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  
Beg. der Wehen
Description

Beg. der Wehen

Alias
UMLS CUI-1
C0022868
Tag
Description

Day

Data type

text

Alias
UMLS CUI [1]
C0439228
Mon.
Description

Month

Data type

text

Alias
UMLS CUI [1]
C0439231
Uhrzeit
Description

Time

Data type

time

Alias
UMLS CUI [1]
C0040223
spontan
Description

Spontaneous onset of labor

Data type

boolean

Alias
UMLS CUI [1]
C0474461
Einleitung mit
Description

Induction of labor

Data type

text

Alias
UMLS CUI [1]
C0259787
Blasensprung
Description

Blasensprung

Alias
UMLS CUI-1
C0948106
Tag
Description

Day

Data type

text

Alias
UMLS CUI [1]
C0439228
Mon.
Description

Month

Data type

text

Alias
UMLS CUI [1]
C0439231
Uhrzeit
Description

Time

Data type

time

Alias
UMLS CUI [1]
C0040223
Blasensprung
Description

Rupture of membranes type

Data type

text

Alias
UMLS CUI [1,1]
C0948106
UMLS CUI [1,2]
C0332307
FW-Farbe
Description

Color of amniotic fluid

Data type

text

Alias
UMLS CUI [1]
C1443316
Geburt I
Description

Geburt I

Alias
UMLS CUI-1
C0005615
Tag
Description

Day

Data type

text

Alias
UMLS CUI [1]
C0439228
Mon.
Description

Month

Data type

text

Alias
UMLS CUI [1]
C0439231
Uhrzeit
Description

Time

Data type

time

Alias
UMLS CUI [1]
C0040223
aus:
Description

fetal position

Data type

text

Alias
UMLS CUI [1]
C1286298
Geburt II
Description

Geburt II

Alias
UMLS CUI-1
C0005615
Tag
Description

Day

Data type

text

Alias
UMLS CUI [1]
C0439228
Mon.
Description

Month

Data type

text

Alias
UMLS CUI [1]
C0439231
Uhrzeit
Description

Time

Data type

time

Alias
UMLS CUI [1]
C0040223
aus:
Description

fetal position

Data type

text

Alias
UMLS CUI [1]
C1286298
Weitere Maßnahmen
Description

Weitere Maßnahmen

Alias
UMLS CUI-1
C0199171
Geburtsanästhesie
Description

Anesthesia

Data type

text

Alias
UMLS CUI [1]
C0002903
Art der Geburt
Description

Type of birth

Data type

text

Alias
UMLS CUI [1]
C2239272
operativ durch:
Description

birth method

Data type

text

Alias
UMLS CUI [1]
C2825496
Operateur
Description

Surgeon

Data type

text

Alias
UMLS CUI [1]
C0582175
Indikation
Description

Indication

Data type

text

Alias
UMLS CUI [1]
C3146298
Ausstoßung der Nachgeburt
Description

Ausstoßung der Nachgeburt

Alias
UMLS CUI-1
C0233171
Tag
Description

Day

Data type

text

Alias
UMLS CUI [1]
C0439228
Mon.
Description

Month

Data type

text

Alias
UMLS CUI [1]
C0439231
Uhrzeit
Description

Time

Data type

time

Alias
UMLS CUI [1]
C0040223
spontan
Description

Spontaneous

Data type

boolean

Alias
UMLS CUI [1]
C0205359
Cord-traction
Description

Cord-traction

Data type

boolean

Alias
UMLS CUI [1]
C0404385
Nachtastung
Description

palpation

Data type

boolean

Alias
UMLS CUI [1]
C0030247
Man. Lösung
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
vollst.
Description

Complete placenta

Data type

boolean

Alias
UMLS CUI [1]
C0426227
unvollst.
Description

Incomplete placenta

Data type

boolean

Alias
UMLS CUI [1]
C0542485
Infarkte
Description

Infarcts

Data type

boolean

Alias
UMLS CUI [1]
C0021308
Kalkinkrustationen
Description

Calcareous incrustation

Data type

boolean

Alias
UMLS CUI [1]
C0333582
Placenta-Histologie
Description

Histology placenta

Data type

boolean

Alias
UMLS CUI [1,1]
C0019638
UMLS CUI [1,2]
C0032043
Eihäute
Description

Eihäute

Alias
UMLS CUI-1
C0002630
vollst.
Description

Complete

Data type

boolean

Alias
UMLS CUI [1]
C0205197
fehlen z. T.
Description

Incomplete

Data type

boolean

Alias
UMLS CUI [1]
C0205257
3 IE Oxytocin i. v.
Description

Oxytocin intravenous

Data type

boolean

Alias
UMLS CUI [1,1]
C0030095
UMLS CUI [1,2]
C0348016
0,2 mg Methergin i. v.
Description

Methergin intravenous

Data type

boolean

Alias
UMLS CUI [1,1]
C0733811
UMLS CUI [1,2]
C0348016
Nabelschnur und Blutverlust
Description

