Information:
Fel:
ID
24426
Beskrivning
Routine documentation in German hospitals. Source file name: TH130110_Prämedikationsprotokoll Examplary forms provided by DMI (http://www.dmi.de/)
Länk
Nyckelord
Versioner (3)
- 2017-06-30 2017-06-30 -
- 2017-06-30 2017-06-30 -
- 2017-07-31 2017-07-31 -
Uppladdad den
31 juli 2017
DOI
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Licens
Creative Commons BY-NC 3.0
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Premedication record Routine documentation in German hospitals DMI
Premedication record Routine documentation in German hospitals DMI
Similar models
Premedication record Routine documentation in German hospitals DMI
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
Alias
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])
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])
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])
C0543467 (UMLS CUI [1,2])
Scheduled date of surgery
Item
OP-Termin
date
C1301732 (UMLS CUI [1,1])
C1628561 (UMLS CUI [1,2])
C1628561 (UMLS CUI [1,2])
Urgency
Item
Dringlichkeit
text
C4049774 (UMLS CUI [1])
Position of patient
Item
Lagerung
text
C1561964 (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])
C0445204 (UMLS CUI [1,2])
risk score Postoperative Nausea and Vomiting
Item
Apfel
integer
C0086930 (UMLS CUI [1,1])
C0520909 (UMLS CUI [1,2])
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])
C0445204 (UMLS CUI [1,2])
nutritional condition Preoperative
Item
Präoperativer Zustand EZ
text
C1608413 (UMLS CUI [1,1])
C0445204 (UMLS CUI [1,2])
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])
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])
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])
C0022646 (UMLS CUI [2])
C0030274 (UMLS CUI [3])
C0023884 (UMLS CUI [4])
Long-term medication
Item
Dauermedikation
text
C0420257 (UMLS CUI [1])
Type of anesthesia
Item
Anästhesieform
text
C1305863 (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])
C0445204 (UMLS CUI [1,2])
Medication
Item
Morgenmedikation
text
C0013227 (UMLS CUI [1])
Time of premedication
Item
Prämedikationszeit
text
C0040223 (UMLS CUI [1,1])
C0033045 (UMLS CUI [1,2])
C0033045 (UMLS CUI [1,2])
Premedication
Item
Prämedikation
text
C0033045 (UMLS CUI [1])
eating
Item
Essen möglich bis
text
C0013470 (UMLS CUI [1])
drinking
Item
Trinken möglich bis
text
C0684271 (UMLS CUI [1])
Transfer post operative
Item
Verlegung Post OP
text
C0030704 (UMLS CUI [1,1])
C0241311 (UMLS CUI [1,2])
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])
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])
C0033045 (UMLS CUI [1,2])
Person Premedication
Item
Prämediziert durch
text
C0027361 (UMLS CUI [1,1])
C0033045 (UMLS CUI [1,2])
C0033045 (UMLS CUI [1,2])