ID

24426

Beschreibung

Routine documentation in German hospitals. Source file name: TH130110_Prämedikationsprotokoll Examplary forms provided by DMI (http://www.dmi.de/)

Link

http://www.dmi.de/

Stichworte

Versionen (3)
  1. 30.06.17 30.06.17 -
  2. 30.06.17 30.06.17 -
  3. 31.07.17 31.07.17 -
Hochgeladen am

31. Juli 2017

DOI

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Premedication record Routine documentation in German hospitals DMI

Deutsch Englisch

Premedication record Routine documentation in German hospitals DMI

1 Formulare  
Patient data
Beschreibung

Patient data

Alias
UMLS CUI-1
C2707520
Surname
Beschreibung

Surname

Datentyp

text

Alias
UMLS CUI [1]
C0421448
First name
Beschreibung

First name

Datentyp

text

Alias
UMLS CUI [1]
C1443235
Case ID
Beschreibung

Case ID

Datentyp

text

Alias
UMLS CUI [1,1]
C1698493
UMLS CUI [1,2]
C1300638
Date of birth
Beschreibung

Date of birth

Datentyp

date

Alias
UMLS CUI [1]
C0421451
Age
Beschreibung

Age

Datentyp

integer

Maßeinheiten
  • years
Alias
UMLS CUI [1]
C0001779
years
Weight
Beschreibung

Weight

Datentyp

float

Maßeinheiten
  • kg
Alias
UMLS CUI [1]
C0005910
kg
Height
Beschreibung

Height

Datentyp

integer

Maßeinheiten
  • cm
Alias
UMLS CUI [1]
C0005890
cm
Sex
Beschreibung

Sex

Datentyp

text

Alias
UMLS CUI [1]
C0079399
Organizational unit
Beschreibung

Organizational unit

Datentyp

text

Alias
UMLS CUI [1]
C0029246
Hospital stay
Beschreibung

Hospital stay

Datentyp

text

Alias
UMLS CUI [1]
C3489408
Surgery
Beschreibung

Surgery

Alias
UMLS CUI-1
C0543467
Diagnosis
Beschreibung

Diagnosis

Datentyp

text

Alias
UMLS CUI [1]
C0011900
Planned surgical procedure
Beschreibung

Planned surgical procedure

Datentyp

text

Alias
UMLS CUI [1,1]
C1301732
UMLS CUI [1,2]
C0543467
Scheduled date of surgery
Beschreibung

Scheduled date of surgery

Datentyp

date

Alias
UMLS CUI [1,1]
C1301732
UMLS CUI [1,2]
C1628561
Urgency
Beschreibung

Urgency

Datentyp

text

Alias
UMLS CUI [1]
C4049774
Position of patient
Beschreibung

Position of patient

Datentyp

text

Alias
UMLS CUI [1]
C1561964
Preoperative assessment
Beschreibung

Preoperative assessment

Alias
UMLS CUI-1
C0178808
BMI
Beschreibung

Body mass index

Datentyp

float

Maßeinheiten
  • kg/m^2
Alias
UMLS CUI [1]
C1305855
kg/m^2
BSA
Beschreibung

Body surface area

Datentyp

float

Maßeinheiten
  • m²
Alias
UMLS CUI [1]
C0005902
m²
VT
Beschreibung

Tidal volume

Datentyp

integer

Maßeinheiten
  • ml
Alias
UMLS CUI [1]
C0040210
ml
ASA
Beschreibung

ASA classification

Datentyp

integer

Alias
UMLS CUI [1]
C0450990
MET
Beschreibung

Functional capacity, metabolic equivalents

Datentyp

text

Alias
UMLS CUI [1]
C2983100
Preoperative risk score
Beschreibung

risk score Preoperative

Datentyp

integer

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

risk score Postoperative Nausea and Vomiting

Datentyp

integer

Alias
UMLS CUI [1,1]
C0086930
UMLS CUI [1,2]
C0520909
Allergies
Beschreibung

Allergies

Datentyp

text

Alias
UMLS CUI [1]
C0020517
Mallampati
Beschreibung

Mallampati classification

Datentyp

integer

Alias
UMLS CUI [1]
C1829463
Mouth opening
Beschreibung

Mouth opening

Datentyp

float

Maßeinheiten
  • cm
Alias
UMLS CUI [1]
C0226895
cm
Head reclination
Beschreibung

Head reclination

Datentyp

text

Alias
UMLS CUI [1]
C0444396
Preoperative general condition
Beschreibung

general condition Preoperative

Datentyp

text

Alias
UMLS CUI [1,1]
C1142435
UMLS CUI [1,2]
C0445204
Preoperative nutritional condition
Beschreibung

nutritional condition Preoperative

Datentyp

text

Alias
UMLS CUI [1,1]
C1608413
UMLS CUI [1,2]
C0445204
Physical fitness
Beschreibung

