TEMPLATE Anamnese-ext (Anamnese-ext)

TEMPLATE ID	Anamnese-ext
Concept	Anamnese-ext
Description	Not Specified
Purpose	Not Specified
References
Other Details (Language Independent)	MetaDataSet:Sample Set : Template metadata sample set MD5-CAM-1.0.1: 7512717389b7944f4c42d062a7d4bd37 PARENT:MD5-CAM-1.0.1: 005501C1FA493A4838F5F1121F2870EC Sem Ver: 10.2.1 Build Uid: 63025009-40ce-4fd8-868a-5f0ea6f656b7 Original Language: ISO_639-1::de
Language used	en
Citeable Identifier	1246.169.3576
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
Report ID	Report ID: Identification information about the report.
Status	Status: The status of the entire report. Note: This is not the status of any of the report components.
Familiäre Disposition von Myokardinfarkt oder Schlaganfall	Familiäre Disposition von Myokardinfarkt oder Schlaganfall: Summary information about the prevalence of a risk factor, problem or diagnosis in all family members.
Familiäre Disposition bei Eltern, Geschwistern oder Kindern	Familiäre Disposition bei Eltern, Geschwistern oder Kindern: Narrative description about occurrence in family members. Familiäre Disposition Keine familiäre Disposition
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Beschreibung	Beschreibung: Category of inheritance for the identified risk factor, problem or diagnosis. For example: autosomal dominant, autosomal recessive, X-linked dominant, X-linked recessive, codominant, or mitochondrial.
Ethnischer Hintergrund	Ethnischer Hintergrund: Detaillierte Beschreibung des ethnischen Hintergrundes einer Person, um Besondheiten, wie Medikamentenverträglichkeit oder Gesundheitsrisiken abzubilden.
Ethnischer Hintergrund	Ethnischer Hintergrund: Der ethnische Hintergrund einer Person. Kaukasisch Nicht kaukasisch
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Hautfarbe	Hautfarbe: Zusätzliche Beschreibung über den ethnischen Hintergrund einer Person, die nicht in anderen Datenelementen erfasst ist. Schwarze Hautfarbe Keine schwarze Hautfarbe
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Case identification	Case identification: To record case identification details for public health purposes.
Case identifier	Case identifier: The identifier of this case.
Gender	Gender: Details about the gender of an individual.
Data
Administrative gender	Administrative gender: The gender of an individual used for administrative purposes. This element is what most systems today describes as 'Sex' or 'Gender'. For example 'Male', 'Female', 'Other'. This aligns with HL7 FHIR 'Person.gender'. Coding with a terminology is recommended, where possible. Weiblich Männlich Divers
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Gender category	Gender category: Category describing the alignment of an individual's gender identity with their sex assigned at birth. For example: cisgender; transgender.
Height/Length	Height/Length: Height, or body length, is measured from crown of head to sole of foot. Height is measured with the individual in a standing position and body length in a recumbent position.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Größe	Größe: The length of the body from crown of head to sole of foot. 0..1000 cm
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Body weight	Body weight: Measurement of the body weight of an individual.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Weight	Weight: The weight of the individual. 0..1000 kg
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Kardiovaskuläre Risikofaktoren	Kardiovaskuläre Risikofaktoren: A generic section header which should be renamed in a template to suit a specific clinical context.
Dyslipidämie	Dyslipidämie: A generic section header which should be renamed in a template to suit a specific clinical context.
Dyslipidämie	Dyslipidämie: 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. Dyslipidämie
Feststellungsdatum	Feststellungsdatum: 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.
Ausschluss spezifisch	Ausschluss spezifisch: 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
Problem/diagnosis	Problem/diagnosis: The problem or diagnosis to which the 'Exclusion statement' applies. For example: 'Diabetes', 'COPD' or 'Asthma'. Dyslipidämie
Absence of information	Absence of information: 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". Dyslipidämie
Diabetes Mellitus	Diabetes Mellitus: A generic section header which should be renamed in a template to suit a specific clinical context.
Diabetes Mellitus	Diabetes Mellitus: 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. Diabetes Mellitus
Feststellungsdatum	Feststellungsdatum: 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.
Ausschluss spezifisch	Ausschluss spezifisch: 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
Problem/diagnosis	Problem/diagnosis: The problem or diagnosis to which the 'Exclusion statement' applies. For example: 'Diabetes', 'COPD' or 'Asthma'. Diabetes Mellitus
Absence of information	Absence of information: 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". Diabetes Mellitus
Arterielle Hypertonie	Arterielle Hypertonie: A generic section header which should be renamed in a template to suit a specific clinical context.
