archetype (adl_version=1.4; uid=72c2594f-25df-4153-91f1-e831fef5e49b) openEHR-EHR-CLUSTER.problem_qualifier_local.v0 concept [at0000] -- Problem/Diagnosis qualifier language original_language = <[ISO_639-1::en]> translations = < ["de"] = < language = <[ISO_639-1::de]> author = < ["name"] = <"Simon Schumacher"> ["organisation"] = <"HiGHmed"> ["email"] = <"sschuma9@uni-koeln.de"> > > ["nb"] = < language = <[ISO_639-1::nb]> author = < ["name"] = <"John Tore Valand, Silje Ljosland Bakke"> ["organisation"] = <"Helse Bergen HF, Nasjonal IKT HF"> > > ["pt-br"] = < language = <[ISO_639-1::pt-br]> author = < ["name"] = <"Marivan Abrahão, Gabriela Alves, Adriana Kitajima e Maria Ângela Scatena"> ["organisation"] = <"Core Consulting"> ["email"] = <"contato@coreconsulting.com.br"> > accreditation = <"Hospital Alemão Oswaldo Cruz (HAOC)"> > ["sl"] = < language = <[ISO_639-1::sl]> author = < ["name"] = <"mag. Biljana Prinčič"> ["organisation"] = <"Marand d.o.o., Ljubljana, Slovenija"> ["email"] = <"biljana.princic@marand.si"> > > > description original_author = < ["name"] = <"Dr Ian McNicoll"> ["organisation"] = <"freshEHR Clinical Informatics, United Kingdom"> ["email"] = <"ian@freshehr.com"> ["date"] = <"2013-05-29"> > details = < ["de"] = < language = <[ISO_639-1::de]> purpose = <"Zur Darstellung eines klinischen, kontextspezifischen oder zeitspezifischen Attributs für ein spezifisches Problem oder eine spezifische Diagnose. "> use = <"Zur Darstellung eines kontextspezifischen oder zeitspezifischen Attributs, welches weitere Details liefert, die zum Zeitpunkt der Aufnahme, oder im klinischen Kontext in dem das Problem, oder die Diagnose aufgezeichnet wurde, relevant ist. Das Attribut könnte zu einer anderen Zeit, oder in einem anderen klinischen Kontext, nicht angemessen sein. Dieser Archetyp wurde entworfen, um in den Status SLOT des EVALUATION.problem_diagnosis Archetyps eingefügt zu werden. Die Absicht des EVALUATION.problem_diagnosis Archetypen ist es alle Informationen zu beinhalten, die in allen Kontexten relevant sein könnten. Dieser Archetyp hingegen soll nur Informationen beschreiben, welche von dem Gebrauchskontext abhängen. WICHTIGE ANMERKUNG ZUM IMPLEMENTIEREN DES ARCHETYPEN: -Es ist weder die Absicht, noch wird impliziert, dass irgendein, oder alle Attribute in dem gleichen Kontext, oder in dem gleichen Zeitraum genutzt werden sollten. Im Gegensatz zu dem üblichen Entwurf von Archetypen, wurde dieser Archetyp absichtlich so gestaltet, dass oft genutzte Attribute an einem Platz gesammelt werden können. Dies gewährleistet eine einfache Standardisierung eines sonst sehr wirren Gebietes der klinischen Praxis. Es ist uns bewusst, dass die Datenelemente in diesem Archetypen viele verschiedene Konzepte, und teilweise auch konkurrierende Konzepte, einschließen. Dies wurde hauptsächlich gemacht um die Notwendigkeit von mehreren, meist nur wenige Elemente beinhaltenden, Attribut-Archetypen zu vermeiden. -Manche Datenelemente sind unter Umständen widersprüchlich, wenn Sie gleichzeitig in dem selben Kontext genutzt werden. Zum Beispiel würde die Nutzung eines \"inaktiven\" Problems, zusammen mit einer \"anhaltenden\" Episode keinen Sinn ergeben. Aus diesem Grund sollten diese Status Attribute mit hoher Sorgfalt genutzt werden. Sie können zwar variabel angewandt werden, aber in dem praktischen Gebrauch kann die Interoperabilität nur gewährleistet werden, wenn die Richtlinien innerhalb der klinischen Gemeinschaft in welcher das \"Problem/Diagnose\" und \"Problem/Diagnose Attribut\" Archetyp-Paar ausgetauscht wird, klar definiert sind. Eine komplette DRG Kodierung setzt eine Kombination aus DRG-verwandten Datenelementen dieses Archetypen und von Datenelementen anderer Archetypen voraus. "> keywords = <"Problem", "Aktiv", "Inaktiv", "Status", "Episode", "Diagnose", "Attribut"> misuse = <"Nicht zur Darstellung einer Differenzialdiagnose - nutze den Archetypen EVALUATION.differential_diagnosis für diesen Zweck. Nicht zur Darstellung der diagnostischen Sicherheit - nutze das \"Diagnostic certainty\" Datenelement innerhalb des EVALUATION.problem/diagnosis Archetypen für diesen Zweck."> > ["nb"] = < language = <[ISO_639-1::nb]> purpose = <"For å registrere en kontekstspesifikk eller tidsspesifikk kvalifikator for et problem eller en diagnose."> use = <"Brukes for å registrere en kontekstspesifikk eller tidsspesifikk kvalifikator som gir ytterligere detaljer som er relevante på tidspunktet man registrerer et problem eller en diagnose. Kvalifikatoren er ikke nødvendigvis passende på et annet tidspunkt eller i en annen klinisk sammenheng. Denne arketypen skal brukes i SLOTet \"Status\" i arketypen EVALUATION.problem_diagnosis (Problem/diagnose). Intensjonen er at EVALUATION.problem_diagnosis-arketypen skal inneholde all informasjonen som gjelder i alle sammenhenger, i motsetning til denne arketypen som skal inneholde informasjonen som avhenger av brukssammenheng. VIKTIG INFORMASJON FOR IMPLEMENTERING: - Det er ikke meningen eller implisert at alle disse kvalifikatorene skal brukes i den samme sammenhengen eller det samme tidsperioden. I motsetning til den vanlige måten å lage arketyper på, er denne arketypen laget for å samle flere vanlige kvalifikatorer på ett sted for å forsøksvis oppnå et visst nivå av standardisering innenfor et ganske innfløkt område av klinisk praksis. Det erkjennes at dataelementene i denne arketypen omfatter mange forskjellige, og til dels også konkurrerende, konsepter. Dette ble gjort hovedsakelig for å unngå behov for å ha mange arketyper for kvalifikatorer, der hver av dem kun inneholder ett eller to dataelementer. - Noen av disse dataelementene er potensielt direkte motstridende dersom de brukes samtidig og i den samme sammenhengen. For eksempel gir det ikke mening å ha et \"inaktivt\" problem innenfor en \"pågående\" episode. Av den grunn bør disse kvalifikatorene brukes med stor omhu, siden de i praksis vil brukes for varierende formål, og interoperabilitet kan ikke garanteres med mindre det er definert klare retningslinjer for bruk innenfor de kliniske omstendighetene der \"Problem/diagnose\"- og \"Problem/diagnose-kvalifikatorer\"-arketypeparet brukes. Fullstendig DRG-koding vil kreve DRG-relaterte dataelementer fra denne arketypen, i kombinasjon med elementer fra andre arketyper."> keywords = <"problem", "aktivt", "inaktivt", "status", "episode", "tilstand", "aktiv", "inaktiv", "remisjon", "kronisk", "akutt"> misuse = <"Brukes ikke for å representere differensialdiagnoser. Bruk arketypen EVALUATION.differential_diagnosis for dette formålet. Brukes ikke for å representere diagnostisk sikkerhet. Bruk elementet \"Diagnostisk sikkerhet\" i arketypen EVALUATION.problem_diagnosis."> copyright = <"© openEHR Foundation, HiGHmed"> > ["pt-br"] = < language = <[ISO_639-1::pt-br]> purpose = <"Para gravar um ou mais qualificadores de estado clínico, específicos do contexto ou do tempo, para um problema ou diagnóstico específico"> use = <"Use para gravar um ou mais qualificadores relevantes que fornecem detalhes adicionais de contexto específico ou de tempo específico e que sejam relevantes no momento do registro de um problema ou diagnóstico, ou dentro do contexto clínico onde é registrado, mas que pode não ser apropriado em outro tempo ou em outro contexto clínico. Este arquétipo foi desenvolvido para ser incluído no slot do Estado no arquétipo EVALUATION.problem_diagnosis archetype. Estes qualificadores de estado devem ser usados com cuidado, pois eles são variáveis aplicados na prática e a interoperabilidade não pode ser assegurada, salvo se as diretrizes de uso forem claramente definidas dentro da comunidade clínica em que o par de arquétipos 'Problema / Diagnóstico\" e \"Estado do problema' podem ser compartilhados. A codificação DRG completa vai exigir os elementos de dados DRG deste arquétipo e o arquétipo CLUSTER.procedure_status equivalente, utilizado dentro do arquétipo ACTION.procedure, além de atributos sobre o paciente. O elemento de dados 'não especificado' foi adicionado para facilitar a adição de outros qualificadores que só podem ser usados localmente ou quando o caso de uso não foi claramente estabelecido no momento em que este arquétipo foi publicado. Como outros qualificadores são identificados, eles podem ser adicionados a este arquétipo como uma revisão retroativa."