TEMPLATE CAEHR_C_Anamnese (CAEHR_C_Anamnese)

TEMPLATE ID	CAEHR_C_Anamnese
Concept	CAEHR_C_Anamnese
Description	Template zur Darstellung von Anamnesen in CAEHR Use Case C
Purpose	Template zur Darstellung von Anamnesen in CAEHR Use Case C
References
Authors	name: Severin Kohler; organisation: Berlin Institute of Health; email: severin.kohler@charite.de
Other Details Language	name: Severin Kohler; organisation: Berlin Institute of Health; email: severin.kohler@charite.de
Other Details (Language Independent)	MetaDataSet:Sample Set: Template metadata sample set MD5-CAM-1.0.1: 9e88ab76e8ea2fdf878faef434499e27 PARENT:MD5-CAM-1.0.1: 005501C1FA493A4838F5F1121F2870EC Sem Ver: 260.0.0 Build Uid: 63025009-40ce-4fd8-868a-5f0ea6f656b7 Original Language: ISO_639-1::de
Language used	en
Citeable Identifier	1246.169.3513
Root archetype id	openEHR-EHR-COMPOSITION.report.v1
Report	Report: Document to communicate information to others, commonly in response to a request from another party.
other_context
Other Context
Case identification	Case identification: To record case identification details for public health purposes.
Case identifier	Case identifier: The identifier of this case.
Care journey metadata	Care journey metadata: Tp capture Care plan metadata
Care plan name	Care plan name: The name , preferably coded of the Care plan with which this journey is associated, and against which the composition was updated.
Care plan identifier	Care plan identifier: The identifier , preferably coded, of the Care plan with which this journey is associated, and against which the composition was updated.
Patient journey identifier	Patient journey identifier: A patient-journey specific identifier i.e unique to a patient's journey along a specific care pathway.
Körperliche Untersuchung und soziodemografische Angaben	Körperliche Untersuchung und soziodemografische Angaben: 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
Familiäre Disposition von Myokardinfarkt oder Schlaganfall	Familiäre Disposition von Myokardinfarkt oder Schlaganfall: Summary information about the prevalence of a risk factor, problem or diagnosis in all family members.
Familiäre Disposition von Myokardinfarkt oder Schlaganfall bei Eltern, Geschwistern oder Kindern	Familiäre Disposition von Myokardinfarkt oder Schlaganfall bei Eltern, Geschwistern oder Kindern: Narrative description about occurrence in family members. Familiäre Disposition von Myokardinfarkt oder Schlaganfall
Ethnischer Hintergrund	Ethnischer Hintergrund: Detaillierte Beschreibung des ethnischen Hintergrundes einer Person, um Besondheiten, wie Medikamentenverträglichkeit oder Gesundheitsrisiken abzubilden.
Ethnischer Hintergrund	Ethnischer Hintergrund: Der ethnische Hintergrund einer Person. Terminology: http://snomed.info/sct Caucasian (ethnic group) Other (qualifier value)
Hautfarbe	Hautfarbe: Zusätzliche Beschreibung über den ethnischen Hintergrund einer Person, die nicht in anderen Datenelementen erfasst ist. Terminology: http://snomed.info/sct Black constitutive skin color (finding) Other (qualifier value)
Gender	Gender: Details about the gender of an individual.
Data
Administrative gender	Administrative gender: The gender of an individual used for administrative purposes. This element is what most systems today describes as 'Sex' or 'Gender'. For example 'Male', 'Female', 'Other'. This aligns with HL7 FHIR 'Person.gender'. Coding with a terminology is recommended, where possible. Terminology: http://hl7.org/fhir/ValueSet/administrative-gender Male Female Other Unknown
Sex assigned at birth	Sex assigned at birth: The sex of an individual determined by anatomical characteristics observed and registered at birth. For example: 'Male', 'Female', 'Intersex'. Coding with a terminology is recommended, where possible. Use the element 'Comment' or the SLOT 'Details' if needed to register more specific details of the individuals gender. Terminology: http://fhir.de/CodeSystem/gender-amtlich-de männlich weiblich unbestimmt divers
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
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
Größe	Größe: The length of the body from crown of head to sole of foot. 0..1000 cm
Körpergewicht nicht erhoben	Körpergewicht nicht erhoben: 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". Terminology: http://loinc.org Body weight
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Not recorded (qualifier value)
Körpergröße nicht erhoben	Körpergröße nicht erhoben: 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". Terminology: http://loinc.org Body weight
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Not recorded (qualifier value)
Ausschluss familiäre Disposition	Ausschluss familiäre Disposition: 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
Exclusion statement	Exclusion statement: A qualifying statement about the exclusion of a Problem/diagnosis, Family history, Medication, Procedure, Adverse reaction or other clinical item. This statement is to be used in conjunction with the 'Excluded concept' data element. For example: this data element can support recording general statements such as "No known history of ..." where the 'Excluded concept' identifies the specific problem, diagnosis, substance, procedure or medication. If the 'Excluded concept' data element is used to record a precoordinated term such as 'No family history of diabetes', this element is redundant. Terminology: http://snomed.info/sct Definitely NOT present (qualifier value)
Familiäre Krankengeschichte	Familiäre Krankengeschichte: The Family history item to which the 'Exclusion statement' applies. For example: 'Heart desease', 'Diabetes' or 'Alzheimer'. Familiäre Disposition von Myokardinfarkt oder Schlaganfall
Familiäre Disposition nicht erhoben/unbekannt	Familiäre Disposition nicht erhoben/unbekannt: 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". Familiäre Disposition von Myokardinfarkt oder Schlaganfall
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Not recorded (qualifier value) Unknown (qualifier value)
Hautfarbe nicht erhoben	Hautfarbe nicht erhoben: 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". Terminology: http://snomed.info/sct Finding of color of skin (finding)
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Not recorded (qualifier value)
Ethnie nicht erhoben	Ethnie nicht erhoben: 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". Terminology: http://snomed.info/sct Ethnic group finding (finding)
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Not recorded (qualifier value)
Kardiovaskuläre Risikofaktoren	Kardiovaskuläre Risikofaktoren: A generic section header which should be renamed in a template to suit a specific clinical context.
Rauchverhalten & Alkoholkonsum	Rauchverhalten & Alkoholkonsum: A generic section header which should be renamed in a template to suit a specific clinical context.
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. Terminology: http://snomed.info/sct Never smoked Current smoker Former smoker Non-smoker (finding) Smoker (finding) Ex-smoker (finding)
Ex-Raucher seit:	Ex-Raucher seit:: 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.
Packungsjahr	Packungsjahr: 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
Alcohol consumption summary	Alcohol consumption summary: Summary or persistent information about the typical alcohol consumption of an individual.
Data
Overall status	Overall status: Statement about current consumption for all types of alcohol. Terminology: http://snomed.info/sct Current drinker Former drinker Lifetime non-drinker Current drinker of alcohol (finding) Current non-drinker of alcohol (finding)
Alkoholkonsum nicht erhoben	Alkoholkonsum nicht erhoben: 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". Terminology: http://snomed.info/sct Current drinker of alcohol (finding)
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Not recorded (qualifier value)
Rauchverhalten nicht erhoben	Rauchverhalten nicht erhoben: 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". Terminology: http://snomed.info/sct Smoker (finding)
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Not recorded (qualifier value)
Dyslipidämie	Dyslipidämie: A generic section header which should be renamed in a template to suit a specific clinical context.
Dyslipidämie	Dyslipidämie: 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. Terminology: http://snomed.info/sct Dyslipidemia (disorder)
Ausschluss Dyslipidämie	Ausschluss Dyslipidämie: 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
Exclusion statement	Exclusion statement: A qualifying statement about the exclusion of a Problem/diagnosis, Family history, Medication, Procedure, Adverse reaction or other clinical item. This statement is to be used in conjunction with the 'Excluded concept' data element. For example: this data element can support recording general statements such as "No known history of ..." where the 'Excluded concept' identifies the specific problem, diagnosis, substance, procedure or medication. If the 'Excluded concept' data element is used to record a precoordinated term such as 'No family history of diabetes', this element is redundant. Terminology: http://snomed.info/sct Definitely NOT present (qualifier value)
Problem/Diagnose	Problem/Diagnose: The problem or diagnosis to which the 'Exclusion statement' applies. For example: 'Diabetes', 'COPD' or 'Asthma'. Terminology: http://snomed.info/sct Dyslipidemia (disorder)
Dyslipidämie nicht erhoben	Dyslipidämie nicht erhoben: 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". Terminology: http://snomed.info/sct Dyslipidemia (disorder)
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Not recorded (qualifier value)
Dyslipidämie Behandlung	Dyslipidämie Behandlung: A clinical activity carried out for screening, investigative, diagnostic, curative, therapeutic, evaluative or palliative purposes.
