| TEMPLATE ID | CAEHR_C_Echokardiographie |
|---|---|
| Concept | CAEHR_C_Echokardiographie |
| Description | Das Template Echokardiographie dient der Dokumentation von Echokardiographie Daten von Patienten mit Herzinsuffizienz. Dieses Template wird im Rahmen des Projektes HiGHmed genutzt. |
| Purpose | Das Template Echokardiographie dient der Dokumentation von Echokardiographie Daten von Patienten mit Herzinsuffizienz. Dieses Template wird im Rahmen des Projektes HiGHmed genutzt. |
| References | |
| Other Details (Language Independent) |
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| Language used | en |
| Citeable Identifier | 1246.169.3514 |
| 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 | |
| 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. |
| Rhythmus und Frequenz | Rhythmus und Frequenz: A generic section header which should be renamed in a template to suit a specific clinical context. |
| Rhythmus und Frequenz nicht erhoben | Rhythmus und Frequenz 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
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| 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
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| Rhythmus und Frequenz | Rhythmus und Frequenz: 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 | |
| Rate | Rate: The rate of the pulse or heart beat, measured in beats per minute. 0..1000 /min |
| Schrittmacher | Schrittmacher: Description of the character of the pulse or heart beat. Coding with a terminology is desired, where possible. For example: full, thready, bounding, slow rising, or collapsing. Multiple terms may be recorded.
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| Rhythmus | Rhythmus: Specific conclusion about the rhythm of the pulse or heartbeat, drawn from a combination of the heart rate, pattern and other characteristics observed on examination. Terminology: http://snomed.info/sct
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| nicht erhobene Parameter | nicht erhobene Parameter: A generic section header which should be renamed in a template to suit a specific clinical context. |
| Durchmesser Aortenwurzel nicht erhoben | Durchmesser Aortenwurzel 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".
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| 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
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| Linker Vorhof (endsystolisch) (LA-Diameter) nicht erhoben | Linker Vorhof (endsystolisch) (LA-Diameter) 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".
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| 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
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| Vena cava Durchmesser nicht erhoben | Vena cava Durchmesser 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".
|
| 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
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| Vena cava Atemvariabilität (>50 % Abnahme durch Inspiration) nicht erhoben | Vena cava Atemvariabilität (>50 % Abnahme durch Inspiration) 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".
|
| 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
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| Pulmonalvenöse diastolische Geschwindigkeit (PVdVel) nicht erhoben | Pulmonalvenöse diastolische Geschwindigkeit (PVdVel) 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".
|
| 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
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| Linksventrikuläre Auswurffraktion (LV-EF) + Methode nicht erhoben | Linksventrikuläre Auswurffraktion (LV-EF) + Methode 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
Default value: Left ventricular ejection fraction (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
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| Linksventrikulärer enddiastolischer Diameter (LVED) nicht erhoben | Linksventrikulärer enddiastolischer Diameter (LVED) 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".
|
| 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
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| Linksventrikulärer endsystolischer Diameter (LVEDD) nicht erhoben | Linksventrikulärer endsystolischer Diameter (LVEDD) 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".
|
| 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
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| Linksventrikuläres enddiastolisches Volumen (LVEDV) nicht erhoben | Linksventrikuläres enddiastolisches Volumen (LVEDV) 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
Default value: Cardiac end-diastolic volume (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
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| A-Welle nicht erhoben | A-Welle 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".
|
| 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
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| A´-Welle (lateral) nicht erhoben | A´-Welle (lateral) 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".
|
| 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
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| A´-Welle (medial) nicht erhoben | A´-Welle (medial) 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".
|
| 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
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| E-Welle nicht erhoben | E-Welle 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".
|
| 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
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| E´-Welle (lateral) nicht erhoben | E´-Welle (lateral) 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".
|
| 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
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| E´-Welle (medial) nicht erhoben | E´-Welle (medial) 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".
|
| 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
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| S´-Welle (lateral) nicht erhoben | S´-Welle (lateral) 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".
