ID

23254

Beschrijving

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

Link

http://www.dmi.de/

Trefwoorden

  1. 30-06-17 30-06-17 -
  2. 30-06-17 30-06-17 -
  3. 31-07-17 31-07-17 -
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30 juni 2017

DOI

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Licentie

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

Patient data
Beschrijving

Patient data

Surname
Beschrijving

Surname

Datatype

text

First name
Beschrijving

First name

Datatype

text

Case ID
Beschrijving

Case ID

Datatype

text

Date of birth
Beschrijving

Date of birth

Datatype

date

Alias
UMLS CUI [1]
C0421451
Age
Beschrijving

Age

Datatype

integer

Maateenheden
  • years
Alias
UMLS CUI [1]
C0001779
years
Weight
Beschrijving

Weight

Datatype

float

Maateenheden
  • kg
Alias
UMLS CUI [1]
C0005910
kg
Height
Beschrijving

Height

Datatype

integer

Maateenheden
  • cm
Alias
UMLS CUI [1]
C0005890
cm
Sex
Beschrijving

Sex

Datatype

text

Organizational unit
Beschrijving

Organizational unit

Datatype

text

Hospital stay
Beschrijving

Hospital stay

Datatype

text

Surgery
Beschrijving

Surgery

Diagnosis
Beschrijving

Diagnosis

Datatype

text

Planned surgical procedure
Beschrijving

Planned surgical procedure

Datatype

text

Scheduled date of surgery
Beschrijving

Scheduled date of surgery

Datatype

date

Urgency
Beschrijving

Urgency

Datatype

text

Position of patient
Beschrijving

Position of patient

Datatype

text

Preoperative assessment
Beschrijving

Preoperative assessment

BMI
Beschrijving

Body mass index

Datatype

float

Maateenheden
  • kg/m^2
kg/m^2
BSA
Beschrijving

Body surface area

Datatype

float

Maateenheden
VT
Beschrijving

Tidal volume

Datatype

integer

Maateenheden
  • ml
ml
ASA
Beschrijving

ASA risk classification

Datatype

integer

MET
Beschrijving

Functional capacity, metabolic equivalents

Datatype

text

Preoperative risk score
Beschrijving

Preoperative risk score

Datatype

integer

Apfel
Beschrijving

Apfel score

Datatype

integer

Allergies
Beschrijving

Allergies

Datatype

text

Mallampati
Beschrijving

Mallampati classification

Datatype

integer

Mouth opening
Beschrijving

Mouth opening

Datatype

float

Maateenheden
  • cm
cm
Head reclination
Beschrijving

Head reclination

Datatype

text

Preoperative general condition
Beschrijving

Preoperative general condition

Datatype

text

Preoperative nutritional condition
Beschrijving

Preoperative nutritional condition

Datatype

text

Physical fitness
Beschrijving

Physical fitness

Datatype

text

Dyspnea
Beschrijving

Dyspnea

Datatype

text

Relevant previous operations
Beschrijving

Relevant previous operations

Datatype

text

State of teeth
Beschrijving

State of teeth

Datatype

text

Comorbidities
Beschrijving

Comorbidities

Datatype

text

Heart
Beschrijving

Heart

Datatype

text

Circulation / blood vessels / metabolism & hormones
Beschrijving

Circulation, blood vessels, metabolism, hormones

Datatype

text

Lungs / kidney / pancreas / liver
Beschrijving

Lungs, kidney, pancreas, liver

Datatype

text

Long-term medication
Beschrijving

Long-term medication

Datatype

text

Anesthesia
Beschrijving

Anesthesia

Type of anesthesia
Beschrijving

Type of anesthesia

Datatype

text

Instructions to ward
Beschrijving

Instructions to ward

ECG
Beschrijving

ECG

Datatype

text

Pulmonary function
Beschrijving

Pulmonary function

Datatype

text

Chest X-ray
Beschrijving

Chest X-ray

Datatype

text

Consultation
Beschrijving

Consultation

Datatype

text

Laboratory
Beschrijving

Laboratory

Datatype

text

Medication in the evening before surgery
Beschrijving

Medication the evening before surgery

Datatype

text

Medication on the day of surgery
Beschrijving

Medication on the day of surgery

Medication in the morning
Beschrijving

Medication in the morning

Datatype

text

Time of premedication
Beschrijving

Time of premedication

Datatype

text

Premedication
Beschrijving

Premedication

Datatype

text

Eating / drinking
Beschrijving

Eating / drinking

Eating possible until
Beschrijving

Latest possible food intake before surgery

Datatype

text

Drinking possible until
Beschrijving

Latest possible liquid intake before surgery

Datatype

text

Further information
Beschrijving

Further information

Post-surgery transfer
Beschrijving

Post-surgery transfer

Datatype

text

Release
Beschrijving

Release

Datatype

text

Administrated by
Beschrijving

Administrating person

Datatype

text

Time of administration
Beschrijving

Time of administration

Datatype

time

Date of premedication
Beschrijving

Date of premedication

Datatype

date

Person giving premedication
Beschrijving

Person giving premedication

Datatype

text

Similar models

Premedication record Routine documentation in German hospitals DMI

Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
Patient data
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
Item Group
Surgery
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
Item Group
Preoperative assessment
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
Item
Mallampati
integer
Code List
Mallampati
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
Item Group
Anesthesia
Type of anesthesia
Item
Type of anesthesia
text
Item Group
Instructions to ward
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
Item Group
Medication on the day of surgery
Medication in the morning
Item
Medication in the morning
text
Time of premedication
Item
Time of premedication
text
Premedication
Item
Premedication
text
Item Group
Eating / drinking
Latest possible food intake before surgery
Item
Eating possible until
text
Latest possible liquid intake before surgery
Item
Drinking possible until
text
Item Group
Further information
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

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