Arterielle Hypertonie	Arterielle Hypertonie: 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. Arterielle Hypertonie
Feststellungsdatum	Feststellungsdatum: 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.
Ausschluss spezifisch	Ausschluss spezifisch: 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
Problem/diagnosis	Problem/diagnosis: The problem or diagnosis to which the 'Exclusion statement' applies. For example: 'Diabetes', 'COPD' or 'Asthma'. Arterielle Hypertonie
Absence of information	Absence of information: 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". Arterielle Hypertonie
Rauchverhalten & Alkoholkonsum	Rauchverhalten & Alkoholkonsum: A generic section header which should be renamed in a template to suit a specific clinical context.
Tobacco smoking summary	Tobacco smoking summary: Summary or persistent information about the tobacco smoking habits of an individual.
Data
Overall status	Overall status: Statement about current smoking behaviour for all types of tobacco. Never smoked Current smoker Former smoker
Feststellungsdatum	Feststellungsdatum: The date or partial date when the individual first started frequent or regular, but usually non-daily, smoking of tobacco of any type. Can be a partial date, for example, only a year. For example, this date could represent when the individual commenced smoking every Friday night or at parties.
Datum Abstinenz	Datum Abstinenz: The date or partial date when the individual first started daily smoking of tobacco of any type. Can be a partial date, for example, only a year.
Ex-Raucher seit:	Ex-Raucher seit:: The date when the individual last ceased using tobacco of any type. Can be a partial date, for example, only a year. This date could be used by decision support guidance to determine if the individual is at risk of relapse, for example in the first 12 months since quitting.
Packungsjahr	Packungsjahr: Estimate of the cumulative amount for all types of tobacco smoked. The definition of a pack can be recorded in the protocol of this archetype using the 'Pack definition' data element. >=0
Beschreibung	Beschreibung: Additional narrative about all tobacco smoking that has not been captured in other fields. For example: stopped smoking or reduced amount on becoming pregnant.
Alcohol consumption summary	Alcohol consumption summary: Summary or persistent information about the typical alcohol consumption of an individual.
Data
Feststellungsdatum	Feststellungsdatum: The date or partial date when the individual became intoxicated for the first time. This data point is not intended to record an accidental intoxication but to identify when a behaviour pattern of harmful consumption may have commenced.
Per episode	Per episode: Details about a discrete period of time with a consistent pattern of typical consumption.
Pattern	Pattern: The typical pattern of consumption of alcohol. The typical pattern of use can be made more granular by coding with a terminology or a local value set in a template. Coded Text Daily Non-daily Text
Drinks per Week	Drinks per Week: Estimate of number of alcohol units consumed in the specified time period. >=0 1/wk
Datum Alkoholkrankheit	Datum Alkoholkrankheit: The date when the individual last ceased consuming alcohol of any type. Can be a partial date, for example, only a year. This date could be used by decision support guidance to determine if the individual is at risk of relapse, for example in the first 12 months since quitting.
Ärztlich diagnostizierte Alkoholkrankheit	Ärztlich diagnostizierte Alkoholkrankheit: Additional narrative about all alcohol consumption that has not been captured in other fields. Ärztlich diagnostizierte Alkoholkrankheit Keine ärztlich diagnostizierte Alkoholkrankheit
Niereninsuffizienz	Niereninsuffizienz: A generic section header which should be renamed in a template to suit a specific clinical context.
Niereninsuffizienz	Niereninsuffizienz: 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. Niereninsuffizienz
Dialysepflichtigkeit	Dialysepflichtigkeit: 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. aktuelle Dialysepflicht keine aktuelle Dialysepflicht
Feststellungsdatum	Feststellungsdatum: 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.
Datum Dialysepflichtigkeit	Datum Dialysepflichtigkeit: Estimated or actual date/time the diagnosis or problem was recognised 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 clinical recognition" 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. GFR 90 ml/min oder höher GFR 60 - 89 ml/min GFR 30 - 59 ml/min GFR 15 - 29 ml/min GFR < 15 ml/min oder aktuelle Dialysepflicht
Beschreibung Dialysepflichtigkeit	Beschreibung Dialysepflichtigkeit: Narrative description about the course of the problem or diagnosis since onset.
Datum Schweregrad	Datum Schweregrad: 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.
Kommentar Schweregrad	Kommentar Schweregrad: Additional narrative about the problem or diagnosis not captured in other fields.
Exclusion - specific	Exclusion - specific: 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
Problem/diagnosis	Problem/diagnosis: The problem or diagnosis to which the 'Exclusion statement' applies. For example: 'Diabetes', 'COPD' or 'Asthma'. Niereninsuffizienz
Absence of information	Absence of information: 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". Niereninsuffizienz
Kardiale Diagnosen (Anamnese und Vorbefunde)	Kardiale Diagnosen (Anamnese und Vorbefunde): A generic section header which should be renamed in a template to suit a specific clinical context.
