ID

43812

Descripción

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/

Palabras clave

Versiones (2)
  1. 3/2/17 3/2/17 -
  2. 20/9/21 20/9/21 -
Subido en

20 de septiembre de 2021

DOI

Para solicitar uno, por favor iniciar sesión.

Licencia

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

Alemán Inglés

Final examination/discharge summary

6 formularios  
Pregnancy
Descripción

Pregnancy

Alias
UMLS CUI-1
C0032961
Age
Descripción

Age

Tipo de datos

integer

Alias
UMLS CUI [1]
C0001779
Single
Descripción

Single

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0037179
Nationality
Descripción

Nationality

Tipo de datos

text

Alias
UMLS CUI [1]
C0027473
Pregnancies (including this one)
Descripción

Pregnancies

Tipo de datos

integer

Alias
UMLS CUI [1]
C0552112
Births (including this one)
Descripción

Births

Tipo de datos

integer

Alias
UMLS CUI [1]
C0551759
First examination in week
Descripción

medical examination

Tipo de datos

integer

Alias
UMLS CUI [1]
C0582103
Number of antenatal care examinations
Descripción

medical examinations antenatal care

Tipo de datos

integer

Alias
UMLS CUI [1,1]
C0582103
UMLS CUI [1,2]
C0033052
Presented in hospital before delivery
Descripción

visit hospital

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0545082
UMLS CUI [1,2]
C0019994
Hospitalized ante partum in weeks
Descripción

hospitalization ante partum

Tipo de datos

integer

Alias
UMLS CUI [1,1]
C0019993
UMLS CUI [1,2]
C2709037
Most important risk numbers documented (catalogue A/B, pages 5 and 6)
Descripción

medical risk

Tipo de datos

text

Alias
UMLS CUI [1]
C0419566
Birth
Descripción

Birth

Alias
UMLS CUI-1
C0005615
Date
Descripción

Date

Tipo de datos

date

Alias
UMLS CUI [1]
C0011008
week
Descripción

week

Tipo de datos

integer

Alias
UMLS CUI [1]
C0439230
Out of hospital birth
Descripción

birth Out-of-Hospital

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0005615
UMLS CUI [1,2]
C3844314
1. child live birth
Descripción

live birth

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0481667
1. child gender
Descripción

Gender

Tipo de datos

text

Alias
UMLS CUI [1]
C0079399
1. child mode of birth
Descripción

mode of birth

Tipo de datos

text

Alias
UMLS CUI [1]
C2239272
1. child foetal presentation
Descripción

Fetal presentation

Tipo de datos

text

Alias
UMLS CUI [1]
C0022869
1. child weight
Descripción

Weight

Tipo de datos

float

Unidades de medida
  • g
Alias
UMLS CUI [1]
C0005910
g
1. child Head length/ circumference
Descripción

head circumference

Tipo de datos

float

Unidades de medida
  • cm
Alias
UMLS CUI [1]
C0262499
cm
1. child Apgar score 5’/10’
Descripción

Apgar score

Tipo de datos

text

Alias
UMLS CUI [1]
C0003533
1. child pH level (umbilical artery)
Descripción

pH umbilical artery

Tipo de datos

float

Alias
UMLS CUI [1,1]
C0202165
UMLS CUI [1,2]
C0041632
1. child congenital anomalies
Descripción

Congenital anomalies

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0000768
2. child (twin) live birth
Descripción

live birth

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0481667
2. child (twin) gender
Descripción

Gender

Tipo de datos

text

Alias
UMLS CUI [1]
C0079399
2. child (twin) mode of birth
Descripción

mode of birth

Tipo de datos

text

Alias
UMLS CUI [1]
C2239272
2. child (twin) foetal presentation
Descripción

Fetal presentation

Tipo de datos

text

Alias
UMLS CUI [1]
C0022869
2. child (twin) weight
Descripción

Weight

Tipo de datos

float

Unidades de medida
  • IE/ml
Alias
UMLS CUI [1]
C0005910
IE/ml
2. child (twin) Head length/ circumference
Descripción

head circumference

Tipo de datos

float

Unidades de medida
  • years
Alias
UMLS CUI [1]
C0262499
years
2. child (twin) Apgar score 5’/10’
Descripción