Physical fitness

Datentyp

text

Alias
UMLS CUI [1]
C0031812
Dyspnea
Beschreibung

Dyspnea

Datentyp

text

Alias
UMLS CUI [1]
C0013404
Relevant previous operations
Beschreibung

operations

Datentyp

text

Alias
UMLS CUI [1]
C0543467
State of teeth
Beschreibung

health status teeth

Datentyp

text

Alias
UMLS CUI [1,1]
C0018759
UMLS CUI [1,2]
C0040426
Comorbidities
Beschreibung

Comorbidities

Datentyp

text

Alias
UMLS CUI [1]
C0009488
Heart
Beschreibung

Heart

Datentyp

text

Alias
UMLS CUI [1]
C0018787
Circulation / blood vessels / metabolism & hormones
Beschreibung

blood circulation; blood vessel; hormones

Datentyp

text

Alias
UMLS CUI [1]
C0005775
UMLS CUI [2]
C0005847
UMLS CUI [3]
C0019932
Lungs / kidney / pancreas / liver
Beschreibung

Lungs; kidney; pancreas; liver

Datentyp

text

Alias
UMLS CUI [1]
C0024109
UMLS CUI [2]
C0022646
UMLS CUI [3]
C0030274
UMLS CUI [4]
C0023884
Long-term medication
Beschreibung

Long-term medication

Datentyp

text

Alias
UMLS CUI [1]
C0420257
Anesthesia
Beschreibung

Anesthesia

Alias
UMLS CUI-1
C0002903
Type of anesthesia
Beschreibung

Type of anesthesia

Datentyp

text

Alias
UMLS CUI [1]
C1305863
Instructions to ward
Beschreibung

Instructions to ward

Alias
UMLS CUI-1
C1442085
ECG
Beschreibung

ECG

Datentyp

text

Alias
UMLS CUI [1]
C1623258
Pulmonary function
Beschreibung

Pulmonary function

Datentyp

text

Alias
UMLS CUI [1]
C0024119
Chest X-ray
Beschreibung

Chest X-ray

Datentyp

text

Alias
UMLS CUI [1]
C0039985
Consultation
Beschreibung

Consultation

Datentyp

text

Alias
UMLS CUI [1]
C0009818
Laboratory
Beschreibung

Laboratory

Datentyp

text

Alias
UMLS CUI [1]
C0022877
Medication in the evening before surgery
Beschreibung

Medication Preoperative

Datentyp

text

Alias
UMLS CUI [1,1]
C0013227
UMLS CUI [1,2]
C0445204
Medication on the day of surgery
Beschreibung

Medication on the day of surgery

Alias
UMLS CUI-1
C0013227
Medication in the morning
Beschreibung

Medication

Datentyp

text

Alias
UMLS CUI [1]
C0013227
Time of premedication
Beschreibung

Time of premedication

Datentyp

text

Alias
UMLS CUI [1,1]
C0040223
UMLS CUI [1,2]
C0033045
Premedication
Beschreibung

Premedication

Datentyp

text

Alias
UMLS CUI [1]
C0033045
Eating / drinking
Beschreibung

Eating / drinking

Alias
UMLS CUI-1
C0559899
Eating possible until
Beschreibung

eating

Datentyp

text

Alias
UMLS CUI [1]
C0013470
Drinking possible until
Beschreibung

drinking

Datentyp

text

Alias
UMLS CUI [1]
C0684271
Further information
Beschreibung

Further information

Alias
UMLS CUI-1
C1533716
Post-surgery transfer
Beschreibung

Transfer post operative

Datentyp

text

Alias
UMLS CUI [1,1]
C0030704
UMLS CUI [1,2]
C0241311
Release
Beschreibung

Release

Datentyp

text

Alias
UMLS CUI [1]
C0030685
Administrated by
Beschreibung

person Administration procedure

Datentyp

text

Alias
UMLS CUI [1,1]
C0027361
UMLS CUI [1,2]
C1533734
Time of administration
Beschreibung

Time of administration

Datentyp

time

Alias
UMLS CUI [1]
C1317775
Date of premedication
Beschreibung

Date of premedication

Datentyp

date

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C0033045
Person giving premedication
Beschreibung

