| TEMPLATE ID | GECCO_Fragebogen Arzt |
|---|---|
| Concept | GECCO_Fragebogen Arzt |
| Description | Zur Repräsentation der systematischen Sammlung von wissenschaftlichen Daten zu COVID-19 Patienten im Rahmen des CODEX-Projektes / GECCO-Datensatzes. |
| Use | Für die Abbildung der systematischen Sammlung von wissenschaftlichen Daten zu COVID-19 Patienten im Rahmen des CODEX-Projektes / GECCO-Datensatzes. Diese Daten werden ausschließlich von einem Arzt erhoben. Die Anforderungen, die bei der Erstellung dieses Template verwendet wurden, stammen aus dem FHIR IG - https://simplifier.net/guide/GermanCoronaConsensusDataSet-ImplementationGuide/Home. |
| Misuse | Nicht zur Repräsentation anderer Fragebögen verwenden. Bei Fragen die der Patient selbst beantworten kann, den Fragebogen GECCO_Patientenfragebogen verwenden. |
| Purpose | Zur Repräsentation der systematischen Sammlung von wissenschaftlichen Daten zu COVID-19 Patienten im Rahmen des CODEX-Projektes / GECCO-Datensatzes. |
| References | |
| Authors | Name : Sarah Ballout; Email: ballout.sarah@mh-hannover.de; Organisation : Peter L. Reichertz Institut für Medizinische Informatik; name: Sarah Ballout; organisation: Peter L. Reichertz Institut für Medizinische Informatik; email: ballout.sarah@mh-hannover.de |
| Other Details Language | Name : Sarah Ballout; Email: ballout.sarah@mh-hannover.de; Organisation : Peter L. Reichertz Institut für Medizinische Informatik; name: Sarah Ballout; organisation: Peter L. Reichertz Institut für Medizinische Informatik; email: ballout.sarah@mh-hannover.de |
| Other Details (Language Independent) |
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| Keywords | GECCO; NUM; FoDaPl; CODEX; Arzt Fragebogen, CODEX |
| Language used | en |
| Citeable Identifier | 1246.169.1440 |
| Root archetype id | openEHR-EHR-COMPOSITION.report.v1 |
| Report | Report: Document to communicate information to others, commonly in response to a request from another party. |
| Personendaten | Personendaten: Demografische Daten zu einer Person wie Geburtsdatum und Telefonnummer. |
| Data | |
| Person name | Person name: Details of personal name of an individual, provider or third party. |
| Structured name | Structured name: Name in structured format. |
| Given name | Given name: Given / personal / first name. |
| Middle name | Middle name: Middle name or names. |
| Family name | Family name: Family name or Surname. |
| Angaben zum Tod | Angaben zum Tod: * |
| Verstorben? | Verstorben?: * |
| Angaben zum Tod | Angaben zum Tod: Angaben über den Tod einer Person, die mit übergeordneten Datenelementen für die Registrierung übereinstimmen zB. Sterberegister. |
| Sterbedatum | Sterbedatum: Der Zeitpunkt, an dem die Person verstorben ist. |
| Patient auf der Intensivstation | Patient auf der Intensivstation: An individual- or self-reported questionnaire screening for management or treatment carried out.Annotations
|
| Data | |
| Any event | Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time. |
| Data | |
| Management/treatment activity | Management/treatment activity: Grouping of data elements related to screening for a single management or treatment activity. |
| Activity name | Activity name: Name of the management or treatment activity being screened.
|
| Wird/Wurde die Aktivität durchgeführt? | Wird/Wurde die Aktivität durchgeführt?: The current status of a specific activity. Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=https://www.netzwerk-universitaetsmedizin.de/fhir/ValueSet/yes-no-unknown-other-na
|
| SARS-CoV-2 Exposition | SARS-CoV-2 Exposition: Risk assessment for an individual who may have been exposed to an infectious agent. |
| Data | |
| Infectious agent | Infectious agent: Identification of the organism, material, symptoms or condition to which the individual has been exposed.
|
| Exposition vorhanden? | Exposition vorhanden?: Narrative description about the overall exposure. Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=https://www.netzwerk-universitaetsmedizin.de/fhir/ValueSet/known-exposure |
| Specific exposure details | Specific exposure details: Details about a single exposure. Multiple exposures can be recorded, using one instance of this cluster per exposure. |
| Description of exposure | Description of exposure: Details about the method of exposure. For example: airborne, direct contact, or needle stick.
|
| Date/time of exposure | Date/time of exposure: Date and time of exposure. Can be cloned in template and renamed for specific Date/time at onset of exposure and cessation of exposure. |
| Vitalparameter | Vitalparameter: A generic section header which should be renamed in a template to suit a specific clinical context. |
| Pulse oximetry | Pulse oximetry: Blood oxygen and related measurements, measured by pulse oximetry or pulse CO-oximetry. |
| Data | |
| Any event | Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time. |
| Data | |
| SpO2 | SpO2: The saturation of oxygen in the peripheral blood, measured via pulse oximetry. SpO₂ is defined as the percentage of oxyhaemoglobin (HbO₂) to the total concentration of haemoglobin (HbO₂ + deoxyhaemoglobin) in peripheral blood.
|
| Respiration | Respiration: The characteristics of spontaneous breathing by an individual. |
| Data | |
| Any event | Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time. |
| Data | |
| Rate | Rate: The frequency of spontaneous breathing. 0..200 /min |
| Koerpertemperatur | Koerpertemperatur: A measurement of the body temperature, which is a surrogate for the core body temperature of the individual. |
| Data | |
| Any event | Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time. |
| Data | |
| Temperature | Temperature: The measured temperature. 0..100; 30..200 Units:
|
| Befund der Blutgasanalyse | Befund der Blutgasanalyse: The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual. |
| Data | |
| Any event | Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time. |
| Data | |
| Test name | Test name: Name of the laboratory investigation performed on the specimen(s). A test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'. Terminology: LOINC
|
| Kohlendioxidpartialdruck | Kohlendioxidpartialdruck: The result of a laboratory test for a single analyte value. |
| Untersuchter Analyt | Untersuchter Analyt: The name of the analyte result. The value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies. Optional[{fhir_mapping=Observation.code, hl7v2_mapping=OBX.3}] Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=https://www.netzwerk-universitaetsmedizin.de/fhir/ValueSet/blood-gas-analysis-pco2 |
| Analyte result | Analyte result: The value of the analyte result. For example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details. Optional[{fhir_mapping=Observation.value[x], hl7v2_mapping=OBX.2, OBX.5, OBX.6, OBX.7, OBX.8}] Units: mmHg |
| Result status | Result status: The status of the analyte result value. The values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'. This element allows multiple occurrences to support use cases where more than one type of status need to be implemented. Optional[{fhir_mapping=Observation.status, hl7v2_mapping=OBX.11}]
|
| Sauerstoffpartialdruck | Sauerstoffpartialdruck: The result of a laboratory test for a single analyte value. |
| Untersuchter Analyt | Untersuchter Analyt: The name of the analyte result. The value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies. Optional[{fhir_mapping=Observation.code, hl7v2_mapping=OBX.3}] Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=https://www.netzwerk-universitaetsmedizin.de/fhir/ValueSet/blood-gas-analysis-po2 |
| Analyte result | Analyte result: The value of the analyte result. For example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details. Optional[{fhir_mapping=Observation.value[x], hl7v2_mapping=OBX.2, OBX.5, OBX.6, OBX.7, OBX.8}] Units: mmHg |
| Result status | Result status: The status of the analyte result value. The values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'. This element allows multiple occurrences to support use cases where more than one type of status need to be implemented. Optional[{fhir_mapping=Observation.status, hl7v2_mapping=OBX.11}]
|
| pH-Wert | pH-Wert: The result of a laboratory test for a single analyte value. |
| Untersuchter Analyt | Untersuchter Analyt: The name of the analyte result. The value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies. Optional[{fhir_mapping=Observation.code, hl7v2_mapping=OBX.3}] Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=https://www.netzwerk-universitaetsmedizin.de/fhir/ValueSet/blood-gas-analysis-ph |
| Analyte result | Analyte result: The value of the analyte result. For example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details. Optional[{fhir_mapping=Observation.value[x], hl7v2_mapping=OBX.2, OBX.5, OBX.6, OBX.7, OBX.8}] Units: pH |
| Result status | Result status: The status of the analyte result value. The values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'. This element allows multiple occurrences to support use cases where more than one type of status need to be implemented. Optional[{fhir_mapping=Observation.status, hl7v2_mapping=OBX.11}]
|
| Sauerstoffsättigung | Sauerstoffsättigung: The result of a laboratory test for a single analyte value. |
| Untersuchter Analyt | Untersuchter Analyt: The name of the analyte result. The value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies. Optional[{fhir_mapping=Observation.code, hl7v2_mapping=OBX.3}] Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=https://www.netzwerk-universitaetsmedizin.de/fhir/ValueSet/blood-gas-analysis-sO2 |
| Analyte result | Analyte result: The value of the analyte result. For example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details. Optional[{fhir_mapping=Observation.value[x], hl7v2_mapping=OBX.2, OBX.5, OBX.6, OBX.7, OBX.8}] Units: % |
| Result status | Result status: The status of the analyte result value. The values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'. This element allows multiple occurrences to support use cases where more than one type of status need to be implemented. Optional[{fhir_mapping=Observation.status, hl7v2_mapping=OBX.11}]
|
| Blood pressure | Blood pressure: The local measurement of arterial blood pressure which is a surrogate for arterial pressure in the systemic circulation. Most commonly, use of the term 'blood pressure' refers to measurement of brachial artery pressure in the upper arm. |
| Data | Data: History Structural node. |
| Any event | Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time. |
| Data | |
| Systolic | Systolic: Peak systemic arterial blood pressure - measured in systolic or contraction phase of the heart cycle. 0..1000 mmHg |
| Diastolic | Diastolic: Minimum systemic arterial blood pressure - measured in the diastolic or relaxation phase of the heart cycle. 0..1000 mmHg |
| Herzfrequenz | Herzfrequenz: The rate and associated attributes for a pulse or heart beat. |
| Data | |
| Any event | Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time. |
| Data | |
| Rate | Rate: The rate of the pulse or heart beat, measured in beats per minute. 0..1000 /min |
| Ventilator observations | Ventilator observations: Observation findings returned from ventilator device. |
| Data | |
| Any event | Any event: * |
| Data | |
| Inspired oxygen | Inspired oxygen: The amount of oxygen being delivered, or to be delivered, to the patient given as a fraction, percentage or indirectly as a flow rate. |
| Flow rate | Flow rate: Oxygen flow rate given to an individual. For example '5 l/min'. 0..50000; 0..50 Units:
|
| Inspiratorische Sauerstofffraktion | Inspiratorische Sauerstofffraktion: Percentage of oxygen in inspired air. For example: '24 %'
|
| Clinical Frailty Scale (CFS) | Clinical Frailty Scale (CFS): An assessment scale used to screen for frailty and to broadly stratify degrees of fitness and frailty in an older adult. Also known as the Rockwood Clinical Frailty Scale. Annotations
|
| Data | |
| Any point in time event | Any point in time event: Default, unspecified point in time event which may be explicitly defined in a template or at run-time. |
| Data | |
| Assessment | Assessment: Assessed level of frailty.
|
| SOFA score | SOFA score: A scoring system to grade and follow the development of organ dysfunction in six vital organ systems. Previously known as "Sepsis related Organ Failure Assessment". |
| Data | |
| Any event | Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time. |
| Data | |
| Respiration | Respiration: The ratio between the partial pressure of oxygen (PaO₂) and the fraction of inspired oxygen (FiO₂) is an indicator for a possible dysfunction of the respiratory system. In some localities, the PaO₂/FiO₂ ratio is measured in kPa.