|
| 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
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| S´(medial) nicht erhoben | S´(medial) 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".
|
| 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
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| Pulmonalvenöse systolische Geschwindigkeit (PVsVel) nicht erhoben | Pulmonalvenöse systolische Geschwindigkeit (PVsVel) 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".
|
| 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
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| Perikarderguss nicht erhoben | Perikarderguss 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".
|
| 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
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| TAPSE nicht erhoben | TAPSE 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".
|
| 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
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| MAPSE nicht erhoben | MAPSE 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".
|
| 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
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| RV-Dilatation (Mid-ventrikulär) (Erweiterung rechter Ventrikel) nicht erhoben | RV-Dilatation (Mid-ventrikulär) (Erweiterung rechter Ventrikel) 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".
|
| 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
|
| Linksatriale Fläche 4-Kammer-Blick (endsystolisch) (LA-Fläche 4CH) nicht erhoben | Linksatriale Fläche 4-Kammer-Blick (endsystolisch) (LA-Fläche 4CH) 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".
|
| 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
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| Intraventrikuläres Septum (enddiastolisch) (IVS) nicht erhoben | Intraventrikuläres Septum (enddiastolisch) (IVS) 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".
|
| 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
|
| Linksventrikuläre posteriore Wand (LVPW) nicht errhoben | Linksventrikuläre posteriore Wand (LVPW) nicht errhoben: 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
Default value: Cardiac end-diastolic volume (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
|
| Ergebnis | Ergebnis: A generic section header which should be renamed in a template to suit a specific clinical context. |
| quantitative Parameter | quantitative Parameter: This archetype contains a collection of standard cardiovascular parameters. |
| Data | |
| Any event | Any event: * |
| Data | |
| Kardiologische Messwerte | Kardiologische Messwerte: Kardiologische Standardmesswerte |
| Dimensionen (parasternal lange Achse) | Dimensionen (parasternal lange Achse): * |
| Aortenwurzel | Aortenwurzel: * |
| Diameter Aortenwurzel | Diameter Aortenwurzel: * 0..99 mm |
| Linker Vorhof | Linker Vorhof: * |
| Diameter Linker Vorhof (endsystolisch) | Diameter Linker Vorhof (endsystolisch): * 0..300 mm |
| Linksventrikulärer enddiastolischer Diameter (LVED) | Linksventrikulärer enddiastolischer Diameter (LVED): * |
| Linksventrikulärer enddiastolischer Diameter (LVED) | Linksventrikulärer enddiastolischer Diameter (LVED): * 0..300 mm |
| Linksventrikulärer endsystolischer Diameter (LVEDD) | Linksventrikulärer endsystolischer Diameter (LVEDD): * |
| Linksventrikulärer endsystolischer Diameter (LVEDD) | Linksventrikulärer endsystolischer Diameter (LVEDD): * 0..300 mm |
| Linksventrikuläre posteriore Wand (LVPW) | Linksventrikuläre posteriore Wand (LVPW): * |
| Linksventrikuläre posteriore Wand (LVPW) | Linksventrikuläre posteriore Wand (LVPW): * 0..300 mm |
| Intraventrikuläres Septum (enddiastolisch) (IVS) | Intraventrikuläres Septum (enddiastolisch) (IVS): * |
| Intraventrikuläres Septum (enddiastolisch) (IVS) | Intraventrikuläres Septum (enddiastolisch) (IVS): * Units: mm |
| Mitralklappen-Doppler (PW) | Mitralklappen-Doppler (PW): * |
| E-Welle | E-Welle: * |
| E-Welle | E-Welle: * Units: m/s |
| A-Welle | A-Welle: * |
| A-Welle | A-Welle: * Units: m/s |
| Gewebe-Doppler (TDI) | Gewebe-Doppler (TDI): * |
| E'-Welle (lateral) | E'-Welle (lateral): * |
| E´-Welle (lateral) | E´-Welle (lateral): * Units: m/s |
| A'-Welle (lateral) | A'-Welle (lateral): * |
| A'-Welle (lateral) | A'-Welle (lateral): * Units: m/s |
| S'-Welle (lateral) | S'-Welle (lateral): * |
| S´-Welle (lateral) | S´-Welle (lateral): * Units: m/s |
| A'-Welle (medial) | A'-Welle (medial): * |
| A´-Welle (medial) | A´-Welle (medial): * Units: m/s |
| S'-Welle (medial) | S'-Welle (medial): * |
| S´-Welle (medial) | S´-Welle (medial): * Units: m/s |
