German English

Premedication Example 1 Routine documentation in German hospitals DMI

1 forms  
Patient data
Description

Patient data

Alias
UMLS CUI-1
C2707520
Department
Description

Department

Data type

text

Alias
UMLS CUI [1]
C0019961
Status
Description

Status

Data type

text

Alias
UMLS CUI [1]
C0449438
Age
Description

less than 1 year = 0

Data type

integer

Measurement units
  • YEARS
Alias
UMLS CUI [1]
C0001779
YEARS
Sex
Description

Sex

Data type

text

Alias
UMLS CUI [1]
C0079399
Height
Description

Height

Data type

integer

Alias
UMLS CUI [1]
C0005890
Weight
Description

Weight

Data type

integer

Alias
UMLS CUI [1]
C0005910
Heart rate
Description

Heart rate

Data type

integer

Alias
UMLS CUI [1]
C0018810
Blood Pressure
Description

Blood Pressure

Data type

text

Alias
UMLS CUI [1]
C0005823
Laboratory values
Description

Laboratory values

Alias
UMLS CUI-1
C0022885
Hb
Description

Hemoglobin

Data type

float

Alias
UMLS CUI [1]
C0019046
K
Description

Potassium

Data type

float

Alias
UMLS CUI [1]
C0202194
Blood sugar
Description

Blood sugar

Data type

float

Alias
UMLS CUI [1]
C0392201
Ht
Description

Hematocrit

Data type

float

Alias
UMLS CUI [1]
C0518014
Na
Description

Sodium

Data type

float

Alias
UMLS CUI [1]
C0337443
Creatinine
Description

Creatinine

Data type

float

Alias
UMLS CUI [1]
C0201976
PT
Description

Prothrombin time

Data type

integer

Alias
UMLS CUI [1]
C0033707
PTT
Description

Partial thromboplastin time

Data type

integer

Alias
UMLS CUI [1]
C3525810
Platelets
Description

Platelets

Data type

integer

Alias
UMLS CUI [1]
C0032181
Risk regarding organ function
Description

Risk regarding organ function

Alias
UMLS CUI-1
C0086930
UMLS CUI-2
C0678852
Heart
Description

Heart

Data type

boolean

Alias
UMLS CUI [1]
C0018787
Lungs
Description

Lungs

Data type

boolean

Alias
UMLS CUI [1]
C0024109
Circulation
Description

Circulation

Data type

boolean

Alias
UMLS CUI [1]
C0005775
Neurology / CNS
Description

Neurology

Data type

boolean

Alias
UMLS CUI [1]
C0027765
Metabolism
Description

Metabolism

Data type

boolean

Alias
UMLS CUI [1]
C0025519
BMI > = 40 (ASA III)
Description

BMI

Data type

boolean

Alias
UMLS CUI [1]
C1305855
Preoperative assessment
Description

Preoperative assessment

Alias
UMLS CUI-1
C0198826
Preoperative condition
Description

health condition preoperative

Data type

text

Alias
UMLS CUI [1,1]
C4019131
UMLS CUI [1,2]
C0445204
Re-narcosis
Description

narcosis

Data type

boolean

Alias
UMLS CUI [1]
C0234447
Long-term medication
Description

Long-term medication

Data type

text

Alias
UMLS CUI [1]
C0420257
Allergies
Description

Allergies

Data type

text

Alias
UMLS CUI [1]
C0020517
PONV
Description

Postoperative nausea and vomiting

Data type

boolean

Alias
UMLS CUI [1]
C0520909
Aspiration risk
Description

Aspiration risk

Data type

boolean

Alias
UMLS CUI [1]
C0150012
Difficult intubation
Description

Difficult intubation

Data type

boolean

Alias
UMLS CUI [1]
C0549401
State of teeth
Description

health condition teeth

Data type

text

Alias
UMLS CUI [1,1]
C4019131
UMLS CUI [1,2]
C0040426
Throat Mallampati
Description

