TEMPLATE GECCO_Dokumentation_HD (GECCO_Dokumentation_HD)

TEMPLATE IDGECCO_Dokumentation_HD
ConceptGECCO_Dokumentation_HD
DescriptionNot Specified
PurposeNot Specified
References
OtherDetails Language Independent{PARENT:MD5-CAM-1.0.1=CD5C7EF669BF9300C4CE104319009B71, original_language=ISO_639-1::de, MD5-CAM-1.0.1=0375174383de7ef663139a6f8861d8b8, sem_ver=10.0.0, build_uid=4a434676-179a-4fcd-a26c-5793b9eee226}
KeywordsGECCO; NUM; FoDaPl
Language useden
Citeable Identifier1246.169.2322
AllOperationalTemplate [rootArchetypeId=openEHR-EHR-COMPOSITION.registereintrag.v1, otherContributors=Erenik Krasniqi, tshis=[ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1], code=at0000, itemType=COMPOSITION, level=0, text=GECCO_Dokumentation_HD, description=Generic compilation to represent a data set for research purposes., 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=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content, code=null, itemType=EXPOSED_RM_ATTRIBUTE, level=1, text=content, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EXPOSED_REFERENCE_MODEL_ATTRIBUTE within , 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.registereintrag.v1]/context/other_context[at0001]/items[at0004], code=at0004, itemType=ELEMENT, level=2, text=Status, description=Status of the supplied data for the register entry. Note: This is not the status of individual components., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • registered 
  • preliminary 
  • final 
  • amended 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Vorerkrankungen'], code=at0000, itemType=SECTION, level=1, text=Vorerkrankungen, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Vorerkrankungen']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1], code=at0000, itemType=EVALUATION, level=2, text=Vorliegende Diagnose, description=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., comment=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'., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Vorerkrankungen']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, 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.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Vorerkrankungen']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Problem/Diagnosis name, description=Identification of the problem or diagnosis, by name., comment=Coding of the name of the problem or diagnosis 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=Terminology: http://snomed.info/sct
  • Asthma (disorder) 
  • Chronic obstructive lung disease (disorder) 
  • Fibrosis of lung (disorder) 
  • Pulmonary hypertension (disorder) 
  • Extreme obesity with alveolar hypoventilation (disorder) 418112009 
  • Sleep apnea (disorder) 
  • Obstructive sleep apnea syndrome (disorder) 
  • Cystic fibrosis (disorder) 
  • Hypertensive disorder, systemic arterial (disorder) 
  • |History of clinical finding in subject (situation)|:|Associated finding (attribute)|=|Myocardial infarction (disorder)| 
  • Cardiac arrhythmia (disorder) 
  • Heart failure (disorder) 
  • Peripheral arterial occlusive disease (disorder) 
  • |Past history of procedure (situation)|:|Associated procedure (attribute)|=|Heart revascularization (procedure)| 
  • Coronary arteriosclerosis (disorder) 
  • Carotid artery stenosis (disorder) 
  • Steatosis of liver (disorder) 
  • Cirrhosis of liver (disorder) 
  • Chronic viral hepatitis (disorder) 
  • Autoimmune liver disease (disorder) 
  • Inflammatory bowel disease (disorder) 
  • Rheumatoid arthritis (disorder) 
  • Disorder of connective tissue (disorder) 
  • Vasculitis (disorder) 
  • Congenital immunodeficiency disease (disorder) 
  • Human immunodeficiency virus infection 
  • History of being a tissue or organ recipient 
  • Diabetes mellitus type 1 (disorder) 
  • Diabetes mellitus type 2 (disorder) 
  • Insulin treated type 2 diabetes mellitus (disorder) 
  • Secondary diabetes mellitus (disorder) 
  • Chronic nervous system disorder (disorder) 
  • Mental disorder (disorder) 
  • Anxiety disorder (disorder) 
  • Depressive disorder (disorder) 
  • Psychotic disorder (disorder) 
  • Parkinson's disease (disorder) 
  • Dementia (disorder) 
  • Multiple sclerosis (disorder) 
  • Combined disorder of muscle AND peripheral nerve (disorder) 
  • Epilepsy (disorder) 
  • Migraine (disorder) 
  • History of cerebrovascular accident with residual deficit (situation) 
  • History of cerebrovascular accident without residual deficits (situation 
  • Chronic kidney disease stage 5 on dialysis (disorder) 
  • Chronic kidney disease stage 1 (disorder) 
  • Chronic kidney disease stage 2 (disorder) 
  • Chronic kidney disease stage 3 (disorder) 
  • Chronic kidney disease stage 4 (disorder) 
  • Chronic kidney disease stage 5 (disorder) 
  • Chronic kidney disease (disorder) 
  • Malignant neoplastic disease 
  • Gastrointestinal ulcer 
  • Thrombosis (disorder) 
  • Embolism (disorder) 
  • Infectious disease of lung (disorder) 
  • Infectious agent in bloodstream (finding) 
  • Venous thrombosis (disorder) 
  • Pulmonary embolism (disorder) 
  • Cerebrovascular accident (disorder) 
  • Myocardial infarction (disorder) 
  • Acute renal failure syndrome (disorder) 
  • Disease caused by Severe acute respiratory syndrome coronavirus 2 (disorder) 
  • Autoimmune disease (disorder) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Vorerkrankungen']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.anatomical_location.v1], code=at0000, itemType=CLUSTER, level=4, text=Anatomical location, description=A physical site on or within the human body., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Vorerkrankungen']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.anatomical_location.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=5, text=Body site name, description=Identification of a single physical site either on, or within, the human body., comment=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., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: http://snomed.info/sct
  • Entire heart (body structure) 
  • Entire lung (body structure) 
  • Entire liver (body structure) 
  • Entire kidney (body structure) 
  • Entire pancreas (body structure) 
  • Intestinal structure (body structure) 
  • Entire small intestine (body structure) 
  • Entire large intestine (body structure) 
  • Skin part (body structure) 
  • Entire cornea (body structure) 
  • Ear ossicle structure (body structure) 
  • Entire heart valve (body structure) 
  • Blood vessel part (body structure) 
  • Cerebral meninges structure (body structure) 
  • Bone (tissue) structure (body structure) 
  • Cartilage tissue (body structure) 
  • Tendon structure (body structure) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Vorerkrankungen']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.anatomical_location.v1]/items[at0065], code=at0065, itemType=ELEMENT, level=5, text=Specific site, description=Additional detail using a specific region or a point on, or within, the identified body site., comment=Use to increase precision of identification of the body site, if required. For example, the upper right quadrant or McBurney's point on the abdominal wall or interphalangeal joint of the great toe. If the 'Body site name' data element uses pre-coordinated terms that include the specific site, then this data element is redundant., 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.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Vorerkrankungen']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.anatomical_location.v1]/items[at0002], code=at0002, itemType=ELEMENT, level=5, text=Laterality, description=The side of the body on which the identified body site is located., comment=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., 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.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Vorerkrankungen']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0078], code=at0078, itemType=ELEMENT, level=4, text=Cause, description=A cause, set of causes, or manner of causation of the problem or diagnosis., comment=Also known as 'aetiology' or 'etiology'. Coding with an external terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Vorerkrankungen']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0077], code=at0077, itemType=ELEMENT, level=4, text=Date/time of onset, description=Estimated or actual date/time that signs or symptoms of the problem/diagnosis were first observed., comment=Data captured/imported as "Age at onset" should be converted to a date using the subject's date of birth., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Vorerkrankungen']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0005], code=at0005, itemType=ELEMENT, level=4, text=Severity, description=An assessment of the overall severity of the problem or diagnosis., comment=If severity is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant. Note: more specific grading of severity can be recorded using the Specific details SLOT., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Coded Text
    • Mild 
    • Moderate 
    • Severe 
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Vorerkrankungen']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0030], code=at0030, itemType=ELEMENT, level=4, text=Date/time of resolution, description=Estimated or actual date/time of resolution or remission for this problem or diagnosis, as determined by a healthcare professional., comment=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., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Vorerkrankungen']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0069], code=at0069, itemType=ELEMENT, level=4, text=Comment, description=Additional narrative about the problem or diagnosis 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], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Vorerkrankungen']/items[openEHR-EHR-EVALUATION.exclusion_specific.v1], code=at0000, itemType=EVALUATION, level=2, text=Ausgeschlossene Diagnose, description=A statement of exclusion of a specific Problem/diagnosis, Family history, Medication, Procedure, Adverse reaction or other clinical item that is either not currently present, or have not been present in the past., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Vorerkrankungen']/items[openEHR-EHR-EVALUATION.exclusion_specific.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, 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.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Vorerkrankungen']/items[openEHR-EHR-EVALUATION.exclusion_specific.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Exclusion statement, description=A qualifying statement about the exclusion of a Problem/diagnosis, Family history, Medication, Procedure, Adverse reaction or other clinical item., comment=This statement is to be used in conjunction with the 'Excluded concept' data element. For example: this data element can support recording general statements such as "No known history of ..." where the 'Excluded concept' identifies the specific problem, diagnosis, substance, procedure or medication. If the 'Excluded concept' data element is used to record a precoordinated term such as 'No family history of diabetes', this element is redundant., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: http://snomed.info/sct
  • Known absent (qualifier value) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Vorerkrankungen']/items[openEHR-EHR-EVALUATION.exclusion_specific.v1]/data[at0001]/items[at0003], code=at0003, itemType=ELEMENT, level=4, text=Problem/Diagnose, description=The problem or diagnosis to which the 'Exclusion statement' applies. For example: 'Diabetes', 'COPD' or 'Asthma'., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: http://snomed.info/sct
