TEMPLATE CAEHR_B_Diagnose (CAEHR_B_Diagnose)

TEMPLATE IDCAEHR_B_Diagnose
ConceptCAEHR_B_Diagnose
DescriptionZur Repräsentation von Diagnosen für die Speicherung im Rahmen des CAEHR-Projektes.
UseFür die Abbildung von Haupt- und Nebendiagnosen eines Patienten für die Speicherung im Rahmen des CAEHR Projektes.
MisuseNicht zur Repräsentation von Symptomen und/oder Krankheitsanzeichen verwenden. Hierzu sollte der passende Archetyp im Rahmen eines geeigneten Templates verwendet werden.
PurposeZur Repräsentation von Diagnosen für die Speicherung im Rahmen des CAEHR-Projektes.
References
Authorsdate: 2023-02-27; name: Marina Rudenko; organisation: Vitasystems GmbH; email: marina.rudenko@vitagroup.ag
Other Details Languagedate: 2023-02-27; name: Marina Rudenko; organisation: Vitasystems GmbH; email: marina.rudenko@vitagroup.ag
OtherDetails Language Independent{PARENT:MD5-CAM-1.0.1=005501C1FA493A4838F5F1121F2870EC, original_language=ISO_639-1::de, MD5-CAM-1.0.1=a860ed92d1c727f5867eb3e51ff04cb9, sem_ver=8.0.0}
KeywordsCAEHR; Diagnose; Hauptdiagnose; Komorbidität; Nebendiagnose
Language useden
Citeable Identifier1246.169.2945
AllOperationalTemplate [rootArchetypeId=openEHR-EHR-COMPOSITION.report.v1, otherContributors=Nina Schewe, tshis=[ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1], code=at0000, itemType=COMPOSITION, level=0, text=CAEHR_B_Diagnose, description=Document to communicate information to others, commonly in response to a request from another party., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=COMPOSITION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Hauptdiagnose'], code=at0000, itemType=EVALUATION, level=1, text=Hauptdiagnose, description=Details about a single identified health condition, injury, disability or any other issue which impacts on the physical, mental and/or social well-being of an individual., comment=Clear delineation between the scope of a problem versus a diagnosis is not easy to achieve in practice. For the purposes of clinical documentation with this archetype, problem and diagnosis are regarded as a continuum, with increasing levels of detail and supportive evidence usually providing weight towards the label of 'diagnosis'., uncommonOntologyItems=null, occurencesFormal=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-EVALUATION.problem_diagnosis.v1 and name/value='Hauptdiagnose']/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.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Hauptdiagnose']/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=3, text=Problem/Diagnosis name, description=Identification of the problem or diagnosis, by name., comment=Coding of the name of the problem or diagnosis with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: http://fhir.de/CodeSystem/bfarm/icd-10-gm
Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=http://fhir.de/ValueSet/bfarm/icd-10-gm
  • (Proximale) Epiphyse, Epiphysenlösung (Proximale) Epiphyse, Epiphysenlösung 
  • (Teilweiser) Verlust der oberen Extremität, beidseitig (Teilweiser) Verlust der oberen Extremität, beidseitig 
  • (Teilweiser) Verlust der unteren Extremität, beidseitig (Teilweiser) Verlust der unteren Extremität, beidseitig 
  • 1 Jahr und länger zurückliegend 1 Jahr und länger zurückliegend 
  • 14. Woche bis 19 vollendete Wochen 14. Woche bis 19 vollendete Wochen 
  • 2-Propanol 2-Propanol 
  • 20. Woche bis 25 vollendete Wochen 20. Woche bis 25 vollendete Wochen 
  • 21-Hydroxylase-Mangel [AGS Typ 3], klassische Form 21-Hydroxylase-Mangel [AGS Typ 3], klassische Form 
  • 21-Hydroxylase-Mangel [AGS Typ 3], Late-onset-Form 21-Hydroxylase-Mangel [AGS Typ 3], Late-onset-Form 
  • 26. Woche bis 33 vollendete Wochen 26. Woche bis 33 vollendete Wochen 
  • 29 Tage bis unter 4 Monate zurückliegend 29 Tage bis unter 4 Monate zurückliegend 
  • 30 Minuten bis 24 Stunden 30 Minuten bis 24 Stunden 
  • 34. Woche bis 36 vollendete Wochen 34. Woche bis 36 vollendete Wochen 
  • 37. Woche bis 41 vollendete Wochen 37. Woche bis 41 vollendete Wochen 
  • 4 Monate bis unter 1 Jahr zurückliegend 4 Monate bis unter 1 Jahr zurückliegend 
  • 4-Aminophenol-Derivate 4-Aminophenol-Derivate 
  • 5 bis 13 vollendete Wochen 5 bis 13 vollendete Wochen 
