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Routine documentation ×
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Sommario
  1. 1. Test clinico
  2. 2. Documentazione di routine
  3. 3. Registro / studio di coorte
  4. 4. Garanzia di qualità
  5. 5. Dati Standard
  6. 6. Risultato segnalato dal paziente
  7. 7. Specialità mediche
    1. 7.1. Anestesiologia
    1. 7.2. Dermatologia
    1. 7.3. orecchio naso gola
    1. 7.4. Geriatria
    1. 7.5. Ginecologia / Ostetricia
    1. 7.6. Medicina Interna
      1. Ematologia
      1. Malattie infettive
      1. Cardiologia / Angiologia
      1. pneumologia
      1. Gastroenterologia
      1. Nefrologia
      1. Endocrinologia / Malattie metaboliche
      1. Reumatologia
    1. 7.7. Neurologia
    1. 7.8. Oftalmologia
    1. 7.9. Cure palliative
    1. 7.10. Patologia / Forense
    1. 7.11. Pediatria
    1. 7.12. Psichiatria / Psicosomatica
    1. 7.13. Radiologia
    1. 7.14. Chirurgia
      1. Chirurgia generale / viscerale
      1. Neurochirurgia
      1. Chirurgia plastica
      1. Chirurgia toracica
      1. Trauma / Ortopedia
      1. Chirurgia vascolare
    1. 7.15. Urologia
    1. 7.16. Medicina odontoiatrica / OMS
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Deutscher Diabetes Risiko Test DIfE - Deutscher Diabetes Risiko Test

- 25/08/16 - 1 modulo, 1 ItemGroup, 5 elementi, 2 lingue
ItemGroup: German Diabetes-Risk-Test
Extract of the German Diabetes Risk Test. Auszug aus DRT. Mit Hilfe des vom Deutschen Institut für Ernährungsforschung Potsdam-Rehbrücke (DIfE) entwickelten Risiko-Tests können Sie Ihr persönliches Risiko ermitteln, innerhalb der nächsten 5 Jahre an einem Typ-2-Diabetes zu erkranken. Der Test ist nicht anwendbar, wenn bei Ihnen bereits ein Diabetes bekannt ist. Source: www.dife.de

Eligibility Diabetes NCT02500706

- 31/08/15 - 1 modulo, 3 itemgroups, 9 elementi, 1 linguaggio
Itemgroups: Inclusion Criteria, Exclusion Criteria, Inclusion Criteria
Efficacy and Safety of Faster-acting Insulin Aspart Compared to NovoRapid® Both in Combination With Insulin Degludec in Adults With Type 1 Diabetes; ODM derived from: https://clinicaltrials.gov/show/NCT02500706

Eligibility Diabetes Mellitus NCT01876485

- 31/08/15 - 1 modulo, 2 itemgroups, 14 elementi, 1 linguaggio
Itemgroups: Inclusion Criteria, Exclusion Criteria
Point-of-care Health Literacy and Activation Information to Improve Diabetes Care; ODM derived from: https://clinicaltrials.gov/show/NCT01876485

AB MS PéD Stoffwechselamb University Hospital Muenster (UKM) Subform

- 06/11/16 - 1 modulo, 1 ItemGroup, 27 elementi, 1 linguaggio
ItemGroup: Metabolic Diseases
Hospital Routine Documentation Subform at the University Hospital Muenster

ATC A - Alimentary Tract and Metabolism

- 20/09/21 - 1 modulo, 1 ItemGroup, 1 elemento, 2 lingue
ItemGroup: Alimentary Tract and Metabolism
modified from epSOS value set 1.3.6.1.4.1.12559.11.10.1.3.1.42.24 http://www.epsos.eu http://www.whocc.no/atc_ddd_index/ WHO Collaborating Centre for Drug Statistics Methodology, ATC classification index with DDDs 2015. Oslo, Norway 2014 Copyright ATC index: WHO Collaborating Centre for Drug Statistics Methodology, Oslo, Norway Copying and distribution for commercial purposes is not allowed. German ATC Codes: Datenquelle des amtlichen ATC-Index mit DDD-Angaben: GKV-Arzneimittelindex im Wissenschaftlichen Institut der AOK (WIdO), AOK Bundesverband GbR Stand September 2015. Nur nicht-kommerzielle Nutzung zulässig

