TEMPLATE CAEHR_C_Elektrokardiogramm (CAEHR_C_Elektrokardiogramm)

TEMPLATE ID	CAEHR_C_Elektrokardiogramm
Concept	CAEHR_C_Elektrokardiogramm
Description	Zur Aufzeichnung der Ergebnisse einer Untersuchung mittels Elektrokardiogramm.
Purpose	Zur Aufzeichnung der Ergebnisse einer Untersuchung mittels Elektrokardiogramm.
References
Other Details (Language Independent)	Notes: Generated automatically by Adl Designer MetaDataSet:Sample Set: Template metadata sample set PARENT:MD5-CAM-1.0.1: 005501C1FA493A4838F5F1121F2870EC MD5-CAM-1.0.1: 48249030a9834bdd6dccb5b198cd71ed Sem Ver: 50.0.0 Build Uid: 46b8b50a-d925-4e85-bf13-f7c78d12dfcf Original Language: ISO_639-1::de
Language used	en
Citeable Identifier	1246.169.3516
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.
EKG Ergebnis	EKG Ergebnis: A generic section header which should be renamed in a template to suit a specific clinical context.
ECG result	ECG result: Measurement of the electrical activity generated by the heart. Also known as an electrocardiograph or EKG.
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
Ventricular heart rate	Ventricular heart rate: The frequency of ventricular electrical contractions across the ECG as a whole (multiple leads). Also known as the RR rate, QRS rate or electrical heart rate. The ventricular heart rate is measured from R wave to R wave and calculated across the ECG as a whole (multiple leads). >=0 /min
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QT-Zeit	QT-Zeit: Interval measurement from the onset of the QRS complex to the end of the T wave aacross the ECG as a whole (multiple leads). >=0 ms
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PQ-Zeit	PQ-Zeit: PR interval measurement across the ECG as a whole (multiple leads). The PR interval is measured from onset of P wave to the onset of QRS complex. >=0 ms
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QRS-Dauer	QRS-Dauer: Duration of QRS complex across the ECG as a whole (multiple leads). The QRS complex is measured from its onset to the ST segment onset (J point). >=0 ms
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Rhythmus	Rhythmus: Single word, phrase or brief description that represents a significant finding in the ECG result. For example: 'Normal ECG', 'Equivocal ECG' or 'Abnormal ECG'; 'Spikes from pacemaker signal'; 'ST depression'; or 'Atrial fibrillation'. Coding of the finding with a terminology is preferred, where possible. Terminology: http://snomed.info/sct Atrial fibrillation (disorder) Sinus rhythm (finding) Atrial flutter (disorder)
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Q-Wellen als Hinweis auf abgelaufenen Infarkt	Q-Wellen als Hinweis auf abgelaufenen Infarkt: Single word, phrase or brief description that represents a significant finding in the ECG result. For example: 'Normal ECG', 'Equivocal ECG' or 'Abnormal ECG'; 'Spikes from pacemaker signal'; 'ST depression'; or 'Atrial fibrillation'. Coding of the finding with a terminology is preferred, where possible. Terminology: http://snomed.info/sct Acute non-Q wave infarction (disorder)
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Diskordante T-Negativierungen	Diskordante T-Negativierungen: Single word, phrase or brief description that represents a significant finding in the ECG result. For example: 'Normal ECG', 'Equivocal ECG' or 'Abnormal ECG'; 'Spikes from pacemaker signal'; 'ST depression'; or 'Atrial fibrillation'. Coding of the finding with a terminology is preferred, where possible. Terminology: http://snomed.info/sct Inverted T wave (finding)
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Rythmus	Rythmus: Findings on radiological examination of a specified body structure or region.
Body structure	Body structure: Identification of the body structure or region examined. For example: 'Liver', 'Right ankle' or 'Lymph node group'. Coding of the body structure with an appropriate terminology, such as SNOMED CT, is recommended. If the body structure has been fully identified in this 'Body structure' element, then the 'Body site' data element and 'Structured body site' SLOT become redundant. Terminology: http://snomed.info/sct Finding of heart rhythm (finding)
Anderer Rythmus	Anderer Rythmus: Narrative description of the imaging findings observed during this examination.
State
Schrittmacher Stimulation	Schrittmacher Stimulation: Narrative description about pacemaker activity. This free text field could be further coded in a template to enable a Present/Absent value set if required for reporting purposes. Terminology: http://snomed.info/sct Rhythm from artificial pacing (finding)
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Vorhoferregung durch Schrittmacher	Vorhoferregung durch Schrittmacher: Narrative description about pacemaker activity. This free text field could be further coded in a template to enable a Present/Absent value set if required for reporting purposes. Terminology: http://snomed.info/sct Atrial rhythm from artificial pacing
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Kammererregung durch Schrittmacher	Kammererregung durch Schrittmacher: Narrative description about pacemaker activity. This free text field could be further coded in a template to enable a Present/Absent value set if required for reporting purposes. Terminology: http://snomed.info/sct Ventricular rhythm from artificial pacing (finding)
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Andere Erregung durch Schrittmacher	Andere Erregung durch Schrittmacher: Narrative description about pacemaker activity. This free text field could be further coded in a template to enable a Present/Absent value set if required for reporting purposes. andere Erregung keine andere Erregung
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Andere Erregung spezifizieren	Andere Erregung spezifizieren: Narrative description about pacemaker activity. This free text field could be further coded in a template to enable a Present/Absent value set if required for reporting purposes.