Description
Dyslipidämie	Dyslipidämie: Identification of the procedure by name. Coding of the specific procedure with a terminology is preferred, where possible. Dyslipidämie Behandlung
Auschluss Behandlung	Auschluss Behandlung: 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
Exclusion statement	Exclusion statement: A qualifying statement about the exclusion of a Problem/diagnosis, Family history, Medication, Procedure, Adverse reaction or other clinical item. This statement is to be used in conjunction with the 'Excluded concept' data element. For example: this data element can support recording general statements such as "No known history of ..." where the 'Excluded concept' identifies the specific problem, diagnosis, substance, procedure or medication. If the 'Excluded concept' data element is used to record a precoordinated term such as 'No family history of diabetes', this element is redundant. Terminology: http://snomed.info/sct Definitely NOT present (qualifier value)
Eingriff	Eingriff: The Procedure to which the 'Exclusion statement' applies. For example: 'Heart surgery' or 'Appendectomy' or 'Hip replacement'. Dyslipidämie Behandlung
Behandlung unbekannt	Behandlung unbekannt: 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". Dyslipidämie Behandlung
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Unknown (qualifier value)
Diabetes Mellitus	Diabetes Mellitus: A generic section header which should be renamed in a template to suit a specific clinical context.
Diabetes Mellitus	Diabetes Mellitus: 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. Terminology: http://snomed.info/sct Diabetes mellitus (disorder)
Insulinpflichtig	Insulinpflichtig: Details about a medication or component of a medication, including strength, form and details of any specific constituents.
Insulin	Insulin: The name of the medication or medication component. For example: 'Zinacef 750 mg powder' or 'cefuroxim'. This item should be coded if possible, using for example, RxNorm, DM+D, Australian Medicines Terminology or FEST. Usage of this element will vary according to context of use. This element may be omitted where the name of the medication is recorded in the parent INSTRUCTION or ACTION archetype, and this archetype is only used to record that the form must be or was 'liquid'. Terminology: http://snomed.info/sct Insulin (substance)
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. Terminology: http://snomed.info/sct Typ 1 Typ 2 Typ 3 Typ 4 Diabetes mellitus type 1 (disorder) Diabetes mellitus type 2 (disorder)
Ausschluss Diabetes	Ausschluss Diabetes: 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
Exclusion statement	Exclusion statement: A qualifying statement about the exclusion of a Problem/diagnosis, Family history, Medication, Procedure, Adverse reaction or other clinical item. This statement is to be used in conjunction with the 'Excluded concept' data element. For example: this data element can support recording general statements such as "No known history of ..." where the 'Excluded concept' identifies the specific problem, diagnosis, substance, procedure or medication. If the 'Excluded concept' data element is used to record a precoordinated term such as 'No family history of diabetes', this element is redundant. Terminology: http://snomed.info/sct Definitely NOT present (qualifier value)
Problem/Diagnose	Problem/Diagnose: The problem or diagnosis to which the 'Exclusion statement' applies. For example: 'Diabetes', 'COPD' or 'Asthma'. Terminology: http://snomed.info/sct Diabetis Mellitus
Diabetes nicht erhoben	Diabetes nicht erhoben: 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". Terminology: http://snomed.info/sct Diabetis Mellitus
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Not recorded (qualifier value)
Ausschluss Insulinpflicht	Ausschluss Insulinpflicht: 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
Exclusion statement	Exclusion statement: A qualifying statement about the exclusion of a Problem/diagnosis, Family history, Medication, Procedure, Adverse reaction or other clinical item. This statement is to be used in conjunction with the 'Excluded concept' data element. For example: this data element can support recording general statements such as "No known history of ..." where the 'Excluded concept' identifies the specific problem, diagnosis, substance, procedure or medication. If the 'Excluded concept' data element is used to record a precoordinated term such as 'No family history of diabetes', this element is redundant. Terminology: http://snomed.info/sct Definitely NOT present (qualifier value)
Medikation	Medikation: The Medication to which the 'Exclusion statement' applies. For example: 'Paracetamol', 'Codeine' or 'Antidepressants'. Terminology: http://snomed.info/sct Insulin (substance)
Insulin unbekannt	Insulin unbekannt: 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". Terminology: http://snomed.info/sct Insulin (substance)
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Unknown (qualifier value)
Diabetes Typ unbekannt	Diabetes Typ unbekannt: 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". Terminology: http://snomed.info/sct Diabetes type (observable entity)
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Unknown (qualifier value)
Arterielle Hypertonie	Arterielle Hypertonie: A generic section header which should be renamed in a template to suit a specific clinical context.
Arterielle Hypertonie	Arterielle Hypertonie: 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. Terminology: http://snomed.info/sct Hypertensive disorder, systemic arterial (disorder)
Ausschluss Hypertonie	Ausschluss Hypertonie: 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
Exclusion statement	Exclusion statement: A qualifying statement about the exclusion of a Problem/diagnosis, Family history, Medication, Procedure, Adverse reaction or other clinical item. This statement is to be used in conjunction with the 'Excluded concept' data element. For example: this data element can support recording general statements such as "No known history of ..." where the 'Excluded concept' identifies the specific problem, diagnosis, substance, procedure or medication. If the 'Excluded concept' data element is used to record a precoordinated term such as 'No family history of diabetes', this element is redundant. Terminology: http://snomed.info/sct Definitely NOT present (qualifier value)
Problem/Diagnose	Problem/Diagnose: The problem or diagnosis to which the 'Exclusion statement' applies. For example: 'Diabetes', 'COPD' or 'Asthma'. Terminology: http://snomed.info/sct Hypertensive disorder, systemic arterial (disorder)
Hypertonie nicht erhoben	Hypertonie nicht erhoben: 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". Terminology: http://snomed.info/sct Hypertensive disorder, systemic arterial (disorder)
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Not recorded (qualifier value)
Hypertonie Behandlung	Hypertonie Behandlung: 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. Hypertonie Behandlung
Hypertonie Behandlung unbekannt	Hypertonie Behandlung unbekannt: 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". Hypertonie Behandlung
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Unknown (qualifier value)
Ausschluss Hypertonie Behandlung	Ausschluss Hypertonie Behandlung: 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
Exclusion statement	Exclusion statement: A qualifying statement about the exclusion of a Problem/diagnosis, Family history, Medication, Procedure, Adverse reaction or other clinical item. This statement is to be used in conjunction with the 'Excluded concept' data element. For example: this data element can support recording general statements such as "No known history of ..." where the 'Excluded concept' identifies the specific problem, diagnosis, substance, procedure or medication. If the 'Excluded concept' data element is used to record a precoordinated term such as 'No family history of diabetes', this element is redundant. Terminology: http://snomed.info/sct Definitely NOT present (qualifier value)
Eingriff	Eingriff: The Procedure to which the 'Exclusion statement' applies. For example: 'Heart surgery' or 'Appendectomy' or 'Hip replacement'. Hypertonie Behandlung
Niereninsuffizienz	Niereninsuffizienz: A generic section header which should be renamed in a template to suit a specific clinical context.
