- MetaDataSet:Sample Set : Template metadata sample set
- MD5-CAM-1.0.1: c306b36c2bd947900583ee07ac0ed5d4
- PARENT:MD5-CAM-1.0.1: DE0723367AA22BB716CEC5342B21FF60
- Sem Ver: 10.1.0
- Build Uid: 039069b5-2005-414e-9e40-ca28b72289a5
- Original Language: ISO_639-1::de
e.g. 'Mr', 'Mrs', 'Ms', 'Dr', 'Lord'
For example: physical or postal.
- Physical
- Postal
- Both
Coded Text- Business
- Residential
- Temporary accommodation
Text
This address line represents a low level of geographical/physical description of a location that, used in conjunction with the other high-level address components i.e. ‘Suburb/Town/Locality’, ‘Postcode’, and ‘State/Territory/Province’, forms a complete geographical/physical address. This data element can be used to represent a landmark, such as "The second house north of the general store" or "At the corner of Smith & Brown Streets. The content of this data element may be derived from a concatenation of one or more components from CLUSTER.structured_address. Multiple occurrences allow for as many 'Address' lines, as required. For example: 4 address lines represented as Apartment 7A, 52 Davis Street, Carlton North, Victoria, AUSTRALIA 3042.
Coding with an external terminology is preferred, where possible. For example: Fitzroy, Calgary, Bergen.
Coding with an external terminology is preferred, where possible.
Coding with an external terminology is preferred, where possible. For example: Victoria; Alberta.
Also known as ZIP code.
Coding with an external terminology is preferred, where possible. For example: Australia; Canada
Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=https://www.netzwerk-universitaetsmedizin.de/fhir/ValueSet/ethnic-groups
Annotations
- 424144002: Current chronological age (observable entity)
- 30525-0: Age
P0Y..P200Y
For example: 'Male', 'Female', 'Intersex'. Coding with a terminology is recommended, where possible. Use the element 'Comment' or the SLOT 'Details' if needed to register more specific details of the individuals gender.
Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=https://www.netzwerk-universitaetsmedizin.de/fhir/ValueSet/birth-sex
Height is measured with the individual in a standing position and body length in a recumbent position.
Annotations
- 50373000: Body height measure (observable entity)
- 8302-2: Body height
0..1000 cm
Annotations
- 27113001: Body weight (observable entity)
- 29463-7: Body weight
0..1000 kg
Annotations
- 82810-3: Pregnancy status
- Pregnant
- Not pregnant
- Unknown
Annotations
- 72166-2: Tobacco smoking status
Use this data element to record a narrative description of the tobacco smoking habits for this individual or to incorporate unstructured tobacco smoking information from existing or legacy clinical systems into an archetyped format.
Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=https://www.netzwerk-universitaetsmedizin.de/fhir/ValueSet/smoking-status
Terminology: SNOMED Clinical Terms
- Ja
- Nein
- Unbekannt
Terminology: urn:iso:std:iso:3166
Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=http://hl7.org/fhir/ValueSet/iso3166-1-2
- AD | Andorra
- AE | United Arab Emirates
- AF | Afghanistan
- AG | Antigua and Barbuda
- AI | Anguilla
- AL | Albania
- AM | Armenia
- AO | Angola
- AQ | Antarctica
- AR | Argentina
- AS | American Samoa
- AT | Austria
- AU | Australia
- AW | Aruba
- AX | Åland Islands
- AZ | Azerbaijan
- BA | Bosnia and Herzegovina
- BB | Barbados
- BD | Bangladesh
- BE | Belgium
- BF | Burkina Faso
- BG | Bulgaria
- BH | Bahrain
- BI | Burundi
- BJ | Benin
- ... +224
Different regions within the same country maybe identified if they potentially pose different health risks.
Terminology: urn:iso:std:iso:3166-2:de
Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=http://fhir.de/ValueSet/iso/bundeslaender
- DE-BW | Baden-Württemberg
- DE-BY | Bayern
- DE-BE | Berlin
- DE-BB | Brandenburg
- DE-HB | Bremen
- DE-HH | Hamburg
- DE-HE | Hessen
- DE-MV | Mecklenburg-Vorpommern
- DE-NI | Niedersachsen
- DE-NW | Nordrhein-Westfalen
- DE-RP | Rheinland-Pfalz
- DE-SL | Saarland
- DE-SN | Sachsen
- DE-ST | Sachsen-Anhalt
- DE-SH | Schleswig-Holstein
- DE-TH | Thüringen
Different cities within the same country or region maybe identified if they potentially pose different health risks.
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.
Terminology: SNOMED Clinical Terms
- Nein
Terminology: LOINC
- Reisehistorie
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: LOINC
- Reisehistorie
For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible.
Terminology: SNOMED Clinical Terms
- Unbekannt
Annotations
- 410605003: Confirmed present (qualifier value)
- 75325-1: Symptom
Symptom name should be coded with a terminology, where possible.
