TEMPLATE GECCO_Fragebogen Arzt (GECCO_Fragebogen Arzt)

TEMPLATE IDGECCO_Fragebogen Arzt
ConceptGECCO_Fragebogen Arzt
DescriptionZur Repräsentation der systematischen Sammlung von wissenschaftlichen Daten zu COVID-19 Patienten im Rahmen des CODEX-Projektes / GECCO-Datensatzes.
UseFür 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.
MisuseNicht zur Repräsentation anderer Fragebögen verwenden. Bei Fragen die der Patient selbst beantworten kann, den Fragebogen GECCO_Patientenfragebogen verwenden.
PurposeZur Repräsentation der systematischen Sammlung von wissenschaftlichen Daten zu COVID-19 Patienten im Rahmen des CODEX-Projektes / GECCO-Datensatzes.
References
AuthorsName : 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 LanguageName : 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
OtherDetails Language Independent{MetaDataSet:Sample Set =Template metadata sample set, PARENT:MD5-CAM-1.0.1=DE0723367AA22BB716CEC5342B21FF60, original_language=ISO_639-1::de, MD5-CAM-1.0.1=05cb0d890a77fbde7fa71612d7f150c6}
KeywordsGECCO; NUM; FoDaPl; CODEX; Arzt Fragebogen, CODEX
Language useden
Citeable Identifier1246.169.1440
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  • 1: Very Fit 
  • 2: Well 
  • 3: Managing Well 
  • 4: Vulnerable 
  • 5: Mildly Frail 
  • 6: Moderately Frail 
  • 7: Severely Frail 
  • 8: Very Severely Frail 
  • 9: Terminally Ill 
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  • 1: < 400 
  • 2: < 300 
  • 3: < 200 and artificial respiration 
  • 4: < 100 and artificial respiration 
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  • 1: 13-14 
  • 2: 10-12 
  • 3: 6-9 
  • 4: <6 
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  • 1: MAP < 70 mmHg 
  • 2: Dopamine ≤ 5 µg/kg/min or Dobutamine (regardless of dosage) 
  • 3: Dopamine > 5 µg/kg/min or adrenaline ≤ 0,1 µg/kg/min oder noradrenaline ≤ 0,1 µg/kg/min 
  • 4: Dopamine > 15 µg/kg/min oder adrenaline > 0,1 µg/kg/min or noradrenaline > 0,1 µg/kg/min 
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  • 1: 1,2 -1,9 mg/dl 
  • 2: 2,0 - 5,9 mg/dl 
  • 3: 6,0 - 11,9 mg/dl 
  • 4: >12,0 mg/dl 
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  • 1: < 150 
  • 2: < 100 
  • 3: < 50 
  • 4: < 20 
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  • 1: 1,2 - 1,9 mg/dl 
  • 2: 2,0 - 3,4 mg/dl 
  • 3: 3,5 - 4,9 mg/dl 
  • 4: > 5 mg/dl 
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  • Alter Myokardinfarkt Nicht näher bezeichnet 
  • Essentielle Hypertonie, nicht näher bezeichnet : Ohne Angabe einer hypertensiven Krise 
  • Periphere Gefäßkrankheit, nicht näher bezeichnet 
  • Kardiale Arrhythmie, nicht näher bezeichnet 
  • Herzinsuffizienz, nicht näher bezeichnet 
  • Atherosklerotische Herzkrankheit 
  • Verschluss und Stenose der A. carotis 
  • Vorhandensein eines aortokoronaren Bypasses 
  • Vorhandensein eines Implantates oder Transplantates nach koronarer Gefäßplastik 
  • Infektiöse und parasitäre Krankheiten infolge HIV-Krankheit [Humane Immundefizienz-Viruskrankheit] 
  • Bösartige Neubildungen infolge HIV-Krankheit [Humane Immundefizienz-Viruskrankheit] 
  • Sonstige näher bezeichnete Krankheiten infolge HIV-Krankheit [Humane Immundefizienz-Viruskrankheit] 
  • Nicht näher bezeichnete HIV-Krankheit [Humane Immundefizienz-Viruskrankheit] 
  • Ulcus pepticum jejuni : Weder als akut noch als chronisch bezeichnet, ohne Blutung oder Perforation 
  • Zustand nach Herztransplantation 
  • Zustand nach Lungentransplantation 
  • Zustand nach Lebertransplantation 
  • Zustand nach Nierentransplantation 
  • Zustand nach sonstiger Organ- oder Gewebetransplantation Inkl.: Darm Pankreas 
  • Zustand nach Hauttransplantation 
  • Zustand nach Keratoplastik 
  • Vorhandensein eines Implantates oder Transplantates nach koronarer Gefäßplastik 
  • Vorhandensein von sonstigen kardialen oder vaskulären Implantaten oder Transplantaten 
  • Zustand nach Knochentransplantation 
  • Zustand nach Organ- oder Gewebetransplantation, nicht näher bezeichnet 
  • Zustand nach hämatopoetischer Stammzelltransplantation ohne gegenwärtige Immunsuppression 
  • Zustand nach hämatopoetischer Stammzelltransplantation mit gegenwärtiger Immunsuppression 
  • Zustand nach Herz-Lungen-Transplantation 
  • Pneumonie, nicht näher bezeichnet 
  • Sepsis, nicht näher bezeichnet 
  • Embolie und Thrombose nicht näher bezeichneter Vene 
  • Lungenembolie ohne Angabe eines akuten Cor pulmonale 
  • Schlaganfall, nicht als Blutung oder Infarkt bezeichnet 
  • Akuter Myokardinfarkt, nicht näher bezeichnet 
  • Akutes Nierenversagen, nicht näher bezeichnet 
  • Disease caused by 2019 novel coronavirus (disorder) 
  • Suspected disease caused by 2019 novel coronavirus (situation) 
  • Pneumonia caused by severe acute respiratory syndrome coronavirus 2 (disorder) 
  • Acute respiratory distress syndrome caused by severe acute respiratory syndrome coronavirus 2 (disorder) 
  • Lower respiratory infection caused by severe acute respiratory syndrome coronavirus 2 (disorder) 
  • Acute bronchitis caused by severe acute respiratory syndrome coronavirus 2 (disorder) 
  • Lymphocytopenia associated with severe acute respiratory syndrome coronavirus 2 (disorder) 