Apgar score

Tipo de datos

text

Alias
UMLS CUI [1]
C0003533
2. child (twin) pH level (umbilical artery)
Descripción

pH umbilical artery

Tipo de datos

float

Alias
UMLS CUI [1,1]
C0202165
UMLS CUI [1,2]
C0041632
2. child (twin) congenital anomalies
Descripción

Congenital anomalies

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0000768
Special findings
Descripción

Special findings

Tipo de datos

text

Alias
UMLS CUI [1]
C0311392
Puerperium
Descripción

Puerperium

Alias
UMLS CUI-1
C1879329
Puerperium normal
Descripción

Puerperium

Tipo de datos

boolean

Alias
UMLS CUI [1]
C1879329
Gyn. findings normal
Descripción

findings gynecology

Tipo de datos

boolean

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

hemoglobin

Tipo de datos

float

Alias
UMLS CUI [1]
C0518015
BP
Descripción

Blood pressure

Tipo de datos

text

Alias
UMLS CUI [1]
C0005823
Anti-D prophylaxis
Descripción

Anti-D prophylaxis

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0140430
UMLS CUI [1,2]
C0199176
Mother advised on sufficient iodine intake while nursing
Descripción

iodine intake nursing

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C3661575
UMLS CUI [1,2]
C0006147
Exceptional findings
Descripción

findings

Tipo de datos

text

Alias
UMLS CUI [1]
C0243095
1. child blood group and subtype (only for RH-neg.mother; no official document!)
Descripción

blood group Rh antigen type

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0005810
UMLS CUI [1,2]
C1287272
1. child Direct Coombs test
Descripción

Direct Coombs test

Tipo de datos

text

Alias
UMLS CUI [1]
C0200555
1. child released (without problems) on
Descripción

date release child

Tipo de datos

date

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C0030685
UMLS CUI [1,3]
C0008059
1. Child transferred on
Descripción

date transfer

Tipo de datos

date

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C0030704
1. Child died on
Descripción

date child death

Tipo de datos

date

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C0524343
2. child (twin) blood group and subtype (only for RH-neg.mother; no official document!)
Descripción

blood group Rh antigen type

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0005810
UMLS CUI [1,2]
C1287272
2. child (twin) Direct Coombs test
Descripción

Direct Coombs test

Tipo de datos

text

Alias
UMLS CUI [1]
C0200555
2. child (twin) released (without problems) on
Descripción

date release child

Tipo de datos

date

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C0030685
UMLS CUI [1,3]
C0008059
2. Child (twin) transferred on
Descripción

date transfer

Tipo de datos

date

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C0030704
2. Child (twin) died on
Descripción

date child death

Tipo de datos

date

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C0524343
Date of release examination
Descripción

date Medical Examination release

Tipo de datos

date

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C0582103
UMLS CUI [1,3]
C0030685
Signature/stamp
Descripción

Signature

Tipo de datos

text

Alias
UMLS CUI [1]
C1519316
Abnormalities during puerperium
Descripción

Puerperal Disorders

Tipo de datos

text

Alias
UMLS CUI [1]
C0034040
2. examination after delivery (6th-8th week)
Descripción

2. examination after delivery (6th-8th week)

Alias
UMLS CUI-1
C0582103
UMLS CUI-2
C0086839
Gyn. findings normal
Descripción

findings gynecology

Tipo de datos

boolean

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

hemoglobin

Tipo de datos

float

Unidades de medida
  • g %
Alias
UMLS CUI [1]
C0518015
g %
RR
Descripción

Blood pressure

Tipo de datos

text

Alias
UMLS CUI [1]
C0005823
Urine sugar test
Descripción

urine sugar test

Tipo de datos

text

Alias
UMLS CUI [1]
C2186571
Urine protein test
Descripción

Urine protein test

Tipo de datos

text

Alias
UMLS CUI [1]
C0262923
Urinalysis normal
Descripción

Urinalysis

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0042014
Special findings
Descripción

findings

Tipo de datos

text

Alias
UMLS CUI [1]
C0243095
Mother is breastfeeding
Descripción

breastfeeding

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0006147
Did not breastfeed
Descripción

breastfeed

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0006147
Has weaned child
Descripción

