TEMPLATE Radiologischer Befund - Herz_ Funktion und Myokardvitalität (Radiologischer Befund - Herz_ Funktion und Myokardvitalität)

TEMPLATE ID	Radiologischer Befund - Herz_ Funktion und Myokardvitalität
Concept	Radiologischer Befund - Herz_ Funktion und Myokardvitalität
Description	Not Specified
Purpose	Not Specified
References
Authors	date: 2021-07-13; name: Matthias Thelen; organisation: UK Köln; email: matthias.thelen@rwth-aachen.de
Other Details Language	date: 2021-07-13; name: Matthias Thelen; organisation: UK Köln; email: matthias.thelen@rwth-aachen.de
Other Details (Language Independent)	Sem Ver: 1.0.0 MD5-CAM-1.0.1: 4e46ae5993a00a22a9f32e02c954d630 PARENT:MD5-CAM-1.0.1: DE0723367AA22BB716CEC5342B21FF60 Original Language: ISO_639-1::de
Language used	en
Citeable Identifier	1246.169.1878
Root archetype id	openEHR-EHR-COMPOSITION.report.v1
Radiologischer Befund - Herz: Funktion	Radiologischer Befund - Herz: Funktion: Document to communicate information to others, commonly in response to a request from another party.
Other Context
Report ID	Report ID: Identification information about the report.
Status	Status: The status of the entire report. Note: This is not the status of any of the report components.
Case identification	Case identification: To record case identification details for public health purposes.
Case identifier	Case identifier: The identifier of this case.
Imaging examination result	Imaging examination result: Record the findings and interpretation of an imaging examination performed.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Test name	Test name: The name of the imaging examination or procedure performed. Coding with a terminology, potentially a pre-coordinated term specifying both modality and anatomical location, is desirable where possible. Possible candidate terminologies: LOINC, SNOMED CT or RadLex.
Modality	Modality: Type of equipment that originally acquired the image or series of images. Also known as 'Examination type'. For example: Ultrasound; Computed tomography; or X-ray. Coding with a terminology is desirable, where possible. If the modality is specified by a code in the Examination result name, then this field may be redundant.
Anatomical site	Anatomical site: Simple description about the physical place on, or in, the body that was imaged. This data element is redundant if the anatomical site is identified in the 'Test name'.
Overall result status	Overall result status: The status of the examination result as a whole. Registered Interim Final Amended Cancelled / Aborted
DateTime result issued	DateTime result issued: The date and/or time that the result was issued for the recorded 'Examination result status'.
Clinical information provided	Clinical information provided: Description of clinical information available at the time of interpretation of results. This may include a link to the clinical information provided in the original examination request. If other sources of clinical information have been used, this should be clearly stated using this data element.
Findings	Findings: Narrative description of the clinical findings.
Imaging result	Imaging result: Imaging result as a single value or as a nested group result.
End-diastolisches Volumen (EDV)	End-diastolisches Volumen (EDV): Specific detailed imaging result, including both the value of the result item, and additional information that may be useful for clinical interpretation.
Result	Result: Actual value of the imaging result. The name of this element can be replaced in a template or at run-time to reflect the actual result name and will often be coded. Units: ml
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.
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. Left Right
Imaging result (2)	Imaging result (2): Imaging result as a single value or as a nested group result.
End-systolisches Volumen (ESV)	End-systolisches Volumen (ESV): Specific detailed imaging result, including both the value of the result item, and additional information that may be useful for clinical interpretation.
Result	Result: Actual value of the imaging result. The name of this element can be replaced in a template or at run-time to reflect the actual result name and will often be coded. Units: ml
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.
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. Left Right
Imaging result (3)	Imaging result (3): Imaging result as a single value or as a nested group result.
Schlagvolumen (SV)	Schlagvolumen (SV): Specific detailed imaging result, including both the value of the result item, and additional information that may be useful for clinical interpretation.
Result	Result: Actual value of the imaging result. The name of this element can be replaced in a template or at run-time to reflect the actual result name and will often be coded. Units: ml
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.
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. Left Right
Imaging result (4)	Imaging result (4): Imaging result as a single value or as a nested group result.
Herzzeitvolumen	Herzzeitvolumen: Specific detailed imaging result, including both the value of the result item, and additional information that may be useful for clinical interpretation.
Result	Result: Actual value of the imaging result. The name of this element can be replaced in a template or at run-time to reflect the actual result name and will often be coded. Units: l/min (UCUM: l/m)
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.
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. Left Right
Imaging finding	Imaging finding: A single finding in an imaging examination.
