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ID
23988
Beschrijving
Routine documentation in German hospitals. Source file name: TH130110_Prämedikationsprotokoll Examplary forms provided by DMI (http://www.dmi.de/)
Link
Trefwoorden
Versies (5)
- 12-07-17 12-07-17 -
- 12-07-17 12-07-17 -
- 20-07-17 20-07-17 -
- 31-07-17 31-07-17 -
- 20-09-21 20-09-21 -
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20 juli 2017
DOI
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Creative Commons BY-NC 3.0
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Premedication Example 2 Routine documentation in German hospitals DMI
Premedication Example 2 Routine documentation in German hospitals DMI
Similar models
Premedication Example 2 Routine documentation in German hospitals DMI
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Patient data
Item
Patientendaten
text
Case ID
Item
Fallnummer
text
Surgery ID
Item
OP-Nummer
text
Date of birth
Item
Geburtsdatum
date
C0421451 (UMLS CUI [1])
Age
Item
Alter
integer
Ward
Item
Station
text
Room number
Item
Zimmer-Nummer
text
Elective service
Item
Wahlleistung
boolean
CL Item
ambulant (outpatient)
CL Item
stationär (in-patient)
CL Item
elektiv (>24h) (elective (>24h))
CL Item
innerhalb 24h (within 24h)
CL Item
Notfall < 2h (emergency (< 2h))
CL Item
sofort (immediately)
CL Item
m (male)
CL Item
w (female)
Gravidity
Item
Gravidität
boolean
Height
Item
Größe
integer
Weight
Item
Gewicht
integer
BMI
Item
BMI
integer
Pulse
Item
Puls
integer
Systolic blood pressure
Item
RR systolisch
integer
C0871470 (UMLS CUI [1])
Diastolic blood pressure
Item
RR diastolisch
integer
C0428883 (UMLS CUI [1])
Planned procedure
Item
Geplante Operation
text
Planned anesthetic technique
Item
Geplante Anästhesie
text
No abnormality detected
Item
ohne Befund
boolean
Re-narcosis
Item
Wiederholungsnarkose
boolean
Acute care
Item
Akutversorgung
boolean
ECG / Chest X-ray
Item
EKG / Röntgen-Thorax
text
Heart
Item
Herz
text
Lungs
Item
Lunge
text
Abdomen
Item
Abdomen
text
Other
Item
Varia
text
Long-term medication
Item
Dauermedikation
text
Previous surgeries
Item
Vor-OPs
text
Allergies
Item
Allergie
text
Complications during anesthesia
Item
Narkosekomplikationen
text
Normal findings ECG
Item
normal
boolean
Tachycardia
Item
Tachykardie
boolean
Bradycardia
Item
Bradykardie
boolean
Sinus rhythm absent
Item
fehlender SR
boolean
Conduction defect
Item
Überleitungsstörung
boolean
Extrasystoles
Item
Extrasystolie >5/min.
boolean
Pacemaker ECG
Item
SM-EKG
boolean
Signs of ischemia
Item
Ischämiezeichen
boolean
Signs of infarct
Item
Infarktzeichen
boolean
Disturbance of repolarization
Item
Erregungsrückbildungsstörung
boolean
Normal findings heart
Item
normal
boolean
Coronary heart disease
Item
KHK
boolean
Stable angina pectoris
Item
stabile AP
boolean
Acute coronary syndrome
Item
ACS
boolean
Old myocardial infarction
Item
Myokardinfarkt (alt)
boolean
Heart failure
Item
Herzinsuffizienz
boolean
Cardiomyopathy
Item
Kardiomyopathie
boolean
Aortic / mitral stenosis
Item
Aorten- / Mitralstenose
boolean
Other heart defects
Item
sonstige Herzvitien
boolean
Hemodyn. significant cardiac arrhythmias
Item
Hämodynamisch relevante Herzrhythmusstörungen
boolean
Cor pulmonale
Item
Cor pulmonale
boolean
Florid myocarditis
Item
Floride Myokarditis
boolean
Normal findings lungs
Item
normal
boolean
Dyspnea
Item
Dyspnoe
boolean
Pneumonia
Item
Pneumonie
boolean
Acute bronchitis
Item
Akute Bronchitis
boolean
Chronic obstructive pulmonary disease
Item
COPD
boolean
Obstruction
Item
Obstruktion
boolean
Restriction
Item
Restriktion
boolean
Pleural effusion
Item
Pleuraerguss
boolean
Pneumothorax
Item
Pneumothorax
boolean
Ventilation
Item
Beatmung
boolean
Normal findings circulatory system
Item
normal
boolean
Hypotension
Item
Hypotonie (therapiebed.)
