ID

10046

Description

Documentation form for quality assurance in German Health Care by the institute forapplied quality Improvement and Research in Health Care (Aqua), https://www.aqua-institut.de/en/home. Internal Aqua form version: 17-1 Specification 2015 V02

Link

https://www.aqua-institut.de/en/home

Keywords

  1. 11/23/14 11/23/14 - Julian Varghese
  2. 3/21/15 3/21/15 - Sarah Schulze Sünninghausen
Uploaded on

March 21, 2015

DOI

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License

Creative Commons BY-NC 3.0 Legacy

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Quality assurance Hip Fracture with Osteosynthesis (AQUA)

Quality assurance Hip Fracture with Osteosynthesis (AQUA)

Test
Description

Test

Anamnesis / diagnosis
Description

Anamnesis / diagnosis

ASA classification
Description

ASA classification

Data type

integer

Alias
UMLS CUI-1
C1531480
Wound contamination classifcation of procedure
Description

Wound contamination classifcation of procedure

Data type

integer

Alias
UMLS CUI-1
C1629491
fracture localization
Description

fracture localization

Data type

integer

Alias
UMLS CUI-1
C0475264
femoral fracture near hip - classification by garden
Description

femoral fracture near hip - classification by garden

Data type

integer

Alias
UMLS CUI-1
C0441821
pre-existing coxarthrosis
Description

pre-existing coxarthrosis

Data type

boolean

Alias
UMLS CUI-1
C0029410
Patient was admitted with antithrombotic Extended therapy
Description

Patient was admitted with antithrombotic Extended therapy

Data type

boolean

Type of medication
Description

Type of medication

Data type

integer

Alias
UMLS CUI-1
C1704311
Operation
Description

Operation

Surgical operation date
Description

Surgical operation date

Data type

date

Alias
UMLS CUI-1
C3258210
Time starting surgery (hh:mm)
Description

Time starting surgery (hh:mm)

Data type

text

Alias
UMLS CUI-1
C0944781
Operation
Description

Operation

Data type

integer

Alias
UMLS CUI-1
C0543467
Procedure Duration (in minutes)
Description

Procedure Duration (in minutes)

Data type

integer

Measurement units
  • Minuten
Alias
UMLS CUI-1
C1442476
Minuten
perioperative antibiotic prophylaxis
Description

perioperative antibiotic prophylaxis

Data type

integer

Alias
UMLS CUI-1
C0282638
Operative procedures
Description

Operative procedures

Data type

integer

Alias
UMLS CUI-1
C1550373
Intra- and postoperative course
Description

Intra- and postoperative course

postoperative plain x-ray a/p
Description

postoperative plain x-ray a/p

Data type

boolean

Alias
UMLS CUI-1
C1306645
postoperative radiograph axially or Lauenstein
Description

postoperative radiograph axially or Lauenstein

Data type

boolean

Alias
UMLS CUI-1
C0442269
UMLS CUI-2
C1302237
requiring treatment intra- / postoperative surgical complication (s)
Description

requiring treatment intra- / postoperative surgical complication (s)

Data type

boolean

Alias
UMLS CUI-1
C0021890
UMLS CUI-2
C0032787
Implant malposition
Description

Implant malposition

Data type

integer

Alias
UMLS CUI-1
C0333042
implant dislocation
Description

implant dislocation

Data type

integer

Alias
UMLS CUI-1
C2183848
Wound hematoma / rebleedinghemorrhage
Description

Wound hematoma / rebleedinghemorrhage

Data type

integer

Alias
UMLS CUI-1
C0281860
vascular lesion
Description

vascular lesion

Data type

integer

Alias
UMLS CUI-1
C1402315
Nerve injury
Description

Nerve injury

Data type

integer

Alias
UMLS CUI-1
C0161479
fracture
Description

fracture

Data type

integer

Alias
UMLS CUI-1
C0016658
other
Description

other

Data type

integer

postoperative wound infection
Description

postoperative wound infection

Data type

boolean

Alias
UMLS CUI-1
C1629491
CDC-classification
Description

CDC-classification

Data type

integer

Required repeat Surgery because of complication (s)
Description

Required repeat Surgery because of complication (s)

Data type

boolean

Alias
UMLS CUI-1
C0035110
general postoperative complication (s) needed of treatment
Description

general postoperative complication (s) needed of treatment

Data type

boolean

Alias
UMLS CUI-1
C0032787
Pneumonia
Description

Pneumonia

Data type

integer

Alias
UMLS CUI-1
C0032285
cardiovascular complication (s)
Description

cardiovascular complication (s)

Data type

integer

Alias
UMLS CUI-1
C0032963
deep leg/pelvic vein thrombosis
Description

deep leg/pelvic vein thrombosis<

Data type

integer

Alias
UMLS CUI-1
C0149871
pulmonary embolism
Description

pulmonary embolism

Data type

integer

Alias
UMLS CUI-1
C0034065
other
Description

other

Data type

integer

Discharge
Description

Discharge

independent walking possible at discharge
Description

independent walking possible at discharge

Data type

boolean

Alias
UMLS CUI-1
C0429979
Walking independently prior to the fracture?
Description

Walking independently prior to the fracture?

