ID

24426

Description

Routine documentation in German hospitals. Source file name: TH130110_Prämedikationsprotokoll Examplary forms provided by DMI (http://www.dmi.de/)

Link

http://www.dmi.de/

Keywords

Versions (3)
  1. 6/30/17 6/30/17 -
  2. 6/30/17 6/30/17 -
  3. 7/31/17 7/31/17 -
Uploaded on

July 31, 2017

DOI

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License

Creative Commons BY-NC 3.0
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Premedication record Routine documentation in German hospitals DMI

German English

Premedication record Routine documentation in German hospitals DMI

1 forms  
Patient
Description

Patient

Alias
UMLS CUI-1
C2707520
Nachname
Description

Surname

Data type

text

Alias
UMLS CUI [1]
C0421448
Vorname
Description

First name

Data type

text

Alias
UMLS CUI [1]
C1443235
Fallnummer
Description

Case ID

Data type

text

Alias
UMLS CUI [1,1]
C1698493
UMLS CUI [1,2]
C1300638
Geburtsdatum
Description

Date of birth

Data type

date

Alias
UMLS CUI [1]
C0421451
Alter
Description

Age

Data type

integer

Measurement units
  • years
Alias
UMLS CUI [1]
C0001779
years
Gewicht
Description

Weight

Data type

float

Measurement units
  • kg
Alias
UMLS CUI [1]
C0005910
kg
Größe
Description

Height

Data type

integer

Measurement units
  • cm
Alias
UMLS CUI [1]
C0005890
cm
Geschlecht
Description

Sex

Data type

text

Alias
UMLS CUI [1]
C0079399
Anf. OE
Description

Organizational unit

Data type

text

Alias
UMLS CUI [1]
C0029246
Aufenthalt
Description

Hospital stay

Data type

text

Alias
UMLS CUI [1]
C3489408
OP
Description

OP

Alias
UMLS CUI-1
C0543467
OP-Diagnose(n)
Description

Diagnosis

Data type

text

Alias
UMLS CUI [1]
C0011900
Geplante OP
Description

Planned surgical procedure

Data type

text

Alias
UMLS CUI [1,1]
C1301732
UMLS CUI [1,2]
C0543467
OP-Termin
Description

Scheduled date of surgery

Data type

date

Alias
UMLS CUI [1,1]
C1301732
UMLS CUI [1,2]
C1628561
Dringlichkeit
Description

Urgency

Data type

text

Alias
UMLS CUI [1]
C4049774
Lagerung
Description

Position of patient

Data type

text

Alias
UMLS CUI [1]
C1561964
Präoperativer Zustand
Description

Präoperativer Zustand

Alias
UMLS CUI-1
C0178808
BMI
Description

Body mass index

Data type

float

Measurement units
  • kg/m^2
Alias
UMLS CUI [1]
C1305855
kg/m^2
KOF
Description

Body surface area

Data type

float

Measurement units
  • m²
Alias
UMLS CUI [1]
C0005902
m²
VT
Description

Tidal volume

Data type

integer

Measurement units
  • ml
Alias
UMLS CUI [1]
C0040210
ml
ASA
Description

ASA classification

Data type

integer

Alias
UMLS CUI [1]
C0450990
MET
Description

Functional capacity, metabolic equivalents

Data type

text

Alias
UMLS CUI [1]
C2983100
Präop. Risikoscore
Description

risk score Preoperative

Data type

integer

Alias
UMLS CUI [1,1]
C0086930
UMLS CUI [1,2]
C0445204
Apfel
Description

risk score Postoperative Nausea and Vomiting

Data type

integer

Alias
UMLS CUI [1,1]
C0086930
UMLS CUI [1,2]
C0520909
Allergien
Description

Allergies

Data type

text

Alias
UMLS CUI [1]
C0020517
Mallampati
Description

Mallampati classification

Data type

integer

Alias
UMLS CUI [1]
C1829463
Mundöffnung
Description

Mouth opening

Data type

float

Measurement units
  • cm
Alias
UMLS CUI [1]
C0226895
cm
Kopfreklination
Description

Head reclination

Data type

text

Alias
UMLS CUI [1]
C0444396
Präoperativer Zustand AZ
Description

general condition Preoperative

Data type

text

Alias
UMLS CUI [1,1]
C1142435
UMLS CUI [1,2]
C0445204
Präoperativer Zustand EZ
Description

nutritional condition Preoperative

Data type

text

Alias
UMLS CUI [1,1]
C1608413
UMLS CUI [1,2]
C0445204
Belastbarkeit
Description

Physical fitness

Data type

text

Alias
UMLS CUI [1]
C0031812
Dyspnoe
Description

Dyspnea

Data type

text

Alias
UMLS CUI [1]
C0013404
Relevante Voroperationen
Description

operations

Data type

text

Alias
UMLS CUI [1]
C0543467
Ergänzung Zahnstatus
Description

health status teeth

Data type

text

Alias
UMLS CUI [1,1]
C0018759
UMLS CUI [1,2]
C0040426
Begleiterkrankungen
Description