Koronare Herzkrankheit	Koronare Herzkrankheit: A generic section header which should be renamed in a template to suit a specific clinical context.
Koronare Herzkrankheit	Koronare Herzkrankheit: 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. Koronare Herzkrankheit
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.
Feststellungsdatum	Feststellungsdatum: 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.
Exclusion - specific	Exclusion - specific: 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
Problem/diagnosis	Problem/diagnosis: The problem or diagnosis to which the 'Exclusion statement' applies. For example: 'Diabetes', 'COPD' or 'Asthma'. Koronare Herzkrankheit
Absence of information	Absence of information: 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". Koronare Herzkrankheit
Hauptursache der Herzinsuffizienz	Hauptursache der Herzinsuffizienz: 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. KHK Hypertonie Primäre Herzklappenerkrankung Angeborener Herzfehler Kardiomyopathie Andere Ursache
Wenn Kardiomyopathie	Wenn Kardiomyopathie: 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. DCM HCM RCM ARVC Amyloidose ethyltoxisch Chemotherapie Andere
Feststellungsdatum	Feststellungsdatum: 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.
Course description	Course description: Narrative description about the course of the problem or diagnosis since onset.
Zustand nach Myokardinfarkt	Zustand nach Myokardinfarkt: A generic section header which should be renamed in a template to suit a specific clinical context.
Zustand nach Myokardinfarkt	Zustand nach Myokardinfarkt: 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. Zustand nach Myokardinfarkt
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.
Feststellungsdatum	Feststellungsdatum: 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.
Exclusion - specific	Exclusion - specific: 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
Problem/diagnosis	Problem/diagnosis: The problem or diagnosis to which the 'Exclusion statement' applies. For example: 'Diabetes', 'COPD' or 'Asthma'. Zustand nach Myokardinfarkt
Absence of information	Absence of information: 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". Zustand nach Myokardinfarkt
Zustand nach Myokarditis	Zustand nach Myokarditis: A generic section header which should be renamed in a template to suit a specific clinical context.
Zustand nach Myokarditis	Zustand nach Myokarditis: 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. Zustand nach Myokarditis
Exclusion - specific	Exclusion - specific: 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
Problem/diagnosis	Problem/diagnosis: The problem or diagnosis to which the 'Exclusion statement' applies. For example: 'Diabetes', 'COPD' or 'Asthma'. Zustand nach Myokarditis
Absence of information	Absence of information: 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". Zustand nach Myokarditis
Kardiomyopathie	Kardiomyopathie: A generic section header which should be renamed in a template to suit a specific clinical context.
Problem/Diagnosis	Problem/Diagnosis: 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. Kardiomyopathie
Feststellungsdatum	Feststellungsdatum: 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.
Exclusion - specific	Exclusion - specific: 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
Problem/diagnosis	Problem/diagnosis: The problem or diagnosis to which the 'Exclusion statement' applies. For example: 'Diabetes', 'COPD' or 'Asthma'. Kardiomyopathie
Absence of information	Absence of information: 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". Kardiomyopathie
Zustand nach Dekompensation	Zustand nach Dekompensation: A generic section header which should be renamed in a template to suit a specific clinical context.
Zustand nach Dekompensation	Zustand nach Dekompensation: 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. Zustand nach Dekompensation
Anzahl Dekompensationen stationär behandelt (letzte 12 Monate)	Anzahl Dekompensationen stationär behandelt (letzte 12 Monate): 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.
Feststellungsdatum	Feststellungsdatum: 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.
Course description	Course description: Narrative description about the course of the problem or diagnosis since onset.
Exclusion - specific	Exclusion - specific: 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
Problem/diagnosis	Problem/diagnosis: The problem or diagnosis to which the 'Exclusion statement' applies. For example: 'Diabetes', 'COPD' or 'Asthma'. Zustand nach Dekompensation
Absence of information	Absence of information: 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". Zustand nach Dekompensation
Erstdiagnose Herzinsuffizienz	Erstdiagnose Herzinsuffizienz: 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. Herzinsuffizienz
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.
Erstdiagnose Herzinsuffizienz	Erstdiagnose Herzinsuffizienz: 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.
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. Class I Class II Class III Class IV
Vorhofflimmern	Vorhofflimmern: A generic section header which should be renamed in a template to suit a specific clinical context.
Vorhofflimmern	Vorhofflimmern: 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. Vorhofflimmern
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.
