| TEMPLATE ID | Anamnese_Kardiologie |
|---|---|
| Concept | Anamnese_Kardiologie |
| Description | Zur Repräsentation der Anamnesedaten von Patient*innen mit Herz-Kreislauf-Erkrankungen. |
| Use | Zur Repräsentation der Anamnesedaten von Patient*innen mit Herz-Kreislauf-Erkrankungen. |
| Purpose | Zur Repräsentation der Anamnesedaten von Patient*innen mit Herz-Kreislauf-Erkrankungen. |
| References | |
| Authors | date: 2024-01-26; name: Kim Werle; organisation: Medizinische Hochschule Hannover |
| Other Details Language | date: 2024-01-26; name: Kim Werle; organisation: Medizinische Hochschule Hannover |
| Other Details (Language Independent) |
|
| Keywords | Anamnese, Kardiologie, Kardiovaskuläre Erkrankungen, Herz-Kreislauf-Erkrankungen |
| Language used | en |
| Citeable Identifier | 1246.169.3326 |
| Root archetype id | openEHR-EHR-COMPOSITION.report.v1 |
| Anamnese | Anamnese: Document to communicate information to others, commonly in response to a request from another party. |
| Allgemeine Daten | Allgemeine Daten: A generic section header which should be renamed in a template to suit a specific clinical context. |
| Personendaten | Personendaten: Demografische Daten zu einer Person wie Geburtsdatum und Telefonnummer. |
| Data | |
| Birth data | Birth data: Birth demographic data |
| Birth date | Birth date: The date of birth of a person |
| Country of birth | Country of birth: The country where a person was born Terminology: ISO-3166 ALPHA-2
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| Address | Address: Details about the location of a person, physical building or landmark. |
| State/Territory/Province | State/Territory/Province: The name of a major government district or geographical area that contains the address. Coding with an external terminology is preferred, where possible. For example: 'New South Wales' and 'Queensland' in Australia; 'British Columbia' and 'Nova Scotia' in Canada; and the Counties of 'Cornwall', 'Middlesex' & 'Surrey' in Jamaica.
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| Electronic communication | Electronic communication: Details about a specified type of electronic communication. |
| Type | Type: The type or form of electronic communication. The DV_CODED_TEXT value set supports recording of the most common electronic communications used in health. If other alternatives are required the DV_TEXT data type can be used to record other types of electronic communication such as social media or video conferencing URLs within a template. |
| Value | Value: The unique combination of alphanumeric characters, relevant for representation of 'Type'. For example: area code + landline phone/pager number; country code + mobile phone number; or email address. |
| Ethnic identity | Ethnic identity: Affiliation, kinship or connection with one or more groupings of people, according to common origins or background. |
| Data | |
| Ethnicity | Ethnicity: Name of the ethnic or cultural grouping with whom the individual identifies an affiliation, kinship or connection. For example: Australian; Torres Strait Islander; Maori; Roma Gypsy; Sikh, or Greek. Coding with a terminology is preferred, where possible - for example ABS 1249.0 - Australian Standard Classification of Cultural and Ethnic Groups (ASCCEG), 2019. The occurrences for this data element is set to multiple occurences to allow for more than one social grouping to be selected.
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| Body weight | Body weight: Measurement of the body weight of an individual. |
| Data | |
| Any event | Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time. |
| Data | |
| Weight | Weight: The weight of the individual. 0..1000 kg |
| Gewichtsveränderung | Gewichtsveränderung: Additional narrative about the measurement of Body weight, not captured in other fields.
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| Height/Length | Height/Length: Height, or body length, is measured from crown of head to sole of foot. Height is measured with the individual in a standing position and body length in a recumbent position. |
| Data | |
| Any event | Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time. |
| Data | |
| Height/Length | Height/Length: The length of the body from crown of head to sole of foot. 0..1000 cm |
| Body mass index | Body mass index: Calculated measurement which compares a person's weight and height. Body Mass Index is a calculated ratio describing how an individual's body weight relates to the weight that is regarded as normal, or desirable, for the individual's height. |
| Data | |
| Any event | Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time. |
| Data | |
| Body mass index | Body mass index: Index describing ratio of weight to height. 0..1000 kg/m² |
| Allergie | Allergie: Clinical assessment of the propensity for an individual to experience a harmful or undesirable physiological response if exposed, or re-exposed, to a substance. Substances include, but are not limited to: a therapeutic substance administered correctly at an appropriate dosage for the individual; food; material derived from plants or animals; or venom from insect stings. Optional[{source=openEHR,FHIR}] |
| Data | |
| Substance | Substance: Identification of a substance, or substance class, that is considered to put the individual at risk of an adverse reaction event. Both an individual substance and a substance class are valid entries in 'Substance'. A substance may be a compound of simpler substances, for example a medicinal product. It is strongly recommended that the 'Substance' is coded with a terminology capable of triggering decision support, where possible. For example: Snomed CT, DM+D, RxNorm, NDFRT, ATC, New Zealand Universal List of Medicines and Australian Medicines Terminology. Free text entry should only be used if there is no appropriate terminology available.
