TEMPLATE CAEHR_C_Körperliche_Untersuchung (CAEHR_C_Körperliche_Untersuchung)

TEMPLATE ID	CAEHR_C_Körperliche_Untersuchung
Concept	CAEHR_C_Körperliche_Untersuchung
Description	Dient zur beschreibung einer körperlichen Untersuchung im Rahmen von CAEHR
Use	Körperliche Untersuchung im kardiologischen Rahmen
Misuse	Repräsentation einer Körperlichen Untersuchung im allgemeinen.
Purpose	Dient zur beschreibung einer körperlichen Untersuchung im Rahmen von CAEHR
References
Authors	name: Severin Kohler; organisation: BIH; email: severin.kohler@charite.de
Other Details Language	name: Severin Kohler; organisation: BIH; 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: 7dca70afbbe053590d276375e52d9197 PARENT:MD5-CAM-1.0.1: 005501C1FA493A4838F5F1121F2870EC Sem Ver: 206.0.0 Build Uid: 63025009-40ce-4fd8-868a-5f0ea6f656b7 Original Language: ISO_639-1::de
Language used	en
Citeable Identifier	1246.169.3522
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.
Körperliche Untersuchung	Körperliche Untersuchung: A generic section header which should be renamed in a template to suit a specific clinical context.
Body weight	Body weight: Measurement of the body weight of an individual.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Weight	Weight: The weight of the individual. 0..1000 kg
null_flavour
Height/Length	Height/Length: Height, or body length, is measured from crown of head to sole of foot. Height is measured with the individual in a standing position and body length in a recumbent position.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Größe	Größe: The length of the body from crown of head to sole of foot. 0..1000 cm
null_flavour
Blood pressure	Blood pressure: The local measurement of arterial blood pressure which is a surrogate for arterial pressure in the systemic circulation. Most commonly, use of the term 'blood pressure' refers to measurement of brachial artery pressure in the upper arm.
Data	Data: History Structural node.
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Systolic	Systolic: Peak systemic arterial blood pressure - measured in systolic or contraction phase of the heart cycle. 0..1000 mmHg (UCUM: mm[Hg])
null_flavour
Diastolic	Diastolic: Minimum systemic arterial blood pressure - measured in the diastolic or relaxation phase of the heart cycle. 0..1000 mmHg (UCUM: mm[Hg])
null_flavour
State
Body mass index	Body mass index: Calculated measurement which compares a person's weight and height. Body Mass Index is a calculated ratio describing how an individual's body weight relates to the weight that is regarded as normal, or desirable, for the individual's height.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Body mass index	Body mass index: Index describing ratio of weight to height. 0..1000; 0..1000 Units: kg/m² (UCUM: kg/m2) [lb_av]/[in_i]2
Respiration	Respiration: The characteristics of spontaneous breathing by an individual.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Rate	Rate: The frequency of spontaneous breathing. 0..200 /min
Herz Untersuchungen	Herz Untersuchungen: A generic section header which should be renamed in a template to suit a specific clinical context.
Herzfrequenz	Herzfrequenz: The rate and associated attributes for a pulse or heart beat.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Pulsfrequenz	Pulsfrequenz: The rate of the pulse or heart beat, measured in beats per minute. 0..1000 /min
Regularity	Regularity: Regularity of the pulse or heart beat. Regular Irregular
Herzuntersuchung	Herzuntersuchung: Findings observed during the physical examination of a subject of care.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Herztöne	Herztöne: Findings observed during the physical examination of the heart.
System or structure examined	System or structure examined: Identification of the examined body system or anatomical structure. Coding of the system or structure examined with a terminology is preferred, where possible. Terminology: http://snomed.info/sct Heart Heart sound, function (observable entity)
No abnormality detected	No abnormality detected: Statement that no abnormality was detected (NAD) on physical examination. Record as True if no abnormality was detected on examination. Specific statements about the examination can be included in the 'Clinical Interpretation' data element. If 'No abnormality detected' is selected, then recording of other examination data elements becomes redundant, with the exception of only the 'Clinical interpretation' data element, which may be useful if a normal statement is desired for recording, for example 'Normal examination'.
