ID
27654
Description
Bipolar Affective Disorder (BipoläR) Swedish National Quality Registry Head of Registry: Mikael Landén Professor at the Sahlgrenska Academy, consultant at Sahlgrenska University Hospital, 411 18 Gothenburg Source: http://www.psykiatriregister.se/dokumentarkiv/bipolar S:t Göranprojekts (Making Projects) Anamnesis protocol for bipolar syndrom (version 3)
Link
http://www.psykiatriregister.se/dokumentarkiv/bipolar
Keywords
Versions (2)
- 11/24/17 11/24/17 -
- 3/15/21 3/15/21 - Dr. rer. medic Philipp Neuhaus
Copyright Holder
psykiatriregister.se (BipoläR)
Uploaded on
November 24, 2017
DOI
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License
Creative Commons BY-NC-ND 3.0
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Bipolar Affective Disorder (BipoläR) Swedish National Quality Registry
Anamnesis
- StudyEvent: ODM
Description
Medical History
Alias
- UMLS CUI-1
- C0262926
Description
Investigator
Data type
text
Alias
- UMLS CUI [1]
- C2826892
Description
Date of Medical History Taking
Data type
date
Measurement units
- yyyy-mm-dd
Alias
- UMLS CUI [1,1]
- C0025084
- UMLS CUI [1,2]
- C0011008
Description
Actual Medical History
Data type
text
Alias
- UMLS CUI [1,1]
- C0262926
- UMLS CUI [1,2]
- C0237400
Description
Referral
Data type
text
Alias
- UMLS CUI [1]
- C0034927
Description
Comment
Data type
text
Alias
- UMLS CUI [1]
- C0947611
Description
Social Anamnesis
Alias
- UMLS CUI-1
- C0424945
Description
The question relates to the main situation in the last year. If one of the patient's occupations exceeds 75 percent, only one option is indicated. If none of the patient's occupations exceeds 75 percent, two (2) alternatives may be specified. Several responses are possible.
Data type
text
Alias
- UMLS CUI [1]
- C0242271
Description
Determine the number of affective episodes.
Alias
- UMLS CUI-1
- C1386525
Description
Manic, hypomanic, depressive and mixed episodes separated by 4 weeks eutymi or episode of opposite polarity. Estimate the number when in doubt.
Data type
boolean
Alias
- UMLS CUI [1]
- C0349217
Description
Manic, hypomanic, depressive and mixed episodes separated by 4 weeks eutymi or episode of opposite polarity. Estimate the number when in doubt.
Data type
float
Alias
- UMLS CUI [1,1]
- C0349217
- UMLS CUI [1,2]
- C4086638
Description
Manic, hypomanic, depressive and mixed episodes separated by 4 weeks eutymi or episode of opposite polarity. Estimate the number when in doubt.
Data type
boolean
Alias
- UMLS CUI [1]
- C1396834
Description
Manic, hypomanic, depressive and mixed episodes separated by 4 weeks eutymi or episode of opposite polarity. Estimate the number when in doubt.
Data type
float
Alias
- UMLS CUI [1,1]
- C1396834
- UMLS CUI [1,2]
- C4086638
Description
Manic, hypomanic, depressive and mixed episodes separated by 4 weeks eutymi or episode of opposite polarity. Estimate the number when in doubt.
Data type
boolean
Alias
- UMLS CUI [1]
- C0349208
Description
Manic, hypomanic, depressive and mixed episodes separated by 4 weeks eutymi or episode of opposite polarity. Estimate the number when in doubt.
Data type
float
Alias
- UMLS CUI [1,1]
- C0349208
- UMLS CUI [1,2]
- C4086638
Description
Manic, hypomanic, depressive and mixed episodes separated by 4 weeks eutymi or episode of opposite polarity. Estimate the number when in doubt.
Data type
boolean
Alias
- UMLS CUI [1]
- C4290107
Description
Manic, hypomanic, depressive and mixed episodes separated by 4 weeks eutymi or episode of opposite polarity. Estimate the number when in doubt.
Data type
float
Alias
- UMLS CUI [1,1]
- C4290107
- UMLS CUI [1,2]
- C4086638
Description
Summarize the weeks for all verified affective episodes during the year. Give an approximate value in case of doubt.
Data type
integer
Alias
- UMLS CUI [1,1]
- C1386525
- UMLS CUI [1,2]
- C0449238
Description
Complete remission = no significant signs or symptoms of bipolar affective episodes. Without complete remission between relapses = not completely symptom free but with symptoms of bipolar affective episodes that do not fully meet the criteria. One answer can be given.
