ID

6440

Description

Documentation form for quality assurance in German Health Care by the Institute for Applied Quality Improvement and Research in Health Care (Aqua), https://www.aqua-institut.de/en/home. Internal Aqua form version: 21-3-B Specification 2015 V02

Link

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

Keywords

  1. 12/22/14 12/22/14 - Julian Varghese
  2. 1/19/15 1/19/15 - Sarah Schulze Sünninghausen
  3. 8/12/15 8/12/15 - Julian Varghese
Uploaded on

December 22, 2014

DOI

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License

Creative Commons BY-NC 3.0 Legacy

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Quality assurance Coronary Angiography and Percuteanous Intervention (PCI) - Basic (AQUA)

Quality assurance Coronary Angiography and Percuteanous Intervention (PCI) - Basic (AQUA)

Basic documentation
Description

Basic documentation

Healthcare Facility Identifier
Description

Institutionskennzeichen

Data type

integer

Alias
UMLS CUI-1
C2986045
Zip Code of Discharge
Description

Entlassender Standort

Data type

string

Alias
UMLS CUI-1
C1521842
Facility's Section Identifier
Description

Betriebsstätten-Nummer

Data type

string

Alias
UMLS CUI-1
C1547540
Hospital admission date (DD.MM.YYYY)
Description

Aufnahmedatum Krankenhaus

Data type

date

Alias
UMLS CUI-1
C1302393
Medical specialty
Description

Fachabteilung

Data type

integer

Alias
UMLS CUI-1
C0037778
Healthcare facility is the provider of this procedure (The facility for documenting the procedure and the facility for providing the procedure are not identical)
Description

Verbringungsleistung (Die dokumentierende und die den Eingriff durchführende Einrichtung sind NICHT identisch)

Data type

integer

Patient identification number
Description

Identifikationsnummer des Patienten

Data type

string

Alias
UMLS CUI-1
C1549734
Date of Birth (DD.MM.YYYY)
Description

Geburtsdatum

Data type

date

Alias
UMLS CUI-1
C0421451
Gender
Description

Geschlecht

Data type

integer

Alias
UMLS CUI-1
C0079399
Patient
Description

Patient

diagnostic coronary angiography before this stay
Description

diagnostische Koronarangiographie vor diesem Aufenthalt

Data type

integer

Alias
UMLS CUI-1
C0085532
Catheteral intervention before this stay
Description

Katheterintervention vor diesem Aufenthalt

Data type

integer

Alias
UMLS CUI-1
C1532338
Patient post coronary bypass operation
Description

Zustand nach koronarer Bypass-Op

Data type

integer

Alias
UMLS CUI-1
C0010055
Left ventricular ejection fraction under 40%
Description

Ejektionsfraktion unter 40%

Data type

integer

Alias
UMLS CUI-1
C0428772
Diabetes mellitus
Description

Diabetes mellitus

Data type

integer

Alias
UMLS CUI-1
C0011849
Kidney failure
Description

Niereninsuffizienz

Data type

integer

Alias
UMLS CUI-1
C0035078
Current cardiac medical history (before first procedure)
Description

Current cardiac medical history (before first procedure)

acute coronary syndrome (STEMI or NSTEMI, but with positive lab values or instable angina pectoris (rest angina))
Description

akutes Koronarsyndrom (ST-Hebungsinfarkt oder Infarkt ohne ST-Hebung, aber mit Markererhöhung oder instabile Angina pectoris (Ruheangina) innerhalb der letzten 48 Stunden)

Data type

integer

Alias
UMLS CUI-1
C0948089
Stable angina - according to CCS
Description

stabile Angina pectoris

Data type

integer

Alias
UMLS CUI-1
C1879987
objective (apparatus-based) signs of ischemia - exercise ecg or other non-invasive tests
Description

objektive (apparative) Ischämiezeichen bei Belastung

Data type

integer

Alias
UMLS CUI-1
C0151744
Clinical course
Description

Clinical course

postprocedural myocardial infarction
Description

postprozedural neu aufgetretener Herzinfarkt

Data type

integer

Alias
UMLS CUI-1
C0027051
postprocedural TIA/Stroke
Description

postprozedural neu aufgetretene/r TIA/Schlaganfall

Data type

integer

Alias
UMLS CUI-1
C0007787
UMLS CUI-2
C0038454
postprocedural Emergency-PCI at the same vessel
Description

postprozedurale Notfall-PCI am selben Gefäß

Data type

integer

Alias
UMLS CUI-1
C1532338
postprocedural transferral or admission to emergency CABG surgery
Description

postprozedurale Verlegung bzw. Einweisung zur Notfall CABG-Operation

Data type

integer

Alias
UMLS CUI-1
C0010055
Severe hemorrhage at puncture site
Description

schwere therapiebedürftige Blutung an der Punktionsstelle

Data type

integer

Alias
UMLS CUI-1
C0919883
Therapy of hemarrage at puncture site
Description

Therapie der Blutung an der Punktionsstelle

Data type

integer

Alias
UMLS CUI-1-1
C1522326
UMLS CUI-1-2
C0919883
Vascular thrombosis (close to punction site)
Description

