ID

15707

Description

Routine documentation in German hospitals. Source file name: OP150107_Postoperative Verordnungen/ Postoperative Anweisungen.077 Examplary forms provided by DMI (http://www.dmi.de/)

Link

http://www.dmi.de/

Keywords

Versions (1)
  1. 6/8/16 6/8/16 -
Uploaded on

June 8, 2016

DOI

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License

Creative Commons BY-NC 3.0
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Postoperative Instructions for ICU Routine documentation in German hospitals DMI

German

Postoperative Instructions

1 forms  
Postoperative Anweisung Operateur
Description

Postoperative Anweisung Operateur

Operateur
Description

Surgeon

Data type

text

Alias
UMLS CUI [1]
C0582175
Datum Operation
Description

Date Surgery

Data type

date

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C0543467
Drainage
Description

Drainage

Data type

text

Alias
UMLS CUI [1]
C0013103
Andere Drainage
Description

Other

Data type

text

Alias
UMLS CUI [1]
C0205394
Anzahl
Description

Number

Data type

integer

Alias
UMLS CUI [1]
C0449788
Lage
Description

Site

Data type

text

Alias
UMLS CUI [1]
C1515974
Andere
Description

Other

Data type

text

Alias
UMLS CUI [1]
C0205394
Spülung
Description

Rinsing

Data type

text

Alias
UMLS CUI [1]
C1882955
Katheter (Dauerkatheter)
Description

catheter

Data type

text

Alias
UMLS CUI [1]
C0085590
Tamponade
Description

Tamponade

Data type

text

Alias
UMLS CUI [1]
C0579016
Entfernen
Description

Removal Tamponade

Data type

boolean

Alias
UMLS CUI [1,1]
C0015252
UMLS CUI [1,2]
C0579016
Uhr
Description

Time Removal Tamponade

Data type

time

Alias
UMLS CUI [1,1]
C0040223
UMLS CUI [1,2]
C0015252
UMLS CUI [1,3]
C0579016
Enterostoma
Description

