ID

24490

Description

Routine documentation in German hospitals. Source file name: VL040310_Infektionsdokumentationsbogen Examplary forms provided by DMI (http://www.dmi.de/)

Link

http://www.dmi.de/

Keywords

Versions (3)
  1. 6/8/17 6/8/17 -
  2. 6/16/17 6/16/17 -
  3. 8/2/17 8/2/17 -
Uploaded on

August 2, 2017

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License

Creative Commons BY-NC 3.0
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Infection documentation, nosocomial Routine documentation in German hospitals DMI

German English

Infection documentation, nosocomial Routine documentation in German hospitals DMI

1 forms  
Allgemeine Informationen
Description

Allgemeine Informationen

Alias
UMLS CUI-1
C1508263
Patientenaufkleber
Description

Dieser Bogen liegt jedem Krankenblatt bei. Ist während des Krankenhausaufenthaltes keine NI aufgetreten, nur Personalienfeld ausfüllen und nein ankreuzen. Bei Auftreten einer NI ist der gesamte Fragebogen auszufüllen. Den Bogen anschließend zurück in die Patientenaufnahme /-abmeldung geben.

Data type

text

Alias
UMLS CUI [1]
C2707520
Nosokomiale lnfektion
Description

Nosokomiale lnfektion

Alias
UMLS CUI-1
C0205721
Nosokomiale Infektion (NI)
Description

Nosocomial infection

Data type

boolean

Alias
UMLS CUI [1]
C0205721
Es handelt sich um eine
Description

infection type

Data type

text

Alias
UMLS CUI [1,1]
C0009450
UMLS CUI [1,2]
C0332307
Keimdiagnostik
Description

Keimdiagnostik

Alias
UMLS CUI-1
C0025951
Erreger - Nachweis durchgefuhrt
Description

Pathogen detection

Data type

boolean

Alias
UMLS CUI [1]
C1740302
Erregertyp
Description

pathogen

Data type

text

Alias
UMLS CUI [1]
C0450254
Diagnosen und Eingriff
Description

Diagnosen und Eingriff

Alias
UMLS CUI-1
C0011900
UMLS CUI-3
C0199171
Diagnosen
Description

nur bei vorliegender NI auszufüllen

Data type

text

Alias
UMLS CUI [1]
C0011900
Eingriff
Description

Medical procedure

Data type

text

Alias
UMLS CUI [1]
C0199171
Aufenthalt Intensivstation
Description

Aufenthalt Intensivstation

Alias
UMLS CUI-1
C0085559
UMLS CUI-2
C0023303
Intensivstation
Description

ICU stay

Data type

boolean

Alias
UMLS CUI [1,1]
C0085559
UMLS CUI [1,2]
C0023303
vor OP
Description

before surgery

Data type

boolean

Alias
UMLS CUI [1,1]
C0332152
UMLS CUI [1,2]
C0543467
nach OP
Description

after surgery

Data type

boolean

Alias
UMLS CUI [1]
C0332387
Antibiotika
Description

Antibiotika

Alias
UMLS CUI-1
C0003232
präoperative Antibiotika Prophylaxe
Description

antibiotic prophylaxis preoperative

Data type

boolean

Alias
UMLS CUI [1,1]
C0282638
UMLS CUI [1,2]
C0445204
Antibiotika - Therapie
Description

Antibiotic therapy

Data type

boolean

Alias
UMLS CUI [1]
C0338237
Risikofaktoren
Description

Risikofaktoren

Alias
UMLS CUI-1
C0035648
Diabetes
Description

Diabetes

Data type

boolean

Alias
UMLS CUI [1]
C0011849
Adipositas
Description

Obesity

Data type

boolean

Alias
UMLS CUI [1]
C0028754
Kachexie
Description

Cachexia

Data type

boolean

Alias
UMLS CUI [1]
C0006625
Ca
Description

Carcinoma

Data type

boolean

Alias
UMLS CUI [1]
C0007097
Abusus
Description

Abuse

Data type

boolean

Alias
UMLS CUI [1]
C1546935
lmmundefekte
Description

Immunodeficiency

Data type

boolean

Alias
UMLS CUI [1]
C0021051
Zytostatikatherapie
Description

Cytostatic therapy

Data type

boolean

Alias
UMLS CUI [1]
C2609342
andere
Description

Other

Data type

boolean

Alias
UMLS CUI [1]
C0205394
Signature
Description

Signature

Alias
UMLS CUI-1
C1519316
Datum
Description

Date

Data type

date

Alias
UMLS CUI [1]
C0011008
Unterschrift Arzt
Description

Signature physician

Data type

text

Alias
UMLS CUI [1]
C0807938
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Similar models