  • Thrombocytopenia associated with severe acute respiratory syndrome coronavirus 2 (disorder) 
  • Dependence on ventilator (finding) 
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  • Entire heart (body structure) 
  • Entire lung (body structure) 
  • Entire liver (body structure) 
  • Entire kidney (body structure) 
  • Entire pancreas (body structure) 
  • Entire small intestine (body structure) 
  • Entire large intestine (body structure) 
  • Skin part (body structure) 
  • Entire cornea (body structure) 
  • Ear ossicle structure (body structure) 
  • Entire heart valve (body structure) 
  • Blood vessel part (body structure) 
  • Cerebral meninges structure (body structure) 
  • Bone (tissue) structure (body structure) 
  • Cartilage tissue (body structure) 
  • Tendon structure (body structure) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.anatomical_location.v1]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Laterality, description=The side of the body on which the identified body site is located., comment=If the identified body site has no laterality, this data element should not have a value. If the 'Body site name' data element uses pre-coordinated terms that include laterality, then this data element is redundant., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Left 
  • Right 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[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-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0005], code=at0005, itemType=ELEMENT, level=3, text=Severity, description=An assessment of the overall severity of the problem or diagnosis., comment=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., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Coded Text
    • Mild 
    • Moderate 
    • Severe 
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[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-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0069], code=at0069, itemType=ELEMENT, level=3, text=Comment, description=Additional narrative about the problem or diagnosis 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-EVALUATION.problem_diagnosis.v1]/protocol[at0032], code=at0032, 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.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/protocol[at0032]/items[at0070], code=at0070, itemType=ELEMENT, level=3, text=Last updated, description=The date this problem or diagnosis was last updated., comment=null, 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-EVALUATION.exclusion_specific.v1 and name/value='Ausgeschlossene Diagnose'], code=at0000, itemType=EVALUATION, level=1, text=Ausgeschlossene Diagnose, 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.report.v1]/content[openEHR-EHR-EVALUATION.exclusion_specific.v1 and name/value='Ausgeschlossene Diagnose']/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.report.v1]/content[openEHR-EHR-EVALUATION.exclusion_specific.v1 and name/value='Ausgeschlossene Diagnose']/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=Terminology: SNOMED Clinical Terms
  • Known absent (qualifier value) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.exclusion_specific.v1 and name/value='Ausgeschlossene Diagnose']/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=Terminology: local_terms
  • Alter Myokardinfarkt Nicht näher bezeichnet 
  • Essentielle Hypertonie, nicht näher bezeichnet : Ohne Angabe einer hypertensiven Krise 
  • Periphere Gefäßkrankheit, nicht näher bezeichnet 
  • Kardiale Arrhythmie, nicht näher bezeichnet 
  • Herzinsuffizienz, nicht näher bezeichnet 
  • Atherosklerotische Herzkrankheit 
  • Verschluss und Stenose der A. carotis 
  • Vorhandensein eines aortokoronaren Bypasses 
  • Vorhandensein eines Implantates oder Transplantates nach koronarer Gefäßplastik 
  • Infektiöse und parasitäre Krankheiten infolge HIV-Krankheit [Humane Immundefizienz-Viruskrankheit] 
  • Bösartige Neubildungen infolge HIV-Krankheit [Humane Immundefizienz-Viruskrankheit] 
  • Sonstige näher bezeichnete Krankheiten infolge HIV-Krankheit [Humane Immundefizienz-Viruskrankheit] 
  • Nicht näher bezeichnete HIV-Krankheit [Humane Immundefizienz-Viruskrankheit] 
  • Ulcus pepticum jejuni : Weder als akut noch als chronisch bezeichnet, ohne Blutung oder Perforation 
  • Zustand nach Herztransplantation 
  • Zustand nach Lungentransplantation 
  • Zustand nach Lebertransplantation 
  • Zustand nach Nierentransplantation 
  • Zustand nach sonstiger Organ- oder Gewebetransplantation Inkl.: Darm Pankreas 
  • Zustand nach Hauttransplantation 
  • Zustand nach Keratoplastik 
  • Vorhandensein eines Implantates oder Transplantates nach koronarer Gefäßplastik 
  • Vorhandensein von sonstigen kardialen oder vaskulären Implantaten oder Transplantaten 
  • Zustand nach Knochentransplantation 
  • Zustand nach Organ- oder Gewebetransplantation, nicht näher bezeichnet 
  • Zustand nach hämatopoetischer Stammzelltransplantation ohne gegenwärtige Immunsuppression 
  • Zustand nach hämatopoetischer Stammzelltransplantation mit gegenwärtiger Immunsuppression 
  • Zustand nach Herz-Lungen-Transplantation 
  • Pneumonie, nicht näher bezeichnet 
  • Sepsis, nicht näher bezeichnet 
