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OPS Chapter 5 SURGERIES

- 2021-09-20 - 1 Formulär, 1 Item-grupp, 1 Dataelement, 2 Språk
Item-grupp: OPS 5
derived from: OPS - German Procedure Classification https://www.dimdi.de/static/en/klassi/ops/index.htm DIMDI publishes the OPS classification on behalf of the Federal Ministry of Health; it is in the public domain. Its use in inpatient care is laid down in 301 Volume V of the German Social Security Code (SGB V) and for surgical procedures in the outpatient sector in 295 SGB V.

CDASH Medical History

- 2018-06-20 - 1 Formulär, 4 Item-grupper, 13 Dataelement, 3 Språk
Item-grupper: General information, High Blood Pressure, Appendectomy, Other
modified from http://www.cdisc.org

Montreal Cognitive Assessment (MoCA) - MoCA

- 2017-11-28 - 1 Formulär, 10 Item-grupper, 30 Dataelement, 7 Språk
Item-grupper: Alternating Trail Making, Visuoconstructional Skills, Naming, Memory, Attention, Language, Abstraction, Delayed Recall, Orientation, MoCA
https://en.wikipedia.org/wiki/Montreal_Cognitive_Assessment

Modified Rankin Scale

- 2017-11-28 - 1 Formulär, 1 Item-grupp, 1 Dataelement, 4 Språk
Item-grupp: Modified Rankin Scale
https://en.wikipedia.org/wiki/Modified_Rankin_Scale The modified Rankin Scale (mRS) is a commonly used scale for measuring the degree of disability or dependence in the daily activities of people who have suffered a stroke or other causes of neurological disability. It has become the most widely used clinical outcome measure for stroke clinical trials.

Barthel-Index

- 2017-11-23 - 1 Formulär, 1 Item-grupp, 11 Dataelement, 4 Språk
Item-grupp: Barthel Index
https://de.wikipedia.org/wiki/Barthel-Index

APGAR Score (EHR Archetype) - openEHR-EHR-OBSERVATION.apgar.v1

- 2017-07-08 - 1 Formulär, 1 Item-grupp, 14 Dataelement, 9 Språk
Item-grupp: openEHR-EHR-OBSERVATION.apgar.v1
Derived from www.openehr.org . Allows recording of an assessment of the state of a neonate explicitly as 1, 2, 3, 5 and/or 10 minute events after birth, plus additional events as required. Usual practice is to document the Apgar score at 1 and 5 minutes; further scores can be recorded as clinically indicated. It is possible to record the Apgar score at any time after birth using this archetype. Common clinical practice is to record all 5 parameters plus the total, however this archetype allows any partial information to be recorded, if that is all that is available eg from historical data. If the total is to be calculated, it is necessary for all 5 ordinal values to be recorded. The total is the sum of the five ordinal values (min 0, max 10). It is recognised that mnemonic learning aid for APGAR is commonly taught. For example, in English: A for Appearance (skin color), P for Pulse (heart rate), G for Grimace (reflex irritability), A for Activity (muscle tone), and R for Respiration. As this is not universally applicable for all languages, it is suggested that this mnemonic can be applied by renaming the data elements within templates if desired for a specific clinical scenario.

History of Stroke - Ischemic Infarction and Hemorrhage Protocol PhenX Toolkit

- 2016-04-26 - 1 Formulär, 1 Item-grupp, 33 Dataelement, 1 Språk
Item-grupp: PhenX - history of stroke protocol
The Stroke Symptoms Form from the Jackson Heart Study is an interviewer-administered questionnaire that captures the history of stroke(s) and associated symptoms such as slurred speech, double vision, loss of vision and paralysis. ODM derived from: https://cde.nlm.nih.gov Primary source: https://www.phenxtoolkit.org/ Recent publication: Hendershot, T., Pan, H., Haines, J., Harlan, W.R., Marazita, M.L., McCarty, C.A., Ramos, E.M., and Hamilton, C.M. (2015) Using the PhenX toolkit to add standard measures to a study. Curr. Protoc. Hum. Genet. 86:1.21.1-1.21.17. doi: 10.1002/0471142905.hg0121s86 Permission to publish granted by Carol M. Hamilton.

Quality Assurance Coronary Angiography and Percuteanous Intervention (PCI) - Basic (AQUA) - Quality assurance Coronary Angiography and Percuteanous Intervention (PCI) - Basic (AQUA)

- 2015-08-12 - 1 Formulär, 5 Item-grupper, 32 Dataelement, 2 Språk
Item-grupper: Basisdokumentation, Patient, Aktuelle kardiale Anamnese(vor der ersten Prozedur), Verlauf, Entlassung
Documentation form for quality assurance in German Health Care by the Institute for Applied Quality Improvement and Research in Health Care (Aqua), https://www.aqua-institut.de/en/home. Internal Aqua form version: 21-3-B Specification 2015 V02

CDASH Vital Signs

- 2018-06-20 - 1 Formulär, 2 Item-grupper, 14 Dataelement, 2 Språk
Item-grupper: General information, Vital Sign
modified from http://www.cdisc.org

CDASH Concomitant Medication - Concomitant medication

- 2018-06-20 - 1 Formulär, 2 Item-grupper, 9 Dataelement, 2 Språk
Item-grupper: General information, Details
translated and modified from CDASH 2011-10-24 http://www.cdisc.org

CDASH Adverse Event - Adverse Event

- 2020-03-09 - 1 Formulär, 2 Item-grupper, 18 Dataelement, 2 Språk
Item-grupper: General information, Details Adverse Event
translated and modified from CDASH Adverse Event 2011-10-24 http://www.cdisc.org/

CDASH Demographics - Demographics

- 2021-09-20 - 1 Formulär, 1 Item-grupp, 9 Dataelement, 2 Språk
Item-grupp: Demographics
modified from http://www.cdisc.org

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