Informationen:
Fehler:
ID
21900
Beschreibung
Hospital Routine Documentation at the University Hospital Muenster. Original Form name: MS Anästhesieprotokoll V6.1 inkl. Folgeseiten und MS Postanästhesie-Visite. This form is provided by Univ.-Prof. Dr. Dr. h. c. H. Van Aken (Klinik und Poliklinik fee Anästhesiologie und operative Intensivmedizin, Universitätsklinikum Münster).
Stichworte
Versionen (3)
- 04.05.17 04.05.17 -
- 05.05.17 05.05.17 -
- 08.05.17 08.05.17 -
Hochgeladen am
8. Mai 2017
DOI
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Lizenz
Creative Commons BY-NC 3.0
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Anesthesia Protocol University Hospital Muenster
Anesthesia Protocol University Hospital Muenster
- StudyEvent: ODM
Ähnliche Modelle
Anesthesia Protocol University Hospital Muenster
- StudyEvent: ODM
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Patient Name
Item
Name
text
C0421448 (UMLS CUI [1])
Date of Birth
Item
Date of Birth
date
C0421451 (UMLS CUI [1])
Street
Item
Street
text
C1301826 (UMLS CUI [1,1])
C0421449 (UMLS CUI [1,2])
C0421449 (UMLS CUI [1,2])
City of residence
Item
City of residence
text
C2316883 (UMLS CUI [1])
Health Insurance
Item
Health insurance
text
C0021682 (UMLS CUI [1])
Case number
Item
Case number
text
C1698493 (UMLS CUI [1,1])
C0600091 (UMLS CUI [1,2])
C0600091 (UMLS CUI [1,2])
Age
Item
Age
float
C0001779 (UMLS CUI [1])
CL Item
D (1)
CL Item
M (2)
Body height
Item
Body height
float
C0005890 (UMLS CUI [1])
Body weight
Item
Body weight
float
C0005910 (UMLS CUI [1])
CL Item
in g (1)
CL Item
male (1)
CL Item
female (2)
CL Item
outpatient (1)
CL Item
inpatient (2)
CL Item
private (3)
nursing station
Item
Nursing station
float
C2014007 (UMLS CUI [1])
Room Number
Item
Room Number
float
C1718316 (UMLS CUI [1])
Department
Item
Department
float
C0037778 (UMLS CUI [1])
CL Item
I (1)
CL Item
II (2)
CL Item
III (3)
CL Item
IV (4)
CL Item
V (5)
Item
Classification of surgery
integer
C0543467 (UMLS CUI [1,1])
C0008902 (UMLS CUI [1,2])
C0008902 (UMLS CUI [1,2])
CL Item
I (1)
CL Item
II (2)
CL Item
III (3)
CL Item
I (1)
CL Item
II (2)
CL Item
III (3)
CL Item
IV (4)
CL Item
I (1)
CL Item
II (2)
CL Item
III (3)
CL Item
IV (4)
CL Item
I (1)
CL Item
II (2)
CL Item
III (3)
CL Item
IV (4)
CL Item
I (1)
CL Item
II (2)
CL Item
III (3)
CL Item
IV (4)
CL Item
<1 (1)
CL Item
1-4 (2)
CL Item
5-10 (3)
CL Item
>10 (4)
CL Item
no path. finding, healthy patient (1)
CL Item
repeated anesthesia (2)
CL Item
heart alarm (3)
CL Item
urgent (4)
CL Item
elective (5)
CL Item
emergency (6)
CL Item
cerebral death (7)
CL Item
General anesthesia (1)
CL Item
-RSI (2)
CL Item
-FOI (3)
CL Item
analgosedation (4)
CL Item
Stand by (5)
CL Item
epidural (6)
CL Item
SpA (7)
CL Item
Brachial plexus blockage (8)
CL Item
NFK / NIK (9)
CL Item
other: (10)
