Premedication Example 2 Routine documentation in German hospitals DMI

Patient data
Description

Patient data

Alias
UMLS CUI-1
C2707520
Patient data
Description

Patient data

Data type

text

Alias
UMLS CUI [1]
C2707520
Case ID
Description

Case ID

Data type

text

Alias
UMLS CUI [1,1]
C0868928
UMLS CUI [1,2]
C0600091
Surgery ID
Description

Surgery ID

Data type

text

Alias
UMLS CUI [1,1]
C0543467
UMLS CUI [1,2]
C0600091
Date of birth
Description

Date of birth

Data type

date

Alias
UMLS CUI [1]
C0421451
Age
Description

Age

Data type

integer

Alias
UMLS CUI [1]
C0001779
Ward
Description

Ward

Data type

text

Alias
UMLS CUI [1]
C1305702
Room number
Description

Room number

Data type

text

Alias
UMLS CUI [1]
C1718316
Elective service
Description

Elective

Data type

boolean

Alias
UMLS CUI [1]
C0206058
Type of admission
Description

Type of admission

Data type

text

Alias
UMLS CUI [1]
C1550330
Urgency
Description

Urgency

Data type

text

Alias
UMLS CUI [1]
C4049774
Sex
Description

Sex

Data type

text

Alias
UMLS CUI [1]
C0079399
Gravidity
Description

Gravidity

Data type

boolean

Alias
UMLS CUI [1]
C0600457
Physical parameters
Description

Physical parameters

Alias
UMLS CUI-1
C1269723
Height
Description

Height

Data type

integer

Alias
UMLS CUI [1]
C0005890
Weight
Description

Weight

Data type

integer

Alias
UMLS CUI [1]
C0005910
BMI
Description

BMI

Data type

integer

Alias
UMLS CUI [1]
C1305855
Pulse
Description

Pulse

Data type

integer

Alias
UMLS CUI [1]
C0232117
Systolic blood pressure
Description

Systolic blood pressure

Data type

integer

Alias
UMLS CUI [1]
C0871470
Diastolic blood pressure
Description

Diastolic blood pressure

Data type

integer

Alias
UMLS CUI [1]
C0428883
Medical procedure
Description

Medical procedure

Alias
UMLS CUI-1
C0199171
Planned procedure
Description

Planned procedure

Data type

text

Alias
UMLS CUI [1,1]
C0087111
UMLS CUI [1,2]
C1301732
Planned anesthetic technique
Description

anesthesia

Data type

text

Alias
UMLS CUI [1]
C0002903
Preoperative state and risk factors
Description

Preoperative state and risk factors

Alias
UMLS CUI-1
C0178808
UMLS CUI-3
C0035648
No abnormality detected
Description

