TEMPLATE CALM-QE_Zwischenanamnese (CALM-QE_Zwischenanamnese)

TEMPLATE IDCALM-QE_Zwischenanamnese
ConceptCALM-QE_Zwischenanamnese
DescriptionNot Specified
PurposeNot Specified
References
Authorsname: Maximilian Meixner; organisation: BIH @ Charité - Berlin Institute of Health; email: maximilian.meixner@bih-charite.de; date: 2024-05-15
Other Details Languagename: Maximilian Meixner; organisation: BIH @ Charité - Berlin Institute of Health; email: maximilian.meixner@bih-charite.de; date: 2024-05-15
OtherDetails Language Independent{PARENT:MD5-CAM-1.0.1=005501C1FA493A4838F5F1121F2870EC, original_language=ISO_639-1::de, MD5-CAM-1.0.1=c9803a84d8af1a02d873b669eaceeaea}
Language useden
Citeable Identifier1246.169.3546
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  • Regular 
  • Irregular 
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  • Regularly Irregular 
  • Irregularly Irregular 
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  • Regular 
  • Irregular 
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  • Normal 
  • Shallow 
  • Deep 
  • Variable 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Vitalparameter']/items[openEHR-EHR-OBSERVATION.pulse_oximetry.v1], code=at0000, itemType=OBSERVATION, level=2, text=Pulse oximetry, description=Blood oxygen and related measurements, measured by pulse oximetry or pulse CO-oximetry., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Vitalparameter']/items[openEHR-EHR-OBSERVATION.pulse_oximetry.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Vitalparameter']/items[openEHR-EHR-OBSERVATION.pulse_oximetry.v1]/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=4, text=Any event, description=Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Vitalparameter']/items[openEHR-EHR-OBSERVATION.pulse_oximetry.v1]/data[at0001]/events[at0002]/data[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=5, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Vitalparameter']/items[openEHR-EHR-OBSERVATION.pulse_oximetry.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0006], code=at0006, itemType=ELEMENT, level=6, text=SpO₂, description=The saturation of oxygen in the peripheral blood, measured via pulse oximetry., comment=SpO₂ is defined as the percentage of oxyhaemoglobin (HbO₂) to the total concentration of haemoglobin (HbO₂ + deoxyhaemoglobin) in peripheral blood., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_PROPORTION, bindings=null, values=
  • Percent
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Körperliche Befunde'], code=at0000, itemType=SECTION, level=1, text=Körperliche Befunde, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Körperliche Befunde']/items[openEHR-EHR-OBSERVATION.symptom_sign_screening.v1], code=at0000, itemType=OBSERVATION, level=2, text=Screening von Atemwegssymptomen, description=Series of questions and associated answers used to screen for symptoms or signs., comment=The answers may be self-reported., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Körperliche Befunde']/items[openEHR-EHR-OBSERVATION.symptom_sign_screening.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Körperliche Befunde']/items[openEHR-EHR-OBSERVATION.symptom_sign_screening.v1]/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=4, text=Any event, description=Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Körperliche Befunde']/items[openEHR-EHR-OBSERVATION.symptom_sign_screening.v1]/data[at0001]/events[at0002]/data[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=5, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Körperliche Befunde']/items[openEHR-EHR-OBSERVATION.symptom_sign_screening.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0022 and name/value='Husten'], code=at0022, itemType=CLUSTER, level=6, text=Husten, description=Details about a specific symptom or sign or grouping of symptoms or signs relatevant for the screening purpose., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Körperliche Befunde']/items[openEHR-EHR-OBSERVATION.symptom_sign_screening.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0022 and name/value='Husten']/items[at0004], code=at0004, itemType=ELEMENT, level=7, text=Symptom/sign name, description=Identification of a specific symptom or sign or grouping of symptoms or signs, by name., comment=Coding of the 'Symptom/sign name' with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= Terminology: http://snomed.info/sct
  • Does cough (finding) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Körperliche Befunde']/items[openEHR-EHR-OBSERVATION.symptom_sign_screening.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0022 and name/value='Husten']/items[at0005], code=at0005, itemType=ELEMENT, level=7, text=Presence?, description=Is there a history of the specific symptom or sign being present?, comment=In a template, the data element would usually be renamed to the specific question asked. The proposed value set can be adapted for local use by using the DV_TEXT or the DV_BOOLEAN datatypes choice to match each specific use case., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Yes 
