ID

23559

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

Versions (5)
  1. 7/8/17 7/8/17 -
  2. 7/8/17 7/8/17 -
  3. 7/8/17 7/8/17 -
  4. 7/20/17 7/20/17 -
  5. 7/31/17 7/31/17 -
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July 8, 2017

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Premedication Anesthesiology Intensive care Catholic Clinic Koblenz Montabaur Routine documentation in German hospitals DMI

German English

Premedication Anesthesiology Intensive care Catholic Clinic Koblenz Montabaur Routine documentation in German hospitals DMI

1 forms  
Patientendaten
Description

Patientendaten

Fallnummer
Description

Case ID

Data type

text

Anästhesiedatum
Description

Date of anesthesia

Data type

date

Geburtsdatum
Description

Date of birth

Data type

date

Alias
UMLS CUI [1]
C0421451
Größe
Description

Height

Data type

integer

Gewicht
Description

Weight

Data type

integer

Fachabteilung
Description

Department

Data type

text

Betriebsstätte
Description

Establishment

Data type

text

Geschlecht
Description

Sex

Data type

text

Wahlleistung
Description

Elective service

Data type

text

Status
Description

Status

Data type

text

Dringlichkeit
Description

Urgency

Data type

text

Eingriff
Description

Eingriff

Präoperative Diagnose
Description

Preoperative diagnosis

Data type

text

Geplante Maßnahme/Operation
Description

Planned procedure

Data type

text

Geplante Anästhesietechnik
Description

Planned anesthetic technique

Data type

text

Besonderheiten
Description

Specifics

Data type

text

Ileuseinleitung
Description

Rapid sequence induction

Data type

boolean

Präoperativer Zustand
Description

Präoperativer Zustand

Vorerkrankungen, Voroperationen, Komplikationen bei Vornarkosen
Description

Pre-existing conditions, previous surgeries/narcoses

Data type

text

Re-Narkose
Description

Re-narcosis

Data type

boolean

Akutversorgung
Description

Acute care

Data type

boolean

PONV
Description

Postoperative nausea and vomiting

Data type

integer

ASA
Description

ASA score

Data type

integer

Intubationsprobleme
Description

Intubation problems

Data type

text

Mallampati
Description

Mallampati score

Data type

integer

Blutdruck
Description

Blood Pressure

Data type

text

Alias
UMLS CUI [1]
C0005823
HF
Description

Heart rate

Data type

integer

Alias
UMLS CUI [1]
C0018810
psO2
Description

Peripheral oxygen saturation

Data type

text

Blutgruppe
Description

Blood type

Data type

text

Prüfnummer BG
Description

Approval number BG

Data type

text

irreguläre AK
Description

Irregular antibodies

Data type

text

Zahnstatus
Description

State of teeth

Data type

text

Nüchternzeit
Description

Duration of fasting

Data type

text

Dauermedikation
Description

Long-term medication

Data type

text

Allergien
Description

Allergies

Data type

text

Begleiterkrankungen
Description

Begleiterkrankungen

Blutdruck
Description

Blood pressure

Data type

boolean

Myokard
Description

Myocardium

Data type

boolean

Koronarfunktion
Description

Coronary function

Data type

boolean

EKG
Description

ECG

Data type

boolean

Gefäßsystem
Description

Vascular system

Data type

boolean

Lunge/Atemwege
Description

Lungs/respiratory tract

Data type

boolean

Rö.-Thorax
Description

Chest X-ray

Data type

boolean

Bewusstseinslage
Description

Consciousness

Data type

boolean

Neurologie
Description

Neurology

Data type

boolean

Muskulatur
Description

Muscles

Data type

boolean

Endokrinium
Description

Endocrine system

Data type

boolean

Leber
Description

Liver

Data type

boolean

Niere
Description

Kidney

Data type

boolean

Diabetes mellitus
Description

Diabetes mellitus

Data type

boolean

Hämatologie
Description

Hematology

Data type

boolean

Gerinnung
Description

Coagulation

Data type

boolean

Ernährungszustand
Description

Nutritional status

Data type

boolean

Begleiterkrankungen Freitext
Description

Comorbidites free text

Data type

text

Risiken
Description

Risiken

Aspiration
Description

Aspiration

