Keywords
Routine documentation ×
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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
Selected data models

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- 3/11/19 - 1 form, 6 itemgroups, 55 items, 1 language
Itemgroups: Case data, Medical Department data, Diagnosis details, Procedure Details, PIA-Documentation of services, Modell project
- 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
- 4/19/16 - 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

Header

3 itemgroups, 18 items31
- 5/23/17 - 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
- 6/4/17 - 1 form, 3 itemgroups, 33 items, 2 languages
Itemgroups: Maternal Family History, Paternal Family History, Siblings Family History