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Table of contents
  1. 1. Clinical Trial
  2. 2. Routine Documentation
    1. 2.1. Admission
    1. 2.2. Medical History
    1. 2.3. Physical Examination
    1. 2.4. Assessment Score
    1. 2.5. Nursing Report
    1. 2.6. Apparative Diagnostics
    1. 2.7. Laboratory
    1. 2.8. Pathology/Histology
    1. 2.9. Consent
    1. 2.10. Therapy
    1. 2.11. Operative Report
    1. 2.12. Progress
    1. 2.13. Discharge Summary
    1. 2.14. Aftercare
  3. 3. Registry/Cohort Study
  4. 4. Quality Assurance
  5. 5. Data Standard
  6. 6. Patient-Reported Outcome
  7. 7. Medical Specialty
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COVID-19 Status Form of Rhön-Klinikum Bad Neustadt - Pre-hospital COVID-19-Status Form

- 9/28/21 - 2 forms, 4 itemgroups, 26 items, 1 language
Itemgroups: Exclusion Criteria for inpatient admission, Immune Status COVID-19, Additional Information for risk assessment, Signature
COVID-19 Status forms of the Rhön-Klinikum Campus Bad Neustadt, Germany. * pre-hospital * on admission They are used for the assessment of COVID-19 risk before (via telephone) and on the day of admission. If one of the 4 exclusion criteria is answered with "yes" a physician/clinician has to make the decision about medical requirement for admission. Provided by the Medical Documentation Department of the Rhön-Klinikum Campus Bad Neustadt. German Description: Die Patienten werden zunächst vor dem stationären Aufenthalt angerufen und gefragt, ob sie in Quarantäne sind oder Kontaktpersonen oder vielleicht doch erkrankt. Wurde eine dieser Fragen mit Ja beantwortet, dann muss ein Arzt entscheiden und der Patient wird am Aufnahmetag nur mit medizinischer Notwendigkeit aufgenommen.

COVID-19 Status on admission day

3 itemgroups 14 items

Patient Admision Pediatric Hematology and Oncology UK Muenster

- 9/20/21 - 1 form, 18 itemgroups, 195 items, 2 languages
Itemgroups: Patient, Father, Mother, Living arrangement, Sibling, Medical history, Nursing support, Support device, Personal aids, School, Kindergarten, workshop, Therapies in school, kindergarten, workshop, Medication, Medication history, Therapy, Nutrition, Continence, Catheters and drainages, Other
Freigabe zur Verarbeitung durch Frau Prof. Rössig, Quellenangabe: "Pädiatrische Hämatologie und Onkologie, UKM" Klinik für Kinder- und Jugendmedizin, Universitätsklinikum Münster Released for adaption by Frau Prof. Rössig Source:Pediatric Hematology und Oncology, University hospital Münster

Flowchart inpatient admission Checklist Admission Routine documentation in German hospitals DMI - Flowchart inpatient admission Checklist Admission

- 9/20/21 - 1 form, 4 itemgroups, 27 items, 1 language
Itemgroups: Flowchart Hospital admission Inpatient, X- ray, Ultrasonography; Endoscopy, Examinations Other
Routine documentation in German hospitals. Source file name: AU010104_Checkliste Aufnahme/ Ablaufplan stationäre Aufnahme.045 Examplary forms provided by DMI (http://www.dmi.de/)

Pediatrics UKM Emergency room admission - Emergency room admission

- 9/20/21 - 1 form, 5 itemgroups, 20 items, 2 languages
Itemgroups: Patient demographics, Admission, Health insurance, Legal representative/ policyholder, Footer module
Emergency room admission form converted to ODM format. Routine documentation of University Hospital of Münster. Publication granted by Prof. Dr. Omran.

Emergency room admission Pediatric surgery UKM - Emergency room admission

- 9/20/21 - 1 form, 5 itemgroups, 20 items, 2 languages
Itemgroups: Patient demographics, Admission, Health insurance, Legal representative/ policyholder, Footer module
Emergency room admission form converted to ODM format. Routine documentation of University Hospital of Münster.

