| TEMPLATE ID | Stationärer Versorgungsfall_uksh |
|---|---|
| Concept | Stationärer Versorgungsfall_uksh |
| Description | Zur Repräsentation der administrativen Daten eines Falls (Fallinformationen, Aufnahme, Entlassung) eines Patienten innerhalb einer Einrichtung. Ein “Fall” beginnt mit der Aufnahme ins Krankenhaus an einem Aufnahmedatum und endet mit der Entlassung an einem Entlassungsdatum. |
| Use | Für die Abbildung stationärer Aufenthalte eines Patienten in einer Gesundheitseinrichtung. |
| Misuse | Nicht zur Repräsentation eines einzelnen stationären Aufenthalts eines Patienten auf einer Station zu verwenden. Bitte den Archetyp ADMIN_ENTRY.krankenhausaufenthalt.v0 zur Dokumentation einzelne Aufenthalte unterhalb eines Falls verwenden. |
| Purpose | Zur Repräsentation der administrativen Daten eines Falls (Fallinformationen, Aufnahme, Entlassung) eines Patienten innerhalb einer Einrichtung. Ein “Fall” beginnt mit der Aufnahme ins Krankenhaus an einem Aufnahmedatum und endet mit der Entlassung an einem Entlassungsdatum. |
| References | |
| Other Details (Language Independent) |
|
| Keywords | Versorgungsfall; Fall; Aufnahme |
| Language used | en |
| Citeable Identifier | 1246.169.3564 |
| Root archetype id | openEHR-EHR-COMPOSITION.fall.v1 |
| Stationärer Versorgungsfall | Stationärer Versorgungsfall: Strukturierte Sammlung von Informationen zu einem Sachverhalt oder Problem, der bzw. das bearbeitet werden muss. Die Bearbeitungsschritte eines Falles werden durch Aktivitäten und Bearbeiter definiert, die dem Fall zugeordnet werden. |
| Other Context | |
| Falltyp | Falltyp: Charaktierisierung des Falls, bspw. als Einrichtungskontakt, Abteilungskontakt, Versorgungsstellenkontakt.
|
| Fallklasse | Fallklasse: Nähere Beschreibung des Falls als Fallklasse, z.B. ambulanter Besuch, stationärer, prä- oder nachstationärer Aufenthalt.
|
| Fallstatus | Fallstatus: Status des Falls Status des Falls Optional[{fhir=Encounter.status}] Terminology: http://hl7.org/fhir/encounter-status
Annotations
|
| Fall-Kennung | Fall-Kennung: Eindeutige Identifikation des Falls, z.B. Fallnummer. |
| Übergeordneter Fall | Übergeordneter Fall: Ein anderer Fall, von dem dieser Fall ein Teil ist (administrativ oder zeitlich). Ein anderer Fall, von dem dieser Fall ein Teil ist (administrativ oder zeitlich). Optional[{fhir=Encounter.partOf}] Annotations
|
| Fachliche Organisationseinheit | Fachliche Organisationseinheit: Location includes both casual locations (a place used for health care without prior designation or authorisation) and dedicated, formally designated locations. The sites can be private, public, mobile or fixed.Annotations
|
| Type | Type: *
Annotations
|
| Identifier | Identifier: A group of buildings or other locations such as a site or campus. For example: Campus that is outside the facility, but belongs to the hospital, university. Terminology: Anhang 1 der BPflV (31.12.2003)
Annotations
|
| Name | Name: *Annotations
|
| Active/Inactive | Active/Inactive: *Annotations
|
| Location description | Location description: The field contains the optional free text description of the location, e.g. thoracic, heart and vascular surgery. |
| Aufnahmedaten | Aufnahmedaten: 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: §21 KHEntgG
|
| Aufnahmeanlass | Aufnahmeanlass: Detailed description of the mode of admission. Terminology: §21 KHEntgG
|
| Pre-admit number | Pre-admit number: ID number of patient's pre-admissionAnnotations
|
| Admit date/time | Admit date/time: Date/time the patient was admitted. |
| Vorheriger Patientenstandort (vor Aufnahme) | Vorheriger Patientenstandort (vor Aufnahme): Location includes both casual locations (a place used for health care without prior designation or authorisation) and dedicated, formally designated locations. The sites can be private, public, mobile or fixed. |
| Campus | Campus: A group of buildings or other locations such as a site or campus. For example: Campus that is outside the facility, but belongs to the hospital, university. |
| Building | Building: Either building or structure. These can include rooms, corridors, wings, etc.. It may not have walls or a roof, but is considered a defined/allocated space. |