  • Asthma (disorder) 
  • Chronic obstructive lung disease (disorder) 
  • Fibrosis of lung (disorder) 
  • Pulmonary hypertension (disorder) 
  • Extreme obesity with alveolar hypoventilation (disorder) 418112009 
  • Sleep apnea (disorder) 
  • Obstructive sleep apnea syndrome (disorder) 
  • Cystic fibrosis (disorder) 
  • Hypertensive disorder, systemic arterial (disorder) 
  • |History of clinical finding in subject (situation)|:|Associated finding (attribute)|=|Myocardial infarction (disorder)| 
  • Cardiac arrhythmia (disorder) 
  • Heart failure (disorder) 
  • Peripheral arterial occlusive disease (disorder) 
  • |Past history of procedure (situation)|:|Associated procedure (attribute)|=|Heart revascularization (procedure)| 
  • Coronary arteriosclerosis (disorder) 
  • Carotid artery stenosis (disorder) 
  • Steatosis of liver (disorder) 
  • Cirrhosis of liver (disorder) 
  • Chronic viral hepatitis (disorder) 
  • Autoimmune liver disease (disorder) 
  • Inflammatory bowel disease (disorder) 
  • Rheumatoid arthritis (disorder) 
  • Disorder of connective tissue (disorder) 
  • Vasculitis (disorder) 
  • Congenital immunodeficiency disease (disorder) 
  • Human immunodeficiency virus infection 
  • History of being a tissue or organ recipient 
  • Diabetes mellitus type 1 (disorder) 
  • Diabetes mellitus type 2 (disorder) 
  • Insulin treated type 2 diabetes mellitus (disorder) 
  • Secondary diabetes mellitus (disorder) 
  • Chronic nervous system disorder (disorder) 
  • Mental disorder (disorder) 
  • Anxiety disorder (disorder) 
  • Depressive disorder (disorder) 
  • Psychotic disorder (disorder) 
  • Parkinson's disease (disorder) 
  • Dementia (disorder) 
  • Multiple sclerosis (disorder) 
  • Combined disorder of muscle AND peripheral nerve (disorder) 
  • Epilepsy (disorder) 
  • Migraine (disorder) 
  • History of cerebrovascular accident with residual deficit (situation) 
  • History of cerebrovascular accident without residual deficits (situation 
  • Chronic kidney disease stage 5 on dialysis (disorder) 
  • Chronic kidney disease stage 1 (disorder) 
  • Chronic kidney disease stage 2 (disorder) 
  • Chronic kidney disease stage 3 (disorder) 
  • Chronic kidney disease stage 4 (disorder) 
  • Chronic kidney disease stage 5 (disorder) 
  • Chronic kidney disease (disorder) 
  • Malignant neoplastic disease 
  • Gastrointestinal ulcer 
  • Thrombosis (disorder) 
  • Embolism (disorder) 
  • Infectious disease of lung (disorder) 
  • Infectious agent in bloodstream (finding) 
  • Venous thrombosis (disorder) 
  • Pulmonary embolism (disorder) 
  • Cerebrovascular accident (disorder) 
  • Myocardial infarction (disorder) 
  • Acute renal failure syndrome (disorder) 
  • Disease caused by Severe acute respiratory syndrome coronavirus 2 (disorder) 
  • Autoimmune disease (disorder) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Vorerkrankungen']/items[openEHR-EHR-EVALUATION.exclusion_specific.v1]/data[at0001]/items[at0012], code=at0012, itemType=ELEMENT, level=4, text=Name der Körperstelle, description=Additional narrative about the Specific Exclusion not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: http://snomed.info/sct
  • Entire heart (body structure) 
  • Entire lung (body structure) 
  • Entire liver (body structure) 
  • Entire kidney (body structure) 
  • Entire pancreas (body structure) 
  • Entire small intestine (body structure) 
  • Entire large intestine (body structure) 
  • Skin part (body structure) 
  • Entire cornea (body structure) 
  • Ear ossicle structure (body structure) 
  • Entire heart valve (body structure) 
  • Blood vessel part (body structure) 
  • Cerebral meninges structure (body structure) 
  • Bone (tissue) structure (body structure) 
  • Cartilage tissue (body structure) 
  • Tendon structure (body structure) 
  • Intestinal structure (body structure) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Vorerkrankungen']/items[openEHR-EHR-EVALUATION.absence.v2], code=at0000, itemType=EVALUATION, level=2, text=Unbekannte Diagnose, description=Statement that specified health information is not available for inclusion in the health record or extract at the time of recording., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Vorerkrankungen']/items[openEHR-EHR-EVALUATION.absence.v2]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, 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.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Vorerkrankungen']/items[openEHR-EHR-EVALUATION.absence.v2]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Unbekannte Diagnose, description=Positive statement that no information is available., comment=For example: "No information available about adverse reactions"; No information available about problems or diagnoses"; "No information available about previous procedures performed"; or "No information available about medications used"., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: http://snomed.info/sct
  • Asthma (disorder) 
  • Chronic obstructive lung disease (disorder) 
  • Fibrosis of lung (disorder) 
  • Pulmonary hypertension (disorder) 
  • Extreme obesity with alveolar hypoventilation (disorder) 418112009 
  • Sleep apnea (disorder) 
  • Obstructive sleep apnea syndrome (disorder) 
  • Cystic fibrosis (disorder) 
  • Hypertensive disorder, systemic arterial (disorder) 
  • |History of clinical finding in subject (situation)|:|Associated finding (attribute)|=|Myocardial infarction (disorder)| 
  • Cardiac arrhythmia (disorder) 
  • Heart failure (disorder) 
  • Peripheral arterial occlusive disease (disorder) 
  • |Past history of procedure (situation)|:|Associated procedure (attribute)|=|Heart revascularization (procedure)| 
  • Coronary arteriosclerosis (disorder) 
  • Carotid artery stenosis (disorder) 
  • Steatosis of liver (disorder) 
  • Cirrhosis of liver (disorder) 
  • Chronic viral hepatitis (disorder) 
  • Autoimmune liver disease (disorder) 
  • Inflammatory bowel disease (disorder) 
  • Rheumatoid arthritis (disorder) 
  • Disorder of connective tissue (disorder) 
  • Vasculitis (disorder) 
  • Congenital immunodeficiency disease (disorder) 
  • Human immunodeficiency virus infection 
  • History of being a tissue or organ recipient 
  • Diabetes mellitus type 1 (disorder) 
  • Diabetes mellitus type 2 (disorder) 
  • Insulin treated type 2 diabetes mellitus (disorder) 
  • Secondary diabetes mellitus (disorder) 
  • Chronic nervous system disorder (disorder) 
  • Mental disorder (disorder) 
  • Anxiety disorder (disorder) 
  • Depressive disorder (disorder) 
  • Psychotic disorder (disorder) 
  • Parkinson's disease (disorder) 
  • Dementia (disorder) 
  • Multiple sclerosis (disorder) 
  • Combined disorder of muscle AND peripheral nerve (disorder) 
  • Epilepsy (disorder) 
  • Migraine (disorder) 
  • History of cerebrovascular accident with residual deficit (situation) 
  • History of cerebrovascular accident without residual deficits (situation 
  • Chronic kidney disease stage 5 on dialysis (disorder) 
  • Chronic kidney disease stage 1 (disorder) 
  • Chronic kidney disease stage 2 (disorder) 
  • Chronic kidney disease stage 3 (disorder) 
  • Chronic kidney disease stage 4 (disorder) 
  • Chronic kidney disease stage 5 (disorder) 
  • Chronic kidney disease (disorder) 
  • Malignant neoplastic disease 
  • Gastrointestinal ulcer 
  • Thrombosis (disorder) 
  • Embolism (disorder) 
  • Infectious disease of lung (disorder) 
  • Infectious agent in bloodstream (finding) 
  • Venous thrombosis (disorder) 
  • Pulmonary embolism (disorder) 
  • Cerebrovascular accident (disorder) 
  • Myocardial infarction (disorder) 
  • Acute renal failure syndrome (disorder) 
  • Disease caused by Severe acute respiratory syndrome coronavirus 2 (disorder) 
  • Autoimmune disease (disorder) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Vorerkrankungen']/items[openEHR-EHR-EVALUATION.absence.v2]/data[at0001]/items[at0005], code=at0005, itemType=ELEMENT, level=4, text=Aussage über die fehlende Information, description=Description of the reason why there is no information available., comment=For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: http://snomed.info/sct
  • Unknown (qualifier value) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Symptome'], code=at0000, itemType=SECTION, level=1, text=Symptome, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Symptome']/items[openEHR-EHR-OBSERVATION.symptom_sign.v0], code=at0000, itemType=OBSERVATION, level=2, text=Vorliegendes Symptom, description=Reported observation of a physical or mental disturbance in an individual., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Symptome']/items[openEHR-EHR-OBSERVATION.symptom_sign.v0]/data[at0190], code=at0190, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, 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.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Symptome']/items[openEHR-EHR-OBSERVATION.symptom_sign.v0]/data[at0190]/events[at0191], code=at0191, itemType=EVENT, level=4, text=Any event, description=Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Symptome']/items[openEHR-EHR-OBSERVATION.symptom_sign.v0]/data[at0190]/events[at0191]/data[at0192], code=at0192, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=5, text=Data, 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.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Symptome']/items[openEHR-EHR-OBSERVATION.symptom_sign.v0]/data[at0190]/events[at0191]/data[at0192]/items[at0001], code=at0001, itemType=ELEMENT, level=6, text=Symptom/Sign name, description=The name of the reported symptom or sign., comment=Symptom name should be coded with a terminology, where possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: http://snomed.info/sct
  • Abdominal pain (finding) 
  • Asymptomatic (finding) 
  • Bleeding (finding) 
  • Chest pain (finding) 
  • Chill (finding) 
  • Conjunctivitis (disorder) 
  • Cough (finding) 
  • Diarrhea (finding) 
  • Disturbance of consciousness (finding) 
  • Dyspnea (finding) 
  • Eruption of skin (disorder) 
  • Fatigue (finding) 
  • Feeling feverish (finding) 
  • Fever (finding) 
  • Headache (finding) 
  • Hemoptysis (finding) 
  • Indrawing of ribs during respiration (finding) 
  • Joint pain (finding) 
  • Loss of appetite (finding) 
  • Loss of sense of smell (finding) 
  • Loss of taste (finding) 
  • Lymphadenopathy (disorder) 
  • Malaise (finding) 
  • Muscle pain (finding) 
  • Nasal congestion (finding) 
  • Nasal discharge (finding) 
  • Nausea (finding) 
  • Pain in throat (finding) 
  • Rigor (finding) 
  • Seizure (finding) 
  • Skin ulcer (disorder) 
  • Unable to walk (finding) 
  • Vomiting (disorder) 
  • Wheezing (finding) 
  • Fever greater than 100.4 Fahrenheit / 38° Celsius (finding) 
  • Asthenia (finding) 
  • Pain (finding) 
  • Productive cough (finding) 
  • Dry cough (finding) 
