ID

31099

Description

Emergency protocol by the DIVI (Deutsche Interdisziplinre Vereinigung für Intensiv- und Notfallmedizin). ODM derived from "Notaufnahmeprotokoll Modul Basis V2015.1".

Keywords

Versions (9)
  1. 5/31/18 5/31/18 - Ann-Kristin Kock
  2. 5/31/18 5/31/18 - Ann-Kristin Kock
  3. 5/31/18 5/31/18 - Ann-Kristin Kock
  4. 5/31/18 5/31/18 - Ann-Kristin Kock
  5. 6/6/18 6/6/18 - Ann-Kristin Kock
  6. 6/19/18 6/19/18 -
  7. 6/25/18 6/25/18 -
  8. 7/16/18 7/16/18 - Ann-Kristin Kock
  9. 7/20/18 7/20/18 - Ann-Kristin Kock
Copyright Holder

DIVI (Deutsche Interdisziplinre Vereinigung für Intensiv- und Notfallmedizin)

Uploaded on

July 20, 2018

DOI

To request one please log in.

License

Creative Commons BY-NC 3.0
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S.0010_DIVI Notaufnahmeprotokoll_Basis

German English

Basis

1 forms  
  1. StudyEvent: Study Event
    1. Basis
PATIENTENINFORMATIONEN
Description

PATIENTENINFORMATIONEN

Alias
UMLS CUI-1
C1955348
ID
Description

ID

Data type

text

Alias
UMLS CUI [1]
C1269815
Name des Patienten:
Description

Name des Patienten

Data type

text

Alias
UMLS CUI [1]
C1299487
Straße
Description

Straße

Data type

text

Alias
UMLS CUI [1]
C0421449
Ort
Description

Ort

Data type

text

Alias
UMLS CUI [1,1]
C0421449
UMLS CUI [1,2]
C2316883
Telefon:
Description

Telefon

Data type

integer

Alias
UMLS CUI [1]
C0421455
Versicherungsnummer
Description

Versicherungsnummer

Data type

text

Alias
UMLS CUI [1]
C1549712
Aufnahmedatum
Description

Aufnahmedatum

Data type

date

Alias
UMLS CUI [1]
C1302393
Aufnahmezeit
Description

Aufnahmezeit

Data type

time

Alias
UMLS CUI [1]
C3854259
Geburtsdatum:
Description

Geburtsdatum

Data type

date

Alias
UMLS CUI [1]
C0421451
Versicherung:
Description

Versicherung

Data type

text

Alias
UMLS CUI [1]
C0021672
Geschlecht:
Description

Geschlecht

Data type

text

Alias
UMLS CUI [1]
C0079399
ANDERE INFORMATIONEN
Description

ANDERE INFORMATIONEN

Alias
UMLS CUI-1
C1533716
MTS/ESI
Description

MTS/ESI

Data type

time

Measurement units
  • Uhr
Alias
UMLS CUI [1]
C4076540
UMLS CUI [2]
C3864289
Uhr
Manchester-Triage-System/ Emergency Severity Index (MTS/ ESI):
Description

Manchester-Triage-System/ Emergency Severity Index

Data type

integer

Alias
UMLS CUI [1]
C4076540
UMLS CUI [2]
C3864289
Schwanger:
Description

Schwanger

Data type

text

Alias
UMLS CUI [1]
C0032961
Tetanusschutz:
Description

Tetanusschutz

Data type

text

Alias
UMLS CUI [1]
C0199807
Rankin-Skala:
Description

Rankin-Skala

Data type

integer

Alias
UMLS CUI [1]
C0451405
Isolation:
Description

Isolation

Data type

text

Alias
UMLS CUI [1]
C0030693
Multiresistente Keime:
Description

Multiresistente Keime

Data type

text

Alias
UMLS CUI [1]
C3826980
Zuweisung:
Description

Zuweisung

Data type

text

Alias
UMLS CUI [1]
C1516050
Transportmittel:
Description

Transportmittel

Data type

text

Alias
UMLS CUI [1]
C0150390
VITALPARAMETER
Description

VITALPARAMETER

Alias
UMLS CUI-1
C0518766
AF::
Description

AF:

Data type

integer

Measurement units
  • /min
Alias
UMLS CUI [1]
C0231832
/min
SpO2:
Description

SpO2:

Data type

float

Measurement units
  • %
Alias
UMLS CUI [1]
C2237091
%
RR sys:
Description

RR sys:

