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Routine documentation in German hospitals. Source file name: TH130110_Prämedikationsprotokoll Examplary forms provided by DMI (http://www.dmi.de/)
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- 12-07-17 12-07-17 -
- 12-07-17 12-07-17 -
- 20-07-17 20-07-17 -
- 31-07-17 31-07-17 -
- 20-09-21 20-09-21 -
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20 september 2021
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Creative Commons BY-NC 3.0
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Premedication Example 2 Routine documentation in German hospitals DMI
Premedication Example 2 Routine documentation in German hospitals DMI
Similar models
Premedication Example 2 Routine documentation in German hospitals DMI
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Patient data
Item
Patientendaten
text
C2707520 (UMLS CUI [1])
Case ID
Item
Fallnummer
text
C0868928 (UMLS CUI [1,1])
C0600091 (UMLS CUI [1,2])
C0600091 (UMLS CUI [1,2])
Surgery ID
Item
OP-Nummer
text
C0543467 (UMLS CUI [1,1])
C0600091 (UMLS CUI [1,2])
C0600091 (UMLS CUI [1,2])
Date of birth
Item
Geburtsdatum
date
C0421451 (UMLS CUI [1])
Age
Item
Alter
integer
C0001779 (UMLS CUI [1])
Ward
Item
Station
text
C1305702 (UMLS CUI [1])
Room number
Item
Zimmer-Nummer
text
C1718316 (UMLS CUI [1])
Elective
Item
Wahlleistung
boolean
C0206058 (UMLS CUI [1])
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
elektiv (>24h) (elective (>24h))
CL Item
innerhalb 24h (within 24h)
CL Item
Notfall < 2h (emergency (< 2h))
CL Item
sofort (immediately)
CL Item
m (male)
C0086582 (UMLS CUI-1)
(Comment:en)
(Comment:en)
CL Item
w (female)
C0086287 (UMLS CUI-1)
(Comment:en)
(Comment:en)
Gravidity
Item
Gravidität
boolean
C0600457 (UMLS CUI [1])
Height
Item
Größe
integer
C0005890 (UMLS CUI [1])
Weight
Item
Gewicht
integer
C0005910 (UMLS CUI [1])
BMI
Item
BMI
integer
C1305855 (UMLS CUI [1])
Pulse
Item
Puls
integer
C0232117 (UMLS CUI [1])
Systolic blood pressure
Item
RR systolisch
integer
C0871470 (UMLS CUI [1])
Diastolic blood pressure
Item
RR diastolisch
integer
C0428883 (UMLS CUI [1])
Planned procedure
Item
Geplante Operation
text
C0087111 (UMLS CUI [1,1])
C1301732 (UMLS CUI [1,2])
C1301732 (UMLS CUI [1,2])
anesthesia
Item
Geplante Anästhesie
text
C0002903 (UMLS CUI [1])
Item Group
Präoperativer Status und Risikofaktoren
C0178808 (UMLS CUI-1)
C0035648 (UMLS CUI-3)
C0035648 (UMLS CUI-3)
No abnormality detected
Item
ohne Befund
boolean
C0559229 (UMLS CUI [1])
narcosis
Item
Wiederholungsnarkose
boolean
C0234447 (UMLS CUI [1])
Acute care
Item
Akutversorgung
boolean
C0679878 (UMLS CUI [1])
ECG; Chest X-ray
Item
EKG / Röntgen-Thorax
text
C1623258 (UMLS CUI [1])
C0039985 (UMLS CUI [2])
C0039985 (UMLS CUI [2])
Heart
Item
Herz
text
C0018787 (UMLS CUI [1])
Lungs
Item
Lunge
text
C0024109 (UMLS CUI [1])
Abdomen
Item
Abdomen
text
C0000726 (UMLS CUI [1])
Other
Item
Varia
text
C0205394 (UMLS CUI [1])
Long-term medication
Item
Dauermedikation
text
C0420257 (UMLS CUI [1])
Previous surgeries
Item
Vor-OPs
text
C0744961 (UMLS CUI [1])
Allergies
Item
Allergie
text
C0020517 (UMLS CUI [1])
complications anesthesia
Item
Narkosekomplikationen
text
C0009566 (UMLS CUI [1,1])
C0002903 (UMLS CUI [1,2])
C0002903 (UMLS CUI [1,2])
ECG
Item
normal
boolean
C1623258 (UMLS CUI [1])
Tachycardia
Item
Tachykardie
boolean
C0039231 (UMLS CUI [1])
Bradycardia
Item
Bradykardie
boolean
C0428977 (UMLS CUI [1])
Sinus rhythm
Item
fehlender SR
boolean
C0232201 (UMLS CUI [1])
Conduction defect
Item
Überleitungsstörung
boolean
C0264886 (UMLS CUI [1])
Extrasystoles
Item
Extrasystolie >5/min.
