diff --git a/aom/src/main/java/com/nedap/archie/aom/primitives/CTerminologyCode.java b/aom/src/main/java/com/nedap/archie/aom/primitives/CTerminologyCode.java index 5a0dd265d..b418e1253 100644 --- a/aom/src/main/java/com/nedap/archie/aom/primitives/CTerminologyCode.java +++ b/aom/src/main/java/com/nedap/archie/aom/primitives/CTerminologyCode.java @@ -173,9 +173,9 @@ public boolean cConformsTo(CObject other, BiFunction rm } for (String value : valueSet) { //TODO: redefine validation to actually work here! -// if (!otherValueSet.contains(value)) { -// return false; -// } + if (!otherValueSet.contains(value)) { + return false; + } } return true; } else { diff --git a/better-template/build.gradle b/better-template/build.gradle new file mode 100644 index 000000000..948b679ba --- /dev/null +++ b/better-template/build.gradle @@ -0,0 +1,15 @@ +description = "A parser and converter for the Better Systems JSON template format" + +dependencies { + compile project(':grammars') + compile project(':base') + compile project(':aom') + compile project(':bmm') + compile project(':path-queries') + compile project(':utils') + compile project(':tools') + compile project(':openehr-rm') + compile project(':archie-utils') + compile project(':i18n') + compile project(':referencemodels') +} diff --git a/better-template/src/main/java/com/nedap/archie/template/betterjson/ArchetypeTermFixer.java b/better-template/src/main/java/com/nedap/archie/template/betterjson/ArchetypeTermFixer.java new file mode 100644 index 000000000..79b006edb --- /dev/null +++ b/better-template/src/main/java/com/nedap/archie/template/betterjson/ArchetypeTermFixer.java @@ -0,0 +1,196 @@ +package com.nedap.archie.template.betterjson; + +import com.nedap.archie.aom.Archetype; +import com.nedap.archie.aom.CArchetypeRoot; +import com.nedap.archie.aom.CAttribute; +import com.nedap.archie.aom.CComplexObject; +import com.nedap.archie.aom.CObject; +import com.nedap.archie.aom.CPrimitiveObject; +import com.nedap.archie.aom.Template; +import com.nedap.archie.aom.TemplateOverlay; +import com.nedap.archie.aom.terminology.ArchetypeTerm; +import com.nedap.archie.aom.terminology.ArchetypeTerminology; +import com.nedap.archie.aom.terminology.ValueSet; +import com.nedap.archie.aom.utils.AOMUtils; +import com.nedap.archie.aom.utils.NodeIdUtil; +import com.nedap.archie.base.Interval; +import com.nedap.archie.flattener.InMemoryFullArchetypeRepository; + +import java.util.ArrayList; +import java.util.LinkedHashMap; +import java.util.List; +import java.util.regex.Pattern; + +public class ArchetypeTermFixer { + + private String originalLanguage; + + public void fixTerms(Archetype archetype, FlatArchetypeProvider repo) { + originalLanguage = archetype.getOriginalLanguage().getCodeString(); + addTerminologyIfNotPresent(archetype); + fixTerms(archetype,repo, archetype.getDefinition()); + fixValueSetCodes(archetype, repo); + + removeUntranslatedLanguages(archetype); + + if(archetype instanceof Template) { + Template template = (Template) archetype; + for(TemplateOverlay overlay:template.getTemplateOverlays()) { + addTerminologyIfNotPresent(overlay); + fixTerms(overlay, repo, overlay.getDefinition()); + fixValueSetCodes(overlay, repo); + } + } + } + + private void fixValueSetCodes(Archetype archetype, FlatArchetypeProvider repo) { + String language = originalLanguage; + if(!archetype.getTerminology().getTermDefinitions().containsKey(originalLanguage)) { + language = archetype.getTerminology().getTermDefinitions().keySet().iterator().next(); + } + if(archetype.getTerminology() != null && archetype.getTerminology().getValueSets() != null) { + for(String code:archetype.getTerminology().getValueSets().keySet()) { + if(!archetype.getTerminology().getTermDefinitions().get(language).containsKey(code) && + AOMUtils.getSpecializationDepthFromCode(code) == archetype.specializationDepth()) { + Archetype flatParent = repo.getFlatArchetype(archetype.getParentArchetypeId()); + createTermForNewCodeWithFlatParent(archetype, code, flatParent); + } + for(String valueCode:archetype.getTerminology().getValueSets().get(code).getMembers()) { + if(!archetype.getTerminology().getTermDefinitions().get(language).containsKey(valueCode) && + AOMUtils.getSpecializationDepthFromCode(valueCode) == archetype.specializationDepth()) { + Archetype flatParent = repo.getFlatArchetype(archetype.getParentArchetypeId()); + createTermForNewCodeWithFlatParent(archetype, valueCode, flatParent); + } + } + } + } + } + + private void addTerminologyIfNotPresent(Archetype archetype) { + if(archetype.getTerminology() == null) { + archetype.setTerminology(new ArchetypeTerminology()); + } + if(archetype.getTerminology().getTermDefinitions().isEmpty()) { + archetype.getTerminology().getTermDefinitions().put(originalLanguage, new LinkedHashMap<>()); + } + } + + /** If any languages do not exist in the terminology, remove from translations*/ + private void removeUntranslatedLanguages(Archetype archetype) { + if(archetype.getTranslations() == null) { + return; + } + List toRemove = new ArrayList<>(); + for(String translation:archetype.getTranslations().keySet()) { + if(archetype.getTerminology() != null && !archetype.getTerminology().getTermDefinitions().containsKey(translation)) { + toRemove.add(translation); + } + } + if(!toRemove.isEmpty()) { + for(String translation:toRemove) { + archetype.getTranslations().remove(translation); + } + } + } + + private void fixTerms(Archetype archetype, FlatArchetypeProvider repo, CComplexObject cObject) { + String language = originalLanguage; + if(!archetype.getTerminology().getTermDefinitions().containsKey(originalLanguage)) { + language = archetype.getTerminology().getTermDefinitions().keySet().iterator().next(); + } + if(cObject instanceof CArchetypeRoot) { + if(!archetype.getTerminology().getTermDefinitions().get(language).containsKey(cObject.getNodeId()) && + archetype.specializationDepth() == AOMUtils.getSpecializationDepthFromCode(cObject.getNodeId()) + ) { + Archetype referencedArchetype = repo.getFlatArchetype(((CArchetypeRoot) cObject).getArchetypeRef()); + createTermForNewCodeWithRoot(archetype, cObject.getNodeId(), referencedArchetype); + //TODO: fix lots of problems where node ids are set wrong, for example id2.1 to set the occurrences of id2 to {0} is a problem! + } + } else if(cObject instanceof CComplexObject) { + + if(!archetype.getTerminology().getTermDefinitions().get(language).containsKey(cObject.getNodeId()) && + archetype.specializationDepth() == AOMUtils.getSpecializationDepthFromCode(cObject.getNodeId()) + ) { + Archetype flatParent = repo.getFlatArchetype(archetype.getParentArchetypeId()); + createTermForNewCodeWithFlatParent(archetype, cObject.getNodeId(), flatParent); + //TODO: fix lots of problems where node ids are set wrong, for example id2.1 to set the occurrences of id2 to {0} is a problem! + } + } + for(CAttribute attribute:cObject.getAttributes()) { + fixTerms(archetype, repo, attribute); + } + } + + private void fixTerms(Archetype archetype, FlatArchetypeProvider repo, CAttribute cAttribute) { + + for(CObject cObject:cAttribute.getChildren()) { + if(cObject instanceof CComplexObject) { + fixTerms(archetype, repo, (CComplexObject) cObject); + } + } + } + + private static Pattern synthesizedCodesPattern = Pattern.compile("(id)(0\\.)*9[0-9][0-9][0-9](\\.[0-9]*)*"); + + private void createTermForNewCodeWithRoot(Archetype archetype, String code, Archetype referencedArchetype) { + if(!synthesizedCodesPattern.matcher(code).matches()) { + //if(cObject.getParent().isMultiple()) { + for (String language : archetype.getTerminology().getTermDefinitions().keySet()) { + //TODO: add new archetype term to conversion log? + + ArchetypeTerm newTerm = new ArchetypeTerm(); + newTerm.setCode(code); + ArchetypeTerm rootTerm = null; + if (referencedArchetype != null) { + rootTerm = referencedArchetype.getTerm(referencedArchetype.getDefinition(), language); + if(rootTerm == null) { + rootTerm = referencedArchetype.getDefinition().getTerm(); + } + if(rootTerm == null) { + //yeas this is persistent + rootTerm = referencedArchetype.getTerminology().getTermDefinition("en", "id1"); + } + } + + newTerm.setText(rootTerm == null ? "* missing code" : rootTerm.getText()); + newTerm.setDescription(rootTerm == null ? "* missing code" : rootTerm.getDescription()); + archetype.getTerminology().getTermDefinitions().get(language).put(newTerm.getCode(), newTerm); + + } + } + // } + } + + private void createTermForNewCodeWithFlatParent(Archetype archetype, String code, Archetype flatParent) { + if(!synthesizedCodesPattern.matcher(code).matches()) { + //TODO: better would be, but difficult to do correctly: + // if(cObject.getParent().isMultiple()) { + for (String language : archetype.getTerminology().getTermDefinitions().keySet()) { + //TODO: add new archetype term to conversion log? + + ArchetypeTerm newTerm = new ArchetypeTerm(); + newTerm.setCode(code); + ArchetypeTerm parentTerm = null; + if (flatParent != null) { + ArchetypeTerminology parentTerminology = flatParent.getTerminology(); + if(parentTerminology != null) { + if(parentTerminology.getTermDefinitions().get(language) != null) { + parentTerm = parentTerminology.getTermDefinition(language, AOMUtils.codeAtLevel(code, flatParent.specializationDepth())); + } else { + parentTerm = parentTerminology.getTermDefinition(flatParent.getOriginalLanguage().getCodeString(), AOMUtils.codeAtLevel(code, flatParent.specializationDepth())); + } + } + } + + newTerm.setText(parentTerm == null ? "* missing code" : parentTerm.getText()); + newTerm.setDescription(parentTerm == null ? "* missing code" : parentTerm.getDescription()); + archetype.getTerminology().getTermDefinitions().get(language).put(newTerm.getCode(), newTerm); + + } + } + // } + } + + + +} diff --git a/better-template/src/main/java/com/nedap/archie/template/betterjson/ExternalTermBindingTranslationFixer.java b/better-template/src/main/java/com/nedap/archie/template/betterjson/ExternalTermBindingTranslationFixer.java new file mode 100644 index 000000000..faf885379 --- /dev/null +++ b/better-template/src/main/java/com/nedap/archie/template/betterjson/ExternalTermBindingTranslationFixer.java @@ -0,0 +1,95 @@ +package com.nedap.archie.template.betterjson; + +import com.nedap.archie.adl14.ADL14ConversionConfiguration; +import com.nedap.archie.adl14.ADL14ConversionUtil; +import com.nedap.archie.aom.Archetype; +import com.nedap.archie.aom.CAttribute; +import com.nedap.archie.aom.CObject; +import com.nedap.archie.aom.Template; +import com.nedap.archie.aom.TemplateOverlay; +import com.nedap.archie.aom.terminology.ArchetypeTerm; +import com.nedap.archie.base.terminology.TerminologyCode; +import com.nedap.archie.template.betterjson.parser.TemplateCTerminologyCode; +import com.nedap.archie.template.betterjson.parser.TemplateTermCode; + +import java.net.URI; +import java.net.URISyntaxException; +import java.util.Map; + +public class ExternalTermBindingTranslationFixer { + + public void fixTranslations(ADL14ConversionConfiguration config, Archetype archetype) { + fixInner(config, archetype); + if(archetype instanceof Template) { + Template template = (Template) archetype; + for(TemplateOverlay overlay:template.getTemplateOverlays()) { + fixInner(config, overlay); + } + } + } + + private void fixInner(ADL14ConversionConfiguration config, Archetype archetype) { + fixInner(config, archetype, archetype.getDefinition()); + } + + private void fixInner(ADL14ConversionConfiguration config, Archetype archetype, CObject cObject) { + + if(cObject instanceof TemplateCTerminologyCode) { + TemplateCTerminologyCode templateCode = (TemplateCTerminologyCode) cObject; + if(templateCode.getIncludedExternalTerminologyCodes() != null) { + for (TemplateTermCode templateTermCode : templateCode.getIncludedExternalTerminologyCodes()) { + if(templateTermCode.getValue() == null || templateTermCode.getCode() == null || templateTermCode.getTerminologyId() == null) { + System.out.println("STRANGE TERM CODE FOUND"); + } + try { + String value = templateTermCode.getValue(); + Map uris = archetype.getTerminology().getTermBindings().get(templateTermCode.getTerminologyId()); + URI uri = new ADL14ConversionUtil(config).convertToUri(TerminologyCode.createFromString(templateTermCode.getTerminologyId(), null, templateTermCode.getCode())); + String code = findTermbindingCode(uris, uri); + if(code != null) { + //add translation to terminology IF it was auto-generated + for(String language: archetype.getTerminology().getTermDefinitions().keySet()) { + Map terms = archetype.getTerminology().getTermDefinitions().get(language); + ArchetypeTerm term = terms.get(code); + if(term != null && term.getText().contains("translation not known")) { + term.setText(value); + term.setDescription(value); + } else { + term = new ArchetypeTerm(); + term.setCode(code); + term.setText(value); + term.setDescription(value); + terms.put(code, term); + } + } + } + } catch (URISyntaxException e) { + //not a big problem, just a term will be missing from the terminology. + e.printStackTrace(); + } + + } + } + } + for(CAttribute attribute:cObject.getAttributes()) { + fixInner(config, archetype, attribute); + } + + } + + private String findTermbindingCode(Map uris, URI uri) { + for(Map.Entry u:uris.entrySet()) { + if(u.getValue().equals(uri)) { + return u.getKey(); + } + } + return null; + } + + private void fixInner(ADL14ConversionConfiguration config, Archetype archetype, CAttribute attribute) { + + for(CObject child:attribute.getChildren()) { + fixInner(config, archetype, child); + } + } +} diff --git a/better-template/src/main/java/com/nedap/archie/template/betterjson/FlatArchetypeProvider.java b/better-template/src/main/java/com/nedap/archie/template/betterjson/FlatArchetypeProvider.java new file mode 100644 index 000000000..9478e4dba --- /dev/null +++ b/better-template/src/main/java/com/nedap/archie/template/betterjson/FlatArchetypeProvider.java @@ -0,0 +1,8 @@ +package com.nedap.archie.template.betterjson; + +import com.nedap.archie.aom.Archetype; + +public interface FlatArchetypeProvider { + + Archetype getFlatArchetype(String archetypeId); +} diff --git a/better-template/src/main/java/com/nedap/archie/template/betterjson/LanguageConsistencyFixer.java b/better-template/src/main/java/com/nedap/archie/template/betterjson/LanguageConsistencyFixer.java new file mode 100644 index 000000000..04a98da67 --- /dev/null +++ b/better-template/src/main/java/com/nedap/archie/template/betterjson/LanguageConsistencyFixer.java @@ -0,0 +1,43 @@ +package com.nedap.archie.template.betterjson; + +import com.nedap.archie.aom.Archetype; +import com.nedap.archie.aom.Template; +import com.nedap.archie.aom.TemplateOverlay; +import com.nedap.archie.aom.terminology.ArchetypeTerm; +import com.nedap.archie.aom.terminology.ArchetypeTerminology; +import com.nedap.archie.archetypevalidator.ErrorType; + +import java.util.List; + +public class LanguageConsistencyFixer { + + public void fixLanguageConsistency(Archetype archetype) { + + fixInner(archetype); + if(archetype instanceof Template) { + Template template = (Template) archetype; + for(TemplateOverlay overlay:template.getTemplateOverlays()) { + fixLanguageConsistency(overlay); + } + } + + } + + private void fixInner(Archetype archetype) { + + List codes = archetype.getTerminology().allCodes(); + for(String code:codes) { + for (String language : archetype.getTerminology().getTermDefinitions().keySet()) { + if(!archetype.getTerminology().getTermDefinitions().get(language).containsKey(code)) { + + ArchetypeTerm term = new ArchetypeTerm(); + term.setCode(code); + term.setText("translation missing"); + term.setDescription("translation missing"); + archetype.getTerminology().getTermDefinitions().get(language).put(code, term); + } + } + } + } + +} diff --git a/better-template/src/main/java/com/nedap/archie/template/betterjson/MultiplicityFixer.java b/better-template/src/main/java/com/nedap/archie/template/betterjson/MultiplicityFixer.java new file mode 100644 index 000000000..5da18257e --- /dev/null +++ b/better-template/src/main/java/com/nedap/archie/template/betterjson/MultiplicityFixer.java @@ -0,0 +1,92 @@ +package com.nedap.archie.template.betterjson; + +import com.nedap.archie.adlparser.modelconstraints.ReflectionConstraintImposer; +import com.nedap.archie.aom.Archetype; +import com.nedap.archie.aom.CAttribute; +import com.nedap.archie.aom.CComplexObject; +import com.nedap.archie.aom.CObject; +import com.nedap.archie.aom.Template; +import com.nedap.archie.aom.TemplateOverlay; +import com.nedap.archie.aom.utils.AOMUtils; +import com.nedap.archie.archetypevalidator.ErrorType; +import com.nedap.archie.flattener.InMemoryFullArchetypeRepository; +import com.nedap.archie.rminfo.MetaModel; +import com.nedap.archie.rminfo.MetaModels; +import org.openehr.utils.message.I18n; + +public class MultiplicityFixer { + + private MetaModels combinedModels; + + public void fixMultiplicity(MetaModels metaModels, Archetype archetype, FlatArchetypeProvider repo) { + + combinedModels = metaModels; + metaModels.selectModel(archetype); + + fixMultiplicity(archetype,repo, archetype.getDefinition()); + + + if(archetype instanceof Template) { + Template template = (Template) archetype; + for(TemplateOverlay overlay:template.getTemplateOverlays()) { + fixMultiplicity(overlay, repo, overlay.getDefinition()); + } + } + } + + private void fixMultiplicity(Archetype archetype, FlatArchetypeProvider repo, CObject cObject) { + for(CAttribute attribute:cObject.getAttributes()) { + fixMultiplicity(archetype, repo, attribute); + } + } + + private void fixMultiplicity(Archetype archetype, FlatArchetypeProvider repo, CAttribute cAttribute ) { + for(CObject cObject:cAttribute.getChildren()) { + fixMultiplicity(archetype, repo, cObject); + } + Archetype flatParent = archetype.getParentArchetypeId() == null ? + null : + repo.getFlatArchetype(archetype.getParentArchetypeId()); + if(flatParent == null && cAttribute.getDifferentialPath() != null) { + return; + } + CObject owningObject = cAttribute.getParent(); + if(cAttribute.getDifferentialPath() != null) { + CAttribute differentialPathFromParent = (CAttribute) AOMUtils.getDifferentialPathFromParent(flatParent, cAttribute); + owningObject = differentialPathFromParent == null ? null : differentialPathFromParent.getParent(); + } + if(owningObject != null) { + if (!combinedModels.attributeExists(owningObject.getRmTypeName(), cAttribute.getRmAttributeName())) { + //This is an error that cannot be fixed + } else { + CAttribute defaultAttribute = new ReflectionConstraintImposer(combinedModels).getDefaultAttribute(owningObject.getRmTypeName(), cAttribute.getRmAttributeName()); + if(defaultAttribute != null) { + if(cAttribute.getExistence() != null) { + if(!defaultAttribute.getExistence().contains(cAttribute.getExistence())) { + if(!archetype.isSpecialized() && defaultAttribute.getExistence().equals(cAttribute.getExistence())) { + //does not pass strict validation, but nobody cares, will be deleted in default remover anyway + } else { + //this is an actual error. It can only be 0..0 or 1..1 in parent in this case, so remove the existence here + cAttribute.setExistence(null); + } + } + } + if(defaultAttribute.isMultiple()) { + if(defaultAttribute.getCardinality() != null && cAttribute.getCardinality() != null && cAttribute.getCardinality().getInterval() != null && !defaultAttribute.getCardinality().contains(cAttribute.getCardinality())){ + if(defaultAttribute.getCardinality().equals(cAttribute.getCardinality())) { + //no-one cares about this, will be removed + } else { + ///TODO: cardinality problem. Fixme! not a problem so far ... + } + } + } else { + if(cAttribute.getCardinality() != null) { + //TODO: fix? + } + } + } + } + + } + } +} diff --git a/better-template/src/main/java/com/nedap/archie/template/betterjson/NodeIdFixer.java b/better-template/src/main/java/com/nedap/archie/template/betterjson/NodeIdFixer.java new file mode 100644 index 000000000..0b7fd95e0 --- /dev/null +++ b/better-template/src/main/java/com/nedap/archie/template/betterjson/NodeIdFixer.java @@ -0,0 +1,90 @@ +package com.nedap.archie.template.betterjson; + +import com.nedap.archie.aom.Archetype; +import com.nedap.archie.aom.ArchetypeModelObject; +import com.nedap.archie.aom.CAttribute; +import com.nedap.archie.aom.CObject; +import com.nedap.archie.aom.Template; +import com.nedap.archie.aom.TemplateOverlay; +import com.nedap.archie.aom.terminology.ArchetypeTerminology; +import com.nedap.archie.aom.utils.AOMUtils; +import com.nedap.archie.aom.utils.NodeIdUtil; +import com.nedap.archie.archetypevalidator.ErrorType; +import com.nedap.archie.flattener.InMemoryFullArchetypeRepository; +import org.openehr.utils.message.I18n; + +public class NodeIdFixer { + + private Archetype archetype; + private Archetype flatParent; + + public void fixNodeIds(Archetype archetype, FlatArchetypeProvider repo) { + this.archetype = archetype; + if(archetype.getParentArchetypeId() != null) { + this.flatParent = repo.getFlatArchetype(archetype.getParentArchetypeId()); + } + + fixNodeId(archetype.getDefinition()); + + if(archetype instanceof Template) { + Template template = (Template) archetype; + + for(TemplateOverlay overlay:template.getTemplateOverlays()) { + this.archetype = overlay; + if(archetype.getParentArchetypeId() != null) { + this.flatParent = repo.getFlatArchetype(overlay.getParentArchetypeId()); + } + fixNodeId(overlay.getDefinition()); + } + } + } + + private void fixNodeId(CObject cObject) { + + if (cObject.isRootNode() || !cObject.getParent().isSecondOrderConstrained()) { + if (AOMUtils.getSpecializationDepthFromCode(cObject.getNodeId()) <= flatParent.specializationDepth() + || new NodeIdUtil(cObject.getNodeId()).isRedefined()) { + if (!AOMUtils.isPhantomPathAtLevel(cObject.getPathSegments(), flatParent.specializationDepth())) { + String flatPath = AOMUtils.pathAtSpecializationLevel(cObject.getPathSegments(), flatParent.specializationDepth()); + CObject parentCObject = getCObject(flatParent.itemAtPath(flatPath)); + + if (parentCObject != null) { + if (cObject.isProhibited()) { + if (!parentCObject.getNodeId().equals(cObject.getNodeId())) { + // System.out.println("fixing node id " + cObject.getNodeId() + " for archetype " + archetype.getArchetypeId()); + String oldNodeId = cObject.getNodeId(); + cObject.setNodeId(parentCObject.getNodeId()); + ArchetypeTerminology terminology = cObject.getArchetype().getTerminology(); + for(String language:terminology.getTermDefinitions().keySet()) { + terminology.getTermDefinitions().get(language).remove(oldNodeId); + } + } + } + } + } + } + } + + for(CAttribute attribute:cObject.getAttributes()) { + fixNodeId(attribute); + } + } + + private void fixNodeId(CAttribute cAttribute) { + for(CObject cObject:cAttribute.getChildren()) { + fixNodeId(cObject); + } + } + + private CObject getCObject(ArchetypeModelObject archetypeModelObject) { + if(archetypeModelObject instanceof CAttribute) { + CAttribute attribute = (CAttribute) archetypeModelObject; + if(attribute.getChildren().size() == 1) { + return attribute.getChildren().get(0); + }//TODO: add a numeric identifier to the getPath() method in CObject so this can be deleted and actually works in all cases! + } else if(archetypeModelObject instanceof CObject) { + return (CObject) archetypeModelObject; + } + return null; + } +} diff --git a/better-template/src/main/java/com/nedap/archie/template/betterjson/SpecializedTerminologyCodeFixer.java b/better-template/src/main/java/com/nedap/archie/template/betterjson/SpecializedTerminologyCodeFixer.java new file mode 100644 index 000000000..2d8bf487f --- /dev/null +++ b/better-template/src/main/java/com/nedap/archie/template/betterjson/SpecializedTerminologyCodeFixer.java @@ -0,0 +1,182 @@ +package com.nedap.archie.template.betterjson; + +import com.google.common.collect.Lists; +import com.nedap.archie.adl14.ADL14NodeIDConverter; +import com.nedap.archie.adl14.log.ConvertedCodeResult; +import com.nedap.archie.aom.Archetype; +import com.nedap.archie.aom.ArchetypeModelObject; +import com.nedap.archie.aom.CAttribute; +import com.nedap.archie.aom.CObject; +import com.nedap.archie.aom.Template; +import com.nedap.archie.aom.TemplateOverlay; +import com.nedap.archie.aom.primitives.CTerminologyCode; +import com.nedap.archie.aom.terminology.ArchetypeTerm; +import com.nedap.archie.aom.terminology.ValueSet; +import com.nedap.archie.aom.utils.AOMUtils; + +import java.util.LinkedHashMap; +import java.util.Map; +import java.util.Optional; +import java.util.Set; + +/** + * Lots of errors in the better template where new value sets get created that should have been specialised codes. Fix that here. + */ +public class SpecializedTerminologyCodeFixer { + + Map convertedCodes; + + public void fixTerminologyCodes(Archetype archetype, FlatArchetypeProvider repo) { + fixInner(archetype, getFlatParent(archetype, repo)); + if(archetype instanceof Template) { + Template template = (Template) archetype; + for(TemplateOverlay overlay:template.getTemplateOverlays()) { + fixInner(overlay, getFlatParent(overlay, repo)); + } + } + + } + + private Archetype getFlatParent(Archetype archetype, FlatArchetypeProvider repo) { + Archetype flatParent = null; + if(archetype.getParentArchetypeId() != null) { + flatParent = repo.getFlatArchetype(archetype.getParentArchetypeId()); + } + return flatParent; + } + + private void fixInner(Archetype archetype, Archetype flatParent) { + if(flatParent == null) { + return; + } + convertedCodes = new LinkedHashMap<>(); + fixInner(archetype, archetype.getDefinition(), flatParent); + ADL14NodeIDConverter.convertTermDefinitions(archetype, convertedCodes); + } + + private void fixInner(Archetype archetype, CObject cObject, Archetype flatParent) { + if(cObject instanceof CTerminologyCode) { + CTerminologyCode cTerminologyCode = (CTerminologyCode) cObject; + if(cTerminologyCode.getConstraint() != null && cTerminologyCode.getConstraint().size() > 0) { + String constraint = cTerminologyCode.getConstraint().get(0); + String pathInParent = AOMUtils.pathAtSpecializationLevel(cObject.getPathSegments(), flatParent.specializationDepth()); + ArchetypeModelObject parentCObject = flatParent.itemAtPath(pathInParent); + if(AOMUtils.getSpecializationDepthFromCode(constraint) == archetype.specializationDepth()) { + if(parentCObject instanceof CTerminologyCode) { + fixCTerminologyCode(archetype, cTerminologyCode, constraint, (CTerminologyCode) parentCObject); + } else if (parentCObject instanceof CAttribute) { + CAttribute parentAttribute = (CAttribute) parentCObject; + Optional parent = parentAttribute.getChildren().stream().filter(a -> a instanceof CTerminologyCode).findFirst(); + if(parent.isPresent()) { + fixCTerminologyCode(archetype, cTerminologyCode, constraint, (CTerminologyCode) parent.get()); + } + } + } else if(AOMUtils.getSpecializationDepthFromCode(constraint) < archetype.specializationDepth() && + AOMUtils.isValueCode(constraint)) { + if(parentCObject instanceof CTerminologyCode) { + fixTerminologyCode2(archetype, flatParent, cTerminologyCode, constraint, (CTerminologyCode) parentCObject); + } else if (parentCObject instanceof CAttribute) { + CAttribute parentAttribute = (CAttribute) parentCObject; + Optional parent = parentAttribute.getChildren().stream().filter(a -> a instanceof CTerminologyCode).findFirst(); + if (parent.isPresent()) { + fixTerminologyCode2(archetype, flatParent, cTerminologyCode, constraint, (CTerminologyCode) parent.get()); + } + } + } + } + + } + for(CAttribute attribute:cObject.getAttributes()) { + fixInner(archetype, attribute, flatParent); + } + } + + private void fixTerminologyCode2(Archetype archetype, Archetype flatParent, CTerminologyCode cTerminologyCode, String constraint, CTerminologyCode parentCObject) { + CTerminologyCode codeInParent = parentCObject; + if (codeInParent.getConstraint() != null && codeInParent.getConstraint().size() > 0) { + String constraintInParent = codeInParent.getConstraint().get(0); + if (AOMUtils.isValueCode(constraint) && AOMUtils.isValueSetCode(constraintInParent)) { + //this is invalid. Let's fix it! + //current archetype a single code, parent archetype a value set + //let's assume the code is from the value set, otherwise the validator will check it anyway + String newCode = archetype.generateNextSpecializedIdCode(constraintInParent); + cTerminologyCode.getConstraint().set(0, newCode); + + ValueSet valueSet = new ValueSet(); + valueSet.setId(newCode); + valueSet.setMembers(Lists.newArrayList(constraint)); + archetype.getTerminology().getValueSets().put(newCode, valueSet); + + addTermForValueSet(archetype, flatParent.getTerm(codeInParent, constraintInParent, + flatParent.getOriginalLanguage() == null ? "en" : flatParent.getOriginalLanguage().getCodeString()), + valueSet); + + } + } + } + + private void fixCTerminologyCode(Archetype archetype, CTerminologyCode cTerminologyCode, String constraint, CTerminologyCode parentCObject) { + CTerminologyCode codeInParent = parentCObject; + if (codeInParent.getConstraint() != null && codeInParent.getConstraint().size() > 0) { + String constraintInParent = codeInParent.getConstraint().get(0); + if (AOMUtils.isValueSetCode(constraint) && AOMUtils.isValueSetCode(constraintInParent) && !AOMUtils.codesConformant(constraint, constraintInParent)) { + //this is invalid. Let's fix it! + + String newCode = archetype.generateNextSpecializedIdCode(constraintInParent); + + + ValueSet valueSet = archetype.getTerminology().getValueSets().remove(constraint); + if (valueSet != null) { + cTerminologyCode.getConstraint().set(0, newCode); + //else means validation error + archetype.getTerminology().getValueSets().put(newCode, valueSet); + valueSet.setId(newCode); + convertedCodes.put(constraint, new ConvertedCodeResult(constraint, newCode)); + } + + + + } else if (AOMUtils.isValueSetCode(constraintInParent) && AOMUtils.isValueCode(constraint)) { + System.out.println("fix more"); + } else if (AOMUtils.isValueCode(constraintInParent) && AOMUtils.isValueSetCode(constraint)) { + System.out.println("fix more"); + } + + } + } + + + private void addTermForValueSet(Archetype archetype, ArchetypeTerm termInParent, ValueSet valueSet) { + for(String language: archetype.getTerminology().getTermDefinitions().keySet()) { + //TODO: add new archetype term to conversion log! + + ArchetypeTerm newTerm = new ArchetypeTerm(); + newTerm.setCode(valueSet.getId()); + if(termInParent == null) { + newTerm.setText("unknown valueset name"); + newTerm.setDescription("unknown valueset name"); + } else { + newTerm.setText(termInParent.getText() + " (synthesised)"); + newTerm.setDescription(termInParent.getDescription() + " (synthesised)"); + } + archetype.getTerminology().getTermDefinitions().get(language).put(newTerm.getCode(), newTerm); + } + } + + private void fixInner(Archetype archetype, CAttribute cAttribute, Archetype flatParent) { + + for(CObject child:cAttribute.getChildren()) { + fixInner(archetype, child, flatParent); + } + } + + private ValueSet findValueSet(Archetype archetype, Set localCodes) { + for(ValueSet valueSet:archetype.getTerminology().getValueSets().values()) { + if(valueSet.getMembers().equals(localCodes)) { + return valueSet; + } + } + return null; + } + +} diff --git a/better-template/src/main/java/com/nedap/archie/template/betterjson/ValueSetFixer.java b/better-template/src/main/java/com/nedap/archie/template/betterjson/ValueSetFixer.java new file mode 100644 index 000000000..85abaef58 --- /dev/null +++ b/better-template/src/main/java/com/nedap/archie/template/betterjson/ValueSetFixer.java @@ -0,0 +1,49 @@ +package com.nedap.archie.template.betterjson; + +import com.nedap.archie.adl14.ADL14NodeIDConverter; +import com.nedap.archie.adl14.log.ConvertedCodeResult; +import com.nedap.archie.aom.Archetype; +import com.nedap.archie.aom.Template; +import com.nedap.archie.aom.TemplateOverlay; +import com.nedap.archie.aom.terminology.ValueSet; + +import java.util.ArrayList; +import java.util.LinkedHashMap; +import java.util.List; +import java.util.Map; + +/** converts value sets with old codes to new ones + * The ac-code is already ok + **/ +public class ValueSetFixer { + + + + public void convertValueSets(Archetype archetype) { + convert(archetype); + if(archetype instanceof Template) { + Template template = (Template) archetype; + for(TemplateOverlay overlay:template.getTemplateOverlays()) { + convert(overlay); + } + } + } + + private void convert(Archetype archetype) { + Map convertedCodes = new LinkedHashMap<>(); + if(archetype.getTerminology() == null || archetype.getTerminology().getValueSets() == null) { + return; + } + for(String key:archetype.getTerminology().getValueSets().keySet()) { + ValueSet valueSet = archetype.getTerminology().getValueSets().get(key); + List codes = new ArrayList<>(); + for(String code:valueSet.getMembers()) { + String newCode = ADL14NodeIDConverter.convertCode(code, "at"); + convertedCodes.put(code , new ConvertedCodeResult(code, newCode)); + codes.add(newCode); + } + valueSet.setMembers(codes); + } + ADL14NodeIDConverter.convertTermDefinitions(archetype, convertedCodes); + } +} diff --git a/better-template/src/main/java/com/nedap/archie/template/betterjson/parser/ArchetypeIdConverter.java b/better-template/src/main/java/com/nedap/archie/template/betterjson/parser/ArchetypeIdConverter.java new file mode 100644 index 000000000..d9b50b5e6 --- /dev/null +++ b/better-template/src/main/java/com/nedap/archie/template/betterjson/parser/ArchetypeIdConverter.java @@ -0,0 +1,24 @@ +package com.nedap.archie.template.betterjson.parser; + +import com.fasterxml.jackson.databind.JavaType; +import com.fasterxml.jackson.databind.type.TypeFactory; +import com.fasterxml.jackson.databind.util.Converter; +import com.nedap.archie.aom.ArchetypeHRID; +import com.nedap.archie.rm.support.identification.TerminologyId; + +public class ArchetypeIdConverter implements Converter { + @Override + public ArchetypeHRID convert(MarandArchetypeId value) { + return new ArchetypeHRID(value.getValue()); + } + + @Override + public JavaType getInputType(TypeFactory typeFactory) { + return typeFactory.constructType(MarandArchetypeId.class); + } + + @Override + public JavaType getOutputType(TypeFactory typeFactory) { + return typeFactory.constructType(ArchetypeHRID.class); + } +} diff --git a/better-template/src/main/java/com/nedap/archie/template/betterjson/parser/ArchetypeMixin.java b/better-template/src/main/java/com/nedap/archie/template/betterjson/parser/ArchetypeMixin.java new file mode 100644 index 000000000..cd9af622e --- /dev/null +++ b/better-template/src/main/java/com/nedap/archie/template/betterjson/parser/ArchetypeMixin.java @@ -0,0 +1,14 @@ +package com.nedap.archie.template.betterjson.parser; + +import com.fasterxml.jackson.annotation.JsonIgnoreProperties; +import com.fasterxml.jackson.databind.annotation.JsonDeserialize; +import com.nedap.archie.aom.ArchetypeHRID; + +@JsonIgnoreProperties({"rmName", "templateId"}) +public interface ArchetypeMixin { + + @JsonDeserialize(converter = ArchetypeIdConverter.class) + public void setArchetypeId(ArchetypeHRID archetypeId); + @JsonDeserialize(converter = ArchetypeIdConverter.class) + ArchetypeHRID setParentArchetypeId(ArchetypeHRID archetypeId); +} diff --git a/better-template/src/main/java/com/nedap/archie/template/betterjson/parser/AuthoredResourceMixin.java b/better-template/src/main/java/com/nedap/archie/template/betterjson/parser/AuthoredResourceMixin.java new file mode 100644 index 000000000..69b205493 --- /dev/null +++ b/better-template/src/main/java/com/nedap/archie/template/betterjson/parser/AuthoredResourceMixin.java @@ -0,0 +1,12 @@ +package com.nedap.archie.template.betterjson.parser; + +import com.fasterxml.jackson.databind.annotation.JsonDeserialize; +import com.nedap.archie.aom.TranslationDetails; + +import java.util.Map; + +public interface AuthoredResourceMixin { + + @JsonDeserialize(converter = TranslationConverter.class) + void setTranslations(Map translations); +} diff --git a/better-template/src/main/java/com/nedap/archie/template/betterjson/parser/CArchetypeRootMixin.java b/better-template/src/main/java/com/nedap/archie/template/betterjson/parser/CArchetypeRootMixin.java new file mode 100644 index 000000000..671745bcb --- /dev/null +++ b/better-template/src/main/java/com/nedap/archie/template/betterjson/parser/CArchetypeRootMixin.java @@ -0,0 +1,9 @@ +package com.nedap.archie.template.betterjson.parser; + +import com.fasterxml.jackson.annotation.JsonIgnore; +import com.fasterxml.jackson.annotation.JsonIgnoreProperties; + +@JsonIgnoreProperties({"referenceType"}) +public interface CArchetypeRootMixin { + +} diff --git a/better-template/src/main/java/com/nedap/archie/template/betterjson/parser/CComplexObjectMixin.java b/better-template/src/main/java/com/nedap/archie/template/betterjson/parser/CComplexObjectMixin.java new file mode 100644 index 000000000..ce96bb920 --- /dev/null +++ b/better-template/src/main/java/com/nedap/archie/template/betterjson/parser/CComplexObjectMixin.java @@ -0,0 +1,16 @@ +package com.nedap.archie.template.betterjson.parser; + +import com.fasterxml.jackson.annotation.JsonIgnoreProperties; +import com.fasterxml.jackson.databind.annotation.JsonDeserialize; +import com.nedap.archie.aom.CComplexObject; +import com.nedap.archie.base.OpenEHRBase; + +@JsonIgnoreProperties(value = {"attributeCustomizations"}) +public class CComplexObjectMixin extends CComplexObject { + +// @Override +// @JsonDeserialize(using=DefaultValueDeserializer.class) +// public void setDefaultValue(OpenEHRBase something) { +// +// } +} diff --git a/better-template/src/main/java/com/nedap/archie/template/betterjson/parser/CDefinedObjectMixin.java b/better-template/src/main/java/com/nedap/archie/template/betterjson/parser/CDefinedObjectMixin.java new file mode 100644 index 000000000..e225ed5a4 --- /dev/null +++ b/better-template/src/main/java/com/nedap/archie/template/betterjson/parser/CDefinedObjectMixin.java @@ -0,0 +1,12 @@ +package com.nedap.archie.template.betterjson.parser; + +import com.fasterxml.jackson.databind.annotation.JsonDeserialize; +import com.nedap.archie.aom.CDefinedObject; + +public abstract class CDefinedObjectMixin extends CDefinedObject { +// @Override +// @JsonDeserialize(using=DefaultValueDeserializer.class) +// public abstract void setDefaultValue(Object something); + + +} diff --git a/better-template/src/main/java/com/nedap/archie/template/betterjson/parser/CTerminologyCodeConverter.java b/better-template/src/main/java/com/nedap/archie/template/betterjson/parser/CTerminologyCodeConverter.java new file mode 100644 index 000000000..e2907f376 --- /dev/null +++ b/better-template/src/main/java/com/nedap/archie/template/betterjson/parser/CTerminologyCodeConverter.java @@ -0,0 +1,109 @@ +package com.nedap.archie.template.betterjson.parser; + +import com.fasterxml.jackson.databind.JavaType; +import com.fasterxml.jackson.databind.type.TypeFactory; +import com.fasterxml.jackson.databind.util.Converter; +import com.google.common.collect.Lists; +import com.nedap.archie.aom.Archetype; +import com.nedap.archie.aom.CAttribute; +import com.nedap.archie.aom.CComplexObject; +import com.nedap.archie.aom.CObject; +import com.nedap.archie.aom.Template; +import com.nedap.archie.aom.TemplateOverlay; +import com.nedap.archie.aom.primitives.CTerminologyCode; +import com.nedap.archie.rm.support.identification.TerminologyId; + +import java.util.ArrayList; +import java.util.LinkedHashMap; +import java.util.List; +import java.util.Map; + +public class CTerminologyCodeConverter { + + private final boolean replaceTermCodes; + + public CTerminologyCodeConverter(boolean replaceTermCodes) { + this.replaceTermCodes = replaceTermCodes; + } + + public void fixCTerminologyCodes(Archetype archetype) { + fixInner(archetype); + if(archetype instanceof Template) { + Template template = (Template) archetype; + for(TemplateOverlay overlay:template.getTemplateOverlays()) { + fixInner(overlay); + } + } + } + + private void fixInner(Archetype archetype) { + fixInner(archetype, archetype.getDefinition()); + } + + private void fixInner(Archetype archetype, CObject cObject) { + + for(CAttribute attribute:cObject.getAttributes()) { + fixInner(archetype, attribute); + } + } + + private void fixInner(Archetype archetype, CAttribute attribute) { + Map replacements = new LinkedHashMap<>(); + for(CObject cObject:attribute.getChildren()) { + if(cObject instanceof TemplateCTerminologyCode) { + TemplateCTerminologyCode templateCode = (TemplateCTerminologyCode) cObject; + + CTerminologyCode result = convert(templateCode); + replacements.put(templateCode, result); + + } + fixInner(archetype, cObject); + } + if(replaceTermCodes) { + for (Map.Entry replacement : replacements.entrySet()) { + int index = attribute.getChildren().indexOf(replacement.getKey()); + attribute.getChildren().set(index, replacement.getValue()); + } + } + } + + public CTerminologyCode convert(TemplateCTerminologyCode value) { + //TODO: this should be split into two separate converters/fixers + if(!replaceTermCodes) { + if (value.getTerminologyId() != null && value.getIncludedExternalTerminologyCodes() != null) { + //convert external term codes to the non-parsed format. The converter will handle that + //assuming only one terminology id for now - might not be correct! + List constraints = new ArrayList<>(); + boolean first = true; + for (TemplateTermCode templateTermCode : value.getIncludedExternalTerminologyCodes()) { + if (first) { + constraints.add("[" + value.getTerminologyId().getValue() + "::" + templateTermCode.getCode() + "]"); + first = false; + } else { + constraints.add(templateTermCode.getCode()); + } + } + + value.setConstraint(constraints); + + //TODO: check if it's possible that this is just a term binding to a terminology id? + } else if (value.getTerminologyId() != null && !value.getTerminologyId().getValue().equalsIgnoreCase("local") && value.getConstraint() != null && !value.getConstraint().isEmpty()) { + List constraints = new ArrayList<>(); + constraints.addAll(value.getConstraint()); + String first = "[" + value.getTerminologyId() + "::" + constraints.get(0) + "]"; + constraints.set(0, first); + + value.setConstraint(constraints); + + + } + } + CTerminologyCode result = new CTerminologyCode(); + result.setConstraint(value.getConstraint()); + result.setAssumedValue(value.getAssumedValue()); + result.setDefaultValue(value.getDefaultValue()); + result.setOccurrences(value.getOccurrences()); + return result; + } + +} diff --git a/better-template/src/main/java/com/nedap/archie/template/betterjson/parser/CTerminologyCodeMixin.java b/better-template/src/main/java/com/nedap/archie/template/betterjson/parser/CTerminologyCodeMixin.java new file mode 100644 index 000000000..fd5fe9238 --- /dev/null +++ b/better-template/src/main/java/com/nedap/archie/template/betterjson/parser/CTerminologyCodeMixin.java @@ -0,0 +1,7 @@ +package com.nedap.archie.template.betterjson.parser; + +import com.fasterxml.jackson.databind.annotation.JsonDeserialize; + +@JsonDeserialize(as=TemplateCTerminologyCode.class) +public interface CTerminologyCodeMixin { +} diff --git a/better-template/src/main/java/com/nedap/archie/template/betterjson/parser/CodePhraseMixin.java b/better-template/src/main/java/com/nedap/archie/template/betterjson/parser/CodePhraseMixin.java new file mode 100644 index 000000000..9f7e46e01 --- /dev/null +++ b/better-template/src/main/java/com/nedap/archie/template/betterjson/parser/CodePhraseMixin.java @@ -0,0 +1,14 @@ +package com.nedap.archie.template.betterjson.parser; + +import com.fasterxml.jackson.annotation.JsonAlias; +import com.nedap.archie.rm.support.identification.TerminologyId; + +public interface CodePhraseMixin { + + @JsonAlias("terminology_id") + void setTerminologyId(TerminologyId id); + + @JsonAlias("code_string") + void setCodeString(String codeString); + +} diff --git a/better-template/src/main/java/com/nedap/archie/template/betterjson/parser/DefaultValueDeserializer.java b/better-template/src/main/java/com/nedap/archie/template/betterjson/parser/DefaultValueDeserializer.java new file mode 100644 index 000000000..8939b270e --- /dev/null +++ b/better-template/src/main/java/com/nedap/archie/template/betterjson/parser/DefaultValueDeserializer.java @@ -0,0 +1,54 @@ +package com.nedap.archie.template.betterjson.parser; + +import com.fasterxml.jackson.core.JsonParser; +import com.fasterxml.jackson.core.JsonProcessingException; +import com.fasterxml.jackson.databind.DeserializationContext; +import com.fasterxml.jackson.databind.JsonDeserializer; +import com.fasterxml.jackson.databind.ObjectMapper; +import com.fasterxml.jackson.databind.PropertyNamingStrategy; +import com.nedap.archie.aom.Archetype; +import com.nedap.archie.aom.AuthoredResource; +import com.nedap.archie.aom.CArchetypeRoot; +import com.nedap.archie.aom.CComplexObject; +import com.nedap.archie.aom.Template; +import com.nedap.archie.aom.primitives.CTerminologyCode; +import com.nedap.archie.base.OpenEHRBase; +import com.nedap.archie.base.terminology.TerminologyCode; +import com.nedap.archie.json.JacksonUtil; +import com.nedap.archie.json.RMJacksonConfiguration; +import com.nedap.archie.rm.datavalues.DataValue; +import com.nedap.archie.rm.datavalues.DvCodedText; + +import java.io.IOException; + +public class DefaultValueDeserializer extends JsonDeserializer { + + public DefaultValueDeserializer() { + System.out.println("me!"); + } + + private static final ObjectMapper objectMapper = getObjectMapper(new RMJacksonConfiguration()); + + private static final ObjectMapper getObjectMapper(RMJacksonConfiguration config) { + ObjectMapper objectMapper = new ObjectMapper(); + JacksonUtil.configureObjectMapper(objectMapper, config); + + //objectMapper.setPropertyNamingStrategy(PropertyNamingStrategy.LOWER_CAMEL_CASE); + +// objectMapper.addMixIn(TerminologyCode.class, TerminologyIdParsingTerminologyCodeMixin.class); +// objectMapper.addMixIn(AuthoredResource.class, AuthoredResourceMixin.class); +// objectMapper.addMixIn(Archetype.class, ArchetypeMixin.class); +// objectMapper.addMixIn(Template.class, ArchetypeMixin.class); +// objectMapper.addMixIn(CArchetypeRoot.class, CArchetypeRootMixin.class); +// objectMapper.addMixIn(CComplexObject.class, CComplexObjectMixin.class); +// +// objectMapper.addMixIn(CTerminologyCode.class, CTerminologyCodeMixin.class); + return objectMapper; + } + + + @Override + public OpenEHRBase deserialize(JsonParser p, DeserializationContext ctxt) throws IOException, JsonProcessingException { + return objectMapper.readValue(p, OpenEHRBase.class); + } +} diff --git a/better-template/src/main/java/com/nedap/archie/template/betterjson/parser/DvCodedTextMixin.java b/better-template/src/main/java/com/nedap/archie/template/betterjson/parser/DvCodedTextMixin.java new file mode 100644 index 000000000..0ba0f081a --- /dev/null +++ b/better-template/src/main/java/com/nedap/archie/template/betterjson/parser/DvCodedTextMixin.java @@ -0,0 +1,10 @@ +package com.nedap.archie.template.betterjson.parser; + +import com.fasterxml.jackson.annotation.JsonAlias; +import com.nedap.archie.rm.datatypes.CodePhrase; + +public interface DvCodedTextMixin { + + @JsonAlias("defining_code") + void setDefiningCode(CodePhrase definingCode); +} diff --git a/better-template/src/main/java/com/nedap/archie/template/betterjson/parser/MarandArchetypeId.java b/better-template/src/main/java/com/nedap/archie/template/betterjson/parser/MarandArchetypeId.java new file mode 100644 index 000000000..97bde713a --- /dev/null +++ b/better-template/src/main/java/com/nedap/archie/template/betterjson/parser/MarandArchetypeId.java @@ -0,0 +1,14 @@ +package com.nedap.archie.template.betterjson.parser; + +public class MarandArchetypeId { + + public String value; + + public String getValue() { + return value; + } + + public void setValue(String value) { + this.value = value; + } +} diff --git a/better-template/src/main/java/com/nedap/archie/template/betterjson/parser/TemplateCTerminologyCode.java b/better-template/src/main/java/com/nedap/archie/template/betterjson/parser/TemplateCTerminologyCode.java new file mode 100644 index 000000000..7fd246c9f --- /dev/null +++ b/better-template/src/main/java/com/nedap/archie/template/betterjson/parser/TemplateCTerminologyCode.java @@ -0,0 +1,37 @@ +package com.nedap.archie.template.betterjson.parser; + +import com.nedap.archie.aom.primitives.CTerminologyCode; +import com.nedap.archie.rm.support.identification.TerminologyId; + +import java.util.List; + +public class TemplateCTerminologyCode extends CTerminologyCode { + + private TerminologyId terminologyId; + private List selectedTerminologies; + private List includedExternalTerminologyCodes; + + public TerminologyId getTerminologyId() { + return terminologyId; + } + + public void setTerminologyId(TerminologyId terminologyId) { + this.terminologyId = terminologyId; + } + + public List getSelectedTerminologies() { + return selectedTerminologies; + } + + public void setSelectedTerminologies(List selectedTerminologies) { + this.selectedTerminologies = selectedTerminologies; + } + + public List getIncludedExternalTerminologyCodes() { + return includedExternalTerminologyCodes; + } + + public void setIncludedExternalTerminologyCodes(List includedExternalTerminologyCodes) { + this.includedExternalTerminologyCodes = includedExternalTerminologyCodes; + } +} diff --git a/better-template/src/main/java/com/nedap/archie/template/betterjson/parser/TemplateTermCode.java b/better-template/src/main/java/com/nedap/archie/template/betterjson/parser/TemplateTermCode.java new file mode 100644 index 000000000..94b26a767 --- /dev/null +++ b/better-template/src/main/java/com/nedap/archie/template/betterjson/parser/TemplateTermCode.java @@ -0,0 +1,31 @@ +package com.nedap.archie.template.betterjson.parser; + +public class TemplateTermCode { + private String terminologyId; + private String code; + private String value; + + public String getTerminologyId() { + return terminologyId; + } + + public void setTerminologyId(String terminologyId) { + this.terminologyId = terminologyId; + } + + public String getCode() { + return code; + } + + public void setCode(String code) { + this.code = code; + } + + public String getValue() { + return value; + } + + public void setValue(String value) { + this.value = value; + } +} diff --git a/better-template/src/main/java/com/nedap/archie/template/betterjson/parser/TerminologyIdConverter.java b/better-template/src/main/java/com/nedap/archie/template/betterjson/parser/TerminologyIdConverter.java new file mode 100644 index 000000000..76fd25c56 --- /dev/null +++ b/better-template/src/main/java/com/nedap/archie/template/betterjson/parser/TerminologyIdConverter.java @@ -0,0 +1,23 @@ +package com.nedap.archie.template.betterjson.parser; + +import com.fasterxml.jackson.databind.JavaType; +import com.fasterxml.jackson.databind.type.TypeFactory; +import com.fasterxml.jackson.databind.util.Converter; +import com.nedap.archie.rm.support.identification.TerminologyId; + +public class TerminologyIdConverter implements Converter { + @Override + public String convert(TerminologyId value) { + return value.getValue(); + } + + @Override + public JavaType getInputType(TypeFactory typeFactory) { + return typeFactory.constructType(TerminologyId.class); + } + + @Override + public JavaType getOutputType(TypeFactory typeFactory) { + return typeFactory.constructType(String.class); + } +} diff --git a/better-template/src/main/java/com/nedap/archie/template/betterjson/parser/TerminologyIdParsingTerminologyCodeMixin.java b/better-template/src/main/java/com/nedap/archie/template/betterjson/parser/TerminologyIdParsingTerminologyCodeMixin.java new file mode 100644 index 000000000..4b4931a56 --- /dev/null +++ b/better-template/src/main/java/com/nedap/archie/template/betterjson/parser/TerminologyIdParsingTerminologyCodeMixin.java @@ -0,0 +1,8 @@ +package com.nedap.archie.template.betterjson.parser; + +import com.fasterxml.jackson.databind.annotation.JsonDeserialize; + +public interface TerminologyIdParsingTerminologyCodeMixin { + @JsonDeserialize(converter = TerminologyIdConverter.class) + void setTerminologyId(String terminologyId); +} diff --git a/better-template/src/main/java/com/nedap/archie/template/betterjson/parser/TranslationConverter.java b/better-template/src/main/java/com/nedap/archie/template/betterjson/parser/TranslationConverter.java new file mode 100644 index 000000000..e19b03943 --- /dev/null +++ b/better-template/src/main/java/com/nedap/archie/template/betterjson/parser/TranslationConverter.java @@ -0,0 +1,34 @@ +package com.nedap.archie.template.betterjson.parser; + +import com.fasterxml.jackson.core.type.TypeReference; +import com.fasterxml.jackson.databind.JavaType; +import com.fasterxml.jackson.databind.type.TypeFactory; +import com.fasterxml.jackson.databind.util.Converter; +import com.nedap.archie.aom.TranslationDetails; +import com.nedap.archie.rm.support.identification.TerminologyId; + +import java.util.LinkedHashMap; +import java.util.List; +import java.util.Map; + +public class TranslationConverter implements Converter, Map> { + @Override + public Map convert(List value) { + LinkedHashMap result = new LinkedHashMap(); + for(TranslationDetails v:value) { + result.put(v.getLanguage().getCodeString(), v); + } + return result; + + } + + @Override + public JavaType getInputType(TypeFactory typeFactory) { + return typeFactory.constructType(new TypeReference>() {}); + } + + @Override + public JavaType getOutputType(TypeFactory typeFactory) { + return typeFactory.constructType(new TypeReference>() {}); + } +} diff --git a/better-template/src/test/java/com/nedap/archie/adl14/ConversionConfigForTest.java b/better-template/src/test/java/com/nedap/archie/adl14/ConversionConfigForTest.java new file mode 100644 index 000000000..7562e9b43 --- /dev/null +++ b/better-template/src/test/java/com/nedap/archie/adl14/ConversionConfigForTest.java @@ -0,0 +1,18 @@ +package com.nedap.archie.adl14; + +import com.nedap.archie.json.JacksonUtil; + +import java.io.IOException; +import java.io.InputStream; + +public class ConversionConfigForTest { + + + public static ADL14ConversionConfiguration getConfig() throws IOException { + + try(InputStream stream = ConversionConfigForTest.class.getResourceAsStream("configuration.json")) { + return JacksonUtil.getObjectMapper().readValue(stream, ADL14ConversionConfiguration.class); + } + + } +} diff --git a/better-template/src/test/java/com/nedap/archie/opt_marand/ParseBetterSystemsOptTest.java b/better-template/src/test/java/com/nedap/archie/opt_marand/ParseBetterSystemsOptTest.java new file mode 100644 index 000000000..4369fa79a --- /dev/null +++ b/better-template/src/test/java/com/nedap/archie/opt_marand/ParseBetterSystemsOptTest.java @@ -0,0 +1,357 @@ +package com.nedap.archie.opt_marand; + +import com.fasterxml.jackson.databind.ObjectMapper; +import com.fasterxml.jackson.databind.PropertyNamingStrategy; +import com.google.common.base.Charsets; +import com.google.common.collect.Lists; +import com.nedap.archie.adl14.ADL14ConversionConfiguration; +import com.nedap.archie.adl14.ADL14ConversionUtil; +import com.nedap.archie.adl14.ADL14Converter; +import com.nedap.archie.adl14.ADL14Parser; +import com.nedap.archie.adl14.ADL2ConversionResult; +import com.nedap.archie.adl14.ADL2ConversionResultList; +import com.nedap.archie.adl14.ConversionConfigForTest; +import com.nedap.archie.adlparser.ADLParser; +import com.nedap.archie.aom.Archetype; +import com.nedap.archie.aom.AuthoredResource; +import com.nedap.archie.aom.CArchetypeRoot; +import com.nedap.archie.aom.CComplexObject; +import com.nedap.archie.aom.CDefinedObject; +import com.nedap.archie.aom.Template; +import com.nedap.archie.aom.TemplateOverlay; +import com.nedap.archie.aom.primitives.CTerminologyCode; +import com.nedap.archie.archetypevalidator.ValidationResult; +import com.nedap.archie.base.terminology.TerminologyCode; +import com.nedap.archie.flattener.ArchetypeHRIDMap; +import com.nedap.archie.flattener.Flattener; +import com.nedap.archie.flattener.FlattenerConfiguration; +import com.nedap.archie.template.betterjson.ArchetypeTermFixer; +import com.nedap.archie.flattener.InMemoryFullArchetypeRepository; +import com.nedap.archie.json.JacksonUtil; +import com.nedap.archie.json.RMJacksonConfiguration; +import com.nedap.archie.rm.datatypes.CodePhrase; +import com.nedap.archie.rm.datavalues.DvCodedText; +import com.nedap.archie.rminfo.MetaModels; +import com.nedap.archie.serializer.adl.ADLArchetypeSerializer; +import com.nedap.archie.template.betterjson.ExternalTermBindingTranslationFixer; +import com.nedap.archie.template.betterjson.FlatArchetypeProvider; +import com.nedap.archie.template.betterjson.LanguageConsistencyFixer; +import com.nedap.archie.template.betterjson.MultiplicityFixer; +import com.nedap.archie.template.betterjson.NodeIdFixer; +import com.nedap.archie.template.betterjson.SpecializedTerminologyCodeFixer; +import com.nedap.archie.template.betterjson.ValueSetFixer; +import com.nedap.archie.template.betterjson.parser.*; +import org.junit.Test; +import org.openehr.referencemodels.BuiltinReferenceModels; + +import java.io.File; +import java.io.FileInputStream; +import java.io.FileNotFoundException; +import java.io.FileOutputStream; +import java.io.IOException; +import java.io.InputStream; +import java.net.URI; +import java.net.URISyntaxException; +import java.text.MessageFormat; +import java.util.ArrayList; +import java.util.List; +import java.util.Map; + +import static org.junit.Assert.assertTrue; + +public class ParseBetterSystemsOptTest { + + public static final String OPT_JSON_ARCHETYPES = "/opt_json/Archetypes/"; + private String[] adl2Archetypes = { + "openEHR-EHR-CLUSTER.symptom_sign.v1.0.0.adls" + }; + + private String[] archetypeFiles = { + "openEHR-EHR-CLUSTER.address_cc.v0.adl", + "openEHR-EHR-CLUSTER.dwelling.v0.adl", + "openEHR-EHR-CLUSTER.employment_covid.v0.adl", + "openEHR-EHR-CLUSTER.occupation_record.v1.adl", + "openEHR-EHR-CLUSTER.organisation_cc.v0.adl", + "openEHR-EHR-CLUSTER.outbreak_exposure.v0.adl", + "openEHR-EHR-CLUSTER.overcrowding_screening.v0.adl", + "openEHR-EHR-CLUSTER.problem_qualifier.v1.adl", + // "openEHR-EHR-CLUSTER.symptom_sign.v1.adl", + "openEHR-EHR-CLUSTER.symptom_sign-cvid.v0.adl", + "openEHR-EHR-COMPOSITION.encounter.v1.adl", + "openEHR-EHR-EVALUATION.health_risk.v1.adl", + "openEHR-EHR-EVALUATION.health_risk-covid.v0.adl", + "openEHR-EHR-EVALUATION.living_arrangement.v0.adl", + "openEHR-EHR-EVALUATION.occupation_summary.v1.adl", + "openEHR-EHR-EVALUATION.problem_diagnosis.v1.adl", + "openEHR-EHR-INSTRUCTION.service_request.v1.adl", + "openEHR-EHR-OBSERVATION.body_temperature.v2.adl", + "openEHR-EHR-OBSERVATION.story.v1.adl", + "openEHR-EHR-OBSERVATION.travel_history.v0.adl" + }; + + @Test + public void parseOpt() throws IOException { + try(InputStream stream = getClass().getResourceAsStream("/opt_json/COVID-19-Screening_t.json")) { + RMJacksonConfiguration config = new RMJacksonConfiguration(); + config.setFailOnUnknownProperties(true); + ObjectMapper objectMapper = getObjectMapper(config); + + + Archetype archetype = objectMapper.readValue(stream, Archetype.class); + System.out.println(ADLArchetypeSerializer.serialize(archetype)); + } + } + + private ObjectMapper getObjectMapper(RMJacksonConfiguration config) { + ObjectMapper objectMapper = new ObjectMapper(); + JacksonUtil.configureObjectMapper(objectMapper, config); + + objectMapper.setPropertyNamingStrategy(PropertyNamingStrategy.LOWER_CAMEL_CASE); + + objectMapper.addMixIn(TerminologyCode.class, TerminologyIdParsingTerminologyCodeMixin.class); + objectMapper.addMixIn(AuthoredResource.class, AuthoredResourceMixin.class); + objectMapper.addMixIn(Archetype.class, ArchetypeMixin.class); + objectMapper.addMixIn(Template.class, ArchetypeMixin.class); + objectMapper.addMixIn(CArchetypeRoot.class, CArchetypeRootMixin.class); + objectMapper.addMixIn(CComplexObject.class, CComplexObjectMixin.class); + objectMapper.addMixIn(CDefinedObject.class, CDefinedObjectMixin.class); + + + objectMapper.addMixIn(CTerminologyCode.class, CTerminologyCodeMixin.class); + + + objectMapper.addMixIn(DvCodedText.class, DvCodedTextMixin.class); + objectMapper.addMixIn(CodePhrase.class, CodePhraseMixin.class); + return objectMapper; + } + + private void fixtermBindings(Archetype archetype, ADL14ConversionConfiguration adl14ConversionConfiguration) { + ADL14ConversionUtil adl14ConversionUtil = new ADL14ConversionUtil(adl14ConversionConfiguration); + if(archetype.getTerminology() != null && archetype.getTerminology().getTermBindings() != null) { + Map> termBindings = archetype.getTerminology().getTermBindings(); + for(String terminologyId: termBindings.keySet()) { + for(String key:termBindings.get(terminologyId).keySet()) { + URI uri = termBindings.get(terminologyId).get(key); + if(uri.toString().startsWith("term:")) { + String termCode = "[" + uri.toString().substring(5) + "]"; + try { + termBindings.get(terminologyId).put(key, adl14ConversionUtil.convertToUri(TerminologyCode.createFromString(termCode))); + } catch (URISyntaxException e) { + e.printStackTrace(); + } + } + + } + } + } + } + + @Test + public void parseCovidAssessment() throws Exception { + MetaModels metaModels = BuiltinReferenceModels.getMetaModels(); + ADL14ConversionConfiguration adl14ConversionConfiguration = ConversionConfigForTest.getConfig(); + List archetypes = new ArrayList<>(); + parseADL14Archetypes(metaModels, adl14ConversionConfiguration, archetypes); + ADLParser adl2Parser = new ADLParser(BuiltinReferenceModels.getMetaModels()); + Archetype adl2Symptom = null; + try(InputStream stream = getClass().getResourceAsStream("/opt_json/adl2/" + adl2Archetypes[0])){ + adl2Symptom = adl2Parser.parse(stream); + } + + ADL14Converter adl14ArchetypeConverter = new ADL14Converter(BuiltinReferenceModels.getMetaModels(), adl14ConversionConfiguration); + { + InMemoryFullArchetypeRepository tmpRepository = new InMemoryFullArchetypeRepository(); + tmpRepository.addArchetype(adl2Symptom); + adl14ArchetypeConverter.setExistingRepository(tmpRepository); + } + ADL2ConversionResultList converted = adl14ArchetypeConverter.convert(archetypes); + + output(converted); + output(adl2Symptom); + + checkConversions(converted); + + InMemoryFullArchetypeRepository adl2Repository = createRepository(converted, adl2Symptom); + + RMJacksonConfiguration config = new RMJacksonConfiguration(); + config.setFailOnUnknownProperties(true); + ObjectMapper mapper = getObjectMapper(config); + try(InputStream stream = getClass().getResourceAsStream("/opt_json/Templates/Suspected Covid-19 Assessment.v0.1.t.json")) { + Archetype archetype = mapper.readValue(stream, Archetype.class); + new CTerminologyCodeConverter(false).fixCTerminologyCodes(archetype); + ADL14ConversionConfiguration templateconfig = ConversionConfigForTest.getConfig(); + templateconfig.setApplyDiff(false); + ADL14Converter adl14Converter = new ADL14Converter(BuiltinReferenceModels.getMetaModels(), templateconfig); + adl14Converter.setExistingRepository(adl2Repository); + + new ValueSetFixer().convertValueSets(archetype); + + ADL2ConversionResultList convert = adl14Converter.convert(Lists.newArrayList(archetype)); + + Template foundTemplate = null; + + for(ADL2ConversionResult result:convert.getConversionResults()) { + if(result.getArchetype() instanceof Template) { + foundTemplate = (Template) result.getArchetype(); + //TODO: move to converter! + foundTemplate.setTemplateOverlays(new ArrayList<>());//remove the template overlays for now + } + fixtermBindings(result.getArchetype(), templateconfig); + if(result.getException() != null) { + throw result.getException(); + } + } + + for(ADL2ConversionResult result:convert.getConversionResults()) { + if (result.getArchetype() instanceof TemplateOverlay) { + foundTemplate.addTemplateOverlay((TemplateOverlay) result.getArchetype()); + } + } + + //FIRST remove node ids that shouldn't have been created + //THEN add terms + + //TODO: creating the flatArchetypeProvider again and again is very slow + //but as we are fixing on the fly, it's probably the only way since the fixes can impact the fixing itself + //TODO: even the template over lays should actually be fixed in dependency order. very minor for most templates, major for others + new NodeIdFixer().fixNodeIds(foundTemplate, new FlatArchetypeProvider(adl2Repository)); + new ArchetypeTermFixer().fixTerms(foundTemplate, new FlatArchetypeProvider(adl2Repository)); + new LanguageConsistencyFixer().fixLanguageConsistency(foundTemplate); + new SpecializedTerminologyCodeFixer().fixTerminologyCodes(foundTemplate, new FlatArchetypeProvider(adl2Repository)); + new ExternalTermBindingTranslationFixer().fixTranslations(templateconfig, foundTemplate); + new CTerminologyCodeConverter(true).fixCTerminologyCodes(foundTemplate); + new MultiplicityFixer().fixMultiplicity(BuiltinReferenceModels.getMetaModels(), foundTemplate, new FlatArchetypeProvider(adl2Repository)); + + + + adl2Repository.compile(BuiltinReferenceModels.getMetaModels()); + output(foundTemplate); + + FlatArchetypeProvider provider = new FlatArchetypeProvider(adl2Repository); + + System.out.println(ADLArchetypeSerializer.serialize(foundTemplate, provider::getFlatArchetype)); + FlattenerConfiguration flattenerConfiguration = FlattenerConfiguration.forOperationalTemplate(); + flattenerConfiguration.setRemoveLanguagesFromMetaData(true); + String[] langaugesToKeep = {"en"}; + flattenerConfiguration.setLanguagesToKeep(langaugesToKeep); + Flattener optCreator = new Flattener(adl2Repository, BuiltinReferenceModels.getMetaModels(), flattenerConfiguration); + + //System.out.println("\n\n\n==========================================\nOPT 2\n==================\n\n"); + output(optCreator.flatten(foundTemplate), "opt_thingy"); + + ValidationResult validationResult = adl2Repository.getValidationResult("openEHR-EHR-COMPOSITION.t_encounter.v1.0.0"); + if(!validationResult.passes()) { + throw new RuntimeException(MessageFormat.format("error validating {0}: {1}", validationResult.getArchetypeId(), validationResult)); + } + } + } + + class FlatArchetypeProvider implements com.nedap.archie.template.betterjson.FlatArchetypeProvider { + private InMemoryFullArchetypeRepository repo; + private ArchetypeHRIDMap flatArchetypes = new ArchetypeHRIDMap<>(); + private MetaModels metaModels = BuiltinReferenceModels.getMetaModels(); + + public FlatArchetypeProvider(InMemoryFullArchetypeRepository repo) { + this.repo = repo; + } + + public Archetype getFlatArchetype(String id) { + Archetype flattenedArchetype = repo.getFlattenedArchetype(id); + if(flattenedArchetype != null) { + return flattenedArchetype; + } + flattenedArchetype = flatArchetypes.get(id); + if(flattenedArchetype != null) { + return flattenedArchetype; + } + Archetype archetype = repo.getArchetype(id); + try { + flattenedArchetype = new Flattener(repo, metaModels).flatten(archetype); + flatArchetypes.put(flattenedArchetype.getArchetypeId(), flattenedArchetype); + return flattenedArchetype; + } catch (Exception e) { + e.printStackTrace(); + return null; + } + } + + } + + private void output(ADL2ConversionResultList converted) { + String outputDir = "/Users/pieter.bos/projects/openehr/covid/"; + for(ADL2ConversionResult result:converted.getConversionResults()) { + String fileName = outputDir + result.getArchetypeId() + ".adls"; + + try(FileOutputStream stream = new FileOutputStream(fileName)) { + stream.write(ADLArchetypeSerializer.serialize(result.getArchetype()).getBytes(Charsets.UTF_8)); + stream.flush(); + } catch (FileNotFoundException e) { + e.printStackTrace(); + } catch (IOException e) { + e.printStackTrace(); + } + } + } + + private void output(Archetype template) { + output(template, ""); + + } + + private void output(Archetype template, String suffix) { + String outputDir = "/Users/pieter.bos/projects/openehr/covid/"; + + String fileName = outputDir + template.getArchetypeId().toString() + suffix + ".adls"; + + try(FileOutputStream stream = new FileOutputStream(fileName)) { + stream.write(ADLArchetypeSerializer.serialize(template).getBytes(Charsets.UTF_8)); + stream.flush(); + } catch (FileNotFoundException e) { + e.printStackTrace(); + } catch (IOException e) { + e.printStackTrace(); + } + } + + private InMemoryFullArchetypeRepository createRepository(ADL2ConversionResultList converted, Archetype extraArchetype) { + InMemoryFullArchetypeRepository adl2Repository = new InMemoryFullArchetypeRepository(); + for(ADL2ConversionResult conversionResult:converted.getConversionResults()) { + if(conversionResult.getException() == null && conversionResult.getArchetype() != null) { + adl2Repository.addArchetype(conversionResult.getArchetype()); + } + } + if(extraArchetype != null) { + adl2Repository.addArchetype(extraArchetype); + } + adl2Repository.compile(BuiltinReferenceModels.getMetaModels()); + + for(ValidationResult validationResult:adl2Repository.getAllValidationResults()) { + if(!validationResult.passes()) { + throw new RuntimeException(MessageFormat.format("error validating {0}: {1}", validationResult.getArchetypeId(), validationResult.getErrors())); + } + } + return adl2Repository; + } + + private void parseADL14Archetypes(MetaModels metaModels, ADL14ConversionConfiguration adl14ConversionConfiguration, List archetypes) { + for(String fileName:archetypeFiles) { + try(InputStream stream = getClass().getResourceAsStream(OPT_JSON_ARCHETYPES + fileName)) { + + ADL14Parser parser = new ADL14Parser(metaModels); + Archetype archetype = parser.parse(stream, adl14ConversionConfiguration); + archetypes.add(archetype); + assertTrue(fileName + " should not contain errors", parser.getErrors().hasNoErrors()); + } catch (Exception e) { + throw new RuntimeException(fileName + " did not parse", e); + } + } + } + + private void checkConversions(ADL2ConversionResultList converted) { + for(ADL2ConversionResult conversionResult:converted.getConversionResults()) { + if(conversionResult.getException() != null) { + throw new RuntimeException("problem converting archetype " + conversionResult.getArchetypeId(), conversionResult.getException()); + } + } + } +} diff --git a/better-template/src/test/resources/com/nedap/archie/adl14/configuration.json b/better-template/src/test/resources/com/nedap/archie/adl14/configuration.json new file mode 100644 index 000000000..5957cf218 --- /dev/null +++ b/better-template/src/test/resources/com/nedap/archie/adl14/configuration.json @@ -0,0 +1,25 @@ +{ + "terminology_conversion_templates": [ + { + "terminology_id": "snomedct", + "template": "http://snomed.info/id/$code_string" + }, + { + "terminology_id": "snomed-ct", + "template": "http://snomed.info/id/$code_string" + }, + { + "terminology_id": "snomed", + "template": "http://snomed.info/id/$code_string" + }, + { + "terminology_id": "openehr", + "template": "http://openehr.org/id/$code_string" + }, + { + "terminology_id": "loinc", + "template": "http://loinc.org/id/$code_string" + } + + ] +} \ No newline at end of file diff --git a/better-template/src/test/resources/opt_json/Archetypes/openEHR-EHR-CLUSTER.address_cc.v0.adl b/better-template/src/test/resources/opt_json/Archetypes/openEHR-EHR-CLUSTER.address_cc.v0.adl new file mode 100644 index 000000000..2461b388c --- /dev/null +++ b/better-template/src/test/resources/opt_json/Archetypes/openEHR-EHR-CLUSTER.address_cc.v0.adl @@ -0,0 +1,192 @@ +archetype (adl_version=1.4; uid=a4357b7c-5bf5-47ce-bcdd-f4bbbb56238d) + openEHR-EHR-CLUSTER.address_cc.v0 + +concept + [at0000] + +language + original_language = <[ISO_639-1::en]> + +description + original_author = < + ["date"] = <"2018-07-20"> + ["name"] = <"Hildegard McNicoll"> + ["organisation"] = <"freshEHR Clinical Informatics Ltd."> + ["email"] = <"hildi@freshehr.com"> + > + lifecycle_state = <"in_development"> + details = < + ["en"] = < + language = <[ISO_639-1::en]> + purpose = <"For the recording of address details aligned with corresponding FHIR resource."> + copyright = <"© Apperta Foundation, openEHR Foundation"> + use = <"Use to record address details aligned with the corresponding FHIR resources. + +This cluster archetype is intended to be used inside FHIR resource aligned archetypes such as CLUSTER.fhir_contact.v0 and CLUSTER.fhir_practitioner.v0."> + > + > + other_details = < + ["licence"] = <"This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/."> + ["custodian_organisation"] = <"openEHR Foundation"> + ["references"] = <"https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-Patient-1 cited 30-Jul-2018. + +https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-Practitioner-1 cited 30-Jul-2018."> + ["current_contact"] = <"Hildegard McNicoll, freshEHR Clinical Informatics Ltd."> + ["original_namespace"] = <"org.openehr"> + ["original_publisher"] = <"openEHR Foundation"> + ["custodian_namespace"] = <"org.openehr"> + ["MD5-CAM-1.0.1"] = <"FF6E51F17D43E5321F2138E98147BAFE"> + ["build_uid"] = <"276cb7b3-bf3a-4686-8289-43aef81e8cbd"> + ["revision"] = <"0.0.1-alpha"> + > + +definition + CLUSTER[at0000] matches { -- Address + items cardinality matches {1..*; unordered} matches { + ELEMENT[at0001] occurrences matches {0..1} matches { -- Use + value matches { + DV_CODED_TEXT matches { + defining_code matches { + [local:: + at0002, -- Home + at0003, -- Work + at0004, -- Temp + at0005] -- Old + } + } + } + } + ELEMENT[at0006] occurrences matches {0..1} matches { -- Type + value matches { + DV_CODED_TEXT matches { + defining_code matches { + [local:: + at0007, -- Postal + at0008, -- Physical + at0009] -- Both + } + } + } + } + ELEMENT[at0010] occurrences matches {0..1} matches { -- Text + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0011] occurrences matches {0..*} matches { -- Line + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0012] occurrences matches {0..1} matches { -- City + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0013] occurrences matches {0..1} matches { -- District + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0014] occurrences matches {0..1} matches { -- Postal code + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0015] occurrences matches {0..1} matches { -- Country + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0016] occurrences matches {0..1} matches { -- Valid period start + value matches { + DV_DATE_TIME matches {*} + } + } + ELEMENT[at0017] occurrences matches {0..1} matches { -- Valid period end + value matches { + DV_DATE_TIME matches {*} + } + } + } + } + +ontology + term_definitions = < + ["en"] = < + items = < + ["at0000"] = < + text = <"Address"> + description = <"Address details aligned with FHIR resource."> + > + ["at0001"] = < + text = <"Use"> + description = <"The purpose of the address."> + > + ["at0002"] = < + text = <"Home"> + description = <"Home address."> + > + ["at0003"] = < + text = <"Work"> + description = <"Work address."> + > + ["at0004"] = < + text = <"Temp"> + description = <"Temporary address."> + > + ["at0005"] = < + text = <"Old"> + description = <"Old address."> + > + ["at0006"] = < + text = <"Type"> + description = <"Distinguishes between physical addresses (those you can visit) and mailing addresses (e.g. PO Boxes and care-of addresses). Most addresses are both."> + > + ["at0007"] = < + text = <"Postal"> + description = <"Postal type of address."> + > + ["at0008"] = < + text = <"Physical"> + description = <"Physical type of address."> + > + ["at0009"] = < + text = <"Both"> + description = <"Address which is both physical and postal."> + > + ["at0010"] = < + text = <"Text"> + description = <"A full text representation of the address."> + > + ["at0011"] = < + text = <"Line"> + description = <"This component contains the house number, apartment number, street name, street direction, P.O. Box number, delivery hints, and similar address information."> + > + ["at0012"] = < + text = <"City"> + description = <"The name of the city, town, village or other community or delivery center."> + > + ["at0013"] = < + text = <"District"> + description = <"The name of the administrative area (county)."> + > + ["at0014"] = < + text = <"Postal code"> + description = <"A postal code designating a region defined by the postal service."> + > + ["at0015"] = < + text = <"Country"> + description = <"Country - a nation as commonly understood or generally accepted."> + > + ["at0016"] = < + text = <"Valid period start"> + description = <"The start of the period. The boundary is inclusive."> + > + ["at0017"] = < + text = <"Valid period end"> + description = <"The end of the period. If the end of the period is missing, it means that the period is ongoing. The start may be in the past, and the end date in the future, which means that period is expected/planned to end at that time."> + > + > + > + > diff --git a/better-template/src/test/resources/opt_json/Archetypes/openEHR-EHR-CLUSTER.dwelling.v0.adl b/better-template/src/test/resources/opt_json/Archetypes/openEHR-EHR-CLUSTER.dwelling.v0.adl new file mode 100644 index 000000000..c34ff745d --- /dev/null +++ b/better-template/src/test/resources/opt_json/Archetypes/openEHR-EHR-CLUSTER.dwelling.v0.adl @@ -0,0 +1,705 @@ +archetype (adl_version=1.4; uid=bf2195c5-2f4e-49b8-bfd8-aa6e05e84bb7) + openEHR-EHR-CLUSTER.dwelling.v0 + +concept + [at0000] + +language + original_language = <[ISO_639-1::en]> + translations = < + ["nb"] = < + language = <[ISO_639-1::nb]> + author = < + ["name"] = <"Vebjørn Arntzen"> + ["organisation"] = <"Oslo University Hospital"> + ["email"] = <"varntzen@ous-hf.no"> + > + > + > + +description + original_author = < + ["date"] = <"2018-05-29"> + ["name"] = <"Heather Leslie"> + ["organisation"] = <"Atomica Informatics"> + ["email"] = <"heather.leslie@atomicainformatics.com"> + > + lifecycle_state = <"in_development"> + other_contributors = <"Vebjørn Arntzen, Oslo University Hospital, Norway (openEHR Editor)","Silje Ljosland Bakke, Helse Vest IKT AS, Norway (openEHR Editor)","Marcos Barreto, Universidade Federal da Bahia (UFBA), Brazil","SB Bhattacharyya, Sudisa Consultancy Services, India","Ady Angelica Castro Acosta, CIBERES-Hospital 12 de Octubre, Spain","Evelyn Hovenga, EJSH Consulting, Australia","Heidi Koikkalainen, United Kingdom (openEHR Editor)","Ronald Krawec, Alberta Health Services, Canada","Tomi Laptoš, Marand, Slovenia","Heather Leslie, Atomica Informatics, Australia (openEHR Editor)","Paul Miller, SCIMP NHS Scotland, United Kingdom","Andrej Orel, Marand d.o.o., Slovenia","Anoop Shah, University College London, United Kingdom","Norwegian Review Summary, Nasjonal IKT HF, Norway","Nyree Taylor, Ocean Informatics, Australia","Rowan Thomas, St. Vincent's Hospital Melbourne, Australia","John Tore Valand, Helse Bergen, Norway (openEHR Editor)","Vinicius Tohoru Yoshiura, University of Sao Paulo, Brazil"> + details = < + ["nb"] = < + language = <[ISO_639-1::nb]> + purpose = <"For å registrere en oversikt og beskrivelse om egenskapene til en bolig der et individ bor."> + keywords = <"trapper","soverom","bad","tilgjengelighet","enebolig","leilighet","campingvogn","hytte","etasje","rullestol","areal","universell utforming","UU"> + use = <"Brukes for å registrere detaljer om egenskapene til en bolig der et individ bor, spesielt ting som kan ha betydning for individets helse og sikkerhet, eller ha innvirkning på ytelse av helsetjenester. + +Denne arketypen er utformet for å registrere attributter til et individs hjem, og vil kunne brukes til: +- å identifisere hjelpemidler som kan være nyttig i boligen +- registrere modifikasjoner og forbedringer for å støtte universell utforming (UU), eller +- bidra til offentlige undersøkelser knyttet til sykdomsutbrudd. + +Denne arketypen er utformet for å brukes i EVALUATION.housing_summary (Boligsammendrag) eller CLUSTER.housing_record (Bolig), men kan også bli brukt i hvilken som helst annen passende ENTRY- eller CLUSTER-arketype. + +Dersom det er nødvendig med spesifikke detaljer, kan arketyper legges til i elementet \"Ytterligere detaljer\". + +Grad av overensstemmelse med designprinsipper for universell utforming (UU) bør registreres i en egen arketype, som kan legges til i SLOT'et \"Ytterligere detaljer\"."> + misuse = <"Skal ikke brukes til å registrere detaljer om de sosiale forholdene individet bor under, bruk CLUSTER.living_arrangement til dette. + +Skal ikke brukes til å registrere den fysiske adressen der et individ bor, bruk demografiske arketyper for dette, eller CLUSTER.address (Adresse) dersom det er nødvendig å registrere adressen i den medisinske journalen. + +Skal ikke brukes til å registrere informasjon om boligen som ikke har noe betydning for helse, eller behov for helsetjenester til et individ. For eksempel bør ikke informasjon om dørlåsens kode til bruk for hjemmesykepleietjenesten registreres i denne arketypen. + +Skal ikke brukes for å registrere grad av overenstemmelse med prinsipper for universell utforming."> + > + ["en"] = < + language = <[ISO_639-1::en]> + purpose = <"To record an overview and description about aspects about the dwelling where an individual lives."> + keywords = <"stairs","bedroom","bathroom","access"> + copyright = <"© openEHR Foundation"> + use = <"Use to record details about the dwelling where an individual lives, particularly where this may have an impact on their health and safety or delivery of healthcare services. + +This archetype has been designed to be used to record attributes of an individual's home that might be used to: +- contribute to identification of aids/supports that might be useful in the home; +- record modifications or enhancements to support universal access; or +- inform investigations about public health outbreaks. + +This archetype has been designed to be used within the EVALUATION.housing_summary or CLUSTER.housing_record archetypes, but may be used within any other appropriate ENTRY or CLUSTER archetype. + +If specific measurements or specific details are required, additional archetypes can be nested within the 'Additional details' SLOT. + +Compliance with Universal design principles should be recorded in a separate archetype, which may be nested within the 'Additional details' SLOT."> + misuse = <"Not to be used to record details about the social circumstances in which the individual lives - use CLUSTER.living_arrangement for this purpose. + +Not to be used to record the physical address where an individual lives - use demographic archetypes for this purpose, or CLUSTER.address if the individual's address needs to be recorded within the health record. + +Not to be used to record information about the dwelling that does not impact on the health or health care needs of an individual. For example, the security access code for a home nurse visit should not be recorded using this archetype. + +Not to be used to record compliance with Universal design principles."> + > + > + other_details = < + ["licence"] = <"This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/."> + ["custodian_organisation"] = <"openEHR Foundation"> + ["references"] = <"Home Modification Assessment & Planning Tool [Internet]. Australia: SCOPE Access Home Modifications; 2015 [cited 2019 Dec 19]. Available from: http://scopehomeaccess.com.au/wp-content/uploads/2015/07/AWTS.pdf. + +Opoko A, Ibem E & Adeyemi E. Housing aspiration in an informal urban settlement: A case study [Internet]. 2015; Urbani Izziv. 26. 10.5379/urbani-izziv-en-2015-26-02-003; [cited 2019 Dec 19] . Available at: https://www.researchgate.net/publication/307851190_Housing_aspiration_in_an_informal_urban_settlement_A_case_study."> + ["current_contact"] = <"Heather Leslie, Atomica Informatics"> + ["original_namespace"] = <"org.openehr"> + ["original_publisher"] = <"openEHR Foundation"> + ["custodian_namespace"] = <"org.openehr"> + ["MD5-CAM-1.0.1"] = <"8EF81636931CBD91B3468C1BA5B005EA"> + ["build_uid"] = <"a115b23e-32e1-4e94-b83d-a0a751cb2fcb"> + ["revision"] = <"0.0.1-alpha"> + > + +definition + CLUSTER[at0000] matches { -- Dwelling + items cardinality matches {1..*; unordered} matches { + ELEMENT[at0002] occurrences matches {0..1} matches { -- Type + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0001] occurrences matches {0..1} matches { -- Overall description + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0036] occurrences matches {0..1} matches { -- Condition + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0005] occurrences matches {0..*} matches { -- Access/egress + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0006] occurrences matches {0..*} matches { -- Entrance + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0008] occurrences matches {0..*} matches { -- Hallway + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0041] occurrences matches {0..1} matches { -- Number of floors + value matches { + DV_COUNT matches {*} + } + } + ELEMENT[at0009] occurrences matches {0..*} matches { -- Internal stairs/lifts + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0010] occurrences matches {0..*} matches { -- Living room + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0011] occurrences matches {0..*} matches { -- Kitchen + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0012] occurrences matches {0..*} matches { -- Bedroom + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0028] occurrences matches {0..1} matches { -- Number of bedrooms + value matches { + DV_COUNT matches {*} + } + } + ELEMENT[at0013] occurrences matches {0..*} matches { -- Toilet + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0026] occurrences matches {0..*} matches { -- Toilet type + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0035] occurrences matches {0..1} matches { -- Number of toilets + value matches { + DV_COUNT matches {*} + } + } + ELEMENT[at0014] occurrences matches {0..*} matches { -- Bathroom + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0029] occurrences matches {0..1} matches { -- Number of bathrooms + value matches { + DV_COUNT matches {*} + } + } + ELEMENT[at0015] occurrences matches {0..*} matches { -- Laundry facilities + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0016] occurrences matches {0..*} matches { -- Outdoor space + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0007] occurrences matches {0..*} matches { -- Parking + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0037] occurrences matches {0..*} matches { -- Heating/cooling + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0038] occurrences matches {0..*} matches { -- Energy supply + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0017] occurrences matches {0..*} matches { -- Landline phone + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0040] occurrences matches {0..*} matches { -- Connectivity + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0018] occurrences matches {0..*} matches { -- Fire protection + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0039] occurrences matches {0..*} matches { -- Security and safety + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0020] occurrences matches {0..*} matches { -- Doorbell + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0022] occurrences matches {0..1} matches { -- Mail + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0024] occurrences matches {0..*} matches { -- Rubbish disposal + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0021] occurrences matches {0..*} matches { -- Rubbish collection + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0034] occurrences matches {0..*} matches { -- Sewage disposal + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0033] occurrences matches {0..*} matches { -- Water source + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0023] occurrences matches {0..*} matches { -- Water supply + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0025] occurrences matches {0..*} matches { -- Water storage + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0042] occurrences matches {0..*} matches { -- Critical appliances/services + value matches { + DV_BOOLEAN matches {*} + } + name matches { + DV_CODED_TEXT matches { + defining_code matches { + [local:: + at0044, -- Refrigerator + at0045] -- Hot running water + } + } + } + } + ELEMENT[at0043] occurrences matches {0..*} matches { -- Appliance + value matches { + DV_TEXT matches {*} + } + } + allow_archetype CLUSTER[at0003] occurrences matches {0..*} matches { -- Additional details + include + archetype_id/value matches {/openEHR-EHR-CLUSTER\.multimedia\.v0|openEHR-EHR-CLUSTER\.multimedia\.v1/} + } + ELEMENT[at0004] occurrences matches {0..1} matches { -- Comment + value matches { + DV_TEXT matches {*} + } + } + } + } + +ontology + term_definitions = < + ["en"] = < + items = < + ["at0000"] = < + text = <"Dwelling"> + description = <"An overview about the properties of a single structure, or a discrete space within a structure, and associated spaces in which an individual lives."> + comment = <"The intended scope of dwelling includes, but is not limited to: a building; part of a building; house; apartment; prison; houseboat; mobile home; or vehicle. It can also include the spaces associated with a structure or property, including the basement or yard."> + > + ["at0001"] = < + text = <"Overall description"> + description = <"Narrative description about all aspects of the dwelling."> + comment = <"For example: if basic living facilities are located on the same level."> + > + ["at0002"] = < + text = <"Type"> + description = <"The type of dwelling in which an individual lives."> + comment = <"Coding of the dwelling type with a terminology is preferred, where possible. The value sets for this data element are likely to vary between jurisdictions - it is anticipated that they will usually be set within a use-case specific template. For example: 'separate house'; 'flat, unit or apartment'; 'caravan or tent'; or 'house or flat attached to a shop or office'."> + > + ["at0003"] = < + text = <"Additional details"> + description = <"Further structured details about the dwelling."> + comment = <"This SLOT may be used to nest additional archetypes describing additional details about the dwelling that may be local to a jurisdiction."> + > + ["at0004"] = < + text = <"Comment"> + description = <"Additional narrative about the dwelling, not captured in other fields."> + > + ["at0005"] = < + text = <"Access/egress"> + description = <"Description about access to and egress from the dwelling."> + comment = <"Multiple occurrences will allow details for each access to be recorded. For example: driveway; path; fencing and gates; external stairs or lifts; doorsteps; electric door opener; rails; front access; rear access; lighting; or ramps for wheelchairs."> + > + ["at0006"] = < + text = <"Entrance"> + description = <"Description about an entrance to the dwelling."> + comment = <"Multiple occurrences will allow details for each entrance to be recorded. For example: weight and type of door; door handle; lock mechanism; or threshold step."> + > + ["at0007"] = < + text = <"Parking"> + description = <"Description about vehicle parking at or near the dwelling."> + comment = <"Multiple occurrences will allow details for each parking area to be recorded. The scope for this data element includes cars, motor scooters and other vehicles that require dedicated space or storage outside the home. For example: single/double car park; space to transfer in/out of car; protection from weather; overhead clearance; or garage door details."> + > + ["at0008"] = < + text = <"Hallway"> + description = <"Description about the hallway within the dwelling."> + comment = <"Multiple occurrences will allow details for each hallway to be recorded. For example: floor coverings; trip hazards; lighting or width."> + > + ["at0009"] = < + text = <"Internal stairs/lifts"> + description = <"Description about internal steps and lifts within the dwelling."> + comment = <"Multiple occurrences will allow details for each set of internal stairs or lifts to be recorded. For example: number of steps; condition; lighting; banister; or open/closed risers."> + > + ["at0010"] = < + text = <"Living room"> + description = <"Description about a living room within the dwelling."> + comment = <"Multiple occurrences will allow details for each living room to be recorded. For example: access; circulation space; trip hazards; floor coverings; window; lighting; or chair height."> + > + ["at0011"] = < + text = <"Kitchen"> + description = <"Description about a kitchen within the dwelling."> + comment = <"Multiple occurrences will allow details for each kitchen to be recorded. For example: access; circulation space; trip hazards; storage space; lighting; bench heights; or appliances."> + > + ["at0012"] = < + text = <"Bedroom"> + description = <"Description about a bedroom within the dwelling."> + comment = <"Multiple occurrences will allow details for each bedroom to be recorded. For example: access; bed size and type; bed height; circulation space; window; trip hazards; floor coverings; bedside light; or telephone."> + > + ["at0013"] = < + text = <"Toilet"> + description = <"Description about a toilet fixture within the dwelling."> + comment = <"Multiple occurrences will allow details for each toilet fixture to be recorded. The toilet fixture could be located within a separate toilet room, within a bathroom or within another space in the dwelling or property. For example: location; access; circulation space; emergency access; height of seat pan and distance from walls; or grab rails."> + > + ["at0014"] = < + text = <"Bathroom"> + description = <"Description about a bathroom within the dwelling."> + comment = <"Multiple occurrences will allow details for each bathroom to be recorded. For example: location; access; type of bathing facility - shower/bath/shower over bath; bath height; recess size; screen; window; taps; lighting; or grab rails."> + > + ["at0015"] = < + text = <"Laundry facilities"> + description = <"Description about a laundry facility within, or associated with, the dwelling."> + comment = <"Multiple occurrences will allow details for each space with laundry facilities to be recorded. The laundry facilities could be located within a separate laundry room or within another space in the dwelling or property. For example: access; circulation space; trip hazards; or clothes line location and height."> + > + ["at0016"] = < + text = <"Outdoor space"> + description = <"Description about an outdoor space associated with the the dwelling."> + comment = <"Multiple occurrences will allow details for each outdoor space to be recorded. The intended scope of an outdoor space includes, but is not limited to: a yard; rooftop terrace; balcony; porch; garage; or shed. For example: current condition; size; access; slope; surface; stairs; or maintenance needs."> + > + ["at0017"] = < + text = <"Landline phone"> + description = <"Description about a landline telephone within the dwelling."> + comment = <"Multiple occurrences will allow physical details for each landline phone to be recorded, regardless of the technology used to connect. For example: physical location of fixed phone or base stations; or presence of mobile handsets."> + > + ["at0018"] = < + text = <"Fire protection"> + description = <"Description about fire protection within the dwelling."> + comment = <"Multiple occurrences will allow details for each fire protection system to be recorded. The intended scope for a fire protection system includes, but is not limited to: smoke and carbon monoxide detectors; fire extinguishers; or sprinklers. For example: location; in working order; maintenance needs; central monitoring; or serial connections."> + > + ["at0020"] = < + text = <"Doorbell"> + description = <"Description about a doorbell or alert system within the dwelling."> + comment = <"Multiple occurrences will allow details for each doorbell to be recorded. For example: vibrating, flashing or audible; pitch; or volume."> + > + ["at0021"] = < + text = <"Rubbish collection"> + description = <"Description about rubbish bins and waste collection at the dwelling."> + comment = <"Multiple occurrences will allow details for each type of rubbish collection to be recorded. For example: location of rubbish bins or chute; or type of bins."> + > + ["at0022"] = < + text = <"Mail"> + description = <"Description about mail delivery and collection at the dwelling."> + > + ["at0023"] = < + text = <"Water supply"> + description = <"Description about how water is delivered into the dwelling."> + comment = <"Multiple occurrences will allow details for each water supply to be recorded. For example: piped water (in house); stand pipe; or yard pipe."> + > + ["at0024"] = < + text = <"Rubbish disposal"> + description = <"Description about the system of rubbish disposal from the dwelling."> + comment = <"For example: commercial collection; burning; burying; field; or river."> + > + ["at0025"] = < + text = <"Water storage"> + description = <"Description about the storage of potable water at the dwelling."> + comment = <"Multiple occurrences will allow details for each water storage to be recorded. For example: none; tank; or drum."> + > + ["at0026"] = < + text = <"Toilet type"> + description = <"Description about the type of toilet fixture at the dwelling."> + comment = <"Multiple occurrences will allow details for each toilet fixture to be recorded. For example: flush toilet; or pit latrine."> + > + ["at0028"] = < + text = <"Number of bedrooms"> + description = <"The number of bedrooms in the dwelling."> + > + ["at0029"] = < + text = <"Number of bathrooms"> + description = <"The number of bathrooms in the dwelling."> + > + ["at0033"] = < + text = <"Water source"> + description = <"Description about the source of water used at the dwelling."> + comment = <"Multiple occurrences will allow details for each water source to be recorded. This data element may be used to differentiate between public and private sources as well as the type of source. For example: public; lake; private well; borehole; rain; or water vendors."> + > + ["at0034"] = < + text = <"Sewage disposal"> + description = <"Description about the disposal of sewage from the dwelling."> + comment = <"Multiple occurrences will allow details for each type of sewage disposal to be recorded. For example: septic tank or cesspit; or public sewage system."> + > + ["at0035"] = < + text = <"Number of toilets"> + description = <"The number of toilet fixtures in the dwelling."> + comment = <"The toilet fixture could be located within a bathroom or similar space, or a separate toilet room. For example: toilet suite; urinal, pit latrine."> + > + ["at0036"] = < + text = <"Condition"> + description = <"Narrative description about the overall condition of the dwelling."> + comment = <"For example: leaking roof; rising damp; mould in the bathroom; broken floorboards; or holes in the walls."> + > + ["at0037"] = < + text = <"Heating/cooling"> + description = <"Description about how the dwelling is heated and cooled."> + comment = <"Multiple occurrences will allow details for each heating/cooling source to be recorded. For example: central heating; open fire; or air conditioning."> + > + ["at0038"] = < + text = <"Energy supply"> + description = <"Description about sources of power to the dwelling."> + comment = <"Multiple occurrences will allow details for each energy supply to be recorded. For example: mains electricity; solar power; bottle gas; home generator; or fire wood."> + > + ["at0039"] = < + text = <"Security and safety"> + description = <"Description about security and safety measures within the dwelling."> + comment = <"Multiple occurrences will allow details for each security and safety measure to be recorded."> + > + ["at0040"] = < + text = <"Connectivity"> + description = <"Description about the internet and other forms of connectivity and communication within the dwelling."> + comment = <"Multiple occurrences will allow details for each form of connectivity to be recorded. For example: internet access; cable; or PSTN line."> + > + ["at0041"] = < + text = <"Number of floors"> + description = <"The number of floors within the dwelling."> + > + ["at0042"] = < + text = <"Critical appliances/services"> + description = <"Availability of critical appliances or services at the dwelling, which may support use of clinical decision support."> + comment = <"For example: hot water for hygiene; a refrigerator for food hygiene and safe medication storage."> + > + ["at0043"] = < + text = <"Appliance"> + description = <"Description about an appliance at the dwelling."> + comment = <"Multiple occurrences will allow details for each appliance to be recorded. For example: refrigerator; hot water boiler; clothes washer/dryer or dishwasher."> + > + ["at0044"] = < + text = <"Refrigerator"> + description = <"Access to a refrigerator to store food and medications."> + > + ["at0045"] = < + text = <"Hot running water"> + description = <"Access to hot running water for washing."> + > + > + > + ["nb"] = < + items = < + ["at0000"] = < + text = <"Boligegenskaper"> + description = <"En oversikt over egenskaper til en bygning, eller en separat del av en bygning og tilhørende arealer, der ett eller flere mennesker bor."> + comment = <"Rammen for arketypen inkluderer, men er ikke begrenset til, en bygning, del av en bygning, hus, leilighet, fengsel, husbåt, campingvogn, bobil. Den kan også inkludere opplysninger om tilhørende arealer, som fellesarealer i et borettslag eller sameie, kjeller og hage."> + > + ["at0001"] = < + text = <"Overordnet beskrivelse"> + description = <"Fritekstlig beskrivelse om alle egenskaper til en bolig."> + comment = <"For eksempel om alle basale rom og fasiliteter er i samme etasje."> + > + ["at0002"] = < + text = <"Type bolig"> + description = <"Typen bolig individet bor i."> + comment = <"Dersom det er mulig, bør type bolig kodes med en terminologi. Verdisettet for dette elementet vil sannsynligvis variere mellom myndighetsområder, og det er antatt at verdisettet vil bli gitt i et brukerspesifikt templat. For eksempel verdisettet i OID-8709, eller det som måtte passe med brukssituasjonen."> + > + ["at0003"] = < + text = <"Ytterligere detaljer"> + description = <"Ytterligere strukturerte detaljer om boligen."> + comment = <"Dette SLOT'et kan brukes til å nøste arketyper som beskriver tilleggsdetaljer om boligen og som kan være aktuelle for det gjeldende myndighetsområdet."> + > + ["at0004"] = < + text = <"Kommentar"> + description = <"Ytterligere fritekst om boligen som ikke fanges opp i andre felt."> + > + ["at0005"] = < + text = <"Adkomst"> + description = <"Beskrivelse av hvordan forholdene er når man ankommer og forlater boligen."> + comment = <"Multiple forekomster gjør det mulig å registrere detaljer om flere adkomstveier. For eksempel informasjon om: Innkjørsel, gangsti, gjerder og porter, utvendige trapper, heis, rekkverk, dørterskler, automatisk døråpner, frontinngang, kjellerinngang, belysning, eller rampe for rullestol."> + > + ["at0006"] = < + text = <"Inngang"> + description = <"Beskrivelse om en inngang til en bolig."> + comment = <"Multiple forekomster gjør det mulig å registrere detaljer for hver inngang, for eksempel type og vekt på dør, dørhåndtak, type åpne-/lukkemekanisme eller dørstokk."> + > + ["at0007"] = < + text = <"Parkering"> + description = <"Beskrivelse av parkering i, eller nær boligen."> + comment = <"Multiple forekomster gjør det mulig å registrere detaljer for flere parkeringsområder. Den tiltenkte bruken av dette elementet inkluderer, men er ikke begrenset til: bil, scooter, elektrisk rullestol eller andre kjøretøy som trenger dedikert område eller lagring utendørs. For eksempel: Enkel eller dobbel bilparkering, HC-plass, inn- og utlastingsplass, overbygd eller ikke, takhøyde eller detaljer om garasjedør."> + > + ["at0008"] = < + text = <"Entré/Gang"> + description = <"Beskrivelse av en entré eller gang i boligen."> + comment = <"Multiple forekomster gjør det mulig å registrere detaljer for hver entré/korridor, for eksempel type gulv, bredde, belysning, fare for snubling."> + > + ["at0009"] = < + text = <"Innvendige trapper/heis."> + description = <"Beskrivelse av innvendig trapp og heis i boligen."> + comment = <"Multiple forekomster gjør det mulig å registrere detaljer for hver trapp eller heis, for eksempel type trapp, antall trappetrinn, tilstand, belysning, rekkverk, åpne eller lukkede opptrinn."> + > + ["at0010"] = < + text = <"Stue"> + description = <"Fritekstbeskrivelse av en stue eller oppholdsrom i boligen."> + comment = <"Multiple forekomster gjør det mulig å registrere detaljer for hver stue eller oppholdsrom. For eksempel adkomst, snusirkel, terskler, type gulv, vinduer, belysning eller stolhøyde."> + > + ["at0011"] = < + text = <"Kjøkken"> + description = <"Beskrivelse om et kjøkken i boligen."> + comment = <"Multiple forekomster gjør det mulig å kunne registrere detaljer om hvert kjøkken, om det er flere. For eksempel adkomst, snusirkel, terskler, lagringsplass, belysning, (regulerbar) benkehøyde eller hvitevarer."> + > + ["at0012"] = < + text = <"Soverom"> + description = <"Beskrivelse av et soverom i boligen."> + comment = <"Multiple forekomster vil gjøre det mulig å registrere detaljer om hvert enkelt soverom. For eksempel adkomst, type og størrelse på seng, høyde på seng, snusirkel, snublekanter, terskler, type gulv, lys ved sengen eller telefon."> + > + ["at0013"] = < + text = <"Toalett"> + description = <"Beskrivelse av toalettforholdene i boligen."> + comment = <"Multiple forekomster vil gjøre det mulig å registrere detaljer om hvert enkelt toalettrom. Selve toalettmøbelet kan være plassert i et eget rom, på et baderom eller et annet sted i boligen eller eiendommen. For eksempel plassering, adkomst, snusirkel, terskler, adkomst i nødstilfelle, høyde på sete og avstand fra vegg, eller håndtak."> + > + ["at0014"] = < + text = <"Bad"> + description = <"Beskrivelse av et bad i boligen."> + comment = <"Multiple forekomster vil gjøre det mulig å registrere detaljer om hvert enkelt baderom. For eksempel plassering, adkomst, snusirkel, fasiliteter - dusj i badekar eller separat dusj og badekar, høyde på badekar og vasker, skjerming, armatur eller håndtak."> + > + ["at0015"] = < + text = <"Klesvask"> + description = <"Beskrivelse av fasiliteter for klesvask i eller i tilknytning til boligen."> + comment = <"Multiple forekomster gjør det mulig å registrere flere fasiliteter for klesvask. Disse fasilitetene inkluderer både sted og tilgjengelig utstyr, og kan være i et eget vaskerom eller i et annet rom i boligen eller i tilknytning til eiendommen. Eksempler: Adkomst, snusirkel, terskler, plassering av tørkesnorer og høyde."> + > + ["at0016"] = < + text = <"Uteområde"> + description = <"Beskrivelse av uteområde i tilknytning til boligen."> + comment = <"Multiple forekomster gjør det mulig å registrere detaljer for flere utendørsområder. Den tiltenkte bruken av denne arketypen inkluderer, men er ikke begrenset til: Hage, takterrasse, balkong, bislag, garasje eller bod. For eksempel tilstand, størrelse, adkomst, skrående, underlag, trapper eller vedlikeholdsbehov."> + > + ["at0017"] = < + text = <"Fasttelefon"> + description = <"Beskrivelse av fasttelefon i boligen."> + comment = <"Multiple forekomster gjør det mulig å registrere detaljer om flere fasttelefoner, uavhengig om måten telefoner er koblet til fastlinjen. For eksempel: Fysisk plassering av fasttelefon eller basestasjon, eller tilstedeværelse av mobile håndsett."> + > + ["at0018"] = < + text = <"Brannsikring"> + description = <"Beskrivelse av brannsikring i boligen."> + comment = <"Multiple forekomster gjør det mulig å registrere detaljer om flere brannsikringstiltak. Den tiltenkte bruken av arketypen inkluderer, men er ikke begrenset til: Røyk- eller CO2-varsler, brannslukningsapparat og sprinkeranlegg. For eksempel: Plassering, funksjonell/ikke funksjonell, vedlikeholdsbehov, seriekoblet, eller koblet til sentral."> + > + ["at0020"] = < + text = <"Ringeklokke"> + description = <"Beskrivelse av ringeklokke eller varslingssystem i boligen."> + comment = <"Multiple forekomster gjør det mulig å registrere detaljer for flere ringeklokker eller varslingssystemer. For eksempel: Vibrarsjons-, lys- eller lydvarsling, eller lydvolum."> + > + ["at0021"] = < + text = <"Søppeloppsamling"> + description = <"Beskrivelse av søppelcontainere og annen oppsamling av avfall i boligen."> + comment = <"Multiple forekomster gjør det mulig å registrere detaljer om hver enkel metode for oppsamling av søppel. For eksempel: Plassering av søppelcontainere eller avfallssug, eller type søppelcontainer."> + > + ["at0022"] = < + text = <"Post"> + description = <"Beskrivelse om levering og henting av post til boligen."> + > + ["at0023"] = < + text = <"Vanntilførsel"> + description = <"Beskrivelse av hvordan vann blir tilført boligen."> + comment = <"Multiple forekomster gjør det mulig å registrere detaljer om flere typer vanntilførsel. For eksempel: Innlagt vann, felles/privat utendørs pumpe eller kran."> + > + ["at0024"] = < + text = <"Søppelhåndtering"> + description = <"Beskrivelse av system for hvordan søppel fjernes fra boligen."> + comment = <"For eksempel: Offentlig søppeltømming, brenning, nedgraving, kasting i naturen."> + > + ["at0025"] = < + text = <"Lagring av vann"> + description = <"Beskrivelse av hvorvidt, og i så fall hvordan vann lagres i boligen."> + comment = <"Multiple forekomster gjør det mulig å registrere detaljer om flere vannlagringsmetoder. For eksempel: Ingen, vanntank eller tønne."> + > + ["at0026"] = < + text = <"Type toalett"> + description = <"Beskrivelse av typen avtrede i eller i tilknytning til boligen."> + comment = <"Multiple forekomster vil gjøre det mulig å registrere detaljer for hver enkelt type avtrede. For eksempel vannklosett, utedo eller latrine."> + > + ["at0028"] = < + text = <"Antall soverom"> + description = <"Antall soverom i boligen."> + > + ["at0029"] = < + text = <"Antall baderom"> + description = <"Antall baderom i boligen."> + > + ["at0033"] = < + text = <"Vannkilde"> + description = <"Beskrivelse av en vannkilde til boligen."> + comment = <"Multiple forekomster gjør det mulig å registrere detaljer om flere typer vannkilder. Dette elementet kan brukes til å skille mellom offentlig og privat vannforsyning i tillegg til typen kilde. For eksempel: Offentlig vannforsyning, privat brønn, borrehull, innsjø eller elv, regnvann eller kjøpevann."> + > + ["at0034"] = < + text = <"Kloakksystem"> + description = <"Beskrivelse av hvilket kloakksystem det er i boligen."> + comment = <"Multiple forekomster gjør det mulig å registrere detaljer om flere typer kloakksystem. For eksempel: Septiktank, latrinehull eller offentlig kloakksystem."> + > + ["at0035"] = < + text = <"Antall toalett"> + description = <"Antall toalett, i betydning selve toalettmøbelet, i boligen."> + comment = <"Toalettmøbelet kan være plassert i et eget rom, et baderom eller lignende. Eksempler: vegghengt toalett, urinal eller latrine."> + > + ["at0036"] = < + text = <"Tilstand"> + description = <"Fritekstlig beskrivelse om boligens fysiske tilstand."> + comment = <"For eksempel: Taklekkasje, fuktig kjeller, muggsopp på baderom, dårlig isolasjon, sprukne gulvfliser, hull i veggen."> + > + ["at0037"] = < + text = <"Oppvarming/kjøling"> + description = <"Beskrivelse av hvordan boligen er oppvarmet og/eller kjølet ned."> + comment = <"Multiple forekomster gjør det mulig å registrere detaljer for flere kilder og metoder for oppvarming eller kjøling. For eksempel: Sentralfyring, varmepumpe, vedfyring eller air condition."> + > + ["at0038"] = < + text = <"Energiforsyning"> + description = <"Beskrivelse av energikilder til boligen."> + comment = <"Multiple forekomster gjør det mulig å registrere detaljer for flere energiforsyningskilder. For eksempel: Strømnett, solenergi, gass, generator eller vedfyring."> + > + ["at0039"] = < + text = <"Trygghetstiltak"> + description = <"Beskrivelse av trygghetstiltak i boligen."> + comment = <"Multiple forekomster gjør det mulig å registrere flere trygghetstiltak."> + > + ["at0040"] = < + text = <"Oppkobling"> + description = <"Beskrivelse av oppkobling til internett og andre oppkoblingsmuligheter, og kommunikasjon i boligen."> + comment = <"Multiple forekomster gjør det mulig å registrere flere oppkoblingsteknologier. For eksempel internettoppkobling, kabel eller fasttelefonlinje."> + > + ["at0041"] = < + text = <"Antall etasjer"> + description = <"Hvor mange etasjer boligenheten består av. OBS: Ikke hvilken etasje boenheten er i."> + > + ["at0042"] = < + text = <"Kritiske apparater/tjenester"> + description = <"Tilgjengelighet på kritiske apparater eller tjenester i boligen. Elementet kan bidra til klinisk beslutningsstøtte."> + comment = <"For eksempel: Varmt vann for hygiene, eller kjøleskap for mathygiene og forsvarlig oppbevaring av medikamenter."> + > + ["at0043"] = < + text = <"Apparat"> + description = <"Beskrivelse av apparat eller hvitevare i boligen."> + comment = <"Multiple forekomster gjør det mulig å registrere detaljer om flere apparater. For eksempel: Kjøleskap, fryser, vannkoker, vaskemaskin, tørketrommel eller oppvaskmaskin."> + > + ["at0044"] = < + text = <"Kjøleskap"> + description = <"Tilgang til kjøleskap for å lagre mat og medikamenter."> + > + ["at0045"] = < + text = <"Innlagt varmt vann"> + description = <"Tilgang til innlagt varmt vann for vask."> + > + > + > + > diff --git a/better-template/src/test/resources/opt_json/Archetypes/openEHR-EHR-CLUSTER.employment_covid.v0.adl b/better-template/src/test/resources/opt_json/Archetypes/openEHR-EHR-CLUSTER.employment_covid.v0.adl new file mode 100644 index 000000000..ed1d13562 --- /dev/null +++ b/better-template/src/test/resources/opt_json/Archetypes/openEHR-EHR-CLUSTER.employment_covid.v0.adl @@ -0,0 +1,76 @@ +archetype (adl_version=1.4; uid=5a2846e0-3a2a-4a9e-a896-84964ba882fa) + openEHR-EHR-CLUSTER.employment_covid.v0 + +concept + [at0000] + +language + original_language = <[ISO_639-1::en]> + +description + original_author = < + ["date"] = <"2020-03-12"> + > + lifecycle_state = <"in_development"> + details = < + ["en"] = < + language = <[ISO_639-1::en]> + copyright = <"© openEHR Foundation"> + > + > + other_details = < + ["licence"] = <"This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/."> + ["custodian_organisation"] = <"openEHR Foundation"> + ["original_namespace"] = <"org.openehr"> + ["original_publisher"] = <"openEHR Foundation"> + ["custodian_namespace"] = <"org.openehr"> + ["MD5-CAM-1.0.1"] = <"C35F0CD7F5EC0C80B580727E02F8D6CC"> + ["build_uid"] = <"7ddc3448-5b39-4161-8c89-df77f4832086"> + ["revision"] = <"0.0.1-alpha"> + > + +definition + CLUSTER[at0000] matches { -- Healthcare worker + items cardinality matches {1..*; unordered} matches { + ELEMENT[at0001] occurrences matches {0..1} matches { -- Is healthcare worker? + value matches { + DV_CODED_TEXT matches { + defining_code matches { + [local:: + at0002, -- Yes + at0003, -- No + at0004] -- Unknown + } + } + } + } + } + } + +ontology + term_definitions = < + ["en"] = < + items = < + ["at0000"] = < + text = <"Healthcare worker"> + description = <"Addition information for Covid screening on healthcare worker status."> + > + ["at0001"] = < + text = <"Is healthcare worker?"> + description = <"*"> + > + ["at0002"] = < + text = <"Yes"> + description = <"Yes"> + > + ["at0003"] = < + text = <"No"> + description = <"No"> + > + ["at0004"] = < + text = <"Unknown"> + description = <"Unknown"> + > + > + > + > diff --git a/better-template/src/test/resources/opt_json/Archetypes/openEHR-EHR-CLUSTER.occupation_record.v1.adl b/better-template/src/test/resources/opt_json/Archetypes/openEHR-EHR-CLUSTER.occupation_record.v1.adl new file mode 100644 index 000000000..9708d8084 --- /dev/null +++ b/better-template/src/test/resources/opt_json/Archetypes/openEHR-EHR-CLUSTER.occupation_record.v1.adl @@ -0,0 +1,594 @@ +archetype (adl_version=1.4; uid=251b76fc-936e-45df-8869-3babe10969cb) + openEHR-EHR-CLUSTER.occupation_record.v1 + +concept + [at0000] + +language + original_language = <[ISO_639-1::en]> + translations = < + ["nb"] = < + language = <[ISO_639-1::nb]> + author = < + ["name"] = <"Silje Ljosland Bakke and Vebjørn Arntzen"> + ["organisation"] = <"Nasjonal IKT HF"> + ["email"] = <"silje.ljosland.bakke@nasjonalikt.no / varntzen@ous-hf.no"> + > + > + ["it"] = < + language = <[ISO_639-1::it]> + author = < + ["name"] = <"Cecilia Mascia"> + ["organisation"] = <"CRS4 - Center for advanced studies, research and development in Sardinia, Pula (Cagliari), Italy"> + ["email"] = <"ceclila.mascia@crs4.it"> + > + > + ["es"] = < + language = <[ISO_639-1::es]> + author = < + ["name"] = <"Diego Bosca"> + ["organisation"] = <"VeraTech for Health"> + ["email"] = <"diebosto@veratech.es"> + > + > + > + +description + original_author = < + ["date"] = <"2010-12-17"> + ["name"] = <"Heather Leslie"> + ["organisation"] = <"Atomica Informatics"> + ["email"] = <"heather.leslie@atomicainformatics.com"> + > + lifecycle_state = <"published"> + other_contributors = <"Morten Aas, Diakonhjemmet Sykehus, Norway","Tomas Alme, DIPS ASA, Norway","Erling Are Hole, Helse Bergen, Norway","Vebjørn Arntzen, Oslo University Hospital, Norway (openEHR Editor)","Koray Atalag, University of Auckland, New Zealand","Heidi Aursand, Oslo universitetssykehus, Norway","Silje Ljosland Bakke, Nasjonal IKT HF, Norway (openEHR Editor)","Marcus Baw, openGPSoC / BawMedical Ltd, United Kingdom","Ivar Berge, Oslo Universitetssykehus, Norway","Anita Bjørnnes, Helse Bergen, Norway","Bjørn Christensen, Helse Bergen HF, Norway","Angela Crovetti, CDC/NIOSH, United States","Lisbeth Dahlhaug, Helse Midt - Norge IT, Norway","Jayne Donaldson, University of Stirling, United Kingdom","Bjørg Eli Hollund, helse-bergen, Norway","Stig Erik Hegrestad, Helse Førde, Norway","Samuel Frade, Marand, Portugal","Hildegard Franke, freshEHR Clinical Informatics Ltd., United Kingdom","Sergio Freire, State University of Rio de Janeiro, Brazil","Mikkel Gaup Grønmo, FSE, Helse Nord, Norway (Nasjonal IKT redaktør)","Heather Grain, Llewelyn Grain Informatics, Australia","Anne Gunn Haugland, Helse Bergen HF, Norway","Sam Heard, Ocean Informatics, Australia","Kristian Heldal, Telemark Hospital Trust, Norway","Jørn Henrik Vold, Helse Bergen, Avdeling for rusmedisin, Norway","Anca Heyd, DIPS ASA, Norway","Teresa Highway, Alberta Health Services, Canada","Annette Hole Sjøborg, DIPS ASA, Norway","Evelyn Hovenga, EJSH Consulting, Australia","Kaja Irgens-Hansen, Yrkesmedisinsk avdeling, Haukeland universitetssykehus, Norway","Susanna Jönsson, Landstinget i Värmland, Sweden","Tom K. Grimsrud, Kreftregisteret, Norway","Tone Klund, DIPS AS, Norway","Nils Kolstrup, Skansen Legekontor og Nasjonalt Senter for samhandling og telemedisin, Norway","Harmony Kosola, Alberta Health Services, Canada","Ron Krawec, Alberta Health Services, Canada","Liv Laugen, Oslo universitetssykehus, Norway","Heather Leslie, Atomica Informatics, Australia (openEHR Editor)","Pedro Leuschner, Centro Hospitalar do Porto, Portugal","Hallvard Lærum, Direktoratet for e-helse, Norway","Rose Mari Eikås, Helse Bergen, Norway","Siv Marie Lien, DIPS ASA, Norway","Hildegard McNicoll, freshEHR Clinical Informatics Ltd., United Kingdom","Ian McNicoll, freshEHR Clinical Informatics, United Kingdom","John Meredith, NHS Wales Informatics Service, United Kingdom","Lars Morgan Karlsen, Nordlandssykehuset Bodø, Norway","Erik Nissen, Cambio Healthcare Systems AB, Sweden","Bjørn Næss, DIPS ASA, Norway","Andrej Orel, Marand d.o.o., Slovenia","Anne Pauline Anderssen, Helse Nord RHF, Norway","Martin Paulson, Sykehuset i Vestfold, Norway","Georg Reinhardt, Helse Fonna, Norway","Tanja Riise, Nasjonal IKT HF, Norway","Gro-Hilde Severinsen, Norwegian center for ehealthresearch, Norway","Line Silsand, Universitetssykehuset i Nord-Norge, Norway","Niclas Skyttberg, Karolinska Institutet, Sweden","Norwegian Review Summary, Nasjonal IKT HF, Norway","Andreas Sundstrom, Capio S:t Gorans Hospital, Sweden","Nyree Taylor, Ocean Informatics, Australia","Tesfay Teame, Folkehelseinstittutet, Norway","Susanne Trønnes, Norway","Jon Tysdahl, Furst medlab AS, Norway","John Tore Valand, Helse Bergen, Norway (openEHR Editor)"> + details = < + ["nb"] = < + language = <[ISO_639-1::nb]> + purpose = <"For å registrere detaljert informasjon om en jobb eller rolle individet har, eller har hatt i en spesifisert tidsperiode."> + keywords = <"arbeid","arbeidstaker","arbeidsgiver","arbeidsforhold","arbeidshistorikk","jobb","ansatt","yrke","arbeidsløs","studerer","student","elev","trygdet","ufør","arbeidssituasjon","erverv","yrkestilknytning","pensjon","pensjonist","attføring","bransje","arbeidsledig","hjemmeværende","stilling","profesjon","frivillig","vernepliktig","sektor","næring","verv"> + copyright = <"© 2010 NEHTA, openEHR Foundation, Nasjonal IKT HF"> + use = <"Brukes for å registrere detaljert informasjon om en jobb eller rolle individet har, eller har hatt i en spesifisert tidsperiode. + +Arketypen omfatter alle typer arbeid eller aktiviteter individet har eller har hatt. For eksempel: En/et betalt eller ubetalt jobb/arbeid/verv, samt ulike roller som for eksempel pensjonist, hjemmeværende eller student. + +Ved å benytte denne arketypen til gjentatte registreringer, vil en få fram en historisk oversikt over nåværende og tidligere arbeidsforhold /roller et individ har eller har hatt. + +Et aktivt, nåværende arbeidsforhold/roller kan bli utledet fra \"Dato for oppstart\" hvis det ikke er registrert noe i \"Dato for opphør\". + +Et individ kan ha mange samtidige arbeidsforhold/rolle, og de kan hver for seg være betalt eller ubetalt. Hvert slik arbeidsforhold registreres i egne instanser av denne arketypen. + +Hvis detaljer om et arbeidsforhold/rolle endrer seg vesentlig, som forandring av tittel eller stillingsprosent, registreres dette i egne instanser av denne arketypen. + +Arketypen er laget for å benyttes i SLOTet \"Arbeidsepisode\" i arketypen EVALUATION.occupation_summary (Arbeidssammendrag), men kan også brukes innen andre ENTRY- eller CLUSTER-arketyper der det er klinisk relevant. + +Det kan fremstå som å være overlapp, reell eller tilsynelatende, mellom dataelementene i denne arketypen og demografiske opplysninger om sysselsetting/arbeidsforhold andre steder i kliniske systemer. Dataelementene i denne arketypen er laget spesifikt for å støtte kliniske bruksområder, inkludert sykemeldinger eller legeerklæringer."> + misuse = <"Brukes ikke for å registrere midlertidige endringer eller episoder innen en enkelt arbeidsepisode, som å være i permisjon. Dette er ikke innenfor anvendelsesområdet for denne arketypen, og skal registreres i et personal- eller HR-system. + +Brukes ikke for å beskrive helserisikoer eller eksponering for farlige substanser i arbeidssituasjonen. Til dette brukes henholdsvis arketypene EVALUATION.health_risk (Helserisiko) eller EVALUATION.exposure. + +Brukes ikke for å registrere informasjon om individets inntektskilder eller detaljer om inntekt. Bruk arketypen EVALUATION.income_summary for dette formålet. + +Brukes ikke for å registrere informasjon om arbeid /rolle for et individ på en bestemt dato (for eksempel 16. juni 2014) eller i løpet av en relativ tidsperiode, som for eksempel \"siste 30 dager\". Dette kan utledes fra \"Dato for oppstart\" hvis det ikke er registrert noe i \"Dato for opphør\", og må registreres i en egen OBSERVATION-arketype for dette formålet."> + > + ["en"] = < + language = <[ISO_639-1::en]> + purpose = <"To record details about a single job or role carried out by an individual during a specified period of time."> + keywords = <"employment","employer","job","occupation","work","profession","unemployed","employee","unemployment","studying","employed","student","sector","profession","volunteer","vocation","trade","worker","volunteer","position"> + copyright = <"© Australian Digital Health Agency, openEHR Foundation, Nasjonal IKT HF"> + use = <"Use to record details about a single job or role carried out by an individual during a specified period of time. + +The scope of this archetype is inclusive of all occupations or activities undertaken by an individual. For example: a paid job or employment; unpaid work of any type such as a volunteer position; or roles such as being retired or a student. + +Multiple instances of this archetype captured over time will result in the aggregation of a history of past and present jobs and/or roles. + +An active, or current occupation may be implied from a 'Date commenced' but no 'Date ceased'. + +An individual may carry out many simultaneous occupations, each of which may be paid or unpaid. Each occupation should be recorded in a separate instance of this archetype. + +If occupation attributes change significantly, such as a change of role/title or number of hours, then this should be recorded as a separate instance of this archetype. + +This archetype has been specifically designed to be used in the 'Occupation episode' SLOT within the EVALUATION.occupation_summary archetype, but can also be used within any other ENTRY or CLUSTER archetypes, where clinically appropriate. + +There may be some apparent or real overlap between the data elements in this archetype and occupation/employment details that may be stored as demographic details in clinical or administrative systems. These data elements have been designed specifically to support clinical purposes including generation of a medical certificate to a current employer."> + misuse = <"Not to be used to record temporary changes or episodes within a single occupation record, such as being on leave. This is out of scope for this archetype and should be part of an employer's human relations system. + +Not to be used for detailed descriptions of health risks or exposure to hazardous substances in the workplace. Use the archetypes EVALUATION.health_risk or EVALUATION.exposure for this purpose. + +Not to be used to record information about sources of income or income details for the individual. Use the EVALUATION.income_summary archetype for this purpose. + +Not to be used to record information about the occupation of an individual at a specific point in time (for example, on June 16, 2014) or during a relative interval of time (for example 'in the past 30 days'. Use an appropriate OBSERVATION archetype for this purpose."> + > + ["it"] = < + language = <[ISO_639-1::it]> + purpose = <"Registrare i dettagli della singola professione svolta o ruolo ricoperto da un individuo durante un determinato periodo di tempo."> + keywords = <"lavoro, impiego, datore di lavoro, occupazione, disoccupazione, professione, disoccupato, occupato, dipendente, impiegato, studente, settore, volontario, vocazione, mestiere, lavoratore, posizione", ...> + use = <"Usato per registrare i dettagli della singola professione svolta o ruolo ricoperto da un individuo durante un determinato periodo di tempo. + +L'ambito di questo archetipo comprende tutte le occupazioni o attività svolte da un individuo. Ad esempio: un lavoro o impiego retribuiti; un qualsiasi lavoro non retribuito, come un'attività di volontariato; o ruoli come essere in pensione o uno studente. + +Più istanze di questo archetipo catturate nel tempo possono essere aggregate per costruire la storia occupazionale di un individuo, che comprende occupazioni e ruoli passati e presenti. + +È possibile dedurre se l'occupazione sia attiva/corrente se è presente una 'Data di inizio' ma non una 'Data di cessazione'. + +Un individuo può avere più occupazioni contemporaneamente, ciascuna delle quali può essere retribuita o meno. Ogni occupazione dovrebbe essere registrata in una istanza separata di questo archetipo. + +Se i dettagli dell'occupazione cambiano significativamente, ad esempio in caso di modifica del ruolo/titolo o numero di ore, questo dovrebbe corrispondere ad un'istanza separata di questo archetipo. + +Questo archetipo è stato sviluppato per essere usato nello SLOT 'Episodio lavorativo' all'interno dell'archetipo EVALUATION.occupation_summary, ma è possibile utilizzarlo all'interno di altri archetipi di tipo ENTRY o CLUSTER quando clinicamente appropriato. + +Ci potrebbe essere una sovrapposizione, apparente o reale, tra i dati all'interno di questo archetipo e i dettegli sull'occupazione/impiego memorizzati come informazioni demografiche all'interno di sistemi clinici o amministrativi. I contenuti sono stati espressamente progettati per supportare l'attività clinica, compresa la generazione di certificati medici per un datore di lavoro."> + misuse = <"Non utilizzare per memorizzare cambiamenti o episodi temporanei all'interno di un singolo record di occupazione, come ad esempio essere in congedo. Questo non rientra nello scopo dell'archetipo e dovrebbe far parte del sistema di gestione delle risorse umane del datore di lavoro. + +Non utilizzare per descrizioni dettagliate dei rischi per la salute o dell'esposizione a sostanze pericolose nel luogo di lavoro. Utilizzare invece gli archetipi EVALUATION.health_risk o EVALUATION.exposure. + +Non utilizzare per memorizzare informazioni sulle fonti o dettagli del reddito dell'individuo. Per questo scopo, utilizzare l'archetipo EVALUATION.income_summary. + +Non utilizzare per memorizzare informazioni sull'occupazione di un individuo in uno specifico punto nel tempo (ad esempio, il 16 giugno 2014) o durante un intervallo di tempo (ad esempio 'negli ultimi 30 giorni'). Per questo scopo, usare un appropriato archetipo di tipo OBSERVATION. "> + > + ["es"] = < + language = <[ISO_639-1::es]> + purpose = <"Para registrar detalles sobre un trabajo o rol llevado a cabo por un individuo durante un periodo de tiempo especificado."> + keywords = <"empleo","empleador","trabajo","ocupación","tarea","profesión","desempleado","empleado","desempleo","estudiando","empleado","estudiante","sector","profesión","voluntario","vocación","comercio","trabajador","voluntario","cargo"> + use = <"Usar para registrar detalles sobre un trabajo o rol particular llevado a cabo por un individuo durante un periodo de tiempo especificado. + +El alcance de este arquetipo incluye todos los empleos o actividades llevadas a cabo por el individuo. Por ejemplo: Un trabajo o empleo pagado; trabajo no remunerado de cualquier tipo como voluntario; o roles tales como estar jubilado o ser estudiante. + +Múltiples instancias de este arquetipo capturadas a lo largo del tiempo resultarán en una agregación de un histórico de trabajos y/o roles presentes o pasados. + +Un trabajo actual puede deducirse de la 'Fecha empezado' pero no de la 'Fecha finalizado'. + +Un individuo puede llevar a cabo muchas ocupaciones al mismo tiempo, las cuales pueden ser remuneradas o no remuneradas. Cada ocupación debería de ser registrada en una instancia separada de este arquetipo. + +Si los atributos de la ocupación cambian significativamente, tales como cambios en el título/rol o el número de horas, éstas se deberían de registrar en una instancia separada de este arquetipo. + +Este arquetipo ha sido específicamente diseñado para ser usado en el SLOT de 'Episodio de ocupación' dentro del arquetipo EVALUATION.occupation_summary, pero también puede ser usado dentro de cualquier otro arquetipo ENTRY o CLUSTER, cuando sea clínicamente apropiado. + +Puede haber una superposición aparente o real entre los elementos de datos en este arquetipo y detalles sobre la ocupación/empleo que puedan haber sido incluidos como detalles demográficos en sistemas clínicos o administrativos. Estos elementos de datos se han diseñado específicamente para dar soporte a propósitos clínicos como puede ser la generación de un certificado médico para el empleador actual."> + misuse = <"No debe ser usado para registrar cambios temporales o episodios dentro de un único registro ocupacional, tales como estar de baja. Esto está fuera del alcance de este arquetipo y debería ser parte de un sistema de recursos humanos del empleador. + +No debe ser usado para una descripción detallada de los riesgos de salud o exposición a sustancias nocivas en el lugar de trabajo. Para este propósito use los arquetipos EVALUATION.health_risk o EVALUATION.exposure. + +No debe ser usado para registrar información sobre fuentes o detalles de ingresos de un individuo. Para este propósito use el arquetipo EVALUATION.income_summary. + +No debe ser usado para registrar información sobre la ocupación de un individuo en un punto concreto de tiempo (por ejemplo, el 16 de Junio de 2014) o durante un periodo de tiempo relativo (por ejemplo 'durante los últimos 30 días'). Para este propósito use un arquetipo OBSERVATION adecuado."> + > + > + other_details = < + ["licence"] = <"This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/."> + ["custodian_organisation"] = <"openEHR Foundation"> + ["references"] = <"Derived from: Employment Summary, Draft Archetype [Internet]. NEHTA, Australia, NEHTA Clinical Knowledge Manager [cited: 2016-01-11]. No longer available."> + ["current_contact"] = <"Heather Leslie, Atomica Informatics"> + ["original_namespace"] = <"org.openehr"> + ["original_publisher"] = <"openEHR Foundation"> + ["custodian_namespace"] = <"org.openehr"> + ["MD5-CAM-1.0.1"] = <"8A419A318393ABB88CF8188C747918D2"> + ["build_uid"] = <"7dcc2206-32d3-4e9f-89a2-a05bdeedf3b9"> + ["revision"] = <"1.0.2"> + > + +definition + CLUSTER[at0000] matches { -- Occupation record + items cardinality matches {1..*; unordered} matches { + ELEMENT[at0005] matches { -- Job title/role + value matches { + DV_TEXT matches {*} + } + } + allow_archetype CLUSTER[at0004] occurrences matches {0..*} matches { -- Organisation details + include + archetype_id/value matches {/openEHR-EHR-CLUSTER\.organisation(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.organisation(-[a-zA-Z0-9_]+)*\.v1/} + } + ELEMENT[at0016] occurrences matches {0..1} matches { -- Description + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0007] occurrences matches {0..1} matches { -- Date commenced + value matches { + DV_DATE_TIME matches {*} + } + } + ELEMENT[at0001] occurrences matches {0..1} matches { -- Paid employment status + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0013] occurrences matches {0..1} matches { -- Full time equivalent + value matches { + DV_PROPORTION matches { + numerator matches {|>=0.0|} + type matches {1,2} + } + DV_CODED_TEXT matches { + defining_code matches { + [local:: + at0020, -- Full-time + at0021] -- Part-time + } + } + } + } + ELEMENT[at0019] occurrences matches {0..1} matches { -- Time allocated + value matches { + C_DV_QUANTITY < + + list = < + ["1"] = < + units = <"h/d"> + magnitude = <|>=0.0|> + precision = <|2|> + > + ["2"] = < + units = <"h/wk"> + magnitude = <|>=0.0|> + precision = <|2|> + > + ["3"] = < + units = <"h/mo"> + magnitude = <|>=0.0|> + precision = <|2|> + > + ["4"] = < + units = <"h/a"> + magnitude = <|>=0.0|> + precision = <|2|> + > + ["5"] = < + units = <"d/wk"> + magnitude = <|>=0.0|> + precision = <|2|> + > + ["6"] = < + units = <"d/mo"> + magnitude = <|>=0.0|> + precision = <|2|> + > + ["7"] = < + units = <"wk/mo"> + magnitude = <|>=0.0|> + precision = <|2|> + > + ["8"] = < + units = <"d/a"> + magnitude = <|>=0.0|> + precision = <|2|> + > + ["9"] = < + units = <"wk/a"> + magnitude = <|>=0.0|> + precision = <|2|> + > + ["10"] = < + units = <"mo/a"> + magnitude = <|>=0.0|> + precision = <|2|> + > + > + > + } + } + ELEMENT[at0002] occurrences matches {0..1} matches { -- Industry category + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0006] occurrences matches {0..1} matches { -- Job category + value matches { + DV_TEXT matches {*} + } + } + allow_archetype CLUSTER[at0018] occurrences matches {0..*} matches { -- Additional details + include + archetype_id/value matches {/.*/} + } + ELEMENT[at0008] occurrences matches {0..1} matches { -- Date ceased + value matches { + DV_DATE_TIME matches {*} + } + } + ELEMENT[at0014] occurrences matches {0..1} matches { -- Comment + value matches { + DV_TEXT matches {*} + } + } + } + } + +ontology + term_definitions = < + ["en"] = < + items = < + ["at0000"] = < + text = <"Occupation record"> + description = <"A single job or role carried out by an individual during a specified period of time."> + > + ["at0001"] = < + text = <"Paid employment status"> + description = <"The status of a worker in terms of being paid or unpaid."> + comment = <"For example: unpaid; paid; self-employed; or volunteer. Coding with a terminology is desirable, where possible."> + > + ["at0002"] = < + text = <"Industry category"> + description = <"The type of industry in which the individual works."> + comment = <"For example: Mining, manufacturing, construction. Coding with a terminology is desirable, where possible."> + > + ["at0004"] = < + text = <"Organisation details"> + description = <"Details about the employer or institution."> + > + ["at0005"] = < + text = <"Job title/role"> + description = <"The main job title or the role of the individual."> + comment = <"For example: Chief Executive Officer; Carer; or Student. Each of these job titles or roles may be comprised of multiple duties."> + > + ["at0006"] = < + text = <"Job category"> + description = <"The type of job undertaken by the individual."> + comment = <"Coding with a terminology is desirable, where possible, such as ISCO-08. +For example: Sales manager or software engineer."> + > + ["at0007"] = < + text = <"Date commenced"> + description = <"The date when an individual commenced the job or role."> + > + ["at0008"] = < + text = <"Date ceased"> + description = <"The date when an individual ceased working in a job or role."> + > + ["at0013"] = < + text = <"Full time equivalent"> + description = <"The time spent in this job or role relative to full-time."> + comment = <"Full time equivalent may also be known as 'FTE'. For example: 0.5; 50 %; or \"part time\"."> + > + ["at0014"] = < + text = <"Comment"> + description = <"Additional narrative about the occupation record not captured in other fields."> + > + ["at0016"] = < + text = <"Description"> + description = <"Narrative description about the job or role carried out by the individual."> + > + ["at0018"] = < + text = <"Additional details"> + description = <"Further detail about an occupation record."> + comment = <"For example: workplace location and conditions; or combat zone experience."> + > + ["at0019"] = < + text = <"Time allocated"> + description = <"The amount of time an individual is allocated to carry out the job or role per specified period of this occupation record."> + comment = <"For example: '3 days per week', '10 days per month' or '2 hours per day'."> + > + ["at0020"] = < + text = <"Full-time"> + description = <"The individual carries out this occupation for equal to or more than the amount of time that is officially regarded as 'full-time' for the occupation."> + > + ["at0021"] = < + text = <"Part-time"> + description = <"The individual carries out this occupation for less than the amount of time that is officially regarded as 'full-time' for the occupation."> + > + > + > + ["nb"] = < + items = < + ["at0000"] = < + text = <"Arbeidsforhold/rolle"> + description = <"En jobb eller rolle individet har, eller har hatt i en spesifisert tidsperiode."> + > + ["at0001"] = < + text = <"Status lønnet arbeid"> + description = <"Om individet har lønnet eller ulønnet arbeid."> + comment = <"For eksempel: \"Ulønnet\", \"Lønnet\", \"Selvstendig næringsdrivende\" eller \"Frivillig arbeid\". Koding av denne statusen med en terminologi er anbefalt, der det er mulig."> + > + ["at0002"] = < + text = <"Bransje"> + description = <"Klassifisering av bransje eller sektor der individet har arbeidsforholdet/rollen."> + comment = <"For eksempel: \"Jordbruk, skogbruk og fiske\", \"Varehandel\", \"Bygg- og anleggsvirksomhet\". Koding av \"Bransje\" med en terminologi er anbefalt, der det er mulig."> + > + ["at0004"] = < + text = <"Organisasjonsdetaljer"> + description = <"Detaljer om arbeidsgiver eller institusjon/organisasjon."> + > + ["at0005"] = < + text = <"Tittel/rolle"> + description = <"Stillingstittel eller betegnelse for dette arbeidsforholdet/rollen/vervet."> + comment = <"For eksempel: Administrerende direktør, hjemmeværende eller student. Hver av disse stillingstitlene eller rollene kan omfatte flere arbeidsoppgaver."> + > + ["at0006"] = < + text = <"Yrke"> + description = <"Klassifisering av yrket individet har."> + comment = <"Koding med en terminologi er ønskelig om mulig. For eksempel kategorisering i henhold til STYRK-08. +For eksempel: \"Salgssjef\" eller \"Programvareutvikler\"."> + > + ["at0007"] = < + text = <"Dato for oppstart"> + description = <"Datoen arbeidsforholdet/rollen startet."> + > + ["at0008"] = < + text = <"Dato for opphør"> + description = <"Datoen arbeidsforholdet/rollen opphørte."> + > + ["at0013"] = < + text = <"Heltidsekvivalent"> + description = <"Arbeidsforholdet/rollens andel eller prosent av en heltidsstilling."> + comment = <"Definisjonen av \"heltid\" kan variere mellom ulike yrker. For eksempel \"0,5\", 50 %\" eller \"deltid\". I noen situasjoner kan det være passende å registrere faktisk antall arbeidstimer i elementet \"Antall arbeidstimer\"."> + > + ["at0014"] = < + text = <"Kommentar"> + description = <"Ytterligere fritekstkommentar om arbeidsforholdet/rollen som ikke passer i andre felt."> + > + ["at0016"] = < + text = <"Beskrivelse"> + description = <"Fritekstbeskrivelse av arbeidsforholdet/rollen."> + > + ["at0018"] = < + text = <"Ytterligere detaljer"> + description = <"Ytterligere detaljer om arbeidsforholdet/rollen."> + comment = <"For eksempel: Forhold på arbeidsplassen eller erfaring fra krigssoner."> + > + ["at0019"] = < + text = <"Avsatt tid"> + description = <"Den avtalte tiden som er satt av til å utføre jobben eller rollen per tidsperiode for dette arbeidsforholdet."> + comment = <"For eksempel: \"3 dager per uke\", \"10 dager per måned\" eller \"2 timer per dag\"."> + > + ["at0020"] = < + text = <"Heltid"> + description = <"Individet bruker lik eller lengre tid på jobben/rollen enn definisjonen av full stilling i lov- eller avtaleverk (tariffavtale)."> + > + ["at0021"] = < + text = <"Deltid"> + description = <"Individet bruker kortere tid på jobben/rollen enn definisjonen av full stilling i lov- eller avtaleverk (tariffavtale)."> + > + > + > + ["it"] = < + items = < + ["at0000"] = < + text = <"Occupazione"> + description = <"Singola professione svolta o ruolo ricoperto da un individuo durante un determinato periodo di tempo."> + > + ["at0001"] = < + text = <"Stato di retribuzione"> + description = <"Lo status di un lavoratore in termini di retribuzione o non retribuzione."> + comment = <"Ad esempio: non retribuito; retribuito; lavoratore autonomo; o volontario. + +Si preferisce, ove possibile, la codifica con una terminologia."> + > + ["at0002"] = < + text = <"Settore industriale"> + description = <"Il settore dell'azienda in cui l'individuo lavora."> + comment = <"Ad esempio: Estrazione, produzione, costruzione. + +Si preferisce, ove possibile, la codifica con una terminologia."> + > + ["at0004"] = < + text = <"Dettagli sull'azienda"> + description = <"Dettagli sul datore di lavoro o sull'azienda."> + > + ["at0005"] = < + text = <"Qualifica/ruolo"> + description = <"La qualifica professionale o il ruolo dell'individuo."> + comment = <"Ad esempio: Amminstratore delegato; Assistente; o Studente. Ciascuna qualifica o ruolo può comprendere più mansioni."> + > + ["at0006"] = < + text = <"Categoria professionale"> + description = <"Il tipo di lavoro svolto dall'individuo."> + comment = <"La codifica con una terminologia è preferibile, quando possibile, ad esempio attraverso la ISCO-08. + +Ad esempio: Responsabile delle vendite o ingegnere del software."> + > + ["at0007"] = < + text = <"Data di inizio"> + description = <"Data in cui l'individuo a iniziato ad esercitare la professione o ricoprire il ruolo."> + > + ["at0008"] = < + text = <"Data di cessazione"> + description = <"Data in cui l'individuo a terminato di esercitare la professione o ricoprire il ruolo."> + > + ["at0013"] = < + text = <"Equivalente a tempo pieno"> + description = <"La porzione di tempo dedicato a questa professione/ruolo rispetto al tempo pieno. "> + comment = <"L' equivalente a tempo pieno è anche conosciuto come 'FTE' - Full time equivalent. + +Ad esempio: 0.5; 50 %; o \"part time\". "> + > + ["at0014"] = < + text = <"Commento"> + description = <"Note aggiuntive sull'occupazione non rilevate dagli altri campi. "> + > + ["at0016"] = < + text = <"Descrizione"> + description = <"Descrizione narrativa della professione svolta o del ruolo ricoperto dall'individuo. "> + > + ["at0018"] = < + text = <"Ulteriori dettagli"> + description = <"Ulteriori dettagli sull'occupazione."> + comment = <"Ad esempio: l'ubicazione del posto di lavoro e le condizioni; o esperienza in zone di combattimento."> + > + ["at0019"] = < + text = <"Orario di lavoro"> + description = <"Il tempo assegnato all'individuo per svolgere la professione/ruolo nel periodo specificato."> + comment = <"Ad esempio: '3 giorni a settimana', '10 giorni al mese' o '2 ore al giorno'."> + > + ["at0020"] = < + text = <"Tempo pieno"> + description = <"Il lavoro è svolto per un periodo di tempo pari o superiore a quello ufficialmente considerato a \"tempo pieno\" per l'occupazione."> + > + ["at0021"] = < + text = <"Tempo parziale"> + description = <"Il lavoro è svolto per un periodo di tempo inferiore a quello ufficialmente considerato a \"tempo pieno\" per l'occupazione."> + > + > + > + ["es"] = < + items = < + ["at0000"] = < + text = <"Registro ocupacional"> + description = <"Un único trabajo o rol llevado a cabo por un individuo durante un periodo de tiempo especificado."> + > + ["at0001"] = < + text = <"Estado trabajo remunerado."> + description = <"El estado de un trabajador en términos de ser pagado o no pagado."> + comment = <"Por ejemplo: no remunerado; autoempelado; o voluntario. Se recomienda codificarlo con una terminología donde sea posible."> + > + ["at0002"] = < + text = <"Sector industrial"> + description = <"El tipo de sector industrial en el que trabaja el individuo."> + comment = <"Por ejemplo: Minería, Fabricación, Construcción. Donde sea posible se recomienda codificar con una terminología."> + > + ["at0004"] = < + text = <"Detalles de la organización"> + description = <"Detalles sobre el empleador o institución."> + > + ["at0005"] = < + text = <"Cargo/rol"> + description = <"El cargo, puesto o rol del individuo"> + comment = <"Por ejemplo: Director ejecutivo; Cuidador; o Estudiante. Cada uno de estos cargos o roles pueden estar compuestos de muchos deberes."> + > + ["at0006"] = < + text = <"Categoría profesional"> + description = <"El tipo de trabajo llevado a cabo por el individuo."> + comment = <"Donde sea posible se recomienda codificar con una terminología, tal como CIUO-08"> + > + ["at0007"] = < + text = <"Fecha de inicio"> + description = <"La fecha en la que un individuo inicia el trabajo o rol."> + > + ["at0008"] = < + text = <"Fecha de fin"> + description = <"La fecha cuando un individuo deja de trabajar en un trabajo o rol."> + > + ["at0013"] = < + text = <"Equivalencia a tiempo completo"> + description = <"El tiempo usado en este trabajo o rol relativo a tiempo completo."> + comment = <"El tiempo completo puede ser también conocido como 'ETC'. Por ejemplo: 0.5; 50 %; o \"tiempo parcial\""> + > + ["at0014"] = < + text = <"Comentario"> + description = <"Narrativa adiciona sobre el registro de ocupación no capturada en otros campos."> + > + ["at0016"] = < + text = <"Descripción"> + description = <"Descripción narrativa sobre el trabajo o rol llevado a cabo por el individuo."> + > + ["at0018"] = < + text = <"Detalles adicionales"> + description = <"Información adicional sobre un registro ocupacional."> + comment = <"Por ejemplo: Localización y condiciones del lugar de trabajo; o experiencia en zona de combate."> + > + ["at0019"] = < + text = <"Tiempo asignado"> + description = <"La cantidad de tiempo que se le asigna a un individuo para llevar a cabo el trabajo o rol por periodo específico de su registro ocupacional."> + comment = <"Por ejemplo: '3 días a la semana', '10 días al mes' o '2 horas al día'"> + > + ["at0020"] = < + text = <"Tiempo completo"> + description = <"El individuo lleva a cabo su ocupación por un tiempo igual o superior al oficialmente establecido como 'tiempo completo' para dicha ocupación."> + > + ["at0021"] = < + text = <"Tiempo parcial"> + description = <"El individuo lleva a cabo su ocupación por un tiempo menor al oficialmente establecido como 'tiempo completo' para dicha ocupación."> + > + > + > + > diff --git a/better-template/src/test/resources/opt_json/Archetypes/openEHR-EHR-CLUSTER.organisation_cc.v0.adl b/better-template/src/test/resources/opt_json/Archetypes/openEHR-EHR-CLUSTER.organisation_cc.v0.adl new file mode 100644 index 000000000..948456ab1 --- /dev/null +++ b/better-template/src/test/resources/opt_json/Archetypes/openEHR-EHR-CLUSTER.organisation_cc.v0.adl @@ -0,0 +1,135 @@ +archetype (adl_version=1.4; uid=b1a8e64b-0cb5-45af-97e0-55e787b70d28) + openEHR-EHR-CLUSTER.organisation_cc.v0 + +concept + [at0000] + +language + original_language = <[ISO_639-1::en]> + +description + original_author = < + ["date"] = <"2018-07-20"> + ["name"] = <"Hildegard McNicoll"> + ["organisation"] = <"freshEHR Clinical Informatics Ltd."> + ["email"] = <"hildi@freshehr.com"> + > + lifecycle_state = <"in_development"> + details = < + ["en"] = < + language = <[ISO_639-1::en]> + purpose = <"For the recording of organisation details aligned with corresponding FHIR resource."> + copyright = <"© Apperta Foundation, openEHR Foundation"> + use = <"Use to record organisation details aligned with the corresponding FHIR resources. + +The slots for telecoms, address and contact should be filled with the appropriate FHIR resource-aligned clusters. + +This cluster archetype is intended to be used inside FHIR resource aligned archetypes such as CLUSTER.fhir_contact.v0 and CLUSTER.fhir_practitioner.v0."> + > + > + other_details = < + ["licence"] = <"This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/."> + ["custodian_organisation"] = <"openEHR Foundation"> + ["references"] = <"https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-Organization-1 cited 20-Jul-2018."> + ["current_contact"] = <"Hildegard McNicoll, freshEHR Clinical Informatics Ltd."> + ["original_namespace"] = <"org.openehr"> + ["original_publisher"] = <"openEHR Foundation"> + ["custodian_namespace"] = <"org.openehr"> + ["MD5-CAM-1.0.1"] = <"AA189406473B39A80DB01615BA770868"> + ["build_uid"] = <"e98583a8-38bc-4b02-a11f-c239d06bf9d6"> + ["revision"] = <"0.0.1-alpha"> + > + +definition + CLUSTER[at0000] matches { -- Organisation + items cardinality matches {1..*; unordered} matches { + allow_archetype CLUSTER[at0018] occurrences matches {0..*} matches { -- Identifier + include + archetype_id/value matches {/openEHR-EHR-CLUSTER\.identifier_cc\.v0/} + } + ELEMENT[at0010] occurrences matches {0..1} matches { -- Active + value matches { + DV_BOOLEAN matches {*} + } + } + ELEMENT[at0011] occurrences matches {0..*} matches { -- Type + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0012] occurrences matches {0..1} matches { -- Name + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0013] occurrences matches {0..*} matches { -- Alias + value matches { + DV_TEXT matches {*} + } + } + allow_archetype CLUSTER[at0014] occurrences matches {0..*} matches { -- Telecom + include + archetype_id/value matches {/openEHR-EHR-CLUSTER\.telecom_cc\.v0/} + } + allow_archetype CLUSTER[at0015] occurrences matches {0..*} matches { -- Address + include + archetype_id/value matches {/openEHR-EHR-CLUSTER\.address_cc\.v0/} + } + allow_archetype CLUSTER[at0017] occurrences matches {0..*} matches { -- Part of + include + archetype_id/value matches {/openEHR-EHR-CLUSTER\.organisation_cc\.v0/} + } + allow_archetype CLUSTER[at0016] occurrences matches {0..*} matches { -- Contact + include + archetype_id/value matches {/openEHR-EHR-CLUSTER\.contact_cc\.v0/} + } + } + } + +ontology + term_definitions = < + ["en"] = < + items = < + ["at0000"] = < + text = <"Organisation"> + description = <"Organisation details aligned with FHIR resource."> + > + ["at0010"] = < + text = <"Active"> + description = <"Whether the organization's record is still in active use."> + > + ["at0011"] = < + text = <"Type"> + description = <"The kind(s) of organization that this is."> + > + ["at0012"] = < + text = <"Name"> + description = <"Name associated with the organisation."> + > + ["at0013"] = < + text = <"Alias"> + description = <"A list of alternate names that the organisation is known as, or was known as in the past."> + > + ["at0014"] = < + text = <"Telecom"> + description = <"Contact detail for the organisation."> + > + ["at0015"] = < + text = <"Address"> + description = <"Address detail for the organisation."> + > + ["at0016"] = < + text = <"Contact"> + description = <"Contact for the organisation for a certain purpose."> + > + ["at0017"] = < + text = <"Part of"> + description = <"The organization of which this organization forms a part."> + > + ["at0018"] = < + text = <"Identifier"> + description = <"The organisation identifier(s)."> + > + > + > + > diff --git a/better-template/src/test/resources/opt_json/Archetypes/openEHR-EHR-CLUSTER.outbreak_exposure.v0.adl b/better-template/src/test/resources/opt_json/Archetypes/openEHR-EHR-CLUSTER.outbreak_exposure.v0.adl new file mode 100644 index 000000000..f5577c4ab --- /dev/null +++ b/better-template/src/test/resources/opt_json/Archetypes/openEHR-EHR-CLUSTER.outbreak_exposure.v0.adl @@ -0,0 +1,131 @@ +archetype (adl_version=1.4; uid=54ed4751-7f28-4558-ab97-c683650f1ac0) + openEHR-EHR-CLUSTER.outbreak_exposure.v0 + +concept + [at0000] + +language + original_language = <[ISO_639-1::en]> + +description + original_author = < + ["date"] = <"2020-02-27"> + ["name"] = <"Ian McNicoll"> + ["organisation"] = <"freshEHR Clinical Informatics Ltd."> + ["email"] = <"ian@freshehr.com"> + > + lifecycle_state = <"in_development"> + details = < + ["en"] = < + language = <[ISO_639-1::en]> + keywords = <"location, outbreak, infection,", ...> + copyright = <"© openEHR Foundation"> + use = <"To record details of potential exposure to a potentially harmful agent, relating to a specific location, typically an outbreak of infectious disease."> + > + > + other_details = < + ["licence"] = <"This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/."> + ["custodian_organisation"] = <"openEHR Foundation"> + ["original_namespace"] = <"org.openehr"> + ["original_publisher"] = <"openEHR Foundation"> + ["custodian_namespace"] = <"org.openehr"> + ["MD5-CAM-1.0.1"] = <"8F872A09963D031C6CB5FD7F26A0137A"> + ["build_uid"] = <"05f2b51b-1338-4a44-a1b9-fc581080f74d"> + ["revision"] = <"0.0.1-alpha"> + > + +definition + CLUSTER[at0000] matches { -- Location-based exposure + items cardinality matches {1..*; unordered} matches { + ELEMENT[at0007] occurrences matches {0..*} matches { -- Outbreak location + value matches { + DV_TEXT matches {*} + DV_CODED_TEXT matches {*} + } + name matches { + DV_CODED_TEXT matches { + defining_code matches { + [local:: + at0026, -- City + at0027, -- Region + at0028] -- Country + } + } + } + } + ELEMENT[at0021] occurrences matches {0..*} matches { -- Location identifier + value matches { + DV_IDENTIFIER matches {*} + } + } + ELEMENT[at0024] occurrences matches {0..1} matches { -- Risk category + value matches { + DV_CODED_TEXT matches {*} + DV_TEXT matches {*} + DV_ORDINAL matches {*} + } + } + ELEMENT[at0022] occurrences matches {0..1} matches { -- Date entered location + value matches { + DV_DATE matches {*} + } + } + ELEMENT[at0023] occurrences matches {0..1} matches { -- Date left location + value matches { + DV_DATE_TIME matches {*} + } + } + allow_archetype CLUSTER[at0025] occurrences matches {0..*} matches { -- Sub-location + include + archetype_id/value matches {/.*|openEHR-EHR-CLUSTER\.outbreak_exposure\.v0/} + } + } + } + +ontology + term_definitions = < + ["en"] = < + items = < + ["at0000"] = < + text = <"Location-based exposure"> + description = <"Details of potential exposure to a potentially harmful agent, relating to a specific location, typically an outbreak of infectious disease."> + > + ["at0007"] = < + text = <"Outbreak location"> + description = <"*"> + > + ["at0021"] = < + text = <"Location identifier"> + description = <"*"> + > + ["at0022"] = < + text = <"Date entered location"> + description = <"*"> + > + ["at0023"] = < + text = <"Date left location"> + description = <"*"> + > + ["at0024"] = < + text = <"Risk category"> + description = <"*"> + > + ["at0025"] = < + text = <"Sub-location"> + description = <"*"> + > + ["at0026"] = < + text = <"City"> + description = <"The name of the city visited."> + > + ["at0027"] = < + text = <"Region"> + description = <"The name of a region or district visited."> + > + ["at0028"] = < + text = <"Country"> + description = <"The name of the country visited."> + > + > + > + > diff --git a/better-template/src/test/resources/opt_json/Archetypes/openEHR-EHR-CLUSTER.overcrowding_screening.v0.adl b/better-template/src/test/resources/opt_json/Archetypes/openEHR-EHR-CLUSTER.overcrowding_screening.v0.adl new file mode 100644 index 000000000..5146831f4 --- /dev/null +++ b/better-template/src/test/resources/opt_json/Archetypes/openEHR-EHR-CLUSTER.overcrowding_screening.v0.adl @@ -0,0 +1,71 @@ +archetype (adl_version=1.4; uid=308cb826-e224-4456-abba-b7fd0faf5ffd) + openEHR-EHR-CLUSTER.overcrowding_screening.v0 + +concept + [at0000] + +language + original_language = <[ISO_639-1::en]> + +description + original_author = < + ["date"] = <"2020-03-13"> + ["name"] = <"Heather Leslie"> + ["organisation"] = <"Atomica Informatics"> + ["email"] = <"heather.leslie@atomicainformatics.com"> + > + lifecycle_state = <"in_development"> + details = < + ["en"] = < + language = <[ISO_639-1::en]> + purpose = <"To record screening parameters that help to identify when a dwelling is too small for the size and composition of the household living in it."> + copyright = <"© openEHR Foundation"> + use = <"Use to record screening parameters that help to identify when a dwelling is too small for the size and composition of the household living in it."> + > + > + other_details = < + ["licence"] = <"This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/."> + ["custodian_organisation"] = <"openEHR Foundation"> + ["original_namespace"] = <"org.openehr"> + ["original_publisher"] = <"openEHR Foundation"> + ["custodian_namespace"] = <"org.openehr"> + ["MD5-CAM-1.0.1"] = <"2E86C36DB5F28FF22F6A30301022EF81"> + ["build_uid"] = <"373ffd56-2dcc-4215-9069-26ced0c60fd4"> + ["revision"] = <"0.0.1-alpha"> + > + +definition + CLUSTER[at0000] matches { -- Overcrowding screening + items cardinality matches {1..*; unordered} matches { + ELEMENT[at0001] occurrences matches {0..1} matches { -- Persons per room + value matches { + DV_COUNT matches {*} + } + } + ELEMENT[at0002] occurrences matches {0..1} matches { -- Persons per bedroom + value matches { + DV_COUNT matches {*} + } + } + } + } + +ontology + term_definitions = < + ["en"] = < + items = < + ["at0000"] = < + text = <"Overcrowding screening"> + description = <"Screening to identify when a dwelling is too small for the size and composition of the household living in it."> + > + ["at0001"] = < + text = <"Persons per room"> + description = <"Number of people per room in a dwelling."> + > + ["at0002"] = < + text = <"Persons per bedroom"> + description = <"Number of people per bedroom in a dwelling."> + > + > + > + > diff --git a/better-template/src/test/resources/opt_json/Archetypes/openEHR-EHR-CLUSTER.problem_qualifier.v1.adl b/better-template/src/test/resources/opt_json/Archetypes/openEHR-EHR-CLUSTER.problem_qualifier.v1.adl new file mode 100644 index 000000000..056476902 --- /dev/null +++ b/better-template/src/test/resources/opt_json/Archetypes/openEHR-EHR-CLUSTER.problem_qualifier.v1.adl @@ -0,0 +1,1519 @@ +archetype (adl_version=1.4; uid=31b57fae-c87d-415d-8ccf-4549c51f4b3c) + openEHR-EHR-CLUSTER.problem_qualifier.v1 + +concept + [at0000] + +language + original_language = <[ISO_639-1::en]> + translations = < + ["de"] = < + language = <[ISO_639-1::de]> + author = < + ["name"] = <"Simon Schumacher"> + ["organisation"] = <"HiGHmed"> + ["email"] = <"sschuma9@uni-koeln.de"> + > + > + ["nb"] = < + language = <[ISO_639-1::nb]> + author = < + ["name"] = <"John Tore Valand, Silje Ljosland Bakke"> + ["organisation"] = <"Helse Bergen HF, Nasjonal IKT HF"> + > + > + ["ko"] = < + language = <[ISO_639-1::ko]> + author = < + ["name"] = <"Seung-Jong Yu"> + ["organisation"] = <"InfoClinic Co.,Ltd."> + ["email"] = <"seungjong.yu@gmail.com"> + > + accreditation = <"M.D."> + > + ["pt-br"] = < + language = <[ISO_639-1::pt-br]> + author = < + ["name"] = <"Adriana Kitajima, Debora Farage, Fernanda Maia, Ana Andrade e Clovis Puttini"> + ["organisation"] = <"Core Consulting"> + ["email"] = <"contato@coreconsulting.com.br"> + > + accreditation = <"Hospital Alemão Oswaldo Cruz (HAOC)"> + > + ["sl"] = < + language = <[ISO_639-1::sl]> + author = < + ["name"] = <"mag. Biljana Prinčič"> + ["organisation"] = <"Marand d.o.o., Ljubljana, Slovenija"> + ["email"] = <"biljana.princic@marand.si"> + > + > + ["it"] = < + language = <[ISO_639-1::it]> + author = < + ["name"] = <"Francesca Frexia"> + ["organisation"] = <"CRS4 - Center for advanced studies, research and development in Sardinia, Pula (Cagliari), Italy"> + ["email"] = <"francesca.frexia@crs4.it"> + > + > + > + +description + original_author = < + ["date"] = <"2013-05-29"> + ["name"] = <"Dr Ian McNicoll"> + ["organisation"] = <"freshEHR Clinical Informatics, United Kingdom"> + ["email"] = <"ian@freshehr.com"> + > + lifecycle_state = <"in_development"> + other_contributors = <"Nadim Anani, Karolinska Institutet, Sweden","Erling Are Hole, Helse Bergen, Norway","Vebjørn Arntzen, Oslo University Hospital, Norway","Koray Atalag, University of Auckland, New Zealand","Silje Ljosland Bakke, Nasjonal IKT HF, Norway (openEHR Editor)","Malin Berg, DIPS ASA, Norway","Lars Bitsch-Larsen, Haukeland University hospital, Norway","Alexander Davey, HSC NI, United Kingdom","Aitor Eguzkitza, UPNA (Public University of Navarre) - CHN (Complejo Hospitalario de Navarra), Spain","Arild Faxvaag, NTNU, Norway","Shahla Foozonkhah, Iran ministry of health and education, Iran","Einar Fosse, National Centre for Integrated Care and Telemedicine, Norway","Bente Gjelsvik, Helse Bergen, Norway","Heather Grain, Llewelyn Grain Informatics, Australia","Sam Heard, Ocean Informatics, Australia","Andreas Hering, Helse Bergen HF, Haukeland universitetssjukehus, Norway","Anca Heyd, DIPS ASA, Norway","Hilde Hollås, DIPS AS, Norway","Evelyn Hovenga, EJSH Consulting, Australia","Lars Ivar Mehlum, Helse Bergen HF, Norway","Tom Jarl Jakobsen, Helse Bergen, Norway","Lars Morgan Karlsen, DIPS ASA, Norway","Shinji Kobayashi, Kyoto University, Japan","Sabine Leh, Haukeland University Hospital, Department of Pathology, Norway","Heather Leslie, Atomica Informatics, Australia (openEHR Editor)","Hugh Leslie, Ocean Informatics, Australia","Hallvard Lærum, Norwegian Directorate of e-health, Norway","Chunlan Ma, Ocean Informatics, Australia","Luis Marco Ruiz, NST, Spain","Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (openEHR Editor)","Bjørn Næss, DIPS ASA, Norway","Andrej Orel, Marand d.o.o., Slovenia","Jussara Rotzsch, Hospital Alemão Oswaldo Cruz, Brazil","Thomas Schopf, University Hospital of North-Norway, Norway","Anoop Shah, University College London, United Kingdom","Line Silsand, Universitetssykehuset i Nord-Norge, Norway","Line Sæle, Nasjonal IKT HF, Norway","Nyree Taylor, Ocean Informatics, Australia","Richard Townley-O'Neill, Australian Digital Health Agency, Australia","Jon Tysdahl, Furst medlab AS, Norway","Gro-Hilde Ulriksen, Norwegian center for ehealthresearch, Norway","John Tore Valand, Helse Bergen, Norway (openEHR Editor)"> + details = < + ["de"] = < + language = <[ISO_639-1::de]> + purpose = <"Zur Darstellung eines klinischen, kontextspezifischen oder zeitspezifischen Attributs für ein spezifisches Problem oder eine spezifische Diagnose. +"> + keywords = <"Problem","Aktiv","Inaktiv","Status","Episode","Diagnose","Attribut"> + use = <"Zur Darstellung eines kontextspezifischen oder zeitspezifischen Attributs, welches weitere Details liefert, die zum Zeitpunkt der Aufnahme, oder im klinischen Kontext in dem das Problem, oder die Diagnose aufgezeichnet wurde, relevant ist. Das Attribut könnte zu einer anderen Zeit, oder in einem anderen klinischen Kontext, nicht angemessen sein. + +Dieser Archetyp wurde entworfen, um in den Status SLOT des EVALUATION.problem_diagnosis Archetyps eingefügt zu werden. Die Absicht des EVALUATION.problem_diagnosis Archetypen ist es alle Informationen zu beinhalten, die in allen Kontexten relevant sein könnten. Dieser Archetyp hingegen soll nur Informationen beschreiben, welche von dem Gebrauchskontext abhängen. + +WICHTIGE ANMERKUNG ZUM IMPLEMENTIEREN DES ARCHETYPEN: +-Es ist weder die Absicht, noch wird impliziert, dass irgendein, oder alle Attribute in dem gleichen Kontext, oder in dem gleichen Zeitraum genutzt werden sollten. Im Gegensatz zu dem üblichen Entwurf von Archetypen, wurde dieser Archetyp absichtlich so gestaltet, dass oft genutzte Attribute an einem Platz gesammelt werden können. Dies gewährleistet eine einfache Standardisierung eines sonst sehr wirren Gebietes der klinischen Praxis. Es ist uns bewusst, dass die Datenelemente in diesem Archetypen viele verschiedene Konzepte, und teilweise auch konkurrierende Konzepte, einschließen. Dies wurde hauptsächlich gemacht um die Notwendigkeit von mehreren, meist nur wenige Elemente beinhaltenden, Attribut-Archetypen zu vermeiden. +-Manche Datenelemente sind unter Umständen widersprüchlich, wenn Sie gleichzeitig in dem selben Kontext genutzt werden. Zum Beispiel würde die Nutzung eines \"inaktiven\" Problems, zusammen mit einer \"anhaltenden\" Episode keinen Sinn ergeben. Aus diesem Grund sollten diese Status Attribute mit hoher Sorgfalt genutzt werden. Sie können zwar variabel angewandt werden, aber in dem praktischen Gebrauch kann die Interoperabilität nur gewährleistet werden, wenn die Richtlinien innerhalb der klinischen Gemeinschaft in welcher das \"Problem/Diagnose\" und \"Problem/Diagnose Attribut\" Archetyp-Paar ausgetauscht wird, klar definiert sind. + +Eine komplette DRG Kodierung setzt eine Kombination aus DRG-verwandten Datenelementen dieses Archetypen und von Datenelementen anderer Archetypen voraus. + +"> + misuse = <"Nicht zur Darstellung einer Differenzialdiagnose - nutze den Archetypen EVALUATION.differential_diagnosis für diesen Zweck. + +Nicht zur Darstellung der diagnostischen Sicherheit - nutze das \"Diagnostic certainty\" Datenelement innerhalb des EVALUATION.problem/diagnosis Archetypen für diesen Zweck."> + > + ["nb"] = < + language = <[ISO_639-1::nb]> + purpose = <"For å registrere en kontekstspesifikk eller tidsspesifikk kvalifikator for et problem eller en diagnose."> + keywords = <"problem","aktivt","inaktivt","status","episode","tilstand","aktiv","inaktiv","remisjon","kronisk","akutt"> + use = <"Brukes for å registrere en kontekstspesifikk eller tidsspesifikk kvalifikator som gir ytterligere detaljer som er relevante på tidspunktet man registrerer et problem eller en diagnose. Kvalifikatoren er ikke nødvendigvis passende på et annet tidspunkt eller i en annen klinisk sammenheng. + +Denne arketypen skal brukes i SLOTet \"Status\" i arketypen EVALUATION.problem_diagnosis (Problem/diagnose). Intensjonen er at EVALUATION.problem_diagnosis-arketypen skal inneholde all informasjonen som gjelder i alle sammenhenger, i motsetning til denne arketypen som skal inneholde informasjonen som avhenger av brukssammenheng. + +VIKTIG INFORMASJON FOR IMPLEMENTERING: +- Det er ikke meningen eller implisert at alle disse kvalifikatorene skal brukes i den samme sammenhengen eller det samme tidsperioden. I motsetning til den vanlige måten å lage arketyper på, er denne arketypen laget for å samle flere vanlige kvalifikatorer på ett sted for å forsøksvis oppnå et visst nivå av standardisering innenfor et ganske innfløkt område av klinisk praksis. Det erkjennes at dataelementene i denne arketypen omfatter mange forskjellige, og til dels også konkurrerende, konsepter. Dette ble gjort hovedsakelig for å unngå behov for å ha mange arketyper for kvalifikatorer, der hver av dem kun inneholder ett eller to dataelementer. +- Noen av disse dataelementene er potensielt direkte motstridende dersom de brukes samtidig og i den samme sammenhengen. For eksempel gir det ikke mening å ha et \"inaktivt\" problem innenfor en \"pågående\" episode. Av den grunn bør disse kvalifikatorene brukes med stor omhu, siden de i praksis vil brukes for varierende formål, og interoperabilitet kan ikke garanteres med mindre det er definert klare retningslinjer for bruk innenfor de kliniske omstendighetene der \"Problem/diagnose\"- og \"Problem/diagnose-kvalifikatorer\"-arketypeparet brukes. + +Fullstendig DRG-koding vil kreve DRG-relaterte dataelementer fra denne arketypen, i kombinasjon med elementer fra andre arketyper."> + misuse = <"Brukes ikke for å representere differensialdiagnoser. Bruk arketypen EVALUATION.differential_diagnosis for dette formålet. + +Brukes ikke for å representere diagnostisk sikkerhet. Bruk elementet \"Diagnostisk sikkerhet\" i arketypen EVALUATION.problem_diagnosis."> + > + ["ko"] = < + language = <[ISO_639-1::ko]> + purpose = <"특정 문제 또는 진단을 위한 임상 문맥-특징적인 또는 시간-특징적인 한정자(qualifier)를 기록하기 위함."> + keywords = <"문제","활성","비활성","상태","에피소드","진단"> + use = <"어떤 문제 또는 진단을 기록하는 경우, 임상 문맥을 기록하는 시점 또는 그 안에서 관계되는 추가적인 상세내용을 제공하는 관련된 문맥-특징적인 또는 시간-특징적인 한정자를 기록하는데 사용. 한정자가 다른 시간이나 임상 문맥에서는 부적당할 수도 있음. + +이 아키타입은 EVALUATION.problem_diagnosis archetype 내의 Status SLOT에 포함하도록 설계됨. 의도는 이 아카타입이 사용되는 문맥에 따르는 정보만을 기술하는 것과 반대로 모든 문맥에 적용되는 모든 정보를 포함하는 EVALUATION.problem_diagnosis archetype을 위한 것임. + +구현을 위한 중요 사항: +- 이것은 이 한정자 일부 또는 전부가 같은 문맥 또는 같은 시간의 기간 내에 사용되어야 하는 것을 의도하거나 의미하지 않음. 일반적인 아키타입 설계와 다르게, 이 아카타입은 매우 복잡한 임상 실무 영역 내에서 간단히 표준화하기 위한 노력으로 많은 공통 한정자를 한 곳에 수집하기 위해 의도적으로 설계됨. 이 아키타입에 포함된 데이터 엘리먼트는 많은 상이한 그리고 때때로 심지어 경쟁적인 개념을 포괄하는 것으로 인정됨. 이것은 주로 오직 하나 또는 2개의 데이터 엘리먼트를 포함하는 여러 개의 한정자 아키타입을 필요로 하지 않도록 함. +- 몇몇의 이런 데이터 엘리먼트는 같은 문맥에서 동시에 사용된다면 잠재적으로 직접적으로 충돌하는데, 예를 들어, '진행중'인 어떤 에피소드와 함께 '비활성' 문제를 가지는 것은 이치에 맞지 않음. 이와 같이, 이 상태 한정자는 실무에서 매우 다양하게 적용되는 것처럼 극단적인 진료환경에서 함께 사용되어야 하고, 사용 지침이 'Problem/Diagnosis'와 'Problem/Diagnosis qualifier' archetype 쌍이 공유될 수도 있는 임상 커뮤니티 내에서 명확하게 정의되어야 상호운용성을 보장할 수 있음. + +완전한 DRG 코딩은 다른 아키타입의 데이터 엘리먼트와 조합해서 이 아키타입의 DRG와 관련된 데이터 엘리먼트를 요구할 것임."> + misuse = <"감별진단을 표현하는데 사용하지 않아야 함 - 이 목적을 위해서는 EVALUATION.differential_diagnosis archetype를 사용해야 함. + +진단의 확실성(certainty)를 표현하기 위해 사용하지 않아야 함 - EVALUATION.problem_diagnosis archetype 내의 'Diagnostic certainty' 데이터 엘리먼트를 사용해야 함."> + > + ["pt-br"] = < + language = <[ISO_639-1::pt-br]> + purpose = <"Para gravar um contexto clínico específico ou qualificador de tempo específico para um problema ou diagnóstico específico."> + keywords = <"problema","ativo","inativo","estado","episódio","diagnóstico"> + use = <"Use para gravar um qualificador de contexto específico ou tempo específico relevante que forneça detalhes adicionais de ou de e que sejam relevantes no momento do registro de um problema ou diagnóstico, ou dentro do contexto clínico onde é registrado, mas que pode não ser apropriado em outro tempo ou em outro contexto clínico. + +Este arquétipo foi projetado para ser incluído no slot Estado no arquétipo EVALUATION.problem_diagnosis archetype. A intenção é que o arquétipo EVALUATION.problem_diagnosis mantenha todas as informações que se aplicam em todos os contextos, em contraste com esse arquétipo que descreve apenas as informações que dependem do contexto de uso. + +NOTAS IMPORTANTES PARA IMPLEMENTAÇÃO: +- Não é intencional ou implícito que algum ou todos esses qualificadores devam ser usados dentro do mesmo contexto ou período de tempo. Em contraste com o design usual de arquétipos, esse arquétipo foi deliberadamente projetado para coletar uma série de qualificadores comuns em um único lugar, em um esforço para tentar alguma padronização simples dentro de uma área muito confusa da prática clínica. Reconhece-se que os elementos de dados contidos neste arquétipo abrangem muitos conceitos diferentes e às vezes até concorrentes. Isso foi feito principalmente para evitar a necessidade de vários arquétipos de qualificadores, cada um contendo apenas um ou dois elementos de dados. +- Alguns desses elementos de dados são potencialmente conflitantes se usados simultaneamente dentro do mesmo contexto, por exemplo, não faria sentido ter um problema 'inativo' junto com um Episódio 'em andamento'. Assim, esses qualificadores de status devem ser usados com extremo cuidado, pois são aplicados na prática e a interoperabilidade não pode ser assegurada, a menos que as diretrizes de uso estejam claramente definidas na comunidade clínica na qual o par de arquétipos 'Problema / Diagnóstico' e 'Qualificador do Problema / Diagnóstico' pode ser compartilhado. + +A codificação DRG completa vai exigir os elementos de dados DRG deste arquétipo em combinação com elementos de dados de outros arquétipos."