ID

43812

Description

The Federal Joint Committee (G-BA) Maternity Directive serves to ensure adequate, expedient and economical medical care for insured persons during pregnancy and after birth, in accordance with the medical state of the art and the current standard of care. Comprehensive care aims to avert possible risks to the life and health of the mother and child, and to recognize and treat health disorders promptly. Nearly all screening examinations can be performed by midwives or physicians and entered in the maternity record. These do not include ultrasound examinations (see below), which can be performed only in a gynaecology practice. A woman who suffers symptoms during pregnancy should seek gynaecological care. A maternity record is issued at the first screening examination. Only the examinations listed there are considered regular screening examinations as offered by the Maternity Directive. Information on the woman's general state of health is logged in the maternity record, along with information on the course of the pregnancy and any complications. Source: Gemeinsamer Bundesausschuss (G-BA), juristische Person des öffentlichen Rechts, Wegelystr. 8, 10623 Berlin, https://www.g-ba.de/institution/themenschwerpunkte/familienplanung/mutterschaft/, Publication granted by Dr. Beate Axmann.

Link

https://www.g-ba.de/institution/themenschwerpunkte/familienplanung/mutterschaft/

Keywords

Versions (2)
  1. 2/3/17 2/3/17 -
  2. 9/20/21 9/20/21 -
Uploaded on

September 20, 2021

DOI

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License

Creative Commons BY-NC 3.0
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German Maternity Records G-BA

German English

Final examination/discharge summary

6 forms  
Schwangerschaft
Description

Schwangerschaft

Alias
UMLS CUI-1
C0032961
Alter
Description

Age

Data type

integer

Alias
UMLS CUI [1]
C0001779
alleinstehend
Description

Single

Data type

boolean

Alias
UMLS CUI [1]
C0037179
Staatsangehörigkeit
Description

Nationality

Data type

text

Alias
UMLS CUI [1]
C0027473
Schwangerschaften (mit dieser)
Description

Pregnancies

Data type

integer

Alias
UMLS CUI [1]
C0552112
Geburten (mit dieser)
Description

Births

Data type

integer

Alias
UMLS CUI [1]
C0551759
Erst-Untersuchung in SSW
Description

medical examination

Data type

integer

Alias
UMLS CUI [1]
C0582103
Anzahl der Vorsorgeuntersuchungen
Description

medical examinations antenatal care

Data type

integer

Alias
UMLS CUI [1,1]
C0582103
UMLS CUI [1,2]
C0033052
vor Entbindung in Klinik vorgestellt
Description

visit hospital

Data type

boolean

Alias
UMLS CUI [1,1]
C0545082
UMLS CUI [1,2]
C0019994
stat. Aufenthalt ante partum in Wochen
Description

hospitalization ante partum

Data type

integer

Alias
UMLS CUI [1,1]
C0019993
UMLS CUI [1,2]
C2709037
Nach Katalog A/B (Seite 5 und 6) dokumentierte wichtigste Risikonummern
Description

medical risk

Data type

text

Alias
UMLS CUI [1]
C0419566
Geburt
Description

Geburt

Alias
UMLS CUI-1
C0005615
Datum
Description

Date

Data type

date

Alias
UMLS CUI [1]
C0011008
SSW
Description

week

Data type

integer

Alias
UMLS CUI [1]
C0439230
extern entbunden
Description

birth Out-of-Hospital

Data type

boolean

Alias
UMLS CUI [1,1]
C0005615
UMLS CUI [1,2]
C3844314
1. Kind Lebendgeburt
Description

live birth

Data type

boolean

Alias
UMLS CUI [1]
C0481667
1. Kind Geschlecht
Description

Gender

Data type

text

Alias
UMLS CUI [1]
C0079399
1. Kind Geburtsmodus
Description

mode of birth

Data type

text

Alias
UMLS CUI [1]
C2239272
1. Kind Kindslage
Description

Fetal presentation

Data type

text

Alias
UMLS CUI [1]
C0022869
1. Kind Gewicht
Description

Weight

Data type

float

Measurement units
  • g
Alias
UMLS CUI [1]
C0005910
g
1. Kind Länge/Kopfumfang
Description

head circumference

Data type

float

Measurement units
  • cm
Alias
UMLS CUI [1]
C0262499
cm
1. Kind Apgar-Zahl 5’/10’
Description

