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ID

24428

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

Anästhesiologie

Körperliche Untersuchung

Routine documentation

Anamnesenerhebung

Hochgeladen am

31. Juli 2017

DOI

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Lizenz

Creative Commons BY-NC 3.0

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Premedication Example 1 Routine documentation in German hospitals DMI

Modell
Details

Premedication Example 1 Routine documentation in German hospitals DMI

StudyEvent: ODM
1. Premedication Example 1 Routine documentation in German hospitals DMI

Name

Typ

Description | Question | Decode (Coded Value)

Datentyp

Alias

Item Group

Patient data

C2707520 (UMLS CUI-1)

Item

Department

text

C0019961 (UMLS CUI [1])

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])

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])

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])

Laboratory values

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])

risk assessment Organ function

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])

Preoperative assessment

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])

health condition teeth

Item

State of teeth

text

C4019131 (UMLS CUI [1,1])
C0040426 (UMLS CUI [1,2])

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)

Mallampati score

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])

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])

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)

Medical procedure

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)

visit preoperative

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])

duration visit preoperative

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])

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])

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])

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])

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])

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])

Pulmonary function

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])

Code List

Checklist Chest X-ray

CL Item

To be done (To be done)

CL Item

Not required (Not required)

CL Item

Done (Done)

Autologous blood

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)

Autologous blood

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)

Fresh frozen plasma

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)

Fresh frozen plasma

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)

blood allogeneic

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)

blood allogeneic

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)

blood allogeneic

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)

blood allogeneic

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)

Fresh frozen plasma

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)

Fresh frozen plasma

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])

Further instructions

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])

Further information

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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