TEMPLATE KDS_Diagnose (KDS_Diagnose)

TEMPLATE IDKDS_Diagnose
ConceptKDS_Diagnose
DescriptionZur Repräsentation einer fallspezifischen oder fallunabhängigen Diagnose eines Patienten.
UseFür die Repräsentation einer Diagnose eines Patienten.
MisuseNicht zur Repräsentation spezifischer Diagnosen oder Zustände, die weitere Angaben erfordern (z. B. Tumordiagnosen in ICD-O). Nicht zur Repräsentation von Symptomen. Dafür bitte eigene Templates unter Nutzung des Problem/Diagnose-Archetyps anlegen.
PurposeZur Repräsentation einer fallspezifischen oder fallunabhängigen Diagnose eines Patienten.
References
Authorsdate: 2020-04-21; email: bode.louisa@mh-hannover.de; organisation: Medizinische Hochschule Hannover; name: Louisa Bode
Other Details Languagedate: 2020-04-21; email: bode.louisa@mh-hannover.de; organisation: Medizinische Hochschule Hannover; name: Louisa Bode
OtherDetails Language Independent{PARENT:MD5-CAM-1.0.1=DE0723367AA22BB716CEC5342B21FF60, original_language=ISO_639-1::de, notes=Generated automatically by Adl Designer, MetaDataSet:Sample Set=Template metadata sample set, MD5-CAM-1.0.1=0450ae0bd46505c402d3f4c4f34388a8}
KeywordsDiagnose, Problemliste, ICD
Language useden
Citeable Identifier1246.169.714
AllOperationalTemplate [rootArchetypeId=openEHR-EHR-COMPOSITION.report.v1, otherContributors=null, tshis=[ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1], code=at0000, itemType=COMPOSITION, level=0, text=Diagnose, description=Document to communicate information to others, commonly in response to a request from another party., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=COMPOSITION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=null, code=null, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=1, text=Other Context, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/context/other_context[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=2, text=Report ID, description=Identification information about the report., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/context/other_context[at0001]/items[at0005], code=at0005, itemType=ELEMENT, level=2, text=Status, description=The status of the entire report. Note: This is not the status of any of the report components., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • registriert
  • vorläufig
  • final
  • geändert
  • [...]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.case_identification.v0], code=at0000, itemType=CLUSTER, level=2, text=Case identification, description=To record case identification details for public health purposes., 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]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.case_identification.v0]/items[at0001], code=at0001, itemType=ELEMENT, level=3, text=Case identifier, description=The identifier of this case., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v2], code=at0000, itemType=CLUSTER, level=2, 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]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v2]/items[at0063], code=at0063, itemType=ELEMENT, level=3, text=Diagnoserolle, 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=Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=http://hl7.org/fhir/ValueSet/diagnosis-role
  • Principal diagnosis 
  • Secondary diagnosis 
  • Complication 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Primärcode'], code=at0000, itemType=EVALUATION, level=1, text=Primärcode, 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. 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'., uncommonOntologyItems=null, occurencesFormal=1..*, occurencesText=Mandatory, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Primärcode']/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=2, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Primärcode']/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=3, text=Kodierte Diagnose, description=Identification of the problem or diagnosis, by name., comment=Coding of the name of the problem or diagnosis with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Value set: external, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Primärcode']/data[at0001]/items[at0009], code=at0009, itemType=ELEMENT, level=3, text=Freitextbeschreibung, description=Narrative description about the problem or diagnosis., comment=Use to provide background and context, including evolution, episodes or exacerbations, progress and any other relevant details, about the problem or diagnosis., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Primärcode']/data[at0001]/items[at0012 and name/value='Körperstelle'], code=at0012, itemType=ELEMENT, level=3, text=Körperstelle, description=Identification of a simple body site for the location of the problem or diagnosis., comment=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., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: http://snomed.info/sct
Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=http://hl7.org/fhir/ValueSet/body-site
  • 10 to 19 percent of body surface 10 to 19 percent of body surface 
  • 12 nm filaments 12 nm filaments 
  • 20 to 29 percent of body surface 20 to 29 percent of body surface 
  • 30 to 39 percent of body surface 30 to 39 percent of body surface 
  • 40 to 49 percent of body surface 40 to 49 percent of body surface 
  • 5/6 interchondral joint 5/6 interchondral joint 
  • 50 to 59 percent of body surface 50 to 59 percent of body surface 
  • 6/7 interchondral joint 6/7 interchondral joint 
  • 60 to 69 percent of body surface 60 to 69 percent of body surface 
  • 7 nm filaments 7 nm filaments 
  • 7/8 interchondral joint 7/8 interchondral joint 
  • 70 to 79 percent of body surface 70 to 79 percent of body surface 
  • 8/9 interchondral joint 8/9 interchondral joint 
  • 80 to 89 percent of body surface 80 to 89 percent of body surface 
  • 9 nm filaments 9 nm filaments 
  • 90 percent of body surface or more 90 percent of body surface or more 
  • A band A band 
  • Abdomen Abdomen 
  • Abdomen excluding retroperitoneal region Abdomen excluding retroperitoneal region 
  • Abdomen proper Abdomen proper 
  • Abdomen proper cavity Abdomen proper cavity 
  • Abdomen proper segment of trunk Abdomen proper segment of trunk 
  • Abdominal aorta structure Abdominal aorta structure 
  • Abdominal aortic plexus structure Abdominal aortic plexus structure 
  • Abdominal blood vessel Abdominal blood vessel 
  • ... +35713 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Primärcode']/data[at0001]/items[at0012 and name/value='Seitenlokalisation'], code=at0012, itemType=ELEMENT, level=3, text=Seitenlokalisation, description=Identification of a simple body site for the location of the problem or diagnosis., comment=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., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: https://fhir.kbv.de/CodeSystem/KBV_CS_SFHIR_ICD_SEITENLOKALISATION
Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=https://fhir.kbv.de/ValueSet/KBV_VS_SFHIR_ICD_SEITENLOKALISATION
  • beiderseits beiderseits 
  • links links 
  • rechts rechts 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Primärcode']/data[at0001]/items[at0077], code=at0077, itemType=ELEMENT, level=3, text=Klinisch relevanter Zeitraum (Zeitpunkt des Auftretens), description=Estimated or actual date/time that signs or symptoms of the problem/diagnosis were first observed., comment=Data captured/imported as "Age at onset" 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='Primärcode']/data[at0001]/items[at0003], code=at0003, itemType=ELEMENT, level=3, text=Feststellungsdatum, description=Estimated or actual date/time the diagnosis or problem was recognised by a healthcare professional., comment=Partial dates are acceptable. 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=1..1, occurencesText=Mandatory, 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='Primärcode']/data[at0001]/items[at0005], code=at0005, itemType=ELEMENT, level=3, text=Severity, description=An assessment of the overall severity of the problem or diagnosis., comment=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., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  •  
  •  
  •  
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Primärcode']/data[at0001]/items[openEHR-EHR-CLUSTER.lebensphase.v0], code=at0000, itemType=CLUSTER, level=3, text=Lebensphase, description=Beschreibung des ungefähren Alters, wann die Erkrankung durchgemacht wurde. Ungefähre Angabe des Alters, da häufig keine genaue Angabe des Zeitpunktes (klinisch relevanter Zeitraum) der Erkrankung möglich ist, vor allem wenn die Diagnose nicht durch die eintragende ärztliche Person erfolgt., 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='Primärcode']/data[at0001]/items[openEHR-EHR-CLUSTER.lebensphase.v0]/items[at0001], code=at0001, itemType=ELEMENT, level=4, text=Beginn, description=Lebensphase, in der das Problem / eine Erkrankung zum ersten Mal aufgetreten ist / diagnostiziert wurde, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: http://snomed.info/sct
Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=http://fhir.de/ValueSet/lebensphase-de
  • 41847000 | Adulthood 
  • 263659003 | Adolescence 
  • 255398004 | Childhood 
  • 713153009 | Toddler 
  • 3658006 | Infancy 
  • 255407002 | Neonatal 
