ID

24389

Description

Routine documentation in German hospitals. Source file name: SD070109_Geburtenbogen. Examplary forms provided by DMI (http://www.dmi.de/)

Link

http://www.dmi.de/

Keywords

Versions (2)
  1. 6/8/17 6/8/17 -
  2. 7/30/17 7/30/17 -
Uploaded on

July 30, 2017

DOI

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License

Creative Commons BY-NC 3.0
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Birth sheet, delivery Routine documentation in German hospitals DMI

German English

Birth sheet, delivery Routine documentation in German hospitals DMI

1 forms  
Beginning of labor
Description

Beginning of labor

Alias
UMLS CUI-1
C0022868
Day
Description

Day

Data type

text

Alias
UMLS CUI [1]
C0439228
Month
Description

Month

Data type

text

Alias
UMLS CUI [1]
C0439231
Time
Description

Time

Data type

time

Alias
UMLS CUI [1]
C0040223
Spontaneous
Description

Spontaneous onset of labor

Data type

boolean

Alias
UMLS CUI [1]
C0474461
Induction with
Description

Induction of labor

Data type

text

Alias
UMLS CUI [1]
C0259787
Rupture of membranes (ROM)
Description

Rupture of membranes (ROM)

Alias
UMLS CUI-1
C0948106
Day
Description

Day

Data type

text

Alias
UMLS CUI [1]
C0439228
Month
Description

Month

Data type

text

Alias
UMLS CUI [1]
C0439231
Time
Description

Time

Data type

time

Alias
UMLS CUI [1]
C0040223
Type of ROM
Description

Rupture of membranes type

Data type

text

Alias
UMLS CUI [1,1]
C0948106
UMLS CUI [1,2]
C0332307
Color of amniotic fluid
Description

