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  1. 1. Estudo clínico
  2. 2. Documentação de rotina
    1. 2.1. Internação
    1. 2.2. Anamnese
    1. 2.3. Exame físico
    1. 2.4. Score
    1. 2.5. Relatório de enfermagem
    1. 2.6. Diagnóstico com aparelhos
    1. 2.7. Laboratório
    1. 2.8. Patologia/histologia
    1. 2.9. Esclarecimento/consentimento
    1. 2.10. Terapia
    1. 2.11. Relatório da operação
    1. 2.12. Decurso
    1. 2.13. Alta
    1. 2.14. Cuidados posteriores
  3. 3. Estudos de registo/coortes
  4. 4. Garantia da qualidade
  5. 5. Padrão de dados
  6. 6. Questionário do paciente
  7. 7. Especialidade médica
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UKHD - Transitionsvorbereitungsbogen und Fragebogen zum Wechsel aus der Kinder- und Jugendmedizin in die Erwachsenenmedizin - Fragebogen zum Wechsel

- 18/03/2022 - 2 Formulários, 8 Grupos de itens, 32 Elementos de dados, 1 Idioma
Grupos de itens: Demografie, Allgemeine Fragen, Wissen zur Erkrankung , Therapie und Behandlung, Unterstützung und Informationen, Pläne zur Zukunft und zum Beruf, Klinikkontakte, Anmerkungen Fragen Wünsche
Stand: 24.02.2022 Transitionsvorbereitungsbogen und Fragebogen zum Wechsel aus der Kinder- und Jugendmedizin in die Erwachsenenmedizin Urheber: Frau PD Dr. med. Daniela Choukair, Frau Dr. med. Janna Mittnacht, Frau Dr. med. Susanne Rieger und Frau Dorothea Treiber Klinik für Allgemeine Pädiatrie, Neuropädiatrie, Stoffwechsel, Gastroenterologie, Nephrologie Zentrum für Kinder- und Jugendmedizin Angelika-Lautenschläger-Klinik Universitätsklinikum Heidelberg, Im Neuenheimer Feld 672, 69120 Heidelberg Literatur: Traq 5.0 Wood, Sawicki, Reiss, Livingood & Kramer, 2014 TRAQ GV-15 Culen, Wood, Straub, 2019 Findorff, J, Müther, S, von Moers, A, Nolting, H-D, Burger, W (2016): Das Berliner Transitionsprogramm. Berlin, Boston, De Gruyter Minden, K, Berlin; Schalm, S, München; Arbeitskreis Transition der Deutschen Gesellschaft für Rheumatologie e.V., Fragebogen für die Jugendsprechstunde https://gkjr.de/fuer-mitglieder/informationen-fuer-mitglieder/transitionsunterlagen/ The Royal Children’s Hospital Melbourne: http://www.rch.org.au/transition/factsheets_and_tools/transition_checklists/ Southampton Children’s Hospital, Transition to adult care: Ready Steady Go: http://www.uhs.nhs.uk/OurServices/Childhealth/TransitiontoadultcareReadySteadyGo/Transitiontoadultcare.aspx Grasemann C Ein strukturierter Versorgungspfad von der Pädiatrie in die Erwachsenenmedizin für Jugendliche und junge Erwachsene mit einer seltenen Erkrankung. Monatsschrift Kinderheilkunde 1-2022 S. 61-69

Transitionsvorbereitungsbogen

5 Grupos de itens 25 Elementos de dados

Pediatric surgery UKM - Head injury admission form

- 27/09/2021 - 1 Formulário, 3 Grupos de itens, 22 Elementos de dados, 2 Idiomas
Grupos de itens: Patient identification, Glasgow coma scale, Neurological assessment
Head injury admission form converted to ODM format. Routine documentation of University Hospital of Münster.