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T negativ unbestimmt	T negativ unbestimmt: 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 Inverted T wave (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 Undetermined (qualifier value)
Ausschluss T negativ	Ausschluss T negativ: 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 Inverted T wave (finding)
Ausschluss Schrittmacher Rhythmus	Ausschluss Schrittmacher Rhythmus: 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 Rhythm from artificial pacing (finding)
Schrittmacher Rhythmus unbestimmt	Schrittmacher Rhythmus unbestimmt: 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 Rhythm from artificial pacing (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 Undetermined (qualifier value)
Q-Wellen abgelaufener Infarkt unbestimmt	Q-Wellen abgelaufener Infarkt unbestimmt: 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 Rhythm from artificial pacing (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 Undetermined (qualifier value)
Ausschluss Q-Wellen abgelaufener Infarkt	Ausschluss Q-Wellen abgelaufener Infarkt: 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 Acute non-Q wave infarction (disorder)
AV-Block	AV-Block: Framework for consistent modelling of content within a template for a Problem list. Intended to be used within the COMPOSITION.problem_list.
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 Atrioventricular block (disorder)
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 First degree atrioventricular block (disorder) Second degree atrioventricular block (disorder) Mobitz type II atrioventricular block (disorder) Complete atrioventricular block (disorder)
Ausschluss AV-Block	Ausschluss AV-Block: 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 Atrioventricular block (disorder)
AV-Block unbestimmt	AV-Block unbestimmt: 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 Atrioventricular block (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 Undetermined (qualifier value)
AV-Block Schweregrad unbestimmt	AV-Block Schweregrad unbestimmt: 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". AV Block Schweregrad
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 Undetermined (qualifier value)
Schenkelblock	Schenkelblock: Framework for consistent modelling of content within a template for a Problem list. Intended to be used within the COMPOSITION.problem_list.
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 Bundle branch block (disorder) Left bundle branch block (disorder) Right bundle branch block (disorder) Incomplete left bundle branch block (disorder) Incomplete right bundle branch block (disorder) Complete left bundle branch block (disorder) Complete right bundle branch block (disorder)
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 Left bundle branch structure (body structure) Structure of right branch of atrioventricular bundle (body structure) Structure of bundle branches (body structure)
Ausschluss Rechtsschenkelblock	Ausschluss Rechtsschenkelblock: 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 Right bundle branch block (disorder)
Ausschluss Linksschenkelblock	Ausschluss Linksschenkelblock: 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 Left bundle branch block (disorder)
Linksschenkelblock unbestimmt	Linksschenkelblock unbestimmt: 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 Left bundle branch block (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 Undetermined (qualifier value)
Schenkelblock Typ unbestimmt	Schenkelblock Typ unbestimmt: 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". Schenkelblock 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 Undetermined (qualifier value)
Rechtsschenkelblock unbestimmt	Rechtsschenkelblock unbestimmt: 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 Right bundle branch block (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 Undetermined (qualifier value)
ST-Strecken pathologisch	ST-Strecken pathologisch: Framework for consistent modelling of content within a template for a Problem list. Intended to be used within the COMPOSITION.problem_list.
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 ST segment depression (finding) ST segment elevation (finding)
Ausschluss ST Segment depression	Ausschluss ST Segment depression: 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 ST segment depression (finding)
Ausschluss ST Segment elevation	Ausschluss ST Segment elevation: 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 ST segment elevation (finding)
ST Segment elevation unbestimmt	ST Segment elevation unbestimmt: 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 ST segment elevation (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 Undetermined (qualifier value)
St Segment depression unbestimmt	St Segment depression unbestimmt: 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 ST segment depression (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 Undetermined (qualifier value)
Hemiblock	Hemiblock: Framework for consistent modelling of content within a template for a Problem list. Intended to be used within the COMPOSITION.problem_list.
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 Monofascicular block (disorder) Left anterior fascicular block (disorder) Left posterior fascicular block (disorder)
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 Structure of bundle branches (body structure)
Ausschluss Hemiblock	Ausschluss Hemiblock: 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 Monofascicular block (disorder)
Hemiblock unbestimmt	Hemiblock unbestimmt: 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 Monofascicular block (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 Undetermined (qualifier value)