boolean
C0541950 (UMLS CUI [1])
Pacemaker ECG
Item
SM-EKG
boolean
C1287695 (UMLS CUI [1])
Signs of ischemia
Item
Ischämiezeichen
boolean
C1141959 (UMLS CUI [1])
Signs of infarct
Item
Infarktzeichen
boolean
C3854475 (UMLS CUI [1])
Disturbance of repolarization
Item
Erregungsrückbildungsstörung
boolean
C3279217 (UMLS CUI [1])
heart
Item
normal
boolean
C0018787 (UMLS CUI [1])
Coronary heart disease
Item
KHK
boolean
C0010068 (UMLS CUI [1])
Stable angina pectoris
Item
stabile AP
boolean
C0340288 (UMLS CUI [1])
Acute coronary syndrome
Item
ACS
boolean
C0948089 (UMLS CUI [1])
Old myocardial infarction
Item
Myokardinfarkt (alt)
boolean
C0155668 (UMLS CUI [1])
Heart failure
Item
Herzinsuffizienz
boolean
C0018801 (UMLS CUI [1])
Cardiomyopathy
Item
Kardiomyopathie
boolean
C0878544 (UMLS CUI [1])
Aortic stenosis
Item
Aorten- / Mitralstenose
boolean
C0003507 (UMLS CUI [1])
heart defects
Item
sonstige Herzvitien
boolean
C0018799 (UMLS CUI [1])
cardiac arrhythmias
Item
Hämodynamisch relevante Herzrhythmusstörungen
boolean
C0003811 (UMLS CUI [1])
Cor pulmonale
Item
Cor pulmonale
boolean
C0034072 (UMLS CUI [1])
myocarditis
Item
Floride Myokarditis
boolean
C0027059 (UMLS CUI [1])
lungs
Item
normal
boolean
C0024109 (UMLS CUI [1])
Dyspnea
Item
Dyspnoe
boolean
C0013404 (UMLS CUI [1])
Pneumonia
Item
Pneumonie
boolean
C0032285 (UMLS CUI [1])
Acute bronchitis
Item
Akute Bronchitis
boolean
C0149514 (UMLS CUI [1])
Chronic obstructive pulmonary disease
Item
COPD
boolean
C0024117 (UMLS CUI [1])
Obstruction
Item
Obstruktion
boolean
C0028778 (UMLS CUI [1])
Restriction
Item
Restriktion
boolean
C0443288 (UMLS CUI [1])
Pleural effusion
Item
Pleuraerguss
boolean
C0032227 (UMLS CUI [1])
Pneumothorax
Item
Pneumothorax
boolean
C0032326 (UMLS CUI [1])
Ventilation
Item
Beatmung
boolean
C2945579 (UMLS CUI [1])
Cardiovascular system
Item
normal
boolean
C0007226 (UMLS CUI [1])
Hypotension
Item
Hypotonie (therapiebed.)
boolean
C0020649 (UMLS CUI [1])
Hypertension
Item
Hypertonie
boolean
C0020538 (UMLS CUI [1])
Embolism
Item
Embolie
boolean
C0013922 (UMLS CUI [1])
Thrombosis
Item
Thrombose
boolean
C0040053 (UMLS CUI [1])
Artery occlusive disease
Item
AVK
boolean
C0264995 (UMLS CUI [1])
cerebral blood flow
Item
zerebrale Durchblutungsstörung
boolean
C0428714 (UMLS CUI [1])
Neurology
Item
normal
boolean
C0027765 (UMLS CUI [1])
Somnolence
Item
Somnolenz
boolean
C2830004 (UMLS CUI [1])
Coma
Item
Koma
boolean
C0009421 (UMLS CUI [1])
Traumatic brain injury
Item
SHT
boolean
C0876926 (UMLS CUI [1])
Intracerebral hemorrhage
Item
ICB / Raumforderung
boolean
C2937358 (UMLS CUI [1])
Stroke
Item
Schlaganfall
boolean
C0038454 (UMLS CUI [1])
Transient ischemic attack
Item
TIA
boolean
C0007787 (UMLS CUI [1])
Parkinsons disease
Item
Parkinson
boolean
C0030567 (UMLS CUI [1])
Alzheimers disease
Item
Alzheimer / Demenz
boolean
C0002395 (UMLS CUI [1])
Multiple sclerosis
Item
MS
boolean
C0026769 (UMLS CUI [1])
Amyotrophic lateral sclerosis
Item
ALS
boolean
C0002736 (UMLS CUI [1])
Epilepsy
Item
Epilepsie
boolean
C0014544 (UMLS CUI [1])
Neuromuscular disease
Item
neuromuskuläre Erkrankung
boolean
C0027868 (UMLS CUI [1])
metabolism
Item
normal
boolean
C0025519 (UMLS CUI [1])
(Non-) Insulin-dependent diabetes mellitus
Item
(N) IDDM
boolean
C0011860 (UMLS CUI [1])
Endocrine disorder
Item
Klinisch symptomatische Hormonstörung
boolean
C0014130 (UMLS CUI [1])
Enzymatic genetic defect
Item
Enzymatische Gendefekte
boolean
C1394815 (UMLS CUI [1])
findings
Item
normal
boolean
C0243095 (UMLS CUI [1])
Infectious disease
Item
Infektiöse Erkrankung
boolean
C0009450 (UMLS CUI [1])
Resistant germs
Item
resistente Keime
boolean
C1444089 (UMLS CUI [1])
Obstructive sleep apnea
Item
OSAS
boolean
C0037315 (UMLS CUI [1])
Renal failure
Item
Niereninsuffizienz
boolean
C0035078 (UMLS CUI [1])
laboratory findings
Item
normal
boolean
C0022877 (UMLS CUI [1])
blood count
Item
kleines BB pathologisch
boolean
C0005771 (UMLS CUI [1])
acid-base balance
Item
SBH pathologisch
boolean
C0150116 (UMLS CUI [1])
coagulation
Item
Gerinnung pathologisch
boolean
C0005778 (UMLS CUI [1])
Electrolytes
Item
Elektrolyte pathologisch
boolean
C0013832 (UMLS CUI [1])
findings
Item
andere pathologisch
boolean
C0243095 (UMLS CUI [1])
Hemoglobin
Item
Hb
float
C0019046 (UMLS CUI [1])
Hematocrit
Item
Hk
float
C0518014 (UMLS CUI [1])
Platelets
Item
Thr
integer
C0032181 (UMLS CUI [1])
Prothrombin time
Item
Quick
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
Kalium
float
C0202194 (UMLS CUI [1])
Creatinine
Item
Krea
float
C0201976 (UMLS CUI [1])
Blood sugar
Item
BZ
float
C0392201 (UMLS CUI [1])
Gamma-glutamyltransferase
Item
gamma-GT
float
C0202035 (UMLS CUI [1])
Acetylsalicylic acid
Item
ASS
boolean
C0004057 (UMLS CUI [1])
duration
Item
ASS bis
date
C0449238 (UMLS CUI [1])
antagonists & inhibitors
Item
Rez.-Antagonisierung
boolean
C0003139 (UMLS CUI [1])
duration administration
Item
Rez.-Antag. bis
date
C0449238 (UMLS CUI [1,1])
C1533734 (UMLS CUI [1,2])
C1533734 (UMLS CUI [1,2])
Heparin
Item
Heparin sc/iv
boolean
C0019134 (UMLS CUI [1])
Heparin
Item
Heparin sc/iv until
date
C0019134 (UMLS CUI [1])
Nonsteroidal anti-inflammatory drugs
Item
NSAR
boolean
C0003211 (UMLS CUI [1,1])
C0205360 (UMLS CUI [1,2])
C0205360 (UMLS CUI [1,2])
NSAIDs
