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24429
Beschreibung
Routine documentation in German hospitals. Source file name: TH130110_Prämedikationsprotokoll Examplary forms provided by DMI (http://www.dmi.de/)
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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
31. 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
Fallnummer
text
C1698493 (UMLS CUI [1,1])
C0600091 (UMLS CUI [1,2])
C0600091 (UMLS CUI [1,2])
Date of anesthesia
Item
Anästhesiedatum
date
C0002903 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,2])
Date of birth
Item
Geburtsdatum
date
C0421451 (UMLS CUI [1])
Height
Item
Größe
integer
C0005890 (UMLS CUI [1])
Weight
Item
Gewicht
integer
C0005910 (UMLS CUI [1])
CL Item
AIN (Anesthesiology/Intensive care medicine)
C0002930 (UMLS CUI-1)
(Comment:en)
(Comment:en)
CL Item
ACH (General and visceral surgery)
C1274039 (UMLS CUI-1)
(Comment:en)
(Comment:en)
CL Item
GYN (Gynecology)
C0018417 (UMLS CUI-1)
(Comment:en)
(Comment:en)
CL Item
URO (Urology)
C0042077 (UMLS CUI-1)
(Comment:en)
(Comment:en)
CL Item
TCH (Thoracic surgery)
C0587506 (UMLS CUI-1)
(Comment:en)
(Comment:en)
CL Item
MKG (Oral and maxillofacial surgery)
C0812928 (UMLS CUI-1)
(Comment:en)
(Comment:en)
CL Item
HNO (Otolaryngology)
C0029892 (UMLS CUI-1)
(Comment:en)
(Comment:en)
CL Item
NEU (Neurology)
C0027855 (UMLS CUI-1)
(Comment:en)
(Comment:en)
CL Item
RAD (Radiology)
C0034599 (UMLS CUI-1)
(Comment:en)
(Comment:en)
CL Item
Sonst (Other)
C0205394 (UMLS CUI-1)
(Comment:en)
(Comment:en)
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)
C0029921 (UMLS CUI-1)
(Comment:en)
(Comment:en)
CL Item
stationär (in-patient)
C0021562 (UMLS CUI-1)
(Comment:en)
(Comment:en)
CL Item
privat (private)
(Comment:en)
CL Item
dringlich (urgent)
C3272275 (UMLS CUI-1)
(Comment:en)
(Comment:en)
CL Item
Notfall (emergency)
C4264510 (UMLS CUI-1)
(Comment:en)
(Comment:en)
CL Item
elektiv (elective)
C0206058 (UMLS CUI-1)
(Comment:en)
(Comment:en)
Preoperative diagnosis
Item
Präoperative Diagnose
text
C1318968 (UMLS CUI [1])
Planned procedure
Item
Geplante Maßnahme/Operation
text
C0087111 (UMLS CUI [1,1])
C1301732 (UMLS CUI [1,2])
C1301732 (UMLS CUI [1,2])
anesthesia
Item
Geplante Anästhesietechnik
text
C0002903 (UMLS CUI [1])
Specifics
Item
Besonderheiten
text
C2348235 (UMLS CUI [1])
Rapid sequence induction
Item
Ileuseinleitung
boolean
C0412767 (UMLS CUI [1])
Item Group
Präoperativer Zustand
C1516048 (UMLS CUI-1)
