TEMPLATE Nephro_klinische Daten (Nephro_klinische Daten)

TEMPLATE IDNephro_klinische Daten
ConceptNephro_klinische Daten
DescriptionZur Darstellung von klinischen Patientendaten innerhalb des Nephro-Digital Projektes.
UseZur Repräsentation der klinischen Patientendaten (Vitalparameter, Diagnosen etc.)
PurposeZur Darstellung von klinischen Patientendaten innerhalb des Nephro-Digital Projektes.
References
AuthorsName: Nina Schewe; Organisation: Medizinische Hochschule Hannover; Email: schewe.nina@mh-hannover.de
Other Details LanguageName: Nina Schewe; Organisation: Medizinische Hochschule Hannover; Email: schewe.nina@mh-hannover.de
OtherDetails Language Independent{MetaDataSet:Sample Set =Template metadata sample set}
KeywordsKlinische Daten; Diagnosen; Blutdruck; Puls; Trinkmenge; Immunitätsstatus; Infektion; Transplantation
Language useden
Citeable Identifier1246.169.1046
AllOperationalTemplate [rootArchetypeId=openEHR-EHR-COMPOSITION.report.v1, otherContributors=null, tshis=[ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1], code=at0000, itemType=COMPOSITION, level=0, text=Klinische Daten, description=Document to communicate information to others, commonly in response to a request from another party., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=COMPOSITION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=null, code=null, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=1, text=Other Context, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.case_identification.v0], code=at0000, itemType=CLUSTER, level=2, text=Case identification, description=To record case identification details for public health purposes., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.case_identification.v0]/items[at0001], code=at0001, itemType=ELEMENT, level=3, text=Case identifier, description=The identifier of this case., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Diagnosen'], code=at0000, itemType=SECTION, level=1, text=Diagnosen, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Diagnosen']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1], code=at0000, itemType=EVALUATION, level=2, text=Problem/Diagnosis, description=Details about a single identified health condition, injury, disability or any other issue which impacts on the physical, mental and/or social well-being of an individual., comment=Clear delineation between the scope of a problem versus a diagnosis is not easy to achieve in practice. For the purposes of clinical documentation with this archetype, problem and diagnosis are regarded as a continuum, with increasing levels of detail and supportive evidence usually providing weight towards the label of 'diagnosis'., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Diagnosen']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=3, text=Name der Diagnose, description=Identification of the problem or diagnosis, by name., comment=Coding of the name of the problem or diagnosis with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Diagnosen']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0009], code=at0009, itemType=ELEMENT, level=3, text=Clinical description, description=Narrative description about the problem or diagnosis., comment=Use to provide background and context, including evolution, episodes or exacerbations, progress and any other relevant details, about the problem or diagnosis., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Diagnosen']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0077], code=at0077, itemType=ELEMENT, level=3, text=Date/time of onset, description=Estimated or actual date/time that signs or symptoms of the problem/diagnosis were first observed., comment=Data captured/imported as "Age at onset" should be converted to a date using the subject's date of birth., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Diagnosen']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0003], code=at0003, itemType=ELEMENT, level=3, text=Date/time clinically recognised, description=Estimated or actual date/time the diagnosis or problem was recognised by a healthcare professional., comment=Partial dates are acceptable. If the subject of care is under the age of one year, then the complete date or a minimum of the month and year is necessary to enable accurate age calculations - for example, if used to drive decision support. Data captured/imported as "Age at time of clinical recognition" should be converted to a date using the subject's date of birth., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Diagnosen']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.diagnose_details.v0], code=at0000, itemType=CLUSTER, level=3, text=Diagnosedetails, description=Diagnosebezogene Informationen., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Diagnosen']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.diagnose_details.v0]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Diagnosetyp, description=Art der Diagnose. Bei der Angabe des Diagnosetyps ist darauf zu achten, dass dieser auch im richtigen Kontext verwendet wird. Zum Beispiel wird es bei der Beschreibung einer Diagnose im Rahmen einer Überweisung nicht den Diagnosetyp "Entlassdiagnose" geben., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Grunderkrankung
  • Komorbidität