| E'-Welle (medial) | E'-Welle (medial): * |
| E´-Welle (medial) | E´-Welle (medial): * Units: m/s |
| 2D-Messungen | 2D-Messungen: * |
| Linksventrikuläre Auswurffraktion (LV-EF) | Linksventrikuläre Auswurffraktion (LV-EF): * |
| Linksventrikuläre Auswurffraktion (LV-EF) | Linksventrikuläre Auswurffraktion (LV-EF): * Units: % |
| Linksventrikuläres enddiastolisches Volumen (LVEDV) | Linksventrikuläres enddiastolisches Volumen (LVEDV): * |
| Linksventrikuläres enddiastolisches Volumen (LVEDV) | Linksventrikuläres enddiastolisches Volumen (LVEDV): * Units: mm³ |
| Linksatriale enddiastolische Fläche 4-Kammer-Blick | Linksatriale enddiastolische Fläche 4-Kammer-Blick: * |
| Linksatriale enddiastolische Fläche 4-Kammer-Blick | Linksatriale enddiastolische Fläche 4-Kammer-Blick: * Units: mm² |
| Mitral Annular Plane Systolic Excursion (MAPSE) | Mitral Annular Plane Systolic Excursion (MAPSE): * |
| Mitral Annular Plane Systolic Excursion (MAPSE) | Mitral Annular Plane Systolic Excursion (MAPSE): * Units: mmHg |
| Tricuspid Annular Plane Systolic Excursion (TAPSE) | Tricuspid Annular Plane Systolic Excursion (TAPSE): * |
| Tricuspid Annular Plane Systolic Excursion (TAPSE) | Tricuspid Annular Plane Systolic Excursion (TAPSE): * Units: mmHg |
| Mittelventrikuläre RV-Dilatation | Mittelventrikuläre RV-Dilatation: * |
| Mittelventrikuläre RV-Dilatation | Mittelventrikuläre RV-Dilatation: * Units: mm |
| Perikarderguss | Perikarderguss: * |
| Perikarderguss / Perikardseparation | Perikarderguss / Perikardseparation: * Units: mm |
| Vena Cava | Vena Cava: * |
| Durchmesser Vena Cava | Durchmesser Vena Cava: * Units: mm |
| Atemvariabilität Vena Cava | Atemvariabilität Vena Cava: * Units: % |
| Pulmonalvenöser Fluss | Pulmonalvenöser Fluss: * |
| Pulmonalvenöse systolische Geschwindigkeit (PVsVel) | Pulmonalvenöse systolische Geschwindigkeit (PVsVel): * |
| Pulmonalvenöse systolische Geschwindigkeit (PVsVel) | Pulmonalvenöse systolische Geschwindigkeit (PVsVel): * Units: cm/s |
| Pulmonalvenöse diastolische Geschwindigkeit (PVdVel) | Pulmonalvenöse diastolische Geschwindigkeit (PVdVel): * |
| Pulmonalvenöse diastolische Geschwindigkeit (PVdVel) | Pulmonalvenöse diastolische Geschwindigkeit (PVdVel): * Units: cm/s |
| Diagnostik Insuffizienzen und Stenosen | Diagnostik Insuffizienzen und Stenosen: A generic section header which should be renamed in a template to suit a specific clinical context. |
| Ausschluss | Ausschluss: A generic section header which should be renamed in a template to suit a specific clinical context. |
| Ausschluss Mitralklappeninsuffizienz (MI) | Ausschluss Mitralklappeninsuffizienz (MI): 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
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| 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
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| Ausschluss Aortenklappenstenose (AS) | Ausschluss Aortenklappenstenose (AS): 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
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| 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
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| Ausschluss Pulmonalklappeninsuffizienz (PI) | Ausschluss Pulmonalklappeninsuffizienz (PI): 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
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| 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
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| Ausschluss Trikuspidalklappeninsuffizienz (TI) | Ausschluss Trikuspidalklappeninsuffizienz (TI): 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
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| 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
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| Ausschluss Aortenklappeninsuffizienz (AI) | Ausschluss Aortenklappeninsuffizienz (AI): 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
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| 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
|
| Ausschluss Mitralklappenstenose (MS) | Ausschluss Mitralklappenstenose (MS): 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
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| 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
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| Nicht erhobene Parameter | Nicht erhobene Parameter: A generic section header which should be renamed in a template to suit a specific clinical context. |
| Mitralklappeninsuffizienz (MI) nicht erfasst | Mitralklappeninsuffizienz (MI) nicht erfasst: 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
