ID

23254

Description

Routine documentation in German hospitals. Source file name: TH130110_Prämedikationsprotokoll Examplary forms provided by DMI (http://www.dmi.de/)

Link

http://www.dmi.de/

Keywords

  1. 6/30/17 6/30/17 -
  2. 6/30/17 6/30/17 -
  3. 7/31/17 7/31/17 -
Uploaded on

June 30, 2017

DOI

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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

Patient data
Description

Patient data

Surname
Description

Surname

Data type

text

First name
Description

First name

Data type

text

Case ID
Description

Case ID

Data type

text

Date of birth
Description

Date of birth

Data type

date

Alias
UMLS CUI [1]
C0421451
Age
Description

Age

Data type

integer

Measurement units
  • years
Alias
UMLS CUI [1]
C0001779
years
Weight
Description

Weight

Data type

float

Measurement units
  • kg
Alias
UMLS CUI [1]
C0005910
kg
Height
Description

Height

Data type

integer

Measurement units
  • cm
Alias
UMLS CUI [1]
C0005890
cm
Sex
Description

Sex

Data type

text

Organizational unit
Description

Organizational unit

Data type

text

Hospital stay
Description

Hospital stay

Data type

text

Surgery
Description

Surgery

Diagnosis
Description

Diagnosis

Data type

text

Planned surgical procedure
Description

Planned surgical procedure

Data type

text

Scheduled date of surgery
Description

Scheduled date of surgery

Data type

date

Urgency
Description

Urgency

Data type

text

Position of patient
Description

Position of patient

Data type

text

Preoperative assessment
Description

Preoperative assessment

BMI
Description

Body mass index

Data type

float

Measurement units
  • kg/m^2
kg/m^2
BSA
Description

Body surface area

Data type

float

Measurement units
VT
Description

Tidal volume

Data type

integer

Measurement units
  • ml
ml
ASA
Description

ASA risk classification

Data type

integer

MET
Description

Functional capacity, metabolic equivalents

Data type

text

Preoperative risk score
Description

Preoperative risk score

Data type

integer

Apfel
Description

Apfel score

Data type

integer

Allergies
Description

Allergies

Data type

text

Mallampati
Description

Mallampati classification

Data type

integer

Mouth opening
Description

Mouth opening

Data type

float

Measurement units
  • cm
cm
Head reclination
Description

Head reclination

Data type

text

Preoperative general condition
Description

Preoperative general condition

Data type

text

Preoperative nutritional condition
Description

Preoperative nutritional condition

Data type

text

Physical fitness
Description

Physical fitness

Data type

text

Dyspnea
Description

Dyspnea

Data type

text

Relevant previous operations
Description

Relevant previous operations

Data type

text

State of teeth
Description

State of teeth

Data type

text

Comorbidities
Description

Comorbidities

Data type

text

Heart
Description

Heart

Data type

text

Circulation / blood vessels / metabolism & hormones
Description

Circulation, blood vessels, metabolism, hormones

Data type

text

Lungs / kidney / pancreas / liver
Description

Lungs, kidney, pancreas, liver

Data type

text

Long-term medication
Description

Long-term medication

Data type

text

Anesthesia
Description

Anesthesia

Type of anesthesia
Description

Type of anesthesia

Data type

text

Instructions to ward
Description

Instructions to ward

ECG
Description

ECG

Data type

text

Pulmonary function
Description

Pulmonary function

Data type

text

Chest X-ray
Description

Chest X-ray

Data type

text

Consultation
Description

Consultation

Data type

text

Laboratory
Description

Laboratory

Data type

text

Medication in the evening before surgery
Description

Medication the evening before surgery

Data type

text

Medication on the day of surgery
Description

Medication on the day of surgery

Medication in the morning
Description

Medication in the morning

Data type

text

Time of premedication
Description

Time of premedication

Data type

text

Premedication
Description

Premedication

Data type

text

Eating / drinking
Description

Eating / drinking

Eating possible until
Description

Latest possible food intake before surgery

Data type

text

Drinking possible until
Description

Latest possible liquid intake before surgery

Data type

text

Further information
Description

Further information

Post-surgery transfer
Description

Post-surgery transfer

Data type

text

Release
Description

Release

Data type

text

Administrated by
Description

Administrating person

Data type

text

Time of administration
Description

Time of administration

Data type

time

Date of premedication
Description

Date of premedication

Data type

date

Person giving premedication
Description

Person giving premedication

Data type

text

Similar models

Premedication record Routine documentation in German hospitals DMI

Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Patient data
Surname
Item
Surname
text
First name
Item
First name
text
Case ID
Item
Case ID
text
Date of birth
Item
Date of birth
date
C0421451 (UMLS CUI [1])
Age
Item
Age
integer
C0001779 (UMLS CUI [1])
Weight
Item
Weight
float
C0005910 (UMLS CUI [1])
Height
Item
Height
integer
C0005890 (UMLS CUI [1])
Sex
Item
Sex
text
Organizational unit
Item
Organizational unit
text
Hospital stay
Item
Hospital stay
text
Item Group
Surgery
Diagnosis
Item
Diagnosis
text
Planned surgical procedure
Item
Planned surgical procedure
text
Scheduled date of surgery
Item
Scheduled date of surgery
date
Urgency
Item
Urgency
text
Position of patient
Item
Position of patient
text
Item Group
Preoperative assessment
Body mass index
Item
BMI
float
Body surface area
Item
BSA
float
Tidal volume
Item
VT
integer
ASA risk classification
Item
ASA
integer
Functional capacity, metabolic equivalents
Item
MET
text
Preoperative risk score
Item
Preoperative risk score
integer
Apfel score
Item
Apfel
integer
Allergies
Item
Allergies
text
Item
Mallampati
integer
Code List
Mallampati
Mouth opening
Item
Mouth opening
float
Head reclination
Item
Head reclination
text
Preoperative general condition
Item
Preoperative general condition
text
Preoperative nutritional condition
Item
Preoperative nutritional condition
text
Physical fitness
Item
Physical fitness
text
Dyspnea
Item
Dyspnea
text
Relevant previous operations
Item
Relevant previous operations
text
State of teeth
Item
State of teeth
text
Comorbidities
Item
Comorbidities
text
Heart
Item
Heart
text
Circulation, blood vessels, metabolism, hormones
Item
Circulation / blood vessels / metabolism & hormones
text
Lungs, kidney, pancreas, liver
Item
Lungs / kidney / pancreas / liver
text
Long-term medication
Item
Long-term medication
text
Item Group
Anesthesia
Type of anesthesia
Item
Type of anesthesia
text
Item Group
Instructions to ward
ECG
Item
ECG
text
Pulmonary function
Item
Pulmonary function
text
Chest X-ray
Item
Chest X-ray
text
Consultation
Item
Consultation
text
Laboratory
Item
Laboratory
text
Medication the evening before surgery
Item
Medication in the evening before surgery
text
Item Group
Medication on the day of surgery
Medication in the morning
Item
Medication in the morning
text
Time of premedication
Item
Time of premedication
text
Premedication
Item
Premedication
text
Item Group
Eating / drinking
Latest possible food intake before surgery
Item
Eating possible until
text
Latest possible liquid intake before surgery
Item
Drinking possible until
text
Item Group
Further information
Post-surgery transfer
Item
Post-surgery transfer
text
Release
Item
Release
text
Administrating person
Item
Administrated by
text
Time of administration
Item
Time of administration
time
Date of premedication
Item
Date of premedication
date
Person giving premedication
Item
Person giving premedication
text

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