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Diagnosen']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0030], code=at0030, itemType=ELEMENT, level=3, text=Date/time of resolution, description=Estimated or actual date/time of resolution or remission for this problem or diagnosis, as determined by a healthcare professional., comment=Partial dates are acceptable. If the subject of care is under the age of one year, then the complete date or a minimum of the month and year is necessary to enable accurate age calculations - for example, if used to drive decision support. Data captured/imported as "Age at time of resolution" should be converted to a date using the subject's date of birth., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Immunitätsstatus EBV/CBV'], code=at0000, itemType=SECTION, level=1, text=Immunitätsstatus EBV/CBV, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Immunitätsstatus EBV/CBV']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1 and name/value='EBV Immunitätsstatus'], code=at0000, itemType=OBSERVATION, level=2, text=EBV Immunitätsstatus, description=The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Immunitätsstatus EBV/CBV']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1 and name/value='EBV Immunitätsstatus']/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=3, text=Any event, description=Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Immunitätsstatus EBV/CBV']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1 and name/value='EBV Immunitätsstatus']/data[at0001]/events[at0002]/data[at0003]/items[at0005], code=at0005, itemType=ELEMENT, level=4, text=Test name, description=Name of the laboratory investigation performed on the specimen(s)., comment=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)'., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • EBV Immunitätsstatus
Default value: EBV Immunitätsstatus, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Immunitätsstatus EBV/CBV']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1 and name/value='EBV Immunitätsstatus']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.laboratory_test_analyte.v1], code=at0000, itemType=CLUSTER, level=4, text=Laboratory analyte result, description=The result of a laboratory test for a single analyte value., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Immunitätsstatus EBV/CBV']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1 and name/value='EBV Immunitätsstatus']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.laboratory_test_analyte.v1]/items[at0024], code=at0024, itemType=ELEMENT, level=5, text=Virus, description=The name of the analyte result., comment=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., uncommonOntologyItems={fhir_mapping=Observation.code, hl7v2_mapping=OBX.3}, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • EBV
Default value: EBV, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Immunitätsstatus EBV/CBV']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1 and name/value='EBV Immunitätsstatus']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.laboratory_test_analyte.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=5, text=Nachweis, description=The value of the analyte result., comment=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., uncommonOntologyItems={fhir_mapping=Observation.value[x], hl7v2_mapping=OBX.2, OBX.5, OBX.6, OBX.7, OBX.8}, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • positiv
  • negativ
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Immunitätsstatus EBV/CBV']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1 and name/value='EBV Immunitätsstatus']/data[at0001]/events[at0002]/data[at0003]/items[at0101], code=at0101, itemType=ELEMENT, level=4, text=Comment, description=Additional narrative about the test result not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Immunitätsstatus EBV/CBV']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1 and name/value='EBV Immunitätsstatus']/data[at0001]/events[at0002]/state[at0112]/items[at0113], code=at0113, itemType=ELEMENT, level=4, text=Confounding factors, description=Issues or circumstances that impact on the accurate interpretation of the measurement or test result., comment='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., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Immunitätsstatus EBV/CBV']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1 and name/value='EBV Immunitätsstatus']/protocol[at0004]/items[at0094], code=at0094, itemType=CLUSTER, level=3, text=Test request details, description=Details about the test request., comment=In most situations there is one test request and a single corresponding test result, however this repeating cluster allows for the situation where there may be multiple test requests reported using a single test result. As an example: 'a clinician asks for blood glucose in one request and Urea/electrolytes in a second request, but the lab analyser does both and the lab wishes to report these together'., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Immunitätsstatus EBV/CBV']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1 and name/value='CMV Immunitätsstatus'], code=at0000, itemType=OBSERVATION, level=2, text=CMV Immunitätsstatus, description=The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Immunitätsstatus EBV/CBV']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1 and name/value='CMV Immunitätsstatus']/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=3, text=Any event, description=Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Immunitätsstatus EBV/CBV']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1 and name/value='CMV Immunitätsstatus']/data[at0001]/events[at0002]/data[at0003]/items[at0005], code=at0005, itemType=ELEMENT, level=4, text=Test name, description=Name of the laboratory investigation performed on the specimen(s)., comment=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)'., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • CMV Immunitätsstatus
Default value: CMV Immunitätsstatus, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Immunitätsstatus EBV/CBV']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1 and name/value='CMV Immunitätsstatus']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.laboratory_test_analyte.v1], code=at0000, itemType=CLUSTER, level=4, text=Laboratory analyte result, description=The result of a laboratory test for a single analyte value., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Immunitätsstatus EBV/CBV']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1 and name/value='CMV Immunitätsstatus']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.laboratory_test_analyte.v1]/items[at0024], code=at0024, itemType=ELEMENT, level=5, text=Virus, description=The name of the analyte result., comment=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., uncommonOntologyItems={fhir_mapping=Observation.code, hl7v2_mapping=OBX.3}, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • CMV
