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Table of contents
  1. 1. Clinical Trial
  2. 2. Routine Documentation
  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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24412 Search results.

SF-36 (RAND)

- 7/3/19 - 1 form, 7 itemgroups, 36 items, 1 language
Itemgroups: General Info, Current health limitations, Physical Health related problems during past 4 weeks, Emotional problems during past 4 weeks, Past 4 weeks, Emotions in past 4 weeks, General statements
This document contains the 36-Item Short Form Survey Instrument Version 1 (SF-36) form, developed at RAND as part of the Medical Outcomes Study. RAND owns the copyright. All of the surveys and tools from RAND Health are public documents, available without charge. For more information - e.g. on terms and conditions for use or scoring instructions: https://www.rand.org/health-care/surveys_tools/mos/36-item-short-form.html Changes made to the questionnaire should be made clearly identifiable.

NIHSS - NIH Stroke Scale

- 6/18/17 - 1 form, 1 itemgroup, 16 items, 9 languages
Itemgroup: NIHSS
https://en.wikipedia.org/wiki/National_Institutes_of_Health_Stroke_Scale

CDASH Medical History

- 6/20/18 - 1 form, 4 itemgroups, 13 items, 3 languages
Itemgroups: General information, High Blood Pressure, Appendectomy, Other
modified from http://www.cdisc.org

Modified Rankin Scale

- 11/28/17 - 1 form, 1 itemgroup, 1 item, 4 languages
Itemgroup: Modified Rankin Scale
https://en.wikipedia.org/wiki/Modified_Rankin_Scale The modified Rankin Scale (mRS) is a commonly used scale for measuring the degree of disability or dependence in the daily activities of people who have suffered a stroke or other causes of neurological disability. It has become the most widely used clinical outcome measure for stroke clinical trials.

Montreal Cognitive Assessment (MoCA) - MoCA

- 11/28/17 - 1 form, 10 itemgroups, 30 items, 7 languages
Itemgroups: Alternating Trail Making, Visuoconstructional Skills, Naming, Memory, Attention, Language, Abstraction, Delayed Recall, Orientation, MoCA
https://en.wikipedia.org/wiki/Montreal_Cognitive_Assessment

Barthel-Index

- 11/23/17 - 1 form, 1 itemgroup, 11 items, 4 languages
Itemgroup: Barthel Index
https://de.wikipedia.org/wiki/Barthel-Index

ADT and Gekid shared uniform oncological basic data set - Uniform oncological basic data set

- 7/13/17 - 1 form, 19 itemgroups, 123 items, 2 languages
Itemgroups: Reason for report, Administrative Data, Reporting institution, Diagnosis, Histology, TNM Classification, Other classifications, Residual status, Distant metastases, Surgery, Complications, Radiotherapy, Radiotherapy Side effects, Systemic therapy, Systemic or expectant treatment, Systemic therapy side effects, Follow-Up, Tumor conference, Death
The uniform oncological basic data set of ADT and GEKID was adopted in March 2008 and updated in February, 2014. It applies to all types of cancer and is continuously supplemented by tumor-specific modules. By harmonizing Oncology base record, an instrument has been created which provides a harmonized oncological standard , prevents multiple documentaries and allows comparable acquisition and evaluation of cancer treatments in all clinical structures and federal states . Source: http://www.tumorzentren.de/onkol-basisdatensatz.html

Urinanalysis (EHR Archetype) - openEHR-EHR-OBSERVATION.urinalysis.v1

- 7/10/17 - 1 form, 1 itemgroup, 18 items, 5 languages
Itemgroup: openEHR-EHR-OBSERVATION.urinalysis.v1.xml
Derived from www.openehr.org . Use to record the results of a qualitative and semi-quantitative test array performed on a sample of urine, using reagent test strips. On exposure to urine, chemical pads on the reagent test strip change colour and the test result is read by visual comparison to a color chart at specified times after exposure or by an automated device. Different commercial products carry a variety of test /reagent pads. This archetype is heavily influenced by the commonly available Multistix test strips in Australia, recording ten commonly used analytes, but is intended to be generically applicable. If requirements for other parameters become apparent to meet the requirements for other test strips then product-specific urinalysis archetypes may need to be developed.