Mitralklappen-Vitium	Mitralklappen-Vitium: The name of the finding. Coding with an external terminology is strongly recommended. Optional[{fhir_mapping=Observation.code, hl7v2_mapping=OBX.3}]
Presence?	Presence?: The presence or absence of the finding. For example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details. Optional[{fhir_mapping=Observation.value[x], hl7v2_mapping=OBX.2, OBX.5, OBX.6, OBX.7, OBX.8}] Present Absent Indeterminate
Description	Description: Narrative description about the observed clinical finding. Stenose Insuffizienz Kombiniert
Comparison to previous	Comparison to previous: Narrative description about the difference between a previous finding and the finding in this report. Coded Text Improving Unchanged Worsening Text
Comment	Comment: Additional narrative about the finding, not captured in other fields. Optional[{fhir_mapping=Observation.note, hl7v2_mapping=NTE.3}] Leichtgradig Mittelgradig Hochgradig
Imaging finding (2)	Imaging finding (2): A single finding in an imaging examination.
Aortenklappen-Vitium	Aortenklappen-Vitium: The name of the finding. Coding with an external terminology is strongly recommended. Optional[{fhir_mapping=Observation.code, hl7v2_mapping=OBX.3}]
Presence?	Presence?: The presence or absence of the finding. For example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details. Optional[{fhir_mapping=Observation.value[x], hl7v2_mapping=OBX.2, OBX.5, OBX.6, OBX.7, OBX.8}] Present Absent Indeterminate
Description	Description: Narrative description about the observed clinical finding. Stenose Insuffizienz Kombiniert
Comparison to previous	Comparison to previous: Narrative description about the difference between a previous finding and the finding in this report. Coded Text Improving Unchanged Worsening Text
Comment	Comment: Additional narrative about the finding, not captured in other fields. Optional[{fhir_mapping=Observation.note, hl7v2_mapping=NTE.3}] Leichtgradig Mittelgradig Hochgradig
Imaging finding (3)	Imaging finding (3): A single finding in an imaging examination.
Linksventrikuläre Wandbewegungsstörung	Linksventrikuläre Wandbewegungsstörung: The name of the finding. Coding with an external terminology is strongly recommended. Optional[{fhir_mapping=Observation.code, hl7v2_mapping=OBX.3}]
Anatomical location	Anatomical location: Simple description of anatomical location. basisnah anterior (AHA-Segment 1) basisnah anteroseptal (AHA-Segment 2) basisnah inferoseptal (AHA-Segment 3) basisnah inferior (AHA-Segment 4) basisnah inferolateral (AHA-Segment 5) basisnah anterolateral (AHA-Segment 6) midventrikulär anterior (AHA-Segment 7) midventrikulär anteroseptal (AHA-Segment 8) midventrikulär inferoseptal (AHA-Segment 9) midventrikulär inferior (AHA-Segment 10) midventrikulär inferolateral (AHA-Segment 11) midventrikulär anterolaterl (AHA-Segment 12) apexnah anterior (AHA-Segment 13) apexnah septal (AHA-Segment 14) apexnah inferior (AHA-Segment 15) apexnah lateral (AHA-Segment 16) apikal (AHA-Segment 17)
Presence?	Presence?: The presence or absence of the finding. For example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details. Optional[{fhir_mapping=Observation.value[x], hl7v2_mapping=OBX.2, OBX.5, OBX.6, OBX.7, OBX.8}] Present Absent Indeterminate
Description	Description: Narrative description about the observed clinical finding. normokinetisch hypokinetisch akinetisch dyskinetisch
Comparison to previous	Comparison to previous: Narrative description about the difference between a previous finding and the finding in this report. Coded Text Improving Unchanged Worsening Text
Comment	Comment: Additional narrative about the finding, not captured in other fields. Optional[{fhir_mapping=Observation.note, hl7v2_mapping=NTE.3}]
Imaging finding (4)	Imaging finding (4): A single finding in an imaging examination.
Late gadolinium Enhancement	Late gadolinium Enhancement: The name of the finding. Coding with an external terminology is strongly recommended. Optional[{fhir_mapping=Observation.code, hl7v2_mapping=OBX.3}]
Anatomical location	Anatomical location: Simple description of anatomical location. basisnah anterior (AHA-Segment 1) basisnah anteroseptal (AHA-Segment 2) basisnah inferoseptal (AHA-Segment 3) basisnah inferior (AHA-Segment 4) basisnah inferolateral (AHA-Segment 5) basisnah anterolateral (AHA-Segment 6) midventrikulär anterior (AHA-Segment 7) midventrikulär anteroseptal (AHA-Segment 8) midventrikulär inferoseptal (AHA-Segment 9) midventrikulär inferior (AHA-Segment 10) midventrikulär inferolateral (AHA-Segment 11) midventrikulär anterolaterl (AHA-Segment 12) apexnah anterior (AHA-Segment 13) apexnah septal (AHA-Segment 14) apexnah inferior (AHA-Segment 15) apexnah lateral (AHA-Segment 16) apikal (AHA-Segment 17)
Presence?	Presence?: The presence or absence of the finding. For example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details. Optional[{fhir_mapping=Observation.value[x], hl7v2_mapping=OBX.2, OBX.5, OBX.6, OBX.7, OBX.8}] Present Absent Indeterminate
Description	Description: Narrative description about the observed clinical finding. Transmural Subendokardial Epikardial Intramural
Comparison to previous	Comparison to previous: Narrative description about the difference between a previous finding and the finding in this report. Coded Text Improving Unchanged Worsening Text
Comment	Comment: Additional narrative about the finding, not captured in other fields. Optional[{fhir_mapping=Observation.note, hl7v2_mapping=NTE.3}] <50% Transmuralität >50% Transmuralität Default value: <50% Transmuralität
Imaging finding (5)	Imaging finding (5): A single finding in an imaging examination.
