ID

43974

Description

Routine documentation in German hospitals. Source file name: VL010107_NIH Stroke Scale. Examplary forms provided by DMI (http://www.dmi.de/)

Link

http://www.dmi.de/

Keywords

  1. 6/24/17 6/24/17 -
  2. 7/31/17 7/31/17 -
  3. 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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NIH Stroke Scale Routine documentation in German hospitals DMI

NIH Stroke Scale Routine documentation in German hospitals DMI

Patient
Description

Patient

Alias
UMLS CUI-1
C1299487
Patient name
Description

Patient name

Data type

text

Alias
UMLS CUI [1]
C1299487
NIH Stroke Scale
Description

NIH Stroke Scale

Alias
UMLS CUI-1
C1697238
Day
Description

Day

Data type

text

Alias
UMLS CUI [1]
C0439228
Date
Description

Date

Data type

date

Alias
UMLS CUI [1]
C0011008
Scheduled time
Description

Scheduled time

Data type

integer

Alias
UMLS CUI [1,1]
C0040223
UMLS CUI [1,2]
C1301732
Level of consciousness
Description

Level of consciousness

Data type

integer

Alias
UMLS CUI [1]
C2234452
Orientation (date, age)
Description

Orientation

Data type

integer

Alias
UMLS CUI [1]
C0029266
Attention (patient is asked to open and close the eyes and then to grip and release the non-paretic Hand)
Description

Attention

Data type

integer

Alias
UMLS CUI [1]
C3649005
Visual field
Description

Visual field

Data type

integer

Alias
UMLS CUI [1]
C0042826
Gaze
Description

Eye movements

Data type

integer

Alias
UMLS CUI [1]
C0015413
Facial Palsy
Description

Facial paresis

Data type

integer

Alias
UMLS CUI [1]
C0427055
Motor Arm (Extend the arms (palms down) 90 degrees (if sitting) or 45 degrees (if supine). Drift is scored if the arm falls before 10 seconds.)
Description

Motor Arm

Data type

integer

Alias
UMLS CUI [1]
C3476118
Motor Leg (Hold the leg at 30 degrees. Always tested supine.)
Description

Motor Leg

Data type

integer

Alias
UMLS CUI [1]
C3476119
Limb Ataxia
Description

Extremity ataxia

Data type

integer

Alias
UMLS CUI [1]
C4015302
Sensory
Description

Sensibilities

Data type

integer

Alias
UMLS CUI [1]
C0439823
Extinction and Inattention
Description

Formerly Neglect.