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| Comment | Comment: Additional narrative about the propensity for the adverse reaction, not captured in other fields. For example: including reason for flagging a 'Criticality' of 'High risk'; and instructions related to future exposure or administration of the Substance, such as administration within an Intensive Care Unit or under corticosteroid cover. |
| Exclusion - specific | Exclusion - specific: 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. |
| Data | |
| Nebenwirkungen auslösende Substanz/Allergen | Nebenwirkungen auslösende Substanz/Allergen: The Adverse reaction substance/agent to which the 'Exclusion statement' applies. For example: 'Penicillin', 'Peanuts' or 'Latex'.
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| Absence of information | Absence of information: Statement that specified health information is not available for inclusion in the health record or extract at the time of recording. |
| Data | |
| Absence statement | Absence statement: Positive statement that no information is available. 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".
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| Modified Rankin Scale (mRS) | Modified Rankin Scale (mRS): An assessment tool used to measure the degree of disability and level of assistance required after a stroke or another neurological event. |
| Data | |
| Any point in time event | Any point in time event: Default, unspecified point in time event which may be explicitly defined in a template or at run-time. |
| Data | |
| Modified Rankin Scale | Modified Rankin Scale: Degree of disability and level of assistance required after a stroke or another neurological event.
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| Kardiovaskuläre Risikofaktoren | Kardiovaskuläre Risikofaktoren: A generic section header which should be renamed in a template to suit a specific clinical context. |
| Blood pressure | Blood pressure: The local measurement of arterial blood pressure which is a surrogate for arterial pressure in the systemic circulation. Most commonly, use of the term 'blood pressure' refers to measurement of brachial artery pressure in the upper arm. |
| Data | Data: History Structural node. |
| Any event | Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time. |
| Data | |
| Systolic | Systolic: Peak systemic arterial blood pressure - measured in systolic or contraction phase of the heart cycle. 0..1000 mmHg |
| Diastolic | Diastolic: Minimum systemic arterial blood pressure - measured in the diastolic or relaxation phase of the heart cycle. 0..1000 mmHg |
| Tobacco smoking summary | Tobacco smoking summary: Summary or persistent information about the tobacco smoking habits of an individual. |
| Data | |
| Overall status | Overall status: Statement about current smoking behaviour for all types of tobacco.
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| Overall description | Overall description: Narrative summary about the individual's overall tobacco smoking pattern and history. Use this data element to record a narrative description of the tobacco smoking habits for this individual or to incorporate unstructured tobacco smoking information from existing or legacy clinical systems into an archetyped format. |
| Regular smoking commenced | Regular smoking commenced: The date or partial date when the individual first started frequent or regular, but usually non-daily, smoking of tobacco of any type. Can be a partial date, for example, only a year. For example, this date could represent when the individual commenced smoking every Friday night or at parties. |
| Overall quit date | Overall quit date: The date when the individual last ceased using tobacco of any type. Can be a partial date, for example, only a year. This date could be used by decision support guidance to determine if the individual is at risk of relapse, for example in the first 12 months since quitting. |
| Overall years of smoking | Overall years of smoking: The cumulative number of years that the individual has smoked tobacco. This data element does not take into account the amount of tobacco smoked. It may be used to calculate the 'Smoking index'. >=0 yr |
| Smoking index | Smoking index: An indication of the cumulative amount of tobacco smoking exposure. This parameter is similar to Pack Years but based on units of cigarettes, bidis etc smoked per day, rather than packs. >=0 |
| Overall pack years | Overall pack years: Estimate of the cumulative amount for all types of tobacco smoked. The definition of a pack can be recorded in the protocol of this archetype using the 'Pack definition' data element. >=0 |
| Overall comment | Overall comment: Additional narrative about all tobacco smoking that has not been captured in other fields. For example: stopped smoking or reduced amount on becoming pregnant. |
| Alcohol consumption summary | Alcohol consumption summary: Summary or persistent information about the typical alcohol consumption of an individual. |
| Data | |
| Momentaner Alkoholkonsum | Momentaner Alkoholkonsum: Details about a discrete period of time with a consistent pattern of typical consumption. |
| Status | Status: Statement about current alcohol drinking behaviour.