  • 271872005 | Old age 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Primärcode']/data[at0001]/items[openEHR-EHR-CLUSTER.lebensphase.v0]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Ende, description=Lebensphase, in der das Problem / eine Erkrankung zum letzen Mal aufgetreten ist / zuletzt diagnostiziert wurde, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: http://snomed.info/sct
Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=http://fhir.de/ValueSet/lebensphase-de
  • 41847000 | Adulthood 
  • 263659003 | Adolescence 
  • 255398004 | Childhood 
  • 713153009 | Toddler 
  • 3658006 | Infancy 
  • 255407002 | Neonatal 
  • 271872005 | Old age 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Primärcode']/data[at0001]/items[openEHR-EHR-CLUSTER.multiple_coding_icd10gm.v1], code=at0000, itemType=CLUSTER, level=3, text=Multiple_coding_ICD-10-GM, description=Additional codes for postcoordinated ICD-10-GM codes according to the Cross-Star system., 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='Primärcode']/data[at0001]/items[openEHR-EHR-CLUSTER.multiple_coding_icd10gm.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=4, text=Multiple coding identifier, description=ICD-10 GM additional codes according to cross-star system, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Coded Text
    • † 
    • * 
    • ! 
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Primärcode']/data[at0001]/items[at0030], code=at0030, itemType=ELEMENT, level=3, text=Klinisch relevanter Zeitraum (Zeitpunkt der Genesung), description=Estimated or actual date/time of resolution or remission for this problem or diagnosis, as determined by a healthcare professional., comment=Partial dates are acceptable. 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 resolution" 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='Primärcode']/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v2], code=at0000, itemType=CLUSTER, level=3, text=Klinischer Status, 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='Primärcode']/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v2]/items[at0003], code=at0003, itemType=ELEMENT, level=4, text=Klinischer Status, description=Category that supports division of problems and diagnoses into Active or Inactive problem lists., comment=The Active/Inactive and Current/Past data elements have similar clinical impact but represent slightly different semantics. Both are actively used in different clinical settings, but usually not together. If a Current/Past qualifier is recorded, then this data element is likely to be redundant. An exception where a condition can be current but inactive is asthma that is not causing acute symptoms., 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=http://hl7.org/fhir/ValueSet/condition-clinical
  • Active 
  • Inactive 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Primärcode']/data[at0001]/items[at0073], code=at0073, itemType=ELEMENT, level=3, text=Diagnosesicherheit, 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=Terminology: local https://fhir.kbv.de/CodeSystem/KBV_CS_SFHIR_ICD_DIAGNOSESICHERHEIT
Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=https://fhir.kbv.de/ValueSet/KBV_VS_SFHIR_ICD_DIAGNOSESICHERHEIT
  • Suspected 
  • Probable 
  • Confirmed 
  • A | ausgeschlossen 
  • G | gesicherte Diagnose 
  • V | Verdacht auf / zum Ausschluss von 
  • Z | Zustand nach 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Primärcode']/data[at0001]/items[at0069], code=at0069, itemType=ELEMENT, level=3, text=Diagnoseerläuterung, description=Additional narrative about the problem or diagnosis not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Primärcode']/protocol[at0032], code=at0032, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=2, text=Protocol, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Primärcode']/protocol[at0032]/items[at0070], code=at0070, itemType=ELEMENT, level=3, text=Letztes Dokumentationsdatum, description=The date this problem or diagnosis was last updated., comment=null, 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='Sekundärcode'], code=at0000, itemType=EVALUATION, level=1, text=Sekundärcode, 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. 