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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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AAFP: Acute Myocardial Infarction Admission Order

- 6/26/16 - 1 form, 12 itemgroups, 56 items, 2 languages
Itemgroups: Default Itemgroup, Status, Attending, Admitting Diagnosis, Condition, Allergies, Diet, Activity, Nursing, Medications, Lab, Consider
AAFP: Acute Myocardial Infarction 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 second section ("Acute Myocardial Infarction Admission Order").

Kerndatensatz Herzinsuffizienz DZHI (Core data set heart failure CHFC) - Scores, Symptome und Zeichen von Herzinsuffizienz (Scores, Symptoms and signs heart failure)

- 3/24/20 - 1 form, 4 itemgroups, 15 items, 1 language
Itemgroups: Logistics, NYHA, LQ, Symptoms and signs of heart failure
Core data set on heart failure, developed by the Comprehensive Heart Failure Center (CHFC). The CHFC researches and treats the complex disease heart failure and its comorbidities in a comprehensive approach. This form contains information about scores, symptoms and signs of heart failure Kerndatensatz zu Herzinsuffizienz, entwickelt vom Deutschen Zentrum für Herzinsuffizienz (DZHI). Das DZHI erforscht und therapiert in einem ganzheitlichen Ansatz die Systemerkrankung Herzinsuffizienz samt ihrer Begleit- und Folgeerkrankungen. Dieses Formular enthält Informationen über Scores, Symptome und Zeichen einer Herzinsuffizienz.

Lab tests cardiac surgery UKM - Lab tests

- 7/10/17 - 1 form, 2 itemgroups, 22 items, 2 languages
Itemgroups: Patient demographics, Lab tests
Lab tests form converted to ODM format. Routine documentation of University Hospital of Münster. Publication granted by Univ.-Prof. Dr. med. Sven Martens.

Eligibility Hypertension NCT02047019

- 9/1/15 - 1 form, 2 itemgroups, 14 items, 1 language
Itemgroups: Inclusion Criteria, Exclusion Criteria
Monotherapy-Controlled Study of Nifedipine Gastrointestinal Therapeutic System and Candesartan Cilexetil in Combination in Subjects With Essential Hypertension Inadequately Controlled on Candesartan Cilexetil; ODM derived from: https://clinicaltrials.gov/show/NCT02047019

Eligibility Coronary Artery Disease NCT02327455

- 8/30/15 - 1 form, 2 itemgroups, 10 items, 1 language
Itemgroups: Inclusion Criteria, Exclusion Criteria
Integrated RF and B-mode Deformation Analysis for 4D Stress Echocardiography; ODM derived from: https://clinicaltrials.gov/show/NCT02327455

Cardiology Audit and Registration Data Standards for Coronary Care Unit [CCU]/Acute Coronary Syndrome [ACS] admissions. - CCU/ACS Data Standards

- 9/20/21 - 1 form, 10 itemgroups, 109 items, 1 language
Itemgroups: Demographics, Past History relevant to Coronary Artery Disease, Medication: pre hospital, Working Diagnosis, Investigations and Treatment, Medication during hospital stay, Outcome, Medication at discharge, Follow up, Medication at follow up
The main objective of each of the Expert Committees was to produce standardised data sets limited to less than 100 variables. The variables derived had to reflect current treatment guidelines, and also were to be of use for clinical audit, clinical care of patients, service planning and epidemiology. The process involved regular meetings of the Expert Committees, electronic communication between members, and consultation with specialist groups and cardiac societies represented by the European Society of Cardiology. The development of the draft data standards for the three modules was completed in April 2004.

Eligibility Essential Arterial Hypertension NCT02493322

- 8/31/15 - 1 form, 2 itemgroups, 15 items, 1 language
Itemgroups: Inclusion Criteria, Exclusion Criteria
Efficacy and Safety of Olmesartan Associated With Chlorthalidone in Essential Arterial Hypertension Control; ODM derived from: https://clinicaltrials.gov/show/NCT02493322

AF MS Angio LSTM Sub University Hospital Muenster (UKM) Subform

- 11/17/16 - 1 form, 3 itemgroups, 41 items, 1 language
Itemgroups: General information, Clinical data, Requested examinations
Hospital Routine Documentation Subform at the University Hospital Muenster. Original Form name: AF MS Angio LSTM Sub.

Heart failure summary record - Fixed components

- 9/20/21 - 1 form, 1 itemgroup, 4 items, 1 language
Itemgroup: Fixed components
Derived from public deliverables of SemanticHealthNet (http://www.semantichealthnet.eu/index.cfm/deliverables/) http://www.semantichealthnet.eu/SemanticHealthNet/assets/File/SHN%20288408%20D%201_2%20v2%20with%20Annexes.pdf

AAFP: Congestive Heart Failure Admission Order

- 6/26/16 - 1 form, 16 itemgroups, 67 items, 2 languages
Itemgroups: Default Itemgroup, Status, Attending, Admitting Diagnosis, Condition, Allergies, Diet, Activity, Nursing, Medications, IV, Lab, Diagnostic Studies, Consult, Patient Education, Other Orders
AAFP: Congestive Heart Failure 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 sixth section ("Congestive Heart Failure Admission Order").

Heart failure summary record - Occasional Updates

- 8/18/15 - 1 form, 10 itemgroups, 70 items, 1 language
Itemgroups: Social Circumstances, Lifestyle, Comorbidity, Primary Cause of Heart Failure, Cardiac Phenotype, ECG, Chest X-ray, Spirometry, Specialised Tests, Device Therapy
Derived from public deliverables of SemanticHealthNet (http://www.semantichealthnet.eu/index.cfm/deliverables/) http://www.semantichealthnet.eu/SemanticHealthNet/assets/File/SHN%20288408%20D%201_2%20v2%20with%20Annexes.pdf

Heart failure summary record - Frequent Updates (Monitoring)

- 8/18/15 - 1 form, 3 itemgroups, 38 items, 1 language
Itemgroups: Symptoms, Signs, Blood tests
Derived from public deliverables of SemanticHealthNet (http://www.semantichealthnet.eu/index.cfm/deliverables/) http://www.semantichealthnet.eu/SemanticHealthNet/assets/File/SHN%20288408%20D%201_2%20v2%20with%20Annexes.pdf

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