No abnormality detected

Data type

boolean

Alias
UMLS CUI [1]
C0559229
Re-narcosis
Description

narcosis

Data type

boolean

Alias
UMLS CUI [1]
C0234447
Acute care
Description

Acute care

Data type

boolean

Alias
UMLS CUI [1]
C0679878
ECG / Chest X-ray
Description

ECG; Chest X-ray

Data type

text

Alias
UMLS CUI [1]
C1623258
UMLS CUI [2]
C0039985
Heart
Description

Heart

Data type

text

Alias
UMLS CUI [1]
C0018787
Lungs
Description

Lungs

Data type

text

Alias
UMLS CUI [1]
C0024109
Abdomen
Description

Abdomen

Data type

text

Alias
UMLS CUI [1]
C0000726
Other
Description

Other

Data type

text

Alias
UMLS CUI [1]
C0205394
Long-term medication
Description

Long-term medication

Data type

text

Alias
UMLS CUI [1]
C0420257
Previous surgeries
Description

Previous surgeries

Data type

text

Alias
UMLS CUI [1]
C0744961
Allergies
Description

Allergies

Data type

text

Alias
UMLS CUI [1]
C0020517
Complications during anesthesia
Description

complications anesthesia

Data type

text

Alias
UMLS CUI [1,1]
C0009566
UMLS CUI [1,2]
C0002903
Findings: ECG
Description

Findings: ECG

Alias
UMLS CUI-1
C1623258
Normal findings
Description

ECG

Data type

boolean

Alias
UMLS CUI [1]
C1623258
Tachycardia
Description

pathological finding with relevance for anesthesia

Data type

boolean

Alias
UMLS CUI [1]
C0039231
Bradycardia
Description

pathological finding with relevance for anesthesia

Data type

boolean

Alias
UMLS CUI [1]
C0428977
Sinus rhythm absent
Description

pathological finding with relevance for anesthesia

Data type

boolean

Alias
UMLS CUI [1]
C0232201
Conduction defect
Description

pathological finding with relevance for anesthesia

Data type

boolean

Alias
UMLS CUI [1]
C0264886
Extrasystoles >5/min.
Description

pathological finding with relevance for anesthesia

Data type

boolean

Alias
UMLS CUI [1]
C0541950
Pacemaker ECG
Description

pathological finding with relevance for anesthesia

Data type

boolean

Alias
UMLS CUI [1]
C1287695
Signs of ischemia
Description

pathological finding with relevance for anesthesia

Data type

boolean

Alias
UMLS CUI [1]
C1141959
Signs of infarct
Description

pathological finding with relevance for anesthesia

Data type

boolean

Alias
UMLS CUI [1]
C3854475
Disturbance of repolarization
Description

pathological finding with relevance for anesthesia

Data type

boolean

Alias
UMLS CUI [1]
C3279217
Findings: Heart
Description

Findings: Heart

Alias
UMLS CUI-1
C0018787
Normal findings
Description

heart

Data type

boolean

Alias
UMLS CUI [1]
C0018787
Coronary heart disease
Description

pathological finding with relevance for anesthesia

Data type

boolean

Alias
UMLS CUI [1]
C0010068
Stable angina pectoris
Description

pathological finding with relevance for anesthesia

Data type

boolean

Alias
UMLS CUI [1]
C0340288
Acute coronary syndrome
Description

pathological finding with relevance for anesthesia

Data type

boolean

Alias
UMLS CUI [1]
C0948089
Myocardial infarction (old)
Description

pathological finding with relevance for anesthesia

Data type

boolean

Alias
UMLS CUI [1]
C0155668
Heart failure
Description

pathological finding with relevance for anesthesia

Data type

boolean

Alias
UMLS CUI [1]
C0018801
Cardiomyopathy
Description

pathological finding with relevance for anesthesia

Data type

boolean

Alias
UMLS CUI [1]
C0878544
Aortic / mitral stenosis
Description

pathological finding with relevance for anesthesia

Data type

boolean

Alias
UMLS CUI [1]
C0003507
Other heart defects
Description

pathological finding with relevance for anesthesia

Data type

boolean

Alias
UMLS CUI [1]
C0018799
Hemodynamically significant cardiac arrhythmias
Description

pathological finding with relevance for anesthesia

Data type

boolean

Alias
UMLS CUI [1]
C0003811
Cor pulmonale
Description

pathological finding with relevance for anesthesia

Data type

boolean

Alias
UMLS CUI [1]
C0034072
Florid myocarditis
Description

pathological finding with relevance for anesthesia

Data type

boolean

Alias
UMLS CUI [1]
C0027059
Findings: Lungs
Description

Findings: Lungs

Alias
UMLS CUI-1
C0024109
Normal findings
Description

lungs

Data type

boolean

Alias
UMLS CUI [1]
C0024109
Dyspnea
Description

pathological finding with relevance for anesthesia

Data type

boolean

Alias
UMLS CUI [1]
C0013404
Pneumonia
Description

pathological finding with relevance for anesthesia

Data type

boolean

Alias
UMLS CUI [1]
C0032285
Acute bronchitis
Description

pathological finding with relevance for anesthesia

Data type

boolean

Alias
UMLS CUI [1]
C0149514
COPD
Description

pathological finding with relevance for anesthesia

Data type

boolean

Alias
UMLS CUI [1]
C0024117
Obstruction
Description

pathological finding with relevance for anesthesia

Data type

boolean

Alias
UMLS CUI [1]
C0028778
Restriction
Description

pathological finding with relevance for anesthesia

Data type

boolean

Alias
UMLS CUI [1]
C0443288
Pleural effusion
Description

pathological finding with relevance for anesthesia

Data type

boolean

Alias
UMLS CUI [1]
C0032227
Pneumothorax
Description

pathological finding with relevance for anesthesia

Data type

boolean

Alias
UMLS CUI [1]
C0032326
Ventilation
Description

pathological finding with relevance for anesthesia

Data type

boolean

Alias
UMLS CUI [1]
C2945579
Findings: Circulatory system
Description

Findings: Circulatory system

Alias
UMLS CUI-1
C0007226
Normal findings
Description

Cardiovascular system

Data type

boolean

Alias
UMLS CUI [1]
C0007226
Hypotension (therapy required)
Description

pathological finding with relevance for anesthesia

Data type

boolean

Alias
UMLS CUI [1]
C0020649
Hypertension
Description

pathological finding with relevance for anesthesia

Data type

boolean

Alias
UMLS CUI [1]
C0020538
Embolism
Description

pathological finding with relevance for anesthesia

Data type

boolean

Alias
UMLS CUI [1]
C0013922
Thrombosis
Description

pathological finding with relevance for anesthesia

Data type

boolean

Alias
UMLS CUI [1]
C0040053
Artery occlusive disease
Description

pathological finding with relevance for anesthesia

Data type

boolean

Alias
UMLS CUI [1]
C0264995
Impaired cerebral blood flow
Description

pathological finding with relevance for anesthesia

Data type

boolean

Alias
UMLS CUI [1]
C0428714
Findings: CNS / Neurology
Description

Findings: CNS / Neurology

Alias
UMLS CUI-1
C0027765
Normal findings
Description

Neurology

Data type

boolean

Alias
UMLS CUI [1]
C0027765
Somnolence
Description

pathological finding with relevance for anesthesia

Data type

boolean

Alias
UMLS CUI [1]
C2830004
Coma
Description

pathological finding with relevance for anesthesia

Data type

boolean

Alias
UMLS CUI [1]
C0009421
Traumatic brain injury
Description

pathological finding with relevance for anesthesia

Data type

boolean

Alias
UMLS CUI [1]
C0876926
Intracerebral hemorrhage / Space-occupying lesion
Description

