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SHORT STAY RECORD ID NOTE-ENDO - HIS

- 27-09-21 - 1 Formulier, 4 Itemgroepen, 94 Data-elementen, 2 Talen

Itemgroepen: SHORT STAY RECORD ID NOTE-ENDO, Chief Complaint, Physical Exam, Prior Medical History

Form from HIS OpenVista

Birth sheet, obstetric sheet Routine documentation in German hospitals DMI

- 20-09-21 - 1 Formulier, 6 Itemgroepen, 44 Data-elementen, 2 Talen

Itemgroepen: General information, Medical history, Medical examination, General findings, Current pregnancy, Current pregnancy complications

Routine documentation in German hospitals. Source file name: SD070109_Geburtenbogen. Examplary forms provided by DMI (http://www.dmi.de/)

Premedication Example 2 Routine documentation in German hospitals DMI

- 20-09-21 - 1 Formulier, 20 Itemgroepen, 158 Data-elementen, 2 Talen

Itemgroepen: Patient data, Physical parameters, Medical procedure, Preoperative state; risk factors, ECG, heart, lungs, circulatory system, Neurology, metabolism, Other findings, Laboratory, Blood test, Anticoagulation, assessment Preoperative, instructions preoperative, Transfusion, criteria surgery, food intake, Premedication

Routine documentation in German hospitals. Source file name: TH130110_Prämedikationsprotokoll Examplary forms provided by DMI (http://www.dmi.de/)

Premedication Example 1 Routine documentation in German hospitals DMI

- 20-09-21 - 1 Formulier, 9 Itemgroepen, 74 Data-elementen, 2 Talen

Itemgroepen: Patient data, Laboratory values, risk assessment Organ function, Preoperative assessment, Medical procedure, Checklist, Medication, Further instructions, Further information

Routine documentation in German hospitals. Source file name: TH130110_Prämedikationsprotokoll Examplary forms provided by DMI (http://www.dmi.de/)

Lebendspende NTX Befund MS University Hospital Muenster (UKM)

- 20-09-21 - 1 Formulier, 3 Itemgroepen, 52 Data-elementen, 1 Taal

Itemgroepen: General information, Diagnostics of antigens and antibodies, Examinations

Hospital Routine Documentation Form at the University Hospital Muenster. Original Form name: Lebendspende NTX Befund MS.

openEHR-EHR-CLUSTER.palpation_of_fetus.v1

- 10-04-18 - 1 Formulier, 1 Itemgroep, 18 Data-elementen, 1 Taal

Itemgroep: openEHR-EHR-CLUSTER.palpation_of_fetus.v1.xml

http://openehr.org/ckm/ Use to record examination findings on palpation of the fetus while in utero. This archetype can be used to record either abdominal or vaginal examination findings, including during labor. This archetype has been designed to be nested inside the OBSERVATION.exam archetype or other relevant CLUSTER archetypes, for example providing specific detail about the fetus in CLUSTER.palpation_of_uterus. Record the details of only one fetus using this archetype. Recording details about multiple fetuses will require the multiple separate instances of this archetype.

openEHR-EHR-CLUSTER.palpation_of_cervix.v1

- 10-04-18 - 1 Formulier, 1 Itemgroep, 16 Data-elementen, 1 Taal

Itemgroep: openEHR-EHR-CLUSTER.palpation_of_cervix.v1.xml

http://openehr.org/ckm/ Use to record examination findings on palpation of the cervix, including findings during pregnancy and labour. This archetype has been designed to be nested inside the OBSERVATION.exam archetype (and its specialisations) or other relevant CLUSTER archetypes. For example, this archetype may be used as one component of a complete record of a bimanual pelvic examination - either nested within, or placed alongside, CLUSTER.palpation_of_uterus, as required by the specific clinical scenario being modelled.

openEHR-EHR-CLUSTER.palpation_of_uterus.v1

- 10-04-18 - 1 Formulier, 1 Itemgroep, 14 Data-elementen, 1 Taal

Itemgroep: openEHR-EHR-CLUSTER.palpation_of_uterus.v1.xml

http://openehr.org/ckm/ Use to record examination findings on palpation of the uterus. This archetype can be used to record either abdominal or vaginal examination findings, and including findings about the pregnant uterus. This archetype has been designed to be nested inside the OBSERVATION.exam archetype (and its specialisations) or other relevant CLUSTER archetypes, for example providing specific detail in CLUSTER.palpation_of_abdomen which describes palpation of the whole abdomen.

openEHR-EHR-CLUSTER.refraction_details.v1

- 10-04-18 - 1 Formulier, 1 Itemgroep, 9 Data-elementen, 1 Taal

Itemgroep: openEHR-EHR-CLUSTER.refraction_details.v1.xml

http://openehr.org/ckm/ This archetype is normally used within the OBSERVATION.visual_acuity archetype to record a refraction applied as part of measurement or within INSTRUCTION and ACTION archetypes where a prescription order and supply process is being modelled.

openEHR-EHR-CLUSTER.exam_sputum.v0

- 10-04-18 - 1 Formulier, 1 Itemgroep, 19 Data-elementen, 1 Taal

Itemgroep: openEHR-EHR-CLUSTER.exam_sputum.v0.xml

http://openehr.org/ckm/ Use to record a narrative description, structured details and clinical interpretation about the findings observed during examination of sputum, which could occur during routine clinical observations or as part of a physical examination. This archetype has been designed to record the examination findings of sputum being observed. It is assumed that the option to record whether sputum is present/absent or if a cough is productive/unproductive will be captured in the relevant parent archetype. This archetype has been designed to be used within: - the 'Examination findings' SLOT in the OBSERVATION.exam and related CLUSTER archetypes; - the OBSERVATION.fluid_output to describe the sputum being measured; or - the OBSERVATION.laboratory_test to desctibe physical properties about a sputum sample/specimen. It can also be used within other OBSERVATION or CLUSTER archetypes, where clinically appropriate.

openEHR-EHR-CLUSTER.exam_skin.v0

- 10-04-18 - 1 Formulier, 1 Itemgroep, 15 Data-elementen, 2 Talen

Itemgroep: openEHR-EHR-CLUSTER.exam_skin.v0.xml

Use to record a description of the overall findings observed during the physical examination of an area of skin. This archetype has been specifically designed to be used in the 'Examination findings' SLOT within many of the CLUSTER archetypes for examination of various regions or anatomical structures - for example, CLUSTER.exam_abdomen or CLUSTER.exam_breast - but can also be used within the OBSERVATION.exam. Use to provide a framework in which CLUSTER archetypes can be nested in the 'Examination findings' SLOT to record additional structured physical examination findings. The CLUSTER.exclusion_exam archetype can be nested within the 'Examination not done' SLOT to optionally record explicit details about the examination not being performed. Use to incorporate the narrative descriptions of clinical findings within existing or legacy clinical systems into an archetyped format, using the 'Clinical Description' data element.

openEHR-EHR-CLUSTER.exam_pinna.v1

- 10-04-18 - 1 Formulier, 1 Itemgroep, 12 Data-elementen, 1 Taal

Itemgroep: openEHR-EHR-CLUSTER.exam_pinna.v1.xml

http://openehr.org/ckm/ Use to record findings observed during the physical examination of a specified pinna and associated scars. Use to incorporate the narrative descriptions of clinical findings within existing or legacy clinical systems into an archetyped format, using the 'Clinical Description' data element. Specifically designed to be used within the CLUSTER.exam_ears archetype, but may be used within any clinically appropriate ENTRY or CLUSTER archetype related to physical examination of the ear.

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