Data type

boolean

self care in the daily hygiene possible at discharge
Description

self care in the daily hygiene possible at discharge

Data type

boolean

Alias
UMLS CUI-1
C0518462
independently in daily hygiene prior to fracture?
Description

independently in daily hygiene prior to fracture?

Data type

boolean

Hostpital discharge date (DD.MM.YYYY)
Description

Hostpital discharge date (DD.MM.YYYY)

Data type

date

Alias
UMLS CUI-1
C2710998
Discharge diagnoses
Description

Discharge diagnoses

Data type

integer

Alias
UMLS CUI-1
C0011900
Reason for Discharge
Description

Reason for Discharge

Data type

integer

Alias
UMLS CUI-1
C3164834

Similar models

Quality assurance Hip Fracture with Osteosynthesis (AQUA)

Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Item Group
Anamnesis / diagnosis
Item
ASA classification
integer
C1531480 (UMLS CUI-1)
Code List
ASA classification
CL Item
normal healthy patient (1)
CL Item
patient with mild systemic disease (2)
CL Item
patient with severe systemic disease (3)
CL Item
patient with severe systemic disease that is a constant threat to life (4)
CL Item
moribund patient who is not expected to survive without the operation (5)
Item
Wound contamination classifcation of procedure
integer
C1629491 (UMLS CUI-1)
Code List
Wound contamination classifcation of procedure
CL Item
aseptic procedure (1)
CL Item
partially aseptic procedure (2)
CL Item
procedure with contamination (3)
CL Item
septic procedure (4)
Item
fracture localization
integer
C0475264 (UMLS CUI-1)
Code List
fracture localization
CL Item
medial (1)
CL Item
lateral (2)
CL Item
pertrochantär (3)
CL Item
other (9)
Item
femoral fracture near hip - classification by garden
integer
C0441821 (UMLS CUI-1)
Code List
femoral fracture near hip - classification by garden
CL Item
abduction fracture (1)
CL Item
unshifted (2)
CL Item
shifted (3)
CL Item
completely shifted (4)
vorbestehende Koxarthrose
Item
pre-existing coxarthrosis
boolean
C0029410 (UMLS CUI-1)
Patient wurde mit antithrombotischer Dauertherapie aufgenommen
Item
Patient was admitted with antithrombotic Extended therapy
boolean
Item
Type of medication
integer
C1704311 (UMLS CUI-1)
Code List
Type of medication
CL Item
vitamin K antagonists (eg phenprocoumon, warfarin) (1)
CL Item
acetylsalicylic acid (2)
CL Item
other antiplatelet agents (eg clopidogrel, prasugrel, ticagrelor, cilostazol) (3)
CL Item
direct thrombin inhibitors (eg argatroban, dabigatran) (4)
CL Item
other (eg rivaroxaban, fondaparinux) (9)
Item Group
Operation
OP-Datum (TT.MM.JJJJ)
Item
Surgical operation date
date
C3258210 (UMLS CUI-1)
Uhrzeit OP-Beginn
Item
Time starting surgery (hh:mm)
text
C0944781 (UMLS CUI-1)
Operation
Item
Operation
integer
C0543467 (UMLS CUI-1)
Dauer des Eingriffs
Item
Procedure Duration (in minutes)
integer
C1442476 (UMLS CUI-1)
Item
perioperative antibiotic prophylaxis
integer
C0282638 (UMLS CUI-1)
Code List
perioperative antibiotic prophylaxis
CL Item
no (0)
CL Item
single shot (1)
CL Item
second dose (2)
CL Item
more often (3)
Item
Operative procedures
integer
C1550373 (UMLS CUI-1)
Code List
Operative procedures
CL Item
DHS, angle plate (1)
CL Item
intramedullary stabilization (eg, PFN, gamma nail) (2)
CL Item
Tightening (3)
CL Item
other (9)
Item Group
Intra- and postoperative course
postoperatives Röntgenbild a/p
Item
postoperative plain x-ray a/p
boolean
C1306645 (UMLS CUI-1)
postoperatives Röntgenbild axial oder Lauenstein
Item
postoperative radiograph axially or Lauenstein
boolean
C0442269 (UMLS CUI-1)
C1302237 (UMLS CUI-2)
behandlungsbedürftige intra-/postoperative chirurgische Komplikation(en)
Item
requiring treatment intra- / postoperative surgical complication (s)