Apgar score

Data type

text

Alias
UMLS CUI [1]
C0003533
1. Kind pH-Wert (Nabelarterie)
Description

pH umbilical artery

Data type

float

Alias
UMLS CUI [1,1]
C0202165
UMLS CUI [1,2]
C0041632
1. Kind auffällige Fehlbildung
Description

Congenital anomalies

Data type

boolean

Alias
UMLS CUI [1]
C0000768
2. Kind (Zwilling) Lebendgeburt
Description

live birth

Data type

boolean

Alias
UMLS CUI [1]
C0481667
2. Kind (Zwilling) Geschlecht
Description

Gender

Data type

text

Alias
UMLS CUI [1]
C0079399
2. Kind (Zwilling) Geburtsmodus
Description

mode of birth

Data type

text

Alias
UMLS CUI [1]
C2239272
2. Kind (Zwilling) Kindslage
Description

Fetal presentation

Data type

text

Alias
UMLS CUI [1]
C0022869
2. Kind (Zwilling) Gewicht
Description

Weight

Data type

float

Measurement units
  • IE/ml
Alias
UMLS CUI [1]
C0005910
IE/ml
2. Kind (Zwilling) Länge/Kopfumfang
Description

head circumference

Data type

float

Measurement units
  • years
Alias
UMLS CUI [1]
C0262499
years
2. Kind (Zwilling)Apgar-Zahl 5’/10’
Description

Apgar score

Data type

text

Alias
UMLS CUI [1]
C0003533
2. Kind (Zwilling) pH-Wert (Nabelarterie)
Description

pH umbilical artery

Data type

float

Alias
UMLS CUI [1,1]
C0202165
UMLS CUI [1,2]
C0041632
2. Kind (Zwilling) auffällige Fehlbildung
Description

Congenital anomalies

Data type

boolean

Alias
UMLS CUI [1]
C0000768
Besonderheiten
Description

Special findings

Data type

text

Alias
UMLS CUI [1]
C0311392
Wochenbett
Description

Wochenbett

Alias
UMLS CUI-1
C1879329
Wochenbett normal
Description

Puerperium

Data type

boolean

Alias
UMLS CUI [1]
C1879329
gyn. Befund normal
Description

findings gynecology

Data type

boolean

Alias
UMLS CUI [1,1]
C0243095
UMLS CUI [1,2]
C0018417
Hb
Description

hemoglobin

Data type

float

Alias
UMLS CUI [1]
C0518015
RR
Description

Blood pressure

Data type

text

Alias
UMLS CUI [1]
C0005823
Anti-D-Prophylaxe
Description

Anti-D prophylaxis

Data type

boolean

Alias
UMLS CUI [1,1]
C0140430
UMLS CUI [1,2]
C0199176
Beratung über ausreichende Jodzufuhr während der Stillzeit erfolgt
Description

iodine intake nursing

Data type

boolean

Alias
UMLS CUI [1,1]
C3661575
UMLS CUI [1,2]
C0006147
Besonderheiten
Description

findings

Data type

text

Alias
UMLS CUI [1]
C0243095
1. Kind Blutgruppe und Untergruppen (nur bei RH neg.- Mutter; kein Ausweis!)
Description

blood group Rh antigen type

Data type

text

Alias
UMLS CUI [1,1]
C0005810
UMLS CUI [1,2]
C1287272
1. Kind direkter Coombstest
Description