Terminology: http://snomed.info/sct
- Abdominal pain (finding)
- Asymptomatic (finding)
- Bleeding (finding)
- Chest pain (finding)
- Chill (finding)
- Conjunctivitis (disorder)
- Cough (finding)
- Diarrhea (finding)
- Disturbance of consciousness (finding)
- Dyspnea (finding)
- Eruption of skin (disorder)
- Fatigue (finding)
- Feeling feverish (finding)
- Fever (finding)
- Headache (finding)
- Hemoptysis (finding)
- Indrawing of ribs during respiration (finding)
- Joint pain (finding)
- Loss of appetite (finding)
- Loss of sense of smell (finding)
- Loss of taste (finding)
- Lymphadenopathy (disorder)
- Malaise (finding)
- Muscle pain (finding)
- Nasal congestion (finding)
- Nasal discharge (finding)
- Nausea (finding)
- Pain in throat (finding)
- Rigor (finding)
- Seizure (finding)
- Skin ulcer (disorder)
- Unable to walk (finding)
- Vomiting (disorder)
- Wheezing (finding)
- Fever greater than 100.4 Fahrenheit / 38° Celsius (finding)
- Asthenia (finding)
- Pain (finding)
- Productive cough (finding)
- Dry cough (finding)
- Clouded consciousness (finding)
Occurrences of this data element are set to 0..* to allow multiple body sites to be separated out in a template if desired. This allows for representation of clinical scenarios where a symptom or sign needs to be recorded in multiple locations or identifying both the originating and distal site in pain radiation, but where all of the other attributes such as impact and duration are identical. If the requirements for recording the body site are determined at run-time by the application or require more complex modelling such as relative locations then use the CLUSTER.anatomical_location or CLUSTER.relative_location within the Detailed anatomical location' SLOT in this archetype. If the anatomical location is included in the Symptom name via precoordinated codes, this data element becomes redundant. If the anatomical location is recorded using the 'Structured body site' SLOT, then use of this data element is not allowed - record only the simple 'Body site' OR 'Structured body site', but not both.
While partial dates are permitted, the exact date and time of onset can be recorded, if appropriate. If this symptom or sign is experienced for the first time or is a re-occurrence, this date is used to represent the onset of this episode. If this symptom or sign is ongoing, this data element may be redundant if it has been recorded previously.
Defining values such as mild, moderate or severe in such a way that is applicable to multiple symptoms or signs plus allows multiple users to interpret and record them consistently is not easy. Some organisations extend the value set further with inclusion of additional values such as 'Trivial' and 'Very severe', and/or 'Mild-Moderate' and 'Moderate-Severe', adds to the definitional difficulty and may also worsen inter-recorder reliability issues. Use of 'Life-threatening' and 'Fatal' is also often considered as part of this value set, although from a pure point of view it may actually reflect an outcome rather than a severity. In view of the above, keeping to a well-defined but smaller list is preferred and so the mild/moderate/severe value set is offered, however the choice of other text allows for other value sets to be included at this data element in a template. Note: more specific grading of severity can be recorded using the 'Specific details' SLOT.
Terminology: http://snomed.info/sct
- Mild (qualifier value)
- Moderate (severity modifier) (qualifier value)
- Severe (severity modifier) (qualifier value)
- Life threatening severity (qualifier value)
If 'Date/time of onset' and 'Duration' are used in systems, this data element may be calculated, or alternatively, considered redundant. While partial dates are permitted, the exact date and time of resolution can be recorded, if appropriate.
This is not limited to activities performed based on medication orders from clinicians, but could also include for example taking over the counter medication.
For example: 'Atenolol 100mg' or 'Tenormin tablets 100mg'. It is strongly recommended that the 'Medication item' is coded with a terminology capable of triggering decision support, where possible. The extent of coding may vary from the simple name of the medication item through to structured details about the actual medication pack 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/vaccines-snomed
Annotations
- ATC: https://fhir.kbv.de/ValueSet/KBV_VS_MIO_Vaccination_Vaccine_List_ATC
- PZN: http://fhir.de/CodeSystem/ifa/pzn
- SNOMED: https://fhir.kbv.de/ValueSet/KBV_VS_MIO_Vaccination_Vaccine_List
For example: '2 tablets at 6pm' or '20mg three times per day'. Please note: this cluster allows multiple occurrences to enable representation of a complete set of dose patterns for a single dose direction.
For example: '1', '2', '3'. Where multiple dosages are expressed, the 'Pattern sequence' makes the order in which they should be executed explicit. For example: (1) 1 tab in the morning, (2) 2 tab at 2pm, (3) 1 tab at night.
>=1
For example: 1, 1.5, 0.125 or 1-2, 12.5-20.5
>=0
For example: 'Postponed - Patient not avalable at administration time', 'Cancelled - Adverse reaction'. Note: This is not the reason for the medication instruction, but rather the specific reason that a care step was carried out, and will often be used to document some variance from the original order.
Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=https://fhir.kbv.de/ValueSet/KBV_VS_MIO_Vaccination_TargetDisease
For example: 'Patient was in radiology department', 'Accidental injection into blood vessel during IM administration'.
For example: "No information available about adverse reactions"; No information available about problems or diagnoses"; "No information available about previous procedures performed"; or "No information available about medications used".
Value set: terminology://fhir.hl7.org//ValueSet/$expand?url=http://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-immunizations-uv-ips