boolean
C0021890 (UMLS CUI-1)
C0032787 (UMLS CUI-2)
Item
Implant malposition
integer
C0333042 (UMLS CUI-1)
Code List
Implant malposition
CL Item
yes (1)
Item
implant dislocation
integer
C2183848 (UMLS CUI-1)
Code List
implant dislocation
CL Item
yes (1)
Item
Wound hematoma / rebleedinghemorrhage
integer
C0281860 (UMLS CUI-1)
Code List
Wound hematoma / rebleedinghemorrhage
CL Item
yes (1)
Item
vascular lesion
integer
C1402315 (UMLS CUI-1)
Code List
vascular lesion
CL Item
yes (1)
Item
Nerve injury
integer
C0161479 (UMLS CUI-1)
Code List
Nerve injury
CL Item
yes (1)
Item
fracture
integer
C0016658 (UMLS CUI-1)
Code List
fracture
CL Item
yes (1)
Item
other
integer
Code List
other
CL Item
yes (1)
postoperative Wundinfektion
Item
postoperative wound infection
boolean
C1629491 (UMLS CUI-1)
Item
CDC-classification
integer
Code List
CDC-classification
CL Item
A1 (superficial infection) (1)
CL Item
A2 (deep infection) (2)
CL Item
A3 (cavitas/organ) (3)
Reoperation wegen Komplikation(en) erforderlich
Item
Required repeat Surgery because of complication (s)
boolean
C0035110 (UMLS CUI-1)
allgemeine behandlungsbedürftige postoperative Komplikation(en)
Item
general postoperative complication (s) needed of treatment
boolean
C0032787 (UMLS CUI-1)
Item
Pneumonia
integer
C0032285 (UMLS CUI-1)
Code List
Pneumonia
CL Item
yes (1)
Item
cardiovascular complication (s)
integer
C0032963 (UMLS CUI-1)
Code List
cardiovascular complication (s)
CL Item
yes (1)
Item
deep leg/pelvic vein thrombosis
integer
C0149871 (UMLS CUI-1)
Code List
deep leg/pelvic vein thrombosis
CL Item
yes (1)
Item
pulmonary embolism
integer
C0034065 (UMLS CUI-1)
Code List
pulmonary embolism
CL Item
yes (1)
Item
other
integer
Code List
other
CL Item
yes (1)
Item Group
Discharge
selbstständiges Gehen bei Entlassung möglich
Item
independent walking possible at discharge
boolean
C0429979 (UMLS CUI-1)
War der Patient vor der Fraktur selbstständig gehfähig?
Item
Walking independently prior to the fracture?
boolean
selbstständige Versorgung in der täglichen Hygiene bei Entlassung möglich
Item
self care in the daily hygiene possible at discharge
boolean
C0518462 (UMLS CUI-1)
War der Patient vor der Fraktur selbstständig in der täglichen Hygiene?
Item
independently in daily hygiene prior to fracture?
boolean
Entlassungsdatum Krankenhaus
Item
Hostpital discharge date (DD.MM.YYYY)
date
C2710998 (UMLS CUI-1)
Entlassungsdiagnose(n)
Item
Discharge diagnoses
integer
C0011900 (UMLS CUI-1)
Item
Reason for Discharge
integer
C3164834 (UMLS CUI-1)
Code List
Reason for Discharge
CL Item
treatment finished as planned (1)
CL Item
transferral to nursing facility (10)
CL Item
discharge to hospice (11)
CL Item
external transferral to psychiatric treatment (13)
CL Item
treatment finished because of other reasons, postdischarge treatment is planned (14)
CL Item
treatment aborted against medical advice, postdischarge treatment is planned (15)
CL Item
internal transferral with change of DRG payment areas (17)
CL Item
treatment finished as planned, postdischarge treatment is planned (2)
CL Item
case termination (internal transferral) with change between full- and partial stationary care (22)
CL Item
discharge at the end of the year with admission in previous year (25)
CL Item
treatment finished because of other reasons (3)
CL Item
treatment aborted against medical advice (4)
CL Item
change of jurisdiction of insurer or other payer (5)
CL Item
transferral to another hospital (6)
CL Item
death (7)
CL Item
transferral to another hospital within cooperative and governmental policies  (8)
CL Item
transferral to rehabilitation facility (9)

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