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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
    1. 7.1. Anesthesiology
    1. 7.2. Dermatology
    1. 7.3. ENT
    1. 7.4. Geriatrics
    1. 7.5. Gynecology/Obstetrics
    1. 7.6. Internal Medicine
      1. Hematology
      1. Infectious Diseases
      1. Cardiology/Angiology
      1. Pneumology
      1. Gastroenterology
      1. Nephrology
      1. Endocrinology/Metabolic Diseases
      1. Rheumatology
    1. 7.7. Neurology
    1. 7.8. Ophthalmology
    1. 7.9. Palliative Care
    1. 7.10. Pathology/Forensics
    1. 7.11. Pediatrics
    1. 7.12. Psychiatry/Psychosomatics
    1. 7.13. Radiology
    1. 7.14. Surgery
      1. General/Visceral Surgery
      1. Neurosurgery
      1. Plastic Surgery
      1. Thoracic Surgery
      1. Trauma/Orthopedics
      1. Vascular Surgery
    1. 7.15. Urology
    1. 7.16. Dental Medicine/OMS
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Example 1 Discharge Letter CRVO

- 2/5/18 - 1 form, 10 itemgroups, 37 items, 1 language
Itemgroups: Administrative data, Diagnosis Right eye, Visual Acuity, Intraocular pressure, Slit lamp biomicroscopy Right eye, Ophthalmoscopy Right eye, Ophthalmoscopy Left eye, SD- OCT Right eye, SD- OCT Left eye, Evaluation; Treatment
Routine documentation for Central Retinal Vein Occlusion. Eye clinic, University Clinic of Muenster.

Example 2 Discharge Letter CRVO

- 2/5/18 - 1 form, 8 itemgroups, 28 items, 1 language
Itemgroups: Administrative data, Diagnosis, Visual Acuity, Intraocular pressure, Slit lamp biomicroscopy, SD- OCT Left eye, SD- OCT Right eye, Evaluation; Treatment
Routine documentation for Central Retinal Vein Occlusion. Eye clinic, University Clinic of Muenster.

Example 3 Discharge Letter CRVO

- 2/5/18 - 1 form, 8 itemgroups, 28 items, 1 language
Itemgroups: Administrative data, Diagnosis, Visual Acuity, Intraocular pressure, Slit lamp biomicroscopy, Ophthalmoscopy, OCT Macula, Evaluation; Treatment
Routine documentation for Central Retinal Vein Occlusion. Eye clinic, University Clinic of Muenster.

Findings Fidus Ophthalmology UKM - Orthoptics and Eye Movements

- 3/22/18 - 5 forms, 2 itemgroups, 18 items, 1 language
Itemgroups: Orthoptics , Eye Movements
Items used as routine documentation by Ophthalmology of University Clinic Muenster. ODM dereived from Befund.

Slit lamp Examination

2 itemgroups 22 items

Test Methods

1 itemgroup 12 items

Visual Fields

1 itemgroup 12 items

Fundus

1 itemgroup 12 items

Example 1 Discharge Letter Diabetic Retinopathy - Example 1

- 9/17/21 - 2 forms, 13 itemgroups, 44 items, 1 language
Itemgroups: Administrative data, Diagnosis Right eye, Diagnosis Left eye, Vision, Intraocular pressure, Slit lamp biomicroscopy Right eye, Slit lamp biomicroscopy Left eye, Ophthalmoscopy Right eye, Ophthalmoscopy Left eye, SD- OCT Right eye, SD- OCT Left eye, Fluorescein Angiography, Evaluation; Treatment
Routine documentation for Diabetic Retinopathy. Eye clinic, University Clinic of Muenster.

Example 2

0 itemgroup 0 item

Example 2 Discharge Letter AMD

- 9/17/21 - 1 form, 14 itemgroups, 46 items, 1 language
Itemgroups: Administrative data, Diagnosis Right eye, Diagnosis Left eye, Vision, Intraocular pressure, Slit lamp biomicroscopy Right eye, Slit lamp biomicroscopy Left eye, Ophthalmoscopy Right eye, Ophthalmoscopy Left eye, OCT Macula Right eye, OCT Macula Left eye, Fluorescein Angiography, Indocyanine green angiography, Evaluation; Treatment
Routine documentation for Age-Related Macular Degeneration. Eye clinic, University Clinic of Muenster.

