archetype (adl_version=1.4; uid=dd317ee0-e9aa-4799-b124-8e1e013a224a) openEHR-EHR-ADMIN_ENTRY.admission.v0 concept [at0000] -- Patient admission language original_language = <[ISO_639-1::en]> translations = < ["de"] = < language = <[ISO_639-1::de]> author = < ["name"] = <"Anneka Sargeant"> ["organisation"] = <"UMG Göttingen"> ["email"] = <"anneka.sargeant@med.uni-goettingen.de"> > > ["pt-br"] = < language = <[ISO_639-1::pt-br]> author = < ["name"] = <"Osmeire Chamelette Sanzovo, Beatriz de Faria Leão, Vladimir Pizzo"> ["organisation"] = <"Hospital Sírio Libanês - SP"> ["email"] = <"osmeire.acsanzovo@hsl.org.br"> > > ["ar-sy"] = < language = <[ISO_639-1::ar-sy]> author = < ["name"] = <"Mona Saleh"> > > > description original_author = < ["name"] = <"Chunlan Ma"> ["organisation"] = <"Ocean Informatics"> ["email"] = <"chunlan.ma@oceaninformatics.com"> ["date"] = <"19/07/07"> > details = < ["de"] = < language = <[ISO_639-1::de]> purpose = <"Dieser ADMIN_ENTRY-Archetyp wurde für die Darstellung der minimalen Daten bei der Patientenaufnahme entwickelt. Er basiert auf der australischen/neuseeländischen Standardimplementierung von Health Level Seven (HL7) Version 2.4 (Teil 1: Patientenverwaltung) und Health Level Seven (HL7) Standard Version 2.3.1."> use = <""> keywords = <"Daten", "Aufnahme", "Aufnahmedaten", "Patient", "Patientenaufnahme", "Patient"> misuse = <""> copyright = <"© 2011 openEHR Foundation, openEHR Foundation, HiGHmed"> > ["pt-br"] = < language = <[ISO_639-1::pt-br]> purpose = <"Este arquétipo ADMIN_ENTRY de admissão foi projetado para representar os dados mínimos de admissão. Foi baseado na Implementação padrão da Austrália/Nova Zelândia, padrão HL7 versão 2.4 (parte 1: administração paciente ) e HL7 versão 2.3.1."> use = <""> misuse = <""> copyright = <"© 2011 openEHR Foundation, openEHR Foundation, HiGHmed"> > ["ar-sy"] = < language = <[ISO_639-1::ar-sy]> purpose = <"هذا النموذج الخاص بإدخال المريض تم تصميمه لتمثيل الحد الأدنى من بيانات إدخال المريض. و هذا يستخدم التطبيق العياري في أستراليا و نيوزيلندة للمستوى الصحي السابع النسخة/الإصدار 2.4 (الجزء الأول:إدراة المريض), و الإصدار 2.3.1 من المستوى الصحي السابع."> use = <""> misuse = <""> copyright = <"© 2011 openEHR Foundation, openEHR Foundation, HiGHmed"> > ["en"] = < language = <[ISO_639-1::en]> purpose = <"This admission ADMIN_ENTRY archetype was designed for representing the minimum admission data. This is based on the Australian/New Zealand Standard Implementation of Health Level Seven (HL7) Version 2.4 (Part 1: Patient administration) and Health Level Seven (HL7) Standard Version 2.3.1."> use = <""> misuse = <""> copyright = <"© 2011 openEHR Foundation, openEHR Foundation, HiGHmed"> > > lifecycle_state = <"in_development"> other_contributors = <"Sistine Barretto", ...> 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: "> ["original_namespace"] = <"org.highmed"> ["original_publisher"] = <"HiGHmed"> ["custodian_namespace"] = <"org.highmed"> ["MD5-CAM-1.0.1"] = <"0DB5717EC257D7BC74B61204247D769C"> ["build_uid"] = <"1c173686-9df0-498f-b63f-5d7bb6fe0f26"> ["revision"] = <"0.0.1-alpha"> > definition ADMIN_ENTRY[at0000] matches { -- Patientenaufnahme data matches { ITEM_TREE[at0001] matches { -- Tree items cardinality matches {1..*; unordered} matches { ELEMENT[at0002] occurrences matches {0..1} matches { -- Patientenklasse value matches { DV_TEXT matches {*} } } ELEMENT[at0013] occurrences matches {0..