TEMPLATE Nephro_klinische Eckdaten (Nephro_klinische Eckdaten)

TEMPLATE ID	Nephro_klinische Eckdaten
Concept	Nephro_klinische Eckdaten
Description	Zur Darstellung von klinischen Eckdaten des Patienten innerhalb des Nephro-Digital Projektes.
Use	Zur Repräsentation der klinischen Eckdaten eines Patienten (Vitalparameter, Infektionen etc.)
Purpose	Zur Darstellung von klinischen Eckdaten des Patienten innerhalb des Nephro-Digital Projektes.
References
Authors	Name: Nina Schewe; Organisation: Medizinische Hochschule Hannover; Email: schewe.nina@mh-hannover.de
Other Details Language	Name: Nina Schewe; Organisation: Medizinische Hochschule Hannover; Email: schewe.nina@mh-hannover.de
Other Details (Language Independent)	MetaDataSet:Sample Set : Template metadata sample set
Keywords	Klinische Daten; Blutdruck; Puls; Trinkmenge; Immunitätsstatus; Infektion; Transplantation; Hepatitis; HIV; Dialyse
Language used	en
Citeable Identifier	1246.169.1046
Root archetype id	openEHR-EHR-COMPOSITION.report.v1
Klinische Eckdaten	Klinische Eckdaten: Document to communicate information to others, commonly in response to a request from another party.
Other Context
Case identification	Case identification: To record case identification details for public health purposes.
Case identifier	Case identifier: The identifier of this case.
Dialyse	Dialyse: A clinical activity carried out for screening, investigative, diagnostic, curative, therapeutic, evaluative or palliative purposes.
Name der Dialyse	Name der Dialyse: Identification of the procedure by name. Coding of the specific procedure with a terminology is preferred, where possible. Terminology: SNOMED-CT Renal dialysis (procedure)
Methode der Dialyse	Methode der Dialyse: Identification of specific method or technique for the procedure. Use this data element to record simple terms or a narrative description. If the requirements for recording the method require more complex modelling then this can be represented by additional archetypes within the 'Procedure detail' SLOT in this archetype. If the method is included in the 'Procedure name' via precoordinated codes, this data element becomes redundant. Terminology: SNOMED-CT Hemodialysis (procedure) Peritoneal dialysis (procedure)
Startdatum	Startdatum: The date and/or time on which the procedure is intended to be performed. Only for use in association with the 'Procedure scheduled' pathway step.
Transplantation	Transplantation: A clinical activity carried out for screening, investigative, diagnostic, curative, therapeutic, evaluative or palliative purposes.
Procedure name	Procedure name: Identification of the procedure by name. Coding of the specific procedure with a terminology is preferred, where possible. Terminology: SNOMED-CT Transplant of kidney (procedure)
Art der Transplantation	Art der Transplantation: Identification of specific method or technique for the procedure. Use this data element to record simple terms or a narrative description. If the requirements for recording the method require more complex modelling then this can be represented by additional archetypes within the 'Procedure detail' SLOT in this archetype. If the method is included in the 'Procedure name' via precoordinated codes, this data element becomes redundant. Lebendspende Todspende
Transplantationsdatum	Transplantationsdatum: The date and/or time on which the procedure is intended to be performed. Only for use in association with the 'Procedure scheduled' pathway step.
Comment	Comment: Additional narrative about the activity or care pathway step not captured in other fields.
Hepatitis Immunitätsstatus	Hepatitis Immunitätsstatus: The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.
Laborabnahme	Laborabnahme: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Test name	Test name: Name of the laboratory investigation performed on the specimen(s). A test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'. Terminology: SNOMED-CT Hepatitis A virus antibody measurement (procedure) Hepatitis C antibody measurement (procedure) Hepatitis D antibody measurement (procedure) Hepatitis E antibody measurement (procedure) Hepatitis Be antibody measurement (procedure)
Laboratory analyte result	Laboratory analyte result: The result of a laboratory test for a single analyte value.
Virus	Virus: The name of the analyte result. The value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies. Optional[{fhir_mapping=Observation.code, hl7v2_mapping=OBX.3}] Terminology: LOINC Hepatitis A virus IgG Ab [Presence] in Serum Hepatitis A virus IgG Ab [Presence] in Serum by Immunoassay Hepatitis D virus IgG Ab [Presence] in Serum Hepatitis D virus IgG Ab [Presence] in Serum by Immunoassay Hepatitis B virus core IgG Ab [Presence] in Serum Hepatitis B virus core IgG Ab [Presence] in Serum by Immunoassay Hepatitis C virus IgG Ab [Presence] in Serum Hepatitis C virus IgG Ab [Presence] in Serum by Immunoblot Hepatitis C virus IgG Ab [Presence] in Serum or Plasma by Immunoassay Hepatitis C virus IgG Ab [Presence] in Serum, Plasma or Blood by Rapid immunoassay Hepatitis E virus IgG Ab [Presence in Serum Hepatitis E virus IgG Ab [Presence] in Serum by Immunoassay
Nachweis	Nachweis: The value of the analyte result. For example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details. Optional[{fhir_mapping=Observation.value[x], hl7v2_mapping=OBX.2, OBX.5, OBX.6, OBX.7, OBX.8}] IgG positiv IgG negativ
Comment	Comment: Additional narrative about the test result not captured in other fields.