Enterostomy procedure

Data type

text

Alias
UMLS CUI [1]
C0014370
Ampicillin comp. 1,5g
Description

Ampicillin

Data type

boolean

Alias
UMLS CUI [1]
C0002680
Zeit
Description

Time

Data type

time

Alias
UMLS CUI [1]
C0040223
Ampicillin 2g
Description

Ampicillin

Data type

boolean

Alias
UMLS CUI [1]
C0002680
Zeit
Description

Time

Data type

time

Alias
UMLS CUI [1]
C0040223
Cefazolin 2000mg
Description

Cefazolin

Data type

boolean

Alias
UMLS CUI [1]
C0007546
Zeit
Description

Time

Data type

time

Alias
UMLS CUI [1]
C0040223
Ceftriaxon
Description

Ceftriaxone

Data type

boolean

Alias
UMLS CUI [1]
C0007561
Zeit
Description

Time

Data type

time

Alias
UMLS CUI [1]
C0040223
Metronidazol 500mg
Description

Metronidazole

Data type

boolean

Alias
UMLS CUI [1]
C0025872
Zeit
Description

Time

Data type

time

Alias
UMLS CUI [1]
C0040223
Cefotaxim 2g
Description

Cefotaxime

Data type

boolean

Alias
UMLS CUI [1]
C0007554
Zeit
Description

Time

Data type

time

Alias
UMLS CUI [1]
C0040223
Gentamycin 80mg
Description

Gentamicin

Data type

boolean

Alias
UMLS CUI [1]
C0017436
Tgl
Description

Dose

Data type

text

Alias
UMLS CUI [1]
C3174092
Andere Dosis
Description

other Dose

Data type

text

Alias
UMLS CUI [1,1]
C0205394
UMLS CUI [1,2]
C3174092
Tag
Description

Day

Data type

text

Alias
UMLS CUI [1]
C0449238
Bemerkung
Description

Note

Data type

text

Alias
UMLS CUI [1]
C1317574
Keine Anweisung
Description

instructions

Data type

text

Alias
UMLS CUI [1]
C1442085
Postoperative Anweisung Anesthetist
Description

Postoperative Anweisung Anesthetist

Novaminsulfon
Description

Novaminsulfone

Data type

boolean

Alias
UMLS CUI [1]
C0936240
Dosis
Description

dose

Data type

float

Measurement units
  • m/g
Alias
UMLS CUI [1]
C3174092
m/g
Trpf/ supp
Description

Drops

Data type

text

Alias
UMLS CUI [1]
C2347093
i.v
Description

intravenous

Data type

text

Alias
UMLS CUI [1]
C0348016
Kurzinf.
Description

Infusion

Data type

text

Alias
UMLS CUI [1]
C0574032
bei Bed.
Description

as required

Data type

text

Alias
UMLS CUI [1]
C0558288
Uhr
Description

Time

Data type

time

Alias
UMLS CUI [1]
C0040223
Intervall/ h
Description

Interval

Data type

text

Alias
UMLS CUI [1]
C1272706
Dipidolor- Piritramid
Description

Dipidolor Piritramide

Data type

boolean

Alias
UMLS CUI [1,1]
C0809927
UMLS CUI [1,2]
C0031982
Dosis
Description

dose

Data type

float

Measurement units
  • m/g
Alias
UMLS CUI [1]
C3174092
m/g
Trpf/ supp
Description

Drops

Data type

text

Alias
UMLS CUI [1]
C2347093
i.v
Description

intravenous

Data type

text

Alias
UMLS CUI [1]
C0348016
Kurzinf.
Description

Infusion

Data type

text

Alias
UMLS CUI [1]
C0574032
bei Bed.
Description

as required

Data type

text

Alias
UMLS CUI [1]
C0558288
Uhr
Description

Time

Data type

time

Alias
UMLS CUI [1]
C0040223
Intervall/ h
Description

Interval

Data type

text

Alias
UMLS CUI [1]
C1272706
Tramadol
Description

Tramadol

Data type

boolean

Alias
UMLS CUI [1]
C0040610
Dosis
Description

dose

Data type

float

Measurement units
  • m/g
Alias
UMLS CUI [1]
C3174092
m/g
Trpf/ supp
Description

Drops

Data type

text

Alias
UMLS CUI [1]
C2347093
i.v
Description

intravenous

Data type

text

Alias
UMLS CUI [1]
C0348016
Kurzinf.
Description

Infusion

Data type

text

Alias
UMLS CUI [1]
C0574032
bei Bed.
Description

as required

Data type

text

Alias
UMLS CUI [1]
C0558288
Uhr
Description

Time

Data type

time

Alias
UMLS CUI [1]
C0040223
Intervall/ h
Description

Interval

Data type

text

Alias
UMLS CUI [1]
C1272706
Paracetamol
Description

Paracetamol

Data type

boolean

Alias
UMLS CUI [1]
C0000970
Dosis
Description

dose

Data type

float

Measurement units
  • m/g
Alias
UMLS CUI [1]
C3174092
m/g
Trpf/ supp
Description

Drops

Data type

text

Alias
UMLS CUI [1]
C2347093
i.v
Description

