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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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70 Search results.
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Physician letter (short)

- 3/15/21 - 1 form, 3 itemgroups, 302 items, 1 language
Itemgroups: Current episode, Diagnosis, Current medication
derived from http://www.arztbriefmanager.de/ (Dr. Wolfram Arends, Tutzing, Germany)

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

OPAP DiagProz Sub SVF University Hospital Muenster (UKM) Subform

- 9/27/21 - 1 form, 2 itemgroups, 25 items, 1 language
Itemgroups: Diagnoses, Procedures
Hospital Routine Documentation Subform at the University Hospital Muenster. Original Form name: OPAP DiagProz Sub SVF

Swedish Stroke Registry RIKSSTROKE - Acute Phase for Registration of Stroke

- 9/20/21 - 1 form, 12 itemgroups, 122 items, 2 languages
Itemgroups: Acute Phase for Registration of Stroke - Personal Information, Sequence of care, Aftercare, ADL/Accommodation BEFORE ONSET of stroke, Risk Factors Stroke, Acute Care/Diagnosis Stroke, Pharmaceutical Treatment, Thrombolysis, Thrombectomy, Hemicraniectomy, Information and Follow-up, Rehabilitation
Schwedisches Schlaganfallregister RIKSSTROKE Quelle: http://www.riksstroke.org/eng/ Riksstroke – a Swedish national quality register for stroke care primarily aimed at health professionals and decision makers in health care. We collect, analyze and follow-up data on morbidity and hospital stay. Acute Phase for Registration of Stroke

Premedication Example 2 Routine documentation in German hospitals DMI

- 9/20/21 - 1 form, 20 itemgroups, 158 items, 2 languages
Itemgroups: Patient data, Physical parameters, Medical procedure, Preoperative state; risk factors, ECG, heart, lungs, circulatory system, Neurology, metabolism, Other findings, Laboratory, Blood test, Anticoagulation, assessment Preoperative, instructions preoperative, Transfusion, criteria surgery, food intake, Premedication
Routine documentation in German hospitals. Source file name: TH130110_Prämedikationsprotokoll Examplary forms provided by DMI (http://www.dmi.de/)

Premedication Example 1 Routine documentation in German hospitals DMI

- 9/20/21 - 1 form, 9 itemgroups, 74 items, 2 languages
Itemgroups: Patient data, Laboratory values, risk assessment Organ function, Preoperative assessment, Medical procedure, Checklist, Medication, Further instructions, Further information
Routine documentation in German hospitals. Source file name: TH130110_Prämedikationsprotokoll Examplary forms provided by DMI (http://www.dmi.de/)

Birth sheet, obstetric sheet Routine documentation in German hospitals DMI

- 9/20/21 - 1 form, 6 itemgroups, 44 items, 2 languages
Itemgroups: General information, Medical history, Medical examination, General findings, Current pregnancy, Current pregnancy complications
Routine documentation in German hospitals. Source file name: SD070109_Geburtenbogen. Examplary forms provided by DMI (http://www.dmi.de/)

Lebendspende NTX Befund MS University Hospital Muenster (UKM)

- 9/20/21 - 1 form, 3 itemgroups, 52 items, 1 language
Itemgroups: General information, Diagnostics of antigens and antibodies, Examinations
Hospital Routine Documentation Form at the University Hospital Muenster. Original Form name: Lebendspende NTX Befund MS.

ASIA score

- 9/20/21 - 1 form, 8 itemgroups, 29 items, 1 language
Itemgroups: Patient information, Sensory- Key sensory points, Total score sensory, Motor- Key muscles, Total score motor, Neurological levels, Zone of partial preservation, Classification
Items used as routine documentation by the university hospital muenster. Derived from original form "Biobank MS". converted to ODM format.

epSOS Illnesses and Disorders

- 9/20/21 - 1 form, 1 itemgroup, 1 item, 2 languages
Itemgroup: epSOS Illnesses and Disorders
epSOSIllnessesandDisorders Value Set 1.3.6.1.4.1.12559.11.10.1.3.1.42.5 derived from http://www.epsos.eu/ and http://decor.nictiz.nl/art-decor/decor-datasets--epsos-

Test task - Patient admission form

- 9/20/21 - 1 form, 6 itemgroups, 118 items, 1 language
Itemgroups: Personal information, Admission information, Complaints, Physical examination, Past medical history, Diagnosis
Test task

Systemic lupus erythematosus EBMT General Information Form

- 9/17/21 - 1 form, 16 itemgroups, 118 items, 1 language
Itemgroups: GENERAL INFORMATION, Patient, Disease, SYSTEMIC LUPUS ERITHEMATOSUS (SLE), INITIAL DIAGNOSIS, DIAGNOSTIC CRITERIA FOR SYSTEMIC LUPUS ERYTHEMATOSUS, FIRST LINE THERAPIES, DATE OF HSCT, STATUS OF DISEASE AT MOBILISATION, SLEDAI (Systemic Lupus Erythematosus Disease Activity Index) score, LABORATORY VALUES, PATIENT’S SELF ASSESSMENT PRIOR TO MOBILISATION, HEALTH ASSESSMENT QUESTIONNAIRE (HAQ), STATUS OF DISEASE AT HSCT, ADDITIONAL TREATMENT POST-HSCT, FORMS TO BE FILLED IN
ODM form derived from 119pp EBMT SLE 16SLE please refer to: http://www.ebmt.org/Contents/Data-Management/Registrystructure/MED-ABdatacollectionforms/Pages/MED-AB-data-collection-forms.aspx

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