Data type

integer

Measurement units
  • mmHg
Alias
UMLS CUI [1]
C0871470
mmHg
HF:
Description

HF:

Data type

integer

Measurement units
  • bpm
Alias
UMLS CUI [1]
C0018810
bpm
Augenöffnung
Description

Augenöffnung

Data type

text

Alias
UMLS CUI [1]
C0559289
Verbale Antwort
Description

Verbale Antwort

Data type

text

Alias
UMLS CUI [1]
C3648957
Motorische Antwort
Description

Motorische Antwort

Data type

text

Alias
UMLS CUI [1]
C3648958
Glasgow-Koma-Skala:
Description

Glasgow-Koma-Skala

Data type

integer

Alias
UMLS CUI [1]
C1271007
Rechte Pupillenweite:
Description

Rechte Pupillenweite

Data type

text

Alias
UMLS CUI [1,1]
C0517965
UMLS CUI [1,2]
C0205090
Linke Pupillenweite:
Description

Linke Pupillenweite

Data type

text

Alias
UMLS CUI [1,1]
C0517965
UMLS CUI [1,2]
C0205091
Lichtreaktion (rechts):
Description

Lichtreaktion (rechts)

Data type

text

Alias
UMLS CUI [1,1]
C1287558
UMLS CUI [1,2]
C0205090
Lichtreaktion (links):
Description

Lichtreaktion (links)

Data type

text

Alias
UMLS CUI [1,1]
C1287558
UMLS CUI [1,2]
C0205091
Schmerzskala:
Description

schmerzskala

Data type

integer

Alias
UMLS CUI [1]
C1518471
KKT
Description

KKT

Data type

text

Measurement units
  • °C
Alias
UMLS CUI [1]
C0456240
°C
DIAGNOSTIK:
Description

DIAGNOSTIK:

Alias
UMLS CUI-1
C0086141
Labor:
Description

Labor

Data type

text

Alias
UMLS CUI [1]
C0022885
Labor Zeit:
Description

Labor Zeit

Data type

time

Alias
UMLS CUI [1,1]
C0022885
UMLS CUI [1,2]
C0040223
BGA:
Description

BGA

Data type

text

Alias
UMLS CUI [1]
C0005800
Blutgasanalyse Zeit:
Description

Blutgasanalyse Zeit

Data type

time

Alias
UMLS CUI [1,1]
C0005800
UMLS CUI [1,2]
C0040223
U-Stix:
Description

U-Stix

Data type

text

Alias
UMLS CUI [1]
C0462970
U-Stix Zeit:
Description

U-Stix Zeit

Data type

time

Alias
UMLS CUI [1,1]
C0462970
UMLS CUI [1,2]
C0040223
EKG:
Description

EKG

Data type

text

Alias
UMLS CUI [1]
C0013798
EKG Zeit:
Description

EKG Zeit

Data type

time

Alias
UMLS CUI [1,1]
C0013798
UMLS CUI [1,2]
C0040223
Sono:
Description

Sono

Data type

text

Alias
UMLS CUI [1]
C0041618
Sono Zeit:
Description

Sono Zeit

Data type

time

Alias
UMLS CUI [1,1]
C0041618
UMLS CUI [1,2]
C0040223
Echo:
Description

Echo

Data type

text

Alias
UMLS CUI [1]
C0013516
Echo Zeit:
Description

Echo Zeit

Data type

time

Alias
UMLS CUI [1,1]
C0013516
UMLS CUI [1,2]
C0040223
CCT:
Description

CCT

Data type

text

Alias
UMLS CUI [1]
C3515744
CCT Zeit:
Description

CCT Zeit

Data type

time

Alias
UMLS CUI [1,1]
C3515744
UMLS CUI [1,2]
C0040223
CT:
Description

CT

Data type

text

Alias
UMLS CUI [1]
C0040405
CT Zeit:
Description

CT Zeit

Data type

time

Alias
UMLS CUI [1,1]
C0040405
UMLS CUI [1,2]
C0040223
Traumascan:
Description

Traumascan

Data type

text

Alias
UMLS CUI [1,1]
C3714660
UMLS CUI [1,2]
C0441633
Traumascan Zeit:
Description

Traumascan Zeit

Data type

time

Alias
UMLS CUI [1,1]
C3714660
UMLS CUI [1,2]
C0441633
UMLS CUI [1,3]
C0040223
Rö. WS:
Description

