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ID
23254
Beschreibung
Routine documentation in German hospitals. Source file name: TH130110_Prämedikationsprotokoll Examplary forms provided by DMI (http://www.dmi.de/)
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Stichworte
Versionen (3)
- 30.06.17 30.06.17 -
- 30.06.17 30.06.17 -
- 31.07.17 31.07.17 -
Hochgeladen am
30. Juni 2017
DOI
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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
Ähnliche Modelle
Premedication record Routine documentation in German hospitals DMI
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Surname
Item
Surname
text
First name
Item
First name
text
Case ID
Item
Case ID
text
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
Organizational unit
Item
Organizational unit
text
Hospital stay
Item
Hospital stay
text
Diagnosis
Item
Diagnosis
text
Planned surgical procedure
Item
Planned surgical procedure
text
Scheduled date of surgery
Item
Scheduled date of surgery
date
Urgency
Item
Urgency
text
Position of patient
Item
Position of patient
text
Body mass index
Item
BMI
float
Body surface area
Item
BSA
float
Tidal volume
Item
VT
integer
ASA risk classification
Item
ASA
integer
Functional capacity, metabolic equivalents
Item
MET
text
Preoperative risk score
Item
Preoperative risk score
integer
Apfel score
Item
Apfel
integer
Allergies
Item
Allergies
text
Mouth opening
Item
Mouth opening
float
Head reclination
Item
Head reclination
text
Preoperative general condition
Item
Preoperative general condition
text
Preoperative nutritional condition
Item
Preoperative nutritional condition
text
Physical fitness
Item
Physical fitness
text
Dyspnea
Item
Dyspnea
text
Relevant previous operations
Item
Relevant previous operations
text
State of teeth
Item
State of teeth
text
Comorbidities
Item
Comorbidities
text
Heart
Item
Heart
text
Circulation, blood vessels, metabolism, hormones
Item
Circulation / blood vessels / metabolism & hormones
text
Lungs, kidney, pancreas, liver
Item
Lungs / kidney / pancreas / liver
text
Long-term medication
Item
Long-term medication
text
Type of anesthesia
Item
Type of anesthesia
text
ECG
Item
ECG
text
Pulmonary function
Item
Pulmonary function
text
Chest X-ray
Item
Chest X-ray
text
Consultation
Item
Consultation
text
Laboratory
Item
Laboratory
text
Medication the evening before surgery
Item
Medication in the evening before surgery
text
Medication in the morning
Item
Medication in the morning
text
Time of premedication
Item
Time of premedication
text
Premedication
Item
Premedication
text
Latest possible food intake before surgery
Item
Eating possible until
text
Latest possible liquid intake before surgery
Item
Drinking possible until
text
Post-surgery transfer
Item
Post-surgery transfer
text
Release
Item
Release
text
Administrating person
Item
Administrated by
text
Time of administration
Item
Time of administration
time
Date of premedication
Item
Date of premedication
date
Person giving premedication
Item
Person giving premedication
text