ID
24442
Beschrijving
Routine documentation in German hospitals. Source file name: TH130110_Prämedikationsprotokoll Examplary forms provided by DMI (http://www.dmi.de/)
Link
Trefwoorden
Versies (5)
- 12-07-17 12-07-17 -
- 12-07-17 12-07-17 -
- 20-07-17 20-07-17 -
- 31-07-17 31-07-17 -
- 20-09-21 20-09-21 -
Geüploaded op
31 juli 2017
DOI
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Licentie
Creative Commons BY-NC 3.0
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Premedication Example 2 Routine documentation in German hospitals DMI
Premedication Example 2 Routine documentation in German hospitals DMI
Beschrijving
Physical parameters
Alias
- UMLS CUI-1
- C1269723
Beschrijving
Height
Datatype
integer
Alias
- UMLS CUI [1]
- C0005890
Beschrijving
Weight
Datatype
integer
Alias
- UMLS CUI [1]
- C0005910
Beschrijving
BMI
Datatype
integer
Alias
- UMLS CUI [1]
- C1305855
Beschrijving
Pulse
Datatype
integer
Alias
- UMLS CUI [1]
- C0232117
Beschrijving
Systolic blood pressure
Datatype
integer
Alias
- UMLS CUI [1]
- C0871470
Beschrijving
Diastolic blood pressure
Datatype
integer
Alias
- UMLS CUI [1]
- C0428883
Beschrijving
Medical procedure
Alias
- UMLS CUI-1
- C0199171
Beschrijving
Preoperative state and risk factors
Alias
- UMLS CUI-1
- C0178808
- UMLS CUI-3
- C0035648
Beschrijving
No abnormality detected
Datatype
boolean
Alias
- UMLS CUI [1]
- C0559229
Beschrijving
narcosis
Datatype
boolean
Alias
- UMLS CUI [1]
- C0234447
Beschrijving
Acute care
Datatype
boolean
Alias
- UMLS CUI [1]
- C0679878
Beschrijving
ECG; Chest X-ray
Datatype
text
Alias
- UMLS CUI [1]
- C1623258
- UMLS CUI [2]
- C0039985
Beschrijving
Heart
Datatype
text
Alias
- UMLS CUI [1]
- C0018787
Beschrijving
Lungs
Datatype
text
Alias
- UMLS CUI [1]
- C0024109
Beschrijving
Abdomen
Datatype
text
Alias
- UMLS CUI [1]
- C0000726
Beschrijving
Other
Datatype
text
Alias
- UMLS CUI [1]
- C0205394
Beschrijving
Long-term medication
Datatype
text
Alias
- UMLS CUI [1]
- C0420257
Beschrijving
Previous surgeries
Datatype
text
Alias
- UMLS CUI [1]
- C0744961
Beschrijving
Allergies
Datatype
text
Alias
- UMLS CUI [1]
- C0020517
Beschrijving
complications anesthesia
Datatype
text
Alias
- UMLS CUI [1,1]
- C0009566
- UMLS CUI [1,2]
- C0002903
Beschrijving
Findings: ECG
Alias
- UMLS CUI-1
- C1623258
Beschrijving
ECG
Datatype
boolean
Alias
- UMLS CUI [1]
- C1623258
Beschrijving
pathological finding with relevance for anesthesia
Datatype
boolean
Alias
- UMLS CUI [1]
- C0039231
Beschrijving
pathological finding with relevance for anesthesia
Datatype
boolean
Alias
- UMLS CUI [1]
- C0428977
Beschrijving
pathological finding with relevance for anesthesia
Datatype
boolean
Alias
- UMLS CUI [1]
- C0232201
Beschrijving
pathological finding with relevance for anesthesia
Datatype
boolean
Alias
- UMLS CUI [1]
- C0264886
Beschrijving
pathological finding with relevance for anesthesia
Datatype
boolean
Alias
- UMLS CUI [1]
- C0541950
Beschrijving
pathological finding with relevance for anesthesia
Datatype
boolean
Alias
- UMLS CUI [1]
- C1287695
Beschrijving
pathological finding with relevance for anesthesia
Datatype