Mallampati score

Data type

integer

Alias
UMLS CUI [1]
C0451276
ASA
Description

ASA score

Data type

text

Alias
UMLS CUI [1]
C1531480
Urgency
Description

Urgency

Data type

text

Alias
UMLS CUI [1]
C4049774
Medical procedure
Description

Medical procedure

Alias
UMLS CUI-1
C0199171
Procedure
Description

Procedure

Data type

text

Alias
UMLS CUI [1]
C0184661
Diagnosis
Description

Diagnosis

Data type

text

Alias
UMLS CUI [1]
C0011900
Anesthetic technique
Description

anesthesia

Data type

text

Alias
UMLS CUI [1]
C0002903
Planned anesthetic technique
Description

anesthesia

Data type

text

Alias
UMLS CUI [1]
C0002903
Preoperative round
Description

visit preoperative

Data type

text

Alias
UMLS CUI [1,1]
C0545082
UMLS CUI [1,2]
C0445204
Preoperative round conducted
Description

visit preoperative

Data type

boolean

Alias
UMLS CUI [1,1]
C0545082
UMLS CUI [1,2]
C0445204
Duration of preoperative round
Description

duration visit preoperative

Data type

integer

Measurement units
  • min
Alias
UMLS CUI [1,1]
C0449238
UMLS CUI [1,2]
C0545082
UMLS CUI [1,3]
C0445204
Type of duty
Description

job

Data type

text

Alias
UMLS CUI [1]
C0028811
Date of premedication
Description

Date of premedication

Data type

date

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C0033045
Checklist for ward
Description

Checklist for ward

Alias
UMLS CUI-1
C1707357
Checklist Laboratory
Description

Laboratory

Data type

text

Alias
UMLS CUI [1]
C0022877
Checklist ECG
Description

ECG

Data type

text

Alias
UMLS CUI [1]
C1623258
Checklist Blood type
Description

Blood type

Data type

text

Alias
UMLS CUI [1]
C0005810
Blood type AB0
Description

Blood type

Data type

text

Alias
UMLS CUI [1]
C0005810
Blood type Rhesus
Description

Blood Rhesus

Data type

text

Alias
UMLS CUI [1]
C2041464
Checklist Consultation
Description

Consultation

Data type

text

Alias
UMLS CUI [1]
C0009818
Consultation
Description

Consultation

Data type

text

Alias
UMLS CUI [1]
C0009818
Checklist Pulmonary function
Description

Pulmonary function

Data type

text

Alias
UMLS CUI [1]
C0024119
Checklist Chest X-ray
Description

Chest X-ray

Data type

text

Alias
UMLS CUI [1]
C0039985
Checklist Autologous blood
Description

Autologous blood

Data type

text

Alias
UMLS CUI [1]
C1277076
Autologous blood
Description

Autologous blood

Data type

integer

Alias
UMLS CUI [1]
C1277076
Checklist Autologous FFP
Description

Fresh frozen plasma

Data type

text

Alias
UMLS CUI [1]
C0016709
Autologous FFP
Description

Fresh frozen plasma

Data type

integer

Alias
UMLS CUI [1]
C0016709
Checklist Allogeneic blood on demand
Description

blood allogeneic

Data type

text

Alias
UMLS CUI [1,1]
C0005767
UMLS CUI [1,2]
C1515895
Allogeneic blood on demand
Description

blood allogeneic

Data type

integer

Alias
UMLS CUI [1,1]
C0005767
UMLS CUI [1,2]
C1515895
Checklist Allogeneic blood in OR
Description

blood allogeneic

Data type

text

Alias
UMLS CUI [1,1]
C0005767
UMLS CUI [1,2]
C1515895
Allogeneic blood in OR
Description

blood allogeneic

Data type

integer

Alias
UMLS CUI [1,1]
C0005767
UMLS CUI [1,2]
C1515895
Checklist FFP in OR
Description

