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ID
23989
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 (4)
- 7/5/17 7/5/17 -
- 7/20/17 7/20/17 -
- 7/31/17 7/31/17 -
- 9/20/21 9/20/21 -
Uploaded on
July 20, 2017
DOI
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License
Creative Commons BY-NC 3.0
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Premedication Example 1 Routine documentation in German hospitals DMI
Premedication Example 1 Routine documentation in German hospitals DMI
Similar models
Premedication Example 1 Routine documentation in German hospitals DMI
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
CL Item
Anesthesiology/Intensive care medicine (Anesthesiology/Intensive care medicine)
CL Item
General and visceral surgery (General and visceral surgery)
CL Item
Ophthalmology (Ophthalmology)
CL Item
Gynecology (Gynecology)
CL Item
Vascular surgery (Vascular surgery)
CL Item
MSZ (MSZ)
CL Item
Pediatric surgery (Pediatric surgery)
CL Item
Urology (Urology)
CL Item
Thoracic surgery (Thoracic surgery)
CL Item
Oral and maxillofacial surgery (Oral and maxillofacial surgery)
CL Item
Otolaryngology (Otolaryngology)
CL Item
Internal medicine (Internal medicine)
CL Item
Neurology (Neurology)
CL Item
Neurosurgery (Neurosurgery)
CL Item
Pediatrics (Pediatrics)
CL Item
Radiology (Radiology)
CL Item
Nuclear medicine (Nuclear medicine)
CL Item
Plastic surgery and burn treatment (Plastic surgery and burn treatment)
CL Item
Dermatology (Dermatology)
CL Item
Other (Other)
CL Item
outpatient (outpatient)
CL Item
in-patient (in-patient)
CL Item
private (private)
Age
Item
Age
integer
CL Item
intersex (intersex)
CL Item
(male)
CL Item
(female)
Height
Item
Height
integer
Weight
Item
Weight
integer
Heart rate
Item
Heart rate
integer
C0018810 (UMLS CUI [1])
Blood Pressure
Item
Blood Pressure
text
C0005823 (UMLS CUI [1])
Hemoglobin
Item
Hb
float
Potassium
Item
K
float
Blood sugar
Item
Blood sugar
float
Hematocrit
Item
Ht
float
Sodium
Item
Na
float
Creatinine
Item
Creatinine
float
Prothrombin time
Item
PT
integer
Partial thromboplastin time
Item
PTT
integer
Platelets
Item
Platelets
integer
Heart
Item
Heart
boolean
Lungs
Item
Lungs
boolean
Circulation
Item
Circulation
boolean
Neurology / CNS
Item
Neurology / CNS
boolean
Metabolism
Item
Metabolism
boolean
ASA
Item
BMI > = 40 (ASA III)
boolean
Preoperative condition
Item
Preoperative condition
text
Re-narcosis
Item
Re-narcosis
boolean
Long-term medication
Item
Long-term medication
text
Allergies
Item
Allergies
text
Postoperative nausea and vomiting
Item
PONV
boolean
Aspiration risk
Item
Aspiration risk
boolean
Difficult intubation
Item
Difficult intubation
boolean
CL Item
normal (normal)
CL Item
restored (restored)
CL Item
prosthesis (prosthesis)
CL Item
in need of treatment (in need of treatment)
CL Item
at risk (at risk)
CL Item
1 (1)
CL Item
2 (2)
CL Item
3 (3)
CL Item
4 (4)
CL Item
ASA I (ASA I)
CL Item
ASA II (ASA II)
CL Item
ASA III (ASA III)
CL Item
ASA IV (ASA IV)
CL Item
ASA V (ASA V)
CL Item
Brain death (Brain death)
CL Item
planned procedure (planned procedure)
CL Item
urgent (urgent)
CL Item
emergency (emergency)
Procedure
Item
Procedure
text
Diagnosis
Item
Diagnosis
text
Anesthetic technique
Item
Anesthetic technique
text
CL Item
TIVA (TIVA)
CL Item
Balanced anesthesia (Balanced anesthesia)
CL Item
RSI (RSI)
CL Item
Spinal anesthesia (Spinal anesthesia)
CL Item
Lumbar EDA (Lumbar EDA)
CL Item
Thoracic EDA (Thoracic EDA)
CL Item
Peripheral local anesthesia (Peripheral local anesthesia)
CL Item
Local anesthesia with catheter (Local anesthesia with catheter)
CL Item
Analgosedation (Analgosedation)
CL Item
Stand-by/Monitored care (Stand-by/Monitored care)
CL Item
other (other)
CL Item
documents incomplete (documents incomplete)
CL Item
findings missing (findings missing)
CL Item
patient not informed (patient not informed)
CL Item
patient not present (patient not present)
Preoperative round conducted
Item
Preoperative round conducted
boolean
CL Item
5 (5)
CL Item
10 (10)
CL Item
15 (15)
CL Item
20 (20)
CL Item
25 (25)
CL Item
30 (30)
CL Item
40 (40)
CL Item
regular (regular)
CL Item
overtime/on-call (overtime/on-call)
CL Item
weekend/holiday (weekend/holiday)
CL Item
20-22 (20-22)
CL Item
22-6 (22-6)
Date of premedication
Item
Date of premedication
date
CL Item
To be done (To be done)
CL Item
Not required (Not required)
CL Item
Done (Done)
CL Item
To be done (To be done)
CL Item
Not required (Not required)
CL Item
Done (Done)
CL Item
Done (Done)
CL Item
(To be done)
CL Item
(Not required)
Blood type AB0
Item
Blood type AB0
text
Blood type Rhesus
Item
Blood type Rhesus
text
CL Item
To be done (To be done)
CL Item
Not required (Not required)
CL Item
Done (Done)
Consultation
Item
Consultation
text
CL Item
To be done (To be done)
CL Item
Not required (Not required)
CL Item
Done (Done)
CL Item
To be done (To be done)
CL Item
Not required (Not required)
CL Item
Done (Done)
CL Item
To be done (To be done)
CL Item
Not required (Not required)
CL Item
Done (Done)
CL Item
1 (1)
CL Item
2 (2)
CL Item
3 (3)
CL Item
4 (4)
CL Item
To be done (To be done)
CL Item
Not required (Not required)
CL Item
Done (Done)
CL Item
1 (1)
CL Item
2 (2)
CL Item
3 (3)
CL Item
4 (4)
CL Item
To be done (To be done)
CL Item
Not required (Not required)
CL Item
Done (Done)
CL Item
1 (1)
CL Item
2 (2)
CL Item
3 (3)
CL Item
4 (4)
CL Item
To be done (To be done)
CL Item
Not required (Not required)
CL Item
Done (Done)
CL Item
1 (1)
CL Item
2 (2)
CL Item
3 (3)
CL Item
4 (4)
CL Item
To be done (To be done)
CL Item
Not required (Not required)
CL Item
Done (Done)
CL Item
1 (1)
CL Item
2 (2)
CL Item
3 (3)
CL Item
4 (4)
Premedication
Item
Premedication
text
Medication
Item
Medication
text
Dosage
Item
Dosage
text
Administration
Item
Administration
text
Signature
Item
Signature
text
Further instructions
Item
Further instructions
text
Signature
Item
Signature
text
Continued self-medication
Item
Continued self-medication
boolean
Continued self-medication exceptions
Item
Exceptions from continued self-medication
text
Name
Item
Name
text
Signature
Item
Signature
text
Time
Item
Time
time