  • No 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Körperliche Befunde']/items[openEHR-EHR-OBSERVATION.symptom_sign_screening.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0022 and name/value='Sputum'], code=at0022, itemType=CLUSTER, level=6, text=Sputum, description=Details about a specific symptom or sign or grouping of symptoms or signs relatevant for the screening purpose., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Körperliche Befunde']/items[openEHR-EHR-OBSERVATION.symptom_sign_screening.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0022 and name/value='Sputum']/items[at0004], code=at0004, itemType=ELEMENT, level=7, text=Symptom/sign name, description=Identification of a specific symptom or sign or grouping of symptoms or signs, by name., comment=Coding of the 'Symptom/sign name' with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= Terminology: http://snomed.info/sct
  • Does cough up sputum (finding) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Körperliche Befunde']/items[openEHR-EHR-OBSERVATION.symptom_sign_screening.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0022 and name/value='Sputum']/items[at0005], code=at0005, itemType=ELEMENT, level=7, text=Presence?, description=Is there a history of the specific symptom or sign being present?, comment=In a template, the data element would usually be renamed to the specific question asked. The proposed value set can be adapted for local use by using the DV_TEXT or the DV_BOOLEAN datatypes choice to match each specific use case., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Yes 
  • No 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Körperliche Befunde']/items[openEHR-EHR-OBSERVATION.symptom_sign_screening.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0022 and name/value='Atemnot'], code=at0022, itemType=CLUSTER, level=6, text=Atemnot, description=Details about a specific symptom or sign or grouping of symptoms or signs relatevant for the screening purpose., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Körperliche Befunde']/items[openEHR-EHR-OBSERVATION.symptom_sign_screening.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0022 and name/value='Atemnot']/items[at0004], code=at0004, itemType=ELEMENT, level=7, text=Symptom/sign name, description=Identification of a specific symptom or sign or grouping of symptoms or signs, by name., comment=Coding of the 'Symptom/sign name' with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= Terminology: http://snomed.info/sct
  • Dyspnea (finding) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Körperliche Befunde']/items[openEHR-EHR-OBSERVATION.symptom_sign_screening.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0022 and name/value='Atemnot']/items[at0005], code=at0005, itemType=ELEMENT, level=7, text=Presence?, description=Is there a history of the specific symptom or sign being present?, comment=In a template, the data element would usually be renamed to the specific question asked. The proposed value set can be adapted for local use by using the DV_TEXT or the DV_BOOLEAN datatypes choice to match each specific use case., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Yes 
  • No 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Körperliche Befunde']/items[openEHR-EHR-OBSERVATION.symptom_sign_screening.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0022 and name/value='Thorakales Engegefühl'], code=at0022, itemType=CLUSTER, level=6, text=Thorakales Engegefühl, description=Details about a specific symptom or sign or grouping of symptoms or signs relatevant for the screening purpose., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Körperliche Befunde']/items[openEHR-EHR-OBSERVATION.symptom_sign_screening.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0022 and name/value='Thorakales Engegefühl']/items[at0004], code=at0004, itemType=ELEMENT, level=7, text=Symptom/sign name, description=Identification of a specific symptom or sign or grouping of symptoms or signs, by name., comment=Coding of the 'Symptom/sign name' with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= Terminology: http://snomed.info/sct
  • Tight chest (finding) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Körperliche Befunde']/items[openEHR-EHR-OBSERVATION.symptom_sign_screening.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0022 and name/value='Thorakales Engegefühl']/items[at0005], code=at0005, itemType=ELEMENT, level=7, text=Presence?, description=Is there a history of the specific symptom or sign being present?, comment=In a template, the data element would usually be renamed to the specific question asked. The proposed value set can be adapted for local use by using the DV_TEXT or the DV_BOOLEAN datatypes choice to match each specific use case., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Yes 
  • No 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Körperliche Befunde']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Auskultationsbefunde der Lunge'], code=at0000, itemType=SECTION, level=2, text=Auskultationsbefunde der Lunge, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Körperliche Befunde']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Perkussionsbefunde der Lunge'], code=at0000, itemType=SECTION, level=2, text=Perkussionsbefunde der Lunge, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Körperliche Befunde']/items[openEHR-EHR-OBSERVATION.problem_screening.v1], code=at0000, itemType=OBSERVATION, level=2, text=Screening von Inspektionsbefunden, description=Series of questions and associated answers used to screen for issues, problems or diagnoses., comment=The answers may be self-reported., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Körperliche Befunde']/items[openEHR-EHR-OBSERVATION.problem_screening.