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Table of contents
  1. 1. Clinical Trial
  2. 2. Routine Documentation
  3. 3. Registry/Cohort Study
  4. 4. Quality Assurance
  5. 5. Data Standard
  6. 6. Patient-Reported Outcome
  7. 7. Medical Specialty
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273 Search results.
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Family history - HIS

- 6/4/17 - 1 form, 3 itemgroups, 33 items, 2 languages
Itemgroups: Maternal Family History, Paternal Family History, Siblings Family History
Form from HIS OpenVistA

Physician letter Internal Medicine

- 7/9/16 - 1 form, 20 itemgroups, 313 items, 1 language
Itemgroups: 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
derived from http://www.arztbriefmanager.de/ (Dr. Wolfram Arends, Tutzing, Germany)

CDA discharge letter VHitG 1.50 CDA_discharge_letter_1.50 any condition - CDA discharge letter VHitG 1.50

- 9/27/12 - 1 form, 2 itemgroups, 55 items, 2 languages
Itemgroups: CDA Header, CDA R2 Body
ODM derived from http://www.bvitg.de/arztbrief.html

Physician letter surgery

- 9/20/21 - 1 form, 12 itemgroups, 173 items, 1 language
Itemgroups: Medical History , Finding, Clinical presentation, Initial therapy, Lab , Psychiatrics, Epicrisis, Consultation, Clinical course, Mobilization and social service, Patient education and discharge, Procedere
derived from http://www.arztbriefmanager.de/ (Dr. Wolfram Arends, Tutzing, Germany)

Der Notfalldatensatz der eGK nfdm - Der Notfalldatensatz der eGK

- 2/7/13 - 1 form, 72 itemgroups, 263 items, 2 languages
Itemgroups: Notfalldatensatz, Zusätzliche_Information, Diagnose_1, Identifier_Codiersystem_Diagnose_1, Diagnose_2, Identifier_Codiersystem_Diagnose_2, Diagnose_3, Identifier_Codiersystem_Diagnose_3, Diagnose_4, Identifier_Codiersystem_Diagnose_4, Diagnose_5, Identifier_Codiersystem_Diagnose_5, Diagnose_6, Identifier_Codiersystem_Diagnose_6, Diagnose_7, Identifier_Codiersystem_Diagnose_7, Diagnose_8, Identifier_Codiersystem_Diagnose_8, Diagnose_9, Identifier_Codiersystem_Diagnose_9, Diagnose_10, Identifier_Codiersystem_Diagnose_10, Diagnose_11, Identifier_Codiersystem_Diagnose_11, Diagnose_12, Identifier_Codiersystem_Diagnose_12, Diagnose_13, Identifier_Codiersystem_Diagnose_13, Diagnose_14, Identifier_Codiersystem_Diagnose_14, Diagnose_15, Identifier_Codiersystem_Diagnose_15, Diagnose_16, Identifier_Codiersystem_Diagnose_16, Diagnose_17, Identifier_Codiersystem_Diagnose_17, Diagnose_18, Identifier_Codiersystem_Diagnose_18, Diagnose_19, Identifier_Codiersystem_Diagnose_19, Diagnose_20, Identifier_Codiersystem_Diagnose_20, Allergie_Unverträglichkeiten_1, Allergie_Unverträglichkeiten_2, Allergie_Unverträglichkeiten_3, Allergie_Unverträglichkeiten_4, Allergie_Unverträglichkeiten_5, Allergie_Unverträglichkeiten_6, Allergie_Unverträglichkeiten_7, Allergie_Unverträglichkeiten_8, Allergie_Unverträglichkeiten_9, Allergie_Unverträglichkeiten_10, Behandelnder_Arzt_Institution_1, Behandelnder_Arzt_Institution_2, Behandelnder_Arzt_Institution_3, Einverständniserklärung_Arzt, Zu_benachrichtigende_Person_Institution_1, Zu_benachrichtigende_Person_Institution_2, Zu_benachrichtigende_Person_Institution_3, Versicherter, Besondere_Hinweise, Schwangerschaft, Implantate_1, Implantate_2, Implantate_3, Implantate_4, Implantate_5, Implantate_6, Implantate_7, Implantate_8, Implantate_9, Implantate_10
Der NFDM der eGK nach Lastenheft der BÄK, Version 1.2.0. Momentan ohne Medikation, daher unvollständig.

HIS Review of Systems - HIS

- 9/20/21 - 1 form, 13 itemgroups, 111 items, 2 languages
Itemgroups: GENERAL, EYE, EAR, NOSE, MOUTH, RESPIRATORY, CARDIOVASCULAR, GASTROINTESTINAL, GENITOURINARY, MUSCULOSKELETAL, NEUROLOGIC, PAIN, GERIATRIC
Form from HIS OpenVistA

