TEMPLATE Stationärer Versorgungsfall_uksh (Stationärer Versorgungsfall_uksh)

TEMPLATE IDStationärer Versorgungsfall_uksh
ConceptStationärer Versorgungsfall_uksh
DescriptionZur Repräsentation der administrativen Daten eines Falls (Fallinformationen, Aufnahme, Entlassung) eines Patienten innerhalb einer Einrichtung. Ein “Fall” beginnt mit der Aufnahme ins Krankenhaus an einem Aufnahmedatum und endet mit der Entlassung an einem Entlassungsdatum.
UseFür die Abbildung stationärer Aufenthalte eines Patienten in einer Gesundheitseinrichtung.
MisuseNicht zur Repräsentation eines einzelnen stationären Aufenthalts eines Patienten auf einer Station zu verwenden. Bitte den Archetyp ADMIN_ENTRY.krankenhausaufenthalt.v0 zur Dokumentation einzelne Aufenthalte unterhalb eines Falls verwenden.
PurposeZur Repräsentation der administrativen Daten eines Falls (Fallinformationen, Aufnahme, Entlassung) eines Patienten innerhalb einer Einrichtung. Ein “Fall” beginnt mit der Aufnahme ins Krankenhaus an einem Aufnahmedatum und endet mit der Entlassung an einem Entlassungsdatum.
References
OtherDetails Language Independent{MetaDataSet:Sample Set =Template metadata sample set, PARENT:MD5-CAM-1.0.1=AFFFB351A3113D61F0822FEBDF5F42E3, original_language=ISO_639-1::de, MD5-CAM-1.0.1=9aa7feba879aa3e931604e0e9f4c088d}
KeywordsVersorgungsfall; Fall; Aufnahme
Language useden
Citeable Identifier1246.169.3297
AllOperationalTemplate [rootArchetypeId=openEHR-EHR-COMPOSITION.fall.v1, otherContributors=null, tshis=[ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.fall.v1], code=at0000, itemType=COMPOSITION, level=0, text=Stationärer Versorgungsfall, description=Strukturierte Sammlung von Informationen zu einem Sachverhalt oder Problem, der bzw. das bearbeitet werden muss. Die Bearbeitungsschritte eines Falles werden durch Aktivitäten und Bearbeiter definiert, die dem Fall zugeordnet werden., 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=null, code=null, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=1, text=Other Context, description=null, 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.fall.v1]/context/other_context[at0001]/items[at0005], code=at0005, itemType=ELEMENT, level=2, text=Falltyp, description=Charaktierisierung des Falls, bspw. als Einrichtungskontakt, Abteilungskontakt, Versorgungsstellenkontakt., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Einrichtungskontakt
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.fall.v1]/context/other_context[at0001]/items[at0004], code=at0004, itemType=ELEMENT, level=2, text=Fallklasse, description=Nähere Beschreibung des Falls als Fallklasse, z.B. ambulanter Besuch, stationärer, prä- oder nachstationärer Aufenthalt., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Stationär
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.fall.v1]/context/other_context[at0001]/items[at0010], code=at0010, itemType=ELEMENT, level=2, text=Fallstatus, description=Status des Falls, comment=Status des Falls, uncommonOntologyItems={fhir=Encounter.status}, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: http://hl7.org/fhir/encounter-status
  • Planned 
  • In Progress 
  • On Leave 
  • Finished 
  • Cancelled 
  • Entered in Error 
  • Unknown 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.fall.v1]/context/other_context[at0001]/items[at0003], code=at0003, itemType=ELEMENT, level=2, text=Fall-Kennung, description=Eindeutige Identifikation des Falls, z.B. Fallnummer., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.fall.v1]/context/other_context[at0001]/items[at0011], code=at0011, itemType=ELEMENT, level=2, text=Übergeordneter Fall, description=Ein anderer Fall, von dem dieser Fall ein Teil ist (administrativ oder zeitlich)., comment=Ein anderer Fall, von dem dieser Fall ein Teil ist (administrativ oder