Item
NSAR bis
date
C0003211 (UMLS CUI [1])
Marcumar
Item
Marcumar
boolean
C0918269 (UMLS CUI [1])
Marcumar
Item
Marcumar bis
date
C0918269 (UMLS CUI [1])
anticoagulants
Item
andere
boolean
C0003280 (UMLS CUI [1])
Anticoagulation
Item
andere bis
date
C0449867 (UMLS CUI [1])
Item Group
Präoperativer Zustand
C1516048 (UMLS CUI-1)
C0445204 (UMLS CUI-2)
C0445204 (UMLS CUI-2)
CL Item
Prothese (prosthesis)
CL Item
o. B. (no abnormality detected)
CL Item
locker/besch. (loose/damaged)
Bleeding tendency
Item
Blutungsneigung
boolean
C1458140 (UMLS CUI [1])
aspiration risk
Item
Aspirationsrisiko
boolean
C0349707 (UMLS CUI [1,1])
C0035647 (UMLS CUI [1,2])
C0035647 (UMLS CUI [1,2])
Nicotine
Item
Nikotin
boolean
C0028040 (UMLS CUI [1])
Alcohol
Item
Alkohol
boolean
C0001948 (UMLS CUI [1])
Drugs
Item
Drogen
boolean
C0013227 (UMLS CUI [1])
Allergies
Item
Allergie
boolean
C0020517 (UMLS CUI [1])
CL Item
I (1)
CL Item
II (2)
CL Item
III (3)
CL Item
IV (4)
CL Item
V (5)
CL Item
VI (6)
CL Item
I (1)
CL Item
II (2)
CL Item
II (3)
CL Item
IV (4)
CL Item
I (I)
CL Item
II (II)
CL Item
III (III)
CL Item
IV (IV)
CL Item
n. b. (unknown)
CL Item
Keine Hinweise (No indication)
CL Item
Bekannt (known)
CL Item
Vermutet (assumed)
Item Group
Präoperative Anordnungen
C1442085 (UMLS CUI-1)
C0445204 (UMLS CUI-2)
C0445204 (UMLS CUI-2)
surgery
Item
Vorabend
boolean
C0543467 (UMLS CUI [1])
day surgery
Item
OP-Tag
boolean
C0439228 (UMLS CUI [1,1])
C0543467 (UMLS CUI [1,2])
C0543467 (UMLS CUI [1,2])
Medication
Item
Medikament
text
C0013227 (UMLS CUI [1])
Administration
Item
Applikation
text
C1533734 (UMLS CUI [1])
Time
Item
Uhrzeit
time
C0040223 (UMLS CUI [1])
Signature
Item
Unterschrift
text
C1519316 (UMLS CUI [1])
Blood type
Item
Blutgruppe
boolean
C0005810 (UMLS CUI [1])
Coombs test
Item
AK-Suchtest
boolean
C0009961 (UMLS CUI [1])
Red cell concentrate
Item
EK
integer
C0443095 (UMLS CUI [1])
Fresh frozen plasma
Item
FFP
integer
C0016709 (UMLS CUI [1])
Platelet concentrate
Item
TK
integer
C2362067 (UMLS CUI [1])
Item Group
Vor OP-Freigabe erforderlich
C0242801 (UMLS CUI-1)
C0543467 (UMLS CUI-2)
C0543467 (UMLS CUI-2)
Consent
Item
Patienteneinverständnis
boolean
C1511481 (UMLS CUI [1])
Findings
Item
Befunde
boolean
C0243095 (UMLS CUI [1])
Follow-up visit
Item
Wiedervorstellung
boolean
C0589121 (UMLS CUI [1])
solid food
Item
fest
time
C0453855 (UMLS CUI [1])
liquids
Item
flüssig
time
C0302908 (UMLS CUI [1])
Date of premedication
Item
Datum Prämedikation
date
C0011008 (UMLS CUI [1,1])
C0033045 (UMLS CUI [1,2])
C0033045 (UMLS CUI [1,2])
Anesthesist
Item
Anästhesist/-in
text
C1550495 (UMLS CUI [1])
CL Item
RD (regular)
CL Item
ÜS (overtime)
CL Item
BD (on-call)
Time
Item
Uhrzeit (Beginn)
time
C0040223 (UMLS CUI [1])
Duration
Item
Dauer
integer
C0449238 (UMLS CUI [1])
premedication
Item
PM vorstationär
boolean
C0033045 (UMLS CUI [1])
outpatient department Anesthesia
Item
Anästh.-Ambulanz
boolean
C0557824 (UMLS CUI [1,1])
C0002903 (UMLS CUI [1,2])
C0002903 (UMLS CUI [1,2])
premedication; surgery
Item
Nach Prämed. keine OP
boolean
C0033045 (UMLS CUI [1])
C0543467 (UMLS CUI [2])
C0543467 (UMLS CUI [2])
Name of physician
Item
Name Arzt/Ärztin
text
C0027365 (UMLS CUI [1,1])
C0031831 (UMLS CUI [1,2])
C0031831 (UMLS CUI [1,2])
Signature physician
Item
Unterschrift Arzt/Ärztin
text
C0807938 (UMLS CUI [1])