Stichworte
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Inhaltsverzeichnis
  1. 1. Klinische Studie
  2. 2. Routinedokumentation
  3. 3. Register-/Kohortenstudien
  4. 4. Qualitätssicherung
  5. 5. Datenstandard
  6. 6. Patientenfragebogen
  7. 7. Medizinische Fachrichtung
Ausgewählte Datenmodelle

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- 17.11.21 - 1 Formular, 10 Itemgruppen, 150 Datenelemente, 2 Sprachen
Itemgruppen: Demographics, Medical History, Medical device, Diagnosis, Procedure, Findings, Laboratory Findings, Medication, Scores&Classifications, Patient Characteristics
- 20.09.21 - 4 Formulare, 9 Itemgruppen, 26 Datenelemente, 2 Sprachen
Itemgruppen: Treatment goals, Treatment plan, Equipment and Resources, Healing and therapy process, Hygiene activity, Wound protection, Therapy, causal, Education of patient and relatives, Treatment results, preliminary

Body - Anamnese (medical history)

11 Itemgruppen 36 Datenelemente

Body - Diagnose (diagnosis)

2 Itemgruppen 6 Datenelemente

Header

3 Itemgruppen 18 Datenelemente
- 08.06.17 - 1 Formular, 36 Itemgruppen, 383 Datenelemente, 2 Sprachen
Itemgruppen: Nursing Assessment, Neurological status, GLASGOW COMA SCALE, PUPILS, ORIENTATION, Cardiovascular, Eyes Ear Nose & Throat, EYES, EARS, NOSE, THROAT, Respiratory, Gastrointestinal, Genitourinary, Musculoskeletal, Skin, PRESSURE ULCER ASSESSMENT, Wound(s), INCISION(S), Nutrition, IV Therapy, Safety, Hendrich II Fall Risk Assessment, INTERVENTIONS, IMPAIRED MOBILITY RISK, ALTERED ELIMINATION, HIGH RISK FALL MEDICATIONS (ANTIEPILEPTICS & BENZODIAZEPINES), INTERVENTIONS (FOR ONCOLOGY USE ONLY), ONN Unit specific, Antepartum specific, Post partum specific, Post Surgical, ADOLESCENT INTERACTION, GERIATRIC INTERVENTION (65+), Hendrich Fall Risk, SUGGESTED INTERVENTIONS
- 20.09.21 - 2 Formulare, 9 Itemgruppen, 52 Datenelemente, 2 Sprachen
Itemgruppen: Care problem, Score, Care goal, Nursing procedure, Activities of daily living, Homecare Status, Social Environment, Legal Aspects, Medical information

Header

3 Itemgruppen 18 Datenelemente
- 27.09.21 - 1 Formular, 21 Itemgruppen, 341 Datenelemente, 2 Sprachen
Itemgruppen: 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
- 20.09.21 - 1 Formular, 15 Itemgruppen, 54 Datenelemente, 3 Sprachen
Itemgruppen: Allergy, Medical Alert Information, History of Past Illness, Social History, Pregnancy History, Vaccination, Medical Devices and Implants, Medical problems (current), Vital Signs Observations, Diagnostic Tests, Disability or function, Medication, Surgical Procedure, Treatments, Care plan
- 25.06.21 - 1 Formular, 11 Itemgruppen, 110 Datenelemente, 2 Sprachen
Itemgruppen: History and Physical Examination Elements, Patient History, Family History, Patient Assessment, Laboratory Results Elements, Diagnostic and Therapeutic Procedures Elements, Diagnostic Procedure Results, Therapeutic Procedures, Therapeutic Procedure Device Implants, Pharmacological Therapy Data Elements, Outcomes Data Elements
- 13.04.21 - 1 Formular, 1 Itemgruppe, 3 Datenelemente, 2 Sprachen
Itemgruppe: Pain NRS

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