| TEMPLATE ID | Familienanamnese Krebs |
|---|---|
| Concept | Familienanamnese Krebs |
| Description | Zur Repräsentation von Familienanamnesedaten bei Patienten mit einer onkologischen Diagnose im HiGHmed Projekt. |
| Use | Dieses Template wird verwendet, um Familienanamnesedaten von Patienten mit einer onkologischen Diagnose zu repräsentieren. Es sollen Familienerkrankungsdaten zu Tumordiagnosen von dem Patienten erfasst werden. |
| Misuse | Dieses Template soll nicht verwendet werden, um Familienanamnese außerhalb des onkologischen Anwendungsbereichs darzustellen. |
| Purpose | Zur Repräsentation von Familienanamnesedaten bei Patienten mit einer onkologischen Diagnose im HiGHmed Projekt. |
| References | |
| Authors | date: 2020-02-05 |
| Other Details Language | date: 2020-02-05 |
| Other Details (Language Independent) |
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| Keywords | Anamnese, Onkologie, Tumor, Diagnose, Familienanamnese, Familie, genetisch, Stammbaum, Verwandter, erblich, vererbt, familär, Vererbung |
| Language used | en |
| Citeable Identifier | 1246.169.517 |
| Root archetype id | openEHR-EHR-COMPOSITION.report.v1 |
| Familienanamnese Krebs | Familienanamnese Krebs: 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.
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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. |
| 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".
|
| Reason for absence | Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible. |
| 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 | |
| Familiäre Krankengeschichte | Familiäre Krankengeschichte: The Family history item to which the 'Exclusion statement' applies. For example: 'Heart desease', 'Diabetes' or 'Alzheimer'.
|
| Familienanamnese Krebs | Familienanamnese Krebs: Summary information about the significant health-related problems found in family members. |
| Data | |
| Per problem | Per problem: Details about the presence of a specific problem or diagnosis in family members. If the problem has a genetic predisposition within families, then only genetic relatives should be considered as part of this data. If the problem has psychosocial or environmental effects then non-genetic family members may also be included. |
| Problem/diagnosis name | Problem/diagnosis name: Identification of the significant problem or diagnosis in the family overall. This is the problem for which aggregated data involving all family members will be collected. Coding of the index problem with a terminology is preferred, where possible.
|
| Per family member | Per family member: Details about a specific family member. The data elements in this cluster will relate to the individual identified either by name or by alias. Repeat the use of the cluster for other family members. |
| Kennung des Familienmitglieds (ID) | Kennung des Familienmitglieds (ID): An alternative name or label to uniquely identify a family member, without using a personal name which might publicly identify the individual. To be used to assist in distinguishing one individual from multiple family members with identical relationships. For example, the label to distinguish one specific sister from three known sisters might be 'eldest sister' 'sister with the red hair' or 'sister #1'. |
| Anmerkung zum Familienmitglied | Anmerkung zum Familienmitglied: Free text. |
| Anmerkung | Anmerkung: Free text. |
| Relationship | Relationship: The relationship of the family member to the subject of care. For example: mother, step-father, maternal grandmother, or paternal uncle. Coding of the relationship with a terminology is preferred, where possible and including specification of maternal and paternal as required.
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| Relationship degree | Relationship degree: The degree of relationship between the subject of care and the family member. If the 'Relationship' data element uses pre-coordinated terms that include the degree of relationship, then this data element is redundant.
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| Family line | Family line: Identification of the maternal or paternal family line in the relationship. If the 'Relationship' data element uses pre-coordinated terms that include the family line, then this data element is redundant.
|
| Clinical history | Clinical history: Detail about problems or diagnoses for the family member. If more detail is required, suggest using EVALUATION.problem_diagnosis or the ACTION.procedure archetype and specifying the 'Subject of Care' as the family member, rather than the subject of the health record. |
| Tumordiagnose (ICD 10) | Tumordiagnose (ICD 10): Identification of the significant problem or diagnosis in the identified family member. Coding of the family member's problem or diagnosis with a terminology is preferred, where possible. May link from this data element to a detailed record of a Problem/Diagnosis using the EVALUATION.problem_diagnosis archetype with the Subject of Care set to the family member, not to the patient. |
| Tumordiagnose Beschreibung | Tumordiagnose Beschreibung: Narrative description or comments about clinical aspects of the family member's problem/diagnosis. |
| Alter bei Erstdiagnose (Y) | Alter bei Erstdiagnose (Y): Estimated or actual age of the family member when the problem/diagnosis was clinically recognised. For health problems with multiple occurrences, this describes the first nown occurrence. Units: Year |
| Altersgruppe bei Erstdiagnose | Altersgruppe bei Erstdiagnose: Relationship of the problem/diagnosis to the death of this family member.
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| Assoziierte Erkrankung/Krebsrisiko Syndrom | Assoziierte Erkrankung/Krebsrisiko Syndrom: Additional narrative about the family member not captured in other fields. |
| Pathogene Keimbahnvariante | Pathogene Keimbahnvariante: Detailed information about measurable indicators of a biological state or condition of the family member. For example: detailed information on BRCA mutations in family members. Note: More data elements will be needed in future to record detailed genetic marker information. |
| Pathogene Keimbahnvariante? | Pathogene Keimbahnvariante?: Description of risk-related biological markers identified in this family member.
|
| Genetic variant presence | Genetic variant presence: Assessment of the presence or absence of a specific genetic variant in a sequenced specimen. |
| Variante Name | Variante Name: The name of the variant. |
| Protocol | |
| Last Updated | Last Updated: The date this family history summary was last updated. |