zeitlich)., uncommonOntologyItems={fhir=Encounter.partOf}, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.fall.v1]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.organization.v0], code=at0000, itemType=CLUSTER, level=2, text=Fachliche Organisationseinheit, description=Location includes both casual locations (a place used for health care without prior designation or authorisation) and dedicated, formally designated locations. The sites can be private, public, mobile or fixed., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.fall.v1]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.organization.v0]/items[at0051], code=at0051, itemType=ELEMENT, level=3, text=Type, description=*, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Hospital Department
  • [...]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.fall.v1]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.organization.v0]/items[at0024], code=at0024, itemType=ELEMENT, level=3, text=Identifier, description=A group of buildings or other locations such as a site or campus. For example: Campus that is outside the facility, but belongs to the hospital, university., 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: Anhang 1 der BPflV (31.12.2003)
  • Innere Medizin 
  • Geriatrie 
  • Kardiologie 
  • Nephrologie 
  • Hamatologie und internistische Onkologie 
  • Endokrinologie 
  • Gastroenterologie 
  • Pneumologie 
  • Rheumatologie 
  • Padiatrie 
  • Kinderkardiologie 
  • Neonatologie 
  • Kinderchirurgie 
  • Lungen- und Bronchialheilkunde 
  • Allgemeine Chirurgie 
  • Unfallchirurgie 
  • Neurochirurgie 
  • Gefa.chirurgie 
  • Plastische Chirurgie 
  • Thoraxchirurgie 
  • Herzchirurgie 
  • Urologie 
  • Orthopadie 
  • Frauenheilkunde und Geburtshilfe 
  • Geburtshilfe 
  • Hals-, Nasen-, Ohrenheilkunde 
  • Augenheilkunde 
  • Neurologie 
  • Allgemeine Psychiatrie 
  • Kinder- und Jugendpsychiatrie 
  • Psychosomatik/Psychotherapie 
  • Nuklearmedizin 
  • Strahlenheilkunde 
  • Dermatologie 
  • Zahn- und Kieferheilkunde, Mund- und Kieferchirurgie 
  • Intensivmedizin 
  • Orthopadie und Unfallchirurgie 
  • Frauenheilkunde 
  • Sonstige Fachabteilung 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.fall.v1]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.organization.v0]/items[at0052], code=at0052, itemType=ELEMENT, level=3, text=Name, description=*, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.fall.v1]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.organization.v0]/items[at0050], code=at0050, itemType=ELEMENT, level=3, text=Active/Inactive, description=*, comment=null, 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.fall.v1]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.organization.v0]/items[at0046], code=at0046, itemType=ELEMENT, level=3, text=Location description, description=The field contains the optional free text description of the location, e.g. thoracic, heart and vascular surgery., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.fall.v1]/content[openEHR-EHR-ADMIN_ENTRY.admission.v0], code=at0000, itemType=ADMIN_ENTRY, level=1, text=Aufnahmedaten, description=Used for admitted patient only. It signals the beginning of a patient's stay in a health care facility., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ADMIN_ENTRY, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.fall.v1]/content[openEHR-EHR-ADMIN_ENTRY.admission.v0]/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.fall.v1]/content[openEHR-EHR-ADMIN_ENTRY.admission.v0]/data[at0001]/items[at0013], code=at0013, itemType=ELEMENT, level=3, text=Admission type, description=The circumstance under which the patient will be admitted., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: §21 KHEntgG
  • Krankenhausbehandlung, vollstationär 
  • Krankenhausbehandlung, vollstationär mit vorausgegangener vorstationärer Behandlung 
  • Krankenhausbehandlung, teilstationär 