> keywords = <"problema", "ativo", "inativo", "estado", "episódio", "diagnóstico"> misuse = <"Não deve ser usado para representar um diagnóstico diferencial - use o arquétipo EVALUATION.differential_diagnosis para esta finalidade."> copyright = <"© openEHR Foundation, HiGHmed"> > ["sl"] = < language = <[ISO_639-1::sl]> purpose = <"Za zapisovanje različnih statusov, ki se ponavadi uporablja za aplikacijskimi in kliničnimi sporočili, ki so odvisna od definirane vsebine "> use = <"Za dodeljevanje pravic EVALUATION.problem_diagnosis.v1 archetype, dodaja informacije za povezovanje. "> keywords = <"problem", "aktiven", "ni aktiven"> misuse = <"It should not be assumed that these qualifiers are safely interoperable unless further definition and alignment is agreed between all sharing parties. A problem which has been defined as 'Inactive' during a hospital admission cannot be assumed to be regarded as 'Inactive' in a primary care setting , where a much longer term perspective is being taken. Similarly terms such as Initial, Interim and Final, whilst helpful to the human observer are unlikely to be precisely enough defined to be safely computable e.g. for decision support. "> copyright = <"© openEHR Foundation, HiGHmed"> > ["en"] = < language = <[ISO_639-1::en]> purpose = <"To record a clinical context-specific or time-specific qualifier for a specified problem or diagnosis."> use = <"Use to record a relevant context-specific or time-specific qualifier that provides additional detail which is relevant at the time of recording or within the clinical context where a problem or diagnosis is recorded. The qualifier may not be appropriate at another time or in another clinical context. This archetype is designed to be included in Status SLOT in the EVALUATION.problem_diagnosis archetype. The intent is for the EVALUATION.problem_diagnosis archetype to hold all of the information that applies in all contexts, in contrast to this archetype describing only information that depends on the context of use. IMPORTANT NOTES FOR IMPLEMENTATION: - It is not intended or implied that any or all of these qualifiers should be used within the same context or period of time. In contrast to the usual design of archetypes, this archetype has been deliberately designed to collect a number of common qualifiers into one place in an effort to attempt some simple standardisation within a very messy area of clinical practice. It is acknowledged that the data elements contained in this archetype embrace many different, and sometimes even competing, concepts. This has been done mainly to prevent the need for multiple qualifier archetypes, each containing only one or two data elements. - Some of these data elements are potentially directly conflicting if used simultaneously within the same context, for example it would not make sense to have an 'inactive' problem together with an Episode that is 'ongoing'. As such, these status qualifiers should be used with extreme care as they are variably applied in practice and interoperability cannot be assured unless usage guidelines are clearly defined within the clinical community in which the 'Problem/Diagnosis' and 'Problem/Diagnosis qualifier' archetype pair may be shared. Full DRG coding will require the DRG-related data elements from this archetype in combination with data elements from other archetypes."> keywords = <"problem", "active", "inactive", "status", "episode", "diagnosis"> misuse = <"Not to be used to represent a differential diagnosis - use the archetype EVALUATION.differential_diagnosis for this purpose. Not to be used to represent diagnostic certainty - use the 'Diagnostic certainty' data element within the EVALUATION.problem_diagnosis archetype."> copyright = <"© openEHR Foundation, HiGHmed"> > > lifecycle_state = <"rejected"> other_contributors = <"Nadim Anani, Karolinska Institutet, Sweden", "Erling Are Hole, Helse Bergen, Norway", "Vebjørn Arntzen, Oslo University Hospital, Norway", "Koray Atalag, University of Auckland, New Zealand", "Silje Ljosland Bakke, Nasjonal IKT HF, Norway (openEHR Editor)", "Malin Berg, DIPS ASA, Norway", "Lars Bitsch-Larsen, Haukeland University hospital, Norway", "Alexander Davey, HSC NI, United Kingdom", "Aitor Eguzkitza, UPNA (Public University of Navarre) - CHN (Complejo Hospitalario de Navarra), Spain", "Arild Faxvaag, NTNU, Norway", "Shahla Foozonkhah, Iran ministry of health and education, Iran", "Einar Fosse, National Centre for Integrated Care and Telemedicine, Norway", "Bente Gjelsvik, Helse Bergen, Norway", "Heather Grain, Llewelyn Grain Informatics, Australia", "Sam Heard, Ocean Informatics, Australia", "Andreas Hering, Helse Bergen HF, Haukeland universitetssjukehus, Norway", "Anca Heyd, DIPS ASA, Norway", "Hilde Hollås, DIPS AS, Norway", "Evelyn Hovenga, EJSH Consulting, Australia", "Lars Ivar Mehlum, Helse Bergen HF, Norway", "Tom Jarl Jakobsen, Helse Bergen, Norway", "Lars Morgan Karlsen, DIPS ASA, Norway", "Shinji Kobayashi, Kyoto University, Japan", "Sabine Leh, Haukeland University Hospital, Department of Pathology, Norway", "Heather Leslie, Atomica Informatics, Australia (openEHR Editor)", "Hugh Leslie, Ocean Informatics, Australia", "Hallvard Lærum, Norwegian Directorate of e-health, Norway", "Chunlan Ma, Ocean Informatics, Australia", "Luis Marco Ruiz, NST, Spain", "Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (openEHR Editor)", "Bjørn Næss, DIPS ASA, Norway", "Andrej Orel, Marand d.o.o., Slovenia", "Jussara Rotzsch, Hospital Alemão Oswaldo Cruz, Brazil", "Thomas Schopf, University Hospital of North-Norway, Norway", "Anoop Shah, University College London, United Kingdom", "Line Silsand, Universitetssykehuset i Nord-Norge, Norway", "Line Sæle, Nasjonal IKT HF, Norway", "Nyree Taylor, Ocean Informatics, Australia", "Richard Townley-O'Neill, Australian Digital Health Agency, Australia", "Jon Tysdahl, Furst medlab AS, Norway", "Gro-Hilde Ulriksen, Norwegian center for ehealthresearch, Norway", "John Tore Valand, Helse Bergen, Norway (openEHR Editor)"> other_details = < ["licence"] = <"This work is licensed under the Creative Commons Attribution-ShareAlike 3.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/3.0/."> ["custodian_organisation"] = <"HiGHmed"> ["references"] = <"Derived from: "> ["current_contact"] = <"Heather Leslie, Atomica Informatics"> ["original_namespace"] = <"org.highmed"> ["original_publisher"] = <"HiGHmed"> ["custodian_namespace"] = <"org.highmed"> ["MD5-CAM-1.0.1"] = <"9DB3D4FD1ADD7F7FAF421EBB99A4CE75"> ["build_uid"] = <"1b972de2-eda5-4eb4-9d57-a0ccca7b60ca"> ["ip_acknowledgements"] = <"This artefact includes content from SNOMED Clinical Terms® (SNOMED CT®) which is copyrighted material of the International Health Terminology Standards Development Organisation (IHTSDO). Where an implementation of this artefact makes use of SNOMED CT content, the implementer must have the appropriate SNOMED CT Affiliate license - for more information contact http://www.snomed.org/snomed-ct/get-snomedct or info@snomed.org."> ["revision"] = <"0.0.1"> > definition CLUSTER[at0000] matches { -- Problem/Diagnosis qualifier items cardinality matches {1..*; unordered} matches { ELEMENT[at0004] occurrences matches {0..1} matches { -- Diagnostic status value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0016, -- Preliminary at0017, -- Working at0018, -- Established at0088] -- Refuted } } } } ELEMENT[at0060] occurrences matches {0..1} matches { -- Current/Past? value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0062, -- Current at0061] -- Past } } } } ELEMENT[at0003] occurrences matches {0..1} matches { -- Active/Inactive? value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0026, -- Active at0027] -- Inactive } } } } ELEMENT[at0083] occurrences matches {0..1} matches { -- Resolution phase value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0085, -- Resolving at0086, -- Not resolving at0084, -- Resolved at0087, -- Indeterminate at0098] -- Relapsed } } } } ELEMENT[at0089] occurrences matches {0..1} matches { -- Remission status value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0090, -- In complete remission at0092, -- Not in remission at0093] -- Indeterminate } } } } ELEMENT[at0001] occurrences matches {0..1} matches { -- Episodicity value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0034, -- New at0035, -- Ongoing at0070] -- Indeterminate } } } } ELEMENT[at0095] occurrences matches {0..1} matches { -- Occurrence value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0096, -- First occurrence at0097] -- Recurrence } } } } ELEMENT[at0077] occurrences matches {0..1} matches { -- Course label value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0081, -- Acute at0094, -- Acute-on-chronic at0079] -- Chronic } } } } ELEMENT[at0063] occurrences matches {0..