean
Transfer to pediatric clinic, reason
Item
Transfer to pediatric clinic because of
text
Oxygen mask
Item
Oxygen mask
boolean
Intubation
Item
Intubation
boolean
Normal child development
Item
Normal
boolean
Child development, description
Item
Child development
text
Medical history
Item
Medical history
text
Surgery
Item
Surgery
text
Family history
Item
Family history
text
Normal course
Item
Normal course
text
Severe vomiting
Item
Severe vomiting
text
Edemas, protein, hypertension
Item
Edemas, protein, hypertension
text
Fever (also viral disease)
Item
Fever (also viral disease)
text
Urinary tract infection
Item
Urinary tract infection
text
Bleeding during pregnancy
Item
Bleeding during pregnancy
text
Anemia
Item
Anemia
text
Surgery
Item
Surgery
text
Medication/Hormones
Item
Medication/Hormones
text
Other diseases/trouble
Item
Other diseases/trouble
text
Smoking, drugs, alcohol
Item
Smoking, drugs, alcohol
text
Contraceptives
Item
Contraceptives
text
Mode of conception
Item
Mode of conception
text
Rubella titer
Item
Rubella titer
text
HBsAg
Item
HBsAg
text
Anti-D
Item
Anti-D
text
Breastfeeding
Item
Breastfeeding
text
Crédé desired
Item
Crédé desired
text
Date
Item
Date
date
Menstruation
Item
Menstruation
text
Curettage
Item
Curettage (where)
text
Complications
Item
Complications
text
Date
Item
Date
date
Type and place of delivery
Item
Delivery: Type and place
text
Duration of delivery
Item
Delivery: Duration
text
Complications during delivery
Item
Delivery: Complications
text
CL Item
male (male)
CL Item
female (female)
Weight of newborn
Item
Newborn: Weight
text
Specifics of newborn
Item
Newborn: Specifics
text
Weeks
Item
Weeks
integer
Resistance Index (RI)
Item
Resistance Index (RI)
float
Weeks
Item
Weeks
integer
Pulsatility Index (PI)
Item
Pulsatility Index (PI)
float
Weeks
Item
Weeks
integer
Resistance Index (RI)
Item
Resistance Index (RI)
float
Weeks
Item
Weeks
integer
Resistance Index (RI)
Item
Resistance Index (RI)
float
Date
Item
Date
date
Week of gestation
Item
Week of gestation
integer
Arteria umbilicalis
Item
UMB
float
Arteria cerebri media
Item
ACM
float
Ducuts venosus
Item
Duct. ven.
text
Right Arteria uterina
Item
UT right
float
Left Arteria uterina
Item
UT left
float
Physician name
Item
Physician
text
Calculated gestational age
Item
Calculated gestational age
text
Findings
Item
Findings
text
Crown-rump length (CRL)
Item
CRL
float
Cerebellum
Item
Cerebellum
float
Biparietal diameter/Occipitofrontal diameter
Item
BPD/OFD
float
Abdominal transverse diameter/Sagittal abdominal diameter
Item
ATD/SAD
float
Femur
Item
Femur
float
Fetal movements/cardiac activity
Item
Fetal movements/cardiac activity
text
Position
Item
Position
text
Placental location
Item
Placental location
text
Volume of amniotic fluid (AFI)
Item
Volume of amniotic fluid (AFI)
text
Other
Item
Other
text
Picture
Item
Picture
text
Date
Item
Date
date
Physician name
Item
Physician
text
Health insurance
Item
Health insurance
text
Referring physician
Item
Referring physician
text
Referring physician, telephone number
Item
Referring physician, telephone number
integer
Medical specialist
Item
Medical specialist
text
Medical specialist, telephone number
Item
Medical specialist, telephone number
integer
Medical history
Item
Medical history
text
Person taking medical history
Item
Medical history taken by
text
Date
Item
Date
date
Family history
Item
Family history
text
Family history, specifics
Item
No specifics
boolean
Social history
Item
Social history
text
Occupation of mother
Item
Occupation of mother
text
Occupation of father
Item
Occupation of father
text
Personal medical history
Item
Personal medical history
text
Allergy
Item
Allergy
text
Medication
Item
Medication
text
Nicotine
Item
Nicotine
text
Alcohol
Item
Alcohol
text
Specifics
Item
Specifics
text
State at admission
Item
State at admission
text
Heart
Item
Heart
text
Lungs
Item
Lungs
text
Abdomen
Item
Abdomen
text
Blood type
Item
Blood type
text
Rh factor
Item
Rh factor
text
Antibodies
Item
Antibodies
text
Rubella titer
Item
Rubella titer
text
HbsAG
Item
HbsAG
text
Height
Item
Height
text
Weight
Item
Weight
text
Edemata
Item
Edemata
text
Varices
Item
Varices
text
Urine test strip
Item
Urine test strip
text
HIV
Item
HIV
text
Hepatitis C
Item
Hepatitis C
text
Item Group
Obstetric sheet: Current pregnancy, anamnesis of menstrual cycle
Last period
Item
Last period
text
Estimated due date (EDD)
Item
EDD
date
Date of conception based on ultrasound diagnostics
Item
Date of conception based on ultrasound diagnostics
date
Week of gestation
Item
Week of gestation
text
Item Group
Obstetric sheet: Current pregnancy, complications
Complications and diseases, current pregnancy
Item
Complications and diseases during current pregnancy
text
In-patient treatment
Item
In-patient treatment
text
In-patient treatment, reason
Item
In-patient treatment because of
text
In-patient treatment, duration
Item
In-patient treatment until
date
In-patient treatment, therapy
Item
Therapy
text
Date
Item
Date
date
Time
Item
Time
time
Observations
Item
Observations
text
Signature
Item
Signature
text
Initials
Item
Initials
text