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Premedication Example 1 Routine documentation in German hospitals DMI

1 Formulare  
Patient data
Beschreibung

Patient data

Department
Beschreibung

Department

Datentyp

text

Status
Beschreibung

Status

Datentyp

text

Age
Beschreibung

less than 1 year = 0

Datentyp

integer

Maßeinheiten
  • YEARS
YEARS
Sex
Beschreibung

Sex

Datentyp

text

Height
Beschreibung

Height

Datentyp

integer

Weight
Beschreibung

Weight

Datentyp

integer

Heart rate
Beschreibung

Heart rate

Datentyp

integer

Alias
UMLS CUI [1]
C0018810
Blood Pressure
Beschreibung

Blood Pressure

Datentyp

text

Alias
UMLS CUI [1]
C0005823
Laboratory values
Beschreibung

Laboratory values

Hb
Beschreibung

Hemoglobin

Datentyp

float

K
Beschreibung

Potassium

Datentyp

float

Blood sugar
Beschreibung

Blood sugar

Datentyp

float

Ht
Beschreibung

Hematocrit

Datentyp

float

Na
Beschreibung

Sodium

Datentyp

float

Creatinine
Beschreibung

Creatinine

Datentyp

float

PT
Beschreibung

Prothrombin time

Datentyp

integer

PTT
Beschreibung

Partial thromboplastin time

Datentyp

integer

Platelets
Beschreibung

Platelets

Datentyp

integer

Risk regarding organ function
Beschreibung

Risk regarding organ function

Heart
Beschreibung

Heart

Datentyp

boolean

Lungs
Beschreibung

Lungs

Datentyp

boolean

Circulation
Beschreibung

Circulation

Datentyp

boolean

Neurology / CNS
Beschreibung

Neurology / CNS

Datentyp

boolean

Metabolism
Beschreibung

Metabolism

Datentyp

boolean

BMI > = 40 (ASA III)
Beschreibung

ASA

Datentyp

boolean

Preoperative assessment
Beschreibung

Preoperative assessment

Preoperative condition
Beschreibung

Preoperative condition

Datentyp

text

Re-narcosis
Beschreibung

Re-narcosis

Datentyp

boolean

Long-term medication
Beschreibung

Long-term medication

Datentyp

text

Allergies
Beschreibung

Allergies

Datentyp

text

PONV
Beschreibung

Postoperative nausea and vomiting

Datentyp

boolean

Aspiration risk
Beschreibung

Aspiration risk

Datentyp

boolean

Difficult intubation
Beschreibung

Difficult intubation

Datentyp

boolean

State of teeth
Beschreibung

State of teeth

Datentyp

text

Throat Mallampati
Beschreibung

Mallampati score

Datentyp

integer

ASA
Beschreibung

ASA score

Datentyp

text

Urgency
Beschreibung

Urgency

Datentyp

text

Medical procedure
Beschreibung

Medical procedure

Procedure
Beschreibung

Procedure

Datentyp

text

Diagnosis
Beschreibung

Diagnosis

Datentyp

text

Anesthetic technique
Beschreibung

Anesthetic technique

Datentyp

text

Planned anesthetic technique
Beschreibung

Planned anesthetic technique

Datentyp

text

Preoperative round
Beschreibung

Preoperative round

Datentyp

text

Preoperative round conducted
Beschreibung

Preoperative round conducted

Datentyp

boolean

Duration of preoperative round
Beschreibung

Duration of preoperative round

Datentyp

integer

Maßeinheiten
  • min
Type of duty
Beschreibung

Type of duty

Datentyp

text

Date of premedication
Beschreibung

Date of premedication

Datentyp

date

Checklist for ward
Beschreibung

Checklist for ward

Checklist Laboratory
Beschreibung

Checklist Laboratory

Datentyp

text

Checklist ECG
Beschreibung

Checklist ECG

Datentyp

text

Checklist Blood type
Beschreibung

Checklist Blood type

Datentyp

text

Blood type AB0
Beschreibung

Blood type AB0

Datentyp

text

