ID

42103

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: NLS Specification 2015 V02

Link

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

Keywords

Versions (2)
  1. 11/28/17 11/28/17 - Julian Varghese
  2. 4/10/21 4/10/21 - Ahmed Rafee, MD
Copyright Holder

AQUA institute

Uploaded on

April 10, 2021

DOI

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License

Creative Commons BY 4.0
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Quality assurance Living Donor Renal Transplant (AQUA)

German English

Quality assurance Living Donor Renal Transplant (AQUA)

1 forms  
Basic documentation
Description

Basic documentation

Healthcare facility Identifier
Description

Institutionskennzeichen

Data type

integer

Alias
UMLS CUI [1]
C2986045
Zip Code of Discharge
Description

Entlassender Standort

Data type

text

Alias
UMLS CUI [1,1]
C0030685
UMLS CUI [1,2]
C1521842
Facility's Section Identifier
Description

Betriebsstätten-Nummer

Data type

text

Alias
UMLS CUI [1]
C1547540
Admission date (dd.mm.yyyy)
Description

Aufnahmedatum Krankenhaus

Data type

date

Alias
UMLS CUI-1
Code finden
Medical specialty
Description

Fachabteilung

Data type

integer

Alias
UMLS CUI-1
Code finden
Donor ID (ET-Number)
Description

Spender ID

Data type

integer

Alias
UMLS CUI [1]
C1718162
Date of Birth (DD.MM.YYYY)
Description

Geburtsdatum

Data type

date

Alias
UMLS CUI [1]
C0421451
Gender
Description

Geschlecht

Data type

integer

Alias
UMLS CUI [1]
C0079399
Body Height (in cm)
Description

Körpergröße

Data type

integer

Measurement units
  • cm
Alias
UMLS CUI [1]
C0005890
cm
Body weight at admission time (in kg)
Description

Körpergewicht bei Aufnahme

Data type

integer

Measurement units
  • kg
Alias
UMLS CUI [1]
C0005910
kg
Case history
Description

Case history

Preoperative arterial hypertension
Description

arterielle Hypertonie präoperativ

Data type

boolean

Alias
UMLS CUI [1,1]
C0020538
UMLS CUI [1,2]
C044520
Serum creatinine level (in mg/dl)
Description

Kreatininwert i.S. in mg/dl

Data type

integer

Measurement units
  • mg/dl
Alias
UMLS CUI [1]
C0201976
mg/dl
Serum creatinine level(in µmol/l)
Description

Kreatininwert i.S. in µmol/l

Data type

integer

Measurement units
  • µmol/l
Alias
UMLS CUI [1]
C0201976
µmol/l
Surgery
Description

Surgery

Surgical operation date
Description

OP-Datum

Data type

date

Alias
UMLS CUI [1]
C3258210
Procedure codes
Description

Operation

Data type

integer

Alias
UMLS CUI-1
Code finden
Procedure Duration (in minutes)
Description

Dauer des Eingriffs

Data type

integer

Measurement units
  • minutes
Alias
UMLS CUI-1
Code finden
minutes
Progress
Description

Progress

intra/postoperative (severe) complications requiring action
Description

behandlungsbedürftige (schwere) intra- oder postoperative Komplikation(en)

Data type

boolean

Alias
UMLS CUI [1,1]
C0021890
UMLS CUI [1,2]
C0032787
Hemorrhage
Description

Blutung

Data type

integer

Alias
UMLS CUI [1]
C0019080
Required surgical revision
Description

Reoperation erforderlich

Data type

integer

Alias
UMLS CUI [1,1]
C0035110
UMLS CUI [1,2]
C1514873
Other complication
Description

sonstige Komplikationen

Data type

integer

Alias
UMLS CUI [1,1]
C0009566
UMLS CUI [1,2]
C0205394
Discharge
Description

Discharge

Donor is dependent on renal dialysis at discharge
Description

Spender bei Entlassung dialysepflichtig?

Data type

boolean

Alias
UMLS CUI [1,1]
C0524376
UMLS CUI [1,2]
C0030685
Serum creatinine level (in mg/dl) at discharge
Description

Kreatininwert i.S. in mg/dl

Data type

integer

Measurement units
  • mg/dl
Alias
UMLS CUI [1,1]
C0201976
UMLS CUI [1,2]
C1548175
mg/dl
Serum creatinine level(in µmol/l) at discharge
Description

Kreatininwert i.S. in µmol/l

Data type

integer

Measurement units
  • µmol/l
Alias
UMLS CUI [1,1]
C0201976
UMLS CUI [1,2]
C1548175
µmol/l
Urine albumin Level (in mg/l)
Description

Albumin i. U.

Data type

integer

Measurement units
  • mg/l
Alias
UMLS CUI [1]
C1318429
mg/l
Urine albumin/creatinine ratio measurement (in mg/g)
Description

Albumin-Kreatinin-Verhältnis i. U.