  • Clouded consciousness (finding) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Symptome']/items[openEHR-EHR-OBSERVATION.symptom_sign.v0]/data[at0190]/events[at0191]/data[at0192]/items[at0151], code=at0151, itemType=ELEMENT, level=6, text=Body site, description=Simple body site where the symptom or sign was reported., comment=Occurrences of this data element are set to 0..* to allow multiple body sites to be separated out in a template if desired. This allows for representation of clinical scenarios where a symptom or sign needs to be recorded in multiple locations or identifying both the originating and distal site in pain radiation, but where all of the other attributes such as impact and duration are identical. If the requirements for recording the body site 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 Detailed anatomical location' SLOT in this archetype. If the anatomical location is included in the Symptom name via precoordinated codes, this data element becomes redundant. If the anatomical location is recorded using the 'Structured body site' SLOT, then use of this data element is not allowed - record only the simple 'Body site' OR 'Structured body site', but not both., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Symptome']/items[openEHR-EHR-OBSERVATION.symptom_sign.v0]/data[at0190]/events[at0191]/data[at0192]/items[at0152], code=at0152, itemType=ELEMENT, level=6, text=Episode onset, description=The onset for this episode of the symptom or sign., comment=While partial dates are permitted, the exact date and time of onset can be recorded, if appropriate. If this symptom or sign is experienced for the first time or is a re-occurrence, this date is used to represent the onset of this episode. If this symptom or sign is ongoing, this data element may be redundant if it has been recorded previously., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Symptome']/items[openEHR-EHR-OBSERVATION.symptom_sign.v0]/data[at0190]/events[at0191]/data[at0192]/items[at0021], code=at0021, itemType=ELEMENT, level=6, text=Severity category, description=Category representing the overall severity of the symptom or sign., comment=Defining values such as mild, moderate or severe in such a way that is applicable to multiple symptoms or signs plus allows multiple users to interpret and record them consistently is not easy. Some organisations extend the value set further with inclusion of additional values such as 'Trivial' and 'Very severe', and/or 'Mild-Moderate' and 'Moderate-Severe', adds to the definitional difficulty and may also worsen inter-recorder reliability issues. Use of 'Life-threatening' and 'Fatal' is also often considered as part of this value set, although from a pure point of view it may actually reflect an outcome rather than a severity. In view of the above, keeping to a well-defined but smaller list is preferred and so the mild/moderate/severe value set is offered, however the choice of other text allows for other value sets to be included at this data element in a template. Note: more specific grading of severity can be recorded using the 'Specific details' SLOT., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: http://snomed.info/sct
  • Mild (qualifier value) 
  • Moderate (severity modifier) (qualifier value) 
  • Severe (severity modifier) (qualifier value) 
  • Life threatening severity (qualifier value) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Symptome']/items[openEHR-EHR-OBSERVATION.symptom_sign.v0]/data[at0190]/events[at0191]/data[at0192]/items[at0161], code=at0161, itemType=ELEMENT, level=6, text=Resolution date/time, description=The timing of the cessation of this episode of the symptom or sign., comment=If 'Date/time of onset' and 'Duration' are used in systems, this data element may be calculated, or alternatively, considered redundant. While partial dates are permitted, the exact date and time of resolution can be recorded, if appropriate., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Symptome']/items[openEHR-EHR-EVALUATION.exclusion_specific.v1], code=at0000, itemType=EVALUATION, level=2, text=Ausgeschlossenes Symptom, description=A statement of exclusion of a specific Problem/diagnosis, Family history, Medication, Procedure, Adverse reaction or other clinical item that is either not currently present, or have not been present in the past., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Symptome']/items[openEHR-EHR-EVALUATION.exclusion_specific.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, 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.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Symptome']/items[openEHR-EHR-EVALUATION.exclusion_specific.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Exclusion statement, description=A qualifying statement about the exclusion of a Problem/diagnosis, Family history, Medication, Procedure, Adverse reaction or other clinical item., comment=This statement is to be used in conjunction with the 'Excluded concept' data element. For example: this data element can support recording general statements such as "No known history of ..." where the 'Excluded concept' identifies the specific problem, diagnosis, substance, procedure or medication. If the 'Excluded concept' data element is used to record a precoordinated term such as 'No family history of diabetes', this element is redundant., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: http://snomed.info/sct
  • Known absent (qualifier value) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Symptome']/items[openEHR-EHR-EVALUATION.exclusion_specific.v1]/data[at0001]/items[at0003], code=at0003, itemType=ELEMENT, level=4, text=Problem/Diagnose, description=The problem or diagnosis to which the 'Exclusion statement' applies. For example: 'Diabetes', 'COPD' or 'Asthma'., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: http://snomed.info/sct
  • Abdominal pain (finding) 
  • Asymptomatic (finding) 
  • Bleeding (finding) 
  • Chest pain (finding) 
  • Chill (finding) 
  • Conjunctivitis (disorder) 
  • Cough (finding) 
  • Diarrhea (finding) 
  • Disturbance of consciousness (finding) 
  • Dyspnea (finding) 
  • Eruption of skin (disorder) 
  • Fatigue (finding) 
  • Feeling feverish (finding) 
  • Fever (finding) 
  • Headache (finding) 
  • Hemoptysis (finding) 
  • Indrawing of ribs during respiration (finding) 
  • Joint pain (finding) 
  • Loss of appetite (finding) 
  • Loss of sense of smell (finding) 
  • Loss of taste (finding) 
  • Lymphadenopathy (disorder) 
  • Malaise (finding) 
  • Muscle pain (finding) 
  • Nasal congestion (finding) 
  • Nasal discharge (finding) 
  • Nausea (finding) 
  • Pain in throat (finding) 
  • Rigor (finding) 
  • Seizure (finding) 
  • Skin ulcer (disorder) 
  • Unable to walk (finding) 
  • Vomiting (disorder) 
  • Wheezing (finding) 
  • Fever greater than 100.4 Fahrenheit / 38° Celsius (finding) 
  • Asthenia (finding) 
  • Pain (finding) 
  • Productive cough (finding) 
  • Dry cough (finding) 
  • Clouded consciousness (finding) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Symptome']/items[openEHR-EHR-EVALUATION.absence.v2], code=at0000, itemType=EVALUATION, level=2, text=Unbekanntes Symptom, description=Statement that specified health information is not available for inclusion in the health record or extract at the time of recording., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Symptome']/items[openEHR-EHR-EVALUATION.absence.v2]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, 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.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Symptome']/items[openEHR-EHR-EVALUATION.absence.v2]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Unbekanntes Symptom, description=Positive statement that no information is available., comment=For example: "No information available about adverse reactions"; No information available about problems or diagnoses"; "No information available about previous procedures performed"; or "No information available about medications used"., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: http://snomed.info/sct
  • Abdominal pain (finding) 
  • Asymptomatic (finding) 
  • Bleeding (finding) 
  • Chest pain (finding) 
  • Chill (finding) 
  • Conjunctivitis (disorder) 
  • Cough (finding) 
  • Diarrhea (finding) 
  • Disturbance of consciousness (finding) 
  • Dyspnea (finding) 
  • Eruption of skin (disorder) 
  • Fatigue (finding) 
  • Feeling feverish (finding) 
  • Fever (finding) 
  • Headache (finding) 
  • Hemoptysis (finding) 
  • Indrawing of ribs during respiration (finding) 
  • Joint pain (finding) 
  • Loss of appetite (finding) 
  • Loss of sense of smell (finding) 
  • Loss of taste (finding) 
  • Lymphadenopathy (disorder) 
  • Malaise (finding) 
  • Muscle pain (finding) 
  • Nasal congestion (finding) 
  • Nasal discharge (finding) 
  • Nausea (finding) 
  • Pain in throat (finding) 
  • Rigor (finding) 
  • Seizure (finding) 
  • Skin ulcer (disorder) 
  • Unable to walk (finding) 
  • Vomiting (disorder) 
  • Wheezing (finding) 
  • Fever greater than 100.4 Fahrenheit / 38° Celsius (finding) 
  • Asthenia (finding) 
  • Pain (finding) 
  • Productive cough (finding) 
  • Dry cough (finding) 
  • Clouded consciousness (finding) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Symptome']/items[openEHR-EHR-EVALUATION.absence.v2]/data[at0001]/items[at0005], code=at0005, itemType=ELEMENT, level=4, text=Aussage über die fehlende Information, description=Description of the reason why there is no information available., comment=For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: http://snomed.info/sct
  • Unknown (qualifier value) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Prozeduren'], code=at0000, itemType=SECTION, level=1, text=Prozeduren, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Prozeduren']/items[openEHR-EHR-ACTION.procedure.v1], code=at0000, itemType=ACTION, level=2, text=Procedure, description=A clinical activity carried out for screening, investigative, diagnostic, curative, therapeutic, evaluative or palliative purposes., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ACTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Prozeduren']/items[openEHR-EHR-ACTION.procedure.v1]/description[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, 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.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Prozeduren']/items[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Procedure name, 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=Terminology: http://snomed.info/sct
  • Dialysis procedure (procedure) 
  • Apheresis (procedure) 
  • Placing subject in prone position (procedure) 
  • Extracorporeal membrane oxygenation (procedure) 
  • Oxygen administration by nasal cannula (procedure) 
  • Noninvasive ventilation (procedure) 
  • Artificial respiration (procedure) 
  • Plain radiography 
  • Computerized axial tomography (procedure) 
  • Diagnostic ultrasonography (procedure) 
  • Therapeutic procedure (procedure) 
  • Respiratory therapy (procedure) 
  • Noninvasive ventilation (procedure) 
  • Oxygen administration by nasal cannula (procedure) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Prozeduren']/items[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[at0070], code=at0070, itemType=ELEMENT, level=4, text=Indication, description=The clinical or process-related reason for the procedure., comment=Coding of the indication with a terminology is preferred, where possible. This data element allows multiple occurrences. For example: 'Failed bowel preparation' or 'Bowel cancer screening'., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Prozeduren']/items[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[at0063], code=at0063, itemType=ELEMENT, level=4, text=Body site, 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=Terminology: http://snomed.info/sct