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Körperliche Befunde']/items[openEHR-EHR-OBSERVATION.problem_screening.v1]/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=4, text=Any event, description=Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Körperliche Befunde']/items[openEHR-EHR-OBSERVATION.problem_screening.v1]/data[at0001]/events[at0002]/data[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=5, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Körperliche Befunde']/items[openEHR-EHR-OBSERVATION.problem_screening.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0022 and name/value='Zyanose'], code=at0022, itemType=CLUSTER, level=6, text=Zyanose, description=Details about a specific issue, problem or diagnosis or grouping of problems or diagnoses relevant for the screening purpose., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Körperliche Befunde']/items[openEHR-EHR-OBSERVATION.problem_screening.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0022 and name/value='Zyanose']/items[at0004], code=at0004, itemType=ELEMENT, level=7, text=Problem/diagnosis name, description=Identification of an issue, problem or diagnosis, or grouping of issues, problems or diagnoses, by name., comment=Coding of the 'Problem/diagnosis name' with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= Terminology: http://snomed.info/sct
  • Cyanosis (finding) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Körperliche Befunde']/items[openEHR-EHR-OBSERVATION.problem_screening.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0022 and name/value='Zyanose']/items[at0005], code=at0005, itemType=ELEMENT, level=7, text=Presence?, description=Is there a history of the specific issue, problem or diagnosis?, comment=In a template, the data element would usually be renamed to the specific question asked. The proposed value set can be adapted for local use by using the DV_TEXT or the DV_BOOLEAN datatypes choice to match each specific use case., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Yes 
  • No 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Körperliche Befunde']/items[openEHR-EHR-OBSERVATION.problem_screening.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0022 and name/value='Periphere Ödeme'], code=at0022, itemType=CLUSTER, level=6, text=Periphere Ödeme, description=Details about a specific issue, problem or diagnosis or grouping of problems or diagnoses relevant for the screening purpose., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Körperliche Befunde']/items[openEHR-EHR-OBSERVATION.problem_screening.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0022 and name/value='Periphere Ödeme']/items[at0004], code=at0004, itemType=ELEMENT, level=7, text=Problem/diagnosis name, description=Identification of an issue, problem or diagnosis, or grouping of issues, problems or diagnoses, by name., comment=Coding of the 'Problem/diagnosis name' with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= Terminology: http://snomed.info/sct
  • Peripheral edema (disorder) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Körperliche Befunde']/items[openEHR-EHR-OBSERVATION.problem_screening.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0022 and name/value='Periphere Ödeme']/items[at0005], code=at0005, itemType=ELEMENT, level=7, text=Presence?, description=Is there a history of the specific issue, problem or diagnosis?, comment=In a template, the data element would usually be renamed to the specific question asked. The proposed value set can be adapted for local use by using the DV_TEXT or the DV_BOOLEAN datatypes choice to match each specific use case., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Yes 
  • No 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Körperliche Befunde']/items[openEHR-EHR-OBSERVATION.problem_screening.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0022 and name/value='Lungenüberblähung'], code=at0022, itemType=CLUSTER, level=6, text=Lungenüberblähung, description=Details about a specific issue, problem or diagnosis or grouping of problems or diagnoses relevant for the screening purpose., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Körperliche Befunde']/items[openEHR-EHR-OBSERVATION.problem_screening.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0022 and name/value='Lungenüberblähung']/items[at0004], code=at0004, itemType=ELEMENT, level=7, text=Problem/diagnosis name, description=Identification of an issue, problem or diagnosis, or grouping of issues, problems or diagnoses, by name., comment=Coding of the 'Problem/diagnosis name' with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= Terminology: http://snomed.info/sct
  • Chest over-expanded (finding) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Körperliche Befunde']/items[openEHR-EHR-OBSERVATION.problem_screening.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0022 and name/value='Lungenüberblähung']/items[at0005], code=at0005, itemType=ELEMENT, level=7, text=Presence?, description=Is there a history of the specific issue, problem or diagnosis?, comment=In a template, the data element would usually be renamed to the specific question asked. The proposed value set can be adapted for local use by using the DV_TEXT or the DV_BOOLEAN datatypes choice to match each specific use case., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Yes 