pathological finding with relevance for anesthesia

Data type

boolean

Alias
UMLS CUI [1]
C2937358
Stroke
Description

pathological finding with relevance for anesthesia

Data type

boolean

Alias
UMLS CUI [1]
C0038454
TIA
Description

pathological finding with relevance for anesthesia

Data type

boolean

Alias
UMLS CUI [1]
C0007787
Parkinson's disease
Description

pathological finding with relevance for anesthesia

Data type

boolean

Alias
UMLS CUI [1]
C0030567
Alzheimer's disease / Dementia
Description

pathological finding with relevance for anesthesia

Data type

boolean

Alias
UMLS CUI [1]
C0002395
Multiple sclerosis
Description

pathological finding with relevance for anesthesia

Data type

boolean

Alias
UMLS CUI [1]
C0026769
Amyotrophic lateral sclerosis
Description

pathological finding with relevance for anesthesia

Data type

boolean

Alias
UMLS CUI [1]
C0002736
Epilepsy
Description

pathological finding with relevance for anesthesia

Data type

boolean

Alias
UMLS CUI [1]
C0014544
Neuromuscular disease
Description

pathological finding with relevance for anesthesia

Data type

boolean

Alias
UMLS CUI [1]
C0027868
Findings: metabolism
Description

Findings: metabolism

Alias
UMLS CUI-1
C0025519
Normal findings
Description

metabolism

Data type

boolean

Alias
UMLS CUI [1]
C0025519
(Non-) Insulin-dependent diabetes mellitus
Description

pathological finding with relevance for anesthesia

Data type

boolean

Alias
UMLS CUI [1]
C0011860
Endocrine disorder
Description

pathological finding with relevance for anesthesia

Data type

boolean

Alias
UMLS CUI [1]
C0014130
Enzymatic genetic defect
Description

pathological finding with relevance for anesthesia

Data type

boolean

Alias
UMLS CUI [1]
C1394815
Other findings
Description

Other findings

Alias
UMLS CUI-1
C0243095
Normal findings
Description

findings

Data type

boolean

Alias
UMLS CUI [1]
C0243095
Infectious disease
Description

pathological finding with relevance for anesthesia

Data type

boolean

Alias
UMLS CUI [1]
C0009450
Resistant germs
Description

pathological finding with relevance for anesthesia

Data type

boolean

Alias
UMLS CUI [1]
C1444089
Obstructive sleep apnea
Description

pathological finding with relevance for anesthesia

Data type

boolean

Alias
UMLS CUI [1]
C0037315
Renal failure
Description

pathological finding with relevance for anesthesia

Data type

boolean

Alias
UMLS CUI [1]
C0035078
Findings: Laboratory
Description

Findings: Laboratory

Alias
UMLS CUI-1
C0022877
Normal findings
Description

laboratory findings

Data type

boolean

Alias
UMLS CUI [1]
C0022877
Pathological basic blood count
Description

pathological finding with relevance for anesthesia

Data type

boolean

Alias
UMLS CUI [1]
C0005771
Pathological acid-base balance
Description

pathological finding with relevance for anesthesia

Data type

boolean

Alias
UMLS CUI [1]
C0150116
Pathological coagulation
Description

pathological finding with relevance for anesthesia

Data type

boolean

Alias
UMLS CUI [1]
C0005778
Electrolytes pathological
Description

pathological finding with relevance for anesthesia

Data type

boolean

Alias
UMLS CUI [1]
C0013832
Other pathological findings
Description

pathological finding with relevance for anesthesia

Data type

boolean

Alias
UMLS CUI [1]
C0243095
Blood values
Description

Blood values

Alias
UMLS CUI-1
C0018941
Hb
Description

Hemoglobin

Data type

float

Alias
UMLS CUI [1]
C0019046
Ht
Description

Hematocrit

Data type

float

Alias
UMLS CUI [1]
C0518014
Platelets
Description

Platelets

Data type

integer

Alias
UMLS CUI [1]
C0032181
PT
Description

Prothrombin time

Data type

integer

Alias
UMLS CUI [1]
C0033707
INR
Description

International Normalized Ratio

Data type

float

Alias
UMLS CUI [1]
C0525032
PTT
Description

Partial thromboplastin time

Data type

integer

Alias
UMLS CUI [1]
C3525810
Description

Potassium

Data type

float

Alias
UMLS CUI [1]
C0202194
Creatinine
Description

Creatinine

Data type

float

Alias
UMLS CUI [1]
C0201976
Glucose
Description

Blood sugar

Data type

float

Alias
UMLS CUI [1]
C0392201
GGT
Description

Gamma-glutamyltransferase

Data type

float

Alias
UMLS CUI [1]
C0202035
Anticoagulation
Description

Anticoagulation

Alias
UMLS CUI-1
C0003281
ASS
Description

Acetylsalicylic acid

Data type

boolean

Alias
UMLS CUI [1]
C0004057
ASS until
Description

duration

Data type

date

Alias
UMLS CUI [1]
C0449238
Antagonization
Description

antagonists & inhibitors

Data type

boolean

Alias
UMLS CUI [1]
C0003139
Rez.-Antag. until
Description

duration administration

Data type

date

Alias
UMLS CUI [1,1]
C0449238
UMLS CUI [1,2]
C1533734
Heparin s.c./i.v.
Description

