Information:
Fel:
ID
24429
Beskrivning
Routine documentation in German hospitals. Source file name: TH130110_Prämedikationsprotokoll Examplary forms provided by DMI (http://www.dmi.de/)
Länk
Nyckelord
Versioner (5)
- 2017-07-08 2017-07-08 -
- 2017-07-08 2017-07-08 -
- 2017-07-08 2017-07-08 -
- 2017-07-20 2017-07-20 -
- 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 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
Similar models
Premedication Anesthesiology Intensive care Catholic Clinic Koblenz Montabaur Routine documentation in German hospitals DMI
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
Alias
Case ID
Item
Case ID
text
C1698493 (UMLS CUI [1,1])
C0600091 (UMLS CUI [1,2])
C0600091 (UMLS CUI [1,2])
Date of anesthesia
Item
Date of anesthesia
date
C0002903 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,2])
Date of birth
Item
Date of birth
date
C0421451 (UMLS CUI [1])
Height
Item
Height
integer
C0005890 (UMLS CUI [1])
Weight
Item
Weight
integer
C0005910 (UMLS CUI [1])
CL Item
Anesthesiology/Intensive care medicine (Anesthesiology/Intensive care medicine)
C0002930 (UMLS CUI-1)
(Comment:en)
(Comment:en)
CL Item
General and visceral surgery (General and visceral surgery)
C1274039 (UMLS CUI-1)
(Comment:en)
(Comment:en)
CL Item
Gynecology (Gynecology)
C0018417 (UMLS CUI-1)
(Comment:en)
(Comment:en)
CL Item
Urology (Urology)
C0042077 (UMLS CUI-1)
(Comment:en)
(Comment:en)
CL Item
Thoracic surgery (Thoracic surgery)
C0587506 (UMLS CUI-1)
(Comment:en)
(Comment:en)
CL Item
Oral and maxillofacial surgery (Oral and maxillofacial surgery)
C0812928 (UMLS CUI-1)
(Comment:en)
(Comment:en)
CL Item
Otolaryngology (Otolaryngology)
C0029892 (UMLS CUI-1)
(Comment:en)
(Comment:en)
CL Item
Neurology (Neurology)
C0027855 (UMLS CUI-1)
(Comment:en)
(Comment:en)
CL Item
Radiology (Radiology)
C0034599 (UMLS CUI-1)
(Comment:en)
(Comment:en)
CL Item
Other (Other)
C0205394 (UMLS CUI-1)
(Comment:en)
(Comment:en)
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
männlich (male)
CL Item
weiblich (female)
CL Item
yes (yes)
CL Item
no (no)
CL Item
unknown (unknown)
CL Item
outpatient (outpatient)
C0029921 (UMLS CUI-1)
(Comment:en)
(Comment:en)
CL Item
in-patient (in-patient)
C0021562 (UMLS CUI-1)
(Comment:en)
(Comment:en)
CL Item
private (private)
(Comment:en)
CL Item
urgent (urgent)
C3272275 (UMLS CUI-1)
(Comment:en)
(Comment:en)
CL Item
emergency (emergency)
C4264510 (UMLS CUI-1)
(Comment:en)
(Comment:en)
CL Item
elektiv (elective)
C0206058 (UMLS CUI-1)
(Comment:en)
(Comment:en)
Preoperative diagnosis
Item
Preoperative diagnosis
text
C1318968 (UMLS CUI [1])
Planned procedure
Item
Planned procedure
text
C0087111 (UMLS CUI [1,1])
C1301732 (UMLS CUI [1,2])
C1301732 (UMLS CUI [1,2])
anesthesia
Item
Planned anesthetic technique
text
C0002903 (UMLS CUI [1])
Specifics
Item
Specifics
text
C2348235 (UMLS CUI [1])
Rapid sequence induction
Item
Rapid sequence induction (RSI)
boolean
C0412767 (UMLS CUI [1])
Item Group
Preoperative assessment
C1516048 (UMLS CUI-1)
C0445204 (UMLS CUI-2)
C0445204 (UMLS CUI-2)
comorbity; surgery
Item
Pre-existing conditions, previous surgeries, complications during previos narcoses
text
C0009488 (UMLS CUI [1])
C0543467 (UMLS CUI [2])
C0543467 (UMLS CUI [2])
narcosis
Item
Re-narcosis
boolean
C0234447 (UMLS CUI [1])
Acute care
Item
Acute care
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
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
C0451276 (UMLS CUI [1])
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
C2317096 (UMLS CUI [1])
Blood type
Item
Blood type
text
C0005810 (UMLS CUI [1])
Insurance number
Item
Employer's Liability Insurance Association number
text
C0021672 (UMLS CUI [1,1])
C1300638 (UMLS CUI [1,2])
C1300638 (UMLS CUI [1,2])
antibodies
Item
Irregular antibodies
text
C0003241 (UMLS CUI [1])
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
C0420257 (UMLS CUI [1])
Allergies
Item
Allergies
text
C0020517 (UMLS CUI [1])
Blood pressure
Item
Blood pressure
boolean
C0005823 (UMLS CUI [1])
Myocardium
Item
Myocardium
boolean
C0027061 (UMLS CUI [1])
Coronary function
Item
Coronary function
boolean
C1522318 (UMLS CUI [1,1])
C0542341 (UMLS CUI [1,2])
C0542341 (UMLS CUI [1,2])
ECG
Item
ECG
boolean
