Table 2.

Top 50 of most frequent concepts with absolute concept frequency and sorted by medical category^a.

No.	Concept	Documentation category	ACF	A	B	C	D	E
1	Patient internal identifier	Administrative/demographics	12	✓	✓	✓	✓
2	Patient name	Administrative/demographics	9	✓	✓	✓	✓
3	Gender	Administrative/demographics	9	✓	✓	✓	✓	✓
4	Patient date of birth, age	Administrative/demographics	19	✓	✓	✓	✓	✓
5	Date of admission	Administrative/demographics	13	✓	✓	✓	✓	✓
6	Discharge date	Administrative/demographics	12	✓	✓	✓	✓	✓
7	Living situation (alone, independent, or family home)	Administrative/demographics	17	✓	✓	✓	✓
8	Death (finding, date/time)	Administrative/demographics	18	✓	✓	✓	✓
9	Symptom findings in relation to time, time to treatment	Diagnostic/medical history	23	✓		✓	✓	✓
10	Diagnosis (transient ischemic attack, Ischemic stroke and localization, brain hemorrhage, and localization)	Diagnostic/medical history	132	✓	✓	✓	✓	✓
11	History of cerebrovascular accident and further medical history	Diagnostic/medical history	21	✓	✓	✓	✓
12	Etiology	Diagnostic/medical history	19	✓		✓	✓
13	Pre-existing conditions and risk factors	Diagnostic/medical history	104	✓	✓	✓	✓	✓
14	Vital signs (blood pressure, heart rate, SpO2, breathing rate, body temperature)	Diagnostic/medical history	67	✓	✓	✓	✓	✓
15	Neurologic symptoms and neurological deficit	Examination/follow-up	8	✓		✓
16	General physical examination	Examination/follow-up	65	✓	✓	✓	✓
17	National Institutes of Health Stroke Scale	Examination/follow-up	142	✓	✓	✓	✓	✓
18	Dysphagia/deglutition disorders	Examination/follow-up	23	✓	✓	✓		✓
19	Quality of vision-vision disorders?	Examination/follow-up	13	✓	✓
20	Modified Rankin Scale	Nursing issues, rehabilitation	25	✓	✓	✓	✓
21	Barthel index	Nursing issues, rehabilitation	17		✓	✓	✓
22	Diagnostic imaging (magnetic resonance imaging, computed tomography, and ultrasonography)	Apparatus-based diagnostics	73	✓	✓	✓
23	Angiography and digital subtraction	Apparatus-based diagnostics	9	✓	✓	✓		✓
24	Routine blood tests	Laboratory: blood panel	93	✓		✓	✓
25	Medication list	Medication	37	✓	✓	✓	✓	✓
26	Anticoagulants	Medication	43	✓	✓	✓	✓	✓
27	Antiplatelet agents	Medication	30	✓	✓	✓	✓	✓
28	Thrombolytic therapy	Treatment details	23	✓	✓	✓	✓	✓
29	Angioplasty and stenting	Treatment details	26	✓		✓
30	Physiotherapy and ergotherapy	Treatment details	38	✓	✓	✓

^aThe common data elements (CDEs) for physiotherapy and ergotherapy are listed together in the 30th line. Columns, A, B, C, D and E present the occurrence of CDEs in the documentations of the according contexts (findings in Figure 2: Context A: Clinical routine documentation (stroke units), Context B: Documentation from rehabilitation, Context C: Registries and quality standards, Context D: Documentation from clinical trial research, and Context E: International standards).