Other Type of Anesthesia
Item
Other:
text
C1305863 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
C0205394 (UMLS CUI [1,2])
Pain scale
Item
Pain scale (0-10) current pain intensity
float
C1504479 (UMLS CUI [1])
Indication of surgery
Item
Indication of surgery:
text
C3871280 (UMLS CUI [1])
Type Of Surgery
Item
planned surgery:
text
C0543467 (UMLS CUI [1,1])
C0332307 (UMLS CUI [1,2])
C0332307 (UMLS CUI [1,2])
Systolic blood pressure
Item
Systolic blood pressure at admission
float
C0871470 (UMLS CUI [1,1])
C0030673 (UMLS CUI [1,2])
C0030673 (UMLS CUI [1,2])
Diastolic blood pressure
Item
Diastolic blood pressure at admission
float
C0428883 (UMLS CUI [1,1])
C0030673 (UMLS CUI [1,2])
C0030673 (UMLS CUI [1,2])
heart rate
Item
Heart rate
float
C0018810 (UMLS CUI [1])
hemoglobin
Item
Hemoglobin
float
C0019046 (UMLS CUI [1])
blood platelets
Item
Platelets
float
C0005821 (UMLS CUI [1])
Quick
Item
Quick
float
C0483455 (UMLS CUI [1])
PTT
Item
PTT
float
C0030605 (UMLS CUI [1,1])
C0018017 (UMLS CUI [1,2])
C0018017 (UMLS CUI [1,2])
Creatinine
Item
Creatinine
float
C0201976 (UMLS CUI [1])
Urea
Item
Urea
float
C0523961 (UMLS CUI [1])
Blood Glucose
Item
Blood Glucose
float
C0005802 (UMLS CUI [1])
Potassium
Item
Potassium
float
C0202194 (UMLS CUI [1])
Physical examination
Item
Findings on physical examination:
text
C0031809 (UMLS CUI [1])
long-term medication
Item
Long-term medication:
text
C0420257 (UMLS CUI [1])
anticoagulation
Item
Anticoagulation:
text
C0449867 (UMLS CUI [1])
CAVE
Item
CAVE
text
C0871599 (UMLS CUI [1])
Allergies / atypical antibodies?
Item
Allergies? / atypical antibodies?
text
C0020517 (UMLS CUI [1])
C0741108 (UMLS CUI [2])
C0741108 (UMLS CUI [2])
Oral &or dental status? / Airway?
Item
Dental status? / Airway?
text
C2707314 (UMLS CUI [1])
C0458827 (UMLS CUI [2])
C0458827 (UMLS CUI [2])
Item Group
Nursing Station Procedures
C2014007 (UMLS CUI-1)
C2700391 (UMLS CUI-2)
C2700391 (UMLS CUI-2)
Item
Registration of Medical Examination
integer
C0582103 (UMLS CUI [1,1])
C1514821 (UMLS CUI [1,2])
C1514821 (UMLS CUI [1,2])
CL Item
ECG (1)
CL Item
Lung function test (2)
CL Item
Chest x-ray (3)
CL Item
Blood type (4)
CL Item
EC (5)
CL Item
GFR (6)
CL Item
TC (7)
Other Medical Examination
Item
Other:
text
C0582103 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
C0205394 (UMLS CUI [1,2])
time
Item
Time
time
C0040223 (UMLS CUI [1])
Pharmaceutical Preparations
Item
Medication
text
C0013227 (UMLS CUI [1])
Dose
Item
Dose
float
C3174092 (UMLS CUI [1])
Application
Item
Application
text
C0013153 (UMLS CUI [1])
Signature
Item
Signature
text
C1519316 (UMLS CUI [1,1])
C1710470 (UMLS CUI [1,2])
C1710470 (UMLS CUI [1,2])
Food regulations
Item
Food, cloudy liquids until:
time
C0086311 (UMLS CUI [1,1])
C1522314 (UMLS CUI [1,2])
C1522314 (UMLS CUI [1,2])
intake regulations fluids
Item
Water, clear tea until:
time
C0553741 (UMLS CUI [1,1])
C1522314 (UMLS CUI [1,2])
C1522314 (UMLS CUI [1,2])
CL Item
5 (1)
CL Item
10 (2)
CL Item
20 (3)
CL Item
30 (4)
CL Item
40 (5)
CL Item
50 (6)
CL Item
60 (7)
Premedication whilst regular working hours
Item
Premedication within regular working hours
boolean
C2135639 (UMLS CUI [1])
Date of Premedication
Item
Date of Premedication
date
C0011008 (UMLS CUI [1])
Time of Premedication
Item
Time of day
time
C0040223 (UMLS CUI [1])
Anesthesist
Item
Anesthesist
text
C1550495 (UMLS CUI [1])
Signature Of Physician
Item
Signature of Physician
text
C0807938 (UMLS CUI [1])
Date of Anesthesia
Item
Date of Anesthesia
date
C2316983 (UMLS CUI [1])
CL Item
General (1)
CL Item
Regional (2)
CL Item
Combinated (3)
CL Item
Processed (4)
CL Item
Analgosedation (5)
CL Item
Standby (6)
CL Item
Own (1)
CL Item
MLMa (2)
CL Item
oral (3)
CL Item
nasal (4)
CL Item
located (5)
CL Item
Tra (6)
CL Item
Jet (7)
CL Item
without Cuff (8)
CL Item
Umint. (9)
CL Item
FOI (10)
CL Item
RSI (11)
CL Item
DLT (12)
tbs and tbt
Item
Tubetype and -size
text
C1561954 (UMLS CUI [1])
C1561954 (UMLS CUI [2,1])
C0332307 (UMLS CUI [2,2])
C1561954 (UMLS CUI [2,1])
C0332307 (UMLS CUI [2,2])
Device
Item
Device No.
float
C0025080 (UMLS CUI [1])
CL Item
I (1)
CL Item
II (2)
CL Item
III (3)
CL Item
IV (4)
CL Item
spinal (1)
CL Item
Epidural lumb. (2)
CL Item
Epidural thor. (3)
CL Item
Epidural caud. (4)
CL Item
Arm Plex. Ax. (5)
CL Item
Arm Plex. so. (6)
CL Item
Leg Isch (7)
CL Item
Leg Fem. (8)
CL Item
IVRA (9)
CL Item
per. nerv. (10)
CL Item
see regional anesthesia protocol (11)
CL Item
Sono (1)
CL Item
Stimulation of nerve (2)
Needle
Item
Needle
text
C1882041 (UMLS CUI [1])
Puncture
Item
Puncture
text
C0034117 (UMLS CUI [1])
Number
Item
Count
float
C0449788 (UMLS CUI [1])
Tunnel
Item
Tunnel
float
C0337138 (UMLS CUI [1])
Puncture wound depth
Item
Depth of puncture wound
float
C0033119 (UMLS CUI [1,1])
C0205125 (UMLS CUI [1,2])
C0205125 (UMLS CUI [1,2])
Skinlevel incl. Tunnel
Item
Skinlevel incl. Tunnel
float
C0444099 (UMLS CUI [1])
Catheter
Item
Catheter
boolean
C0085590 (UMLS CUI [1])
Single Shot
Item
Single Shot
boolean
C4080740 (UMLS CUI [1])
Test dose
Item
Test dose
boolean
C1868831 (UMLS CUI [1])
CL Item
pre incision (1)
CL Item
post incision (2)
Dose
Item
Dose
text
C3174092 (UMLS CUI [1])
Peripheral venous access
Item
Peripheral venous access, placed:
text
C0750164 (UMLS CUI [1])
CL Item
li (1)
CL Item
re (2)
CL Item
li (3)
CL Item
re (4)
CL Item
li (5)
CL Item
re (6)
CL Item
SONO (1)
CL Item
EKG (2)
CL Item
liegt (3)
CL Item
VJI li (4)
CL Item
VJI re (5)
CL Item
VJE li (6)
CL Item
VJE re (7)
CL Item
SCI li (8)
CL Item
SCI re (9)
CL Item
Bas li (10)
CL Item
Bas re (11)
CL Item
Fem li (12)
CL Item
Fem re (13)
CL Item
1 (14)
CL Item
2 (15)
CL Item
3 (16)
CL Item
>3 (17)
CL Item
ZVK (18)
CL Item
PAK (19)
CL Item
Sch (20)
CL Item
HiFl (21)
CL Item
SONO (1)
CL Item
EKG (2)
CL Item
liegt (3)
CL Item
VJI li (4)
CL Item
VJI re (5)
CL Item
VJE li (6)
CL Item
VJE re (7)
CL Item
SCI li (8)
CL Item
SCI re (9)
CL Item
Bas li (10)
CL Item
Bas re (11)
CL Item
Fem li (12)
CL Item
Fem re (13)
CL Item
1 (14)
CL Item
2 (15)
CL Item
3 (16)
CL Item
>3 (17)
CL Item
ZVK (18)
CL Item
PAK (19)
CL Item
Sch (20)
CL Item
HiFl (21)
CL Item
SONO (1)
CL Item
placed (2)
CL Item
Rad. right (3)
CL Item
Rad. left (4)
CL Item
Fem. right (5)
CL Item
Fem. left (6)
CL Item
son. right (7)
CL Item
son. left (8)
CL Item
Heating pad (1)
CL Item
Heat gun (2)
CL Item
Heating infusion (3)
CL Item
Heating lamp (4)
CL Item
Cooling (5)
CL Item
MS (6)
CL Item
Bronchoscopy (7)
CL Item
Pacer (8)
CL Item
Cardiov./Defibrillator (9)
CL Item
Reanimation (10)
CL Item
Cellsaver (11)
CL Item
Sitting (1)
CL Item
Repositioning (2)
CL Item
Back (3)
CL Item
Stomach (4)
CL Item
Trendelenburg position (5)
CL Item
Lithotomy position (6)
CL Item
Arm abducted left (7)
CL Item
Arm abducted right (8)
CL Item
Knee-Ell. (9)
CL Item
Eye protection (10)
CL Item
Lithotomy (11)
CL Item
obstetrics (1)
CL Item
cesarean section (2)
CL Item
Polytra. (3)
CL Item
Intratho. (4)
CL Item
Intracran. (5)
CL Item
Exploration (6)
CL Item
catheter placement (7)
CL Item
Transplantation (8)
Start of Anesthesiapresence
Item
Start of Anesthesia presence
time
C1690493 (UMLS CUI [1])
Anesthesia Start Time
Item
Anesthesia Start Time
time
C1301945 (UMLS CUI [1])
Operation Time
Item
Operation
time
C3494201 (UMLS CUI [1])
Anesthesia End Time
Item
Anesthesia End Time
time
C1301859 (UMLS CUI [1])
End of Anesthesia presence
Item
End of Anesthesia presence
time
C2223794 (UMLS CUI [1])
End of Recovery Room
Item
End of Recovery Room
time
C0034871 (UMLS CUI [1])
Start of Operative Actions
Item
Start of Operative Actions
time
C0445204 (UMLS CUI [1,1])
C1301880 (UMLS CUI [1,2])
C1301880 (UMLS CUI [1,2])
Incision
Item
Incision
time
C0439659 (UMLS CUI [1,1])
C0543467 (UMLS CUI [1,2])
C0543467 (UMLS CUI [1,2])
End time Operation
Item
Suture
time
C1522314 (UMLS CUI [1,1])
C3494201 (UMLS CUI [1,2])
C3494201 (UMLS CUI [1,2])
End of Operative Actions
Item
End of Operative Actions
time
C0032790 (UMLS CUI [1,1])
C1522314 (UMLS CUI [1,2])
C1522314 (UMLS CUI [1,2])
No Operative Times
Item
No Incision-Suture Times
boolean
C3494201 (UMLS CUI [1,1])
C0040223 (UMLS CUI [1,2])
C0040223 (UMLS CUI [1,2])
operating room
Item
Operating room number
float
C0029064 (UMLS CUI [1])
Initiation
Item
Intervention in initiation
boolean
C1704686 (UMLS CUI [1])
Bedside Test
Item
Bedside Test
text
C0282662 (UMLS CUI [1])
Name
Item
1
text
C0027365 (UMLS CUI [1])
Name
Item
2
text
C0421448 (UMLS CUI [1])
Name
Item
3
text
C0027365 (UMLS CUI [1])
Name
Item
4
text
C0027365 (UMLS CUI [1])
Specialty department
Item
Specialty department
text
C1704729 (UMLS CUI [1])
More Departments
Item
More
boolean
C1704729 (UMLS CUI [1,1])
C0449788 (UMLS CUI [1,2])
C0449788 (UMLS CUI [1,2])
Contact person Surgeon
Item
Operational contact
text
C0337611 (UMLS CUI [1,1])
C0582175 (UMLS CUI [1,2])
C0582175 (UMLS CUI [1,2])
Surgical intervention
Item
Surgical intervention
text
C0549433 (UMLS CUI [1])
CL Item
Thi (1)
CL Item
Eto (2)
CL Item
Pro (3)
CL Item
Mid (4)
CL Item
S-Ket (5)
CL Item
Cloni (6)
Medication dose
Item
Dose
text
C3174092 (UMLS CUI [1])
Pharmaceutical Preparations
Item
Timing of administration
time
C0013227 (UMLS CUI [1])
CL Item
Suf (1)
CL Item
Rem (2)
CL Item
Pirl (3)
CL Item
Mo (4)
CL Item
Peth (5)
CL Item
Fent (6)
Medication dose
Item
Dose
text
C3174092 (UMLS CUI [1])
Pharmaceutical Preparations
Item
Timing of administration
time
C0013227 (UMLS CUI [1])
CL Item
Miv (1)
CL Item
CisA (2)
CL Item
Roc (3)
CL Item
Suc (4)
CL Item
Vec (5)
CL Item
Dexa (6)
Medication dose
Item
Dose
text
C3174092 (UMLS CUI [1])
Pharmaceutical Preparations
Item
Timing of administration
time
C0013227 (UMLS CUI [1])
Fresh gas flow
Item
Fresh gas flow
float
C0428716 (UMLS CUI [1])
Medication dose
Item
Dose
text
C3174092 (UMLS CUI [1])
Pharmaceutical Preparations
Item
Timing of administration
time
C0013227 (UMLS CUI [1])
Item
Gas Flow Narcosis
integer
C0234447 (UMLS CUI [1,1])
C0428715 (UMLS CUI [1,2])
C0428715 (UMLS CUI [1,2])
CL Item
Iso (1)
CL Item
Sev (2)
CL Item
Des (3)
Medication dose
Item
Dose
text
C3174092 (UMLS CUI [1])
Pharmaceutical Preparations
Item
Timing of administration
time
C0013227 (UMLS CUI [1])
Item
Catecholamines, Antiarrhythmics, Inotropics
integer
C0007412 (UMLS CUI [1])
C0003195 (UMLS CUI [2])
C0304509 (UMLS CUI [3])
C0003195 (UMLS CUI [2])
C0304509 (UMLS CUI [3])
CL Item
Dub (1)
CL Item
Adr (2)
CL Item
NA (3)
CL Item
Etil (4)
CL Item
Phen (5)
CL Item
Akri (6)
CL Item
Metop. (7)
Medication dose
Item
Dose
text
C3174092 (UMLS CUI [1])
Pharmaceutical Preparations
Item
Timing of administration
time
C0013227 (UMLS CUI [1])
CL Item
20 (1)
CL Item
VE (2)
CL Item
NaCl (3)
CL Item
Pad (4)
Medication dose
Item
Dose
text
C3174092 (UMLS CUI [1])
Pharmaceutical Preparations
Item
Timing of administration
time
C0013227 (UMLS CUI [1])
CL Item
50 (1)
CL Item
Haes (2)
Medication dose
Item
Dose
text
C3174092 (UMLS CUI [1])
Pharmaceutical Preparations
Item
Timing of administration
time
C0013227 (UMLS CUI [1])
CL Item
100 EK / Sav (1)
Medication dose
Item
Dose
text
C3174092 (UMLS CUI [1])
Pharmaceutical Preparations
Item
Timing of administration
time
C0013227 (UMLS CUI [1])
Item
Fresh frozen plasma / platelet concentrate
integer
C0016709 (UMLS CUI [1])
C1294041 (UMLS CUI [2])
C1294041 (UMLS CUI [2])
CL Item
250 (1)
CL Item
GFP / TK (2)
Medication dose
Item
Dose
text
C3174092 (UMLS CUI [1])
Pharmaceutical Preparations
Item
Timing of administration
time
C0013227 (UMLS CUI [1])
Double occupation of physician
Item
Double occupation of physician
boolean
C2826892 (UMLS CUI [1,1])
C0028811 (UMLS CUI [1,2])
C0028811 (UMLS CUI [1,2])
Location
Item
Location
integer
C0450429 (UMLS CUI [1])
Hydrogen ion concentration measurement
Item
Hydrogen ion concentration
float
C0202165 (UMLS CUI [1])
Carbon dioxide content measurement
Item
Carbon dioxide content
float
C0201930 (UMLS CUI [1])
Blood Oxygen Pressure
Item
Blood Oxygen Pressure
float
C1291013 (UMLS CUI [1])
Base Excess Measurement
Item
BE
float
C0201985 (UMLS CUI [1])
Oxygen saturation measurement
Item
SaO2
float
C0523807 (UMLS CUI [1])
Hemoglobin measurement
Item
Hb
float
C0518015 (UMLS CUI [1])
Sodium
Item
Sodium
float
C0337443 (UMLS CUI [1])
Potassium
Item
Potassium
float
C0202194 (UMLS CUI [1])
Chloride measurement
Item
Chloride
float
C0201952 (UMLS CUI [1])
Calcium measurement
Item
Calcium
float
C0201925 (UMLS CUI [1])
Blood glucose level
Item
Blood glucose
float
C0392201 (UMLS CUI [1])
Lactate
Item
Lactate
float
C0376261 (UMLS CUI [1])
Quick
Item
Quick
float
C0483455 (UMLS CUI [1])
PTT
Item
PTT
float
C0030605 (UMLS CUI [1])
Platelet Count
Item
Platelets
float
C0032181 (UMLS CUI [1])
Item Group
Fluid Management Operation Room
C0553741 (UMLS CUI-1)
C0543467 (UMLS CUI-2)
C0543467 (UMLS CUI-2)
Crystalloid solutions
Item
Crystalloids
float
C0056562 (UMLS CUI [1])
Colloids
Item
Colloids
float
C0009361 (UMLS CUI [1])
Blood
Item
Blood
float
C0005767 (UMLS CUI [1])
Fluid Intake
Item
Fluid intake
float
C0429646 (UMLS CUI [1])
Urine
Item
Urine
float
C0042036 (UMLS CUI [1])
Blood
Item
Blood
float
C0005767 (UMLS CUI [1])
Tubes
Item
Tubes
float
C1546420 (UMLS CUI [1])
Fluid Output
Item
Fluid output
float
C3251815 (UMLS CUI [1])
Crystalloid solutions
Item
Crystalloids
float
C0056562 (UMLS CUI [1])
Colloids
Item
Colloids
float
C0009361 (UMLS CUI [1])
Blood
Item
Blood
float
C0005767 (UMLS CUI [1])
Fluid Intake
Item
Fluid intake
float
C0429646 (UMLS CUI [1])
Urine
Item
Urine
float
C0042036 (UMLS CUI [1])
Blood
Item
Blood
float
C0005767 (UMLS CUI [1])
Tubes
Item
Tubes
float
C1546420 (UMLS CUI [1])
Fluid Output
Item
Fluid output
float
C3251815 (UMLS CUI [1])
Comment Operating Room
Item
Comment Operating Room
text
C0543467 (UMLS CUI [1,1])
C0947611 (UMLS CUI [1,2])
C0947611 (UMLS CUI [1,2])
Time
Item
Time of handing over
time
C0586001 (UMLS CUI [1,1])
C0040223 (UMLS CUI [1,2])
C0040223 (UMLS CUI [1,2])
Signature Treating Physician
Item
Signature anesthesist
text
C1519316 (UMLS CUI [1,1])
C1710470 (UMLS CUI [1,2])
C1710470 (UMLS CUI [1,2])
Comment Recovery Room
Item
Comment recovery room
text
C0034871 (UMLS CUI [1,1])
C0947611 (UMLS CUI [1,2])
C0947611 (UMLS CUI [1,2])
Time
Item
Time of handing over
time
C0586001 (UMLS CUI [1,1])
C0040223 (UMLS CUI [1,2])
C0040223 (UMLS CUI [1,2])
Signature Treating Physician
Item
Signature anesthesist
text
C1519316 (UMLS CUI [1,1])
C1710470 (UMLS CUI [1,2])
C1710470 (UMLS CUI [1,2])
Item Group
Instructions for Recovery Room
C0034871 (UMLS CUI-1)
C1442085 (UMLS CUI-2)
C1442085 (UMLS CUI-2)
Laboratory
Item
Laboratory
text
C0022877 (UMLS CUI [1])
Positioning of patient
Item
Positioning of patient
text
C1561964 (UMLS CUI [1])
Fluid
Item
Fluid (rest+ ....ml)
text
C0429791 (UMLS CUI [1])
Analgesia
Item
Analgesia
text
C0853389 (UMLS CUI [1])
Other Instructions
Item
Other
text
C1442085 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
C0205394 (UMLS CUI [1,2])
Signature Recovery Room Nurse
Item
Signature Recovery Room Nurse
text
C1519316 (UMLS CUI [1,1])
C0557536 (UMLS CUI [1,2])
C0557536 (UMLS CUI [1,2])
Item Group
Patient Transfer
C0030704 (UMLS CUI-1)
C0034871 (UMLS CUI-2)
C0029064 (UMLS CUI-3)
C0034871 (UMLS CUI-2)
C0029064 (UMLS CUI-3)
Pain scale at transfer
Item
Pain scale at transfer
float
C1504479 (UMLS CUI [1])
Item Group
Recommendation for Department
C1305702 (UMLS CUI-1)
C0034866 (UMLS CUI-2)
C0034866 (UMLS CUI-2)
Patient Observation
Item
Observation
text
C0700325 (UMLS CUI [1])
Pain Management
Item
Pain therapy
text
C0002766 (UMLS CUI [1])
Acute Pain Service Guardiance
Item
Guardiance of acute pain service
boolean
C0242934 (UMLS CUI [1,1])
C0870627 (UMLS CUI [1,2])
C0870627 (UMLS CUI [1,2])
Fluid Intake Start
Item
Fluid intake from:
time
C0429791 (UMLS CUI [1,1])
C3897500 (UMLS CUI [1,2])
C3897500 (UMLS CUI [1,2])
Signature Nurse
Item
Signature nurse
text
C1519316 (UMLS CUI [1,1])
C0028661 (UMLS CUI [1,2])
C0028661 (UMLS CUI [1,2])
Item Group
Diagnoses/ perioperative Record / Documentation
C0011900 (UMLS CUI-1)
C0946279 (UMLS CUI-2)
C0920316 (UMLS CUI-3)
C0946279 (UMLS CUI-2)
C0920316 (UMLS CUI-3)
Name
Item
Name
text
C0421448 (UMLS CUI [1])
Birth Date
Item
Birth date
date
C0421451 (UMLS CUI [1])
Street
Item
Street
text
C1301826 (UMLS CUI [1,1])
C0421449 (UMLS CUI [1,2])
C0421449 (UMLS CUI [1,2])
City of residence
Item
City of residence
text
C2316883 (UMLS CUI [1])
Health Insurance
Item
Health insurance
text
C0021682 (UMLS CUI [1])
Case number
Item
Case number
text
C1698493 (UMLS CUI [1,1])
C0600091 (UMLS CUI [1,2])
C0600091 (UMLS CUI [1,2])
Date of Anesthesia
Item
Date of anesthesia
date
C0002903 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,2])
Name /Signature
Item
Name (in block capitals) / signature
text
C0421448 (UMLS CUI [1])
C1519316 (UMLS CUI [2])
C1519316 (UMLS CUI [2])
Item
Not routinely for operation corresponding procedures
integer
C1550373 (UMLS CUI [1,1])
C1561591 (UMLS CUI [1,2])
C1561591 (UMLS CUI [1,2])
CL Item
Anesthesia, intravenous (8-900) (1)
CL Item
Anesthesia, inhalation (8-901) (2)
CL Item
Anesthesia, balanced (8-902) (3)
CL Item
(analog-)Sedation (8-903) (4)
CL Item
Regional anesthesia (8-910 ff) (5)
CL Item
catheter placement (8-831 ff) (6)
CL Item
bronchoscopy (1-620.00) (7)
CL Item
chest tube left (8-144L) (8)
CL Item
chest tube right (8-144R) (9)
CL Item
systemic thrombolysis (8-020.8) (10)
CL Item
difficult intubation (T88.4) (1)
CL Item
Aspiration (Mendelson´s -Syndrom) J95.4 (2)
CL Item
Acute severe asthma (J46) (3)
CL Item
Syncope and collapse (R55) (4)
CL Item
Myocardial infarction, acute n.n.b. (I21.9) (5)
CL Item
pulmonary embolism with cor pulmonale (I26.0) (6)
CL Item
cardiogenic shock (R57.0) (7)
CL Item
hypovolaemic shock (R75.1) (8)
CL Item
Left heart failure with discomfort at rest (I50.14) (9)
CL Item
primary right heart failure (I50.00) (10)
CL Item
paroxysmal atrial flutter (I48.00) (11)
CL Item
paroxysmal atrial fibrillation (I48.10) (12)
CL Item
AV Block II° (I44.1) (13)
CL Item
AV Block III° (I44.2) (14)
CL Item
ventricular premature beats (I49.3) (15)
CL Item
ventricular tachycardia (I47.2) (16)
CL Item
ventricular fibrillation /-flutter (I49.0) (17)
CL Item
Cardiac arrest with successful resuscitation (I46.0) (18)
CL Item
malignant hyperthermia (T88.3) (19)
CL Item
anaphylactic shock on drugs (T88.6) (20)
CL Item
anaphylactic shock on serum (T80.5) (21)
CL Item
acute blood loss anemia (D62) (22)
CL Item
acquired deficiency of coagulation factors (D68.4) (23)
CL Item
Post puncture headache (G97.0) (24)
CL Item
pneumothorax, iatrogenic (J95.80) (25)
Other Diagnosis Codes (ICD 10)
Item
Other Diagnosis Codes (ICD 10)
text
C2598420 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
C0205394 (UMLS CUI [1,2])
Other Procedure Code (OPS)
Item
Other Procedure Code (OPS)
text
C1550373 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
C0205394 (UMLS CUI [1,2])
Anesthesist
Item
Anesthesist
text
C1550495 (UMLS CUI [1])
Name /Signature
Item
Name (in block capitals) / signature
text
C0421448 (UMLS CUI [1])
C1519316 (UMLS CUI [2])
C1519316 (UMLS CUI [2])
Date of Anesthesia
Item
Date of anesthesia
date
C0002903 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,2])
Date of Visit
Item
Visit
date
C1320303 (UMLS CUI [1])
Time of Visit
Item
Time
time
C1320304 (UMLS CUI [1])
Pain scale
Item
Pain scale (0-10) current pain intensity
float
C1504479 (UMLS CUI [1])
CL Item
vomit (1)
CL Item
nausea (2)
CL Item
Patient <24h on ICU (3)
Comment
Item
Specialties:
text
C0947611 (UMLS CUI [1])
Start Time
Item
Beginning of 1st emergency service
time
C1301880 (UMLS CUI [1])
End Time
Item
Ending of 1st emergency service
time
C1522314 (UMLS CUI [1])
Start Time
Item
Beginning of 2nd emergency service
time
C1301880 (UMLS CUI [1])
End Time
Item
Ending of 2nd emergency service
time
C1522314 (UMLS CUI [1])