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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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- 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
- 21.05.15 - 1 Formular, 10 Itemgruppen, 150 Datenelemente, 2 Sprachen
Itemgruppen: Demographics, Medical History, Medical device, Diagnosis, Procedure, Findings, Laboratory Findings, Medication, Scores&Classifications, Patient Characteristics
- 19.04.16 - 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
- 23.05.17 - 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
- 04.06.17 - 1 Formular, 3 Itemgruppen, 33 Datenelemente, 2 Sprachen
Itemgruppen: Maternal Family History, Paternal Family History, Siblings Family History
- 09.07.16 - 1 Formular, 20 Itemgruppen, 313 Datenelemente, 1 Sprache
Itemgruppen: 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
- 22.08.15 - 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
- 25.06.15 - 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