Birth sheet, obstetric sheet Routine documentation in German hospitals DMI

Allgemeine Informationen
Description

Allgemeine Informationen

Alias
UMLS CUI-1
C1508263
Krankenkasse
Description

Health insurance

Data type

text

Alias
UMLS CUI [1]
C0021682
Einweisender Arzt
Description

Referring physician

Data type

text

Alias
UMLS CUI [1]
C1709880
Tel.:
Description

telephone number Referring physician

Data type

integer

Alias
UMLS CUI [1,1]
C1515258
UMLS CUI [1,2]
C1709880
Facharzt
Description

specialist

Data type

text

Alias
UMLS CUI [1]
C2348234
Tel.:
Description

telephone number Medical specialist

Data type

integer

Alias
UMLS CUI [1,1]
C1515258
UMLS CUI [1,2]
C1515258
Anamnese
Description

Medical history

Data type

text

Alias
UMLS CUI [1]
C0262926
Erhoben von
Description

Person taking medical history

Data type

text

Alias
UMLS CUI [1,1]
C0025084
UMLS CUI [1,2]
C3476341
Datum
Description

Date

Data type

date

Alias
UMLS CUI [1]
C0011008
Anamnese
Description

Anamnese

Alias
UMLS CUI-1
C0262926
Familienanamnese
Description

Family history

Data type

text

Alias
UMLS CUI [1]
C0241889
keine Besonderheiten
Description

specifics

Data type

boolean

Alias
UMLS CUI [1]
C2348235
Sozialanamnese
Description

Social history

Data type

text

Alias
UMLS CUI [1]
C3714536
Beruf der Mutter
Description

Occupation of mother

Data type

text

Alias
UMLS CUI [1]
C0337613
Beruf des Vaters
Description

Occupation father

Data type

text

Alias
UMLS CUI [1,1]
C0028811
UMLS CUI [1,2]
C0015671
Eigene Anamnese
Description

medical history

Data type

text

Alias
UMLS CUI [1]
C0262926
Allergie
Description

Allergy

Data type

text

Alias
UMLS CUI [1]
C0020517
Medikamente
Description

Medication

Data type

text

Alias
UMLS CUI [1]
C0013227
Nikotin
Description

Nicotine

Data type

text

Alias
UMLS CUI [1]
C0028040
Alkohol
Description

Alcohol

Data type

text

Alias
UMLS CUI [1]
C0001948
Besonderheiten
Description

Specifics

Data type

text

Alias
UMLS CUI [1]
C2348235
Untersuchung
Description

Untersuchung

Alias
UMLS CUI-1
C0582103
Aufnahmestatus
Description

Admission statuses

Data type

text

Alias
UMLS CUI [1]
C0586002
Herz
Description

Heart

Data type

text

Alias
UMLS CUI [1]
C0018787
Lunge
Description

Lungs

Data type

text

Alias
UMLS CUI [1]
C0024109
Abdomen
Description

Abdomen

Data type

text

Alias
UMLS CUI [1]
C0000726
Allgemeinbefunde
Description

Allgemeinbefunde

Alias
UMLS CUI-1
C0243095
Blutgruppe
Description

Blood type

Data type

text

Alias
UMLS CUI [1]
C0005810
Rh Faktor
Description

Rh factor

Data type

text

Alias
UMLS CUI [1]
C0035403
Antikörper
Description

Antibodies

Data type

text

Alias
UMLS CUI [1]
C0003241
Röteln-Titer
Description

Rubella titer

Data type

text

Alias
UMLS CUI [1]
C0474654
HbsAG
Description

HbsAG

Data type

text

Alias
UMLS CUI [1]
C0201477
Größe
Description

Height

Data type

text

Alias
UMLS CUI [1]
C0005890
Gewicht
Description

Weight

Data type

text

Alias
UMLS CUI [1]
C0005910
Ödeme
Description

Edema

Data type

text

Alias
UMLS CUI [1]
C0013604
Varizen
Description

Varices

Data type

text

Alias
UMLS CUI [1]
C0042345
Urinstix
Description

Urine test strip

Data type

text

Alias
UMLS CUI [1]
C0462956
HIV
Description

HIV

Data type

text

Alias
UMLS CUI [1]
C0019682
Hep C
Description

Hepatitis C

Data type

text

Alias
UMLS CUI [1]
C0019196
Jetzige Schwangerschaft Zyklusanamnese
Description

Jetzige Schwangerschaft Zyklusanamnese

Alias
UMLS CUI-1
C0747843
Letzte Periode
Description

period

Data type

text

Alias
UMLS CUI [1]
C0025344
ET
Description

Estimated due date

Data type

date

Alias
UMLS CUI [1]
C2825543
Konz. Termin n. USD
Description

Date of conception ultrasonography

Data type

date

Alias
UMLS CUI [1,1]
C1317261
UMLS CUI [1,2]
C0041618
SSW
Description

Week of gestation

Data type

text

Alias
UMLS CUI [1]
C1135241
Jetzige Schwangerschaft Komplikationen
Description

Jetzige Schwangerschaft Komplikationen

Alias
UMLS CUI-1
C0747843
UMLS CUI-2
C0009566
Komplikationen + Krankheiten der jetzigen Schwangerschaft
Description