Fresh frozen plasma

Data type

text

Alias
UMLS CUI [1]
C0016709
FFP in OR
Description

Fresh frozen plasma

Data type

integer

Alias
UMLS CUI [1]
C0016709
Medication
Description

Medication

Alias
UMLS CUI-1
C0013227
Premedication
Description

Premedication

Data type

text

Alias
UMLS CUI [1]
C0033045
Medication
Description

Medication

Data type

text

Alias
UMLS CUI [1]
C0013227
Dosage
Description

Dosage

Data type

text

Alias
UMLS CUI [1]
C0178602
Administration
Description

Administration

Data type

text

Alias
UMLS CUI [1]
C1533734
Signature
Description

Signature

Data type

text

Alias
UMLS CUI [1]
C1519316
Further instructions
Description

Further instructions

Alias
UMLS CUI-1
C1517331
UMLS CUI-2
C1442085
Further instructions
Description

Further instructions

Data type

text

Alias
UMLS CUI [1,1]
C1517331
UMLS CUI [1,2]
C1442085
Signature
Description

Signature

Data type

text

Alias
UMLS CUI [1]
C1519316
Further information
Description

Further information

Alias
UMLS CUI-1
C1533716
Continued self-medication
Description

self-medication

Data type

boolean

Alias
UMLS CUI [1]
C0599404
Exceptions from continued self-medication
Description

self-medication Exceptions

Data type

text

Alias
UMLS CUI [1,1]
C0599404
UMLS CUI [1,2]
C1519435
Name
Description

Name

Data type

text

Alias
UMLS CUI [1]
C0027365
Signature
Description

Signature

Data type

text

Alias
UMLS CUI [1]
C1519316
Time
Description

Time

Data type

time

Alias
UMLS CUI [1]
C0040223
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Similar models

