TEMPLATE CAEHR_C_Körperliche_Untersuchung (CAEHR_C_Körperliche_Untersuchung)

TEMPLATE IDCAEHR_C_Körperliche_Untersuchung
ConceptCAEHR_C_Körperliche_Untersuchung
DescriptionDient zur beschreibung einer körperlichen Untersuchung im Rahmen von CAEHR
UseKörperliche Untersuchung im kardiologischen Rahmen
MisuseRepräsentation einer Körperlichen Untersuchung im allgemeinen.
PurposeDient zur beschreibung einer körperlichen Untersuchung im Rahmen von CAEHR
References
Authorsname: Severin Kohler; organisation: BIH; email: severin.kohler@charite.de
Other Details Languagename: Severin Kohler; organisation: BIH; email: severin.kohler@charite.de
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Language useden
Citeable Identifier1246.169.2836
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Units:
  • kg/m2
  • [lb_av]/[in_i]2
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[path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Herz Untersuchungen'], code=at0000, itemType=SECTION, level=2, text=Herz Untersuchungen, 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.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Herz Untersuchungen']/items[openEHR-EHR-OBSERVATION.pulse.v2], code=at0000, itemType=OBSERVATION, level=3, text=Herzfrequenz, description=The rate and associated attributes for a pulse or heart beat., 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.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Herz Untersuchungen']/items[openEHR-EHR-OBSERVATION.pulse.v2]/data[at0002], code=at0002, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, 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.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Herz Untersuchungen']/items[openEHR-EHR-OBSERVATION.pulse.v2]/data[at0002]/events[at0003], code=at0003, itemType=EVENT, level=5, 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.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Herz Untersuchungen']/items[openEHR-EHR-OBSERVATION.pulse.v2]/data[at0002]/events[at0003]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=6, 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.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Herz Untersuchungen']/items[openEHR-EHR-OBSERVATION.pulse.v2]/data[at0002]/events[at0003]/data[at0001]/items[at0004], code=at0004, itemType=ELEMENT, level=7, text=Pulsfrequenz, description=The rate of the pulse or heart beat, measured in beats per minute., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=0..1000 /min, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Herz Untersuchungen']/items[openEHR-EHR-OBSERVATION.pulse.v2]/data[at0002]/events[at0003]/data[at0001]/items[at0005], code=at0005, itemType=ELEMENT, level=7, text=Regularity, description=Regularity of the pulse or heart beat., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Regular 
  • Irregular 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Herz Untersuchungen']/items[openEHR-EHR-OBSERVATION.exam.v1], code=at0000, itemType=OBSERVATION, level=3, text=Herzuntersuchung, description=Findings observed during the physical examination of a subject of care., 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.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Herz Untersuchungen']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, 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.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Herz Untersuchungen']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=5, 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.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Herz Untersuchungen']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=6, 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.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Herz Untersuchungen']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam-heart.v0 and name/value='Herztöne'], code=at0000.1, itemType=CLUSTER, level=7, text=Herztöne, description=Findings observed during the physical examination of the heart., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Herz Untersuchungen']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam-heart.v0 and name/value='Herztöne']/items[at0001.1], code=at0001.1, itemType=ELEMENT, level=8, text=System or structure examined, description=Identification of the examined body system or anatomical structure., comment=Coding of the system or structure examined 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
  • Heart 
  • Heart sound, function (observable entity) 

Default value: Heart sound, function (observable entity), extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Herz Untersuchungen']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam-heart.v0 and name/value='Herztöne']/items[at0002], code=at0002, itemType=ELEMENT, level=8, text=No abnormality detected, description=Statement that no abnormality was detected (NAD) on physical examination., comment=Record as True if no abnormality was detected on examination. Specific statements about the examination can be included in the 'Clinical Interpretation' data element. If 'No abnormality detected' is selected, then recording of other examination data elements becomes redundant, with the exception of only the 'Clinical interpretation' data element, which may be useful if a normal statement is desired for recording, for example 'Normal examination'., 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.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Herz Untersuchungen']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam-heart.v0 and name/value='Herztöne']/items[at0.2], code=at0.2, itemType=ELEMENT, level=8, text=Heart sounds description, description=Narrative description of the heart sounds., 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
  • Heart sounds normal (finding) 
  • Heart sounds abnormal (finding) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Herz Untersuchungen']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam-heart.v0 and name/value='Herzgeräusche'], code=at0000.1, itemType=CLUSTER, level=7, text=Herzgeräusche, description=Findings observed during the physical examination of the heart., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Herz Untersuchungen']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam-heart.v0 and name/value='Herzgeräusche']/items[at0001.1], code=at0001.1, itemType=ELEMENT, level=8, text=System or structure examined, description=Identification of the examined body system or anatomical structure., comment=Coding of the system or structure examined 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
  • Heart 
  • Heart murmur (finding) 

Default value: Heart murmur (finding), extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Herz Untersuchungen']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam-heart.v0 and name/value='Herzgeräusche']/items[at0012], code=at0012, itemType=ELEMENT, level=8, text=Body site, description=Identification of the area of the body under examination., comment=If the body site has been fully identified in the 'System or structure examined' data element, this data element becomes 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
  • Heart structure (body structure) 