Color of amniotic fluid

Data type

text

Alias
UMLS CUI [1]
C1443316
Birth I
Description

Birth I

Alias
UMLS CUI-1
C0005615
Day
Description

Day

Data type

text

Alias
UMLS CUI [1]
C0439228
Month
Description

Month

Data type

text

Alias
UMLS CUI [1]
C0439231
Time
Description

Time

Data type

time

Alias
UMLS CUI [1]
C0040223
From:
Description

fetal position

Data type

text

Alias
UMLS CUI [1]
C1286298
Birth II
Description

Birth II

Alias
UMLS CUI-1
C0005615
Day
Description

Day

Data type

text

Alias
UMLS CUI [1]
C0439228
Month
Description

Month

Data type

text

Alias
UMLS CUI [1]
C0439231
Time
Description

Time

Data type

time

Alias
UMLS CUI [1]
C0040223
From:
Description

fetal position

Data type

text

Alias
UMLS CUI [1]
C1286298
Medical procedures
Description

Medical procedures

Alias
UMLS CUI-1
C0199171
Anesthesia
Description

Anesthesia

Data type

text

Alias
UMLS CUI [1]
C0002903
Type of birth
Description

Type of birth

Data type

text

Alias
UMLS CUI [1]
C2239272
Operative by:
Description

birth method

Data type

text

Alias
UMLS CUI [1]
C2825496
Surgeon
Description

Surgeon

Data type

text

Alias
UMLS CUI [1]
C0582175
Indication
Description

Indication

Data type

text

Alias
UMLS CUI [1]
C3146298
Placental expulsion
Description

Placental expulsion

Alias
UMLS CUI-1
C0233171
Day
Description

Day

Data type

text

Alias
UMLS CUI [1]
C0439228
Month
Description

Month

Data type

text

Alias
UMLS CUI [1]
C0439231
Time
Description

Time

Data type

time

Alias
UMLS CUI [1]
C0040223
Spontaneous
Description

Spontaneous

Data type

boolean

Alias
UMLS CUI [1]
C0205359
Cord-traction
Description

Cord-traction

Data type

boolean

Alias
UMLS CUI [1]
C0404385
Postpartal palpation
Description

palpation

Data type

boolean

Alias
UMLS CUI [1]
C0030247
Manual placenta removal
Description

Manual placenta removal

Data type

boolean

Alias
UMLS CUI [1]
C0438074
Curettage
Description

Curettage

Data type

boolean

Alias
UMLS CUI [1]
C0010468
Placenta
Description

Placenta

Alias
UMLS CUI-1
C0032043
Complete placenta
Description

Complete placenta

Data type

boolean

Alias
UMLS CUI [1]
C0426227
Incomplete
Description

Incomplete placenta

Data type

boolean

Alias
UMLS CUI [1]
C0542485
Infarcts
Description

Infarcts

Data type

boolean

Alias
UMLS CUI [1]
C0021308
Calcareous incrustation
Description

Calcareous incrustation

Data type

boolean

Alias
UMLS CUI [1]
C0333582
Placenta histology
Description

Histology placenta

Data type

boolean

Alias
UMLS CUI [1,1]
C0019638
UMLS CUI [1,2]
C0032043
Amniotic membranes
Description

Amniotic membranes

Alias
UMLS CUI-1
C0002630
Complete
Description

Complete

Data type

boolean

Alias
UMLS CUI [1]
C0205197
Incomplete
Description

Incomplete

Data type

boolean

Alias
UMLS CUI [1]
C0205257
3 IE Oxytocin IV
Description

Oxytocin intravenous

Data type

boolean

Alias
UMLS CUI [1,1]
C0030095
UMLS CUI [1,2]
C0348016
0,2 mg Methergin IV
Description

Methergin intravenous

Data type

boolean

Alias
UMLS CUI [1,1]
C0733811
UMLS CUI [1,2]
C0348016
Umbilical cord and blood loss
Description

Umbilical cord and blood loss

Alias
UMLS CUI-1
C0041633
UMLS CUI-2
C3163616
Umbilical cord: Normal insertion
Description

umbilical cord insertion normal

Data type

boolean

Alias
UMLS CUI [1,1]
C1404744
UMLS CUI [1,2]
C0205307
Umbilical cord: Insertion
Description

umbilical cord insertion

Data type

text

Alias
UMLS CUI [1]
C1404744
True umbilical cord knot
Description

True umbilical cord knot

Data type

boolean

Alias
UMLS CUI [1]
C0266791
Nuchal cord
Description

Nuchal cord

Data type

boolean

Alias
UMLS CUI [1]
C0405124
Blood loss
Description

Blood loss

Data type

integer

Measurement units
  • ml
Alias
UMLS CUI [1]
C3163616
ml
Perineum and vagina
Description

Perineum and vagina

Alias
UMLS CUI-1
C0031066
UMLS CUI-3
C0042232
Intact
Description

Intact

Data type

boolean

Alias
UMLS CUI [1]
C0205266
Perineal tear
Description

Perineal tear

Data type

boolean

Alias
UMLS CUI [1]
C2053302
Grade of perineal tear
Description

Grade of perineal tear

Data type

integer

Alias
UMLS CUI [1]
C3533198
Cervical tear
Description

Cervical tear

Data type

boolean

Alias
UMLS CUI [1]
C0157358
Episiotomy
Description

Episiotomy

Data type

boolean

Alias
UMLS CUI [1]
C0014586
Vaginal-labial tear
Description

Vaginal-labial tear

Data type

boolean

Alias
UMLS CUI [1]
C0405231
Combined lesions
Description

lesions Combined

Data type

boolean

Alias
UMLS CUI [1,1]
C0221198
UMLS CUI [1,2]
C0205195
Type of treatment: Suture
Description

Suture

Data type

boolean

Alias
UMLS CUI [1]
C0038969
Type of treatment: Suture in
Description

site Suture

Data type

text

Alias
UMLS CUI [1,1]
C1515974
UMLS CUI [1,2]
C0038969
Type of treatment: Anesthesia
Description