  • Lung structure (body structure) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Prozeduren']/items[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[openEHR-EHR-CLUSTER.device.v1], code=at0000, itemType=CLUSTER, level=4, text=Medical device, description=An instrument, apparatus, implant, material or similar, used in the provision of healthcare. In this context, a medical device includes a broad range of devices which act through a variety of physical, mechanical, thermal or similar means but specifically excludes devices which act through medicinal means such as pharmacological, metabolic or immunological methods. The scope is inclusive of disposable devices as well as durable or persisting devices that require tracking, maintenance activities or regular calibration, recognising that each type of device has specific data recording requirements., 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.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Prozeduren']/items[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[openEHR-EHR-CLUSTER.device.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=5, text=Device name, description=Identification of the medical device, preferably by a common name, a formal fully descriptive name or, if required, by class or category of device., comment=This data element will capture the term, phrase or category used in clinical practice. For example: <brand name><machine> (XYZ Audiometer); <size> <brand name> <intravenous catheter> (14G Jelco IV catheter); or <brand name/type> <implant>. Coding with a terminology is desirable, where possible, although this may be local and depending on local supplies available., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: http://snomed.info/sct
  • Tracheostomy tube, device (physical object) 
  • Endotracheal tube, device (physical object) 
  • High flow oxygen nasal cannula (physical object) 
  • Endotracheal tube, device (physical object) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Prozeduren']/items[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[at0067], code=at0067, itemType=ELEMENT, level=4, text=Procedure type, description=The type of procedure., comment=This pragmatic data element may be used to support organisation within the user interface., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: http://snomed.info/sct
  • Diagnostic procedure 
  • Imaging 
  • Surgical procedure 
  • Administration of medicine 
  • Therapeutic procedure (procedure) 
  • Other category 
  • Procedures relating to positioning and support (procedure) 
  • Respiratory therapy (procedure) 
  • Noninvasive ventilation (procedure) 
  • Oxygen administration by nasal cannula (procedure) 
  • Artificial respiration (procedure) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Prozeduren']/items[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[at0014], code=at0014, itemType=ELEMENT, level=4, 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=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Prozeduren']/items[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[at0005], code=at0005, itemType=ELEMENT, level=4, 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], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Prozeduren']/items[openEHR-EHR-EVALUATION.exclusion_specific.v1], code=at0000, itemType=EVALUATION, level=2, text=Nicht durchgeführte Prozedur, description=A statement of exclusion of a specific Problem/diagnosis, Family history, Medication, Procedure, Adverse reaction or other clinical item that is either not currently present, or have not been present in the past., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Prozeduren']/items[openEHR-EHR-EVALUATION.exclusion_specific.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, 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.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Prozeduren']/items[openEHR-EHR-EVALUATION.exclusion_specific.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Exclusion statement, description=A qualifying statement about the exclusion of a Problem/diagnosis, Family history, Medication, Procedure, Adverse reaction or other clinical item., comment=This statement is to be used in conjunction with the 'Excluded concept' data element. For example: this data element can support recording general statements such as "No known history of ..." where the 'Excluded concept' identifies the specific problem, diagnosis, substance, procedure or medication. If the 'Excluded concept' data element is used to record a precoordinated term such as 'No family history of diabetes', this element is redundant., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • not done
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Prozeduren']/items[openEHR-EHR-EVALUATION.exclusion_specific.v1]/data[at0001]/items[at0003], code=at0003, itemType=ELEMENT, level=4, text=Eingriff, description=The Procedure to which the 'Exclusion statement' applies. For example: 'Heart surgery' or 'Appendectomy' or 'Hip replacement'., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: http://snomed.info/sct
  • Dialysis procedure (procedure) 
  • Apheresis (procedure) 
  • Placing subject in prone position (procedure) 
  • Extracorporeal membrane oxygenation (procedure) 
  • Oxygen administration by nasal cannula (procedure) 
  • Noninvasive ventilation (procedure) 
  • Artificial respiration (procedure) 
  • Plain radiography 
  • Computerized axial tomography (procedure) 
  • Diagnostic ultrasonography (procedure) 
  • Therapeutic procedure (procedure) 
  • Respiratory therapy (procedure) 
  • Noninvasive ventilation (procedure) 
  • Oxygen administration by nasal cannula (procedure) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Prozeduren']/items[openEHR-EHR-EVALUATION.absence.v2], code=at0000, itemType=EVALUATION, level=2, text=Unbekannte Prozedur, description=Statement that specified health information is not available for inclusion in the health record or extract at the time of recording., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Prozeduren']/items[openEHR-EHR-EVALUATION.absence.v2]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, 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.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Prozeduren']/items[openEHR-EHR-EVALUATION.absence.v2]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Unbekannte Prozedur, description=Positive statement that no information is available., comment=For example: "No information available about adverse reactions"; No information available about problems or diagnoses"; "No information available about previous procedures performed"; or "No information available about medications used"., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: http://snomed.info/sct
  • Dialysis procedure (procedure) 
  • Apheresis (procedure) 
  • Placing subject in prone position (procedure) 
  • Extracorporeal membrane oxygenation (procedure) 
  • Oxygen administration by nasal cannula (procedure) 
  • Noninvasive ventilation (procedure) 
  • Artificial respiration (procedure) 
  • Plain radiography 
  • Computerized axial tomography (procedure) 
  • Diagnostic ultrasonography (procedure) 
  • Therapeutic procedure (procedure) 
  • Respiratory therapy (procedure) 
  • Noninvasive ventilation (procedure) 
  • Oxygen administration by nasal cannula (procedure) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Prozeduren']/items[openEHR-EHR-EVALUATION.absence.v2]/data[at0001]/items[at0005], code=at0005, itemType=ELEMENT, level=4, text=Aussage über die fehlende Information, description=Description of the reason why there is no information available., comment=For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • unknown
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Raucherverhalten'], code=at0000, itemType=SECTION, level=1, text=Raucherverhalten, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Raucherverhalten']/items[openEHR-EHR-EVALUATION.tobacco_smoking_summary.v1], code=at0000, itemType=EVALUATION, level=2, text=Raucherstatus, description=Summary or persistent information about the tobacco smoking habits of an individual., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Raucherverhalten']/items[openEHR-EHR-EVALUATION.tobacco_smoking_summary.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, 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.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Raucherverhalten']/items[openEHR-EHR-EVALUATION.tobacco_smoking_summary.v1]/data[at0001]/items[at0089], code=at0089, itemType=ELEMENT, level=4, text=Overall status, description=Statement about current smoking behaviour for all types of tobacco., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Never smoked 
  • Current smoker 
  • Former smoker 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Raucherverhalten']/items[openEHR-EHR-EVALUATION.tobacco_smoking_summary.v1]/data[at0001]/items[at0043], code=at0043, itemType=ELEMENT, level=4, text=Overall description, description=Narrative summary about the individual's overall tobacco smoking pattern and history., comment=Use this data element to record a narrative description of the tobacco smoking habits for this individual or to incorporate unstructured tobacco smoking information from existing or legacy clinical systems into an archetyped format., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: http://loinc.org
  • Ja 
  • Nichtraucher 
  • Ehemaliger Raucher 
  • Unbekannt 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Frailty-Skala'], code=at0000, itemType=SECTION, level=1, text=Frailty-Skala, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Frailty-Skala']/items[openEHR-EHR-OBSERVATION.clinical_frailty_scale.v1], code=at0000, itemType=OBSERVATION, level=2, text=Clinical Frailty Scale (CFS), description=An assessment scale used to screen for frailty and to broadly stratify degrees of fitness and frailty in an older adult., comment=Also known as the Rockwood Clinical Frailty Scale., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Frailty-Skala']/items[openEHR-EHR-OBSERVATION.clinical_frailty_scale.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, 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.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Frailty-Skala']/items[openEHR-EHR-OBSERVATION.clinical_frailty_scale.v1]/data[at0001]/events[at0002], code=at0002, itemType=POINT_EVENT, level=4, text=Any point in time event, description=Default, unspecified point in time event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=1..*, occurencesText=Mandatory, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=POINT_EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Frailty-Skala']/items[openEHR-EHR-OBSERVATION.clinical_frailty_scale.v1]/data[at0001]/events[at0002]/data[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=5, text=Data, 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.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Frailty-Skala']/items[openEHR-EHR-OBSERVATION.clinical_frailty_scale.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=6, text=Assessment, description=Assessed level of frailty., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_ORDINAL, bindings=null, values=
  • 1: Very Fit 
  • 2: Well 
  • 3: Managing Well 
  • 4: Vulnerable 
  • 5: Mildly Frail 
  • 6: Moderately Frail 
  • 7: Severely Frail 
  • 8: Very Severely Frail 
  • 9: Terminally Ill 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='DNR-Anordnung'], code=at0000, itemType=SECTION, level=1, text=DNR-Anordnung, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='DNR-Anordnung']/items[openEHR-EHR-EVALUATION.advance_care_directive.v1], code=at0000, itemType=EVALUATION, level=2, text=Advance care directive, description=A framework to communicate the preferences of an individual for future medical treatment and care., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='DNR-Anordnung']/items[openEHR-EHR-EVALUATION.advance_care_directive.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, 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.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='DNR-Anordnung']/items[openEHR-EHR-EVALUATION.advance_care_directive.v1]/data[at0001]/items[at0005], code=at0005, itemType=ELEMENT, level=4, text=Type of directive, description=The type of advance care directive., comment=A short text description of the nature of the advance care directive. Coding of the type of directive with a terminology is preferred, where possible. It is expected that this is largely localised to reflect local policy and legislation. For example, in the Netherlands, advance care directive types include, but are not limited to, 'Treatment prohibition', 'Treatment prohibition with completion of Completed Life', 'Euthanasia request' and 'Declaration of life'. In the UK, advance care directive types include 'Advance Decision', 'Advance Directive' and 'Advance Statement'., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: http://terminology.hl7.org/CodeSystem/consentcategorycodes