Glasgow Coma Scale (EHR Archetype) - openEHR-EHR-OBSERVATION.glasgow_coma_scale.v1

- 7/9/17 - 1 form, 1 itemgroup, 7 items, 4 languages
Itemgroup: openEHR-EHR-OBSERVATION.glasgow_coma_scale.v1.xml
Derived from www.openehr.org . Use to record clinical responses of an adult subject of care to stimuli. It is commonly used to establish a baseline conscious state and neurological function assessment and/or to detect patients who may require immediate medical intervention. The Glasgow coma scale has three subscales E (eye), V (verbal) and M (motor). In clinical practice all three subscales are reported individually plus the 'Total score', if applicable. A recorded response for each of E, V and M is mandatory. If a response cannot be tested, then the 'Not Applicable' null flavour should be recorded; do not use the 'None' ordinal value to record a missing component. Details about the reason for not being able to test a response can be recorded in the 'Confounding factors' data element. The 'Total score' can be derived as the sum of the recorded eye, motor and verbal response scores. It is not appropriate to report a 'Total score' when one or more components are not testable because the score will be artificially low - in this situation record the EVM profile instead. The three response values are considered separately as well as their sum. The 'EVM profile' can be derived as a concatenation of each of the recorded eye, motor and verbal response scores. For example, E3 V4 M2 represents the conscious state of a subject who opens eyes to speech, utters incomprehensible sounds and has an extensor response to stimulation. The minimum possible 'Total score' value is 3 (equivalent to E1 V1 M1) and the maximum possible is 15 (equivalent to E4 V5 M6). In practical use, Glasgow coma scale is recorded as one component of clinical monitoring, using sequential and repeated point-in-time measurements. Date and time should be recorded for each measurement, as well as any factors that may influence interpretation of changes. Changes in 'Total score' or any E, V or M values may have as much clinical significance as the value recorded initially.

APGAR Score (EHR Archetype) - openEHR-EHR-OBSERVATION.apgar.v1

- 7/8/17 - 1 form, 1 itemgroup, 14 items, 9 languages
Itemgroup: openEHR-EHR-OBSERVATION.apgar.v1
Derived from www.openehr.org . Allows recording of an assessment of the state of a neonate explicitly as 1, 2, 3, 5 and/or 10 minute events after birth, plus additional events as required. Usual practice is to document the Apgar score at 1 and 5 minutes; further scores can be recorded as clinically indicated. It is possible to record the Apgar score at any time after birth using this archetype. Common clinical practice is to record all 5 parameters plus the total, however this archetype allows any partial information to be recorded, if that is all that is available eg from historical data. If the total is to be calculated, it is necessary for all 5 ordinal values to be recorded. The total is the sum of the five ordinal values (min 0, max 10). It is recognised that mnemonic learning aid for APGAR is commonly taught. For example, in English: A for Appearance (skin color), P for Pulse (heart rate), G for Grimace (reflex irritability), A for Activity (muscle tone), and R for Respiration. As this is not universally applicable for all languages, it is suggested that this mnemonic can be applied by renaming the data elements within templates if desired for a specific clinical scenario.

Stroke in French: Volet Accident Vasculaire Cérébral (AVC) - Multiprofessional evaluation post stroke (évaluation pluri professionnelle PostAVC)

- 7/6/17 - 14 forms, 6 itemgroups, 47 items, 3 languages
Itemgroups: Active pathologies and risk factors, Medical History, Physical Impairment, Limitation of Activity, Neuropsychological assessment, Personal milestones
source: http://esante.gouv.fr/sites/default/files/asset/document/ci-sis_contenu_volet_avc_v2.1.0.pdf

Care plan (Plan soins)

12 itemgroups, 41 items

Discharge letter stroke unit (document sortie d'unité neurovasculaire)

3 itemgroups, 26 items

Imaging results (Résultats d'imagerie)

6 itemgroups, 39 items

Initial therapy (Traitement initial)

3 itemgroups, 47 items
9 more forms meeting the search are available in the detailed view.

BRADEN SCALE - BRADEN SCALE

- 6/15/17 - 1 form, 1 itemgroup, 7 items, 4 languages
Itemgroup: 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.