ID
43984
Description
Routine documentation in German hospitals. Source file name: TH130110_Prämedikationsprotokoll Examplary forms provided by DMI (http://www.dmi.de/)
Link
Keywords
Versions (5)
- 7/12/17 7/12/17 -
- 7/12/17 7/12/17 -
- 7/20/17 7/20/17 -
- 7/31/17 7/31/17 -
- 9/20/21 9/20/21 -
Uploaded on
September 20, 2021
DOI
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License
Creative Commons BY-NC 3.0
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Premedication Example 2 Routine documentation in German hospitals DMI
Premedication Example 2 Routine documentation in German hospitals DMI
Description
Physical parameters
Alias
- UMLS CUI-1
- C1269723
Description
Height
Data type
integer
Alias
- UMLS CUI [1]
- C0005890
Description
Weight
Data type
integer
Alias
- UMLS CUI [1]
- C0005910
Description
BMI
Data type
integer
Alias
- UMLS CUI [1]
- C1305855
Description
Pulse
Data type
integer
Alias
- UMLS CUI [1]
- C0232117
Description
Systolic blood pressure
Data type
integer
Alias
- UMLS CUI [1]
- C0871470
Description
Diastolic blood pressure
Data type
integer
Alias
- UMLS CUI [1]
- C0428883
Description
Medical procedure
Alias
- UMLS CUI-1
- C0199171
Description
Preoperative state and risk factors
Alias
- UMLS CUI-1
- C0178808
- UMLS CUI-3
- C0035648
Description
No abnormality detected
Data type
boolean
Alias
- UMLS CUI [1]
- C0559229
Description
narcosis
Data type
boolean
Alias
- UMLS CUI [1]
- C0234447
Description
Acute care
Data type
boolean
Alias
- UMLS CUI [1]
- C0679878
Description
ECG; Chest X-ray
Data type
text
Alias
- UMLS CUI [1]
- C1623258
- UMLS CUI [2]
- C0039985
Description
Heart
Data type
text
Alias
- UMLS CUI [1]
- C0018787
Description
Lungs
Data type
text
Alias
- UMLS CUI [1]
- C0024109
Description
Abdomen
Data type
text
Alias
- UMLS CUI [1]
- C0000726
Description
Other
Data type
text
Alias
- UMLS CUI [1]
- C0205394
Description
Long-term medication
Data type
text
Alias
- UMLS CUI [1]
- C0420257
Description
Previous surgeries
Data type
text
Alias
- UMLS CUI [1]
- C0744961
Description
Allergies
Data type
text
Alias
- UMLS CUI [1]
- C0020517
Description
complications anesthesia
Data type
text
Alias
- UMLS CUI [1,1]
- C0009566
- UMLS CUI [1,2]
- C0002903
Description
Findings: ECG
Alias
- UMLS CUI-1
- C1623258
Description
ECG
Data type
boolean
Alias
- UMLS CUI [1]
- C1623258
Description
pathological finding with relevance for anesthesia
Data type
boolean
Alias
- UMLS CUI [1]
- C0039231
Description
pathological finding with relevance for anesthesia
Data type
boolean
Alias
- UMLS CUI [1]
- C0428977
Description
pathological finding with relevance for anesthesia
Data type
boolean
Alias
- UMLS CUI [1]
- C0232201
Description
pathological finding with relevance for anesthesia
Data type
boolean
Alias
- UMLS CUI [1]
- C0264886
Description
pathological finding with relevance for anesthesia
Data type
boolean
Alias
- UMLS CUI [1]
- C0541950
Description
pathological finding with relevance for anesthesia
Data type
boolean
Alias
- UMLS CUI [1]
- C1287695
Description
pathological finding with relevance for anesthesia
Data type
boolean
Alias
- UMLS CUI [1]
- C1141959
Description
pathological finding with relevance for anesthesia
Data type
boolean
Alias
- UMLS CUI [1]
- C3854475
Description
pathological finding with relevance for anesthesia
Data type
boolean
Alias
- UMLS CUI [1]
- C3279217
Description
Findings: Heart
Alias
- UMLS CUI-1
- C0018787
Description
heart
Data type
boolean
Alias
- UMLS CUI [1]
- C0018787
Description
pathological finding with relevance for anesthesia
Data type
boolean
Alias
- UMLS CUI [1]
- C0010068
Description
pathological finding with relevance for anesthesia
Data type
boolean
Alias
- UMLS CUI [1]
- C0340288
Description
pathological finding with relevance for anesthesia
Data type
boolean
Alias
- UMLS CUI [1]
- C0948089
Description
pathological finding with relevance for anesthesia