C0445204 (UMLS CUI-2)
C0445204 (UMLS CUI-2)
comorbity; surgery
Item
Vorerkrankungen, Voroperationen, Komplikationen bei Vornarkosen
text
C0009488 (UMLS CUI [1])
C0543467 (UMLS CUI [2])
C0543467 (UMLS CUI [2])
narcosis
Item
Re-Narkose
boolean
C0234447 (UMLS CUI [1])
Acute care
Item
Akutversorgung
boolean
C0679878 (UMLS CUI [1])
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
C0451276 (UMLS CUI [1])
Blood Pressure
Item
Blutdruck
text
C0005823 (UMLS CUI [1])
Heart rate
Item
HF
integer
C0018810 (UMLS CUI [1])
Peripheral oxygen saturation
Item
psO2
text
C2317096 (UMLS CUI [1])
Blood type
Item
Blutgruppe
text
C0005810 (UMLS CUI [1])
Insurance number
Item
Prüfnummer BG
text
C0021672 (UMLS CUI [1,1])
C1300638 (UMLS CUI [1,2])
C1300638 (UMLS CUI [1,2])
antibodies
Item
irreguläre AK
text
C0003241 (UMLS CUI [1])
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
C0420257 (UMLS CUI [1])
Allergies
Item
Allergien
text
C0020517 (UMLS CUI [1])
Blood pressure
Item
Blutdruck
boolean
C0005823 (UMLS CUI [1])
Myocardium
Item
Myokard
boolean
C0027061 (UMLS CUI [1])
Coronary function
Item
Koronarfunktion
boolean
C1522318 (UMLS CUI [1,1])
C0542341 (UMLS CUI [1,2])
C0542341 (UMLS CUI [1,2])
ECG
Item
EKG
boolean
C1623258 (UMLS CUI [1])
Vascular system
Item
Gefäßsystem
boolean
C0489903 (UMLS CUI [1])
respiratory tract
Item
Lunge/Atemwege
boolean
C0035237 (UMLS CUI [1])
Chest X-ray
Item
Rö.-Thorax
boolean
C0039985 (UMLS CUI [1])
Consciousness
Item
Bewusstseinslage
boolean
C0234421 (UMLS CUI [1])
Neurology
Item
Neurologie
boolean
C0027765 (UMLS CUI [1])
Muscles
Item
Muskulatur
boolean
C0026845 (UMLS CUI [1])
Endocrine system
Item
Endokrinium
boolean
C0014136 (UMLS CUI [1])
Liver
Item
Leber
boolean
C0023884 (UMLS CUI [1])
Kidney
Item
Niere
boolean
C0022646 (UMLS CUI [1])
Diabetes mellitus
Item
Diabetes mellitus
boolean
C0011849 (UMLS CUI [1])
Hematology
Item
Hämatologie
boolean
C0474523 (UMLS CUI [1])
Coagulation
Item
Gerinnung
boolean
C0005778 (UMLS CUI [1])
Nutritional status
Item
Ernährungszustand
boolean
C0392209 (UMLS CUI [1])
free text
Item
Begleiterkrankungen Freitext
text
C2348713 (UMLS CUI [1])
Aspiration
Item
Aspiration
boolean
C0349707 (UMLS CUI [1])
Polytrauma
Item
Polytrauma
boolean
C0026771 (UMLS CUI [1])
Intensive care patient
Item
Intensivpatient
boolean
C0010337 (UMLS CUI [1])
MI
Item
MI < 6 Wochen
boolean
C0027051 (UMLS CUI [1])
Acute coronary syndrome
Item
Akutes Koronarsyndrom
boolean
C0948089 (UMLS CUI [1])
Catecholamines
Item
Katecholaminpfl.
