Keywords
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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
Selected data models

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- 9/20/21 - 4 forms, 9 itemgroups, 26 items, 2 languages
Itemgroups: 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 itemgroups 36 items

Body - Diagnose (diagnosis)

2 itemgroups 6 items

Header

3 itemgroups 18 items
- 9/20/21 - 2 forms, 9 itemgroups, 52 items, 2 languages
Itemgroups: Care problem,Score,Care goal,Nursing procedure,Activities of daily living,Homecare Status,Social Environment,Legal Aspects,Medical information

Header

3 itemgroups 18 items
- 7/20/19 - 1 form, 6 itemgroups, 55 items, 1 language
Itemgroups: Case data,Medical Department data,Diagnosis details,Procedure Details,PIA-Documentation of services,Modell project
- 9/27/21 - 1 form, 21 itemgroups, 341 items, 2 languages
Itemgroups: 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
- 6/8/17 - 1 form, 36 itemgroups, 383 items, 2 languages
Itemgroups: 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
- 9/20/21 - 1 form, 15 itemgroups, 54 items, 3 languages
Itemgroups: Allergy,Medical Alert Information,History of Past Illness,Social History,Pregnancy History,Vaccination,Medical Devices and Implants,Medical problems (current),Vital Signs Observations,Diagnostic Tests,Disability or function,Medication,Surgical Procedure,Treatments,Care plan
- 6/25/21 - 1 form, 11 itemgroups, 110 items, 2 languages
Itemgroups: History and Physical Examination Elements,Patient History,Family History,Patient Assessment,Laboratory Results Elements,Diagnostic and Therapeutic Procedures Elements,Diagnostic Procedure Results,Therapeutic Procedures,Therapeutic Procedure Device Implants,Pharmacological Therapy Data Elements,Outcomes Data Elements

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