Informationen:
Fehler:
ID
44104
Beschreibung
Routine documentation in German hospitals. Source file name: VL010107_NIH Stroke Scale. Examplary forms provided by DMI (http://www.dmi.de/)
Link
Stichworte
Versionen (4)
- 24.06.17 24.06.17 -
- 31.07.17 31.07.17 -
- 28.11.17 28.11.17 -
- 20.09.21 20.09.21 -
Rechteinhaber
National Institutes of Health
Hochgeladen am
20. September 2021
DOI
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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
- StudyEvent: ODM
Ähnliche Modelle
NIH Stroke Scale Routine documentation in German hospitals DMI
- StudyEvent: ODM
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Patient data
Item
Patient data
text
C2707520 (UMLS CUI [1])
Date
Item
Date
date
C0011008 (UMLS CUI [1])
Day of treatment
Item
Day of treatment
text
C3468389 (UMLS CUI [1])
CL Item
8.00 (8.00)
CL Item
14.00 (14.00)
CL Item
19.00 (19.00)
CL Item
24.00 (24.00)
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
1b Orientation (The patient is asked the month and his/her age)
integer
C0029266 (UMLS CUI [1])
CL Item
Answers both questions correctly. (0)
CL Item
Answers one question correctly. (1)
CL Item
Answers neither question correctly. (2)
Item
1c 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
1c 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)
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)
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)
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
5 Motor function right 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
C0234130 (UMLS CUI [1,1])
C4048756 (UMLS CUI [1,2])
C4048756 (UMLS CUI [1,2])
Code List
5 Motor function right 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
5 Motor function left 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
C0234130 (UMLS CUI [1,1])
C3844326 (UMLS CUI [1,2])
C3844326 (UMLS CUI [1,2])
Code List
5 Motor function left 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
6 Motor function right leg (Hold the leg at 30 degrees. Always tested supine.)
integer
C0234130 (UMLS CUI [1,1])
C0230415 (UMLS CUI [1,2])
C0230415 (UMLS CUI [1,2])
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
6 Motor Leg (Hold the leg at 30 degrees. Always tested supine.)
integer
C0234130 (UMLS CUI [1,1])
C0230416 (UMLS CUI [1,2])
C0230416 (UMLS CUI [1,2])
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)
CL Item
Absent. (0)
CL Item
Present in one limb. (1)
CL Item
Present in two limbs. (2)
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)
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)
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)
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)
NIHSS score
Item
NIHSS score
integer
C1697238 (UMLS CUI [1])
Signature physician
Item
Signature physician
text
C0807938 (UMLS CUI [1])
Print
Item
Print, daily
text
C0033161 (UMLS CUI [1])
Neurologist
Item
Neurologist, daily
text
C0237426 (UMLS CUI [1])
Speech therapy
Item
Speech therapy, daily*
text
C0037831 (UMLS CUI [1])
Occupational therapy
Item
Occupational therapy, daily*
text
C1318464 (UMLS CUI [1])
Physiotherapy
Item
Physiotherapy, daily*
text
C0949766 (UMLS CUI [1])