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  2. 2. Rutindokumentation
    1. 2.1. Registrering
    2. 2.2. Anamnes
    3. 2.3. Kroppsundersökning
    4. 2.4. Poäng
    5. 2.5. Omvårdnadsepikris
    6. 2.6. Apparativ diagnostik
    7. 2.7. Laboratorium
    8. 2.8. Patologi och histologi
    9. 2.9. Upplysning/samtycke
    10. 2.10. Terapi
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    14. 2.14. Eftervård
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  4. 4. Kvalitetssäkring
  5. 5. Datastandard
  6. 6. Frågeformulär för patienter
  7. 7. Medicinsk specialitet
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1282 Sökresultat.

DIVI Kerndatensatz Intensivmedizin 2010 - Entlassung von der Intensivtherapiestation

- 2020-03-19 - 5 Formulär, 2 Item-grupper, 16 Dataelement, 1 Språk
Item-grupper: DNR (do not resuscitate) / AND (allowed natural death), Procedures and complications
Kerndatensatz Intensivmedizin 2010 der DIVI und DGAI (nur patientenbezogene Daten, ohne Strukturdaten der Intensivtherapiestation und der Klinik ). Deutsche interdisziplinaere Vereinigung fuer Intensiv und Notfallmedizin DIVI (German interdisciplinary association for intensive and emergeny medical care), http://www.divi.de/images/Dokumente/Empfehlungen/Strukturempfehlungen/2010_KerndatensatzIntensivmedizin.pdf

Strukturdaten

1 Item-grupp, 28 Dataelement

Entlassung aus dem Krankenhaus

1 Item-grupp, 2 Dataelement

Tägliche Datenerhebung

2 Item-grupper, 25 Dataelement

Aufnahmestatus

2 Item-grupper, 37 Dataelement

Paragraph 21 Datensatz 2017 - Paragraph 21 medical data

- 2019-07-20 - 1 Formulär, 6 Item-grupper, 55 Dataelement, 1 Språk
Item-grupper: Case data, Medical Department data, Diagnosis details, Procedure Details, PIA-Documentation of services, Modell project
Medizinische Daten des Behandlungsfalls

NURSING ASSESSMENT (adult) - HIS

- 2017-06-08 - 1 Formulär, 36 Item-grupper, 383 Dataelement, 2 Språk
Item-grupper: 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

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

- 2017-05-23 - 4 Formulär, 9 Item-grupper, 26 Dataelement, 2 Språk
Item-grupper: 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 Item-grupper, 36 Dataelement

Body - Diagnose (diagnosis)

2 Item-grupper, 6 Dataelement

Header

3 Item-grupper, 18 Dataelement

Telephone notes Pediatric Hematology and Oncology UK Muenster

- 2016-12-15 - 1 Formulär, 3 Item-grupper, 24 Dataelement, 2 Språk
Item-grupper: Telephone notes, Laboratory, Current Medication
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

EHR4CR data inventory

- 2014-08-08 - 1 Formulär, 7 Item-grupper, 75 Dataelement, 2 Språk
Item-grupper: Demographics, Medical History, Diagnosis, Procedure, Findings, Laboratory Findings, Medication
Doods J, Botteri F, Dugas M, Fritz F; EHR4CR WP7. A European inventory of common electronic health record data elements for clinical trial feasibility. Trials. 2014 Jan 10;15:18 http://www.ncbi.nlm.nih.gov/pubmed/24410735

ePflegebericht (electronic nursing report) - Body

- 2016-04-19 - 2 Formulär, 9 Item-grupper, 52 Dataelement, 2 Språk
Item-grupper: Care problem, Score, Care goal, Nursing procedure, Activities of daily living, Homecare Status, Social Environment, Legal Aspects, Medical information
ePflegebericht Prof. Dr. Ursula Hübner Forschungsgruppe Informatik im Gesundheitswesen Hochschule Osnabrück Fakultät Wirtschafts- und Sozialwissenschaften http://wiki.hl7.de/index.php?title=IG:Pflegebericht

Header

3 Item-grupper, 18 Dataelement

Physician referral letter

- 2017-05-23 - 1 Formulär, 21 Item-grupper, 341 Dataelement, 2 Språk
Item-grupper: Current episode, Transfer diagnosis, Other Diagnoses, Beta blocker, Calcium Channel Blockers, Angiotensin 2 Receptor Blocker, ACE inhibitors, Diuretics, Cardiac drugs, Antikoagulanzien, Antidiabetics , Antidepressive Agents, Neuroleptic Drugs, Hormonal contraceptives, Bronchodilator Agents, Antilipemic agent, Analgesics, Anti-Infective Agents, Antiparkinson Agents, Glucocorticoids, Other medication
derived from http://www.arztbriefmanager.de/ (Dr. Wolfram Arends, Tutzing, Germany)

BRADEN SCALE - BRADEN SCALE

- 2017-06-15 - 1 Formulär, 1 Item-grupp, 7 Dataelement, 4 Språk
Item-grupp: 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.

Family history - HIS

- 2017-06-04 - 1 Formulär, 3 Item-grupper, 33 Dataelement, 2 Språk
Item-grupper: Maternal Family History, Paternal Family History, Siblings Family History
Form from HIS OpenVistA

Nursing relevant Questions UKM - Nursing relevant Questions UKM

- 2017-04-06 - 1 Formulär, 10 Item-grupper, 47 Dataelement, 11 Språk
Item-grupper: 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

Physician letter (short)

- 2016-07-17 - 1 Formulär, 3 Item-grupper, 302 Dataelement, 1 Språk
Item-grupper: Current episode, Diagnosis, Current medication
derived from http://www.arztbriefmanager.de/ (Dr. Wolfram Arends, Tutzing, Germany)