ID

37617

Descripción

Der UAW-Meldebogen des Bundesinstituts für Arzneimittel und Medizinprodukte. https://www.bfarm.de/SharedDocs/Formulare/DE/Arzneimittel/Pharmakovigilanz/aa-uaw-melde-bogen.html The english translation of the german form is not an official state-approved version, but a translation by the researchers at the institute for medical informatics. Das Bundesinstitut für Arzneimittel und Medizinprodukte bittet Sie, Meldungen über unerwünschte Arzneimittelwirkungen auf dem vorliegenden Berichtsbogen BfArM 643 zu erstatten, damit eine rasche Auswertung und EDV-mäßige Bearbeitung gewährleistet ist. Je vollständiger der Berichtsbogen ausgefüllt wird, um so sicherer wird die Auswertung und Abschätzungeines Arzneimittelrisikos sein können. Unvollständige Daten sollten jedoch kein Hinderungsgrund für eine Meldung sein. Um auch bisher unbekannte Arzneimittelrisiken erfassen zu können, ist es notwendig,auch in Verdachtsfällen und beim Auftreten unerwünschter Wirkungen, die bisher nicht mit den verabreichten Arzneimitteln in Verbindung gebracht wurden, einen Berichtsbogen auszufüllen. Dem Berichtsbogen können alle Ihnen zu dieser unerwünschten Arzneimittelwirkung, insbesondere über die Symptomatik und den Verlauf zur Verfügung stehende Unterlagen (z.B. Untersuchungsbefunde,Labordaten, Sektionsprotokolle) in Kopie beigelegt werden. Füllen Sie die Angaben zur Person des Patienten bitte so vollständig wie möglich aus, da hierdurch doppelt gemeldete unerwünschte Wirkungen erkannt werden können. Geben Sie die Initialen des Patienten bitte in der Reihenfolge Name - Vorname an. Die Daten zu den verabreichten Arzneimitteln sollten so genau wie möglich, d.h. unter Berücksichtigungder vollständigen Bezeichnung (z.B. retard, forte), der Darreichungsform, der Stärke, der Dosierung und der Art der Anwendung (z.B. p.o., i.v., i.m.) angegeben werden. Das Arzneimittel, das vermutlich die unerwünschte Wirkung ausgelöst hat, sollte entsprechend gekennzeichnet werden. Alle auf dem Berichtsbogen angegebenen patienten- und arztbezogenen Daten werden den Bestimmungen des Bundesdatenschutzgesetzes entsprechend vertraulich behandelt. Weitere Vordrucke des Berichtsbogens sind beim Bundesinstitut für Arzneimittel und Medizinprodukte,Kurt-Georg-Kiesinger-Allee 3, 53175 Bonn erhältlich.

Link

https://www.bfarm.de/SharedDocs/Formulare/DE/Arzneimittel/Pharmakovigilanz/aa-uaw-melde-bogen.html

Palabras clave

  1. 11/8/19 11/8/19 -
Titular de derechos de autor

Bundesinstitut für Arzneimittel und Medizinprodkte

Subido en

11 de agosto de 2019

DOI

Para solicitar uno, por favor iniciar sesión.

Licencia

Creative Commons BY-NC 3.0

Comentarios del modelo :

Puede comentar sobre el modelo de datos aquí. A través de las burbujas de diálogo en los grupos de elementos y elementos, puede agregar comentarios específicos.

Comentarios de grupo de elementos para :

Comentarios del elemento para :

Para descargar modelos de datos, debe haber iniciado sesión. Por favor iniciar sesión o Registrate gratis.

Bfarm Pharmacovigilance

Report about an adverse Drug Reaction (BERICHT ÜBER UNERWÜNSCHTE ARZNEIMITTELWIRKUNGEN)

Basic Data
Descripción

Basic Data

Alias
UMLS CUI-1
C1320722
Patient Initials Surname
Descripción

Patient Initials Surname

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0421448
UMLS CUI [1,2]
C2986440
Patient initials forename
Descripción

Patient initials forename

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0421447
UMLS CUI [1,2]
C2986440
Date of birth
Descripción