Rö. WS

Data type

text

Alias
UMLS CUI [1]
C0203139
Rö. WS Zeit:
Description

Rö. WS Zeit

Data type

time

Alias
UMLS CUI [1,1]
C0203139
UMLS CUI [1,2]
C0040223
Rö. Thorax:
Description

Rö. Thorax

Data type

text

Alias
UMLS CUI [1]
C0039985
Rö. Thorax Zeit:
Description

Rö. Thorax Zeit

Data type

time

Alias
UMLS CUI [1,1]
C0039985
UMLS CUI [1,2]
C0040223
Rö. Becken:
Description

Rö. Becken

Data type

text

Alias
UMLS CUI [1]
C0554740
Rö. Becken Zeit:
Description

Rö. Becken Zeit

Data type

time

Alias
UMLS CUI [1,1]
C0554740
UMLS CUI [1,2]
C0040223
Rö. Extremität:
Description

Rö. Extremität

Data type

text

Alias
UMLS CUI [1,1]
C0034571
UMLS CUI [1,2]
C0015385
Rö. Extremität Zeit:
Description

Rö. Extremität Zeit

Data type

time

Alias
UMLS CUI [1,1]
C0034571
UMLS CUI [1,2]
C0015385
UMLS CUI [1,3]
C0040223
Rö. Sonstiges:
Description

Rö. Sonstiges

Data type

text

Alias
UMLS CUI [1,1]
C0034571
UMLS CUI [1,2]
C0205394
Rö. Sonstiges Zeit:
Description

Rö. Sonstiges Zeit

Data type

time

Alias
UMLS CUI [1,1]
C0034571
UMLS CUI [1,2]
C0205394
UMLS CUI [1,3]
C0040223
MRT:
Description

MRT

Data type

text

Alias
UMLS CUI [1]
C0024485
MRT Zeit:
Description

MRT Zeit

Data type

time

Alias
UMLS CUI [1,1]
C0024485
UMLS CUI [1,2]
C0040223
NOTFALLANAMNESE
Description

NOTFALLANAMNESE

Alias
UMLS CUI-1
C0262926
UMLS CUI-2
C0013956
Allergien:
Description

Allergien

Data type

text

Alias
UMLS CUI [1]
C0020517
Allergien
Description

Allergien

Data type

text

Alias
UMLS CUI [1]
C0020517
Leitsymptom:
Description

Leitsymptom

Data type

text

Alias
UMLS CUI [1,1]
C1457887
UMLS CUI [1,2]
C1542147
CEDIS
Description

CEDIS

Data type

text

Leitsymptom seit:
Description

Leitsymptom seit

Data type

time

Alias
UMLS CUI [1,1]
C1457887
UMLS CUI [1,2]
C1542147
UMLS CUI [1,3]
C0040223
Notfallanamnese/relevante Eigenmedikation/körp. Untersuchung
Description

Relevante Eigenmedikation

Data type

text

Alias
UMLS CUI [1,1]
C0262926
UMLS CUI [1,2]
C0013956
UMLS CUI [2]
C0013227
UMLS CUI [3]
C0031809
Erster Arztkontakt:
Description

Erster Arztkontakt

Data type

time

Alias
UMLS CUI [1,1]
C0031831
UMLS CUI [1,2]
C0332158
UMLS CUI [1,3]
C0205435
verantw. Arzt
Description

verantw. Arzt

Data type

text

Alias
UMLS CUI [1,1]
C0031831
UMLS CUI [1,2]
C1273518
Befunde/ Verlauf / durchgeführte Therapie:
Description

Befunde/Verlauf / durchgeführte Therapie

Data type

text

Alias
UMLS CUI [1]
C0243095
UMLS CUI [2]
C0750729
UMLS CUI [3]
C0087111
Initiierung Therapie:
Description

Initiierung Therapie

Data type

time

Alias
UMLS CUI [1,1]
C0087111
UMLS CUI [1,2]
C1704686
Abschlussdiagnosen:
Description

Abschlussdiagnosen

Data type

text

Alias
UMLS CUI [1,1]
C0011900
UMLS CUI [1,2]
C2828389
ICD 10:
Description

ICD 10

Data type

text

Alias
UMLS CUI [1]
C1137110
Weiteres Procedere /Therapieempfehlung / Weiterbehandler:
Description

