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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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Klinische Dokumentation Med. V - Follow Up AML - Klinische Dokumentation Med. V AML

- 1/31/22 - 1 form, 12 itemgroups, 94 items, 2 languages
Itemgroups: Patienten-Stammdaten, Diagnose: Akute myeloische Leukämie, Zuweiser, Vorausgegangene Therapie, Charakteristika bei Erstdiagnose, Rezidiv der AML, MRD-Verlauf, Nebendiagnosen, Biobank, Aktuelle Diagnostik, Aktueller Patientenstatus, Therapieverlauf
Dokumentation des Follow-Up für Patienten mit AML am Universitätsklinikum Heidelberg. Prof. Dr. med. Sascha Dietrich; Dr. med. Tim Sauer; Medizinischen Klinik V - Klinik für Hämatologie, Onkologie, Rheumatologie - Universitätsklinikum Heidelberg

Klinische Dokumentation Med. V - Follow Up CLL/HCL - Klinische Dokumentation Med. V CLL/HCL

- 1/31/22 - 1 form, 9 itemgroups, 68 items, 2 languages
Itemgroups: Patienten-Stammdaten, Diagnose: CLL/ HCL, Charakteristika bei Erstdiagnose, Zytogenetik und Mutationsstatus, Nebendiagnosen, Biobank, Aktuelle Diagnostik, Aktueller Patientenstatus, Therapieverlauf
Dokumentation des Follow-Up für Patienten mit CLL/HCL am Universitätsklinikum Heidelberg. Prof. Dr. med. Sascha Dietrich; Dr. med. Tim Sauer; Medizinischen Klinik V - Klinik für Hämatologie, Onkologie, Rheumatologie - Universitätsklinikum Heidelberg

Klinische Dokumentation Med. V - Follow Up - Lymphom - Klinische Dokumentation Med. V Lymphom

- 1/31/22 - 1 form, 8 itemgroups, 97 items, 2 languages
Itemgroups: Patienten-Stammdaten, Diagnose: Lymphom, Charakteristika bei Erstdiagnose, Nebendiagnosen, Biobank, Aktuelle Diagnostik, Aktueller Patientenstatus, Therapieverlauf
Dokumentation des Follow-Up für Patienten mit Lymphom am Universitätsklinikum Heidelberg. Prof. Dr. med. Sascha Dietrich Dr. med. Tim Sauer Medizinischen Klinik V - Klinik für Hämatologie, Onkologie, Rheumatologie - Universitätsklinikum Heidelberg

Heidelberg Perioperative Deep Data Study – a prospective cohort study - PDMS ICU - Primary data

- 1/10/22 - 1 form, 8 itemgroups, 125 items, 1 language
Itemgroups: Respiratory system data, Cardiovascular system data, Diagnosis related data, Laboratory values, Medication related data, Medical Scores, Medical device related data, Quantitative data body fluids
HeiPoDD registry will form a clinical database and a corresponding biobank as the basis to predict overall postoperative morbidity and mortality using data-driven, personalized risk prediction from the entirety of available clinical records. Prospective single-center observational registry. DRKS00025924

Heidelberg Perioperative Deep Data Study – a prospective cohort study - DRKS00025924 - Patient monitoring - primary data

- 12/28/21 - 1 form, 9 itemgroups, 242 items, 1 language
Itemgroups: Height Weight BSA, Respiratory system data, Laboratory data, Medication data, Neurological data, Clinical Scores, Temperature data, Electrocardiography data, Cardiovascular system data
HeiPoDD registry will form a clinical database and a corresponding biobank as the basis to predict overall postoperative morbidity and mortality using data-driven, personalized risk prediction from the entirety of available clinical records. Prospective single-center observational registry. DRKS00025924

Device Accountability Log: CRF Wisconsin Madison

- 11/17/21 - 1 form, 4 itemgroups, 17 items, 1 language
Itemgroups: Header, Device Accountability Log: Device Receipt, Device Accountability Log: Device Use, Device Accountability Log: Device Return/Repair/Destruction
ODM Form derived from: https://ictr.wisc.edu/CaseReptTempt. Template Name: Device Accountability Log. Case Report Form (CRF)/Source Document templates were created for University of Wisconsin-Madison researchers. These templates are consistent with the FDA's CDASH (Clinical Data Acquisition Standards Harmonization) standards. The CDASH standards identify those elements that should be captured on a Case Report Form (CRF). The forms serve only as templates, and must be edited to meet the study data collection needs as described in the protocol.

KIORTH CPChild MS University Hospital Muenster (UKM)

- 11/17/21 - 1 form, 11 itemgroups, 159 items, 1 language
Itemgroups: General information, 1. Personal care/ Activities of daily living, 2. Positioning, Transferring & Mobility, 3. Comfort & Emotions, 4. Communication & Social Interaction, 5. Health, 6. Overall Quality of Life, 7. Importance of items to your child's quality of life, 8. Facts about your child, 9. Facts about you, CPChild result
Hospital Routine Documentation Form at the University Hospital Muenster. Original Form name: KIORTH CPChild MS. German description: CPChild Ein Index zur gesundheitsbezogenen Lebensqualität bei Menschen mit Behinderung

Admission Checklist Children Oncology Pediatric Hematology and Oncology UK Muenster

- 11/17/21 - 1 form, 12 itemgroups, 60 items, 2 languages
Itemgroups: Checklist, InInfectivity, Planned therapy, Supportive therapy, Transfusions, Chemotherapy flush, Intensive Care, Laboratories and Diagnostics, Hypersensitivities and Premedication, Next visits, Other, KIONK Physician
Bei Aufnahme eines Patienten außerhalb 17A West und KMT-Station, aber innerhalb des Zentrums für Kinder- und Jugendmedizin. 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

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

documentation standard - breast cancer - talk after biopsy - HIS

- 9/27/21 - 1 form, 4 itemgroups, 44 items, 2 languages
Itemgroups: Administrative Information, Patienteninformation, geplante Operation, Patienteninformation II
documentation standard - breast cancer - gynecology, with friendly permission (Dr. Tio) - kooperatives Brustzentrum Münster, Bereich Senologie an der Klinik und Poliklinik für Frauenheilkunde und Geburtshilfe - Leitung: Dr. med. Joke Tio

Item List QS System UKM Part 8 from 61 - QS Items UKM

- 9/27/21 - 1 form, 1 itemgroup, 100 items, 2 languages
Itemgroup: All Items
Item list consisting of 100 items from QS System (GE) (August 2016), which is in use at the University Hospital Muenster, Germany. Permission granted by Dr. Volkert. This is item list part 8 from 61. Original QS Item Ids are represented by ItemDef OIDs.

Item List QS System UKM Part 8 from 61 - QS Items UKM

- 9/27/21 - 1 form, 1 itemgroup, 100 items, 2 languages
Itemgroup: All Items
Item list consisting of 100 items from QS System (GE) (August 2016), which is in use at the University Hospital Muenster, Germany. Permission granted by Dr. Volkert. This is item list part 8 from 61. Original QS Item Ids are represented by ItemDef OIDs.

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