Gefäßthrombose (punktionsnah)

Data type

integer

Alias
UMLS CUI-1
C2938969
Pseudoaneurysm with new compression (at site of punctutre)
Description

Aneurysma spurium mit erneuter Kompression (punktionsnah)

Data type

integer

Alias
UMLS CUI-1
C1510412
other postprocedural events - e.g. Sepsis
Description

sonstige postprozedural festgestellte Ereignisse

Data type

integer

Death - every Deathcase independent from cause
Description

Tod

Data type

integer

Alias
UMLS CUI-1
C1306577
Discharge
Description

Discharge

Did the patient stay at heart surgery or has he/she been transferred there for elective purposes ?
Description

Lag der Patient in der Herzchirurgie oder wurde er elektiv dorthin verlegt/überwiesen?

Data type

integer

Hostpital discharge date (DD.MM.YYYY)
Description

Entlassungsdatum Krankenhaus

Data type

date

Alias
UMLS CUI-1
C2710998
Reason for Discharge
Description

Entlassungsgrund

Data type

integer

Alias
UMLS CUI-1
C3164834
Discharge diagnoses - ICD codes
Description

Entlassungsdiagnose(n) (stationär) ICD-10-GM

Data type

integer

Alias
UMLS CUI-1
C0011900

Similar models

Quality assurance Coronary Angiography and Percuteanous Intervention (PCI) - Basic (AQUA)

Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Basic documentation
Institutionskennzeichen
Item
Healthcare Facility Identifier
integer
C2986045 (UMLS CUI-1)
Entlassender Standort
Item
Zip Code of Discharge
string
C1521842 (UMLS CUI-1)
Betriebsstätten-Nummer
Item
Facility's Section Identifier
string
C1547540 (UMLS CUI-1)
Aufnahmedatum Krankenhaus
Item
Hospital admission date (DD.MM.YYYY)
date
C1302393 (UMLS CUI-1)
Item
Medical specialty
integer
C0037778 (UMLS CUI-1)
Code List
Medical specialty
CL Item
 (0100)
CL Item
 (0102)
CL Item
 (0103)
CL Item
 (0104)
CL Item
 (0105)
CL Item
 (0106)
CL Item
 (0107)
CL Item
 (0108)
CL Item
 (0109)
CL Item
 (0114)
CL Item
 (0150)
CL Item
 (0151)
CL Item
 (0152)
CL Item
 (0153)
CL Item
 (0154)
CL Item
 (0156)
CL Item
 (0190)
CL Item
 (0200)
CL Item
 (0224)
CL Item
 (0260)
CL Item
 (0261)
CL Item
 (0290)
CL Item
 (0300)
CL Item
 (0400)
CL Item
 (0410)
CL Item
 (0436)
CL Item
 (0490)
CL Item
 (0500)
CL Item
 (0510)
CL Item
 (0524)
CL Item
 (0533)
CL Item
 (0590)
CL Item
 (0600)
CL Item
 (0607)
CL Item
 (0610)
CL Item
 (0690)
CL Item
 (0700)
CL Item
 (0706)
CL Item
 (0710)
CL Item
 (0790)
CL Item
 (0800)
CL Item
 (0900)
CL Item
 (0910)
CL Item
 (0990)
CL Item
 (1000)
CL Item
 (1004)
CL Item
 (1005)
CL Item
 (1006)
CL Item
 (1007)
CL Item
 (1009)
CL Item
 (1011)
CL Item
 (1012)
CL Item
 (1014)
CL Item
 (1028)
CL Item
 (1050)
CL Item
 (1051)
CL Item
 (1090)
CL Item
 (1100)
CL Item
 (1136)
CL Item
 (1190)
CL Item
 (1200)
CL Item
 (1300)
CL Item
 (1400)
CL Item
 (1410)
CL Item
 (1490)
CL Item
 (1500)
CL Item
 (1513)
CL Item
 (1516)
CL Item
 (1518)
CL Item
 (1519)
CL Item
 (1520)
CL Item
 (1523)
CL Item
 (1536)
CL Item
 (1550)
CL Item
 (1551)
CL Item
 (1590)
CL Item
 (1600)
CL Item
 (1700)
CL Item
 (1800)
CL Item
 (1900)
CL Item
 (2000)
CL Item
 (2021)
CL Item
 (2036)
CL Item
 (2050)
CL Item
 (2090)
CL Item
 (2100)
CL Item
 (2118)
CL Item
 (2120)
CL Item
 (2136)
CL Item
 (2150)
CL Item
 (2190)
CL Item
 (2200)
CL Item
 (2300)
CL Item
 (2309)
CL Item
 (2315)
CL Item
 (2316)
CL Item
 (2390)
CL Item
 (2400)
CL Item
 (2402)
CL Item
 (2405)
CL Item
 (2406)
CL Item
 (2425)
CL Item
 (2490)
CL Item
 (2500)
CL Item
 (2600)
CL Item
 (2700)
CL Item
 (2800)
CL Item
 (2810)
CL Item
 (2856)
CL Item
 (2890)
CL Item
 (2900)
CL Item
 (2928)
CL Item
 (2930)
CL Item
 (2931)
CL Item
 (2950)
CL Item
 (2951)
CL Item
 (2952)
CL Item
 (2953)
CL Item
 (2954)
CL Item
 (2955)
CL Item
 (2956)
CL Item
 (2960)
CL Item
 (2961)
CL Item
 (2990)
CL Item
 (3000)
CL Item
 (3060)
CL Item
 (3061)
CL Item
 (3090)
CL Item
 (3100)
CL Item
 (3110)
CL Item
 (3160)
CL Item
 (3161)
CL Item
 (3190)
CL Item
 (3200)
CL Item
 (3233)
CL Item
 (3290)
CL Item
 (3300)
CL Item
 (3305)
CL Item
 (3350)
CL Item
 (3390)
CL Item
 (3400)
CL Item
 (3460)
CL Item
 (3490)
CL Item
 (3500)
CL Item
 (3600)
CL Item
 (3601)
CL Item
 (3603)
CL Item
 (3610)
CL Item
 (3617)
CL Item
 (3618)
CL Item
 (3621)
CL Item
 (3622)
CL Item
 (3624)
CL Item
 (3626)
CL Item
 (3628)
CL Item
 (3650)
CL Item
 (3651)
CL Item
 (3652)
CL Item
 (3690)
CL Item
 (3700)
CL Item
 (3750)
CL Item
 (3751)
CL Item
 (3752)
CL Item
 (3753)
CL Item
 (3754)
CL Item
 (3755)
CL Item
 (3756)
CL Item
 (3757)
CL Item
 (3790)
Item
Healthcare facility is the provider of this procedure (The facility for documenting the procedure and the facility for providing the procedure are not identical)
integer
Code List
Healthcare facility is the provider of this procedure (The facility for documenting the procedure and the facility for providing the procedure are not identical)
CL Item
 (0)
CL Item
 (1)
Identifikationsnummer des Patienten
Item
Patient identification number
string
C1549734 (UMLS CUI-1)
Geburtsdatum
Item
Date of Birth (DD.MM.YYYY)
date
C0421451 (UMLS CUI-1)
Item
Gender
integer
C0079399 (UMLS CUI-1)
Code List
Gender
CL Item
 (1)
CL Item
 (2)
Item Group
Patient
Item
diagnostic coronary angiography before this stay
integer
C0085532 (UMLS CUI-1)
Code List
diagnostic coronary angiography before this stay
CL Item
 (0)
CL Item
 (1)
CL Item
 (9)
Item
Catheteral intervention before this stay
integer
C1532338 (UMLS CUI-1)
Code List