Niereninsuffizienz	Niereninsuffizienz: 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. Terminology: http://snomed.info/sct Renal insufficiency (disorder)
Dialysepflichtigkeit	Dialysepflichtigkeit: 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. Terminology: http://snomed.info/sct Dependence on renal dialysis (finding)
Severity	Severity: An assessment of the overall severity of the problem or diagnosis. If severity is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant. Note: more specific grading of severity can be recorded using the Specific details SLOT. Terminology: http://fhir.de/CodeSystem/bfarm/icd-10-gm GFR 90ml/min oder höher GFR 60 - 89 ml/min GFR 30 - 59 ml/min GFR 15- 29 ml/min GFR < 15 ml/min oder aktuelle Dialysepflicht
Ausschluss Niereninsuffizienz	Ausschluss Niereninsuffizienz: 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
Exclusion statement	Exclusion statement: A qualifying statement about the exclusion of a Problem/diagnosis, Family history, Medication, Procedure, Adverse reaction or other clinical item. This statement is to be used in conjunction with the 'Excluded concept' data element. For example: this data element can support recording general statements such as "No known history of ..." where the 'Excluded concept' identifies the specific problem, diagnosis, substance, procedure or medication. If the 'Excluded concept' data element is used to record a precoordinated term such as 'No family history of diabetes', this element is redundant. Terminology: http://snomed.info/sct Definitely NOT present (qualifier value)
Problem/Diagnose	Problem/Diagnose: The problem or diagnosis to which the 'Exclusion statement' applies. For example: 'Diabetes', 'COPD' or 'Asthma'. Terminology: http://snomed.info/sct Renal insufficiency (disorder)
Niereninsuffizienz nicht erhoben	Niereninsuffizienz nicht erhoben: 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". Terminology: http://snomed.info/sct Renal insufficiency (disorder)
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Not recorded (qualifier value)
Schweregrad nicht erhoben oder unbekannt	Schweregrad nicht erhoben oder unbekannt: 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". Terminology: http://snomed.info/sct Glomerular filtration rate (observable entity)
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Not recorded (qualifier value) Unknown (qualifier value)
Ausschluss Dialysepflicht	Ausschluss Dialysepflicht: 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
Exclusion statement	Exclusion statement: A qualifying statement about the exclusion of a Problem/diagnosis, Family history, Medication, Procedure, Adverse reaction or other clinical item. This statement is to be used in conjunction with the 'Excluded concept' data element. For example: this data element can support recording general statements such as "No known history of ..." where the 'Excluded concept' identifies the specific problem, diagnosis, substance, procedure or medication. If the 'Excluded concept' data element is used to record a precoordinated term such as 'No family history of diabetes', this element is redundant. Terminology: http://snomed.info/sct Definitely NOT present (qualifier value)
Problem/Diagnose	Problem/Diagnose: The problem or diagnosis to which the 'Exclusion statement' applies. For example: 'Diabetes', 'COPD' or 'Asthma'. Terminology: http://snomed.info/sct Dependence on renal dialysis (finding)
Dialysepflicht nicht erhoben oder unbekannt	Dialysepflicht nicht erhoben oder unbekannt: 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". Terminology: http://snomed.info/sct Dependence on renal dialysis (finding)
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Not recorded (qualifier value) Unknown (qualifier value)
Kardiale Diagnosen (Anamnese und Vorbefunde)	Kardiale Diagnosen (Anamnese und Vorbefunde): A generic section header which should be renamed in a template to suit a specific clinical context.
Koronare Herzkrankheit	Koronare Herzkrankheit: A generic section header which should be renamed in a template to suit a specific clinical context.
Koronare Herzkrankheit	Koronare Herzkrankheit: 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. Terminology: http://snomed.info/sct Coronary arteriosclerosis (disorder)
Ausschluss Koronare Herzkrankheit	Ausschluss Koronare Herzkrankheit: 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
Exclusion statement	Exclusion statement: A qualifying statement about the exclusion of a Problem/diagnosis, Family history, Medication, Procedure, Adverse reaction or other clinical item. This statement is to be used in conjunction with the 'Excluded concept' data element. For example: this data element can support recording general statements such as "No known history of ..." where the 'Excluded concept' identifies the specific problem, diagnosis, substance, procedure or medication. If the 'Excluded concept' data element is used to record a precoordinated term such as 'No family history of diabetes', this element is redundant. Terminology: http://snomed.info/sct Definitely NOT present (qualifier value)
Problem/Diagnose	Problem/Diagnose: The problem or diagnosis to which the 'Exclusion statement' applies. For example: 'Diabetes', 'COPD' or 'Asthma'. Terminology: http://snomed.info/sct Coronary arteriosclerosis (disorder)
Koronare Herzkrankheit nicht erhoben	Koronare Herzkrankheit nicht erhoben: 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". Terminology: http://snomed.info/sct Coronary arteriosclerosis (disorder)
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Not recorded (qualifier value)
Zustand nach Myokardinfarkt	Zustand nach Myokardinfarkt: A generic section header which should be renamed in a template to suit a specific clinical context.
Myokardinfarkt	Myokardinfarkt: 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. Terminology: http://snomed.info/sct Myocardial infarction (disorder)
Problem/Diagnosis qualifier	Problem/Diagnosis qualifier: Contextual or temporal qualifier for a specified problem or diagnosis.
Current/Past?	Current/Past?: Category that supports division of problems and diagnoses into Current or Past problem lists. The Current/Past and Active/Inactive data elements have similar clinical impact but represent slightly different semantics. Both are actively used in different clinical settings, but usually not together. If an Active/Inactive qualifier is recorded, then this data element is likely to be redundant. An exception where a condition can be current but inactive is asthma that is not causing acute symptoms. Past
Ausschluss Myokardinfarkt	Ausschluss Myokardinfarkt: 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
Exclusion statement	Exclusion statement: A qualifying statement about the exclusion of a Problem/diagnosis, Family history, Medication, Procedure, Adverse reaction or other clinical item. This statement is to be used in conjunction with the 'Excluded concept' data element. For example: this data element can support recording general statements such as "No known history of ..." where the 'Excluded concept' identifies the specific problem, diagnosis, substance, procedure or medication. If the 'Excluded concept' data element is used to record a precoordinated term such as 'No family history of diabetes', this element is redundant. Terminology: http://snomed.info/sct Definitely NOT present (qualifier value)
Problem/Diagnose	Problem/Diagnose: The problem or diagnosis to which the 'Exclusion statement' applies. For example: 'Diabetes', 'COPD' or 'Asthma'. Terminology: http://snomed.info/sct Myocardial infarction (disorder)
Myokardinfarkt nicht erhoben	Myokardinfarkt nicht erhoben: 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". Terminology: http://snomed.info/sct Myocardial infarction (disorder)
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Not recorded (qualifier value) Default value: Not recorded (qualifier value)
Kardiomyopathie	Kardiomyopathie: 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. Terminology: http://snomed.info/sct Cardiomyopathy (disorder)
Ausschluss Kardiomyopathie	Ausschluss Kardiomyopathie: 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
Exclusion statement	Exclusion statement: A qualifying statement about the exclusion of a Problem/diagnosis, Family history, Medication, Procedure, Adverse reaction or other clinical item. This statement is to be used in conjunction with the 'Excluded concept' data element. For example: this data element can support recording general statements such as "No known history of ..." where the 'Excluded concept' identifies the specific problem, diagnosis, substance, procedure or medication. If the 'Excluded concept' data element is used to record a precoordinated term such as 'No family history of diabetes', this element is redundant. Terminology: http://snomed.info/sct Definitely NOT present (qualifier value)
Problem/Diagnose	Problem/Diagnose: The problem or diagnosis to which the 'Exclusion statement' applies. For example: 'Diabetes', 'COPD' or 'Asthma'. Terminology: http://snomed.info/sct Cardiomyopathy (disorder)
Kardiomyopathie nicht erhoben	Kardiomyopathie nicht erhoben: 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". Terminology: http://snomed.info/sct Cardiomyopathy (disorder)
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Not recorded (qualifier value)
Vorhofflimmern	Vorhofflimmern: A generic section header which should be renamed in a template to suit a specific clinical context.