  • Embolie und Thrombose nicht näher bezeichneter Vene 
  • Lungenembolie ohne Angabe eines akuten Cor pulmonale 
  • Schlaganfall, nicht als Blutung oder Infarkt bezeichnet 
  • Akuter Myokardinfarkt, nicht näher bezeichnet 
  • Akutes Nierenversagen, nicht näher bezeichnet 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.absence.v2 and name/value='Unbekannte Diagnose'], code=at0000, itemType=EVALUATION, level=1, text=Unbekannte Diagnose, 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.report.v1]/content[openEHR-EHR-EVALUATION.absence.v2 and name/value='Unbekannte Diagnose']/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.report.v1]/content[openEHR-EHR-EVALUATION.absence.v2 and name/value='Unbekannte Diagnose']/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=3, text=Unbekannte Diagnose, 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=Terminology: local_terms
  • Alter Myokardinfarkt Nicht näher bezeichnet 
  • Essentielle Hypertonie, nicht näher bezeichnet : Ohne Angabe einer hypertensiven Krise 
  • Periphere Gefäßkrankheit, nicht näher bezeichnet 
  • Kardiale Arrhythmie, nicht näher bezeichnet 
  • Herzinsuffizienz, nicht näher bezeichnet 
  • Atherosklerotische Herzkrankheit 
  • Verschluss und Stenose der A. carotis 
  • Vorhandensein eines aortokoronaren Bypasses 
  • Vorhandensein eines Implantates oder Transplantates nach koronarer Gefäßplastik 
  • Infektiöse und parasitäre Krankheiten infolge HIV-Krankheit [Humane Immundefizienz-Viruskrankheit] 
  • Bösartige Neubildungen infolge HIV-Krankheit [Humane Immundefizienz-Viruskrankheit] 
  • Sonstige näher bezeichnete Krankheiten infolge HIV-Krankheit [Humane Immundefizienz-Viruskrankheit] 
  • Nicht näher bezeichnete HIV-Krankheit [Humane Immundefizienz-Viruskrankheit] 
  • Ulcus pepticum jejuni : Weder als akut noch als chronisch bezeichnet, ohne Blutung oder Perforation 
  • Zustand nach Herztransplantation 
  • Zustand nach Lungentransplantation 
  • Zustand nach Lebertransplantation 
  • Zustand nach Nierentransplantation 
  • Zustand nach sonstiger Organ- oder Gewebetransplantation Inkl.: Darm Pankreas 
  • Zustand nach Hauttransplantation 
  • Zustand nach Keratoplastik 
  • Vorhandensein eines Implantates oder Transplantates nach koronarer Gefäßplastik 
  • Vorhandensein von sonstigen kardialen oder vaskulären Implantaten oder Transplantaten 
  • Zustand nach Knochentransplantation 
  • Zustand nach Organ- oder Gewebetransplantation, nicht näher bezeichnet 
  • Zustand nach hämatopoetischer Stammzelltransplantation ohne gegenwärtige Immunsuppression 
  • Zustand nach hämatopoetischer Stammzelltransplantation mit gegenwärtiger Immunsuppression 
  • Zustand nach Herz-Lungen-Transplantation 
  • Pneumonie, nicht näher bezeichnet 
  • Sepsis, nicht näher bezeichnet 
  • Embolie und Thrombose nicht näher bezeichneter Vene 
  • Lungenembolie ohne Angabe eines akuten Cor pulmonale 
  • Schlaganfall, nicht als Blutung oder Infarkt bezeichnet 
  • Akuter Myokardinfarkt, nicht näher bezeichnet 
  • Akutes Nierenversagen, nicht näher bezeichnet 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.absence.v2 and name/value='Unbekannte Diagnose']/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=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: SNOMED Clinical Terms
  • Unknown (qualifier value) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.gecco_study_participation.v0], code=at0000, itemType=EVALUATION, level=1, text=Studienteilnahme, description=GECCO_Studienteilnahme, 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-EVALUATION.gecco_study_participation.v0]/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.report.v1]/content[openEHR-EHR-EVALUATION.gecco_study_participation.v0]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=3, text=Bereits an interventionellen klinischen Studien teilgenommen?, description=*, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: SNOMED Clinical Terms
  • Yes (qualifier value) 
  • No (qualifier value) 
  • Unknown (qualifier value) 
  • Other (qualifier value) 
  • Not applicable (qualifier value) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.gecco_study_participation.v0]/data[at0001]/items[openEHR-EHR-CLUSTER.study_participation.v1], code=at0000, itemType=CLUSTER, level=3, text=Studienteilnahme, description=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., 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]/content[openEHR-EHR-EVALUATION.gecco_study_participation.v0]/data[at0001]/items[openEHR-EHR-CLUSTER.study_participation.v1]/items[openEHR-EHR-CLUSTER.study_details.v1], code=at0000, itemType=CLUSTER, level=4, text=Studie/Prüfung, description=Detaillierte Informationen über eine klinische Prüfung, Beobachtungs-, Register-, Diagnostik-, Therapiestudie oder ein anderes medizinisches Forschungsvorhaben an Menschen., 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]/content[openEHR-EHR-EVALUATION.gecco_study_participation.v0]/data[at0001]/items[openEHR-EHR-CLUSTER.study_participation.v1]/items[openEHR-EHR-CLUSTER.study_details.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=5, text=Titel der Studie/Prüfung, description=Titel des Forschungsvorhabens., comment=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.", uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: eCRF
