Category | Subcategory | Number of data elements | Mandatory | Optional |
---|---|---|---|---|
1-Personal Information | 1–1-Personal Information | 10 | 10 | 0 |
2-Admission Details | 2–1-Admission Details | 10 | 9 | 1 |
3-Present illness | 3–1-Respiratory disease | 10 | 9 | 1 |
3–2-Renal disease | 6 | 3 | 3 | |
3–3-Gastrointestinal disease/ Liver disease | 6 | 6 | 0 | |
3–4-Endocrine disease | 7 | 2 | 5 | |
3–5-Cardiovascular disease | 3 | 3 | 0 | |
3–6-Hematologic disease | 2 | 0 | 2 | |
3–7-Neurologic disease | 6 | 5 | 1 | |
3–8-Infectious disease | 3 | 1 | 2 | |
3–9-Trauma | 6 | 3 | 3 | |
3–10-Drugs | 54 | 33 | 21 | |
3–11-Toxins | 21 | 5 | 16 | |
Total | 125 | 71 | 54 | |
4-Past Medical History: | 4–1-Respiratory disease | 9 | 5 | 4 |
4–2-Renal disease | 18 | 8 | 10 | |
4–3-Gastrointestinal disease/ Liver disease | 7 | 2 | 5 | |
4–4-Endocrine disease | 24 | 3 | 21 | |
4–5-Cardiovascular disease | 1 | 1 | 0 | |
4–6-Hematologic disease | 5 | 1 | 4 | |
4–7-Neurologic disease | 5 | 4 | 1 | |
4–8-Genetic/Congenital disorders | 18 | 0 | 18 | |
4–9-Rheumatology/ musculoskeletal disease | 4 | 0 | 4 | |
4–10- Malignancy | 1 | 0 | 1 | |
Total | 92 | 24 | 68 | |
5-Social status | 5–1-Social status | 4 | 4 | 0 |
-Physical examination | 6–1-vital signs | 7 | 7 | 0 |
6–2-GCS (physician note) | 1 | 1 | 0 | |
6–3-Respiratory (FiO2%): | 4 | 4 | 0 | |
6–4-Sedation status (RAS score) | 1 | 1 | 0 | |
6–5-Numeric pain scale | 1 | 1 | 0 | |
6–6-Behavioral Pain Score | 1 | 1 | 0 | |
6–7-Diaphoresis | 1 | 1 | 0 | |
6–8-Shivering | 1 | 1 | 0 | |
6–9-Cyanosis (if spO2 unavailable or suspicious) | 1 | 1 | 0 | |
6–10-Urine output | 1 | 1 | 0 | |
6–11-Nasogastric drainage | 1 | 1 | 0 | |
6–12-Edematous states | 1 | 1 | 0 | |
6–13-Poor tissue perfusion (regional hypo-perfusion) | 1 | 1 | 0 | |
Total | 22 | 22 | 0 | |
7-Para-clinical investigation | 7–1- Para-clinical investigation | 29 | 11 | 18 |
8-Blood gas parameter | 8–1- Blood gas parameter | 7 | 7 | 0 |
9-SOFA score | 9–1- SOFA score | 6 | 6 | 0 |
10-Sampling technique | 10–1- Sampling technique errors (ABG Error) | 9 | 9 | 0 |
 | Total | 313 | 172 | 141 |