TEMPLATE Pneumo_Körperliche Untersuchung (Pneumo_Körperliche Untersuchung)

TEMPLATE IDPneumo_Körperliche Untersuchung
ConceptPneumo_Körperliche Untersuchung
DescriptionZur Repräsentation der Körperlichen Untersuchung einer Person im Rahmen der Pneumo_App.
UseFür 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.
MisuseNicht zur Repräsentation über die Art der Verabreichungswege der Medikationen verwenden.
PurposeZur Repräsentation der Körperlichen Untersuchung einer Person im Rahmen der Pneumo_App.
References
Authorsdate: 2022-09-05; name: Sarah Ballout; organisation: Peter L. Reichertz Institute for Medical Informatics; email: ballout.sarah@mh-hannover.de
Other Details Languagedate: 2022-09-05; name: Sarah Ballout; organisation: Peter L. Reichertz Institute for Medical Informatics; email: ballout.sarah@mh-hannover.de
OtherDetails Language Independent{PARENT:MD5-CAM-1.0.1=CD5C7EF669BF9300C4CE104319009B71, original_language=ISO_639-1::de, MD5-CAM-1.0.1=38a52eb08a493f61810f9d9f1bee3a88, sem_ver=15.0.0}
KeywordsPneumo, Pneumologie, Impfung, Allergien, Impfstatus
Language useden
Citeable Identifier1246.169.2579
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  • preliminary 
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  • amended 
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  • Percent
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  • Ja
  • Nein
  • Weiß nicht / keine Angabe
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  • Grippe (Influenza)
  • Pneumokokken
  • Tetanus (Wundstarrkrampf)
  • Polio
  • Diphterie
  • Pertussis (Keuchhusten)
  • SARS-CoV-2 (COVID-19)
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-EVALUATION.absence.v2], code=at0000, itemType=EVALUATION, level=1, text=Welche der folgenden Beschwerden bestehen bei Ihnen aktuell?, 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-EVALUATION.absence.v2]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=2, 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-EVALUATION.absence.v2]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=3, text=Auswurf, 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_TEXT, bindings=null, values=
  • Ja
  • Nein
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-EVALUATION.absence.v2]/data[at0001]/items[at0005 and name/value='Husten'], code=at0005, itemType=ELEMENT, level=3, text=Husten, 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=
  • Ja
  • Nein
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  • Ja
  • Nein
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-EVALUATION.absence.v2]/data[at0001]/items[at0005 and name/value='Brustenge/ -schmerzen'], code=at0005, itemType=ELEMENT, level=3, text=Brustenge/ -schmerzen, 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=
  • Ja
  • Nein
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-EVALUATION.absence.v2]/data[at0001]/items[at0005 and name/value='Gewichtsverlust'], code=at0005, itemType=ELEMENT, level=3, text=Gewichtsverlust, 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=
  • Ja
  • Nein
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-EVALUATION.absence.v2]/data[at0001]/items[at0005 and name/value='Arthritis (Gelenkentzündung)'], code=at0005, itemType=ELEMENT, level=3, text=Arthritis (Gelenkentzündung), 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=
  • Ja
  • Nein
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-EVALUATION.absence.v2]/data[at0001]/items[at0005 and name/value='Nächtliches Wasserlassen (Nykturie)'], code=at0005, itemType=ELEMENT, level=3, text=Nächtliches Wasserlassen (Nykturie), 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=
  • Ja
  • Nein
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-EVALUATION.absence.v2]/data[at0001]/items[at0005 and name/value='Hämoptysen (Bluthusten)'], code=at0005, itemType=ELEMENT, level=3, text=Hämoptysen (Bluthusten), 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=
  • Ja
  • Nein
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-EVALUATION.absence.v2]/data[at0001]/items[at0005 and name/value='Infektsymptome/ Fieber'], code=at0005, itemType=ELEMENT, level=3, text=Infektsymptome/ Fieber, 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=
  • Ja
  • Nein
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-EVALUATION.absence.v2]/data[at0001]/items[at0005 and name/value='Kopfschmerzen/ Sehstörungen'], code=at0005, itemType=ELEMENT, level=3, text=Kopfschmerzen/ Sehstörungen, 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=
  • Ja
  • Nein
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-EVALUATION.absence.v2]/data[at0001]/items[at0005 and name/value='Reflux (Sodbrennen)'], code=at0005, itemType=ELEMENT, level=3, text=Reflux (Sodbrennen), 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=
  • Ja
  • Nein
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-EVALUATION.absence.v2]/data[at0001]/items[at0005 and name/value='Nachtschweiss'], code=at0005, itemType=ELEMENT, level=3, text=Nachtschweiss, 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=
  • Ja
  • Nein
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-EVALUATION.absence.v2]/data[at0001]/items[at0005 and name/value='Synkopen (plötzl. Bewusstlosigkeit)'], code=at0005, itemType=ELEMENT, level=3, text=Synkopen (plötzl. Bewusstlosigkeit), 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=
  • Ja
  • Nein
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-EVALUATION.absence.v2]/data[at0001]/items[at0005 and name/value='Sie haben oben angegeben Auswurf zu haben. Welche Farbe hat Ihr Auswurf derzeit überwiegend?'], code=at0005, itemType=ELEMENT, level=3, text=Sie haben oben angegeben Auswurf zu haben. Welche Farbe hat Ihr Auswurf derzeit überwiegend?, 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=
  • weißlich/ klar
  • gelblich
  • grünlich
  • blutig/ rot
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-ACTION.medication.v1 and name/value='Allergie und Medikamenten-Unverträglichkeit'], code=at0000, itemType=ACTION, level=1, text=Allergie und Medikamenten-Unverträglichkeit, 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-ACTION.medication.v1 and name/value='Allergie und Medikamenten-Unverträglichkeit']/description[at0017], code=at0017, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=2, text=Description, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-ACTION.medication.v1 and name/value='Allergie und Medikamenten-Unverträglichkeit']/description[at0017]/items[at0020], code=at0020, itemType=ELEMENT, level=3, text=Allergien oder bekannte Medikamenten-Unverträglichkeiten?, 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_TEXT, bindings=null, values=
  • Ja
  • Nein
  • Weiß nicht / keine Angabe
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-ACTION.medication.v1 and name/value='Allergie und Medikamenten-Unverträglichkeit']/description[at0017]/items[at0021], code=at0021, itemType=ELEMENT, level=3, text=Wenn ja, gegen was?, 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=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Penicillin
  • Nickel
  • Katze
  • Milben
  • Bäume
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-ACTION.medication.v1 and name/value='Allergie und Medikamenten-Unverträglichkeit']/description[at0017]/items[at0024], code=at0024, itemType=ELEMENT, level=3, text=Weitere Unverträglichkeiten, description=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., comment=For example: 'Patient was in radiology department', 'Accidental injection into blood vessel during IM administration'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null]], templateType=normal]