Direct Coombs test

Data type

text

Alias
UMLS CUI [1]
C0200555
1. Kind unauffällig entl. am
Description

date release child

Data type

date

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C0030685
UMLS CUI [1,3]
C0008059
1. Kind verlegt am
Description

date transfer

Data type

date

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C0030704
1. Kind verstorben am
Description

date child death

Data type

date

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C0524343
2. Kind (Zwilling) Blutgruppe und Untergruppen (nur bei RH neg.- Mutter; kein Ausweis!)
Description

blood group Rh antigen type

Data type

text

Alias
UMLS CUI [1,1]
C0005810
UMLS CUI [1,2]
C1287272
2. Kind (Zwilling) direkter Coombstest
Description

Direct Coombs test

Data type

text

Alias
UMLS CUI [1]
C0200555
2. Kind (Zwilling) unauffällig entl. am
Description

date release child

Data type

date

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C0030685
UMLS CUI [1,3]
C0008059
2. Kind (Zwilling) verlegt am
Description

date transfer

Data type

date

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C0030704
2. Kind (Zwilling) verstorben am
Description

date child death

Data type

date

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C0524343
Datum der Entlassungsuntersuchung
Description

date Medical Examination release

Data type

date

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C0582103
UMLS CUI [1,3]
C0030685
Unterschrift/Stempel
Description

Signature

Data type

text

Alias
UMLS CUI [1]
C1519316
Besonderheiten im Wochenbett
Description

Puerperal Disorders

Data type

text

Alias
UMLS CUI [1]
C0034040
2. Untersuchung nach Entbindung (6.-8. Woche)
Description

2. Untersuchung nach Entbindung (6.-8. Woche)

Alias
UMLS CUI-1
C0582103
UMLS CUI-2
C0086839
gynäkol. Befund unauffällig
Description

findings gynecology

Data type

boolean

Alias
UMLS CUI [1,1]
C0243095
UMLS CUI [1,2]
C0018417
Hb
Description

hemoglobin

Data type

float

Measurement units
  • g %
Alias
UMLS CUI [1]
C0518015
g %
RR
Description

Blood pressure

Data type

text

Alias
UMLS CUI [1]
C0005823
Urin Zucker Test
Description

urine sugar test

Data type

text

Alias
UMLS CUI [1]
C2186571
Urin Eiweiß Test
Description

Urine protein test

Data type

text

Alias
UMLS CUI [1]
C0262923
Sediment
Description

Urinalysis

Data type

boolean

Alias
UMLS CUI [1]
C0042014
Besonderheiten
Description

findings

Data type

text

Alias
UMLS CUI [1]
C0243095
Mutter stillt
Description

breastfeeding

Data type

boolean

Alias
UMLS CUI [1]
C0006147
hat nicht gestillt
Description

breastfeed

Data type

boolean

Alias
UMLS CUI [1]
C0006147
hat abgestillt
Description

Weaning

Data type

boolean

Alias
UMLS CUI [1]
C0043084
1. Kind U 3 durchgeführt
Description

medical examination child

Data type

boolean

Alias
UMLS CUI [1,1]
C0582103
UMLS CUI [1,2]
C0008059
1. Kind lebt und ist gesund
Description

child alive healthy

Data type

boolean

Alias
UMLS CUI [1,1]
C0008059
UMLS CUI [1,2]
C2584946
UMLS CUI [1,3]
C3898900
1. Kind ist lt. U 3 behandlungsbedürftig
Description

therapy medical examination child

Data type

boolean

Alias
UMLS CUI [1,1]
C0087111
UMLS CUI [1,2]
C0582103
UMLS CUI [1,3]
C0008059
1. Kind ist verstorben am
Description

date child death

Data type

date

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C0524343
2. Kind (Zwilling) U 3 durchgeführt
Description

medical examination child

Data type

boolean

Alias
UMLS CUI [1,1]
C0582103
UMLS CUI [1,2]
C0008059
2. Kind (Zwilling) lebt und ist gesund
Description

child alive healthy

Data type

boolean

Alias
UMLS CUI [1,1]
C0008059
UMLS CUI [1,2]
C2584946
UMLS CUI [1,3]
C3898900
2. Kind (Zwilling) ist lt. U 3 behandlungsbedürftig
Description

therapy medical examination child

Data type

boolean

Alias
UMLS CUI [1,1]
C0087111
UMLS CUI [1,2]
C0582103
UMLS CUI [1,3]
C0008059
2. Kind (Zwilling) ist verstorben am
Description

date child death

Data type

date

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C0524343
Untersuchungsdatum
Description