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| Pattern | Pattern: The typical pattern of consumption of alcohol. The typical pattern of use can be made more granular by coding with a terminology or a local value set in a template.
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| Menge des Alkoholkonsums | Menge des Alkoholkonsums: Additional narrative about alcohol consumption during the specified episode, not captured in other fields. For example: alcohol consumed as a hangover remedy eg 'hair of the dog'.
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| Problem/Diagnosis | Problem/Diagnosis: 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 name | Problem/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.
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| Behandlung | Behandlung: Narrative description about the problem or diagnosis. Use to provide background and context, including evolution, episodes or exacerbations, progress and any other relevant details, about the problem or diagnosis.
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| Cause | Cause: A cause, set of causes, or manner of causation of the problem or diagnosis. Also known as 'aetiology' or 'etiology'. Coding with an external terminology is preferred, where possible.
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| Date/time of onset | Date/time of onset: Estimated or actual date/time that signs or symptoms of the problem/diagnosis were first observed. Data captured/imported as "Age at onset" should be converted to a date using the subject's date of birth. |
| Diabetes Typ | Diabetes Typ: Diabetes mellitus umfasst eine Gruppe von Stoffwechselerkrankungen mit unterschiedlichen Ursachen. Diese Erkrankungen sind gekennzeichnet durch einen chronisch erhöhten Blutzuckerspiegel die auf Insulinmangel oder Insulinresistenz beruhen. Es ist eine Einteilung in verschiedene Diabetes mellitus Typen üblich. |
| Diabetes Typ | Diabetes Typ: Diabetes mellitus Typ des Patienten.
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| Comment | Comment: Additional narrative about the problem or diagnosis not captured in other fields. |
| Family history | Family history: Summary information about the significant health-related problems found in family members. |
| Data | |
| Summary | Summary: Narrative overview about problems, diagnoses, psychosocial, environmental and genetic markers that have been identified in family members. This field can be used to record a summary or the conclusion of all the findings, for unstructured family history information recorded in clinical records, or to import textual data from existing/legacy clinical systems.
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| Per problem | Per problem: Details about the presence of a specific problem or diagnosis in family members. If the problem has a genetic predisposition within families, then only genetic relatives should be considered as part of this data. If the problem has psychosocial or environmental effects then non-genetic family members may also be included. |
| Problem/diagnosis name | Problem/diagnosis name: Identification of the significant problem or diagnosis in the family overall. This is the problem for which aggregated data involving all family members will be collected. Coding of the index problem with a terminology is preferred, where possible.
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| Exclusion - specific | Exclusion - specific: 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. |
| Data | |
| (Excluded concept) | (Excluded concept): Identification of the specific concept which has been excluded. Use this data element in one of two ways. Firstly, exclusion of family history of diabetes can be expressed by using 'Family problem/diagnosis' as the run-time name constraint and 'diabetes' as the value for this data point. Alternatively the value could contain precoordinated terms such as 'No past family history of diabetes'. Coding of the value for 'Excluded concept', either as a simple or precoordinated term, with a terminology is desirable where possible. If a precoordinated term is used with this data element the 'Exclusion statement' becomes redundant.
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| Absence of information | Absence of information: Statement that specified health information is not available for inclusion in the health record or extract at the time of recording. |
| Data | |
| Absence statement | Absence statement: Positive statement that no information is available. 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".
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| Vorerkrankungen | Vorerkrankungen: A generic section header which should be renamed in a template to suit a specific clinical context. |
| Problem/Diagnosis | Problem/Diagnosis: 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 name | Problem/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.
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| Variant | Variant: Specific variant or subtype of the Diagnosis, if relevant. For example: 'acute motor axonal neuropathy' as a variant of Guillain-Barre Syndrome. Coding of the name of the variant with a terminology is preferred, where possible.
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| Behandlung | Behandlung: Narrative description about the problem or diagnosis. Use to provide background and context, including evolution, episodes or exacerbations, progress and any other relevant details, about the problem or diagnosis.
