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ID
43984
Description
Routine documentation in German hospitals. Source file name: TH130110_Prämedikationsprotokoll Examplary forms provided by DMI (http://www.dmi.de/)
Link
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
September 20, 2021
DOI
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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
C2707520 (UMLS CUI [1])
Case ID
Item
Case ID
text
C0868928 (UMLS CUI [1,1])
C0600091 (UMLS CUI [1,2])
C0600091 (UMLS CUI [1,2])
Surgery ID
Item
Surgery ID
text
C0543467 (UMLS CUI [1,1])
C0600091 (UMLS CUI [1,2])
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])
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
elektiv (>24h) (elective (>24h))
CL Item
within 24h (within 24h)
CL Item
emergency(< 2h) (emergency (< 2h))
CL Item
immediately (immediately)
CL Item
male (male)
C0086582 (UMLS CUI-1)
(Comment:en)
(Comment:en)
CL Item
female (female)
C0086287 (UMLS CUI-1)
(Comment:en)
(Comment:en)
Gravidity
Item
Gravidity
boolean
C0600457 (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])
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])
Item Group
Preoperative state and risk factors
C0178808 (UMLS CUI-1)
C0035648 (UMLS CUI-3)
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])
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])
C0002903 (UMLS CUI [1,2])
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])
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])
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])
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])
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])
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])
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])
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])
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])
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])
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])
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)
C0445204 (UMLS CUI-2)
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])
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])
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)
Item Group
Preoperative instructions
C1442085 (UMLS CUI-1)
C0445204 (UMLS CUI-2)
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])
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])
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)
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])
solid food
Item
Solid
time
C0453855 (UMLS CUI [1])
liquids
Item
Liquid
time
C0302908 (UMLS CUI [1])
Date of premedication
Item
Date of premedication
date
C0011008 (UMLS CUI [1,1])
C0033045 (UMLS CUI [1,2])
C0033045 (UMLS CUI [1,2])
Anesthesist
Item
Anesthesist
text
C1550495 (UMLS CUI [1])
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])
C0002903 (UMLS CUI [1,2])
premedication; surgery
Item
No surgery after premedication
boolean
C0033045 (UMLS CUI [1])
C0543467 (UMLS CUI [2])
C0543467 (UMLS CUI [2])
Name of physician
Item
Name of physician
text
C0027365 (UMLS CUI [1,1])
C0031831 (UMLS CUI [1,2])
C0031831 (UMLS CUI [1,2])
Signature physician
Item
Signature physician
text
C0807938 (UMLS CUI [1])