boolean
Hypertension
Item
Hypertonie
boolean
Embolism
Item
Embolie
boolean
Thrombosis
Item
Thrombose
boolean
Artery occlusive disease
Item
AVK
boolean
Impaired cerebral blood flow
Item
zerebrale Durchblutungsstörung
boolean
Normal findings CNS / Neurology
Item
normal
boolean
Somnolence
Item
Somnolenz
boolean
Coma
Item
Koma
boolean
Traumatic brain injury
Item
SHT
boolean
Intracerebral hemorrhage / Space-occupying lesion
Item
ICB / Raumforderung
boolean
Stroke
Item
Schlaganfall
boolean
Transient ischemic attack
Item
TIA
boolean
Parkinsons disease
Item
Parkinson
boolean
Alzheimers disease / Dementia
Item
Alzheimer / Demenz
boolean
Multiple sclerosis
Item
MS
boolean
Amyotrophic lateral sclerosis
Item
ALS
boolean
Epilepsy
Item
Epilepsie
boolean
Neuromuscular disease
Item
neuromuskuläre Erkrankung
boolean
Normal findings metabolism
Item
normal
boolean
(Non-) Insulin-dependent diabetes mellitus
Item
(N) IDDM
boolean
Endocrine disorder
Item
Klinisch symptomatische Hormonstörung
boolean
Enzymatic genetic defect
Item
Enzymatische Gendefekte
boolean
Normal findings other
Item
normal
boolean
Infectious disease
Item
Infektiöse Erkrankung
boolean
Resistant germs
Item
resistente Keime
boolean
Obstructive sleep apnea
Item
OSAS
boolean
Renal failure
Item
Niereninsuffizienz
boolean
Normal laboratory findings
Item
normal
boolean
Pathological basic blood count
Item
kleines BB pathologisch
boolean
Pathological acid-base balance
Item
SBH pathologisch
boolean
Pathological coagulation
Item
Gerinnung pathologisch
boolean
Electrolytes pathological
Item
Elektrolyte pathologisch
boolean
Other pathological findings
Item
andere pathologisch
boolean
Hemoglobin
Item
Hb
float
Hematocrit
Item
Hk
float
Platelets
Item
Thr
integer
Prothrombin time
Item
Quick
integer
International Normalized Ratio
Item
INR
float
Partial thromboplastin time
Item
PTT
integer
Potassium
Item
Kalium
float
Creatinine
Item
Krea
float
Blood sugar
Item
BZ
float
Gamma-glutamyltransferase
Item
gamma-GT
float
Acetylsalicylic acid
Item
ASS
boolean
ASS administration duration
Item
ASS bis
date
Antagonization
Item
Rez.-Antagonisierung
boolean
Rez.-Antag. administration duration
Item
Rez.-Antag. bis
date
Heparin
Item
Heparin sc/iv
boolean
Heparin administration duration
Item
Heparin sc/iv until
date
Nonsteroidal anti-inflammatory drugs
Item
NSAR
boolean
NSAIDs administration duration
Item
NSAR bis
date
Marcumar
Item
Marcumar
boolean
Marcumar administration duration
Item
Marcumar bis
date
Other anticoagulants
Item
andere
boolean
Administration of other anticoagulants duration
Item
andere bis
date
CL Item
Prothese (prosthesis)
CL Item
o. B. (no abnormality detected)
CL Item
locker/besch. (loose/damaged)
Bleeding tendency
Item
Blutungsneigung
boolean
Risk of aspiration
Item
Aspirationsrisiko
boolean
Nicotine
Item
Nikotin
boolean
Alcohol
Item
Alkohol
boolean
Drugs
Item
Drogen
boolean
Allergies
Item
Allergie
boolean
CL Item
I (1)
CL Item
II (2)
CL Item
III (3)
CL Item
IV (4)
CL Item
V (5)
CL Item
VI (6)
CL Item
I (1)
CL Item
II (2)
CL Item
II (3)
CL Item
IV (4)
CL Item
I (I)
CL Item
II (II)
CL Item
III (III)
CL Item
IV (IV)
CL Item
n. b. (unknown)
CL Item
Keine Hinweise (No indication)
CL Item
Bekannt (known)
CL Item
Vermutet (assumed)
Evening before surgery
Item
Vorabend
boolean
Day of surgery
Item
OP-Tag
boolean
Medication
Item
Medikament
text
Administration
Item
Applikation
text
Time
Item
Uhrzeit
time
Signature
Item
Unterschrift
text
Blood type
Item
Blutgruppe
boolean
Coombs test
Item
AK-Suchtest
boolean
Red cell concentrate
Item
EK
integer
Fresh frozen plasma
Item
FFP
integer
Platelet concentrate
Item
TK
integer
Consent by patient
Item
Patienteneinverständnis
boolean
Findings
Item
Befunde
boolean
Follow-up visit
Item
Wiedervorstellung
boolean
Time of solid food intake
Item
fest
time
Time of intake of liquids
Item
flüssig
time
Date of premedication
Item
Datum Prämedikation
date
Anesthesist
Item
Anästhesist/-in
text
CL Item
RD (regular)
CL Item
ÜS (overtime)
CL Item
BD (on-call)
Time
Item
Uhrzeit (Beginn)
time
Duration
Item
Dauer
integer
Preadmission premedication
Item
PM vorstationär
boolean
Anesthesia outpatient department
Item
Anästh.-Ambulanz
boolean
No surgery after premedication
Item
Nach Prämed. keine OP
boolean
Name of physician
Item
Name Arzt/Ärztin
text
Signature physician
Item
Unterschrift Arzt/Ärztin
text