Heparin

Data type

boolean

Alias
UMLS CUI [1]
C0019134
Heparin s.c./i.v. until
Description

Heparin

Data type

date

Alias
UMLS CUI [1]
C0019134
NSAIDs
Description

Nonsteroidal anti-inflammatory drugs

Data type

boolean

Alias
UMLS CUI [1,1]
C0003211
UMLS CUI [1,2]
C0205360
NSAIDs until
Description

NSAIDs

Data type

date

Alias
UMLS CUI [1]
C0003211
Marcumar
Description

Marcumar

Data type

boolean

Alias
UMLS CUI [1]
C0918269
Marcumar until
Description

Marcumar

Data type

date

Alias
UMLS CUI [1]
C0918269
Other anticoagulants
Description

anticoagulants

Data type

boolean

Alias
UMLS CUI [1]
C0003280
other anticoagulants until
Description

Anticoagulation

Data type

date

Alias
UMLS CUI [1]
C0449867
Preoperative assessment
Description

Preoperative assessment

Alias
UMLS CUI-1
C1516048
UMLS CUI-2
C0445204
Teeth
Description

health condition teeth

Data type

text

Alias
UMLS CUI [1,1]
C4019131
UMLS CUI [1,2]
C0040426
Bleeding tendency
Description

Bleeding tendency

Data type

boolean

Alias
UMLS CUI [1]
C1458140
Risk of aspiration
Description

aspiration risk

Data type

boolean

Alias
UMLS CUI [1,1]
C0349707
UMLS CUI [1,2]
C0035647
Nicotine
Description

Nicotine

Data type

boolean

Alias
UMLS CUI [1]
C0028040
Alcohol
Description

Alcohol

Data type

boolean

Alias
UMLS CUI [1]
C0001948
Drugs
Description

Drugs

Data type

boolean

Alias
UMLS CUI [1]
C0013227
Allergies
Description

Allergies

Data type

boolean

Alias
UMLS CUI [1]
C0020517
ASA
Description

ASA score

Data type

integer

Alias
UMLS CUI [1]
C1531480
NYHA
Description

NYHA classification

Data type

integer

Alias
UMLS CUI [1]
C1275491
Mallampati
Description

Mallampati score

Data type

text

Alias
UMLS CUI [1]
C0451276
Difficult airway management
Description

airway management

Data type

text

Alias
UMLS CUI [1]
C0150126
Preoperative instructions
Description

Preoperative instructions

Alias
UMLS CUI-1
C1442085
UMLS CUI-2
C0445204
Evening before surgery
Description

surgery

Data type

boolean

Alias
UMLS CUI [1]
C0543467
Day of surgery
Description

day surgery

Data type

boolean

Alias
UMLS CUI [1,1]
C0439228
UMLS CUI [1,2]
C0543467
Medication
Description

Medication

Data type

text

Alias
UMLS CUI [1]
C0013227
Administration
Description

Administration

Data type

text

Alias
UMLS CUI [1]
C1533734
Time
Description

Time

Data type

time

Alias
UMLS CUI [1]
C0040223
Signature
Description

Signature

Data type

text

Alias
UMLS CUI [1]
C1519316
Transfusion pre-order
Description

Transfusion pre-order

Alias
UMLS CUI-1
C1879316
Blood type
Description

Blood type

Data type

boolean

Alias
UMLS CUI [1]
C0005810
Coombs test
Description

Coombs test

Data type

boolean

Alias
UMLS CUI [1]
C0009961
Red cell concentrate
Description

Red cell concentrate

Data type

integer

Alias
UMLS CUI [1]
C0443095
FFP
Description

Fresh frozen plasma

Data type

integer

Alias
UMLS CUI [1]
C0016709
Platelet concentrate
Description

Platelet concentrate

Data type

integer

Alias
UMLS CUI [1]
C2362067
Requirements prior to approval of surgery
Description

Requirements prior to approval of surgery

Alias
UMLS CUI-1
C0242801
UMLS CUI-2
C0543467
Patient's consent
Description

Consent

Data type

boolean

Alias
UMLS CUI [1]
C1511481
Findings
Description

Findings

Data type

boolean

Alias
UMLS CUI [1]
C0243095
Follow-up visit
Description

Follow-up visit

Data type

boolean

Alias
UMLS CUI [1]
C0589121
Time of latest food intake
Description

Time of latest food intake

Alias
UMLS CUI-1
C0086311
Solid
Description

solid food

Data type

time

Alias
UMLS CUI [1]
C0453855
Liquid
Description

liquids

Data type

time

Alias
UMLS CUI [1]
C0302908
Premedication
Description

Premedication

Alias
UMLS CUI-1
C0033045
Date of premedication
Description

Date of premedication

Data type

date

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C0033045
Anesthesist
Description