  • Participation in interventional clinical trials 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.gecco_study_participation.v0]/data[at0001]/items[openEHR-EHR-CLUSTER.study_participation.v1]/items[openEHR-EHR-CLUSTER.study_details.v1]/items[at0004], code=at0004, itemType=ELEMENT, level=5, text=Beschreibung, description=Kurze Beschreibung des Forschungsvorhabens., comment=Beschreibung des Forschungsvorhabens in leicht verständlicher Formulierung für Laien., 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-EVALUATION.gecco_study_participation.v0]/data[at0001]/items[openEHR-EHR-CLUSTER.study_participation.v1]/items[openEHR-EHR-CLUSTER.study_details.v1]/items[at0033], code=at0033, itemType=CLUSTER, level=5, text=Registrierung, description=Registrierung der Studie in Registern., comment=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)., 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-EVALUATION.gecco_study_participation.v0]/data[at0001]/items[openEHR-EHR-CLUSTER.study_participation.v1]/items[openEHR-EHR-CLUSTER.study_details.v1]/items[at0033]/items[at0035], code=at0035, itemType=ELEMENT, level=6, text=Registername, description=Studienregister, wo die Studie registriert ist und eine eindeutige Identifikationsnummer besitzt., comment=Zum Beispiel: Europäischen Arzneimittelagentur (EudraCT) oder Webseite Clinicaltrials.gov (US NCT-Nummer)., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: eCRF
  • EudraCT Number‎ 
  • NCT number 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.gecco_study_participation.v0]/data[at0001]/items[openEHR-EHR-CLUSTER.study_participation.v1]/items[openEHR-EHR-CLUSTER.study_details.v1]/items[at0033]/items[at0034], code=at0034, itemType=ELEMENT, level=6, text=Registrierungsnummer, description=Eindeutige Identifikationsnummer an dem angezeigten Register., comment=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., 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-EVALUATION.gecco_study_participation.v0]/data[at0001]/items[openEHR-EHR-CLUSTER.study_participation.v1]/items[at0014], code=at0014, itemType=ELEMENT, level=4, text=Bestätigte Covid-19-Diagnose als Hauptursache für Aufnahme in Studie, description=Zusätzliche Informationen zu der Studienteilnahme., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: SNOMED Clinical Terms
  • Yes (qualifier value) 
  • No (qualifier value) 
  • Unknown (qualifier value) 
  • Other (qualifier value) 
  • Not applicable (qualifier value) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0], code=at0000, itemType=OBSERVATION, level=1, text=Imaging examination result, description=Record the findings and interpretation of an imaging examination performed., 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-OBSERVATION.imaging_exam_result.v0]/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.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/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=1..1, occurencesText=Mandatory, 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-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003], code=at0003, 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.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=5, text=Test name, description=The name of the imaging examination or procedure performed., comment=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., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: LOINC
  • Diagnostic imaging study 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0008], code=at0008, itemType=ELEMENT, level=5, text=Findings, description=Narrative description of the clinical findings., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: SNOMED-CT
  • Unspezifischer Befund 
  • COVID-19-typischer Befund 
  • Normalbefund 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1 and name/value='Serologischer Befund'], code=at0000, itemType=OBSERVATION, level=1, text=Serologischer Befund, 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=1..1, occurencesText=Mandatory, 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-OBSERVATION.laboratory_test_result.v1 and name/value='Serologischer Befund']/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.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1 and name/value='Serologischer Befund']/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=1..*, occurencesText=Mandatory, 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-OBSERVATION.laboratory_test_result.v1 and name/value='Serologischer Befund']/data[at0001]/events[at0002]/data[at0003], code=at0003, 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.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1 and name/value='Serologischer Befund']/data[at0001]/events[at0002]/data[at0003]/items[at0005], code=at0005, itemType=ELEMENT, level=5, 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_CODED_TEXT, bindings=null, values=Terminology: SNOMED CT
