Information:
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Nyckelord
- Routine documentation (1270)
- EHR (268)
- Medical History Taking (83)
- Patient Admission (76)
- General Surgery (72)
- Pediatrics (66)
- Neurology (53)
- Physical Examination (48)
- Scores & Instruments (48)
- Hematology (45)
- Insurance, Health (45)
- Patient Discharge Summaries (43)
- Laboratories (42)
- Therapeutics (41)
- Medical Oncology (40)
- Cardiology (34)
- Diagnostic Procedure (33)
- Patient Discharge (33)
- Stroke (32)
- Diagnostic Imaging (31)
- Breast Neoplasms (29)
- Pulmonary Medicine (27)
- Clinical Trial (27)
- Released Standard (25)
- Nursing Assessment (25)
- Pulmonary Disease, Chronic Obstructive (24)
- Hospital Information Systems (24)
- Prostatic Neoplasms (23)
- Psychiatry (23)
- Intensive Care (23)
- Classification (23)
- Endoscopy (22)
- Ophthalmology (22)
- Radiology (19)
- On-Study Form (19)
- Gastroenterology (18)
- Deprecated Standard (17)
- Drug Therapy (17)
- Drug Prescriptions (16)
- Prescriptions (16)
- Leukemia (16)
- Registries (15)
- General report (15)
- Gynecology (15)
- Rehabilitation (14)
- Physical Therapy Specialty (14)
- Treatment Form (14)
- Diagnosis (14)
- Neonatology (14)
- Gynaecology (13)
- AML (13)
- Intensive Care Units (13)
- Neoplasms (13)
- Urology (12)
- Dermatology (12)
- Hospitals, University (12)
- Psychotherapy (11)
- Radiology Information Systems (11)
- Wisconsin (11)
- Clinical Laboratory Services (11)
- Organization and Administration (11)
- Clinical Conference (10)
- Vital Signs (10)
- Surgical Reporting Form (10)
- Eligibility Determination (10)
- Anesthesia (10)
- Paresis (10)
- Kidney Transplantation (9)
- Sepsis (9)
- Physiotherapy (9)
- Insurance, Health, Reimbursement (9)
- Anesthesiology (9)
- Wounds and Injuries (8)
- Emergency protocol (8)
- Pressure Ulcer (8)
- Histology (8)
- Orthopedics (8)
- Pruritus (7)
- Psychosomatic Medicine (7)
- Quality of Life (7)
- Referral and Consultation (7)
- Surgical Procedures, Operative (7)
- Traumatology (7)
- Cardiovascular Diseases (7)
- Symptom Assessment (7)
- Common Data Elements (CDE) (7)
- Progress Note (7)
- DIVI (7)
- Microbiology (7)
- Nursing Services (7)
- Obstetrics (7)
- Pain (7)
- Pathology (7)
- Ultrasonography (6)
- Blood Gas Analysis (6)
- Diagnostic Techniques and Procedures (6)
- Stem Cell Transplantation (6)
- Checklist (6)
- Adverse event (6)
- Concomitant Medication (6)
Innehållsförteckning
Valda datamodeller
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1270 Sökresultat.
Item-grupper:
Case data, Medical Department data, Diagnosis details, Procedure Details, PIA-Documentation of services, Modell project
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
Item-grupp:
Hospital and intensive care unit structure data
Tägliche Datenerhebung
2 Item-grupper, 25 Dataelement31Aufnahmestatus
2 Item-grupper, 37 Dataelement31Entlassung von der Intensivtherapiestation
2 Item-grupper, 16 Dataelement31Entlassung aus dem Krankenhaus
1 Item-grupp, 2 Dataelement31
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
Body - Anamnese (medical history)
11 Item-grupper, 36 Dataelement31Body - Diagnose (diagnosis)
2 Item-grupper, 6 Dataelement31Header
3 Item-grupper, 18 Dataelement31
Item-grupper:
Telephone notes, Laboratory, Current Medication
Item-grupper:
Demographics, Medical History, Diagnosis, Procedure, Findings, Laboratory Findings, Medication
Item-grupper:
Care problem, Score, Care goal, Nursing procedure, Activities of daily living, Homecare Status, Social Environment, Legal Aspects, Medical information
Header
3 Item-grupper, 18 Dataelement31
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
Item-grupp:
BRADEN SCALE
Item-grupper:
Maternal Family History, Paternal Family History, Siblings Family History
Item-grupper:
Resting; Sleeping, moving, Getting washed or dressed, Eating and Drinking, Elimination, communication, conscious, meaning of life, Examinations, Miscellaneous
Item-grupper:
Current episode, Diagnosis, Current medication