Eligibility Diabetes Mellitus, Type 2 NCT02481596

- 31/08/15 - 1 modulo, 5 itemgroups, 19 elementi, 1 linguaggio
Itemgroups: Criteria, Inclusion Criteria, Exclusion Criteria, Inclusion Criteria, Exclusion Criteria
Family-Focused Mobile Health Intervention; ODM ODM derived from: https://clinicaltrials.gov/show/NCT02481596

Eligibility Diabetes Mellitus, Type 2 NCT01984606

- 31/08/15 - 1 modulo, 3 itemgroups, 15 elementi, 1 linguaggio
Itemgroups: Inclusion Criteria, Inclusion Criteria, Exclusion Criteria
Efficacy and Safety of Empagliflozin Versus Sitagliptin in Patients With Type 2 Diabetes; ODM derived from: https://clinicaltrials.gov/show/NCT01984606

AAFP: Acute Pancreatitis Admission Order

- 25/07/16 - 1 modulo, 15 itemgroups, 42 elementi, 1 linguaggio
Itemgroups: Default Itemgroup, Status, Attending, Admitting Diagnosis, Condition, Allergies, Diet, Activity, Nursing, IV, Lab, Medications, Radiology, Consider, Other Order
AAFP: Acute Pancreatitis Admission Order , Standardizes Admission Orders, Author: Robert M. Wiprud, MD The primary purpose of these Ordersets is to decrease unnecessary variability and to improve quality through standardized Admission Orders. Developed by the Scott & White Clinic at College Station, Texas. Copyright © 2006 American Academy of Family Physicians. Physicians may photocopy or adapt for use in their own practices; all other rights reserved. Wiprud RM. Providing consistent care with standardized admission orders. Fam Pract Manag. September 2006: 49-52 See http://www.aafp.org/fpm/2006/0900/p49.html This ODM Form includes the twenty-third section ("AAFP: Acute Pancreatitis Admission Order ")

Feet Form University Hospital Muenster (UKM)

- 30/09/16 - 1 modulo, 4 itemgroups, 31 elementi, 1 linguaggio
Itemgroups: Patient Information, Anamnesis, Neurology, Foot Finding
Hospital Routine Documentation Form at the University Hospital Muenster. Original Form name: Fußbogen MS.

AAFP: Diabetic Ketoacidosis Admission Order

- 27/06/16 - 1 modulo, 15 itemgroups, 49 elementi, 1 linguaggio
Itemgroups: Default Itemgroup, Status, Attending, Admitting Diagnosis, Condition, Allergies, Diet, Activity, Nursing, Medications, IV, Lab, Mg, PO4, Other
AAFP: Diabetic Ketoacidosis Admission Order, Standardizes Admission Orders, Author: Robert M. Wiprud, MD The primary purpose of these Ordersets is to decrease unnecessary variability and to improve quality through standardized Admission Orders. Developed by the Scott & White Clinic at College Station, Texas. Copyright © 2006 American Academy of Family Physicians. Physicians may photocopy or adapt for use in their own practices; all other rights reserved. Wiprud RM. Providing consistent care with standardized admission orders. Fam Pract Manag. September 2006: 49-52 See http://www.aafp.org/fpm/2006/0900/p49.html This ODM Form includes the ninth section ("Diabetic Ketoacidosis Admission Order").

Diabetic cardiac surgery UKM - Diabetic chart

- 29/06/17 - 1 modulo, 2 itemgroups, 16 elementi, 2 lingue
Itemgroups: Patient demographics, Diabetes evaluation
Diabetic chart form converted to ODM format. Routine documentation of University Hospital of Münster. Publication granted by Univ.-Prof. Dr. med. Sven Martens.

Example 1 Discharge Letter Diabetic Retinopathy - Example 1

- 17/09/21 - 2 moduli, 13 itemgroups, 44 elementi, 1 linguaggio
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 elemento

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