Confounding factors	Confounding factors: Issues or circumstances that impact on the accurate interpretation of the measurement or test result. 'Confounding factors' should be reserved for uncontrolled/unplanned issues of patient state/physiology that might affect interpretation, for example 'recent exercise' or 'recent tobacco smoking'. Known or required preconditions, such as 'fasting' should be carried in the 'Sampling conditions' element within the CLUSTER.specimen archetype . In some cases preconditions are captured as part of the test name, for example 'Fasting blood glucose'. Known issues with specimen collection or handling, such as 'prolonged use of tourniquet' or 'sample haemolysed', should be carried in the 'Specimen quality' elements within CLUSTER.specimen archetype. Coding with a terminology is desirable, where possible.
HIV Immunitätsstatus	HIV Immunitätsstatus: The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.
Laborabnahme	Laborabnahme: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Test name	Test name: Name of the laboratory investigation performed on the specimen(s). A test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'. Terminology: SNOMED-CT Measurement of Human immunodeficiency virus 1 antibody (procedure) Measurement of Human immunodeficiency virus 2 antibody (procedure)
Laboratory analyte result	Laboratory analyte result: The result of a laboratory test for a single analyte value.
Analyte name	Analyte name: The name of the analyte result. The value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies. Optional[{fhir_mapping=Observation.code, hl7v2_mapping=OBX.3}] Terminology: LOINC HIV 2 IgG Ab [Presence] in Serum HIV 2 IgG Ab [Presence] in Serum by Immunoblot HIV 1 IgG Ab [Presence] in Serum HIV 1 IgG Ab [Presence] in Serum by Immunoblot
Nachweis	Nachweis: The value of the analyte result. For example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details. Optional[{fhir_mapping=Observation.value[x], hl7v2_mapping=OBX.2, OBX.5, OBX.6, OBX.7, OBX.8}] IgG positiv IgG negativ
Comment	Comment: Additional narrative about the test result not captured in other fields.
Confounding factors	Confounding factors: Issues or circumstances that impact on the accurate interpretation of the measurement or test result. 'Confounding factors' should be reserved for uncontrolled/unplanned issues of patient state/physiology that might affect interpretation, for example 'recent exercise' or 'recent tobacco smoking'. Known or required preconditions, such as 'fasting' should be carried in the 'Sampling conditions' element within the CLUSTER.specimen archetype . In some cases preconditions are captured as part of the test name, for example 'Fasting blood glucose'. Known issues with specimen collection or handling, such as 'prolonged use of tourniquet' or 'sample haemolysed', should be carried in the 'Specimen quality' elements within CLUSTER.specimen archetype. Coding with a terminology is desirable, where possible.
CMV Immunitätsstatus	CMV Immunitätsstatus: The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Test name	Test name: Name of the laboratory investigation performed on the specimen(s). A test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'. Terminology: SNOMED-CT Serologic test for cytomegalovirus (procedure)
Laboratory analyte result	Laboratory analyte result: The result of a laboratory test for a single analyte value.
Analyte name	Analyte name: The name of the analyte result. The value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies. Optional[{fhir_mapping=Observation.code, hl7v2_mapping=OBX.3}] Terminology: LOINC Cytomegalovirus IgG Ab [Titer] in Serum or Plasma Cytomegalovirus IgG Ab [Titer] in Serum or Plasma by Immunofluorescence
Nachweis	Nachweis: The value of the analyte result. For example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details. Optional[{fhir_mapping=Observation.value[x], hl7v2_mapping=OBX.2, OBX.5, OBX.6, OBX.7, OBX.8}] IgG positiv IgG negativ
Comment	Comment: Additional narrative about the test result not captured in other fields.
Confounding factors	Confounding factors: Issues or circumstances that impact on the accurate interpretation of the measurement or test result. 'Confounding factors' should be reserved for uncontrolled/unplanned issues of patient state/physiology that might affect interpretation, for example 'recent exercise' or 'recent tobacco smoking'. Known or required preconditions, such as 'fasting' should be carried in the 'Sampling conditions' element within the CLUSTER.specimen archetype . In some cases preconditions are captured as part of the test name, for example 'Fasting blood glucose'. Known issues with specimen collection or handling, such as 'prolonged use of tourniquet' or 'sample haemolysed', should be carried in the 'Specimen quality' elements within CLUSTER.specimen archetype. Coding with a terminology is desirable, where possible.