Examination date

Data type

date

Alias
UMLS CUI [1]
C2826643
Unterschrift/Stempel
Description

Signature

Data type

text

Alias
UMLS CUI [1]
C1519316
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Similar models

Final examination/discharge summary

6 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Schwangerschaft
C0032961 (UMLS CUI-1)
Age
Item
Alter
integer
C0001779 (UMLS CUI [1])
Single
Item
alleinstehend
boolean
C0037179 (UMLS CUI [1])
Nationality
Item
Staatsangehörigkeit
text
C0027473 (UMLS CUI [1])
Pregnancies
Item
Schwangerschaften (mit dieser)
integer
C0552112 (UMLS CUI [1])
Births
Item
Geburten (mit dieser)
integer
C0551759 (UMLS CUI [1])
medical examination
Item
Erst-Untersuchung in SSW
integer
C0582103 (UMLS CUI [1])
medical examinations antenatal care
Item
Anzahl der Vorsorgeuntersuchungen
integer
C0582103 (UMLS CUI [1,1])
C0033052 (UMLS CUI [1,2])
visit hospital
Item
vor Entbindung in Klinik vorgestellt
boolean
C0545082 (UMLS CUI [1,1])
C0019994 (UMLS CUI [1,2])
hospitalization ante partum
Item
stat. Aufenthalt ante partum in Wochen
integer
C0019993 (UMLS CUI [1,1])
C2709037 (UMLS CUI [1,2])
medical risk
Item
Nach Katalog A/B (Seite 5 und 6) dokumentierte wichtigste Risikonummern
text
C0419566 (UMLS CUI [1])
Item Group
Geburt
C0005615 (UMLS CUI-1)
Date
Item
Datum
date
C0011008 (UMLS CUI [1])
week
Item
SSW
integer
C0439230 (UMLS CUI [1])
birth Out-of-Hospital
Item
extern entbunden
boolean
C0005615 (UMLS CUI [1,1])
C3844314 (UMLS CUI [1,2])
live birth
Item
1. Kind Lebendgeburt
boolean
C0481667 (UMLS CUI [1])
Item
1. Kind Geschlecht
text
C0079399 (UMLS CUI [1])
Gender
Code List
1. Kind Geschlecht
CL Item
m (1)
CL Item
w (2)
Item
1. Kind Geburtsmodus
text
C2239272 (UMLS CUI [1])
mode of birth
Code List
1. Kind Geburtsmodus
CL Item
sp (1)
CL Item
S (2)
CL Item
vag. Op. (3)
Item
1. Kind Kindslage
text
C0022869 (UMLS CUI [1])
Fetal presentation
Code List
1. Kind Kindslage
CL Item
SL (1)
CL Item
BEL (2)
CL Item
QL (3)
Weight
Item
1. Kind Gewicht
float
C0005910 (UMLS CUI [1])
head circumference
Item
1. Kind Länge/Kopfumfang
float
C0262499 (UMLS CUI [1])
Apgar score
Item
1. Kind Apgar-Zahl 5’/10’
text
C0003533 (UMLS CUI [1])
pH umbilical artery
Item
1. Kind pH-Wert (Nabelarterie)
float
C0202165 (UMLS CUI [1,1])
C0041632 (UMLS CUI [1,2])
Congenital anomalies
Item
1. Kind auffällige Fehlbildung
boolean
C0000768 (UMLS CUI [1])
live birth
Item
2. Kind (Zwilling) Lebendgeburt
boolean
C0481667 (UMLS CUI [1])
Item
2. Kind (Zwilling) Geschlecht
text
C0079399 (UMLS CUI [1])
Gender
Code List
2. Kind (Zwilling) Geschlecht
CL Item
m  (1)
CL Item
w (2)
Item
2. Kind (Zwilling) Geburtsmodus
text