| Level | Level: A level in a multi-level building/structure. |
| Ward | Ward: A ward is part of a medical facility that can contain rooms and other types of locations. |
| Room | Room: A location that was declared as a room. Some locations can have the room in the corridor, e.g. ward XYZ corridor 2; where bed space 2 is in the corridor of the respective ward. |
| Bed Location | Bed Location: Used to document information about the bed space e.g. bed was placed next to the window or next to the door. |
| Location description | Location description: The field contains the optional free text description of the location, e.g. thoracic, heart and vascular surgery. |
| Vorherige verantwortliche Organisationseinheit (vor Aufnahme) | Vorherige verantwortliche Organisationseinheit (vor Aufnahme): Location includes both casual locations (a place used for health care without prior designation or authorisation) and dedicated, formally designated locations. The sites can be private, public, mobile or fixed.Annotations
|
| Type | Type: *Annotations
|
| Identifier | Identifier: A group of buildings or other locations such as a site or campus. For example: Campus that is outside the facility, but belongs to the hospital, university.Annotations
|
| Name | Name: *Annotations
|
| Active/Inactive | Active/Inactive: *Annotations
|
| Location description | Location description: The field contains the optional free text description of the location, e.g. thoracic, heart and vascular surgery. |
| Discharge summary | Discharge summary: Used for discharged patient only. |
| Data | |
| Discharge status | Discharge status: Discharge status. Terminology: §21 KHEntgG
|
| Clinical condition of the patient | Clinical condition of the patient: Clinical condition of the patient.
|
| Datum/Uhrzeit der Entlassung | Datum/Uhrzeit der Entlassung: Date/Time the patiente was discharge. |
| Additional information | Additional information: Comments |
| Zugewiesener Standort (bei Entlassung) | Zugewiesener Standort (bei Entlassung): Location includes both casual locations (a place used for health care without prior designation or authorisation) and dedicated, formally designated locations. The sites can be private, public, mobile or fixed. |
| Campus | Campus: A group of buildings or other locations such as a site or campus. For example: Campus that is outside the facility, but belongs to the hospital, university. |
| Building | Building: Either building or structure. These can include rooms, corridors, wings, etc.. It may not have walls or a roof, but is considered a defined/allocated space. |
| Level | Level: A level in a multi-level building/structure. |
| Ward | Ward: A ward is part of a medical facility that can contain rooms and other types of locations. |
| Room | Room: A location that was declared as a room. Some locations can have the room in the corridor, e.g. ward XYZ corridor 2; where bed space 2 is in the corridor of the respective ward. |
| Bed Location | Bed Location: Used to document information about the bed space e.g. bed was placed next to the window or next to the door. |
| Location description | Location description: The field contains the optional free text description of the location, e.g. thoracic, heart and vascular surgery. |
| Zugewiesene verantwortliche Organisationseinheit (bei Entlassung) | Zugewiesene verantwortliche Organisationseinheit (bei Entlassung): Location includes both casual locations (a place used for health care without prior designation or authorisation) and dedicated, formally designated locations. The sites can be private, public, mobile or fixed.Annotations
|
| Type | Type: *Annotations
|
| Identifier | Identifier: A group of buildings or other locations such as a site or campus. For example: Campus that is outside the facility, but belongs to the hospital, university.Annotations
|
| Name | Name: *Annotations
|
| Active/Inactive | Active/Inactive: *Annotations
|
| Location description | Location description: The field contains the optional free text description of the location, e.g. thoracic, heart and vascular surgery. |