  • A. carotis communis A. carotis communis 
  • A. carotis externa A. carotis externa 
  • A. carotis interna A. carotis interna 
  • A. carotis, Teil nicht näher bezeichnet A. carotis, Teil nicht näher bezeichnet 
  • AB0-Isoimmunisierung beim Fetus und Neugeborenen AB0-Isoimmunisierung beim Fetus und Neugeborenen 
  • AB0-Unverträglichkeitsreaktion AB0-Unverträglichkeitsreaktion 
  • Abdomen Abdomen 
  • Abdominale Aktinomykose Abdominale Aktinomykose 
  • ... +17003 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Hauptdiagnose']/data[at0001]/items[at0003], code=at0003, itemType=ELEMENT, level=3, text=Date/time clinically recognised, description=Estimated or actual date/time the diagnosis or problem was recognised by a healthcare professional., comment=Partial dates are acceptable. If the subject of care is under the age of one year, then the complete date or a minimum of the month and year is necessary to enable accurate age calculations - for example, if used to drive decision support. Data captured/imported as "Age at time of clinical recognition" should be converted to a date using the subject's date of birth., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Hauptdiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v2], code=at0000, itemType=CLUSTER, level=3, text=Problem/Diagnosis qualifier, description=Contextual or temporal qualifier for a specified problem or diagnosis., 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-EVALUATION.problem_diagnosis.v1 and name/value='Hauptdiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v2]/items[at0063], code=at0063, itemType=ELEMENT, level=4, text=Diagnostic category, description=Category of the problem or diagnosis within a specified episode of care and/or local care context., comment=This data element contains a value set commonly used in diagnostic categorisation. In episodic care contexts (commonly secondary care) it is common to categorise/organise diagnoses according to their relationship to the principal diagnosis being addressed during that episode of care. These categories may also be used for clinical coding, reporting and billing purposes. In some countries the diagnostic category may be known as a DRG. In addition, the free text choice permits use of other local value sets, as required., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Principal diagnosis 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Hauptdiagnose']/data[at0001]/items[at0073], code=at0073, itemType=ELEMENT, level=3, text=Diagnostic certainty, description=The level of confidence in the identification of the diagnosis., comment=If an alternative valueset is required, these values can be added to the DV_TEXT data type in a template., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Suspected 
  • Probable 
  • Confirmed 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Nebendiagnose'], code=at0000, itemType=EVALUATION, level=1, text=Nebendiagnose, description=Details about a single identified health condition, injury, disability or any other issue which impacts on the physical, mental and/or social well-being of an individual., comment=Clear delineation between the scope of a problem versus a diagnosis is not easy to achieve in practice. For the purposes of clinical documentation with this archetype, problem and diagnosis are regarded as a continuum, with increasing levels of detail and supportive evidence usually providing weight towards the label of 'diagnosis'., uncommonOntologyItems=null, occurencesFormal=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-EVALUATION.problem_diagnosis.v1 and name/value='Nebendiagnose']/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.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Nebendiagnose']/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=3, text=Problem/Diagnosis name, description=Identification of the problem or diagnosis, by name., comment=Coding of the name of the problem or diagnosis with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: http://fhir.de/CodeSystem/bfarm/icd-10-gm
Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=http://fhir.de/ValueSet/bfarm/icd-10-gm