Infection documentation, nosocomial Routine documentation in German hospitals DMI

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Allgemeine Informationen
C1508263 (UMLS CUI-1)
Patient data
Item
Patientenaufkleber
text
C2707520 (UMLS CUI [1])
Item Group
Nosokomiale lnfektion
C0205721 (UMLS CUI-1)
Nosocomial infection
Item
Nosokomiale Infektion (NI)
boolean
C0205721 (UMLS CUI [1])
Item
Es handelt sich um eine
text
C0009450 (UMLS CUI [1,1])
C0332307 (UMLS CUI [1,2])
Type of infection
Code List
Es handelt sich um eine
CL Item
Wundinfektion (Wound infection)
CL Item
Harnwegsinfektion (Urinary tract infection)
CL Item
Atemwegsinfektion (Respiratory tract infection)
CL Item
Septikämie (Septicemia)
CL Item
Venenkatheterinfektion (peripher) (Peripheral venous catheter infection)
CL Item
Venenkatheterinfektion (zentral) (Central venous catheter infection)
CL Item
sonstige lnfektion (Other infection)
Item Group
Keimdiagnostik
C0025951 (UMLS CUI-1)
Pathogen detection
Item
Erreger - Nachweis durchgefuhrt
boolean
C1740302 (UMLS CUI [1])
pathogen
Item
Erregertyp
text
C0450254 (UMLS CUI [1])
Item Group
Diagnosen und Eingriff
C0011900 (UMLS CUI-1)
C0199171 (UMLS CUI-3)
Diagnoses
Item
Diagnosen
text
C0011900 (UMLS CUI [1])
Item
Eingriff
text
C0199171 (UMLS CUI [1])
Medical procedure
Code List
Eingriff
CL Item
aseptisch (aseptic)
C0232920 (UMLS CUI-1)
(Comment:en)
CL Item
besiedelt/kontaminiert (colonization/contamination)
C4289767 (UMLS CUI-1)
(Comment:en)
CL Item
infiziert (infection)
C0009450 (UMLS CUI-1)
(Comment:en)
Item Group
Aufenthalt Intensivstation
C0085559 (UMLS CUI-1)
C0023303 (UMLS CUI-2)
ICU stay
Item
Intensivstation
boolean
C0085559 (UMLS CUI [1,1])
C0023303 (UMLS CUI [1,2])
before surgery
Item
vor OP
boolean
C0332152 (UMLS CUI [1,1])
C0543467 (UMLS CUI [1,2])
after surgery
Item
nach OP
boolean
C0332387 (UMLS CUI [1])
Item Group
Antibiotika
C0003232 (UMLS CUI-1)
antibiotic prophylaxis preoperative
Item
präoperative Antibiotika Prophylaxe
boolean
C0282638 (UMLS CUI [1,1])
C0445204 (UMLS CUI [1,2])
Antibiotic therapy
Item
Antibiotika - Therapie
boolean
C0338237 (UMLS CUI [1])
Item Group
Risikofaktoren
C0035648 (UMLS CUI-1)
Diabetes
Item
Diabetes
boolean
C0011849 (UMLS CUI [1])
Obesity
Item
Adipositas
boolean
C0028754 (UMLS CUI [1])
Cachexia
Item
Kachexie
boolean
C0006625 (UMLS CUI [1])
Carcinoma
Item
Ca
boolean
C0007097 (UMLS CUI [1])
Abuse
Item
Abusus
boolean
C1546935 (UMLS CUI [1])
Immunodeficiency
Item
lmmundefekte
boolean
C0021051 (UMLS CUI [1])
Cytostatic therapy
Item
Zytostatikatherapie
boolean
C2609342 (UMLS CUI [1])
Other
Item
andere
boolean
C0205394 (UMLS CUI [1])
Item Group
C1519316 (UMLS CUI-1)
Date
Item
Datum
date
C0011008 (UMLS CUI [1])
Signature physician
Item
Unterschrift Arzt
text
C0807938 (UMLS CUI [1])
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