Pediatric oncology (Kinderonkologie) - Medical history (Anamnese)

- 27/09/2021 - 1 Formulário, 8 Grupos de itens, 74 Elementos de dados, 2 Idiomas
Grupos de itens: Pregnancy, Childbirth, Postpartum development, Kindergarten / school, Puberty stage, Other information, Physical examination basic information, Physical examination (further information)
This form about medical history originates from the Department of Pediatric Oncology, Hematology and Clinical Immunology of the University Hospital Düsseldorf.

Pediatric medical history MS University Hospital Muenster (UKM) Subform - Pädiatrische Anamnese MS University Hospital Muenster (UKM) Subform

- 20/09/2021 - 1 Formulário, 10 Grupos de itens, 80 Elementos de dados, 1 Idioma
Grupos de itens: General information, Current medical history, Medical history, Peripartum history, Milestones, Prior hospital admission and surgery, Family social history, Examination, Treatment plan, Patient chart: medical orders
Hospital Routine Documentation Subform at the University Hospital Muenster. Original Form name: Pädiatrische Anamnese

Pediatrics UKM Emergency room admission - Emergency room admission

- 20/09/2021 - 1 Formulário, 5 Grupos de itens, 20 Elementos de dados, 2 Idiomas
Grupos de itens: 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

- 20/09/2021 - 1 Formulário, 5 Grupos de itens, 20 Elementos de dados, 2 Idiomas
Grupos de itens: 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.

Chest questionnaire Pediatric surgery UKM - Chest questionnaire

- 20/09/2021 - 1 Formulário, 6 Grupos de itens, 31 Elementos de dados, 2 Idiomas
Grupos de itens: Patient demographics, Congenital breast deformities, Impaired health due to chest deformity, Standing position improvements, Reason to play sports, What do you dislike about physical education?
Chest questionnaire form converted to ODM format. Routine documentation of University Hospital of Münster.

Balance Sheet Pediatric surgery UKM - Patient admission

- 20/09/2021 - 1 Formulário, 2 Grupos de itens, 44 Elementos de dados, 2 Idiomas
Grupos de itens: Patient admission, Patient questionnaire
Balance Sheet converted to ODM format. Routine documentation of University Hospital of Münster. Publication granted by Dr. med. V. Müller

KBV Certificate for Sickness Benefits in case of Childrens Illnesses Template 21

- 07/09/2017 - 1 Formulário, 4 Grupos de itens, 32 Elementos de dados, 1 Idioma
Grupos de itens: Header, Care, Patient administration, Footer
Muster 21 - Ärztliche Bescheinigung für den Bezug von Krankengeld bei Erkrankung eines Kindes (Freigabe 01.09.2014). 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 --- Template 21 - Certificate for Sickness Benefits in case of Childrens Illnesses (Released 09-01-2014). 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 Certificate of premature birth for grant of maternity benefit Template 9 - KBV Certificate of premature birth for grant of maternity benefit Template 9

- 06/09/2017 - 1 Formulário, 4 Grupos de itens, 15 Elementos de dados, 1 Idioma
Grupos de itens: Header, Certificate of premature birth for grant of maternity benefit, Reason, Footer
Muster 9 - Ärztliche Bescheinigung für die Gewährung von Mutterschaftsgeld bei Frühgeburten (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

Glasgow Coma Scale, pediatric Routine documentation in German hospitals DMI

- 30/07/2017 - 1 Formulário, 2 Grupos de itens, 11 Elementos de dados, 2 Idiomas
Grupos de itens: Glasgow Coma Scale pediatric, grading PGCS
Routine documentation in German hospitals. Source file name: VL010106_Glasgow_Coma_Scale Examplary forms provided by DMI (http://www.dmi.de/)

Assessment of burn injuries Pediatric surgery UKM - Assessment of burn injuries

- 01/06/2017 - 1 Formulário, 2 Grupos de itens, 23 Elementos de dados, 2 Idiomas
Grupos de itens: Footer module, Assessment of burn injuries
Assessment of burn injuries form converted to ODM format. Routine documentation of University Hospital of Münster. Publication granted by Dr. med. V. Müller

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