TEMPLATE General condition UCO (General condition UCO)

TEMPLATE IDGeneral condition UCO
ConceptGeneral condition UCO
DescriptionNot Specified
PurposeNot Specified
References
Authorsdate: 2019-12-04; name: Katrin Tröltzsch; organisation: Universitätsklinik Heidelberg; email: katrin.troeltzsch@med.uni-heidelberg.de
Other Details Languagedate: 2019-12-04; name: Katrin Tröltzsch; organisation: Universitätsklinik Heidelberg; email: katrin.troeltzsch@med.uni-heidelberg.de
Other Details (Language Independent)
  • Licence: This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/.
  • Custodian Organisation: openEHR Foundation
  • Original Namespace: org.openehr
  • Original Publisher: openEHR Foundation
  • Custodian Namespace: org.openehr
  • PARENT:MD5-CAM-1.0.1: 005501C1FA493A4838F5F1121F2870EC
  • MD5-CAM-1.0.1: 20dfbaedf80a5a9aaeed5bc1e82ff915
  • Sem Ver: 5.0.0
  • Original Language: ISO_639-1::en
Language useden
Citeable Identifier1246.169.3394
Root archetype idopenEHR-EHR-COMPOSITION.report.v1
General condition UCOGeneral condition UCO: 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.
Case identificationCase identification: To record case identification details for public health purposes.
Case identifierCase identifier: The identifier of this case.
Body heightBody height: 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 eventAny event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Height/LengthHeight/Length: The length of the body from crown of head to sole of foot.
0..1000 cm
null_reason
null_flavour
Body weightBody weight: Measurement of the body weight of an individual.
Data
Any eventAny event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
WeightWeight: The weight of the individual.
0..1000 kg
Pain scale (VAS)Pain scale (VAS): The pain scale VAS is a visual analog scale for the subjective measurement of the sensation intensity of pain.
Data
Any eventAny event: A defined point in time that can be explicitly defined in the template or at application runtime.
Data
Overall scoreOverall score: Pain intensity from 0 (no pain) to 10 (most severe, unbearable pain).
0..10
CommentComment: Additional information that is not adequately captured by the visual scale but may be helpful in assessing pain.
ECOG performance statusECOG performance status: A scale used by clinicians to assess the functional performance status of a patient with a diagnosis of cancer. Also known as the WHO performance status or Zubrod performance status.
Data
Any eventAny event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
ECOG performance statusECOG performance status: The functional performance status of a patient with a diagnosis of cancer.
  • 0: Asymptomatic 
  • 1: Symptomatic, fully ambulatory 
  • 2: Symptomatic, in bed <50% of the day 
  • 3: Symptomatic, in bed >50% of the day (but not bedridden) 
  • 4: Bedridden 
  • 5: Dead 
CommentComment: Additional narrative about the overall ECOG performance status not captured in other fields.
Karnofsky Performance Status ScaleKarnofsky Performance Status Scale: A scale used by clinical personnel to record symptom-related Not to be used to record examination results.
Data
Any eventAny event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Performance StatusPerformance Status: Symptom-related limitations of activity, self-care and self-determination of cancer patients.
  • 0: Dead 
  • 10: Moribund 
  • 20: Very sick 
  • 30: Severely disabled 
  • 40: Disabled 
  • 50: Requires occasional assistance 
  • 60: Requires occasional assistance 
  • 70: Cares for self 
  • 80: Normal activity with effort 
  • 90: Able to carry on normal activity 
  • 100: Normal no complaints 
CommentComment: Additional narrative about symptom-related limitations of activity, self-supply and self-determination not captured in other fields.
Child-Pugh scoreChild-Pugh score: Tool used to assess the prognosis of chronic liver disease, mainly cirrhosis.
Data
Any EventAny Event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Total bilirubinTotal bilirubin: Score for total bilirubin in micromole per litre.
  • 1: Less than 34 
  • 2: 34 to 50 
  • 3: Greater than 50 
Serum albuminSerum albumin: Score for serum albumin in grams per litre.
  • 1: Greater than 35 
  • 2: 28 to 35 
  • 3: Less than 28 
INRINR: Score for INR.
  • 1: Less than 1.7 
  • 2: 1.7 to 2.3 
  • 3: Greater than 2.3 
AscitesAscites: Score for presence of ascites.
  • 1: None 
  • 2: Mild 
  • 3: Moderate to severe 
Hepatic encephalopathyHepatic encephalopathy: Score for presence of hepatic encephalopathy.
  • 1: None 
  • 2: Grade I to II or suppressed with medication 
  • 3: Grade III to IV or refractory 
Adjusted bilirubinAdjusted bilirubin: Score for total bilirubin if the patient has primary biliary cirrhosis or sclerosing cholangitis.
  • 1: Less than 68 
  • 2: 68 to 170 
  • 3: Greater than 170 
Total scoreTotal score: Sum of the individual scores assigned for each of the contributing variables.
5..15
GradeGrade: Grading, based on total score.
  • Class A 5 to 6 points 
  • Class B 7 to 9 points 
  • Class C 10 to 15 points 
New York Heart Association functional classificationNew 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 eventAny event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Functional capacityFunctional 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.
  • Class I 
  • Class II 
  • Class III 
  • Class IIIa 
  • Class IIIb 
  • Class IV 
ALBI gradeALBI grade: The instrument used to assess the survival prognosis of patients with hepatocellular carcinoma.
Data
Any eventAny event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Serum albuminSerum albumin: Serum albumin in grams per liter.
Units: g/l
Total bilirubinTotal bilirubin: Total bilirubin in micromoles per liter.
Units: μmol/l
Overall scoreOverall score: The score calculated from the laboratory values.
Units:
GradeGrade: The ALBI grade assigned based on the total score.
  • grade 1 
  • grade 2 
  • grade 3