Nabelschnur und Blutverlust

Alias
UMLS CUI-1
C0041633
UMLS CUI-2
C3163616
Nabelschnur: Insertio normal
Description

umbilical cord insertion normal

Data type

boolean

Alias
UMLS CUI [1,1]
C1404744
UMLS CUI [1,2]
C0205307
Nabelschnur: Insertio
Description

umbilical cord insertion

Data type

text

Alias
UMLS CUI [1]
C1404744
Echter Knoten
Description

True umbilical cord knot

Data type

boolean

Alias
UMLS CUI [1]
C0266791
Umschlingung
Description

Nuchal cord

Data type

boolean

Alias
UMLS CUI [1]
C0405124
Blutverlust
Description

Blood loss

Data type

integer

Measurement units
  • ml
Alias
UMLS CUI [1]
C3163616
ml
Damm und Scheide
Description

Damm und Scheide

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

Intact

Data type

boolean

Alias
UMLS CUI [1]
C0205266
DR
Description

Perineal tear

Data type

boolean

Alias
UMLS CUI [1]
C2053302
Grad DR
Description

Grade of perineal tear

Data type

integer

Alias
UMLS CUI [1]
C3533198
Cervix-Riss
Description

Cervical tear

Data type

boolean

Alias
UMLS CUI [1]
C0157358
Epi
Description

Episiotomy

Data type

boolean

Alias
UMLS CUI [1]
C0014586
Scheiden-Labien-Riss
Description

Vaginal-labial tear

Data type

boolean

Alias
UMLS CUI [1]
C0405231
Komb. Schäden
Description

lesions Combined

Data type

boolean

Alias
UMLS CUI [1,1]
C0221198
UMLS CUI [1,2]
C0205195
Art der Versorgung: Naht
Description

Suture

Data type

boolean

Alias
UMLS CUI [1]
C0038969
Art der Versorgung: Naht in
Description

site Suture

Data type

text

Alias
UMLS CUI [1,1]
C1515974
UMLS CUI [1,2]
C0038969
Art der Versorgung: Narkose
Description

