TEMPLATE Nephro_Diagnose (Nephro_Diagnose)

TEMPLATE ID	Nephro_Diagnose
Concept	Nephro_Diagnose
Description	Zur Repräsentation einer Diagnose/Infektion eines Patienten im Rahmen des NephroDigital Projektes.
Use	Für die Repräsentation einer Diagnose/Infektion eines Patienten.
Purpose	Zur Repräsentation einer Diagnose/Infektion eines Patienten im Rahmen des NephroDigital Projektes.
References
Authors	Name: Nina Schewe; Organisation: Medizinische Hochschule Hannover; Email: Schewe.Nina@mh-hannover.de
Other Details Language	Name: Nina Schewe; Organisation: Medizinische Hochschule Hannover; Email: Schewe.Nina@mh-hannover.de
Other Details (Language Independent)	MetaDataSet:Sample Set : Template metadata sample set
Keywords	Diagnose; diagnosis; Problemliste; Problem
Language used	en
Citeable Identifier	1246.169.1897
Root archetype id	openEHR-EHR-COMPOSITION.report.v1
Diagnose	Diagnose: Document to communicate information to others, commonly in response to a request from another party.
Other Context
Case identification	Case identification: To record case identification details for public health purposes.
Case identifier	Case identifier: The identifier of this case.
Problem/Diagnosis	Problem/Diagnosis: 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. 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'.
Name der Diagnose	Name der Diagnose: Identification of the problem or diagnosis, by name. Coding of the name of the problem or diagnosis with a terminology is preferred, where possible.
Clinical description	Clinical description: Narrative description about the problem or diagnosis. Use to provide background and context, including evolution, episodes or exacerbations, progress and any other relevant details, about the problem or diagnosis.
Date/time of onset	Date/time of onset: Estimated or actual date/time that signs or symptoms of the problem/diagnosis were first observed. Data captured/imported as "Age at onset" should be converted to a date using the subject's date of birth.
Date/time clinically recognised	Date/time clinically recognised: Estimated or actual date/time the diagnosis or problem was recognised by a healthcare professional. 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 clinical recognition" should be converted to a date using the subject's date of birth.
Diagnostische Kategorie	Diagnostische Kategorie: Contextual or temporal qualifier for a specified problem or diagnosis.
Current/Past?	Current/Past?: Category that supports division of problems and diagnoses into Current or Past problem lists. The Current/Past and Active/Inactive data elements have similar clinical impact but represent slightly different semantics. Both are actively used in different clinical settings, but usually not together. If an Active/Inactive qualifier is recorded, then this data element is likely to be redundant. An exception where a condition can be current but inactive is asthma that is not causing acute symptoms. Current Past
Diagnostic category	Diagnostic category: Category of the problem or diagnosis within a specified episode of care and/or local care context. This data element contains a value set commonly used in diagnostic categorisation. In episodic care contexts (commonly secondary care) it is common to categorise/organise diagnoses according to their relationship to the principal diagnosis being addressed during that episode of care. These categories may also be used for clinical coding, reporting and billing purposes. In some countries the diagnostic category may be known as a DRG. In addition, the free text choice permits use of other local value sets, as required. Ursache der Nierenerkrankung Komorbidität
Erstvorstellung Heilberufler	Erstvorstellung Heilberufler: Zur Dokumentation der Erstvorstellung eines Patienten bei einem Heilberufler. Zum Beispiel das Datum der Erstvorstellung bei einem Nephrologen.
Datum der Erstvorstellung	Datum der Erstvorstellung: Das Datum der Erstvorstellung eines Patienten bei einem Heilberufler.
Date/time of resolution	Date/time of resolution: Estimated or actual date/time of resolution or remission for this problem or diagnosis, as determined by a healthcare professional. 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.