Vorhofflimmern	Vorhofflimmern: 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. Terminology: http://snomed.info/sct Atrial fibrillation (disorder)
Ausschluss Vorhofflimmern	Ausschluss Vorhofflimmern: 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
Exclusion statement	Exclusion statement: A qualifying statement about the exclusion of a Problem/diagnosis, Family history, Medication, Procedure, Adverse reaction or other clinical item. This statement is to be used in conjunction with the 'Excluded concept' data element. For example: this data element can support recording general statements such as "No known history of ..." where the 'Excluded concept' identifies the specific problem, diagnosis, substance, procedure or medication. If the 'Excluded concept' data element is used to record a precoordinated term such as 'No family history of diabetes', this element is redundant. Terminology: http://snomed.info/sct Definitely NOT present (qualifier value)
Problem/Diagnose	Problem/Diagnose: The problem or diagnosis to which the 'Exclusion statement' applies. For example: 'Diabetes', 'COPD' or 'Asthma'. Terminology: http://snomed.info/sct Atrial fibrillation (disorder)
Vorhofflimmern nicht erhoben	Vorhofflimmern nicht erhoben: 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". Terminology: http://snomed.info/sct Atrial fibrillation (disorder)
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Not recorded (qualifier value)
Aktuelle oder frühere Herzklappenerkrankung	Aktuelle oder frühere Herzklappenerkrankung: A generic section header which should be renamed in a template to suit a specific clinical context.
aktuelle oder frühere Herzklappenerkrankung	aktuelle oder frühere Herzklappenerkrankung: 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. Terminology: http://snomed.info/sct Heart valve disorder (disorder)
Problem/Diagnosis qualifier	Problem/Diagnosis qualifier: Contextual or temporal qualifier for a specified problem or diagnosis.
Current/Past?	Current/Past?: Category that supports division of problems and diagnoses into Current or Past problem lists. The Current/Past and Active/Inactive data elements have similar clinical impact but represent slightly different semantics. Both are actively used in different clinical settings, but usually not together. If an Active/Inactive qualifier is recorded, then this data element is likely to be redundant. An exception where a condition can be current but inactive is asthma that is not causing acute symptoms. Current Past
Ausschluss Herzklappenerkankung	Ausschluss Herzklappenerkankung: 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
Exclusion statement	Exclusion statement: A qualifying statement about the exclusion of a Problem/diagnosis, Family history, Medication, Procedure, Adverse reaction or other clinical item. This statement is to be used in conjunction with the 'Excluded concept' data element. For example: this data element can support recording general statements such as "No known history of ..." where the 'Excluded concept' identifies the specific problem, diagnosis, substance, procedure or medication. If the 'Excluded concept' data element is used to record a precoordinated term such as 'No family history of diabetes', this element is redundant. Terminology: http://snomed.info/sct Definitely NOT present (qualifier value)
Problem/Diagnose	Problem/Diagnose: The problem or diagnosis to which the 'Exclusion statement' applies. For example: 'Diabetes', 'COPD' or 'Asthma'. Terminology: http://snomed.info/sct Heart valve disorder (disorder)
Herzklappenerkrankung nicht erhoben	Herzklappenerkrankung nicht erhoben: 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". Terminology: http://snomed.info/sct Heart valve disorder (disorder)
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Not recorded (qualifier value)
Herzinsuffizienz	Herzinsuffizienz: A generic section header which should be renamed in a template to suit a specific clinical context.
Herzinsuffizienz	Herzinsuffizienz: 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. Terminology: http://snomed.info/sct Heart failure (disorder)
Erstdiagnose Herzinsuffizienz	Erstdiagnose Herzinsuffizienz: 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.
Dekompensation	Dekompensation: A generic section header which should be renamed in a template to suit a specific clinical context.
Zustand nach Dekompensation	Zustand nach Dekompensation: 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. Terminology: http://snomed.info/sct Decompensation (finding)
Problem/Diagnosis qualifier	Problem/Diagnosis qualifier: Contextual or temporal qualifier for a specified problem or diagnosis.
Current/Past?	Current/Past?: Category that supports division of problems and diagnoses into Current or Past problem lists. The Current/Past and Active/Inactive data elements have similar clinical impact but represent slightly different semantics. Both are actively used in different clinical settings, but usually not together. If an Active/Inactive qualifier is recorded, then this data element is likely to be redundant. An exception where a condition can be current but inactive is asthma that is not causing acute symptoms. Past
Ausschluss Dekompensation	Ausschluss Dekompensation: 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
Exclusion statement	Exclusion statement: A qualifying statement about the exclusion of a Problem/diagnosis, Family history, Medication, Procedure, Adverse reaction or other clinical item. This statement is to be used in conjunction with the 'Excluded concept' data element. For example: this data element can support recording general statements such as "No known history of ..." where the 'Excluded concept' identifies the specific problem, diagnosis, substance, procedure or medication. If the 'Excluded concept' data element is used to record a precoordinated term such as 'No family history of diabetes', this element is redundant. Terminology: http://snomed.info/sct Definitely NOT present (qualifier value)
Problem/Diagnose	Problem/Diagnose: The problem or diagnosis to which the 'Exclusion statement' applies. For example: 'Diabetes', 'COPD' or 'Asthma'. Terminology: http://snomed.info/sct Decompensation (finding)
Dekompensation nicht erhoben	Dekompensation nicht erhoben: 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". Terminology: http://snomed.info/sct Decompensation (finding)
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Not recorded (qualifier value)
NYHA	NYHA: A generic section header which should be renamed in a template to suit a specific clinical context.
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. Terminology: local_terms Class I Class II Class III Class IIIa Class IIIb Class IV New York Heart Association Classification - Class I (finding) New York Heart Association Classification - Class II (finding) New York Heart Association Classification - Class III (finding) New York Heart Association Classification - Class IV (finding)
NYHA nicht erhoben	NYHA nicht erhoben: 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". Terminology: http://snomed.info/sct New York Heart Classification finding (finding)
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Not recorded (qualifier value)
Herzinsuffizienz nicht erhoben	Herzinsuffizienz nicht erhoben: 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". Terminology: http://snomed.info/sct Heart failure (disorder)
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Not recorded (qualifier value)
Ausschluss Herzinsuffizienz	Ausschluss Herzinsuffizienz: 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
Exclusion statement	Exclusion statement: A qualifying statement about the exclusion of a Problem/diagnosis, Family history, Medication, Procedure, Adverse reaction or other clinical item. This statement is to be used in conjunction with the 'Excluded concept' data element. For example: this data element can support recording general statements such as "No known history of ..." where the 'Excluded concept' identifies the specific problem, diagnosis, substance, procedure or medication. If the 'Excluded concept' data element is used to record a precoordinated term such as 'No family history of diabetes', this element is redundant. Terminology: http://snomed.info/sct Definitely NOT present (qualifier value)
Problem/Diagnose	Problem/Diagnose: The problem or diagnosis to which the 'Exclusion statement' applies. For example: 'Diabetes', 'COPD' or 'Asthma'. Terminology: http://snomed.info/sct Heart failure (disorder)
Zustand nach Endokarditis	Zustand nach Endokarditis: 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. Terminology: http://snomed.info/sct Endocarditis (disorder)
Problem/Diagnosis qualifier	Problem/Diagnosis qualifier: Contextual or temporal qualifier for a specified problem or diagnosis.
