TEMPLATE Elektrokardiogramm (Elektrokardiogramm)

TEMPLATE ID	Elektrokardiogramm
Concept	Elektrokardiogramm
Description	Zur Aufzeichnung der Ergebnisse einer Untersuchung mittels Elektrokardiogramm.
Purpose	Zur Aufzeichnung der Ergebnisse einer Untersuchung mittels Elektrokardiogramm.
References
Other Details (Language Independent)	MetaDataSet:Sample Set : Template metadata sample set PARENT:MD5-CAM-1.0.1: 005501C1FA493A4838F5F1121F2870EC MD5-CAM-1.0.1: 3d27a0339ce8ba049ba4d9ef1fa0f257 Sem Ver: 2.0.0 Build Uid: 46b8b50a-d925-4e85-bf13-f7c78d12dfcf Original Language: ISO_639-1::de
Language used	en
Citeable Identifier	1246.169.7
Root archetype id	openEHR-EHR-COMPOSITION.report.v1
Report	Report: 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.
ECG result	ECG result: Measurement of the electrical activity generated by the heart. Also known as an electrocardiograph or EKG.
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
Ventricular heart rate	Ventricular heart rate: The frequency of ventricular electrical contractions across the ECG as a whole (multiple leads). Also known as the RR rate, QRS rate or electrical heart rate. The ventricular heart rate is measured from R wave to R wave and calculated across the ECG as a whole (multiple leads). >=0 /min
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QT-Zeit	QT-Zeit: Interval measurement from the onset of the QRS complex to the end of the T wave aacross the ECG as a whole (multiple leads). >=0 ms
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PQ-Zeit	PQ-Zeit: PR interval measurement across the ECG as a whole (multiple leads). The PR interval is measured from onset of P wave to the onset of QRS complex. >=0 ms
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QRS-Dauer	QRS-Dauer: Duration of QRS complex across the ECG as a whole (multiple leads). The QRS complex is measured from its onset to the ST segment onset (J point). >=0 ms
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Rhythmus	Rhythmus: Single word, phrase or brief description that represents a significant finding in the ECG result. For example: 'Normal ECG', 'Equivocal ECG' or 'Abnormal ECG'; 'Spikes from pacemaker signal'; 'ST depression'; or 'Atrial fibrillation'. Coding of the finding with a terminology is preferred, where possible. Sinusrhythmus Vorhofflimmern Vorhofflattern Anderer Rhythmus
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Q-Wellen als Hinweis auf abgelaufenen Infarkt	Q-Wellen als Hinweis auf abgelaufenen Infarkt: Single word, phrase or brief description that represents a significant finding in the ECG result. For example: 'Normal ECG', 'Equivocal ECG' or 'Abnormal ECG'; 'Spikes from pacemaker signal'; 'ST depression'; or 'Atrial fibrillation'. Coding of the finding with a terminology is preferred, where possible. Q-Wellen festgestellt keine Q-Wellen festgestellt
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Diskordante T-Negativierungen	Diskordante T-Negativierungen: Single word, phrase or brief description that represents a significant finding in the ECG result. For example: 'Normal ECG', 'Equivocal ECG' or 'Abnormal ECG'; 'Spikes from pacemaker signal'; 'ST depression'; or 'Atrial fibrillation'. Coding of the finding with a terminology is preferred, where possible. Diskordante T-Negativierungen festgestellt keine diskordanten T-Negativierungen festgestellt
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State
Schrittmacher Stimulation	Schrittmacher Stimulation: Narrative description about pacemaker activity. This free text field could be further coded in a template to enable a Present/Absent value set if required for reporting purposes. Schrittmacher Stimulation keine Schrittmacher Stimulation
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Vorhoferregung durch Schrittmacher	Vorhoferregung durch Schrittmacher: Narrative description about pacemaker activity. This free text field could be further coded in a template to enable a Present/Absent value set if required for reporting purposes. Vorhoferregung keine Vorhoferregung
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Kammererregung durch Schrittmacher	Kammererregung durch Schrittmacher: Narrative description about pacemaker activity. This free text field could be further coded in a template to enable a Present/Absent value set if required for reporting purposes. Kammererregung keine Kammererregung
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Andere Erregung durch Schrittmacher	Andere Erregung durch Schrittmacher: Narrative description about pacemaker activity. This free text field could be further coded in a template to enable a Present/Absent value set if required for reporting purposes. andere Erregung keine andere Erregung
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Andere Erregung spezifizieren	Andere Erregung spezifizieren: Narrative description about pacemaker activity. This free text field could be further coded in a template to enable a Present/Absent value set if required for reporting purposes.