Weiteres Procedere /Therapieempfehlung / Weiterbehandler

Data type

text

Alias
UMLS CUI [1,1]
C0087111
UMLS CUI [1,2]
C1517331
UMLS CUI [2,1]
C0087111
UMLS CUI [2,2]
C0034866
UMLS CUI [3,1]
C1710470
UMLS CUI [3,2]
C1517331
Übergabe an WB
Description

Zeitpunkt Verlegung/Entlasssung

Data type

time

Alias
UMLS CUI [1,1]
C0030704
UMLS CUI [1,2]
C1710470
UMLS CUI [1,3]
C1517331
Kommentare:
Description

Kommentare

Data type

text

Alias
UMLS CUI [1]
C0947611
Zusatzmodule
Description

Zusatzmodule (Überwachung, Trauma, Konsil, Neurologie, Anästhesie), bitte die passenden Module eintragen

Data type

text

Alias
UMLS CUI [1]
C2348609
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Basis

1 forms
  1. StudyEvent: Study Event
    1. Basis
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
PATIENTENINFORMATIONEN
C1955348 (UMLS CUI-1)
ID
Item
ID
text
C1269815 (UMLS CUI [1])
Patient´s name
Item
Name des Patienten:
text
C1299487 (UMLS CUI [1])
Straße
Item
Straße
text
C0421449 (UMLS CUI [1])
Ort
Item
Ort
text
C0421449 (UMLS CUI [1,1])
C2316883 (UMLS CUI [1,2])
Patient telephone number
Item
Telefon:
integer
C0421455 (UMLS CUI [1])
Versicherungsnummer
Item
Versicherungsnummer
text
C1549712 (UMLS CUI [1])
Admission date
Item
Aufnahmedatum
date
C1302393 (UMLS CUI [1])
Aufnahmezeit
Item
Aufnahmezeit
time
C3854259 (UMLS CUI [1])
Date of birth
Item
Geburtsdatum:
date
C0421451 (UMLS CUI [1])
Item
Versicherung:
text
C0021672 (UMLS CUI [1])
Insurance
Code List
Versicherung:
CL Item
GKV (1)
CL Item
BG (2)
CL Item
UTV (3)
CL Item
P (4)
Item
Geschlecht:
text
C0079399 (UMLS CUI [1])
Gender
Code List
Geschlecht:
CL Item
männlich  (1)
CL Item
weiblich (2)
Item Group
ANDERE INFORMATIONEN
C1533716 (UMLS CUI-1)
MTS/ESI
Item
MTS/ESI
time
C4076540 (UMLS CUI [1])
C3864289 (UMLS CUI [2])
Item
Manchester-Triage-System/ Emergency Severity Index (MTS/ ESI):
integer
C4076540 (UMLS CUI [1])
C3864289 (UMLS CUI [2])
Manchester-Triage-System/ Emergency Severity Index
Code List
Manchester-Triage-System/ Emergency Severity Index (MTS/ ESI):
CL Item
0 (1)
CL Item
10 (2)
CL Item
30 (3)
CL Item
90 (4)
CL Item
120 (5)
Item
Schwanger:
text
C0032961 (UMLS CUI [1])
Pregnancy
Code List
Schwanger:
CL Item
ja (1)
CL Item
nein (2)
CL Item
unbekannt (3)
Item
Tetanusschutz:
text
C0199807 (UMLS CUI [1])
tetanus vaccination
Code List
Tetanusschutz:
CL Item
ja (1)
CL Item
nein (2)
CL Item
unbekannt (3)
Item
Rankin-Skala:
integer
C0451405 (UMLS CUI [1])
Rankin scale
Code List
Rankin-Skala:
CL Item
0 (1)
CL Item
1 (2)
CL Item
2 (3)
CL Item
3 (4)
CL Item
4 (5)
CL Item
5 (6)
Item
Isolation:
text
C0030693 (UMLS CUI [1])
Isolation
Code List
Isolation:
CL Item
Nein (1)
CL Item
Multiresistenter Keim (2)
CL Item
Gastroenteritis (3)
CL Item
Tuberkulose (4)
CL Item
Meningitis (5)
CL Item
Umkehriso (6)
CL Item
Andere (7)
Item
