Premedication record Routine documentation in German hospitals DMI

Patient
Beskrivning

Patient

Alias
UMLS CUI-1
C2707520
Nachname
Beskrivning

Surname

Datatyp

text

Alias
UMLS CUI [1]
C0421448
Vorname
Beskrivning

First name

Datatyp

text

Alias
UMLS CUI [1]
C1443235
Fallnummer
Beskrivning

Case ID

Datatyp

text

Alias
UMLS CUI [1,1]
C1698493
UMLS CUI [1,2]
C1300638
Geburtsdatum
Beskrivning

Date of birth

Datatyp

date

Alias
UMLS CUI [1]
C0421451
Alter
Beskrivning

Age

Datatyp

integer

Måttenheter
  • years
Alias
UMLS CUI [1]
C0001779
years
Gewicht
Beskrivning

Weight

Datatyp

float

Måttenheter
  • kg
Alias
UMLS CUI [1]
C0005910
kg
Größe
Beskrivning

Height

Datatyp

integer

Måttenheter
  • cm
Alias
UMLS CUI [1]
C0005890
cm
Geschlecht
Beskrivning

Sex

Datatyp

text

Alias
UMLS CUI [1]
C0079399
Anf. OE
Beskrivning

Organizational unit

Datatyp

text

Alias
UMLS CUI [1]
C0029246
Aufenthalt
Beskrivning

Hospital stay

Datatyp

text

Alias
UMLS CUI [1]
C3489408
OP
Beskrivning

OP

Alias
UMLS CUI-1
C0543467
OP-Diagnose(n)
Beskrivning

Diagnosis

Datatyp

text

Alias
UMLS CUI [1]
C0011900
Geplante OP
Beskrivning

Planned surgical procedure

Datatyp

text

Alias
UMLS CUI [1,1]
C1301732
UMLS CUI [1,2]
C0543467
OP-Termin
Beskrivning

Scheduled date of surgery

Datatyp

date

Alias
UMLS CUI [1,1]
C1301732
UMLS CUI [1,2]
C1628561
Dringlichkeit
Beskrivning

Urgency

Datatyp

text

Alias
UMLS CUI [1]
C4049774
Lagerung
Beskrivning

Position of patient

Datatyp

text

Alias
UMLS CUI [1]
C1561964
Präoperativer Zustand
Beskrivning

Präoperativer Zustand

Alias
UMLS CUI-1
C0178808
BMI
Beskrivning

Body mass index

Datatyp

float

Måttenheter
  • kg/m^2
Alias
UMLS CUI [1]
C1305855
kg/m^2
KOF
Beskrivning

Body surface area

Datatyp

float

Måttenheter
Alias
UMLS CUI [1]
C0005902
VT
Beskrivning

Tidal volume

Datatyp

integer

Måttenheter
  • ml
Alias
UMLS CUI [1]
C0040210
ml
ASA
Beskrivning

ASA classification

Datatyp

integer

Alias
UMLS CUI [1]
C0450990
MET
Beskrivning

Functional capacity, metabolic equivalents

Datatyp

text

Alias
UMLS CUI [1]
C2983100
Präop. Risikoscore
Beskrivning

risk score Preoperative

Datatyp

integer

Alias
UMLS CUI [1,1]
C0086930
UMLS CUI [1,2]
C0445204
Apfel
Beskrivning

risk score Postoperative Nausea and Vomiting

Datatyp

integer

Alias
UMLS CUI [1,1]
C0086930
UMLS CUI [1,2]
C0520909
Allergien
Beskrivning

Allergies

Datatyp

text

Alias
UMLS CUI [1]
C0020517
Mallampati
Beskrivning

Mallampati classification

Datatyp

integer

Alias
UMLS CUI [1]
C1829463
Mundöffnung
Beskrivning

Mouth opening

Datatyp

float

Måttenheter
  • cm
Alias
UMLS CUI [1]
C0226895
cm
Kopfreklination
Beskrivning

Head reclination

Datatyp

text

Alias
UMLS CUI [1]
C0444396
Präoperativer Zustand AZ
Beskrivning

general condition Preoperative

Datatyp

text

Alias
UMLS CUI [1,1]
C1142435
UMLS CUI [1,2]
C0445204
Präoperativer Zustand EZ
Beskrivning