*} matches { -- Aufnahmegrund value matches { DV_TEXT matches {*} } } ELEMENT[at0049] occurrences matches {0..1} matches { -- Art der Aufnahme value matches { DV_TEXT matches {*} } } ELEMENT[at0023] occurrences matches {0..1} matches { -- Kennung vor der Aufnahme value matches { DV_TEXT matches {*} } } CLUSTER[at0098] occurrences matches {0..*} matches { -- Behandelnder Arzt items cardinality matches {1..*; unordered} matches { ELEMENT[at0099] occurrences matches {0..1} matches { -- ID value matches { DV_TEXT matches {*} } } ELEMENT[at0100] occurrences matches {0..1} matches { -- Familienname value matches { DV_TEXT matches {*} } } ELEMENT[at0120] occurrences matches {0..1} matches { -- Nachname value matches { DV_TEXT matches {*} } } } } CLUSTER[at0025] occurrences matches {0..1} matches { -- Überweisender Arzt items cardinality matches {1..*; unordered} matches { use_node ELEMENT /data[at0001]/items[at0098]/items[at0099] -- /data[Tree]/items[Behandelnder Arzt]/items[ID] use_node ELEMENT /data[at0001]/items[at0098]/items[at0100] -- /data[Tree]/items[Behandelnder Arzt]/items[Familienname] use_node ELEMENT /data[at0001]/items[at0098]/items[at0120] -- /data[Tree]/items[Behandelnder Arzt]/items[Nachname] } } CLUSTER[at0121] occurrences matches {0..*} matches { -- Konsultierter Arzt items cardinality matches {1..*; unordered} matches { use_node ELEMENT /data[at0001]/items[at0098]/items[at0099] -- /data[Tree]/items[Behandelnder Arzt]/items[ID] use_node ELEMENT /data[at0001]/items[at0098]/items[at0100] -- /data[Tree]/items[Behandelnder Arzt]/items[Familienname] use_node ELEMENT /data[at0001]/items[at0098]/items[at0120] -- /data[Tree]/items[Behandelnder Arzt]/items[Nachname] } } ELEMENT[at0041] occurrences matches {0..1} matches { -- Krankenhausdienst value matches { DV_TEXT matches {*} } } CLUSTER[at0051] occurrences matches {0..1} matches { -- Aufnehmender Arzt items cardinality matches {1..*; unordered} matches { use_node ELEMENT /data[at0001]/items[at0098]/items[at0099] -- /data[Tree]/items[Behandelnder Arzt]/items[ID] use_node ELEMENT /data[at0001]/items[at0098]/items[at0100] -- /data[Tree]/items[Behandelnder Arzt]/items[Familienname] use_node ELEMENT /data[at0001]/items[at0098]/items[at0120] -- /data[Tree]/items[Behandelnder Arzt]/items[Nachname] } } ELEMENT[at0061] occurrences matches {0..1} matches { -- Art der Finanzierung value matches { DV_TEXT matches {*} } } ELEMENT[at0071] matches { -- Datum/Uhrzeit der Aufnahme value matches { DV_DATE_TIME matches {*} } } allow_archetype CLUSTER[at0131] occurrences matches {0..*} matches { -- Zugewiesener Patientenstandort include archetype_id/value matches {/.*/} } allow_archetype CLUSTER[at0132] occurrences matches {0..*} matches { -- Vorheriger Patientenstandort include archetype_id/value matches {/.*/} } } } } } ontology term_definitions = < ["en"] = < items = < ["at0000"] = < text = <"Patient admission"> description = <"Used for admitted patient only. It signals the beginning of a patient's stay in a health care facility."> > ["at0001"] = < text = <"Tree"> description = <"@ internal @"> > ["at0002"] = < text = <"Patient class"> description = <"Intended mode of treatement."> > ["at0013"] = < text = <"Admission type"> description = <"The circumstance under which the patient will be admitted."> > ["at0023"] = < text = <"Pre-admit number"> description = <"ID number of patient's pre-admission"> > ["at0025"] = < text = <"Referring doctor"> description = <"Clinician who referred patient to the consulting doctor"> > ["at0041"] = < text = <"Hospital service"> description = <"For local use, this field hold the type of organizational unit or clinical unit, e.g. CARDO1."