Current/Past?	Current/Past?: Category that supports division of problems and diagnoses into Current or Past problem lists. The Current/Past and Active/Inactive data elements have similar clinical impact but represent slightly different semantics. Both are actively used in different clinical settings, but usually not together. If an Active/Inactive qualifier is recorded, then this data element is likely to be redundant. An exception where a condition can be current but inactive is asthma that is not causing acute symptoms. Past
Endokarditis nicht erhoben	Endokarditis nicht erhoben: 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". Terminology: http://snomed.info/sct Endocarditis (disorder)
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Not recorded (qualifier value)
Ausschluss Endokarditis	Ausschluss Endokarditis: 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
Exclusion statement	Exclusion statement: A qualifying statement about the exclusion of a Problem/diagnosis, Family history, Medication, Procedure, Adverse reaction or other clinical item. This statement is to be used in conjunction with the 'Excluded concept' data element. For example: this data element can support recording general statements such as "No known history of ..." where the 'Excluded concept' identifies the specific problem, diagnosis, substance, procedure or medication. If the 'Excluded concept' data element is used to record a precoordinated term such as 'No family history of diabetes', this element is redundant. Terminology: http://snomed.info/sct Definitely NOT present (qualifier value)
Problem/Diagnose	Problem/Diagnose: The problem or diagnosis to which the 'Exclusion statement' applies. For example: 'Diabetes', 'COPD' or 'Asthma'. Terminology: http://snomed.info/sct Endocarditis (disorder)
Angeborener Herzfehler	Angeborener Herzfehler: 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. Terminology: http://snomed.info/sct Congenital heart disease (disorder)
Angeborener Herzfehler nicht erhoben	Angeborener Herzfehler nicht erhoben: 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". Terminology: http://snomed.info/sct Congenital heart disease (disorder)
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Not recorded (qualifier value)
Ausschluss angeborener Herzfehler	Ausschluss angeborener Herzfehler: 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
Exclusion statement	Exclusion statement: A qualifying statement about the exclusion of a Problem/diagnosis, Family history, Medication, Procedure, Adverse reaction or other clinical item. This statement is to be used in conjunction with the 'Excluded concept' data element. For example: this data element can support recording general statements such as "No known history of ..." where the 'Excluded concept' identifies the specific problem, diagnosis, substance, procedure or medication. If the 'Excluded concept' data element is used to record a precoordinated term such as 'No family history of diabetes', this element is redundant. Terminology: http://snomed.info/sct Definitely NOT present (qualifier value)
Problem/Diagnose	Problem/Diagnose: The problem or diagnosis to which the 'Exclusion statement' applies. For example: 'Diabetes', 'COPD' or 'Asthma'. Terminology: http://snomed.info/sct Congenital heart disease (disorder)
Zustand nach Revaskularisation	Zustand nach Revaskularisation: A generic section header which should be renamed in a template to suit a specific clinical context.
Revaskularisation	Revaskularisation: 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. Terminology: http://snomed.info/sct Heart revascularization (procedure)
Problem/Diagnosis qualifier	Problem/Diagnosis qualifier: Contextual or temporal qualifier for a specified problem or diagnosis.
Current/Past?	Current/Past?: Category that supports division of problems and diagnoses into Current or Past problem lists. The Current/Past and Active/Inactive data elements have similar clinical impact but represent slightly different semantics. Both are actively used in different clinical settings, but usually not together. If an Active/Inactive qualifier is recorded, then this data element is likely to be redundant. An exception where a condition can be current but inactive is asthma that is not causing acute symptoms. Past
Ausschluss Revaskularisation	Ausschluss Revaskularisation: 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
Exclusion statement	Exclusion statement: A qualifying statement about the exclusion of a Problem/diagnosis, Family history, Medication, Procedure, Adverse reaction or other clinical item. This statement is to be used in conjunction with the 'Excluded concept' data element. For example: this data element can support recording general statements such as "No known history of ..." where the 'Excluded concept' identifies the specific problem, diagnosis, substance, procedure or medication. If the 'Excluded concept' data element is used to record a precoordinated term such as 'No family history of diabetes', this element is redundant. Terminology: http://snomed.info/sct Definitely NOT present (qualifier value)
Problem/Diagnose	Problem/Diagnose: The problem or diagnosis to which the 'Exclusion statement' applies. For example: 'Diabetes', 'COPD' or 'Asthma'. Terminology: http://snomed.info/sct Heart revascularization (procedure)
Revaskularisation nicht erhoben	Revaskularisation nicht erhoben: 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". Terminology: http://snomed.info/sct Heart revascularization (procedure)
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Not recorded (qualifier value)
Bisherige kardiovaskuläre Interventionen	Bisherige kardiovaskuläre Interventionen: A generic section header which should be renamed in a template to suit a specific clinical context.
Interventionelle koronare Revaskularisation	Interventionelle koronare Revaskularisation: A generic section header which should be renamed in a template to suit a specific clinical context.
Interventionelle koronare Revaskularisation	Interventionelle koronare Revaskularisation: 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. Terminology: http://snomed.info/sct Heart revascularization (procedure)
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. Terminology: http://snomed.info/sct Coronary artery structure (body structure)
Datum des letzten Ereignisses	Datum des letzten Ereignisses: 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.
Procedure type	Procedure type: The type of procedure. This pragmatic data element may be used to support organisation within the user interface. Terminology: http://snomed.info/sct Interventional cardiology (qualifier value)
Letzter Eingriff nicht erhoben	Letzter Eingriff nicht erhoben: 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". Datum der letzten interventionellen koronaren Revaskularisation
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Unknown (qualifier value) Not recorded (qualifier value)
Interventionelle koronare Revaskularisation nicht erhoben	Interventionelle koronare Revaskularisation nicht erhoben: 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". Interventionelle koronare Revaskularisation
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Not recorded (qualifier value)
Ausschluss interventionelle koronare Revaskularisation	Ausschluss interventionelle koronare Revaskularisation: 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
Exclusion statement	Exclusion statement: A qualifying statement about the exclusion of a Problem/diagnosis, Family history, Medication, Procedure, Adverse reaction or other clinical item. This statement is to be used in conjunction with the 'Excluded concept' data element. For example: this data element can support recording general statements such as "No known history of ..." where the 'Excluded concept' identifies the specific problem, diagnosis, substance, procedure or medication. If the 'Excluded concept' data element is used to record a precoordinated term such as 'No family history of diabetes', this element is redundant. Terminology: http://snomed.info/sct Definitely NOT present (qualifier value)
Eingriff	Eingriff: The Procedure to which the 'Exclusion statement' applies. For example: 'Heart surgery' or 'Appendectomy' or 'Hip replacement'. Interventionelle koronare Revaskularisation
Periphere Revaskularisation	Periphere Revaskularisation: A generic section header which should be renamed in a template to suit a specific clinical context.
Periphere Revaskularisation	Periphere Revaskularisation: 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. Periphere Revaskularisation
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. Terminology: http://snomed.info/sct Structure of peripheral artery (body structure)
Datum des letzten Ereignisses	Datum des letzten Ereignisses: 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.
Procedure type	Procedure type: The type of procedure. This pragmatic data element may be used to support organisation within the user interface. Terminology: http://snomed.info/sct Revascularization - action (qualifier value)
Ausschluss periphere Revaskularisation	Ausschluss periphere Revaskularisation: 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
Exclusion statement	Exclusion statement: A qualifying statement about the exclusion of a Problem/diagnosis, Family history, Medication, Procedure, Adverse reaction or other clinical item. This statement is to be used in conjunction with the 'Excluded concept' data element. For example: this data element can support recording general statements such as "No known history of ..." where the 'Excluded concept' identifies the specific problem, diagnosis, substance, procedure or medication. If the 'Excluded concept' data element is used to record a precoordinated term such as 'No family history of diabetes', this element is redundant. Terminology: http://snomed.info/sct Definitely NOT present (qualifier value)
Eingriff	Eingriff: The Procedure to which the 'Exclusion statement' applies. For example: 'Heart surgery' or 'Appendectomy' or 'Hip replacement'. Periphere Revaskularisation
Periphere Revaskularisation nicht erhoben	Periphere Revaskularisation nicht erhoben: 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". Periphere Revaskularisation
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Not recorded (qualifier value)
Koronare Bypass-Operation	Koronare Bypass-Operation: A generic section header which should be renamed in a template to suit a specific clinical context.
Koronare Bypass-Operation	Koronare Bypass-Operation: 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. Terminology: http://snomed.info/sct Coronary artery bypass grafting (procedure)
Datum des letzten Ereignisses	Datum des letzten Ereignisses: 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.
