| TEMPLATE ID | KDS_Prozedur_UKSH |
|---|---|
| Concept | KDS_Prozedur_UKSH |
| Description | Not Specified |
| Purpose | Not Specified |
| References | |
| Authors | name: Louisa Bode; organisation: MHH-Hannover; email: bode.louisa@mh-hannover.de; date: 2020-09-15 |
| Other Details Language | name: Louisa Bode; organisation: MHH-Hannover; email: bode.louisa@mh-hannover.de; date: 2020-09-15 |
| Other Details (Language Independent) |
|
| Language used | en |
| Citeable Identifier | 1246.169.3581 |
| Root archetype id | openEHR-EHR-COMPOSITION.report.v1 |
| KDS_Prozedur | KDS_Prozedur: 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. |
| Case identification | Case identification: To record case identification details for public health purposes. |
| Case identifier | Case identifier: The identifier of this case. |
| Case started | Case started: The date that the case was commenced. |
| Status | Status: The status of the case. A status of completed means the patient has been associated with the given case number.
A status of aborted means the patient was associated with the case number in error.
|
| Case identified | Case identified: Text or coded description of the case identified. |
| Procedure | Procedure: 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. Annotations
|
| Freitextbeschreibung | Freitextbeschreibung: 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. |
| Indication | Indication: The clinical or process-related reason for the procedure. Coding of the indication with a terminology is preferred, where possible. This data element allows multiple occurrences. For example: 'Failed bowel preparation' or 'Bowel cancer screening'. |
| Method | Method: Identification of specific method or technique for the procedure. Use this data element to record simple terms or a narrative description. If the requirements for recording the method require more complex modelling then this can be represented by additional archetypes within the 'Procedure detail' SLOT in this archetype. If the method is included in the 'Procedure name' via precoordinated codes, this data element becomes redundant. |
| Körperstelle | Körperstelle: Identification of the body site for the procedure. Occurrences for this data element are unbounded to allow for clinical scenarios such as removing multiple skin lesions in different places, but where all of the other attributes are identical. Use this data element to record simple terms or 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 'Procedure detail' SLOT in this archetype. If the anatomical location is included in the 'Procedure name' via precoordinated codes, this data element becomes redundant. |
| Seitenlokalisation | Seitenlokalisation: Identification of the body site for the procedure. Occurrences for this data element are unbounded to allow for clinical scenarios such as removing multiple skin lesions in different places, but where all of the other attributes are identical. Use this data element to record simple terms or 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 'Procedure detail' SLOT in this archetype. If the anatomical location is included in the 'Procedure name' via precoordinated codes, this data element becomes redundant. |
| Kategorie der Prozedur | Kategorie der Prozedur: The type of procedure. This pragmatic data element may be used to support organisation within the user interface. |
| Durchführungsabsicht | Durchführungsabsicht: Reason that the activity or care pathway step for the identified procedure was carried out. For example: the reason for the cancellation or suspension of the procedure. |
| Comment | Comment: Additional narrative about the activity or care pathway step not captured in other fields. |