Comorbidities

Data type

text

Alias
UMLS CUI [1]
C0009488
Herz
Description

Heart

Data type

text

Alias
UMLS CUI [1]
C0018787
Kreislauf / Gefäße / Stoffwechsel & Hormone
Description

blood circulation; blood vessel; hormones

Data type

text

Alias
UMLS CUI [1]
C0005775
UMLS CUI [2]
C0005847
UMLS CUI [3]
C0019932
Lunge / Niere / Pankreas / Leber
Description

Lungs; kidney; pancreas; liver

Data type

text

Alias
UMLS CUI [1]
C0024109
UMLS CUI [2]
C0022646
UMLS CUI [3]
C0030274
UMLS CUI [4]
C0023884
Dauermedikation
Description

Long-term medication

Data type

text

Alias
UMLS CUI [1]
C0420257
Anästhesie
Description

Anästhesie

Alias
UMLS CUI-1
C0002903
Anästhesieform
Description

Type of anesthesia

Data type

text

Alias
UMLS CUI [1]
C1305863
Anordnungen für die Station
Description

Anordnungen für die Station

Alias
UMLS CUI-1
C1442085
EKG
Description

ECG

Data type

text

Alias
UMLS CUI [1]
C1623258
LuFu
Description

Pulmonary function

Data type

text

Alias
UMLS CUI [1]
C0024119
Rö.-Thorax
Description

Chest X-ray

Data type

text

Alias
UMLS CUI [1]
C0039985
Konsil
Description

Consultation

Data type

text

Alias
UMLS CUI [1]
C0009818
Labor
Description

Laboratory

Data type

text

Alias
UMLS CUI [1]
C0022877
Medikation am Vorabend
Description

Medication Preoperative

Data type

text

Alias
UMLS CUI [1,1]
C0013227
UMLS CUI [1,2]
C0445204
Medikation OP-Tag
Description

Medikation OP-Tag

Alias
UMLS CUI-1
C0013227
Morgenmedikation
Description

Medication

Data type

text

Alias
UMLS CUI [1]
C0013227
Prämedikationszeit
Description

Time of premedication

Data type

text

Alias
UMLS CUI [1,1]
C0040223
UMLS CUI [1,2]
C0033045
Prämedikation
Description

Premedication

Data type

text

Alias
UMLS CUI [1]
C0033045
Essen /Trinken
Description

Essen /Trinken

Alias
UMLS CUI-1
C0559899
Essen möglich bis
Description

eating

Data type

text

Alias
UMLS CUI [1]
C0013470
Trinken möglich bis
Description

drinking

Data type

text

Alias
UMLS CUI [1]
C0684271
Sonstiges
Description

Sonstiges

Alias
UMLS CUI-1
C1533716
Verlegung Post OP
Description

Transfer post operative

Data type

text

Alias
UMLS CUI [1,1]
C0030704
UMLS CUI [1,2]
C0241311
Freigabe
Description

Release

Data type

text

Alias
UMLS CUI [1]
C0030685
Verabreicht von
Description

person Administration procedure

Data type

text

Alias
UMLS CUI [1,1]
C0027361
UMLS CUI [1,2]
C1533734
Verabreicht um
Description

Time of administration

Data type

time

Alias
UMLS CUI [1]
C1317775
Prämediziert am
Description

Date of premedication

Data type

date

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C0033045
Prämediziert durch
Description

Person Premedication

Data type

text

Alias
UMLS CUI [1,1]
C0027361
UMLS CUI [1,2]
C0033045
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Similar models