Date of birth

Tipo de datos

date

Alias
UMLS CUI [1]
C0421451
Gender
Descripción

Gender

Tipo de datos

integer

Alias
UMLS CUI [1]
C0079399
Height
Descripción

Height

Tipo de datos

float

Alias
UMLS CUI [1]
C0005890
Weight
Descripción

Weight

Tipo de datos

float

Alias
UMLS CUI [1]
C0005910
Weeks pregnant
Descripción

Leave empty if not pregnant

Tipo de datos

float

Alias
UMLS CUI [1]
C1135241
Observed adverse drug reaction
Descripción

Observed adverse drug reaction

Alias
UMLS CUI-1
C1441672
UMLS CUI-2
C0041755
Observed adverse drug reaction
Descripción

Please fill in all observed symptoms here

Tipo de datos

text

Alias
UMLS CUI [1,1]
C1441672
UMLS CUI [1,2]
C0041755
Occured on
Descripción

Occured on

Tipo de datos

date

Alias
UMLS CUI [1,1]
C1441672
UMLS CUI [1,2]
C0041755
UMLS CUI [1,3]
C0011008
Duration
Descripción

Duration

Tipo de datos

text

Alias
UMLS CUI [1,1]
C1441672
UMLS CUI [1,2]
C0041755
UMLS CUI [1,3]
C0449238
Involved Drugs
Descripción

Involved Drugs

Alias
UMLS CUI-1
C0013227
UMLS CUI-2
C1314939
Medication/Preparation
Descripción

Please fill in the batch number

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0013227
UMLS CUI [1,2]
C3641829
Daily Dose
Descripción

Daily Dose

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0013227
UMLS CUI [1,2]
C2348070
Application
Descripción

Application

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0013227
UMLS CUI [1,2]
C0185125
Given from
Descripción

Given from

Tipo de datos

date

Alias
UMLS CUI [1,1]
C2348343
UMLS CUI [1,2]
C1517320
Given until
Descripción

Given until

Tipo de datos

date

Alias
UMLS CUI [1,1]
C2348343
UMLS CUI [1,2]
C1720302
Indication
Descripción

Indication

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0013227
UMLS CUI [1,2]
C3146298
Suspected Drug
Descripción

Suspected Drug

Alias
UMLS CUI-1
C0013227
UMLS CUI-2
C1314939
Suspected Connection with drug number:
Descripción

Suspected Connection with drug number:

Tipo de datos

integer

Alias
UMLS CUI [1,1]
C0750491
UMLS CUI [1,2]
C0449379
UMLS CUI [1,3]
C0013227
Drug administered previously
Descripción

Drug administered previously

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0806914
UMLS CUI [1,2]
C0332152
Drug Tolerated
Descripción

Drug Tolerated

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0013220
UMLS CUI [1,2]
C0332152
Possible re-exposition
Descripción

Possible re-exposition

Tipo de datos

integer

Alias
UMLS CUI [1,1]
C0743284
UMLS CUI [1,2]
C0205341
UMLS CUI [1,3]
C0332149
Diseases
Descripción

Diseases

Alias
UMLS CUI-1
C0012634
Primary Disease
Descripción

Primary Disease

Tipo de datos

text

Alias
UMLS CUI [1]
C0277554
Comorbidity
Descripción

Comorbidity

Tipo de datos

text

Alias
UMLS CUI [1]
C0009488
Anamnestic Specifics
Descripción

Anamnestic Specifics

Alias
UMLS CUI-1
C1521970
UMLS CUI-2
C0262926
Nicotine
Descripción

Nicotine

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0028040
Alcohol
Descripción

Alcohol

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0001962
Contraceptives
Descripción

Contraceptives

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0009871
Pacemaker
Descripción

Pacemaker

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0810633
Implants
Descripción

Implants

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0021102
Radiation therapy
Descripción

Radiation therapy

Tipo de datos

boolean

Alias
UMLS CUI [1]
C1522449
Physical therapy
Descripción

Physical therapy

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0949766
Diet
Descripción

Diet

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0012155
Allergies
Descripción

Allergies

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0020517
Metabolic defects
Descripción

Metabolic defects

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0025517
(Medical) Drug Abuse
Descripción

(Medical) Drug Abuse

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0260268
Other specifics
Descripción

Other specifics

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C1521970
UMLS CUI [1,2]
C0205394
Further explanations
Descripción

Further explanations

Tipo de datos

text

Alias
UMLS CUI [1,1]
C1517331
UMLS CUI [1,2]
C0681841
Clinical Laboratory Tests
Descripción