Weaning

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0043084
1. child Examination U3 conducted
Descripción

medical examination child

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0582103
UMLS CUI [1,2]
C0008059
1. child alive and healthy
Descripción

child alive healthy

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0008059
UMLS CUI [1,2]
C2584946
UMLS CUI [1,3]
C3898900
1. child requires treatment after pediatric examination U3
Descripción

therapy medical examination child

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0087111
UMLS CUI [1,2]
C0582103
UMLS CUI [1,3]
C0008059
1. child died on
Descripción

date child death

Tipo de datos

date

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C0524343
2. child (twin) Examination U3 conducted
Descripción

medical examination child

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0582103
UMLS CUI [1,2]
C0008059
2. child (twin) alive and healthy
Descripción

child alive healthy

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0008059
UMLS CUI [1,2]
C2584946
UMLS CUI [1,3]
C3898900
2. child (twin) requires treatment after pediatric examination U3
Descripción

therapy medical examination child

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0087111
UMLS CUI [1,2]
C0582103
UMLS CUI [1,3]
C0008059
2. child (twin) died on
Descripción

date child death

Tipo de datos

date

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C0524343
Examination date
Descripción

Examination date

Tipo de datos

date

Alias
UMLS CUI [1]
C2826643
Signature/stamp
Descripción

Signature

Tipo de datos

text

Alias
UMLS CUI [1]
C1519316
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Similar models