boolean
Alias
- UMLS CUI [1]
- C1141959
Beschrijving
pathological finding with relevance for anesthesia
Datatype
boolean
Alias
- UMLS CUI [1]
- C3854475
Beschrijving
pathological finding with relevance for anesthesia
Datatype
boolean
Alias
- UMLS CUI [1]
- C3279217
Beschrijving
Findings: Heart
Alias
- UMLS CUI-1
- C0018787
Beschrijving
heart
Datatype
boolean
Alias
- UMLS CUI [1]
- C0018787
Beschrijving
pathological finding with relevance for anesthesia
Datatype
boolean
Alias
- UMLS CUI [1]
- C0010068
Beschrijving
pathological finding with relevance for anesthesia
Datatype
boolean
Alias
- UMLS CUI [1]
- C0340288
Beschrijving
pathological finding with relevance for anesthesia
Datatype
boolean
Alias
- UMLS CUI [1]
- C0948089
Beschrijving
pathological finding with relevance for anesthesia
Datatype
boolean
Alias
- UMLS CUI [1]
- C0155668
Beschrijving
pathological finding with relevance for anesthesia
Datatype
boolean
Alias
- UMLS CUI [1]
- C0018801
Beschrijving
pathological finding with relevance for anesthesia
Datatype
boolean
Alias
- UMLS CUI [1]
- C0878544
Beschrijving
pathological finding with relevance for anesthesia
Datatype
boolean
Alias
- UMLS CUI [1]
- C0003507
Beschrijving
pathological finding with relevance for anesthesia
Datatype
boolean
Alias
- UMLS CUI [1]
- C0018799
Beschrijving
pathological finding with relevance for anesthesia
Datatype
boolean
Alias
- UMLS CUI [1]
- C0003811
Beschrijving
pathological finding with relevance for anesthesia
Datatype
boolean
Alias
- UMLS CUI [1]
- C0034072
Beschrijving
pathological finding with relevance for anesthesia
Datatype
boolean
Alias
- UMLS CUI [1]
- C0027059
Beschrijving
Findings: Lungs
Alias
- UMLS CUI-1
- C0024109
Beschrijving
lungs
Datatype
boolean
Alias
- UMLS CUI [1]
- C0024109
Beschrijving
pathological finding with relevance for anesthesia
Datatype
boolean
Alias
- UMLS CUI [1]
- C0013404
Beschrijving
pathological finding with relevance for anesthesia
Datatype
boolean
Alias
- UMLS CUI [1]
- C0032285
Beschrijving
pathological finding with relevance for anesthesia
Datatype
boolean
Alias
- UMLS CUI [1]
- C0149514
Beschrijving
pathological finding with relevance for anesthesia
Datatype
boolean
Alias
- UMLS CUI [1]
- C0024117
Beschrijving
pathological finding with relevance for anesthesia
Datatype
boolean
Alias
- UMLS CUI [1]
- C0028778
Beschrijving
pathological finding with relevance for anesthesia
Datatype
boolean
Alias
- UMLS CUI [1]
- C0443288
Beschrijving
pathological finding with relevance for anesthesia
Datatype
boolean
Alias
- UMLS CUI [1]
- C0032227
Beschrijving
pathological finding with relevance for anesthesia
Datatype
boolean
Alias
- UMLS CUI [1]
- C0032326
Beschrijving
pathological finding with relevance for anesthesia
Datatype
boolean
Alias
- UMLS CUI [1]
- C2945579
Beschrijving
Findings: Circulatory system
Alias
- UMLS CUI-1
- C0007226
Beschrijving
Cardiovascular system
Datatype
boolean
Alias
- UMLS CUI [1]
- C0007226
Beschrijving
pathological finding with relevance for anesthesia
Datatype
boolean
Alias
- UMLS CUI [1]
- C0020649
Beschrijving
pathological finding with relevance for anesthesia
