ID

44682

Description

Head injury admission form converted to ODM format. Routine documentation of University Hospital of Münster.

Keywords

  1. 1/2/17 1/2/17 -
  2. 9/27/21 9/27/21 -
Copyright Holder

UKM

Uploaded on

September 27, 2021

DOI

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License

Creative Commons BY-NC 3.0

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Pediatric surgery UKM

Head injury admission form

Patientendaten
Description

Patientendaten

Name
Description

Patient name

Data type

integer

Alias
UMLS CUI [1]
C1299487
Geburtsdatum
Description

Patient date of birth

Data type

date

Alias
UMLS CUI [1]
C0421451
Krankenversicherung
Description

Health insurance

Data type

integer

Alias
UMLS CUI [1]
C0021682
Geschlecht
Description

Gender

Data type

integer

Alias
UMLS CUI [1]
C0079399
Glasgow coma scale
Description

Glasgow coma scale

Augen öffnen
Description

Eye response

Data type

integer

Alias
UMLS CUI [1]
C4086337
verbale Reaktion
Description

Verbal response

Data type

integer

Alias
UMLS CUI [1]
C2830372
motorische Reaktion
Description

Motor response

Data type

integer

Alias
UMLS CUI [1]
C0559290
Ergebnis GCS
Description

Glasgow coma score finding

Data type

integer

Alias
UMLS CUI [1]
C1271007
Untersuchung
Description

Untersuchung

Prellmarke frontal
Description

Contusion frontal surface of scalp

Data type

boolean

Alias
UMLS CUI [1]
C2104819
Prellmarke temporal
Description

Contusion mark temporal

Data type

boolean

Alias
UMLS CUI [1]
C1393928
Prellmarke parietal
Description

Contusion region parietal

Data type

boolean

Alias
UMLS CUI [1]
C1393911
Prellmarke occipital
Description

Contusion region occipital

Data type

boolean

Alias
UMLS CUI [1]
C1393907
Bewusstlosigkeit
Description

Coma

Data type

boolean

Alias
UMLS CUI [1]
C0041657
Neurologie o.B.
Description

Neurology examination finding NAD

Data type

boolean

Alias
UMLS CUI [1,1]
C0438117
UMLS CUI [1,2]
C0559229
Pupillmotorik o.B.
Description

Pupil motoric

Data type

boolean

Alias
UMLS CUI [1]
C0946327
Pupillendifferenz
Description

Anisocoria

Data type

boolean

Alias
UMLS CUI [1]
C0003079
Liquorrhoe
Description

Liquorrhea

Data type

boolean

Alias
UMLS CUI [1]
C0860578
Hämatotympanon
Description

Haematotympanum

Data type

boolean

Alias
UMLS CUI [1]
C0019125
mental o.B.
Description

Mental health

Data type

boolean

Alias
UMLS CUI [1]
C0025353
Erbrechen
Description

Vomiting

Data type

boolean

Alias
UMLS CUI [1]
C0042963
Kopfschmerzen
Description

Headache

Data type

boolean

Alias
UMLS CUI [1]
C0018681
Stationäre Aufnahme
Description

Hospital admission

Data type

boolean

Alias
UMLS CUI [1]
C0420279

Similar models

Head injury admission form

Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Patientendaten
Patient name
Item
Name
integer
C1299487 (UMLS CUI [1])
Patient date of birth
Item
Geburtsdatum
date
C0421451 (UMLS CUI [1])
Health insurance
Item
Krankenversicherung
integer
C0021682 (UMLS CUI [1])
Item
Geschlecht
integer
C0079399 (UMLS CUI [1])
Code List
Geschlecht
CL Item
m (1)
C0086582 (UMLS CUI-1)
CL Item
f (2)
C0086287 (UMLS CUI-1)
Item Group
Glasgow coma scale
Item
Augen öffnen
integer
C4086337 (UMLS CUI [1])
Code List
Augen öffnen
CL Item
keine Reaktion (1)
C0551549 (UMLS CUI-1)
CL Item
auf Schmerzreiz  (2)
C0551549 (UMLS CUI-1)
CL Item
Oauf Ansprechen  (3)
C0551549 (UMLS CUI-1)
CL Item
spontan (4)
C0551549 (UMLS CUI-1)
Item
verbale Reaktion
integer
C2830372 (UMLS CUI [1])
Code List
verbale Reaktion
CL Item
keine Reaktion  (1)
C2012060 (UMLS CUI-1)
CL Item
Stöhnen / unklare Laute (2)
C2012057 (UMLS CUI-1)
CL Item
Schreien untröstbar (3)
C2012058 (UMLS CUI-1)
CL Item
Schreien tröstbar  (4)
C2012056 (UMLS CUI-1)
CL Item
plappern, brabbeln (5)
C2012059 (UMLS CUI-1)
Item
motorische Reaktion
integer
C0559290 (UMLS CUI [1])
Code List
motorische Reaktion
CL Item
keine Reaktion (1)
C2012054 (UMLS CUI-1)
CL Item
Strecksynergismen (2)
C2012050 (UMLS CUI-1)
CL Item
Beugesynergismen (3)
C2012051 (UMLS CUI-1)
CL Item
Massenbewegung  (4)
C2012052 (UMLS CUI-1)
CL Item
gezielte Abwehr (5)
C2012055 (UMLS CUI-1)
CL Item
befolgt Aufforderung (6)
C2012055 (UMLS CUI-1)
Glasgow coma score finding
Item
Ergebnis GCS
integer
C1271007 (UMLS CUI [1])
Item Group
Untersuchung
Contusion frontal surface of scalp
Item
Prellmarke frontal
boolean
C2104819 (UMLS CUI [1])
Contusion mark temporal
Item
Prellmarke temporal
boolean
C1393928 (UMLS CUI [1])
Contusion region parietal
Item
Prellmarke parietal
boolean
C1393911 (UMLS CUI [1])
Contusion region occipital
Item
Prellmarke occipital
boolean
C1393907 (UMLS CUI [1])
Coma
Item
Bewusstlosigkeit
boolean
C0041657 (UMLS CUI [1])
Neurology examination finding NAD
Item
Neurologie o.B.
boolean
C0438117 (UMLS CUI [1,1])
C0559229 (UMLS CUI [1,2])
Pupil motoric
Item
Pupillmotorik o.B.
boolean
C0946327 (UMLS CUI [1])
Anisocoria
Item
Pupillendifferenz
boolean
C0003079 (UMLS CUI [1])
Liquorrhea
Item
Liquorrhoe
boolean
C0860578 (UMLS CUI [1])
Haematotympanum
Item
Hämatotympanon
boolean
C0019125 (UMLS CUI [1])
Mental health
Item
mental o.B.
boolean
C0025353 (UMLS CUI [1])
Vomiting
Item
Erbrechen
boolean
C0042963 (UMLS CUI [1])
Headache
Item
Kopfschmerzen
boolean
C0018681 (UMLS CUI [1])
Hospital admission
Item
Stationäre Aufnahme
boolean
C0420279 (UMLS CUI [1])

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