  • No 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Körperliche Befunde']/items[openEHR-EHR-OBSERVATION.problem_screening.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0022 and name/value='Thorakale Einziehungen'], code=at0022, itemType=CLUSTER, level=6, text=Thorakale Einziehungen, description=Details about a specific issue, problem or diagnosis or grouping of problems or diagnoses relevant for the screening purpose., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Körperliche Befunde']/items[openEHR-EHR-OBSERVATION.problem_screening.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0022 and name/value='Thorakale Einziehungen']/items[at0004], code=at0004, itemType=ELEMENT, level=7, text=Problem/diagnosis name, description=Identification of an issue, problem or diagnosis, or grouping of issues, problems or diagnoses, by name., comment=Coding of the 'Problem/diagnosis name' with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= Terminology: http://snomed.info/sct
  • Chest wall retraction (finding) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Körperliche Befunde']/items[openEHR-EHR-OBSERVATION.problem_screening.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0022 and name/value='Thorakale Einziehungen']/items[at0005], code=at0005, itemType=ELEMENT, level=7, text=Presence?, description=Is there a history of the specific issue, problem or diagnosis?, comment=In a template, the data element would usually be renamed to the specific question asked. The proposed value set can be adapted for local use by using the DV_TEXT or the DV_BOOLEAN datatypes choice to match each specific use case., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Yes 
  • No 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Körperliche Befunde']/items[openEHR-EHR-OBSERVATION.problem_screening.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0022 and name/value='Fassthorax'], code=at0022, itemType=CLUSTER, level=6, text=Fassthorax, description=Details about a specific issue, problem or diagnosis or grouping of problems or diagnoses relevant for the screening purpose., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Körperliche Befunde']/items[openEHR-EHR-OBSERVATION.problem_screening.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0022 and name/value='Fassthorax']/items[at0004], code=at0004, itemType=ELEMENT, level=7, text=Problem/diagnosis name, description=Identification of an issue, problem or diagnosis, or grouping of issues, problems or diagnoses, by name., comment=Coding of the 'Problem/diagnosis name' with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= Terminology: http://snomed.info/sct
  • Barrel chest (disorder) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Körperliche Befunde']/items[openEHR-EHR-OBSERVATION.problem_screening.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0022 and name/value='Fassthorax']/items[at0005], code=at0005, itemType=ELEMENT, level=7, text=Presence?, description=Is there a history of the specific issue, problem or diagnosis?, comment=In a template, the data element would usually be renamed to the specific question asked. The proposed value set can be adapted for local use by using the DV_TEXT or the DV_BOOLEAN datatypes choice to match each specific use case., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Yes 
  • No 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Exazerbationen'], code=at0000, itemType=SECTION, level=1, text=Exazerbationen, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Exazerbationen']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Exazerbation COPD'], code=at0000, itemType=EVALUATION, level=2, text=Exazerbation COPD, description=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., comment=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'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Exazerbationen']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Exazerbation COPD']/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Exazerbationen']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Exazerbation COPD']/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Problem/Diagnosis name, description=Identification of the problem or diagnosis, by name., comment=Coding of the name of the problem or diagnosis with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= Terminology: http://snomed.info/sct
  • Acute exacerbation of chronic obstructive pulmonary disease (disorder) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Exazerbationen']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Exazerbation COPD']/data[at0001]/items[at0077], code=at0077, itemType=ELEMENT, level=4, text=Startzeitpunkt, description=Estimated or actual date/time that signs or symptoms of the problem/diagnosis were first observed., comment=Data captured/imported as "Age at onset" should be converted to a date using the subject's date of birth., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Exazerbationen']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Exazerbation COPD']/data[at0001]/items[at0005], code=at0005, itemType=ELEMENT, level=4, text=Severity, description=An assessment of the overall severity of the problem or diagnosis., comment=If severity is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant. Note: more specific grading of severity can be recorded using the Specific details SLOT., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= Terminology: http://snomed.info/sct
  • Mild 
  • Moderate 
  • Severe 
  • Mild (qualifier value) 