*} matches { -- Diagnostic category value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0064, -- Principal diagnosis at0066, -- Secondary diagnosis at0076] -- Complication } } DV_TEXT matches {*} } } ELEMENT[at0073] occurrences matches {0..1} matches { -- Admission diagnosis? value matches { DV_BOOLEAN matches { value matches {true} } } } } } ontology terminologies_available = <"SNOMED-CT", ...> term_definitions = < ["en"] = < items = < ["at0000"] = < text = <"Problem/Diagnosis qualifier"> description = <"Contextual or temporal qualifier for a specified problem or diagnosis."> > ["at0001"] = < text = <"Episodicity"> description = <"Category of this episode for the identified problem/diagnosis."> comment = <"For example: 'New' will enable clinicians to distinguish a new, acute episode of otitis media that may have arisen soon after a previous diagnosis, to distinguish it from an unresolved or 'Ongoing' diagnosis of chronic otitis media. Treatment of recurring, new and acute, episodes of a condition may differ significantly from the same condition that is not resolving or responding to treatment. In many situations the clinician will not be able to tell, and so indeterminate may be appropriate."> > ["at0003"] = < text = <"Active/Inactive?"> description = <"Category that supports division of problems and diagnoses into Active or Inactive problem lists."> comment = <"The Active/Inactive and Current/Past data elements have similar clinical impact but represent slightly different semantics. Both are actively used in different clinical settings, but usually not together. If a Current/Past qualifier is recorded, then this data element is likely to be redundant. An exception where a condition can be current but inactive is asthma that is not causing acute symptoms."> > ["at0004"] = < text = <"Diagnostic status"> description = <"Stage or phase of diagnostic process."> comment = <"The status is usually determined by a combination of the timing of diagnosis plus level of clinical certainty resulting from diagnostic tests and clinical evidence available. This data element and 'Diagnostic certainty' in EVALUATION.problem_diagnosis are two important axes of the diagnostic process, and valid combinations will need to be presented by software that exposes both data elements, so it is not possible for users to select conflicting combinations. Preliminary or working diagnoses are intended to represent the single most likely choice out of all differential diagnosis options."> > ["at0016"] = < text = <"Preliminary"> description = <"The initial diagnosis made, usually associated with a low level of clinical certainty. It may change as test results or advice become available."> > ["at0017"] = < text = <"Working"> description = <"Interim diagnosis, based on a reasonable amount of clinical certainty but pending further test results or clinical advice. It may still change as test results or advice become available."> > ["at0018"] = < text = <"Established"> description = <"Final substantiated diagnosis, based on a high level of clinical certainty, which may include clinical evidence from test results. It is not expected to change."> > ["at0026"] = < text = <"Active"> description = <"The problem or diagnosis is currently active and clinically relevant."> > ["at0027"] = < text = <"Inactive"> description = <"The problem or diagnosis is not completely resolved but is inactive or felt less relevant to the current clinical context."> > ["at0034"] = < text = <"New"> description = <"A new occurrence of either a new or existing problem or diagnosis. A flag for 'First occurrence' can be recorded separately to distinguish the first from other occurrences."> > ["at0035"] = < text = <"Ongoing"> description = <"The issue, problem or diagnosis continues, without new, acute episodes occurring."> > ["at0060"] = < text = <"Current/Past?"> description = <"Category that supports division of problems and diagnoses into Current or Past problem lists."> comment = <"The Current/Past and Active/Inactive data elements have similar clinical impact but represent slightly different semantics. Both are actively used in different clinical settings, but usually not together. If an Active/Inactive qualifier is recorded, then this data element is likely to be redundant. An exception where a condition can be current but inactive is asthma that is not causing acute symptoms."> > ["at0061"] = < text = <"Past"> description = <"An issue which ocurred in the past."> > ["at0062"] = < text = <"Current"> description = <"An issue occuring at present."> > ["at0063"] = < text = <"Diagnostic category"> description = <"Category of the problem or diagnosis within a specified episode of care and/or local care context."> comment = <"This data element contains a value set commonly used in diagnostic categorisation. In episodic care contexts (commonly secondary care) it is common to categorise/organise diagnoses according to their relationship to the principal diagnosis being addressed during that episode of care. These categories may also be used for clinical coding, reporting and billing purposes. In some countries the diagnostic category may be known as a DRG. In addition, the free text choice permits use of other local value sets, as required."> > ["at0064"] = < text = <"Principal diagnosis"> description = <"The diagnosis determined to be chiefly responsible for occasionaing an episode of admitted patient care, an episode of residential care or an attendance at the health care establishment."> > ["at0066"] = < text = <"Secondary diagnosis"> description = <"A problem or diagnosis that is occurs at the same time as the primary problem or diagnosis. May also be known as a comorbid condition."> > ["at0070"] = < text = <"Indeterminate"> description = <"It is not possible to determine if this occurrence of the problem or diagnosis is new or ongoing."> > ["at0073"] = < text = <"Admission diagnosis?"> description = <"Was the problem or diagnosis present at admission?"> comment = <"Record as True if the problem or diagnosis was present on admission. This data element is a requirement from DRG reporting in some countries."> > ["at0076"] = < text = <"Complication"> description = <"An unfavorable evolution of a problem or diagnosis."> > ["at0077"] = < text = <"Course label"> description = <"Category reflecting the speed of onset and/or duration and persistence of the problem or diagnosis."> comment = <"Definitions of acute vs chronic will differ for each diagnosis."> > ["at0079"] = < text = <"Chronic"> description = <"A problem or diagnosis with persistent or long-lasting effects, or that evolves over time."> > ["at0081"] = < text = <"Acute"> description = <"A problem or diagnosis with a rapid onset, a short course, or both."> > ["at0083"] = < text = <"Resolution phase"> description = <"Phase of healing for an acute problem or diagnosis."> comment = <"For example: tracking the progress of resolution of a middle ear infection."> > ["at0084"] = < text = <"Resolved"> description = <"Problem or diagnosis has completed the normal phases of restoration or healing and can be considered resolved."> > ["at0085"] = < text = <"Resolving"> description = <"Problem or diagnosis is progressing satisfactorily through the normal stages of restoration or healing towards resolution."> > ["at0086"] = < text = <"Not resolving"> description = <"Problem or diagnosis is not progressing satisfactorily through the normal stages of restoration or healing towards resolution."