Informatie:
Fout:
ID
43812
Beschrijving
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/
Trefwoorden
Versies (2)
- 03-02-17 03-02-17 -
- 20-09-21 20-09-21 -
Geüploaded op
20 september 2021
DOI
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Licentie
Creative Commons BY-NC 3.0
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German Maternity Records G-BA
Final examination/discharge summary
Similar models
Final examination/discharge summary
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
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])
C0033052 (UMLS CUI [1,2])
visit hospital
Item
Presented in hospital before delivery
boolean
C0545082 (UMLS CUI [1,1])
C0019994 (UMLS CUI [1,2])
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])
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])
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])
C3844314 (UMLS CUI [1,2])
live birth
Item
1. child live birth
boolean
C0481667 (UMLS CUI [1])
CL Item
male (1)
CL Item
female (2)
CL Item
V (1)
CL Item
CS (2)
CL Item
Assisted vag. birth (3)
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])
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])
CL Item
male (1)
CL Item
female (2)
CL Item
V (1)
CL Item
CS (2)
CL Item
Assisted vag. birth (3)
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])
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])
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])
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])
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])
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])
C1287272 (UMLS CUI [1,2])
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])
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])
C0030704 (UMLS CUI [1,2])
date child death
Item
1. Child died on
date
C0011008 (UMLS CUI [1,1])
C0524343 (UMLS CUI [1,2])
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])
C1287272 (UMLS CUI [1,2])
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])
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])
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])
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])
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)
C0086839 (UMLS CUI-2)
findings gynecology
Item
Gyn. findings normal
boolean
C0243095 (UMLS CUI [1,1])
C0018417 (UMLS CUI [1,2])
C0018417 (UMLS CUI [1,2])
hemoglobin
Item
Hb
float
C0518015 (UMLS CUI [1])
Blood pressure
Item
RR
text
C0005823 (UMLS CUI [1])
CL Item
neg. (1)
CL Item
pos. (2)
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])
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])
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])
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])
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])
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])
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])
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])
C0524343 (UMLS CUI [1,2])
Examination date
Item
Examination date
date
C2826643 (UMLS CUI [1])
Signature
Item
Signature/stamp
text
C1519316 (UMLS CUI [1])