> > ["at0049"] = < text = <"Admit source"> description = <"Detailed description of the mode of admission."> > ["at0051"] = < text = <"Admitting doctor"> description = <"*"> > ["at0061"] = < text = <"Financial class"> description = <"*"> > ["at0071"] = < text = <"Admit date/time"> description = <"Date/time the patient was admitted."> > ["at0098"] = < text = <"Attending doctor"> description = <"The attending doctor providing services to the patient"> > ["at0099"] = < text = <"ID"> description = <"*"> > ["at0100"] = < text = <"Family name"> description = <"*"> > ["at0120"] = < text = <"Last name"> description = <"*"> > ["at0121"] = < text = <"Consulting doctor"> description = <"Consultant responsible for the care of the patient,including salaried specialist, visiting medical officer"> > ["at0131"] = < text = <"*Cluster(en)"> description = <"**(en)"> > ["at0132"] = < text = <"*Cluster(en)"> description = <"**(en)"> > > > ["ar-sy"] = < items = < ["at0000"] = < text = <"إدخال المريض"> description = <"يستخدم فقط للمرضى الذين تم إدخالهم. و ذلك يشير إلى بداية بقاء المريض في مؤسسة الرعاية الصحية"> > ["at0001"] = < text = <"*Tree(en)"> description = <"*@ internal @(en)"> > ["at0002"] = < text = <"درجة المريض"> description = <"أسلوب المعاملة المقصود"> > ["at0013"] = < text = <"نوع الإدخال"> description = <"الظروف التي يتم إدخال المريض تحتها"> > ["at0023"] = < text = <"رقم ما قبل الإدخال"> description = <"الرقم التعريفي للمريض ما قبل الإدخال"> > ["at0025"] = < text = <"الطبيب صاحب الإحالة"> description = <"الطبيب الذي قام بإحالة المريض إلى الطبيب الاستشاري"> > ["at0041"] = < text = <"خدمة المستشفى"> description = <"للاستخدام المحلي, و يمثل هذا الحق نو الوحدة التنظيمية أو السريرية, مثل: CARDO1"> > ["at0049"] = < text = <"مصدر الإدخال"> description = <"برجاء الرجوع إلى طريق الإدخال في NHDD 000385 و مصدر الإحالة إلى المستشفى النفسي العام NHDD 000150 "> > ["at0051"] = < text = <"الطبيب المسئول عن الإدخال"> description = <"*"> > ["at0061"] = < text = <"الدرجة الاقتصادية"> description = <"*"> > ["at0071"] = < text = <"وقت/ تاريخ الإدخال"> description = <"الوقت و التاريخ الذين تم فيهما إدخال المريض"> > ["at0098"] = < text = <"الطبيب الحاضر"> description = <"الطبيب الحاضر الذي يقدم الخدمات للمريض"> > ["at0099"] = < text = <"العتصر التعريفي"> description = <"*"> > ["at0100"] = < text = <"اسم العائلة"> description = <"*"> > ["at0120"] = < text = <"الاسم الأخير"> description = <"*"> > ["at0121"] = < text = <"الطبيب الاستشاري"> description = <"الطبيب الاستشاري المسئول عن تقديم الرعاية للمريض, بنا قي ذلك الأخصائي الذي يعمل بأجر, و المسئول الطبي الزائر"> > ["at0131"] = < text = <"*Cluster(en)"> description = <"**(en)"> > ["at0132"] = < text = <"*Cluster(en)"> description = <"**(en)"> > > > ["pt-br"] = < items = < ["at0000"] = < text = <"Admissão do paciente"> description = <"Somente utilizado para paciente internado. Sinaliza o início da estadia de um paciente em uma unidade de saúde."> > ["at0001"] = < text = <"*Tree(en)"> description = <"*@ internal @(en)"> > ["at0002"] = < text = <"Classificação do paciente"> description = <"O tipo de tratamento pretendido."> > ["at0013"] = < text = <"Tipo de Admissão"> description = <"Circunstância na qual o paciente foi admitido."> > ["at0023"] = < text = <"Número da pré-admissão"> description = <"Número do ID da pré-admissão do paciente."