Final examination/discharge summary

6 formularios
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
Alias
Item Group
Pregnancy
C0032961 (UMLS CUI-1)
Age
Item
Age
integer
C0001779 (UMLS CUI [1])
Single
Item
Single
boolean
C0037179 (UMLS CUI [1])
Nationality
Item
Nationality
text
C0027473 (UMLS CUI [1])
Pregnancies
Item
Pregnancies (including this one)
integer
C0552112 (UMLS CUI [1])
Births
Item
Births (including this one)
integer
C0551759 (UMLS CUI [1])
medical examination
Item
First examination in week
integer
C0582103 (UMLS CUI [1])
medical examinations antenatal care
Item
Number of antenatal care examinations
integer
C0582103 (UMLS CUI [1,1])
C0033052 (UMLS CUI [1,2])
visit hospital
Item
Presented in hospital before delivery
boolean
C0545082 (UMLS CUI [1,1])
C0019994 (UMLS CUI [1,2])
hospitalization ante partum
Item
Hospitalized ante partum in weeks
integer
C0019993 (UMLS CUI [1,1])
C2709037 (UMLS CUI [1,2])
medical risk
Item
Most important risk numbers documented (catalogue A/B, pages 5 and 6)
text
C0419566 (UMLS CUI [1])
Item Group
Birth
C0005615 (UMLS CUI-1)
Date
Item
Date
date
C0011008 (UMLS CUI [1])
week
Item
week
integer
C0439230 (UMLS CUI [1])
birth Out-of-Hospital
Item
Out of hospital birth
boolean
C0005615 (UMLS CUI [1,1])
C3844314 (UMLS CUI [1,2])
live birth
Item
1. child live birth
boolean
C0481667 (UMLS CUI [1])
Item
1. child gender
text
C0079399 (UMLS CUI [1])
Gender
Code List
1. child gender
CL Item
male (1)
CL Item
female (2)
Item
1. child mode of birth
text
C2239272 (UMLS CUI [1])
mode of birth
Code List
1. child mode of birth
CL Item
V (1)
CL Item
CS (2)
CL Item
Assisted vag. birth (3)
Item
1. child foetal presentation
text
C0022869 (UMLS CUI [1])
Fetal presentation
Code List
1. child foetal presentation
CL Item
CP (1)
CL Item
BP (2)
CL Item
TP (3)
Weight
Item
1. child weight
float
C0005910 (UMLS CUI [1])
head circumference
Item
1. child Head length/ circumference
float
C0262499 (UMLS CUI [1])
Apgar score
Item
1. child Apgar score 5’/10’
text
C0003533 (UMLS CUI [1])
pH umbilical artery
Item
1. child pH level (umbilical artery)
float
C0202165 (UMLS CUI [1,1])
C0041632 (UMLS CUI [1,2])
Congenital anomalies
Item
1. child congenital anomalies
boolean
C0000768 (UMLS CUI [1])
live birth
Item
2. child (twin) live birth
boolean
C0481667 (UMLS CUI [1])
Item
2. child (twin) gender
text
C0079399 (UMLS CUI [1])
Gender
Code List
2. child (twin) gender
CL Item
male  (1)
CL Item
female (2)
Item
2. child (twin) mode of birth
text
C2239272 (UMLS CUI [1])
mode of birth
Code List
2. child (twin) mode of birth
CL Item
V  (1)
CL Item
CS  (2)
CL Item
Assisted vag. birth (3)
Item
2. child (twin) foetal presentation
text
C0022869 (UMLS CUI [1])
Fetal presentation
Code List
2. child (twin) foetal presentation
CL Item
CP  (1)
CL Item
BP  (2)
CL Item
TP (3)
Weight
Item
2. child (twin) weight
float
C0005910 (UMLS CUI [1])
head circumference
Item
2. child (twin) Head length/ circumference
float
C0262499 (UMLS CUI [1])
Apgar score
Item
2. child (twin) Apgar score 5’/10’
text
C0003533 (UMLS CUI [1])
pH umbilical artery
Item
2. child (twin) pH level (umbilical artery)
float
C0202165 (UMLS CUI [1,1])
C0041632 (UMLS CUI [1,2])
Congenital anomalies
Item
2. child (twin) congenital anomalies
boolean
C0000768 (UMLS CUI [1])
Special findings
Item
Special findings
text
C0311392 (UMLS CUI [1])
Item Group
Puerperium
C1879329 (UMLS CUI-1)
Puerperium
Item
Puerperium normal
boolean
C1879329 (UMLS CUI [1])
findings gynecology
Item
Gyn. findings normal
boolean
C0243095 (UMLS CUI [1,1])
C0018417 (UMLS CUI [1,2])
hemoglobin
Item
Hb
float
C0518015 (UMLS CUI [1])
Blood pressure
Item
BP
text
C0005823 (UMLS CUI [1])
Anti-D prophylaxis
Item
Anti-D prophylaxis
boolean
C0140430 (UMLS CUI [1,1])
C0199176 (UMLS CUI [1,2])
iodine intake nursing
Item
Mother advised on sufficient iodine intake while nursing
boolean
C3661575 (UMLS CUI [1,1])
