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eWundbericht (electronic wound report) - Body - Therapie (therapy)

- 20/09/21 - 4 moduli, 9 itemgroups, 26 elementi, 2 lingue
Itemgroups: Treatment goals, Treatment plan, Equipment and Resources, Healing and therapy process, Hygiene activity, Wound protection, Therapy, causal, Education of patient and relatives, Treatment results, preliminary
eWundbericht Prof. Dr. Ursula Hübner Forschungsgruppe Informatik im Gesundheitswesen Hochschule Osnabrück Fakultät Wirtschafts- und Sozialwissenschaften http://wiki.hl7.de/index.php/EWundbericht_(Projekt)

Body - Anamnese (medical history)

11 itemgroups 36 elementi

Body - Diagnose (diagnosis)

2 itemgroups 6 elementi

Header

3 itemgroups 18 elementi

NURSING ASSESSMENT (adult) - HIS

- 08/06/17 - 1 modulo, 36 itemgroups, 383 elementi, 2 lingue
Itemgroups: Nursing Assessment, Neurological status, GLASGOW COMA SCALE, PUPILS, ORIENTATION, Cardiovascular, Eyes Ear Nose & Throat, EYES, EARS, NOSE, THROAT, Respiratory, Gastrointestinal, Genitourinary, Musculoskeletal, Skin, PRESSURE ULCER ASSESSMENT, Wound(s), INCISION(S), Nutrition, IV Therapy, Safety, Hendrich II Fall Risk Assessment, INTERVENTIONS, IMPAIRED MOBILITY RISK, ALTERED ELIMINATION, HIGH RISK FALL MEDICATIONS (ANTIEPILEPTICS & BENZODIAZEPINES), INTERVENTIONS (FOR ONCOLOGY USE ONLY), ONN Unit specific, Antepartum specific, Post partum specific, Post Surgical, ADOLESCENT INTERACTION, GERIATRIC INTERVENTION (65+), Hendrich Fall Risk, SUGGESTED INTERVENTIONS
Form from HIS OpenVista

BRADEN SCALE - BRADEN SCALE

- 15/06/17 - 1 modulo, 1 ItemGroup, 7 elementi, 4 lingue
ItemGroup: BRADEN SCALE
Kozier, Barbara, Glenora Erb, Shirlee Snyder, and Audrey Berman. Fundamentals of Nursing: Concepts, Process, and Practice. 8th ed. Upper Saddle Riveer, NJ: Pearson Education, 2008. 905-907.

Nursing relevant Questions UKM - Nursing relevant Questions UKM

- 06/04/17 - 1 modulo, 10 itemgroups, 47 elementi, 11 lingue
Itemgroups: Resting; Sleeping, moving, Getting washed or dressed, Eating and Drinking, Elimination, communication, conscious, meaning of life, Examinations, Miscellaneous
Nursing relevant Questions are a set of questions from the brochure „Pflegerelevante Fragen“, used in University Hospital of Muenster, Germany. The aim of the brochure is to ease the communication between the nursing team and the international patients, who do not speak german. Broschüre "Pflegerelevante Fragen" des Internationalen Patientenmanagements des Universitätsklinikums Münster. Permission granted by Dr. Hofbauer. Source: International Patient Management, University Hospital of Muenster, Germany

Delirium Screening UKHD - Nu-DESC -DE

- 01/02/22 - 1 modulo, 2 itemgroups, 7 elementi, 1 linguaggio
Itemgroups: Delir-Symptomatik, Resultat
A screening tool designed for nurses to use at the end of their shift to identify patients with delirium, derived from the Confusion Rating Scale (CRS). Raters reference behaviors that they have witnessed in the patient or that the patient’s nurse has witnessed during their shift to score the Nu-DESC. The Nu-DESC can be rated one or more times daily. This work was created by the NIDUS Measurement and Harmonization Core (Leaders Richard N. Jones, ScD and Dale M. Needham, MD, PhD), funded by NIA R24AG054259, and is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/. Requested citation: NIDUS-Network for Investigation of Delirium: Unifying Scientists, https://deliriumnetwork.org/ Instrument and instructions available at http://dx.doi.org/10.1016/j.jpainsymman.2004.07.009

Dekurs HAUT Infusion MS University Hospital Muenster (UKM)

- 20/09/21 - 1 modulo, 5 itemgroups, 20 elementi, 1 linguaggio
Itemgroups: Diagnosis, Last Examinations, Physician's Documentation, Nursing Documentation, Comments
Hospital Routine Documentation Form at the University Hospital Muenster. Original Form name: Dekurs HAUT Infusion.