Feststellungsdatum	Feststellungsdatum: 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.
Exclusion - specific	Exclusion - specific: 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
Problem/diagnosis	Problem/diagnosis: The problem or diagnosis to which the 'Exclusion statement' applies. For example: 'Diabetes', 'COPD' or 'Asthma'. Vorhofflimmern
Absence of information	Absence of information: 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". Vorhofflimmern
Aktuelle oder frühere Herzklappenerkrankung	Aktuelle oder frühere Herzklappenerkrankung: A generic section header which should be renamed in a template to suit a specific clinical context.
aktuelle oder frühere Herzklappenerkrankung	aktuelle oder frühere Herzklappenerkrankung: 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. Herzklappenerkrankung
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.
Feststellungsdatum	Feststellungsdatum: 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.
Aktuell/Vergangen?	Aktuell/Vergangen?: Additional narrative about the problem or diagnosis not captured in other fields. frühere Herzklappenerkrankung aktuelle Herzklappenerkrankung aktuelle und frühere Herzklappenerkrankung
Exclusion - specific	Exclusion - specific: 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
Problem/diagnosis	Problem/diagnosis: The problem or diagnosis to which the 'Exclusion statement' applies. For example: 'Diabetes', 'COPD' or 'Asthma'. Herzklappenerkrankung
Absence of information	Absence of information: 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". Herzklappenerkrankung
Bisherige kardiovaskuläre Interventionen	Bisherige kardiovaskuläre Interventionen: A generic section header which should be renamed in a template to suit a specific clinical context.
Interventionelle Koronare Revaskularisation	Interventionelle Koronare Revaskularisation: A generic section header which should be renamed in a template to suit a specific clinical context.
Interventionelle koronare Revaskularisation	Interventionelle koronare Revaskularisation: 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. Interventionelle koronare Revaskularisation
Datum des letzten Ereignisses	Datum des letzten Ereignisses: The date and/or time on which the procedure is intended to be performed. Only for use in association with the 'Procedure scheduled' pathway step.
Exclusion - specific	Exclusion - specific: 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
Procedure	Procedure: The Procedure to which the 'Exclusion statement' applies. For example: 'Heart surgery' or 'Appendectomy' or 'Hip replacement'. Interventionelle koronare Revaskularisation
Absence of information	Absence of information: 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". Interventionelle koronare Revaskularisation
Periphere Revaskularisation	Periphere Revaskularisation: A generic section header which should be renamed in a template to suit a specific clinical context.
Periphere Revaskularisation	Periphere Revaskularisation: 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. Periphere Revaskularisation
Datum des letzten Ereignisses	Datum des letzten Ereignisses: The date and/or time on which the procedure is intended to be performed. Only for use in association with the 'Procedure scheduled' pathway step.
Exclusion - specific	Exclusion - specific: 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
Procedure	Procedure: The Procedure to which the 'Exclusion statement' applies. For example: 'Heart surgery' or 'Appendectomy' or 'Hip replacement'. Periphere Revaskularisation
Absence of information	Absence of information: 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". Periphere Revaskularisation
Koronare Bypass-Operation	Koronare Bypass-Operation: A generic section header which should be renamed in a template to suit a specific clinical context.
Koronare Bypass-Operation	Koronare Bypass-Operation: 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. Koronare Bypass-Operation
Klinische Beschreibung	Klinische Beschreibung: 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.
Datum des letzten Ereignisses	Datum des letzten Ereignisses: The date and/or time on which the procedure is intended to be performed. Only for use in association with the 'Procedure scheduled' pathway step.
Exclusion - specific	Exclusion - specific: 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
Procedure	Procedure: The Procedure to which the 'Exclusion statement' applies. For example: 'Heart surgery' or 'Appendectomy' or 'Hip replacement'. Koronare Bypass-Operation
Absence of information	Absence of information: 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". Koronare Bypass-Operation
Sonstige Gefäß-Operation	Sonstige Gefäß-Operation: A generic section header which should be renamed in a template to suit a specific clinical context.
Sonstige Gefäß-Operation	Sonstige Gefäß-Operation: 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. Sonstige Gefäß-Operation
Datum des letzten Ereignisses	Datum des letzten Ereignisses: The date and/or time on which the procedure is intended to be performed. Only for use in association with the 'Procedure scheduled' pathway step.
Art der sonstigen Gefäßoperation	Art der sonstigen Gefäßoperation: Additional narrative about the activity or care pathway step not captured in other fields.