  • vorstationäre Behandlung ohne anschließende vollstationäre Behandlung 
  • Stationäre Entbindung 
  • Geburt 
  • Wiederaufnahme wegen Komplikationen (Fallpauschale) nach KFPV 2003 
  • Stationäre Aufnahme zur Organentnahme 
  • Stationsäquivalente Behandlung 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.fall.v1]/content[openEHR-EHR-ADMIN_ENTRY.admission.v0]/data[at0001]/items[at0049], code=at0049, itemType=ELEMENT, level=3, text=Aufnahmeanlass, description=Detailed description of the mode of admission., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: §21 KHEntgG
  • Einweisung durch einen Arzt 
  • Einweisung durch einen Zahnarzt 
  • Notfall 
  • Aufnahme nach vorausgehender Behandlung in einer Rehabilitationseinrichtung 
  • Verlegung mit Behandlungsdauer im verlegenden Krankenhaus länger als 24 Stunden 
  • Verlegung mit Behandlungsdauer im verlegenden Krankenhaus bis zu 24 Stunden 
  • Geburt 
  • Begleitperson oder mitaufgenommene Pflegekraft 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.fall.v1]/content[openEHR-EHR-ADMIN_ENTRY.admission.v0]/data[at0001]/items[at0023], code=at0023, itemType=ELEMENT, level=3, text=Pre-admit number, description=ID number of patient's pre-admission, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.fall.v1]/content[openEHR-EHR-ADMIN_ENTRY.admission.v0]/data[at0001]/items[at0071], code=at0071, itemType=ELEMENT, level=3, text=Admit date/time, description=Date/time the patient was admitted., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.fall.v1]/content[openEHR-EHR-ADMIN_ENTRY.admission.v0]/data[at0001]/items[openEHR-EHR-CLUSTER.location.v1], code=at0000, itemType=CLUSTER, level=3, text=Vorheriger Patientenstandort (vor Aufnahme), description=Location includes both casual locations (a place used for health care without prior designation or authorisation) and dedicated, formally designated locations. The sites can be private, public, mobile or fixed., 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.fall.v1]/content[openEHR-EHR-ADMIN_ENTRY.admission.v0]/data[at0001]/items[openEHR-EHR-CLUSTER.location.v1]/items[at0024], code=at0024, itemType=ELEMENT, level=4, text=Campus, description=A group of buildings or other locations such as a site or campus. For example: Campus that is outside the facility, but belongs to the hospital, university., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.fall.v1]/content[openEHR-EHR-ADMIN_ENTRY.admission.v0]/data[at0001]/items[openEHR-EHR-CLUSTER.location.v1]/items[at0025], code=at0025, itemType=ELEMENT, level=4, text=Building, description=Either building or structure. These can include rooms, corridors, wings, etc.. It may not have walls or a roof, but is considered a defined/allocated space., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.fall.v1]/content[openEHR-EHR-ADMIN_ENTRY.admission.v0]/data[at0001]/items[openEHR-EHR-CLUSTER.location.v1]/items[at0028], code=at0028, itemType=ELEMENT, level=4, text=Level, description=A level in a multi-level building/structure., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.fall.v1]/content[openEHR-EHR-ADMIN_ENTRY.admission.v0]/data[at0001]/items[openEHR-EHR-CLUSTER.location.v1]/items[at0027], code=at0027, itemType=ELEMENT, level=4, text=Ward, description=A ward is part of a medical facility that can contain rooms and other types of locations., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.fall.v1]/content[openEHR-EHR-ADMIN_ENTRY.admission.v0]/data[at0001]/items[openEHR-EHR-CLUSTER.location.v1]/items[at0029], code=at0029, itemType=ELEMENT, level=4, text=Room, description=A location that was declared as a room. Some locations can have the room in the corridor, e.g. ward XYZ corridor 2; where bed space 2 is in the corridor of the respective ward., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.fall.v1]/content[openEHR-EHR-ADMIN_ENTRY.admission.v0]/data[at0001]/items[openEHR-EHR-CLUSTER.location.v1]/items[at0034], code=at0034, itemType=ELEMENT, level=4, text=Bed