> + misuse = <"Não deve ser usado para representar um diagnóstico diferencial - use o arquétipo EVALUATION.differential_diagnosis para este fim. + +Não deve ser usado para representar certeza diagnóstica - use elemento de dado \"Certeza de diagnóstico\" no arquétipo EVALUATION.problem_diagnosis."> + > + ["sl"] = < + language = <[ISO_639-1::sl]> + purpose = <"Za zapisovanje različnih statusov, ki se ponavadi uporablja za aplikacijskimi in kliničnimi sporočili, ki so odvisna od definirane vsebine + +"> + keywords = <"problem","aktiven","ni aktiven"> + copyright = <"© openEHR Foundation"> + use = <"Za dodeljevanje pravic EVALUATION.problem_diagnosis.v1 archetype, dodaja informacije za povezovanje. "> + misuse = <"It should not be assumed that these qualifiers are safely interoperable unless further definition and alignment is agreed between all sharing parties. A problem which has been defined as 'Inactive' during a hospital admission cannot be assumed to be regarded as 'Inactive' in a primary care setting , where a much longer term perspective is being taken. Similarly terms such as Initial, Interim and Final, whilst helpful to the human observer are unlikely to be precisely enough defined to be safely computable e.g. for decision support. "> + > + ["en"] = < + language = <[ISO_639-1::en]> + purpose = <"To record a clinical context-specific or time-specific qualifier for a specified problem or diagnosis."> + keywords = <"problem","active","inactive","status","episode","diagnosis"> + copyright = <"© openEHR Foundation"> + use = <"Use to record a relevant context-specific or time-specific qualifier that provides additional detail which is relevant at the time of recording or within the clinical context where a problem or diagnosis is recorded. The qualifier may not be appropriate at another time or in another clinical context. + +This archetype is designed to be included in Status SLOT in the EVALUATION.problem_diagnosis archetype. The intent is for the EVALUATION.problem_diagnosis archetype to hold all of the information that applies in all contexts, in contrast to this archetype describing only information that depends on the context of use. + +IMPORTANT NOTES FOR IMPLEMENTATION: +- It is not intended or implied that any or all of these qualifiers should be used within the same context or period of time. In contrast to the usual design of archetypes, this archetype has been deliberately designed to collect a number of common qualifiers into one place in an effort to attempt some simple standardisation within a very messy area of clinical practice. It is acknowledged that the data elements contained in this archetype embrace many different, and sometimes even competing, concepts. This has been done mainly to prevent the need for multiple qualifier archetypes, each containing only one or two data elements. +- Some of these data elements are potentially directly conflicting if used simultaneously within the same context, for example it would not make sense to have an 'inactive' problem together with an Episode that is 'ongoing'. As such, these status qualifiers should be used with extreme care as they are variably applied in practice and interoperability cannot be assured unless usage guidelines are clearly defined within the clinical community in which the 'Problem/Diagnosis' and 'Problem/Diagnosis qualifier' archetype pair may be shared. + +Full DRG coding will require the DRG-related data elements from this archetype in combination with data elements from other archetypes."> + misuse = <"Not to be used to represent a differential diagnosis - use the archetype EVALUATION.differential_diagnosis for this purpose. + +Not to be used to represent diagnostic certainty - use the 'Diagnostic certainty' data element within the EVALUATION.problem_diagnosis archetype."> + > + ["it"] = < + language = <[ISO_639-1::it]> + purpose = <"Registrare un qualificatore specifico del contesto clinico o temporale per un problema o una diagnosi specifici."> + keywords = <"problema, attivo, inattivo, stato, episodio, diagnosi", ...> + use = <"Usato per registrare un qualificatore specifico del contesto o del tempo che fornisca ulteriori dettagli rilevanti al momento della registrazione o nell'ambito del contesto clinico in cui viene registrato un problema o una diagnosi. Il qualificatore potrebbe non essere appropriato in un altro momento o in un altro contesto clinico. + +Questo archetipo è progettato per essere incluso in Status SLOT nell'archetipo di EVALUATION.problem_diagnosis. L'intento è che l'archetipo EVALUATION.problem_diagnosis contenga tutte le informazioni che si applicano in tutti i contesti, a differenza di questo archetipo che descrive solo le informazioni che dipendono dal contesto d'uso. + +NOTE IMPORTANTI PER L'IMPLEMENTAZIONE: +- Non è inteso o implicito che uno o tutti questi qualificatori debbano essere utilizzati nello stesso contesto o periodo di tempo. In contrasto con il design abituale degli archetipi, questo archetipo è stato deliberatamente progettato per raccogliere una serie di qualificatori comuni in un unico luogo nel tentativo di tentare una semplice standardizzazione all'interno di un'area molto disordinata della pratica clinica. Si riconosce che i dati contenuti in questo archetipo abbracciano molti concetti diversi, e a volte anche in competizione tra loro. Questo è stato fatto principalmente per evitare la necessità di molteplici archetipi di qualificatori, ognuno dei quali contenente solo uno o due data element. +- Alcuni di questi data element sono potenzialmente in conflitto diretto se utilizzati contemporaneamente all'interno dello stesso contesto, ad esempio non avrebbe senso avere un problema \"inattivo\" insieme ad un Episodio \"in corso\". In quanto tali, questi qualificatori di stato dovrebbero essere utilizzati con estrema cautela in quanto sono applicati in modo variabile nella pratica e l'interoperabilità non può essere garantita a meno che le linee guida di utilizzo non siano chiaramente definite all'interno della comunità clinica in cui la coppia di archetipi \"Problema/Diagnosi\" e \"Qualificatore di problema/diagnosi\" possono essere condivisi. + +La codifica DRG completa richiederà che i data element relativi al DRG di questo archetipo siano combinati con data element di altri archetipi."> + misuse = <"Da non utilizzare per rappresentare una diagnosi differenziale - utilizzare a questo scopo l'archetipo EVALUATION.differential_diagnosis. + +Da non utilizzare per rappresentare la certezza diagnostica - utilizzare l'elemento di dati \"Certezza diagnostica\" all'interno dell'archetipo EVALUATION.problem_diagnosis."> + > + > + other_details = < + ["licence"] = <"This work is licensed under the Creative Commons Attribution-ShareAlike 3.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/3.0/."> + ["custodian_organisation"] = <"openEHR Foundation"> + ["current_contact"] = <"Heather Leslie, Atomica Informatics"> + ["original_namespace"] = <"org.openehr"> + ["original_publisher"] = <"openEHR Foundation"> + ["custodian_namespace"] = <"org.openehr"> + ["MD5-CAM-1.0.1"] = <"6467BBA9938EF3141C6611ED2714EE0B"> + ["build_uid"] = <"461b442f-cac1-42d9-8319-9a0c4f4a70f8"> + ["ip_acknowledgements"] = <"This artefact includes content from SNOMED Clinical Terms® (SNOMED CT®) which is copyrighted material of the International Health Terminology Standards Development Organisation (IHTSDO). Where an implementation of this artefact makes use of SNOMED CT content, the implementer must have the appropriate SNOMED CT Affiliate license - for more information contact http://www.snomed.org/snomed-ct/get-snomedct or info@snomed.org."> + ["revision"] = <"1.0.2-alpha"> + > + +definition + CLUSTER[at0000] matches { -- Problem/Diagnosis qualifier + items cardinality matches {1..*; unordered} matches { + ELEMENT[at0004] occurrences matches {0..1} matches { -- Diagnostic status + value matches { + DV_CODED_TEXT matches { + defining_code matches { + [local:: + at0016, -- Preliminary + at0017, -- Working + at0018, -- Established + at0088] -- Refuted + } + } + } + } + ELEMENT[at0060] occurrences matches {0..1} matches { -- Current/Past? + value matches { + DV_CODED_TEXT matches { + defining_code matches { + [local:: + at0062, -- Current + at0061] -- Past + } + } + } + } + ELEMENT[at0003] occurrences matches {0..1} matches { -- Active/Inactive? + value matches { + DV_CODED_TEXT matches { + defining_code matches { + [local:: + at0026, -- Active + at0027] -- Inactive + } + } + } + } + ELEMENT[at0083] occurrences matches {0..1} matches { -- Resolution phase + value matches { + DV_CODED_TEXT matches { + defining_code matches { + [local:: + at0086, -- Not resolving + at0085, -- Resolving + at0084, -- Resolved + at0087, -- Indeterminate + at0097] -- Relapsed + } + } + } + } + ELEMENT[at0089] occurrences matches {0..1} matches { -- Remission status + value matches { + DV_CODED_TEXT matches { + defining_code matches { + [local:: + at0090, -- In remission + at0092, -- Not in remission + at0093] -- Indeterminate + } + } + } + } + ELEMENT[at0001] occurrences matches {0..1} matches { -- Episodicity + value matches { + DV_CODED_TEXT matches { + defining_code matches { + [local:: + at0034, -- New + at0035, -- Ongoing + at0070] -- Indeterminate + } + } + } + } + ELEMENT[at0071] occurrences matches {0..1} matches { -- Occurrence + value matches { + DV_CODED_TEXT matches { + defining_code matches { + [local:: + at0095, -- First occurrence + at0096] -- Recurrence + } + } + } + } + ELEMENT[at0077] occurrences matches {0..1} matches { -- Course label + value matches { + DV_CODED_TEXT matches { + defining_code matches { + [local:: + at0081, -- Acute + at0094, -- Acute-on-chronic + at0079] -- Chronic + } + } + } + } + ELEMENT[at0063] occurrences matches {0..*} matches { -- Diagnostic category + value matches { + DV_CODED_TEXT matches { + defining_code matches { + [local:: + at0064, -- Principal diagnosis + at0066, -- Secondary diagnosis + at0076] -- Complication + } + } + DV_TEXT matches {*} + } + } + ELEMENT[at0073] occurrences matches {0..1} matches { -- Admission diagnosis? + value matches { + DV_BOOLEAN matches { + value matches {true} + } + } + } + } + } + +ontology + terminologies_available = <"SNOMED-CT", ...> + term_definitions = < + ["en"] = < + items = < + ["at0000"] = < + text = <"Problem/Diagnosis qualifier"> + description = <"Contextual or temporal qualifier for a specified problem or diagnosis."> + > + ["at0001"] = < + text = <"Episodicity"> + description = <"Category of this episode for the identified problem/diagnosis."> + comment = <"For example: 'New' will enable clinicians to distinguish a new, acute episode of otitis media that may have arisen soon after a previous diagnosis, to distinguish it from an unresolved or 'Ongoing' diagnosis of chronic otitis media. Treatment of recurring, new and acute, episodes of a condition may differ significantly from the same condition that is not resolving or responding to treatment. In many situations the clinician will not be able to tell, and so indeterminate may be appropriate."> + > + ["at0003"] = < + text = <"Active/Inactive?"> + 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."> + > + ["at0004"] = < + text = <"Diagnostic status"> + description = <"Stage or phase of diagnostic process."> + comment = <"The status is usually determined by a combination of the timing of diagnosis plus level of clinical certainty resulting from diagnostic tests and clinical evidence available. This data element and 'Diagnostic certainty' in EVALUATION.problem_diagnosis are two important axes of the diagnostic process, and valid combinations will need to be presented by software that exposes both data elements, so it is not possible for users to select conflicting combinations. +Preliminary or working diagnoses are intended to represent the single most likely choice out of all differential diagnosis options."> + > + ["at0016"] = < + text = <"Preliminary"> + description = <"The initial diagnosis made, usually associated with a low level of clinical certainty. It may change as test results or advice become available."> + > + ["at0017"] = < + text = <"Working"> + description = <"Interim diagnosis, based on a reasonable amount of clinical certainty but pending further test results or clinical advice. It may still change as test results or advice become available."> + > + ["at0018"] = < + text = <"Established"> + description = <"Final substantiated diagnosis, based on a high level of clinical certainty, which may include clinical evidence from test results. It is not expected to change."> + > + ["at0026"] = < + text = <"Active"> + description = <"The problem or diagnosis is currently active and clinically relevant."> + > + ["at0027"] = < + text = <"Inactive"> + description = <"The problem or diagnosis is not completely resolved but is inactive or felt less relevant to the current clinical context."> + > + ["at0034"] = < + text = <"New"> + description = <"A new occurrence of either a new or existing problem or diagnosis. A flag for 'First occurrence' can be recorded separately to distinguish the first from other occurrences."> + > + ["at0035"] = < + text = <"Ongoing"> + description = <"The issue, problem or diagnosis continues, without new, acute episodes occurring."> + > + ["at0060"] = < + text = <"Current/Past?"> + description = <"Category that supports division of problems and diagnoses into Current or Past problem lists."> + comment = <"The Current/Past and Active/Inactive data elements have similar clinical impact but represent slightly different semantics. Both are actively used in different clinical settings, but usually not together. If an Active/Inactive 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."> + > + ["at0061"] = < + text = <"Past"> + description = <"An issue which ocurred in the past."> + > + ["at0062"] = < + text = <"Current"> + description = <"An issue occuring at present."> + > + ["at0063"] = < + text = <"Diagnostic category"> + 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."> + > + ["at0064"] = < + text = <"Principal diagnosis"> + description = <"The diagnosis determined to be chiefly responsible for occasionaing an episode of admitted patient care, an episode of residential care or an attendance at the health care establishment."> + > + ["at0066"] = < + text = <"Secondary diagnosis"> + description = <"A problem or diagnosis that is occurs at the same time as the primary problem or diagnosis. May also be known as a comorbid condition."> + > + ["at0070"] = < + text = <"Indeterminate"> + description = <"It is not possible to determine if this occurrence of the problem or diagnosis is new or ongoing."> + > + ["at0071"] = < + text = <"Occurrence"> + description = <"Category of the occurrence for this problem or diagnosis."> + comment = <"This data element can be an additional qualifier to the 'New' value in the 'Episodicity' value set, that is a condition such as asthma can have recurring new episodes that have periods of resolution in between. However it can be important to identify the first ever episode of asthma from all of the other episodes."> + > + ["at0073"] = < + text = <"Admission diagnosis?"> + description = <"Was the problem or diagnosis present at admission?"> + comment = <"Record as True if the problem or diagnosis was present on admission. This data element is a requirement from DRG reporting in some countries."> + > + ["at0076"] = < + text = <"Complication"> + description = <"An unfavorable evolution of a problem or diagnosis."> + > + ["at0077"] = < + text = <"Course label"> + description = <"Category reflecting the speed of onset and/or duration and persistence of the problem or diagnosis."> + comment = <"Definitions of acute vs chronic will differ for each diagnosis."> + > + ["at0079"] = < + text = <"Chronic"> + description = <"A problem or diagnosis with persistent or long-lasting effects, or that evolves over time."> + > + ["at0081"] = < + text = <"Acute"> + description = <"A problem or diagnosis with a rapid onset, a short course, or both."> + > + ["at0083"] = < + text = <"Resolution phase"> + description = <"Phase of healing for an acute problem or diagnosis."> + comment = <"For example: tracking the progress of resolution of a middle ear infection."> + > + ["at0084"] = < + text = <"Resolved"> + description = <"Problem or diagnosis has completed the normal phases of restoration or healing and can be considered resolved."> + > + ["at0085"] = < + text = <"Resolving"> + description = <"Problem or diagnosis is progressing satisfactorily through the normal stages of restoration or healing towards resolution."> + > + ["at0086"] = < + text = <"Not resolving"> + description = <"Problem or diagnosis is not progressing satisfactorily through the normal stages of restoration or healing towards resolution."> + > + ["at0087"] = < + text = <"Indeterminate"> + description = <"It is not possible to determine the resolution or healing status of the problem or diagnosis."> + > + ["at0088"] = < + text = <"Refuted"> + description = <"The previously recorded diagnosis has been clinically reassessed or disproved with a high level of clinical certainty. This status is used to correct an error in the health record."> + > + ["at0089"] = < + text = <"Remission status"> + description = <"Status of the remission of an incurable diagnosis."> + comment = <"For example: the status of a cancer or haematological diagnosis."> + > + ["at0090"] = < + text = <"In remission"> + description = <"No ongoing signs or symptoms of the disease have been identified."> + > + ["at0092"] = < + text = <"Not in remission"> + description = <"No diminution of the signs or symptoms of the disease have been identified."> + > + ["at0093"] = < + text = <"Indeterminate"> + description = <"It is not possible to determine if there have been diminution of the signs or symptoms of the disease have been identified."> + > + ["at0094"] = < + text = <"Acute-on-chronic"> + description = <"A problem or diagnosis with an acute exacerbation of a chronic condition."> + > + ["at0095"] = < + text = <"First occurrence"> + description = <"This is the first ever occurrence of this problem or diagnosis."> + > + ["at0096"] = < + text = <"Recurrence"> + description = <"New occurrence of the same problem or diagnosis after a previous episode was resolved."> + > + ["at0097"] = < + text = <"Relapsed"> + description = <"Problem or diagnosis has deteriorated after a period of temporary improvement."> + > + > + > + ["sl"] = < + items = < + ["at0000"] = < + text = <"*Problem/Diagnosis qualifier(en)"> + description = <"*Contextual or temporal qualifier for a specified problem or diagnosis.(en)"> + > + ["at0001"] = < + text = <"*Episodicity(en)"> + description = <"*Category of this episode for the identified problem/diagnosis.(en)"> + comment = <"*For example: 'New' will enable clinicians to distinguish a new, acute episode of otitis media that may have arisen soon after a previous diagnosis, to distinguish it from an unresolved or 'Ongoing' diagnosis of chronic otitis media. Treatment of recurring, new and acute, episodes of a condition may differ significantly from the same condition that is not resolving or responding to treatment. In many situations the clinician will not be able to tell, and so indeterminate may be appropriate.(en)"> + > + ["at0003"] = < + text = <"*Active/Inactive?(en)"> + description = <"*Category that supports division of problems and diagnoses into Active or Inactive problem lists.(en)"> + 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.(en)"> + > + ["at0004"] = < + text = <"*Diagnostic status(en)"> + description = <"*Stage or phase of diagnostic process.(en)"> + comment = <"*The status is usually determined by a combination of the timing of diagnosis plus level of clinical certainty resulting from diagnostic tests and clinical evidence available. This data element and 'Diagnostic certainty' in EVALUATION.problem_diagnosis are two important axes of the diagnostic process, and valid combinations will need to be presented by software that exposes both data elements, so it is not possible for users to select conflicting combinations. +Preliminary or working diagnoses are intended to represent the single most likely choice out of all differential diagnosis options.(en)"> + > + ["at0016"] = < + text = <"*Preliminary(en)"> + description = <"*The initial diagnosis made, based on limited available clinical evidence. It may change as test results or advice become available.(en)"> + > + ["at0017"] = < + text = <"*Working(en)"> + description = <"*Interim diagnosis, based on substantiated clinical evidence but pending further test results or clinical advice. It may still change as test results or advice become available.(en)"> + > + ["at0018"] = < + text = <"*Established(en)"> + description = <"*Final substantiated diagnosis, based on a high level of clinical certainty, which may include clinical evidence from test results. It is not expected to change.(en)"> + > + ["at0026"] = < + text = <"Aktiven"> + description = <"Problem je trenutno aktiven in klinično relevanten"> + > + ["at0027"] = < + text = <"Ni aktiven"> + description = <"Problem trenutno ni aktiven"> + > + ["at0034"] = < + text = <"*New(en)"> + description = <"*A new occurrence of either a new or existing problem or diagnosis. A flag for 'First occurrence' can be recorded separately to distinguish the first from other occurrences.(en)"> + > + ["at0035"] = < + text = <"*Ongoing(en)"> + description = <"*The issue, problem or diagnosis continues, without new, acute episodes occurring.(en)"> + > + ["at0060"] = < + text = <"*Current/Past?(en)"> + description = <"*Category that supports division of problems and diagnoses into Current or Past problem lists.(en)"> + comment = <"*The Current/Past and Active/Inactive data elements have similar clinical impact but represent slightly different semantics. Both are actively used in different clinical settings, but usually not together. If an Active/Inactive 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.(en)"> + > + ["at0061"] = < + text = <"*Past(en)"> + description = <"*An issue which ocurred in the past.(en)"> + > + ["at0062"] = < + text = <"*Current(en)"> + description = <"*An issue occuring at present.(en)"> + > + ["at0063"] = < + text = <"*Diagnostic category(en)"> + description = <"*Category of the problem or diagnosis within a specified episode of care and/or local care context.(en)"> + 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.(en)"> + > + ["at0064"] = < + text = <"*Principal diagnosis(en)"> + description = <"*The diagnosis determined to be chiefly responsible for occasionaing an episode of admitted patient care, an episode of residential care or an attendance at the health care establishment.(en)"> + > + ["at0066"] = < + text = <"*Secondary diagnosis(en)"> + description = <"*A problem or diagnosis that is occurs at the same time as the primary problem or diagnosis. May also be known as a comorbid condition.(en)"> + > + ["at0070"] = < + text = <"*Indeterminate(en)"> + description = <"*It is not possible to determine if this occurrence of the problem or diagnosis is new or ongoing.(en)"> + > + ["at0071"] = < + text = <"*Occurrence (en)"> + description = <"*Category of the occurrence for this problem or diagnosis. (en)"> + comment = <"*This data element can be an additional qualifier to the 'New' value in the 'Episodicity' value set, that is a condition such as asthma can have recurring new episodes that have periods of resolution in between. However it can be important to identify the first ever episode of asthma from all of the other episodes. (en)"> + > + ["at0073"] = < + text = <"*Admission diagnosis?(en)"> + description = <"*Was the problem or diagnosis present at admission?(en)"> + comment = <"*Record as True if the problem or diagnosis was present on admission. This data element is a requirement from DRG reporting in some countries.(en)"> + > + ["at0076"] = < + text = <"*Complication(en)"> + description = <"*An unfavorable evolution of a problem or diagnosis.(en)"> + > + ["at0077"] = < + text = <"*Course label(en)"> + description = <"*Category reflecting the speed of onset and/or duration and persistence of the problem or diagnosis.(en)"> + comment = <"*Definitions of acute vs chronic will differ for each diagnosis.(en)"> + > + ["at0079"] = < + text = <"*Chronic(en)"> + description = <"*A problem or diagnosis with persistent or long-lasting effects, or that evolves over time.(en)"> + > + ["at0081"] = < + text = <"*Acute(en)"> + description = <"*A problem or diagnosis with a rapid onset, a short course, or both.(en)"> + > + ["at0083"] = < + text = <"*Resolution phase(en)"> + description = <"*Phase of healing for an acute problem or diagnosis.(en)"> + comment = <"*For example: tracking the progress of resolution of a middle ear infection.(en)"> + > + ["at0084"] = < + text = <"*Resolved(en)"> + description = <"*Problem or diagnosis has completed the normal phases of restoration or healing and can be considered resolved.(en)"> + > + ["at0085"] = < + text = <"*Resolving(en)"> + description = <"*Problem or diagnosis is progressing satisfactorily through the normal stages of restoration or healing towards resolution.(en)"> + > + ["at0086"] = < + text = <"*Not resolving(en)"> + description = <"*Problem or diagnosis is not progressing satisfactorily through the normal stages of restoration or healing towards resolution.(en)"> + > + ["at0087"] = < + text = <"*Indeterminate(en)"> + description = <"*It is not possible to determine the resolution or healing status of the problem or diagnosis.(en)"> + > + ["at0088"] = < + text = <"*Refuted(en)"> + description = <"*The diagnosis has been clinically reassessed or has been disproved with a high level of clinical certainty.(en)"> + > + ["at0089"] = < + text = <"*Remission status(en)"> + description = <"*Status of the remission of an incurable diagnosis.(en)"> + comment = <"*For example: the status of a cancer or haematological diagnosis.(en)"> + > + ["at0090"] = < + text = <"*In complete remission(en)"> + description = <"*No diminution of signs or symptoms of the disease have been identified.(en)"> + > + ["at0092"] = < + text = <"*Not in remission(en)"> + description = <"*No diminution of the signs or symptoms of the disease have been identified.(en)"> + > + ["at0093"] = < + text = <"*Indeterminate(en)"> + description = <"*It is not possible to determine if there have been diminution of the signs or symptoms of the disease have been identified.(en)"> + > + ["at0094"] = < + text = <"*Acute-on-chronic(en)"> + description = <"**(en)"> + > + ["at0095"] = < + text = <"*First occurrence (en)"> + description = <"*This is the first ever occurrence of this problem or diagnosis. (en)"> + > + ["at0096"] = < + text = <"*Recurrence (en)"> + description = <"*New occurrence of the same problem or diagnosis after a previous episode was resolved. (en)"> + > + ["at0097"] = < + text = <"*Relapsed (en)"> + description = <"*Problem or diagnosis has deteriorated after a period of temporary improvement. (en)"> + > + > + > + ["pt-br"] = < + items = < + ["at0000"] = < + text = <"Qualificador do problema /diagnóstico"> + description = <"Qualificador contextual ou temporal para um problema ou diagnóstico específico."> + > + ["at0001"] = < + text = <"Episodicidade"> + description = <"Categoria deste episódio para o problema / diagnóstico identificado."> + comment = <"Por exemplo: \"Novo\" permitirá aos clínicos distinguir um novo episódio agudo de otite média que pode ter surgido logo após um diagnóstico prévio, para distingui-lo de um diagnóstico não resolvido ou \"Em curso\" da otite média crônica. O tratamento de episódios recorrentes, novos e agudos de uma condição pode diferir significativamente da mesma condição que não está resolvendo ou respondendo ao tratamento. Em muitas situações, o clínico não será capaz de dizer e, portanto, indeterminado pode ser apropriado."> + > + ["at0003"] = < + text = <"Ativo/Inativo?"> + description = <"Categoria que supporta a divisão de problemas and diagnósticos em listas de problemas Ativos ou Inativos."> + comment = <"Os elementos de dados Ativo/Inativo e Atual/Passado e têm impacto clínico similar mas com representação semântica ligeiramente diferente. Ambos são usados ativamente em diferentes contextos clínicos, mas geralmente não juntos. Se um qualificador Atual/Passado for registrado, esse elemento de dados provavelmente será redundante. Uma exceção onde uma condição pode ser atual mas inativa é a asma que não está causando sintomas agudos."> + > + ["at0004"] = < + text = <"Estado do diagnóstico"> + description = <"Estágio ou fase do processo diagnóstico."> + comment = <"O estado geralmente é determinado por uma combinação do tempo de diagnóstico mais o nível de certeza clínica resultante de testes diagnósticos e evidências clínicas disponíveis. Este elemento de dados e \"Certeza diagnóstica\" no EVALUATION.problem_diagnosis são dois eixos importantes do processo de diagnóstico e combinações válidas precisarão ser apresentadas pelo software que expõe ambos os elementos de dados, portanto, não é possível para os usuários selecionar combinações conflitantes. Diagnósticos preliminares ou em trabalho destinam-se a representar a escolha mais provável dentre todas as opções de diagnóstico diferencial."> + > + ["at0016"] = < + text = <"Preliminar"> + description = <"O diagnóstico inicial feito, geralmente associado a um baixo nível de certeza clínica. Pode mudar à medida que os resultados dos testes ou conselhos estiverem disponíveis."> + > + ["at0017"] = < + text = <"Trabalhando"> + description = <"Diagnóstico provisório, com base em numa certeza clínica razoável, mas na pendência de novos resultados de testes ou orientação clínica. Pode ainda mudar à medida que os resultados dos testes ou conselhos estiverem disponíveis."> + > + ["at0018"] = < + text = <"Estabelecido"> + description = <"Diagnóstico final fundamentado, baseado em um alto nível de certeza clínica, que pode incluir evidências clínicas dos resultados dos testes. Não é esperado que mude."> + > + ["at0026"] = < + text = <"Ativo"> + description = <"O problema ou o diagnóstico está atualmente ativo e clinicamente relevante."> + > + ["at0027"] = < + text = <"Inativo"> + description = <"O problema ou diagnóstico não está completamente resolvido, mas está inativo ou é menos relevante no contexto clínico atual."> + > + ["at0034"] = < + text = <"Novo"> + description = <"Uma nova ocorrência de um problema ou diagnóstico novo ou existente. Um sinalizador para \"Primeira ocorrência\" pode ser gravado separadamente para distinguir a primeira das outras ocorrências."> + > + ["at0035"] = < + text = <"Em curso"> + description = <"A questão, problema ou diagnóstico continua, sem novos episódios agudos ocorrendo."> + > + ["at0060"] = < + text = <"Atual/Passado?"> + description = <"Categoria que suporta a divisão de problemas e diagnósticos em listas de problemas Atual ou Passado."> + comment = <"Os elementos de dados Atual/Passado e Ativo/Inativo têm impacto clínico similar mas com representação semântica ligeiramente diferente. Ambos são usados ativamente em diferentes contextos clínicos, mas geralmente não juntos. Se um qualificador Ativo / Inativo for registrado, esse elemento de dados provavelmente será redundante. Uma exceção onde uma condição pode ser atual mas inativa é a asma que não está causando sintomas agudos."> + > + ["at0061"] = < + text = <"Passado"> + description = <"Um problema que ocorreu no passado."> + > + ["at0062"] = < + text = <"Atual"> + description = <"Um problema ocorrendo no momento."> + > + ["at0063"] = < + text = <"Categoria do diagnóstico"> + description = <"Categoria do problema ou diagnóstico dentro de um episódio específico de cuidado e / ou contexto de cuidados local."> + comment = <"Esse elemento de dados contém um conjunto de valores comumente usado na categorização de diagnóstico. Em contextos de cuidados episódicos (geralmente cuidados secundários) é comum categorizar / organizar diagnósticos de acordo com a sua relação com o diagnóstico principal a ser abordado durante esse episódio de atenção. Essas categorias também podem ser usadas para fins clínicos de codificação, geração de relatórios e faturamento. Em alguns países, a categoria de diagnóstico pode ser conhecida como DRG. +Além disso, a opção de texto livre permite o uso de outros conjuntos de valores locais, conforme necessário."> + > + ["at0064"] = < + text = <"Diagnóstico principal"> + description = <"O diagnóstico específico a ser responsável por desencadear um episódio de cuidado do paciente admitido, um episódio de cuidados domiciliares ou um comparecimento no estabelecimento de cuidados de saúde."> + > + ["at0066"] = < + text = <"Diagnóstico secundário"> + description = <"Um problema ou diagnóstico que ocorre ao mesmo tempo que o problema ou diagnóstico principal. Também pode ser conhecido como uma comorbidade."> + > + ["at0070"] = < + text = <"Indeterminado"> + description = <"Não é possível determinar se esta ocorrência do problema ou diagnóstico é nova ou está em curso."> + > + ["at0071"] = < + text = <"Ocorrência"> + description = <"Categoria da ocorrência para este problema ou diagnóstico."> + comment = <"Este elemento de dados pode ser um qualificador adicional para o valor \"Novo\" no conjunto de valores de \"Episodicidade\", ou seja, uma condição como a asma pode ter episódios novos recorrentes com períodos de resolução intermediários. No entanto, pode ser importante identificar o primeiro episódio de asma de todos os outros episódios."> + > + ["at0073"] = < + text = <"Diagnóstico de admissão?"> + description = <"O problema ou diagnóstico estava presente na admissão?"> + comment = <"Registre como Verdadeiro se o problema ou diagnóstico estiver presente na admissão. Esse elemento de dados é um requisito dos relatórios de DRG em alguns países."> + > + ["at0076"] = < + text = <"Complicação"> + description = <"Uma evolução desfavorável de um problema ou diagnóstico."> + > + ["at0077"] = < + text = <"Classificação do curso"> + description = <"Categoria que reflete a velocidade de início e / ou duração e persistência do problema ou diagnóstico."> + comment = <"Definições de aguda / crônica serão diferentes para cada diagnóstico."> + > + ["at0079"] = < + text = <"Crônico"> + description = <"Um problema ou um diagnóstico com efeitos persistentes ou de longa duração ou que evolui ao longo do tempo."> + > + ["at0081"] = < + text = <"Agudo"> + description = <"Um problema ou diagnóstico com um início rápido, um curso curto, ou ambos."> + > + ["at0083"] = < + text = <"Fase de resolução"> + description = <"Fase de cura para um problema agudo ou diagnóstico."> + comment = <"Por exemplo: monitoramento do progresso da resolução de uma infecção do ouvido médio."> + > + ["at0084"] = < + text = <"Resolvido"> + description = <"O problema ou diagnóstico completou as fases normais de reabilitação ou cura e pode ser considerado resolvido."> + > + ["at0085"] = < + text = <"Resolvendo"> + description = <"Problema ou diagnóstico está progredindo satisfatoriamente através dos estágios normais de reabilitação ou cura para a resolução."> + > + ["at0086"] = < + text = <"Não resolvendo"> + description = <"O problema ou diagnóstico não está progredindo satisfatoriamente pelos estágios normais de reabilitação ou de cura em direção a resolução."> + > + ["at0087"] = < + text = <"Indeterminado"> + description = <"Não é possível determinar a resolução ou o estado de cura do problema ou diagnóstico."> + > + ["at0088"] = < + text = <"Descartado"> + description = <"O diagnóstico previamente registrado foi clinicamente reavaliado ou refutado com um alto nível de certeza clínica. Este status é usado para corrigir um erro no registro de funcionamento."> + > + ["at0089"] = < + text = <"Estado de remissão"> + description = <"Status da remissão de um diagnóstico incurável."> + comment = <"Por exemplo: o status de um câncer ou diagnóstico hematológico."> + > + ["at0090"] = < + text = <"Em remissão"> + description = <"Nenhum sinal ou sintoma da doença em andamento foi identificado."> + > + ["at0092"] = < + text = <"Não em remissão"> + description = <"Nenhuma diminuição dos sinais ou sintomas da doença foi identificada."> + > + ["at0093"] = < + text = <"Indeterminado"> + description = <"Não é possível determinar se houve diminuição dos sinais ou sintomas da doença identificada."> + > + ["at0094"] = < + text = <"Crônico-agudizada"> + description = <"Um problema ou diagnóstico com uma exacerbação aguda de uma condição crônica."> + > + ["at0095"] = < + text = <"Primeira ocorrência"> + description = <"Esta é a primeira ocorrência deste problema ou diagnóstico."> + > + ["at0096"] = < + text = <"Recorrência"> + description = <"Nova ocorrência do mesmo problema ou diagnóstico depois que um episódio anterior foi resolvido."> + > + ["at0097"] = < + text = <"Recidiva"> + description = <"Problema ou diagnóstico se deteriorou após um período de melhora temporária."> + > + > + > + ["nb"] = < + items = < + ["at0000"] = < + text = <"Problem/diagnose-kvalifikator"> + description = <"Kontekst- eller tidsspesifikk kvalifikator for et problem eller en diagnose."> + > + ["at0001"] = < + text = <"Episodisitet"> + description = <"Kategorisering av denne episoden av problemet/diagnosen."> + comment = <"For eksempel: \"Ny\" gjør det mulig for klinikere å holde et nytt og akutt tilfelle av mellomørebetennelse som har oppstått raskt etter en tidligere diagnose adskilt fra en pågående kronisk mellomørebetennelse. Behandling av gjentakende, nye og akutte episoder av en tilstand kan være vesentlig forskjellig fra behandling av den samme tilstanden som ikke bedres eller ikke responderer på behandling. I mange situasjoner vil det ikke være mulig for klinikeren å skille dem fra hverandre, og i disse tilfellene vil \"Ubestemmelig\" være relevant."> + > + ["at0003"] = < + text = <"Aktiv/inaktiv?"> + description = <"Kategori som støtter inndeling av problemer og diagnoser i lister over aktive og inaktive problemer."> + comment = <"Elementene Aktiv/inaktiv og Nåværende/tidligere har lignende klinisk innflytelse, men representerer noe forskjellig betydning. Begge brukes aktivt i forskjellige kliniske sammenhenger, men som regel ikke sammen. Dersom Nåværende/tidligere er registrert, er dette elementet sannsynligvis overflødig. Et unntak der en tilstand kan være både nåværende og inaktivt, er astma som ikke forårsaker akutte symptomer."> + > + ["at0004"] = < + text = <"Diagnostisk status"> + description = <"Den diagnostiske prosessens stadium eller fase."> + comment = <"Statusen bestemmes vanligvis ved å kombinere tidspunkt for diagnosen, og nivå av klinisk sikkerhet. Status er et resultat av diagnostiske undersøkelser, og det tilgjengelige kliniske grunnlaget. Dette dataelementet og \"Diagnostisk sikkerhet\" i arketypen EVALUATION.problem_diagnosis er to viktige akser i den diagnostiske prosessen, og gyldige kombinasjoner må håndteres og vises av programvare som bruker begge elementene. Dette for at det ikke skal være mulig for brukere å velge kombinasjoner som er i konflikt med hverandre. Tentative diagnoser eller arbeidsdiagnoser er ment å representere det mest sannsynlige valget av de mulige differensialdiagnosene."> + > + ["at0016"] = < + text = <"Tentativ"> + description = <"En foreløpig diagnose som er en utredningshypotese, og som antas å kunne bli bekreftet ved videre utredning eller observasjon av utvikling. Den kan bli endret etter hvert som undersøkelsesresultater eller annen informasjon blir tilgjengelig."> + > + ["at0017"] = < + text = <"Arbeidsdiagnose"> + description = <"Midlertidig diagnose, basert på en rimelig grad av klinisk sikkerhet, men som avventer videre undersøkelsesresultater eller kliniske råd. Den kan fortsatt endres etter hvert som undersøkelsesresultater eller annen informasjon blir tilgjengelig."> + > + ["at0018"] = < + text = <"Fastslått"> + description = <"Endelig underbygget diagnose, basert på en høy grad av klinisk sikkerhet, som kan omfatte klinisk evidens fra undersøkelser. Den er ikke forventet å endres."> + > + ["at0026"] = < + text = <"Aktiv"> + description = <"Problemet eller diagnosen er aktivt og kliniske relevant ved registreringstidspunktet."> + > + ["at0027"] = < + text = <"Inaktiv"> + description = <"Problemet eller diagnosen er ikke fullstendig bedret, men er inaktivt eller mindre relevant for den nåværende kliniske sammenhengen."> + > + ["at0034"] = < + text = <"Ny"> + description = <"En ny forekomst av enten et nytt eller et eksisterende problem eller diagnose. Et flagg for \"Første forekomst\" kan registreres separat for å skille den første forekomsten fra påfølgende."> + > + ["at0035"] = < + text = <"Pågående"> + description = <"Problemet eller diagnosen er pågående, uten at det har forekommet nye episoder."> + > + ["at0060"] = < + text = <"Nåværende/tidligere?"> + description = <"Kategori som støtter oppdeling av problemer og diagnoser i lister over nåværende og tidligere problemer."> + comment = <"Elementene Nåværende/tidligere og Aktiv/inaktiv har lignende klinisk innflytelse, men representerer noe forskjellig betydning. Begge brukes aktivt i forskjellige kliniske sammenhenger, men som regel ikke sammen. Dersom Aktiv/inaktiv er registrert, er dette elementet sannsynligvis overflødig. Et unntak der en tilstand kan være både nåværende og inaktivt, er astma som ikke forårsaker akutte symptomer."> + > + ["at0061"] = < + text = <"Tidligere"> + description = <"Problemet/diagnosen er ikke lenger tilstede ved registreringstidspunktet."> + > + ["at0062"] = < + text = <"Nåværende"> + description = <"Problemet/diagnosen er tilstede ved registreringstidspunktet."> + > + ["at0063"] = < + text = <"Diagnosisk kategori"> + description = <"Kategorisering av problemet eller diagnosen innenfor en spesifikk kontakt og/eller lokal behandlingssammenheng."> + comment = <"Dette elementet inneholder et verdisett som er i vanlig bruk innen diagnosekategorisering. I episodiske behandlingssammenhenger (som regel spesialisthelsetjenesten) er det vanlig å kategorisere/organisere diagnoser i henhold til deres forhold til hoveddiagnosen som behandles i den aktuelle kontakten. Disse kategoriene kan også brukes for klinisk koding, rapportering og fakturering. I noen land omtales diagnosekategorien som \"en DRG\". I tillegg gjør muligheten for å legge til annen fri eller kodet tekst at det er mulig å bruke andre lokale verdisett ved behov."> + > + ["at0064"] = < + text = <"Hoveddiagnose"> + description = <"Diagnosen som er bestemt å være hovedårsaken til den aktuelle kontakten."> + > + ["at0066"] = < + text = <"Bidiagnose"> + description = <"Et problem eller diagnose som opptrer samtidig som hoveddiagnosen. Kan også omtales som en komorbiditet."> + > + ["at0070"] = < + text = <"Ubestemmelig"> + description = <"Det er ikke mulig å bestemme hvorvidt denne forekomsten av problemet eller diagnosen er ny eller pågående."> + > + ["at0071"] = < + text = <"Forekomst"> + description = <"Kategorisering av forekomsten for dette problemet eller diagnosen."> + comment = <"Dette dataelementet kan brukes som en ytterligere kvalifikator i tillegg til verdien \"Ny\" i elementet \"Episodisitet\". For eksempel kan en sykdom som astma ha gjentakende episoder med bedre perioder mellom, men det kan likevel være viktig å kunne identifisere den første astmaepisoden fra de påfølgende."> + > + ["at0073"] = < + text = <"Tilstede ved innleggelse?"> + description = <"Var problemet eller diagnosen tilstede ved innleggelse?"> + comment = <"Registrer som \"sann\" dersom problemet eller diagnosen var tilstede ved innleggelse. Dette elementet er et krav i forbindelse med DRG i noen land."> + > + ["at0076"] = < + text = <"Komplikasjon"> + description = <"En ugunstig utvikling av et problem eller diagnose."> + > + ["at0077"] = < + text = <"Forløpsbetegnelse"> + description = <"Kategorisering som betegner debuten og/eller varigheten og vedvarenheten av problemet eller diagnosen."> + comment = <"Definisjoner av akutt og kronisk vil variere fra diagnose til diagnose."> + > + ["at0079"] = < + text = <"Kronisk"> + description = <"Et problem eller diagnose med varige eller langvarige effekter, eller som utvikler seg over tid."> + > + ["at0081"] = < + text = <"Akutt"> + description = <"Et problem eller diagnose med en rask inntreden, kortvarig forløp, eller begge."> + > + ["at0083"] = < + text = <"Bedringsfase"> + description = <"Fase av bedring eller tilheling for et akutt problem eller diagnose."> + comment = <"For eksempel for å spore tilhelingen av en mellomørebetennelse."> + > + ["at0084"] = < + text = <"Bedret"> + description = <"Problemet eller diagnosen har fullført de vanlige stadiene av bedring eller tilheling, og kan regnes som bedret."> + > + ["at0085"] = < + text = <"I bedring"> + description = <"Problemet eller diagnosen utvikler seg i ønsket retning gjennom de vanlige stadiene av bedring, eller under tilheling."> + > + ["at0086"] = < + text = <"Ikke i bedring"> + description = <"Problemet eller diagnosen utvikler seg ikke i ønsket retning gjennom de vanlige stadiene av bedring, eller er ikke under tilheling."> + > + ["at0087"] = < + text = <"Ubestemmelig"> + description = <"Det er ikke mulig å bestemme problemet eller diagnosens fase av bedring."> + > + ["at0088"] = < + text = <"Avkreftet"> + description = <"Diagnosen har blitt klinisk revurdert, eller er motbevist med en høy grad av klinisk sikkerhet. Denne statusen brukes for å korrigere feil i journalen."> + > + ["at0089"] = < + text = <"Remisjonsstatus"> + description = <"Remisjonsstatus for en ikke-kurerbar diagnose."> + comment = <"For eksempel status for kreft eller en hematologisk diagnose."> + > + ["at0090"] = < + text = <"I remisjon"> + description = <"Ingen pågående sykdomstegn eller symptomer på sykdommen er identifisert."> + > + ["at0092"] = < + text = <"Ikke i remisjon"> + description = <"Ingen reduksjon av sykdomstegn eller symptomer er identifisert."> + > + ["at0093"] = < + text = <"Ubestemmelig"> + description = <"Det er ikke mulig å bestemme om sykdomstegnene eller symptomene av sykdommen er reduserte."> + > + ["at0094"] = < + text = <"Akutt-på-kronisk"> + description = <"Et problem eller en diagnose med en akutt forverring av en kronisk tilstand."> + > + ["at0095"] = < + text = <"Første forekomst"> + description = <"Dette er den første forekomsten av dette problemet eller diagnosen."> + > + ["at0096"] = < + text = <"Tilbakefall"> + description = <"Ny forekomst av det samme problemet eller diagnosen etter at en tidligere episode var bedret."> + > + ["at0097"] = < + text = <"Residivert"> + description = <"Problemet eller diagnosen har blitt forverret etter en midlertidig forbedret periode."> + > + > + > + ["ko"] = < + items = < + ["at0000"] = < + text = <"문제/진단 한정자"> + description = <"특정 문제 또는 진단을 위한 문맥 또는 시간적 한정자."> + > + ["at0001"] = < + text = <"삽화"> + description = <"확인된 문제/진단에 대한 삽화의 범주."> + comment = <"예: '새로운'은 임상의가 치료되지 않았거나 진행 중인 만성중이염 진단과 이전 진단 이후 바로 발생한 것일 수 있는 새로운 급성 중이염 삽화를 구별할 수 있도록 함. 재발이면서 새로이 발생한 급성 상태의 삽화에 대한 치료는 치료가 안됐거나 치료에 반응하지 않는 같은 상태와 상당히 다를 것임. 많은 상황에서, 임상의는 구별할 수 없을 것이며 그래서 결정불능이 적절할 수도 있음."> + > + ["at0003"] = < + text = <"활성/비활성"> + description = <"문제와 진단을 활성 또는 비활성 문제 목록으로 구분하는 것을 지원하기 위한 범주."> + comment = <"활성/비활성 그리고 현재/과거 데이터 엘리먼트는 비슷한 임상적 영향을 가지지만 약간 다른 의미를 표현함. 둘 다 상이한 임상 환경에서 활발하게 사용되지만 보통 같이 사용되지는 않음. 현재/과거 한정자가 기록되어 있다면, 이 데이터 엘리먼트는 중복일 가능성이 있음. 상태가 현재일 수는 있지만 비활성인 예외 경우는 급성 증상을 일으키지 않는 천식임."> + > + ["at0004"] = < + text = <"진단 상태"> + description = <"진단 과정의 단계."> + comment = <"이 상태는 보통 진단 검사와 가용한 임상 근거에 따른 임상 확실성 수준에, 진단의 시점을 더하기한 조합에 의해 결정됨. 이EVALUATION.problem_diagnosis 내의 데이터 엘리먼트와 'Diagnostic certainty'는 두 개의 중요한 진단 과정의 축이고, 두 개 모두의 데이터 엘리먼트를 노출하는 소프트웨어에 의해 제공될 수 있는 유효한 조합이 필요하기 때문에, 사용자가 이해관계가 충돌하는 조합을 선택하는 것은 불가능 함. +예비 또는 작업 중인 진단은 모든 감별진단 선택 중에서 하나의 가장 가능성 높은 선택을 나타내고자 하는 것임."> + > + ["at0016"] = < + text = <"예비"> + description = <"보통 보통 낮은 수준의 임상적 확실을과 과련된, 초기 진단이 이루어짐. 검사 결과 또는 권고에 따라 변경될 수 있음."> + > + ["at0017"] = < + text = <"진행"> + description = <"합리적 수준의 임상적 확실성에 근거하지만, 좀 더 진전된 검사 결과 또는 임상적 권고를 기다리는 임시적인 진단. 이 또한 검사 결과 또는 권고에 따라 변경될 수 있음."> + > + ["at0018"] = < + text = <"확립"> + description = <"검사결과에 따른 임상 근거를 포함할 수 있는, 높은 수준의 임상적 확실성에 기반한 최종의 실질적인 진단. 변경될 것으로 기대되지 않음."> + > + ["at0026"] = < + text = <"활성"> + description = <"현재 활성화되어 있고 임상적으로 관련된 문제 또는 진단"> + > + ["at0027"] = < + text = <"비활성"> + description = <"완치된 문제 또는 진단은 아니지만 비활성 상태이거나 현재 임상 상황에 거의 관련성이 없다고 느껴짐."> + > + ["at0034"] = < + text = <"새로운"> + description = <"새로 또는 존재하는 문제 또는 진단의 새로운 발생. '처음 발생'을 위한 표시는 다른 발생으로 부터 처음 발생을 구별하기 위해 구분해서 기록될 수 있음."> + > + ["at0035"] = < + text = <"진행중"> + description = <"이슈 또는 문제, 진단이 새로운 급성 삽화의 발생없이 진행 중임."> + > + ["at0060"] = < + text = <"현재/과거?"> + description = <"문제와 진단을 현재 또는 과거 문제 목록으로 구분하는 것을 지원하기 위한 범주."> + comment = <"현재/과거 그리고 활성/비활성 데이터 엘리먼트는 비슷한 임상적 영향을 가지지만 약간 다른 의미를 표현함. 둘 다 상이한 임상 환경에서 활발하게 사용되지만 보통 같이 사용되지는 않음. 활성/비활성 한정자가 기록되어 있다면, 이 데이터 엘리먼트는 중복일 가능성이 있음. 상태가 현재일 수는 있지만 비활성인 예외 경우는 급성 증상을 일으키지 않는 천식임."> + > + ["at0061"] = < + text = <"과거"> + description = <"과거에 발생했던 이슈."> + > + ["at0062"] = < + text = <"현재"> + description = <"현재 발생한 이슈."> + > + ["at0063"] = < + text = <"진단 범주"> + description = <"특별한 진료 그리고/또는 로컬 케어 환경의 삽화 내에서의 문제 또는 진단의 범주"> + comment = <"이 데이터 엘리먼트는 진단 범주에서 공통적으로 사용되는 value set을 포함함. 삽화적인 진료환경(보통 이차 진료)에서, 해당 진료삽화 동안 대처해야하는 주진단과의 관계에 따라 범주화/조직화하는 것이 일반적임. 이 범주는 또한 임상 코딩과 리포팅, 청구목적을 위해 사용될 수 있음. 몇몇 국가에서는 진단 범주가 DRG로 알려지기도 함. +추가로, 자유 텍스트 선택은 요구에 따라 다른 로컬 value set의 사용을 허용함."> + > + ["at0064"] = < + text = <"주요 진단"> + description = <"입원 환자 진료의 삽화 또는 요양 진료의 삽화, 의료기관 방문을 야기하는데 주요하게 책임이 있는 것으로 결정된 진단. +"> + > + ["at0066"] = < + text = <"이차 진단"> + description = <"일차 문제 또는 진단과 동시에 발생한 문제 또는 진단. 동반 상태로 알려질 수도 있음."> + > + ["at0070"] = < + text = <"결정불능"> + description = <"문제 또는 진단의 발생이 새로운 것인지 진행 중인 것인지 구별하는 것이 불가능함."> + > + ["at0071"] = < + text = <"*Occurrence (en)"> + description = <"*Category of the occurrence for this problem or diagnosis. (en)"> + comment = <"*This data element can be an additional qualifier to the 'New' value in the 'Episodicity' value set, that is a condition such as asthma can have recurring new episodes that have periods of resolution in between. However it can be important to identify the first ever episode of asthma from all of the other episodes. (en)"> + > + ["at0073"] = < + text = <"입원 진단?"> + description = <"입원시 존재했던 문제 또는 진단인가?"> + comment = <"문제 또는 진단이 입원 시에 존재했다면 참으로 기록. 이 데이터 엘리먼트는 몇몇 국가에서 DRG 리포팅때 요구사항임."> + > + ["at0076"] = < + text = <"합병증"> + description = <"문제 또는 진단의 원치않는 발전."> + > + ["at0077"] = < + text = <"경과"> + description = <"문제 또는 진단의 발생의 속도 그리고/또는 기간 그리고 영속성을 반영하는 범주."> + comment = <"급성 대 만성의 진단은 각 진단에서 따라 다를 것임."> + > + ["at0079"] = < + text = <"만성"> + description = <"영속적 또는 매우 길게 유지되는 영향을 주는 문제 또는 진단, 또는 계속 진화함."> + > + ["at0081"] = < + text = <"급성"> + description = <"빠른 발생, 짧은 경과 또는 둘 다 가진 문제 또는 진단."> + > + ["at0083"] = < + text = <"치료 단계"> + description = <"급성 문제 또는 진단이 치료되는 단계"> + comment = <"예: 중이염의 치료 단계 추적"> + > + ["at0084"] = < + text = <"완치"> + description = <"문제 또는 진단이 완치가 되는 방향으로 치료되고 있거나 정상 단계로 복귀되는 것을 통해 종료됨."> + > + ["at0085"] = < + text = <"치료중"> + description = <"문제 또는 진단이 완치가 되는 방향으로 치료되고 있거나 정상 단계로 복귀되는 것을 통해 만족스럽게 진행중임."> + > + ["at0086"] = < + text = <"치료안되고 있음"> + description = <"문제 또는 진단이 완치가 되는 방향으로 치료되고 있다거나 정상 단계로 복귀되는 것처럼 만족스럽게 진행되지 않고 있음."> + > + ["at0087"] = < + text = <"결정불능"> + description = <"문제 또는 진단의 완치 또는 치료 상태를 결정할 수 없음."> + > + ["at0088"] = < + text = <"반증"> + description = <"이전에 기록된 진단이 임상적으로 재평가되고 높은 수준의 임상적 확실성으로 반증됨. 이 상태는 건강 기록내의 오류를 교정하는데 사용됨."> + > + ["at0089"] = < + text = <"관해 상태"> + description = <"불치병 진단의 관해 상태."> + comment = <"예: 암 또는 혈액학적 진단 상태."> + > + ["at0090"] = < + text = <"완전 관해"> + description = <"확인되는 진행 중인 질병의 증상이나 징후가 없음."> + > + ["at0092"] = < + text = <"관해 아님"> + description = <"질병의 증상이나 증후의 감소가 확인되지 않음."> + > + ["at0093"] = < + text = <"결정불능"> + description = <"질병의 증상이나 증후의 감소가 있는지 결정하는 것이 불가능함."> + > + ["at0094"] = < + text = <"만성진행 중 급성발생"> + description = <"만성 상태의 급성 악화를 한 문제 또는 진단."> + > + ["at0095"] = < + text = <"*First occurrence (en)"> + description = <"*This is the first ever occurrence of this problem or diagnosis. (en)"> + > + ["at0096"] = < + text = <"*Recurrence (en)"> + description = <"*New occurrence of the same problem or diagnosis after a previous episode was resolved. (en)"> + > + ["at0097"] = < + text = <"*Relapsed (en)"> + description = <"*Problem or diagnosis has deteriorated after a period of temporary improvement. (en)"> + > + > + > + ["de"] = < + items = < + ["at0000"] = < + text = <"Problem/Diagnose Attribut"> + description = <"Kontextuelles oder zeitliches Attribut für ein spezifisches Problem oder eine spezifische Diagnose."> + > + ["at0001"] = < + text = <"Episode"> + description = <"Die Kategorie der Episode für das identifizierte Problem oder die identifizierte Diagnose."> + comment = <"Zum Beispiel: Die Episode \"Neu\" ermöglicht es Klinikern eine neue akute Episode von Otitis media, welche möglicherweise kurz nach einer früheren Otitis media-Diagnose aufgetreten ist, von einer ungelösten oder \"andauernden\" chronischen Diagnose Otitis media zu unterscheiden. Die Behandlung von wiederkehrenden, neuen und akuten Episoden einer Erkrankung kann sich erheblich von der Behandlung der gleichen Erkrankung, welche noch nicht genesen ist, oder keine Reaktion auf eine bestimmte Behandlung gezeigt hat, unterscheiden. In vielen Fällen kann der Kliniker dies nicht sagen und eine Einteilung der Episode als \"Unbestimmt\" könnte angemessen sein."> + > + ["at0003"] = < + text = <"Aktiv/Inaktiv?"> + description = <"Eine Kategorie, die die Aufteilung der Problemlisten von Problemen und Diagnosen in aktiv und inaktiv unterstützt."> + comment = <"Die Aktiv/Inaktiv und Aktuell/Vergangen Datenelemente haben einen ähnlichen klinischen Einfluss, repräsentieren aber eine etwas andere Semantik. Beide werden aktiv in verschiedenen klinischen Rahmen benutzt, aber normalerweise nicht zusammen. Wenn ein Aktuell/Vergangen Attribut dokumentiert wird, dann ist dieses Datenelement wahrscheinlich redundant. Eine Ausnahme ist ein Zustand der aktuell, aber inaktiv ist. Ein Beispiel dafür ist Asthma, welches keine akuten Symptome auslöst."> + > + ["at0004"] = < + text = <"Diagnosestatus"> + description = <"Stadium oder Phase des diagnostischen Prozesses."> + comment = <"Der Status wird normalerweise durch eine Kombination des Diagnosezeitraums und der klinischen Sicherheit, welche von den diagnostischen Tests und der klinischen Evidenz abhängt, bestimmt. Zusammen mit dem Element \"Diagnostische Sicherheit\" des EVALUATION.problem/diagnosis Archetypen, bildet dieses Datenelement eine wichtige Basis für den diagnostischen Prozess. Es muss sichergestellt werden, dass die Software eine gültige Kombination aus den beiden Datenelemente präsentiert, damit Nutzer keine widersprüchlichen Kombinationen der beiden Datenelemente auswählen können. +Bei einer Differentialdiagnose ist es beabsichtigt, dass die vorläufige oder die Arbeitsdiagnose als wahrscheinlichste Diagnose repräsentiert wird."> + > + ["at0016"] = < + text = <"Vorläufig"> + description = <"Die Initialdiagnose, welche normalerweise auf einem geringen Level von klinischer Sicherheit beruht. Sie kann sich ändern, sobald weitere Testergebnisse, Hinweise oder Empfehlungen verfügbar sind."> + > + ["at0017"] = < + text = <"In Bearbeitung"> + description = <"Eine vorübergehende Diagnose, bei welcher Testergebnisse und klinische Hinweise oder Empfehlungen noch ausstehen, welche aber bereits auf einer soliden klinischen Sicherheit beruht. Sobald weitere Testresultate und klinische Hinweise oder Empfehlungen zur Verfügung stehen, kann sich die Diagnose noch ändern."> + > + ["at0018"] = < + text = <"Festgestellt"> + description = <"Die finale Diagnose, welche auf einem hohen Level von klinischer Sicherheit beruht, die klinische Anhaltspunkte von Testergebnissen beinhalten kann. Es ist nicht zu erwarten, dass die Diagnose sich noch ändert."> + > + ["at0026"] = < + text = <"Aktiv"> + description = <"Das Problem oder die Diagnose ist momentan aktiv und klinisch relevant."> + > + ["at0027"] = < + text = <"Inaktiv"> + description = <"Das Problem oder die Diagnose ist nicht komplett behoben, ist aber inaktiv oder ist weniger relevant in dem gegenwärtigen klinischen Kontext."> + > + ["at0034"] = < + text = <"Neu"> + description = <"Ein neues Auftreten eines neuen oder bereits existierenden Problems oder einer Diagnose. Um das erste Auftreten von anderen Vorkommnissen zu unterscheiden, kann eine Kennzeichnung für das \"Erstes Auftreten\" separat dargestellt werden."> + > + ["at0035"] = < + text = <"Andauernd"> + description = <"Die Angelegenheit, das Problem oder die Diagnose setzt sich fort, ohne dass neue oder akute Episoden auftreten."> + > + ["at0060"] = < + text = <"Aktuell/Vergangen?"> + description = <"Eine Kategorie, die die Aufteilung der Problemlisten der Probleme und der Diagnosen in aktuell und vergangen unterstützt."> + comment = <"Die Aktuell/Vergangen und Aktiv/Inaktiv Datenelemente haben einen ähnlichen klinischen Einfluss, repräsentieren aber eine etwas andere Semantik. Beide werden aktiv in verschiedenen klinischen Rahmen benutzt, aber normalerweise nicht zusammen. Wenn ein Aktiv/Inaktiv Attribut dokumentiert wird, dann ist dieses Datenelement wahrscheinlich redundant. Eine Ausnahme ist ein Zustand der aktuell, aber inaktiv ist. Ein Beispiel dafür ist Asthma, welches keine akuten Symptome auslöst."> + > + ["at0061"] = < + text = <"Vergangen"> + description = <"Ein Sachverhalt der in der Vergangenheit aufgetreten ist."> + > + ["at0062"] = < + text = <"Aktuell"> + description = <"Ein aktuelles Problem."> + > + ["at0063"] = < + text = <"Diagnostische Kategorie"> + description = <"Die Kategorie des Problems oder der Diagnose innerhalb eines spezifischen Behandlungszeitraumes und/oder eines lokalen Behandlungskontextes."> + comment = <"Dieses Datenelement enthält eine Gruppe von Werten, welches routinemäßig in der diagnostischen Kategorisierung benutzt wird. Es ist üblich, dass im episodischen Versorgungskontext (üblicherweise in der Sekundärversorgung) die Diagnosen während des aktuellen Behandlungszeitraums in Beziehung zur Hauptdiagnose zu kategorisieren/ zu organisieren sind. Diese Kategorien können ebenfalls für die klinische Kodierung, die Berichterstattung und für Abrechnungsprozesse genutzt werden. In manchen Ländern kann die diagnostische Kategorisierung auch als DRG (diagnosebezogene Fallgruppierungen) bekannt sein. +Falls es nötig sein sollte, erlaubt das Freitextfeld die Benutzung von lokalen Werten."> + > + ["at0064"] = < + text = <"Hauptdiagnose"> + description = <"Die Diagnose, die hauptverantwortlich dafür ist, dass der Patient gelegentlich ärztliche Versorgung benötigt oder zeitweise zuhause gepflegt werden muss, oder generell bei einer Gesundheitseinrichtung vorstellig werden muss."> + > + ["at0066"] = < + text = <"Sekundärdiagnose"> + description = <"Ein Problem oder eine Diagnose, die zur gleichen Zeit auftritt wie das Primärproblem oder die Hauptdiagnose. Könnte auch als komorbider Zustand bekannt sein."> + > + ["at0070"] = < + text = <"Unbestimmt"> + description = <"Es ist nicht möglich zu überprüfen, ob die Episode des Problems oder der Diagnose neu oder andauernd ist."> + > + ["at0073"] = < + text = <"Aufnahmediagnose?"> + description = <"War das Problem oder die Diagnose bei der Aufnahme vorhanden?"> + comment = <"Sollte als Wahr dokumentiert werden, falls das Problem oder die Diagnose bei der Aufnahme vorhanden war. Dieses Datenelement ist in manchen Ländern bei der DRG-Berichterstattung vorausgesetzt."> + > + ["at0076"] = < + text = <"Komplikation"> + description = <"Eine unvorteilhafte Entwicklung eines Problems oder einer Diagnose."> + > + ["at0077"] = < + text = <"Verlaufsbeschreibung"> + description = <"Die Kategorie, die die Geschwindigkeit des Auftretens und/oder die Zeit sowie das Andauern des Problems oder der Diagnose beschreibt."> + comment = <"Die Definition von akut und chronisch wird sich von Diagnose zu Diagnose unterscheiden."> + > + ["at0079"] = < + text = <"Chronisch"> + description = <"Ein Problem oder eine Diagnose mit einem beständigen, langanhaltenden oder sich über die Zeit entwickelnden Effekts."> + > + ["at0081"] = < + text = <"Akut"> + description = <"Ein Problem oder eine Diagnose mit einem schnellen Auftreten, einem kurzen Verlauf, oder beidem."> + > + ["at0083"] = < + text = <"Genesungsphase"> + description = <"Die Phase der Heilung eines akuten Problems oder einer Diagnose."> + comment = <"Zum Beispiel: Das Verfolgen des Verlaufes der Heilung einer Mittelohrentzündung."> + > + ["at0084"] = < + text = <"Genesen"> + description = <"Das Problem oder die Diagnose hat die normalen Phasen der Wiederherstellung oder der Heilung durchlaufen und kann als vollständig genesen angesehen werden."> + > + ["at0085"] = < + text = <"Genesung"> + description = <"Das Durchlaufen der normalen Stadien der Wiederherstellung oder Heilung bis zur vollständigen Genesung des Problems oder der Diagnose läuft zufriedenstellend."> + > + ["at0086"] = < + text = <"Keine Genesung"> + description = <"Das Durchlaufen der normalen Stadien der Wiederherstellung oder Heilung bis zur vollständigen Genesung des Problems oder der Diagnose läuft nicht zufriedenstellend."> + > + ["at0087"] = < + text = <"Unbestimmt"> + description = <"Der Genesungs- oder Heilungsstatus des Problems oder der Diagnose kann nicht bestimmt werden."> + > + ["at0088"] = < + text = <"Widerlegt"> + description = <"Die zuvor gestellte Diagnose wurde klinisch neu bewertet oder mit einem hohen Level an klinischer Sicherheit widerlegt. Dieser Status wird zur Korrektur von Fehlern in der Gesundheitsakte benutzt."> + > + ["at0089"] = < + text = <"Remissionsstatus"> + description = <"Der Remissionsstatus einer nicht heilbaren Krankheit."> + comment = <"Zum Beispiel: Der Status von Krebs oder einer hämatologischen Diagnose."> + > + ["at0090"] = < + text = <"In Remission"> + description = <"Keine anhaltenden Anzeichen oder Symptome der Krankheit konnten festgestellt werden."> + > + ["at0092"] = < + text = <"Nicht in Remission"> + description = <"Keine Minderung der Anzeichen oder der Symptome der Krankheit konnte festgestellt werden."> + > + ["at0093"] = < + text = <"Unbestimmt"> + description = <"Es ist nicht möglich zu überprüfen, ob eine Minderung der Anzeichen oder der Symptome der Krankheit festgestellt wurde."> + > + ["at0094"] = < + text = <"Akut bis chronisch"> + description = <"Ein Problem oder eine Diagnose mit einem akuten Schub eines chronischen Zustandes."> + > + ["at0095"] = < + text = <"Auftreten"> + description = <"Beschreibung des Auftretens des Problems oder der Diagnose. "> + comment = <"Dieses Datenelement kann ein weiteres Attribut zu dem Wert \"Neu\" in dem Werteset \"Episoden\" sein. Asthma wäre ein Beispiel für ein Zustand, welcher wieder auftretende neue Episoden hat, welche durch Perioden der Genesung unterbrochen werden. Allerdings kann es wichtig sein, die allererste Episode, in der Asthma aufgetreten ist, von den anderen Episoden zu trennen. "> + > + ["at0096"] = < + text = <"Erstauftreten"> + description = <"Dies ist das allererste Mal, dass das Problem oder die Diagnose auftritt."> + > + ["at0097"] = < + text = <"Wiederauftreten"> + description = <"Wiederauftreten des gleichen Problems oder der gleichen Diagnose, nachdem eine vorherige Episode bereits erfolgreich behandelt oder gelöst wurde."> + > + ["at0071"] = < + text = <"*Occurrence(en)"> + description = <"*Category of the occurrence for this problem or diagnosis.(en)"> + comment = <"*This data element can be an additional qualifier to the 'New' value in the 'Episodicity' value set, that is a condition such as asthma can have recurring new episodes that have periods of resolution in between. However it can be important to identify the first ever episode of asthma from all of the other episodes.(en)"> + > + > + > + ["it"] = < + items = < + ["at0000"] = < + text = <"Qualificatore di problema/diagnosi."> + description = <"Qualificatore di contesto o di tempo per uno specifico problema o una specifica diagnosi."> + > + ["at0001"] = < + text = <"Episodicità"> + description = <"Categoria di questo episodio per il problema/diagnosi identificati. "> + comment = <"Ad esempio: \"Nuovo\" permetterà ai medici di distinguere un nuovo episodio acuto di otite media che può essere sorto subito dopo una diagnosi precedente, per distinguerlo da una diagnosi irrisolta o \"in corso\" di otite media cronica. Il trattamento di episodi ricorrenti, nuovi e acuti di una patologia, può differire significativamente dalla stessa patologia che non si risolve o non risponde al trattamento. In molte situazioni il clinico non sarà in grado di dirlo, e quindi indeterminato può essere appropriato."> + > + ["at0003"] = < + text = <"Attivo/Inattivo?"> + description = <"Categoria che supporta la divisione di problemi e diagnosi in elenchi di problemi Attivi o Inattivi."> + comment = <"I dati Attivo/Inattivo e Corrente/Passato hanno un impatto clinico simile, ma rappresentano una semantica leggermente diversa. Entrambi sono utilizzati attivamente in contesti clinici diversi, ma di solito non insieme. Se viene registrato un qualificatore Corrente/Passato, è probabile che questo dato sia ridondante. Un'eccezione in cui una condizione può essere corrente ma inattiva è l'asma che non causa sintomi acuti."> + > + ["at0004"] = < + text = <"Stato diagnostico"> + description = <"Stadio o fase del processo diagnostico."> + comment = <"Lo stato è solitamente determinato da una combinazione delle tempistiche di diagnosi più il livello di certezza clinica risultante dai test diagnostici e dalle prove cliniche disponibili. +Questo dato e la 'Certezza diagnostica' in EVALUATION.problem_diagnosis sono due assi importanti del processo diagnostico, e combinazioni valide dovranno essere presentate da un software che esponga entrambi i dati, quindi non è possibile per gli utenti selezionare combinazioni contrastanti. +Le diagnosi preliminari o di lavoro sono destinate a rappresentare la scelta più probabile tra tutte le opzioni di diagnosi differenziale."> + > + ["at0016"] = < + text = <"Preliminare"> + description = <"La diagnosi inizialmente fatta, di solito associata ad un basso livello di certezza clinica. Può cambiare man mano che risultati di test o indicazioni diventano disponibili."> + > + ["at0017"] = < + text = <"Interim"> + description = <"Diagnosi di lavoro, basata su una ragionevole certezza clinica, ma in attesa di ulteriori risultati di test o di consigli clinici. Può comunque cambiare man mano che i risultati dei test o i indicazioni diventano disponibili."> + > + ["at0018"] = < + text = <"Definitiva"> + description = <"Diagnosi definitiva documentata, basata su un alto livello di certezza clinica, che può includere l'evidenza clinica dei risultati dei test. Non ci si aspetta che cambi."> + > + ["at0026"] = < + text = <"Attivo"> + description = <"Il problema o la diagnosi sono attualmente attivi e clinicamente rilevanti."> + > + ["at0027"] = < + text = <"Inattivo"> + description = <"Il problema o la diagnosi non sono completamente risolti, ma sono inattivi o ritenuti meno rilevanti nel contesto clinico attuale."> + > + ["at0034"] = < + text = <"Nuovo"> + description = <"Una nuova insorgenza di un problema o di una diagnosi nuova o già esistente. Un flag per \"Prima occorrenza\" può essere registrato separatamente per distinguere la prima da altre occorrenze."> + > + ["at0035"] = < + text = <"In corso"> + description = <"Il fenomeno, il problema o la diagnosi continua, senza che si verifichino nuovi episodi acuti."> + > + ["at0060"] = < + text = <"Corrente/Passato?"> + description = <"Categoria che supporta la divisione di problemi e diagnosi in elenchi di problemi Correnti o Passati."> + comment = <"I dati Corrente/Passato e Attivo/Inattivo hanno hanno un impatto clinico simile, ma rappresentano una semantica leggermente diversa. Entrambi sono utilizzati attivamente in contesti clinici diversi, ma di solito non insieme. Se viene registrato un qualificatore Attivo/Inattivo, è probabile che questo dato sia ridondante. Un'eccezione in cui una condizione può essere corrente ma inattiva è l'asma che non causa sintomi acuti."> + > + ["at0061"] = < + text = <"Passato"> + description = <"Un problema che si è verificato in passato."> + > + ["at0062"] = < + text = <"Corrente"> + description = <"Un problema che si sta verificando al momento."> + > + ["at0063"] = < + text = <"Categoria diagnostica"> + description = <"Categoria del problema o diagnosi all'interno di un episodio specifico di cura e/o contesto di cura locale."> + comment = <"Questo dato contiene un set di valori comunemente usato nella categorizzazione diagnostica. In contesti di assistenza episodica (comunemente assistenza secondaria) è comune categorizzare/organizzare le diagnosi in base alla loro relazione con la diagnosi principale che viene affrontata durante quell'episodio di assistenza. Queste categorie possono essere utilizzate anche per la codifica clinica, la segnalazione e la fatturazione. In alcuni paesi la categoria diagnostica può essere conosciuta come DRG. + Inoltre, la scelta del testo libero permette l'uso di altri set di valori locali, come richiesto."> + > + ["at0064"] = < + text = <"Diagnosi principale"> + description = <"La diagnosi è stata determinata come responsabile principale di un episodio di ricovero del paziente, di un episodio di assistenza residenziale o di una presenza presso la struttura sanitaria."> + > + ["at0066"] = < + text = <"Diagnosi secondaria"> + description = <"Un problema o una diagnosi che si verifica contemporaneamente al problema o alla diagnosi primaria. Può anche essere conosciuta come una condizione di comorbidità."> + > + ["at0070"] = < + text = <"Indeterminato"> + description = <"Non è possibile determinare se il problema o la diagnosi sono nuovi o in corso."> + > + ["at0071"] = < + text = <"Occorrenza"> + description = <"Categoria di occorrenza per questo problema o diagnosi."> + comment = <"Questo dato può essere un qualificatore aggiuntivo al valore \"Nuovo\" nel set di valori \"Episodicità\", cioè una condizione come l'asma può avere nuovi episodi ricorrenti che hanno periodi di risoluzione nel mezzo. Tuttavia può essere importante identificare il primo episodio di asma da tutti gli altri episodi."> + > + ["at0073"] = < + text = <"Diagnosi di ammissione?"> + description = <"Il problema o la diagnosi erano presenti al momento del ricovero? "> + comment = <"Registrare come vero se il problema o la diagnosi erano presenti al momento del ricovero. Questo dato è un requisito della registrazione DRG in alcuni paesi."> + > + ["at0076"] = < + text = <"Complicazione"> + description = <"Un'evoluzione sfavorevole di un problema o di una diagnosi."> + > + ["at0077"] = < + text = <"Decorso"> + description = <"Categoria che riflette la velocità di insorgenza e/o la durata e la persistenza del problema o della diagnosi."> + comment = <"Le definizioni di acuto e cronico differiscono per ogni diagnosi."> + > + ["at0079"] = < + text = <"Cronico"> + description = <"Un problema o una diagnosi con effetti persistenti o di lunga durata, o che evolve nel tempo."> + > + ["at0081"] = < + text = <"Acuto"> + description = <"Un problema o una diagnosi con un inizio rapido, un breve decorso o entrambi."> + > + ["at0083"] = < + text = <"Fase risolutoria"> + description = <"Fase di guarigione per un problema acuto o una diagnosi. "> + comment = <"Per esempio: tracking del progresso della risoluzione di un'infezione dell'orecchio medio. "> + > + ["at0084"] = < + text = <"Risolto"> + description = <"Il problema o la diagnosi ha completato le normali fasi di recupero o di guarigione e possono essere considerati risolti. "> + > + ["at0085"] = < + text = <"In risoluzione"> + description = <"Il problema o la diagnosi sta progredendo in modo soddisfacente attraverso le normali fasi di recupero o di guarigione verso la risoluzione."> + > + ["at0086"] = < + text = <"Non in risoluzione"> + description = <"Il problema o la diagnosi non sta progredendo in modo soddisfacente attraverso le normali fasi di recupero o di guarigione verso la risoluzione."> + > + ["at0087"] = < + text = <"Indeterminato"> + description = <"Non è possibile determinare la risoluzione o lo stato di guarigione del problema o della diagnosi."> + > + ["at0088"] = < + text = <"Confutato"> + description = <"La diagnosi precedentemente registrata è stata clinicamente rivalutata o smentita con un alto livello di certezza clinica. Questo stato viene utilizzato per correggere un errore nella cartella clinica."> + > + ["at0089"] = < + text = <"Stato di recesso"> + description = <"Stato di recesso di una diagnosi incurabile."> + comment = <"Per esempio: lo stato di un cancro o la diagnosi ematologica."> + > + ["at0090"] = < + text = <"In recesso"> + description = <"Non sono stati identificati segni o sintomi in corso della malattia."> + > + ["at0092"] = < + text = <"Non in recesso"> + description = <"Non è stata identificata alcuna diminuzione dei segni o dei sintomi della malattia."> + > + ["at0093"] = < + text = <"Indeterminato"> + description = <"Non è possibile determinare se ci sia stata una diminuzione dei segni o dei sintomi della malattia."> + > + ["at0094"] = < + text = <"Acuto-su-cronico"> + description = <"Un problema o una diagnosi con esacerbazione acuta di una condizione cronica. "> + > + ["at0095"] = < + text = <"Prima occorrenza"> + description = <"Questa è la prima occorrenza di questo problema o questa diagnosi."> + > + ["at0096"] = < + text = <"Ricorrenza"> + description = <"Nuova comparsa dello stesso problema o diagnosi dopo un episodio precedente è stata risolta."> + > + ["at0097"] = < + text = <"Recidiva"> + description = <"Il problema o la diagnosi sono peggiorati dopo un periodo di miglioramento temporaneo."> + > + > + > + > + term_bindings = < + ["SNOMED-CT"] = < + items = < + ["at0001"] = <[SNOMED-CT::288526004]> + ["at0004"] = <[SNOMED-CT::106229004]> + ["at0016"] = <[SNOMED-CT::148006]> + ["at0017"] = <[SNOMED-CT::5558000]> + ["at0060"] = <[SNOMED-CT::410511007]> + ["at0061"] = <[SNOMED-CT::410513005]> + ["at0062"] = <[SNOMED-CT::15240007]> + ["at0077"] = <[SNOMED-CT::288524001]> + ["at0018"] = <[SNOMED-CT::14657009]> + ["at0064"] = <[SNOMED-CT::8319008]> + ["at0066"] = <[SNOMED-CT::85097005]> + > + > + > diff --git a/better-template/src/test/resources/opt_json/Archetypes/openEHR-EHR-CLUSTER.symptom_sign-cvid.v0.adl b/better-template/src/test/resources/opt_json/Archetypes/openEHR-EHR-CLUSTER.symptom_sign-cvid.v0.adl new file mode 100644 index 000000000..c9a67e654 --- /dev/null +++ b/better-template/src/test/resources/opt_json/Archetypes/openEHR-EHR-CLUSTER.symptom_sign-cvid.v0.adl @@ -0,0 +1,2286 @@ +archetype (adl_version=1.4; uid=58414310-36c9-46a8-861f-604330913760) + openEHR-EHR-CLUSTER.symptom_sign-cvid.v0 +specialize + openEHR-EHR-CLUSTER.symptom_sign.v1 + +concept + [at0000.1] + +language + original_language = <[ISO_639-1::en]> + translations = < + ["de"] = < + language = <[ISO_639-1::de]> + author = < + ["name"] = <"Jasmin Buck, Sebastian Garde, Kim Sommer"> + ["organisation"] = <"University of Heidelberg, Central Queensland University, Medizinische Hochschule Hannover"> + > + > + ["fi"] = < + language = <[ISO_639-1::fi]> + author = < + ["name"] = <"Kalle Vuorinen"> + ["organisation"] = <"Tieto Healthcare & Welfare Oy"> + ["email"] = <"kalle.vuorinen@tieto.com"> + > + > + ["sv"] = < + language = <[ISO_639-1::sv]> + author = < + ["name"] = <"Kirsi Poikela"> + ["organisation"] = <"Tieto Sweden AB"> + ["email"] = <"ext.kirsi.poikela@tieto.com"> + > + > + ["nb"] = < + language = <[ISO_639-1::nb]> + author = < + ["name"] = <"Lars Bitsch-Larsen"> + ["organisation"] = <"Haukeland University Hospital of Bergen, Norway"> + ["email"] = <"lbla@helse-bergen.no"> + > + accreditation = <"MD, DEAA, MBA, spec in anesthesia, spec in tropical medicine."> + > + ["pt-br"] = < + language = <[ISO_639-1::pt-br]> + author = < + ["name"] = <"Vladimir Pizzo"> + ["organisation"] = <"Hospital Sirio Libanes - Brazil"> + ["email"] = <"vladimir.pizzo@hsl.org.br"> + > + > + ["ar-sy"] = < + language = <[ISO_639-1::ar-sy]> + author = < + ["name"] = <"Mona Saleh"> + > + > + > + +description + original_author = < + ["date"] = <"2007-02-20"> + ["name"] = <"Tony Shannon"> + ["organisation"] = <"UK NHS, Connecting for Health"> + ["email"] = <"tony.shannon@nhs.net"> + > + lifecycle_state = <"in_development"> + other_contributors = <"Tomas Alme, DIPS, Norway","Vebjørn Arntzen, Oslo University Hospital, Norway","Koray Atalag, University of Auckland, New Zealand","Silje Ljosland Bakke, Nasjonal IKT HF, Norway (openEHR Editor)","Lars Bitsch-Larsen, Haukeland University hospital, Norway","Rong Chen, Cambio Healthcare Systems, Sweden","Stephen Chu, Queensland Health, Australia","Einar Fosse, National Centre for Integrated Care and Telemedicine, Norway","Samuel Frade, Marand, Portugal","Sebastian Garde, Ocean Informatics, Germany","Yves Genevier, Privantis SA, Switzerland","Heather Grain, Llewelyn Grain Informatics, Australia","Sam Heard, Ocean Informatics, Australia","Evelyn Hovenga, EJSH Consulting, Australia","Lars Karlsen, DIPS ASA, Norway","Lars Morgan Karlsen, DIPS ASA, Norway","Shinji Kobayashi, Kyoto University, Japan","Sabine Leh, Haukeland University Hospital, Department of Pathology, Norway","Heather Leslie, Atomica Informatics, Australia (openEHR Editor)","Hallvard Lærum, Norwegian Directorate of e-health, Norway","Luis Marco Ruiz, Norwegian Center for Integrated Care and Telemedicine, Norway","Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (openEHR Editor)","Bjoern Naess, DIPS ASA, Norway","Andrej Orel, Marand d.o.o., Slovenia","Jussara Rotzsch, Hospital Alemão Oswaldo Cruz, Brazil","Anoop Shah, University College London, United Kingdom","Norwegian Review Summary, Nasjonal IKT HF, Norway","Rowan Thomas, St. Vincent's Hospital Melbourne, Australia","John Tore Valand, Helse Bergen, Norway","Jon Tysdahl, Norway"> + details = < + ["de"] = < + language = <[ISO_639-1::de]> + purpose = <"Zur Erfassung von Details über eine einzelne Episode eines berichteten Symptoms/Krankheitsanzeichens. Zusammenhänge zu früheren Episoden (ohne Angabe von Details) sollen, wenn angemessen, ebenfalls aufgeführt werden."> + keywords = <"Beschwerde","Symptom","Störung","Problem","gegenwärtige Beschwerde","gegenwärtiges Symptom","Zeichen","Anzeichen","Krankheitsanzeichen"> + copyright = <"© openEHR Foundation"> + use = <"Zu Verwenden, um Details über eine einzelne Episode eines Symptoms oder eines berichteten Krankheitsanzeichens einer Person zu dokumentieren, wie es von der Person, dem Elternteil, dem Betreuer oder einer anderen Partei berichtet wurde. Es kann von einem Arzt als Teil einer Krankengeschichte dokumentiert werden, oder wie es dem Arzt berichtet wurde/wie er es beobachtet hat, oder als Teil eines selbst aufgezeichneten klinischen Fragebogens oder einer persönlichen Gesundheitsakte. Eine vollständige Krankengeschichte kann mehrere Episoden eines identifizierten Symptoms/Krankheitsanzeichens, mit variierendem Detaillierungsgrad, sowie mehrere Symptome/Krankheitsanzeichen beinhalten. + +Symptome sind subjektive Beobachtungen einer körperlichen oder geistigen Störung und Krankheitsanzeichen sind objektive Beobachtungen dieser Störung, wie sie von einer Person erlebt und dem Dokumentierenden von derselben Person oder einer anderen Partei berichtet werden. Aus dieser Logik folgt, dass zwei Archetypen benötigt werden, um die Krankengeschichte aufzuzeichnen - einen für berichtete Symptome und einen weiteren für berichtete Krankheitsanzeichen. Für die Praxis ist dies ungeeignet, da es die Eingabe klinischer Daten in eines der beiden Modelle erfordert, was den Modellierern und denen, die die Daten eingeben, erheblichen Mehraufwand verursacht. Darüber hinaus gibt es oft Überschneidungen von klinischen Konzepten - z.B. ist vorangegangenes Erbrechen oder sind Blutungen als Symptom oder berichtetes Krankheitsanzeichen zu kategorisieren? Als Antwort darauf wurde dieser Archetyp speziell entwickelt, um ein einziges Informationsmodell zu erproben, das es ermöglicht, das gesamte Spektrum von klar identifizierbaren Symptomen bis hin zu berichteten Krankheitsanzeichen bei der Dokumentation einer Krankengeschichte zu erfassen. + +Dieser Archetyp wurde als generisches Muster für alle Symptome und Krankheitsanzeichen entwickelt. Der Slot \"Spezifische Details\" kann verwendet werden, um den Archetyp um zusätzliche, spezifische Datenelemente für komplexere Symptome oder Krankheitsanzeichen zu erweitern. + +Dieser Archetyp wurde speziell für die Verwendung im Slot \"Strukturiertes Detail\" innerhalb des Archetyps OBSERVATION.story entwickelt, kann aber auch in anderen OBSERVATION- oder CLUSTER-Archetypen und in den Slots \"Assoziierte Symptome/Krankheitsanzeichen\" oder \"Vorangegangene Episoden\" in anderen Instanzen dieses CLUSTER.symptom_sign Archetyps verwendet werden. + +Ärzte benutzen häufig den Ausdruck \"nicht signifikant\", um festzuhalten, dass sie eine Person bezüglich des Symptoms/Krankheitsanzeichens befragt haben und es nicht berichtet wurde, dass Unannehmlichkeiten oder Störungen vorliegen - es wird also eher wie eine \"normale Aussage\" als wie ein ausdrücklicher Ausschluss verwendet. Das Datenelement \"Nicht signifikant\" wurde bewusst in diesen Archetyp aufgenommen, um Ärzten zu ermöglichen, dieselben Informationen auf einfache und effektive Weise in einem klinischen System zu dokumentieren. Es kann verwendet werden, um eine Benutzeroberfläche zu steuern, z.B. wenn \"Nicht signifikant\" als wahr dokumentiert wird, dann können die restlichen Datenelemente auf einem Dateneingabebildschirm ausgeblendet werden. Dieser pragmatische Ansatz unterstützt die Mehrheit der einfachen Anforderungen an die klinische Aufzeichnung im Bereich der berichteten Symptome/Krankheitsanzeichen. + +Wenn es jedoch klinisch zwingend erforderlich ist, explizit zu erfassen, dass ein Symptom oder Krankheitsanzeichen als nicht vorhanden berichtet wurde, z.B. wenn es zur Unterstützung der klinischen Entscheidung verwendet wird, dann wäre es besser, den Archetyp CLUSTER.exclusion_symptom_sign zu verwenden. Die Verwendung von CLUSTER.exclusion_symptom_sign soll die Komplexität der Template-Modellierung, -Implementierung und -Abfrage erhöhen. Es wird empfohlen, den Archetyp CLUSTER.exclusion_symptom_sign nur dann für die Verwendung in Betracht zu ziehen, wenn in bestimmten Situationen ein klarer Nutzen erkennbar ist, aber nicht für die routinemäßige Aufnahme von Symptomen und Krankheitsanzeichen."> + misuse = <"Nicht zu verwenden, um zu dokumentieren, dass ein Symptom oder ein Krankheitsanzeichen explizit als nicht vorhanden berichtet wurde - verwenden Sie CLUSTER.exclusion_symptom_sign sorgfältig für bestimmte Zwecke, bei denen der durch die Aufzeichnung entstehende Mehraufwand die zusätzliche Komplexität rechtfertigt, und nur dann, wenn das \"Nicht signifikant\" in diesem Archetyp nicht spezifisch genug für den Zweck der Dokumentation ist. + +Nicht zur Erfassung objektiver Befunde im Rahmen einer körperlichen Untersuchung verwenden - verwenden Sie zu diesem Zweck OBSERVATION.exam und verwandte Untersuchung-CLUSTER-Archetypen. + +Nicht für Diagnosen und Probleme, die Teil einer bestehenden Problemliste sind, verwenden - verwenden Sie EVALUATION.problem_diagnosis. +"> + > + ["sv"] = < + language = <[ISO_639-1::sv]> + purpose = <"Att registrera ett uppvisat symtom eller tecken ifrån en enskild episod, inklusive kontext, men inte detaljer om tidigare episoder, om det är tillämpligt."> + keywords = <"besvär","symtom","störning","problem","obehag","uppvisar besvär","uppvisar symtom","tecken"> + copyright = <"© openEHR Foundation"> + use = <"Används för att beskriva detaljer för en individs rapporterade symtom eller tecken ifrån en enskild episod, som rapporterats av personen, föräldern, hälso- o sjukvårdspersonal eller annan part. Det kan registreras av hälso- o sjukvårdspersonal som en del av en anamnes som rapporterats till hälso- o sjukvårdspersonalen, observerad av eller registrerats själv av personen som en del av ett kliniskt frågeformulär eller personligt hälsodokument. En komplett anamnes eller patientjournal kan innehålla varierande detaljnivå från flera episoder av ett identifierat symtom eller rapporterade tecken, såväl som multipla symtom och tecken. + +Symtom är subjektiva observationer från en fysisk eller psykisk störning och tecken är objektiva observationer av densamma, upplevda av en individ och rapporteras till journalföraren av samma individ eller annan part. +Ur denna logik följer att vi behöver två arketyper för att registrera klinisk anamnes , en för rapporterade symtom och en annan för rapporterade tecken. I verkligheten är detta opraktiskt eftersom det kommer att kräva tillgång till kliniska data i någon av dessa mallar, vilket innebär signifikant merarbete för mallarna och dem som matar in data. Dessutom finns det ofta överlappningar i kliniska koncept, exempevisl är tidigare kräkningar eller blödningar att kategoriserade som ett symtom eller rapporterat tecken? +Som svar har denna arketyp utformats specifikt för att möjliggöra registrering av en sammanhängande enhet mellan tydligt identifierbara symtom och rapporterade tecken vid registrering av en klinisk anamnes. + +Används som en allmän mall för alla symtom och rapporterade tecken. Fältet \"Specifika detaljer\" kan användas för att utöka arketypen för att inkludera ytterligare, specifika datakomponenter för mer komplexa symtom eller tecken. + +Arketypen är speciellt utformad för att användas i fältet \"Detaljstruktur\" i OBSERVATION.story-arketypen, men kan även användas inom andra OBSERVATION- eller CLUSTER-arketyper och i \"Associerade symtom och tecken\" eller i fältet \"Tidigare episod\" inom andra exempel av denna CLUSTER.symptom_sign arketypen. Hälso- o sjukvårdspersonal registrerar ofta uttrycket \"Används inte för att dokumentera ett symtom eller tecken\" som uttryckligen rapporteras som inte förekommande. + +Använd CLUSTER.exclusion_symptom_sign med försiktighet för specifika ändamål där merarbetet för registreringarna på detta sätt motiverar extra komplexitet och endast om \"Noll signifikanta\" fältet i denna arketyp inte är tillräckligt specifik för syftet för registreringen. Används inte för att dokumentera ett symtom eller tecken som uttryckligen rapporteras som inte förekommande – använd CLUSTER.exclusion_symptom_sign med försiktighet för specifika ändamål där merarbetet för registreringarna på detta sätt motiverar extra komplexitet och endast om \"Noll signifikanta\" fältet i denna arketyp inte är tillräckligt specifik för syftet för registreringen. För specifika symtom eller rapporterade tecken som en effektiv metod för att indikera att individen tillfrågats och det inte rapporterades som obehag eller störning - används mer effektivt som ett \"normalt utlåtande\" snarare än en uttrycklig uteslutning. Det \"Noll signifikanta\" fältet har medvetet inkluderats i denna arketyp för att kliniker kan registrera samma information på ett enkelt och effektivt sätt i ett kliniskt system. Det kan användas för att driva ett användargränssnitt, exempelvis om \"Noll signifikant\" är registrerad som sann kan de återstående fälten döljas på en dataskärm. Denna pragmatiska metod stöder majoriteten av enkla kliniska registreringskrav kring rapporterade symtom och tecken. + +Däremot om det finns en klinisk nödvändighet att uttryckligen registrera att ett symtom eller tecken rapporterades som inte förekommande, exempelvis om det kommer att användas som ett kliniskt beslutsstöd, föredras CLUSTER.exclusion_symptom_sign arketypen. Användningen av CLUSTER.exclusion_symptom_sign ökar komplexiteten i mallutformningen, implementeringen och utfrågningen. Det rekommenderas att CLUSTER.exclusion_symptom_sign arketypen endast beaktas för användning om tydlig fördel kan identifieras i specifika situationer, men ska inte användas för rutinmässigt symtom och tecken registrering. + + +"> + misuse = <"Ska inte användas för att dokumentera ett symtom eller tecken som uttryckligen rapporteras som inte förekommande. Använd CLUSTER.exclusion_symptom_sign med försiktighet för specifika ändamål där merarbetet för registreringarna på detta sätt motiverar extra komplexitet och endast om \"Noll significant\" fältet i denna arketyp inte är tillräckligt specifik för registreringens syfte. + +Ska inte användas för att registrera objektiva fynd som en del av en fysisk undersökning . Använd OBSERVATION.exam och relaterad undersökning CLUSTER-arketyper för detta ändamål. + +Ska inte användas för diagnoser och problem som ingår i en kvarstående problemlista. Använd då istället EVALUATION.problem_diagnosis."> + > + ["fi"] = < + language = <[ISO_639-1::fi]> + purpose = <"*To record details about a single episode of a reported symptom or sign including context, but not details, of previous episodes if appropriate.(en)"> + keywords = <"*complaint(en)","*symptom(en)","*disturbance(en)","*problem(en)","*discomfort(en)","*presenting complaint(en)","*presenting symptom(en)","*sign(en)"> + copyright = <"© openEHR Foundation"> + use = <"*Use to record details about a single episode of a symptom or reported sign in an individual, as reported by the individual, parent, care-giver or other party. It may be recorded by a clinician as part of a clinical history record as reported to them, observed by the clinician or self-recorded as part of a clinical questionnaire or personal health record. A complete clinical history or patient story may include varying level of details about multiple episodes of an identified symptom or reported sign, as well as multiple symptoms/signs. + +In the purest sense, symptoms are subjective observations of a physical or mental disturbance and signs are objective observations of the same, as experienced by an individual and reported to the history taker by the same individual or another party. From this logic it follows that we will need two archetypes to record clinical history - one for reported symptoms and another for reported signs. In reality this is impractical as it will require clinical data entry into either one of these models which adds signficant overheads to modellers and those entering data. In addition, there is often overlap in clinical concepts - for example, is previous vomiting or bleeding to be categorised as a symptom or reported sign? In response, this archetype has been specifically designed to proved a single information model that allows for recording of the entire continuum between clearly identifable symptoms and reported signs when recording a clinical history. + +This archetype has been intended to be used as a generic pattern for all symptoms and reported signs. The 'Specific details' SLOT can be used to extend the archetype to include additional, specific data elements for more complex symptoms or signs. + +This archetype has been specifically designed to be used in the 'Structured detail' SLOT within the OBSERVATION.story archetype, but can also be used within other OBSERVATION or CLUSTER archetypes and in the 'Associated symptom/sign' or 'Previous episode' SLOT within other instances of this CLUSTER.symptom_sign archetype. + +Clinicians frequently record the phrase 'nil significant' against specific symptoms or reported signs as an efficient method to indicate that they asked the individual and it was not reported as causing any discomfort or disturbance - effectively used more like a 'normal statement' rather than an explicit exclusion. The 'Nil significant' data element has been deliberately included in this archetype to allow clinicians to record this same information in a simple and effective way in a clinical system. It can be used to drive a user interface, for example if 'Nil significant' is recorded as true then the remaining data elements can be hidden on a data entry screen. This pragmatic approach supports the majority of simple clinical recording requirements around reported symptoms and signs. + +However if there is a clinical imperative to explicitly record that a Symptom or Sign was reported as not present, for example if it will be used to drive clinical decision support, then it would be preferable to use the CLUSTER.exclusion_symptom_sign archetype. The use of CLUSTER.exclusion_symptom_sign will increase the complexity of template modelling, implementation and querying. It is recommended that the CLUSTER.exclusion_symptom_sign archetype only be considered for use if clear benefit can be identified in specific situations, but should not be used for routine symptom/sign recording.(en)"> + misuse = <"*Not to be used to record that a symptom or sign was explicitly reported as not present - use CLUSTER.exclusion_symptom_sign carefully for specific purposes where the overheads of recording in this way warrant the additional complexity, and only if the 'Nil significant' in this archetype is not specific enough for recording purposes. + +Not to be used for recording objective findings as part of a physical examination - use OBSERVATION.exam and related examination CLUSTER archetypes for this purpose. + +Not to be used for diagnoses and problems that form part of a persisting Problem List - use EVALUATION.problem_diagnosis.(en)"> + > + ["nb"] = < + language = <[ISO_639-1::nb]> + purpose = <"For å registrere detaljer om en enkeltepisode av et rapportert symptom eller sykdomstegn. Dette kan omfatte kontekst, men ikke detaljer, om tidligere episoder av symptomet/sykdomstegnet."> + keywords = <"lidelse","plage","problem","ubehag","symptom","sykdomstegn","lyte","skavank"> + copyright = <"© openEHR Foundation"> + use = <"For å registrere detaljer om en enkeltepisode av et rapportert symptom eller sykdomstegn hos et individ, som redegjort av personen selv, foreldre, omsorgsperson eller andre parter. Registrering kan skje i forbindelse med opptak av anamnese, eller som en selvregistrering som en del av et klinisk spørreskjema eller personlig journal. +En fullstendig klinisk anamnese eller pasientanamnese kan inneholde beskrivelser med ulikt detaljnivå om flere episoder knyttet til samme symptom eller sykdomstegn, og vil også kunne inneholde flere ulike symptomer eller sykdomstegn. + +I egentlig forstand er symptomer subjektive opplevelser av en fysisk eller mental forstyrrelse mens sykdomstegn er objektive observasjoner av det samme, som er erfart av et individ og rapportert til en kliniker av individet eller av andre. Fra denne logikken følger at det burde være to arketyper til å registrere klinisk anamnese; en for rapporterte symptomer og en for rapporterte sykdomstegn. I virkeligheten er dette upraktisk og vil kreve registrering av kliniske data i enten den ene eller den andre av disse modellene. I praksis vil dette øke kompleksitet og tidsbruk knyttet til modellering og registrering av data. I tillegg overlapper ofte de kliniske konseptene, for eksempel: Vil tidligere oppkast eller blødning kategoriseres som et symptom eller som et rapportert sykdomstegn? +Som svar på dette er arketypen laget for å tillate registrering av hele kontinuumet mellom tydelig definerte symptomer og rapporterte sykdomstegn når en registrerer en klinisk anamnese. + +Arketypen er designet for å gi et generisk rammeverk for alle symptomer og rapporterte sykdomstegn. SLOTet \"Spesifikke detaljer\" kan brukes for å utvide arketypen med ytterligere spesifikke dataelementer for komplekse symptomer eller sykdomstegn. + +Arketypen skal settes inn i \"Detaljer\"-SLOTet i OBSERVATION.story-arketypen men kan også brukes i en hvilken som helst OBSERVATION eller CLUSTER-arketype. Arketypen kan også gjenbrukes i andre instanser av CLUSTER.symptom_sign-arketypen i SLOTene \"Assosierte symptomer\" eller \"Tidligere detaljer\". + +Klinikere registrerer ofte frasen \"Ikke av betydning\" i forbindelse med spesifikke symptomer eller rapporterte tegn for å indikere at det er eksplisitt spurt om det spesifikke symptomet, og at det ble svart at symptomet ikke er tilstede i en slik grad at det påfører pasienten ubehag eller uro. Frasen brukes mer som en normalbeskrivelse enn en eksplisitt eksklusjon. Dataelementet \"Ikke av betydning\" er med hensikt lagt til for å tillate at klinikere enkelt og effektivt kan registrere denne informasjonen i det kliniske systemet. Eksempelvis kan \"Ikke av betydning\" brukes i brukergrensesnittet, er dette registrert som \"Sann\" kan de resterende dataelementene skjules i brukergrensesnittet. Denne pragmatiske tilnærmingen støtter hoveddelen av enkel klinisk journalføring av symptomer og sykdomstegn. + +Imidlertid kan det være fordelaktig å bruke arketypen CLUSTER.exclusion_symptom_sign dersom det er klinisk behov for å eksplisitt registrere at et symptom eller sykdomstegn ikke er tilstede, for eksempel dersom dette skal brukes til klinisk beslutningsstøtte. Bruk av CLUSTER.exclusion_symptom_sign vil øke kompleksiteten i templatmodellering, implementasjon og spørring. Det anbefales at CLUSTER.exclusion_symptom_sign kun vurderes brukt dersom man kan identifisere en klar gevinst, men bør ikke brukes for rutineregistreringer av symptomer eller sykdomstegn."> + misuse = <"Brukes ikke til eksplisitt registrering av at et symptom eller sykdomstegn ikke er tilstede. Bruk CLUSTER.exclusion_symptom_sign varsomt da det øker tidsbruk ved registrering og tilfører økt kompleksitet, og bare når dataelementet \"Ikke av betydning\" i denne arketypen ikke er eksplisitt nok for registreringen. + +Brukes ikke til registrering av objektive funn som en del av en fysisk undersøkelse. Bruk OBSERVATION.exam og relaterte CLUSTER.exam-arketyper for dette formålet. + +Brukes ikke til registrering av problemer og diagnoser som en del av en persistent problemliste, til dette brukes EVALUATION.problem_diagnosis. + +Brukes ikke til å dokumentere tiltak og resultat i løpet av hele perioden individet er under behandling, da arketypen er beregnet til å dokumentere symptomer og sykdomstegn som et øyeblikksbilde."> + > + ["pt-br"] = < + language = <[ISO_639-1::pt-br]> + purpose = <"Registrar detalhes sobre um episódio único de um sinal ou sintoma relatado incluindo contexto, mas não detalhes, de episódios prévios se apropriado."> + keywords = <"queixa","sintoma","distúrbio","problema","desconforto","queixa atual","sintoma atual","sinal"> + copyright = <"© openEHR Foundation"> + use = <"Usar para relatar detalhes sobre um episódio único de um sintoma ou sinal reportado em um indivíduo, como reportado pelo indivíduo, parente, cuidador ou outra arte. Deve ser registrado por um clínico como parte de um relato de história clínica como reportado por eles, observado pelo clínico ou registrado pelo próprio como parte de um questionário ou relato pessoal de saúde. Uma história clínica completa ou história pessoal deve conter - com variáveis níves de detalhes - múltiplos episódios de um sinal ou sintoma identificado ou reportado assim como múltiplos sinais/sintomas. + +No sentido mais puro, sintomas são observações subjetivas de um distúrbio físico ou mental e sinais são observações objetivas dos mesmos, como experimentado por um indivíduo e reportado para o tomador da história pelo mesmo indivíduo ou outra parte. Por esta lógica segue que serão necessários dois arquétipos para registrar a história clínica - um para sintomas e outro para sinais relatados. Na realidade isto é pouco prático pois vai requerer entrada de dados clínicos em cada um destes modelos o que acrescenta problemas significantes aos modeladores e aqueles que coletam o dado. Em adição, frequentemente há uma interposição entre os conceitos clínicos - por exemplo: vômitos ou sangramentos prévios devem ser considerados sintomas ou sinais reportados? Em resposta, este arquétipo foi especificamente desenhado para prover um modelo de informação único que permita o registro de todo o continuum entre sintomas claramente identificáveis e sinais reportados quando do reistro de uma história clínica. + +Este arquétipo pretende ser utilizado como um padrão genérico para todos os sintomas e sinais reportados. O SLOT 'Detalhes específicos' pode ser utilizado para estender o arquétipo e incluir elementos de dados específicos ou adicionais para sinais e sintomas mais complexos. + +Este arquétipo foi desenhado especificamennte para ser utilizado no SLOT 'Detalhe estruturado' com o arquétipo OBSERVATION.story, mas pode também ser utilizado com outros arquétipos OBSERVATION ou CLUSTER e nos SLOTS 'Sinal/sintoma associado' ou 'Episódio prévio' em outras instâncias deste arquétipo CLUSTER.symptom_sign. + +Clínicos frequentemente registram a frase 'não significante' em sintomas específicos ou sinais relatados como um método eficiente de indicar que eles perguntaram ao indivíduo e foi relatado como não causador de desconforto ou distúrbio - efetivamente é utilizado mais como 'referido como normal' do que uma exclusão explícita. O elemento de dado 'não significante' tem sido incluído deliberadamente neste arquétipo para permitir aos clínicos registrarem esta mesma informação de uma maneira simples e efetiva num sistema clínico. Pode ser utilizado para dirigir uma interface de usuário, por exemplo se 'não significante' é registrado como verdadeiro então os demais elementos de dados podem ser ocultos na tela de entrada de dados. Esta abordagem pragmática dá suporte à maioria dos requerimentos de registros clínicos com relação a sinais e sintomas relatados. + +Entretanto se houver um imperativo clínico para explicitar o registro de que um Sintoma ou Sinal foi reportado como ausente, por exemplo se for utilizado para orientar suporte à decisão clínica, então pode ser preferível usar o arquétipo CLUSTER.exclusion_symptom_sign. O uso de CLUSTER.exclusion_symptom_sign vai aumentar a complexidade da modelagem de template, implementação e pesquisa. É recomendado que o arquétipo CLUSTER.exclusion_symptom_sign apenas seja considerado se um benefício claro for identificado em situações específicas e não deve ser utilizado rotineiramente para o registro de sinais/sintomas."> + misuse = <"Não deve ser utilizado para registrar que um sintoma ou sinal foi explicitamente relatado como ausente - utilizar CLUSTER.exclusion_symptom_sign cuidadosamente para fins específicos em que os problemas de registro garantam complexidade adicional e apenas se o 'não significante' neste arquétipo não for específico suficiente para fins de registro. + +Não deve ser utilizado para registrar achados objetivos como parte de um exame físico - utilizar OBSERVATION.exam e arquétipos do tipo CLUSTER relacionados a exame para esta finalidade. + +Não dever ser utilizado para diagnósticos e problemas que fazem parte de uma lista de problemas - utilizar EVALUATION.problem_diagnosis."> + > + ["en"] = < + language = <[ISO_639-1::en]> + purpose = <"To record details about a single episode of a reported symptom or sign including context, but not details, of previous episodes if appropriate."> + keywords = <"complaint","symptom","disturbance","problem","discomfort","presenting complaint","presenting symptom","sign"> + copyright = <"© openEHR Foundation"> + use = <"Use to record details about a single episode of a symptom or reported sign in an individual, as reported by the individual, parent, care-giver or other party. It may be recorded by a clinician as part of a clinical history record as reported to them, observed by the clinician or self-recorded as part of a clinical questionnaire or personal health record. A complete clinical history or patient story may include varying level of details about multiple episodes of an identified symptom or reported sign, as well as multiple symptoms/signs. + +In the purest sense, symptoms are subjective observations of a physical or mental disturbance and signs are objective observations of the same, as experienced by an individual and reported to the history taker by the same individual or another party. From this logic it follows that we will need two archetypes to record clinical history - one for reported symptoms and another for reported signs. In reality this is impractical as it will require clinical data entry into either one of these models which adds signficant overheads to modellers and those entering data. In addition, there is often overlap in clinical concepts - for example, is previous vomiting or bleeding to be categorised as a symptom or reported sign? In response, this archetype has been specifically designed to proved a single information model that allows for recording of the entire continuum between clearly identifable symptoms and reported signs when recording a clinical history. + +This archetype has been intended to be used as a generic pattern for all symptoms and reported signs. The 'Specific details' SLOT can be used to extend the archetype to include additional, specific data elements for more complex symptoms or signs. + +This archetype has been specifically designed to be used in the 'Structured detail' SLOT within the OBSERVATION.story archetype, but can also be used within other OBSERVATION or CLUSTER archetypes and in the 'Associated symptom/sign' or 'Previous episode' SLOT within other instances of this CLUSTER.symptom_sign archetype. + +Clinicians frequently record the phrase 'nil significant' against specific symptoms or reported signs as an efficient method to indicate that they asked the individual and it was not reported as causing any discomfort or disturbance - effectively used more like a 'normal statement' rather than an explicit exclusion. The 'Nil significant' data element has been deliberately included in this archetype to allow clinicians to record this same information in a simple and effective way in a clinical system. It can be used to drive a user interface, for example if 'Nil significant' is recorded as true then the remaining data elements can be hidden on a data entry screen. This pragmatic approach supports the majority of simple clinical recording requirements around reported symptoms and signs. + +However if there is a clinical imperative to explicitly record that a Symptom or Sign was reported as not present, for example if it will be used to drive clinical decision support, then it would be preferable to use the CLUSTER.exclusion_symptom_sign archetype. The use of CLUSTER.exclusion_symptom_sign will increase the complexity of template modelling, implementation and querying. It is recommended that the CLUSTER.exclusion_symptom_sign archetype only be considered for use if clear benefit can be identified in specific situations, but should not be used for routine symptom/sign recording."> + misuse = <"Not to be used to record that a symptom or sign was explicitly reported as not present - use CLUSTER.exclusion_symptom_sign carefully for specific purposes where the overheads of recording in this way warrant the additional complexity, and only if the 'Nil significant' in this archetype is not specific enough for recording purposes. + +Not to be used for recording objective findings as part of a physical examination - use OBSERVATION.exam and related examination CLUSTER archetypes for this purpose. + +Not to be used for diagnoses and problems that form part of a persisting Problem List - use EVALUATION.problem_diagnosis."> + > + ["ar-sy"] = < + language = <[ISO_639-1::ar-sy]> + purpose = <"*To record detail about a symptom - either self-recorded by an individual or recorded on the behalf of a patient by a clinician. A complete patient history may include varying level of details about a variety of symptoms.(en)"> + copyright = <"© openEHR Foundation"> + use = <"*Use to record detailed information about a symptom as told to a clinician by a patient or self-recorded by the individual/patient. + +This archetype allows a 'nil significant' statement to be explicitly recorded.(en)"> + misuse = <"*Not to be used to record details about pain. Use the specialisation of this archetype - the CLUSTER.symptom-pain instead. + +Not to be used for diagnoses and problems that form part of a persisting Problem List - use EVALUATION.problem_diagnosis.(en)"> + > + > + other_details = < + ["licence"] = <"This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/."> + ["custodian_organisation"] = <"openEHR Foundation"> + ["references"] = <"Common Terminology Criteria for Adverse Events (CTCAE) [Internet]. National Cancer Institute, USA. Available from: http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm (accessed 2015-07-13)."> + ["current_contact"] = <"Heather Leslie, Ocean Informatics, heather.leslie@oceaninformatics.com"> + ["original_namespace"] = <"org.openehr"> + ["original_publisher"] = <"openEHR Foundation"> + ["custodian_namespace"] = <"org.openehr"> + ["MD5-CAM-1.0.1"] = <"D52BB4ECB2B0380CB1C0F3A4FBC6BB5C"> + ["build_uid"] = <"91cfb84d-f6d5-4240-8de6-234c0581f543"> + ["ip_acknowledgements"] = <"This artefact includes content from SNOMED Clinical Terms® (SNOMED CT®) which is copyrighted material of the International Health Terminology Standards Development Organisation (IHTSDO). Where an implementation of this artefact makes use of SNOMED CT content, the implementer must have the appropriate SNOMED CT Affiliate license - for more information contact http://www.snomed.org/snomed-ct/get-snomedct or info@snomed.org."> + ["revision"] = <"0.0.1-alpha"> + > + +definition + CLUSTER[at0000.1] matches { -- Covid-19 symptom + items cardinality matches {1..*; unordered} matches { + ELEMENT[at0001.1] matches { -- Symptom/Sign name + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0035] occurrences matches {0..1} matches { -- Nil significant + value matches { + DV_BOOLEAN matches { + value matches {true} + } + } + } + ELEMENT[at0002] occurrences matches {0..1} matches { -- Description + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0151] occurrences matches {0..*} matches { -- Body site + value matches { + DV_TEXT matches {*} + } + } + allow_archetype CLUSTER[at0147] occurrences matches {0..*} matches { -- Structured body site + include + archetype_id/value matches {/openEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER.anatomical_location_circle(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.v1/} + exclude + archetype_id/value matches {/.*/} + } + ELEMENT[at0175] occurrences matches {0..1} matches { -- Episodicity + value matches { + DV_CODED_TEXT matches { + defining_code matches { + [local:: + at0176, -- New + at0178, -- Ongoing + at0177] -- Indeterminate + } + } + } + } + ELEMENT[at0186] occurrences matches {0..1} matches { -- First ever? + value matches { + DV_BOOLEAN matches { + value matches {true} + } + } + } + ELEMENT[at0152] occurrences matches {0..1} matches { -- Episode onset + value matches { + DV_DATE_TIME matches {*} + } + } + ELEMENT[at0164] occurrences matches {0..1} matches { -- Onset type + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0028] occurrences matches {0..1} matches { -- Duration + value matches { + DV_DURATION matches {*} + } + } + ELEMENT[at0021] occurrences matches {0..1} matches { -- Severity category + value matches { + DV_CODED_TEXT matches { + defining_code matches { + [local:: + at0023, -- Mild + at0024, -- Moderate + at0025] -- Severe + } + } + DV_TEXT matches {*} + } + } + ELEMENT[at0026] occurrences matches {0..*} matches { -- Severity rating + value matches { + C_DV_QUANTITY < + property = <[openehr::380]> + list = < + ["1"] = < + units = <"1"> + magnitude = <|0.0..10.0|> + precision = <|1|> + > + > + > + } + } + ELEMENT[at0180] occurrences matches {0..*} matches { -- Progression + value matches { + DV_CODED_TEXT matches { + defining_code matches { + [local:: + at0183, -- Worsening + at0182, -- Unchanged + at0181, -- Improving + at0184] -- Resolved + } + } + } + } + ELEMENT[at0003] occurrences matches {0..1} matches { -- Pattern + value matches { + DV_TEXT matches {*} + } + } + CLUSTER[at0018] occurrences matches {0..*} matches { -- Modifying factor + items cardinality matches {1..*; unordered} matches { + ELEMENT[at0019] occurrences matches {0..1} matches { -- Factor + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0017] occurrences matches {0..1} matches { -- Effect + value matches { + DV_CODED_TEXT matches { + defining_code matches { + [local:: + at0159, -- Relieves + at0156, -- No effect + at0158] -- Worsens + } + } + } + } + ELEMENT[at0056] occurrences matches {0..1} matches { -- Description + value matches { + DV_TEXT matches {*} + } + } + } + } + CLUSTER[at0165] occurrences matches {0..*} matches { -- Precipitating/resolving factor + name matches { + DV_CODED_TEXT matches { + defining_code matches { + [local:: + at0167, -- Precipitating factor + at0168] -- Resolving factor + } + } + } + items cardinality matches {1..*; unordered} matches { + ELEMENT[at0170] occurrences matches {0..1} matches { -- Factor + value matches { + DV_TEXT matches {*} + } + } + allow_archetype CLUSTER[at0154] occurrences matches {0..*} matches { -- Factor detail + include + archetype_id/value matches {/openEHR-EHR-CLUSTER\.health_event(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.symptom_sign(-[a-zA-Z0-9_]+)*\.v1/} + } + ELEMENT[at0171] occurrences matches {0..1} matches { -- Time interval + value matches { + DV_DURATION matches {*} + } + } + ELEMENT[at0185] occurrences matches {0..1} matches { -- Description + value matches { + DV_TEXT matches {*} + } + } + } + } + ELEMENT[at0155] occurrences matches {0..*} matches { -- Impact + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0037] occurrences matches {0..1} matches { -- Episode description + value matches { + DV_TEXT matches {*} + } + } + allow_archetype CLUSTER[at0153] occurrences matches {0..*} matches { -- Specific details + include + archetype_id/value matches {/.*/} + } + ELEMENT[at0161] occurrences matches {0..1} matches { -- Resolution date/time + value matches { + DV_DATE_TIME matches {*} + } + } + ELEMENT[at0057] occurrences matches {0..1} matches { -- Description of previous episodes + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0031] occurrences matches {0..1} matches { -- Number of previous episodes + value matches { + DV_COUNT matches { + magnitude matches {|>=0|} + } + } + } + allow_archetype CLUSTER[at0146] occurrences matches {0..*} matches { -- Previous episodes + include + archetype_id/value matches {/openEHR-EHR-CLUSTER\.symptom_sign(-[a-zA-Z0-9_]+)*\.v1/} + } + allow_archetype CLUSTER[at0063] occurrences matches {0..*} matches { -- Associated symptom/sign + include + archetype_id/value matches {/openEHR-EHR-CLUSTER\.symptom_sign(-[a-zA-Z0-9_]+)*\.v1/} + } + ELEMENT[at0163] occurrences matches {0..1} matches { -- Comment + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0.1] occurrences matches {0..1} matches { -- Presence + value matches { + DV_CODED_TEXT matches { + defining_code matches { + [local:: + at0.2, -- Present + at0.3, -- Absent + at0.4] -- Unknown + } + } + } + } + } + } + +ontology + terminologies_available = <"SNOMED-CT", ...> + term_definitions = < + ["ar-sy"] = < + items = < + ["at0187"] = < + text = <"*First occurrence (en)"> + description = <"*This is the first ever occurrence of this symptom or sign. (en)"> + > + ["at0188"] = < + text = <"*Recurrence (en)"> + description = <"*This is the first ever occurrence of this symptom or sign. (en)"> + > + ["at0189"] = < + text = <"*Character (en)"> + description = <"*Word or short phrase describing the nature of the symptom or sign. (en)"> + comment = <"*For example: pain could be described as 'gnawing', 'burning', or 'like an electric shock'; a headache could be 'throbbing' or 'constant'. Coding with an external terminology is preferred, where possible. (en)"> + > + ["at0000.1"] = < + text = <"*Symptom/Sign(en)"> + description = <"*Reported observation of a physical or mental disturbance in an individual.(en)"> + > + ["at0.1"] = < + text = <"*DV_TEXT (en)"> + description = <"*"> + > + ["at0.2"] = < + text = <"*Present (en)"> + description = <"*The symptom is present. (en)"> + > + ["at0.3"] = < + text = <"*Absent (en)"> + description = <"*The symptom is absent. (en)"> + > + ["at0.4"] = < + text = <"*Unknown (en)"> + description = <"*It is not known if the symptom is present. (en)"> + > + ["at0001.1"] = < + text = <"*Symptom/Sign name(en)"> + description = <"*The name of the reported symptom or sign.(en)"> + comment = <"*Symptom name should be coded with a terminology, where possible.(en)"> + > + ["at0000"] = < + text = <"*Symptom/Sign(en)"> + description = <"*Reported observation of a physical or mental disturbance in an individual.(en)"> + > + ["at0001"] = < + text = <"*Symptom/Sign name(en)"> + description = <"*The name of the reported symptom or sign.(en)"> + comment = <"*Symptom name should be coded with a terminology, where possible.(en)"> + > + ["at0002"] = < + text = <"*Description(en)"> + description = <"*Narrative description about the reported symptom or sign.(en)"> + > + ["at0003"] = < + text = <"*Pattern(en)"> + description = <"*Narrative description about the pattern of the symptom or sign during this episode.(en)"> + comment = <"*For example: pain could be described as constant or colicky.(en)"> + > + ["at0017"] = < + text = <"*Effect(en)"> + description = <"*Perceived effect of the modifying factor on the symptom or sign.(en)"> + > + ["at0018"] = < + text = <"*Modifying factor(en)"> + description = <"*Detail about how a specific factor effects the identified symptom or sign during this episode.(en)"> + > + ["at0019"] = < + text = <"*Factor(en)"> + description = <"*Name of the modifying factor.(en)"> + comment = <"*Examples of modifying factor: lying on multiple pillows, eating or administration of a specific medication.(en)"> + > + ["at0021"] = < + text = <"*Severity category(en)"> + description = <"*Category representing the overall severity of the symptom or sign.(en)"> + comment = <"*Defining values such as mild, moderate or severe in such a way that is applicable to multiple symptoms or signs plus allows multiple users to interpret and record them consistently is not easy. Some organisations extend the value set further with inclusion of additional values such as 'Trivial' and 'Very severe', and/or 'Mild-Moderate' and 'Moderate-Severe', adds to the definitional difficulty and may also worsen inter-recorder reliability issues. Use of 'Life-threatening' and 'Fatal' is also often considered as part of this value set, although from a pure point of view it may actually reflect an outcome rather than a severity. In view of the above, keeping to a well-defined but smaller list is preferred and so the mild/moderate/severe value set is offered, however the choice of other text allows for other value sets to be included at this data element in a template. Note: more specific grading of severity can be recorded using the 'Specific details' SLOT.(en)"> + > + ["at0023"] = < + text = <"*Mild(en)"> + description = <"*The intensity of the symptom or sign does not cause interference with normal activity.(en)"> + > + ["at0024"] = < + text = <"*Moderate(en)"> + description = <"*The intensity of the symptom or sign causes interference with normal activity.(en)"> + > + ["at0025"] = < + text = <"*Severe(en)"> + description = <"*The intensity of the symptom or sign causes prevents normal activity.(en)"> + > + ["at0026"] = < + text = <"*Severity rating(en)"> + description = <"*Numerical rating scale representing the overall severity of the symptom or sign.(en)"> + comment = <"*Symptom severity can be rated by the individual by recording a score from 0 (ie symptom not present) to 10.0 (ie symptom is as severe as the individual can imagine). This score can be represented in the user interface as a visual analogue scale. The data element has occurrences set to 0..* to allow for variations such as 'maximal severity' or 'average severity' to be included in a template.(en)"> + > + ["at0028"] = < + text = <"*Duration(en)"> + description = <"*The duration of the symptom or sign since onset.(en)"> + comment = <"*If 'Date/time of onset' and 'Date/time of resolution' are used in systems, this data element may be calculated, or alternatively, be considered redundant in this scenario.(en)"> + > + ["at0031"] = < + text = <"*Number of previous episodes(en)"> + description = <"*The number of times this symptom or sign has previously occurred.(en)"> + > + ["at0035"] = < + text = <"*Nil significant(en)"> + description = <"*The identified symptom or sign was reported as not being present to any significant degree.(en)"> + comment = <"*Record as True if the subject of care has reported the symptom as not significant. For example, the patient may experience a basal level of pain, which is regarded as normal for them. In this situation 'nil significant' enables recording of no additional pain that could be considered as significant or relevant to the history-taking.(en)"> + > + ["at0037"] = < + text = <"*Episode description(en)"> + description = <"*Narrative description about the course of the symptom or sign during this episode.(en)"> + comment = <"*For example: a text description of the immediate onset of the symptom, activities that worsened or relieved the symptom, whether it is improving or worsening and how it resolved over weeks.(en)"> + > + ["at0056"] = < + text = <"*Description(en)"> + description = <"*Narrative description of the effect of the modifying factor on the symptom or sign.(en)"> + > + ["at0057"] = < + text = <"*Description of previous episodes(en)"> + description = <"*Narrative description of any or all previous episodes.(en)"> + comment = <"*For example: frequency/periodicity - per hour, day, week, month, year; and regularity. May include a comparison to this episode.(en)"> + > + ["at0063"] = < + text = <"*Associated symptom/sign(en)"> + description = <"*Structured details about any associated symptoms or signs that are concurrent.(en)"> + comment = <"*In linked clinical systems, it is possible that associated symptoms or signs are already recorded within the EHR. Systems can allow the clinician to LINK to relevant associated symptoms/signs. However in a system or message without LINKs to existing data or with a new patient, additional instances of the symptom archetype could be included here to represent associated symptoms/signs.(en)"> + > + ["at0146"] = < + text = <"*Previous episodes(en)"> + description = <"*Structured details of the symptom or sign during a previous episode.(en)"> + comment = <"*In linked clinical systems, it is possible that previous episodes are already recorded within the EHR. Systems can allow the clinician to LINK to relevant previous episodes. However in a system or message without LINKs to existing data or with a new patient, additional instances of the symptom archetype could be included here to represent previous episodes. It is recommended that new instances of the Symptom archetype inserted in this SLOT represent one or many previous episodes to this Symptom instance only.(en)"> + > + ["at0147"] = < + text = <"*Structured body site(en)"> + description = <"*Structured body site where the symptom or sign was reported.(en)"> + comment = <"*If the anatomical location is included in the Symptom name via precoordinated codes, use of this SLOT becomes redundant. If the anatomical location is recorded using the 'Body site' data element, then use of CLUSTER archetypes in this SLOT is not allowed - record only the simple 'Body site' OR 'Structured body site', but not both.(en)"> + > + ["at0151"] = < + text = <"*Body site(en)"> + description = <"*Simple body site where the symptom or sign was reported.(en)"> + comment = <"*Occurrences of this data element are set to 0..* to allow multiple body sites to be separated out in a template if desired. This allows for representation of clinical scenarios where a symptom or sign needs to be recorded in multiple locations or identifying both the originating and distal site in pain radiation, but where all of the other attributes such as impact and duration are identical. If the requirements for recording the body site 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 Detailed anatomical location' SLOT in this archetype. +If the anatomical location is included in the Symptom name via precoordinated codes, this data element becomes redundant. If the anatomical location is recorded using the 'Structured body site' SLOT, then use of this data element is not allowed - record only the simple 'Body site' OR 'Structured body site', but not both.(en)"> + > + ["at0152"] = < + text = <"*Onset date/time(en)"> + description = <"*The onset for this episode of the symptom or sign.(en)"> + comment = <"*While partial dates are permitted, the exact date and time of onset can be recorded, if appropriate. If this is a recurring symptom, this date is used to represent the most recent date or onset of exacerbation, relevant to the clinical presentation. If this is the first instance of this symptom, this date is used to represent the first ever start of symptoms.(en)"> + > + ["at0153"] = < + text = <"*Specific details(en)"> + description = <"*Specific data elements that are additionally required to record as unique attributes of the identified symptom or sign.(en)"> + comment = <"*For example: CTCAE grading.(en)"> + > + ["at0154"] = < + text = <"*Factor detail(en)"> + description = <"*Structured detail about the factor associated with the identified symptom or sign.(en)"> + > + ["at0155"] = < + text = <"*Impact(en)"> + description = <"*Description of the impact of this symptom or sign.(en)"> + comment = <"*Assessment of impact could consider the severity, duration and frequency of the symptom as well as the type of impact including, but not limited to, functional, social and emotional impact. Occurrences of this data element are set to 0..* to allow multiple types of impact to be separated out in a template if desired. Examples for functional impact from hearing loss may include: 'Difficulty Hearing in Quiet Environment'; 'Difficulty Hearing the TV or Radio'; 'Difficulty Hearing Group Conversation'; and 'Difficulty Hearing on Phone'.(en)"> + > + ["at0156"] = < + text = <"*No effect(en)"> + description = <"*Presence of the factor has no impact on the symptom or sign.(en)"> + > + ["at0158"] = < + text = <"*Worsens(en)"> + description = <"*Presence of the factor exaccerbates severity or impact of the symptom or sign.(en)"> + > + ["at0159"] = < + text = <"*Relieves(en)"> + description = <"*Presence of the factor reduces the severity or impact of the symptom or sign.(en)"> + > + ["at0161"] = < + text = <"*Resolution date/time(en)"> + description = <"*The timing of the cessation of this episode of the symptom or sign.(en)"> + comment = <"*If 'Date/time of onset' and 'Duration' are used in systems, this data element may be calculated, or alternatively, considered redundant. While partial dates are permitted, the exact date and time of resolution can be recorded, if appropriate.(en)"> + > + ["at0163"] = < + text = <"*Comment(en)"> + description = <"*Additional narrative about the symptom or sign not captured in other fields.(en)"> + > + ["at0164"] = < + text = <"*Onset type(en)"> + description = <"*Description of the onset of the symptom or sign.(en)"> + comment = <"*The type of the onset can be coded with a terminology, if desired. For example: gradual; or sudden.(en)"> + > + ["at0165"] = < + text = <"*Precipitating/resolving factor(en)"> + description = <"*Details about a health event, symptom, sign or other factor associated with the onset or cessation of the symptom or sign.(en)"> + comment = <"*For example: onset of headache occurred one week prior to menstruation; or onset of headache occurred one hour after fall of bicycle.(en)"> + > + ["at0167"] = < + text = <"*Precipitating factor(en)"> + description = <"*Identification of factors/events associated with onset or commencement of the symptom or sign.(en)"> + > + ["at0168"] = < + text = <"*Resolving factor(en)"> + description = <"*Identification of factors/events associated with cessation of the symptom or sign.(en)"> + > + ["at0170"] = < + text = <"*Factor(en)"> + description = <"*Name of the health event, symptom, reported sign or other factor.(en)"> + comment = <"*For example: onset of another symptom; onset of menstruation; or fall off bicycle.(en)"> + > + ["at0171"] = < + text = <"*Time interval(en)"> + description = <"*The interval of time between the occurrence or onset of the factor and onset/resolution of the symptom or sign.(en)"> + > + ["at0175"] = < + text = <"*Episodicity(en)"> + description = <"*Category of this epsiode for the identified symptom or sign.(en)"> + > + ["at0176"] = < + text = <"*New(en)"> + description = <"*This is the first ever episode of the symptom or sign.(en)"> + > + ["at0177"] = < + text = <"*Reoccurrence(en)"> + description = <"*This is a second or subsequent discrete episode of the symptom or sign, where each previous episode has completely resolved.(en)"> + > + ["at0178"] = < + text = <"*Ongoing(en)"> + description = <"*This symptom or sign is continuously present, effectively a single, ongoing episode.(en)"> + > + ["at0180"] = < + text = <"*Progression(en)"> + description = <"*Description progression of the symptom or sign at the time of reporting.(en)"> + comment = <"*Occurrences of this data element are set to 0..* to allow multiple types of progression to be separated out in a template if desired - for example, severity or frequency.(en)"> + > + ["at0181"] = < + text = <"*Improving(en)"> + description = <"*The severity of the symptom or sign has improved overall during this episode.(en)"> + > + ["at0182"] = < + text = <"*Unchanged(en)"> + description = <"*The severity of the symptom or sign has not changed overall during this episode.(en)"> + > + ["at0183"] = < + text = <"*Worsening(en)"> + description = <"*The severity of the symptom or sign has worsened overall during this episode.(en)"> + > + ["at0184"] = < + text = <"*Resolved(en)"> + description = <"*The severity of the symptom or sign has resolved.(en)"> + > + ["at0185"] = < + text = <"*Description(en)"> + description = <"*Narrative description about the effect of the factor on the identified symptom or sign.(en)"> + > + ["at0186"] = < + text = <"*New element(en)"> + description = <"**(en)"> + > + > + > + ["en"] = < + items = < + ["at0187"] = < + text = <"First occurrence"> + description = <"This is the first ever occurrence of this symptom or sign."> + > + ["at0188"] = < + text = <"Recurrence"> + description = <"This is the first ever occurrence of this symptom or sign."> + > + ["at0189"] = < + text = <"Character"> + description = <"Word or short phrase describing the nature of the symptom or sign."> + comment = <"For example: pain could be described as 'gnawing', 'burning', or 'like an electric shock'; a headache could be 'throbbing' or 'constant'. Coding with an external terminology is preferred, where possible."> + > + ["at0000.1"] = < + text = <"Covid-19 symptom"> + description = <"Symptoms known to be indicators of suspected Covid-19 infection"> + > + ["at0.1"] = < + text = <"Presence"> + description = <"Is the symptom present or not?"> + > + ["at0.2"] = < + text = <"Present"> + description = <"The symptom is present."> + > + ["at0.3"] = < + text = <"Absent"> + description = <"The symptom is absent."> + > + ["at0.4"] = < + text = <"Unknown"> + description = <"It is not known if the symptom is present."> + > + ["at0001.1"] = < + text = <"Symptom/Sign name"> + description = <"The name of the reported symptom or sign."> + comment = <"Symptom name should be coded with a terminology, where possible."> + > + ["at0000"] = < + text = <"Symptom/Sign"> + description = <"Reported observation of a physical or mental disturbance in an individual."> + > + ["at0001"] = < + text = <"Symptom/Sign name"> + description = <"The name of the reported symptom or sign."> + comment = <"Symptom name should be coded with a terminology, where possible."> + > + ["at0002"] = < + text = <"Description"> + description = <"Narrative description about the reported symptom or sign."> + > + ["at0003"] = < + text = <"Pattern"> + description = <"Narrative description about the pattern of the symptom or sign during this episode."> + comment = <"For example: pain could be described as constant or intermittent."> + > + ["at0017"] = < + text = <"Effect"> + description = <"Perceived effect of the modifying factor on the symptom or sign."> + > + ["at0018"] = < + text = <"Modifying factor"> + description = <"Detail about how a specific factor effects the identified symptom or sign during this episode."> + > + ["at0019"] = < + text = <"Factor"> + description = <"Name of the modifying factor."> + comment = <"Examples of modifying factor: lying on multiple pillows, eating or administration of a specific medication."> + > + ["at0021"] = < + text = <"Severity category"> + description = <"Category representing the overall severity of the symptom or sign."> + comment = <"Defining values such as mild, moderate or severe in such a way that is applicable to multiple symptoms or signs plus allows multiple users to interpret and record them consistently is not easy. Some organisations extend the value set further with inclusion of additional values such as 'Trivial' and 'Very severe', and/or 'Mild-Moderate' and 'Moderate-Severe', adds to the definitional difficulty and may also worsen inter-recorder reliability issues. Use of 'Life-threatening' and 'Fatal' is also often considered as part of this value set, although from a pure point of view it may actually reflect an outcome rather than a severity. In view of the above, keeping to a well-defined but smaller list is preferred and so the mild/moderate/severe value set is offered, however the choice of other text allows for other value sets to be included at this data element in a template. Note: more specific grading of severity can be recorded using the 'Specific details' SLOT."> + > + ["at0023"] = < + text = <"Mild"> + description = <"The intensity of the symptom or sign does not cause interference with normal activity."> + > + ["at0024"] = < + text = <"Moderate"> + description = <"The intensity of the symptom or sign causes interference with normal activity."> + > + ["at0025"] = < + text = <"Severe"> + description = <"The intensity of the symptom or sign causes prevents normal activity."> + > + ["at0026"] = < + text = <"Severity rating"> + description = <"Numerical rating scale representing the overall severity of the symptom or sign."> + comment = <"Symptom severity can be rated by the individual by recording a score from 0 (ie symptom not present) to 10.0 (ie symptom is as severe as the individual can imagine). This score can be represented in the user interface as a visual analogue scale. The data element has occurrences set to 0..* to allow for variations such as 'maximal severity' or 'average severity' to be included in a template."> + > + ["at0028"] = < + text = <"Duration"> + description = <"The duration of this episode of the symptom or sign since onset."> + comment = <"If 'Date/time of onset' and 'Date/time of resolution' are used in systems, this data element may be calculated, or alternatively, be considered redundant in this scenario."> + > + ["at0031"] = < + text = <"Number of previous episodes"> + description = <"The number of times this symptom or sign has previously occurred."> + > + ["at0035"] = < + text = <"Nil significant"> + description = <"The identified symptom or sign was reported as not being present to any significant degree."> + comment = <"Record as True if the subject of care has reported the symptom as not significant. For example: if the individual has never experienced the symptom it is appropriate to record 'nil significant'; or if the individual commonly experiences the symptom, in some circumstances it may be considered appropriate to record 'nil significant' if the individual has experienced no deviation from their 'normal' baseline."> + > + ["at0037"] = < + text = <"Episode description"> + description = <"Narrative description about the course of the symptom or sign during this episode."> + comment = <"For example: a text description of the immediate onset of the symptom, activities that worsened or relieved the symptom, whether it is improving or worsening and how it resolved over weeks."> + > + ["at0056"] = < + text = <"Description"> + description = <"Narrative description of the effect of the modifying factor on the symptom or sign."> + > + ["at0057"] = < + text = <"Description of previous episodes"> + description = <"Narrative description of any or all previous episodes."> + comment = <"For example: frequency/periodicity - per hour, day, week, month, year; and regularity. May include a comparison to this episode."> + > + ["at0063"] = < + text = <"Associated symptom/sign"> + description = <"Structured details about any associated symptoms or signs that are concurrent."> + comment = <"In linked clinical systems, it is possible that associated symptoms or signs are already recorded within the EHR. Systems can allow the clinician to LINK to relevant associated symptoms/signs. However in a system or message without LINKs to existing data or with a new patient, additional instances of the symptom archetype could be included here to represent associated symptoms/signs."> + > + ["at0146"] = < + text = <"Previous episodes"> + description = <"Structured details of the symptom or sign during a previous episode."> + comment = <"In linked clinical systems, it is possible that previous episodes are already recorded within the EHR. Systems can allow the clinician to LINK to relevant previous episodes. However in a system or message without LINKs to existing data or with a new patient, additional instances of the symptom archetype could be included here to represent previous episodes. It is recommended that new instances of the Symptom archetype inserted in this SLOT represent one or many previous episodes to this Symptom instance only."> + > + ["at0147"] = < + text = <"Structured body site"> + description = <"Structured body site where the symptom or sign was reported."> + comment = <"If the anatomical location is included in the Symptom name via precoordinated codes, use of this SLOT becomes redundant. If the anatomical location is recorded using the 'Body site' data element, then use of CLUSTER archetypes in this SLOT is not allowed - record only the simple 'Body site' OR 'Structured body site', but not both."> + > + ["at0151"] = < + text = <"Body site"> + description = <"Simple body site where the symptom or sign was reported."> + comment = <"Occurrences of this data element are set to 0..* to allow multiple body sites to be separated out in a template if desired. This allows for representation of clinical scenarios where a symptom or sign needs to be recorded in multiple locations or identifying both the originating and distal site in pain radiation, but where all of the other attributes such as impact and duration are identical. If the requirements for recording the body site 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 Detailed anatomical location' SLOT in this archetype. +If the anatomical location is included in the Symptom name via precoordinated codes, this data element becomes redundant. If the anatomical location is recorded using the 'Structured body site' SLOT, then use of this data element is not allowed - record only the simple 'Body site' OR 'Structured body site', but not both."> + > + ["at0152"] = < + text = <"Episode onset"> + description = <"The onset for this episode of the symptom or sign."> + comment = <"While partial dates are permitted, the exact date and time of onset can be recorded, if appropriate. If this symptom or sign is experienced for the first time or is a re-occurrence, this date is used to represent the onset of this episode. If this symptom or sign is ongoing, this data element may be redundant if it has been recorded previously."> + > + ["at0153"] = < + text = <"Specific details"> + description = <"Specific data elements that are additionally required to record as unique attributes of the identified symptom or sign."> + comment = <"For example: CTCAE grading."> + > + ["at0154"] = < + text = <"Factor detail"> + description = <"Structured detail about the factor associated with the identified symptom or sign."> + > + ["at0155"] = < + text = <"Impact"> + description = <"Description of the impact of this symptom or sign."> + comment = <"Assessment of impact could consider the severity, duration and frequency of the symptom as well as the type of impact including, but not limited to, functional, social and emotional impact. Occurrences of this data element are set to 0..* to allow multiple types of impact to be separated out in a template if desired. Examples for functional impact from hearing loss may include: 'Difficulty Hearing in Quiet Environment'; 'Difficulty Hearing the TV or Radio'; 'Difficulty Hearing Group Conversation'; and 'Difficulty Hearing on Phone'."> + > + ["at0156"] = < + text = <"No effect"> + description = <"The factor has no impact on the symptom or sign."> + > + ["at0158"] = < + text = <"Worsens"> + description = <"The factor increases the severity or impact of the symptom or sign."> + > + ["at0159"] = < + text = <"Relieves"> + description = <"The factor decreases the severity or impact of the symptom or sign, but does not fully resolve it."> + > + ["at0161"] = < + text = <"Resolution date/time"> + description = <"The timing of the cessation of this episode of the symptom or sign."> + comment = <"If 'Date/time of onset' and 'Duration' are used in systems, this data element may be calculated, or alternatively, considered redundant. While partial dates are permitted, the exact date and time of resolution can be recorded, if appropriate."> + > + ["at0163"] = < + text = <"Comment"> + description = <"Additional narrative about the symptom or sign not captured in other fields."> + > + ["at0164"] = < + text = <"Onset type"> + description = <"Description of the onset of the symptom or sign."> + comment = <"The type of the onset can be coded with a terminology, if desired. For example: gradual; or sudden."> + > + ["at0165"] = < + text = <"Precipitating/resolving factor"> + description = <"Details about specified factors that are associated with the precipitation or resolution of the symptom or sign."> + comment = <"For example: onset of headache occurred one week prior to menstruation; or onset of headache occurred one hour after fall of bicycle."> + > + ["at0167"] = < + text = <"Precipitating factor"> + description = <"Identification of factors or events that trigger the onset or commencement of the symptom or sign."> + > + ["at0168"] = < + text = <"Resolving factor"> + description = <"Identification of factors or events that trigger resolution or cessation of the symptom or sign."> + > + ["at0170"] = < + text = <"Factor"> + description = <"Name of the health event, symptom, reported sign or other factor."> + comment = <"For example: onset of another symptom; onset of menstruation; or fall off bicycle."> + > + ["at0171"] = < + text = <"Time interval"> + description = <"The interval of time between the occurrence or onset of the factor and onset/resolution of the symptom or sign."> + > + ["at0175"] = < + text = <"Episodicity"> + description = <"Category of this episode for the identified symptom or sign."> + > + ["at0176"] = < + text = <"New"> + description = <"A new episode of the symptom or sign - either the first ever occurrence or a reoccurrence where the previous episode had completely resolved."> + > + ["at0177"] = < + text = <"Indeterminate"> + description = <"It is not possible to determine if this occurrence of the symptom or sign is new or ongoing."> + > + ["at0178"] = < + text = <"Ongoing"> + description = <"This symptom or sign is ongoing, effectively a single, continuous episode."> + > + ["at0180"] = < + text = <"Progression"> + description = <"Description progression of the symptom or sign at the time of reporting."> + comment = <"Occurrences of this data element are set to 0..* to allow multiple types of progression to be separated out in a template if desired - for example, severity or frequency."> + > + ["at0181"] = < + text = <"Improving"> + description = <"The severity of the symptom or sign has improved overall during this episode."> + > + ["at0182"] = < + text = <"Unchanged"> + description = <"The severity of the symptom or sign has not changed overall during this episode."> + > + ["at0183"] = < + text = <"Worsening"> + description = <"The severity of the symptom or sign has worsened overall during this episode."> + > + ["at0184"] = < + text = <"Resolved"> + description = <"The severity of the symptom or sign has resolved."> + > + ["at0185"] = < + text = <"Description"> + description = <"Narrative description about the effect of the factor on the identified symptom or sign."> + > + ["at0186"] = < + text = <"First ever?"> + description = <"Is this the first ever occurrence of this symptom or sign?"> + comment = <"Record as True if this is the first ever occurrence of this symptom or sign."> + > + > + > + ["de"] = < + items = < + ["at0187"] = < + text = <"Erstmaliges Auftreten"> + description = <"Dies ist das erstmalige Auftreten des Symptoms/Krankheitsanzeichens."> + > + ["at0188"] = < + text = <"Erneutes Auftreten"> + description = <"Das Symptom/Krankheitsanzeichen ist in der Vergangenheit bereits aufgetreten."> + > + ["at0189"] = < + text = <"Charakteristik"> + description = <"Wort oder kurzer Satz, mit dem die Charakteristik des Symptoms/Krankheitsanzeichens beschrieben wird."> + comment = <"Zum Beispiel: Schmerzen können als \"bohrend\", \"brennend\" oder \"wie ein Stromschlag\" beschrieben werden; Kopfschmerzen können \"pochend\" oder \"konstant\" sein. Wenn möglich soll eine Kodierung mit einer externen Terminologie bevorzugt werden."> + > + ["at0000.1"] = < + text = <"Symptom/Krankheitsanzeichen"> + description = <"Festgestellte Beobachtung einer körperlichen oder geistigen Störung bei einer Person."> + > + ["at0.1"] = < + text = <"*DV_TEXT (en)"> + description = <"*"> + > + ["at0.2"] = < + text = <"*Present (en)"> + description = <"*The symptom is present. (en)"> + > + ["at0.3"] = < + text = <"*Absent (en)"> + description = <"*The symptom is absent. (en)"> + > + ["at0.4"] = < + text = <"*Unknown (en)"> + description = <"*It is not known if the symptom is present. (en)"> + > + ["at0001.1"] = < + text = <"*Symptom/Sign name(en)"> + description = <"*The name of the reported symptom or sign.(en)"> + comment = <"*Symptom name should be coded with a terminology, where possible.(en)"> + > + ["at0000"] = < + text = <"*Symptom/Sign(en)"> + description = <"*Reported observation of a physical or mental disturbance in an individual.(en)"> + > + ["at0001"] = < + text = <"*Symptom/Sign name(en)"> + description = <"*The name of the reported symptom or sign.(en)"> + comment = <"*Symptom name should be coded with a terminology, where possible.(en)"> + > + ["at0002"] = < + text = <"*Description(en)"> + description = <"*Narrative description about the reported symptom or sign.(en)"> + > + ["at0003"] = < + text = <"*Pattern(en)"> + description = <"*Narrative description about the pattern of the symptom or sign during this episode.(en)"> + comment = <"*For example: pain could be described as constant or colicky.(en)"> + > + ["at0017"] = < + text = <"*Effect(en)"> + description = <"*Perceived effect of the modifying factor on the symptom or sign.(en)"> + > + ["at0018"] = < + text = <"*Modifying factor(en)"> + description = <"*Detail about how a specific factor effects the identified symptom or sign during this episode.(en)"> + > + ["at0019"] = < + text = <"*Factor(en)"> + description = <"*Name of the modifying factor.(en)"> + comment = <"*Examples of modifying factor: lying on multiple pillows, eating or administration of a specific medication.(en)"> + > + ["at0021"] = < + text = <"*Severity category(en)"> + description = <"*Category representing the overall severity of the symptom or sign.(en)"> + comment = <"*Defining values such as mild, moderate or severe in such a way that is applicable to multiple symptoms or signs plus allows multiple users to interpret and record them consistently is not easy. Some organisations extend the value set further with inclusion of additional values such as 'Trivial' and 'Very severe', and/or 'Mild-Moderate' and 'Moderate-Severe', adds to the definitional difficulty and may also worsen inter-recorder reliability issues. Use of 'Life-threatening' and 'Fatal' is also often considered as part of this value set, although from a pure point of view it may actually reflect an outcome rather than a severity. In view of the above, keeping to a well-defined but smaller list is preferred and so the mild/moderate/severe value set is offered, however the choice of other text allows for other value sets to be included at this data element in a template. Note: more specific grading of severity can be recorded using the 'Specific details' SLOT.(en)"> + > + ["at0023"] = < + text = <"*Mild(en)"> + description = <"*The intensity of the symptom or sign does not cause interference with normal activity.(en)"> + > + ["at0024"] = < + text = <"*Moderate(en)"> + description = <"*The intensity of the symptom or sign causes interference with normal activity.(en)"> + > + ["at0025"] = < + text = <"*Severe(en)"> + description = <"*The intensity of the symptom or sign causes prevents normal activity.(en)"> + > + ["at0026"] = < + text = <"*Severity rating(en)"> + description = <"*Numerical rating scale representing the overall severity of the symptom or sign.(en)"> + comment = <"*Symptom severity can be rated by the individual by recording a score from 0 (ie symptom not present) to 10.0 (ie symptom is as severe as the individual can imagine). This score can be represented in the user interface as a visual analogue scale. The data element has occurrences set to 0..* to allow for variations such as 'maximal severity' or 'average severity' to be included in a template.(en)"> + > + ["at0028"] = < + text = <"*Duration(en)"> + description = <"*The duration of the symptom or sign since onset.(en)"> + comment = <"*If 'Date/time of onset' and 'Date/time of resolution' are used in systems, this data element may be calculated, or alternatively, be considered redundant in this scenario.(en)"> + > + ["at0031"] = < + text = <"*Number of previous episodes(en)"> + description = <"*The number of times this symptom or sign has previously occurred.(en)"> + > + ["at0035"] = < + text = <"*Nil significant(en)"> + description = <"*The identified symptom or sign was reported as not being present to any significant degree.(en)"> + comment = <"*Record as True if the subject of care has reported the symptom as not significant. For example, the patient may experience a basal level of pain, which is regarded as normal for them. In this situation 'nil significant' enables recording of no additional pain that could be considered as significant or relevant to the history-taking.(en)"> + > + ["at0037"] = < + text = <"*Episode description(en)"> + description = <"*Narrative description about the course of the symptom or sign during this episode.(en)"> + comment = <"*For example: a text description of the immediate onset of the symptom, activities that worsened or relieved the symptom, whether it is improving or worsening and how it resolved over weeks.(en)"> + > + ["at0056"] = < + text = <"*Description(en)"> + description = <"*Narrative description of the effect of the modifying factor on the symptom or sign.(en)"> + > + ["at0057"] = < + text = <"*Description of previous episodes(en)"> + description = <"*Narrative description of any or all previous episodes.(en)"> + comment = <"*For example: frequency/periodicity - per hour, day, week, month, year; and regularity. May include a comparison to this episode.(en)"> + > + ["at0063"] = < + text = <"*Associated symptom/sign(en)"> + description = <"*Structured details about any associated symptoms or signs that are concurrent.(en)"> + comment = <"*In linked clinical systems, it is possible that associated symptoms or signs are already recorded within the EHR. Systems can allow the clinician to LINK to relevant associated symptoms/signs. However in a system or message without LINKs to existing data or with a new patient, additional instances of the symptom archetype could be included here to represent associated symptoms/signs.(en)"> + > + ["at0146"] = < + text = <"*Previous episodes(en)"> + description = <"*Structured details of the symptom or sign during a previous episode.(en)"> + comment = <"*In linked clinical systems, it is possible that previous episodes are already recorded within the EHR. Systems can allow the clinician to LINK to relevant previous episodes. However in a system or message without LINKs to existing data or with a new patient, additional instances of the symptom archetype could be included here to represent previous episodes. It is recommended that new instances of the Symptom archetype inserted in this SLOT represent one or many previous episodes to this Symptom instance only.(en)"> + > + ["at0147"] = < + text = <"*Structured body site(en)"> + description = <"*Structured body site where the symptom or sign was reported.(en)"> + comment = <"*If the anatomical location is included in the Symptom name via precoordinated codes, use of this SLOT becomes redundant. If the anatomical location is recorded using the 'Body site' data element, then use of CLUSTER archetypes in this SLOT is not allowed - record only the simple 'Body site' OR 'Structured body site', but not both.(en)"> + > + ["at0151"] = < + text = <"*Body site(en)"> + description = <"*Simple body site where the symptom or sign was reported.(en)"> + comment = <"*Occurrences of this data element are set to 0..* to allow multiple body sites to be separated out in a template if desired. This allows for representation of clinical scenarios where a symptom or sign needs to be recorded in multiple locations or identifying both the originating and distal site in pain radiation, but where all of the other attributes such as impact and duration are identical. If the requirements for recording the body site 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 Detailed anatomical location' SLOT in this archetype. +If the anatomical location is included in the Symptom name via precoordinated codes, this data element becomes redundant. If the anatomical location is recorded using the 'Structured body site' SLOT, then use of this data element is not allowed - record only the simple 'Body site' OR 'Structured body site', but not both.(en)"> + > + ["at0152"] = < + text = <"*Onset date/time(en)"> + description = <"*The onset for this episode of the symptom or sign.(en)"> + comment = <"*While partial dates are permitted, the exact date and time of onset can be recorded, if appropriate. If this is a recurring symptom, this date is used to represent the most recent date or onset of exacerbation, relevant to the clinical presentation. If this is the first instance of this symptom, this date is used to represent the first ever start of symptoms.(en)"> + > + ["at0153"] = < + text = <"*Specific details(en)"> + description = <"*Specific data elements that are additionally required to record as unique attributes of the identified symptom or sign.(en)"> + comment = <"*For example: CTCAE grading.(en)"> + > + ["at0154"] = < + text = <"*Factor detail(en)"> + description = <"*Structured detail about the factor associated with the identified symptom or sign.(en)"> + > + ["at0155"] = < + text = <"*Impact(en)"> + description = <"*Description of the impact of this symptom or sign.(en)"> + comment = <"*Assessment of impact could consider the severity, duration and frequency of the symptom as well as the type of impact including, but not limited to, functional, social and emotional impact. Occurrences of this data element are set to 0..* to allow multiple types of impact to be separated out in a template if desired. Examples for functional impact from hearing loss may include: 'Difficulty Hearing in Quiet Environment'; 'Difficulty Hearing the TV or Radio'; 'Difficulty Hearing Group Conversation'; and 'Difficulty Hearing on Phone'.(en)"> + > + ["at0156"] = < + text = <"*No effect(en)"> + description = <"*Presence of the factor has no impact on the symptom or sign.(en)"> + > + ["at0158"] = < + text = <"*Worsens(en)"> + description = <"*Presence of the factor exaccerbates severity or impact of the symptom or sign.(en)"> + > + ["at0159"] = < + text = <"*Relieves(en)"> + description = <"*Presence of the factor reduces the severity or impact of the symptom or sign.(en)"> + > + ["at0161"] = < + text = <"*Resolution date/time(en)"> + description = <"*The timing of the cessation of this episode of the symptom or sign.(en)"> + comment = <"*If 'Date/time of onset' and 'Duration' are used in systems, this data element may be calculated, or alternatively, considered redundant. While partial dates are permitted, the exact date and time of resolution can be recorded, if appropriate.(en)"> + > + ["at0163"] = < + text = <"*Comment(en)"> + description = <"*Additional narrative about the symptom or sign not captured in other fields.(en)"> + > + ["at0164"] = < + text = <"*Onset type(en)"> + description = <"*Description of the onset of the symptom or sign.(en)"> + comment = <"*The type of the onset can be coded with a terminology, if desired. For example: gradual; or sudden.(en)"> + > + ["at0165"] = < + text = <"*Precipitating/resolving factor(en)"> + description = <"*Details about a health event, symptom, sign or other factor associated with the onset or cessation of the symptom or sign.(en)"> + comment = <"*For example: onset of headache occurred one week prior to menstruation; or onset of headache occurred one hour after fall of bicycle.(en)"> + > + ["at0167"] = < + text = <"*Precipitating factor(en)"> + description = <"*Identification of factors/events associated with onset or commencement of the symptom or sign.(en)"> + > + ["at0168"] = < + text = <"*Resolving factor(en)"> + description = <"*Identification of factors/events associated with cessation of the symptom or sign.(en)"> + > + ["at0170"] = < + text = <"*Factor(en)"> + description = <"*Name of the health event, symptom, reported sign or other factor.(en)"> + comment = <"*For example: onset of another symptom; onset of menstruation; or fall off bicycle.(en)"> + > + ["at0171"] = < + text = <"*Time interval(en)"> + description = <"*The interval of time between the occurrence or onset of the factor and onset/resolution of the symptom or sign.(en)"> + > + ["at0175"] = < + text = <"*Episodicity(en)"> + description = <"*Category of this epsiode for the identified symptom or sign.(en)"> + > + ["at0176"] = < + text = <"*New(en)"> + description = <"*This is the first ever episode of the symptom or sign.(en)"> + > + ["at0177"] = < + text = <"*Reoccurrence(en)"> + description = <"*This is a second or subsequent discrete episode of the symptom or sign, where each previous episode has completely resolved.(en)"> + > + ["at0178"] = < + text = <"*Ongoing(en)"> + description = <"*This symptom or sign is continuously present, effectively a single, ongoing episode.(en)"> + > + ["at0180"] = < + text = <"*Progression(en)"> + description = <"*Description progression of the symptom or sign at the time of reporting.(en)"> + comment = <"*Occurrences of this data element are set to 0..* to allow multiple types of progression to be separated out in a template if desired - for example, severity or frequency.(en)"> + > + ["at0181"] = < + text = <"*Improving(en)"> + description = <"*The severity of the symptom or sign has improved overall during this episode.(en)"> + > + ["at0182"] = < + text = <"*Unchanged(en)"> + description = <"*The severity of the symptom or sign has not changed overall during this episode.(en)"> + > + ["at0183"] = < + text = <"*Worsening(en)"> + description = <"*The severity of the symptom or sign has worsened overall during this episode.(en)"> + > + ["at0184"] = < + text = <"*Resolved(en)"> + description = <"*The severity of the symptom or sign has resolved.(en)"> + > + ["at0185"] = < + text = <"*Description(en)"> + description = <"*Narrative description about the effect of the factor on the identified symptom or sign.(en)"> + > + ["at0186"] = < + text = <"*New element(en)"> + description = <"**(en)"> + > + > + > + ["nb"] = < + items = < + ["at0187"] = < + text = <"*First occurrence (en)"> + description = <"*This is the first ever occurrence of this symptom or sign. (en)"> + > + ["at0188"] = < + text = <"*Recurrence (en)"> + description = <"*This is the first ever occurrence of this symptom or sign. (en)"> + > + ["at0189"] = < + text = <"*Character (en)"> + description = <"*Word or short phrase describing the nature of the symptom or sign. (en)"> + comment = <"*For example: pain could be described as 'gnawing', 'burning', or 'like an electric shock'; a headache could be 'throbbing' or 'constant'. Coding with an external terminology is preferred, where possible. (en)"> + > + ["at0000.1"] = < + text = <"Symptom/Sykdomstegn"> + description = <"Rapportert observasjon av fysiske tegn eller beskrivelse av unormale eller ubehagelige fornemmelser i kropp og/eller sinn."> + > + ["at0.1"] = < + text = <"*DV_TEXT (en)"> + description = <"*"> + > + ["at0.2"] = < + text = <"*Present (en)"> + description = <"*The symptom is present. (en)"> + > + ["at0.3"] = < + text = <"*Absent (en)"> + description = <"*The symptom is absent. (en)"> + > + ["at0.4"] = < + text = <"*Unknown (en)"> + description = <"*It is not known if the symptom is present. (en)"> + > + ["at0001.1"] = < + text = <"Navn på symptom/sykdomstegn"> + description = <"Navnet på det rapporterte symptomet eller sykdomstegnet."> + comment = <"Navnet på symptom/sykdomstegn bør kodes med en terminologi om mulig."> + > + ["at0000"] = < + text = <"Symptom/Sykdomstegn"> + description = <"Rapportert observasjon av fysiske tegn eller beskrivelse av unormale eller ubehagelige fornemmelser i kropp og/eller sinn."> + > + ["at0001"] = < + text = <"Navn på symptom/sykdomstegn"> + description = <"Navnet på det rapporterte symptomet eller sykdomstegnet."> + comment = <"Navnet på symptom/sykdomstegn bør kodes med en terminologi om mulig."> + > + ["at0002"] = < + text = <"Beskrivelse"> + description = <"Fritekstbeskrivelse av det rapporterte symptomet eller sykdomstegnet."> + comment = <"Eksempel: \"Svimmelhet med rotasjonsfølelse og av og til besvimelsesfølelse. Hurtig bevegelse fra sittende eller liggende til stående stilling virker å være en utløsende faktor. Opptrer typisk flere ganger daglig, og varer i ca et halvt til ett minutt hver gang. Å sette eller legge seg ned virker lindrende.\""> + > + ["at0003"] = < + text = <"Mønster"> + description = <"Fritekstbeskrivelse av symptomet eller sykdomstegnet i løpet av denne episoden."> + comment = <"For eksempel: Smerte kan beskrives som konstant eller intermitterende. Dette elementet kan brukes til å registrere tekstlige beskrivelser (enten det er fri eller kodet tekst) av den typiske frekvensen og varigheten av symptomanfall under den aktuelle episoden."> + > + ["at0017"] = < + text = <"Effekt"> + description = <"Oppfattet effekt av den modifiserende faktoren på symptomet eller sykdomstegnet."> + > + ["at0018"] = < + text = <"Modifiserende faktor"> + description = <"Detaljer om hvordan en spesifikk faktor påvirker det identifiserte symptomet eller sykdomstegnet i løpet av denne episoden."> + > + ["at0019"] = < + text = <"Faktor"> + description = <"Navn på den modifiserende faktoren."> + comment = <"Dette elementet er ment for å dokumentere faktorer, terapeutiske eller andre, som har innvirkning på symptomet. En oversikt over planlagte og utførte tiltak for symptomet eller sykdomstegnet må dokumenteres ved hjelp av andre arketyper. +Eksempel på modifiserende faktor: sengeleie med flere puter, spising, eller administrering av et spesifikt legemiddel."> + > + ["at0021"] = < + text = <"Alvorlighetskategori"> + description = <"Kategori for å beskrive symptomets eller sykdomstegnets helhetlige alvorlighet."> + comment = <"Det er vanskelig å definere verdier som mild, moderat og alvorlig på en slik måte at det kan brukes om flere symptomer, og som samtidig sikrer at tolkning og registrering av verdiene er konsistent. Ved å utvide verdisettet med verdier som \"ubetydelig\" og \"veldig alvorlig\", og/eller \"moderat mild\" og \"moderat alvorlig\" øker kompleksiteten, og påliteligheten i registreringen reduseres. Bruk av verdier som \"Livstruende\" eller \"fatal\" tas ofte med i et slikt verdisett, men disse verdiene gjenspeiler heller resultat enn alvorlighet. I lys av dette foretrekkes en mindre, mer veldefinert liste. NB: En mer spesifikk gradering av alvorlighet kan registreres ved bruk av SLOTet \"Spesifikke detaljer\"."> + > + ["at0023"] = < + text = <"Mild"> + description = <"Symptomet eller sykdomstegnets intensitet forstyrrer ikke normal aktivitet."> + > + ["at0024"] = < + text = <"Moderat"> + description = <"Symptomet eller sykdomstegnet intensitet forstyrrer normal aktivitet."> + > + ["at0025"] = < + text = <"Alvorlig"> + description = <"Symptomets eller sykdomstegnets intensitet hindrer normal aktivitet."> + > + ["at0026"] = < + text = <"Gradering av alvorlighet"> + description = <"Numerisk graderings skala som representerer den overordnede alvorligheten til symptomet eller sykdomstegnet."> + comment = <"Symptomets alvorlighet graderes av individet ved å registrere en skår fra 0 (symptom ikke tilstede) til 10 (symptomet er så alvorlig som individet kan forestille seg). Denne skåringen kan representeres i brukergrensesnittet som en visuell analog skala, Dataelementet er satt til 0..* for å tillate variasjonen som \"maksimum alvorlighet\" og \"gjennomsnittlig alvorlighet\" i et templat."> + > + ["at0028"] = < + text = <"Varighet"> + description = <"Varigheten av denne episoden av symptomet eller sykdomstegnet siden debut."> + comment = <"Brukes \"Dato/tid for debut\" og \"Dato/tid for opphør\" i systemer, kan dette dataelementet kalkuleres av systemet eller være overflødig."> + > + ["at0031"] = < + text = <"Antall tidligere episoder"> + description = <"Antall ganger symptomet eller sykdomstegnet tidligere har forekommet."> + > + ["at0035"] = < + text = <"Ikke av betydning"> + description = <"Symptomet eller sykdomstegnet ble rapportert som ikke tilstede i betydningsfull grad."> + comment = <"Registrer som Sann dersom helsetjenestemottakeren har rapportert symptomet eller sykdomstegnet som ikke tilstede i betydningsfull grad. For eksempel: Dersom individet aldri har opplevd symptomet vil det være riktig registrere \"Ikke av betydning\". Dersom individet vanligvis opplever symptomet, kan det i noen tilfeller være riktig å registrere \"Ikke av betydning\" dersom individet ikke har opplevd noen endring fra sin normaltilstand."> + > + ["at0037"] = < + text = <"Episodebeskrivelse"> + description = <"Fritekstbeskrivelse av symptomet eller sykdomstegnets utvikling gjennom denne episoden."> + comment = <"For eksempel: Fritekstbeskrivelse av symptomdebuten, aktiviteter som forverret eller forbedret symptomet, om det er i bedring eller forverring og hvordan det ble fullstendig bedret i løpet av uker."> + > + ["at0056"] = < + text = <"Beskrivelse"> + description = <"Fritekstbeskrivelse av den modifiserende faktorens effekt på symptomet eller sykdomstegnet."> + > + ["at0057"] = < + text = <"Beskrivelse av tidligere episoder"> + description = <"Fritekstbeskrivelse av tidligere episoder."> + comment = <"For eksempel: Frekvens/periodisitet - pr. time, dag, uke, måned, år og regularitet. Kan inneholde en sammenligning med denne episoden."> + > + ["at0063"] = < + text = <"Tilknyttede symptomer/sykdomstegn"> + description = <"Strukturerte detaljer om ethvert tilknyttet symptom eller sykdomstegn som er tilstede samtidig."> + comment = <"I kliniske systemer med mulighet for linking er det mulig at tilknyttede symptomer/sykdomstegn allerede er registrert i det kliniske systemet. Systemet kan tillatte en kliniker å linke til relevante tilknyttede symptomer/sykdomstegn. Tillater ikke systemet linking eller det er en pasient som ikke har noen tilknyttede symptomer registrert, kan man legge til ytterligere instanser av symptom-arketypen for å beskrive de tidligere episodene."> + > + ["at0146"] = < + text = <"Tidligere episoder"> + description = <"Strukturerte detaljer om symptomet eller sykdomstegnet i løpet av en tidligere episode."> + comment = <"I kliniske systemer med mulighet for linking er det mulig at tidligere episoder allerede er registrert i det kliniske systemet. Systemet kan tillatte en kliniker å linke til relevante tilknyttede symptomer. Tillater ikke systemet linking eller det er en pasient som ikke har noen tilknyttede symptomer registrert, kan man legge til ytterligere instanser av symptom-arketypen for å beskrive de tidligere episodene."> + > + ["at0147"] = < + text = <"Strukturert anatomisk lokalisering"> + description = <"Strukturert anatomisk lokalisering hvor symptomet eller sykdomstegnet ble rapportert."> + comment = <"Hvis den anatomiske lokaliseringen allerede er satt i elementet \"Navn på symptom/sykdomstegn\" via prekoordinerte koder, blir dette SLOTet overflødig. Er den anatomiske lokaliseringen registrert i dataelementet \"Anatomisk lokalisering\", er bruken av dette SLOTet ikke tillatt. Registrer bare \"Anatomisk lokalisering\" eller \"Strukturert anatomisk lokalisering\", ikke begge."> + > + ["at0151"] = < + text = <"Anatomisk lokalisering"> + description = <"Registrering av ett enkelt område på kroppen hvor symptomet eller sykdomstegnet var rapportert."> + comment = <"Forekomster for dette dataelementet er satt 0..* for å tillate at flere kroppssted kan trekkes ut i et templat om ønsket. Dette åpner for å representere kliniske scenarier hvor et symptom må registreres flere steder på kroppen eller for å identifisere både opphavssted for smerte og ytterpunkt for utstråling av smerter, og alle andre dataelementer i arketypen som \"Innvirkning\" og \"Varighet\" er like. Om kravet for registrering av kroppsplassering er bestemt i en applikasjon eller krever en mer kompleks modellering som for eksempel relativ lokalisering, bruk arketypen CLUSTER.anatomical_location eller CLUSTER.relative_location i \"Strukturert anatomisk lokalisering\"-SLOTet i denne arketypen. Er den anatomiske lokaliseringen inkludert i \"Navn på symptom/sykdomstegn\" via prekoordinerte koder er dette dataelementet overflødig. Registreres den anatomiske lokaliseringen i SLOTet \"Strukturert anatomisk lokalisering\" er bruken av dette dataelementet ikke tillatt. Registrer enten i \"Anatomisk lokalisering\" eller i \"Strukturert anatomisk lokalisering\", ikke i begge. + +"> + > + ["at0152"] = < + text = <"Dato/tid for episodens debut"> + description = <"Debuttidspunkt for denne episoden av symptomet eller sykdomstegnet."