TEMPLATE Patient Characteristics LEOSS (Patient Characteristics LEOSS)

TEMPLATE ID	Patient Characteristics LEOSS
Concept	Patient Characteristics LEOSS
Description	Zur Repräsentation der Patienten Charakteristika aus den LEOSS-Datensatz.
Purpose	Zur Repräsentation der Patienten Charakteristika aus den LEOSS-Datensatz.
References
Other Details (Language Independent)	MetaDataSet:Sample Set : Template metadata sample set
Language used	en
Citeable Identifier	1246.169.792
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
Identifikator des Laborbefunds	Identifikator des Laborbefunds: 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. Zwischenbefund Endbefund
Case identification	Case identification: To record case identification details for public health purposes.
Case identifier	Case identifier: The identifier of this case.
Ethnischer Hintergrund	Ethnischer Hintergrund: Detaillierte Beschreibung des ethnischen Hintergrundes einer Person, um Besondheiten, wie Medikamentenverträglichkeit oder Gesundheitsrisiken abzubilden.
Ethnischer Hintergrund	Ethnischer Hintergrund: Der ethnische Hintergrund einer Person. African & African American American Asian & Pacific Islander Caucasian Hispanic or Latino Unknown
Address	Address: Address details aligned with FHIR resource.
Country	Country: Country - a nation as commonly understood or generally accepted.
Demographic Information	Demographic Information: A generic section header which should be renamed in a template to suit a specific clinical context.
Age	Age: Details about the age 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
Alterskategorie	Alterskategorie: Additional narrative about the age of an individual, not captured in other fields. For example: pre-term delivery <1 year 1-3 years 4-8 years 9-14 years 15-17 years 18-25 years 26-35 years 36-45 years 46-55 years 56-65 years 66-75 years 76-85 years >85 years
Gender	Gender: Details about the gender of an individual.
Data
Administrative gender	Administrative gender: The gender of an individual used for administrative purposes. This element is what most systems today describes as 'Sex' or 'Gender'. For example 'Male', 'Female', 'Other'. This aligns with HL7 FHIR 'Person.gender'. Coding with a terminology is recommended, where possible. male female divers not specified
General Information on consultation	General Information on consultation: A generic section header which should be renamed in a template to suit a specific clinical context.
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. COVID-19
Date/time clinically recognised	Date/time clinically recognised: Estimated or actual date/time the diagnosis or problem was recognised by a healthcare professional. 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.
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. Not recovered recovered dead from covid19 Dead from other causes Unknown
Date/time of resolution	Date/time of resolution: Estimated or actual date/time of resolution or remission for this problem or diagnosis, as determined by a healthcare professional. 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.
Protocol
Address	Address: Address details aligned with FHIR resource.
Region of diagnosis	Region of diagnosis: The name of the administrative area (county).
Postal code	Postal code: A postal code designating a region defined by the postal service.
Country of diagnosis	Country of diagnosis: Country - a nation as commonly understood or generally accepted.
Service	Service: A general clinical activity carried out for the patient to receive a specified service, advice or care from an expert healthcare provider.
Description
Service name	Service name: Identification of the clinical service to be/being carried out. Coding of the specific service name with a terminology is preferred, where possible. Consultation
Reason for consultation	Reason for consultation: Reason that the activity or care pathway step for the identified service was carried out. For example: the reason for the cancellation or suspension of the service.
Management/treatment screening questionnaire	Management/treatment screening questionnaire: An individual- or self-reported questionnaire screening for management or treatment carried out.
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
Availability of biomaterial	Availability of biomaterial: The reason for overall screening. For example: screening for an infectious disease, such as SARS-COV-2. Serum Blood Cells Stool Cerebrospinal fluid other Not done/Unknown
Informed Consent	Informed Consent: Record of status and details of informed consent from a patient (or patient's agent) for a proposed procedure, trial or other healthcare-related activity (including treatments and investigations), based upon a clear appreciation and understanding of the facts, implications, and possible future consequences by the patient or patient's agent.
Description
Procedure/Trial/Activity	Procedure/Trial/Activity: Identification of the procedure, clinical trial or healthcare-related activity (including correct side/correct site, where appropriate) against which the consent status and details are recorded. LEOSS
Consent Description	Consent Description: Narrative description of the informed consent required or recorded prior to performing the proposed procedure, clinical trial or healthcare-related activity. Yes, to share data Yes, to share biometarial sample No Unknown
Patient admission	Patient admission: Used for admitted patient only. It signals the beginning of a patient's stay in a health care facility.