nutritional condition Preoperative

Datatyp

text

Alias
UMLS CUI [1,1]
C1608413
UMLS CUI [1,2]
C0445204
Belastbarkeit
Beskrivning

Physical fitness

Datatyp

text

Alias
UMLS CUI [1]
C0031812
Dyspnoe
Beskrivning

Dyspnea

Datatyp

text

Alias
UMLS CUI [1]
C0013404
Relevante Voroperationen
Beskrivning

operations

Datatyp

text

Alias
UMLS CUI [1]
C0543467
Ergänzung Zahnstatus
Beskrivning

health status teeth

Datatyp

text

Alias
UMLS CUI [1,1]
C0018759
UMLS CUI [1,2]
C0040426
Begleiterkrankungen
Beskrivning

Comorbidities

Datatyp

text

Alias
UMLS CUI [1]
C0009488
Herz
Beskrivning

Heart

Datatyp

text

Alias
UMLS CUI [1]
C0018787
Kreislauf / Gefäße / Stoffwechsel & Hormone
Beskrivning

blood circulation; blood vessel; hormones

Datatyp

text

Alias
UMLS CUI [1]
C0005775
UMLS CUI [2]
C0005847
UMLS CUI [3]
C0019932
Lunge / Niere / Pankreas / Leber
Beskrivning

Lungs; kidney; pancreas; liver

Datatyp

text

Alias
UMLS CUI [1]
C0024109
UMLS CUI [2]
C0022646
UMLS CUI [3]
C0030274
UMLS CUI [4]
C0023884
Dauermedikation
Beskrivning

Long-term medication

Datatyp

text

Alias
UMLS CUI [1]
C0420257
Anästhesie
Beskrivning

Anästhesie

Alias
UMLS CUI-1
C0002903
Anästhesieform
Beskrivning

Type of anesthesia

Datatyp

text

Alias
UMLS CUI [1]
C1305863
Anordnungen für die Station
Beskrivning

Anordnungen für die Station

Alias
UMLS CUI-1
C1442085
EKG
Beskrivning

ECG

Datatyp

text

Alias
UMLS CUI [1]
C1623258
LuFu
Beskrivning

Pulmonary function

Datatyp

text

Alias
UMLS CUI [1]
C0024119
Rö.-Thorax
Beskrivning

Chest X-ray

Datatyp

text

Alias
UMLS CUI [1]
C0039985
Konsil
Beskrivning

Consultation

Datatyp

text

Alias
UMLS CUI [1]
C0009818
Labor
Beskrivning

Laboratory

Datatyp

text

Alias
UMLS CUI [1]
C0022877
Medikation am Vorabend
Beskrivning

Medication Preoperative

Datatyp

text

Alias
UMLS CUI [1,1]
C0013227
UMLS CUI [1,2]
C0445204
Medikation OP-Tag
Beskrivning