Default value: CMV, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Immunitätsstatus EBV/CBV']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1 and name/value='CMV Immunitätsstatus']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.laboratory_test_analyte.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=5, text=Nachweis, description=The value of the analyte result., comment=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., uncommonOntologyItems={fhir_mapping=Observation.value[x], hl7v2_mapping=OBX.2, OBX.5, OBX.6, OBX.7, OBX.8}, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • positiv
  • negativ
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Immunitätsstatus EBV/CBV']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1 and name/value='CMV Immunitätsstatus']/data[at0001]/events[at0002]/data[at0003]/items[at0101], code=at0101, itemType=ELEMENT, level=4, text=Comment, description=Additional narrative about the test result not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Immunitätsstatus EBV/CBV']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1 and name/value='CMV Immunitätsstatus']/protocol[at0004]/items[at0094], code=at0094, itemType=CLUSTER, level=3, text=Test request details, description=Details about the test request., comment=In most situations there is one test request and a single corresponding test result, however this repeating cluster allows for the situation where there may be multiple test requests reported using a single test result. As an example: 'a clinician asks for blood glucose in one request and Urea/electrolytes in a second request, but the lab analyser does both and the lab wishes to report these together'., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Infektion'], code=at0000, itemType=SECTION, level=1, text=Infektion, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Infektion']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1], code=at0000, itemType=EVALUATION, level=2, text=Problem/Diagnosis, description=Details about a single identified health condition, injury, disability or any other issue which impacts on the physical, mental and/or social well-being of an individual., comment=Clear delineation between the scope of a problem versus a diagnosis is not easy to achieve in practice. For the purposes of clinical documentation with this archetype, problem and diagnosis are regarded as a continuum, with increasing levels of detail and supportive evidence usually providing weight towards the label of 'diagnosis'., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Infektion']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=3, text=Name der Infektion, description=Identification of the problem or diagnosis, by name., comment=Coding of the name of the problem or diagnosis with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Infektion']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0077], code=at0077, itemType=ELEMENT, level=3, text=Date/time of onset, description=Estimated or actual date/time that signs or symptoms of the problem/diagnosis were first observed., comment=Data captured/imported as "Age at onset" should be converted to a date using the subject's date of birth., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Infektion']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0003], code=at0003, itemType=ELEMENT, level=3, text=Date/time clinically recognised, description=Estimated or actual date/time the diagnosis or problem was recognised by a healthcare professional., comment=Partial dates are acceptable. If the subject of care is under the age of one year, then the complete date or a minimum of the month and year is necessary to enable accurate age calculations - for example, if used to drive decision support. Data captured/imported as "Age at time of clinical recognition" should be converted to a date using the subject's date of birth., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Infektion']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.diagnose_details.v0], code=at0000, itemType=CLUSTER, level=3, text=Diagnosedetails, description=Diagnosebezogene Informationen., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Infektion']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.diagnose_details.v0]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Diagnosetyp, description=Art der Diagnose. Bei der Angabe des Diagnosetyps ist darauf zu achten, dass dieser auch im richtigen Kontext verwendet wird. Zum Beispiel wird es bei der Beschreibung einer Diagnose im Rahmen einer Überweisung nicht den Diagnosetyp "Entlassdiagnose" geben., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Infektion
Default value: Infektion, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Infektion']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.diagnose_details.v0]/items[at0016], code=at0016, itemType=ELEMENT, level=4, text=Aktuell?, description=Ist die Diagnose bei der Aufnahme in die Gesundheiteinrichtung vorhanden?, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Infektion']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0030], code=at0030, itemType=ELEMENT, level=3, text=Date/time of resolution, description=Estimated or actual date/time of resolution or remission for this problem or diagnosis, as determined by a healthcare professional., comment=Partial dates are acceptable. If the subject of care is under the age of one year, then the complete date or a minimum of the month and year is necessary to enable accurate age calculations - for example, if used to drive decision support. Data captured/imported as "Age at time of resolution" should be converted to a date using the subject's date of birth., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Transplantation'], code=at0000, itemType=SECTION, level=1, text=Transplantation, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Transplantation']/items[openEHR-EHR-ACTION.procedure.v1], code=at0000, itemType=ACTION, level=2, text=Transplantation, description=A clinical activity carried out for screening, investigative, diagnostic, curative, therapeutic, evaluative or palliative purposes., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ACTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Transplantation']/items[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=3, text=Procedure name, description=Identification of the procedure by name., comment=Coding of the specific procedure with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Transplantation