Ausschluss Koronare Bypass-Operation	Ausschluss Koronare Bypass-Operation: 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
Exclusion statement	Exclusion statement: A qualifying statement about the exclusion of a Problem/diagnosis, Family history, Medication, Procedure, Adverse reaction or other clinical item. This statement is to be used in conjunction with the 'Excluded concept' data element. For example: this data element can support recording general statements such as "No known history of ..." where the 'Excluded concept' identifies the specific problem, diagnosis, substance, procedure or medication. If the 'Excluded concept' data element is used to record a precoordinated term such as 'No family history of diabetes', this element is redundant. Terminology: http://snomed.info/sct Definitely NOT present (qualifier value)
Eingriff	Eingriff: The Procedure to which the 'Exclusion statement' applies. For example: 'Heart surgery' or 'Appendectomy' or 'Hip replacement'. Terminology: http://snomed.info/sct Coronary artery bypass grafting (procedure)
Koronare Bypass-Operation nicht erhoben	Koronare Bypass-Operation nicht erhoben: 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". Terminology: http://snomed.info/sct Coronary artery bypass grafting (procedure)
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Not recorded (qualifier value)
Letzter Eingriff nicht erhoben	Letzter Eingriff nicht erhoben: 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". Datum des letzten Eingriffes
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Unknown (qualifier value) Not recorded (qualifier value)
Sonstige Gefäß-Operation	Sonstige Gefäß-Operation: A generic section header which should be renamed in a template to suit a specific clinical context.
Sonstige Gefäß-Operation	Sonstige Gefäß-Operation: A clinical activity carried out for screening, investigative, diagnostic, curative, therapeutic, evaluative or palliative purposes.
Description
Sonstige Gefäß-Operation	Sonstige Gefäß-Operation: Identification of the procedure by name. Coding of the specific procedure with a terminology is preferred, where possible.
Datum des letzten Ereignisses	Datum des letzten Ereignisses: 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.
Ausschluss sonstige	Ausschluss sonstige: 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
Exclusion statement	Exclusion statement: A qualifying statement about the exclusion of a Problem/diagnosis, Family history, Medication, Procedure, Adverse reaction or other clinical item. This statement is to be used in conjunction with the 'Excluded concept' data element. For example: this data element can support recording general statements such as "No known history of ..." where the 'Excluded concept' identifies the specific problem, diagnosis, substance, procedure or medication. If the 'Excluded concept' data element is used to record a precoordinated term such as 'No family history of diabetes', this element is redundant. Terminology: http://snomed.info/sct Definitely NOT present (qualifier value)
Eingriff	Eingriff: The Procedure to which the 'Exclusion statement' applies. For example: 'Heart surgery' or 'Appendectomy' or 'Hip replacement'. Sonstige Gefäß-Operation
Sonstige nicht erhoben	Sonstige nicht erhoben: 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". Sonstige Gefäß-Operation
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Not recorded (qualifier value)
Herzklappen-Intervention	Herzklappen-Intervention: A generic section header which should be renamed in a template to suit a specific clinical context.
Aortenklappe	Aortenklappe: A generic section header which should be renamed in a template to suit a specific clinical context.
Aortenklappe-Intervention	Aortenklappe-Intervention: 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. Terminology: http://snomed.info/sct Aortic valve and adjacent structure operations (procedure) Heart valve reconstruction (procedure)
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. Terminology: http://snomed.info/sct Aortic valve structure (body structure)
Medical device	Medical device: An instrument, apparatus, implant, material or similar, used in the provision of healthcare. In this context, a medical device includes a broad range of devices which act through a variety of physical, mechanical, thermal or similar means but specifically excludes devices which act through medicinal means such as pharmacological, metabolic or immunological methods. The scope is inclusive of disposable devices as well as durable or persisting devices that require tracking, maintenance activities or regular calibration, recognising that each type of device has specific data recording requirements.
Device name	Device name: Identification of the medical device, preferably by a common name, a formal fully descriptive name or, if required, by class or category of device. This data element will capture the term, phrase or category used in clinical practice. For example: <brand name><machine> (XYZ Audiometer); <size> <brand name> <intravenous catheter> (14G Jelco IV catheter); or <brand name/type> <implant>. Coding with a terminology is desirable, where possible, although this may be local and depending on local supplies available. Terminology: http://snomed.info/sct Mechanical cardiac valve prosthesis (physical object) Transcatheter aortic valve implantation (procedure) Aortic valve bioprosthesis (physical object)
Aortenklappe nicht erhoben	Aortenklappe nicht erhoben: 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". Terminology: http://snomed.info/sct Aortic valve and adjacent structure operations (procedure)
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Not recorded (qualifier value)
Native Aortenklappe	Native Aortenklappe: 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
Exclusion statement	Exclusion statement: A qualifying statement about the exclusion of a Problem/diagnosis, Family history, Medication, Procedure, Adverse reaction or other clinical item. This statement is to be used in conjunction with the 'Excluded concept' data element. For example: this data element can support recording general statements such as "No known history of ..." where the 'Excluded concept' identifies the specific problem, diagnosis, substance, procedure or medication. If the 'Excluded concept' data element is used to record a precoordinated term such as 'No family history of diabetes', this element is redundant. Terminology: http://snomed.info/sct Definitely NOT present (qualifier value)
Eingriff	Eingriff: The Procedure to which the 'Exclusion statement' applies. For example: 'Heart surgery' or 'Appendectomy' or 'Hip replacement'. Terminology: http://snomed.info/sct Aortic valve and adjacent structure operations (procedure)
Trikuspidalklappe	Trikuspidalklappe: A generic section header which should be renamed in a template to suit a specific clinical context.
Trikuspidalklappe-Intervention	Trikuspidalklappe-Intervention: 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. Terminology: http://snomed.info/sct Tricuspid valve operation (procedure) Heart valve reconstruction (procedure)
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. Terminology: http://snomed.info/sct Tricuspid valve structure (body structure)
Medical device	Medical device: An instrument, apparatus, implant, material or similar, used in the provision of healthcare. In this context, a medical device includes a broad range of devices which act through a variety of physical, mechanical, thermal or similar means but specifically excludes devices which act through medicinal means such as pharmacological, metabolic or immunological methods. The scope is inclusive of disposable devices as well as durable or persisting devices that require tracking, maintenance activities or regular calibration, recognising that each type of device has specific data recording requirements.
Device name	Device name: Identification of the medical device, preferably by a common name, a formal fully descriptive name or, if required, by class or category of device. This data element will capture the term, phrase or category used in clinical practice. For example: <brand name><machine> (XYZ Audiometer); <size> <brand name> <intravenous catheter> (14G Jelco IV catheter); or <brand name/type> <implant>. Coding with a terminology is desirable, where possible, although this may be local and depending on local supplies available. Terminology: http://snomed.info/sct Biologic cardiac valve prosthesis (physical object) Mechanical cardiac valve prosthesis (physical object)
Trikuspidalklappe nicht erhoben	Trikuspidalklappe nicht erhoben: 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". Terminology: http://snomed.info/sct Tricuspid valve operation (procedure)
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Not recorded (qualifier value)
Trikuspidalklappe nativ	Trikuspidalklappe nativ: 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
Exclusion statement	Exclusion statement: A qualifying statement about the exclusion of a Problem/diagnosis, Family history, Medication, Procedure, Adverse reaction or other clinical item. This statement is to be used in conjunction with the 'Excluded concept' data element. For example: this data element can support recording general statements such as "No known history of ..." where the 'Excluded concept' identifies the specific problem, diagnosis, substance, procedure or medication. If the 'Excluded concept' data element is used to record a precoordinated term such as 'No family history of diabetes', this element is redundant. Terminology: http://snomed.info/sct Definitely NOT present (qualifier value)
Eingriff	Eingriff: The Procedure to which the 'Exclusion statement' applies. For example: 'Heart surgery' or 'Appendectomy' or 'Hip replacement'. Terminology: http://snomed.info/sct Tricuspid valve operation (procedure)
Pulmonalklappe	Pulmonalklappe: A generic section header which should be renamed in a template to suit a specific clinical context.
Pulmonalklappe-Intervention	Pulmonalklappe-Intervention: 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. Terminology: http://snomed.info/sct Pulmonary valve operation (procedure) Heart valve reconstruction (procedure)
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. Terminology: http://snomed.info/sct Pulmonary valve structure (body structure)
Medical device	Medical device: An instrument, apparatus, implant, material or similar, used in the provision of healthcare. In this context, a medical device includes a broad range of devices which act through a variety of physical, mechanical, thermal or similar means but specifically excludes devices which act through medicinal means such as pharmacological, metabolic or immunological methods. The scope is inclusive of disposable devices as well as durable or persisting devices that require tracking, maintenance activities or regular calibration, recognising that each type of device has specific data recording requirements.
Device name	Device name: Identification of the medical device, preferably by a common name, a formal fully descriptive name or, if required, by class or category of device. This data element will capture the term, phrase or category used in clinical practice. For example: <brand name><machine> (XYZ Audiometer); <size> <brand name> <intravenous catheter> (14G Jelco IV catheter); or <brand name/type> <implant>. Coding with a terminology is desirable, where possible, although this may be local and depending on local supplies available. Terminology: http://snomed.info/sct Pulmonary valve bioprosthesis (physical object) Mechanical cardiac valve prosthesis (physical object)
Pulmonalklappe nativ	Pulmonalklappe nativ: 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
Exclusion statement	Exclusion statement: A qualifying statement about the exclusion of a Problem/diagnosis, Family history, Medication, Procedure, Adverse reaction or other clinical item. This statement is to be used in conjunction with the 'Excluded concept' data element. For example: this data element can support recording general statements such as "No known history of ..." where the 'Excluded concept' identifies the specific problem, diagnosis, substance, procedure or medication. If the 'Excluded concept' data element is used to record a precoordinated term such as 'No family history of diabetes', this element is redundant. Terminology: http://snomed.info/sct Definitely NOT present (qualifier value)
Eingriff	Eingriff: The Procedure to which the 'Exclusion statement' applies. For example: 'Heart surgery' or 'Appendectomy' or 'Hip replacement'. Terminology: http://snomed.info/sct Pulmonary valve operation (procedure)
Pulmonalklappe nicht erhoben	Pulmonalklappe nicht erhoben: 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". Terminology: http://snomed.info/sct Pulmonary valve operation (procedure)
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Not recorded (qualifier value)
Mitralklappe	Mitralklappe: A generic section header which should be renamed in a template to suit a specific clinical context.
Mitralklappe-Intervention	Mitralklappe-Intervention: 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. Terminology: http://snomed.info/sct Mitral valve operation (procedure) Heart valve reconstruction (procedure)
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. Terminology: http://snomed.info/sct Mitral valve structure (body structure)
Medical device	Medical device: An instrument, apparatus, implant, material or similar, used in the provision of healthcare. In this context, a medical device includes a broad range of devices which act through a variety of physical, mechanical, thermal or similar means but specifically excludes devices which act through medicinal means such as pharmacological, metabolic or immunological methods. The scope is inclusive of disposable devices as well as durable or persisting devices that require tracking, maintenance activities or regular calibration, recognising that each type of device has specific data recording requirements.
Device name	Device name: Identification of the medical device, preferably by a common name, a formal fully descriptive name or, if required, by class or category of device. This data element will capture the term, phrase or category used in clinical practice. For example: <brand name><machine> (XYZ Audiometer); <size> <brand name> <intravenous catheter> (14G Jelco IV catheter); or <brand name/type> <implant>. Coding with a terminology is desirable, where possible, although this may be local and depending on local supplies available. Terminology: http://snomed.info/sct Mitral valve bioprosthesis (physical object) Mechanical cardiac valve prosthesis (physical object) Mitral valve clip (physical object)
Mitralklappe nativ	Mitralklappe nativ: 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
Exclusion statement	Exclusion statement: A qualifying statement about the exclusion of a Problem/diagnosis, Family history, Medication, Procedure, Adverse reaction or other clinical item. This statement is to be used in conjunction with the 'Excluded concept' data element. For example: this data element can support recording general statements such as "No known history of ..." where the 'Excluded concept' identifies the specific problem, diagnosis, substance, procedure or medication. If the 'Excluded concept' data element is used to record a precoordinated term such as 'No family history of diabetes', this element is redundant. Terminology: http://snomed.info/sct Definitely NOT present (qualifier value)
Eingriff	Eingriff: The Procedure to which the 'Exclusion statement' applies. For example: 'Heart surgery' or 'Appendectomy' or 'Hip replacement'. Terminology: http://snomed.info/sct Mitral valve operation (procedure)
Mitralklappe nicht erhoben	Mitralklappe nicht erhoben: 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". Terminology: http://snomed.info/sct Mitral valve operation (procedure)
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Not recorded (qualifier value)
Operation generell	Operation generell: A generic section header which should be renamed in a template to suit a specific clinical context.
Herzklappen-Intervention	Herzklappen-Intervention: 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. Terminology: http://snomed.info/sct Operation on heart valve (procedure)
Art des letzten Ereignisses	Art des letzten Ereignisses: 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. Terminology: http://snomed.info/sct Cardiac catheterization (procedure) Operation on heart valve (procedure)
Datum des letzten Ereignisses	Datum des letzten Ereignisses: 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.
Ausschluss Herzklappen	Ausschluss Herzklappen: 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
Exclusion statement	Exclusion statement: A qualifying statement about the exclusion of a Problem/diagnosis, Family history, Medication, Procedure, Adverse reaction or other clinical item. This statement is to be used in conjunction with the 'Excluded concept' data element. For example: this data element can support recording general statements such as "No known history of ..." where the 'Excluded concept' identifies the specific problem, diagnosis, substance, procedure or medication. If the 'Excluded concept' data element is used to record a precoordinated term such as 'No family history of diabetes', this element is redundant. Terminology: http://snomed.info/sct Definitely NOT present (qualifier value)
Eingriff	Eingriff: The Procedure to which the 'Exclusion statement' applies. For example: 'Heart surgery' or 'Appendectomy' or 'Hip replacement'. Terminology: http://snomed.info/sct Operation on heart valve (procedure)
Herzklappen nicht erhoben	Herzklappen nicht erhoben: 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". Terminology: http://snomed.info/sct Operation on heart valve (procedure)
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Not recorded (qualifier value)
Datum fehlt	Datum fehlt: 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". Datum der letzten Herzklappen Operation
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Unknown (qualifier value) Not recorded (qualifier value)
Art des letzten Eingriffes fehlt	Art des letzten Eingriffes fehlt: 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". Art des letzten Eingriffes
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Unknown (qualifier value) Not recorded (qualifier value)
Implantierter Herzschrittmacher oder Defibrillator	Implantierter Herzschrittmacher oder Defibrillator: A generic section header which should be renamed in a template to suit a specific clinical context.
Implantierter Defibrilator	Implantierter Defibrilator: An ongoing and persistent overview about medical devices that have been fitted or implanted.
Data
Implantierter Defibrilator?	Implantierter Defibrilator?: Name of the type of medical device. For example: Assisted hearing devices, eyeglasses, contact lens, dental braces, dentures, orthotics or artificial limbs. Terminology: http://snomed.info/sct Implantable defibrillator, device (physical object)
Device details	Device details: Details about each device.
Datum des letzten Ereignisses (Implantation/Wechsel)	Datum des letzten Ereignisses (Implantation/Wechsel): Date of fitting or implant of the device.
Implantierter Herzschrittmacher	Implantierter Herzschrittmacher: An ongoing and persistent overview about medical devices that have been fitted or implanted.
Data
Implantierter Herzschrittmacher?	Implantierter Herzschrittmacher?: Name of the type of medical device. For example: Assisted hearing devices, eyeglasses, contact lens, dental braces, dentures, orthotics or artificial limbs. Terminology: http://snomed.info/sct Cardiac pacemaker, device (physical object)
Device details	Device details: Details about each device.
Wenn ja, bitte Schrittmachertyp angeben:	Wenn ja, bitte Schrittmachertyp angeben:: Identification of the specific device, by name. 1-Kammer-Schrittmacher (z.B. VVI) 2-Kammer-Schrittmacher (z.B.DDD) biventrikulärer Schrittmacher (CRT)
Datum des letzten Ereignisses (Implantation/Wechsel)	Datum des letzten Ereignisses (Implantation/Wechsel): Date of fitting or implant of the device.
Implantierter CCM	Implantierter CCM: An ongoing and persistent overview about medical devices that have been fitted or implanted.
Data
Implantierter CCM	Implantierter CCM: Name of the type of medical device. For example: Assisted hearing devices, eyeglasses, contact lens, dental braces, dentures, orthotics or artificial limbs. Terminology: http://snomed.info/sct Cardiac contractility modulation system (physical object)
Anderes Device	Anderes Device: Details about each device.