Balance Sheet Pediatric surgery UKM - Patient admission

- 9/20/21 - 1 form, 2 itemgroups, 44 items, 2 languages
Itemgroups: Patient admission, Patient questionnaire
Balance Sheet converted to ODM format. Routine documentation of University Hospital of Münster. Publication granted by Dr. med. V. Müller

Admission checklist Psychiatry UKM - Admission checklist

- 9/20/21 - 1 form, 3 itemgroups, 21 items, 2 languages
Itemgroups: Patient demographics, Admission status, Documentation
Admission checklist converted to ODM format. Routine documentation of University Hospital of Münster. Publication granted by Univ.-Prof. Dr. med. Volker Arolt

Q801NWD 16 Aufnahme University Hospital Muenster (UKM) Subform

- 9/20/21 - 1 form, 5 itemgroups, 20 items, 1 language
Itemgroups: Anamnesis and symptoms at admission, Comorbidity, Rankin Scale, Barthel index at admission, NIHSS
Hospital Routine Documentation Subform at the University Hospital Muenster. Original Form name: Q801NWD 16 Aufnahme.

Admission checklist Psychiatry UKM - Admission checklist

- 9/20/21 - 1 form, 3 itemgroups, 21 items, 2 languages
Itemgroups: Patient demographics, Admission status, Documentation
Admission checklist converted to ODM format. Routine documentation of University Hospital of Münster. Publication granted by Univ.-Prof. Dr. med. Volker Arolt.

AAFP: Pelvic Inflammatory Disease Admission Order

- 9/17/21 - 1 form, 12 itemgroups, 31 items, 1 language
Itemgroups: Default Itemgroup, Status, Attending, Admitting Diagnosis, Condition, Allergies, Diet, Activity, Nursing, Medications, IV, Lab
AAFP: Pelvic Inflammatory Disease 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-sixth section ("AAFP: Pelvic Inflammatory Disease Admission Order")

Befundbogen_NTX_ohneLabor S.0002 Befundbogen_NTX_ohneLabor - Befundbogen_NTX_ohneLabor

- 4/13/21 - 1 form, 9 itemgroups, 95 items, 2 languages
Itemgroups: Patients identity details, Dialysis Center, Patient Immunology, Conversations, Family anamnesis, Patient anamnesis, Renal anamnesis, Results of obligatory examinations , Results of Optional Examinations
Befundbogen fuer die Aufnahme von Patienten in der Nierentrasplantransplantion, siehe Laborbefund_Nierentransplantationspatient für den entsprechenden Laborbefundbogen. Quelle: Transplantationsnephrologie, Wartelistenbüro, Univeritätsklinikum Münster

KBV Referral to hospital Template 2 - KBV Referral to hospital Template 2b

- 9/5/17 - 3 forms, 4 itemgroups, 18 items, 1 language
Itemgroups: Header, Referral to hospital, Footer, Further information
Muster 2 - Verordnung von Krankenhausbehandlung (Freigabe: 01.09.2014) - 10.2014, Formulare für die vertragsärztliche Versorgung Freigabe durch Dezernat 4 - Ärztliche Leistungen und Versorgungsstruktur Geschäftsbereich Sicherstellung und Versorgungsstruktur Abteilung Sicherstellung Herbert-Lewin-Platz 2 10623 Berlin Tel: + 49 (0) 30 - 4005 -1418 Fax: + 49 (0) 30 - 4005 - 271418 Email: SJohn@KBV.de Web: www.kbv.de Quelle: http://www.kbv.de/html/formulare.php Forms for contract medical care Released by Department 4 - Medical treatment and structure of supply, division ensurance and structure of supply, department ensurance Herbert-Lewin-Platz 2 10623 Berlin Tel: + 49 (0) 30 - 4005 -1418 Fax: + 49 (0) 30 - 4005 - 271418 Email: SJohn@KBV.de Web: www.kbv.de Source: http://www.kbv.de/html/formulare.php

KBV Referral to hospital Template 2c

4 itemgroups 18 items

KBV Referral to hospital Template 2a

4 itemgroups 17 items

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