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23988
Description
Routine documentation in German hospitals. Source file name: TH130110_Prämedikationsprotokoll Examplary forms provided by DMI (http://www.dmi.de/)
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Keywords
Versions (5)
- 7/12/17 7/12/17 -
- 7/12/17 7/12/17 -
- 7/20/17 7/20/17 -
- 7/31/17 7/31/17 -
- 9/20/21 9/20/21 -
Uploaded on
July 20, 2017
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License
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)
Data type
Alias
Patient data
Item
Patient data
text
Case ID
Item
Case ID
text
Surgery ID
Item
Surgery ID
text
Date of birth
Item
Date of birth
date
C0421451 (UMLS CUI [1])
Age
Item
Age
integer
Ward
Item
Ward
text
Room number
Item
Room number
text
Elective service
Item
Elective service
boolean
CL Item
outpatient (outpatient)
CL Item
in-patient (in-patient)
CL Item
elektiv (>24h) (elective (>24h))
CL Item
within 24h (within 24h)
CL Item
emergency(< 2h) (emergency (< 2h))
CL Item
immediately (immediately)
CL Item
male (male)
CL Item
female (female)
Gravidity
Item
Gravidity
boolean
Height
Item
Height
integer
Weight
Item
Weight
integer
BMI
Item
BMI
integer
Pulse
Item
Pulse
integer
Systolic blood pressure
Item
Systolic blood pressure
integer
C0871470 (UMLS CUI [1])
Diastolic blood pressure
Item
Diastolic blood pressure
integer
C0428883 (UMLS CUI [1])
Planned procedure
Item
Planned procedure
text
Planned anesthetic technique
Item
Planned anesthetic technique
text
No abnormality detected
Item
No abnormality detected
boolean
Re-narcosis
Item
Re-narcosis
boolean
Acute care
Item
Acute care
boolean
ECG / Chest X-ray
Item
ECG / Chest X-ray
text
Heart
Item
Heart
text
Lungs
Item
Lungs
text
Abdomen
Item
Abdomen
text
Other
Item
Other
text
Long-term medication
Item
Long-term medication
text
Previous surgeries
Item
Previous surgeries
text
Allergies
Item
Allergies
text
Complications during anesthesia
Item
Complications during anesthesia
text
Normal findings ECG
Item
Normal findings
boolean
Tachycardia
Item
Tachycardia
boolean
Bradycardia
Item
Bradycardia
boolean
Sinus rhythm absent
Item
Sinus rhythm absent
boolean
Conduction defect
Item
Conduction defect
boolean
Extrasystoles
Item
Extrasystoles >5/min.
boolean
Pacemaker ECG
Item
Pacemaker ECG
boolean
Signs of ischemia
Item
Signs of ischemia
boolean
Signs of infarct
Item
Signs of infarct
boolean
Disturbance of repolarization
Item
Disturbance of repolarization
boolean
Normal findings heart
Item
Normal findings
boolean
Coronary heart disease
Item
Coronary heart disease
boolean
Stable angina pectoris
Item
Stable angina pectoris
boolean
Acute coronary syndrome
Item
Acute coronary syndrome
boolean
Old myocardial infarction
Item
Myocardial infarction (old)
boolean
Heart failure
Item
Heart failure
boolean
Cardiomyopathy
Item
Cardiomyopathy
boolean
Aortic / mitral stenosis
Item
Aortic / mitral stenosis
boolean
Other heart defects
Item
Other heart defects
boolean
Hemodyn. significant cardiac arrhythmias
Item
Hemodynamically significant cardiac arrhythmias
boolean
Cor pulmonale
Item
Cor pulmonale
boolean
Florid myocarditis
Item
Florid myocarditis
boolean
Normal findings lungs
Item
Normal findings
boolean
Dyspnea
Item
Dyspnea
boolean
Pneumonia
Item
Pneumonia
boolean
Acute bronchitis
Item
Acute bronchitis
boolean
Chronic obstructive pulmonary disease
Item
COPD
boolean
Obstruction
Item
Obstruction
boolean
Restriction
Item
Restriction
boolean
Pleural effusion
Item
Pleural effusion
boolean
Pneumothorax
Item
Pneumothorax
boolean
Ventilation
Item
Ventilation
boolean
Normal findings circulatory system
Item
Normal findings
boolean
Hypotension
Item
Hypotension (therapy required)
boolean
Hypertension
Item
Hypertension
boolean
Embolism
Item
Embolism
boolean
Thrombosis
Item
Thrombosis
boolean
Artery occlusive disease
Item
Artery occlusive disease
boolean
Impaired cerebral blood flow
Item
Impaired cerebral blood flow
boolean
Normal findings CNS / Neurology
Item
Normal findings
boolean
Somnolence
Item
Somnolence
boolean
Coma
Item
Coma
boolean
Traumatic brain injury
Item
Traumatic brain injury
boolean
