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ID
23254
Description
Routine documentation in German hospitals. Source file name: TH130110_Prämedikationsprotokoll Examplary forms provided by DMI (http://www.dmi.de/)
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Keywords
Versions (3)
- 6/30/17 6/30/17 -
- 6/30/17 6/30/17 -
- 7/31/17 7/31/17 -
Uploaded on
June 30, 2017
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License
Creative Commons BY-NC 3.0
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Premedication record Routine documentation in German hospitals DMI
Premedication record Routine documentation in German hospitals DMI
Similar models
Premedication record Routine documentation in German hospitals DMI
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Surname
Item
Nachname
text
First name
Item
Vorname
text
Case ID
Item
Fallnummer
text
Date of birth
Item
Geburtsdatum
date
C0421451 (UMLS CUI [1])
Age
Item
Alter
integer
C0001779 (UMLS CUI [1])
Weight
Item
Gewicht
float
C0005910 (UMLS CUI [1])
Height
Item
Größe
integer
C0005890 (UMLS CUI [1])
Sex
Item
Geschlecht
text
Organizational unit
Item
Anf. OE
text
Hospital stay
Item
Aufenthalt
text
Diagnosis
Item
OP-Diagnose(n)
text
Planned surgical procedure
Item
Geplante OP
text
Scheduled date of surgery
Item
OP-Termin
date
Urgency
Item
Dringlichkeit
text
Position of patient
Item
Lagerung
text
Body mass index
Item
BMI
float
Body surface area
Item
KOF
float
Tidal volume
Item
VT
integer
ASA risk classification
Item
ASA
integer
Functional capacity, metabolic equivalents
Item
MET
text
Preoperative risk score
Item
Präop. Risikoscore
integer
Apfel score
Item
Apfel
integer
Allergies
Item
Allergien
text
Mouth opening
Item
Mundöffnung
float
Head reclination
Item
Kopfreklination
text
Preoperative general condition
Item
Präoperativer Zustand AZ
text
Preoperative nutritional condition
Item
Präoperativer Zustand EZ
text
Physical fitness
Item
Belastbarkeit
text
Dyspnea
Item
Dyspnoe
text
Relevant previous operations
Item
Relevante Voroperationen
text
State of teeth
Item
Ergänzung Zahnstatus
text
Comorbidities
Item
Begleiterkrankungen
text
Heart
Item
Herz
text
Circulation, blood vessels, metabolism, hormones
Item
Kreislauf / Gefäße / Stoffwechsel & Hormone
text
Lungs, kidney, pancreas, liver
Item
Lunge / Niere / Pankreas / Leber
text
Long-term medication
Item
Dauermedikation
text
Type of anesthesia
Item
Anästhesieform
text
ECG
Item
EKG
text
Pulmonary function
Item
LuFu
text
Chest X-ray
Item
Rö.-Thorax
text
Consultation
Item
Konsil
text
Laboratory
Item
Labor
text
Medication the evening before surgery
Item
Medikation am Vorabend
text
Medication in the morning
Item
Morgenmedikation
text
Time of premedication
Item
Prämedikationszeit
text
Premedication
Item
Prämedikation
text
Latest possible food intake before surgery
Item
Essen möglich bis
text
Latest possible liquid intake before surgery
Item
Trinken möglich bis
text
Post-surgery transfer
Item
Verlegung Post OP
text
Release
Item
Freigabe
text
Administrating person
Item
Verabreicht von
text
Time of administration
Item
Verabreicht um
time
Date of premedication
Item
Prämediziert am
date
Person giving premedication
Item
Prämediziert durch
text