| TEMPLATE ID | CAEHR_C_Herzkatheter |
|---|---|
| Concept | CAEHR_C_Herzkatheter |
| Description | Zur Repräsentation einer Herzkatheteruntersuchung einschließlich der Befunde. |
| Purpose | Zur Repräsentation einer Herzkatheteruntersuchung einschließlich der Befunde. |
| References | |
| Other Details (Language Independent) |
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| Keywords | Herzkatheter; Hämodynamik; Koronararterien; Pumpfunktion; KHK |
| Language used | en |
| Citeable Identifier | 1246.169.3519 |
| 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. |
| Ergebnis Herzkatheteruntersuchung | Ergebnis Herzkatheteruntersuchung: Die Herzkatheteruntersuchung ist eine minimalinvasive medizinische Untersuchung des Herzens über einen Katheter, der über venöse oder arterielle Adern der Leiste, der Ellenbeuge oder über das Handgelenk eingeführt wird. |
| Data | |
| Jedes Ereignis | Jedes Ereignis: Generic event. |
| Data | |
| Linksventrikulärer enddiastolischer Druck (LVEDP) | Linksventrikulärer enddiastolischer Druck (LVEDP): Druck im linken Herzventrikel am Ende der Diastole, Kennwert für Herzinsuffizienz. Die Abkürzung LVEDP wird teilweise synonym verwendet. 0..150 mmHg |
| null_flavour | |
| Herzzeitvolumen | Herzzeitvolumen: Blutvolumen, welches vom Herz pro Zeiteinheit in den Kreislauf gepumpt wird. Schlüsselwert für Herzleistung. 0..30 l/min |
| null_flavour | |
| Systolischer pulmonalarterieller Druck | Systolischer pulmonalarterieller Druck: Druck in der Arteria pulmonalis (Lungenarterie) während der Systole. 0..200 mmHg |
| null_flavour | |
| Diastolischer pulmonalarterieller Druck | Diastolischer pulmonalarterieller Druck: Druck in der Arteria pulmonalis (Lungenarterie) während der Diastole. 0..200 mmHg |
| null_flavour | |
| Mittlerer pulmonalarterieller Druck | Mittlerer pulmonalarterieller Druck: Mittlerer Druck in der Arteria pulmonalis (Lungenarterie). 0..200 mmHg |
| null_flavour | |
| Pulmonalkapillärer Druck (PCWP) | Pulmonalkapillärer Druck (PCWP): Verschlussdruck der Lungenkapillaren. Erlaubt indirekt die Bestimmung einer Beteiligung des Herzens an einer Lungendruckerhöhung. Die Abkürzung PCWP wird teilweise synonym verwendet. 0..100 mmHg |
| null_flavour | |
| Zentralvenöse Sauerstoffsättigung | Zentralvenöse Sauerstoffsättigung: Sauerstoffsättigung des venösen Blutes bei Erreichen des rechten Vorhofs. 0..100 % |
| null_flavour | |
| Arterielle Sauerstoffsättigung | Arterielle Sauerstoffsättigung: Sauerstoffsättigung des von der Lunge kommenden Blutes. 0..100 % |
| null_flavour | |
| Transpulmonaler Gradient | Transpulmonaler Gradient: Gradient zwischen mittlerem pulmonal arteriellen Druck und pulmonal arteriellen Verschlussdruck. Die Abkürzung TPG wird teilweise synonym verwendet. 0..100 mmHg |
| null_flavour | |
| Lungengefäßwiderstand | Lungengefäßwiderstand: Gefäßwiderstand im Lungenkreislauf. Berechnet auf Basis des Wedge-Drucks (Transpulmonaler Gradient/ Herzzeitvolumen * 80). Die Abkürzung PVR wird teilweise Synonym verwendet. 0..9000 dyn.s.cm-5 |
| null_flavour | |
| Systemischer Gefäßwiderstand (SVR) | Systemischer Gefäßwiderstand (SVR): Gefäßwiderstand des peripheren Gefäßsystems im systemischen Kreislauf. Berechnet aus dem Übergangswiderstand zwischen dem arteriellen und venösen System und dem Herzzeitvolumen der letzten 12 Sekunden. Die Abkürzung SVR wird teilweise synonym verwendet. 0..5000 dyn.s.cm-5 |
| null_flavour | |
| Mittel '+'dP/dT LV | Mittel '+'dP/dT LV: Mittlerer Druckanstieg pro Zeit im linken Ventrikel während der Systole. 0..50000 mm[Hg]/s |
| null_flavour | |
| Mittel '-'dP/dT LV | Mittel '-'dP/dT LV: Mittlerer Druckabfall pro Zeit im linken Ventrikel während der Diastole. 0..50000 mm[Hg]/s |
| null_flavour | |
| Transaortaler Gradient | Transaortaler Gradient: Druckgradient vor und nach Aortenklappe. 0..500 mmHg |
| null_flavour | |
| Cardiac Index | Cardiac Index: Herzzeitvolumen pro Körperoberfläche. 0..10 l/min/m2 |
| null_flavour | |
| Systolische Ejektionszeit | Systolische Ejektionszeit: Dauer pro Ausstoß aus der Herzkammer während der Diastole. 0..5000 ms |
| null_flavour | |
| Diastolische Füllungszeit | Diastolische Füllungszeit: Dauer der Füllung der Herzkammer während der Diastole. 0..5000 ms |
| null_flavour | |
| Pumpfunktion | Pumpfunktion: Die Auswertung der linksventrikulären (Pump)-funktion erfolgt qualitativ: 1. Beurteilung von Wandbewegungsstörungen nach der von Herman et al. definierten Nomenklatur (Herman et al.).