Data
Admit source	Admit source: Detailed description of the mode of admission. inpatient stay ICU
Admit date/time	Admit date/time: Date/time the patient was admitted.
Discharge summary	Discharge summary: Used for discharged patient only.
Data
Discharge status	Discharge status: Discharge status.
Discharge date/time	Discharge date/time: Date/Time the patiente was discharge.
Lenght of stay	Lenght of stay: Lenght of stay on hospital Units: yr (UCUM: a) h mo wk d
Stage at diagnosis	Stage at diagnosis: Comments uncomplicated phase complicated phase critical phase recovery phase
Ventilator observations	Ventilator observations: Observation findings returned from ventilator device.
Data
Any event	Any event: *
Data
Beatmungsstunden	Beatmungsstunden: Die Beatmungsstunden sind als Gesamtbeatmungszeit für den Krankenhausfall entsprechend DKR anzu-geben.
Beatmungsstunden	Beatmungsstunden: Gesamtanzahl der Stunden mit künstlicher Beatmung >=0 h
Further Conditions	Further Conditions: A generic section header which should be renamed in a template to suit a specific clinical context.
Ausschluss Rauchen	Ausschluss Rauchen: 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
Adverse reaction substance	Adverse reaction substance: The Adverse reaction substance/agent to which the 'Exclusion statement' applies. For example: 'Penicillin', 'Peanuts' or 'Latex'. Rauchen
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. Current smoker Former smoker
Overall description	Overall description: Narrative summary about the individual's overall tobacco smoking pattern and history. Use this data element to record a narrative description of the tobacco smoking habits for this individual or to incorporate unstructured tobacco smoking information from existing or legacy clinical systems into an archetyped format. 1-10 pack years 11-20 pack years > 21 pack years Smoker, unkown
Ausschluss Rauchen e-Cigarrettes	Ausschluss Rauchen e-Cigarrettes: 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
Adverse reaction substance	Adverse reaction substance: The Adverse reaction substance/agent to which the 'Exclusion statement' applies. For example: 'Penicillin', 'Peanuts' or 'Latex'. Rauchen e-Cigarrettes
Zusammenfassung Rauchverhalten e-Cigarrettes	Zusammenfassung Rauchverhalten e-Cigarrettes: 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. Current smoker
Overall description	Overall description: Narrative summary about the individual's overall tobacco smoking pattern and history. Use this data element to record a narrative description of the tobacco smoking habits for this individual or to incorporate unstructured tobacco smoking information from existing or legacy clinical systems into an archetyped format. e-Cigarrettes
Body mass index	Body mass index: Calculated measurement which compares a person's weight and height. Body Mass Index is a calculated ratio describing how an individual's body weight relates to the weight that is regarded as normal, or desirable, for the individual's height.
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
Body mass index	Body mass index: Index describing ratio of weight to height. 0..1000; 0..1000 Units: kg/m² (UCUM: kg/m2) [lb_av]/[in_i]2
Immunosuppressive therapy (last 3 months)	Immunosuppressive therapy (last 3 months): Questionnaire information about the administration or consumption of any medication, a specified medication or type/class of medication at or during an event such as a specific point in time or duration of time.
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
Specific medication class	Specific medication class: Details about the use of a specific class of medication.
Medication class name	Medication class name: Name of class or type of medication. For example: opioid; or analgesic. Immunosuppressive therapy (last 3 months)
Medication class in use?	Medication class in use?: Is the individual using the medication, class or type of medication at or during the identified event? In use Not in use Unknown
Kennzeichnung Erregernachweis	Kennzeichnung Erregernachweis: Dokumentation eines Nachweis eines Erregers bei einem Patienten.
Data
Erregernachweis	Erregernachweis: Bei dem Patienten wurde ein Erreger nachgewiesen.
Erregername	Erregername: Der Name des nachgewiesenen Erregers bei dem Patienten. None MRSA VRE VRE-LTD 3MGRN 4MRGN Other Unknown
Zeitpunkt der Kennzeichnung	Zeitpunkt der Kennzeichnung: *
Protocol
Zuletzt aktualisiert	Zuletzt aktualisiert: Datum der letzten Aktualisierung der Diagnose bzw. des Problems.