> > ["at0087"] = < text = <"Indeterminate"> description = <"It is not possible to determine the resolution or healing status of the problem or diagnosis."> > ["at0088"] = < text = <"Refuted"> description = <"The previously recorded diagnosis has been clinically reassessed or disproved with a high level of clinical certainty. This status is used to correct an error in the health record."> > ["at0089"] = < text = <"Remission status"> description = <"Status of the remission of an incurable diagnosis."> comment = <"For example: the status of a cancer or haematological diagnosis."> > ["at0090"] = < text = <"In complete remission"> description = <"No ongoing signs or symptoms of the disease have been identified."> > ["at0092"] = < text = <"Not in remission"> description = <"No diminution of the signs or symptoms of the disease have been identified."> > ["at0093"] = < text = <"Indeterminate"> description = <"It is not possible to determine if there have been diminution of the signs or symptoms of the disease have been identified."> > ["at0094"] = < text = <"Acute-on-chronic"> description = <"A problem or diagnosis with an acute exacerbation of a chronic condition."> > ["at0095"] = < text = <"Occurrence"> description = <"Category of the occurrence for this problem or diagnosis."> comment = <"This data element can be an additional qualifier to the 'New' value in the 'Episodicity' value set, that is a condition such as asthma can have recurring new episodes that have periods of resolution in between. However it can be important to identify the first ever episode of asthma from all of the other episodes."> > ["at0096"] = < text = <"First occurrence"> description = <"This is the first ever occurrence of this problem or diagnosis."> > ["at0097"] = < text = <"Recurrence"> description = <"New occurrence of the same problem or diagnosis after a previous episode was resolved."> > ["at0098"] = < text = <"Relapsed"> description = <"Problem or diagnosis has deteriorated after a period of temporary improvement."> > > > ["sl"] = < items = < ["at0000"] = < text = <"*Problem/Diagnosis qualifier(en)"> description = <"*Contextual or temporal qualifier for a specified problem or diagnosis.(en)"> > ["at0001"] = < text = <"*Episodicity(en)"> description = <"*Category of this episode for the identified problem/diagnosis.(en)"> comment = <"*For example: 'New' will enable clinicians to distinguish a new, acute episode of otitis media that may have arisen soon after a previous diagnosis, to distinguish it from an unresolved or 'Ongoing' diagnosis of chronic otitis media. Treatment of recurring, new and acute, episodes of a condition may differ significantly from the same condition that is not resolving or responding to treatment. In many situations the clinician will not be able to tell, and so indeterminate may be appropriate.(en)"> > ["at0003"] = < text = <"*Active/Inactive?(en)"> description = <"*Category that supports division of problems and diagnoses into Active or Inactive problem lists.(en)"> comment = <"*The Active/Inactive and Current/Past data elements have similar clinical impact but represent slightly different semantics. Both are actively used in different clinical settings, but usually not together. If a Current/Past qualifier is recorded, then this data element is likely to be redundant. An exception where a condition can be current but inactive is asthma that is not causing acute symptoms.(en)"> > ["at0004"] = < text = <"*Diagnostic status(en)"> description = <"*Stage or phase of diagnostic process.(en)"> comment = <"*The status is usually determined by a combination of the timing of diagnosis plus level of clinical certainty resulting from diagnostic tests and clinical evidence available. This data element and 'Diagnostic certainty' in EVALUATION.problem_diagnosis are two important axes of the diagnostic process, and valid combinations will need to be presented by software that exposes both data elements, so it is not possible for users to select conflicting combinations. Preliminary or working diagnoses are intended to represent the single most likely choice out of all differential diagnosis options.(en)"> > ["at0016"] = < text = <"*Preliminary(en)"> description = <"*The initial diagnosis made, based on limited available clinical evidence. It may change as test results or advice become available.(en)"> > ["at0017"] = < text = <"*Working(en)"> description = <"*Interim diagnosis, based on substantiated clinical evidence but pending further test results or clinical advice. It may still change as test results or advice become available.(en)"> > ["at0018"] = < text = <"*Established(en)"> description = <"*Final substantiated diagnosis, based on a high level of clinical certainty, which may include clinical evidence from test results. It is not expected to change.(en)"> > ["at0026"] = < text = <"Aktiven"> description = <"Problem je trenutno aktiven in klinično relevanten"> > ["at0027"] = < text = <"Ni aktiven"> description = <"Problem trenutno ni aktiven"> > ["at0034"] = < text = <"*New(en)"> description = <"*A new occurrence of either a new or existing problem or diagnosis. A flag for 'First occurrence' can be recorded separately to distinguish the first from other occurrences.(en)"> > ["at0035"] = < text = <"*Ongoing(en)"> description = <"*The issue, problem or diagnosis continues, without new, acute episodes occurring.(en)"> > ["at0060"] = < text = <"*Current/Past?(en)"> description = <"*Category that supports division of problems and diagnoses into Current or Past problem lists.(en)"> comment = <"*The Current/Past and Active/Inactive data elements have similar clinical impact but represent slightly different semantics. Both are actively used in different clinical settings, but usually not together. If an Active/Inactive qualifier is recorded, then this data element is likely to be redundant. An exception where a condition can be current but inactive is asthma that is not causing acute symptoms.(en)"> > ["at0061"] = < text = <"*Past(en)"> description = <"*An issue which ocurred in the past.(en)"> > ["at0062"] = < text = <"*Current(en)"> description = <"*An issue occuring at present.(en)"> > ["at0063"] = < text = <"*Diagnostic category(en)"> description = <"*Category of the problem or diagnosis within a specified episode of care and/or local care context.(en)"> comment = <"*This data element contains a value set commonly used in diagnostic categorisation. In episodic care contexts (commonly secondary care) it is common to categorise/organise diagnoses according to their relationship to the principal diagnosis being addressed during that episode of care. These categories may also be used for clinical coding, reporting and billing purposes. In some countries the diagnostic category may be known as a DRG. In addition, the free text choice permits use of other local value sets, as required.(en)"> > ["at0064"] = < text = <"*Principal diagnosis(en)"> description = <"*The diagnosis determined to be chiefly responsible for occasionaing an episode of admitted patient care, an episode of residential care or an attendance at the health care establishment.(en)"> > ["at0066"] = < text = <"*Secondary diagnosis(en)"> description = <"*A problem or diagnosis that is occurs at the same time as the primary problem or diagnosis. May also be known as a comorbid condition.(en)"> > ["at0070"] = < text = <"*Indeterminate(en)"> description = <"*It is not possible to determine if this occurrence of the problem or diagnosis is new or ongoing.(en)"> > ["at0073"] = < text = <"*Admission diagnosis?(en)"> description = <"*Was the problem or diagnosis present at admission?(en)"> comment = <"*Record as True if the problem or diagnosis was present on admission. This data element is a requirement from DRG reporting in some countries.(en)"> > ["at0076"] = < text = <"*Complication(en)"> description = <"*An unfavorable evolution of a problem or diagnosis.(en)"> > ["at0077"] = < text = <"*Course label(en)"> description = <"*Category reflecting the speed of onset and/or duration and persistence of the problem or diagnosis.(en)"> comment = <"*Definitions of acute vs chronic will differ for each diagnosis.