boolean
C0007412 (UMLS CUI [1])
Respiratory tract infection
Item
Atemwegsinfekt
boolean
C0035243 (UMLS CUI [1])
Chronic obstructive pulmonary disease
Item
COPD
boolean
C0024117 (UMLS CUI [1])
Asthma
Item
Asthma
boolean
C0004096 (UMLS CUI [1])
Sepsis
Item
Sepsis
boolean
C0243026 (UMLS CUI [1])
Pregnancy
Item
Schwangerschaft
boolean
C0032961 (UMLS CUI [1])
Preterm birth
Item
Frühgeburt
boolean
C0151526 (UMLS CUI [1])
HIV
Item
HIV
boolean
C0019682 (UMLS CUI [1])
Viral hepatitis
Item
Virus-Hepatits
boolean
C0042721 (UMLS CUI [1])
malignant hyperpyrexia
Item
MH-Disposition
boolean
C1276019 (UMLS CUI [1])
Alcohol
Item
Alkohol
boolean
C0001948 (UMLS CUI [1])
Nicotine
Item
Nikotin
boolean
C0028040 (UMLS CUI [1])
Drugs
Item
Drogen
boolean
C0013227 (UMLS CUI [1])
Hematocrit
Item
Hkt/Hb
text
C0518014 (UMLS CUI [1])
Leukocytes
Item
Leukos
integer
C0023508 (UMLS CUI [1])
Sodium
Item
Na
float
C0337443 (UMLS CUI [1])
Potassium
Item
K
float
C0202194 (UMLS CUI [1])
Calcium
Item
Ca
float
C0201925 (UMLS CUI [1])
Creatinine
Item
Krea
float
C0201976 (UMLS CUI [1])
Blood sugar
Item
Glukose
float
C0392201 (UMLS CUI [1])
Glutamic oxaloacetic transaminase
Item
GOT
float
C0201899 (UMLS CUI [1])
Glutamate-pyruvate transaminase
Item
GPT
float
C0201836 (UMLS CUI [1])
Gamma-glutamyltransferase
Item
gamma-GT
float
C0202035 (UMLS CUI [1])
Platelets
Item
Thrombos
integer
C0032181 (UMLS CUI [1])
Prothrombin time
Item
Quick
integer
C0033707 (UMLS CUI [1])
Partial thromboplastin time
Item
PTT
integer
C3525810 (UMLS CUI [1])
Thrombin time
Item
TZ
float
C0427596 (UMLS CUI [1])
Red cell concentrate
Item
Erykonz. (Anzahl)
integer
C0443095 (UMLS CUI [1])
Fresh frozen plasma
Item
FFP (Anzahl)
integer
C0016709 (UMLS CUI [1])
Other
Item
Sonst.
text
C0205394 (UMLS CUI [1])
Medication
Item
Medikament
text
C0013227 (UMLS CUI [1])
Dosage
Item
Dosis
text
C0178602 (UMLS CUI [1])
Administration
Item
Applikation
text
C1533734 (UMLS CUI [1])
Time
Item
Uhrzeit
time
C0040223 (UMLS CUI [1])
Signature
Item
Signatur
text
C1519316 (UMLS CUI [1])
Medication
Item
Medikament
text
C0013227 (UMLS CUI [1])
Dosage
Item
Dosis
text
C0178602 (UMLS CUI [1])
Administration
Item
Applikation
text
C1533734 (UMLS CUI [1])
Time
Item
Uhrzeit
text
C0040223 (UMLS CUI [1])
Signature
Item
Signatur
text
C1519316 (UMLS CUI [1])
Laboratory
Item
Labor
boolean
C0022877 (UMLS CUI [1])
Coagulation
Item
G-Status
text
C0005778 (UMLS CUI [1])
ECG
Item
EKG
boolean
C1623258 (UMLS CUI [1])
Chest X-ray
Item
Röntgen-Thorax
boolean
C0039985 (UMLS CUI [1])
Pulmonary function
Item
Lungenfunktion
boolean
C0024119 (UMLS CUI [1])
Consultation
Item
Konsil
boolean
C0009818 (UMLS CUI [1])
Specifications
Item
Spezifikationen
text
C2348235 (UMLS CUI [1])
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
C0011008 (UMLS CUI [1])
Time
Item
Uhrzeit
time
C0040223 (UMLS CUI [1])
Name
Item
Name
text
C0027365 (UMLS CUI [1])
Signature
Item
Unterschrift
text
C1519316 (UMLS CUI [1])
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
C0011008 (UMLS CUI [1])
Time
Item
Uhrzeit
time
C0040223 (UMLS CUI [1])
Name
Item
Name
text
C0027365 (UMLS CUI [1])
Signature
Item
Unterschrift
text
C1519316 (UMLS CUI [1])
premedication; surgery
Item
nach Prämed. keine OP
boolean
C0033045 (UMLS CUI [1])
C0543467 (UMLS CUI [2])
C0543467 (UMLS CUI [2])