Premedication Example 1 Routine documentation in German hospitals DMI

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Patient data
C2707520 (UMLS CUI-1)
Item
Department
text
C0019961 (UMLS CUI [1])
Department
Code List
Department
CL Item
Anesthesiology/Intensive care medicine (Anesthesiology/Intensive care medicine)
C0002930 (UMLS CUI-1)
(Comment:en)
CL Item
General and visceral surgery (General and visceral surgery)
C1274039 (UMLS CUI-1)
(Comment:en)
CL Item
Ophthalmology (Ophthalmology)
C0029087 (UMLS CUI-1)
(Comment:en)
CL Item
Gynecology (Gynecology)
C0018417 (UMLS CUI-1)
(Comment:en)
CL Item
Vascular surgery (Vascular surgery)
C0042381 (UMLS CUI-1)
(Comment:en)
CL Item
MSZ (MSZ)
(Comment:en)
CL Item
Pediatric surgery (Pediatric surgery)
C0279077 (UMLS CUI-1)
(Comment:en)
CL Item
Urology (Urology)
C0042077 (UMLS CUI-1)
(Comment:en)
CL Item
Thoracic surgery (Thoracic surgery)
C0587506 (UMLS CUI-1)
(Comment:en)
CL Item
Oral and maxillofacial surgery (Oral and maxillofacial surgery)
C0812928 (UMLS CUI-1)
(Comment:en)
CL Item
Otolaryngology (Otolaryngology)
CL Item
Internal medicine (Internal medicine)
CL Item
Neurology (Neurology)
CL Item
Neurosurgery (Neurosurgery)
CL Item
Pediatrics (Pediatrics)
CL Item
Radiology (Radiology)
CL Item
Nuclear medicine (Nuclear medicine)
CL Item
Plastic surgery and burn treatment (Plastic surgery and burn treatment)
CL Item
Dermatology (Dermatology)
CL Item
Other (Other)
Item
Status
text
C0449438 (UMLS CUI [1])
Status
Code List
Status
CL Item
outpatient (outpatient)
C0029921 (UMLS CUI-1)
(Comment:en)
CL Item
in-patient (in-patient)
C0021562 (UMLS CUI-1)
(Comment:en)
CL Item
private (private)
(Comment:en)
Age
Item
Age
integer
C0001779 (UMLS CUI [1])
Item
Sex
text
C0079399 (UMLS CUI [1])
Sex
Code List
Sex
CL Item
intersex (intersex)
C1704620 (UMLS CUI-1)
(Comment:en)
CL Item
männlich (male)
C0086582 (UMLS CUI-1)
(Comment:en)
CL Item
weiblich (female)
C0015780 (UMLS CUI-1)
(Comment:en)
Height
Item
Height
integer
C0005890 (UMLS CUI [1])
Weight
Item
Weight
integer
C0005910 (UMLS CUI [1])
Heart rate
Item
Heart rate
integer
C0018810 (UMLS CUI [1])
Blood Pressure
Item
Blood Pressure
text
C0005823 (UMLS CUI [1])
Item Group
Laboratory values
C0022885 (UMLS CUI-1)
Hemoglobin
Item
Hb
float
C0019046 (UMLS CUI [1])
Potassium
Item
K
float
C0202194 (UMLS CUI [1])
Blood sugar
Item
Blood sugar
float
C0392201 (UMLS CUI [1])
Hematocrit
Item
Ht
float
C0518014 (UMLS CUI [1])
Sodium
Item
Na
float
C0337443 (UMLS CUI [1])
Creatinine
Item
Creatinine
float
C0201976 (UMLS CUI [1])
Prothrombin time
Item
PT
integer
C0033707 (UMLS CUI [1])
Partial thromboplastin time
Item
PTT
integer
C3525810 (UMLS CUI [1])
Platelets
Item
Platelets
integer
C0032181 (UMLS CUI [1])
Item Group
Risk regarding organ function
C0086930 (UMLS CUI-1)
C0678852 (UMLS CUI-2)
Heart
Item
Heart
boolean
C0018787 (UMLS CUI [1])
Lungs
Item
Lungs
boolean
C0024109 (UMLS CUI [1])
Circulation
Item
Circulation
boolean
C0005775 (UMLS CUI [1])
Neurology
Item
Neurology / CNS
boolean
C0027765 (UMLS CUI [1])
Metabolism
Item
Metabolism
boolean
C0025519 (UMLS CUI [1])
BMI
Item
BMI > = 40 (ASA III)
boolean
C1305855 (UMLS CUI [1])
Item Group
Preoperative assessment
C0198826 (UMLS CUI-1)
health condition preoperative
Item
Preoperative condition
text
C4019131 (UMLS CUI [1,1])
C0445204 (UMLS CUI [1,2])
narcosis
Item
Re-narcosis
boolean
C0234447 (UMLS CUI [1])
Long-term medication
Item
Long-term medication
text
C0420257 (UMLS CUI [1])
Allergies
Item
Allergies
text
C0020517 (UMLS CUI [1])
Postoperative nausea and vomiting
Item
PONV
boolean
C0520909 (UMLS CUI [1])
Aspiration risk
Item
Aspiration risk
boolean
C0150012 (UMLS CUI [1])
Difficult intubation
Item
Difficult intubation
boolean
C0549401 (UMLS CUI [1])
Item
