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Stroke Common Data Elements (CDE) - Administrative/Demographics

- 2020-12-06 - 8 Formulär, 1 Item-grupp, 10 Dataelement, 1 Språk
Item-grupp: Administrative documentation, Demographics Domain
Common Data Elements for Stroke

Diagnostic/Medical History

8 Item-grupper 47 Dataelement

Apparatus-based Diagnostics

5 Item-grupper 18 Dataelement

Examination/Follow-up

2 Item-grupper 2 Dataelement

Nursing issues, Rehabilitation

2 Item-grupper 16 Dataelement

Lab: Blood Panel

4 Item-grupper 21 Dataelement

Treatment Details

2 Item-grupper 8 Dataelement

Acute Coronary Syndrome Common Data Elements - Medication

- 2021-09-27 - 10 Formulär, 23 Item-grupper, 68 Dataelement, 1 Språk
Item-grupper: Medication, Aspirin, Anticoagulation, Thrombolytics, Clopidogrel, Low molecular weight heparin, Glycoprotein 2b/3a inhibitors, Unfractionated heparin, Beta-Blocker, Statins, ACE Inhibitors, Angiotensin 2 Receptor Antagonists, Warfarin, Prasugrel, Ticagrelor, Bivalirudin, Fondaparinux, Ticlopidine, Dabigatran, Aldosterone Blocking Agent, Rivaroxaban, Dalteparin, Apixaban
Common Data Elements for Acute Coronary Syndrome

Laboratory

2 Item-grupper 36 Dataelement

Patient history

1 Item-grupp 8 Dataelement

ACS-Timepoints

1 Item-grupp 16 Dataelement

Patient data

2 Item-grupper 27 Dataelement

Procedures

11 Item-grupper 45 Dataelement

Diagnosis

8 Item-grupper 29 Dataelement

Common Data Elements for Retinal Neovascular Diseases - Risk Factors or Past Medical History

- 2021-09-20 - 4 Formulär, 1 Item-grupp, 35 Dataelement, 2 Språk
Item-grupp: Risk Factors; Past Medical History
Common Data Elements for retinal neovascular diseases. The CDEs may be used in clinical routine, clinical trial, patient outcome, quality assurance and registry documentation of Age related macular degeneration (AMD), Diabetic Retinopathy (DR) and Retinal vein occlusion (RVO). The CDEs were developed by the Institute of Medical Informatics of the University Muenster in cooperation with the Department of Ophthalmology of the University Hospital Muenster.

Diagnosis and Examination

1 Item-grupp 11 Dataelement

Eye Examination

1 Item-grupp 18 Dataelement

Therapy

1 Item-grupp 9 Dataelement

Neuroinflammatory demyelinating diseases CNS Common Data Elements

- 2021-09-17 - 1 Formulär, 13 Item-grupper, 46 Dataelement, 2 Språk
Item-grupper: Diagnosis Demyelinating disease of central nervous system, MS, NMOSD, Acute disseminated encephalomyelitis (ADEM), CSF, Current relapse, Previous relapses, EDSS, Current therapy, Risk stratification Natalizumab, Previous Therapy, MRI Results, Other medical information
Common Data Elements for Neuroinflammatory Demyelinating Diseases of the central nervous system (NID CDEs). The NID CDEs may be used in clinical routine, clinical trial and registry documentation of Multiple Sclerosis (MS), Neuromyelitis Optica Spectrum Disorders (NMOSD) and Acute Disseminated Encephalomyelitis (ADEM). The NID CDEs were developed by the Institute of Medical Informatics of the University Muenster in cooperation with the Department of Neurology of the University Hospital Muenster.

Neuroinflammatory demyelinating diseases CNS Common Data Elements - Benutzerumfrage nach Einsatz der Basisdokumentation neuroinflammatorische Erkrankungen (User survey after application of basic documentation neuroinflammatory diseases)

