ID
23727
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
July 12, 2017
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
Körperliche Merkmale
Description
Height
Data type
integer
Description
Weight
Data type
integer
Description
BMI
Data type
integer
Description
Pulse
Data type
integer
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
Eingriff
Description
Präoperativer Status und Risikofaktoren
Description
No abnormality detected
Data type
boolean
Description
Re-narcosis
Data type
boolean
Description
Acute care
Data type
boolean
Description
ECG / Chest X-ray
Data type
text
Description
Heart
Data type
text
Description
Lungs
Data type
text
Description
Abdomen
Data type
text
Description
Other
Data type
text
Description
Long-term medication
Data type
text
Description
Previous surgeries
Data type
text
Description
Allergies
Data type
text
Description
Complications during anesthesia
Data type
text
Description
Befunde: EKG
Description
Normal findings ECG
Data type
boolean
Description
Tachycardia
Data type
boolean
Description
Bradycardia
Data type
boolean
Description
Sinus rhythm absent
Data type
boolean
Description
Conduction defect
Data type
boolean
Description
Extrasystoles
Data type
boolean
Description
Pacemaker ECG
Data type
boolean
Description
Signs of ischemia
Data type
boolean
Description
Signs of infarct
Data type
boolean
Description
Disturbance of repolarization
Data type
boolean
Description
Befunde: Herz
Description
Normal findings heart
Data type
text
Description
Coronary heart disease
Data type
boolean
Description
Stable angina pectoris
Data type
boolean
Description
Acute coronary syndrome
Data type
boolean
Description
Old myocardial infarction
Data type
boolean
Description
Heart failure
Data type
boolean
Description
Cardiomyopathy
Data type
boolean
Description
Aortic / mitral stenosis
Data type
boolean
Description
Other heart defects
Data type
boolean
Description
Hemodyn. significant cardiac arrhythmias
Data type
boolean
Description
Cor pulmonale
Data type
boolean
Description
Florid myocarditis
Data type
boolean
Description
Befunde: Lunge
Description
Normal findings lungs
Data type
text
Description
Dyspnea
Data type
boolean
Description
Pneumonia
Data type
boolean
Description
Acute bronchitis
Data type
boolean
Description
Chronic obstructive pulmonary disease
Data type
boolean
Description
Obstruction
Data type
boolean
Description
Restriction
Data type
boolean
Description
Pleural effusion
Data type
boolean
Description
Pneumothorax
Data type
boolean
Description
Ventilation
Data type
boolean
Description
Befunde: Kreislauf
Description
Normal findings circulatory system
Data type
text
Description
Hypotension
Data type
boolean
Description
Hypertension
Data type
boolean
Description
Embolism
Data type
boolean
Description
Thrombosis
Data type
boolean
Description
Artery occlusive disease
Data type
boolean
Description
Impaired cerebral blood flow
Data type
boolean
Description
Befunde: ZNS / Neurologie
Description
Normal findings CNS / Neurology
Data type
text
Description
Somnolence
Data type
boolean
Description
Coma
Data type
boolean
Description
Traumatic brain injury
Data type
boolean
Description
Intracerebral hemorrhage / Space-occupying lesion
Data type
boolean
Description
Stroke
Data type
boolean
Description
Transient ischemic attack
Data type
boolean
Description
Parkinsons disease
Data type
boolean
Description
Alzheimers disease / Dementia
Data type
boolean
Description
Multiple sclerosis
Data type
boolean
Description
Amyotrophic lateral sclerosis
Data type
boolean
Description
Epilepsy
Data type
boolean
Description
Neuromuscular disease
Data type
boolean
Description
Befunde: Stoffwechsel
Description
Befunde: Sonstiges
Description
Normal findings other
Data type
boolean
Description
Infectious disease
Data type
boolean
Description
Resistant germs
Data type
boolean
Description
Obstructive sleep apnea
Data type
boolean
Description
Renal failure
Data type
boolean
Description
Befunde: Labor
Description
Normal laboratory findings
Data type
boolean
Description
Pathological basic blood count
Data type
boolean
Description
Pathological acid-base balance
Data type
boolean
Description
Pathological coagulation
Data type
boolean
Description
Electrolytes pathological
Data type
boolean
Description
Other pathological findings
Data type
boolean
Description
Blutwerte
Description
Hemoglobin
Data type
float
Description
Hematocrit
Data type
float
Description
Platelets
Data type
integer
Description
Prothrombin time
Data type
integer
Description
International Normalized Ratio
Data type
float
Description
Partial thromboplastin time
Data type
integer
Description
Potassium
Data type
float
Description
Creatinine
Data type
float
Description
Blood sugar
Data type
float
Description
Gamma-glutamyltransferase
Data type
float
Description
Antikoagulation
Description
Acetylsalicylic acid
Data type
boolean
Description
ASS administration duration
Data type
date
Description
Rez.-Antag.
Data type
boolean
Description
Rez.-Antag. administration duration
Data type
date
Description
Heparin
Data type
boolean
Description
Heparin administration duration
Data type
date
Description
Nonsteroidal anti-inflammatory drugs
Data type
boolean
Description
NSAIDs administration duration
Data type
date
Description
Marcumar
Data type
boolean
Description
Marcumar administration duration
Data type
date
Description
Other anticoagulants
Data type
boolean
Description
Administration of other anticoagulants duration
Data type
date
Description
Präoperativer Zustand
Description
State of teeth
Data type
text
Description
Bleeding tendency
Data type
boolean
Description
Risk of aspiration
Data type
boolean
Description
Nicotine
Data type
boolean
Description
Alcohol
Data type
boolean
Description
Drugs
Data type
boolean
Description
Allergies
Data type
boolean
Description
ASA score
Data type
integer
Description
NYHA classification
Data type
integer
Description
Mallampati score
Data type
text
Description
Difficult airway management
Data type
text
Description
Präoperative Anordnungen
Description
Evening before surgery
Data type
boolean
Description
Day of surgery
Data type
boolean
Description
Medication
Data type
text
Description
Administration
Data type
text
Description
Time
Data type
time
Description
Signature
Data type
text
Description
Transfusionsvorbestellung
Description
Vor OP-Freigabe erforderlich
Description
Letzte Nahrungsaufnahme
Description
Prämedikation
Description
Date of premedication
Data type
date
Description
Anesthesist
Data type
text
Description
Type of duty
Data type
text
Description
Time
Data type
time
Description
Duration
Data type
integer
Measurement units
- min
Description
Preadmission premedication
Data type
boolean
Description
Anesthesia outpatient department
Data type
boolean
Description
No surgery after premedication
Data type
boolean
Description
Name of physician
Data type
text
Description
Signature physician
Data type
text