archetype (adl_version=1.4; uid=28d27d74-3405-4799-aad9-364ebd28f539) openEHR-EHR-ADMIN_ENTRY.discharge_summary.v0 concept [at0000] -- Discharge summary language original_language = <[ISO_639-1::en]> translations = < ["de"] = < language = <[ISO_639-1::de]> author = < ["name"] = <"Kim Sommer, Antje Wulff"> ["organisation"] = <"MHH, Peter L. Reichertz Institut für Medizinische Informatik der TU Braunschweig und der Medizinischen Hochschule Hannover"> ["email"] = <"antje.wulff@plri.de"> > > > description original_author = < ["name"] = <"Priscila Maranhao; Gustavo Bacelar"> ["organisation"] = <"MEDCIDES/FMUP; VirtualCare"> ["email"] = <"priscilamaranhao@gmail.com; gbacalar@gmail.com"> ["date"] = <"2017-06-27"> > details = < ["de"] = < language = <[ISO_639-1::de]> purpose = <"Dieser Archetyp wurde für die Darstellung der Entlassungsdaten entwickelt."> use = <""> keywords = <"Entlassung", "Entlassdaten", "Entlassungsdaten", "Entlassungsbericht"> misuse = <""> > ["en"] = < language = <[ISO_639-1::en]> purpose = <"This archetype was designed for presenting the discharged data. "> use = <""> misuse = <""> copyright = <"© openEHR Foundation, HiGHmed"> > > lifecycle_state = <"in_development"> other_contributors = <"Ricardo Correia, FMUP, Portugal", "Pedro Vieira-Marques, FMUP, Portugal", "Duarte Ferreira, FMUP, Portugal"> 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: - Tyler M; Boyer A; Martin S; Neiman J, Bakel LA, Brittan M. Development of a discharge readiness report within the electronic health record - a discharge planning tool. Journal of Hospital Medicine, v9«.9, n.8. 2014. "> ["original_namespace"] = <"org.highmed"> ["original_publisher"] = <"HiGHmed"> ["custodian_namespace"] = <"org.highmed"> ["MD5-CAM-1.0.1"] = <"FFF8C6A6D1CCF30F6FF5B70CB57F52B7"> ["build_uid"] = <"f9876465-7f7e-464e-8360-4203ea903104"> ["revision"] = <"0.0.1-alpha"> > definition ADMIN_ENTRY[at0000] matches { -- Entlassungsdaten data matches { ITEM_TREE[at0001] matches { -- Tree items cardinality matches {0..*; unordered} matches { ELEMENT[at0040] occurrences matches {0..1} matches { -- Art der Entlassung value matches { DV_TEXT matches {*} } } ELEMENT[at0002] occurrences matches {0..1} matches { -- Klinischer Zustand des Patienten value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0003, -- Geheilt at0004, -- Verbessert at0005, -- Identischer Zustand at0006, -- Schlechter at0007, -- Verstorben at0008, -- Unbestimmt at0068] -- Sonstige } } } } ELEMENT[at0011] occurrences matches {0..1} matches { -- Entlassungsdatum/-uhrzeit value matches { DV_DATE_TIME matches {*} } } ELEMENT[at0038] occurrences matches {0..1} matches { -- Aufenthaltsdauer value matches { C_DV_QUANTITY < property = <[openehr::128]> list = < ["1"] = < units = <"a"> > ["2"] = < units = <"h"> > ["3"] = < units = <"mo"> > ["4"] = < units = <"wk"> > ["5"] = < units = <"d"> > > > } } ELEMENT[at0051] occurrences matches {0..1} matches { -- Entlassungsanweisungen value matches { DV_TEXT matches {*} } } ELEMENT[at0050] occurrences matches {0..1} matches { -- Zusätzliche Informationen value matches { DV_TEXT matches {*} } } CLUSTER[at0058] occurrences matches {0..1} matches { -- Behandelnder Arzt items cardinality matches {1..*; unordered} matches { ELEMENT[at0059] occurrences matches {0..1} matches { -- ID value matches { DV_TEXT matches {*} } } ELEMENT[at0060] occurrences matches {0..1} matches { -- Familienname value matches { DV_TEXT matches {*} } } ELEMENT[at0061] occurrences matches {0..1} matches { -- Nachname value matches { DV_TEXT matches {*} } } } } CLUSTER[at0062] occurrences matches {0..1} matches { -- Überweisender Arzt items cardinality matches {1..*; unordered} matches { ELEMENT[at0065] occurrences matches {0..1} matches { -- ID value matches { DV_TEXT matches {*} } } ELEMENT[at0064] occurrences matches {0..1} matches { -- Familienname value matches { DV_TEXT matches {*} } } ELEMENT[at0063] occurrences matches {0..1} matches { -- Nachname value matches { DV_TEXT matches {*} } } } } CLUSTER[at0033] occurrences matches {0..1} matches { -- Entlassungsarzt items cardinality matches {1..*; unordered} matches { ELEMENT[at0034] occurrences matches {0..1} matches { -- ID value matches { DV_TEXT matches {*} } } ELEMENT[at0035] occurrences matches {0..1} matches { -- Familienname value matches { DV_TEXT matches {*} } } ELEMENT[at0036] occurrences matches {0..1} matches { -- Nachname value matches { DV_TEXT matches {*} } } } } allow_archetype CLUSTER[at0066] occurrences matches {0..*} matches { -- Letzter Patientenstandort include archetype_id/value matches {/.*/} } allow_archetype CLUSTER[at0067] occurrences matches {0..*} matches { -- Zugewiesener Patientenstandort include archetype_id/value matches {/.