Anesthesist

Data type

text

Alias
UMLS CUI [1]
C1550495
Type of duty
Description

job

Data type

text

Alias
UMLS CUI [1]
C0028811
Time (beginning)
Description

Time

Data type

time

Alias
UMLS CUI [1]
C0040223
Duration
Description

Duration

Data type

integer

Measurement units
  • min
Alias
UMLS CUI [1]
C0449238
min
Preadmission premedication
Description

premedication

Data type

boolean

Alias
UMLS CUI [1]
C0033045
Anesthesia outpatient department
Description

outpatient department Anesthesia

Data type

boolean

Alias
UMLS CUI [1,1]
C0557824
UMLS CUI [1,2]
C0002903
No surgery after premedication
Description

premedication; surgery

Data type

boolean

Alias
UMLS CUI [1]
C0033045
UMLS CUI [2]
C0543467
Name of physician
Description

Name of physician

Data type

text

Alias
UMLS CUI [1,1]
C0027365
UMLS CUI [1,2]
C0031831
Signature physician
Description

Signature physician

Data type

text

Alias
UMLS CUI [1]
C0807938

Similar models

Premedication Example 2 Routine documentation in German hospitals DMI

Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Patient data
C2707520 (UMLS CUI-1)
Patient data
Item
Patient data
text
C2707520 (UMLS CUI [1])
Case ID
Item
Case ID
text
C0868928 (UMLS CUI [1,1])
C0600091 (UMLS CUI [1,2])
Surgery ID
Item
Surgery ID
text
C0543467 (UMLS CUI [1,1])
C0600091 (UMLS CUI [1,2])
Date of birth
Item
Date of birth
date
C0421451 (UMLS CUI [1])
Age
Item
Age
integer
C0001779 (UMLS CUI [1])
Ward
Item
Ward
text
C1305702 (UMLS CUI [1])
Room number
Item
Room number
text
C1718316 (UMLS CUI [1])
Elective
Item
Elective service
boolean
C0206058 (UMLS CUI [1])
Item
Type of admission
text
C1550330 (UMLS CUI [1])
Code List
Type of admission
CL Item
outpatient (outpatient)
C0029921 (UMLS CUI-1)
(Comment:en)
CL Item
in-patient (in-patient)
C0021562 (UMLS CUI-1)
(Comment:en)
Item
Urgency
text
C4049774 (UMLS CUI [1])
Code List
Urgency
CL Item
elektiv (>24h) (elective (>24h))
CL Item
within 24h (within 24h)
CL Item
emergency(< 2h) (emergency (< 2h))
CL Item
immediately (immediately)
Item
Sex
text
C0079399 (UMLS CUI [1])
Code List
Sex
CL Item
male (male)
C0086582 (UMLS CUI-1)
(Comment:en)
CL Item
female (female)
C0086287 (UMLS CUI-1)
(Comment:en)
Gravidity
Item
Gravidity
boolean
C0600457 (UMLS CUI [1])
Item Group
Physical parameters
C1269723 (UMLS CUI-1)
Height
Item
Height
integer
C0005890 (UMLS CUI [1])
Weight
Item
Weight
integer
C0005910 (UMLS CUI [1])
BMI
Item
BMI
integer
C1305855 (UMLS CUI [1])
Pulse
Item
Pulse
integer
C0232117 (UMLS CUI [1])
Systolic blood pressure
Item
Systolic blood pressure
integer
C0871470 (UMLS CUI [1])
Diastolic blood pressure
Item
Diastolic blood pressure
integer
C0428883 (UMLS CUI [1])
Item Group
Medical procedure
C0199171 (UMLS CUI-1)
Planned procedure
Item
Planned procedure
text
C0087111 (UMLS CUI [1,1])
C1301732 (UMLS CUI [1,2])
anesthesia
Item
Planned anesthetic technique
text
C0002903 (UMLS CUI [1])
Item Group
Preoperative state and risk factors
C0178808 (UMLS CUI-1)
C0035648 (UMLS CUI-3)
No abnormality detected
Item
No abnormality detected
boolean
C0559229 (UMLS CUI [1])
narcosis
Item
Re-narcosis
boolean
C0234447 (UMLS CUI [1])
Acute care
Item
Acute care
boolean
C0679878 (UMLS CUI [1])
ECG; Chest X-ray
Item
ECG / Chest X-ray
text
C1623258 (UMLS CUI [1])
C0039985 (UMLS CUI [2])
Heart
Item
Heart
text
C0018787 (UMLS CUI [1])
Lungs
Item
Lungs
text
C0024109 (UMLS CUI [1])
Abdomen
Item
Abdomen
text
C0000726 (UMLS CUI [1])
Other
Item
Other
text
C0205394 (UMLS CUI [1])
Long-term medication
Item
Long-term medication
