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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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Family history - HIS

- 6/4/17 - 1 form, 3 itemgroups, 33 items, 2 languages
Itemgroups: Maternal Family History, Paternal Family History, Siblings Family History
Form from HIS OpenVistA

HIS Review of Systems - HIS

- 9/20/21 - 1 form, 13 itemgroups, 111 items, 2 languages
Itemgroups: GENERAL, EYE, EAR, NOSE, MOUTH, RESPIRATORY, CARDIOVASCULAR, GASTROINTESTINAL, GENITOURINARY, MUSCULOSKELETAL, NEUROLOGIC, PAIN, GERIATRIC
Form from HIS OpenVistA

Polyclinic Medical History University Hospital Cologne

- 3/5/17 - 1 form, 13 itemgroups, 77 items, 1 language
Itemgroups: Patient data, Vital Signs, Medical History, Medication, Operative Surgical Procedures, Pregnancy, Pregnancy, Medical History, Physical Examination, Ultrasonography, Diagnosis, Procedure, Signature
Hospital Routine Documentation Subform at the University Hospital Cologne. Original Form Name: Poliklinik Anamnese

Clinical Documentation Med. V Medical History B symptoms - F.1

- 8/17/23 - 1 form, 6 itemgroups, 56 items, 2 languages
Itemgroups: IG.1, IG.2, IG.3, IG.4, IG.5, IG.6
Documentation of medical history for patients who present themselves in the outpatient clinic of Medical Clinic V - Clinic for Haematology, Oncology, Rheumatology - Heidelberg University Hospital

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 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 - 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

SHORT STAY RECORD ID NOTE-ENDO - HIS

- 9/27/21 - 1 form, 4 itemgroups, 94 items, 2 languages
Itemgroups: SHORT STAY RECORD ID NOTE-ENDO, Chief Complaint, Physical Exam, Prior Medical History
Form from HIS OpenVista

EHR Medical History Cardiac Patients - Anamnese Kardiologische Patienten

- 9/27/21 - 1 form, 2 itemgroups, 68 items, 2 languages
Itemgroups: Medical History, Indication and clinical question
EHR Medical History Cardiac Patients. From the University Hospital of Münster, Germany, Department of Nuclear Medicine. AN MS MSZ Studie NUK

Pediatric oncology (Kinderonkologie) - Medical history (Anamnese)

- 9/27/21 - 1 form, 8 itemgroups, 74 items, 2 languages
Itemgroups: Pregnancy, Childbirth, Postpartum development, Kindergarten / school, Puberty stage, Other information, Physical examination basic information, Physical examination (further information)
This form about medical history originates from the Department of Pediatric Oncology, Hematology and Clinical Immunology of the University Hospital Düsseldorf.

ASIA Score

- 9/20/21 - 1 form, 1 itemgroup, 154 items, 2 languages
Itemgroup: ASIA Classification
Original Form name: ASIA Score. INTERNATIONAL STANDARDS FOR NEUROLOGICAL CLASSIFICATION OF SPINAL CORD INJURY (ISNCSCI) Owner: American Spinal Injury Association. Used as Hospital Routine Documentation Form at the University Hospital Muenster.

Patient Admision Pediatric Hematology and Oncology UK Muenster

- 9/20/21 - 1 form, 18 itemgroups, 195 items, 2 languages
Itemgroups: Patient, Father, Mother, Living arrangement, Sibling, Medical history, Nursing support, Support device, Personal aids, School, Kindergarten, workshop, Therapies in school, kindergarten, workshop, Medication, Medication history, Therapy, Nutrition, Continence, Catheters and drainages, Other
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

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