  • (Proximale) Epiphyse, Epiphysenlösung (Proximale) Epiphyse, Epiphysenlösung 
  • (Teilweiser) Verlust der oberen Extremität, beidseitig (Teilweiser) Verlust der oberen Extremität, beidseitig 
  • (Teilweiser) Verlust der unteren Extremität, beidseitig (Teilweiser) Verlust der unteren Extremität, beidseitig 
  • 1 Jahr und länger zurückliegend 1 Jahr und länger zurückliegend 
  • 14. Woche bis 19 vollendete Wochen 14. Woche bis 19 vollendete Wochen 
  • 2-Propanol 2-Propanol 
  • 20. Woche bis 25 vollendete Wochen 20. Woche bis 25 vollendete Wochen 
  • 21-Hydroxylase-Mangel [AGS Typ 3], klassische Form 21-Hydroxylase-Mangel [AGS Typ 3], klassische Form 
  • 21-Hydroxylase-Mangel [AGS Typ 3], Late-onset-Form 21-Hydroxylase-Mangel [AGS Typ 3], Late-onset-Form 
  • 26. Woche bis 33 vollendete Wochen 26. Woche bis 33 vollendete Wochen 
  • 29 Tage bis unter 4 Monate zurückliegend 29 Tage bis unter 4 Monate zurückliegend 
  • 30 Minuten bis 24 Stunden 30 Minuten bis 24 Stunden 
  • 34. Woche bis 36 vollendete Wochen 34. Woche bis 36 vollendete Wochen 
  • 37. Woche bis 41 vollendete Wochen 37. Woche bis 41 vollendete Wochen 
  • 4 Monate bis unter 1 Jahr zurückliegend 4 Monate bis unter 1 Jahr zurückliegend 
  • 4-Aminophenol-Derivate 4-Aminophenol-Derivate 
  • 5 bis 13 vollendete Wochen 5 bis 13 vollendete Wochen 
  • A. carotis communis A. carotis communis 
  • A. carotis externa A. carotis externa 
  • A. carotis interna A. carotis interna 
  • A. carotis, Teil nicht näher bezeichnet A. carotis, Teil nicht näher bezeichnet 
  • AB0-Isoimmunisierung beim Fetus und Neugeborenen AB0-Isoimmunisierung beim Fetus und Neugeborenen 
  • AB0-Unverträglichkeitsreaktion AB0-Unverträglichkeitsreaktion 
  • Abdomen Abdomen 
  • Abdominale Aktinomykose Abdominale Aktinomykose 
  • ... +17003 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Nebendiagnose']/data[at0001]/items[at0003], code=at0003, itemType=ELEMENT, level=3, text=Date/time clinically recognised, description=Estimated or actual date/time the diagnosis or problem was recognised by a healthcare professional., comment=Partial dates are acceptable. If the subject of care is under the age of one year, then the complete date or a minimum of the month and year is necessary to enable accurate age calculations - for example, if used to drive decision support. Data captured/imported as "Age at time of clinical recognition" should be converted to a date using the subject's date of birth., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Nebendiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v2], code=at0000, itemType=CLUSTER, level=3, text=Problem/Diagnosis qualifier, description=Contextual or temporal qualifier for a specified problem or diagnosis., 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-EVALUATION.problem_diagnosis.v1 and name/value='Nebendiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v2]/items[at0063], code=at0063, itemType=ELEMENT, level=4, text=Diagnostic category, description=Category of the problem or diagnosis within a specified episode of care and/or local care context., comment=This data element contains a value set commonly used in diagnostic categorisation. In episodic care contexts (commonly secondary care) it is common to categorise/organise diagnoses according to their relationship to the principal diagnosis being addressed during that episode of care. These categories may also be used for clinical coding, reporting and billing purposes. In some countries the diagnostic category may be known as a DRG. In addition, the free text choice permits use of other local value sets, as required., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Secondary diagnosis 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Nebendiagnose']/data[at0001]/items[at0073], code=at0073, itemType=ELEMENT, level=3, text=Diagnostic certainty, description=The level of confidence in the identification of the diagnosis., comment=If an alternative valueset is required, these values can be added to the DV_TEXT data type in a template., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Suspected 
  • Probable 
  • Confirmed 
, extendedValues=null]], templateType=normal]