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SHORT STAY RECORD ID NOTE-ENDO - HIS

- 9/27/21 - 1 form, 4 itemgroups, 94 items, 2 languages
Itemgroups: SHORT STAY RECORD ID NOTE-ENDO, Chief Complaint, Physical Exam, Prior Medical History
Form from HIS OpenVista

Premedication Example 2 Routine documentation in German hospitals DMI

- 9/20/21 - 1 form, 20 itemgroups, 158 items, 2 languages
Itemgroups: 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

- 9/20/21 - 1 form, 9 itemgroups, 74 items, 2 languages
Itemgroups: 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/)

Birth sheet, obstetric sheet Routine documentation in German hospitals DMI

- 9/20/21 - 1 form, 6 itemgroups, 44 items, 2 languages
Itemgroups: 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/)

Fidus Ophthalmology UKM - Autorefraction

- 3/22/18 - 1 form, 5 itemgroups, 50 items, 1 language
Itemgroups: Eye refractometry, Visual acuity , Eyeglasses , Subjective refraction , medical history
Items used as routine documentation by Ophthalmology of University Clinic Muenster. ODM dereived from Voruntersuchung Individuell

Fidus Ophthalmology UKM - Documentation

- 3/22/18 - 3 forms, 5 itemgroups, 24 items, 1 language
Itemgroups: Documentation , time , Complication , Therapy , Preparation
Items used as routine documentation by Ophthalmology of University Clinic Muenster. ODM dereived from OP.

Planning of Surgical Procedures

2 itemgroups 22 items

Laser Surgery

1 itemgroup 9 items

Measurements Fidus Ophthalmology UKM - Autorefraction

- 3/22/18 - 6 forms, 5 itemgroups, 44 items, 1 language
Itemgroups: Eye refractometry , Intraocular pressure , Subjective refraction , Eyeglasses , medical history
Items used as routine documentation by Ophthalmology of University Clinic Muenster. ODM dereived from Messungen.

Contact Lenses

2 itemgroups 28 items

Intraocular pressure

1 itemgroup 10 items

Photoropter

1 itemgroup 28 items

Eyeglasses

1 itemgroup 26 items

Keratometer

0 itemgroup 0 item

Findings Fidus Ophthalmology UKM - Orthoptics and Eye Movements

- 3/22/18 - 5 forms, 2 itemgroups, 18 items, 1 language
Itemgroups: Orthoptics , Eye Movements
Items used as routine documentation by Ophthalmology of University Clinic Muenster. ODM dereived from Befund.

Slit lamp Examination

2 itemgroups 22 items

Test Methods

1 itemgroup 12 items

Visual Fields

1 itemgroup 12 items

Fundus

1 itemgroup 12 items

Premedication Anesthesiology Intensive care Catholic Clinic Koblenz Montabaur Routine documentation in German hospitals DMI

- 7/31/17 - 1 form, 12 itemgroups, 116 items, 2 languages
Itemgroups: Patient data, Medical procedure, assessment Preoperative, Comorbidities, Risk assessment, Laboratory values, Blood order, Premedication, Medication, Medical orders, Premedication, premedication
Routine documentation in German hospitals. Source file name: TH130110_Prämedikationsprotokoll Examplary forms provided by DMI (http://www.dmi.de/)

Premedication record Routine documentation in German hospitals DMI

- 7/31/17 - 1 form, 8 itemgroups, 55 items, 2 languages
Itemgroups: Patient data, Surgery, Preoperative state, Anesthesia, Instructions, Medication, Eating and drinking, Further information
Routine documentation in German hospitals. Source file name: TH130110_Prämedikationsprotokoll Examplary forms provided by DMI (http://www.dmi.de/)

SHORT STAY RECORD-ORTHO SURGICARE - HIS

- 6/6/17 - 1 form, 3 itemgroups, 26 items, 2 languages
Itemgroups: Medical History, Physical Examination, Diagnosis and Plan
Form from HIS OpenVistA

AN MS MEDD Anamnese KU NTX University Hospital Muenster (UKM) Subform

- 11/30/16 - 1 form, 5 itemgroups, 125 items, 2 languages
Itemgroups: General information, Vegetative anamnesis and management of risk factors, Clinical examination, Sonography of transplanted kidney, Summary/Procedure
Hospital Routine Documentation Subform at the University Hospital Muenster. Original Form name: AN MS MEDD Anamnese KU NTX.

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