ID

24426

Description

Routine documentation in German hospitals. Source file name: TH130110_Prämedikationsprotokoll Examplary forms provided by DMI (http://www.dmi.de/)

Link

http://www.dmi.de/

Keywords

Versions (3)
  1. 6/30/17 6/30/17 -
  2. 6/30/17 6/30/17 -
  3. 7/31/17 7/31/17 -
Uploaded on

July 31, 2017

DOI

To request one please log in.

License

Creative Commons BY-NC 3.0
Model comments :

You can comment on the data model here. Via the speech bubbles at the itemgroups and items you can add comments to those specificially.

Back to model comments
Itemgroup comments for :

Item comments for :

In order to download data models you must be logged in. Please log in or register for free.

Premedication record Routine documentation in German hospitals DMI

German English

Premedication record Routine documentation in German hospitals DMI

1 forms  
Patient data
Description

Patient data

Alias
UMLS CUI-1
C2707520
Surname
Description

Surname

Data type

text

Alias
UMLS CUI [1]
C0421448
First name
Description

First name

Data type

text

Alias
UMLS CUI [1]
C1443235
Case ID
Description

Case ID

Data type

text

Alias
UMLS CUI [1,1]
C1698493
UMLS CUI [1,2]
C1300638
Date of birth
Description

Date of birth

Data type

date

Alias
UMLS CUI [1]
C0421451
Age
Description

Age

Data type

integer

Measurement units
  • years
Alias
UMLS CUI [1]
C0001779
years
Weight
Description

Weight

Data type

float

Measurement units
  • kg
Alias
UMLS CUI [1]
C0005910
kg
Height
Description

Height

Data type

integer

Measurement units
  • cm
Alias
UMLS CUI [1]
C0005890
cm
Sex
Description

Sex

Data type

text

Alias
UMLS CUI [1]
C0079399
Organizational unit
Description

Organizational unit

Data type

text

Alias
UMLS CUI [1]
C0029246
Hospital stay
Description

Hospital stay

Data type

text

Alias
UMLS CUI [1]
C3489408
Surgery
Description

Surgery

Alias
UMLS CUI-1
C0543467
Diagnosis
Description

Diagnosis

Data type

text

Alias
UMLS CUI [1]
C0011900
Planned surgical procedure
Description

Planned surgical procedure

Data type

text

Alias
UMLS CUI [1,1]
C1301732
UMLS CUI [1,2]
C0543467
Scheduled date of surgery
Description

Scheduled date of surgery

Data type

date

Alias
UMLS CUI [1,1]
C1301732
UMLS CUI [1,2]
C1628561
Urgency
Description

Urgency

Data type

text

Alias
UMLS CUI [1]
C4049774
Position of patient
Description

Position of patient

Data type

text

Alias
UMLS CUI [1]
C1561964
Preoperative assessment
Description

Preoperative assessment

Alias
UMLS CUI-1
C0178808
BMI
Description

Body mass index

Data type

float

Measurement units
  • kg/m^2
Alias
UMLS CUI [1]
C1305855
kg/m^2
BSA
Description

Body surface area

Data type

float

Measurement units
  • m²
Alias
UMLS CUI [1]
C0005902
m²
VT
Description

Tidal volume

Data type

integer

Measurement units
  • ml
Alias
UMLS CUI [1]
C0040210
ml
ASA
Description

ASA classification

Data type

integer

Alias
UMLS CUI [1]
C0450990
MET
Description

Functional capacity, metabolic equivalents

Data type

text

Alias
UMLS CUI [1]
C2983100
Preoperative risk score
Description

risk score Preoperative

Data type

integer

Alias
UMLS CUI [1,1]
C0086930
UMLS CUI [1,2]
C0445204
Apfel
Description

risk score Postoperative Nausea and Vomiting

Data type

integer

Alias
UMLS CUI [1,1]
C0086930
UMLS CUI [1,2]
C0520909
Allergies
Description

Allergies

Data type

text

Alias
UMLS CUI [1]
C0020517
Mallampati
Description

Mallampati classification

Data type

integer

Alias
UMLS CUI [1]
C1829463
Mouth opening
Description

Mouth opening

Data type

float

Measurement units
  • cm
Alias
UMLS CUI [1]
C0226895
cm
Head reclination
Description

Head reclination

Data type

text

Alias
UMLS CUI [1]
C0444396
Preoperative general condition
Description

general condition Preoperative

Data type

text

Alias
UMLS CUI [1,1]
C1142435
UMLS CUI [1,2]
C0445204
Preoperative nutritional condition
Description

nutritional condition Preoperative

Data type

text

Alias
UMLS CUI [1,1]
C1608413
UMLS CUI [1,2]
C0445204
Physical fitness
Description

