| TEMPLATE ID | INA_Protokolle_UKSH |
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| Concept | INA_Protokolle_UKSH |
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| Description | zur Erfassung der interdisziplinären Notaufnahme-Protokolle des UKSH |
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| Purpose | zur Erfassung der interdisziplinären Notaufnahme-Protokolle des UKSH |
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| References | |
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| Authors | date: 2026-02-02; name: Rony Ventura; organisation: Universitätsklinikum Schleswig-Holstein; email: rony.ventura@uksh.de |
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| Other Details Language | date: 2026-02-02; name: Rony Ventura; organisation: Universitätsklinikum Schleswig-Holstein; email: rony.ventura@uksh.de |
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| Other Details (Language Independent) | - Sem Ver: 30.2.0
- MD5-CAM-1.0.1: 2a59279ea6ddae946daf25de12a511d3
- PARENT:MD5-CAM-1.0.1: A60D0B7F52F1F9C3C9B3518DB83ACDAE
- Original Language: ISO_639-1::de
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| Keywords | interdisziplinäre notaufnahme |
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| Language used | en |
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| Citeable Identifier | 1246.169.3973 |
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| Root archetype id | openEHR-EHR-COMPOSITION.report.v1 |
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| INA_Protokolle_UKSH | INA_Protokolle_UKSH: Document to communicate information to others, commonly in response to a request from another party. |
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| Other Context | |
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| Report ID | Report ID: Identification information about the report. |
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| Case identification | Case identification: To record case identification details for public health purposes. |
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| Case identifier | Case identifier: The identifier of this case. |
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| Reason for encounter | Reason for encounter: The reason for initiation of any healthcare encounter or contact by the individual who is the subject of care. |
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| Data | |
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| Presenting problem | Presenting problem: Identification of the clinical or social problem motivating the subject of care to seeking healthcare.
Coding of the 'Presenting problem' with a terminology is desirable, where possible. Clinical or social reasons for seeking healthcare can include health issues, symptoms or physical signs. Examples: health issues - desire to quit smoking, domestic violence; symptoms - abdominal pain, shortness of breath; physical signs - an altered conscious state. 'Chief complaint' may be used as a valid synonym for 'Presenting problem' in templates. |
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| 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'. |
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| Data | |
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| 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. |
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| Problem/Diagnosis qualifier | Problem/Diagnosis qualifier: Contextual or temporal qualifier for a specified problem or diagnosis. |
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| Diagnostic category | Diagnostic category: Category of the problem or diagnosis within a specified episode of care and/or local care context.
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.
 Coded Text- Principal diagnosis
- Secondary diagnosis
- Complication
 Text
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| Story/History | Story/History: The subjective clinical history of the subject of care as recorded directly by the subject, or reported to a clinician by the subject or a carer. |
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| Data | |
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| Any event | Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time. |
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| Data | |
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| Symptom/Sign | Symptom/Sign: Reported observation of a physical or mental disturbance in an individual. |
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| Symptom/Sign name | Symptom/Sign name: The name of the reported symptom or sign.
Symptom name should be coded with a terminology, where possible. |
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| qSOFA score | qSOFA score: Quick Sepsis-related Organ Failure Assessment (qSOFA) is a simplified version of the SOFA score, which is used outside intensive care units to quickly assess sepsis risk in adults. |
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| Data | |
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| Any point in time event | Any point in time event: Unspecified point in time event which may be explicitly defined in a template or at run-time. |
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| Data | |
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| qSOFA score | qSOFA score: The qSOFA score is the sum of the scores for the three parameters.
0..3 |
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| Procedure | Procedure: A clinical activity carried out for screening, investigative, diagnostic, curative, therapeutic, evaluative or palliative purposes. |
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| Description | |
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| Procedure name | Procedure name: Identification of the procedure by name.
Coding of the specific procedure with a terminology is preferred, where possible. |
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| 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'. |
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| Protocol | |
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| Location | Location: Location includes both casual locations (a place used for health care without prior designation or authorisation) and dedicated, formally designated locations. The sites can be private, public, mobile or fixed. |
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| Ward | Ward: A ward is part of a medical facility that can contain rooms and other types of locations. |
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| Body weight | Body weight: Measurement of the body weight of an individual. |
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| Data | |
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| Any event | Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time. |
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| Data | |
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| Weight | Weight: The weight of the individual.
0..1000; 0..2000; 0..1000000
Units: |
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| Pulse/Heart beat | Pulse/Heart beat: The rate and associated attributes for a pulse or heart beat. |
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| Data | |
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| Any event | Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time. |
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| Data | |
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| Rate | Rate: The rate of the pulse or heart beat, measured in beats per minute.
0..1000 /min |
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| 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. |
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| Data | Data: History Structural node. |
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| Any event | Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time. |
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| Data | |
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| Systolic | Systolic: Peak systemic arterial blood pressure - measured in systolic or contraction phase of the heart cycle.
0..1000 mmHg (UCUM: mm[Hg]) |
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| Diastolic | Diastolic: Minimum systemic arterial blood pressure - measured in the diastolic or relaxation phase of the heart cycle.
0..1000 mmHg (UCUM: mm[Hg]) |
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| Body temperature | Body temperature: A measurement of the body temperature, which is a surrogate for the core body temperature of the individual. |
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| Data | |
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| Any event | Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time. |
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| Data | |
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| Temperature | Temperature: The measured temperature.
0..100; 30..200
Units:- °C (UCUM: Cel)
- °F (UCUM: [degF])
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| Pulse oximetry | Pulse oximetry: Blood oxygen and related measurements, measured by pulse oximetry or pulse CO-oximetry. |
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| Data | |
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| Any event | Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time. |
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| Data | |
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| SpO₂ | SpO₂: The saturation of oxygen in the peripheral blood, measured via pulse oximetry.
SpO₂ is defined as the percentage of oxyhaemoglobin (HbO₂) to the total concentration of haemoglobin (HbO₂ + deoxyhaemoglobin) in peripheral blood.
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| Glasgow Coma Scale (GCS) | Glasgow Coma Scale (GCS): Fifteen point scale used to assess impairment of consciousness in response to defined stimuli.
More correctly known as the Modified Glasgow coma scale. |
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| Data | |
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| Any event | Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time. |
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| Data | |
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| Best eye response (E) | Best eye response (E): Best response of eyes to test stimulus.
Most commonly, the score for eye response will be selected from one of the ordinal values, however if a response cannot be tested, for example if the subject of care cannot physically open their eyes due to other injuries, then the "Not Applicable" null flavour should be recorded.
- 1: None
- 2: To pressure
- 3: To sound
- 4: Spontaneous
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| Best verbal response (V) | Best verbal response (V): Best verbal response to test stimulus.
Most commonly, the score for verbal response will be selected from one of the ordinal values, however if a response cannot be tested, for example if the subject of care is intubated, then the "Not Applicable" null flavour should be recorded.
- 1: None
- 2: Sounds
- 3: Words
- 4: Confused
- 5: Orientated
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| Best motor response (M) | Best motor response (M): Best motor response to test stimulus.
Most commonly, the score for motor response will be selected from one of the ordinal values, however if a response cannot be tested, for example if the subject of care cannot move their limbs due to injury or paralysis, then the "Not Applicable" null flavour should be recorded.
- 1: None
- 2: Extension
- 3: Abnormal flexion
- 4: Normal flexion
- 5: Localising
- 6: Obeys commands
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| Total score | Total score: The sum of the ordinal scores recorded for each of the three component responses.
The Total Score may be derived as the sum of the three response data elements and, if so, should be validated by the clinical information system against the individual scores entered by the clinician to ensure there is no conflict or inconsistency. Do not report a total score when one or more components are not testable because the score will be artificially low - in this situation record the EVM profile.
3..15 |
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| Triage | Triage: The assignment of a degree of urgency to wounds or illnesses, in order to decide the order of treatment of a large number of patients or casualties. |
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| Data | |
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| Priority assignment | Priority assignment: Clinical assessment of the degree of urgency appropriate for treatement of an injury or illness.
There are many examples of triage categories in use. This archetype allows for any and all to be modelled by inclusion of specific values in this data element within a template for a specific clinical scenario. For example: High or Low; Now (immediate/life-threatening), Soon (urgent, up to 1 hour), Walk (delayed; up to 3 hours), Dead (no care required); or other defined categories. |
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| 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. |
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| Data | |
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| Any event | Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time. |
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| Data | |
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| Height/Length | Height/Length: The length of the body from crown of head to sole of foot.
0..1000; 0..250
Units: |
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