Datum des letzten Ereignisses (Implantation/Wechsel)	Datum des letzten Ereignisses (Implantation/Wechsel): Date of fitting or implant of the device.
Andere Devices	Andere Devices: An ongoing and persistent overview about medical devices that have been fitted or implanted.
Data
Andere Devices	Andere Devices: Name of the type of medical device. For example: Assisted hearing devices, eyeglasses, contact lens, dental braces, dentures, orthotics or artificial limbs. Anderes Device
Anderes Device	Anderes Device: Details about each device.
Sonstige Devices	Sonstige Devices: Identification of the specific device, by name.
Datum der Implantation/des letzten Wechsels	Datum der Implantation/des letzten Wechsels: Date of fitting or implant of the device.
Datum nicht erhoben/unbekannt Defibrilator	Datum nicht erhoben/unbekannt Defibrilator: 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". Datum der Implantation/des letzten Wechsels
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Not recorded (qualifier value) Unknown (qualifier value)
Anderes implantiertes Gerät als Defibrilator, Schrittmacher oder CCM nicht erhoben	Anderes implantiertes Gerät als Defibrilator, Schrittmacher oder CCM nicht erhoben: 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". Anderes implantiertes Gerät als Defibrilator, Schrittmacher oder CCM
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Not recorded (qualifier value)
Defibrilator nicht erhoben	Defibrilator nicht erhoben: 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". Terminology: http://snomed.info/sct Implantable defibrillator, device (physical object)
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Not recorded (qualifier value)
Ausschluss Defibrilator	Ausschluss Defibrilator: 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
Exclusion statement	Exclusion statement: A qualifying statement about the exclusion of a Problem/diagnosis, Family history, Medication, Procedure, Adverse reaction or other clinical item. This statement is to be used in conjunction with the 'Excluded concept' data element. For example: this data element can support recording general statements such as "No known history of ..." where the 'Excluded concept' identifies the specific problem, diagnosis, substance, procedure or medication. If the 'Excluded concept' data element is used to record a precoordinated term such as 'No family history of diabetes', this element is redundant. Terminology: http://snomed.info/sct Definitely NOT present (qualifier value)
Eingriff	Eingriff: The Procedure to which the 'Exclusion statement' applies. For example: 'Heart surgery' or 'Appendectomy' or 'Hip replacement'. Terminology: http://snomed.info/sct Implantable defibrillator, device (physical object)
Schrittmacher nicht erhoben	Schrittmacher nicht erhoben: 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". Terminology: http://snomed.info/sct Cardiac pacemaker, device (physical object)
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Not recorded (qualifier value)
Ausschluss Schrittmacher	Ausschluss Schrittmacher: 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
Exclusion statement	Exclusion statement: A qualifying statement about the exclusion of a Problem/diagnosis, Family history, Medication, Procedure, Adverse reaction or other clinical item. This statement is to be used in conjunction with the 'Excluded concept' data element. For example: this data element can support recording general statements such as "No known history of ..." where the 'Excluded concept' identifies the specific problem, diagnosis, substance, procedure or medication. If the 'Excluded concept' data element is used to record a precoordinated term such as 'No family history of diabetes', this element is redundant. Terminology: http://snomed.info/sct Definitely NOT present (qualifier value)
Eingriff	Eingriff: The Procedure to which the 'Exclusion statement' applies. For example: 'Heart surgery' or 'Appendectomy' or 'Hip replacement'. Terminology: http://snomed.info/sct Cardiac pacemaker, device (physical object)
Ausschluss CCM	Ausschluss CCM: 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
Exclusion statement	Exclusion statement: A qualifying statement about the exclusion of a Problem/diagnosis, Family history, Medication, Procedure, Adverse reaction or other clinical item. This statement is to be used in conjunction with the 'Excluded concept' data element. For example: this data element can support recording general statements such as "No known history of ..." where the 'Excluded concept' identifies the specific problem, diagnosis, substance, procedure or medication. If the 'Excluded concept' data element is used to record a precoordinated term such as 'No family history of diabetes', this element is redundant. Terminology: http://snomed.info/sct Definitely NOT present (qualifier value)
Eingriff	Eingriff: The Procedure to which the 'Exclusion statement' applies. For example: 'Heart surgery' or 'Appendectomy' or 'Hip replacement'. Terminology: http://snomed.info/sct Cardiac contractility modulation system (physical object)
CCM nicht erhoben	CCM nicht erhoben: 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". Terminology: http://snomed.info/sct Cardiac contractility modulation system (physical object)
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Not recorded (qualifier value)
Schrittmacher Typ nicht erhoben	Schrittmacher Typ nicht erhoben: 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". Schrittmacher Typ
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Not recorded (qualifier value)
Datum nicht erhoben/unbekannt Schrittmacher	Datum nicht erhoben/unbekannt Schrittmacher: 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". Datum der Implantation/des letzten Wechsels
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Not recorded (qualifier value) Unknown (qualifier value)
Datum nicht erhoben/unbekannt CCM	Datum nicht erhoben/unbekannt CCM: 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". Datum der Implantation/des letzten Wechsels
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Not recorded (qualifier value) Unknown (qualifier value)
Datum nicht erhoben/unbekannt Anderes Gerät	Datum nicht erhoben/unbekannt Anderes Gerät: 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". Datum der Implantation/des letzten Wechsels
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Not recorded (qualifier value) Unknown (qualifier value)
Ausschluss Anderes implantiertes Gerät als Defibrilator, Schrittmacher oder CCM	Ausschluss Anderes implantiertes Gerät als Defibrilator, Schrittmacher oder CCM: 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
Exclusion statement	Exclusion statement: A qualifying statement about the exclusion of a Problem/diagnosis, Family history, Medication, Procedure, Adverse reaction or other clinical item. This statement is to be used in conjunction with the 'Excluded concept' data element. For example: this data element can support recording general statements such as "No known history of ..." where the 'Excluded concept' identifies the specific problem, diagnosis, substance, procedure or medication. If the 'Excluded concept' data element is used to record a precoordinated term such as 'No family history of diabetes', this element is redundant. Terminology: http://snomed.info/sct Definitely NOT present (qualifier value)
Eingriff	Eingriff: The Procedure to which the 'Exclusion statement' applies. For example: 'Heart surgery' or 'Appendectomy' or 'Hip replacement'. Anderes implantiertes Gerät als Defibrilator, Schrittmacher oder CCM
Blutdruck nach 5 Minuten Ruhe	Blutdruck nach 5 Minuten Ruhe: A generic section header which should be renamed in a template to suit a specific clinical context.
Blutdruck nach 5 Minuten Ruhe	Blutdruck nach 5 Minuten Ruhe: 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 (UCUM: mm[Hg])
Diastolic	Diastolic: Minimum systemic arterial blood pressure - measured in the diastolic or relaxation phase of the heart cycle. 0..1000 mmHg (UCUM: mm[Hg])
State
Level of exertion	Level of exertion: Record information about level of exertion.
Phase	Phase: The phase or context of exercise. At rest
Blutdruck nicht erhoben	Blutdruck nicht erhoben: 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". Terminology: http://snomed.info/sct Blood pressure (observable entity)
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Not recorded (qualifier value)
Herzfrequenz nach 5 Minuten sitzen	Herzfrequenz nach 5 Minuten sitzen: A generic section header which should be renamed in a template to suit a specific clinical context.
Herzfrequenz nach 5 Minuten sitzen	Herzfrequenz nach 5 Minuten sitzen: The rate and associated attributes for a pulse or heart beat.
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
Pulsfrequenz	Pulsfrequenz: The rate of the pulse or heart beat, measured in beats per minute. 0..1000 /min
Regularity	Regularity: Regularity of the pulse or heart beat. Regular Irregular
State
Position	Position: The body position of the subject during the observation. Sitting
Herzfrequenz nicht erhoben	Herzfrequenz nicht erhoben: 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". Terminology: http://snomed.info/sct Heart rate (observable entity)
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Not recorded (qualifier value)
Other contributors	Thomas Haese,; Alexander Bartschke,; Dirk Meyer zum Büschenfelde