  • Do No Resusciate 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='DNR-Anordnung']/items[openEHR-EHR-EVALUATION.advance_care_directive.v1]/data[at0001]/items[at0006], code=at0006, itemType=ELEMENT, level=4, text=Description, description=Narrative description of the overall advance care directive., comment=May be used to record a narrative overview of the complete advance care directive, which may or may not be supported by structured data. Details of specific structured findings can be included using CLUSTER archetypes in the 'Directive details' slot. This data element may be used to capture legacy data that is not available in a structured format., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: http://snomed.info/sct
  • For resuscitation (finding) 
  • Not for resuscitation (finding) 
  • Unknown (qualifier value) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Reisehistorie'], code=at0000, itemType=SECTION, level=1, text=Reisehistorie, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Reisehistorie']/items[openEHR-EHR-ADMIN_ENTRY.travel_event.v0], code=at0000, itemType=ADMIN_ENTRY, level=2, text=Reisehistorie, description=Details about a specific trip or travel event., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ADMIN_ENTRY, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Reisehistorie']/items[openEHR-EHR-ADMIN_ENTRY.travel_event.v0]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, 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.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Reisehistorie']/items[openEHR-EHR-ADMIN_ENTRY.travel_event.v0]/data[at0001]/items[at0022], code=at0022, itemType=ELEMENT, level=4, text=Description, description=Narrative description about the whole trip, especially about potential exposure to health risks., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: http://snomed.info/sct
  • Yes (qualifier value) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Reisehistorie']/items[openEHR-EHR-ADMIN_ENTRY.travel_event.v0]/data[at0001]/items[at0010], code=at0010, itemType=CLUSTER, level=4, text=Specific destination, description=Details about a single location visited on a trip., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Reisehistorie']/items[openEHR-EHR-ADMIN_ENTRY.travel_event.v0]/data[at0001]/items[at0010]/items[at0011], code=at0011, itemType=ELEMENT, level=5, text=Country, description=The country visited., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: urn:iso:std:iso:3166; iso3166-1-2
  • Andorra 
  • United Arab Emirates 
  • Afghanistan 
  • Antigua and Barbuda 
  • Anguilla 
  • Albania 
  • Armenia 
  • Angola 
  • Antarctica 
  • Argentina 
  • American Samoa 
  • Austria 
  • Australia 
  • Aruba 
  • Åland Islands 
  • Azerbaijan 
  • Bosnia and Herzegovina 
  • Barbados 
  • Bangladesh 
  • Belgium 
  • Burkina Faso 
  • Bulgaria 
  • Bahrain 
  • Burundi 
  • Benin 
  • Saint Barthélemy 
  • Bermuda 
  • Brunei Darussalam 
  • Bolivia, Plurinational State of 
  • Bonaire, Sint Eustatius and Saba 
  • Brazil 
  • Bahamas 
  • Bhutan 
  • Bouvet Island 
  • Botswana 
  • Belarus 
  • Belize 
  • Canada 
  • Cocos (Keeling) Islands 
  • Congo, the Democratic Republic of the 
  • Central African Republic 
  • Congo 
  • Switzerland 
  • Côte d''Ivoire 
  • Cook Islands 
  • Chile 
  • Cameroon 
  • China 
  • Colombia 
  • Costa Rica 
  • Cuba 
  • Cabo Verde 
  • Curaçao 
  • Christmas Island 
  • Cyprus 
  • Czechia 
  • Germany 
  • Djibouti 
  • Denmark 
  • Dominica 
  • Dominican Republic 
  • Algeria 
  • Ecuador 
  • Estonia 
  • Egypt 
  • Western Sahara 
  • Eritrea 
  • Spain 
  • Ethiopia 
  • Finland 
  • Fiji 
  • Falkland Islands (Malvinas) 
  • Micronesia, Federated States of 
  • Faroe Islands 
  • France 
  • Gabon 
  • United Kingdom of Great Britain and Northern Ireland 
  • Grenada 
  • Georgia 
  • French Guiana 
  • Guernsey 
  • Ghana 
  • Gibraltar 
  • Greenland 
  • Gambia 
  • Guinea 
  • Guadeloupe 
  • Equatorial Guinea 
  • Greece 
  • South Georgia and the South Sandwich Islands 
  • Guatemala 
  • Guam 
  • Guinea-Bissau 
  • Guyana 
  • Hong Kong 
  • Heard Island and McDonald Islands 
  • Honduras 
  • Croatia 
  • Haiti 
  • Hungary 
  • Indonesia 
  • Ireland 
  • Israel 
  • Isle of Man 
  • India 
  • British Indian Ocean Territory 
  • Iraq 
  • Iran, Islamic Republic of 
  • Iceland 
  • Italy 
  • Jersey 
  • Jamaica 
  • Jordan 
  • Japan 
  • Kenya 
  • Kyrgyzstan 
  • Cambodia 
  • Kiribati 
  • Comoros 
  • Saint Kitts and Nevis 
  • Korea, Democratic People''s Republic of 
  • Korea, Republic of 
  • Kuwait 
  • Cayman Islands 
  • Kazakhstan 
  • Lao People''s Democratic Republic 
  • Lebanon 
  • Saint Lucia 
  • Liechtenstein 
  • Sri Lanka 
  • Liberia 
  • Lesotho 
  • Lithuania 
  • Luxembourg 
  • Latvia 
  • Libya 
  • Morocco 
  • Monaco 
  • Moldova, Republic of 
  • Montenegro 
  • Saint Martin (French part) 
  • Madagascar 
  • Marshall Islands 
  • Macedonia, the former Yugoslav Republic of 
  • Mali 
  • Myanmar 
  • Mongolia 
  • Macao 
  • Northern Mariana Islands 
  • Martinique 
  • Mauritania 
  • Montserrat 
  • Malta 
  • Mauritius 
  • Maldives 
  • Malawi 
  • Mexico 
  • Malaysia 
  • Mozambique 
  • Namibia 
  • New Caledonia 
  • Niger 
  • Norfolk Island 
  • Nigeria 
  • Nicaragua 
  • Netherlands 
  • Norway 
  • Nepal 
  • Nauru 
  • Niue 
  • New Zealand 
  • Oman 
  • Panama 
  • Peru 
  • French Polynesia 
  • Papua New Guinea 
  • Philippines 
  • Pakistan 
  • Poland 
  • Saint Pierre and Miquelon 
  • Pitcairn 
  • Puerto Rico 
  • Palestine, State of 
  • Portugal 
  • Palau 
  • Paraguay 
  • Qatar 
  • Réunion 
  • Romania 
  • Serbia 
  • Russian Federation 
  • Rwanda 
  • Saudi Arabia 
  • Solomon Islands 
  • Seychelles 
  • Sudan 
  • Sweden 
  • Singapore 
  • Saint Helena, Ascension and Tristan da Cunha 
  • Slovenia 
  • Svalbard and Jan Mayen 
  • Slovakia 
  • Sierra Leone 
  • San Marino 
  • Senegal 
  • Somalia 
  • Suriname 
  • South Sudan 
  • Sao Tome and Principe 
  • El Salvador 
  • Sint Maarten (Dutch part) 
  • Syrian Arab Republic 
  • Swaziland 
  • Turks and Caicos Islands 
  • Chad 
  • French Southern Territories 
  • Togo 
  • Thailand 
  • Tajikistan 
  • Tokelau 
  • Timor-Leste 
  • Turkmenistan 
  • Tunisia 
  • Tonga 
  • Turkey 
  • Trinidad and Tobago 
  • Tuvalu 
  • Taiwan, Province of China 
  • Tanzania, United Republic of 
  • Ukraine 
  • Uganda 
  • United States Minor Outlying Islands 
  • United States of America 
  • Uruguay 
  • Uzbekistan 
  • Holy See 
  • Saint Vincent and the Grenadines 
  • Venezuela, Bolivarian Republic of 
  • Virgin Islands, British 
  • Virgin Islands, 
  • Viet Nam 
  • Vanuatu 
  • Wallis and Futuna 
  • Samoa 
  • Yemen 
  • Mayotte 
  • South Africa 
  • Zambia 
  • Zimbabwe 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Reisehistorie']/items[openEHR-EHR-ADMIN_ENTRY.travel_event.v0]/data[at0001]/items[at0010]/items[at0012], code=at0012, itemType=ELEMENT, level=5, text=State/region, description=The region visited., comment=Different regions within the same country maybe identified if they potentially pose different health risks., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: iso/bundeslaender
  • Baden-Württemberg 
  • Bayern 
  • Berlin 
  • Brandenburg 
  • Bremen 
  • Hamburg 
  • Hessen 
  • Mecklenburg-Vorpommern 
  • Niedersachsen 
  • Nordrhein-Westfalen 
  • Rheinland-Pfalz 
  • Saarland 
  • Sachsen 
  • Sachsen-Anhalt 
  • Schleswig-Holstein 
  • Thüringen 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Reisehistorie']/items[openEHR-EHR-ADMIN_ENTRY.travel_event.v0]/data[at0001]/items[at0010]/items[at0013], code=at0013, itemType=ELEMENT, level=5, text=City, description=The city visited., comment=Different cities within the same country or region maybe identified if they potentially pose different health risks., 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.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Reisehistorie']/items[openEHR-EHR-ADMIN_ENTRY.travel_event.v0]/data[at0001]/items[at0010]/items[at0014], code=at0014, itemType=ELEMENT, level=5, text=Date of entry, description=Date of entry to the identified location., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Reisehistorie']/items[openEHR-EHR-ADMIN_ENTRY.travel_event.v0]/data[at0001]/items[at0010]/items[at0015], code=at0015, itemType=ELEMENT, level=5, text=Date of exit, description=Date of exit from the identified location., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Reisehistorie']/items[openEHR-EHR-EVALUATION.exclusion_specific.v1], code=at0000, itemType=EVALUATION, level=2, text=Keine Reisehistorie, description=A statement of exclusion of a specific Problem/diagnosis, Family history, Medication, Procedure, Adverse reaction or other clinical item that is either not currently present, or have not been present in the past., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Reisehistorie']/items[openEHR-EHR-EVALUATION.exclusion_specific.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, 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.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Reisehistorie']/items[openEHR-EHR-EVALUATION.exclusion_specific.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Exclusion statement, description=A qualifying statement about the exclusion of a Problem/diagnosis, Family history, Medication, Procedure, Adverse reaction or other clinical item., comment=This statement is to be used in conjunction with the 'Excluded concept' data element. For example: this data element can support recording general statements such as "No known history of ..." where the 'Excluded concept' identifies the specific problem, diagnosis, substance, procedure or medication. If the 'Excluded concept' data element is used to record a precoordinated term such as 'No family history of diabetes', this element is redundant., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: http://snomed.info/sct
  • No (qualifier value) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Reisehistorie']/items[openEHR-EHR-EVALUATION.exclusion_specific.v1]/data[at0001]/items[at0003], code=at0003, itemType=ELEMENT, level=4, text=Problem/Diagnose, description=The problem or diagnosis to which the 'Exclusion statement' applies. For example: 'Diabetes', 'COPD' or 'Asthma'., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: http://loinc.org
  • History of Travel 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Reisehistorie']/items[openEHR-EHR-EVALUATION.absence.v2], code=at0000, itemType=EVALUATION, level=2, text=Unbekannte Reisehistorie, description=Statement that specified health information is not available for inclusion in the health record or extract at the time of recording., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Reisehistorie']/items[openEHR-EHR-EVALUATION.absence.v2]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, 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.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Reisehistorie']/items[openEHR-EHR-EVALUATION.absence.v2]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Fehlende Information, description=Positive statement that no information is available., comment=For example: "No information available about adverse reactions"; No information available about problems or diagnoses"; "No information available about previous procedures performed"; or "No information available about medications used"., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: http://loinc.org
