TEMPLATE CAEHR_C_Zwischenanamnese_Akute_Symptomatik (CAEHR_C_Zwischenanamnese_Akute_Symptomatik)

TEMPLATE ID	CAEHR_C_Zwischenanamnese_Akute_Symptomatik
Concept	CAEHR_C_Zwischenanamnese_Akute_Symptomatik
Description	Dokumentation von zwischen Anamnese und akuter Symptomatik
Purpose	Dokumentation von zwischen Anamnese und akuter Symptomatik
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: 4e81ca97eefe46fa8f610002647f3b0e PARENT:MD5-CAM-1.0.1: 005501C1FA493A4838F5F1121F2870EC Sem Ver: 215.0.0 Build Uid: 63025009-40ce-4fd8-868a-5f0ea6f656b7 Original Language: ISO_639-1::de
Language used	en
Citeable Identifier	1246.169.3529
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.
Zwischenzeitliche Ereignisse	Zwischenzeitliche Ereignisse: A generic section header which should be renamed in a template to suit a specific clinical context.
Kardialer Eingriff	Kardialer Eingriff: 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.
Description	Description: Narrative description about the procedure, as appropriate for the pathway step. For example: description about the performance and findings from the the procedure, the aborted attempt or the cancellation of the procedure. Terminology: http://snomed.info/sct Procedure on heart (procedure)
Kardiale Zwischendiagnose	Kardiale Zwischendiagnose: 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.
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. Terminology: http://snomed.info/sct Cardiac finding (finding)
Ausschluss kardiale Eingriffe	Ausschluss kardiale Eingriffe: 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)
Eingriff	Eingriff: The Procedure to which the 'Exclusion statement' applies. For example: 'Heart surgery' or 'Appendectomy' or 'Hip replacement'. Zwischenzeitliche kardiale Eingriffe
Ausschluss kardiale Diagnosen	Ausschluss kardiale 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'. Zwischenzeitliche kardiale Diagnosen
Zwischenzeitliche Ereignisse nicht erhoben	Zwischenzeitliche Ereignisse 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". Zwischenzeitliche Diagnose/Eingriffe
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)
Belastungsdyspnoe	Belastungsdyspnoe: A generic section header which should be renamed in a template to suit a specific clinical context.
Belastungsdyspnoe	Belastungsdyspnoe: 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 Dyspnea on exertion (finding)
Ausschluss Belastungsdyspnoe	Ausschluss Belastungsdyspnoe: 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 Dyspnea on exertion (finding)
Belastungsdyspnoe nicht erhoben	Belastungsdyspnoe 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 Dyspnea on exertion (finding)
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Not recorded (qualifier value)
Ruhedyspnoe	Ruhedyspnoe: A generic section header which should be renamed in a template to suit a specific clinical context.
Ruhedyspnoe	Ruhedyspnoe: 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 Dyspnea at rest (finding)
Ausschluss Ruhedyspnoe	Ausschluss Ruhedyspnoe: 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 Dyspnea at rest (finding)
Ruhedyspnoe nicht erhoben	Ruhedyspnoe 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 Dyspnea at rest (finding)
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Not recorded (qualifier value)
Periphere Ödeme	Periphere Ödeme: A generic section header which should be renamed in a template to suit a specific clinical context.
Periphere Ödeme	Periphere Ödeme: 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 edema (disorder)
Ausschluss periphere Ödeme	Ausschluss periphere Ödeme: 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 edema (disorder)
Periphere Ödeme nicht erhoben	Periphere Ödeme 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 edema (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)
Halsvenenstauung	Halsvenenstauung: A generic section header which should be renamed in a template to suit a specific clinical context.
Halsvenenstauung	Halsvenenstauung: 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 Jugular venous engorgement (finding)
Ausschluss Halsvenenstauung	Ausschluss Halsvenenstauung: 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)
Halsvenenstauung nicht erhoben	Halsvenenstauung 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 Jugular venous engorgement (finding)
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Not recorded (qualifier value)
Pulmonale Rasselgeräusche	Pulmonale Rasselgeräusche: A generic section header which should be renamed in a template to suit a specific clinical context.
