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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- 9/20/21 - 4 forms, 11 itemgroups, 36 items, 2 languages
Itemgroups: Wound assessment,Patient status,Psychosocial factors,Risk factors,Risk Assessment,Hygiene assessment,Skin assessment,Healed wounds,Adherence,Physical impairment,Psychosocial impairment

Header

11 itemgroups 36 items

Body - Therapie (therapy)

11 itemgroups 36 items

Body - Diagnose (diagnosis)

11 itemgroups 36 items
- 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

Header

9 itemgroups 52 items
- 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
- 7/20/19 - 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
- 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
- 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

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