Data type
text
Alias
- UMLS CUI [1,1]
- C0040223
- UMLS CUI [1,2]
- C0332288
- UMLS CUI [1,3]
- C1386525
Description
Self-Injurious Behavior
Alias
- UMLS CUI-1
- C0085271
Description
Self-harmful action refers to the intentionally inflicting bodily injury without suicidal insight (eg by biting, headache, scratching, tearing, cutting, drowning of the body, ingestion of inedible substances and fluids, taking out of medication beyond ordination, dose poisoning with apparently non-lethal dosage or by burning).
Data type
text
Alias
- UMLS CUI [1]
- C3641595
Description
One Answer only.
Data type
text
Alias
- UMLS CUI [1,1]
- C3641595
- UMLS CUI [1,2]
- C0439228
Description
Suicide attempts are meant to be life-threatening or apparently life-threatening behavior, in order to put their lives at stake or to express such an intention but do not lead to death (eg severe tablet poisoning, drowning, shooting, hanging / tightening).
Data type
text
Alias
- UMLS CUI [1]
- C0038663
Description
One Answer only.
Data type
text
Alias
- UMLS CUI [1,1]
- C0038663
- UMLS CUI [1,2]
- C0750480
Description
Treatment History
Alias
- UMLS CUI-1
- C0814462
Description
Treatment for bipolar disorder
Data type
text
Alias
- UMLS CUI [1,1]
- C0005586
- UMLS CUI [1,2]
- C0087111
Description
- Patient education for bipolar disorder (educational initiative that follows a predefined education program comprising a number of training courses where the content aims to provide increased knowledge about disease and treatment, strategies to handle everyday symptoms and opportunity for exchange of experience) - Systematic psychological treatment (eg psychodynamic, dialectic-behavioral, interpersonal, cognitive or cognitive behavioral therapeutic treatment) - Neuropsychological investigation (investigation with standardized tests that measure cognitive functions as attention, memory function, concentration ability, learning ability)
Data type
text
Alias
- UMLS CUI [1,1]
- C0005586
- UMLS CUI [1,2]
- C0087111
- UMLS CUI [1,3]
- C2348235
Description
Treatment for bipolar disorder: Time of Treatment
Data type
text
Alias
- UMLS CUI [1,1]
- C0005586
- UMLS CUI [1,2]
- C0087111
- UMLS CUI [1,3]
- C2348792
Description
- Patient education for bipolar disorder (educational initiative that follows a predefined education program comprising a number of training courses where the content aims to provide increased knowledge about disease and treatment, strategies to handle everyday symptoms and opportunity for exchange of experience) - Systematic psychological treatment (eg psychodynamic, dialectic-behavioral, interpersonal, cognitive or cognitive behavioral therapeutic treatment) - Neuropsychological investigation (investigation with standardized tests that measure cognitive functions as attention, memory function, concentration ability, learning ability)
Data type
text
Alias
- UMLS CUI [1,1]
- C0005586
- UMLS CUI [1,2]
- C0087111
- UMLS CUI [1,3]
- C2348792
- UMLS CUI [1,4]
- C2348235
Description
Regardless of the number of times in a treatment series. ECT = Electroconvulsive Treatment (KVÅ codes DA006, DA024 and DA025)
Data type
text
Alias
- UMLS CUI [1]
- C0013806
Description
Electroconvulsive Therapy: Number
Data type
float
Alias
- UMLS CUI [1,1]
- C0013806
- UMLS CUI [1,2]
- C0449788
Description
Estimate the treatment effect according to CGI-I. Compared with the patient's condition before treatment, how much has he / she changed? Circle the appropriate option.
Data type
integer
Alias
- UMLS CUI [1,1]
- C0013806
- UMLS CUI [1,2]
- C1547647
Description
Electroconvulsive Therapy: Last Treatment
Data type
text
Alias
- UMLS CUI [1,1]
- C0013806
- UMLS CUI [1,2]
- C1517741
- UMLS CUI [1,3]
- C2745955
Description
Ongoing Pharmacotherapy
Alias
- UMLS CUI-1
- C0013216
- UMLS CUI-2
- C0549178
Description
Refers to ongoing drug treatment and includes Karbamazepine, Clonazepam, Lamotrigine, Lithium, Oxcarbazepine, Quetiapine, Topiramate, Valproate, and other mood stabilizing drugs. One answer can be given.
Data type
text
Alias
- UMLS CUI [1]
- C1533054
Description
Several answers are possible.