> + comment = <"Partielle datoer er tillatt. Nøyaktig tid for symptomets debut kan registreres, dersom relevant. Dersom dette symptomet eller sykdomstegnet oppleves for første gang eller er en ny episode av et tidligere opplevd symptom, kan denne datoen brukes for å representere debuten for denne episoden. Dersom symptomet eller sykdomstegnet opptrer kontinuerlig, kan dette dataelementet være overflødig dersom det er registrert tidligere."> + > + ["at0153"] = < + text = <"Spesifikke detaljer"> + description = <"Ekstra dataelementer som er nødvendige for å registrere egenskaper unike for det identifiserte symptomet eller sykdomstegnet."> + comment = <"For eksempel: Graderingen \"Common Terminology Criteria for Adverse Events\"."> + > + ["at0154"] = < + text = <"Faktordetaljer"> + description = <"Strukturerte detaljer om faktoren som er forbundet med det identifiserte symptomet eller sykdomstegnet."> + > + ["at0155"] = < + text = <"Innvirkning"> + description = <"Beskrivelse av symptomet eller sykdomstegnets innvirkning."> + comment = <"Bedømmelsen av innvirkning må ta høyde for alvorlighet, varighet og frekvens av symptomet, i tillegg til type innvirkning, for eksempel: funksjonell, sosial og emosjonell innvirkning. Dataelementet er satt til 0..* for å tillate at flere typer innvirkning kan trekkes ut i et templat om ønskelig. For hørselstap vil innvirkning kunne omfatte \"Vansker med å høre i et stille miljø\", \"Vansker med å høre TV eller radio\"; \"Vansker med å høre gruppesamtaler\" og \"Vansker med å høre i telefon\"."> + > + ["at0156"] = < + text = <"Ingen effekt"> + description = <"Faktoren har ingen effekt på symptomet eller sykdomstegnet."> + > + ["at0158"] = < + text = <"Forverrer"> + description = <"Faktoren øker alvorlighet eller innvirkning av symptomet eller sykdomstegnet."> + > + ["at0159"] = < + text = <"Lindrer"> + description = <"Faktoren reduserer alvorligheten eller innvirkning av symptomet eller sykdomstegnet, men får det ikke til å opphøre fullstendig."> + > + ["at0161"] = < + text = <"Dato/tid for opphør"> + description = <"Dato/tid for opphør av denne episoden av symptomet eller sykdomstegnet."> + comment = <"Brukes \"Dato/tid for debut\" og \"Varighet\" i systemer, kan dette dataelementet kalkuleres av systemet eller være overflødig. Ufullstendig dato er tillatt, nøyaktig dato og tid for opphør kan registreres om ønskelig."> + > + ["at0163"] = < + text = <"Kommentar"> + description = <"Ytterligere fritekst om symptomet eller sykdomstegnet som ikke dekkes i andre felt."> + > + ["at0164"] = < + text = <"Debuttype"> + description = <"Beskrivelse av symptomets eller sykdomstegnets debut."> + comment = <"Debuttypen kan kodes med en terminologi om ønsket. For eksempel: Gradvis eller plutselig."> + > + ["at0165"] = < + text = <"Utløsende/avsluttende faktor"> + description = <"Detaljer om spesifikke faktorer som utløser eller som får symptomet eller sykdomstegnet til å opphøre."> + comment = <"For eksempel: Debut av hodepine oppstod en uke før menstruasjon eller debut av hodepine oppstod en time etter fall på sykkel, halsbrannen forsvant ved administrasjon av syrenøytraliserende eller brystsmerter forsvant ved hvile."> + > + ["at0167"] = < + text = <"Utløsende faktor"> + description = <"Identifisering av faktorer eller hendelser som utløser debut av symptomet eller sykdomstegnet."> + > + ["at0168"] = < + text = <"Avsluttende faktor"> + description = <"Identifisering av faktorer eller hendelser som utløser opphør av symptomet eller sykdomstegnet."> + > + ["at0170"] = < + text = <"Faktor"> + description = <"Navn på helserelatert hendelse, symptom, rapportert sykdomstegn eller annen faktor."> + comment = <"For eksempel: Debut av annet symptom, menstruasjons debut, falt av sykkel."> + > + ["at0171"] = < + text = <"Tidsintervall"> + description = <"Tidsintervall mellom forekomst eller debut av faktoren og debut/opphør av symptomet eller sykdomstegnet."> + > + ["at0175"] = < + text = <"Episodisitet"> + description = <"Kategorisering av denne episoden av det identifiserte symptomet eller sykdomstegnet."> + > + ["at0176"] = < + text = <"Nytt"> + description = <"En ny episode av symptomet eller sykdomstegnet - enten den første forekomsten eller en ny forekomst der den tidligere episoden var fullstendig opphørt."> + > + ["at0177"] = < + text = <"Ubestemt"> + description = <"Det er ikke mulig å bestemme om denne forekomsten av symptomet er ny eller pågående."> + > + ["at0178"] = < + text = <"Kontinuerlig"> + description = <"Symptomet eller sykdomstegnet er kontinuerlig tilstedeværende, i praksis en enkelt pågående episode."> + > + ["at0180"] = < + text = <"Progresjon"> + description = <"Beskrivelse av symptomets eller sykdomstegnets progresjon ved rapporteringstidspunktet."> + comment = <"Dataelementet er definert som 0..* for å tillate at flere typer progresjon trekkes ut i et templat om ønsket. For eksempel: alvorlighet eller frekvens."> + > + ["at0181"] = < + text = <"Forbedret"> + description = <"Symptomet eller sykdomstegnets alvorlighetsgrad er forbedret i løpet av denne episoden."> + > + ["at0182"] = < + text = <"Uendret"> + description = <"Symptomet eller sykdomstegnets alvorlighetsgrad er ikke endret i løpet av denne episoden."> + > + ["at0183"] = < + text = <"Forverret"> + description = <"Symptomet eller sykdomstegnets alvorighetsgrad har blitt forverret i løpet av denne episoden."> + > + ["at0184"] = < + text = <"Opphørt"> + description = <"Symptomet eller sykdomstegnets alvorlighetsgrad er opphørt i løpet av denne episoden."> + > + ["at0185"] = < + text = <"Beskrivelse"> + description = <"Fritekstbeskrivelse av faktorens effekt på det identifiserte symptomet eller sykdomstegnet."> + > + ["at0186"] = < + text = <"Nyoppstått?"> + description = <"Er dette et nyoppstått tilfelle av dette symptomet eller sykdomstegnet?"> + comment = <"Registrer som \"Sann\" dersom symptomet eller sykdomstegnet er nyoppstått."> + > + > + > + ["fi"] = < + items = < + ["at0187"] = < + text = <"*First occurrence (en)"> + description = <"*This is the first ever occurrence of this symptom or sign. (en)"> + > + ["at0188"] = < + text = <"*Recurrence (en)"> + description = <"*This is the first ever occurrence of this symptom or sign. (en)"> + > + ["at0189"] = < + text = <"*Character (en)"> + description = <"*Word or short phrase describing the nature of the symptom or sign. (en)"> + comment = <"*For example: pain could be described as 'gnawing', 'burning', or 'like an electric shock'; a headache could be 'throbbing' or 'constant'. Coding with an external terminology is preferred, where possible. (en)"> + > + ["at0000.1"] = < + text = <"Oire"> + description = <"Reported observation of a physical or mental disturbance in an individual.(en)"> + > + ["at0.1"] = < + text = <"*DV_TEXT (en)"> + description = <"*"> + > + ["at0.2"] = < + text = <"*Present (en)"> + description = <"*The symptom is present. (en)"> + > + ["at0.3"] = < + text = <"*Absent (en)"> + description = <"*The symptom is absent. (en)"> + > + ["at0.4"] = < + text = <"*Unknown (en)"> + description = <"*It is not known if the symptom is present. (en)"> + > + ["at0001.1"] = < + text = <"Oireen nimi"> + description = <"The name of the reported symptom or sign.(en)"> + comment = <"*Symptom name should be coded with a terminology, where possible.(en)"> + > + ["at0000"] = < + text = <"Oire"> + description = <"Reported observation of a physical or mental disturbance in an individual.(en)"> + > + ["at0001"] = < + text = <"Oireen nimi"> + description = <"The name of the reported symptom or sign.(en)"> + comment = <"*Symptom name should be coded with a terminology, where possible.(en)"> + > + ["at0002"] = < + text = <"Kuvaus"> + description = <"Narrative description about the reported symptom or sign.(en)"> + > + ["at0003"] = < + text = <"Malli"> + description = <"Narrative description about the pattern of the symptom or sign during this episode.(en)"> + comment = <"*For example: pain could be described as constant or intermittent.(en)"> + > + ["at0017"] = < + text = <"Vaikutus"> + description = <"Perceived effect of the modifying factor on the symptom or sign.(en)"> + > + ["at0018"] = < + text = <"Vaikuttajan kerroin"> + description = <"Detail about how a specific factor effects the identified symptom or sign during this episode.(en)"> + > + ["at0019"] = < + text = <"Vaikuttaja"> + description = <"Name of the modifying factor.(en)"> + comment = <"*Examples of modifying factor: lying on multiple pillows, eating or administration of a specific medication.(en)"> + > + ["at0021"] = < + text = <"Vakavuusasteikko"> + description = <"Category representing the overall severity of the symptom or sign.(en)"> + comment = <"*Defining values such as mild, moderate or severe in such a way that is applicable to multiple symptoms or signs plus allows multiple users to interpret and record them consistently is not easy. Some organisations extend the value set further with inclusion of additional values such as 'Trivial' and 'Very severe', and/or 'Mild-Moderate' and 'Moderate-Severe', adds to the definitional difficulty and may also worsen inter-recorder reliability issues. Use of 'Life-threatening' and 'Fatal' is also often considered as part of this value set, although from a pure point of view it may actually reflect an outcome rather than a severity. In view of the above, keeping to a well-defined but smaller list is preferred and so the mild/moderate/severe value set is offered, however the choice of other text allows for other value sets to be included at this data element in a template. Note: more specific grading of severity can be recorded using the 'Specific details' SLOT.(en)"> + > + ["at0023"] = < + text = <"Vähäinen"> + description = <"The intensity of the symptom or sign does not cause interference with normal activity.(en)"> + > + ["at0024"] = < + text = <"Kohtuullinen"> + description = <"The intensity of the symptom or sign causes interference with normal activity.(en)"> + > + ["at0025"] = < + text = <"Vakava"> + description = <"The intensity of the symptom or sign causes prevents normal activity.(en)"> + > + ["at0026"] = < + text = <"Vakavuusaste"> + description = <"Numerical rating scale representing the overall severity of the symptom or sign.(en)"> + comment = <"*Symptom severity can be rated by the individual by recording a score from 0 (ie symptom not present) to 10.0 (ie symptom is as severe as the individual can imagine). This score can be represented in the user interface as a visual analogue scale. The data element has occurrences set to 0..* to allow for variations such as 'maximal severity' or 'average severity' to be included in a template.(en)"> + > + ["at0028"] = < + text = <"Kesto"> + description = <"The duration of this episode of the symptom or sign since onset.(en)"> + comment = <"*If 'Date/time of onset' and 'Date/time of resolution' are used in systems, this data element may be calculated, or alternatively, be considered redundant in this scenario.(en)"> + > + ["at0031"] = < + text = <"Aikasempien kohtauksien lukumäärä"> + description = <"The number of times this symptom or sign has previously occurred.(en)"> + > + ["at0035"] = < + text = <"Olematon"> + description = <"The identified symptom or sign was reported as not being present to any significant degree.(en)"> + comment = <"*Record as True if the subject of care has reported the symptom as not significant. For example: if the individual has never experienced the symptom it is appropriate to record 'nil significant'; or if the individual commonly experiences the symptom, in some circumstances it may be considered appropriate to record 'nil significant' if the individual has experienced no deviation from their 'normal' baseline.(en)"> + > + ["at0037"] = < + text = <"Kohtauksen kuvaus"> + description = <"Narrative description about the course of the symptom or sign during this episode.(en)"> + comment = <"*For example: a text description of the immediate onset of the symptom, activities that worsened or relieved the symptom, whether it is improving or worsening and how it resolved over weeks.(en)"> + > + ["at0056"] = < + text = <"Kuvaus"> + description = <"Narrative description of the effect of the modifying factor on the symptom or sign.(en)"> + > + ["at0057"] = < + text = <"Edellisen kohtausten kuvaus"> + description = <"Narrative description of any or all previous episodes.(en)"> + comment = <"*For example: frequency/periodicity - per hour, day, week, month, year; and regularity. May include a comparison to this episode.(en)"> + > + ["at0063"] = < + text = <"Liittyvä oire"> + description = <"Structured details about any associated symptoms or signs that are concurrent.(en)"> + comment = <"*In linked clinical systems, it is possible that associated symptoms or signs are already recorded within the EHR. Systems can allow the clinician to LINK to relevant associated symptoms/signs. However in a system or message without LINKs to existing data or with a new patient, additional instances of the symptom archetype could be included here to represent associated symptoms/signs.(en)"> + > + ["at0146"] = < + text = <"Edelliset kohtaukset"> + description = <"Structured details of the symptom or sign during a previous episode.(en)"> + comment = <"*In linked clinical systems, it is possible that previous episodes are already recorded within the EHR. Systems can allow the clinician to LINK to relevant previous episodes. However in a system or message without LINKs to existing data or with a new patient, additional instances of the symptom archetype could be included here to represent previous episodes. It is recommended that new instances of the Symptom archetype inserted in this SLOT represent one or many previous episodes to this Symptom instance only.(en)"> + > + ["at0147"] = < + text = <"Rakenteellinen kehon alue"> + description = <"Structured body site where the symptom or sign was reported.(en)"> + comment = <"*If the anatomical location is included in the Symptom name via precoordinated codes, use of this SLOT becomes redundant. If the anatomical location is recorded using the 'Body site' data element, then use of CLUSTER archetypes in this SLOT is not allowed - record only the simple 'Body site' OR 'Structured body site', but not both.(en)"> + > + ["at0151"] = < + text = <"Kehon alue"> + description = <"Simple body site where the symptom or sign was reported.(en)"> + comment = <"*Occurrences of this data element are set to 0..* to allow multiple body sites to be separated out in a template if desired. This allows for representation of clinical scenarios where a symptom or sign needs to be recorded in multiple locations or identifying both the originating and distal site in pain radiation, but where all of the other attributes such as impact and duration are identical. If the requirements for recording the body site 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 Detailed anatomical location' SLOT in this archetype. +If the anatomical location is included in the Symptom name via precoordinated codes, this data element becomes redundant. If the anatomical location is recorded using the 'Structured body site' SLOT, then use of this data element is not allowed - record only the simple 'Body site' OR 'Structured body site', but not both.(en)"> + > + ["at0152"] = < + text = <"Kohtauksen alku"> + description = <"The onset for this episode of the symptom or sign.(en)"> + comment = <"*While partial dates are permitted, the exact date and time of onset can be recorded, if appropriate. If this symptom or sign is experienced for the first time or is a re-occurrence, this date is used to represent the onset of this episode. If this symptom or sign is ongoing, this data element may be redundant if it has been recorded previously.(en)"> + > + ["at0153"] = < + text = <"Ominaistiedot"> + description = <"Specific data elements that are additionally required to record as unique attributes of the identified symptom or sign.(en)"> + comment = <"*For example: CTCAE grading.(en)"> + > + ["at0154"] = < + text = <"Vaikutustiedot"> + description = <"Structured detail about the factor associated with the identified symptom or sign.(en)"> + > + ["at0155"] = < + text = <"Vaikutus"> + description = <"Description of the impact of this symptom or sign.(en)"> + comment = <"*Assessment of impact could consider the severity, duration and frequency of the symptom as well as the type of impact including, but not limited to, functional, social and emotional impact. Occurrences of this data element are set to 0..* to allow multiple types of impact to be separated out in a template if desired. Examples for functional impact from hearing loss may include: 'Difficulty Hearing in Quiet Environment'; 'Difficulty Hearing the TV or Radio'; 'Difficulty Hearing Group Conversation'; and 'Difficulty Hearing on Phone'.(en)"> + > + ["at0156"] = < + text = <"Ei vaikutusta"> + description = <"The factor has no impact on the symptom or sign.(en)"> + > + ["at0158"] = < + text = <"Pahentaa"> + description = <"The factor increases the severity or impact of the symptom or sign.(en)"> + > + ["at0159"] = < + text = <"Helpottaa"> + description = <"The factor decreases the severity or impact of the symptom or sign, but does not fully resolve it.(en)"> + > + ["at0161"] = < + text = <"Päättymisaika"> + description = <"The timing of the cessation of this episode of the symptom or sign.(en)"> + comment = <"*If 'Date/time of onset' and 'Duration' are used in systems, this data element may be calculated, or alternatively, considered redundant. While partial dates are permitted, the exact date and time of resolution can be recorded, if appropriate.(en)"> + > + ["at0163"] = < + text = <"Kommentti"> + description = <"Additional narrative about the symptom or sign not captured in other fields.(en)"> + > + ["at0164"] = < + text = <"Oireen puhkeaminen"> + description = <"Description of the onset of the symptom or sign.(en)"> + comment = <"*The type of the onset can be coded with a terminology, if desired. For example: gradual; or sudden.(en)"> + > + ["at0165"] = < + text = <"Kiihdyttävä/ratkaiseva tekijä"> + description = <"Details about specified factors that are associated with the precipitation or resolution of the symptom or sign.(en)"> + comment = <"*For example: onset of headache occurred one week prior to menstruation; or onset of headache occurred one hour after fall of bicycle.(en)"> + > + ["at0167"] = < + text = <"Kiihdyttävä tekijä"> + description = <"Identification of factors or events that trigger the onset or commencement of the symptom or sign.(en)"> + > + ["at0168"] = < + text = <"Ratkaiseva tekijä"> + description = <"Identification of factors or events that trigger resolution or cessation of the symptom or sign.(en)"> + > + ["at0170"] = < + text = <"Vaikuttaja"> + description = <"Name of the health event, symptom, reported sign or other factor.(en)"> + comment = <"*For example: onset of another symptom; onset of menstruation; or fall off bicycle.(en)"> + > + ["at0171"] = < + text = <"Aikaväli"> + description = <"The interval of time between the occurrence or onset of the factor and onset/resolution of the symptom or sign.(en)"> + > + ["at0175"] = < + text = <"Jaksollisuus"> + description = <"Category of this episode for the identified symptom or sign.(en)"> + > + ["at0176"] = < + text = <"Uusi"> + description = <"A new episode of the symptom or sign - either the first ever occurrence or a reoccurrence where the previous episode had completely resolved.(en)"> + > + ["at0177"] = < + text = <"Epämääräinen"> + description = <"It is not possible to determine if this occurrence of the symptom or sign is new or ongoing.(en)"> + > + ["at0178"] = < + text = <"Meneillään oleva"> + description = <"This symptom or sign is ongoing, effectively a single, continuous episode.(en)"> + > + ["at0180"] = < + text = <"Progressio"> + description = <"Description progression of the symptom or sign at the time of reporting.(en)"> + comment = <"*Occurrences of this data element are set to 0..* to allow multiple types of progression to be separated out in a template if desired - for example, severity or frequency.(en)"> + > + ["at0181"] = < + text = <"Parantuva"> + description = <"The severity of the symptom or sign has improved overall during this episode.(en)"> + > + ["at0182"] = < + text = <"Ei muutosta"> + description = <"The severity of the symptom or sign has not changed overall during this episode.(en)"> + > + ["at0183"] = < + text = <"Pahentuva"> + description = <"The severity of the symptom or sign has worsened overall during this episode.(en)"> + > + ["at0184"] = < + text = <"Ratkaistu"> + description = <"The severity of the symptom or sign has resolved.(en)"> + > + ["at0185"] = < + text = <"Kuvaus"> + description = <"Narrative description about the effect of the factor on the identified symptom or sign.(en)"> + > + ["at0186"] = < + text = <"Ensimmäinen koskaan?"> + description = <"Is this the first ever occurrence of this symptom or sign?(en)"> + comment = <"*Record as True if this is the first ever occurrence of this symptom or sign.(en)"> + > + > + > + ["sv"] = < + items = < + ["at0187"] = < + text = <"*First occurrence (en)"> + description = <"*This is the first ever occurrence of this symptom or sign. (en)"> + > + ["at0188"] = < + text = <"*Recurrence (en)"> + description = <"*This is the first ever occurrence of this symptom or sign. (en)"> + > + ["at0189"] = < + text = <"*Character (en)"> + description = <"*Word or short phrase describing the nature of the symptom or sign. (en)"> + comment = <"*For example: pain could be described as 'gnawing', 'burning', or 'like an electric shock'; a headache could be 'throbbing' or 'constant'. Coding with an external terminology is preferred, where possible. (en)"> + > + ["at0000.1"] = < + text = <"Symtom och tecken"> + description = <"Rapporterad observation av en fysisk eller psykisk störning hos en individ."> + > + ["at0.1"] = < + text = <"*DV_TEXT (en)"> + description = <"*"> + > + ["at0.2"] = < + text = <"*Present (en)"> + description = <"*The symptom is present. (en)"> + > + ["at0.3"] = < + text = <"*Absent (en)"> + description = <"*The symptom is absent. (en)"> + > + ["at0.4"] = < + text = <"*Unknown (en)"> + description = <"*It is not known if the symptom is present. (en)"> + > + ["at0001.1"] = < + text = <"Symtom och teckennamn"> + description = <"Namnet på det uppvisade symtomet eller tecknet."> + comment = <"Symtomnamnet ska kodas med en terminologi, där det är möjligt."> + > + ["at0000"] = < + text = <"Symtom och tecken"> + description = <"Rapporterad observation av en fysisk eller psykisk störning hos en individ."> + > + ["at0001"] = < + text = <"Symtom och teckennamn"> + description = <"Namnet på det uppvisade symtomet eller tecknet."> + comment = <"Symtomnamnet ska kodas med en terminologi, där det är möjligt."> + > + ["at0002"] = < + text = <"Beskrivning"> + description = <"Beskrivning av det uppvisade symtomet eller tecknet."> + > + ["at0003"] = < + text = <"Mönster för episod"> + description = <"En beskrivning av den här episodens mönster av symtomet eller tecknet."> + comment = <"Exempelvis: smärta som kan beskrivas som konstant eller intermittent."> + > + ["at0017"] = < + text = <"Effekt"> + description = <"Förnimmad effekt av påverkande faktorn av symtomet eller tecknet."> + > + ["at0018"] = < + text = <"Påverkande faktor"> + description = <"Detalj om en specifik faktor som påverkar det identifierade symtomet eller tecknet under denna episod."> + > + ["at0019"] = < + text = <"Faktor"> + description = <"Namn på den påverkande faktorn."> + comment = <"Exempel på påverkande faktorn: Ligger på flera kuddar, äter eller ges ett specifikt läkemedel."> + > + ["at0021"] = < + text = <"Svårighetsgrad kategori"> + description = <"Kategori som presenterar symtomens eller tecknets totala svårighetsgrad."> + comment = <"Att definiera värden som mild, måttlig eller svår på ett sådant sätt som är tillämpligt på flera symtom eller tecken plus som tillåter flera användare att tolka och registrera dem konsekvent är inte lätt. Vissa organisationer utökar inställningen av värdet ytterligare med att inkludera värden som \"Obetydlig\" och \"Mycket svår\" och\"Mild-Måttlig\" och \"Måttlig-Svår\", vilket ger problem med att förstå skillnaden mellan olika definitioner samt ger svårigheter att jämföra olika mätresultat. + +Användning av \"Livshotande\" och \"Dödlig\" anses ofta också som en del av denna värdeskattning, men det kan faktiskt reflektera ett resultat snarare än en svårighetsgrad. Med tanke på ovanstående är det att föredra att hålla sig till en väldefinierad men mindre lista, och sålunda erbjuds den milda/måttligt svåra värdesatsen, men valet av annan text tillåter att andra värdesatser inkluderas i detta dataelement i en mall. Obs! Mer specifik gradering av svårighetsgrad kan registreras i fältet \"Specifika Detaljer\"."> + > + ["at0023"] = < + text = <"Mild"> + description = <"Symtomet eller tecknets intensitet orsakar inte störningar i normal aktivitet. +"> + > + ["at0024"] = < + text = <"Måttlig"> + description = <"Symtomet eller tecknets intensitet orsakar störningar i normal aktivitet."> + > + ["at0025"] = < + text = <"Svår"> + description = <"Symtomets eller tecknets intensitet förhindrar normal aktivitet."> + > + ["at0026"] = < + text = <"Skattning av svårighetsgrad"> + description = <"Numerisk skattningsskala som presenterar symtomens eller tecknets övergripande svårighetsgrad."> + comment = <"Svårighetsgraden kan bedömas av individen genom att registrera poäng från 0 (dvs. ingen förekomst av symtom) till 10,0 (dvs. symtomet är så svårt som individen kan tänka sig). Denna poäng kan presenteras i användargränssnittet som en visuell analog skala. Fältet innehåller händelser som är satta till 0.. * för att tillåta att variationer som exempelvis \"maximal svårighetsgrad\" eller \"genomsnittlig svårighetsgrad\" ska kunna ingå i en mall."> + > + ["at0028"] = < + text = <"Varaktighet"> + description = <"Den här episodens varaktighet av symtomet eller tecknet sedan debuten."> + comment = <"Om \"Datum och tidpunkt för debut\" och \"Datum och tid för uppklarande\" används i systemet, kan det här fältet övervägas eller alternativt anses vara överflödigt i detta scenario."> + > + ["at0031"] = < + text = <"Antal tidigare inträffade episoder"> + description = <"Antalet gånger detta symtom eller tecken har förekommit tidigare."> + > + ["at0035"] = < + text = <"Noll signifikant"> + description = <"Det identifierade symtomet eller tecknet rapporterades som inte förekommande i någon signifikant grad."> + comment = <"Registrera som Sann om patienten har rapporterat symtomet som inte signifikant. Exempelvis om patienten aldrig har upplevt symtomet är det lämpligt att registrera \"Noll signifikant\", likaså om patienten ofta upplever symtomet kan det under vissa omständigheter anses lämpligt att registrera det som 'Noll signifikant', om patienten exempelvis inte har upplevt någon avvikelse från sin \"normala\" baslinje."> + > + ["at0037"] = < + text = <"Episodbeskrivning"> + description = <"Beskrivning av symtomet eller tecknet under denna episod."> + comment = <"Exempelvis: En textbeskrivning om symtomets debut, aktiviteter som förvärrade eller lindrade symtomen, om det förbättras eller förvärras och hur det uppklaras över veckor."> + > + ["at0056"] = < + text = <"Beskrivning"> + description = <"Beskrivning av påverkande faktorns effekt på symtomet eller tecknet."> + > + ["at0057"] = < + text = <"Beskrivning av tidigare episoder"> + description = <"Beskrivning av några eller alla tidigare episoder."> + comment = <"Exempelvis: frekvens och periodicitet, per timme, dag, vecka, månad, år och regelbundenhet. Den kan innehålla en jämförelse med den här episoden."> + > + ["at0063"] = < + text = <"Associerade symtom och tecken"> + description = <"Strukturerade detaljer om eventuella samtidiga tillhörande symtom eller tecken. +"> + comment = <"I länkade kliniska system är det möjligt att sammankopplade symtom eller tecken redan är registrerade inom EHR. System kan låta klinikern LÄNKA till relevanta associerade symtom coh tecken. Däremot i ett system eller i meddelanden utan LÄNKar till befintliga data eller med en ny patient kan ytterligare fall av symtomarketypen ingå för att presentera associerade symtom och tecken."> + > + ["at0146"] = < + text = <"Tidigare episoder"> + description = <"Strukturerade detaljer om symtomet eller tecken under en tidigare episod."> + comment = <"I länkade kliniska system är det möjligt att tidigare episoder redan är registrerade inom EHR. System kan låta klinikern LÄNKA till relevanta tidigare episoder. Men i ett system eller meddelande utan LÄNKAR till befintlig data eller med en ny patient kan ytterligare fall av symtomarketypen ingå här för att presentera tidigare episoder. Det rekommenderas att nya fall av Symtom-arketypen som förs in i detta FÄLT presenterar endast en eller flera tidigare episoder i det här Symtomfallet."> + > + ["at0147"] = < + text = <"Strukturerad lokalisering"> + description = <"Strukturerad lokalisering av plats på kroppen där symtomen eller tecknet uppvisades."> + comment = <"Om den anatomiska platsen ingår i Symtom-namnet via fördeffinierade koder blir användningen av detta fält överflödig. Om den anatomiska platsen registreras med hjälp av \"Lokalisering\" -fältet, är det inte tillåtet att använda CLUSTER-arketyper i det här fältet, registrera endast den enkla \"Lokalisering\" ELLER \"Strukturerad lokalisering\", men inte båda."> + > + ["at0151"] = < + text = <"Lokalisation"> + description = <"Lokalisation av plats på kroppen där symtomet eller tecknet rapporterats."> + comment = <"Förekomster i det här fältet är inställda på 0.. * för att tillåta att flera lokaliseringar av kroppsställen kan delas upp i en mall om så önskas. Detta möjliggör presentation av kliniska scenarion där ett symtom eller tecken måste registreras på flera ställen eller för att identifiera både uppkomst- och distalplatsen i smärtstrålning, men där alla andra egenskaper som påverkan och varaktighet är identiska. Om registreringskraven för lokalisering av kroppsplats har fastställts vid körning av applikationen eller kräver mer komplex utformning, såsom relativa platser, använd i så fall CLUSTER.anatomical_location eller CLUSTER.relative_location inom fältet 'Detaljerade anatomiska platsen' i den här arketypen. + +Om den anatomiska platsen ingår i Symtom-namnet via förkordinerade koder blir det här fältet överflödigt. Om den anatomiska platsen beskrivs i fältet \"Strukturerad lokalisering\", är det inte tillåtet att använda detta fält, registrera då endast den enkla \"Lokalisering\" ELLER \"Strukturerad lokalisering\", men inte båda."> + > + ["at0152"] = < + text = <"Episoddebut"> + description = <"Debut för denna episod av symtomet eller tecknet."> + comment = <"Medan partiella datum är tillåtna kan det exakta datumet och tiden för debut registreras, om det är lämpligt. Om det här symtomet eller tecknet upplevs för första gången eller är återkommande, används det här datumet för att utgöra början på denna episod. Om det här symtomet eller tecknet är pågående kan det här fältet vara överflödigt om det redan tidigare har beskrivits."> + > + ["at0153"] = < + text = <"Specifika detaljer"> + description = <"Specifika datakomponenter som krävs för att det identifierade symtomet eller tecknet ska kunna registreras som unika egenskaper."> + comment = <"Exempelvis: CTCAE-skattning."> + > + ["at0154"] = < + text = <"Faktordetalj"> + description = <"Strukturerad detalj om den faktor som är kopplad till det identifierade symtomet eller tecknet."> + > + ["at0155"] = < + text = <"Verkan"> + description = <"Beskrivning av det här symptomet eller tecknets verkan."> + comment = <"I bedömningen av verkan kan symtomets svårighetsgrad, varaktighet och frekvens samt typ av verkan inklusive, men inte begränsat till, funktionell, social och emotionell påverkan beaktas. Förekomster i det här datafältet är inställda på 0 .. * för att tillåta flera typer av verkan att separeras i en mall om så önskas. Exempel på funktionell påverkan av hörselnedsättning kan innefatta: \"Svårigheter att höra i lugn miljö\"; \"Svårighet att höra tv eller radio\",\"Svårighet att höra gruppkonversation\" och \"Svårighet att höra vid telefonsamtal\"."> + > + ["at0156"] = < + text = <"Ingen effekt"> + description = <"Faktorn har ingen effekt på symtomet eller tecknet."> + > + ["at0158"] = < + text = <"Försämrar"> + description = <"Faktorn ökar symtomets eller tecknets svårighetsgrad eller effekt."> + > + ["at0159"] = < + text = <"Lindrar"> + description = <"Faktorn minskar svårighetsgraden eller påverkan på symtomet eller tecknet, men blir inte fullständigt utrett."> + > + ["at0161"] = < + text = <"Uppklarandedatum och tid"> + description = <"Tidpunkt när denna episod av symtomen eller tecknet upphör."> + comment = <"Om \"Datum och tidpunkt för start\" och \"Varaktighet\" används i systemen, kan detta fält beaktas eller alternativt betraktas som överflödigt. Medan partiella datum är tillåtna kan det exakta datumet och tiden för upplösning registreras, om det är lämpligt."> + > + ["at0163"] = < + text = <"Kommentar"> + description = <"Ytterligare beskriving av symtomet eller tecknet som inte tagits upp i andra fält."> + > + ["at0164"] = < + text = <"Typ av debut"> + description = <"Beskrivning av symtomets eller tecknets debut."> + comment = <"Typ av debut kan kodas med en terminologi, om så önskas. Exempelvis: gradvis eller plötslig."> + > + ["at0165"] = < + text = <"Precipitation och uppklarande faktor"> + description = <"Detaljer om specificerade faktorer som är kopplade till symtomet eller tecknets utlösande eller uppklarande."> + comment = <"Exempelvis: Debuten av huvudvärk inträffade en vecka före menstruation eller debuten av huvudvärk inträffade en timme efter fallet av cykeln."> + > + ["at0167"] = < + text = <"Utlösande faktor"> + description = <"Identifiering av faktorer eller händelser som utlöser symtomets eller tecknets debut eller begynnelse."> + > + ["at0168"] = < + text = <"Uppklarande faktor"> + description = <"Identifiering av faktorer eller händelser som utlöser uppklarande eller upphörande av symtomet eller tecknet."> + > + ["at0170"] = < + text = <"Faktor"> + description = <"Namn på hälsohändelsen, symtomet, uppvisade tecknet eller annan faktor."> + comment = <"Exempelvis: Debuten av ett annat symtom, menstruationens början eller fall från cykel."> + > + ["at0171"] = < + text = <"Tidsintervall"> + description = <"Tidsintervallet mellan förekomsten eller debuten av faktorn och debuten och uppklarandet av symtomet eller tecknet."> + > + ["at0175"] = < + text = <"Episodicitet"> + description = <"Den här episodens kategori för det identifierade symtomet eller tecknet."> + > + ["at0176"] = < + text = <"Ny"> + description = <"En ny episod av symtomet eller tecknet, antingen debut eller en återkommande förekomst där den föregående episoden utretts helt."> + > + ["at0177"] = < + text = <"Obestämd"> + description = <"Det är inte möjligt att avgöra om denna förekomst av symtomet eller tecknet är nytt eller pågående."> + > + ["at0178"] = < + text = <"Pågående"> + description = <"Detta symptom eller tecken är pågående, registrad som en enskild kontinuerlig episod."> + > + ["at0180"] = < + text = <"Progression"> + description = <"Beskrivning av progressionen av symtomet eller tecknet vid rapporteringstidpunkten."> + comment = <"Förekomster i det här fältet är inställda på 0.. * för att tillåta flera typer av progression att separeras i en mall om så önskas, exempelvis svårighetsgrad eller frekvens."> + > + ["at0181"] = < + text = <"Under förbättring"> + description = <"Svårighetsgraden av symtomet eller tecknet har förbättrats totalt sett under den här episoden."> + > + ["at0182"] = < + text = <"Oförändrat tillstånd"> + description = <"Svårighetsgraden av symtomet eller tecknet har inte förändrats totalt sett under denna episod."> + > + ["at0183"] = < + text = <"Under försämring"> + description = <"Svårighetsgraden av symtomet eller tecknet har förvärrats totalt sett under denna episod."> + > + ["at0184"] = < + text = <"Löst"> + description = <"Svårighetsgraden av symtomet eller tecknet har lösts."> + > + ["at0185"] = < + text = <"Beskrivning"> + description = <"Beskrivning av faktorns effekt på det identifierade symtomet eller tecknet."> + > + ["at0186"] = < + text = <"Första någonsin?"> + description = <"Är detta den första förekomsten av detta symtom eller tecken?"> + comment = <"Registrera som sann om detta är den första förekomsten av detta symtom eller tecken."> + > + > + > + ["pt-br"] = < + items = < + ["at0187"] = < + text = <"*First occurrence (en)"> + description = <"*This is the first ever occurrence of this symptom or sign. (en)"> + > + ["at0188"] = < + text = <"*Recurrence (en)"> + description = <"*This is the first ever occurrence of this symptom or sign. (en)"> + > + ["at0189"] = < + text = <"*Character (en)"> + description = <"*Word or short phrase describing the nature of the symptom or sign. (en)"> + comment = <"*For example: pain could be described as 'gnawing', 'burning', or 'like an electric shock'; a headache could be 'throbbing' or 'constant'. Coding with an external terminology is preferred, where possible. (en)"> + > + ["at0000.1"] = < + text = <"Sintoma/sinal"> + description = <"Observação de um distúrbio físico ou mental relatada em um indivíduo."> + > + ["at0.1"] = < + text = <"*DV_TEXT (en)"> + description = <"*"> + > + ["at0.2"] = < + text = <"*Present (en)"> + description = <"*The symptom is present. (en)"> + > + ["at0.3"] = < + text = <"*Absent (en)"> + description = <"*The symptom is absent. (en)"> + > + ["at0.4"] = < + text = <"*Unknown (en)"> + description = <"*It is not known if the symptom is present. (en)"> + > + ["at0001.1"] = < + text = <"Nome do sintoma/sinal"> + description = <"O nome do sintoma ou sinal relatado."> + comment = <"Nome do sintoma deve ser codificado com uma terminologia, se possível."> + > + ["at0000"] = < + text = <"Sintoma/sinal"> + description = <"Observação de um distúrbio físico ou mental relatada em um indivíduo."> + > + ["at0001"] = < + text = <"Nome do sintoma/sinal"> + description = <"O nome do sintoma ou sinal relatado."> + comment = <"Nome do sintoma deve ser codificado com uma terminologia, se possível."> + > + ["at0002"] = < + text = <"Descrição"> + description = <"Descrição narrativa sobre o sintoma ou sinal relatado."> + > + ["at0003"] = < + text = <"Padrão"> + description = <"Descrição narrativa sobre o padrão do sintoma ou sinal durante este episódio."> + comment = <"Por exemplo: dor pode ser descrita como constante ou intermitente."> + > + ["at0017"] = < + text = <"Efeito"> + description = <"Efeito percebido do fator modificador sobre o sintoma ou sinal."> + > + ["at0018"] = < + text = <"Fator modificador"> + description = <"Detalhe sobre como um fator específico afeta o sintoma ou sinal identificado durante este episódio."> + > + ["at0019"] = < + text = <"Fator"> + description = <"Nome do fator modificador."> + comment = <"Exemplos de fatores modificadores: deitar sobre múltiplos travesseiros, comer ou administração de um medicamento específico."> + > + ["at0021"] = < + text = <"Categoria de gravidade"> + description = <"Categoria representando a gravidade geral do sintoma ou sinal."> + comment = <"Definir valores como leve, moderado ou grave de modo a ser aplicável a múltiplos sintomas ou sinais e permitir que múltiplos usuários interpretem e registrem pode não ser fácil. Algumas organizações estendem a gama de valores com a introdução da valores adicionais como 'Trivial' ou ' Muito grave' e/ou 'Leve a moderado' ou 'Moderado a grave', adiciona dificuldade e pode dificultar a reprodutibilidade. Utilizar 'Ameaçador da vida' e 'Fatal' pode ser considerada valro possível, embora de um ponto de vista mais purista representa melhor um desfecho do que gravidade. Com o exposto acima, uma lista menor é preferida como leve/moderado/grave, entretanto a escolha de outras opções de textos nestas listas podem ser úteis. Note: a gravidade pode ser registrada de maneira mais específica utilizando o SLOT 'Detalhes específicos'."> + > + ["at0023"] = < + text = <"Leve"> + description = <"A intensidade do sintoma ou sinal não causa interferência com a atividade normal."> + > + ["at0024"] = < + text = <"Moderada"> + description = <"A intensidade do sintoma ou sinal causa interferência com a atividade normal."> + > + ["at0025"] = < + text = <"Grave"> + description = <"A intensidade do sintoma ou sinal impede a atividade normal."> + > + ["at0026"] = < + text = <"Classificação de gravidade"> + description = <"Escala de gradação numérica representando a gravidade geral de um sintoma ou sinal."> + comment = <"Gravidade do sintoma pode ser graduada pelo registro individual de um score de 0 (sintoma ausente) a 10 (sintoma mais grave que o indivíduo pode imaginar). Este score pode ser representado na interface ao usuário como escala visual analógica. O elemento de dado tem ocorrências de 0..* para permitir variações como 'gravidade máxima' para ser incluída no template."> + > + ["at0028"] = < + text = <"Duração"> + description = <"A duração deste episódio de sintoma ou sinal desde o início."> + comment = <"Se 'Data/hora de início' e 'Data/hora de resolução' forem utilizados, este elemento de dado pode ser calculado, ou alternativamente, ser considerado redundante neste cenário."> + > + ["at0031"] = < + text = <"Número de episódios prévios"> + description = <"O número de vezes que este sintoma ou sinal cocorreu previamente."> + > + ["at0035"] = < + text = <"Não significante"> + description = <"O sintoma ou sinal identificado foi relatado como não sendo presente num nível significante."> + comment = <"Registrar como Verdadeiro se o sujeito do cuidado tiver reportado o sintoma como não significante. Por exemplo: se o indivíduo nunca experimentou o sintoma é apropriado registrar 'não significante'; ou se o indivíduo comumente experimenta o sintoma, em algumas circunstâncias pode ser considerado apropriado registrar 'não significante' se o indivíduo não experimenta desvio no seu baseline 'normal'."> + > + ["at0037"] = < + text = <"Descrição do episódio"> + description = <"Descrição narrativa sobre o curso do sintoma ou sinal durante o episódio."> + comment = <"Por exemplo: uma descrição em texto do início imediato do sintoma, atividades que pioram ou aliviam o sintoma, se está melhorando ou piorando e como se resolveu ao longo de semanas."> + > + ["at0056"] = < + text = <"Descrição"> + description = <"Descrição narrativa do efeito do fato modificador no sintoma ou sinal."> + > + ["at0057"] = < + text = <"Descrição de episódios prévios"> + description = <"Descrição narrativa de alguns ou todos os episódios prévios."> + comment = <"Por exemplo: frequência/periodicidade - por hora, dia, semana, mês, ano; e regularidade. Pode incluir uma comparação com o episódio atual."> + > + ["at0063"] = < + text = <"Sintoma/sinal associado"> + description = <"Detalhes estruturados sobre quaisquer sintomas ou sinais associados que sejam concorrentes."> + comment = <"Em sistemas clínicos concatenados, é possível que sintomas ou sinais associados já estejam registrados no PEP. O sistema pode permitir que o clínico relacione com sintomas e sinais associados. Entretanto em um sistema ou mensagem sem este relacionamento com dados existentes ou com um novo paciente, instâncias adicionais do arquétipo de sintoma podem ser incluídas para representar sintomas ou sinais associados."> + > + ["at0146"] = < + text = <"Episódios prévios"> + description = <"Detalhes estruturados do sintoma ou sinal durante um episódio prévio."> + comment = <"Em sistemas clínicos concatenados, é possível que episódios prévios já etejam registrados no PEP. O sistema pode permitir que o clínico relacione este a episódios relevantes prévios. Entretanto em um sistema ou mensagem sem este relacionamento com dados existentes ou com um novo paciente, instâncias adicionais do arquétipo de sintoma podem ser incluídas para representar episódios prévios. É recomendado que novas instâncias do arquétipo de Sintomas inseridas neste SLOT representem um ou vários episódios prévios relacionados à esta instância."> + > + ["at0147"] = < + text = <"Parte do corpo estruturada"> + description = <"Parte do corpo estruturada em que o sintoma ou sinal foi relatado."> + comment = <"Se a localização anatômica estiver incluída no nome do Sintoma através de códigos pré-coordenados, a utilização deste SLOT torna-se redundante. Se a localização anatômica for registrada utilizando o elemento de dado 'Parte do corpo', então o uso de arquétipos CLUSTER neste SLOT não é permitido - registre apenas o 'Parte do corpo' simples ou 'Parte do corpo estruturada' mas não ambos."> + > + ["at0151"] = < + text = <"Parte do corpo"> + description = <"Parte do corpo em que o sintoma ou sinal foi relatado."> + comment = <"Ocorrências deste elemento de dado são ajustadas de 0..* para permitir múltiplas partes do corpo para serem separadas num template se desejado. Isto permite a representação de cenários clínicos em que o sintoma ou sinal precise ser registrado em múltiplas localizações ou identificar tanto local original e local distante de irradiação de dor, mas em que todos os outros atributos como o impacto e duração são idênticos. Se os requerimntos para registro da parte do corpo for determinado em tempo real pela aplicação ou requeira modelagem mais complexa como localizações relativas então utilize CLUSTER.anatomical_location ou CLUSTER.relative_location no SLOT 'Localização anatômica detalhada' neste arquétipo. +Se a localização anatômica estiver incluída no nome do Sintoma através de códigos pré-coordenados, este elemento de dado torna-se redundante. Se a localização anatômica for registrada utilizando o SLOT 'Parte do corpo estruturada', então a utilização deste elemento de dado não é permitida - registre apenas o 'Parte do corpo' simples ou 'Parte do corpo estruturada', mas não ambos."> + > + ["at0152"] = < + text = <"Início do episódio"> + description = <"O início para este epsiódio de sintoma ou sinal."> + comment = <"Datas parciais são permitidas, a data e hora exata do início pode ser registrada, se apropriado. Se este sintoma ou sinal for experimentado pela primeira ou se for uma recorrência, esta data é utilizada para representar o início deste episódio. Se o sintoma ou sinal estiver em curso, este elemento de dado pode ser redundante se já tiver sido registrado anteriormente."> + > + ["at0153"] = < + text = <"Detalhes específicos"> + description = <"Elementos de dados específicos que são necessários adicionar para registrar atributos exclusivos do sintoma ou sinal identificado."> + comment = <"Por exemplo: graduação CTCAE."> + > + ["at0154"] = < + text = <"Dealhes do fator"> + description = <"Detalhe estruturado sobre o fator associado com o sintoma ou sinal identificado."> + > + ["at0155"] = < + text = <"Impacto"> + description = <"Descrição do impacto deste sintoma ou sinal."> + comment = <"Avaliação do impacto pode considerar a gravidade, duração e frequência do sintoma ou sinal como também o tipo de impacto incluindo, mas limitado a, impacto funcional, social e emocional. Ocorrências deste elemento de dado são setadas para 0..* para permitir múltiplos tipos de impacto para serem separados no template se desejado. Exemplos de impacto funcional para perda auditiva podem incluir: 'Dificuldade de audição em ambiente quieto'; 'Dificuldade para ouvir rádio e TV'; 'Dificuldade de audição para conversa em grupo' e 'Dificuldade de audição ao telefone'."> + > + ["at0156"] = < + text = <"Sem efeito"> + description = <"O fator não tem impacto no sintoma ou sinal."> + > + ["at0158"] = < + text = <"Piora"> + description = <"O fator aumenta a gravidade ou impacto do sintoma ou sinal."> + > + ["at0159"] = < + text = <"Alivia"> + description = <"O fator diminui a gravidade ou impacto do sintoma ou sinal mas não resolve completamente."> + > + ["at0161"] = < + text = <"Data/hora de resolução"> + description = <"O momento de cessação deste episódio de sintoma ou sinal."> + comment = <"Se 'Data/hora de início' e 'Duração' são utilizados no sistema, este elemento de dado pode ser calculado, ou alternativamente, considerado redundante. Datas parciais são permitidas, a data e hora exatas de resolução podem ser registradas, se apropriado."> + > + ["at0163"] = < + text = <"Comentários"> + description = <"Narrativa adicional sobre o sintoma ou sinal não capturada em outros campos."> + > + ["at0164"] = < + text = <"Tipo de início"> + description = <"Descrição do inicio do sintoma ou sinal."> + comment = <"O tipo de início pode ser codificado utilizando uma terminologia, se desejado. Por exemplo: gradual; ou súbito."> + > + ["at0165"] = < + text = <"Fator precipitante ou de resolução"> + description = <"Detalhes sobre fatores específicos que estão associados com a precipitação ou resolução do sintoma ou sinal."> + comment = <"Por exemplo: início de cefaleia ocorreu uma semana antes da menstruação; ou o início da cefaleia ocorreu uma hora após queda de bicicleta."> + > + ["at0167"] = < + text = <"Fator precipitante"> + description = <"Identificação de fatores ou eventos que deflagram o início ou começo de um sintoma ou sinal."> + > + ["at0168"] = < + text = <"Fator de resolução"> + description = <"Identificação de fatores ou eventos que deflagram a resolução ou cessação de um sintoma ou sinal."> + > + ["at0170"] = < + text = <"Fator"> + description = <"Nome do evento de saúde, sintoma, sinal relatado ou outro fator."> + comment = <"Por exemplo: início de outro sintoma; início da menstruação. ou queda da bicicleta."> + > + ["at0171"] = < + text = <"Intervalo de tempo"> + description = <"O intervalo de tempo entre a ocorrência ou o início do fator e o início ou resolução do sintoma ou sinal."> + > + ["at0175"] = < + text = <"Episodicidade"> + description = <"Categoria deste episódio para o sintoma ou sinal identificado."> + > + ["at0176"] = < + text = <"Novo"> + description = <"Um episódio novo de sintoma ou sinal - tanto para primeira ocorrência como para uma reccorrência quando o episódio prévio estiver completamente resolvido."> + > + ["at0177"] = < + text = <"Indeterminado"> + description = <"Não é possível determinar se esta ocorrência de sintoma ou sinal é nova ou em curso."> + > + ["at0178"] = < + text = <"Em curso"> + description = <"O sintoma ou sinal está em curso, efetivamente um episódio único e contínuo."> + > + ["at0180"] = < + text = <"Progressão"> + description = <"Descrição da progressão do sintoma ou sinal no momento do relato."> + comment = <"Ocorrências deste elemento de dado são setadas para 0..* para permitir múltiplos tipos de progressão para serem separadas no template se desejado - por exemplo, gravidade ou frequência."> + > + ["at0181"] = < + text = <"Melhorando"> + description = <"O gravidade do sintoma ou sinal melhorou ao longo deste episódio."> + > + ["at0182"] = < + text = <"Imutável"> + description = <"O gravidade do sintoma ou sinal não mudou ao longo deste episódio."> + > + ["at0183"] = < + text = <"Piorando"> + description = <"O gravidade do sintoma ou sinal piorou ao longo deste episódio."> + > + ["at0184"] = < + text = <"Resolvido"> + description = <"A gravidade do sintoma ou sinal resolveu-se."> + > + ["at0185"] = < + text = <"Descrição"> + description = <"Descrição narrativa sobre o efeito do fator no sintoma ou sinal identificado."> + > + ["at0186"] = < + text = <"Primeira vez?"> + description = <"Esta é a primeira ocorrência deste sintoma ou sinal?"> + comment = <"Registrar como Verdadeiro se esta for a primeira ocorrência deste sintoma ou sinal."> + > + > + > + > + term_bindings = < + ["SNOMED-CT"] = < + items = < + ["at0001.1"] = <[SNOMED-CT::418799008]> + ["at0002"] = <[SNOMED-CT::162408000]> + ["at0021"] = <[SNOMED-CT::162465004]> + ["at0023"] = <[SNOMED-CT::162468002]> + ["at0024"] = <[SNOMED-CT::162469005]> + ["at0025"] = <[SNOMED-CT::162470006]> + ["at0028"] = <[SNOMED-CT::162442009]> + > + > + > diff --git a/better-template/src/test/resources/opt_json/Archetypes/openEHR-EHR-CLUSTER.symptom_sign.v1.adl b/better-template/src/test/resources/opt_json/Archetypes/openEHR-EHR-CLUSTER.symptom_sign.v1.adl new file mode 100644 index 000000000..48629d15f --- /dev/null +++ b/better-template/src/test/resources/opt_json/Archetypes/openEHR-EHR-CLUSTER.symptom_sign.v1.adl @@ -0,0 +1,1988 @@ +archetype (adl_version=1.4; uid=ac33fa64-f61a-4feb-bd29-0e5b1f4710a0) + openEHR-EHR-CLUSTER.symptom_sign.v1 + +concept + [at0000] + +language + original_language = <[ISO_639-1::en]> + translations = < + ["de"] = < + language = <[ISO_639-1::de]> + author = < + ["name"] = <"Jasmin Buck, Sebastian Garde"> + ["organisation"] = <"University of Heidelberg, Central Queensland University"> + > + > + ["fi"] = < + language = <[ISO_639-1::fi]> + author = < + ["name"] = <"Kalle Vuorinen"> + ["organisation"] = <"Tieto Healthcare & Welfare Oy"> + ["email"] = <"kalle.vuorinen@tieto.com"> + > + > + ["sv"] = < + language = <[ISO_639-1::sv]> + author = < + ["name"] = <"Kirsi Poikela"> + ["organisation"] = <"Tieto Sweden AB"> + ["email"] = <"ext.kirsi.poikela@tieto.com"> + > + > + ["nb"] = < + language = <[ISO_639-1::nb]> + author = < + ["name"] = <"Lars Bitsch-Larsen"> + ["organisation"] = <"Haukeland University Hospital of Bergen, Norway"> + ["email"] = <"lbla@helse-bergen.no"> + > + accreditation = <"MD, DEAA, MBA, spec in anesthesia, spec in tropical medicine."> + > + ["pt-br"] = < + language = <[ISO_639-1::pt-br]> + author = < + ["name"] = <"Vladimir Pizzo"> + ["organisation"] = <"Hospital Sirio Libanes - Brazil"> + ["email"] = <"vladimir.pizzo@hsl.org.br"> + > + > + ["ar-sy"] = < + language = <[ISO_639-1::ar-sy]> + author = < + ["name"] = <"Mona Saleh"> + > + > + > + +description + original_author = < + ["date"] = <"2007-02-20"> + ["name"] = <"Tony Shannon"> + ["organisation"] = <"UK NHS, Connecting for Health"> + ["email"] = <"tony.shannon@nhs.net"> + > + lifecycle_state = <"published"> + other_contributors = <"Tomas Alme, DIPS, Norway","Vebjørn Arntzen, Oslo University Hospital, Norway","Koray Atalag, University of Auckland, New Zealand","Silje Ljosland Bakke, Nasjonal IKT HF, Norway (openEHR Editor)","Lars Bitsch-Larsen, Haukeland University hospital, Norway","Rong Chen, Cambio Healthcare Systems, Sweden","Stephen Chu, Queensland Health, Australia","Einar Fosse, National Centre for Integrated Care and Telemedicine, Norway","Samuel Frade, Marand, Portugal","Sebastian Garde, Ocean Informatics, Germany","Yves Genevier, Privantis SA, Switzerland","Heather Grain, Llewelyn Grain Informatics, Australia","Sam Heard, Ocean Informatics, Australia","Evelyn Hovenga, EJSH Consulting, Australia","Lars Karlsen, DIPS ASA, Norway","Lars Morgan Karlsen, DIPS ASA, Norway","Shinji Kobayashi, Kyoto University, Japan","Sabine Leh, Haukeland University Hospital, Department of Pathology, Norway","Heather Leslie, Atomica Informatics, Australia (openEHR Editor)","Hallvard Lærum, Norwegian Directorate of e-health, Norway","Luis Marco Ruiz, Norwegian Center for Integrated Care and Telemedicine, Norway","Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (openEHR Editor)","Bjoern Naess, DIPS ASA, Norway","Andrej Orel, Marand d.o.o., Slovenia","Jussara Rotzsch, UNB, Brazil","Anoop Shah, University College London, United Kingdom","Norwegian Review Summary, Nasjonal IKT HF, Norway","Rowan Thomas, St. Vincent's Hospital Melbourne, Australia","John Tore Valand, Helse Bergen, Norway"> + details = < + ["de"] = < + language = <[ISO_639-1::de]> + purpose = <"*To record detail about a symptom - either self-recorded by an individual or recorded on the behalf of a patient by a clinician. A complete patient history may include varying level of details about a variety of symptoms.(en)"> + copyright = <"© openEHR Foundation"> + use = <"*Use to record detailed information about a symptom as told to a clinician by a patient or self-recorded by the individual/patient. + +This archetype allows a 'nil significant' statement to be explicitly recorded.(en)"> + misuse = <"*Sollte nur für Symptome benutzt werden. (en)"> + > + ["fi"] = < + language = <[ISO_639-1::fi]> + purpose = <"*To record details about a single episode of a reported symptom or sign including context, but not details, of previous episodes if appropriate.(en)"> + keywords = <"*complaint(en)","*symptom(en)","*disturbance(en)","*problem(en)","*discomfort(en)","*presenting complaint(en)","*presenting symptom(en)","*sign(en)"> + use = <"*Use to record details about a single episode of a symptom or reported sign in an individual, as reported by the individual, parent, care-giver or other party. It may be recorded by a clinician as part of a clinical history record as reported to them, observed by the clinician or self-recorded as part of a clinical questionnaire or personal health record. A complete clinical history or patient story may include varying level of details about multiple episodes of an identified symptom or reported sign, as well as multiple symptoms/signs. + +In the purest sense, symptoms are subjective observations of a physical or mental disturbance and signs are objective observations of the same, as experienced by an individual and reported to the history taker by the same individual or another party. From this logic it follows that we will need two archetypes to record clinical history - one for reported symptoms and another for reported signs. In reality this is impractical as it will require clinical data entry into either one of these models which adds signficant overheads to modellers and those entering data. In addition, there is often overlap in clinical concepts - for example, is previous vomiting or bleeding to be categorised as a symptom or reported sign? In response, this archetype has been specifically designed to proved a single information model that allows for recording of the entire continuum between clearly identifable symptoms and reported signs when recording a clinical history. + +This archetype has been intended to be used as a generic pattern for all symptoms and reported signs. The 'Specific details' SLOT can be used to extend the archetype to include additional, specific data elements for more complex symptoms or signs. + +This archetype has been specifically designed to be used in the 'Structured detail' SLOT within the OBSERVATION.story archetype, but can also be used within other OBSERVATION or CLUSTER archetypes and in the 'Associated symptom/sign' or 'Previous episode' SLOT within other instances of this CLUSTER.symptom_sign archetype. + +Clinicians frequently record the phrase 'nil significant' against specific symptoms or reported signs as an efficient method to indicate that they asked the individual and it was not reported as causing any discomfort or disturbance - effectively used more like a 'normal statement' rather than an explicit exclusion. The 'Nil significant' data element has been deliberately included in this archetype to allow clinicians to record this same information in a simple and effective way in a clinical system. It can be used to drive a user interface, for example if 'Nil significant' is recorded as true then the remaining data elements can be hidden on a data entry screen. This pragmatic approach supports the majority of simple clinical recording requirements around reported symptoms and signs. + +However if there is a clinical imperative to explicitly record that a Symptom or Sign was reported as not present, for example if it will be used to drive clinical decision support, then it would be preferable to use the CLUSTER.exclusion_symptom_sign archetype. The use of CLUSTER.exclusion_symptom_sign will increase the complexity of template modelling, implementation and querying. It is recommended that the CLUSTER.exclusion_symptom_sign archetype only be considered for use if clear benefit can be identified in specific situations, but should not be used for routine symptom/sign recording.(en)"> + misuse = <"*Not to be used to record that a symptom or sign was explicitly reported as not present - use CLUSTER.exclusion_symptom_sign carefully for specific purposes where the overheads of recording in this way warrant the additional complexity, and only if the 'Nil significant' in this archetype is not specific enough for recording purposes. + +Not to be used for recording objective findings as part of a physical examination - use OBSERVATION.exam and related examination CLUSTER archetypes for this purpose. + +Not to be used for diagnoses and problems that form part of a persisting Problem List - use EVALUATION.problem_diagnosis.(en)"> + > + ["sv"] = < + language = <[ISO_639-1::sv]> + purpose = <"Att registrera ett uppvisat symtom eller tecken ifrån en enskild episod, inklusive kontext, men inte detaljer om tidigare episoder, om det är tillämpligt."> + keywords = <"besvär","symtom","störning","problem","obehag","uppvisar besvär","uppvisar symtom","tecken"> + use = <"Används för att beskriva detaljer för en individs rapporterade symtom eller tecken ifrån en enskild episod, som rapporterats av personen, föräldern, hälso- o sjukvårdspersonal eller annan part. Det kan registreras av hälso- o sjukvårdspersonal som en del av en anamnes som rapporterats till hälso- o sjukvårdspersonalen, observerad av eller registrerats själv av personen som en del av ett kliniskt frågeformulär eller personligt hälsodokument. En komplett anamnes eller patientjournal kan innehålla varierande detaljnivå från flera episoder av ett identifierat symtom eller rapporterade tecken, såväl som multipla symtom och tecken. + +Symtom är subjektiva observationer från en fysisk eller psykisk störning och tecken är objektiva observationer av densamma, upplevda av en individ och rapporteras till journalföraren av samma individ eller annan part. +Ur denna logik följer att vi behöver två arketyper för att registrera klinisk anamnes , en för rapporterade symtom och en annan för rapporterade tecken. I verkligheten är detta opraktiskt eftersom det kommer att kräva tillgång till kliniska data i någon av dessa mallar, vilket innebär signifikant merarbete för mallarna och dem som matar in data. Dessutom finns det ofta överlappningar i kliniska koncept, exempevisl är tidigare kräkningar eller blödningar att kategoriserade som ett symtom eller rapporterat tecken? +Som svar har denna arketyp utformats specifikt för att möjliggöra registrering av en sammanhängande enhet mellan tydligt identifierbara symtom och rapporterade tecken vid registrering av en klinisk anamnes. + +Används som en allmän mall för alla symtom och rapporterade tecken. Fältet \"Specifika detaljer\" kan användas för att utöka arketypen för att inkludera ytterligare, specifika datakomponenter för mer komplexa symtom eller tecken. + +Arketypen är speciellt utformad för att användas i fältet \"Detaljstruktur\" i OBSERVATION.story-arketypen, men kan även användas inom andra OBSERVATION- eller CLUSTER-arketyper och i \"Associerade symtom och tecken\" eller i fältet \"Tidigare episod\" inom andra exempel av denna CLUSTER.symptom_sign arketypen. Hälso- o sjukvårdspersonal registrerar ofta uttrycket \"Används inte för att dokumentera ett symtom eller tecken\" som uttryckligen rapporteras som inte förekommande. + +Använd CLUSTER.exclusion_symptom_sign med försiktighet för specifika ändamål där merarbetet för registreringarna på detta sätt motiverar extra komplexitet och endast om \"Noll signifikanta\" fältet i denna arketyp inte är tillräckligt specifik för syftet för registreringen. Används inte för att dokumentera ett symtom eller tecken som uttryckligen rapporteras som inte förekommande – använd CLUSTER.exclusion_symptom_sign med försiktighet för specifika ändamål där merarbetet för registreringarna på detta sätt motiverar extra komplexitet och endast om \"Noll signifikanta\" fältet i denna arketyp inte är tillräckligt specifik för syftet för registreringen. För specifika symtom eller rapporterade tecken som en effektiv metod för att indikera att individen tillfrågats och det inte rapporterades som obehag eller störning - används mer effektivt som ett \"normalt utlåtande\" snarare än en uttrycklig uteslutning. Det \"Noll signifikanta\" fältet har medvetet inkluderats i denna arketyp för att kliniker kan registrera samma information på ett enkelt och effektivt sätt i ett kliniskt system. Det kan användas för att driva ett användargränssnitt, exempelvis om \"Noll signifikant\" är registrerad som sann kan de återstående fälten döljas på en dataskärm. Denna pragmatiska metod stöder majoriteten av enkla kliniska registreringskrav kring rapporterade symtom och tecken. + +Däremot om det finns en klinisk nödvändighet att uttryckligen registrera att ett symtom eller tecken rapporterades som inte förekommande, exempelvis om det kommer att användas som ett kliniskt beslutsstöd, föredras CLUSTER.exclusion_symptom_sign arketypen. Användningen av CLUSTER.exclusion_symptom_sign ökar komplexiteten i mallutformningen, implementeringen och utfrågningen. Det rekommenderas att CLUSTER.exclusion_symptom_sign arketypen endast beaktas för användning om tydlig fördel kan identifieras i specifika situationer, men ska inte användas för rutinmässigt symtom och tecken registrering. + + +"> + misuse = <"Ska inte användas för att dokumentera ett symtom eller tecken som uttryckligen rapporteras som inte förekommande. Använd CLUSTER.exclusion_symptom_sign med försiktighet för specifika ändamål där merarbetet för registreringarna på detta sätt motiverar extra komplexitet och endast om \"Noll significant\" fältet i denna arketyp inte är tillräckligt specifik för registreringens syfte. + +Ska inte användas för att registrera objektiva fynd som en del av en fysisk undersökning . Använd OBSERVATION.exam och relaterad undersökning CLUSTER-arketyper för detta ändamål. + +Ska inte användas för diagnoser och problem som ingår i en kvarstående problemlista. Använd då istället EVALUATION.problem_diagnosis."> + > + ["nb"] = < + language = <[ISO_639-1::nb]> + purpose = <"For å registrere detaljer om en enkeltepisode av et rapportert symptom eller sykdomstegn. Dette kan omfatte kontekst, men ikke detaljer, om tidligere episoder av symptomet/sykdomstegnet."> + keywords = <"lidelse","plage","problem","ubehag","symptom","sykdomstegn","lyte","skavank"> + copyright = <"© openEHR Foundation"> + use = <"For å registrere detaljer om en enkeltepisode av et rapportert symptom eller sykdomstegn hos et individ, som redegjort av personen selv, foreldre, omsorgsperson eller andre parter. Registrering kan skje i forbindelse med opptak av anamnese, eller som en selvregistrering som en del av et klinisk spørreskjema eller personlig journal. +En fullstendig klinisk anamnese eller pasientanamnese kan inneholde beskrivelser med ulikt detaljnivå om flere episoder knyttet til samme symptom eller sykdomstegn, og vil også kunne inneholde flere ulike symptomer eller sykdomstegn. + +I egentlig forstand er symptomer subjektive opplevelser av en fysisk eller mental forstyrrelse mens sykdomstegn er objektive observasjoner av det samme, som er erfart av et individ og rapportert til en kliniker av individet eller av andre. Fra denne logikken følger at det burde være to arketyper til å registrere klinisk anamnese; en for rapporterte symptomer og en for rapporterte sykdomstegn. I virkeligheten er dette upraktisk og vil kreve registrering av kliniske data i enten den ene eller den andre av disse modellene. I praksis vil dette øke kompleksitet og tidsbruk knyttet til modellering og registrering av data. I tillegg overlapper ofte de kliniske konseptene, for eksempel: Vil tidligere oppkast eller blødning kategoriseres som et symptom eller som et rapportert sykdomstegn? +Som svar på dette er arketypen laget for å tillate registrering av hele kontinuumet mellom tydelig definerte symptomer og rapporterte sykdomstegn når en registrerer en klinisk anamnese. + +Arketypen er designet for å gi et generisk rammeverk for alle symptomer og rapporterte sykdomstegn. SLOTet \"Spesifikke detaljer\" kan brukes for å utvide arketypen med ytterligere spesifikke dataelementer for komplekse symptomer eller sykdomstegn. + +Arketypen skal settes inn i \"Detaljer\"-SLOTet i OBSERVATION.story-arketypen men kan også brukes i en hvilken som helst OBSERVATION eller CLUSTER-arketype. Arketypen kan også gjenbrukes i andre instanser av CLUSTER.symptom_sign-arketypen i SLOTene \"Assosierte symptomer\" eller \"Tidligere detaljer\". + +Klinikere registrerer ofte frasen \"Ikke av betydning\" i forbindelse med spesifikke symptomer eller rapporterte tegn for å indikere at det er eksplisitt spurt om det spesifikke symptomet, og at det ble svart at symptomet ikke er tilstede i en slik grad at det påfører pasienten ubehag eller uro. Frasen brukes mer som en normalbeskrivelse enn en eksplisitt eksklusjon. Dataelementet \"Ikke av betydning\" er med hensikt lagt til for å tillate at klinikere enkelt og effektivt kan registrere denne informasjonen i det kliniske systemet. Eksempelvis kan \"Ikke av betydning\" brukes i brukergrensesnittet, er dette registrert som \"Sann\" kan de resterende dataelementene skjules i brukergrensesnittet. Denne pragmatiske tilnærmingen støtter hoveddelen av enkel klinisk journalføring av symptomer og sykdomstegn. + +Imidlertid kan det være fordelaktig å bruke arketypen CLUSTER.exclusion_symptom_sign dersom det er klinisk behov for å eksplisitt registrere at et symptom eller sykdomstegn ikke er tilstede, for eksempel dersom dette skal brukes til klinisk beslutningsstøtte. Bruk av CLUSTER.exclusion_symptom_sign vil øke kompleksiteten i templatmodellering, implementasjon og spørring. Det anbefales at CLUSTER.exclusion_symptom_sign kun vurderes brukt dersom man kan identifisere en klar gevinst, men bør ikke brukes for rutineregistreringer av symptomer eller sykdomstegn."> + misuse = <"Brukes ikke til eksplisitt registrering av at et symptom eller sykdomstegn ikke er tilstede. Bruk CLUSTER.exclusion_symptom_sign varsomt da det øker tidsbruk ved registrering og tilfører økt kompleksitet, og bare når dataelementet \"Ikke av betydning\" i denne arketypen ikke er eksplisitt nok for registreringen. + +Brukes ikke til registrering av objektive funn som en del av en fysisk undersøkelse. Bruk OBSERVATION.exam og relaterte CLUSTER.exam-arketyper for dette formålet. + +Brukes ikke til registrering av problemer og diagnoser som en del av en persistent problemliste, til dette brukes EVALUATION.problem_diagnosis. + +Brukes ikke til å dokumentere tiltak og resultat i løpet av hele perioden individet er under behandling, da arketypen er beregnet til å dokumentere symptomer og sykdomstegn som et øyeblikksbilde."> + > + ["pt-br"] = < + language = <[ISO_639-1::pt-br]> + purpose = <"Registrar detalhes sobre um episódio único de um sinal ou sintoma relatado incluindo contexto, mas não detalhes, de episódios prévios se apropriado."> + keywords = <"queixa","sintoma","distúrbio","problema","desconforto","queixa atual","sintoma atual","sinal"> + use = <"Usar para relatar detalhes sobre um episódio único de um sintoma ou sinal reportado em um indivíduo, como reportado pelo indivíduo, parente, cuidador ou outra arte. Deve ser registrado por um clínico como parte de um relato de história clínica como reportado por eles, observado pelo clínico ou registrado pelo próprio como parte de um questionário ou relato pessoal de saúde. Uma história clínica completa ou história pessoal deve conter - com variáveis níves de detalhes - múltiplos episódios de um sinal ou sintoma identificado ou reportado assim como múltiplos sinais/sintomas. + +No sentido mais puro, sintomas são observações subjetivas de um distúrbio físico ou mental e sinais são observações objetivas dos mesmos, como experimentado por um indivíduo e reportado para o tomador da história pelo mesmo indivíduo ou outra parte. Por esta lógica segue que serão necessários dois arquétipos para registrar a história clínica - um para sintomas e outro para sinais relatados. Na realidade isto é pouco prático pois vai requerer entrada de dados clínicos em cada um destes modelos o que acrescenta problemas significantes aos modeladores e aqueles que coletam o dado. Em adição, frequentemente há uma interposição entre os conceitos clínicos - por exemplo: vômitos ou sangramentos prévios devem ser considerados sintomas ou sinais reportados? Em resposta, este arquétipo foi especificamente desenhado para prover um modelo de informação único que permita o registro de todo o continuum entre sintomas claramente identificáveis e sinais reportados quando do reistro de uma história clínica. + +Este arquétipo pretende ser utilizado como um padrão genérico para todos os sintomas e sinais reportados. O SLOT 'Detalhes específicos' pode ser utilizado para estender o arquétipo e incluir elementos de dados específicos ou adicionais para sinais e sintomas mais complexos. + +Este arquétipo foi desenhado especificamennte para ser utilizado no SLOT 'Detalhe estruturado' com o arquétipo OBSERVATION.story, mas pode também ser utilizado com outros arquétipos OBSERVATION ou CLUSTER e nos SLOTS 'Sinal/sintoma associado' ou 'Episódio prévio' em outras instâncias deste arquétipo CLUSTER.symptom_sign. + +Clínicos frequentemente registram a frase 'não significante' em sintomas específicos ou sinais relatados como um método eficiente de indicar que eles perguntaram ao indivíduo e foi relatado como não causador de desconforto ou distúrbio - efetivamente é utilizado mais como 'referido como normal' do que uma exclusão explícita. O elemento de dado 'não significante' tem sido incluído deliberadamente neste arquétipo para permitir aos clínicos registrarem esta mesma informação de uma maneira simples e efetiva num sistema clínico. Pode ser utilizado para dirigir uma interface de usuário, por exemplo se 'não significante' é registrado como verdadeiro então os demais elementos de dados podem ser ocultos na tela de entrada de dados. Esta abordagem pragmática dá suporte à maioria dos requerimentos de registros clínicos com relação a sinais e sintomas relatados. + +Entretanto se houver um imperativo clínico para explicitar o registro de que um Sintoma ou Sinal foi reportado como ausente, por exemplo se for utilizado para orientar suporte à decisão clínica, então pode ser preferível usar o arquétipo CLUSTER.exclusion_symptom_sign. O uso de CLUSTER.exclusion_symptom_sign vai aumentar a complexidade da modelagem de template, implementação e pesquisa. É recomendado que o arquétipo CLUSTER.exclusion_symptom_sign apenas seja considerado se um benefício claro for identificado em situações específicas e não deve ser utilizado rotineiramente para o registro de sinais/sintomas."> + misuse = <"Não deve ser utilizado para registrar que um sintoma ou sinal foi explicitamente relatado como ausente - utilizar CLUSTER.exclusion_symptom_sign cuidadosamente para fins específicos em que os problemas de registro garantam complexidade adicional e apenas se o 'não significante' neste arquétipo não for específico suficiente para fins de registro. + +Não deve ser utilizado para registrar achados objetivos como parte de um exame físico - utilizar OBSERVATION.exam e arquétipos do tipo CLUSTER relacionados a exame para esta finalidade. + +Não dever ser utilizado para diagnósticos e problemas que fazem parte de uma lista de problemas - utilizar EVALUATION.problem_diagnosis."> + > + ["ar-sy"] = < + language = <[ISO_639-1::ar-sy]> + purpose = <"*To record detail about a symptom - either self-recorded by an individual or recorded on the behalf of a patient by a clinician. A complete patient history may include varying level of details about a variety of symptoms.(en)"> + copyright = <"© openEHR Foundation"> + use = <"*Use to record detailed information about a symptom as told to a clinician by a patient or self-recorded by the individual/patient. + +This archetype allows a 'nil significant' statement to be explicitly recorded.(en)"> + misuse = <"*Not to be used to record details about pain. Use the specialisation of this archetype - the CLUSTER.symptom-pain instead. + +Not to be used for diagnoses and problems that form part of a persisting Problem List - use EVALUATION.problem_diagnosis.(en)"> + > + ["en"] = < + language = <[ISO_639-1::en]> + purpose = <"To record details about a single episode of a reported symptom or sign including context, but not details, of previous episodes if appropriate."> + keywords = <"complaint","symptom","disturbance","problem","discomfort","presenting complaint","presenting symptom","sign"> + copyright = <"© openEHR Foundation"> + use = <"Use to record details about a single episode of a symptom or reported sign in an individual, as reported by the individual, parent, care-giver or other party. It may be recorded by a clinician as part of a clinical history record as reported to them, observed by the clinician or self-recorded as part of a clinical questionnaire or personal health record. A complete clinical history or patient story may include varying level of details about multiple episodes of an identified symptom or reported sign, as well as multiple symptoms/signs. + +In the purest sense, symptoms are subjective observations of a physical or mental disturbance and signs are objective observations of the same, as experienced by an individual and reported to the history taker by the same individual or another party. From this logic it follows that we will need two archetypes to record clinical history - one for reported symptoms and another for reported signs. In reality this is impractical as it will require clinical data entry into either one of these models which adds signficant overheads to modellers and those entering data. In addition, there is often overlap in clinical concepts - for example, is previous vomiting or bleeding to be categorised as a symptom or reported sign? In response, this archetype has been specifically designed to proved a single information model that allows for recording of the entire continuum between clearly identifable symptoms and reported signs when recording a clinical history. + +This archetype has been intended to be used as a generic pattern for all symptoms and reported signs. The 'Specific details' SLOT can be used to extend the archetype to include additional, specific data elements for more complex symptoms or signs. + +This archetype has been specifically designed to be used in the 'Structured detail' SLOT within the OBSERVATION.story archetype, but can also be used within other OBSERVATION or CLUSTER archetypes and in the 'Associated symptom/sign' or 'Previous episode' SLOT within other instances of this CLUSTER.symptom_sign archetype. + +Clinicians frequently record the phrase 'nil significant' against specific symptoms or reported signs as an efficient method to indicate that they asked the individual and it was not reported as causing any discomfort or disturbance - effectively used more like a 'normal statement' rather than an explicit exclusion. The 'Nil significant' data element has been deliberately included in this archetype to allow clinicians to record this same information in a simple and effective way in a clinical system. It can be used to drive a user interface, for example if 'Nil significant' is recorded as true then the remaining data elements can be hidden on a data entry screen. This pragmatic approach supports the majority of simple clinical recording requirements around reported symptoms and signs. + +However if there is a clinical imperative to explicitly record that a Symptom or Sign was reported as not present, for example if it will be used to drive clinical decision support, then it would be preferable to use the CLUSTER.exclusion_symptom_sign archetype. The use of CLUSTER.exclusion_symptom_sign will increase the complexity of template modelling, implementation and querying. It is recommended that the CLUSTER.exclusion_symptom_sign archetype only be considered for use if clear benefit can be identified in specific situations, but should not be used for routine symptom/sign recording."> + misuse = <"Not to be used to record that a symptom or sign was explicitly reported as not present - use CLUSTER.exclusion_symptom_sign carefully for specific purposes where the overheads of recording in this way warrant the additional complexity, and only if the 'Nil significant' in this archetype is not specific enough for recording purposes. + +Not to be used for recording objective findings as part of a physical examination - use OBSERVATION.exam and related examination CLUSTER archetypes for this purpose. + +Not to be used for diagnoses and problems that form part of a persisting Problem List - use EVALUATION.problem_diagnosis."> + > + > + other_details = < + ["licence"] = <"This work is licensed under the Creative Commons Attribution-ShareAlike 3.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/3.0/."> + ["custodian_organisation"] = <"openEHR Foundation"> + ["references"] = <"Common Terminology Criteria for Adverse Events (CTCAE) [Internet]. National Cancer Institute, USA. Available from: http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm (accessed 2015-07-13)."> + ["current_contact"] = <"Heather Leslie, Ocean Informatics, heather.leslie@oceaninformatics.com"> + ["original_namespace"] = <"org.openehr"> + ["original_publisher"] = <"openEHR Foundation"> + ["custodian_namespace"] = <"org.openehr"> + ["MD5-CAM-1.0.1"] = <"722FB3886409D9A08A7FD119D76254B0"> + ["build_uid"] = <"dd98851b-f9ff-4e6c-883c-c1384f36ed59"> + ["revision"] = <"1.0.1"> + > + +definition + CLUSTER[at0000] matches { -- Symptom/Sign + items cardinality matches {1..*; unordered} matches { + ELEMENT[at0001] matches { -- Symptom/Sign name + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0035] occurrences matches {0..1} matches { -- Nil significant + value matches { + DV_BOOLEAN matches { + value matches {true} + } + } + } + ELEMENT[at0002] occurrences matches {0..1} matches { -- Description + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0151] occurrences matches {0..*} matches { -- Body site + value matches { + DV_TEXT matches {*} + } + } + allow_archetype CLUSTER[at0147] occurrences matches {0..*} matches { -- Structured body site + include + archetype_id/value matches {/openEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_clock(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.v1/} + exclude + archetype_id/value matches {/.*/} + } + ELEMENT[at0175] occurrences matches {0..1} matches { -- Episodicity + value matches { + DV_CODED_TEXT matches { + defining_code matches { + [local:: + at0176, -- New + at0178, -- Ongoing + at0177] -- Indeterminate + } + } + } + } + ELEMENT[at0186] occurrences matches {0..1} matches { -- First ever? + value matches { + DV_BOOLEAN matches { + value matches {true} + } + } + } + ELEMENT[at0152] occurrences matches {0..1} matches { -- Episode onset + value matches { + DV_DATE_TIME matches {*} + } + } + ELEMENT[at0164] occurrences matches {0..1} matches { -- Onset type + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0028] occurrences matches {0..1} matches { -- Duration + value matches { + DV_DURATION matches {*} + } + } + ELEMENT[at0021] occurrences matches {0..1} matches { -- Severity category + value matches { + DV_CODED_TEXT matches { + defining_code matches { + [local:: + at0023, -- Mild + at0024, -- Moderate + at0025] -- Severe + } + } + DV_TEXT matches {*} + } + } + ELEMENT[at0026] occurrences matches {0..*} matches { -- Severity rating + value matches { + C_DV_QUANTITY < + property = <[openehr::380]> + list = < + ["1"] = < + units = <"1"> + magnitude = <|0.0..10.0|> + precision = <|1|> + > + > + > + } + } + ELEMENT[at0180] occurrences matches {0..*} matches { -- Progression + value matches { + DV_CODED_TEXT matches { + defining_code matches { + [local:: + at0183, -- Worsening + at0182, -- Unchanged + at0181, -- Improving + at0184] -- Resolved + } + } + } + } + ELEMENT[at0003] occurrences matches {0..1} matches { -- Pattern + value matches { + DV_TEXT matches {*} + } + } + CLUSTER[at0018] occurrences matches {0..*} matches { -- Modifying factor + items cardinality matches {1..*; unordered} matches { + ELEMENT[at0019] occurrences matches {0..1} matches { -- Factor + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0017] occurrences matches {0..1} matches { -- Effect + value matches { + DV_CODED_TEXT matches { + defining_code matches { + [local:: + at0159, -- Relieves + at0156, -- No effect + at0158] -- Worsens + } + } + } + } + ELEMENT[at0056] occurrences matches {0..1} matches { -- Description + value matches { + DV_TEXT matches {*} + } + } + } + } + CLUSTER[at0165] occurrences matches {0..*} matches { -- Precipitating/resolving factor + name matches { + DV_CODED_TEXT matches { + defining_code matches { + [local:: + at0167, -- Precipitating factor + at0168] -- Resolving factor + } + } + } + items cardinality matches {1..*; unordered} matches { + ELEMENT[at0170] occurrences matches {0..1} matches { -- Factor + value matches { + DV_TEXT matches {*} + } + } + allow_archetype CLUSTER[at0154] occurrences matches {0..*} matches { -- Factor detail + include + archetype_id/value matches {/openEHR-EHR-CLUSTER\.health_event(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.symptom_sign(-[a-zA-Z0-9_]+)*\.v1/} + } + ELEMENT[at0171] occurrences matches {0..1} matches { -- Time interval + value matches { + DV_DURATION matches {*} + } + } + ELEMENT[at0185] occurrences matches {0..1} matches { -- Description + value matches { + DV_TEXT matches {*} + } + } + } + } + ELEMENT[at0155] occurrences matches {0..*} matches { -- Impact + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0037] occurrences matches {0..1} matches { -- Episode description + value matches { + DV_TEXT matches {*} + } + } + allow_archetype CLUSTER[at0153] occurrences matches {0..*} matches { -- Specific details + include + archetype_id/value matches {/.*/} + } + ELEMENT[at0161] occurrences matches {0..1} matches { -- Resolution date/time + value matches { + DV_DATE_TIME matches {*} + } + } + ELEMENT[at0057] occurrences matches {0..1} matches { -- Description of previous episodes + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0031] occurrences matches {0..1} matches { -- Number of previous episodes + value matches { + DV_COUNT matches { + magnitude matches {|>=0|} + } + } + } + allow_archetype CLUSTER[at0146] occurrences matches {0..*} matches { -- Previous episodes + include + archetype_id/value matches {/openEHR-EHR-CLUSTER\.symptom_sign(-[a-zA-Z0-9_]+)*\.v1/} + } + allow_archetype CLUSTER[at0063] occurrences matches {0..*} matches { -- Associated symptom/sign + include + archetype_id/value matches {/openEHR-EHR-CLUSTER\.symptom_sign(-[a-zA-Z0-9_]+)*\.v1/} + } + ELEMENT[at0163] occurrences matches {0..1} matches { -- Comment + value matches { + DV_TEXT matches {*} + } + } + } + } + +ontology + terminologies_available = <"SNOMED-CT", ...> + term_definitions = < + ["ar-sy"] = < + items = < + ["at0000"] = < + text = <"*Symptom/Sign(en)"> + description = <"*Reported observation of a physical or mental disturbance in an individual.(en)"> + > + ["at0001"] = < + text = <"*Symptom/Sign name(en)"> + description = <"*The name of the reported symptom or sign.(en)"> + comment = <"*Symptom name should be coded with a terminology, where possible.(en)"> + > + ["at0002"] = < + text = <"*Description(en)"> + description = <"*Narrative description about the reported symptom or sign.(en)"> + > + ["at0003"] = < + text = <"*Pattern(en)"> + description = <"*Narrative description about the pattern of the symptom or sign during this episode.(en)"> + comment = <"*For example: pain could be described as constant or colicky.(en)"> + > + ["at0017"] = < + text = <"*Effect(en)"> + description = <"*Perceived effect of the modifying factor on the symptom or sign.(en)"> + > + ["at0018"] = < + text = <"*Modifying factor(en)"> + description = <"*Detail about how a specific factor effects the identified symptom or sign during this episode.(en)"> + > + ["at0019"] = < + text = <"*Factor(en)"> + description = <"*Name of the modifying factor.(en)"> + comment = <"*Examples of modifying factor: lying on multiple pillows, eating or administration of a specific medication.(en)"> + > + ["at0021"] = < + text = <"*Severity category(en)"> + description = <"*Category representing the overall severity of the symptom or sign.(en)"> + comment = <"*Defining values such as mild, moderate or severe in such a way that is applicable to multiple symptoms or signs plus allows multiple users to interpret and record them consistently is not easy. Some organisations extend the value set further with inclusion of additional values such as 'Trivial' and 'Very severe', and/or 'Mild-Moderate' and 'Moderate-Severe', adds to the definitional difficulty and may also worsen inter-recorder reliability issues. Use of 'Life-threatening' and 'Fatal' is also often considered as part of this value set, although from a pure point of view it may actually reflect an outcome rather than a severity. In view of the above, keeping to a well-defined but smaller list is preferred and so the mild/moderate/severe value set is offered, however the choice of other text allows for other value sets to be included at this data element in a template. Note: more specific grading of severity can be recorded using the 'Specific details' SLOT.(en)"> + > + ["at0023"] = < + text = <"*Mild(en)"> + description = <"*The intensity of the symptom or sign does not cause interference with normal activity.(en)"> + > + ["at0024"] = < + text = <"*Moderate(en)"> + description = <"*The intensity of the symptom or sign causes interference with normal activity.(en)"> + > + ["at0025"] = < + text = <"*Severe(en)"> + description = <"*The intensity of the symptom or sign causes prevents normal activity.(en)"> + > + ["at0026"] = < + text = <"*Severity rating(en)"> + description = <"*Numerical rating scale representing the overall severity of the symptom or sign.(en)"> + comment = <"*Symptom severity can be rated by the individual by recording a score from 0 (ie symptom not present) to 10.0 (ie symptom is as severe as the individual can imagine). This score can be represented in the user interface as a visual analogue scale. The data element has occurrences set to 0..* to allow for variations such as 'maximal severity' or 'average severity' to be included in a template.(en)"> + > + ["at0028"] = < + text = <"*Duration(en)"> + description = <"*The duration of the symptom or sign since onset.(en)"> + comment = <"*If 'Date/time of onset' and 'Date/time of resolution' are used in systems, this data element may be calculated, or alternatively, be considered redundant in this scenario.(en)"> + > + ["at0031"] = < + text = <"*Number of previous episodes(en)"> + description = <"*The number of times this symptom or sign has previously occurred.(en)"> + > + ["at0035"] = < + text = <"*Nil significant(en)"> + description = <"*The identified symptom or sign was reported as not being present to any significant degree.(en)"> + comment = <"*Record as True if the subject of care has reported the symptom as not significant. For example, the patient may experience a basal level of pain, which is regarded as normal for them. In this situation 'nil significant' enables recording of no additional pain that could be considered as significant or relevant to the history-taking.(en)"> + > + ["at0037"] = < + text = <"*Episode description(en)"> + description = <"*Narrative description about the course of the symptom or sign during this episode.(en)"> + comment = <"*For example: a text description of the immediate onset of the symptom, activities that worsened or relieved the symptom, whether it is improving or worsening and how it resolved over weeks.(en)"> + > + ["at0056"] = < + text = <"*Description(en)"> + description = <"*Narrative description of the effect of the modifying factor on the symptom or sign.(en)"> + > + ["at0057"] = < + text = <"*Description of previous episodes(en)"> + description = <"*Narrative description of any or all previous episodes.(en)"> + comment = <"*For example: frequency/periodicity - per hour, day, week, month, year; and regularity. May include a comparison to this episode.(en)"> + > + ["at0063"] = < + text = <"*Associated symptom/sign(en)"> + description = <"*Structured details about any associated symptoms or signs that are concurrent.(en)"> + comment = <"*In linked clinical systems, it is possible that associated symptoms or signs are already recorded within the EHR. Systems can allow the clinician to LINK to relevant associated symptoms/signs. However in a system or message without LINKs to existing data or with a new patient, additional instances of the symptom archetype could be included here to represent associated symptoms/signs.(en)"> + > + ["at0146"] = < + text = <"*Previous episodes(en)"> + description = <"*Structured details of the symptom or sign during a previous episode.(en)"> + comment = <"*In linked clinical systems, it is possible that previous episodes are already recorded within the EHR. Systems can allow the clinician to LINK to relevant previous episodes. However in a system or message without LINKs to existing data or with a new patient, additional instances of the symptom archetype could be included here to represent previous episodes. It is recommended that new instances of the Symptom archetype inserted in this SLOT represent one or many previous episodes to this Symptom instance only.(en)"> + > + ["at0147"] = < + text = <"*Structured body site(en)"> + description = <"*Structured body site where the symptom or sign was reported.(en)"> + comment = <"*If the anatomical location is included in the Symptom name via precoordinated codes, use of this SLOT becomes redundant. If the anatomical location is recorded using the 'Body site' data element, then use of CLUSTER archetypes in this SLOT is not allowed - record only the simple 'Body site' OR 'Structured body site', but not both.(en)"> + > + ["at0151"] = < + text = <"*Body site(en)"> + description = <"*Simple body site where the symptom or sign was reported.(en)"> + comment = <"*Occurrences of this data element are set to 0..* to allow multiple body sites to be separated out in a template if desired. This allows for representation of clinical scenarios where a symptom or sign needs to be recorded in multiple locations or identifying both the originating and distal site in pain radiation, but where all of the other attributes such as impact and duration are identical. If the requirements for recording the body site 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 Detailed anatomical location' SLOT in this archetype. +If the anatomical location is included in the Symptom name via precoordinated codes, this data element becomes redundant. If the anatomical location is recorded using the 'Structured body site' SLOT, then use of this data element is not allowed - record only the simple 'Body site' OR 'Structured body site', but not both.(en)"> + > + ["at0152"] = < + text = <"*Onset date/time(en)"> + description = <"*The onset for this episode of the symptom or sign.(en)"> + comment = <"*While partial dates are permitted, the exact date and time of onset can be recorded, if appropriate. If this is a recurring symptom, this date is used to represent the most recent date or onset of exacerbation, relevant to the clinical presentation. If this is the first instance of this symptom, this date is used to represent the first ever start of symptoms.(en)"> + > + ["at0153"] = < + text = <"*Specific details(en)"> + description = <"*Specific data elements that are additionally required to record as unique attributes of the identified symptom or sign.(en)"> + comment = <"*For example: CTCAE grading.(en)"> + > + ["at0154"] = < + text = <"*Factor detail(en)"> + description = <"*Structured detail about the factor associated with the identified symptom or sign.(en)"> + > + ["at0155"] = < + text = <"*Impact(en)"> + description = <"*Description of the impact of this symptom or sign.(en)"> + comment = <"*Assessment of impact could consider the severity, duration and frequency of the symptom as well as the type of impact including, but not limited to, functional, social and emotional impact. Occurrences of this data element are set to 0..* to allow multiple types of impact to be separated out in a template if desired. Examples for functional impact from hearing loss may include: 'Difficulty Hearing in Quiet Environment'; 'Difficulty Hearing the TV or Radio'; 'Difficulty Hearing Group Conversation'; and 'Difficulty Hearing on Phone'.(en)"> + > + ["at0156"] = < + text = <"*No effect(en)"> + description = <"*Presence of the factor has no impact on the symptom or sign.(en)"> + > + ["at0158"] = < + text = <"*Worsens(en)"> + description = <"*Presence of the factor exaccerbates severity or impact of the symptom or sign.(en)"> + > + ["at0159"] = < + text = <"*Relieves(en)"> + description = <"*Presence of the factor reduces the severity or impact of the symptom or sign.(en)"> + > + ["at0161"] = < + text = <"*Resolution date/time(en)"> + description = <"*The timing of the cessation of this episode of the symptom or sign.(en)"> + comment = <"*If 'Date/time of onset' and 'Duration' are used in systems, this data element may be calculated, or alternatively, considered redundant. While partial dates are permitted, the exact date and time of resolution can be recorded, if appropriate.(en)"> + > + ["at0163"] = < + text = <"*Comment(en)"> + description = <"*Additional narrative about the symptom or sign not captured in other fields.(en)"> + > + ["at0164"] = < + text = <"*Onset type(en)"> + description = <"*Description of the onset of the symptom or sign.(en)"> + comment = <"*The type of the onset can be coded with a terminology, if desired. For example: gradual; or sudden.(en)"> + > + ["at0165"] = < + text = <"*Precipitating/resolving factor(en)"> + description = <"*Details about a health event, symptom, sign or other factor associated with the onset or cessation of the symptom or sign.(en)"> + comment = <"*For example: onset of headache occurred one week prior to menstruation; or onset of headache occurred one hour after fall of bicycle.(en)"> + > + ["at0167"] = < + text = <"*Precipitating factor(en)"> + description = <"*Identification of factors/events associated with onset or commencement of the symptom or sign.(en)"> + > + ["at0168"] = < + text = <"*Resolving factor(en)"> + description = <"*Identification of factors/events associated with cessation of the symptom or sign.(en)"> + > + ["at0170"] = < + text = <"*Factor(en)"> + description = <"*Name of the health event, symptom, reported sign or other factor.(en)"> + comment = <"*For example: onset of another symptom; onset of menstruation; or fall off bicycle.(en)"> + > + ["at0171"] = < + text = <"*Time interval(en)"> + description = <"*The interval of time between the occurrence or onset of the factor and onset/resolution of the symptom or sign.(en)"> + > + ["at0175"] = < + text = <"*Episodicity(en)"> + description = <"*Category of this epsiode for the identified symptom or sign.(en)"> + > + ["at0176"] = < + text = <"*New(en)"> + description = <"*This is the first ever episode of the symptom or sign.(en)"> + > + ["at0177"] = < + text = <"*Reoccurrence(en)"> + description = <"*This is a second or subsequent discrete episode of the symptom or sign, where each previous episode has completely resolved.(en)"> + > + ["at0178"] = < + text = <"*Ongoing(en)"> + description = <"*This symptom or sign is continuously present, effectively a single, ongoing episode.(en)"> + > + ["at0180"] = < + text = <"*Progression(en)"> + description = <"*Description progression of the symptom or sign at the time of reporting.(en)"> + comment = <"*Occurrences of this data element are set to 0..* to allow multiple types of progression to be separated out in a template if desired - for example, severity or frequency.(en)"> + > + ["at0181"] = < + text = <"*Improving(en)"> + description = <"*The severity of the symptom or sign has improved overall during this episode.(en)"> + > + ["at0182"] = < + text = <"*Unchanged(en)"> + description = <"*The severity of the symptom or sign has not changed overall during this episode.(en)"> + > + ["at0183"] = < + text = <"*Worsening(en)"> + description = <"*The severity of the symptom or sign has worsened overall during this episode.(en)"> + > + ["at0184"] = < + text = <"*Resolved(en)"> + description = <"*The severity of the symptom or sign has resolved.(en)"> + > + ["at0185"] = < + text = <"*Description(en)"> + description = <"*Narrative description about the effect of the factor on the identified symptom or sign.(en)"> + > + ["at0186"] = < + text = <"*New element(en)"> + description = <"**(en)"> + > + > + > + ["en"] = < + items = < + ["at0000"] = < + text = <"Symptom/Sign"> + description = <"Reported observation of a physical or mental disturbance in an individual."> + > + ["at0001"] = < + text = <"Symptom/Sign name"> + description = <"The name of the reported symptom or sign."> + comment = <"Symptom name should be coded with a terminology, where possible."> + > + ["at0002"] = < + text = <"Description"> + description = <"Narrative description about the reported symptom or sign."> + > + ["at0003"] = < + text = <"Pattern"> + description = <"Narrative description about the pattern of the symptom or sign during this episode."> + comment = <"For example: pain could be described as constant or intermittent."> + > + ["at0017"] = < + text = <"Effect"> + description = <"Perceived effect of the modifying factor on the symptom or sign."> + > + ["at0018"] = < + text = <"Modifying factor"> + description = <"Detail about how a specific factor effects the identified symptom or sign during this episode."> + > + ["at0019"] = < + text = <"Factor"> + description = <"Name of the modifying factor."> + comment = <"Examples of modifying factor: lying on multiple pillows, eating or administration of a specific medication."> + > + ["at0021"] = < + text = <"Severity category"> + description = <"Category representing the overall severity of the symptom or sign."> + comment = <"Defining values such as mild, moderate or severe in such a way that is applicable to multiple symptoms or signs plus allows multiple users to interpret and record them consistently is not easy. Some organisations extend the value set further with inclusion of additional values such as 'Trivial' and 'Very severe', and/or 'Mild-Moderate' and 'Moderate-Severe', adds to the definitional difficulty and may also worsen inter-recorder reliability issues. Use of 'Life-threatening' and 'Fatal' is also often considered as part of this value set, although from a pure point of view it may actually reflect an outcome rather than a severity. In view of the above, keeping to a well-defined but smaller list is preferred and so the mild/moderate/severe value set is offered, however the choice of other text allows for other value sets to be included at this data element in a template. Note: more specific grading of severity can be recorded using the 'Specific details' SLOT."> + > + ["at0023"] = < + text = <"Mild"> + description = <"The intensity of the symptom or sign does not cause interference with normal activity."> + > + ["at0024"] = < + text = <"Moderate"> + description = <"The intensity of the symptom or sign causes interference with normal activity."> + > + ["at0025"] = < + text = <"Severe"> + description = <"The intensity of the symptom or sign causes prevents normal activity."> + > + ["at0026"] = < + text = <"Severity rating"> + description = <"Numerical rating scale representing the overall severity of the symptom or sign."> + comment = <"Symptom severity can be rated by the individual by recording a score from 0 (ie symptom not present) to 10.0 (ie symptom is as severe as the individual can imagine). This score can be represented in the user interface as a visual analogue scale. The data element has occurrences set to 0..* to allow for variations such as 'maximal severity' or 'average severity' to be included in a template."> + > + ["at0028"] = < + text = <"Duration"> + description = <"The duration of this episode of the symptom or sign since onset."> + comment = <"If 'Date/time of onset' and 'Date/time of resolution' are used in systems, this data element may be calculated, or alternatively, be considered redundant in this scenario."> + > + ["at0031"] = < + text = <"Number of previous episodes"> + description = <"The number of times this symptom or sign has previously occurred."> + > + ["at0035"] = < + text = <"Nil significant"> + description = <"The identified symptom or sign was reported as not being present to any significant degree."> + comment = <"Record as True if the subject of care has reported the symptom as not significant. For example: if the individual has never experienced the symptom it is appropriate to record 'nil significant'; or if the individual commonly experiences the symptom, in some circumstances it may be considered appropriate to record 'nil significant' if the individual has experienced no deviation from their 'normal' baseline."> + > + ["at0037"] = < + text = <"Episode description"> + description = <"Narrative description about the course of the symptom or sign during this episode."> + comment = <"For example: a text description of the immediate onset of the symptom, activities that worsened or relieved the symptom, whether it is improving or worsening and how it resolved over weeks."> + > + ["at0056"] = < + text = <"Description"> + description = <"Narrative description of the effect of the modifying factor on the symptom or sign."> + > + ["at0057"] = < + text = <"Description of previous episodes"> + description = <"Narrative description of any or all previous episodes."> + comment = <"For example: frequency/periodicity - per hour, day, week, month, year; and regularity. May include a comparison to this episode."> + > + ["at0063"] = < + text = <"Associated symptom/sign"> + description = <"Structured details about any associated symptoms or signs that are concurrent."> + comment = <"In linked clinical systems, it is possible that associated symptoms or signs are already recorded within the EHR. Systems can allow the clinician to LINK to relevant associated symptoms/signs. However in a system or message without LINKs to existing data or with a new patient, additional instances of the symptom archetype could be included here to represent associated symptoms/signs."> + > + ["at0146"] = < + text = <"Previous episodes"> + description = <"Structured details of the symptom or sign during a previous episode."> + comment = <"In linked clinical systems, it is possible that previous episodes are already recorded within the EHR. Systems can allow the clinician to LINK to relevant previous episodes. However in a system or message without LINKs to existing data or with a new patient, additional instances of the symptom archetype could be included here to represent previous episodes. It is recommended that new instances of the Symptom archetype inserted in this SLOT represent one or many previous episodes to this Symptom instance only."> + > + ["at0147"] = < + text = <"Structured body site"> + description = <"Structured body site where the symptom or sign was reported."> + comment = <"If the anatomical location is included in the Symptom name via precoordinated codes, use of this SLOT becomes redundant. If the anatomical location is recorded using the 'Body site' data element, then use of CLUSTER archetypes in this SLOT is not allowed - record only the simple 'Body site' OR 'Structured body site', but not both."> + > + ["at0151"] = < + text = <"Body site"> + description = <"Simple body site where the symptom or sign was reported."> + comment = <"Occurrences of this data element are set to 0..* to allow multiple body sites to be separated out in a template if desired. This allows for representation of clinical scenarios where a symptom or sign needs to be recorded in multiple locations or identifying both the originating and distal site in pain radiation, but where all of the other attributes such as impact and duration are identical. If the requirements for recording the body site 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 Detailed anatomical location' SLOT in this archetype. +If the anatomical location is included in the Symptom name via precoordinated codes, this data element becomes redundant. If the anatomical location is recorded using the 'Structured body site' SLOT, then use of this data element is not allowed - record only the simple 'Body site' OR 'Structured body site', but not both."> + > + ["at0152"] = < + text = <"Episode onset"> + description = <"The onset for this episode of the symptom or sign."> + comment = <"While partial dates are permitted, the exact date and time of onset can be recorded, if appropriate. If this symptom or sign is experienced for the first time or is a re-occurrence, this date is used to represent the onset of this episode. If this symptom or sign is ongoing, this data element may be redundant if it has been recorded previously."> + > + ["at0153"] = < + text = <"Specific details"> + description = <"Specific data elements that are additionally required to record as unique attributes of the identified symptom or sign."> + comment = <"For example: CTCAE grading."> + > + ["at0154"] = < + text = <"Factor detail"> + description = <"Structured detail about the factor associated with the identified symptom or sign."> + > + ["at0155"] = < + text = <"Impact"> + description = <"Description of the impact of this symptom or sign."> + comment = <"Assessment of impact could consider the severity, duration and frequency of the symptom as well as the type of impact including, but not limited to, functional, social and emotional impact. Occurrences of this data element are set to 0..* to allow multiple types of impact to be separated out in a template if desired. Examples for functional impact from hearing loss may include: 'Difficulty Hearing in Quiet Environment'; 'Difficulty Hearing the TV or Radio'; 'Difficulty Hearing Group Conversation'; and 'Difficulty Hearing on Phone'."> + > + ["at0156"] = < + text = <"No effect"> + description = <"The factor has no impact on the symptom or sign."> + > + ["at0158"] = < + text = <"Worsens"> + description = <"The factor increases the severity or impact of the symptom or sign."> + > + ["at0159"] = < + text = <"Relieves"> + description = <"The factor decreases the severity or impact of the symptom or sign, but does not fully resolve it."> + > + ["at0161"] = < + text = <"Resolution date/time"> + description = <"The timing of the cessation of this episode of the symptom or sign."> + comment = <"If 'Date/time of onset' and 'Duration' are used in systems, this data element may be calculated, or alternatively, considered redundant. While partial dates are permitted, the exact date and time of resolution can be recorded, if appropriate."> + > + ["at0163"] = < + text = <"Comment"> + description = <"Additional narrative about the symptom or sign not captured in other fields."> + > + ["at0164"] = < + text = <"Onset type"> + description = <"Description of the onset of the symptom or sign."> + comment = <"The type of the onset can be coded with a terminology, if desired. For example: gradual; or sudden."> + > + ["at0165"] = < + text = <"Precipitating/resolving factor"> + description = <"Details about specified factors that are associated with the precipitation or resolution of the symptom or sign."> + comment = <"For example: onset of headache occurred one week prior to menstruation; or onset of headache occurred one hour after fall of bicycle."> + > + ["at0167"] = < + text = <"Precipitating factor"> + description = <"Identification of factors or events that trigger the onset or commencement of the symptom or sign."> + > + ["at0168"] = < + text = <"Resolving factor"> + description = <"Identification of factors or events that trigger resolution or cessation of the symptom or sign."> + > + ["at0170"] = < + text = <"Factor"> + description = <"Name of the health event, symptom, reported sign or other factor."> + comment = <"For example: onset of another symptom; onset of menstruation; or fall off bicycle."> + > + ["at0171"] = < + text = <"Time interval"> + description = <"The interval of time between the occurrence or onset of the factor and onset/resolution of the symptom or sign."> + > + ["at0175"] = < + text = <"Episodicity"> + description = <"Category of this episode for the identified symptom or sign."> + > + ["at0176"] = < + text = <"New"> + description = <"A new episode of the symptom or sign - either the first ever occurrence or a reoccurrence where the previous episode had completely resolved."> + > + ["at0177"] = < + text = <"Indeterminate"> + description = <"It is not possible to determine if this occurrence of the symptom or sign is new or ongoing."> + > + ["at0178"] = < + text = <"Ongoing"> + description = <"This symptom or sign is ongoing, effectively a single, continuous episode."> + > + ["at0180"] = < + text = <"Progression"> + description = <"Description progression of the symptom or sign at the time of reporting."> + comment = <"Occurrences of this data element are set to 0..* to allow multiple types of progression to be separated out in a template if desired - for example, severity or frequency."> + > + ["at0181"] = < + text = <"Improving"> + description = <"The severity of the symptom or sign has improved overall during this episode."> + > + ["at0182"] = < + text = <"Unchanged"> + description = <"The severity of the symptom or sign has not changed overall during this episode."> + > + ["at0183"] = < + text = <"Worsening"> + description = <"The severity of the symptom or sign has worsened overall during this episode."> + > + ["at0184"] = < + text = <"Resolved"> + description = <"The severity of the symptom or sign has resolved."> + > + ["at0185"] = < + text = <"Description"> + description = <"Narrative description about the effect of the factor on the identified symptom or sign."> + > + ["at0186"] = < + text = <"First ever?"> + description = <"Is this the first ever occurrence of this symptom or sign?"> + comment = <"Record as True if this is the first ever occurrence of this symptom or sign."> + > + > + > + ["de"] = < + items = < + ["at0000"] = < + text = <"*Symptom/Sign(en)"> + description = <"*Reported observation of a physical or mental disturbance in an individual.(en)"> + > + ["at0001"] = < + text = <"*Symptom/Sign name(en)"> + description = <"*The name of the reported symptom or sign.(en)"> + comment = <"*Symptom name should be coded with a terminology, where possible.(en)"> + > + ["at0002"] = < + text = <"*Description(en)"> + description = <"*Narrative description about the reported symptom or sign.(en)"> + > + ["at0003"] = < + text = <"*Pattern(en)"> + description = <"*Narrative description about the pattern of the symptom or sign during this episode.(en)"> + comment = <"*For example: pain could be described as constant or colicky.(en)"> + > + ["at0017"] = < + text = <"*Effect(en)"> + description = <"*Perceived effect of the modifying factor on the symptom or sign.(en)"> + > + ["at0018"] = < + text = <"*Modifying factor(en)"> + description = <"*Detail about how a specific factor effects the identified symptom or sign during this episode.(en)"> + > + ["at0019"] = < + text = <"*Factor(en)"> + description = <"*Name of the modifying factor.(en)"> + comment = <"*Examples of modifying factor: lying on multiple pillows, eating or administration of a specific medication.(en)"> + > + ["at0021"] = < + text = <"*Severity category(en)"> + description = <"*Category representing the overall severity of the symptom or sign.(en)"> + comment = <"*Defining values such as mild, moderate or severe in such a way that is applicable to multiple symptoms or signs plus allows multiple users to interpret and record them consistently is not easy. Some organisations extend the value set further with inclusion of additional values such as 'Trivial' and 'Very severe', and/or 'Mild-Moderate' and 'Moderate-Severe', adds to the definitional difficulty and may also worsen inter-recorder reliability issues. Use of 'Life-threatening' and 'Fatal' is also often considered as part of this value set, although from a pure point of view it may actually reflect an outcome rather than a severity. In view of the above, keeping to a well-defined but smaller list is preferred and so the mild/moderate/severe value set is offered, however the choice of other text allows for other value sets to be included at this data element in a template. Note: more specific grading of severity can be recorded using the 'Specific details' SLOT.(en)"> + > + ["at0023"] = < + text = <"*Mild(en)"> + description = <"*The intensity of the symptom or sign does not cause interference with normal activity.(en)"> + > + ["at0024"] = < + text = <"*Moderate(en)"> + description = <"*The intensity of the symptom or sign causes interference with normal activity.(en)"> + > + ["at0025"] = < + text = <"*Severe(en)"> + description = <"*The intensity of the symptom or sign causes prevents normal activity.(en)"> + > + ["at0026"] = < + text = <"*Severity rating(en)"> + description = <"*Numerical rating scale representing the overall severity of the symptom or sign.(en)"> + comment = <"*Symptom severity can be rated by the individual by recording a score from 0 (ie symptom not present) to 10.0 (ie symptom is as severe as the individual can imagine). This score can be represented in the user interface as a visual analogue scale. The data element has occurrences set to 0..* to allow for variations such as 'maximal severity' or 'average severity' to be included in a template.(en)"> + > + ["at0028"] = < + text = <"*Duration(en)"> + description = <"*The duration of the symptom or sign since onset.(en)"> + comment = <"*If 'Date/time of onset' and 'Date/time of resolution' are used in systems, this data element may be calculated, or alternatively, be considered redundant in this scenario.(en)"> + > + ["at0031"] = < + text = <"*Number of previous episodes(en)"> + description = <"*The number of times this symptom or sign has previously occurred.(en)"> + > + ["at0035"] = < + text = <"*Nil significant(en)"> + description = <"*The identified symptom or sign was reported as not being present to any significant degree.(en)"> + comment = <"*Record as True if the subject of care has reported the symptom as not significant. For example, the patient may experience a basal level of pain, which is regarded as normal for them. In this situation 'nil significant' enables recording of no additional pain that could be considered as significant or relevant to the history-taking.(en)"> + > + ["at0037"] = < + text = <"*Episode description(en)"> + description = <"*Narrative description about the course of the symptom or sign during this episode.(en)"> + comment = <"*For example: a text description of the immediate onset of the symptom, activities that worsened or relieved the symptom, whether it is improving or worsening and how it resolved over weeks.(en)"> + > + ["at0056"] = < + text = <"*Description(en)"> + description = <"*Narrative description of the effect of the modifying factor on the symptom or sign.(en)"> + > + ["at0057"] = < + text = <"*Description of previous episodes(en)"> + description = <"*Narrative description of any or all previous episodes.(en)"> + comment = <"*For example: frequency/periodicity - per hour, day, week, month, year; and regularity. May include a comparison to this episode.(en)"> + > + ["at0063"] = < + text = <"*Associated symptom/sign(en)"> + description = <"*Structured details about any associated symptoms or signs that are concurrent.(en)"> + comment = <"*In linked clinical systems, it is possible that associated symptoms or signs are already recorded within the EHR. Systems can allow the clinician to LINK to relevant associated symptoms/signs. However in a system or message without LINKs to existing data or with a new patient, additional instances of the symptom archetype could be included here to represent associated symptoms/signs.(en)"> + > + ["at0146"] = < + text = <"*Previous episodes(en)"> + description = <"*Structured details of the symptom or sign during a previous episode.(en)"> + comment = <"*In linked clinical systems, it is possible that previous episodes are already recorded within the EHR. Systems can allow the clinician to LINK to relevant previous episodes. However in a system or message without LINKs to existing data or with a new patient, additional instances of the symptom archetype could be included here to represent previous episodes. It is recommended that new instances of the Symptom archetype inserted in this SLOT represent one or many previous episodes to this Symptom instance only.(en)"> + > + ["at0147"] = < + text = <"*Structured body site(en)"> + description = <"*Structured body site where the symptom or sign was reported.(en)"> + comment = <"*If the anatomical location is included in the Symptom name via precoordinated codes, use of this SLOT becomes redundant. If the anatomical location is recorded using the 'Body site' data element, then use of CLUSTER archetypes in this SLOT is not allowed - record only the simple 'Body site' OR 'Structured body site', but not both.(en)"> + > + ["at0151"] = < + text = <"*Body site(en)"> + description = <"*Simple body site where the symptom or sign was reported.(en)"> + comment = <"*Occurrences of this data element are set to 0..* to allow multiple body sites to be separated out in a template if desired. This allows for representation of clinical scenarios where a symptom or sign needs to be recorded in multiple locations or identifying both the originating and distal site in pain radiation, but where all of the other attributes such as impact and duration are identical. If the requirements for recording the body site 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 Detailed anatomical location' SLOT in this archetype. +If the anatomical location is included in the Symptom name via precoordinated codes, this data element becomes redundant. If the anatomical location is recorded using the 'Structured body site' SLOT, then use of this data element is not allowed - record only the simple 'Body site' OR 'Structured body site', but not both.(en)"> + > + ["at0152"] = < + text = <"*Onset date/time(en)"> + description = <"*The onset for this episode of the symptom or sign.(en)"> + comment = <"*While partial dates are permitted, the exact date and time of onset can be recorded, if appropriate. If this is a recurring symptom, this date is used to represent the most recent date or onset of exacerbation, relevant to the clinical presentation. If this is the first instance of this symptom, this date is used to represent the first ever start of symptoms.(en)"> + > + ["at0153"] = < + text = <"*Specific details(en)"> + description = <"*Specific data elements that are additionally required to record as unique attributes of the identified symptom or sign.(en)"> + comment = <"*For example: CTCAE grading.(en)"> + > + ["at0154"] = < + text = <"*Factor detail(en)"> + description = <"*Structured detail about the factor associated with the identified symptom or sign.(en)"> + > + ["at0155"] = < + text = <"*Impact(en)"> + description = <"*Description of the impact of this symptom or sign.(en)"> + comment = <"*Assessment of impact could consider the severity, duration and frequency of the symptom as well as the type of impact including, but not limited to, functional, social and emotional impact. Occurrences of this data element are set to 0..* to allow multiple types of impact to be separated out in a template if desired. Examples for functional impact from hearing loss may include: 'Difficulty Hearing in Quiet Environment'; 'Difficulty Hearing the TV or Radio'; 'Difficulty Hearing Group Conversation'; and 'Difficulty Hearing on Phone'.(en)"> + > + ["at0156"] = < + text = <"*No effect(en)"> + description = <"*Presence of the factor has no impact on the symptom or sign.(en)"> + > + ["at0158"] = < + text = <"*Worsens(en)"> + description = <"*Presence of the factor exaccerbates severity or impact of the symptom or sign.(en)"> + > + ["at0159"] = < + text = <"*Relieves(en)"> + description = <"*Presence of the factor reduces the severity or impact of the symptom or sign.(en)"> + > + ["at0161"] = < + text = <"*Resolution date/time(en)"> + description = <"*The timing of the cessation of this episode of the symptom or sign.(en)"> + comment = <"*If 'Date/time of onset' and 'Duration' are used in systems, this data element may be calculated, or alternatively, considered redundant. While partial dates are permitted, the exact date and time of resolution can be recorded, if appropriate.(en)"> + > + ["at0163"] = < + text = <"*Comment(en)"> + description = <"*Additional narrative about the symptom or sign not captured in other fields.(en)"> + > + ["at0164"] = < + text = <"*Onset type(en)"> + description = <"*Description of the onset of the symptom or sign.(en)"> + comment = <"*The type of the onset can be coded with a terminology, if desired. For example: gradual; or sudden.(en)"> + > + ["at0165"] = < + text = <"*Precipitating/resolving factor(en)"> + description = <"*Details about a health event, symptom, sign or other factor associated with the onset or cessation of the symptom or sign.(en)"> + comment = <"*For example: onset of headache occurred one week prior to menstruation; or onset of headache occurred one hour after fall of bicycle.(en)"> + > + ["at0167"] = < + text = <"*Precipitating factor(en)"> + description = <"*Identification of factors/events associated with onset or commencement of the symptom or sign.(en)"> + > + ["at0168"] = < + text = <"*Resolving factor(en)"> + description = <"*Identification of factors/events associated with cessation of the symptom or sign.(en)"> + > + ["at0170"] = < + text = <"*Factor(en)"> + description = <"*Name of the health event, symptom, reported sign or other factor.(en)"> + comment = <"*For example: onset of another symptom; onset of menstruation; or fall off bicycle.(en)"> + > + ["at0171"] = < + text = <"*Time interval(en)"> + description = <"*The interval of time between the occurrence or onset of the factor and onset/resolution of the symptom or sign.(en)"> + > + ["at0175"] = < + text = <"*Episodicity(en)"> + description = <"*Category of this epsiode for the identified symptom or sign.(en)"> + > + ["at0176"] = < + text = <"*New(en)"> + description = <"*This is the first ever episode of the symptom or sign.(en)"> + > + ["at0177"] = < + text = <"*Reoccurrence(en)"> + description = <"*This is a second or subsequent discrete episode of the symptom or sign, where each previous episode has completely resolved.(en)"> + > + ["at0178"] = < + text = <"*Ongoing(en)"> + description = <"*This symptom or sign is continuously present, effectively a single, ongoing episode.(en)"> + > + ["at0180"] = < + text = <"*Progression(en)"> + description = <"*Description progression of the symptom or sign at the time of reporting.(en)"> + comment = <"*Occurrences of this data element are set to 0..* to allow multiple types of progression to be separated out in a template if desired - for example, severity or frequency.(en)"> + > + ["at0181"] = < + text = <"*Improving(en)"> + description = <"*The severity of the symptom or sign has improved overall during this episode.(en)"> + > + ["at0182"] = < + text = <"*Unchanged(en)"> + description = <"*The severity of the symptom or sign has not changed overall during this episode.(en)"> + > + ["at0183"] = < + text = <"*Worsening(en)"> + description = <"*The severity of the symptom or sign has worsened overall during this episode.(en)"> + > + ["at0184"] = < + text = <"*Resolved(en)"> + description = <"*The severity of the symptom or sign has resolved.(en)"> + > + ["at0185"] = < + text = <"*Description(en)"> + description = <"*Narrative description about the effect of the factor on the identified symptom or sign.(en)"> + > + ["at0186"] = < + text = <"*New element(en)"> + description = <"**(en)"> + > + > + > + ["nb"] = < + items = < + ["at0000"] = < + text = <"Symptom/Sykdomstegn"> + description = <"Rapportert observasjon av fysiske tegn eller beskrivelse av unormale eller ubehagelige fornemmelser i kropp og/eller sinn."> + > + ["at0001"] = < + text = <"Navn på symptom/sykdomstegn"> + description = <"Navnet på det rapporterte symptomet eller sykdomstegnet."> + comment = <"Navnet på symptom/sykdomstegn bør kodes med en terminologi om mulig."> + > + ["at0002"] = < + text = <"Beskrivelse"> + description = <"Fritekstbeskrivelse av det rapporterte symptomet eller sykdomstegnet."> + comment = <"Eksempel: \"Svimmelhet med rotasjonsfølelse og av og til besvimelsesfølelse. Hurtig bevegelse fra sittende eller liggende til stående stilling virker å være en utløsende faktor. Opptrer typisk flere ganger daglig, og varer i ca et halvt til ett minutt hver gang. Å sette eller legge seg ned virker lindrende.\""> + > + ["at0003"] = < + text = <"Mønster"> + description = <"Fritekstbeskrivelse av symptomet eller sykdomstegnet i løpet av denne episoden."> + comment = <"For eksempel: Smerte kan beskrives som konstant eller intermitterende. Dette elementet kan brukes til å registrere tekstlige beskrivelser (enten det er fri eller kodet tekst) av den typiske frekvensen og varigheten av symptomanfall under den aktuelle episoden."> + > + ["at0017"] = < + text = <"Effekt"> + description = <"Oppfattet effekt av den modifiserende faktoren på symptomet eller sykdomstegnet."> + > + ["at0018"] = < + text = <"Modifiserende faktor"> + description = <"Detaljer om hvordan en spesifikk faktor påvirker det identifiserte symptomet eller sykdomstegnet i løpet av denne episoden."> + > + ["at0019"] = < + text = <"Faktor"> + description = <"Navn på den modifiserende faktoren."> + comment = <"Dette elementet er ment for å dokumentere faktorer, terapeutiske eller andre, som har innvirkning på symptomet. En oversikt over planlagte og utførte tiltak for symptomet eller sykdomstegnet må dokumenteres ved hjelp av andre arketyper. +Eksempel på modifiserende faktor: sengeleie med flere puter, spising, eller administrering av et spesifikt legemiddel."> + > + ["at0021"] = < + text = <"Alvorlighetskategori"> + description = <"Kategori for å beskrive symptomets eller sykdomstegnets helhetlige alvorlighet."> + comment = <"Det er vanskelig å definere verdier som mild, moderat og alvorlig på en slik måte at det kan brukes om flere symptomer, og som samtidig sikrer at tolkning og registrering av verdiene er konsistent. Ved å utvide verdisettet med verdier som \"ubetydelig\" og \"veldig alvorlig\", og/eller \"moderat mild\" og \"moderat alvorlig\" øker kompleksiteten, og påliteligheten i registreringen reduseres. Bruk av verdier som \"Livstruende\" eller \"fatal\" tas ofte med i et slikt verdisett, men disse verdiene gjenspeiler heller resultat enn alvorlighet. I lys av dette foretrekkes en mindre, mer veldefinert liste. NB: En mer spesifikk gradering av alvorlighet kan registreres ved bruk av SLOTet \"Spesifikke detaljer\"."> + > + ["at0023"] = < + text = <"Mild"> + description = <"Symptomet eller sykdomstegnets intensitet forstyrrer ikke normal aktivitet."> + > + ["at0024"] = < + text = <"Moderat"> + description = <"Symptomet eller sykdomstegnet intensitet forstyrrer normal aktivitet."> + > + ["at0025"] = < + text = <"Alvorlig"> + description = <"Symptomets eller sykdomstegnets intensitet hindrer normal aktivitet."> + > + ["at0026"] = < + text = <"Gradering av alvorlighet"> + description = <"Numerisk graderings skala som representerer den overordnede alvorligheten til symptomet eller sykdomstegnet."> + comment = <"Symptomets alvorlighet graderes av individet ved å registrere en skår fra 0 (symptom ikke tilstede) til 10 (symptomet er så alvorlig som individet kan forestille seg). Denne skåringen kan representeres i brukergrensesnittet som en visuell analog skala, Dataelementet er satt til 0..* for å tillate variasjonen som \"maksimum alvorlighet\" og \"gjennomsnittlig alvorlighet\" i et templat."> + > + ["at0028"] = < + text = <"Varighet"> + description = <"Varigheten av denne episoden av symptomet eller sykdomstegnet siden debut."> + comment = <"Brukes \"Dato/tid for debut\" og \"Dato/tid for opphør\" i systemer, kan dette dataelementet kalkuleres av systemet eller være overflødig."> + > + ["at0031"] = < + text = <"Antall tidligere episoder"> + description = <"Antall ganger symptomet eller sykdomstegnet tidligere har forekommet."> + > + ["at0035"] = < + text = <"Ikke av betydning"> + description = <"Symptomet eller sykdomstegnet ble rapportert som ikke tilstede i betydningsfull grad."> + comment = <"Registrer som Sann dersom helsetjenestemottakeren har rapportert symptomet eller sykdomstegnet som ikke tilstede i betydningsfull grad. For eksempel: Dersom individet aldri har opplevd symptomet vil det være riktig registrere \"Ikke av betydning\". Dersom individet vanligvis opplever symptomet, kan det i noen tilfeller være riktig å registrere \"Ikke av betydning\" dersom individet ikke har opplevd noen endring fra sin normaltilstand."> + > + ["at0037"] = < + text = <"Episodebeskrivelse"> + description = <"Fritekstbeskrivelse av symptomet eller sykdomstegnets utvikling gjennom denne episoden."> + comment = <"For eksempel: Fritekstbeskrivelse av symptomdebuten, aktiviteter som forverret eller forbedret symptomet, om det er i bedring eller forverring og hvordan det ble fullstendig bedret i løpet av uker."> + > + ["at0056"] = < + text = <"Beskrivelse"> + description = <"Fritekstbeskrivelse av den modifiserende faktorens effekt på symptomet eller sykdomstegnet."> + > + ["at0057"] = < + text = <"Beskrivelse av tidligere episoder"> + description = <"Fritekstbeskrivelse av tidligere episoder."> + comment = <"For eksempel: Frekvens/periodisitet - pr. time, dag, uke, måned, år og regularitet. Kan inneholde en sammenligning med denne episoden."> + > + ["at0063"] = < + text = <"Tilknyttede symptomer/sykdomstegn"> + description = <"Strukturerte detaljer om ethvert tilknyttet symptom eller sykdomstegn som er tilstede samtidig."> + comment = <"I kliniske systemer med mulighet for linking er det mulig at tilknyttede symptomer/sykdomstegn allerede er registrert i det kliniske systemet. Systemet kan tillatte en kliniker å linke til relevante tilknyttede symptomer/sykdomstegn. Tillater ikke systemet linking eller det er en pasient som ikke har noen tilknyttede symptomer registrert, kan man legge til ytterligere instanser av symptom-arketypen for å beskrive de tidligere episodene."> + > + ["at0146"] = < + text = <"Tidligere episoder"> + description = <"Strukturerte detaljer om symptomet eller sykdomstegnet i løpet av en tidligere episode."> + comment = <"I kliniske systemer med mulighet for linking er det mulig at tidligere episoder allerede er registrert i det kliniske systemet. Systemet kan tillatte en kliniker å linke til relevante tilknyttede symptomer. Tillater ikke systemet linking eller det er en pasient som ikke har noen tilknyttede symptomer registrert, kan man legge til ytterligere instanser av symptom-arketypen for å beskrive de tidligere episodene."> + > + ["at0147"] = < + text = <"Strukturert anatomisk lokalisering"> + description = <"Strukturert anatomisk lokalisering hvor symptomet eller sykdomstegnet ble rapportert."> + comment = <"Hvis den anatomiske lokaliseringen allerede er satt i elementet \"Navn på symptom/sykdomstegn\" via prekoordinerte koder, blir dette SLOTet overflødig. Er den anatomiske lokaliseringen registrert i dataelementet \"Anatomisk lokalisering\", er bruken av dette SLOTet ikke tillatt. Registrer bare \"Anatomisk lokalisering\" eller \"Strukturert anatomisk lokalisering\", ikke begge."> + > + ["at0151"] = < + text = <"Anatomisk lokalisering"> + description = <"Registrering av ett enkelt område på kroppen hvor symptomet eller sykdomstegnet var rapportert."> + comment = <"Forekomster for dette dataelementet er satt 0..* for å tillate at flere kroppssted kan trekkes ut i et templat om ønsket. Dette åpner for å representere kliniske scenarier hvor et symptom må registreres flere steder på kroppen eller for å identifisere både opphavssted for smerte og ytterpunkt for utstråling av smerter, og alle andre dataelementer i arketypen som \"Innvirkning\" og \"Varighet\" er like. Om kravet for registrering av kroppsplassering er bestemt i en applikasjon eller krever en mer kompleks modellering som for eksempel relativ lokalisering, bruk arketypen CLUSTER.anatomical_location eller CLUSTER.relative_location i \"Strukturert anatomisk lokalisering\"-SLOTet i denne arketypen. Er den anatomiske lokaliseringen inkludert i \"Navn på symptom/sykdomstegn\" via prekoordinerte koder er dette dataelementet overflødig. Registreres den anatomiske lokaliseringen i SLOTet \"Strukturert anatomisk lokalisering\" er bruken av dette dataelementet ikke tillatt. Registrer enten i \"Anatomisk lokalisering\" eller i \"Strukturert anatomisk lokalisering\", ikke i begge. + +"> + > + ["at0152"] = < + text = <"Dato/tid for episodens debut"> + description = <"Debuttidspunkt for denne episoden av symptomet eller sykdomstegnet."> + comment = <"Partielle datoer er tillatt. Nøyaktig tid for symptomets debut kan registreres, dersom relevant. Dersom dette symptomet eller sykdomstegnet oppleves for første gang eller er en ny episode av et tidligere opplevd symptom, kan denne datoen brukes for å representere debuten for denne episoden. Dersom symptomet eller sykdomstegnet opptrer kontinuerlig, kan dette dataelementet være overflødig dersom det er registrert tidligere."> + > + ["at0153"] = < + text = <"Spesifikke detaljer"> + description = <"Ekstra dataelementer som er nødvendige for å registrere egenskaper unike for det identifiserte symptomet eller sykdomstegnet."> + comment = <"For eksempel: Graderingen \"Common Terminology Criteria for Adverse Events\"."> + > + ["at0154"] = < + text = <"Faktordetaljer"> + description = <"Strukturerte detaljer om faktoren som er forbundet med det identifiserte symptomet eller sykdomstegnet."> + > + ["at0155"] = < + text = <"Innvirkning"> + description = <"Beskrivelse av symptomet eller sykdomstegnets innvirkning."> + comment = <"Bedømmelsen av innvirkning må ta høyde for alvorlighet, varighet og frekvens av symptomet, i tillegg til type innvirkning, for eksempel: funksjonell, sosial og emosjonell innvirkning. Dataelementet er satt til 0..* for å tillate at flere typer innvirkning kan trekkes ut i et templat om ønskelig. For hørselstap vil innvirkning kunne omfatte \"Vansker med å høre i et stille miljø\", \"Vansker med å høre TV eller radio\"; \"Vansker med å høre gruppesamtaler\" og \"Vansker med å høre i telefon\"."> + > + ["at0156"] = < + text = <"Ingen effekt"> + description = <"Faktoren har ingen effekt på symptomet eller sykdomstegnet."> + > + ["at0158"] = < + text = <"Forverrer"> + description = <"Faktoren øker alvorlighet eller innvirkning av symptomet eller sykdomstegnet."> + > + ["at0159"] = < + text = <"Lindrer"> + description = <"Faktoren reduserer alvorligheten eller innvirkning av symptomet eller sykdomstegnet, men får det ikke til å opphøre fullstendig."> + > + ["at0161"] = < + text = <"Dato/tid for opphør"> + description = <"Dato/tid for opphør av denne episoden av symptomet eller sykdomstegnet."> + comment = <"Brukes \"Dato/tid for debut\" og \"Varighet\" i systemer, kan dette dataelementet kalkuleres av systemet eller være overflødig. Ufullstendig dato er tillatt, nøyaktig dato og tid for opphør kan registreres om ønskelig."> + > + ["at0163"] = < + text = <"Kommentar"> + description = <"Ytterligere fritekst om symptomet eller sykdomstegnet som ikke dekkes i andre felt."> + > + ["at0164"] = < + text = <"Debuttype"> + description = <"Beskrivelse av symptomets eller sykdomstegnets debut."> + comment = <"Debuttypen kan kodes med en terminologi om ønsket. For eksempel: Gradvis eller plutselig."> + > + ["at0165"] = < + text = <"Utløsende/avsluttende faktor"> + description = <"Detaljer om spesifikke faktorer som utløser eller som får symptomet eller sykdomstegnet til å opphøre."> + comment = <"For eksempel: Debut av hodepine oppstod en uke før menstruasjon eller debut av hodepine oppstod en time etter fall på sykkel, halsbrannen forsvant ved administrasjon av syrenøytraliserende eller brystsmerter forsvant ved hvile."> + > + ["at0167"] = < + text = <"Utløsende faktor"> + description = <"Identifisering av faktorer eller hendelser som utløser debut av symptomet eller sykdomstegnet."> + > + ["at0168"] = < + text = <"Avsluttende faktor"> + description = <"Identifisering av faktorer eller hendelser som utløser opphør av symptomet eller sykdomstegnet."> + > + ["at0170"] = < + text = <"Faktor"> + description = <"Navn på helserelatert hendelse, symptom, rapportert sykdomstegn eller annen faktor."> + comment = <"For eksempel: Debut av annet symptom, menstruasjons debut, falt av sykkel."> + > + ["at0171"] = < + text = <"Tidsintervall"> + description = <"Tidsintervall mellom forekomst eller debut av faktoren og debut/opphør av symptomet eller sykdomstegnet."> + > + ["at0175"] = < + text = <"Episodisitet"> + description = <"Kategorisering av denne episoden av det identifiserte symptomet eller sykdomstegnet."> + > + ["at0176"] = < + text = <"Nytt"> + description = <"En ny episode av symptomet eller sykdomstegnet - enten den første forekomsten eller en ny forekomst der den tidligere episoden var fullstendig opphørt."> + > + ["at0177"] = < + text = <"Ubestemt"> + description = <"Det er ikke mulig å bestemme om denne forekomsten av symptomet er ny eller pågående."> + > + ["at0178"] = < + text = <"Kontinuerlig"> + description = <"Symptomet eller sykdomstegnet er kontinuerlig tilstedeværende, i praksis en enkelt pågående episode."> + > + ["at0180"] = < + text = <"Progresjon"> + description = <"Beskrivelse av symptomets eller sykdomstegnets progresjon ved rapporteringstidspunktet."> + comment = <"Dataelementet er definert som 0..* for å tillate at flere typer progresjon trekkes ut i et templat om ønsket. For eksempel: alvorlighet eller frekvens."> + > + ["at0181"] = < + text = <"Forbedret"> + description = <"Symptomet eller sykdomstegnets alvorlighetsgrad er forbedret i løpet av denne episoden."> + > + ["at0182"] = < + text = <"Uendret"> + description = <"Symptomet eller sykdomstegnets alvorlighetsgrad er ikke endret i løpet av denne episoden."> + > + ["at0183"] = < + text = <"Forverret"> + description = <"Symptomet eller sykdomstegnets alvorighetsgrad har blitt forverret i løpet av denne episoden."> + > + ["at0184"] = < + text = <"Opphørt"> + description = <"Symptomet eller sykdomstegnets alvorlighetsgrad er opphørt i løpet av denne episoden."> + > + ["at0185"] = < + text = <"Beskrivelse"> + description = <"Fritekstbeskrivelse av faktorens effekt på det identifiserte symptomet eller sykdomstegnet."> + > + ["at0186"] = < + text = <"Nyoppstått?"> + description = <"Er dette et nyoppstått tilfelle av dette symptomet eller sykdomstegnet?"> + comment = <"Registrer som \"Sann\" dersom symptomet eller sykdomstegnet er nyoppstått."> + > + > + > + ["fi"] = < + items = < + ["at0000"] = < + text = <"Oire"> + description = <"Reported observation of a physical or mental disturbance in an individual.(en)"> + > + ["at0001"] = < + text = <"Oireen nimi"> + description = <"The name of the reported symptom or sign.(en)"> + comment = <"*Symptom name should be coded with a terminology, where possible.(en)"> + > + ["at0002"] = < + text = <"Kuvaus"> + description = <"Narrative description about the reported symptom or sign.(en)"> + > + ["at0003"] = < + text = <"Malli"> + description = <"Narrative description about the pattern of the symptom or sign during this episode.(en)"> + comment = <"*For example: pain could be described as constant or intermittent.(en)"> + > + ["at0017"] = < + text = <"Vaikutus"> + description = <"Perceived effect of the modifying factor on the symptom or sign.(en)"> + > + ["at0018"] = < + text = <"Vaikuttajan kerroin"> + description = <"Detail about how a specific factor effects the identified symptom or sign during this episode.(en)"> + > + ["at0019"] = < + text = <"Vaikuttaja"> + description = <"Name of the modifying factor.(en)"> + comment = <"*Examples of modifying factor: lying on multiple pillows, eating or administration of a specific medication.(en)"> + > + ["at0021"] = < + text = <"Vakavuusasteikko"> + description = <"Category representing the overall severity of the symptom or sign.(en)"> + comment = <"*Defining values such as mild, moderate or severe in such a way that is applicable to multiple symptoms or signs plus allows multiple users to interpret and record them consistently is not easy. Some organisations extend the value set further with inclusion of additional values such as 'Trivial' and 'Very severe', and/or 'Mild-Moderate' and 'Moderate-Severe', adds to the definitional difficulty and may also worsen inter-recorder reliability issues. Use of 'Life-threatening' and 'Fatal' is also often considered as part of this value set, although from a pure point of view it may actually reflect an outcome rather than a severity. In view of the above, keeping to a well-defined but smaller list is preferred and so the mild/moderate/severe value set is offered, however the choice of other text allows for other value sets to be included at this data element in a template. Note: more specific grading of severity can be recorded using the 'Specific details' SLOT.(en)"> + > + ["at0023"] = < + text = <"Vähäinen"> + description = <"The intensity of the symptom or sign does not cause interference with normal activity.(en)"> + > + ["at0024"] = < + text = <"Kohtuullinen"> + description = <"The intensity of the symptom or sign causes interference with normal activity.(en)"> + > + ["at0025"] = < + text = <"Vakava"> + description = <"The intensity of the symptom or sign causes prevents normal activity.(en)"> + > + ["at0026"] = < + text = <"Vakavuusaste"> + description = <"Numerical rating scale representing the overall severity of the symptom or sign.(en)"> + comment = <"*Symptom severity can be rated by the individual by recording a score from 0 (ie symptom not present) to 10.0 (ie symptom is as severe as the individual can imagine). This score can be represented in the user interface as a visual analogue scale. The data element has occurrences set to 0..* to allow for variations such as 'maximal severity' or 'average severity' to be included in a template.(en)"> + > + ["at0028"] = < + text = <"Kesto"> + description = <"The duration of this episode of the symptom or sign since onset.(en)"> + comment = <"*If 'Date/time of onset' and 'Date/time of resolution' are used in systems, this data element may be calculated, or alternatively, be considered redundant in this scenario.(en)"> + > + ["at0031"] = < + text = <"Aikasempien kohtauksien lukumäärä"> + description = <"The number of times this symptom or sign has previously occurred.(en)"> + > + ["at0035"] = < + text = <"Olematon"> + description = <"The identified symptom or sign was reported as not being present to any significant degree.(en)"> + comment = <"*Record as True if the subject of care has reported the symptom as not significant. For example: if the individual has never experienced the symptom it is appropriate to record 'nil significant'; or if the individual commonly experiences the symptom, in some circumstances it may be considered appropriate to record 'nil significant' if the individual has experienced no deviation from their 'normal' baseline.(en)"> + > + ["at0037"] = < + text = <"Kohtauksen kuvaus"> + description = <"Narrative description about the course of the symptom or sign during this episode.(en)"> + comment = <"*For example: a text description of the immediate onset of the symptom, activities that worsened or relieved the symptom, whether it is improving or worsening and how it resolved over weeks.(en)"> + > + ["at0056"] = < + text = <"Kuvaus"> + description = <"Narrative description of the effect of the modifying factor on the symptom or sign.(en)"> + > + ["at0057"] = < + text = <"Edellisen kohtausten kuvaus"> + description = <"Narrative description of any or all previous episodes.(en)"> + comment = <"*For example: frequency/periodicity - per hour, day, week, month, year; and regularity. May include a comparison to this episode.(en)"> + > + ["at0063"] = < + text = <"Liittyvä oire"> + description = <"Structured details about any associated symptoms or signs that are concurrent.(en)"> + comment = <"*In linked clinical systems, it is possible that associated symptoms or signs are already recorded within the EHR. Systems can allow the clinician to LINK to relevant associated symptoms/signs. However in a system or message without LINKs to existing data or with a new patient, additional instances of the symptom archetype could be included here to represent associated symptoms/signs.(en)"> + > + ["at0146"] = < + text = <"Edelliset kohtaukset"> + description = <"Structured details of the symptom or sign during a previous episode.(en)"> + comment = <"*In linked clinical systems, it is possible that previous episodes are already recorded within the EHR. Systems can allow the clinician to LINK to relevant previous episodes. However in a system or message without LINKs to existing data or with a new patient, additional instances of the symptom archetype could be included here to represent previous episodes. It is recommended that new instances of the Symptom archetype inserted in this SLOT represent one or many previous episodes to this Symptom instance only.(en)"> + > + ["at0147"] = < + text = <"Rakenteellinen kehon alue"> + description = <"Structured body site where the symptom or sign was reported.(en)"> + comment = <"*If the anatomical location is included in the Symptom name via precoordinated codes, use of this SLOT becomes redundant. If the anatomical location is recorded using the 'Body site' data element, then use of CLUSTER archetypes in this SLOT is not allowed - record only the simple 'Body site' OR 'Structured body site', but not both.(en)"> + > + ["at0151"] = < + text = <"Kehon alue"> + description = <"Simple body site where the symptom or sign was reported.(en)"> + comment = <"*Occurrences of this data element are set to 0..* to allow multiple body sites to be separated out in a template if desired. This allows for representation of clinical scenarios where a symptom or sign needs to be recorded in multiple locations or identifying both the originating and distal site in pain radiation, but where all of the other attributes such as impact and duration are identical. If the requirements for recording the body site 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 Detailed anatomical location' SLOT in this archetype. +If the anatomical location is included in the Symptom name via precoordinated codes, this data element becomes redundant. If the anatomical location is recorded using the 'Structured body site' SLOT, then use of this data element is not allowed - record only the simple 'Body site' OR 'Structured body site', but not both.(en)"> + > + ["at0152"] = < + text = <"Kohtauksen alku"> + description = <"The onset for this episode of the symptom or sign.(en)"> + comment = <"*While partial dates are permitted, the exact date and time of onset can be recorded, if appropriate. If this symptom or sign is experienced for the first time or is a re-occurrence, this date is used to represent the onset of this episode. If this symptom or sign is ongoing, this data element may be redundant if it has been recorded previously.(en)"> + > + ["at0153"] = < + text = <"Ominaistiedot"> + description = <"Specific data elements that are additionally required to record as unique attributes of the identified symptom or sign.(en)"> + comment = <"*For example: CTCAE grading.(en)"> + > + ["at0154"] = < + text = <"Vaikutustiedot"> + description = <"Structured detail about the factor associated with the identified symptom or sign.(en)"> + > + ["at0155"] = < + text = <"Vaikutus"> + description = <"Description of the impact of this symptom or sign.(en)"> + comment = <"*Assessment of impact could consider the severity, duration and frequency of the symptom as well as the type of impact including, but not limited to, functional, social and emotional impact. Occurrences of this data element are set to 0..* to allow multiple types of impact to be separated out in a template if desired. Examples for functional impact from hearing loss may include: 'Difficulty Hearing in Quiet Environment'; 'Difficulty Hearing the TV or Radio'; 'Difficulty Hearing Group Conversation'; and 'Difficulty Hearing on Phone'.(en)"> + > + ["at0156"] = < + text = <"Ei vaikutusta"> + description = <"The factor has no impact on the symptom or sign.(en)"> + > + ["at0158"] = < + text = <"Pahentaa"> + description = <"The factor increases the severity or impact of the symptom or sign.(en)"> + > + ["at0159"] = < + text = <"Helpottaa"> + description = <"The factor decreases the severity or impact of the symptom or sign, but does not fully resolve it.(en)"> + > + ["at0161"] = < + text = <"Päättymisaika"> + description = <"The timing of the cessation of this episode of the symptom or sign.(en)"> + comment = <"*If 'Date/time of onset' and 'Duration' are used in systems, this data element may be calculated, or alternatively, considered redundant. While partial dates are permitted, the exact date and time of resolution can be recorded, if appropriate.(en)"> + > + ["at0163"] = < + text = <"Kommentti"> + description = <"Additional narrative about the symptom or sign not captured in other fields.(en)"> + > + ["at0164"] = < + text = <"Oireen puhkeaminen"> + description = <"Description of the onset of the symptom or sign.(en)"> + comment = <"*The type of the onset can be coded with a terminology, if desired. For example: gradual; or sudden.(en)"> + > + ["at0165"] = < + text = <"Kiihdyttävä/ratkaiseva tekijä"> + description = <"Details about specified factors that are associated with the precipitation or resolution of the symptom or sign.(en)"> + comment = <"*For example: onset of headache occurred one week prior to menstruation; or onset of headache occurred one hour after fall of bicycle.(en)"> + > + ["at0167"] = < + text = <"Kiihdyttävä tekijä"> + description = <"Identification of factors or events that trigger the onset or commencement of the symptom or sign.(en)"> + > + ["at0168"] = < + text = <"Ratkaiseva tekijä"> + description = <"Identification of factors or events that trigger resolution or cessation of the symptom or sign.(en)"> + > + ["at0170"] = < + text = <"Vaikuttaja"> + description = <"Name of the health event, symptom, reported sign or other factor.(en)"> + comment = <"*For example: onset of another symptom; onset of menstruation; or fall off bicycle.(en)"> + > + ["at0171"] = < + text = <"Aikaväli"> + description = <"The interval of time between the occurrence or onset of the factor and onset/resolution of the symptom or sign.(en)"> + > + ["at0175"] = < + text = <"Jaksollisuus"> + description = <"Category of this episode for the identified symptom or sign.(en)"> + > + ["at0176"] = < + text = <"Uusi"> + description = <"A new episode of the symptom or sign - either the first ever occurrence or a reoccurrence where the previous episode had completely resolved.(en)"> + > + ["at0177"] = < + text = <"Epämääräinen"> + description = <"It is not possible to determine if this occurrence of the symptom or sign is new or ongoing.(en)"> + > + ["at0178"] = < + text = <"Meneillään oleva"> + description = <"This symptom or sign is ongoing, effectively a single, continuous episode.(en)"> + > + ["at0180"] = < + text = <"Progressio"> + description = <"Description progression of the symptom or sign at the time of reporting.(en)"> + comment = <"*Occurrences of this data element are set to 0..* to allow multiple types of progression to be separated out in a template if desired - for example, severity or frequency.(en)"> + > + ["at0181"] = < + text = <"Parantuva"> + description = <"The severity of the symptom or sign has improved overall during this episode.(en)"> + > + ["at0182"] = < + text = <"Ei muutosta"> + description = <"The severity of the symptom or sign has not changed overall during this episode.(en)"> + > + ["at0183"] = < + text = <"Pahentuva"> + description = <"The severity of the symptom or sign has worsened overall during this episode.(en)"> + > + ["at0184"] = < + text = <"Ratkaistu"> + description = <"The severity of the symptom or sign has resolved.(en)"> + > + ["at0185"] = < + text = <"Kuvaus"> + description = <"Narrative description about the effect of the factor on the identified symptom or sign.(en)"> + > + ["at0186"] = < + text = <"Ensimmäinen koskaan?"> + description = <"Is this the first ever occurrence of this symptom or sign?(en)"> + comment = <"*Record as True if this is the first ever occurrence of this symptom or sign.(en)"> + > + > + > + ["sv"] = < + items = < + ["at0000"] = < + text = <"Symtom och tecken"> + description = <"Rapporterad observation av en fysisk eller psykisk störning hos en individ."> + > + ["at0001"] = < + text = <"Symtom och teckennamn"> + description = <"Namnet på det uppvisade symtomet eller tecknet."> + comment = <"Symtomnamnet ska kodas med en terminologi, där det är möjligt."> + > + ["at0002"] = < + text = <"Beskrivning"> + description = <"Beskrivning av det uppvisade symtomet eller tecknet."> + > + ["at0003"] = < + text = <"Mönster för episod"> + description = <"En beskrivning av den här episodens mönster av symtomet eller tecknet."> + comment = <"Exempelvis: smärta som kan beskrivas som konstant eller intermittent."> + > + ["at0017"] = < + text = <"Effekt"> + description = <"Förnimmad effekt av påverkande faktorn av symtomet eller tecknet."> + > + ["at0018"] = < + text = <"Påverkande faktor"> + description = <"Detalj om en specifik faktor som påverkar det identifierade symtomet eller tecknet under denna episod."> + > + ["at0019"] = < + text = <"Faktor"> + description = <"Namn på den påverkande faktorn."> + comment = <"Exempel på påverkande faktorn: Ligger på flera kuddar, äter eller ges ett specifikt läkemedel."> + > + ["at0021"] = < + text = <"Svårighetsgrad kategori"> + description = <"Kategori som presenterar symtomens eller tecknets totala svårighetsgrad."> + comment = <"Att definiera värden som mild, måttlig eller svår på ett sådant sätt som är tillämpligt på flera symtom eller tecken plus som tillåter flera användare att tolka och registrera dem konsekvent är inte lätt. Vissa organisationer utökar inställningen av värdet ytterligare med att inkludera värden som \"Obetydlig\" och \"Mycket svår\" och\"Mild-Måttlig\" och \"Måttlig-Svår\", vilket ger problem med att förstå skillnaden mellan olika definitioner samt ger svårigheter att jämföra olika mätresultat. + +Användning av \"Livshotande\" och \"Dödlig\" anses ofta också som en del av denna värdeskattning, men det kan faktiskt reflektera ett resultat snarare än en svårighetsgrad. Med tanke på ovanstående är det att föredra att hålla sig till en väldefinierad men mindre lista, och sålunda erbjuds den milda/måttligt svåra värdesatsen, men valet av annan text tillåter att andra värdesatser inkluderas i detta dataelement i en mall. Obs! Mer specifik gradering av svårighetsgrad kan registreras i fältet \"Specifika Detaljer\"."> + > + ["at0023"] = < + text = <"Mild"> + description = <"Symtomet eller tecknets intensitet orsakar inte störningar i normal aktivitet. +"> + > + ["at0024"] = < + text = <"Måttlig"> + description = <"Symtomet eller tecknets intensitet orsakar störningar i normal aktivitet."> + > + ["at0025"] = < + text = <"Svår"> + description = <"Symtomets eller tecknets intensitet förhindrar normal aktivitet."> + > + ["at0026"] = < + text = <"Skattning av svårighetsgrad"> + description = <"Numerisk skattningsskala som presenterar symtomens eller tecknets övergripande svårighetsgrad."> + comment = <"Svårighetsgraden kan bedömas av individen genom att registrera poäng från 0 (dvs. ingen förekomst av symtom) till 10,0 (dvs. symtomet är så svårt som individen kan tänka sig). Denna poäng kan presenteras i användargränssnittet som en visuell analog skala. Fältet innehåller händelser som är satta till 0.. * för att tillåta att variationer som exempelvis \"maximal svårighetsgrad\" eller \"genomsnittlig svårighetsgrad\" ska kunna ingå i en mall."> + > + ["at0028"] = < + text = <"Varaktighet"> + description = <"Den här episodens varaktighet av symtomet eller tecknet sedan debuten."> + comment = <"Om \"Datum och tidpunkt för debut\" och \"Datum och tid för uppklarande\" används i systemet, kan det här fältet övervägas eller alternativt anses vara överflödigt i detta scenario."> + > + ["at0031"] = < + text = <"Antal tidigare inträffade episoder"> + description = <"Antalet gånger detta symtom eller tecken har förekommit tidigare."> + > + ["at0035"] = < + text = <"Noll signifikant"> + description = <"Det identifierade symtomet eller tecknet rapporterades som inte förekommande i någon signifikant grad."> + comment = <"Registrera som Sann om patienten har rapporterat symtomet som inte signifikant. Exempelvis om patienten aldrig har upplevt symtomet är det lämpligt att registrera \"Noll signifikant\", likaså om patienten ofta upplever symtomet kan det under vissa omständigheter anses lämpligt att registrera det som 'Noll signifikant', om patienten exempelvis inte har upplevt någon avvikelse från sin \"normala\" baslinje."> + > + ["at0037"] = < + text = <"Episodbeskrivning"> + description = <"Beskrivning av symtomet eller tecknet under denna episod."> + comment = <"Exempelvis: En textbeskrivning om symtomets debut, aktiviteter som förvärrade eller lindrade symtomen, om det förbättras eller förvärras och hur det uppklaras över veckor."> + > + ["at0056"] = < + text = <"Beskrivning"> + description = <"Beskrivning av påverkande faktorns effekt på symtomet eller tecknet."> + > + ["at0057"] = < + text = <"Beskrivning av tidigare episoder"> + description = <"Beskrivning av några eller alla tidigare episoder."> + comment = <"Exempelvis: frekvens och periodicitet, per timme, dag, vecka, månad, år och regelbundenhet. Den kan innehålla en jämförelse med den här episoden."> + > + ["at0063"] = < + text = <"Associerade symtom och tecken"> + description = <"Strukturerade detaljer om eventuella samtidiga tillhörande symtom eller tecken. +"> + comment = <"I länkade kliniska system är det möjligt att sammankopplade symtom eller tecken redan är registrerade inom EHR. System kan låta klinikern LÄNKA till relevanta associerade symtom coh tecken. Däremot i ett system eller i meddelanden utan LÄNKar till befintliga data eller med en ny patient kan ytterligare fall av symtomarketypen ingå för att presentera associerade symtom och tecken."> + > + ["at0146"] = < + text = <"Tidigare episoder"> + description = <"Strukturerade detaljer om symtomet eller tecken under en tidigare episod."> + comment = <"I länkade kliniska system är det möjligt att tidigare episoder redan är registrerade inom EHR. System kan låta klinikern LÄNKA till relevanta tidigare episoder. Men i ett system eller meddelande utan LÄNKAR till befintlig data eller med en ny patient kan ytterligare fall av symtomarketypen ingå här för att presentera tidigare episoder. Det rekommenderas att nya fall av Symtom-arketypen som förs in i detta FÄLT presenterar endast en eller flera tidigare episoder i det här Symtomfallet."> + > + ["at0147"] = < + text = <"Strukturerad lokalisering"> + description = <"Strukturerad lokalisering av plats på kroppen där symtomen eller tecknet uppvisades."> + comment = <"Om den anatomiska platsen ingår i Symtom-namnet via fördeffinierade koder blir användningen av detta fält överflödig. Om den anatomiska platsen registreras med hjälp av \"Lokalisering\" -fältet, är det inte tillåtet att använda CLUSTER-arketyper i det här fältet, registrera endast den enkla \"Lokalisering\" ELLER \"Strukturerad lokalisering\", men inte båda."> + > + ["at0151"] = < + text = <"Lokalisation"> + description = <"Lokalisation av plats på kroppen där symtomet eller tecknet rapporterats."> + comment = <"Förekomster i det här fältet är inställda på 0.. * för att tillåta att flera lokaliseringar av kroppsställen kan delas upp i en mall om så önskas. Detta möjliggör presentation av kliniska scenarion där ett symtom eller tecken måste registreras på flera ställen eller för att identifiera både uppkomst- och distalplatsen i smärtstrålning, men där alla andra egenskaper som påverkan och varaktighet är identiska. Om registreringskraven för lokalisering av kroppsplats har fastställts vid körning av applikationen eller kräver mer komplex utformning, såsom relativa platser, använd i så fall CLUSTER.anatomical_location eller CLUSTER.relative_location inom fältet 'Detaljerade anatomiska platsen' i den här arketypen. + +Om den anatomiska platsen ingår i Symtom-namnet via förkordinerade koder blir det här fältet överflödigt. Om den anatomiska platsen beskrivs i fältet \"Strukturerad lokalisering\", är det inte tillåtet att använda detta fält, registrera då endast den enkla \"Lokalisering\" ELLER \"Strukturerad lokalisering\", men inte båda."> + > + ["at0152"] = < + text = <"Episoddebut"> + description = <"Debut för denna episod av symtomet eller tecknet."> + comment = <"Medan partiella datum är tillåtna kan det exakta datumet och tiden för debut registreras, om det är lämpligt. Om det här symtomet eller tecknet upplevs för första gången eller är återkommande, används det här datumet för att utgöra början på denna episod. Om det här symtomet eller tecknet är pågående kan det här fältet vara överflödigt om det redan tidigare har beskrivits."> + > + ["at0153"] = < + text = <"Specifika detaljer"> + description = <"Specifika datakomponenter som krävs för att det identifierade symtomet eller tecknet ska kunna registreras som unika egenskaper."> + comment = <"Exempelvis: CTCAE-skattning."> + > + ["at0154"] = < + text = <"Faktordetalj"> + description = <"Strukturerad detalj om den faktor som är kopplad till det identifierade symtomet eller tecknet."> + > + ["at0155"] = < + text = <"Verkan"> + description = <"Beskrivning av det här symptomet eller tecknets verkan."> + comment = <"I bedömningen av verkan kan symtomets svårighetsgrad, varaktighet och frekvens samt typ av verkan inklusive, men inte begränsat till, funktionell, social och emotionell påverkan beaktas. Förekomster i det här datafältet är inställda på 0 .. * för att tillåta flera typer av verkan att separeras i en mall om så önskas. Exempel på funktionell påverkan av hörselnedsättning kan innefatta: \"Svårigheter att höra i lugn miljö\"; \"Svårighet att höra tv eller radio\",\"Svårighet att höra gruppkonversation\" och \"Svårighet att höra vid telefonsamtal\"."> + > + ["at0156"] = < + text = <"Ingen effekt"> + description = <"Faktorn har ingen effekt på symtomet eller tecknet."> + > + ["at0158"] = < + text = <"Försämrar"> + description = <"Faktorn ökar symtomets eller tecknets svårighetsgrad eller effekt."> + > + ["at0159"] = < + text = <"Lindrar"> + description = <"Faktorn minskar svårighetsgraden eller påverkan på symtomet eller tecknet, men blir inte fullständigt utrett."> + > + ["at0161"] = < + text = <"Uppklarandedatum och tid"> + description = <"Tidpunkt när denna episod av symtomen eller tecknet upphör."> + comment = <"Om \"Datum och tidpunkt för start\" och \"Varaktighet\" används i systemen, kan detta fält beaktas eller alternativt betraktas som överflödigt. Medan partiella datum är tillåtna kan det exakta datumet och tiden för upplösning registreras, om det är lämpligt."> + > + ["at0163"] = < + text = <"Kommentar"> + description = <"Ytterligare beskriving av symtomet eller tecknet som inte tagits upp i andra fält."> + > + ["at0164"] = < + text = <"Typ av debut"> + description = <"Beskrivning av symtomets eller tecknets debut."> + comment = <"Typ av debut kan kodas med en terminologi, om så önskas. Exempelvis: gradvis eller plötslig."> + > + ["at0165"] = < + text = <"Precipitation och uppklarande faktor"> + description = <"Detaljer om specificerade faktorer som är kopplade till symtomet eller tecknets utlösande eller uppklarande."> + comment = <"Exempelvis: Debuten av huvudvärk inträffade en vecka före menstruation eller debuten av huvudvärk inträffade en timme efter fallet av cykeln."> + > + ["at0167"] = < + text = <"Utlösande faktor"> + description = <"Identifiering av faktorer eller händelser som utlöser symtomets eller tecknets debut eller begynnelse."> + > + ["at0168"] = < + text = <"Uppklarande faktor"> + description = <"Identifiering av faktorer eller händelser som utlöser uppklarande eller upphörande av symtomet eller tecknet."> + > + ["at0170"] = < + text = <"Faktor"> + description = <"Namn på hälsohändelsen, symtomet, uppvisade tecknet eller annan faktor."> + comment = <"Exempelvis: Debuten av ett annat symtom, menstruationens början eller fall från cykel."> + > + ["at0171"] = < + text = <"Tidsintervall"> + description = <"Tidsintervallet mellan förekomsten eller debuten av faktorn och debuten och uppklarandet av symtomet eller tecknet."> + > + ["at0175"] = < + text = <"Episodicitet"> + description = <"Den här episodens kategori för det identifierade symtomet eller tecknet."> + > + ["at0176"] = < + text = <"Ny"> + description = <"En ny episod av symtomet eller tecknet, antingen debut eller en återkommande förekomst där den föregående episoden utretts helt."> + > + ["at0177"] = < + text = <"Obestämd"> + description = <"Det är inte möjligt att avgöra om denna förekomst av symtomet eller tecknet är nytt eller pågående."> + > + ["at0178"] = < + text = <"Pågående"> + description = <"Detta symptom eller tecken är pågående, registrad som en enskild kontinuerlig episod."> + > + ["at0180"] = < + text = <"Progression"> + description = <"Beskrivning av progressionen av symtomet eller tecknet vid rapporteringstidpunkten."> + comment = <"Förekomster i det här fältet är inställda på 0.. * för att tillåta flera typer av progression att separeras i en mall om så önskas, exempelvis svårighetsgrad eller frekvens."> + > + ["at0181"] = < + text = <"Under förbättring"> + description = <"Svårighetsgraden av symtomet eller tecknet har förbättrats totalt sett under den här episoden."> + > + ["at0182"] = < + text = <"Oförändrat tillstånd"> + description = <"Svårighetsgraden av symtomet eller tecknet har inte förändrats totalt sett under denna episod."> + > + ["at0183"] = < + text = <"Under försämring"> + description = <"Svårighetsgraden av symtomet eller tecknet har förvärrats totalt sett under denna episod."> + > + ["at0184"] = < + text = <"Löst"> + description = <"Svårighetsgraden av symtomet eller tecknet har lösts."> + > + ["at0185"] = < + text = <"Beskrivning"> + description = <"Beskrivning av faktorns effekt på det identifierade symtomet eller tecknet."> + > + ["at0186"] = < + text = <"Första någonsin?"> + description = <"Är detta den första förekomsten av detta symtom eller tecken?"> + comment = <"Registrera som sann om detta är den första förekomsten av detta symtom eller tecken."> + > + > + > + ["pt-br"] = < + items = < + ["at0000"] = < + text = <"Sintoma/sinal"> + description = <"Observação de um distúrbio físico ou mental relatada em um indivíduo."> + > + ["at0001"] = < + text = <"Nome do sintoma/sinal"> + description = <"O nome do sintoma ou sinal relatado."> + comment = <"Nome do sintoma deve ser codificado com uma terminologia, se possível."> + > + ["at0002"] = < + text = <"Descrição"> + description = <"Descrição narrativa sobre o sintoma ou sinal relatado."> + > + ["at0003"] = < + text = <"Padrão"> + description = <"Descrição narrativa sobre o padrão do sintoma ou sinal durante este episódio."> + comment = <"Por exemplo: dor pode ser descrita como constante ou intermitente."> + > + ["at0017"] = < + text = <"Efeito"> + description = <"Efeito percebido do fator modificador sobre o sintoma ou sinal."> + > + ["at0018"] = < + text = <"Fator modificador"> + description = <"Detalhe sobre como um fator específico afeta o sintoma ou sinal identificado durante este episódio."> + > + ["at0019"] = < + text = <"Fator"> + description = <"Nome do fator modificador."