State of teeth
text
C4019131 (UMLS CUI [1,1])
C0040426 (UMLS CUI [1,2])
State of teeth
Code List
State of teeth
CL Item
normal (normal)
CL Item
restored (restored)
CL Item
prosthesis (prosthesis)
CL Item
in need of treatment (in need of treatment)
CL Item
at risk (at risk)
Item
Throat Mallampati
integer
C0451276 (UMLS CUI [1])
Mallampati score
Code List
Throat Mallampati
CL Item
1 (1)
CL Item
2 (2)
CL Item
3 (3)
CL Item
4 (4)
Item
ASA
text
C1531480 (UMLS CUI [1])
ASA score
Code List
ASA
CL Item
ASA I (ASA I)
CL Item
ASA II (ASA II)
CL Item
ASA III (ASA III)
CL Item
ASA IV (ASA IV)
CL Item
ASA V (ASA V)
CL Item
Brain death (Brain death)
Item
Urgency
text
C4049774 (UMLS CUI [1])
Urgency
Code List
Urgency
CL Item
planned procedure (planned procedure)
C0087111 (UMLS CUI-1)
C1301732 (UMLS CUI-2)
(Comment:en)
CL Item
urgent (urgent)
C3272275 (UMLS CUI-1)
(Comment:en)
CL Item
emergency (emergency)
C4264510 (UMLS CUI-1)
(Comment:en)
Item Group
Medical procedure
C0199171 (UMLS CUI-1)
Procedure
Item
Procedure
text
C0184661 (UMLS CUI [1])
Diagnosis
Item
Diagnosis
text
C0011900 (UMLS CUI [1])
anesthesia
Item
Anesthetic technique
text
C0002903 (UMLS CUI [1])
Item
Planned anesthetic technique
text
C0002903 (UMLS CUI [1])
Planned anesthetic technique
Code List
Planned anesthetic technique
CL Item
TIVA (TIVA)
C3854651 (UMLS CUI-1)
(Comment:en)
CL Item
Balanced anesthesia (Balanced anesthesia)
C2936341 (UMLS CUI-1)
(Comment:en)
CL Item
RSI (RSI)
(Comment:en)
CL Item
Spinal anesthesia (Spinal anesthesia)
C0002928 (UMLS CUI-1)
(Comment:en)
CL Item
Lumbar EDA (Lumbar EDA)
(Comment:en)
CL Item
Thoracic EDA (Thoracic EDA)
(Comment:en)
CL Item
Peripheral local anesthesia (Peripheral local anesthesia)
(Comment:en)
CL Item
Local anesthesia with catheter (Local anesthesia with catheter)
(Comment:en)
CL Item
Analgosedation (Analgosedation)
C0344106 (UMLS CUI-1)
C0002766 (UMLS CUI-2)
(Comment:en)
CL Item
Stand-by/Monitored care (Stand-by/Monitored care)
(Comment:en)
Item
Preoperative round
text
C0545082 (UMLS CUI [1,1])
C0445204 (UMLS CUI [1,2])
Preoperative round
Code List
Preoperative round
CL Item
other (other)
CL Item
documents incomplete (documents incomplete)
CL Item
findings missing (findings missing)
CL Item
patient not informed (patient not informed)
CL Item
patient not present (patient not present)
visit preoperative
Item
Preoperative round conducted
boolean
C0545082 (UMLS CUI [1,1])
C0445204 (UMLS CUI [1,2])
Item
Duration of preoperative round
integer
C0449238 (UMLS CUI [1,1])
C0545082 (UMLS CUI [1,2])
C0445204 (UMLS CUI [1,3])
Duration of preoperative round
Code List
Duration of preoperative round
CL Item
5 (5)
CL Item
10 (10)
CL Item
15 (15)
CL Item
20 (20)
CL Item
25 (25)
CL Item
30 (30)
CL Item
40 (40)
Item
Type of duty
text
C0028811 (UMLS CUI [1])
Type of duty
Code List
Type of duty
CL Item
regular (regular)
CL Item
overtime/on-call (overtime/on-call)
CL Item
weekend/holiday (weekend/holiday)
CL Item
20-22 (20-22)
CL Item
22-6 (22-6)
Date of premedication
Item
Date of premedication
date
C0011008 (UMLS CUI [1,1])
C0033045 (UMLS CUI [1,2])
Item Group
Checklist for ward
C1707357 (UMLS CUI-1)
Item
Checklist Laboratory
text
C0022877 (UMLS CUI [1])
Laboratory
Code List
Checklist Laboratory
CL Item
To be done (To be done)
CL Item
Not required (Not required)
CL Item
Done (Done)
Item
Checklist ECG
text
C1623258 (UMLS CUI [1])
ECG
Code List
Checklist ECG
CL Item
To be done (To be done)
CL Item
Not required (Not required)
CL Item
Done (Done)
Item
Checklist Blood type
text
C0005810 (UMLS CUI [1])
Blood type
Code List
Checklist Blood type
CL Item
Done (Done)
CL Item
zu erledigen (To be done)
CL Item
nicht erforderlich (Not required)
Blood type
Item
Blood type AB0
text
C0005810 (UMLS CUI [1])
Blood Rhesus
Item
