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ID
23989
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 (4)
- 7/5/17 7/5/17 -
- 7/20/17 7/20/17 -
- 7/31/17 7/31/17 -
- 9/20/21 9/20/21 -
Uploaded on
July 20, 2017
DOI
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License
Creative Commons BY-NC 3.0
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Premedication Example 1 Routine documentation in German hospitals DMI
Premedication Example 1 Routine documentation in German hospitals DMI
Similar models
Premedication Example 1 Routine documentation in German hospitals DMI
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
CL Item
AIN (Anesthesiology/Intensive care medicine)
CL Item
ACH (General and visceral surgery)
CL Item
AUG (Ophthalmology)
CL Item
GYN (Gynecology)
CL Item
GCH (Vascular surgery)
CL Item
MSZ (MSZ)
CL Item
PCH (Pediatric surgery)
CL Item
URO (Urology)
CL Item
TCH (Thoracic surgery)
CL Item
MKG (Oral and maxillofacial surgery)
CL Item
HNO (Otolaryngology)
CL Item
MED (Internal medicine)
CL Item
NEU (Neurology)
CL Item
NCH (Neurosurgery)
CL Item
PED (Pediatrics)
CL Item
RAD (Radiology)
CL Item
NUC (Nuclear medicine)
CL Item
PWC (Plastic surgery and burn treatment)
CL Item
DRM (Dermatology)
CL Item
SON (Other)
CL Item
ambulant (outpatient)
CL Item
stationär (in-patient)
CL Item
privat (private)
Age
Item
Alter
integer
CL Item
intersex (intersex)
CL Item
männlich (male)
CL Item
weiblich (female)
Height
Item
Größe
integer
Weight
Item
Gewicht
integer
Heart rate
Item
HF
integer
C0018810 (UMLS CUI [1])
Blood Pressure
Item
RR
text
C0005823 (UMLS CUI [1])
Hemoglobin
Item
Hb
float
Potassium
Item
K
float
Blood sugar
Item
BZ
float
Hematocrit
Item
Hk
float
Sodium
Item
Na
float
Creatinine
Item
Krea
float
Prothrombin time
Item
Quick
integer
Partial thromboplastin time
Item
PTT
integer
Platelets
Item
Thr
integer
Heart
Item
Herz
boolean
Lungs
Item
Lunge
boolean
Circulation
Item
Kreislauf
boolean
Neurology / CNS
Item
Neurologie / ZNS
boolean
Metabolism
Item
Stoffwechsel
boolean
ASA
Item
BMI > = 40 (ASA III)
boolean
Preoperative condition
Item
Präoperativer Zustand
text
Re-narcosis
Item
Wiederholungsnarkose
boolean
Long-term medication
Item
Dauermedikation
text
Allergies
Item
Allergien
text
Postoperative nausea and vomiting
Item
PONV
boolean
Aspiration risk
Item
Aspirationsrisiko
boolean
Difficult intubation
Item
erschwerte Intubat.
boolean
CL Item
normal (normal)
CL Item
saniert (restored)
CL Item
Prothese (prosthesis)
CL Item
beh. bed. (in need of treatment)
CL Item
gefährdet (at risk)
CL Item
1 (1)
CL Item
2 (2)
CL Item
3 (3)
CL Item
4 (4)
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
Hirntod (Brain death)
CL Item
geplanter Eingriff (planned procedure)
CL Item
dringlich (urgent)
CL Item
Notfall (emergency)
Procedure
Item
Eingriff
text
Diagnosis
Item
Diagnose
text
Anesthetic technique
Item
Anästhesieverfahren
text
CL Item
TIVA (TIVA)
CL Item
Balancierte Anästhesie (Balanced anesthesia)
CL Item
RSI (RSI)
CL Item
Spinalanästhesie (Spinal anesthesia)
CL Item
EDA lumbal (Lumbar EDA)
CL Item
EDA thorakal (Thoracic EDA)
CL Item
Periphere Regionalanästhesie (Peripheral local anesthesia)
CL Item
Regionalanästhesie mit Katheterverfahren (Local anesthesia with catheter)
CL Item
Analgosedierung (Analgosedation)
CL Item
Stand by/Monitored care (Stand-by/Monitored care)
CL Item
Sonstiges (other)
CL Item
Unterlagen unvollst. (documents incomplete)
CL Item
fehlende Befunde (findings missing)
CL Item
Pat. nicht informiert (patient not informed)
CL Item
Pat. nicht anwesend (patient not present)
Preoperative round conducted
Item
Präop. Visite durchgeführt
boolean
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)
CL Item
RG (regular)
CL Item
ÜS/BD (overtime/on-call)
CL Item
Sa/So/F (weekend/holiday)
CL Item
20-22 (20-22)
CL Item
22-6 (22-6)
Date of premedication
Item
Prämedikationsdatum
date
CL Item
zu erledigen (To be done)
CL Item
nicht erforderlich (Not required)
CL Item
erledigt (Done)
CL Item
zu erledigen (To be done)
CL Item
nicht erforderlich (Not required)
CL Item
erledigt (Done)
CL Item
erledigt (Done)
CL Item
zu erledigen (To be done)
CL Item
nicht erforderlich (Not required)
Blood type AB0
Item
Blutgruppe AB0
text
Blood type Rhesus
Item
Blutgruppe Rhesus
text
CL Item
zu erledigen (To be done)
CL Item
nicht erforderlich (Not required)
CL Item
erledigt (Done)
Consultation
Item
Konsilium
text
CL Item
zu erledigen (To be done)
CL Item
nicht erforderlich (Not required)
CL Item
erledigt (Done)
CL Item
zu erledigen (To be done)
CL Item
nicht erforderlich (Not required)
CL Item
erledigt (Done)
CL Item
zu erledigen (To be done)
CL Item
nicht erforderlich (Not required)
CL Item
erledigt (Done)
CL Item
1 (1)
CL Item
2 (2)
CL Item
3 (3)
CL Item
4 (4)
CL Item
zu erledigen (To be done)
CL Item
nicht erforderlich (Not required)
CL Item
erledigt (Done)
CL Item
1 (1)
CL Item
2 (2)
CL Item
3 (3)
CL Item
4 (4)
CL Item
zu erledigen (To be done)
CL Item
nicht erforderlich (Not required)
CL Item
erledigt (Done)
CL Item
1 (1)
CL Item
2 (2)
CL Item
3 (3)
CL Item
4 (4)
CL Item
zu erledigen (To be done)
CL Item
nicht erforderlich (Not required)
CL Item
erledigt (Done)
CL Item
1 (1)
CL Item
2 (2)
CL Item
3 (3)
CL Item
4 (4)
CL Item
zu erledigen (To be done)
CL Item
nicht erforderlich (Not required)
CL Item
erledigt (Done)
CL Item
1 (1)
CL Item
2 (2)
CL Item
3 (3)
CL Item
4 (4)
Premedication
Item
Prämedikation
text
Medication
Item
Medikament
text
Dosage
Item
Dosis
text
Administration
Item
Appl.
text
Signature
Item
Signat.
text
Further instructions
Item
Weitere Anweisungen
text
Signature
Item
Signatur
text
Continued self-medication
Item
Eigenmedikation weiter
boolean
Continued self-medication exceptions
Item
Eigenmedikation weiter, außer:
text
Name
Item
Name
text
Signature
Item
Unterschrift
text
Time
Item
Uhrzeit
time