TEMPLATE Symptom (Symptom)

TEMPLATE IDSymptom
ConceptSymptom
DescriptionZur Repräsentation von COVID-19-Symptomen im Rahmen des FoDaPl-Projektes / GECCO-Datensatzes. Es können vorliegende, unbekannte und explizit ausgeschlossene Symptome angelegt werden.
UseFür die Abbildung von COVID-19-Symptomen für die Speicherung im Rahmen des FoDaPI-Projektes / GECCO-Datensatzes.
MisuseNicht für die Abbildung von Diagnosen/Problemen, die durch eine/n KlinikerIn evaluiert wurde.
PurposeZur Repräsentation von COVID-19-Symptomen im Rahmen des FoDaPl-Projektes / GECCO-Datensatzes. Es können vorliegende, unbekannte und explizit ausgeschlossene Symptome angelegt werden.
References
Authorsdate: 2020-09-15; name: Antje Wulff; organisation: Peter L. Reichertz Institut für Medizinische Informatik; email: antje.wulff@plri.de
Other Details Languagedate: 2020-09-15; name: Antje Wulff; organisation: Peter L. Reichertz Institut für Medizinische Informatik; email: antje.wulff@plri.de
OtherDetails Language Independent{PARENT:MD5-CAM-1.0.1=137DCA7D21FA274494054E1B81B67FC5, original_language=ISO_639-1::de, MD5-CAM-1.0.1=1711fd10e62812d62aa0eec82176226a}
KeywordsGECCO; NUM; FoDaPl; Symptom
Language useden
Citeable Identifier1246.169.1109
AllOperationalTemplate [rootArchetypeId=openEHR-EHR-COMPOSITION.registereintrag.v1, otherContributors=Sarah Ballout, tshis=[ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1], code=at0000, itemType=COMPOSITION, level=0, text=COVID-19 Symptom, description=Generische Zusammenstellung zur Darstellung eines Datensatzes für Forschungszwecke., 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.registereintrag.v1]/context/other_context[at0001]/items[at0004], code=at0004, itemType=ELEMENT, level=2, text=Status, description=Status der gelieferten Daten für den Registereintrag. Hinweis: Dies ist nicht der Status einzelner Komponenten., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • registriert  [*]
  • vorläufig  [*]
  • final  [*]
  • geändert  [*]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/context/other_context[at0001]/items[at0005], code=at0005, itemType=ELEMENT, level=2, text=Kategorie, description=Die Klassifikation des Registereintrags (z.B. Typ der Observation des FHIR-Profils)., 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], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-OBSERVATION.symptom_sign.v0], code=at0000, itemType=OBSERVATION, level=1, text=Vorliegendes Symptom, description=Reported observation of a physical or mental disturbance in an 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.registereintrag.v1]/content[openEHR-EHR-OBSERVATION.symptom_sign.v0]/data[at0190], code=at0190, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=2, text=Data, 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.registereintrag.v1]/content[openEHR-EHR-OBSERVATION.symptom_sign.v0]/data[at0190]/events[at0191], code=at0191, 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=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-OBSERVATION.symptom_sign.v0]/data[at0190]/events[at0191]/data[at0192], code=at0192, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Data, 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.registereintrag.v1]/content[openEHR-EHR-OBSERVATION.symptom_sign.v0]/data[at0190]/events[at0191]/data[at0192]/items[at0001], code=at0001, itemType=ELEMENT, level=5, text=Symptom/Sign name, description=The name of the reported symptom or sign., comment=Symptom name should be coded with a terminology, where possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Abdominal pain (finding)  []
  • Asymptomatic (finding)  []
  • Bleeding (finding)  []
  • Chest pain (finding)  []
  • Chill (finding)  []
  • Conjunctivitis (disorder)  []
  • Cough (finding)  []
  • Diarrhea (finding)  []
  • Disturbance of consciousness (finding)  []
  • Dyspnea (finding)  []
  • Eruption of skin (disorder)  []
  • Fatigue (finding)  []
  • Feeling feverish (finding)  []
  • Fever (finding)  []
  • Headache (finding)  []
  • Hemoptysis (finding)  []
  • Indrawing of ribs during respiration (finding)  []
  • Joint pain (finding)  []
  • Loss of appetite (finding)  []
  • Loss of sense of smell (finding)  []
  • Loss of taste (finding)  []
  • Lymphadenopathy (disorder)  []
  • Malaise (finding)  []
  • Muscle pain (finding)  []
  • Nasal congestion (finding)  []
  • Nasal discharge (finding)  []
  • Nausea (finding)  []
  • Pain in throat (finding)  []
  • Rigor (finding)  []
  • Seizure (finding)  []
  • Skin ulcer (disorder)  []
  • Unable to walk (finding)  []
  • Vomiting (disorder)  []
  • Wheezing (finding)  []
  • Fever greater than 100.4 Fahrenheit / 38° Celsius (finding)  []
  • Asthenia (finding)  []
  • Pain (finding)  []
  • Productive cough (finding)  []
  • Dry cough (finding)  []
  • Clouded consciousness (finding)  []
