TEMPLATE CALM-QE_Zwischenanamnese (CALM-QE_Zwischenanamnese)

TEMPLATE ID	CALM-QE_Zwischenanamnese
Concept	CALM-QE_Zwischenanamnese
Description	Not Specified
Purpose	Not Specified
References
Authors	name: Maximilian Meixner; organisation: BIH @ Charité - Berlin Institute of Health; email: maximilian.meixner@bih-charite.de; date: 2024-05-15
Other Details Language	name: Maximilian Meixner; organisation: BIH @ Charité - Berlin Institute of Health; email: maximilian.meixner@bih-charite.de; date: 2024-05-15
Other Details (Language Independent)	MD5-CAM-1.0.1: 56f596dcadb9d8e24f79d1db4fe148ab PARENT:MD5-CAM-1.0.1: 005501C1FA493A4838F5F1121F2870EC Original Language: ISO_639-1::de
Language used	en
Citeable Identifier	1246.169.3546
Root archetype id	openEHR-EHR-COMPOSITION.report.v1
CALM-QE_Zwischenanamnese	CALM-QE_Zwischenanamnese: Document to communicate information to others, commonly in response to a request from another party.
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.
Vitalparameter	Vitalparameter: A generic section header which should be renamed in a template to suit a specific clinical context.
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])
Diastolic	Diastolic: Minimum systemic arterial blood pressure - measured in the diastolic or relaxation phase of the heart cycle. 0..1000 mmHg (UCUM: mm[Hg])
Pulse/Heart beat	Pulse/Heart beat: 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
Rate	Rate: 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
Irregular type	Irregular type: More specific pattern of an irregular pulse or heart beat. Selection of a value from this value set is only valid if 'Irregular' is selected from the 'Regularity' data element. Regularly Irregular Irregularly Irregular
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
Regularity	Regularity: The regularity of spontaneous breathing. Regular Irregular
Depth	Depth: The depth of spontaneous breathing. Normal Shallow Deep Variable
Pulse oximetry	Pulse oximetry: Blood oxygen and related measurements, measured by pulse oximetry or pulse CO-oximetry.
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
SpO₂	SpO₂: The saturation of oxygen in the peripheral blood, measured via pulse oximetry. SpO₂ is defined as the percentage of oxyhaemoglobin (HbO₂) to the total concentration of haemoglobin (HbO₂ + deoxyhaemoglobin) in peripheral blood. Percent
Körperliche Befunde	Körperliche Befunde: A generic section header which should be renamed in a template to suit a specific clinical context.
Screening von Atemwegssymptomen	Screening von Atemwegssymptomen: Series of questions and associated answers used to screen for symptoms or signs. The answers may be self-reported.
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
Husten	Husten: Details about a specific symptom or sign or grouping of symptoms or signs relatevant for the screening purpose.
Symptom/sign name	Symptom/sign name: Identification of a specific symptom or sign or grouping of symptoms or signs, by name. Coding of the 'Symptom/sign name' with a terminology is preferred, where possible. Terminology: http://snomed.info/sct Does cough (finding)
Presence?	Presence?: Is there a history of the specific symptom or sign being present? 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. Yes No
Sputum	Sputum: Details about a specific symptom or sign or grouping of symptoms or signs relatevant for the screening purpose.
Symptom/sign name	Symptom/sign name: Identification of a specific symptom or sign or grouping of symptoms or signs, by name. Coding of the 'Symptom/sign name' with a terminology is preferred, where possible. Terminology: http://snomed.info/sct Does cough up sputum (finding)
Presence?	Presence?: Is there a history of the specific symptom or sign being present? 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. Yes No
Atemnot	Atemnot: Details about a specific symptom or sign or grouping of symptoms or signs relatevant for the screening purpose.