Exclusion - specific	Exclusion - specific: 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
Procedure	Procedure: The Procedure to which the 'Exclusion statement' applies. For example: 'Heart surgery' or 'Appendectomy' or 'Hip replacement'. Sonstige Gefäß-Operation
Absence of information	Absence of information: 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". Sonstige Gefäß-Operation
Herzklappen-Intervention	Herzklappen-Intervention: A generic section header which should be renamed in a template to suit a specific clinical context.
Herzklappen-Intervention	Herzklappen-Intervention: 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. Herzklappen-Intervention
Art des letzten Ereignisses	Art des letzten Ereignisses: 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. katheterbasiert offen chirurgisch
Aortenklappe	Aortenklappe: A physical site on or within the human body.
Body site name	Body site name: Identification of a single physical site either on, or within, the human body. This data element is the only mandated data point in this archetype and should be used as the primary data point to record an anatomical location with a commonly used name. It is strongly recommended that 'Body site name' be recorded as specifically as is anatomically possible. For example: record 'upper eyelid' rather than recording 'eyelid' with 'upper' as a qualifier; 'fifth rib' rather than 'rib' with a numeric qualifier. Use the other data elements for laterality, aspect, region and anatomical line to provide more detail. This data element should be coded with a terminology capable of triggering decision support, where possible - an appropriate termset for use here could comprise individual concepts or a list of precoordinated terms. Free text should be used only if there is no appropriate terminology available. If body site name is already identified in the parent archetype, then this data element may be redundant. Alternatively, a use case has been identified where the value may be duplicated into this element to support semantic querying using this archetype, rather than the data element within the parent. Aortenklappe
Klinische Beschreibung	Klinische Beschreibung: Additional detail using a specific region or a point on, or within, the identified body site. Use to increase precision of identification of the body site, if required. For example, the upper right quadrant or McBurney's point on the abdominal wall or interphalangeal joint of the great toe. If the 'Body site name' data element uses pre-coordinated terms that include the specific site, then this data element is redundant.
Art der Prozedur	Art der Prozedur: Narrative description that can be used to further refine and support the 'Body site name'. For example: adjacent to the vermilion border; a tattoo covers the bottom half of this area. Nativ Rekonstruktion Mechanische Prothese Bioprothese TAVI
Pulmonalklappe	Pulmonalklappe: A physical site on or within the human body.
Body site name	Body site name: Identification of a single physical site either on, or within, the human body. This data element is the only mandated data point in this archetype and should be used as the primary data point to record an anatomical location with a commonly used name. It is strongly recommended that 'Body site name' be recorded as specifically as is anatomically possible. For example: record 'upper eyelid' rather than recording 'eyelid' with 'upper' as a qualifier; 'fifth rib' rather than 'rib' with a numeric qualifier. Use the other data elements for laterality, aspect, region and anatomical line to provide more detail. This data element should be coded with a terminology capable of triggering decision support, where possible - an appropriate termset for use here could comprise individual concepts or a list of precoordinated terms. Free text should be used only if there is no appropriate terminology available. If body site name is already identified in the parent archetype, then this data element may be redundant. Alternatively, a use case has been identified where the value may be duplicated into this element to support semantic querying using this archetype, rather than the data element within the parent. Pulmonalklappe
Klinische Beschreibung	Klinische Beschreibung: Additional detail using a specific region or a point on, or within, the identified body site. Use to increase precision of identification of the body site, if required. For example, the upper right quadrant or McBurney's point on the abdominal wall or interphalangeal joint of the great toe. If the 'Body site name' data element uses pre-coordinated terms that include the specific site, then this data element is redundant.
Art der Prozedur	Art der Prozedur: Narrative description that can be used to further refine and support the 'Body site name'. For example: adjacent to the vermilion border; a tattoo covers the bottom half of this area. Nativ Rekonstruktion Mechanische Prothese Bioprothese
Mitralklappe	Mitralklappe: A physical site on or within the human body.
Body site name	Body site name: Identification of a single physical site either on, or within, the human body. This data element is the only mandated data point in this archetype and should be used as the primary data point to record an anatomical location with a commonly used name. It is strongly recommended that 'Body site name' be recorded as specifically as is anatomically possible. For example: record 'upper eyelid' rather than recording 'eyelid' with 'upper' as a qualifier; 'fifth rib' rather than 'rib' with a numeric qualifier. Use the other data elements for laterality, aspect, region and anatomical line to provide more detail. This data element should be coded with a terminology capable of triggering decision support, where possible - an appropriate termset for use here could comprise individual concepts or a list of precoordinated terms. Free text should be used only if there is no appropriate terminology available. If body site name is already identified in the parent archetype, then this data element may be redundant. Alternatively, a use case has been identified where the value may be duplicated into this element to support semantic querying using this archetype, rather than the data element within the parent. Mitralklappe
Klinische Beschreibung	Klinische Beschreibung: Additional detail using a specific region or a point on, or within, the identified body site. Use to increase precision of identification of the body site, if required. For example, the upper right quadrant or McBurney's point on the abdominal wall or interphalangeal joint of the great toe. If the 'Body site name' data element uses pre-coordinated terms that include the specific site, then this data element is redundant.