Data type

integer

Alias
UMLS CUI [1]
C0452129
Dysarthria
Description

Dysarthria

Data type

integer

Alias
UMLS CUI [1]
C0013362
Language
Description

Speech

Data type

integer

Alias
UMLS CUI [1]
C0037817
NIHSS score
Description

NIHSS score

Data type

integer

Alias
UMLS CUI [1]
C1697238
Initials
Description

Initials

Data type

text

Alias
UMLS CUI [1]
C2986440
Actual time
Description

Actual time

Data type

time

Alias
UMLS CUI [1]
C0040223

Similar models

NIH Stroke Scale Routine documentation in German hospitals DMI

Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Patient
C1299487 (UMLS CUI-1)
Patient name
Item
Patient name
text
C1299487 (UMLS CUI [1])
Item Group
NIH Stroke Scale
C1697238 (UMLS CUI-1)
Item
Day
text
C0439228 (UMLS CUI [1])
Code List
Day
CL Item
Day 2 (Day 2)
CL Item
Day 3 (Day 3)
CL Item
Day 4 (Day 4)
CL Item
Day 1 (Day 1)
Date
Item
Date
date
C0011008 (UMLS CUI [1])
Item
Scheduled time
integer
C0040223 (UMLS CUI [1,1])
C1301732 (UMLS CUI [1,2])
Code List
Scheduled time
CL Item
08 (08)
CL Item
14 (14)
CL Item
20 (20)
CL Item
24 (24)
Item
Level of consciousness
integer
C2234452 (UMLS CUI [1])
Code List
Level of consciousness
CL Item
Alert; keenly responsive (0)
CL Item
Not alert; but arousable by minor stimulation to obey, answer, or respond. (1)
CL Item
Not alert; requires repeated stimulation to attend, or is obtunded and requires strong or painful stimulation to make movements (not stereotyped). (2)
CL Item
Responds only with reflex motor or autonomic effects, or totally unresponsive, flaccid, and areflexic. (3)
Item
Orientation (date, age)
integer
C0029266 (UMLS CUI [1])
Code List
Orientation (date, age)
CL Item
Answers both questions correctly. (0)
CL Item
Answers one question correctly. (1)
CL Item
Answers neither question correctly. (2)
Item
Attention (patient is asked to open and close the eyes and then to grip and release the non-paretic Hand)
integer
C3649005 (UMLS CUI [1])
Code List
Attention (patient is asked to open and close the eyes and then to grip and release the non-paretic Hand)
CL Item
Performs both tasks correctly. (0)
CL Item
Performs one task correctly. (1)
CL Item
Performs neither task correctly. (2)
Item
Visual field
integer
C0042826 (UMLS CUI [1])
Code List
Visual field
CL Item
No visual loss. (0)
CL Item
Partial hemianopia (1)
CL Item
Complete hemianopia. (2)
CL Item
Bilateral hemianopia (blind including cortical blindness). (3)
Item
Gaze
integer
C0015413 (UMLS CUI [1])
Code List
Gaze
CL Item
Normal. (0)
CL Item
Partial gaze palsy; gaze is abnormal in one or both eyes, but forced deviation or total gaze paresis is not present. (1)
CL Item
Forced deviation, or total gaze paresis is not overcome by the oculocephalic maneuver. (2)
Item
Facial Palsy
integer
C0427055 (UMLS CUI [1])
Code List
Facial Palsy
CL Item
Normal symmetrical movements. (0)
CL Item
Minor paralysis (flattened nasolabial fold, asymmetry on smiling). (1)
CL Item
Partial paralysis (total or near-total paralysis of lower face). (2)
CL Item
Complete paralysis of one or both sides (absence of facial movement in the upper and lower face). (3)
Item
Motor Arm (Extend the arms (palms down) 90 degrees (if sitting) or 45 degrees (if supine). Drift is scored if the arm falls before 10 seconds.)
integer
C3476118 (UMLS CUI [1])
Code List
Motor Arm (Extend the arms (palms down) 90 degrees (if sitting) or 45 degrees (if supine). Drift is scored if the arm falls before 10 seconds.)
CL Item
No drift; limb holds 90 (or 45) degrees for full 10 seconds. (0)
CL Item
Drift; limb holds 90 (or 45) degrees, but drifts down before full 10 seconds; does not hit bed or other support. (1)
CL Item
Some effort against gravity; limb cannot get to or maintain (if cued) 90 (or 45) degrees, drifts down to bed, but has some effort against gravity. (2)
CL Item
No effort against gravity; limb falls. (3)
CL Item
No movement. (4)
Item
Motor Leg (Hold the leg at 30 degrees. Always tested supine.)
integer
C3476119 (UMLS CUI [1])
Code List
Motor Leg (Hold the leg at 30 degrees. Always tested supine.)
CL Item
No drift; leg holds 30-degree position for full 5 seconds. (0)
CL Item
Drift; leg falls by the end of the 5- second period but does not hit the bed. (1)
CL Item
Some effort against gravity; leg falls to bed by 5 seconds but has some effort against gravity. (2)
CL Item
No effort against gravity; leg falls to bed immediately. (3)
CL Item
No movement. (4)
Item
Limb Ataxia
integer
C4015302 (UMLS CUI [1])
Code List
Limb Ataxia
CL Item
Absent. (0)
CL Item
Present in one limb. (1)
CL Item
Present in two limbs. (2)
Item
Sensory
integer
C0439823 (UMLS CUI [1])
Code List
Sensory
CL Item
Normal; no sensory loss. (0)
CL Item
Mild-to-moderate sensory loss; patient feels pinprick is less sharp or is dull on the affected side; or there is a loss of superficial pain with pinprick, but patient is aware of being touched. (1)
CL Item
Severe or total sensory loss; patient is not aware of being touched in the face, arm, and leg. (2)
Item
Extinction and Inattention
integer
C0452129 (UMLS CUI [1])
Code List
Extinction and Inattention
CL Item
No abnormality. (0)
CL Item
Visual, tactile, auditory, spatial, or personal inattention, or extinction to bilateral simultaneous stimulation in one of the sensory modalities. (1)
CL Item
Profound hemi-inattention or extinction to more than one modality; does not recognize own hand or orients to only one side of space. (2)
Item
Dysarthria
integer
C0013362 (UMLS CUI [1])
Code List
Dysarthria
CL Item
Normal; clear and smooth speech (0)
CL Item
Mild-to-moderate dysarthria; some slurring of speech, however the patient can be understood (1)
CL Item
Severe dysarthria; patient's speech is so slurred as to be unintelligible in the absence of or out of proportion to any dysphasia, or is mute/anarthric. (2)
Item
Language
integer
C0037817 (UMLS CUI [1])
Code List
Language
CL Item
No aphasia; normal. (0)
CL Item
Mild-to-moderate aphasia; detectable loss in fluency, however, the examiner should still be able to extract information from patient´s speech. (1)
CL Item
Severe aphasia; all speech is fragmented, and examiner is unable to extract the figure´s content from the patients speech. (2)
CL Item
Mute, global aphasia; no usable speech or auditory comprehension. (3)
NIHSS score
Item
NIHSS score
integer
C1697238 (UMLS CUI [1])
Initials
Item
Initials
text
C2986440 (UMLS CUI [1])
Actual time
Item
Actual time
time
C0040223 (UMLS CUI [1])

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