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| Behandlung 2 | Behandlung 2: A cause, set of causes, or manner of causation of the problem or diagnosis. Also known as 'aetiology' or 'etiology'. Coding with an external terminology is preferred, where possible.
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| Date/time of onset | Date/time of onset: Estimated or actual date/time that signs or symptoms of the problem/diagnosis were first observed. Data captured/imported as "Age at onset" should be converted to a date using the subject's date of birth. |
| Datum/Zeitpunkt des letztmaligen Auftretens | Datum/Zeitpunkt des letztmaligen Auftretens: Estimated or actual date/time the diagnosis or problem was recognised by a healthcare professional. 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. |
| Symptom/Sign | Symptom/Sign: Reported observation of a physical or mental disturbance in an individual. |
| Symptom/Sign name | Symptom/Sign name: The name of the reported symptom or sign. Symptom name should be coded with a terminology, where possible.
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| Course description | Course description: Narrative description about the course of the problem or diagnosis since onset.
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| Comment | Comment: Additional narrative about the problem or diagnosis not captured in other fields.
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| Exclusion - specific | Exclusion - specific: 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. |
| Data | |
| Problem/Diagnose | Problem/Diagnose: The problem or diagnosis to which the 'Exclusion statement' applies. For example: 'Diabetes', 'COPD' or 'Asthma'.
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| Absence of information | Absence of information: Statement that specified health information is not available for inclusion in the health record or extract at the time of recording. |
| Data | |
| Absence statement | Absence statement: Positive statement that no information is available. 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".
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| Kardiovaskuläre Erkrankungen | Kardiovaskuläre Erkrankungen: A generic section header which should be renamed in a template to suit a specific clinical context. |
| Problem/Diagnosis | Problem/Diagnosis: 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 name | Problem/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.
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| Variant | Variant: Specific variant or subtype of the Diagnosis, if relevant. For example: 'acute motor axonal neuropathy' as a variant of Guillain-Barre Syndrome. Coding of the name of the variant with a terminology is preferred, where possible.
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| Body site | Body site: Identification of a simple body site for the location of the problem or diagnosis. Coding of the name of the anatomical location with a terminology is preferred, where possible. Use this data element to record precoordinated anatomical locations. If the requirements for recording the anatomical location are determined at run-time by the application or require more complex modelling such as relative locations then use the CLUSTER.anatomical_location or CLUSTER.relative_location within the 'Structured anatomical location' SLOT in this archetype. Occurrences for this data element are unbounded to allow for clinical scenarios such as describing a rash in multiple locations but where all of the other attributes are identical. If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant.
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| Cause | Cause: A cause, set of causes, or manner of causation of the problem or diagnosis. Also known as 'aetiology' or 'etiology'. Coding with an external terminology is preferred, where possible.
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| Date/time of onset | Date/time of onset: Estimated or actual date/time that signs or symptoms of the problem/diagnosis were first observed. Data captured/imported as "Age at onset" should be converted to a date using the subject's date of birth. |
| Datum/Zeitpunkt des letztmaligen Auftretens | Datum/Zeitpunkt des letztmaligen Auftretens: Estimated or actual date/time the diagnosis or problem was recognised by a healthcare professional. 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. |
| Comment | Comment: Additional narrative about the problem or diagnosis not captured in other fields. |
| Protocol | |
| Krankenhausaufenthalt | Krankenhausaufenthalt: Zur Darstellung eines stationären oder ambulaten Krankenhausaufenthaltes an einem Ort innerhalb einer Klinik. |
| Details zum Aufenthalt | Details zum Aufenthalt: Details zum Aufenthalt. |
| Grund | Grund: Was war der Grund für den Krankenhausaufenthalt des Patienten? Verschiedene Gründe für einen Krankenhausaufenthalt können dabei über eine Wiederholung des Clusters "Details zum Aufenthalt" dokumentiert werden.
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| Anzahl | Anzahl: Wie viele Krankenhausaufenthalte hatte der Patient zum Zeitpunkt der Dokumentation? >=0 |
| Medication management | Medication management: 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. This is not limited to activities performed based on medication orders from clinicians, but could also include for example taking over the counter medication. |
| Description | |
| Medication item | Medication item: Name of the medication, vaccine or other therapeutic/prescribable item which was the focus of the activity. 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.
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| Comment | Comment: 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. For example: 'Patient was in radiology department', 'Accidental injection into blood vessel during IM administration'.
