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Table of contents
  1. 1. Clinical Trial
  2. 2. Routine Documentation
    1. 2.1. Admission
    1. 2.2. Medical History
    1. 2.3. Physical Examination
    1. 2.4. Assessment Score
    1. 2.5. Nursing Report
    1. 2.6. Apparative Diagnostics
    1. 2.7. Laboratory
    1. 2.8. Pathology/Histology
    1. 2.9. Consent
    1. 2.10. Therapy
    1. 2.11. Operative Report
    1. 2.12. Progress
    1. 2.13. Discharge Summary
    1. 2.14. Aftercare
  3. 3. Registry/Cohort Study
  4. 4. Quality Assurance
  5. 5. Data Standard
  6. 6. Patient-Reported Outcome
  7. 7. Medical Specialty
Selected data models

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271 Search results.
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eWundbericht (electronic wound report) - Body - Therapie (therapy)

- 9/20/21 - 4 forms, 9 itemgroups, 26 items, 2 languages
Itemgroups: 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
eWundbericht Prof. Dr. Ursula Hübner Forschungsgruppe Informatik im Gesundheitswesen Hochschule Osnabrück Fakultät Wirtschafts- und Sozialwissenschaften http://wiki.hl7.de/index.php/EWundbericht_(Projekt)

Body - Anamnese (medical history)

11 itemgroups 36 items

Body - Diagnose (diagnosis)

2 itemgroups 6 items

Header

3 itemgroups 18 items

NURSING ASSESSMENT (adult) - HIS

- 6/8/17 - 1 form, 36 itemgroups, 383 items, 2 languages
Itemgroups: 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
Form from HIS OpenVista

EHR4CR data inventory

- 9/20/21 - 1 form, 7 itemgroups, 75 items, 2 languages
Itemgroups: Demographics, Medical History, Diagnosis, Procedure, Findings, Laboratory Findings, Medication
Doods J, Botteri F, Dugas M, Fritz F; EHR4CR WP7. A European inventory of common electronic health record data elements for clinical trial feasibility. Trials. 2014 Jan 10;15:18 http://www.ncbi.nlm.nih.gov/pubmed/24410735

ePflegebericht (electronic nursing report) - Body

- 9/20/21 - 2 forms, 9 itemgroups, 52 items, 2 languages
Itemgroups: Care problem, Score, Care goal, Nursing procedure, Activities of daily living, Homecare Status, Social Environment, Legal Aspects, Medical information
ePflegebericht Prof. Dr. Ursula Hübner Forschungsgruppe Informatik im Gesundheitswesen Hochschule Osnabrück Fakultät Wirtschafts- und Sozialwissenschaften http://wiki.hl7.de/index.php?title=IG:Pflegebericht

Header

3 itemgroups 18 items

Physician referral letter

- 9/27/21 - 1 form, 21 itemgroups, 341 items, 2 languages
Itemgroups: 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
derived from http://www.arztbriefmanager.de/ (Dr. Wolfram Arends, Tutzing, Germany)

Clinical Data epSOS Patient summary

- 9/20/21 - 1 form, 15 itemgroups, 54 items, 3 languages
Itemgroups: 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
derived from http://www.epsos.eu/ and http://decor.nictiz.nl/art-decor/decor-datasets--epsos-

ACCF/AHA 2011 Key Data Elements and Definitions of a Base Cardiovascular Vocabulary for Electronic Health Records - Key Data Elements

- 6/25/21 - 1 form, 11 itemgroups, 110 items, 2 languages
Itemgroups: 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
http://circ.ahajournals.org/content/124/1/103.full

NRS pain

- 4/13/21 - 1 form, 1 itemgroup, 3 items, 2 languages
Itemgroup: Pain NRS
Numerical Rating Scale Pain

Physician letter (short)

- 3/15/21 - 1 form, 3 itemgroups, 302 items, 1 language
Itemgroups: Current episode, Diagnosis, Current medication
derived from http://www.arztbriefmanager.de/ (Dr. Wolfram Arends, Tutzing, Germany)

Blood Pressure (EHR Archetype) - openEHR-EHR-OBSERVATION.blood_pressure.v1

- 7/9/17 - 1 form, 1 itemgroup, 24 items, 10 languages
Itemgroup: openEHR-EHR-OBSERVATION.blood_pressure.v1.xml
Derived from www.openehr.org . Use to record all representations of systemic arterial blood pressure measurement, no matter which method or body location is used to record it. The archetype is intended to capture blood pressure measurements in all clinical scenarios - for example, self-measurement with a home blood pressure machine; an emergency assessment of systolic using palpation and a sphygmomanometer; measurements taken in clinical consultations or during exercise stress testing; and a series of measurements made by a machine in Intensive Care. There is a rich state model that supports interpretation of measurements through identifying patient position, exercise, confounding factors and angle of a tilt table in research. Named events have been limited to average over a 24 hour period, however templates can further constrain the default 'any event' to cater for specific requirements for blood pressure measurements such as recording Blood Pressure against specific points in time, or over a range of intervals (+/- mathematical functions).

BRADEN SCALE - BRADEN SCALE

- 6/15/17 - 1 form, 1 itemgroup, 7 items, 4 languages
Itemgroup: BRADEN SCALE
Kozier, Barbara, Glenora Erb, Shirlee Snyder, and Audrey Berman. Fundamentals of Nursing: Concepts, Process, and Practice. 8th ed. Upper Saddle Riveer, NJ: Pearson Education, 2008. 905-907.

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

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