Data type
text
Alias
- UMLS CUI [1,1]
- C1533054
- UMLS CUI [1,2]
- C2348235
Description
Lithium Therapy: Start Date
Data type
date
Measurement units
- yyyy
Alias
- UMLS CUI [1,1]
- C3540800
- UMLS CUI [1,2]
- C1531783
Description
(decimal with one decimal place)
Data type
float
Measurement units
- mmol/L
Alias
- UMLS CUI [1]
- C0337452
Description
Renal Function
Data type
text
Alias
- UMLS CUI [1]
- C0232804
Description
Creatinine
Data type
integer
Measurement units
- μmol/L
Description
Cystatin C
Data type
float
Measurement units
- mg/L
Alias
- UMLS CUI [1]
- C1619716
Description
Iohexol Clearance
Data type
integer
Measurement units
- mL/min/1,73 m2
Alias
- UMLS CUI [1,1]
- C0017654
- UMLS CUI [1,2]
- C0022005
Description
Renal Function Test
Data type
text
Alias
- UMLS CUI [1,1]
- C0232804
- UMLS CUI [1,2]
- C0022885
Description
Refers to ongoing drug treatment including Alimemazine, Aripiprazole, Dixyrazine, Flufenazine, Flupentixol, Haloperidol, Chlorpromazine, Kloprotixen, Klozapine, Levomepromazine, Melperon, Olanzapine, Paliperidone, Perfenazine, Pimozide, Quetiapine, Risperidone, Sertindole, Sulpiride, Tioridazine, Ziprasidone, Zuclopentixol, Ev other antipsychotic drug.
Data type
text
Alias
- UMLS CUI [1]
- C0040615
Description
Examples of typical antipsychotic drugs: Dixyrazine, Flufenazine, Haloperidol, Chlorpromazine, Chlorprotixen, Levomepromazine, Perfenazine, Tioridazine. Examples of atypical antipsychotic drugs: Aripiprazole, Klozapine, Risperidone, Olanzapine, Quetiapine, Paliperidone, Sertindole, Ziprasidone. Several response options can be specified
Data type
text
Alias
- UMLS CUI [1,1]
- C0040615
- UMLS CUI [1,2]
- C2348235
Description
Antidepressive Agents
Data type
text
Alias
- UMLS CUI [1]
- C0003289
Description
Antidepressive Agents: Specification
Data type
text
Alias
- UMLS CUI [1,1]
- C0003289
- UMLS CUI [1,2]
- C2348235
Description
Refers to ongoing drug treatment and includes Atomoxetine, central stimulant, and any other drug against ADHD. By central stimulant medicine is meant e.g. methylphenidate, dexamethetamine, modafinil, but not atomoxetine. One answer can be given.
Data type
text
Alias
- UMLS CUI [1,1]
- C1263846
- UMLS CUI [1,2]
- C0013216
Description
Several answers are possible.
Data type
text
Alias
- UMLS CUI [1,1]
- C1263846
- UMLS CUI [1,2]
- C0013216
- UMLS CUI [1,3]
- C2348235
Description
Refers to ongoing drug treatment and includes Alprazolam, Buspiron, Diazepam, Flunitrazepam, Hydroxizin, Lorazepam, Klometiazole, Nitrazepam, Oxazepam, Pregabalin, Prometazin, Propiomazine, Propranolol, Triazolam, Valeriana, Zaleplon, Zolpidem, Zopiclone, and other benzodiazepine-like drugs.
Data type
text
Alias
- UMLS CUI [1]
- C0005064
Description
Levothyroxine
Data type
text
Alias
- UMLS CUI [1]
- C1881373
Description
Adverse reaction to drug
Data type
text
Alias
- UMLS CUI [1]
- C0041755
Description
Adverse reaction to drug: Preparation
Data type
text
Alias
- UMLS CUI [1,1]
- C0041755
- UMLS CUI [1,2]
- C1521827
Description
Adverse reaction to drug: Specification
Data type
text
Alias
- UMLS CUI [1,1]
- C0041755
- UMLS CUI [1,2]
- C2348235
Description
Somatic Factors
Alias
- UMLS CUI-1
- C2986476
Description
Includes diagnosed states, suspected conditions investigated (even if diagnosis is not yet established) as well as complicating circumstances.
Data type
text
Alias
- UMLS CUI [1]
- C2986476
Description
Several answers are possible.
Data type
text
Description
Somatic Factors: Others
Data type
text
Alias
- UMLS CUI [1,1]
- C2986476
- UMLS CUI [1,2]
- C0205394
Description
HbA1c
Data type
boolean
Alias
- UMLS CUI [1]
- C0019018
Description
HbA1c = "long-term measure" of glucose levels (blood sugar). The HbA1c level reflects the average P-Glucose level below the last 6-8 weeks before sampling. The answer is given in integers.