Terminology: SNOMED Clinical Terms, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-OBSERVATION.symptom_sign.v0]/data[at0190]/events[at0191]/data[at0192]/items[at0151], code=at0151, itemType=ELEMENT, level=5, text=Body site, description=Simple body site where the symptom or sign was reported., comment=Occurrences of this data element are set to 0..* to allow multiple body sites to be separated out in a template if desired. This allows for representation of clinical scenarios where a symptom or sign needs to be recorded in multiple locations or identifying both the originating and distal site in pain radiation, but where all of the other attributes such as impact and duration are identical. If the requirements for recording the body site are determined at run-time by the application or require more complex modelling such as relative locations then use the CLUSTER.anatomical_location or CLUSTER.relative_location within the Detailed anatomical location' SLOT in this archetype. If the anatomical location is included in the Symptom name via precoordinated codes, this data element becomes redundant. If the anatomical location is recorded using the 'Structured body site' SLOT, then use of this data element is not allowed - record only the simple 'Body site' OR 'Structured body site', but not both., 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.registereintrag.v1]/content[openEHR-EHR-OBSERVATION.symptom_sign.v0]/data[at0190]/events[at0191]/data[at0192]/items[at0152], code=at0152, itemType=ELEMENT, level=5, text=Episode onset, description=The onset for this episode of the symptom or sign., comment=While partial dates are permitted, the exact date and time of onset can be recorded, if appropriate. If this symptom or sign is experienced for the first time or is a re-occurrence, this date is used to represent the onset of this episode. If this symptom or sign is ongoing, this data element may be redundant if it has been recorded previously., 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.registereintrag.v1]/content[openEHR-EHR-OBSERVATION.symptom_sign.v0]/data[at0190]/events[at0191]/data[at0192]/items[at0021], code=at0021, itemType=ELEMENT, level=5, text=Severity category, description=Category representing the overall severity of the symptom or sign., comment=Defining values such as mild, moderate or severe in such a way that is applicable to multiple symptoms or signs plus allows multiple users to interpret and record them consistently is not easy. Some organisations extend the value set further with inclusion of additional values such as 'Trivial' and 'Very severe', and/or 'Mild-Moderate' and 'Moderate-Severe', adds to the definitional difficulty and may also worsen inter-recorder reliability issues. Use of 'Life-threatening' and 'Fatal' is also often considered as part of this value set, although from a pure point of view it may actually reflect an outcome rather than a severity. In view of the above, keeping to a well-defined but smaller list is preferred and so the mild/moderate/severe value set is offered, however the choice of other text allows for other value sets to be included at this data element in a template. Note: more specific grading of severity can be recorded using the 'Specific details' SLOT., 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.registereintrag.v1]/content[openEHR-EHR-OBSERVATION.symptom_sign.v0]/data[at0190]/events[at0191]/data[at0192]/items[at0161], code=at0161, itemType=ELEMENT, level=5, text=Resolution date/time, description=The timing of the cessation of this episode of the symptom or sign., comment=If 'Date/time of onset' and 'Duration' are used in systems, this data element may be calculated, or alternatively, considered redundant. While partial dates are permitted, the exact date and time of resolution can be recorded, if appropriate., 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.registereintrag.v1]/content[openEHR-EHR-OBSERVATION.symptom_sign.v0]/protocol[at0193], code=at0193, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=2, text=Protocol, 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.registereintrag.v1]/content[openEHR-EHR-EVALUATION.exclusion_specific.v1], code=at0000, itemType=EVALUATION, level=1, text=Ausgeschlossenes Symptom, description=A statement of exclusion of a specific Problem/diagnosis, Family history, Medication, Procedure, Adverse reaction or other clinical item that is either not currently present, or have not been present in the past., 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.registereintrag.v1]/content[openEHR-EHR-EVALUATION.exclusion_specific.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=2, text=Data, 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.registereintrag.v1]/content[openEHR-EHR-EVALUATION.exclusion_specific.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=3, text=Exclusion statement, description=A qualifying statement about the exclusion of a Problem/diagnosis, Family history, Medication, Procedure, Adverse reaction or other clinical item., comment=This statement is to be used in conjunction with the 'Excluded concept' data element. For example: this data element can support recording general statements such as "No known history of ..." where the 'Excluded concept' identifies the specific problem, diagnosis, substance, procedure or medication. If the 'Excluded concept' data element is used to record a precoordinated term such as 'No family history of diabetes', this element is redundant., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Known absent (qualifier value)  []
