| TEMPLATE ID | NATARS_Tzusatz |
|---|---|
| Concept | NATARS_Tzusatz |
| Description | Das Template dient zum Erfassen der Daten aus dem NATARS-Projekt und wird hier für die Darstellung der Fragebögen zum Thema Sturzgeschehen, Schmerzerfassung und BMI verwendet. |
| Purpose | Das Template dient zum Erfassen der Daten aus dem NATARS-Projekt und wird hier für die Darstellung der Fragebögen zum Thema Sturzgeschehen, Schmerzerfassung und BMI verwendet. |
| References | |
| Authors | name: Bianca Frenzel; organisation: Medizinische Hochschule Hannover - Peter L. Reichertz Institut für Medizinische Informatik; email: frenzel.bianca@mh-hannover.de; date: 2021-06-09 |
| Other Details Language | name: Bianca Frenzel; organisation: Medizinische Hochschule Hannover - Peter L. Reichertz Institut für Medizinische Informatik; email: frenzel.bianca@mh-hannover.de; date: 2021-06-09 |
| Other Details (Language Independent) |
|
| Keywords | NATARS; Sturzgeschehen; ProFaNE; Schmerzerfassung; BMI |
| Language used | en |
| Citeable Identifier | 1246.169.1827 |
| Root archetype id | openEHR-EHR-COMPOSITION.report.v1 |
| NATARS_Tzusatz | NATARS_Tzusatz: Document to communicate information to others, commonly in response to a request from another party. |
| Other Context | |
| Assessment Block | Assessment Block: Identification information about the report. Terminology: local_terms
|
| null_flavour | |
| Bemerkungen | Bemerkungen: The status of the entire report. Note: This is not the status of any of the report components. |
| null_flavour | |
| Abfrage Sturzgeschehen ProFaNE | Abfrage Sturzgeschehen ProFaNE: Abfrage eines Sturzgeschehens bei Senioren nach Prevention of Falls Network Europe (ProFaNE). |
| Data | |
| Jedes Ereignis | Jedes Ereignis: Standardwert, ein undefinierter/s Zeitpunkt oder Intervallereignis, das explizit im Template oder zur Laufzeit der Anwendung definiert werden kann. |
| Data | |
| Sturzgeschehen | Sturzgeschehen: Sie sind seit meinem letzten Besuch gestürzt, ausgerutscht oder gestolpert, sodass Sie auf dem Boden zum Liegen gekommen sind. |
| null_flavour | |
| Sturzhäufigkeit | Sturzhäufigkeit: Wenn ein Sturzgeschehen vorlag, wie häufig ist das seit meinem letzten Besuch passiert? >=0 |
| null_flavour | |
| Verletzung | Verletzung: * |
| Sturzzeitpunkt | Sturzzeitpunkt: Wann sind Sie genau gestürzt? |
| null_flavour | |
| Verletzung erlitten | Verletzung erlitten: Sie haben sich bei einem der Stürze verletzt. |
| null_flavour | |
| Bruch | Bruch: Sie haben sich etwas gebrochen. |
| null_flavour | |
| Lokalisation des Bruches | Lokalisation des Bruches: Was haben Sie sich gebrochen? |
| null_flavour | |
| Weitere Verletzungen | Weitere Verletzungen: Sie haben weitere Verletzungen erlitten. |
| null_flavour | |
| Art der Verletzungen | Art der Verletzungen: Welche weiteren Verletzungen haben Sie erlitten? |
| null_flavour | |
| Bemerkungen | Bemerkungen: Weitere Bemerkungen, die während des Erfassens aufgetreten sind. |
| null_flavour | |
| Protocol | |
| Exclusion of examination | Exclusion of examination: Positive statement to record that a physical examination or clinical test was not performed. |
| Examination not done | Examination not done: Statement to explicity record that the examination was not performed. Record as True if the examination was not performed. |
| null_flavour | |
| Reason | Reason: Reason for the 'not done' statement. For example: patient factors, equipment factors, time constraints. Terminology: local_terms
|
| null_flavour | |
| Schmerzerfassung | Schmerzerfassung: Answers to pre-defined screening questions about symptoms or signs. The answers may be self-reported. |
| Data | |
| Any event | Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time. |
| Data | |
| Bemerkungen | Bemerkungen: The context or reason for screening. This data element is intended to provide collection context for the question/answer groups when queried at a later date. It is not expected that this data element will be exposed to the individual, but only stored in data. For example: 'pre-admission screening' or the name of the actual questionnaire. |
| null_flavour | |
| Schmerzen vorhanden | Schmerzen vorhanden: Presence of symptoms or signs related to the screening purpose.