C2239272 (UMLS CUI [1])
mode of birth
Code List
2. Kind (Zwilling) Geburtsmodus
CL Item
sp (1)
CL Item
S  (2)
CL Item
vag. Op. (3)
Item
2. Kind (Zwilling) Kindslage
text
C0022869 (UMLS CUI [1])
Fetal presentation
Code List
2. Kind (Zwilling) Kindslage
CL Item
SL (1)
CL Item
BEL  (2)
CL Item
QL (3)
Weight
Item
2. Kind (Zwilling) Gewicht
float
C0005910 (UMLS CUI [1])
head circumference
Item
2. Kind (Zwilling) Länge/Kopfumfang
float
C0262499 (UMLS CUI [1])
Apgar score
Item
2. Kind (Zwilling)Apgar-Zahl 5’/10’
text
C0003533 (UMLS CUI [1])
pH umbilical artery
Item
2. Kind (Zwilling) pH-Wert (Nabelarterie)
float
C0202165 (UMLS CUI [1,1])
C0041632 (UMLS CUI [1,2])
Congenital anomalies
Item
2. Kind (Zwilling) auffällige Fehlbildung
boolean
C0000768 (UMLS CUI [1])
Special findings
Item
Besonderheiten
text
C0311392 (UMLS CUI [1])
Item Group
Wochenbett
C1879329 (UMLS CUI-1)
Puerperium
Item
Wochenbett normal
boolean
C1879329 (UMLS CUI [1])
findings gynecology
Item
gyn. Befund normal
boolean
C0243095 (UMLS CUI [1,1])
C0018417 (UMLS CUI [1,2])
hemoglobin
Item
Hb
float
C0518015 (UMLS CUI [1])
Blood pressure
Item
RR
text
C0005823 (UMLS CUI [1])
Anti-D prophylaxis
Item
Anti-D-Prophylaxe
boolean
C0140430 (UMLS CUI [1,1])
C0199176 (UMLS CUI [1,2])
iodine intake nursing
Item
Beratung über ausreichende Jodzufuhr während der Stillzeit erfolgt
boolean
C3661575 (UMLS CUI [1,1])
C0006147 (UMLS CUI [1,2])
findings
Item
Besonderheiten
text
C0243095 (UMLS CUI [1])
blood group Rh antigen type
Item
1. Kind Blutgruppe und Untergruppen (nur bei RH neg.- Mutter; kein Ausweis!)
text
C0005810 (UMLS CUI [1,1])
C1287272 (UMLS CUI [1,2])
Item
1. Kind direkter Coombstest
text
C0200555 (UMLS CUI [1])
Direct Coombs test
Code List
1. Kind direkter Coombstest
CL Item
neg. (1)
CL Item
pos. (2)
date release child
Item
1. Kind unauffällig entl. am
date
C0011008 (UMLS CUI [1,1])
C0030685 (UMLS CUI [1,2])
C0008059 (UMLS CUI [1,3])
date transfer
Item
1. Kind verlegt am
date
C0011008 (UMLS CUI [1,1])
C0030704 (UMLS CUI [1,2])
date child death
Item
1. Kind verstorben am
date
C0011008 (UMLS CUI [1,1])
C0524343 (UMLS CUI [1,2])
blood group Rh antigen type
Item
2. Kind (Zwilling) Blutgruppe und Untergruppen (nur bei RH neg.- Mutter; kein Ausweis!)
text
C0005810 (UMLS CUI [1,1])
C1287272 (UMLS CUI [1,2])
Item
2. Kind (Zwilling) direkter Coombstest
text
C0200555 (UMLS CUI [1])
Direct Coombs test
Code List
2. Kind (Zwilling) direkter Coombstest
CL Item
neg.  (1)
CL Item
pos. (2)
date release child
Item
2. Kind (Zwilling) unauffällig entl. am
date
C0011008 (UMLS CUI [1,1])
C0030685 (UMLS CUI [1,2])
C0008059 (UMLS CUI [1,3])
date transfer
Item
2. Kind (Zwilling) verlegt am