Catheteral intervention before this stay
CL Item
 (0)
CL Item
 (1)
CL Item
 (9)
Item
Patient post coronary bypass operation
integer
C0010055 (UMLS CUI-1)
Code List
Patient post coronary bypass operation
CL Item
 (0)
CL Item
 (1)
CL Item
 (9)
Item
Left ventricular ejection fraction under 40%
integer
C0428772 (UMLS CUI-1)
Code List
Left ventricular ejection fraction under 40%
CL Item
 (0)
CL Item
 (1)
CL Item
 (2)
CL Item
 (9)
Item
Diabetes mellitus
integer
C0011849 (UMLS CUI-1)
Code List
Diabetes mellitus
CL Item
 (0)
CL Item
 (1)
CL Item
 (2)
CL Item
 (9)
Item
Kidney failure
integer
C0035078 (UMLS CUI-1)
Code List
Kidney failure
CL Item
 (0)
CL Item
 (1)
CL Item
 (2)
CL Item
 (9)
Item Group
Current cardiac medical history (before first procedure)
Item
acute coronary syndrome (STEMI or NSTEMI, but with positive lab values or instable angina pectoris (rest angina))
integer
C0948089 (UMLS CUI-1)
Code List
acute coronary syndrome (STEMI or NSTEMI, but with positive lab values or instable angina pectoris (rest angina))
CL Item
 (0)
CL Item
 (1)
Item
Stable angina - according to CCS
integer
C1879987 (UMLS CUI-1)
Code List
Stable angina - according to CCS
CL Item
 (0)
CL Item
 (1)
CL Item
 (2)
CL Item
 (3)
Item
objective (apparatus-based) signs of ischemia - exercise ecg or other non-invasive tests
integer
C0151744 (UMLS CUI-1)
Code List
objective (apparatus-based) signs of ischemia - exercise ecg or other non-invasive tests
CL Item
 (0)
CL Item
 (1)
CL Item
 (2)
CL Item
 (9)
Item Group
Clinical course
Item
postprocedural myocardial infarction
integer
C0027051 (UMLS CUI-1)
Code List
postprocedural myocardial infarction
CL Item
 (0)
CL Item
 (1)
CL Item
 (2)
Item
postprocedural TIA/Stroke
integer
C0007787 (UMLS CUI-1)
C0038454 (UMLS CUI-2)
Code List
postprocedural TIA/Stroke
CL Item
 (0)
CL Item
 (1)
CL Item
 (2)
Item
postprocedural Emergency-PCI at the same vessel
integer
C1532338 (UMLS CUI-1)
Code List
postprocedural Emergency-PCI at the same vessel
CL Item
 (0)
CL Item
 (1)
CL Item
 (2)
Item
postprocedural transferral or admission to emergency CABG surgery
integer
C0010055 (UMLS CUI-1)
Code List
postprocedural transferral or admission to emergency CABG surgery
CL Item
 (0)
CL Item
 (1)
CL Item
 (2)
Item
Severe hemorrhage at puncture site
integer
C0919883 (UMLS CUI-1)
Code List
Severe hemorrhage at puncture site
CL Item
 (0)
CL Item
 (1)
CL Item
 (2)
Item
Therapy of hemarrage at puncture site
integer
C1522326 (UMLS CUI-1-1)
C0919883 (UMLS CUI-1-2)
Code List
Therapy of hemarrage at puncture site
CL Item
 (1)
CL Item
 (2)
CL Item
 (3)
Item
Vascular thrombosis (close to punction site)
integer
C2938969 (UMLS CUI-1)
Code List
Vascular thrombosis (close to punction site)
CL Item
 (0)
CL Item
 (1)
CL Item
 (2)
Item
Pseudoaneurysm with new compression (at site of punctutre)
integer
C1510412 (UMLS CUI-1)
Code List
Pseudoaneurysm with new compression (at site of punctutre)
CL Item
 (0)
CL Item
 (1)
CL Item
 (2)
Item
other postprocedural events - e.g. Sepsis
integer
Code List
other postprocedural events - e.g. Sepsis
CL Item
 (0)
CL Item
 (1)
CL Item
 (2)
Item
Death - every Deathcase independent from cause
integer
C1306577 (UMLS CUI-1)
Code List
Death - every Deathcase independent from cause
CL Item
 (0)
CL Item
 (1)
CL Item
 (2)
Item Group
Discharge
Item
Did the patient stay at heart surgery or has he/she been transferred there for elective purposes ?
integer
Code List
Did the patient stay at heart surgery or has he/she been transferred there for elective purposes ?
CL Item
 (0)
CL Item
 (1)
Entlassungsdatum Krankenhaus
Item
Hostpital discharge date (DD.MM.YYYY)
date
C2710998 (UMLS CUI-1)
Item
Reason for Discharge
integer
C3164834 (UMLS CUI-1)
Code List
Reason for Discharge
CL Item
 (1)
CL Item
 (10)
CL Item
 (11)
CL Item
 (13)
CL Item
 (14)
CL Item
 (15)
CL Item
 (17)
CL Item
 (2)
CL Item
 (22)
CL Item
 (25)
CL Item
 (3)
CL Item
 (4)
CL Item
 (5)
CL Item
 (6)
CL Item
 (7)
CL Item
 (8)
CL Item
 (9)
Entlassungsdiagnose(n) (stationär) ICD-10-GM
Item
Discharge diagnoses - ICD codes
integer
C0011900 (UMLS CUI-1)

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