(en)"> > ["at0079"] = < text = <"*Chronic(en)"> description = <"*A problem or diagnosis with persistent or long-lasting effects, or that evolves over time.(en)"> > ["at0081"] = < text = <"*Acute(en)"> description = <"*A problem or diagnosis with a rapid onset, a short course, or both.(en)"> > ["at0083"] = < text = <"*Resolution phase(en)"> description = <"*Phase of healing for an acute problem or diagnosis.(en)"> comment = <"*For example: tracking the progress of resolution of a middle ear infection.(en)"> > ["at0084"] = < text = <"*Resolved(en)"> description = <"*Problem or diagnosis has completed the normal phases of restoration or healing and can be considered resolved.(en)"> > ["at0085"] = < text = <"*Resolving(en)"> description = <"*Problem or diagnosis is progressing satisfactorily through the normal stages of restoration or healing towards resolution.(en)"> > ["at0086"] = < text = <"*Not resolving(en)"> description = <"*Problem or diagnosis is not progressing satisfactorily through the normal stages of restoration or healing towards resolution.(en)"> > ["at0087"] = < text = <"*Indeterminate(en)"> description = <"*It is not possible to determine the resolution or healing status of the problem or diagnosis.(en)"> > ["at0088"] = < text = <"*Refuted(en)"> description = <"*The diagnosis has been clinically reassessed or has been disproved with a high level of clinical certainty.(en)"> > ["at0089"] = < text = <"*Remission status(en)"> description = <"*Status of the remission of an incurable diagnosis.(en)"> comment = <"*For example: the status of a cancer or haematological diagnosis.(en)"> > ["at0090"] = < text = <"*In complete remission(en)"> description = <"*No diminution of signs or symptoms of the disease have been identified.(en)"> > ["at0092"] = < text = <"*Not in remission(en)"> description = <"*No diminution of the signs or symptoms of the disease have been identified.(en)"> > ["at0093"] = < text = <"*Indeterminate(en)"> description = <"*It is not possible to determine if there have been diminution of the signs or symptoms of the disease have been identified.(en)"> > ["at0094"] = < text = <"*Acute-on-chronic(en)"> description = <"**(en)"> > ["at0095"] = < text = <"*Occurrence (en)"> description = <"*Category of the occurrence for this problem or diagnosis. (en)"> comment = <"*This data element can be an additional qualifier to the 'New' value in the 'Episodicity' value set, that is a condition such as asthma can have recurring new episodes that have periods of resolution in between. However it can be important to identify the first ever episode of asthma from all of the other episodes. (en)"> > ["at0096"] = < text = <"*Erstauftreten (de)"> description = <"*"> > ["at0097"] = < text = <"*Wiederauftreten (de)"> description = <"*"> > ["at0098"] = < text = <"*Rückfällig (de)"> description = <"*Nach einer Phase der Verbesserung hat sich das Problem oder die Diagnose wieder verschlechtert. (de)"> > > > ["pt-br"] = < items = < ["at0000"] = < text = <"*Problem/Diagnosis qualifier(en)"> description = <"*Contextual or temporal qualifier for a specified problem or diagnosis.(en)"> > ["at0001"] = < text = <"*Episodicity(en)"> description = <"*Category of this episode for the identified problem/diagnosis.(en)"> comment = <"*For example: 'New' will enable clinicians to distinguish a new, acute episode of otitis media that may have arisen soon after a previous diagnosis, to distinguish it from an unresolved or 'Ongoing' diagnosis of chronic otitis media. Treatment of recurring, new and acute, episodes of a condition may differ significantly from the same condition that is not resolving or responding to treatment. In many situations the clinician will not be able to tell, and so indeterminate may be appropriate.(en)"> > ["at0003"] = < text = <"*Active/Inactive?(en)"> description = <"*Category that supports division of problems and diagnoses into Active or Inactive problem lists.(en)"> comment = <"*The Active/Inactive and Current/Past data elements have similar clinical impact but represent slightly different semantics. Both are actively used in different clinical settings, but usually not together. If a Current/Past qualifier is recorded, then this data element is likely to be redundant. An exception where a condition can be current but inactive is asthma that is not causing acute symptoms.(en)"> > ["at0004"] = < text = <"*Diagnostic status(en)"> description = <"*Stage or phase of diagnostic process.(en)"> comment = <"*The status is usually determined by a combination of the timing of diagnosis plus level of clinical certainty resulting from diagnostic tests and clinical evidence available. This data element and 'Diagnostic certainty' in EVALUATION.problem_diagnosis are two important axes of the diagnostic process, and valid combinations will need to be presented by software that exposes both data elements, so it is not possible for users to select conflicting combinations. Preliminary or working diagnoses are intended to represent the single most likely choice out of all differential diagnosis options.(en)"> > ["at0016"] = < text = <"Preliminar"> description = <"O diagnóstico inicial feito, geralmente associado a um baixo nível de certeza clínica. Pode mudar à medida que os resultados dos testes ou conselhos estiverem disponíveis."> > ["at0017"] = < text = <"Trabalhando [(Interrogado)]"> description = <"Diagnóstico provisório, com base em numa certeza clínica razoável, mas na pendência de novos resultados de testes ou orientação clínica. Pode ainda mudar à medida que os resultados dos testes ou conselhos estiverem disponíveis."> > ["at0018"] = < text = <"*Established(en)"> description = <"*Final substantiated diagnosis, based on a high level of clinical certainty, which may include clinical evidence from test results. It is not expected to change.(en)"> > ["at0026"] = < text = <"Ativo"> description = <"O problema ou o diagnóstico está atualmente ativo e clinicamente relevante."> > ["at0027"] = < text = <"Inativo"> description = <"O problema ou diagnóstico não está completamente resolvido, mas está inativo ou é menos relevante no contexto clínico atual."> > ["at0034"] = < text = <"*New(en)"> description = <"*A new occurrence of either a new or existing problem or diagnosis. A flag for 'First occurrence' can be recorded separately to distinguish the first from other occurrences.(en)"> > ["at0035"] = < text = <"*Ongoing(en)"> description = <"*The issue, problem or diagnosis continues, without new, acute episodes occurring.(en)"> > ["at0060"] = < text = <"*Current/Past?(en)"> description = <"*Category that supports division of problems and diagnoses into Current or Past problem lists.(en)"> comment = <"*The Current/Past and Active/Inactive data elements have similar clinical impact but represent slightly different semantics. Both are actively used in different clinical settings, but usually not together. If an Active/Inactive qualifier is recorded, then this data element is likely to be redundant. An exception where a condition can be current but inactive is asthma that is not causing acute symptoms.(en)"> > ["at0061"] = < text = <"*Past(en)"> description = <"*An issue which ocurred in the past.(en)"> > ["at0062"] = < text = <"*Current(en)"> description = <"*An issue occuring at present.(en)"> > ["at0063"] = < text = <"*Diagnostic category(en)"> description = <"*Category of the problem or diagnosis within a specified episode of care and/or local care context.(en)"> comment = <"*This data element contains a value set commonly used in diagnostic categorisation. In episodic care contexts (commonly secondary care) it is common to categorise/organise diagnoses according to their relationship to the principal diagnosis being addressed during that episode of care. These categories may also be used for clinical coding, reporting and billing purposes. In some countries the diagnostic category may be known as a DRG. In addition, the free text choice permits use of other local value sets, as required.(en)"> > ["at0064"] = < text = <"Diagnóstico principal"> description = <"O diagnóstico específico a ser responsável por desencadear um episódio de cuidado do paciente admitido, um episódio de cuidados domiciliares ou um comparecimento no estabelecimento de cuidados de saúde."