*/} } } } } } ontology term_definitions = < ["en"] = < items = < ["at0000"] = < text = <"Discharge summary"> description = <"Used for discharged patient only. "> > ["at0001"] = < text = <"Tree"> description = <"@ internal @"> > ["at0002"] = < text = <"Clinical condition of the patient"> description = <"Clinical condition of the patient. "> > ["at0003"] = < text = <"Cured"> description = <"Patient is cured. "> > ["at0004"] = < text = <"Improved"> description = <"Patient is improved"> > ["at0005"] = < text = <"Same state"> description = <"The patient is in the same state of admission. "> > ["at0006"] = < text = <"Worse"> description = <"The patient is worse than on admission. "> > ["at0007"] = < text = <"Deceased"> description = <"The patient died during hospitalization. "> > ["at0008"] = < text = <"Undetermined. "> description = <"Undetermined. "> > ["at0011"] = < text = <"Discharge date/time"> description = <"Date/Time the patiente was discharge. "> > ["at0033"] = < text = <"Discharge doctor "> description = <"Discharge doctor informations. "> > ["at0034"] = < text = <"ID"> description = <"*"> > ["at0035"] = < text = <"Family name"> description = <"*"> > ["at0036"] = < text = <"Last name"> description = <"*"> > ["at0038"] = < text = <"Lenght of stay"> description = <"Lenght of stay on hospital "> > ["at0040"] = < text = <"Discharge status"> description = <"Discharge status. "> > ["at0050"] = < text = <"Additional information"> description = <"Comments"> > ["at0051"] = < text = <"Discharge instructions "> description = <"Discharge instructions to patients. "> > ["at0058"] = < text = <"Attending doctor"> description = <"The attending doctor providing services to the patient. "> > ["at0059"] = < text = <"ID"> description = <"*"> > ["at0060"] = < text = <"Family name"> description = <"*"> > ["at0061"] = < text = <"Last name"> description = <"*"> > ["at0062"] = < text = <"Referring doctor"> description = <"Clinician who referred patient to the consulting doctor. "> > ["at0063"] = < text = <"Last name"> description = <"*"> > ["at0064"] = < text = <"Family name"> description = <"*"> > ["at0065"] = < text = <"ID"> description = <"*"> > ["at0066"] = < text = <"Last patient location"> description = <"*"> > ["at0067"] = < text = <"*Cluster(en)"> description = <"**(en)"> > ["at0068"] = < text = <"*Sonstige(en)"> description = <"*Sonstige(en)"> > > > ["de"] = < items = < ["at0000"] = < text = <"Entlassungsdaten"> description = <"Wird nur für entlassene Patienten verwendet."> > ["at0001"] = < text = <"Tree"> description = <"@ internal @"> > ["at0002"] = < text = <"Klinischer Zustand des Patienten"> description = <"Klinischer Zustand des Patienten."> > ["at0003"] = < text = <"Geheilt"> description = <"Der Patient ist geheilt."> > ["at0004"] = < text = <"Verbessert"> description = <"Der Gesundheitszustand des Patienten hat sich verbessert."> > ["at0005"] = < text = <"Identischer Zustand"> description = <"Der Gesundheitszustand des Patienten ist identisch, wie bei der Aufnahme."> > ["at0006"] = < text = <"Schlechter"> description = <"Der Gesundheitszustand des Patienten ist schlechter, als bei der Aufnahme."> > ["at0007"] = < text = <"Verstorben"> description = <"Der Patient verstarb während des Krankenhausaufenthaltes."> > ["at0008"] = < text = <"Unbestimmt"> description = <"Unbestimmt."> > ["at0011"] = < text = <"Entlassungsdatum/-uhrzeit"> description = <"Datum/Uhrzeit, an dem der Patient entlassen wurde."> > ["at0033"] = < text = <"Entlassungsarzt"> description = <"Informationen zum Entlassungsarzt."> > ["at0034"] = < text = <"ID"> description = <"*"> > ["at0035"] = < text = <"Familienname"> description = <"*"> > ["at0036"] = < text = <"Nachname"> description = <"*"> > ["at0038"] = < text = <"Aufenthaltsdauer"> description = <"Dauer des Krankenhausaufenthaltes."> > ["at0040"] = < text = <"Art der Entlassung"> description = <"Grund der Entlassung"> > ["at0050"] = < text = <"Zusätzliche Informationen"> description = <"Kommentare"> > ["at0051"] = < text = <"Entlassungsanweisungen"> description = <"Entlassungsanweisungen für Patienten."> > ["at0058"] = < text = <"Behandelnder Arzt"> description = <"Der behandelnde Arzt, der dem Patienten eine Dienstleistung erbracht hat."> > ["at0059"] = < text = <"ID"> description = <"*"> > ["at0060"] = < text = <"Familienname"> description = <"*"> > ["at0061"] = < text = <"Nachname"> description = <"*"> > ["at0062"] = < text = <"Überweisender Arzt"> description = <"Arzt, der den Patienten an den behandelnden Arzt überwiesen hat."> > ["at0063"] = < text = <"Nachname"> description = <"*"> > ["at0064"] = < text = <"Familienname"> description = <"*"> > ["at0065"] = < text = <"ID"> description = <"*"> > ["at0066"] = < text = <"Letzter Patientenstandort"> description = <"*"> > ["at0067"] = < text = <"Zugewiesener Patientenstandort"> description = <"Für die lokale Verwendung enthält dieses Feld den Typ der Organisationseinheit oder der klinischen Einheit."> > ["at0068"] = < text = <"Sonstige"> description = <"Sonstige"> > > > >