Keywords
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Table of contents
  1. 1. Clinical Trial
  2. 2. Routine Documentation
    1. 2.1. Admission
    2. 2.2. Medical History
    3. 2.3. Physical Examination
    4. 2.4. Assessment Score
    5. 2.5. Nursing Report
    6. 2.6. Apparative Diagnostics
    7. 2.7. Laboratory
    8. 2.8. Pathology/Histology
    9. 2.9. Consent
    10. 2.10. Therapy
    11. 2.11. Operative Report
    12. 2.12. Progress
    13. 2.13. Discharge Summary
    14. 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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- 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
- 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
- 5/23/17 - 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 items31

Body - Diagnose (diagnosis)

2 itemgroups, 6 items31

Header

3 itemgroups, 18 items31
- 4/19/16 - 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 items31
- 5/23/17 - 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
- 6/4/17 - 1 form, 3 itemgroups, 33 items, 2 languages
Itemgroups: Maternal Family History, Paternal Family History, Siblings Family History