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| Exclusion - specific | Exclusion - specific: 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. |
| Data | |
| (Excluded concept) | (Excluded concept): Identification of the specific concept which has been excluded. Use this data element in one of two ways. Firstly, exclusion of family history of diabetes can be expressed by using 'Family problem/diagnosis' as the run-time name constraint and 'diabetes' as the value for this data point. Alternatively the value could contain precoordinated terms such as 'No past family history of diabetes'. Coding of the value for 'Excluded concept', either as a simple or precoordinated term, with a terminology is desirable where possible. If a precoordinated term is used with this data element the 'Exclusion statement' becomes redundant.
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| Absence of information | Absence of information: Statement that specified health information is not available for inclusion in the health record or extract at the time of recording. |
| Data | |
| Absence statement | Absence statement: Positive statement that no information is available. 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".
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| New York Heart Association functional classification | New York Heart Association functional classification: A simple method of classifying the extent of heart failure, as defined by the New York Heart Association. |
| Data | |
| Any event | Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time. |
| Data | |
| Functional capacity | Functional capacity: Assessment of heart failure based on how a patient with cardiac disease feels during physical activity. Class III and the Class III subtypes, IIIa and IIIb, are intended to be mutually exclusive but are included in this internal code set for completeness. Within a template either the Class III alone or both of the subtypes, IIIa and IIIb, should be set to inactive.
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| EHRA-Score | EHRA-Score: Der EHRA-Score (European Heart Rhythm Association) wird verwendet, um den Schweregrad der Symptome bei Vorhofflimmern zu bestimmen. |
| Data | |
| Beliebiges Ereignis | Beliebiges Ereignis: Standardmäßiger, nicht näher beschriebener Zeitpunkt oder Intervall Ereignis welches in einem Template oder bei der Anwendung genauer definiert werden kann. |
| Data | |
| EHRA-Klassifikation | EHRA-Klassifikation: Schweregrad der Symptome bei Vorhofflimmern.
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| EHRA-Score Vorhofflattern | EHRA-Score Vorhofflattern: Der EHRA-Score (European Heart Rhythm Association) wird verwendet, um den Schweregrad der Symptome bei Vorhofflimmern zu bestimmen. |
| Data | |
| Beliebiges Ereignis | Beliebiges Ereignis: Standardmäßiger, nicht näher beschriebener Zeitpunkt oder Intervall Ereignis welches in einem Template oder bei der Anwendung genauer definiert werden kann. |
| Data | |
| EHRA-Klassifikation | EHRA-Klassifikation: Schweregrad der Symptome bei Vorhofflimmern.
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| Fontaine-Klassifikation | Fontaine-Klassifikation: Die Fontaine-Klassifikation ist eine Stadieneinteilung der peripheren arteriellen Verschlusskrankheit (pAVK). |
| Data | |
| Beliebiges Ereignis | Beliebiges Ereignis: Standardmäßiger, nicht näher beschriebener Zeitpunkt oder Intervall Ereignis welches in einem Template oder bei der Anwendung genauer definiert werden kann. |
| Data | |
| Fontaine-Klassifikation | Fontaine-Klassifikation: *
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| Angina symptom classification (CCS) | Angina symptom classification (CCS): Angina symptom score based on Canadian Cardiovascular Society (CCS) Angina Status score. |
| Data | |
| Any event | Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time. |
| Data | |
| Angina classification | Angina classification: Angina symptom score based on Canadian Cardiovascular Society (CCS) Angina Status classification.
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| Kardiovaskuläre Eingriffe | Kardiovaskuläre Eingriffe: A generic section header which should be renamed in a template to suit a specific clinical context. |
| Medical device summary | Medical device summary: An ongoing and persistent overview about medical devices that have been fitted or implanted. |
| Data | |
| Device type | Device type: Name of the type of medical device. For example: Assisted hearing devices, eyeglasses, contact lens, dental braces, dentures, orthotics or artificial limbs.
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| Device details | Device details: Details about each device. |
| Medizinprodukttyp | Medizinprodukttyp: Identification of the specific device, by name.
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| Procedure | Procedure: A clinical activity carried out for screening, investigative, diagnostic, curative, therapeutic, evaluative or palliative purposes. |
| Description | |
| Procedure name | Procedure name: Identification of the procedure by name. Coding of the specific procedure with a terminology is preferred, where possible.