2. Die Dokumentation der Einteilung und Beurteilung der einzelnen Wandareale erfolgt nach dem CoronaryArteryDisease Reporting System der AHA (Austen et al.).
|
| null_flavour | |
| Protocol | |
| Durchführung Rechtsherzkatheteruntersuchung | Durchführung Rechtsherzkatheteruntersuchung: Wurde die Rechtsherzkatheteruntersuchung durchgeführt? |
| null_flavour | |
| Durchführung Linksherzkatheteruntersuchung | Durchführung Linksherzkatheteruntersuchung: Wurde die Linksherzkatheteruntersuchung durchgeführt? |
| null_flavour | |
| Ausschluss Herzkatheteruntersuchung | Ausschluss Herzkatheteruntersuchung: A generic section header which should be renamed in a template to suit a specific clinical context. |
| Exclusion - specific | Exclusion - specific: 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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| Eingriff | Eingriff: The Procedure to which the 'Exclusion statement' applies. For example: 'Heart surgery' or 'Appendectomy' or 'Hip replacement'. Terminology: http://snomed.info/sct
|
| Koronare Herzkrankheit | Koronare Herzkrankheit: 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
|
| Clinical description | Clinical description: Narrative description about the problem or diagnosis. Use to provide background and context, including evolution, episodes or exacerbations, progress and any other relevant details, about the problem or diagnosis.
|
| null_flavour | |
| Exclusion - specific | Exclusion - specific: 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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| Absence of information | Absence of information: 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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| Myokardbiopsie | Myokardbiopsie: A generic section header which should be renamed in a template to suit a specific clinical context. |
| Procedure | Procedure: A clinical activity carried out for screening, investigative, diagnostic, curative, therapeutic, evaluative or palliative purposes. |
| Description | |
| Procedure name | Procedure name: Identification of the procedure by name. Coding of the specific procedure with a terminology is preferred, where possible. Terminology: http://snomed.info/sct
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| Final end date/time | Final end date/time: The date and/or time when the entire procedure, or the last component of a multicomponent procedure, was finished. Only for use in association with the 'Procedure performed' pathway step, and in situations where the procedure is repeated on multiple occasions before being completed or there are multiple components to the whole procedure. This may be the same as the RM time attribute for the 'Procedure completed' pathway step. |
| Ventrikel | Ventrikel: The type of procedure. This pragmatic data element may be used to support organisation within the user interface.
|
| Protocol | |
| Befundendes Institut | Befundendes Institut: The ID assigned to the order by the healthcare provider or organisation receiving the request for service. This is also referred to as Filler Order Identifier. This is equivalent to Filler Order Number in HL7 v2 specifications.
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| Exclusion - specific | Exclusion - specific: 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
|
| Eingriff | Eingriff: The Procedure to which the 'Exclusion statement' applies. For example: 'Heart surgery' or 'Appendectomy' or 'Hip replacement'. Terminology: http://snomed.info/sct
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| Absence of information | Absence of information: 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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| Nicht erhobene Parameter | Nicht erhobene Parameter: A generic section header which should be renamed in a template to suit a specific clinical context. |
| Linksventrikulärer enddiastolischer Druck (LVEDP) | Linksventrikulärer enddiastolischer Druck (LVEDP): 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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| Herzzeitvolumen | Herzzeitvolumen: 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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| Systolischer pulmonal-arterieller Druck | Systolischer pulmonal-arterieller Druck: 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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| Diastolischer pulmonal-arterieller Druck | Diastolischer pulmonal-arterieller Druck: 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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| Mittlerer pulmonal-arterieller Druck | Mittlerer pulmonal-arterieller Druck: 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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| Pulmonalkapillärer Druck (PCWP) | Pulmonalkapillärer Druck (PCWP): 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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| Zentralvenöse Sauerstoffsättigung | Zentralvenöse Sauerstoffsättigung: 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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| Transpulmonaler Gradient | Transpulmonaler Gradient: 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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| Lungengefäßwiderstand | Lungengefäßwiderstand: 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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| Systemischer Gefäßwiderstand (SVR) | Systemischer Gefäßwiderstand (SVR): 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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| Pumpfunktion | Pumpfunktion: 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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| Mittel '+' dp/dT LV | Mittel '+' dp/dT LV: 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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| Mittel '-' dp/dT LV | Mittel '-' dp/dT LV: 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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| Transaortaler Gradient | Transaortaler Gradient: 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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| Cardiac Index | Cardiac Index: 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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| Systolische Ejektionszeit | Systolische Ejektionszeit: 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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| Diastolische Füllungszeit | Diastolische Füllungszeit: 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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