Terminology: SNOMED Clinical Terms, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-EVALUATION.exclusion_specific.v1]/data[at0001]/items[at0003], code=at0003, itemType=ELEMENT, level=3, text=Problem/Diagnose, description=The problem or diagnosis to which the 'Exclusion statement' applies. For example: 'Diabetes', 'COPD' or 'Asthma'., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Abdominal pain (finding)  []
  • Asymptomatic (finding)  []
  • Bleeding (finding)  []
  • Chest pain (finding)  []
  • Chill (finding)  []
  • Conjunctivitis (disorder)  []
  • Cough (finding)  []
  • Diarrhea (finding)  []
  • Disturbance of consciousness (finding)  []
  • Dyspnea (finding)  []
  • Eruption of skin (disorder)  []
  • Fatigue (finding)  []
  • Feeling feverish (finding)  []
  • Fever (finding)  []
  • Headache (finding)  []
  • Hemoptysis (finding)  []
  • Indrawing of ribs during respiration (finding)  []
  • Joint pain (finding)  []
  • Loss of appetite (finding)  []
  • Loss of sense of smell (finding)  []
  • Loss of taste (finding)  []
  • Lymphadenopathy (disorder)  []
  • Malaise (finding)  []
  • Muscle pain (finding)  []
  • Nasal congestion (finding)  []
  • Nasal discharge (finding)  []
  • Nausea (finding)  []
  • Pain in throat (finding)  []
  • Rigor (finding)  []
  • Seizure (finding)  []
  • Skin ulcer (disorder)  []
  • Unable to walk (finding)  []
  • Vomiting (disorder)  []
  • Wheezing (finding)  []
  • Fever greater than 100.4 Fahrenheit / 38° Celsius (finding)  []
  • Asthenia (finding)  []
  • Pain (finding)  []
  • Productive cough (finding)  []
  • Dry cough (finding)  []
  • Clouded consciousness (finding)  []
Terminology: SNOMED Clinical Terms, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-EVALUATION.exclusion_specific.v1]/protocol[at0009], code=at0009, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=2, text=Protocol, 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.registereintrag.v1]/content[openEHR-EHR-EVALUATION.absence.v2], code=at0000, itemType=EVALUATION, level=1, text=Unbekanntes Symptom, description=Statement that specified health information is not available for inclusion in the health record or extract at the time of recording., 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.registereintrag.v1]/content[openEHR-EHR-EVALUATION.absence.v2]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=2, text=Data, 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.registereintrag.v1]/content[openEHR-EHR-EVALUATION.absence.v2]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=3, text=Unbekanntes Symptom, description=Positive statement that no information is available., comment=For example: "No information available about adverse reactions"; No information available about problems or diagnoses"; "No information available about previous procedures performed"; or "No information available about medications used"., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Abdominal pain (finding)  []
  • Asymptomatic (finding)  []
  • Bleeding (finding)  []
  • Chest pain (finding)  []
  • Chill (finding)  []
  • Conjunctivitis (disorder)  []
  • Cough (finding)  []
  • Diarrhea (finding)  []
  • Disturbance of consciousness (finding)  []
  • Dyspnea (finding)  []
  • Eruption of skin (disorder)  []
  • Fatigue (finding)  []
  • Feeling feverish (finding)  []
  • Fever (finding)  []
  • Headache (finding)  []
  • Hemoptysis (finding)  []
  • Indrawing of ribs during respiration (finding)  []
  • Joint pain (finding)  []
  • Loss of appetite (finding)  []
  • Loss of sense of smell (finding)  []
  • Loss of taste (finding)  []
  • Lymphadenopathy (disorder)  []
  • Malaise (finding)  []
  • Muscle pain (finding)  []
  • Nasal congestion (finding)  []
  • Nasal discharge (finding)  []
  • Nausea (finding)  []
  • Pain in throat (finding)  []
  • Rigor (finding)  []
  • Seizure (finding)  []
  • Skin ulcer (disorder)  []
  • Unable to walk (finding)  []
  • Vomiting (disorder)  []
  • Wheezing (finding)  []
  • Fever greater than 100.4 Fahrenheit / 38° Celsius (finding)  []
  • Asthenia (finding)  []
  • Pain (finding)  []
  • Productive cough (finding)  []
  • Dry cough (finding)  []
  • Clouded consciousness (finding)  []
Terminology: SNOMED Clinical Terms, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-EVALUATION.absence.v2]/data[at0001]/items[at0005], code=at0005, itemType=ELEMENT, level=3, text=Aussage über die fehlende Information, description=Description of the reason why there is no information available., comment=For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Unknown (qualifier value)  []
Terminology: SNOMED Clinical Terms, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-EVALUATION.absence.v2]/protocol[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=2, text=Protocol, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null]], templateType=normal]