Current pregnancy complications

Data type

text

Alias
UMLS CUI [1,1]
C0747843
UMLS CUI [1,2]
C0009566
Stat. Behandlung
Description

In-patient treatment

Data type

text

Alias
UMLS CUI [1]
C0021562
Warum?
Description

reason

Data type

text

Alias
UMLS CUI [1]
C0392360
Bis:
Description

therapy duration

Data type

date

Alias
UMLS CUI [1]
C0444921
Therapie
Description

therapy

Data type

text

Alias
UMLS CUI [1]
C0087111

Similar models

Birth sheet, obstetric sheet Routine documentation in German hospitals DMI

Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Allgemeine Informationen
C1508263 (UMLS CUI-1)
Health insurance
Item
Krankenkasse
text
C0021682 (UMLS CUI [1])
Referring physician
Item
Einweisender Arzt
text
C1709880 (UMLS CUI [1])
telephone number Referring physician
Item
Tel.:
integer
C1515258 (UMLS CUI [1,1])
C1709880 (UMLS CUI [1,2])
specialist
Item
Facharzt
text
C2348234 (UMLS CUI [1])
telephone number Medical specialist
Item
Tel.:
integer
C1515258 (UMLS CUI [1,1])
C1515258 (UMLS CUI [1,2])
Medical history
Item
Anamnese
text
C0262926 (UMLS CUI [1])
Person taking medical history
Item
Erhoben von
text
C0025084 (UMLS CUI [1,1])
C3476341 (UMLS CUI [1,2])
Date
Item
Datum
date
C0011008 (UMLS CUI [1])
Item Group
Anamnese
C0262926 (UMLS CUI-1)
Family history
Item
Familienanamnese
text
C0241889 (UMLS CUI [1])
specifics
Item
keine Besonderheiten
boolean
C2348235 (UMLS CUI [1])
Social history
Item
Sozialanamnese
text
C3714536 (UMLS CUI [1])
Occupation of mother
Item
Beruf der Mutter
text
C0337613 (UMLS CUI [1])
Occupation father
Item
Beruf des Vaters
text
C0028811 (UMLS CUI [1,1])
C0015671 (UMLS CUI [1,2])
medical history
Item
Eigene Anamnese
text
C0262926 (UMLS CUI [1])
Allergy
Item
Allergie
text
C0020517 (UMLS CUI [1])
Medication
Item
Medikamente
text
C0013227 (UMLS CUI [1])
Nicotine
Item
Nikotin
text
C0028040 (UMLS CUI [1])
Alcohol
Item
Alkohol
text
C0001948 (UMLS CUI [1])
Specifics
Item
Besonderheiten
text
C2348235 (UMLS CUI [1])
Item Group
Untersuchung
C0582103 (UMLS CUI-1)
Admission statuses
Item
Aufnahmestatus
text
C0586002 (UMLS CUI [1])
Heart
Item
Herz
text
C0018787 (UMLS CUI [1])
Lungs
Item
Lunge
text
C0024109 (UMLS CUI [1])
Abdomen
Item
Abdomen
text
C0000726 (UMLS CUI [1])
Item Group
Allgemeinbefunde
C0243095 (UMLS CUI-1)
Blood type
Item
Blutgruppe
text
C0005810 (UMLS CUI [1])
Rh factor
Item
Rh Faktor
text
C0035403 (UMLS CUI [1])
Antibodies
Item
Antikörper
text
C0003241 (UMLS CUI [1])
Rubella titer
Item
Röteln-Titer
text
C0474654 (UMLS CUI [1])
HbsAG
Item
HbsAG
text
C0201477 (UMLS CUI [1])
Height
Item
Größe
text
C0005890 (UMLS CUI [1])
Weight
Item
Gewicht
text
C0005910 (UMLS CUI [1])
Edema
Item
Ödeme
text
C0013604 (UMLS CUI [1])
Varices
Item
Varizen
text
C0042345 (UMLS CUI [1])
Urine test strip
Item
Urinstix
text
C0462956 (UMLS CUI [1])
HIV
Item
HIV
text
C0019682 (UMLS CUI [1])
Hepatitis C
Item
Hep C
text
C0019196 (UMLS CUI [1])
Item Group
Jetzige Schwangerschaft Zyklusanamnese
C0747843 (UMLS CUI-1)
period
Item
Letzte Periode
text
C0025344 (UMLS CUI [1])
Estimated due date
Item
ET
date
C2825543 (UMLS CUI [1])
Date of conception ultrasonography
Item
Konz. Termin n. USD
date
C1317261 (UMLS CUI [1,1])
C0041618 (UMLS CUI [1,2])
Week of gestation
Item
SSW
text
C1135241 (UMLS CUI [1])
Item Group
Jetzige Schwangerschaft Komplikationen
C0747843 (UMLS CUI-1)
C0009566 (UMLS CUI-2)
Current pregnancy complications
Item
Komplikationen + Krankheiten der jetzigen Schwangerschaft
text
C0747843 (UMLS CUI [1,1])
C0009566 (UMLS CUI [1,2])
In-patient treatment
Item
Stat. Behandlung
text
C0021562 (UMLS CUI [1])
reason
Item
Warum?
text
C0392360 (UMLS CUI [1])
therapy duration
Item
Bis:
date
C0444921 (UMLS CUI [1])
therapy
Item
Therapie
text
C0087111 (UMLS CUI [1])