Pulmonale Rasselgeräusche	Pulmonale Rasselgeräusche: 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 Respiratory crackles (finding)
Ausschluss pulmonale Rasselgeräusche	Ausschluss pulmonale Rasselgeräusche: 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 Respiratory crackles (finding)
Pulmonale Rasselgeräusche nicht erhoben	Pulmonale Rasselgeräusche 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 Respiratory crackles (finding)
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. Terminology: http://snomed.info/sct Not recorded (qualifier value)
Belastbarkeit	Belastbarkeit: A generic section header which should be renamed in a template to suit a specific clinical context.
Belastbarkeit	Belastbarkeit: 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
Belastbarkeit bei z.B. Treppensteigen	Belastbarkeit bei z.B. Treppensteigen: Narrative description of the overall findings observed during a physical examination of a patient. May be used to record a narrative summary of the complete clinical examination or key aspects of clinical examination findings, which will be supported by structured data. Details of specific structured findings can be included using CLUSTER archetypes in the 'Examination Detail' slot. This data element may be used to capture legacy data that is not available in a structured format. Terminology: http://snomed.info/sct Physical fitness behavior (observable entity)
Belastbarkeit	Belastbarkeit: 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 Impairment (finding)
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 Mild (qualifier value) Moderate (severity modifier) (qualifier value) Severe (severity modifier) (qualifier value)
Ausschluss Belastbarkeit	Ausschluss Belastbarkeit: 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 Impairment (finding)
NYHA	NYHA: A generic section header which should be renamed in a template to suit a specific clinical context.
New York Heart Association functional classification	New York Heart Association functional classification: A simple method of classifying the extent of heart failure, as defined by the New York Heart Association.
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
Functional capacity	Functional capacity: Assessment of heart failure based on how a patient with cardiac disease feels during physical activity. Class III and the Class III subtypes, IIIa and IIIb, are intended to be mutually exclusive but are included in this internal code set for completeness. Within a template either the Class III alone or both of the subtypes, IIIa and IIIb, should be set to inactive. Terminology: http://snomed.info/sct Class I Class II Class III Class IIIa Class IIIb Class IV New York Heart Association Classification - Class I (finding) New York Heart Association Classification - Class II (finding) New York Heart Association Classification - Class III (finding) New York Heart Association Classification - Class IV (finding)
NYHA nicht erhoben	NYHA 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 New York Heart Association Classification (assessment scale)
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)
Menstruation	Menstruation: A generic section header which should be renamed in a template to suit a specific clinical context.
Menstruation summary	Menstruation summary: Summary or persistent information about an individual's menstruation history.
Data
Menstrual status	Menstrual status: Statement about the current menstrual activity. If this data element is updated, the 'Date last updated' in Protocol should also be amended. Terminology: http://snomed.info/sct Premenarchal Premenopausal Perimenopausal Postmenopausal Postmenopausal state (finding) Premenopausal state (finding) Perimenopausal state (finding)
Per episode	Per episode: Details about a typical pattern of menstruation during a specified interval of time. If the pattern of menstruation changes significantly, or other factors significantly interrupt (for example, a full term pregnancy) or influence (for example, changing contraception methods) the menstrual cycle, then it may be useful to record as a new episode .
Tag Beginn der letzten Regelblutung	Tag Beginn der letzten Regelblutung: Date when this episode commenced. Can be a partial date, for example, only a year.
Alter in den Wechseljahren	Alter in den Wechseljahren: Cessation of all menstrual cycles. This data element allows 2 occurrences in a template, if required. Use the DV_DATE data type to represent a partial date, such as year only, of menopause and the DV_DURATION data type to represent the age at menopause. >=P0M Units: Year Month
Other contributors	Thomas Haese,; Alexander Bartschke