> > ["at0066"] = < text = <"Diagnóstico secundário"> description = <"Um problema ou diagnóstico que ocorre ao mesmo tempo que o problema ou de diagnóstico principal. Também pode ser conhecido como uma comorbidade."> > ["at0070"] = < text = <"Indeterminado"> description = <"Não é possível determinar se esta ocorrência do problema ou diagnóstico é nova ou está em curso."> > ["at0073"] = < text = <"*Admission diagnosis?(en)"> description = <"*Was the problem or diagnosis present at admission?(en)"> comment = <"*Record as True if the problem or diagnosis was present on admission. This data element is a requirement from DRG reporting in some countries.(en)"> > ["at0076"] = < text = <"Complicação"> description = <"Uma evolução desfavorável de um problema ou diagnóstico."> > ["at0077"] = < text = <"*Course label(en)"> description = <"*Category reflecting the speed of onset and/or duration and persistence of the problem or diagnosis.(en)"> comment = <"*Definitions of acute vs chronic will differ for each diagnosis.(en)"> > ["at0079"] = < text = <"Crônico"> description = <"Um problema ou um diagnóstico com efeitos persistentes ou de longa duração ou que evolui ao longo do tempo."> > ["at0081"] = < text = <"Agudo"> description = <"Um problema ou diagnóstico com um início rápido, um curso curto, ou ambos."> > ["at0083"] = < text = <"*Resolution phase(en)"> description = <"*Phase of healing for an acute problem or diagnosis.(en)"> comment = <"*For example: tracking the progress of resolution of a middle ear infection.(en)"> > ["at0084"] = < text = <"Resolvido"> description = <"Problema ou diagnóstico que finalizou as fases normais de reabilitação ou de cura e pode ser considerado resolvido."> > ["at0085"] = < text = <"Resolvendo"> description = <"Um problema ou um diagnóstico que está evoluindo de forma satisfatória pelos estágios normais de reabilitação ou de cura evoluindo para a resolução."> > ["at0086"] = < text = <"Não resolvendo"> description = <"Um problema ou um diagnóstico que não está progredindo satisfatoriamente pelos estágios normais de reabilitação ou de cura em direção a resolução."> > ["at0087"] = < text = <"*Indeterminate(en)"> description = <"*It is not possible to determine the resolution or healing status of the problem or diagnosis.(en)"> > ["at0088"] = < text = <"Descartado"> description = <"O diagnóstico foi reavaliado clinicamente ou foi refutado com um elevado nível de segurança clínica."> > ["at0089"] = < text = <"*Remission status(en)"> description = <"*Status of the remission of an incurable diagnosis.(en)"> comment = <"*For example: the status of a cancer or haematological diagnosis.(en)"> > ["at0090"] = < text = <"*In complete remission(en)"> description = <"*No diminution of signs or symptoms of the disease have been identified.(en)"> > ["at0092"] = < text = <"*Not in remission(en)"> description = <"*No diminution of the signs or symptoms of the disease have been identified.(en)"> > ["at0093"] = < text = <"*Indeterminate(en)"> description = <"*It is not possible to determine if there have been diminution of the signs or symptoms of the disease have been identified.(en)"> > ["at0094"] = < text = <"*Acute-on-chronic(en)"> description = <"**(en)"> > ["at0095"] = < text = <"*Occurrence (en)"> description = <"*Category of the occurrence for this problem or diagnosis. (en)"> comment = <"*This data element can be an additional qualifier to the 'New' value in the 'Episodicity' value set, that is a condition such as asthma can have recurring new episodes that have periods of resolution in between. However it can be important to identify the first ever episode of asthma from all of the other episodes. (en)"> > ["at0096"] = < text = <"*Erstauftreten (de)"> description = <"*"> > ["at0097"] = < text = <"*Wiederauftreten (de)"> description = <"*"> > ["at0098"] = < text = <"*Rückfällig (de)"> description = <"*Nach einer Phase der Verbesserung hat sich das Problem oder die Diagnose wieder verschlechtert. (de)"> > > > ["nb"] = < items = < ["at0000"] = < text = <"Problem/diagnose-kvalifikator"> description = <"Kontekst- eller tidsspesifikk kvalifikator for et problem eller en diagnose."> > ["at0001"] = < text = <"Episodisitet"> description = <"Kategorisering av denne episoden av problemet/diagnosen."> comment = <"For eksempel: \"Ny\" gjør det mulig for klinikere å holde et nytt og akutt tilfelle av mellomørebetennelse som har oppstått raskt etter en tidligere diagnose adskilt fra en pågående kronisk mellomørebetennelse. Behandling av gjentakende, nye og akutte episoder av en tilstand kan være vesentlig forskjellig fra behandling av den samme tilstanden som ikke bedres eller ikke responderer på behandling. I mange situasjoner vil det ikke være mulig for klinikeren å skille dem fra hverandre, og i disse tilfellene vil \"Ubestemmelig\" være relevant."> > ["at0003"] = < text = <"Aktiv/inaktiv?"> description = <"Kategori som støtter inndeling av problemer og diagnoser i lister over aktive og inaktive problemer."> comment = <"Elementene Aktiv/inaktiv og Nåværende/tidligere har lignende klinisk innflytelse, men representerer noe forskjellig betydning. Begge brukes aktivt i forskjellige kliniske sammenhenger, men som regel ikke sammen. Dersom Nåværende/tidligere er registrert, er dette elementet sannsynligvis overflødig. Et unntak der en tilstand kan være både nåværende og inaktivt, er astma som ikke forårsaker akutte symptomer."> > ["at0004"] = < text = <"Diagnostisk status"> description = <"Den diagnostiske prosessens stadium eller fase."> comment = <"Statusen bestemmes vanligvis ved å kombinere tidspunkt for diagnosen, og nivå av klinisk sikkerhet. Status er et resultat av diagnostiske undersøkelser, og det tilgjengelige kliniske grunnlaget. Dette dataelementet og \"Diagnostisk sikkerhet\" i arketypen EVALUATION.problem_diagnosis er to viktige akser i den diagnostiske prosessen, og gyldige kombinasjoner må håndteres og vises av programvare som bruker begge elementene. Dette for at det ikke skal være mulig for brukere å velge kombinasjoner som er i konflikt med hverandre. Tentative diagnoser eller arbeidsdiagnoser er ment å representere det mest sannsynlige valget av de mulige differensialdiagnosene."> > ["at0016"] = < text = <"Tentativ"> description = <"En foreløpig diagnose som er en utredningshypotese, og som antas å kunne bli bekreftet ved videre utredning eller observasjon av utvikling. Den kan bli endret etter hvert som undersøkelsesresultater eller annen informasjon blir tilgjengelig."> > ["at0017"] = < text = <"Arbeidsdiagnose"> description = <"Midlertidig diagnose, basert på en rimelig grad av klinisk sikkerhet, men som avventer videre undersøkelsesresultater eller kliniske råd. Den kan fortsatt endres etter hvert som undersøkelsesresultater eller annen informasjon blir tilgjengelig."> > ["at0018"] = < text = <"Fastslått"> description = <"Endelig underbygget diagnose, basert på en høy grad av klinisk sikkerhet, som kan omfatte klinisk evidens fra undersøkelser. Den er ikke forventet å endres."> > ["at0026"] = < text = <"Aktiv"> description = <"Problemet eller diagnosen er aktivt og kliniske relevant ved registreringstidspunktet."> > ["at0027"] = < text = <"Inaktiv"> description = <"Problemet eller diagnosen er ikke fullstendig bedret, men er inaktivt eller mindre relevant for den nåværende kliniske sammenhengen."> > ["at0034"] = < text = <"Ny"> description = <"En ny forekomst av enten et nytt eller et eksisterende problem eller diagnose. Et flagg for \"Første forekomst\" kan registreres separat for å skille den første forekomsten fra påfølgende."> > ["at0035"] = < text = <"Pågående"> description = <"Problemet eller diagnosen er pågående, uten at det har forekommet nye episoder."> > ["at0060"] = < text = <"Nåværende/tidligere?"> description = <"Kategori som støtter oppdeling av problemer og diagnoser i lister over nåværende og tidligere problemer."> comment = <"Elementene Nåværende/tidligere og Aktiv/inaktiv har lignende klinisk innflytelse, men representerer noe forskjellig betydning. Begge brukes aktivt i forskjellige kliniske sammenhenger, men som regel ikke sammen. Dersom Aktiv/inaktiv er registrert, er dette elementet sannsynligvis overflødig. Et unntak der en tilstand kan være både nåværende og inaktivt, er astma som ikke forårsaker akutte symptomer."