TEMPLATE Diagnosen UCO (Diagnosen UCO)

TEMPLATE IDDiagnosen UCO
ConceptDiagnosen UCO
DescriptionZur Repräsentation von Nebendiagnosen eines Patienten mit einer onkologischen Erkrankung im HiGHmed Projekt.
UseDieses Template wird verwendet, um Nebendiagnosen eines Patienten mit einer onkologischen Erkrankung aufzuzeichnen. Es werden relevante Nebenerkrankungen mit zusätzlichen spezifischen Angaben wie Diabetestyp, Ätiopathogenese oder Schweregrad einer Erkrankung erfasst.
MisuseNicht zur Repräsentation der Tumordiagnose des Patienten geeignet. Für diese Daten bitte das "Tumordiagnose Bericht" Template benutzen. Nicht zur Repräsentation des MII Kerndatensatzes Moduls Diagnosen verwenden. Für diese Darstellung bitte das "KDS_Diagnose" Template verwenden.
PurposeZur Repräsentation von Nebendiagnosen eines Patienten mit einer onkologischen Erkrankung im HiGHmed Projekt.
References
Authorsdate: 2020-12-15; email: rehberg.alina@mh-hannover.de; organisation: Medizinische Hochschule Hannover; name: Alina Rehberg
Other Details Languagedate: 2020-12-15; email: rehberg.alina@mh-hannover.de; organisation: Medizinische Hochschule Hannover; name: Alina Rehberg
OtherDetails Language Independent{PARENT:MD5-CAM-1.0.1=641B268BE8805CEB8DC21AB82C53AB3F, original_language=ISO_639-1::de, notes=Generated automatically by Adl Designer, MetaDataSet:Sample Set=Template metadata sample set, MD5-CAM-1.0.1=990746a019928fadc4e02f23d3b3bf96, build_uid=64fed64e-1163-44ce-bcb9-472bd3f6ea82, sem_ver=6.1.0}
KeywordsDiagnose, Problemliste, ICD, Ätiopathogenese, Anamnese, Begleiterkrankungen, Nebenerkrankungen
Language useden
Citeable Identifier1246.169.1463
AllOperationalTemplate [rootArchetypeId=openEHR-EHR-COMPOSITION.report.v1, otherContributors=null, tshis=[ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1], code=at0000, itemType=COMPOSITION, level=0, text=Diagnosen UCO, description=Document to communicate information to others, commonly in response to a request from another party., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=COMPOSITION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=null, code=null, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=1, text=Other Context, description=null, 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]/context/other_context[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=2, text=Report ID, description=Identification information about the report., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.case_identification.v0], code=at0000, itemType=CLUSTER, level=2, text=Case identification, description=To record case identification details for public health purposes., 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]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.case_identification.v0]/items[at0001], code=at0001, itemType=ELEMENT, level=3, text=Case identifier, description=The identifier of this case., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, 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], code=at0000, itemType=EVALUATION, level=1, text=Problem/Diagnosis, description=Details about a single identified health condition, injury, disability or any other issue which impacts on the physical, mental and/or social well-being of an individual., comment=Clear delineation between the scope of a problem versus a diagnosis is not easy to achieve in practice. For the purposes of clinical documentation with this archetype, problem and diagnosis are regarded as a continuum, with increasing levels of detail and supportive evidence usually providing weight towards the label of 'diagnosis'., uncommonOntologyItems=null, occurencesFormal=1..*, occurencesText=Mandatory, repeating, 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.problem_diagnosis.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.problem_diagnosis.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=3, text=Relevante Nebenerkrankung (ICD-10), description=Identification of the problem or diagnosis, by name., comment=Coding of the name of the problem or diagnosis 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= Value set: external, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0009], code=at0009, itemType=ELEMENT, level=3, text=Clinical description, description=Narrative description about the problem or diagnosis., comment=Use to provide background and context, including evolution, episodes or exacerbations, progress and any other relevant details, about the problem or diagnosis., 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]/data[at0001]/items[at0012 and name/value='Körperstelle'], code=at0012, itemType=ELEMENT, level=3, text=Körperstelle, description=Identification of a simple body site for the location of the problem or diagnosis., comment=Coding of the name of the anatomical location with a terminology is preferred, where possible. Use this data element to record 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 'Structured anatomical location' SLOT in this archetype. Occurrences for this data element are unbounded to allow for clinical scenarios such as describing a rash in multiple locations but where all of the other attributes are identical. If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= Terminology: http://snomed.info/sct
Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=http://hl7.org/fhir/ValueSet/body-site
  • 56244007 | 10 to 19 percent of body surface 
  • 37491003 | 12 nm filaments 
  • 78777002 | 20 to 29 percent of body surface 
  • 12423009 | 30 to 39 percent of body surface 
  • 36849000 | 40 to 49 percent of body surface 
  • 305024009 | 5/6 interchondral joint 
  • 76152003 | 50 to 59 percent of body surface 
  • 305005006 | 6/7 interchondral joint 
  • 91551007 | 60 to 69 percent of body surface 
  • 64700008 | 7 nm filaments 
  • 305006007 | 7/8 interchondral joint 
  • 75324005 | 70 to 79 percent of body surface 
  • 305007003 | 8/9 interchondral joint 
  • 19738007 | 80 to 89 percent of body surface 
  • 19904008 | 9 nm filaments 
  • 91035006 | 90 percent of body surface or more 
  • 51878007 | A band 
  • 818983003 | Abdomen 
  • 108350001 | Abdomen excluding retroperitoneal region 
  • 818984009 | Abdomen proper 
  • 281902004 | Abdomen proper cavity 
  • 818985005 | Abdomen proper segment of trunk 
  • 7832008 | Abdominal aorta structure 
  • 4158003 | Abdominal aortic plexus structure 
  • 818999009 | Abdominal blood vessel 
  • ... +36762 
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Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=https://fhir.kbv.de/ValueSet/KBV_VS_SFHIR_ICD_SEITENLOKALISATION
  • B | beiderseits 
  • L | links 
  • R | rechts 
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  • Typ 1 
  • Typ 2 
  • Typ 3 
  • Typ 4 
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  •  Coded Text
    • *Arbeitsrisikofaktoren(en) 
    • *Biologisch(en) 
    • *Chemische Verletzung(en) 
    • *ernährungsrelevante Faktoren(en) 
    • *Genetische Herkunft(en) 
    • *Immunologische Herkunft(en) 
    • *Infektion(en) 
    • *Körperliche Verletzung(en) 
    • *Lebenswandel-bezogene Faktoren(en) 
    • *Metabolisch-endokriner Herkunft(en) 
    • *Neuropsychiatrische Herkunft(en) 
    • *Umweltexposition(en) 
    • *Sonstiges (de) 
  •  Text
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  • Typ A
  • Typ B
  • Typ C
  • Typ D
  • Typ E
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