Anesthesia type

Data type

text

Alias
UMLS CUI [1]
C1305863
Further information
Description

Further information

Alias
UMLS CUI-1
C1533716
Extraordinary incidents during birth
Description

event

Data type

text

Alias
UMLS CUI [1]
C0441471
Physician in charge
Description

Physician

Data type

text

Alias
UMLS CUI [1]
C0031831
Midwife
Description

Midwife

Data type

text

Alias
UMLS CUI [1]
C0026083
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Similar models

Birth sheet, delivery Routine documentation in German hospitals DMI

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Beginning of labor
C0022868 (UMLS CUI-1)
Day
Item
Day
text
C0439228 (UMLS CUI [1])
Month
Item
Month
text
C0439231 (UMLS CUI [1])
Time
Item
Time
time
C0040223 (UMLS CUI [1])
Spontaneous onset of labor
Item
Spontaneous
boolean
C0474461 (UMLS CUI [1])
Induction of labor
Item
Induction with
text
C0259787 (UMLS CUI [1])
Item Group
Rupture of membranes (ROM)
C0948106 (UMLS CUI-1)
Day
Item
Day
text
C0439228 (UMLS CUI [1])
Month
Item
Month
text
C0439231 (UMLS CUI [1])
Time
Item
Time
time
C0040223 (UMLS CUI [1])
Item
Type of ROM
text
C0948106 (UMLS CUI [1,1])
C0332307 (UMLS CUI [1,2])
Time of rupture of membranes
Code List
Type of ROM
CL Item
premature (premature)
C0015944 (UMLS CUI-1)
(Comment:en)
CL Item
early (early)
(Comment:en)
CL Item
timely (timely)
(Comment:en)
CL Item
spontaneous (spontaneous)
C0205359 (UMLS CUI-1)
(Comment:en)
CL Item
artificial (artificial)
(Comment:en)
Item
Color of amniotic fluid
text
C1443316 (UMLS CUI [1])
Color of amniotic fluid
Code List
Color of amniotic fluid
CL Item
clear (clear)
CL Item
green (green)
CL Item
similar to pea-soup (similar to pea-soup)
CL Item
sanguineous (sanguineous)
Item Group
Birth I
C0005615 (UMLS CUI-1)
Day
Item
Day
text
C0439228 (UMLS CUI [1])
Month
Item
Month
text
C0439231 (UMLS CUI [1])
Time
Item
Time
time
C0040223 (UMLS CUI [1])
fetal position
Item
From:
text
C1286298 (UMLS CUI [1])
Item Group
Birth II
C0005615 (UMLS CUI-1)
Day
Item
Day
text
C0439228 (UMLS CUI [1])
Month
Item
Month
text
C0439231 (UMLS CUI [1])
Time
Item
Time
time
C0040223 (UMLS CUI [1])
fetal position
Item
From:
text
C1286298 (UMLS CUI [1])
Item Group
Medical procedures
C0199171 (UMLS CUI-1)
Item
Anesthesia
text
C0002903 (UMLS CUI [1])
Anesthesia
Code List
Anesthesia
CL Item
local (local)
C0002921 (UMLS CUI-1)
(Comment:en)
CL Item
pudendal nerve (pudendal nerve)
(Comment:en)
CL Item
PDA (PDA)
(Comment:en)
CL Item
endotracheal anesthesia (endotracheal anesthesia)
(Comment:en)
Item
Type of birth
text
C2239272 (UMLS CUI [1])
Type of birth
Code List
Type of birth
CL Item
spontaneous (spontaneous)
CL Item
operative (operative)
birth method
Item
Operative by:
text
C2825496 (UMLS CUI [1])
Surgeon
Item
Surgeon
text
C0582175 (UMLS CUI [1])
Indication
Item
Indication
text
C3146298 (UMLS CUI [1])
Item Group
Placental expulsion
C0233171 (UMLS CUI-1)
Day