Intracerebral hemorrhage / Space-occupying lesion
Item
Intracerebral hemorrhage / Space-occupying lesion
boolean
Stroke
Item
Stroke
boolean
Transient ischemic attack
Item
TIA
boolean
Parkinsons disease
Item
Parkinson's disease
boolean
Alzheimers disease / Dementia
Item
Alzheimer's disease / Dementia
boolean
Multiple sclerosis
Item
Multiple sclerosis
boolean
Amyotrophic lateral sclerosis
Item
Amyotrophic lateral sclerosis
boolean
Epilepsy
Item
Epilepsy
boolean
Neuromuscular disease
Item
Neuromuscular disease
boolean
Normal findings metabolism
Item
Normal findings
boolean
(Non-) Insulin-dependent diabetes mellitus
Item
(Non-) Insulin-dependent diabetes mellitus
boolean
Endocrine disorder
Item
Endocrine disorder
boolean
Enzymatic genetic defect
Item
Enzymatic genetic defect
boolean
Normal findings other
Item
Normal findings
boolean
Infectious disease
Item
Infectious disease
boolean
Resistant germs
Item
Resistant germs
boolean
Obstructive sleep apnea
Item
Obstructive sleep apnea
boolean
Renal failure
Item
Renal failure
boolean
Normal laboratory findings
Item
Normal findings
boolean
Pathological basic blood count
Item
Pathological basic blood count
boolean
Pathological acid-base balance
Item
Pathological acid-base balance
boolean
Pathological coagulation
Item
Pathological coagulation
boolean
Electrolytes pathological
Item
Electrolytes pathological
boolean
Other pathological findings
Item
Other pathological findings
boolean
Hemoglobin
Item
Hb
float
Hematocrit
Item
Ht
float
Platelets
Item
Platelets
integer
Prothrombin time
Item
PT
integer
International Normalized Ratio
Item
INR
float
Partial thromboplastin time
Item
PTT
integer
Potassium
Item
K
float
Creatinine
Item
Creatinine
float
Blood sugar
Item
Glucose
float
Gamma-glutamyltransferase
Item
GGT
float
Acetylsalicylic acid
Item
ASS
boolean
ASS administration duration
Item
ASS until
date
Antagonization
Item
Antagonization
boolean
Rez.-Antag. administration duration
Item
Rez.-Antag. until
date
Heparin
Item
Heparin s.c./i.v.
boolean
Heparin administration duration
Item
Heparin s.c./i.v. until
date
Nonsteroidal anti-inflammatory drugs
Item
NSAIDs
boolean
NSAIDs administration duration
Item
NSAIDs until
date
Marcumar
Item
Marcumar
boolean
Marcumar administration duration
Item
Marcumar until
date
Other anticoagulants
Item
Other anticoagulants
boolean
Administration of other anticoagulants duration
Item
other anticoagulants until
date
CL Item
prosthesis (prosthesis)
CL Item
no abnormality detected (no abnormality detected)
CL Item
loose/damaged (loose/damaged)
Bleeding tendency
Item
Bleeding tendency
boolean
Risk of aspiration
Item
Risk of aspiration
boolean
Nicotine
Item
Nicotine
boolean
Alcohol
Item
Alcohol
boolean
Drugs
Item
Drugs
boolean
Allergies
Item
Allergies
boolean
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
unknown (unknown)
CL Item
No indication (No indication)
CL Item
known (known)
CL Item
assumed (assumed)
Evening before surgery
Item
Evening before surgery
boolean
Day of surgery
Item
Day of surgery
boolean
Medication
Item
Medication
text
Administration
Item
Administration
text
Time
Item
Time
time
Signature
Item
Signature
text
Blood type
Item
Blood type
boolean
Coombs test
Item
Coombs test
boolean
Red cell concentrate
Item
Red cell concentrate
integer
Fresh frozen plasma
Item
FFP
integer
Platelet concentrate
Item
Platelet concentrate
integer
Consent by patient
Item
Patient's consent
boolean
Findings
Item
Findings
boolean
Follow-up visit
Item
Follow-up visit
boolean
Time of solid food intake
Item
Solid
time
Time of intake of liquids
Item
Liquid
time
Date of premedication
Item
Date of premedication
date
Anesthesist
Item
Anesthesist
text
CL Item
regular (regular)
CL Item
overtime (overtime)
CL Item
on-call (on-call)
Time
Item
Time (beginning)
time
Duration
Item
Duration
integer
Preadmission premedication
Item
Preadmission premedication
boolean
Anesthesia outpatient department
Item
Anesthesia outpatient department
boolean
No surgery after premedication
Item
No surgery after premedication
boolean
Name of physician
Item
Name of physician
text
Signature physician
Item
Signature physician
text