Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
Alias
Item Group
Patientendaten
C2707520 (UMLS CUI-1)
Patient data
Item
Patientendaten
text
C2707520 (UMLS CUI [1])
Case ID
Item
Fallnummer
text
C0868928 (UMLS CUI [1,1])
C0600091 (UMLS CUI [1,2])
Surgery ID
Item
OP-Nummer
text
C0543467 (UMLS CUI [1,1])
C0600091 (UMLS CUI [1,2])
Date of birth
Item
Geburtsdatum
date
C0421451 (UMLS CUI [1])
Age
Item
Alter
integer
C0001779 (UMLS CUI [1])
Ward
Item
Station
text
C1305702 (UMLS CUI [1])
Room number
Item
Zimmer-Nummer
text
C1718316 (UMLS CUI [1])
Elective
Item
Wahlleistung
boolean
C0206058 (UMLS CUI [1])
Item
Aufnahmeart
text
C1550330 (UMLS CUI [1])
CL Item
ambulant (outpatient)
C0029921 (UMLS CUI-1)
(Comment:en)
CL Item
stationär (in-patient)
C0021562 (UMLS CUI-1)
(Comment:en)
Item
Dringlichkeit
text
C4049774 (UMLS CUI [1])
CL Item
elektiv (>24h) (elective (>24h))
CL Item
innerhalb 24h (within 24h)
CL Item
Notfall < 2h (emergency (< 2h))
CL Item
sofort (immediately)
Item
Geschlecht
text
C0079399 (UMLS CUI [1])
CL Item
m (male)
C0086582 (UMLS CUI-1)
(Comment:en)
CL Item
w (female)
C0086287 (UMLS CUI-1)
(Comment:en)
Gravidity
Item
Gravidität
boolean
C0600457 (UMLS CUI [1])
Item Group
Körperliche Merkmale
C1269723 (UMLS CUI-1)
Height
Item
Größe
integer
C0005890 (UMLS CUI [1])
Weight
Item
Gewicht
integer
C0005910 (UMLS CUI [1])
BMI
Item
BMI
integer
C1305855 (UMLS CUI [1])
Pulse
Item
Puls
integer
C0232117 (UMLS CUI [1])
Systolic blood pressure
Item
RR systolisch
integer
C0871470 (UMLS CUI [1])
Diastolic blood pressure
Item
RR diastolisch
integer
C0428883 (UMLS CUI [1])
Item Group
Eingriff
C0199171 (UMLS CUI-1)
Planned procedure
Item
Geplante Operation
text
C0087111 (UMLS CUI [1,1])
C1301732 (UMLS CUI [1,2])
anesthesia
Item
Geplante Anästhesie
text
C0002903 (UMLS CUI [1])
Item Group
Präoperativer Status und Risikofaktoren
C0178808 (UMLS CUI-1)
C0035648 (UMLS CUI-3)
No abnormality detected
Item
ohne Befund
boolean
C0559229 (UMLS CUI [1])
narcosis
Item
Wiederholungsnarkose
boolean
C0234447 (UMLS CUI [1])
Acute care
Item
Akutversorgung
boolean
C0679878 (UMLS CUI [1])
ECG; Chest X-ray
Item
EKG / Röntgen-Thorax
text
C1623258 (UMLS CUI [1])
C0039985 (UMLS CUI [2])
Heart
Item
Herz
text
C0018787 (UMLS CUI [1])
Lungs
Item
Lunge
text
C0024109 (UMLS CUI [1])
Abdomen
Item
Abdomen
text
C0000726 (UMLS CUI [1])
Other
Item
Varia
text
C0205394 (UMLS CUI [1])
Long-term medication
Item
Dauermedikation
text
C0420257 (UMLS CUI [1])
Previous surgeries
Item
Vor-OPs
text
C0744961 (UMLS CUI [1])
Allergies
Item
Allergie
text
C0020517 (UMLS CUI [1])
complications anesthesia
Item
Narkosekomplikationen
text
C0009566 (UMLS CUI [1,1])
C0002903 (UMLS CUI [1,2])
Item Group
Befunde: EKG
C1623258 (UMLS CUI-1)
ECG
Item
normal
boolean
C1623258 (UMLS CUI [1])
Tachycardia
Item
Tachykardie
boolean
C0039231 (UMLS CUI [1])
Bradycardia
Item
Bradykardie
boolean
C0428977 (UMLS CUI [1])
Sinus rhythm
Item
fehlender SR
boolean
C0232201 (UMLS CUI [1])
Conduction defect
Item
Überleitungsstörung
boolean
C0264886 (UMLS CUI [1])
Extrasystoles
Item
Extrasystolie >5/min.
