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ID
23992
Descripción
Routine documentation in German hospitals. Source file name: TH130110_Prämedikationsprotokoll Examplary forms provided by DMI (http://www.dmi.de/)
Link
Palabras clave
Versiones (5)
- 8/7/17 8/7/17 -
- 8/7/17 8/7/17 -
- 8/7/17 8/7/17 -
- 20/7/17 20/7/17 -
- 31/7/17 31/7/17 -
Subido en
20 de julio de 2017
DOI
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Licencia
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
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Premedication Anesthesiology Intensive care Catholic Clinic Koblenz Montabaur Routine documentation in German hospitals DMI
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
Alias
Case ID
Item
Fallnummer
text
Date of anesthesia
Item
Anästhesiedatum
date
Date of birth
Item
Geburtsdatum
date
C0421451 (UMLS CUI [1])
Height
Item
Größe
integer
Weight
Item
Gewicht
integer
CL Item
AIN (Anesthesiology/Intensive care medicine)
CL Item
ACH (General and visceral surgery)
CL Item
GYN (Gynecology)
CL Item
URO (Urology)
CL Item
TCH (Thoracic surgery)
CL Item
MKG (Oral and maxillofacial surgery)
CL Item
HNO (Otolaryngology)
CL Item
NEU (Neurology)
CL Item
RAD (Radiology)
CL Item
Sonst (Other)
CL Item
KAR (Cardiology)
CL Item
PNE (Pneumology)
CL Item
SMT (Pain therapy)
CL Item
UCH (Trauma surgery)
CL Item
WSCH (Spinal surgery)
CL Item
Endo (Endoprosthetics)
CL Item
Arthro (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
männlich (male)
CL Item
weiblich (female)
CL Item
ja (yes)
CL Item
nein (no)
CL Item
unbekannt (unknown)
CL Item
ambulant (outpatient)
CL Item
stationär (in-patient)
CL Item
privat (private)
CL Item
dringlich (urgent)
CL Item
Notfall (emergency)
CL Item
elektiv (elective)
Preoperative diagnosis
Item
Präoperative Diagnose
text
Planned procedure
Item
Geplante Maßnahme/Operation
text
Planned anesthetic technique
Item
Geplante Anästhesietechnik
text
Specifics
Item
Besonderheiten
text
Rapid sequence induction
Item
Ileuseinleitung
boolean
Pre-existing conditions, previous surgeries/narcoses
Item
Vorerkrankungen, Voroperationen, Komplikationen bei Vornarkosen
text
Re-narcosis
Item
Re-Narkose
boolean
Acute care
Item
Akutversorgung
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
zu erwarten (to be expected)
CL Item
bekannt (known)
CL Item
Reklination eingeschränkt (restricted reclination)
CL Item
Mallampati (Mallampati)
Mallampati score
Item
Mallampati
integer
Blood Pressure
Item
Blutdruck
text
C0005823 (UMLS CUI [1])
Heart rate
Item
HF
integer
C0018810 (UMLS CUI [1])
Peripheral oxygen saturation
Item
psO2
text
Blood type
Item
Blutgruppe
text
Employer's Liability Insurance Association number
Item
Prüfnummer BG
text
Irregular antibodies
Item
irreguläre AK
text
CL Item
Prothese (prosthesis)
CL Item
behandlungsbed. (in need of treatment)
CL Item
gefährdet (at risk)
CL Item
saniert/normal (restored/normal)
CL Item
>6 (>6)
CL Item
<6 (<6)
Long-term medication
Item
Dauermedikation
text
Allergies
Item
Allergien
text
Blood pressure
Item
Blutdruck
boolean
Myocardium
Item
Myokard
boolean
Coronary function
Item
Koronarfunktion
boolean
ECG
Item
EKG
boolean
Vascular system
Item
Gefäßsystem
boolean
Lungs/respiratory tract
Item
Lunge/Atemwege
boolean
Chest X-ray
Item
Rö.-Thorax
boolean
Consciousness
Item
Bewusstseinslage
boolean
Neurology
Item
Neurologie
boolean
Muscles
Item
Muskulatur
boolean
Endocrine system
Item
Endokrinium
boolean
Liver
Item
Leber
boolean
Kidney
Item
Niere
boolean
Diabetes mellitus
Item
Diabetes mellitus
boolean
Hematology
Item
Hämatologie
boolean
Coagulation
Item
Gerinnung
boolean
Nutritional status
Item
Ernährungszustand
boolean
Comorbidites free text
Item
Begleiterkrankungen Freitext
text
Aspiration
Item
Aspiration
boolean
Polytrauma
Item
Polytrauma
boolean
Intensive care patient
Item
Intensivpatient
boolean
MI
Item
MI < 6 Wochen
boolean
Acute coronary syndrome
Item
Akutes Koronarsyndrom
boolean
Catecholamines
Item
Katecholaminpfl.
boolean
Respiratory tract infection
Item
Atemwegsinfekt
boolean
Chronic obstructive pulmonary disease
Item
COPD
boolean
Asthma
Item
Asthma
boolean
Sepsis
Item
Sepsis
boolean
Pregnancy
Item
Schwangerschaft
boolean
Preterm birth
Item
Frühgeburt
boolean
HIV
Item
HIV
boolean
Viral hepatits
Item
Virus-Hepatits
boolean
Disposition for malignant hyperpyrexia
Item
MH-Disposition
boolean
Alcohol
Item
Alkohol
boolean
Nicotine
Item
Nikotin
boolean
Drugs
Item
Drogen
boolean
Hematocrit/Hemoglobin
Item
Hkt/Hb
text
Leukocytes
Item
Leukos
integer
Sodium
Item
Na
float
Potassium
Item
K
float
Calcium
Item
Ca
float
Creatinine
Item
Krea
float
Blood sugar
Item
Glukose
float
Glutamic oxaloacetic transaminase
Item
GOT
float
Glutamate-pyruvate transaminase
Item
GPT
float
Gamma-glutamyltransferase
Item
gamma-GT
float
Platelets
Item
Thrombos
integer
Prothrombin time
Item
Quick
integer
Partial thromboplastin time
Item
PTT
integer
Thrombin time
Item
TZ
float
Red cell concentrate
Item
Erykonz. (Anzahl)
integer
Fresh frozen plasma
Item
FFP (Anzahl)
integer
Other
Item
Sonst.
text
Medication
Item
Medikament
text
Dosage
Item
Dosis
text
Administration
Item
Applikation
text
Time
Item
Uhrzeit
time
Signature
Item
Signatur
text
Medication
Item
Medikament
text
Dosage
Item
Dosis
text
Administration
Item
Applikation
text
Time
Item
Uhrzeit
text
Signature
Item
Signatur
text
Laboratory
Item
Labor
boolean
Coagulation status
Item
G-Status
text
ECG
Item
EKG
boolean
Chest X-ray
Item
Röntgen-Thorax
boolean
Pulmonary function
Item
Lungenfunktion
boolean
Consultation
Item
Konsil
boolean
Medical orders specifications
Item
Spezifikationen
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
RD (regular)
CL Item
ÜS (overtime)
CL Item
BD (on-call)
CL Item
(day)
Date
Item
Datum
date
Time
Item
Uhrzeit
time
Name
Item
Name
text
Signature
Item
Unterschrift
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
ÜS (overtime)
CL Item
BD (on-call)
CL Item
RD (regular)
CL Item
TD (day)
Date
Item
Datum
date
Time
Item
Uhrzeit
time
Name
Item
Name
text
Signature
Item
Unterschrift
text
No surgey after premedication
Item
nach Prämed. keine OP
boolean