Data type

integer

Measurement units
  • mg/g
Alias
UMLS CUI [1]
C0455271
mg/g
Arterial hypertension at discharge
Description

arterielle Hypertonie

Data type

boolean

Alias
UMLS CUI [1,1]
C0020538
UMLS CUI [1,2]
C0030685
Hostpital discharge date (DD.MM.YYYY)
Description

Entlassungsdatum Krankenhaus

Data type

date

Alias
UMLS CUI [1]
C2710998
Discharge diagnosis/es
Description

Entlassungsdiagnose(n)

Data type

integer

Alias
UMLS CUI [1,1]
C0030685
UMLS CUI [1,2]
C0011900
Reason for discharge
Description

Entlassungsgrund

Data type

integer

Alias
UMLS CUI [1]
C4034196
Cause of Death
Description

Todesursache

Data type

integer

Alias
UMLS CUI [1]
C0007465
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Similar models

Quality assurance Living Donor Renal Transplant (AQUA)

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Basic documentation
Institutionskennzeichen
Item
Healthcare facility Identifier
integer
C2986045 (UMLS CUI [1])
Entlassender Standort
Item
Zip Code of Discharge
text
C0030685 (UMLS CUI [1,1])
C1521842 (UMLS CUI [1,2])
Betriebsstätten-Nummer
Item
Facility's Section Identifier
text
C1547540 (UMLS CUI [1])
Aufnahmedatum Krankenhaus
Item
Admission date (dd.mm.yyyy)
date
Code finden (UMLS CUI-1)
Item
Medical specialty
integer
Code finden (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)
Spender ID
Item
Donor ID (ET-Number)
integer
C1718162 (UMLS CUI [1])
Geburtsdatum
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)
Körpergröße
Item
Body Height (in cm)
integer
C0005890 (UMLS CUI [1])
Körpergewicht bei Aufnahme
Item
Body weight at admission time (in kg)
integer
C0005910 (UMLS CUI [1])
Item Group
Case history
arterielle Hypertonie präoperativ
Item
Preoperative arterial hypertension
boolean
C0020538 (UMLS CUI [1,1])
C044520 (UMLS CUI [1,2])
Kreatininwert i.S. in mg/dl
Item
Serum creatinine level (in mg/dl)
integer
C0201976 (UMLS CUI [1])
Kreatininwert i.S. in µmol/l
Item
Serum creatinine level(in µmol/l)
integer
C0201976 (UMLS CUI [1])
Item Group
Surgery
OP-Datum
Item
Surgical operation date
date
C3258210 (UMLS CUI [1])
Operation
Item
Procedure codes
integer
Code finden (UMLS CUI-1)
Dauer des Eingriffs
Item
Procedure Duration (in minutes)
integer
Code finden (UMLS CUI-1)
Item Group
Progress
behandlungsbedürftige (schwere) intra- oder postoperative Komplikation(en)
Item
intra/postoperative (severe) complications requiring action
boolean
C0021890 (UMLS CUI [1,1])
C0032787 (UMLS CUI [1,2])
Item
Hemorrhage
integer
C0019080 (UMLS CUI [1])
Blutung
Code List
Hemorrhage
CL Item
yes (1)
Item
Required surgical revision
integer
C0035110 (UMLS CUI [1,1])
C1514873 (UMLS CUI [1,2])
Reoperation erforderlich
Code List
Required surgical revision
CL Item
yes (1)
Item
Other complication
integer
C0009566 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
sonstige Komplikationen
Code List
Other complication
CL Item
yes (1)
Item Group
Discharge
Spender bei Entlassung dialysepflichtig?
Item
Donor is dependent on renal dialysis at discharge
boolean
C0524376 (UMLS CUI [1,1])
C0030685 (UMLS CUI [1,2])
Kreatininwert i.S. in mg/dl
Item
Serum creatinine level (in mg/dl) at discharge
integer
C0201976 (UMLS CUI [1,1])
C1548175 (UMLS CUI [1,2])
Kreatininwert i.S. in µmol/l
Item
Serum creatinine level(in µmol/l) at discharge
integer
C0201976 (UMLS CUI [1,1])
C1548175 (UMLS CUI [1,2])
Albumin i. U.
Item
Urine albumin Level (in mg/l)
integer
C1318429 (UMLS CUI [1])
Albumin-Kreatinin-Verhältnis i. U.
Item
Urine albumin/creatinine ratio measurement (in mg/g)
integer
C0455271 (UMLS CUI [1])
arterielle Hypertonie
Item
Arterial hypertension at discharge
boolean
C0020538 (UMLS CUI [1,1])
C0030685 (UMLS CUI [1,2])
Entlassungsdatum Krankenhaus
Item
Hostpital discharge date (DD.MM.YYYY)
date
C2710998 (UMLS CUI [1])
Entlassungsdiagnose(n)
Item
Discharge diagnosis/es
integer
C0030685 (UMLS CUI [1,1])
C0011900 (UMLS CUI [1,2])
Item
Reason for discharge
integer
C4034196 (UMLS CUI [1])
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)
Item
Cause of Death
integer
C0007465 (UMLS CUI [1])
Todesursache
Code List
Cause of Death
CL Item
infection (1)
CL Item
cardiovascular (2)
CL Item
cerebrovascular (3)
CL Item
other (4)
CL Item
unknown (9)
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