|
| Cardiovascular system | Cardiovascular system: The mean arterial pressure (MAP), or the need for vasopressors (VP), (dopamine (DA), adrenaline (A), noradrenaline (NA) or dobutamine) are indicators for a possible dysfunction of the cardiovascular system.
|
| Central nervous system | Central nervous system: The Glasgow Coma Scale (GCS) is an indicator for a possible dysfunction of the central nervous system.
|
| Renal function | Renal function: Creatinine concentration and 24 h urine output (UOP) are indicators for a possible dysfunction of the central nervous system. In some localities, creatinine concentration is measured in μmol/L.
|
| Liver function | Liver function: Bilirubin concentration is an indicator for a possible dysfunction of the central nervous system. In some localities, bilirubin concentration is measured in μmol/L.
|
| Blood clotting | Blood clotting: Platelets concentration is an indicator for a possible dysfunction of the blood clotting system.
|
| Total score | Total score: The total sum of each component parameter for the SOFA score. 0..24 |
| Diagnose | Diagnose: A generic section header which should be renamed in a template to suit a specific clinical context. |
| Vorliegende Diagnose | Vorliegende Diagnose: 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. 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'. |
| Data | |
| Problem/Diagnosis name | Problem/Diagnosis name: Identification of the problem or diagnosis, by name. Coding of the name of the problem or diagnosis with a terminology is preferred, where possible. Value set: terminology://fhir.hl7.org//ValueSet/$expand?url=https://www.netzwerk-universitaetsmedizin.de/fhir/ValueSet/diseases-combined |
| Date/time of onset | Date/time of onset: Estimated or actual date/time that signs or symptoms of the problem/diagnosis were first observed. Data captured/imported as "Age at onset" should be converted to a date using the subject's date of birth. |
| Severity | Severity: An assessment of the overall severity of the problem or diagnosis. If severity is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant. Note: more specific grading of severity can be recorded using the Specific details SLOT. Terminology: SNOMED Clinical Terms
|
| Date/time of resolution | Date/time of resolution: Estimated or actual date/time of resolution or remission for this problem or diagnosis, as determined by a healthcare professional. Partial dates are acceptable. If the subject of care is under the age of one year, then the complete date or a minimum of the month and year is necessary to enable accurate age calculations - for example, if used to drive decision support. Data captured/imported as "Age at time of resolution" should be converted to a date using the subject's date of birth. |
| Comment | Comment: Additional narrative about the problem or diagnosis not captured in other fields. |
| Protocol | |
| Last updated | Last updated: The date this problem or diagnosis was last updated. |
| GECCO_Studienteilnahme | GECCO_Studienteilnahme: GECCO_Studienteilnahme |
| Data | |
| Bereits an interventionellen klinischen Studien teilgenommen? | Bereits an interventionellen klinischen Studien teilgenommen?: * Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=https://www.netzwerk-universitaetsmedizin.de/fhir/ValueSet/yes-no-unknown-other-na |
| Studienteilnahme | Studienteilnahme: Detaillierte Informationen über die Teilnahme an einer klinischen Prüfung, Beobachtungs-, Register-, Diagnostik-, Therapiestudie oder an einem anderen medizinischen Forschungsvorhaben in der Rolle eines Studienpatienten oder Probanden. |
| Studie/Prüfung | Studie/Prüfung: Detaillierte Informationen über eine klinische Prüfung, Beobachtungs-, Register-, Diagnostik-, Therapiestudie oder ein anderes medizinisches Forschungsvorhaben an Menschen. |
| Titel der Studie/Prüfung | Titel der Studie/Prüfung: Titel des Forschungsvorhabens. Zum Beispiel: "Eine randomisierte Phase-II-Studie mit nal-Iri plus 5-Fluorouracil im Vergleich zu 5-Fluorouracil bei stationären Patienten mit Cholangio- und Gallenblasenkarzinom, die zuvor mit Gemcitabin oder Gemcitabin-haltigen Therapien behandelt wurden." Terminology: eCRF
|
| Beschreibung | Beschreibung: Kurze Beschreibung des Forschungsvorhabens. Beschreibung des Forschungsvorhabens in leicht verständlicher Formulierung für Laien. |
