TEMPLATE CAEHR_C_Herzkatheter (CAEHR_C_Herzkatheter)

TEMPLATE IDCAEHR_C_Herzkatheter
ConceptCAEHR_C_Herzkatheter
DescriptionZur Repräsentation einer Herzkatheteruntersuchung einschließlich der Befunde.
PurposeZur Repräsentation einer Herzkatheteruntersuchung einschließlich der Befunde.
References
Other Details (Language Independent)
  • MetaDataSet:Sample Set: Template metadata sample set
  • MD5-CAM-1.0.1: 9ac158a4eff93d188d324f5bef037c95
  • PARENT:MD5-CAM-1.0.1: 005501C1FA493A4838F5F1121F2870EC
  • Sem Ver: 15.0.0
  • Build Uid: 5c9ce799-4353-4bdf-b843-e991b100e350
  • Original Language: ISO_639-1::de
KeywordsHerzkatheter; Hämodynamik; Koronararterien; Pumpfunktion; KHK
Language useden
Citeable Identifier1246.169.3519
Root archetype idopenEHR-EHR-COMPOSITION.report.v1
ReportReport: Document to communicate information to others, commonly in response to a request from another party.
Other Context
Case identificationCase identification: To record case identification details for public health purposes.
Case identifierCase identifier: The identifier of this case.
Care journey metadataCare journey metadata: Tp capture Care plan metadata
Care plan nameCare 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 identifierCare 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 identifierPatient journey identifier: A patient-journey specific identifier i.e unique to a patient's journey along a specific care pathway.
Ergebnis HerzkatheteruntersuchungErgebnis 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 EreignisJedes 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
HerzzeitvolumenHerzzeitvolumen: Blutvolumen, welches vom Herz pro Zeiteinheit in den Kreislauf gepumpt wird. Schlüsselwert für Herzleistung.
0..30 l/min
null_flavour
Systolischer pulmonalarterieller DruckSystolischer pulmonalarterieller Druck: Druck in der Arteria pulmonalis (Lungenarterie) während der Systole.
0..200 mmHg
null_flavour
Diastolischer pulmonalarterieller DruckDiastolischer pulmonalarterieller Druck: Druck in der Arteria pulmonalis (Lungenarterie) während der Diastole.
0..200 mmHg
null_flavour
Mittlerer pulmonalarterieller DruckMittlerer 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 SauerstoffsättigungZentralvenöse Sauerstoffsättigung: Sauerstoffsättigung des venösen Blutes bei Erreichen des rechten Vorhofs.
0..100 %
null_flavour
Arterielle SauerstoffsättigungArterielle Sauerstoffsättigung: Sauerstoffsättigung des von der Lunge kommenden Blutes.
0..100 %
null_flavour
Transpulmonaler GradientTranspulmonaler Gradient: Gradient zwischen mittlerem pulmonal arteriellen Druck und pulmonal arteriellen Verschlussdruck.
Die Abkürzung TPG wird teilweise synonym verwendet.
0..100 mmHg
null_flavour
LungengefäßwiderstandLungengefäßwiderstand: 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 LVMittel '+'dP/dT LV: Mittlerer Druckanstieg pro Zeit im linken Ventrikel während der Systole.
0..50000 mm[Hg]/s
null_flavour
Mittel '-'dP/dT LVMittel '-'dP/dT LV: Mittlerer Druckabfall pro Zeit im linken Ventrikel während der Diastole.
0..50000 mm[Hg]/s
null_flavour
Transaortaler GradientTransaortaler Gradient: Druckgradient vor und nach Aortenklappe.
0..500 mmHg
null_flavour
Cardiac IndexCardiac Index: Herzzeitvolumen pro Körperoberfläche.
0..10 l/min/m2
null_flavour
Systolische EjektionszeitSystolische Ejektionszeit: Dauer pro Ausstoß aus der Herzkammer während der Diastole.