  • History of Travel 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Reisehistorie']/items[openEHR-EHR-EVALUATION.absence.v2]/data[at0001]/items[at0005], code=at0005, itemType=ELEMENT, level=4, text=Aussage über die fehlende Information, description=Description of the reason why there is no information available., comment=For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: http://snomed.info/sct
  • Unknown (qualifier value) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Radiologischer Befund'], code=at0000, itemType=SECTION, level=1, text=Radiologischer Befund, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Radiologischer Befund']/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v0], code=at0000, itemType=OBSERVATION, level=2, text=Imaging examination result, description=Record the findings and interpretation of an imaging examination performed., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Radiologischer Befund']/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, 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.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Radiologischer Befund']/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=4, text=Any event, description=Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Radiologischer Befund']/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=5, text=Data, 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.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Radiologischer Befund']/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=6, text=Test name, description=The name of the imaging examination or procedure performed., comment=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., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: http://loinc.org
  • Diagnostic imaging study 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Radiologischer Befund']/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0008], code=at0008, itemType=ELEMENT, level=6, text=Findings, description=Narrative description of the clinical findings., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: http://snomed.info/sct
  • |Radiologic finding (finding)|:|Has interpretation (attribute)|=|Undetermined (qualifier value)| 
  • |Radiologic finding (finding)|:{|Has interpretation (attribute)|=|Abnormal (qualifier value)|,|Due to (attribute)|=|Disease caused by severe acute respiratory syndrome coronavirus 2 (disorder)|} 
  • |Radiologic finding (finding)|:|Has interpretation (attribute)|=|Normal (qualifier value)| 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Körpergewicht'], code=at0000, itemType=SECTION, level=1, text=Körpergewicht, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Körpergewicht']/items[openEHR-EHR-OBSERVATION.body_weight.v2], code=at0000, itemType=OBSERVATION, level=2, text=Body weight, description=Measurement of the body weight of an individual., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Körpergewicht']/items[openEHR-EHR-OBSERVATION.body_weight.v2]/data[at0002], code=at0002, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, 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.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Körpergewicht']/items[openEHR-EHR-OBSERVATION.body_weight.v2]/data[at0002]/events[at0003], code=at0003, itemType=EVENT, level=4, text=Any event, description=Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Körpergewicht']/items[openEHR-EHR-OBSERVATION.body_weight.v2]/data[at0002]/events[at0003]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=5, text=Data, 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.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Körpergewicht']/items[openEHR-EHR-OBSERVATION.body_weight.v2]/data[at0002]/events[at0003]/data[at0001]/items[at0004], code=at0004, itemType=ELEMENT, level=6, text=Weight, description=The weight of the individual., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=0..1000 kg, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Körpergröße'], code=at0000, itemType=SECTION, level=1, text=Körpergröße, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Körpergröße']/items[openEHR-EHR-OBSERVATION.height.v2], code=at0000, itemType=OBSERVATION, level=2, text=Height/Length, description=Height, or body length, is measured from crown of head to sole of foot., comment=Height is measured with the individual in a standing position and body length in a recumbent position., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Körpergröße']/items[openEHR-EHR-OBSERVATION.height.v2]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, 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.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Körpergröße']/items[openEHR-EHR-OBSERVATION.height.v2]/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=4, text=Any event, description=Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Körpergröße']/items[openEHR-EHR-OBSERVATION.height.v2]/data[at0001]/events[at0002]/data[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=5, text=Data, 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.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Körpergröße']/items[openEHR-EHR-OBSERVATION.height.v2]/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=6, text=Height/Length, description=The length of the body from crown of head to sole of foot., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=0..1000; 0..250
Units:
  • cm
  • [in_i]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Personendaten'], code=at0000, itemType=SECTION, level=1, text=Personendaten, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Personendaten']/items[openEHR-EHR-ADMIN_ENTRY.person_data.v0], code=at0000, itemType=ADMIN_ENTRY, level=2, text=Personendaten, description=Demografische Daten zu einer Person wie Geburtsdatum und Telefonnummer., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ADMIN_ENTRY, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Personendaten']/items[openEHR-EHR-ADMIN_ENTRY.person_data.v0]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, 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.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Personendaten']/items[openEHR-EHR-ADMIN_ENTRY.person_data.v0]/data[at0001]/items[at0024], code=at0024, itemType=CLUSTER, level=4, text=Angaben zum Tod, description=*, 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.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Personendaten']/items[openEHR-EHR-ADMIN_ENTRY.person_data.v0]/data[at0001]/items[at0024]/items[at0025], code=at0025, itemType=ELEMENT, level=5, text=Verstorben?, description=*, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Personendaten']/items[openEHR-EHR-ADMIN_ENTRY.person_data.v0]/data[at0001]/items[openEHR-EHR-CLUSTER.ethnischer_hintergrund.v0], code=at0000, itemType=CLUSTER, level=4, text=Ethnischer Hintergrund, description=Detaillierte Beschreibung des ethnischen Hintergrundes einer Person, um Besondheiten, wie Medikamentenverträglichkeit oder Gesundheitsrisiken abzubilden., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Personendaten']/items[openEHR-EHR-ADMIN_ENTRY.person_data.v0]/data[at0001]/items[openEHR-EHR-CLUSTER.ethnischer_hintergrund.v0]/items[at0002], code=at0002, itemType=ELEMENT, level=5, text=Ethnischer Hintergrund, description=Der ethnische Hintergrund einer Person., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Coded TextTerminology: http://snomed.info/sct
    • Caucasian 
    • Black African 
    • Asian 
    • Arabs 
    • Other ethnic, mixed origin 
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Personendaten']/items[openEHR-EHR-EVALUATION.gender.v1], code=at0000, itemType=EVALUATION, level=2, text=Gender, description=Details about the gender of an individual., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Personendaten']/items[openEHR-EHR-EVALUATION.gender.v1]/data[at0002], code=at0002, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, 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.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Personendaten']/items[openEHR-EHR-EVALUATION.gender.v1]/data[at0002]/items[at0022], code=at0022, itemType=ELEMENT, level=4, text=Administrative gender, description=The gender of an individual used for administrative purposes., comment=This element is what most systems today describes as 'Sex' or 'Gender'. For example 'Male', 'Female', 'Other'. This aligns with HL7 FHIR 'Person.gender'. Coding with a terminology is recommended, where possible., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: local_terms
  • Male 
  • Female 
  • Unknown 
  • Other 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Personendaten']/items[openEHR-EHR-EVALUATION.gender.v1]/data[at0002]/items[at0019], code=at0019, itemType=ELEMENT, level=4, text=Geschlecht bei der Geburt, description=The sex of an individual determined by anatomical characteristics observed and registered at birth., comment=For example: 'Male', 'Female', 'Intersex'. Coding with a terminology is recommended, where possible. Use the element 'Comment' or the SLOT 'Details' if needed to register more specific details of the individuals gender., 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.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Impfstatus'], code=at0000, itemType=SECTION, level=1, text=Impfstatus, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Impfstatus']/items[openEHR-EHR-ACTION.medication.v1], code=at0000, itemType=ACTION, level=2, text=Impfung, description=Any activity related to the planning, scheduling, prescription management, dispensing, administration, cessation and other use of a medication, vaccine, nutritional product or other therapeutic item., comment=This is not limited to activities performed based on medication orders from clinicians, but could also include for example taking over the counter medication., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ACTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Impfstatus']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017], code=at0017, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, 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.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Impfstatus']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[at0020], code=at0020, itemType=ELEMENT, level=4, text=Impfstoff, description=Name of the medication, vaccine or other therapeutic/prescribable item which was the focus of the activity., comment=For example: 'Atenolol 100mg' or 'Tenormin tablets 100mg'. It is strongly recommended that the 'Medication item' is coded with a terminology capable of triggering decision support, where possible. The extent of coding may vary from the simple name of the medication item through to structured details about the actual medication pack used. Free text entry should only be used if there is no appropriate terminology available., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: http://snomed.info/sct
  • Diphtheria + pertussis + tetanus vaccine (product) 
  • Vaccine product (product) 
  • Typhus vaccine (product) 
  • Varicella-zoster live attenuated vaccine (product) 
  • Vaccine product (product): Has active ingredient (attribute) = Rubella and mumps vaccine (substance) 
  • Vaccine product (product): { Has active ingredient (attribute) = Diphtheria vaccine (substance) } { Has active ingredient (attribute) = Haemophilus influenzae type b vaccine (substance) } { Has active ingredient (attribute) = Pertussis vaccine (substance) } { Has active ingredient (attribute) = Tetanus vaccine (substance) } { Has active ingredient (attribute) = Hepatitis B virus vaccine (substance) } { Has active ingredient (attribute) = Meningococcus group A vaccine (substance) } { Has active ingredient (attribute) = Meningococcus group C vaccine (substance) } 
  • Diphtheria + tetanus + pertussis + poliomyelitis + recombinant hepatitis B virus vaccine (product) 
  • Vaccine product (product): { Has active ingredient (attribute) = Diphtheria vaccine (substance) } { Has active ingredient (attribute) = Haemophilus influenzae type b vaccine (substance) } { Has active ingredient (attribute) = Pertussis vaccine (substance) } { Has active ingredient (attribute) = Tetanus vaccine (substance) } { Has active ingredient (attribute) = Hepatitis B virus vaccine (substance) } 
  • Hepatitis A+typhoid vaccine (product) 
  • Diphtheria + tetanus + pertussis + poliomyelitis + recombinant hepatitis B virus + recombinant haemophilus influenzae type B vaccine (product) 
  • Haemophilus influenzae Type b + recombinant hepatitis B virus vaccine (product) 
  • Vaccine product (product): { Has active ingredient (attribute) = Diphtheria vaccine (substance) } { Has active ingredient (attribute) = Hepatitis B virus vaccine (substance) } { Has active ingredient (attribute) = Tetanus vaccine (substance) } 
  • Diphtheria + tetanus + pertussis + poliomyelitis + haemophilus influenzae b vaccine (product) 
  • Diphtheria + tetanus + pertussis + recombinant hepatitis B virus vaccine (product) 
  • Vaccine product (product): { Has active ingredient (attribute) = Haemophilus influenzae type b vaccine (substance) } { Has active ingredient (attribute) = Live Poliovirus vaccine (substance) } 
  • Vaccine product (product): { Has active ingredient (attribute) = Diphtheria vaccine (substance) } { Has active ingredient (attribute) = Rubella vaccine (substance) } { Has active ingredient (attribute) = Tetanus vaccine (substance) } 
  • Diphtheria + tetanus + pertussis + poliomyelitis vaccine (product) 
  • Diphtheria + tetanus + poliomyelitis vaccine (product) 
  • Measles + mumps + rubella + varicella vaccine (product) 
  • Vaccine product (product): { Has active ingredient (attribute) = Measles vaccine (substance) } { Has active ingredient (attribute) = Rubella vaccine (substance) } 
  • Measles, mumps and rubella vaccine (product) 
  • Measles and mumps vaccine (product) 
  • Hepatitis A+B vaccine (product) 
  • Diphtheria + tetanus vaccine (product) 
  • Vaccine product (product): { Has active ingredient (attribute) = Pneumococcal vaccine (substance) } { Has active ingredient (attribute) = Haemophilus influenzae type b vaccine (substance) } 
  • Haemophilus influenzae type b + Meningococcal group C vaccine (product) 
  • Vaccine product (product): { Has active ingredient (attribute) = Haemophilus influenzae type b vaccine (substance) } { Has active ingredient (attribute) = Pertussis vaccine (substance) } { Has active ingredient (attribute) = Toxoid (substance) } 
  • Vaccine product (product): { Has active ingredient (attribute) = Cholera vaccine (substance) } { Has active ingredient (attribute) = Typhoid vaccine (substance) } 
  • Product containing normal immunoglobulin human (medicinal product) 
  • Product containing human anti-D immunoglobulin (medicinal product)| 
  • Product containing tetanus antitoxin (medicinal product) 
  • Product containing Varicella-zoster virus antibody (medicinal product) 
  • Product containing Hepatitis B surface antigen immunoglobulin (medicinal product) 
  • Product containing rabies human immune globulin (medicinal product) 
  • Product containing Cytomegalovirus antibody (medicinal product) 
  • Product containing palivizumab (medicinal product) 
  • Product containing bezlotoxumab (medicinal product) 
  • Vaccine product containing only Severe acute respiratory syndrome coronavirus 2 antigen (medicinal product) 
  • Vaccine product containing only Severe acute respiratory syndrome coronavirus 2 messenger ribonucleic acid (medicinal product) 
  • Vaccine product containing Bordetella pertussis and Clostridium tetani and Corynebacterium diphtheriae antigens (medicinal product) 
  • Vaccine product containing only live attenuated Human alphaherpesvirus 3 antigen (medicinal product) 
  • Vaccine product containing Mumps orthorubulavirus and Rubella virus antigens (medicinal product) 
  • Vaccine product containing only Corynebacterium diphtheriae antigen (medicinal product) + Vaccine product containing Haemophilus influenzae type B antigen (medicinal product) + Vaccine product containing Bordetella pertussis antigen (medicinal product) + Vaccine product containing Clostridium tetani antigen (medicinal product) + Vaccine product containing Hepatitis B virus antigen (medicinal product) + Vaccine product containing only Neisseria meningitidis serogroup A and C antigens (medicinal product) 
  • Vaccine product containing Bordetella pertussis and Clostridium tetani and Corynebacterium diphtheriae and Hepatitis B virus and Human poliovirus antigens (medicinal product) 
  • Vaccine product containing only Corynebacterium diphtheriae antigen (medicinal product) + Vaccine product containing Haemophilus influenzae type B antigen (medicinal product) + Vaccine product containing Bordetella pertussis antigen (medicinal product) + Vaccine product containing Clostridium tetani antigen (medicinal product) + Vaccine product containing Hepatitis B virus antigen (medicinal product) 
  • Vaccine product containing Hepatitis A virus and Salmonella enterica subspecies enterica serovar Typhi antigens (medicinal product) 
  • Vaccine product containing Bordetella pertussis and Clostridium tetani and Corynebacterium diphtheriae and Haemophilus influenzae type B and Hepatitis B virus and Human poliovirus antigens (medicinal product) 
  • Vaccine product containing Haemophilus influenzae type B and Hepatitis B virus antigens (medicinal product) 
  • Vaccine product containing only Corynebacterium diphtheriae antigen (medicinal product) + Vaccine product containing Hepatitis B virus antigen (medicinal product) + Vaccine product containing Clostridium tetani antigen (medicinal product) 
  • Vaccine product containing Bordetella pertussis and Clostridium tetani and Corynebacterium diphtheriae and Haemophilus influenzae type B and Human poliovirus antigens (medicinal product) 
  • Vaccine product containing Bordetella pertussis and Clostridium tetani and Corynebacterium diphtheriae and Hepatitis B virus (medicinal product) 
  • Vaccine product containing Haemophilus influenzae type B antigen (medicinal product) + Vaccine product containing Human poliovirus antigen (medicinal product) 
  • Vaccine product containing only Corynebacterium diphtheriae antigen (medicinal product) + Vaccine product containing Rubella virus antigen (medicinal product) + Vaccine product containing Clostridium tetani antigen (medicinal product) 
  • Vaccine product containing Bordetella pertussis and Clostridium tetani and Corynebacterium diphtheriae and Human poliovirus antigens (medicinal product) 
  • Vaccine product containing Clostridium tetani and Corynebacterium diphtheriae and Human poliovirus antigens (medicinal product) 
  • Vaccine product containing Human alphaherpesvirus 3 and Measles morbillivirus and Mumps orthorubulavirus and Rubella virus antigens (medicinal product) 
  • Vaccine product containing Measles morbillivirus antigen (medicinal product) + Vaccine product containing Rubella virus antigen (medicinal product) 
  • Vaccine product containing Measles morbillivirus and Mumps orthorubulavirus and Rubella virus antigens (medicinal product) 
  • Vaccine product containing Measles morbillivirus and Mumps orthorubulavirus antigens (medicinal product) 
  • Vaccine product containing Hepatitis A and Hepatitis B virus antigens (medicinal product) 
  • Vaccine product containing Clostridium tetani and Corynebacterium diphtheriae antigens (medicinal product) 
  • Vaccine product containing Streptococcus pneumoniae antigen (medicinal product) + Vaccine product containing Haemophilus influenzae type B antigen (medicinal product) 
  • Vaccine product containing only Haemophilus influenzae type B and Neisseria meningitidis serogroup C antigens (medicinal product) 
  • Vaccine product containing Haemophilus influenzae type B antigen (medicinal product) + Vaccine product containing Bordetella pertussis antigen (medicinal product) 
  • Vaccine product containing Vibrio cholerae antigen (medicinal product) + Vaccine product containing Salmonella enterica subspecies enterica serovar Typhi antigen (medicinal product) 
  • Vaccine product containing Japanese encephalitis virus antigen (medicinal product) 
  • Vaccine product containing Tick-borne encephalitis virus antigen (medicinal product) 
  • Vaccine product containing only live attenuated Mumps orthorubulavirus antigen (medicinal product) 
  • Vaccine product containing Human poliovirus antigen (medicinal product) 
  • Vaccine product containing Rotavirus antigen (medicinal product) 
  • Vaccine product containing Rabies lyssavirus antigen (medicinal product) 
  • Vaccine product containing Human alphaherpesvirus 3 antigen (medicinal product) 
  • Vaccine product containing Vaccinia virus antigen (medicinal product) 
  • Vaccine product containing Human papillomavirus antigen (medicinal product) 
  • Vaccine product containing Yellow fever virus antigen (medicinal product) 
  • Vaccine product containing Rubella virus antigen (medicinal product) 
  • Vaccine product containing Measles morbillivirus antigen (medicinal product) 
  • Vaccine product containing Hepatitis A virus antigen (medicinal product) 
  • Vaccine product containing Hepatitis B virus antigen (medicinal product) 
  • Vaccine product containing Influenza virus antigen (medicinal product) 
  • Vaccine product containing Salmonella enterica subspecies enterica serovar Typhi antigen (medicinal product) 
  • Vaccine product containing live attenuated Mycobacterium bovis antigen (medicinal product) 
  • Vaccine product containing Clostridium tetani antigen (medicinal product) 
  • Vaccine product containing Streptococcus pneumoniae antigen (medicinal product) 
  • Vaccine product containing Yersinia pestis antigen (medicinal product) 
  • Vaccine product containing Bordetella pertussis antigen (medicinal product) 
  • Vaccine product containing Neisseria meningitidis antigen (medicinal product) 
  • Vaccine product containing Haemophilus influenzae type B antigen (medicinal product) 
  • Vaccine product containing Corynebacterium diphtheriae antigen (medicinal product) 
  • Vaccine product containing Vibrio cholerae antigen (medicinal product) 
  • Vaccine product containing Bacillus anthracis antigen (medicinal product) 
  • Vaccine product containing only Severe acute respiratory syndrome coronavirus 2 antigen (medicinal product) 
  • Vaccine product containing only Severe acute respiratory syndrome coronavirus 2 messenger ribonucleic acid (medicinal product) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Impfstatus']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v1], code=at0000, itemType=CLUSTER, level=4, text=Verabreichte Dosis, description=The combination of a medication amount and administration timing for a single day, in the context of a medication order or medication management., comment=For example: '2 tablets at 6pm' or '20mg three times per day'. Please note: this cluster allows multiple occurrences to enable representation of a complete set of dose patterns for a single dose direction., 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.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Impfstatus']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v1]/items[at0164], code=at0164, itemType=ELEMENT, level=5, text=Dosage sequence, description=The intended position of this dosage within the overall sequence of dosages., comment=For example: '1', '2', '3'. Where multiple dosages are expressed, the 'Pattern sequence' makes the order in which they should be executed explicit. For example: (1) 1 tab in the morning, (2) 2 tab at 2pm, (3) 1 tab at night., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=>=1, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Impfstatus']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v1]/items[at0144], code=at0144, itemType=ELEMENT, level=5, text=Dose amount, description=The value of the amount of medication administered at one time, as a real number, or range of real numbers, and associated with the Dose unit., comment=For example: 1, 1.5, 0.125 or 1-2, 12.5-20.5, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=>=0 , extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Impfstatus']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[at0156], code=at0156, itemType=ELEMENT, level=4, text=Clinical indication, description=The clinical reason for the medication activity., comment=For example: 'Angina' or 'Pain'. Coding of the indication with a terminology is preferred, where possible. This data element allows multiple occurrences. If only an ACTION is used to record a medication indication, this data element can be used without additional consideration. However, if a clinical indication is recorded for both the Medication order INSTRUCTION and this Medication management ACTION, be aware that these indications might not be consistent.", 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.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Impfstatus']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[at0021], code=at0021, itemType=ELEMENT, level=4, text=Impfung gegen, description=Reason that the pathway step for the identified medication was carried out., comment=For example: 'Postponed - Patient not avalable at administration time', 'Cancelled - Adverse reaction'. Note: This is not the reason for the medication instruction, but rather the specific reason that a care step was carried out, and will often be used to document some variance from the original order., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: http://snomed.info/sct
  • Disease caused by Severe acute respiratory syndrome coronavirus 2 (disorder) 
  • Infectious disease (disorder) 
  • Central European encephalitis (disorder) 
  • Disease (disorder) 
  • Rhesus isoimmunization due to anti-D (disorder) 
  • Louse-borne typhus (disorder) 
  • Cytomegalovirus infection (disorder) 
  • Respiratory syncytial virus infection (disorder) 
  • Clostridioides difficile infection (disorder) 
  • Smallpox 
  • human papilomavirus infection 
  • Yellow fever 
  • Herpes Zoster 
  • Varicella 
  • Rubella 
  • Rabies 
  • Acute Poliomyelitis 
  • Mumps 
  • Measles 
  • Viral hepatitis, type A 
  • Viral hepatitis, type B 
  • Influenza 
  • Japanese encephalitis virus disease 
  • Disease caused by Rotavirus 
  • Thyphoid fever 
  • Tuberculosis 
  • Tetanus 
  • Pneumococcal infectious disease 
  • Plague 
  • Pertussis 
  • Meningococcal infectious disease 
  • Haemophilus influenzae type b infection 
  • Diphtheria caused by Corynebacterium diphtheriae 
  • Cholera 
  • Brucellosis 
  • Anthrax 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Impfstatus']/items[openEHR-EHR-EVALUATION.absence.v2], code=at0000, itemType=EVALUATION, level=2, text=Unbekannter Impfstatus, description=Statement that specified health information is not available for inclusion in the health record or extract at the time of recording., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Impfstatus']/items[openEHR-EHR-EVALUATION.absence.v2]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, 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.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Impfstatus']/items[openEHR-EHR-EVALUATION.absence.v2]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Absence statement, description=Positive statement that no information is available., comment=For example: "No information available about adverse reactions"; No information available about problems or diagnoses"; "No information available about previous procedures performed"; or "No information available about medications used"., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: http://hl7.org/fhir/uv/ips/CodeSystem/absent-unknown-uv-ips
  • No information about immunizations 
  • No known immunizations 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Impfstatus']/items[openEHR-EHR-EVALUATION.absence.v2]/protocol[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, 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.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Impfstatus']/items[openEHR-EHR-EVALUATION.absence.v2]/protocol[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=4, text=Last updated, description=The date at which the absence was last updated., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='SARS-CoV-2 Exposition'], code=at0000, itemType=SECTION, level=1, text=SARS-CoV-2 Exposition, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='SARS-CoV-2 Exposition']/items[openEHR-EHR-EVALUATION.infectious_exposure.v0], code=at0000, itemType=EVALUATION, level=2, text=SARS-CoV-2 Exposition, description=Risk assessment for an individual who may have been exposed to an infectious agent., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='SARS-CoV-2 Exposition']/items[openEHR-EHR-EVALUATION.infectious_exposure.v0]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, 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.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='SARS-CoV-2 Exposition']/items[openEHR-EHR-EVALUATION.infectious_exposure.v0]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Infectious agent, description=Identification of the organism, material, symptoms or condition to which the individual has been exposed., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • SARS-CoV-2
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='SARS-CoV-2 Exposition']/items[openEHR-EHR-EVALUATION.infectious_exposure.v0]/data[at0001]/items[at0003], code=at0003, itemType=ELEMENT, level=4, text=Exposition vorhanden?, description=Narrative description about the overall exposure., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: http://snomed.info/sct
  • Exposure to severe acute respiratory syndrome coronavirus 2 (event) 
  • No (qualifier value) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='SARS-CoV-2 Exposition']/items[openEHR-EHR-EVALUATION.infectious_exposure.v0]/data[at0001]/items[at0005], code=at0005, itemType=CLUSTER, level=4, text=Specific exposure details, description=Details about a single exposure., comment=Multiple exposures can be recorded, using one instance of this cluster per exposure., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='SARS-CoV-2 Exposition']/items[openEHR-EHR-EVALUATION.infectious_exposure.v0]/data[at0001]/items[at0005]/items[at0006], code=at0006, itemType=ELEMENT, level=5, text=Description of exposure, description=Details about the method of exposure., comment=For example: airborne, direct contact, or needle stick., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Kontakt zu COVID-19 erkrankter Person
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='SARS-CoV-2 Exposition']/items[openEHR-EHR-EVALUATION.infectious_exposure.v0]/data[at0001]/items[at0005]/items[at0007], code=at0007, itemType=ELEMENT, level=5, text=Date/time of exposure, description=Date and time of exposure., comment=Can be cloned in template and renamed for specific Date/time at onset of exposure and cessation of exposure., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Schwangerschaftsstatus'], code=at0000, itemType=SECTION, level=1, text=Schwangerschaftsstatus, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Schwangerschaftsstatus']/items[openEHR-EHR-OBSERVATION.pregnancy_status.v0], code=at0000, itemType=OBSERVATION, level=2, text=Pregnancy status, description=Statement about whether the individual is or may be pregnant or not., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Schwangerschaftsstatus']/items[openEHR-EHR-OBSERVATION.pregnancy_status.v0]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, 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.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Schwangerschaftsstatus']/items[openEHR-EHR-OBSERVATION.pregnancy_status.v0]/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=4, text=Any event, description=*, comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Schwangerschaftsstatus']/items[openEHR-EHR-OBSERVATION.pregnancy_status.v0]/data[at0001]/events[at0002]/data[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=5, text=Data, 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.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Schwangerschaftsstatus']/items[openEHR-EHR-OBSERVATION.pregnancy_status.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0011], code=at0011, itemType=ELEMENT, level=6, text=Status, description=Is there a pregnancy present?, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: http://loinc.org
  • Pregnant 
  • Possible pregnancy 
  • Not pregnant 
  • Unknown 
  • Pregnant 
  • Not pregnant 
  • Unknown 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Körpertemperatur'], code=at0000, itemType=SECTION, level=1, text=Körpertemperatur, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Körpertemperatur']/items[openEHR-EHR-OBSERVATION.body_temperature.v2], code=at0000, itemType=OBSERVATION, level=2, text=Body temperature, description=A measurement of the body temperature, which is a surrogate for the core body temperature of the individual., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Körpertemperatur']/items[openEHR-EHR-OBSERVATION.body_temperature.v2]/data[at0002], code=at0002, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, 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.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Körpertemperatur']/items[openEHR-EHR-OBSERVATION.body_temperature.v2]/data[at0002]/events[at0003], code=at0003, itemType=EVENT, level=4, text=Any event, description=Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Körpertemperatur']/items[openEHR-EHR-OBSERVATION.body_temperature.v2]/data[at0002]/events[at0003]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=5, text=Data, 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.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Körpertemperatur']/items[openEHR-EHR-OBSERVATION.body_temperature.v2]/data[at0002]/events[at0003]/data[at0001]/items[at0004], code=at0004, itemType=ELEMENT, level=6, text=Temperature, description=The measured temperature., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=0..100; 30..200
Units:
  • Cel
  • [degF]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Körpertemperatur']/items[openEHR-EHR-OBSERVATION.body_temperature.v2]/protocol[at0020], code=at0020, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, 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.registereintrag.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Körpertemperatur']/items[openEHR-EHR-OBSERVATION.body_temperature.v2]/protocol[at0020]/items[at0021], code=at0021, itemType=ELEMENT, level=4, text=Location of measurement, description=Simple description about the site of measurement., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Coded Text
    • Rectum 
    • Axilla 
    • Ear canal 
    • Forehead 
    • Mouth 
    • Nasopharynx 
    • Urinary bladder 
    • Intravascular 
    • Skin 
    • Vagina 
    • Oesophagus 
    • Inguinal skin crease 
    • Temple 
  •  Text
, extendedValues=null]], templateType=normal]