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| 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
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| Pulmonalklappeninsuffizienz (PI) nicht erfasst | Pulmonalklappeninsuffizienz (PI) nicht erfasst: 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
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| 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
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| Trikuspidalklappeninsuffizienz (TI) nicht erfasst | Trikuspidalklappeninsuffizienz (TI) nicht erfasst: 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
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| 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
|
| Aortenklappenstenose (AS) nicht erfasst | Aortenklappenstenose (AS) nicht erfasst: 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
|
| 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
|
| Aortenklappeninsuffizienz (AI) nicht erfasst | Aortenklappeninsuffizienz (AI) nicht erfasst: 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
|
| 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
|
| Mitralklappenstenose (MS) nicht erfasst | Mitralklappenstenose (MS) nicht erfasst: 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
|
| 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
|
| Mitralklappeninsuffizienz (MI) | Mitralklappeninsuffizienz (MI): A generic section header which should be renamed in a template to suit a specific clinical context. |
| Grad der Mitralklappeninsuffizienz (MI) | Grad der Mitralklappeninsuffizienz (MI): 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
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| Body site | Body site: Identification of a simple body site for the location of the problem or diagnosis. Coding of the name of the anatomical location with a terminology is preferred, where possible. Use this data element to record precoordinated anatomical locations. If the requirements for recording the anatomical location are determined at run-time by the application or require more complex modelling such as relative locations then use the CLUSTER.anatomical_location or CLUSTER.relative_location within the 'Structured anatomical location' SLOT in this archetype. Occurrences for this data element are unbounded to allow for clinical scenarios such as describing a rash in multiple locations but where all of the other attributes are identical. If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant. Terminology: http://snomed.info/sct
Default value: Mitral valve structure (body structure) |
| 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://snomed.info/sct
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| Pulmonalklappeninsuffizienz (PI) | Pulmonalklappeninsuffizienz (PI): A generic section header which should be renamed in a template to suit a specific clinical context. |
| Grad der Pulmonalklappeninsuffizienz (PI) | Grad der Pulmonalklappeninsuffizienz (PI): 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
|
| Body site | Body site: Identification of a simple body site for the location of the problem or diagnosis. Coding of the name of the anatomical location with a terminology is preferred, where possible. Use this data element to record precoordinated anatomical locations. If the requirements for recording the anatomical location are determined at run-time by the application or require more complex modelling such as relative locations then use the CLUSTER.anatomical_location or CLUSTER.relative_location within the 'Structured anatomical location' SLOT in this archetype. Occurrences for this data element are unbounded to allow for clinical scenarios such as describing a rash in multiple locations but where all of the other attributes are identical. If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant. Terminology: http://snomed.info/sct
Default value: Pulmonary valve structure (body structure) |
| 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://snomed.info/sct
|
| Trikuspidalklappeninsuffizienz (TI) | Trikuspidalklappeninsuffizienz (TI): A generic section header which should be renamed in a template to suit a specific clinical context. |
| Grad der Trikuspidalklappeninsuffizienz (TI) | Grad der Trikuspidalklappeninsuffizienz (TI): 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
|
