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ID
23992
Beschreibung
Routine documentation in German hospitals. Source file name: TH130110_Prämedikationsprotokoll Examplary forms provided by DMI (http://www.dmi.de/)
Link
Stichworte
Versionen (5)
- 08.07.17 08.07.17 -
- 08.07.17 08.07.17 -
- 08.07.17 08.07.17 -
- 20.07.17 20.07.17 -
- 31.07.17 31.07.17 -
Hochgeladen am
20. Juli 2017
DOI
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Creative Commons BY-NC 3.0
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Premedication Anesthesiology Intensive care Catholic Clinic Koblenz Montabaur Routine documentation in German hospitals DMI
Premedication Anesthesiology Intensive care Catholic Clinic Koblenz Montabaur Routine documentation in German hospitals DMI
Ähnliche Modelle
Premedication Anesthesiology Intensive care Catholic Clinic Koblenz Montabaur Routine documentation in German hospitals DMI
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Case ID
Item
Case ID
text
Date of anesthesia
Item
Date of anesthesia
date
Date of birth
Item
Date of birth
date
C0421451 (UMLS CUI [1])
Height
Item
Height
integer
Weight
Item
Weight
integer
CL Item
Anesthesiology/Intensive care medicine (Anesthesiology/Intensive care medicine)
CL Item
General and visceral surgery (General and visceral surgery)
CL Item
Gynecology (Gynecology)
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
Neurology (Neurology)
CL Item
Radiology (Radiology)
CL Item
Other (Other)
CL Item
Cardiology (Cardiology)
CL Item
Pneumology (Pneumology)
CL Item
Pain therapy (Pain therapy)
CL Item
Trauma surgery (Trauma surgery)
CL Item
Spinal surgery (Spinal surgery)
CL Item
Endoprosthetics (Endoprosthetics)
CL Item
Arthroscopic surgery (Arthroscopic surgery)
CL Item
MH Koblenz (MH Koblenz)
CL Item
BH Koblenz (BH Koblenz)
CL Item
BKH Montabaur (BKH Montabaur)
CL Item
intersex (intersex)
CL Item
(male)
CL Item
(female)
CL Item
yes (yes)
CL Item
no (no)
CL Item
unknown (unknown)
CL Item
outpatient (outpatient)
CL Item
in-patient (in-patient)
CL Item
private (private)
CL Item
urgent (urgent)
CL Item
emergency (emergency)
CL Item
(elective)
Preoperative diagnosis
Item
Preoperative diagnosis
text
Planned procedure
Item
Planned procedure
text
Planned anesthetic technique
Item
Planned anesthetic technique
text
Specifics
Item
Specifics
text
Rapid sequence induction
Item
Rapid sequence induction (RSI)
boolean
Pre-existing conditions, previous surgeries/narcoses
Item
Pre-existing conditions, previous surgeries, complications during previos narcoses
text
Re-narcosis
Item
Re-narcosis
boolean
Acute care
Item
Acute care
boolean
CL Item
0 (0)
CL Item
1 (1)
CL Item
2 (2)
CL Item
3 (3)
CL Item
4 (4)
CL Item
4+ (5)
CL Item
1 (1)
CL Item
2 (2)
CL Item
3 (3)
CL Item
4 (4)
CL Item
5 (5)
CL Item
to be expected (to be expected)
CL Item
known (known)
CL Item
restricted reclination (restricted reclination)
CL Item
Mallampati (Mallampati)
Mallampati score
Item
Mallampati
integer
Blood Pressure
Item
Blood Pressure
text
C0005823 (UMLS CUI [1])
Heart rate
Item
Heart rate
integer
C0018810 (UMLS CUI [1])
Peripheral oxygen saturation
Item
psO2
text
Blood type
Item
Blood type
text
Employer's Liability Insurance Association number
Item
Employer's Liability Insurance Association number
text
Irregular antibodies
Item
Irregular antibodies
text
CL Item
prosthesis (prosthesis)
CL Item
in need of treatment (in need of treatment)
CL Item
at risk (at risk)
CL Item
restored/normal (restored/normal)