NURSING ASSESSMENT (pedi) - HIS

- 20/09/21 - 1 modulo, 32 itemgroups, 326 elementi, 2 lingue
Itemgroups: Child Nursing Assessment, Neurological status, GLASGOW COMA SCALE ADULT, PUPILS, GLASGOW COMA SCALE CHILD, ORIENTATION, Cardiovascular, Eyes Ear Nose and Throat, EYES, EARS, NOSE, THROAT, Respiratory, Gastrointestinal, Genitourinary, Musculoskeletal, Skin, INCISION(S), Wound(s), Nutrition, IV Therapy, Safety, Pediatric Fall Risk Assessment, INTERVENTIONS, IMPAIRED MOBILITY RISK, ALTERED ELIMINATION, HIGH RISK FALL MEDICATIONS (ANTIEPILEPTICS & BENZODIAZEPINES), Hendrich II Fall Risk Assessment, ONN Unit specific, Post Surgical, ADOLESCENT INTERACTION, GERIATRIC INTERVENTION (65+)
Form from HIS OpenVista

Stoma Dokumentationsbogen MS University Hospital Muenster (UKM)

- 08/10/18 - 1 modulo, 4 itemgroups, 39 elementi, 1 linguaggio
Itemgroups: Hospital Stay, Stoma, Stoma self-sufficiency, Patient Education and Compliance
Hospital Routine Documentation Form at the University Hospital Muenster. Original Form name: Stoma-Dokumentationsbogen.

SOCIAL SERVICES PSYCHOSOCIAL ASSESSMENT NOTE - HIS

- 08/06/17 - 1 modulo, 14 itemgroups, 134 elementi, 2 lingue
Itemgroups: Psychosocial Assessment, THERAPIES, Time, Patient Status, Living Situation, FINANCIAL INFORMATION, SUPPORT SYSTEM, CAREGIVER, SKILLED NEEDS, CURRENT ASSISTIVE DEVICES EQUIPMENT NEEDS, DAILY LIVING ACTIVITY, PSYCHOSOCIAL ASSESSMENT, RELIGIOUS/CULTURAL PREFERENCE, POSSIBLE NEEDS
Form from HIS OpenVista

Neonatal nursing Gynaecology UKM - Neonatal nursing

- 16/05/17 - 1 modulo, 9 itemgroups, 48 elementi, 2 lingue
Itemgroups: Patient demographics, Birth, Special nursing, Nutrition, Medication, Skin care, Breast care, Diagnostic therapy, Footer module
Neonatal nursing form converted to ODM format. Routine documentation of University Hospital of Münster. Publication granted by Prof. Dr. med. Ludwig Kiesel

Nursing report, University Hospital Cologne

- 02/05/17 - 1 modulo, 10 itemgroups, 76 elementi, 1 linguaggio
Itemgroups: Nursing report: Patient data, Nursing report: General information, Nursing report: Communication, Nursing report: Vital signs, Nursing report: Nutrition, Nursing report: Skin, Nursing report: Excretion, Nursing report: Movement, Nursing report: Rest, Nursing report: Special information
Hospital Routine Documentation Subform at the University Hospital Cologne. Original Form name: Pflegeüberleitung

Multiresistant pathogens, University Hospital Cologne

- 01/05/17 - 1 modulo, 4 itemgroups, 20 elementi, 1 linguaggio
Itemgroups: Documentation of expenditure of time with treatment of patients with multiresistant pathogens, Basics module, Patient module, Additional module
Hospital Routine Documentation Subform at the University Hospital Cologne. Original Form name: Erfassung_MRE

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