Der Notfalldatensatz der eGK nfdm - Der Notfalldatensatz der eGK

- 3/13/15 - 1 form, 72 itemgroups, 263 items, 1 language
Itemgroups: Notfalldatensatz, Zusätzliche_Information, Diagnose_1, Identifier_Codiersystem_Diagnose_1, Diagnose_2, Identifier_Codiersystem_Diagnose_2, Diagnose_3, Identifier_Codiersystem_Diagnose_3, Diagnose_4, Identifier_Codiersystem_Diagnose_4, Diagnose_5, Identifier_Codiersystem_Diagnose_5, Diagnose_6, Identifier_Codiersystem_Diagnose_6, Diagnose_7, Identifier_Codiersystem_Diagnose_7, Diagnose_8, Identifier_Codiersystem_Diagnose_8, Diagnose_9, Identifier_Codiersystem_Diagnose_9, Diagnose_10, Identifier_Codiersystem_Diagnose_10, Diagnose_11, Identifier_Codiersystem_Diagnose_11, Diagnose_12, Identifier_Codiersystem_Diagnose_12, Diagnose_13, Identifier_Codiersystem_Diagnose_13, Diagnose_14, Identifier_Codiersystem_Diagnose_14, Diagnose_15, Identifier_Codiersystem_Diagnose_15, Diagnose_16, Identifier_Codiersystem_Diagnose_16, Diagnose_17, Identifier_Codiersystem_Diagnose_17, Diagnose_18, Identifier_Codiersystem_Diagnose_18, Diagnose_19, Identifier_Codiersystem_Diagnose_19, Diagnose_20, Identifier_Codiersystem_Diagnose_20, Allergie_Unverträglichkeiten_1, Allergie_Unverträglichkeiten_2, Allergie_Unverträglichkeiten_3, Allergie_Unverträglichkeiten_4, Allergie_Unverträglichkeiten_5, Allergie_Unverträglichkeiten_6, Allergie_Unverträglichkeiten_7, Allergie_Unverträglichkeiten_8, Allergie_Unverträglichkeiten_9, Allergie_Unverträglichkeiten_10, Behandelnder_Arzt_Institution_1, Behandelnder_Arzt_Institution_2, Behandelnder_Arzt_Institution_3, Einverständniserklärung_Arzt, Zu_benachrichtigende_Person_Institution_1, Zu_benachrichtigende_Person_Institution_2, Zu_benachrichtigende_Person_Institution_3, Versicherter, Besondere_Hinweise, Schwangerschaft, Implantate_1, Implantate_2, Implantate_3, Implantate_4, Implantate_5, Implantate_6, Implantate_7, Implantate_8, Implantate_9, Implantate_10
nfdm of eGK

Device Accountability Log: CRF Wisconsin Madison

- 11/17/21 - 1 form, 4 itemgroups, 17 items, 1 language
Itemgroups: Header, Device Accountability Log: Device Receipt, Device Accountability Log: Device Use, Device Accountability Log: Device Return/Repair/Destruction
ODM Form derived from: https://ictr.wisc.edu/CaseReptTempt. Template Name: Device Accountability Log. Case Report Form (CRF)/Source Document templates were created for University of Wisconsin-Madison researchers. These templates are consistent with the FDA's CDASH (Clinical Data Acquisition Standards Harmonization) standards. The CDASH standards identify those elements that should be captured on a Case Report Form (CRF). The forms serve only as templates, and must be edited to meet the study data collection needs as described in the protocol.

COVID-19 Status Form of Rhön-Klinikum Bad Neustadt - Pre-hospital COVID-19-Status Form

- 9/28/21 - 2 forms, 4 itemgroups, 26 items, 1 language
Itemgroups: Exclusion Criteria for inpatient admission, Immune Status COVID-19, Additional Information for risk assessment, Signature
COVID-19 Status forms of the Rhön-Klinikum Campus Bad Neustadt, Germany. * pre-hospital * on admission They are used for the assessment of COVID-19 risk before (via telephone) and on the day of admission. If one of the 4 exclusion criteria is answered with "yes" a physician/clinician has to make the decision about medical requirement for admission. Provided by the Medical Documentation Department of the Rhön-Klinikum Campus Bad Neustadt. German Description: Die Patienten werden zunächst vor dem stationären Aufenthalt angerufen und gefragt, ob sie in Quarantäne sind oder Kontaktpersonen oder vielleicht doch erkrankt. Wurde eine dieser Fragen mit Ja beantwortet, dann muss ein Arzt entscheiden und der Patient wird am Aufnahmetag nur mit medizinischer Notwendigkeit aufgenommen.

COVID-19 Status on admission day

3 itemgroups 14 items

documentation standard - breast cancer - talk after biopsy - HIS

- 9/27/21 - 1 form, 4 itemgroups, 44 items, 2 languages
Itemgroups: Administrative Information, Patienteninformation, geplante Operation, Patienteninformation II
documentation standard - breast cancer - gynecology, with friendly permission (Dr. Tio) - kooperatives Brustzentrum Münster, Bereich Senologie an der Klinik und Poliklinik für Frauenheilkunde und Geburtshilfe - Leitung: Dr. med. Joke Tio

SHORT STAY RECORD ID NOTE-ENDO - HIS

- 9/27/21 - 1 form, 4 itemgroups, 94 items, 2 languages
Itemgroups: SHORT STAY RECORD ID NOTE-ENDO, Chief Complaint, Physical Exam, Prior Medical History
Form from HIS OpenVista

ATC A - Alimentary Tract and Metabolism

- 9/20/21 - 1 form, 1 itemgroup, 1 item, 2 languages
Itemgroup: Alimentary Tract and Metabolism
modified from epSOS value set 1.3.6.1.4.1.12559.11.10.1.3.1.42.24 http://www.epsos.eu http://www.whocc.no/atc_ddd_index/ WHO Collaborating Centre for Drug Statistics Methodology, ATC classification index with DDDs 2015. Oslo, Norway 2014 Copyright ATC index: WHO Collaborating Centre for Drug Statistics Methodology, Oslo, Norway Copying and distribution for commercial purposes is not allowed. German ATC Codes: Datenquelle des amtlichen ATC-Index mit DDD-Angaben: GKV-Arzneimittelindex im Wissenschaftlichen Institut der AOK (WIdO), AOK Bundesverband GbR Stand September 2015. Nur nicht-kommerzielle Nutzung zulässig

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