Premedication record Routine documentation in German hospitals DMI

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Patient
C2707520 (UMLS CUI-1)
Surname
Item
Nachname
text
C0421448 (UMLS CUI [1])
First name
Item
Vorname
text
C1443235 (UMLS CUI [1])
Case ID
Item
Fallnummer
text
C1698493 (UMLS CUI [1,1])
C1300638 (UMLS CUI [1,2])
Date of birth
Item
Geburtsdatum
date
C0421451 (UMLS CUI [1])
Age
Item
Alter
integer
C0001779 (UMLS CUI [1])
Weight
Item
Gewicht
float
C0005910 (UMLS CUI [1])
Height
Item
Größe
integer
C0005890 (UMLS CUI [1])
Sex
Item
Geschlecht
text
C0079399 (UMLS CUI [1])
Organizational unit
Item
Anf. OE
text
C0029246 (UMLS CUI [1])
Hospital stay
Item
Aufenthalt
text
C3489408 (UMLS CUI [1])
Item Group
OP
C0543467 (UMLS CUI-1)
Diagnosis
Item
OP-Diagnose(n)
text
C0011900 (UMLS CUI [1])
Planned surgical procedure
Item
Geplante OP
text
C1301732 (UMLS CUI [1,1])
C0543467 (UMLS CUI [1,2])
Scheduled date of surgery
Item
OP-Termin
date
C1301732 (UMLS CUI [1,1])
C1628561 (UMLS CUI [1,2])
Urgency
Item
Dringlichkeit
text
C4049774 (UMLS CUI [1])
Position of patient
Item
Lagerung
text
C1561964 (UMLS CUI [1])
Item Group
Präoperativer Zustand
C0178808 (UMLS CUI-1)
Body mass index
Item
BMI
float
C1305855 (UMLS CUI [1])
Body surface area
Item
KOF
float
C0005902 (UMLS CUI [1])
Tidal volume
Item
VT
integer
C0040210 (UMLS CUI [1])
ASA classification
Item
ASA
integer
C0450990 (UMLS CUI [1])
Functional capacity, metabolic equivalents
Item
MET
text
C2983100 (UMLS CUI [1])
risk score Preoperative
Item
Präop. Risikoscore
integer
C0086930 (UMLS CUI [1,1])
C0445204 (UMLS CUI [1,2])
risk score Postoperative Nausea and Vomiting
Item
Apfel
integer
C0086930 (UMLS CUI [1,1])
C0520909 (UMLS CUI [1,2])
Allergies
Item
Allergien
text
C0020517 (UMLS CUI [1])
Mallampati classification
Item
Mallampati
integer
C1829463 (UMLS CUI [1])
Mouth opening
Item
Mundöffnung
float
C0226895 (UMLS CUI [1])
Head reclination
Item
Kopfreklination
text
C0444396 (UMLS CUI [1])
general condition Preoperative
Item
Präoperativer Zustand AZ
text
C1142435 (UMLS CUI [1,1])
C0445204 (UMLS CUI [1,2])
nutritional condition Preoperative
Item
Präoperativer Zustand EZ
text
C1608413 (UMLS CUI [1,1])
C0445204 (UMLS CUI [1,2])
Physical fitness
Item
Belastbarkeit
text
C0031812 (UMLS CUI [1])
Dyspnea
Item
Dyspnoe
text
C0013404 (UMLS CUI [1])
operations
Item
Relevante Voroperationen
text
C0543467 (UMLS CUI [1])
health status teeth
Item
Ergänzung Zahnstatus
text
C0018759 (UMLS CUI [1,1])
C0040426 (UMLS CUI [1,2])
Comorbidities
Item
Begleiterkrankungen
text
C0009488 (UMLS CUI [1])
Heart
Item
Herz
text
C0018787 (UMLS CUI [1])
blood circulation; blood vessel; hormones
Item
Kreislauf / Gefäße / Stoffwechsel & Hormone
text
C0005775 (UMLS CUI [1])
C0005847 (UMLS CUI [2])
C0019932 (UMLS CUI [3])
Lungs; kidney; pancreas; liver
Item
Lunge / Niere / Pankreas / Leber
text
C0024109 (UMLS CUI [1])
C0022646 (UMLS CUI [2])
C0030274 (UMLS CUI [3])
C0023884 (UMLS CUI [4])
Long-term medication
Item
Dauermedikation
text
C0420257 (UMLS CUI [1])
Item Group
Anästhesie
C0002903 (UMLS CUI-1)
Type of anesthesia
Item
Anästhesieform
text
C1305863 (UMLS CUI [1])
Item Group
Anordnungen für die Station
C1442085 (UMLS CUI-1)
ECG
Item
EKG
text
C1623258 (UMLS CUI [1])
Pulmonary function
Item
LuFu
text
C0024119 (UMLS CUI [1])
Chest X-ray
Item
Rö.-Thorax
text
C0039985 (UMLS CUI [1])
Consultation
Item
Konsil
text
C0009818 (UMLS CUI [1])
Laboratory
Item
Labor
text
C0022877 (UMLS CUI [1])
Medication Preoperative
Item
Medikation am Vorabend
text
C0013227 (UMLS CUI [1,1])
C0445204 (UMLS CUI [1,2])
Item Group
Medikation OP-Tag
C0013227 (UMLS CUI-1)
Medication
Item
Morgenmedikation
text
C0013227 (UMLS CUI [1])
Time of premedication
Item
Prämedikationszeit
text
C0040223 (UMLS CUI [1,1])
C0033045 (UMLS CUI [1,2])
Premedication
Item
Prämedikation
text
C0033045 (UMLS CUI [1])
Item Group
Essen /Trinken
C0559899 (UMLS CUI-1)
eating
Item
Essen möglich bis
text
C0013470 (UMLS CUI [1])
drinking
Item
Trinken möglich bis
text
C0684271 (UMLS CUI [1])
Item Group
Sonstiges
C1533716 (UMLS CUI-1)
Transfer post operative
Item
Verlegung Post OP
text
C0030704 (UMLS CUI [1,1])
C0241311 (UMLS CUI [1,2])
Release
Item
Freigabe
text
C0030685 (UMLS CUI [1])
person Administration procedure
Item
Verabreicht von
text
C0027361 (UMLS CUI [1,1])
C1533734 (UMLS CUI [1,2])
Time of administration
Item
Verabreicht um
time
C1317775 (UMLS CUI [1])
Date of premedication
Item
Prämediziert am
date
C0011008 (UMLS CUI [1,1])
C0033045 (UMLS CUI [1,2])
Person Premedication
Item
Prämediziert durch
text
C0027361 (UMLS CUI [1,1])
C0033045 (UMLS CUI [1,2])
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