Classification
ASA
integer
surgery classification
integer
Mallampati score
integer
Postoperative Nausea and Vomiting
integer
Revised Cardiac Risk Index
integer
NYHA
integer
Metabolic Equivalent of Task
integer
Anesthesia procedures
urgency
integer
Type of Anesthesia
integer
Other Type of Anesthesia
text
Pain scale
float
Medical History
Indication of surgery
text
Type Of Surgery
text
Systolic blood pressure
float
Diastolic blood pressure
float
heart rate
float
hemoglobin
float
blood platelets
float
Quick
float
PTT
float
Creatinine
float
Urea
float
Blood Glucose
float
Potassium
float
Physical examination
text
long-term medication
text
anticoagulation
text
CAVE
text
Allergies / atypical antibodies?
text
Oral &or dental status? / Airway?
text
Nursing Station Procedures
Registration of Medical Examination
integer
Other Medical Examination
text
Instructions
time
time
Pharmaceutical Preparations
text
Dose
float
Application
text
Signature
text
Food regulations
time
intake regulations fluids
time
Premedication
Duration
integer
Premedication whilst regular working hours
boolean
Date of Premedication
date
Time of Premedication
time
Anesthesist
text
Signature Of Physician
text
Anesthesia procedures
Date of Anesthesia
date
Anesthesia method
integer
Airway
integer
tbs and tbt
text
Device
float
laryngoscopy
integer
Regional Anesthesia
integer
Regional Anesthesia Event
integer
Needle
text
Puncture
text
Number
float
Tunnel
float
Puncture wound depth
float
Skinlevel incl. Tunnel
float
Catheter
boolean
Single Shot
boolean
Test dose
boolean
Time
integer
Dose
text
Peripheral venous access
text
Peripheral venous access
integer
Central venous access
integer
Central venous access
integer
Artery
integer
Actions
integer
Patient storage
integer
Special Medical Procedure
integer
Anesthesia Times
Start of Anesthesiapresence
time
Anesthesia Start Time
time
Operation Time
time
Anesthesia End Time
time
End of Anesthesia presence
time
End of Recovery Room
time
Operation Times
Start of Operative Actions
time
Incision
time
End time Operation
time
End of Operative Actions
time
No Operative Times
boolean
operating room
float
Initiation
boolean
Bedside Test
text
Staff
Name
text
Name
text
Name
text
Name
text
Specialty department
text
More Departments
boolean
Contact person Surgeon
text
Surgical intervention
text
Anesthesia Protocol
Hypnotics
integer
Medication dose
text
Pharmaceutical Preparations
time
Analgetics
integer
Medication dose
text
Pharmaceutical Preparations
time
Muscle relaxants
integer
Medication dose
text
Pharmaceutical Preparations
time
Fresh gas flow
float
Medication dose
text
Pharmaceutical Preparations
time
Gas Flow Narcosis
integer
Medication dose
text
Pharmaceutical Preparations
time
Catecholamines Antiarrhythmics Inotropics
integer
Medication dose
text
Pharmaceutical Preparations
time
Administration of electrolytes
integer
Medication dose
text
Pharmaceutical Preparations
time
Colloids
integer
Medication dose
text
Pharmaceutical Preparations
time
Red blood cell transfusion
integer
Medication dose
text
Pharmaceutical Preparations
time
Fresh frozen plasma / platelet concentrate
integer
Medication dose
text
Pharmaceutical Preparations
time
Double occupation of physician
boolean
Laboratory (Time)
Location
integer
Hydrogen ion concentration measurement
float
Carbon dioxide content measurement
float
Blood Oxygen Pressure
float
Base Excess Measurement
float
Oxygen saturation measurement
float
Hemoglobin measurement
float
Sodium
float
Potassium
float
Chloride measurement
float
Calcium measurement
float
Blood glucose level
float
Lactate
float
Quick
float
PTT
float
Platelet Count
float
Fluid Management Operation Room
Crystalloid solutions
float
Colloids
float
Blood
float
Fluid Intake
float
Urine
float
Blood
float
Tubes
float
Fluid Output
float
Fluid Management Recovery Room
Crystalloid solutions
float
Colloids
float
Blood
float
Fluid Intake
float
Urine
float
Blood
float
Tubes
float
Fluid Output
float
Operating Room
Comment Operating Room
text
Time
time
Signature Treating Physician
text
Recovery Room
Comment Recovery Room
text
Time
time
Signature Treating Physician
text
Instructions for Recovery Room
Laboratory
text
Positioning of patient
text
Fluid
text
Analgesia
text
Other Instructions
text
Signature Recovery Room Nurse
text
Patient Transfer
Recommendation for Department
Patient Observation
text
Pain Management
text
Acute Pain Service Guardiance
boolean
Fluid Intake Start
time
Signature Nurse
text
Diagnoses/ perioperative Record / Documentation
Name
text
Birth Date
date
Street
text
City of residence
text
Health Insurance
text
Case number
text
Date of Anesthesia
date
Name /Signature
text
None routine procedures
integer
Diagnosis
integer
Other Diagnosis Codes (ICD 10)
text
Other Procedure Code (OPS)
text
Post-anesthesia Assessment
Anesthesist
text
Name /Signature
text
Date of Anesthesia
date
Date of Visit
date
Time of Visit
time
Pain scale
float
post operative care
integer
Comment
text
Physician Stand-By Service
Start Time
time
End Time
time
Start Time
time
End Time
time