Globale systolische Ventrikelfunktion	Globale systolische Ventrikelfunktion: The name of the finding. Coding with an external terminology is strongly recommended. Optional[{fhir_mapping=Observation.code, hl7v2_mapping=OBX.3}]
Anatomical location	Anatomical location: Simple description of anatomical location. Linksventrikulär Rechtsventrikulär
Description	Description: Narrative description about the observed clinical finding. geringgradig eingeschränkt mittelgradig eingeschränkt hochgradig eingeschränkt
Comparison to previous	Comparison to previous: Narrative description about the difference between a previous finding and the finding in this report. Coded Text Improving Unchanged Worsening Text
Comparison with previous	Comparison with previous: Narrative descripition about the comparison of this image, or series of images, with previous similar examinations. If there is no availability of previous imaging and/or reports this should also be stated using this data element.
Conclusion	Conclusion: Narrative concise, clinically relevant interpretation of all imaging findings, and include a comparison with previous studies where appropriate. Also referred to as 'Opinion' or 'Impression'.
Imaging differential diagnosis	Imaging differential diagnosis: Single word, phrase or brief description representing a possible condition or diagnosis. This data element has multiple occurrences to allow for more than one differential diagnoses. Coding with a terminology is preferred, where possible. This data element should be regarded as mutually exclusive to 'Imaging diagnosis' - only one of 'Differential diagnoses' OR 'Imaging diagnosis' should be present in each Imaging examination result.
Imaging diagnosis	Imaging diagnosis: Single word, phrase or brief description representing the likely condition or diagnosis. This data element has multiple occurrences to allow for more than one diagnoses. Coding with a terminology is preferred, where possible. This data element should be regarded as mutually exclusive to 'Differential diagnoses' - only one of 'Differential diagnoses' OR 'Imaging diagnosis' should be present in the each Imaging examination result.
Recommendation	Recommendation: Suggestion for further imaging, investigations and/or referral, and associated rationale. This data element has 0..* occurrences to allow for more than one recommendation and associated rationale. Formal orders for additional imaging examination, investigation should be recorded using an INSTRUCTION archetype, such as INSTRUCTION.service_request.
Comment	Comment: Additional narrative about the examination not captured in other fields. For example: a note that the film was given to the patient.
State
Confounding factors	Confounding factors: Narrative description of factors, not recorded elsewhere, that may influence the examination findings and/or result.
Protocol
Technique	Technique: Narrative description about the technical details and procedure. For example: outline of technique; non-routine alternative or additional imaging; nature and route of administration of contrast agent, radiopharmaceuticals and/or treatments administered; adverse reactions to contrast media.
Imaging quality	Imaging quality: Narrative description about the quality of the examination. For example: the nature of any limitations and their impact on interpretation.
Examination request details	Examination request details: Details concerning a single examination requested. Note: Usually there is one examination request for each result, however in some circumstances multiple examination requests may be represented using a single Imaging examination result archetype.
Requester order identifier	Requester order identifier: The local identifier assigned to the order by the order requester. Equivalent to the HL7 Placer Order Identifier.
Examination requested name	Examination requested name: Identification of imaging examination or procedure requested, where the examination requested differs from the examination actually performed.
Receiver order identifier	Receiver order identifier: The local identifier assigned to the examination order by the order filler, usually by the Radiology Information System (RIS). Usually equivalent to the HL7 Filler Order Number.
DICOM study identifier	DICOM study identifier: Unique identifier of this study allocated by the imaging service.
Report identifier	Report identifier: The local identifier given to the imaging examination report.
(Image details)	(Image details): Images referred to, or provided, to assist clinical understanding of the examination. If attached image is in DICOM format, all the fields below should be populated so the values are available to software that does not process DICOM images.
Image identifier	Image identifier: Unique identifier of this image allocated by the imaging service (often the DICOM image instance UID).
DICOM series identifier	DICOM series identifier: Unique identifier of this series allocated by the imaging service.
View	View: The name of the imaging view e.g Lateral or Antero-posterior (AP). Coding using a terminology is desirable, where possible.
Position	Position: Description of the subject of care's positon when the image was performed.
Image DateTime	Image DateTime: Specific date/time the imaging examination was performed.
Image	Image: An attached or referenced image of a current view.