text
C0420257 (UMLS CUI [1])
Previous surgeries
Item
Previous surgeries
text
C0744961 (UMLS CUI [1])
Allergies
Item
Allergies
text
C0020517 (UMLS CUI [1])
complications anesthesia
Item
Complications during anesthesia
text
C0009566 (UMLS CUI [1,1])
C0002903 (UMLS CUI [1,2])
Item Group
Findings: ECG
C1623258 (UMLS CUI-1)
ECG
Item
Normal findings
boolean
C1623258 (UMLS CUI [1])
Tachycardia
Item
Tachycardia
boolean
C0039231 (UMLS CUI [1])
Bradycardia
Item
Bradycardia
boolean
C0428977 (UMLS CUI [1])
Sinus rhythm
Item
Sinus rhythm absent
boolean
C0232201 (UMLS CUI [1])
Conduction defect
Item
Conduction defect
boolean
C0264886 (UMLS CUI [1])
Extrasystoles
Item
Extrasystoles >5/min.
boolean
C0541950 (UMLS CUI [1])
Pacemaker ECG
Item
Pacemaker ECG
boolean
C1287695 (UMLS CUI [1])
Signs of ischemia
Item
Signs of ischemia
boolean
C1141959 (UMLS CUI [1])
Signs of infarct
Item
Signs of infarct
boolean
C3854475 (UMLS CUI [1])
Disturbance of repolarization
Item
Disturbance of repolarization
boolean
C3279217 (UMLS CUI [1])
Item Group
Findings: Heart
C0018787 (UMLS CUI-1)
heart
Item
Normal findings
boolean
C0018787 (UMLS CUI [1])
Coronary heart disease
Item
Coronary heart disease
boolean
C0010068 (UMLS CUI [1])
Stable angina pectoris
Item
Stable angina pectoris
boolean
C0340288 (UMLS CUI [1])
Acute coronary syndrome
Item
Acute coronary syndrome
boolean
C0948089 (UMLS CUI [1])
Old myocardial infarction
Item
Myocardial infarction (old)
boolean
C0155668 (UMLS CUI [1])
Heart failure
Item
Heart failure
boolean
C0018801 (UMLS CUI [1])
Cardiomyopathy
Item
Cardiomyopathy
boolean
C0878544 (UMLS CUI [1])
Aortic stenosis
Item
Aortic / mitral stenosis
boolean
C0003507 (UMLS CUI [1])
heart defects
Item
Other heart defects
boolean
C0018799 (UMLS CUI [1])
cardiac arrhythmias
Item
Hemodynamically significant cardiac arrhythmias
boolean
C0003811 (UMLS CUI [1])
Cor pulmonale
Item
Cor pulmonale
boolean
C0034072 (UMLS CUI [1])
myocarditis
Item
Florid myocarditis
boolean
C0027059 (UMLS CUI [1])
Item Group
Findings: Lungs
C0024109 (UMLS CUI-1)
lungs
Item
Normal findings
boolean
C0024109 (UMLS CUI [1])
Dyspnea
Item
Dyspnea
boolean
C0013404 (UMLS CUI [1])
Pneumonia
Item
Pneumonia
boolean
C0032285 (UMLS CUI [1])
Acute bronchitis
Item
Acute bronchitis
boolean
C0149514 (UMLS CUI [1])
Chronic obstructive pulmonary disease
Item
COPD
boolean
C0024117 (UMLS CUI [1])
Obstruction
Item
Obstruction
boolean
C0028778 (UMLS CUI [1])
Restriction
Item
Restriction
boolean
C0443288 (UMLS CUI [1])
Pleural effusion
Item
Pleural effusion
boolean
C0032227 (UMLS CUI [1])
Pneumothorax
Item
Pneumothorax
boolean
C0032326 (UMLS CUI [1])
Ventilation
Item
Ventilation
boolean
C2945579 (UMLS CUI [1])
Item Group
Findings: Circulatory system
C0007226 (UMLS CUI-1)
Cardiovascular system
Item
Normal findings
boolean
C0007226 (UMLS CUI [1])
Hypotension
Item
Hypotension (therapy required)
boolean
C0020649 (UMLS CUI [1])
Hypertension
Item
Hypertension
boolean
C0020538 (UMLS CUI [1])
Embolism
Item
Embolism
boolean
C0013922 (UMLS CUI [1])
Thrombosis
Item
Thrombosis
boolean
C0040053 (UMLS CUI [1])
Artery occlusive disease
Item
Artery occlusive disease
boolean
C0264995 (UMLS CUI [1])
cerebral blood flow
Item
Impaired cerebral blood flow
boolean
C0428714 (UMLS CUI [1])
Item Group
Findings: CNS / Neurology
C0027765 (UMLS CUI-1)
Neurology
Item
Normal findings
boolean
C0027765 (UMLS CUI [1])
Somnolence
Item
Somnolence
boolean
C2830004 (UMLS CUI [1])
Coma
Item
Coma
boolean
C0009421 (UMLS CUI [1])
Traumatic brain injury
Item