intravenous

Data type

text

Alias
UMLS CUI [1]
C0348016
Kurzinf.
Description

Infusion

Data type

text

Alias
UMLS CUI [1]
C0574032
bei Bed.
Description

as required

Data type

text

Alias
UMLS CUI [1]
C0558288
Uhr
Description

Time

Data type

time

Alias
UMLS CUI [1]
C0040223
Intervall/ h
Description

Interval

Data type

text

Alias
UMLS CUI [1]
C1272706
MCP
Description

MCP

Data type

boolean

Alias
UMLS CUI [1]
C0025853
Dosis
Description

dose

Data type

float

Measurement units
  • m/g
Alias
UMLS CUI [1]
C3174092
m/g
Trpf/ supp
Description

Drops

Data type

text

Alias
UMLS CUI [1]
C2347093
i.v
Description

intravenous

Data type

text

Alias
UMLS CUI [1]
C0348016
Kurzinf.
Description

Infusion

Data type

text

Alias
UMLS CUI [1]
C0574032
bei Bed.
Description

as required

Data type

text

Alias
UMLS CUI [1]
C0558288
Uhr
Description

Time

Data type

time

Alias
UMLS CUI [1]
C0040223
Intervall/ h
Description

Interval

Data type

text

Alias
UMLS CUI [1]
C1272706
Ondansetron/ Zofran
Description

Ondansetron

Data type

boolean

Alias
UMLS CUI [1]
C0061851
Dosis
Description

dose

Data type

float

Measurement units
  • m/g
Alias
UMLS CUI [1]
C3174092
m/g
Trpf/ supp
Description

Drops

Data type

text

Alias
UMLS CUI [1]
C2347093
i.v
Description

intravenous

Data type

text

Alias
UMLS CUI [1]
C0348016
Kurzinf.
Description

Infusion

Data type

text

Alias
UMLS CUI [1]
C0574032
bei Bed.
Description

as required

Data type

text

Alias
UMLS CUI [1]
C0558288
Uhr
Description

Time

Data type

time

Alias
UMLS CUI [1]
C0040223
Intervall/ h
Description

Interval

Data type

text

Alias
UMLS CUI [1]
C1272706
Fortecortin
Description

Fortecortin

Data type

boolean

Alias
UMLS CUI [1]
C0525283
Dosis
Description

dose

Data type

float

Measurement units
  • m/g
Alias
UMLS CUI [1]
C3174092
m/g
Trpf/ supp
Description

Drops

Data type

text

Alias
UMLS CUI [1]
C2347093
i.v
Description

intravenous

Data type

text

Alias
UMLS CUI [1]
C0348016
Kurzinf.
Description

Infusion

Data type

text

Alias
UMLS CUI [1]
C0574032
bei Bed.
Description

as required

Data type

text

Alias
UMLS CUI [1]
C0558288
Uhr
Description

Time

Data type

time

Alias
UMLS CUI [1]
C0040223
Intervall/ h
Description

Interval

Data type

text

Alias
UMLS CUI [1]
C1272706
Vomex A- Dimenhydrinat
Description

Vomex

Data type

boolean

Alias
UMLS CUI [1]
C1569385
Dosis
Description

dose

Data type

float

Measurement units
  • m/g
Alias
UMLS CUI [1]
C3174092
m/g
Trpf/ supp
Description

Drops

Data type

text

Alias
UMLS CUI [1]
C2347093
i.v
Description

intravenous

Data type

text

Alias
UMLS CUI [1]
C0348016
Kurzinf.
Description

Infusion

Data type

text

Alias
UMLS CUI [1]
C0574032
bei Bed.
Description

as required

Data type

text

Alias
UMLS CUI [1]
C0558288
Uhr
Description

Time

Data type

time

Alias
UMLS CUI [1]
C0040223
Intervall/ h
Description

Interval

Data type

text

Alias
UMLS CUI [1]
C1272706
Infusion
Description

Infusion

Data type

text

Alias
UMLS CUI [1]
C0574032
Menge
Description

Infusion volume

Data type

text

Alias
UMLS CUI [1,1]
C0574032
UMLS CUI [1,2]
C0449468
Dauer/h
Description

Duration

Data type

text

Zugang ZVK zur Infusionstherapie freigeben
Description

central vein catheter

Data type

text

Alias
UMLS CUI [1]
C0882959
Sauerstoffgabe
Description

Oxygen

Data type

float

Measurement units
  • ml/min
Alias
UMLS CUI [1]
C0030054
ml/min
Bis
Description

Time

Data type

time

Measurement units
  • Uhr
Alias
UMLS CUI [1]
C0040223
Uhr
RR- Kontrolle
Description

Blood pressure monitoring

Data type

boolean

Alias
UMLS CUI [1]
C0026426
RR über
Description

Blood pressure

Data type

integer

Measurement units
  • mmHg
mmHg
Bei Bed. 1 Kaps. Adalat geben, dosis:
Description

Adalat

Data type

float

Measurement units
  • mg/sl
Alias
UMLS CUI [1]
C0590658
mg/sl
BZ- Kontrolle
Description

Blood sugar monitoring

Data type

boolean

Alias
UMLS CUI [1]
C3825243
BZ über
Description

Blood sugar

Data type

float

Measurement units
  • mg/dl
Alias
UMLS CUI [1]
C0392201
mg/dl
Alt-Insulin
Description

insulin

Data type

float

Measurement units
  • IE
Alias
UMLS CUI [1]
C0021641
IE
Trinken
Description

Drink

Data type

text

Alias
UMLS CUI [1]
C0452428
Kost
Description

Diet

Data type

text

Alias
UMLS CUI [1]
C0012155
Mobilisierung sofort?
Description

mobilisation

Data type

boolean

Alias
UMLS CUI [1]
C0026597
Bemerkung
Description

Note

Data type

text

Alias
UMLS CUI [1]
C1317574
Anästhesist
Description

Anesthetist

Data type

text

Alias
UMLS CUI [1]
C0473161
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Similar models

Postoperative Instructions

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Postoperative Anweisung Operateur
Surgeon
Item
Operateur
text
C0582175 (UMLS CUI [1])
Date Surgery
Item
Datum Operation
date
C0011008 (UMLS CUI [1,1])
C0543467 (UMLS CUI [1,2])
Item
Drainage
text
C0013103 (UMLS CUI [1])
Drainage
Code List
Drainage
CL Item
Robinsondrain (1)
CL Item
Redon mit Sog (2)
CL Item
Redon ohne Sog (3)
CL Item
Easy- Flow (4)
CL Item
Spüldrain (5)
CL Item
andere (6)
Other
Item
Andere Drainage
text
C0205394 (UMLS CUI [1])
Number
Item
Anzahl
integer
C0449788 (UMLS CUI [1])
Item
Lage
text
C1515974 (UMLS CUI [1])
Site
Code List
Lage
CL Item
OB (1)
CL Item
MB (2)
CL Item
UB (3)
CL Item
Hals (4)
CL Item
Brust (5)
CL Item
Rücken (6)
CL Item
Leiste (7)
CL Item
Gesäß (8)
CL Item
rechts (9)
CL Item
mittig (10)
CL Item
links (11)
CL Item
andere (12)
Other
Item
Andere
text
C0205394 (UMLS CUI [1])
Item
Spülung
text
C1882955 (UMLS CUI [1])
Rinsing
Code List
Spülung
CL Item
Klarspülung (1)
CL Item
Adhäsionsspülung (2)
CL Item
septische Spülung (3)
CL Item
nur Ablauf (4)
catheter
Item
Katheter (Dauerkatheter)
text
C0085590 (UMLS CUI [1])
Item
Tamponade
text
C0579016 (UMLS CUI [1])
Tamponade
Code List
Tamponade
CL Item
vaginal (1)
CL Item
anal (2)
CL Item
resorbierbar anal (Spongostan) (3)
Removal Tamponade
Item
Entfernen
boolean
C0015252 (UMLS CUI [1,1])
C0579016 (UMLS CUI [1,2])
Time Removal Tamponade
Item
Uhr
time
C0040223 (UMLS CUI [1,1])
C0015252 (UMLS CUI [1,2])
C0579016 (UMLS CUI [1,3])
Item
Enterostoma
text
C0014370 (UMLS CUI [1])
Enterostomy procedure
Code List
Enterostoma
CL Item
Ileostoma (1)
CL Item
Colostoma (2)
Ampicillin
Item
Ampicillin comp. 1,5g
boolean
C0002680 (UMLS CUI [1])
Time
Item
Zeit
time
C0040223 (UMLS CUI [1])
Ampicillin
Item
Ampicillin 2g
boolean
C0002680 (UMLS CUI [1])
Time
Item
Zeit
time
C0040223 (UMLS CUI [1])
Cefazolin
Item
Cefazolin 2000mg
boolean
C0007546 (UMLS CUI [1])
Time
Item
Zeit
time
C0040223 (UMLS CUI [1])
Ceftriaxone
Item
Ceftriaxon
boolean
C0007561 (UMLS CUI [1])
Time
Item
Zeit
time
C0040223 (UMLS CUI [1])
Metronidazole
Item
Metronidazol 500mg
boolean
C0025872 (UMLS CUI [1])
Time
Item
Zeit
time
C0040223 (UMLS CUI [1])
Cefotaxime
Item
Cefotaxim 2g
boolean
C0007554 (UMLS CUI [1])
Time
Item
Zeit
time
C0040223 (UMLS CUI [1])
Gentamicin
Item
Gentamycin 80mg
boolean
C0017436 (UMLS CUI [1])
Item
Tgl
text
C3174092 (UMLS CUI [1])
Dose
Code List
Tgl
CL Item
1X (1)
CL Item
2X (2)
CL Item
3X (3)
CL Item
Andere (4)
other Dose
Item
Andere Dosis
text
C0205394 (UMLS CUI [1,1])
C3174092 (UMLS CUI [1,2])
Item
Tag
text
C0449238 (UMLS CUI [1])
Day
Code List
Tag
CL Item
1 (1)
CL Item
3 (2)
CL Item
5 (3)
CL Item
7 (4)
Note
Item
Bemerkung
text
C1317574 (UMLS CUI [1])
instructions
Item
Keine Anweisung
text
C1442085 (UMLS CUI [1])
Item Group
Postoperative Anweisung Anesthetist
Novaminsulfone
Item
Novaminsulfon
boolean
C0936240 (UMLS CUI [1])
dose
Item
Dosis
float
C3174092 (UMLS CUI [1])
Drops
Item
Trpf/ supp
text
C2347093 (UMLS CUI [1])
intravenous
Item
i.v
text
C0348016 (UMLS CUI [1])
Infusion
Item
Kurzinf.
text
C0574032 (UMLS CUI [1])
as required
Item
bei Bed.
text
C0558288 (UMLS CUI [1])
Time
Item
Uhr
time
C0040223 (UMLS CUI [1])
Interval
Item
Intervall/ h
text
C1272706 (UMLS CUI [1])
Dipidolor Piritramide
Item
Dipidolor- Piritramid
boolean
C0809927 (UMLS CUI [1,1])
C0031982 (UMLS CUI [1,2])
dose
Item
Dosis
float
C3174092 (UMLS CUI [1])
Drops
Item
Trpf/ supp
text
C2347093 (UMLS CUI [1])
intravenous
Item
i.v
text
C0348016 (UMLS CUI [1])
Infusion
Item
Kurzinf.
text
C0574032 (UMLS CUI [1])
as required
Item
bei Bed.
text
C0558288 (UMLS CUI [1])
Time
Item
Uhr
time
C0040223 (UMLS CUI [1])
Interval
Item
Intervall/ h
text
C1272706 (UMLS CUI [1])
Tramadol
Item
Tramadol
boolean
C0040610 (UMLS CUI [1])
dose
Item
Dosis
float
C3174092 (UMLS CUI [1])
Drops
Item
Trpf/ supp
text
C2347093 (UMLS CUI [1])
intravenous
Item
i.v
text
C0348016 (UMLS CUI [1])
Infusion
Item
Kurzinf.
text
C0574032 (UMLS CUI [1])
as required
Item
bei Bed.
text
C0558288 (UMLS CUI [1])
Time
Item
Uhr
time
C0040223 (UMLS CUI [1])
Interval
Item
Intervall/ h
text
C1272706 (UMLS CUI [1])
Paracetamol
Item
Paracetamol
boolean
C0000970 (UMLS CUI [1])
dose
Item
Dosis
float
C3174092 (UMLS CUI [1])
Drops
Item
Trpf/ supp
text
C2347093 (UMLS CUI [1])
intravenous
Item
i.v
text
C0348016 (UMLS CUI [1])
Infusion
Item
Kurzinf.
text
C0574032 (UMLS CUI [1])
as required
Item
bei Bed.
text
C0558288 (UMLS CUI [1])
Time
Item
Uhr
time
C0040223 (UMLS CUI [1])
Interval
Item
Intervall/ h
text
C1272706 (UMLS CUI [1])
MCP
Item
MCP
boolean
C0025853 (UMLS CUI [1])
dose
Item
Dosis
float
C3174092 (UMLS CUI [1])
Drops
Item
Trpf/ supp
text
C2347093 (UMLS CUI [1])
intravenous
Item
i.v
text
C0348016 (UMLS CUI [1])
Infusion
Item
Kurzinf.
text
C0574032 (UMLS CUI [1])
as required
Item
bei Bed.
text
C0558288 (UMLS CUI [1])
Time
Item
Uhr
time
C0040223 (UMLS CUI [1])
Interval
Item
Intervall/ h
text
C1272706 (UMLS CUI [1])
Ondansetron
Item
Ondansetron/ Zofran
boolean
C0061851 (UMLS CUI [1])
dose
Item
Dosis
float
C3174092 (UMLS CUI [1])
Drops
Item
Trpf/ supp
text
C2347093 (UMLS CUI [1])
intravenous
Item
i.v
text
C0348016 (UMLS CUI [1])
Infusion
Item
Kurzinf.
text
C0574032 (UMLS CUI [1])
as required
Item
bei Bed.
text
C0558288 (UMLS CUI [1])
Time
Item
Uhr
time
C0040223 (UMLS CUI [1])
Interval
Item
Intervall/ h
text
C1272706 (UMLS CUI [1])
Fortecortin
Item
Fortecortin
boolean
C0525283 (UMLS CUI [1])
dose
Item
Dosis
float
C3174092 (UMLS CUI [1])
Drops
Item
Trpf/ supp
text
C2347093 (UMLS CUI [1])
intravenous
Item
i.v
text
C0348016 (UMLS CUI [1])
Infusion
Item
Kurzinf.
text
C0574032 (UMLS CUI [1])
as required
Item
bei Bed.
text
C0558288 (UMLS CUI [1])
Time
Item
Uhr
time
C0040223 (UMLS CUI [1])
Interval
Item
Intervall/ h
text
C1272706 (UMLS CUI [1])
Vomex
Item
Vomex A- Dimenhydrinat
boolean
C1569385 (UMLS CUI [1])
dose
Item
Dosis
float
C3174092 (UMLS CUI [1])
Drops
Item
Trpf/ supp
text
C2347093 (UMLS CUI [1])
intravenous
Item
i.v
text
C0348016 (UMLS CUI [1])
Infusion
Item
Kurzinf.
text
C0574032 (UMLS CUI [1])
as required
Item
bei Bed.
text
C0558288 (UMLS CUI [1])
Time
Item
Uhr
time
C0040223 (UMLS CUI [1])
Interval
Item
Intervall/ h
text
C1272706 (UMLS CUI [1])
Item
Infusion
text
C0574032 (UMLS CUI [1])
Infusion
Code List
Infusion
CL Item
Sterofundin (1)
CL Item
Ringer- Lactat (2)
CL Item
Aminoven 3,5% (3)
Item
Menge
text
C0574032 (UMLS CUI [1,1])
C0449468 (UMLS CUI [1,2])
Infusion volume
Code List
Menge
CL Item
500ml (1)
CL Item
1000ml (2)
CL Item
1500ml (3)
Duration
Item
Dauer/h
text
Item
Zugang ZVK zur Infusionstherapie freigeben
text
C0882959 (UMLS CUI [1])
central vein catheter
Code List
Zugang ZVK zur Infusionstherapie freigeben
CL Item
ja (1)
CL Item
nein (2)
CL Item
Magensonde (3)
Oxygen
Item
Sauerstoffgabe
float
C0030054 (UMLS CUI [1])
Time
Item
Bis
time
C0040223 (UMLS CUI [1])
Blood pressure monitoring
Item
RR- Kontrolle
boolean
C0026426 (UMLS CUI [1])
Blood pressure
Item
RR über
integer
Adalat
Item
Bei Bed. 1 Kaps. Adalat geben, dosis:
float
C0590658 (UMLS CUI [1])
Blood sugar monitoring
Item
BZ- Kontrolle
boolean
C3825243 (UMLS CUI [1])
Blood sugar
Item
BZ über
float
C0392201 (UMLS CUI [1])
insulin
Item
Alt-Insulin
float
C0021641 (UMLS CUI [1])
Item
Trinken
text
C0452428 (UMLS CUI [1])
Drink
Code List
Trinken
CL Item
sofort (1)
CL Item
schluckweise (2)
Item
Kost
text
C0012155 (UMLS CUI [1])
Diet
Code List
Kost
CL Item
sofort (1)
CL Item
flüssig (2)
mobilisation
Item
Mobilisierung sofort?
boolean
C0026597 (UMLS CUI [1])
Note
Item
Bemerkung
text
C1317574 (UMLS CUI [1])
Anesthetist
Item
Anästhesist
text
C0473161 (UMLS CUI [1])
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