Blood type Rhesus
text
C2041464 (UMLS CUI [1])
Item
Checklist Consultation
text
C0009818 (UMLS CUI [1])
Consultation
Code List
Checklist Consultation
CL Item
To be done (To be done)
CL Item
Not required (Not required)
CL Item
Done (Done)
Consultation
Item
Consultation
text
C0009818 (UMLS CUI [1])
Item
Checklist Pulmonary function
text
C0024119 (UMLS CUI [1])
Pulmonary function
Code List
Checklist Pulmonary function
CL Item
To be done (To be done)
CL Item
Not required (Not required)
CL Item
Done (Done)
Item
Checklist Chest X-ray
text
C0039985 (UMLS CUI [1])
Chest X-ray
Code List
Checklist Chest X-ray
CL Item
To be done (To be done)
CL Item
Not required (Not required)
CL Item
Done (Done)
Item
Checklist Autologous blood
text
C1277076 (UMLS CUI [1])
Autologous blood
Code List
Checklist Autologous blood
CL Item
To be done (To be done)
CL Item
Not required (Not required)
CL Item
Done (Done)
Item
Autologous blood
integer
C1277076 (UMLS CUI [1])
Autologous blood
Code List
Autologous blood
CL Item
1 (1)
CL Item
2 (2)
CL Item
3 (3)
CL Item
4 (4)
Item
Checklist Autologous FFP
text
C0016709 (UMLS CUI [1])
Fresh frozen plasma
Code List
Checklist Autologous FFP
CL Item
To be done (To be done)
CL Item
Not required (Not required)
CL Item
Done (Done)
Item
Autologous FFP
integer
C0016709 (UMLS CUI [1])
Fresh frozen plasma
Code List
Autologous FFP
CL Item
1 (1)
CL Item
2 (2)
CL Item
3 (3)
CL Item
4 (4)
Item
Checklist Allogeneic blood on demand
text
C0005767 (UMLS CUI [1,1])
C1515895 (UMLS CUI [1,2])
Allogeneic blood on demand
Code List
Checklist Allogeneic blood on demand
CL Item
To be done (To be done)
CL Item
Not required (Not required)
CL Item
Done (Done)
Item
Allogeneic blood on demand
integer
C0005767 (UMLS CUI [1,1])
C1515895 (UMLS CUI [1,2])
Allogeneic blood on demand
Code List
Allogeneic blood on demand
CL Item
1 (1)
CL Item
2 (2)
CL Item
3 (3)
CL Item
4 (4)
Item
Checklist Allogeneic blood in OR
text
C0005767 (UMLS CUI [1,1])
C1515895 (UMLS CUI [1,2])
Allogeneic blood in operating room
Code List
Checklist Allogeneic blood in OR
CL Item
To be done (To be done)
CL Item
Not required (Not required)
CL Item
Done (Done)
Item
Allogeneic blood in OR
integer
C0005767 (UMLS CUI [1,1])
C1515895 (UMLS CUI [1,2])
Allogeneic blood in operating room
Code List
Allogeneic blood in OR
CL Item
1 (1)
CL Item
2 (2)
CL Item
3 (3)
CL Item
4 (4)
Item
Checklist FFP in OR
text
C0016709 (UMLS CUI [1])
Fresh frozen plasma in operating room
Code List
Checklist FFP in OR
CL Item
To be done (To be done)
CL Item
Not required (Not required)
CL Item
Done (Done)
Item
FFP in OR
integer
C0016709 (UMLS CUI [1])
Fresh frozen plasma in operating room
Code List
FFP in OR
CL Item
1 (1)
CL Item
2 (2)
CL Item
3 (3)
CL Item
4 (4)
Item Group
Medication
C0013227 (UMLS CUI-1)
Premedication
Item
Premedication
text
C0033045 (UMLS CUI [1])
Medication
Item
Medication
text
C0013227 (UMLS CUI [1])
Dosage
Item
Dosage
text
C0178602 (UMLS CUI [1])
Administration
Item
Administration
text
C1533734 (UMLS CUI [1])
Signature
Item
Signature
text
C1519316 (UMLS CUI [1])
Item Group
Further instructions
C1517331 (UMLS CUI-1)
C1442085 (UMLS CUI-2)
Further instructions
Item
Further instructions
text
C1517331 (UMLS CUI [1,1])
C1442085 (UMLS CUI [1,2])
Signature
Item
Signature
text
C1519316 (UMLS CUI [1])
Item Group
Further information
C1533716 (UMLS CUI-1)
self-medication
Item
Continued self-medication
boolean
C0599404 (UMLS CUI [1])
self-medication Exceptions
Item
Exceptions from continued self-medication
text
C0599404 (UMLS CUI [1,1])
C1519435 (UMLS CUI [1,2])
Name
Item
Name
text
C0027365 (UMLS CUI [1])
Signature
Item
Signature
text
C1519316 (UMLS CUI [1])
Time
Item
Time
time
C0040223 (UMLS CUI [1])
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