- 2019-08-19 - 1 Formulär, 4 Item-grupper, 18 Dataelement, 2 Språk
Item-grupper: System usability scale, Additional Data, Documentation time, Basic administrative documentation
Das Formular „Basisdokumentation neuroinflammatorische Erkrankungen“ wurde vom Institut der Medizinischen Informatik in Kooperation mit der Klinik für Neurologie am Universitätsklinikum Münster entwickelt. Es wurde zur Strukturierung und Harmonisierung der Anamnese bzw. Dokumentation von Patienten mit entzündlich-demyelinisierenden Erkrankungen des ZNS entwickelt. Hierbei dient es der Erfassung der erkrankungsspezifischen „Kernelemente“ zur Multiplen Sklerose, Neuromyelitis optica und Akuten disseminierten Enzephalomyelitis. Das Ziel der Umfrage ist die Zufriedenheit der Dokumentationsabläufe vor demEinsatz der Basisdokumentation (hierzu zählt das mehrfache Erheben der Daten zuverschiedenen Zwecken in verschiedenen Systemen – beispielsweise zunächst auf Papier, gefolgt von der Übertragung in die elektronische Patientenakte und denArztbrief, oder zum Diktat inkl. Rückfragen aus dem Schreibbüro) mit derZufriedenheit mit Einsatz der Basisdokumentation (Eingabe der Daten in dasFormular, Nutzung des Textbausteins) zu vergleichen. Die enthaltene "system usability scale" stammt von Brooke, J.: SUS: a "quick and dirty" usability scale. In: P. W. Jordan, B. Thomas, B. A. Weerdmeester, & A. L. McClelland (Hrsg.): Usability Evaluation in Industry. London: Taylor and Francis, 1996. Unter folgendem Link ist die Basisdokumentation zu finden: https://medical-data-models.org/29131 The form "Basisdokumentation neuroinflammatorische Erkrankungen" was developed by the Institute of Medical Informatics in cooperation with the department of neurology at the university hospital Münster. It was developed to structure and harmonize medical history and documentation of patients with inflammatory demyelinating diseases of the central nervous system. It serves to record the disease-specific "core elements" of multiple sclerosis, neuromyelitis optica and acute disseminated encephalomyelitis. The aim of the survey is to compare the satisfaction of documentation processes before the use of the basic documentation (this includes the multiple collection of the data for different purposes in different systems - for example first on paper, followed by the transfer into the electronic patient file and the doctor's letter, or on the dictation including queries from the typing office) with the satisfaction of use of the basic documentation (input of the data into the form, use of the text module). The included "system usability scale" originates from Brooke, J.: SUS: a "quick and dirty" usability scale. In: P. W. Jordan, B. Thomas, B. A. Weerdmeester, & A. L. McClelland (Ed.): Usability Evaluation in Industry. London: Taylor and Francis, 1996. The basic documentation can be found here: https://medical-data-models.org/29131

Neuroinflammatory demyelinating diseases CNS Common Data Elements - Benutzerumfrage vor Einsatz der Basisdokumentation neuroinflammatorische Erkrankungen (User survey before application of basic documentation neuroinflammatory diseases)

- 2019-08-19 - 1 Formulär, 3 Item-grupper, 17 Dataelement, 2 Språk
Item-grupper: System usability scale, Documentation time, Basic administrative documentation
Das Formular „Basisdokumentation neuroinflammatorische Erkrankungen“ wurde vom Institut der Medizinischen Informatik in Kooperation mit der Klinik für Neurologie am Universitätsklinikum Münster entwickelt. Es wurde zur Strukturierung und Harmonisierung der Anamnese bzw. Dokumentation von Patienten mit entzündlich-demyelinisierenden Erkrankungen des ZNS entwickelt. Hierbei dient es der Erfassung der erkrankungsspezifischen „Kernelemente“ zur Multiplen Sklerose, Neuromyelitis optica und Akuten disseminierten Enzephalomyelitis. Das Ziel der Umfrage ist die Zufriedenheit der Dokumentationsabläufe vor dem Einsatz der Basisdokumentation (hierzu zählt das mehrfache Erheben der Daten zuverschiedenen Zwecken in verschiedenen Systemen – beispielsweise zunächst auf Papier, gefolgt von der Übertragung in die elektronische Patientenakte und denArztbrief, oder zum Diktat inkl. Rückfragen aus dem Schreibbüro) mit der Zufriedenheit mit Einsatz der Basisdokumentation (Eingabe der Daten in dasFormular, Nutzung des Textbausteins) zu vergleichen. Die enthaltene "system usability scale" stammt von Brooke, J.: SUS: a "quick and dirty" usability scale. In: P. W. Jordan, B. Thomas, B. A. Weerdmeester, & A. L. McClelland (Hrsg.): Usability Evaluation in Industry. London: Taylor and Francis, 1996. Unter folgendem Link ist die Basisdokumentation zu finden: https://medical-data-models.org/29131 The form "Basisdokumentation neuroinflammatorische Erkrankungen" was developed by the Institute of Medical Informatics in cooperation with the department of neurology at the university hospital Münster. It was developed to structure and harmonize medical history and documentation of patients with inflammatory demyelinating diseases of the central nervous system. It serves to record the disease-specific "core elements" of multiple sclerosis, neuromyelitis optica and acute disseminated encephalomyelitis. The aim of the survey is to compare the satisfaction of documentation processes before the use of the basic documentation (this includes the multiple collection of the data for different purposes in different systems - for example first on paper, followed by the transfer into the electronic patient file and the doctor's letter, or on the dictation including queries from the typing office) with the satisfaction of use of the basic documentation (input of the data into the form, use of the text module). The included "system usability scale" originates from Brooke, J.: SUS: a "quick and dirty" usability scale. In: P. W. Jordan, B. Thomas, B. A. Weerdmeester, & A. L. McClelland (Ed.): Usability Evaluation in Industry. London: Taylor and Francis, 1996. The basic documentation can be found here: https://medical-data-models.org/29131

The GRDR® Registry Model Common Data Elements (CDEs) - The GRDR® Registry Model Common Data Elements (CDEs)