Datatype
boolean
Alias
- UMLS CUI [1]
- C0020538
Beschrijving
pathological finding with relevance for anesthesia
Datatype
boolean
Alias
- UMLS CUI [1]
- C0013922
Beschrijving
pathological finding with relevance for anesthesia
Datatype
boolean
Alias
- UMLS CUI [1]
- C0040053
Beschrijving
pathological finding with relevance for anesthesia
Datatype
boolean
Alias
- UMLS CUI [1]
- C0264995
Beschrijving
pathological finding with relevance for anesthesia
Datatype
boolean
Alias
- UMLS CUI [1]
- C0428714
Beschrijving
Findings: CNS / Neurology
Alias
- UMLS CUI-1
- C0027765
Beschrijving
Neurology
Datatype
boolean
Alias
- UMLS CUI [1]
- C0027765
Beschrijving
pathological finding with relevance for anesthesia
Datatype
boolean
Alias
- UMLS CUI [1]
- C2830004
Beschrijving
pathological finding with relevance for anesthesia
Datatype
boolean
Alias
- UMLS CUI [1]
- C0009421
Beschrijving
pathological finding with relevance for anesthesia
Datatype
boolean
Alias
- UMLS CUI [1]
- C0876926
Beschrijving
pathological finding with relevance for anesthesia
Datatype
boolean
Alias
- UMLS CUI [1]
- C2937358
Beschrijving
pathological finding with relevance for anesthesia
Datatype
boolean
Alias
- UMLS CUI [1]
- C0038454
Beschrijving
pathological finding with relevance for anesthesia
Datatype
boolean
Alias
- UMLS CUI [1]
- C0007787
Beschrijving
pathological finding with relevance for anesthesia
Datatype
boolean
Alias
- UMLS CUI [1]
- C0030567
Beschrijving
pathological finding with relevance for anesthesia
Datatype
boolean
Alias
- UMLS CUI [1]
- C0002395
Beschrijving
pathological finding with relevance for anesthesia
Datatype
boolean
Alias
- UMLS CUI [1]
- C0026769
Beschrijving
pathological finding with relevance for anesthesia
Datatype
boolean
Alias
- UMLS CUI [1]
- C0002736
Beschrijving
pathological finding with relevance for anesthesia
Datatype
boolean
Alias
- UMLS CUI [1]
- C0014544
Beschrijving
pathological finding with relevance for anesthesia
Datatype
boolean
Alias
- UMLS CUI [1]
- C0027868
Beschrijving
Findings: metabolism
Alias
- UMLS CUI-1
- C0025519
Beschrijving
metabolism
Datatype
boolean
Alias
- UMLS CUI [1]
- C0025519
Beschrijving
pathological finding with relevance for anesthesia
Datatype
boolean
Alias
- UMLS CUI [1]
- C0011860
Beschrijving
pathological finding with relevance for anesthesia
Datatype
boolean
Alias
- UMLS CUI [1]
- C0014130
Beschrijving
pathological finding with relevance for anesthesia
Datatype
boolean
Alias
- UMLS CUI [1]
- C1394815
Beschrijving
Other findings
Alias
- UMLS CUI-1
- C0243095
Beschrijving
findings
Datatype
boolean
Alias
- UMLS CUI [1]
- C0243095
Beschrijving
pathological finding with relevance for anesthesia
Datatype
boolean
Alias
- UMLS CUI [1]
- C0009450
Beschrijving
pathological finding with relevance for anesthesia
Datatype
boolean
Alias
- UMLS CUI [1]
- C1444089
Beschrijving
pathological finding with relevance for anesthesia
Datatype
boolean
Alias
- UMLS CUI [1]
- C0037315
Beschrijving
pathological finding with relevance for anesthesia
Datatype
boolean
Alias
- UMLS CUI [1]
- C0035078
Beschrijving
Findings: Laboratory
Alias