Blood type Rhesus
Beschreibung

Blood type Rhesus

Datentyp

text

Checklist Consultation
Beschreibung

Checklist Consultation

Datentyp

text

Consultation
Beschreibung

Consultation

Datentyp

text

Checklist Pulmonary function
Beschreibung

Checklist Pulmonary function

Datentyp

text

Checklist Chest X-ray
Beschreibung

Checklist Chest X-ray

Datentyp

text

Checklist Autologous blood
Beschreibung

Checklist Autologous blood

Datentyp

text

Autologous blood
Beschreibung

Autologous blood

Datentyp

integer

Checklist Autologous FFP
Beschreibung

Checklist Autologous Fresh frozen plasma

Datentyp

text

Autologous FFP
Beschreibung

Autologous Fresh frozen plasma

Datentyp

integer

Checklist Allogeneic blood on demand
Beschreibung

Checklist Allogeneic blood on demand

Datentyp

text

Allogeneic blood on demand
Beschreibung

Allogeneic blood on demand

Datentyp

integer

Checklist Allogeneic blood in OR
Beschreibung

Checklist Allogeneic blood in OR

Datentyp

text

Allogeneic blood in OR
Beschreibung

Allogeneic blood in OR

Datentyp

integer

Checklist FFP in OR
Beschreibung

Checklist Fresh frozen plasma in OR

Datentyp

text

FFP in OR
Beschreibung

Fresh frozen plasma in OR

Datentyp

integer

Medication
Beschreibung

Medication

Premedication
Beschreibung

Premedication

Datentyp

text

Medication
Beschreibung

Medication

Datentyp

text

Dosage
Beschreibung

Dosage

Datentyp

text

Administration
Beschreibung

Administration

Datentyp

text

Signature
Beschreibung

Signature

Datentyp

text

Further instructions
Beschreibung

Further instructions

Further instructions
Beschreibung

Further instructions

Datentyp

text

Signature
Beschreibung

Signature

Datentyp

text

Further information
Beschreibung

Further information

Continued self-medication
Beschreibung

Continued self-medication

Datentyp

boolean

Exceptions from continued self-medication
Beschreibung

Continued self-medication exceptions

Datentyp

text

Name
Beschreibung

Name

Datentyp

text

Signature
Beschreibung

Signature

Datentyp

text

Time
Beschreibung

Time

Datentyp

time

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Ähnliche Modelle

Premedication Example 1 Routine documentation in German hospitals DMI

1 Formulare
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
Patient data
Item
Department
text
Department
Code List
Department
CL Item
Anesthesiology/Intensive care medicine (Anesthesiology/Intensive care medicine)
CL Item
General and visceral surgery (General and visceral surgery)
CL Item
Ophthalmology (Ophthalmology)
CL Item
Gynecology (Gynecology)
CL Item
Vascular surgery (Vascular surgery)
CL Item
MSZ (MSZ)
CL Item
Pediatric surgery (Pediatric surgery)
CL Item
Urology (Urology)
CL Item
Thoracic surgery (Thoracic surgery)
CL Item
Oral and maxillofacial surgery (Oral and maxillofacial surgery)
CL Item
Otolaryngology (Otolaryngology)
CL Item
Internal medicine (Internal medicine)
CL Item
Neurology (Neurology)
CL Item
Neurosurgery (Neurosurgery)
CL Item
Pediatrics (Pediatrics)
CL Item
Radiology (Radiology)
CL Item
Nuclear medicine (Nuclear medicine)
CL Item
Plastic surgery and burn treatment (Plastic surgery and burn treatment)
CL Item
Dermatology (Dermatology)
CL Item
Other (Other)
Item
Status
text
Status
Code List
Status
CL Item
outpatient (outpatient)
CL Item
in-patient (in-patient)
CL Item
private (private)
Age
Item
Age
integer
Item
Sex
text