Art der Prozedur	Art der Prozedur: Narrative description that can be used to further refine and support the 'Body site name'. For example: adjacent to the vermilion border; a tattoo covers the bottom half of this area. Nativ Mechanische Prothese Clipping Rekonstruktion Bioprothese
Trikuspidalklappe	Trikuspidalklappe: A physical site on or within the human body.
Body site name	Body site name: Identification of a single physical site either on, or within, the human body. This data element is the only mandated data point in this archetype and should be used as the primary data point to record an anatomical location with a commonly used name. It is strongly recommended that 'Body site name' be recorded as specifically as is anatomically possible. For example: record 'upper eyelid' rather than recording 'eyelid' with 'upper' as a qualifier; 'fifth rib' rather than 'rib' with a numeric qualifier. Use the other data elements for laterality, aspect, region and anatomical line to provide more detail. This data element should be coded with a terminology capable of triggering decision support, where possible - an appropriate termset for use here could comprise individual concepts or a list of precoordinated terms. Free text should be used only if there is no appropriate terminology available. If body site name is already identified in the parent archetype, then this data element may be redundant. Alternatively, a use case has been identified where the value may be duplicated into this element to support semantic querying using this archetype, rather than the data element within the parent. Trikuspidalklappe
Klinische Beschreibung	Klinische Beschreibung: Additional detail using a specific region or a point on, or within, the identified body site. Use to increase precision of identification of the body site, if required. For example, the upper right quadrant or McBurney's point on the abdominal wall or interphalangeal joint of the great toe. If the 'Body site name' data element uses pre-coordinated terms that include the specific site, then this data element is redundant.
Art der Prozedur	Art der Prozedur: Narrative description that can be used to further refine and support the 'Body site name'. For example: adjacent to the vermilion border; a tattoo covers the bottom half of this area. Nativ Mechanische Prothese Clipping Rekonstruktion Bioprothese
Datum des letzten Ereignisses	Datum des letzten Ereignisses: The date and/or time on which the procedure is intended to be performed. Only for use in association with the 'Procedure scheduled' pathway step.
Exclusion - specific	Exclusion - specific: 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
Procedure	Procedure: The Procedure to which the 'Exclusion statement' applies. For example: 'Heart surgery' or 'Appendectomy' or 'Hip replacement'. Herzklappen-Intervention
Absence of information	Absence of information: 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". Herzklappen-Intervention
Implantierter Herzschrittmacher oder Defibrillator	Implantierter Herzschrittmacher oder Defibrillator: A generic section header which should be renamed in a template to suit a specific clinical context.
Implantierter Herzschrittmacher	Implantierter Herzschrittmacher: An ongoing and persistent overview about medical devices that have been fitted or implanted.
Data
Implantierter Herzschrittmacher?	Implantierter Herzschrittmacher?: Name of the type of medical device. For example: Assisted hearing devices, eyeglasses, contact lens, dental braces, dentures, orthotics or artificial limbs. Schrittmacher implantiert kein Schrittmacher implantiert
Status des Schrittmachers	Status des Schrittmachers: Assertion about the fitting or implanting of devices, as at the date 'Last updated'. Never Current Previous
Description	Description: Narrative description about the use of the fitted device type.
Device details	Device details: Details about each device.
Wenn ja, bitte Schrittmachertyp angeben:	Wenn ja, bitte Schrittmachertyp angeben:: Identification of the specific device, by name. 1-Kammer-Schrittmacher (z.B. VVI) 2-Kammer-Schrittmacher (z.B.DDD) biventrikulärer Schrittmacher (CRT)
Datum des letzten Ereignisses (Implantation/Wechsel)	Datum des letzten Ereignisses (Implantation/Wechsel): Date of fitting or implant of the device.
Implantierter Defibrillator	Implantierter Defibrillator: An ongoing and persistent overview about medical devices that have been fitted or implanted.
Data
Implantierter Defibrillator?	Implantierter Defibrillator?: Name of the type of medical device. For example: Assisted hearing devices, eyeglasses, contact lens, dental braces, dentures, orthotics or artificial limbs. Defibrillator implantiert kein Defibrillator implantiert
Description	Description: Narrative description about the use of the fitted device type.
Device details	Device details: Details about each device.