C1623258 (UMLS CUI [1])
Vascular system
Item
Vascular system
boolean
C0489903 (UMLS CUI [1])
respiratory tract
Item
Lungs/respiratory tract
boolean
C0035237 (UMLS CUI [1])
Chest X-ray
Item
Chest X-ray
boolean
C0039985 (UMLS CUI [1])
Consciousness
Item
Consciousness
boolean
C0234421 (UMLS CUI [1])
Neurology
Item
Neurology
boolean
C0027765 (UMLS CUI [1])
Muscles
Item
Muscles
boolean
C0026845 (UMLS CUI [1])
Endocrine system
Item
Endocrine system
boolean
C0014136 (UMLS CUI [1])
Liver
Item
Liver
boolean
C0023884 (UMLS CUI [1])
Kidney
Item
Kidney
boolean
C0022646 (UMLS CUI [1])
Diabetes mellitus
Item
Diabetes mellitus
boolean
C0011849 (UMLS CUI [1])
Hematology
Item
Hematology
boolean
C0474523 (UMLS CUI [1])
Coagulation
Item
Coagulation
boolean
C0005778 (UMLS CUI [1])
Nutritional status
Item
Nutritional status
boolean
C0392209 (UMLS CUI [1])
free text
Item
Free text
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
Intensive care patient
boolean
C0010337 (UMLS CUI [1])
MI
Item
MI < 6 Wochen
boolean
C0027051 (UMLS CUI [1])
Acute coronary syndrome
Item
Acute coronary syndrome
boolean
C0948089 (UMLS CUI [1])
Catecholamines
Item
Intake of catecholamines required
boolean
C0007412 (UMLS CUI [1])
Respiratory tract infection
Item
Respiratory tract infection
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
Pregnancy
boolean
C0032961 (UMLS CUI [1])
Preterm birth
Item
Preterm birth
boolean
C0151526 (UMLS CUI [1])
HIV
Item
HIV
boolean
C0019682 (UMLS CUI [1])
Viral hepatitis
Item
Viral hepatitis
boolean
C0042721 (UMLS CUI [1])
malignant hyperpyrexia
Item
Disposition for malignant hyperpyrexia
boolean
C1276019 (UMLS CUI [1])
Alcohol
Item
Alcohol
boolean
C0001948 (UMLS CUI [1])
Nicotine
Item
Nicotine
boolean
C0028040 (UMLS CUI [1])
Drugs
Item
Drugs
boolean
C0013227 (UMLS CUI [1])
Hematocrit
Item
Hb/Ht
text
C0518014 (UMLS CUI [1])
Leukocytes
Item
Leukocytes
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
Creatinine
float
C0201976 (UMLS CUI [1])
Blood sugar
Item
Glucose
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
GGT
float
C0202035 (UMLS CUI [1])
Platelets
Item
Platelets
integer
C0032181 (UMLS CUI [1])
Prothrombin time
Item
PT
integer
C0033707 (UMLS CUI [1])
Partial thromboplastin time
Item
PTT
integer
C3525810 (UMLS CUI [1])
Thrombin time
Item
TT
float
C0427596 (UMLS CUI [1])
Red cell concentrate
Item
Red cell concentrate (number)
integer
C0443095 (UMLS CUI [1])
Fresh frozen plasma
Item
FFP (number)
integer
C0016709 (UMLS CUI [1])
Other
Item
Other
text
C0205394 (UMLS CUI [1])
Medication
Item
Medication
text
C0013227 (UMLS CUI [1])
Dosage
Item
Dosage
text
C0178602 (UMLS CUI [1])
Administration
Item
Administration
text
C1533734 (UMLS CUI [1])
Time
Item
Time
time
C0040223 (UMLS CUI [1])
Signature
Item
Signature
text
C1519316 (UMLS CUI [1])
Medication
Item
Medication
text
C0013227 (UMLS CUI [1])
Dosage
Item
Dosage
text
C0178602 (UMLS CUI [1])
Administration
Item
Administration
text
C1533734 (UMLS CUI [1])
Time
Item
Time
text
C0040223 (UMLS CUI [1])
Signature
Item
Signature
text
C1519316 (UMLS CUI [1])
Laboratory
Item
Laboratory
boolean
C0022877 (UMLS CUI [1])
Coagulation
Item
Coagulation status
text
C0005778 (UMLS CUI [1])
ECG
Item
ECG
boolean
C1623258 (UMLS CUI [1])
Chest X-ray
Item
Chest X-ray
boolean
C0039985 (UMLS CUI [1])
Pulmonary function
Item
Pulmonary function
boolean
C0024119 (UMLS CUI [1])
Consultation
Item
Consultation
boolean
C0009818 (UMLS CUI [1])
Specifications
Item
Specifications
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
regular (regular)
CL Item
overtime (overtime)
CL Item
on-call (on-call)
CL Item
day (day)
Date
Item
Date
date
C0011008 (UMLS CUI [1])
Time
Item
Time
time
C0040223 (UMLS CUI [1])
Name
Item
Name
text
C0027365 (UMLS CUI [1])
Signature
Item
Signature
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
overtime (overtime)
CL Item
on-call (on-call)
CL Item
regular (regular)
CL Item
day (day)
Date
Item
Date
date
C0011008 (UMLS CUI [1])
Time
Item
Time
time
C0040223 (UMLS CUI [1])
Name
Item
Name
text
C0027365 (UMLS CUI [1])
Signature
Item
Signature
text
C1519316 (UMLS CUI [1])
premedication; surgery
Item
No surgey after premedication
boolean
C0033045 (UMLS CUI [1])
C0543467 (UMLS CUI [2])
C0543467 (UMLS CUI [2])