| TEMPLATE ID | GECCO_Prozedur |
|---|---|
| Concept | GECCO_Prozedur |
| Description | Zur Repräsentation von Prozeduren im Rahmen des FoDaPl-Projektes / GECCO-Datensatzes. Es können vorliegende, unbekannte und explizit ausgeschlossene Prozeduren angelegt werden. |
| Use | Für die Abbildung von Prozeduren für die Speicherung im Rahmen des FoDaPI-Projektes / GECCO-Datensatzes. |
| Purpose | Zur Repräsentation von Prozeduren im Rahmen des FoDaPl-Projektes / GECCO-Datensatzes. Es können vorliegende, unbekannte und explizit ausgeschlossene Prozeduren angelegt werden. |
| References | |
| Authors | date: 2020-11-10; name: Antje Wulff; organisation: Peter L. Reichertz Institut für Medizinische Informatik; email: antje.wulff@plri.de |
| Other Details Language | date: 2020-11-10; name: Antje Wulff; organisation: Peter L. Reichertz Institut für Medizinische Informatik; email: antje.wulff@plri.de |
| Other Details (Language Independent) |
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| Keywords | GECCO; NUM; FoDaPl; Prozedur; CODEX |
| Language used | en |
| Citeable Identifier | 1246.169.1269 |
| Root archetype id | openEHR-EHR-COMPOSITION.registereintrag.v1 |
| GECCO_Prozedur | GECCO_Prozedur: Generic compilation to represent a data set for research purposes. |
| Other Context | |
| Status | Status: Status of the supplied data for the register entry. Note: This is not the status of individual components.
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| Category | Category: The classification of the register entry (e.g. type of observation of the FHIR profile). Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=https://www.netzwerk-universitaetsmedizin.de/fhir/ValueSet/procedure-category |
| Procedure | Procedure: A clinical activity carried out for screening, investigative, diagnostic, curative, therapeutic, evaluative or palliative purposes. |
| Description | |
| Procedure name | Procedure name: Identification of the procedure by name. Coding of the specific procedure with a terminology is preferred, where possible. Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=https://www.netzwerk-universitaetsmedizin.de/fhir/ValueSet/procedures-combined |
| Indication | Indication: The clinical or process-related reason for the procedure. Coding of the indication with a terminology is preferred, where possible. This data element allows multiple occurrences. For example: 'Failed bowel preparation' or 'Bowel cancer screening'. |
| Body site | Body site: Identification of the body site for the procedure. Occurrences for this data element are unbounded to allow for clinical scenarios such as removing multiple skin lesions in different places, but where all of the other attributes are identical. Use this data element to record simple terms or precoordinated anatomical locations. If the requirements for recording the anatomical location 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 'Procedure detail' SLOT in this archetype. If the anatomical location is included in the 'Procedure name' via precoordinated codes, this data element becomes redundant. Terminology: http://snomed.info/sct Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=http://hl7.org/fhir/ValueSet/body-site
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| Medical device | Medical device: An instrument, apparatus, implant, material or similar, used in the provision of healthcare. In this context, a medical device includes a broad range of devices which act through a variety of physical, mechanical, thermal or similar means but specifically excludes devices which act through medicinal means such as pharmacological, metabolic or immunological methods. The scope is inclusive of disposable devices as well as durable or persisting devices that require tracking, maintenance activities or regular calibration, recognising that each type of device has specific data recording requirements. |
| Device name | Device name: Identification of the medical device, preferably by a common name, a formal fully descriptive name or, if required, by class or category of device. This data element will capture the term, phrase or category used in clinical practice. For example: <brand name><machine> (XYZ Audiometer); <size> <brand name> <intravenous catheter> (14G Jelco IV catheter); or <brand name/type> <implant>. Coding with a terminology is desirable, where possible, although this may be local and depending on local supplies available. Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=https://www.netzwerk-universitaetsmedizin.de/fhir/ValueSet/procedure-medical-device-name |
| Procedure type | Procedure type: The type of procedure. This pragmatic data element may be used to support organisation within the user interface. Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=https://www.netzwerk-universitaetsmedizin.de/fhir/ValueSet/procedures-combined |
| Durchführungsabsicht | Durchführungsabsicht: Reason that the activity or care pathway step for the identified procedure was carried out. For example: the reason for the cancellation or suspension of the procedure. |
| Comment | Comment: Additional narrative about the activity or care pathway step not captured in other fields. |
| Nicht durchgeführte Prozedur | Nicht durchgeführte Prozedur: A statement of exclusion of a specific Problem/diagnosis, Family history, Medication, Procedure, Adverse reaction or other clinical item that is either not currently present, or have not been present in the past. |
| Data | |
| Exclusion statement | Exclusion statement: A qualifying statement about the exclusion of a Problem/diagnosis, Family history, Medication, Procedure, Adverse reaction or other clinical item. This statement is to be used in conjunction with the 'Excluded concept' data element. For example: this data element can support recording general statements such as "No known history of ..." where the 'Excluded concept' identifies the specific problem, diagnosis, substance, procedure or medication. If the 'Excluded concept' data element is used to record a precoordinated term such as 'No family history of diabetes', this element is redundant.
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| Eingriff | Eingriff: The Procedure to which the 'Exclusion statement' applies. For example: 'Heart surgery' or 'Appendectomy' or 'Hip replacement'. Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=https://www.netzwerk-universitaetsmedizin.de/fhir/ValueSet/procedures-combined |
| Unbekannte Prozedur | Unbekannte Prozedur: Statement that specified health information is not available for inclusion in the health record or extract at the time of recording. |
| Data | |
| Unbekannte Prozedur | Unbekannte Prozedur: Positive statement that no information is available. 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". Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=https://www.netzwerk-universitaetsmedizin.de/fhir/ValueSet/procedures-combined |
| Aussage über die fehlende Information | Aussage über die fehlende Information: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible.
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| Other contributors | Sarah Ballout |