Sex
Code List
Sex
CL Item
intersex (intersex)
CL Item
 (male)
CL Item
 (female)
Height
Item
Height
integer
Weight
Item
Weight
integer
Heart rate
Item
Heart rate
integer
C0018810 (UMLS CUI [1])
Blood Pressure
Item
Blood Pressure
text
C0005823 (UMLS CUI [1])
Item Group
Laboratory values
Hemoglobin
Item
Hb
float
Potassium
Item
K
float
Blood sugar
Item
Blood sugar
float
Hematocrit
Item
Ht
float
Sodium
Item
Na
float
Creatinine
Item
Creatinine
float
Prothrombin time
Item
PT
integer
Partial thromboplastin time
Item
PTT
integer
Platelets
Item
Platelets
integer
Item Group
Risk regarding organ function
Heart
Item
Heart
boolean
Lungs
Item
Lungs
boolean
Circulation
Item
Circulation
boolean
Neurology / CNS
Item
Neurology / CNS
boolean
Metabolism
Item
Metabolism
boolean
ASA
Item
BMI > = 40 (ASA III)
boolean
Item Group
Preoperative assessment
Preoperative condition
Item
Preoperative condition
text
Re-narcosis
Item
Re-narcosis
boolean
Long-term medication
Item
Long-term medication
text
Allergies
Item
Allergies
text
Postoperative nausea and vomiting
Item
PONV
boolean
Aspiration risk
Item
Aspiration risk
boolean
Difficult intubation
Item
Difficult intubation
boolean
Item
State of teeth
text
State of teeth
Code List
State of teeth
CL Item
normal (normal)
CL Item
restored (restored)
CL Item
prosthesis (prosthesis)
CL Item
in need of treatment (in need of treatment)
CL Item
at risk (at risk)
Item
Throat Mallampati
integer
Mallampati score
Code List
Throat Mallampati
CL Item
1 (1)
CL Item
2 (2)
CL Item
3 (3)
CL Item
4 (4)
Item
ASA
text
ASA score
Code List
ASA
CL Item
ASA I (ASA I)
CL Item
ASA II (ASA II)
CL Item
ASA III (ASA III)
CL Item
ASA IV (ASA IV)
CL Item
ASA V (ASA V)
CL Item
Brain death (Brain death)
Item
Urgency
text
Urgency
Code List
Urgency
CL Item
planned procedure (planned procedure)
CL Item
urgent (urgent)
CL Item
emergency (emergency)
Item Group
Medical procedure
Procedure
Item
Procedure
text
Diagnosis
Item
Diagnosis
text
Anesthetic technique
Item
Anesthetic technique
text
Item
Planned anesthetic technique
text
Planned anesthetic technique
Code List
Planned anesthetic technique
CL Item
TIVA (TIVA)
CL Item
Balanced anesthesia (Balanced anesthesia)
CL Item
RSI (RSI)
CL Item
Spinal anesthesia (Spinal anesthesia)
CL Item
Lumbar EDA (Lumbar EDA)
CL Item
Thoracic EDA (Thoracic EDA)
CL Item
Peripheral local anesthesia (Peripheral local anesthesia)
CL Item
Local anesthesia with catheter (Local anesthesia with catheter)
CL Item
Analgosedation (Analgosedation)
CL Item
Stand-by/Monitored care (Stand-by/Monitored care)
Item
Preoperative round
text
Preoperative round
Code List
Preoperative round
CL Item
other (other)
CL Item
documents incomplete (documents incomplete)
CL Item
findings missing (findings missing)
CL Item
patient not informed (patient not informed)
CL Item
patient not present (patient not present)
Preoperative round conducted
Item
Preoperative round conducted
boolean
Item
Duration of preoperative round
integer
Duration of preoperative round
Code List
Duration of preoperative round
CL Item
5 (5)
CL Item
10 (10)
CL Item
15 (15)
CL Item
20 (20)
CL Item
25 (25)
CL Item
30 (30)
CL Item
40 (40)
Item
Type of duty
text
Type of duty
Code List
Type of duty
CL Item
regular (regular)
CL Item
overtime/on-call (overtime/on-call)
CL Item
weekend/holiday (weekend/holiday)
CL Item
20-22 (20-22)
CL Item
22-6 (22-6)
Date of premedication
Item
Date of premedication