Datum des letzten Ereignisses (Implantation/Wechsel)	Datum des letzten Ereignisses (Implantation/Wechsel): Date of fitting or implant of the device.
Andere Devices	Andere Devices: An ongoing and persistent overview about medical devices that have been fitted or implanted.
Data
Andere Devices	Andere Devices: Name of the type of medical device. For example: Assisted hearing devices, eyeglasses, contact lens, dental braces, dentures, orthotics or artificial limbs. Anderes Device Kein anderes Device
Cardiac Contractility Modulation	Cardiac Contractility Modulation: Narrative description about the use of the fitted device type. Cardiac Contractility Modulation Kein Cardiac Contractility Modulation
Device details	Device details: Details about each device.
Sonstige Devices	Sonstige Devices: Identification of the specific device, by name.
Feststellungsdatum	Feststellungsdatum: Date when the device stopped being used or was removed.
Aktuelle Nebendiagnosen	Aktuelle Nebendiagnosen: A generic section header which should be renamed in a template to suit a specific clinical context.
periphere Arterielle Verschlusskrankheit (pAVK)	periphere Arterielle Verschlusskrankheit (pAVK): A generic section header which should be renamed in a template to suit a specific clinical context.
periphere Arterielle Verschlusskrankheit (pAVK)	periphere Arterielle Verschlusskrankheit (pAVK): 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. periphere Arterielle Verschlusskrankheit (pAVK)
Fontaine-Stadium	Fontaine-Stadium: 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. I IIa IIb III IV
Feststellungsdatum	Feststellungsdatum: 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.
Course description	Course description: Narrative description about the course of the problem or diagnosis since onset.
Exclusion - specific	Exclusion - specific: 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
Problem/diagnosis	Problem/diagnosis: The problem or diagnosis to which the 'Exclusion statement' applies. For example: 'Diabetes', 'COPD' or 'Asthma'. periphere Arterielle Verschlusskrankheit (pAVK)
Absence of information	Absence of information: 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". periphere Arterielle Verschlusskrankheit (pAVK)
Schlaganfall/TIA	Schlaganfall/TIA: A generic section header which should be renamed in a template to suit a specific clinical context.
Schlaganfall/TIA	Schlaganfall/TIA: 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. Schlaganfall/TIA
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.
Diagnose	Diagnose: Identification of a simple body site for the location of the problem or diagnosis. Coding of the name of the anatomical location with a terminology is preferred, where possible. Use this data element to record precoordinated anatomical locations. If the requirements for recording the anatomical location are determined at run-time by the application or require more complex modelling such as relative locations then use the CLUSTER.anatomical_location or CLUSTER.relative_location within the 'Structured anatomical location' SLOT in this archetype. Occurrences for this data element are unbounded to allow for clinical scenarios such as describing a rash in multiple locations but where all of the other attributes are identical. If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant. TIA Schlaganfall
Datum des letzten Schlaganfalls/TIA	Datum des letzten Schlaganfalls/TIA: 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.
Exclusion - specific	Exclusion - specific: 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
Problem/diagnosis	Problem/diagnosis: The problem or diagnosis to which the 'Exclusion statement' applies. For example: 'Diabetes', 'COPD' or 'Asthma'. Schlaganfall/TIA
Absence of information	Absence of information: 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". Schlaganfall/TIA
Chronische Lungenerkrankung	Chronische Lungenerkrankung: A generic section header which should be renamed in a template to suit a specific clinical context.
Chronische Lungenerkrankung	Chronische Lungenerkrankung: 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. Chronische Lungenerkrankung
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.
Feststellungsdatum	Feststellungsdatum: 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.
Protocol
Exclusion - specific	Exclusion - specific: 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
Problem/diagnosis	Problem/diagnosis: The problem or diagnosis to which the 'Exclusion statement' applies. For example: 'Diabetes', 'COPD' or 'Asthma'. Chronische Lungenerkrankung
Absence of information	Absence of information: 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". Chronische Lungenerkrankung
Primäre pulmonale Hypertonie	Primäre pulmonale Hypertonie: A generic section header which should be renamed in a template to suit a specific clinical context.
Primäre pulmonale Hypertonie	Primäre pulmonale Hypertonie: 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. Primäre pulmonale Hypertonie
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.
Feststellungsdatum	Feststellungsdatum: 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.
Protocol
Exclusion - specific	Exclusion - specific: 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
Problem/diagnosis	Problem/diagnosis: The problem or diagnosis to which the 'Exclusion statement' applies. For example: 'Diabetes', 'COPD' or 'Asthma'. Primäre pulmonale Hypertonie
Absence of information	Absence of information: 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". Primäre pulmonale Hypertonie
Depression	Depression: A generic section header which should be renamed in a template to suit a specific clinical context.