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'., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Sekundärcode']/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=2, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Sekundärcode']/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=3, text=Kodierte Diagnose, description=Identification of the problem or diagnosis, by name., comment=Coding of the name of the problem or diagnosis with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Value set: external, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Sekundärcode']/data[at0001]/items[at0009], code=at0009, itemType=ELEMENT, level=3, text=Freitextbeschreibung, description=Narrative description about the problem or diagnosis., comment=Use to provide background and context, including evolution, episodes or exacerbations, progress and any other relevant details, about the problem or diagnosis., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Sekundärcode']/data[at0001]/items[at0012 and name/value='Körperstelle'], code=at0012, itemType=ELEMENT, level=3, text=Körperstelle, description=Identification of a simple body site for the location of the problem or diagnosis., comment=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., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: http://snomed.info/sct
Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=http://hl7.org/fhir/ValueSet/body-site
  • 10 to 19 percent of body surface 10 to 19 percent of body surface 
  • 12 nm filaments 12 nm filaments 
  • 20 to 29 percent of body surface 20 to 29 percent of body surface 
  • 30 to 39 percent of body surface 30 to 39 percent of body surface 
  • 40 to 49 percent of body surface 40 to 49 percent of body surface 
  • 5/6 interchondral joint 5/6 interchondral joint 
  • 50 to 59 percent of body surface 50 to 59 percent of body surface 
  • 6/7 interchondral joint 6/7 interchondral joint 
  • 60 to 69 percent of body surface 60 to 69 percent of body surface 
  • 7 nm filaments 7 nm filaments 
  • 7/8 interchondral joint 7/8 interchondral joint 
  • 70 to 79 percent of body surface 70 to 79 percent of body surface 
  • 8/9 interchondral joint 8/9 interchondral joint 
  • 80 to 89 percent of body surface 80 to 89 percent of body surface 
  • 9 nm filaments 9 nm filaments 
  • 90 percent of body surface or more 90 percent of body surface or more 
  • A band A band 
  • Abdomen Abdomen 
  • Abdomen excluding retroperitoneal region Abdomen excluding retroperitoneal region 
  • Abdomen proper Abdomen proper 
  • Abdomen proper cavity Abdomen proper cavity 
  • Abdomen proper segment of trunk Abdomen proper segment of trunk 
  • Abdominal aorta structure Abdominal aorta structure 
  • Abdominal aortic plexus structure Abdominal aortic plexus structure 
  • Abdominal blood vessel Abdominal blood vessel 
  • ... +35713 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Sekundärcode']/data[at0001]/items[at0012 and name/value='Seitenlokalisation'], code=at0012, itemType=ELEMENT, level=3, text=Seitenlokalisation, description=Identification of a simple body site for the location of the problem or diagnosis., comment=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., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: https://fhir.kbv.de/CodeSystem/KBV_CS_SFHIR_ICD_SEITENLOKALISATION
Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=https://fhir.kbv.de/ValueSet/KBV_VS_SFHIR_ICD_SEITENLOKALISATION
  • beiderseits beiderseits 
  • links links 
  • rechts rechts 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Sekundärcode']/data[at0001]/items[at0077], code=at0077, itemType=ELEMENT, level=3, text=Klinisch relevanter Zeitraum (Zeitpunkt des Auftretens), description=Estimated or actual date/time that signs or symptoms of the problem/diagnosis were first observed., comment=Data captured/imported as "Age at onset" 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='Sekundärcode']/data[at0001]/items[at0003], code=at0003, itemType=ELEMENT, level=3, text=Feststellungsdatum, description=Estimated or actual date/time the diagnosis or problem was recognised by a healthcare professional., comment=Partial dates are acceptable. 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=1..1, occurencesText=Mandatory, 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='Sekundärcode']/data[at0001]/items[at0005], code=at0005, itemType=ELEMENT, level=3, text=Severity, description=An assessment of the overall severity of the problem or diagnosis., comment=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., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  •  
  •  
  •  
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Sekundärcode']/data[at0001]/items[openEHR-EHR-CLUSTER.lebensphase.v0], code=at0000, itemType=CLUSTER, level=3, text=Lebensphase, description=Beschreibung des ungefähren Alters, wann die Erkrankung durchgemacht wurde. Ungefähre Angabe des Alters, da häufig keine genaue Angabe des Zeitpunktes (klinisch relevanter Zeitraum) der Erkrankung möglich ist, vor allem wenn die Diagnose nicht durch die eintragende ärztliche Person erfolgt., 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='Sekundärcode']/data[at0001]/items[openEHR-EHR-CLUSTER.lebensphase.v0]/items[at0001], code=at0001, itemType=ELEMENT, level=4, text=Beginn, description=Lebensphase, in der das Problem / eine Erkrankung zum ersten Mal aufgetreten ist / diagnostiziert wurde, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: http://snomed.info/sct
Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=http://fhir.de/ValueSet/lebensphase-de
  • 41847000 | Adulthood 
  • 263659003 | Adolescence 
  • 255398004 | Childhood 
  • 713153009 | Toddler 
  • 3658006 | Infancy 
  • 255407002 | Neonatal 
  • 271872005 | Old age 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Sekundärcode']/data[at0001]/items[openEHR-EHR-CLUSTER.lebensphase.v0]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Ende, description=Lebensphase, in der das Problem / eine Erkrankung zum letzen Mal aufgetreten ist / zuletzt diagnostiziert wurde, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: http://snomed.info/sct
Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=http://fhir.de/ValueSet/lebensphase-de
  • 41847000 | Adulthood 
  • 263659003 | Adolescence 
  • 255398004 | Childhood 
  • 713153009 | Toddler 
  • 3658006 | Infancy 
  • 255407002 | Neonatal 
  • 271872005 | Old age 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Sekundärcode']/data[at0001]/items[openEHR-EHR-CLUSTER.multiple_coding_icd10gm.v1], code=at0000, itemType=CLUSTER, level=3, text=Multiple_coding_ICD-10-GM, description=Additional codes for postcoordinated ICD-10-GM codes according to the Cross-Star system., 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='Sekundärcode']/data[at0001]/items[openEHR-EHR-CLUSTER.multiple_coding_icd10gm.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=4, text=Multiple coding identifier, description=ICD-10 GM additional codes according to cross-star system, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Coded Text
    • † 
    • * 
    • ! 
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Sekundärcode']/data[at0001]/items[at0030], code=at0030, itemType=ELEMENT, level=3, text=Klinisch relevanter Zeitraum (Zeitpunkt der Genesung), description=Estimated or actual date/time of resolution or remission for this problem or diagnosis, as determined by a healthcare professional., comment=Partial dates are acceptable. 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 resolution" 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='Sekundärcode']/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v2], code=at0000, itemType=CLUSTER, level=3, text=Klinischer Status, 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='Sekundärcode']/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v2]/items[at0003], code=at0003, itemType=ELEMENT, level=4, text=Klinischer Status, description=Category that supports division of problems and diagnoses into Active or Inactive problem lists., comment=The Active/Inactive and Current/Past data elements have similar clinical impact but represent slightly different semantics. Both are actively used in different clinical settings, but usually not together. If a Current/Past qualifier is recorded, then this data element is likely to be redundant. An exception where a condition can be current but inactive is asthma that is not causing acute symptoms., 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=http://hl7.org/fhir/ValueSet/condition-clinical
  • Active 
  • Inactive 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Sekundärcode']/data[at0001]/items[at0073], code=at0073, itemType=ELEMENT, level=3, text=Diagnosesicherheit, 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=Terminology: local https://fhir.kbv.de/CodeSystem/KBV_CS_SFHIR_ICD_DIAGNOSESICHERHEIT
Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=https://fhir.kbv.de/ValueSet/KBV_VS_SFHIR_ICD_DIAGNOSESICHERHEIT
  • Suspected 
  • Probable 
  • Confirmed 
  • A | ausgeschlossen 
  • G | gesicherte Diagnose 
  • V | Verdacht auf / zum Ausschluss von 
  • Z | Zustand nach 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Sekundärcode']/data[at0001]/items[at0069], code=at0069, itemType=ELEMENT, level=3, text=Diagnoseerläuterung, description=Additional narrative about the problem or diagnosis not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Sekundärcode']/protocol[at0032], code=at0032, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=2, text=Protocol, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='Sekundärcode']/protocol[at0032]/items[at0070], code=at0070, itemType=ELEMENT, level=3, text=Letztes Dokumentationsdatum, description=The date this problem or diagnosis was last updated., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null]], templateType=normal]