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| Description | Description: Narrative description about the procedure, as appropriate for the pathway step. For example: description about the performance and findings from the the procedure, the aborted attempt or the cancellation of the procedure. |
| Indication | Indication: The clinical or process-related reason for the procedure. Coding of the indication with a terminology is preferred, where possible. This data element allows multiple occurrences. For example: 'Failed bowel preparation' or 'Bowel cancer screening'.
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| Method | Method: Identification of specific method or technique for the procedure. Use this data element to record simple terms or a narrative description. If the requirements for recording the method require more complex modelling then this can be represented by additional archetypes within the 'Procedure detail' SLOT in this archetype. If the method is included in the 'Procedure name' via precoordinated codes, this data element becomes redundant.
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| Body site | Body site: Identification of the body site for the procedure. Occurrences for this data element are unbounded to allow for clinical scenarios such as removing multiple skin lesions in different places, but where all of the other attributes are identical. Use this data element to record simple terms or precoordinated anatomical locations. If the requirements for recording the anatomical location are determined at run-time by the application or require more complex modelling such as relative locations then use the CLUSTER.anatomical_location or CLUSTER.relative_location within the 'Procedure detail' SLOT in this archetype. If the anatomical location is included in the 'Procedure name' via precoordinated codes, this data element becomes redundant.
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| Scheduled date/time | Scheduled date/time: The date and/or time on which the procedure is intended to be performed. Only for use in association with the 'Procedure scheduled' pathway step. |
| Comment | Comment: Additional narrative about the activity or care pathway step not captured in other fields. |
| Exclusion - specific | Exclusion - specific: 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. |
| Data | |
| Eingriff | Eingriff: The Procedure to which the 'Exclusion statement' applies. For example: 'Heart surgery' or 'Appendectomy' or 'Hip replacement'.
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| Protocol | |
| Symptom/Sign | Symptom/Sign: Reported observation of a physical or mental disturbance in an individual. |
| Indikation | Indikation: The name of the reported symptom or sign. Symptom name should be coded with a terminology, where possible.
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| Körperstelle | Körperstelle: Simple body site where the symptom or sign was reported. Occurrences of this data element are set to 0..* to allow multiple body sites to be separated out in a template if desired. This allows for representation of clinical scenarios where a symptom or sign needs to be recorded in multiple locations or identifying both the originating and distal site in pain radiation, but where all of the other attributes such as impact and duration are identical. If the requirements for recording the body site are determined at run-time by the application or require more complex modelling such as relative locations then use the CLUSTER.anatomical_location or CLUSTER.relative_location within the Detailed anatomical location' SLOT in this archetype. If the anatomical location is included in the Symptom name via precoordinated codes, this data element becomes redundant. If the anatomical location is recorded using the 'Structured body site' SLOT, then use of this data element is not allowed - record only the simple 'Body site' OR 'Structured body site', but not both.
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| Absence of information | Absence of information: Statement that specified health information is not available for inclusion in the health record or extract at the time of recording. |
| Data | |
| Absence statement | Absence statement: Positive statement that no information is available. 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".
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| Protocol | |
| Symptom/Sign | Symptom/Sign: Reported observation of a physical or mental disturbance in an individual. |
| Indikation | Indikation: The name of the reported symptom or sign. Symptom name should be coded with a terminology, where possible.
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| Körperstelle | Körperstelle: Simple body site where the symptom or sign was reported. Occurrences of this data element are set to 0..* to allow multiple body sites to be separated out in a template if desired. This allows for representation of clinical scenarios where a symptom or sign needs to be recorded in multiple locations or identifying both the originating and distal site in pain radiation, but where all of the other attributes such as impact and duration are identical. If the requirements for recording the body site are determined at run-time by the application or require more complex modelling such as relative locations then use the CLUSTER.anatomical_location or CLUSTER.relative_location within the Detailed anatomical location' SLOT in this archetype. If the anatomical location is included in the Symptom name via precoordinated codes, this data element becomes redundant. If the anatomical location is recorded using the 'Structured body site' SLOT, then use of this data element is not allowed - record only the simple 'Body site' OR 'Structured body site', but not both.
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| Sonstiges | Sonstiges: A generic section header which should be renamed in a template to suit a specific clinical context. |
| Clinical synopsis | Clinical synopsis: Narrative summary or overview about a patient, specifically from the perspective of a healthcare provider, and with or without associated interpretations. |
| Data | |
| Synopsis | Synopsis: The summary, assessment, conclusions or evaluation of the clinical findings. |