ID

37980

Description

Documentation form for quality assurance in German Health Care by the institute forapplied quality Improvement and Research in Health Care (Aqua), https://www.aqua-institut.de/en/home. Internal Aqua form version: HEP-B Specification 2015 V02

Link

https://www.aqua-institut.de/en/home

Keywords

Versions (3)
  1. 11/23/14 11/23/14 - Julian Varghese
  2. 3/21/15 3/21/15 - Sarah Schulze Sünninghausen
  3. 9/5/19 9/5/19 - Julian Varghese
Copyright Holder

IQTIG

Uploaded on

September 5, 2019

DOI

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License

Creative Commons BY-NC 3.0
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Quality assurance Hip Replacement - Basic (AQUA)

German English

Quality assurance Hip Replacement - Basic (AQUA)

1 forms  
Patient identifying data
Description

Patient identifying data

Patient insurance ID
Description

Patient insurance ID

Data type

text

Alias
UMLS CUI-1
C1548070
Providers identifying data
Description

Providers identifying data

Healthcare Facility Identifier
Description

Healthcare Facility Identifier

Data type

integer

Alias
UMLS CUI-1
C2986045
Zip Code of Discharge
Description

Zip Code of Discharge

Data type

text

Alias
UMLS CUI-1
C1521842
Facility's Section Identifier
Description

Facility's Section Identifier

Data type

text

Alias
UMLS CUI-1
C1547540
Medical specialty
Description

Medical specialty

Data type

integer

Alias
UMLS CUI-1
C0037778
Patient
Description

Patient

Patient identification number
Description

Patient identification number

Data type

text

Alias
UMLS CUI-1
C1549734
Hospital admission date (DD.MM.YYYY)
Description

Hospital admission date (DD.MM.YYYY)

Data type

date

Alias
UMLS CUI-1
C1302393
Admission time (hh:mm)
Description

Admission time (hh:mm)

Data type

text

Alias
UMLS CUI-1
C2215405
Reason for admission
Description

Reason for admission

Data type

integer

Date of Birth (DD.MM.YYYY)
Description

Date of Birth (DD.MM.YYYY)

Data type

date

Alias
UMLS CUI-1
C0421451
Gender
Description

Gender

Data type

integer

Alias
UMLS CUI-1
C0079399
Preoperative anamnesis
Description

Preoperative anamnesis

Walking aids (at admission or prior to fracture)
Description

Walking aids (at admission or prior to fracture)

Data type

integer

Alias
UMLS CUI-1
C0557834
Walking distance (at admission or prior to fracture)
Description

Walking distance (at admission or prior to fracture)

Data type

integer

Alias
UMLS CUI-1
C0429886
Basic documentation intra- and postoperative course
Description

Basic documentation intra- and postoperative course

Were there any general complications requiring treatment?
Description

Were there any general complications requiring treatment?

Data type

boolean

Alias
UMLS CUI-1
C0032787
Pneumonia
Description

Pneumonia

Data type

integer

Alias
UMLS CUI-1
C0032285
cardiovascular complication (s)
Description

cardiovascular complication (s)

Data type

integer

Alias
UMLS CUI-1
C0032963
deep leg/pelvic vein thrombosis
Description

deep leg/pelvic vein thrombosis

Data type

integer

Alias
UMLS CUI-1
C0149871
pulmonary embolism
Description

pulmonary embolism

Data type

integer

Alias
UMLS CUI-1
C0034065
postoperative catheter-associated urinary tract infection
Description

postoperative catheter-associated urinary tract infection

Data type

integer

Alias
UMLS CUI-1
C3838785
UMLS CUI-2
C0403709
Stroke
Description

Stroke

Data type

integer

Alias
UMLS CUI-1
C0038454
Acute gastrointestinal hemorrhage
Description

Acute gastrointestinal hemorrhage

Data type

integer

Alias
UMLS CUI-1
C0266807
acute renal failure
Description

acute renal failure

Data type

integer

Alias
UMLS CUI-1
C0022660
New onset Pressure Ulcer
Description

New onset Pressure Ulcer

Data type

integer

Alias
UMLS CUI-1
C0011127
other general complications requiring treatment
Description

other general complications requiring treatment

Data type

integer

Prevention measures
Description

Prevention measures

systematic collection of individual fall risk factors of the patient
Description

systematic collection of individual fall risk factors of the patient

Data type

boolean

Alias
UMLS CUI-1
C1532976
Were taken preventive measures? (s. also nursing documentation)
Description

Were taken preventive measures? (s. also nursing documentation)

Data type

boolean

Alias
UMLS CUI-1
C0518064
Patient has received gait training
Description

Patient has received gait training

Data type

integer

Alias
UMLS CUI-1
C0085673
Patient has received aids (eg walking aids) and their application has been trained
Description

Patient has received aids (eg walking aids) and their application has been trained

Data type

integer

Alias
UMLS CUI-1
C0184009
Medication the patient was checked and adjusted if necessary
Description

Medication the patient was checked and adjusted if necessary

Data type

integer

Patient and/or family members were informed about the individual patients fall risk, of potential hazards in the home and of possible measures to Fall Prevention
Description