C0006147 (UMLS CUI [1,2])
findings
Item
Exceptional findings
text
C0243095 (UMLS CUI [1])
blood group Rh antigen type
Item
1. child blood group and subtype (only for RH-neg.mother; no official document!)
text
C0005810 (UMLS CUI [1,1])
C1287272 (UMLS CUI [1,2])
Item
1. child Direct Coombs test
text
C0200555 (UMLS CUI [1])
Direct Coombs test
Code List
1. child Direct Coombs test
CL Item
neg. (1)
CL Item
pos. (2)
date release child
Item
1. child released (without problems) on
date
C0011008 (UMLS CUI [1,1])
C0030685 (UMLS CUI [1,2])
C0008059 (UMLS CUI [1,3])
date transfer
Item
1. Child transferred on
date
C0011008 (UMLS CUI [1,1])
C0030704 (UMLS CUI [1,2])
date child death
Item
1. Child died on
date
C0011008 (UMLS CUI [1,1])
C0524343 (UMLS CUI [1,2])
blood group Rh antigen type
Item
2. child (twin) blood group and subtype (only for RH-neg.mother; no official document!)
text
C0005810 (UMLS CUI [1,1])
C1287272 (UMLS CUI [1,2])
Item
2. child (twin) Direct Coombs test
text
C0200555 (UMLS CUI [1])
Direct Coombs test
Code List
2. child (twin) Direct Coombs test
CL Item
neg.  (1)
CL Item
pos. (2)
date release child
Item
2. child (twin) released (without problems) on
date
C0011008 (UMLS CUI [1,1])
C0030685 (UMLS CUI [1,2])
C0008059 (UMLS CUI [1,3])
date transfer
Item
2. Child (twin) transferred on
date
C0011008 (UMLS CUI [1,1])
C0030704 (UMLS CUI [1,2])
date child death
Item
2. Child (twin) died on
date
C0011008 (UMLS CUI [1,1])
C0524343 (UMLS CUI [1,2])
date Medical Examination release
Item
Date of release examination
date
C0011008 (UMLS CUI [1,1])
C0582103 (UMLS CUI [1,2])
C0030685 (UMLS CUI [1,3])
Signature
Item
Signature/stamp
text
C1519316 (UMLS CUI [1])
Puerperal Disorders
Item
Abnormalities during puerperium
text
C0034040 (UMLS CUI [1])
Item Group
2. examination after delivery (6th-8th week)
C0582103 (UMLS CUI-1)
C0086839 (UMLS CUI-2)
findings gynecology
Item
Gyn. findings 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])
Item
Urine sugar test
text
C2186571 (UMLS CUI [1])
Direct Coombs test
Code List
Urine sugar test
CL Item
neg.  (1)
CL Item
pos. (2)
Item
Urine protein test
text
C0262923 (UMLS CUI [1])
Abnormalities
Code List
Urine protein test
CL Item
yes (1)
CL Item
no (2)
CL Item
check up (3)
Urinalysis
Item
Urinalysis normal
boolean
C0042014 (UMLS CUI [1])
findings
Item
Special findings
text
C0243095 (UMLS CUI [1])
breastfeeding
Item
Mother is breastfeeding
boolean
C0006147 (UMLS CUI [1])
breastfeed
Item
Did not breastfeed
boolean
C0006147 (UMLS CUI [1])
Weaning
Item
Has weaned child
boolean
C0043084 (UMLS CUI [1])
medical examination child
Item
1. child Examination U3 conducted
boolean
C0582103 (UMLS CUI [1,1])
C0008059 (UMLS CUI [1,2])
child alive healthy
Item
1. child alive and healthy
boolean
C0008059 (UMLS CUI [1,1])
C2584946 (UMLS CUI [1,2])
C3898900 (UMLS CUI [1,3])
therapy medical examination child
Item
1. child requires treatment after pediatric examination U3
boolean
C0087111 (UMLS CUI [1,1])
C0582103 (UMLS CUI [1,2])
C0008059 (UMLS CUI [1,3])
date child death
Item
1. child died on
date
C0011008 (UMLS CUI [1,1])
C0524343 (UMLS CUI [1,2])
medical examination child
Item
2. child (twin) Examination U3 conducted
boolean
C0582103 (UMLS CUI [1,1])
C0008059 (UMLS CUI [1,2])
child alive healthy
Item
2. child (twin) alive and healthy
boolean
C0008059 (UMLS CUI [1,1])
C2584946 (UMLS CUI [1,2])
C3898900 (UMLS CUI [1,3])
therapy medical examination child
Item
2. child (twin) requires treatment after pediatric examination U3
boolean
C0087111 (UMLS CUI [1,1])
C0582103 (UMLS CUI [1,2])
C0008059 (UMLS CUI [1,3])
date child death
Item
2. child (twin) died on
date
C0011008 (UMLS CUI [1,1])
C0524343 (UMLS CUI [1,2])
Examination date
Item
Examination date
date
C2826643 (UMLS CUI [1])
Signature
Item
Signature/stamp
text
C1519316 (UMLS CUI [1])
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