Comorbidities	Comorbidities: A generic section header which should be renamed in a template to suit a specific clinical context.
Cardiovascular Comorbidities	Cardiovascular Comorbidities: An individual- or self-reported questionnaire screening for symptoms and signs.
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
Specific symptom/sign	Specific symptom/sign: Grouping of data elements related to screening for a single symptom or sign.
Symptom or sign name	Symptom or sign name: Name of the symptom or sign being screened. Coronary artery disease Myocardial infarction Hypertension Atrial fibrillation AV block Aortic stenosis Peripher vascular disease Myocarditis Carotid arterial disease Chronic heart failure Thrombembolic diseases (DVT, PE)
Presence?	Presence?: Presence of the symptom or sign. Present Absent Unknown
Problem/Diagnose heart failure	Problem/Diagnose heart failure: 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. heart failure
Beschreibung Prior heart failure at diagnosis	Beschreibung Prior heart failure at diagnosis: 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. None < 1 year 1-5 years > 5 years unknown
Schweregrad Ejection fraction	Schweregrad Ejection fraction: 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. <20% 20-30% 31%-40% 41% -55% > 55 % not done unknown
Date/time of resolution	Date/time of resolution: Estimated or actual date/time of resolution or remission for this problem or diagnosis, as determined by a healthcare professional. 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.
New York Heart Association functional classification	New York Heart Association functional classification: A simple method of classifying the extent of heart failure, as defined by the New York Heart Association.
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
Functional capacity	Functional capacity: Assessment of heart failure based on how a patient with cardiac disease feels during physical activity. Class III and the Class III subtypes, IIIa and IIIb, are intended to be mutually exclusive but are included in this internal code set for completeness. Within a template either the Class III alone or both of the subtypes, IIIa and IIIb, should be set to inactive. Class I Class II Class III Class IV
Pulmonary comobidities	Pulmonary comobidities: An individual- or self-reported questionnaire screening for symptoms and signs.
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
Specific symptom/sign	Specific symptom/sign: Grouping of data elements related to screening for a single symptom or sign.
Symptom or sign name	Symptom or sign name: Name of the symptom or sign being screened. Asthma COPD Other chronic pulmonary diseases
Presence?	Presence?: Presence of the symptom or sign. Present Absent Unknown
Neurological comorbidities	Neurological comorbidities: An individual- or self-reported questionnaire screening for symptoms and signs.
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
Specific symptom/sign	Specific symptom/sign: Grouping of data elements related to screening for a single symptom or sign.
Symptom or sign name	Symptom or sign name: Name of the symptom or sign being screened. Hemiplegia Dementia Cerebrovascular disease, stroke, TIA Motoneuron diseases Movement disorder Multiple sclerosis Myasthenia gravis Neuromyelitis optica spectrum disorder (NMOSD) Other neurological autoimmune diseases Other prior neurological diagnosis
Presence?	Presence?: Presence of the symptom or sign. Present Absent Unknown
Hemato/oncological comorbidities	Hemato/oncological comorbidities: An individual- or self-reported questionnaire screening for symptoms and signs.
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
Specific symptom/sign	Specific symptom/sign: Grouping of data elements related to screening for a single symptom or sign.
Symptom or sign name	Symptom or sign name: Name of the symptom or sign being screened. Leukemia Lymphoma Solid tumor Solid tumor, metastasized Stem cell transplantation
Presence?	Presence?: Presence of the symptom or sign. Present Absent Unknown
Other comorbidities	Other comorbidities: An individual- or self-reported questionnaire screening for symptoms and signs.
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
Specific symptom/sign	Specific symptom/sign: Grouping of data elements related to screening for a single symptom or sign.
Symptom or sign name	Symptom or sign name: Name of the symptom or sign being screened. Connective tissue disase Peptic ulcer disease Chronic liver disease Liver cirrhosis Diabetes, no end-organ damage Diabetes, with end-organ damage Acute kidney injury Chronic kidney disease On dialysis Organ transplantation Rheumatic disease HIV/AIDS
Presence?	Presence?: Presence of the symptom or sign. Present Absent Unknown