- UMLS CUI-1
- C0022877
Beschrijving
laboratory findings
Datatype
boolean
Alias
- UMLS CUI [1]
- C0022877
Beschrijving
pathological finding with relevance for anesthesia
Datatype
boolean
Alias
- UMLS CUI [1]
- C0005771
Beschrijving
pathological finding with relevance for anesthesia
Datatype
boolean
Alias
- UMLS CUI [1]
- C0150116
Beschrijving
pathological finding with relevance for anesthesia
Datatype
boolean
Alias
- UMLS CUI [1]
- C0005778
Beschrijving
pathological finding with relevance for anesthesia
Datatype
boolean
Alias
- UMLS CUI [1]
- C0013832
Beschrijving
pathological finding with relevance for anesthesia
Datatype
boolean
Alias
- UMLS CUI [1]
- C0243095
Beschrijving
Blood values
Alias
- UMLS CUI-1
- C0018941
Beschrijving
Hemoglobin
Datatype
float
Alias
- UMLS CUI [1]
- C0019046
Beschrijving
Hematocrit
Datatype
float
Alias
- UMLS CUI [1]
- C0518014
Beschrijving
Platelets
Datatype
integer
Alias
- UMLS CUI [1]
- C0032181
Beschrijving
Prothrombin time
Datatype
integer
Alias
- UMLS CUI [1]
- C0033707
Beschrijving
International Normalized Ratio
Datatype
float
Alias
- UMLS CUI [1]
- C0525032
Beschrijving
Partial thromboplastin time
Datatype
integer
Alias
- UMLS CUI [1]
- C3525810
Beschrijving
Potassium
Datatype
float
Alias
- UMLS CUI [1]
- C0202194
Beschrijving
Creatinine
Datatype
float
Alias
- UMLS CUI [1]
- C0201976
Beschrijving
Blood sugar
Datatype
float
Alias
- UMLS CUI [1]
- C0392201
Beschrijving
Gamma-glutamyltransferase
Datatype
float
Alias
- UMLS CUI [1]
- C0202035
Beschrijving
Anticoagulation
Alias
- UMLS CUI-1
- C0003281
Beschrijving
Acetylsalicylic acid
Datatype
boolean
Alias
- UMLS CUI [1]
- C0004057
Beschrijving
duration
Datatype
date
Alias
- UMLS CUI [1]
- C0449238
Beschrijving
antagonists & inhibitors
Datatype
boolean
Alias
- UMLS CUI [1]
- C0003139
Beschrijving
duration administration
Datatype
date
Alias
- UMLS CUI [1,1]
- C0449238
- UMLS CUI [1,2]
- C1533734
Beschrijving
Heparin
Datatype
boolean
Alias
- UMLS CUI [1]
- C0019134
Beschrijving
Heparin
Datatype
date
Alias
- UMLS CUI [1]
- C0019134
Beschrijving
Nonsteroidal anti-inflammatory drugs
Datatype
boolean
Alias
- UMLS CUI [1,1]
- C0003211
- UMLS CUI [1,2]
- C0205360
Beschrijving
NSAIDs
Datatype
date
Alias
- UMLS CUI [1]
- C0003211
Beschrijving
Marcumar
Datatype
boolean
Alias
- UMLS CUI [1]
- C0918269
Beschrijving
Marcumar
Datatype
date
Alias
- UMLS CUI [1]
- C0918269
Beschrijving
anticoagulants
Datatype
boolean
Alias
- UMLS CUI [1]
- C0003280
Beschrijving
Anticoagulation
Datatype
date
Alias
- UMLS CUI [1]
- C0449867
Beschrijving
Preoperative assessment
Alias
- UMLS CUI-1
- C1516048
- UMLS CUI-2
- C0445204
Beschrijving
health condition teeth
Datatype
text
Alias
- UMLS CUI [1,1]
- C4019131
- UMLS CUI [1,2]
- C0040426
Beschrijving
Bleeding tendency
Datatype
boolean
Alias
- UMLS CUI [1]
- C1458140
Beschrijving
aspiration risk
Datatype
boolean
Alias
- UMLS CUI [1,1]
- C0349707
- UMLS CUI [1,2]
- C0035647
Beschrijving
Nicotine
Datatype
boolean
Alias
- UMLS CUI [1]
- C0028040
Beschrijving
Alcohol
Datatype
boolean
Alias
- UMLS CUI [1]
- C0001948
Beschrijving
Drugs
Datatype
boolean