> + comment = <"Exemplos de fatores modificadores: deitar sobre múltiplos travesseiros, comer ou administração de um medicamento específico."> + > + ["at0021"] = < + text = <"Categoria de gravidade"> + description = <"Categoria representando a gravidade geral do sintoma ou sinal."> + comment = <"Definir valores como leve, moderado ou grave de modo a ser aplicável a múltiplos sintomas ou sinais e permitir que múltiplos usuários interpretem e registrem pode não ser fácil. Algumas organizações estendem a gama de valores com a introdução da valores adicionais como 'Trivial' ou ' Muito grave' e/ou 'Leve a moderado' ou 'Moderado a grave', adiciona dificuldade e pode dificultar a reprodutibilidade. Utilizar 'Ameaçador da vida' e 'Fatal' pode ser considerada valro possível, embora de um ponto de vista mais purista representa melhor um desfecho do que gravidade. Com o exposto acima, uma lista menor é preferida como leve/moderado/grave, entretanto a escolha de outras opções de textos nestas listas podem ser úteis. Note: a gravidade pode ser registrada de maneira mais específica utilizando o SLOT 'Detalhes específicos'."> + > + ["at0023"] = < + text = <"Leve"> + description = <"A intensidade do sintoma ou sinal não causa interferência com a atividade normal."> + > + ["at0024"] = < + text = <"Moderada"> + description = <"A intensidade do sintoma ou sinal causa interferência com a atividade normal."> + > + ["at0025"] = < + text = <"Grave"> + description = <"A intensidade do sintoma ou sinal impede a atividade normal."> + > + ["at0026"] = < + text = <"Classificação de gravidade"> + description = <"Escala de gradação numérica representando a gravidade geral de um sintoma ou sinal."> + comment = <"Gravidade do sintoma pode ser graduada pelo registro individual de um score de 0 (sintoma ausente) a 10 (sintoma mais grave que o indivíduo pode imaginar). Este score pode ser representado na interface ao usuário como escala visual analógica. O elemento de dado tem ocorrências de 0..* para permitir variações como 'gravidade máxima' para ser incluída no template."> + > + ["at0028"] = < + text = <"Duração"> + description = <"A duração deste episódio de sintoma ou sinal desde o início."> + comment = <"Se 'Data/hora de início' e 'Data/hora de resolução' forem utilizados, este elemento de dado pode ser calculado, ou alternativamente, ser considerado redundante neste cenário."> + > + ["at0031"] = < + text = <"Número de episódios prévios"> + description = <"O número de vezes que este sintoma ou sinal cocorreu previamente."> + > + ["at0035"] = < + text = <"Não significante"> + description = <"O sintoma ou sinal identificado foi relatado como não sendo presente num nível significante."> + comment = <"Registrar como Verdadeiro se o sujeito do cuidado tiver reportado o sintoma como não significante. Por exemplo: se o indivíduo nunca experimentou o sintoma é apropriado registrar 'não significante'; ou se o indivíduo comumente experimenta o sintoma, em algumas circunstâncias pode ser considerado apropriado registrar 'não significante' se o indivíduo não experimenta desvio no seu baseline 'normal'."> + > + ["at0037"] = < + text = <"Descrição do episódio"> + description = <"Descrição narrativa sobre o curso do sintoma ou sinal durante o episódio."> + comment = <"Por exemplo: uma descrição em texto do início imediato do sintoma, atividades que pioram ou aliviam o sintoma, se está melhorando ou piorando e como se resolveu ao longo de semanas."> + > + ["at0056"] = < + text = <"Descrição"> + description = <"Descrição narrativa do efeito do fato modificador no sintoma ou sinal."> + > + ["at0057"] = < + text = <"Descrição de episódios prévios"> + description = <"Descrição narrativa de alguns ou todos os episódios prévios."> + comment = <"Por exemplo: frequência/periodicidade - por hora, dia, semana, mês, ano; e regularidade. Pode incluir uma comparação com o episódio atual."> + > + ["at0063"] = < + text = <"Sintoma/sinal associado"> + description = <"Detalhes estruturados sobre quaisquer sintomas ou sinais associados que sejam concorrentes."> + comment = <"Em sistemas clínicos concatenados, é possível que sintomas ou sinais associados já estejam registrados no PEP. O sistema pode permitir que o clínico relacione com sintomas e sinais associados. Entretanto em um sistema ou mensagem sem este relacionamento com dados existentes ou com um novo paciente, instâncias adicionais do arquétipo de sintoma podem ser incluídas para representar sintomas ou sinais associados."> + > + ["at0146"] = < + text = <"Episódios prévios"> + description = <"Detalhes estruturados do sintoma ou sinal durante um episódio prévio."> + comment = <"Em sistemas clínicos concatenados, é possível que episódios prévios já etejam registrados no PEP. O sistema pode permitir que o clínico relacione este a episódios relevantes prévios. Entretanto em um sistema ou mensagem sem este relacionamento com dados existentes ou com um novo paciente, instâncias adicionais do arquétipo de sintoma podem ser incluídas para representar episódios prévios. É recomendado que novas instâncias do arquétipo de Sintomas inseridas neste SLOT representem um ou vários episódios prévios relacionados à esta instância."> + > + ["at0147"] = < + text = <"Parte do corpo estruturada"> + description = <"Parte do corpo estruturada em que o sintoma ou sinal foi relatado."> + comment = <"Se a localização anatômica estiver incluída no nome do Sintoma através de códigos pré-coordenados, a utilização deste SLOT torna-se redundante. Se a localização anatômica for registrada utilizando o elemento de dado 'Parte do corpo', então o uso de arquétipos CLUSTER neste SLOT não é permitido - registre apenas o 'Parte do corpo' simples ou 'Parte do corpo estruturada' mas não ambos."> + > + ["at0151"] = < + text = <"Parte do corpo"> + description = <"Parte do corpo em que o sintoma ou sinal foi relatado."> + comment = <"Ocorrências deste elemento de dado são ajustadas de 0..* para permitir múltiplas partes do corpo para serem separadas num template se desejado. Isto permite a representação de cenários clínicos em que o sintoma ou sinal precise ser registrado em múltiplas localizações ou identificar tanto local original e local distante de irradiação de dor, mas em que todos os outros atributos como o impacto e duração são idênticos. Se os requerimntos para registro da parte do corpo for determinado em tempo real pela aplicação ou requeira modelagem mais complexa como localizações relativas então utilize CLUSTER.anatomical_location ou CLUSTER.relative_location no SLOT 'Localização anatômica detalhada' neste arquétipo. +Se a localização anatômica estiver incluída no nome do Sintoma através de códigos pré-coordenados, este elemento de dado torna-se redundante. Se a localização anatômica for registrada utilizando o SLOT 'Parte do corpo estruturada', então a utilização deste elemento de dado não é permitida - registre apenas o 'Parte do corpo' simples ou 'Parte do corpo estruturada', mas não ambos."> + > + ["at0152"] = < + text = <"Início do episódio"> + description = <"O início para este epsiódio de sintoma ou sinal."> + comment = <"Datas parciais são permitidas, a data e hora exata do início pode ser registrada, se apropriado. Se este sintoma ou sinal for experimentado pela primeira ou se for uma recorrência, esta data é utilizada para representar o início deste episódio. Se o sintoma ou sinal estiver em curso, este elemento de dado pode ser redundante se já tiver sido registrado anteriormente."> + > + ["at0153"] = < + text = <"Detalhes específicos"> + description = <"Elementos de dados específicos que são necessários adicionar para registrar atributos exclusivos do sintoma ou sinal identificado."> + comment = <"Por exemplo: graduação CTCAE."> + > + ["at0154"] = < + text = <"Dealhes do fator"> + description = <"Detalhe estruturado sobre o fator associado com o sintoma ou sinal identificado."> + > + ["at0155"] = < + text = <"Impacto"> + description = <"Descrição do impacto deste sintoma ou sinal."> + comment = <"Avaliação do impacto pode considerar a gravidade, duração e frequência do sintoma ou sinal como também o tipo de impacto incluindo, mas limitado a, impacto funcional, social e emocional. Ocorrências deste elemento de dado são setadas para 0..* para permitir múltiplos tipos de impacto para serem separados no template se desejado. Exemplos de impacto funcional para perda auditiva podem incluir: 'Dificuldade de audição em ambiente quieto'; 'Dificuldade para ouvir rádio e TV'; 'Dificuldade de audição para conversa em grupo' e 'Dificuldade de audição ao telefone'."> + > + ["at0156"] = < + text = <"Sem efeito"> + description = <"O fator não tem impacto no sintoma ou sinal."> + > + ["at0158"] = < + text = <"Piora"> + description = <"O fator aumenta a gravidade ou impacto do sintoma ou sinal."> + > + ["at0159"] = < + text = <"Alivia"> + description = <"O fator diminui a gravidade ou impacto do sintoma ou sinal mas não resolve completamente."> + > + ["at0161"] = < + text = <"Data/hora de resolução"> + description = <"O momento de cessação deste episódio de sintoma ou sinal."> + comment = <"Se 'Data/hora de início' e 'Duração' são utilizados no sistema, este elemento de dado pode ser calculado, ou alternativamente, considerado redundante. Datas parciais são permitidas, a data e hora exatas de resolução podem ser registradas, se apropriado."> + > + ["at0163"] = < + text = <"Comentários"> + description = <"Narrativa adicional sobre o sintoma ou sinal não capturada em outros campos."> + > + ["at0164"] = < + text = <"Tipo de início"> + description = <"Descrição do inicio do sintoma ou sinal."> + comment = <"O tipo de início pode ser codificado utilizando uma terminologia, se desejado. Por exemplo: gradual; ou súbito."> + > + ["at0165"] = < + text = <"Fator precipitante ou de resolução"> + description = <"Detalhes sobre fatores específicos que estão associados com a precipitação ou resolução do sintoma ou sinal."> + comment = <"Por exemplo: início de cefaleia ocorreu uma semana antes da menstruação; ou o início da cefaleia ocorreu uma hora após queda de bicicleta."> + > + ["at0167"] = < + text = <"Fator precipitante"> + description = <"Identificação de fatores ou eventos que deflagram o início ou começo de um sintoma ou sinal."> + > + ["at0168"] = < + text = <"Fator de resolução"> + description = <"Identificação de fatores ou eventos que deflagram a resolução ou cessação de um sintoma ou sinal."> + > + ["at0170"] = < + text = <"Fator"> + description = <"Nome do evento de saúde, sintoma, sinal relatado ou outro fator."> + comment = <"Por exemplo: início de outro sintoma; início da menstruação. ou queda da bicicleta."> + > + ["at0171"] = < + text = <"Intervalo de tempo"> + description = <"O intervalo de tempo entre a ocorrência ou o início do fator e o início ou resolução do sintoma ou sinal."> + > + ["at0175"] = < + text = <"Episodicidade"> + description = <"Categoria deste episódio para o sintoma ou sinal identificado."> + > + ["at0176"] = < + text = <"Novo"> + description = <"Um episódio novo de sintoma ou sinal - tanto para primeira ocorrência como para uma reccorrência quando o episódio prévio estiver completamente resolvido."> + > + ["at0177"] = < + text = <"Indeterminado"> + description = <"Não é possível determinar se esta ocorrência de sintoma ou sinal é nova ou em curso."> + > + ["at0178"] = < + text = <"Em curso"> + description = <"O sintoma ou sinal está em curso, efetivamente um episódio único e contínuo."> + > + ["at0180"] = < + text = <"Progressão"> + description = <"Descrição da progressão do sintoma ou sinal no momento do relato."> + comment = <"Ocorrências deste elemento de dado são setadas para 0..* para permitir múltiplos tipos de progressão para serem separadas no template se desejado - por exemplo, gravidade ou frequência."> + > + ["at0181"] = < + text = <"Melhorando"> + description = <"O gravidade do sintoma ou sinal melhorou ao longo deste episódio."> + > + ["at0182"] = < + text = <"Imutável"> + description = <"O gravidade do sintoma ou sinal não mudou ao longo deste episódio."> + > + ["at0183"] = < + text = <"Piorando"> + description = <"O gravidade do sintoma ou sinal piorou ao longo deste episódio."> + > + ["at0184"] = < + text = <"Resolvido"> + description = <"A gravidade do sintoma ou sinal resolveu-se."> + > + ["at0185"] = < + text = <"Descrição"> + description = <"Descrição narrativa sobre o efeito do fator no sintoma ou sinal identificado."> + > + ["at0186"] = < + text = <"Primeira vez?"> + description = <"Esta é a primeira ocorrência deste sintoma ou sinal?"> + comment = <"Registrar como Verdadeiro se esta for a primeira ocorrência deste sintoma ou sinal."> + > + > + > + > + term_bindings = < + ["SNOMED-CT"] = < + items = < + ["at0001"] = <[SNOMED-CT::418799008]> + ["at0002"] = <[SNOMED-CT::162408000]> + ["at0021"] = <[SNOMED-CT::162465004]> + ["at0023"] = <[SNOMED-CT::162468002]> + ["at0024"] = <[SNOMED-CT::162469005]> + ["at0025"] = <[SNOMED-CT::162470006]> + ["at0028"] = <[SNOMED-CT::162442009]> + > + > + > diff --git a/better-template/src/test/resources/opt_json/Archetypes/openEHR-EHR-COMPOSITION.encounter.v1.adl b/better-template/src/test/resources/opt_json/Archetypes/openEHR-EHR-COMPOSITION.encounter.v1.adl new file mode 100644 index 000000000..df9ae5b63 --- /dev/null +++ b/better-template/src/test/resources/opt_json/Archetypes/openEHR-EHR-COMPOSITION.encounter.v1.adl @@ -0,0 +1,534 @@ +archetype (adl_version=1.4; uid=52fa2b9c-ed55-4821-a300-1150fb382c05) + openEHR-EHR-COMPOSITION.encounter.v1 + +concept + [at0000] + +language + original_language = <[ISO_639-1::en]> + translations = < + ["de"] = < + language = <[ISO_639-1::de]> + author = < + ["name"] = <"Anneka Sargeant"> + ["organisation"] = <"Medizinische Informatik, UMG"> + ["email"] = <"anneka.sargeant@med.uni-goettingen.de"> + > + > + ["sv"] = < + language = <[ISO_639-1::sv]> + author = < + ["name"] = <"Kirsi Poikela"> + ["organisation"] = <"Tieto Sweden AB"> + ["email"] = <"ext.kirsi.poikela@tieto.com"> + > + > + ["fi"] = < + language = <[ISO_639-1::fi]> + author = < + > + > + ["es-ar"] = < + language = <[ISO_639-1::es-ar]> + author = < + ["name"] = <"Edgardo Vazquez"> + ["organisation"] = <"VinculoMedico"> + > + accreditation = <"Medical Doctor"> + > + ["ko"] = < + language = <[ISO_639-1::ko]> + author = < + ["name"] = <"Seung-Jong Yu"> + ["organisation"] = <"NOUSCO Co.,Ltd."> + ["email"] = <"seungjong.yu@gmail.com"> + > + accreditation = <"Certified Board of Family Medicine in South Korea"> + > + ["pt-br"] = < + language = <[ISO_639-1::pt-br]> + author = < + ["name"] = <"Vladimir Pizzo"> + ["organisation"] = <"Hospital Sirio Libanes, Brazil"> + ["email"] = <"vladimir.pizzo@hsl.org.br"> + > + > + ["ar-sy"] = < + language = <[ISO_639-1::ar-sy]> + author = < + ["name"] = <"Mona Saleh"> + > + > + ["it"] = < + language = <[ISO_639-1::it]> + author = < + ["name"] = <"Paolo Anedda"> + ["organisation"] = <"Inpeco"> + ["email"] = <"paolo.anedda@inpeco.com"> + > + > + ["es"] = < + language = <[ISO_639-1::es]> + author = < + ["name"] = <"Pablo Pazos"> + ["organisation"] = <"CaboLabs"> + > + accreditation = <"Computer Engineer"> + > + ["nl"] = < + language = <[ISO_639-1::nl]> + author = < + ["name"] = <"Dennis Valk"> + ["organisation"] = <"Code24 BV"> + ["email"] = <"dennis.valk@code24.nl, dennis@code24.nl"> + > + accreditation = <"Code24 BV"> + > + > + +description + original_author = < + ["date"] = <"2005-10-10"> + ["name"] = <"Thomas Beale"> + ["organisation"] = <"Ocean Informatics, UK"> + ["email"] = <"thomas.beale@oceaninformatics.com"> + > + lifecycle_state = <"published"> + other_contributors = <"Tomas Alme, DIPS, Norway","Nadim Anani, Karolinska Institutet, Sweden","Koray Atalag, University of Auckland, New Zealand","Silje Bakke, Bergen Hospital Trust, Norway","Steve Bentley, NHS CfH, United Kingdom","Rong Chen, Cambio Healthcare Systems, Sweden","Stephen Chu, NeHTA, Australia","Shahla Foozonkhah, Ocean Informatics, Australia","Konstantinos Kalliamvakos, Cambio Healthcare Systems, Sweden","Lars Karlsen, DIPS ASA, Norway","Heather Leslie, Ocean Informatics, Australia (Editor)","Luis Marco Ruiz, Norwegian Center for Integrated Care and Telemedicine, Norway","Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (Editor)","Pablo Pazos, CaboLabs.com Health Informatics, Uruguay"> + details = < + ["de"] = < + language = <[ISO_639-1::de]> + purpose = <"Dient zur Erfassung der Details auf Dokumentebene einer einzelnen Interaktion, eines Kontaktes oder eines Pflegeereignisses zwischen einer zu pflegenden Person und Gesundheitsdienstleistern für die Bereitstellung von Gesundheitsdienstleistung. Dies kann entweder Angesicht zu Angesicht (Face-to-Face), über Telefon oder ein anderes elektronisches Medium erfolgen."> + keywords = <"Begegnung","Kontakt","Visite","Pflegeereignis","Ereignis","Besuch"> + use = <"Verwendung als generischer Container auf Dokumentebene zum Aufzeichnen von Details einer einzelnen Interaktion, eines Kontakts oder eines Pflegeereignisses zwischen einem Subjekt und einem Gesundheitsdienstleister. +Der Kontakt kann von Angesicht zu Angesicht, über Telefon oder ein anderes elektronisches Medium erfolgen. Die Modalität kann bei Bedarf über das Referenzmodell COMPOSITION / mode Attribut erfasst werden. + +Die Hauptabschnitte / Inhaltskomponente wurde absichtlich nicht stark eingeschränkt. Dies ermöglicht es, diese Composition innerhalb eines Templates mit beliebigen SECTION- oder ENTRY-Archetypen zu füllen, die für den klinischen Zweck geeignet sind. + +Auch wenn sie für den klinischen Inhalt nicht eingeschränkt sind, bietet die Spezifikation von COMPOSITION.Encounter einen signifikanten Wert, da sie eine explizite Abfrage aller Encounter innerhalb einer Patientenakte ermöglicht. + +Die Context-Komponente enthält einen optionalen 'Extension' SLOT, der während des Template-Designs zu verschiedenen Zwecken verwendet werden kann: +- Zum Hinzufügen von optionalen Kontextinformationen, wie Informationen zur Episode +- Zur Vereinheitlichung oder Verknüpfung mit Modellformalismen wie FHIR oder CIMI + +Typische Beispiele sind eine klinische Visite, eine pflegerische Überwachung oder eine telemedizinische Beratung."> + misuse = <"Nicht zur Darstellung von Details einer gesamten Behandlungsepisode geeignet. + +Nicht zur Darstellung von persistenten, zusammengefassten Patienteninformationen wie eine Problemliste oder eine Medikamentenübersicht geeignet. + +Nicht zur Darstellung von Berichten eines Diagnosedienstes, z.B. Bildgebung oder Labortests, geeignet. + +Nicht zur Darstellung von der gleichnamige FHIR-Ressource geeignet- dort liegt eine Diskrepanz vor."> + > + ["sv"] = < + language = <[ISO_639-1::sv]> + purpose = <"Att registrera detaljer av en enskild interaktion, kontakt eller en vårdhändelse mellan vårdtagare och vårdgivare inom hälso-och sjukvården. Interaktionen kan både vara genom ett fysiskt möte eller på distans."> + keywords = <"vårdtillfälle","kontakt","besök","vårdhändelse"> + use = <"Används för att registrera detaljer från en enskild interaktion, kontakt eller vårdhändelse mellan vårdtagare och vårdgivare. + +Kontakten kan ske genom ett fysiskt möte eller via telefon eller annat elektroniskt medium. Uppgifter om mötesform kan vid behov läggas till i egenskaperna i referensmodellen Composition/mode. + +De huvudsakliga avsnitts- och innehållskomponenterna har avsiktligt lämnats utan begränsning. Det tillåter ifyllning med SECTION eller ENTRY-arketyper som är lämpliga för det kliniska syftet. + +Trots att det inte finns någon begränsning för kliniskt innehåll ger specifikationen för COMPOSITION.Encounter ett signifikant värde genom att tillåta detaljerade förfrågningar om alla händelser i en patientjournal. + +Fältet Extra information kan användas till att lägga till valfri kontextuell information, exempelvis episoduppgifter eller uppgifter som möjliggör samordning eller anpassning till andra modellformalismer som FHIR eller CIMI samt detaljerade beskrivningar av deltagare. + +Typiska exempel är ett klinikbesök, en observation av sjuksköterska eller en telemedicinsk konsultation."> + misuse = <"Ska inte användas för att registrera detaljer om en hel vårdepisod. + +Ska inte användas för beständig patientinformation som exempelvis en problemlista eller medicinsk sammanfattning. + +Ska inte användas för att presentera en rapport från en diagnostisk tjänst, exempelvis en röntgenbild eller laboratorietest. + +Ska inte användas för att presentera FHIR-resursen med samma namn. Det finns en motsättning mellan räckvidd och avsikt."> + > + ["fi"] = < + language = <[ISO_639-1::fi]> + purpose = <"*To record the document level details of a single interaction, contact or care event between a subject of care and healthcare provider(s) for the provision of healthcare service(s). This can be either a face-to-face or remote interaction.(en)"> + keywords = <"*encounter(en)","*contact(en)","*visit(en)","*care event(en)"> + use = <"*Use as a generic document-level container for recording details of a single interaction, contact or care event between a subject of care and healthcare provider(s). +The contact may be face-to-face, via telephone or another electronic medium. Modality can be captured, if required, via the reference model COMPOSITION/mode attribute. + +The main Sections/Content component has been deliberately left unconstrained. This will allow it to be populated with any SECTION or ENTRY archetypes appropriate for the clinical purpose within a template. + +Even though unconstrained for clinical content, specification of COMPOSITION.Encounter provides significant value by allowing for explicit querying of all Encounters within a patient record. + +The Context component contains an optional 'Extension' SLOT that can be used in template design to: +- add optional contextual information, such as episode information; or +- allow for harmonisation or alignment with other model formalisms such as FHIR or CIMI, such as explicit representation of participants that are usually managed by the openEHR Reference Model in an openEHR archetype. + +Typical examples are a clinic visit, a nursing observation or a telemedicine consultation.(en)"> + misuse = <"*Not to be used to record details about an entire episode of care. + +Not to be used to carry persistent, summarised patient information, such as a problem list or medication summary. + +Not to be used to represent the report of a diagnostic service, such as imaging or laboratory testing. + +Not to be used to represent the FHIR resource of the same name - there is a mismatch scope and intent.(en)"> + > + ["es-ar"] = < + language = <[ISO_639-1::es-ar]> + purpose = <"Registrar los detalles documentales de una única interacción, contacto o evento de cuidado entre un sujeto de cuidados y uno o más proveedores de uno o más servicios de salud. Esta interacción puede ser presencial o remota."> + keywords = <"encuentro","contacto","visita","evento de cuidados","consulta"> + copyright = <"© openEHR Foundation"> + use = <"Utilícese como un contendor de nivel de documento para el registro de una única interacción, contacto o evento de cuidados entre un sujeto de cuidados y uno o mas proveedores de cuidados de la salud. +El contacto puede ser cara a cara, o por vía telefónicao de cualquier otro medio electrónico. La modalidad puede ser representada, si asi se requiere, por medio del atributo modo de la COMPOSITION. +El componente principal de Secciones o Contenido se ha mantenido deliberadamente libre de restricciones. Esto permite que se incluya en la plantilla cualquier Sección (SECTION) o Asiento (ENTRY) apropiado al propósito clínico. +Aún cuando se encuentra libre de restricciones en cuanto al contenido clínico, la especificación del COMPOSITION.Encounter agreva valor significativo al permitir la consulta explícita de todos los encuentros conteidos en una historia clínica. +El componente de Contexto contiene un slot opcional \"Extensión\" que puede ser utilizado en el diseño de una plantilla para: +-agregar información opcional de contexto, tal como información sobre el episodio, o +-permitir la armonización o alineamiento con otros formalismos de modelado tales como FHIR o CIMI, como puede ser la representación explícita de participantes que son generalmente manejados por el Modelo de Referencia en un arquetipo openEHR. +Son ejemplos típicos una visita a consultorio, una observación de enfermería o una consulta de telemedicina."> + misuse = <"No debe ser utilizado para registrar los detalles de la totalidad de un episodio de cuidado +No debe ser utilizado para almacenar información sumaria persistente de un paciente, tale como una lista de problemas o un resumen de medicamentos. +No debe ser utilizado para representar el informe de un servicio diagnóstico, tal como un estudio de imágenes o una pruena de laboratorio. +No debe ser utilizado para representar el recurso FHIR del mismo nombre ya que existe una diapridad de alcance y propósito."> + > + ["ko"] = < + language = <[ISO_639-1::ko]> + purpose = <"외래기록, 경과기록, 간호기록과 일반적인 노트 등과 같은 환자를 대면한 후 작성하는 기록"> + keywords = <"*경과(ko)","*노트(ko)","*외래(ko)"> + copyright = <"© openEHR Foundation"> + > + ["pt-br"] = < + language = <[ISO_639-1::pt-br]> + purpose = <"Registrar os detalhes de uma interação, contato ou episódio de cuidado para a provisão de serviços de saúde entre um sujeito do cuidado e um profissional de saúde. Pode se referir tanto a uma interação presencial quanto à distância."> + keywords = <"encontro","contato","visita","episódio de cuidado"> + use = <"Usar como um documento genérico para registrar detalhes de uma interação simples, contato ou episódio de atenção à saúde entre um sujeito do cuidado e profissional(is) de saúde. +O contato pode ser presencial, via telefone ou outro meio eletrônico. A modalidade pode ser identificada, se necessário, através do modelo de referência COMPOSITION/mode attribute. + +O componente main Sections/Content foi deixado deliberadamente sem restrições. Isto permitirá que ele seja populado com qualquer arquétipo SECTION ou ENTRY apropriado para o propósito clínico em um template. + +Embora sem restrições para conteúdo clínico, especificação de COMPOSITION, Encounter oferece importante valor por permitir pesquisa de todos os Encontros num prontuário do paciente. + +O componente Contexto contem um SLOT 'Extensão' opcional que pode ser usado no design do template para: +- adicionar informação contextual opcional, como informação do episódio; ou +- permitir a harmonização ou alinhamento com outros modelos ou formalismos como FHIR ou CIMI, como uma representação explícita de participantes que normalmente são gerenciados pelo Modelo de Referência openEHR num arquétipo openEHR. + +Exemplos típicos são visita a uma clínica, observação de enfermagem ou uma consulta de telemedicina."> + misuse = <"Não deve ser utilizado para registrar detalhes de um episódio de cuidado completo. + +Não deve ser utilizado para guardar informações persistentes, resumidas de um paciente, como uma lista de problemas ou resumo de medicamentos. + +Não deve ser utilizado para representar o relato de um serviço diagnóstico como exames laboratoriais ou de imagem. + +Não deve ser utilizado para representar recurso FHIR do mesmo nome - há uma incompatibilidade de objetivo e intenção."> + > + ["ar-sy"] = < + language = <[ISO_639-1::ar-sy]> + purpose = <"تسجيل المقابلة على هيئة ملاحظة تقدم الحالة"> + keywords = <"التقدم","ملاحظة","المقابلة"> + copyright = <"© openEHR Foundation"> + > + ["en"] = < + language = <[ISO_639-1::en]> + purpose = <"To record the document level details of a single interaction, contact or care event between a subject of care and healthcare provider(s) for the provision of healthcare service(s). This can be either a face-to-face or remote interaction."> + keywords = <"encounter","contact","visit","care event"> + copyright = <"© openEHR Foundation"> + use = <"Use as a generic document-level container for recording details of a single interaction, contact or care event between a subject of care and healthcare provider(s). +The contact may be face-to-face, via telephone or another electronic medium. Modality can be captured, if required, via the reference model COMPOSITION/mode attribute. + +The main Sections/Content component has been deliberately left unconstrained. This will allow it to be populated with any SECTION or ENTRY archetypes appropriate for the clinical purpose within a template. + +Even though unconstrained for clinical content, specification of COMPOSITION.Encounter provides significant value by allowing for explicit querying of all Encounters within a patient record. + +The Context component contains an optional 'Extension' SLOT that can be used in template design to: +- add optional contextual information, such as episode information; or +- allow for harmonisation or alignment with other model formalisms such as FHIR or CIMI, such as explicit representation of participants that are usually managed by the openEHR Reference Model in an openEHR archetype. + +Typical examples are a clinic visit, a nursing observation or a telemedicine consultation."> + misuse = <"Not to be used to record details about an entire episode of care. + +Not to be used to carry persistent, summarised patient information, such as a problem list or medication summary. + +Not to be used to represent the report of a diagnostic service, such as imaging or laboratory testing. + +Not to be used to represent the FHIR resource of the same name - there is a mismatch scope and intent."> + > + ["it"] = < + language = <[ISO_639-1::it]> + purpose = <"Registrare i dettagli a livello di documento di una singola interazione, contatto o evento di cura tra un soggetto di cura e il/i fornitore/i di assistenza sanitaria per la fornitura di servizi sanitari. Può trattarsi di un'interazione faccia a faccia o a distanza."> + keywords = <"incontro","contatto","visita","evento di cura"> + use = <"Utilizzare come contenitore generico a livello di documento per registrare i dettagli di una singola interazione, contatto o evento di cura tra un soggetto di cura e il/i fornitore/i di assistenza sanitaria. +Il contatto può avvenire faccia a faccia, per telefono o su un altro mezzo elettronico. La modalità può essere catturata, se necessario, tramite il modello di riferimento COMPOSITION/mode attribute. + +La principale sezione/componente del contenuto è stata volutamente lasciata libera. Ciò consentirà di popolarla con qualsiasi archetipo di SECTION o ENTRY propriato per lo scopo clinico all'interno di un modello. + +Anche se non è vincolata al contenuto clinico, la specificazione di COMPOSITION.Contatto fornisce un valore significativo, consentendo l'interrogazione esplicita di tutti gli Incontri all'interno della cartella clinica di un paziente. + +Il componente Context contiene un SLOT opzionale 'Extension' SLOT che può essere utilizzato nella progettazione del template per: +- aggiungere informazioni contestuali opzionali, come le informazioni sugli episodi; oppure +- consentire l'armonizzazione o l'allineamento con altri formalismi del modello come FHIR o CIMI, come la rappresentazione esplicita dei partecipanti che sono solitamente gestiti dal modello di riferimento openEHR in un archetipo openEHR. + +Esempi tipici sono una visita in clinica, un'osservazione infermieristica o un consulto di telemedicina."> + misuse = <"Da non utilizzare per portare informazioni persistenti e riassunte sui pazienti, come un elenco di problemi o un sommario dei farmaci. + +Da non utilizzare per rappresentare il rapporto di un servizio diagnostico, come l'imaging o gli esami di laboratorio. + +Non deve essere utilizzato per rappresentare l'omonima risorsa FHIR - c'è un disallineamento di scopo e di intenti."> + > + ["es"] = < + language = <[ISO_639-1::es]> + purpose = <"Registrar, a nivel de documento, una única interacción, contacto o evento de cuidado, entre un sujeto de cuidado (paciente) y un proveedor de servicios de salud (profesional médico, de enfermería, etc.). Puede ser una interacción cara a cara o remota."> + keywords = <"encuentro","contacto","visita","evento de cuidado"> + use = <"Se debe usar como una definición de documento genérico para registrar información de una única interacción o contacto con un proveedor de salud. Esta definición no especifica la estructura interna de secciones y entradas. Dicha especificación debería hacerse mediante especializaciones del arquetipo o mediante plantillas operativas (Operational Templates - OPT)."> + misuse = <"No se debe utilizar para registrar información de un episodio de salud entero. + +No debe contener información persistente o resúmenes, como lista de problemas o medicación. + +No se debe usar para registrar resultados de laboratorio o imagenología. +"> + > + ["nl"] = < + language = <[ISO_639-1::nl]> + purpose = <"Om de documentniveau-details van een enkele interactie, contact of zorggebeurtenis tussen een onderwerp van zorg en een zorgverlener vast te leggen voor de voorziening van zorgverlening. Dit kan face-to-face-contact zijn of interactie op afstand."> + keywords = <"contact","ontmoeting","bezoek","zorggebeurtenis","zorg"> + use = <"Gebruik als een generiek document-niveau container voor het vastleggen van details van een enkele interactie, contact of zorg gebeurtenis tussen een onderwerp van zorg en zorgverlener(s). +Het contact kan face-to-face zijn, telefonisch of via een ander elektronisch medium. Modaliteit kan, indien nodig, vastgelegd worden met behulp van het referentiemodel COMPOSITION/mode kenmerk. + +Het voornaamste Secties/Inhoud component is opzettelijk onbeperkt gelaten. Hierdoor is het toegestaan dat het gevuld wordt met een willekeurige SECTION of ENTRY archetype die toepasselijk is voor de klinische toepassing binnen een template. + +Ondanks de onbeperktheid voor klinische inhoud, zal specificatie van de COMPOSITION.Encounter een belangrijke waarde leveren door het toestaan van expliciet querien binnen alle contacten van een patient-record. + +De Context-component bevat een optioneel 'Extensie'-slot (koppelpunt) dat gebruikt kan worden in ontwerp van templates om: +- optionele contextuele informatie toe te voegen, zoals episode informatie; of +- harmonisatie of uitlijning met andere model formalismen toe te staan zoals FHIR of CIMI, zoals een expliciete representatie van deelnemers die gewoonlijk geregeld wordt door het openEHR referentiemodel in een openEHR archetype. + +Typische voorbeelden zijn een klinisch bezoek, een verpleegkundige observatie of een tele-medisch consult."> + misuse = <"Niet te gebruiken om details vast te leggen over een volledige zorg-episode. + +Niet te gebruiken om volhardende, samengevatte patient-gegevens te bevatten, zoals een probleemlijst or samenvatting van medicatie. + +Niet te gebruiken om een rapport van een diagnostische dienst te representeren, zoals beelden of laboratorium-onderzoek. + +Niet te gebruiken om een FHIR-bron met eenzelfde naam te representeren - dan is er een conflict in de scope en doelstelling."> + > + > + other_details = < + ["licence"] = <"This work is licensed under the Creative Commons Attribution-ShareAlike 3.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/3.0/."> + ["custodian_organisation"] = <"openEHR Foundation"> + ["references"] = <"TC 251, European Committee for Standardization: EN 13940-1:2007 Health informatics - System of concepts to support continuity of care - Part 1: Basic concepts."> + ["original_namespace"] = <"org.openehr"> + ["original_publisher"] = <"openEHR Foundation"> + ["custodian_namespace"] = <"org.openehr"> + ["MD5-CAM-1.0.1"] = <"706E6DA39FA082EE75E0F0D4E4A87F25"> + ["build_uid"] = <"a25deeff-00a9-456d-9e52-83e206b2d5d7"> + ["revision"] = <"1.0.5"> + > + +definition + COMPOSITION[at0000] matches { -- Encounter + category matches { + DV_CODED_TEXT matches { + defining_code matches { + [openehr::433] + } + } + } + context matches { + EVENT_CONTEXT matches { + other_context matches { + ITEM_TREE[at0001] matches { -- Tree + items cardinality matches {0..*; unordered} matches { + allow_archetype CLUSTER[at0002] occurrences matches {0..*} matches { -- Extension + include + archetype_id/value matches {/.*/} + } + } + } + } + } + } + } + +ontology + term_definitions = < + ["ar-sy"] = < + items = < + ["at0000"] = < + text = <"*Encounter(en)"> + description = <"*Interaction, contact or care event between a subject of care and healthcare provider(s).(en)"> + > + ["at0001"] = < + text = <"*Tree(en)"> + description = <"*@ internal @(en)"> + > + ["at0002"] = < + text = <"*Extension(en)"> + description = <"*Additional information required to capture local context or to align with other reference models/formalisms.(en)"> + comment = <"*e.g. Local hospital departmental infomation or additional metadata to align with FHIR or CIMI equivalents.(en)"> + > + > + > + ["en"] = < + items = < + ["at0000"] = < + text = <"Encounter"> + description = <"Interaction, contact or care event between a subject of care and healthcare provider(s)."> + > + ["at0001"] = < + text = <"Tree"> + description = <"@ internal @"> + > + ["at0002"] = < + text = <"Extension"> + description = <"Additional information required to capture local context or to align with other reference models/formalisms."> + comment = <"e.g. Local hospital departmental infomation or additional metadata to align with FHIR or CIMI equivalents."> + > + > + > + ["es-ar"] = < + items = < + ["at0000"] = < + text = <"Encuentro"> + description = <"Interacción, contacto o evento de cuidados entre un sujeto de cuidados y uno o más proveedores de cuidados de la salud."> + > + ["at0001"] = < + text = <"*Tree(en)"> + description = <"*@ internal @(en)"> + > + ["at0002"] = < + text = <"Extensión"> + description = <"Información adicional requerida para representar el contexto local o para alineamiento con otros modelos de referencia y formalismos."> + comment = <"Ej.: Información local del departamento hospitalario o metadatos adicionales para alineamiento con los equivalentes en FHIR o CIMI."> + > + > + > + ["ko"] = < + items = < + ["at0000"] = < + text = <"*Encounter(en)"> + description = <"*Interaction, contact or care event between a subject of care and healthcare provider(s).(en)"> + > + ["at0001"] = < + text = <"*Tree(en)"> + description = <"*@ internal @(en)"> + > + ["at0002"] = < + text = <"*Extension(en)"> + description = <"*Additional information required to capture local context or to align with other reference models/formalisms.(en)"> + comment = <"*e.g. Local hospital departmental infomation or additional metadata to align with FHIR or CIMI equivalents.(en)"> + > + > + > + ["pt-br"] = < + items = < + ["at0000"] = < + text = <"Encontro"> + description = <"Interação, contato ou cuidado entre o sujeito do cuidado e profissional(is) de saúde."> + > + ["at0001"] = < + text = <"Tree"> + description = <"@ internal @"> + > + ["at0002"] = < + text = <"Extensão"> + description = <"Informações adicionais necessárias para identificar contexto local ou alinhar com outros formalismos/modelos de referência."> + comment = <"Por exemplo: informação departamental local de hospital ou metadados adicionais para alinhar com equivalentes FHIR ou CIMI."> + > + > + > + ["es"] = < + items = < + ["at0000"] = < + text = <"Encuentro"> + description = <"Interacción, contacto o evento de cuidado entre un paciente y un proveedor de salud."> + > + ["at0001"] = < + text = <"Tree"> + description = <"@ internal @"> + > + ["at0002"] = < + text = <"Extensión"> + description = <"Información adicional requerida para capturar el contexto local o alinear con otros modelos de referencia o formalismos."> + comment = <"*e.g. Local hospital departmental infomation or additional metadata to align with FHIR or CIMI equivalents.(en)"> + > + > + > + ["nl"] = < + items = < + ["at0000"] = < + text = <"Contact"> + description = <"Interactie, contact of zorggebeurtenis tussen een onderwerp van zorg en zorgverlener(s)."> + > + ["at0001"] = < + text = <"Tree"> + description = <"@ internal @"> + > + ["at0002"] = < + text = <"Extensie"> + description = <"Aanvullende informatie die vereist is om de lokale context vast te leggen of in lijn te brengen met andere referentie-modellen/formalismen."> + comment = <"Bijvoorbeeld lokale ziekenhuisafdeling informatie of aanvullende metadata om uit in lijn te brengen met FHIR of CIMI-equivalenten."> + > + > + > + ["sv"] = < + items = < + ["at0000"] = < + text = <"Vårdtillfälle"> + description = <"Interaktion, kontakt eller vårdhändelse mellan vårdtagare och vårdgivare inom hälso- och sjukvården."> + > + ["at0001"] = < + text = <"Tree"> + description = <"@ internal @"> + > + ["at0002"] = < + text = <"Extra information"> + description = <"Extra information som krävs för att fånga lokal kontext eller för anpassning till andra referensmodeller och formalismer."> + comment = <"Exempelvis information om en lokal sjukhusavdelning eller ytterligare metadata för anpassning till FHIR- eller CIMI-motsvarigheter."> + > + > + > + ["de"] = < + items = < + ["at0000"] = < + text = <"Kontakt"> + description = <"Interaktion, Kontakt oder Versorgungsereignis, zwischen einem Versorgungsempfänger und einem Gesundheitsdienstleister."> + > + ["at0001"] = < + text = <"Tree"> + description = <"@ internal @"> + > + ["at0002"] = < + text = <"Erweiterung"> + description = <"Zusätzliche Informationen, zur Erfassung lokaler Inhalte oder Anpassung an andere Referenzmodelle / Formalismen."> + comment = <"Zum Beispiel Informationen zu lokalen Krankenhausabteilungen oder zusätzliche Metadaten zur Übereinstimmung mit FHIR- oder CIMI-Äquivalenten."> + > + > + > + ["fi"] = < + items = < + ["at0000"] = < + text = <"Kontakti"> + description = <"Hoitohenkilön ja terveydenhuollon tarjoajan välinen vuorovaikutus, kontakti- tai hoitotapahtuma."> + > + ["at0001"] = < + text = <"Tree"> + description = <"@ internal @"> + > + ["at0002"] = < + text = <"Laajennus"> + description = <"*Additional information required to capture local context or to align with other reference models/formalisms.(en)"> + comment = <"*e.g. Local hospital departmental infomation or additional metadata to align with FHIR or CIMI equivalents.(en)"> + > + > + > + ["it"] = < + items = < + ["at0000"] = < + text = <"Contatto"> + description = <"Interazione, contatto o evento di cura tra un soggetto di cura e il/i fornitore/i di assistenza sanitaria."> + > + ["at0001"] = < + text = <"Tree"> + description = <"@ internal @"> + > + ["at0002"] = < + text = <"Estensione"> + description = <"Informazioni aggiuntive necessarie per catturare il contesto locale o per allinearsi con altri modelli/formalismi di riferimento."> + comment = <"e.g. Informazioni sul reparto ospedaliero locale o metadati aggiuntivi da allineare con gli equivalenti FHIR o CIMI."> + > + > + > + > diff --git a/better-template/src/test/resources/opt_json/Archetypes/openEHR-EHR-EVALUATION.health_risk-covid.v0.adl b/better-template/src/test/resources/opt_json/Archetypes/openEHR-EHR-EVALUATION.health_risk-covid.v0.adl new file mode 100644 index 000000000..2c2b89b8b --- /dev/null +++ b/better-template/src/test/resources/opt_json/Archetypes/openEHR-EHR-EVALUATION.health_risk-covid.v0.adl @@ -0,0 +1,1470 @@ +archetype (adl_version=1.4; uid=2acdfde3-dedf-4980-ae48-5f52e5e35a6c) + openEHR-EHR-EVALUATION.health_risk-covid.v0 +specialize + openEHR-EHR-EVALUATION.health_risk.v1 + +concept + [at0000.1] + +language + original_language = <[ISO_639-1::en]> + translations = < + ["de"] = < + language = <[ISO_639-1::de]> + author = < + ["name"] = <"Jasmin Buck, Sebastian Garde"> + ["organisation"] = <"University of Heidelberg, Cental Queensland University"> + > + > + ["sv"] = < + language = <[ISO_639-1::sv]> + author = < + ["name"] = <"Annika Terner"> + ["organisation"] = <"B3 Healthcare Consulting AB"> + ["email"] = <"annika.terner@b3.se"> + > + accreditation = <"."> + > + ["es-ar"] = < + language = <[ISO_639-1::es-ar]> + author = < + ["name"] = <"Alan March"> + ["organisation"] = <"Hospital Universitario Austral, Pilar, Buenos Aires, Argentina"> + ["email"] = <"alandmarch@gmail.com"> + > + > + ["nb"] = < + language = <[ISO_639-1::nb]> + author = < + > + > + ["ar-sy"] = < + language = <[ISO_639-1::ar-sy]> + author = < + ["name"] = <"Mona Saleh"> + > + > + > + +description + original_author = < + ["date"] = <"2006-04-23"> + ["name"] = <"Sam Heard"> + ["organisation"] = <"Ocean Informatics"> + ["email"] = <"sam.heard@oceaninformatics.com"> + > + lifecycle_state = <"in_development"> + other_contributors = <"Tomas Alme, DIPS, Norway","Nadim Anani, Karolinska Institutet, Sweden","Vebjørn Arntzen, Oslo University Hospital, Norway","Koray Atalag, University of Auckland, New Zealand","Silje Ljosland Bakke, Nasjonal IKT HF, Norway (openEHR Editor)","Lars Bitsch-Larsen, Haukeland University hospital, Norway","Rong Chen, Cambio Healthcare Systems, Sweden","Stephen Chu, Queensland Health, Australia","Shahla Foozonkhah, Iran ministry of health and education, Iran","Einar Fosse, National Centre for Integrated Care and Telemedicine, Norway","Sebastian Garde, Ocean Informatics, Germany","Heather Grain, Llewelyn Grain Informatics, Australia","Anca Heyd, DIPS ASA, Norway","Lars Karlsen, DIPS ASA, Norway","Lars Morgan Karlsen, DIPS ASA, Norway","Heather Leslie, Atomica Informatics, Australia (openEHR Editor)","Hallvard Lærum, Norwegian Directorate of e-health, Norway","Luis Marco Ruiz, Norwegian Center for Integrated Care and Telemedicine, Norway","Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (openEHR Editor)","Jussara Rotzsch, UNB, Brazil","Norwegian Review Summary, Nasjonal IKT HF, Norway","John Tore Valand, Helse Bergen, Norway"> + details = < + ["de"] = < + language = <[ISO_639-1::de]> + purpose = <"Zur Dokumentation des Vorhandenseins eines Risikos mit möglichen Auswirkungen jetzt oder in der Zukunft"> + keywords = <"Einschätzung", ...> + copyright = <"© openEHR Foundation"> + use = <"*Use to record known risk factors for an identified disease, condition, or other potentially adverse health issue, and/or an evaluation of the likelihood of the individual experiencing it in the future. + +As risk factors may be gradually identified over time and the overall risk reassessed as a result, the 'Date identified' will record the date on which each risk factor has been identified and the 'Last updated' data element will record the last time that the whole assessment was updated.(en)"> + > + ["sv"] = < + language = <[ISO_639-1::sv]> + purpose = <"Att registrera kända riskfaktorer för en identifierad sjukdom, tillstånd eller annat potentiellt skadligt hälsotillstånd, och / eller en utvärdering av sannolikheten för att personen upplever det i framtiden. + +Denna arketyp har medvetet lämnats öppen och omfattande. Risken kan bestämmas av riskfaktorer från någon eller alla följande domäner: medicinska; biomarkör; livsstil; social; yrkesrisk; eller miljödomäner. + +Avsikten med denna arketyp är att dokumentera potentiell risk vid en tidpunkt och att stödja beslutsfattande som kan minska den identifierade risken, vare sig av kliniker eller individen själva."> + keywords = <"Bedömning","Risk","Utvärdering","Negativ","Faktor","Hälsa","Fråga","Beräknad","Förvaltning","Riskfaktor","Risklagstiftning","Hälsorisk"> + use = <"Används för att registrera kända riskfaktorer för en identifierad sjukdom, tillstånd eller annat potentiellt skadligt hälsotillstånd, och / eller en utvärdering av sannolikheten för att personen drabbas av det i framtiden. + +Eftersom riskfaktorer kan identifieras gradvis över tiden och den övergripande risken omvärderas som ett resultat kommer den \"identifierade Datum\" att registrera det datum då varje riskfaktor har identifierats och \"Senast uppdaterad\" dataelement registrerar sista gången att hela utvärderingen uppdaterades."> + > + ["es-ar"] = < + language = <[ISO_639-1::es-ar]> + purpose = <"Para el registro de factores de riesgo para una enfermedad, condición u otro problema potencialmente adverso para la salud, y/o para la evaluación de la probabilidad de que el individuo experimente estas situaciones en el futuro. +Este arquetipo se mantiene deliberadamente abierto y amplio en su alcance. El 'Riesgo para la Salud' puede ser determinado a partir de todos o algunos de los factores de riesgo: médicos, marcadores biológicos, estilo de vidas, sociales, riesgo ocupacional o cuestiones ambientales. +El propósito de este arquetipo es la documentación de un riesgo potencial en un punto en el tiempo, y para asistir en la toma de decisiones que puedan reducir el mencionado riesgo, ya sea por parte de los médicos o del/de los individuo/s mismo/s."> + keywords = <"evaluación","riesgo","adverso","factor","salud","problema","estimado","manejo","factor de riesgo","estratificación de riesgo"> + use = <"*Use to record known risk factors for an identified disease, condition, or other potentially adverse health issue, and/or an evaluation of the likelihood of the individual experiencing it in the future. + +As risk factors may be gradually identified over time and the overall risk reassessed as a result, the 'Date identified' will record the date on which each risk factor has been identified and the 'Last updated' data element will record the last time that the whole assessment was updated.(en)"> + > + ["nb"] = < + language = <[ISO_639-1::nb]> + copyright = <"© openEHR Foundation"> + > + ["en"] = < + language = <[ISO_639-1::en]> + purpose = <"To record known risk factors for, and assess the potential risk of Covid-19 infection. + +The intent of this archetype is to document potential risk at a point in time, and to support decision-making that may reduce the identified risk, whether by clinicians or the individual themselves."> + keywords = <"assessment","risk","evaluation","adverse","factor","health","issue","estimated","management","risk factor","risk stratification"> + copyright = <"© openEHR Foundation"> + use = <"To record known risk factors for, and assess the potential risk of Covid-19 infection. + +As risk factors may be gradually identified over time and the overall risk reassessed as a result, the 'Date identified' will record the date on which each risk factor has been identified and the 'Last updated' data element will record the last time that the whole assessment was updated."> + > + ["ar-sy"] = < + language = <[ISO_639-1::ar-sy]> + purpose = <"لتسجيل التخاطر/احتمالية الخطر لظرف صحي قد يحدث في المستقبل"> + keywords = <"تقييم", ...> + copyright = <"© openEHR Foundation"> + use = <"*Use to record known risk factors for an identified disease, condition, or other potentially adverse health issue, and/or an evaluation of the likelihood of the individual experiencing it in the future. + +As risk factors may be gradually identified over time and the overall risk reassessed as a result, the 'Date identified' will record the date on which each risk factor has been identified and the 'Last updated' data element will record the last time that the whole assessment was updated.(en)"> + > + > + other_details = < + ["licence"] = <"This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/."> + ["custodian_organisation"] = <"openEHR Foundation"> + ["references"] = <"Health Risk, draft archetype, NEHTA Clinical Knowledge Manager [Internet]. Australia: National eHealth Transition Authority. Authored: 2006 Apr 23. Available at: http://dcm.nehta.org.au/ckm/#showArchetype_1013.1.1276 (accessed 2015 Mar 04). Archetype originated from the openEHR CKM."> + ["current_contact"] = <"Heather Leslie, Ocean Informatics, heather.leslie@oceaninformatics.com"> + ["original_namespace"] = <"org.openehr"> + ["original_publisher"] = <"openEHR Foundation"> + ["custodian_namespace"] = <"org.openehr"> + ["MD5-CAM-1.0.1"] = <"03B14078CEB48557FFC1FD66146A5504"> + ["build_uid"] = <"969a371b-422b-4ed0-8637-8405244540af"> + ["revision"] = <"0.0.1-alpha"> + > + +definition + EVALUATION[at0000.1] matches { -- Covid-19 infection risk assessment + data matches { + ITEM_TREE[at0001] matches { -- structure + items cardinality matches {1..*; ordered} matches { + ELEMENT[at0002.1] matches { -- Health risk + value matches { + DV_CODED_TEXT matches { + defining_code matches { + [local::at0.1] -- COVID-19 Risk assessment + } + } + } + } + CLUSTER[at0016] occurrences matches {0..*} matches { -- Risk factors + items cardinality matches {1..*; unordered} matches { + ELEMENT[at0013.1] matches { -- Risk factor + value matches { + DV_CODED_TEXT matches { + defining_code matches { + [local:: + at0.9, -- Contact with confirmed Covid-19 case + at0.14, -- Potential contact exposure based on location + at0.10, -- Contact with suspected case/ pneumonia case + at0.13, -- Contact with severe, unexplained respiratory disease + at0.11, -- Contact with birds in China + at0.12, -- Contact with confirmed human case of Avian flu in China + at0.18, -- Needs admission for respiratory disease + at0.19, -- Other household members are ill + at0.20] -- Household members with travel exposure + } + } + } + } + ELEMENT[at0017.1] occurrences matches {0..1} matches { * -- Presence + -- value matches { + -- DV_CODED_TEXT matches { + -- defining_code matches { + -- [local:: + -- at0018, -- Present + -- at0019, -- Absent + -- at0.15] -- Unknown + -- } + -- } + -- } + } + ELEMENT[at0014] occurrences matches {0..1} matches { -- Description + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0029] occurrences matches {0..1} matches { -- Date identified + value matches { + DV_DATE_TIME matches {*} + } + } + ELEMENT[at0028] occurrences matches {0..1} matches { -- Mitigated + value matches { + DV_BOOLEAN matches { + value matches {true} + } + } + } + ELEMENT[at0012] occurrences matches {0..*} matches { -- Link to evidence + value matches { + DV_URI matches {*} + } + } + allow_archetype CLUSTER[at0027.1] occurrences matches {0..*} matches { -- Detail + include + archetype_id/value matches {/.*/} + } + ELEMENT[at0030] occurrences matches {0..1} matches { -- Comment + value matches { + DV_TEXT matches {*} + } + } + } + } + ELEMENT[at0003.1] occurrences matches {0..1} matches { -- Risk assessment + value matches { + DV_CODED_TEXT matches { + defining_code matches { + [local:: + at0.16, -- Low risk + at0.17] -- High risk + } + } + } + } + ELEMENT[at0020] occurrences matches {0..1} matches { -- Assessment type + value matches { + DV_CODED_TEXT matches { + defining_code matches { + [local:: + at0021, -- Relative risk + at0022] -- Absolute risk + } + } + } + } + ELEMENT[at0023] occurrences matches {0..1} matches { -- Time period + value matches { + DV_DURATION matches {*} + } + } + ELEMENT[at0004] occurrences matches {0..1} matches { -- Rationale + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0015] occurrences matches {0..1} matches { -- Comment + value matches { + DV_TEXT matches {*} + } + } + } + } + } + protocol matches { + ITEM_TREE[at0010] matches { -- Tree + items cardinality matches {0..*; unordered} matches { + ELEMENT[at0024] occurrences matches {0..1} matches { -- Last updated + value matches { + DV_DATE_TIME matches {*} + } + } + ELEMENT[at0025] occurrences matches {0..1} matches { -- Assessment method + value matches { + DV_TEXT matches {*} + } + } + allow_archetype CLUSTER[at0011] occurrences matches {0..*} matches { -- Extension + include + archetype_id/value matches {/.*/} + } + } + } + } + } + +ontology + term_definitions = < + ["ar-sy"] = < + items = < + ["at0000.1"] = < + text = <"*Health risk assessment(en)"> + description = <"*Assessment of the potential and likelihood of future adverse health effects as determined by identified risk factors.(en)"> + > + ["at0002.1"] = < + text = <"*Health risk(en)"> + description = <"*Identification of the potential future disease, condition or health issue for which the risk is being assessed, by name.(en)"> + comment = <"*Coding of 'Health risk' with a terminology is preferred, where possible. Free text should be used only if there is no appropriate terminology available. For example: risk of cardiovascular disease, with risk factors of hypertension and hypercholesterolaemia.(en)"> + > + ["at0.1"] = < + text = <"*COVID-19 Risk assessment (en)"> + description = <"*Assessment of risk of COVID-19 infection (en)"> + > + ["at0013.1"] = < + text = <"*Risk factor(en)"> + description = <"*Identification of the risk factor, by name.(en)"> + comment = <"*For example: hypertension and hypercholesterolaemia, which may be used as part of the overall assessment for cardiovascular disease; or a genetic marker. Coding of +'Risk factor' with a terminology, where possible.(en)"> + > + ["at0.9"] = < + text = <"*Contact with confirmed Covid-19 case (en)"> + description = <"*"> + > + ["at0.10"] = < + text = <"*Contact with suspected case/ pneumonia case (en)"> + description = <"*Contact with suspected case/ pneumonia case within 14 days before symptom onset. (en)"> + > + ["at0.11"] = < + text = <"*Contact with birds in China (en)"> + description = <"*Contact with birds in China in 10 days before symptom onset. (en)"> + > + ["at0.12"] = < + text = <"*Contact with confirmed human case of Avian flu in China (en)"> + description = <"*Contact with confirmed human case of Avian flu in China in 10 days before symptom onset. (en)"> + > + ["at0.13"] = < + text = <"*Contact with severe, unexplained respiratory disease (en)"> + description = <"*Contact with severe, unexplained respiratory disease in 10 days before symptom onset. (en)"> + > + ["at0.14"] = < + text = <"*Potential contact exposure based on location (en)"> + description = <"*Potential contact exposure based on location (en)"> + > + ["at0027.1"] = < + text = <"*Detail(en)"> + description = <"*Structured detail about other aspects of the risk factor assessment.(en)"> + comment = <"*For example: Prevalence of the risk factor in family members.(en)"> + > + ["at0017.1"] = < + text = <"*Presence(en)"> + description = <"*Presence of the risk factor.(en)"> + > + ["at0.15"] = < + text = <"*Unknown (en)"> + description = <"*No information is available for this risk factor. (en)"> + > + ["at0003.1"] = < + text = <"*Risk assessment(en)"> + description = <"*Evaluation of the health risk.(en)"> + comment = <"*There may be multiple variations on the assessment of risk. The Choice data type allows for recording of the assessment as either free text or value sets (such as low, medium or hig). The proportion data type allows recording of a percentage, a ratio or a fraction. The quantity data type allows recording of a decimal number.(en)"> + > + ["at0.16"] = < + text = <"*Low risk (en)"> + description = <"*Covid19 infection is assessed to be low-risk (en)"> + > + ["at0.17"] = < + text = <"*High risk (en)"> + description = <"*The risk of the a patient having a Covid-19 infection is assessed to be high. (en)"> + > + ["at0.18"] = < + text = <"*Needs admission for respiratory disease (en)"> + description = <"*Does the patient require hospital admission with either clinical or radiological evidence of pneumonia, adult respiratory distress syndrome, or influenza like illness? (en)"> + > + ["at0000"] = < + text = <"*Health risk assessment(en)"> + description = <"*Assessment of the potential and likelihood of future adverse health effects as determined by identified risk factors.(en)"> + > + ["at0001"] = < + text = <"*structure(en)"> + description = <"*@ internal @(en)"> + > + ["at0002"] = < + text = <"*Health risk(en)"> + description = <"*Identification of the potential future disease, condition or health issue for which the risk is being assessed, by name.(en)"> + comment = <"*Coding of 'Health risk' with a terminology is preferred, where possible. Free text should be used only if there is no appropriate terminology available. For example: risk of cardiovascular disease, with risk factors of hypertension and hypercholesterolaemia.(en)"> + > + ["at0003"] = < + text = <"*Risk assessment(en)"> + description = <"*Evaluation of the health risk.(en)"> + comment = <"*There may be multiple variations on the assessment of risk. The Choice data type allows for recording of the assessment as either free text or value sets (such as low, medium or hig). The proportion data type allows recording of a percentage, a ratio or a fraction. The quantity data type allows recording of a decimal number.(en)"> + > + ["at0004"] = < + text = <"*Rationale(en)"> + description = <"*Justification for this risk assessment.(en)"> + comment = <"*Details that may be added to this data element may include information about the population subgroups etc against which the determination of risk is assessed.(en)"> + > + ["at0010"] = < + text = <"*Tree(en)"> + description = <"*@ internal @(en)"> + > + ["at0011"] = < + text = <"*Extension(en)"> + description = <"*Additional information required to capture local content or to align with other reference models/formalisms.(en)"> + comment = <"*For example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.(en)"> + > + ["at0012"] = < + text = <"*Link to evidence(en)"> + description = <"*Identification of the path to the archetype or data node for the evidence of risk.(en)"> + > + ["at0013"] = < + text = <"*Risk factor(en)"> + description = <"*Identification of the risk factor, by name.(en)"> + comment = <"*For example: hypertension and hypercholesterolaemia, which may be used as part of the overall assessment for cardiovascular disease; or a genetic marker. Coding of +'Risk factor' with a terminology, where possible.(en)"> + > + ["at0014"] = < + text = <"*Description(en)"> + description = <"*Narrative description about the risk factor.(en)"> + > + ["at0015"] = < + text = <"*Comment(en)"> + description = <"*Additional narrative about the risk assessment not captured in other fields.(en)"> + > + ["at0016"] = < + text = <"*Risk factors(en)"> + description = <"*Details about each possible risk factor.(en)"> + > + ["at0017"] = < + text = <"*Presence(en)"> + description = <"*Presence of the risk factor.(en)"> + > + ["at0018"] = < + text = <"*Present(en)"> + description = <"*The risk factor has been identified for this individual.(en)"> + > + ["at0019"] = < + text = <"*Absent(en)"> + description = <"*The risk factor has not been identified for this individual.(en)"> + > + ["at0020"] = < + text = <"*Assessment type(en)"> + description = <"*Record of whether the risk assessment is a relative or absolute.(en)"> + > + ["at0021"] = < + text = <"*Relative risk(en)"> + description = <"*Ratio of probability of a health event or condition occurring compared to a population with similar characteristics eg same age and sex.(en)"> + > + ["at0022"] = < + text = <"*Absolute risk(en)"> + description = <"*Ratio of probability of a health event or condition occurring compared to the population as a whole.(en)"> + > + ["at0023"] = < + text = <"*Time period(en)"> + description = <"*The time period during which the predicted health risk is relevant.(en)"> + comment = <"*That is: the risk of experiencing the identified 'Health risk' in the next years.(en)"> + > + ["at0024"] = < + text = <"*Last Updated(en)"> + description = <"*The date this health risk assessment was last updated.(en)"> + comment = <"*This data element may be thought redundant if the data is recorded and stored using COMPOSITIONs within a closed clinical system. However if this information is extracted from its original COMPOSITION context, for example, to be included in another document or message then the temporal context is effectively removed. This 'Last updated' data element has been explicitly added to allow the critical temporal data to be kept alongside the clinical data in all circumstances. It is assumed that the clinical system can copy the date from the COMPOSITION to reduce the need for duplication of data entry by the clinician. (en)"> + > + ["at0025"] = < + text = <"*Assessment method(en)"> + description = <"*Identification of the algorithm or guideline used to make the assessment of risk.(en)"> + comment = <"*For example: Framingham cardiovascular risk calculator.(en)"> + > + ["at0026"] = < + text = <"*Indeterminate(en)"> + description = <"*It is not possible to determine if the risk factor is present or absent.(en)"> + > + ["at0027"] = < + text = <"*Detail(en)"> + description = <"*Structured detail about other aspects of the risk factor assessment.(en)"> + comment = <"*For example: Prevalence of the risk factor in family members.(en)"> + > + ["at0028"] = < + text = <"*Mitigated(en)"> + description = <"*The risk factor has been identified as present, but then subsequently been mitigated by treatment or investigation.(en)"> + comment = <"*Record as True if the risk factor has been treated or investigated and risk from this risk factor is considered to be lessened. For example: an infant given gentamicin in neonatal intensive care is regarded as having a risk of permanent hearing loss. If diagnostic testing shows no evidence of hearing loss in the first year of life, the risk of later hearing loss is considered to be much reduced, but still possible. This data element allows clinicians to say that the risk has been mitigated but should still be considered as a possibility in future. In practice, the risk factor could be maintained in the risk assessment in case it might impact the individual's health at a future time, but flagging that its contribution to risk calculation may not be as great as if it had not been previously treated or investigated. (en)"> + > + ["at0029"] = < + text = <"*Date identified(en)"> + description = <"*The date/time that the risk factor was identified.(en)"> + > + ["at0030"] = < + text = <"*Comment(en)"> + description = <"*Additional narrative about the risk factor not captured in other fields.(en)"> + > + ["at0.19"] = < + text = <"*Other household members are ill (en)"> + description = <"*The patient is in a house with other household members who are ill (en)"> + > + ["at0.20"] = < + text = <"*Household members with travel exposure (en)"> + description = <"*Members of the patient's household have travel exposure. (en)"> + > + > + > + ["de"] = < + items = < + ["at0000.1"] = < + text = <"*Health risk assessment(en)"> + description = <"*Assessment of the potential and likelihood of future adverse health effects as determined by identified risk factors.(en)"> + > + ["at0002.1"] = < + text = <"*Health risk(en)"> + description = <"*Identification of the potential future disease, condition or health issue for which the risk is being assessed, by name.(en)"> + comment = <"*Coding of 'Health risk' with a terminology is preferred, where possible. Free text should be used only if there is no appropriate terminology available. For example: risk of cardiovascular disease, with risk factors of hypertension and hypercholesterolaemia.(en)"> + > + ["at0.1"] = < + text = <"*COVID-19 Risk assessment (en)"> + description = <"*Assessment of risk of COVID-19 infection (en)"> + > + ["at0013.1"] = < + text = <"*Risk factor(en)"> + description = <"*Identification of the risk factor, by name.(en)"> + comment = <"*For example: hypertension and hypercholesterolaemia, which may be used as part of the overall assessment for cardiovascular disease; or a genetic marker. Coding of +'Risk factor' with a terminology, where possible.(en)"> + > + ["at0.9"] = < + text = <"*Contact with confirmed Covid-19 case (en)"> + description = <"*"> + > + ["at0.10"] = < + text = <"*Contact with suspected case/ pneumonia case (en)"> + description = <"*Contact with suspected case/ pneumonia case within 14 days before symptom onset. (en)"> + > + ["at0.11"] = < + text = <"*Contact with birds in China (en)"> + description = <"*Contact with birds in China in 10 days before symptom onset. (en)"> + > + ["at0.12"] = < + text = <"*Contact with confirmed human case of Avian flu in China (en)"> + description = <"*Contact with confirmed human case of Avian flu in China in 10 days before symptom onset. (en)"> + > + ["at0.13"] = < + text = <"*Contact with severe, unexplained respiratory disease (en)"> + description = <"*Contact with severe, unexplained respiratory disease in 10 days before symptom onset. (en)"> + > + ["at0.14"] = < + text = <"*Potential contact exposure based on location (en)"> + description = <"*Potential contact exposure based on location (en)"> + > + ["at0027.1"] = < + text = <"*Detail(en)"> + description = <"*Structured detail about other aspects of the risk factor assessment.(en)"> + comment = <"*For example: Prevalence of the risk factor in family members.(en)"> + > + ["at0017.1"] = < + text = <"*Presence(en)"> + description = <"*Presence of the risk factor.(en)"> + > + ["at0.15"] = < + text = <"*Unknown (en)"> + description = <"*No information is available for this risk factor. (en)"> + > + ["at0003.1"] = < + text = <"*Risk assessment(en)"> + description = <"*Evaluation of the health risk.(en)"> + comment = <"*There may be multiple variations on the assessment of risk. The Choice data type allows for recording of the assessment as either free text or value sets (such as low, medium or hig). The proportion data type allows recording of a percentage, a ratio or a fraction. The quantity data type allows recording of a decimal number.(en)"> + > + ["at0.16"] = < + text = <"*Low risk (en)"> + description = <"*Covid19 infection is assessed to be low-risk (en)"> + > + ["at0.17"] = < + text = <"*High risk (en)"> + description = <"*The risk of the a patient having a Covid-19 infection is assessed to be high. (en)"> + > + ["at0.18"] = < + text = <"*Needs admission for respiratory disease (en)"> + description = <"*Does the patient require hospital admission with either clinical or radiological evidence of pneumonia, adult respiratory distress syndrome, or influenza like illness? (en)"> + > + ["at0000"] = < + text = <"*Health risk assessment(en)"> + description = <"*Assessment of the potential and likelihood of future adverse health effects as determined by identified risk factors.(en)"> + > + ["at0001"] = < + text = <"structure"> + description = <"@ internal @"> + > + ["at0002"] = < + text = <"*Health risk(en)"> + description = <"*Identification of the potential future disease, condition or health issue for which the risk is being assessed, by name.(en)"> + comment = <"*Coding of 'Health risk' with a terminology is preferred, where possible. Free text should be used only if there is no appropriate terminology available. For example: risk of cardiovascular disease, with risk factors of hypertension and hypercholesterolaemia.(en)"> + > + ["at0003"] = < + text = <"*Risk assessment(en)"> + description = <"*Evaluation of the health risk.(en)"> + comment = <"*There may be multiple variations on the assessment of risk. The Choice data type allows for recording of the assessment as either free text or value sets (such as low, medium or hig). The proportion data type allows recording of a percentage, a ratio or a fraction. The quantity data type allows recording of a decimal number.(en)"> + > + ["at0004"] = < + text = <"*Rationale(en)"> + description = <"*Justification for this risk assessment.(en)"> + comment = <"*Details that may be added to this data element may include information about the population subgroups etc against which the determination of risk is assessed.(en)"> + > + ["at0010"] = < + text = <"*Tree(en)"> + description = <"*@ internal @(en)"> + > + ["at0011"] = < + text = <"*Extension(en)"> + description = <"*Additional information required to capture local content or to align with other reference models/formalisms.(en)"> + comment = <"*For example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.(en)"> + > + ["at0012"] = < + text = <"*Link to evidence(en)"> + description = <"*Identification of the path to the archetype or data node for the evidence of risk.(en)"> + > + ["at0013"] = < + text = <"*Risk factor(en)"> + description = <"*Identification of the risk factor, by name.(en)"> + comment = <"*For example: hypertension and hypercholesterolaemia, which may be used as part of the overall assessment for cardiovascular disease; or a genetic marker. Coding of +'Risk factor' with a terminology, where possible.(en)"> + > + ["at0014"] = < + text = <"*Description(en)"> + description = <"*Narrative description about the risk factor.(en)"> + > + ["at0015"] = < + text = <"*Comment(en)"> + description = <"*Additional narrative about the risk assessment not captured in other fields.(en)"> + > + ["at0016"] = < + text = <"*Risk factors(en)"> + description = <"*Details about each possible risk factor.(en)"> + > + ["at0017"] = < + text = <"*Presence(en)"> + description = <"*Presence of the risk factor.(en)"> + > + ["at0018"] = < + text = <"*Present(en)"> + description = <"*The risk factor has been identified for this individual.(en)"> + > + ["at0019"] = < + text = <"*Absent(en)"> + description = <"*The risk factor has not been identified for this individual.(en)"> + > + ["at0020"] = < + text = <"*Assessment type(en)"> + description = <"*Record of whether the risk assessment is a relative or absolute.(en)"> + > + ["at0021"] = < + text = <"*Relative risk(en)"> + description = <"*Ratio of probability of a health event or condition occurring compared to a population with similar characteristics eg same age and sex.(en)"> + > + ["at0022"] = < + text = <"*Absolute risk(en)"> + description = <"*Ratio of probability of a health event or condition occurring compared to the population as a whole.(en)"> + > + ["at0023"] = < + text = <"*Time period(en)"> + description = <"*The time period during which the predicted health risk is relevant.(en)"> + comment = <"*That is: the risk of experiencing the identified 'Health risk' in the next years.(en)"> + > + ["at0024"] = < + text = <"*Last Updated(en)"> + description = <"*The date this health risk assessment was last updated.(en)"> + comment = <"*This data element may be thought redundant if the data is recorded and stored using COMPOSITIONs within a closed clinical system. However if this information is extracted from its original COMPOSITION context, for example, to be included in another document or message then the temporal context is effectively removed. This 'Last updated' data element has been explicitly added to allow the critical temporal data to be kept alongside the clinical data in all circumstances. It is assumed that the clinical system can copy the date from the COMPOSITION to reduce the need for duplication of data entry by the clinician. (en)"> + > + ["at0025"] = < + text = <"*Assessment method(en)"> + description = <"*Identification of the algorithm or guideline used to make the assessment of risk.(en)"> + comment = <"*For example: Framingham cardiovascular risk calculator.(en)"> + > + ["at0026"] = < + text = <"*Indeterminate(en)"> + description = <"*It is not possible to determine if the risk factor is present or absent.(en)"> + > + ["at0027"] = < + text = <"*Detail(en)"> + description = <"*Structured detail about other aspects of the risk factor assessment.(en)"> + comment = <"*For example: Prevalence of the risk factor in family members.(en)"> + > + ["at0028"] = < + text = <"*Mitigated(en)"> + description = <"*The risk factor has been identified as present, but then subsequently been mitigated by treatment or investigation.(en)"> + comment = <"*Record as True if the risk factor has been treated or investigated and risk from this risk factor is considered to be lessened. For example: an infant given gentamicin in neonatal intensive care is regarded as having a risk of permanent hearing loss. If diagnostic testing shows no evidence of hearing loss in the first year of life, the risk of later hearing loss is considered to be much reduced, but still possible. This data element allows clinicians to say that the risk has been mitigated but should still be considered as a possibility in future. In practice, the risk factor could be maintained in the risk assessment in case it might impact the individual's health at a future time, but flagging that its contribution to risk calculation may not be as great as if it had not been previously treated or investigated. (en)"> + > + ["at0029"] = < + text = <"*Date identified(en)"> + description = <"*The date/time that the risk factor was identified.(en)"> + > + ["at0030"] = < + text = <"*Comment(en)"> + description = <"*Additional narrative about the risk factor not captured in other fields.(en)"> + > + ["at0.19"] = < + text = <"*Other household members are ill (en)"> + description = <"*The patient is in a house with other household members who are ill (en)"> + > + ["at0.20"] = < + text = <"*Household members with travel exposure (en)"> + description = <"*Members of the patient's household have travel exposure. (en)"> + > + > + > + ["en"] = < + items = < + ["at0000.1"] = < + text = <"Covid-19 infection risk assessment"> + description = <"Assessment of the potential and likelihood of Covid-19 infection as determined by identified risk factors."> + > + ["at0002.1"] = < + text = <"Health risk"> + description = <"Identification of the potential future disease, condition or health issue for which the risk is being assessed, by name."> + comment = <"Coding of 'Health risk' with a terminology is preferred, where possible. Free text should be used only if there is no appropriate terminology available. For example: risk of cardiovascular disease, with risk factors of hypertension and hypercholesterolaemia."> + > + ["at0.1"] = < + text = <"COVID-19 Risk assessment"> + description = <"Assessment of risk of COVID-19 infection."> + > + ["at0013.1"] = < + text = <"Risk factor"> + description = <"Identification of the risk factor, by name."> + comment = <"For example: hypertension and hypercholesterolaemia, which may be used as part of the overall assessment for cardiovascular disease; or a genetic marker. Coding of +'Risk factor' with a terminology, where possible."> + > + ["at0.9"] = < + text = <"Contact with confirmed Covid-19 case"> + description = <"Contact with confirmed Covid-19 case within 14 days before symptom onset."> + > + ["at0.10"] = < + text = <"Contact with suspected case/ pneumonia case"> + description = <"Contact with suspected case/ pneumonia case within 14 days before symptom onset."> + > + ["at0.11"] = < + text = <"Contact with birds in China"> + description = <"Contact with birds in China in 10 days before symptom onset."> + > + ["at0.12"] = < + text = <"Contact with confirmed human case of Avian flu in China"> + description = <"Contact with confirmed human case of Avian flu in China in 10 days before symptom onset."> + > + ["at0.13"] = < + text = <"Contact with severe, unexplained respiratory disease"> + description = <"Contact with severe, unexplained respiratory disease in 10 days before symptom onset."> + > + ["at0.14"] = < + text = <"Potential contact exposure based on location"> + description = <"Potential contact exposure based on location."> + > + ["at0027.1"] = < + text = <"Detail"> + description = <"Structured detail about other aspects of the risk factor assessment."> + comment = <"For example: Prevalence of the risk factor in family members."> + > + ["at0017.1"] = < + text = <"Presence"> + description = <"Presence of the risk factor."> + > + ["at0.15"] = < + text = <"Unknown"> + description = <"No information is available for this risk factor."> + > + ["at0003.1"] = < + text = <"Risk assessment"> + description = <"Evaluation of the health risk."> + comment = <"There may be multiple variations on the assessment of risk. The Choice data type allows for recording of the assessment as either free text or value sets (such as low, medium or hig). The proportion data type allows recording of a percentage, a ratio or a fraction. The quantity data type allows recording of a decimal number."> + > + ["at0.16"] = < + text = <"Low risk"> + description = <"The risk of the a patient having a Covid-19 infection is assessed to be low."> + > + ["at0.17"] = < + text = <"High risk"> + description = <"The risk of the a patient having a Covid-19 infection is assessed to be high."> + > + ["at0.18"] = < + text = <"Needs admission for respiratory disease"> + description = <"Does the patient require hospital admission with either clinical or radiological evidence of pneumonia, adult respiratory distress syndrome, or influenza like illness?"> + > + ["at0000"] = < + text = <"Health risk assessment"> + description = <"Assessment of the potential and likelihood of future adverse health effects as determined by identified risk factors."> + > + ["at0001"] = < + text = <"structure"> + description = <"@ internal @"> + > + ["at0002"] = < + text = <"Health risk"> + description = <"Identification of the potential future disease, condition or health issue for which the risk is being assessed, by name."> + comment = <"Coding of 'Health risk' with a terminology is preferred, where possible. Free text should be used only if there is no appropriate terminology available. For example: risk of cardiovascular disease, with risk factors of hypertension and hypercholesterolaemia."> + > + ["at0003"] = < + text = <"Risk assessment"> + description = <"Evaluation of the health risk."> + comment = <"There may be multiple variations on the assessment of risk. The Choice data type allows for recording of the assessment as either free text or value sets (such as low, medium or hig). The proportion data type allows recording of a percentage, a ratio or a fraction. The quantity data type allows recording of a decimal number."> + > + ["at0004"] = < + text = <"Rationale"> + description = <"Justification for this risk assessment."> + comment = <"Details that may be added to this data element may include information about the population subgroups etc against which the determination of risk is assessed."> + > + ["at0010"] = < + text = <"Tree"> + description = <"@ internal @"> + > + ["at0011"] = < + text = <"Extension"> + description = <"Additional information required to capture local content or to align with other reference models/formalisms."> + comment = <"For example: local information requirements or additional metadata to align with FHIR or CIMI equivalents."> + > + ["at0012"] = < + text = <"Link to evidence"> + description = <"Identification of the path to the archetype or data node for the evidence of risk."> + > + ["at0013"] = < + text = <"Risk factor"> + description = <"Identification of the risk factor, by name."> + comment = <"For example: hypertension and hypercholesterolaemia, which may be used as part of the overall assessment for cardiovascular disease; or a genetic marker. Coding of +'Risk factor' with a terminology, where possible."> + > + ["at0014"] = < + text = <"Description"> + description = <"Narrative description about the risk factor."> + > + ["at0015"] = < + text = <"Comment"> + description = <"Additional narrative about the risk assessment not captured in other fields."> + > + ["at0016"] = < + text = <"Risk factors"> + description = <"Details about each possible risk factor."> + > + ["at0017"] = < + text = <"Presence"> + description = <"Presence of the risk factor."> + > + ["at0018"] = < + text = <"Present"> + description = <"The risk factor has been identified for this individual."> + > + ["at0019"] = < + text = <"Absent"> + description = <"The risk factor has not been identified for this individual."> + > + ["at0020"] = < + text = <"Assessment type"> + description = <"Record of whether the risk assessment is a relative or absolute."> + > + ["at0021"] = < + text = <"Relative risk"> + description = <"Ratio of probability of a health event or condition occurring compared to a population with similar characteristics eg same age and sex."> + > + ["at0022"] = < + text = <"Absolute risk"> + description = <"Ratio of probability of a health event or condition occurring compared to the population as a whole."> + > + ["at0023"] = < + text = <"Time period"> + description = <"The time period during which the predicted health risk is relevant."> + comment = <"That is: the risk of experiencing the identified 'Health risk' in the next years."> + > + ["at0024"] = < + text = <"Last updated"> + description = <"The date this health risk assessment was last updated."> + comment = <"This data element may be thought redundant if the data is recorded and stored using COMPOSITIONs within a closed clinical system. However if this information is extracted from its original COMPOSITION context, for example, to be included in another document or message then the temporal context is effectively removed. This 'Last updated' data element has been explicitly added to allow the critical temporal data to be kept alongside the clinical data in all circumstances. It is assumed that the clinical system can copy the date from the COMPOSITION to reduce the need for duplication of data entry by the clinician."> + > + ["at0025"] = < + text = <"Assessment method"> + description = <"Identification of the algorithm or guideline used to make the assessment of risk."> + comment = <"For example: Framingham cardiovascular risk calculator."> + > + ["at0026"] = < + text = <"Indeterminate"> + description = <"It is not possible to determine if the risk factor is present or absent."> + > + ["at0027"] = < + text = <"Detail"> + description = <"Structured detail about other aspects of the risk factor assessment."> + comment = <"For example: Prevalence of the risk factor in family members."> + > + ["at0028"] = < + text = <"Mitigated"> + description = <"The risk factor has been identified as present, but then subsequently been mitigated by treatment or investigation."> + comment = <"Record as True if the risk factor has been treated or investigated and risk from this risk factor is considered to be lessened. For example: an infant given gentamicin in neonatal intensive care is regarded as having a risk of permanent hearing loss. If diagnostic testing shows no evidence of hearing loss in the first year of life, the risk of later hearing loss is considered to be much reduced, but still possible. This data element allows clinicians to say that the risk has been mitigated but should still be considered as a possibility in future. In practice, the risk factor could be maintained in the risk assessment in case it might impact the individual's health at a future time, but flagging that its contribution to risk calculation may not be as great as if it had not been previously treated or investigated. "> + > + ["at0029"] = < + text = <"Date identified"> + description = <"The date/time that the risk factor was identified."> + > + ["at0030"] = < + text = <"Comment"> + description = <"Additional narrative about the risk factor not captured in other fields."> + > + ["at0.19"] = < + text = <"Other household members are ill"> + description = <"The patient is in a house with other household members who are ill"> + > + ["at0.20"] = < + text = <"Household members with travel exposure"> + description = <"Members of the patient's household have travel exposure."> + > + > + > + ["es-ar"] = < + items = < + ["at0000.1"] = < + text = <"Evaluacion de riesgo para la salud"> + description = <"Evaluación del potencial y probabilidad de futuros efectos adversos para la salud determinados por la identificación de factores de riesgo."> + > + ["at0002.1"] = < + text = <"Riesgo para la salud"> + description = <"Identificación, por nombre, de la enfermedad, condición o problema de salud potenciales para el cual se evalua el riesgo."> + comment = <"Se prefiere la codificación del 'Riesgo para la salud' mediante una terminología cuando esto sea posible. El texto libre solo debería ser utilizado cuando no se disponga de una terminología adecuada. Por ejemplo: riesgo de enfermedad cardiovascular con factores de riesgo de hipertensión arterial e hipercolesterolemia."> + > + ["at0.1"] = < + text = <"*COVID-19 Risk assessment (en)"> + description = <"*Assessment of risk of COVID-19 infection (en)"> + > + ["at0013.1"] = < + text = <"Factor de riesgo"> + description = <"Identificación, por nombre, del factor de riesgo."> + comment = <"Por ejemplo: hipertensión arterial e hipercolesterolemia, que pueden ser utilizados como parte de una evaluación general de enfermedad cardiovascular; o un marcador genético. Codificar el factor de riesgo mediante una terminología cuando esto sea posible."> + > + ["at0.9"] = < + text = <"*Contact with confirmed Covid-19 case (en)"> + description = <"*"> + > + ["at0.10"] = < + text = <"*Contact with suspected case/ pneumonia case (en)"> + description = <"*Contact with suspected case/ pneumonia case within 14 days before symptom onset. (en)"> + > + ["at0.11"] = < + text = <"*Contact with birds in China (en)"> + description = <"*Contact with birds in China in 10 days before symptom onset. (en)"> + > + ["at0.12"] = < + text = <"*Contact with confirmed human case of Avian flu in China (en)"> + description = <"*Contact with confirmed human case of Avian flu in China in 10 days before symptom onset. (en)"> + > + ["at0.13"] = < + text = <"*Contact with severe, unexplained respiratory disease (en)"> + description = <"*Contact with severe, unexplained respiratory disease in 10 days before symptom onset. (en)"> + > + ["at0.14"] = < + text = <"*Potential contact exposure based on location (en)"> + description = <"*Potential contact exposure based on location (en)"> + > + ["at0027.1"] = < + text = <"Detalle"> + description = <"Detalle estructurado acerca de otros aspectos de la evaluación del factor de riesgo."> + comment = <"Por ejemplo: Prevalencia del factor de riesgo en famililares."> + > + ["at0017.1"] = < + text = <"Presencia"> + description = <"Presencia del factor de riesgo."> + > + ["at0.15"] = < + text = <"*Unknown (en)"> + description = <"*No information is available for this risk factor. (en)"> + > + ["at0003.1"] = < + text = <"Evaluación de riesgo"> + description = <"Evaluación del riesgo para la salud."> + comment = <"Pueden haber múltiples variaciones en la evaluación de riesgo. La elección del tipo de dato permite el registro de la evaluación tanto mediante texto libre como mediante un conjunto de valores (tales como bajo, medio o alto). El tipo de dato 'proporción' permite el registro como un porcentaje, una tasa o una fracción. El tipo de dato 'cantidad' permite el registro como un número decimal."> + > + ["at0.16"] = < + text = <"*Low risk (en)"> + description = <"*Covid19 infection is assessed to be low-risk (en)"> + > + ["at0.17"] = < + text = <"*High risk (en)"> + description = <"*The risk of the a patient having a Covid-19 infection is assessed to be high. (en)"> + > + ["at0.18"] = < + text = <"*Needs admission for respiratory disease (en)"> + description = <"*Does the patient require hospital admission with either clinical or radiological evidence of pneumonia, adult respiratory distress syndrome, or influenza like illness? (en)"> + > + ["at0000"] = < + text = <"Evaluacion de riesgo para la salud"> + description = <"Evaluación del potencial y probabilidad de futuros efectos adversos para la salud determinados por la identificación de factores de riesgo."> + > + ["at0001"] = < + text = <"structure"> + description = <"@ internal @"> + > + ["at0002"] = < + text = <"Riesgo para la salud"> + description = <"Identificación, por nombre, de la enfermedad, condición o problema de salud potenciales para el cual se evalua el riesgo."> + comment = <"Se prefiere la codificación del 'Riesgo para la salud' mediante una terminología cuando esto sea posible. El texto libre solo debería ser utilizado cuando no se disponga de una terminología adecuada. Por ejemplo: riesgo de enfermedad cardiovascular con factores de riesgo de hipertensión arterial e hipercolesterolemia."> + > + ["at0003"] = < + text = <"Evaluación de riesgo"> + description = <"Evaluación del riesgo para la salud."> + comment = <"Pueden haber múltiples variaciones en la evaluación de riesgo. La elección del tipo de dato permite el registro de la evaluación tanto mediante texto libre como mediante un conjunto de valores (tales como bajo, medio o alto). El tipo de dato 'proporción' permite el registro como un porcentaje, una tasa o una fracción. El tipo de dato 'cantidad' permite el registro como un número decimal."> + > + ["at0004"] = < + text = <"Razón"> + description = <"Justificación para esta evaluación de riesgo."> + comment = <"Detalles que pueden ser agregados en este elemento pueden incluir información acerca de la población, subgrupos, etc, frente a los cuales se evalúa el riesgo."> + > + ["at0010"] = < + text = <"Tree"> + description = <"@ internal @"> + > + ["at0011"] = < + text = <"Extensión"> + description = <"Información adicional requerida para registrar contenido local o para alinear con otros modelos o formalismos de referencia."> + comment = <"Por ejemplo: requerimientos locales de información o metadatos adicionales para alinear con equivalentes FHIR o CIMI."> + > + ["at0012"] = < + text = <"Vínculo a la evidencia"> + description = <"Identificación del path al arquetipo o nodo de datos que contiene la evidencia del riesgo."> + > + ["at0013"] = < + text = <"Factor de riesgo"> + description = <"Identificación, por nombre, del factor de riesgo."> + comment = <"Por ejemplo: hipertensión arterial e hipercolesterolemia, que pueden ser utilizados como parte de una evaluación general de enfermedad cardiovascular; o un marcador genético. Codificar el factor de riesgo mediante una terminología cuando esto sea posible."> + > + ["at0014"] = < + text = <"Descripción"> + description = <"Descripción narrativa del factor de riesgo."> + > + ["at0015"] = < + text = <"Comentario"> + description = <"Narrativa adicional acerca de la evaluación de riesgo no contemplada en otros campos."> + > + ["at0016"] = < + text = <"Factores de riesgo"> + description = <"Detalles acerca de cada factor de riesgo posible."> + > + ["at0017"] = < + text = <"Presencia"> + description = <"Presencia del factor de riesgo."> + > + ["at0018"] = < + text = <"Presente"> + description = <"El factor de riesgo ha sido identificado para este individuo."> + > + ["at0019"] = < + text = <"Ausente"> + description = <"El factor de riesgo no ha sido identificado para este individuo."> + > + ["at0020"] = < + text = <"Tipo de evaluación"> + description = <"Registro acerca de la condición relativa o absoluta de la evaluación del riesgo."> + > + ["at0021"] = < + text = <"Riesgo relativo"> + description = <"Probabilidad de la ocurrencia de un evento o condición de salud en comparación con una población de características similares. Ejemplo: mismo sexo y edad."> + > + ["at0022"] = < + text = <"Riesgo absoluto"> + description = <"Probabilidad de la ocurrencia de un evento o condición de salud en comparación con el total de la población."> + > + ["at0023"] = < + text = <"Período de tiempo"> + description = <"El período de tiempo durante el cual el riesgo para la salud previsto es relevante."> + comment = <"Esto es: el riesgo de incurrir en el 'riesgo para la salud' identificado, en el curso de los próximos años."> + > + ["at0024"] = < + text = <"Última actualización"> + description = <"La fecha en la cual se realizó la ultima actualización de este factor de riesgo para la salud."> + comment = <"*This data element may be thought redundant if the data is recorded and stored using COMPOSITIONs within a closed clinical system. However if this information is extracted from its original COMPOSITION context, for example, to be included in another document or message then the temporal context is effectively removed. This 'Last updated' data element has been explicitly added to allow the critical temporal data to be kept alongside the clinical data in all circumstances. It is assumed that the clinical system can copy the date from the COMPOSITION to reduce the need for duplication of data entry by the clinician. (en)"> + > + ["at0025"] = < + text = <"Método de evaluación"> + description = <"Identificación del algoritmo o de la guia utilziada para realizar la evaluación de riesgo."> + comment = <"Por ejemplo: el cálculo de riesgo cardiovascular de Framingham."> + > + ["at0026"] = < + text = <"Indeterminado"> + description = <"No es posible determinar la presencia o ausencia del factor de riesgo."> + > + ["at0027"] = < + text = <"Detalle"> + description = <"Detalle estructurado acerca de otros aspectos de la evaluación del factor de riesgo."> + comment = <"Por ejemplo: Prevalencia del factor de riesgo en famililares."> + > + ["at0028"] = < + text = <"Mitigado"> + description = <"El factor de riesgo esta presente pero ha sido subsecuentemente mitigado por tratamiento o investigación."> + comment = <"Registrar como Verdadero si el factor de riesgo ha sido tratado o mejor investigado como para determinar que el riesgo puede considerarse disminuido. Por ejemplo: un niño ha recibido gentamicina en la unidad de cuidados intensivos neonatales puede considerarse en riesgo para hipoacusia permanente. Si los estudios diagnósticos no muestran evidencia de hipoacusia en el primer año de vida, el riesgo de hipoacusia posterior pueden considerarse como muy disminuido pero aún posible. Este dato permite a los clínicos considerar que el riesgo ha sido mitigado pero debe aún ser considerado como una posibildiad futura. En la práctica, el factor de riesgo puede mantenerse para la evaluación de riesgo en caso de poder tener impacto futuro sobre la salud del individuo, pero señalando que su contribución a la determinación del riesgo puede no ser tan importante como si no hubiera sido tratado o investigado."> + > + ["at0029"] = < + text = <"*Date identified(en)"> + description = <"*The date/time that the risk factor was identified.(en)"> + > + ["at0030"] = < + text = <"*Comment(en)"> + description = <"*Additional narrative about the risk factor not captured in other fields.(en)"> + > + ["at0.19"] = < + text = <"*Other household members are ill (en)"> + description = <"*The patient is in a house with other household members who are ill (en)"> + > + ["at0.20"] = < + text = <"*Household members with travel exposure (en)"> + description = <"*Members of the patient's household have travel exposure. (en)"> + > + > + > + ["sv"] = < + items = < + ["at0000.1"] = < + text = <"Riskbedömning"> + description = <"Bedömning av potential och sannolikhet för framtida negativa hälsoeffekter som bestäms av identifierade riskfaktorer."> + > + ["at0002.1"] = < + text = <"Risk"> + description = <"Identifiering med namn av den potentiella framtida sjukdomen, tillståndet eller hälsotillståndet för vilken risken är bedömd."> + comment = <"Vid kodning av \"Risk\" med en terminologi är att föredra, om möjligt. Fri text ska endast användas om det inte finns någon lämplig terminologi. Till exempel: risk för kardiovaskulär sjukdom, med riskfaktorer för hypertension och hyperkolesterolemi."> + > + ["at0.1"] = < + text = <"*COVID-19 Risk assessment (en)"> + description = <"*Assessment of risk of COVID-19 infection (en)"> + > + ["at0013.1"] = < + text = <"Riskfaktor"> + description = <"Identifiering med namn av riskfaktorn."> + comment = <"Till exempel: högt blodtryck och hyperkolesterolemi, som kan användas som en del av den övergripande bedömningen för kardiovaskulär sjukdom; eller en genetisk markör. Vid kodning av +Riskfaktor använd en terminologi om det är möjligt."> + > + ["at0.9"] = < + text = <"*Contact with confirmed Covid-19 case (en)"> + description = <"*"> + > + ["at0.10"] = < + text = <"*Contact with suspected case/ pneumonia case (en)"> + description = <"*Contact with suspected case/ pneumonia case within 14 days before symptom onset. (en)"> + > + ["at0.11"] = < + text = <"*Contact with birds in China (en)"> + description = <"*Contact with birds in China in 10 days before symptom onset. (en)"> + > + ["at0.12"] = < + text = <"*Contact with confirmed human case of Avian flu in China (en)"> + description = <"*Contact with confirmed human case of Avian flu in China in 10 days before symptom onset. (en)"> + > + ["at0.13"] = < + text = <"*Contact with severe, unexplained respiratory disease (en)"> + description = <"*Contact with severe, unexplained respiratory disease in 10 days before symptom onset. (en)"> + > + ["at0.14"] = < + text = <"*Potential contact exposure based on location (en)"> + description = <"*Potential contact exposure based on location (en)"> + > + ["at0027.1"] = < + text = <"Detaljer"> + description = <"Strukturerad detalj om andra aspekter av riskfaktorbedömningen."> + comment = <"Till exempel: Förekomst av riskfaktorn hos familjemedlemmar."> + > + ["at0017.1"] = < + text = <"Förekomst"> + description = <"Förekomst av riskfaktor."> + > + ["at0.15"] = < + text = <"*Unknown (en)"> + description = <"*No information is available for this risk factor. (en)"> + > + ["at0003.1"] = < + text = <"Riskbedömning"> + description = <"Utvärdering av hälsorisken."> + comment = <"Det kan finnas flera variationer i riskbedömningen. Datatypen val (choice) möjliggör registrering av bedömningen som antingen fritext eller vallista (t.ex. låg, medium eller hög). Datatypen andel (proportion) tillåter registrering av en procentandel, ett förhållande eller en fraktion. Datatypen numerisk (quantity) tillåter registrering av ett decimaltal."> + > + ["at0.16"] = < + text = <"*Low risk (en)"> + description = <"*Covid19 infection is assessed to be low-risk (en)"> + > + ["at0.17"] = < + text = <"*High risk (en)"> + description = <"*The risk of the a patient having a Covid-19 infection is assessed to be high. (en)"> + > + ["at0.18"] = < + text = <"*Needs admission for respiratory disease (en)"> + description = <"*Does the patient require hospital admission with either clinical or radiological evidence of pneumonia, adult respiratory distress syndrome, or influenza like illness? (en)"> + > + ["at0000"] = < + text = <"Riskbedömning"> + description = <"Bedömning av potential och sannolikhet för framtida negativa hälsoeffekter som bestäms av identifierade riskfaktorer."> + > + ["at0001"] = < + text = <"structure"> + description = <"@ internal @"> + > + ["at0002"] = < + text = <"Risk"> + description = <"Identifiering med namn av den potentiella framtida sjukdomen, tillståndet eller hälsotillståndet för vilken risken är bedömd."> + comment = <"Vid kodning av \"Risk\" med en terminologi är att föredra, om möjligt. Fri text ska endast användas om det inte finns någon lämplig terminologi. Till exempel: risk för kardiovaskulär sjukdom, med riskfaktorer för hypertension och hyperkolesterolemi."> + > + ["at0003"] = < + text = <"Riskbedömning"> + description = <"Utvärdering av hälsorisken."> + comment = <"Det kan finnas flera variationer i riskbedömningen. Datatypen val (choice) möjliggör registrering av bedömningen som antingen fritext eller vallista (t.ex. låg, medium eller hög). Datatypen andel (proportion) tillåter registrering av en procentandel, ett förhållande eller en fraktion. Datatypen numerisk (quantity) tillåter registrering av ett decimaltal."> + > + ["at0004"] = < + text = <"Motivering"> + description = <"Motivering för denna riskbedömning."> + comment = <"Detaljer som kan läggas till i detta dataelement kan innehålla information om befolkningsundergrupperna etc mot vilka bestämningen av risken bedöms."> + > + ["at0010"] = < + text = <"Tree"> + description = <"@ internal @"> + > + ["at0011"] = < + text = <"Extension"> + description = <"Ytterligare information som krävs för att fånga upp lokalt innehåll eller för anpassning sig till andra referensmodeller / formaliteter."> + comment = <"Till exempel: lokala informationskrav eller ytterligare metadata för att anpassa sig till FHIR- eller CIMI-ekvivalenter."> + > + ["at0012"] = < + text = <"Länk till evidens"> + description = <"Identifiering av sökvägen till arketypen eller datanoden för evidensen för risk."> + > + ["at0013"] = < + text = <"Riskfaktor"> + description = <"Identifiering med namn av riskfaktorn."> + comment = <"Till exempel: högt blodtryck och hyperkolesterolemi, som kan användas som en del av den övergripande bedömningen för kardiovaskulär sjukdom; eller en genetisk markör. Vid kodning av +Riskfaktor använd en terminologi om det är möjligt."> + > + ["at0014"] = < + text = <"Beskrivning"> + description = <"Berättande beskrivning om riksfaktorn."> + > + ["at0015"] = < + text = <"Kommentar"> + description = <"Ytterligare beskrivning om riskbedömningen som inte tagits med i andra fält."> + > + ["at0016"] = < + text = <"Riskfaktorer"> + description = <"Detaljer om varje möjlig riskfaktor."> + > + ["at0017"] = < + text = <"Förekomst"> + description = <"Förekomst av riskfaktor."> + > + ["at0018"] = < + text = <"Nuvarande"> + description = <"Riskfaktorn har identifierats för den här personen."> + > + ["at0019"] = < + text = <"Frånvarande"> + description = <"Riskfaktorn har inte identifierats för den här personen."> + > + ["at0020"] = < + text = <"Bedömningstyp"> + description = <"Uppgift om riskbedömningen är relativ eller absolut."> + > + ["at0021"] = < + text = <"Relativ risk"> + description = <"Förhållande mellan sannolikheten för ett hälsohändelse eller ett tillstånd som uppstår jämfört med en befolkning med liknande egenskaper, t.ex. samma ålder och kön."> + > + ["at0022"] = < + text = <"Absolut risk"> + description = <"Förhållandet mellan sannolikheten för en hälsohändelse eller ett tillstånd som uppstår i förhållande till befolkningen som helhet."> + > + ["at0023"] = < + text = <"Tidsperiod"> + description = <"Den tidsperiod under vilken den förutspådda hälsorisken är relevant."> + comment = <"Det vill säga: risken att drabbas av den identifierade hälsorisken under de kommande åren."> + > + ["at0024"] = < + text = <"Senast uppdaterad"> + description = <"Datumet när hälsoriskbedömningen senast uppdaterades."> + comment = <"*This data element may be thought redundant if the data is recorded and stored using COMPOSITIONs within a closed clinical system. However if this information is extracted from its original COMPOSITION context, for example, to be included in another document or message then the temporal context is effectively removed. This 'Last updated' data element has been explicitly added to allow the critical temporal data to be kept alongside the clinical data in all circumstances. It is assumed that the clinical system can copy the date from the COMPOSITION to reduce the need for duplication of data entry by the clinician. (en)"> + > + ["at0025"] = < + text = <"Bedömningsmetod"> + description = <"Identifiering av metoden eller riktlinjen som används för bedömning av risker."> + comment = <"Till exempel: Framingham kardiovaskulär riskkalkylator. +"> + > + ["at0026"] = < + text = <"Obestämd"> + description = <"Det är inte möjligt att bestämma om riskfaktorn finns eller är frånvarande."> + > + ["at0027"] = < + text = <"Detaljer"> + description = <"Strukturerad detalj om andra aspekter av riskfaktorbedömningen."> + comment = <"Till exempel: Förekomst av riskfaktorn hos familjemedlemmar."> + > + ["at0028"] = < + text = <"Minskad/mildrad"> + description = <"Riskfaktorn har identifierats att den finns, men har därefter minskats genom behandling eller undersökning."> + comment = <"Anteckna som sant om riskfaktorn har behandlats eller undersökts och risken från denna riskfaktor anses vara nedsatt. Till exempel: ett barn som ges gentamicin i neonatal intensivvård anses ha risk för permanent hörselnedsättning. Om diagnostisk testning inte visar någon hörselnedsättning under det första levnadsåret, anses risken för senare hörselnedsättning vara mycket reducerad men fortfarande möjlig. Detta dataelement gör det möjligt för kliniker att säga att risken har minskats men ska betraktas som en möjlighet i framtiden. I praktiken kan riskfaktorn bibehållas i riskbedömningen om det kan påverka den enskilda människans hälsa i framtiden, men att det inte är så stort att dess bidrag till riskberäkning är lika stort som om det inte tidigare har behandlats eller undersökts."> + > + ["at0029"] = < + text = <"Datum för konstaterande"> + description = <"Datum/tid då riskfaktorn konstaterades."> + > + ["at0030"] = < + text = <"Kommentar"> + description = <"Ytterligare beskrivning av riskfaktorn som inte fångats i andra fält."> + > + ["at0.19"] = < + text = <"*Other household members are ill (en)"> + description = <"*The patient is in a house with other household members who are ill (en)"> + > + ["at0.20"] = < + text = <"*Household members with travel exposure (en)"> + description = <"*Members of the patient's household have travel exposure. (en)"> + > + > + > + ["nb"] = < + items = < + ["at0000.1"] = < + text = <"Helserisiko"> + description = <"Vurdering av potensiale og sannsynlighet for fremtidige uønskede helseeffekter, bestemt ut fra spesifikke risikofaktorer."> + > + ["at0002.1"] = < + text = <"Helserisiko"> + description = <"Navnet på den potensielle fremtidige sykdommen, tilstanden eller helseproblemet som risikoen gjelder."> + comment = <"*Coding of 'Health risk' with a terminology is preferred, where possible. Free text should be used only if there is no appropriate terminology available. For example: risk of cardiovascular disease, with risk factors of hypertension and hypercholesterolaemia. (en)"> + > + ["at0.1"] = < + text = <"COVID-19 Risk assessment"> + description = <"Assessment of risk of COVID-19 infection"> + > + ["at0013.1"] = < + text = <"Risikofaktor"> + description = <"Navnet på risikofaktoren."> + comment = <"*For example: hypertension and hypercholesterolaemia, which may be used as part of the overall assessment for cardiovascular disease; or a genetic marker. Coding of +'Risk factor' with a terminology, where possible. (en)"> + > + ["at0.9"] = < + text = <"Contact with confirmed Covid-19 case"> + description = <"Contact with confirmed Covid-19 case within 14 days before symptom onset."> + > + ["at0.10"] = < + text = <"Contact with suspected case/ pneumonia case"> + description = <"Contact with suspected case/ pneumonia case within 14 days before symptom onset."> + > + ["at0.11"] = < + text = <"Contact with birds in China"> + description = <"Contact with birds in China in 10 days before symptom onset."> + > + ["at0.12"] = < + text = <"Contact with confirmed human case of Avian flu in China"> + description = <"Contact with confirmed human case of Avian flu in China in 10 days before symptom onset."> + > + ["at0.13"] = < + text = <"Contact with severe, unexplained respiratory disease"> + description = <"Contact with severe, unexplained respiratory disease in 10 days before symptom onset."> + > + ["at0.14"] = < + text = <"Potential contact exposure based on location"> + description = <"Potential contact exposure based on location"> + > + ["at0027.1"] = < + text = <"Detail"> + description = <"Structured detail about other aspects of the risk factor assessment."> + comment = <"For example: Prevalence of the risk factor in family members."> + > + ["at0017.1"] = < + text = <"Presence"> + description = <"Presence of the risk factor."> + > + ["at0.15"] = < + text = <"*Unknown (en)"> + description = <"*No information is available for this risk factor. (en)"> + > + ["at0003.1"] = < + text = <"Risk assessment"> + description = <"Evaluation of the health risk."> + comment = <"There may be multiple variations on the assessment of risk. The Choice data type allows for recording of the assessment as either free text or value sets (such as low, medium or hig). The proportion data type allows recording of a percentage, a ratio or a fraction. The quantity data type allows recording of a decimal number."> + > + ["at0.16"] = < + text = <"*Low risk (en)"> + description = <"*Covid19 infection is assessed to be low-risk (en)"> + > + ["at0.17"] = < + text = <"*High risk (en)"> + description = <"*The risk of the a patient having a Covid-19 infection is assessed to be high. (en)"> + > + ["at0.18"] = < + text = <"*Needs admission for respiratory disease (en)"> + description = <"*Does the patient require hospital admission with either clinical or radiological evidence of pneumonia, adult respiratory distress syndrome, or influenza like illness? (en)"> + > + ["at0000"] = < + text = <"Health risk assessment"> + description = <"Assessment of the potential and likelihood of future adverse health effects as determined by identified risk factors."> + > + ["at0001"] = < + text = <"structure"> + description = <"@ internal @"> + > + ["at0002"] = < + text = <"Health risk"> + description = <"Identification of the potential future disease, condition or health issue for which the risk is being assessed, by name."> + comment = <"Coding of 'Health risk' with a terminology is preferred, where possible. Free text should be used only if there is no appropriate terminology available. For example: risk of cardiovascular disease, with risk factors of hypertension and hypercholesterolaemia."> + > + ["at0003"] = < + text = <"Risk assessment"> + description = <"Evaluation of the health risk."> + comment = <"There may be multiple variations on the assessment of risk. The Choice data type allows for recording of the assessment as either free text or value sets (such as low, medium or hig). The proportion data type allows recording of a percentage, a ratio or a fraction. The quantity data type allows recording of a decimal number."> + > + ["at0004"] = < + text = <"Rationale"> + description = <"Justification for this risk assessment."> + comment = <"Details that may be added to this data element may include information about the population subgroups etc against which the determination of risk is assessed."> + > + ["at0010"] = < + text = <"Tree"> + description = <"@ internal @"> + > + ["at0011"] = < + text = <"Extension"> + description = <"Additional information required to capture local content or to align with other reference models/formalisms."> + comment = <"For example: local information requirements or additional metadata to align with FHIR or CIMI equivalents."> + > + ["at0012"] = < + text = <"Link to evidence"> + description = <"Identification of the path to the archetype or data node for the evidence of risk."> + > + ["at0013"] = < + text = <"Risk factor"> + description = <"Identification of the risk factor, by name."> + comment = <"For example: hypertension and hypercholesterolaemia, which may be used as part of the overall assessment for cardiovascular disease; or a genetic marker. Coding of +'Risk factor' with a terminology, where possible."> + > + ["at0014"] = < + text = <"Description"> + description = <"Narrative description about the risk factor."> + > + ["at0015"] = < + text = <"Comment"> + description = <"Additional narrative about the risk assessment not captured in other fields."> + > + ["at0016"] = < + text = <"Risk factors"> + description = <"Details about each possible risk factor."> + > + ["at0017"] = < + text = <"Presence"> + description = <"Presence of the risk factor."> + > + ["at0018"] = < + text = <"Present"> + description = <"The risk factor has been identified for this individual."> + > + ["at0019"] = < + text = <"Absent"> + description = <"The risk factor has not been identified for this individual."> + > + ["at0020"] = < + text = <"Assessment type"> + description = <"Record of whether the risk assessment is a relative or absolute."> + > + ["at0021"] = < + text = <"Relative risk"> + description = <"Ratio of probability of a health event or condition occurring compared to a population with similar characteristics eg same age and sex."> + > + ["at0022"] = < + text = <"Absolute risk"> + description = <"Ratio of probability of a health event or condition occurring compared to the population as a whole."> + > + ["at0023"] = < + text = <"Time period"> + description = <"The time period during which the predicted health risk is relevant."> + comment = <"That is: the risk of experiencing the identified 'Health risk' in the next years."> + > + ["at0024"] = < + text = <"Last updated"> + description = <"The date this health risk assessment was last updated."> + comment = <"This data element may be thought redundant if the data is recorded and stored using COMPOSITIONs within a closed clinical system. However if this information is extracted from its original COMPOSITION context, for example, to be included in another document or message then the temporal context is effectively removed. This 'Last updated' data element has been explicitly added to allow the critical temporal data to be kept alongside the clinical data in all circumstances. It is assumed that the clinical system can copy the date from the COMPOSITION to reduce the need for duplication of data entry by the clinician."> + > + ["at0025"] = < + text = <"Assessment method"> + description = <"Identification of the algorithm or guideline used to make the assessment of risk."> + comment = <"For example: Framingham cardiovascular risk calculator."> + > + ["at0026"] = < + text = <"Indeterminate"> + description = <"It is not possible to determine if the risk factor is present or absent."> + > + ["at0027"] = < + text = <"Detail"> + description = <"Structured detail about other aspects of the risk factor assessment."> + comment = <"For example: Prevalence of the risk factor in family members."> + > + ["at0028"] = < + text = <"Mitigated"> + description = <"The risk factor has been identified as present, but then subsequently been mitigated by treatment or investigation."> + comment = <"Record as True if the risk factor has been treated or investigated and risk from this risk factor is considered to be lessened. For example: an infant given gentamicin in neonatal intensive care is regarded as having a risk of permanent hearing loss. If diagnostic testing shows no evidence of hearing loss in the first year of life, the risk of later hearing loss is considered to be much reduced, but still possible. This data element allows clinicians to say that the risk has been mitigated but should still be considered as a possibility in future. In practice, the risk factor could be maintained in the risk assessment in case it might impact the individual's health at a future time, but flagging that its contribution to risk calculation may not be as great as if it had not been previously treated or investigated. "> + > + ["at0029"] = < + text = <"Date identified"> + description = <"The date/time that the risk factor was identified."> + > + ["at0030"] = < + text = <"Comment"> + description = <"Additional narrative about the risk factor not captured in other fields."> + > + ["at0.19"] = < + text = <"*Other household members are ill (en)"> + description = <"*The patient is in a house with other household members who are ill (en)"> + > + ["at0.20"] = < + text = <"*Household members with travel exposure (en)"> + description = <"*Members of the patient's household have travel exposure. (en)"> + > + > + > + > diff --git a/better-template/src/test/resources/opt_json/Archetypes/openEHR-EHR-EVALUATION.health_risk.v1.adl b/better-template/src/test/resources/opt_json/Archetypes/openEHR-EHR-EVALUATION.health_risk.v1.adl new file mode 100644 index 000000000..fd37a7872 --- /dev/null +++ b/better-template/src/test/resources/opt_json/Archetypes/openEHR-EHR-EVALUATION.health_risk.v1.adl @@ -0,0 +1,843 @@ +archetype (adl_version=1.4; uid=70e1c139-739e-42be-992a-bb1891d222e8) + openEHR-EHR-EVALUATION.health_risk.v1 + +concept + [at0000] + +language + original_language = <[ISO_639-1::en]> + translations = < + ["de"] = < + language = <[ISO_639-1::de]> + author = < + ["name"] = <"Jasmin Buck, Sebastian Garde"> + ["organisation"] = <"University of Heidelberg, Cental Queensland University"> + > + > + ["sv"] = < + language = <[ISO_639-1::sv]> + author = < + ["name"] = <"Annika Terner"> + ["organisation"] = <"B3 Healthcare Consulting AB"> + ["email"] = <"annika.terner@b3.se"> + > + accreditation = <"."> + > + ["es-ar"] = < + language = <[ISO_639-1::es-ar]> + author = < + ["name"] = <"Alan March"> + ["organisation"] = <"Hospital Universitario Austral, Pilar, Buenos Aires, Argentina"> + ["email"] = <"alandmarch@gmail.com"> + > + > + ["ar-sy"] = < + language = <[ISO_639-1::ar-sy]> + author = < + ["name"] = <"Mona Saleh"> + > + > + > + +description + original_author = < + ["date"] = <"2006-04-23"> + ["name"] = <"Sam Heard"> + ["organisation"] = <"Ocean Informatics"> + ["email"] = <"sam.heard@oceaninformatics.com"> + > + lifecycle_state = <"published"> + other_contributors = <"Tomas Alme, DIPS, Norway","Nadim Anani, Karolinska Institutet, Sweden","Vebjørn Arntzen, Oslo University Hospital, Norway","Koray Atalag, University of Auckland, New Zealand","Silje Ljosland Bakke, Nasjonal IKT HF, Norway (openEHR Editor)","Lars Bitsch-Larsen, Haukeland University hospital, Norway","Rong Chen, Cambio Healthcare Systems, Sweden","Stephen Chu, Queensland Health, Australia","Shahla Foozonkhah, Iran ministry of health and education, Iran","Einar Fosse, National Centre for Integrated Care and Telemedicine, Norway","Sebastian Garde, Ocean Informatics, Germany","Heather Grain, Llewelyn Grain Informatics, Australia","Anca Heyd, DIPS ASA, Norway","Lars Karlsen, DIPS ASA, Norway","Lars Morgan Karlsen, DIPS ASA, Norway","Heather Leslie, Atomica Informatics, Australia (openEHR Editor)","Hallvard Lærum, Norwegian Directorate of e-health, Norway","Luis Marco Ruiz, Norwegian Center for Integrated Care and Telemedicine, Norway","Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (openEHR Editor)","Jussara Rotzsch, UNB, Brazil","Norwegian Review Summary, Nasjonal IKT HF, Norway","John Tore Valand, Helse Bergen, Norway"> + details = < + ["de"] = < + language = <[ISO_639-1::de]> + purpose = <"Zur Dokumentation des Vorhandenseins eines Risikos mit möglichen Auswirkungen jetzt oder in der Zukunft"> + keywords = <"Einschätzung", ...> + copyright = <"© openEHR Foundation"> + use = <"*Use to record known risk factors for an identified disease, condition, or other potentially adverse health issue, and/or an evaluation of the likelihood of the individual experiencing it in the future. + +As risk factors may be gradually identified over time and the overall risk reassessed as a result, the 'Date identified' will record the date on which each risk factor has been identified and the 'Last updated' data element will record the last time that the whole assessment was updated.(en)"> + > + ["sv"] = < + language = <[ISO_639-1::sv]> + purpose = <"Att registrera kända riskfaktorer för en identifierad sjukdom, tillstånd eller annat potentiellt skadligt hälsotillstånd, och / eller en utvärdering av sannolikheten för att personen upplever det i framtiden. + +Denna arketyp har medvetet lämnats öppen och omfattande. Risken kan bestämmas av riskfaktorer från någon eller alla följande domäner: medicinska; biomarkör; livsstil; social; yrkesrisk; eller miljödomäner. + +Avsikten med denna arketyp är att dokumentera potentiell risk vid en tidpunkt och att stödja beslutsfattande som kan minska den identifierade risken, vare sig av kliniker eller individen själva."> + keywords = <"Bedömning","Risk","Utvärdering","Negativ","Faktor","Hälsa","Fråga","Beräknad","Förvaltning","Riskfaktor","Risklagstiftning","Hälsorisk"> + use = <"Används för att registrera kända riskfaktorer för en identifierad sjukdom, tillstånd eller annat potentiellt skadligt hälsotillstånd, och / eller en utvärdering av sannolikheten för att personen drabbas av det i framtiden. + +Eftersom riskfaktorer kan identifieras gradvis över tiden och den övergripande risken omvärderas som ett resultat kommer den \"identifierade Datum\" att registrera det datum då varje riskfaktor har identifierats och \"Senast uppdaterad\" dataelement registrerar sista gången att hela utvärderingen uppdaterades."> + > + ["es-ar"] = < + language = <[ISO_639-1::es-ar]> + purpose = <"Para el registro de factores de riesgo para una enfermedad, condición u otro problema potencialmente adverso para la salud, y/o para la evaluación de la probabilidad de que el individuo experimente estas situaciones en el futuro. +Este arquetipo se mantiene deliberadamente abierto y amplio en su alcance. El 'Riesgo para la Salud' puede ser determinado a partir de todos o algunos de los factores de riesgo: médicos, marcadores biológicos, estilo de vidas, sociales, riesgo ocupacional o cuestiones ambientales. +El propósito de este arquetipo es la documentación de un riesgo potencial en un punto en el tiempo, y para asistir en la toma de decisiones que puedan reducir el mencionado riesgo, ya sea por parte de los médicos o del/de los individuo/s mismo/s."> + keywords = <"evaluación","riesgo","adverso","factor","salud","problema","estimado","manejo","factor de riesgo","estratificación de riesgo"> + use = <"*Use to record known risk factors for an identified disease, condition, or other potentially adverse health issue, and/or an evaluation of the likelihood of the individual experiencing it in the future. + +As risk factors may be gradually identified over time and the overall risk reassessed as a result, the 'Date identified' will record the date on which each risk factor has been identified and the 'Last updated' data element will record the last time that the whole assessment was updated.(en)"> + > + ["ar-sy"] = < + language = <[ISO_639-1::ar-sy]> + purpose = <"لتسجيل التخاطر/احتمالية الخطر لظرف صحي قد يحدث في المستقبل"> + keywords = <"تقييم", ...> + copyright = <"© openEHR Foundation"> + use = <"*Use to record known risk factors for an identified disease, condition, or other potentially adverse health issue, and/or an evaluation of the likelihood of the individual experiencing it in the future. + +As risk factors may be gradually identified over time and the overall risk reassessed as a result, the 'Date identified' will record the date on which each risk factor has been identified and the 'Last updated' data element will record the last time that the whole assessment was updated.(en)"> + > + ["en"] = < + language = <[ISO_639-1::en]> + purpose = <"To record known risk factors for an identified disease, condition, or other potentially adverse health issue, and/or an evaluation of the likelihood of the individual experiencing it in the future. + +This archetype has been deliberately left open and broad in scope. The 'Health Risk' could be determined from risk factors from any or all of: medical; biomarker; lifestyle; social; occupational hazard; or environmental domains. + +The intent of this archetype is to document potential risk at a point in time, and to support decision-making that may reduce the identified risk, whether by clinicians or the individual themselves."> + keywords = <"assessment","risk","evaluation","adverse","factor","health","issue","estimated","management","risk factor","risk stratification"> + copyright = <"© openEHR Foundation"> + use = <"Use to record known risk factors for an identified disease, condition, or other potentially adverse health issue, and/or an evaluation of the likelihood of the individual experiencing it in the future. + +As risk factors may be gradually identified over time and the overall risk reassessed as a result, the 'Date identified' will record the date on which each risk factor has been identified and the 'Last updated' data element will record the last time that the whole assessment was updated."> + > + > + other_details = < + ["licence"] = <"This work is licensed under the Creative Commons Attribution-ShareAlike 3.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/3.0/."> + ["custodian_organisation"] = <"openEHR Foundation"> + ["references"] = <"Health Risk, draft archetype, NEHTA Clinical Knowledge Manager [Internet]. Australia: National eHealth Transition Authority. Authored: 2006 Apr 23. Available at: http://dcm.nehta.org.au/ckm/#showArchetype_1013.1.1276 (accessed 2015 Mar 04). Archetype originated from the openEHR CKM."> + ["current_contact"] = <"Heather Leslie, Ocean Informatics, heather.leslie@oceaninformatics.com"> + ["original_namespace"] = <"org.openehr"> + ["original_publisher"] = <"openEHR Foundation"> + ["custodian_namespace"] = <"org.openehr"> + ["MD5-CAM-1.0.1"] = <"02D192406E166FE33B093EAECA549A37"> + ["build_uid"] = <"0f3642f7-aa95-48ee-a370-36344ba07815"> + ["revision"] = <"1.1.2"> + > + +definition + EVALUATION[at0000] matches { -- Health risk assessment + data matches { + ITEM_TREE[at0001] matches { -- structure + items cardinality matches {1..*; ordered} matches { + ELEMENT[at0002] matches { -- Health risk + value matches { + DV_TEXT matches {*} + } + } + CLUSTER[at0016] occurrences matches {0..*} matches { -- Risk factors + items cardinality matches {1..*; unordered} matches { + ELEMENT[at0013] matches { -- Risk factor + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0017] occurrences matches {0..1} matches { -- Presence + value matches { + DV_CODED_TEXT matches { + defining_code matches { + [local:: + at0018, -- Present + at0026, -- Indeterminate + at0019] -- Absent + } + } + } + } + ELEMENT[at0014] occurrences matches {0..1} matches { -- Description + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0029] occurrences matches {0..1} matches { -- Date identified + value matches { + DV_DATE_TIME matches {*} + } + } + ELEMENT[at0028] occurrences matches {0..1} matches { -- Mitigated + value matches { + DV_BOOLEAN matches { + value matches {true} + } + } + } + ELEMENT[at0012] occurrences matches {0..*} matches { -- Link to evidence + value matches { + DV_URI matches {*} + } + } + allow_archetype CLUSTER[at0027] occurrences matches {0..*} matches { -- Detail + include + archetype_id/value matches {/openEHR-EHR-CLUSTER\.family_prevalence\.v1/} + } + ELEMENT[at0030] occurrences matches {0..1} matches { -- Comment + value matches { + DV_TEXT matches {*} + } + } + } + } + ELEMENT[at0003] occurrences matches {0..1} matches { -- Risk assessment + value matches { + DV_TEXT matches {*} + DV_PROPORTION matches {*} + C_DV_QUANTITY < + property = <[openehr::380]> + list = < + ["1"] = < + units = <"1"> + > + > + > + } + } + ELEMENT[at0020] occurrences matches {0..1} matches { -- Assessment type + value matches { + DV_CODED_TEXT matches { + defining_code matches { + [local:: + at0021, -- Relative risk + at0022] -- Absolute risk + } + } + } + } + ELEMENT[at0023] occurrences matches {0..1} matches { -- Time period + value matches { + DV_DURATION matches {*} + } + } + ELEMENT[at0004] occurrences matches {0..1} matches { -- Rationale + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0015] occurrences matches {0..1} matches { -- Comment + value matches { + DV_TEXT matches {*} + } + } + } + } + } + protocol matches { + ITEM_TREE[at0010] matches { -- Tree + items cardinality matches {0..*; unordered} matches { + ELEMENT[at0024] occurrences matches {0..1} matches { -- Last updated + value matches { + DV_DATE_TIME matches {*} + } + } + ELEMENT[at0025] occurrences matches {0..1} matches { -- Assessment method + value matches { + DV_TEXT matches {*} + } + } + allow_archetype CLUSTER[at0011] occurrences matches {0..*} matches { -- Extension + include + archetype_id/value matches {/.*/} + } + } + } + } + } + +ontology + term_definitions = < + ["ar-sy"] = < + items = < + ["at0000"] = < + text = <"*Health risk assessment(en)"> + description = <"*Assessment of the potential and likelihood of future adverse health effects as determined by identified risk factors.(en)"> + > + ["at0001"] = < + text = <"*structure(en)"> + description = <"*@ internal @(en)"> + > + ["at0002"] = < + text = <"*Health risk(en)"> + description = <"*Identification of the potential future disease, condition or health issue for which the risk is being assessed, by name.(en)"> + comment = <"*Coding of 'Health risk' with a terminology is preferred, where possible. Free text should be used only if there is no appropriate terminology available. For example: risk of cardiovascular disease, with risk factors of hypertension and hypercholesterolaemia.(en)"> + > + ["at0003"] = < + text = <"*Risk assessment(en)"> + description = <"*Evaluation of the health risk.(en)"> + comment = <"*There may be multiple variations on the assessment of risk. The Choice data type allows for recording of the assessment as either free text or value sets (such as low, medium or hig). The proportion data type allows recording of a percentage, a ratio or a fraction. The quantity data type allows recording of a decimal number.(en)"> + > + ["at0004"] = < + text = <"*Rationale(en)"> + description = <"*Justification for this risk assessment.(en)"> + comment = <"*Details that may be added to this data element may include information about the population subgroups etc against which the determination of risk is assessed.(en)"> + > + ["at0010"] = < + text = <"*Tree(en)"> + description = <"*@ internal @(en)"> + > + ["at0011"] = < + text = <"*Extension(en)"> + description = <"*Additional information required to capture local content or to align with other reference models/formalisms.(en)"> + comment = <"*For example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.(en)"> + > + ["at0012"] = < + text = <"*Link to evidence(en)"> + description = <"*Identification of the path to the archetype or data node for the evidence of risk.(en)"> + > + ["at0013"] = < + text = <"*Risk factor(en)"> + description = <"*Identification of the risk factor, by name.(en)"> + comment = <"*For example: hypertension and hypercholesterolaemia, which may be used as part of the overall assessment for cardiovascular disease; or a genetic marker. Coding of +'Risk factor' with a terminology, where possible.(en)"> + > + ["at0014"] = < + text = <"*Description(en)"> + description = <"*Narrative description about the risk factor.(en)"> + > + ["at0015"] = < + text = <"*Comment(en)"> + description = <"*Additional narrative about the risk assessment not captured in other fields.(en)"> + > + ["at0016"] = < + text = <"*Risk factors(en)"> + description = <"*Details about each possible risk factor.(en)"> + > + ["at0017"] = < + text = <"*Presence(en)"> + description = <"*Presence of the risk factor.(en)"> + > + ["at0018"] = < + text = <"*Present(en)"> + description = <"*The risk factor has been identified for this individual.(en)"> + > + ["at0019"] = < + text = <"*Absent(en)"> + description = <"*The risk factor has not been identified for this individual.(en)"> + > + ["at0020"] = < + text = <"*Assessment type(en)"> + description = <"*Record of whether the risk assessment is a relative or absolute.(en)"> + > + ["at0021"] = < + text = <"*Relative risk(en)"> + description = <"*Ratio of probability of a health event or condition occurring compared to a population with similar characteristics eg same age and sex.(en)"> + > + ["at0022"] = < + text = <"*Absolute risk(en)"> + description = <"*Ratio of probability of a health event or condition occurring compared to the population as a whole.(en)"> + > + ["at0023"] = < + text = <"*Time period(en)"> + description = <"*The time period during which the predicted health risk is relevant.(en)"> + comment = <"*That is: the risk of experiencing the identified 'Health risk' in the next years.(en)"> + > + ["at0024"] = < + text = <"*Last Updated(en)"> + description = <"*The date this health risk assessment was last updated.(en)"> + comment = <"*This data element may be thought redundant if the data is recorded and stored using COMPOSITIONs within a closed clinical system. However if this information is extracted from its original COMPOSITION context, for example, to be included in another document or message then the temporal context is effectively removed. This 'Last updated' data element has been explicitly added to allow the critical temporal data to be kept alongside the clinical data in all circumstances. It is assumed that the clinical system can copy the date from the COMPOSITION to reduce the need for duplication of data entry by the clinician. (en)"> + > + ["at0025"] = < + text = <"*Assessment method(en)"> + description = <"*Identification of the algorithm or guideline used to make the assessment of risk.(en)"> + comment = <"*For example: Framingham cardiovascular risk calculator.(en)"> + > + ["at0026"] = < + text = <"*Indeterminate(en)"> + description = <"*It is not possible to determine if the risk factor is present or absent.(en)"> + > + ["at0027"] = < + text = <"*Detail(en)"> + description = <"*Structured detail about other aspects of the risk factor assessment.(en)"> + comment = <"*For example: Prevalence of the risk factor in family members.(en)"> + > + ["at0028"] = < + text = <"*Mitigated(en)"> + description = <"*The risk factor has been identified as present, but then subsequently been mitigated by treatment or investigation.(en)"> + comment = <"*Record as True if the risk factor has been treated or investigated and risk from this risk factor is considered to be lessened. For example: an infant given gentamicin in neonatal intensive care is regarded as having a risk of permanent hearing loss. If diagnostic testing shows no evidence of hearing loss in the first year of life, the risk of later hearing loss is considered to be much reduced, but still possible. This data element allows clinicians to say that the risk has been mitigated but should still be considered as a possibility in future. In practice, the risk factor could be maintained in the risk assessment in case it might impact the individual's health at a future time, but flagging that its contribution to risk calculation may not be as great as if it had not been previously treated or investigated. (en)"> + > + ["at0029"] = < + text = <"*Date identified(en)"> + description = <"*The date/time that the risk factor was identified.(en)"> + > + ["at0030"] = < + text = <"*Comment(en)"> + description = <"*Additional narrative about the risk factor not captured in other fields.(en)"> + > + > + > + ["de"] = < + items = < + ["at0000"] = < + text = <"*Health risk assessment(en)"> + description = <"*Assessment of the potential and likelihood of future adverse health effects as determined by identified risk factors.(en)"> + > + ["at0001"] = < + text = <"structure"> + description = <"@ internal @"> + > + ["at0002"] = < + text = <"*Health risk(en)"> + description = <"*Identification of the potential future disease, condition or health issue for which the risk is being assessed, by name.(en)"> + comment = <"*Coding of 'Health risk' with a terminology is preferred, where possible. Free text should be used only if there is no appropriate terminology available. For example: risk of cardiovascular disease, with risk factors of hypertension and hypercholesterolaemia.(en)"> + > + ["at0003"] = < + text = <"*Risk assessment(en)"> + description = <"*Evaluation of the health risk.(en)"> + comment = <"*There may be multiple variations on the assessment of risk. The Choice data type allows for recording of the assessment as either free text or value sets (such as low, medium or hig). The proportion data type allows recording of a percentage, a ratio or a fraction. The quantity data type allows recording of a decimal number.(en)"> + > + ["at0004"] = < + text = <"*Rationale(en)"> + description = <"*Justification for this risk assessment.(en)"> + comment = <"*Details that may be added to this data element may include information about the population subgroups etc against which the determination of risk is assessed.(en)"> + > + ["at0010"] = < + text = <"*Tree(en)"> + description = <"*@ internal @(en)"> + > + ["at0011"] = < + text = <"*Extension(en)"> + description = <"*Additional information required to capture local content or to align with other reference models/formalisms.(en)"> + comment = <"*For example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.(en)"> + > + ["at0012"] = < + text = <"*Link to evidence(en)"> + description = <"*Identification of the path to the archetype or data node for the evidence of risk.(en)"> + > + ["at0013"] = < + text = <"*Risk factor(en)"> + description = <"*Identification of the risk factor, by name.(en)"> + comment = <"*For example: hypertension and hypercholesterolaemia, which may be used as part of the overall assessment for cardiovascular disease; or a genetic marker. Coding of +'Risk factor' with a terminology, where possible.(en)"> + > + ["at0014"] = < + text = <"*Description(en)"> + description = <"*Narrative description about the risk factor.(en)"> + > + ["at0015"] = < + text = <"*Comment(en)"> + description = <"*Additional narrative about the risk assessment not captured in other fields.(en)"> + > + ["at0016"] = < + text = <"*Risk factors(en)"> + description = <"*Details about each possible risk factor.(en)"> + > + ["at0017"] = < + text = <"*Presence(en)"> + description = <"*Presence of the risk factor.(en)"> + > + ["at0018"] = < + text = <"*Present(en)"> + description = <"*The risk factor has been identified for this individual.(en)"> + > + ["at0019"] = < + text = <"*Absent(en)"> + description = <"*The risk factor has not been identified for this individual.(en)"> + > + ["at0020"] = < + text = <"*Assessment type(en)"> + description = <"*Record of whether the risk assessment is a relative or absolute.(en)"> + > + ["at0021"] = < + text = <"*Relative risk(en)"> + description = <"*Ratio of probability of a health event or condition occurring compared to a population with similar characteristics eg same age and sex.(en)"> + > + ["at0022"] = < + text = <"*Absolute risk(en)"> + description = <"*Ratio of probability of a health event or condition occurring compared to the population as a whole.(en)"> + > + ["at0023"] = < + text = <"*Time period(en)"> + description = <"*The time period during which the predicted health risk is relevant.(en)"> + comment = <"*That is: the risk of experiencing the identified 'Health risk' in the next years.(en)"> + > + ["at0024"] = < + text = <"*Last Updated(en)"> + description = <"*The date this health risk assessment was last updated.(en)"> + comment = <"*This data element may be thought redundant if the data is recorded and stored using COMPOSITIONs within a closed clinical system. However if this information is extracted from its original COMPOSITION context, for example, to be included in another document or message then the temporal context is effectively removed. This 'Last updated' data element has been explicitly added to allow the critical temporal data to be kept alongside the clinical data in all circumstances. It is assumed that the clinical system can copy the date from the COMPOSITION to reduce the need for duplication of data entry by the clinician. (en)"> + > + ["at0025"] = < + text = <"*Assessment method(en)"> + description = <"*Identification of the algorithm or guideline used to make the assessment of risk.(en)"> + comment = <"*For example: Framingham cardiovascular risk calculator.(en)"> + > + ["at0026"] = < + text = <"*Indeterminate(en)"> + description = <"*It is not possible to determine if the risk factor is present or absent.(en)"> + > + ["at0027"] = < + text = <"*Detail(en)"> + description = <"*Structured detail about other aspects of the risk factor assessment.(en)"> + comment = <"*For example: Prevalence of the risk factor in family members.(en)"> + > + ["at0028"] = < + text = <"*Mitigated(en)"> + description = <"*The risk factor has been identified as present, but then subsequently been mitigated by treatment or investigation.(en)"> + comment = <"*Record as True if the risk factor has been treated or investigated and risk from this risk factor is considered to be lessened. For example: an infant given gentamicin in neonatal intensive care is regarded as having a risk of permanent hearing loss. If diagnostic testing shows no evidence of hearing loss in the first year of life, the risk of later hearing loss is considered to be much reduced, but still possible. This data element allows clinicians to say that the risk has been mitigated but should still be considered as a possibility in future. In practice, the risk factor could be maintained in the risk assessment in case it might impact the individual's health at a future time, but flagging that its contribution to risk calculation may not be as great as if it had not been previously treated or investigated. (en)"> + > + ["at0029"] = < + text = <"*Date identified(en)"> + description = <"*The date/time that the risk factor was identified.(en)"> + > + ["at0030"] = < + text = <"*Comment(en)"> + description = <"*Additional narrative about the risk factor not captured in other fields.(en)"> + > + > + > + ["en"] = < + items = < + ["at0000"] = < + text = <"Health risk assessment"> + description = <"Assessment of the potential and likelihood of future adverse health effects as determined by identified risk factors."> + > + ["at0001"] = < + text = <"structure"> + description = <"@ internal @"> + > + ["at0002"] = < + text = <"Health risk"> + description = <"Identification of the potential future disease, condition or health issue for which the risk is being assessed, by name."> + comment = <"Coding of 'Health risk' with a terminology is preferred, where possible. Free text should be used only if there is no appropriate terminology available. For example: risk of cardiovascular disease, with risk factors of hypertension and hypercholesterolaemia."> + > + ["at0003"] = < + text = <"Risk assessment"> + description = <"Evaluation of the health risk."> + comment = <"There may be multiple variations on the assessment of risk. The Choice data type allows for recording of the assessment as either free text or value sets (such as low, medium or hig). The proportion data type allows recording of a percentage, a ratio or a fraction. The quantity data type allows recording of a decimal number."> + > + ["at0004"] = < + text = <"Rationale"> + description = <"Justification for this risk assessment."> + comment = <"Details that may be added to this data element may include information about the population subgroups etc against which the determination of risk is assessed."> + > + ["at0010"] = < + text = <"Tree"> + description = <"@ internal @"> + > + ["at0011"] = < + text = <"Extension"> + description = <"Additional information required to capture local content or to align with other reference models/formalisms."> + comment = <"For example: local information requirements or additional metadata to align with FHIR or CIMI equivalents."> + > + ["at0012"] = < + text = <"Link to evidence"> + description = <"Identification of the path to the archetype or data node for the evidence of risk."> + > + ["at0013"] = < + text = <"Risk factor"> + description = <"Identification of the risk factor, by name."> + comment = <"For example: hypertension and hypercholesterolaemia, which may be used as part of the overall assessment for cardiovascular disease; or a genetic marker. Coding of +'Risk factor' with a terminology, where possible."> + > + ["at0014"] = < + text = <"Description"> + description = <"Narrative description about the risk factor."> + > + ["at0015"] = < + text = <"Comment"> + description = <"Additional narrative about the risk assessment not captured in other fields."> + > + ["at0016"] = < + text = <"Risk factors"> + description = <"Details about each possible risk factor."> + > + ["at0017"] = < + text = <"Presence"> + description = <"Presence of the risk factor."> + > + ["at0018"] = < + text = <"Present"> + description = <"The risk factor has been identified for this individual."> + > + ["at0019"] = < + text = <"Absent"> + description = <"The risk factor has not been identified for this individual."> + > + ["at0020"] = < + text = <"Assessment type"> + description = <"Record of whether the risk assessment is a relative or absolute."> + > + ["at0021"] = < + text = <"Relative risk"> + description = <"Ratio of probability of a health event or condition occurring compared to a population with similar characteristics eg same age and sex."> + > + ["at0022"] = < + text = <"Absolute risk"> + description = <"Ratio of probability of a health event or condition occurring compared to the population as a whole."> + > + ["at0023"] = < + text = <"Time period"> + description = <"The time period during which the predicted health risk is relevant."> + comment = <"That is: the risk of experiencing the identified 'Health risk' in the next years."> + > + ["at0024"] = < + text = <"Last updated"> + description = <"The date this health risk assessment was last updated."> + comment = <"This data element may be thought redundant if the data is recorded and stored using COMPOSITIONs within a closed clinical system. However if this information is extracted from its original COMPOSITION context, for example, to be included in another document or message then the temporal context is effectively removed. This 'Last updated' data element has been explicitly added to allow the critical temporal data to be kept alongside the clinical data in all circumstances. It is assumed that the clinical system can copy the date from the COMPOSITION to reduce the need for duplication of data entry by the clinician."> + > + ["at0025"] = < + text = <"Assessment method"> + description = <"Identification of the algorithm or guideline used to make the assessment of risk."> + comment = <"For example: Framingham cardiovascular risk calculator."> + > + ["at0026"] = < + text = <"Indeterminate"> + description = <"It is not possible to determine if the risk factor is present or absent."> + > + ["at0027"] = < + text = <"Detail"> + description = <"Structured detail about other aspects of the risk factor assessment."> + comment = <"For example: Prevalence of the risk factor in family members."> + > + ["at0028"] = < + text = <"Mitigated"> + description = <"The risk factor has been identified as present, but then subsequently been mitigated by treatment or investigation."> + comment = <"Record as True if the risk factor has been treated or investigated and risk from this risk factor is considered to be lessened. For example: an infant given gentamicin in neonatal intensive care is regarded as having a risk of permanent hearing loss. If diagnostic testing shows no evidence of hearing loss in the first year of life, the risk of later hearing loss is considered to be much reduced, but still possible. This data element allows clinicians to say that the risk has been mitigated but should still be considered as a possibility in future. In practice, the risk factor could be maintained in the risk assessment in case it might impact the individual's health at a future time, but flagging that its contribution to risk calculation may not be as great as if it had not been previously treated or investigated. "> + > + ["at0029"] = < + text = <"Date identified"> + description = <"The date/time that the risk factor was identified."> + > + ["at0030"] = < + text = <"Comment"> + description = <"Additional narrative about the risk factor not captured in other fields."> + > + > + > + ["es-ar"] = < + items = < + ["at0000"] = < + text = <"Evaluacion de riesgo para la salud"> + description = <"Evaluación del potencial y probabilidad de futuros efectos adversos para la salud determinados por la identificación de factores de riesgo."> + > + ["at0001"] = < + text = <"structure"> + description = <"@ internal @"> + > + ["at0002"] = < + text = <"Riesgo para la salud"> + description = <"Identificación, por nombre, de la enfermedad, condición o problema de salud potenciales para el cual se evalua el riesgo."> + comment = <"Se prefiere la codificación del 'Riesgo para la salud' mediante una terminología cuando esto sea posible. El texto libre solo debería ser utilizado cuando no se disponga de una terminología adecuada. Por ejemplo: riesgo de enfermedad cardiovascular con factores de riesgo de hipertensión arterial e hipercolesterolemia."> + > + ["at0003"] = < + text = <"Evaluación de riesgo"> + description = <"Evaluación del riesgo para la salud."> + comment = <"Pueden haber múltiples variaciones en la evaluación de riesgo. La elección del tipo de dato permite el registro de la evaluación tanto mediante texto libre como mediante un conjunto de valores (tales como bajo, medio o alto). El tipo de dato 'proporción' permite el registro como un porcentaje, una tasa o una fracción. El tipo de dato 'cantidad' permite el registro como un número decimal."> + > + ["at0004"] = < + text = <"Razón"> + description = <"Justificación para esta evaluación de riesgo."> + comment = <"Detalles que pueden ser agregados en este elemento pueden incluir información acerca de la población, subgrupos, etc, frente a los cuales se evalúa el riesgo."> + > + ["at0010"] = < + text = <"Tree"> + description = <"@ internal @"> + > + ["at0011"] = < + text = <"Extensión"> + description = <"Información adicional requerida para registrar contenido local o para alinear con otros modelos o formalismos de referencia."> + comment = <"Por ejemplo: requerimientos locales de información o metadatos adicionales para alinear con equivalentes FHIR o CIMI."> + > + ["at0012"] = < + text = <"Vínculo a la evidencia"> + description = <"Identificación del path al arquetipo o nodo de datos que contiene la evidencia del riesgo."> + > + ["at0013"] = < + text = <"Factor de riesgo"> + description = <"Identificación, por nombre, del factor de riesgo."> + comment = <"Por ejemplo: hipertensión arterial e hipercolesterolemia, que pueden ser utilizados como parte de una evaluación general de enfermedad cardiovascular; o un marcador genético. Codificar el factor de riesgo mediante una terminología cuando esto sea posible."> + > + ["at0014"] = < + text = <"Descripción"> + description = <"Descripción narrativa del factor de riesgo."> + > + ["at0015"] = < + text = <"Comentario"> + description = <"Narrativa adicional acerca de la evaluación de riesgo no contemplada en otros campos."> + > + ["at0016"] = < + text = <"Factores de riesgo"> + description = <"Detalles acerca de cada factor de riesgo posible."> + > + ["at0017"] = < + text = <"Presencia"> + description = <"Presencia del factor de riesgo."> + > + ["at0018"] = < + text = <"Presente"> + description = <"El factor de riesgo ha sido identificado para este individuo."> + > + ["at0019"] = < + text = <"Ausente"> + description = <"El factor de riesgo no ha sido identificado para este individuo."> + > + ["at0020"] = < + text = <"Tipo de evaluación"> + description = <"Registro acerca de la condición relativa o absoluta de la evaluación del riesgo."> + > + ["at0021"] = < + text = <"Riesgo relativo"> + description = <"Probabilidad de la ocurrencia de un evento o condición de salud en comparación con una población de características similares. Ejemplo: mismo sexo y edad."> + > + ["at0022"] = < + text = <"Riesgo absoluto"> + description = <"Probabilidad de la ocurrencia de un evento o condición de salud en comparación con el total de la población."> + > + ["at0023"] = < + text = <"Período de tiempo"> + description = <"El período de tiempo durante el cual el riesgo para la salud previsto es relevante."> + comment = <"Esto es: el riesgo de incurrir en el 'riesgo para la salud' identificado, en el curso de los próximos años."> + > + ["at0024"] = < + text = <"Última actualización"> + description = <"La fecha en la cual se realizó la ultima actualización de este factor de riesgo para la salud."> + comment = <"*This data element may be thought redundant if the data is recorded and stored using COMPOSITIONs within a closed clinical system. However if this information is extracted from its original COMPOSITION context, for example, to be included in another document or message then the temporal context is effectively removed. This 'Last updated' data element has been explicitly added to allow the critical temporal data to be kept alongside the clinical data in all circumstances. It is assumed that the clinical system can copy the date from the COMPOSITION to reduce the need for duplication of data entry by the clinician. (en)"> + > + ["at0025"] = < + text = <"Método de evaluación"> + description = <"Identificación del algoritmo o de la guia utilziada para realizar la evaluación de riesgo."> + comment = <"Por ejemplo: el cálculo de riesgo cardiovascular de Framingham."> + > + ["at0026"] = < + text = <"Indeterminado"> + description = <"No es posible determinar la presencia o ausencia del factor de riesgo."> + > + ["at0027"] = < + text = <"Detalle"> + description = <"Detalle estructurado acerca de otros aspectos de la evaluación del factor de riesgo."> + comment = <"Por ejemplo: Prevalencia del factor de riesgo en famililares."> + > + ["at0028"] = < + text = <"Mitigado"> + description = <"El factor de riesgo esta presente pero ha sido subsecuentemente mitigado por tratamiento o investigación."> + comment = <"Registrar como Verdadero si el factor de riesgo ha sido tratado o mejor investigado como para determinar que el riesgo puede considerarse disminuido. Por ejemplo: un niño ha recibido gentamicina en la unidad de cuidados intensivos neonatales puede considerarse en riesgo para hipoacusia permanente. Si los estudios diagnósticos no muestran evidencia de hipoacusia en el primer año de vida, el riesgo de hipoacusia posterior pueden considerarse como muy disminuido pero aún posible. Este dato permite a los clínicos considerar que el riesgo ha sido mitigado pero debe aún ser considerado como una posibildiad futura. En la práctica, el factor de riesgo puede mantenerse para la evaluación de riesgo en caso de poder tener impacto futuro sobre la salud del individuo, pero señalando que su contribución a la determinación del riesgo puede no ser tan importante como si no hubiera sido tratado o investigado."> + > + ["at0029"] = < + text = <"*Date identified(en)"> + description = <"*The date/time that the risk factor was identified.(en)"> + > + ["at0030"] = < + text = <"*Comment(en)"> + description = <"*Additional narrative about the risk factor not captured in other fields.(en)"> + > + > + > + ["sv"] = < + items = < + ["at0000"] = < + text = <"Riskbedömning"> + description = <"Bedömning av potential och sannolikhet för framtida negativa hälsoeffekter som bestäms av identifierade riskfaktorer."> + > + ["at0001"] = < + text = <"structure"> + description = <"@ internal @"> + > + ["at0002"] = < + text = <"Risk"> + description = <"Identifiering med namn av den potentiella framtida sjukdomen, tillståndet eller hälsotillståndet för vilken risken är bedömd."> + comment = <"Vid kodning av \"Risk\" med en terminologi är att föredra, om möjligt. Fri text ska endast användas om det inte finns någon lämplig terminologi. Till exempel: risk för kardiovaskulär sjukdom, med riskfaktorer för hypertension och hyperkolesterolemi."> + > + ["at0003"] = < + text = <"Riskbedömning"> + description = <"Utvärdering av hälsorisken."> + comment = <"Det kan finnas flera variationer i riskbedömningen. Datatypen val (choice) möjliggör registrering av bedömningen som antingen fritext eller vallista (t.ex. låg, medium eller hög). Datatypen andel (proportion) tillåter registrering av en procentandel, ett förhållande eller en fraktion. Datatypen numerisk (quantity) tillåter registrering av ett decimaltal."> + > + ["at0004"] = < + text = <"Motivering"> + description = <"Motivering för denna riskbedömning."> + comment = <"Detaljer som kan läggas till i detta dataelement kan innehålla information om befolkningsundergrupperna etc mot vilka bestämningen av risken bedöms."> + > + ["at0010"] = < + text = <"Tree"> + description = <"@ internal @"> + > + ["at0011"] = < + text = <"Extension"> + description = <"Ytterligare information som krävs för att fånga upp lokalt innehåll eller för anpassning sig till andra referensmodeller / formaliteter."> + comment = <"Till exempel: lokala informationskrav eller ytterligare metadata för att anpassa sig till FHIR- eller CIMI-ekvivalenter."> + > + ["at0012"] = < + text = <"Länk till evidens"> + description = <"Identifiering av sökvägen till arketypen eller datanoden för evidensen för risk."> + > + ["at0013"] = < + text = <"Riskfaktor"> + description = <"Identifiering med namn av riskfaktorn."> + comment = <"Till exempel: högt blodtryck och hyperkolesterolemi, som kan användas som en del av den övergripande bedömningen för kardiovaskulär sjukdom; eller en genetisk markör. Vid kodning av +Riskfaktor använd en terminologi om det är möjligt."> + > + ["at0014"] = < + text = <"Beskrivning"> + description = <"Berättande beskrivning om riksfaktorn."> + > + ["at0015"] = < + text = <"Kommentar"> + description = <"Ytterligare beskrivning om riskbedömningen som inte tagits med i andra fält."> + > + ["at0016"] = < + text = <"Riskfaktorer"> + description = <"Detaljer om varje möjlig riskfaktor."> + > + ["at0017"] = < + text = <"Förekomst"> + description = <"Förekomst av riskfaktor."> + > + ["at0018"] = < + text = <"Nuvarande"> + description = <"Riskfaktorn har identifierats för den här personen."> + > + ["at0019"] = < + text = <"Frånvarande"> + description = <"Riskfaktorn har inte identifierats för den här personen."> + > + ["at0020"] = < + text = <"Bedömningstyp"> + description = <"Uppgift om riskbedömningen är relativ eller absolut."> + > + ["at0021"] = < + text = <"Relativ risk"> + description = <"Förhållande mellan sannolikheten för ett hälsohändelse eller ett tillstånd som uppstår jämfört med en befolkning med liknande egenskaper, t.ex. samma ålder och kön."> + > + ["at0022"] = < + text = <"Absolut risk"> + description = <"Förhållandet mellan sannolikheten för en hälsohändelse eller ett tillstånd som uppstår i förhållande till befolkningen som helhet."> + > + ["at0023"] = < + text = <"Tidsperiod"> + description = <"Den tidsperiod under vilken den förutspådda hälsorisken är relevant."> + comment = <"Det vill säga: risken att drabbas av den identifierade hälsorisken under de kommande åren."> + > + ["at0024"] = < + text = <"Senast uppdaterad"> + description = <"Datumet när hälsoriskbedömningen senast uppdaterades."> + comment = <"*This data element may be thought redundant if the data is recorded and stored using COMPOSITIONs within a closed clinical system. However if this information is extracted from its original COMPOSITION context, for example, to be included in another document or message then the temporal context is effectively removed. This 'Last updated' data element has been explicitly added to allow the critical temporal data to be kept alongside the clinical data in all circumstances. It is assumed that the clinical system can copy the date from the COMPOSITION to reduce the need for duplication of data entry by the clinician. (en)"> + > + ["at0025"] = < + text = <"Bedömningsmetod"> + description = <"Identifiering av metoden eller riktlinjen som används för bedömning av risker."> + comment = <"Till exempel: Framingham kardiovaskulär riskkalkylator. +"> + > + ["at0026"] = < + text = <"Obestämd"> + description = <"Det är inte möjligt att bestämma om riskfaktorn finns eller är frånvarande."> + > + ["at0027"] = < + text = <"Detaljer"> + description = <"Strukturerad detalj om andra aspekter av riskfaktorbedömningen."> + comment = <"Till exempel: Förekomst av riskfaktorn hos familjemedlemmar."> + > + ["at0028"] = < + text = <"Minskad/mildrad"> + description = <"Riskfaktorn har identifierats att den finns, men har därefter minskats genom behandling eller undersökning."> + comment = <"Anteckna som sant om riskfaktorn har behandlats eller undersökts och risken från denna riskfaktor anses vara nedsatt. Till exempel: ett barn som ges gentamicin i neonatal intensivvård anses ha risk för permanent hörselnedsättning. Om diagnostisk testning inte visar någon hörselnedsättning under det första levnadsåret, anses risken för senare hörselnedsättning vara mycket reducerad men fortfarande möjlig. Detta dataelement gör det möjligt för kliniker att säga att risken har minskats men ska betraktas som en möjlighet i framtiden. I praktiken kan riskfaktorn bibehållas i riskbedömningen om det kan påverka den enskilda människans hälsa i framtiden, men att det inte är så stort att dess bidrag till riskberäkning är lika stort som om det inte tidigare har behandlats eller undersökts."> + > + ["at0029"] = < + text = <"Datum för konstaterande"> + description = <"Datum/tid då riskfaktorn konstaterades."> + > + ["at0030"] = < + text = <"Kommentar"> + description = <"Ytterligare beskrivning av riskfaktorn som inte fångats i andra fält."> + > + > + > + > diff --git a/better-template/src/test/resources/opt_json/Archetypes/openEHR-EHR-EVALUATION.living_arrangement.v0.adl b/better-template/src/test/resources/opt_json/Archetypes/openEHR-EHR-EVALUATION.living_arrangement.v0.adl new file mode 100644 index 000000000..32a2220b7 --- /dev/null +++ b/better-template/src/test/resources/opt_json/Archetypes/openEHR-EHR-EVALUATION.living_arrangement.v0.adl @@ -0,0 +1,179 @@ +archetype (adl_version=1.4; uid=7badddf7-2954-4f05-9a4b-73219ee1bdf6) + openEHR-EHR-EVALUATION.living_arrangement.v0 + +concept + [at0000] + +language + original_language = <[ISO_639-1::en]> + +description + original_author = < + ["date"] = <"2018-05-29"> + ["name"] = <"Heather Leslie"> + ["organisation"] = <"Atomica Informatics"> + ["email"] = <"heather.leslie@atomicainformatics.com"> + > + lifecycle_state = <"in_development"> + other_contributors = <"John Tore Valand, Helse Bergen, Norway","Vebjørn Arntzen, Oslo University Hospital, Norway","Silje Ljosland Bakke, Nasjonal IKT HF, Norway","Nyree Taylor, Ocean Informatics, Australia"> + details = < + ["en"] = < + language = <[ISO_639-1::en]> + purpose = <"To record the circumstances about how an individual lives alone or with others."> + keywords = <"alone","solo","family","friends","others","household"> + copyright = <"© openEHR Foundation"> + use = <"Use to record the circumstances about how an individual lives alone or with others. + +The intent of this archetype is to provide a sense of the level of day-to-day support, both physically and emotionally, that may be available to an individual in their 'home' setting. + +The concepts around housing, accommodation and living arrangements are complex and often potentially overlapping. Within this archetype, the intent of the concept of 'household' is to capture information about the group of people (one or more) who live in the same dwelling and share meals or living accommodation. A single dwelling may be considered to contain multiple households if either meals or living space are not shared. In this context households can include varieties of blended families, share housing, group homes, boarding houses, and a single room occupancy. + +This archetype has been designed to be used within the EVALUATION.housing_summary archetype, but may be used within any other appropriate ENTRY or CLUSTER archetype related to recording social context."> + misuse = <"Not to be used to record details about the physical structure in which an individual lives - use CLUSTER.dwelling for this purpose. + +Not to be used to record details about the setting in which an individual usually resides - use CLUSTER.accommodation for this purpose."> + > + > + other_details = < + ["licence"] = <"This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/."> + ["custodian_organisation"] = <"openEHR Foundation"> + ["references"] = <"Derived from: Household, Draft Archetype [Internet]. Australian Digital Health Agency, Australian Digital Health Agency Clinical Knowledge Manager. No longer available. + +National Housing and Homelessness Data Dictionary [Internet]. Canberra, Australia: Australian Institute of Health and Welfare (AIHW); 2013 [cited 2018 May 30]. Version 1. Cat. no. HOU 269. Available from: https://www.aihw.gov.au/getmedia/a47d4c86-a8aa-4f00-a889-42edea09cc2f/17841.pdf"> + ["current_contact"] = <"Heather Leslie, Atomica Informatics"> + ["original_namespace"] = <"org.openehr"> + ["original_publisher"] = <"openEHR Foundation"> + ["custodian_namespace"] = <"org.openehr"> + ["MD5-CAM-1.0.1"] = <"3B904FAD4A5459C4CA09D5A9B921CC37"> + ["build_uid"] = <"723aab03-8390-4c37-b0e7-fcf8621ff66b"> + ["revision"] = <"0.0.1-alpha"> + > + +definition + EVALUATION[at0000] matches { -- Living arrangement + data matches { + ITEM_TREE[at0001] matches { -- Item tree + items cardinality matches {0..*; unordered} matches { + ELEMENT[at0003] occurrences matches {0..1} matches { -- Description + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0004] occurrences matches {0..1} matches { -- Living arrangement + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0005] occurrences matches {0..1} matches { -- Household composition + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0006] occurrences matches {0..1} matches { -- Household description + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0007] occurrences matches {0..1} matches { -- Number of household members + value matches { + DV_COUNT matches {*} + } + } + allow_archetype CLUSTER[at0008] occurrences matches {0..*} matches { -- Additional details + include + archetype_id/value matches {/.*/} + } + ELEMENT[at0009] occurrences matches {0..1} matches { -- Pets + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0010] occurrences matches {0..1} matches { -- Comment + value matches { + DV_TEXT matches {*} + } + } + } + } + } + protocol matches { + ITEM_TREE[at0002] matches { -- Item tree + items cardinality matches {0..*; unordered} matches { + ELEMENT[at0012] occurrences matches {0..1} matches { -- Last updated + value matches { + DV_DATE_TIME matches {*} + } + } + allow_archetype CLUSTER[at0011] occurrences matches {0..*} matches { -- Extension + include + archetype_id/value matches {/.*/} + } + } + } + } + } + +ontology + term_definitions = < + ["en"] = < + items = < + ["at0000"] = < + text = <"Living arrangement"> + description = <"The circumstances about an individual living alone or with others."> + comment = <"This information will provide a sense of the level of support, both physically and emotionally, to which an individual may have access."> + > + ["at0001"] = < + text = <"Item tree"> + description = <"@ internal @"> + > + ["at0002"] = < + text = <"Item tree"> + description = <"@ internal @"> + > + ["at0003"] = < + text = <"Description"> + description = <"Narrative description about the living arrangements."> + > + ["at0004"] = < + text = <"Living arrangement"> + description = <"Single word or phrase that describes if an individual usually resides alone or with others."> + comment = <"Coding of the living arrangement with a terminology is preferred, where possible. The value sets for this data element are likely to vary between jurisdictions - it is anticipated that they will usually be set within a use-case specific template. For example: 'lives alone'; 'lives with family'; or 'lives with others'."> + > + ["at0005"] = < + text = <"Household composition"> + description = <"Single word or phrase that describes the relationship between people who reside together."> + comment = <"Coding of the household composition with a terminology is preferred, where possible. For example: single; sole parent with children aged less than 16 years; couple; couple with children aged less than 16 years; family; family with other non-related members present; or group of unrelated adults."> + > + ["at0006"] = < + text = <"Household description"> + description = <"Narrative description about the relationship between people who reside together."> + > + ["at0007"] = < + text = <"Number of household members"> + description = <"The number of individuals who are in the household."> + > + ["at0008"] = < + text = <"Additional details"> + description = <"Further details about the living arrangement."> + comment = <"This SLOT may be used to nest additional archetypes describing additional details about living arrangements that may be local to a jurisdiction."> + > + ["at0009"] = < + text = <"Pets"> + description = <"Narrative description about the pets who reside with an individual."> + > + ["at0010"] = < + text = <"Comment"> + description = <"Additional narrative about the living arrangement not captured in other fields."> + > + ["at0011"] = < + text = <"Extension"> + description = <"Additional information required to extend the model with local content or to align with other reference models/formalisms."> + comment = <"For example: local information requirements; or additional metadata to align with FHIR."> + > + ["at0012"] = < + text = <"Last updated"> + description = <"The date this summary was last updated."