Multiresistente Keime:
text
C3826980 (UMLS CUI [1])
Multi-resistant germs
Code List
Multiresistente Keime:
CL Item
Ja (1)
CL Item
Verdacht (2)
CL Item
MRSA (3)
CL Item
3-MRGN (4)
CL Item
4-MRGN (5)
CL Item
VRE (6)
CL Item
Andere (7)
CL Item
Nein (8)
Item
Zuweisung:
text
C1516050 (UMLS CUI [1])
Assignment
Code List
Zuweisung:
CL Item
Ohne (1)
CL Item
Vertragsarzt/ Praxis (2)
CL Item
KV-Notdienst am KH (3)
CL Item
KV-Notdienst außerhalb KH (4)
CL Item
Rettungsdienst (5)
CL Item
Notarzt (6)
CL Item
Klinik/ Verlegung (7)
CL Item
Andere (8)
Item
Transportmittel:
text
C0150390 (UMLS CUI [1])
Patient Transport
Code List
Transportmittel:
CL Item
Ohne (1)
CL Item
KTW (2)
CL Item
RTW (3)
CL Item
NAW/NEF/ITW (4)
CL Item
RTH/ITH (5)
CL Item
Anderes (6)
Item Group
VITALPARAMETER
C0518766 (UMLS CUI-1)
Respiratory rate
Item
AF::
integer
C0231832 (UMLS CUI [1])
oxygen saturation
Item
SpO2:
float
C2237091 (UMLS CUI [1])
systolic pressure
Item
RR sys:
integer
C0871470 (UMLS CUI [1])
heart rate
Item
HF:
integer
C0018810 (UMLS CUI [1])
Item
Augenöffnung
text
C0559289 (UMLS CUI [1])
Augenöffnung
Code List
Augenöffnung
CL Item
keine (1)
CL Item
Schmerzreiz (2)
CL Item
Auffordernd (3)
CL Item
spontan (4)
Item
Verbale Antwort
text
C3648957 (UMLS CUI [1])
Verbale Antwort
Code List
Verbale Antwort
CL Item
keine  (1)
CL Item
unverständlich (2)
CL Item
Inadäquat (3)
CL Item
verwirrt (4)
CL Item
orientiert (5)
Item
Motorische Antwort
text
C3648958 (UMLS CUI [1])
Motorische Antwort
Code List
Motorische Antwort
CL Item
keine (1)
CL Item
Streckkrämpfe (2)
CL Item
Beugekrämpfe (3)
CL Item
ungezielt (4)
CL Item
gezielt (5)
CL Item
Aufforderung (6)
Glasgow Coma Scale
Item
Glasgow-Koma-Skala:
integer
C1271007 (UMLS CUI [1])
Item
Rechte Pupillenweite:
text
C0517965 (UMLS CUI [1,1])
C0205090 (UMLS CUI [1,2])
Size of right pupil
Code List
Rechte Pupillenweite:
CL Item
weit (1)
CL Item
mittel (2)
CL Item
eng (3)
Item
Linke Pupillenweite:
text
C0517965 (UMLS CUI [1,1])
C0205091 (UMLS CUI [1,2])
Size of left pupil
Code List
Linke Pupillenweite:
CL Item
weit (1)
CL Item
mittel (2)
CL Item
eng (3)
Item
Lichtreaktion (rechts):
text
C1287558 (UMLS CUI [1,1])
C0205090 (UMLS CUI [1,2])
undefined item
Code List
Lichtreaktion (rechts):
CL Item
prompt (1)
CL Item
träge (2)
CL Item
keine (3)
Item
Lichtreaktion (links):
text
C1287558 (UMLS CUI [1,1])
C0205091 (UMLS CUI [1,2])
Pupil reaction to light (left)
Code List
Lichtreaktion (links):
CL Item
prompt (1)
CL Item
träge (2)
CL Item
keine (3)
Numeric Pain Scale
Item
Schmerzskala:
integer
C1518471 (UMLS CUI [1])
KKT
Item
KKT
text
C0456240 (UMLS CUI [1])
Item Group
DIAGNOSTIK:
C0086141 (UMLS CUI-1)
Item
Labor:
text
C0022885 (UMLS CUI [1])
Laboratory Procedures
Code List
Labor:
CL Item
ja (1)
CL Item
nein (2)
CL Item
opB  (3)
time
Item
Labor Zeit:
time
C0022885 (UMLS CUI [1,1])