Anesthesia type

Data type

text

Alias
UMLS CUI [1]
C1305863
Weitere Informationen
Description

Weitere Informationen

Alias
UMLS CUI-1
C1533716
Außergewöhnliche Geburtsereignisse
Description

event

Data type

text

Alias
UMLS CUI [1]
C0441471
Geburtsleitung
Description

Physician

Data type

text

Alias
UMLS CUI [1]
C0031831
Hebamme
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
Beg. der Wehen
C0022868 (UMLS CUI-1)
Day
Item
Tag
text
C0439228 (UMLS CUI [1])
Month
Item
Mon.
text
C0439231 (UMLS CUI [1])
Time
Item
Uhrzeit
time
C0040223 (UMLS CUI [1])
Spontaneous onset of labor
Item
spontan
boolean
C0474461 (UMLS CUI [1])
Induction of labor
Item
Einleitung mit
text
C0259787 (UMLS CUI [1])
Item Group
Blasensprung
C0948106 (UMLS CUI-1)
Day
Item
Tag
text
C0439228 (UMLS CUI [1])
Month
Item
Mon.
text
C0439231 (UMLS CUI [1])
Time
Item
Uhrzeit
time
C0040223 (UMLS CUI [1])
Item
Blasensprung
text
C0948106 (UMLS CUI [1,1])
C0332307 (UMLS CUI [1,2])
Time of rupture of membranes
Code List
Blasensprung
CL Item
vorz. (premature)
C0015944 (UMLS CUI-1)
(Comment:en)
CL Item
frühz. (early)
(Comment:en)
CL Item
rechtz. (timely)
(Comment:en)
CL Item
spontan (spontaneous)
C0205359 (UMLS CUI-1)
(Comment:en)
CL Item
instrumentell (artificial)
(Comment:en)
Item
FW-Farbe
text
C1443316 (UMLS CUI [1])
Color of amniotic fluid
Code List
FW-Farbe
CL Item
klar (clear)
CL Item
grün (green)
CL Item
erbsbreiartig (similar to pea-soup)
CL Item
sanguin. (sanguineous)
Item Group
Geburt I
C0005615 (UMLS CUI-1)
Day
Item
Tag
text
C0439228 (UMLS CUI [1])
Month
Item
Mon.
text
C0439231 (UMLS CUI [1])
Time
Item
Uhrzeit
time
C0040223 (UMLS CUI [1])
fetal position
Item
aus:
text
C1286298 (UMLS CUI [1])
Item Group
Geburt II
C0005615 (UMLS CUI-1)
Day
Item
Tag
text
C0439228 (UMLS CUI [1])
Month
Item
Mon.
text
C0439231 (UMLS CUI [1])
Time
Item
Uhrzeit
time
C0040223 (UMLS CUI [1])
fetal position
Item
aus:
text
C1286298 (UMLS CUI [1])
Item Group
Weitere Maßnahmen
C0199171 (UMLS CUI-1)
Item
Geburtsanästhesie
text
C0002903 (UMLS CUI [1])
Anesthesia
Code List
Geburtsanästhesie
CL Item
Lokal (local)
C0002921 (UMLS CUI-1)
(Comment:en)
CL Item
Pudendus (pudendal nerve)
(Comment:en)
CL Item
PDA (PDA)
(Comment:en)
CL Item
ITN (endotracheal anesthesia)
(Comment:en)
Item
Art der Geburt
text
C2239272 (UMLS CUI [1])
Type of birth
Code List
Art der Geburt
CL Item
spontan (spontaneous)
CL Item
operativ (operative)
birth method
Item
operativ durch:
text
C2825496 (UMLS CUI [1])
Surgeon
Item
Operateur
text
C0582175 (UMLS CUI [1])
Indication
Item
Indikation
text
C3146298 (UMLS CUI [1])
Item Group
Ausstoßung der Nachgeburt
C0233171 (UMLS CUI-1)
Day
Item
Tag
text
C0439228 (UMLS CUI [1])
Month
Item
Mon.
text
C0439231 (UMLS CUI [1])
Time
Item
Uhrzeit
time
C0040223 (UMLS CUI [1])
Spontaneous
Item
spontan
boolean
C0205359 (UMLS CUI [1])
Cord-traction
Item
Cord-traction
boolean
C0404385 (UMLS CUI [1])
palpation
Item
Nachtastung
boolean
C0030247 (UMLS CUI [1])
Manual placenta removal
Item
Man. Lösung
boolean
C0438074 (UMLS CUI [1])
Curettage
Item
Curettage
boolean
C0010468 (UMLS CUI [1])
Item Group
Placenta
C0032043 (UMLS CUI-1)
Complete placenta
Item
vollst.
boolean
C0426227 (UMLS CUI [1])
Incomplete placenta
Item
unvollst.
boolean
C0542485 (UMLS CUI [1])
Infarcts
Item
Infarkte
boolean
C0021308 (UMLS CUI [1])
Calcareous incrustation
Item
Kalkinkrustationen
boolean
C0333582 (UMLS CUI [1])
Histology placenta
Item
Placenta-Histologie
boolean
C0019638 (UMLS CUI [1,1])
C0032043 (UMLS CUI [1,2])
Item Group
Eihäute
C0002630 (UMLS CUI-1)
Complete
Item
vollst.
boolean
C0205197 (UMLS CUI [1])
Incomplete
Item
fehlen z. T.
boolean
C0205257 (UMLS CUI [1])
Oxytocin intravenous
Item
3 IE Oxytocin i. v.
boolean
C0030095 (UMLS CUI [1,1])
C0348016 (UMLS CUI [1,2])
Methergin intravenous
Item
0,2 mg Methergin i. v.
boolean
C0733811 (UMLS CUI [1,1])
C0348016 (UMLS CUI [1,2])
Item Group
Nabelschnur und Blutverlust
C0041633 (UMLS CUI-1)
C3163616 (UMLS CUI-2)
umbilical cord insertion normal
Item
Nabelschnur: Insertio normal
boolean
C1404744 (UMLS CUI [1,1])
C0205307 (UMLS CUI [1,2])
umbilical cord insertion
Item
Nabelschnur: Insertio
text
C1404744 (UMLS CUI [1])
True umbilical cord knot
Item
Echter Knoten
boolean
C0266791 (UMLS CUI [1])
Nuchal cord
Item
Umschlingung
boolean
C0405124 (UMLS CUI [1])
Blood loss
Item
Blutverlust
integer
C3163616 (UMLS CUI [1])
Item Group
Damm und Scheide
C0031066 (UMLS CUI-1)
C0042232 (UMLS CUI-3)
Intact
Item
intakt
boolean
C0205266 (UMLS CUI [1])
Perineal tear
Item
DR
boolean
C2053302 (UMLS CUI [1])
Grade of perineal tear
Item
Grad DR
integer
C3533198 (UMLS CUI [1])
Cervical tear
Item
Cervix-Riss
boolean
C0157358 (UMLS CUI [1])
Episiotomy
Item
Epi
boolean
C0014586 (UMLS CUI [1])
Vaginal-labial tear
Item
Scheiden-Labien-Riss
boolean
C0405231 (UMLS CUI [1])
lesions Combined
Item
Komb. Schäden
boolean
C0221198 (UMLS CUI [1,1])
C0205195 (UMLS CUI [1,2])
Suture
Item
Art der Versorgung: Naht
boolean
C0038969 (UMLS CUI [1])
site Suture
Item
Art der Versorgung: Naht in
text
C1515974 (UMLS CUI [1,1])
C0038969 (UMLS CUI [1,2])
Anesthesia type
Item
Art der Versorgung: Narkose
text
C1305863 (UMLS CUI [1])
Item Group
Weitere Informationen
C1533716 (UMLS CUI-1)
event
Item
Außergewöhnliche Geburtsereignisse
text
C0441471 (UMLS CUI [1])
Physician
Item
Geburtsleitung
text
C0031831 (UMLS CUI [1])
Midwife
Item
Hebamme
text
C0026083 (UMLS CUI [1])
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