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Protocol
Device interpretation comment	Device interpretation comment: Comment about the interpretation by the device. For example: identification of the algorithm used; or description of technical limitations.
AV-Block	AV-Block: Framework for consistent modelling of content within a template for a Problem list. Intended to be used within the COMPOSITION.problem_list.
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'.
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. AV-Block
Severity	Severity: An assessment of the overall severity of the problem or diagnosis. If severity is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant. Note: more specific grading of severity can be recorded using the Specific details SLOT. I II (Typ nicht näher spezifiziert) II Wenkebach Typ 1 II Mobitz Typ 2 III
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
Problem/diagnosis	Problem/diagnosis: The problem or diagnosis to which the 'Exclusion statement' applies. For example: 'Diabetes', 'COPD' or 'Asthma'. AV-Block
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". AV-Block
Schenkelblock	Schenkelblock: Framework for consistent modelling of content within a template for a Problem list. Intended to be used within the COMPOSITION.problem_list.
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'.
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. Schenkelblock
Body site	Body site: Identification of a simple body site for the location of the problem or diagnosis. Coding of the name of the anatomical location with a terminology is preferred, where possible. Use this data element to record 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 'Structured anatomical location' SLOT in this archetype. Occurrences for this data element are unbounded to allow for clinical scenarios such as describing a rash in multiple locations but where all of the other attributes are identical. If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant. Linksschenkelblock (LSB) Rechtsschenkelblock (RSB)
Severity	Severity: An assessment of the overall severity of the problem or diagnosis. If severity is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant. Note: more specific grading of severity can be recorded using the Specific details SLOT. komplett inkomplett
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
Problem/diagnosis	Problem/diagnosis: The problem or diagnosis to which the 'Exclusion statement' applies. For example: 'Diabetes', 'COPD' or 'Asthma'. Schenkelblock
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". Schenkelblock
Hemiblock	Hemiblock: Framework for consistent modelling of content within a template for a Problem list. Intended to be used within the COMPOSITION.problem_list.
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'.
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. Hemiblock
Body site	Body site: Identification of a simple body site for the location of the problem or diagnosis. Coding of the name of the anatomical location with a terminology is preferred, where possible. Use this data element to record 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 'Structured anatomical location' SLOT in this archetype. Occurrences for this data element are unbounded to allow for clinical scenarios such as describing a rash in multiple locations but where all of the other attributes are identical. If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant. Linksanteriorer Hemiblock (LAH) Linksposteriorer Hemiblock (LPH)
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
Problem/diagnosis	Problem/diagnosis: The problem or diagnosis to which the 'Exclusion statement' applies. For example: 'Diabetes', 'COPD' or 'Asthma'. Hemiblock
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". Hemiblock
ST-Strecken pathologisch	ST-Strecken pathologisch: Framework for consistent modelling of content within a template for a Problem list. Intended to be used within the COMPOSITION.problem_list.
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'.
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. ST-Strecken pathologisch
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
Problem/diagnosis	Problem/diagnosis: The problem or diagnosis to which the 'Exclusion statement' applies. For example: 'Diabetes', 'COPD' or 'Asthma'. ST-Strecken pathologisch
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". ST-Strecken pathologisch