| TEMPLATE ID | Fragebogen Körperliche Untersuchung |
|---|---|
| Concept | Fragebogen Körperliche Untersuchung |
| Description | Zur Repräsentation der Körperlichen Untersuchung einer Person im Rahmen der Pneumo_App. |
| Use | Für die Abbildung der Körperlichen Untersuchung einer Person im Rahmen der Pneumo_App. Es wird hier nach Körpergröße, Körpergewicht, Impfstatus und nach der Allergischen Verträglichkeit bestimmter Medikamente oder Umwelteinflüsse gefragt. |
| Misuse | Nicht zur Repräsentation über die Art der Verabreichungswege der Medikationen verwenden. |
| Purpose | Zur Repräsentation der Körperlichen Untersuchung einer Person im Rahmen der Pneumo_App. |
| References | |
| Authors | date: 2022-09-05; name: Sarah Ballout; organisation: Peter L. Reichertz Institute for Medical Informatics; email: ballout.sarah@mh-hannover.de |
| Other Details Language | date: 2022-09-05; name: Sarah Ballout; organisation: Peter L. Reichertz Institute for Medical Informatics; email: ballout.sarah@mh-hannover.de |
| Other Details (Language Independent) |
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| Keywords | Pneumo, Pneumologie, Impfung, Allergien, Impfstatus |
| Language used | en |
| Citeable Identifier | 1246.169.2579 |
| Root archetype id | openEHR-EHR-COMPOSITION.registereintrag.v1 |
| Fragebogen Körperliche Untersuchung | Fragebogen Körperliche Untersuchung: Generic compilation to represent a data set for research purposes. |
| Other Context | |
| Status | Status: Status of the supplied data for the register entry. Note: This is not the status of individual components.
|
| Category | Category: The classification of the register entry (e.g. type of observation of the FHIR profile). |
| Body weight | Body weight: Measurement of the body weight of an individual. |
| Data | |
| Any event | Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time. |
| Data | |
| Weight | Weight: The weight of the individual. 0..1000 kg |
| Körpergröße | Körpergröße: Height, or body length, is measured from crown of head to sole of foot. Height is measured with the individual in a standing position and body length in a recumbent position. |
| Data | |
| Any event | Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time. |
| Data | |
| Körpergröße | Körpergröße: The length of the body from crown of head to sole of foot. 0..1000 cm |
| Blood pressure | Blood pressure: The local measurement of arterial blood pressure which is a surrogate for arterial pressure in the systemic circulation. Most commonly, use of the term 'blood pressure' refers to measurement of brachial artery pressure in the upper arm. |
| Data | Data: History Structural node. |
| Any event | Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time. |
| Data | |
| Systolic | Systolic: Peak systemic arterial blood pressure - measured in systolic or contraction phase of the heart cycle. 0..1000 mmHg |
| Diastolic | Diastolic: Minimum systemic arterial blood pressure - measured in the diastolic or relaxation phase of the heart cycle. 0..1000 mmHg |
| Herzfrequenz | Herzfrequenz: The rate and associated attributes for a pulse or heart beat. |
| Data | |
| Any event | Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time. |
| Data | |
| Rate | Rate: The rate of the pulse or heart beat, measured in beats per minute. 0..1000 /min |
| Pulse oximetry | Pulse oximetry: Blood oxygen and related measurements, measured by pulse oximetry or pulse CO-oximetry. |
| Data | |
| Any event | Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time. |
| Data | |
| SpO₂ | SpO₂: The saturation of oxygen in the peripheral blood, measured via pulse oximetry. SpO₂ is defined as the percentage of oxyhaemoglobin (HbO₂) to the total concentration of haemoglobin (HbO₂ + deoxyhaemoglobin) in peripheral blood.
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| Impfung | Impfung: 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. This is not limited to activities performed based on medication orders from clinicians, but could also include for example taking over the counter medication. |
| Description | |
| Impfung | Impfung: Name of the medication, vaccine or other therapeutic/prescribable item which was the focus of the activity. 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.
|
| Datum letzter Impfung | Datum letzter Impfung: The datetime at which the medication action was scheduled to occur. Used to compare variance from actual action time where this is not readily calculable from the original instruction. |
| Impfung gegen | Impfung gegen: Reason that the pathway step for the identified medication was carried out. 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.
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| Welche der folgenden Beschwerden bestehen bei Ihnen aktuell? | Welche der folgenden Beschwerden bestehen bei Ihnen aktuell?: Statement that specified health information is not available for inclusion in the health record or extract at the time of recording. |
| Data | |
| Auswurf | Auswurf: Positive statement that no information is available. 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".
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| Husten | Husten: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible.
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| Übelkeit oder Erbrechen | Übelkeit oder Erbrechen: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible.
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| Brustenge/ -schmerzen | Brustenge/ -schmerzen: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible.
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| Gewichtsverlust | Gewichtsverlust: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible.
|
| Arthritis (Gelenkentzündung) | Arthritis (Gelenkentzündung): Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible.
|
| Nächtliches Wasserlassen (Nykturie) | Nächtliches Wasserlassen (Nykturie): Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible.
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| Hämoptysen (Bluthusten) | Hämoptysen (Bluthusten): Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible.
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| Infektsymptome/ Fieber | Infektsymptome/ Fieber: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible.
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| Kopfschmerzen/ Sehstörungen | Kopfschmerzen/ Sehstörungen: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible.
|
| Reflux (Sodbrennen) | Reflux (Sodbrennen): Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible.
|
| Nachtschweiss | Nachtschweiss: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible.
|
| Synkopen (plötzl. Bewusstlosigkeit) | Synkopen (plötzl. Bewusstlosigkeit): Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible.
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| Sie haben oben angegeben Auswurf zu haben. Welche Farbe hat Ihr Auswurf derzeit überwiegend? | Sie haben oben angegeben Auswurf zu haben. Welche Farbe hat Ihr Auswurf derzeit überwiegend?: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible.
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| Allergie und Medikamenten-Unverträglichkeit | Allergie und Medikamenten-Unverträglichkeit: 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. This is not limited to activities performed based on medication orders from clinicians, but could also include for example taking over the counter medication. |
| Description | |
| Allergien oder bekannte Medikamenten-Unverträglichkeiten? | Allergien oder bekannte Medikamenten-Unverträglichkeiten?: Name of the medication, vaccine or other therapeutic/prescribable item which was the focus of the activity. 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.
|
| Wenn ja, gegen was? | Wenn ja, gegen was?: Reason that the pathway step for the identified medication was carried out. 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.
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| Weitere Unverträglichkeiten | Weitere Unverträglichkeiten: Additional narrative about the activity or pathway step not captured in other fields, including details of any variance between the intended action and the action actually performed. For example: 'Patient was in radiology department', 'Accidental injection into blood vessel during IM administration'. |