  • Serologic test (procedure) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1 and name/value='Serologischer Befund']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.laboratory_test_panel.v0], code=at0000, itemType=CLUSTER, level=5, text=Laboratory test panel, description=Laboratory test result as a panel/battery/profile structure common to clinical pathology testing., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, 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-OBSERVATION.laboratory_test_result.v1 and name/value='Serologischer Befund']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.laboratory_test_panel.v0]/items[openEHR-EHR-CLUSTER.laboratory_test_analyte.v1], code=at0000, itemType=CLUSTER, level=6, text=Pro Analyt, description=The result of a laboratory test for a single analyte value., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, 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-OBSERVATION.laboratory_test_result.v1 and name/value='Serologischer Befund']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.laboratory_test_panel.v0]/items[openEHR-EHR-CLUSTER.laboratory_test_analyte.v1]/items[at0024], code=at0024, itemType=ELEMENT, level=7, text=Virusnachweistest, 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_CODED_TEXT, bindings=null, values=Terminology: LOINC
  • SARS-CoV-2 (COVID-19) Ab [Units/volume] in Serum or Plasma by Immunoassay 
  • SARS-CoV-2 (COVID-19) Ab [Presence] in Serum or Plasma by Immunoassay 
  • SARS-CoV-2 (COVID-19) IgA Ab [Units/volume] in Serum or Plasma by Immunoassay 
  • SARS-CoV-2 (COVID-19) IgA Ab [Presence] in Serum or Plasma by Immunoassay 
  • SARS-CoV-2 (COVID-19) IgG Ab [Units/volume] in Serum or Plasma by Immunoassay 
  • SARS-CoV-2 (COVID-19) IgG Ab [Presence] in Serum or Plasma by Immunoassay 
  • SARS-CoV-2 (COVID-19) IgM Ab [Units/volume] in Serum or Plasma by Immunoassay 
  • SARS-CoV-2 (COVID-19) IgM Ab [Presence] in Serum or Plasma by Immunoassay 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1 and name/value='Serologischer Befund']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.laboratory_test_panel.v0]/items[openEHR-EHR-CLUSTER.laboratory_test_analyte.v1]/items[at0001 and name/value='Nachweis'], code=at0001, itemType=ELEMENT, level=7, 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=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: SNOMED Clinical Terms
  • Detected (qualifier value) 
  • Not detected (qualifier value) 
  • Inconclusive (qualifier value) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1 and name/value='Serologischer Befund']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.laboratory_test_panel.v0]/items[openEHR-EHR-CLUSTER.laboratory_test_analyte.v1]/items[at0001 and name/value='Quantitatives Ergebnis'], code=at0001, itemType=ELEMENT, level=7, text=Quantitatives Ergebnis, 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=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ANY, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1 and name/value='Serologischer Befund']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.laboratory_test_panel.v0]/items[openEHR-EHR-CLUSTER.laboratory_test_analyte.v1]/items[at0005], code=at0005, itemType=ELEMENT, level=7, text=Result status, description=The status of the analyte result value., comment=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'., uncommonOntologyItems={fhir_mapping=Observation.status, hl7v2_mapping=OBX.11}, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Coded Text
    • Registered 
    • Partial 
    • Preliminary 
    • Final 
    • Amended 
    • Corrected 
    • Appended 
    • Cancelled 
    • Entered in error 
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1 and name/value='Serologischer Befund']/protocol[at0004], code=at0004, 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.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1 and name/value='Serologischer Befund']/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-OBSERVATION.laboratory_test_result.v1 and name/value='Serologischer Befund']/protocol[at0004]/items[at0094]/items[at0106], code=at0106, itemType=ELEMENT, level=4, text=Anforderung, description=Name of the original laboratory test requested., comment=This data element is to be used when the test requested differs from the test actually performed by the laboratory., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: LOINC
  • SARS-CoV-2 (COVID-19) Ab panel - Serum or Plasma by Immunoassay 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1 and name/value='Virologischer Befund'], code=at0000, itemType=OBSERVATION, level=1, text=Virologischer Befund, 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=1..1, occurencesText=Mandatory, 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-OBSERVATION.laboratory_test_result.v1 and name/value='Virologischer Befund']/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.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1 and name/value='Virologischer Befund']/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=1..1, occurencesText=Mandatory, 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-OBSERVATION.laboratory_test_result.v1 and name/value='Virologischer Befund']/data[at0001]/events[at0002]/data[at0003], code=at0003, 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.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1 and name/value='Virologischer Befund']/data[at0001]/events[at0002]/data[at0003]/items[at0005], code=at0005, itemType=ELEMENT, level=5, 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_CODED_TEXT, bindings=null, values=Terminology: SNOMED CT
