| TEMPLATE ID | Operation |
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| Concept | Operation |
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| Description | Zur Repräsentation von Daten zu einer Operation eines Patienten im HiGHmed Projekt. |
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| Use | Dieses Template wird verwendet, um Daten zu einer Operation von Patienten zu verzeichnen. Es sollen folgende Daten zu der Operation wie Bezeichnung der Operation, Komplikationen, Intention und Anmerkungen erfasst werden. |
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| Misuse | Dieses Template soll nicht verwendet werden, um andere Therapien oder Prozeduren des Patienten zu verzeichnen. Für diese Daten sind jeweils andere Templates zu benutzen. |
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| Purpose | Zur Repräsentation von Daten zu einer Operation eines Patienten im HiGHmed Projekt. |
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| References | |
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| Authors | date: 2019-12-03; name: Alina Rehberg; organisation: Medizinische Hochschule Hannover; email: rehberg.alina@mh-hannover.de |
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| Other Details Language | date: 2019-12-03; name: Alina Rehberg; organisation: Medizinische Hochschule Hannover; email: rehberg.alina@mh-hannover.de |
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| 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: 62b48aaf4140de9217d4c6d98ffbcfcd
- Original Language: ISO_639-1::de
- Sem Ver: 2.0.0
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| Keywords | OP; Chirurigscher Eingriff; Operative Prozedur; Notfalleingriff |
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| Language used | en |
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| Citeable Identifier | 1246.169.350 |
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| Root archetype id | openEHR-EHR-COMPOSITION.report.v1 |
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| Operation | Operation: Document to communicate information to others, commonly in response to a request from another party. |
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| Other Context | |
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| Report ID | Report ID: Identification information about the report. |
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| Status | Status: The status of the entire report. Note: This is not the status of any of the report components.
- Zwischenbericht
- Endbericht
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| Case identification | Case identification: To record case identification details for public health purposes. |
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| Case identifier | Case identifier: The identifier of this case. |
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| Operation | Operation: A clinical activity carried out for screening, investigative, diagnostic, curative, therapeutic, evaluative or palliative purposes. |
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| Description | |
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| Name der Operation (OPS) | Name der Operation (OPS): Identification of the procedure by name.
Coding of the specific procedure with a terminology is preferred, where possible. |
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| Operation Beschreibung | Operation Beschreibung: 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. |
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| Complication | Complication: Details about any complication arising from the procedure.
Use this data element to record simple terms or precoordinated complications. If the requirements for recording complication are more complex then use of a specific CLUSTER archetype within the 'Procedure detail' SLOT in this archetype is advised and this data element becomes redundant. Examples: Hematuria after a kidney biopsy, tissue irritation after insertion of intravenous catheter.
- Fistel
- Arrosionsblutungen
- Tumorperforation
- Keine
- [...]
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| Intention | Intention: Reason that the activity or care pathway step for the identified procedure was carried out.
For example: the reason for the cancellation or suspension of the procedure.
Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=http://highmed.org/fhir/ValueSet/onko/intention-der-therapie |
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| Anmerkungen | Anmerkungen: Additional narrative about the activity or care pathway step not captured in other fields. |
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| Protocol | |
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| Operation ID | Operation ID: The local ID assigned to the order by the healthcare provider or organisation requesting the service.
This is equivalent to Placer Order Number in HL7 v2 specifications.
 Text Identifier
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| Tumordiagnose_section | Tumordiagnose_section: Framework for consistent modelling of content within a template for a Problem list.
Intended to be used within the COMPOSITION.problem_list. |
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| Tumordiagnose | Tumordiagnose: 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'. |
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| Data | |
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| Diagnose Name (ICD-10) | Diagnose Name (ICD-10): 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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| Diagnose Beschreibung | Diagnose Beschreibung: 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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| Erstdiagnosedatum | Erstdiagnosedatum: 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. |
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| Protocol | |
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| Tumor ID | Tumor ID: Zur Darstellung der ID des Tumors. |
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| Tumor ID | Tumor ID: Die ID/Kennung des Tumors. |
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