> > ["at0025"] = < text = <"Médico solicitante"> description = <"Médico que solicitou a internação."> > ["at0041"] = < text = <"Unidade hospitalar"> description = <"Para uso local, este campo contém o tipo de unidade organizacional ou clínica, por exemplo: Cardiologia1."> > ["at0049"] = < text = <"Fonte da admissão"> description = <"Referência para NHDD 000385 Modo de admissão e NHDD 000150 Fonte de encaminhamento para o hospital psiquiátrico público."> > ["at0051"] = < text = <"Médico da admissão"> description = <"*"> > ["at0061"] = < text = <"Tipo de financiamento"> description = <"Fonte pagadora"> > ["at0071"] = < text = <"Data/hora admissão"> description = <"Data/hora que o paciente foi admitido."> > ["at0098"] = < text = <"Médico do atendimento"> description = <"O médico responsável pela prestação de serviços ao paciente."> > ["at0099"] = < text = <"ID"> description = <"*"> > ["at0100"] = < text = <"Nome"> description = <"*"> > ["at0120"] = < text = <"Sobrenome"> description = <"*"> > ["at0121"] = < text = <"Médico especialista"> description = <"Médico responsável pelo cuidado do paciente, incluindo especialista assalariado ou visitador."> > ["at0131"] = < text = <"*Cluster(en)"> description = <"**(en)"> > ["at0132"] = < text = <"*Cluster(en)"> description = <"**(en)"> > > > ["de"] = < items = < ["at0000"] = < text = <"Patientenaufnahme"> description = <"Wird nur für aufgenommene Patienten verwendet. Es signalisiert den Beginn des Aufenthalts eines Patienten in einer Gesundheitseinrichtung."> > ["at0001"] = < text = <"Tree"> description = <"@ internal @"> > ["at0002"] = < text = <"Patientenklasse"> description = <"Bestimmte Behandlungsmethode oder Vorgesehene Behandlungsmethode."> > ["at0013"] = < text = <"Aufnahmegrund"> description = <"Der Umstand, unter dem der Patient aufgenommen wird."> > ["at0023"] = < text = <"Kennung vor der Aufnahme"> description = <"Kennung vor der Aufnahme"> > ["at0025"] = < text = <"Überweisender Arzt"> description = <"Arzt, der den Patienten an den konsultierten Arzt überwiesen hat."> > ["at0041"] = < text = <"Krankenhausdienst"> description = <"Für die lokale Verwendung enthält dieses Feld die Art der Organisationseinheit oder klinischen Einheit, z.B. CARDIO."> > ["at0049"] = < text = <"Art der Aufnahme"> description = <"Nähere Beschreibung der Art der Aufnahme, z.B. Unfall oder Notfall."> > ["at0051"] = < text = <"Aufnehmender Arzt"> description = <"Der Arzt, welche den Patienten aufgenommen hat."> > ["at0061"] = < text = <"Art der Finanzierung"> description = <"Die Art der Finanzierung."> > ["at0071"] = < text = <"Datum/Uhrzeit der Aufnahme"> description = <"Datum/Zeit, an dem der Patient aufgenommen wurde."> > ["at0098"] = < text = <"Behandelnder Arzt"> description = <"Der behandelnde Arzt, der Dienstleistungen für den Patienten erbringt."> > ["at0099"] = < text = <"ID"> description = <"Identifikationsnummer"> > ["at0100"] = < text = <"Familienname"> description = <"Familienname"> > ["at0120"] = < text = <"Nachname"> description = <"Nachname"> > ["at0121"] = < text = <"Konsultierter Arzt"> description = <"Für die Behandlung des Patienten verantwortlicher Berater, einschließlich angestellter Facharzt, Amtsarzt."> > ["at0131"] = < text = <"Zugewiesener Patientenstandort"> description = <"Zugewiesener Patientenstandort"> > ["at0132"] = < text = <"Vorheriger Patientenstandort"> description = <"Vorheriger Patientenstandort"> > > > >