  • Detection of virus (procedure) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1 and name/value='Virologischer Befund']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.laboratory_test_panel.v0], code=at0000, itemType=CLUSTER, level=5, text=Laboratory test panel, description=Laboratory test result as a panel/battery/profile structure common to clinical pathology testing., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, 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-OBSERVATION.laboratory_test_result.v1 and name/value='Virologischer Befund']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.laboratory_test_panel.v0]/items[openEHR-EHR-CLUSTER.laboratory_test_analyte.v1], code=at0000, itemType=CLUSTER, level=6, text=Pro Analyt, description=The result of a laboratory test for a single analyte value., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, 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-OBSERVATION.laboratory_test_result.v1 and name/value='Virologischer Befund']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.laboratory_test_panel.v0]/items[openEHR-EHR-CLUSTER.laboratory_test_analyte.v1]/items[at0024], code=at0024, itemType=ELEMENT, level=7, text=Virusnachweistest, 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_CODED_TEXT, bindings=null, values=Terminology: LOINC
  • SARS-CoV-2 (COVID-19) RNA [Presence] in Respiratory specimen by NAA with probe detection 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1 and name/value='Virologischer Befund']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.laboratory_test_panel.v0]/items[openEHR-EHR-CLUSTER.laboratory_test_analyte.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=7, 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=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: SNOMED Clinical Terms
  • Detected (qualifier value) 
  • Not detected (qualifier value) 
  • Inconclusive (qualifier value) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1 and name/value='Virologischer Befund']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.laboratory_test_panel.v0]/items[openEHR-EHR-CLUSTER.laboratory_test_analyte.v1]/items[at0005], code=at0005, itemType=ELEMENT, level=7, text=Result status, description=The status of the analyte result value., comment=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'., uncommonOntologyItems={fhir_mapping=Observation.status, hl7v2_mapping=OBX.11}, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • registered
  • preliminary
  • final
  • amended
  • corrected
  • cancelled
  • entered-in-error
  • unknown
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1 and name/value='Virologischer Befund']/protocol[at0004], code=at0004, 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.report.v1]/content[openEHR-EHR-ACTION.procedure.v1], code=at0000, itemType=ACTION, level=1, text=Procedure, 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-ACTION.procedure.v1]/description[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=2, text=Description, 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-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_CODED_TEXT, bindings=null, values=Terminology: SNOMED Clinical Terms
  • Dialysis procedure (procedure) 
  • Apheresis (procedure) 
  • Placing subject in prone position (procedure) 
  • Extracorporeal membrane oxygenation (procedure) 
  • Oxygen administration by nasal cannula (procedure) 
  • Noninvasive ventilation (procedure) 
  • Artificial respiration (procedure) 
  • Plain radiography 
  • Computerized axial tomography (procedure) 
  • Diagnostic ultrasonography (procedure) 
  • Therapeutic procedure (procedure) 
  • Respiratory therapy (procedure) 
  • Noninvasive ventilation (procedure) 
  • Oxygen administration by nasal cannula (procedure) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[at0070], code=at0070, itemType=ELEMENT, level=3, text=Indication, description=The clinical or process-related reason for the procedure., comment=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'., 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-ACTION.procedure.v1]/description[at0001]/items[at0063], code=at0063, itemType=ELEMENT, level=3, text=Body site, description=Identification of the body site for the procedure., comment=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., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: SNOMED Clinical Terms
  • Lung structure (body structure) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[openEHR-EHR-CLUSTER.device.v1], code=at0000, itemType=CLUSTER, level=3, text=Medical device, description=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., 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]/content[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[openEHR-EHR-CLUSTER.device.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=4, text=Device name, description=Identification of the medical device, preferably by a common name, a formal fully descriptive name or, if required, by class or category of device., comment=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., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: SNOMED Clinical Terms