0..5000 ms
null_flavour
Diastolische FüllungszeitDiastolische Füllungszeit: Dauer der Füllung der Herzkammer während der Diastole.
0..5000 ms
null_flavour
PumpfunktionPumpfunktion: 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.).
  • 1: Gut 
  • 2: Leicht eingeschränkt 
  • 3: Mittelgradig eingeschränkt 
  • 4: Hochgradig eingeschränkt 
null_flavour
Protocol
Durchführung RechtsherzkatheteruntersuchungDurchführung Rechtsherzkatheteruntersuchung: Wurde die Rechtsherzkatheteruntersuchung durchgeführt?
null_flavour
Durchführung LinksherzkatheteruntersuchungDurchführung Linksherzkatheteruntersuchung: Wurde die Linksherzkatheteruntersuchung durchgeführt?
null_flavour
Ausschluss HerzkatheteruntersuchungAusschluss Herzkatheteruntersuchung: A generic section header which should be renamed in a template to suit a specific clinical context.
Exclusion - specificExclusion - 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 statementExclusion 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) 
EingriffEingriff: The Procedure to which the 'Exclusion statement' applies. For example: 'Heart surgery' or 'Appendectomy' or 'Hip replacement'.
Terminology: http://snomed.info/sct
  • Cardiac catheterization (procedure) 
Koronare HerzkrankheitKoronare Herzkrankheit: Framework for consistent modelling of content within a template for a Problem list.
Intended to be used within the COMPOSITION.problem_list.
Problem/DiagnosisProblem/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 nameProblem/Diagnosis name: Identification of the problem or diagnosis, by name.
Coding of the name of the problem or diagnosis with a terminology is preferred, where possible.
Terminology: http://snomed.info/sct
  • Coronary arteriosclerosis (disorder) 
Clinical descriptionClinical 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.
  • Koronarsklerose
  • 1-Gefäß-KHK
  • 2-Gefäß-KHK
  • 3-Gefäß-KHK
null_flavour
Exclusion - specificExclusion - 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 statementExclusion 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/DiagnoseProblem/Diagnose: The problem or diagnosis to which the 'Exclusion statement' applies. For example: 'Diabetes', 'COPD' or 'Asthma'.
Terminology: http://snomed.info/sct
  • Coronary arteriosclerosis (disorder) 
Absence of informationAbsence 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 statementAbsence statement: Positive statement that no information is available.
For example: "No information available about adverse reactions"; No information available about problems or diagnoses"; "No information available about previous procedures performed"; or "No information available about medications used".
Terminology: http://snomed.info/sct
  • Coronary arteriosclerosis (disorder) 
Reason for absenceReason for absence: Description of the reason why there is no information available.
For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible.
Terminology: http://snomed.info/sct
  • Not recorded (qualifier value) 
MyokardbiopsieMyokardbiopsie: A generic section header which should be renamed in a template to suit a specific clinical context.
ProcedureProcedure: A clinical activity carried out for screening, investigative, diagnostic, curative, therapeutic, evaluative or palliative purposes.
Description
Procedure nameProcedure name: Identification of the procedure by name.
Coding of the specific procedure with a terminology is preferred, where possible.
Terminology: http://snomed.info/sct
  • Myocardial biopsy (procedure) 
Final end date/timeFinal 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.
VentrikelVentrikel: The type of procedure.
This pragmatic data element may be used to support organisation within the user interface.
  • LV
  • RV
  • LV und RV
Protocol
Befundendes InstitutBefundendes 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.
  •  Text
  •  Identifier
Exclusion - specificExclusion - 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 statementExclusion 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
  • Definitely NOT present (qualifier value) 
EingriffEingriff: The Procedure to which the 'Exclusion statement' applies. For example: 'Heart surgery' or 'Appendectomy' or 'Hip replacement'.
Terminology: http://snomed.info/sct
  • Myocardial biopsy (procedure) 
Absence of informationAbsence 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 statementAbsence statement: Positive statement that no information is available.