Heart sounds description	Heart sounds description: Narrative description of the heart sounds. Terminology: http://snomed.info/sct Heart sounds normal (finding) Heart sounds abnormal (finding)
Herzgeräusche	Herzgeräusche: Findings observed during the physical examination of the heart.
System or structure examined	System or structure examined: Identification of the examined body system or anatomical structure. Coding of the system or structure examined with a terminology is preferred, where possible. Terminology: http://snomed.info/sct Heart Heart murmur (finding)
Body site	Body site: Identification of the area of the body under examination. If the body site has been fully identified in the 'System or structure examined' data element, this data element becomes redundant. Terminology: http://snomed.info/sct Heart structure (body structure)
No abnormality detected	No abnormality detected: Statement that no abnormality was detected (NAD) on physical examination. Record as True if no abnormality was detected on examination. Specific statements about the examination can be included in the 'Clinical Interpretation' data element. If 'No abnormality detected' is selected, then recording of other examination data elements becomes redundant, with the exception of only the 'Clinical interpretation' data element, which may be useful if a normal statement is desired for recording, for example 'Normal examination'.
Clinical interpretation	Clinical interpretation: Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings. Coding of the 'Clinical interpretation' with a terminology is preferred, where possible. Terminology: http://snomed.info/sct Systolic murmur (finding) Diastolic murmur (finding)
Füllung der Halsvenen	Füllung der Halsvenen: Findings observed during the physical examination of the cardiovascular system as a whole.
System or structure examined	System or structure examined: Identification of the examined body system or anatomical structure. Coding of the system or structure examined with a terminology is preferred, where possible. Terminology: http://snomed.info/sct Cardiovascular system Structure of jugular vein (body structure)
No abnormality detected	No abnormality detected: Statement that no abnormality was detected (NAD) on physical examination. Record as True if no abnormality was detected on examination. Specific statements about the examination can be included in the 'Clinical Interpretation' data element. If 'No abnormality detected' is selected, then recording of other examination data elements becomes redundant, with the exception of only the 'Clinical interpretation' data element, which may be useful if a normal statement is desired for recording, for example 'Normal examination'.
Clinical interpretation	Clinical interpretation: Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings. Coding of the 'Clinical interpretation' with a terminology is preferred, where possible. Terminology: http://snomed.info/sct Jugular venous engorgement (finding)
Ausschluss Füllung der Halsvene	Ausschluss Füllung der Halsvene: 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 Jugular venous engorgement (finding)
Allgemeiner Eindruck	Allgemeiner Eindruck: A generic section header which should be renamed in a template to suit a specific clinical context.
Physical examination findings	Physical examination findings: Findings observed during the physical examination of a subject of care.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Ernährungszustand	Ernährungszustand: Findings observed during the physical examination of a body system or anatomical structure.
System or structure examined	System or structure examined: Identification of the examined body system or anatomical structure. Coding of the system or structure examined with a terminology is preferred, where possible. Terminology: http://snomed.info/sct Nutritional status (observable entity)
Clinical interpretation	Clinical interpretation: Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings. For example: 'No abnormality detected' or 'Moderate inflammation present'. Coding of the 'Clinical interpretation' with a terminology is preferred, where possible. Terminology: http://snomed.info/sct Normal (qualifier value) Reduced (qualifier value)
Allgemeinzustand	Allgemeinzustand: Findings observed during the physical examination of a body system or anatomical structure.
System or structure examined	System or structure examined: Identification of the examined body system or anatomical structure. Coding of the system or structure examined with a terminology is preferred, where possible. Terminology: http://snomed.info/sct General clinical state (observable entity)
Clinical interpretation	Clinical interpretation: Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings. For example: 'No abnormality detected' or 'Moderate inflammation present'. Coding of the 'Clinical interpretation' with a terminology is preferred, where possible. Terminology: http://snomed.info/sct Normal (qualifier value) Reduced (qualifier value)
Other contributors	Thomas Haese,; Alexander Bartschke