date
Item Group
Checklist for ward
Item
Checklist Laboratory
text
Laboratory
Code List
Checklist Laboratory
CL Item
To be done (To be done)
CL Item
Not required (Not required)
CL Item
Done (Done)
Item
Checklist ECG
text
ECG
Code List
Checklist ECG
CL Item
To be done (To be done)
CL Item
Not required (Not required)
CL Item
Done (Done)
Item
Checklist Blood type
text
Blood type
Code List
Checklist Blood type
CL Item
Done (Done)
CL Item
 (To be done)
CL Item
 (Not required)
Blood type AB0
Item
Blood type AB0
text
Blood type Rhesus
Item
Blood type Rhesus
text
Item
Checklist Consultation
text
Consultation
Code List
Checklist Consultation
CL Item
To be done (To be done)
CL Item
Not required (Not required)
CL Item
Done (Done)
Consultation
Item
Consultation
text
Item
Checklist Pulmonary function
text
Pulmonary function
Code List
Checklist Pulmonary function
CL Item
To be done (To be done)
CL Item
Not required (Not required)
CL Item
Done (Done)
Item
Checklist Chest X-ray
text
Chest X-ray
Code List
Checklist Chest X-ray
CL Item
To be done (To be done)
CL Item
Not required (Not required)
CL Item
Done (Done)
Item
Checklist Autologous blood
text
Autologous blood
Code List
Checklist Autologous blood
CL Item
To be done (To be done)
CL Item
Not required (Not required)
CL Item
Done (Done)
Item
Autologous blood
integer
Autologous blood
Code List
Autologous blood
CL Item
1 (1)
CL Item
2 (2)
CL Item
3 (3)
CL Item
4 (4)
Item
Checklist Autologous FFP
text
Fresh frozen plasma
Code List
Checklist Autologous FFP
CL Item
To be done (To be done)
CL Item
Not required (Not required)
CL Item
Done (Done)
Item
Autologous FFP
integer
Fresh frozen plasma
Code List
Autologous FFP
CL Item
1 (1)
CL Item
2 (2)
CL Item
3 (3)
CL Item
4 (4)
Item
Checklist Allogeneic blood on demand
text
Allogeneic blood on demand
Code List
Checklist Allogeneic blood on demand
CL Item
To be done (To be done)
CL Item
Not required (Not required)
CL Item
Done (Done)
Item
Allogeneic blood on demand
integer
Allogeneic blood on demand
Code List
Allogeneic blood on demand
CL Item
1 (1)
CL Item
2 (2)
CL Item
3 (3)
CL Item
4 (4)
Item
Checklist Allogeneic blood in OR
text
Allogeneic blood in operating room
Code List
Checklist Allogeneic blood in OR
CL Item
To be done (To be done)
CL Item
Not required (Not required)
CL Item
Done (Done)
Item
Allogeneic blood in OR
integer
Allogeneic blood in operating room
Code List
Allogeneic blood in OR
CL Item
1 (1)
CL Item
2 (2)
CL Item
3 (3)
CL Item
4 (4)
Item
Checklist FFP in OR
text
Fresh frozen plasma in operating room
Code List
Checklist FFP in OR
CL Item
To be done (To be done)
CL Item
Not required (Not required)
CL Item
Done (Done)
Item
FFP in OR
integer
Fresh frozen plasma in operating room
Code List
FFP in OR
CL Item
1 (1)
CL Item
2 (2)
CL Item
3 (3)
CL Item
4 (4)
Item Group
Medication
Premedication
Item
Premedication
text
Medication
Item
Medication
text
Dosage
Item
Dosage
text
Administration
Item
Administration
text
Signature
Item
Signature
text
Item Group
Further instructions
Further instructions
Item
Further instructions
text
Signature
Item
Signature
text
Item Group
Further information
Continued self-medication
Item
Continued self-medication
boolean
Continued self-medication exceptions
Item
Exceptions from continued self-medication
text
Name
Item
Name
text
Signature
Item
Signature
text
Time
Item
Time
time
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