boolean
C0541950 (UMLS CUI [1])
Pacemaker ECG
Item
SM-EKG
boolean
C1287695 (UMLS CUI [1])
Signs of ischemia
Item
Ischämiezeichen
boolean
C1141959 (UMLS CUI [1])
Signs of infarct
Item
Infarktzeichen
boolean
C3854475 (UMLS CUI [1])
Disturbance of repolarization
Item
Erregungsrückbildungsstörung
boolean
C3279217 (UMLS CUI [1])
Item Group
Befunde: Herz
C0018787 (UMLS CUI-1)
heart
Item
normal
boolean
C0018787 (UMLS CUI [1])
Coronary heart disease
Item
KHK
boolean
C0010068 (UMLS CUI [1])
Stable angina pectoris
Item
stabile AP
boolean
C0340288 (UMLS CUI [1])
Acute coronary syndrome
Item
ACS
boolean
C0948089 (UMLS CUI [1])
Old myocardial infarction
Item
Myokardinfarkt (alt)
boolean
C0155668 (UMLS CUI [1])
Heart failure
Item
Herzinsuffizienz
boolean
C0018801 (UMLS CUI [1])
Cardiomyopathy
Item
Kardiomyopathie
boolean
C0878544 (UMLS CUI [1])
Aortic stenosis
Item
Aorten- / Mitralstenose
boolean
C0003507 (UMLS CUI [1])
heart defects
Item
sonstige Herzvitien
boolean
C0018799 (UMLS CUI [1])
cardiac arrhythmias
Item
Hämodynamisch relevante Herzrhythmusstörungen
boolean
C0003811 (UMLS CUI [1])
Cor pulmonale
Item
Cor pulmonale
boolean
C0034072 (UMLS CUI [1])
myocarditis
Item
Floride Myokarditis
boolean
C0027059 (UMLS CUI [1])
Item Group
Befunde: Lunge
C0024109 (UMLS CUI-1)
lungs
Item
normal
boolean
C0024109 (UMLS CUI [1])
Dyspnea
Item
Dyspnoe
boolean
C0013404 (UMLS CUI [1])
Pneumonia
Item
Pneumonie
boolean
C0032285 (UMLS CUI [1])
Acute bronchitis
Item
Akute Bronchitis
boolean
C0149514 (UMLS CUI [1])
Chronic obstructive pulmonary disease
Item
COPD
boolean
C0024117 (UMLS CUI [1])
Obstruction
Item
Obstruktion
boolean
C0028778 (UMLS CUI [1])
Restriction
Item
Restriktion
boolean
C0443288 (UMLS CUI [1])
Pleural effusion
Item
Pleuraerguss
boolean
C0032227 (UMLS CUI [1])
Pneumothorax
Item
Pneumothorax
boolean
C0032326 (UMLS CUI [1])
Ventilation
Item
Beatmung
boolean
C2945579 (UMLS CUI [1])
Item Group
Befunde: Kreislauf
C0007226 (UMLS CUI-1)
Cardiovascular system
Item
normal
boolean
C0007226 (UMLS CUI [1])
Hypotension
Item
Hypotonie (therapiebed.)
boolean
C0020649 (UMLS CUI [1])
Hypertension
Item
Hypertonie
boolean
C0020538 (UMLS CUI [1])
Embolism
Item
Embolie
boolean
C0013922 (UMLS CUI [1])
Thrombosis
Item
Thrombose
boolean
C0040053 (UMLS CUI [1])
Artery occlusive disease
Item
AVK
boolean
C0264995 (UMLS CUI [1])
cerebral blood flow
Item
zerebrale Durchblutungsstörung
boolean
C0428714 (UMLS CUI [1])
Item Group
Befunde: ZNS / Neurologie
C0027765 (UMLS CUI-1)
Neurology
Item
normal
boolean
C0027765 (UMLS CUI [1])
Somnolence
Item
Somnolenz
boolean
C2830004 (UMLS CUI [1])
Coma
Item
Koma
boolean
C0009421 (UMLS CUI [1])
Traumatic brain injury
Item
SHT
boolean
C0876926 (UMLS CUI [1])
Intracerebral hemorrhage
Item
ICB / Raumforderung
boolean
C2937358 (UMLS CUI [1])
Stroke
Item
Schlaganfall
boolean
C0038454 (UMLS CUI [1])
Transient ischemic attack
Item
TIA
boolean
C0007787 (UMLS CUI [1])
Parkinsons disease
Item
Parkinson
boolean
C0030567 (UMLS CUI [1])
Alzheimers disease
Item
Alzheimer / Demenz
boolean
C0002395 (UMLS CUI [1])
Multiple sclerosis
Item
MS
boolean
C0026769 (UMLS CUI [1])
Amyotrophic lateral sclerosis
Item
ALS
boolean
C0002736 (UMLS CUI [1])
Epilepsy
Item
Epilepsie
boolean
C0014544 (UMLS CUI [1])
Neuromuscular disease
Item
neuromuskuläre Erkrankung
boolean
C0027868 (UMLS CUI [1])
Item Group
Befunde: Stoffwechsel
C0025519 (UMLS CUI-1)
metabolism
Item
normal
boolean
C0025519 (UMLS CUI [1])
(Non-) Insulin-dependent diabetes mellitus
Item
(N) IDDM
boolean
C0011860 (UMLS CUI [1])
Endocrine disorder
Item
Klinisch symptomatische Hormonstörung
boolean
C0014130 (UMLS CUI [1])
Enzymatic genetic defect
Item
Enzymatische Gendefekte
boolean
C1394815 (UMLS CUI [1])
Item Group
Befunde: Sonstiges
C0243095 (UMLS CUI-1)
findings
Item
normal
boolean
C0243095 (UMLS CUI [1])
Infectious disease
Item
Infektiöse Erkrankung
boolean
C0009450 (UMLS CUI [1])
Resistant germs
Item
resistente Keime
boolean
C1444089 (UMLS CUI [1])
Obstructive sleep apnea
Item
OSAS
boolean
C0037315 (UMLS CUI [1])
Renal failure
Item
Niereninsuffizienz
boolean
C0035078 (UMLS CUI [1])
Item Group
Befunde: Labor
C0022877 (UMLS CUI-1)
laboratory findings
Item
normal
boolean
C0022877 (UMLS CUI [1])
blood count
Item
kleines BB pathologisch
boolean
C0005771 (UMLS CUI [1])
acid-base balance
Item
SBH pathologisch
boolean
C0150116 (UMLS CUI [1])
coagulation
Item
Gerinnung pathologisch
boolean
C0005778 (UMLS CUI [1])
Electrolytes
Item
Elektrolyte pathologisch
boolean
C0013832 (UMLS CUI [1])
findings
Item
andere pathologisch
boolean
C0243095 (UMLS CUI [1])
Item Group
Blutwerte
C0018941 (UMLS CUI-1)
Hemoglobin
Item
Hb
float
C0019046 (UMLS CUI [1])
Hematocrit
Item
Hk
float
C0518014 (UMLS CUI [1])
Platelets
Item
Thr
integer
C0032181 (UMLS CUI [1])
Prothrombin time
Item
Quick
integer
C0033707 (UMLS CUI [1])
International Normalized Ratio
Item
INR
float
C0525032 (UMLS CUI [1])
Partial thromboplastin time
Item
PTT
integer
C3525810 (UMLS CUI [1])
Potassium
Item
Kalium
float
C0202194 (UMLS CUI [1])
Creatinine
Item
Krea
float
C0201976 (UMLS CUI [1])
Blood sugar
Item
BZ
float
C0392201 (UMLS CUI [1])
Gamma-glutamyltransferase
Item
gamma-GT
float
C0202035 (UMLS CUI [1])
Item Group
Antikoagulation
C0003281 (UMLS CUI-1)
Acetylsalicylic acid
Item
ASS
boolean
C0004057 (UMLS CUI [1])
duration
Item
ASS bis
date
C0449238 (UMLS CUI [1])
antagonists & inhibitors
Item
Rez.-Antagonisierung
boolean
C0003139 (UMLS CUI [1])
duration administration
Item
Rez.-Antag. bis
date
C0449238 (UMLS CUI [1,1])
C1533734 (UMLS CUI [1,2])
Heparin
Item
Heparin sc/iv
boolean
C0019134 (UMLS CUI [1])
Heparin
Item
Heparin sc/iv until
date
C0019134 (UMLS CUI [1])
Nonsteroidal anti-inflammatory drugs
Item
NSAR
boolean
C0003211 (UMLS CUI [1,1])
C0205360 (UMLS CUI [1,2])
NSAIDs
Item
NSAR bis
date
C0003211 (UMLS CUI [1])
Marcumar
Item
Marcumar
boolean
C0918269 (UMLS CUI [1])
Marcumar
Item
Marcumar bis
date
C0918269 (UMLS CUI [1])
anticoagulants
Item
andere
boolean
C0003280 (UMLS CUI [1])
Anticoagulation
Item
andere bis
date
C0449867 (UMLS CUI [1])
Item Group
Präoperativer Zustand
C1516048 (UMLS CUI-1)
C0445204 (UMLS CUI-2)
Item
Zähne
text
C4019131 (UMLS CUI [1,1])
C0040426 (UMLS CUI [1,2])
CL Item
Prothese (prosthesis)
CL Item
o. B. (no abnormality detected)
CL Item
locker/besch. (loose/damaged)
Bleeding tendency
Item
Blutungsneigung
boolean
C1458140 (UMLS CUI [1])
aspiration risk
Item
Aspirationsrisiko
boolean
C0349707 (UMLS CUI [1,1])
C0035647 (UMLS CUI [1,2])
Nicotine
Item
Nikotin
boolean
C0028040 (UMLS CUI [1])
Alcohol
Item
Alkohol
boolean
C0001948 (UMLS CUI [1])
Drugs
Item
Drogen
boolean
C0013227 (UMLS CUI [1])
Allergies
Item
Allergie
boolean
C0020517 (UMLS CUI [1])
Item
ASA
integer
C1531480 (UMLS CUI [1])
Item
NYHA
integer
C1275491 (UMLS CUI [1])
Item
Mallampati
text
C0451276 (UMLS CUI [1])
Item
Erschwerte Atemwegssicherung
text
C0150126 (UMLS CUI [1])
Code List
Erschwerte Atemwegssicherung
CL Item
Keine Hinweise (No indication)
CL Item
Vermutet (assumed)
Item Group
Präoperative Anordnungen
C1442085 (UMLS CUI-1)
C0445204 (UMLS CUI-2)
surgery
Item
Vorabend
boolean
C0543467 (UMLS CUI [1])
day surgery
Item
OP-Tag
boolean
C0439228 (UMLS CUI [1,1])
C0543467 (UMLS CUI [1,2])
Medication
Item
Medikament
text
C0013227 (UMLS CUI [1])
Administration
Item
Applikation
text
C1533734 (UMLS CUI [1])
Time
Item
Uhrzeit
time
C0040223 (UMLS CUI [1])
Signature
Item
Unterschrift
text
C1519316 (UMLS CUI [1])
Item Group
Transfusionsvorbestellung
C1879316 (UMLS CUI-1)
Blood type
Item
Blutgruppe
boolean
C0005810 (UMLS CUI [1])
Coombs test
Item
AK-Suchtest
boolean
C0009961 (UMLS CUI [1])
Red cell concentrate
Item
EK
integer
C0443095 (UMLS CUI [1])
Fresh frozen plasma
Item
FFP
integer
C0016709 (UMLS CUI [1])
Platelet concentrate
Item
TK
integer
C2362067 (UMLS CUI [1])
Item Group
Vor OP-Freigabe erforderlich
C0242801 (UMLS CUI-1)
C0543467 (UMLS CUI-2)
Consent
Item
Patienteneinverständnis
boolean
C1511481 (UMLS CUI [1])
Findings
Item
Befunde
boolean
C0243095 (UMLS CUI [1])
Follow-up visit
Item
Wiedervorstellung
boolean
C0589121 (UMLS CUI [1])
Item Group
Letzte Nahrungsaufnahme
C0086311 (UMLS CUI-1)
solid food
Item
fest
time
C0453855 (UMLS CUI [1])
liquids
Item
flüssig
time
C0302908 (UMLS CUI [1])
Item Group
Prämedikation
C0033045 (UMLS CUI-1)
Date of premedication
Item
Datum Prämedikation
date
C0011008 (UMLS CUI [1,1])
C0033045 (UMLS CUI [1,2])
Anesthesist
Item
Anästhesist/-in
text
C1550495 (UMLS CUI [1])
Item
Dienstart
text
C0028811 (UMLS CUI [1])
Time
Item
Uhrzeit (Beginn)
time
C0040223 (UMLS CUI [1])
Duration
Item
Dauer
integer
C0449238 (UMLS CUI [1])
premedication
Item
PM vorstationär
boolean
C0033045 (UMLS CUI [1])
outpatient department Anesthesia
Item
Anästh.-Ambulanz
boolean
C0557824 (UMLS CUI [1,1])
C0002903 (UMLS CUI [1,2])
premedication; surgery
Item
Nach Prämed. keine OP
boolean
C0033045 (UMLS CUI [1])
C0543467 (UMLS CUI [2])
Name of physician
Item
Name Arzt/Ärztin
text
C0027365 (UMLS CUI [1,1])
C0031831 (UMLS CUI [1,2])
Signature physician
Item
Unterschrift Arzt/Ärztin
text
C0807938 (UMLS CUI [1])