C0040223 (UMLS CUI [1,2])
Item
BGA:
text
C0005800 (UMLS CUI [1])
Blood Gas Analysis
Code List
BGA:
CL Item
ja (1)
CL Item
nein (2)
CL Item
opB  (3)
Time
Item
Blutgasanalyse Zeit:
time
C0005800 (UMLS CUI [1,1])
C0040223 (UMLS CUI [1,2])
Item
U-Stix:
text
C0462970 (UMLS CUI [1])
Labstix urine testing strip
Code List
U-Stix:
CL Item
ja (1)
CL Item
nein (2)
CL Item
opB (3)
Time
Item
U-Stix Zeit:
time
C0462970 (UMLS CUI [1,1])
C0040223 (UMLS CUI [1,2])
Item
EKG:
text
C0013798 (UMLS CUI [1])
Electrocardiogram
Code List
EKG:
CL Item
ja (1)
CL Item
nein (2)
CL Item
opB  (3)
Time
Item
EKG Zeit:
time
C0013798 (UMLS CUI [1,1])
C0040223 (UMLS CUI [1,2])
Item
Sono:
text
C0041618 (UMLS CUI [1])
Ultrasonography
Code List
Sono:
CL Item
ja (1)
CL Item
nein (2)
CL Item
opB (3)
Time
Item
Sono Zeit:
time
C0041618 (UMLS CUI [1,1])
C0040223 (UMLS CUI [1,2])
Item
Echo:
text
C0013516 (UMLS CUI [1])
Echocardiography
Code List
Echo:
CL Item
ja (1)
CL Item
nein (2)
CL Item
opB (3)
Time
Item
Echo Zeit:
time
C0013516 (UMLS CUI [1,1])
C0040223 (UMLS CUI [1,2])
Item
CCT:
text
C3515744 (UMLS CUI [1])
CT scan of cranial cavity
Code List
CCT:
CL Item
ja (1)
CL Item
nein (2)
CL Item
opB (3)
Time
Item
CCT Zeit:
time
C3515744 (UMLS CUI [1,1])
C0040223 (UMLS CUI [1,2])
Item
CT:
text
C0040405 (UMLS CUI [1])
X-Ray Computed Tomography
Code List
CT:
CL Item
ja (1)
CL Item
nein (2)
CL Item
opB (3)
Time
Item
CT Zeit:
time
C0040405 (UMLS CUI [1,1])
C0040223 (UMLS CUI [1,2])
Item
Traumascan:
text
C3714660 (UMLS CUI [1,1])
C0441633 (UMLS CUI [1,2])
undefined item
Code List
Traumascan:
CL Item
ja (1)
CL Item
nein (2)
CL Item
opB  (3)
Time
Item
Traumascan Zeit:
time
C3714660 (UMLS CUI [1,1])
C0441633 (UMLS CUI [1,2])
C0040223 (UMLS CUI [1,3])
Item
Rö. WS:
text
C0203139 (UMLS CUI [1])
Vertebral X-ray
Code List
Rö. WS:
CL Item
ja (1)
CL Item
nein (2)
CL Item
opB (3)
Time
Item
Rö. WS Zeit:
time
C0203139 (UMLS CUI [1,1])
C0040223 (UMLS CUI [1,2])
Item
Rö. Thorax:
text
C0039985 (UMLS CUI [1])
Chest X-Ray
Code List
Rö. Thorax:
CL Item
ja (1)
CL Item
nein (2)
CL Item
opB (3)
Time
Item
Rö. Thorax Zeit:
time
C0039985 (UMLS CUI [1,1])
C0040223 (UMLS CUI [1,2])
Item
Rö. Becken:
text
C0554740 (UMLS CUI [1])
Pelvis X-ray
Code List
Rö. Becken:
CL Item
ja (1)
CL Item
nein (2)
CL Item
opB (3)
Time
Item
Rö. Becken Zeit:
time
C0554740 (UMLS CUI [1,1])
C0040223 (UMLS CUI [1,2])
Item
Rö. Extremität:
text
C0034571 (UMLS CUI [1,1])
C0015385 (UMLS CUI [1,2])
Extremity X-ray
Code List
Rö. Extremität:
CL Item
ja (1)
CL Item
nein (2)
CL Item
opB  (3)
Time
Item
Rö. Extremität Zeit:
time
C0034571 (UMLS CUI [1,1])
C0015385 (UMLS CUI [1,2])
C0040223 (UMLS CUI [1,3])
Item
Rö. Sonstiges:
text
C0034571 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
Other X-ray
Code List
Rö. Sonstiges:
CL Item
ja (1)
CL Item
nein (2)
CL Item
opB  (3)
Time