> + > + > + > + > diff --git a/better-template/src/test/resources/opt_json/Archetypes/openEHR-EHR-EVALUATION.occupation_summary.v1.adl b/better-template/src/test/resources/opt_json/Archetypes/openEHR-EHR-EVALUATION.occupation_summary.v1.adl new file mode 100644 index 000000000..97a47ae10 --- /dev/null +++ b/better-template/src/test/resources/opt_json/Archetypes/openEHR-EHR-EVALUATION.occupation_summary.v1.adl @@ -0,0 +1,289 @@ +archetype (adl_version=1.4; uid=82275b1b-765c-42fe-8a3f-2a2b19d54ac1) + openEHR-EHR-EVALUATION.occupation_summary.v1 + +concept + [at0000] + +language + original_language = <[ISO_639-1::en]> + translations = < + ["nb"] = < + language = <[ISO_639-1::nb]> + author = < + ["name"] = <"Silje Ljosland Bakke"> + ["organisation"] = <"Nasjonal IKT HF"> + > + > + ["it"] = < + language = <[ISO_639-1::it]> + author = < + ["name"] = <"Cecilia Mascia"> + ["organisation"] = <"CRS4 - Center for advanced studies, research and development in Sardinia, Pula (Cagliari), Italy"> + ["email"] = <"cecilia.mascia@crs4.it"> + > + > + > + +description + original_author = < + ["date"] = <"2010-12-17"> + ["name"] = <"Heather Leslie"> + ["organisation"] = <"Atomica Informatics"> + ["email"] = <"heather.leslie@atomicainformatics.com"> + > + lifecycle_state = <"published"> + other_contributors = <"Paula Anderson, UCLH, United Kingdom","Erling Are Hole, Helse Bergen, Norway","Vebjørn Arntzen, Oslo University Hospital, Norway (openEHR Editor)","Koray Atalag, University of Auckland, New Zealand","Heidi Aursand, Oslo universitetssykehus, Norway","Silje Ljosland Bakke, Nasjonal IKT HF, Norway (openEHR Editor)","Marcus Baw, openGPSoC / BawMedical Ltd, United Kingdom","Maria Beate Nupen-Stieng, Oslo Universitetssykehus, Norway","Ivar Berge, Oslo Universitetssykehus, Norway","Anita Bjørnnes, Helse Bergen, Norway","Bjørn Christensen, Helse Bergen HF, Norway","Angela Crovetti, CDC/NIOSH, United States","Lisbeth Dahlhaug, Helse Midt - Norge IT, Norway","Jayne Donaldson, University of Stirling, United Kingdom","Bjørg Eli Hollund, helse-bergen, Norway","Hildegard Franke, freshEHR Clinical Informatics Ltd., United Kingdom","Sergio Freire, State University of Rio de Janeiro, Brazil","Mikkel Gaup Grønmo, FSE, Helse Nord, Norway (Nasjonal IKT redaktør)","Heather Grain, Llewelyn Grain Informatics, Australia","Anne Gunn Haugland, Helse Bergen HF, Norway","Kristian Heldal, Telemark Hospital Trust, Norway","Evelyn Hovenga, EJSH Consulting, Australia","Kaja Irgens-Hansen, Yrkesmedisinsk avdeling, Haukeland universitetssykehus, Norway","Susanna Jönsson, Landstinget i Värmland, Sweden","Nils Kolstrup, Skansen Legekontor og Nasjonalt Senter for samhandling og telemedisin, Norway","Harmony Kosola, Alberta Health Services, Canada","Ron Krawec, Alberta Health Services, Canada","Liv Laugen, Oslo universitetssykehus, Norway","Heather Leslie, Atomica Informatics, Australia (openEHR Editor)","Rose Mari Eikås, Helse Bergen, Norway","Siv Marie Lien, DIPS ASA, Norway","Hildegard McNicoll, freshEHR Clinical Informatics Ltd., United Kingdom","Ian McNicoll, freshEHR Clinical Informatics, United Kingdom","John Meredith, NHS Wales Informatics Service, United Kingdom","Lars Morgan Karlsen, Nordlandssykehuset Bodø, Norway","Erik Nissen, Cambio Healthcare Systems AB, Sweden","Bjørn Næss, DIPS ASA, Norway","Andrej Orel, Marand d.o.o., Slovenia","Martin Paulson, Sykehuset i Vestfold, Norway","Tanja Riise, Nasjonal IKT HF, Norway","Jussara Rotzsch, Hospital Alemão Oswaldo Cruz, Brazil","Gro-Hilde Severinsen, Norwegian center for ehealthresearch, Norway","Line Silsand, Universitetssykehuset i Nord-Norge, Norway","Niclas Skyttberg, Karolinska Institutet, Sweden","Norwegian Review Summary, Nasjonal IKT HF, Norway","Nyree Taylor, Ocean Informatics, Australia","Tesfay Teame, Folkehelseinstittutet, Norway","Jon Tysdahl, Furst medlab AS, Norway","John Tore Valand, Helse Bergen, Norway (openEHR Editor)","Pelle Viana Lindén, Capio, Sweden"> + details = < + ["nb"] = < + language = <[ISO_639-1::nb]> + purpose = <"For å registrere et sammendrag eller varig (persistent) informasjon om et individs nåværende eller tidligere arbeid og/eller roller."> + keywords = <"arbeid","arbeidstaker","arbeidsgiver","arbeidsforhold","arbeidshistorikk","jobb","ansatt","yrke","arbeidsløs","studerer","student","elev","trygdet","ufør","arbeidssituasjon","erverv","yrkestilknytning","pensjon","pensjonist","attføring","bransje","arbeidsledig","hjemmeværende","stilling","profesjon","frivillig"> + copyright = <"© openEHR Foundation"> + use = <"Brukes for å registrere et sammendrag eller varig (persistent) informasjon om et individs nåværende eller tidligere arbeid og/eller roller. + +Arketypen er laget for å være en frittstående arketype, og kan benyttes som del av individets sosialanamnese i en templat. +Den er ment å gi et sammendrag over alle former for arbeid/roller. For hver enkelt jobb eller rolle brukes én instans av arketypen CLUSTER.occupation_record (Arbeidsforhold/rolle) i SLOTet \"Arbeidsepisode\"."> + misuse = <"Brukes ikke for å registrere strukturerte detaljer om en spesifikk rolle eller bidrag. Bruk arketypen CLUSTER.occupation_record (Arbeidsforhold/rolle) i SLOTet \"Arbeidsepisode\" for dette formålet. + +Brukes ikke for detaljerte beskrivelser av helserisikoer eller eksponering for farlige substanser i arbeidssituasjonen. Til dette brukes henholdsvis arketypene EVALUATION.health_risk (Helserisiko) eller EVALUATION.exposure. + +Brukes ikke for å registrere informasjon om individets inntekt eller inntektskilder. Bruk arketypen CLUSTER.income_summary for dette formålet."> + > + ["en"] = < + language = <[ISO_639-1::en]> + purpose = <"To record a summary or persistent information about an individual's current and past jobs and/or roles."> + keywords = <"employment","study","job","work","carer","role","pensioner","student","employee","employer","profession","unemployment","occupation","child","retiree","disabled"> + copyright = <"© Australian Digital Health Agency, openEHR Foundation"> + use = <"Use to record a summary or persistent information about an individual's current and past jobs and/or roles. + +This archetype has been designed to be used as a standalone archetype within the context of a Social History (or similar) template. It is intended to provide a summary of all occupations, considered in the broadest sense. For each job or role, use a separate instance of the CLUSTER.occupation_record within the SLOT for 'Occupation episode'."> + misuse = <"Not to be used for recording structured details about a specific job or role. Use the CLUSTER.occupation_record archetype within 'Occupation record' SLOT for this purpose. + +Not to be used for detailed descriptions of health risks or exposure to hazardous substances in the workplace. Use the EVALUATION.health_risk or EVALUATION.exposure archetype for these purposes. + +Not to be used to record information about sources of income or income details for the individual. Use the CLUSTER.income_summary archetype for this purpose."> + > + ["it"] = < + language = <[ISO_639-1::it]> + purpose = <"Registrare un sommario o informazioni persistenti sulle attività lavorative e/o ruoli presenti e passati di un individuo."> + keywords = <"impiego, studio, lavoro, occupazione, badante, ruolo, pensionato, studente, impiegato, datore di lavoro, professione, disoccupazione, occupazione, figlio, disabile", ...> + use = <"Usato per registrare un sommario o informazioni persistenti sulle attività lavorative e/o ruoli presenti e passati di un individuo. + +Questo archetipo è stato ideato per essere usato come archetipo a sé stante all'interno di un template per la 'Storia sociale' (o simili). L'archetipo intende fornire un sommario di tutte le occupazioni, considerate nel senso più ampio del termine. Per ogni professione o ruolo, usare una istanza separata dell'archetipo CLUSTER.occupation_record all'interno dello SLOT 'Episodio lavorativo'."> + misuse = <"Non utilizzare per memorizzare dettagli strutturati riguardanti una specifica professione o ruolo. Per questo scopo, usare invece l'archetipo CLUSTER.occupation_record all'interno dello SLOT 'Episodio lavorativo'. + +Non utilizzare per descrizioni dettagliate dei rischi per la salute o dell'esposizione a sostanze pericolose nel luogo di lavoro. Utilizzare invece gli archetipi EVALUATION.health_risk o EVALUATION.exposure. + +Non utilizzare per memorizzare informazioni sulle fonti o dettagli del reddito dell'individuo. Per questo scopo, utilizzare l'archetipo EVALUATION.income_summary."> + > + > + other_details = < + ["licence"] = <"This work is licensed under the Creative Commons Attribution-ShareAlike 3.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/3.0/."> + ["custodian_organisation"] = <"openEHR Foundation"> + ["references"] = <"Derived from: Employment Summary, Draft Archetype [Internet]. Australian Digital Health Agency (NEHTA), ADHA Clinical Knowledge Manager. Authored: 2010 Dec 17 (discontinued)."> + ["current_contact"] = <"Heather Leslie, Atomica Informatics"> + ["original_namespace"] = <"org.openehr"> + ["original_publisher"] = <"openEHR Foundation"> + ["custodian_namespace"] = <"org.openehr"> + ["MD5-CAM-1.0.1"] = <"7E6F0883E14EDE591F38805F00280D56"> + ["build_uid"] = <"3fb2e718-ab4b-477e-a055-47233997916d"> + ["revision"] = <"1.0.1"> + > + +definition + EVALUATION[at0000] matches { -- Occupation summary + data matches { + ITEM_TREE[at0001] matches { -- Tree + items cardinality matches {0..*; unordered} matches { + ELEMENT[at0002] occurrences matches {0..1} matches { -- Description + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0004] occurrences matches {0..*} matches { -- Employment status + value matches { + DV_TEXT matches {*} + } + } + allow_archetype CLUSTER[at0003] occurrences matches {0..*} matches { -- Occupation episode + include + archetype_id/value matches {/openEHR-EHR-CLUSTER\.occupation_record(-[a-zA-Z0-9_]+)*\.v1/} + } + allow_archetype CLUSTER[at0005] occurrences matches {0..*} matches { -- Additional details + include + archetype_id/value matches {/.*/} + } + ELEMENT[at0006] occurrences matches {0..1} matches { -- Comment + value matches { + DV_TEXT matches {*} + } + } + } + } + } + protocol matches { + ITEM_TREE[at0007] matches { -- Tree + items cardinality matches {0..*; unordered} matches { + allow_archetype CLUSTER[at0008] occurrences matches {0..*} matches { -- Extension + include + archetype_id/value matches {/.*/} + } + ELEMENT[at0009] occurrences matches {0..1} matches { -- Last updated + value matches { + DV_DATE_TIME matches {*} + } + } + } + } + } + } + +ontology + term_definitions = < + ["en"] = < + items = < + ["at0000"] = < + text = <"Occupation summary"> + description = <"Summary or persistent information about an individual's current and past jobs and/or roles."> + > + ["at0001"] = < + text = <"Tree"> + description = <"@ internal @"> + > + ["at0002"] = < + text = <"Description"> + description = <"Narrative description about the entire occupation history of the individual."> + > + ["at0003"] = < + text = <"Occupation episode"> + description = <"Structured details about each job or role, both current and past."> + comment = <"An individual may have multiple, concurrent active episodes of an occupation if they have a variety of jobs or roles. For example: carer for 2 days per week and employed in a retail job for 3 days a week; employed part-time to support studies."> + > + ["at0004"] = < + text = <"Employment status"> + description = <"Statement about the individual's current employment."> + comment = <"For example: employed; unemployed; or not in labour force. Coding with a terminology is desirable, where possible. Detail about each occupation can be recorded within the CLUSTER.occupation_record archetype."> + > + ["at0005"] = < + text = <"Additional details"> + description = <"Additional details about the current jobs or roles, or previous occupation history of an individual."> + > + ["at0006"] = < + text = <"Comment"> + description = <"Additional narrative about an individual's current occupation or history of occupations not captured in other fields."> + > + ["at0007"] = < + text = <"Tree"> + description = <"@ internal @"> + > + ["at0008"] = < + text = <"Extension"> + description = <"Additional information required to capture local content or to align with other reference models/formalisms."> + comment = <"For example: local information requirements or additional metadata to align with FHIR or CIMI equivalents."> + > + ["at0009"] = < + text = <"Last updated"> + description = <"Date when the occupation summary or associated occupation records were was updated."> + comment = <"At implementation, it is assumed that if an associated occupation record is added or updated then this date will also be updated."> + > + > + > + ["nb"] = < + items = < + ["at0000"] = < + text = <"Arbeidssammendrag"> + description = <"Sammendrag eller varig (persistent) informasjon om et individs nåværende eller tidligere arbeid og/eller roller."> + > + ["at0001"] = < + text = <"Tree"> + description = <"@ internal @"> + > + ["at0002"] = < + text = <"Beskrivelse"> + description = <"Fritekstbeskrivelse av hele historikken av arbeid og/eller roller til individet. + +"> + > + ["at0003"] = < + text = <"Arbeidsepisode"> + description = <"Strukturerte detaljer om hver enkelt jobb eller rolle, både tidligere og nåværende."> + comment = <"Et individ kan ha flere aktive arbeidsepisoder samtidig. For eksempel \"Hjemmeværende 2 dager i uken og butikkansatt 3 dager i uken\", eller \"Deltidsansatt i en bedrift mens man studerer\"."> + > + ["at0004"] = < + text = <"Arbeidsstatus"> + description = <"Utsagn om individets nåværende jobb/rolle."> + comment = <"For eksempel: \"Inntektsgivende arbeid\", \"Arbeidsledig\", \"Pensjonist\". Koding med en terminologi er ønskelig, der det er mulig, for eksempel OID 8150 (Volven.no). Detaljene om hver enkel jobb/ rolle kan registreres i arketypen CLUSTER.occupation_record (Arbeidsforhold/rolle)."> + > + ["at0005"] = < + text = <"Ytterligere detaljer"> + description = <"Ytterligere strukturerte detaljer om individets nåværende eller tidligere arbeid og/eller roller."> + > + ["at0006"] = < + text = <"Kommentar"> + description = <"Ytterligere fritekstkommentar til individets nåværende eller tidligere jobber/roller, som ikke er fanget i andre felt."> + > + ["at0007"] = < + text = <"*Tree(en)"> + description = <"*@ internal @(en)"> + > + ["at0008"] = < + text = <"Tilleggsinformasjon"> + description = <"Ytterligere informasjon som trengs for å kunne registrere lokalt definert innhold eller for å tilpasse til andre referansemodeller/formalismer."> + comment = <"For eksempel lokale informasjonsbehov eller ytterligere metadata for å kunne tilpasse til tilsvarende konsepter i FHIR eller CIMI."> + > + ["at0009"] = < + text = <"Sist oppdatert"> + description = <"Datoen da arbeidssammendraget eller tilknyttede arbeidsepisoder sist ble oppdatert."> + comment = <"Ved implementering av arketypen forutsettes det at dersom en arbeidsepisode legges til eller oppdateres, vil også denne datoen oppdateres."> + > + > + > + ["it"] = < + items = < + ["at0000"] = < + text = <"Occupazione - sommario"> + description = <"Informazioni riepilogative o persistenti sull'attuale stato occupazionale (professione o ruolo) di un individuo."> + > + ["at0001"] = < + text = <"Tree"> + description = <"@ internal @"> + > + ["at0002"] = < + text = <"Descrizione"> + description = <"Descrizione della storia occupazionale dell'individuo."> + > + ["at0003"] = < + text = <"Episodio lavorativo"> + description = <"Dettagli strutturati circa ogni professione svolta o ruolo ricoperto dall'individuo, attuali e passati."> + comment = <"Un individuo può avere più episodi lavorativi attivi e simultanei se svolge più di una professione o ricopre più di un ruolo. Ad esempio: badante per 2 giorni alla settimana e impiegato in un lavoro di vendita al dettaglio per 3 giorni alla settimana; impiegato a tempo parziale per sostenere gli studi"> + > + ["at0004"] = < + text = <"Stato occupazionale"> + description = <"Stato del'occupazione attuale dell'individuo."> + comment = <"Ad esempio: occupato; disoccupato; o non in forza lavoro. La codifica con una terminologia è preferibile, quando possibile. I dettagli circa ogni occupazione possono essere inseriti all'interno dell'archetipo CLUSTER.occupation_record."> + > + ["at0005"] = < + text = <"Ulteriori dettagli"> + description = <"Ulteriori dettagli sull'attuale professione o ruolo ricoperto, o sulla storia lavorativa dell'individuo."> + > + ["at0006"] = < + text = <"Commento"> + description = <"Note aggiuntive sull'occupazione attuale o sulla storia lavorativa non rilevate dagli altri campi. "> + > + ["at0007"] = < + text = <"Tree"> + description = <"@ internal @"> + > + ["at0008"] = < + text = <"Estensione"> + description = <"Informazioni aggiuntive necessarie per registrare specifici contenuti locali o per allinearsi con altri modelli/formalismi di riferimento."> + comment = <"Ad esempio: requisiti informativi locali o metadati addizionali per l'allineamento ai corrispondenti modelli FHIR o CIMI."> + > + ["at0009"] = < + text = <"Data ultimo aggiornamento"> + description = <"Data in cui il riepilogo occupazionale e i singoli record degli episodi lavorativi associati sono stati aggiornati."> + comment = <"Si assume che, al momento dell'implementazione, questa data venga aggiornata ogni volta che un record di un'episodio lavorativo viene aggiunto o aggiornato."> + > + > + > + > diff --git a/better-template/src/test/resources/opt_json/Archetypes/openEHR-EHR-EVALUATION.problem_diagnosis.v1.adl b/better-template/src/test/resources/opt_json/Archetypes/openEHR-EHR-EVALUATION.problem_diagnosis.v1.adl new file mode 100644 index 000000000..f5dbe0485 --- /dev/null +++ b/better-template/src/test/resources/opt_json/Archetypes/openEHR-EHR-EVALUATION.problem_diagnosis.v1.adl @@ -0,0 +1,1925 @@ +archetype (adl_version=1.4; uid=cc3a20b3-8928-4c2a-babd-fe9e28987be7) + openEHR-EHR-EVALUATION.problem_diagnosis.v1 + +concept + [at0000] + +language + original_language = <[ISO_639-1::en]> + translations = < + ["de"] = < + language = <[ISO_639-1::de]> + author = < + ["name"] = <"Aljoscha Kindermann, Jasmin Buck, Sebastian Garde"> + ["organisation"] = <"Universityhospital of Heidelberg, University of Heidelberg, Central Queensland University"> + > + > + ["sv"] = < + language = <[ISO_639-1::sv]> + author = < + ["name"] = <"Kirsi Poikela"> + ["organisation"] = <"Tieto Sweden AB"> + ["email"] = <"ext.kirsi.poikela@tieto.com"> + > + > + ["fi"] = < + language = <[ISO_639-1::fi]> + author = < + > + > + ["es-ar"] = < + language = <[ISO_639-1::es-ar]> + author = < + ["name"] = <"Alan March"> + ["organisation"] = <"Hospital Universitario Austral, Buenos Aires, Argentina"> + ["email"] = <"alandmarch@gmail.com"> + > + accreditation = <"-"> + > + ["nb"] = < + language = <[ISO_639-1::nb]> + author = < + ["name"] = <"Silje Ljosland Bakke, John Tore Valand"> + ["organisation"] = <"Helse Bergen HF"> + > + > + ["ko"] = < + language = <[ISO_639-1::ko]> + author = < + ["name"] = <"Seung-Jong Yu"> + ["organisation"] = <"InfoClinic Co.,Ltd."> + ["email"] = <"seungjong.yu@gmail.com"> + > + accreditation = <"M.D."> + > + ["pt-br"] = < + language = <[ISO_639-1::pt-br]> + author = < + ["name"] = <"Adriana Kitajima, Gabriela Alves, Maria Angela Scatena, Marivan Abrahäo"> + ["organisation"] = <"Core Consulting"> + ["email"] = <"contato@coreconsulting.com.br"> + > + accreditation = <"Hospital Alemão Oswaldo Cruz (HAOC)"> + > + ["ar-sy"] = < + language = <[ISO_639-1::ar-sy]> + author = < + ["name"] = <"Mona Saleh"> + > + > + ["it"] = < + language = <[ISO_639-1::it]> + author = < + ["name"] = <"Cecilia Mascia"> + ["organisation"] = <"CRS4 - Center for advanced studies, research and development in Sardinia, Pula (Cagliari), Italy"> + ["email"] = <"cecilia.mascia@crs4.it"> + > + > + ["es"] = < + language = <[ISO_639-1::es]> + author = < + ["name"] = <"Pablo Pazos"> + ["organisation"] = <"CaboLabs"> + > + accreditation = <"Computer Engineer"> + > + > + +description + original_author = < + ["date"] = <"2006-04-23"> + ["name"] = <"Sam Heard"> + ["organisation"] = <"Ocean Informatics"> + ["email"] = <"sam.heard@oceaninformatics.com"> + > + lifecycle_state = <"published"> + other_contributors = <"Grethe Almenning, Bergen kommune, Norway","Tomas Alme, DIPS, Norway","Nadim Anani, Karolinska Institutet, Sweden","Erling Are Hole, Helse Bergen, Norway","Vebjørn Arntzen, Oslo universitetssykehus HF, Norway (Nasjonal IKT redaktør)","Koray Atalag, University of Auckland, New Zealand","Silje Ljosland Bakke, Nasjonal IKT HF, Norway (openEHR Editor)","John Bennett, NEHTA, Australia","Steve Bentley, Allscripts, United Kingdom","Lars Bitsch-Larsen, Haukeland University hospital, Norway","Terje Bless, Helse Nord FIKS, Norway","Fredrik Borchsenius, Oslo universitetssykehus, Norway","Ian Bull, ACT Health, Australia","Sergio Carmona, Chile","Rong Chen, Cambio Healthcare Systems, Sweden","Stephen Chu, Queensland Health, Australia","Ed Conley, Cardiff University, United Kingdom","Matthew Cordell, NEHTA, Australia","Inderjit Daphu, Helse Bergen, Norway","Paul Donaldson, Nursing Informatics Australia, Australia","Gail Easterbrook, Flinders Medical Centre, Australia","Aitor Eguzkitza, UPNA (Public University of Navarre) - CHN (Complejo Hospitalario de Navarra), Spain","Tone Engen, Norway","David Evans, Queensland Health, Australia","Arild Faxvaag, NTNU, Norway","Shahla Foozonkhah, Iran ministry of health and education, Iran","Einar Fosse, National Centre for Integrated Care and Telemedicine, Norway","Peter Garcia-Webb, Australia","Sebastian Garde, Ocean Informatics, Germany","Bente Gjelsvik, Helse Bergen, Norway","Andrew Goodchild, NEHTA, Australia","Anneke Goossen, Results 4 Care, Netherlands","Gyri Gradek, Senter for medisinsk genetikk og molekylærmedisin, Haukeland Universitetssykehus, Norway","Heather Grain, Llewelyn Grain Informatics, Australia","Trina Gregory, cpc, Australia","Bjørn Grøva, Diretoratet for e-helse, Norway","Dag Hanoa, Oslo universitetssykehus, Norway","Knut Harboe, Stavanger Universitetssjukehus, Norway","Sam Heard, Ocean Informatics, Australia","Ingrid Heitmann, Oslo universitetssykehus HF, Norway","Kristian Heldal, Telemark Hospital Trust, Norway","Andreas Hering, Helse Bergen HF, Haukeland universitetssjukehus, Norway","Anca Heyd, DIPS ASA, Norway","Hilde Hollås, DIPS AS, Norway","Evelyn Hovenga, EJSH Consulting, Australia","Eugene Igras, IRIS Systems, Inc., Canada","Lars Ivar Mehlum, Helse Bergen HF, Norway","Tom Jarl Jakobsen, Helse Bergen, Norway","Aud Jorunn Mjelstad, Helse Bergen, Norway","Gunnar Jårvik, Nasjonal IKT HF, Norway","Lars Morgan Karlsen, DIPS ASA, Norway","Mary Kelaher, NEHTA, Australia","Eizen Kimura, Ehime Univ., Japan","Shinji Kobayashi, Kyoto University, Japan","Robert L'egan, NEHTA, Australia","Sabine Leh, Haukeland University Hospital, Department of Pathology, Norway","Heather Leslie, Atomica Informatics, Australia (openEHR Editor)","Hugh Leslie, Ocean Informatics, Australia (Editor)","Hallvard Lærum, Norwegian Directorate of e-health, Norway","Luis Marco Ruiz, NST, Spain","Siv Marie Lien, DIPS ASA, Norway","Rohan Martin, Ambulance Victoria, Australia","David McKillop, NEHTA, Australia","Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (openEHR Editor)","Chris Mitchell, RACGP, Australia","Stewart Morrison, NEHTA, Australia","Jörg Niggemann, compugroup, Germany","Bjørn Næss, DIPS ASA, Norway","Mona Oppedal, Helse Bergen, Norway","Andrej Orel, Marand d.o.o., Slovenia","Anne Pauline Anderssen, Helse Nord RHF, Norway","Chris Pearce, Melbourne East GP Network, Australia","Camilla Preeston, Royal Australian College of General Practitioners, Australia","Margaret Prichard, NEHTA, Australia","Jodie Pycroft, Adelaide Northern Division of General Practice Ltd, Australia","Cathy Richardson, NEHTA, Australia","Robyn Richards, NEHTA - Clinical Terminology, Australia","Jussara Rotzsch, Hospital Alemão Oswaldo Cruz, Brazil","Thomas Schopf, University Hospital of North-Norway, Norway","Thilo Schuler, Australia","Anoop Shah, University College London, United Kingdom","Arild Stangeland, Helse Bergen, Norway","Line Sæle, Nasjonal IKT HF, Norway","Line Sørensen, Helse Bergen, Norway","Gordon Tomes, Australian Institute of Health and Welfare, Australia","Richard Townley-O'Neill, NEHTA, Australia","Donna Truran, ACCTI-UoW, Australia","Jon Tysdahl, Furst medlab AS, Norway","John Tore Valand, Helse Bergen, Norway (openEHR Editor)","Kylie Young, The Royal Australian College of General Practitioners, Australia"> + details = < + ["de"] = < + language = <[ISO_639-1::de]> + purpose = <"Zur Darstellung von Details über ein einzelnes identifiziertes gesundheitliches Problem oder eine Diagnose. + +Der angestrebte Anwendungsbereich eines gesundheitlichen Problems wurde im Rahmen der medizinischen Dokumentation bewusst breit gehalten, um die reale und wahrgenommene Beeinträchtigungen, die auf das Wohlbefinden eines Individuums nachteilig auswirken könnten, zu erfassen. Ein gesundheitliches Problem kann durch das Individuum selber, durch einen Betreuer oder eine medizinische Fachkraft festgestellt werden. Im Gegensatz dazu wird eine Diagnose zusätzlich durch objektive klinische Kriterien definiert und wird normalerweise nur durch eine medizinische Fachkraft festgestellt."> + keywords = <"Sachverhalt","Beschwerde","Problem","Diagnose","Befinden","Verletzung","Klinisches Bild"> + copyright = <"© openEHR Foundation"> + use = <"Zur Dokumentation eines einzelnen identifizierten gesundheitlichen Problems bzw. einer Diagnose. + +Klare Definitionen, welche eine eindeutige Abgrenzung zwischen einem 'Problem' und einer 'Diagnose' zulassen würden, sind in der praktischen Anwendung nahezu unmöglich - wir können nicht verlässlich festlegen, wann ein Problem als Diagnose angesehen werden sollte. Wenn Diagnose- oder Klassifizierungskriterien zutreffen, können wir einen Gesundheitszustand mit Bestimmtheit als Diagnose bezeichnen. Jedoch kann, auch wenn diese Kriterien noch nicht zutreffen, die Bezeichnung 'Diagnose' zutreffend sein. Die Menge an unterstützenden Hinweisen, die für die Bezeichnung 'Diagnose' notwendig ist, ist nicht einfach festzulegen und variiert in Wirklichkeit wohl abhängig vom Gesundheitszustand. Viele Normungsgremien haben sich mit dieser Definitionsproblematik seit Jahren befasst, ohne zu einem eindeutigen Ergebnis zu kommen. + +Für den Zweck der klinischen Dokumentation im Zuge dieses Archetyps werden Problem und Diagnose als Kontinuum betrachtet, wobei ein zunehmender Detaillierungsgrad und unterstützende Beweise in der Regel dem Label der 'Diagnose' Gewicht verleihen. In diesem Archetyp ist es nicht notwendig eine Zuordnung des Gesundheitszustandes als 'Problem' oder 'Diagnose' vorzunehmen. Die Datenanforderungen zur Unterstützung der beiden sind identisch, wobei eine zusätzliche Datenstruktur erforderlich ist, um die Einbeziehung der Nachweise zu unterstützen, wenn und sobald sie verfügbar sind. Beispiele von Problemen beinhalten: Der vom Individuum geäußerte Wunsch, Gewicht zu verlieren, ohne die formale Diagnose der Fettleibigkeit; oder ein Beziehungsproblem mit einem Familienmitglied. Beispiele formaler Diagnosen beinhalten: Krebs, welcher durch historische Information gestützt wird; Untersuchungsergebnisse; histopathologische Ergebnisse; radiologische Befunde - Diese erfüllen die Anforderungen an diagnostische Kriterien. In der Realität sind Probleme und Diagnosen nicht eindeutig einem der beiden Extreme des Problem-Diagnose-Spektrums zuzuordnen, sondern irgendwo dazwischen. + +Dieser Archetyp kann in verschiedenen Zusammenhängen verwendet werden. Zum Beispiel: Dokumentation eines Problems oder einer Diagnose während einer klinischen Beratung; Ausfüllen einer persistenten Problemliste; Zusammenfassende Aussage in einem Entlassungsdokument. + +In der Praxis verwenden Kliniker viele kontextspezifische Merkmale wie Vergangenheit/Gegenwart, Primär/Sekundär, Aktiv/Inaktiv, Aufnahme/Entlassung etc. Die Zusammenhänge können orts-, spezialisierungs-, episoden- oder workflowspezifisch sein, was zu Verwirrung oder gar potenziellen Sicherheitsproblemen führen kann, wenn die Merkmale in Problemlisten fortbestehen oder in Dokumenten geteilt werden, die außerhalb des ursprünglichen Kontextes liegen. Diese Merkmale können separat archetypisiert und in den Slot 'Status' aufgenommen werden, da ihre Verwendung unter verschiedenen Bedingungen variiert. Es wird erwartet, dass diese meist im entsprechenden Kontext verwendet und nicht ohne klares Verständnis der möglichen Folgen aus diesem Kontext heraus geteilt werden. So kann beispielsweise eine Primärdiagnose des einen Arztes eine Sekundärdiagnose für einen anderen Spezialisten darstellen; ein aktives Problem kann inaktiv werden (oder umgekehrt) und dies kann sich auf die sichere Verwendung der klinischen Entscheidungshilfe auswirken. Die Problem/Diagnose Merkmale sollen generell an die Kontexte der lokalen klinischen Systeme angepasst werden und in der Praxis sollte der jeweilige Status von Klinikern manuell kuratiert werden, um sicherzustellen, dass die Listen der aktuellen/vergangenen, aktiven/inaktiven oder primären/sekundären Probleme klinisch korrekt sind. + +Dieser Archetyp wird als Komponente im Sinne des von Larry Weed beschriebenen 'Problem Oriented Medical Record' verwendet. Zusätzliche Archetypen, die klinische Konzepte wie z.B. die Erkrankung als übergreifender Organisator für Diagnosen usw. repräsentieren, müssen entwickelt werden, um diesen Ansatz zu unterstützen. + +In einigen Situationen könnte angenommen werden, dass die Identifizierung einer Diagnose nur innerhalb der Expertise von Ärzten liegt, aber das ist nicht die Absicht dieses Archetyps. Diagnosen können mit diesem Archetyp von jedem Angehörigen der Gesundheitsberufe erfasst werden."> + misuse = <"Nicht zur Dokumentation von Symptomen, welche vom Individuum beschrieben werden. Verwenden Sie den Archetyp CLUSTER.symptom, normalerweise innerhalb des OBSERVATION.story Archetyps. + +Nicht zur Dokumentation von Untersuchungsergebnissen. Verwenden Sie untersuchungsbezogene CLUSTER Archetypen, normalerweise verschachtelt innerhalb des OBSERVATION.exam Archetyps. + +Nicht zur Dokumentation von Laborergebnissen oder verwandten Diagnosen. Verwenden Sie einen geeigneten Archetyp aus der Familie der Labor-OBSERVATION Archetypen. + +Nicht zur Dokumentation von Ergebnissen aus bildgebenden Verfahren. Verwenden Sie einen geeigneten Archetyp aus der Famile der Bildgebung-OBSERVATION Archetypen. + +Nicht zur Dokumentation von Differentialdiagnosen. Verwenden Sie den Archetyp EVALUATION.differential_diagnosis. + +Nicht zur Dokumentation von 'Grund für Kontakt' oder 'Bestehende Beschwerden'. Verwenden Sie den Archetyp EVALUATION.reason_for_encounter. + +Nicht zur Dokumentation von Prozeduren. Verwenden Sie den Archetyp ACTION.procedure. + +Nicht zur Dokumentation von Details über Schwangerschaft. Verwenden Sie die Archetypen EVALUATION.pregnancy_bf_status und EVALUATION.pregnancy sowie verwandte Archetypen. + +Nicht zur Dokumentation von Aussagen über Gesundheitsrisiken oder potentielle Gesundheitsprobleme. Verwenden Sie den Archetyp EVALUATION.health_risk. + +Nicht zur Dokumentation von Aussagen über Nebenwirkungen, Allergien oder Intoleranzen. Verwenden Sie den Archetyp EVALUATION.adverse_reaction. + +Nicht zur Dokumentation einer expliziten Abwesenheit oder Nicht-Anwesenheit eines Problems oder einer Diagnose, wie zum Beispiel 'Kein bekanntes Problem bzw. Diagnose' oder 'Kein Diabetes festgestellt'. Verwenden Sie den Archetyp EVALUATION.exclusion-problem_diagnosis um eine postitive Aussage über den Ausschluss eines Problems oder einer Diagnose zu treffen."> + > + ["sv"] = < + language = <[ISO_639-1::sv]> + purpose = <"Att dokumentera ett enskilt identifierat hälsoproblem eller diagnos. Spännvidden av ett hälsoproblem har avsiktligt gjorts bred, för att kunna fånga upp eventuella verkliga eller upplevda *oroskänslor* som kan inverka negativt på en individs välbefinnande. Ett hälsoproblem kan identifieras av individen, en vårdgivare eller en sjukvårdspersonal. En diagnos definieras däremot baserat på objektiva kliniska kriterier, oftast fastställd endast av sjukvårdspersonal."> + keywords = <"*fråga","tillstånd","problem","diagnos","oro","skada","klinisk tolkning"> + use = <"Används för att beskriva ett enskilt identifierat hälsoproblem eller diagnos. +Tydliga definitioner som möjliggör en differentiering mellan ett \"problem\" och en \"diagnos\" är nästan omöjliga i praktiken. Vi kan inte på ett tillförlitligt sätt säga när ett problem bör betraktas som en diagnos. När diagnostiska eller klassificeringskriterier är uppfyllda kan vi tryggt kalla tillståndet en formell diagnos. + +Om det finns stödjande bevis tillgängligt, kan det ändå vara giltigt att använda termen \"diagnos\" trots att dessa villkor ännu inte uppfyllts. Det är inte lätt att definiera mängden stödjande bevis som krävs för diagnosmärkning och i verkligheten varierar det från fall till fall. Många standardkommittéer har brottats med denna definitionsgåta i åratal utan tydlig upplösning. + +Vid tillämpning av klinisk dokumentation med denna arketyp betraktas problem och diagnoser som ett kontinuum med utrymme för fler detaljer och stödjande bevis som vanligtvis ger stöd för märkningen \"diagnos\". I denna arketyp är det inte nödvändigt att klassificera tillståndet som ett \"problem\" eller \"diagnos\". Kraven för att stödja dokumentation av vardera är identiska, innehållande extra datastruktur som krävs för att stödja inmatning av bevis om och när den blir tillgänglig. +Exempel på problem är: individens uttryckliga önskan att gå ner i vikt, men utan en formell diagnos av fetma eller ett relationsproblem med en familjemedlem. Exempel på formella diagnoser skulle omfatta cancer som stöds av anamnes, undersökningsfynd, histopatologiska fynd, radiologiska fynd samt möter alla kända kriteriekrav för diagnostik. + +I praktiken befinner sig de flesta problem eller diagnoser inte i någon ände av problemet-diagnos spektrumet, utan någonstans däremellan. +Denna arketyp kan användas i flera kontexter, exempelvis för dokumentation av ett problem eller en klinisk diagnos under en klinisk konsultation, ifyllnad av en fast problemlista eller för en redogörande sammanfattning i ett utskrivningsdokument. + +I praktiken använder kliniker många kontext-specifika bestämningar som exempelvis tidigare och nuvarande, primär och sekundär, aktiv och inaktiv, inskrivning och utskrivning etc. Kontexterna kan vara plats-, specialitet-, episod-eller arbetsflödes-specifika. Dessa kan orsaka förvirring eller t.o.m. vara potentiella säkerhetsproblem om de förevigas i problemlistor eller delas i dokument som är utanför den ursprungliga kontexten. +Dessa bestämningar kan vara separata i arketyperna och ingår i \"status\"-fältet, eftersom deras användning varierar i olika inställningar. +Det förväntas att de huvudsakligen används i en lämplig kontext och inte sprids utanför kontexten utan tydlig förståelse för potentiella konsekvenser. +Exempelvis kan en diagnos vara primär för en kliniker och sekundär för en annan specialist, ett aktivt problem kan bli inaktivt (eller vice versa) och detta kan påverka den säkra användningen av kliniskt beslutsstöd. + +I allmänhet bör dessa bestämningar tillämpas lokalt inom ramen för det kliniska systemet, och i praktiken bör dessa tillstånd ordnas manuellt av kliniker för att säkerställa att listor över nuvarande och tidigare, aktiv och inaktiv eller primärt och sekundärt problem är kliniskt korrekta. +Denna arketyp kommer att användas som en komponent inom den problemorienterade patientjournalen som beskrivs av Larry Weed. Ytterligare arketyper, som presenterar kliniska begrepp som villkor som en övergripande organisatör för diagnoser etc. kommer att behöva utvecklas för att stödja denna strategi. + +I vissa situationer, kan identifiering av en diagnos vara lämplig enbart inom läkarnas expertis, men det är inte avsikten med denna arketyp. Diagnoser kan dokumenteras med hjälp av denna arketyp av vilken som helst sjukvårdspersonal. +"> + misuse = <"Ska inte användas för att dokumentera symtom som beskrivs av individen. Använd CLUSTER. symptom arketypen vanligtvis inom OBSERVATION.story-arketypen för det ändamålet. + +Ska inte användas för att dokumentera undersökningsfynd. Använda då istället arketyper från den undersökningsrelaterade gruppen CLUSTER- som oftast är inkapslad i Observation Exam-arketypen. + +Ska inte användas för att dokumentera testresultat från laboratoriet eller till relaterade diagnoser, exempelvis patologiska diagnoser. Använd då istället en lämplig arketyp från laboratoriegruppen OBSERVATION. + +Ska inte användas för att dokumentera undersökningsfynd genom bildmedia eller bilddiagnostik. Använd då istället en lämplig arketyp från bildmediegruppen OBSERVATION arketyper. + +Ska inte användas för att dokumentera \"differentialdiagnostik\". Använd då istället EVALUATION.differential_diagnosis-arketypen. + +Ska inte användas för att dokumentera \"Anledning till Vårdtillfälle\" eller \"Huvudsakligt besvär\". Använd EVALUATION.reason_for_encounter-arketypen till dessa ändamål. + +Ska inte användas för att dokumentera åtgärder. Använd då istället ACTION.procedure-arketypen. + +Ska inte användas för att dokumentera uppgifter om graviditet. Använd EVALUATION.pregnancy_bf_status och EVALUATION.pregnancy och relaterade arketyper till dessa ändamål. + +Ska inte användas för att dokumentera bedömningar om hälsorisker eller potentiella problem. Använd då istället EVALUATION.health_risk-arketypen. + +Ska inte användas för att dokumentera redogörelser om biverkningar, allergier eller intoleranser. Använd EVALUATION.adverse_reaction-arketyp för dessa ändamål. + +Ska inte användas för särskild dokumentering av frånvaro (eller negativ närvaro) av ett problem eller en diagnos, exempelvis \"inga kända problem eller diagnoser\" eller \"Ingen känd diabetes\". Använd EVALUATION.exclusion-problem_arketypen för att uttrycka ett positivt utlåtande om uteslutning av ett problem eller diagnos. + +"> + > + ["fi"] = < + language = <[ISO_639-1::fi]> + purpose = <"*For recording details about a single, identified health problem or diagnosis. + +The intended scope of a health problem is deliberately kept loose in the context of clinical documentation, so as to capture any real or perceived concerns that may adversely affect an individual's wellbeing to any degree. A health problem may be identified by the individual, a carer or a healthcare professional. However, a diagnosis is additionally defined based on objective clinical criteria, and usually determined only by a healthcare professional.(en)"> + keywords = <"*issue(en)","*condition(en)","*problem(en)","*diagnosis(en)","*concern(en)","*injury(en)","*clinical impression(en)"> + use = <"*Use for recording details about a single, identified health problem or diagnosis. + +Clear definitions that enable differentiation between a 'problem' and a 'diagnosis' are almost impossible in practice - we cannot reliably tell when a problem should be regarded as a diagnosis. When diagnostic or classification criteria are successfully met, then we can confidently call the condition a formal diagnosis, but prior to these conditions being met and while there is supportive evidence available, it can also be valid to use the term 'diagnosis'. The amount of supportive evidence required for the label of diagnosis is not easy to define and in reality probably varies from condition to condition. Many standards committees have grappled with this definitional conundrum for years without clear resolution. + +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'. In this archetype it is not neccessary to classify the condition as a 'problem' or 'diagnosis'. The data requirements to support documentation of either are identical, with additional data structure required to support inclusion of the evidence if and when it becomes available. Examples of problems include: the individual's expressed desire to lose weight, but without a formal diagnosis of Obesity; or a relationship problem with a family member. Examples of formal diagnoses would include a cancer that is supported by historical information, examination findings, histopathological findings, radiological findings and meets all requirements for known diagnostic criteria. In practice, most problems or diagnoses do not sit at either end of the problem-diagnosis spectrum, but somewhere in between. + +This archetype can be used within many contexts. For example, recording a problem or a clinical diagnosis during a clinical consultation; populating a persistent Problem List; or to provide a summary statement within a Discharge Summary document. + +In practice, clinicians use many context-specific qualifiers such as past/present, primary/secondary, active/inactive, admission/discharge etc. The contexts can be location-, specialisation-, episode- or workflow-specific, and these can cause confusion or even potential safety issues if perpetuated in Problem Lists or shared in documents that are outside of the original context. These qualifiers can be archetyped separately and included in the ‘Status’ slot, because their use varies in different settings. It is expected that these will be used mostly within the appropriate context and not shared out of that context without clear understanding of potential consequences. For example, a primary diagnosis to one clinician may be a secondary one to another specialist; an active problem can become inactive (or vice versa) and this can impact the safe use of clinical decision support. In general these qualifiers should be applied locally within the context of the clinical system, and in practice these statuses should be manually curated by clinicians to ensure that lists of Current/Past, Active/Inactive or Primary/Secondary Problems are clinically accurate. + +This archetype will be used as a component within the Problem Oriented Medical Record as described by Larry Weed. Additional archetypes, representing clinical concepts such as condition as an overarching organiser for diagnoses etc, will need to be developed to support this approach. + +In some situations, it may be assumed that identification of a diagnosis fits only within the expertise of physicians, but this is not the intent for this archetype. Diagnoses can be recorded using this archetype by any healthcare professional.(en)"> + misuse = <"*Not to be used to record symptoms as described by the individual - use the CLUSTER.symptom archetype, usually within the OBSERVATION.story archetype. + +Not to be used to record examination findings - use the family of examination-related CLUSTER archetypes, usually nested within the OBSERVATION.exam archetype. + +Not to be used to record laboratory test results or related diagnoses, for example pathological diagnoses - use an appropriate archetype from the laboratory family of OBSERVATION archetypes. + +Not to be used to record imaging examination results or imaging diagnoses - use an appropriate archetype from the imaging family of OBSERVATION archetypes. + +Not to be used to record 'Differential Diagnoses' - use the EVALUATION.differential_diagnosis archetype. + +Not to be used to record 'Reason for Encounter' or 'Presenting Complaint' - use the EVALUATION.reason_for_encounter archetype. + +Not to be used to record procedures - use the ACTION.procedure archetype. + +Not to be used to record details about pregnancy - use the EVALUATION.pregnancy_bf_status and EVALUATION.pregnancy and related archetypes. + +Not to be used to record statements about health risk or potential problems - use the EVALUATION.health_risk archetype. + +Not to be used to record statements about adverse reactions, allergies or intolerances - use the EVALUATION.adverse_reaction archetype. + +Not to be used for the explicit recording of an absence (or negative presence) of a problem or diagnosis, for example ‘No known problem or diagnoses’ or ‘No known diabetes’. Use the EVALUATION.exclusion-problem_diagnosis archetype to express a positive statement about exclusion of a problem or diagnosis.(en)"> + > + ["es-ar"] = < + language = <[ISO_639-1::es-ar]> + purpose = <"Para el registro de detalles acerca de un único problema de salud o diagnóstico. +El alcance previsto del problema de salud se mantiene deliberadamente poco definido en el contexto de la documentación clínica, de modo tal que pueda representarse cualquier problema, real o percibido, que pueda afectar al bienestar de un individuo en cualquier grado. Un problema de salud puede ser identificado por un individuo, un cuidador, o un profesional de la salud. Para la definición de un diagnóstico se require además de criterios clínicos objetivos, habitualmente determinados por un profesional de la salud."> + keywords = <"asunto","condición","problema","diagnóstico","preocupación","lesión","impresión clínica"> + copyright = <"© openEHR Foundation"> + use = <"Utilícese para registrar detalles acerca de un único problema de salud o diagnóstico. + +Una definición clara que permita diferenciar un \"problema\" de un \"diagnóstico\" es casi imposible en la práctica - no podemos determinar en forma confiable cuando un problema debería ser considerado un diagnóstico. Cuando se cumplen con éxito determinados criterios diagnósticos o de clasificación es posible denominar una condición como un diagnóstico formal, pero previo al cumplimiento de dichos criterios y en tanto exista evidencia clínica que lo sustente, también puede ser válido el uso del término \"diagnóstico\". La cantidad de evidencia de apoyo varía de caso en caso. Muchos comités de estándares han lidiado con este problema por años sin lograr una resolución clara. + +A los fines de la documentación clínica mediante este arquetipo, problema y diagnóstico son considerados como un continuo, donde el incremento de los niveles de detalle y sustento en la evidencia inclinan la balanza hacia la etiqueta de \"diagnóstico\". Los requerimientos de datos que sustentan la documentación de ambos son idénticos, siendo necesarias estructuras de datos adicionales para sustentar la inclusión de la evidencia cuando esta exista y se encuentre disponible. Los ejemplos de problemas incluyen: la expresión del deseo de bajar de peso por parte de un individuo sin la existencia de un diagnóstico formal de obesidad, o un problema de relación con un familiar. Los ejemplos de diagnósticos formales incluyen un cáncer fundamentado en información histórica, los hallazgos de un examen, los hallazgos histopatológicos, los hallazgos radiológicos, y que cumplen todos los criterios diagnósticos. En la práctica, la mayoría de los problemas o diagnósticos no se encuentran en los extremos del espectro problema-diagnóstico sino que se ubican en alguna posición intermedia. + +Este arquetipo puede ser utilizado en diversos contextos. Por ejemplo, para registrar un problema o diagnóstico clínico durante una consulta clínica, para la elaboración de una Lista de Problemas persistente, o para proveer una afirmación sumaria dentro de un documento de Resumen de Alta. + +En la práctica, los clínicos utilizan muchos calificadores dependientes del contexto, tales como pasado/actual, primario/secundario, activo/inactivo, admisión/egreso, etc. Estos contextos pueden ser relativos a la localización, la especialización, el episodio, o a un instancia de un proceso, pudiendo entonces generar confusión o riesgos potenciales de seguridad para el paciente si son incluidos en Listas de Problemas o documentos compartidos que carecen del contexto original. Estos contextos pueden ser arquetipados en forma separada e incluidos en el slot de \"Estado\", dado que su uso varía en diferentes escenarios. Su uso mayormente pretendido debe darse en el contexto apropiado y no debería ser compartido fuera de dicho contexto sin una clara comprensión de sus consecuencias potenciales. Por ejemplo: un diagnóstico primario podría ser un diagnóstico secundario para otro especialista; un problema activo puede tornarse inactivo (o viceversa) e impactar en la seguridad de una decisión clínica. En general, estos calificadores deberían aplicarse localmente dentro del contexto del sistema clínico y en la práctica estos estados deberían ser manualmente mantenidos por clínicos a fin de asegurar que las listas de problemas, actuales o pasados, activos o inactivos o primarios y secundarios, sean clínicamente exactos. + +Este arquetipo será utilizado como un componente del Registro Médico Orientado al Problema descripto por Larry Weed. Se requerirá del desarrollo de arquetipos adicionales para la representación de conceptos clínicos tales como una condición para un organizador general de diagnósticos, etc. + +En algunas situaciones puede asumirse que la identificación de un diagnóstico solo se ajusta a la experticia del médico, pero no es el propósito de este arquetipo. Los diagnósticos pueden ser registrados mediante este arquetipo por parte de cualquier profesional. +"> + misuse = <"No debe ser utilizado para registrar síntomas tal cual fueron descriptos por el individuo; para ello se debe utilizar el arquetipo CLUSTER.symptom, habitualmente dentro del contexto del arquetipo OBSERVATION.story. + +No debe ser utilizado para registrar hallazgo de exámenes, para ello se debe utilizar la familia de arquetipos relacionados a exámenes, habitualmente contenidos dentro del arquetipo OBSERVATION.exam. + +No debe ser utilizado para registrar hallazgos de pruebas de laboratorio o diagnósticos relacionados (como por ejemplo diagnósticos patológicos); para ello se debe utilizar un arquetipo apropiado de la familia de arquetipos del tipo OBSERVATION. + +No debe ser utilizado para registrar resultados de exámenes por imágenes o diagnósticos imagenológicos; para ello se debe utilizar un arquetipo apropiado de la familia de arquetipos del tipo OBSERVATION. + +No debe ser utilizado para registrar diagnósticos diferenciales; para ello se debe utilizar el arquetipo EVALUATION.differential_diagnosis. + +No debe ser utilizado para registrar \"Motivos de Consulta\"; para ello se debe utilizar el arquetipo EVALUATION.reason_for_encounter. + +No debe ser utilizado para registrar procedimientos; para ello se debe utilizar el arquetipo ACTION.procedure. + +No debe ser utilizado para registrar detalles acerca del embarazo; para ello se debe utilizar los arquetipos EVALUATION.pregnancy_bf_status, EVALUATION.pregnancy y los arquetipos relacionados. + +No debe ser utilizado para registrar aseveraciones acerca de riesgos para la salud o problemas potenciales; para ello se debe utilizar el arquetipo EVALUATION.health_risk. + +No debe ser utilizado para registrar aseveraciones acerca de reacciones adversas, alergias o intolerancias; para ello se debe utilizar el arquetipo EVALUATION.adverse_reaction. + + +No debe ser utilizado para registrar la ausencia explícita (o presencia negativa) de un problema o diagnóstico (como por ejemplo \"sin diagnósticos o problemas conocidos\" o \"sin diabetes conocida\"); para expresar una aseveración positiva acerca de la exclusión de un problema o diagnóstico se debe utilizar el arquetipo EVALUATION.exclusion-problem_diagnosis."> + > + ["nb"] = < + language = <[ISO_639-1::nb]> + purpose = <"For å registrere detaljer om ett identifisert helseproblem eller en diagnose. + +Omfanget for et helseproblem er med vilje løst definert, for å kunne registrere en reell eller selvoppfattet bekymring som i større eller mindre grad kan påvirke et individs velvære negativt. Et helseproblem kan identifiseres av individet selv, en omsorgsperson eller av helsepersonell. En diagnose er derimot definert basert på objektive kliniske kriterier, og stilles som regel bare av helsepersonell."> + keywords = <"emne","problem","tilstand","hindring","diagnose","helseproblem","bekymring","funn","helsetilstand","konflikt","utfordring","klinisk bilde"> + copyright = <"© openEHR Foundation"> + use = <"Brukes til å registrere detaljer om ett identifisert helseproblem eller en diagnose. + +Å klart definere skillet mellom et \"problem\" og en \"diagnose\" er i praksis nesten umulig, og vi kan ikke på en pålitelig måte si når et problem skal ses på som en diagnose. Når diagnostiske- eller klassifikasjonskriterier er innfridd kan vi trygt kalle tilstanden en formell diagnose, men før disse kriteriene er møtt kan det dersom det finnes støttende funn også være riktig å kalle den en diagnose. Mengden støttende funn som kreves for å sette merkelappen \"diagnose\" er ikke lett å definere, og varierer sannsynligvis i praksis fra tilstand til tilstand. Mange standardiseringskomiteer har arbeidet med dette definisjonsproblemet i årevis uten å komme til noen klar konklusjon. + +Når det gjelder klinisk dokumentasjon med denne arketypen må problemer og diagnoser ses på som deler av et spektrum der økende detaljgrad og mengde støttende funn som regel gir vekt mot merkelappen \"diagnose\". I denne arketypen er det ikke nødvendig å klassifisere tilstanden som enten et problem eller en diagnose. Datastrukturen for å dokumentere dem er identisk, med tilleggsstrukturer som støtter inklusjon av nye funn når eller hvis de blir tilgjengelige. Eksempler på problemer kan være et individs uttrykte ønske om å gå ned i vekt uten en formell diagnose av fedme, eller problemer i forholdet til et familiemedlem. Eksempler på formelle diagnoser kan være en kreftsvulst der diagnosen er støttet av historisk informasjon, undersøkelsesfunn, histologiske funn, radiologiske funn, og som møter alle diagnosekriterier. I praksis er de fleste problemer eller diagnoser ikke i hver sin ende av problem/diagnose-spektrumet, men et sted mellom. + +Denne arketypen kan brukes i mange sammenhenger. Eksempler kan være å registrere et problem eller en klinisk diagnose under en klinisk konsultasjon, fylle en persistent problemliste, eller for å gi oppsummerende informasjon i en epikrise. + +I praksis bruker klinikere mange kvalifikatorer som nåværende/tidligere, hoved/bidiagnose, aktiv/inaktiv, innleggelse/utskriving, etc. Sammenhengene kan være steds-, spesialiserings-, episode- eller arbeidsflytspesifikke, og disse kan forårsake forvirring eller til og med mulige sikkerhetsrisikoer dersom de videreføres i problemlister eller deles i dokumenter utenfor sin opprinnelige sammenheng. Disse kvalifikatorene kan arketypes separat og inkluderes i \"Status\"-SLOTet, fordi bruken varierer i ulike settinger. Disse vil sannsynligvis hovedsakelig brukes i passende sammenhenger, og ikke deles utenfor sammenhengen uten en klar forståelse av mulige konsekvenser. For eksempel kan en hoveddiagnose for en kliniker være en bidiagnose for en annen spesialist, et aktivt problem kan bli inaktivt (og omvendt), og dette kan ha innvirkning på sikkerhet og beslutningsstøtte. Generelt burde disse kvalifikatorene brukes lokalt og innenfor kontekst i det kliniske systemet, og i praksis bør de manuelt administreres av klinikere for å sikre at lister over nåværende/tidligere, aktiv/inaktiv eller hoved/bidiagnoser er klinisk presise. + +Denne arketypen vil bli brukt som en komponent i den problemorienterte journalen som beskrevet av Larry Weed. Tilleggsarketyper som representerer kliniske konsepter som f.eks. \"tilstand\" som en overbygning for diagnoser etc, vil måtte utvikles for å støtte dette. + +I noen situasjoner antas det at å stille en diagnose ligger fullstendig innenfor legers domene, men dette er ikke hensikten med denne arketypen. Diagnoser kan registreres av alt helsepersonell ved hjelp av denne arketypen."> + misuse = <"Brukes ikke til å registrere symptomer slik de beskrives av individet. Til dette brukes CLUSTER.symptom-arketypen, som regel innenfor OBSERVATION.story-arketypen. + +Brukes ikke til å registrere funn ved klinisk undersøkelse. Til dette brukes gruppen av undersøkelsesrelaterte CLUSTER-arketyper, som regel innenfor OBSERVATION.exam-arketypen. + +Brukes ikke til å registrere laboratoriesvar eller relaterte diagnoser for eksempel patologiske diagnoser. Til dette brukes en passende arketype fra laboratoriefamilien av OBSERVATION-arketyper. + +Brukes ikke til å registrere billeddiagnostiske svar eller diagnoser. Til dette brukes en passende arketype fra billeddiagnostikkfamilien av OBSERVATION-arketyper. + +Brukes ikke til å registrere differensialdiagnoser. Til dette brukes EVALUATION.differential_diagnosis-arketypen. + +Brukes ikke til å registrere kontaktårsak eller klinisk problemstilling ved kontakt. Til dette brukes EVALUATION.reason_for_encounter-arketypen. + +Brukes ikke til å registrere prosedyrer, til dette brukes ACTION.procedure-arketypen. + +Brukes ikke til å registrere detaljer om graviditet utover diagnoser. Til dette brukes EVALUATION.pregnancy_bf_status og EVALUATION.pregnancy, samt relaterte arketyper. + +Brukes ikke til å registrere vurderinger av potensiale og sannsynlighet for fremtidige problemer, diagnoser eller andre uønskede helseeffekter, til dette brukes EVALUATION.health_risk-arketypen. + +Brukes ikke til å registrere utsagn om uønskede reaksjoner, allergier eller intoleranser - bruk EVALUATION.adverse_reaction-arketypen. + +Brukes ikke til å registrere et eksplisitt fravær (eller negativ tilstedeværelse) av et problem eller en diagnose, f.eks. \"ingen kjente problemer eller diagnoser\" eller \"ingen kjent diabetes\". Bruk EVALUATION.exclusion-problem_diagnosis for å uttrykke fravær av et problem eller en diagnose. + +Brukes ikke til å registrere pasientens tilgjengelige ressurser for egenomsorg - bruk egne EVALUATION-arketyper for dette formålet."> + > + ["ko"] = < + language = <[ISO_639-1::ko]> + purpose = <"단일한 확인된 건강 문제 또는 진단에 대한 상세내역을 기록하기 위함. + +의도된 건강 문제의 범위는 어느 정도로 개인의 웰빙에 좋지않은 방향으로 영향을 주는 모든 실제 또는 인지된 걱정(concern)를 획득하기 위해 궁극적으로 임상 문서의 문맥에서 느슨하게 유지됨. 건강 문제는 해당 개인, 또는 보호자, 헬스케어 전문가에 의해 확인될 수도 있음. 그러나 진단은 객관적인 임상적 기준에 근거하여 추가적으로 정의되며, 일반적으로 헬스케어 전문가들에 의해서만 결정됨."> + keywords = <"이슈","상태","진단","걱정","상해","임상소견"> + use = <"단일한 확인된 건강 문제 또는 진단에 대한 상세내역을 기록하기 위함. + +'문제(problem)'와 '진단(diagnosis)' 간의 차이를 구분할 수 있는 명확한 정의는 실무에서 거의 불가능함 - 우리는 문제가 언제 진단으로 간주되어야 하는지를 신뢰성있게 구별할 수 없음. 진단 또는 분류 기준이 성공적으로 만족될 때, 우리는 상태(condition)를 정규적인 진단으로 확실하게 말할 수 있지만, 이런 상태를 만족하기 이전에, 지지할 수 있는 증거를 이용가능하다면 '진단'이라는 용어를 또한 사용하는 것이 유효할 수 있음. 진단이라는 표시를 위해 필요한 지지할 수 있는 증거의 양은 정의하기 쉽지 않고 실제로 상태에 따라 다양할 수 있음. 많은 표준 기구는 수 년 동안 명확한 해결책없이 이러한 정의적인 문제로 가득 차 있음. + +이 아키타입을 통한 임상 문서의 목적을 위해서, 증가하는 상세내용의 수준과 일반적으로 '진단'의 표시에 대한 무게감을 제공하는 지지할 수 있는 증거를 가지고, 문제와 진단은 연속된 것(a continuum)으로 간주됨. 이 아키타입 내에서 상태를 '문제' 또는 '진단'로 분류할 필요는 없음. 두 가지의 문서화를 보조하기 위한 데이터 요구사항은 동일하며, 증거가 이용가능하거나/이용가능할 때 이 증거의 포함(inclusion)을 지원하는 데 필요한 추가적인 데이터 구조를 가지고 있음. 문제의 예는 다음을 포함함 : 체중을 줄이고 싶다는 개인의 표현, 그러나 비만의 정규적인 진단은 없음. 또는 가정 구성원과의 관계 문제. 정규적인 진단의 예는 과거 정보와 검사 소견, 조직병리학적 소견, 영상의학적 소견에 의해 지지되고 알려진 진단적 기준을 위한 모든 요구사항을 만족하는 암이 포함됨. 실무에서 대부분의 문제와 진단은 문제-진단 스펙트럼의 양 끝에 있지 않지만 그 사이 어딘가에 있음. + +이 아키타입은 많은 문맥 내에서 사용될 수 있음. 예를 들어, 임상 자문 동안 문제 또는 임상적 진단를 기록하는 것; 영속적인 문제 목록(persistent Problem List)을 채우는 것; 또는 퇴원 요약 문서(Dischatge Summary document) 내에 요약 문장(summary statement)을 제공하는 것. + +실무에서 임상의는 과거/현재(Present/Past), 일차/이차(Primary/Secondary), 활성/비활성(Active/Inactive), 입원/퇴원(Admission/Discharge) 등 많은 문맥-특징적인 한정자(qualifiers)를 사용함. 문맥은 위치-, 세부전공-, 에피소드-, 워크플로우-특징적 이며 이러한 것들은 원래 문맥에서 벗어난 문제 목록에서 유지되거나 문서 내에서 공유된다면 혼란 또는 심어서 잠재적인 안전 이슈를 발생시킬 수 있음. 이러한 한정자의 이용이 잠재적인 결과에 대한 명확한 이해없이 문맥에 따라 다양하기 때문에, 한정자는 구분되어 아키타입화될 수 있고 'Status' slot에 포함될 수 있음. 예를 들어, 어떤 한 임상의의 일차 진단은 다른 전문의에게는 이차 진단일 수 있음; 현재 활성화된(active) 진단은 비활성화될 수 있음 (또는 그 반대) 그리고 이것은 안전한 임상의사결정의 사용에 영향을 줄 수 있음. 일반적으로 이러한 한정자는 임상 시스템의 문맥 내에서 그 부분에서 적용되어야 하고, 실무에서 이러한 상태는, 현재/과거 또는 활성/비활성, 일차/이차 문제의 목록은 임상적으로 정확하다는 것을 보장하기위해서 임상의에 의해 수기로 조정될 수 있음. + +이 아키타입은 Larry Weed가 기술한 문제지향의무기록(Problem Oriented Medical Record) 내에서 컴포넌트로 사용될 것임. 상태와 같은 임상 개념을 진단을 위한 포괄적인 구성자(organizer)로 표현하는 추가적인 아키타입은 이러한 접근방식을 지원하기 위해 개발될 필요가 있을 것임. + +몇몇 상황에서, 진단의 확인은 임상의의 전문성 안에서만 적용한다는 가정이 될 수 있지만 이것은 이 아카타입이 의도하는 바는 아님. 모든 헬스케어 전문가가 이 아키타입을 이용해 진단을 기록할 수 있음."> + misuse = <"개인에 의해 기술된 증상을 기록하는데 사용하지 않아야 함 - 보통 OBSERVATION.story archetype 내에서 CLUSTER.symptom archetype을 사용해야 함. + +검사 소견을 기록하는데 사용하지 않아야 함 - 보통 OBSERVATION.exam archetype 내에 중첩되어, examination-related CLUSTER archetypes 계열을 사용해야 함. + +검사실 검사 결과 또는 병리학적 검사와 같은 관련된 진단을 기록하는데 사용하지 않아야 함 - 보통 검사실 계열의 OBSERVATION archetype에서 적당한 archetype을 사용해야 함. + +이미지 검사 결과 또는 이미지 진단을 기록하는데 사용하지 않아야 함 - 이미지 계열의 OBSERVATION archetype에서 적당한 archetype을 사용해야 함. + +'감별 진단'을 기록하는데 사용하지 않아야 함 - EVALUATION.differential_diagnosis archetype을 사용해야 함. + +'내원의 이유(Reason for Encounter)' 또는 '주호소(Presenting Complaint)'를 기록하는데 사용지 않아야 함 - EVALUATION.reason_for_encounter archetype을 사용해야 함. + +'처치(procedure)'를 기록하는데 사용하지 않아야 함 - ACTION.procedure archetype를 사용해야 함. + +임신에 대한 상세내용을 기록하는데 사용하지 않아야 함 - EVALUATION.pregnancy_bf_status와 EVALUATION.pregnancy 그리고 관련된 archetypes를 사용해야 함. + +건강 위험요소(health risk) 및 잠재적인 문제에 대한 진술문을 기록하는데 사용하지 않아야 함 - EVALUATION.health_risk archetype을 사용해야 함. + +이상반응(adverse reactions), 알레르기(allergies) 또는 불내성(intolerances)에 대한 진술문을 기록하는데 사용하지 않아야 함 - EVALUATION.adverse_reaction archetype을 사용해야 함. + +'알려진 문제 또는 진단 없음' 또는 '알려진 당뇨병 없음' 등과 같은 문제와 진단의 부재(absence (or negative presence))을 명시적으로 기록하는데 사용하지 않아야 함 - 문제 또는 진단의 배제(exclusion)에 대한 긍정 진술문(positive statement)을 표현하는데 EVALUATION.exclusion-problem_diagnosis archetype을 사용해야 함."> + > + ["pt-br"] = < + language = <[ISO_639-1::pt-br]> + purpose = <"Para gravar detalhes sobre um único problema de saúde ou diagnóstico identificado. + +O escopo pretendido de um problema de saúde é deliberadamente mantido livre no contexto da documentação clínica, de forma a captar quaisquer preocupações reais ou percebidas que podem afetar adversamente, em qualquer grau, o bem-estar de um indivíduo. Um problema de saúde pode ser identificado pela o indivíduo, um prestador de cuidados ou de um profissional de saúde. No entanto, o diagnóstico é adicionalmente definido com base em critérios clínicos objetivos, e, geralmente, determinado apenas por um profissional de saúde."> + keywords = <"caso","condição","problema","diagnóstico","preocupação","prejuízo","impressão clínica"> + copyright = <"© openEHR Foundation"> + use = <"Para gravar detalhes sobre um único problema de saúde ou diagnóstico identificado. + +Definições claras que permitem a diferenciação entre um \"problema\" e um \"diagnóstico\" são quase impossíveis na prática - não podemos dizer de forma segura quando um problema deve ser considerado como um diagnóstico. Quando o diagnóstico ou os critérios de classificação são cumpridos com sucesso, então com confiança podemos chamar a condição de um diagnóstico formal, mas antes que essas condições sejam cumpridas e enquanto houver evidências para tanto, também pode ser válido usar o termo \"diagnóstico\". A quantidade de evidências de apoio requerida para a indicação de diagnóstico não é fácil de ser definida e na realidade, provavelmente varia de condição para condição. Muitos comitês de padrões têm, por anos, se confrontado com esse dilema de definição sem resolução clara. + +Este arquétipo pode ser utilizado em muitos contextos. Por exemplo, na gravação de um problema ou um diagnóstico durante uma consulta clínica; preencher uma lista de problema persistente; ou para fornecer uma declaração de resumo de um documento Sumário de Alta. + +Na prática, os clínicos usam muitos qualificadores de contexto específico, como passado / presente, primário / secundário, ativo / inativo, admissão / alta, etc. Os contextos podem ser: localização, especialização, episódio ou específicos de fluxo de trabalho, e estes podem causar confusão ou até mesmo potenciais problemas de segurança se persistido nas listas de problemas ou compartilhados em documentos que estão fora do contexto original. Estes qualificadores podem ser arquetipados separadamente e incluídos no slot 'Estado', porque seu uso varia em diferentes contextos. Espera-se que estes serão utilizados em sua maioria dentro do contexto apropriado e não compartilhados fora desse contexto, sem compreensão clara das consequências potenciais. Por exemplo, um diagnóstico primário para um clínico pode ser um secundário para outro especialista; um problema ativo pode se tornar inativo (ou vice-versa) e isso pode impactar no uso seguro do apoio à decisão clínica. Em geral, estes qualificadores devem ser aplicados localmente dentro do contexto do sistema clínico e na prática, esses estados devem ser criados manualmente pelos clínicos para assegurar que as listas de problemas: Presente / Passado, ativo / inativo ou primário / secundário são clinicamente precisas. + +Este arquétipo será usado como um componente dentro do Registro Clínico Orientado à Problemas, tal como descrito por Larry Weed. Arquétipos adicionais, que representam conceitos clínicos, tais como: condição como um organizador abrangente para diagnósticos etc, terão de ser desenvolvidos para apoiar esta abordagem. + +Em algumas situações, pode ser assumido que a identificação de um diagnóstico só se encaixa dentro da expertise do médico, mas esta não é a intenção para este arquétipo. Os diagnósticos podem ser gravados utilizando esse arquétipo por qualquer profissional de saúde."> + misuse = <"Não deve ser usado para registrar os sintomas descritos pelo indivíduo, para isso, use o arquétipo CLUSTER.symptom, geralmente dentro do arquétipo OBSERVATION.story. + +Não deve ser usado para registrar achados do exame, use o CLUSTER da família de arquétipos relacionadas ao exame, geralmente aninhados dentro do arquétipo OBSERVATION.exam. + +Não deve ser usado para registrar os resultados dos testes de laboratório ou diagnósticos relacionados, por exemplo, em diagnósticos patológicos use um arquétipo apropriado da família de laboratório dos arquétipos OBSERVATION. + +Não deve ser usado para registrar os resultados dos exames de imagem ou de diagnóstico por imagem, use um arquétipo apropriado a partir da família de imagem dos arquétipos OBSERVATION. + +Não deve ser usado para gravar 'diagnósticos diferenciais', use o arquétipo EVALUATION.differential_diagnosis. + +Não deve ser usado para gravar 'Motivo do Encontro \"ou\" queixa apresentada', use o arquétipo EVALUATION.reason_for_encounter. + +Não deve ser usado para gravar procedimentos, use o arquétipo ACTION.procedure. + +Não deve ser usado para registrar detalhes sobre a gravidez, use o EVALUATION.pregnancy_bf_status e EVALUATION.pregnancy e os arquétipos relacionados. + +Não deve ser usado para gravar o estadiamento sobre o risco ou os problemas de saúde potenciais, use o arquétipo risco EVALUATION.health. + +Não deve ser usado para gravar declarações sobre reações adversas, alergias ou intolerâncias, use o arquétipo EVALUATION.adverse_reaction. + +Não deve ser usado para a gravação de uma ausência explícita (ou presença negativa) de um problema ou diagnóstico, por exemplo: \"sem problema ou diagnósticos conhecido\" ou \"diabetes não conhecido\". Use o arquétipo EVALUATION.exclusion-problem_diagnosis para expressar uma declaração positiva sobre a exclusão de um problema ou diagnóstico."> + > + ["ar-sy"] = < + language = <[ISO_639-1::ar-sy]> + purpose = <"لتسجيل تفاصيل حول قضية أو عقبة تؤثر على السلامة البدنية, العقلية و/أو الاجتماعية لشخص ما"> + keywords = <"القضية","الظرف الصحي","المشكلة","العقبة"> + copyright = <"© openEHR Foundation"> + use = <"يستخدم لتسجيل المعلومات العامة حول المشكلات المتعلقة بالصحة. +يحتوي النموذج على معلومات متعددة,و يمكن استخدامه في تسجيل المشكلات الحاضرة و السابقة. +و يمكن تحديد المشكلة بواسطة المريض نفسه أو من يقوم بتقديم الرعاية الصحية. +بعض الأمثلة تتضمن ما يلي: +- بعض الأعراض التي لا تزال تحت الملاحظة و لكنها تمثل تشخيصات مبدأية +- الرغبة لفقد الوزن دون تشخيص مؤكد بالسمنة +- الرغبة بالإقلاع عن التدخين بواسطة الشخص +- مشكلة في العلاقة مع أحد أفراد العائلة"> + misuse = <"لا يستخدم لتسجيل التشخيصات المؤكدة. استخدم بدلا من ذلك النموذج المخصص من هذا النموذج, تقييم.المشكلة - التشخيص"> + > + ["en"] = < + language = <[ISO_639-1::en]> + purpose = <"For recording details about a single, identified health problem or diagnosis. + +The intended scope of a health problem is deliberately kept loose in the context of clinical documentation, so as to capture any real or perceived concerns that may adversely affect an individual's wellbeing to any degree. A health problem may be identified by the individual, a carer or a healthcare professional. However, a diagnosis is additionally defined based on objective clinical criteria, and usually determined only by a healthcare professional."> + keywords = <"issue","condition","problem","diagnosis","concern","injury","clinical impression"> + copyright = <"© openEHR Foundation"> + use = <"Use for recording details about a single, identified health problem or diagnosis. + +Clear definitions that enable differentiation between a 'problem' and a 'diagnosis' are almost impossible in practice - we cannot reliably tell when a problem should be regarded as a diagnosis. When diagnostic or classification criteria are successfully met, then we can confidently call the condition a formal diagnosis, but prior to these conditions being met and while there is supportive evidence available, it can also be valid to use the term 'diagnosis'. The amount of supportive evidence required for the label of diagnosis is not easy to define and in reality probably varies from condition to condition. Many standards committees have grappled with this definitional conundrum for years without clear resolution. + +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'. In this archetype it is not neccessary to classify the condition as a 'problem' or 'diagnosis'. The data requirements to support documentation of either are identical, with additional data structure required to support inclusion of the evidence if and when it becomes available. Examples of problems include: the individual's expressed desire to lose weight, but without a formal diagnosis of Obesity; or a relationship problem with a family member. Examples of formal diagnoses would include a cancer that is supported by historical information, examination findings, histopathological findings, radiological findings and meets all requirements for known diagnostic criteria. In practice, most problems or diagnoses do not sit at either end of the problem-diagnosis spectrum, but somewhere in between. + +This archetype can be used within many contexts. For example, recording a problem or a clinical diagnosis during a clinical consultation; populating a persistent Problem List; or to provide a summary statement within a Discharge Summary document. + +In practice, clinicians use many context-specific qualifiers such as past/present, primary/secondary, active/inactive, admission/discharge etc. The contexts can be location-, specialisation-, episode- or workflow-specific, and these can cause confusion or even potential safety issues if perpetuated in Problem Lists or shared in documents that are outside of the original context. These qualifiers can be archetyped separately and included in the ‘Status’ slot, because their use varies in different settings. It is expected that these will be used mostly within the appropriate context and not shared out of that context without clear understanding of potential consequences. For example, a primary diagnosis to one clinician may be a secondary one to another specialist; an active problem can become inactive (or vice versa) and this can impact the safe use of clinical decision support. In general these qualifiers should be applied locally within the context of the clinical system, and in practice these statuses should be manually curated by clinicians to ensure that lists of Current/Past, Active/Inactive or Primary/Secondary Problems are clinically accurate. + +This archetype will be used as a component within the Problem Oriented Medical Record as described by Larry Weed. Additional archetypes, representing clinical concepts such as condition as an overarching organiser for diagnoses etc, will need to be developed to support this approach. + +In some situations, it may be assumed that identification of a diagnosis fits only within the expertise of physicians, but this is not the intent for this archetype. Diagnoses can be recorded using this archetype by any healthcare professional."> + misuse = <"Not to be used to record symptoms as described by the individual - use the CLUSTER.symptom archetype, usually within the OBSERVATION.story archetype. + +Not to be used to record examination findings - use the family of examination-related CLUSTER archetypes, usually nested within the OBSERVATION.exam archetype. + +Not to be used to record laboratory test results or related diagnoses, for example pathological diagnoses - use an appropriate archetype from the laboratory family of OBSERVATION archetypes. + +Not to be used to record imaging examination results or imaging diagnoses - use an appropriate archetype from the imaging family of OBSERVATION archetypes. + +Not to be used to record 'Differential Diagnoses' - use the EVALUATION.differential_diagnosis archetype. + +Not to be used to record 'Reason for Encounter' or 'Presenting Complaint' - use the EVALUATION.reason_for_encounter archetype. + +Not to be used to record procedures - use the ACTION.procedure archetype. + +Not to be used to record details about pregnancy - use the EVALUATION.pregnancy_bf_status and EVALUATION.pregnancy and related archetypes. + +Not to be used to record statements about health risk or potential problems - use the EVALUATION.health_risk archetype. + +Not to be used to record statements about adverse reactions, allergies or intolerances - use the EVALUATION.adverse_reaction archetype. + +Not to be used for the explicit recording of an absence (or negative presence) of a problem or diagnosis, for example ‘No known problem or diagnoses’ or ‘No known diabetes’. Use the EVALUATION.exclusion-problem_diagnosis archetype to express a positive statement about exclusion of a problem or diagnosis."> + > + ["it"] = < + language = <[ISO_639-1::it]> + purpose = <"Registrare i dettagli di un singolo problema di salute identificato o di una diagnosi. + +L'ambito previsto di un problema di salute viene deliberatamente lasciato libero nel contesto della documentazione clinica, in modo da catturare qualsiasi preoccupazione reale o percepita che possa influire negativamente sul benessere di un individuo in qualsiasi misura. Un problema di salute può essere identificato dall'individuo, da un caregiver o da un operatore sanitario. Tuttavia, una diagnosi viene definita in aggiunta sulla base di criteri clinici oggettivi e solitamente determinata solo da un professionista sanitario."> + keywords = <"problema, condizione, diagnosi, preoccupazione, lesione, impressione clinica", ...> + use = <"Usato per registrare i dettagli di un singolo problema di salute identificato o di una diagnosi. + +Definizioni chiare che consentono di distinguere tra un \"problema\" e una \"diagnosi\" sono quasi impossibili nella pratica - non possiamo dire in modo affidabile quando un problema deve essere considerato una diagnosi. Quando i criteri diagnostici o di classificazione sono soddisfatti con successo, allora possiamo tranquillamente definire la condizione come una diagnosi formale, ma prima che queste condizioni siano soddisfatte e mentre ci sono prove di supporto disponibili, può anche essere valido l'uso del termine \"diagnosi\". La quantità delle prove di supporto richieste per la classificazione della diagnosi non è facile da definire e in realtà probabilmente varia da una condizione all'altra. Molti comitati di standardizzazione si sono trovati alle prese con questo enigma di definizione per anni senza una chiara risoluzione. + +Ai fini della documentazione clinica con questo archetipo, il problema e la diagnosi sono considerati un continuum, con livelli crescenti di dettaglio e prove di supporto che di solito fanno propendere verso all'etichetta di \"diagnosi\". In questo archetipo non è necessario classificare la condizione come \"problema\" o \"diagnosi\". I requisiti dei dati a supporto della documentazione di entrambi sono identici, con una struttura di dati aggiuntivi necessari per supportare l'inclusione dell'evidenza se e quando essa diventa disponibile. Esempi di problemi sono: il desiderio espresso dall'individuo di perdere peso, ma senza una diagnosi formale di obesità; o un problema di relazione con un membro della famiglia. Esempi di diagnosi formali includono un cancro che è supportato da informazioni storiche, risultati di esami, risultati istopatologici, risultati radiologici e soddisfa tutti i requisiti per i criteri diagnostici noti. In pratica, la maggior parte dei problemi o delle diagnosi non si colloca ad una delle due estremità dello spettro diagnostico del problema, ma da qualche parte nel mezzo. + +Questo archetipo può essere utilizzato in molti contesti. Per esempio, la registrazione di un problema o di una diagnosi clinica durante un consulto clinico; la compilazione di un Elenco dei Problemi persistente; o per fornire una dichiarazione riassuntiva all'interno di un documento di Riepilogo delle dimissioni. + +In pratica, i clinici usano molte qualificazioni specifiche del contesto, come passato/presente, primario/secondario, attivo/inattivo, ricovero/dimissione, ecc. I contesti possono essere specifici per il luogo, la specializzazione, l'episodio o il flusso di lavoro, e questi possono causare confusione o anche potenziali problemi di sicurezza se vengono riportati in elenchi di problemi o condivisi in documenti che sono al di fuori del contesto originale. Questi qualificatori possono essere archetipizzati separatamente e inclusi nello slot \"Status\", perché il loro uso varia in diverse configurazioni. Ci si aspetta che questi vengano usati per lo più all'interno del contesto appropriato e che non vengano condivisi al di fuori di tale contesto senza una chiara comprensione delle potenziali conseguenze. Per esempio, una diagnosi primaria per un clinico può essere secondaria per un altro specialista; un problema attivo può diventare inattivo (o viceversa) e questo può avere un impatto sull'uso sicuro del supporto decisionale clinico. In generale queste qualificazioni dovrebbero essere applicate localmente nel contesto del sistema clinico, e in pratica questi stati dovrebbero essere gestiti manualmente dai clinici per assicurare che le liste dei problemi attuali/passivi, attivi/inattivi o primari/secondari siano clinicamente accurate. + +Questo archetipo sarà utilizzato come componente all'interno della cartella clinica orientata ai problemi, come descritto da Larry Weed. Ulteriori archetipi - che rappresentano concetti clinici come la condizione come un organizzatore generale per le diagnosi, ecc. - dovrà essere sviluppato per sostenere questo approccio. + +In alcune situazioni, si può presumere che l'identificazione di una diagnosi rientri solo nelle competenze dei medici, ma questo non è l'intento di questo archetipo. Le diagnosi possono essere registrate utilizzando questo archetipo da qualsiasi professionista sanitario."> + misuse = <"Da non utilizzare per registrare i sintomi come descritto dall'individuo - utilizzare l'archetipo di CLUSTER.symptom, di solito all'interno dell'archetipo di OBSERVATION.story. + +Da non utilizzare per registrare i risultati dell'esame - utilizzare la famiglia di archetipi CLUSTER.symptom, di solito annidati all'interno dell'archetipo di OBSERVATION.exam. + +Da non utilizzare per registrare i risultati di esami di laboratorio o diagnosi correlate, ad esempio diagnosi patologiche - utilizzare un archetipo appropriato della famiglia di archetipi di OBSERVATION.exam. + +Da non utilizzare per registrare i risultati degli esami di imaging o le diagnosi di imaging - utilizzare un archetipo appropriato della famiglia di archetipi di imaging dell'OBSERVATION. + +Da non utilizzare per registrare le \"diagnosi differenziali\" - utilizzare l'archetipo EVALUATION.differential_diagnosis. + +Da non utilizzare per registrare \"Motivo dell'incontro\" o \"Presentazione di un reclamo\" - utilizzare l'archetipo EVALUATION.reason_for_encounter. + +Da non utilizzare per registrare le procedure - utilizzare l'archetipo ACTION.procedure. + +Da non utilizzare per registrare i dettagli sulla gravidanza - utilizzare lo stato di EVALUATION.pregnancy_bf_status e EVALUATION.pregnancy e i relativi archetipi. + +Da non utilizzare per registrare dichiarazioni sul rischio per la salute o su potenziali problemi - utilizzare l'archetipo EVALUATION.health_risk. + +Da non utilizzare per registrare dichiarazioni su reazioni avverse, allergie o intolleranze - utilizzare l'archetipo EVALUATION.adverse_reaction. + +Da non utilizzare per la registrazione esplicita di un'assenza (o presenza negativa) di un problema o di una diagnosi, ad esempio \"Nessun problema o diagnosi nota\" o \"Nessun diabete noto\". Utilizzare l'archetipo EVALUATION.exclusion-problem_diagnosis per esprimere una dichiarazione positiva sull'esclusione di un problema o di una diagnosi."> + > + ["es"] = < + language = <[ISO_639-1::es]> + purpose = <"Este arquetipo se utilizará para registrar un único problema de salud o diagnóstico identificado para el paciente. + +El alcance del arquetipo se dejó deliberadamente abierto, para poder capturar cualquier inquietud real o percibida que afecte en cualquier grado la salud de un paciente. Independientemente de quién detecte el problema, el diagnóstico debe ser definido basado en criterios clínicos objetivos, determinados por un profesional clínico."> + keywords = <"problema","diagnóstico","preocupación","condición","enfermedad"> + copyright = <"© openEHR Foundation"> + use = <"Este arquetipo se utilizará para registrar un único problema de salud o diagnóstico identificado para el paciente."> + misuse = <"No se debe utilizar para registrar síntomas descritos por el paciente, para eso utilizar el arquetipo CLUSTER.symtom. + +No se debe utilizar para registrar hallazgos, para eso utilizar arquetipos relacionados con la examinación, usualmente relacionados con el arquetipo OBSERVATION.exam + +No se debe utilizar para registrar diagnósticos realizados sobre resultados de estudios diagnósticos como laboratorio o imagenología. + +No se debe utilizar para registrar el motivo de consulta o problema presentado por el paciente, para eso utilizar el arquetipo EVALUATION.reason_for_encounter + +No se debe utilizar para registrar riesgos o problemas potenciales, para eso utilizar el arquetipo EVALUATION.health_risk + +No se debe utilizar para registrar la ausencia de un problema, para eso utilizar el arquetipo EVALUATION.exclusion-problem_diagnosis"> + > + > + other_details = < + ["licence"] = <"This work is licensed under the Creative Commons Attribution-ShareAlike 3.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/3.0/."> + ["custodian_organisation"] = <"openEHR Foundation"> + ["references"] = <"Problem/Diagnosis, Draft Archetype [Internet]. National eHealth Transition Authority, NEHTA Clinical Knowledge Manager [cited: 2015-03-12]. Available from: http://dcm.nehta.org.au/ckm/#showArchetype_1013.1.896. + +ISO/DIS 13940 Health informatics -- System of concepts to support continuity of care., International Organization for Standardization [Internet]. Available at: http://www.iso.org/iso/catalogue_detail.htm?csnumber=58102 (accessed 2015 -04-09). + +Common Terminology Criteria for Adverse Events (CTCAE) [Internet]. National Cancer Institute, USA. Available from: http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm (accessed 2015-07-13). + +Weed LL. Medical records that guide and teach. N Engl J Med. 1968 Mar 14;278(11):593-600. PubMed PMID: 5637758. Available from: http://www.nejm.org/doi/full/10.1056/NEJM196803142781105 (accessed 2015-07-13)."> + ["current_contact"] = <"Heather Leslie, Ocean Informatics, heather.leslie@oceaninformatics.com"> + ["original_namespace"] = <"org.openehr"> + ["original_publisher"] = <"openEHR Foundation"> + ["custodian_namespace"] = <"org.openehr"> + ["MD5-CAM-1.0.1"] = <"1BA7DBDFBC67678A19B93822D9F3A6A7"> + ["build_uid"] = <"49d5253b-19cc-49b7-b240-b6836690b27d"> + ["revision"] = <"1.0.10"> + > + +definition + EVALUATION[at0000] matches { -- Problem/Diagnosis + data matches { + ITEM_TREE[at0001] matches { -- structure + items cardinality matches {1..*; unordered} matches { + ELEMENT[at0002] matches { -- Problem/Diagnosis name + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0009] occurrences matches {0..1} matches { -- Clinical description + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0012] occurrences matches {0..*} matches { -- Body site + value matches { + DV_TEXT matches {*} + } + } + allow_archetype CLUSTER[at0039] occurrences matches {0..*} matches { -- Structured body site + include + archetype_id/value matches {/openEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_clock(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.v1/} + } + ELEMENT[at0077] occurrences matches {0..1} matches { -- Date/time of onset + value matches { + DV_DATE_TIME matches {*} + } + } + ELEMENT[at0003] occurrences matches {0..1} matches { -- Date/time clinically recognised + value matches { + DV_DATE_TIME matches {*} + } + } + ELEMENT[at0005] occurrences matches {0..1} matches { -- Severity + value matches { + DV_CODED_TEXT matches { + defining_code matches { + [local:: + at0047, -- Mild + at0048, -- Moderate + at0049] -- Severe + } + } + DV_TEXT matches {*} + } + } + allow_archetype CLUSTER[at0043] occurrences matches {0..*} matches { -- Specific details + include + archetype_id/value matches {/.*/} + } + ELEMENT[at0072] occurrences matches {0..1} matches { -- Course description + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0030] occurrences matches {0..1} matches { -- Date/time of resolution + value matches { + DV_DATE_TIME matches {*} + } + } + allow_archetype CLUSTER[at0046] occurrences matches {0..*} matches { -- Status + include + archetype_id/value matches {/openEHR-EHR-CLUSTER\.problem_qualifier(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.problem_qualifier(-[a-zA-Z0-9_]+)*\.v1/} + } + ELEMENT[at0073] occurrences matches {0..1} matches { -- Diagnostic certainty + value matches { + DV_CODED_TEXT matches { + defining_code matches { + [local:: + at0074, -- Suspected + at0075, -- Probable + at0076] -- Confirmed + } + } + DV_TEXT matches {*} + } + } + ELEMENT[at0069] occurrences matches {0..1} matches { -- Comment + value matches { + DV_TEXT matches {*} + } + } + } + } + } + protocol matches { + ITEM_TREE[at0032] matches { -- Tree + items cardinality matches {0..*; unordered} matches { + ELEMENT[at0070] occurrences matches {0..1} matches { -- Last updated + value matches { + DV_DATE_TIME matches {*} + } + } + allow_archetype CLUSTER[at0071] occurrences matches {0..*} matches { -- Extension + include + archetype_id/value matches {/.*/} + } + } + } + } + } + +ontology + term_definitions = < + ["es"] = < + items = < + ["at0000"] = < + text = <"*Problem/Diagnosis(en)"> + 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.(en)"> + 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'.(en)"> + > + ["at0001"] = < + text = <"structure"> + description = <"@ internal @"> + > + ["at0002"] = < + text = <"*Problem/Diagnosis name(en)"> + description = <"*Identification of the problem or diagnosis, by name.(en)"> + comment = <"*Coding of the name of the problem or diagnosis with a terminology is preferred, where possible.(en)"> + > + ["at0003"] = < + text = <"Momento de reconocimiento del problema"> + description = <"Fecha y hora, estimado o real, cuándo el problema/diagnóstico es detectado por un profesional de la salud"> + > + ["at0005"] = < + text = <"Severidad"> + description = <"Valoración de la severidad del problema/diagnóstico"> + > + ["at0009"] = < + text = <"Descripción clínica"> + description = <"Descripción narrativa del problema/diagnóstico"> + > + ["at0012"] = < + text = <"*Body site(en)"> + description = <"*Identification of a simple body site for the location of the problem or diagnosis.(en)"> + 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. + +(en)"> + > + ["at0030"] = < + text = <"Momento de resolución"> + description = <"Día y hora, estimado o real, en que el problema/diagnóstico fue resuelto o entró en remisión"> + > + ["at0032"] = < + text = <"Tree"> + description = <"@ internal @"> + > + ["at0039"] = < + text = <"*Structured body site(en)"> + description = <"*A structured anatomical location for the problem or diagnosis.(en)"> + comment = <"*Use this SLOT to insert the CLUSTER.anatomical_location or CLUSTER.relative_location archetypes 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. + +If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, use of this SLOT becomes redundant. + +(en)"> + > + ["at0043"] = < + text = <"Detalles específicos"> + description = <"Detalles adicionales para el problema/diagnóstico"> + > + ["at0046"] = < + text = <"*Status(en)"> + description = <"*Structured details for location-, domain-, episode- or workflow-specific aspects of the diagnostic process.(en)"> + comment = <"*Use status or context qualifiers with care, as they are variably used in practice and interoperability cannot be assured unless usage is clearly defined with the community of use. For example: active status - active, inactive, resolved, in remission; evolution status - initial, interim/working, final; temporal status - current, past; episodicity status - first, new, ongoing; admission status - admission, discharge; or priority status - primary, secondary.(en)"> + > + ["at0047"] = < + text = <"Leve"> + description = <"El problema tiene severidad leve"> + > + ["at0048"] = < + text = <"Moderada"> + description = <"El problema tiene severidad moderada"> + > + ["at0049"] = < + text = <"Severo"> + description = <"El problema tiene severidad severo"> + > + ["at0069"] = < + text = <"Comentario"> + description = <"Comentario narrativo adicional sobre el problema/diagnóstico no capturado en otros campos"> + > + ["at0070"] = < + text = <"Última actualización"> + description = <"Fecha en la que el problema/diagnóstico fue actualizado"> + > + ["at0071"] = < + text = <"Extensión"> + description = <"Información adicional requerida para capturar el contenido local o alinear con otros modelos o formalismos para el problema/diagnóstico"> + > + ["at0072"] = < + text = <"Progreso"> + description = <"Descripción narrativa del progreso del problema/diagnóstico desde su comienzo"> + > + ["at0073"] = < + text = <"*Diagnostic certainty(en)"> + description = <"*The level of confidence in the identification of the diagnosis.(en)"> + > + ["at0074"] = < + text = <"*Suspected(en)"> + description = <"*The diagnosis has been identified with a low level of certainty.(en)"> + > + ["at0075"] = < + text = <"*Probable(en)"> + description = <"*The diagnosis has been identified with a high level of certainty.(en)"> + > + ["at0076"] = < + text = <"*Confirmed(en)"> + description = <"*The diagnosis has been confirmed against recognised criteria.(en)"> + > + ["at0077"] = < + text = <"*Date of onset(en)"> + description = <"*Estimated or actual date/time that signs or symptoms of the problem/diagnosis were first observed. +(en)"> + > + > + > + ["es-ar"] = < + items = < + ["at0000"] = < + text = <"Problema/Diagnóstico"> + description = <"Detalles acerca de una condición de salud, lesión, incapacidad o cualquier otra cuerstión, univocamente identificadas, que impacta sobre el bienestar físico, mental y/o social de un individuo"> + comment = <"La delineación entre el alcance de un problema versus el diagnóstico puede no ser fácil de lograr en la práctica. A los fines de la documentación clínica mediante este arquetipo, problema y diagnóstico son considerados un continuo, donde niveles incrementales de detalles y evidencia de apoyo otorgan mas peso a la etiqueta de \"diagnóstico\"."> + > + ["at0001"] = < + text = <"*structure(en)"> + description = <"*@ internal @(en)"> + > + ["at0002"] = < + text = <"Nombre del problema/diagnóstico"> + description = <"Identificación del problema o diagnóstico, por nombre."> + comment = <"Se prefiere la codificación del nombre del problema o diagnóstico mediante una terminología cuando esto sea posible."> + > + ["at0003"] = < + text = <"Fecha y hora del reconocimiento clínico"> + description = <"Fecha y hora estimadas o confirmadas en las cuales el diagnóstico o problema fue reconocido por el profesional de la salud."> + comment = <"El uso de fechas parciales es aceptable. Si el sujeto de cuidados tiene menos de un año de edad, se requiere la fecha completa o al menos el año y mes para permitir cálculos adecuados (si por ejemplo se utiliza para guiar un apoyo a la toma de decisiones). Los datos registrados o importados como \"Edad a la aparición\" deberán ser convertidos a una fecha utilizando la fecha de nacimiento del sujeto."> + > + ["at0005"] = < + text = <"Severidad"> + description = <"Una evaluación de la severidad general del problema o diagnóstico."> + comment = <"Si la severidad del problema o diagnóstico esta incluida en su nombre mediante códigos precoordinados, este dato se torna redundante. Nota: una gradación ,as específica de severidad puede ser registrada utilizando el slot de Detalles específicos."> + > + ["at0009"] = < + text = <"Descripción clínica"> + description = <"Descripción narrativa del problema o diagnóstico."> + comment = <"Utilizar para proveer trasfondo y contexto, incluyendo evolución, episodios o exacerbaciones, progreso y cualquier otro detalles relevante acerca del problema o diagnóstico."> + > + ["at0012"] = < + text = <"Sitio corporal"> + description = <"Identificación de un sitio corporal simple para la localización o el problema."> + comment = <"Se prefiere la codificación de la localización anatómica mediante una terminología cuando esto sea posible. +Utilícese este dato para registrar localizaciones anatómicas precoordinadas. Si los requerimientos para el registro de una localización anatómica son determinadas en tiempo de ejecución por parte de la aplicación, o se requiere un modelado más complejo tal como una localización relativa, utilícese CLUSTER.anatomical_location or CLUSTER.relative_location dentro del slot \"localización anatómica estructurada\" en este arquetipo. Las ocurrencias de este dato son ilimitadas para así permitir escenarios clínicos tales como la descripción de un rash en múltiples localizaciones pero donde todos los demás atributos son idénticos. Si la localización anatómica esta incluida en el nombre del problema o diagnóstico mediante códigos precoordinados, este dato se torna redundante."> + > + ["at0030"] = < + text = <"Fecha/hora de resolución"> + description = <"Fecha y hora estimadas o confirmadas en las cuales este problema o diagnóstico remitió o se resolvió, determinadas de un profesional de la salud."> + comment = <"El uso de fechas parciales es aceptable. Si el sujeto de cuidados tiene menos de un año de edad, se requiere la fecha completa o al menos el año y mes para permitir cálculos adecuados (si por ejemplo se utiliza para guiar un apoyo a la toma de decisiones)."> + > + ["at0032"] = < + text = <"*Tree(en)"> + description = <"*@ internal @(en)"> + > + ["at0039"] = < + text = <"Sitio corporal estructurado"> + description = <"una localización anatómica estructurada para el problema o diagnóstico."> + comment = <"Utilícese este slot para insertar los arqeutipos de CLUSTER.anatomical_location o CLUSTER.relative_location si los requerimientos de registro de la localización anatómica son determinados en tiempo de ejecución por la aplicación o se requiere un modelado más complejo tal como localizaciones relativas. +Si la localización anatómica está incluida en el nombre del problema o diagnóstico mediante códigos precoordinados, este dato se torna redundante."> + > + ["at0043"] = < + text = <"Detalles específicos"> + description = <"Detalles adicionales requeridos para registrar como atributos unívocos del este problema o diagnóstico."> + comment = <"Puede incluir detalles estructurados acerca del grado o estadificación del diagnóstico, criterios diagnósticos, criterios de clasificación o una evaluación formal de severidad tal como los Criterios Terminológicos Comunes para Eventos Adversos."> + > + ["at0046"] = < + text = <"Estado"> + description = <"Detalles estructurados para los aspectos específicos de localización, dominio, episodio o decurso del proceso diagnóstico."> + comment = <"Los calificadores de estado o contexto con cuidado ya que son variables en su utilización y la interoperabilidad no puede ser garantizada excepto en casos en que se encuentren claramente definidos en el seno de la comunidad de uso. Por ejemplo, el estado de actividad (activo, inactivo, resuelto o en remisión), el estado de evolución (inicial, interino o de trabajo, final), el estado temporal (actual, pasado), el estado episódico (primero, inicial, en curso), el estado de admisión (admisión, egreso) o el estado de prioridad (primario, secundario)."> + > + ["at0047"] = < + text = <"Leve"> + description = <"El problema o diagnóstico no interfiere con la actividad normal o puede causar daños a la salud si no es tratado."> + > + ["at0048"] = < + text = <"Moderado"> + description = <"El problema o diagnóstico interfiere con la actividad normal o puede dañar la salud si no es tratado."> + > + ["at0049"] = < + text = <"Severo"> + description = <"El problema o diagnóstico impide la actividad normal o pude dañar seriamente la salud si no es tratado."> + > + ["at0069"] = < + text = <"Comentario"> + description = <"Narrativa adicional acerca del problema o diagnóstico que no ha sido consignada en otros campos."> + > + ["at0070"] = < + text = <"Última actualización."> + description = <"La fecha de la última actualización de este problema o diagnóstico."> + > + ["at0071"] = < + text = <"Extensión"> + description = <"Información adicional requerida para consignar contenidos locales o alinear con otros modelos de referencia o formalismos."> + comment = <"Por ejemplo: requerimientos de información local o metadatos adicionales para alineamiento con equivalentes en FHIR o CIMI."> + > + ["at0072"] = < + text = <"Descripción del curso"> + description = <"Descripción narrativa del curso del problema o diagnóstico desde su aparición."> + > + ["at0073"] = < + text = <"Certeza diagnóstica"> + description = <"El nivel de certeza de la identificación del diagnóstico."> + > + ["at0074"] = < + text = <"Sospechado"> + description = <"El diagnóstico ha sido identificado con un bajo nivel de certeza."> + > + ["at0075"] = < + text = <"Probable"> + description = <"El diagnóstico ha sido identificado con un alto nivel de certeza."> + > + ["at0076"] = < + text = <"Confirmado"> + description = <"El diagnóstico ha sido confirmado en base a criterios reconocidos."> + > + ["at0077"] = < + text = <"Fecha/hora de aparición"> + description = <"Fecha y hora estimadas o confirmadas en las cuales los signos o síntomas del problema fueron observados por primera vez."> + comment = <"Los datos registrados o importados como \"Edad a la aparición\" deberán ser convertidos a una fecha utilizando la fecha de nacimiento del sujeto."> + > + > + > + ["de"] = < + items = < + ["at0000"] = < + text = <"Problem/Diagnose"> + description = <"Angaben über einen einzelnen identifizierten Gesundheitszustand, eine Verletzung, eine Behinderung oder ein Problem, welches das körperliche, geistige und/oder soziale Wohlergehen einer Einzelperson beeinträchtigt."> + comment = <"Eine klare Abgrenzung zwischen Problem und Diagnose ist in der Praxis nicht einfach zu erreichen. Für die Zwecke der klinischen Dokumentation mit diesem Archetyp werden Problem und Diagnose als ein Kontinuum betrachtet, mit zunehmendem Detaillierungsgrad und unterstützenden Beweisen, die in der Regel dem Etikett \"Diagnose\" Gewicht verleihen."> + > + ["at0001"] = < + text = <"Structure"> + description = <"@ internal @"> + > + ["at0002"] = < + text = <"Name des Problems/ der Diagnose"> + description = <"Namentliche Identifikation des Problems oder der Diagnose."> + comment = <"Wo möglich, ist die Kodierung des Problems oder der Diagnose über eine Terminologie zu bevorzugen."> + > + ["at0003"] = < + text = <"Datum/Zeitpunkt der klinischen Feststellung"> + description = <"Geschätzte oder exakte Zeit (bzw. Datum), zu der die Diagnose oder das Problem von einer medizinischen Fachkraft festgestellt wurde."> + comment = <"Unvollständige Datumsangaben sind zulässig. Wenn der Patient unter einem Jahr alt ist, dann ist das vollständige Datum oder ein Minimum von Monat und Jahr notwendig, um genaue Altersberechnungen zu ermöglichen - z.B. wenn es zur Entscheidungsunterstützung verwendet wird. Datumswerte, die als \"Alter zum Zeitpunkt der klinischen Feststellung\" erfasst/importiert werden, sollten anhand des Geburtsdatums der Person in ein Datum umgewandelt werden."> + > + ["at0005"] = < + text = <"Schweregrad"> + description = <"Eine Gesamtbeurteilung des Schweregrades des Problems oder der Diagnose."> + comment = <"Ist der Schweregrad über vordefinierte Codes im Element \"Name des Problems/ der Diagnose\" enthalten, wird dieses Datenelement überflüssig. Hinweis: Eine spezifischere Einstufung des Schweregrads kann mit Hilfe des SLOTs \"Spezifische Angaben\" angegeben werden."> + > + ["at0009"] = < + text = <"Klinische Beschreibung"> + description = <"Beschreibung des Problems oder der Diagnose."> + comment = <"Wird verwendet, um Hintergrund und Kontext, einschließlich Entwicklung, Episoden oder Verschlechterungen, Fortschritt und andere relevante Details über das Problem oder die Diagnose zu liefern."> + > + ["at0012"] = < + text = <"Körperstelle"> + description = <"Identifikation einer einfachen Körperstelle zur Lokalisierung des Problems oder der Diagnose."> + comment = <"Wo dies möglich ist, ist die Kodierung der anatomischen Lokalisation über eine Terminologie zu bevorzugen. Verwenden Sie dieses Datenelement, um vorab präkoordinierte anatomische Lokalisationen zu erfassen. Wenn die Anforderungen an die Erfassung der anatomischen Lokalisation zur Laufzeit durch die Anwendung bestimmt werden oder komplexere Modellierungen, wie z.B. relative Lokalisationen erforderlich sind, dann verwenden Sie in diesem Archetyp den CLUSTER.anatomical_location oder CLUSTER.relative_location innerhalb des SLOT 'Structured anatomical location'. Die Anzahl für dieses Datenelement ist unbegrenzt, um klinische Szenarien wie die Beschreibung eines Hautausschlags an mehreren Stellen zu ermöglichen, wobei jedoch alle anderen Attribute identisch sind. Falls die anatomische Lage über präkoordinierte Codes im Namen des Problems/Diagnose enthalten ist, wird dieses Datenelement überflüssig."> + > + ["at0030"] = < + text = <"Datum/Zeitpunkt der Genesung"> + description = <"Geschätzte oder exakte Zeit (bzw. Datum), zu der von einer medizinischen Fachkraft die Genesung oder die Remission des Problems oder der Diagnose festgestellt wurde."> + comment = <"Unvollständige Datumsangaben sind zulässig. Wenn der Patient unter einem Jahr alt ist, dann ist das vollständige Datum oder ein Minimum von Monat und Jahr notwendig, um genaue Altersberechnungen zu ermöglichen - z.B. wenn es zur Entscheidungsunterstützung verwendet wird. Datumswerte, die als \"Alter zum Zeitpunkt der Genesung\" erfasst/importiert werden, sollten anhand des Geburtsdatums der Person in ein Datum umgewandelt werden."> + > + ["at0032"] = < + text = <"Tree"> + description = <"@ internal @"> + > + ["at0039"] = < + text = <"Anatomische Stelle (strukturiert)"> + description = <"Eine strukturierte anatomische Lokalisation des Problems oder der Diagnose."> + comment = <"Verwenden Sie diesen SLOT, um die Archetypen CLUSTER.anatomical_location oder CLUSTER.relative_location einzufügen, wenn die Anforderungen für die Aufnahme der anatomischen Position zur Laufzeit der Anwendung bestimmt werden oder komplexere Modellierungen wie z.B. relative Positionen erforderlich sind. Ist die anatomische Lokalisation über präkoordinierte Codes im Namen des Problems/Diagnose enthalten, wird die Verwendung dieses SLOT überflüssig."> + > + ["at0043"] = < + text = <"Spezifische Angaben"> + description = <"Zusätzlich benötigte Angaben, welche als eindeutige Merkmale des Problem/der Diagnose erfasst werden sollten."> + comment = <"Hier können strukturierte Angaben über die Einstufung oder das Stadium der Diagnose enthalten sein; diagnostische Kriterien, Klassifizierungskriterien oder formale Bewertungen des Schweregrades wie z.B. \"Common Terminology Criteria for Adverse Events\"."> + > + ["at0046"] = < + text = <"Status"> + description = <"Strukturierte Angaben zu standort-, domänen-, episoden- oder workflow-spezifischen Aspekten des diagnostischen Prozesses."> + comment = <"Verwenden Sie Status- oder Kontext-Merkmale mit Vorsicht, da sie in der Praxis variabel eingesetzt werden und die Interoperabilität nicht gewährleistet werden kann, sofern die Verwendung nicht mit der Nutzungsgemeinschaft klar abgestimmt wird. Beispiel: aktiver Status - aktiv, inaktiv, genesen, in Remission; Entwicklungsstatus - initial, interim/working, final; zeitlicher Status - aktuell, vergangen; Episodenstatus - erstmalig, neu, laufend; Aufnahmestatus - Aufnahme, Entlassung; oder Prioritätsstatus - primär, sekundär."> + > + ["at0047"] = < + text = <"Leicht"> + description = <"Das Problem oder die Diagnose beeinträchtigt die normale Aktivität nicht, bzw. verursacht nicht bleibende gesundheitliche Schäden, falls es nicht behandelt wird."> + > + ["at0048"] = < + text = <"Mäßig"> + description = <"Das Problem oder die Diagnose beeinträchtigt die normale Aktivität oder verursacht bleibende gesundheitliche Schäden, falls es nicht behandelt wird."> + > + ["at0049"] = < + text = <"Schwer"> + description = <"Das Problem oder die Diagnose verhindert die normale Aktivität oder verursacht schwerwiegende gesundheitliche Schäden, falls es nicht behandelt wird."> + > + ["at0069"] = < + text = <"Kommentar"> + description = <"Ergänzende Beschreibung des Problems oder der Diagnose, die nicht anderweitig erfasst wurde."> + > + ["at0070"] = < + text = <"Zuletzt aktualisiert"> + description = <"Datum der letzten Aktualisierung der Diagnose bzw. des Problems."> + > + ["at0071"] = < + text = <"Erweiterung"> + description = <"Zusätzliche Informationen zur Erfassung lokaler Inhalte oder Anpassung an andere Referenzmodelle/Formalismen."> + comment = <"Zum Beispiel: Lokaler Informationsbedarf oder zusätzliche Metadaten zur Anpassung an FHIR-Ressourcen oder CIMI-Modelle."> + > + ["at0072"] = < + text = <"Beschreibung des Verlaufs"> + description = <"Beschreibung des Problem-/ Diagnoseverlaufs seit Beginn."> + > + ["at0073"] = < + text = <"Diagnostische Sicherheit"> + description = <"Grad der Sicherheit, mit der die Diagnose festgestellt wurde."> + > + ["at0074"] = < + text = <"Vermutet"> + description = <"Die Diagnose wurde mit einem niedrigen Grad an Sicherheit gestellt."> + > + ["at0075"] = < + text = <"Wahrscheinlich"> + description = <"Die Diagnose wurde mit einem hohen Maß an Sicherheit gestellt."> + > + ["at0076"] = < + text = <"Bestätigt"> + description = <"Die Diagnose wurde anhand anerkannter Kriterien bestätigt."> + > + ["at0077"] = < + text = <"Datum/ Zeitpunkt des Auftretens/ der Erstdiagnose"> + description = <"Geschätzte oder exakte Zeit (bzw. Datum), zu der die Krankheitsanzeichen oder Symptome zum ersten mal beobachtet wurden."> + comment = <"Datumswerte, die als \"Alter zu Beginn\" erfasst/importiert werden, sollten anhand des Geburtsdatums der Person in ein Datum umgewandelt werden."> + > + > + > + ["en"] = < + items = < + ["at0000"] = < + text = <"Problem/Diagnosis"> + 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'."> + > + ["at0001"] = < + text = <"structure"> + description = <"@ internal @"> + > + ["at0002"] = < + text = <"Problem/Diagnosis name"> + 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."> + > + ["at0003"] = < + text = <"Date/time clinically recognised"> + 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."> + > + ["at0005"] = < + 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."> + > + ["at0009"] = < + text = <"Clinical description"> + 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."> + > + ["at0012"] = < + text = <"Body site"> + 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. + +"> + > + ["at0030"] = < + text = <"Date/time of resolution"> + 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. +"> + > + ["at0032"] = < + text = <"Tree"> + description = <"@ internal @"> + > + ["at0039"] = < + text = <"Structured body site"> + description = <"A structured anatomical location for the problem or diagnosis."> + comment = <"Use this SLOT to insert the CLUSTER.anatomical_location or CLUSTER.relative_location archetypes 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. + +If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, use of this SLOT becomes redundant. + +"> + > + ["at0043"] = < + text = <"Specific details"> + description = <"Details that are additionally required to record as unique attributes of this problem or diagnosis."> + comment = <"May include structured detail about the grading or staging of the diagnosis; diagnostic criteria, classification criteria or formal severity assessments such as Common Terminology Criteria for Adverse Events."> + > + ["at0046"] = < + text = <"Status"> + description = <"Structured details for location-, domain-, episode- or workflow-specific aspects of the diagnostic process."> + comment = <"Use status or context qualifiers with care, as they are variably used in practice and interoperability cannot be assured unless usage is clearly defined with the community of use. For example: active status - active, inactive, resolved, in remission; evolution status - initial, interim/working, final; temporal status - current, past; episodicity status - first, new, ongoing; admission status - admission, discharge; or priority status - primary, secondary."> + > + ["at0047"] = < + text = <"Mild"> + description = <"The problem or diagnosis does not interfere with normal activity or may cause damage to health if left untreated."> + > + ["at0048"] = < + text = <"Moderate"> + description = <"The problem or diagnosis causes interference with normal activity or will damage health if left untreated."> + > + ["at0049"] = < + text = <"Severe"> + description = <"The problem or diagnosis prevents normal activity or will seriously damage health if left untreated."> + > + ["at0069"] = < + text = <"Comment"> + description = <"Additional narrative about the problem or diagnosis not captured in other fields."> + > + ["at0070"] = < + text = <"Last updated"> + description = <"The date this problem or diagnosis was last updated."> + > + ["at0071"] = < + text = <"Extension"> + description = <"Additional information required to capture local content or to align with other reference models/formalisms."> + comment = <"For example: local information requirements or additional metadata to align with FHIR or CIMI equivalents."> + > + ["at0072"] = < + text = <"Course description"> + description = <"Narrative description about the course of the problem or diagnosis since onset."> + > + ["at0073"] = < + text = <"Diagnostic certainty"> + description = <"The level of confidence in the identification of the diagnosis."> + > + ["at0074"] = < + text = <"Suspected"> + description = <"The diagnosis has been identified with a low level of certainty."> + > + ["at0075"] = < + text = <"Probable"> + description = <"The diagnosis has been identified with a high level of certainty."> + > + ["at0076"] = < + text = <"Confirmed"> + description = <"The diagnosis has been confirmed against recognised criteria."> + > + ["at0077"] = < + text = <"Date/time of onset"> + 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."> + > + > + > + ["ar-sy"] = < + items = < + ["at0000"] = < + text = <"*Problem/Diagnosis(en)"> + 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.(en)"> + 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'.(en)"> + > + ["at0001"] = < + text = <"*structure(en)"> + description = <"*@ internal @(en)"> + > + ["at0002"] = < + text = <"*Problem/Diagnosis name(en)"> + description = <"*Identification of the problem or diagnosis, by name.(en)"> + comment = <"*Coding of the name of the problem or diagnosis with a terminology is preferred, where possible.(en)"> + > + ["at0003"] = < + text = <"*Date/time clinically recognised(en)"> + description = <"*Estimated or actual date/time the diagnosis or problem was recognised by a healthcare professional.(en)"> + 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.(en)"> + > + ["at0005"] = < + text = <"*Severity(en)"> + description = <"*An assessment of the overall severity of the problem or diagnosis.(en)"> + 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.(en)"> + > + ["at0009"] = < + text = <"*Clinical description(en)"> + description = <"*Narrative description about the problem or diagnosis.(en)"> + comment = <"*Use to provide background and context, including evolution, episodes or exacerbations, progress and any other relevant details, about the problem or diagnosis.(en)"> + > + ["at0012"] = < + text = <"*Body site(en)"> + description = <"*Identification of a simple body site for the location of the problem or diagnosis.(en)"> + 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. + +(en)"> + > + ["at0030"] = < + text = <"*Date/time of resolution(en)"> + description = <"*Estimated or actual date/time of resolution or remission for this problem or diagnosis, as determined by a healthcare professional.(en)"> + 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.(en)"> + > + ["at0032"] = < + text = <"*Tree(en)"> + description = <"*@ internal @(en)"> + > + ["at0039"] = < + text = <"*Structured body site(en)"> + description = <"*A structured anatomical location for the problem or diagnosis.(en)"> + comment = <"*Use this SLOT to insert the CLUSTER.anatomical_location or CLUSTER.relative_location archetypes 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. + +If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, use of this SLOT becomes redundant. + +(en)"> + > + ["at0043"] = < + text = <"*Specific details(en)"> + description = <"*Details that are additionally required to record as unique attributes of this problem or diagnosis.(en)"> + comment = <"*May include structured detail about the grading or staging of the diagnosis; diagnostic criteria, classification criteria or formal severity assessments such as Common Terminology Criteria for Adverse Events.(en)"> + > + ["at0046"] = < + text = <"*Status(en)"> + description = <"*Structured details for location-, domain-, episode- or workflow-specific aspects of the diagnostic process.(en)"> + comment = <"*Use status or context qualifiers with care, as they are variably used in practice and interoperability cannot be assured unless usage is clearly defined with the community of use. For example: active status - active, inactive, resolved, in remission; evolution status - initial, interim/working, final; temporal status - current, past; episodicity status - first, new, ongoing; admission status - admission, discharge; or priority status - primary, secondary.(en)"> + > + ["at0047"] = < + text = <"*Mild(en)"> + description = <"*The problem or diagnosis does not interfere with normal activity.(en)"> + > + ["at0048"] = < + text = <"*Moderate(en)"> + description = <"*The problem or diagnosis causes interference with normal activity.(en)"> + > + ["at0049"] = < + text = <"*Severe(en)"> + description = <"*The problem or diagnosis prevents normal activity.(en)"> + > + ["at0069"] = < + text = <"*Comment(en)"> + description = <"*Additional narrative about the problem or diagnosis not captured in other fields.(en)"> + > + ["at0070"] = < + text = <"*Last updated(en)"> + description = <"*The date this problem or diagnosis was last updated.(en)"> + > + ["at0071"] = < + text = <"*Extension(en)"> + description = <"*Additional information required to capture local content or to align with other reference models/formalisms.(en)"> + comment = <"*For example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.(en)"> + > + ["at0072"] = < + text = <"*Course description(en)"> + description = <"*Narrative description about the course of the problem or diagnosis since onset.(en)"> + > + ["at0073"] = < + text = <"*Diagnostic certainty(en)"> + description = <"*The level of confidence in the identification of the diagnosis.(en)"> + > + ["at0074"] = < + text = <"*Suspected(en)"> + description = <"*The diagnosis has been identified with a low level of certainty.(en)"> + > + ["at0075"] = < + text = <"*Probable(en)"> + description = <"*The diagnosis has been identified with a high level of certainty.(en)"> + > + ["at0076"] = < + text = <"*Confirmed(en)"> + description = <"*The diagnosis has been confirmed against recognised criteria.(en)"> + > + ["at0077"] = < + text = <"*Date of onset(en)"> + description = <"*Estimated or actual date/time that signs or symptoms of the problem/diagnosis were first observed. +(en)"> + > + > + > + ["pt-br"] = < + items = < + ["at0000"] = < + text = <"Problema /Diagnóstico"> + description = <"Detalhes sobre uma única condição de saúde identificada, lesões, deficiência ou qualquer outra questão que tenha impacto sobre o bem-estar físico, mental e / ou social de um indivíduo."> + comment = <"Delimitação clara entre o âmbito de um problema em comparação a um diagnóstico, não é fácil de se conseguir na prática. Para fins de documentação clínica com este arquétipo, problema e diagnóstico são considerados como uma continuidade, com níveis crescentes de detalhes e evidência de apoio, geralmente fornecendo peso para o rótulo de \"diagnóstico\"."> + > + ["at0001"] = < + text = <"structure"> + description = <"@ internal @"> + > + ["at0002"] = < + text = <"Nome do Problema / Diagnóstico"> + description = <"Identificação do problema ou diagnóstico, por nome."> + comment = <"Quando possível, é preferível usar a codificação do nome do problema ou diagnóstico com uma terminologia."> + > + ["at0003"] = < + text = <"Data / hora da reconhecimento clínico"> + description = <"Data / hora, estimada ou real, que o diagnóstico ou o problema foi reconhecido por um profissional de saúde."> + comment = <"Datas parciais são aceitáveis. +Se o tema do cuidado está com idade inferior a um ano, então a data completa ou no mínimo o mês e o ano são necessários para permitir cálculos de idade precisos, por exemplo, se usado para conduzir apoio à decisão. Os dados capturados / importados como \"Idade no momento do reconhecimento clínico\" deve ser convertida para uma data usando o sujeito data de nascimento."> + > + ["at0005"] = < + text = <"Severidade"> + description = <"Uma avaliação global da severidade do problema ou diagnóstico."> + comment = <"Se a severidade está incluída no nome do Problema / diagnóstico através de códigos pré-coordenados, este elemento de dados torna-se redundante. +Nota: a classificação mais específica da gravidade pode ser gravada utilizando os detalhes específicos SLOT."> + > + ["at0009"] = < + text = <"Descrição clínica"> + description = <"Descrição narrativa sobre o problema ou diagnóstico."> + comment = <"Usar para fornecer conhecimento e contexto, incluindo evolução, episódios ou exacerbações, progresso e quaisquer outros detalhes relevantes, sobre o problema ou diagnóstico."> + > + ["at0012"] = < + text = <"Local do corpo"> + description = <"Simples identificação de um local do corpo para a localização do problema ou diagnóstico."> + comment = <"A codificação do nome da localização anatômica com uma terminologia é preferível, quando possível. +Utilize este elemento de dados para gravar localizações anatômicas precoordenadas. Se os requisitos para gravar a localização anatômica são determinados em tempo real através da aplicação ou requerem uma modelagem mais complexa, como localizações relativas, em seguida, use o CLUSTER.anatomical_location ou CLUSTER.relative_location dentro do SLOT 'localização anatômica estruturada\" neste arquétipo. +Ocorrências para este elemento de dados são ilimitadas para permitir cenários clínicos tais como a descrição de uma erupção cutânea em vários locais, mas em que todos os outros atributos são idênticos. Se a localização anatômica é incluída ao nome do Problema / diagnóstico, através de códigos pré-coordenados, este elemento de dados torna-se redundante."> + > + ["at0030"] = < + text = <"Data /tempo de resolução"> + description = <"Data / tempo, estimado ou atual, de resolução ou de dispensa desse problema ou diagnóstico, como determinado por um profissional de saúde."> + comment = <"Datas parciais são aceitáveis. +Se o tema do cuidado está com idade inferior a um ano, então a data completa ou no mínimo o mês e o ano são necessários para permitir cálculos de idade precisos, por exemplo, se usado para conduzir apoio à decisão. Os dados capturados / importados como \"Idade na ocasião da resolução\" deve ser convertida para uma data usando o sujeito data de nascimento."> + > + ["at0032"] = < + text = <"Tree(en)"> + description = <"@ internal @"> + > + ["at0039"] = < + text = <"Local estruturado do corpo"> + description = <"A localização anatômica estruturada para o problema ou diagnóstico."> + comment = <"Use esse SLOT para inserir os arquétipos CLUSTER.anatomical_location ou CLUSTER.relative_location se os requisitos para gravar a localização anatômica são determinados em tempo real através da aplicação ou requer uma modelagem mais complexa, como localizações relativas. + +Se a localização anatômica está incluída ao nome Problema / diagnóstico, através de códigos pré-coordenados, o uso deste SLOT torna-se redundante."> + > + ["at0043"] = < + text = <"Detalhes específicos"> + description = <"Detalhes que são adicionalmente necessários para gravar atributos como únicos deste problema ou diagnóstico."> + comment = <"Pode incluir detalhes estruturados sobre a classificação ou a realização do diagnóstico; critérios de diagnóstico, critérios de classificação ou avaliação formal da severidade, como os critérios de terminologia comum para eventos adversos."> + > + ["at0046"] = < + text = <"Estado"> + description = <"Detalhes estruturados para localização, domínio, episódio ou aspectos específicos do fluxo de trabalho do processo de diagnóstico."> + comment = <"Use o estado ou os qualificadores contexto com cuidado, pois eles são variáveis quando usados na prática e a interoperabilidade não pode ser assegurada, salvo se o uso está claramente definido com a comunidade de uso. +Por exemplo: evolução do estado: inicial, inativo, resolvido, em remissão; estado de evolução: inicial, provisório / trabalhando, final; estado temporal: presente, passado; estado do episodio: primeiro, novo, em curso; estado de admissão: admissão, alta; ou estado de prioridade: primário, secundário."> + > + ["at0047"] = < + text = <"Suave"> + description = <"O problema ou o diagnóstico não interfere na atividade normal ou causa danos à saúde, se não for tratado."> + > + ["at0048"] = < + text = <"Moderado"> + description = <"O problema ou o diagnóstico interfere na atividade normal ou prejudicará a saúde, se não for tratado."> + > + ["at0049"] = < + text = <"Severo"> + description = <"O problema ou diagnóstico impede a atividade normal ou causará sérios danos à saúde se não tratado."> + > + ["at0069"] = < + text = <"Comentário"> + description = <"Narrativa adicional sobre o problema ou diagnóstico, não capturados em outros campos."> + > + ["at0070"] = < + text = <"Ultima atualização"> + description = <"A data este problema ou diagnóstico foi atualizado pela última vez."> + > + ["at0071"] = < + text = <"Extensão"> + description = <"Informações adicionais necessárias para capturar o conteúdo local ou para alinhar com outros modelos de referência / formalismos."> + comment = <"Por exemplo: requisitos de informação locais ou metadados adicionais para alinhar com FHIR ou CIMI equivalentes."> + > + ["at0072"] = < + text = <"Descrição do curso"> + description = <"Descrição narrativa sobre o curso do problema ou diagnóstico, desde o início."> + > + ["at0073"] = < + text = <"Certeza do diagnóstico"> + description = <"O nível de confiança da identificação do diagnóstico."> + > + ["at0074"] = < + text = <"Suspeito"> + description = <"O diagnóstico foi identificado com um nível baixo de convicção."> + > + ["at0075"] = < + text = <"Provável"> + description = <"O diagnóstico foi identificado com um elevado grau de certeza."> + > + ["at0076"] = < + text = <"confirmado"> + description = <"O diagnóstico foi confirmado com base em critérios reconhecidos."> + > + ["at0077"] = < + text = <"Data / tempo de início"> + description = <"Data / tempo, estimada ou real, que os sinais ou sintomas do problema / diagnóstico foram observados pela primeira vez."> + comment = <"Os dados capturados / importados como \"A idade de início\" devem ser convertidos para uma data, usando o sujeito data de nascimento."> + > + > + > + ["nb"] = < + items = < + ["at0000"] = < + text = <"Problem/diagnose"> + description = <"Detaljer om én identifisert helsetilstand, skade, funksjonshemming eller annet forhold som påvirker et individs fysiske, mentale og/eller sosiale velvære. +"> + comment = <"Det er i praksis ikke lett å oppnå et klart skille mellom et problem og en diagnose. I klinisk dokumentasjon med denne arketypen ses problem og diagnose som et kontinuum, med økende krav til detaljer og støttende evidens for å underbygge en diagnose."> + > + ["at0001"] = < + text = <"structure"> + description = <"@ internal @"> + > + ["at0002"] = < + text = <"Problem/diagnosenavn"> + description = <"Identifisering av problemet eller diagnosen ved hjelp av navn."> + comment = <"Koding av navnet på problemet eller diagnosen med en terminologi er foretrukket, der det er mulig."> + > + ["at0003"] = < + text = <"Dato/tid for klinisk bekreftelse"> + description = <"Anslått eller faktisk dato/tid da diagnosen eller problemet ble bekreftet av helsepersonell."> + comment = <"Delvise datoer er tillatt. Dersom individet er under ett år gammel, må komplett dato eller som et minimum måned og år oppgis for å muliggjøre presise beregninger av alder, f.eks. ved bruk i beslutningsstøttesystemer. Data registrert eller importert som \"alder ved tidspunkt når diagnosen stilles\" bør konverteres til en dato ved hjelp av individets fødselsdato."> + > + ["at0005"] = < + text = <"Alvorlighetsgrad"> + description = <"En vurdering av problemet eller diagnosens overordnede alvorlighetsgrad."> + comment = <"Dersom alvorlighetsgrad inkluderes i feltet \"Problem/diagnosenavn\" via prekoordinerte koder blir dette dataelementet overflødig. Merk: Mer spesifikk gradering av alvorlighetsgrad kan registreres ved å bruke SLOTet \"Spesifikke detaljer\""> + > + ["at0009"] = < + text = <"Klinisk beskrivelse"> + description = <"Fritekstbeskrivelse av problemet eller diagnosen."> + comment = <"Brukes til å gi bakgrunn og kontekst, inkludert utvikling, episoder eller forverringer, fremgang og alle andre relevante detaljer, om problemet eller diagnosen."> + > + ["at0012"] = < + text = <"Anatomisk lokalisering"> + description = <"Registrering av et enkelt og usammensatt anatomisk sted der problemet eller diagnosen er lokalisert."> + comment = <"Koding av navnet på den anatomiske lokaliseringen ved hjelp av en terminologi er foretrukket når dette er mulig. +Bruk dette dataelementet for å registrere prekoordinerte anatomiske lokaliseringer. Dersom behovene for å registrere anatomisk sted bestemmes i applikasjonen eller trenger større grad av kompleksitet som f.eks. relativ lokalisering, er det anbefalt å bruke CLUSTER.anatomical_location eller CLUSTER.relative_location innenfor SLOTet \"Strukturert anatomisk lokalisering\" i denne arketypen. Dette dataelementet kan ha ubegrenset antall forekomster, for å gjøre det mulig å registrere kliniske scenarier som f.eks. å beskrive et utslett som opptrer flere steder på kroppen, men der alle andre attributter er identiske. Dersom den anatomiske lokaliseringen inkluderes i feltet \"Problem/diagnosenavn\" via prekoordinerte koder blir dette dataelementet overflødig."> + > + ["at0030"] = < + text = <"Dato/tid for bedring/remisjon"> + description = <"Estimert eller faktisk dato/tid for bedring eller remisjon av det aktuelle problemet eller diagnosen, fastslått av helsepersonell."> + comment = <"Delvise datoer er tillatt. Dersom individet er under ett år gammel, må komplett dato eller som et minimum måned og år oppgis for å muliggjøre presise beregninger av alder, f.eks. ved bruk i beslutningsstøttesystemer. +Data registrert eller importert som \"alder ved bedring\" bør konverteres til en dato ved hjelp av individets fødselsdato."> + > + ["at0032"] = < + text = <"Tree"> + description = <"@ internal @"> + > + ["at0039"] = < + text = <"Strukturert anatomisk lokalisering"> + description = <"SLOT som kan inneholde en eller flere detaljerte og strukturerte anatomiske lokaliseringer."> + comment = <"Dersom behovene for å registrere anatomisk sted bestemmes i applikasjonen eller trenger større grad av kompleksitet som f.eks. relativ lokalisering, er det anbefalt å bruke CLUSTER.anatomical_location eller CLUSTER.relative_location i dette SLOTet. + +Dersom den anatomiske lokaliseringen inkluderes i feltet \"Problem/diagnosenavn\" via prekoordinerte koder blir dette dataelementet overflødig."> + > + ["at0043"] = < + text = <"Spesifikke detaljer"> + description = <"Detaljer som er nødvendige for å registrere det aktuelle problemet eller diagnosens unike egenskaper."> + comment = <"Kan omfatte strukturerte detaljer om klassifisering eller stadier av diagnosen; diagnosiske kriterier, klassifikasjon eller formelle vurderinger av alvorlighetsgrad, som f.eks. Common Terminology Criteria for Adverse Events."> + > + ["at0046"] = < + text = <"Status"> + description = <"Strukturerte detaljer for lokalisering-, fagområde-, episode- eller arbeidsflytsspesifikke aspekter av den diagnostiske prosessen."> + comment = <"Bruk status eller kontekstkvalifikatorer med omhu, da bruken varierer og interoperabilitet kan ikke garanteres med mindre bruken er klart definert innen miljøet som bruker dem. F.eks. aktiv status - aktiv, inaktiv, løst, i bedring; utviklingsstatus - første, midlertidig, endelig; tidsstatus - nåværende, tidligere; episodisk status - første, ny, pågående; innleggelsesstatus - innleggelse, utskriving; eller prioritetsstatus - primær, sekundær."> + > + ["at0047"] = < + text = <"Mild"> + description = <"Problemet eller diagnosen forstyrrer ikke normal aktivitet."> + > + ["at0048"] = < + text = <"Moderat"> + description = <"Problemet eller diagnosen forstyrrer normal aktivitet."> + > + ["at0049"] = < + text = <"Alvorlig"> + description = <"Problemet eller diagnosen forhindrer normal aktivitet."> + > + ["at0069"] = < + text = <"Kommentar"> + description = <"Utdypende fritekst om problemet eller diagnosen, som ikke passer i andre felt."> + > + ["at0070"] = < + text = <"Sist oppdatert"> + description = <"Datoen da problemet eller diagnosen sist ble oppdatert."> + > + ["at0071"] = < + text = <"Utvidelse"> + description = <"Ytterligere informasjon som trengs for å kunne registrere lokalt definert innhold eller for å tilpasse til andre referansemodeller/formalismer. + + + +"> + comment = <"For eksempel lokale informasjonsbehov eller ytterligere metadata for å kunne tilpasse til tilsvarende konsepter i FHIR eller CIMI."> + > + ["at0072"] = < + text = <"Forløpsbeskrivelse"> + description = <"Fritekstbeskrivelse av forløpet av problemet eller diagnosen siden debut."> + > + ["at0073"] = < + text = <"Diagnostisk sikkerhet"> + description = <"Grad av sikkerhet i identifikasjonen av diagnosen."> + > + ["at0074"] = < + text = <"Mistenkt"> + description = <"Diagnoses er identifisert med en lav grad av sikkerhet."> + > + ["at0075"] = < + text = <"Sannsynlig"> + description = <"Diagnosen er identifisert med en stor grad av sikkerhet."> + > + ["at0076"] = < + text = <"Bekreftet"> + description = <"Diagnosen er bekreftet opp mot anerkjente kriterier."> + > + ["at0077"] = < + text = <"Dato/ tid for debut"> + description = <"Antatt eller faktisk dato/tid da tegn eller symptomer på problemet eller diagnosen først ble observert."> + comment = <"Data registrert eller importert som \"alder ved debut\" bør konverteres til en dato ved hjelp av individets fødselsdato."> + > + > + > + ["sv"] = < + items = < + ["at0000"] = < + text = <"Problem/Diagnos"> + description = <"Detaljer av ett enskilt identifierat hälsotillstånd, skada, funktionshinder eller något annat problem som påverkar individens fysiska, psykiska och eller sociala välbefinnande."> + comment = <"Det är inte lätt att i praktiken uppnå en tydlig avgränsning mellan ett problem och en diagnos. Vid tillämpning av klinisk dokumentation med denna arketyp betraktas problem och diagnos som ett kontinuum, med plats för fler detaljer och stödjande bevis som vanligtvis ger tyngd till etiketten ”diagnos”."> + > + ["at0001"] = < + text = <"structure"> + description = <"@ internal @"> + > + ["at0002"] = < + text = <"Problem/Diagnos namn"> + description = <"Identifiering av problemet eller diagnosen efter namn."> + comment = <"Kodning av namnet på problemet eller diagnosen med en terminologi är att föredra, om det är tillämpligt."> + > + ["at0003"] = < + text = <"Datum och tid för kliniskt erkänd"> + description = <"Uppskattat eller reellt datum coh tid som diagnosen eller problemet erkändes av sjukvårdspersonal."> + comment = <"Partiella datum är acceptabla. Om patienten är under ett år, då är det fullständiga datumet eller ett minimum av månad och år nödvändigt för korrekta åldersberäkningar exempelvis om de används för beslutsstöd. Data som registreras och importeras som \"Ålder vid tidpunkten för kliniskt erkännande\" ska omvandlas till ett datum med hjälp av patientens födelsedatum."> + > + ["at0005"] = < + text = <"Svårighetsgrad"> + description = <"En bedömning av problemets eller diagnosens totala svårighetsgrad."> + comment = <"Om svårighetsgraden har lagts till i Problem- och diagnos-namnet via förkoordinerade koder, blir detta fält överflödigt. Obs: mer specifik gradering av svårighetsgrad kan registreras i fältet ”specifika detaljer.”"> + > + ["at0009"] = < + text = <"Klinisk beskrivning"> + description = <"En beskrivning av problemet eller diagnosen."> + comment = <"Används för att ge bakgrund och kontext, inklusive utveckling, episoder eller exacerbationer, framsteg och andra relevanta detaljer om problemet eller diagnosen."> + > + ["at0012"] = < + text = <"Anatomisk plats"> + description = <"Identifiering av problemets eller diagnosens anatomiska plats."> + comment = <"Kodning av den anatomiska platsens namn med en terminologi är att föredra, om det är tillämpligt. Använd det här fältet för att dokumentera förkoordinerade anatomiska platser. Om kraven för att dokumentera den anatomiska platsen bestäms automatiskt av applikationen eller kräver mer komplicerad modellering som exempelvis relativa platser, använd i så fall Cluster.anatomical_location eller cluster. relative_location inom \"Strukturerad anatomisk plats '-fältet i denna arketyp. I detta fält är det möjligt att dokumentera kliniska scenarier som exempelvis att beskriva ett utslag på flera platser, men där alla andra egenskaper är identiska. Om den anatomiska platsen ingår i problem-och diagnos-namnet via förkoordinerade koder, blir detta fält överflödigt."> + > + ["at0030"] = < + text = <"Datum och tid för upplösning"> + description = <"Uppskattat eller reellt datum och tid för upplösning eller remission av detta problem eller diagnos, som fastställts av sjukvårdspersonal."> + comment = <"Partiella datum är acceptabla. Om patienten är under ett år är det fullständiga datumet eller ett minimum av månad och år nödvändigt för korrekta åldersberäkningar, exempelvis om de används för beslutsstöd. Data som registreras och importeras som \"Ålder vid tidpunkten för upplösning\" ska konverteras till ett datum med hjälp av patientens födelsedatum."> + > + ["at0032"] = < + text = <"Tree"> + description = <"@ internal @"> + > + ["at0039"] = < + text = <"Strukturerad anatomisk plats"> + description = <"En strukturerad anatomisk plats för problemet eller diagnosen."> + comment = <"Använd det här fältet för att infoga CLUSTER.anatomical_location eller CLUSTER.relative_location-arketyper om den anatomiska platsen bestäms automatiskt av applikationen eller kräver mer komplicerad modellering som exempelvis relativa platser. Om den anatomiska platsen är inkluderad i problem- och diagnos-namnet via förkoordinerade koder, blir detta fält överflödigt."> + > + ["at0043"] = < + text = <"Specifika detaljer"> + description = <"Detaljer som krävs för att kunna dokumenteras som unika egenskaper i den här problem eller diagnos arketypen."> + comment = <"Fältet kan innehålla strukturerad detalj om klassificering eller stadieindelning av diagnosen diagnostiska kriterier, klassificeringskriterier eller formella bedömningar av svårighetsgrad, såsom gemensamma terminologikriterier för biverkningar."> + > + ["at0046"] = < + text = <"Status"> + description = <"Strukturerade detaljer för plats-, domän-, episod-eller arbetsflödes specifika aspekter av diagnosprocessen. +"> + comment = <"Använd status- eller kontextbestämningar med omsorg, pga. varierande användning i praktiken samt pga. att driftskompabilitet inte kan garanteras om inte användningen är tydligt definierad i gruppen exempelvis: +Status: Aktiv och inaktiv, utredd och i remission Utvecklingsstatus: Initial, interimistisk preliminär och slutlig +Temporal status: Nuvarande och tidigare +Episodicitet status: Första, nytt och pågående +Inskrivningsstatus: Inskrivning och utskrivning Prioritetsstatus: Primär och sekundär."> + > + ["at0047"] = < + text = <"Mild"> + description = <"Problemet eller diagnosen stör inte normal aktivitet eller kan orsaka hälsoskador om den lämnas obehandlad."> + > + ["at0048"] = < + text = <"Medel"> + description = <"Problemet eller diagnosen orsakar störningar i normal aktivitet eller kommer att skada hälsan om den lämnas obehandlad."> + > + ["at0049"] = < + text = <"Svår"> + description = <"Problemet eller diagnosen förhindrar normal aktivitet eller allvarligt kommer att skada hälsan om den lämnas obehandlad."> + > + ["at0069"] = < + text = <"Kommentar"> + description = <"En extra beskrivning av problemet eller diagnosen som inte tagits upp i andra fält."> + > + ["at0070"] = < + text = <"Senast uppdaterad"> + description = <"Datumet då problemet eller diagnosen senast uppdaterades."> + > + ["at0071"] = < + text = <"Extra information"> + description = <"Ytterligare uppgifter som krävs för att fånga lokalt innehåll eller för anpassning till andra referens modeller och formalismer."> + comment = <"Exempelvis: lokala informationskrav eller ytterligare metadata för anpassning till FHIR-eller CIMI -motsvarigheter."> + > + ["at0072"] = < + text = <"Förlopp"> + description = <"Beskrivning av problemets eller diagnosen förlopp sedan debuten."> + > + ["at0073"] = < + text = <"Diagnostisk säkerhet"> + description = <"Säkerhetsgraden för identifiering av diagnos."> + > + ["at0074"] = < + text = <"Misstänkt"> + description = <"Diagnosen har identifierats med en låg grad av säkerhet."> + > + ["at0075"] = < + text = <"Sannolik"> + description = <"Diagnosen har identifierats med en hög grad av säkerhet."> + > + ["at0076"] = < + text = <"Bekräftad"> + description = <"Diagnosen har bekräftats mot kända kriterier."> + > + ["at0077"] = < + text = <"Datum och tid för debut"> + description = <"Uppskattat eller reellt datum och tid när problemets eller diagnosens tecken eller symtom först observerades."> + comment = <"Data som dokumenteras och importeras som \"Ålder vid debut\" ska konverteras till ett datum med hjälp av patientens födelsedatum."> + > + > + > + ["ko"] = < + items = < + ["at0000"] = < + text = <"문제/진단"> + description = <"한 개인의 신체, 정신 그리고/또는 사회적 웰빙에 영향을 주는 단일한 확인된 건강 성태, 상해, 장애 또는 다른 이슈에 대한 상세내용."> + comment = <"실무에서 문제와 진단의 범위 간의 명확한 구분을 하기 쉽지 않음. 이 아키타입을 통한 임상 문서의 목적을 위해서, 증가하는 상세내용의 수준과 일반적으로 '진단'의 표시에 대한 무게감을 제공하는 지지할 수 있는 증거를 가지고, 문제와 진단은 연속된 것(a continuum)으로 간주됨."> + > + ["at0001"] = < + text = <"structure"> + description = <"@ internal @"> + > + ["at0002"] = < + text = <"문제/진단명"> + description = <"명칭으로 문제 또는 진단의 식별."> + comment = <"가능하다면, 용어체계를 통한 문제 또는 진단의 명칭을 코딩하는 것이 좋음."> + > + ["at0003"] = < + text = <"임상적으로 인지된 날짜/시간"> + description = <"진단 또는 문가가 헬스케어 전문가에게 인지된 추정 또는 실제 날짜/시간."> + comment = <"부분 날짜도 허용됨. 진료의 주체가 한 살 이하이면, 완전한 날짜 또는 달과 년의 하한이 정확한 나이 계산을 위해 필요함 - 예를 들어, 의사결정지원을 사용하는 경우. \\\"임상적으로 인지된 시점의 나이\\\"로 획득/입력된 데이터는 진료의 주체의 생일을 이용해 날짜로 변환되어야 함."> + > + ["at0005"] = < + text = <"중증도"> + description = <"문제 또는 진단의 전반적인 중증도 평가."> + comment = <"중증도가 선조합코드로 문제/진단 내에 포함된다면, 이 데이터 엘레먼트는 중복이 됨. 주의 : 더 상세한 중증도 등급은 Specific details SLOT을 이용해 기록할 수 있음."> + > + ["at0009"] = < + text = <"임상적 서술"> + description = <"문제 또는 진단에 대한 서술 기록."> + comment = <"문제와 진단에 대한 진화(evolution)와 에피소드 또는 악화, 경과를 포함한 배경과 문액 그리고 다른 관련된 상세내용을 제공하는데 사용함."> + > + ["at0012"] = < + text = <"신체 위치"> + description = <"문제 또는 진단의 위치를 위해 간단한 신체 위치 확인"> + comment = <"가능하다면, 용어체계를 통한 해부학적 위치의 명칭을 코딩하는 것이 좋음. +이 데이터 엘리먼트에 선조합된 해부학적 위치를 사용. 해부학적 위치를 기록하기 위한 요구사항이 애플리케이션 실행 때 결정되거나 또는 상대적인 위치와 같은 더 복잡한 모델링을 요구한다면, 이 아키타입의 'Structured anatomical location' SLOT 내의 CLUSTER.anatomical_location 또는 CLUSTER.relative_location를 이용. 이 데이터 엘리먼트을 위한 Occurrences는 여러 위치에 생긴 발진(rash)을 기술하는 것과 같은 임상 시나리오를 허용하는데 제한이 없지만 모든 다른 속성(attributes)은 동일해야 함. 해부학적 위치가 문제/진단명에 선조합코드로 포함된다면 이 데이터 엘리먼트는 중복이 됨."> + > + ["at0030"] = < + text = <"완치 날짜/시간"> + description = <"헬스케어 전문가에 의해 결정된 이 문제나 진단의 추정 또는 실제 완치 또는 관해 날짜시간."> + comment = <"부분 날짜는 허용됨. 진료의 주체가 한 살 이하면, 완전한 날짜 또는 달과 년의 하한이 정확한 나이 계산을 위해 필요함 - 예를 들어, 의사결정지원을 사용하는 경우. \\\"임상적으로 인지된 시점의 나이\\\"로 획득/입력된 데이터는 진료의 주체의 생일을 이용해 날짜로 변환되어야 함."> + > + ["at0032"] = < + text = <"Tree"> + description = <"@ internal @"> + > + ["at0039"] = < + text = <"구조화된 신체 위치"> + description = <"문제 또는 진단을 위한 구조화된 해부학적 위치"> + comment = <"해부학적 위치를 기록하기 위한 요구사항이 애플리케이션 실행 때 결정되거나 또는 상대적인 위치와 같은 더 복잡한 모델링을 요구한다면, 이 아키타입의 SLOT에 CLUSTER.anatomical_location 또는 CLUSTER.relative_location를 삽입하여 이용 + +해부학적 위치가 문제/진단명에 선조합코드로 포함된다면 이 슬롯의 사용은 중복이 됨."> + > + ["at0043"] = < + text = <"특정 상세내용"> + description = <"이 문제 또는 진단의 유일한 속성으로 기록하는데 필요한 상세내용."> + comment = <"진단의 단계(grading 또는 staging)에 대한 구조화된 상세내용을 포함할 수 있음; 진단 기준, 분류 기준 또는 이상 상황(Adverse Events)을 위한 공통 용어체계 기준(Common Terminology Criteria)와 같은 정규적인 중등도 평가."> + > + ["at0046"] = < + text = <"상태"> + description = <"진단 과정의 위치-, 도메인-, 에피소드- 또는 워크플로우-특징적인 측면에 대한 구조화된 상세내용."> + comment = <"사용법이 사용하는 곳에서 명확히 정의되지 않으면, 실무에서 다양하게 사용되고 상호운용성을 확신할 수 없는 것과 마찬가지로 진료에서 상태 또는 문맥 한정자를 사용. 예를 들어: 활성 상태(active status) - 활성(active), 비활성(inactive), 치료됨(resolved), 관해 상태(in remission); 진화 상태(evolution status) - 초기(initial), 작업중(interim/working), 완료(final); 시간 상태(temporal status) - 현재(current), 과거(past); 에피소드 상태(episodicity status) - 처음(first), 새로(new), 진행중(ongoing); 입퇴원 상태(admission status) - 입원(admission), 퇴원(discharge); 또는 우선순위 상태(priority status) - 일차(primary), 이차(secondary)."> + > + ["at0047"] = < + text = <"경도"> + description = <"문제나 진단이 정상 활동을 방해하지 않거나 치료하지 않으면 건강에 해를 일으킬 수 있음."> + > + ["at0048"] = < + text = <"중등도"> + description = <"문제나 진단이 정상 활동에 방해가 되거나 치료하지 않으면 건강에 해가 됨."> + > + ["at0049"] = < + text = <"증증도"> + description = <"문제나 진단이 정상 활동을 할 수 없게 하거나 치료하지 않으면 건강에 심각한 해가 됨."> + > + ["at0069"] = < + text = <"코멘트"> + description = <"다른 필드에서 획득되지 않은 문제 또는 진단에 대한 추가적인 서술내용"> + > + ["at0070"] = < + text = <"최종 업데이트 날짜"> + description = <"문제 또는 진단이 최종 업데이트된 날짜."> + > + ["at0071"] = < + text = <"확장"> + description = <"로컬 컨텐트를 획득하거나 다른 참조모델/표기형식과 조율하기 위해 필요한 추가적인 정보."> + comment = <"예: 로컬 정보 요구사항 또는 FHIR 또는 CIMI의 동등한 것과 조율하기위한 추가적인 메타데이터."> + > + ["at0072"] = < + text = <"경과 서술"> + description = <"발병이후 문제 또는 진단의 결과에 대한 서술."> + > + ["at0073"] = < + text = <"진단적 확실성"> + description = <"진단을 확인하는 신뢰의 수준."> + > + ["at0074"] = < + text = <"의심"> + description = <"진단이 낮은 확신 수준으로 식별됨."> + > + ["at0075"] = < + text = <"추정"> + description = <"진단이 높은 확신 수준으로 식별됨."> + > + ["at0076"] = < + text = <"확진"> + description = <"진단이 인정된 기준에 대해 확진됨."> + > + ["at0077"] = < + text = <"발병 날짜/시간"> + description = <"문제/진단의 증상 또는 징후가 처음 관찰된 추정 또는 실제 날짜/시간."> + comment = <"\\\"발병 나이\\\"로 획득/입력된 데이터는 진료의 주체의 생일을 이용해 날짜로 변환되어 함."> + > + > + > + ["fi"] = < + items = < + ["at0000"] = < + text = <"Ongelma/Diagnoosi"> + description = <"Yksityiskohdat yksittäisestä tunnistetusta terveystilasta, vammasta, vammasta tai muusta aiheesta, joka vaikuttaa yksilön fyysiseen, henkiseen ja / tai sosiaaliseen hyvinvointiin."> + 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'.(en)"> + > + ["at0001"] = < + text = <"structure"> + description = <"@ internal @"> + > + ["at0002"] = < + text = <"Ongelman/Diagnoosin nimi"> + description = <"Ongelman tai diagnoosin tunnistaminen nimellä."> + comment = <"*Coding of the name of the problem or diagnosis with a terminology is preferred, where possible.(en)"> + > + ["at0003"] = < + text = <"Toteamispäivämäärä"> + description = <"Arvioitu tai tarkka ajankohta ongelman tai diagnoosin toteamiselle terv.huollon ammattilaisen tekemänä"> + 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.(en)"> + > + ["at0005"] = < + text = <"Vakavuus"> + description = <"Arvioitu vakavuus oireen tai diagnoosin kohdalla"> + 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.(en)"> + > + ["at0009"] = < + text = <"Kliininen kuvaus"> + description = <"Ongelman tai diagnoosin vapaamuotoinen selitys"> + comment = <"*Use to provide background and context, including evolution, episodes or exacerbations, progress and any other relevant details, about the problem or diagnosis.(en)"> + > + ["at0012"] = < + text = <"Kehonosa"> + description = <"Yksinkertaisen vartalokohdan tunnistaminen ongelman tai diagnoosin sijaintia varten."> + 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. + +(en)"> + > + ["at0030"] = < + text = <"Toteamise pvm"> + description = <"ongelman tai diagnoosin arvioitu tai todellinen ratkaisemis- tai loppumispäivämäärä / -aika, jonka on määrittänyt terveydenhuollon ammattilainen."> + 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. +(en)"> + > + ["at0032"] = < + text = <"Tree"> + description = <"@ internal @"> + > + ["at0039"] = < + text = <"Anatominen alue"> + description = <"Ongelman tai diagnoosin anatominen alue"> + comment = <"*Use this SLOT to insert the CLUSTER.anatomical_location or CLUSTER.relative_location archetypes 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. + +If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, use of this SLOT becomes redundant. + +(en)"> + > + ["at0043"] = < + text = <"Tarkennettu tieto"> + description = <"Tiedot, joita tarvitaan lisäksi tämän ongelman tai diagnoosin yksilöivinä ominaisuuksina tallentamiseksi."> + comment = <"*May include structured detail about the grading or staging of the diagnosis; diagnostic criteria, classification criteria or formal severity assessments such as Common Terminology Criteria for Adverse Events.(en)"> + > + ["at0046"] = < + text = <"Status"> + description = <"Jäsennellyt yksityiskohdat diagnosointiprosessin sijainti-, alue-, jakso- tai työnkulkukohtaisista näkökohdista."> + comment = <"*Use status or context qualifiers with care, as they are variably used in practice and interoperability cannot be assured unless usage is clearly defined with the community of use. For example: active status - active, inactive, resolved, in remission; evolution status - initial, interim/working, final; temporal status - current, past; episodicity status - first, new, ongoing; admission status - admission, discharge; or priority status - primary, secondary.(en)"> + > + ["at0047"] = < + text = <"Vähäinen"> + description = <"Ongelma tai diagnoosi ei häiritse normaalia toimintaa tai voi aiheuttaa terveysvaurioita, jos sitä ei hoideta."> + > + ["at0048"] = < + text = <"Kohtalainen"> + description = <"Ongelma tai diagnoosi häiritsee normaalia toimintaa tai vahingoittaa terveyttä, jos sitä jätetään hoitamatta."> + > + ["at0049"] = < + text = <"Vakava"> + description = <"Ongelma tai diagnoosi estää normaalia toimintaa tai vahingoittaa vakavasti terveyttä, jos sitä jätetään hoitamatta."> + > + ["at0069"] = < + text = <"Kommentti"> + description = <"Lisätietoa ongelmasta tai diagnoosista, jota ei voi asettaa edeltäville tietokentille. "> + > + ["at0070"] = < + text = <"Viimeksi päivitetty"> + description = <"Ongelman tai diagnoosin viimeisin päivityspäivämäärä"> + > + ["at0071"] = < + text = <"Laajennus"> + description = <"Additional information required to capture local content or to align with other reference models/formalisms."> + comment = <"*For example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.(en)"> + > + ["at0072"] = < + text = <"Ongelman kulku"> + description = <"Kuvaus ongelman tai diagnoosin etenemisestä alusta."> + > + ["at0073"] = < + text = <"Diagnoosin varmuus"> + description = <"Diagnoosin tunnistamisen luotettavuus"> + > + ["at0074"] = < + text = <"Epäilty"> + description = <"Diagnoosi on tunnistettu alhaisella varmuustasolla."> + > + ["at0075"] = < + text = <"Mahdollinen"> + description = <"Diagnoosi on tunnistettu erittäin varmuudella."> + > + ["at0076"] = < + text = <"Varmistettu"> + description = <"Diagnoosi on vahvistettu tunnustettujen kriteerien perusteella."> + > + ["at0077"] = < + text = <"Alkamis pvm"> + description = <"Arvioitu tai todellinen päivämäärä / aika, jolloin ongelman / diagnoosin merkkejä tai oireita havaittiin ensimmäisen kerran."> + comment = <"*Data captured/imported as \"Age at onset\" should be converted to a date using the subject's date of birth.(en)"> + > + > + > + ["it"] = < + items = < + ["at0000"] = < + text = <"Problema/Diagnosi"> + description = <"Dettagli su una specifica condizione di salute, una lesione, una disabilità o un qualsiasi altro problema individuato su un individuo che abbia un impatto sul benessere fisico, mentale e/o sociale."> + comment = <"Nella pratica, non è facile fare una distinzione netta tra gli ambiti dei concetti 'problema' e 'diagnosi'. Ai fini della documentazione clinica con questo archetipo, problema e diagnosi sono considerati un continuum, con livelli crescenti di dettagli ed evidenze a supporto a supporto dell'etichetta 'diagnosi'."> + > + ["at0001"] = < + text = <"structure"> + description = <"@ internal @"> + > + ["at0002"] = < + text = <"Nome del problema/diagnosi"> + description = <"Nome/identificativo del problema o della diagnosi."> + comment = <"Si preferisce, ove possibile, la codifica del problema o diagnosi con una terminologia."> + > + ["at0003"] = < + text = <"Data/ora di riconoscimento clinico"> + description = <"Data/ora, stimate o effettive, in cui la diagnosi o il problema sono stati riconosciuti da un operatore sanitario."> + comment = <"Sono accettabili le date parziali. Se il soggetto ha età inferiore ad un anno, sono necessari la data completa o almeno il mese e l'anno per permettere un calcolo accurato dell'età - ad esempio, se utilizzato per guidare il supporto decisionale. I dati acquisiti/importati come 'Età al momento del riconoscimento clinico' dovrebbero essere convertiti in una data usando la data di nascita del soggetto."> + > + ["at0005"] = < + text = <"Severità"> + description = <"Una valutazione generale della severità del problema o della diagnosi."> + comment = <"Se la severità è inclusa nel campo 'Nome del problema/diagnosi' attraverso una codifica prestabilita, questo elemento risulta ridondante. Nota: una classificazione più specifica della severità può essere memorizzata usando lo SLOT 'Dettagli specifici'."> + > + ["at0009"] = < + text = <"Descrizione clinica"> + description = <"Descrizione narrativa del problema o della +diagnosi."> + comment = <"Utilizzare questo campo per fornire il background e il contesto, compresa l'evoluzione, gli episodi o le esacerbazioni, i progressi e qualsiasi altro dettaglio rilevante circa il problema o la diagnosi."> + > + ["at0012"] = < + text = <"Sito corporeo"> + description = <"Identificativo di un semplice sito corporeo per per la localizzazione del problema o della diagnosi."> + comment = <"Si preferisce, ove possibile, la codifica del sito anatomico con una terminologia. Utilizzare questo campo per memorizzare posizioni anatomiche precoordinate. Se i requisiti per la registrazione della localizzazione sono determinati in fase di esecuzione dell'applicazione (run-time) o se richiedono una modellazione più complessa, come ad esempio le posizioni relative, allora utilizzare gli archetipi CLUSTER.anatomical_location o CLUSTER.relative_location all'interno dello SLOT di questo archetipo 'Dettagli strutturati del sito corporeo'. Questo campo non ha limite sulle occorrenze per essere adattabile a scenari clinici come la descrizione di un'eruzione cutanea che coinvolge più siti corporei, ma dove tutti gli altri attributi sono identici. Se la posizione anatomica è inclusa nel campo 'Nome del problema/diagnosi attraverso una codifica prestabilita, questo elemento risulta ridondante."> + > + ["at0030"] = < + text = <"Data/ora di risoluzione"> + description = <"Data/ora, stimate o effettive, della risoluzione o remissione del problema o della diagnosi come determinato da un operatore sanitario."> + comment = <"Sono accettabili le date parziali. Se il soggetto ha età inferiore ad un anno, sono necessari la data completa o almeno il mese e l'anno per permettere un calcolo accurato dell'età - ad esempio, se utilizzato per guidare il supporto decisionale. I dati acquisiti/importati come 'Età al momento della risoluzione' dovrebbero essere convertiti in una data usando la data di nascita del soggetto."> + > + ["at0032"] = < + text = <"Tree"> + description = <"@ internal @"> + > + ["at0039"] = < + text = <"Dettagli strutturati del sito corporeo"> + description = <"Una descrizione strutturata della localizzazione anatomica a cui il problema o la diagnosi si riferiscono."> + comment = <"Usare questo SLOT per inserire gli archetipi CLUSTER.anatomical_location o CLUSTER.relative_location se i requisiti per la registrazione della localizzazione sono determinati in fase di esecuzione dell'applicazione (run-time) o se richiedono una modellazione più complessa, come ad esempio per le posizioni relative. Se la posizione anatomica è inclusa nel campo 'Nome del problema/diagnosi attraverso una codifica prestabilita, questo elemento risulta ridondante."> + > + ["at0043"] = < + text = <"Ulteriori dettagli"> + description = <"Ulteriori dettagli richiesti per memorizzare attributi specifici del problema o della diagnosi."> + comment = <"Può includere dettagli strutturati sulla classificazione o la stadiazione della diagnosi; criteri diagnostici, criteri di classificazione o valutazioni formali della severità, come ad esempio CTCAE - Common Terminology Criteria for Adverse Events."> + > + ["at0046"] = < + text = <"Stato"> + description = <"Dettagli strutturati per descrivere aspetti del processo diagnostico specifici in relazione alla localizzazione, dominio, episodio o workflow."> + comment = <"L'uso di qualificatori per indicare lo stato o il contesto dovrebbe essere fatto con attenzione, in quanto il loro utilizzo varia nella pratica e l'interoperabilità non può essere garantita a meno che l'utilizzo di quei codici non sia universalmente accettato dalla comunità. Ad esempio: stato attivo - attivo, inattivo, risolto, in remissione; stato evolutivo - iniziale, intermedio/in progressione, finale; stato temporale - attuale, passato; stato di episodicità - primo, nuovo, in corso; stato di ammissione - ammissione, dimissione; o stato di priorità - primario, secondario. "> + > + ["at0047"] = < + text = <"Lieve"> + description = <"Il problema o la diagnosi non interferiscono con la normale attività o potrebbero causare problemi di salute salute se non trattati."> + > + ["at0048"] = < + text = <"Moderato"> + description = <"Il problema o la diagnosi interferiscono con la normale attività o causerebbero problemi di salute se non trattati."> + > + ["at0049"] = < + text = <"Severo"> + description = <"Il problema o la diagnosi impediscono la normale attività o causerebbero problemi di salute importanti se non trattati."> + > + ["at0069"] = < + text = <"Commento"> + description = <"Informazioni aggiuntive sul problema o diagnosi non catturate in altri campi."> + > + ["at0070"] = < + text = <"Ultimo aggiornamento"> + description = <"La data in cui questo record di Problema/Diagnosi è stato aggiornato l'ultima volta."> + > + ["at0071"] = < + text = <"Estensione"> + description = <"Informazioni aggiuntive necessarie per registrare specifici contenuti locali o per allinearsi con altri modelli/formalismi di riferimento."> + comment = <"Ad esempio: requisiti informativi locali o metadati addizionali per l'allineamento ai corrispondenti modelli FHIR o CIMI."> + > + ["at0072"] = < + text = <"Decorso"> + description = <"Descrizione testuale del decorso del problema o della diagnosi a partire dall'insorgenza."> + > + ["at0073"] = < + text = <"Certezza diagnostica"> + description = <"Grado di certezza nell'identificazione della diagnosi."> + > + ["at0074"] = < + text = <"Sospetto"> + description = <"La diagnosi è identificata con un basso livello di certezza."> + > + ["at0075"] = < + text = <"Probabile"> + description = <"La diagnosi è identificata con un alto livello di certezza."> + > + ["at0076"] = < + text = <"Confermato"> + description = <"La diagnosi è stata confermata in base a criteri riconosciuti."> + > + ["at0077"] = < + text = <"Data/ora di insorgenza"> + description = <"Data/ora, stimate o effettive, in cui sono stati per la prima volta osservati i sintomi del problema/diagnosi."> + comment = <"I dati acquisiti/importati come 'Età al momento dell'insorgenza' dovrebbero essere convertiti in una data usando la data di nascita del soggetto."> + > + > + > + > diff --git a/better-template/src/test/resources/opt_json/Archetypes/openEHR-EHR-INSTRUCTION.service_request.v1.adl b/better-template/src/test/resources/opt_json/Archetypes/openEHR-EHR-INSTRUCTION.service_request.v1.adl new file mode 100644 index 000000000..6e9c219b0 --- /dev/null +++ b/better-template/src/test/resources/opt_json/Archetypes/openEHR-EHR-INSTRUCTION.service_request.v1.adl @@ -0,0 +1,745 @@ +archetype (adl_version=1.4; uid=d7cf88fd-5324-4005-9f1b-d0f4f8e112ba) + openEHR-EHR-INSTRUCTION.service_request.v1 + +concept + [at0000] + +language + original_language = <[ISO_639-1::en]> + translations = < + ["nb"] = < + language = <[ISO_639-1::nb]> + author = < + ["name"] = <"Silje Ljosland Bakke"> + ["organisation"] = <"Nasjonal IKT HF, Norway"> + > + > + ["it"] = < + language = <[ISO_639-1::it]> + author = < + ["name"] = <"Francesca Frexia"> + ["organisation"] = <"CRS4 - Center for advanced studies, research and development in Sardinia, Pula (Cagliari), Italy"> + ["email"] = <"francesca.frexia@crs4.it"> + > + > + > + +description + original_author = < + ["date"] = <"2009-12-08"> + ["name"] = <"Dr Ian McNicoll"> + ["organisation"] = <"Ocean Informatics, United Kingdom"> + ["email"] = <"ian.mcnicoll@oceaninformatics.com"> + > + lifecycle_state = <"published"> + other_contributors = <"Fatima Almeida, Critical SW, Portugal","Tomas Alme, DIPS ASA, Norway","Vebjørn Arntzen, Oslo University Hospital, Norway","Koray Atalag, University of Auckland, New Zealand","Silje Ljosland Bakke, Nasjonal IKT HF, Norway (openEHR Editor)","Lars Bitsch-Larsen, Haukeland University hospital, Norway","Anita Bjørnnes, Helse Bergen, Norway","Lisbeth Dahlhaug, Helse Midt - Norge IT, Norway","Einar Fosse, UNN HF, Norwegian Centre for Integrated Care and Telemedicine, Norway","Hildegard Franke, freshEHR Clinical Informatics Ltd., United Kingdom","Heather Grain, Llewelyn Grain Informatics, Australia","Knut Harboe, Stavanger Universitetssjukehus, Norway","Sam Heard, Ocean Informatics, Australia","Ingrid Heitmann, Oslo universitetssykehus HF, Norway","Andreas Hering, Helse Bergen HF, Haukeland universitetssjukehus, Norway","Anca Heyd, DIPS ASA, Norway","Hilde Hollås, DIPS AS, Norway","Evelyn Hovenga, EJSH Consulting, Australia","Lars Ivar Mehlum, Helse Bergen HF, Norway","Lars Morgan Karlsen, DIPS ASA, Norway","Shinji Kobayashi, Kyoto University, Japan","Heather Leslie, Atomica Informatics, Australia (openEHR Editor)","Hallvard Lærum, Direktoratet for e-helse, Norway","Rose Mari Eikås, Helse Bergen, Norway","Ole Martin Sand, DIPS ASA, Norway","Hildegard McNicoll, freshEHR Clinical Informatics Ltd., United Kingdom","Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (openEHR Editor)","Bjørn Næss, DIPS ASA, Norway","Andrej Orel, Marand d.o.o., Slovenia","Anne Pauline Anderssen, Helse Nord RHF, Norway","Pablo Pazos, CaboLabs.com Health Informatics, Uruguay","Rune Pedersen, Universitetssykehuset i Nord Norge, Norway","Jussara Rotzsch, Hospital Alemão Oswaldo Cruz, Brazil","Line Silsand, Universitetssykehuset i Nord-Norge, Norway","Norwegian Review Summary, Nasjonal IKT HF, Norway","Line Sæle, Nasjonal IKT HF, Norway","Nyree Taylor, Ocean Informatics, Australia","John Tore Valand, Haukeland Universitetssjukehus, Norway (Nasjonal IKT redaktør)","Richard Townley-O'Neill, Australian Digital Health Agency, Australia","Gro-Hilde Ulriksen, Norwegian center for ehealthresearch, Norway"> + details = < + ["nb"] = < + language = <[ISO_639-1::nb]> + purpose = <"Generisk forespørsel om utførelse av en helsetjeneste, til annet helsepersonell eller andre organisasjoner."> + keywords = <"rekvisisjon","bestilling","foreskriving","tjeneste","tjenesteyter","rekvirere","bestille","anmodning","forespørre","forespørsel","anmode","tilsyn"> + copyright = <"© openEHR Foundation, Nasjonal IKT HF"> + use = <"Brukes til å registrere en forespørsel om en helserelatert tjeneste eller aktivitet som skal utføres av en kliniker, organisasjon eller virksomhet. + +Arketypen er designer som et rammeverk som kan brukes som grunnlag for: +- En forespørsel om en helserelatert tjeneste, fra en kliniker eller organisasjon til en annen kliniker eller organisasjon. For eksempel: En henvisning til en spesialist for behandling eller second opinion, ansvarsoverføring til akuttmottaket, monitorering av vitale tegn hver 4. time, eller hjemmesykepleie fra kommunen. +- En forespørsel om oppfølging fra samme kliniker eller organisasjon, for eksempel kontroll på poliklinikk om 6 uker. + +Kliniske brukseksempler: +- Dersom en kliniker setter opp en kontrolltime om 6 uker: \"Tjenestenavn\" settes til \"Kontroll\". Dersom klinikeren skriver inn \"6 uker\" som tid for kontrolltime i brukergrensesnittet, vil det kliniske systemet registrere datoen 6 uker etter registreringsdatoen i elementet \"Dato/tid forfall\". +- Dersom en kliniker setter opp en pasient til \"undervisning om diabetes\" i \"Tjenestenavn\". Verdiene for \"Årsak for forespørsel\" kan være \"Ny diagnose\" og \"Forebygging av ketoacidose\". \"Klinisk indikasjon\" kan være \"Diabetes type 1\", som kan lenkes til en Problem/diagnose og/eller et Laboratorieprøveresultat. Dersom det er nødvendig med et kurs på 4 uker, med 4 ukentlige undervisningsøkter, må en bruke arketypene CLUSTER.service_direction og CLUSTER.timing_nondaily for å registrere kompleks timinginformasjon. +- Dersom en kliniker ordinerer en gjentagende blodprøve, som for eksempel INR: Den komplekse timingen for dette krever bruk av arketypene CLUSTER.service_direction og CLUSTER.timing_nondaily for å definere hver timing i en sekvens, for eksempel \"daglig i en uke, ukentlig i 4 uker, månedlig i 6 måneder\". + +En grunnleggende antagelse for denne arketypen er at den er en forespørsel for én enkelt helsetjeneste. Dersom man trenger en gjentagende tjeneste, kan dette spesifiseres ved å bruke arketypen CLUSTER.service_direction i SLOTet \"Kompleks timing\". + +I mange situasjoner vil det være mulig å registrere stegene som gjennomgås i utførelsen av forespørselen ved hjelp av den generiske arketypen ACTION.service. Imidlertid vil det være mange tilfeller der det vil være behov for en spesifikk ACTION-arketype, for å kunne oppfylle behov om spesifikke dataelementer, registreringsmønstre eller prosesstrinn. Eksempler på dette er ACTION.screening og ACTION.health_education."> + > + ["en"] = < + language = <[ISO_639-1::en]> + purpose = <"Generic request framework for a health-related service or activity to be delivered by a clinician, organisation or agency."> + keywords = <"request","order","service","provide","referral"> + copyright = <"© openEHR Foundation, Nasjonal IKT HF"> + use = <"Use to record a request for a health-related service or activity to be delivered by a clinician, organisation or agency. + +This archetype has been designed as a framework that can be used as the basis for: +- a request from one clinician, organisation or agency to another clinician, organisation or agency for a health-related service. For example: a referral to a specialist clinician for treatment or a second clinical opinion; transfer of care to an emergency department; four hourly vital signs monitoring; and provision of home services from a municipal council; or +- a request for a follow up service to be scheduled for the same clinician, organisation or agency. For example: a review appointment in outpatients in 6 weeks. + +Clinical use cases: +- consider a clinician ordering a follow-up appointment in 6 weeks. 'Follow-up appointment' will be the 'Service name'. If they enter '6 weeks' as the proposed timing for the appointment in the User Interface, the clinical system will record the date six weeks from today in the 'Service due' data element. +- consider a clinician ordering Diabetes Education as the 'Service name'. The values for 'Reason for request' may be 'New diagnosis' and 'Prevention of ketoacidosis'. The 'Clinical indication' will be 'Diabetes Type 1', which may be linked to the Problem Diagnosis and/or Laboratory test results. If a 4 week course is required, with sessions organised at weekly intervals on 4 separate occasions, then the complex timing requires use of the CLUSTER.service_direction and associated CLUSTER.timing_nondaily archetype. +- consider a clinician ordering a recurring blood test, such as an INR. The complex timing for this requires use of the CLUSTER.service_direction and associated CLUSTER.timing_nondaily archetype to define each timing in a sequence of tests, such as 'daily for one week, weekly for 4 weeks, monthly for 6 months'. + +The default assumption for this archetype is that it's a request for a single service. If a series of services are required, use the CLUSTER.service_direction archetype within the 'Complex timing' SLOT. + +In many situations it will be possible to record the steps that occur as part of this request being carried out using the corresponding generic ACTION.service. However, there will be many occasions where the required ACTION archetype will be very specific for purpose, as the data requirements for recording provision of many health-related services will need quite unique data elements, recording patterns or pathway steps. For example: ACTION.screening or ACTION.health_education."> + > + ["it"] = < + language = <[ISO_639-1::it]> + purpose = <"Quadro generico di richiesta per un servizio o un'attività sanitaria che deve essere fornita da un medico, da un'organizzazione o da un'agenzia."> + keywords = <"richiesta, ordine, servizio, fornire, indirizzamento", ...> + use = <"Usato per registrare la richiesta di un servizio o di un'attività sanitaria da parte di un clinico, di un'organizzazione o di un'agenzia. + +Questo archetipo è stato progettato come una cornice che possa essere utilizzata come base per: +- una richiesta da un clinico, organizzazione o agenzia ad un altro clinico, organizzazione o agenzia per un servizio sanitario. Per esempio: la richiesta di un medico specialista per un trattamento o un secondo parere clinico; il trasferimento delle cure a un reparto di emergenza; il monitoraggio dei segni vitali ogni quattro ore; e la fornitura di servizi a domicilio da parte di un consiglio comunale; oppure +- una richiesta di un servizio di follow-up da programmare per lo stesso clinico, organizzazione o agenzia. Ad esempio: un appuntamento di controllo in ambulatorio in 6 settimane. + +Casi d'uso clinico: +- si prenda in considerazione l'idea di un clinico che ordini un appuntamento di follow-up tra 6 settimane. L'\"Appuntamento di follow-up\" sarà il \"Nome del servizio\". Se si inseriscono '6 settimane' come tempistica proposta per l'appuntamento nell'interfaccia utente, il sistema clinico registrerà la data a sei settimane da oggi nell'elemento \"Tempistica per la fornitura del servizio\". +- si consideri un clinico che ordina l'educazione al diabete come 'Nome del servizio'. I valori per 'Motivo della richiesta' possono essere 'Nuova diagnosi' e 'Prevenzione della chetoacidosi'. L'\"Indicazione clinica\" sarà \"Diabete di tipo 1\", che può essere collegato all'archetipo Problem Diagnosis e/o a Laboratory test results. Se è richiesto un corso di 4 settimane, con sessioni organizzate a intervalli settimanali in 4 occasioni separate, allora la complessa tempistica richiede l'uso dell'archetipo CLUSTER.service_direction e dell'associato CLUSTER.timing_nondaily. +- si prenda in considerazione un medico che ordina un esame del sangue ricorrente, come ad esempio un INR. La complessa tempistica per questo richiede l'uso del CLUSTER.service_direction e dell'archetipo CLUSTER.timing_nondaily associato per definire ogni tempistica in una sequenza di test, come ad esempio \"giornalmente per una settimana, settimanalmente per 4 settimane, mensilmente per 6 mesi\". + +Il presupposto di default per questo archetipo è che si tratti di una richiesta per un singolo servizio. Se è richiesta una serie di servizi, utilizzare l'archetipo CLUSTER.service_direction all'interno dello SLOT 'Tempistica Complessa'. + +In molte situazioni sarà possibile registrare i passaggi che si verificano nell'ambito di questa richiesta che viene effettuata utilizzando il corrispondente generico ACTION.service. Tuttavia, ci saranno molte occasioni in cui l'archetipo di ACTION richiesto sarà molto specifico per lo scopo, in quanto i requisiti di dati per la registrazione della fornitura di molti servizi sanitari avranno bisogno di elementi, pattern di registrazione o fasi di percorso piuttosto unici. Ad esempio: ACTION.screening o ACTION. health_education. + + + +"> + > + > + other_details = < + ["licence"] = <"This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/."> + ["custodian_organisation"] = <"openEHR Foundation"> + ["current_contact"] = <"Heather Leslie, Atomica Informatics"> + ["original_namespace"] = <"org.openehr"> + ["original_publisher"] = <"openEHR Foundation"> + ["custodian_namespace"] = <"org.openehr"> + ["MD5-CAM-1.0.1"] = <"79322C35117205D99CB2DD0C4EBF6130"> + ["build_uid"] = <"ab4b237e-21e2-471a-b2e1-7bc34d81cc3f"> + ["revision"] = <"1.0.2"> + > + +definition + INSTRUCTION[at0000] matches { -- Service request + activities cardinality matches {0..*; unordered} matches { + ACTIVITY[at0001] occurrences matches {1..*} matches { -- Current Activity + description matches { + ITEM_TREE[at0009] matches { -- Tree + items cardinality matches {1..*; unordered} matches { + ELEMENT[at0121] matches { -- Service name + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0148] occurrences matches {0..1} matches { -- Service type + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0135] occurrences matches {0..1} matches { -- Description + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0062] occurrences matches {0..*} matches { -- Reason for request + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0064] occurrences matches {0..1} matches { -- Reason description + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0152] occurrences matches {0..*} matches { -- Clinical indication + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0065] occurrences matches {0..*} matches { -- Intent + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0068] occurrences matches {0..1} matches { -- Urgency + value matches { + DV_CODED_TEXT matches { + defining_code matches { + [local:: + at0136, -- Emergency + at0137, -- Urgent + at0138] -- Routine + } + } + DV_TEXT matches {*} + } + } + ELEMENT[at0040] occurrences matches {0..1} matches { -- Service due + value matches { + DV_DATE_TIME matches {*} + DV_INTERVAL matches { + upper matches { + DV_DATE_TIME matches {*} + } + lower matches { + DV_DATE_TIME matches {*} + } + } + DV_TEXT matches {*} + } + } + allow_archetype CLUSTER[at0151] occurrences matches {0..