  • Tracheostomy tube, device (physical object) 
  • Endotracheal tube, device (physical object) 
  • High flow oxygen nasal cannula (physical object) 
  • Endotracheal tube, device (physical object) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[at0067], code=at0067, itemType=ELEMENT, level=3, text=Procedure type, description=The type of procedure., comment=This pragmatic data element may be used to support organisation within the user interface., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: SNOMED Clinical Terms
  • Diagnostic procedure 
  • Imaging 
  • Surgical procedure 
  • Administration of medicine 
  • Therapeutic procedure (procedure) 
  • Other category 
  • Procedures relating to positioning and support (procedure) 
  • Respiratory therapy (procedure) 
  • Noninvasive ventilation (procedure) 
  • Oxygen administration by nasal cannula (procedure) 
  • Artificial respiration (procedure) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[at0014], code=at0014, itemType=ELEMENT, level=3, text=Durchführungsabsicht, description=Reason that the activity or care pathway step for the identified procedure was carried out., comment=For example: the reason for the cancellation or suspension of the procedure., 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-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-EVALUATION.exclusion_specific.v1 and name/value='Nicht durchgeführte Prozedur'], code=at0000, itemType=EVALUATION, level=1, text=Nicht durchgeführte Prozedur, 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.report.v1]/content[openEHR-EHR-EVALUATION.exclusion_specific.v1 and name/value='Nicht durchgeführte Prozedur']/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.report.v1]/content[openEHR-EHR-EVALUATION.exclusion_specific.v1 and name/value='Nicht durchgeführte Prozedur']/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_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.exclusion_specific.v1 and name/value='Nicht durchgeführte Prozedur']/data[at0001]/items[at0003], code=at0003, itemType=ELEMENT, level=3, text=Eingriff, description=The Procedure to which the 'Exclusion statement' applies. For example: 'Heart surgery' or 'Appendectomy' or 'Hip replacement'., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: SNOMED Clinical Terms
  • Dialysis procedure (procedure) 
  • Apheresis (procedure) 
  • Placing subject in prone position (procedure) 
  • Extracorporeal membrane oxygenation (procedure) 
  • Oxygen administration by nasal cannula (procedure) 
  • Noninvasive ventilation (procedure) 
  • Artificial respiration (procedure) 
  • Plain radiography 
  • Computerized axial tomography (procedure) 
  • Diagnostic ultrasonography (procedure) 
  • Therapeutic procedure (procedure) 
  • Respiratory therapy (procedure) 
  • Noninvasive ventilation (procedure) 
  • Oxygen administration by nasal cannula (procedure) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.absence.v2 and name/value='Unbekannte Prozedur'], code=at0000, itemType=EVALUATION, level=1, text=Unbekannte Prozedur, 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.report.v1]/content[openEHR-EHR-EVALUATION.absence.v2 and name/value='Unbekannte Prozedur']/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.report.v1]/content[openEHR-EHR-EVALUATION.absence.v2 and name/value='Unbekannte Prozedur']/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=3, text=Unbekannte Prozedur, 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=Terminology: SNOMED Clinical Terms
  • Dialysis procedure (procedure) 
  • Apheresis (procedure) 
  • Placing subject in prone position (procedure) 
  • Extracorporeal membrane oxygenation (procedure) 
  • Oxygen administration by nasal cannula (procedure) 
  • Noninvasive ventilation (procedure) 
  • Artificial respiration (procedure) 
  • Plain radiography 
  • Computerized axial tomography (procedure) 
  • Diagnostic ultrasonography (procedure) 
  • Therapeutic procedure (procedure) 
  • Respiratory therapy (procedure) 
  • Noninvasive ventilation (procedure) 
  • Oxygen administration by nasal cannula (procedure) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.absence.v2 and name/value='Unbekannte Prozedur']/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=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • unknown
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.advance_care_directive.v1], code=at0000, itemType=EVALUATION, level=1, text=DNR-Anordnung, description=A framework to communicate the preferences of an individual for future medical treatment and care., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, 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-EVALUATION.advance_care_directive.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.report.v1]/content[openEHR-EHR-EVALUATION.advance_care_directive.v1]/data[at0001]/items[at0005], code=at0005, itemType=ELEMENT, level=3, text=Type of directive, description=The type of advance care directive., comment=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'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: http://terminology.hl7.org/CodeSystem/consentcategorycodes
