TEMPLATE CAEHR_B_Diagnose (CAEHR_B_Diagnose)

TEMPLATE IDCAEHR_B_Diagnose
ConceptCAEHR_B_Diagnose
DescriptionZur Repräsentation von Diagnosen für die Speicherung im Rahmen des CAEHR-Projektes.
UseFür die Abbildung von Haupt- und Nebendiagnosen eines Patienten für die Speicherung im Rahmen des CAEHR Projektes.
MisuseNicht zur Repräsentation von Symptomen und/oder Krankheitsanzeichen verwenden. Hierzu sollte der passende Archetyp im Rahmen eines geeigneten Templates verwendet werden.
PurposeZur Repräsentation von Diagnosen für die Speicherung im Rahmen des CAEHR-Projektes.
References
Authorsdate: 2023-02-27; name: Marina Rudenko; organisation: Vitasystems GmbH; email: marina.rudenko@vitagroup.ag
Other Details Languagedate: 2023-02-27; name: Marina Rudenko; organisation: Vitasystems GmbH; email: marina.rudenko@vitagroup.ag
OtherDetails Language Independent{PARENT:MD5-CAM-1.0.1=005501C1FA493A4838F5F1121F2870EC, original_language=ISO_639-1::de, MD5-CAM-1.0.1=4ce87f1510f1362683bfb6db00b026c9, sem_ver=11.0.0}
KeywordsCAEHR; Diagnose; Hauptdiagnose; Komorbidität; Nebendiagnose
Language useden
Citeable Identifier1246.169.3600
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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., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Hauptdiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v2], code=at0000, itemType=CLUSTER, level=3, text=Problem/Diagnosis qualifier, description=Contextual or temporal qualifier for a specified problem or diagnosis., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Hauptdiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v2]/items[at0063], code=at0063, itemType=ELEMENT, level=4, text=Diagnostic category, description=Category of the problem or diagnosis within a specified episode of care and/or local care context., comment=This data element contains a value set commonly used in diagnostic categorisation. In episodic care contexts (commonly secondary care) it is common to categorise/organise diagnoses according to their relationship to the principal diagnosis being addressed during that episode of care. These categories may also be used for clinical coding, reporting and billing purposes. In some countries the diagnostic category may be known as a DRG. In addition, the free text choice permits use of other local value sets, as required., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Principal diagnosis 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Hauptdiagnose']/data[at0001]/items[at0073], code=at0073, itemType=ELEMENT, level=3, text=Diagnostic certainty, description=The level of confidence in the identification of the diagnosis., comment=If an alternative valueset is required, these values can be added to the DV_TEXT data type in a template., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= Value set: terminology://fhir.hl7.org//ValueSet/$expand?url=https://fhir.kbv.de/ValueSet/KBV_VS_SFHIR_ICD_DIAGNOSESICHERHEIT
  • Suspected 
  • Probable 
  • Confirmed 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Nebendiagnose'], code=at0000, itemType=EVALUATION, level=1, text=Nebendiagnose, description=Details about a single identified health condition, injury, disability or any other issue which impacts on the physical, mental and/or social well-being of an individual., comment=Clear delineation between the scope of a problem versus a diagnosis is not easy to achieve in practice. 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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., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Nebendiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v2], code=at0000, itemType=CLUSTER, level=3, text=Problem/Diagnosis qualifier, description=Contextual or temporal qualifier for a specified problem or diagnosis., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Nebendiagnose']/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v2]/items[at0063], code=at0063, itemType=ELEMENT, level=4, text=Diagnostic category, description=Category of the problem or diagnosis within a specified episode of care and/or local care context., comment=This data element contains a value set commonly used in diagnostic categorisation. In episodic care contexts (commonly secondary care) it is common to categorise/organise diagnoses according to their relationship to the principal diagnosis being addressed during that episode of care. These categories may also be used for clinical coding, reporting and billing purposes. In some countries the diagnostic category may be known as a DRG. In addition, the free text choice permits use of other local value sets, as required., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Secondary diagnosis 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Nebendiagnose']/data[at0001]/items[at0073], code=at0073, itemType=ELEMENT, level=3, text=Diagnostic certainty, description=The level of confidence in the identification of the diagnosis., comment=If an alternative valueset is required, these values can be added to the DV_TEXT data type in a template., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= Value set: terminology://fhir.hl7.org//ValueSet/$expand?url=https://fhir.kbv.de/ValueSet/KBV_VS_SFHIR_ICD_DIAGNOSESICHERHEIT
  • Suspected 
  • Probable 
  • Confirmed 
, extendedValues=null]], templateType=normal]