Keywords
Routine documentation ×
Medical History Taking ×
Show more Keywords
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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- 6/4/17 - 1 form, 3 itemgroups, 33 items, 2 languages
Itemgroups: Maternal Family History, Paternal Family History, Siblings Family History
- 5/21/14 - 1 form, 13 itemgroups, 111 items, 2 languages
Itemgroups: GENERAL, EYE, EAR, NOSE, MOUTH, RESPIRATORY, CARDIOVASCULAR, GASTROINTESTINAL, GENITOURINARY, MUSCULOSKELETAL, NEUROLOGIC, PAIN, GERIATRIC
- 3/5/17 - 1 form, 13 itemgroups, 77 items, 1 language
Itemgroups: Patient data, Vital Signs, Medical History, Medication, Operative Surgical Procedures, Pregnancy, Pregnancy, Medical History, Physical Examination, Ultrasonography, Diagnosis, Procedure, Signature
- 2/10/20 - 1 form, 24 itemgroups, 201 items, 2 languages
Itemgroups: Cardiologic medical history and findings, Angina pectoris symptoms, Signs for heart failure, Myocardial Infarction History, Cardiac Arrhythmias, Medical History: diagnostic cardiac catheter, Medical History: coronary angioplasty, Medical history: electrophysiological diagnosis/therapy, Medical history: cardiac pre-operation, Current medication and dosage, Current medication name and dosage, Cardiac risk factors, Arteriosclerosis, Other diseases, Other complaints, Physical examination: general, Physical examination: cor, Physical examination: pulmo, Edemas, Physical examination: arteries, Physical examination: venous system, Physical examination: Scar conditions, Other pathological examination findings, Signature
- 5/31/19 - 1 form, 8 itemgroups, 74 items, 2 languages
Itemgroups: Pregnancy, Childbirth, Postpartum development, Kindergarten / school, Puberty stage, Other information, Physical examination basic information, Physical examination (further information)
- 3/22/18 - 6 forms, 5 itemgroups, 44 items, 1 language
Itemgroups: Eye refractometry , Intraocular pressure , Subjective refraction , Eyeglasses , medical history

Contact Lenses

2 itemgroups, 28 items31

Intraocular pressure

1 itemgroup, 10 items31

Photoropter

1 itemgroup, 28 items31

Eyeglasses

1 itemgroup, 26 items31