Patient and/or family members were informed about the individual patients fall risk, of potential hazards in the home and of possible measures to Fall Prevention

Data type

integer

Alias
UMLS CUI-1
C0030688
Postoperative range of motion
Description

Postoperative range of motion

Passive range of motion with neutral zero method is determined (affected side)
Description

Passive range of motion with neutral zero method is determined (affected side)

Data type

boolean

Alias
UMLS CUI-1
C0079991
Extension/flexion 1 at discharge (in degrees)
Description

Extension / flexion 1 at discharge (in degrees)

Data type

integer

Measurement units
  • grade
Alias
UMLS CUI-1
C0522009
UMLS CUI-2
C0231452
grade
Extension/flexion 2 at discharge (in degrees)
Description

Extension/flexion 2 at discharge (in degrees)

Data type

integer

Measurement units
  • grade
grade
Extension/flexion 3 at discharge (in degrees)
Description

Extension/flexion 3 at discharge (in degrees)

Data type

integer

Measurement units
  • grade
grade
Discharge
Description

Discharge

Walking distance at discharge
Description

Walking distance at discharge

Data type

integer

Alias
UMLS CUI-1
C0429886
Walking aids at discharge
Description

Walking aids at discharge

Data type

integer

Hostpital discharge date (DD.MM.YYYY)
Description

Hostpital discharge date (DD.MM.YYYY)

Data type

date

Alias
UMLS CUI-1
C2710998
Reason for Discharge
Description

Reason for Discharge

Data type

integer

Discharge diagnosis
Description

Discharge diagnosis

Data type

integer

Alias
UMLS CUI-1
C0011900
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Similar models

Quality assurance Hip Replacement - Basic (AQUA)

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Patient identifying data
eGK-Versichertennummer
Item
Patient insurance ID
text
C1548070 (UMLS CUI-1)
Item Group
Providers identifying data
Institutionskennzeichen
Item
Healthcare Facility Identifier
integer
C2986045 (UMLS CUI-1)
entlassender Standort ([0-9]{2})
Item
Zip Code of Discharge
text
C1521842 (UMLS CUI-1)
Betriebsstätten-Nummer
Item
Facility's Section Identifier
text
C1547540 (UMLS CUI-1)
Item
Medical specialty
integer
C0037778 (UMLS CUI-1)
Fachabteilung
Code List
Medical specialty
CL Item
internal medicine (0100)
CL Item
internal medicine: geriatrics (0102)
CL Item
internal medicine: cardiology (0103)
CL Item
internal medicine: nephrology (0104)
CL Item
internal medicine: hematology and internal oncology  (0105)
CL Item
internal medicine: endocrinology (0106)
CL Item
internal medicine: gastroenterology  (0107)
CL Item
internal medicine: pneumonology (0108)
CL Item
internal medicine: rheumatology (0109)
CL Item
internal medicine: pulmonology (0114)
CL Item
internal medicine: tumor research (0150)
CL Item
internal medicine: coloproctology (0151)
CL Item
internal medicine: infectiology (0152)
CL Item
internal medicine: diabetes (0153)
CL Item
internal medicine: naturopathy (0154)
CL Item
internal medicine: stroke unit (0156)
CL Item
internal medicine (0190)
CL Item
geriatry (0200)
CL Item
geriatry: gynecology  (0224)
CL Item
geriatry: day unit (for semi-residential care)  (0260)
CL Item
geriaty: night unit (for semi-residential care) (0261)
CL Item
geriatry (0290)
CL Item
cardiology (0300)
CL Item
nephrology (0400)
CL Item
nephrology: pediatrics (0410)
CL Item
nephrology: intensive care (0436)
CL Item
nephrology (0490)
CL Item
hematology and internal oncology  (0500)
CL Item
hematology and internal oncology: pediatrics (0510)
CL Item
hematology and internal oncology: gynacology (0524)
CL Item
hematology and internal oncology: radiation therapy (0533)
CL Item
hematology and internal oncology  (0590)
CL Item
endocrinology (0600)
CL Item
endicrinology: gastroenterology (0607)
CL Item
endocrinology: pediatrics (0610)
CL Item
endocrinology (0690)
CL Item
gastroenterology (0700)
CL Item
gastroenterology: endocrinology (0706)
CL Item
gastroenterology: pediatrics (0710)
CL Item
gastroenterology (0790)
CL Item
pneumology (0800)
CL Item
rheumatology (0900)
CL Item
rheumatology: pediatrics (0910)
CL Item
rheumatology (0990)
CL Item
pediatrics (1000)
CL Item
pediatrics: nephrology (1004)
CL Item
pediatrics: hematology and internal oncology  (1005)
CL Item
pediatrics: endocrinology (1006)
CL Item
pediatrics: gastroenterology (1007)
CL Item
pediatrics: rheumatology (1009)
CL Item
pediatrics: pediatric cardiology (1011)
CL Item
pediatrics: nephrology (1012)
CL Item
pediatrics: pulmonology (1014)
CL Item
pediatrics: pediatric neurology (1028)
CL Item
pediatrics: perinatal medicine (1050)
CL Item
continuing care for children (1051)
CL Item
pediatrics (1090)
CL Item
pediatric cardiology (1100)
CL Item
pediatric cardiology: intensive care (1136)
CL Item
pediatric cardiology (1190)
CL Item
neonatology (1200)
CL Item
pediatric surgery (1300)
CL Item
pulmonology (1400)
CL Item
pulmonology: pediatrics (1410)
CL Item
pulmonology (1490)
CL Item
general surgery (1500)
CL Item
general surgery: pediatric surgery (1513)
CL Item
general surgery: trauma surgery (1516)
CL Item
general surgery: vascular surgery (1518)
CL Item
general surgery: plastic surgery (1519)
CL Item
general surgery: thoracic surgery (1520)
CL Item
general surgery: orthopedics (1523)
CL Item
general surgery: intensive care (1536)
CL Item
general surgery: abdominal- and vascular surgery (1550)
CL Item
Allgemeine Chirurgie: hand surgery (1551)
CL Item
general surgery (1590)
CL Item
trauma surgery (1600)
CL Item
neurosurgery (1700)
CL Item
vascular surgery (1800)
CL Item
plastic surgery (1900)
CL Item
thoracic surgery (2000)
CL Item
thoracic surgery: cardiac surgery (2021)
CL Item
thoracic surgery: intensive care (2036)
CL Item
thoracic surgery: cardiac surgery intensive care (2050)
CL Item
thoracic surgery (2090)
CL Item
cardiac surgery (2100)
CL Item
cardiac surgery: vascular surgery (2118)
CL Item
cardiac surgery: thoracic surgery (2120)
CL Item
cardiac surgery: intensive care (2136)
CL Item
cardiac surgery: thoracic surgery and intensive care (2150)
CL Item
cardiac surgery (2190)
CL Item
urology (2200)
CL Item
orthopedics (2300)
CL Item
orthopedics: rheumatology (2309)
CL Item
orthopedics: surgery (2315)
CL Item
orthopedics and trauma surgery (2316)
CL Item
orthopedics (2390)
CL Item
gynecology and obstetrics (2400)
CL Item
gynecology: geriatry (2402)
CL Item
gynecology: hematology and internal oncology  (2405)
CL Item
gynecology: endocrinology (2406)
CL Item
gynecology (2425)
CL Item
gynecology and obstetrics (2490)
CL Item
obstetrics (2500)
CL Item
otolaryngology (2600)
CL Item
ophthalmology (2700)
CL Item
neurology: (2800)
CL Item
neurology: pediatrics (2810)
CL Item
neurology: stroke units (2856)
CL Item
neurology (2890)
CL Item
general psychiatry: (2900)
CL Item
general psychiatry: neurology (2928)
CL Item
general psychiatry: child and adolescent psychiatry (2930)
CL Item
general psychiatry: psychosomatics and psychotherapy (2931)
CL Item
general psychiatry: addiction treatment (2950)
CL Item
general psychiatry: geropsychiatry (2951)
CL Item
general psychiatry: forensic treatment (2952)
CL Item
general psychiatry: addiction treatment (day unit) (2953)
CL Item
general psychiatry: addiction treatment (night unit) (2954)
CL Item
general psychiatry: geropsychiatry (day unit) (2955)
CL Item
general psychiatry: geropsychiatry (night unit) (2956)
CL Item
general psychiatry: day unit (for semi-residential care) (2960)
CL Item
general psychiatry: night unit (for semi-residential care) (2961)
CL Item
general psychiatry (2990)
CL Item
child and adolescent psychiatry (3000)
CL Item
child and adolescent psychiatry: day unit (for semi-residential care) (3060)
CL Item
child and adolescent psychiatry: night unit (for semi-residential care) (3061)
CL Item
child and adolescent psychiatry (3090)
CL Item
psychosomatic/psychotherapy (3100)
CL Item
psychosomatic/psychotherapy: child and adolescent psychiatry (3110)
CL Item
psychosomatic/psychotherapy: day unit (for semi-residential care) (3160)
CL Item
psychosomatic/psychotherapy: night unit (for semi-residential care) (3161)
CL Item
psychosomatic/psychotherapy (3190)
CL Item
nuclear medicine (3200)
CL Item
nuclear medicine: radiation therapy (3233)
CL Item
nuclear medicine (3290)
CL Item
radiation therapy (3300)
CL Item
radiation therapy: hematology and internal oncology  (3305)
CL Item
radiation therapy: radiology (3350)
CL Item
radiation therapy (3390)
CL Item
dermatology (3400)
CL Item
dermatology: day unit (for semi-residential care) (3460)
CL Item
dermatology (3490)
CL Item
dentistry, orthodontics, maxillofacial surgery (3500)
CL Item
intensive-care medicine (3600)
CL Item
intensive-care medicine: internal medicine (3601)
CL Item
intensive-care medicine: cardiology (3603)
CL Item
intensive-care medicine: pediatrics (3610)
CL Item
intensive-care medicine: neurosurgery (3617)
CL Item
intensive-care medicine: surgery (3618)
CL Item
intensive-care medicine: cardiac surgery (3621)
CL Item
intensive-care medicine: urology (3622)
CL Item
intensive-care medicine: gynecology and obstetrics (3624)
CL Item
intensive-care medicine: otolaryngology  (3626)
CL Item
intensive-care medicine: neurology (3628)
CL Item
operative intensive-care medicine: surgery (3650)
CL Item
intensive-care medicine: thorax-heart surgery (3651)
CL Item
intensive-care medicine: heart-thorax surgery (3652)
CL Item
intensive-care medicine (3690)
CL Item
other medical specialty (3700)
CL Item
angiology (3750)
CL Item
radiology (3751)
CL Item
palliative care (3752)
CL Item
pain therapy (3753)
CL Item
section for alternative health practice (3754)
CL Item
spinal surgery (3755)
CL Item
addiction medicine (3756)
CL Item
visceral surgery (3757)
CL Item
other medical specialty (3790)
Item Group
Patient
einrichtungsinterne Identifikationsnummer des Patienten
Item
Patient identification number
text
C1549734 (UMLS CUI-1)
Aufnahmedatum (TT.MM.JJJJ)
Item
Hospital admission date (DD.MM.YYYY)
date
C1302393 (UMLS CUI-1)
Aufnahmeuhrzeit
Item
Admission time (hh:mm)
text
C2215405 (UMLS CUI-1)
Item
Reason for admission
integer
Aufnahmegrund
Code List
Reason for admission
CL Item
hospitalization, inpatient, normally (0101 )
CL Item
hospitalization, inpatient, accidents at work / occupational disease (11, para. 5 SGB V) (0102 )
CL Item
hospitalization, inpatient, traffic accident / sports accident / other accidents (eg 116 SGB X) (0103 )
CL Item
hospitalization, inpatient, reference to the action of external force (0104 )
CL Item
hospitalization, inpatient, free (0105 )
CL Item
hospitalization, inpatient, war-Cripples -suffering / BVG-suffering (0106 )
CL Item
hospitalization, inpatient, emergency (0107 )
CL Item
hospitalization, inpatient, normally, payers exchange (0121 )
CL Item
hospitalization, inpatient, accidents at work / occupational disease (11, para. 5 SGB V) cost carrier exchange (0122 )
CL Item
hospitalization, inpatient, traffic accident / sports accident / other accidents (eg 116 SGB X) Cost volume change (0123 )
CL Item
hospitalization, inpatient, reference to the action of external force, payers exchange (0124 )
CL Item
hospitalization, inpatient, free, payers exchange (0125 )
CL Item
hospitalization, inpatient, war wounded Cripples / BVG-suffering, payers exchange (0126 )
CL Item
hospitalization, inpatient, emergency, payers exchange (0127 )
CL Item
hospitalization, inpatient, normally, IV (0141 )
CL Item
hospitalization, inpatient, accidents at work / occupational disease (11, para. 5 SGB V), IV (0142 )
CL Item
hospitalization, inpatient, traffic accident / sports accident / other accidents (eg 116 SGB X), IV (0143 )
CL Item
hospitalization, inpatient, reference to the action of external force, by IV (0144 )
CL Item
hospitalization, inpatient, free, IV (0145 )
CL Item
hospitalization, inpatient, war wounded Cripples / BVG-suffering, IV (0146 )
CL Item
hospitalization, inpatient, emergency, IV (0147 )
CL Item
hospitalization, inpatient with prior pre-admission treatment, usually (0201 )
CL Item
hospitalization, inpatient with prior pre-admission treatment, industrial injury / occupational disease (11, para. 5 SGB V) (0202 )
CL Item
hospitalization, inpatient with prior pre-admission treatment, traffic accident / sports accident / other accidents (eg 116 SGB X) (0203 )
CL Item
hospitalization, inpatient with prior pre-admission treatment, reference to the action of external force (0204 )
CL Item
hospitalization, inpatient with prior treatment pre-admission free (0205 )
CL Item
hospitalization, inpatient with prior treatment pre-admission, war wounded Cripples / BVG-suffering (0206 )
CL Item
hospitalization, inpatient with prior pre-admission care, emergency (0207 )
CL Item
hospitalization, inpatient with prior pre-admission treatment, normally, payers exchange (0221 )
CL Item
hospitalization, inpatient with prior pre-admission treatment, industrial injury / occupational disease (11, para. 5 SGB V), payers exchange (0222 )
CL Item
hospitalization, inpatient with prior pre-admission treatment, traffic accident / sports accident / other accidents (eg 116 SGB X), cost volume change (0223 )
CL Item
hospitalization, inpatient with prior pre-admission treatment, reference to the action of external force, payers exchange (0224 )
CL Item
hospitalization, inpatient with prior treatment pre-admission, free, payers exchange (0225 )
CL Item
hospitalization, inpatient with prior treatment pre-admission, war wounded Cripples / BVG-suffering, payers exchange (0226 )
CL Item
hospitalization, inpatient with prior pre-admission care, emergency, payers exchange (0227 )
CL Item
hospitalization, inpatient with prior pre-admission treatment, normally, IV (0241 )
CL Item
hospitalization, inpatient with prior pre-admission treatment, industrial injury / occupational disease (11, para. 5 SGB V), IV (0242 )
CL Item
hospitalization, inpatient with prior pre-admission treatment, traffic accident / sports accident / other accidents (eg 116 SGB X), IV (0243 )
CL Item
hospitalization, inpatient with prior pre-admission treatment, indication of the effect of external violence, IV (0244 )
CL Item
hospitalization, inpatient with prior treatment pre-admission, free, IV (0245 )
CL Item
hospitalization, inpatient with prior treatment pre-admission, war wounded Cripples / BVG-suffering, IV (0246 )
CL Item
hospitalization, inpatient with prior pre-admission care, emergency, IV (0247 )
CL Item
hospitalization, day patient, usually (0301 )
CL Item
hospitalization, day patient, accidents at work / occupational disease (11, para. 5 SGB V) (0302 )
CL Item
hospitalization, day patient, traffic accident / sports accident / other accidents (eg 116 SGB X) (0303 )
CL Item
hospitalization, day patient, regard to the action of external force (0304 )
CL Item
hospitalization, day patient, free (0305 )
CL Item
hospitalization, day patient, war wounded Cripples / BVG-suffering (0306 )
CL Item
hospital treatment, partial inpatient, emergency (0307 )
CL Item
hospitalization, day patient, normally, payers exchange (0321 )
CL Item
hospitalization, day patient, accidents at work / occupational disease (11, para. 5 SGB V), payers exchange (0322 )
CL Item
hospitalization, day patient, traffic accident / sports accident / other accidents (eg 116 SGB X), cost volume change (0323 )
CL Item
hospitalization, day patient, regard to the action of external force, payers exchange (0324 )
CL Item
hospitalization, day patient, free, payers exchange (0325 )
CL Item
hospitalization, day patient, war wounded Cripples / BVG-suffering, payers exchange (0326 )
CL Item
hospital treatment, partial inpatient, emergency, payers exchange (0327 )
CL Item
hospitalization, day patient, normally, IV (0341 )
CL Item
hospitalization, day patient, accidents at work / occupational disease (11, para. 5 SGB V), IV (0342 )
CL Item
hospitalization, day patient, traffic accident / sports accident / other accidents (eg 116 SGB X), IV (0343 )
CL Item
hospitalization, day patient, regard to the action of external force, by IV (0344 )
CL Item
hospitalization, day patient, free, IV (0345 )
CL Item
hospitalization, day patient, war wounded Cripples / BVG-suffering, IV (0346 )
CL Item
hospital treatment, partial inpatient, emergency, IV (0347 )
CL Item
pre-admission treatment without subsequent inpatient treatment, usually (0401 )
CL Item
pre-admission treatment without subsequent inpatient treatment, industrial injury / occupational disease (11, para. 5 SGB V) (0402 )
CL Item
pre-admission treatment without subsequent inpatient treatment, traffic accident / sports accident / other accidents (eg 116 SGB X) (0403 )
CL Item
pre-admission treatment without subsequent inpatient treatment, reference to the action of external force (0404 )
CL Item
pre-admission treatment without subsequent inpatient treatment, free (0405 )
CL Item
pre-admission treatment without subsequent inpatient treatment, War Cripples suffering / BVG-suffering (0406 )
CL Item
pre-admission treatment without subsequent inpatient care, emergency (0407 )
CL Item
pre-admission treatment without subsequent inpatient treatment, normally, payers exchange (0421 )
CL Item
pre-admission treatment without subsequent inpatient treatment, industrial injury / occupational disease (11, para. 5 SGB V), payers exchange (0422 )
CL Item
pre-admission treatment without subsequent inpatient treatment, traffic accident / sports accident / other accidents (eg 116 SGB X), cost volume change (0423 )
CL Item
pre-admission treatment without subsequent inpatient treatment, reference to the action of external force, payers exchange (0424 )
CL Item
pre-admission treatment without subsequent inpatient treatment, free, payers exchange (0425 )
CL Item
pre-admission treatment without subsequent inpatient treatment, War Cripples suffering / BVG-suffering, payers exchange (0426 )
CL Item
pre-admission treatment without subsequent inpatient care, emergency, payers exchange (0427 )
CL Item
pre-admission treatment without subsequent inpatient treatment, normally, IV (0441 )
CL Item
pre-admission treatment without subsequent inpatient treatment, industrial injury / occupational disease (11, para. 5 SGB V), IV (0442 )
CL Item
pre-admission treatment without subsequent inpatient treatment, traffic accident / sports accident / other accidents (eg 116 SGB X), IV (0443 )
CL Item
pre-admission treatment without subsequent inpatient treatment, indication of the effect of external violence, IV (0444 )
CL Item
pre-admission treatment without subsequent inpatient treatment, free, IV (0445 )
CL Item
pre-admission treatment without subsequent inpatient treatment, War Cripples suffering / BVG-suffering, IV (0446 )
CL Item
pre-admission treatment without subsequent inpatient care, emergency, IV (0447 )
CL Item
Stationary delivery, normally (0501 )
CL Item
Inpatient maternity, employment injury / occupational disease (11, para. 5 SGB V) (0502 )
CL Item
Inpatient maternity, accident / sports accident / other accidents (eg 116 SGB X) (0503 )
CL Item
Inpatient confinement regard to the action of external force (0504 )
CL Item
Stationary delivery, free (0505 )
CL Item
Stationary childbirth, war wounded suffering / BVG-suffering (0506 )
CL Item
Inpatient maternity, emergency (0507 )
CL Item
Stationary delivery, normally, payers exchange (0521 )
CL Item
Inpatient maternity, employment injury / occupational disease (11, para. 5 SGB V), payers exchange (0522 )
CL Item
Inpatient maternity, accident / sports accident / other accidents (eg 116 SGB X), cost volume change (0523 )
CL Item
Inpatient confinement regard to the action of external force, payers exchange (0524 )
CL Item
Inpatient confinement, free, payers exchange (0525 )
CL Item
Stationary childbirth, war wounded Cripples / BVG-suffering, payers exchange (0526 )
CL Item
Inpatient maternity, emergency, payers exchange (0527 )
CL Item
Stationary delivery, normally, IV (0541 )
CL Item
Inpatient maternity, employment injury / occupational disease (11, para. 5 SGB V), IV (0542 )
CL Item
Inpatient maternity, accident / sports accident / other accidents (eg 116 SGB X), IV (0543 )
CL Item
Inpatient confinement regard to the action of external force, by IV (0544 )
CL Item
Inpatient confinement, free, IV (0545 )
CL Item
Stationary childbirth, war wounded Cripples / BVG-suffering, IV (0546 )
CL Item
Inpatient maternity, emergency, IV (0547 )
CL Item
born, normally (0601 )
CL Item
birth, accidents at work / occupational disease (11, para. 5 SGB V) (0602 )
CL Item
born, traffic accident / sports accident / other accidents (eg 116 SGB X) (0603 )
CL Item
born, reference to the action of external force (0604 )
CL Item
born, free (0605 )
CL Item
born, war wounded suffering / BVG-suffering (0606 )
CL Item
born, emergency (0607 )
CL Item
born, normally, payers exchange (0621 )
CL Item
birth, accidents at work / occupational disease (11, para. 5 SGB V), payers exchange (0622 )
CL Item
born, traffic accident / sports accident / other accidents (eg 116 SGB X), cost volume change (0623 )
CL Item
born, reference to the action of external force, payers exchange (0624 )
CL Item
born, free, payers exchange (0625 )
CL Item
born, war wounded Cripples / BVG-suffering, payers exchange (0626 )
CL Item
born, emergency, payers exchange (0627 )
CL Item
born, normally, IV (0641 )
CL Item
birth, accidents at work / occupational disease (11, para. 5 SGB V), IV (0642 )
CL Item
born, traffic accident / sports accident / other accidents (eg 116 SGB X), IV (0643 )
CL Item
born, reference to the action of external force, by IV (0644 )
CL Item
born, free, IV (0645 )
CL Item
born, war wounded Cripples / BVG-suffering, IV (0646 )
CL Item
born, emergency, IV (0647 )
CL Item
recovery due to complications (flat rate) to KFPV 2003 normally (0701 )
CL Item
recovery due to complications (flat rate) to KFPV 2003 work injury / occupational disease (11, para. 5 SGB V) (0702 )
CL Item
recovery due to complications (flat rate) to KFPV 2003 traffic accident / sports accident / other accidents (eg 116 SGB X) (0703 )
CL Item
recovery due to complications (flat rate) to KFPV 2003 Note on the action of external force (0704 )
CL Item
recovery due to complications (flat rate) to KFPV 2003 free (0705 )
CL Item
recovery due to complications (flat rate) to KFPV 2003 War Cripples suffering / BVG-suffering (0706 )
CL Item
recovery due to complications (flat rate) to KFPV 2003 Emergency (0707 )
CL Item
recovery due to complications (flat rate) to KFPV 2003 Normally, payers exchange (0721 )
CL Item
recovery due to complications (flat rate) to KFPV 2003 work injury / occupational disease (11, para. 5 SGB V), payers exchange (0722 )
CL Item
recovery due to complications (flat rate) to KFPV 2003 traffic accident / sports accident / other accidents (eg 116 SGB X), cost volume change (0723 )
CL Item
recovery due to complications (flat rate) to KFPV 2003 Note on the action of external force, payers exchange (0724 )
CL Item
recovery due to complications (flat rate) to KFPV 2003 free, cost volume change (0725 )
CL Item
recovery due to complications (flat rate) to KFPV 2003 War Cripples suffering / BVG-suffering, payers exchange (0726 )
CL Item
recovery due to complications (flat rate) to KFPV 2003 emergency, payers exchange (0727 )
CL Item
recovery due to complications (flat rate) to KFPV 2003 Normally, IV (0741 )
CL Item
recovery due to complications (flat rate) to KFPV 2003 work injury / occupational disease (11, para. 5 SGB V), IV (0742 )
CL Item
recovery due to complications (flat rate) to KFPV 2003 traffic accident / sports accident / other accidents (eg 116 SGB X), IV (0743 )
CL Item
recovery due to complications (flat rate) to KFPV 2003 Note on the action of external force, by IV (0744 )
CL Item
recovery due to complications (flat rate) to KFPV 2003 free, IV (0745 )
CL Item
recovery due to complications (flat rate) to KFPV 2003 War Cripples suffering / BVG-suffering, IV (0746 )
CL Item
recovery due to complications (flat rate) to KFPV 2003 emergency, IV (0747 )
CL Item
Hospitalisation for organ removal, normally (0801 )
CL Item
Hospitalisation for organ removal, accidents at work / occupational disease (11, para. 5 SGB V) (0802 )
CL Item
Hospitalisation for organ removal, traffic accident / sports accident / other accidents (eg 116 SGB X) (0803 )
CL Item
Hospitalisation for organ removal, reference to the action of external force (0804 )
CL Item
Hospitalisation for organ removal, free (0805 )
CL Item
Hospitalisation for organ removal, war wounded suffering / BVG-suffering (0806 )
CL Item
Hospitalisation for organ removal, emergency (0807 )
CL Item
Hospitalisation for organ removal, normally, payers exchange (0821 )
CL Item
Hospitalisation for organ removal, accidents at work / occupational disease (11, para. 5 SGB V), payers exchange (0822 )
CL Item
Hospitalisation for organ removal, traffic accident / sports accident / other accidents (eg 116 SGB X), cost volume change (0823 )
CL Item
Hospitalisation for organ removal, reference to the action of external force, payers exchange (0824 )
CL Item
Hospitalisation for organ removal, free, payers exchange (0825 )
CL Item
Hospitalisation for organ removal, war wounded suffering / BVG-suffering, payers exchange (0826 )
CL Item
Hospitalisation for organ removal, emergency, payers exchange (0827 )
CL Item
Hospitalisation for organ removal, normally, IV (0841 )
CL Item
Hospitalisation for organ removal, accidents at work / occupational disease (11, para. 5 SGB V), IV (0842 )
CL Item
Hospitalisation for organ removal, traffic accident / sports accident / other accidents (eg 116 SGB X), IV (0843 )
CL Item
Hospitalisation for organ removal, reference to the action of external force, by IV (0844 )
CL Item
Hospitalisation for organ removal, free, IV (0845 )
CL Item
Hospitalisation for organ removal, war wounded suffering / BVG-suffering, IV (0846 )
CL Item
Hospitalisation for organ removal, emergency, IV (0847 )
Geburtsdatum (TT.MM.JJJJ)
Item
Date of Birth (DD.MM.YYYY)
date
C0421451 (UMLS CUI-1)
Item
Gender
integer
C0079399 (UMLS CUI-1)
Geschlecht
Code List
Gender
CL Item
male (1)
CL Item
female (2)
Item Group
Preoperative anamnesis
Item
Walking aids (at admission or prior to fracture)
integer
C0557834 (UMLS CUI-1)
Gehhilfen (bei Aufnahme oder vor der Fraktur)
Code List
Walking aids (at admission or prior to fracture)
CL Item
no (0)
CL Item
Crutches (1)
CL Item
rollator / walker (2)
CL Item
wheelchair (3)
CL Item
bedridden (4)
Item
Walking distance (at admission or prior to fracture)
integer
C0429886 (UMLS CUI-1)
Gehstrecke (bei Aufnahme oder vor der Fraktur)
Code List
Walking distance (at admission or prior to fracture)
CL Item
unlimited (1)
CL Item
go straight possible to 500m (2)
CL Item
at the station level mobile (walking distance: 50m) (3)
CL Item
in-room mobile (4)
CL Item
immobile (5)
Item Group
Basic documentation intra- and postoperative course
Gab es allgemeine behandlungsbedürftige Komplikationen?
Item
Were there any general complications requiring treatment?
boolean
C0032787 (UMLS CUI-1)
Item
Pneumonia
integer
C0032285 (UMLS CUI-1)
Pneumonie
Code List
Pneumonia
CL Item
yes (1)
Item
cardiovascular complication (s)
integer
C0032963 (UMLS CUI-1)
behandlungsbedürftige kardiovaskuläre Komplikation(en)
Code List
cardiovascular complication (s)
CL Item
yes (1)
Item
deep leg/pelvic vein thrombosis
integer
C0149871 (UMLS CUI-1)
tiefe Bein- /Beckenthrombose
Code List
deep leg/pelvic vein thrombosis
CL Item
yes (1)
Item
pulmonary embolism
integer
C0034065 (UMLS CUI-1)
Lungenembolie
Code List
pulmonary embolism
CL Item
yes (1)
Item
postoperative catheter-associated urinary tract infection
integer
C3838785 (UMLS CUI-1)
C0403709 (UMLS CUI-2)
postoperative katheterassoziierte Harnwegsinfektion
Code List
postoperative catheter-associated urinary tract infection
CL Item
yes (1)
Item
Stroke
integer
C0038454 (UMLS CUI-1)
Apoplex
Code List
Stroke
CL Item
yes (1)
Item
Acute gastrointestinal hemorrhage
integer
C0266807 (UMLS CUI-1)
akute gastrointestinale Blutung
Code List
Acute gastrointestinal hemorrhage
CL Item
yes (1)
Item
acute renal failure
integer
C0022660 (UMLS CUI-1)
akute Niereninsuffizienz
Code List
acute renal failure
CL Item
yes (1)
Item
New onset Pressure Ulcer
integer
C0011127 (UMLS CUI-1)
neu aufgetretener Dekubitus
Code List
New onset Pressure Ulcer
CL Item
yes (1)
Item
other general complications requiring treatment
integer
sonstige allgemeine behandlungsbedürftige Komplikationen
Code List
other general complications requiring treatment
CL Item
yes (1)
Item Group
Prevention measures
Ist eine systematische Erfassung der individuellen Sturzrisikofaktoren des Patienten erfolgt?
Item
systematic collection of individual fall risk factors of the patient
boolean
C1532976 (UMLS CUI-1)
Wurden Präventionsmaßnahmen ergriffen? (s. auch Pflegedokumentation)
Item
Were taken preventive measures? (s. also nursing documentation)
boolean
C0518064 (UMLS CUI-1)
Item
Patient has received gait training
integer
C0085673 (UMLS CUI-1)
Patient hat Gehtraining erhalten
Code List
Patient has received gait training
CL Item
yes (1)
Item
Patient has received aids (eg walking aids) and their application has been trained
integer
C0184009 (UMLS CUI-1)
Patient hat Hilfsmittel erhalten (z.B. Gehhilfen) und deren Anwendung wurde trainiert
Code List
Patient has received aids (eg walking aids) and their application has been trained
CL Item
yes (1)
Item
Medication the patient was checked and adjusted if necessary
integer
Medikation des Patienten wurde überprüft und ggf. angepasst
Code List
Medication the patient was checked and adjusted if necessary
CL Item
yes (1)
Item
Patient and/or family members were informed about the individual patients fall risk, of potential hazards in the home and of possible measures to Fall Prevention
integer
C0030688 (UMLS CUI-1)
Patient und/oder Angehörige wurden über das individuelle Sturzrisiko des Patienten, über potentielle Gefahrenquellen im häuslichen Umfeld und über mögliche Maßnahmen zur Sturzprophylaxe aufgeklärt
Code List
Patient and/or family members were informed about the individual patients fall risk, of potential hazards in the home and of possible measures to Fall Prevention
CL Item
yes (1)
Item Group
Postoperative range of motion
Bewegungsausmaß passiv mit Neutral-Null-Methode bestimmt (betroffene Seite)
Item
Passive range of motion with neutral zero method is determined (affected side)
boolean
C0079991 (UMLS CUI-1)
Extension/Flexion 1 bei Entlassung (in Grad)
Item
Extension/flexion 1 at discharge (in degrees)
integer
C0522009 (UMLS CUI-1)
C0231452 (UMLS CUI-2)
Extension/Flexion 2 bei Entlassung
Item
Extension/flexion 2 at discharge (in degrees)
integer
Extension/Flexion 3 bei Entlassung
Item
Extension/flexion 3 at discharge (in degrees)
integer
Item Group
Discharge
Item
Walking distance at discharge
integer
C0429886 (UMLS CUI-1)
Gehstrecke bei Entlassung
Code List
Walking distance at discharge
CL Item
unlimited (1)
CL Item
go straight possible to 500m (2)
CL Item
at the station level mobile (walking distance: 50m) (3)
CL Item
in-room mobile (4)
CL Item
immobile (5)
Item
Walking aids at discharge
integer
Gehhilfen bei Entlassung
Code List
Walking aids at discharge
CL Item
no (0)
CL Item
Crutches (1)
CL Item
rollator / walker (2)
CL Item
wheelchair (3)
CL Item
bedridden (4)
Entlassungsdatum (TT.MM.JJJJ)
Item
Hostpital discharge date (DD.MM.YYYY)
date
C2710998 (UMLS CUI-1)
Item
Reason for Discharge
integer
Entlassungsgrund
Code List
Reason for Discharge
CL Item
treatment finished as planned (1)
CL Item
transferral to nursing facility (10)
CL Item
discharge to hospice (11)
CL Item
external transferral to psychiatric treatment (13)
CL Item
treatment finished because of other reasons, postdischarge treatment is planned (14)
CL Item
treatment aborted against medical advice, postdischarge treatment is planned (15)
CL Item
internal transferral with change of DRG payment areas (17)
CL Item
treatment finished as planned, postdischarge treatment is planned (2)
CL Item
case termination (internal transferral) with change between full- and partial stationary care (22)
CL Item
discharge at the end of the year with admission in previous year (25)
CL Item
treatment finished because of other reasons (3)
CL Item
treatment aborted against medical advice (4)
CL Item
change of jurisdiction of insurer or other payer (5)
CL Item
transferral to another hospital (6)
CL Item
death (7)
CL Item
transferral to another hospital within cooperative and governmental policies  (8)
CL Item
transferral to rehabilitation facility (9)
Entlassungsdiagnosen (ICD-10-GM)
Item
Discharge diagnosis
integer
C0011900 (UMLS CUI-1)
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