Person Premedication

Datentyp

text

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

Premedication record Routine documentation in German hospitals DMI

1 Formulare
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
Patient data
C2707520 (UMLS CUI-1)
Surname
Item
Surname
text
C0421448 (UMLS CUI [1])
First name
Item
First name
text
C1443235 (UMLS CUI [1])
Case ID
Item
Case ID
text
C1698493 (UMLS CUI [1,1])
C1300638 (UMLS CUI [1,2])
Date of birth
Item
Date of birth
date
C0421451 (UMLS CUI [1])
Age
Item
Age
integer
C0001779 (UMLS CUI [1])
Weight
Item
Weight
float
C0005910 (UMLS CUI [1])
Height
Item
Height
integer
C0005890 (UMLS CUI [1])
Sex
Item
Sex
text
C0079399 (UMLS CUI [1])
Organizational unit
Item
Organizational unit
text
C0029246 (UMLS CUI [1])
Hospital stay
Item
Hospital stay
text
C3489408 (UMLS CUI [1])
Item Group
Surgery
C0543467 (UMLS CUI-1)
Diagnosis
Item
Diagnosis
text
C0011900 (UMLS CUI [1])
Planned surgical procedure
Item
Planned surgical procedure
text
C1301732 (UMLS CUI [1,1])
C0543467 (UMLS CUI [1,2])
Scheduled date of surgery
Item
Scheduled date of surgery
date
C1301732 (UMLS CUI [1,1])
C1628561 (UMLS CUI [1,2])
Urgency
Item
Urgency
text
C4049774 (UMLS CUI [1])
Position of patient
Item
Position of patient
text
C1561964 (UMLS CUI [1])
Item Group
Preoperative assessment
C0178808 (UMLS CUI-1)
Body mass index
Item
BMI
float
C1305855 (UMLS CUI [1])
Body surface area
Item
BSA
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
Preoperative risk score
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
Allergies
text
C0020517 (UMLS CUI [1])
Mallampati classification
Item
Mallampati
integer
C1829463 (UMLS CUI [1])
Mouth opening
Item
Mouth opening
float
C0226895 (UMLS CUI [1])
Head reclination
Item
Head reclination
text
C0444396 (UMLS CUI [1])
general condition Preoperative
Item
Preoperative general condition
text
C1142435 (UMLS CUI [1,1])
C0445204 (UMLS CUI [1,2])
nutritional condition Preoperative
Item
Preoperative nutritional condition
text
C1608413 (UMLS CUI [1,1])
C0445204 (UMLS CUI [1,2])
Physical fitness
Item
Physical fitness
text
C0031812 (UMLS CUI [1])
Dyspnea
Item
Dyspnea
text
C0013404 (UMLS CUI [1])
operations
Item
Relevant previous operations
text
C0543467 (UMLS CUI [1])
health status teeth
Item
State of teeth
text
C0018759 (UMLS CUI [1,1])
C0040426 (UMLS CUI [1,2])
Comorbidities
Item
Comorbidities
text
C0009488 (UMLS CUI [1])
Heart
Item
Heart
text
C0018787 (UMLS CUI [1])
blood circulation; blood vessel; hormones
Item
Circulation / blood vessels / metabolism & hormones
text
C0005775 (UMLS CUI [1])
C0005847 (UMLS CUI [2])
C0019932 (UMLS CUI [3])
Lungs; kidney; pancreas; liver
Item
Lungs / kidney / pancreas / liver
text
C0024109 (UMLS CUI [1])
C0022646 (UMLS CUI [2])
C0030274 (UMLS CUI [3])
C0023884 (UMLS CUI [4])
Long-term medication
Item
Long-term medication
text
C0420257 (UMLS CUI [1])
Item Group
Anesthesia
C0002903 (UMLS CUI-1)
Type of anesthesia
Item
Type of anesthesia
text
C1305863 (UMLS CUI [1])
Item Group
Instructions to ward
C1442085 (UMLS CUI-1)
ECG
Item
ECG
text
C1623258 (UMLS CUI [1])
Pulmonary function
Item
Pulmonary function
text
C0024119 (UMLS CUI [1])
Chest X-ray
Item
Chest X-ray
text
C0039985 (UMLS CUI [1])
Consultation
Item
Consultation
text
C0009818 (UMLS CUI [1])
Laboratory
Item
Laboratory
text
C0022877 (UMLS CUI [1])
Medication Preoperative
Item
Medication in the evening before surgery
text
C0013227 (UMLS CUI [1,1])
C0445204 (UMLS CUI [1,2])
Item Group
Medication on the day of surgery
C0013227 (UMLS CUI-1)
Medication
Item
Medication in the morning
text
C0013227 (UMLS CUI [1])
Time of premedication
Item
Time of premedication
text
C0040223 (UMLS CUI [1,1])
C0033045 (UMLS CUI [1,2])
Premedication
Item
Premedication
text
C0033045 (UMLS CUI [1])
Item Group
Eating / drinking
C0559899 (UMLS CUI-1)
eating
Item
Eating possible until
text
C0013470 (UMLS CUI [1])
drinking
Item
Drinking possible until
text
C0684271 (UMLS CUI [1])
Item Group
Further information
C1533716 (UMLS CUI-1)
Transfer post operative
Item
Post-surgery transfer
text
C0030704 (UMLS CUI [1,1])
C0241311 (UMLS CUI [1,2])
Release
Item
Release
text
C0030685 (UMLS CUI [1])
person Administration procedure
Item
Administrated by
text
C0027361 (UMLS CUI [1,1])
C1533734 (UMLS CUI [1,2])
Time of administration
Item
Time of administration
time
C1317775 (UMLS CUI [1])
Date of premedication
Item
Date of premedication
date
C0011008 (UMLS CUI [1,1])
C0033045 (UMLS CUI [1,2])
Person Premedication
Item
Person giving premedication
text
C0027361 (UMLS CUI [1,1])
C0033045 (UMLS CUI [1,2])
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