Palabras clave
EHR ×
Tabla de contenido
  1. 1. Ensayo clínico
  2. 2. Documentación de rutina
  3. 3. Estudio de registro / cohorte
  4. 4. Seguro de calidad
  5. 5. Estándar de datos
  6. 6. Resultado reportado por el paciente
  7. 7. Especialidad médica
    1. 7.1. Anestesiología
    1. 7.2. Dermatología
    1. 7.3. ENT
    1. 7.4. Geriatría
    1. 7.5. Ginecología / Obstetricia
    1. 7.6. Medicina Interna
      1. Hematología
      1. Enfermedades infecciosas
      1. Cardiología / Angiología
      1. Neumología
      1. Gastroenterología
      1. Nefrología
      1. Endocrinología / Enfermedades metabólicas
      1. Reumatología
    1. 7.7. Neurología
    1. 7.8. Oftalmología
    1. 7.9. Cuidados paliativos
    1. 7.10. Patología / Forense
    1. 7.11. Pediatría
    1. 7.12. Psiquiatría / Psicosomática
    1. 7.13. Radiología
    1. 7.14. Cirugía
      1. Cirugía General / Visceral
      1. Neurocirugía
      1. Cirugía plástica
      1. Cirugía Torácica
      1. Traumatología / Ortopedia
      1. Cirugía vascular
    1. 7.15. Urología
    1. 7.16. Odontología / OMS
Modelos de datos seleccionados

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- 13/4/21 - 1 formulario, 10 itemgroups, 57 items, 2 idiomas
Itemgroups: Signs and Symptoms, Physical evaluation, Diagnostics, noninvasive, Diagnostics, invasive, Pharmacological Therapy Claudication, Exercise Program, Therapeutic Procedures, Procedure Outcomes, Clinical Outcomes, Cardiovascular Outcomes
- 13/4/21 - 1 formulario, 9 itemgroups, 52 items, 2 idiomas
Itemgroups: Patient history, Anatomic High-Risk Conditions, Comorbitiy, cardiopulmonary, Patient assessment, Diagnostic Procedures, Therapeutic Procedures, invasive, Outcomes, Patient education, Outcomes
- 13/4/21 - 1 formulario, 9 itemgroups, 35 items, 2 idiomas
Itemgroups: Patient history, Diagnostics, noninvasive, Diagnostics, invasive, Medication, Therapy, invasive, Outcomes of Endovascular/Open Surgical Procedures, Patient education/Counseling, Follow-up, Outcome assessment
- 20/9/21 - 1 formulario, 10 itemgroups, 37 items, 2 idiomas
Itemgroups: Patient history, Physical examination, Laboratory Testing, Diagnosis, Noninvasive, Diagnostics, invasive, Therapeutic Procedures, Outcomes, Patient education, Follow-up, Outcomes
- 20/9/21 - 1 formulario, 6 itemgroups, 70 items, 2 idiomas
Itemgroups: Personal Information, Diagnosis, Therapy, Anamnesis, Clinical evaluation, Immunological data
Item used as routine documentation by Clinic Bremen-Mitte, Urology Department, Kidney transplant. ODM derived from form “Anmdeldebogen- NTx” Number TPLF006, Version 3, Transplant Center Bremen, Clinic Bremen-Mitte gGmbH 28177 Bremen. Investigations before registering for kidney transplant (Application with medical report and Epicrisis) 1. Obligatory examinations 1.1. Imaging techniques - Chest X-ray in two planes (Finding and image) - X- ray pelvis overview (without gonad protection in females) (Finding and image) - Abdominal ultrasonography (liver, gall bladder, kidney own, aorta) 1.2. Consultation and additional examinations - Ophthalmologist - Gynecologist - Dermatologist - Otolaryngologist - Dentist - Urologist: Uroflow (rest precipitation> 500 mL / d), residual urine, sediment, urine culture, Prostate palpation and PSA determination aged 30 and older - Cardiologist: ECG (Original / Copy) 1.3. Laboratory tests Blood count, electrolytes, urea, creatinine, uric acid, iPTH, inorg. Phosphate, alkaline phosphatase, GGT, ALT, AST, LDH, total Bilirubin, total Protein, fasting blood sugar level, basal C-peptide and HbA1c (In all diabetics), triglycerides, cholesterol, BSG, BM-Test Colon albumin (3x), 55 years and older colonoscopy (according to current guideline) 1.4. Virology - Hepatitis (HBsAg, HBcAK, HBsAK, HCV antibodies) - HIV (1 and 2), CMV, EBV, VZV 1.5. Hepatitis B vaccination (with antibody detection) 2. Selective indicated examinations 2.1. Imaging tests - Abdominal CT by cystic kidneys, tumors in the History, Analgesic nephropathy - Coronary angiography by cardiac risk, by diabetics - Arterial angiography by PAD, pelvic vascular sclerosis in pelvic x- ray - Colonoscopy / Colon contrast enema with diverticulosis - CT abdomen on spec diverticulitis - Voiding cystourethrogram (VCUG) at Pyelonephritis-, urinary tract infection or stone in the urinary tract , unclear etiology of renal insufficiency - Urethro cystoscopy, retrograde Urethrography left/ right and Bladder irrigation left/ right Analgesic nephropathy or hematuria - Kidney bladder overview by medical history of kidney stone 2.2. Other examinations - Echocardiography, exercise ECG by aged 50 and older and by all diabetics - Gastroscopy at ulcer anamnesis - Lung function tests only if indicated (all smokers) - Carotid Doppler by flow noise or cerebral circulatory disorder
- 10/2/20 - 1 formulario, 24 itemgroups, 201 items, 2 idiomas
Itemgroups: Cardiologic medical history and findings, Angina pectoris symptoms, Signs for heart failure, Myocardial Infarction History, Cardiac Arrhythmias, Medical History: diagnostic cardiac catheter, Medical History: coronary angioplasty, Medical history: electrophysiological diagnosis/therapy, Medical history: cardiac pre-operation, Current medication and dosage, Current medication name and dosage, Cardiac risk factors, Arteriosclerosis, Other diseases, Other complaints, Physical examination: general, Physical examination: cor, Physical examination: pulmo, Edemas, Physical examination: arteries, Physical examination: venous system, Physical examination: Scar conditions, Other pathological examination findings, Signature

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