TEMPLATE Psych_Fragebogen Patient (Psych_Fragebogen Patient)

TEMPLATE IDPsych_Fragebogen Patient
ConceptPsych_Fragebogen Patient
DescriptionNot Specified
PurposeNot Specified
References
Authorsdate: 2023-10-23; name: test
Other Details Languagedate: 2023-10-23; name: test
Other Details (Language Independent)
  • Sem Ver: 54.1.0
  • MD5-CAM-1.0.1: 91f709a383d024d6066e1e5367dffa8e
  • PARENT:MD5-CAM-1.0.1: 005501C1FA493A4838F5F1121F2870EC
  • Original Language: ISO_639-1::de
Language useden
Citeable Identifier1246.169.3233
Root archetype idopenEHR-EHR-COMPOSITION.report.v1
Psych_Fragebogen PatientPsych_Fragebogen Patient: Document to communicate information to others, commonly in response to a request from another party.
Other Context
Report IDReport ID: Identification information about the report.
StatusStatus: The status of the entire report. Note: This is not the status of any of the report components.
PersonendatenPersonendaten: Demografische Daten zu einer Person wie Geburtsdatum und Telefonnummer.
Data
PersonPerson: An individual human being.
Studiensetting_1Studiensetting_1: The unstructured name for the individual.
The content of this data element may be derived from one or more components from CLUSTER.structured_name combined together as a text string. For example: 'John Markham', 'Professor Sir John Markham', 'John Markham Jnr MP'.
Terminology: local_terms_setting1
  • Psychiatrie 
  • Psychosomatik Station/TKL 
  • Kaufsuchtsprechstunde PSO 
  • SH-Gruppe 
  • Entwöhnung/Sucht 
Studiensetting_2Studiensetting_2: A label for the individual.
For example: 'Neighbour in the house with the red door'.
Terminology: local_terms_setting2
  • nicht klinisch 
  • stationär/tagesklinisch 
  • ambulant 
VP_IDVP_ID: Identifier associated with the individual.
Occurrences for this data element is set to 0..* to allow for more than one Identifier to be recorded. Note that the DV_IDENTIFIER data type contains multiple subcomponents for recording the ID value, type, issuer and assigned. For example - social security number; driver's license; or passport number.
  •  Identifier
  •  Text
Case identificationCase identification: To record case identification details for public health purposes.
RekrutierungsortRekrutierungsort: The identifier of this case.
Terminology: local_terms_ort
  • PSO MHH 
  • PSY MHH 
  • Duisburg 
  • salus Klinik Friedrichsdorf 
  • Hannover 
  • Berlin 
  • Erlangen 
  • Nürnberg 
Datum AmbulanzterminDatum Ambulanztermin: The date that the case was commenced.
DiagnoseDiagnose: 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.
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'.
Data
Problem/Diagnosis nameProblem/Diagnosis name: Identification of the problem or diagnosis, by name.
Coding of the name of the problem or diagnosis with a terminology is preferred, where possible.
  •  Coded Text Terminology: ICD-10-GM
    • Mittelschwere depressive Episode 
    • Rezidivierende depressive Störung, aktuelle Episode leicht 
    • Rezidivierende depressive Störung, aktuelle Episode schwergradig ohne psychotische Symptome 
    • Anhaltende affektive Störung, bipolare affektive Störung, derzeitige Episode gemischt 
    • Soziale Phobie 
    • Generalisierte Angststörung 
    • Zwanghafte Störungen [Zwänge] mit psychotischen Symptomen 
    • Andere näher bezeichnete Zwangsstörungen 
    • Somatoforme autonome Funktionsstörung des Magens und des Darmes 
    • Nicht näher bezeichnete Essstörung 
    • Emotional instabile Persönlichkeitsstörung des Borderline-Typs 
    • Andere näher bezeichnete Impulssteuerungsstörungen 
    • Hyperkinetische Störung 
  •  Text