Default value: Transplantation, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Transplantation']/items[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[at0065], code=at0065, itemType=ELEMENT, level=3, text=Method, description=Identification of specific method or technique for the procedure., comment=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., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Lebendspende
  • Todspende
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Transplantation']/items[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[at0066], code=at0066, itemType=ELEMENT, level=3, text=Transplantationsdatum, description=The date and/or time on which the procedure is intended to be performed., comment=Only for use in association with the 'Procedure scheduled' pathway step., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Transplantation']/items[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[at0005], code=at0005, itemType=ELEMENT, level=3, text=Comment, description=Additional narrative about the activity or care pathway step not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Dialysedaten'], code=at0000, itemType=SECTION, level=1, text=Dialysedaten, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Dialysedaten']/items[openEHR-EHR-ACTION.procedure.v1], code=at0000, itemType=ACTION, level=2, text=Dialyse, description=A clinical activity carried out for screening, investigative, diagnostic, curative, therapeutic, evaluative or palliative purposes., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ACTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Dialysedaten']/items[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=3, text=Procedure name, description=Identification of the procedure by name., comment=Coding of the specific procedure with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Dialyse
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Dialysedaten']/items[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[at0065], code=at0065, itemType=ELEMENT, level=3, text=Method, description=Identification of specific method or technique for the procedure., comment=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., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Hämodialyse
  • Peritonealdialyse
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Dialysedaten']/items[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[at0066], code=at0066, itemType=ELEMENT, level=3, text=Startdatum, description=The date and/or time on which the procedure is intended to be performed., comment=Only for use in association with the 'Procedure scheduled' pathway step., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='körperliche Parameter'], code=at0000, itemType=SECTION, level=1, text=körperliche Parameter, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='körperliche Parameter']/items[openEHR-EHR-OBSERVATION.body_weight.v2], code=at0000, itemType=OBSERVATION, level=2, text=Body weight, description=Measurement of the body weight of an individual., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='körperliche Parameter']/items[openEHR-EHR-OBSERVATION.body_weight.v2]/data[at0002]/events[at0003], code=at0003, itemType=EVENT, level=3, text=Any event, description=Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='körperliche Parameter']/items[openEHR-EHR-OBSERVATION.body_weight.v2]/data[at0002]/events[at0003]/data[at0001]/items[at0004], code=at0004, itemType=ELEMENT, level=4, text=Weight, description=The weight of the individual., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=0..1000; 0..1000000
Units:
  • kg
  • g
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='körperliche Parameter']/items[openEHR-EHR-OBSERVATION.body_weight.v2]/data[at0002]/events[at0003]/state[at0008], code=at0008, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=State, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='körperliche Parameter']/items[openEHR-EHR-OBSERVATION.height.v2], code=at0000, itemType=OBSERVATION, level=2, text=Height/Length, description=Height, or body length, is measured from crown of head to sole of foot., comment=Height is measured with the individual in a standing position and body length in a recumbent position., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='körperliche Parameter']/items[openEHR-EHR-OBSERVATION.height.v2]/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=3, text=Any event, description=Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='körperliche Parameter']/items[openEHR-EHR-OBSERVATION.height.v2]/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=4, text=Height/Length, description=The length of the body from crown of head to sole of foot., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=0..1000 cm, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Vitalparameter'], code=at0000, itemType=SECTION, level=1, text=Vitalparameter, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Vitalparameter']/items[openEHR-EHR-OBSERVATION.pulse.v2], code=at0000, itemType=OBSERVATION, level=2, text=Pulse/Heart beat, description=The rate and associated attributes for a pulse or heart