  • Moderate (severity modifier) (qualifier value) 
  • Severe (severity modifier) (qualifier value) 
  • Life threatening severity (qualifier value) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Exazerbationen']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Exazerbation COPD']/data[at0001]/items[at0030], code=at0030, itemType=ELEMENT, level=4, text=Endzeitpunkt, description=Estimated or actual date/time of resolution or remission for this problem or diagnosis, as determined by a healthcare professional., comment=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 resolution" should be converted to a date using the subject's date of birth., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Exazerbationen']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Exazerbation Asthma'], code=at0000, itemType=EVALUATION, level=2, text=Exazerbation Asthma, description=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., comment=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'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Exazerbationen']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Exazerbation Asthma']/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Exazerbationen']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Exazerbation Asthma']/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Problem/Diagnosis name, description=Identification of the problem or diagnosis, by name., comment=Coding of the name of the problem or diagnosis with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= Terminology: http://snomed.info/sct
  • Exacerbation of asthma (disorder) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Exazerbationen']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Exazerbation Asthma']/data[at0001]/items[at0077], code=at0077, itemType=ELEMENT, level=4, text=Startzeitpunkt, description=Estimated or actual date/time that signs or symptoms of the problem/diagnosis were first observed., comment=Data captured/imported as "Age at onset" should be converted to a date using the subject's date of birth., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Exazerbationen']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Exazerbation Asthma']/data[at0001]/items[at0005], code=at0005, itemType=ELEMENT, level=4, text=Severity, description=An assessment of the overall severity of the problem or diagnosis., comment=If severity is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant. Note: more specific grading of severity can be recorded using the Specific details SLOT., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= Terminology: http://snomed.info/sct
  • Mild 
  • Moderate 
  • Severe 
  • Mild to moderate (qualifier value) 
  • Severe (severity modifier) (qualifier value) 
  • Life threatening severity (qualifier value) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Exazerbationen']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Exazerbation Asthma']/data[at0001]/items[at0030], code=at0030, itemType=ELEMENT, level=4, text=Endzeitpunkt, description=Estimated or actual date/time of resolution or remission for this problem or diagnosis, as determined by a healthcare professional., comment=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 resolution" should be converted to a date using the subject's date of birth., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Hospitalisierung'], code=at0000, itemType=SECTION, level=1, text=Hospitalisierung, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Hospitalisierung']/items[openEHR-EHR-ADMIN_ENTRY.admission.v0], code=at0000, itemType=ADMIN_ENTRY, level=2, text=Patient admission, description=Used for admitted patient only. It signals the beginning of a patient's stay in a health care facility., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ADMIN_ENTRY, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Hospitalisierung']/items[openEHR-EHR-ADMIN_ENTRY.admission.v0]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Hospitalisierung']/items[openEHR-EHR-ADMIN_ENTRY.admission.v0]/data[at0001]/items[at0013], code=at0013, itemType=ELEMENT, level=4, text=Admission type, description=The circumstance under which the patient will be admitted., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= Terminology: http://snomed.info/sct
  • Disorder of respiratory system (disorder) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Hospitalisierung']/items[openEHR-EHR-ADMIN_ENTRY.admission.v0]/data[at0001]/items[at0071], code=at0071, itemType=ELEMENT, level=4, text=Admit date/time, description=Date/time the patient was admitted., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Hospitalisierung']/items[openEHR-EHR-ADMIN_ENTRY.discharge_summary.v0], code=at0000, itemType=ADMIN_ENTRY, level=2, text=Discharge summary, description=Used for discharged patient only., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ADMIN_ENTRY, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Hospitalisierung']/items[openEHR-EHR-ADMIN_ENTRY.discharge_summary.v0]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Hospitalisierung']/items[openEHR-EHR-ADMIN_ENTRY.discharge_summary.v0]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Clinical condition of the patient, description=Clinical condition of the patient., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Improved 
  • Same state 
  • Worse 
  • Deceased 
  • Undetermined. 
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