> > ["at0061"] = < text = <"Tidligere"> description = <"Problemet/diagnosen er ikke lenger tilstede ved registreringstidspunktet."> > ["at0062"] = < text = <"Nåværende"> description = <"Problemet/diagnosen er tilstede ved registreringstidspunktet."> > ["at0063"] = < text = <"Diagnosisk kategori"> description = <"Kategorisering av problemet eller diagnosen innenfor en spesifikk kontakt og/eller lokal behandlingssammenheng."> comment = <"Dette elementet inneholder et verdisett som er i vanlig bruk innen diagnosekategorisering. I episodiske behandlingssammenhenger (som regel spesialisthelsetjenesten) er det vanlig å kategorisere/organisere diagnoser i henhold til deres forhold til hoveddiagnosen som behandles i den aktuelle kontakten. Disse kategoriene kan også brukes for klinisk koding, rapportering og fakturering. I noen land omtales diagnosekategorien som \"en DRG\". I tillegg gjør muligheten for å legge til annen fri eller kodet tekst at det er mulig å bruke andre lokale verdisett ved behov."> > ["at0064"] = < text = <"Hoveddiagnose"> description = <"Diagnosen som er bestemt å være hovedårsaken til den aktuelle kontakten."> > ["at0066"] = < text = <"Bidiagnose"> description = <"Et problem eller diagnose som opptrer samtidig som hoveddiagnosen. Kan også omtales som en komorbiditet."> > ["at0070"] = < text = <"Ubestemmelig"> description = <"Det er ikke mulig å bestemme hvorvidt denne forekomsten av problemet eller diagnosen er ny eller pågående."> > ["at0073"] = < text = <"Tilstede ved innleggelse?"> description = <"Var problemet eller diagnosen tilstede ved innleggelse?"> comment = <"Registrer som \"sann\" dersom problemet eller diagnosen var tilstede ved innleggelse. Dette elementet er et krav i forbindelse med DRG i noen land."> > ["at0076"] = < text = <"Komplikasjon"> description = <"En ugunstig utvikling av et problem eller diagnose."> > ["at0077"] = < text = <"Forløpsbetegnelse"> description = <"Kategorisering som betegner debuten og/eller varigheten og vedvarenheten av problemet eller diagnosen."> comment = <"Definisjoner av akutt og kronisk vil variere fra diagnose til diagnose."> > ["at0079"] = < text = <"Kronisk"> description = <"Et problem eller diagnose med varige eller langvarige effekter, eller som utvikler seg over tid."> > ["at0081"] = < text = <"Akutt"> description = <"Et problem eller diagnose med en rask inntreden, kortvarig forløp, eller begge."> > ["at0083"] = < text = <"Bedringsfase"> description = <"Fase av bedring eller tilheling for et akutt problem eller diagnose."> comment = <"For eksempel for å spore tilhelingen av en mellomørebetennelse."> > ["at0084"] = < text = <"Bedret"> description = <"Problemet eller diagnosen har fullført de vanlige stadiene av bedring eller tilheling, og kan regnes som bedret."> > ["at0085"] = < text = <"I bedring"> description = <"Problemet eller diagnosen utvikler seg i ønsket retning gjennom de vanlige stadiene av bedring, eller under tilheling."> > ["at0086"] = < text = <"Ikke i bedring"> description = <"Problemet eller diagnosen utvikler seg ikke i ønsket retning gjennom de vanlige stadiene av bedring, eller er ikke under tilheling."> > ["at0087"] = < text = <"Ubestemmelig"> description = <"Det er ikke mulig å bestemme problemet eller diagnosens fase av bedring."> > ["at0088"] = < text = <"Avkreftet"> description = <"Diagnosen har blitt klinisk revurdert, eller er motbevist med en høy grad av klinisk sikkerhet. Denne statusen brukes for å korrigere feil i journalen."> > ["at0089"] = < text = <"Remisjonsstatus"> description = <"Remisjonsstatus for en ikke-kurerbar diagnose."> comment = <"For eksempel status for kreft eller en hematologisk diagnose."> > ["at0090"] = < text = <"Komplett remisjon"> description = <"Ingen pågående sykdomstegn eller symptomer på sykdommen er identifisert."> > ["at0092"] = < text = <"Ikke i remisjon"> description = <"Ingen minsking av sykdomstegn eller symptomer er identifisert."> > ["at0093"] = < text = <"Ubestemmelig"> description = <"Det er ikke mulig å bestemme om sykdomstegnene eller symptomene av sykdommen er minsket."> > ["at0094"] = < text = <"Akutt-på-kronisk"> description = <"Et problem eller en diagnose med en akutt forverring av en kronisk tilstand."> > ["at0095"] = < text = <"*Occurrence (en)"> description = <"*Category of the occurrence for this problem or diagnosis. (en)"> comment = <"*This data element can be an additional qualifier to the 'New' value in the 'Episodicity' value set, that is a condition such as asthma can have recurring new episodes that have periods of resolution in between. However it can be important to identify the first ever episode of asthma from all of the other episodes. (en)"> > ["at0096"] = < text = <"*Erstauftreten (de)"> description = <"*"> > ["at0097"] = < text = <"*Wiederauftreten (de)"> description = <"*"> > ["at0098"] = < text = <"*Rückfällig (de)"> description = <"*Nach einer Phase der Verbesserung hat sich das Problem oder die Diagnose wieder verschlechtert. (de)"> > > > ["de"] = < items = < ["at0000"] = < text = <"Problem/Diagnose Attribut"> description = <"Kontextuelles oder zeitliches Attribut für ein spezifisches Problem oder eine spezifische Diagnose."> > ["at0001"] = < text = <"Episode"> description = <"Die Kategorie der Episode für das identifizierte Problem oder die identifizierte Diagnose."> comment = <"Zum Beispiel: Die Episode \"Neu\" ermöglicht es Klinikern eine neue akute Episode von Otitis media, welche möglicherweise kurz nach einer früheren Otitis media-Diagnose aufgetreten ist, von einer ungelösten oder \"andauernden\" chronischen Diagnose Otitis media zu unterscheiden. Die Behandlung von wiederkehrenden, neuen und akuten Episoden einer Erkrankung kann sich erheblich von der Behandlung der gleichen Erkrankung, welche noch nicht genesen ist, oder keine Reaktion auf eine bestimmte Behandlung gezeigt hat, unterscheiden. In vielen Fällen kann der Kliniker dies nicht sagen und eine Einteilung der Episode als \"Unbestimmt\" könnte angemessen sein."> > ["at0003"] = < text = <"Aktiv/Inaktiv?"> description = <"Eine Kategorie, die die Aufteilung der Problemlisten von Problemen und Diagnosen in aktiv und inaktiv unterstützt."> comment = <"Die Aktiv/Inaktiv und Aktuell/Vergangen Datenelemente haben einen ähnlichen klinischen Einfluss, repräsentieren aber eine etwas andere Semantik. Beide werden aktiv in verschiedenen klinischen Rahmen benutzt, aber normalerweise nicht zusammen. Wenn ein Aktuell/Vergangen Attribut dokumentiert wird, dann ist dieses Datenelement wahrscheinlich redundant. Eine Ausnahme ist ein Zustand der aktuell, aber inaktiv ist. Ein Beispiel dafür ist Asthma, welches keine akuten Symptome auslöst."> > ["at0004"] = < text = <"Diagnosestatus"> description = <"Stadium oder Phase des diagnostischen Prozesses."> comment = <"Der Status wird normalerweise durch eine Kombination des Diagnosezeitraums und der klinischen Sicherheit, welche von den diagnostischen Tests und der klinischen Evidenz abhängt, bestimmt. Zusammen mit dem Element \"Diagnostische Sicherheit\" des EVALUATION.problem/diagnosis Archetypen, bildet dieses Datenelement eine wichtige Basis für den diagnostischen Prozess. Es muss sichergestellt werden, dass die Software eine gültige Kombination aus den beiden Datenelemente präsentiert, damit Nutzer keine widersprüchlichen Kombinationen der beiden Datenelemente auswählen können. Bei einer Differentialdiagnose ist es beabsichtigt, dass die vorläufige oder die Arbeitsdiagnose als wahrscheinlichste Diagnose repräsentiert wird."> > ["at0016"] = < text = <"Vorläufig"> description = <"Die Initialdiagnose, welche normalerweise auf einem geringen Level von klinischer Sicherheit beruht. Sie kann sich ändern, sobald weitere Testergebnisse, Hinweise oder Empfehlungen verfügbar sind."> > ["at0017"] = < text = <"In Bearbeitung"> description = <"Eine vorübergehende Diagnose, bei welcher Testergebnisse und klinische Hinweise oder Empfehlungen noch ausstehen, welche aber bereits auf einer soliden klinischen Sicherheit beruht. Sobald weitere Testresultate und klinische Hinweise oder Empfehlungen zur Verfügung stehen, kann sich die Diagnose noch ändern."