beat., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Vitalparameter']/items[openEHR-EHR-OBSERVATION.pulse.v2]/data[at0002]/events[at0003], code=at0003, itemType=EVENT, level=3, text=Any event, description=Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Vitalparameter']/items[openEHR-EHR-OBSERVATION.pulse.v2]/data[at0002]/events[at0003]/data[at0001]/items[at0004], code=at0004, itemType=ELEMENT, level=4, text=Rate, description=The rate of the pulse or heart beat, measured in beats per minute., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=0..1000 /min, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Vitalparameter']/items[openEHR-EHR-OBSERVATION.blood_pressure.v2], code=at0000, itemType=OBSERVATION, level=2, text=Blood pressure, description=The local measurement of arterial blood pressure which is a surrogate for arterial pressure in the systemic circulation., comment=Most commonly, use of the term 'blood pressure' refers to measurement of brachial artery pressure in the upper arm., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Vitalparameter']/items[openEHR-EHR-OBSERVATION.blood_pressure.v2]/data[at0001]/events[at0006], code=at0006, itemType=EVENT, level=3, text=Any event, description=Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Vitalparameter']/items[openEHR-EHR-OBSERVATION.blood_pressure.v2]/data[at0001]/events[at0006]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=4, text=Systolic, description=Peak systemic arterial blood pressure - measured in systolic or contraction phase of the heart cycle., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=0..1000 mm[Hg], extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Vitalparameter']/items[openEHR-EHR-OBSERVATION.blood_pressure.v2]/data[at0001]/events[at0006]/data[at0003]/items[at0005], code=at0005, itemType=ELEMENT, level=4, text=Diastolic, description=Minimum systemic arterial blood pressure - measured in the diastolic or relaxation phase of the heart cycle., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=0..1000 mm[Hg], extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Vitalparameter']/items[openEHR-EHR-OBSERVATION.blood_pressure.v2]/data[at0001]/events[at0006]/data[at0003]/items[at1006], code=at1006, itemType=ELEMENT, level=4, text=Mean arterial pressure, description=The average arterial pressure that occurs over the entire course of the heart contraction and relaxation cycle., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=0..1000 mm[Hg], extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Vitalparameter']/items[openEHR-EHR-OBSERVATION.blood_pressure.v2]/data[at0001]/events[at0006]/data[at0003]/items[at1007], code=at1007, itemType=ELEMENT, level=4, text=Pulse pressure, description=The difference between the systolic and diastolic pressure., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=0..1000 mm[Hg], extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Flüssigkeitshaushalt'], code=at0000, itemType=SECTION, level=1, text=Flüssigkeitshaushalt, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Flüssigkeitshaushalt']/items[openEHR-EHR-OBSERVATION.fluid_input.v1], code=at0000, itemType=OBSERVATION, level=2, text=Fluid input, description=The amount of fluid ingested or administered to the individual., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Flüssigkeitshaushalt']/items[openEHR-EHR-OBSERVATION.fluid_input.v1]/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=3, text=Any event, description=Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Flüssigkeitshaushalt']/items[openEHR-EHR-OBSERVATION.fluid_input.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0036], code=at0036, itemType=ELEMENT, level=4, text=Fluid name, description=Identification of the fluid ingested or administered., comment=For example: 0.9% NaCl; tea; or parenteral nutrition. The fluid name can be entered manually or derived from the fluid order by the clinical system., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Flüssigkeitshaushalt']/items[openEHR-EHR-OBSERVATION.fluid_input.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0035], code=at0035, itemType=ELEMENT, level=4, text=Volume, description=The volume of fluid ingested or administered., comment=The volume can be entered manually or derived from the fluid order by the clinical system., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=>=0; >=0
Units:
  • ml
  • l
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Klinische Untersuchung'], code=at0000, itemType=SECTION, level=1, text=Klinische Untersuchung, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Klinische Untersuchung']/items[openEHR-EHR-OBSERVATION.exam.v1], code=at0000, itemType=OBSERVATION, level=2, text=klinische Untersuchung, description=Findings observed during the physical examination of a subject of care., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Klinische Untersuchung']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=3, text=Any event, description=Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Klinische Untersuchung']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=4, text=Description, description=Narrative description of the overall findings observed during a physical examination of a patient., comment=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., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Klinische Untersuchung']/items[openEHR-EHR-EVALUATION.clinical_synopsis.v1], code=at0000, itemType=EVALUATION, level=2, text=Verlauf des Gesundheitszustandes, description=Narrative summary or overview about a patient, specifically from the perspective of a healthcare provider, and with or without associated interpretations., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Klinische Untersuchung']/items[openEHR-EHR-EVALUATION.clinical_synopsis.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=3, text=Verlaufstext, description=The summary, assessment, conclusions or evaluation of the clinical findings., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null]], templateType=normal]