| TEMPLATE ID | Nephro_Arztbrief |
|---|---|
| Concept | Nephro_Arztbrief |
| Description | Zur Repräsentation von Arztbriefen eines Patienten im Rahmen des NephroDigital-Projektes. |
| Use | Für die Abbildung von Arztbriefen. |
| Misuse | Nicht zur Abbildung von strukturierten Entlassdaten verwenden. Dieses Template dient ausschließlich der Dokumentation von unsktrukturierten Entlassbefunden (Arztbriefe). |
| Purpose | Zur Repräsentation von Arztbriefen eines Patienten im Rahmen des NephroDigital-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) |
|
| Keywords | Entlassungsbrief; Arztbrief; Epikrise; Befundbericht |
| Language used | en |
| Citeable Identifier | 1246.169.1347 |
| Root archetype id | openEHR-EHR-COMPOSITION.report.v1 |
| Epikrise | Epikrise: 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. |
| Clinical synopsis | Clinical synopsis: Narrative summary or overview about a patient, specifically from the perspective of a healthcare provider, and with or without associated interpretations. |
| Synopsis | Synopsis: The summary, assessment, conclusions or evaluation of the clinical findings. |
| Media file | Media file: A media file that is acquired or used as part of the healthcare process, and associated metadata. |
| Content | Content: Digital representation of the media file. If the file is stored locally, the actual content will be captured and stored using the Multimedia data type. For example: RTF or PDF for a document; JPG for an image; MP4 for a video; or WAV for an audio file. If the file is stored at a location outside of the health record, the detailed path to the file is captured using the URI attribute in the Multimedia data type. The Multimedia data type has many RM attributes such as the size of file and URI to an external source - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_multimedia_class. |
| Content name | Content name: Descriptive name or title for the media file. A description of the content of the media file. Use an agreed standardised naming convention, if available. For example: "Right hand burn #1" or "Cardiology video consultation on May 2". |
| Description | Description: Narrative description about the media file. |
| Created | Created: The date/time, partial date or period when the media file was generated or authored. |
| Comment | Comment: Additional narrative about the media file not captured in other fields. |