date
C0011008 (UMLS CUI [1,1])
C0030704 (UMLS CUI [1,2])
date child death
Item
2. Kind (Zwilling) verstorben am
date
C0011008 (UMLS CUI [1,1])
C0524343 (UMLS CUI [1,2])
date Medical Examination release
Item
Datum der Entlassungsuntersuchung
date
C0011008 (UMLS CUI [1,1])
C0582103 (UMLS CUI [1,2])
C0030685 (UMLS CUI [1,3])
Signature
Item
Unterschrift/Stempel
text
C1519316 (UMLS CUI [1])
Puerperal Disorders
Item
Besonderheiten im Wochenbett
text
C0034040 (UMLS CUI [1])
Item Group
2. Untersuchung nach Entbindung (6.-8. Woche)
C0582103 (UMLS CUI-1)
C0086839 (UMLS CUI-2)
findings gynecology
Item
gynäkol. Befund unauffällig
boolean
C0243095 (UMLS CUI [1,1])
C0018417 (UMLS CUI [1,2])
hemoglobin
Item
Hb
float
C0518015 (UMLS CUI [1])
Blood pressure
Item
RR
text
C0005823 (UMLS CUI [1])
Item
Urin Zucker Test
text
C2186571 (UMLS CUI [1])
Direct Coombs test
Code List
Urin Zucker Test
CL Item
neg.  (1)
CL Item
pos. (2)
Item
Urin Eiweiß Test
text
C0262923 (UMLS CUI [1])
Abnormalities
Code List
Urin Eiweiß Test
CL Item
ja (1)
CL Item
nein (2)
CL Item
Kontrolle (3)
Urinalysis
Item
Sediment
boolean
C0042014 (UMLS CUI [1])
findings
Item
Besonderheiten
text
C0243095 (UMLS CUI [1])
breastfeeding
Item
Mutter stillt
boolean
C0006147 (UMLS CUI [1])
breastfeed
Item
hat nicht gestillt
boolean
C0006147 (UMLS CUI [1])
Weaning
Item
hat abgestillt
boolean
C0043084 (UMLS CUI [1])
medical examination child
Item
1. Kind U 3 durchgeführt
boolean
C0582103 (UMLS CUI [1,1])
C0008059 (UMLS CUI [1,2])
child alive healthy
Item
1. Kind lebt und ist gesund
boolean
C0008059 (UMLS CUI [1,1])
C2584946 (UMLS CUI [1,2])
C3898900 (UMLS CUI [1,3])
therapy medical examination child
Item
1. Kind ist lt. U 3 behandlungsbedürftig
boolean
C0087111 (UMLS CUI [1,1])
C0582103 (UMLS CUI [1,2])
C0008059 (UMLS CUI [1,3])
date child death
Item
1. Kind ist verstorben am
date
C0011008 (UMLS CUI [1,1])
C0524343 (UMLS CUI [1,2])
medical examination child
Item
2. Kind (Zwilling) U 3 durchgeführt
boolean
C0582103 (UMLS CUI [1,1])
C0008059 (UMLS CUI [1,2])
child alive healthy
Item
2. Kind (Zwilling) lebt und ist gesund
boolean
C0008059 (UMLS CUI [1,1])
C2584946 (UMLS CUI [1,2])
C3898900 (UMLS CUI [1,3])
therapy medical examination child
Item
2. Kind (Zwilling) ist lt. U 3 behandlungsbedürftig
boolean
C0087111 (UMLS CUI [1,1])
C0582103 (UMLS CUI [1,2])
C0008059 (UMLS CUI [1,3])
date child death
Item
2. Kind (Zwilling) ist verstorben am
date
C0011008 (UMLS CUI [1,1])
C0524343 (UMLS CUI [1,2])
Examination date
Item
Untersuchungsdatum
date
C2826643 (UMLS CUI [1])
Signature
Item
Unterschrift/Stempel
text
C1519316 (UMLS CUI [1])
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