TEMPLATE KDS_Prozedur (KDS_Prozedur)

TEMPLATE IDKDS_Prozedur
ConceptKDS_Prozedur
DescriptionZur Erfassung von Informationen über klinische Aktivitäten.
UseZur Darstellung von Prozeduren zu verwenden. Für spezifische Anwendungsfälle mit weiteren Details (z.B. Operationen) wird empfohlen, ein eigenes Template unter Benutzung des Archetypes ACTION.procedure zu modellieren. Für das initiale Laden der im Rahmen der MI-Initiative abgestimmten Kerndatensatzelemente zu verwenden.
MisuseNicht zur Darstellung umfangreicher Details über spezifische Prozeduren, wie z.B. bildgebende Verfahren oder Operationen. Bitte dazu eigene Templates unter Nutzung des Archetypes ACTION.procedure erstellen.
PurposeZur Erfassung von Informationen über klinische Aktivitäten.
References
Authorsname: Louisa Bode; organisation: MHH-Hannover; email: bode.louisa@mh-hannover.de; date: 2020-09-15
Other Details Languagename: Louisa Bode; organisation: MHH-Hannover; email: bode.louisa@mh-hannover.de; date: 2020-09-15
OtherDetails Language Independent{MetaDataSet:Sample Set =Template metadata sample set, PARENT:MD5-CAM-1.0.1=005501C1FA493A4838F5F1121F2870EC, original_language=ISO_639-1::de, MD5-CAM-1.0.1=858c2f2a8ad3f82c8f075dedb43d6c2c, sem_ver=0.1.0}
KeywordsVorgehen; Aktivität; OPS; Operation; Therapie; Behandlung
Language useden
Citeable Identifier1246.169.206
AllOperationalTemplate [rootArchetypeId=openEHR-EHR-COMPOSITION.report.v1, otherContributors=null, tshis=[ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1], code=at0000, itemType=COMPOSITION, level=0, text=KDS_Prozedur, 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=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]/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=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]/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-ACTION.procedure.v1], code=at0000, itemType=ACTION, level=1, text=Procedure, description=A clinical activity carried out for screening, investigative, diagnostic, curative, therapeutic, evaluative or palliative purposes., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ACTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.procedure.v1]/description[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=2, text=Description, 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-ACTION.procedure.v1]/description[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=3, text=Name der Prozedur, description=Identification of the procedure by name., comment=Coding of the specific procedure 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-ACTION.procedure.v1]/description[at0001]/items[at0049], code=at0049, itemType=ELEMENT, level=3, text=Freitextbeschreibung, description=Narrative description about the procedure, as appropriate for the pathway step., comment=For example: description about the performance and findings from the the procedure, the aborted attempt or the cancellation of the procedure., 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-ACTION.procedure.v1]/description[at0001]/items[at0063 and name/value='Körperstelle'], code=at0063, itemType=ELEMENT, level=3, text=Körperstelle, description=Identification of the body site for the procedure., comment=Occurrences for this data element are unbounded to allow for clinical scenarios such as removing multiple skin lesions in different places, but where all of the other attributes are identical. Use this data element to record simple terms or 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 'Procedure detail' SLOT in this archetype. If the anatomical location is included in the 'Procedure 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=Value set: external, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[at0063 and name/value='Seitenlokalisation'], code=at0063, itemType=ELEMENT, level=3, text=Seitenlokalisation, description=Identification of the body site for the procedure., comment=Occurrences for this data element are unbounded to allow for clinical scenarios such as removing multiple skin lesions in different places, but where all of the other attributes are identical. Use this data element to record simple terms or 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 'Procedure detail' SLOT in this archetype. If the anatomical location is included in the 'Procedure 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=Value set: external, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[at0067], code=at0067, itemType=ELEMENT, level=3, text=Kategorie der Prozedur, description=The type of procedure., comment=This pragmatic data element may be used to support organisation within the user interface., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, 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-ACTION.procedure.v1]/description[at0001]/items[at0014], code=at0014, itemType=ELEMENT, level=3, text=Durchführungsabsicht, description=Reason that the activity or care pathway step for the identified procedure was carried out., comment=For example: the reason for the cancellation or suspension of the procedure., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, 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-ACTION.procedure.v1]/description[at0001]/items[at0005], code=at0005, itemType=ELEMENT, level=3, text=Comment, description=Additional narrative about the activity or care pathway step not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null]], templateType=normal]