Data type
integer
Measurement units
- mmol/mol
Alias
- UMLS CUI [1,1]
- C0019018
- UMLS CUI [1,2]
- C0587081
Description
Systolic Blood Pressure
Data type
boolean
Alias
- UMLS CUI [1]
- C0871470
Description
Systolic blood pressure, upper pressure (mm Hg) registered in sitting after at least two minutes rest (recommendation).
Data type
integer
Measurement units
- mmHg
Alias
- UMLS CUI [1,1]
- C0871470
- UMLS CUI [1,2]
- C0587081
Description
Diastolic Blood Pressure
Data type
boolean
Alias
- UMLS CUI [1]
- C0428883
Description
Diastolic blood pressure, lower pressure (mm Hg) recorded in sitting after at least two minutes rest (recommendation).
Data type
integer
Measurement units
- mmHg
Alias
- UMLS CUI [1,1]
- C0428883
- UMLS CUI [1,2]
- C0587081
Description
Body Weight
Data type
boolean
Alias
- UMLS CUI [1]
- C0005910
Description
Weight = kg, without outerwear, jacket and shoes. (Decimal by one decimal place)
Data type
float
Measurement units
- kg
Description
Body Height
Data type
boolean
Alias
- UMLS CUI [1]
- C0005890
Description
Length = cm, without shoes.
Data type
integer
Measurement units
- cm
Alias
- UMLS CUI [1,1]
- C0005890
- UMLS CUI [1,2]
- C0587081
Description
Substance Use Disorders
Alias
- UMLS CUI-1
- C0038586
Description
Nicotine
Data type
text
Alias
- UMLS CUI [1]
- C0376384
Description
By nicotine replacement, nicotine patches and nicotine gum. Several responses can be specified.
Data type
text
Alias
- UMLS CUI [1,1]
- C0376384
- UMLS CUI [1,2]
- C2348235
Description
AUDIT C are the first three questions of the AUDIT. Score: 0-12 Risk Use ≥ 4 points (man), ≥ 3 points (female). A glass is defined as one of the following: 45 cl beer, 33 cl beer, 15 cl of wine, fortified wine Cl 8, 4 cl liquor.
Data type
integer
Alias
- UMLS CUI [1,1]
- C0001948
- UMLS CUI [1,2]
- C0439603
Description
AUDIT C are the first three questions of the AUDIT. Score: 0-12 Risk Use ≥ 4 points (man), ≥ 3 points (female). A glass is defined as one of the following: 45 cl beer, 33 cl beer, 15 cl of wine, fortified wine Cl 8, 4 cl liquor.
Data type
integer
Alias
- UMLS CUI [1]
- C0560578
Description
AUDIT C are the first three questions of the AUDIT. Score: 0-12 Risk Use ≥ 4 points (man), ≥ 3 points (female). A glass is defined as one of the following: 45 cl beer, 33 cl beer, 15 cl of wine, fortified wine Cl 8, 4 cl liquor.
Data type
integer
Alias
- UMLS CUI [1,1]
- C0001948
- UMLS CUI [1,2]
- C0442802
Description
(0 - 12 points)
Data type
integer
Alias
- UMLS CUI [1,1]
- C0001948
- UMLS CUI [1,2]
- C0449820
Description
Psychiatric comorbidity - Based on clinical interview, MINI interview or other instruments:
Alias
- UMLS CUI-1
- C0004936
Description
Psychiatric comorbidity
Data type
text
Alias
- UMLS CUI [1]
- C0004936
Description
Several answers are possible.
Data type
text
Alias
- UMLS CUI [1,1]
- C0004936
- UMLS CUI [1,2]
- C2348235
Description
One answer only.
Data type
text
Alias
- UMLS CUI [1]
- C0041671
Description
Substance abuse refers to malicious use and / or addiction. Combination (F19.1 / F19.2) is applied when it is known that two or more psychoactive substances have been used but when it is impossible to determine which one contributed most to the disturbance. The category should be used as well when one or more of the substances are unknown or can not be accurately identified. Several answers are possible.