Symptom/sign name	Symptom/sign name: Identification of a specific symptom or sign or grouping of symptoms or signs, by name. Coding of the 'Symptom/sign name' with a terminology is preferred, where possible. Terminology: http://snomed.info/sct Dyspnea (finding)
Presence?	Presence?: Is there a history of the specific symptom or sign being present? 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. Yes No
Thorakales Engegefühl	Thorakales Engegefühl: Details about a specific symptom or sign or grouping of symptoms or signs relatevant for the screening purpose.
Symptom/sign name	Symptom/sign name: Identification of a specific symptom or sign or grouping of symptoms or signs, by name. Coding of the 'Symptom/sign name' with a terminology is preferred, where possible. Terminology: http://snomed.info/sct Tight chest (finding)
Presence?	Presence?: Is there a history of the specific symptom or sign being present? 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. Yes No
Screening von Inspektionsbefunden	Screening von Inspektionsbefunden: Series of questions and associated answers used to screen for issues, problems or diagnoses. The answers may be self-reported.
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
Zyanose	Zyanose: Details about a specific issue, problem or diagnosis or grouping of problems or diagnoses relevant for the screening purpose.
Problem/diagnosis name	Problem/diagnosis name: Identification of an issue, problem or diagnosis, or grouping of issues, problems or diagnoses, by name. Coding of the 'Problem/diagnosis name' with a terminology is preferred, where possible. Terminology: http://snomed.info/sct Cyanosis (finding)
Presence?	Presence?: Is there a history of the specific issue, problem or diagnosis? 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. Yes No
Periphere Ödeme	Periphere Ödeme: Details about a specific issue, problem or diagnosis or grouping of problems or diagnoses relevant for the screening purpose.
Problem/diagnosis name	Problem/diagnosis name: Identification of an issue, problem or diagnosis, or grouping of issues, problems or diagnoses, by name. Coding of the 'Problem/diagnosis name' with a terminology is preferred, where possible. Terminology: http://snomed.info/sct Peripheral edema (disorder)
Presence?	Presence?: Is there a history of the specific issue, problem or diagnosis? 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. Yes No
Lungenüberblähung	Lungenüberblähung: Details about a specific issue, problem or diagnosis or grouping of problems or diagnoses relevant for the screening purpose.
Problem/diagnosis name	Problem/diagnosis name: Identification of an issue, problem or diagnosis, or grouping of issues, problems or diagnoses, by name. Coding of the 'Problem/diagnosis name' with a terminology is preferred, where possible. Terminology: http://snomed.info/sct Chest over-expanded (finding)
Presence?	Presence?: Is there a history of the specific issue, problem or diagnosis? 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. Yes No
Thorakale Einziehungen	Thorakale Einziehungen: Details about a specific issue, problem or diagnosis or grouping of problems or diagnoses relevant for the screening purpose.
Problem/diagnosis name	Problem/diagnosis name: Identification of an issue, problem or diagnosis, or grouping of issues, problems or diagnoses, by name. Coding of the 'Problem/diagnosis name' with a terminology is preferred, where possible. Terminology: http://snomed.info/sct Chest wall retraction (finding)
Presence?	Presence?: Is there a history of the specific issue, problem or diagnosis? 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. Yes No
Fassthorax	Fassthorax: Details about a specific issue, problem or diagnosis or grouping of problems or diagnoses relevant for the screening purpose.
Problem/diagnosis name	Problem/diagnosis name: Identification of an issue, problem or diagnosis, or grouping of issues, problems or diagnoses, by name. Coding of the 'Problem/diagnosis name' with a terminology is preferred, where possible. Terminology: http://snomed.info/sct Barrel chest (disorder)
Presence?	Presence?: Is there a history of the specific issue, problem or diagnosis? 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. Yes No
Perkussionsbefunde der Lunge	Perkussionsbefunde der Lunge: 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
Examination of a lung	Examination of a lung: Findings observed during the physical examination of a single lung, including specific parts of a lung.
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. Left lung Right lung
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'.