Alias
- UMLS CUI [1]
- C0013227
Beschrijving
Allergies
Datatype
boolean
Alias
- UMLS CUI [1]
- C0020517
Beschrijving
ASA score
Datatype
integer
Alias
- UMLS CUI [1]
- C1531480
Beschrijving
NYHA classification
Datatype
integer
Alias
- UMLS CUI [1]
- C1275491
Beschrijving
Mallampati score
Datatype
text
Alias
- UMLS CUI [1]
- C0451276
Beschrijving
airway management
Datatype
text
Alias
- UMLS CUI [1]
- C0150126
Beschrijving
Preoperative instructions
Alias
- UMLS CUI-1
- C1442085
- UMLS CUI-2
- C0445204
Beschrijving
surgery
Datatype
boolean
Alias
- UMLS CUI [1]
- C0543467
Beschrijving
day surgery
Datatype
boolean
Alias
- UMLS CUI [1,1]
- C0439228
- UMLS CUI [1,2]
- C0543467
Beschrijving
Medication
Datatype
text
Alias
- UMLS CUI [1]
- C0013227
Beschrijving
Administration
Datatype
text
Alias
- UMLS CUI [1]
- C1533734
Beschrijving
Time
Datatype
time
Alias
- UMLS CUI [1]
- C0040223
Beschrijving
Signature
Datatype
text
Alias
- UMLS CUI [1]
- C1519316
Beschrijving
Transfusion pre-order
Alias
- UMLS CUI-1
- C1879316
Beschrijving
Blood type
Datatype
boolean
Alias
- UMLS CUI [1]
- C0005810
Beschrijving
Coombs test
Datatype
boolean
Alias
- UMLS CUI [1]
- C0009961
Beschrijving
Red cell concentrate
Datatype
integer
Alias
- UMLS CUI [1]
- C0443095
Beschrijving
Fresh frozen plasma
Datatype
integer
Alias
- UMLS CUI [1]
- C0016709
Beschrijving
Platelet concentrate
Datatype
integer
Alias
- UMLS CUI [1]
- C2362067
Beschrijving
Requirements prior to approval of surgery
Alias
- UMLS CUI-1
- C0242801
- UMLS CUI-2
- C0543467
Beschrijving
Time of latest food intake
Alias
- UMLS CUI-1
- C0086311
Beschrijving
Premedication
Alias
- UMLS CUI-1
- C0033045
Beschrijving
Date of premedication
Datatype
date
Alias
- UMLS CUI [1,1]
- C0011008
- UMLS CUI [1,2]
- C0033045
Beschrijving
Anesthesist
Datatype
text
Alias
- UMLS CUI [1]
- C1550495
Beschrijving
job
Datatype
text
Alias
- UMLS CUI [1]
- C0028811
Beschrijving
Time
Datatype
time
Alias
- UMLS CUI [1]
- C0040223
Beschrijving
Duration
Datatype
integer
Maateenheden
- min
Alias
- UMLS CUI [1]
- C0449238
Beschrijving
premedication
Datatype
boolean
Alias
- UMLS CUI [1]
- C0033045
Beschrijving
outpatient department Anesthesia
Datatype
boolean
Alias
- UMLS CUI [1,1]
- C0557824
- UMLS CUI [1,2]
- C0002903
Beschrijving
premedication; surgery
Datatype
boolean
Alias
- UMLS CUI [1]
- C0033045
- UMLS CUI [2]
- C0543467
Beschrijving
Name of physician
Datatype
text
Alias
- UMLS CUI [1,1]
- C0027365
- UMLS CUI [1,2]
- C0031831
Beschrijving
Signature physician
Datatype
text
Alias
- UMLS CUI [1]
- C0807938
Similar models
Premedication Example 2 Routine documentation in German hospitals DMI
C0600091 (UMLS CUI [1,2])
C0600091 (UMLS CUI [1,2])
(Comment:en)
(Comment:en)
(Comment:en)
(Comment:en)
C1301732 (UMLS CUI [1,2])
C0035648 (UMLS CUI-3)
C0039985 (UMLS CUI [2])
C0002903 (UMLS CUI [1,2])
C1533734 (UMLS CUI [1,2])
C0205360 (UMLS CUI [1,2])
C0445204 (UMLS CUI-2)
C0035647 (UMLS CUI [1,2])
C0445204 (UMLS CUI-2)
C0543467 (UMLS CUI [1,2])
C0543467 (UMLS CUI-2)
C0033045 (UMLS CUI [1,2])
C0002903 (UMLS CUI [1,2])
C0543467 (UMLS CUI [2])
C0031831 (UMLS CUI [1,2])