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ID
43977
Beschrijving
Routine documentation in German hospitals. Source file name: TH130110_Prämedikationsprotokoll Examplary forms provided by DMI (http://www.dmi.de/)
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Versies (4)
- 05-07-17 05-07-17 -
- 20-07-17 20-07-17 -
- 31-07-17 31-07-17 -
- 20-09-21 20-09-21 -
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20 september 2021
DOI
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Licentie
Creative Commons BY-NC 3.0
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Premedication Example 1 Routine documentation in German hospitals DMI
Premedication Example 1 Routine documentation in German hospitals DMI
Similar models
Premedication Example 1 Routine documentation in German hospitals DMI
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
CL Item
Anesthesiology/Intensive care medicine (Anesthesiology/Intensive care medicine)
C0002930 (UMLS CUI-1)
(Comment:en)
(Comment:en)
CL Item
General and visceral surgery (General and visceral surgery)
C1274039 (UMLS CUI-1)
(Comment:en)
(Comment:en)
CL Item
Ophthalmology (Ophthalmology)
C0029087 (UMLS CUI-1)
(Comment:en)
(Comment:en)
CL Item
Gynecology (Gynecology)
C0018417 (UMLS CUI-1)
(Comment:en)
(Comment:en)
CL Item
Vascular surgery (Vascular surgery)
C0042381 (UMLS CUI-1)
(Comment:en)
(Comment:en)
CL Item
MSZ (MSZ)
(Comment:en)
CL Item
Pediatric surgery (Pediatric surgery)
C0279077 (UMLS CUI-1)
(Comment:en)
(Comment:en)
CL Item
Urology (Urology)
C0042077 (UMLS CUI-1)
(Comment:en)
(Comment:en)
CL Item
Thoracic surgery (Thoracic surgery)
C0587506 (UMLS CUI-1)
(Comment:en)
(Comment:en)
CL Item
Oral and maxillofacial surgery (Oral and maxillofacial surgery)
C0812928 (UMLS CUI-1)
(Comment:en)
(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)
CL Item
outpatient (outpatient)
C0029921 (UMLS CUI-1)
(Comment:en)
(Comment:en)
CL Item
in-patient (in-patient)
C0021562 (UMLS CUI-1)
(Comment:en)
(Comment:en)
CL Item
private (private)
(Comment:en)
Age
Item
Age
integer
C0001779 (UMLS CUI [1])
CL Item
intersex (intersex)
C1704620 (UMLS CUI-1)
(Comment:en)
(Comment:en)
CL Item
männlich (male)
C0086582 (UMLS CUI-1)
(Comment:en)
(Comment:en)
CL Item
weiblich (female)
C0086287 (UMLS CUI-1)
(Comment:en)
(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])
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)
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])
health condition preoperative
Item
Preoperative condition
text
C4019131 (UMLS CUI [1,1])
C0445204 (UMLS CUI [1,2])
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])
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)
CL Item
1 (1)
CL Item
2 (2)
CL Item
3 (3)
CL Item
4 (4)
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)
CL Item
planned procedure (planned procedure)
C0087111 (UMLS CUI-1)
C1301732 (UMLS CUI-2)
(Comment:en)
C1301732 (UMLS CUI-2)
(Comment:en)
CL Item
urgent (urgent)
C3272275 (UMLS CUI-1)
(Comment:en)
(Comment:en)
CL Item
emergency (emergency)
C4264510 (UMLS CUI-1)
(Comment:en)
(Comment:en)
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])
CL Item
TIVA (TIVA)
C3854651 (UMLS CUI-1)
(Comment:en)
(Comment:en)
CL Item
Balanced anesthesia (Balanced anesthesia)
C2936341 (UMLS CUI-1)
(Comment:en)
(Comment:en)
CL Item
RSI (RSI)
(Comment:en)
CL Item
Spinal anesthesia (Spinal anesthesia)
C0002928 (UMLS CUI-1)
(Comment:en)
(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)
C0002766 (UMLS CUI-2)
(Comment:en)
CL Item
Stand-by/Monitored care (Stand-by/Monitored care)
(Comment:en)
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])
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])
C0545082 (UMLS CUI [1,2])
C0445204 (UMLS CUI [1,3])
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)
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])
C0033045 (UMLS CUI [1,2])
CL Item
To be done (To be done)
CL Item
Not required (Not required)
CL Item
Done (Done)
CL Item
To be done (To be done)
CL Item
Not required (Not required)
CL Item
Done (Done)
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])
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])
CL Item
To be done (To be done)
CL Item
Not required (Not required)
CL Item
Done (Done)
CL Item
To be done (To be done)
CL Item
Not required (Not required)
CL Item
Done (Done)
CL Item
To be done (To be done)
CL Item
Not required (Not required)
CL Item
Done (Done)
CL Item
1 (1)
CL Item
2 (2)
CL Item
3 (3)
CL Item
4 (4)
CL Item
To be done (To be done)
CL Item
Not required (Not required)
CL Item
Done (Done)
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])
C1515895 (UMLS CUI [1,2])
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])
C1515895 (UMLS CUI [1,2])
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])
C1515895 (UMLS CUI [1,2])
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])
C1515895 (UMLS CUI [1,2])
CL Item
1 (1)
CL Item
2 (2)
CL Item
3 (3)
CL Item
4 (4)
CL Item
To be done (To be done)
CL Item
Not required (Not required)
CL Item
Done (Done)
CL Item
1 (1)
CL Item
2 (2)
CL Item
3 (3)
CL Item
4 (4)
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
Further instructions
text
C1517331 (UMLS CUI [1,1])
C1442085 (UMLS CUI [1,2])
C1442085 (UMLS CUI [1,2])
Signature
Item
Signature
text
C1519316 (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])
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])