*} matches { -- Complex timing + include + archetype_id/value matches {/openEHR-EHR-CLUSTER\.service_direction(-[a-zA-Z0-9_]+)*\.v0/} + } + ELEMENT[at0145] occurrences matches {0..1} matches { -- Service period start + value matches { + DV_DATE_TIME matches {*} + } + } + ELEMENT[at0144] occurrences matches {0..1} matches { -- Service period expiry + value matches { + DV_DATE_TIME matches {*} + } + } + ELEMENT[at0147] occurrences matches {0..1} matches { -- Indefinite? + value matches { + DV_BOOLEAN matches { + value matches {true} + } + } + } + allow_archetype CLUSTER[at0132] occurrences matches {0..*} matches { -- Specific details + include + archetype_id/value matches {/.*/} + } + allow_archetype CLUSTER[at0149] occurrences matches {0..*} matches { -- Supporting information + include + archetype_id/value matches {/openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v0/} + } + ELEMENT[at0076] occurrences matches {0..1} matches { -- Supplementary information + value matches { + DV_BOOLEAN matches { + value matches {true} + } + } + } + ELEMENT[at0078] occurrences matches {0..1} matches { -- Information description + value matches { + DV_TEXT matches {*} + } + } + allow_archetype CLUSTER[at0116] occurrences matches {0..*} matches { -- Patient requirements + include + archetype_id/value matches {/.*/} + } + ELEMENT[at0150] occurrences matches {0..1} matches { -- Comment + value matches { + DV_TEXT matches {*} + } + } + } + } + } + } + } + protocol matches { + ITEM_TREE[at0008] matches { -- Tree + items cardinality matches {1..*; unordered} matches { + ELEMENT[at0010] occurrences matches {0..1} matches { -- Requester order identifier + value matches { + DV_TEXT matches {*} + DV_IDENTIFIER matches {*} + } + } + allow_archetype CLUSTER[at0141] occurrences matches {0..1} matches { -- Requester + include + archetype_id/value matches {/.*/} + } + ELEMENT[at0011] occurrences matches {0..1} matches { -- Receiver order identifier + value matches { + DV_TEXT matches {*} + DV_IDENTIFIER matches {*} + } + } + allow_archetype CLUSTER[at0142] occurrences matches {0..1} matches { -- Receiver + include + archetype_id/value matches {/.*/} + } + ELEMENT[at0127] occurrences matches {0..1} matches { -- Request status + value matches { + DV_TEXT matches {*} + } + } + allow_archetype CLUSTER[at0128] occurrences matches {0..*} matches { -- Distribution list + include + archetype_id/value matches {/openEHR-EHR-CLUSTER\.distribution\.v1/} + } + allow_archetype CLUSTER[at0112] occurrences matches {0..*} matches { -- Extension + include + archetype_id/value matches {/.*/} + } + } + } + } + } + +ontology + term_definitions = < + ["en"] = < + items = < + ["at0000"] = < + text = <"Service request"> + description = <"Request for a health-related service or activity to be delivered by a clinician, organisation or agency."> + > + ["at0001"] = < + text = <"Current Activity"> + description = <"Current Activity."> + > + ["at0008"] = < + text = <"Tree"> + description = <"@ internal @"> + > + ["at0009"] = < + text = <"Tree"> + description = <"@ internal @"> + > + ["at0010"] = < + text = <"Requester order identifier"> + description = <"The local identifier assigned by the requesting clinical system."> + comment = <"Usually equivalent to the HL7 Placer Order Identifier."> + > + ["at0011"] = < + text = <"Receiver order identifier"> + description = <"The local identifier assigned to the request by the clinician or organisation receiving the request for service."> + comment = <"Usually equivalent to the HL7 Filler Order Identifier."> + > + ["at0040"] = < + text = <"Service due"> + description = <"The date/time, or acceptable interval of date/time, for provision of the service."> + comment = <"This data element allows for recording of the timing for a single service, either as a date and time, a date ranges or a text descriptor which can allow for 'next available. In practice, clinicians will often think in terms of ordering services as approximate timing, for example: review in 3 months, 6 months or 12 months. As clinical systems need more exact parameters to operate on, this '3 months' will usually be converted to an exact date 3 months from the date of recording and stored using this data element. If complex timing or sequences of timings are required, use the CLUSTER.service_direction archetype within the 'Complex timing' SLOT and this data element becomes redundant."> + > + ["at0062"] = < + text = <"Reason for request"> + description = <"A short phrase describing the reason for the request."> + comment = <"Coding of the 'Reason for request' with a coding system is desirable, if available. This data element allows multiple occurrences to enable the user to record a multiple responses, if required. For example: 'manage diabetes complications'."> + > + ["at0064"] = < + text = <"Reason description"> + description = <"Narrative description about the reason for request."> + comment = <"For example: 'The patient's diabetes has recently become more difficult to stabilise and renal function is deteriorating'."> + > + ["at0065"] = < + text = <"Intent"> + description = <"Description of the intent for the request."> + comment = <"For example: a referral to a specialist may have the intent of the specialist taking over responsibility for care of the patient, or it may be to provide a second opinion on treatment options. Coding of the 'Intent' with a coding system is desirable, if available. This data element allows multiple occurrences to enable the user to record a multiple responses, if required."> + > + ["at0068"] = < + text = <"Urgency"> + description = <"Urgency of the request for service."> + comment = <"Specific definitions of emergency and urgent will vary between clinical contexts, clinical systems and the nature of the request itself, so have not been defined in this archetype. If explicit timing is required then the Service period should be clearly stated."> + > + ["at0076"] = < + text = <"Supplementary information"> + description = <"Supplementary information will be following request."> + comment = <"Record as TRUE if additional information has been identified and will be forwarded when available. For example: pending test results."> + > + ["at0078"] = < + text = <"Information description"> + description = <"Description of the supplementary information."> + > + ["at0112"] = < + text = <"Extension"> + description = <"Additional information required to capture local content or to align with other reference models/formalisms."> + comment = <"For example: local information requirements or additional metadata to align with FHIR or CIMI equivalents."> + > + ["at0116"] = < + text = <"Patient requirements"> + description = <"Language, transport or other personal requirements to support the patient's attendance or participation in provision of the service."> + > + ["at0121"] = < + text = <"Service name"> + description = <"The name of the single service or activity requested."> + comment = <"Coding of the 'Service name' with a coding system is desirable, if available. For example: 'referral' to an endocrinologist for diabetes management."> + > + ["at0127"] = < + text = <"Request status"> + description = <"The status of the request for service as indicated by the requester."> + comment = <"Status is used to denote whether this is the initial request, or a follow-up request to change or provide supplementary information. Coding with a terminology is preferred, where possible."> + > + ["at0128"] = < + text = <"Distribution list"> + description = <"Details of additional clinicians, organisations or agencies who require copies of any communication."> + > + ["at0132"] = < + text = <"Specific details"> + description = <"Additional detail about the service requested."> + comment = <"For example: Specimen details for a laboratory test request, or anatomical location for a procedure request."> + > + ["at0135"] = < + text = <"Description"> + description = <"Narrative description about the service requested."> + comment = <"This data point should be used to describe the named service in more detail, including how it should be delivered, patient concerns and issues that might be encountered in delivering the service."> + > + ["at0136"] = < + text = <"Emergency"> + description = <"The request requires immediate attention."> + > + ["at0137"] = < + text = <"Urgent"> + description = <"The request requires prioritised attention."> + > + ["at0138"] = < + text = <"Routine"> + description = <"The request does not require prioritised scheduling."> + > + ["at0141"] = < + text = <"Requester"> + description = <"Details about the clinician or organisation requesting the service."> + > + ["at0142"] = < + text = <"Receiver"> + description = <"Details about the clinician or organisation receiving the request for service."> + > + ["at0144"] = < + text = <"Service period expiry"> + description = <"The date/time that marks the conclusion of the clinically valid period of time for delivery of this service."> + comment = <"This date/time is the equivalent to the latest possible date for service delivery or to the date of expiry for this request. For example: a service may be required to be completed before another event, such as scheduled surgery."> + > + ["at0145"] = < + text = <"Service period start"> + description = <"The date/time that marks the beginning of the valid period of time for delivery of this service."> + comment = <"This date/time is the equivalent to the earliest possible date for service delivery. For example: sometimes a certain amount of time must pass before a service can be performed, for example some procedures can only be performed once the patient has stopped taking medications for a specific amount of time."> + > + ["at0147"] = < + text = <"Indefinite?"> + description = <"The valid period for this request is open ended and has no date of expiry."> + comment = <"Record as TRUE to record explicity that the request has no expiry date. For example: commonly required for a referral to a specialist for long-term or lifelong care."> + > + ["at0148"] = < + text = <"Service type"> + description = <"Category of service requested."> + comment = <"Coding of the 'Service type' with a coding system is desirable, if available. If the 'Service name' was coded, it is possible for this data point to be derived from the code. For example: biochemistry or microbiology laboratory, ultrasound or CT imaging."> + > + ["at0149"] = < + text = <"Supporting information"> + description = <"Digital document, image, video or diagram supplied as additional information to support or inform the request."> + > + ["at0150"] = < + text = <"Comment"> + description = <"Additional narrative about the service request not captured in other fields."> + > + ["at0151"] = < + text = <"Complex timing"> + description = <"Details about a complex service request requiring a sequence of timings."> + comment = <"For example: 'hourly vital signs observations for 4 hours, then 4 hourly for 20 hours' or 'every third Wednesday for 3 visits' or ."> + > + ["at0152"] = < + text = <"Clinical indication"> + description = <"The clinical reason for the ordered service."> + comment = <"Coding of the clinical indication with a terminology is preferred, where possible. This data element allows multiple occurrences. For example: 'Angina' or 'Type 1 Diabetes mellitus'."> + > + > + > + ["nb"] = < + items = < + ["at0000"] = < + text = <"Helsetjenesteforespørsel"> + description = <"Forespørsel om utførelse av en helsetjeneste, til annet helsepersonell eller andre organisasjoner."> + > + ["at0001"] = < + text = <"Forespørsel"> + description = <"Beskrivelse av tjenesten som forespørres."> + > + ["at0008"] = < + text = <"Tree"> + description = <"@ internal @"> + > + ["at0009"] = < + text = <"Tree"> + description = <"@ internal @"> + > + ["at0010"] = < + text = <"Rekvisisjonsidentifikator"> + description = <"Den lokale identifikatoren tilordnet av systemet til den som forespør tjenesten."> + comment = <"Som regel tilsvarende HL7 Placer Order Identifier."> + > + ["at0011"] = < + text = <"Mottakers rekvisisjonsidentifikator"> + description = <"Rekvisisjonens identifikator, tilordnet av den som mottar forespørselen."> + comment = <"Som regel tilsvarende HL7 Filler Order Identifier."> + > + ["at0040"] = < + text = <"Dato/tid forfall"> + description = <"Dato/tid, eller akseptabelt intervall av dato/tid, da tjenesten skal utføres."> + comment = <"Dette dataelementet tillater registrering av timing for én tjeneste, enten som dato/tid, intervall av dato/tid, eller som en tekstbeskrivelsen som kan understøtte \"neste tilgjengelige\". I praksis vil klinikere ofte tenke i omtrentlig timing, for eksempel \"revurdering om 3 måneder, 6 måneder eller 12 måneder. Siden kliniske systemer trenger mer eksakte tidsangivelser, vil \"3 måneder\" som regel konverteres til en eksakt dato 3 måneder fra registreringsdatoen, og lagres i dette dataelementet. Dersom det er behov for kompleks timing eller sekvenser av timing, bruk arketypen CLUSTER.service_direction i SLOTet \"Kompleks timing\". I disse tilfellene blir dette dataelementet redundant."> + > + ["at0062"] = < + text = <"Årsak for forespørsel"> + description = <"En kort beskrivelse av årsaken for forespørselen."> + comment = <"Koding av forespørselsårsaken med et kodeverk er ønskelig, dersom tilgjengelig. Dette dataelementet tillater flere forekomster, for å gjøre det mulig for brukeren å registrere flere svar om nødvendig. For eksempel \"følge opp diabeteskomplikasjoner\"."> + > + ["at0064"] = < + text = <"Årsaksbeskrivelse"> + description = <"Fritekstbeskrivelse av årsaken til forespørselen."> + comment = <"For eksempel \"Pasientens diabetes har i det siste blitt vanskeligere å stabilisere, og nyrefunksjonen er under forverring\"."> + > + ["at0065"] = < + text = <"Hensikt"> + description = <"Beskrivelse av hensikten med forespørselen."> + comment = <"For eksempel kan en henvisning til en spesialist ha som hensikt at spesialisten tar over oppfølgingsansvaret for pasienten, eller det kan være å få en second opinion for behandlingsmuligheteter. Koding av hensikten med et kodeverk er ønskelig, dersom tilgjengelig. Dette dataelementet tillater flere forekomster, for å gjøre det mulig for brukeren å registrere flere svar om nødvendig."> + > + ["at0068"] = < + text = <"Hastegrad"> + description = <"Hastegrad for utførelse av tjenesten."> + comment = <"Spesifikke definisjoner av \"akutt\" og \"haster\" vil variere mellom kliniske settinger, kliniske systemer, og forespørselens natur, og de er derfor ikke definert i arketypen. Dersom det er nødvendig å bruke eksplisitt timing, bør \"Tjenesteintervall\" oppgis."> + > + ["at0076"] = < + text = <"Supplerende informasjon"> + description = <"Supplerende informasjon vil ettersendes forespørselen."> + comment = <"Registrer som SANN dersom ytterligere informasjon er identifisert, og vil bli ettersendt når den er tilgjengelig. For eksempel: ufullstendige prøvesvar."> + > + ["at0078"] = < + text = <"Informasjonsbeskrivelse"> + description = <"Beskrivelse av den supplerende informasjonen."> + > + ["at0112"] = < + text = <"Tilleggsinformasjon"> + description = <"Ytterligere informasjon som trengs for å kunne registrere lokalt definert innhold eller for å tilpasse til andre referansemodeller/formalismer."> + comment = <"For eksempel lokale informasjonsbehov eller ytterligere metadata for å kunne tilpasse til tilsvarende konsepter i FHIR eller CIMI."> + > + ["at0116"] = < + text = <"Pasientens behov"> + description = <"Språk, transport eller andre personlige behov som er nødvendige for å sikre pasientens oppmøte eller deltakelse i utførelsen av den forespurte tjenesten."> + > + ["at0121"] = < + text = <"Tjenestenavn"> + description = <"Navn på forespurt tjeneste."> + comment = <"Koding av tjenestenavnet med et kodeverk er ønskelig, dersom tilgjengelig. For eksempel: \"henvisning\" til en endokrinolog for diabetesoppfølging."> + > + ["at0127"] = < + text = <"Rekvisisjonsstatus"> + description = <"Status for forespørselen oppgitt av rekvirenten."> + comment = <"Status brukes for å vise om dette er den primære forespørselen, en endring eller supplerende informasjon. Koding med en terminologi foretrekkes, der det er mulig."> + > + ["at0128"] = < + text = <"Svarmottakere"> + description = <"En liste over personer eller organisasjoner som bør motta svar på forespørselen."> + > + ["at0132"] = < + text = <"Spesifikke detaljer"> + description = <"Ytterligere detaljer om den forespurte tjenesten."> + comment = <"Eksempel: Detaljer om prøvemateriale for en forespørsel om laboratorieanalyse, eller anatomisk lokalisering for en forespørsel om en prosedyre."> + > + ["at0135"] = < + text = <"Beskrivelse"> + description = <"Fritekstbeskrivelse av tjenesten som forespørres."> + comment = <"Dette dataelementet kan brukes til å beskrive den aktuelle tjenesten i mer detalj, for eksempel hvordan den skal utføres, pasientens egne ønsker, eller problemer man kan støte på under utførelsen."> + > + ["at0136"] = < + text = <"Akutt"> + description = <"Forespørselen krever øyeblikkelig oppmerksomhet."> + > + ["at0137"] = < + text = <"Haster"> + description = <"Forespørselen krever prioritert oppmerksomhet."> + > + ["at0138"] = < + text = <"Rutine"> + description = <"Forespørslene krever ikke prioritert oppmerksomhet."> + > + ["at0141"] = < + text = <"Rekvirent"> + description = <"Detaljer om helsepersonellet eller organisasjonen som har forespurt tjenesten."> + > + ["at0142"] = < + text = <"Mottaker"> + description = <"Detaljer om helsepersonellet eller organisasjonen som mottar tjenesteforespørselen."> + > + ["at0144"] = < + text = <"Tjenesteintervall slutt"> + description = <"Dato/tiden som markerer slutten på tidsintervallet tjenesten kan utføres i."> + comment = <"Denne dato/tiden representerer den seneste datoen/tiden tjenesten kan utføres på. For eksempel i noen tilfeller må en tjeneste være utført før en annen hendelse, f.eks. planlagt kirurgi."> + > + ["at0145"] = < + text = <"Tjenesteintervall start"> + description = <"Dato/tiden som markerer starten på tidsintervallet tjenesten kan utføres i."> + comment = <"Denne dato/tiden representerer den tidligste datoen/tiden tjenesten kan utføres på. For eksempel må noen ganger en viss tid løpe før en tjeneste kan utføres, f.eks. ved noen prosedyrer er en avhengig av at pasienten har seponert legemidler i en periode før prosedyren."> + > + ["at0147"] = < + text = <"Uavgrenset?"> + description = <"Tidsintervallet tjenesten kan utføres i er uavgrenset."> + comment = <"Registreres som SANN for å eksplisitt registrere at forespørselen ikke har noen utløpstid. For eksempel kan dette elementet brukes når det sendes henvisning til en spesialist for langvarig eller livslang oppfølging."> + > + ["at0148"] = < + text = <"Tjenestetype"> + description = <"Kategorisering av den forespurte tjenesten."> + comment = <"Koding av tjenestetypen med et kodeverk er ønskelig, dersom tilgjengelig. Dersom \"Tjenestenavn\" er kodet kan dette elementet i noen tilfeller utledes fra koden. For eksempel klinisk biokjemi eller mikrobiologisk laboratorium, ultralyd eller CT."> + > + ["at0149"] = < + text = <"Understøttende informasjon"> + description = <"Digitalt dokument, bilde, video eller diagram som supplerende informasjon for å understøtte forespørselen."> + > + ["at0150"] = < + text = <"Kommentar"> + description = <"Ytterligere fritekst om tjenesteforespørselen, som ikke er dekket av andre elementer."> + > + ["at0151"] = < + text = <"Kompeks timing"> + description = <"Detaljer om en kompleks tjenesteforespørsel som trenger komplekse timingangivelser."> + comment = <"For eksempel \"vitale observasjoner hver time i 4 timer, deretter hver 4. time i 20 timer\", eller \"hver tredje onsdag, totalt 3 ganger\"."> + > + ["at0152"] = < + text = <"Klinisk indikasjon"> + description = <"Den kliniske årsaken for den forespurte tjenesten."> + comment = <"For eksempel \"angina\" eller \"diabetes mellitus type 1\". Koding av indikasjonen med et kodeverk er ønskelig, dersom tilgjengelig. Dette dataelementet tillater flere forekomster."> + > + > + > + ["it"] = < + items = < + ["at0000"] = < + text = <"Richiesta di un servizio."> + description = <"Richiesta di un servizio o di un'attività sanitaria da parte di un clinico, di un'organizzazione o di un'agenzia."> + > + ["at0001"] = < + text = <"Attività corrente"> + description = <"Attività corrente."> + > + ["at0008"] = < + text = <"Tree"> + description = <"@ internal @"> + > + ["at0009"] = < + text = <"Tree"> + description = <"@ internal @"> + > + ["at0010"] = < + text = <"Identificativo dell'ordine per il richiedente"> + description = <"L'identificativo locale assegnato dal sistema clinico richiedente."> + comment = <"Di solito equivalente a HL7 Placer Order Identifier."> + > + ["at0011"] = < + text = <"Identificativo dell'ordine per il ricevente"> + description = <"L'identificativo locale assegnato alla richiesta dal clinico o dall'organizzazione che riceve la richiesta per il servizio."> + comment = <"Di solito equivalente a HL7 Filler Order Identifier."> + > + ["at0040"] = < + text = <"Tempistica per la fornitura del servizio"> + description = <"La data/ora, o intervallo accettabile di data/ora, per la fornitura del servizio."> + comment = <"Questo dato permette di registrare la tempistica di un singolo servizio, sia come data e ora, sia come intervallo di date o come descrittore testuale che possa consentire l'immediata disponibilità. In pratica, i medici penseranno spesso in termini di ordini di servizi come tempistiche approssimative, ad esempio: revisione in 3 mesi, 6 mesi o 12 mesi. Poiché i sistemi clinici hanno bisogno di parametri più precisi per funzionare, questi \"3 mesi\" saranno di solito convertiti in una data esatta a 3 mesi dalla data di registrazione e memorizzati utilizzando questo dato. Se sono necessari tempi complessi o sequenze di temporizzazioni complesse, utilizzare l'archetipo CLUSTER.service_direction all'interno dello SLOT 'Tempistica Complessa' e questo dato diventa ridondante."> + > + ["at0062"] = < + text = <"Motivo della richiesta"> + description = <"Una breve frase che descriva il motivo della richiesta."> + comment = <"È auspicabile la codifica del \"Motivo della richiesta\" con un sistema di codifica, se disponibile. Questo dato consente di registrare più occorrenze per consentire all'utente di registrare una risposta multipla, se necessario. Ad esempio: \"gestire le complicazioni del diabete\"."> + > + ["at0064"] = < + text = <"Descrizione del motivo"> + description = <"Descrizione narrativa del motivo della richiesta."> + comment = <"Ad esempio: \"Il diabete del paziente è diventato di recente più difficile da stabilizzare e la funzione renale si sta deteriorando\"."> + > + ["at0065"] = < + text = <"Intento"> + description = <"Descrizione dell'intento della richiesta."> + comment = <"Ad esempio: un indirizzamento a uno specialista può avere l'intento di far assumere allo specialista la responsabilità della cura del paziente, oppure può essere quello di fornire una seconda opinione sulle opzioni di trattamento. È auspicabile una codifica dell'\"Intento\" con un sistema di codifica, se disponibile. Questo dato consente di registrare più occorrenze per consentire all'utente di annotare una risposta multipla, se necessario."> + > + ["at0068"] = < + text = <"Urgenza"> + description = <"Urgenza per la richiesta di servizio"> + comment = <"Le definizioni specifiche di emergenza e di urgenza variano a seconda dei contesti clinici, dei sistemi clinici e della natura della richiesta stessa, quindi non sono state definite in questo archetipo. Se è richiesta una tempistica esplicita, allora il periodo di servizio deve essere chiaramente indicato."> + > + ["at0076"] = < + text = <"Informazioni supplementari"> + description = <"Indicazione sul fatto che informazioni supplementari saranno fornite su richiesta."> + comment = <"Registrare come VERO se sono state identificate informazioni aggiuntive che saranno trasmesse quando disponibili. Ad esempio: in attesa dei risultati del test."> + > + ["at0078"] = < + text = <"Descrizione delle informazioni"> + description = <"Descrizione delle informazioni supplementari."> + > + ["at0112"] = < + text = <"Estensione"> + description = <"Informazioni aggiuntive necessarie per rilevare il contenuto locale o per allinearsi con altri modelli/formalismi di riferimento."> + comment = <"Ad esempio: requisiti informativi locali o metadati aggiuntivi per allinearsi agli equivalenti FHIR o CIMI."> + > + ["at0116"] = < + text = <"Requisiti per il paziente"> + description = <"Lingua, trasporto o altre esigenze personali per sostenere la presenza o la partecipazione del paziente alla fornitura del servizio."> + > + ["at0121"] = < + text = <"Nome del servizio"> + description = <"Il nome del singolo servizio o attività richiesti."> + comment = <"È auspicabile la codifica del \"Nome del servizio\" con un sistema di codifica, se disponibile. Ad esempio: 'indirizzamento' a un endocrinologo per la gestione del diabete."> + > + ["at0127"] = < + text = <"Stato della richiesta"> + description = <"Lo stato della richiesta di servizio come indicato dal richiedente."> + comment = <"Lo stato è usato per indicare se questa è la richiesta iniziale, o una richiesta successiva per cambiare o fornire informazioni supplementari. La codifica con una terminologia è preferibile, ove possibile."> + > + ["at0128"] = < + text = <"Lista di distribuzione"> + description = <"Dettagli di altri medici, organizzazioni o agenzie che richiedono copie di qualsiasi comunicazione."> + > + ["at0132"] = < + text = <"Dettagli specifici"> + description = <"Ulteriori dettagli sul servizio richiesto."> + comment = <"Per esempio: Dettagli del campione per una richiesta di test di laboratorio, o la posizione anatomica per una richiesta di procedura."> + > + ["at0135"] = < + text = <"Descrizione"> + description = <"Descrizione narrativa del servizio richiesto."> + comment = <"Questo dato puntuale dovrebbe essere utilizzato per descrivere il servizio in questione in modo più dettagliato, comprese le modalità di erogazione, le preoccupazioni dei pazienti e i problemi che si potrebbero incontrare nell'erogazione del servizio."> + > + ["at0136"] = < + text = <"Emergenza"> + description = <"La richiesta richiede un'attenzione immediata."> + > + ["at0137"] = < + text = <"Urgente"> + description = <"La richiesta richiede un'attenzione prioritaria. "> + > + ["at0138"] = < + text = <"Routine"> + description = <"La richiesta non richiede una programmazione con priorità."> + > + ["at0141"] = < + text = <"Richiedente"> + description = <"Dettagli sul clinico o sull'organizzazione che richiede il servizio."> + > + ["at0142"] = < + text = <"Ricevente"> + description = <"Dettagli sul clinico o sull'organizzazione che riceve la richiesta di servizio."> + > + ["at0144"] = < + text = <"Scadenza del periodo di validità per il servizio"> + description = <"La data/ora che segnano la conclusione del periodo di tempo clinicamente valido per la fornitura di questo servizio."> + comment = <"Questa data/ora equivale all'ultima data possibile per la fornitura del servizio o alla data di scadenza per questa richiesta. Ad esempio: può essere richiesto di completare un servizio prima di un altro evento, come ad esempio un intervento chirurgico programmato."> + > + ["at0145"] = < + text = <"Inizio del periodo del servizio"> + description = <"La data/ora che segna l'inizio del periodo di tempo valido per la fornitura di questo servizio. "> + comment = <"Questa data/ora equivale alla data più vicina possibile per la fornitura del servizio. Ad esempio: a volte deve passare un certo periodo di tempo prima che un servizio possa essere eseguito, ad esempio alcune procedure possono essere eseguite solo dopo che il paziente ha smesso di assumere farmaci per un determinato periodo di tempo."> + > + ["at0147"] = < + text = <"Indefinito?"> + description = <"Il periodo valido per questa richiesta è aperto e non ha data di scadenza."> + comment = <"Registrare come VERO per registrare esplicitamente che la richiesta non ha una data di scadenza. Ad esempio: comunemente richiesto per l'indirizzamento a uno specialista per l'assistenza a lungo termine o per tutta la vita."> + > + ["at0148"] = < + text = <"Tipo di servizio"> + description = <"Categoria di servizio richiesto."> + comment = <"È auspicabile una codifica del \" Tipo di servizio\" con un sistema di codifica, se disponibile. Se il \"Nome del servizio\" è stato codificato, è possibile derivare questo dato dal codice. Ad esempio: laboratorio di biochimica o microbiologia, ecografia o TAC."> + > + ["at0149"] = < + text = <"Informazione di supporto"> + description = <"Documento digitale, immagine, video o diagramma forniti come informazioni aggiuntive per supportare o motivare la richiesta."> + > + ["at0150"] = < + text = <"Commento"> + description = <"Narrativa aggiuntiva sulla richiesta di servizio non acquisita in altri campi."> + > + ["at0151"] = < + text = <"Tempistica complessa"> + description = <"Dettagli su una richiesta di servizio complessa che richiede una sequenza di temporizzazioni."> + comment = <"Per fare un esempio: \"osservazioni orarie dei segni vitali per 4 ore, poi 4 ore per 20 ore\" o \"ogni terzo mercoledì per 3 visite\"."> + > + ["at0152"] = < + text = <"Indicazione clinica"> + description = <"La motivazione clinica del servizio ordinato."> + comment = <"Si preferisce, ove possibile, la codifica dell'indicazione clinica con una terminologia. Questo dato consente più occorrenze. Ad esempio: 'Angina' o 'Diabete mellito di tipo 1'."> + > + > + > + > diff --git a/better-template/src/test/resources/opt_json/Archetypes/openEHR-EHR-OBSERVATION.body_temperature.v2.adl b/better-template/src/test/resources/opt_json/Archetypes/openEHR-EHR-OBSERVATION.body_temperature.v2.adl new file mode 100644 index 000000000..0257452ee --- /dev/null +++ b/better-template/src/test/resources/opt_json/Archetypes/openEHR-EHR-OBSERVATION.body_temperature.v2.adl @@ -0,0 +1,2264 @@ +archetype (adl_version=1.4; uid=fbff84f3-2b33-4245-94f1-6dafe6679c54) + openEHR-EHR-OBSERVATION.body_temperature.v2 + +concept + [at0000] + +language + original_language = <[ISO_639-1::en]> + translations = < + ["de"] = < + language = <[ISO_639-1::de]> + author = < + ["name"] = <"Sebastian Garde"> + ["organisation"] = <"Ocean Informatics"> + > + > + ["ru"] = < + language = <[ISO_639-1::ru]> + author = < + ["name"] = <"Igor Lizunov"> + ["email"] = <"i.lizunov@infinnity.ru"> + > + > + ["sv"] = < + language = <[ISO_639-1::sv]> + author = < + ["name"] = <"Kirsi Poikela"> + ["organisation"] = <"Tieto Sweden AB"> + ["email"] = <"ext.kirsi.poikela@tieto.com"> + > + > + ["fi"] = < + language = <[ISO_639-1::fi]> + author = < + ["name"] = <"Vesa Peltola"> + ["organisation"] = <"Tieto Finland"> + ["email"] = <"vesa.peltola@tieto.com"> + > + > + ["es-ar"] = < + language = <[ISO_639-1::es-ar]> + author = < + ["name"] = <"Domingo Liotta"> + ["organisation"] = <"University of Morón"> + > + accreditation = <"University of Morón"> + > + ["nb"] = < + language = <[ISO_639-1::nb]> + author = < + ["name"] = <"Lars Bitsch-Larsen"> + ["organisation"] = <"Haukeland University Hospital of Bergen, Norway"> + ["email"] = <"lbla@helse-bergen.no + +"> + > + accreditation = <"MD, DEAA, MBA, spec in anesthesia, spec in tropical medicine."> + > + ["pt-br"] = < + language = <[ISO_639-1::pt-br]> + author = < + ["name"] = <"Ana Paula de Andrade"> + ["organisation"] = <"Core Consulting"> + ["email"] = <"ana.andrade@coreconsulting.com.br"> + > + > + ["ja"] = < + language = <[ISO_639-1::ja]> + author = < + ["name"] = <"Shinji Kobayashi"> + ["email"] = <"skoba@moss.gr.jp"> + > + > + ["ar-sy"] = < + language = <[ISO_639-1::ar-sy]> + author = < + ["name"] = <"Mona Saleh"> + > + > + ["fa"] = < + language = <[ISO_639-1::fa]> + author = < + ["name"] = <"Shahla Foozonkhah"> + ["organisation"] = <"Ocean Informatics"> + > + > + ["it"] = < + language = <[ISO_639-1::it]> + author = < + ["name"] = <"Paolo Anedda"> + ["organisation"] = <"Inpeco"> + ["email"] = <"paolo.anedda@inpeco.com"> + > + > + ["es"] = < + language = <[ISO_639-1::es]> + author = < + ["name"] = <"Domingo Liotta"> + ["organisation"] = <"University of Morón"> + > + accreditation = <"University of Morón"> + > + > + +description + original_author = < + ["date"] = <"2004-05-18"> + ["name"] = <"Sam Heard"> + ["organisation"] = <"Ocean Informatics"> + ["email"] = <"sam.heard@oceaninformatics.com"> + > + lifecycle_state = <"published"> + other_contributors = <"Morten Aas, Oslo Universitetssykehus, Norway","Tomas Alme, DIPS ASA, Norway","Erling Are Hole, Helse Bergen, Norway","Vebjørn Arntzen, Oslo universitetssykehus HF, Norway","Silje Ljosland Bakke, Nasjonal IKT HF, Norway (openEHR Editor)","Knut Bernstein","Lars Bitsch-Larsen, Haukeland University Hospital, Bergen, Norway","Shahla Foozonkhah","Einar Fosse, UNN HF, Norwegian Centre for Integrated Care and Telemedicine, Norway","Sebastian Garde","Bjørn Grøva, Helsedirektoratet, Norway","Atle Hansen, Universitetssykehuset Nord-Norge, Norway","Kristian Heldal, Telemark Hospital Trust, Norway","Andreas Hering, Helse Bergen HF, Haukeland universitetssjukehus, Norway","Anca Heyd, DIPS ASA, Norway","Omer Hotomaroglu","Jan Inge Sørheim, Helse Bergen, Haukeland uniersitetssjukehus, Norway","Lars Ivar Mehlum, Helse Bergen HF, Norway","Sundaresan Jaganathan","Heather Leslie, Atomica Informatics, Australia (openEHR Editor)","Hallvard Lærum, Oslo Universitetssykehus HF, Norway","Arne Løberg Sæter, DIPS ASA, Norway","Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (openEHR Editor)","Mette Monsen, Helse Bergen HF, Norway","Hugo Nilssen, UNN HF K3K/Tromsø, Norway","Anne Pauline Anderssen, Helse Nord RHF, Norway","Thomas Schopf, University Hospital of North-Norway, Norway","Ingrid Smith, Helse Bergen, Norway","Line Sæle, Helse Vest IKT, Norway","Micaela Thierley, Helse Bergen, Norway","Nils Thomas Songstad, UNN HF, BUK, Barneavdelingen., Norway","Kevin Thon, SKDE, Norway","John Tore Valand, Haukeland Universitetssjukehus, Norway (Editor)"> + details = < + ["de"] = < + language = <[ISO_639-1::de]> + purpose = <"Zur Messung der Temperatur einer Person - als Surrogat for die Temperatur des gesamten Körpers."> + keywords = <"Temperatur","Körper","Kern","Fieber","Hypothermie","Hyperthermie"> + copyright = <"© openEHR Foundation"> + use = <"Benutzt zur Aufzeichnung der gesamten Körpertemperatur einer Person oder eines Körpers. + + + +Wenn benötigt, können zusätzliche Cluster Archetypen eingefügt werden, um zusätzliche Statusdaten bereitzustellen - darunter Details zu Umgebungsbedingungen, Menstruationszyklus und Betätigung. + + + +Bitte beachten: Die Stelle und Methode der Messung muss ggf. dem Endverbraucher angezeigt werden, um eine präzise Interpretation der gemessenen Temperatur zu ermöglichen."> + misuse = <"Dieser Archetyp soll nicht benutzt werden, um die Messung der Temperatur irgendeines anderen Objekts zu dokumentieren. + + + +Dieser Archetyp soll nicht benutzt werden, um die Temperatur eines Körperteils isoliert zu messen, z. B. die Temperatur an der Fußsohle im Rahmen des Managements von chronischem Diabetes."> + > + ["ru"] = < + language = <[ISO_639-1::ru]> + purpose = <"Для записи измеряемой температуры человека - в качестве суррогата температуры всего тела."> + keywords = <"температура","лихорадка","жар","гипертермия","гипотермия"> + copyright = <"© openEHR Foundation"> + use = <"Используется для записи температуры тела пациента или органа. +Дополнительные кластеры могут быть включены для получения дополнительной информации о состоянии - в том числе условия внешней среды, фаза менструального цикла и другие детали, где это уместно. +Обратите внимание: запись о месте и методе измерения может потребоваться для облегчения точной интерпретации регистрируемой температуры."> + misuse = <"Этот архетип не следует использовать для записи температуры любого другого объекта. +Этот архетип не следует использовать для записи температуры части тела, например, отдельного измерения температуры ступни в лечении больных с диабетической стопой."> + > + ["sv"] = < + language = <[ISO_639-1::sv]> + purpose = <"Att mäta en individs kroppstemperatur som är ett surrogat för kroppens kärntemperatur."> + keywords = <"temperatur","kropp","kärna","feber","hypotermi","hypertermi"> + use = <"Används för att mäta en individs kroppstemperatur som är ett surrogat för individens kärntemperatur. +Ytterligare kluster kan läggas till för ytterligare tillståndsdata såsom miljöförhållanden och detaljer från ansträngningstest där det är lämpligt. + +Observera: Platsen och mätmetoden kan behöva visas för slutanvändaren för att underlätta korrekt tolkning av den uppmätta temperaturen. +"> + misuse = <"Ska inte användas för att mäta temperaturen av något annat föremål. + +Ska inte användas för att mäta temperaturen av en isolerad kroppsdel, exempelvis temperaturen av fotsulan som en del i kronisk diabetesskötsel. +"> + > + ["fi"] = < + language = <[ISO_639-1::fi]> + purpose = <"Henkilön lämpötilan mittaamista varten. "> + keywords = <"lämpötila, kuume, hypotermia, hypertermia", ...> + use = <"Yksilön lämpötilan kirjaamista varten. + +Lisäklustereita voidaan sisällyttää lisätietojen tallentamista varten, mukaan lukien ympäristöolosuhteet ja yksityiskohtaiset rasitustiedot. + +Huomio: Mittauspaikka ja mittaustapa voi olla hyödyllistä näyttää käyttäjälle lämpötilan tarkan tulkinnan helpottamiseksi."> + misuse = <"Tätä arkkityyppiä ei käytetä kuvaamaan minkään muun kohteen kuin potilaan lämpötilaa. + +Tätä arkkityyppiä ei käytetä kehon osan lämpötilan tallentamiseen erillään, esim. jalan pohjan lämpötila osana kroonista diabeteksen hoitoa."> + > + ["nb"] = < + language = <[ISO_639-1::nb]> + purpose = <"Brukes til å registrere et individs målte kroppstemperatur, som uttrykk for kjernetemperaturen."> + keywords = <"temperatur","kropp","kjerne","feber","hypotermi","hypertermi","temperaturmåling","overoppheting","nedkjøling","heteslag"> + copyright = <"© openEHR Foundation"> + use = <"Brukes til å dokumentere et individs kjernetemperatur. Det kan legges til CLUSTERE for å tilføre tillegsinformasjon, inkludert miljømessige forhold (eksponering), detaljer om menstruasjonssyklus og informasjon om fysisk anstrengelse, der hvor dette er relevant. NB: Målemetode og -sted vil ofte måtte vises til sluttbruker for at de dokumenterte temperaturverdiene skal kunne tolkes korrekt."> + misuse = <"Arketypen skal ikke brukes til å registrere andre objekters eller en isolert kroppsdels temperatur."> + > + ["es-ar"] = < + language = <[ISO_639-1::es-ar]> + purpose = <"Registrar la temperatura medida de una persona - como un derivado de la temperatura corporal"> + keywords = <"temperatura","cuerpo","central","fiebre","hipotermia","hipertermia"> + copyright = <"© openEHR Foundation"> + use = <"Usar para registrar la temperatura corporal de una persona o cuerpo. +Clusters adicionales pueden incluirse para proveer datos adicionales de estado - incluyendo condiciones ambientales, detalles del ciclo menstrual y de ejercicio físico, cuando se considera apropiado. +Tener en cuenta: El sitio y el método del registro quizás sea necesario mostrarlo al usuario final, para la adecuada interpretación del registro de temperatura."> + misuse = <"Este arquetipo no debe usarse para registrar la temperatura de cualquier otro objeto. +Este arquetipo no debe usarse para registrar la temperatura de una parte del cuerpo aislado por ej: la temperatura de la planta del pie como parte del manejo de la diabetes crónica."> + > + ["pt-br"] = < + language = <[ISO_639-1::pt-br]> + purpose = <"Registrar a temperatura aferida de uma pessoa - substituto para temperatura corporal central."> + keywords = <"temperatura","corpo","central","febre","hipotermia","hipertermia"> + copyright = <"© openEHR Foundation"> + use = <"Usado para registrar a temperatura corporal de uma pessoa, o qual é um substituto para a temperatura corporal central. +Clusters adicionais podem ser incluídos para fornecer dados adicionais - incluindo as condições ambientais e detalhes de esforço, quando apropriado. + +Observação: O local e método de gravação podem precisar ser exibidos ao usuário final para facilitar a interpretação exata da temperatura registrada."> + misuse = <"Esse arquétipo não pode ser usado para registrar a temperatura de qualquer outro objeto. +Esse arquétipo não pode ser usado para registrar a temperatura de uma parte do corpo isoladamente, por exemplo, temperatura da sola do pé, como parte do controle de diabetes crônica."> + > + ["ja"] = < + language = <[ISO_639-1::ja]> + purpose = <"全身の温度の代用として計測された人の体温を記録する。"> + keywords = <"*temperature(en)","*body(en)","*core(en)","*fever(en)","*hypothermia(en)","*hyperthermia(en)"> + use = <"人や体の全体の温度を記録するために用いられる。 +さらに状態データを表すために、追加のクラスタを内包することもできる。たとえば、環境条件や、月経周期の詳細、労作についての詳細を必要に応じて内包する。 +注意：計測された温度を正確に解釈するためにエンドユーザーに記録方法や部位を示す必要があるかもしれません。"> + misuse = <"このアーキタイプは、人体以外の温度を計測するためには用いられない。 +このアーキタイプは、身体において独立した一部の温度を記録するためには用いられない。たとえば、糖尿病の慢性期管理の一貫として、測定の温度を計測すること。"> + > + ["ar-sy"] = < + language = <[ISO_639-1::ar-sy]> + purpose = <"لتسجيل درجة الحرارة التي تم قياسها للشخص - كبديل عن درجة حرارة الجسم كله"> + keywords = <"الحرارة","الجسم","اللُّب","الحمى","انخفاض الحرارة","فرط الحرارة"> + copyright = <"© openEHR Foundation"> + use = <"يستخدم لتسجيل حرارة جميع الجسم للشخص أو الجثة. +يمكن تضمين عناقيد أخرى للإمداد بالمزيد من تفاصيل الحالة - بما في ذلك العوامل البيئية, تفاصيل الدورة الشهرية, تفاصيل المجهود, حيثما تطلب الأمر. +الرجاء ملاحظة: قد يكون من الواجب عرض هذا الموقع و طريقة التسجيل للمستخدِم النهائي لتسهيل التفسير الدقيق للحرارة التي يتم تسجيلها."> + misuse = <"هذا النموذج لا يستخدم لتسجيل حرارة أي شيئ آخر. +هذا النموذج لا يستخدم لتسجيل الحرارة لجزء معزول من الجسم, مثلا حرارة أخمص القدم كجزء من التدبير العلاجي لمرض السكري المزمن."> + > + ["en"] = < + language = <[ISO_639-1::en]> + purpose = <"To record the measured temperature of a person - as a surrogate for the core body temperature."> + keywords = <"temperature","body","core","fever","hypothermia","hyperthermia"> + copyright = <"© openEHR Foundation"> + use = <"Used for recording the measurement of an individual's body temperature, which is a surrogate for the core body temperature of the individual. + +Additional clusters can be included to provide additional state data - including environmental conditions and exertion details, where appropriate. + +Please Note: The site and method of recording may need to be displayed to the end user to facilitate accurate interpretation of the temperature recorded."> + misuse = <"This archetype is not to be used to record the temperature of any other object. + +This archetype is not to be used to record the temperature of a part of the body in isolation e.g. temperature of the sole of the foot as a part of chronic diabetes management."> + > + ["fa"] = < + language = <[ISO_639-1::fa]> + purpose = <"برای ثبت اندازه گیری دمای بدن یک فرد بکار می رود- به عنوان جایگزینی برای دمای کل بدن"> + keywords = <"دما","بدن","مرکز","تب","کاهش دمای بدن","افزایش دمای بدن"> + copyright = <"© openEHR Foundation"> + use = <"برای ثبت دمای کل بدن فرد یا بدن استفاده می شود . خوشه‌های اضافی، برای در بر گرفتن داده‌های حالت بیشتر، شامل شرایط محیطی ، جزییات عادت ماهیانه و جزییات جنب و جوش فرد، هر جا که مناسب باشند، می‌توانند گنجانده شوند. +لطفا توجه داشته باشید که برای تسهیل در تفسیر صحیح دما ثبت شده، توسط کاربر نهایی ممکن است که نمایش محل و روش ثبت لازم باشد"> + misuse = <"این الگو ساز جهت ثبت دما اشیا دیگر بکار نمی رود . +این الگو ساز جهت ثبت دمای بخشهایی از بدن - +به عنوان مثال دمای کف پا به عنوان بخشی از پایش دیابت مزمن- بصورت جداگانه استفاده نمی شود + "> + > + ["it"] = < + language = <[ISO_639-1::it]> + purpose = <"Registrare la temperatura misurata di una persona - come surrogato della temperatura del corpo centrale."> + keywords = <"temperatura, corpo, tronco, febbre, ipotermia, ipertermia", ...> + use = <" +Utilizzato per registrare la misurazione della temperatura corporea di un individuo, che è un indicatore della temperatura corporea interna dell'individuo. + +Possono essere inclusi ulteriori cluster per fornire dati aggiuntivi sullo stato - comprese le condizioni ambientali e i dettagli dello stato di fatica, se del caso. + +Nota: il sito e il metodo di registrazione potrebbero dover essere visualizzati all'utente finale per facilitare l'interpretazione accurata della temperatura registrata."> + misuse = <"Questo archetipo non deve essere usato per registrare la temperatura di alcun altro oggetto. + +Questo archetipo non deve essere usato per registrare la temperatura di una parte del corpo in isolamento, ad esempio la temperatura della pianta del piede come parte della gestione del diabete cronico"> + > + ["es"] = < + language = <[ISO_639-1::es]> + purpose = <"Registrar la temperatura medida de una persona - como un derivado de la temperatura corporal"> + keywords = <"temperatura","cuerpo","central","fiebre","hipotermia","hipertermia"> + copyright = <"© openEHR Foundation"> + use = <"Usar para registrar la temperatura corporal de una persona o cuerpo. +Clusters adicionales pueden incluirse para proveer datos adicionales de estado - incluyendo condiciones ambientales, detalles del ciclo menstrual y de ejercicio físico, cuando se considera apropiado. +Tener en cuenta: El sitio y el método del registro quizás sea necesario mostrarlo al usuario final, para la adecuada interpretación del registro de temperatura."> + misuse = <"Este arquetipo no debe usarse para registrar la temperatura de cualquier otro objeto. +Este arquetipo no debe usarse para registrar la temperatura de una parte del cuerpo aislado por ej: la temperatura de la planta del pie como parte del manejo de la diabetes crónica."> + > + > + other_details = < + ["licence"] = <"This work is licensed under the Creative Commons Attribution-ShareAlike 3.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/3.0/."> + ["custodian_organisation"] = <"Nasjonal IKT"> + ["references"] = <"Body temperature, Deprecated archetype [Internet]. openEHR Foundation, openEHR Clinical Knowledge Manager [cited: 2018-01-11]. Available from: http://openehr.org/ckm/#showArchetype_1013.1.49"> + ["current_contact"] = <"Heather Leslie, Atomica Informatics"> + ["original_namespace"] = <"org.openehr"> + ["original_publisher"] = <"openEHR Foundation"> + ["custodian_namespace"] = <"no.nasjonalikt"> + ["MD5-CAM-1.0.1"] = <"A6618A05BBB42A6FCB5DFACFAD13C7A6"> + ["build_uid"] = <"fef1bf11-ab52-41bd-904d-4877acf06d1c"> + ["ip_acknowledgements"] = <"This artefact includes content from SNOMED Clinical Terms® (SNOMED CT®) which is copyrighted material of the International Health Terminology Standards Development Organisation (IHTSDO). Where an implementation of this artefact makes use of SNOMED CT content, the implementer must have the appropriate SNOMED CT Affiliate license - for more information contact http://www.snomed.org/snomed-ct/get-snomedct or info@snomed.org."> + ["revision"] = <"2.0.4"> + > + +definition + OBSERVATION[at0000] matches { -- Body temperature + data matches { + HISTORY[at0002] matches { -- History + events cardinality matches {1..*; unordered} matches { + EVENT[at0003] occurrences matches {0..*} matches { -- Any event + data matches { + ITEM_TREE[at0001] matches { -- Tree + items cardinality matches {1..*; unordered} matches { + ELEMENT[at0004] matches { -- Temperature + value matches { + C_DV_QUANTITY < + property = <[openehr::127]> + list = < + ["1"] = < + units = <"Cel"> + magnitude = <|0.0..<100.0|> + precision = <|1|> + > + ["2"] = < + units = <"[degF]"> + magnitude = <|30.0..<200.0|> + precision = <|1|> + > + > + > + } + } + ELEMENT[at0063] occurrences matches {0..1} matches { -- Comment + value matches { + DV_TEXT matches {*} + } + } + } + } + } + state matches { + ITEM_TREE[at0029] matches { -- State + items cardinality matches {0..*; ordered} matches { + ELEMENT[at0030] occurrences matches {0..1} matches { -- Body exposure + value matches { + DV_CODED_TEXT matches { + defining_code matches { + [local:: + at0031, -- Naked + at0032, -- Reduced clothing/bedding + at0033, -- Appropriate clothing/bedding + at0034; -- Increased clothing/bedding + at0033] + } + } + DV_TEXT matches {*} + } + } + ELEMENT[at0041] occurrences matches {0..1} matches { -- Description of thermal stress + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0065] occurrences matches {0..1} matches { -- Current day of menstrual cycle + value matches { + DV_COUNT matches { + magnitude matches {|>=1|} + } + } + } + allow_archetype CLUSTER[at0056] occurrences matches {0..*} matches { -- Environmental conditions + include + archetype_id/value matches {/openEHR-EHR-CLUSTER\.environmental_conditions\.v1|openEHR-EHR-CLUSTER\.environmental_conditions\.v0|openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1/} + } + allow_archetype CLUSTER[at0057] occurrences matches {0..1} matches { -- Exertion + include + archetype_id/value matches {/openEHR-EHR-CLUSTER\.level_of_exertion\.v1|openEHR-EHR-CLUSTER\.level_of_exertion\.v0/} + } + } + } + } + } + } + } + } + protocol matches { + ITEM_TREE[at0020] matches { -- Protocol + items cardinality matches {0..*; ordered} matches { + ELEMENT[at0021] occurrences matches {0..1} matches { -- Location of measurement + value matches { + DV_CODED_TEXT matches { + defining_code matches { + [local:: + at0025, -- Rectum + at0024, -- Axilla + at0023, -- Ear canal + at0061, -- Forehead + at0022, -- Mouth + at0026, -- Nasopharynx + at0027, -- Urinary bladder + at0028, -- Intravascular + at0043, -- Skin + at0051, -- Vagina + at0054, -- Oesophagus + at0055, -- Inguinal skin crease + at0060] -- Temple + } + } + DV_TEXT matches {*} + } + } + allow_archetype CLUSTER[at0064] occurrences matches {0..*} matches { -- Structured measurement location + include + archetype_id/value matches {/openEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1/} + } + allow_archetype CLUSTER[at0059] occurrences matches {0..1} matches { -- Device + include + archetype_id/value matches {/openEHR-EHR-CLUSTER\.device\.v1/} + } + allow_archetype CLUSTER[at0062] occurrences matches {0..*} matches { -- Extension + include + archetype_id/value matches {/.*/} + } + } + } + } + } + +ontology + terminologies_available = <"LNC205","SNOMED-CT"> + term_definitions = < + ["ar-sy"] = < + items = < + ["at0000"] = < + text = <"درجة حرارة الجسم"> + description = <"قياس لدرجة حرارة الجسم, و التي تحل كبديل لدرجة الحرارة الكلية لجسم الشخص"> + > + ["at0001"] = < + text = <"مُفرَد"> + description = <"*"> + > + ["at0002"] = < + text = <"*History(en)"> + description = <"*@ internal @(en)"> + > + ["at0003"] = < + text = <"*Any event(en)"> + description = <"*Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.(en)"> + > + ["at0004"] = < + text = <"درجة الحرارة"> + description = <"درجة الحرارة التي تم قياسها - كبديل عن الجسم الكلي"> + > + ["at0020"] = < + text = <"*Protocol(en)"> + description = <"*@ internal @(en)"> + > + ["at0021"] = < + text = <"*Location of measurement(en)"> + description = <"*The anatomical site of measurement of the temperature.(en)"> + > + ["at0022"] = < + text = <"الفم"> + description = <"يتم قياس الحرارة في داخل الفم"> + > + ["at0023"] = < + text = <"قناة الأذن"> + description = <"يتم قياس درجة الحرارة من داخل القناة السمعية الخارجية"> + > + ["at0024"] = < + text = <"الإبط"> + description = <"يتم قياس درجة الحرارة من بشرة/ جلد الإبط في حالة وضع الذراع جانبا و هو متجه إلى أسفل"> + > + ["at0025"] = < + text = <"المستقيم"> + description = <"درجة الحرارة التي يتم قياسها في داخل المستقيم"> + > + ["at0026"] = < + text = <"البلعوم الأنفي"> + description = <"درجة الحرارة التي يتم قياسها من داخل البلعوم الأنفي"> + > + ["at0027"] = < + text = <"المثانة البولية"> + description = <"يتم قياس درجة الحرارة من داخل المثانة البولية"> + > + ["at0028"] = < + text = <"داخل الأوعية الدموية"> + description = <"يتم قياس درجة الحرارة من داخل الجهاز الدوري - الأوعية الدموية"> + > + ["at0029"] = < + text = <"الحالة"> + description = <"معلومات حول حالة المريض"> + > + ["at0030"] = < + text = <"تَعَرُّض الجسم"> + description = <"الموقف الحراري للشخص الذي يتم قياس درجة حرارته"> + > + ["at0031"] = < + text = <"مُعرَّى"> + description = <"لا يوجد ملابس أو شراشف أو غطاء"> + > + ["at0032"] = < + text = <"ملابس/ شراشف خفيفة"> + description = <"الشخص مُغَطَّى بكمية من الملابس أو الشراشف أقل من تلك المناسبة للظروف البيئية المحيطة"> + > + ["at0033"] = < + text = <"ملابس/شراشف مناسبة"> + description = <"الشخص مُغَطَّى بكمية من الملابس أو الشراشف المناسبة للظروف البيئية المحيطة"> + > + ["at0034"] = < + text = <"ملابس/شراشف زائدة"> + description = <"الشخص مُغَطَّى بكمية زائدة من الملابس/ الشراشف المناسبة للظروف البيئية المحيطة"> + > + ["at0041"] = < + text = <"وصف الضغط الحرارة"> + description = <"وصف للظروف المُطبَّقة على المريض و التي قد تؤثر على درجة الحرارة التي يتم قياسها"> + > + ["at0043"] = < + text = <"الجلد/ البشرة"> + description = <"يتم قياس درجة الحرارة من الجلد المُعَرَّض/ المكشوف"> + > + ["at0051"] = < + text = <"المهبل"> + description = <"يتم قياس درجة الحرارة من داخل المهبل"> + > + ["at0054"] = < + text = <"المريئ"> + description = <"يتم قياس درجة الحرارة من داخل المريئ"> + > + ["at0055"] = < + text = <"غضن الجلد عند الأربتين"> + description = <"يتم قياس درجة الحرارة عند غضن الجلد بين الأربتين - بين الرجل و جدار البطن"> + > + ["at0056"] = < + text = <"*Environmental conditions(en)"> + description = <"*Details about the environmental conditions at the time of temperature measurement.(en)"> + > + ["at0057"] = < + text = <"المجهود"> + description = <"تفاصيل حول المجهود الذي يقوم به الشخص في وقت قياس درجة الحرارة"> + > + ["at0059"] = < + text = <"الجهيزة"> + description = <"تفاصيل حول الجهيزة المستخدمة لقياس درجة حرارة الجسم"> + > + ["at0060"] = < + text = <"*Tinning(en)"> + description = <"*Temperatur målt i tinningen over arteria temporalis.(en)"> + > + ["at0061"] = < + text = <"*Panne(en)"> + description = <"*Temperatur målt i pannen.(en)"> + > + ["at0062"] = < + text = <"*Extension(en)"> + description = <"*Additional information required to capture local content or to align with other reference models/formalisms.(en)"> + comment = <"*e.g. Local information requirements or additional metadata to align with FHIR or CIMI equivalents.(en)"> + > + ["at0063"] = < + text = <"*Comment(en)"> + description = <"*Additional comment about the body temperature measurement not captured in other fields.(en)"> + > + ["at0064"] = < + text = <"*Structured measurement location(en)"> + description = <"*Structured anatomical location of where the measurement was taken.(en)"> + > + ["at0065"] = < + text = <"*Current day of menstrual cycle(en)"> + description = <"*Number of days since onset of last normal menstrual period.(en)"> + > + > + > + ["ru"] = < + items = < + ["at0000"] = < + text = <"Температура тела"> + description = <"Измерение температуры тела, которая является суррогатом температуры тела человека в целом."> + > + ["at0001"] = < + text = <"*Single(en)"> + description = <"**(en)"> + > + ["at0002"] = < + text = <"*History(en)"> + description = <"*@ internal @(en)"> + > + ["at0003"] = < + text = <"*Any event(en)"> + description = <"*Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.(en)"> + > + ["at0004"] = < + text = <"Температура(ru)"> + description = <"Измеряется температура тела (как суррогат для всего тела)."> + > + ["at0020"] = < + text = <"*Protocol(en)"> + description = <"*@ internal @(en)"> + > + ["at0021"] = < + text = <"*Location of measurement(en)"> + description = <"*The anatomical site of measurement of the temperature.(en)"> + > + ["at0022"] = < + text = <"Рот"> + description = <"Температура измеряется в ротовой полости."> + > + ["at0023"] = < + text = <"Наружный слуховой проход"> + description = <"Температура измеряется в наружном слуховом проходе."> + > + ["at0024"] = < + text = <"Подмышечная впадина"> + description = <"Температура измеряется в кожной складке в подмышечной впадине, рука опущена вниз и прижата к туловищу."> + > + ["at0025"] = < + text = <"Прямая кишка"> + description = <"Температура измеряется внутри прямой кишки."> + > + ["at0026"] = < + text = <"Носоглотка"> + description = <"Температура измеряется в носоглотке."> + > + ["at0027"] = < + text = <"Мочевой пузырь"> + description = <"Температура измеряется внутри мочевого пузыря."> + > + ["at0028"] = < + text = <"Внутрисосудистая"> + description = <"Температура измеряется внутри сосоудистого русла."> + > + ["at0029"] = < + text = <"Состояние"> + description = <"Информация о состоянии пациента."> + > + ["at0030"] = < + text = <"*Body exposure(en)"> + description = <"*The thermal situation of the person who is having the temperature taken(en)"> + > + ["at0031"] = < + text = <"Обнажён"> + description = <"Без одежды, ничем не укрыт."> + > + ["at0032"] = < + text = <"Лёгкая одежда/постель"> + description = <"На пациенте меньшее количество одежды / постельных принадлежностей, чем этого требуют условия внешней среды."> + > + ["at0033"] = < + text = <"Соответствующая одежда/постель"> + description = <"Одежда/постельные принадлежности пациента соответствуют условиям внешней среды."> + > + ["at0034"] = < + text = <"Теплая одежда/постель"> + description = <"На пациенте большее количество одежды / постельных принадлежностей, чем этого требуют условия внешней среды."> + > + ["at0041"] = < + text = <"Тепловой стресс"> + description = <"Описание особенностей, которые могут повлиять на результат измерения температуры тела."> + > + ["at0043"] = < + text = <"Кожа"> + description = <"Температура измеряется на поверхности кожи."> + > + ["at0051"] = < + text = <"Влагалище"> + description = <"Температура измеряется внутри влагвалища."> + > + ["at0054"] = < + text = <"Пищевод"> + description = <"Температура измеряется внитри пищевода."> + > + ["at0055"] = < + text = <"Паховая складка"> + description = <"Температура измеряется в паховой складке кожи между ногой и передней брюшной стенкой."> + > + ["at0056"] = < + text = <"*Environmental conditions(en)"> + description = <"*Details about the environmental conditions at the time of temperature measurement.(en)"> + > + ["at0057"] = < + text = <"Нагрузка"> + description = <"Подробная информация о нагрузках в момент измерения температуры."> + > + ["at0059"] = < + text = <"Устройство"> + description = <"Информация об устройстве, используемом для измерения температуры тела."> + > + ["at0060"] = < + text = <"*Tinning(en)"> + description = <"*Temperatur målt i tinningen over arteria temporalis.(en)"> + > + ["at0061"] = < + text = <"*Panne(en)"> + description = <"*Temperatur målt i pannen.(en)"> + > + ["at0062"] = < + text = <"*Extension(en)"> + description = <"*Additional information required to capture local content or to align with other reference models/formalisms.(en)"> + comment = <"*e.g. Local information requirements or additional metadata to align with FHIR or CIMI equivalents.(en)"> + > + ["at0063"] = < + text = <"*Comment(en)"> + description = <"*Additional comment about the body temperature measurement not captured in other fields.(en)"> + > + ["at0064"] = < + text = <"*Structured measurement location(en)"> + description = <"*Structured anatomical location of where the measurement was taken.(en)"> + > + ["at0065"] = < + text = <"*Current day of menstrual cycle(en)"> + description = <"*Number of days since onset of last normal menstrual period.(en)"> + > + > + > + ["nb"] = < + items = < + ["at0000"] = < + text = <"Kroppstemperatur"> + description = <"Måling av kroppstemperatur som skal gjenspeile et individs kjernetemperatur."> + > + ["at0001"] = < + text = <"*Single(en)"> + description = <"**(en)"> + > + ["at0002"] = < + text = <"*History(en)"> + description = <"*@ internal @(en)"> + > + ["at0003"] = < + text = <"Uspesifisert hendelse"> + description = <"Standard, uspesifisert tidspunkt eller tidsintervall som kan defineres mer eksplisitt i en template eller i en applikasjon."> + > + ["at0004"] = < + text = <"Temperatur"> + description = <"Målt kroppstemperatur som uttrykk for kjernetemperatur."> + > + ["at0020"] = < + text = <"*Protocol(en)"> + description = <"*@ internal @(en)"> + > + ["at0021"] = < + text = <"Målested"> + description = <"Det anatomiske målestedet for måling av temperatur."> + > + ["at0022"] = < + text = <"Munn"> + description = <"Temperatur målt i munnhulen (under tungen)."> + > + ["at0023"] = < + text = <"Øre"> + description = <"Temperatur målt ved infrarød stråling fra trommehinnen i ytre ørekanal."> + > + ["at0024"] = < + text = <"Armhule"> + description = <"Temperatur er målt i armhulen med armen posisjonert ned langs siden."> + > + ["at0025"] = < + text = <"Endetarm"> + description = <"Temperatur målt i endetarm (rektum)."> + > + ["at0026"] = < + text = <"Nesesvelg"> + description = <"Temperatur målt i nesesvelget (nasofarynks)."> + > + ["at0027"] = < + text = <"Urinblære"> + description = <"Temperatur målt i urinblære."> + > + ["at0028"] = < + text = <"Intravaskulært"> + description = <"Temperatur målt intravaskulært."> + > + ["at0029"] = < + text = <"Tilstanden"> + description = <"Informasjon om tilstanden til en pasient."> + > + ["at0030"] = < + text = <"Kroppseksponering"> + description = <"Grad av tildekking av individet da temperaturen ble målt."> + > + ["at0031"] = < + text = <"Naken"> + description = <"Ingen klær eller tildekking"> + > + ["at0032"] = < + text = <"Redusert påkledning/tildekking"> + description = <"Individet er mindre påkledt eller tildekket enn temperaturen i omgivelsene skulle tilsi."> + > + ["at0033"] = < + text = <"Passende påkleding/tildekking"> + description = <"Individet er passende påkledt eller tildekket i forhold til hva temperaturen i omgivelsene skulle tilsi."> + > + ["at0034"] = < + text = <"Økt påkledning/tildekking"> + description = <"Individet er mer påkledt eller tildekket enn temperaturen i omgivelsene skulle tilsi."> + > + ["at0041"] = < + text = <"Aktiv temperaturpåvirkning"> + description = <"Beskrivelse av aktive tiltak som påvirker den målte kroppstemperaturen, f.eks. bruk av varmeteppe, kalde omslag, isbad eller hjerte/lungemaskin ved oppvarming av hypotermiske pasienter."> + > + ["at0043"] = < + text = <"Hud"> + description = <"Temperaturen målt på eksponert hud."> + > + ["at0051"] = < + text = <"Skjede"> + description = <"Temperatur målt i skjeden (vagina)."> + > + ["at0054"] = < + text = <"Spiserør"> + description = <"Temperatur målt i spiserøret (øsofagus)."> + > + ["at0055"] = < + text = <"Lyske"> + description = <"Temperatur målt i lysken."> + > + ["at0056"] = < + text = <"Detaljer om temperaturpåvirkning"> + description = <"Detaljer om omgivelser eller midler for aktiv temperaturpåvirkning da temperaturen ble målt."> + > + ["at0057"] = < + text = <"Fysisk anstrengelse"> + description = <"Detaljer om anstrengelse/aktivitet hos individet da temperaturen ble målt."> + > + ["at0059"] = < + text = <"Måleinstrument"> + description = <"Detaljer om måleinstrumentet som ble brukt til å måle temperaturen."> + > + ["at0060"] = < + text = <"Tinning"> + description = <"Temperatur målt i tinningen over arteria temporalis."> + > + ["at0061"] = < + text = <"Panne"> + description = <"Temperatur målt på pannen."> + > + ["at0062"] = < + text = <"Tilleggsinformasjon"> + description = <"Ytterligere informasjon som trengs for å kunne registrere lokalt definert innhold eller for å tilpasse til andre referansemodeller/formalismer."> + comment = <"For eksempel lokale informasjonsbehov eller ytterligere metadata for å kunne tilpasse til tilsvarende konsepter i FHIR eller CIMI."> + > + ["at0063"] = < + text = <"Kommentar"> + description = <"Ytterligere beskrivelse av målingen av kroppstemperatur som ikke dekkes i andre felt."> + > + ["at0064"] = < + text = <"Strukturert målested"> + description = <"Strukturert anatomisk lokalisering der målingen ble utført."> + > + ["at0065"] = < + text = <"Menstruasjonssyklusdag"> + description = <"Antall dager siden forrige normale menstruasjon startet."> + > + > + > + ["es-ar"] = < + items = < + ["at0000"] = < + text = <"Temperatura Corporal"> + description = <"La medición de la temperatura corporal, que deriva en la temperatura de todo el cuerpo de una persona."> + > + ["at0001"] = < + text = <"Aislado"> + description = <"Registro aislado de la temperatura."> + > + ["at0002"] = < + text = <"*History(en)"> + description = <"*@ internal @(en)"> + > + ["at0003"] = < + text = <"*Any event(en)"> + description = <"*Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.(en)"> + > + ["at0004"] = < + text = <"Temperatura"> + description = <"La temperatura corporal medida (representa la temperatura de todo el cuerpo)."> + > + ["at0020"] = < + text = <"*Protocol(en)"> + description = <"*@ internal @(en)"> + > + ["at0021"] = < + text = <"*Location of measurement(en)"> + description = <"*The anatomical site of measurement of the temperature.(en)"> + > + ["at0022"] = < + text = <"Boca"> + description = <"Temperatura bucal."> + > + ["at0023"] = < + text = <"Canal auditivo"> + description = <"La temperatura se mide en el canal auditivo externo."> + > + ["at0024"] = < + text = <"Axila"> + description = <"La temperatura se mide en el hueco axilar con el brazo posicionado al costado del cuerpo."> + > + ["at0025"] = < + text = <"Recto"> + description = <"Temperatura rectal."> + > + ["at0026"] = < + text = <"Nasofaríngeo"> + description = <"La temperatura se mide dentro de la nasofaringe."> + > + ["at0027"] = < + text = <"Vejiga urinaria"> + description = <"La temperatura se mide en la vejiga urinaria."> + > + ["at0028"] = < + text = <"Intravascular"> + description = <"La temperatura se mide dentro del sistema vascular."> + > + ["at0029"] = < + text = <"Estado"> + description = <"Estado de la información del paciente."> + > + ["at0030"] = < + text = <"Exposición corporal"> + description = <"La situación térmica de la persona al cual se le registra la temperatura."> + > + ["at0031"] = < + text = <"Desnudo"> + description = <"Sin ropas, sabanas o coberturas."> + > + ["at0032"] = < + text = <"Ropas/lecho reducidas"> + description = <"La persona esta cubierto por una cantidad menor de ropas o sabanas que lo considerado apropiado para las circunstancias ambientales."> + > + ["at0033"] = < + text = <"Ropas/lecho apropiadas"> + description = <"La persona esta cubierta por una adecuada cantidad de ropas o sabanas, que lo considerado apropiado para las circunstancias ambientales."> + > + ["at0034"] = < + text = <"Ropas/lecho aumentado"> + description = <"La persona se encuentra cubierto por una cantidad incrementada de ropas o sabanas que lo considerado apropiado para las circunstancias ambientales."> + > + ["at0041"] = < + text = <"Descripción de estrés térmico"> + description = <"Descripción de las condiciones que le suceden al sujeto que puede influenciar la temperatura corporal medida."> + > + ["at0043"] = < + text = <"Piel"> + description = <"La temperatura se mide sobre la piel expuesta."> + > + ["at0051"] = < + text = <"Vagina"> + description = <"Temperatura vaginal."> + > + ["at0054"] = < + text = <"Esófago"> + description = <"Temperatura se mide dentro del esófago."> + > + ["at0055"] = < + text = <"Pliegue inguinal"> + description = <"La temperatura se mide en el pliegue inguinal entre el muslo y la pared abdominal."> + > + ["at0056"] = < + text = <"*Environmental conditions(en)"> + description = <"*Details about the environmental conditions at the time of temperature measurement.(en)"> + > + ["at0057"] = < + text = <"Ejercicio"> + description = <"Detalles sobre la actividad física de la persona al momento de la medición de la temperatura."> + > + ["at0059"] = < + text = <"Dispositivo"> + description = <"Detalles sobre el dispositivo usado para medir la temperatura corporal."> + > + ["at0060"] = < + text = <"*Tinning(en)"> + description = <"*Temperatur målt i tinningen over arteria temporalis.(en)"> + > + ["at0061"] = < + text = <"*Panne(en)"> + description = <"*Temperatur målt i pannen.(en)"> + > + ["at0062"] = < + text = <"*Extension(en)"> + description = <"*Additional information required to capture local content or to align with other reference models/formalisms.(en)"> + comment = <"*e.g. Local information requirements or additional metadata to align with FHIR or CIMI equivalents.(en)"> + > + ["at0063"] = < + text = <"*Comment(en)"> + description = <"*Additional comment about the body temperature measurement not captured in other fields.(en)"> + > + ["at0064"] = < + text = <"*Structured measurement location(en)"> + description = <"*Structured anatomical location of where the measurement was taken.(en)"> + > + ["at0065"] = < + text = <"*Current day of menstrual cycle(en)"> + description = <"*Number of days since onset of last normal menstrual period.(en)"> + > + > + > + ["fa"] = < + items = < + ["at0000"] = < + text = <"دمای بدن"> + description = <"اندازه گیری دمای بدن که جایگزینی برای دمای کل بدن فرد است"> + > + ["at0001"] = < + text = <"منفرد"> + description = <"*"> + > + ["at0002"] = < + text = <"*History(en)"> + description = <"*@ internal @(en)"> + > + ["at0003"] = < + text = <"*Any event(en)"> + description = <"*Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.(en)"> + > + ["at0004"] = < + text = <"دما"> + description = <"دمای اندازه گیری شده از بدن (به عنوان جایگزینی برای کل بدن)٬"> + > + ["at0020"] = < + text = <"*Protocol(en)"> + description = <"*@ internal @(en)"> + > + ["at0021"] = < + text = <"*Location of measurement(en)"> + description = <"*The anatomical site of measurement of the temperature.(en)"> + > + ["at0022"] = < + text = <"ماه"> + description = <"دما در عرض یک ماه اندازه گیری می شود"> + > + ["at0023"] = < + text = <"کانال گوش"> + description = <"دما از طریق کانال شنوایی خارجی اندازه گیری می شود"> + > + ["at0024"] = < + text = <"زیر بغل"> + description = <"دما از طریق پوستی و در زیر بغل، بصورتی که بازو پایین و در کنار بدن باشد، اندازه گیری می شود"> + > + ["at0025"] = < + text = <"مقعد"> + description = <"دما از طریق مقعد اندازه گیری می شود"> + > + ["at0026"] = < + text = <"بینی حلقی"> + description = <"دما از طریق بینی حلقی اندازه گیری می شود"> + > + ["at0027"] = < + text = <"مثانه"> + description = <"دما از طریق مثانه اندازه گیری می شود"> + > + ["at0028"] = < + text = <"داخل عروقی"> + description = <"دما از طریق سیستم عروقی اندازه گیری می شود"> + > + ["at0029"] = < + text = <"حالت"> + description = <"اطلاعات حالت بیمار"> + > + ["at0030"] = < + text = <"نحوه پوشش بدن"> + description = <"وضعیت گرمایی (به لحاظ پوشش) فردی که دمایش گرفته شده است"> + > + ["at0031"] = < + text = <"لخت"> + description = <"بدون لباس ، ملافه و یا پوشش +"> + > + ["at0032"] = < + text = <"لباس و یا ملافه کم"> + description = <"فرد با مقدار لباس و یا ملافه کمتر از حد مناسب با شرایط محیطی پوشانده شده است"> + > + ["at0033"] = < + text = <"لباس یا ملافه مناسب"> + description = <"فرد با لباس و یا ملافه مناسب با شرایط محیطی پوشانده شده است"> + > + ["at0034"] = < + text = <"لباس و یا ملافه زیاد"> + description = <"فرد با مقدار لباس و یا ملافه بیشتر از حد مناسب با شرایط محیطی پوشانده شده است"> + > + ["at0041"] = < + text = <"توصیف استرسهای گرمایی"> + description = <"توصیف شرایط اعمال شده به شخص که ممکن است اندازه گیری دمای بدن فرد را تحت تاثیر قرار دهد"> + > + ["at0043"] = < + text = <"پوست"> + description = <"دما از طریق پوست بدن اندازه گیری می شود"> + > + ["at0051"] = < + text = <"مهبل"> + description = <"دما از طریق داخل مهبل اندازه گیری می شود"> + > + ["at0054"] = < + text = <"مری"> + description = <"دما از طریق داخل مری اندازه گیری می شود"> + > + ["at0055"] = < + text = <"چین پوستی کشاله رانی"> + description = <"دما از طریق چین پوستی کشاله ران بین ران و دیواره شکم اندازه گیری می شود"> + > + ["at0056"] = < + text = <"*Environmental conditions(en)"> + description = <"*Details about the environmental conditions at the time of temperature measurement.(en)"> + > + ["at0057"] = < + text = <"جنب و جوش"> + description = <"جزییاتی در مورد جنب و جوش فرد در زمان اندازه گیری دما "> + > + ["at0059"] = < + text = <"تجهیز"> + description = <"جزییاتی در موردتجهیزات استفاده شده در اندازه گیری دمای بدن"> + > + ["at0060"] = < + text = <"*Tinning(en)"> + description = <"*Temperatur målt i tinningen over arteria temporalis.(en)"> + > + ["at0061"] = < + text = <"*Panne(en)"> + description = <"*Temperatur målt i pannen.(en)"> + > + ["at0062"] = < + text = <"*Extension(en)"> + description = <"*Additional information required to capture local content or to align with other reference models/formalisms.(en)"> + comment = <"*e.g. Local information requirements or additional metadata to align with FHIR or CIMI equivalents.(en)"> + > + ["at0063"] = < + text = <"*Comment(en)"> + description = <"*Additional comment about the body temperature measurement not captured in other fields.(en)"> + > + ["at0064"] = < + text = <"*Structured measurement location(en)"> + description = <"*Structured anatomical location of where the measurement was taken.(en)"> + > + ["at0065"] = < + text = <"*Current day of menstrual cycle(en)"> + description = <"*Number of days since onset of last normal menstrual period.(en)"> + > + > + > + ["pt-br"] = < + items = < + ["at0000"] = < + text = <"Temperatura Corporal"> + description = <"Registrar a temperatura aferida de uma pessoa - substituto para temperatura corporal central."> + > + ["at0001"] = < + text = <"Single"> + description = <"*"> + > + ["at0002"] = < + text = <"History"> + description = <"@ internal @"> + > + ["at0003"] = < + text = <"Qualquer evento"> + description = <"Padrão, ponto indeterminado no tempo ou evento intervalar que pode ser explicitamente definido em um template ou em tempo de execução."> + > + ["at0004"] = < + text = <"Temperatura"> + description = <"A temperatura corporal aferida (como substituta para temperatura corporal central)."> + > + ["at0020"] = < + text = <"Protocol"> + description = <"@ internal @"> + > + ["at0021"] = < + text = <"Local de aferição"> + description = <"Local anatômico de aferição da temperatura"> + > + ["at0022"] = < + text = <"Boca"> + description = <"A temperatura é aferida no interior da boca."> + > + ["at0023"] = < + text = <"Canal auditivo"> + description = <"A temperatura é aferida no canal auditivo externo."> + > + ["at0024"] = < + text = <"Axilla"> + description = <"A temperatura é aferida na pele da axila com o braço posicionado ao lado do corpo."> + > + ["at0025"] = < + text = <"Reto"> + description = <"A temperatura é aferida no reto."> + > + ["at0026"] = < + text = <"Nasofaringe"> + description = <"A temperatura é aferida dentro da nasofaringe."> + > + ["at0027"] = < + text = <"Bexiga"> + description = <"A temperatura é aferida na bexiga."> + > + ["at0028"] = < + text = <"Intravascular"> + description = <"A temperatura é aferida no sistema vascular."> + > + ["at0029"] = < + text = <"Estado"> + description = <"Informações sobre o estado do paciente."> + > + ["at0030"] = < + text = <"Exposição do corpo"> + description = <"O grau de exposição do indivíduo no momento da medição."> + > + ["at0031"] = < + text = <"Despido"> + description = <"Sem roupas, camisola ou capa."> + > + ["at0032"] = < + text = <"Vestuário reduzido"> + description = <"A pessoa está vestida com quantidade de roupa ou lençóis menor do que a apropriada para as circunstâncias ambientais."> + > + ["at0033"] = < + text = <"Apropriadamente vestido"> + description = <"A pessoa está coberta por uma quantidade de roupa ou lençóis considerada apropriada para as circunstâncias ambientais."> + > + ["at0034"] = < + text = <"Excessivamente vestido"> + description = <"A pessoa está coberta por uma quantidade de roupas ou lençóis maior do que a apropriada para as circunstâncias ambientais."> + > + ["at0041"] = < + text = <"Descrição de estresse térmico"> + description = <"Descrição das condições aplicadas ao sujeito que possa influenciar a aferição de sua temperatura corporal."> + > + ["at0043"] = < + text = <"Pele"> + description = <"A temperatura é aferida a partir da pele exposta."> + > + ["at0051"] = < + text = <"Vagina"> + description = <"A temperatura é aferida no interior da vagina."> + > + ["at0054"] = < + text = <"Esôfago"> + description = <"A temperatura é aferida no esôfago."> + > + ["at0055"] = < + text = <"Região inguinal"> + description = <"A temperatura é medida no sulco inguinal da pele entre a perna e a parede abdominal."> + > + ["at0056"] = < + text = <"Condições ambientais"> + description = <"Detalhes sobre as condições ambientais no momento da aferição de temperatura."> + > + ["at0057"] = < + text = <"Esforço"> + description = <"Detalhes sobre esforço que a pessoa fez no momento da aferição da temperatura."> + > + ["at0059"] = < + text = <"Dispositivo"> + description = <"Detalhes sobre o dispositivo utilizado para medir a temperatura corporal."> + > + ["at0060"] = < + text = <"Têmpora"> + description = <"A temperatura é medida na têmpora, sobre a artéria temporal superficial."> + > + ["at0061"] = < + text = <"Testa"> + description = <"A temperatura é aferida na testa."> + > + ["at0062"] = < + text = <"Extensão"> + description = <"Informações adicionais necessárias para capturar conteúdo local ou para alinhar com outros modelos de referência/formalismos."> + comment = <"Por exemplo, requisitos locais de informações ou metadados adicionais para alinhar com FHIR ou outras iniciativas de modelagem de informações clínicas. +"> + > + ["at0063"] = < + text = <"Comentário"> + description = <"Comentário adicional sobre a aferição de temperatura não capturado em outros campos."> + > + ["at0064"] = < + text = <"Localização estruturada de aferição"> + description = <"Localização anatômica estruturada de onde a medição foi feita."> + > + ["at0065"] = < + text = <"Dia atual do ciclo menstrual"> + description = <"Número de dias desde o início do último período menstrual normal."> + > + > + > + ["en"] = < + items = < + ["at0000"] = < + text = <"Body temperature"> + description = <"A measurement of the body temperature, which is a surrogate for the core body temperature of the individual."> + > + ["at0001"] = < + text = <"Tree"> + description = <"@ internal @"> + > + ["at0002"] = < + text = <"History"> + description = <"@ internal @"> + > + ["at0003"] = < + text = <"Any event"> + description = <"Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time."> + > + ["at0004"] = < + text = <"Temperature"> + description = <"The measured body temperature (as a surrogate for the core of the body)."> + > + ["at0020"] = < + text = <"Protocol"> + description = <"@ internal @"> + > + ["at0021"] = < + text = <"Location of measurement"> + description = <"The anatomical site of measurement of the temperature."> + > + ["at0022"] = < + text = <"Mouth"> + description = <"Temperature is measured within the mouth."> + > + ["at0023"] = < + text = <"Ear canal"> + description = <"Temperature is measured from within the external auditory canal."> + > + ["at0024"] = < + text = <"Axilla"> + description = <"Temperature is measured from the skin of the axilla with the arm positioned down by the side."> + > + ["at0025"] = < + text = <"Rectum"> + description = <"Temperature measured within the rectum."> + > + ["at0026"] = < + text = <"Nasopharynx"> + description = <"Temperature is measured within the nasopharynx."> + > + ["at0027"] = < + text = <"Urinary bladder"> + description = <"Temperature is measured in the urinary bladder."> + > + ["at0028"] = < + text = <"Intravascular"> + description = <"Temperature is measured within the vascular system."> + > + ["at0029"] = < + text = <"State"> + description = <"State information about the patient."> + > + ["at0030"] = < + text = <"Body exposure"> + description = <"The degree of exposure of the individual at the time of measurement."> + > + ["at0031"] = < + text = <"Naked"> + description = <"No clothing, bedding or covering."> + > + ["at0032"] = < + text = <"Reduced clothing/bedding"> + description = <"The person is covered by a lesser amount of clothing or bedding than deemed appropriate for the environmental circumstances."> + > + ["at0033"] = < + text = <"Appropriate clothing/bedding"> + description = <"The person is covered by an amount of clothing or bedding deemed appropriate for the environmental circumstances."> + > + ["at0034"] = < + text = <"Increased clothing/bedding"> + description = <"The person is covered by an increased amount of clothing or bedding than deemed appropriate for the environmental circumstances."> + > + ["at0041"] = < + text = <"Description of thermal stress"> + description = <"Description of the conditions applied to the subject that might influence their measured body temperature."> + > + ["at0043"] = < + text = <"Skin"> + description = <"Temperature is measured from exposed skin."> + > + ["at0051"] = < + text = <"Vagina"> + description = <"Temperature is measured within the vagina."> + > + ["at0054"] = < + text = <"Oesophagus"> + description = <"Temperatue is measured within the oesophagus."> + > + ["at0055"] = < + text = <"Inguinal skin crease"> + description = <"Temperature is measured in the inguinal skin crease between the leg and abdominal wall."> + > + ["at0056"] = < + text = <"Environmental conditions"> + description = <"Details about the environmental conditions at the time of temperature measurement."> + > + ["at0057"] = < + text = <"Exertion"> + description = <"Details about the exertion of the person at the time of temperature measurement."> + > + ["at0059"] = < + text = <"Device"> + description = <"Details about the device use to measure body temperature."> + > + ["at0060"] = < + text = <"Temple"> + description = <"Temperature is measured at the temple, over the superficial temporal artery."> + > + ["at0061"] = < + text = <"Forehead"> + description = <"Temperature is measured on the forehead."> + > + ["at0062"] = < + text = <"Extension"> + description = <"Additional information required to capture local content or to align with other reference models/formalisms."> + comment = <"e.g. Local information requirements or additional metadata to align with FHIR or CIMI equivalents."> + > + ["at0063"] = < + text = <"Comment"> + description = <"Additional comment about the body temperature measurement not captured in other fields."> + > + ["at0064"] = < + text = <"Structured measurement location"> + description = <"Structured anatomical location of where the measurement was taken."> + > + ["at0065"] = < + text = <"Current day of menstrual cycle"> + description = <"Number of days since onset of last normal menstrual period."> + > + > + > + ["de"] = < + items = < + ["at0000"] = < + text = <"Körpertemperatur"> + description = <"Eine Messung der Körpertemperatur an einer bestimmten Stelle als Surrogat für den gesamten Körper der Person."> + > + ["at0001"] = < + text = <"Single"> + description = <"*"> + > + ["at0002"] = < + text = <"History"> + description = <"@ internal @"> + > + ["at0003"] = < + text = <"*Any event(en)"> + description = <"*Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.(en)"> + > + ["at0004"] = < + text = <"Temperatur"> + description = <"Die gemessene Körpertemperatur (als Surrogat für den gesamten Körper)."> + > + ["at0020"] = < + text = <"Protocol"> + description = <"@ internal @"> + > + ["at0021"] = < + text = <"*Location of measurement(en)"> + description = <"*The anatomical site of measurement of the temperature.(en)"> + > + ["at0022"] = < + text = <"Mund"> + description = <"Messung der Temperatur im Mund."> + > + ["at0023"] = < + text = <"Ohrenkanal"> + description = <"Messung der Temperatur innerhalb des äußeren Gehörgangs."> + > + ["at0024"] = < + text = <"Achselhöhle"> + description = <"Messung der Temperatur an der Haut der Achselhöhle mit seitlich angelegtem Arm."> + > + ["at0025"] = < + text = <"Rektum"> + description = <"Messung der Temperatur innerhalb des Rektums."> + > + ["at0026"] = < + text = <"Nasopharynx"> + description = <"Messung der Temperatur innerhalb des Nasopharynxs (Nasenrachens)."> + > + ["at0027"] = < + text = <"Harnblase"> + description = <"Messung der Temperatur in der Harnblase."> + > + ["at0028"] = < + text = <"Intravaskulär"> + description = <"Messung der Temperatur innerhalb des vaskulären Systems."> + > + ["at0029"] = < + text = <"Status"> + description = <"Statusinformationen über die Person."> + > + ["at0030"] = < + text = <"Körperexposition"> + description = <"Die thermale Situation der Person, deren Temperatur gemessen wird."> + > + ["at0031"] = < + text = <"Nackt"> + description = <"Keine Kleidung, Bettzeug oder andere Bedeckung."> + > + ["at0032"] = < + text = <"Verminderte Kleidung/Bettzeug"> + description = <"Die Person wird bedeckt von einer geringeren Menge an Kleidung oder Bettzeug als für die Umgebungsbedingungen angemessen erscheint."> + > + ["at0033"] = < + text = <"Angemessene Kleidung/Bettzeug"> + description = <"Die Person wird bedeckt von einer Menge an Kleidung oder Bettzeug, die den Umgebungsbedingungen angemessen erscheint."> + > + ["at0034"] = < + text = <"Erhöhte Kleidung/Bettzeug"> + description = <"Die Person wird bedeckt von einer größeren Menge an Kleidung oder Bettzeug als für die Umgebungsbedingungen angemessen erscheint."> + > + ["at0041"] = < + text = <"Beschreibung der Wärmebelastung"> + description = <"Beschreibung von Bedingungen, denen die Person ausgesetzt ist, welche die gemessene Körpertemperatur beeinflussen könnten."> + > + ["at0043"] = < + text = <"Haut"> + description = <"Messung der Temperatur an freiliegender Haut."> + > + ["at0051"] = < + text = <"Vagina"> + description = <"Messung der Temperatur innerhalb der Vagina."> + > + ["at0054"] = < + text = <"Oesophagus"> + description = <"Messung der Temperatur innerhalb des Oesophagus."> + > + ["at0055"] = < + text = <"Inguinale Hautfalte"> + description = <"Messung der Temperatur in der inguinalen Hautfalte zwischen Bein und Abdominalwand."> + > + ["at0056"] = < + text = <"*Environmental conditions(en)"> + description = <"*Details about the environmental conditions at the time of temperature measurement.(en)"> + > + ["at0057"] = < + text = <"Betätigung"> + description = <"Details über die Betätigung der Person zum Zeitpunkt der Messung der Temperatur."> + > + ["at0059"] = < + text = <"Gerät"> + description = <"Details über das Gerät, das zur Temperaturmessung benutzt wurde."> + > + ["at0060"] = < + text = <"*Tinning(en)"> + description = <"*Temperatur målt i tinningen over arteria temporalis.(en)"> + > + ["at0061"] = < + text = <"*Panne(en)"> + description = <"*Temperatur målt i pannen.(en)"> + > + ["at0062"] = < + text = <"*Extension(en)"> + description = <"*Additional information required to capture local content or to align with other reference models/formalisms.(en)"> + comment = <"*e.g. Local information requirements or additional metadata to align with FHIR or CIMI equivalents.(en)"> + > + ["at0063"] = < + text = <"*Comment(en)"> + description = <"*Additional comment about the body temperature measurement not captured in other fields.(en)"> + > + ["at0064"] = < + text = <"*Structured measurement location(en)"> + description = <"*Structured anatomical location of where the measurement was taken.(en)"> + > + ["at0065"] = < + text = <"*Current day of menstrual cycle(en)"> + description = <"*Number of days since onset of last normal menstrual period.(en)"> + > + > + > + ["es"] = < + items = < + ["at0000"] = < + text = <"Temperatura Corporal"> + description = <"La medición de la temperatura corporal, que deriva en la temperatura de todo el cuerpo de una persona."> + > + ["at0001"] = < + text = <"Aislado"> + description = <"Registro aislado de la temperatura."> + > + ["at0002"] = < + text = <"*History(en)"> + description = <"*@ internal @(en)"> + > + ["at0003"] = < + text = <"*Any event(en)"> + description = <"*Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.(en)"> + > + ["at0004"] = < + text = <"Temperatura"> + description = <"La temperatura corporal medida (representa la temperatura de todo el cuerpo)."> + > + ["at0020"] = < + text = <"*Protocol(en)"> + description = <"*@ internal @(en)"> + > + ["at0021"] = < + text = <"*Location of measurement(en)"> + description = <"*The anatomical site of measurement of the temperature.(en)"> + > + ["at0022"] = < + text = <"Boca"> + description = <"Temperatura bucal."> + > + ["at0023"] = < + text = <"Canal auditivo"> + description = <"La temperatura se mide en el canal auditivo externo."> + > + ["at0024"] = < + text = <"Axila"> + description = <"La temperatura se mide en el hueco axilar con el brazo posicionado al costado del cuerpo."> + > + ["at0025"] = < + text = <"Recto"> + description = <"Temperatura rectal."> + > + ["at0026"] = < + text = <"Nasofaríngeo"> + description = <"La temperatura se mide dentro de la nasofaringe."> + > + ["at0027"] = < + text = <"Vejiga urinaria"> + description = <"La temperatura se mide en la vejiga urinaria."> + > + ["at0028"] = < + text = <"Intravascular"> + description = <"La temperatura se mide dentro del sistema vascular."> + > + ["at0029"] = < + text = <"Estado"> + description = <"Estado de la información del paciente."> + > + ["at0030"] = < + text = <"Exposición corporal"> + description = <"La situación térmica de la persona al cual se le registra la temperatura."> + > + ["at0031"] = < + text = <"Desnudo"> + description = <"Sin ropas, sabanas o coberturas."> + > + ["at0032"] = < + text = <"Ropas/lecho reducidas"> + description = <"La persona esta cubierto por una cantidad menor de ropas o sabanas que lo considerado apropiado para las circunstancias ambientales."> + > + ["at0033"] = < + text = <"Ropas/lecho apropiadas"> + description = <"La persona esta cubierta por una adecuada cantidad de ropas o sabanas, que lo considerado apropiado para las circunstancias ambientales."> + > + ["at0034"] = < + text = <"Ropas/lecho aumentado"> + description = <"La persona se encuentra cubierto por una cantidad incrementada de ropas o sabanas que lo considerado apropiado para las circunstancias ambientales."> + > + ["at0041"] = < + text = <"Descripción de estrés térmico"> + description = <"Descripción de las condiciones que le suceden al sujeto que puede influenciar la temperatura corporal medida."> + > + ["at0043"] = < + text = <"Piel"> + description = <"La temperatura se mide sobre la piel expuesta."> + > + ["at0051"] = < + text = <"Vagina"> + description = <"Temperatura vaginal."> + > + ["at0054"] = < + text = <"Esófago"> + description = <"Temperatura se mide dentro del esófago."> + > + ["at0055"] = < + text = <"Pliegue inguinal"> + description = <"La temperatura se mide en el pliegue inguinal entre el muslo y la pared abdominal."> + > + ["at0056"] = < + text = <"*Environmental conditions(en)"> + description = <"*Details about the environmental conditions at the time of temperature measurement.(en)"> + > + ["at0057"] = < + text = <"Ejercicio"> + description = <"Detalles sobre la actividad física de la persona al momento de la medición de la temperatura."> + > + ["at0059"] = < + text = <"Dispositivo"> + description = <"Detalles sobre el dispositivo usado para medir la temperatura corporal."> + > + ["at0060"] = < + text = <"*Tinning(en)"> + description = <"*Temperatur målt i tinningen over arteria temporalis.(en)"> + > + ["at0061"] = < + text = <"*Panne(en)"> + description = <"*Temperatur målt i pannen.(en)"> + > + ["at0062"] = < + text = <"*Extension(en)"> + description = <"*Additional information required to capture local content or to align with other reference models/formalisms.(en)"> + comment = <"*e.g. Local information requirements or additional metadata to align with FHIR or CIMI equivalents.(en)"> + > + ["at0063"] = < + text = <"*Comment(en)"> + description = <"*Additional comment about the body temperature measurement not captured in other fields.(en)"> + > + ["at0064"] = < + text = <"*Structured measurement location(en)"> + description = <"*Structured anatomical location of where the measurement was taken.(en)"> + > + ["at0065"] = < + text = <"*Current day of menstrual cycle(en)"> + description = <"*Number of days since onset of last normal menstrual period.(en)"> + > + > + > + ["sv"] = < + items = < + ["at0000"] = < + text = <"Kroppstemperatur"> + description = <"Mätning av kroppstemperaturen, som är ett surrogat för individens kärntemperatur."> + > + ["at0001"] = < + text = <"Tree"> + description = <"@ internal @"> + > + ["at0002"] = < + text = <"History"> + description = <"@ internal @"> + > + ["at0003"] = < + text = <"Ospecificerad händelse"> + description = <"Standard, ospecificerad händelse vid en tidpunkt eller ett tidsintervall som explicit kan definieras i en mall eller vid körning av program."> + > + ["at0004"] = < + text = <"Temperatur"> + description = <"Den uppmätta kroppstemperaturen (som ett surrogat för kroppens kärntemperatur)."> + > + ["at0020"] = < + text = <"Protocol"> + description = <"@ internal @"> + > + ["at0021"] = < + text = <"Mätplats"> + description = <"Den anatomiska platsen för temperaturmätning."> + > + ["at0022"] = < + text = <"Mun"> + description = <"Temperaturen mäts i munnen."> + > + ["at0023"] = < + text = <"Hörselgång"> + description = <"Temperaturen mäts inifrån den externa hörselgången."> + > + ["at0024"] = < + text = <"Axill"> + description = <"Temperaturen mäts på armens hud, med armen placerad nedåt vid sidan."> + > + ["at0025"] = < + text = <"Rektum"> + description = <"Temperaturen mäts i ändtarmen."> + > + ["at0026"] = < + text = <"Nasofarynx"> + description = <"Temperaturen mäts i nasofarynxen."> + > + ["at0027"] = < + text = <"Urinblåsa"> + description = <"Temperaturen mäts i urinblåsan."> + > + ["at0028"] = < + text = <"Intravaskulär"> + description = <"Temperaturen mäts i kärlsystemet."> + > + ["at0029"] = < + text = <"Status"> + description = <"Information om individens tillstånd."> + > + ["at0030"] = < + text = <"Kroppsexponering"> + description = <"Individens kroppsexponering vid tidpunkten för mätningen."> + > + ["at0031"] = < + text = <"Naken"> + description = <"Individen har inga kläder, sängkläder eller överdrag på sig."> + > + ["at0032"] = < + text = <"Mindre mängd kläder och sängkläder"> + description = <"Individen är täckt av en mindre mängd kläder eller sängkläder än vad som bedöms vara lämpliga för miljöförhållandena."> + > + ["at0033"] = < + text = <"Lämplig mängd kläder och sängkläder"> + description = <"Individen är täckt av en mängd kläder eller sängkläder som bedöms vara lämpliga för miljöförhållandena."> + > + ["at0034"] = < + text = <"Större mängd kläder och sängkläder"> + description = <"Individen är täckt av en större mängd kläder eller sängkläder än vad som bedöms vara lämpliga för miljöförhållandena."> + > + ["at0041"] = < + text = <"Beskrivning av termisk stress"> + description = <"Beskrivning av rådande förhållanden som kan påverka individens uppmätta kroppstemperatur."> + > + ["at0043"] = < + text = <"Hud"> + description = <"Temperaturen mäts från exponerad hud."> + > + ["at0051"] = < + text = <"Vagina"> + description = <"Temperaturen mäts i vaginan."> + > + ["at0054"] = < + text = <"Esofagus"> + description = <"Temperaturen mäts i matstrupen."> + > + ["at0055"] = < + text = <"Ljumskveck"> + description = <"Temperaturen mäts i ljumskens hudveck mellan benet och bukväggen."> + > + ["at0056"] = < + text = <"Miljöförhållanden"> + description = <"Information om rådande miljöförhållanden vid tidpunkten för temperaturmätning."> + > + ["at0057"] = < + text = <"Ansträngning"> + description = <"Uppgifter om individens ansträngning vid tidpunkten för temperaturmätning."> + > + ["at0059"] = < + text = <"Utrustning"> + description = <"Information om utrustningen som används för att mäta kroppstemperatur."> + > + ["at0060"] = < + text = <"Tinning"> + description = <"Temperaturen mäts på tinningen, över den ytliga temporalartären."> + > + ["at0061"] = < + text = <"Panna"> + description = <"Temperaturen mäts på pannan."> + > + ["at0062"] = < + text = <"Extra information"> + description = <"Extra information som krävs för att fånga lokalt innehåll eller som anpassning till andra referensmodeller eller formalismer."> + comment = <"Exempelvis: lokala informationskrav eller ytterligare metadata för anpassning till FHIR- eller CIMI motsvarigheter."> + > + ["at0063"] = < + text = <"Kommentar"> + description = <"Extra kommentar om kroppstemperaturen som inte beskrivits i andra fält."> + > + ["at0064"] = < + text = <"Strukturerad mätplats"> + description = <"Strukturerad anatomisk plats där mätningen gjordes."> + > + ["at0065"] = < + text = <"Aktuell dag i menstruationscykeln"> + description = <"Antal dagar sedan den senaste normala menstruationsperiodens start."> + > + > + > + ["ja"] = < + items = < + ["at0000"] = < + text = <"体温"> + description = <"ヒトの全身温度の代理として測定された体温"> + > + ["at0001"] = < + text = <"Tree"> + description = <"@ internal @"> + > + ["at0002"] = < + text = <"History"> + description = <"@ internal @"> + > + ["at0003"] = < + text = <"任意のイベント"> + description = <"任意のイベント"> + > + ["at0004"] = < + text = <"温度"> + description = <"計測された体温（全身の代理として）"> + > + ["at0020"] = < + text = <"Protocol"> + description = <"@ internal @"> + > + ["at0021"] = < + text = <"計測部位"> + description = <"体温を計測した解剖学的な部位。"> + > + ["at0022"] = < + text = <"口腔"> + description = <"口腔内で計測された温度"> + > + ["at0023"] = < + text = <"外耳道"> + description = <"外耳道内で計測された温度。"> + > + ["at0024"] = < + text = <"腋窩"> + description = <"腕を脇につけた状態で測定された腋窩の皮膚から計測された温度。"> + > + ["at0025"] = < + text = <"直腸"> + description = <"直腸内で計測された温度。"> + > + ["at0026"] = < + text = <"鼻咽頭"> + description = <"鼻咽頭内で計測された温度。"> + > + ["at0027"] = < + text = <"膀胱"> + description = <"膀胱内で計測された温度"> + > + ["at0028"] = < + text = <"血管内"> + description = <"血管系の内部で計測された温度。"> + > + ["at0029"] = < + text = <"*State(en)"> + description = <"*State information about the patient.(en)"> + > + ["at0030"] = < + text = <"身体暴露"> + description = <"温度を計測した際のヒトの温度環境"> + > + ["at0031"] = < + text = <"裸体"> + description = <"着衣、寝具や被服がない状態"> + > + ["at0032"] = < + text = <"着衣や寝具が減らされている状態"> + description = <"周辺環境として適切と見なされるよりも少ない着衣や寝具に覆われた状態のヒト"> + > + ["at0033"] = < + text = <"適切な着衣、寝具が与えられている状態"> + description = <"着衣や寝具が周囲の環境として適切と考えられる量で覆われている状態の人"> + > + ["at0034"] = < + text = <"過剰な着衣や寝具"> + description = <"環境として適切であると考えられる量よりも多くの着衣や寝具で覆われている状態の人。"> + > + ["at0041"] = < + text = <"熱応力についての記載"> + description = <"体温計測に影響を起こしうる対象についてかせられた条件についての記載。"> + > + ["at0043"] = < + text = <"皮膚"> + description = <"露出された皮膚で計測された温度。"> + > + ["at0051"] = < + text = <"膣"> + description = <"膣内で計測された温度。"> + > + ["at0054"] = < + text = <"食道"> + description = <"食道内で計測された温度。"> + > + ["at0055"] = < + text = <"鼠径ひだ状皮膚"> + description = <"歌詞と腹壁の間にある鼠径ひだ状皮膚で計測された温度。"> + > + ["at0056"] = < + text = <"環境条件"> + description = <"体温を計測した時点での環境条件についての詳細。"> + > + ["at0057"] = < + text = <"労作"> + description = <"体温を計測した時点での労作状態についての詳細"> + > + ["at0059"] = < + text = <"機器"> + description = <"体温測定に使用された機器についての詳細"> + > + ["at0060"] = < + text = <"*Temple(en)"> + description = <"*Temperature is measured at the temple, over the superficial temporal artery.(en)"> + > + ["at0061"] = < + text = <"*Forehead(en)"> + description = <"*Temperature is measured on the forehead.(en)"> + > + ["at0062"] = < + text = <"*Extension(en)"> + description = <"*Additional information required to capture local content or to align with other reference models/formalisms.(en)"> + > + ["at0063"] = < + text = <"*Comment(en)"> + description = <"*Additional comment about the body temperature measurement not captured in other fields.(en)"> + > + ["at0064"] = < + text = <"*Structured measurement location(en)"> + description = <"*Structured anatomical location of where the measurement was taken.(en)"> + > + ["at0065"] = < + text = <"月経周期"> + description = <"女性の月経周期についての詳細"> + > + > + > + ["fi"] = < + items = < + ["at0000"] = < + text = <"Ruumiinlämpö"> + description = <"Ruumiin lämpötilan mittaus, joka toimii korvikkeena henkilön ydinlämpötilalle."> + > + ["at0001"] = < + text = <"Tree"> + description = <"@ internal @"> + > + ["at0002"] = < + text = <"History"> + description = <"@ internal @"> + > + ["at0003"] = < + text = <"Mikä tahansa tapahtuma"> + description = <"Oletusarvoinen, määrittämättömänä ajanhetkenä tai ajanjaksolla ilmenevä tapahtuma, joka voi olla määritetty tarkasti jossakin mallissa tai suorituksen aikana."> + > + ["at0004"] = < + text = <"Ruumiinlämpö"> + description = <"Mitattu ruumiinlämpö (korvikkeena ydinlämpötilalle)."> + > + ["at0020"] = < + text = <"Protocol"> + description = <"@ internal @"> + > + ["at0021"] = < + text = <"Mittauskohta"> + description = <"Ruumiinlämmön anatominen mittauskohta."> + > + ["at0022"] = < + text = <"Suu"> + description = <"Ruumiinlämpö mitataan suusta."> + > + ["at0023"] = < + text = <"Korvakäytävästä"> + description = <"Ruumiinlämpö mitataan korvakäytävästä."> + > + ["at0024"] = < + text = <"Kainalo"> + description = <"Ruumiinlämpö mitataan kainalon iholta käsivarren ollessa kyljen myötäisesti."> + > + ["at0025"] = < + text = <"Peräsuoli"> + description = <"Ruumiinlämpö mitataan peräsuolesta."> + > + ["at0026"] = < + text = <"Nenänielu"> + description = <"Ruumiinlämpö mitataan nenänielusta."> + > + ["at0027"] = < + text = <"Virtsarakko"> + description = <"Ruumiinlämpö mitataan virtsarakosta."> + > + ["at0028"] = < + text = <"Suonensisäinen"> + description = <"Ruumiinlämpö mitataan suonensisäisesti."> + > + ["at0029"] = < + text = <"Tila"> + description = <"Tieto potilaan tilasta."> + > + ["at0030"] = < + text = <"Kehon paljaus"> + description = <"Henkilön kehon paljaus mittaushetkellä."> + > + ["at0031"] = < + text = <"Alaston"> + description = <"Ei vaatteita, vuodevaatteita eikä peittoja."> + > + ["at0032"] = < + text = <"Tavallista vähemmän vaatteita/vuodevaatteita"> + description = <"Henkilöllä on päällään vähemmän vaatteita tai vuodevaatteita, kuin ympäristöolosuhteisiin nähden olisi suotavaa."> + > + ["at0033"] = < + text = <"Asianmukaisesti vaatteita/vuodevaatteita"> + description = <"Henkilöllä on päällään ympäristöolosuhteisiin nähden asianmukaisesti vaatteita tai vuodevaatteita."> + > + ["at0034"] = < + text = <"Tavallista enemmän vaatteita/vuodevaatteita"> + description = <"Henkilöllä on päällään enemmän vaatteita tai vuodevaatteita, kuin ympäristöolosuhteisiin nähden olisi suotavaa."> + > + ["at0041"] = < + text = <"Lämpöstressin kuvaus"> + description = <"Kuvaus tutkittavaan vaikuttavista olosuhteista, jotka saattavat vaikuttaa mitattuun ruumiinlämpöön."> + > + ["at0043"] = < + text = <"Iho"> + description = <"Lämpötila mitataan paljaalta iholta."> + > + ["at0051"] = < + text = <"Emätin"> + description = <"Ruumiinlämpö mitataan emättimestä."> + > + ["at0054"] = < + text = <"Ruokatorvi"> + description = <"Ruumiinlämpö mitataan ruokatorvesta."> + > + ["at0055"] = < + text = <"Nivustaive"> + description = <"Ruumiinlämpö mitataan jalan ja vatsanpeitteiden välissä olevasta nivuspoimusta."> + > + ["at0056"] = < + text = <"Ympäristöolosuhteet"> + description = <"Tiedot ympäristöolosuhteista ruumiinlämmön mittaushetkellä."> + > + ["at0057"] = < + text = <"Rasitus"> + description = <"Tiedot rasituksesta, jolle henkilö altistuu ruumiinlämmön mittaushetkellä."> + > + ["at0059"] = < + text = <"Laite"> + description = <"Tiedot laitteesta, jolla ruumiinlämpö mitataan."> + > + ["at0060"] = < + text = <"Ohimo"> + description = <"Ruumiinlämpö mitataan ohimolta, pinnallisen ohimovaltimon päältä."> + > + ["at0061"] = < + text = <"Otsa"> + description = <"Ruumiinlämpö mitataan otsalta."> + > + ["at0062"] = < + text = <"Laajennus"> + description = <"Lisätiedot, joita tarvitaan paikallisen sisällön kirjaamiseksi tai yhtenäistämiseksi muiden viitemallien tai formalismien kanssa."> + comment = <"Esimerkiksi paikalliset tietovaatimukset tai muu metadata, joilla saadaan aikaan vastaavuus vastaavien FHIR- tai CIMI-tietojen kanssa."> + > + ["at0063"] = < + text = <"Kommentti"> + description = <"Ruumiinlämmön mittauksen kertomusmuodossa olevat lisätiedot, joita ei voida ilmoittaa muissa kentissä."> + > + ["at0064"] = < + text = <"Rakenteellinen mittauskohta"> + description = <"Rakenteellinen anatominen kohta, josta mittaus tehtiin."> + > + ["at0065"] = < + text = <"Kuukautiskierron nykyinen päivä"> + description = <"Viimeisten normaalien kuukautisten alkamisesta kuluneiden päivien lukumäärä."> + > + > + > + ["it"] = < + items = < + ["at0000"] = < + text = <"Temperatura corporea"> + description = <"Una misura della temperatura corporea, che è un surrogato della temperatura corporea del corpo centrale dell'individuo. "> + > + ["at0001"] = < + text = <"Tree"> + description = <"@ internal @"> + > + ["at0002"] = < + text = <"History"> + description = <"@ internal @"> + > + ["at0003"] = < + text = <"Qualsiasi evento"> + description = <"Evento predefinito, non specificato nel tempo o nell'intervallo di tempo, che può essere definito esplicitamente in un modello o in fase di esecuzione."> + > + ["at0004"] = < + text = <"Temperatura"> + description = <"La temperatura corporea misurata (come surrogato del nucleo del corpo). "> + > + ["at0020"] = < + text = <"Protocol"> + description = <"@ internal @"> + > + ["at0021"] = < + text = <"Posizione della misura"> + description = <"Il sito anatomico di misurazione della temperatura."> + > + ["at0022"] = < + text = <"Bocca"> + description = <"La temperatura viene misurata all'interno della bocca."> + > + ["at0023"] = < + text = <"Canale uditivo"> + description = <"La temperatura viene misurata dall'interno del canale uditivo esterno."> + > + ["at0024"] = < + text = <"Ascella"> + description = <"La temperatura viene misurata dalla pelle dell'ascella con il braccio posizionato lateralmente."> + > + ["at0025"] = < + text = <"Retto"> + description = <"Temperatura misurata all'interno del retto. "> + > + ["at0026"] = < + text = <"Rinofaringe"> + description = <"La temperatura viene misurata all'interno del rinofaringe."> + > + ["at0027"] = < + text = <"Vescica urinaria"> + description = <"La temperatura viene misurata nella vescica urinaria."> + > + ["at0028"] = < + text = <"Intravascolare"> + description = <"La temperatura viene misurata all'interno del sistema vascolare."> + > + ["at0029"] = < + text = <"Stato"> + description = <"Informazioni sullo stato del paziente."> + > + ["at0030"] = < + text = <"Esposizione corporale"> + description = <"Il grado di esposizione dell'individuo al momento della misurazione."> + > + ["at0031"] = < + text = <"Nudo"> + description = <"Nessun abbigliamento, biancheria da letto o copertura."> + > + ["at0032"] = < + text = <"Abbigliamento/biancheria da letto ridotta"> + description = <"La persona è coperta da una quantità di indumenti o biancheria da letto inferiore a quella ritenuta appropriata per le circostanze ambientali. "> + > + ["at0033"] = < + text = <"Abbigliamento/biancheria da letto appropriata"> + description = <"La persona è coperta da una quantità di indumenti o biancheria da letto ritenuta adeguata alle circostanze ambientali. "> + > + ["at0034"] = < + text = <"Abbigliamento/biancheria da letto maggiorata"> + description = <"La persona è coperta da una quantità maggiore di indumenti o biancheria da letto rispetto a quanto ritenuto appropriato per le circostanze ambientali."> + > + ["at0041"] = < + text = <"Descrizione dello stress termico"> + description = <"Descrizione delle condizioni applicate al soggetto che potrebbero influenzare la temperatura corporea misurata. "> + > + ["at0043"] = < + text = <"Pelle"> + description = <"La temperatura viene misurata dalla pelle esposta."> + > + ["at0051"] = < + text = <"Vagina"> + description = <"La temperatura viene misurata all'interno della vagina."> + > + ["at0054"] = < + text = <"Esofago"> + description = <"La temperatura viene misurata all'interno dell'esofago."> + > + ["at0055"] = < + text = <"Piega della pelle inguinale"> + description = <"La temperatura viene misurata nella piega inguinale della pelle tra la gamba e la parete addominale."> + > + ["at0056"] = < + text = <"Condizioni ambientali"> + description = <"Dettagli sulle condizioni ambientali al momento della misurazione della temperatura."> + > + ["at0057"] = < + text = <"Sforzo"> + description = <"Dettagli sullo sforzo della persona al momento della misurazione della temperatura."> + > + ["at0059"] = < + text = <"Dispositivo"> + description = <"Dettagli sull'uso del dispositivo per misurare la temperatura corporea."> + > + ["at0060"] = < + text = <"Tempie"> + description = <"La temperatura viene misurata alle tempie, sopra l'arteria temporale superficiale."> + > + ["at0061"] = < + text = <"Fronte"> + description = <"La temperatura viene misurata sulla fronte. "> + > + ["at0062"] = < + text = <"Estensione"> + description = <"Informazioni aggiuntive necessarie per catturare contenuti locali o per allinearsi con altri modelli/formalismi di riferimento."> + comment = <"Ad esempio: requisiti informativi locali o metadati aggiuntivi per allinearsi agli equivalenti FHIR o CIMI."> + > + ["at0063"] = < + text = <"Commento"> + description = <"Commento aggiuntivo sulla misurazione della temperatura corporea non catturato in altri campi."> + > + ["at0064"] = < + text = <"Luogo di misura strutturato"> + description = <"Posizione anatomica strutturata del luogo in cui è stata effettuata la misurazione."> + > + ["at0065"] = < + text = <"Giorno corrente del ciclo mestruale"> + description = <"Numero di giorni dall'inizio dell'ultimo periodo mestruale normale."> + > + > + > + > + term_bindings = < + ["LNC205"] = < + items = < + ["at0004"] = <[LNC205::8310-5]> + > + > + ["SNOMED-CT"] = < + items = < + ["at0004"] = <[SNOMED-CT::386725007]> + > + > + > diff --git a/better-template/src/test/resources/opt_json/Archetypes/openEHR-EHR-OBSERVATION.story.v1.adl b/better-template/src/test/resources/opt_json/Archetypes/openEHR-EHR-OBSERVATION.story.v1.adl new file mode 100644 index 000000000..5f803b8dc --- /dev/null +++ b/better-template/src/test/resources/opt_json/Archetypes/openEHR-EHR-OBSERVATION.story.v1.adl @@ -0,0 +1,476 @@ +archetype (adl_version=1.4; uid=7e289b5c-e123-4dc0-9aad-548352b64915) + openEHR-EHR-OBSERVATION.story.v1 + +concept + [at0000] + +language + original_language = <[ISO_639-1::en]> + translations = < + ["ko"] = < + language = <[ISO_639-1::ko]> + author = < + ["name"] = <"Seung-Jong Yu"> + ["organisation"] = <"NOUSCO Co.,Ltd."> + ["email"] = <"seungjong.yu@gmail.com"> + > + accreditation = <"Certified board of Family medicine"> + > + ["es-ar"] = < + language = <[ISO_639-1::es-ar]> + author = < + ["name"] = <"Guillermo Palli"> + > + > + ["nb"] = < + language = <[ISO_639-1::nb]> + author = < + ["name"] = <"Silje Ljosland Bakke"> + ["organisation"] = <"Nasjonal IKT HF"> + > + > + ["pt-br"] = < + language = <[ISO_639-1::pt-br]> + author = < + ["name"] = <"Osmeire Chamelette Sanzovo"> + ["organisation"] = <"Hospital Sírio Libanês - SP"> + ["email"] = <"osmeire.acsanzovo@hsl.org.br"> + > + > + ["ar-sy"] = < + language = <[ISO_639-1::ar-sy]> + author = < + ["name"] = <"Mona Saleh"> + > + > + ["it"] = < + language = <[ISO_639-1::it]> + author = < + ["name"] = <"Francesca Frexia"> + ["organisation"] = <"CRS4 - Center for advanced studies, research and development in Sardinia, Pula (Cagliari), Italy"> + ["email"] = <"francesca.frexia@crs4.it"> + > + > + > + +description + original_author = < + ["date"] = <"2008-05-15"> + ["name"] = <"Heather Leslie"> + ["organisation"] = <"Ocean Informatics"> + ["email"] = <"heather.leslie@oceaninformatics.com"> + > + lifecycle_state = <"published"> + other_contributors = <"Tomas Alme, DIPS ASA, Norway","Nadim Anani, Karolinska Institutet, Sweden","Vebjørn Arntzen, Oslo universitetssykehus HF, Norway (Nasjonal IKT redaktør)","Koray Atalag, University of Auckland, New Zealand","Gustavo Bacelar-Silva, Healthcare Designs, Brazil (openEHR Editor)","Silje Ljosland Bakke, Nasjonal IKT HF, Norway (openEHR Editor)","Lars Bitsch-Larsen, Haukeland University hospital, Norway","Lisbeth Dahlhaug, Helse Midt - Norge IT, Norway","Shahla Foozonkhah, Iran ministry of health and education, Iran","Einar Fosse, National Centre for Integrated Care and Telemedicine, Norway","Sam Heard, Ocean Informatics, Australia","Andreas Hering, Helse Bergen HF, Haukeland universitetssjukehus, Norway","Anca Heyd, DIPS ASA, Norway","Lars Morgan Karlsen, DIPS ASA, Norway","Shinji Kobayashi, Kyoto University, Japan","Heather Leslie, Atomica Informatics, Australia (openEHR Editor)","Hallvard Lærum, Direktoratet for e-helse, Norway","Arne Løberg Sæter, DIPS ASA, Norway","Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (openEHR Editor)","Bjørn Næss, DIPS ASA, Norway","Andrej Orel, Marand d.o.o., Slovenia","Rune Pedersen, Universitetssykehuset i Nord Norge, Norway","Micaela Thierley, Helse Bergen/Haraldsplass sykehus, Norway","John Tore Valand, Haukeland Universitetssjukehus, Norway (Nasjonal IKT redaktør)"> + details = < + ["es-ar"] = < + language = <[ISO_639-1::es-ar]> + purpose = <"*To record a narrative description of the clinical history, as told to a clinician or recorded directly by an individual/patient, and to provide a framework in which to nest detailed CLUSTER archetypes, each of which will describe the various aspects of the clinical history in further detail.(en)"> + copyright = <"© openEHR Foundation"> + > + ["ko"] = < + language = <[ISO_639-1::ko]> + purpose = <"개인/환자가 의사에게 이야기하거나 직접 기록한 임상 병력에 대한 서술을 기록하기 위한 것과 상세한 CLUSTER archetypes를 포함할 수 있는 프레임워크를 제공하는 것으로 각각에 임상 병력의 다양한 측면들을 상세하게 기술될 것이다."> + keywords = <"*병력(ko)","*현재(ko)","*호소(ko)","*이야기(ko)"> + copyright = <"© openEHR Foundation"> + use = <"환자가 의사에게 이야기한 공식적인 '현재 호소하는 병력(History of Presenting Complaint)'을 기록하기 위해서 사용함; 또는 (예를 들어 개인건강기록에 있는) 개인 자신의 증상들의 '이야기(story)를 설명한 것을 기록하기 위해 사용함. + +기존 또는 이전의 임상 시스템 내의 임상 병력의 서술을 'Story' data element을 사용하여 archetyped format으로 통합하기위해 사용함. + +단순한 서술을 기록하기 위해 사용함 그리고/또는 container archetype으로써 - 추가적이고 특정한 그리고 상세한 CLUSTER archetypes에 의해 확장될 수 있는 공통의 쿼리가능한 ENTRY archetype framework를 제공함. 각각에 임상병력의 다양한 측면을 기술될 것임. 병력과 관련된 CLUSTER archetypes의 예는 CLUSTER.symptom 또는 CLUSTER.health_event를 포함한다."> + > + ["nb"] = < + language = <[ISO_639-1::nb]> + purpose = <"For å registrere en fritekstbeskrivelse av individets sykehistorie/anamnese og som et rammeverk for å nøste detaljerte CLUSTER-arketyper som hver for seg kan detaljere ulike aspekter av sykehistorien, som symptomer, helserelaterte hendelser, og andre tilgrensende emner. + +Brukes for å registrere detaljer om sykehistorien slik den blir fortalt av et individ, pårørende, eller en annen part. Det kan registreres av en kliniker som del av opptak av sykehistorie, eller selvregistreres som del av et spørreskjema eller personlig helsearkiv."> + keywords = <"anamnese","sykehistorie","problem","helseplage","bekymring"> + use = <"Brukes for å registrere en beskrivelse av subjektive helserelaterte observasjoner eller inntrykk fra individets synsvinkel. + +Når anamnesen registreres av en kliniker i en konsultasjon kan arketypen brukes for å registrere den kliniske historikken til individet, rapportert av individet selv, en forelder, pårørende eller en annen involvert part. Dersom den registreres av individet selv, kan den brukes som en oversikt over symptom- og helseerfaringer, som kan deles med helsepersonell eller som dokumentasjon i deres eget helsearkiv. + +Brukes: +- for å registrere en enkelt fritekst +- som et rammeverk for å registrere en detaljert strukturert historikk ved å inkludere relevante CLUSTER-arketyper i SLOTet \"Strukturerte detaljer\". Eksempler kan være CLUSTER.symptom_sign eller CLUSTER.health_event. + +Brukes for å kunne gjenbruke anamnese i eksisterende systemer inn i et arketypeformat ved hjelp av 'Anamnese'-dataelementet."> + misuse = <"Skal ikke brukes for å registrere formelle vurderinger av klinikere. Disse registreres ved hjelp av forskjellige arketyper av klassen EVALUATION."> + > + ["pt-br"] = < + language = <[ISO_639-1::pt-br]> + purpose = <"Para registrar uma descrição narrativa da história clínica do sujeito do cuidado e para fornecer um quadro no qual se aninha arquétipos CLUSTER detalhados, cada um dos quais irão apoiar a narrativa com detalhes estruturados adicionais para sintomas, eventos de saúde e tópicos relacionados. + +Use para registrar detalhes sobre a história clínica relatada por um indivíduo, pais, cuidador ou outra pessoa. Pode ser registrado pelo médico como parte de um registro de história clínica relatado, ou auto-registrado como parte de um questionário clínico ou registro de saúde pessoal."> + keywords = <"história","queixa","sintoma","saúde","gravar","apresentando queixa","anamnese","presente"> + use = <"Use para registrar uma descrição sobre observações ou impressões subjetivas relacionadas à saúde do ponto de vista do sujeito do cuidado. + +Quando registrado por um médico dentro do contexto de provisão de cuidados de saúde, a história pode ser utilizada para capturar a história clínica, como relatado pelo próprio sujeito, pais, cuidador ou outra parte relacionada. Se gravado pelo próprio sujeito, pode ser usado como um relato de sua \"história\" de sintomas e experiências de saúde, que pode ser usado para compartilhar com os prestadores de cuidados de saúde ou para documentar dentro do seu próprio registro de saúde pessoal. + +Usar: +- para gravar uma narrativa simples; e/ou +- como um arquétipo contêiner para permitir o registro de um histórico detalhado por inclusão de arquétipos CLUSTER relevantes dentro do SLOT Detalhes. Por exemplo: arquétipos CLUSTER.symptom, CLUSTER.issue ou CLUSTER.health_event podem ser adequadamente utilizados neste SLOT. + +Use para incorporar as descrições narrativas da história clínica capturadas de sistemas clínicos existentes ou herdados em um formato arquetipado, usando o elemento de dados de texto \"História\"."> + misuse = <"Não deve ser usado para gravar avaliações formais por médicos que normalmente seriam gravadas usando a classe de arquétipos EVALUATION."> + > + ["ar-sy"] = < + language = <[ISO_639-1::ar-sy]> + purpose = <"*To record a narrative description of the clinical history, as told to a clinician or recorded directly by an individual/patient, and to provide a framework in which to nest detailed CLUSTER archetypes, each of which will describe the various aspects of the clinical history in further detail.(en)"> + copyright = <"© openEHR Foundation"> + > + ["en"] = < + language = <[ISO_639-1::en]> + purpose = <"To record a narrative description of the clinical history of the subject of care and to provide a framework in which to nest detailed CLUSTER archetypes, each of which will support the narrative with additional structured detail for symptoms, health events and related topics. + +Use to record detail about the clinical history as reported by an individual, parent, care-giver or other party. It may be recorded by a clinician as part of a clinical history record as reported to them, or self-recorded as part of a clinical questionnaire or personal health record."> + keywords = <"history","presenting","complaint","story","symptom","health","record","presenting complaint","anamnesis"> + copyright = <"© openEHR Foundation"> + use = <"Use to record a description about subjective health-related observations or impressions from the point of view of the subject of care. + +When recorded by a clinician within the context of healthcare provision the story can be used for capturing the clinical history, as reported by the subject themselves, a parent, care-giver or other related party. If recorded by the subject, it can be used as an account of their 'story' of symptoms and health experiences, which might be used to share with healthcare providers or to document within their own personal health record. + +Use: +- to record a simple narrative; and/or +- as a container archetype to enable recording of a detailed structured history by inclusion of relevant CLUSTER archetypes within the 'Detail' SLOT. For example: CLUSTER.symptom, CLUSTER.issue or CLUSTER.health_event archetypes can be appropriately used in this SLOT. + +Use to incorporate the narrative descriptions of clinical history captured from existing or legacy clinical systems into an archetyped format, using the 'Story' text data element."> + misuse = <"Not to be used to record formal assessments by clinicians which would usually be recorded using the EVALUATION class of archetypes."> + > + ["it"] = < + language = <[ISO_639-1::it]> + purpose = <"Registrare una descrizione narrativa della storia clinica del soggetto di cura e fornire un quadro in cui annidare gli archetipi dettagliati di CLUSTER, ognuno dei quali supporterà la narrazione con ulteriori dettagli strutturati per i sintomi, gli eventi sanitari e gli argomenti correlati. + +Usato per registrare i dettagli della storia clinica come riportata da un individuo, da un genitore, da un caregiver o da un altro soggetto. Può essere registrato da un clinico come parte di una storia clinica così come riportata, o autoregistrato come parte di un questionario clinico o di una cartella clinica personale."> + keywords = <"cronologia, presentazione, segnalazione, storia, sintomo, salute, registrazione, presentazione di una lamentela, anamnesi", ...> + use = <"Usato per registrare una descrizione delle osservazioni o impressioni soggettive relative alla salute dal punto di vista del soggetto di cura. + +Quando viene registrata da un clinico nell'ambito dell'assistenza sanitaria, la storia può essere utilizzata per acquisire l'anamnesi clinica, come riportata dal soggetto stesso, da un genitore, da un care-giver o da altre parti correlate. Se registrata dal soggetto, può essere utilizzata come resoconto della sua \"cronologia\" di sintomi ed esperienze di salute, e può essere utilizzata per condividerla con gli operatori sanitari o per documentare all'interno della cartella clinica personale del soggetto. + +Utilizzo: +- per registrare una semplice narrazione; e/o +- come archetipo di contenitore per consentire la registrazione di una storia strutturata e dettagliata includendo i relativi archetipi di CLUSTER all'interno dello SLOT \"Dettaglio\". Per esempio: Gli archetipi di CLUSTER.symptom, CLUSTER.issue o CLUSTER.health_event possono essere utilizzati in modo appropriato in questo SLOT. + +Utilizzare per incorporare le descrizioni narrative della storia clinica acquisite da sistemi clinici esistenti o preesistenti in un formato archetipizzato, utilizzando l'elemento \"Storia\". +"> + misuse = <"Da non utilizzare per registrare le valutazioni formali dei clinici che di solito vengono registrate utilizzando la classe EVALUATION degli archetipi."> + > + > + other_details = < + ["licence"] = <"This work is licensed under the Creative Commons Attribution-ShareAlike 3.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/3.0/."> + ["custodian_organisation"] = <"openEHR Foundation"> + ["references"] = <"Direct communication with clinicians."> + ["current_contact"] = <"Heather Leslie, Ocean Informatics, heather.leslie@oceaninformatics.com"> + ["original_namespace"] = <"org.openehr"> + ["original_publisher"] = <"openEHR Foundation"> + ["custodian_namespace"] = <"org.openehr"> + ["MD5-CAM-1.0.1"] = <"D5AC52C70A99C8A90ED0239A76BB61B9"> + ["build_uid"] = <"94f4a320-77a2-4354-8dac-ac37cd33dbbc"> + ["revision"] = <"1.1.3"> + > + +definition + OBSERVATION[at0000] matches { -- Story/History + data matches { + HISTORY[at0001] matches { -- Event Series + events cardinality matches {1..*; unordered} matches { + EVENT[at0002] occurrences matches {0..*} matches { -- Any event + data matches { + ITEM_TREE[at0003] matches { -- Tree + items cardinality matches {1..*; unordered} matches { + ELEMENT[at0004] occurrences matches {0..*} matches { -- Story + value matches { + DV_TEXT matches {*} + } + } + allow_archetype CLUSTER[at0006] occurrences matches {0..*} matches { -- Structured detail + include + archetype_id/value matches {/openEHR-EHR-CLUSTER\.health_event(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.issue(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.symptom_sign(-[a-zA-Z0-9_]+)*\.v1/} + } + } + } + } + } + } + } + } + protocol matches { + ITEM_TREE[at0007] matches { -- Tree + items cardinality matches {0..*; unordered} matches { + allow_archetype CLUSTER[at0008] occurrences matches {0..*} matches { -- Extension + include + archetype_id/value matches {/.*/} + } + } + } + } + } + +ontology + term_definitions = < + ["ar-sy"] = < + items = < + ["at0000"] = < + text = <"*Story/History(en)"> + description = <"*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.(en)"> + > + ["at0001"] = < + text = <"*Event Series(en)"> + description = <"*@ internal @(en)"> + > + ["at0002"] = < + text = <"إحدى الوقائع"> + description = <"*Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.(en)"> + > + ["at0003"] = < + text = <"*Tree(en)"> + description = <"*@ internal @(en)"> + > + ["at0004"] = < + text = <"*Story(en)"> + description = <"*Narrative description of the story or clinical history for the subject of care.(en)"> + > + ["at0006"] = < + text = <"*Structured detail(en)"> + description = <"*Structured detail about the individual's story or patient's history.(en)"> + comment = <"*For example: a specific symptom such as nausea or pain; an event such as a fall off a bicycle; or an issue such as a desire to quit using tobacco.(en)"> + > + ["at0007"] = < + text = <"*Tree(en)"> + description = <"*@ internal @(en)"> + > + ["at0008"] = < + text = <"*Extension(en)"> + description = <"*Additional information required to capture local content or to align with other reference models/formalisms.(en)"> + comment = <"*For example: Local information requirements or additional metadata to align with FHIR or CIMI equivalents.(en)"> + > + > + > + ["en"] = < + items = < + ["at0000"] = < + text = <"Story/History"> + description = <"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."> + > + ["at0001"] = < + text = <"Event Series"> + description = <"@ internal @"> + > + ["at0002"] = < + text = <"Any event"> + description = <"Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time."> + > + ["at0003"] = < + text = <"Tree"> + description = <"@ internal @"> + > + ["at0004"] = < + text = <"Story"> + description = <"Narrative description of the story or clinical history for the subject of care."> + > + ["at0006"] = < + text = <"Structured detail"> + description = <"Structured detail about the individual's story or patient's history."> + comment = <"For example: a specific symptom such as nausea or pain; an event such as a fall off a bicycle; or an issue such as a desire to quit using tobacco."> + > + ["at0007"] = < + text = <"Tree"> + description = <"@ internal @"> + > + ["at0008"] = < + text = <"Extension"> + description = <"Additional information required to capture local content or to align with other reference models/formalisms."> + comment = <"For example: Local information requirements or additional metadata to align with FHIR or CIMI equivalents."> + > + > + > + ["es-ar"] = < + items = < + ["at0000"] = < + text = <"*Story/History(en)"> + description = <"*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.(en)"> + > + ["at0001"] = < + text = <"Eventos"> + description = <"@ internal @"> + > + ["at0002"] = < + text = <"*Any event(en)"> + description = <"*Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.(en)"> + > + ["at0003"] = < + text = <"Arbol"> + description = <"@ internal @"> + > + ["at0004"] = < + text = <"*Story(en)"> + description = <"*Narrative description of the story or clinical history for the subject of care.(en)"> + > + ["at0006"] = < + text = <"*Structured detail(en)"> + description = <"*Structured detail about the individual's story or patient's history.(en)"> + comment = <"*For example: a specific symptom such as nausea or pain; an event such as a fall off a bicycle; or an issue such as a desire to quit using tobacco.(en)"> + > + ["at0007"] = < + text = <"*Tree(en)"> + description = <"*@ internal @(en)"> + > + ["at0008"] = < + text = <"*Extension(en)"> + description = <"*Additional information required to capture local content or to align with other reference models/formalisms.(en)"> + comment = <"*For example: Local information requirements or additional metadata to align with FHIR or CIMI equivalents.(en)"> + > + > + > + ["ko"] = < + items = < + ["at0000"] = < + text = <"*Story/History(en)"> + description = <"*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.(en)"> + > + ["at0001"] = < + text = <"*Event Series(en)"> + description = <"*@ internal @(en)"> + > + ["at0002"] = < + text = <"*Any event(en)"> + description = <"*Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.(en)"> + > + ["at0003"] = < + text = <"*Tree(en)"> + description = <"*@ internal @(en)"> + > + ["at0004"] = < + text = <"*Story(en)"> + description = <"*Narrative description of the story or clinical history for the subject of care.(en)"> + > + ["at0006"] = < + text = <"*Structured detail(en)"> + description = <"*Structured detail about the individual's story or patient's history.(en)"> + comment = <"*For example: a specific symptom such as nausea or pain; an event such as a fall off a bicycle; or an issue such as a desire to quit using tobacco.(en)"> + > + ["at0007"] = < + text = <"*Tree(en)"> + description = <"*@ internal @(en)"> + > + ["at0008"] = < + text = <"*Extension(en)"> + description = <"*Additional information required to capture local content or to align with other reference models/formalisms.(en)"> + comment = <"*For example: Local information requirements or additional metadata to align with FHIR or CIMI equivalents.(en)"> + > + > + > + ["nb"] = < + items = < + ["at0000"] = < + text = <"Anamnese"> + description = <"Et individs sykehistorie/anamnese, som fortalt til kliniker eller dokumentert direkte av individet."> + > + ["at0001"] = < + text = <"Event Series"> + description = <"@ internal @"> + > + ["at0002"] = < + text = <"Uspesifisert hendelse"> + description = <"Standard, uspesifisert tidspunkt eller tidsintervall som kan defineres mer eksplisitt i en templat eller i en applikasjon."> + > + ["at0003"] = < + text = <"Tree"> + description = <"@ internal @"> + > + ["at0004"] = < + text = <"Anamnese"> + description = <"Narrativ beskrivelse av sykehistorie/anamnese for et individ."> + > + ["at0006"] = < + text = <"Strukturerte detaljer"> + description = <"Ytterligere detaljer i strukturert form, knyttet til individets sykehistorie/anamnese."> + comment = <"Eksempel: et spesifikt symptom som kvalme eller smerte, en hendelse som en sykkelvelt, eller en problemstilling som et ønske om å slutte med tobakk."> + > + ["at0007"] = < + text = <"*Tree(en)"> + description = <"*@ internal @(en)"> + > + ["at0008"] = < + text = <"Tilleggsinformasjon"> + description = <"Ytterligere informasjon som trengs for å kunne registrere lokalt definert innhold eller for å tilpasse til andre referansemodeller/formalismer."> + comment = <"For eksempel lokale informasjonsbehov eller ytterligere metadata for å kunne tilpasse til tilsvarende konsepter i FHIR eller CIMI."> + > + > + > + ["pt-br"] = < + items = < + ["at0000"] = < + text = <"História"> + description = <"A história clínica subjetiva do sujeito do cuidado como registrada diretamente por ele, ou relatada a um médico pelo sujeito ou por um cuidador."> + > + ["at0001"] = < + text = <"Event Series"> + description = <"@ internal @"> + > + ["at0002"] = < + text = <"Algum Evento"> + description = <"Padrão, ponto indeterminado no tempo ou intervalo do evento que pode ser explicitamente definido em um modelo ou em tempo de execução."> + > + ["at0003"] = < + text = <"Tree"> + description = <"@ internal @"> + > + ["at0004"] = < + text = <"História"> + description = <"Descrição narrativa da história ou da história clínica para o sujeito do cuidado."> + > + ["at0006"] = < + text = <"Detalhes Estruturados"> + description = <"Detalhes estruturados sobre a história do indivíduo ou a história do paciente."> + comment = <"Por exemplo: um sintoma específico, tais como náuseas ou dor; um evento como uma queda de bicicleta; ou um problema como o desejo de parar de usar tabaco."> + > + ["at0007"] = < + text = <"Tree"> + description = <"@ internal @"> + > + ["at0008"] = < + text = <"Extensão"> + description = <"Informações adicionais necessárias para capturar o conteúdo local ou para se alinhar com outros modelos/formalismos de referência."> + comment = <"Por exemplo: requisitos de informação locais ou metadados adicionais para alinhar com FHIR ou CIMI equivalentes."> + > + > + > + ["it"] = < + items = < + ["at0000"] = < + text = <"Storia/Cronologia"> + description = <"La storia clinica soggettiva del persona assistita come registrata direttamente dal soggetto, o riportata ad un clinico dal soggetto o da chi lo assiste."> + > + ["at0001"] = < + text = <"Serie di eventi"> + description = <"@ internal @"> + > + ["at0002"] = < + text = <"Qualsiasi evento"> + description = <"Evento predefinito, non specificato nel tempo o nell'intervallo di tempo, che può essere definito esplicitamente in un modello o in fase di esecuzione."> + > + ["at0003"] = < + text = <"Tree"> + description = <"@ internal @"> + > + ["at0004"] = < + text = <"Storia"> + description = <"Descrizione narrativa della storia o dell'anamnesi clinica del soggetto da curare."> + > + ["at0006"] = < + text = <"Dettaglio strutturato"> + description = <"Dettagli strutturati sulla storia dell'individuo o sull'anamnesi del paziente."> + comment = <"Per esempio: un sintomo specifico come la nausea o il dolore; un evento come una caduta dalla bicicletta; o un fenomeno come il desiderio di smettere di usare il tabacco. "> + > + ["at0007"] = < + text = <"Tree"> + description = <"@ internal @"> + > + ["at0008"] = < + text = <"Estensione"> + description = <"Informazioni aggiuntive necessarie per acquisire contenuti locali o per allinearsi con altri modelli/formalismi di riferimento. "> + comment = <"Per esempio: Requisiti locali di informazione o metadati aggiuntivi per allinearsi con gli equivalenti FHIR o CIMI."> + > + > + > + > diff --git a/better-template/src/test/resources/opt_json/Archetypes/openEHR-EHR-OBSERVATION.travel_history.v0.adl b/better-template/src/test/resources/opt_json/Archetypes/openEHR-EHR-OBSERVATION.travel_history.v0.adl new file mode 100644 index 000000000..3ff1f2511 --- /dev/null +++ b/better-template/src/test/resources/opt_json/Archetypes/openEHR-EHR-OBSERVATION.travel_history.v0.adl @@ -0,0 +1,1395 @@ +archetype (adl_version=1.4; uid=c8cdb7a6-0870-4f74-b1f0-6624003c4c2a) + openEHR-EHR-OBSERVATION.travel_history.v0 + +concept + [at0000] + +language + original_language = <[ISO_639-1::en]> + translations = < + ["fi"] = < + language = <[ISO_639-1::fi]> + author = < + > + > + ["nb"] = < + language = <[ISO_639-1::nb]> + author = < + ["name"] = <"Bjørn Næss"> + ["organisation"] = <"DIPS AS"> + ["email"] = <"bna@dips.no"> + > + > + ["it"] = < + language = <[ISO_639-1::it]> + author = < + ["name"] = <"Paolo Anedda"> + ["organisation"] = <"Inpeco"> + ["email"] = <"paolo.anedda@inpeco.com"> + > + > + > + +description + original_author = < + ["date"] = <"2020-02-27"> + ["name"] = <"Ian McNicoll"> + ["organisation"] = <"freshEHR Clinical Informatics Ltd."> + ["email"] = <"ian@freshehr.com"> + > + lifecycle_state = <"in_development"> + other_contributors = <"Bjørn Næss ", ...> + details = < + ["fi"] = < + language = <[ISO_639-1::fi]> + purpose = <"*To record details of a travel trip with respect to exposure to potential risk.(en)"> + keywords = <"*travel, trip, tropical(en)", ...> + use = <"*To record details of a travel trip with respect to exposure to potential risk.(en)"> + > + ["nb"] = < + language = <[ISO_639-1::nb]> + purpose = <"Benyttes for å kartlegge reiseaktivitet i forbindelse med risiko for smitte og sykdom. "> + keywords = <"Reise, smitte", ...> + copyright = <"© openEHR Foundation"> + > + ["en"] = < + language = <[ISO_639-1::en]> + purpose = <"To record details of a travel trip with respect to exposure to potential risk."> + keywords = <"travel, trip, tropical", ...> + copyright = <"© openEHR Foundation"> + use = <"To record details of a travel trip with respect to exposure to potential risk."> + > + ["it"] = < + language = <[ISO_639-1::it]> + purpose = <"Registrare i dettagli di un viaggio in relazione all'esposizione a potenziali rischi."> + keywords = <"viaggio, trasferta, tropicale", ...> + use = <"Registrare i dettagli di un viaggio in relazione all'esposizione a potenziali rischi."> + > + > + other_details = < + ["licence"] = <"This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/."> + ["custodian_organisation"] = <"openEHR Foundation"> + ["references"] = <"Fairley J. General Approach to the Returned Traveler - Chapter 11 - 2020 Yellow Book | Travelers’ Health | CDC. wwwnc.cdc.gov. https://wwwnc.cdc.gov/travel/yellowbook/2020/posttravel-evaluation/general-approach-to-the-returned-traveler. Published 2020. Accessed March 7, 2020. +‌"> + ["original_namespace"] = <"org.openehr"> + ["original_publisher"] = <"openEHR Foundation"> + ["custodian_namespace"] = <"org.openehr"> + ["MD5-CAM-1.0.1"] = <"FD67CADAD2EAF2ECB89AF1F1E15D1D9C"> + ["build_uid"] = <"ddcd2de7-b436-40a5-ad11-b4863fbc238d"> + ["revision"] = <"0.0.1-alpha"> + > + +definition + OBSERVATION[at0000] matches { -- Travel trip history + data matches { + HISTORY[at0001] matches { -- History + events cardinality matches {0..*; unordered} matches { + EVENT[at0002] occurrences matches {0..1} matches { -- Any event + data matches { + ITEM_TREE[at0003] matches { -- Tree + items cardinality matches {0..*; unordered} matches { + ELEMENT[at0111] occurrences matches {0..1} matches { -- Recent travel + value matches { + DV_CODED_TEXT matches { + defining_code matches { + [local:: + at0112, -- Yes + at0113, -- No + at0114] -- Unknown + } + } + } + } + ELEMENT[at0115] occurrences matches {0..1} matches { -- Incubation period + value matches { + DV_DURATION matches {*} + } + } + ELEMENT[at0059] occurrences matches {0..*} matches { -- Reason for travel + value matches { + DV_CODED_TEXT matches { + defining_code matches { + [local:: + at0060, -- Leisure + at0061, -- Visiting friends and relatives + at0062, -- Business + at0063, -- Research/education + at0064, -- Missionary/volunteer work + at0065, -- Providing medical care + at0066] -- Receiving medical care + } + } + DV_TEXT matches {*} + } + } + ELEMENT[at0070] occurrences matches {0..1} matches { -- Duration of travel + value matches { + DV_DURATION matches {*} + } + } + ELEMENT[at0071] occurrences matches {0..1} matches { -- Date of return + value matches { + DV_DATE_TIME matches {*} + } + } + CLUSTER[at0120] occurrences matches {0..1} matches { -- Known contacts + items cardinality matches {1..*; unordered} matches { + ELEMENT[at0121] occurrences matches {0..1} matches { -- Confirmed contact + value matches { + DV_CODED_TEXT matches { + defining_code matches { + [local:: + at0122, -- Yes + at0123, -- No + at0124] -- Unknown + } + } + } + } + ELEMENT[at0131] occurrences matches {0..1} matches { -- Contact setting + value matches { + DV_TEXT matches {*} + } + } + CLUSTER[at0125] occurrences matches {0..1} matches { -- Contact details + items cardinality matches {1..*; unordered} matches { + ELEMENT[at0126] occurrences matches {0..1} matches { -- Case identifier + value matches { + DV_TEXT matches {*} + DV_IDENTIFIER matches {*} + } + } + ELEMENT[at0129] occurrences matches {0..1} matches { -- Date of first exposure + value matches { + DV_DATE_TIME matches {*} + } + } + ELEMENT[at0130] occurrences matches {0..1} matches { -- Date of last exposure + value matches { + DV_DATE_TIME matches {*} + } + } + } + } + } + } + CLUSTER[at0134] occurrences matches {0..1} matches { -- Location history + items cardinality matches {1..*; unordered} matches { + ELEMENT[at0132] occurrences matches {0..*} matches { -- Likely location for exposure + value matches { + DV_TEXT matches {*} + } + } + allow_archetype CLUSTER[at0135] occurrences matches {0..*} matches { -- Location visited + include + archetype_id/value matches {/.*/} + } + } + } + ELEMENT[at0072] occurrences matches {0..1} matches { -- Type of accommodations and sleeping arrangements + value matches { + DV_CODED_TEXT matches {*} + } + } + ELEMENT[at0116] occurrences matches {0..1} matches { -- Visited healthcare facilities + value matches { + DV_CODED_TEXT matches { + defining_code matches { + [local:: + at0117, -- Yes + at0118, -- No + at0119] -- Unknown + } + } + } + } + ELEMENT[at0049] occurrences matches {0..*} matches { -- Recreational activities + value matches { + DV_CODED_TEXT matches { + defining_code matches { + [local:: + at0050, -- Safari + at0051, -- Hiking + at0052, -- Swimming + at0053, -- Ocean (scuba diving, marine life exposure) + at0054, -- Freshwater exposure (lake, river, stream) + at0055, -- Swimming pools and hot tubs + at0056, -- Rafting/boating + at0057, -- Sightseeing + at0058] -- Other adventuresome activities + } + } + } + } + ELEMENT[at0102] occurrences matches {0..1} matches { -- Common exposures + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0103] occurrences matches {0..1} matches { -- Insect bites + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0085] occurrences matches {0..*} matches { -- Foods eaten + value matches { + DV_CODED_TEXT matches { + defining_code matches { + [local:: + at0086, -- Raw produce + at0087, -- Undercooked meat + at0088, -- Unpasteurized dairy products + at0089] -- Seafood + } + } + } + } + ELEMENT[at0104] occurrences matches {0..1} matches { -- Source of drinking water + value matches { + DV_TEXT matches {*} + } + } + ELEMENT[at0091] occurrences matches {0..*} matches { -- Other exposures + value matches { + DV_CODED_TEXT matches { + defining_code matches { + [local:: + at0092, -- Sexual activity during travel (use of condoms, new partner) + at0093, -- Tattoos or piercings received while traveling + at0094, -- Animal or arthropod bites, stings, or scratches + at0095] -- Known outbreaks in the countries visited + } + } + DV_TEXT matches {*} + } + } + ELEMENT[at0096] occurrences matches {0..*} matches { -- Use of travel precautions + value matches { + DV_CODED_TEXT matches { + defining_code matches { + [local:: + at0097, -- Effective insect repellent (DEET 25%–40% or other EPA-registered product) + at0098, -- Bed nets + at0099] -- Adherence to malaria prophylaxis + } + } + } + } + allow_archetype CLUSTER[at0109] occurrences matches {0..*} matches { -- Exposure details + include + archetype_id/value matches {/.*/} + } + } + } + } + } + } + } + } + protocol matches { + ITEM_TREE[at0100] matches { -- Item tree + items cardinality matches {0..*; unordered} matches { + allow_archetype CLUSTER[at0101] occurrences matches {0..*} matches { -- Extension + include + archetype_id/value matches {/.*/} + } + } + } + } + } + +ontology + term_definitions = < + ["en"] = < + items = < + ["at0000"] = < + text = <"Travel trip history"> + description = <"Details of a travel trip with respect to exposure to potential risk."> + > + ["at0001"] = < + text = <"History"> + description = <"@ internal @"> + > + ["at0002"] = < + text = <"Any event"> + description = <"*"> + > + ["at0003"] = < + text = <"Tree"> + description = <"@ internal @"> + > + ["at0049"] = < + text = <"Recreational activities"> + description = <"*"> + > + ["at0050"] = < + text = <"Safari"> + description = <"*"> + > + ["at0051"] = < + text = <"Hiking"> + description = <"*"> + > + ["at0052"] = < + text = <"Swimming"> + description = <"*"> + > + ["at0053"] = < + text = <"Ocean (scuba diving, marine life exposure)"> + description = <"*"> + > + ["at0054"] = < + text = <"Freshwater exposure (lake, river, stream)"> + description = <"*"> + > + ["at0055"] = < + text = <"Swimming pools and hot tubs"> + description = <"*"> + > + ["at0056"] = < + text = <"Rafting/boating"> + description = <"*"> + > + ["at0057"] = < + text = <"Sightseeing"> + description = <"*"> + > + ["at0058"] = < + text = <"Other adventuresome activities"> + description = <"*"> + > + ["at0059"] = < + text = <"Reason for travel"> + description = <"*"> + > + ["at0060"] = < + text = <"Leisure"> + description = <"*"> + > + ["at0061"] = < + text = <"Visiting friends and relatives"> + description = <"*"> + > + ["at0062"] = < + text = <"Business"> + description = <"*"> + > + ["at0063"] = < + text = <"Research/education"> + description = <"*"> + > + ["at0064"] = < + text = <"Missionary/volunteer work"> + description = <"*"> + > + ["at0065"] = < + text = <"Providing medical care"> + description = <"*"> + > + ["at0066"] = < + text = <"Receiving medical care"> + description = <"*"> + > + ["at0070"] = < + text = <"Duration of travel"> + description = <"*"> + > + ["at0071"] = < + text = <"Date of return"> + description = <"*"> + > + ["at0072"] = < + text = <"Type of accommodations and sleeping arrangements"> + description = <"*"> + > + ["at0085"] = < + text = <"Foods eaten"> + description = <"*"> + > + ["at0086"] = < + text = <"Raw produce"> + description = <"*"> + > + ["at0087"] = < + text = <"Undercooked meat"> + description = <"*"> + > + ["at0088"] = < + text = <"Unpasteurized dairy products"> + description = <"*"> + > + ["at0089"] = < + text = <"Seafood"> + description = <"*"> + > + ["at0091"] = < + text = <"Other exposures"> + description = <"*"> + > + ["at0092"] = < + text = <"Sexual activity during travel (use of condoms, new partner)"> + description = <"*"> + > + ["at0093"] = < + text = <"Tattoos or piercings received while traveling"> + description = <"*"> + > + ["at0094"] = < + text = <"Animal or arthropod bites, stings, or scratches"> + description = <"*"> + > + ["at0095"] = < + text = <"Known outbreaks in the countries visited"> + description = <"*"> + > + ["at0096"] = < + text = <"Use of travel precautions"> + description = <"*"> + > + ["at0097"] = < + text = <"Effective insect repellent (DEET 25%–40% or other EPA-registered product)"> + description = <"*"> + > + ["at0098"] = < + text = <"Bed nets"> + description = <"*"> + > + ["at0099"] = < + text = <"Adherence to malaria prophylaxis"> + description = <"*"> + > + ["at0100"] = < + text = <"Item tree"> + description = <"@ internal @"> + > + ["at0101"] = < + text = <"Extension"> + description = <"*"> + > + ["at0102"] = < + text = <"Common exposures"> + description = <"*"> + > + ["at0103"] = < + text = <"Insect bites"> + description = <"*"> + comment = <" (for example, mosquito, tick, sand fly, tsetse fly)"> + > + ["at0104"] = < + text = <"Source of drinking water"> + description = <"*"> + > + ["at0109"] = < + text = <"Exposure details"> + description = <"*"> + > + ["at0111"] = < + text = <"Recent travel"> + description = <"Has the patient travelled recently? The definition of 'recently' may vary depending on circumstances of the wider patient story and known currnet infection risk."> + > + ["at0112"] = < + text = <"Yes"> + description = <"The patient has recently traveled."> + > + ["at0113"] = < + text = <"No"> + description = <"The patient has not recently traveled."> + > + ["at0114"] = < + text = <"Unknown"> + description = <"Unknown."> + > + ["at0115"] = < + text = <"Incubation period"> + description = <"*"> + > + ["at0116"] = < + text = <"Visited healthcare facilities"> + description = <"*"> + > + ["at0117"] = < + text = <"Yes"> + description = <"The patient has visited a healthcare facility."> + > + ["at0118"] = < + text = <"No"> + description = <"The patient has not visited a healthcare facility."> + > + ["at0119"] = < + text = <"Unknown"> + description = <"It is not known if the patient has visited a healthcare facility."> + > + ["at0120"] = < + text = <"Known contacts"> + description = <"*"> + > + ["at0121"] = < + text = <"Confirmed contact"> + description = <"*"> + > + ["at0122"] = < + text = <"Yes"> + description = <"The patient has had contact with a confirmed case within the known incubation period."> + > + ["at0123"] = < + text = <"No"> + description = <"The patient has had not contact with a confirmed case within the known incubation period."> + > + ["at0124"] = < + text = <"Unknown"> + description = <"It is unknown if the patient has had contact with a confirmed case within the known incubation period."> + > + ["at0125"] = < + text = <"Contact details"> + description = <"*"> + > + ["at0126"] = < + text = <"Case identifier"> + description = <"*"> + > + ["at0129"] = < + text = <"Date of first exposure"> + description = <"*"> + > + ["at0130"] = < + text = <"Date of last exposure"> + description = <"*"> + > + ["at0131"] = < + text = <"Contact setting"> + description = <"*"> + > + ["at0132"] = < + text = <"Likely location for exposure"> + description = <"*"> + > + ["at0134"] = < + text = <"Location history"> + description = <"*"> + > + ["at0135"] = < + text = <"Location visited"> + description = <"*"> + > + > + > + ["nb"] = < + items = < + ["at0000"] = < + text = <"Reisehistorie"> + description = <"Detaljer om en reise med hensyn til eksponering for potensiell risiko."> + > + ["at0001"] = < + text = <"History"> + description = <"@ internal @"> + > + ["at0002"] = < + text = <"Any event"> + description = <"*"> + > + ["at0003"] = < + text = <"Tree"> + description = <"@ internal @"> + > + ["at0049"] = < + text = <"Fritidsaktivitet"> + description = <"*"> + > + ["at0050"] = < + text = <"Safari"> + description = <"*"> + > + ["at0051"] = < + text = <"Fottur"> + description = <"*"> + > + ["at0052"] = < + text = <"Svømming"> + description = <"*"> + > + ["at0053"] = < + text = <"Hav (dykking, eksponering for marint liv)"> + description = <"*"> + > + ["at0054"] = < + text = <"Ferskvannseksponering (innsjø, elv, bekk)"> + description = <"*"> + > + ["at0055"] = < + text = <"Svømmebassenger og boblebad"> + description = <"*"> + > + ["at0056"] = < + text = <"Rafting / båt"> + description = <"*"> + > + ["at0057"] = < + text = <"Sightseeing"> + description = <"*"> + > + ["at0058"] = < + text = <"Andre spennende aktiviteter"> + description = <"*"> + > + ["at0059"] = < + text = <"Årsak til reise"> + description = <"*"> + > + ["at0060"] = < + text = <"Fritid"> + description = <"*"> + > + ["at0061"] = < + text = <"Besøke venner og slektninger"> + description = <"*"> + > + ["at0062"] = < + text = <"Forretning"> + description = <"*"> + > + ["at0063"] = < + text = <"Forskning/utdanning"> + description = <"*"> + > + ["at0064"] = < + text = <"Misjons-/frivillig arbeid"> + description = <"*"> + > + ["at0065"] = < + text = <"Gi medisinsk behandling"> + description = <"*"> + > + ["at0066"] = < + text = <"Motta medisinsk behandling"> + description = <"*"> + > + ["at0070"] = < + text = <"Lengden på reisen"> + description = <"*"> + > + ["at0071"] = < + text = <"Dato for hjemkomst"> + description = <"*"> + > + ["at0072"] = < + text = <"Type innkvartering og overnatting"> + description = <"*"> + > + ["at0085"] = < + text = <"Mat spist"> + description = <"*"> + > + ["at0086"] = < + text = <"Råvarer"> + description = <"*"> + > + ["at0087"] = < + text = <"Underkokt kjøtt"> + description = <"*"> + > + ["at0088"] = < + text = <"Upasteuriserte meieriprodukter"> + description = <"*"> + > + ["at0089"] = < + text = <"Sjømat"> + description = <"*"> + > + ["at0091"] = < + text = <"Andre eksponeringer"> + description = <"*"> + > + ["at0092"] = < + text = <"Seksuell aktivitet under reise (bruk av kondom, ny partner)"> + description = <"*"> + > + ["at0093"] = < + text = <"Tatoveringer eller piercinger tatt under reise"> + description = <"*"> + > + ["at0094"] = < + text = <"Bitt, stikk eller ripe fra dyr eller leddyr"> + description = <"*"> + > + ["at0095"] = < + text = <"Kjente utbrudd i besøkte land"> + description = <"*"> + > + ["at0096"] = < + text = <"Bruk av reiseforholdsregler"> + description = <"*"> + > + ["at0097"] = < + text = <"Effektiv insektavvisende middel (DEET 25% –40% eller annet EPA-registrert produkt)"> + description = <"*"> + > + ["at0098"] = < + text = <"Sengegarn/-nett"> + description = <"*"> + > + ["at0099"] = < + text = <"Overholdelse av malaria profylakse"> + description = <"*"> + > + ["at0100"] = < + text = <"Item tree"> + description = <"@ internal @"> + > + ["at0101"] = < + text = <"Utvidelse"> + description = <"*"> + > + ["at0102"] = < + text = <"Vanlige eksponeringer"> + description = <"*"> + > + ["at0103"] = < + text = <"Insektbutt"> + description = <"*"> + comment = <"* (for example, mosquito, tick, sand fly, tsetse fly) (en)"> + > + ["at0104"] = < + text = <"Kilde for drikkevann"> + description = <"*"> + > + ["at0109"] = < + text = <"Eksponeringsdetaljer"> + description = <"*"> + > + ["at0111"] = < + text = <"*DV_BOOLEAN (en)"> + description = <"*"> + > + ["at0112"] = < + text = <"*Yes (en)"> + description = <"*The patient has recently traveled. (en)"> + > + ["at0113"] = < + text = <"*No (en)"> + description = <"*The patient has not recently traveled. (en)"> + > + ["at0114"] = < + text = <"*Unknown (en)"> + description = <"*Unknown. (en)"> + > + ["at0115"] = < + text = <"*DV_DURATION (en)"> + description = <"*"> + > + ["at0116"] = < + text = <"*DV_CODED_TEXT (en)"> + description = <"*"> + > + ["at0117"] = < + text = <"*Yes (en)"> + description = <"*The patient has visited a healthcare facility. (en)"> + > + ["at0118"] = < + text = <"*No (en)"> + description = <"*The patient has not visited a healthcare facility. (en)"> + > + ["at0119"] = < + text = <"*Unknown (en)"> + description = <"*It is not known if the patient has visited a healthcare facility. (en)"> + > + ["at0120"] = < + text = <"*CLUSTER (en)"> + description = <"*"> + > + ["at0121"] = < + text = <"*DV_CODED_TEXT (en)"> + description = <"*"> + > + ["at0122"] = < + text = <"*Yes (en)"> + description = <"*The patient has had contact with a confirmed case within the known incubation period. (en)"> + > + ["at0123"] = < + text = <"*No (en)"> + description = <"*The patient has had not contact with a confirmed case within the known incubation period. (en)"> + > + ["at0124"] = < + text = <"*Unknown (en)"> + description = <"*It is unknown if the patient has had contact with a confirmed case within the known incubation period. (en)"> + > + ["at0125"] = < + text = <"*CLUSTER (en)"> + description = <"*"> + > + ["at0126"] = < + text = <"*DV_TEXT (en)"> + description = <"*"> + > + ["at0129"] = < + text = <"*DV_DATE_TIME (en)"> + description = <"*"> + > + ["at0130"] = < + text = <"*DV_DATE_TIME (en)"> + description = <"*"> + > + ["at0131"] = < + text = <"*DV_TEXT (en)"> + description = <"*"> + > + ["at0132"] = < + text = <"*DV_TEXT (en)"> + description = <"*"> + > + ["at0134"] = < + text = <"*CLUSTER (en)"> + description = <"*"> + > + ["at0135"] = < + text = <"*CLUSTER_SLOT (en)"> + description = <"*"> + > + > + > + ["fi"] = < + items = < + ["at0000"] = < + text = <"Matkustushistoria"> + description = <"Matkustustiedot, jolloin on voinut altistua tartunnalle tai on ollut riski altistumiselle."> + > + ["at0001"] = < + text = <"History"> + description = <"@ internal @"> + > + ["at0002"] = < + text = <"*Any event(en)"> + description = <"*"> + > + ["at0003"] = < + text = <"Tree"> + description = <"@ internal @"> + > + ["at0049"] = < + text = <"Aktiviteetit"> + description = <"*"> + > + ["at0050"] = < + text = <"Safari"> + description = <"*"> + > + ["at0051"] = < + text = <"Vaellus"> + description = <"*"> + > + ["at0052"] = < + text = <"Uinti"> + description = <"*"> + > + ["at0053"] = < + text = <"Aktiviteetit merellä"> + description = <"*"> + > + ["at0054"] = < + text = <"Aktiviteetit sisävesillä"> + description = <"*"> + > + ["at0055"] = < + text = <"Uima-allas / poreamme"> + description = <"*"> + > + ["at0056"] = < + text = <"Koskenlasku / veneily"> + description = <"*"> + > + ["at0057"] = < + text = <"Kiertoajelu"> + description = <"*"> + > + ["at0058"] = < + text = <"Muu aktiviteetti"> + description = <"*"> + > + ["at0059"] = < + text = <"Matkustuksen syy"> + description = <"*"> + > + ["at0060"] = < + text = <"Vapaa-ajan matkustus"> + description = <"*"> + > + ["at0061"] = < + text = <"Sukulaisten tai ystävien luona vierailu"> + description = <"*"> + > + ["at0062"] = < + text = <"Liikematka"> + description = <"*"> + > + ["at0063"] = < + text = <"Tutkimus/opetusmatka"> + description = <"*"> + > + ["at0064"] = < + text = <"Vapaaehtoistyö / Lähetystyö"> + description = <"*"> + > + ["at0065"] = < + text = <"Sairaanhoidon tarjoaminen"> + description = <"*"> + > + ["at0066"] = < + text = <"Sairaanhoidon saaminen"> + description = <"*"> + > + ["at0070"] = < + text = <"Matkan kesto"> + description = <"*"> + > + ["at0071"] = < + text = <"Paluu pvm"> + description = <"*"> + > + ["at0072"] = < + text = <"Majoitusjärjestelty"> + description = <"*"> + > + ["at0085"] = < + text = <"Syöty ruoka"> + description = <"*"> + > + ["at0086"] = < + text = <"Raat tuotteet"> + description = <"*"> + > + ["at0087"] = < + text = <"Alikypsennetty liha"> + description = <"*"> + > + ["at0088"] = < + text = <"Pastöroimattomat maitotuotteet"> + description = <"*"> + > + ["at0089"] = < + text = <"Merenelävät"> + description = <"*"> + > + ["at0091"] = < + text = <"Muut altistumiset"> + description = <"*"> + > + ["at0092"] = < + text = <"Seksuaalinen aktiivisuus matkan aikana ( uusi kumppani, kondomin käyttö )"> + description = <"*"> + > + ["at0093"] = < + text = <"Hankitut tatuoinnit / lävistykset matkan aikana"> + description = <"*"> + > + ["at0094"] = < + text = <"Hyönteisten/eläinten puremat, pistot tai raapaisut"> + description = <"*"> + > + ["at0095"] = < + text = <"Tiedetyt puhkeamiset vierailuilla alueilla"> + description = <"*"> + > + ["at0096"] = < + text = <"Matkustus rokotukset"> + description = <"*"> + > + ["at0097"] = < + text = <"Karkotteiden käyttö"> + description = <"*"> + > + ["at0098"] = < + text = <"Harsotettu sänky"> + description = <"*"> + > + ["at0099"] = < + text = <"Malarian ehkäisy"> + description = <"*"> + > + ["at0100"] = < + text = <"Item tree"> + description = <"@ internal @"> + > + ["at0101"] = < + text = <"Laajennus"> + description = <"*"> + > + ["at0102"] = < + text = <"Yleinen altistuminen"> + description = <"*"> + > + ["at0103"] = < + text = <"Hyönteisen purema / pistos"> + description = <"*"> + comment = <"* (for example, mosquito, tick, sand fly, tsetse fly)(en)"> + > + ["at0104"] = < + text = <"Juomaveden alkuperä"> + description = <"*"> + > + ["at0109"] = < + text = <"Tietoa altistumisesta"> + description = <"*"> + > + ["at0111"] = < + text = <"Viimeaikainen matkustaminen"> + description = <"*Has the patient travelled recently? The definition of 'recently' may vary depending on circumstances of the wider patient story and known currnet infection risk.(en)"> + > + ["at0112"] = < + text = <"Kyllä"> + description = <"*The patient has recently traveled.(en)"> + > + ["at0113"] = < + text = <"Ei"> + description = <"*The patient has not recently traveled.(en)"> + > + ["at0114"] = < + text = <"Ei tietoa"> + description = <"*Unknown.(en)"> + > + ["at0115"] = < + text = <"itämisaikai"> + description = <"*"> + > + ["at0116"] = < + text = <"Vieraulut terveydenhuollon tiloissa"> + description = <"*"> + > + ["at0117"] = < + text = <"Kyllä"> + description = <"*The patient has visited a healthcare facility.(en)"> + > + ["at0118"] = < + text = <"Ei"> + description = <"*The patient has not visited a healthcare facility.(en)"> + > + ["at0119"] = < + text = <"Ei tietoa"> + description = <"*It is not known if the patient has visited a healthcare facility.(en)"> + > + ["at0120"] = < + text = <"Tiedetyt kontaktit"> + description = <"*"> + > + ["at0121"] = < + text = <"Varmistetut kontaktit"> + description = <"*"> + > + ["at0122"] = < + text = <"Kyllä"> + description = <"*The patient has had contact with a confirmed case within the known incubation period.(en)"> + > + ["at0123"] = < + text = <"Ei"> + description = <"*The patient has had not contact with a confirmed case within the known incubation period.(en)"> + > + ["at0124"] = < + text = <"Ei tietoa"> + description = <"*It is unknown if the patient has had contact with a confirmed case within the known incubation period.(en)"> + > + ["at0125"] = < + text = <"Kontaktin yhteystiedot"> + description = <"*"> + > + ["at0126"] = < + text = <"Tapaustunniste"> + description = <"*"> + > + ["at0129"] = < + text = <"Ensimmäisen altistumisen pvm"> + description = <"*"> + > + ["at0130"] = < + text = <"Viimeinen altistumisen pvm"> + description = <"*"> + > + ["at0131"] = < + text = <"Yhteystiedot"> + description = <"*"> + > + ["at0132"] = < + text = <"Oletettu sijainti altistumiselle"> + description = <"*"> + > + ["at0134"] = < + text = <"Sijainnin historia"> + description = <"*"> + > + ["at0135"] = < + text = <"Vierailu sijainnissa"> + description = <"*"> + > + > + > + ["it"] = < + items = < + ["at0000"] = < + text = <"Cronologia del viaggio"> + description = <"Dettagli del viaggio rispetto all'esposizione al rischio potenziale."> + > + ["at0001"] = < + text = <"History"> + description = <"@ internal @"> + > + ["at0002"] = < + text = <"Qualsiasi evento"> + description = <"*"> + > + ["at0003"] = < + text = <"Tree"> + description = <"@ internal @"> + > + ["at0049"] = < + text = <"Attività ricreative"> + description = <"*"> + > + ["at0050"] = < + text = <"Safari"> + description = <"*"> + > + ["at0051"] = < + text = <"Escursioni"> + description = <"*"> + > + ["at0052"] = < + text = <"Nuoto"> + description = <"*"> + > + ["at0053"] = < + text = <"Mare (immersione, esposizione alla vita marina)"> + description = <"*"> + > + ["at0054"] = < + text = <"Bagni in acqua dolce (lago, fiume, torrente)"> + description = <"*"> + > + ["at0055"] = < + text = <"Piscine e vasche idromassaggio"> + description = <"*"> + > + ["at0056"] = < + text = <"Rafting/boating"> + description = <"*"> + > + ["at0057"] = < + text = <"Visite turistiche"> + description = <"*"> + > + ["at0058"] = < + text = <"Altre attività avventurose"> + description = <"*"> + > + ["at0059"] = < + text = <"Scopo del viaggio"> + description = <"*"> + > + ["at0060"] = < + text = <"Piacere"> + description = <"*"> + > + ["at0061"] = < + text = <"Visita di amici e parenti"> + description = <"*"> + > + ["at0062"] = < + text = <"Lavoro"> + description = <"*"> + > + ["at0063"] = < + text = <"Ricerca/Studio"> + description = <"*"> + > + ["at0064"] = < + text = <"Lavoro missionario/volontario"> + description = <"*"> + > + ["at0065"] = < + text = <"Fornire assistenza medica"> + description = <"*"> + > + ["at0066"] = < + text = <"Ricevere assistenza medica"> + description = <"*"> + > + ["at0070"] = < + text = <"Durata del viaggio"> + description = <"*"> + > + ["at0071"] = < + text = <"Data di ritorno"> + description = <"*"> + > + ["at0072"] = < + text = <"Tipo di alloggio e sistemazione dei posti letto"> + description = <"*"> + > + ["at0085"] = < + text = <"Cibi mangiati"> + description = <"*"> + > + ["at0086"] = < + text = <"Prodotti grezzi"> + description = <"*"> + > + ["at0087"] = < + text = <"Carne cotta"> + description = <"*"> + > + ["at0088"] = < + text = <"Prodotti lattiero-caseari non pastorizzati"> + description = <"*"> + > + ["at0089"] = < + text = <"Cibo di mare"> + description = <"*"> + > + ["at0091"] = < + text = <"Altre esposizioni"> + description = <"*"> + > + ["at0092"] = < + text = <"Attività sessuale durante il viaggio (uso del preservativo, nuovo partner)"> + description = <"*"> + > + ["at0093"] = < + text = <"Tatuaggi o piercing ricevuti durante il viaggio"> + description = <"*"> + > + ["at0094"] = < + text = <"Morsi, punture o graffi di animali o artropodi (it)"> + description = <"*"> + > + ["at0095"] = < + text = <"Focolai noti nei paesi visitati"> + description = <"*"> + > + ["at0096"] = < + text = <"Uso delle precauzioni di viaggio"> + description = <"*"> + > + ["at0097"] = < + text = <"Repellente efficace per insetti (DEET 25%-40% o altro prodotto registrato EPA)"> + description = <"*"> + > + ["at0098"] = < + text = <"Reti da letto"> + description = <"*"> + > + ["at0099"] = < + text = <"Aderenza alla profilassi della malaria"> + description = <"*"> + > + ["at0100"] = < + text = <"Item tree"> + description = <"@ internal @"> + > + ["at0101"] = < + text = <"Estensione"> + description = <"*"> + > + ["at0102"] = < + text = <"Esposizioni comuni"> + description = <"*"> + > + ["at0103"] = < + text = <"Morsi di insetti"> + description = <"*"> + comment = <"* (for example, mosquito, tick, sand fly, tsetse fly)(en)"> + > + ["at0104"] = < + text = <"Fonte di acqua potabile"> + description = <"*"> + > + ["at0109"] = < + text = <"Dettagli dell'esposizione"> + description = <"*"> + > + ["at0111"] = < + text = <"Viaggio recente"> + description = <"Il paziente ha viaggiato di recente? La definizione di \"di recente\" può variare a seconda delle circostanze della storia più ampia del paziente e del rischio noto di infezione corrente."> + > + ["at0112"] = < + text = <"Si"> + description = <"Il paziente ha viaggiato di recente. "> + > + ["at0113"] = < + text = <"No"> + description = <"Il paziente non ha viaggiato di recente."> + > + ["at0114"] = < + text = <"Sconosciuto"> + description = <"Sconosciuto"> + > + ["at0115"] = < + text = <"Periodo di incubazione"> + description = <"*"> + > + ["at0116"] = < + text = <"Strutture sanitarie visitate"> + description = <"*"> + > + ["at0117"] = < + text = <"Si"> + description = <"Il paziente ha visitato una struttura sanitaria."> + > + ["at0118"] = < + text = <"No"> + description = <"Il paziente non ha visitato una struttura sanitaria."> + > + ["at0119"] = < + text = <"Sconosciuto"> + description = <"Non si sa se il paziente ha visitato una struttura sanitaria. "> + > + ["at0120"] = < + text = <"Contatti noti"> + description = <"*"> + > + ["at0121"] = < + text = <"Contatto confermato"> + description = <"*"> + > + ["at0122"] = < + text = <"Si"> + description = <"Il paziente ha avuto contatto con un caso confermato nel periodo di incubazione conosciuto."> + > + ["at0123"] = < + text = <"No"> + description = <"Il paziente non ha avuto contatti con un caso confermato nel periodo di incubazione conosciuto. "> + > + ["at0124"] = < + text = <"Sconosciuto"> + description = <"Non si sa se il paziente ha avuto contatti con un caso confermato entro il periodo di incubazione noto. "> + > + ["at0125"] = < + text = <"Dettagli del contatto"> + description = <"*"> + > + ["at0126"] = < + text = <"Identificatore del caso"> + description = <"*"> + > + ["at0129"] = < + text = <"Data della prima esposizione"> + description = <"*"> + > + ["at0130"] = < + text = <"Data dell'ultima esposizione"> + description = <"*"> + > + ["at0131"] = < + text = <"Impostazione del contatto"> + description = <"*"> + > + ["at0132"] = < + text = <"Posizione ideale per l'esposizione"> + description = <"*"> + > + ["at0134"] = < + text = <"Storia della posizione"> + description = <"*"> + > + ["at0135"] = < + text = <"Località visitata"> + description = <"*"> + > + > + > + > diff --git a/better-template/src/test/resources/opt_json/COVID-19-Screening_t.json b/better-template/src/test/resources/opt_json/COVID-19-Screening_t.json new file mode 100644 index 000000000..06205eeb6 --- /dev/null +++ b/better-template/src/test/resources/opt_json/COVID-19-Screening_t.json @@ -0,0 +1,6692 @@ +{ + "@type":"TEMPLATE", + "uid":"b86e0402-7378-4ef0-a3ba-378e99c7b277", + "description":{ + "@type":"RESOURCE_DESCRIPTION", + "originalAuthor":{ + + }, + "otherContributors":[ + + ], + "lifecycleState":{ + "codeString":"Initial" + }, + "ipAcknowledgements":{ + + }, + "references":{ + + }, + "conversionDetails":{ + + }, + "otherDetails":{ + "MetaDataSet:Sample Set ":"Template metadata sample set ", + "Acknowledgements":"", + "Business Process Level":"", + "Care setting":"", + "Client group":"", + "Clinical Record Element":"", + "Copyright":"", + "Issues":"", + "Owner":"", + "Sign off":"", + "Speciality":"", + "User roles":"", + "MD5-CAM-1.0.1":"c900c0530853ee5e2391704a00ae471f", + "PARENT:MD5-CAM-1.0.1":"6562F732112B8B3F94790E178F4243A5" + }, + "details":{ + "en":{ + "@type":"RESOURCE_DESCRIPTION_ITEM", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"en" + }, + "purpose":"", + "use":"", + "misuse":"", + "originalResourceUri":{ + + }, + "otherDetails":{ + + } + }, + "es-ar":{ + "@type":"RESOURCE_DESCRIPTION_ITEM", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"es-ar" + }, + "purpose":"Registrar una consulta como una nota de evolucion", + "keywords":[ + "Evolucion", + "Notas", + "Encuentro", + "Consulta" + ], + "copyright":"© Nasjonal IKT HF", + "originalResourceUri":{ + + }, + "otherDetails":{ + + } + }, + "nb":{ + "@type":"RESOURCE_DESCRIPTION_ITEM", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"nb" + }, + "purpose":"For å registrere detaljer om en enkel interaksjon, kontakt eller omsorgshendelse mellom et individ og helsepersonell, der kontakten omhandler helsetjenester. Den kliniske kontakten kan være direkte ved ansikt-til-ansikt, indirekte via telefon eller videokonferanse, eller asynkron via elektronisk konsultasjon eller brev.", + "keywords":[ + "møte", + "kontakt", + "besøk", + "visitt", + "omsorgshendelse", + "konsultasjon", + "pasientkontakt", + "time", + "poliklinisk", + "hendelse", + "aktivitet", + "e-konsultasjon", + "elektronisk", + "telemedisinsk" + ], + "use":"Brukes som en generisk container på dokument-nivå for å registrere detaljer om en enkel interaksjon, kontakt eller omsorgshendelse mellom et individ og helsepersonell. Den kliniske kontakten kan være direkte ved ansikt-til-ansikt, indirekte via telefon eller videokonferanse, eller asynkron via elektronisk konsultasjon eller brev. Modalitet kan registreres, om nødvendig, via referansemodell-attributten COMPOSITION/mode.\r\n\r\nInnholdskomponenten er bevisst latt være ubegrenset. Dette tillater bruk av enhver SECTION- og/eller ENTRY-arketype som er nødvendig/hensiktsmessig i templaten brukt i den aktuelle kliniske konteksten.\r\n\r\nTross ubegrenset plass for klinisk innhold, gir spesifikasjonen av COMPOSITION.encounter betydelig verdi ved å tillate eksplisitt spørring på alle kontakter innenfor en pasientjournal.\r\n\r\nKomponenten 'Context' har en valgfri utvidelse ('SLOT') som kan brukes ved design av templaten, for å:\r\n-legge til valgfri kontekstuell informasjon om, f.eks., episoden; eller\r\n-tillate harmonisering eller justering i forhold til andre informasjonsmodeller, f.eks. FHIR eller CIMI, som f.eks. eksplisitte representasjoner av 'Participants' som i en openEHR-arketype ordinært vil håndteres av openEHR-referansemodellen.\r\n\r\nTypiske eksempler kan være en poliklinikktime, en sykepleierobservasjon eller en telemedisinsk konsultasjon.", + "misuse":"Brukes ikke til registrering av detaljer om et helt behandlingsforløp.\r\nBrukes ikke til å inneholde persistent, oppsummert informasjon om individet, som f.eks. problemliste eller medikamentliste.\r\nBrukes ikke som rapport fra en diagnostisk service, som billeddiagnostikk eller laboratorieprøve.\r\nBrukes ikke til å representere FHIR-ressursen av samme navn - disse har forskjellig omfang og bruksområde.", + "copyright":"© Nasjonal IKT HF", + "originalResourceUri":{ + + }, + "otherDetails":{ + + } + }, + "ko":{ + "@type":"RESOURCE_DESCRIPTION_ITEM", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"ko" + }, + "purpose":"외래기록, 경과기록, 간호기록과 일반적인 노트 등과 같은 환자를 대면한 후 작성하는 기록", + "keywords":[ + "*경과(ko)", + "*노트(ko)", + "*외래(ko)" + ], + "copyright":"© Nasjonal IKT HF", + "originalResourceUri":{ + + }, + "otherDetails":{ + + } + }, + "ar-sy":{ + "@type":"RESOURCE_DESCRIPTION_ITEM", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"ar-sy" + }, + "purpose":"تسجيل المقابلة على هيئة ملاحظة تقدم الحالة", + "keywords":[ + "التقدم", + "ملاحظة", + "المقابلة" + ], + "copyright":"© Nasjonal IKT HF", + "originalResourceUri":{ + + }, + "otherDetails":{ + + } + } + } + }, + "parentArchetypeId":"openEHR-EHR-COMPOSITION.encounter.v1", + "differential":true, + "archetypeId":{ + "@type":"ARCHETYPE_HRID", + "value":"openEHR-EHR-COMPOSITION.t_encounter.v1" + }, + "definition":{ + "@type":"C_COMPLEX_OBJECT", + "rmTypeName":"COMPOSITION", + "nodeId":"at0000.1", + "attributes":[ + { + "@type":"C_ATTRIBUTE", + "rmAttributeName":"context", + "children":[ + { + "@type":"C_COMPLEX_OBJECT", + "rmTypeName":"EVENT_CONTEXT", + "attributes":[ + + ], + "attributeTuples":[ + + ] + } + ] + }, + { + "@type":"C_ATTRIBUTE", + "rmAttributeName":"content", + "existence":"0..1", + "children":[ + { + "@type":"C_ARCHETYPE_ROOT", + "rmTypeName":"SECTION", + "occurrences":"0..1", + "nodeId":"at0.1", + "attributes":[ + + ], + "attributeTuples":[ + + ], + "archetypeRef":"openEHR-EHR-SECTION.ovl-adhoc-000.v1", + "referenceType":"archetypeOverlay" + }, + { + "@type":"C_ARCHETYPE_ROOT", + "rmTypeName":"SECTION", + "occurrences":"0..1", + "nodeId":"at0.2", + "attributes":[ + + ], + "attributeTuples":[ + + ], + "archetypeRef":"openEHR-EHR-SECTION.ovl-adhoc-006.v1", + "referenceType":"archetypeOverlay" + }, + { + "@type":"C_ARCHETYPE_ROOT", + "rmTypeName":"SECTION", + "occurrences":"0..1", + "nodeId":"at0.3", + "attributes":[ + + ], + "attributeTuples":[ + + ], + "archetypeRef":"openEHR-EHR-SECTION.ovl-adhoc-009.v1", + "referenceType":"archetypeOverlay" + } + ] + } + ], + "attributeTuples":[ + + ] + }, + "terminology":{ + "@type":"ARCHETYPE_TERMINOLOGY", + "conceptCode":"at0000", + "termDefinitions":{ + "ar-sy":{ + "at0000.1":{ + "@type":"ARCHETYPE_TERM", + "code":"at0000.1", + "text":"COVID-19-Screening", + "description":"*Interaction, contact or care event between a subject of care and healthcare provider(s).