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- Routine documentation (271)
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Table des matières
Modèles de données sélectionnés
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271 Résultats de recherche.
Groupes Item: 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 Groupes Item 36 Eléments de donnéesBody - Diagnose (diagnosis)
2 Groupes Item 6 Eléments de donnéesHeader
3 Groupes Item 18 Eléments de données Groupes Item: 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
Groupes Item: Demographics, Medical History, Diagnosis, Procedure, Findings, Laboratory Findings, Medication
Groupes Item: Care problem, Score, Care goal, Nursing procedure, Activities of daily living, Homecare Status, Social Environment, Legal Aspects, Medical information
Header
3 Groupes Item 18 Eléments de données Groupes Item: 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
Groupes Item: 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
Groupes Item: 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
Groupe Item: Pain NRS
Groupes Item: Current episode, Diagnosis, Current medication
Groupe Item: openEHR-EHR-OBSERVATION.blood_pressure.v1.xml
Groupe Item: BRADEN SCALE
Groupes Item: Maternal Family History, Paternal Family History, Siblings Family History