For example: "No information available about adverse reactions"; No information available about problems or diagnoses"; "No information available about previous procedures performed"; or "No information available about medications used".
Terminology: http://snomed.info/sct
  • Myocardial biopsy (procedure) 
Reason for absenceReason for absence: Description of the reason why there is no information available.
For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible.
Terminology: http://snomed.info/sct
  • Not recorded (qualifier value) 
Nicht erhobene ParameterNicht 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 statementAbsence 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 ventricular end-diastolic pressure (observable entity) 
Reason for absenceReason for absence: Description of the reason why there is no information available.
For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible.
Terminology: http://snomed.info/sct
  • Not recorded (qualifier value) 
HerzzeitvolumenHerzzeitvolumen: Statement that specified health information is not available for inclusion in the health record or extract at the time of recording.
Data
Absence statementAbsence statement: Positive statement that no information is available.
For example: "No information available about adverse reactions"; No information available about problems or diagnoses"; "No information available about previous procedures performed"; or "No information available about medications used".
Terminology: http://snomed.info/sct
  • Cardiac output (observable entity) 
Reason for absenceReason for absence: Description of the reason why there is no information available.
For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible.
Terminology: http://snomed.info/sct
  • Not recorded (qualifier value) 
Systolischer pulmonal-arterieller DruckSystolischer 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 statementAbsence statement: Positive statement that no information is available.
For example: "No information available about adverse reactions"; No information available about problems or diagnoses"; "No information available about previous procedures performed"; or "No information available about medications used".
Terminology: http://snomed.info/sct
  • Pulmonary artery systolic pressure (observable entity) 
Reason for absenceReason for absence: Description of the reason why there is no information available.
For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible.
Terminology: http://snomed.info/sct
  • Not recorded (qualifier value) 
Diastolischer pulmonal-arterieller DruckDiastolischer 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 statementAbsence statement: Positive statement that no information is available.
For example: "No information available about adverse reactions"; No information available about problems or diagnoses"; "No information available about previous procedures performed"; or "No information available about medications used".
Terminology: http://snomed.info/sct
  • Pulmonary artery diastolic pressure (observable entity) 
Reason for absenceReason for absence: Description of the reason why there is no information available.
For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible.
Terminology: http://snomed.info/sct
  • Not recorded (qualifier value) 
Mittlerer pulmonal-arterieller DruckMittlerer 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 statementAbsence statement: Positive statement that no information is available.
For example: "No information available about adverse reactions"; No information available about problems or diagnoses"; "No information available about previous procedures performed"; or "No information available about medications used".
Terminology: http://snomed.info/sct
  • Pulmonary artery mean pressure (observable entity) 
Reason for absenceReason for absence: Description of the reason why there is no information available.
For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible.
Terminology: http://snomed.info/sct
  • Not recorded (qualifier value) 
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 statementAbsence statement: Positive statement that no information is available.
For example: "No information available about adverse reactions"; No information available about problems or diagnoses"; "No information available about previous procedures performed"; or "No information available about medications used".
Terminology: http://snomed.info/sct
  • Pulmonary artery wedge pressure (observable entity) 
Reason for absenceReason for absence: Description of the reason why there is no information available.
For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible.
Terminology: http://snomed.info/sct
  • Not recorded (qualifier value) 
Zentralvenöse SauerstoffsättigungZentralvenöse Sauerstoffsättigung: Statement that specified health information is not available for inclusion in the health record or extract at the time of recording.
Data
Absence statementAbsence 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
  • Central venous oxygenation saturation (observable entity) 
Reason for absenceReason for absence: Description of the reason why there is no information available.
For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible.
Terminology: http://snomed.info/sct
  • Not recorded (qualifier value) 
Transpulmonaler GradientTranspulmonaler Gradient: Statement that specified health information is not available for inclusion in the health record or extract at the time of recording.