Location, description=Used to document information about the bed space e.g. bed was placed next to the window or next to the door., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.fall.v1]/content[openEHR-EHR-ADMIN_ENTRY.admission.v0]/data[at0001]/items[openEHR-EHR-CLUSTER.location.v1]/items[at0046], code=at0046, itemType=ELEMENT, level=4, text=Location description, description=The field contains the optional free text description of the location, e.g. thoracic, heart and vascular surgery., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.fall.v1]/content[openEHR-EHR-ADMIN_ENTRY.admission.v0]/data[at0001]/items[openEHR-EHR-CLUSTER.organization.v0], code=at0000, itemType=CLUSTER, level=3, text=Vorherige verantwortliche Organisationseinheit (vor Aufnahme), description=Location includes both casual locations (a place used for health care without prior designation or authorisation) and dedicated, formally designated locations. The sites can be private, public, mobile or fixed., 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.fall.v1]/content[openEHR-EHR-ADMIN_ENTRY.admission.v0]/data[at0001]/items[openEHR-EHR-CLUSTER.organization.v0]/items[at0051], code=at0051, itemType=ELEMENT, level=4, text=Type, description=*, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.fall.v1]/content[openEHR-EHR-ADMIN_ENTRY.admission.v0]/data[at0001]/items[openEHR-EHR-CLUSTER.organization.v0]/items[at0024], code=at0024, itemType=ELEMENT, level=4, text=Identifier, description=A group of buildings or other locations such as a site or campus. For example: Campus that is outside the facility, but belongs to the hospital, university., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.fall.v1]/content[openEHR-EHR-ADMIN_ENTRY.admission.v0]/data[at0001]/items[openEHR-EHR-CLUSTER.organization.v0]/items[at0052], code=at0052, itemType=ELEMENT, level=4, text=Name, description=*, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.fall.v1]/content[openEHR-EHR-ADMIN_ENTRY.admission.v0]/data[at0001]/items[openEHR-EHR-CLUSTER.organization.v0]/items[at0050], code=at0050, itemType=ELEMENT, level=4, text=Active/Inactive, description=*, comment=null, 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.fall.v1]/content[openEHR-EHR-ADMIN_ENTRY.admission.v0]/data[at0001]/items[openEHR-EHR-CLUSTER.organization.v0]/items[at0046], code=at0046, itemType=ELEMENT, level=4, text=Location description, description=The field contains the optional free text description of the location, e.g. thoracic, heart and vascular surgery., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.fall.v1]/content[openEHR-EHR-ADMIN_ENTRY.discharge_summary.v0], code=at0000, itemType=ADMIN_ENTRY, level=1, text=Discharge summary, description=Used for discharged patient only., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ADMIN_ENTRY, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.fall.v1]/content[openEHR-EHR-ADMIN_ENTRY.discharge_summary.v0]/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.fall.v1]/content[openEHR-EHR-ADMIN_ENTRY.discharge_summary.v0]/data[at0001]/items[at0040], code=at0040, itemType=ELEMENT, level=3, text=Discharge status, description=Discharge status., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: §21 KHEntgG
  • Behandlung regulär beendet 
  • Behandlung regulär beendet, nachstationäre Behandlung vorgesehen 
  • Behandlung aus sonstigen Gründen beendet 
  • Behandlung gegen ärztlichen Rat beendet 
  • Zuständigkeitswechsel des Kostenträgers 
  • Verlegung in ein anderes Krankenhaus 
  • Tod 
  • Verlegung in ein anderes Krankenhaus im Rahmen einer Zusammenarbeit (§ 14 Abs. 5 Satz 2 BPflV in der am 31.12.2003 geltenden Fassung) 
  • Entlassung in eine Rehabilitationseinrichtung 
  • Entlassung in eine Pflegeeinrichtung 
  • Entlassung in ein Hospiz 