| Registrierung | Registrierung: Registrierung der Studie in Registern. Wenn die Studie auf der Webseite Clinicaltrials.gov registriert ist, besitzt sie eine US NCT-Nummer. Zum Beispiel: NCT03772405. Eine EudraCT Nummer wird von der Europäischen Arzneimittelagentur vergeben. Wenn die klinische Prüfung auf der Webseite Current Controlled Trials registriert ist, besitzt sie eine ISRCTN-Nummer (International Standard Randomised Controlled Trial Number). |
| Registername | Registername: Studienregister, wo die Studie registriert ist und eine eindeutige Identifikationsnummer besitzt. Zum Beispiel: Europäischen Arzneimittelagentur (EudraCT) oder Webseite Clinicaltrials.gov (US NCT-Nummer). Terminology: eCRF
|
| Registrierungsnummer | Registrierungsnummer: Eindeutige Identifikationsnummer an dem angezeigten Register. Zum Beispiel die EudraCT Nummer, die von der Europäischen Arzneimittelagentur vergeben wird, oder ISRCTN (International Standard Randomised Controlled Trial Number). Wenn die klinische Prüfung auf der Webseite Current Controlled Trials registriert ist, besitzt sie eine ISRCTN-Nummer. |
| Bestätigte Covid-19-Diagnose als Hauptursache für Aufnahme in Studie | Bestätigte Covid-19-Diagnose als Hauptursache für Aufnahme in Studie: Zusätzliche Informationen zu der Studienteilnahme. Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=https://www.netzwerk-universitaetsmedizin.de/fhir/ValueSet/yes-no-unknown-other-na |
| Imaging examination result | Imaging examination result: Record the findings and interpretation of an imaging examination performed. |
| Data | |
| Any event | Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time. |
| Data | |
| Test name | Test name: The name of the imaging examination or procedure performed. Coding with a terminology, potentially a pre-coordinated term specifying both modality and anatomical location, is desirable where possible. Possible candidate terminologies: LOINC, SNOMED CT or RadLex. Terminology: LOINC
|
| Findings | Findings: Narrative description of the clinical findings. Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=https://www.netzwerk-universitaetsmedizin.de/fhir/ValueSet/radiology-findings |
| Prozedur | Prozedur: A generic section header which should be renamed in a template to suit a specific clinical context. |
| 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/$expand?url=https://www.netzwerk-universitaetsmedizin.de/fhir/ValueSet/procedures-combined |
| Indication | Indication: The clinical or process-related reason for the procedure. Coding of the indication with a terminology is preferred, where possible. This data element allows multiple occurrences. For example: 'Failed bowel preparation' or 'Bowel cancer screening'. |
| Medical device | Medical device: An instrument, apparatus, implant, material or similar, used in the provision of healthcare. In this context, a medical device includes a broad range of devices which act through a variety of physical, mechanical, thermal or similar means but specifically excludes devices which act through medicinal means such as pharmacological, metabolic or immunological methods. The scope is inclusive of disposable devices as well as durable or persisting devices that require tracking, maintenance activities or regular calibration, recognising that each type of device has specific data recording requirements. |
| Device name | Device name: Identification of the medical device, preferably by a common name, a formal fully descriptive name or, if required, by class or category of device. This data element will capture the term, phrase or category used in clinical practice. For example: <brand name><machine> (XYZ Audiometer); <size> <brand name> <intravenous catheter> (14G Jelco IV catheter); or <brand name/type> <implant>. Coding with a terminology is desirable, where possible, although this may be local and depending on local supplies available. Value set: terminology://fhir.hl7.org/ValueSet/$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/$expand?url=https://www.netzwerk-universitaetsmedizin.de/fhir/ValueSet/procedures-combined |
| Durchführungsabsicht | Durchführungsabsicht: Reason that the activity or care pathway step for the identified procedure was carried out. For example: the reason for the cancellation or suspension of the procedure. |
| Comment | Comment: Additional narrative about the activity or care pathway step not captured in other fields. |
| DNR-Anordnung | DNR-Anordnung: A framework to communicate the preferences of an individual for future medical treatment and care.Annotations
|
| Data | |
