TEMPLATE CAEHR_C_Komorbiditäten (CAEHR_C_Komorbiditäten)

TEMPLATE ID	CAEHR_C_Komorbiditäten
Concept	CAEHR_C_Komorbiditäten
Description	Dokumentation von Komorbiditäten in CAEHR
Purpose	Dokumentation von Komorbiditäten in CAEHR
References
Authors	name: Severin Kohler; organisation: Berlin Institute of Health; email: severin.kohler@charite.de
Other Details Language	name: Severin Kohler; organisation: Berlin Institute of Health; email: severin.kohler@charite.de
Other Details (Language Independent)	Notes: Generated automatically by Adl Designer MetaDataSet:Sample Set: Template metadata sample set MD5-CAM-1.0.1: 7644a8feab25b707ba3d1755d809599a PARENT:MD5-CAM-1.0.1: 005501C1FA493A4838F5F1121F2870EC Sem Ver: 202.0.0 Build Uid: 63025009-40ce-4fd8-868a-5f0ea6f656b7 Original Language: ISO_639-1::de
Keywords	Kardiologie, CAEHR, Komorbiditäten
Language used	en
Citeable Identifier	1246.169.3521
Root archetype id	openEHR-EHR-COMPOSITION.report.v1
Report	Report: Document to communicate information to others, commonly in response to a request from another party.
other_context
Other Context
Case identification	Case identification: To record case identification details for public health purposes.
Case identifier	Case identifier: The identifier of this case.
Care journey metadata	Care journey metadata: Tp capture Care plan metadata
Care plan name	Care plan name: The name , preferably coded of the Care plan with which this journey is associated, and against which the composition was updated.
Care plan identifier	Care plan identifier: The identifier , preferably coded, of the Care plan with which this journey is associated, and against which the composition was updated.
Patient journey identifier	Patient journey identifier: A patient-journey specific identifier i.e unique to a patient's journey along a specific care pathway.
Periphere arterielle Verschlusskrankheit (pAVK)	Periphere arterielle Verschlusskrankheit (pAVK): A generic section header which should be renamed in a template to suit a specific clinical context.
Periphere arterielle Verschlusskrankheit (pAVK)	Periphere arterielle Verschlusskrankheit (pAVK): 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 Peripheral arterial occlusive disease (disorder)
Fontaine-Stadium	Fontaine-Stadium: Narrative description about the problem or diagnosis. Use to provide background and context, including evolution, episodes or exacerbations, progress and any other relevant details, about the problem or diagnosis. Terminology: http://fhir.de/CodeSystem/bfarm/icd-10-gm Stadium 1: Becken-Bein-Typ, ohne Beschwerden Stadium 2a: Becken-Bein-Typ, mit belastungsinduziertem Ischämieschmerz, Gehstrecke 200 m und mehr Stadium 2b: Becken-Bein-Typ, mit belastungsinduziertem Ischämieschmerz, Gehstrecke weniger als 200 m Stadium 3: Becken-Bein-Typ, mit Ruheschmerz Stadium 4: Becken-Bein-Typ, mit Ulzeration Stadium 4: Becken-Bein-Typ, mit Gangrän
Ausschluss pAVK	Ausschluss pAVK: 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 Peripheral arterial occlusive disease (disorder)
PAVK nicht erhoben	PAVK nicht erhoben: Statement that specified health information is not available for inclusion in the health record or extract at the time of recording.
Data
Absence statement	Absence statement: Positive statement that no information is available. For example: "No information available about adverse reactions"; No information available about problems or diagnoses"; "No information available about previous procedures performed"; or "No information available about medications used". Terminology: http://snomed.info/sct Peripheral arterial occlusive disease (disorder)
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Not recorded (qualifier value)
Stadium pAVK nicht erhoben/unbekannt	Stadium pAVK nicht erhoben/unbekannt: Statement that specified health information is not available for inclusion in the health record or extract at the time of recording.
