| TEMPLATE ID | Anamnese Test |
|---|---|
| Concept | Anamnese Test |
| Description | Not Specified |
| Purpose | Not Specified |
| References | |
| Authors | date: 2020-03-23; name: Peer |
| Other Details Language | date: 2020-03-23; name: Peer |
| Other Details (Language Independent) |
|
| Language used | en |
| Citeable Identifier | 1246.169.3684 |
| Root archetype id | openEHR-EHR-COMPOSITION.report.v1 |
| Anamnese Test | Anamnese Test: 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. |
| Angaben zur Person | Angaben zur Person: A generic section header which should be renamed in a template to suit a specific clinical context. |
| Personendaten | Personendaten: Demografische Daten zu einer Person wie Geburtsdatum und Telefonnummer. |
| Data | |
| Structured name of a person | Structured name of a person: Discrete components of an individual's name. |
| Given name | Given name: One or more unique name(s) used to identify an individual within a family group. Occurrences for this data element are set to 0..* to allow for more than one Given name to be recorded. In addition, this data element may be cloned and renamed within a template to allow discrete recording of different types of Given name - for example 'First name', 'Middle name', 'Preferred name' or 'Nickname', as required for a specific use case. |
| Family name | Family name: One or more name(s) that an individual has in common with a family group. Also known as 'Last name' or 'Surname'. Occurrences for this data element are set to 0..* to allow for more than one Family name to be recorded. Complex names such as 'El Haddad' or 'van der Heyden' can be recorded using this naming pattern, as identified in ISO 22220 (Annex F), but for the intended use case for this archetype it is most likely that the full family name will be recorded as a string. |
| Birth data | Birth data: Birth demographic data |
| Birth date | Birth date: The date of birth of a person |
| Allgemeine Anamnese | Allgemeine Anamnese: A generic section header which should be renamed in a template to suit a specific clinical context. |
| Größe | Größe: 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; 0..250 Units:
|
| 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; 0..2000; 0..1000000 Units:
|
| Allergien | Allergien: Clinical assessment of the propensity for an individual to experience a harmful or undesirable physiological response if exposed, or re-exposed, to a substance. Substances include, but are not limited to: a therapeutic substance administered correctly at an appropriate dosage for the individual; food; material derived from plants or animals; or venom from insect stings. Optional[{source=openEHR,FHIR}] |
| Data | |
| Substance | Substance: Identification of a substance, or substance class, that is considered to put the individual at risk of an adverse reaction event. Both an individual substance and a substance class are valid entries in 'Substance'. A substance may be a compound of simpler substances, for example a medicinal product. It is strongly recommended that the 'Substance' is coded with a terminology capable of triggering decision support, where possible. For example: Snomed CT, DM+D, RxNorm, NDFRT, ATC, New Zealand Universal List of Medicines and Australian Medicines Terminology. Free text entry should only be used if there is no appropriate terminology available. |
| Onset of first reaction | Onset of first reaction: The onset of the first known occurrence of a reaction event. For example: the actual date and/or time of onset; the interval of time during which the onset occurred; the age of the individual at the time of the onset; or the duration of time since the onset occurred. A partial date is valid, using the DV_DATE_TIME data type, to record only a year. |
| Comment | Comment: Additional narrative about the propensity for the adverse reaction, not captured in other fields. For example: including reason for flagging a 'Criticality' of 'High risk'; and instructions related to future exposure or administration of the Substance, such as administration within an Intensive Care Unit or under corticosteroid cover. |
| Ausschluss - Allergien | Ausschluss - Allergien: 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/Diagnose | Problem/Diagnose: The problem or diagnosis to which the 'Exclusion statement' applies. For example: 'Diabetes', 'COPD' or 'Asthma'.
|
| Medication management | Medication management: Any activity related to the planning, scheduling, prescription management, dispensing, administration, cessation and other use of a medication, vaccine, nutritional product or other therapeutic item. This is not limited to activities performed based on medication orders from clinicians, but could also include for example taking over the counter medication. |
| Description | |
| Medication item | Medication item: Name of the medication, vaccine or other therapeutic/prescribable item which was the focus of the activity. For example: 'Atenolol 100mg' or 'Tenormin tablets 100mg'. It is strongly recommended that the 'Medication item' is coded with a terminology capable of triggering decision support, where possible. The extent of coding may vary from the simple name of the medication item through to structured details about the actual medication pack used. Free text entry should only be used if there is no appropriate terminology available. |
| Ausschluss - Arzneimittel | Ausschluss - Arzneimittel: 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 | |
| Medikation | Medikation: The Medication to which the 'Exclusion statement' applies. For example: 'Paracetamol', 'Codeine' or 'Antidepressants'.
|
| Herz-/Kreislauferkrankungen | Herz-/Kreislauferkrankungen: Details about a single identified health condition, injury, disability or any other issue which impacts on the physical, mental and/or social well-being of an individual. Clear delineation between the scope of a problem versus a diagnosis is not easy to achieve in practice. For the purposes of clinical documentation with this archetype, problem and diagnosis are regarded as a continuum, with increasing levels of detail and supportive evidence usually providing weight towards the label of 'diagnosis'. |
| Data | |
| Problem/Diagnosis name | Problem/Diagnosis name: Identification of the problem or diagnosis, by name. Coding of the name of the problem or diagnosis with a terminology is preferred, where possible. Terminology: ICD-10
Default value: Sonstige und nicht näher bezeichnete Krankheiten des Kreislaufsystems |
| 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.
|
| Stoffwechselkrankheiten | Stoffwechselkrankheiten: 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.
|
| 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.
|
| Infektionskrankheiten | Infektionskrankheiten: 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.
|
| Ausschluss - Diagnose | Ausschluss - Diagnose: 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/Diagnose | Problem/Diagnose: The problem or diagnosis to which the 'Exclusion statement' applies. For example: 'Diabetes', 'COPD' or 'Asthma'.
|
| 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.
|
| Zahnärztliche Anamnese | Zahnärztliche Anamnese: A generic section header which should be renamed in a template to suit a specific clinical context. |
| Beschwerden | Beschwerden: 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.
|
| Behandlungen | Behandlungen: 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.
|