Percussion note	Percussion note: Sound elicited by tapping on the chest wall. Normal Dull Hyperresonant
Auskultationsbefunde	Auskultationsbefunde: 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
Auscultation of breath sounds	Auscultation of breath sounds: Findings observed during the auscultation of breath sounds in the chest or abdomen.
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. Chest Abdomen
Presence	Presence: The presence of breath sounds. Present Absent
Abnormal breath sounds	Abnormal breath sounds: Details about abnormal breath sounds heard on auscultation.
Breath sound	Breath sound: Name of the breath sound. Fine crackles Coarse crackles Wheezes Rhonchus Crackling rales
Phase	Phase: Phase of the breathing cycle. Inspiratory Expiratory Inspiratory and expiratory
Exazerbationen	Exazerbationen: A generic section header which should be renamed in a template to suit a specific clinical context.
Exazerbation COPD	Exazerbation COPD: 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 Acute exacerbation of chronic obstructive pulmonary disease (disorder)
Startzeitpunkt	Startzeitpunkt: Estimated or actual date/time that signs or symptoms of the problem/diagnosis were first observed. Data captured/imported as "Age at onset" should be converted to a date using the subject's date of birth.
Severity	Severity: An assessment of the overall severity of the problem or diagnosis. 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. Terminology: http://snomed.info/sct Mild (qualifier value) Moderate (severity modifier) (qualifier value) Severe (severity modifier) (qualifier value) Life threatening severity (qualifier value)
Endzeitpunkt	Endzeitpunkt: Estimated or actual date/time of resolution or remission for this problem or diagnosis, as determined by a healthcare professional. Partial dates are acceptable. If the subject of care is under the age of one year, then the complete date or a minimum of the month and year is necessary to enable accurate age calculations - for example, if used to drive decision support. Data captured/imported as "Age at time of resolution" should be converted to a date using the subject's date of birth.
Exazerbation Asthma	Exazerbation Asthma: 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 Exacerbation of asthma (disorder)
Startzeitpunkt	Startzeitpunkt: Estimated or actual date/time that signs or symptoms of the problem/diagnosis were first observed. Data captured/imported as "Age at onset" should be converted to a date using the subject's date of birth.
Severity	Severity: An assessment of the overall severity of the problem or diagnosis. 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. Terminology: http://snomed.info/sct Mild to moderate (qualifier value) Severe (severity modifier) (qualifier value) Life threatening severity (qualifier value)
Endzeitpunkt	Endzeitpunkt: Estimated or actual date/time of resolution or remission for this problem or diagnosis, as determined by a healthcare professional. Partial dates are acceptable. If the subject of care is under the age of one year, then the complete date or a minimum of the month and year is necessary to enable accurate age calculations - for example, if used to drive decision support. Data captured/imported as "Age at time of resolution" should be converted to a date using the subject's date of birth.
Hospitalisierung	Hospitalisierung: A generic section header which should be renamed in a template to suit a specific clinical context.
Patient admission	Patient admission: Used for admitted patient only. It signals the beginning of a patient's stay in a health care facility.
Data
Admission type	Admission type: The circumstance under which the patient will be admitted. Terminology: http://snomed.info/sct Disorder of respiratory system (disorder)
Admit date/time	Admit date/time: Date/time the patient was admitted.
Discharge summary	Discharge summary: Used for discharged patient only.
Data
Clinical condition of the patient	Clinical condition of the patient: Clinical condition of the patient. Improved Same state Worse Deceased Undetermined.
Discharge date/time	Discharge date/time: Date/Time the patiente was discharge.
Lenght of stay	Lenght of stay: Lenght of stay on hospital Units: d
Death details	Death details: Information about the death of a person that matches higher-level data elements for registration e.g. Mortality Register.
Date of death	Date of death: The date on which the person died.
Death due to primary diagnosis?	Death due to primary diagnosis?: Is death due to the primary diagnosis?