  • interne Verlegung 
  • externe Verlegung zur psychiatrischen Behandlung 
  • Behandlung aus sonstigen Gründen beendet, nachstationäre Behandlung vorgesehen 
  • Behandlung gegen ärztlichen Rat beendet, nachstationäre Behandlung vorgesehen 
  • externe Verlegung mit Rückverlegung oder Wechsel zwischen den Entgeltbereichen der DRG-Fallpau- schalen, nach der BPflV oder für besondere Einrichtungen nach § 17b Abs. 1 Satz 15 KHG mit Rückverlegung 
  • interne Verlegung mit Wechsel zwischen den Entgeltbereichen der DRG-Fallpauschalen, nach der BPflV oder für besondere Einrichtungen nach § 17b Abs. 1 Satz 15 KHG 
  • Rückverlegung 
  • Entlassung vor Wiederaufnahme mit Neueinstufung 
  • Entlassung vor Wiederaufnahme mit Neueinstufung wegen Komplikation 
  • Entlassung oder Verlegung mit nachfolgender Wiederaufnahme 
  • Fallabschluss (interne Verlegung) bei Wechsel zwischen voll-, teilstationärer und stationsäquivalenter Behandlung 
  • Beginn eines externen Aufenthalts mit Abwesenheit über Mitternacht (BPflV-Bereich – für verlegende Fachabteilung) 
  • Beendigung eines externen Aufenthalts mit Abwesenheit über Mitternacht (BPflV-Bereich – für Pseudo-Fachabteilung 0003) 
  • Entlassung zum Jahresende bei Aufnahme im Vorjahr (für Zwecke der Abrechnung - § 4 PEPPV) 
  • Beginn eines Zeitraumes ohne direkten Patientenkontakt (stationsäquivalente Behandlung) 
  • Beendigung eines Zeitraumes ohne direkten Patientenkontakt (stationsäquivalente Behandlung – für Pseudo-Fachabteilung 0004) 
  • Behandlung regulär beendet, beatmet entlassen 
  • Behandlung regulär beendet, beatmet verlegt 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.fall.v1]/content[openEHR-EHR-ADMIN_ENTRY.discharge_summary.v0]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=3, text=Clinical condition of the patient, description=Clinical condition of the patient., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Cured 
  • Improved 
  • Same state 
  • Worse 
  • Deceased 
  • Undetermined. 
  • *Sonstige(en) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.fall.v1]/content[openEHR-EHR-ADMIN_ENTRY.discharge_summary.v0]/data[at0001]/items[at0011], code=at0011, itemType=ELEMENT, level=3, text=Datum/Uhrzeit der Entlassung, description=Date/Time the patiente was discharge., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.fall.v1]/content[openEHR-EHR-ADMIN_ENTRY.discharge_summary.v0]/data[at0001]/items[at0050], code=at0050, itemType=ELEMENT, level=3, text=Additional information, description=Comments, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.fall.v1]/content[openEHR-EHR-ADMIN_ENTRY.discharge_summary.v0]/data[at0001]/items[openEHR-EHR-CLUSTER.location.v1], code=at0000, itemType=CLUSTER, level=3, text=Zugewiesener Standort (bei Entlassung), description=Location includes both casual locations (a place used for health care without prior designation or authorisation) and dedicated, formally designated locations. The sites can be private, public, mobile or fixed., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.fall.v1]/content[openEHR-EHR-ADMIN_ENTRY.discharge_summary.v0]/data[at0001]/items[openEHR-EHR-CLUSTER.location.v1]/items[at0024], code=at0024, itemType=ELEMENT, level=4, text=Campus, description=A group of buildings or other locations such as a site or campus. For example: Campus that is outside the facility, but belongs to the hospital, university., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.fall.v1]/content[openEHR-EHR-ADMIN_ENTRY.discharge_summary.v0]/data[at0001]/items[openEHR-EHR-CLUSTER.location.v1]/items[at0025], code=at0025, itemType=ELEMENT, level=4, text=Building, description=Either building or structure. These can include rooms, corridors, wings, etc.. It may not have walls or a roof, but is considered a defined/allocated space., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.fall.v1]/content[openEHR-EHR-ADMIN_ENTRY.discharge_summary.v0]/data[at0001]/items[openEHR-EHR-CLUSTER.location.v1]/items[at0028], code=at0028, itemType=ELEMENT, level=4, text=Level, description=A level in a multi-level building/structure., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.fall.v1]/content[openEHR-EHR-ADMIN_ENTRY.discharge_summary.v0]/data[at0001]/items[openEHR-EHR-CLUSTER.location.v1]/items[at0027], code=at0027, itemType=ELEMENT, level=4, text=Ward, description=A ward is part of a medical facility that can contain rooms and other types of locations., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.fall.v1]/content[openEHR-EHR-ADMIN_ENTRY.discharge_summary.v0]/data[at0001]/items[openEHR-EHR-CLUSTER.location.v1]/items[at0029], code=at0029, itemType=ELEMENT, level=4, text=Room, description=A location that was declared as a room. Some locations can have the room in the corridor, e.g. ward XYZ corridor 2; where bed space 2 is in the corridor of the respective ward., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.fall.v1]/content[openEHR-EHR-ADMIN_ENTRY.discharge_summary.v0]/data[at0001]/items[openEHR-EHR-CLUSTER.location.v1]/items[at0034], code=at0034, itemType=ELEMENT, level=4, text=Bed Location, description=Used to document information about the bed space e.g. bed was placed next to the window or next to the door., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.fall.v1]/content[openEHR-EHR-ADMIN_ENTRY.discharge_summary.v0]/data[at0001]/items[openEHR-EHR-CLUSTER.location.v1]/items[at0046], code=at0046, itemType=ELEMENT, level=4, text=Location description, description=The field contains the optional free text description of the location, e.g. thoracic, heart and vascular surgery., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.fall.v1]/content[openEHR-EHR-ADMIN_ENTRY.discharge_summary.v0]/data[at0001]/items[openEHR-EHR-CLUSTER.organization.v0], code=at0000, itemType=CLUSTER, level=3, text=Zugewiesene verantwortliche Organisationseinheit (bei Entlassung), description=Location includes both casual locations (a place used for health care without prior designation or authorisation) and dedicated, formally designated locations. The sites can be private, public, mobile or fixed., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.fall.v1]/content[openEHR-EHR-ADMIN_ENTRY.discharge_summary.v0]/data[at0001]/items[openEHR-EHR-CLUSTER.organization.v0]/items[at0051], code=at0051, itemType=ELEMENT, level=4, text=Type, description=*, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.fall.v1]/content[openEHR-EHR-ADMIN_ENTRY.discharge_summary.v0]/data[at0001]/items[openEHR-EHR-CLUSTER.organization.v0]/items[at0024], code=at0024, itemType=ELEMENT, level=4, text=Identifier, description=A group of buildings or other locations such as a site or campus. For example: Campus that is outside the facility, but belongs to the hospital, university., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.fall.v1]/content[openEHR-EHR-ADMIN_ENTRY.discharge_summary.v0]/data[at0001]/items[openEHR-EHR-CLUSTER.organization.v0]/items[at0052], code=at0052, itemType=ELEMENT, level=4, text=Name, description=*, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.fall.v1]/content[openEHR-EHR-ADMIN_ENTRY.discharge_summary.v0]/data[at0001]/items[openEHR-EHR-CLUSTER.organization.v0]/items[at0050], code=at0050, itemType=ELEMENT, level=4, text=Active/Inactive, description=*, comment=null, 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.fall.v1]/content[openEHR-EHR-ADMIN_ENTRY.discharge_summary.v0]/data[at0001]/items[openEHR-EHR-CLUSTER.organization.v0]/items[at0046], code=at0046, itemType=ELEMENT, level=4, text=Location description, description=The field contains the optional free text description of the location, e.g. thoracic, heart and vascular surgery., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null]], templateType=normal]