Data
Absence statementAbsence 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".
  • Transpulmonaler Gradient
Default value: Transpulmonaler Gradient
Reason for absenceReason for absence: Description of the reason why there is no information available.
For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible.
Terminology: http://snomed.info/sct
  • Not recorded (qualifier value) 
LungengefäßwiderstandLungengefäßwiderstand: Statement that specified health information is not available for inclusion in the health record or extract at the time of recording.
Data
Absence statementAbsence statement: Positive statement that no information is available.
For example: "No information available about adverse reactions"; No information available about problems or diagnoses"; "No information available about previous procedures performed"; or "No information available about medications used".
Terminology: http://snomed.info/sct
  • Pulmonary vascular resistance (observable entity) 
Reason for absenceReason for absence: Description of the reason why there is no information available.
For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible.
Terminology: http://snomed.info/sct
  • Not recorded (qualifier value) 
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 statementAbsence 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
  • Systemic vascular resistance (observable entity) 
Reason for absenceReason for absence: Description of the reason why there is no information available.
For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible.
Terminology: http://snomed.info/sct
  • Not recorded (qualifier value) 
PumpfunktionPumpfunktion: Statement that specified health information is not available for inclusion in the health record or extract at the time of recording.
Data
Absence statementAbsence 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".
  • Pumpfunktion
Default value: Pumpfunktion
Reason for absenceReason for absence: Description of the reason why there is no information available.
For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible.
Terminology: http://snomed.info/sct
  • Not recorded (qualifier value) 
Mittel '+' dp/dT LVMittel '+' 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 statementAbsence 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
  • Dp/Dt - left ventricle (observable entity) 
Reason for absenceReason for absence: Description of the reason why there is no information available.
For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible.
Terminology: http://snomed.info/sct
  • Not recorded (qualifier value) 
Mittel '-' dp/dT LVMittel '-' 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 statementAbsence 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
  • Dp/Dt - left ventricle (observable entity) 
Reason for absenceReason for absence: Description of the reason why there is no information available.
For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible.
Terminology: http://snomed.info/sct
  • Not recorded (qualifier value) 
Transaortaler GradientTransaortaler Gradient: Statement that specified health information is not available for inclusion in the health record or extract at the time of recording.
Data
Absence statementAbsence 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".
  • Transaortaler Gradient
Reason for absenceReason for absence: Description of the reason why there is no information available.
For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible.
Terminology: http://snomed.info/sct
  • Not recorded (qualifier value) 
Cardiac IndexCardiac Index: Statement that specified health information is not available for inclusion in the health record or extract at the time of recording.
Data
Absence statementAbsence statement: Positive statement that no information is available.
For example: "No information available about adverse reactions"; No information available about problems or diagnoses"; "No information available about previous procedures performed"; or "No information available about medications used".
Terminology: http://snomed.info/sct
  • Cardiac index (observable entity) 
Reason for absenceReason for absence: Description of the reason why there is no information available.
For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible.
Terminology: http://snomed.info/sct
  • Not recorded (qualifier value) 
Systolische EjektionszeitSystolische Ejektionszeit: Statement that specified health information is not available for inclusion in the health record or extract at the time of recording.
Data
Absence statementAbsence 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".
  • Systolische Ejektionszeit
Default value: Systolische Ejektionszeit
Reason for absenceReason for absence: Description of the reason why there is no information available.
For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible.
Terminology: http://snomed.info/sct
  • Not recorded (qualifier value) 
Diastolische FüllungszeitDiastolische Füllungszeit: Statement that specified health information is not available for inclusion in the health record or extract at the time of recording.
Data
Absence statementAbsence 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".
  • Diastolische Füllungszeit
Reason for absenceReason for absence: Description of the reason why there is no information available.
For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible.
Terminology: http://snomed.info/sct
  • Not recorded (qualifier value)