(en)" + } + }, + "es-ar":{ + "at0000.1":{ + "@type":"ARCHETYPE_TERM", + "code":"at0000.1", + "text":"COVID-19-Screening", + "description":"*Interaction, contact or care event between a subject of care and healthcare provider(s).(en)" + } + }, + "en":{ + "at0000.1":{ + "@type":"ARCHETYPE_TERM", + "code":"at0000.1", + "text":"COVID-19-Screening", + "description":"Interaction, contact or care event between a subject of care and healthcare provider(s)." + } + }, + "ko":{ + "at0000.1":{ + "@type":"ARCHETYPE_TERM", + "code":"at0000.1", + "text":"COVID-19-Screening", + "description":"*Interaction, contact or care event between a subject of care and healthcare provider(s).(en)" + } + }, + "nb":{ + "at0000.1":{ + "@type":"ARCHETYPE_TERM", + "code":"at0000.1", + "text":"COVID-19-Screening", + "description":"Interaksjon, kontakt eller omsorgshendelse mellom et individ og helsepersonell." + } + } + }, + "termBindings":{ + + }, + "terminologyExtracts":{ + + }, + "valueSets":{ + + } + }, + "adlVersion":"1.4", + "buildUid":"64906c61-b3e8-4b00-a0b0-7f19facefdf6", + "rmName":"openehr", + "rmRelease":"1.0.3", + "generated":true, + "templateId":"COVID-19-Screening", + "otherMetaData":{ + + }, + "templateOverlays":[ + { + "@type":"TEMPLATE_OVERLAY", + "uid":"459e617e-5bf3-4a8c-b0fe-5acbbd0ae385", + "description":{ + "@type":"RESOURCE_DESCRIPTION", + "originalAuthor":{ + + }, + "otherContributors":[ + + ], + "ipAcknowledgements":{ + + }, + "references":{ + + }, + "conversionDetails":{ + + }, + "otherDetails":{ + "PARENT:MD5-CAM-1.0.1":"BCC0605A5537A43198F2069B6B38AF3A" + }, + "details":{ + "ru":{ + "@type":"RESOURCE_DESCRIPTION_ITEM", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"ru" + }, + "purpose":"Базовый заголовок раздела, должен быть переименован в локальном шаблоне ", + "keywords":[ + "раздел", + "шаблон", + "заготовка", + "название", + "образец" + ], + "use":"используется для создания и именования разделов в локальных шаблонах", + "copyright":"© openEHR Foundation", + "originalResourceUri":{ + + }, + "otherDetails":{ + + } + }, + "nb":{ + "@type":"RESOURCE_DESCRIPTION_ITEM", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"nb" + }, + "purpose":"Brukes som en generisk seksjonsoverskrift som skal gis nytt navn i en templat for å passe i en gitt klinisk kontekst.", + "keywords":[ + + ], + "use":"Brukes til å lage en seksjonsoverskrift i en templat, hvis navn deretter endres for å passe i den aktuelle kliniske konteksten. For eksempel: \"Templat-overskrift\" endret til \"Funn ved undersøkelse\", \"Anamnese\", \"Personopplysninger\" eller \"Oppsummering\".", + "misuse":"Skal ikke stå med uendret navn i en templat.", + "originalResourceUri":{ + + }, + "otherDetails":{ + + } + }, + "es-ar":{ + "@type":"RESOURCE_DESCRIPTION_ITEM", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"es-ar" + }, + "purpose":"Proporcionar un encabezado de sección de tipo genérico que será renombrado en una plantilla para su empleo en un contexto clínico específico.", + "keywords":[ + + ], + "use":"Utilizar para construir un encabezado de sección en una plantilla y que será renombrado para su empleo en un contexto clínico específico. Por ejemplo, \"Encabezado ad hoc\" puede renombrarse como \"Hallazgos de examen\".", + "misuse":"No debe mantenerse sin cambios en una plantilla.", + "copyright":"© openEHR Foundation", + "originalResourceUri":{ + + }, + "otherDetails":{ + + } + }, + "sl":{ + "@type":"RESOURCE_DESCRIPTION_ITEM", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"sl" + }, + "purpose":"*To provide a generic section header which will be renamed in a template to suit a specific clinical context.(en)", + "keywords":[ + + ], + "use":"*Use to construct a section heading in a template that will be renamed to suit the specific clinical context. For example: \"Ad hoc heading\" renamed to \"Examination findings\".(en)", + "misuse":"*Not to be left unchanged in a template.(en)", + "copyright":"© openEHR Foundation", + "originalResourceUri":{ + + }, + "otherDetails":{ + + } + }, + "en":{ + "@type":"RESOURCE_DESCRIPTION_ITEM", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"en" + }, + "purpose":"To provide a generic section header which will be renamed in a template to suit a specific clinical context.", + "keywords":[ + + ], + "use":"Use to construct a section heading in a template that will be renamed to suit the specific clinical context. For example: \"Ad hoc heading\" renamed to \"Examination findings\".", + "misuse":"Not to be left unchanged in a template.", + "copyright":"© openEHR Foundation", + "originalResourceUri":{ + + }, + "otherDetails":{ + + } + } + } + }, + "parentArchetypeId":"openEHR-EHR-SECTION.adhoc.v1", + "differential":true, + "archetypeId":{ + "@type":"ARCHETYPE_HRID", + "value":"openEHR-EHR-SECTION.ovl-adhoc-000.v1" + }, + "definition":{ + "@type":"C_COMPLEX_OBJECT", + "rmTypeName":"SECTION", + "nodeId":"at0000.1", + "attributes":[ + { + "@type":"C_ATTRIBUTE", + "rmAttributeName":"items", + "existence":"0..1", + "children":[ + { + "@type":"C_ARCHETYPE_ROOT", + "rmTypeName":"OBSERVATION", + "occurrences":"0..*", + "nodeId":"at0.1", + "attributes":[ + + ], + "attributeTuples":[ + + ], + "archetypeRef":"openEHR-EHR-OBSERVATION.ovl-story-001.v1", + "referenceType":"archetypeOverlay" + }, + { + "@type":"C_ARCHETYPE_ROOT", + "rmTypeName":"EVALUATION", + "occurrences":"0..1", + "nodeId":"at0.2", + "attributes":[ + + ], + "attributeTuples":[ + + ], + "archetypeRef":"openEHR-EHR-EVALUATION.ovl-health_risk-005.v1", + "referenceType":"archetypeOverlay" + } + ] + } + ], + "attributeTuples":[ + + ] + }, + "terminology":{ + "@type":"ARCHETYPE_TERMINOLOGY", + "conceptCode":"at0000", + "termDefinitions":{ + "en":{ + "at0000.1":{ + "@type":"ARCHETYPE_TERM", + "code":"at0000.1", + "text":"Screening", + "description":"A generic section header which should be renamed in a template to suit a specific clinical context." + } + }, + "ru":{ + "at0000.1":{ + "@type":"ARCHETYPE_TERM", + "code":"at0000.1", + "text":"Screening", + "description":"*A generic section header which should be renamed in a template to suit a specific clinical context.(en)" + } + }, + "es-ar":{ + "at0000.1":{ + "@type":"ARCHETYPE_TERM", + "code":"at0000.1", + "text":"Screening", + "description":"Un encabezado de sección de tipo genérico que será renombrado en una plantilla para su empleo en un contexto clínico específico." + } + }, + "sl":{ + "at0000.1":{ + "@type":"ARCHETYPE_TERM", + "code":"at0000.1", + "text":"Screening", + "description":"Naslov sekcije" + } + }, + "nb":{ + "at0000.1":{ + "@type":"ARCHETYPE_TERM", + "code":"at0000.1", + "text":"Screening", + "description":"En generisk seksjonsoverskrift som skal gis nytt navn i en templat for å passe i en gitt klinisk kontekst." + } + } + }, + "termBindings":{ + + }, + "terminologyExtracts":{ + + }, + "valueSets":{ + + } + }, + "adlVersion":"1.4", + "buildUid":"2c955ca2-a3f8-4576-b87c-0a11ec09118b", + "rmName":"openehr", + "rmRelease":"1.0.3", + "generated":true, + "otherMetaData":{ + + }, + "originalLanguage":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"en" + }, + "translations":[ + { + "@type":"TRANSLATION_DETAILS", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"ru" + }, + "author":{ + "name":"Art Latyp Латыпов Артур Шамилевич", + "organisation":"RusBITech РусБИТех, Москва" + }, + "otherDetails":{ + + } + }, + { + "@type":"TRANSLATION_DETAILS", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"nb" + }, + "author":{ + "einar.fosse@unn.no":"einar.fosse@unn.no", + "name":"Einar Fosse", + "organisation":"Norwegian Centre for Integrated Care and Telemedicine, Tromsø, Norway" + }, + "otherDetails":{ + + } + }, + { + "@type":"TRANSLATION_DETAILS", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"es-ar" + }, + "author":{ + "name":"Alan March", + "organisation":"Hospital Universitario Austral, Buenos Aires, Argentina" + }, + "otherDetails":{ + + } + }, + { + "@type":"TRANSLATION_DETAILS", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"sl" + }, + "author":{ + "name":"?" + }, + "otherDetails":{ + + } + } + ] + }, + { + "@type":"TEMPLATE_OVERLAY", + "uid":"cdaed5ae-8651-4c00-97ab-95d117fd52e2", + "description":{ + "@type":"RESOURCE_DESCRIPTION", + "originalAuthor":{ + + }, + "otherContributors":[ + + ], + "ipAcknowledgements":{ + + }, + "references":{ + + }, + "conversionDetails":{ + + }, + "otherDetails":{ + "PARENT:MD5-CAM-1.0.1":"CA7D830939884D77B23BDAA5CA34A7AE" + }, + "details":{ + "nb":{ + "@type":"RESOURCE_DESCRIPTION_ITEM", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"nb" + }, + "purpose":"For å registrere en fritekstbeskrivelse av individets sykehistorie/anamnese og som et rammeverk for å nøste detaljerte CLUSTER-arketyper som hver for seg kan detaljere ulike aspekter av sykehistorien, som symptomer, helserelaterte hendelser, og andre tilgrensende emner.\r\n\r\nBrukes for å registrere detaljer om sykehistorien slik den blir fortalt av et individ, pårørende, eller en annen part. Det kan registreres av en kliniker som del av opptak av sykehistorie, eller selvregistreres som del av et spørreskjema eller personlig helsearkiv.", + "keywords":[ + "anamnese", + "sykehistorie", + "problem", + "helseplage", + "bekymring" + ], + "use":"Brukes for å registrere en beskrivelse av subjektive helserelaterte observasjoner eller inntrykk fra individets synsvinkel.\r\n\r\nNår anamnesen registreres av en kliniker i en konsultasjon kan arketypen brukes for å registrere den kliniske historikken til individet, rapportert av individet selv, en forelder, pårørende eller en annen involvert part. Dersom den registreres av individet selv, kan den brukes som en oversikt over symptom- og helseerfaringer, som kan deles med helsepersonell eller som dokumentasjon i deres eget helsearkiv.\r\n\r\nBrukes:\r\n- for å registrere en enkelt fritekst\r\n- som et rammeverk for å registrere en detaljert strukturert historikk ved å inkludere relevante CLUSTER-arketyper i SLOTet \"Strukturerte detaljer\". Eksempler kan være CLUSTER.symptom_sign eller CLUSTER.health_event.\r\n\r\nBrukes for å kunne gjenbruke anamnese i eksisterende systemer inn i et arketypeformat ved hjelp av 'Anamnese'-dataelementet.", + "misuse":"Skal ikke brukes for å registrere formelle vurderinger av klinikere. Disse registreres ved hjelp av forskjellige arketyper av klassen EVALUATION.", + "originalResourceUri":{ + + }, + "otherDetails":{ + + } + }, + "ko":{ + "@type":"RESOURCE_DESCRIPTION_ITEM", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"ko" + }, + "purpose":"개인/환자가 의사에게 이야기하거나 직접 기록한 임상 병력에 대한 서술을 기록하기 위한 것과 상세한 CLUSTER archetypes를 포함할 수 있는 프레임워크를 제공하는 것으로 각각에 임상 병력의 다양한 측면들을 상세하게 기술될 것이다.", + "keywords":[ + "*병력(ko)", + "*현재(ko)", + "*호소(ko)", + "*이야기(ko)" + ], + "use":"환자가 의사에게 이야기한 공식적인 '현재 호소하는 병력(History of Presenting Complaint)'을 기록하기 위해서 사용함; 또는 (예를 들어 개인건강기록에 있는) 개인 자신의 증상들의 '이야기(story)를 설명한 것을 기록하기 위해 사용함.\r\n\r\n기존 또는 이전의 임상 시스템 내의 임상 병력의 서술을 'Story' data element을 사용하여 archetyped format으로 통합하기위해 사용함.\r\n\r\n단순한 서술을 기록하기 위해 사용함 그리고/또는 container archetype으로써 - 추가적이고 특정한 그리고 상세한 CLUSTER archetypes에 의해 확장될 수 있는 공통의 쿼리가능한 ENTRY archetype framework를 제공함. 각각에 임상병력의 다양한 측면을 기술될 것임. 병력과 관련된 CLUSTER archetypes의 예는 CLUSTER.symptom 또는 CLUSTER.health_event를 포함한다.", + "copyright":"© openEHR Foundation", + "originalResourceUri":{ + + }, + "otherDetails":{ + + } + }, + "es-ar":{ + "@type":"RESOURCE_DESCRIPTION_ITEM", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"es-ar" + }, + "purpose":"*To record a narrative description of the clinical history, as told to a clinician or recorded directly by an individual/patient, and to provide a framework in which to nest detailed CLUSTER archetypes, each of which will describe the various aspects of the clinical history in further detail.(en)", + "keywords":[ + + ], + "copyright":"© openEHR Foundation", + "originalResourceUri":{ + + }, + "otherDetails":{ + + } + }, + "en":{ + "@type":"RESOURCE_DESCRIPTION_ITEM", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"en" + }, + "purpose":"To record a narrative description of the clinical history of the subject of care and to provide a framework in which to nest detailed CLUSTER archetypes, each of which will support the narrative with additional structured detail for symptoms, health events and related topics.\r\n\r\nUse to record detail about the clinical history as reported by an individual, parent, care-giver or other party. It may be recorded by a clinician as part of a clinical history record as reported to them, or self-recorded as part of a clinical questionnaire or personal health record.", + "keywords":[ + "history", + "presenting", + "complaint", + "story", + "symptom", + "health", + "record", + "presenting complaint", + "anamnesis" + ], + "use":"Use to record a description about subjective health-related observations or impressions from the point of view of the subject of care. \r\n\r\nWhen recorded by a clinician within the context of healthcare provision the story can be used for capturing the clinical history, as reported by the subject themselves, a parent, care-giver or other related party. If recorded by the subject, it can be used as an account of their 'story' of symptoms and health experiences, which might be used to share with healthcare providers or to document within their own personal health record.\r\n\r\nUse:\r\n- to record a simple narrative; and/or \r\n- as a container archetype to enable recording of a detailed structured history by inclusion of relevant CLUSTER archetypes within the 'Detail' SLOT. For example: CLUSTER.symptom, CLUSTER.issue or CLUSTER.health_event archetypes can be appropriately used in this SLOT.\r\n\r\nUse to incorporate the narrative descriptions of clinical history captured from existing or legacy clinical systems into an archetyped format, using the 'Story' text data element.", + "misuse":"Not to be used to record formal assessments by clinicians which would usually be recorded using the EVALUATION class of archetypes.", + "copyright":"© openEHR Foundation", + "originalResourceUri":{ + + }, + "otherDetails":{ + + } + }, + "ar-sy":{ + "@type":"RESOURCE_DESCRIPTION_ITEM", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"ar-sy" + }, + "purpose":"*To record a narrative description of the clinical history, as told to a clinician or recorded directly by an individual/patient, and to provide a framework in which to nest detailed CLUSTER archetypes, each of which will describe the various aspects of the clinical history in further detail.(en)", + "keywords":[ + + ], + "copyright":"© openEHR Foundation", + "originalResourceUri":{ + + }, + "otherDetails":{ + + } + } + } + }, + "parentArchetypeId":"openEHR-EHR-OBSERVATION.story.v1", + "differential":true, + "archetypeId":{ + "@type":"ARCHETYPE_HRID", + "value":"openEHR-EHR-OBSERVATION.ovl-story-001.v1" + }, + "definition":{ + "@type":"C_COMPLEX_OBJECT", + "rmTypeName":"OBSERVATION", + "nodeId":"at0000.1", + "attributes":[ + { + "@type":"C_ATTRIBUTE", + "rmAttributeName":"data", + "children":[ + { + "@type":"C_COMPLEX_OBJECT", + "rmTypeName":"HISTORY", + "nodeId":"at0001", + "attributes":[ + { + "@type":"C_ATTRIBUTE", + "rmAttributeName":"events", + "children":[ + { + "@type":"C_COMPLEX_OBJECT", + "rmTypeName":"EVENT", + "nodeId":"at0002", + "attributes":[ + { + "@type":"C_ATTRIBUTE", + "rmAttributeName":"data", + "children":[ + { + "@type":"C_COMPLEX_OBJECT", + "rmTypeName":"ITEM_TREE", + "nodeId":"at0003", + "attributes":[ + { + "@type":"C_ATTRIBUTE", + "rmAttributeName":"items", + "children":[ + { + "@type":"C_ARCHETYPE_ROOT", + "rmTypeName":"CLUSTER", + "occurrences":"0..1", + "nodeId":"at0006.1", + "attributes":[ + + ], + "attributeTuples":[ + + ], + "archetypeRef":"openEHR-EHR-CLUSTER.ovl-symptom_sign-002.v1", + "referenceType":"archetypeOverlay" + }, + { + "@type":"C_ARCHETYPE_ROOT", + "rmTypeName":"CLUSTER", + "occurrences":"0..1", + "nodeId":"at0006.2", + "attributes":[ + + ], + "attributeTuples":[ + + ], + "archetypeRef":"openEHR-EHR-CLUSTER.ovl-symptom_sign-003.v1", + "referenceType":"archetypeOverlay" + }, + { + "@type":"C_ARCHETYPE_ROOT", + "rmTypeName":"CLUSTER", + "occurrences":"0..1", + "nodeId":"at0006.3", + "attributes":[ + + ], + "attributeTuples":[ + + ], + "archetypeRef":"openEHR-EHR-CLUSTER.ovl-symptom_sign-004.v1", + "referenceType":"archetypeOverlay" + } + ] + } + ], + "attributeTuples":[ + + ] + } + ] + } + ], + "attributeTuples":[ + + ] + } + ] + } + ], + "attributeTuples":[ + + ] + } + ] + }, + { + "@type":"C_ATTRIBUTE", + "rmAttributeName":"protocol", + "children":[ + { + "@type":"C_COMPLEX_OBJECT", + "rmTypeName":"ITEM_TREE", + "nodeId":"at0007.1", + "attributes":[ + + ], + "attributeTuples":[ + + ] + } + ] + } + ], + "attributeTuples":[ + + ] + }, + "terminology":{ + "@type":"ARCHETYPE_TERMINOLOGY", + "conceptCode":"at0000", + "termDefinitions":{ + "ar-sy":{ + + }, + "en":{ + + }, + "es-ar":{ + + }, + "ko":{ + + }, + "nb":{ + + } + }, + "termBindings":{ + + }, + "terminologyExtracts":{ + + }, + "valueSets":{ + + } + }, + "adlVersion":"1.4", + "buildUid":"ba510205-a5b7-4826-944c-07a68d96d296", + "rmName":"openehr", + "rmRelease":"1.0.3", + "generated":true, + "otherMetaData":{ + + }, + "originalLanguage":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"en" + }, + "translations":[ + { + "@type":"TRANSLATION_DETAILS", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"es-ar" + }, + "author":{ + "name":"Guillermo Palli" + }, + "otherDetails":{ + + } + }, + { + "@type":"TRANSLATION_DETAILS", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"ko" + }, + "author":{ + "name":"Seung-Jong Yu", + "organisation":"NOUSCO Co.,Ltd.", + "email":"seungjong.yu@gmail.com" + }, + "accreditation":"Certified board of Family medicine", + "otherDetails":{ + + } + }, + { + "@type":"TRANSLATION_DETAILS", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"nb" + }, + "author":{ + "name":"Silje Ljosland Bakke", + "organisation":"Nasjonal IKT HF" + }, + "otherDetails":{ + + } + }, + { + "@type":"TRANSLATION_DETAILS", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"ar-sy" + }, + "author":{ + "name":"Mona Saleh" + }, + "otherDetails":{ + + } + } + ] + }, + { + "@type":"TEMPLATE_OVERLAY", + "uid":"028d58b1-9b5a-404e-abc7-b88fc9a24b56", + "description":{ + "@type":"RESOURCE_DESCRIPTION", + "originalAuthor":{ + + }, + "otherContributors":[ + + ], + "ipAcknowledgements":{ + + }, + "references":{ + + }, + "conversionDetails":{ + + }, + "otherDetails":{ + "PARENT:MD5-CAM-1.0.1":"C2D2E09F61486B4CFDEB673D0D79646A" + }, + "details":{ + "de":{ + "@type":"RESOURCE_DESCRIPTION_ITEM", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"de" + }, + "purpose":"*To record detail about a symptom - either self-recorded by an individual or recorded on the behalf of a patient by a clinician. A complete patient history may include varying level of details about a variety of symptoms.(en)", + "keywords":[ + + ], + "use":"*Use to record detailed information about a symptom as told to a clinician by a patient or self-recorded by the individual/patient.\r\n\r\nThis archetype allows a 'nil significant' statement to be explicitly recorded.(en)", + "misuse":"*Sollte nur für Symptome benutzt werden. (en)", + "copyright":"© openEHR Foundation", + "originalResourceUri":{ + + }, + "otherDetails":{ + + } + }, + "nb":{ + "@type":"RESOURCE_DESCRIPTION_ITEM", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"nb" + }, + "purpose":"For å registrere detaljer om en enkeltepisode av et rapportert symptom eller sykdomstegn. Dette kan omfatte kontekst, men ikke detaljer, om tidligere episoder av symptomet/sykdomstegnet.", + "keywords":[ + "lidelse", + "plage", + "problem", + "ubehag", + "symptom", + "sykdomstegn", + "lyte", + "skavank" + ], + "use":"For å registrere detaljer om en enkeltepisode av et rapportert symptom eller sykdomstegn hos et individ, som redegjort av personen selv, foreldre, omsorgsperson eller andre parter. Registrering kan skje i forbindelse med opptak av anamnese, eller som en selvregistrering som en del av et klinisk spørreskjema eller personlig journal. \r\nEn fullstendig klinisk anamnese eller pasientanamnese kan inneholde beskrivelser med ulikt detaljnivå om flere episoder knyttet til samme symptom eller sykdomstegn, og vil også kunne inneholde flere ulike symptomer eller sykdomstegn.\r\n\r\nI egentlig forstand er symptomer subjektive opplevelser av en fysisk eller mental forstyrrelse mens sykdomstegn er objektive observasjoner av det samme, som er erfart av et individ og rapportert til en kliniker av individet eller av andre. Fra denne logikken følger at det burde være to arketyper til å registrere klinisk anamnese; en for rapporterte symptomer og en for rapporterte sykdomstegn. I virkeligheten er dette upraktisk og vil kreve registrering av kliniske data i enten den ene eller den andre av disse modellene. I praksis vil dette øke kompleksitet og tidsbruk knyttet til modellering og registrering av data. I tillegg overlapper ofte de kliniske konseptene, for eksempel: Vil tidligere oppkast eller blødning kategoriseres som et symptom eller som et rapportert sykdomstegn?\r\nSom svar på dette er arketypen laget for å tillate registrering av hele kontinuumet mellom tydelig definerte symptomer og rapporterte sykdomstegn når en registrerer en klinisk anamnese.\r\n\r\nArketypen er designet for å gi et generisk rammeverk for alle symptomer og rapporterte sykdomstegn. SLOTet \"Spesifikke detaljer\" kan brukes for å utvide arketypen med ytterligere spesifikke dataelementer for komplekse symptomer eller sykdomstegn.\r\n\r\nArketypen skal settes inn i \"Detaljer\"-SLOTet i OBSERVATION.story-arketypen men kan også brukes i en hvilken som helst OBSERVATION eller CLUSTER-arketype. Arketypen kan også gjenbrukes i andre instanser av CLUSTER.symptom_sign-arketypen i SLOTene \"Assosierte symptomer\" eller \"Tidligere detaljer\".\r\n\r\nKlinikere registrerer ofte frasen \"Ikke av betydning\" i forbindelse med spesifikke symptomer eller rapporterte tegn for å indikere at det er eksplisitt spurt om det spesifikke symptomet, og at det ble svart at symptomet ikke er tilstede i en slik grad at det påfører pasienten ubehag eller uro. Frasen brukes mer som en normalbeskrivelse enn en eksplisitt eksklusjon. Dataelementet \"Ikke av betydning\" er med hensikt lagt til for å tillate at klinikere enkelt og effektivt kan registrere denne informasjonen i det kliniske systemet. Eksempelvis kan \"Ikke av betydning\" brukes i brukergrensesnittet, er dette registrert som \"Sann\" kan de resterende dataelementene skjules i brukergrensesnittet. Denne pragmatiske tilnærmingen støtter hoveddelen av enkel klinisk journalføring av symptomer og sykdomstegn. \r\n\r\nImidlertid kan det være fordelaktig å bruke arketypen CLUSTER.exclusion_symptom_sign dersom det er klinisk behov for å eksplisitt registrere at et symptom eller sykdomstegn ikke er tilstede, for eksempel dersom dette skal brukes til klinisk beslutningsstøtte. Bruk av CLUSTER.exclusion_symptom_sign vil øke kompleksiteten i templatmodellering, implementasjon og spørring. Det anbefales at CLUSTER.exclusion_symptom_sign kun vurderes brukt dersom man kan identifisere en klar gevinst, men bør ikke brukes for rutineregistreringer av symptomer eller sykdomstegn.", + "misuse":"Brukes ikke til eksplisitt registrering av at et symptom eller sykdomstegn ikke er tilstede. Bruk CLUSTER.exclusion_symptom_sign varsomt da det øker tidsbruk ved registrering og tilfører økt kompleksitet, og bare når dataelementet \"Ikke av betydning\" i denne arketypen ikke er eksplisitt nok for registreringen.\r\n\r\nBrukes ikke til registrering av objektive funn som en del av en fysisk undersøkelse. Bruk OBSERVATION.exam og relaterte CLUSTER.exam-arketyper for dette formålet. \r\n\r\nBrukes ikke til registrering av problemer og diagnoser som en del av en persistent problemliste, til dette brukes EVALUATION.problem_diagnosis.\r\n\r\nBrukes ikke til å dokumentere tiltak og resultat i løpet av hele perioden individet er under behandling, da arketypen er beregnet til å dokumentere symptomer og sykdomstegn som et øyeblikksbilde.", + "copyright":"© openEHR Foundation", + "originalResourceUri":{ + + }, + "otherDetails":{ + + } + }, + "en":{ + "@type":"RESOURCE_DESCRIPTION_ITEM", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"en" + }, + "purpose":"To record details about a single episode of a reported symptom or sign including context, but not details, of previous episodes if appropriate.", + "keywords":[ + "complaint", + "symptom", + "disturbance", + "problem", + "discomfort", + "presenting complaint", + "presenting symptom", + "sign" + ], + "use":"Use to record details about a single episode of a symptom or reported sign in an individual, as reported by the individual, parent, care-giver or other party. It may be recorded by a clinician as part of a clinical history record as reported to them, observed by the clinician or self-recorded as part of a clinical questionnaire or personal health record. A complete clinical history or patient story may include varying level of details about multiple episodes of an identified symptom or reported sign, as well as multiple symptoms/signs.\r\n\r\nIn the purest sense, symptoms are subjective observations of a physical or mental disturbance and signs are objective observations of the same, as experienced by an individual and reported to the history taker by the same individual or another party. From this logic it follows that we will need two archetypes to record clinical history - one for reported symptoms and another for reported signs. In reality this is impractical as it will require clinical data entry into either one of these models which adds signficant overheads to modellers and those entering data. In addition, there is often overlap in clinical concepts - for example, is previous vomiting or bleeding to be categorised as a symptom or reported sign? In response, this archetype has been specifically designed to proved a single information model that allows for recording of the entire continuum between clearly identifable symptoms and reported signs when recording a clinical history.\r\n\r\nThis archetype has been intended to be used as a generic pattern for all symptoms and reported signs. The 'Specific details' SLOT can be used to extend the archetype to include additional, specific data elements for more complex symptoms or signs. \r\n\r\nThis archetype has been specifically designed to be used in the 'Structured detail' SLOT within the OBSERVATION.story archetype, but can also be used within other OBSERVATION or CLUSTER archetypes and in the 'Associated symptom/sign' or 'Previous episode' SLOT within other instances of this CLUSTER.symptom_sign archetype.\r\n\r\nClinicians frequently record the phrase 'nil significant' against specific symptoms or reported signs as an efficient method to indicate that they asked the individual and it was not reported as causing any discomfort or disturbance - effectively used more like a 'normal statement' rather than an explicit exclusion. The 'Nil significant' data element has been deliberately included in this archetype to allow clinicians to record this same information in a simple and effective way in a clinical system. It can be used to drive a user interface, for example if 'Nil significant' is recorded as true then the remaining data elements can be hidden on a data entry screen. This pragmatic approach supports the majority of simple clinical recording requirements around reported symptoms and signs. \r\n\r\nHowever if there is a clinical imperative to explicitly record that a Symptom or Sign was reported as not present, for example if it will be used to drive clinical decision support, then it would be preferable to use the CLUSTER.exclusion_symptom_sign archetype. The use of CLUSTER.exclusion_symptom_sign will increase the complexity of template modelling, implementation and querying. 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Use the specialisation of this archetype - the CLUSTER.symptom-pain instead.\r\n\r\nNot to be used for diagnoses and problems that form part of a persisting Problem List - use EVALUATION.problem_diagnosis.(en)", + "copyright":"© openEHR Foundation", + "originalResourceUri":{ + + }, + "otherDetails":{ + + } + } + } + }, + "parentArchetypeId":"openEHR-EHR-CLUSTER.symptom_sign.v1", + "differential":true, + "archetypeId":{ + "@type":"ARCHETYPE_HRID", + "value":"openEHR-EHR-CLUSTER.ovl-symptom_sign-002.v1" + }, + "definition":{ + "@type":"C_COMPLEX_OBJECT", + "rmTypeName":"CLUSTER", + "nodeId":"at0000.1", + "attributes":[ + { + "@type":"C_ATTRIBUTE", + "rmAttributeName":"items", + "children":[ + { + "@type":"C_COMPLEX_OBJECT", + "rmTypeName":"ELEMENT", + "nodeId":"at0001.1", + "attributes":[ + { + "@type":"C_ATTRIBUTE", + "rmAttributeName":"value", + "children":[ + { + "@type":"C_COMPLEX_OBJECT", + "rmTypeName":"DV_CODED_TEXT", + "occurrences":"1..1", + "attributes":[ + { + 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fornemmelser i kropp og/eller sinn." + } + } + }, + "termBindings":{ + "SNOMED-CT":{ + "at0000.1":"term:SNOMED-CT::19019007", + "at0001.1":"term:SNOMED-CT::19019007", + "at0002.1":"term:SNOMED-CT::162408000", + "at0028.1":"term:SNOMED-CT::162442009", + "at0021.1":"term:SNOMED-CT::162465004" + } + }, + "terminologyExtracts":{ + + }, + "valueSets":{ + + } + }, + "adlVersion":"1.4", + "buildUid":"3f866553-0487-479f-b418-d0f7a6a33f10", + "rmName":"openehr", + "rmRelease":"1.0.3", + "generated":true, + "otherMetaData":{ + + }, + "originalLanguage":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"en" + }, + "translations":[ + { + "@type":"TRANSLATION_DETAILS", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"de" + }, + "author":{ + "name":"Jasmin Buck, Sebastian Garde", + "organisation":"University of Heidelberg, Central Queensland University" + }, + "otherDetails":{ + + } + }, + { + "@type":"TRANSLATION_DETAILS", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"nb" + }, + "author":{ + "name":"Lars Bitsch-Larsen", + "organisation":"Haukeland University Hospital of Bergen, Norway", + "email":"lbla@helse-bergen.no" + }, + "accreditation":"MD, DEAA, MBA, spec in anesthesia, spec in tropical medicine.", + "otherDetails":{ + + } + }, + { + "@type":"TRANSLATION_DETAILS", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"ar-sy" + }, + "author":{ + "name":"Mona Saleh" + }, + "otherDetails":{ + + } + } + ] + }, + { + "@type":"TEMPLATE_OVERLAY", + "uid":"028d58b1-9b5a-404e-abc7-b88fc9a24b56", + "description":{ + "@type":"RESOURCE_DESCRIPTION", + "originalAuthor":{ + + }, + "otherContributors":[ + + ], + "ipAcknowledgements":{ + + }, + "references":{ + + }, + "conversionDetails":{ + + }, + "otherDetails":{ + "PARENT:MD5-CAM-1.0.1":"C2D2E09F61486B4CFDEB673D0D79646A" + }, + "details":{ + "de":{ + "@type":"RESOURCE_DESCRIPTION_ITEM", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"de" + }, + "purpose":"*To record detail about a symptom - either self-recorded by an individual or recorded on the behalf of a patient by a clinician. A complete patient history may include varying level of details about a variety of symptoms.(en)", + "keywords":[ + + ], + "use":"*Use to record detailed information about a symptom as told to a clinician by a patient or self-recorded by the individual/patient.\r\n\r\nThis archetype allows a 'nil significant' statement to be explicitly recorded.(en)", + "misuse":"*Sollte nur für Symptome benutzt werden. (en)", + "copyright":"© openEHR Foundation", + "originalResourceUri":{ + + }, + "otherDetails":{ + + } + }, + "nb":{ + "@type":"RESOURCE_DESCRIPTION_ITEM", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"nb" + }, + "purpose":"For å registrere detaljer om en enkeltepisode av et rapportert symptom eller sykdomstegn. Dette kan omfatte kontekst, men ikke detaljer, om tidligere episoder av symptomet/sykdomstegnet.", + "keywords":[ + "lidelse", + "plage", + "problem", + "ubehag", + "symptom", + "sykdomstegn", + "lyte", + "skavank" + ], + "use":"For å registrere detaljer om en enkeltepisode av et rapportert symptom eller sykdomstegn hos et individ, som redegjort av personen selv, foreldre, omsorgsperson eller andre parter. Registrering kan skje i forbindelse med opptak av anamnese, eller som en selvregistrering som en del av et klinisk spørreskjema eller personlig journal. \r\nEn fullstendig klinisk anamnese eller pasientanamnese kan inneholde beskrivelser med ulikt detaljnivå om flere episoder knyttet til samme symptom eller sykdomstegn, og vil også kunne inneholde flere ulike symptomer eller sykdomstegn.\r\n\r\nI egentlig forstand er symptomer subjektive opplevelser av en fysisk eller mental forstyrrelse mens sykdomstegn er objektive observasjoner av det samme, som er erfart av et individ og rapportert til en kliniker av individet eller av andre. Fra denne logikken følger at det burde være to arketyper til å registrere klinisk anamnese; en for rapporterte symptomer og en for rapporterte sykdomstegn. I virkeligheten er dette upraktisk og vil kreve registrering av kliniske data i enten den ene eller den andre av disse modellene. I praksis vil dette øke kompleksitet og tidsbruk knyttet til modellering og registrering av data. I tillegg overlapper ofte de kliniske konseptene, for eksempel: Vil tidligere oppkast eller blødning kategoriseres som et symptom eller som et rapportert sykdomstegn?\r\nSom svar på dette er arketypen laget for å tillate registrering av hele kontinuumet mellom tydelig definerte symptomer og rapporterte sykdomstegn når en registrerer en klinisk anamnese.\r\n\r\nArketypen er designet for å gi et generisk rammeverk for alle symptomer og rapporterte sykdomstegn. SLOTet \"Spesifikke detaljer\" kan brukes for å utvide arketypen med ytterligere spesifikke dataelementer for komplekse symptomer eller sykdomstegn.\r\n\r\nArketypen skal settes inn i \"Detaljer\"-SLOTet i OBSERVATION.story-arketypen men kan også brukes i en hvilken som helst OBSERVATION eller CLUSTER-arketype. Arketypen kan også gjenbrukes i andre instanser av CLUSTER.symptom_sign-arketypen i SLOTene \"Assosierte symptomer\" eller \"Tidligere detaljer\".\r\n\r\nKlinikere registrerer ofte frasen \"Ikke av betydning\" i forbindelse med spesifikke symptomer eller rapporterte tegn for å indikere at det er eksplisitt spurt om det spesifikke symptomet, og at det ble svart at symptomet ikke er tilstede i en slik grad at det påfører pasienten ubehag eller uro. Frasen brukes mer som en normalbeskrivelse enn en eksplisitt eksklusjon. Dataelementet \"Ikke av betydning\" er med hensikt lagt til for å tillate at klinikere enkelt og effektivt kan registrere denne informasjonen i det kliniske systemet. Eksempelvis kan \"Ikke av betydning\" brukes i brukergrensesnittet, er dette registrert som \"Sann\" kan de resterende dataelementene skjules i brukergrensesnittet. Denne pragmatiske tilnærmingen støtter hoveddelen av enkel klinisk journalføring av symptomer og sykdomstegn. \r\n\r\nImidlertid kan det være fordelaktig å bruke arketypen CLUSTER.exclusion_symptom_sign dersom det er klinisk behov for å eksplisitt registrere at et symptom eller sykdomstegn ikke er tilstede, for eksempel dersom dette skal brukes til klinisk beslutningsstøtte. Bruk av CLUSTER.exclusion_symptom_sign vil øke kompleksiteten i templatmodellering, implementasjon og spørring. Det anbefales at CLUSTER.exclusion_symptom_sign kun vurderes brukt dersom man kan identifisere en klar gevinst, men bør ikke brukes for rutineregistreringer av symptomer eller sykdomstegn.", + "misuse":"Brukes ikke til eksplisitt registrering av at et symptom eller sykdomstegn ikke er tilstede. Bruk CLUSTER.exclusion_symptom_sign varsomt da det øker tidsbruk ved registrering og tilfører økt kompleksitet, og bare når dataelementet \"Ikke av betydning\" i denne arketypen ikke er eksplisitt nok for registreringen.\r\n\r\nBrukes ikke til registrering av objektive funn som en del av en fysisk undersøkelse. Bruk OBSERVATION.exam og relaterte CLUSTER.exam-arketyper for dette formålet. \r\n\r\nBrukes ikke til registrering av problemer og diagnoser som en del av en persistent problemliste, til dette brukes EVALUATION.problem_diagnosis.\r\n\r\nBrukes ikke til å dokumentere tiltak og resultat i løpet av hele perioden individet er under behandling, da arketypen er beregnet til å dokumentere symptomer og sykdomstegn som et øyeblikksbilde.", + "copyright":"© openEHR Foundation", + "originalResourceUri":{ + + }, + "otherDetails":{ + + } + }, + "en":{ + "@type":"RESOURCE_DESCRIPTION_ITEM", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"en" + }, + "purpose":"To record details about a single episode of a reported symptom or sign including context, but not details, of previous episodes if appropriate.", + "keywords":[ + "complaint", + "symptom", + "disturbance", + "problem", + "discomfort", + "presenting complaint", + "presenting symptom", + "sign" + ], + "use":"Use to record details about a single episode of a symptom or reported sign in an individual, as reported by the individual, parent, care-giver or other party. It may be recorded by a clinician as part of a clinical history record as reported to them, observed by the clinician or self-recorded as part of a clinical questionnaire or personal health record. A complete clinical history or patient story may include varying level of details about multiple episodes of an identified symptom or reported sign, as well as multiple symptoms/signs.\r\n\r\nIn the purest sense, symptoms are subjective observations of a physical or mental disturbance and signs are objective observations of the same, as experienced by an individual and reported to the history taker by the same individual or another party. From this logic it follows that we will need two archetypes to record clinical history - one for reported symptoms and another for reported signs. In reality this is impractical as it will require clinical data entry into either one of these models which adds signficant overheads to modellers and those entering data. In addition, there is often overlap in clinical concepts - for example, is previous vomiting or bleeding to be categorised as a symptom or reported sign? In response, this archetype has been specifically designed to proved a single information model that allows for recording of the entire continuum between clearly identifable symptoms and reported signs when recording a clinical history.\r\n\r\nThis archetype has been intended to be used as a generic pattern for all symptoms and reported signs. The 'Specific details' SLOT can be used to extend the archetype to include additional, specific data elements for more complex symptoms or signs. \r\n\r\nThis archetype has been specifically designed to be used in the 'Structured detail' SLOT within the OBSERVATION.story archetype, but can also be used within other OBSERVATION or CLUSTER archetypes and in the 'Associated symptom/sign' or 'Previous episode' SLOT within other instances of this CLUSTER.symptom_sign archetype.\r\n\r\nClinicians frequently record the phrase 'nil significant' against specific symptoms or reported signs as an efficient method to indicate that they asked the individual and it was not reported as causing any discomfort or disturbance - effectively used more like a 'normal statement' rather than an explicit exclusion. The 'Nil significant' data element has been deliberately included in this archetype to allow clinicians to record this same information in a simple and effective way in a clinical system. It can be used to drive a user interface, for example if 'Nil significant' is recorded as true then the remaining data elements can be hidden on a data entry screen. This pragmatic approach supports the majority of simple clinical recording requirements around reported symptoms and signs. \r\n\r\nHowever if there is a clinical imperative to explicitly record that a Symptom or Sign was reported as not present, for example if it will be used to drive clinical decision support, then it would be preferable to use the CLUSTER.exclusion_symptom_sign archetype. The use of CLUSTER.exclusion_symptom_sign will increase the complexity of template modelling, implementation and querying. It is recommended that the CLUSTER.exclusion_symptom_sign archetype only be considered for use if clear benefit can be identified in specific situations, but should not be used for routine symptom/sign recording.", + "misuse":"Not to be used to record that a symptom or sign was explicitly reported as not present - use CLUSTER.exclusion_symptom_sign carefully for specific purposes where the overheads of recording in this way warrant the additional complexity, and only if the 'Nil significant' in this archetype is not specific enough for recording purposes.\r\n\r\nNot to be used for recording objective findings as part of a physical examination - use OBSERVATION.exam and related examination CLUSTER archetypes for this purpose.\r\n\r\nNot to be used for diagnoses and problems that form part of a persisting Problem List - use EVALUATION.problem_diagnosis.", + "copyright":"© openEHR Foundation", + "originalResourceUri":{ + + }, + "otherDetails":{ + + } + }, + "ar-sy":{ + "@type":"RESOURCE_DESCRIPTION_ITEM", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"ar-sy" + }, + "purpose":"*To record detail about a symptom - either self-recorded by an individual or recorded on the behalf of a patient by a clinician. 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Use the specialisation of this archetype - the CLUSTER.symptom-pain instead.\r\n\r\nNot to be used for diagnoses and problems that form part of a persisting Problem List - use EVALUATION.problem_diagnosis.(en)", + "copyright":"© openEHR Foundation", + "originalResourceUri":{ + + }, + "otherDetails":{ + + } + } + } + }, + "parentArchetypeId":"openEHR-EHR-CLUSTER.symptom_sign.v1", + "differential":true, + "archetypeId":{ + "@type":"ARCHETYPE_HRID", + "value":"openEHR-EHR-CLUSTER.ovl-symptom_sign-003.v1" + }, + "definition":{ + "@type":"C_COMPLEX_OBJECT", + "rmTypeName":"CLUSTER", + "nodeId":"at0000.1", + "attributes":[ + { + "@type":"C_ATTRIBUTE", + "rmAttributeName":"items", + "children":[ + { + "@type":"C_COMPLEX_OBJECT", + "rmTypeName":"ELEMENT", + "nodeId":"at0001.1", + "attributes":[ + { + "@type":"C_ATTRIBUTE", + "rmAttributeName":"value", + "children":[ + { + "@type":"C_COMPLEX_OBJECT", + "rmTypeName":"DV_CODED_TEXT", + "occurrences":"0..1", + "attributes":[ + { + 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+ } + }, + "termBindings":{ + "SNOMED-CT":{ + "at0000.1":"term:SNOMED-CT::19019007", + "at0001.1":"term:SNOMED-CT::19019007", + "at0002.1":"term:SNOMED-CT::162408000", + "at0028.1":"term:SNOMED-CT::162442009", + "at0021.1":"term:SNOMED-CT::162465004" + } + }, + "terminologyExtracts":{ + + }, + "valueSets":{ + + } + }, + "adlVersion":"1.4", + "buildUid":"3f866553-0487-479f-b418-d0f7a6a33f10", + "rmName":"openehr", + "rmRelease":"1.0.3", + "generated":true, + "otherMetaData":{ + + }, + "originalLanguage":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"en" + }, + "translations":[ + { + "@type":"TRANSLATION_DETAILS", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"de" + }, + "author":{ + "name":"Jasmin Buck, Sebastian Garde", + "organisation":"University of Heidelberg, Central Queensland University" + }, + "otherDetails":{ + + } + }, + { + "@type":"TRANSLATION_DETAILS", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"nb" + }, + "author":{ + "name":"Lars Bitsch-Larsen", + "organisation":"Haukeland University Hospital of Bergen, Norway", + "email":"lbla@helse-bergen.no" + }, + "accreditation":"MD, DEAA, MBA, spec in anesthesia, spec in tropical medicine.", + "otherDetails":{ + + } + }, + { + "@type":"TRANSLATION_DETAILS", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"ar-sy" + }, + "author":{ + "name":"Mona Saleh" + }, + "otherDetails":{ + + } + } + ] + }, + { + "@type":"TEMPLATE_OVERLAY", + "uid":"028d58b1-9b5a-404e-abc7-b88fc9a24b56", + "description":{ + "@type":"RESOURCE_DESCRIPTION", + "originalAuthor":{ + + }, + "otherContributors":[ + + ], + "ipAcknowledgements":{ + + }, + "references":{ + + }, + "conversionDetails":{ + + }, + "otherDetails":{ + "PARENT:MD5-CAM-1.0.1":"C2D2E09F61486B4CFDEB673D0D79646A" + }, + "details":{ + "de":{ + "@type":"RESOURCE_DESCRIPTION_ITEM", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"de" + }, + "purpose":"*To record detail about a symptom - either self-recorded by an individual or recorded on the behalf of a patient by a clinician. A complete patient history may include varying level of details about a variety of symptoms.(en)", + "keywords":[ + + ], + "use":"*Use to record detailed information about a symptom as told to a clinician by a patient or self-recorded by the individual/patient.\r\n\r\nThis archetype allows a 'nil significant' statement to be explicitly recorded.(en)", + "misuse":"*Sollte nur für Symptome benutzt werden. (en)", + "copyright":"© openEHR Foundation", + "originalResourceUri":{ + + }, + "otherDetails":{ + + } + }, + "nb":{ + "@type":"RESOURCE_DESCRIPTION_ITEM", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"nb" + }, + "purpose":"For å registrere detaljer om en enkeltepisode av et rapportert symptom eller sykdomstegn. Dette kan omfatte kontekst, men ikke detaljer, om tidligere episoder av symptomet/sykdomstegnet.", + "keywords":[ + "lidelse", + "plage", + "problem", + "ubehag", + "symptom", + "sykdomstegn", + "lyte", + "skavank" + ], + "use":"For å registrere detaljer om en enkeltepisode av et rapportert symptom eller sykdomstegn hos et individ, som redegjort av personen selv, foreldre, omsorgsperson eller andre parter. Registrering kan skje i forbindelse med opptak av anamnese, eller som en selvregistrering som en del av et klinisk spørreskjema eller personlig journal. \r\nEn fullstendig klinisk anamnese eller pasientanamnese kan inneholde beskrivelser med ulikt detaljnivå om flere episoder knyttet til samme symptom eller sykdomstegn, og vil også kunne inneholde flere ulike symptomer eller sykdomstegn.\r\n\r\nI egentlig forstand er symptomer subjektive opplevelser av en fysisk eller mental forstyrrelse mens sykdomstegn er objektive observasjoner av det samme, som er erfart av et individ og rapportert til en kliniker av individet eller av andre. Fra denne logikken følger at det burde være to arketyper til å registrere klinisk anamnese; en for rapporterte symptomer og en for rapporterte sykdomstegn. I virkeligheten er dette upraktisk og vil kreve registrering av kliniske data i enten den ene eller den andre av disse modellene. I praksis vil dette øke kompleksitet og tidsbruk knyttet til modellering og registrering av data. I tillegg overlapper ofte de kliniske konseptene, for eksempel: Vil tidligere oppkast eller blødning kategoriseres som et symptom eller som et rapportert sykdomstegn?\r\nSom svar på dette er arketypen laget for å tillate registrering av hele kontinuumet mellom tydelig definerte symptomer og rapporterte sykdomstegn når en registrerer en klinisk anamnese.\r\n\r\nArketypen er designet for å gi et generisk rammeverk for alle symptomer og rapporterte sykdomstegn. SLOTet \"Spesifikke detaljer\" kan brukes for å utvide arketypen med ytterligere spesifikke dataelementer for komplekse symptomer eller sykdomstegn.\r\n\r\nArketypen skal settes inn i \"Detaljer\"-SLOTet i OBSERVATION.story-arketypen men kan også brukes i en hvilken som helst OBSERVATION eller CLUSTER-arketype. Arketypen kan også gjenbrukes i andre instanser av CLUSTER.symptom_sign-arketypen i SLOTene \"Assosierte symptomer\" eller \"Tidligere detaljer\".\r\n\r\nKlinikere registrerer ofte frasen \"Ikke av betydning\" i forbindelse med spesifikke symptomer eller rapporterte tegn for å indikere at det er eksplisitt spurt om det spesifikke symptomet, og at det ble svart at symptomet ikke er tilstede i en slik grad at det påfører pasienten ubehag eller uro. Frasen brukes mer som en normalbeskrivelse enn en eksplisitt eksklusjon. Dataelementet \"Ikke av betydning\" er med hensikt lagt til for å tillate at klinikere enkelt og effektivt kan registrere denne informasjonen i det kliniske systemet. Eksempelvis kan \"Ikke av betydning\" brukes i brukergrensesnittet, er dette registrert som \"Sann\" kan de resterende dataelementene skjules i brukergrensesnittet. Denne pragmatiske tilnærmingen støtter hoveddelen av enkel klinisk journalføring av symptomer og sykdomstegn. \r\n\r\nImidlertid kan det være fordelaktig å bruke arketypen CLUSTER.exclusion_symptom_sign dersom det er klinisk behov for å eksplisitt registrere at et symptom eller sykdomstegn ikke er tilstede, for eksempel dersom dette skal brukes til klinisk beslutningsstøtte. Bruk av CLUSTER.exclusion_symptom_sign vil øke kompleksiteten i templatmodellering, implementasjon og spørring. Det anbefales at CLUSTER.exclusion_symptom_sign kun vurderes brukt dersom man kan identifisere en klar gevinst, men bør ikke brukes for rutineregistreringer av symptomer eller sykdomstegn.", + "misuse":"Brukes ikke til eksplisitt registrering av at et symptom eller sykdomstegn ikke er tilstede. Bruk CLUSTER.exclusion_symptom_sign varsomt da det øker tidsbruk ved registrering og tilfører økt kompleksitet, og bare når dataelementet \"Ikke av betydning\" i denne arketypen ikke er eksplisitt nok for registreringen.\r\n\r\nBrukes ikke til registrering av objektive funn som en del av en fysisk undersøkelse. Bruk OBSERVATION.exam og relaterte CLUSTER.exam-arketyper for dette formålet. \r\n\r\nBrukes ikke til registrering av problemer og diagnoser som en del av en persistent problemliste, til dette brukes EVALUATION.problem_diagnosis.\r\n\r\nBrukes ikke til å dokumentere tiltak og resultat i løpet av hele perioden individet er under behandling, da arketypen er beregnet til å dokumentere symptomer og sykdomstegn som et øyeblikksbilde.", + "copyright":"© openEHR Foundation", + "originalResourceUri":{ + + }, + "otherDetails":{ + + } + }, + "en":{ + "@type":"RESOURCE_DESCRIPTION_ITEM", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"en" + }, + "purpose":"To record details about a single episode of a reported symptom or sign including context, but not details, of previous episodes if appropriate.", + "keywords":[ + "complaint", + "symptom", + "disturbance", + "problem", + "discomfort", + "presenting complaint", + "presenting symptom", + "sign" + ], + "use":"Use to record details about a single episode of a symptom or reported sign in an individual, as reported by the individual, parent, care-giver or other party. It may be recorded by a clinician as part of a clinical history record as reported to them, observed by the clinician or self-recorded as part of a clinical questionnaire or personal health record. A complete clinical history or patient story may include varying level of details about multiple episodes of an identified symptom or reported sign, as well as multiple symptoms/signs.\r\n\r\nIn the purest sense, symptoms are subjective observations of a physical or mental disturbance and signs are objective observations of the same, as experienced by an individual and reported to the history taker by the same individual or another party. From this logic it follows that we will need two archetypes to record clinical history - one for reported symptoms and another for reported signs. In reality this is impractical as it will require clinical data entry into either one of these models which adds signficant overheads to modellers and those entering data. In addition, there is often overlap in clinical concepts - for example, is previous vomiting or bleeding to be categorised as a symptom or reported sign? In response, this archetype has been specifically designed to proved a single information model that allows for recording of the entire continuum between clearly identifable symptoms and reported signs when recording a clinical history.\r\n\r\nThis archetype has been intended to be used as a generic pattern for all symptoms and reported signs. The 'Specific details' SLOT can be used to extend the archetype to include additional, specific data elements for more complex symptoms or signs. \r\n\r\nThis archetype has been specifically designed to be used in the 'Structured detail' SLOT within the OBSERVATION.story archetype, but can also be used within other OBSERVATION or CLUSTER archetypes and in the 'Associated symptom/sign' or 'Previous episode' SLOT within other instances of this CLUSTER.symptom_sign archetype.\r\n\r\nClinicians frequently record the phrase 'nil significant' against specific symptoms or reported signs as an efficient method to indicate that they asked the individual and it was not reported as causing any discomfort or disturbance - effectively used more like a 'normal statement' rather than an explicit exclusion. The 'Nil significant' data element has been deliberately included in this archetype to allow clinicians to record this same information in a simple and effective way in a clinical system. It can be used to drive a user interface, for example if 'Nil significant' is recorded as true then the remaining data elements can be hidden on a data entry screen. This pragmatic approach supports the majority of simple clinical recording requirements around reported symptoms and signs. \r\n\r\nHowever if there is a clinical imperative to explicitly record that a Symptom or Sign was reported as not present, for example if it will be used to drive clinical decision support, then it would be preferable to use the CLUSTER.exclusion_symptom_sign archetype. The use of CLUSTER.exclusion_symptom_sign will increase the complexity of template modelling, implementation and querying. It is recommended that the CLUSTER.exclusion_symptom_sign archetype only be considered for use if clear benefit can be identified in specific situations, but should not be used for routine symptom/sign recording.", + "misuse":"Not to be used to record that a symptom or sign was explicitly reported as not present - use CLUSTER.exclusion_symptom_sign carefully for specific purposes where the overheads of recording in this way warrant the additional complexity, and only if the 'Nil significant' in this archetype is not specific enough for recording purposes.\r\n\r\nNot to be used for recording objective findings as part of a physical examination - use OBSERVATION.exam and related examination CLUSTER archetypes for this purpose.\r\n\r\nNot to be used for diagnoses and problems that form part of a persisting Problem List - use EVALUATION.problem_diagnosis.", + "copyright":"© openEHR Foundation", + "originalResourceUri":{ + + }, + "otherDetails":{ + + } + }, + "ar-sy":{ + "@type":"RESOURCE_DESCRIPTION_ITEM", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"ar-sy" + }, + "purpose":"*To record detail about a symptom - either self-recorded by an individual or recorded on the behalf of a patient by a clinician. 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Exempel på formella diagnoser skulle omfatta cancer som stöds av anamnes, undersökningsfynd, histopatologiska fynd, radiologiska fynd samt möter alla kända kriteriekrav för diagnostik. \r\n\r\nI praktiken befinner sig de flesta problem eller diagnoser inte i någon ände av problemet-diagnos spektrumet, utan någonstans däremellan. \r\nDenna arketyp kan användas i flera kontexter, exempelvis för dokumentation av ett problem eller en klinisk diagnos under en klinisk konsultation, ifyllnad av en fast problemlista eller för en redogörande sammanfattning i ett utskrivningsdokument.\r\n\r\nI praktiken använder kliniker många kontext-specifika bestämningar som exempelvis tidigare och nuvarande, primär och sekundär, aktiv och inaktiv, inskrivning och utskrivning etc. Kontexterna kan vara plats-, specialitet-, episod-eller arbetsflödes-specifika. Dessa kan orsaka förvirring eller t.o.m. vara potentiella säkerhetsproblem om de förevigas i problemlistor eller delas i dokument som är utanför den ursprungliga kontexten.\r\nDessa bestämningar kan vara separata i arketyperna och ingår i \"status\"-fältet, eftersom deras användning varierar i olika inställningar. \r\nDet förväntas att de huvudsakligen används i en lämplig kontext och inte sprids utanför kontexten utan tydlig förståelse för potentiella konsekvenser.\r\nExempelvis kan en diagnos vara primär för en kliniker och sekundär för en annan specialist, ett aktivt problem kan bli inaktivt (eller vice versa) och detta kan påverka den säkra användningen av kliniskt beslutsstöd.\r\n\r\nI allmänhet bör dessa bestämningar tillämpas lokalt inom ramen för det kliniska systemet, och i praktiken bör dessa tillstånd ordnas manuellt av kliniker för att säkerställa att listor över nuvarande och tidigare, aktiv och inaktiv eller primärt och sekundärt problem är kliniskt korrekta.\r\nDenna arketyp kommer att användas som en komponent inom den problemorienterade patientjournalen som beskrivs av Larry Weed. Ytterligare arketyper, som presenterar kliniska begrepp som villkor som en övergripande organisatör för diagnoser etc. kommer att behöva utvecklas för att stödja denna strategi.\r\n\r\nI vissa situationer, kan identifiering av en diagnos vara lämplig enbart inom läkarnas expertis, men det är inte avsikten med denna arketyp. Diagnoser kan dokumenteras med hjälp av denna arketyp av vilken som helst sjukvårdspersonal.\r\n", + "misuse":"Ska inte användas för att dokumentera symtom som beskrivs av individen. Använd CLUSTER. symptom arketypen vanligtvis inom OBSERVATION.story-arketypen för det ändamålet.\r\n\r\nSka inte användas för att dokumentera undersökningsfynd. Använda då istället arketyper från den undersökningsrelaterade gruppen CLUSTER- som oftast är inkapslad i Observation Exam-arketypen.\r\n\r\nSka inte användas för att dokumentera testresultat från laboratoriet eller till relaterade diagnoser, exempelvis patologiska diagnoser. Använd då istället en lämplig arketyp från laboratoriegruppen OBSERVATION.\r\n\r\nSka inte användas för att dokumentera undersökningsfynd genom bildmedia eller bilddiagnostik. Använd då istället en lämplig arketyp från bildmediegruppen OBSERVATION arketyper.\r\n\r\nSka inte användas för att dokumentera \"differentialdiagnostik\". Använd då istället EVALUATION.differential_diagnosis-arketypen.\r\n\r\nSka inte användas för att dokumentera \"Anledning till Vårdtillfälle\" eller \"Huvudsakligt besvär\". Använd EVALUATION.reason_for_encounter-arketypen till dessa ändamål.\r\n\r\nSka inte användas för att dokumentera åtgärder. Använd då istället ACTION.procedure-arketypen.\r\n\r\nSka inte användas för att dokumentera uppgifter om graviditet. Använd EVALUATION.pregnancy_bf_status och EVALUATION.pregnancy och relaterade arketyper till dessa ändamål.\r\n\r\nSka inte användas för att dokumentera bedömningar om hälsorisker eller potentiella problem. Använd då istället EVALUATION.health_risk-arketypen.\r\n\r\nSka inte användas för att dokumentera redogörelser om biverkningar, allergier eller intoleranser. Använd EVALUATION.adverse_reaction-arketyp för dessa ändamål.\r\n\r\nSka inte användas för särskild dokumentering av frånvaro (eller negativ närvaro) av ett problem eller en diagnos, exempelvis \"inga kända problem eller diagnoser\" eller \"Ingen känd diabetes\". Använd EVALUATION.exclusion-problem_arketypen för att uttrycka ett positivt utlåtande om uteslutning av ett problem eller diagnos. \r\n\r\n", + "originalResourceUri":{ + + }, + "otherDetails":{ + + } + }, + "nb":{ + "@type":"RESOURCE_DESCRIPTION_ITEM", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"nb" + }, + "purpose":"For å registrere detaljer om ett identifisert helseproblem eller en diagnose.\r\n\r\nOmfanget for et helseproblem er med vilje løst definert, for å kunne registrere en reell eller selvoppfattet bekymring som i større eller mindre grad kan påvirke et individs velvære negativt. Et helseproblem kan identifiseres av individet selv, en omsorgsperson eller av helsepersonell. En diagnose er derimot definert basert på objektive kliniske kriterier, og stilles som regel bare av helsepersonell.", + "keywords":[ + "emne", + "problem", + "tilstand", + "hindring", + "diagnose", + "helseproblem", + "bekymring", + "funn", + "helsetilstand", + "konflikt", + "utfordring", + "klinisk bilde" + ], + "use":"Brukes til å registrere detaljer om ett identifisert helseproblem eller en diagnose. \r\n\r\nÅ klart definere skillet mellom et \"problem\" og en \"diagnose\" er i praksis nesten umulig, og vi kan ikke på en pålitelig måte si når et problem skal ses på som en diagnose. Når diagnostiske- eller klassifikasjonskriterier er innfridd kan vi trygt kalle tilstanden en formell diagnose, men før disse kriteriene er møtt kan det dersom det finnes støttende funn også være riktig å kalle den en diagnose. Mengden støttende funn som kreves for å sette merkelappen \"diagnose\" er ikke lett å definere, og varierer sannsynligvis i praksis fra tilstand til tilstand. Mange standardiseringskomiteer har arbeidet med dette definisjonsproblemet i årevis uten å komme til noen klar konklusjon.\r\n\r\nNår det gjelder klinisk dokumentasjon med denne arketypen må problemer og diagnoser ses på som deler av et spektrum der økende detaljgrad og mengde støttende funn som regel gir vekt mot merkelappen \"diagnose\". I denne arketypen er det ikke nødvendig å klassifisere tilstanden som enten et problem eller en diagnose. Datastrukturen for å dokumentere dem er identisk, med tilleggsstrukturer som støtter inklusjon av nye funn når eller hvis de blir tilgjengelige. Eksempler på problemer kan være et individs uttrykte ønske om å gå ned i vekt uten en formell diagnose av fedme, eller problemer i forholdet til et familiemedlem. Eksempler på formelle diagnoser kan være en kreftsvulst der diagnosen er støttet av historisk informasjon, undersøkelsesfunn, histologiske funn, radiologiske funn, og som møter alle diagnosekriterier. I praksis er de fleste problemer eller diagnoser ikke i hver sin ende av problem/diagnose-spektrumet, men et sted mellom.\r\n\r\nDenne arketypen kan brukes i mange sammenhenger. Eksempler kan være å registrere et problem eller en klinisk diagnose under en klinisk konsultasjon, fylle en persistent problemliste, eller for å gi oppsummerende informasjon i en epikrise.\r\n\r\nI praksis bruker klinikere mange kvalifikatorer som nåværende/tidligere, hoved/bidiagnose, aktiv/inaktiv, innleggelse/utskriving, etc. Sammenhengene kan være steds-, spesialiserings-, episode- eller arbeidsflytspesifikke, og disse kan forårsake forvirring eller til og med mulige sikkerhetsrisikoer dersom de videreføres i problemlister eller deles i dokumenter utenfor sin opprinnelige sammenheng. Disse kvalifikatorene kan arketypes separat og inkluderes i \"Status\"-SLOTet, fordi bruken varierer i ulike settinger. Disse vil sannsynligvis hovedsakelig brukes i passende sammenhenger, og ikke deles utenfor sammenhengen uten en klar forståelse av mulige konsekvenser. For eksempel kan en hoveddiagnose for en kliniker være en bidiagnose for en annen spesialist, et aktivt problem kan bli inaktivt (og omvendt), og dette kan ha innvirkning på sikkerhet og beslutningsstøtte. Generelt burde disse kvalifikatorene brukes lokalt og innenfor kontekst i det kliniske systemet, og i praksis bør de manuelt administreres av klinikere for å sikre at lister over nåværende/tidligere, aktiv/inaktiv eller hoved/bidiagnoser er klinisk presise.\r\n\r\nDenne arketypen vil bli brukt som en komponent i den problemorienterte journalen som beskrevet av Larry Weed. Tilleggsarketyper som representerer kliniske konsepter som f.eks. \"tilstand\" som en overbygning for diagnoser etc, vil måtte utvikles for å støtte dette.\r\n\r\nI noen situasjoner antas det at å stille en diagnose ligger fullstendig innenfor legers domene, men dette er ikke hensikten med denne arketypen. Diagnoser kan registreres av alt helsepersonell ved hjelp av denne arketypen.", + "misuse":"Brukes ikke til å registrere symptomer slik de beskrives av individet. Til dette brukes CLUSTER.symptom-arketypen, som regel innenfor OBSERVATION.story-arketypen.\r\n\r\nBrukes ikke til å registrere funn ved klinisk undersøkelse. Til dette brukes gruppen av undersøkelsesrelaterte CLUSTER-arketyper, som regel innenfor OBSERVATION.exam-arketypen.\r\n\r\nBrukes ikke til å registrere laboratoriesvar eller relaterte diagnoser for eksempel patologiske diagnoser. Til dette brukes en passende arketype fra laboratoriefamilien av OBSERVATION-arketyper.\r\n\r\nBrukes ikke til å registrere billeddiagnostiske svar eller diagnoser. Til dette brukes en passende arketype fra billeddiagnostikkfamilien av OBSERVATION-arketyper.\r\n\r\nBrukes ikke til å registrere differensialdiagnoser. Til dette brukes EVALUATION.differential_diagnosis-arketypen.\r\n\r\nBrukes ikke til å registrere kontaktårsak eller klinisk problemstilling ved kontakt. Til dette brukes EVALUATION.reason_for_encounter-arketypen.\r\n\r\nBrukes ikke til å registrere prosedyrer, til dette brukes ACTION.procedure-arketypen.\r\n\r\nBrukes ikke til å registrere detaljer om graviditet utover diagnoser. Til dette brukes EVALUATION.pregnancy_bf_status og EVALUATION.pregnancy, samt relaterte arketyper.\r\n\r\nBrukes ikke til å registrere vurderinger av potensiale og sannsynlighet for fremtidige problemer, diagnoser eller andre uønskede helseeffekter, til dette brukes EVALUATION.health_risk-arketypen.\r\n\r\nBrukes ikke til å registrere utsagn om uønskede reaksjoner, allergier eller intoleranser - bruk EVALUATION.adverse_reaction-arketypen.\r\n\r\nBrukes ikke til å registrere et eksplisitt fravær (eller negativ tilstedeværelse) av et problem eller en diagnose, f.eks. \"ingen kjente problemer eller diagnoser\" eller \"ingen kjent diabetes\". Bruk EVALUATION.exclusion-problem_diagnosis for å uttrykke fravær av et problem eller en diagnose.\r\n\r\nBrukes ikke til å registrere pasientens tilgjengelige ressurser for egenomsorg - bruk egne EVALUATION-arketyper for dette formålet.", + "copyright":"© openEHR Foundation", + "originalResourceUri":{ + + }, + "otherDetails":{ + + } + }, + "es-ar":{ + "@type":"RESOURCE_DESCRIPTION_ITEM", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"es-ar" + }, + "purpose":"Para el registro de detalles acerca de un único problema de salud o diagnóstico.\r\nEl alcance previsto del problema de salud se mantiene deliberadamente poco definido en el contexto de la documentación clínica, de modo tal que pueda representarse cualquier problema, real o percibido, que pueda afectar al bienestar de un individuo en cualquier grado. Un problema de salud puede ser identificado por un individuo, un cuidador, o un profesional de la salud. Para la definición de un diagnóstico se require además de criterios clínicos objetivos, habitualmente determinados por un profesional de la salud.", + "keywords":[ + "asunto", + "condición", + "problema", + "diagnóstico", + "preocupación", + "lesión", + "impresión clínica" + ], + "use":"Utilícese para registrar detalles acerca de un único problema de salud o diagnóstico.\r\n\r\nUna definición clara que permita diferenciar un \"problema\" de un \"diagnóstico\" es casi imposible en la práctica - no podemos determinar en forma confiable cuando un problema debería ser considerado un diagnóstico. Cuando se cumplen con éxito determinados criterios diagnósticos o de clasificación es posible denominar una condición como un diagnóstico formal, pero previo al cumplimiento de dichos criterios y en tanto exista evidencia clínica que lo sustente, también puede ser válido el uso del término \"diagnóstico\". La cantidad de evidencia de apoyo varía de caso en caso. Muchos comités de estándares han lidiado con este problema por años sin lograr una resolución clara.\r\n\r\nA los fines de la documentación clínica mediante este arquetipo, problema y diagnóstico son considerados como un continuo, donde el incremento de los niveles de detalle y sustento en la evidencia inclinan la balanza hacia la etiqueta de \"diagnóstico\". Los requerimientos de datos que sustentan la documentación de ambos son idénticos, siendo necesarias estructuras de datos adicionales para sustentar la inclusión de la evidencia cuando esta exista y se encuentre disponible. Los ejemplos de problemas incluyen: la expresión del deseo de bajar de peso por parte de un individuo sin la existencia de un diagnóstico formal de obesidad, o un problema de relación con un familiar. Los ejemplos de diagnósticos formales incluyen un cáncer fundamentado en información histórica, los hallazgos de un examen, los hallazgos histopatológicos, los hallazgos radiológicos, y que cumplen todos los criterios diagnósticos. En la práctica, la mayoría de los problemas o diagnósticos no se encuentran en los extremos del espectro problema-diagnóstico sino que se ubican en alguna posición intermedia.\r\n\r\nEste arquetipo puede ser utilizado en diversos contextos. Por ejemplo, para registrar un problema o diagnóstico clínico durante una consulta clínica, para la elaboración de una Lista de Problemas persistente, o para proveer una afirmación sumaria dentro de un documento de Resumen de Alta.\r\n\r\nEn la práctica, los clínicos utilizan muchos calificadores dependientes del contexto, tales como pasado/actual, primario/secundario, activo/inactivo, admisión/egreso, etc. Estos contextos pueden ser relativos a la localización, la especialización, el episodio, o a un instancia de un proceso, pudiendo entonces generar confusión o riesgos potenciales de seguridad para el paciente si son incluidos en Listas de Problemas o documentos compartidos que carecen del contexto original. Estos contextos pueden ser arquetipados en forma separada e incluidos en el slot de \"Estado\", dado que su uso varía en diferentes escenarios. Su uso mayormente pretendido debe darse en el contexto apropiado y no debería ser compartido fuera de dicho contexto sin una clara comprensión de sus consecuencias potenciales. Por ejemplo: un diagnóstico primario podría ser un diagnóstico secundario para otro especialista; un problema activo puede tornarse inactivo (o viceversa) e impactar en la seguridad de una decisión clínica. En general, estos calificadores deberían aplicarse localmente dentro del contexto del sistema clínico y en la práctica estos estados deberían ser manualmente mantenidos por clínicos a fin de asegurar que las listas de problemas, actuales o pasados, activos o inactivos o primarios y secundarios, sean clínicamente exactos.\r\n\r\nEste arquetipo será utilizado como un componente del Registro Médico Orientado al Problema descripto por Larry Weed. Se requerirá del desarrollo de arquetipos adicionales para la representación de conceptos clínicos tales como una condición para un organizador general de diagnósticos, etc.\r\n\r\nEn algunas situaciones puede asumirse que la identificación de un diagnóstico solo se ajusta a la experticia del médico, pero no es el propósito de este arquetipo. Los diagnósticos pueden ser registrados mediante este arquetipo por parte de cualquier profesional.\r\n", + "misuse":"No debe ser utilizado para registrar síntomas tal cual fueron descriptos por el individuo; para ello se debe utilizar el arquetipo CLUSTER.symptom, habitualmente dentro del contexto del arquetipo OBSERVATION.story.\r\n\r\nNo debe ser utilizado para registrar hallazgo de exámenes, para ello se debe utilizar la familia de arquetipos relacionados a exámenes, habitualmente contenidos dentro del arquetipo OBSERVATION.exam.\r\n\r\nNo debe ser utilizado para registrar hallazgos de pruebas de laboratorio o diagnósticos relacionados (como por ejemplo diagnósticos patológicos); para ello se debe utilizar un arquetipo apropiado de la familia de arquetipos del tipo OBSERVATION.\r\n\r\nNo debe ser utilizado para registrar resultados de exámenes por imágenes o diagnósticos imagenológicos; para ello se debe utilizar un arquetipo apropiado de la familia de arquetipos del tipo OBSERVATION.\r\n\r\nNo debe ser utilizado para registrar diagnósticos diferenciales; para ello se debe utilizar el arquetipo EVALUATION.differential_diagnosis.\r\n\r\nNo debe ser utilizado para registrar \"Motivos de Consulta\"; para ello se debe utilizar el arquetipo EVALUATION.reason_for_encounter.\r\n\r\nNo debe ser utilizado para registrar procedimientos; para ello se debe utilizar el arquetipo ACTION.procedure.\r\n\r\nNo debe ser utilizado para registrar detalles acerca del embarazo; para ello se debe utilizar los arquetipos EVALUATION.pregnancy_bf_status, EVALUATION.pregnancy y los arquetipos relacionados.\r\n\r\nNo debe ser utilizado para registrar aseveraciones acerca de riesgos para la salud o problemas potenciales; para ello se debe utilizar el arquetipo EVALUATION.health_risk.\r\n\r\nNo debe ser utilizado para registrar aseveraciones acerca de reacciones adversas, alergias o intolerancias; para ello se debe utilizar el arquetipo EVALUATION.adverse_reaction.\r\n\r\n\r\nNo debe ser utilizado para registrar la ausencia explícita (o presencia negativa) de un problema o diagnóstico (como por ejemplo \"sin diagnósticos o problemas conocidos\" o \"sin diabetes conocida\"); para expresar una aseveración positiva acerca de la exclusión de un problema o diagnóstico se debe utilizar el arquetipo EVALUATION.exclusion-problem_diagnosis.", + "copyright":"© openEHR Foundation", + "originalResourceUri":{ + + }, + "otherDetails":{ + + } + }, + "pt-br":{ + "@type":"RESOURCE_DESCRIPTION_ITEM", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"pt-br" + }, + "purpose":"Para gravar detalhes sobre um único problema de saúde ou diagnóstico identificado.\r\n\r\nO escopo pretendido de um problema de saúde é deliberadamente mantido livre no contexto da documentação clínica, de forma a captar quaisquer preocupações reais ou percebidas que podem afetar adversamente, em qualquer grau, o bem-estar de um indivíduo. Um problema de saúde pode ser identificado pela o indivíduo, um prestador de cuidados ou de um profissional de saúde. No entanto, o diagnóstico é adicionalmente definido com base em critérios clínicos objetivos, e, geralmente, determinado apenas por um profissional de saúde.", + "keywords":[ + "caso", + "condição", + "problema", + "diagnóstico", + "preocupação", + "prejuízo", + "impressão clínica" + ], + "use":"Para gravar detalhes sobre um único problema de saúde ou diagnóstico identificado.\r\n\r\nDefinições claras que permitem a diferenciação entre um \"problema\" e um \"diagnóstico\" são quase impossíveis na prática - não podemos dizer de forma segura quando um problema deve ser considerado como um diagnóstico. Quando o diagnóstico ou os critérios de classificação são cumpridos com sucesso, então com confiança podemos chamar a condição de um diagnóstico formal, mas antes que essas condições sejam cumpridas e enquanto houver evidências para tanto, também pode ser válido usar o termo \"diagnóstico\". A quantidade de evidências de apoio requerida para a indicação de diagnóstico não é fácil de ser definida e na realidade, provavelmente varia de condição para condição. Muitos comitês de padrões têm, por anos, se confrontado com esse dilema de definição sem resolução clara. \r\n\r\nEste arquétipo pode ser utilizado em muitos contextos. Por exemplo, na gravação de um problema ou um diagnóstico durante uma consulta clínica; preencher uma lista de problema persistente; ou para fornecer uma declaração de resumo de um documento Sumário de Alta.\r\n\r\nNa prática, os clínicos usam muitos qualificadores de contexto específico, como passado / presente, primário / secundário, ativo / inativo, admissão / alta, etc. Os contextos podem ser: localização, especialização, episódio ou específicos de fluxo de trabalho, e estes podem causar confusão ou até mesmo potenciais problemas de segurança se persistido nas listas de problemas ou compartilhados em documentos que estão fora do contexto original. Estes qualificadores podem ser arquetipados separadamente e incluídos no slot 'Estado', porque seu uso varia em diferentes contextos. Espera-se que estes serão utilizados em sua maioria dentro do contexto apropriado e não compartilhados fora desse contexto, sem compreensão clara das consequências potenciais. Por exemplo, um diagnóstico primário para um clínico pode ser um secundário para outro especialista; um problema ativo pode se tornar inativo (ou vice-versa) e isso pode impactar no uso seguro do apoio à decisão clínica. Em geral, estes qualificadores devem ser aplicados localmente dentro do contexto do sistema clínico e na prática, esses estados devem ser criados manualmente pelos clínicos para assegurar que as listas de problemas: Presente / Passado, ativo / inativo ou primário / secundário são clinicamente precisas.\r\n\r\nEste arquétipo será usado como um componente dentro do Registro Clínico Orientado à Problemas, tal como descrito por Larry Weed. Arquétipos adicionais, que representam conceitos clínicos, tais como: condição como um organizador abrangente para diagnósticos etc, terão de ser desenvolvidos para apoiar esta abordagem.\r\n\r\nEm algumas situações, pode ser assumido que a identificação de um diagnóstico só se encaixa dentro da expertise do médico, mas esta não é a intenção para este arquétipo. Os diagnósticos podem ser gravados utilizando esse arquétipo por qualquer profissional de saúde.", + "misuse":"Não deve ser usado para registrar os sintomas descritos pelo indivíduo, para isso, use o arquétipo CLUSTER.symptom, geralmente dentro do arquétipo OBSERVATION.story.\r\n\r\nNão deve ser usado para registrar achados do exame, use o CLUSTER da família de arquétipos relacionadas ao exame, geralmente aninhados dentro do arquétipo OBSERVATION.exam.\r\n\r\nNão deve ser usado para registrar os resultados dos testes de laboratório ou diagnósticos relacionados, por exemplo, em diagnósticos patológicos use um arquétipo apropriado da família de laboratório dos arquétipos OBSERVATION.\r\n\r\nNão deve ser usado para registrar os resultados dos exames de imagem ou de diagnóstico por imagem, use um arquétipo apropriado a partir da família de imagem dos arquétipos OBSERVATION.\r\n\r\nNão deve ser usado para gravar 'diagnósticos diferenciais', use o arquétipo EVALUATION.differential_diagnosis.\r\n\r\nNão deve ser usado para gravar 'Motivo do Encontro \"ou\" queixa apresentada', use o arquétipo EVALUATION.reason_for_encounter.\r\n\r\nNão deve ser usado para gravar procedimentos, use o arquétipo ACTION.procedure.\r\n\r\nNão deve ser usado para registrar detalhes sobre a gravidez, use o EVALUATION.pregnancy_bf_status e EVALUATION.pregnancy e os arquétipos relacionados.\r\n\r\nNão deve ser usado para gravar o estadiamento sobre o risco ou os problemas de saúde potenciais, use o arquétipo risco EVALUATION.health.\r\n\r\nNão deve ser usado para gravar declarações sobre reações adversas, alergias ou intolerâncias, use o arquétipo EVALUATION.adverse_reaction.\r\n\r\nNão deve ser usado para a gravação de uma ausência explícita (ou presença negativa) de um problema ou diagnóstico, por exemplo: \"sem problema ou diagnósticos conhecido\" ou \"diabetes não conhecido\". Use o arquétipo EVALUATION.exclusion-problem_diagnosis para expressar uma declaração positiva sobre a exclusão de um problema ou diagnóstico.", + "copyright":"© openEHR Foundation", + "originalResourceUri":{ + + }, + "otherDetails":{ + + } + }, + "en":{ + "@type":"RESOURCE_DESCRIPTION_ITEM", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"en" + }, + "purpose":"For recording details about a single, identified health problem or diagnosis. \r\n\r\nThe intended scope of a health problem is deliberately kept loose in the context of clinical documentation, so as to capture any real or perceived concerns that may adversely affect an individual's wellbeing to any degree. A health problem may be identified by the individual, a carer or a healthcare professional. However, a diagnosis is additionally defined based on objective clinical criteria, and usually determined only by a healthcare professional.", + "keywords":[ + "issue", + "condition", + "problem", + "diagnosis", + "concern", + "injury", + "clinical impression" + ], + "use":"Use for recording details about a single, identified health problem or diagnosis. \r\n\r\nClear definitions that enable differentiation between a 'problem' and a 'diagnosis' are almost impossible in practice - we cannot reliably tell when a problem should be regarded as a diagnosis. When diagnostic or classification criteria are successfully met, then we can confidently call the condition a formal diagnosis, but prior to these conditions being met and while there is supportive evidence available, it can also be valid to use the term 'diagnosis'. The amount of supportive evidence required for the label of diagnosis is not easy to define and in reality probably varies from condition to condition. Many standards committees have grappled with this definitional conundrum for years without clear resolution.\r\n\r\nFor 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'. In this archetype it is not neccessary to classify the condition as a 'problem' or 'diagnosis'. The data requirements to support documentation of either are identical, with additional data structure required to support inclusion of the evidence if and when it becomes available. Examples of problems include: the individual's expressed desire to lose weight, but without a formal diagnosis of Obesity; or a relationship problem with a family member. Examples of formal diagnoses would include a cancer that is supported by historical information, examination findings, histopathological findings, radiological findings and meets all requirements for known diagnostic criteria. In practice, most problems or diagnoses do not sit at either end of the problem-diagnosis spectrum, but somewhere in between.\r\n\r\nThis archetype can be used within many contexts. For example, recording a problem or a clinical diagnosis during a clinical consultation; populating a persistent Problem List; or to provide a summary statement within a Discharge Summary document.\r\n\r\nIn practice, clinicians use many context-specific qualifiers such as past/present, primary/secondary, active/inactive, admission/discharge etc. The contexts can be location-, specialisation-, episode- or workflow-specific, and these can cause confusion or even potential safety issues if perpetuated in Problem Lists or shared in documents that are outside of the original context. These qualifiers can be archetyped separately and included in the ‘Status’ slot, because their use varies in different settings. It is expected that these will be used mostly within the appropriate context and not shared out of that context without clear understanding of potential consequences. For example, a primary diagnosis to one clinician may be a secondary one to another specialist; an active problem can become inactive (or vice versa) and this can impact the safe use of clinical decision support. In general these qualifiers should be applied locally within the context of the clinical system, and in practice these statuses should be manually curated by clinicians to ensure that lists of Current/Past, Active/Inactive or Primary/Secondary Problems are clinically accurate. \r\n\r\nThis archetype will be used as a component within the Problem Oriented Medical Record as described by Larry Weed. Additional archetypes, representing clinical concepts such as condition as an overarching organiser for diagnoses etc, will need to be developed to support this approach.\r\n\r\nIn some situations, it may be assumed that identification of a diagnosis fits only within the expertise of physicians, but this is not the intent for this archetype. Diagnoses can be recorded using this archetype by any healthcare professional.", + "misuse":"Not to be used to record symptoms as described by the individual - use the CLUSTER.symptom archetype, usually within the OBSERVATION.story archetype.\r\n\r\nNot to be used to record examination findings - use the family of examination-related CLUSTER archetypes, usually nested within the OBSERVATION.exam archetype.\r\n\r\nNot to be used to record laboratory test results or related diagnoses, for example pathological diagnoses - use an appropriate archetype from the laboratory family of OBSERVATION archetypes.\r\n\r\nNot to be used to record imaging examination results or imaging diagnoses - use an appropriate archetype from the imaging family of OBSERVATION archetypes.\r\n\r\nNot to be used to record 'Differential Diagnoses' - use the EVALUATION.differential_diagnosis archetype.\r\n\r\nNot to be used to record 'Reason for Encounter' or 'Presenting Complaint' - use the EVALUATION.reason_for_encounter archetype.\r\n\r\nNot to be used to record procedures - use the ACTION.procedure archetype.\r\n\r\nNot to be used to record details about pregnancy - use the EVALUATION.pregnancy_bf_status and EVALUATION.pregnancy and related archetypes.\r\n\r\nNot to be used to record statements about health risk or potential problems - use the EVALUATION.health_risk archetype.\r\n\r\nNot to be used to record statements about adverse reactions, allergies or intolerances - use the EVALUATION.adverse_reaction archetype.\r\n\r\nNot to be used for the explicit recording of an absence (or negative presence) of a problem or diagnosis, for example ‘No known problem or diagnoses’ or ‘No known diabetes’. Use the EVALUATION.exclusion-problem_diagnosis archetype to express a positive statement about exclusion of a problem or diagnosis.", + "copyright":"© openEHR Foundation", + "originalResourceUri":{ + + }, + "otherDetails":{ + + } + }, + "ar-sy":{ + "@type":"RESOURCE_DESCRIPTION_ITEM", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"ar-sy" + }, + "purpose":"لتسجيل تفاصيل حول قضية أو عقبة تؤثر على السلامة البدنية, العقلية و/أو الاجتماعية لشخص ما", + "keywords":[ + "القضية", + "الظرف الصحي", + "المشكلة", + "العقبة" + ], + "use":"يستخدم لتسجيل المعلومات العامة حول المشكلات المتعلقة بالصحة.\r\nيحتوي النموذج على معلومات متعددة,و يمكن استخدامه في تسجيل المشكلات الحاضرة و السابقة.\r\nو يمكن تحديد المشكلة بواسطة المريض نفسه أو من يقوم بتقديم الرعاية الصحية.\r\nبعض الأمثلة تتضمن ما يلي:\r\n- بعض الأعراض التي لا تزال تحت الملاحظة و لكنها تمثل تشخيصات مبدأية\r\n- الرغبة لفقد الوزن دون تشخيص مؤكد بالسمنة\r\n- الرغبة بالإقلاع عن التدخين بواسطة الشخص\r\n- مشكلة في العلاقة مع أحد أفراد العائلة", + "misuse":"لا يستخدم لتسجيل التشخيصات المؤكدة. استخدم بدلا من ذلك النموذج المخصص من هذا النموذج, تقييم.المشكلة - التشخيص", + "copyright":"© openEHR Foundation", + "originalResourceUri":{ + + }, + "otherDetails":{ + + } + }, + "es":{ + "@type":"RESOURCE_DESCRIPTION_ITEM", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"es" + }, + "purpose":"Este arquetipo se utilizará para registrar un único problema de salud o diagnóstico identificado para el paciente.\r\n\r\nEl alcance del arquetipo se dejó deliberadamente abierto, para poder capturar cualquier inquietud real o percibida que afecte en cualquier grado la salud de un paciente. Independientemente de quién detecte el problema, el diagnóstico debe ser definido basado en criterios clínicos objetivos, determinados por un profesional clínico.", + "keywords":[ + "problema", + "diagnóstico", + "preocupación", + "condición", + "enfermedad" + ], + "use":"Este arquetipo se utilizará para registrar un único problema de salud o diagnóstico identificado para el paciente.", + "misuse":"No se debe utilizar para registrar síntomas descritos por el paciente, para eso utilizar el arquetipo CLUSTER.symtom.\r\n\r\nNo se debe utilizar para registrar hallazgos, para eso utilizar arquetipos relacionados con la examinación, usualmente relacionados con el arquetipo OBSERVATION.exam\r\n\r\nNo se debe utilizar para registrar diagnósticos realizados sobre resultados de estudios diagnósticos como laboratorio o imagenología.\r\n\r\nNo se debe utilizar para registrar el motivo de consulta o problema presentado por el paciente, para eso utilizar el arquetipo EVALUATION.reason_for_encounter\r\n\r\nNo se debe utilizar para registrar riesgos o problemas potenciales, para eso utilizar el arquetipo EVALUATION.health_risk\r\n\r\nNo se debe utilizar para registrar la ausencia de un problema, para eso utilizar el arquetipo EVALUATION.exclusion-problem_diagnosis", + "copyright":"© openEHR Foundation", + "originalResourceUri":{ + + }, + "otherDetails":{ + + } + } + } + }, + "parentArchetypeId":"openEHR-EHR-EVALUATION.problem_diagnosis.v1", + "differential":true, + "archetypeId":{ + "@type":"ARCHETYPE_HRID", + "value":"openEHR-EHR-EVALUATION.ovl-problem_diagnosis-007.v1" + }, + "definition":{ + "@type":"C_COMPLEX_OBJECT", + "rmTypeName":"EVALUATION", + "nodeId":"at0000.1", + "attributes":[ + { + "@type":"C_ATTRIBUTE", + "rmAttributeName":"data", + "children":[ + { + "@type":"C_COMPLEX_OBJECT", + "rmTypeName":"ITEM_TREE", + "nodeId":"at0001", + "attributes":[ + { + "@type":"C_ATTRIBUTE", + "rmAttributeName":"items", + "children":[ + { + "@type":"C_COMPLEX_OBJECT", + "rmTypeName":"ELEMENT", + "nodeId":"at0002.1", + "attributes":[ + { + "@type":"C_ATTRIBUTE", + "rmAttributeName":"value", + "children":[ + { + "@type":"C_COMPLEX_OBJECT", + "rmTypeName":"DV_CODED_TEXT", + "occurrences":"0..1", + "attributes":[ + { + "@type":"C_ATTRIBUTE", + "rmAttributeName":"defining_code", + "existence":"0..1", + "children":[ + { + "@type":"C_TERMINOLOGY_CODE", + "terminologyId":{ + "value":"SNOMED-CT" + }, + "constraint":[ + + ], + "includedExternalTerminologyCodes":[ + { + "terminologyId":"SNOMED-CT", + "code":"840533007", + "value":"2019-nCOV" + } + ] + } + ] + } + ], + "attributeTuples":[ + + ] + } + ] + } + ], + "attributeTuples":[ + + ] + }, + { + "@type":"C_COMPLEX_OBJECT", + "rmTypeName":"ELEMENT", + "occurrences":"0..0", + "nodeId":"at0009.1", + "attributes":[ + + ], + "attributeTuples":[ + + ] + }, + { + "@type":"C_COMPLEX_OBJECT", + "rmTypeName":"ELEMENT", + "occurrences":"0..0", + "nodeId":"at0012.1", + "attributes":[ + + ], + "attributeTuples":[ + + ] + }, + { + "@type":"C_COMPLEX_OBJECT", + "rmTypeName":"ELEMENT", + "occurrences":"0..0", + "nodeId":"at0077.1", + "attributes":[ + + ], + "attributeTuples":[ + + ] + }, + { + "@type":"C_COMPLEX_OBJECT", + "rmTypeName":"ELEMENT", + "occurrences":"0..0", + "nodeId":"at0005.1", + "attributes":[ + { + "@type":"C_ATTRIBUTE", + "rmAttributeName":"value", + "children":[ + { + "@type":"C_COMPLEX_OBJECT", + "rmTypeName":"DV_CODED_TEXT", + "attributes":[ + { + "@type":"C_ATTRIBUTE", + "rmAttributeName":"defining_code", + "children":[ + { + "@type":"C_TERMINOLOGY_CODE", + "rmTypeName":"CODE_PHRASE", + "occurrences":"1..1", + "terminologyId":{ + "value":"local" + }, + "constraint":[ + "at0047", + "at0048", + "at0049" + ] + } + ] + } + ], + "attributeTuples":[ + + ] + }, + { + "@type":"C_COMPLEX_OBJECT", + "rmTypeName":"DV_TEXT", + "attributes":[ + + ], + "attributeTuples":[ + + ] + } + ] + } + ], + "attributeTuples":[ + + ] + }, + { + "@type":"C_COMPLEX_OBJECT", + "rmTypeName":"ELEMENT", + "occurrences":"0..0", + "nodeId":"at0072.1", + "attributes":[ + + ], + "attributeTuples":[ + + ] + }, + { + "@type":"C_COMPLEX_OBJECT", + "rmTypeName":"ELEMENT", + "occurrences":"0..0", + "nodeId":"at0030.1", + "attributes":[ + + ], + "attributeTuples":[ + + ] + }, + { + "@type":"C_COMPLEX_OBJECT", + "rmTypeName":"ELEMENT", + "occurrences":"0..0", + "nodeId":"at0073.1", + "attributes":[ + { + "@type":"C_ATTRIBUTE", + "rmAttributeName":"value", + "children":[ + { + "@type":"C_COMPLEX_OBJECT", + "rmTypeName":"DV_CODED_TEXT", + "attributes":[ + { + "@type":"C_ATTRIBUTE", + "rmAttributeName":"defining_code", + "children":[ + { + "@type":"C_TERMINOLOGY_CODE", + "rmTypeName":"CODE_PHRASE", + "occurrences":"1..1", + "terminologyId":{ + "value":"local" + }, + "constraint":[ + "at0074", + "at0075", + "at0076" + ] + } + ] + } + ], + "attributeTuples":[ + + ] + }, + { + "@type":"C_COMPLEX_OBJECT", + "rmTypeName":"DV_TEXT", + "attributes":[ + + ], + "attributeTuples":[ + + ] + } + ] + } + ], + "attributeTuples":[ + + ] + }, + { + "@type":"C_ARCHETYPE_ROOT", + "rmTypeName":"CLUSTER", + "occurrences":"0..*", + "nodeId":"at0043.1", + "attributes":[ + + ], + "attributeTuples":[ + + ], + "archetypeRef":"openEHR-EHR-CLUSTER.ovl-problem_qualifier_dips-008.v0", + "referenceType":"archetypeOverlay" + } + ] + } + ], + "attributeTuples":[ + + ] + } + ] + } + ], + "attributeTuples":[ + + ] + }, + "terminology":{ + "@type":"ARCHETYPE_TERMINOLOGY", + "conceptCode":"at0000", + "termDefinitions":{ + "es":{ + "at0000.1":{ + "@type":"ARCHETYPE_TERM", + "code":"at0000.1", + "text":"2019-cCOV problem", + "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.(en)", + "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'.(en)" + } + }, + "es-ar":{ + "at0000.1":{ + "@type":"ARCHETYPE_TERM", + "code":"at0000.1", + "text":"2019-cCOV problem", + "description":"Detalles acerca de una condición de salud, lesión, incapacidad o cualquier otra cuerstión, univocamente identificadas, que impacta sobre el bienestar físico, mental y/o social de un individuo", + "comment":"La delineación entre el alcance de un problema versus el diagnóstico puede no ser fácil de lograr en la práctica. A los fines de la documentación clínica mediante este arquetipo, problema y diagnóstico son considerados un continuo, donde niveles incrementales de detalles y evidencia de apoyo otorgan mas peso a la etiqueta de \"diagnóstico\"." + } + }, + "de":{ + "at0000.1":{ + "@type":"ARCHETYPE_TERM", + "code":"at0000.1", + "text":"2019-cCOV problem", + "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.(en)", + "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'.(en)" + } + }, + "en":{ + "at0000.1":{ + "@type":"ARCHETYPE_TERM", + "code":"at0000.1", + "text":"2019-cCOV problem", + "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'." + } + }, + "ar-sy":{ + "at0000.1":{ + "@type":"ARCHETYPE_TERM", + "code":"at0000.1", + "text":"2019-cCOV problem", + "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.(en)", + "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'.(en)" + } + }, + "pt-br":{ + "at0000.1":{ + "@type":"ARCHETYPE_TERM", + "code":"at0000.1", + "text":"2019-cCOV problem", + "description":"Detalhes sobre uma única condição de saúde identificada, lesões, deficiência ou qualquer outra questão que tenha impacto sobre o bem-estar físico, mental e / ou social de um indivíduo.", + "comment":"Delimitação clara entre o âmbito de um problema em comparação a um diagnóstico, não é fácil de se conseguir na prática. Para fins de documentação clínica com este arquétipo, problema e diagnóstico são considerados como uma continuidade, com níveis crescentes de detalhes e evidência de apoio, geralmente fornecendo peso para o rótulo de \"diagnóstico\"." + } + }, + "nb":{ + "at0000.1":{ + "@type":"ARCHETYPE_TERM", + "code":"at0000.1", + "text":"2019-cCOV problem", + "description":"Detaljer om én identifisert helsetilstand, skade, funksjonshemming eller annet forhold som påvirker et individs fysiske, mentale og/eller sosiale velvære.\r\n", + "comment":"Det er i praksis ikke lett å oppnå et klart skille mellom et problem og en diagnose. I klinisk dokumentasjon med denne arketypen ses problem og diagnose som et kontinuum, med økende krav til detaljer og støttende evidens for å underbygge en diagnose." + } + }, + "sv":{ + "at0000.1":{ + "@type":"ARCHETYPE_TERM", + "code":"at0000.1", + "text":"2019-cCOV problem", + "description":"Detaljer av ett enskilt identifierat hälsotillstånd, skada, funktionshinder eller något annat problem som påverkar individens fysiska, psykiska och eller sociala välbefinnande.", + "comment":"Det är inte lätt att i praktiken uppnå en tydlig avgränsning mellan ett problem och en diagnos. Vid tillämpning av klinisk dokumentation med denna arketyp betraktas problem och diagnos som ett kontinuum, med plats för fler detaljer och stödjande bevis som vanligtvis ger tyngd till etiketten ”diagnos”." + } + } + }, + "termBindings":{ + + }, + "terminologyExtracts":{ + + }, + "valueSets":{ + + } + }, + "adlVersion":"1.4", + "buildUid":"38cc7b71-a180-4ca1-ad7e-75fb9b893bec", + "rmName":"openehr", + "rmRelease":"1.0.3", + "generated":true, + "otherMetaData":{ + + }, + "originalLanguage":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"en" + }, + "translations":[ + { + "@type":"TRANSLATION_DETAILS", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"de" + }, + "author":{ + "name":"Jasmin Buck, Sebastian Garde", + "organisation":"University of Heidelberg, Central Queensland University" + }, + "otherDetails":{ + + } + }, + { + "@type":"TRANSLATION_DETAILS", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"sv" + }, + "author":{ + "name":"Kirsi Poikela", + "organisation":"Tieto Sweden AB", + "email":"ext.kirsi.poikela@tieto.com" + }, + "otherDetails":{ + + } + }, + { + "@type":"TRANSLATION_DETAILS", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"es-ar" + }, + "author":{ + "name":"Alan March", + "organisation":"Hospital Universitario Austral, Buenos Aires, Argentina", + "email":"alandmarch@gmail.com" + }, + "accreditation":"-", + "otherDetails":{ + + } + }, + { + "@type":"TRANSLATION_DETAILS", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"nb" + }, + "author":{ + "name":"Silje Ljosland Bakke, John Tore Valand", + "organisation":"Helse Bergen HF" + }, + "otherDetails":{ + + } + }, + { + "@type":"TRANSLATION_DETAILS", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"pt-br" + }, + "author":{ + "name":"Adriana Kitajima, Gabriela Alves, Maria Angela Scatena, Marivan Abrahäo", + "organisation":"Core Consulting", + "email":"contato@coreconsulting.com.br" + }, + "accreditation":"Hospital Alemão Oswaldo Cruz (HAOC)", + "otherDetails":{ + + } + }, + { + "@type":"TRANSLATION_DETAILS", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"ar-sy" + }, + "author":{ + "name":"Mona Saleh" + }, + "otherDetails":{ + + } + }, + { + "@type":"TRANSLATION_DETAILS", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"es" + }, + "author":{ + "name":"Pablo Pazos", + "organisation":"CaboLabs" + }, + "accreditation":"Computer Engineer", + "otherDetails":{ + + } + } + ] + }, + { + "@type":"TEMPLATE_OVERLAY", + "uid":"4d663d95-3024-4c5d-8d6a-b1a1c2fc71e4", + "description":{ + "@type":"RESOURCE_DESCRIPTION", + "originalAuthor":{ + + }, + "otherContributors":[ + + ], + "ipAcknowledgements":{ + + }, + "references":{ + + }, + "conversionDetails":{ + + }, + "otherDetails":{ + "PARENT:MD5-CAM-1.0.1":"F3E4A415B1CFBDA6EEC7690F63F0D39D" + }, + "details":{ + "ko":{ + "@type":"RESOURCE_DESCRIPTION_ITEM", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"ko" + }, + "purpose":"특정 문제 또는 진단을 위한 임상 문맥-특징적인 또는 시간-특징적인 한정자(qualifier)를 기록하기 위함.", + "keywords":[ + "문제", + "활성", + "비활성", + "상태", + "에피소드", + "진단" + ], + "use":"어떤 문제 또는 진단을 기록하는 경우, 임상 문맥을 기록하는 시점 또는 그 안에서 관계되는 추가적인 상세내용을 제공하는 관련된 문맥-특징적인 또는 시간-특징적인 한정자를 기록하는데 사용. 한정자가 다른 시간이나 임상 문맥에서는 부적당할 수도 있음.\r\n\r\n이 아키타입은 EVALUATION.problem_diagnosis archetype 내의 Status SLOT에 포함하도록 설계됨. 의도는 이 아카타입이 사용되는 문맥에 따르는 정보만을 기술하는 것과 반대로 모든 문맥에 적용되는 모든 정보를 포함하는 EVALUATION.problem_diagnosis archetype을 위한 것임.\r\n\r\n구현을 위한 중요 사항:\r\n- 이것은 이 한정자 일부 또는 전부가 같은 문맥 또는 같은 시간의 기간 내에 사용되어야 하는 것을 의도하거나 의미하지 않음. 일반적인 아키타입 설계와 다르게, 이 아카타입은 매우 복잡한 임상 실무 영역 내에서 간단히 표준화하기 위한 노력으로 많은 공통 한정자를 한 곳에 수집하기 위해 의도적으로 설계됨. 이 아키타입에 포함된 데이터 엘리먼트는 많은 상이한 그리고 때때로 심지어 경쟁적인 개념을 포괄하는 것으로 인정됨. 이것은 주로 오직 하나 또는 2개의 데이터 엘리먼트를 포함하는 여러 개의 한정자 아키타입을 필요로 하지 않도록 함. \r\n- 몇몇의 이런 데이터 엘리먼트는 같은 문맥에서 동시에 사용된다면 잠재적으로 직접적으로 충돌하는데, 예를 들어, '진행중'인 어떤 에피소드와 함께 '비활성' 문제를 가지는 것은 이치에 맞지 않음. 이와 같이, 이 상태 한정자는 실무에서 매우 다양하게 적용되는 것처럼 극단적인 진료환경에서 함께 사용되어야 하고, 사용 지침이 'Problem/Diagnosis'와 'Problem/Diagnosis qualifier' archetype 쌍이 공유될 수도 있는 임상 커뮤니티 내에서 명확하게 정의되어야 상호운용성을 보장할 수 있음.\r\n\r\n완전한 DRG 코딩은 다른 아키타입의 데이터 엘리먼트와 조합해서 이 아키타입의 DRG와 관련된 데이터 엘리먼트를 요구할 것임.", + "misuse":"감별진단을 표현하는데 사용하지 않아야 함 - 이 목적을 위해서는 EVALUATION.differential_diagnosis archetype를 사용해야 함.\r\n\r\n진단의 확실성(certainty)를 표현하기 위해 사용하지 않아야 함 - EVALUATION.problem_diagnosis archetype 내의 'Diagnostic certainty' 데이터 엘리먼트를 사용해야 함.", + "originalResourceUri":{ + + }, + "otherDetails":{ + + } + }, + "nb":{ + "@type":"RESOURCE_DESCRIPTION_ITEM", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"nb" + }, + "purpose":"For å registrere en kontekstspesifikk eller tidsspesifikk kvalifikator for et problem eller en diagnose.", + "keywords":[ + "problem", + "aktivt", + "inaktivt", + "status", + "episode", + "tilstand", + "aktiv", + "inaktiv", + "remisjon", + "kronisk", + "akutt" + ], + "use":"Brukes for å registrere en kontekstspesifikk eller tidsspesifikk kvalifikator som gir ytterligere detaljer som er relevante på tidspunktet man registrerer et problem eller en diagnose. Kvalifikatoren er ikke nødvendigvis passende på et annet tidspunkt eller i en annen klinisk sammenheng.\r\n\r\nDenne arketypen skal brukes i SLOTet \"Status\" i arketypen EVALUATION.problem_diagnosis (Problem/diagnose). Intensjonen er at EVALUATION.problem_diagnosis-arketypen skal inneholde all informasjonen som gjelder i alle sammenhenger, i motsetning til denne arketypen som skal inneholde informasjonen som avhenger av brukssammenheng.\r\n\r\nVIKTIG INFORMASJON FOR IMPLEMENTERING:\r\n- Det er ikke meningen eller implisert at alle disse kvalifikatorene skal brukes i den samme sammenhengen eller det samme tidsperioden. I motsetning til den vanlige måten å lage arketyper på, er denne arketypen laget for å samle flere vanlige kvalifikatorer på ett sted for å forsøksvis oppnå et visst nivå av standardisering innenfor et ganske innfløkt område av klinisk praksis. Det erkjennes at dataelementene i denne arketypen omfatter mange forskjellige, og til dels også konkurrerende, konsepter. Dette ble gjort hovedsakelig for å unngå behov for å ha mange arketyper for kvalifikatorer, der hver av dem kun inneholder ett eller to dataelementer.\r\n- Noen av disse dataelementene er potensielt direkte motstridende dersom de brukes samtidig og i den samme sammenhengen. For eksempel gir det ikke mening å ha et \"inaktivt\" problem innenfor en \"pågående\" episode. Av den grunn bør disse kvalifikatorene brukes med stor omhu, siden de i praksis vil brukes for varierende formål, og interoperabilitet kan ikke garanteres med mindre det er definert klare retningslinjer for bruk innenfor de kliniske omstendighetene der \"Problem/diagnose\"- og \"Problem/diagnose-kvalifikatorer\"-arketypeparet brukes.\r\n\r\nFullstendig DRG-koding vil kreve DRG-relaterte dataelementer fra denne arketypen, i kombinasjon med elementer fra andre arketyper.", + "misuse":"Brukes ikke for å representere differensialdiagnoser. Bruk arketypen EVALUATION.differential_diagnosis for dette formålet.\r\n\r\nBrukes ikke for å representere diagnostisk sikkerhet. Bruk elementet \"Diagnostisk sikkerhet\" i arketypen EVALUATION.problem_diagnosis.", + "originalResourceUri":{ + + }, + "otherDetails":{ + + } + }, + "pt-br":{ + "@type":"RESOURCE_DESCRIPTION_ITEM", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"pt-br" + }, + "purpose":"Para gravar um ou mais qualificadores de estado clínico, específicos do contexto ou do tempo, para um problema ou diagnóstico específico", + "keywords":[ + "problema", + "ativo", + "inativo", + "estado", + "episódio", + "diagnóstico" + ], + "use":"Use para gravar um ou mais qualificadores relevantes que fornecem detalhes adicionais de contexto específico ou de tempo específico e que sejam relevantes no momento do registro de um problema ou diagnóstico, ou dentro do contexto clínico onde é registrado, mas que pode não ser apropriado em outro tempo ou em outro contexto clínico.\r\n\r\nEste arquétipo foi desenvolvido para ser incluído no slot do Estado no arquétipo EVALUATION.problem_diagnosis archetype.\r\n\r\nEstes qualificadores de estado devem ser usados com cuidado, pois eles são variáveis aplicados na prática e a interoperabilidade não pode ser assegurada, salvo se as diretrizes de uso forem claramente definidas dentro da comunidade clínica em que o par de arquétipos 'Problema / Diagnóstico\" e \"Estado do problema' podem ser compartilhados.\r\n\r\nA codificação DRG completa vai exigir os elementos de dados DRG deste arquétipo e o arquétipo CLUSTER.procedure_status equivalente, utilizado dentro do arquétipo ACTION.procedure, além de atributos sobre o paciente.\r\n\r\nO elemento de dados 'não especificado' foi adicionado para facilitar a adição de outros qualificadores que só podem ser usados localmente ou quando o caso de uso não foi claramente estabelecido no momento em que este arquétipo foi publicado. Como outros qualificadores são identificados, eles podem ser adicionados a este arquétipo como uma revisão retroativa.", + "misuse":"Não deve ser usado para representar um diagnóstico diferencial - use o arquétipo EVALUATION.differential_diagnosis para esta finalidade.", + "originalResourceUri":{ + + }, + "otherDetails":{ + + } + }, + "en":{ + "@type":"RESOURCE_DESCRIPTION_ITEM", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"en" + }, + "purpose":"To record a clinical context-specific or time-specific qualifier for a specified problem or diagnosis.", + "keywords":[ + "problem", + "active", + "inactive", + "status", + "episode", + "diagnosis" + ], + "use":"Use to record a relevant context-specific or time-specific qualifier that provides additional detail which is relevant at the time of recording or within the clinical context where a problem or diagnosis is recorded. The qualifier may not be appropriate at another time or in another clinical context. \r\n\r\nThis archetype is designed to be included in Status SLOT in the EVALUATION.problem_diagnosis archetype. The intent is for the EVALUATION.problem_diagnosis archetype to hold all of the information that applies in all contexts, in contrast to this archetype describing only information that depends on the context of use.\r\n\r\nIMPORTANT NOTES FOR IMPLEMENTATION: \r\n- It is not intended or implied that any or all of these qualifiers should be used within the same context or period of time. In contrast to the usual design of archetypes, this archetype has been deliberately designed to collect a number of common qualifiers into one place in an effort to attempt some simple standardisation within a very messy area of clinical practice. It is acknowledged that the data elements contained in this archetype embrace many different, and sometimes even competing, concepts. This has been done mainly to prevent the need for multiple qualifier archetypes, each containing only one or two data elements. \r\n- Some of these data elements are potentially directly conflicting if used simultaneously within the same context, for example it would not make sense to have an 'inactive' problem together with an Episode that is 'ongoing'. As such, these status qualifiers should be used with extreme care as they are variably applied in practice and interoperability cannot be assured unless usage guidelines are clearly defined within the clinical community in which the 'Problem/Diagnosis' and 'Problem/Diagnosis qualifier' archetype pair may be shared. \r\n\r\nFull DRG coding will require the DRG-related data elements from this archetype in combination with data elements from other archetypes.", + "misuse":"Not to be used to represent a differential diagnosis - use the archetype EVALUATION.differential_diagnosis for this purpose.\r\n\r\nNot to be used to represent diagnostic certainty - use the 'Diagnostic certainty' data element within the EVALUATION.problem_diagnosis archetype.", + "copyright":"© openEHR Foundation", + "originalResourceUri":{ + + }, + "otherDetails":{ + + } + }, + "sl":{ + "@type":"RESOURCE_DESCRIPTION_ITEM", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"sl" + }, + "purpose":"Za zapisovanje različnih statusov, ki se ponavadi uporablja za aplikacijskimi in kliničnimi sporočili, ki so odvisna od definirane vsebine\r\n\r\n", + "keywords":[ + "problem", + "aktiven", + "ni aktiven" + ], + "use":"Za dodeljevanje pravic EVALUATION.problem_diagnosis.v1 archetype, dodaja informacije za povezovanje. ", + "misuse":"It should not be assumed that these qualifiers are safely interoperable unless further definition and alignment is agreed between all sharing parties. A problem which has been defined as 'Inactive' during a hospital admission cannot be assumed to be regarded as 'Inactive' in a primary care setting , where a much longer term perspective is being taken. Similarly terms such as Initial, Interim and Final, whilst helpful to the human observer are unlikely to be precisely enough defined to be safely computable e.g. for decision support. ", + "copyright":"© openEHR Foundation", + "originalResourceUri":{ + + }, + "otherDetails":{ + + } + } + } + }, + "parentArchetypeId":"openEHR-EHR-CLUSTER.problem_qualifier_dips.v0", + "differential":true, + "archetypeId":{ + "@type":"ARCHETYPE_HRID", + "value":"openEHR-EHR-CLUSTER.ovl-problem_qualifier_dips-008.v0" + }, + "definition":{ + "@type":"C_COMPLEX_OBJECT", + "rmTypeName":"CLUSTER", + "nodeId":"at0000.1", + "attributes":[ + { + "@type":"C_ATTRIBUTE", + "rmAttributeName":"items", + "children":[ + { + "@type":"C_COMPLEX_OBJECT", + "rmTypeName":"ELEMENT", + "occurrences":"0..0", + "nodeId":"at0060.1", + "attributes":[ + { + "@type":"C_ATTRIBUTE", + "rmAttributeName":"value", + "children":[ + { + "@type":"C_COMPLEX_OBJECT", + "rmTypeName":"DV_CODED_TEXT", + "attributes":[ + { + "@type":"C_ATTRIBUTE", + "rmAttributeName":"defining_code", + "children":[ + { + "@type":"C_TERMINOLOGY_CODE", + "rmTypeName":"CODE_PHRASE", + "occurrences":"1..1", + "terminologyId":{ + "value":"local" + 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+ }, + { + "@type":"TRANSLATION_DETAILS", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"sl" + }, + "author":{ + "name":"?" + }, + "otherDetails":{ + + } + } + ] + } + ], + "originalLanguage":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"en" + }, + "translations":[ + { + "@type":"TRANSLATION_DETAILS", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"nb" + }, + "author":{ + "name":"Lars Bitsch-Larsen", + "organisation":"Haukeland University Hospital of Bergen, Norway", + "email":"lbla@helse-bergen.no" + }, + "accreditation":"MD, DEAA, MBA, spec in anesthesia, spec in tropical medicine.", + "otherDetails":{ + + } + }, + { + "@type":"TRANSLATION_DETAILS", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"ko" + }, + "author":{ + "name":"Seung-Jong Yu", + "organisation":"NOUSCO Co.,Ltd.", + "email":"seungjong.yu@gmail.com" + }, + "accreditation":"Certified Board of Family Medicine in South Korea", + "otherDetails":{ + + } + }, + { + "@type":"TRANSLATION_DETAILS", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"es-ar" + }, + "author":{ + "name":"Edgardo Vazquez", + "organisation":"VinculoMedico" + }, + "accreditation":"Medical Doctor", + "otherDetails":{ + + } + }, + { + "@type":"TRANSLATION_DETAILS", + "language":{ + "terminologyId":{ + "value":"ISO_639-1" + }, + "codeString":"ar-sy" + }, + "author":{ + "name":"Mona Saleh" + }, + "otherDetails":{ + + } + } + ] +} \ No newline at end of file diff --git a/better-template/src/test/resources/opt_json/Templates/Suspected Covid-19 Assessment.v0.1.opt b/better-template/src/test/resources/opt_json/Templates/Suspected Covid-19 Assessment.v0.1.opt new file mode 100644 index 000000000..cefc037ed --- /dev/null +++ b/better-template/src/test/resources/opt_json/Templates/Suspected Covid-19 Assessment.v0.1.opt @@ -0,0 +1,12706 @@ + + diff --git a/better-template/src/test/resources/opt_json/Templates/Suspected Covid-19 Assessment.v0.1.t.json b/better-template/src/test/resources/opt_json/Templates/Suspected Covid-19 Assessment.v0.1.t.json new file mode 100644 index 000000000..2ad79e2aa --- /dev/null +++ b/better-template/src/test/resources/opt_json/Templates/Suspected Covid-19 Assessment.v0.1.t.json @@ -0,0 +1,12655 @@ +{ + "@type" : "TEMPLATE", + "uid" : "cafb06d0-f1f6-4eaa-abc7-f64985332c52", + "description" : { + "@type" : "RESOURCE_DESCRIPTION", + "originalAuthor" : { + "name" : "Ian McNicoll", + "organisation" : "freshEHR Clinical Informatics Ltd.", + "email" : "ian@freshehr.com", + "date" : "2020-02-27" + }, + "otherContributors" : [ ], + "lifecycleState" : { + "codeString" : "release_candidate" + }, + "ipAcknowledgements" : { }, + "references" : { }, + "conversionDetails" : { }, + "otherDetails" : { + "licence" : "This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/.", + "custodian_organisation" : "openEHR Foundation", + "original_namespace" : "org.openehr", + "original_publisher" : "openEHR Foundation", + "custodian_namespace" : "org.openehr", + "MD5-CAM-1.0.1" : "d1fb926f81506ba236ac56a31d19f283", + "build_uid" : "7efc32bc-561b-4334-a918-cfed0e233ef2", + "PARENT:MD5-CAM-1.0.1" : "706E6DA39FA082EE75E0F0D4E4A87F25", + "sem_ver" : "0.1.5.0" + }, + "details" : { + "en" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "en" + }, + "purpose" : "To record the information required to evaluate the potential risk of Covid-19 infection, as part of professional screening or self-assessment. \n\nThis is based on \n- The current NHS-111 UK self-assessment app at https://111.nhs.uk/covid-19\n- A similar risk assessment app developed for pre-hospital admission by DIPS.no\n- Public Health England COVID-19: investigation and initial clinical management of possible cases https://www.gov.uk/government/publications/wuhan-novel-coronavirus-initial-investigation-of-possible-cases\n\nThe exact risk factors are subject to continual update as the disease progresses.\n\nNote that a critical part of the information, exposure locations, has been left open, so as to allow the list to be updated very regularly and in alignment with local or national policy.\n\nWe have decided to leave in 'older' questions such as 'Exposure to birds in China' until such time that we get clear professional guidance that these are no longer necessary or useful.", + "keywords" : [ "covid-19, risk, screening, triage, coronavirus" ], + "use" : "To record the information required to evaluate the potential risk of Covid-19 infection, as part of professional screening or self-assessment. \n\nThis is based on \n- The current NHS-111 UK self-assessment app at https://111.nhs.uk/covid-19 \n- A similar risk assessment app developed for pre-hospital admission by DIPS.no\n- Public Health England COVID-19: investigation and initial clinical management of possible cases https://www.gov.uk/government/publications/wuhan-novel-coronavirus-initial-investigation-of-possible-cases\nThe exact risk factors are subject to continual update as the disease progresses.\n\nNote that a critical part of the information, exposure locations, has been left open, so as to allow the list to be updated very regularly and in alignment with local or national policy.\n\n", + "misuse" : "This assessment is not intended to act directly as part of any public health reporting documentation - further work is being undertaken to support this use-case.\nPlease also be aware that this assessment dataset is likely to be a superset of the questions and criteria required in any single country or setting. \n\nYou should check the exact requirements for your country and clinical setting and adapt appropriately. For similar reasons we have not embedded any particular guidance or rules on how high / low risk should be estimated - you should follow local guidance.", + "copyright" : "openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "de" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "de" + }, + "purpose" : "Dient zur Erfassung der Details auf Dokumentebene einer einzelnen Interaktion, eines Kontaktes oder eines Pflegeereignisses zwischen einer zu pflegenden Person und Gesundheitsdienstleistern für die Bereitstellung von Gesundheitsdienstleistung. Dies kann entweder Angesicht zu Angesicht (Face-to-Face), über Telefon oder ein anderes elektronisches Medium erfolgen.", + "keywords" : [ "Begegnung", "Kontakt", "Visite", "Pflegeereignis", "Ereignis", "Besuch" ], + "use" : "Verwendung als generischer Container auf Dokumentebene zum Aufzeichnen von Details einer einzelnen Interaktion, eines Kontakts oder eines Pflegeereignisses zwischen einem Subjekt und einem Gesundheitsdienstleister.\r\nDer Kontakt kann von Angesicht zu Angesicht, über Telefon oder ein anderes elektronisches Medium erfolgen. Die Modalität kann bei Bedarf über das Referenzmodell COMPOSITION / mode Attribut erfasst werden.\r\n\r\nDie Hauptabschnitte / Inhaltskomponente wurde absichtlich nicht stark eingeschränkt. Dies ermöglicht es, diese Composition innerhalb eines Templates mit beliebigen SECTION- oder ENTRY-Archetypen zu füllen, die für den klinischen Zweck geeignet sind.\r\n\r\nAuch wenn sie für den klinischen Inhalt nicht eingeschränkt sind, bietet die Spezifikation von COMPOSITION.Encounter einen signifikanten Wert, da sie eine explizite Abfrage aller Encounter innerhalb einer Patientenakte ermöglicht.\r\n\r\nDie Context-Komponente enthält einen optionalen 'Extension' SLOT, der während des Template-Designs zu verschiedenen Zwecken verwendet werden kann:\r\n- Zum Hinzufügen von optionalen Kontextinformationen, wie Informationen zur Episode \r\n- Zur Vereinheitlichung oder Verknüpfung mit Modellformalismen wie FHIR oder CIMI \r\n\r\nTypische Beispiele sind eine klinische Visite, eine pflegerische Überwachung oder eine telemedizinische Beratung.", + "misuse" : "Nicht zur Darstellung von Details einer gesamten Behandlungsepisode geeignet.\r\n\r\nNicht zur Darstellung von persistenten, zusammengefassten Patienteninformationen wie eine Problemliste oder eine Medikamentenübersicht geeignet.\r\n\r\nNicht zur Darstellung von Berichten eines Diagnosedienstes, z.B. Bildgebung oder Labortests, geeignet.\r\n\r\nNicht zur Darstellung von der gleichnamige FHIR-Ressource geeignet- dort liegt eine Diskrepanz vor.", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "sv" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "sv" + }, + "purpose" : "Att registrera detaljer av en enskild interaktion, kontakt eller en vårdhändelse mellan vårdtagare och vårdgivare inom hälso-och sjukvården. Interaktionen kan både vara genom ett fysiskt möte eller på distans.", + "keywords" : [ "vårdtillfälle", "kontakt", "besök", "vårdhändelse" ], + "use" : "Används för att registrera detaljer från en enskild interaktion, kontakt eller vårdhändelse mellan vårdtagare och vårdgivare. \r\n \r\nKontakten kan ske genom ett fysiskt möte eller via telefon eller annat elektroniskt medium. Uppgifter om mötesform kan vid behov läggas till i egenskaperna i referensmodellen Composition/mode. \r\n\r\nDe huvudsakliga avsnitts- och innehållskomponenterna har avsiktligt lämnats utan begränsning. Det tillåter ifyllning med SECTION eller ENTRY-arketyper som är lämpliga för det kliniska syftet.\r\n\r\nTrots att det inte finns någon begränsning för kliniskt innehåll ger specifikationen för COMPOSITION.Encounter ett signifikant värde genom att tillåta detaljerade förfrågningar om alla händelser i en patientjournal.\r\n\r\nFältet Extra information kan användas till att lägga till valfri kontextuell information, exempelvis episoduppgifter eller uppgifter som möjliggör samordning eller anpassning till andra modellformalismer som FHIR eller CIMI samt detaljerade beskrivningar av deltagare.\r\n\r\nTypiska exempel är ett klinikbesök, en observation av sjuksköterska eller en telemedicinsk konsultation.", + "misuse" : "Ska inte användas för att registrera detaljer om en hel vårdepisod. \r\n\r\nSka inte användas för beständig patientinformation som exempelvis en problemlista eller medicinsk sammanfattning.\r\n\r\nSka inte användas för att presentera en rapport från en diagnostisk tjänst, exempelvis en röntgenbild eller laboratorietest.\r\n\r\nSka inte användas för att presentera FHIR-resursen med samma namn. Det finns en motsättning mellan räckvidd och avsikt.", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "es-ar" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "es-ar" + }, + "purpose" : "Registrar los detalles documentales de una única interacción, contacto o evento de cuidado entre un sujeto de cuidados y uno o más proveedores de uno o más servicios de salud. Esta interacción puede ser presencial o remota.", + "keywords" : [ "encuentro", "contacto", "visita", "evento de cuidados", "consulta" ], + "use" : "Utilícese como un contendor de nivel de documento para el registro de una única interacción, contacto o evento de cuidados entre un sujeto de cuidados y uno o mas proveedores de cuidados de la salud.\r\nEl contacto puede ser cara a cara, o por vía telefónicao de cualquier otro medio electrónico. La modalidad puede ser representada, si asi se requiere, por medio del atributo modo de la COMPOSITION.\r\nEl componente principal de Secciones o Contenido se ha mantenido deliberadamente libre de restricciones. Esto permite que se incluya en la plantilla cualquier Sección (SECTION) o Asiento (ENTRY) apropiado al propósito clínico.\r\nAún cuando se encuentra libre de restricciones en cuanto al contenido clínico, la especificación del COMPOSITION.Encounter agreva valor significativo al permitir la consulta explícita de todos los encuentros conteidos en una historia clínica.\r\nEl componente de Contexto contiene un slot opcional \"Extensión\" que puede ser utilizado en el diseño de una plantilla para:\r\n-agregar información opcional de contexto, tal como información sobre el episodio, o\r\n-permitir la armonización o alineamiento con otros formalismos de modelado tales como FHIR o CIMI, como puede ser la representación explícita de participantes que son generalmente manejados por el Modelo de Referencia en un arquetipo openEHR.\r\nSon ejemplos típicos una visita a consultorio, una observación de enfermería o una consulta de telemedicina.", + "misuse" : "No debe ser utilizado para registrar los detalles de la totalidad de un episodio de cuidado\r\nNo debe ser utilizado para almacenar información sumaria persistente de un paciente, tale como una lista de problemas o un resumen de medicamentos.\r\nNo debe ser utilizado para representar el informe de un servicio diagnóstico, tal como un estudio de imágenes o una pruena de laboratorio.\r\nNo debe ser utilizado para representar el recurso FHIR del mismo nombre ya que existe una diapridad de alcance y propósito.", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "ko" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "ko" + }, + "purpose" : "외래기록, 경과기록, 간호기록과 일반적인 노트 등과 같은 환자를 대면한 후 작성하는 기록", + "keywords" : [ "*경과(ko)", "*노트(ko)", "*외래(ko)" ], + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "pt-br" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "pt-br" + }, + "purpose" : "Registrar os detalhes de uma interação, contato ou episódio de cuidado para a provisão de serviços de saúde entre um sujeito do cuidado e um profissional de saúde. Pode se referir tanto a uma interação presencial quanto à distância.", + "keywords" : [ "encontro", "contato", "visita", "episódio de cuidado" ], + "use" : "Usar como um documento genérico para registrar detalhes de uma interação simples, contato ou episódio de atenção à saúde entre um sujeito do cuidado e profissional(is) de saúde.\r\nO contato pode ser presencial, via telefone ou outro meio eletrônico. A modalidade pode ser identificada, se necessário, através do modelo de referência COMPOSITION/mode attribute.\r\n\r\nO componente main Sections/Content foi deixado deliberadamente sem restrições. Isto permitirá que ele seja populado com qualquer arquétipo SECTION ou ENTRY apropriado para o propósito clínico em um template.\r\n\r\nEmbora sem restrições para conteúdo clínico, especificação de COMPOSITION, Encounter oferece importante valor por permitir pesquisa de todos os Encontros num prontuário do paciente.\r\n\r\nO componente Contexto contem um SLOT 'Extensão' opcional que pode ser usado no design do template para:\r\n- adicionar informação contextual opcional, como informação do episódio; ou\r\n- permitir a harmonização ou alinhamento com outros modelos ou formalismos como FHIR ou CIMI, como uma representação explícita de participantes que normalmente são gerenciados pelo Modelo de Referência openEHR num arquétipo openEHR.\r\n\r\nExemplos típicos são visita a uma clínica, observação de enfermagem ou uma consulta de telemedicina.", + "misuse" : "Não deve ser utilizado para registrar detalhes de um episódio de cuidado completo.\r\n\r\nNão deve ser utilizado para guardar informações persistentes, resumidas de um paciente, como uma lista de problemas ou resumo de medicamentos.\r\n\r\nNão deve ser utilizado para representar o relato de um serviço diagnóstico como exames laboratoriais ou de imagem.\r\n\r\nNão deve ser utilizado para representar recurso FHIR do mesmo nome - há uma incompatibilidade de objetivo e intenção.", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "ar-sy" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "ar-sy" + }, + "purpose" : "تسجيل المقابلة على هيئة ملاحظة تقدم الحالة", + "keywords" : [ "التقدم", "ملاحظة", "المقابلة" ], + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "es" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "es" + }, + "purpose" : "Registrar, a nivel de documento, una única interacción, contacto o evento de cuidado, entre un sujeto de cuidado (paciente) y un proveedor de servicios de salud (profesional médico, de enfermería, etc.). Puede ser una interacción cara a cara o remota.", + "keywords" : [ "encuentro", "contacto", "visita", "evento de cuidado" ], + "use" : "Se debe usar como una definición de documento genérico para registrar información de una única interacción o contacto con un proveedor de salud. Esta definición no especifica la estructura interna de secciones y entradas. Dicha especificación debería hacerse mediante especializaciones del arquetipo o mediante plantillas operativas (Operational Templates - OPT).", + "misuse" : "No se debe utilizar para registrar información de un episodio de salud entero.\r\n\r\nNo debe contener información persistente o resúmenes, como lista de problemas o medicación.\r\n\r\nNo se debe usar para registrar resultados de laboratorio o imagenología.\r\n", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "nl" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "nl" + }, + "purpose" : "Om de documentniveau-details van een enkele interactie, contact of zorggebeurtenis tussen een onderwerp van zorg en een zorgverlener vast te leggen voor de voorziening van zorgverlening. Dit kan face-to-face-contact zijn of interactie op afstand.", + "keywords" : [ "encounter", "ontmoeting", "contact(en)", "bezoek", "zorggebeurtenis", "zorg" ], + "use" : "Gebruik als een generiek document-niveau container voor het vastleggen van details van een enkele interactie, contact of zorg gebeurtenis tussen een onderwerp van zorg en zorgverlener(s).\r\nHet contact kan face-to-face zijn, telefonisch of via een ander elektronisch medium. Modaliteit kan, indien nodig, vastgelegd worden met behulp van het referentiemodel COMPOSITION/mode kenmerk.\r\n\r\nHet voornaamste Secties/Inhoud component is opzettelijk onbeperkt gelaten. Hierdoor is het toegestaan dat het gevuld wordt met een willekeurige SECTION of ENTRY archetype die toepasselijk is voor de klinische toepassing binnen een template.\r\n\r\nOndanks de onbeperktheid voor klinische inhoud, zal specificatie van de COMPOSITION.Encounter een belangrijke waarde leveren door het toestaan van expliciet querien binnen alle encounters van een patient-record.\r\n\r\nDe Context-component bevat een optioneel 'Extensie'-slot (koppelpunt) dat gebruikt kan worden in ontwerp van templates om:\r\n- optionele contextuele informatie toe te voegen, zoals episode informatie; of\r\n- harmonisatie of uitlijning met andere model formalismen toe te staan zoals FHIR of CIMI, zoals een expliciete representatie van deelnemers die gewoonlijk geregeld wordt door het openEHR referentiemodel in een openEHR archetype.\r\n\r\nTypische voorbeelden zijn een klinisch bezoek, een verpleegkundige observatie of een tele-medisch consult.", + "misuse" : "Niet te gebruiken om details vast te leggen over een volledige zorg-episode.\r\nNiet te gebruiken om volhardende, samengevatte patient-gegevens te bevatten, zoals een probleemlijst or samenvatting van medicatie.\r\nNiet te gebruiken om een rapport van een diagnostische dienst te representeren, zoals beelden of laboratorium-onderzoek.\r\nNiet te gebruiken om een FHIR-bron met eenzelfde naam te representeren - dan is er een conflict in de scope en doelstelling.", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "fi" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "fi" + }, + "purpose" : "*To record the document level details of a single interaction, contact or care event between a subject of care and healthcare provider(s) for the provision of healthcare service(s). This can be either a face-to-face or remote interaction.(en)", + "keywords" : [ "*encounter(en)", "*contact(en)", "*visit(en)", "*care event(en)" ], + "use" : "*Use as a generic document-level container for recording details of a single interaction, contact or care event between a subject of care and healthcare provider(s).\r\nThe contact may be face-to-face, via telephone or another electronic medium. Modality can be captured, if required, via the reference model COMPOSITION/mode attribute.\r\n\r\nThe main Sections/Content component has been deliberately left unconstrained. This will allow it to be populated with any SECTION or ENTRY archetypes appropriate for the clinical purpose within a template.\r\n\r\nEven though unconstrained for clinical content, specification of COMPOSITION.Encounter provides significant value by allowing for explicit querying of all Encounters within a patient record.\r\n\r\nThe Context component contains an optional 'Extension' SLOT that can be used in template design to:\r\n- add optional contextual information, such as episode information; or\r\n- allow for harmonisation or alignment with other model formalisms such as FHIR or CIMI, such as explicit representation of participants that are usually managed by the openEHR Reference Model in an openEHR archetype.\r\n\r\nTypical examples are a clinic visit, a nursing observation or a telemedicine consultation.(en)", + "misuse" : "*Not to be used to record details about an entire episode of care.\r\n\r\nNot to be used to carry persistent, summarised patient information, such as a problem list or medication summary.\r\n\r\nNot to be used to represent the report of a diagnostic service, such as imaging or laboratory testing.\r\n\r\nNot to be used to represent the FHIR resource of the same name - there is a mismatch scope and intent.(en)", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "it" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "it" + }, + "purpose" : "Registrare i dettagli a livello di documento di una singola interazione, contatto o evento di cura tra un soggetto di cura e il/i fornitore/i di assistenza sanitaria per la fornitura di servizi sanitari. Può trattarsi di un'interazione faccia a faccia o a distanza.", + "keywords" : [ "incontro", "contatto", "visita", "evento di cura" ], + "use" : "Utilizzare come contenitore generico a livello di documento per registrare i dettagli di una singola interazione, contatto o evento di cura tra un soggetto di cura e il/i fornitore/i di assistenza sanitaria.\r\nIl contatto può avvenire faccia a faccia, per telefono o su un altro mezzo elettronico. La modalità può essere catturata, se necessario, tramite il modello di riferimento COMPOSITION/mode attribute.\r\n\r\nLa principale sezione/componente del contenuto è stata volutamente lasciata libera. Ciò consentirà di popolarla con qualsiasi archetipo di SECTION o ENTRY propriato per lo scopo clinico all'interno di un modello.\r\n\r\nAnche se non è vincolata al contenuto clinico, la specificazione di COMPOSITION.Contatto fornisce un valore significativo, consentendo l'interrogazione esplicita di tutti gli Incontri all'interno della cartella clinica di un paziente.\r\n\r\nIl componente Context contiene un SLOT opzionale 'Extension' SLOT che può essere utilizzato nella progettazione del template per:\r\n- aggiungere informazioni contestuali opzionali, come le informazioni sugli episodi; oppure\r\n- consentire l'armonizzazione o l'allineamento con altri formalismi del modello come FHIR o CIMI, come la rappresentazione esplicita dei partecipanti che sono solitamente gestiti dal modello di riferimento openEHR in un archetipo openEHR.\r\n\r\nEsempi tipici sono una visita in clinica, un'osservazione infermieristica o un consulto di telemedicina.", + "misuse" : "Da non utilizzare per portare informazioni persistenti e riassunte sui pazienti, come un elenco di problemi o un sommario dei farmaci.\r\n\r\nDa non utilizzare per rappresentare il rapporto di un servizio diagnostico, come l'imaging o gli esami di laboratorio.\r\n\r\nNon deve essere utilizzato per rappresentare l'omonima risorsa FHIR - c'è un disallineamento di scopo e di intenti.", + "originalResourceUri" : { }, + "otherDetails" : { } + } + } + }, + "parentArchetypeId" : "openEHR-EHR-COMPOSITION.encounter.v1", + "differential" : true, + "archetypeId" : { + "@type" : "ARCHETYPE_HRID", + "value" : "openEHR-EHR-COMPOSITION.t_encounter.v1" + }, + "definition" : { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "COMPOSITION", + "nodeId" : "at0000.1", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "context", + "children" : [ { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "EVENT_CONTEXT", + "attributes" : [ ], + "attributeTuples" : [ ] + } ] + }, { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "content", + "existence" : "0..1", + "children" : [ { + "@type" : "C_ARCHETYPE_ROOT", + "rmTypeName" : "OBSERVATION", + "occurrences" : "0..1", + "nodeId" : "at0.9", + "attributes" : [ ], + "attributeTuples" : [ ], + "archetypeRef" : "openEHR-EHR-OBSERVATION.ovl-story-001.v1", + "referenceType" : "archetypeOverlay" + }, { + "@type" : "C_ARCHETYPE_ROOT", + "rmTypeName" : "OBSERVATION", + "occurrences" : "0..1", + "nodeId" : "at0.7", + "attributes" : [ ], + "attributeTuples" : [ ], + "archetypeRef" : "openEHR-EHR-OBSERVATION.ovl-body_temperature-008.v2", + "referenceType" : "archetypeOverlay" + }, { + "@type" : "C_ARCHETYPE_ROOT", + "rmTypeName" : "OBSERVATION", + "occurrences" : "0..1", + "nodeId" : "at0.21", + "attributes" : [ ], + "attributeTuples" : [ ], + "archetypeRef" : "openEHR-EHR-OBSERVATION.ovl-travel_history-007.v0", + "referenceType" : "archetypeOverlay" + }, { + "@type" : "C_ARCHETYPE_ROOT", + "rmTypeName" : "EVALUATION", + "occurrences" : "0..1", + "nodeId" : "at0.22", + "attributes" : [ ], + "attributeTuples" : [ ], + "archetypeRef" : "openEHR-EHR-EVALUATION.ovl-health_risk-covid-001.v0", + "referenceType" : "archetypeOverlay" + }, { + "@type" : "C_ARCHETYPE_ROOT", + "rmTypeName" : "EVALUATION", + "occurrences" : "0..1", + "nodeId" : "at0.20", + "attributes" : [ ], + "attributeTuples" : [ ], + "archetypeRef" : "openEHR-EHR-EVALUATION.ovl-occupation_summary-001.v1", + "referenceType" : "archetypeOverlay" + }, { + "@type" : "C_ARCHETYPE_ROOT", + "rmTypeName" : "EVALUATION", + "occurrences" : "0..1", + "nodeId" : "at0.29", + "attributes" : [ ], + "attributeTuples" : [ ], + "archetypeRef" : "openEHR-EHR-EVALUATION.ovl-living_arrangement-001.v0", + "referenceType" : "archetypeOverlay" + }, { + "@type" : "C_ARCHETYPE_ROOT", + "rmTypeName" : "EVALUATION", + "occurrences" : "0..*", + "nodeId" : "at0.14", + "attributes" : [ ], + "attributeTuples" : [ ], + "archetypeRef" : "openEHR-EHR-EVALUATION.ovl-problem_diagnosis-001.v1", + "referenceType" : "archetypeOverlay" + }, { + "@type" : "C_ARCHETYPE_ROOT", + "rmTypeName" : "INSTRUCTION", + "occurrences" : "0..*", + "nodeId" : "at0.6", + "attributes" : [ ], + "attributeTuples" : [ ], + "archetypeRef" : "openEHR-EHR-INSTRUCTION.ovl-service_request-011.v1", + "referenceType" : "archetypeOverlay" + } ] + } ], + "attributeTuples" : [ ], + "attributeCustomizations" : { + "content" : { + "aliases" : { + "ar-sy" : "content", + "en" : "content", + "es-ar" : "content", + "ko" : "content", + "pt-br" : "content", + "es" : "content", + "nl" : "content", + "sv" : "content", + "de" : "content" + } + } + } + }, + "terminology" : { + "@type" : "ARCHETYPE_TERMINOLOGY", + "conceptCode" : "at0000", + "termDefinitions" : { + "ar-sy" : { + "at0000.1" : { + "@type" : "ARCHETYPE_TERM", + "code" : "at0000.1", + "text" : "openEHR-Suspected Covid-19 assessment.v0.5", + "description" : "*Interaction, contact or care event between a subject of care and healthcare provider(s).(en)" + } + }, + "en" : { + "at0000.1" : { + "@type" : "ARCHETYPE_TERM", + "code" : "at0000.1", + "text" : "Suspected Covid-19 risk assessment", + "description" : "Interaction, contact or care event between a subject of care and healthcare provider(s)." + } + }, + "es-ar" : { + "at0000.1" : { + "@type" : "ARCHETYPE_TERM", + "code" : "at0000.1", + "text" : "openEHR-Suspected Covid-19 assessment.v0.5", + "description" : "Interacción, contacto o evento de cuidados entre un sujeto de cuidados y uno o más proveedores de cuidados de la salud." + } + }, + "ko" : { + "at0000.1" : { + "@type" : "ARCHETYPE_TERM", + "code" : "at0000.1", + "text" : "openEHR-Suspected Covid-19 assessment.v0.5", + "description" : "*Interaction, contact or care event between a subject of care and healthcare provider(s).(en)" + } + }, + "pt-br" : { + "at0000.1" : { + "@type" : "ARCHETYPE_TERM", + "code" : "at0000.1", + "text" : "openEHR-Suspected Covid-19 assessment.v0.5", + "description" : "Interação, contato ou cuidado entre o sujeito do cuidado e profissional(is) de saúde." + } + }, + "es" : { + "at0000.1" : { + "@type" : "ARCHETYPE_TERM", + "code" : "at0000.1", + "text" : "openEHR-Suspected Covid-19 assessment.v0.5", + "description" : "Interacción, contacto o evento de cuidado entre un paciente y un proveedor de salud." + } + }, + "nl" : { + "at0000.1" : { + "@type" : "ARCHETYPE_TERM", + "code" : "at0000.1", + "text" : "openEHR-Suspected Covid-19 assessment.v0.5", + "description" : "Interactie, contact of zorggebeurtenis tussen een onderwerp van zorg en zorgverlener(s)." + } + }, + "sv" : { + "at0000.1" : { + "@type" : "ARCHETYPE_TERM", + "code" : "at0000.1", + "text" : "openEHR-Suspected Covid-19 assessment.v0.5", + "description" : "Interaktion, kontakt eller vårdhändelse mellan vårdtagare och vårdgivare inom hälso- och sjukvården." + } + }, + "de" : { + "at0000.1" : { + "@type" : "ARCHETYPE_TERM", + "code" : "at0000.1", + "text" : "openEHR-Suspected Covid-19 assessment.v0.5", + "description" : "Interaktion, Kontakt oder Versorgungsereignis, zwischen einem Versorgungsempfänger und einem Gesundheitsdienstleister." + } + }, + "fi" : { }, + "it" : { } + }, + "termBindings" : { }, + "terminologyExtracts" : { }, + "valueSets" : { } + }, + "adlVersion" : "1.4", + "buildUid" : "234f7014-c2ad-3e95-a55e-d9df42c42d64", + "rmName" : "openehr", + "rmRelease" : "1.0.3", + "generated" : true, + "templateId" : "Suspected Covid-19 Assessment.v0.1", + "otherMetaData" : { }, + "templateOverlays" : [ { + "@type" : "TEMPLATE_OVERLAY", + "uid" : "c8cdb7a6-0870-4f74-b1f0-6624003c4c2a", + "description" : { + "@type" : "RESOURCE_DESCRIPTION", + "originalAuthor" : { }, + "otherContributors" : [ ], + "ipAcknowledgements" : { }, + "references" : { }, + "conversionDetails" : { }, + "otherDetails" : { + "PARENT:MD5-CAM-1.0.1" : "FD67CADAD2EAF2ECB89AF1F1E15D1D9C" + }, + "details" : { + "nb" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "nb" + }, + "purpose" : "Benyttes for å kartlegge reiseaktivitet i forbindelse med risiko for smitte og sykdom. ", + "keywords" : [ "Reise, smitte" ], + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "en" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "en" + }, + "purpose" : "To record details of a travel trip with respect to exposure to potential risk.", + "keywords" : [ "travel, trip, tropical" ], + "use" : "To record details of a travel trip with respect to exposure to potential risk.", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "fi" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "fi" + }, + "purpose" : "*To record details of a travel trip with respect to exposure to potential risk.(en)", + "keywords" : [ "*travel, trip, tropical(en)" ], + "use" : "*To record details of a travel trip with respect to exposure to potential risk.(en)", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "it" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "it" + }, + "purpose" : "Registrare i dettagli di un viaggio in relazione all'esposizione a potenziali rischi.", + "keywords" : [ "viaggio, trasferta, tropicale" ], + "use" : "Registrare i dettagli di un viaggio in relazione all'esposizione a potenziali rischi.", + "originalResourceUri" : { }, + "otherDetails" : { } + } + } + }, + "parentArchetypeId" : "openEHR-EHR-OBSERVATION.travel_history.v0", + "differential" : true, + "archetypeId" : { + "@type" : "ARCHETYPE_HRID", + "value" : "openEHR-EHR-OBSERVATION.ovl-travel_history-007.v0" + }, + "definition" : { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "OBSERVATION", + "nodeId" : "at0000.1", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "data", + "children" : [ { + "@type" : "C_COMPLEX_OBJECT", + 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"otherMetaData" : { }, + "originalLanguage" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "en" + }, + "translations" : [ { + "@type" : "TRANSLATION_DETAILS", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "nb" + }, + "author" : { + "name" : "Bjørn Næss", + "organisation" : "DIPS AS", + "email" : "bna@dips.no" + }, + "otherDetails" : { } + }, { + "@type" : "TRANSLATION_DETAILS", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "fi" + }, + "author" : { }, + "otherDetails" : { } + }, { + "@type" : "TRANSLATION_DETAILS", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "it" + }, + "author" : { + "name" : "Paolo Anedda", + "organisation" : "Inpeco", + "email" : "paolo.anedda@inpeco.com" + }, + "otherDetails" : { } + } ] + }, { + "@type" : "TEMPLATE_OVERLAY", + "uid" : "fbff84f3-2b33-4245-94f1-6dafe6679c54", + "description" : { + "@type" : "RESOURCE_DESCRIPTION", + "originalAuthor" : { }, + "otherContributors" : [ ], + "ipAcknowledgements" : { }, + "references" : { }, + "conversionDetails" : { }, + "otherDetails" : { + "PARENT:MD5-CAM-1.0.1" : "A6618A05BBB42A6FCB5DFACFAD13C7A6" + }, + "details" : { + "de" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "de" + }, + "purpose" : "Zur Messung der Temperatur einer Person - als Surrogat for die Temperatur des gesamten Körpers.", + "keywords" : [ "Temperatur", "Körper", "Kern", "Fieber", "Hypothermie", "Hyperthermie" ], + "use" : "Benutzt zur Aufzeichnung der gesamten Körpertemperatur einer Person oder eines Körpers.\r\n\r\n\r\n\r\nWenn benötigt, können zusätzliche Cluster Archetypen eingefügt werden, um zusätzliche Statusdaten bereitzustellen - darunter Details zu Umgebungsbedingungen, Menstruationszyklus und Betätigung.\r\n\r\n\r\n\r\nBitte beachten: Die Stelle und Methode der Messung muss ggf. dem Endverbraucher angezeigt werden, um eine präzise Interpretation der gemessenen Temperatur zu ermöglichen.", + "misuse" : "Dieser Archetyp soll nicht benutzt werden, um die Messung der Temperatur irgendeines anderen Objekts zu dokumentieren.\r\n\r\n\r\n\r\nDieser Archetyp soll nicht benutzt werden, um die Temperatur eines Körperteils isoliert zu messen, z. B. die Temperatur an der Fußsohle im Rahmen des Managements von chronischem Diabetes.", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "ru" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "ru" + }, + "purpose" : "Для записи измеряемой температуры человека - в качестве суррогата температуры всего тела.", + "keywords" : [ "температура", "лихорадка", "жар", "гипертермия", "гипотермия" ], + "use" : "Используется для записи температуры тела пациента или органа.\r\nДополнительные кластеры могут быть включены для получения дополнительной информации о состоянии - в том числе условия внешней среды, фаза менструального цикла и другие детали, где это уместно.\r\nОбратите внимание: запись о месте и методе измерения может потребоваться для облегчения точной интерпретации регистрируемой температуры.", + "misuse" : "Этот архетип не следует использовать для записи температуры любого другого объекта.\r\nЭтот архетип не следует использовать для записи температуры части тела, например, отдельного измерения температуры ступни в лечении больных с диабетической стопой.", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "sv" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "sv" + }, + "purpose" : "Att mäta en individs kroppstemperatur som är ett surrogat för kroppens kärntemperatur.", + "keywords" : [ "temperatur", "kropp", "kärna", "feber", "hypotermi", "hypertermi" ], + "use" : "Används för att mäta en individs kroppstemperatur som är ett surrogat för individens kärntemperatur.\r\nYtterligare kluster kan läggas till för ytterligare tillståndsdata såsom miljöförhållanden och detaljer från ansträngningstest där det är lämpligt.\r\n\r\nObservera: Platsen och mätmetoden kan behöva visas för slutanvändaren för att underlätta korrekt tolkning av den uppmätta temperaturen. \r\n", + "misuse" : "Ska inte användas för att mäta temperaturen av något annat föremål.\r\n\r\nSka inte användas för att mäta temperaturen av en isolerad kroppsdel, exempelvis temperaturen av fotsulan som en del i kronisk diabetesskötsel.\r\n", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "fi" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "fi" + }, + "purpose" : "Henkilön lämpötilan mittaamista varten. ", + "keywords" : [ "lämpötila, kuume, hypotermia, hypertermia" ], + "use" : "Yksilön lämpötilan kirjaamista varten.\r\n\r\nLisäklustereita voidaan sisällyttää lisätietojen tallentamista varten, mukaan lukien ympäristöolosuhteet ja yksityiskohtaiset rasitustiedot.\r\n\r\nHuomio: Mittauspaikka ja mittaustapa voi olla hyödyllistä näyttää käyttäjälle lämpötilan tarkan tulkinnan helpottamiseksi.", + "misuse" : "Tätä arkkityyppiä ei käytetä kuvaamaan minkään muun kohteen kuin potilaan lämpötilaa.\r\n\r\nTätä arkkityyppiä ei käytetä kehon osan lämpötilan tallentamiseen erillään, esim. jalan pohjan lämpötila osana kroonista diabeteksen hoitoa.", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "nb" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "nb" + }, + "purpose" : "Brukes til å registrere et individs målte kroppstemperatur, som uttrykk for kjernetemperaturen.", + "keywords" : [ "temperatur", "kropp", "kjerne", "feber", "hypotermi", "hypertermi", "temperaturmåling", "overoppheting", "nedkjøling", "heteslag" ], + "use" : "Brukes til å dokumentere et individs kjernetemperatur. Det kan legges til CLUSTERE for å tilføre tillegsinformasjon, inkludert miljømessige forhold (eksponering), detaljer om menstruasjonssyklus og informasjon om fysisk anstrengelse, der hvor dette er relevant. NB: Målemetode og -sted vil ofte måtte vises til sluttbruker for at de dokumenterte temperaturverdiene skal kunne tolkes korrekt.", + "misuse" : "Arketypen skal ikke brukes til å registrere andre objekters eller en isolert kroppsdels temperatur.", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "es-ar" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "es-ar" + }, + "purpose" : "Registrar la temperatura medida de una persona - como un derivado de la temperatura corporal", + "keywords" : [ "temperatura", "cuerpo", "central", "fiebre", "hipotermia", "hipertermia" ], + "use" : "Usar para registrar la temperatura corporal de una persona o cuerpo.\r\nClusters adicionales pueden incluirse para proveer datos adicionales de estado - incluyendo condiciones ambientales, detalles del ciclo menstrual y de ejercicio físico, cuando se considera apropiado.\r\nTener en cuenta: El sitio y el método del registro quizás sea necesario mostrarlo al usuario final, para la adecuada interpretación del registro de temperatura.", + "misuse" : "Este arquetipo no debe usarse para registrar la temperatura de cualquier otro objeto.\r\nEste arquetipo no debe usarse para registrar la temperatura de una parte del cuerpo aislado por ej: la temperatura de la planta del pie como parte del manejo de la diabetes crónica.", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "pt-br" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "pt-br" + }, + "purpose" : "Registrar a temperatura aferida de uma pessoa - substituto para temperatura corporal central.", + "keywords" : [ "temperatura", "corpo", "central", "febre", "hipotermia", "hipertermia" ], + "use" : "Usado para registrar a temperatura corporal de uma pessoa, o qual é um substituto para a temperatura corporal central.\r\nClusters adicionais podem ser incluídos para fornecer dados adicionais - incluindo as condições ambientais e detalhes de esforço, quando apropriado.\r\n\r\nObservação: O local e método de gravação podem precisar ser exibidos ao usuário final para facilitar a interpretação exata da temperatura registrada.", + "misuse" : "Esse arquétipo não pode ser usado para registrar a temperatura de qualquer outro objeto.\r\nEsse arquétipo não pode ser usado para registrar a temperatura de uma parte do corpo isoladamente, por exemplo, temperatura da sola do pé, como parte do controle de diabetes crônica.", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "ja" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "ja" + }, + "purpose" : "全身の温度の代用として計測された人の体温を記録する。", + "keywords" : [ "*temperature(en)", "*body(en)", "*core(en)", "*fever(en)", "*hypothermia(en)", "*hyperthermia(en)" ], + "use" : "人や体の全体の温度を記録するために用いられる。\r\nさらに状態データを表すために、追加のクラスタを内包することもできる。たとえば、環境条件や、月経周期の詳細、労作についての詳細を必要に応じて内包する。\r\n注意：計測された温度を正確に解釈するためにエンドユーザーに記録方法や部位を示す必要があるかもしれません。", + "misuse" : "このアーキタイプは、人体以外の温度を計測するためには用いられない。\r\nこのアーキタイプは、身体において独立した一部の温度を記録するためには用いられない。たとえば、糖尿病の慢性期管理の一貫として、測定の温度を計測すること。", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "ar-sy" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "ar-sy" + }, + "purpose" : "لتسجيل درجة الحرارة التي تم قياسها للشخص - كبديل عن درجة حرارة الجسم كله", + "keywords" : [ "الحرارة", "الجسم", "اللُّب", "الحمى", "انخفاض الحرارة", "فرط الحرارة" ], + "use" : "يستخدم لتسجيل حرارة جميع الجسم للشخص أو الجثة.\r\nيمكن تضمين عناقيد أخرى للإمداد بالمزيد من تفاصيل الحالة - بما في ذلك العوامل البيئية, تفاصيل الدورة الشهرية, تفاصيل المجهود, حيثما تطلب الأمر.\r\nالرجاء ملاحظة: قد يكون من الواجب عرض هذا الموقع و طريقة التسجيل للمستخدِم النهائي لتسهيل التفسير الدقيق للحرارة التي يتم تسجيلها.", + "misuse" : "هذا النموذج لا يستخدم لتسجيل حرارة أي شيئ آخر.\r\nهذا النموذج لا يستخدم لتسجيل الحرارة لجزء معزول من الجسم, مثلا حرارة أخمص القدم كجزء من التدبير العلاجي لمرض السكري المزمن.", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "en" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "en" + }, + "purpose" : "To record the measured temperature of a person - as a surrogate for the core body temperature.", + "keywords" : [ "temperature", "body", "core", "fever", "hypothermia", "hyperthermia" ], + "use" : "Used for recording the measurement of an individual's body temperature, which is a surrogate for the core body temperature of the individual.\r\n\r\nAdditional clusters can be included to provide additional state data - including environmental conditions and exertion details, where appropriate.\r\n\r\nPlease Note: The site and method of recording may need to be displayed to the end user to facilitate accurate interpretation of the temperature recorded.", + "misuse" : "This archetype is not to be used to record the temperature of any other object.\r\n\r\nThis archetype is not to be used to record the temperature of a part of the body in isolation e.g. temperature of the sole of the foot as a part of chronic diabetes management.", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "fa" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "fa" + }, + "purpose" : "برای ثبت اندازه گیری دمای بدن یک فرد بکار می رود- به عنوان جایگزینی برای دمای کل بدن", + "keywords" : [ "دما", "بدن", "مرکز", "تب", "کاهش دمای بدن", "افزایش دمای بدن" ], + "use" : "برای ثبت دمای کل بدن فرد یا بدن استفاده می شود . خوشه‌های اضافی، برای در بر گرفتن داده‌های حالت بیشتر، شامل شرایط محیطی ، جزییات عادت ماهیانه و جزییات جنب و جوش فرد، هر جا که مناسب باشند، می‌توانند گنجانده شوند.\r\nلطفا توجه داشته باشید که برای تسهیل در تفسیر صحیح دما ثبت شده، توسط کاربر نهایی ممکن است که نمایش محل و روش ثبت لازم باشد", + "misuse" : "این الگو ساز جهت ثبت دما اشیا دیگر بکار نمی رود .\r\nاین الگو ساز جهت ثبت دمای بخشهایی از بدن -\r\nبه عنوان مثال دمای کف پا به عنوان بخشی از پایش دیابت مزمن- بصورت جداگانه استفاده نمی شود\r\n ", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "es" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "es" + }, + "purpose" : "Registrar la temperatura medida de una persona - como un derivado de la temperatura corporal", + "keywords" : [ "temperatura", "cuerpo", "central", "fiebre", "hipotermia", "hipertermia" ], + "use" : "Usar para registrar la temperatura corporal de una persona o cuerpo.\r\nClusters adicionales pueden incluirse para proveer datos adicionales de estado - incluyendo condiciones ambientales, detalles del ciclo menstrual y de ejercicio físico, cuando se considera apropiado.\r\nTener en cuenta: El sitio y el método del registro quizás sea necesario mostrarlo al usuario final, para la adecuada interpretación del registro de temperatura.", + "misuse" : "Este arquetipo no debe usarse para registrar la temperatura de cualquier otro objeto.\r\nEste arquetipo no debe usarse para registrar la temperatura de una parte del cuerpo aislado por ej: la temperatura de la planta del pie como parte del manejo de la diabetes crónica.", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "it" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "it" + }, + "purpose" : "Registrare la temperatura misurata di una persona - come surrogato della temperatura del corpo centrale.", + "keywords" : [ "temperatura, corpo, tronco, febbre, ipotermia, ipertermia" ], + "use" : "\r\nUtilizzato per registrare la misurazione della temperatura corporea di un individuo, che è un indicatore della temperatura corporea interna dell'individuo.\r\n\r\nPossono essere inclusi ulteriori cluster per fornire dati aggiuntivi sullo stato - comprese le condizioni ambientali e i dettagli dello stato di fatica, se del caso.\r\n\r\nNota: il sito e il metodo di registrazione potrebbero dover essere visualizzati all'utente finale per facilitare l'interpretazione accurata della temperatura registrata.", + "misuse" : "Questo archetipo non deve essere usato per registrare la temperatura di alcun altro oggetto.\r\n\r\nQuesto archetipo non deve essere usato per registrare la temperatura di una parte del corpo in isolamento, ad esempio la temperatura della pianta del piede come parte della gestione del diabete cronico", + "originalResourceUri" : { }, + 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"otherDetails" : { } + }, { + "@type" : "TRANSLATION_DETAILS", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "it" + }, + "author" : { + "name" : "Paolo Anedda", + "organisation" : "Inpeco", + "email" : "paolo.anedda@inpeco.com" + }, + "otherDetails" : { } + } ] + }, { + "@type" : "TEMPLATE_OVERLAY", + "uid" : "d7cf88fd-5324-4005-9f1b-d0f4f8e112ba", + "description" : { + "@type" : "RESOURCE_DESCRIPTION", + "originalAuthor" : { }, + "otherContributors" : [ ], + "ipAcknowledgements" : { }, + "references" : { }, + "conversionDetails" : { }, + "otherDetails" : { + "PARENT:MD5-CAM-1.0.1" : "79322C35117205D99CB2DD0C4EBF6130" + }, + "details" : { + "nb" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "nb" + }, + "purpose" : "Generisk forespørsel om utførelse av en helsetjeneste, til annet helsepersonell eller andre organisasjoner.", + "keywords" : [ "rekvisisjon", "bestilling", "foreskriving", "tjeneste", "tjenesteyter", "rekvirere", "bestille", "anmodning", "forespørre", "forespørsel", "anmode", "tilsyn" ], + "use" : "Brukes til å registrere en forespørsel om en helserelatert tjeneste eller aktivitet som skal utføres av en kliniker, organisasjon eller virksomhet.\r\n\r\nArketypen er designer som et rammeverk som kan brukes som grunnlag for:\r\n- En forespørsel om en helserelatert tjeneste, fra en kliniker eller organisasjon til en annen kliniker eller organisasjon. For eksempel: En henvisning til en spesialist for behandling eller second opinion, ansvarsoverføring til akuttmottaket, monitorering av vitale tegn hver 4. time, eller hjemmesykepleie fra kommunen.\r\n- En forespørsel om oppfølging fra samme kliniker eller organisasjon, for eksempel kontroll på poliklinikk om 6 uker.\r\n\r\nKliniske brukseksempler:\r\n- Dersom en kliniker setter opp en kontrolltime om 6 uker: \"Tjenestenavn\" settes til \"Kontroll\". Dersom klinikeren skriver inn \"6 uker\" som tid for kontrolltime i brukergrensesnittet, vil det kliniske systemet registrere datoen 6 uker etter registreringsdatoen i elementet \"Dato/tid forfall\".\r\n- Dersom en kliniker setter opp en pasient til \"undervisning om diabetes\" i \"Tjenestenavn\". Verdiene for \"Årsak for forespørsel\" kan være \"Ny diagnose\" og \"Forebygging av ketoacidose\". \"Klinisk indikasjon\" kan være \"Diabetes type 1\", som kan lenkes til en Problem/diagnose og/eller et Laboratorieprøveresultat. Dersom det er nødvendig med et kurs på 4 uker, med 4 ukentlige undervisningsøkter, må en bruke arketypene CLUSTER.service_direction og CLUSTER.timing_nondaily for å registrere kompleks timinginformasjon.\r\n- Dersom en kliniker ordinerer en gjentagende blodprøve, som for eksempel INR: Den komplekse timingen for dette krever bruk av arketypene CLUSTER.service_direction og CLUSTER.timing_nondaily for å definere hver timing i en sekvens, for eksempel \"daglig i en uke, ukentlig i 4 uker, månedlig i 6 måneder\".\r\n\r\nEn grunnleggende antagelse for denne arketypen er at den er en forespørsel for én enkelt helsetjeneste. Dersom man trenger en gjentagende tjeneste, kan dette spesifiseres ved å bruke arketypen CLUSTER.service_direction i SLOTet \"Kompleks timing\".\r\n\r\nI mange situasjoner vil det være mulig å registrere stegene som gjennomgås i utførelsen av forespørselen ved hjelp av den generiske arketypen ACTION.service. Imidlertid vil det være mange tilfeller der det vil være behov for en spesifikk ACTION-arketype, for å kunne oppfylle behov om spesifikke dataelementer, registreringsmønstre eller prosesstrinn. Eksempler på dette er ACTION.screening og ACTION.health_education.", + "copyright" : "© openEHR Foundation, Nasjonal IKT HF", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "en" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "en" + }, + "purpose" : "Generic request framework for a health-related service or activity to be delivered by a clinician, organisation or agency.", + "keywords" : [ "request", "order", "service", "provide", "referral" ], + "use" : "Use to record a request for a health-related service or activity to be delivered by a clinician, organisation or agency.\r\n\r\nThis archetype has been designed as a framework that can be used as the basis for:\r\n- a request from one clinician, organisation or agency to another clinician, organisation or agency for a health-related service. For example: a referral to a specialist clinician for treatment or a second clinical opinion; transfer of care to an emergency department; four hourly vital signs monitoring; and provision of home services from a municipal council; or\r\n- a request for a follow up service to be scheduled for the same clinician, organisation or agency. For example: a review appointment in outpatients in 6 weeks. \r\n\r\nClinical use cases:\r\n- consider a clinician ordering a follow-up appointment in 6 weeks. 'Follow-up appointment' will be the 'Service name'. If they enter '6 weeks' as the proposed timing for the appointment in the User Interface, the clinical system will record the date six weeks from today in the 'Service due' data element.\r\n- consider a clinician ordering Diabetes Education as the 'Service name'. The values for 'Reason for request' may be 'New diagnosis' and 'Prevention of ketoacidosis'. The 'Clinical indication' will be 'Diabetes Type 1', which may be linked to the Problem Diagnosis and/or Laboratory test results. If a 4 week course is required, with sessions organised at weekly intervals on 4 separate occasions, then the complex timing requires use of the CLUSTER.service_direction and associated CLUSTER.timing_nondaily archetype.\r\n- consider a clinician ordering a recurring blood test, such as an INR. The complex timing for this requires use of the CLUSTER.service_direction and associated CLUSTER.timing_nondaily archetype to define each timing in a sequence of tests, such as 'daily for one week, weekly for 4 weeks, monthly for 6 months'.\r\n\r\nThe default assumption for this archetype is that it's a request for a single service. If a series of services are required, use the CLUSTER.service_direction archetype within the 'Complex timing' SLOT.\r\n\r\nIn many situations it will be possible to record the steps that occur as part of this request being carried out using the corresponding generic ACTION.service. However, there will be many occasions where the required ACTION archetype will be very specific for purpose, as the data requirements for recording provision of many health-related services will need quite unique data elements, recording patterns or pathway steps. For example: ACTION.screening or ACTION.health_education.", + "copyright" : "© openEHR Foundation, Nasjonal IKT HF", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "it" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "it" + }, + "purpose" : "Quadro generico di richiesta per un servizio o un'attività sanitaria che deve essere fornita da un medico, da un'organizzazione o da un'agenzia.", + "keywords" : [ "richiesta, ordine, servizio, fornire, indirizzamento" ], + "use" : "Usato per registrare la richiesta di un servizio o di un'attività sanitaria da parte di un clinico, di un'organizzazione o di un'agenzia.\r\n\r\nQuesto archetipo è stato progettato come una cornice che possa essere utilizzata come base per:\r\n- una richiesta da un clinico, organizzazione o agenzia ad un altro clinico, organizzazione o agenzia per un servizio sanitario. Per esempio: la richiesta di un medico specialista per un trattamento o un secondo parere clinico; il trasferimento delle cure a un reparto di emergenza; il monitoraggio dei segni vitali ogni quattro ore; e la fornitura di servizi a domicilio da parte di un consiglio comunale; oppure\r\n- una richiesta di un servizio di follow-up da programmare per lo stesso clinico, organizzazione o agenzia. Ad esempio: un appuntamento di controllo in ambulatorio in 6 settimane. \r\n\r\nCasi d'uso clinico:\r\n- si prenda in considerazione l'idea di un clinico che ordini un appuntamento di follow-up tra 6 settimane. L'\"Appuntamento di follow-up\" sarà il \"Nome del servizio\". Se si inseriscono '6 settimane' come tempistica proposta per l'appuntamento nell'interfaccia utente, il sistema clinico registrerà la data a sei settimane da oggi nell'elemento \"Tempistica per la fornitura del servizio\".\r\n- si consideri un clinico che ordina l'educazione al diabete come 'Nome del servizio'. I valori per 'Motivo della richiesta' possono essere 'Nuova diagnosi' e 'Prevenzione della chetoacidosi'. L'\"Indicazione clinica\" sarà \"Diabete di tipo 1\", che può essere collegato all'archetipo Problem Diagnosis e/o a Laboratory test results. Se è richiesto un corso di 4 settimane, con sessioni organizzate a intervalli settimanali in 4 occasioni separate, allora la complessa tempistica richiede l'uso dell'archetipo CLUSTER.service_direction e dell'associato CLUSTER.timing_nondaily.\r\n- si prenda in considerazione un medico che ordina un esame del sangue ricorrente, come ad esempio un INR. La complessa tempistica per questo richiede l'uso del CLUSTER.service_direction e dell'archetipo CLUSTER.timing_nondaily associato per definire ogni tempistica in una sequenza di test, come ad esempio \"giornalmente per una settimana, settimanalmente per 4 settimane, mensilmente per 6 mesi\".\r\n\r\nIl presupposto di default per questo archetipo è che si tratti di una richiesta per un singolo servizio. Se è richiesta una serie di servizi, utilizzare l'archetipo CLUSTER.service_direction all'interno dello SLOT 'Tempistica Complessa'.\r\n\r\nIn molte situazioni sarà possibile registrare i passaggi che si verificano nell'ambito di questa richiesta che viene effettuata utilizzando il corrispondente generico ACTION.service. Tuttavia, ci saranno molte occasioni in cui l'archetipo di ACTION richiesto sarà molto specifico per lo scopo, in quanto i requisiti di dati per la registrazione della fornitura di molti servizi sanitari avranno bisogno di elementi, pattern di registrazione o fasi di percorso piuttosto unici. Ad esempio: ACTION.screening o ACTION. health_education.\r\n\r\n\r\n\r\n", + "originalResourceUri" : { }, + "otherDetails" : { } + } + } + }, + "parentArchetypeId" : "openEHR-EHR-INSTRUCTION.service_request.v1", + "differential" : true, + "archetypeId" : { + "@type" : "ARCHETYPE_HRID", + "value" : "openEHR-EHR-INSTRUCTION.ovl-service_request-011.v1" + }, + "definition" : { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "INSTRUCTION", + "nodeId" : "at0000.1", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "activities", + "children" : [ { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ACTIVITY", + "nodeId" : "at0001", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "description", + "children" : [ { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ITEM_TREE", + "nodeId" : "at0009", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "items", + "children" : [ { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + 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"codeString" : "nb" + }, + "author" : { + "name" : "Silje Ljosland Bakke", + "organisation" : "Nasjonal IKT HF, Norway" + }, + "otherDetails" : { } + }, { + "@type" : "TRANSLATION_DETAILS", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "it" + }, + "author" : { + "name" : "Francesca Frexia", + "organisation" : "CRS4 - Center for advanced studies, research and development in Sardinia, Pula (Cagliari), Italy", + "email" : "francesca.frexia@crs4.it" + }, + "otherDetails" : { } + } ] + }, { + "@type" : "TEMPLATE_OVERLAY", + "uid" : "58414310-36c9-46a8-861f-604330913760", + "description" : { + "@type" : "RESOURCE_DESCRIPTION", + "originalAuthor" : { }, + "otherContributors" : [ ], + "ipAcknowledgements" : { }, + "references" : { }, + "conversionDetails" : { }, + "otherDetails" : { + "PARENT:MD5-CAM-1.0.1" : "D52BB4ECB2B0380CB1C0F3A4FBC6BB5C", + "ip_acknowledgements" : "This artefact includes content from SNOMED Clinical Terms® (SNOMED CT®) which is copyrighted material of the International Health Terminology Standards Development Organisation (IHTSDO). Where an implementation of this artefact makes use of SNOMED CT content, the implementer must have the appropriate SNOMED CT Affiliate license - for more information contact http://www.snomed.org/snomed-ct/get-snomedct or info@snomed.org." + }, + "details" : { + "de" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "de" + }, + "purpose" : "Zur Erfassung von Details über eine einzelne Episode eines berichteten Symptoms/Krankheitsanzeichens. Zusammenhänge zu früheren Episoden (ohne Angabe von Details) sollen, wenn angemessen, ebenfalls aufgeführt werden.", + "keywords" : [ "Beschwerde", "Symptom", "Störung", "Problem", "gegenwärtige Beschwerde", "gegenwärtiges Symptom", "Zeichen", "Anzeichen", "Krankheitsanzeichen" ], + "use" : "Zu Verwenden, um Details über eine einzelne Episode eines Symptoms oder eines berichteten Krankheitsanzeichens einer Person zu dokumentieren, wie es von der Person, dem Elternteil, dem Betreuer oder einer anderen Partei berichtet wurde. Es kann von einem Arzt als Teil einer Krankengeschichte dokumentiert werden, oder wie es dem Arzt berichtet wurde/wie er es beobachtet hat, oder als Teil eines selbst aufgezeichneten klinischen Fragebogens oder einer persönlichen Gesundheitsakte. Eine vollständige Krankengeschichte kann mehrere Episoden eines identifizierten Symptoms/Krankheitsanzeichens, mit variierendem Detaillierungsgrad, sowie mehrere Symptome/Krankheitsanzeichen beinhalten.\r\n\r\nSymptome sind subjektive Beobachtungen einer körperlichen oder geistigen Störung und Krankheitsanzeichen sind objektive Beobachtungen dieser Störung, wie sie von einer Person erlebt und dem Dokumentierenden von derselben Person oder einer anderen Partei berichtet werden. Aus dieser Logik folgt, dass zwei Archetypen benötigt werden, um die Krankengeschichte aufzuzeichnen - einen für berichtete Symptome und einen weiteren für berichtete Krankheitsanzeichen. Für die Praxis ist dies ungeeignet, da es die Eingabe klinischer Daten in eines der beiden Modelle erfordert, was den Modellierern und denen, die die Daten eingeben, erheblichen Mehraufwand verursacht. Darüber hinaus gibt es oft Überschneidungen von klinischen Konzepten - z.B. ist vorangegangenes Erbrechen oder sind Blutungen als Symptom oder berichtetes Krankheitsanzeichen zu kategorisieren? Als Antwort darauf wurde dieser Archetyp speziell entwickelt, um ein einziges Informationsmodell zu erproben, das es ermöglicht, das gesamte Spektrum von klar identifizierbaren Symptomen bis hin zu berichteten Krankheitsanzeichen bei der Dokumentation einer Krankengeschichte zu erfassen.\r\n\r\nDieser Archetyp wurde als generisches Muster für alle Symptome und Krankheitsanzeichen entwickelt. Der Slot \"Spezifische Details\" kann verwendet werden, um den Archetyp um zusätzliche, spezifische Datenelemente für komplexere Symptome oder Krankheitsanzeichen zu erweitern. \r\n\r\nDieser Archetyp wurde speziell für die Verwendung im Slot \"Strukturiertes Detail\" innerhalb des Archetyps OBSERVATION.story entwickelt, kann aber auch in anderen OBSERVATION- oder CLUSTER-Archetypen und in den Slots \"Assoziierte Symptome/Krankheitsanzeichen\" oder \"Vorangegangene Episoden\" in anderen Instanzen dieses CLUSTER.symptom_sign Archetyps verwendet werden.\r\n\r\nÄrzte benutzen häufig den Ausdruck \"nicht signifikant\", um festzuhalten, dass sie eine Person bezüglich des Symptoms/Krankheitsanzeichens befragt haben und es nicht berichtet wurde, dass Unannehmlichkeiten oder Störungen vorliegen - es wird also eher wie eine \"normale Aussage\" als wie ein ausdrücklicher Ausschluss verwendet. Das Datenelement \"Nicht signifikant\" wurde bewusst in diesen Archetyp aufgenommen, um Ärzten zu ermöglichen, dieselben Informationen auf einfache und effektive Weise in einem klinischen System zu dokumentieren. Es kann verwendet werden, um eine Benutzeroberfläche zu steuern, z.B. wenn \"Nicht signifikant\" als wahr dokumentiert wird, dann können die restlichen Datenelemente auf einem Dateneingabebildschirm ausgeblendet werden. Dieser pragmatische Ansatz unterstützt die Mehrheit der einfachen Anforderungen an die klinische Aufzeichnung im Bereich der berichteten Symptome/Krankheitsanzeichen. \r\n\r\nWenn es jedoch klinisch zwingend erforderlich ist, explizit zu erfassen, dass ein Symptom oder Krankheitsanzeichen als nicht vorhanden berichtet wurde, z.B. wenn es zur Unterstützung der klinischen Entscheidung verwendet wird, dann wäre es besser, den Archetyp CLUSTER.exclusion_symptom_sign zu verwenden. Die Verwendung von CLUSTER.exclusion_symptom_sign soll die Komplexität der Template-Modellierung, -Implementierung und -Abfrage erhöhen. Es wird empfohlen, den Archetyp CLUSTER.exclusion_symptom_sign nur dann für die Verwendung in Betracht zu ziehen, wenn in bestimmten Situationen ein klarer Nutzen erkennbar ist, aber nicht für die routinemäßige Aufnahme von Symptomen und Krankheitsanzeichen.", + "misuse" : "Nicht zu verwenden, um zu dokumentieren, dass ein Symptom oder ein Krankheitsanzeichen explizit als nicht vorhanden berichtet wurde - verwenden Sie CLUSTER.exclusion_symptom_sign sorgfältig für bestimmte Zwecke, bei denen der durch die Aufzeichnung entstehende Mehraufwand die zusätzliche Komplexität rechtfertigt, und nur dann, wenn das \"Nicht signifikant\" in diesem Archetyp nicht spezifisch genug für den Zweck der Dokumentation ist.