Clinical Laboratory Tests

Alias
UMLS CUI-1
C0260877
Changes of Laboratory parameters along with the adverse drug reaction
Descripción

append results if applicable

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0392747
UMLS CUI [1,2]
C0587081
UMLS CUI [1,3]
C1707520
UMLS CUI [1,4]
C0041755
Therapy of adverse drug reaction
Descripción

Therapy of adverse drug reaction

Alias
UMLS CUI-1
C0041755
UMLS CUI-2
C0087111
Course of the therapy of the adverse drug reaction
Descripción

Course of the therapy of the adverse drug reaction

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0750729
UMLS CUI [1,2]
C0041755
UMLS CUI [1,3]
C0087111
Life-threatening
Descripción

Life-threatening

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0041755
UMLS CUI [1,2]
C2826244
Outcome of the adverse drug reaction
Descripción

Outcome of the adverse drug reaction

Alias
UMLS CUI-1
C0041755
UMLS CUI-2
C1274040
Outcome of the adverse drug reaction
Descripción

Outcome of the adverse drug reaction

Tipo de datos

integer

Alias
UMLS CUI [1,1]
C0041755
UMLS CUI [1,2]
C1274040
Autopsy
Descripción

append results if applicable

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0004398
Cause of death
Descripción

Cause of death

Tipo de datos

text

Alias
UMLS CUI [1]
C0007465
Causality
Descripción

Causality

Alias
UMLS CUI-1
C4684583
Assessment of causality
Descripción

Assessment of causality

Tipo de datos

integer

Alias
UMLS CUI [1]
C4684583
Further comments
Descripción

Further comments

Tipo de datos

text

Alias
UMLS CUI [1,1]
C1517331
UMLS CUI [1,2]
C0947611
Informed entities
Descripción

Informed entities

Alias
UMLS CUI-1
C0678367
UMLS CUI-2
C1522154
Was the BfarM informed?
Descripción

BfArM informed

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C1522154
UMLS CUI [1,2]
C0162696
UMLS CUI [1,3]
C0678367
Was the Manufacturer informed?
Descripción

Manufacturer informed

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C1522154
UMLS CUI [1,2]
C0947322
Were the Drug comission doctors informed?
Descripción

Drug comission doctors informed

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C1522154
UMLS CUI [1,2]
C2986529
Who was informed Others
Descripción

Who was informed Others

Tipo de datos

text

Alias
UMLS CUI [1,1]
C1522154
UMLS CUI [1,2]
C0205394
Signatory Data
Descripción

Signatory Data

Alias
UMLS CUI-1
C1511726
UMLS CUI-2
C4288222
Name of the doctor
Descripción

Name of the doctor

Tipo de datos

text

Alias
UMLS CUI [1]
C2361125
Specialty
Descripción

Specialty

Tipo de datos

text

Alias
UMLS CUI [1]
C0037778
Postal Code
Descripción

Postal Code

Tipo de datos

float

Alias
UMLS CUI [1]
C1514254
Clinic
Descripción

Clinic

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0442592
Seal
Descripción

possibly, not necessarily

Tipo de datos

text

Alias
UMLS CUI [1,1]
C1708936
UMLS CUI [1,2]
C0018704
Manufacturer
Descripción

Manufacturer

Alias
UMLS CUI-1
C0947322
Manufacturer
Descripción

Manufacturer

Tipo de datos

text

Alias
UMLS CUI [1]
C0947322
Signature
Descripción

Signature

Alias
UMLS CUI-1
C1519316
Date
Descripción

Date

Tipo de datos

date

Alias
UMLS CUI [1]
C0011008
Signature
Descripción

Signature

Tipo de datos

text

Alias
UMLS CUI [1]
C1519316

Similar models

Report about an adverse Drug Reaction (BERICHT ÜBER UNERWÜNSCHTE ARZNEIMITTELWIRKUNGEN)

Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
Alias
Item Group
Basic Data
C1320722 (UMLS CUI-1)
Patient Initials Surname
Item
Patient Initials Surname
text
C0421448 (UMLS CUI [1,1])
C2986440 (UMLS CUI [1,2])
Patient initials forename
Item
Patient initials forename
text
C0421447 (UMLS CUI [1,1])
C2986440 (UMLS CUI [1,2])
Date of birth
Item
Date of birth
date
C0421451 (UMLS CUI [1])
Item
Gender
integer
C0079399 (UMLS CUI [1])
Code List
Gender
CL Item
m (1)
CL Item
f (2)
Height
Item
Height
float
C0005890 (UMLS CUI [1])
Weight
Item
Weight
float
C0005910 (UMLS CUI [1])
Weeks pregnant
Item
Weeks pregnant
float
C1135241 (UMLS CUI [1])
Item Group
Observed adverse drug reaction
C1441672 (UMLS CUI-1)
C0041755 (UMLS CUI-2)
Observed adverse drug reaction
Item
Observed adverse drug reaction
text
C1441672 (UMLS CUI [1,1])
C0041755 (UMLS CUI [1,2])
Occured on
Item
Occured on
date
C1441672 (UMLS CUI [1,1])
C0041755 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,3])
Duration
Item
Duration
text
C1441672 (UMLS CUI [1,1])
C0041755 (UMLS CUI [1,2])
C0449238 (UMLS CUI [1,3])
Item Group
Involved Drugs
C0013227 (UMLS CUI-1)
C1314939 (UMLS CUI-2)
Medication
Item
Medication/Preparation
text
C0013227 (UMLS CUI [1,1])
C3641829 (UMLS CUI [1,2])
Daily Dose
Item
Daily Dose
text
C0013227 (UMLS CUI [1,1])
C2348070 (UMLS CUI [1,2])
Application
Item
Application
text
C0013227 (UMLS CUI [1,1])
C0185125 (UMLS CUI [1,2])
Given from
Item
Given from
date
C2348343 (UMLS CUI [1,1])
C1517320 (UMLS CUI [1,2])
Given until
Item
Given until
date
C2348343 (UMLS CUI [1,1])
C1720302 (UMLS CUI [1,2])
Indication
Item
Indication
text
C0013227 (UMLS CUI [1,1])
C3146298 (UMLS CUI [1,2])
Item Group
Suspected Drug
C0013227 (UMLS CUI-1)
C1314939 (UMLS CUI-2)
Item
Suspected Connection with drug number:
integer
C0750491 (UMLS CUI [1,1])
C0449379 (UMLS CUI [1,2])
C0013227 (UMLS CUI [1,3])
Code List
Suspected Connection with drug number:
CL Item
1 (1)
CL Item
2 (2)
CL Item
3 (3)
CL Item
4 (4)
Drug administered previously
Item
Drug administered previously
boolean
C0806914 (UMLS CUI [1,1])
C0332152 (UMLS CUI [1,2])
Drug Tolerated
Item
Drug Tolerated
boolean
C0013220 (UMLS CUI [1,1])
C0332152 (UMLS CUI [1,2])
Item
Possible re-exposition
integer
C0743284 (UMLS CUI [1,1])
C0205341 (UMLS CUI [1,2])
C0332149 (UMLS CUI [1,3])
Code List
Possible re-exposition
CL Item
neg. (1)
CL Item
pos. (2)
Item Group
Diseases
C0012634 (UMLS CUI-1)
Primary Disease
Item
Primary Disease
text
C0277554 (UMLS CUI [1])
Comorbidity
Item
Comorbidity
text
C0009488 (UMLS CUI [1])
Item Group
Anamnestic Specifics
C1521970 (UMLS CUI-1)
C0262926 (UMLS CUI-2)
Nicotine
Item
Nicotine
boolean
C0028040 (UMLS CUI [1])
Alcohol
Item
Alcohol
boolean
C0001962 (UMLS CUI [1])
Contraceptives
Item
Contraceptives
boolean
C0009871 (UMLS CUI [1])
Pacemaker
Item
Pacemaker
boolean
C0810633 (UMLS CUI [1])
Implants
Item
Implants
boolean
C0021102 (UMLS CUI [1])
Radiation therapy
Item
Radiation therapy
boolean
C1522449 (UMLS CUI [1])
Physical therapy
Item
Physical therapy
boolean
C0949766 (UMLS CUI [1])
Diet
Item
Diet
boolean
C0012155 (UMLS CUI [1])
Allergies
Item
Allergies
boolean
C0020517 (UMLS CUI [1])
Metabolic defects
Item
Metabolic defects
boolean
C0025517 (UMLS CUI [1])