Example 2 Discharge Letter Diabetic Retinopathy - Example 2

- 2/5/18 - 2 forms, 12 itemgroups, 36 items, 1 language
Itemgroups: Administrative data, Diagnosis Both eyes, Diagnosis Left eye, Therapeutic procedures, Vision, Intraocular pressure, Slit lamp biomicroscopy Both eyes, Ophthalmoscopy Right eye, Ophthalmoscopy Left eye, OCT Macula, Fluorescein Angiography, Evaluation; Treatment
Routine documentation for Diabetic Retinopathy. Eye clinic, University Clinic of Muenster.

Example 2

0 itemgroup 0 item

Example 3 Discharge Letter Diabetic Retinopathy - Example 3

- 2/5/18 - 2 forms, 9 itemgroups, 25 items, 1 language
Itemgroups: Administrative data, Diagnosis Both eyes, Diagnosis Right eye, Diagnosis Left eye, Vision, Intraocular pressure, Slit lamp biomicroscopy Right eye, Slit lamp biomicroscopy Left eye, Evaluation; Treatment
Routine documentation for Diabetic Retinopathy. Eye clinic, University Clinic of Muenster

Example 2

0 itemgroup 0 item

Example 1 Discharge Letter AMD

- 2/5/18 - 1 form, 15 itemgroups, 50 items, 1 language
Itemgroups: Administrative data, Diagnosis Right eye, Diagnosis Left eye, Vision, Intraocular pressure, Slit lamp biomicroscopy Right eye, Slit lamp biomicroscopy Left eye, Ophthalmoscopy Right eye, Ophthalmoscopy Left eye, SD- OCT Right eye, SD- OCT Left eye, Autofluorescence, Fluorescein Angiography, Indocyanine green angiography, Evaluation; Treatment
Routine documentation for Age-Related Macular Degeneration. Eye clinic, University Clinic of Muenster.

Example 3 Discharge Letter AMD

- 2/5/18 - 1 form, 13 itemgroups, 41 items, 1 language
Itemgroups: Administrative data, Diagnosis Right eye, Diagnosis Left eye, Vision, Intraocular pressure, Slit lamp biomicroscopy Right eye, Slit lamp biomicroscopy Left eye, Ophthalmoscopy Right eye, Ophthalmoscopy Left eye, OCT Macula Right eye, OCT Macula Left eye, Fluorescein Angiography; Indocyanine green angiography, Evaluation; Treatment
Routine documentation for Age-Related Macular Degeneration. Eye clinic, University Clinic of Muenster

Discharge Letter AMD Example 1

- 10/23/17 - 1 form, 15 itemgroups, 50 items, 1 language
Itemgroups: Administrative data, Diagnosis Right eye, Diagnosis Left eye, Vision, Intraocular pressure, Slit lamp biomicroscopy Right eye, Slit lamp biomicroscopy Left eye, Ophthalmoscopy Right eye, Ophthalmoscopy Left eye, SD- OCT Right eye, SD- OCT Left eye, Autofluorescence, Fluorescein Angiography, Indocyanine green angiography, Evaluation; Treatment
Routine documentation from Eye clinic University Clinic of Muenster. Provided by Dr. Maged Alnawaiseh.

Measurements Fidus Ophthalmology UKM - Contact Lenses

- 3/22/18 - 6 forms, 2 itemgroups, 28 items, 1 language
Itemgroups: Contact Lenses , Eye refractometry
Items used as routine documentation by Ophthalmology of University Clinic Muenster. ODM dereived from Messungen.

Autorefraction

5 itemgroups 44 items

Intraocular pressure

1 itemgroup 10 items

Photoropter

1 itemgroup 28 items

Eyeglasses

1 itemgroup 26 items

Keratometer

0 itemgroup 0 item

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