Data type

boolean

Polytrauma
Description

Polytrauma

Data type

boolean

Intensivpatient
Description

Intensive care patient

Data type

boolean

MI < 6 Wochen
Description

MI

Data type

boolean

Akutes Koronarsyndrom
Description

Acute coronary syndrome

Data type

boolean

Katecholaminpfl.
Description

Catecholamines

Data type

boolean

Atemwegsinfekt
Description

Respiratory tract infection

Data type

boolean

COPD
Description

Chronic obstructive pulmonary disease

Data type

boolean

Asthma
Description

Asthma

Data type

boolean

Sepsis
Description

Sepsis

Data type

boolean

Schwangerschaft
Description

Pregnancy

Data type

boolean

Frühgeburt
Description

Preterm birth

Data type

boolean

HIV
Description

HIV

Data type

boolean

Virus-Hepatits
Description

Viral hepatits

Data type

boolean

MH-Disposition
Description

Disposition for malignant hyperpyrexia

Data type

boolean

Alkohol
Description

Alcohol

Data type

boolean

Nikotin
Description

Nicotine

Data type

boolean

Drogen
Description

Drugs

Data type

boolean

Laborwerte
Description

Laborwerte

Hkt/Hb
Description

Hematocrit/Hemoglobin

Data type

text

Leukos
Description

Leukocytes

Data type

integer

Na
Description

Sodium

Data type

float

K
Description

Potassium

Data type

float

Ca
Description

Calcium

Data type

float

Krea
Description

Creatinine

Data type

float

Glukose
Description

Blood sugar

Data type

float

GOT
Description

Glutamic oxaloacetic transaminase

Data type

float

GPT
Description

Glutamate-pyruvate transaminase

Data type

float

gamma-GT
Description

Gamma-glutamyltransferase

Data type

float

Thrombos
Description

Platelets

Data type

integer

Quick
Description

Prothrombin time

Data type

integer

PTT
Description

Partial thromboplastin time

Data type

integer

TZ
Description

Thrombin time

Data type

float

Blutbestellung
Description

Blutbestellung

Erykonz. (Anzahl)
Description

(nur Kreuzbl. / gekreuzt)

Data type

integer

FFP (Anzahl)
Description

(nur Kreuzbl. / gekreuzt)

Data type

integer

Sonst.
Description

(nur Kreuzbl. / gekreuzt)

Data type

text

Vorabend
Description

Vorabend

Medikament
Description

Medication

Data type

text

Dosis
Description

Dosage

Data type

text

Applikation
Description

Administration

Data type

text

Uhrzeit
Description

Time

Data type

time

Signatur
Description

Signature

Data type

text

OP-Tag
Description

OP-Tag

Medikament
Description

Medication

Data type

text

Dosis
Description

Dosage

Data type

text

Applikation
Description

Administration

Data type

text

Uhrzeit
Description

Time

Data type

text

Signatur
Description

Signature

Data type

text

Anordnungen
Description

Anordnungen

Labor
Description

Laboratory

Data type

boolean

G-Status
Description

Coagulation status

Data type

text

EKG
Description

ECG

Data type

boolean

Röntgen-Thorax
Description

Chest X-ray

Data type

boolean

Lungenfunktion
Description

Pulmonary function

Data type

boolean

Konsil
Description

Consultation

Data type

boolean

Spezifikationen
Description

Medical orders specifications

Data type

text

Prämedikation
Description

Prämedikation

Dauer
Description

Duration

Data type

integer

Dienstart
Description

Type of duty

Data type

text

Datum
Description

Date

Data type

date

Uhrzeit
Description

Time

Data type

time

Name
Description

Name

Data type

text

Unterschrift
Description

Signature

Data type

text

2. Prämedikation
Description

2. Prämedikation

Dauer
Description

Duration

Data type

integer

Dienstart
Description

Type of duty

Data type

text

Datum
Description

Date

Data type

date

Uhrzeit
Description

Time

Data type

time

Name
Description

Name

Data type

text

Unterschrift
Description

Signature

Data type

text

nach Prämed. keine OP
Description

No surgey after premedication

Data type

boolean

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Similar models

Premedication Anesthesiology Intensive care Catholic Clinic Koblenz Montabaur Routine documentation in German hospitals DMI

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Patientendaten
Case ID
Item
Fallnummer
text
Date of anesthesia
Item
Anästhesiedatum
date
Date of birth
Item
Geburtsdatum
date
C0421451 (UMLS CUI [1])
Height
Item
Größe
integer
Weight
Item
Gewicht
integer
Item
Fachabteilung
text
Department
Code List
Fachabteilung
CL Item
AIN (Anesthesiology/Intensive care medicine)
CL Item
ACH (General and visceral surgery)
CL Item
GYN (Gynecology)
CL Item
URO (Urology)
CL Item
TCH (Thoracic surgery)
CL Item
MKG (Oral and maxillofacial surgery)
CL Item
HNO (Otolaryngology)
CL Item
NEU (Neurology)
CL Item
RAD (Radiology)
CL Item
Sonst (Other)
CL Item
ENDO (Endo)
CL Item
KAR (Cardiology)
CL Item
Arthro (Arthro)
CL Item
PNE (Pneumology)
CL Item
SMT (Pain therapy)
CL Item
UCH (Trauma surgery)
CL Item
WSCH (Spinal surgery)
Item
Betriebsstätte
text
Establishment
Code List
Betriebsstätte
CL Item
MH Koblenz (MH Koblenz)
CL Item
BH Koblenz (BH Koblenz)
CL Item
BKH Montabaur (BKH Montabaur)
Item
Geschlecht
text
Sex
Code List
Geschlecht
CL Item
intersex (intersex)
CL Item
männlich (male)
CL Item
weiblich (female)
Item
Wahlleistung
text
Elective service
Code List
Wahlleistung
CL Item
ja (yes)
CL Item
nein (no)
CL Item
unbekannt (unknown)
Item
Status
text
Status
Code List
Status
CL Item
ambulant (outpatient)
CL Item
stationär (in-patient)
CL Item
privat (private)
Item
Dringlichkeit
text
Urgency
Code List
Dringlichkeit
CL Item
dringlich (urgent)
CL Item
Notfall (emergency)
CL Item
elektiv (elective)
Item Group
Eingriff
Preoperative diagnosis
Item
Präoperative Diagnose
text
Planned procedure
Item
Geplante Maßnahme/Operation
text
Planned anesthetic technique
Item
Geplante Anästhesietechnik
text
Specifics
Item
Besonderheiten
text
Rapid sequence induction
Item
Ileuseinleitung
boolean
Item Group
Präoperativer Zustand
Pre-existing conditions, previous surgeries/narcoses
Item
Vorerkrankungen, Voroperationen, Komplikationen bei Vornarkosen
text
Re-narcosis
Item
Re-Narkose
boolean
Acute care
Item
Akutversorgung
boolean
Postoperative nausea and vomiting
Code List
PONV
CL Item
0 (0)
CL Item
1 (1)
CL Item
2 (2)
CL Item
3 (3)
CL Item
4 (4)
CL Item
4+ (5)
Item
ASA
integer
ASA score
Code List
ASA
CL Item
1 (1)
CL Item
2 (2)
CL Item
3 (3)
CL Item
4 (4)
CL Item
5 (5)
Item
Intubationsprobleme
text
Intubation problems
Code List
Intubationsprobleme
CL Item
zu erwarten (to be expected)
CL Item
bekannt (known)
CL Item
Reklination eingeschränkt (restricted reclination)
CL Item
Mallampati (Mallampati)
Mallampati score
Item
Mallampati
integer
Blood Pressure
Item
Blutdruck
text
C0005823 (UMLS CUI [1])
Heart rate
Item
HF
integer
C0018810 (UMLS CUI [1])
Peripheral oxygen saturation
Item
psO2
text
Blood type
Item
Blutgruppe
text
Approval number BG
Item
Prüfnummer BG
text
Irregular antibodies
Item
irreguläre AK
text
Item
Zahnstatus
text
State of teeth
Code List
Zahnstatus
CL Item
Prothese (prosthesis)
CL Item
behandlungsbed. (in need of treatment)
CL Item
gefährdet (at risk)
CL Item
saniert/normal (restored/normal)
Item
Nüchternzeit
text
Duration of fasting
Code List
Nüchternzeit
CL Item
>6 (>6)
CL Item
<6 (<6)
Long-term medication
Item
Dauermedikation
text
Allergies
Item
Allergien
text
Item Group
Begleiterkrankungen
Blood pressure
Item
Blutdruck
boolean
Myocardium
Item
Myokard
boolean
Coronary function
Item
Koronarfunktion
boolean
ECG
Item
EKG
boolean
Vascular system
Item
Gefäßsystem
boolean
Lungs/respiratory tract
Item
Lunge/Atemwege
boolean
Chest X-ray
Item
Rö.-Thorax
boolean
Consciousness
Item
Bewusstseinslage
boolean
Neurology
Item
Neurologie
boolean
Muscles
Item
Muskulatur
boolean
Endocrine system
Item
Endokrinium
boolean
Liver
Item
Leber
boolean
Kidney
Item
Niere
boolean
Diabetes mellitus
Item
Diabetes mellitus
boolean
Hematology
Item
Hämatologie
boolean
Coagulation
Item
Gerinnung
boolean
Nutritional status
Item
Ernährungszustand
boolean
Comorbidites free text
Item
Begleiterkrankungen Freitext
text
Item Group
Risiken
Aspiration
Item
Aspiration
boolean
Polytrauma
Item
Polytrauma
boolean
Intensive care patient
Item
Intensivpatient
boolean
MI
Item
MI < 6 Wochen
boolean
Acute coronary syndrome
Item
Akutes Koronarsyndrom
boolean
Catecholamines
Item
Katecholaminpfl.
boolean
Respiratory tract infection
Item
Atemwegsinfekt
boolean
Chronic obstructive pulmonary disease
Item
COPD
boolean
Asthma
Item
Asthma
boolean
Sepsis
Item
Sepsis
boolean
Pregnancy
Item
Schwangerschaft
boolean
Preterm birth
Item
Frühgeburt
boolean
HIV
Item
HIV
boolean
Viral hepatits
Item
Virus-Hepatits
boolean
Disposition for malignant hyperpyrexia
Item
MH-Disposition
boolean
Alcohol
Item
Alkohol
boolean
Nicotine
Item
Nikotin
boolean
Drugs
Item
Drogen
boolean
Item Group
Laborwerte
Hematocrit/Hemoglobin
Item
Hkt/Hb
text
Leukocytes
Item
Leukos
integer
Sodium
Item
Na
float
Potassium
Item
K
float
Calcium
Item
Ca
float
Creatinine
Item
Krea
float
Blood sugar
Item
Glukose
float
Glutamic oxaloacetic transaminase
Item
GOT
float
Glutamate-pyruvate transaminase
Item
GPT
float
Gamma-glutamyltransferase
Item
gamma-GT
float
Platelets
Item
Thrombos
integer
Prothrombin time
Item
Quick
integer
Partial thromboplastin time
Item
PTT
integer
Thrombin time
Item
TZ
float
Item Group
Blutbestellung
Red cell concentrate
Item
Erykonz. (Anzahl)
integer
Fresh frozen plasma
Item
FFP (Anzahl)
integer
Other
Item
Sonst.
text
Medication
Item
Medikament
text
Dosage
Item
Dosis
text
Administration
Item
Applikation
text
Time
Item
Uhrzeit
time
Signature
Item
Signatur
text
Medication
Item
Medikament
text
Dosage
Item
Dosis
text
Administration
Item
Applikation
text
Time
Item
Uhrzeit
text
Signature
Item
Signatur
text
Item Group
Anordnungen
Laboratory
Item
Labor
boolean
Coagulation status
Item
G-Status
text
ECG
Item
EKG
boolean
Chest X-ray
Item
Röntgen-Thorax
boolean
Pulmonary function
Item
Lungenfunktion
boolean
Consultation
Item
Konsil
boolean
Medical orders specifications
Item
Spezifikationen
text
Item Group
Prämedikation
Item
Dauer
integer
Duration
Code List
Dauer
CL Item
5 (5)
CL Item
10 (10)
CL Item
20 (20)
CL Item
30 (30)
CL Item
40 (40)
CL Item
50 (50)
CL Item
60 (60)
Item
Dienstart
text
Type of duty
Code List
Dienstart
CL Item
RD (regular)
CL Item
TD (TD)
CL Item
ÜS (overtime)
CL Item
BD (on-call)
Date
Item
Datum
date
Time
Item
Uhrzeit
time
Name
Item
Name
text
Signature
Item
Unterschrift
text
Item Group
2. Prämedikation
Item
Dauer
integer
Duration
Code List
Dauer
CL Item
5 (5)
CL Item
10 (10)
CL Item
20 (20)
CL Item
30 (30)
CL Item
40 (40)
CL Item
50 (50)
CL Item
60 (60)
Item
Dienstart
text
Type of duty
Code List
Dienstart
CL Item
TD (TD)
CL Item
ÜS (overtime)
CL Item
BD (on-call)
CL Item
RD (regular)
Date
Item
Datum
date
Time
Item
Uhrzeit
time
Name
Item
Name
text
Signature
Item
Unterschrift
text
No surgey after premedication
Item
nach Prämed. keine OP
boolean
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