| Body site | Body site: Identification of a simple body site for the location of the problem or diagnosis. Coding of the name of the anatomical location with a terminology is preferred, where possible. Use this data element to record precoordinated anatomical locations. If the requirements for recording the anatomical location are determined at run-time by the application or require more complex modelling such as relative locations then use the CLUSTER.anatomical_location or CLUSTER.relative_location within the 'Structured anatomical location' SLOT in this archetype. Occurrences for this data element are unbounded to allow for clinical scenarios such as describing a rash in multiple locations but where all of the other attributes are identical. If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant. Terminology: http://snomed.info/sct
Default value: Tricuspid valve structure (body structure) |
| 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://snomed.info/sct
|
| Aortenklappenstenose (AS) | Aortenklappenstenose (AS): A generic section header which should be renamed in a template to suit a specific clinical context. |
| Grad der Aortenklappenstenose (AS) | Grad der Aortenklappenstenose (AS): 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
|
| Body site | Body site: Identification of a simple body site for the location of the problem or diagnosis. Coding of the name of the anatomical location with a terminology is preferred, where possible. Use this data element to record precoordinated anatomical locations. If the requirements for recording the anatomical location are determined at run-time by the application or require more complex modelling such as relative locations then use the CLUSTER.anatomical_location or CLUSTER.relative_location within the 'Structured anatomical location' SLOT in this archetype. Occurrences for this data element are unbounded to allow for clinical scenarios such as describing a rash in multiple locations but where all of the other attributes are identical. If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant. Terminology: http://snomed.info/sct
Default value: Aortic valve structure (body structure) |
| 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://snomed.info/sct
|
| Aortenklappeninsuffizienz (AI) | Aortenklappeninsuffizienz (AI): A generic section header which should be renamed in a template to suit a specific clinical context. |
| Grad der Aortenklappeninsuffizienz (AI) | Grad der Aortenklappeninsuffizienz (AI): 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
|
| Body site | Body site: Identification of a simple body site for the location of the problem or diagnosis. Coding of the name of the anatomical location with a terminology is preferred, where possible. Use this data element to record precoordinated anatomical locations. If the requirements for recording the anatomical location are determined at run-time by the application or require more complex modelling such as relative locations then use the CLUSTER.anatomical_location or CLUSTER.relative_location within the 'Structured anatomical location' SLOT in this archetype. Occurrences for this data element are unbounded to allow for clinical scenarios such as describing a rash in multiple locations but where all of the other attributes are identical. If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant. Terminology: http://snomed.info/sct
Default value: Aortic valve structure (body structure) |
| 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://snomed.info/sct
|
| Mitralklappenstenose (MS) | Mitralklappenstenose (MS): A generic section header which should be renamed in a template to suit a specific clinical context. |
| Grad der Mitralklappenstenose (MS) | Grad der Mitralklappenstenose (MS): 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
|
| Body site | Body site: Identification of a simple body site for the location of the problem or diagnosis. Coding of the name of the anatomical location with a terminology is preferred, where possible. Use this data element to record precoordinated anatomical locations. If the requirements for recording the anatomical location are determined at run-time by the application or require more complex modelling such as relative locations then use the CLUSTER.anatomical_location or CLUSTER.relative_location within the 'Structured anatomical location' SLOT in this archetype. Occurrences for this data element are unbounded to allow for clinical scenarios such as describing a rash in multiple locations but where all of the other attributes are identical. If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant. Terminology: http://snomed.info/sct
Default value: Mitral valve structure (body structure) |
| 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://snomed.info/sct
|