- 27-09-21 - 1 Formulier, 21 Itemgroepen, 341 Data-elementen, 2 Talen
Itemgroepen: Current episode, Transfer diagnosis, Other Diagnoses, Beta blocker, Calcium Channel Blockers, Angiotensin 2 Receptor Blocker, ACE inhibitors, Diuretics, Cardiac drugs, Antikoagulanzien, Antidiabetics , Antidepressive Agents, Neuroleptic Drugs, Hormonal contraceptives, Bronchodilator Agents, Antilipemic agent, Analgesics, Anti-Infective Agents, Antiparkinson Agents, Glucocorticoids, Other medication
- 09-07-16 - 1 Formulier, 20 Itemgroepen, 313 Data-elementen, 1 Taal
Itemgroepen: Medical History, Befund, Clinical presentation, General therapy, Lab, Diagnostics, Cor, Hematology, Gastrointestinal system, Diabetes, Kidney, CNS, Lung, Psychiatrics, Epicrisis, Consultation, Clinical course, Mobilization and social service, Patient education and discharge, Procedere
- 20-09-21 - 1 Formulier, 12 Itemgroepen, 173 Data-elementen, 1 Taal
Itemgroepen: Medical History , Finding, Clinical presentation, Initial therapy, Lab , Psychiatrics, Epicrisis, Consultation, Clinical course, Mobilization and social service, Patient education and discharge, Procedere
- 27-09-21 - 12 Formulieren, 25 Itemgroepen, 146 Data-elementen, 3 Talen
Itemgroepen: Administrative Data, Principal Diagnosis, Risk Stratification of Therapy with Natalizumab, Secondary Diagnosis, Reason for Admission, Medical History, Medication on Admission, Neurological Examination: Cranial Nerves, Neurological Examination: Motor, Neurological Examination: Reflexes, Neurological Examination: Sensibility , Neurological Examination: Coordination and Gait, Neurological Examination: On Discharge, Laboratory Results Urine, Laboratory Results Urine Analysis FACS, Laboratory Results Pregnancy, Laboratory Results Serum, Laboratory Results Small EDTA, Laboratory Results Differential EDTA, Laboratory Results Blood coagulation tests, Laboratory Results Thyroid Function Tests, Laboratory Results Calculated, Laboratory Results Cellular Immune State, Summary and Procedures, Medication on Discharge

Discharge Letter Items -31562 Multiple Sclerosis

14 Itemgroepen 81 Data-elementen
- 17-09-21 - 1 Formulier, 27 Itemgroepen, 520 Data-elementen, 1 Taal
Itemgroepen: Medical history, Vegetative medical history, Risk factors and risk behavior, Family medical history, Current medical complaints, Subjective impairments in daily living and occupation, Understanding of disease and coping strategies, Treatment at admittance, Patient social history, Patient occupational history, Sick leave, Physical examination, Functional and activity impairment, Psychosomatic assessment, Laboratory procedures, ECG, Exercise Test at admittance, 24hour ECG, 24hour blood pressure measurement, Cardiologic Ultrasound, Rehabilitation diagnosis, Rehabilitation goals, Rehabilitation course and epicrisis, Rehabilitation outcome and discharge assessment, Social epicrisis, Patient self-assessment, Procedure
- 17-09-21 - 1 Formulier, 14 Itemgroepen, 46 Data-elementen, 1 Taal
Itemgroepen: Administrative data, Diagnosis Right eye, Diagnosis Left eye, Vision, Intraocular pressure, Slit lamp biomicroscopy Right eye, Slit lamp biomicroscopy Left eye, Ophthalmoscopy Right eye, Ophthalmoscopy Left eye, OCT Macula Right eye, OCT Macula Left eye, Fluorescein Angiography, Indocyanine green angiography, Evaluation; Treatment
- 17-09-21 - 2 Formulieren, 13 Itemgroepen, 44 Data-elementen, 1 Taal
Itemgroepen: Administrative data, Diagnosis Right eye, Diagnosis Left eye, Vision, Intraocular pressure, Slit lamp biomicroscopy Right eye, Slit lamp biomicroscopy Left eye, Ophthalmoscopy Right eye, Ophthalmoscopy Left eye, SD- OCT Right eye, SD- OCT Left eye, Fluorescein Angiography, Evaluation; Treatment

Example 2

0 Itemgroep 0 Data-element
- 15-03-21 - 1 Formulier, 14 Itemgroepen, 36 Data-elementen, 1 Taal
Itemgroepen: Administrative Data, Diagnosis, Secondary Diagnoses, Allergies, Therapy and course of disease, Current reason for presentation, Immunophenotyping, Medical History, Physical Examination, Lab Results, Apparative Diagnostics, Inpatient Treatment, Medication List, Procedures
- 15-03-21 - 1 Formulier, 13 Itemgroepen, 43 Data-elementen, 1 Taal
Itemgroepen: Administrative Data, Diagnosis, Secondary Diagnoses, Allergies, Therapy and course of disease, Current reason for presentation, Medical History, Physical Examination, Lab Results, Apparative Diagnostics, Inpatient Treatment, Medication List, Procedures

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