Data
Absence statement	Absence statement: Positive statement that no information is available. For example: "No information available about adverse reactions"; No information available about problems or diagnoses"; "No information available about previous procedures performed"; or "No information available about medications used". Stadium der pAVK
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Not recorded (qualifier value) Unknown (qualifier value)
Schlaganfall/TIA	Schlaganfall/TIA: A generic section header which should be renamed in a template to suit a specific clinical context.
Schlaganfall	Schlaganfall: 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 Cerebrovascular accident (disorder)
Datum des letzten Schlaganfalls/TIA	Datum des letzten Schlaganfalls/TIA: Estimated or actual date/time that signs or symptoms of the problem/diagnosis were first observed. Data captured/imported as "Age at onset" should be converted to a date using the subject's date of birth.
Ausschluss Schlaganfall	Ausschluss Schlaganfall: 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 Cerebrovascular accident (disorder)
Schlaganfall nicht erhoben	Schlaganfall nicht erhoben: Statement that specified health information is not available for inclusion in the health record or extract at the time of recording.
Data
Absence statement	Absence statement: Positive statement that no information is available. For example: "No information available about adverse reactions"; No information available about problems or diagnoses"; "No information available about previous procedures performed"; or "No information available about medications used". Terminology: http://snomed.info/sct Cerebrovascular accident (disorder)
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Not recorded (qualifier value)
TIA	TIA: 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 Transient ischemic attack (disorder)
Datum des letzten TIA	Datum des letzten TIA: Estimated or actual date/time that signs or symptoms of the problem/diagnosis were first observed. Data captured/imported as "Age at onset" should be converted to a date using the subject's date of birth.
TIA nicht erhoben	TIA nicht erhoben: Statement that specified health information is not available for inclusion in the health record or extract at the time of recording.
Data
Absence statement	Absence statement: Positive statement that no information is available. For example: "No information available about adverse reactions"; No information available about problems or diagnoses"; "No information available about previous procedures performed"; or "No information available about medications used". Terminology: http://snomed.info/sct Transient ischemic attack (disorder)
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Not recorded (qualifier value)
Ausschluss TIA	Ausschluss TIA: 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 Transient ischemic attack (disorder)
Schlaganfall Datum unbekannt	Schlaganfall Datum unbekannt: Statement that specified health information is not available for inclusion in the health record or extract at the time of recording.
Data
Absence statement	Absence statement: Positive statement that no information is available. For example: "No information available about adverse reactions"; No information available about problems or diagnoses"; "No information available about previous procedures performed"; or "No information available about medications used". Datum des letzten Schlaganfall
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Unknown (qualifier value)
TIA Datum unbekannt	TIA Datum unbekannt: Statement that specified health information is not available for inclusion in the health record or extract at the time of recording.
Data
Absence statement	Absence statement: Positive statement that no information is available. For example: "No information available about adverse reactions"; No information available about problems or diagnoses"; "No information available about previous procedures performed"; or "No information available about medications used". Datum des letzten TIA
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Unknown (qualifier value)
Chronische Lungenerkrankung	Chronische Lungenerkrankung: A generic section header which should be renamed in a template to suit a specific clinical context.
Chronische Lungenerkrankung	Chronische Lungenerkrankung: 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 Chronic lung disease (disorder)
Variant	Variant: Specific variant or subtype of the Diagnosis, if relevant. For example: 'acute motor axonal neuropathy' as a variant of Guillain-Barre Syndrome. Coding of the name of the variant with a terminology is preferred, where possible.
Protocol
Ausschluss chronische Lungenerkrankung	Ausschluss chronische Lungenerkrankung: 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 Chronic lung disease (disorder)
Chronische Lungenerkrankung nicht erhoben	Chronische Lungenerkrankung nicht erhoben: Statement that specified health information is not available for inclusion in the health record or extract at the time of recording.
Data
Absence statement	Absence statement: Positive statement that no information is available. For example: "No information available about adverse reactions"; No information available about problems or diagnoses"; "No information available about previous procedures performed"; or "No information available about medications used". Terminology: http://snomed.info/sct Chronic lung disease (disorder)
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Not recorded (qualifier value)
Primäre pulmonale Hypertonie	Primäre pulmonale Hypertonie: A generic section header which should be renamed in a template to suit a specific clinical context.
Primäre pulmonale Hypertonie	Primäre pulmonale Hypertonie: Details about a single identified health condition, injury, disability or any other issue which impacts on the physical, mental and/or social well-being of an individual. Clear delineation between the scope of a problem versus a diagnosis is not easy to achieve in practice. For the purposes of clinical documentation with this archetype, problem and diagnosis are regarded as a continuum, with increasing levels of detail and supportive evidence usually providing weight towards the label of 'diagnosis'.
Data
Problem/Diagnosis name	Problem/Diagnosis name: Identification of the problem or diagnosis, by name. Coding of the name of the problem or diagnosis with a terminology is preferred, where possible. Terminology: http://snomed.info/sct Pulmonary hypertensive arterial disease (disorder)
Protocol
Ausschluss pulmonale Hypertonie	Ausschluss pulmonale Hypertonie: A statement of exclusion of a specific Problem/diagnosis, Family history, Medication, Procedure, Adverse reaction or other clinical item that is either not currently present, or have not been present in the past.
Data
Exclusion statement	Exclusion statement: A qualifying statement about the exclusion of a Problem/diagnosis, Family history, Medication, Procedure, Adverse reaction or other clinical item. This statement is to be used in conjunction with the 'Excluded concept' data element. For example: this data element can support recording general statements such as "No known history of ..." where the 'Excluded concept' identifies the specific problem, diagnosis, substance, procedure or medication. If the 'Excluded concept' data element is used to record a precoordinated term such as 'No family history of diabetes', this element is redundant. Terminology: http://snomed.info/sct Definitely NOT present (qualifier value)
Problem/Diagnose	Problem/Diagnose: The problem or diagnosis to which the 'Exclusion statement' applies. For example: 'Diabetes', 'COPD' or 'Asthma'. Terminology: http://snomed.info/sct Pulmonary hypertensive arterial disease (disorder)
Pulmonale Hypertonie nicht erhoben	Pulmonale Hypertonie nicht erhoben: Statement that specified health information is not available for inclusion in the health record or extract at the time of recording.
Data
Absence statement	Absence statement: Positive statement that no information is available. For example: "No information available about adverse reactions"; No information available about problems or diagnoses"; "No information available about previous procedures performed"; or "No information available about medications used". Terminology: http://snomed.info/sct Pulmonary hypertensive arterial disease (disorder)
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Not recorded (qualifier value)
Depression	Depression: A generic section header which should be renamed in a template to suit a specific clinical context.
Depression	Depression: 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 Depressive disorder (disorder)
Protocol
Ausschluss Depression	Ausschluss 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 Depressive disorder (disorder)
Depression nicht erhoben	Depression nicht erhoben: Statement that specified health information is not available for inclusion in the health record or extract at the time of recording.
Data
Absence statement	Absence statement: Positive statement that no information is available. For example: "No information available about adverse reactions"; No information available about problems or diagnoses"; "No information available about previous procedures performed"; or "No information available about medications used". Terminology: http://snomed.info/sct Depressive disorder (disorder)
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Not recorded (qualifier value)
Krebserkrankung vor mehr als 5 Jahren	Krebserkrankung vor mehr als 5 Jahren: A generic section header which should be renamed in a template to suit a specific clinical context.
Krebserkrankung vor mehr als 5 Jahren	Krebserkrankung vor mehr als 5 Jahren: 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 Malignant neoplastic disease (disorder)
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. Krebserkrankung vor mehr als 5 Jahren
Problem/Diagnosis qualifier	Problem/Diagnosis qualifier: Contextual or temporal qualifier for a specified problem or diagnosis.