CL Item
>6 (>6)
CL Item
<6 (<6)
Long-term medication
Item
Long-term medication
text
Allergies
Item
Allergies
text
Blood pressure
Item
Blood pressure
boolean
Myocardium
Item
Myocardium
boolean
Coronary function
Item
Coronary function
boolean
ECG
Item
ECG
boolean
Vascular system
Item
Vascular system
boolean
Lungs/respiratory tract
Item
Lungs/respiratory tract
boolean
Chest X-ray
Item
Chest X-ray
boolean
Consciousness
Item
Consciousness
boolean
Neurology
Item
Neurology
boolean
Muscles
Item
Muscles
boolean
Endocrine system
Item
Endocrine system
boolean
Liver
Item
Liver
boolean
Kidney
Item
Kidney
boolean
Diabetes mellitus
Item
Diabetes mellitus
boolean
Hematology
Item
Hematology
boolean
Coagulation
Item
Coagulation
boolean
Nutritional status
Item
Nutritional status
boolean
Comorbidites free text
Item
Free text
text
Aspiration
Item
Aspiration
boolean
Polytrauma
Item
Polytrauma
boolean
Intensive care patient
Item
Intensive care patient
boolean
MI
Item
MI < 6 Wochen
boolean
Acute coronary syndrome
Item
Acute coronary syndrome
boolean
Catecholamines
Item
Intake of catecholamines required
boolean
Respiratory tract infection
Item
Respiratory tract infection
boolean
Chronic obstructive pulmonary disease
Item
COPD
boolean
Asthma
Item
Asthma
boolean
Sepsis
Item
Sepsis
boolean
Pregnancy
Item
Pregnancy
boolean
Preterm birth
Item
Preterm birth
boolean
HIV
Item
HIV
boolean
Viral hepatits
Item
Viral hepatits
boolean
Disposition for malignant hyperpyrexia
Item
Disposition for malignant hyperpyrexia
boolean
Alcohol
Item
Alcohol
boolean
Nicotine
Item
Nicotine
boolean
Drugs
Item
Drugs
boolean
Hematocrit/Hemoglobin
Item
Hb/Ht
text
Leukocytes
Item
Leukocytes
integer
Sodium
Item
Na
float
Potassium
Item
K
float
Calcium
Item
Ca
float
Creatinine
Item
Creatinine
float
Blood sugar
Item
Glucose
float
Glutamic oxaloacetic transaminase
Item
GOT
float
Glutamate-pyruvate transaminase
Item
GPT
float
Gamma-glutamyltransferase
Item
GGT
float
Platelets
Item
Platelets
integer
Prothrombin time
Item
PT
integer
Partial thromboplastin time
Item
PTT
integer
Thrombin time
Item
TT
float
Red cell concentrate
Item
Red cell concentrate (number)
integer
Fresh frozen plasma
Item
FFP (number)
integer
Other
Item
Other
text
Medication
Item
Medication
text
Dosage
Item
Dosage
text
Administration
Item
Administration
text
Time
Item
Time
time
Signature
Item
Signature
text
Medication
Item
Medication
text
Dosage
Item
Dosage
text
Administration
Item
Administration
text
Time
Item
Time
text
Signature
Item
Signature
text
Laboratory
Item
Laboratory
boolean
Coagulation status
Item
Coagulation status
text
ECG
Item
ECG
boolean
Chest X-ray
Item
Chest X-ray
boolean
Pulmonary function
Item
Pulmonary function
boolean
Consultation
Item
Consultation
boolean
Medical orders specifications
Item
Specifications
text
CL Item
5 (5)
CL Item
10 (10)
CL Item
20 (20)
CL Item
30 (30)
CL Item
40 (40)
CL Item
50 (50)
CL Item
60 (60)
CL Item
regular (regular)
CL Item
overtime (overtime)
CL Item
on-call (on-call)
CL Item
day (day)
Date
Item
Date
date
Time
Item
Time
time
Name
Item
Name
text
Signature
Item
Signature
text
CL Item
5 (5)
CL Item
10 (10)
CL Item
20 (20)
CL Item
30 (30)
CL Item
40 (40)
CL Item
50 (50)
CL Item
60 (60)
CL Item
overtime (overtime)
CL Item
on-call (on-call)
CL Item
regular (regular)
CL Item
day (day)
Date
Item
Date
date
Time
Item
Time
time
Name
Item
Name
text
Signature
Item
Signature
text
No surgey after premedication
Item
No surgey after premedication
boolean