Data type
text
Alias
- UMLS CUI [1]
- C0038586
Description
Global Assessment of Functioning
Description
The question is answered if the patient is 21 years of age or older. The GAF scale is a global functional assessment scale for estimating psychological, social and professional functionalities. Instruction: Note that the value 0 (insufficient information) should always be stated when it is estimated that there is no basis for a clinically relevant assessment on the part scale. This may be the case when the symptom source makes the assessment of the level of functioning too uncertain or when the assessment is made in circumstances that are not representative or adequate as a basis for a functional assessment, e.g. when the patient is in closed care. (0 - 100)
Data type
integer
Alias
- UMLS CUI [1,1]
- C0017644
- UMLS CUI [1,2]
- C0814554
Description
The question is answered if the patient is 21 years of age or older. The GAF scale is a global function estimation scale for estimating psychological, social and professional functioning. Instruction: Note that the value 0 (insufficient information) should always be is stated when it is estimated that no clinical data can be obtained relevant estimation on the part scale. This can for example be the case when it is difficult to communicate with the patient that the symptom source can not clarified. (0 - 100)
Data type
integer
Alias
- UMLS CUI [1,1]
- C0017644
- UMLS CUI [1,2]
- C0004936
Description
(The question is answered if the patient is 20 years and younger) One answer only.
Data type
text
Alias
- UMLS CUI [1]
- C0450973
Description
Estimate the person's most impaired overall functional level during the specified time period by selecting the lowest level describing his / her functioning on a hypothetical continuum of health / illness. Also use intermediate levels (eg 35, 58, 62). The value "0" = insufficient information to be able to tax. C-GAS = Children's Global Assessment Scale. (0 - 100)
Data type
integer
Alias
- UMLS CUI [1]
- C3472495
Description
(0 - 100)
Data type
integer
Alias
- UMLS CUI [1]
- C0017644
Description
(0 - 100)
Data type
integer
Alias
- UMLS CUI [1,1]
- C0017644
- UMLS CUI [1,2]
- C1457887
Description
CGI-S (Clinical Global Impression - Severity, Overall Clinical Impression of Disease Severity) * * Mandatory
Alias
- UMLS CUI-1
- C3639708
Description
One answer only.
Data type
text
Alias
- UMLS CUI [1,1]
- C3639708
- UMLS CUI [1,2]
- C0024713
Description
One answer only.
Data type
text
Alias
- UMLS CUI [1,1]
- C3639708
- UMLS CUI [1,2]
- C0011581
Description
Clinical Global Impression
Data type
text
Alias
- UMLS CUI [1]
- C3639708
Similar models
Anamnesis
- StudyEvent: ODM
C0600091 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,2])
C0237400 (UMLS CUI [1,2])
C4086638 (UMLS CUI [1,2])
C4086638 (UMLS CUI [1,2])
C4086638 (UMLS CUI [1,2])
C4086638 (UMLS CUI [1,2])
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C0439228 (UMLS CUI [1,2])
C0750480 (UMLS CUI [1,2])
C0087111 (UMLS CUI [1,2])
C0087111 (UMLS CUI [1,2])
C2348235 (UMLS CUI [1,3])
C0087111 (UMLS CUI [1,2])
C2348792 (UMLS CUI [1,3])
C0087111 (UMLS CUI [1,2])
C2348792 (UMLS CUI [1,3])
C2348235 (UMLS CUI [1,4])
C0449788 (UMLS CUI [1,2])
C1547647 (UMLS CUI [1,2])
C1517741 (UMLS CUI [1,2])
C2745955 (UMLS CUI [1,3])
C0549178 (UMLS CUI-2)
C2348235 (UMLS CUI [1,2])
C1531783 (UMLS CUI [1,2])
C0022005 (UMLS CUI [1,2])
C0022885 (UMLS CUI [1,2])
C2348235 (UMLS CUI [1,2])
C2348235 (UMLS CUI [1,2])
C0013216 (UMLS CUI [1,2])
C0013216 (UMLS CUI [1,2])
C2348235 (UMLS CUI [1,3])
C1521827 (UMLS CUI [1,2])
C2348235 (UMLS CUI [1,2])
C0205394 (UMLS CUI [1,2])
C0587081 (UMLS CUI [1,2])
C0587081 (UMLS CUI [1,2])
C0587081 (UMLS CUI [1,2])
C0587081 (UMLS CUI [1,2])
C2348235 (UMLS CUI [1,2])
C0439603 (UMLS CUI [1,2])
C0442802 (UMLS CUI [1,2])
C0449820 (UMLS CUI [1,2])
C2348235 (UMLS CUI [1,2])
C0814554 (UMLS CUI [1,2])
C0004936 (UMLS CUI [1,2])
C1457887 (UMLS CUI [1,2])
C0024713 (UMLS CUI [1,2])
C0011581 (UMLS CUI [1,2])