TEMPLATE Schmerzerfassung_Test (Schmerzerfassung_Test)

TEMPLATE IDSchmerzerfassung_Test
ConceptSchmerzerfassung_Test
DescriptionNot Specified
PurposeNot Specified
References
Authorsname: Bianca Frenzel; organisation: Medizinische Hochschule Hannover - Peter L. Reichertz Institut für Medizinische Informatik; email: frenzel.bianca@mh-hannover.de; date: 2021-08-09
Other Details Languagename: Bianca Frenzel; organisation: Medizinische Hochschule Hannover - Peter L. Reichertz Institut für Medizinische Informatik; email: frenzel.bianca@mh-hannover.de; date: 2021-08-09
OtherDetails Language Independent{PARENT:MD5-CAM-1.0.1=641B268BE8805CEB8DC21AB82C53AB3F, original_language=ISO_639-1::de, MD5-CAM-1.0.1=f16f6698c555530684b87eb2b019cf05, sem_ver=3.0.0}
Language useden
Citeable Identifier1246.169.1905
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  • Present 
  • Absent 
  • Unknown 
  • test 
  • test Nein 
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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. 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If the 'Body site name' data element uses pre-coordinated terms that include laterality, then this data element is redundant., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Left 
  • Right 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.symptom_sign_screening.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0022]/items[openEHR-EHR-CLUSTER.symptom_sign.v1]/items[openEHR-EHR-CLUSTER.anatomical_location.v1]/items[at0023], code=at0023, itemType=ELEMENT, level=8, text=Description, description=Narrative description that can be used to further refine and support the 'Body site name'., comment=For example: adjacent to the vermilion border; a tattoo covers the bottom half of this area., 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-OBSERVATION.symptom_sign_screening.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0022]/items[openEHR-EHR-CLUSTER.symptom_sign.v1]/items[at0002], code=at0002, itemType=ELEMENT, level=7, text=Dauer der Schmerzen, description=Narrative description about the reported symptom or sign., comment=null, 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-OBSERVATION.symptom_sign_screening.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0022]/items[openEHR-EHR-CLUSTER.symptom_sign.v1]/items[at0026 and name/value='Schmerzstärke'], code=at0026, itemType=ELEMENT, level=7, text=Schmerzstärke, description=Numerical rating scale representing the overall severity of the symptom or sign., comment=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. 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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., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=0..10 , extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.symptom_sign_screening.v0]/protocol[at0007], code=at0007, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=2, text=Protocol, 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-OBSERVATION.symptom_sign_screening.v0]/protocol[at0007]/items[openEHR-EHR-CLUSTER.exclusion_exam.v1], code=at0000, itemType=CLUSTER, level=3, text=Exclusion of examination, description=Positive statement to record that a physical examination or clinical test was not performed., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.symptom_sign_screening.v0]/protocol[at0007]/items[openEHR-EHR-CLUSTER.exclusion_exam.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=4, text=Examination not done, description=Statement to explicity record that the examination was not performed., comment=Record as True if the examination was not performed., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.symptom_sign_screening.v0]/protocol[at0007]/items[openEHR-EHR-CLUSTER.exclusion_exam.v1]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Reason, description=Reason for the 'not done' statement., comment=For example: patient factors, equipment factors, time constraints., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null]], templateType=normal]