- 2015-12-02 - 1 Formulär, 10 Item-grupper, 76 Dataelement, 1 Språk
Item-grupper: Current Contact Information, Socio-Demographic, Diagnosis, Family History, Anthropometric, Patient reported outcome, Devices and Health services, Clinical Research Participation and Biospecimen, Contact and Communication Preferences, Administrative
The main goals of the GRDR (Global Rare Diseases Patient Registry and Data Repository) CDE (Common Data Elements) effort are to: 1) develop a set of CDEs to facilitate data collection for the GRDR in a standardized and meaningful manner; 2) assist organizations that have no patient registry to establish a registry and be able to share data with the GRDR or other databases; 3) facilitate harmonization among the many organizations collecting patient information. NIH has developed Model Registry CDEs (ORDR CDEs) for patient data entry to be used in any rare disease registry, including a subset of CDEs (GRDR CDEs) to collect only de-identified information for the GRDR data repository. ODM derived from: https://ncats.nih.gov/grdr Permission to publish granted by Yaffa Rubinstein.

Breast Cancer DataMart Common Data Elements for Adjuvant Clinical Trials

- 2021-09-20 - 1 Formulär, 16 Item-grupper, 122 Dataelement, 1 Språk
Item-grupper: Patient Characteristics, Patient Performance Status, Protocol Design, Surgical Procedures, Pathologic Disease Classification, Pathology: Assessment of Lymph Nodes, Margins, Estrogen Status, Progesterone Status, Pathology: Breast Tumor Markers, Pathology: Assessment of Ductal Carcinoma In Situ (DCIS), Pathology: Assessment of Lobular Carcinoma In Situ (LCIS), Endpoints, Tumor Response, Sites of Progression, Notice of New Primary
Treatment - Breast Cancer DataMart Common Data Elements for Adjuvant Clinical Trials - 2719861v1.0 Breast Cancer DataMart Common Data Elements for Adjuvant Clinical Trials Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=43B3F0AE-1119-0B42-E044-0003BA3F9857

Use Case driven Common Data Elements in Intensive Care, v0.1 - Intensivdaten

- 2017-03-15 - 1 Formulär, 13 Item-grupper, 65 Dataelement, 1 Språk
Item-grupper: Allgemeine Daten, Diagnosen, Prozeduren, SAPS2, Atmung und Beatmung, Labordaten, Monitoring/klinische Befunde, Blut und Blutprodukte , Medikamente und Flüssigkeit, Mikrobiologie Keime und Resistenz, Schichtberichte, Radiologiebefunde, CAM-ICU
Common Data Elements in Intensive Care; first version as basis for collaborative curation (initially focussed on research on ARDS). Permission granted by Prof. Dr. N. Weiler, University Kiel, Germany.

Treatment - Breast Cancer DataMart Common Data Elements Surgical Template - 2723098v1.0 - Breast Cancer DataMart Common Data Elements Surgical Template

- 2017-09-20 - 1 Formulär, 5 Item-grupper, 24 Dataelement, 1 Språk
Item-grupper: Tumor Assessment, Assessment of Lymph Nodes, Surgical Procedures, Margins, Breast Reconstruction
Breast Cancer DataMart Common Data Elements Surgical Template Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=443F4BFB-7974-666C-E044-0003BA3F9857

Treatment - Proposed Breast Cancer DataMart Common Data Elements for Pre-Operative Clinical Trials - 2722335v1.0 - Proposed Breast Cancer DataMart Common Data Elements for Pre-Operative Clinical Trials

- 2012-09-20 - 1 Formulär, 7 Item-grupper, 53 Dataelement, 1 Språk
Item-grupper: Clinical/Imaging Examination of the Breast, Clinical/Imaging Examination of Lymph Nodes, Pre-operative Surgical Evaluation, Diagnostic Pathology of Breast and Lymph Nodes, Marker Status, Therapeutic Changes, Residual Cancer Burden
Proposed Breast Cancer DataMart Common Data Elements for Pre-Operative Clinical Trials Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=43F0A8A5-2CF0-6BFA-E044-0003BA3F9857

Top 300 Dataset of the Medical Informatics Initiative Germany (MII) - Laboratory Tests (Overview)

- 2019-04-29 - 1 Formulär, 1 Item-grupp, 300 Dataelement, 2 Språk
Item-grupp: Laboratory Tests
The Top 300 Dataset (Kerndatensatz Labor) was developed by the Medical Informatics Initiative Germany (MII) and contains frequency-sorted, LOINC-coded analyses of the university clinics in Göttingen, Gießen, Munich, Greifswald and Erlangen. This form shows an overview of the preferred presentation of the most common laboratory parameters. Official german translations were used where available. https://www.medizininformatik-initiative.de/de/labordaten-in-der-medizininformatik-initiative Explanation of abbreviations (english / german): Bld = Blood / Blut BldA = arterial blood / arterielles Blut Ser = Serum / Serum Plas = Plasma / Plasma RBC = Red blood cells / Erythrozyten PPP = Platelet poor plasma / plättchenarmes Plasma Urine sed = Urine sediment / Urinsediment CSF = Cerebral spinal fluid / Liquor Body fld = Body fluid / Körperflüssigkeit

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