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EHR ×
- Routine documentation (271)
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- Released Standard (21)
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273 Search results.
Itemgroups: Demographics,Medical History,Medical device,Diagnosis,Procedure,Findings,Laboratory Findings,Medication,Scores&Classifications,Patient Characteristics
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 itemsBody - Diagnose (diagnosis)
2 itemgroups 6 itemsHeader
3 itemgroups 18 items Itemgroups: Demographics,Medical History,Diagnosis,Procedure,Findings,Laboratory Findings,Medication
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 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
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
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
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
Itemgroup: Pain NRS
Itemgroups: Current episode,Diagnosis,Current medication
Itemgroups: Medical History ,Finding,Clinical presentation,Initial therapy,Lab ,Psychiatrics,Epicrisis,Consultation,Clinical course,Mobilization and social service,Patient education and discharge,Procedere
Itemgroup: BRADEN SCALE