Physical parameters
Height
integer
Weight
integer
BMI
integer
Pulse
integer
Systolic blood pressure
integer
Diastolic blood pressure
integer
Medical procedure
Preoperative state and risk factors
No abnormality detected
boolean
Re-narcosis
boolean
Acute care
boolean
ECG / Chest X-ray
text
Heart
text
Lungs
text
Abdomen
text
Other
text
Long-term medication
text
Previous surgeries
text
Allergies
text
Complications during anesthesia
text
Findings: ECG
Normal findings ECG
boolean
Tachycardia
boolean
Bradycardia
boolean
Sinus rhythm absent
boolean
Conduction defect
boolean
Extrasystoles
boolean
Pacemaker ECG
boolean
Signs of ischemia
boolean
Signs of infarct
boolean
Disturbance of repolarization
boolean
Findings: Heart
Normal findings heart
text
Coronary heart disease
boolean
Stable angina pectoris
boolean
Acute coronary syndrome
boolean
Old myocardial infarction
boolean
Heart failure
boolean
Cardiomyopathy
boolean
Aortic / mitral stenosis
boolean
Other heart defects
boolean
Hemodyn. significant cardiac arrhythmias
boolean
Cor pulmonale
boolean
Florid myocarditis
boolean
Findings: Lungs
Normal findings lungs
text
Dyspnea
boolean
Pneumonia
boolean
Acute bronchitis
boolean
Chronic obstructive pulmonary disease
boolean
Obstruction
boolean
Restriction
boolean
Pleural effusion
boolean
Pneumothorax
boolean
Ventilation
boolean
Findings: Circulatory system
Normal findings circulatory system
text
Hypotension
boolean
Hypertension
boolean
Embolism
boolean
Thrombosis
boolean
Artery occlusive disease
boolean
Impaired cerebral blood flow
boolean
Findings: CNS / Neurology
Normal findings CNS / Neurology
text
Somnolence
boolean
Coma
boolean
Traumatic brain injury
boolean
Intracerebral hemorrhage / Space-occupying lesion
boolean
Stroke
boolean
Transient ischemic attack
boolean
Parkinsons disease
boolean
Alzheimers disease / Dementia
boolean
Multiple sclerosis
boolean
Amyotrophic lateral sclerosis
boolean
Epilepsy
boolean
Neuromuscular disease
boolean
Findings: metabolism
Normal findings metabolism
boolean
(Non-) Insulin-dependent diabetes mellitus
boolean
Endocrine disorder
boolean
Enzymatic gend.
boolean
Other findings
Normal findings other
boolean
Infectious disease
boolean
Resistant germs
boolean
Obstructive sleep apnea
boolean
Renal failure
boolean
Findings: Laboratory
Normal laboratory findings
boolean
Pathological basic blood count
boolean
Pathological acid-base balance
boolean
Pathological coagulation
boolean
Electrolytes pathological
boolean
Other pathological findings
boolean
Blood values
Hemoglobin
float
Hematocrit
float
Platelets
integer
Prothrombin time
integer
International Normalized Ratio
float
Partial thromboplastin time
integer
Potassium
float
Creatinine
float
Blood sugar
float
Gamma-glutamyltransferase
float
Anticoagulation
Acetylsalicylic acid
boolean
ASS administration duration
date
Rez.-Antag.
boolean
Rez.-Antag. administration duration
date
Heparin
boolean
Heparin administration duration
date
Nonsteroidal anti-inflammatory drugs
boolean
NSAIDs administration duration
date
Marcumar
boolean
Marcumar administration duration
date
Other anticoagulants
boolean
Administration of other anticoagulants duration
date
Preoperative assessment
State of teeth
text
Bleeding tendency
boolean
Risk of aspiration
boolean
Nicotine
boolean
Alcohol
boolean
Drugs
boolean
Allergies
boolean
ASA score
integer
NYHA classification
integer
Mallampati score
text
Difficult airway management
text
Preoperative instructions
Evening before surgery
boolean
Day of surgery
boolean
Medication
text
Administration
text
Time
time
Signature
text
Transfusion pre-order
Blood type
boolean
Coombs test
boolean
Red cell concentrate
integer
Fresh frozen plasma
integer
Platelet concentrate
integer
Requirements prior to approval of surgery
Time of latest food intake
Premedication
Date of premedication
date
Anesthesist
text
Type of duty
text
Time
time
Duration
integer
Preadmission premedication
boolean
Anesthesia outpatient department
boolean
No surgery after premedication
boolean
Name of physician
text
Signature physician
text