| Type of directive | Type of directive: The type of advance care directive. A short text description of the nature of the advance care directive. Coding of the type of directive with a terminology is preferred, where possible. It is expected that this is largely localised to reflect local policy and legislation. For example, in the Netherlands, advance care directive types include, but are not limited to, 'Treatment prohibition', 'Treatment prohibition with completion of Completed Life', 'Euthanasia request' and 'Declaration of life'. In the UK, advance care directive types include 'Advance Decision', 'Advance Directive' and 'Advance Statement'. Terminology: local_terms
|
| Description | Description: Narrative description of the overall advance care directive. May be used to record a narrative overview of the complete advance care directive, which may or may not be supported by structured data. Details of specific structured findings can be included using CLUSTER archetypes in the 'Directive details' slot. This data element may be used to capture legacy data that is not available in a structured format. Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=https://www.netzwerk-universitaetsmedizin.de/fhir/ValueSet/resuscitation-status |
| Medikamentöse Therapie | Medikamentöse Therapie: A generic section header which should be renamed in a template to suit a specific clinical context. |
| Kategorie | Kategorie: Statement that specified health information is not available for inclusion in the health record or extract at the time of recording. |
| Data | |
| Patientenstatus | Patientenstatus: 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". Terminology: http://terminology.hl7.org/CodeSystem/medication-statement-category Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=http://hl7.org/fhir/ValueSet/medication-statement-category
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| COVID-19 Therapie | COVID-19 Therapie: A snapshot view about the use of a specified medication. |
| Data | |
| Any event | Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time. |
| Data | |
| Medication item name | Medication item name: Name of the medication, vaccine or other therapeutic/prescribable item. It is strongly recommended that the 'Medication item' be coded with a terminology capable of triggering decision support, where possible. The extent of coding may vary from the simple generic or product name of the medication item through to structured details about the actual medication pack to be used. Free text entry should only be used if there is no appropriate terminology available. Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=https://www.netzwerk-universitaetsmedizin.de/fhir/ValueSet/pharmacological-therapy-atc |
| Status | Status: The status of use of the medication. For example: the medication is still actively being taken; or a course of antibiotics has been completed.
|
| Grund | Grund: The clinical reason for use of the medication item. For example: 'Angina'. Coding of the clinical indication with a terminology is preferred, where possible. This data element allows multiple occurrences. Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=https://www.netzwerk-universitaetsmedizin.de/fhir/ValueSet/therapeutic-intent |
| Protocol | |
| Status | Status: Ein Code, der die Einschätzung des Patienten oder einer anderen Ursache über den Zustand des verwendeten Medikaments darstellt, mit dem sich diese Angabe befasst. Im Allgemeinen wird dies aktiv oder abgeschlossen sein. |
| Status | Status: Status der Einnahme des Medikamentes im Verlauf oder nach dem Ende der Therapie bzw. der Nachsorge.
|
| ACE-Hemmer | ACE-Hemmer: A snapshot view about the use of a specified medication. |
| Data | |
| Any event | Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time. |
| Data | |
| Medication item name | Medication item name: Name of the medication, vaccine or other therapeutic/prescribable item. It is strongly recommended that the 'Medication item' be coded with a terminology capable of triggering decision support, where possible. The extent of coding may vary from the simple generic or product name of the medication item through to structured details about the actual medication pack to be used. Free text entry should only be used if there is no appropriate terminology available. Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=https://www.netzwerk-universitaetsmedizin.de/fhir/ValueSet/ace-inhibitors-atc |
| Status | Status: The status of use of the medication. For example: the medication is still actively being taken; or a course of antibiotics has been completed.