Data type
boolean
Alias
- UMLS CUI [1]
- C0155668
Description
pathological finding with relevance for anesthesia
Data type
boolean
Alias
- UMLS CUI [1]
- C0018801
Description
pathological finding with relevance for anesthesia
Data type
boolean
Alias
- UMLS CUI [1]
- C0878544
Description
pathological finding with relevance for anesthesia
Data type
boolean
Alias
- UMLS CUI [1]
- C0003507
Description
pathological finding with relevance for anesthesia
Data type
boolean
Alias
- UMLS CUI [1]
- C0018799
Description
pathological finding with relevance for anesthesia
Data type
boolean
Alias
- UMLS CUI [1]
- C0003811
Description
pathological finding with relevance for anesthesia
Data type
boolean
Alias
- UMLS CUI [1]
- C0034072
Description
pathological finding with relevance for anesthesia
Data type
boolean
Alias
- UMLS CUI [1]
- C0027059
Description
Findings: Lungs
Alias
- UMLS CUI-1
- C0024109
Description
lungs
Data type
boolean
Alias
- UMLS CUI [1]
- C0024109
Description
pathological finding with relevance for anesthesia
Data type
boolean
Alias
- UMLS CUI [1]
- C0013404
Description
pathological finding with relevance for anesthesia
Data type
boolean
Alias
- UMLS CUI [1]
- C0032285
Description
pathological finding with relevance for anesthesia
Data type
boolean
Alias
- UMLS CUI [1]
- C0149514
Description
pathological finding with relevance for anesthesia
Data type
boolean
Alias
- UMLS CUI [1]
- C0024117
Description
pathological finding with relevance for anesthesia
Data type
boolean
Alias
- UMLS CUI [1]
- C0028778
Description
pathological finding with relevance for anesthesia
Data type
boolean
Alias
- UMLS CUI [1]
- C0443288
Description
pathological finding with relevance for anesthesia
Data type
boolean
Alias
- UMLS CUI [1]
- C0032227
Description
pathological finding with relevance for anesthesia
Data type
boolean
Alias
- UMLS CUI [1]
- C0032326
Description
pathological finding with relevance for anesthesia
Data type
boolean
Alias
- UMLS CUI [1]
- C2945579
Description
Findings: Circulatory system
Alias
- UMLS CUI-1
- C0007226
Description
Cardiovascular system
Data type
boolean
Alias
- UMLS CUI [1]
- C0007226
Description
pathological finding with relevance for anesthesia
Data type
boolean
Alias
- UMLS CUI [1]
- C0020649
Description
pathological finding with relevance for anesthesia
Data type
boolean
Alias
- UMLS CUI [1]
- C0020538
Description
pathological finding with relevance for anesthesia
Data type
boolean
Alias
- UMLS CUI [1]
- C0013922
Description
pathological finding with relevance for anesthesia
Data type
boolean
Alias
- UMLS CUI [1]
- C0040053
Description
pathological finding with relevance for anesthesia
Data type
boolean
Alias
- UMLS CUI [1]
- C0264995
Description
pathological finding with relevance for anesthesia
Data type
boolean
Alias
- UMLS CUI [1]
- C0428714
Description
Findings: CNS / Neurology
Alias
- UMLS CUI-1
- C0027765
Description
Neurology
Data type
boolean
Alias
- UMLS CUI [1]
- C0027765
Description
pathological finding with relevance for anesthesia
Data type
boolean
Alias
- UMLS CUI [1]
- C2830004
Description
pathological finding with relevance for anesthesia
Data type
boolean
Alias
- UMLS CUI [1]
- C0009421
Description
pathological finding with relevance for anesthesia
Data type
boolean
Alias
- UMLS CUI [1]
- C0876926
Description
pathological finding with relevance for anesthesia
Data type
boolean
Alias
- UMLS CUI [1]
- C2937358
Description
pathological finding with relevance for anesthesia
Data type
boolean
Alias
- UMLS CUI [1]
- C0038454
Description
pathological finding with relevance for anesthesia
Data type
boolean
Alias
- UMLS CUI [1]
- C0007787
Description
pathological finding with relevance for anesthesia
Data type
boolean
Alias
- UMLS CUI [1]
- C0030567
Description
pathological finding with relevance for anesthesia
Data type
boolean
Alias
- UMLS CUI [1]
- C0002395
Description
pathological finding with relevance for anesthesia
Data type
boolean
Alias
- UMLS CUI [1]
- C0026769
Description
pathological finding with relevance for anesthesia
Data type
boolean
Alias
- UMLS CUI [1]
- C0002736
Description
pathological finding with relevance for anesthesia
Data type
boolean
Alias
- UMLS CUI [1]
- C0014544
Description
pathological finding with relevance for anesthesia
Data type
boolean
Alias
- UMLS CUI [1]
- C0027868
Description
Findings: metabolism
Alias
- UMLS CUI-1
- C0025519
Description
metabolism
Data type
boolean
Alias
- UMLS CUI [1]
- C0025519
Description
pathological finding with relevance for anesthesia
Data type
boolean
Alias
- UMLS CUI [1]
- C0011860
Description
pathological finding with relevance for anesthesia
Data type
boolean
Alias
- UMLS CUI [1]
- C0014130
Description
pathological finding with relevance for anesthesia
Data type
boolean
Alias
- UMLS CUI [1]
- C1394815
Description
Other findings
Alias
- UMLS CUI-1
- C0243095
Description
findings
Data type
boolean
Alias
- UMLS CUI [1]
- C0243095
Description
pathological finding with relevance for anesthesia
Data type
boolean
Alias
- UMLS CUI [1]
- C0009450
Description
pathological finding with relevance for anesthesia
Data type
boolean
Alias
- UMLS CUI [1]
- C1444089
Description
pathological finding with relevance for anesthesia
Data type
boolean
Alias
- UMLS CUI [1]
- C0037315
Description
pathological finding with relevance for anesthesia
Data type
boolean
Alias
- UMLS CUI [1]
- C0035078
Description
Findings: Laboratory
Alias
- UMLS CUI-1
- C0022877
Description
laboratory findings
Data type
boolean
Alias
- UMLS CUI [1]
- C0022877
Description
pathological finding with relevance for anesthesia
Data type
boolean
Alias
- UMLS CUI [1]
- C0005771
Description
pathological finding with relevance for anesthesia
Data type
boolean
Alias
- UMLS CUI [1]
- C0150116
Description
pathological finding with relevance for anesthesia
Data type
boolean
Alias
- UMLS CUI [1]
- C0005778
Description
pathological finding with relevance for anesthesia
Data type
boolean
Alias
- UMLS CUI [1]
- C0013832
Description
pathological finding with relevance for anesthesia
Data type
boolean
Alias
- UMLS CUI [1]
- C0243095
Description
Blood values
Alias
- UMLS CUI-1
- C0018941
Description
Hemoglobin
Data type
float
Alias
- UMLS CUI [1]
- C0019046
Description
Hematocrit
Data type
float
Alias
- UMLS CUI [1]
- C0518014
Description
Platelets
Data type
integer
Alias
- UMLS CUI [1]
- C0032181
Description
Prothrombin time
Data type
integer
Alias
- UMLS CUI [1]
- C0033707
Description
International Normalized Ratio
Data type
float
Alias
- UMLS CUI [1]
- C0525032
Description
Partial thromboplastin time
Data type
integer
Alias
- UMLS CUI [1]
- C3525810
Description
Potassium
Data type
float
Alias
- UMLS CUI [1]
- C0202194
Description
Creatinine
Data type
float
Alias
- UMLS CUI [1]
- C0201976
Description
Blood sugar
Data type
float
Alias
- UMLS CUI [1]
- C0392201
Description
Gamma-glutamyltransferase
Data type
float
Alias
- UMLS CUI [1]
- C0202035
Description
Anticoagulation
Alias
- UMLS CUI-1
- C0003281
Description
Acetylsalicylic acid
Data type
boolean
Alias
- UMLS CUI [1]
- C0004057
Description
duration
Data type
date
Alias
- UMLS CUI [1]
- C0449238
Description
antagonists & inhibitors
Data type
boolean
Alias
- UMLS CUI [1]
- C0003139
Description
duration administration
Data type
date
Alias
- UMLS CUI [1,1]
- C0449238
- UMLS CUI [1,2]
- C1533734
Description
Heparin
Data type
boolean
Alias
- UMLS CUI [1]
- C0019134
Description
Heparin
Data type
date
Alias
- UMLS CUI [1]
- C0019134
Description
Nonsteroidal anti-inflammatory drugs
Data type
boolean
Alias
- UMLS CUI [1,1]
- C0003211
- UMLS CUI [1,2]
- C0205360
Description
NSAIDs
Data type
date
Alias
- UMLS CUI [1]
- C0003211
Description
Marcumar
Data type
boolean
Alias
- UMLS CUI [1]
- C0918269
Description
Marcumar
Data type
date
Alias
- UMLS CUI [1]
- C0918269
Description
anticoagulants
Data type
boolean
Alias
- UMLS CUI [1]
- C0003280
Description
Anticoagulation
Data type
date
Alias
- UMLS CUI [1]
- C0449867
Description
Preoperative assessment
Alias
- UMLS CUI-1
- C1516048
- UMLS CUI-2
- C0445204
Description
health condition teeth
Data type
text
Alias
- UMLS CUI [1,1]
- C4019131
- UMLS CUI [1,2]
- C0040426
Description
Bleeding tendency
Data type
boolean
Alias
- UMLS CUI [1]
- C1458140
Description
aspiration risk
Data type
boolean
Alias
- UMLS CUI [1,1]
- C0349707
- UMLS CUI [1,2]
- C0035647
Description
Nicotine
Data type
boolean
Alias
- UMLS CUI [1]
- C0028040
Description
Alcohol
Data type
boolean
Alias
- UMLS CUI [1]
- C0001948
Description
Drugs
Data type
boolean
Alias
- UMLS CUI [1]
- C0013227
Description
Allergies
Data type
boolean
Alias
- UMLS CUI [1]
- C0020517
Description
ASA score
Data type
integer
Alias
- UMLS CUI [1]
- C1531480
Description
NYHA classification
Data type
integer
Alias
- UMLS CUI [1]
- C1275491
Description
Mallampati score
Data type
text
Alias
- UMLS CUI [1]
- C0451276
Description
airway management
Data type
text
Alias
- UMLS CUI [1]
- C0150126
Description
Preoperative instructions
Alias
- UMLS CUI-1
- C1442085
- UMLS CUI-2
- C0445204
Description
surgery
Data type
boolean
Alias
- UMLS CUI [1]
- C0543467
Description
day surgery
Data type
boolean
Alias
- UMLS CUI [1,1]
- C0439228
- UMLS CUI [1,2]
- C0543467
Description
Medication
Data type
text
Alias
- UMLS CUI [1]
- C0013227
Description
Administration
Data type
text
Alias
- UMLS CUI [1]
- C1533734
Description
Time
Data type
time
Alias
- UMLS CUI [1]
- C0040223
Description
Signature
Data type
text
Alias
- UMLS CUI [1]
- C1519316
Description
Transfusion pre-order
Alias
- UMLS CUI-1
- C1879316
Description
Blood type
Data type
boolean
Alias
- UMLS CUI [1]
- C0005810
Description
Coombs test
Data type
boolean
Alias
- UMLS CUI [1]
- C0009961
Description
Red cell concentrate
Data type
integer
Alias
- UMLS CUI [1]
- C0443095
Description
Fresh frozen plasma
Data type
integer
Alias
- UMLS CUI [1]
- C0016709
Description
Platelet concentrate
Data type
integer
Alias
- UMLS CUI [1]
- C2362067
Description
Requirements prior to approval of surgery
Alias
- UMLS CUI-1
- C0242801
- UMLS CUI-2
- C0543467
Description
Time of latest food intake
Alias
- UMLS CUI-1
- C0086311
Description
Premedication
Alias
- UMLS CUI-1
- C0033045
Description
Date of premedication
Data type
date
Alias
- UMLS CUI [1,1]
- C0011008
- UMLS CUI [1,2]
- C0033045
Description
Anesthesist
Data type
text
Alias
- UMLS CUI [1]
- C1550495
Description
job
Data type
text
Alias
- UMLS CUI [1]
- C0028811
Description
Time
Data type
time
Alias
- UMLS CUI [1]
- C0040223
Description
Duration
Data type
integer
Measurement units
- min
Alias
- UMLS CUI [1]
- C0449238
Description
premedication
Data type
boolean
Alias
- UMLS CUI [1]
- C0033045
Description
outpatient department Anesthesia
Data type
boolean
Alias
- UMLS CUI [1,1]
- C0557824
- UMLS CUI [1,2]
- C0002903
Description
premedication; surgery
Data type
boolean
Alias
- UMLS CUI [1]
- C0033045
- UMLS CUI [2]
- C0543467
Description
Name of physician
Data type
text
Alias
- UMLS CUI [1,1]
- C0027365
- UMLS CUI [1,2]
- C0031831
Description
Signature physician
Data type
text
Alias
- UMLS CUI [1]
- C0807938
Similar models
Premedication Example 2 Routine documentation in German hospitals DMI
C0600091 (UMLS CUI [1,2])
C0600091 (UMLS CUI [1,2])
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C1301732 (UMLS CUI [1,2])
C0035648 (UMLS CUI-3)
C0039985 (UMLS CUI [2])
C0002903 (UMLS CUI [1,2])
C1533734 (UMLS CUI [1,2])
C0205360 (UMLS CUI [1,2])
C0445204 (UMLS CUI-2)
C0035647 (UMLS CUI [1,2])
C0445204 (UMLS CUI-2)
C0543467 (UMLS CUI [1,2])
C0543467 (UMLS CUI-2)
C0033045 (UMLS CUI [1,2])
C0002903 (UMLS CUI [1,2])
C0543467 (UMLS CUI [2])
C0031831 (UMLS CUI [1,2])