(Medical) Drug Abuse
Item
(Medical) Drug Abuse
boolean
C0260268 (UMLS CUI [1])
Other specifics
Item
Other specifics
boolean
C1521970 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
Further explanations
Item
Further explanations
text
C1517331 (UMLS CUI [1,1])
C0681841 (UMLS CUI [1,2])
Item Group
Clinical Laboratory Tests
C0260877 (UMLS CUI-1)
Changes of Laboratory parameters along with the adverse drug reaction
Item
Changes of Laboratory parameters along with the adverse drug reaction
text
C0392747 (UMLS CUI [1,1])
C0587081 (UMLS CUI [1,2])
C1707520 (UMLS CUI [1,3])
C0041755 (UMLS CUI [1,4])
Item Group
Therapy of adverse drug reaction
C0041755 (UMLS CUI-1)
C0087111 (UMLS CUI-2)
Course of the therapy of the adverse drug reaction
Item
Course of the therapy of the adverse drug reaction
text
C0750729 (UMLS CUI [1,1])
C0041755 (UMLS CUI [1,2])
C0087111 (UMLS CUI [1,3])
Life-threatening
Item
Life-threatening
boolean
C0041755 (UMLS CUI [1,1])
C2826244 (UMLS CUI [1,2])
Item Group
Outcome of the adverse drug reaction
C0041755 (UMLS CUI-1)
C1274040 (UMLS CUI-2)
Item
Outcome of the adverse drug reaction
integer
C0041755 (UMLS CUI [1,1])
C1274040 (UMLS CUI [1,2])
Code List
Outcome of the adverse drug reaction
CL Item
Restituted (1)
CL Item
Permanent Damages (2)
CL Item
Not yet restituted (3)
CL Item
Unkown (4)
CL Item
Lethal Exit (5)
Autopsy
Item
Autopsy
boolean
C0004398 (UMLS CUI [1])
Cause of death
Item
Cause of death
text
C0007465 (UMLS CUI [1])
Item Group
Causality
C4684583 (UMLS CUI-1)
Item
Assessment of causality
integer
C4684583 (UMLS CUI [1])
Code List
Assessment of causality
CL Item
ensured (1)
CL Item
likely (2)
CL Item
possible (3)
CL Item
unlikely (4)
CL Item
not assessed (5)
CL Item
not assessible (6)
Further comments
Item
Further comments
text
C1517331 (UMLS CUI [1,1])
C0947611 (UMLS CUI [1,2])
Item Group
Informed entities
C0678367 (UMLS CUI-1)
C1522154 (UMLS CUI-2)
BfArM informed
Item
Was the BfarM informed?
boolean
C1522154 (UMLS CUI [1,1])
C0162696 (UMLS CUI [1,2])
C0678367 (UMLS CUI [1,3])
Manufacturer informed
Item
Was the Manufacturer informed?
boolean
C1522154 (UMLS CUI [1,1])
C0947322 (UMLS CUI [1,2])
Drug comission doctors informed
Item
Were the Drug comission doctors informed?
boolean
C1522154 (UMLS CUI [1,1])
C2986529 (UMLS CUI [1,2])
Who was informed Others
Item
Who was informed Others
text
C1522154 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
Item Group
Signatory Data
C1511726 (UMLS CUI-1)
C4288222 (UMLS CUI-2)
Name of the doctor
Item
Name of the doctor
text
C2361125 (UMLS CUI [1])
Specialty
Item
Specialty
text
C0037778 (UMLS CUI [1])
Postal Code
Item
Postal Code
float
C1514254 (UMLS CUI [1])
Clinic
Item
Clinic
boolean
C0442592 (UMLS CUI [1])
Seal
Item
Seal
text
C1708936 (UMLS CUI [1,1])
C0018704 (UMLS CUI [1,2])
Item Group
Manufacturer
C0947322 (UMLS CUI-1)
Manufacturer
Item
Manufacturer
text
C0947322 (UMLS CUI [1])
Item Group
Signature
C1519316 (UMLS CUI-1)
Date
Item
Date
date
C0011008 (UMLS CUI [1])
Signature
Item
Signature
text
C1519316 (UMLS CUI [1])

Utilice este formulario para comentarios, preguntas y sugerencias.

Los campos marcados con * son obligatorios.

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial