ID
41997
Beschreibung
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
Stichworte
Versionen (2)
- 24.11.17 24.11.17 -
- 15.03.21 15.03.21 - Dr. rer. medic Philipp Neuhaus
Rechteinhaber
psykiatriregister.se (BipoläR)
Hochgeladen am
15. März 2021
DOI
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Lizenz
Creative Commons BY-NC-ND 3.0
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Bipolar Affective Disorder (BipoläR) Swedish National Quality Registry
Anamnesis
- StudyEvent: ODM
Beschreibung
Medical History
Alias
- UMLS CUI-1
- C0262926
Beschreibung
Investigator
Datentyp
text
Alias
- UMLS CUI [1]
- C2826892
Beschreibung
Date of Medical History Taking
Datentyp
date
Maßeinheiten
- yyyy-mm-dd
Alias
- UMLS CUI [1,1]
- C0025084
- UMLS CUI [1,2]
- C0011008
Beschreibung
Actual Medical History
Datentyp
text
Alias
- UMLS CUI [1,1]
- C0262926
- UMLS CUI [1,2]
- C0237400
Beschreibung
Referral
Datentyp
text
Alias
- UMLS CUI [1]
- C0034927
Beschreibung
Comment
Datentyp
text
Alias
- UMLS CUI [1]
- C0947611
Beschreibung
Social Anamnesis
Alias
- UMLS CUI-1
- C0424945
Beschreibung
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.
Datentyp
text
Alias
- UMLS CUI [1]
- C0242271
Beschreibung
Determine the number of affective episodes.
Alias
- UMLS CUI-1
- C1386525
Beschreibung
Manic, hypomanic, depressive and mixed episodes separated by 4 weeks eutymi or episode of opposite polarity. Estimate the number when in doubt.
Datentyp
boolean
Alias
- UMLS CUI [1]
- C0349217
Beschreibung
Manic, hypomanic, depressive and mixed episodes separated by 4 weeks eutymi or episode of opposite polarity. Estimate the number when in doubt.
Datentyp
float
Alias
- UMLS CUI [1,1]
- C0349217
- UMLS CUI [1,2]
- C4086638
Beschreibung
Manic, hypomanic, depressive and mixed episodes separated by 4 weeks eutymi or episode of opposite polarity. Estimate the number when in doubt.
Datentyp
boolean
Alias
- UMLS CUI [1]
- C1396834
Beschreibung
Manic, hypomanic, depressive and mixed episodes separated by 4 weeks eutymi or episode of opposite polarity. Estimate the number when in doubt.
Datentyp
float
Alias
- UMLS CUI [1,1]
- C1396834
- UMLS CUI [1,2]
- C4086638
Beschreibung
Manic, hypomanic, depressive and mixed episodes separated by 4 weeks eutymi or episode of opposite polarity. Estimate the number when in doubt.
Datentyp
boolean
Alias
- UMLS CUI [1]
- C0349208
Beschreibung
Manic, hypomanic, depressive and mixed episodes separated by 4 weeks eutymi or episode of opposite polarity. Estimate the number when in doubt.
Datentyp
float
Alias
- UMLS CUI [1,1]
- C0349208
- UMLS CUI [1,2]
- C4086638
Beschreibung
Manic, hypomanic, depressive and mixed episodes separated by 4 weeks eutymi or episode of opposite polarity. Estimate the number when in doubt.
Datentyp
boolean
Alias
- UMLS CUI [1]
- C4290107
Beschreibung
Manic, hypomanic, depressive and mixed episodes separated by 4 weeks eutymi or episode of opposite polarity. Estimate the number when in doubt.
Datentyp
float
Alias
- UMLS CUI [1,1]
- C4290107
- UMLS CUI [1,2]
- C4086638
Beschreibung
Summarize the weeks for all verified affective episodes during the year. Give an approximate value in case of doubt.
Datentyp
integer
Alias
- UMLS CUI [1,1]
- C1386525
- UMLS CUI [1,2]
- C0449238
Beschreibung
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.
Datentyp
text
Alias
- UMLS CUI [1,1]
- C0040223
- UMLS CUI [1,2]
- C0332288
- UMLS CUI [1,3]
- C1386525
Beschreibung
Self-Injurious Behavior
Alias
- UMLS CUI-1
- C0085271
Beschreibung
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).
Datentyp
text
Alias
- UMLS CUI [1]
- C3641595
Beschreibung
One Answer only.
Datentyp
text
Alias
- UMLS CUI [1,1]
- C3641595
- UMLS CUI [1,2]
- C0439228
Beschreibung
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).
Datentyp
text
Alias
- UMLS CUI [1]
- C0038663
Beschreibung
One Answer only.
Datentyp
text
Alias
- UMLS CUI [1,1]
- C0038663
- UMLS CUI [1,2]
- C0750480
Beschreibung
Treatment History
Alias
- UMLS CUI-1
- C0814462
Beschreibung
Treatment for bipolar disorder
Datentyp
text
Alias
- UMLS CUI [1,1]
- C0005586
- UMLS CUI [1,2]
- C0087111
Beschreibung
- 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)
Datentyp
text
Alias
- UMLS CUI [1,1]
- C0005586
- UMLS CUI [1,2]
- C0087111
- UMLS CUI [1,3]
- C2348235
Beschreibung
Treatment for bipolar disorder: Time of Treatment
Datentyp
text
Alias
- UMLS CUI [1,1]
- C0005586
- UMLS CUI [1,2]
- C0087111
- UMLS CUI [1,3]
- C2348792
Beschreibung
- 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)
Datentyp
text
Alias
- UMLS CUI [1,1]
- C0005586
- UMLS CUI [1,2]
- C0087111
- UMLS CUI [1,3]
- C2348792
- UMLS CUI [1,4]
- C2348235
Beschreibung
Regardless of the number of times in a treatment series. ECT = Electroconvulsive Treatment (KVÅ codes DA006, DA024 and DA025)
Datentyp
text
Alias
- UMLS CUI [1]
- C0013806
Beschreibung
Electroconvulsive Therapy: Number
Datentyp
float
Alias
- UMLS CUI [1,1]
- C0013806
- UMLS CUI [1,2]
- C0449788
Beschreibung
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.
Datentyp
integer
Alias
- UMLS CUI [1,1]
- C0013806
- UMLS CUI [1,2]
- C1547647
Beschreibung
Electroconvulsive Therapy: Last Treatment
Datentyp
text
Alias
- UMLS CUI [1,1]
- C0013806
- UMLS CUI [1,2]
- C1517741
- UMLS CUI [1,3]
- C2745955
Beschreibung
Ongoing Pharmacotherapy
Alias
- UMLS CUI-1
- C0013216
- UMLS CUI-2
- C0549178
Beschreibung
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.
Datentyp
text
Alias
- UMLS CUI [1]
- C1533054
Beschreibung
Several answers are possible.
Datentyp
text
Alias
- UMLS CUI [1,1]
- C1533054
- UMLS CUI [1,2]
- C2348235
Beschreibung
Lithium Therapy: Start Date
Datentyp
date
Maßeinheiten
- yyyy
Alias
- UMLS CUI [1,1]
- C3540800
- UMLS CUI [1,2]
- C3173309
Beschreibung
(decimal with one decimal place)
Datentyp
float
Maßeinheiten
- mmol/L
Alias
- UMLS CUI [1]
- C0337452
Beschreibung
Renal Function
Datentyp
text
Alias
- UMLS CUI [1]
- C0232804
Beschreibung
Creatinine
Datentyp
integer
Maßeinheiten
- μmol/L
Beschreibung
Cystatin C
Datentyp
float
Maßeinheiten
- mg/L
Alias
- UMLS CUI [1]
- C1619716
Beschreibung
Iohexol Clearance
Datentyp
integer
Maßeinheiten
- mL/min/1,73 m2
Alias
- UMLS CUI [1,1]
- C0017654
- UMLS CUI [1,2]
- C0022005
Beschreibung
Renal Function Test
Datentyp
text
Alias
- UMLS CUI [1,1]
- C0232804
- UMLS CUI [1,2]
- C0022885
Beschreibung
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.
Datentyp
text
Alias
- UMLS CUI [1]
- C0040615
Beschreibung
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
Datentyp
text
Alias
- UMLS CUI [1,1]
- C0040615
- UMLS CUI [1,2]
- C2348235
Beschreibung
Antidepressive Agents
Datentyp
text
Alias
- UMLS CUI [1]
- C0003289
Beschreibung
Antidepressive Agents: Specification
Datentyp
text
Alias
- UMLS CUI [1,1]
- C0003289
- UMLS CUI [1,2]
- C2348235
Beschreibung
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.
Datentyp
text
Alias
- UMLS CUI [1,1]
- C1263846
- UMLS CUI [1,2]
- C0013216
Beschreibung
Several answers are possible.
Datentyp
text
Alias
- UMLS CUI [1,1]
- C1263846
- UMLS CUI [1,2]
- C0013216
- UMLS CUI [1,3]
- C2348235
Beschreibung
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.
Datentyp
text
Alias
- UMLS CUI [1]
- C0005064
Beschreibung
Levothyroxine
Datentyp
text
Alias
- UMLS CUI [1]
- C1881373
Beschreibung
Adverse reaction to drug
Datentyp
text
Alias
- UMLS CUI [1]
- C0041755
Beschreibung
Adverse reaction to drug: Preparation
Datentyp
text
Alias
- UMLS CUI [1,1]
- C0041755
- UMLS CUI [1,2]
- C1521827
Beschreibung
Adverse reaction to drug: Specification
Datentyp
text
Alias
- UMLS CUI [1,1]
- C0041755
- UMLS CUI [1,2]
- C2348235
Beschreibung
Somatic Factors
Alias
- UMLS CUI-1
- C2986476
Beschreibung
Includes diagnosed states, suspected conditions investigated (even if diagnosis is not yet established) as well as complicating circumstances.
Datentyp
text
Alias
- UMLS CUI [1]
- C2986476
Beschreibung
Several answers are possible.
Datentyp
text
Beschreibung
Somatic Factors: Others
Datentyp
text
Alias
- UMLS CUI [1,1]
- C2986476
- UMLS CUI [1,2]
- C0205394
Beschreibung
HbA1c
Datentyp
boolean
Alias
- UMLS CUI [1]
- C0019018
Beschreibung
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.
Datentyp
integer
Maßeinheiten
- mmol/mol
Alias
- UMLS CUI [1,1]
- C0019018
- UMLS CUI [1,2]
- C0587081
Beschreibung
Systolic Blood Pressure
Datentyp
boolean
Alias
- UMLS CUI [1]
- C0871470
Beschreibung
Systolic blood pressure, upper pressure (mm Hg) registered in sitting after at least two minutes rest (recommendation).
Datentyp
integer
Maßeinheiten
- mmHg
Alias
- UMLS CUI [1,1]
- C0871470
- UMLS CUI [1,2]
- C0587081
Beschreibung
Diastolic Blood Pressure
Datentyp
boolean
Alias
- UMLS CUI [1]
- C0428883
Beschreibung
Diastolic blood pressure, lower pressure (mm Hg) recorded in sitting after at least two minutes rest (recommendation).
Datentyp
integer
Maßeinheiten
- mmHg
Alias
- UMLS CUI [1,1]
- C0428883
- UMLS CUI [1,2]
- C0587081
Beschreibung
Body Weight
Datentyp
boolean
Alias
- UMLS CUI [1]
- C0005910
Beschreibung
Weight = kg, without outerwear, jacket and shoes. (Decimal by one decimal place)
Datentyp
float
Maßeinheiten
- kg
Beschreibung
Body Height
Datentyp
boolean
Alias
- UMLS CUI [1]
- C0005890
Beschreibung
Length = cm, without shoes.
Datentyp
integer
Maßeinheiten
- cm
Alias
- UMLS CUI [1,1]
- C0005890
- UMLS CUI [1,2]
- C0587081
Beschreibung
Substance Use Disorders
Alias
- UMLS CUI-1
- C0038586
Beschreibung
Nicotine
Datentyp
text
Alias
- UMLS CUI [1]
- C0376384
Beschreibung
By nicotine replacement, nicotine patches and nicotine gum. Several responses can be specified.
Datentyp
text
Alias
- UMLS CUI [1,1]
- C0376384
- UMLS CUI [1,2]
- C2348235
Beschreibung
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.
Datentyp
integer
Alias
- UMLS CUI [1,1]
- C0001948
- UMLS CUI [1,2]
- C0439603
Beschreibung
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.
Datentyp
integer
Alias
- UMLS CUI [1]
- C0560578
Beschreibung
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.
Datentyp
integer
Alias
- UMLS CUI [1,1]
- C0001948
- UMLS CUI [1,2]
- C0442802
Beschreibung
(0 - 12 points)
Datentyp
integer
Alias
- UMLS CUI [1,1]
- C0001948
- UMLS CUI [1,2]
- C0449820
Beschreibung
Psychiatric comorbidity - Based on clinical interview, MINI interview or other instruments:
Alias
- UMLS CUI-1
- C0004936
Beschreibung
Psychiatric comorbidity
Datentyp
text
Alias
- UMLS CUI [1]
- C0004936
Beschreibung
Several answers are possible.
Datentyp
text
Alias
- UMLS CUI [1,1]
- C0004936
- UMLS CUI [1,2]
- C2348235
Beschreibung
One answer only.
Datentyp
text
Alias
- UMLS CUI [1]
- C0041671
Beschreibung
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.
Datentyp
text
Alias
- UMLS CUI [1]
- C0038586
Beschreibung
Global Assessment of Functioning
Beschreibung
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)
Datentyp
integer
Alias
- UMLS CUI [1,1]
- C0017644
- UMLS CUI [1,2]
- C0814554
Beschreibung
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)
Datentyp
integer
Alias
- UMLS CUI [1,1]
- C0017644
- UMLS CUI [1,2]
- C0004936
Beschreibung
(The question is answered if the patient is 20 years and younger) One answer only.
Datentyp
text
Alias
- UMLS CUI [1]
- C0450973
Beschreibung
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)
Datentyp
integer
Alias
- UMLS CUI [1]
- C3472495
Beschreibung
(0 - 100)
Datentyp
integer
Alias
- UMLS CUI [1]
- C0017644
Beschreibung
(0 - 100)
Datentyp
integer
Alias
- UMLS CUI [1,1]
- C0017644
- UMLS CUI [1,2]
- C1457887
Beschreibung
CGI-S (Clinical Global Impression - Severity, Overall Clinical Impression of Disease Severity) * * Mandatory
Alias
- UMLS CUI-1
- C3639708
Beschreibung
One answer only.
Datentyp
text
Alias
- UMLS CUI [1,1]
- C3639708
- UMLS CUI [1,2]
- C0024713
Beschreibung
One answer only.
Datentyp
text
Alias
- UMLS CUI [1,1]
- C3639708
- UMLS CUI [1,2]
- C0011581
Beschreibung
Clinical Global Impression
Datentyp
text
Alias
- UMLS CUI [1]
- C3639708
Ähnliche Modelle
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])
C0449238 (UMLS CUI [1,2])
C0332288 (UMLS CUI [1,2])
C1386525 (UMLS CUI [1,3])
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])
C3173309 (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])