Depression	Depression: 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. Depression
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.
Feststellungsdatum	Feststellungsdatum: 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.
Protocol
Exclusion - specific	Exclusion - specific: 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
Problem/diagnosis	Problem/diagnosis: The problem or diagnosis to which the 'Exclusion statement' applies. For example: 'Diabetes', 'COPD' or 'Asthma'. Depression
Absence of information	Absence of information: 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". Depression
Krebserkrankung vor mehr als 5 Jahren	Krebserkrankung vor mehr als 5 Jahren: A generic section header which should be renamed in a template to suit a specific clinical context.
Krebserkrankung vor mehr als 5 Jahren	Krebserkrankung vor mehr als 5 Jahren: 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. Krebserkrankung vor mehr als 5 Jahren
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.
Feststellungsdatum	Feststellungsdatum: 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.
Exclusion - specific	Exclusion - specific: 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
Problem/diagnosis	Problem/diagnosis: The problem or diagnosis to which the 'Exclusion statement' applies. For example: 'Diabetes', 'COPD' or 'Asthma'. Krebserkrankung vor mehr als 5 Jahren
Absence of information	Absence of information: 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". Krebserkrankung vor mehr als 5 Jahren
Krebserkrankung vor weniger als 5 Jahren	Krebserkrankung vor weniger als 5 Jahren: A generic section header which should be renamed in a template to suit a specific clinical context.
Krebserkrankung vor weniger als 5 Jahren	Krebserkrankung vor weniger als 5 Jahren: 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. Krebserkrankung vor weniger als 5 Jahren
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.
Feststellungsdatum	Feststellungsdatum: 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.
Exclusion - specific	Exclusion - specific: 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
Problem/diagnosis	Problem/diagnosis: The problem or diagnosis to which the 'Exclusion statement' applies. For example: 'Diabetes', 'COPD' or 'Asthma'. Krebserkrankung vor weniger als 5 Jahren
Absence of information	Absence of information: 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". Krebserkrankung vor weniger als 5 Jahren
Blutdruck nach 5 Minuten Ruhe	Blutdruck nach 5 Minuten Ruhe: 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])
State
Herzfrequenz (Pulsmessung)	Herzfrequenz (Pulsmessung): A generic section header which should be renamed in a template to suit a specific clinical context.
Herzfrequenz	Herzfrequenz: The rate and associated attributes for a pulse or heart beat.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Pulsfrequenz	Pulsfrequenz: The rate of the pulse or heart beat, measured in beats per minute. 0..1000 /min
Weitere Diagnosen	Weitere Diagnosen: A generic section header which should be renamed in a template to suit a specific clinical context.
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. Belastungsdyspnoe
Exclusion - specific	Exclusion - specific: 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
Problem/diagnosis	Problem/diagnosis: The problem or diagnosis to which the 'Exclusion statement' applies. For example: 'Diabetes', 'COPD' or 'Asthma'. Belastungsdyspnoe
Absence of information	Absence of information: 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". Belastungsdyspnoe
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. Ruhedyspnoe
Exclusion - specific	Exclusion - specific: 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
Problem/diagnosis	Problem/diagnosis: The problem or diagnosis to which the 'Exclusion statement' applies. For example: 'Diabetes', 'COPD' or 'Asthma'. Ruhedyspnoe
Absence of information	Absence of information: 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". Ruhedyspnoe
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. Periphere Ödeme
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.
Feststellungsdatum	Feststellungsdatum: 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.
Exclusion - specific	Exclusion - specific: 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
Problem/diagnosis	Problem/diagnosis: The problem or diagnosis to which the 'Exclusion statement' applies. For example: 'Diabetes', 'COPD' or 'Asthma'. Periphere Ödeme
Absence of information	Absence of information: 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". Periphere Ödeme
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. Halsvenenstauung
Exclusion - specific	Exclusion - specific: 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
Problem/diagnosis	Problem/diagnosis: The problem or diagnosis to which the 'Exclusion statement' applies. For example: 'Diabetes', 'COPD' or 'Asthma'. Halsvenenstauung
Absence of information	Absence of information: 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". Halsvenenstauung
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. Pulmonale Rasselgeräusche
Exclusion - specific	Exclusion - specific: 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
Problem/diagnosis	Problem/diagnosis: The problem or diagnosis to which the 'Exclusion statement' applies. For example: 'Diabetes', 'COPD' or 'Asthma'. Pulmonale Rasselgeräusche
Absence of information	Absence of information: 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". Pulmonale Rasselgeräusche