Traumatic brain injury
boolean
C0876926 (UMLS CUI [1])
Intracerebral hemorrhage
Item
Intracerebral hemorrhage / Space-occupying lesion
boolean
C2937358 (UMLS CUI [1])
Stroke
Item
Stroke
boolean
C0038454 (UMLS CUI [1])
Transient ischemic attack
Item
TIA
boolean
C0007787 (UMLS CUI [1])
Parkinsons disease
Item
Parkinson's disease
boolean
C0030567 (UMLS CUI [1])
Alzheimers disease
Item
Alzheimer's disease / Dementia
boolean
C0002395 (UMLS CUI [1])
Multiple sclerosis
Item
Multiple sclerosis
boolean
C0026769 (UMLS CUI [1])
Amyotrophic lateral sclerosis
Item
Amyotrophic lateral sclerosis
boolean
C0002736 (UMLS CUI [1])
Epilepsy
Item
Epilepsy
boolean
C0014544 (UMLS CUI [1])
Neuromuscular disease
Item
Neuromuscular disease
boolean
C0027868 (UMLS CUI [1])
Item Group
Findings: metabolism
C0025519 (UMLS CUI-1)
metabolism
Item
Normal findings
boolean
C0025519 (UMLS CUI [1])
(Non-) Insulin-dependent diabetes mellitus
Item
(Non-) Insulin-dependent diabetes mellitus
boolean
C0011860 (UMLS CUI [1])
Endocrine disorder
Item
Endocrine disorder
boolean
C0014130 (UMLS CUI [1])
Enzymatic genetic defect
Item
Enzymatic genetic defect
boolean
C1394815 (UMLS CUI [1])
Item Group
Other findings
C0243095 (UMLS CUI-1)
findings
Item
Normal findings
boolean
C0243095 (UMLS CUI [1])
Infectious disease
Item
Infectious disease
boolean
C0009450 (UMLS CUI [1])
Resistant germs
Item
Resistant germs
boolean
C1444089 (UMLS CUI [1])
Obstructive sleep apnea
Item
Obstructive sleep apnea
boolean
C0037315 (UMLS CUI [1])
Renal failure
Item
Renal failure
boolean
C0035078 (UMLS CUI [1])
Item Group
Findings: Laboratory
C0022877 (UMLS CUI-1)
laboratory findings
Item
Normal findings
boolean
C0022877 (UMLS CUI [1])
blood count
Item
Pathological basic blood count
boolean
C0005771 (UMLS CUI [1])
acid-base balance
Item
Pathological acid-base balance
boolean
C0150116 (UMLS CUI [1])
coagulation
Item
Pathological coagulation
boolean
C0005778 (UMLS CUI [1])
Electrolytes
Item
Electrolytes pathological
boolean
C0013832 (UMLS CUI [1])
findings
Item
Other pathological findings
boolean
C0243095 (UMLS CUI [1])
Item Group
Blood values
C0018941 (UMLS CUI-1)
Hemoglobin
Item
Hb
float
C0019046 (UMLS CUI [1])
Hematocrit
Item
Ht
float
C0518014 (UMLS CUI [1])
Platelets
Item
Platelets
integer
C0032181 (UMLS CUI [1])
Prothrombin time
Item
PT
integer
C0033707 (UMLS CUI [1])
International Normalized Ratio
Item
INR
float
C0525032 (UMLS CUI [1])
Partial thromboplastin time
Item
PTT
integer
C3525810 (UMLS CUI [1])
Potassium
Item
K
float
C0202194 (UMLS CUI [1])
Creatinine
Item
Creatinine
float
C0201976 (UMLS CUI [1])
Blood sugar
Item
Glucose
float
C0392201 (UMLS CUI [1])
Gamma-glutamyltransferase
Item
GGT
float
C0202035 (UMLS CUI [1])
Item Group
Anticoagulation
C0003281 (UMLS CUI-1)
Acetylsalicylic acid
Item
ASS
boolean
C0004057 (UMLS CUI [1])
duration
Item
ASS until
date
C0449238 (UMLS CUI [1])
antagonists & inhibitors
Item
Antagonization
boolean
C0003139 (UMLS CUI [1])
duration administration
Item
Rez.-Antag. until
date
C0449238 (UMLS CUI [1,1])
C1533734 (UMLS CUI [1,2])
Heparin
Item
Heparin s.c./i.v.
boolean
C0019134 (UMLS CUI [1])
Heparin
Item
Heparin s.c./i.v. until
date
C0019134 (UMLS CUI [1])
Nonsteroidal anti-inflammatory drugs
Item
NSAIDs
boolean
C0003211 (UMLS CUI [1,1])
C0205360 (UMLS CUI [1,2])
NSAIDs
Item
NSAIDs until
date
C0003211 (UMLS CUI [1])
Marcumar
Item
Marcumar
boolean
C0918269 (UMLS CUI [1])
Marcumar
Item
Marcumar until
date
C0918269 (UMLS CUI [1])
anticoagulants
Item
Other anticoagulants
boolean
C0003280 (UMLS CUI [1])