> > ["at0018"] = < text = <"Festgestellt"> description = <"Die finale Diagnose, welche auf einem hohen Level von klinischer Sicherheit beruht, die klinische Anhaltspunkte von Testergebnissen beinhalten kann. Es ist nicht zu erwarten, dass die Diagnose sich noch ändert."> > ["at0026"] = < text = <"Aktiv"> description = <"Das Problem oder die Diagnose ist momentan aktiv und klinisch relevant."> > ["at0027"] = < text = <"Inaktiv"> description = <"Das Problem oder die Diagnose ist nicht komplett behoben, ist aber inaktiv oder ist weniger relevant in dem gegenwärtigen klinischen Kontext."> > ["at0034"] = < text = <"Neu"> description = <"Ein neues Auftreten eines neuen oder bereits existierenden Problems oder einer Diagnose. Um das erste Auftreten von anderen Vorkommnissen zu unterscheiden, kann eine Kennzeichnung für das \"Erstes Auftreten\" separat dargestellt werden."> > ["at0035"] = < text = <"Andauernd"> description = <"Die Angelegenheit, das Problem oder die Diagnose setzt sich fort, ohne dass neue oder akute Episoden auftreten."> > ["at0060"] = < text = <"Aktuell/Vergangen?"> description = <"Eine Kategorie, die die Aufteilung der Problemlisten der Probleme und der Diagnosen in aktuell und vergangen unterstützt."> comment = <"Die Aktuell/Vergangen und Aktiv/Inaktiv Datenelemente haben einen ähnlichen klinischen Einfluss, repräsentieren aber eine etwas andere Semantik. Beide werden aktiv in verschiedenen klinischen Rahmen benutzt, aber normalerweise nicht zusammen. Wenn ein Aktiv/Inaktiv Attribut dokumentiert wird, dann ist dieses Datenelement wahrscheinlich redundant. Eine Ausnahme ist ein Zustand der aktuell, aber inaktiv ist. Ein Beispiel dafür ist Asthma, welches keine akuten Symptome auslöst."> > ["at0061"] = < text = <"Vergangen"> description = <"Ein Sachverhalt der in der Vergangenheit aufgetreten ist."> > ["at0062"] = < text = <"Aktuell"> description = <"Ein aktuelles Problem."> > ["at0063"] = < text = <"Diagnostische Kategorie"> description = <"Die Kategorie des Problems oder der Diagnose innerhalb eines spezifischen Behandlungszeitraumes und/oder eines lokalen Behandlungskontextes."> comment = <"Dieses Datenelement enthält eine Gruppe von Werten, welches routinemäßig in der diagnostischen Kategorisierung benutzt wird. Es ist üblich, dass im episodischen Versorgungskontext (üblicherweise in der Sekundärversorgung) die Diagnosen während des aktuellen Behandlungszeitraums in Beziehung zur Hauptdiagnose zu kategorisieren/ zu organisieren sind. Diese Kategorien können ebenfalls für die klinische Kodierung, die Berichterstattung und für Abrechnungsprozesse genutzt werden. In manchen Ländern kann die diagnostische Kategorisierung auch als DRG (diagnosebezogene Fallgruppierungen) bekannt sein. Falls es nötig sein sollte, erlaubt das Freitextfeld die Benutzung von lokalen Werten."> > ["at0064"] = < text = <"Hauptdiagnose"> description = <"Die Diagnose, die hauptverantwortlich dafür ist, dass der Patient gelegentlich ärztliche Versorgung benötigt oder zeitweise zuhause gepflegt werden muss, oder generell bei einer Gesundheitseinrichtung vorstellig werden muss."> > ["at0066"] = < text = <"Sekundärdiagnose"> description = <"Ein Problem oder eine Diagnose, die zur gleichen Zeit auftritt wie das Primärproblem oder die Hauptdiagnose. Könnte auch als komorbider Zustand bekannt sein."> > ["at0070"] = < text = <"Unbestimmt"> description = <"Es ist nicht möglich zu überprüfen, ob die Episode des Problems oder der Diagnose neu oder andauernd ist."> > ["at0073"] = < text = <"Aufnahmediagnose?"> description = <"War das Problem oder die Diagnose bei der Aufnahme vorhanden?"> comment = <"Sollte als Wahr dokumentiert werden, falls das Problem oder die Diagnose bei der Aufnahme vorhanden war. Dieses Datenelement ist in manchen Ländern bei der DRG-Berichterstattung vorausgesetzt."> > ["at0076"] = < text = <"Komplikation"> description = <"Eine unvorteilhafte Entwicklung eines Problems oder einer Diagnose."> > ["at0077"] = < text = <"Verlaufsbeschreibung"> description = <"Die Kategorie, die die Geschwindigkeit des Auftretens und/oder die Zeit sowie das Andauern des Problems oder der Diagnose beschreibt."> comment = <"Die Definition von akut und chronisch wird sich von Diagnose zu Diagnose unterscheiden."> > ["at0079"] = < text = <"Chronisch"> description = <"Ein Problem oder eine Diagnose mit einem beständigen, langanhaltenden oder sich über die Zeit entwickelnden Effekts."> > ["at0081"] = < text = <"Akut"> description = <"Ein Problem oder eine Diagnose mit einem schnellen Auftreten, einem kurzen Verlauf, oder beidem."> > ["at0083"] = < text = <"Genesungsphase"> description = <"Die Phase der Heilung eines akuten Problems oder einer Diagnose."> comment = <"Zum Beispiel: Das Verfolgen des Verlaufes der Heilung einer Mittelohrentzündung."> > ["at0084"] = < text = <"Genesen"> description = <"Das Problem oder die Diagnose hat die normalen Phasen der Wiederherstellung oder der Heilung durchlaufen und kann als vollständig genesen angesehen werden."> > ["at0085"] = < text = <"Genesung"> description = <"Das Durchlaufen der normalen Stadien der Wiederherstellung oder Heilung bis zur vollständigen Genesung des Problems oder der Diagnose läuft zufriedenstellend."> > ["at0086"] = < text = <"Keine Genesung"> description = <"Das Durchlaufen der normalen Stadien der Wiederherstellung oder Heilung bis zur vollständigen Genesung des Problems oder der Diagnose läuft nicht zufriedenstellend."> > ["at0087"] = < text = <"Unbestimmt"> description = <"Der Genesungs- oder Heilungsstatus des Problems oder der Diagnose kann nicht bestimmt werden."> > ["at0088"] = < text = <"Widerlegt"> description = <"Die zuvor gestellte Diagnose wurde klinisch neu bewertet oder mit einem hohen Level an klinischer Sicherheit widerlegt. Dieser Status wird zur Korrektur von Fehlern in der Gesundheitsakte benutzt."> > ["at0089"] = < text = <"Remissionsstatus"> description = <"Der Remissionsstatus einer nicht heilbaren Krankheit."> comment = <"Zum Beispiel: Der Status von Krebs oder einer hämatologischen Diagnose."> > ["at0090"] = < text = <"In Remission"> description = <"Keine anhaltenden Anzeichen oder Symptome der Krankheit konnten festgestellt werden."> > ["at0092"] = < text = <"Nicht in Remission"> description = <"Keine Minderung der Anzeichen oder der Symptome der Krankheit konnte festgestellt werden."> > ["at0093"] = < text = <"Unbestimmt"> description = <"Es ist nicht möglich zu überprüfen, ob eine Minderung der Anzeichen oder der Symptome der Krankheit festgestellt wurde."> > ["at0094"] = < text = <"Akut bis chronisch"> description = <"Ein Problem oder eine Diagnose mit einem akuten Schub eines chronischen Zustandes."> > ["at0095"] = < text = <"Auftreten"> description = <"Beschreibung des Auftretens des Problems oder der Diagnose. "> comment = <"Dieses Datenelement kann ein weiteres Attribut zu dem Wert \"Neu\" in dem Werteset \"Episoden\" sein. Asthma wäre ein Beispiel für ein Zustand, welcher wieder auftretende neue Episoden hat, welche durch Perioden der Genesung unterbrochen werden. Allerdings kann es wichtig sein, die allererste Episode, in der Asthma aufgetreten ist, von den anderen Episoden zu trennen. "> > ["at0096"] = < text = <"Erstauftreten"> description = <"Dies ist das allererste Mal, dass das Problem oder die Diagnose auftritt."> > ["at0097"] = < text = <"Wiederauftreten"> description = <"Wiederauftreten des gleichen Problems oder der gleichen Diagnose, nachdem eine vorherige Episode bereits erfolgreich behandelt oder gelöst wurde."> > ["at0098"] = < text = <"Rückfällig"> description = <"Nach einer vorübergehenden Besserung hat sich das Problem oder die Diagnose wieder verschlechtert."> > > > > term_bindings = < ["SNOMED-CT"] = < items = < ["at0001"] = <[SNOMED-CT::288526004]> ["at0004"] = <[SNOMED-CT::106229004]> ["at0016"] = <[SNOMED-CT::148006]> ["at0017"] = <[SNOMED-CT::5558000]> ["at0060"] = <[SNOMED-CT::410511007]> ["at0061"] = <[SNOMED-CT::410513005]> ["at0062"] = <[SNOMED-CT::15240007]> ["at0077"] = <[SNOMED-CT::288524001]> ["at0018"] = <[SNOMED-CT::14657009]> ["at0064"] = <[SNOMED-CT::8319008]> ["at0066"] = <[SNOMED-CT::85097005]> > > >