Medikation OP-Tag

Alias
UMLS CUI-1
C0013227
Morgenmedikation
Beskrivning

Medication

Datatyp

text

Alias
UMLS CUI [1]
C0013227
Prämedikationszeit
Beskrivning

Time of premedication

Datatyp

text

Alias
UMLS CUI [1,1]
C0040223
UMLS CUI [1,2]
C0033045
Prämedikation
Beskrivning

Premedication

Datatyp

text

Alias
UMLS CUI [1]
C0033045
Essen /Trinken
Beskrivning

Essen /Trinken

Alias
UMLS CUI-1
C0559899
Essen möglich bis
Beskrivning

eating

Datatyp

text

Alias
UMLS CUI [1]
C0013470
Trinken möglich bis
Beskrivning

drinking

Datatyp

text

Alias
UMLS CUI [1]
C0684271
Sonstiges
Beskrivning

Sonstiges

Alias
UMLS CUI-1
C1533716
Verlegung Post OP
Beskrivning

Transfer post operative

Datatyp

text

Alias
UMLS CUI [1,1]
C0030704
UMLS CUI [1,2]
C0241311
Freigabe
Beskrivning

Release

Datatyp

text

Alias
UMLS CUI [1]
C0030685
Verabreicht von
Beskrivning

person Administration procedure

Datatyp

text

Alias
UMLS CUI [1,1]
C0027361
UMLS CUI [1,2]
C1533734
Verabreicht um
Beskrivning

Time of administration

Datatyp

time

Alias
UMLS CUI [1]
C1317775
Prämediziert am
Beskrivning

Date of premedication

Datatyp

date

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C0033045
Prämediziert durch
Beskrivning

Person Premedication

Datatyp

text

Alias
UMLS CUI [1,1]
C0027361
UMLS CUI [1,2]
C0033045

Similar models

Premedication record Routine documentation in German hospitals DMI

Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
Alias
Item Group
Patient
C2707520 (UMLS CUI-1)
Surname
Item
Nachname
text
C0421448 (UMLS CUI [1])
First name
Item
Vorname
text
C1443235 (UMLS CUI [1])
Case ID
Item
Fallnummer
text
C1698493 (UMLS CUI [1,1])
C1300638 (UMLS CUI [1,2])
Date of birth
Item
Geburtsdatum
date
C0421451 (UMLS CUI [1])
Age
Item
Alter
integer
C0001779 (UMLS CUI [1])
Weight
Item
Gewicht
float
C0005910 (UMLS CUI [1])
Height
Item
Größe
integer
C0005890 (UMLS CUI [1])
Sex
Item
Geschlecht
text
C0079399 (UMLS CUI [1])
Organizational unit
Item
Anf. OE
text
C0029246 (UMLS CUI [1])
Hospital stay
Item
Aufenthalt
text
C3489408 (UMLS CUI [1])
Item Group
OP
C0543467 (UMLS CUI-1)
Diagnosis
Item
OP-Diagnose(n)
text
C0011900 (UMLS CUI [1])
Planned surgical procedure
Item
Geplante OP
text
C1301732 (UMLS CUI [1,1])
C0543467 (UMLS CUI [1,2])
Scheduled date of surgery
Item
OP-Termin
date
C1301732 (UMLS CUI [1,1])
C1628561 (UMLS CUI [1,2])
Urgency
Item
Dringlichkeit
text
C4049774 (UMLS CUI [1])
Position of patient
Item
Lagerung
text
C1561964 (UMLS CUI [1])
Item Group
Präoperativer Zustand
C0178808 (UMLS CUI-1)
Body mass index
Item
BMI
float
C1305855 (UMLS CUI [1])
Body surface area
Item
KOF
float
C0005902 (UMLS CUI [1])
Tidal volume
Item
VT
integer
C0040210 (UMLS CUI [1])
ASA classification
Item
ASA
integer
C0450990 (UMLS CUI [1])
Functional capacity, metabolic equivalents
Item
MET
text
C2983100 (UMLS CUI [1])
risk score Preoperative
Item
Präop. Risikoscore
integer
C0086930 (UMLS CUI [1,1])
C0445204 (UMLS CUI [1,2])
risk score Postoperative Nausea and Vomiting
Item
Apfel
integer
C0086930 (UMLS CUI [1,1])
C0520909 (UMLS CUI [1,2])
Allergies
Item
Allergien
text
C0020517 (UMLS CUI [1])
Mallampati classification
Item
Mallampati
integer
C1829463 (UMLS CUI [1])
Mouth opening
Item
Mundöffnung
float
C0226895 (UMLS CUI [1])
Head reclination
Item
Kopfreklination
text
C0444396 (UMLS CUI [1])
general condition Preoperative
Item
Präoperativer Zustand AZ
text
C1142435 (UMLS CUI [1,1])
C0445204 (UMLS CUI [1,2])
nutritional condition Preoperative
Item
Präoperativer Zustand EZ
text
C1608413 (UMLS CUI [1,1])
C0445204 (UMLS CUI [1,2])
Physical fitness
Item
Belastbarkeit
text
C0031812 (UMLS CUI [1])
Dyspnea
Item
Dyspnoe
text
C0013404 (UMLS CUI [1])
operations
Item
Relevante Voroperationen
text
C0543467 (UMLS CUI [1])
health status teeth
Item
Ergänzung Zahnstatus
text
C0018759 (UMLS CUI [1,1])
C0040426 (UMLS CUI [1,2])
Comorbidities
Item
Begleiterkrankungen
text
C0009488 (UMLS CUI [1])
Heart
Item
Herz
text
C0018787 (UMLS CUI [1])
blood circulation; blood vessel; hormones
Item
Kreislauf / Gefäße / Stoffwechsel & Hormone
text
C0005775 (UMLS CUI [1])
C0005847 (UMLS CUI [2])
C0019932 (UMLS CUI [3])
Lungs; kidney; pancreas; liver
Item
Lunge / Niere / Pankreas / Leber
text
C0024109 (UMLS CUI [1])
C0022646 (UMLS CUI [2])
C0030274 (UMLS CUI [3])
C0023884 (UMLS CUI [4])
Long-term medication
Item
Dauermedikation
text
C0420257 (UMLS CUI [1])
Item Group
Anästhesie
C0002903 (UMLS CUI-1)
Type of anesthesia
Item
Anästhesieform
text
C1305863 (UMLS CUI [1])
Item Group
Anordnungen für die Station
C1442085 (UMLS CUI-1)
ECG
Item
EKG
text
C1623258 (UMLS CUI [1])
Pulmonary function
Item
LuFu
text
C0024119 (UMLS CUI [1])
Chest X-ray
Item
Rö.-Thorax
text
C0039985 (UMLS CUI [1])
Consultation
Item
Konsil
text
C0009818 (UMLS CUI [1])
Laboratory
Item
Labor
text
C0022877 (UMLS CUI [1])
Medication Preoperative
Item
Medikation am Vorabend
text
C0013227 (UMLS CUI [1,1])
C0445204 (UMLS CUI [1,2])
Item Group
Medikation OP-Tag
C0013227 (UMLS CUI-1)
Medication
Item
Morgenmedikation
text
C0013227 (UMLS CUI [1])
Time of premedication
Item
Prämedikationszeit
text
C0040223 (UMLS CUI [1,1])
C0033045 (UMLS CUI [1,2])
Premedication
Item
Prämedikation
text
C0033045 (UMLS CUI [1])
Item Group
Essen /Trinken
C0559899 (UMLS CUI-1)
eating
Item
Essen möglich bis
text
C0013470 (UMLS CUI [1])
drinking
Item
Trinken möglich bis
text
C0684271 (UMLS CUI [1])
Item Group
Sonstiges
C1533716 (UMLS CUI-1)
Transfer post operative
Item
Verlegung Post OP
text
C0030704 (UMLS CUI [1,1])
C0241311 (UMLS CUI [1,2])
Release
Item
Freigabe
text
C0030685 (UMLS CUI [1])
person Administration procedure
Item
Verabreicht von
text
C0027361 (UMLS CUI [1,1])
C1533734 (UMLS CUI [1,2])
Time of administration
Item
Verabreicht um
time
C1317775 (UMLS CUI [1])
Date of premedication
Item
Prämediziert am
date
C0011008 (UMLS CUI [1,1])
C0033045 (UMLS CUI [1,2])
Person Premedication
Item
Prämediziert durch
text
C0027361 (UMLS CUI [1,1])
C0033045 (UMLS CUI [1,2])