|
| null_flavour | |
| Specific symptom/sign | Specific symptom/sign: Details about a specific symptom or sign or grouping of symptoms or signs related to the screening purpose. |
| Symptom/sign name | Symptom/sign name: Identification of a specific symptom or sign or grouping of symptoms or signs, by name. Coding of the 'Symptom/sign name' with a terminology is preferred, where possible.
|
| null_flavour | |
| Symptom/Sign | Symptom/Sign: Reported observation of a physical or mental disturbance in an individual. |
| Symptom/Sign name | Symptom/Sign name: The name of the reported symptom or sign. Symptom name should be coded with a terminology, where possible.
|
| null_flavour | |
| Anatomical location | Anatomical location: A physical site on or within the human body. |
| Body site name | Body site name: Identification of a single physical site either on, or within, the human body. This data element is the only mandated data point in this archetype and should be used as the primary data point to record an anatomical location with a commonly used name. It is strongly recommended that 'Body site name' be recorded as specifically as is anatomically possible. For example: record 'upper eyelid' rather than recording 'eyelid' with 'upper' as a qualifier; 'fifth rib' rather than 'rib' with a numeric qualifier. Use the other data elements for laterality, aspect, region and anatomical line to provide more detail. This data element should be coded with a terminology capable of triggering decision support, where possible - an appropriate termset for use here could comprise individual concepts or a list of precoordinated terms. Free text should be used only if there is no appropriate terminology available. If body site name is already identified in the parent archetype, then this data element may be redundant. Alternatively, a use case has been identified where the value may be duplicated into this element to support semantic querying using this archetype, rather than the data element within the parent. |
| null_flavour | |
| Laterality | Laterality: The side of the body on which the identified body site is located. 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.
|
| null_flavour | |
| Description | Description: Narrative description that can be used to further refine and support the 'Body site name'. For example: adjacent to the vermilion border; a tattoo covers the bottom half of this area. |
| null_flavour | |
| Dauer der Schmerzen | Dauer der Schmerzen: Narrative description about the reported symptom or sign. |
| null_flavour | |
| Schmerzstärke | Schmerzstärke: Numerical rating scale representing the overall severity of the symptom or sign. Symptom severity can be rated by the individual by recording a score from 0 (ie symptom not present) to 10.0 (ie symptom is as severe as the individual can imagine). This score can be represented in the user interface as a visual analogue scale. The data element has occurrences set to 0..* to allow for variations such as 'maximal severity' or 'average severity' to be included in a template. 0..10 |
| null_flavour | |
| Bewegungseinschränkung | Bewegungseinschränkung: Numerical rating scale representing the overall severity of the symptom or sign. Symptom severity can be rated by the individual by recording a score from 0 (ie symptom not present) to 10.0 (ie symptom is as severe as the individual can imagine). This score can be represented in the user interface as a visual analogue scale. The data element has occurrences set to 0..* to allow for variations such as 'maximal severity' or 'average severity' to be included in a template. 0..10 |
| null_flavour | |
| Protocol | |
| Exclusion of examination | Exclusion of examination: Positive statement to record that a physical examination or clinical test was not performed. |
| Examination not done | Examination not done: Statement to explicity record that the examination was not performed. Record as True if the examination was not performed. |
| null_flavour | |
| Reason | Reason: Reason for the 'not done' statement. For example: patient factors, equipment factors, time constraints. Terminology: local_terms
|
| null_flavour | |
| Body mass index | Body mass index: Calculated measurement which compares a person's weight and height. Body Mass Index is a calculated ratio describing how an individual's body weight relates to the weight that is regarded as normal, or desirable, for the individual's height. |
| Data | |
| Any event | Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time. |
| Data | |
| Body mass index | Body mass index: Index describing ratio of weight to height. 10..100 kg/m² |
| null_flavour | |
| Bemerkungen | Bemerkungen: Additional narrative about the calculation, not captured in other fields. |
| null_flavour | |
| Protocol | |
| Method | Method: The method of entering the body mass index.
|
| null_flavour | |
| Exclusion of examination | Exclusion of examination: Positive statement to record that a physical examination or clinical test was not performed. |
| Examination not done | Examination not done: Statement to explicity record that the examination was not performed. Record as True if the examination was not performed. |
| null_flavour | |
| Reason | Reason: Reason for the 'not done' statement. For example: patient factors, equipment factors, time constraints. Terminology: local_terms
|
| null_flavour |