  • Do No Resusciate 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.advance_care_directive.v1]/data[at0001]/items[at0006], code=at0006, itemType=ELEMENT, level=3, text=Description, description=Narrative description of the overall advance care directive., comment=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., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: SNOMED Clinical Terms
  • For resuscitation (finding) 
  • Not for resuscitation (finding) 
  • Unknown (qualifier value) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.medication_statement.v0], code=at0000, itemType=OBSERVATION, level=1, text=Medication statement, description=A snapshot view about the use of a specified medication., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, 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-OBSERVATION.medication_statement.v0]/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.report.v1]/content[openEHR-EHR-OBSERVATION.medication_statement.v0]/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-OBSERVATION.medication_statement.v0]/data[at0001]/events[at0002]/data[at0003], code=at0003, 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.report.v1]/content[openEHR-EHR-OBSERVATION.medication_statement.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0006], code=at0006, itemType=ELEMENT, level=5, text=Medication item name, description=Name of the medication, vaccine or other therapeutic/prescribable item., comment=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., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: SNOMED CT
  • Product containing steroid (product) 
  • Product containing atazanavir (medicinal product) 
  • Product containing darunavir (medicinal product) 
  • Product containing chloroquine (medicinal product) 
  • Product containing hydroxychloroquine (medicinal product) 
  • Product containing ivermectin (medicinal product) 
  • Product containing lopinavir and ritonavir (medicinal product) 
  • Product containing ganciclovir (medicinal product) 
  • Product containing oseltamivir (medicinal product) 
  • Product containing remdesivir (medicinal product) 
  • Product containing ribavirin (medicinal product) 
  • Product containing tocilizumab (medicinal product) 
  • Product containing sarilumab (medicinal product) 
  • Product containing calcineurin inhibitor (product) 
  • Product containing tumor necrosis factor alpha inhibitor (product) 
  • Product containing interleukin 1 receptor antagonist (product) 
  • Product containing ruxolitinib (medicinal product) 
  • Product containing colchicine (medicinal product) 
  • Product containing interferon (product) 
  • Product containing calcifediol (medicinal product) 
  • Product containing zinc (medicinal product) 
  • Product containing angiotensin-converting enzyme inhibitor (product) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.medication_statement.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0008], code=at0008, itemType=ELEMENT, level=5, text=Status, description=The status of use of the medication., comment=For example: the medication is still actively being taken; or a course of antibiotics has been completed., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Planned 
  • Scheduled 
  • Active 
  • Completed 
  • Postponed 
  • Cancelled 
  • Suspended 
  • Discontinued 
  • Unknown 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.medication_statement.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0023], code=at0023, itemType=ELEMENT, level=5, text=Grund, description=The clinical reason for use of the medication item., comment=For example: 'Angina'. Coding of the clinical indication with a terminology is preferred, where possible. This data element allows multiple occurrences., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: SNOMED CT
  • Adjunct - intent (qualifier value) 
  • Adjuvant - intent (qualifier value) 
  • Curative - procedure intent (qualifier value) 
  • Neo-adjuvant - intent (qualifier value) 
  • Prophylaxis - procedure intent (qualifier value) 
  • Supportive - procedure intent (qualifier value) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ADMIN_ENTRY.discharge_summary.v0], code=at0000, itemType=ADMIN_ENTRY, level=1, text=Entlassungsart, description=Used for discharged patient only., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ADMIN_ENTRY, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ADMIN_ENTRY.discharge_summary.v0]/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.report.v1]/content[openEHR-EHR-ADMIN_ENTRY.discharge_summary.v0]/data[at0001]/items[at0040], code=at0040, itemType=ELEMENT, level=3, text=Discharge status, description=Discharge status., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: SNOMED-CT
  • Unknown (qualifier value) 
  • Hospital admission (procedure) 
  • Dead (finding) 
  • Patient discharged alive (finding) 
  • Patient referral (procedure) 
  • Referral to palliative care service (procedure) 
, extendedValues=null]], templateType=normal]