Current/Past?	Current/Past?: Category that supports division of problems and diagnoses into Current or Past problem lists. The Current/Past and Active/Inactive data elements have similar clinical impact but represent slightly different semantics. Both are actively used in different clinical settings, but usually not together. If an Active/Inactive qualifier is recorded, then this data element is likely to be redundant. An exception where a condition can be current but inactive is asthma that is not causing acute symptoms. Past
Ausschluss Krebs >5 Jahre	Ausschluss Krebs >5 Jahre: 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'. Krebserkrankung vor mehr als 5 Jahren
Krebs >5 Jahre nicht erhoben	Krebs >5 Jahre nicht erhoben: Statement that specified health information is not available for inclusion in the health record or extract at the time of recording.
Data
Absence statement	Absence statement: Positive statement that no information is available. For example: "No information available about adverse reactions"; No information available about problems or diagnoses"; "No information available about previous procedures performed"; or "No information available about medications used". Krebserkrankung vor mehr als 5 Jahren
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Not recorded (qualifier value)
Krebserkrankung vor weniger als 5 Jahren	Krebserkrankung vor weniger als 5 Jahren: A generic section header which should be renamed in a template to suit a specific clinical context.
Krebserkrankung vor weniger als 5 Jahren	Krebserkrankung vor weniger als 5 Jahren: 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 Malignant neoplastic disease (disorder)
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. Krebserkrankung vor weniger als 5 Jahren
Date/time clinically recognised	Date/time clinically recognised: Estimated or actual date/time the diagnosis or problem was recognised by a healthcare professional. Partial dates are acceptable. If the subject of care is under the age of one year, then the complete date or a minimum of the month and year is necessary to enable accurate age calculations - for example, if used to drive decision support. Data captured/imported as "Age at time of clinical recognition" should be converted to a date using the subject's date of birth.
Ausschluss Krebs <5 Jahren	Ausschluss Krebs <5 Jahren: 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'. Krebserkrankung vor weniger als 5 Jahren
Krebs <5 Jahren nicht erhoben	Krebs <5 Jahren nicht erhoben: Statement that specified health information is not available for inclusion in the health record or extract at the time of recording.
Data
Absence statement	Absence statement: Positive statement that no information is available. For example: "No information available about adverse reactions"; No information available about problems or diagnoses"; "No information available about previous procedures performed"; or "No information available about medications used". Krebserkrankung vor weniger als 5 Jahren
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Not recorded (qualifier value)
Sonstige Diagnosen	Sonstige Diagnosen: A generic section header which should be renamed in a template to suit a specific clinical context.
Sonstige Diagnosen	Sonstige Diagnosen: 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
Diagnose	Diagnose: Identification of the problem or diagnosis, by name. Coding of the name of the problem or diagnosis with a terminology is preferred, where possible.
Variant	Variant: Specific variant or subtype of the Diagnosis, if relevant. For example: 'acute motor axonal neuropathy' as a variant of Guillain-Barre Syndrome. Coding of the name of the variant with a terminology is preferred, where possible.
Sonstige Diagnosen nicht erhoben	Sonstige Diagnosen nicht erhoben: Statement that specified health information is not available for inclusion in the health record or extract at the time of recording.
Data
Absence statement	Absence statement: Positive statement that no information is available. For example: "No information available about adverse reactions"; No information available about problems or diagnoses"; "No information available about previous procedures performed"; or "No information available about medications used". Sonstige Diagnosen
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Not recorded (qualifier value)
Ausschluss Sonstige Diagnosen	Ausschluss Sonstige Diagnosen: 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'. Sonstige Diagnosen
Other contributors	Alexander Bartschke, BIH @ Charité; Thomas Haese, Charité; Maximilian Meixner, BIH @ Charité