ID
23254
Description
Routine documentation in German hospitals. Source file name: TH130110_Prämedikationsprotokoll Examplary forms provided by DMI (http://www.dmi.de/)
Link
Keywords
Versions (3)
- 6/30/17 6/30/17 -
- 6/30/17 6/30/17 -
- 7/31/17 7/31/17 -
Uploaded on
June 30, 2017
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License
Creative Commons BY-NC 3.0
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Premedication record Routine documentation in German hospitals DMI
Premedication record Routine documentation in German hospitals DMI
Description
Surgery
Description
Diagnosis
Data type
text
Description
Planned surgical procedure
Data type
text
Description
Scheduled date of surgery
Data type
date
Description
Urgency
Data type
text
Description
Position of patient
Data type
text
Description
Preoperative assessment
Description
Body mass index
Data type
float
Measurement units
- kg/m^2
Description
Body surface area
Data type
float
Measurement units
- m²
Description
Tidal volume
Data type
integer
Measurement units
- ml
Description
ASA risk classification
Data type
integer
Description
Functional capacity, metabolic equivalents
Data type
text
Description
Preoperative risk score
Data type
integer
Description
Apfel score
Data type
integer
Description
Allergies
Data type
text
Description
Mallampati classification
Data type
integer
Description
Mouth opening
Data type
float
Measurement units
- cm
Description
Head reclination
Data type
text
Description
Preoperative general condition
Data type
text
Description
Preoperative nutritional condition
Data type
text
Description
Physical fitness
Data type
text
Description
Dyspnea
Data type
text
Description
Relevant previous operations
Data type
text
Description
State of teeth
Data type
text
Description
Comorbidities
Data type
text
Description
Heart
Data type
text
Description
Circulation, blood vessels, metabolism, hormones
Data type
text
Description
Lungs, kidney, pancreas, liver
Data type
text
Description
Long-term medication
Data type
text
Description
Anesthesia
Description
Instructions to ward
Description
ECG
Data type
text
Description
Pulmonary function
Data type
text
Description
Chest X-ray
Data type
text
Description
Consultation
Data type
text
Description
Laboratory
Data type
text
Description
Medication the evening before surgery
Data type
text
Description
Medication on the day of surgery
Description
Eating / drinking
Description
Further information
Description
Post-surgery transfer
Data type
text
Description
Release
Data type
text
Description
Administrating person
Data type
text
Description
Time of administration
Data type
time
Description
Date of premedication
Data type
date
Description
Person giving premedication
Data type
text