Item
Day
text
C0439228 (UMLS CUI [1])
Month
Item
Month
text
C0439231 (UMLS CUI [1])
Time
Item
Time
time
C0040223 (UMLS CUI [1])
Spontaneous
Item
Spontaneous
boolean
C0205359 (UMLS CUI [1])
Cord-traction
Item
Cord-traction
boolean
C0404385 (UMLS CUI [1])
palpation
Item
Postpartal palpation
boolean
C0030247 (UMLS CUI [1])
Manual placenta removal
Item
Manual placenta removal
boolean
C0438074 (UMLS CUI [1])
Curettage
Item
Curettage
boolean
C0010468 (UMLS CUI [1])
Item Group
Placenta
C0032043 (UMLS CUI-1)
Complete placenta
Item
Complete placenta
boolean
C0426227 (UMLS CUI [1])
Incomplete placenta
Item
Incomplete
boolean
C0542485 (UMLS CUI [1])
Infarcts
Item
Infarcts
boolean
C0021308 (UMLS CUI [1])
Calcareous incrustation
Item
Calcareous incrustation
boolean
C0333582 (UMLS CUI [1])
Histology placenta
Item
Placenta histology
boolean
C0019638 (UMLS CUI [1,1])
C0032043 (UMLS CUI [1,2])
Item Group
Amniotic membranes
C0002630 (UMLS CUI-1)
Complete
Item
Complete
boolean
C0205197 (UMLS CUI [1])
Incomplete
Item
Incomplete
boolean
C0205257 (UMLS CUI [1])
Oxytocin intravenous
Item
3 IE Oxytocin IV
boolean
C0030095 (UMLS CUI [1,1])
C0348016 (UMLS CUI [1,2])
Methergin intravenous
Item
0,2 mg Methergin IV
boolean
C0733811 (UMLS CUI [1,1])
C0348016 (UMLS CUI [1,2])
Item Group
Umbilical cord and blood loss
C0041633 (UMLS CUI-1)
C3163616 (UMLS CUI-2)
umbilical cord insertion normal
Item
Umbilical cord: Normal insertion
boolean
C1404744 (UMLS CUI [1,1])
C0205307 (UMLS CUI [1,2])
umbilical cord insertion
Item
Umbilical cord: Insertion
text
C1404744 (UMLS CUI [1])
True umbilical cord knot
Item
True umbilical cord knot
boolean
C0266791 (UMLS CUI [1])
Nuchal cord
Item
Nuchal cord
boolean
C0405124 (UMLS CUI [1])
Blood loss
Item
Blood loss
integer
C3163616 (UMLS CUI [1])
Item Group
Perineum and vagina
C0031066 (UMLS CUI-1)
C0042232 (UMLS CUI-3)
Intact
Item
Intact
boolean
C0205266 (UMLS CUI [1])
Perineal tear
Item
Perineal tear
boolean
C2053302 (UMLS CUI [1])
Grade of perineal tear
Item
Grade of perineal tear
integer
C3533198 (UMLS CUI [1])
Cervical tear
Item
Cervical tear
boolean
C0157358 (UMLS CUI [1])
Episiotomy
Item
Episiotomy
boolean
C0014586 (UMLS CUI [1])
Vaginal-labial tear
Item
Vaginal-labial tear
boolean
C0405231 (UMLS CUI [1])
lesions Combined
Item
Combined lesions
boolean
C0221198 (UMLS CUI [1,1])
C0205195 (UMLS CUI [1,2])
Suture
Item
Type of treatment: Suture
boolean
C0038969 (UMLS CUI [1])
site Suture
Item
Type of treatment: Suture in
text
C1515974 (UMLS CUI [1,1])
C0038969 (UMLS CUI [1,2])
Anesthesia type
Item
Type of treatment: Anesthesia
text
C1305863 (UMLS CUI [1])
Item Group
Further information
C1533716 (UMLS CUI-1)
event
Item
Extraordinary incidents during birth
text
C0441471 (UMLS CUI [1])
Physician
Item
Physician in charge
text
C0031831 (UMLS CUI [1])
Midwife
Item
Midwife
text
C0026083 (UMLS CUI [1])
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