Default value: Heart structure (body structure), extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Herz Untersuchungen']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam-heart.v0 and name/value='Herzgeräusche']/items[at0002], code=at0002, itemType=ELEMENT, level=8, text=No abnormality detected, description=Statement that no abnormality was detected (NAD) on physical examination., comment=Record as True if no abnormality was detected on examination. Specific statements about the examination can be included in the 'Clinical Interpretation' data element. If 'No abnormality detected' is selected, then recording of other examination data elements becomes redundant, with the exception of only the 'Clinical interpretation' data element, which may be useful if a normal statement is desired for recording, for example 'Normal examination'., 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.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Herz Untersuchungen']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam-heart.v0 and name/value='Herzgeräusche']/items[at0006], code=at0006, itemType=ELEMENT, level=8, text=Clinical interpretation, description=Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings., comment=Coding of the 'Clinical interpretation' with a terminology is preferred, where 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
  • Systolic murmur (finding) 
  • Diastolic murmur (finding) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Herz Untersuchungen']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam-cardiovascular_system.v0], code=at0000.1, itemType=CLUSTER, level=7, text=Füllung der Halsvenen, description=Findings observed during the physical examination of the cardiovascular system as a whole., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Herz Untersuchungen']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam-cardiovascular_system.v0]/items[at0001.1], code=at0001.1, itemType=ELEMENT, level=8, text=System or structure examined, description=Identification of the examined body system or anatomical structure., comment=Coding of the system or structure examined 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
  • Cardiovascular system 
  • Structure of jugular vein (body structure) 

Default value: Structure of jugular vein (body structure), extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Herz Untersuchungen']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam-cardiovascular_system.v0]/items[at0002], code=at0002, itemType=ELEMENT, level=8, text=No abnormality detected, description=Statement that no abnormality was detected (NAD) on physical examination., comment=Record as True if no abnormality was detected on examination. Specific statements about the examination can be included in the 'Clinical Interpretation' data element. If 'No abnormality detected' is selected, then recording of other examination data elements becomes redundant, with the exception of only the 'Clinical interpretation' data element, which may be useful if a normal statement is desired for recording, for example 'Normal examination'., 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.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Herz Untersuchungen']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam-cardiovascular_system.v0]/items[at0006], code=at0006, itemType=ELEMENT, level=8, text=Clinical interpretation, description=Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings., comment=Coding of the 'Clinical interpretation' with a terminology is preferred, where 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
  • Jugular venous engorgement (finding) 

Default value: Jugular venous engorgement (finding), extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Herz Untersuchungen']/items[openEHR-EHR-EVALUATION.exclusion_specific.v1], code=at0000, itemType=EVALUATION, level=3, text=Ausschluss Füllung der Halsvene, 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.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Herz Untersuchungen']/items[openEHR-EHR-EVALUATION.exclusion_specific.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, 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.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Herz Untersuchungen']/items[openEHR-EHR-EVALUATION.exclusion_specific.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=5, 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
  • Definitely NOT present (qualifier value) 

Default value: Definitely NOT present (qualifier value), extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Herz Untersuchungen']/items[openEHR-EHR-EVALUATION.exclusion_specific.v1]/data[at0001]/items[at0003], code=at0003, itemType=ELEMENT, level=5, 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
  • Jugular venous engorgement (finding) 

Default value: Jugular venous engorgement (finding), extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Allgemeiner Eindruck'], code=at0000, itemType=SECTION, level=2, text=Allgemeiner Eindruck, 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.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Allgemeiner Eindruck']/items[openEHR-EHR-OBSERVATION.exam.v1], code=at0000, itemType=OBSERVATION, level=3, text=Physical examination findings, description=Findings observed during the physical examination of a subject of care., 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.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Allgemeiner Eindruck']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, 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.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Allgemeiner Eindruck']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=5, 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.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Allgemeiner Eindruck']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=6, 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.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Allgemeiner Eindruck']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam.v2 and name/value='Ernährungszustand'], code=at0000, itemType=CLUSTER, level=7, text=Ernährungszustand, description=Findings observed during the physical examination of a body system or anatomical structure., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Allgemeiner Eindruck']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam.v2 and name/value='Ernährungszustand']/items[at0001], code=at0001, itemType=ELEMENT, level=8, text=System or structure examined, description=Identification of the examined body system or anatomical structure., comment=Coding of the system or structure examined 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
  • Nutritional status (observable entity) 

Default value: Nutritional status (observable entity), extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Allgemeiner Eindruck']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam.v2 and name/value='Ernährungszustand']/items[at0006], code=at0006, itemType=ELEMENT, level=8, text=Clinical interpretation, description=Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings., comment=For example: 'No abnormality detected' or 'Moderate inflammation present'. Coding of the 'Clinical interpretation' with a terminology is preferred, where possible., 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
  • Normal (qualifier value) 
  • Reduced (qualifier value) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Allgemeiner Eindruck']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam.v2 and name/value='Allgemeinzustand'], code=at0000, itemType=CLUSTER, level=7, text=Allgemeinzustand, description=Findings observed during the physical examination of a body system or anatomical structure., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Allgemeiner Eindruck']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam.v2 and name/value='Allgemeinzustand']/items[at0001], code=at0001, itemType=ELEMENT, level=8, text=System or structure examined, description=Identification of the examined body system or anatomical structure., comment=Coding of the system or structure examined 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
  • General clinical state (observable entity) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Allgemeiner Eindruck']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam.v2 and name/value='Allgemeinzustand']/items[at0006], code=at0006, itemType=ELEMENT, level=8, text=Clinical interpretation, description=Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings., comment=For example: 'No abnormality detected' or 'Moderate inflammation present'. Coding of the 'Clinical interpretation' with a terminology is preferred, where possible., 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
  • Normal (qualifier value) 
  • Reduced (qualifier value) 
, extendedValues=null]], templateType=normal]