Anticoagulation
Item
other anticoagulants until
date
C0449867 (UMLS CUI [1])
Item Group
Preoperative assessment
C1516048 (UMLS CUI-1)
C0445204 (UMLS CUI-2)
Item
Teeth
text
C4019131 (UMLS CUI [1,1])
C0040426 (UMLS CUI [1,2])
Code List
Teeth
CL Item
prosthesis (prosthesis)
CL Item
no abnormality detected (no abnormality detected)
CL Item
loose/damaged (loose/damaged)
Bleeding tendency
Item
Bleeding tendency
boolean
C1458140 (UMLS CUI [1])
aspiration risk
Item
Risk of aspiration
boolean
C0349707 (UMLS CUI [1,1])
C0035647 (UMLS CUI [1,2])
Nicotine
Item
Nicotine
boolean
C0028040 (UMLS CUI [1])
Alcohol
Item
Alcohol
boolean
C0001948 (UMLS CUI [1])
Drugs
Item
Drugs
boolean
C0013227 (UMLS CUI [1])
Allergies
Item
Allergies
boolean
C0020517 (UMLS CUI [1])
Item
ASA
integer
C1531480 (UMLS CUI [1])
Code List
ASA
CL Item
I (1)
CL Item
II (2)
CL Item
III (3)
CL Item
IV (4)
CL Item
V (5)
CL Item
VI (6)
Item
NYHA
integer
C1275491 (UMLS CUI [1])
Code List
NYHA
CL Item
I (1)
CL Item
II (2)
CL Item
II (3)
CL Item
IV (4)
Item
Mallampati
text
C0451276 (UMLS CUI [1])
Code List
Mallampati
CL Item
I (I)
CL Item
II (II)
CL Item
III (III)
CL Item
IV (IV)
CL Item
unknown (unknown)
Item
Difficult airway management
text
C0150126 (UMLS CUI [1])
Code List
Difficult airway management
CL Item
No indication (No indication)
CL Item
known (known)
CL Item
assumed (assumed)
Item Group
Preoperative instructions
C1442085 (UMLS CUI-1)
C0445204 (UMLS CUI-2)
surgery
Item
Evening before surgery
boolean
C0543467 (UMLS CUI [1])
day surgery
Item
Day of surgery
boolean
C0439228 (UMLS CUI [1,1])
C0543467 (UMLS CUI [1,2])
Medication
Item
Medication
text
C0013227 (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])
Item Group
Transfusion pre-order
C1879316 (UMLS CUI-1)
Blood type
Item
Blood type
boolean
C0005810 (UMLS CUI [1])
Coombs test
Item
Coombs test
boolean
C0009961 (UMLS CUI [1])
Red cell concentrate
Item
Red cell concentrate
integer
C0443095 (UMLS CUI [1])
Fresh frozen plasma
Item
FFP
integer
C0016709 (UMLS CUI [1])
Platelet concentrate
Item
Platelet concentrate
integer
C2362067 (UMLS CUI [1])
Item Group
Requirements prior to approval of surgery
C0242801 (UMLS CUI-1)
C0543467 (UMLS CUI-2)
Consent
Item
Patient's consent
boolean
C1511481 (UMLS CUI [1])
Findings
Item
Findings
boolean
C0243095 (UMLS CUI [1])
Follow-up visit
Item
Follow-up visit
boolean
C0589121 (UMLS CUI [1])
Item Group
Time of latest food intake
C0086311 (UMLS CUI-1)
solid food
Item
Solid
time
C0453855 (UMLS CUI [1])
liquids
Item
Liquid
time
C0302908 (UMLS CUI [1])
Item Group
Premedication
C0033045 (UMLS CUI-1)
Date of premedication
Item
Date of premedication
date
C0011008 (UMLS CUI [1,1])
C0033045 (UMLS CUI [1,2])
Anesthesist
Item
Anesthesist
text
C1550495 (UMLS CUI [1])
Item
Type of duty
text
C0028811 (UMLS CUI [1])
Code List
Type of duty
CL Item
regular (regular)
CL Item
overtime (overtime)
CL Item
on-call (on-call)
Time
Item
Time (beginning)
time
C0040223 (UMLS CUI [1])
Duration
Item
Duration
integer
C0449238 (UMLS CUI [1])
premedication
Item
Preadmission premedication
boolean
C0033045 (UMLS CUI [1])
outpatient department Anesthesia
Item
Anesthesia outpatient department
boolean
C0557824 (UMLS CUI [1,1])
C0002903 (UMLS CUI [1,2])
premedication; surgery
Item
No surgery after premedication
boolean
C0033045 (UMLS CUI [1])
C0543467 (UMLS CUI [2])
Name of physician
Item
Name of physician
text
C0027365 (UMLS CUI [1,1])
C0031831 (UMLS CUI [1,2])
Signature physician
Item
Signature physician
text
C0807938 (UMLS CUI [1])