|
| Grund | Grund: The clinical reason for use of the medication item. For example: 'Angina'. Coding of the clinical indication with a terminology is preferred, where possible. This data element allows multiple occurrences. Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=https://www.netzwerk-universitaetsmedizin.de/fhir/ValueSet/therapeutic-intent |
| Protocol | |
| Status | Status: Ein Code, der die Einschätzung des Patienten oder einer anderen Ursache über den Zustand des verwendeten Medikaments darstellt, mit dem sich diese Angabe befasst. Im Allgemeinen wird dies aktiv oder abgeschlossen sein. |
| Status | Status: Status der Einnahme des Medikamentes im Verlauf oder nach dem Ende der Therapie bzw. der Nachsorge.
|
| Immunglobuline | Immunglobuline: A snapshot view about the use of a specified medication. |
| Data | |
| Any event | Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time. |
| Data | |
| Medication item name | Medication item name: Name of the medication, vaccine or other therapeutic/prescribable item. It is strongly recommended that the 'Medication item' be coded with a terminology capable of triggering decision support, where possible. The extent of coding may vary from the simple generic or product name of the medication item through to structured details about the actual medication pack to be used. Free text entry should only be used if there is no appropriate terminology available. Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=https://www.netzwerk-universitaetsmedizin.de/fhir/ValueSet/immunoglobulins-atc |
| Status | Status: The status of use of the medication. For example: the medication is still actively being taken; or a course of antibiotics has been completed.
|
| Grund | Grund: The clinical reason for use of the medication item. For example: 'Angina'. Coding of the clinical indication with a terminology is preferred, where possible. This data element allows multiple occurrences. Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=https://www.netzwerk-universitaetsmedizin.de/fhir/ValueSet/therapeutic-intent |
| Protocol | |
| Status | Status: Ein Code, der die Einschätzung des Patienten oder einer anderen Ursache über den Zustand des verwendeten Medikaments darstellt, mit dem sich diese Angabe befasst. Im Allgemeinen wird dies aktiv oder abgeschlossen sein. |
| Status | Status: Status der Einnahme des Medikamentes im Verlauf oder nach dem Ende der Therapie bzw. der Nachsorge.
|
| Antikoagulanzien | Antikoagulanzien: A snapshot view about the use of a specified medication. |
| Data | |
| Any event | Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time. |
| Data | |
| Medication item name | Medication item name: Name of the medication, vaccine or other therapeutic/prescribable item. It is strongly recommended that the 'Medication item' be coded with a terminology capable of triggering decision support, where possible. The extent of coding may vary from the simple generic or product name of the medication item through to structured details about the actual medication pack to be used. Free text entry should only be used if there is no appropriate terminology available. Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=https://www.netzwerk-universitaetsmedizin.de/fhir/ValueSet/anticoagulants-atc |
| Status | Status: The status of use of the medication. For example: the medication is still actively being taken; or a course of antibiotics has been completed.
|
| Grund | Grund: The clinical reason for use of the medication item. For example: 'Angina'. Coding of the clinical indication with a terminology is preferred, where possible. This data element allows multiple occurrences. Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=https://www.netzwerk-universitaetsmedizin.de/fhir/ValueSet/therapeutic-intent |
| Protocol | |
| Status | Status: Ein Code, der die Einschätzung des Patienten oder einer anderen Ursache über den Zustand des verwendeten Medikaments darstellt, mit dem sich diese Angabe befasst. Im Allgemeinen wird dies aktiv oder abgeschlossen sein. |
| Status | Status: Status der Einnahme des Medikamentes im Verlauf oder nach dem Ende der Therapie bzw. der Nachsorge.
|
| Entlassungsart | Entlassungsart: Used for discharged patient only.Annotations
|
| Data | |
| Discharge status | Discharge status: Discharge status. Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=https://www.netzwerk-universitaetsmedizin.de/fhir/ValueSet/discharge-disposition |
| Other contributors | Antje Wulff |