EBV Immunitätsstatus	EBV Immunitätsstatus: The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.
Laborabnahme	Laborabnahme: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Test name	Test name: Name of the laboratory investigation performed on the specimen(s). A test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'. Terminology: SNOMED-CT Epstein-Barr virus serologic test (procedure)
Laboratory analyte result	Laboratory analyte result: The result of a laboratory test for a single analyte value.
Analyte name	Analyte name: The name of the analyte result. The value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies. Optional[{fhir_mapping=Observation.code, hl7v2_mapping=OBX.3}] Terminology: LOINC Epstein Barr virus nuclear IgG Ab [Titer] in Serum Epstein Barr virus nuclear IgG Ab [Titer] in Serum by Immunofluorescence Epstein Barr virus capsid IgG Ab [Titer] in Serum Epstein Barr virus capsid IgG Ab [Titer] in Serum by Immunofluorescence Epstein Barr virus early IgG Ab [Titer] in Serum Epstein Barr virus early IgG Ab [Titer] in Serum by Immunofluorescence
Nachweis	Nachweis: The value of the analyte result. For example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details. Optional[{fhir_mapping=Observation.value[x], hl7v2_mapping=OBX.2, OBX.5, OBX.6, OBX.7, OBX.8}] IgG positiv IgG negativ
Comment	Comment: Additional narrative about the test result not captured in other fields.
Confounding factors	Confounding factors: Issues or circumstances that impact on the accurate interpretation of the measurement or test result. 'Confounding factors' should be reserved for uncontrolled/unplanned issues of patient state/physiology that might affect interpretation, for example 'recent exercise' or 'recent tobacco smoking'. Known or required preconditions, such as 'fasting' should be carried in the 'Sampling conditions' element within the CLUSTER.specimen archetype . In some cases preconditions are captured as part of the test name, for example 'Fasting blood glucose'. Known issues with specimen collection or handling, such as 'prolonged use of tourniquet' or 'sample haemolysed', should be carried in the 'Specimen quality' elements within CLUSTER.specimen archetype. Coding with a terminology is desirable, where possible.
Body weight	Body weight: Measurement of the body weight of an individual.
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Weight	Weight: The weight of the individual. 0..1000; 0..1000000 Units: kg g
Height/Length	Height/Length: Height, or body length, is measured from crown of head to sole of foot. Height is measured with the individual in a standing position and body length in a recumbent position.
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Height/Length	Height/Length: The length of the body from crown of head to sole of foot. 0..1000 cm
Pulse/Heart beat	Pulse/Heart beat: The rate and associated attributes for a pulse or heart beat.
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Rate	Rate: The rate of the pulse or heart beat, measured in beats per minute. 0..1000 /min
Blood pressure	Blood pressure: The local measurement of arterial blood pressure which is a surrogate for arterial pressure in the systemic circulation. Most commonly, use of the term 'blood pressure' refers to measurement of brachial artery pressure in the upper arm.
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Systolic	Systolic: Peak systemic arterial blood pressure - measured in systolic or contraction phase of the heart cycle. 0..1000 mmHg (UCUM: mm[Hg])
Diastolic	Diastolic: Minimum systemic arterial blood pressure - measured in the diastolic or relaxation phase of the heart cycle. 0..1000 mmHg (UCUM: mm[Hg])
Mean arterial pressure	Mean arterial pressure: The average arterial pressure that occurs over the entire course of the heart contraction and relaxation cycle. 0..1000 mmHg (UCUM: mm[Hg])
Pulse pressure	Pulse pressure: The difference between the systolic and diastolic pressure. 0..1000 mmHg (UCUM: mm[Hg])
klinische Untersuchung	klinische Untersuchung: Findings observed during the physical examination of a subject of care.
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Description	Description: Narrative description of the overall findings observed during a physical examination of a patient. May be used to record a narrative summary of the complete clinical examination or key aspects of clinical examination findings, which will be supported by structured data. Details of specific structured findings can be included using CLUSTER archetypes in the 'Examination Detail' slot. This data element may be used to capture legacy data that is not available in a structured format.
Verlauf des Gesundheitszustandes	Verlauf des Gesundheitszustandes: Narrative summary or overview about a patient, specifically from the perspective of a healthcare provider, and with or without associated interpretations.
Verlaufstext	Verlaufstext: The summary, assessment, conclusions or evaluation of the clinical findings.