Physical fitness

Data type

text

Alias
UMLS CUI [1]
C0031812
Dyspnea
Description

Dyspnea

Data type

text

Alias
UMLS CUI [1]
C0013404
Relevant previous operations
Description

operations

Data type

text

Alias
UMLS CUI [1]
C0543467
State of teeth
Description

health status teeth

Data type

text

Alias
UMLS CUI [1,1]
C0018759
UMLS CUI [1,2]
C0040426
Comorbidities
Description

Comorbidities

Data type

text

Alias
UMLS CUI [1]
C0009488
Heart
Description

Heart

Data type

text

Alias
UMLS CUI [1]
C0018787
Circulation / blood vessels / metabolism & hormones
Description

blood circulation; blood vessel; hormones

Data type

text

Alias
UMLS CUI [1]
C0005775
UMLS CUI [2]
C0005847
UMLS CUI [3]
C0019932
Lungs / kidney / pancreas / liver
Description

Lungs; kidney; pancreas; liver

Data type

text

Alias
UMLS CUI [1]
C0024109
UMLS CUI [2]
C0022646
UMLS CUI [3]
C0030274
UMLS CUI [4]
C0023884
Long-term medication
Description

Long-term medication

Data type

text

Alias
UMLS CUI [1]
C0420257
Anesthesia
Description

Anesthesia

Alias
UMLS CUI-1
C0002903
Type of anesthesia
Description

Type of anesthesia

Data type

text

Alias
UMLS CUI [1]
C1305863
Instructions to ward
Description

Instructions to ward

Alias
UMLS CUI-1
C1442085
ECG
Description

ECG

Data type

text

Alias
UMLS CUI [1]
C1623258
Pulmonary function
Description

Pulmonary function

Data type

text

Alias
UMLS CUI [1]
C0024119
Chest X-ray
Description

Chest X-ray

Data type

text

Alias
UMLS CUI [1]
C0039985
Consultation
Description

Consultation

Data type

text

Alias
UMLS CUI [1]
C0009818
Laboratory
Description

Laboratory

Data type

text

Alias
UMLS CUI [1]
C0022877
Medication in the evening before surgery
Description

Medication Preoperative

Data type

text

Alias
UMLS CUI [1,1]
C0013227
UMLS CUI [1,2]
C0445204
Medication on the day of surgery
Description

Medication on the day of surgery

Alias
UMLS CUI-1
C0013227
Medication in the morning
Description

Medication

Data type

text

Alias
UMLS CUI [1]
C0013227
Time of premedication
Description

Time of premedication

Data type

text

Alias
UMLS CUI [1,1]
C0040223
UMLS CUI [1,2]
C0033045
Premedication
Description

Premedication

Data type

text

Alias
UMLS CUI [1]
C0033045
Eating / drinking
Description

Eating / drinking

Alias
UMLS CUI-1
C0559899
Eating possible until
Description

eating

Data type

text

Alias
UMLS CUI [1]
C0013470
Drinking possible until
Description

drinking

Data type

text

Alias
UMLS CUI [1]
C0684271
Further information
Description

Further information

Alias
UMLS CUI-1
C1533716
Post-surgery transfer
Description

Transfer post operative

Data type

text

Alias
UMLS CUI [1,1]
C0030704
UMLS CUI [1,2]
C0241311
Release
Description

Release

Data type

text

Alias
UMLS CUI [1]
C0030685
Administrated by
Description

person Administration procedure

Data type

text

Alias
UMLS CUI [1,1]
C0027361
UMLS CUI [1,2]
C1533734
Time of administration
Description

Time of administration

Data type

time

Alias
UMLS CUI [1]
C1317775
Date of premedication
Description

Date of premedication

Data type

date

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C0033045
Person giving premedication
Description

Person Premedication

Data type

text

Alias
UMLS CUI [1,1]
C0027361
UMLS CUI [1,2]
C0033045
Back to the top of the page

