ID

24426

Descripción

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

Link

http://www.dmi.de/

Palabras clave

Versiones (3)
  1. 30/6/17 30/6/17 -
  2. 30/6/17 30/6/17 -
  3. 31/7/17 31/7/17 -
Subido en

31 de julio de 2017

DOI

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Licencia

Creative Commons BY-NC 3.0
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Premedication record Routine documentation in German hospitals DMI

Alemán Inglés

Premedication record Routine documentation in German hospitals DMI

1 formularios  
Patient data
Descripción

Patient data

Alias
UMLS CUI-1
C2707520
Surname
Descripción

Surname

Tipo de datos

text

Alias
UMLS CUI [1]
C0421448
First name
Descripción

First name

Tipo de datos

text

Alias
UMLS CUI [1]
C1443235
Case ID
Descripción

Case ID

Tipo de datos

text

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

Date of birth

Tipo de datos

date

Alias
UMLS CUI [1]
C0421451
Age
Descripción

Age

Tipo de datos

integer

Unidades de medida
  • years
Alias
UMLS CUI [1]
C0001779
years
Weight
Descripción

Weight

Tipo de datos

float

Unidades de medida
  • kg
Alias
UMLS CUI [1]
C0005910
kg
Height
Descripción

Height

Tipo de datos

integer

Unidades de medida
  • cm
Alias
UMLS CUI [1]
C0005890
cm
Sex
Descripción

Sex

Tipo de datos

text

Alias
UMLS CUI [1]
C0079399
Organizational unit
Descripción

Organizational unit

Tipo de datos

text

Alias
UMLS CUI [1]
C0029246
Hospital stay
Descripción

Hospital stay

Tipo de datos

text

Alias
UMLS CUI [1]
C3489408
Surgery
Descripción

Surgery

Alias
UMLS CUI-1
C0543467
Diagnosis
Descripción

Diagnosis

Tipo de datos

text

Alias
UMLS CUI [1]
C0011900
Planned surgical procedure
Descripción

Planned surgical procedure

Tipo de datos

text

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

Scheduled date of surgery

Tipo de datos

date

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

Urgency

Tipo de datos

text

Alias
UMLS CUI [1]
C4049774
Position of patient
Descripción

Position of patient

Tipo de datos

text

Alias
UMLS CUI [1]
C1561964
Preoperative assessment
Descripción

Preoperative assessment

Alias
UMLS CUI-1
C0178808
BMI
Descripción

Body mass index

Tipo de datos

float

Unidades de medida
  • kg/m^2
Alias
UMLS CUI [1]
C1305855
kg/m^2
BSA
Descripción

Body surface area

Tipo de datos

float

Unidades de medida
  • m²
Alias
UMLS CUI [1]
C0005902
m²
VT
Descripción

Tidal volume

Tipo de datos

integer

Unidades de medida
  • ml
Alias
UMLS CUI [1]
C0040210
ml
ASA
Descripción

ASA classification

Tipo de datos

integer

Alias
UMLS CUI [1]
C0450990
MET
Descripción

Functional capacity, metabolic equivalents

Tipo de datos

text

Alias
UMLS CUI [1]
C2983100
Preoperative risk score
Descripción

risk score Preoperative

Tipo de datos

integer

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

risk score Postoperative Nausea and Vomiting

Tipo de datos

integer

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

Allergies

Tipo de datos

text

Alias
UMLS CUI [1]
C0020517
Mallampati
Descripción

Mallampati classification

Tipo de datos

integer

Alias
UMLS CUI [1]
C1829463
Mouth opening
Descripción

Mouth opening

Tipo de datos

float

Unidades de medida
  • cm
Alias
UMLS CUI [1]
C0226895
cm
Head reclination
Descripción

Head reclination

Tipo de datos

text

Alias
UMLS CUI [1]
C0444396
Preoperative general condition
Descripción

general condition Preoperative

Tipo de datos

text

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

nutritional condition Preoperative

Tipo de datos

text

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

Physical fitness

Tipo de datos

text

Alias
UMLS CUI [1]
C0031812
Dyspnea
Descripción

Dyspnea

Tipo de datos

text

Alias
UMLS CUI [1]
C0013404
Relevant previous operations
Descripción

operations

Tipo de datos

text

Alias
UMLS CUI [1]
C0543467
State of teeth
Descripción

health status teeth

Tipo de datos

text

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

Comorbidities

Tipo de datos

text

Alias
UMLS CUI [1]
C0009488
Heart
Descripción

Heart

Tipo de datos

text

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

blood circulation; blood vessel; hormones

Tipo de datos

text

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

Lungs; kidney; pancreas; liver

Tipo de datos

text

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

Long-term medication

Tipo de datos

text

Alias
UMLS CUI [1]
C0420257
Anesthesia
Descripción

Anesthesia

Alias
UMLS CUI-1
C0002903
Type of anesthesia
Descripción

Type of anesthesia

Tipo de datos

text

Alias
UMLS CUI [1]
C1305863
Instructions to ward
Descripción

Instructions to ward

Alias
UMLS CUI-1
C1442085
ECG
Descripción

ECG

Tipo de datos

text

Alias
UMLS CUI [1]
C1623258
Pulmonary function
Descripción

Pulmonary function

Tipo de datos

text

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

Chest X-ray

Tipo de datos

text

Alias
UMLS CUI [1]
C0039985
Consultation
Descripción

Consultation

Tipo de datos

text

Alias
UMLS CUI [1]
C0009818
Laboratory
Descripción

Laboratory

Tipo de datos

text

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

Medication Preoperative

Tipo de datos

text

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

Medication on the day of surgery

Alias
UMLS CUI-1
C0013227
Medication in the morning
Descripción

Medication

Tipo de datos

text

Alias
UMLS CUI [1]
C0013227
Time of premedication
Descripción

Time of premedication

Tipo de datos

text

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

Premedication

Tipo de datos

text

Alias
UMLS CUI [1]
C0033045
Eating / drinking
Descripción

Eating / drinking

Alias
UMLS CUI-1
C0559899
Eating possible until
Descripción

eating

Tipo de datos

text

Alias
UMLS CUI [1]
C0013470
Drinking possible until
Descripción

drinking

Tipo de datos

text

Alias
UMLS CUI [1]
C0684271
Further information
Descripción

Further information

Alias
UMLS CUI-1
C1533716
Post-surgery transfer
Descripción

Transfer post operative

Tipo de datos

text

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

Release

Tipo de datos

text

Alias
UMLS CUI [1]
C0030685
Administrated by
Descripción

person Administration procedure

Tipo de datos

text

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

Time of administration

Tipo de datos

time

Alias
UMLS CUI [1]
C1317775
Date of premedication
Descripción

Date of premedication

Tipo de datos

date

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

Person Premedication

Tipo de datos

text

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

Premedication record Routine documentation in German hospitals DMI

1 formularios
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
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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