Item
Rö. Sonstiges Zeit:
time
C0034571 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
C0040223 (UMLS CUI [1,3])
Item
MRT:
text
C0024485 (UMLS CUI [1])
Magnetic Resonance Imaging
Code List
MRT:
CL Item
ja (1)
CL Item
nein (2)
CL Item
opB  (3)
Time
Item
MRT Zeit:
time
C0024485 (UMLS CUI [1,1])
C0040223 (UMLS CUI [1,2])
Item Group
NOTFALLANAMNESE
C0262926 (UMLS CUI-1)
C0013956 (UMLS CUI-2)
Item
Allergien:
text
C0020517 (UMLS CUI [1])
Allergies
Code List
Allergien:
CL Item
Ja (1)
CL Item
Nein (2)
CL Item
KM (3)
CL Item
Penicillin (4)
CL Item
Andere (5)
Allergien
Item
Allergien
text
C0020517 (UMLS CUI [1])
Main symptom
Item
Leitsymptom:
text
C1457887 (UMLS CUI [1,1])
C1542147 (UMLS CUI [1,2])
CEDIS
Item
CEDIS
text
time
Item
Leitsymptom seit:
time
C1457887 (UMLS CUI [1,1])
C1542147 (UMLS CUI [1,2])
C0040223 (UMLS CUI [1,3])
Medication
Item
Notfallanamnese/relevante Eigenmedikation/körp. Untersuchung
text
C0262926 (UMLS CUI [1,1])
C0013956 (UMLS CUI [1,2])
C0013227 (UMLS CUI [2])
C0031809 (UMLS CUI [3])
Time
Item
Erster Arztkontakt:
time
C0031831 (UMLS CUI [1,1])
C0332158 (UMLS CUI [1,2])
C0205435 (UMLS CUI [1,3])
verantw. Arzt
Item
verantw. Arzt
text
C0031831 (UMLS CUI [1,1])
C1273518 (UMLS CUI [1,2])
Therapy
Item
Befunde/ Verlauf / durchgeführte Therapie:
text
C0243095 (UMLS CUI [1])
C0750729 (UMLS CUI [2])
C0087111 (UMLS CUI [3])
time
Item
Initiierung Therapie:
time
C0087111 (UMLS CUI [1,1])
C1704686 (UMLS CUI [1,2])
Final diagnosis
Item
Abschlussdiagnosen:
text
C0011900 (UMLS CUI [1,1])
C2828389 (UMLS CUI [1,2])
ICD 10
Item
ICD 10:
text
C1137110 (UMLS CUI [1])
Item
Weiteres Procedere /Therapieempfehlung / Weiterbehandler:
text
C0087111 (UMLS CUI [1,1])
C1517331 (UMLS CUI [1,2])
C0087111 (UMLS CUI [2,1])
C0034866 (UMLS CUI [2,2])
C1710470 (UMLS CUI [3,1])
C1517331 (UMLS CUI [3,2])
Therapy
Code List
Weiteres Procedere /Therapieempfehlung / Weiterbehandler:
CL Item
Verlegung intern Funktion (OP, HKL, oä) (1)
CL Item
Verlegung intern Überwachung (ITS, IMC, oä) (2)
CL Item
Verlegung intern Normalstation (3)
CL Item
Verlegung extern Funktion (OP, HKL, oä) (4)
CL Item
Verlegung extern Überwachung (ITS, IMC, oä) (5)
CL Item
Verlegung extern Normalstation (6)
CL Item
Entlassung nach Hause (7)
CL Item
Entlassung zu weiterbehandl. Arzt (8)
CL Item
Entlassung gegen ärztl. Rat (9)
CL Item
Abbruch durch Pat. (10)
CL Item
Kein Arztkontakt  (11)
CL Item
Sonstiges (12)
CL Item
Tod (13)
time
Item
Übergabe an WB
time
C0030704 (UMLS CUI [1,1])
C1710470 (UMLS CUI [1,2])
C1517331 (UMLS CUI [1,3])
Comments
Item
Kommentare:
text
C0947611 (UMLS CUI [1])
Item
Zusatzmodule
text
C2348609 (UMLS CUI [1])
Supplement
Code List
Zusatzmodule
CL Item
Überwachung (1)
CL Item
Trauma (2)
CL Item
Konsil (3)
CL Item
Neurologie (4)
CL Item
Anästhesie (5)
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