Similar models

Premedication record Routine documentation in German hospitals DMI

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Patient data
C2707520 (UMLS CUI-1)
Surname
Item
Surname
text
C0421448 (UMLS CUI [1])
First name
Item
First name
text
C1443235 (UMLS CUI [1])
Case ID
Item
Case ID
text
C1698493 (UMLS CUI [1,1])
C1300638 (UMLS CUI [1,2])
Date of birth
Item
Date of birth
date
C0421451 (UMLS CUI [1])
Age
Item
Age
integer
C0001779 (UMLS CUI [1])
Weight
Item
Weight
float
C0005910 (UMLS CUI [1])
Height
Item
Height
integer
C0005890 (UMLS CUI [1])
Sex
Item
Sex
text
C0079399 (UMLS CUI [1])
Organizational unit
Item
Organizational unit
text
C0029246 (UMLS CUI [1])
Hospital stay
Item
Hospital stay
text
C3489408 (UMLS CUI [1])
Item Group
Surgery
C0543467 (UMLS CUI-1)
Diagnosis
Item
Diagnosis
text
C0011900 (UMLS CUI [1])
Planned surgical procedure
Item
Planned surgical procedure
text
C1301732 (UMLS CUI [1,1])
C0543467 (UMLS CUI [1,2])
Scheduled date of surgery
Item
Scheduled date of surgery
date
C1301732 (UMLS CUI [1,1])
C1628561 (UMLS CUI [1,2])
Urgency
Item
Urgency
text
C4049774 (UMLS CUI [1])
Position of patient
Item
Position of patient
text
C1561964 (UMLS CUI [1])
Item Group
Preoperative assessment
C0178808 (UMLS CUI-1)
Body mass index
Item
BMI
float
C1305855 (UMLS CUI [1])
Body surface area
Item
BSA
float
C0005902 (UMLS CUI [1])
Tidal volume
Item
VT
integer
C0040210 (UMLS CUI [1])
ASA classification
Item
ASA
integer
C0450990 (UMLS CUI [1])
Functional capacity, metabolic equivalents
Item
MET
text
C2983100 (UMLS CUI [1])
risk score Preoperative
Item
Preoperative risk score
integer
C0086930 (UMLS CUI [1,1])
C0445204 (UMLS CUI [1,2])
risk score Postoperative Nausea and Vomiting
Item
Apfel
integer
C0086930 (UMLS CUI [1,1])
C0520909 (UMLS CUI [1,2])
Allergies
Item
Allergies
text
C0020517 (UMLS CUI [1])
Mallampati classification
Item
Mallampati
integer
C1829463 (UMLS CUI [1])
Mouth opening
Item
Mouth opening
float
C0226895 (UMLS CUI [1])
Head reclination
Item
Head reclination
text
C0444396 (UMLS CUI [1])
general condition Preoperative
Item
Preoperative general condition
text
C1142435 (UMLS CUI [1,1])
C0445204 (UMLS CUI [1,2])
nutritional condition Preoperative
Item
Preoperative nutritional condition
text
C1608413 (UMLS CUI [1,1])
C0445204 (UMLS CUI [1,2])
Physical fitness
Item
Physical fitness
text
C0031812 (UMLS CUI [1])
Dyspnea
Item
Dyspnea
text
C0013404 (UMLS CUI [1])
operations
Item
Relevant previous operations
text
C0543467 (UMLS CUI [1])
health status teeth
Item
State of teeth
text
C0018759 (UMLS CUI [1,1])
C0040426 (UMLS CUI [1,2])
Comorbidities
Item
Comorbidities
text
C0009488 (UMLS CUI [1])
Heart
Item
Heart
text
C0018787 (UMLS CUI [1])
blood circulation; blood vessel; hormones
Item
Circulation / blood vessels / metabolism & hormones
text
C0005775 (UMLS CUI [1])
C0005847 (UMLS CUI [2])
C0019932 (UMLS CUI [3])
Lungs; kidney; pancreas; liver
Item
Lungs / kidney / pancreas / liver
text
C0024109 (UMLS CUI [1])
C0022646 (UMLS CUI [2])
C0030274 (UMLS CUI [3])
C0023884 (UMLS CUI [4])
Long-term medication
Item
Long-term medication
text
C0420257 (UMLS CUI [1])
Item Group
Anesthesia
C0002903 (UMLS CUI-1)
Type of anesthesia
Item
Type of anesthesia
text
C1305863 (UMLS CUI [1])
Item Group
Instructions to ward
C1442085 (UMLS CUI-1)
ECG
Item
ECG
text
C1623258 (UMLS CUI [1])
Pulmonary function
Item
Pulmonary function
text
C0024119 (UMLS CUI [1])
Chest X-ray
Item
Chest X-ray
text
C0039985 (UMLS CUI [1])
Consultation
Item
Consultation
text
C0009818 (UMLS CUI [1])
Laboratory
Item
Laboratory
text
C0022877 (UMLS CUI [1])
Medication Preoperative
Item
Medication in the evening before surgery
text
C0013227 (UMLS CUI [1,1])
C0445204 (UMLS CUI [1,2])
Item Group
Medication on the day of surgery
C0013227 (UMLS CUI-1)
Medication
Item
Medication in the morning
text
C0013227 (UMLS CUI [1])
Time of premedication
Item
Time of premedication
text
C0040223 (UMLS CUI [1,1])
C0033045 (UMLS CUI [1,2])
Premedication
Item
Premedication
text
C0033045 (UMLS CUI [1])
Item Group
Eating / drinking
C0559899 (UMLS CUI-1)
eating
Item
Eating possible until
text
C0013470 (UMLS CUI [1])
drinking
Item
Drinking possible until
text
C0684271 (UMLS CUI [1])
Item Group
Further information
C1533716 (UMLS CUI-1)
Transfer post operative
Item
Post-surgery transfer
text
C0030704 (UMLS CUI [1,1])
C0241311 (UMLS CUI [1,2])
Release
Item
Release
text
C0030685 (UMLS CUI [1])
person Administration procedure
Item
Administrated by
text
C0027361 (UMLS CUI [1,1])
C1533734 (UMLS CUI [1,2])
Time of administration
Item
Time of administration
time
C1317775 (UMLS CUI [1])
Date of premedication
Item
Date of premedication
date
C0011008 (UMLS CUI [1,1])
C0033045 (UMLS CUI [1,2])
Person Premedication
Item
Person giving premedication
text
C0027361 (UMLS CUI [1,1])
C0033045 (UMLS CUI [1,2])
Back to the top of the page 

Contact

Please use this form for feedback, questions and suggestions for improvements.

Fields marked with * are required.

Help

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial