- MD5-CAM-1.0.1: 0375174383de7ef663139a6f8861d8b8
- PARENT:MD5-CAM-1.0.1: CD5C7EF669BF9300C4CE104319009B71
- Original Language: ISO_639-1::de
- Sem Ver: 10.0.0
- Build Uid: 4a434676-179a-4fcd-a26c-5793b9eee226
- registered
- preliminary
- final
- amended
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'.
Coding of the name of the problem or diagnosis with a terminology is preferred, where possible.
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)
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.
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)
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.
If the identified body site has no laterality, this data element should not have a value. If the 'Body site name' data element uses pre-coordinated terms that include laterality, then this data element is redundant.
- Left
- Right
Also known as 'aetiology' or 'etiology'. Coding with an external terminology is preferred, where possible.
Data captured/imported as "Age at onset" should be converted to a date using the subject's date of birth.
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.
Coded Text- Mild
- Moderate
- Severe
Text
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.
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.
Terminology: http://snomed.info/sct
- Known absent (qualifier value)
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)
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)
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".
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)
For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible.
Terminology: http://snomed.info/sct
- Unknown (qualifier value)
Symptom name should be coded with a terminology, where possible.
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)
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.
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.
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.
Terminology: http://snomed.info/sct
- Mild (qualifier value)
- Moderate (severity modifier) (qualifier value)
- Severe (severity modifier) (qualifier value)
- Life threatening severity (qualifier value)
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.
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.
Terminology: http://snomed.info/sct
- Known absent (qualifier value)
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)
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".
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)
For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible.
Terminology: http://snomed.info/sct
- Unknown (qualifier value)
Coding of the specific procedure with a terminology is preferred, where possible.
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)
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'.
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.
Terminology: http://snomed.info/sct
- Lung structure (body structure)
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.
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)
This pragmatic data element may be used to support organisation within the user interface.
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)
For example: the reason for the cancellation or suspension of the procedure.
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.
- not done
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)
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".
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)
For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible.
- unknown
- Never smoked
- Current smoker
- Former smoker
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.
Terminology: http://loinc.org
- Ja
- Nichtraucher
- Ehemaliger Raucher
- Unbekannt
Also known as the Rockwood Clinical Frailty Scale.
- 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
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'.
Terminology: http://terminology.hl7.org/CodeSystem/consentcategorycodes
- Do No Resusciate
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.
Terminology: http://snomed.info/sct
- For resuscitation (finding)
- Not for resuscitation (finding)
- Unknown (qualifier value)
Terminology: http://snomed.info/sct
- Yes (qualifier value)
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
Different regions within the same country maybe identified if they potentially pose different health risks.
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
Different cities within the same country or region maybe identified if they potentially pose different health risks.
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.
Terminology: http://snomed.info/sct
- No (qualifier value)
Terminology: http://loinc.org
- History of Travel
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".
Terminology: http://loinc.org
- History of Travel
For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible.
Terminology: http://snomed.info/sct
- Unknown (qualifier value)
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.
Terminology: http://loinc.org
- Diagnostic imaging study
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)|
0..1000 kg
Height is measured with the individual in a standing position and body length in a recumbent position.
0..1000; 0..250
Units:
- cm
- in
- Coded Text Terminology: http://snomed.info/sct
- Caucasian
- Black African
- Asian
- Arabs
- Other ethnic, mixed origin
- Text
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.
Terminology: local_terms
- Male
- Female
- Unknown
- Other
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.
This is not limited to activities performed based on medication orders from clinicians, but could also include for example taking over the counter medication.
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.
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)
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.
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.
>=1
For example: 1, 1.5, 0.125 or 1-2, 12.5-20.5
>=0
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."
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.
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
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".
Terminology: http://hl7.org/fhir/uv/ips/CodeSystem/absent-unknown-uv-ips
- No information about immunizations
- No known immunizations
- SARS-CoV-2
Terminology: http://snomed.info/sct
- Exposure to severe acute respiratory syndrome coronavirus 2 (event)
- No (qualifier value)
Multiple exposures can be recorded, using one instance of this cluster per exposure.
For example: airborne, direct contact, or needle stick.
- Kontakt zu COVID-19 erkrankter Person
Can be cloned in template and renamed for specific Date/time at onset of exposure and cessation of exposure.
Terminology: http://loinc.org
- Pregnant
- Possible pregnancy
- Not pregnant
- Unknown
- Pregnant
- Not pregnant
- Unknown
0..100; 30..200
Units:
- °C
- °F
- Coded Text
- Rectum
- Axilla
- Ear canal
- Forehead
- Mouth
- Nasopharynx
- Urinary bladder
- Intravascular
- Skin
- Vagina
- Oesophagus
- Inguinal skin crease
- Temple
- Text