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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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ATC L - Antineoplastic and immunomodulating agents

- 9/20/21 - 1 form, 1 itemgroup, 1 item, 2 languages
Itemgroup: Antineoplastic and immunomodulating agents
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-Index: 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

ePrescription epSOS

- 9/20/21 - 1 form, 2 itemgroups, 26 items, 3 languages
Itemgroups: Prescription, Prescriber
derived from http://www.epsos.eu/ and http://decor.nictiz.nl/art-decor/decor-datasets--epsos-

ATC N - Nervous System

- 9/20/21 - 1 form, 1 itemgroup, 1 item, 2 languages
Itemgroup: Nervous System
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-Index: 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

Peripheral Atherosclerotic Vascular Disease EHR key data elements - Peripheral Atherosclerotic Disease (PAD) - General data elements

- 9/20/21 - 1 form, 5 itemgroups, 103 items, 2 languages
Itemgroups: Demographics, Patient history, Physical evaluation, Laboratory Procedures, Current pharmacologic therapy
2012 ACCF / AHA Data Standard Peripheral Atherosclerotic Disease (PAD) General data elements see http://www.ncbi.nlm.nih.gov/pubmed/22144570

Heart failure summary record - Fixed components

- 9/20/21 - 1 form, 1 itemgroup, 4 items, 1 language
Itemgroup: Fixed components
Derived from public deliverables of SemanticHealthNet (http://www.semantichealthnet.eu/index.cfm/deliverables/) http://www.semantichealthnet.eu/SemanticHealthNet/assets/File/SHN%20288408%20D%201_2%20v2%20with%20Annexes.pdf

Electroconvulsive Therapy (ECT) Documentation UKM - EKT PSYCH MS (Version 95)

- 9/20/21 - 1 form, 3 itemgroups, 26 items, 1 language
Itemgroups: ECT, Billing and Coding of Current Therapy Units, Further Procedures
EKT PSYCH MS (Version 95) converted to ODM format. Routine documentation of University Hospital Muenster

Rehabilitation letter cardiology

- 9/17/21 - 1 form, 27 itemgroups, 520 items, 1 language
Itemgroups: Medical history, Vegetative medical history, Risk factors and risk behavior, Family medical history, Current medical complaints, Subjective impairments in daily living and occupation, Understanding of disease and coping strategies, Treatment at admittance, Patient social history, Patient occupational history, Sick leave, Physical examination, Functional and activity impairment, Psychosomatic assessment, Laboratory procedures, ECG, Exercise Test at admittance, 24hour ECG, 24hour blood pressure measurement, Cardiologic Ultrasound, Rehabilitation diagnosis, Rehabilitation goals, Rehabilitation course and epicrisis, Rehabilitation outcome and discharge assessment, Social epicrisis, Patient self-assessment, Procedure
derived from http://www.arztbriefmanager.de/ (Dr. Wolfram Arends, Tutzing, Germany)

AAFP: Pelvic Inflammatory Disease Admission Order

- 9/17/21 - 1 form, 12 itemgroups, 31 items, 1 language
Itemgroups: Default Itemgroup, Status, Attending, Admitting Diagnosis, Condition, Allergies, Diet, Activity, Nursing, Medications, IV, Lab
AAFP: Pelvic Inflammatory Disease Admission Order, Standardizes Admission Orders, Author: Robert M. Wiprud, MD The primary purpose of these Ordersets is to decrease unnecessary variability and to improve quality through standardized Admission Orders. Developed by the Scott & White Clinic at College Station, Texas. Copyright © 2006 American Academy of Family Physicians. Physicians may photocopy or adapt for use in their own practices; all other rights reserved. Wiprud RM. Providing consistent care with standardized admission orders. Fam Pract Manag. September 2006: 49-52 See http://www.aafp.org/fpm/2006/0900/p49.html This ODM Form includes the twenty-sixth section ("AAFP: Pelvic Inflammatory Disease Admission Order")

HIS surgery complication prostate cancer - HIS

- 9/17/21 - 1 form, 5 itemgroups, 21 items, 2 languages
Itemgroups: Admininstrative Daten, Komplikationsbogen, Postoperativer Wundinfekt, Postoperative Revisionseingriffe, Clavien-Dindo Klassifikation
HIS form from Soarian. Urologie Erlangen" with friendly permission of the urology Erlangen (Prof. Wullich) and the medical informatics department Erlangen (PD Dr. Bürkle)

HIS autopsy form prostate cancer - HIS

- 9/17/21 - 1 form, 7 itemgroups, 47 items, 2 languages
Itemgroups: Admininstrative Daten, Tumordiagnose, Autopsiedaten, Tumorausbreitung, Fernmetastasen, TNM-Klassifikation, Tumorhistologie
HIS form from Soarian. Urologie Erlangen" with friendly permission of the urology Erlangen (Prof. Wullich) and the medical informatics department Erlangen (PD Dr. Bürkle)

HIS finding prostate biopsy prostate cancer - HIS

- 6/18/21 - 1 form, 8 itemgroups, 87 items, 2 languages
Itemgroups: Patientenaufkleber groß, Urologische Daten, Pathobefund, Klinik, Aufnahmedaten, Partin Tabellen, Vorerkrankungen, Tumorkonferenz
HIS form ORBIS. with friendly permission form urology (Prof. Semjonow) and medical informatics department (Dr. Breil)

HIS course of treatment - tumortherapy breast cancer - HIS

- 4/13/21 - 1 form, 9 itemgroups, 54 items, 2 languages
Itemgroups: Patientenaufkleber groß, Tumorverlaufsbogen, Tumorbiologie, Hormonrezeptorenstatus, Diagnostik, Anamnese, Therapie, Rezepte, Nächster Zyklus
HIS form ORBIS. with friendly permission form gynecology (Dr. Tio) and medical informatics department (Dr. Breil)

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