\r\n\r\nNicht zur Erfassung objektiver Befunde im Rahmen einer körperlichen Untersuchung verwenden - verwenden Sie zu diesem Zweck OBSERVATION.exam und verwandte Untersuchung-CLUSTER-Archetypen.\r\n\r\nNicht für Diagnosen und Probleme, die Teil einer bestehenden Problemliste sind, verwenden - verwenden Sie EVALUATION.problem_diagnosis.\r\n", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "fi" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "fi" + }, + "purpose" : "*To record details about a single episode of a reported symptom or sign including context, but not details, of previous episodes if appropriate.(en)", + "keywords" : [ "*complaint(en)", "*symptom(en)", "*disturbance(en)", "*problem(en)", "*discomfort(en)", "*presenting complaint(en)", "*presenting symptom(en)", "*sign(en)" ], + "use" : "*Use to record details about a single episode of a symptom or reported sign in an individual, as reported by the individual, parent, care-giver or other party. It may be recorded by a clinician as part of a clinical history record as reported to them, observed by the clinician or self-recorded as part of a clinical questionnaire or personal health record. A complete clinical history or patient story may include varying level of details about multiple episodes of an identified symptom or reported sign, as well as multiple symptoms/signs.\r\n\r\nIn the purest sense, symptoms are subjective observations of a physical or mental disturbance and signs are objective observations of the same, as experienced by an individual and reported to the history taker by the same individual or another party. From this logic it follows that we will need two archetypes to record clinical history - one for reported symptoms and another for reported signs. In reality this is impractical as it will require clinical data entry into either one of these models which adds signficant overheads to modellers and those entering data. In addition, there is often overlap in clinical concepts - for example, is previous vomiting or bleeding to be categorised as a symptom or reported sign? In response, this archetype has been specifically designed to proved a single information model that allows for recording of the entire continuum between clearly identifable symptoms and reported signs when recording a clinical history.\r\n\r\nThis archetype has been intended to be used as a generic pattern for all symptoms and reported signs. The 'Specific details' SLOT can be used to extend the archetype to include additional, specific data elements for more complex symptoms or signs. \r\n\r\nThis archetype has been specifically designed to be used in the 'Structured detail' SLOT within the OBSERVATION.story archetype, but can also be used within other OBSERVATION or CLUSTER archetypes and in the 'Associated symptom/sign' or 'Previous episode' SLOT within other instances of this CLUSTER.symptom_sign archetype.\r\n\r\nClinicians frequently record the phrase 'nil significant' against specific symptoms or reported signs as an efficient method to indicate that they asked the individual and it was not reported as causing any discomfort or disturbance - effectively used more like a 'normal statement' rather than an explicit exclusion. The 'Nil significant' data element has been deliberately included in this archetype to allow clinicians to record this same information in a simple and effective way in a clinical system. It can be used to drive a user interface, for example if 'Nil significant' is recorded as true then the remaining data elements can be hidden on a data entry screen. This pragmatic approach supports the majority of simple clinical recording requirements around reported symptoms and signs. \r\n\r\nHowever if there is a clinical imperative to explicitly record that a Symptom or Sign was reported as not present, for example if it will be used to drive clinical decision support, then it would be preferable to use the CLUSTER.exclusion_symptom_sign archetype. The use of CLUSTER.exclusion_symptom_sign will increase the complexity of template modelling, implementation and querying. It is recommended that the CLUSTER.exclusion_symptom_sign archetype only be considered for use if clear benefit can be identified in specific situations, but should not be used for routine symptom/sign recording.(en)", + "misuse" : "*Not to be used to record that a symptom or sign was explicitly reported as not present - use CLUSTER.exclusion_symptom_sign carefully for specific purposes where the overheads of recording in this way warrant the additional complexity, and only if the 'Nil significant' in this archetype is not specific enough for recording purposes.\r\n\r\nNot to be used for recording objective findings as part of a physical examination - use OBSERVATION.exam and related examination CLUSTER archetypes for this purpose.\r\n\r\nNot to be used for diagnoses and problems that form part of a persisting Problem List - use EVALUATION.problem_diagnosis.(en)", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "sv" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "sv" + }, + "purpose" : "Att registrera ett uppvisat symtom eller tecken ifrån en enskild episod, inklusive kontext, men inte detaljer om tidigare episoder, om det är tillämpligt.", + "keywords" : [ "besvär", "symtom", "störning", "problem", "obehag", "uppvisar besvär", "uppvisar symtom", "tecken" ], + "use" : "Används för att beskriva detaljer för en individs rapporterade symtom eller tecken ifrån en enskild episod, som rapporterats av personen, föräldern, hälso- o sjukvårdspersonal eller annan part. Det kan registreras av hälso- o sjukvårdspersonal som en del av en anamnes som rapporterats till hälso- o sjukvårdspersonalen, observerad av eller registrerats själv av personen som en del av ett kliniskt frågeformulär eller personligt hälsodokument. En komplett anamnes eller patientjournal kan innehålla varierande detaljnivå från flera episoder av ett identifierat symtom eller rapporterade tecken, såväl som multipla symtom och tecken. \r\n\r\nSymtom är subjektiva observationer från en fysisk eller psykisk störning och tecken är objektiva observationer av densamma, upplevda av en individ och rapporteras till journalföraren av samma individ eller annan part. \r\nUr denna logik följer att vi behöver två arketyper för att registrera klinisk anamnes , en för rapporterade symtom och en annan för rapporterade tecken. I verkligheten är detta opraktiskt eftersom det kommer att kräva tillgång till kliniska data i någon av dessa mallar, vilket innebär signifikant merarbete för mallarna och dem som matar in data. Dessutom finns det ofta överlappningar i kliniska koncept, exempevisl är tidigare kräkningar eller blödningar att kategoriserade som ett symtom eller rapporterat tecken? \r\nSom svar har denna arketyp utformats specifikt för att möjliggöra registrering av en sammanhängande enhet mellan tydligt identifierbara symtom och rapporterade tecken vid registrering av en klinisk anamnes.\r\n\r\nAnvänds som en allmän mall för alla symtom och rapporterade tecken. Fältet \"Specifika detaljer\" kan användas för att utöka arketypen för att inkludera ytterligare, specifika datakomponenter för mer komplexa symtom eller tecken. \r\n\r\nArketypen är speciellt utformad för att användas i fältet \"Detaljstruktur\" i OBSERVATION.story-arketypen, men kan även användas inom andra OBSERVATION- eller CLUSTER-arketyper och i \"Associerade symtom och tecken\" eller i fältet \"Tidigare episod\" inom andra exempel av denna CLUSTER.symptom_sign arketypen. Hälso- o sjukvårdspersonal registrerar ofta uttrycket \"Används inte för att dokumentera ett symtom eller tecken\" som uttryckligen rapporteras som inte förekommande. \r\n\r\nAnvänd CLUSTER.exclusion_symptom_sign med försiktighet för specifika ändamål där merarbetet för registreringarna på detta sätt motiverar extra komplexitet och endast om \"Noll signifikanta\" fältet i denna arketyp inte är tillräckligt specifik för syftet för registreringen. Används inte för att dokumentera ett symtom eller tecken som uttryckligen rapporteras som inte förekommande – använd CLUSTER.exclusion_symptom_sign med försiktighet för specifika ändamål där merarbetet för registreringarna på detta sätt motiverar extra komplexitet och endast om \"Noll signifikanta\" fältet i denna arketyp inte är tillräckligt specifik för syftet för registreringen. För specifika symtom eller rapporterade tecken som en effektiv metod för att indikera att individen tillfrågats och det inte rapporterades som obehag eller störning - används mer effektivt som ett \"normalt utlåtande\" snarare än en uttrycklig uteslutning. Det \"Noll signifikanta\" fältet har medvetet inkluderats i denna arketyp för att kliniker kan registrera samma information på ett enkelt och effektivt sätt i ett kliniskt system. Det kan användas för att driva ett användargränssnitt, exempelvis om \"Noll signifikant\" är registrerad som sann kan de återstående fälten döljas på en dataskärm. Denna pragmatiska metod stöder majoriteten av enkla kliniska registreringskrav kring rapporterade symtom och tecken.\r\n\r\nDäremot om det finns en klinisk nödvändighet att uttryckligen registrera att ett symtom eller tecken rapporterades som inte förekommande, exempelvis om det kommer att användas som ett kliniskt beslutsstöd, föredras CLUSTER.exclusion_symptom_sign arketypen. Användningen av CLUSTER.exclusion_symptom_sign ökar komplexiteten i mallutformningen, implementeringen och utfrågningen. Det rekommenderas att CLUSTER.exclusion_symptom_sign arketypen endast beaktas för användning om tydlig fördel kan identifieras i specifika situationer, men ska inte användas för rutinmässigt symtom och tecken registrering.\r\n\r\n\r\n", + "misuse" : "Ska inte användas för att dokumentera ett symtom eller tecken som uttryckligen rapporteras som inte förekommande. Använd CLUSTER.exclusion_symptom_sign med försiktighet för specifika ändamål där merarbetet för registreringarna på detta sätt motiverar extra komplexitet och endast om \"Noll significant\" fältet i denna arketyp inte är tillräckligt specifik för registreringens syfte.\r\n\r\nSka inte användas för att registrera objektiva fynd som en del av en fysisk undersökning . Använd OBSERVATION.exam och relaterad undersökning CLUSTER-arketyper för detta ändamål.\r\n\r\nSka inte användas för diagnoser och problem som ingår i en kvarstående problemlista. Använd då istället EVALUATION.problem_diagnosis.", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "nb" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "nb" + }, + "purpose" : "For å registrere detaljer om en enkeltepisode av et rapportert symptom eller sykdomstegn. Dette kan omfatte kontekst, men ikke detaljer, om tidligere episoder av symptomet/sykdomstegnet.", + "keywords" : [ "lidelse", "plage", "problem", "ubehag", "symptom", "sykdomstegn", "lyte", "skavank" ], + "use" : "For å registrere detaljer om en enkeltepisode av et rapportert symptom eller sykdomstegn hos et individ, som redegjort av personen selv, foreldre, omsorgsperson eller andre parter. Registrering kan skje i forbindelse med opptak av anamnese, eller som en selvregistrering som en del av et klinisk spørreskjema eller personlig journal. \r\nEn fullstendig klinisk anamnese eller pasientanamnese kan inneholde beskrivelser med ulikt detaljnivå om flere episoder knyttet til samme symptom eller sykdomstegn, og vil også kunne inneholde flere ulike symptomer eller sykdomstegn.\r\n\r\nI egentlig forstand er symptomer subjektive opplevelser av en fysisk eller mental forstyrrelse mens sykdomstegn er objektive observasjoner av det samme, som er erfart av et individ og rapportert til en kliniker av individet eller av andre. Fra denne logikken følger at det burde være to arketyper til å registrere klinisk anamnese; en for rapporterte symptomer og en for rapporterte sykdomstegn. I virkeligheten er dette upraktisk og vil kreve registrering av kliniske data i enten den ene eller den andre av disse modellene. I praksis vil dette øke kompleksitet og tidsbruk knyttet til modellering og registrering av data. I tillegg overlapper ofte de kliniske konseptene, for eksempel: Vil tidligere oppkast eller blødning kategoriseres som et symptom eller som et rapportert sykdomstegn?\r\nSom svar på dette er arketypen laget for å tillate registrering av hele kontinuumet mellom tydelig definerte symptomer og rapporterte sykdomstegn når en registrerer en klinisk anamnese.\r\n\r\nArketypen er designet for å gi et generisk rammeverk for alle symptomer og rapporterte sykdomstegn. SLOTet \"Spesifikke detaljer\" kan brukes for å utvide arketypen med ytterligere spesifikke dataelementer for komplekse symptomer eller sykdomstegn.\r\n\r\nArketypen skal settes inn i \"Detaljer\"-SLOTet i OBSERVATION.story-arketypen men kan også brukes i en hvilken som helst OBSERVATION eller CLUSTER-arketype. Arketypen kan også gjenbrukes i andre instanser av CLUSTER.symptom_sign-arketypen i SLOTene \"Assosierte symptomer\" eller \"Tidligere detaljer\".\r\n\r\nKlinikere registrerer ofte frasen \"Ikke av betydning\" i forbindelse med spesifikke symptomer eller rapporterte tegn for å indikere at det er eksplisitt spurt om det spesifikke symptomet, og at det ble svart at symptomet ikke er tilstede i en slik grad at det påfører pasienten ubehag eller uro. Frasen brukes mer som en normalbeskrivelse enn en eksplisitt eksklusjon. Dataelementet \"Ikke av betydning\" er med hensikt lagt til for å tillate at klinikere enkelt og effektivt kan registrere denne informasjonen i det kliniske systemet. Eksempelvis kan \"Ikke av betydning\" brukes i brukergrensesnittet, er dette registrert som \"Sann\" kan de resterende dataelementene skjules i brukergrensesnittet. Denne pragmatiske tilnærmingen støtter hoveddelen av enkel klinisk journalføring av symptomer og sykdomstegn. \r\n\r\nImidlertid kan det være fordelaktig å bruke arketypen CLUSTER.exclusion_symptom_sign dersom det er klinisk behov for å eksplisitt registrere at et symptom eller sykdomstegn ikke er tilstede, for eksempel dersom dette skal brukes til klinisk beslutningsstøtte. Bruk av CLUSTER.exclusion_symptom_sign vil øke kompleksiteten i templatmodellering, implementasjon og spørring. Det anbefales at CLUSTER.exclusion_symptom_sign kun vurderes brukt dersom man kan identifisere en klar gevinst, men bør ikke brukes for rutineregistreringer av symptomer eller sykdomstegn.", + "misuse" : "Brukes ikke til eksplisitt registrering av at et symptom eller sykdomstegn ikke er tilstede. Bruk CLUSTER.exclusion_symptom_sign varsomt da det øker tidsbruk ved registrering og tilfører økt kompleksitet, og bare når dataelementet \"Ikke av betydning\" i denne arketypen ikke er eksplisitt nok for registreringen.\r\n\r\nBrukes ikke til registrering av objektive funn som en del av en fysisk undersøkelse. Bruk OBSERVATION.exam og relaterte CLUSTER.exam-arketyper for dette formålet. \r\n\r\nBrukes ikke til registrering av problemer og diagnoser som en del av en persistent problemliste, til dette brukes EVALUATION.problem_diagnosis.\r\n\r\nBrukes ikke til å dokumentere tiltak og resultat i løpet av hele perioden individet er under behandling, da arketypen er beregnet til å dokumentere symptomer og sykdomstegn som et øyeblikksbilde.", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "pt-br" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "pt-br" + }, + "purpose" : "Registrar detalhes sobre um episódio único de um sinal ou sintoma relatado incluindo contexto, mas não detalhes, de episódios prévios se apropriado.", + "keywords" : [ "queixa", "sintoma", "distúrbio", "problema", "desconforto", "queixa atual", "sintoma atual", "sinal" ], + "use" : "Usar para relatar detalhes sobre um episódio único de um sintoma ou sinal reportado em um indivíduo, como reportado pelo indivíduo, parente, cuidador ou outra arte. Deve ser registrado por um clínico como parte de um relato de história clínica como reportado por eles, observado pelo clínico ou registrado pelo próprio como parte de um questionário ou relato pessoal de saúde. Uma história clínica completa ou história pessoal deve conter - com variáveis níves de detalhes - múltiplos episódios de um sinal ou sintoma identificado ou reportado assim como múltiplos sinais/sintomas. \r\n\r\nNo sentido mais puro, sintomas são observações subjetivas de um distúrbio físico ou mental e sinais são observações objetivas dos mesmos, como experimentado por um indivíduo e reportado para o tomador da história pelo mesmo indivíduo ou outra parte. Por esta lógica segue que serão necessários dois arquétipos para registrar a história clínica - um para sintomas e outro para sinais relatados. Na realidade isto é pouco prático pois vai requerer entrada de dados clínicos em cada um destes modelos o que acrescenta problemas significantes aos modeladores e aqueles que coletam o dado. Em adição, frequentemente há uma interposição entre os conceitos clínicos - por exemplo: vômitos ou sangramentos prévios devem ser considerados sintomas ou sinais reportados? Em resposta, este arquétipo foi especificamente desenhado para prover um modelo de informação único que permita o registro de todo o continuum entre sintomas claramente identificáveis e sinais reportados quando do reistro de uma história clínica. \r\n\r\nEste arquétipo pretende ser utilizado como um padrão genérico para todos os sintomas e sinais reportados. O SLOT 'Detalhes específicos' pode ser utilizado para estender o arquétipo e incluir elementos de dados específicos ou adicionais para sinais e sintomas mais complexos. \r\n\r\nEste arquétipo foi desenhado especificamennte para ser utilizado no SLOT 'Detalhe estruturado' com o arquétipo OBSERVATION.story, mas pode também ser utilizado com outros arquétipos OBSERVATION ou CLUSTER e nos SLOTS 'Sinal/sintoma associado' ou 'Episódio prévio' em outras instâncias deste arquétipo CLUSTER.symptom_sign.\r\n\r\nClínicos frequentemente registram a frase 'não significante' em sintomas específicos ou sinais relatados como um método eficiente de indicar que eles perguntaram ao indivíduo e foi relatado como não causador de desconforto ou distúrbio - efetivamente é utilizado mais como 'referido como normal' do que uma exclusão explícita. O elemento de dado 'não significante' tem sido incluído deliberadamente neste arquétipo para permitir aos clínicos registrarem esta mesma informação de uma maneira simples e efetiva num sistema clínico. Pode ser utilizado para dirigir uma interface de usuário, por exemplo se 'não significante' é registrado como verdadeiro então os demais elementos de dados podem ser ocultos na tela de entrada de dados. Esta abordagem pragmática dá suporte à maioria dos requerimentos de registros clínicos com relação a sinais e sintomas relatados. \r\n\r\nEntretanto se houver um imperativo clínico para explicitar o registro de que um Sintoma ou Sinal foi reportado como ausente, por exemplo se for utilizado para orientar suporte à decisão clínica, então pode ser preferível usar o arquétipo CLUSTER.exclusion_symptom_sign. O uso de CLUSTER.exclusion_symptom_sign vai aumentar a complexidade da modelagem de template, implementação e pesquisa. É recomendado que o arquétipo CLUSTER.exclusion_symptom_sign apenas seja considerado se um benefício claro for identificado em situações específicas e não deve ser utilizado rotineiramente para o registro de sinais/sintomas.", + "misuse" : "Não deve ser utilizado para registrar que um sintoma ou sinal foi explicitamente relatado como ausente - utilizar CLUSTER.exclusion_symptom_sign cuidadosamente para fins específicos em que os problemas de registro garantam complexidade adicional e apenas se o 'não significante' neste arquétipo não for específico suficiente para fins de registro.\r\n\r\nNão deve ser utilizado para registrar achados objetivos como parte de um exame físico - utilizar OBSERVATION.exam e arquétipos do tipo CLUSTER relacionados a exame para esta finalidade.\r\n\r\nNão dever ser utilizado para diagnósticos e problemas que fazem parte de uma lista de problemas - utilizar EVALUATION.problem_diagnosis.", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "ar-sy" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "ar-sy" + }, + "purpose" : "*To record detail about a symptom - either self-recorded by an individual or recorded on the behalf of a patient by a clinician. A complete patient history may include varying level of details about a variety of symptoms.(en)", + "keywords" : [ ], + "use" : "*Use to record detailed information about a symptom as told to a clinician by a patient or self-recorded by the individual/patient.\r\n\r\nThis archetype allows a 'nil significant' statement to be explicitly recorded.(en)", + "misuse" : "*Not to be used to record details about pain. Use the specialisation of this archetype - the CLUSTER.symptom-pain instead.\r\n\r\nNot to be used for diagnoses and problems that form part of a persisting Problem List - use EVALUATION.problem_diagnosis.(en)", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "en" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "en" + }, + "purpose" : "To record details about a single episode of a reported symptom or sign including context, but not details, of previous episodes if appropriate.", + "keywords" : [ "complaint", "symptom", "disturbance", "problem", "discomfort", "presenting complaint", "presenting symptom", "sign" ], + "use" : "Use to record details about a single episode of a symptom or reported sign in an individual, as reported by the individual, parent, care-giver or other party. It may be recorded by a clinician as part of a clinical history record as reported to them, observed by the clinician or self-recorded as part of a clinical questionnaire or personal health record. A complete clinical history or patient story may include varying level of details about multiple episodes of an identified symptom or reported sign, as well as multiple symptoms/signs.\r\n\r\nIn the purest sense, symptoms are subjective observations of a physical or mental disturbance and signs are objective observations of the same, as experienced by an individual and reported to the history taker by the same individual or another party. From this logic it follows that we will need two archetypes to record clinical history - one for reported symptoms and another for reported signs. In reality this is impractical as it will require clinical data entry into either one of these models which adds signficant overheads to modellers and those entering data. In addition, there is often overlap in clinical concepts - for example, is previous vomiting or bleeding to be categorised as a symptom or reported sign? In response, this archetype has been specifically designed to proved a single information model that allows for recording of the entire continuum between clearly identifable symptoms and reported signs when recording a clinical history.\r\n\r\nThis archetype has been intended to be used as a generic pattern for all symptoms and reported signs. The 'Specific details' SLOT can be used to extend the archetype to include additional, specific data elements for more complex symptoms or signs. \r\n\r\nThis archetype has been specifically designed to be used in the 'Structured detail' SLOT within the OBSERVATION.story archetype, but can also be used within other OBSERVATION or CLUSTER archetypes and in the 'Associated symptom/sign' or 'Previous episode' SLOT within other instances of this CLUSTER.symptom_sign archetype.\r\n\r\nClinicians frequently record the phrase 'nil significant' against specific symptoms or reported signs as an efficient method to indicate that they asked the individual and it was not reported as causing any discomfort or disturbance - effectively used more like a 'normal statement' rather than an explicit exclusion. The 'Nil significant' data element has been deliberately included in this archetype to allow clinicians to record this same information in a simple and effective way in a clinical system. It can be used to drive a user interface, for example if 'Nil significant' is recorded as true then the remaining data elements can be hidden on a data entry screen. This pragmatic approach supports the majority of simple clinical recording requirements around reported symptoms and signs. \r\n\r\nHowever if there is a clinical imperative to explicitly record that a Symptom or Sign was reported as not present, for example if it will be used to drive clinical decision support, then it would be preferable to use the CLUSTER.exclusion_symptom_sign archetype. The use of CLUSTER.exclusion_symptom_sign will increase the complexity of template modelling, implementation and querying. It is recommended that the CLUSTER.exclusion_symptom_sign archetype only be considered for use if clear benefit can be identified in specific situations, but should not be used for routine symptom/sign recording.", + "misuse" : "Not to be used to record that a symptom or sign was explicitly reported as not present - use CLUSTER.exclusion_symptom_sign carefully for specific purposes where the overheads of recording in this way warrant the additional complexity, and only if the 'Nil significant' in this archetype is not specific enough for recording purposes.\r\n\r\nNot to be used for recording objective findings as part of a physical examination - use OBSERVATION.exam and related examination CLUSTER archetypes for this purpose.\r\n\r\nNot to be used for diagnoses and problems that form part of a persisting Problem List - use EVALUATION.problem_diagnosis.", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + } + } + }, + "parentArchetypeId" : "openEHR-EHR-CLUSTER.symptom_sign-cvid.v0", + "differential" : true, + "archetypeId" : { + "@type" : "ARCHETYPE_HRID", + "value" : "openEHR-EHR-CLUSTER.ovl-symptom_sign-cvid-001.v0" + }, + "definition" : { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "CLUSTER", + "nodeId" : "at0000.1.1", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "items", + "children" : [ { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "nodeId" : "at0001.1.1", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "value", + "children" : [ { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "DV_CODED_TEXT", + "occurrences" : "0..1", + "defaultValue" : { + "@type" : "DV_CODED_TEXT", + "value" : "Influenza-like symptoms", + "defining_code" : { + "@type" : "CODE_PHRASE", + "terminology_id" : { + "@type" : "TERMINOLOGY_ID", + "value" : "SNOMED-CT" + }, + "code_string" : "315642008" + } + }, + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "defining_code", + "existence" : "0..1", + "children" : [ { + "@type" : "C_TERMINOLOGY_CODE", + "terminologyId" : { + "value" : "SNOMED-CT" + }, + "constraint" : [ ], + "includedExternalTerminologyCodes" : [ { + "terminologyId" : "SNOMED-CT", + "code" : "315642008", + "value" : "Influenza-like symptoms" + } ] + } ] + } ], + "attributeTuples" : [ ] + } ] + } ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "occurrences" : "0..0", + "nodeId" : "at0035.0.1", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "value", + "children" : [ { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "DV_BOOLEAN", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "value", + "children" : [ { + "@type" : "C_BOOLEAN", + "rmTypeName" : "Boolean", + "occurrences" : "1..1", + "constraint" : [ true ] + } ] + } ], + "attributeTuples" : [ ] + } ] + } ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + 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"@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "DV_TEXT", + "attributes" : [ ], + "attributeTuples" : [ ] + } ] + } ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "occurrences" : "0..0", + "nodeId" : "at0026.0.1", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "value", + "children" : [ { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "DV_QUANTITY", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "property", + "children" : [ { + "@type" : "C_TERMINOLOGY_CODE", + "terminologyId" : { + "value" : "openehr" + }, + "constraint" : [ "380" ] + } ] + } ], + "attributeTuples" : [ { + "@type" : "C_ATTRIBUTE_TUPLE", + "members" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "magnitude", + "children" : [ ] + }, { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "units", + "children" : [ ] + } ], + "tuples" : [ { + "@type" : "C_PRIMITIVE_TUPLE", + "members" : [ { + "@type" : "C_REAL", + "constraint" : [ { + "lower" : 0.0, + "upper" : 10.0, + "lowerIncluded" : true, + "upperIncluded" : true, + "lowerUnbounded" : false, + "upperUnbounded" : false + } ] + }, { + "@type" : "C_STRING", + "constraint" : [ "1" ] + } ] + } ] + } ] + } ] + } ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "occurrences" : "0..0", + "nodeId" : "at0180.0.1", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "value", + "children" : [ { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "DV_CODED_TEXT", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "defining_code", + "children" : [ { + "@type" : "C_TERMINOLOGY_CODE", + "rmTypeName" : "CODE_PHRASE", + "occurrences" : "1..1", + "terminologyId" : { + "value" : "local" + }, + "constraint" : [ "at0183", "at0182", "at0181", "at0184" ] + } ] + } ], + "attributeTuples" : [ ] + } ] + } ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" 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"C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "occurrences" : "0..0", + "nodeId" : "at0163.0.1", + "attributes" : [ ], + "attributeTuples" : [ ] + } ] + } ], + "attributeTuples" : [ ] + }, + "terminology" : { + "@type" : "ARCHETYPE_TERMINOLOGY", + "conceptCode" : "at0000.1", + "termDefinitions" : { + "ar-sy" : { + "at0000.1.1" : { + "@type" : "ARCHETYPE_TERM", + "code" : "at0000.1.1", + "text" : "Influenza-like symptoms", + "description" : "*Reported observation of a physical or mental disturbance in an individual.(en)" + } + }, + "en" : { + "at0000.1.1" : { + "@type" : "ARCHETYPE_TERM", + "code" : "at0000.1.1", + "text" : "Influenza-like symptoms", + "description" : "Symptoms known to be indicators of suspected Covid-19 infection" + }, + "at0152.0.1" : { + "@type" : "ARCHETYPE_TERM", + "code" : "at0152.0.1", + "text" : "First onset of symptoms", + "description" : "The onset for this episode of the symptom or sign.", + "comment" : "While partial dates are permitted, the exact date and time of onset can be recorded, if appropriate. If this symptom or sign is experienced for the first time or is a re-occurrence, this date is used to represent the onset of this episode. If this symptom or sign is ongoing, this data element may be redundant if it has been recorded previously." + } + }, + "de" : { + "at0000.1.1" : { + "@type" : "ARCHETYPE_TERM", + "code" : "at0000.1.1", + "text" : "Influenza-like symptoms", + "description" : "Festgestellte Beobachtung einer körperlichen oder geistigen Störung bei einer Person." + } + }, + "nb" : { + "at0000.1.1" : { + "@type" : "ARCHETYPE_TERM", + "code" : "at0000.1.1", + "text" : "Influenza-like symptoms", + "description" : "Rapportert observasjon av fysiske tegn eller beskrivelse av unormale eller ubehagelige fornemmelser i kropp og/eller sinn." + } + }, + "fi" : { + "at0000.1.1" : { + "@type" : "ARCHETYPE_TERM", + "code" : "at0000.1.1", + "text" : "Influenza-like symptoms", + "description" : "Reported observation of a physical or mental disturbance in an individual.(en)" + } + }, + "sv" : { + "at0000.1.1" : { + "@type" : "ARCHETYPE_TERM", + "code" : "at0000.1.1", + "text" : "Influenza-like symptoms", + "description" : "Rapporterad observation av en fysisk eller psykisk störning hos en individ." + } + }, + "pt-br" : { + "at0000.1.1" : { + "@type" : "ARCHETYPE_TERM", + "code" : "at0000.1.1", + "text" : "Influenza-like symptoms", + "description" : "Observação de um distúrbio físico ou mental relatada em um indivíduo." + } + } + }, + "termBindings" : { + "SNOMED-CT" : { + "at0001.1.1" : "term:SNOMED-CT::418799008", + "at0002.0.1" : "term:SNOMED-CT::162408000", + "at0028.0.1" : "term:SNOMED-CT::162442009", + "at0021.0.1" : "term:SNOMED-CT::162465004", + "at0001" : "term:SNOMED-CT::418799008" + } + }, + "terminologyExtracts" : { }, + "valueSets" : { } + }, + "adlVersion" : "1.4", + "buildUid" : "91cfb84d-f6d5-4240-8de6-234c0581f543", + "rmName" : "openehr", + "rmRelease" : "1.0.3", + "generated" : true, + "otherMetaData" : { }, + "originalLanguage" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "en" + }, + "translations" : [ { + "@type" : "TRANSLATION_DETAILS", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "de" + }, + "author" : { + "name" : "Jasmin Buck, Sebastian Garde, Kim Sommer", + "organisation" : "University of Heidelberg, Central Queensland University, Medizinische Hochschule Hannover" + }, + "otherDetails" : { } + }, { + "@type" : "TRANSLATION_DETAILS", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "fi" + }, + "author" : { + "name" : "Kalle Vuorinen", + "organisation" : "Tieto Healthcare & Welfare Oy", + "email" : "kalle.vuorinen@tieto.com" + }, + "otherDetails" : { } + }, { + "@type" : "TRANSLATION_DETAILS", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "sv" + }, + "author" : { + "name" : "Kirsi Poikela", + "organisation" : "Tieto Sweden AB", + "email" : "ext.kirsi.poikela@tieto.com" + }, + "otherDetails" : { } + }, { + "@type" : "TRANSLATION_DETAILS", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "nb" + }, + "author" : { + "name" : "Lars Bitsch-Larsen", + "organisation" : "Haukeland University Hospital of Bergen, Norway", + "email" : "lbla@helse-bergen.no" + }, + "accreditation" : "MD, DEAA, MBA, spec in anesthesia, spec in tropical medicine.", + "otherDetails" : { } + }, { + "@type" : "TRANSLATION_DETAILS", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "pt-br" + }, + "author" : { + "name" : "Vladimir Pizzo", + "organisation" : "Hospital Sirio Libanes - Brazil", + "email" : "vladimir.pizzo@hsl.org.br" + }, + "otherDetails" : { } + }, { + "@type" : "TRANSLATION_DETAILS", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "ar-sy" + }, + "author" : { + "name" : "Mona Saleh" + }, + "otherDetails" : { } + } ] + }, { + "@type" : "TEMPLATE_OVERLAY", + "uid" : "58414310-36c9-46a8-861f-604330913760", + "description" : { + "@type" : "RESOURCE_DESCRIPTION", + "originalAuthor" : { }, + "otherContributors" : [ ], + "ipAcknowledgements" : { }, + "references" : { }, + "conversionDetails" : { }, + "otherDetails" : { + "PARENT:MD5-CAM-1.0.1" : "D52BB4ECB2B0380CB1C0F3A4FBC6BB5C", + "ip_acknowledgements" : "This artefact includes content from SNOMED Clinical Terms® (SNOMED CT®) which is copyrighted material of the International Health Terminology Standards Development Organisation (IHTSDO). Where an implementation of this artefact makes use of SNOMED CT content, the implementer must have the appropriate SNOMED CT Affiliate license - for more information contact http://www.snomed.org/snomed-ct/get-snomedct or info@snomed.org." + }, + "details" : { + "de" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "de" + }, + "purpose" : "Zur Erfassung von Details über eine einzelne Episode eines berichteten Symptoms/Krankheitsanzeichens. Zusammenhänge zu früheren Episoden (ohne Angabe von Details) sollen, wenn angemessen, ebenfalls aufgeführt werden.", + "keywords" : [ "Beschwerde", "Symptom", "Störung", "Problem", "gegenwärtige Beschwerde", "gegenwärtiges Symptom", "Zeichen", "Anzeichen", "Krankheitsanzeichen" ], + "use" : "Zu Verwenden, um Details über eine einzelne Episode eines Symptoms oder eines berichteten Krankheitsanzeichens einer Person zu dokumentieren, wie es von der Person, dem Elternteil, dem Betreuer oder einer anderen Partei berichtet wurde. Es kann von einem Arzt als Teil einer Krankengeschichte dokumentiert werden, oder wie es dem Arzt berichtet wurde/wie er es beobachtet hat, oder als Teil eines selbst aufgezeichneten klinischen Fragebogens oder einer persönlichen Gesundheitsakte. Eine vollständige Krankengeschichte kann mehrere Episoden eines identifizierten Symptoms/Krankheitsanzeichens, mit variierendem Detaillierungsgrad, sowie mehrere Symptome/Krankheitsanzeichen beinhalten.\r\n\r\nSymptome sind subjektive Beobachtungen einer körperlichen oder geistigen Störung und Krankheitsanzeichen sind objektive Beobachtungen dieser Störung, wie sie von einer Person erlebt und dem Dokumentierenden von derselben Person oder einer anderen Partei berichtet werden. Aus dieser Logik folgt, dass zwei Archetypen benötigt werden, um die Krankengeschichte aufzuzeichnen - einen für berichtete Symptome und einen weiteren für berichtete Krankheitsanzeichen. Für die Praxis ist dies ungeeignet, da es die Eingabe klinischer Daten in eines der beiden Modelle erfordert, was den Modellierern und denen, die die Daten eingeben, erheblichen Mehraufwand verursacht. Darüber hinaus gibt es oft Überschneidungen von klinischen Konzepten - z.B. ist vorangegangenes Erbrechen oder sind Blutungen als Symptom oder berichtetes Krankheitsanzeichen zu kategorisieren? Als Antwort darauf wurde dieser Archetyp speziell entwickelt, um ein einziges Informationsmodell zu erproben, das es ermöglicht, das gesamte Spektrum von klar identifizierbaren Symptomen bis hin zu berichteten Krankheitsanzeichen bei der Dokumentation einer Krankengeschichte zu erfassen.\r\n\r\nDieser Archetyp wurde als generisches Muster für alle Symptome und Krankheitsanzeichen entwickelt. Der Slot \"Spezifische Details\" kann verwendet werden, um den Archetyp um zusätzliche, spezifische Datenelemente für komplexere Symptome oder Krankheitsanzeichen zu erweitern. \r\n\r\nDieser Archetyp wurde speziell für die Verwendung im Slot \"Strukturiertes Detail\" innerhalb des Archetyps OBSERVATION.story entwickelt, kann aber auch in anderen OBSERVATION- oder CLUSTER-Archetypen und in den Slots \"Assoziierte Symptome/Krankheitsanzeichen\" oder \"Vorangegangene Episoden\" in anderen Instanzen dieses CLUSTER.symptom_sign Archetyps verwendet werden.\r\n\r\nÄrzte benutzen häufig den Ausdruck \"nicht signifikant\", um festzuhalten, dass sie eine Person bezüglich des Symptoms/Krankheitsanzeichens befragt haben und es nicht berichtet wurde, dass Unannehmlichkeiten oder Störungen vorliegen - es wird also eher wie eine \"normale Aussage\" als wie ein ausdrücklicher Ausschluss verwendet. Das Datenelement \"Nicht signifikant\" wurde bewusst in diesen Archetyp aufgenommen, um Ärzten zu ermöglichen, dieselben Informationen auf einfache und effektive Weise in einem klinischen System zu dokumentieren. Es kann verwendet werden, um eine Benutzeroberfläche zu steuern, z.B. wenn \"Nicht signifikant\" als wahr dokumentiert wird, dann können die restlichen Datenelemente auf einem Dateneingabebildschirm ausgeblendet werden. Dieser pragmatische Ansatz unterstützt die Mehrheit der einfachen Anforderungen an die klinische Aufzeichnung im Bereich der berichteten Symptome/Krankheitsanzeichen. \r\n\r\nWenn es jedoch klinisch zwingend erforderlich ist, explizit zu erfassen, dass ein Symptom oder Krankheitsanzeichen als nicht vorhanden berichtet wurde, z.B. wenn es zur Unterstützung der klinischen Entscheidung verwendet wird, dann wäre es besser, den Archetyp CLUSTER.exclusion_symptom_sign zu verwenden. Die Verwendung von CLUSTER.exclusion_symptom_sign soll die Komplexität der Template-Modellierung, -Implementierung und -Abfrage erhöhen. Es wird empfohlen, den Archetyp CLUSTER.exclusion_symptom_sign nur dann für die Verwendung in Betracht zu ziehen, wenn in bestimmten Situationen ein klarer Nutzen erkennbar ist, aber nicht für die routinemäßige Aufnahme von Symptomen und Krankheitsanzeichen.", + "misuse" : "Nicht zu verwenden, um zu dokumentieren, dass ein Symptom oder ein Krankheitsanzeichen explizit als nicht vorhanden berichtet wurde - verwenden Sie CLUSTER.exclusion_symptom_sign sorgfältig für bestimmte Zwecke, bei denen der durch die Aufzeichnung entstehende Mehraufwand die zusätzliche Komplexität rechtfertigt, und nur dann, wenn das \"Nicht signifikant\" in diesem Archetyp nicht spezifisch genug für den Zweck der Dokumentation ist.\r\n\r\nNicht zur Erfassung objektiver Befunde im Rahmen einer körperlichen Untersuchung verwenden - verwenden Sie zu diesem Zweck OBSERVATION.exam und verwandte Untersuchung-CLUSTER-Archetypen.\r\n\r\nNicht für Diagnosen und Probleme, die Teil einer bestehenden Problemliste sind, verwenden - verwenden Sie EVALUATION.problem_diagnosis.\r\n", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "fi" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "fi" + }, + "purpose" : "*To record details about a single episode of a reported symptom or sign including context, but not details, of previous episodes if appropriate.(en)", + "keywords" : [ "*complaint(en)", "*symptom(en)", "*disturbance(en)", "*problem(en)", "*discomfort(en)", "*presenting complaint(en)", "*presenting symptom(en)", "*sign(en)" ], + "use" : "*Use to record details about a single episode of a symptom or reported sign in an individual, as reported by the individual, parent, care-giver or other party. It may be recorded by a clinician as part of a clinical history record as reported to them, observed by the clinician or self-recorded as part of a clinical questionnaire or personal health record. A complete clinical history or patient story may include varying level of details about multiple episodes of an identified symptom or reported sign, as well as multiple symptoms/signs.\r\n\r\nIn the purest sense, symptoms are subjective observations of a physical or mental disturbance and signs are objective observations of the same, as experienced by an individual and reported to the history taker by the same individual or another party. From this logic it follows that we will need two archetypes to record clinical history - one for reported symptoms and another for reported signs. In reality this is impractical as it will require clinical data entry into either one of these models which adds signficant overheads to modellers and those entering data. In addition, there is often overlap in clinical concepts - for example, is previous vomiting or bleeding to be categorised as a symptom or reported sign? In response, this archetype has been specifically designed to proved a single information model that allows for recording of the entire continuum between clearly identifable symptoms and reported signs when recording a clinical history.\r\n\r\nThis archetype has been intended to be used as a generic pattern for all symptoms and reported signs. The 'Specific details' SLOT can be used to extend the archetype to include additional, specific data elements for more complex symptoms or signs. \r\n\r\nThis archetype has been specifically designed to be used in the 'Structured detail' SLOT within the OBSERVATION.story archetype, but can also be used within other OBSERVATION or CLUSTER archetypes and in the 'Associated symptom/sign' or 'Previous episode' SLOT within other instances of this CLUSTER.symptom_sign archetype.\r\n\r\nClinicians frequently record the phrase 'nil significant' against specific symptoms or reported signs as an efficient method to indicate that they asked the individual and it was not reported as causing any discomfort or disturbance - effectively used more like a 'normal statement' rather than an explicit exclusion. The 'Nil significant' data element has been deliberately included in this archetype to allow clinicians to record this same information in a simple and effective way in a clinical system. It can be used to drive a user interface, for example if 'Nil significant' is recorded as true then the remaining data elements can be hidden on a data entry screen. This pragmatic approach supports the majority of simple clinical recording requirements around reported symptoms and signs. \r\n\r\nHowever if there is a clinical imperative to explicitly record that a Symptom or Sign was reported as not present, for example if it will be used to drive clinical decision support, then it would be preferable to use the CLUSTER.exclusion_symptom_sign archetype. The use of CLUSTER.exclusion_symptom_sign will increase the complexity of template modelling, implementation and querying. It is recommended that the CLUSTER.exclusion_symptom_sign archetype only be considered for use if clear benefit can be identified in specific situations, but should not be used for routine symptom/sign recording.(en)", + "misuse" : "*Not to be used to record that a symptom or sign was explicitly reported as not present - use CLUSTER.exclusion_symptom_sign carefully for specific purposes where the overheads of recording in this way warrant the additional complexity, and only if the 'Nil significant' in this archetype is not specific enough for recording purposes.\r\n\r\nNot to be used for recording objective findings as part of a physical examination - use OBSERVATION.exam and related examination CLUSTER archetypes for this purpose.\r\n\r\nNot to be used for diagnoses and problems that form part of a persisting Problem List - use EVALUATION.problem_diagnosis.(en)", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "sv" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "sv" + }, + "purpose" : "Att registrera ett uppvisat symtom eller tecken ifrån en enskild episod, inklusive kontext, men inte detaljer om tidigare episoder, om det är tillämpligt.", + "keywords" : [ "besvär", "symtom", "störning", "problem", "obehag", "uppvisar besvär", "uppvisar symtom", "tecken" ], + "use" : "Används för att beskriva detaljer för en individs rapporterade symtom eller tecken ifrån en enskild episod, som rapporterats av personen, föräldern, hälso- o sjukvårdspersonal eller annan part. Det kan registreras av hälso- o sjukvårdspersonal som en del av en anamnes som rapporterats till hälso- o sjukvårdspersonalen, observerad av eller registrerats själv av personen som en del av ett kliniskt frågeformulär eller personligt hälsodokument. En komplett anamnes eller patientjournal kan innehålla varierande detaljnivå från flera episoder av ett identifierat symtom eller rapporterade tecken, såväl som multipla symtom och tecken. \r\n\r\nSymtom är subjektiva observationer från en fysisk eller psykisk störning och tecken är objektiva observationer av densamma, upplevda av en individ och rapporteras till journalföraren av samma individ eller annan part. \r\nUr denna logik följer att vi behöver två arketyper för att registrera klinisk anamnes , en för rapporterade symtom och en annan för rapporterade tecken. I verkligheten är detta opraktiskt eftersom det kommer att kräva tillgång till kliniska data i någon av dessa mallar, vilket innebär signifikant merarbete för mallarna och dem som matar in data. Dessutom finns det ofta överlappningar i kliniska koncept, exempevisl är tidigare kräkningar eller blödningar att kategoriserade som ett symtom eller rapporterat tecken? \r\nSom svar har denna arketyp utformats specifikt för att möjliggöra registrering av en sammanhängande enhet mellan tydligt identifierbara symtom och rapporterade tecken vid registrering av en klinisk anamnes.\r\n\r\nAnvänds som en allmän mall för alla symtom och rapporterade tecken. Fältet \"Specifika detaljer\" kan användas för att utöka arketypen för att inkludera ytterligare, specifika datakomponenter för mer komplexa symtom eller tecken. \r\n\r\nArketypen är speciellt utformad för att användas i fältet \"Detaljstruktur\" i OBSERVATION.story-arketypen, men kan även användas inom andra OBSERVATION- eller CLUSTER-arketyper och i \"Associerade symtom och tecken\" eller i fältet \"Tidigare episod\" inom andra exempel av denna CLUSTER.symptom_sign arketypen. Hälso- o sjukvårdspersonal registrerar ofta uttrycket \"Används inte för att dokumentera ett symtom eller tecken\" som uttryckligen rapporteras som inte förekommande. \r\n\r\nAnvänd CLUSTER.exclusion_symptom_sign med försiktighet för specifika ändamål där merarbetet för registreringarna på detta sätt motiverar extra komplexitet och endast om \"Noll signifikanta\" fältet i denna arketyp inte är tillräckligt specifik för syftet för registreringen. Används inte för att dokumentera ett symtom eller tecken som uttryckligen rapporteras som inte förekommande – använd CLUSTER.exclusion_symptom_sign med försiktighet för specifika ändamål där merarbetet för registreringarna på detta sätt motiverar extra komplexitet och endast om \"Noll signifikanta\" fältet i denna arketyp inte är tillräckligt specifik för syftet för registreringen. För specifika symtom eller rapporterade tecken som en effektiv metod för att indikera att individen tillfrågats och det inte rapporterades som obehag eller störning - används mer effektivt som ett \"normalt utlåtande\" snarare än en uttrycklig uteslutning. Det \"Noll signifikanta\" fältet har medvetet inkluderats i denna arketyp för att kliniker kan registrera samma information på ett enkelt och effektivt sätt i ett kliniskt system. Det kan användas för att driva ett användargränssnitt, exempelvis om \"Noll signifikant\" är registrerad som sann kan de återstående fälten döljas på en dataskärm. Denna pragmatiska metod stöder majoriteten av enkla kliniska registreringskrav kring rapporterade symtom och tecken.\r\n\r\nDäremot om det finns en klinisk nödvändighet att uttryckligen registrera att ett symtom eller tecken rapporterades som inte förekommande, exempelvis om det kommer att användas som ett kliniskt beslutsstöd, föredras CLUSTER.exclusion_symptom_sign arketypen. Användningen av CLUSTER.exclusion_symptom_sign ökar komplexiteten i mallutformningen, implementeringen och utfrågningen. Det rekommenderas att CLUSTER.exclusion_symptom_sign arketypen endast beaktas för användning om tydlig fördel kan identifieras i specifika situationer, men ska inte användas för rutinmässigt symtom och tecken registrering.\r\n\r\n\r\n", + "misuse" : "Ska inte användas för att dokumentera ett symtom eller tecken som uttryckligen rapporteras som inte förekommande. Använd CLUSTER.exclusion_symptom_sign med försiktighet för specifika ändamål där merarbetet för registreringarna på detta sätt motiverar extra komplexitet och endast om \"Noll significant\" fältet i denna arketyp inte är tillräckligt specifik för registreringens syfte.\r\n\r\nSka inte användas för att registrera objektiva fynd som en del av en fysisk undersökning . Använd OBSERVATION.exam och relaterad undersökning CLUSTER-arketyper för detta ändamål.\r\n\r\nSka inte användas för diagnoser och problem som ingår i en kvarstående problemlista. Använd då istället EVALUATION.problem_diagnosis.", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "nb" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "nb" + }, + "purpose" : "For å registrere detaljer om en enkeltepisode av et rapportert symptom eller sykdomstegn. Dette kan omfatte kontekst, men ikke detaljer, om tidligere episoder av symptomet/sykdomstegnet.", + "keywords" : [ "lidelse", "plage", "problem", "ubehag", "symptom", "sykdomstegn", "lyte", "skavank" ], + "use" : "For å registrere detaljer om en enkeltepisode av et rapportert symptom eller sykdomstegn hos et individ, som redegjort av personen selv, foreldre, omsorgsperson eller andre parter. Registrering kan skje i forbindelse med opptak av anamnese, eller som en selvregistrering som en del av et klinisk spørreskjema eller personlig journal. \r\nEn fullstendig klinisk anamnese eller pasientanamnese kan inneholde beskrivelser med ulikt detaljnivå om flere episoder knyttet til samme symptom eller sykdomstegn, og vil også kunne inneholde flere ulike symptomer eller sykdomstegn.\r\n\r\nI egentlig forstand er symptomer subjektive opplevelser av en fysisk eller mental forstyrrelse mens sykdomstegn er objektive observasjoner av det samme, som er erfart av et individ og rapportert til en kliniker av individet eller av andre. Fra denne logikken følger at det burde være to arketyper til å registrere klinisk anamnese; en for rapporterte symptomer og en for rapporterte sykdomstegn. I virkeligheten er dette upraktisk og vil kreve registrering av kliniske data i enten den ene eller den andre av disse modellene. I praksis vil dette øke kompleksitet og tidsbruk knyttet til modellering og registrering av data. I tillegg overlapper ofte de kliniske konseptene, for eksempel: Vil tidligere oppkast eller blødning kategoriseres som et symptom eller som et rapportert sykdomstegn?\r\nSom svar på dette er arketypen laget for å tillate registrering av hele kontinuumet mellom tydelig definerte symptomer og rapporterte sykdomstegn når en registrerer en klinisk anamnese.\r\n\r\nArketypen er designet for å gi et generisk rammeverk for alle symptomer og rapporterte sykdomstegn. SLOTet \"Spesifikke detaljer\" kan brukes for å utvide arketypen med ytterligere spesifikke dataelementer for komplekse symptomer eller sykdomstegn.\r\n\r\nArketypen skal settes inn i \"Detaljer\"-SLOTet i OBSERVATION.story-arketypen men kan også brukes i en hvilken som helst OBSERVATION eller CLUSTER-arketype. Arketypen kan også gjenbrukes i andre instanser av CLUSTER.symptom_sign-arketypen i SLOTene \"Assosierte symptomer\" eller \"Tidligere detaljer\".\r\n\r\nKlinikere registrerer ofte frasen \"Ikke av betydning\" i forbindelse med spesifikke symptomer eller rapporterte tegn for å indikere at det er eksplisitt spurt om det spesifikke symptomet, og at det ble svart at symptomet ikke er tilstede i en slik grad at det påfører pasienten ubehag eller uro. Frasen brukes mer som en normalbeskrivelse enn en eksplisitt eksklusjon. Dataelementet \"Ikke av betydning\" er med hensikt lagt til for å tillate at klinikere enkelt og effektivt kan registrere denne informasjonen i det kliniske systemet. Eksempelvis kan \"Ikke av betydning\" brukes i brukergrensesnittet, er dette registrert som \"Sann\" kan de resterende dataelementene skjules i brukergrensesnittet. Denne pragmatiske tilnærmingen støtter hoveddelen av enkel klinisk journalføring av symptomer og sykdomstegn. \r\n\r\nImidlertid kan det være fordelaktig å bruke arketypen CLUSTER.exclusion_symptom_sign dersom det er klinisk behov for å eksplisitt registrere at et symptom eller sykdomstegn ikke er tilstede, for eksempel dersom dette skal brukes til klinisk beslutningsstøtte. Bruk av CLUSTER.exclusion_symptom_sign vil øke kompleksiteten i templatmodellering, implementasjon og spørring. Det anbefales at CLUSTER.exclusion_symptom_sign kun vurderes brukt dersom man kan identifisere en klar gevinst, men bør ikke brukes for rutineregistreringer av symptomer eller sykdomstegn.", + "misuse" : "Brukes ikke til eksplisitt registrering av at et symptom eller sykdomstegn ikke er tilstede. Bruk CLUSTER.exclusion_symptom_sign varsomt da det øker tidsbruk ved registrering og tilfører økt kompleksitet, og bare når dataelementet \"Ikke av betydning\" i denne arketypen ikke er eksplisitt nok for registreringen.\r\n\r\nBrukes ikke til registrering av objektive funn som en del av en fysisk undersøkelse. Bruk OBSERVATION.exam og relaterte CLUSTER.exam-arketyper for dette formålet. \r\n\r\nBrukes ikke til registrering av problemer og diagnoser som en del av en persistent problemliste, til dette brukes EVALUATION.problem_diagnosis.\r\n\r\nBrukes ikke til å dokumentere tiltak og resultat i løpet av hele perioden individet er under behandling, da arketypen er beregnet til å dokumentere symptomer og sykdomstegn som et øyeblikksbilde.", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "pt-br" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "pt-br" + }, + "purpose" : "Registrar detalhes sobre um episódio único de um sinal ou sintoma relatado incluindo contexto, mas não detalhes, de episódios prévios se apropriado.", + "keywords" : [ "queixa", "sintoma", "distúrbio", "problema", "desconforto", "queixa atual", "sintoma atual", "sinal" ], + "use" : "Usar para relatar detalhes sobre um episódio único de um sintoma ou sinal reportado em um indivíduo, como reportado pelo indivíduo, parente, cuidador ou outra arte. Deve ser registrado por um clínico como parte de um relato de história clínica como reportado por eles, observado pelo clínico ou registrado pelo próprio como parte de um questionário ou relato pessoal de saúde. Uma história clínica completa ou história pessoal deve conter - com variáveis níves de detalhes - múltiplos episódios de um sinal ou sintoma identificado ou reportado assim como múltiplos sinais/sintomas. \r\n\r\nNo sentido mais puro, sintomas são observações subjetivas de um distúrbio físico ou mental e sinais são observações objetivas dos mesmos, como experimentado por um indivíduo e reportado para o tomador da história pelo mesmo indivíduo ou outra parte. Por esta lógica segue que serão necessários dois arquétipos para registrar a história clínica - um para sintomas e outro para sinais relatados. Na realidade isto é pouco prático pois vai requerer entrada de dados clínicos em cada um destes modelos o que acrescenta problemas significantes aos modeladores e aqueles que coletam o dado. Em adição, frequentemente há uma interposição entre os conceitos clínicos - por exemplo: vômitos ou sangramentos prévios devem ser considerados sintomas ou sinais reportados? Em resposta, este arquétipo foi especificamente desenhado para prover um modelo de informação único que permita o registro de todo o continuum entre sintomas claramente identificáveis e sinais reportados quando do reistro de uma história clínica. \r\n\r\nEste arquétipo pretende ser utilizado como um padrão genérico para todos os sintomas e sinais reportados. O SLOT 'Detalhes específicos' pode ser utilizado para estender o arquétipo e incluir elementos de dados específicos ou adicionais para sinais e sintomas mais complexos. \r\n\r\nEste arquétipo foi desenhado especificamennte para ser utilizado no SLOT 'Detalhe estruturado' com o arquétipo OBSERVATION.story, mas pode também ser utilizado com outros arquétipos OBSERVATION ou CLUSTER e nos SLOTS 'Sinal/sintoma associado' ou 'Episódio prévio' em outras instâncias deste arquétipo CLUSTER.symptom_sign.\r\n\r\nClínicos frequentemente registram a frase 'não significante' em sintomas específicos ou sinais relatados como um método eficiente de indicar que eles perguntaram ao indivíduo e foi relatado como não causador de desconforto ou distúrbio - efetivamente é utilizado mais como 'referido como normal' do que uma exclusão explícita. O elemento de dado 'não significante' tem sido incluído deliberadamente neste arquétipo para permitir aos clínicos registrarem esta mesma informação de uma maneira simples e efetiva num sistema clínico. Pode ser utilizado para dirigir uma interface de usuário, por exemplo se 'não significante' é registrado como verdadeiro então os demais elementos de dados podem ser ocultos na tela de entrada de dados. Esta abordagem pragmática dá suporte à maioria dos requerimentos de registros clínicos com relação a sinais e sintomas relatados. \r\n\r\nEntretanto se houver um imperativo clínico para explicitar o registro de que um Sintoma ou Sinal foi reportado como ausente, por exemplo se for utilizado para orientar suporte à decisão clínica, então pode ser preferível usar o arquétipo CLUSTER.exclusion_symptom_sign. O uso de CLUSTER.exclusion_symptom_sign vai aumentar a complexidade da modelagem de template, implementação e pesquisa. É recomendado que o arquétipo CLUSTER.exclusion_symptom_sign apenas seja considerado se um benefício claro for identificado em situações específicas e não deve ser utilizado rotineiramente para o registro de sinais/sintomas.", + "misuse" : "Não deve ser utilizado para registrar que um sintoma ou sinal foi explicitamente relatado como ausente - utilizar CLUSTER.exclusion_symptom_sign cuidadosamente para fins específicos em que os problemas de registro garantam complexidade adicional e apenas se o 'não significante' neste arquétipo não for específico suficiente para fins de registro.\r\n\r\nNão deve ser utilizado para registrar achados objetivos como parte de um exame físico - utilizar OBSERVATION.exam e arquétipos do tipo CLUSTER relacionados a exame para esta finalidade.\r\n\r\nNão dever ser utilizado para diagnósticos e problemas que fazem parte de uma lista de problemas - utilizar EVALUATION.problem_diagnosis.", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "ar-sy" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "ar-sy" + }, + "purpose" : "*To record detail about a symptom - either self-recorded by an individual or recorded on the behalf of a patient by a clinician. A complete patient history may include varying level of details about a variety of symptoms.(en)", + "keywords" : [ ], + "use" : "*Use to record detailed information about a symptom as told to a clinician by a patient or self-recorded by the individual/patient.\r\n\r\nThis archetype allows a 'nil significant' statement to be explicitly recorded.(en)", + "misuse" : "*Not to be used to record details about pain. Use the specialisation of this archetype - the CLUSTER.symptom-pain instead.\r\n\r\nNot to be used for diagnoses and problems that form part of a persisting Problem List - use EVALUATION.problem_diagnosis.(en)", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "en" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "en" + }, + "purpose" : "To record details about a single episode of a reported symptom or sign including context, but not details, of previous episodes if appropriate.", + "keywords" : [ "complaint", "symptom", "disturbance", "problem", "discomfort", "presenting complaint", "presenting symptom", "sign" ], + "use" : "Use to record details about a single episode of a symptom or reported sign in an individual, as reported by the individual, parent, care-giver or other party. It may be recorded by a clinician as part of a clinical history record as reported to them, observed by the clinician or self-recorded as part of a clinical questionnaire or personal health record. A complete clinical history or patient story may include varying level of details about multiple episodes of an identified symptom or reported sign, as well as multiple symptoms/signs.\r\n\r\nIn the purest sense, symptoms are subjective observations of a physical or mental disturbance and signs are objective observations of the same, as experienced by an individual and reported to the history taker by the same individual or another party. From this logic it follows that we will need two archetypes to record clinical history - one for reported symptoms and another for reported signs. In reality this is impractical as it will require clinical data entry into either one of these models which adds signficant overheads to modellers and those entering data. In addition, there is often overlap in clinical concepts - for example, is previous vomiting or bleeding to be categorised as a symptom or reported sign? In response, this archetype has been specifically designed to proved a single information model that allows for recording of the entire continuum between clearly identifable symptoms and reported signs when recording a clinical history.\r\n\r\nThis archetype has been intended to be used as a generic pattern for all symptoms and reported signs. The 'Specific details' SLOT can be used to extend the archetype to include additional, specific data elements for more complex symptoms or signs. \r\n\r\nThis archetype has been specifically designed to be used in the 'Structured detail' SLOT within the OBSERVATION.story archetype, but can also be used within other OBSERVATION or CLUSTER archetypes and in the 'Associated symptom/sign' or 'Previous episode' SLOT within other instances of this CLUSTER.symptom_sign archetype.\r\n\r\nClinicians frequently record the phrase 'nil significant' against specific symptoms or reported signs as an efficient method to indicate that they asked the individual and it was not reported as causing any discomfort or disturbance - effectively used more like a 'normal statement' rather than an explicit exclusion. The 'Nil significant' data element has been deliberately included in this archetype to allow clinicians to record this same information in a simple and effective way in a clinical system. It can be used to drive a user interface, for example if 'Nil significant' is recorded as true then the remaining data elements can be hidden on a data entry screen. This pragmatic approach supports the majority of simple clinical recording requirements around reported symptoms and signs. \r\n\r\nHowever if there is a clinical imperative to explicitly record that a Symptom or Sign was reported as not present, for example if it will be used to drive clinical decision support, then it would be preferable to use the CLUSTER.exclusion_symptom_sign archetype. The use of CLUSTER.exclusion_symptom_sign will increase the complexity of template modelling, implementation and querying. It is recommended that the CLUSTER.exclusion_symptom_sign archetype only be considered for use if clear benefit can be identified in specific situations, but should not be used for routine symptom/sign recording.", + "misuse" : "Not to be used to record that a symptom or sign was explicitly reported as not present - use CLUSTER.exclusion_symptom_sign carefully for specific purposes where the overheads of recording in this way warrant the additional complexity, and only if the 'Nil significant' in this archetype is not specific enough for recording purposes.\r\n\r\nNot to be used for recording objective findings as part of a physical examination - use OBSERVATION.exam and related examination CLUSTER archetypes for this purpose.\r\n\r\nNot to be used for diagnoses and problems that form part of a persisting Problem List - use EVALUATION.problem_diagnosis.", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + } + } + }, + "parentArchetypeId" : "openEHR-EHR-CLUSTER.symptom_sign-cvid.v0", + "differential" : true, + "archetypeId" : { + "@type" : "ARCHETYPE_HRID", + "value" : "openEHR-EHR-CLUSTER.ovl-symptom_sign-cvid-002.v0" + }, + "definition" : { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "CLUSTER", + "nodeId" : "at0000.1.1", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "items", + "children" : [ { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "nodeId" : "at0001.1.1", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "value", + "children" : [ { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "DV_CODED_TEXT", + "occurrences" : "0..1", + "defaultValue" : { + "@type" : "DV_CODED_TEXT", + "value" : "Cough", + "defining_code" : { + "@type" : "CODE_PHRASE", + "terminology_id" : { + "@type" : "TERMINOLOGY_ID", + "value" : "SNOMED-CT" + }, + "code_string" : "49727002" + } + }, + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "defining_code", + "existence" : "0..1", + "children" : [ { + "@type" : "C_TERMINOLOGY_CODE", + "terminologyId" : { + "value" : "SNOMED-CT" + }, + "constraint" : [ ], + "includedExternalTerminologyCodes" : [ { + "terminologyId" : "SNOMED-CT", + "code" : "49727002", + "value" : "Cough" + } ] + } ] + } ], + "attributeTuples" : [ ] + } ] + } ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "occurrences" : "0..0", + "nodeId" : "at0035.0.1", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "value", + "children" : [ { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "DV_BOOLEAN", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "value", + "children" : [ { + "@type" : "C_BOOLEAN", + "rmTypeName" : "Boolean", + "occurrences" : "1..1", + "constraint" : [ true ] + } ] + } ], + "attributeTuples" : [ ] + } ] + } ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "occurrences" : 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"C_COMPLEX_OBJECT", + "rmTypeName" : "DV_QUANTITY", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "property", + "children" : [ { + "@type" : "C_TERMINOLOGY_CODE", + "terminologyId" : { + "value" : "openehr" + }, + "constraint" : [ "380" ] + } ] + } ], + "attributeTuples" : [ { + "@type" : "C_ATTRIBUTE_TUPLE", + "members" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "magnitude", + "children" : [ ] + }, { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "units", + "children" : [ ] + } ], + "tuples" : [ { + "@type" : "C_PRIMITIVE_TUPLE", + "members" : [ { + "@type" : "C_REAL", + "constraint" : [ { + "lower" : 0.0, + "upper" : 10.0, + "lowerIncluded" : true, + "upperIncluded" : true, + "lowerUnbounded" : false, + "upperUnbounded" : false + } ] + }, { + "@type" : "C_STRING", + "constraint" : [ "1" ] + } ] + } ] + } ] + } ] + } ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "occurrences" : "0..0", + "nodeId" : "at0180.0.1", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "value", + "children" : [ { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "DV_CODED_TEXT", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "defining_code", + "children" : [ { + "@type" : "C_TERMINOLOGY_CODE", + "rmTypeName" : "CODE_PHRASE", + "occurrences" : "1..1", + "terminologyId" : { + "value" : "local" + }, + "constraint" : [ "at0183", "at0182", "at0181", "at0184" ] + } ] + } ], + "attributeTuples" : [ ] + } ] + } ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "occurrences" : "0..0", + "nodeId" : "at0003.0.1", + "attributes" : [ ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "CLUSTER", + "occurrences" : "0..0", + "nodeId" : "at0018.0.1", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "items", + "children" : [ { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : 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: "Cough", + "description" : "*Reported observation of a physical or mental disturbance in an individual.(en)" + } + }, + "en" : { + "at0000.1.1" : { + "@type" : "ARCHETYPE_TERM", + "code" : "at0000.1.1", + "text" : "Cough", + "description" : "Symptoms known to be indicators of suspected Covid-19 infection" + } + }, + "de" : { + "at0000.1.1" : { + "@type" : "ARCHETYPE_TERM", + "code" : "at0000.1.1", + "text" : "Cough", + "description" : "Festgestellte Beobachtung einer körperlichen oder geistigen Störung bei einer Person." + } + }, + "nb" : { + "at0000.1.1" : { + "@type" : "ARCHETYPE_TERM", + "code" : "at0000.1.1", + "text" : "Cough", + "description" : "Rapportert observasjon av fysiske tegn eller beskrivelse av unormale eller ubehagelige fornemmelser i kropp og/eller sinn." + } + }, + "fi" : { + "at0000.1.1" : { + "@type" : "ARCHETYPE_TERM", + "code" : "at0000.1.1", + "text" : "Cough", + "description" : "Reported observation of a physical or mental disturbance in an individual.(en)" + 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"ISO_639-1" + }, + "codeString" : "en" + }, + "translations" : [ { + "@type" : "TRANSLATION_DETAILS", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "de" + }, + "author" : { + "name" : "Jasmin Buck, Sebastian Garde, Kim Sommer", + "organisation" : "University of Heidelberg, Central Queensland University, Medizinische Hochschule Hannover" + }, + "otherDetails" : { } + }, { + "@type" : "TRANSLATION_DETAILS", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "fi" + }, + "author" : { + "name" : "Kalle Vuorinen", + "organisation" : "Tieto Healthcare & Welfare Oy", + "email" : "kalle.vuorinen@tieto.com" + }, + "otherDetails" : { } + }, { + "@type" : "TRANSLATION_DETAILS", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "sv" + }, + "author" : { + "name" : "Kirsi Poikela", + "organisation" : "Tieto Sweden AB", + "email" : "ext.kirsi.poikela@tieto.com" + }, + "otherDetails" : { } + }, { + "@type" : "TRANSLATION_DETAILS", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "nb" + }, + "author" : { + "name" : "Lars Bitsch-Larsen", + "organisation" : "Haukeland University Hospital of Bergen, Norway", + "email" : "lbla@helse-bergen.no" + }, + "accreditation" : "MD, DEAA, MBA, spec in anesthesia, spec in tropical medicine.", + "otherDetails" : { } + }, { + "@type" : "TRANSLATION_DETAILS", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "pt-br" + }, + "author" : { + "name" : "Vladimir Pizzo", + "organisation" : "Hospital Sirio Libanes - Brazil", + "email" : "vladimir.pizzo@hsl.org.br" + }, + "otherDetails" : { } + }, { + "@type" : "TRANSLATION_DETAILS", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "ar-sy" + }, + "author" : { + "name" : "Mona Saleh" + }, + "otherDetails" : { } + } ] + }, { + "@type" : "TEMPLATE_OVERLAY", + "uid" : "58414310-36c9-46a8-861f-604330913760", + "description" : { + "@type" : "RESOURCE_DESCRIPTION", + "originalAuthor" : { }, + "otherContributors" : [ ], + "ipAcknowledgements" : { }, + "references" : { }, + "conversionDetails" : { }, + "otherDetails" : { + "PARENT:MD5-CAM-1.0.1" : "D52BB4ECB2B0380CB1C0F3A4FBC6BB5C", + "ip_acknowledgements" : "This artefact includes content from SNOMED Clinical Terms® (SNOMED CT®) which is copyrighted material of the International Health Terminology Standards Development Organisation (IHTSDO). Where an implementation of this artefact makes use of SNOMED CT content, the implementer must have the appropriate SNOMED CT Affiliate license - for more information contact http://www.snomed.org/snomed-ct/get-snomedct or info@snomed.org." + }, + "details" : { + "de" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "de" + }, + "purpose" : "Zur Erfassung von Details über eine einzelne Episode eines berichteten Symptoms/Krankheitsanzeichens. Zusammenhänge zu früheren Episoden (ohne Angabe von Details) sollen, wenn angemessen, ebenfalls aufgeführt werden.", + "keywords" : [ "Beschwerde", "Symptom", "Störung", "Problem", "gegenwärtige Beschwerde", "gegenwärtiges Symptom", "Zeichen", "Anzeichen", "Krankheitsanzeichen" ], + "use" : "Zu Verwenden, um Details über eine einzelne Episode eines Symptoms oder eines berichteten Krankheitsanzeichens einer Person zu dokumentieren, wie es von der Person, dem Elternteil, dem Betreuer oder einer anderen Partei berichtet wurde. Es kann von einem Arzt als Teil einer Krankengeschichte dokumentiert werden, oder wie es dem Arzt berichtet wurde/wie er es beobachtet hat, oder als Teil eines selbst aufgezeichneten klinischen Fragebogens oder einer persönlichen Gesundheitsakte. Eine vollständige Krankengeschichte kann mehrere Episoden eines identifizierten Symptoms/Krankheitsanzeichens, mit variierendem Detaillierungsgrad, sowie mehrere Symptome/Krankheitsanzeichen beinhalten.\r\n\r\nSymptome sind subjektive Beobachtungen einer körperlichen oder geistigen Störung und Krankheitsanzeichen sind objektive Beobachtungen dieser Störung, wie sie von einer Person erlebt und dem Dokumentierenden von derselben Person oder einer anderen Partei berichtet werden. Aus dieser Logik folgt, dass zwei Archetypen benötigt werden, um die Krankengeschichte aufzuzeichnen - einen für berichtete Symptome und einen weiteren für berichtete Krankheitsanzeichen. Für die Praxis ist dies ungeeignet, da es die Eingabe klinischer Daten in eines der beiden Modelle erfordert, was den Modellierern und denen, die die Daten eingeben, erheblichen Mehraufwand verursacht. Darüber hinaus gibt es oft Überschneidungen von klinischen Konzepten - z.B. ist vorangegangenes Erbrechen oder sind Blutungen als Symptom oder berichtetes Krankheitsanzeichen zu kategorisieren? Als Antwort darauf wurde dieser Archetyp speziell entwickelt, um ein einziges Informationsmodell zu erproben, das es ermöglicht, das gesamte Spektrum von klar identifizierbaren Symptomen bis hin zu berichteten Krankheitsanzeichen bei der Dokumentation einer Krankengeschichte zu erfassen.\r\n\r\nDieser Archetyp wurde als generisches Muster für alle Symptome und Krankheitsanzeichen entwickelt. Der Slot \"Spezifische Details\" kann verwendet werden, um den Archetyp um zusätzliche, spezifische Datenelemente für komplexere Symptome oder Krankheitsanzeichen zu erweitern. \r\n\r\nDieser Archetyp wurde speziell für die Verwendung im Slot \"Strukturiertes Detail\" innerhalb des Archetyps OBSERVATION.story entwickelt, kann aber auch in anderen OBSERVATION- oder CLUSTER-Archetypen und in den Slots \"Assoziierte Symptome/Krankheitsanzeichen\" oder \"Vorangegangene Episoden\" in anderen Instanzen dieses CLUSTER.symptom_sign Archetyps verwendet werden.\r\n\r\nÄrzte benutzen häufig den Ausdruck \"nicht signifikant\", um festzuhalten, dass sie eine Person bezüglich des Symptoms/Krankheitsanzeichens befragt haben und es nicht berichtet wurde, dass Unannehmlichkeiten oder Störungen vorliegen - es wird also eher wie eine \"normale Aussage\" als wie ein ausdrücklicher Ausschluss verwendet. Das Datenelement \"Nicht signifikant\" wurde bewusst in diesen Archetyp aufgenommen, um Ärzten zu ermöglichen, dieselben Informationen auf einfache und effektive Weise in einem klinischen System zu dokumentieren. Es kann verwendet werden, um eine Benutzeroberfläche zu steuern, z.B. wenn \"Nicht signifikant\" als wahr dokumentiert wird, dann können die restlichen Datenelemente auf einem Dateneingabebildschirm ausgeblendet werden. Dieser pragmatische Ansatz unterstützt die Mehrheit der einfachen Anforderungen an die klinische Aufzeichnung im Bereich der berichteten Symptome/Krankheitsanzeichen. \r\n\r\nWenn es jedoch klinisch zwingend erforderlich ist, explizit zu erfassen, dass ein Symptom oder Krankheitsanzeichen als nicht vorhanden berichtet wurde, z.B. wenn es zur Unterstützung der klinischen Entscheidung verwendet wird, dann wäre es besser, den Archetyp CLUSTER.exclusion_symptom_sign zu verwenden. Die Verwendung von CLUSTER.exclusion_symptom_sign soll die Komplexität der Template-Modellierung, -Implementierung und -Abfrage erhöhen. Es wird empfohlen, den Archetyp CLUSTER.exclusion_symptom_sign nur dann für die Verwendung in Betracht zu ziehen, wenn in bestimmten Situationen ein klarer Nutzen erkennbar ist, aber nicht für die routinemäßige Aufnahme von Symptomen und Krankheitsanzeichen.", + "misuse" : "Nicht zu verwenden, um zu dokumentieren, dass ein Symptom oder ein Krankheitsanzeichen explizit als nicht vorhanden berichtet wurde - verwenden Sie CLUSTER.exclusion_symptom_sign sorgfältig für bestimmte Zwecke, bei denen der durch die Aufzeichnung entstehende Mehraufwand die zusätzliche Komplexität rechtfertigt, und nur dann, wenn das \"Nicht signifikant\" in diesem Archetyp nicht spezifisch genug für den Zweck der Dokumentation ist.\r\n\r\nNicht zur Erfassung objektiver Befunde im Rahmen einer körperlichen Untersuchung verwenden - verwenden Sie zu diesem Zweck OBSERVATION.exam und verwandte Untersuchung-CLUSTER-Archetypen.\r\n\r\nNicht für Diagnosen und Probleme, die Teil einer bestehenden Problemliste sind, verwenden - verwenden Sie EVALUATION.problem_diagnosis.\r\n", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "fi" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "fi" + }, + "purpose" : "*To record details about a single episode of a reported symptom or sign including context, but not details, of previous episodes if appropriate.(en)", + "keywords" : [ "*complaint(en)", "*symptom(en)", "*disturbance(en)", "*problem(en)", "*discomfort(en)", "*presenting complaint(en)", "*presenting symptom(en)", "*sign(en)" ], + "use" : "*Use to record details about a single episode of a symptom or reported sign in an individual, as reported by the individual, parent, care-giver or other party. It may be recorded by a clinician as part of a clinical history record as reported to them, observed by the clinician or self-recorded as part of a clinical questionnaire or personal health record. A complete clinical history or patient story may include varying level of details about multiple episodes of an identified symptom or reported sign, as well as multiple symptoms/signs.\r\n\r\nIn the purest sense, symptoms are subjective observations of a physical or mental disturbance and signs are objective observations of the same, as experienced by an individual and reported to the history taker by the same individual or another party. From this logic it follows that we will need two archetypes to record clinical history - one for reported symptoms and another for reported signs. In reality this is impractical as it will require clinical data entry into either one of these models which adds signficant overheads to modellers and those entering data. In addition, there is often overlap in clinical concepts - for example, is previous vomiting or bleeding to be categorised as a symptom or reported sign? In response, this archetype has been specifically designed to proved a single information model that allows for recording of the entire continuum between clearly identifable symptoms and reported signs when recording a clinical history.\r\n\r\nThis archetype has been intended to be used as a generic pattern for all symptoms and reported signs. The 'Specific details' SLOT can be used to extend the archetype to include additional, specific data elements for more complex symptoms or signs. \r\n\r\nThis archetype has been specifically designed to be used in the 'Structured detail' SLOT within the OBSERVATION.story archetype, but can also be used within other OBSERVATION or CLUSTER archetypes and in the 'Associated symptom/sign' or 'Previous episode' SLOT within other instances of this CLUSTER.symptom_sign archetype.\r\n\r\nClinicians frequently record the phrase 'nil significant' against specific symptoms or reported signs as an efficient method to indicate that they asked the individual and it was not reported as causing any discomfort or disturbance - effectively used more like a 'normal statement' rather than an explicit exclusion. The 'Nil significant' data element has been deliberately included in this archetype to allow clinicians to record this same information in a simple and effective way in a clinical system. It can be used to drive a user interface, for example if 'Nil significant' is recorded as true then the remaining data elements can be hidden on a data entry screen. This pragmatic approach supports the majority of simple clinical recording requirements around reported symptoms and signs. \r\n\r\nHowever if there is a clinical imperative to explicitly record that a Symptom or Sign was reported as not present, for example if it will be used to drive clinical decision support, then it would be preferable to use the CLUSTER.exclusion_symptom_sign archetype. The use of CLUSTER.exclusion_symptom_sign will increase the complexity of template modelling, implementation and querying. It is recommended that the CLUSTER.exclusion_symptom_sign archetype only be considered for use if clear benefit can be identified in specific situations, but should not be used for routine symptom/sign recording.(en)", + "misuse" : "*Not to be used to record that a symptom or sign was explicitly reported as not present - use CLUSTER.exclusion_symptom_sign carefully for specific purposes where the overheads of recording in this way warrant the additional complexity, and only if the 'Nil significant' in this archetype is not specific enough for recording purposes.\r\n\r\nNot to be used for recording objective findings as part of a physical examination - use OBSERVATION.exam and related examination CLUSTER archetypes for this purpose.\r\n\r\nNot to be used for diagnoses and problems that form part of a persisting Problem List - use EVALUATION.problem_diagnosis.(en)", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "sv" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "sv" + }, + "purpose" : "Att registrera ett uppvisat symtom eller tecken ifrån en enskild episod, inklusive kontext, men inte detaljer om tidigare episoder, om det är tillämpligt.", + "keywords" : [ "besvär", "symtom", "störning", "problem", "obehag", "uppvisar besvär", "uppvisar symtom", "tecken" ], + "use" : "Används för att beskriva detaljer för en individs rapporterade symtom eller tecken ifrån en enskild episod, som rapporterats av personen, föräldern, hälso- o sjukvårdspersonal eller annan part. Det kan registreras av hälso- o sjukvårdspersonal som en del av en anamnes som rapporterats till hälso- o sjukvårdspersonalen, observerad av eller registrerats själv av personen som en del av ett kliniskt frågeformulär eller personligt hälsodokument. En komplett anamnes eller patientjournal kan innehålla varierande detaljnivå från flera episoder av ett identifierat symtom eller rapporterade tecken, såväl som multipla symtom och tecken. \r\n\r\nSymtom är subjektiva observationer från en fysisk eller psykisk störning och tecken är objektiva observationer av densamma, upplevda av en individ och rapporteras till journalföraren av samma individ eller annan part. \r\nUr denna logik följer att vi behöver två arketyper för att registrera klinisk anamnes , en för rapporterade symtom och en annan för rapporterade tecken. I verkligheten är detta opraktiskt eftersom det kommer att kräva tillgång till kliniska data i någon av dessa mallar, vilket innebär signifikant merarbete för mallarna och dem som matar in data. Dessutom finns det ofta överlappningar i kliniska koncept, exempevisl är tidigare kräkningar eller blödningar att kategoriserade som ett symtom eller rapporterat tecken? \r\nSom svar har denna arketyp utformats specifikt för att möjliggöra registrering av en sammanhängande enhet mellan tydligt identifierbara symtom och rapporterade tecken vid registrering av en klinisk anamnes.\r\n\r\nAnvänds som en allmän mall för alla symtom och rapporterade tecken. Fältet \"Specifika detaljer\" kan användas för att utöka arketypen för att inkludera ytterligare, specifika datakomponenter för mer komplexa symtom eller tecken. \r\n\r\nArketypen är speciellt utformad för att användas i fältet \"Detaljstruktur\" i OBSERVATION.story-arketypen, men kan även användas inom andra OBSERVATION- eller CLUSTER-arketyper och i \"Associerade symtom och tecken\" eller i fältet \"Tidigare episod\" inom andra exempel av denna CLUSTER.symptom_sign arketypen. Hälso- o sjukvårdspersonal registrerar ofta uttrycket \"Används inte för att dokumentera ett symtom eller tecken\" som uttryckligen rapporteras som inte förekommande. \r\n\r\nAnvänd CLUSTER.exclusion_symptom_sign med försiktighet för specifika ändamål där merarbetet för registreringarna på detta sätt motiverar extra komplexitet och endast om \"Noll signifikanta\" fältet i denna arketyp inte är tillräckligt specifik för syftet för registreringen. Används inte för att dokumentera ett symtom eller tecken som uttryckligen rapporteras som inte förekommande – använd CLUSTER.exclusion_symptom_sign med försiktighet för specifika ändamål där merarbetet för registreringarna på detta sätt motiverar extra komplexitet och endast om \"Noll signifikanta\" fältet i denna arketyp inte är tillräckligt specifik för syftet för registreringen. För specifika symtom eller rapporterade tecken som en effektiv metod för att indikera att individen tillfrågats och det inte rapporterades som obehag eller störning - används mer effektivt som ett \"normalt utlåtande\" snarare än en uttrycklig uteslutning. Det \"Noll signifikanta\" fältet har medvetet inkluderats i denna arketyp för att kliniker kan registrera samma information på ett enkelt och effektivt sätt i ett kliniskt system. Det kan användas för att driva ett användargränssnitt, exempelvis om \"Noll signifikant\" är registrerad som sann kan de återstående fälten döljas på en dataskärm. Denna pragmatiska metod stöder majoriteten av enkla kliniska registreringskrav kring rapporterade symtom och tecken.\r\n\r\nDäremot om det finns en klinisk nödvändighet att uttryckligen registrera att ett symtom eller tecken rapporterades som inte förekommande, exempelvis om det kommer att användas som ett kliniskt beslutsstöd, föredras CLUSTER.exclusion_symptom_sign arketypen. Användningen av CLUSTER.exclusion_symptom_sign ökar komplexiteten i mallutformningen, implementeringen och utfrågningen. Det rekommenderas att CLUSTER.exclusion_symptom_sign arketypen endast beaktas för användning om tydlig fördel kan identifieras i specifika situationer, men ska inte användas för rutinmässigt symtom och tecken registrering.\r\n\r\n\r\n", + "misuse" : "Ska inte användas för att dokumentera ett symtom eller tecken som uttryckligen rapporteras som inte förekommande. Använd CLUSTER.exclusion_symptom_sign med försiktighet för specifika ändamål där merarbetet för registreringarna på detta sätt motiverar extra komplexitet och endast om \"Noll significant\" fältet i denna arketyp inte är tillräckligt specifik för registreringens syfte.\r\n\r\nSka inte användas för att registrera objektiva fynd som en del av en fysisk undersökning . Använd OBSERVATION.exam och relaterad undersökning CLUSTER-arketyper för detta ändamål.\r\n\r\nSka inte användas för diagnoser och problem som ingår i en kvarstående problemlista. Använd då istället EVALUATION.problem_diagnosis.", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "nb" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "nb" + }, + "purpose" : "For å registrere detaljer om en enkeltepisode av et rapportert symptom eller sykdomstegn. Dette kan omfatte kontekst, men ikke detaljer, om tidligere episoder av symptomet/sykdomstegnet.", + "keywords" : [ "lidelse", "plage", "problem", "ubehag", "symptom", "sykdomstegn", "lyte", "skavank" ], + "use" : "For å registrere detaljer om en enkeltepisode av et rapportert symptom eller sykdomstegn hos et individ, som redegjort av personen selv, foreldre, omsorgsperson eller andre parter. Registrering kan skje i forbindelse med opptak av anamnese, eller som en selvregistrering som en del av et klinisk spørreskjema eller personlig journal. \r\nEn fullstendig klinisk anamnese eller pasientanamnese kan inneholde beskrivelser med ulikt detaljnivå om flere episoder knyttet til samme symptom eller sykdomstegn, og vil også kunne inneholde flere ulike symptomer eller sykdomstegn.\r\n\r\nI egentlig forstand er symptomer subjektive opplevelser av en fysisk eller mental forstyrrelse mens sykdomstegn er objektive observasjoner av det samme, som er erfart av et individ og rapportert til en kliniker av individet eller av andre. Fra denne logikken følger at det burde være to arketyper til å registrere klinisk anamnese; en for rapporterte symptomer og en for rapporterte sykdomstegn. I virkeligheten er dette upraktisk og vil kreve registrering av kliniske data i enten den ene eller den andre av disse modellene. I praksis vil dette øke kompleksitet og tidsbruk knyttet til modellering og registrering av data. I tillegg overlapper ofte de kliniske konseptene, for eksempel: Vil tidligere oppkast eller blødning kategoriseres som et symptom eller som et rapportert sykdomstegn?\r\nSom svar på dette er arketypen laget for å tillate registrering av hele kontinuumet mellom tydelig definerte symptomer og rapporterte sykdomstegn når en registrerer en klinisk anamnese.\r\n\r\nArketypen er designet for å gi et generisk rammeverk for alle symptomer og rapporterte sykdomstegn. SLOTet \"Spesifikke detaljer\" kan brukes for å utvide arketypen med ytterligere spesifikke dataelementer for komplekse symptomer eller sykdomstegn.\r\n\r\nArketypen skal settes inn i \"Detaljer\"-SLOTet i OBSERVATION.story-arketypen men kan også brukes i en hvilken som helst OBSERVATION eller CLUSTER-arketype. Arketypen kan også gjenbrukes i andre instanser av CLUSTER.symptom_sign-arketypen i SLOTene \"Assosierte symptomer\" eller \"Tidligere detaljer\".\r\n\r\nKlinikere registrerer ofte frasen \"Ikke av betydning\" i forbindelse med spesifikke symptomer eller rapporterte tegn for å indikere at det er eksplisitt spurt om det spesifikke symptomet, og at det ble svart at symptomet ikke er tilstede i en slik grad at det påfører pasienten ubehag eller uro. Frasen brukes mer som en normalbeskrivelse enn en eksplisitt eksklusjon. Dataelementet \"Ikke av betydning\" er med hensikt lagt til for å tillate at klinikere enkelt og effektivt kan registrere denne informasjonen i det kliniske systemet. Eksempelvis kan \"Ikke av betydning\" brukes i brukergrensesnittet, er dette registrert som \"Sann\" kan de resterende dataelementene skjules i brukergrensesnittet. Denne pragmatiske tilnærmingen støtter hoveddelen av enkel klinisk journalføring av symptomer og sykdomstegn. \r\n\r\nImidlertid kan det være fordelaktig å bruke arketypen CLUSTER.exclusion_symptom_sign dersom det er klinisk behov for å eksplisitt registrere at et symptom eller sykdomstegn ikke er tilstede, for eksempel dersom dette skal brukes til klinisk beslutningsstøtte. Bruk av CLUSTER.exclusion_symptom_sign vil øke kompleksiteten i templatmodellering, implementasjon og spørring. Det anbefales at CLUSTER.exclusion_symptom_sign kun vurderes brukt dersom man kan identifisere en klar gevinst, men bør ikke brukes for rutineregistreringer av symptomer eller sykdomstegn.", + "misuse" : "Brukes ikke til eksplisitt registrering av at et symptom eller sykdomstegn ikke er tilstede. Bruk CLUSTER.exclusion_symptom_sign varsomt da det øker tidsbruk ved registrering og tilfører økt kompleksitet, og bare når dataelementet \"Ikke av betydning\" i denne arketypen ikke er eksplisitt nok for registreringen.\r\n\r\nBrukes ikke til registrering av objektive funn som en del av en fysisk undersøkelse. Bruk OBSERVATION.exam og relaterte CLUSTER.exam-arketyper for dette formålet. \r\n\r\nBrukes ikke til registrering av problemer og diagnoser som en del av en persistent problemliste, til dette brukes EVALUATION.problem_diagnosis.\r\n\r\nBrukes ikke til å dokumentere tiltak og resultat i løpet av hele perioden individet er under behandling, da arketypen er beregnet til å dokumentere symptomer og sykdomstegn som et øyeblikksbilde.", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "pt-br" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "pt-br" + }, + "purpose" : "Registrar detalhes sobre um episódio único de um sinal ou sintoma relatado incluindo contexto, mas não detalhes, de episódios prévios se apropriado.", + "keywords" : [ "queixa", "sintoma", "distúrbio", "problema", "desconforto", "queixa atual", "sintoma atual", "sinal" ], + "use" : "Usar para relatar detalhes sobre um episódio único de um sintoma ou sinal reportado em um indivíduo, como reportado pelo indivíduo, parente, cuidador ou outra arte. Deve ser registrado por um clínico como parte de um relato de história clínica como reportado por eles, observado pelo clínico ou registrado pelo próprio como parte de um questionário ou relato pessoal de saúde. Uma história clínica completa ou história pessoal deve conter - com variáveis níves de detalhes - múltiplos episódios de um sinal ou sintoma identificado ou reportado assim como múltiplos sinais/sintomas. \r\n\r\nNo sentido mais puro, sintomas são observações subjetivas de um distúrbio físico ou mental e sinais são observações objetivas dos mesmos, como experimentado por um indivíduo e reportado para o tomador da história pelo mesmo indivíduo ou outra parte. Por esta lógica segue que serão necessários dois arquétipos para registrar a história clínica - um para sintomas e outro para sinais relatados. Na realidade isto é pouco prático pois vai requerer entrada de dados clínicos em cada um destes modelos o que acrescenta problemas significantes aos modeladores e aqueles que coletam o dado. Em adição, frequentemente há uma interposição entre os conceitos clínicos - por exemplo: vômitos ou sangramentos prévios devem ser considerados sintomas ou sinais reportados? Em resposta, este arquétipo foi especificamente desenhado para prover um modelo de informação único que permita o registro de todo o continuum entre sintomas claramente identificáveis e sinais reportados quando do reistro de uma história clínica. \r\n\r\nEste arquétipo pretende ser utilizado como um padrão genérico para todos os sintomas e sinais reportados. O SLOT 'Detalhes específicos' pode ser utilizado para estender o arquétipo e incluir elementos de dados específicos ou adicionais para sinais e sintomas mais complexos. \r\n\r\nEste arquétipo foi desenhado especificamennte para ser utilizado no SLOT 'Detalhe estruturado' com o arquétipo OBSERVATION.story, mas pode também ser utilizado com outros arquétipos OBSERVATION ou CLUSTER e nos SLOTS 'Sinal/sintoma associado' ou 'Episódio prévio' em outras instâncias deste arquétipo CLUSTER.symptom_sign.\r\n\r\nClínicos frequentemente registram a frase 'não significante' em sintomas específicos ou sinais relatados como um método eficiente de indicar que eles perguntaram ao indivíduo e foi relatado como não causador de desconforto ou distúrbio - efetivamente é utilizado mais como 'referido como normal' do que uma exclusão explícita. O elemento de dado 'não significante' tem sido incluído deliberadamente neste arquétipo para permitir aos clínicos registrarem esta mesma informação de uma maneira simples e efetiva num sistema clínico. Pode ser utilizado para dirigir uma interface de usuário, por exemplo se 'não significante' é registrado como verdadeiro então os demais elementos de dados podem ser ocultos na tela de entrada de dados. Esta abordagem pragmática dá suporte à maioria dos requerimentos de registros clínicos com relação a sinais e sintomas relatados. \r\n\r\nEntretanto se houver um imperativo clínico para explicitar o registro de que um Sintoma ou Sinal foi reportado como ausente, por exemplo se for utilizado para orientar suporte à decisão clínica, então pode ser preferível usar o arquétipo CLUSTER.exclusion_symptom_sign. O uso de CLUSTER.exclusion_symptom_sign vai aumentar a complexidade da modelagem de template, implementação e pesquisa. É recomendado que o arquétipo CLUSTER.exclusion_symptom_sign apenas seja considerado se um benefício claro for identificado em situações específicas e não deve ser utilizado rotineiramente para o registro de sinais/sintomas.", + "misuse" : "Não deve ser utilizado para registrar que um sintoma ou sinal foi explicitamente relatado como ausente - utilizar CLUSTER.exclusion_symptom_sign cuidadosamente para fins específicos em que os problemas de registro garantam complexidade adicional e apenas se o 'não significante' neste arquétipo não for específico suficiente para fins de registro.\r\n\r\nNão deve ser utilizado para registrar achados objetivos como parte de um exame físico - utilizar OBSERVATION.exam e arquétipos do tipo CLUSTER relacionados a exame para esta finalidade.\r\n\r\nNão dever ser utilizado para diagnósticos e problemas que fazem parte de uma lista de problemas - utilizar EVALUATION.problem_diagnosis.", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "ar-sy" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "ar-sy" + }, + "purpose" : "*To record detail about a symptom - either self-recorded by an individual or recorded on the behalf of a patient by a clinician. A complete patient history may include varying level of details about a variety of symptoms.(en)", + "keywords" : [ ], + "use" : "*Use to record detailed information about a symptom as told to a clinician by a patient or self-recorded by the individual/patient.\r\n\r\nThis archetype allows a 'nil significant' statement to be explicitly recorded.(en)", + "misuse" : "*Not to be used to record details about pain. Use the specialisation of this archetype - the CLUSTER.symptom-pain instead.\r\n\r\nNot to be used for diagnoses and problems that form part of a persisting Problem List - use EVALUATION.problem_diagnosis.(en)", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "en" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "en" + }, + "purpose" : "To record details about a single episode of a reported symptom or sign including context, but not details, of previous episodes if appropriate.", + "keywords" : [ "complaint", "symptom", "disturbance", "problem", "discomfort", "presenting complaint", "presenting symptom", "sign" ], + "use" : "Use to record details about a single episode of a symptom or reported sign in an individual, as reported by the individual, parent, care-giver or other party. It may be recorded by a clinician as part of a clinical history record as reported to them, observed by the clinician or self-recorded as part of a clinical questionnaire or personal health record. A complete clinical history or patient story may include varying level of details about multiple episodes of an identified symptom or reported sign, as well as multiple symptoms/signs.\r\n\r\nIn the purest sense, symptoms are subjective observations of a physical or mental disturbance and signs are objective observations of the same, as experienced by an individual and reported to the history taker by the same individual or another party. From this logic it follows that we will need two archetypes to record clinical history - one for reported symptoms and another for reported signs. In reality this is impractical as it will require clinical data entry into either one of these models which adds signficant overheads to modellers and those entering data. In addition, there is often overlap in clinical concepts - for example, is previous vomiting or bleeding to be categorised as a symptom or reported sign? In response, this archetype has been specifically designed to proved a single information model that allows for recording of the entire continuum between clearly identifable symptoms and reported signs when recording a clinical history.\r\n\r\nThis archetype has been intended to be used as a generic pattern for all symptoms and reported signs. The 'Specific details' SLOT can be used to extend the archetype to include additional, specific data elements for more complex symptoms or signs. \r\n\r\nThis archetype has been specifically designed to be used in the 'Structured detail' SLOT within the OBSERVATION.story archetype, but can also be used within other OBSERVATION or CLUSTER archetypes and in the 'Associated symptom/sign' or 'Previous episode' SLOT within other instances of this CLUSTER.symptom_sign archetype.\r\n\r\nClinicians frequently record the phrase 'nil significant' against specific symptoms or reported signs as an efficient method to indicate that they asked the individual and it was not reported as causing any discomfort or disturbance - effectively used more like a 'normal statement' rather than an explicit exclusion. The 'Nil significant' data element has been deliberately included in this archetype to allow clinicians to record this same information in a simple and effective way in a clinical system. It can be used to drive a user interface, for example if 'Nil significant' is recorded as true then the remaining data elements can be hidden on a data entry screen. This pragmatic approach supports the majority of simple clinical recording requirements around reported symptoms and signs. \r\n\r\nHowever if there is a clinical imperative to explicitly record that a Symptom or Sign was reported as not present, for example if it will be used to drive clinical decision support, then it would be preferable to use the CLUSTER.exclusion_symptom_sign archetype. The use of CLUSTER.exclusion_symptom_sign will increase the complexity of template modelling, implementation and querying. It is recommended that the CLUSTER.exclusion_symptom_sign archetype only be considered for use if clear benefit can be identified in specific situations, but should not be used for routine symptom/sign recording.", + "misuse" : "Not to be used to record that a symptom or sign was explicitly reported as not present - use CLUSTER.exclusion_symptom_sign carefully for specific purposes where the overheads of recording in this way warrant the additional complexity, and only if the 'Nil significant' in this archetype is not specific enough for recording purposes.\r\n\r\nNot to be used for recording objective findings as part of a physical examination - use OBSERVATION.exam and related examination CLUSTER archetypes for this purpose.\r\n\r\nNot to be used for diagnoses and problems that form part of a persisting Problem List - use EVALUATION.problem_diagnosis.", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + } + } + }, + "parentArchetypeId" : "openEHR-EHR-CLUSTER.symptom_sign-cvid.v0", + "differential" : true, + "archetypeId" : { + "@type" : "ARCHETYPE_HRID", + "value" : "openEHR-EHR-CLUSTER.ovl-symptom_sign-cvid-003.v0" + }, + "definition" : { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "CLUSTER", + "nodeId" : "at0000.1.1", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "items", + "children" : [ { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "nodeId" : "at0001.1.1", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "value", + "children" : [ { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "DV_CODED_TEXT", + "occurrences" : "0..1", + "defaultValue" : { + "@type" : "DV_CODED_TEXT", + "value" : "Fever", + "defining_code" : { + "@type" : "CODE_PHRASE", + "terminology_id" : { + "@type" : "TERMINOLOGY_ID", + "value" : "SNOMED-CT" + }, + "code_string" : "386661006" + } + }, + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "defining_code", + "existence" : "0..1", + "children" : [ { + "@type" : "C_TERMINOLOGY_CODE", + "terminologyId" : { + "value" : "SNOMED-CT" + }, + "constraint" : [ ], + "includedExternalTerminologyCodes" : [ { + "terminologyId" : "SNOMED-CT", + "code" : "386661006", + "value" : "Fever" + } ] + } ] + } ], + "attributeTuples" : [ ] + } ] + } ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "occurrences" : "0..0", + "nodeId" : "at0035.0.1", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "value", + "children" : [ { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "DV_BOOLEAN", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "value", + "children" : [ { + "@type" : "C_BOOLEAN", + "rmTypeName" : "Boolean", + "occurrences" : "1..1", + "constraint" : [ true ] + } ] + } ], + "attributeTuples" : [ ] + } ] + } ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "occurrences" : "0..0", + "nodeId" : "at0002.0.1", + "attributes" : [ ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "occurrences" : "0..0", + "nodeId" : "at0151.0.1", + "attributes" : [ ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "occurrences" : "0..0", + "nodeId" : "at0175.0.1", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "value", + "children" : [ { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "DV_CODED_TEXT", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "defining_code", + "children" : [ { + "@type" : "C_TERMINOLOGY_CODE", + "rmTypeName" : "CODE_PHRASE", + "occurrences" : "1..1", + "terminologyId" : { + "value" : "local" + }, + "constraint" : [ "at0176", "at0178", "at0177" ] + } ] + } ], + "attributeTuples" : [ ] + } ] + } ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "occurrences" : "0..0", + "nodeId" : "at0186.0.1", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "value", + "children" : [ { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "DV_BOOLEAN", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "value", + "children" : [ { + "@type" : "C_BOOLEAN", + "rmTypeName" : "Boolean", + "occurrences" : "1..1", + "constraint" : [ true ] + } ] + } ], + "attributeTuples" : [ ] + } ] + } ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "occurrences" : "0..0", + "nodeId" : "at0152.0.1", + "attributes" : [ ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "occurrences" : "0..0", + "nodeId" : "at0164.0.1", + "attributes" : [ ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "occurrences" : "0..0", + "nodeId" : "at0028.0.1", + "attributes" : [ ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "occurrences" : "0..0", + "nodeId" : "at0021.0.1", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "value", + "children" : [ { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "DV_CODED_TEXT", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "defining_code", + "children" : [ { + "@type" : "C_TERMINOLOGY_CODE", + "rmTypeName" : "CODE_PHRASE", + "occurrences" : "1..1", + "terminologyId" : { + "value" : "local" + }, + "constraint" : [ "at0023", "at0024", "at0025" ] + } ] + } ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "DV_TEXT", + "attributes" : [ ], + "attributeTuples" : [ ] + } ] + } ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "occurrences" : "0..0", + "nodeId" : "at0026.0.1", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "value", + "children" : [ { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "DV_QUANTITY", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "property", + "children" : [ { + "@type" : "C_TERMINOLOGY_CODE", + "terminologyId" : { + "value" : "openehr" + }, + "constraint" : [ "380" ] + } ] + } ], + "attributeTuples" : [ { + "@type" : "C_ATTRIBUTE_TUPLE", + "members" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "magnitude", + "children" : [ ] + }, { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "units", + "children" : [ ] + } ], + "tuples" : [ { + "@type" : "C_PRIMITIVE_TUPLE", + "members" : [ { + "@type" : "C_REAL", + "constraint" : [ { + "lower" : 0.0, + "upper" : 10.0, + "lowerIncluded" : true, + "upperIncluded" : true, + "lowerUnbounded" : false, + "upperUnbounded" : false + } ] + }, { + "@type" : "C_STRING", + "constraint" : [ "1" ] + } ] + } ] + } ] + } ] + } ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "occurrences" : "0..0", + "nodeId" : "at0180.0.1", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "value", + "children" : [ { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "DV_CODED_TEXT", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "defining_code", + "children" : [ { + "@type" : "C_TERMINOLOGY_CODE", + "rmTypeName" : "CODE_PHRASE", + "occurrences" : "1..1", + "terminologyId" : { + "value" : "local" + }, + "constraint" : [ "at0183", "at0182", "at0181", "at0184" ] + } ] + } ], + "attributeTuples" : [ ] + } ] + } ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "occurrences" : "0..0", + "nodeId" : "at0003.0.1", + "attributes" : [ ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "CLUSTER", + "occurrences" : "0..0", + "nodeId" : "at0018.0.1", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "items", + "children" : [ { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : 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: "Fever", + "description" : "*Reported observation of a physical or mental disturbance in an individual.(en)" + } + }, + "en" : { + "at0000.1.1" : { + "@type" : "ARCHETYPE_TERM", + "code" : "at0000.1.1", + "text" : "Fever", + "description" : "Symptoms known to be indicators of suspected Covid-19 infection" + } + }, + "de" : { + "at0000.1.1" : { + "@type" : "ARCHETYPE_TERM", + "code" : "at0000.1.1", + "text" : "Fever", + "description" : "Festgestellte Beobachtung einer körperlichen oder geistigen Störung bei einer Person." + } + }, + "nb" : { + "at0000.1.1" : { + "@type" : "ARCHETYPE_TERM", + "code" : "at0000.1.1", + "text" : "Fever", + "description" : "Rapportert observasjon av fysiske tegn eller beskrivelse av unormale eller ubehagelige fornemmelser i kropp og/eller sinn." + } + }, + "fi" : { + "at0000.1.1" : { + "@type" : "ARCHETYPE_TERM", + "code" : "at0000.1.1", + "text" : "Fever", + "description" : "Reported observation of a physical or mental disturbance in an individual.(en)" + } + }, + "sv" : { + "at0000.1.1" : { + "@type" : "ARCHETYPE_TERM", + "code" : "at0000.1.1", + "text" : "Fever", + "description" : "Rapporterad observation av en fysisk eller psykisk störning hos en individ." + } + }, + "pt-br" : { + "at0000.1.1" : { + "@type" : "ARCHETYPE_TERM", + "code" : "at0000.1.1", + "text" : "Fever", + "description" : "Observação de um distúrbio físico ou mental relatada em um indivíduo." + } + } + }, + "termBindings" : { + "SNOMED-CT" : { + "at0001.1.1" : "term:SNOMED-CT::418799008", + "at0002.0.1" : "term:SNOMED-CT::162408000", + "at0028.0.1" : "term:SNOMED-CT::162442009", + "at0021.0.1" : "term:SNOMED-CT::162465004", + "at0001" : "term:SNOMED-CT::418799008" + } + }, + "terminologyExtracts" : { }, + "valueSets" : { } + }, + "adlVersion" : "1.4", + "buildUid" : "91cfb84d-f6d5-4240-8de6-234c0581f543", + "rmName" : "openehr", + "rmRelease" : "1.0.3", + "generated" : true, + "otherMetaData" : { }, + "originalLanguage" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "en" + }, + "translations" : [ { + "@type" : "TRANSLATION_DETAILS", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "de" + }, + "author" : { + "name" : "Jasmin Buck, Sebastian Garde, Kim Sommer", + "organisation" : "University of Heidelberg, Central Queensland University, Medizinische Hochschule Hannover" + }, + "otherDetails" : { } + }, { + "@type" : "TRANSLATION_DETAILS", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "fi" + }, + "author" : { + "name" : "Kalle Vuorinen", + "organisation" : "Tieto Healthcare & Welfare Oy", + "email" : "kalle.vuorinen@tieto.com" + }, + "otherDetails" : { } + }, { + "@type" : "TRANSLATION_DETAILS", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "sv" + }, + "author" : { + "name" : "Kirsi Poikela", + "organisation" : "Tieto Sweden AB", + "email" : "ext.kirsi.poikela@tieto.com" + }, + "otherDetails" : { } + }, { + "@type" : "TRANSLATION_DETAILS", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "nb" + }, + "author" : { + "name" : "Lars Bitsch-Larsen", + "organisation" : "Haukeland University Hospital of Bergen, Norway", + "email" : "lbla@helse-bergen.no" + }, + "accreditation" : "MD, DEAA, MBA, spec in anesthesia, spec in tropical medicine.", + "otherDetails" : { } + }, { + "@type" : "TRANSLATION_DETAILS", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "pt-br" + }, + "author" : { + "name" : "Vladimir Pizzo", + "organisation" : "Hospital Sirio Libanes - Brazil", + "email" : "vladimir.pizzo@hsl.org.br" + }, + "otherDetails" : { } + }, { + "@type" : "TRANSLATION_DETAILS", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "ar-sy" + }, + "author" : { + "name" : "Mona Saleh" + }, + "otherDetails" : { } + } ] + }, { + "@type" : "TEMPLATE_OVERLAY", + "uid" : "58414310-36c9-46a8-861f-604330913760", + "description" : { + "@type" : "RESOURCE_DESCRIPTION", + "originalAuthor" : { }, + "otherContributors" : [ ], + "ipAcknowledgements" : { }, + "references" : { }, + "conversionDetails" : { }, + "otherDetails" : { + "PARENT:MD5-CAM-1.0.1" : "D52BB4ECB2B0380CB1C0F3A4FBC6BB5C", + "ip_acknowledgements" : "This artefact includes content from SNOMED Clinical Terms® (SNOMED CT®) which is copyrighted material of the International Health Terminology Standards Development Organisation (IHTSDO). Where an implementation of this artefact makes use of SNOMED CT content, the implementer must have the appropriate SNOMED CT Affiliate license - for more information contact http://www.snomed.org/snomed-ct/get-snomedct or info@snomed.org." + }, + "details" : { + "de" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "de" + }, + "purpose" : "Zur Erfassung von Details über eine einzelne Episode eines berichteten Symptoms/Krankheitsanzeichens. Zusammenhänge zu früheren Episoden (ohne Angabe von Details) sollen, wenn angemessen, ebenfalls aufgeführt werden.", + "keywords" : [ "Beschwerde", "Symptom", "Störung", "Problem", "gegenwärtige Beschwerde", "gegenwärtiges Symptom", "Zeichen", "Anzeichen", "Krankheitsanzeichen" ], + "use" : "Zu Verwenden, um Details über eine einzelne Episode eines Symptoms oder eines berichteten Krankheitsanzeichens einer Person zu dokumentieren, wie es von der Person, dem Elternteil, dem Betreuer oder einer anderen Partei berichtet wurde. Es kann von einem Arzt als Teil einer Krankengeschichte dokumentiert werden, oder wie es dem Arzt berichtet wurde/wie er es beobachtet hat, oder als Teil eines selbst aufgezeichneten klinischen Fragebogens oder einer persönlichen Gesundheitsakte. Eine vollständige Krankengeschichte kann mehrere Episoden eines identifizierten Symptoms/Krankheitsanzeichens, mit variierendem Detaillierungsgrad, sowie mehrere Symptome/Krankheitsanzeichen beinhalten.\r\n\r\nSymptome sind subjektive Beobachtungen einer körperlichen oder geistigen Störung und Krankheitsanzeichen sind objektive Beobachtungen dieser Störung, wie sie von einer Person erlebt und dem Dokumentierenden von derselben Person oder einer anderen Partei berichtet werden. Aus dieser Logik folgt, dass zwei Archetypen benötigt werden, um die Krankengeschichte aufzuzeichnen - einen für berichtete Symptome und einen weiteren für berichtete Krankheitsanzeichen. Für die Praxis ist dies ungeeignet, da es die Eingabe klinischer Daten in eines der beiden Modelle erfordert, was den Modellierern und denen, die die Daten eingeben, erheblichen Mehraufwand verursacht. Darüber hinaus gibt es oft Überschneidungen von klinischen Konzepten - z.B. ist vorangegangenes Erbrechen oder sind Blutungen als Symptom oder berichtetes Krankheitsanzeichen zu kategorisieren? Als Antwort darauf wurde dieser Archetyp speziell entwickelt, um ein einziges Informationsmodell zu erproben, das es ermöglicht, das gesamte Spektrum von klar identifizierbaren Symptomen bis hin zu berichteten Krankheitsanzeichen bei der Dokumentation einer Krankengeschichte zu erfassen.\r\n\r\nDieser Archetyp wurde als generisches Muster für alle Symptome und Krankheitsanzeichen entwickelt. Der Slot \"Spezifische Details\" kann verwendet werden, um den Archetyp um zusätzliche, spezifische Datenelemente für komplexere Symptome oder Krankheitsanzeichen zu erweitern. \r\n\r\nDieser Archetyp wurde speziell für die Verwendung im Slot \"Strukturiertes Detail\" innerhalb des Archetyps OBSERVATION.story entwickelt, kann aber auch in anderen OBSERVATION- oder CLUSTER-Archetypen und in den Slots \"Assoziierte Symptome/Krankheitsanzeichen\" oder \"Vorangegangene Episoden\" in anderen Instanzen dieses CLUSTER.symptom_sign Archetyps verwendet werden.\r\n\r\nÄrzte benutzen häufig den Ausdruck \"nicht signifikant\", um festzuhalten, dass sie eine Person bezüglich des Symptoms/Krankheitsanzeichens befragt haben und es nicht berichtet wurde, dass Unannehmlichkeiten oder Störungen vorliegen - es wird also eher wie eine \"normale Aussage\" als wie ein ausdrücklicher Ausschluss verwendet. Das Datenelement \"Nicht signifikant\" wurde bewusst in diesen Archetyp aufgenommen, um Ärzten zu ermöglichen, dieselben Informationen auf einfache und effektive Weise in einem klinischen System zu dokumentieren. Es kann verwendet werden, um eine Benutzeroberfläche zu steuern, z.B. wenn \"Nicht signifikant\" als wahr dokumentiert wird, dann können die restlichen Datenelemente auf einem Dateneingabebildschirm ausgeblendet werden. Dieser pragmatische Ansatz unterstützt die Mehrheit der einfachen Anforderungen an die klinische Aufzeichnung im Bereich der berichteten Symptome/Krankheitsanzeichen. \r\n\r\nWenn es jedoch klinisch zwingend erforderlich ist, explizit zu erfassen, dass ein Symptom oder Krankheitsanzeichen als nicht vorhanden berichtet wurde, z.B. wenn es zur Unterstützung der klinischen Entscheidung verwendet wird, dann wäre es besser, den Archetyp CLUSTER.exclusion_symptom_sign zu verwenden. Die Verwendung von CLUSTER.exclusion_symptom_sign soll die Komplexität der Template-Modellierung, -Implementierung und -Abfrage erhöhen. Es wird empfohlen, den Archetyp CLUSTER.exclusion_symptom_sign nur dann für die Verwendung in Betracht zu ziehen, wenn in bestimmten Situationen ein klarer Nutzen erkennbar ist, aber nicht für die routinemäßige Aufnahme von Symptomen und Krankheitsanzeichen.", + "misuse" : "Nicht zu verwenden, um zu dokumentieren, dass ein Symptom oder ein Krankheitsanzeichen explizit als nicht vorhanden berichtet wurde - verwenden Sie CLUSTER.exclusion_symptom_sign sorgfältig für bestimmte Zwecke, bei denen der durch die Aufzeichnung entstehende Mehraufwand die zusätzliche Komplexität rechtfertigt, und nur dann, wenn das \"Nicht signifikant\" in diesem Archetyp nicht spezifisch genug für den Zweck der Dokumentation ist.\r\n\r\nNicht zur Erfassung objektiver Befunde im Rahmen einer körperlichen Untersuchung verwenden - verwenden Sie zu diesem Zweck OBSERVATION.exam und verwandte Untersuchung-CLUSTER-Archetypen.\r\n\r\nNicht für Diagnosen und Probleme, die Teil einer bestehenden Problemliste sind, verwenden - verwenden Sie EVALUATION.problem_diagnosis.\r\n", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "fi" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "fi" + }, + "purpose" : "*To record details about a single episode of a reported symptom or sign including context, but not details, of previous episodes if appropriate.(en)", + "keywords" : [ "*complaint(en)", "*symptom(en)", "*disturbance(en)", "*problem(en)", "*discomfort(en)", "*presenting complaint(en)", "*presenting symptom(en)", "*sign(en)" ], + "use" : "*Use to record details about a single episode of a symptom or reported sign in an individual, as reported by the individual, parent, care-giver or other party. It may be recorded by a clinician as part of a clinical history record as reported to them, observed by the clinician or self-recorded as part of a clinical questionnaire or personal health record. A complete clinical history or patient story may include varying level of details about multiple episodes of an identified symptom or reported sign, as well as multiple symptoms/signs.\r\n\r\nIn the purest sense, symptoms are subjective observations of a physical or mental disturbance and signs are objective observations of the same, as experienced by an individual and reported to the history taker by the same individual or another party. From this logic it follows that we will need two archetypes to record clinical history - one for reported symptoms and another for reported signs. In reality this is impractical as it will require clinical data entry into either one of these models which adds signficant overheads to modellers and those entering data. In addition, there is often overlap in clinical concepts - for example, is previous vomiting or bleeding to be categorised as a symptom or reported sign? In response, this archetype has been specifically designed to proved a single information model that allows for recording of the entire continuum between clearly identifable symptoms and reported signs when recording a clinical history.\r\n\r\nThis archetype has been intended to be used as a generic pattern for all symptoms and reported signs. The 'Specific details' SLOT can be used to extend the archetype to include additional, specific data elements for more complex symptoms or signs. \r\n\r\nThis archetype has been specifically designed to be used in the 'Structured detail' SLOT within the OBSERVATION.story archetype, but can also be used within other OBSERVATION or CLUSTER archetypes and in the 'Associated symptom/sign' or 'Previous episode' SLOT within other instances of this CLUSTER.symptom_sign archetype.\r\n\r\nClinicians frequently record the phrase 'nil significant' against specific symptoms or reported signs as an efficient method to indicate that they asked the individual and it was not reported as causing any discomfort or disturbance - effectively used more like a 'normal statement' rather than an explicit exclusion. The 'Nil significant' data element has been deliberately included in this archetype to allow clinicians to record this same information in a simple and effective way in a clinical system. It can be used to drive a user interface, for example if 'Nil significant' is recorded as true then the remaining data elements can be hidden on a data entry screen. This pragmatic approach supports the majority of simple clinical recording requirements around reported symptoms and signs. \r\n\r\nHowever if there is a clinical imperative to explicitly record that a Symptom or Sign was reported as not present, for example if it will be used to drive clinical decision support, then it would be preferable to use the CLUSTER.exclusion_symptom_sign archetype. The use of CLUSTER.exclusion_symptom_sign will increase the complexity of template modelling, implementation and querying. It is recommended that the CLUSTER.exclusion_symptom_sign archetype only be considered for use if clear benefit can be identified in specific situations, but should not be used for routine symptom/sign recording.(en)", + "misuse" : "*Not to be used to record that a symptom or sign was explicitly reported as not present - use CLUSTER.exclusion_symptom_sign carefully for specific purposes where the overheads of recording in this way warrant the additional complexity, and only if the 'Nil significant' in this archetype is not specific enough for recording purposes.\r\n\r\nNot to be used for recording objective findings as part of a physical examination - use OBSERVATION.exam and related examination CLUSTER archetypes for this purpose.\r\n\r\nNot to be used for diagnoses and problems that form part of a persisting Problem List - use EVALUATION.problem_diagnosis.(en)", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "sv" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "sv" + }, + "purpose" : "Att registrera ett uppvisat symtom eller tecken ifrån en enskild episod, inklusive kontext, men inte detaljer om tidigare episoder, om det är tillämpligt.", + "keywords" : [ "besvär", "symtom", "störning", "problem", "obehag", "uppvisar besvär", "uppvisar symtom", "tecken" ], + "use" : "Används för att beskriva detaljer för en individs rapporterade symtom eller tecken ifrån en enskild episod, som rapporterats av personen, föräldern, hälso- o sjukvårdspersonal eller annan part. Det kan registreras av hälso- o sjukvårdspersonal som en del av en anamnes som rapporterats till hälso- o sjukvårdspersonalen, observerad av eller registrerats själv av personen som en del av ett kliniskt frågeformulär eller personligt hälsodokument. En komplett anamnes eller patientjournal kan innehålla varierande detaljnivå från flera episoder av ett identifierat symtom eller rapporterade tecken, såväl som multipla symtom och tecken. \r\n\r\nSymtom är subjektiva observationer från en fysisk eller psykisk störning och tecken är objektiva observationer av densamma, upplevda av en individ och rapporteras till journalföraren av samma individ eller annan part. \r\nUr denna logik följer att vi behöver två arketyper för att registrera klinisk anamnes , en för rapporterade symtom och en annan för rapporterade tecken. I verkligheten är detta opraktiskt eftersom det kommer att kräva tillgång till kliniska data i någon av dessa mallar, vilket innebär signifikant merarbete för mallarna och dem som matar in data. Dessutom finns det ofta överlappningar i kliniska koncept, exempevisl är tidigare kräkningar eller blödningar att kategoriserade som ett symtom eller rapporterat tecken? \r\nSom svar har denna arketyp utformats specifikt för att möjliggöra registrering av en sammanhängande enhet mellan tydligt identifierbara symtom och rapporterade tecken vid registrering av en klinisk anamnes.\r\n\r\nAnvänds som en allmän mall för alla symtom och rapporterade tecken. Fältet \"Specifika detaljer\" kan användas för att utöka arketypen för att inkludera ytterligare, specifika datakomponenter för mer komplexa symtom eller tecken. \r\n\r\nArketypen är speciellt utformad för att användas i fältet \"Detaljstruktur\" i OBSERVATION.story-arketypen, men kan även användas inom andra OBSERVATION- eller CLUSTER-arketyper och i \"Associerade symtom och tecken\" eller i fältet \"Tidigare episod\" inom andra exempel av denna CLUSTER.symptom_sign arketypen. Hälso- o sjukvårdspersonal registrerar ofta uttrycket \"Används inte för att dokumentera ett symtom eller tecken\" som uttryckligen rapporteras som inte förekommande. \r\n\r\nAnvänd CLUSTER.exclusion_symptom_sign med försiktighet för specifika ändamål där merarbetet för registreringarna på detta sätt motiverar extra komplexitet och endast om \"Noll signifikanta\" fältet i denna arketyp inte är tillräckligt specifik för syftet för registreringen. Används inte för att dokumentera ett symtom eller tecken som uttryckligen rapporteras som inte förekommande – använd CLUSTER.exclusion_symptom_sign med försiktighet för specifika ändamål där merarbetet för registreringarna på detta sätt motiverar extra komplexitet och endast om \"Noll signifikanta\" fältet i denna arketyp inte är tillräckligt specifik för syftet för registreringen. För specifika symtom eller rapporterade tecken som en effektiv metod för att indikera att individen tillfrågats och det inte rapporterades som obehag eller störning - används mer effektivt som ett \"normalt utlåtande\" snarare än en uttrycklig uteslutning. Det \"Noll signifikanta\" fältet har medvetet inkluderats i denna arketyp för att kliniker kan registrera samma information på ett enkelt och effektivt sätt i ett kliniskt system. Det kan användas för att driva ett användargränssnitt, exempelvis om \"Noll signifikant\" är registrerad som sann kan de återstående fälten döljas på en dataskärm. Denna pragmatiska metod stöder majoriteten av enkla kliniska registreringskrav kring rapporterade symtom och tecken.\r\n\r\nDäremot om det finns en klinisk nödvändighet att uttryckligen registrera att ett symtom eller tecken rapporterades som inte förekommande, exempelvis om det kommer att användas som ett kliniskt beslutsstöd, föredras CLUSTER.exclusion_symptom_sign arketypen. Användningen av CLUSTER.exclusion_symptom_sign ökar komplexiteten i mallutformningen, implementeringen och utfrågningen. Det rekommenderas att CLUSTER.exclusion_symptom_sign arketypen endast beaktas för användning om tydlig fördel kan identifieras i specifika situationer, men ska inte användas för rutinmässigt symtom och tecken registrering.\r\n\r\n\r\n", + "misuse" : "Ska inte användas för att dokumentera ett symtom eller tecken som uttryckligen rapporteras som inte förekommande. Använd CLUSTER.exclusion_symptom_sign med försiktighet för specifika ändamål där merarbetet för registreringarna på detta sätt motiverar extra komplexitet och endast om \"Noll significant\" fältet i denna arketyp inte är tillräckligt specifik för registreringens syfte.\r\n\r\nSka inte användas för att registrera objektiva fynd som en del av en fysisk undersökning . Använd OBSERVATION.exam och relaterad undersökning CLUSTER-arketyper för detta ändamål.\r\n\r\nSka inte användas för diagnoser och problem som ingår i en kvarstående problemlista. Använd då istället EVALUATION.problem_diagnosis.", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "nb" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "nb" + }, + "purpose" : "For å registrere detaljer om en enkeltepisode av et rapportert symptom eller sykdomstegn. Dette kan omfatte kontekst, men ikke detaljer, om tidligere episoder av symptomet/sykdomstegnet.", + "keywords" : [ "lidelse", "plage", "problem", "ubehag", "symptom", "sykdomstegn", "lyte", "skavank" ], + "use" : "For å registrere detaljer om en enkeltepisode av et rapportert symptom eller sykdomstegn hos et individ, som redegjort av personen selv, foreldre, omsorgsperson eller andre parter. Registrering kan skje i forbindelse med opptak av anamnese, eller som en selvregistrering som en del av et klinisk spørreskjema eller personlig journal. \r\nEn fullstendig klinisk anamnese eller pasientanamnese kan inneholde beskrivelser med ulikt detaljnivå om flere episoder knyttet til samme symptom eller sykdomstegn, og vil også kunne inneholde flere ulike symptomer eller sykdomstegn.\r\n\r\nI egentlig forstand er symptomer subjektive opplevelser av en fysisk eller mental forstyrrelse mens sykdomstegn er objektive observasjoner av det samme, som er erfart av et individ og rapportert til en kliniker av individet eller av andre. Fra denne logikken følger at det burde være to arketyper til å registrere klinisk anamnese; en for rapporterte symptomer og en for rapporterte sykdomstegn. I virkeligheten er dette upraktisk og vil kreve registrering av kliniske data i enten den ene eller den andre av disse modellene. I praksis vil dette øke kompleksitet og tidsbruk knyttet til modellering og registrering av data. I tillegg overlapper ofte de kliniske konseptene, for eksempel: Vil tidligere oppkast eller blødning kategoriseres som et symptom eller som et rapportert sykdomstegn?\r\nSom svar på dette er arketypen laget for å tillate registrering av hele kontinuumet mellom tydelig definerte symptomer og rapporterte sykdomstegn når en registrerer en klinisk anamnese.\r\n\r\nArketypen er designet for å gi et generisk rammeverk for alle symptomer og rapporterte sykdomstegn. SLOTet \"Spesifikke detaljer\" kan brukes for å utvide arketypen med ytterligere spesifikke dataelementer for komplekse symptomer eller sykdomstegn.\r\n\r\nArketypen skal settes inn i \"Detaljer\"-SLOTet i OBSERVATION.story-arketypen men kan også brukes i en hvilken som helst OBSERVATION eller CLUSTER-arketype. Arketypen kan også gjenbrukes i andre instanser av CLUSTER.symptom_sign-arketypen i SLOTene \"Assosierte symptomer\" eller \"Tidligere detaljer\".\r\n\r\nKlinikere registrerer ofte frasen \"Ikke av betydning\" i forbindelse med spesifikke symptomer eller rapporterte tegn for å indikere at det er eksplisitt spurt om det spesifikke symptomet, og at det ble svart at symptomet ikke er tilstede i en slik grad at det påfører pasienten ubehag eller uro. Frasen brukes mer som en normalbeskrivelse enn en eksplisitt eksklusjon. Dataelementet \"Ikke av betydning\" er med hensikt lagt til for å tillate at klinikere enkelt og effektivt kan registrere denne informasjonen i det kliniske systemet. Eksempelvis kan \"Ikke av betydning\" brukes i brukergrensesnittet, er dette registrert som \"Sann\" kan de resterende dataelementene skjules i brukergrensesnittet. Denne pragmatiske tilnærmingen støtter hoveddelen av enkel klinisk journalføring av symptomer og sykdomstegn. \r\n\r\nImidlertid kan det være fordelaktig å bruke arketypen CLUSTER.exclusion_symptom_sign dersom det er klinisk behov for å eksplisitt registrere at et symptom eller sykdomstegn ikke er tilstede, for eksempel dersom dette skal brukes til klinisk beslutningsstøtte. Bruk av CLUSTER.exclusion_symptom_sign vil øke kompleksiteten i templatmodellering, implementasjon og spørring. Det anbefales at CLUSTER.exclusion_symptom_sign kun vurderes brukt dersom man kan identifisere en klar gevinst, men bør ikke brukes for rutineregistreringer av symptomer eller sykdomstegn.", + "misuse" : "Brukes ikke til eksplisitt registrering av at et symptom eller sykdomstegn ikke er tilstede. Bruk CLUSTER.exclusion_symptom_sign varsomt da det øker tidsbruk ved registrering og tilfører økt kompleksitet, og bare når dataelementet \"Ikke av betydning\" i denne arketypen ikke er eksplisitt nok for registreringen.\r\n\r\nBrukes ikke til registrering av objektive funn som en del av en fysisk undersøkelse. Bruk OBSERVATION.exam og relaterte CLUSTER.exam-arketyper for dette formålet. \r\n\r\nBrukes ikke til registrering av problemer og diagnoser som en del av en persistent problemliste, til dette brukes EVALUATION.problem_diagnosis.\r\n\r\nBrukes ikke til å dokumentere tiltak og resultat i løpet av hele perioden individet er under behandling, da arketypen er beregnet til å dokumentere symptomer og sykdomstegn som et øyeblikksbilde.", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "pt-br" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "pt-br" + }, + "purpose" : "Registrar detalhes sobre um episódio único de um sinal ou sintoma relatado incluindo contexto, mas não detalhes, de episódios prévios se apropriado.", + "keywords" : [ "queixa", "sintoma", "distúrbio", "problema", "desconforto", "queixa atual", "sintoma atual", "sinal" ], + "use" : "Usar para relatar detalhes sobre um episódio único de um sintoma ou sinal reportado em um indivíduo, como reportado pelo indivíduo, parente, cuidador ou outra arte. Deve ser registrado por um clínico como parte de um relato de história clínica como reportado por eles, observado pelo clínico ou registrado pelo próprio como parte de um questionário ou relato pessoal de saúde. Uma história clínica completa ou história pessoal deve conter - com variáveis níves de detalhes - múltiplos episódios de um sinal ou sintoma identificado ou reportado assim como múltiplos sinais/sintomas. \r\n\r\nNo sentido mais puro, sintomas são observações subjetivas de um distúrbio físico ou mental e sinais são observações objetivas dos mesmos, como experimentado por um indivíduo e reportado para o tomador da história pelo mesmo indivíduo ou outra parte. Por esta lógica segue que serão necessários dois arquétipos para registrar a história clínica - um para sintomas e outro para sinais relatados. Na realidade isto é pouco prático pois vai requerer entrada de dados clínicos em cada um destes modelos o que acrescenta problemas significantes aos modeladores e aqueles que coletam o dado. Em adição, frequentemente há uma interposição entre os conceitos clínicos - por exemplo: vômitos ou sangramentos prévios devem ser considerados sintomas ou sinais reportados? Em resposta, este arquétipo foi especificamente desenhado para prover um modelo de informação único que permita o registro de todo o continuum entre sintomas claramente identificáveis e sinais reportados quando do reistro de uma história clínica. \r\n\r\nEste arquétipo pretende ser utilizado como um padrão genérico para todos os sintomas e sinais reportados. O SLOT 'Detalhes específicos' pode ser utilizado para estender o arquétipo e incluir elementos de dados específicos ou adicionais para sinais e sintomas mais complexos. \r\n\r\nEste arquétipo foi desenhado especificamennte para ser utilizado no SLOT 'Detalhe estruturado' com o arquétipo OBSERVATION.story, mas pode também ser utilizado com outros arquétipos OBSERVATION ou CLUSTER e nos SLOTS 'Sinal/sintoma associado' ou 'Episódio prévio' em outras instâncias deste arquétipo CLUSTER.symptom_sign.\r\n\r\nClínicos frequentemente registram a frase 'não significante' em sintomas específicos ou sinais relatados como um método eficiente de indicar que eles perguntaram ao indivíduo e foi relatado como não causador de desconforto ou distúrbio - efetivamente é utilizado mais como 'referido como normal' do que uma exclusão explícita. O elemento de dado 'não significante' tem sido incluído deliberadamente neste arquétipo para permitir aos clínicos registrarem esta mesma informação de uma maneira simples e efetiva num sistema clínico. Pode ser utilizado para dirigir uma interface de usuário, por exemplo se 'não significante' é registrado como verdadeiro então os demais elementos de dados podem ser ocultos na tela de entrada de dados. Esta abordagem pragmática dá suporte à maioria dos requerimentos de registros clínicos com relação a sinais e sintomas relatados. \r\n\r\nEntretanto se houver um imperativo clínico para explicitar o registro de que um Sintoma ou Sinal foi reportado como ausente, por exemplo se for utilizado para orientar suporte à decisão clínica, então pode ser preferível usar o arquétipo CLUSTER.exclusion_symptom_sign. O uso de CLUSTER.exclusion_symptom_sign vai aumentar a complexidade da modelagem de template, implementação e pesquisa. É recomendado que o arquétipo CLUSTER.exclusion_symptom_sign apenas seja considerado se um benefício claro for identificado em situações específicas e não deve ser utilizado rotineiramente para o registro de sinais/sintomas.", + "misuse" : "Não deve ser utilizado para registrar que um sintoma ou sinal foi explicitamente relatado como ausente - utilizar CLUSTER.exclusion_symptom_sign cuidadosamente para fins específicos em que os problemas de registro garantam complexidade adicional e apenas se o 'não significante' neste arquétipo não for específico suficiente para fins de registro.\r\n\r\nNão deve ser utilizado para registrar achados objetivos como parte de um exame físico - utilizar OBSERVATION.exam e arquétipos do tipo CLUSTER relacionados a exame para esta finalidade.\r\n\r\nNão dever ser utilizado para diagnósticos e problemas que fazem parte de uma lista de problemas - utilizar EVALUATION.problem_diagnosis.", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "ar-sy" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "ar-sy" + }, + "purpose" : "*To record detail about a symptom - either self-recorded by an individual or recorded on the behalf of a patient by a clinician. A complete patient history may include varying level of details about a variety of symptoms.(en)", + "keywords" : [ ], + "use" : "*Use to record detailed information about a symptom as told to a clinician by a patient or self-recorded by the individual/patient.\r\n\r\nThis archetype allows a 'nil significant' statement to be explicitly recorded.(en)", + "misuse" : "*Not to be used to record details about pain. Use the specialisation of this archetype - the CLUSTER.symptom-pain instead.\r\n\r\nNot to be used for diagnoses and problems that form part of a persisting Problem List - use EVALUATION.problem_diagnosis.(en)", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "en" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "en" + }, + "purpose" : "To record details about a single episode of a reported symptom or sign including context, but not details, of previous episodes if appropriate.", + "keywords" : [ "complaint", "symptom", "disturbance", "problem", "discomfort", "presenting complaint", "presenting symptom", "sign" ], + "use" : "Use to record details about a single episode of a symptom or reported sign in an individual, as reported by the individual, parent, care-giver or other party. It may be recorded by a clinician as part of a clinical history record as reported to them, observed by the clinician or self-recorded as part of a clinical questionnaire or personal health record. A complete clinical history or patient story may include varying level of details about multiple episodes of an identified symptom or reported sign, as well as multiple symptoms/signs.\r\n\r\nIn the purest sense, symptoms are subjective observations of a physical or mental disturbance and signs are objective observations of the same, as experienced by an individual and reported to the history taker by the same individual or another party. From this logic it follows that we will need two archetypes to record clinical history - one for reported symptoms and another for reported signs. In reality this is impractical as it will require clinical data entry into either one of these models which adds signficant overheads to modellers and those entering data. In addition, there is often overlap in clinical concepts - for example, is previous vomiting or bleeding to be categorised as a symptom or reported sign? In response, this archetype has been specifically designed to proved a single information model that allows for recording of the entire continuum between clearly identifable symptoms and reported signs when recording a clinical history.\r\n\r\nThis archetype has been intended to be used as a generic pattern for all symptoms and reported signs. The 'Specific details' SLOT can be used to extend the archetype to include additional, specific data elements for more complex symptoms or signs. \r\n\r\nThis archetype has been specifically designed to be used in the 'Structured detail' SLOT within the OBSERVATION.story archetype, but can also be used within other OBSERVATION or CLUSTER archetypes and in the 'Associated symptom/sign' or 'Previous episode' SLOT within other instances of this CLUSTER.symptom_sign archetype.\r\n\r\nClinicians frequently record the phrase 'nil significant' against specific symptoms or reported signs as an efficient method to indicate that they asked the individual and it was not reported as causing any discomfort or disturbance - effectively used more like a 'normal statement' rather than an explicit exclusion. The 'Nil significant' data element has been deliberately included in this archetype to allow clinicians to record this same information in a simple and effective way in a clinical system. It can be used to drive a user interface, for example if 'Nil significant' is recorded as true then the remaining data elements can be hidden on a data entry screen. This pragmatic approach supports the majority of simple clinical recording requirements around reported symptoms and signs. \r\n\r\nHowever if there is a clinical imperative to explicitly record that a Symptom or Sign was reported as not present, for example if it will be used to drive clinical decision support, then it would be preferable to use the CLUSTER.exclusion_symptom_sign archetype. The use of CLUSTER.exclusion_symptom_sign will increase the complexity of template modelling, implementation and querying. It is recommended that the CLUSTER.exclusion_symptom_sign archetype only be considered for use if clear benefit can be identified in specific situations, but should not be used for routine symptom/sign recording.", + "misuse" : "Not to be used to record that a symptom or sign was explicitly reported as not present - use CLUSTER.exclusion_symptom_sign carefully for specific purposes where the overheads of recording in this way warrant the additional complexity, and only if the 'Nil significant' in this archetype is not specific enough for recording purposes.\r\n\r\nNot to be used for recording objective findings as part of a physical examination - use OBSERVATION.exam and related examination CLUSTER archetypes for this purpose.\r\n\r\nNot to be used for diagnoses and problems that form part of a persisting Problem List - use EVALUATION.problem_diagnosis.", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + } + } + }, + "parentArchetypeId" : "openEHR-EHR-CLUSTER.symptom_sign-cvid.v0", + "differential" : true, + "archetypeId" : { + "@type" : "ARCHETYPE_HRID", + "value" : "openEHR-EHR-CLUSTER.ovl-symptom_sign-cvid-004.v0" + }, + "definition" : { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "CLUSTER", + "nodeId" : "at0000.1.1", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "items", + "children" : [ { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "nodeId" : "at0001.1.1", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "value", + "children" : [ { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "DV_CODED_TEXT", + "occurrences" : "0..1", + "defaultValue" : { + "@type" : "DV_CODED_TEXT", + "value" : "Difficulty breathing", + "defining_code" : { + "@type" : "CODE_PHRASE", + "terminology_id" : { + "@type" : "TERMINOLOGY_ID", + "value" : "SNOMED-CT" + }, + "code_string" : "267036007" + } + }, + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "defining_code", + "existence" : "0..1", + "children" : [ { + "@type" : "C_TERMINOLOGY_CODE", + "terminologyId" : { + "value" : "SNOMED-CT" + }, + "constraint" : [ ], + "includedExternalTerminologyCodes" : [ { + "terminologyId" : "SNOMED-CT", + "code" : "267036007", + "value" : "Difficulty breathing" + } ] + } ] + } ], + "attributeTuples" : [ ] + } ] + } ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "occurrences" : "0..0", + "nodeId" : "at0035.0.1", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "value", + "children" : [ { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "DV_BOOLEAN", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "value", + "children" : [ { + "@type" : "C_BOOLEAN", + "rmTypeName" : "Boolean", + "occurrences" : "1..1", + "constraint" : [ true ] + } ] + } ], + "attributeTuples" : [ ] + } ] + } ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + 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"ARCHETYPE_TERM", + "code" : "at0000.1.1", + "text" : "Difficulty breathing", + "description" : "*Reported observation of a physical or mental disturbance in an individual.(en)" + } + }, + "en" : { + "at0000.1.1" : { + "@type" : "ARCHETYPE_TERM", + "code" : "at0000.1.1", + "text" : "Difficulty breathing", + "description" : "Symptoms known to be indicators of suspected Covid-19 infection" + } + }, + "de" : { + "at0000.1.1" : { + "@type" : "ARCHETYPE_TERM", + "code" : "at0000.1.1", + "text" : "Difficulty breathing", + "description" : "Festgestellte Beobachtung einer körperlichen oder geistigen Störung bei einer Person." + } + }, + "nb" : { + "at0000.1.1" : { + "@type" : "ARCHETYPE_TERM", + "code" : "at0000.1.1", + "text" : "Difficulty breathing", + "description" : "Rapportert observasjon av fysiske tegn eller beskrivelse av unormale eller ubehagelige fornemmelser i kropp og/eller sinn." + } + }, + "fi" : { + "at0000.1.1" : { + "@type" : "ARCHETYPE_TERM", + "code" : "at0000.1.1", + "text" : "Difficulty breathing", + "description" : "Reported observation of a physical or mental disturbance in an individual.(en)" + } + }, + "sv" : { + "at0000.1.1" : { + "@type" : "ARCHETYPE_TERM", + "code" : "at0000.1.1", + "text" : "Difficulty breathing", + "description" : "Rapporterad observation av en fysisk eller psykisk störning hos en individ." + } + }, + "pt-br" : { + "at0000.1.1" : { + "@type" : "ARCHETYPE_TERM", + "code" : "at0000.1.1", + "text" : "Difficulty breathing", + "description" : "Observação de um distúrbio físico ou mental relatada em um indivíduo." + } + } + }, + "termBindings" : { + "SNOMED-CT" : { + "at0001.1.1" : "term:SNOMED-CT::418799008", + "at0002.0.1" : "term:SNOMED-CT::162408000", + "at0028.0.1" : "term:SNOMED-CT::162442009", + "at0021.0.1" : "term:SNOMED-CT::162465004", + "at0001" : "term:SNOMED-CT::418799008" + } + }, + "terminologyExtracts" : { }, + "valueSets" : { } + }, + "adlVersion" : "1.4", + "buildUid" : "91cfb84d-f6d5-4240-8de6-234c0581f543", + "rmName" : "openehr", + "rmRelease" : "1.0.3", + "generated" : true, + "otherMetaData" : { }, + "originalLanguage" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "en" + }, + "translations" : [ { + "@type" : "TRANSLATION_DETAILS", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "de" + }, + "author" : { + "name" : "Jasmin Buck, Sebastian Garde, Kim Sommer", + "organisation" : "University of Heidelberg, Central Queensland University, Medizinische Hochschule Hannover" + }, + "otherDetails" : { } + }, { + "@type" : "TRANSLATION_DETAILS", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "fi" + }, + "author" : { + "name" : "Kalle Vuorinen", + "organisation" : "Tieto Healthcare & Welfare Oy", + "email" : "kalle.vuorinen@tieto.com" + }, + "otherDetails" : { } + }, { + "@type" : "TRANSLATION_DETAILS", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "sv" + }, + "author" : { + "name" : "Kirsi Poikela", + "organisation" : "Tieto Sweden AB", + "email" : "ext.kirsi.poikela@tieto.com" + }, + "otherDetails" : { } + }, { + "@type" : "TRANSLATION_DETAILS", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "nb" + }, + "author" : { + "name" : "Lars Bitsch-Larsen", + "organisation" : "Haukeland University Hospital of Bergen, Norway", + "email" : "lbla@helse-bergen.no" + }, + "accreditation" : "MD, DEAA, MBA, spec in anesthesia, spec in tropical medicine.", + "otherDetails" : { } + }, { + "@type" : "TRANSLATION_DETAILS", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "pt-br" + }, + "author" : { + "name" : "Vladimir Pizzo", + "organisation" : "Hospital Sirio Libanes - Brazil", + "email" : "vladimir.pizzo@hsl.org.br" + }, + "otherDetails" : { } + }, { + "@type" : "TRANSLATION_DETAILS", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "ar-sy" + }, + "author" : { + "name" : "Mona Saleh" + }, + "otherDetails" : { } + } ] + }, { + "@type" : "TEMPLATE_OVERLAY", + "uid" : "58414310-36c9-46a8-861f-604330913760", + "description" : { + "@type" : "RESOURCE_DESCRIPTION", + "originalAuthor" : { }, + "otherContributors" : [ ], + "ipAcknowledgements" : { }, + "references" : { }, + "conversionDetails" : { }, + "otherDetails" : { + "PARENT:MD5-CAM-1.0.1" : "D52BB4ECB2B0380CB1C0F3A4FBC6BB5C", + "ip_acknowledgements" : "This artefact includes content from SNOMED Clinical Terms® (SNOMED CT®) which is copyrighted material of the International Health Terminology Standards Development Organisation (IHTSDO). Where an implementation of this artefact makes use of SNOMED CT content, the implementer must have the appropriate SNOMED CT Affiliate license - for more information contact http://www.snomed.org/snomed-ct/get-snomedct or info@snomed.org." + }, + "details" : { + "de" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "de" + }, + "purpose" : "Zur Erfassung von Details über eine einzelne Episode eines berichteten Symptoms/Krankheitsanzeichens. Zusammenhänge zu früheren Episoden (ohne Angabe von Details) sollen, wenn angemessen, ebenfalls aufgeführt werden.", + "keywords" : [ "Beschwerde", "Symptom", "Störung", "Problem", "gegenwärtige Beschwerde", "gegenwärtiges Symptom", "Zeichen", "Anzeichen", "Krankheitsanzeichen" ], + "use" : "Zu Verwenden, um Details über eine einzelne Episode eines Symptoms oder eines berichteten Krankheitsanzeichens einer Person zu dokumentieren, wie es von der Person, dem Elternteil, dem Betreuer oder einer anderen Partei berichtet wurde. Es kann von einem Arzt als Teil einer Krankengeschichte dokumentiert werden, oder wie es dem Arzt berichtet wurde/wie er es beobachtet hat, oder als Teil eines selbst aufgezeichneten klinischen Fragebogens oder einer persönlichen Gesundheitsakte. Eine vollständige Krankengeschichte kann mehrere Episoden eines identifizierten Symptoms/Krankheitsanzeichens, mit variierendem Detaillierungsgrad, sowie mehrere Symptome/Krankheitsanzeichen beinhalten.\r\n\r\nSymptome sind subjektive Beobachtungen einer körperlichen oder geistigen Störung und Krankheitsanzeichen sind objektive Beobachtungen dieser Störung, wie sie von einer Person erlebt und dem Dokumentierenden von derselben Person oder einer anderen Partei berichtet werden. Aus dieser Logik folgt, dass zwei Archetypen benötigt werden, um die Krankengeschichte aufzuzeichnen - einen für berichtete Symptome und einen weiteren für berichtete Krankheitsanzeichen. Für die Praxis ist dies ungeeignet, da es die Eingabe klinischer Daten in eines der beiden Modelle erfordert, was den Modellierern und denen, die die Daten eingeben, erheblichen Mehraufwand verursacht. Darüber hinaus gibt es oft Überschneidungen von klinischen Konzepten - z.B. ist vorangegangenes Erbrechen oder sind Blutungen als Symptom oder berichtetes Krankheitsanzeichen zu kategorisieren? Als Antwort darauf wurde dieser Archetyp speziell entwickelt, um ein einziges Informationsmodell zu erproben, das es ermöglicht, das gesamte Spektrum von klar identifizierbaren Symptomen bis hin zu berichteten Krankheitsanzeichen bei der Dokumentation einer Krankengeschichte zu erfassen.\r\n\r\nDieser Archetyp wurde als generisches Muster für alle Symptome und Krankheitsanzeichen entwickelt. Der Slot \"Spezifische Details\" kann verwendet werden, um den Archetyp um zusätzliche, spezifische Datenelemente für komplexere Symptome oder Krankheitsanzeichen zu erweitern. \r\n\r\nDieser Archetyp wurde speziell für die Verwendung im Slot \"Strukturiertes Detail\" innerhalb des Archetyps OBSERVATION.story entwickelt, kann aber auch in anderen OBSERVATION- oder CLUSTER-Archetypen und in den Slots \"Assoziierte Symptome/Krankheitsanzeichen\" oder \"Vorangegangene Episoden\" in anderen Instanzen dieses CLUSTER.symptom_sign Archetyps verwendet werden.\r\n\r\nÄrzte benutzen häufig den Ausdruck \"nicht signifikant\", um festzuhalten, dass sie eine Person bezüglich des Symptoms/Krankheitsanzeichens befragt haben und es nicht berichtet wurde, dass Unannehmlichkeiten oder Störungen vorliegen - es wird also eher wie eine \"normale Aussage\" als wie ein ausdrücklicher Ausschluss verwendet. Das Datenelement \"Nicht signifikant\" wurde bewusst in diesen Archetyp aufgenommen, um Ärzten zu ermöglichen, dieselben Informationen auf einfache und effektive Weise in einem klinischen System zu dokumentieren. Es kann verwendet werden, um eine Benutzeroberfläche zu steuern, z.B. wenn \"Nicht signifikant\" als wahr dokumentiert wird, dann können die restlichen Datenelemente auf einem Dateneingabebildschirm ausgeblendet werden. Dieser pragmatische Ansatz unterstützt die Mehrheit der einfachen Anforderungen an die klinische Aufzeichnung im Bereich der berichteten Symptome/Krankheitsanzeichen. \r\n\r\nWenn es jedoch klinisch zwingend erforderlich ist, explizit zu erfassen, dass ein Symptom oder Krankheitsanzeichen als nicht vorhanden berichtet wurde, z.B. wenn es zur Unterstützung der klinischen Entscheidung verwendet wird, dann wäre es besser, den Archetyp CLUSTER.exclusion_symptom_sign zu verwenden. Die Verwendung von CLUSTER.exclusion_symptom_sign soll die Komplexität der Template-Modellierung, -Implementierung und -Abfrage erhöhen. Es wird empfohlen, den Archetyp CLUSTER.exclusion_symptom_sign nur dann für die Verwendung in Betracht zu ziehen, wenn in bestimmten Situationen ein klarer Nutzen erkennbar ist, aber nicht für die routinemäßige Aufnahme von Symptomen und Krankheitsanzeichen.", + "misuse" : "Nicht zu verwenden, um zu dokumentieren, dass ein Symptom oder ein Krankheitsanzeichen explizit als nicht vorhanden berichtet wurde - verwenden Sie CLUSTER.exclusion_symptom_sign sorgfältig für bestimmte Zwecke, bei denen der durch die Aufzeichnung entstehende Mehraufwand die zusätzliche Komplexität rechtfertigt, und nur dann, wenn das \"Nicht signifikant\" in diesem Archetyp nicht spezifisch genug für den Zweck der Dokumentation ist.\r\n\r\nNicht zur Erfassung objektiver Befunde im Rahmen einer körperlichen Untersuchung verwenden - verwenden Sie zu diesem Zweck OBSERVATION.exam und verwandte Untersuchung-CLUSTER-Archetypen.\r\n\r\nNicht für Diagnosen und Probleme, die Teil einer bestehenden Problemliste sind, verwenden - verwenden Sie EVALUATION.problem_diagnosis.\r\n", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "fi" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "fi" + }, + "purpose" : "*To record details about a single episode of a reported symptom or sign including context, but not details, of previous episodes if appropriate.(en)", + "keywords" : [ "*complaint(en)", "*symptom(en)", "*disturbance(en)", "*problem(en)", "*discomfort(en)", "*presenting complaint(en)", "*presenting symptom(en)", "*sign(en)" ], + "use" : "*Use to record details about a single episode of a symptom or reported sign in an individual, as reported by the individual, parent, care-giver or other party. It may be recorded by a clinician as part of a clinical history record as reported to them, observed by the clinician or self-recorded as part of a clinical questionnaire or personal health record. A complete clinical history or patient story may include varying level of details about multiple episodes of an identified symptom or reported sign, as well as multiple symptoms/signs.\r\n\r\nIn the purest sense, symptoms are subjective observations of a physical or mental disturbance and signs are objective observations of the same, as experienced by an individual and reported to the history taker by the same individual or another party. From this logic it follows that we will need two archetypes to record clinical history - one for reported symptoms and another for reported signs. In reality this is impractical as it will require clinical data entry into either one of these models which adds signficant overheads to modellers and those entering data. In addition, there is often overlap in clinical concepts - for example, is previous vomiting or bleeding to be categorised as a symptom or reported sign? In response, this archetype has been specifically designed to proved a single information model that allows for recording of the entire continuum between clearly identifable symptoms and reported signs when recording a clinical history.\r\n\r\nThis archetype has been intended to be used as a generic pattern for all symptoms and reported signs. The 'Specific details' SLOT can be used to extend the archetype to include additional, specific data elements for more complex symptoms or signs. \r\n\r\nThis archetype has been specifically designed to be used in the 'Structured detail' SLOT within the OBSERVATION.story archetype, but can also be used within other OBSERVATION or CLUSTER archetypes and in the 'Associated symptom/sign' or 'Previous episode' SLOT within other instances of this CLUSTER.symptom_sign archetype.\r\n\r\nClinicians frequently record the phrase 'nil significant' against specific symptoms or reported signs as an efficient method to indicate that they asked the individual and it was not reported as causing any discomfort or disturbance - effectively used more like a 'normal statement' rather than an explicit exclusion. The 'Nil significant' data element has been deliberately included in this archetype to allow clinicians to record this same information in a simple and effective way in a clinical system. It can be used to drive a user interface, for example if 'Nil significant' is recorded as true then the remaining data elements can be hidden on a data entry screen. This pragmatic approach supports the majority of simple clinical recording requirements around reported symptoms and signs. \r\n\r\nHowever if there is a clinical imperative to explicitly record that a Symptom or Sign was reported as not present, for example if it will be used to drive clinical decision support, then it would be preferable to use the CLUSTER.exclusion_symptom_sign archetype. The use of CLUSTER.exclusion_symptom_sign will increase the complexity of template modelling, implementation and querying. It is recommended that the CLUSTER.exclusion_symptom_sign archetype only be considered for use if clear benefit can be identified in specific situations, but should not be used for routine symptom/sign recording.(en)", + "misuse" : "*Not to be used to record that a symptom or sign was explicitly reported as not present - use CLUSTER.exclusion_symptom_sign carefully for specific purposes where the overheads of recording in this way warrant the additional complexity, and only if the 'Nil significant' in this archetype is not specific enough for recording purposes.\r\n\r\nNot to be used for recording objective findings as part of a physical examination - use OBSERVATION.exam and related examination CLUSTER archetypes for this purpose.\r\n\r\nNot to be used for diagnoses and problems that form part of a persisting Problem List - use EVALUATION.problem_diagnosis.(en)", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "sv" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "sv" + }, + "purpose" : "Att registrera ett uppvisat symtom eller tecken ifrån en enskild episod, inklusive kontext, men inte detaljer om tidigare episoder, om det är tillämpligt.", + "keywords" : [ "besvär", "symtom", "störning", "problem", "obehag", "uppvisar besvär", "uppvisar symtom", "tecken" ], + "use" : "Används för att beskriva detaljer för en individs rapporterade symtom eller tecken ifrån en enskild episod, som rapporterats av personen, föräldern, hälso- o sjukvårdspersonal eller annan part. Det kan registreras av hälso- o sjukvårdspersonal som en del av en anamnes som rapporterats till hälso- o sjukvårdspersonalen, observerad av eller registrerats själv av personen som en del av ett kliniskt frågeformulär eller personligt hälsodokument. En komplett anamnes eller patientjournal kan innehålla varierande detaljnivå från flera episoder av ett identifierat symtom eller rapporterade tecken, såväl som multipla symtom och tecken. \r\n\r\nSymtom är subjektiva observationer från en fysisk eller psykisk störning och tecken är objektiva observationer av densamma, upplevda av en individ och rapporteras till journalföraren av samma individ eller annan part. \r\nUr denna logik följer att vi behöver två arketyper för att registrera klinisk anamnes , en för rapporterade symtom och en annan för rapporterade tecken. I verkligheten är detta opraktiskt eftersom det kommer att kräva tillgång till kliniska data i någon av dessa mallar, vilket innebär signifikant merarbete för mallarna och dem som matar in data. Dessutom finns det ofta överlappningar i kliniska koncept, exempevisl är tidigare kräkningar eller blödningar att kategoriserade som ett symtom eller rapporterat tecken? \r\nSom svar har denna arketyp utformats specifikt för att möjliggöra registrering av en sammanhängande enhet mellan tydligt identifierbara symtom och rapporterade tecken vid registrering av en klinisk anamnes.\r\n\r\nAnvänds som en allmän mall för alla symtom och rapporterade tecken. Fältet \"Specifika detaljer\" kan användas för att utöka arketypen för att inkludera ytterligare, specifika datakomponenter för mer komplexa symtom eller tecken. \r\n\r\nArketypen är speciellt utformad för att användas i fältet \"Detaljstruktur\" i OBSERVATION.story-arketypen, men kan även användas inom andra OBSERVATION- eller CLUSTER-arketyper och i \"Associerade symtom och tecken\" eller i fältet \"Tidigare episod\" inom andra exempel av denna CLUSTER.symptom_sign arketypen. Hälso- o sjukvårdspersonal registrerar ofta uttrycket \"Används inte för att dokumentera ett symtom eller tecken\" som uttryckligen rapporteras som inte förekommande. \r\n\r\nAnvänd CLUSTER.exclusion_symptom_sign med försiktighet för specifika ändamål där merarbetet för registreringarna på detta sätt motiverar extra komplexitet och endast om \"Noll signifikanta\" fältet i denna arketyp inte är tillräckligt specifik för syftet för registreringen. Används inte för att dokumentera ett symtom eller tecken som uttryckligen rapporteras som inte förekommande – använd CLUSTER.exclusion_symptom_sign med försiktighet för specifika ändamål där merarbetet för registreringarna på detta sätt motiverar extra komplexitet och endast om \"Noll signifikanta\" fältet i denna arketyp inte är tillräckligt specifik för syftet för registreringen. För specifika symtom eller rapporterade tecken som en effektiv metod för att indikera att individen tillfrågats och det inte rapporterades som obehag eller störning - används mer effektivt som ett \"normalt utlåtande\" snarare än en uttrycklig uteslutning. Det \"Noll signifikanta\" fältet har medvetet inkluderats i denna arketyp för att kliniker kan registrera samma information på ett enkelt och effektivt sätt i ett kliniskt system. Det kan användas för att driva ett användargränssnitt, exempelvis om \"Noll signifikant\" är registrerad som sann kan de återstående fälten döljas på en dataskärm. Denna pragmatiska metod stöder majoriteten av enkla kliniska registreringskrav kring rapporterade symtom och tecken.\r\n\r\nDäremot om det finns en klinisk nödvändighet att uttryckligen registrera att ett symtom eller tecken rapporterades som inte förekommande, exempelvis om det kommer att användas som ett kliniskt beslutsstöd, föredras CLUSTER.exclusion_symptom_sign arketypen. Användningen av CLUSTER.exclusion_symptom_sign ökar komplexiteten i mallutformningen, implementeringen och utfrågningen. Det rekommenderas att CLUSTER.exclusion_symptom_sign arketypen endast beaktas för användning om tydlig fördel kan identifieras i specifika situationer, men ska inte användas för rutinmässigt symtom och tecken registrering.\r\n\r\n\r\n", + "misuse" : "Ska inte användas för att dokumentera ett symtom eller tecken som uttryckligen rapporteras som inte förekommande. Använd CLUSTER.exclusion_symptom_sign med försiktighet för specifika ändamål där merarbetet för registreringarna på detta sätt motiverar extra komplexitet och endast om \"Noll significant\" fältet i denna arketyp inte är tillräckligt specifik för registreringens syfte.\r\n\r\nSka inte användas för att registrera objektiva fynd som en del av en fysisk undersökning . Använd OBSERVATION.exam och relaterad undersökning CLUSTER-arketyper för detta ändamål.\r\n\r\nSka inte användas för diagnoser och problem som ingår i en kvarstående problemlista. Använd då istället EVALUATION.problem_diagnosis.", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "nb" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "nb" + }, + "purpose" : "For å registrere detaljer om en enkeltepisode av et rapportert symptom eller sykdomstegn. Dette kan omfatte kontekst, men ikke detaljer, om tidligere episoder av symptomet/sykdomstegnet.", + "keywords" : [ "lidelse", "plage", "problem", "ubehag", "symptom", "sykdomstegn", "lyte", "skavank" ], + "use" : "For å registrere detaljer om en enkeltepisode av et rapportert symptom eller sykdomstegn hos et individ, som redegjort av personen selv, foreldre, omsorgsperson eller andre parter. Registrering kan skje i forbindelse med opptak av anamnese, eller som en selvregistrering som en del av et klinisk spørreskjema eller personlig journal. \r\nEn fullstendig klinisk anamnese eller pasientanamnese kan inneholde beskrivelser med ulikt detaljnivå om flere episoder knyttet til samme symptom eller sykdomstegn, og vil også kunne inneholde flere ulike symptomer eller sykdomstegn.\r\n\r\nI egentlig forstand er symptomer subjektive opplevelser av en fysisk eller mental forstyrrelse mens sykdomstegn er objektive observasjoner av det samme, som er erfart av et individ og rapportert til en kliniker av individet eller av andre. Fra denne logikken følger at det burde være to arketyper til å registrere klinisk anamnese; en for rapporterte symptomer og en for rapporterte sykdomstegn. I virkeligheten er dette upraktisk og vil kreve registrering av kliniske data i enten den ene eller den andre av disse modellene. I praksis vil dette øke kompleksitet og tidsbruk knyttet til modellering og registrering av data. I tillegg overlapper ofte de kliniske konseptene, for eksempel: Vil tidligere oppkast eller blødning kategoriseres som et symptom eller som et rapportert sykdomstegn?\r\nSom svar på dette er arketypen laget for å tillate registrering av hele kontinuumet mellom tydelig definerte symptomer og rapporterte sykdomstegn når en registrerer en klinisk anamnese.\r\n\r\nArketypen er designet for å gi et generisk rammeverk for alle symptomer og rapporterte sykdomstegn. SLOTet \"Spesifikke detaljer\" kan brukes for å utvide arketypen med ytterligere spesifikke dataelementer for komplekse symptomer eller sykdomstegn.\r\n\r\nArketypen skal settes inn i \"Detaljer\"-SLOTet i OBSERVATION.story-arketypen men kan også brukes i en hvilken som helst OBSERVATION eller CLUSTER-arketype. Arketypen kan også gjenbrukes i andre instanser av CLUSTER.symptom_sign-arketypen i SLOTene \"Assosierte symptomer\" eller \"Tidligere detaljer\".\r\n\r\nKlinikere registrerer ofte frasen \"Ikke av betydning\" i forbindelse med spesifikke symptomer eller rapporterte tegn for å indikere at det er eksplisitt spurt om det spesifikke symptomet, og at det ble svart at symptomet ikke er tilstede i en slik grad at det påfører pasienten ubehag eller uro. Frasen brukes mer som en normalbeskrivelse enn en eksplisitt eksklusjon. Dataelementet \"Ikke av betydning\" er med hensikt lagt til for å tillate at klinikere enkelt og effektivt kan registrere denne informasjonen i det kliniske systemet. Eksempelvis kan \"Ikke av betydning\" brukes i brukergrensesnittet, er dette registrert som \"Sann\" kan de resterende dataelementene skjules i brukergrensesnittet. Denne pragmatiske tilnærmingen støtter hoveddelen av enkel klinisk journalføring av symptomer og sykdomstegn. \r\n\r\nImidlertid kan det være fordelaktig å bruke arketypen CLUSTER.exclusion_symptom_sign dersom det er klinisk behov for å eksplisitt registrere at et symptom eller sykdomstegn ikke er tilstede, for eksempel dersom dette skal brukes til klinisk beslutningsstøtte. Bruk av CLUSTER.exclusion_symptom_sign vil øke kompleksiteten i templatmodellering, implementasjon og spørring. Det anbefales at CLUSTER.exclusion_symptom_sign kun vurderes brukt dersom man kan identifisere en klar gevinst, men bør ikke brukes for rutineregistreringer av symptomer eller sykdomstegn.", + "misuse" : "Brukes ikke til eksplisitt registrering av at et symptom eller sykdomstegn ikke er tilstede. Bruk CLUSTER.exclusion_symptom_sign varsomt da det øker tidsbruk ved registrering og tilfører økt kompleksitet, og bare når dataelementet \"Ikke av betydning\" i denne arketypen ikke er eksplisitt nok for registreringen.\r\n\r\nBrukes ikke til registrering av objektive funn som en del av en fysisk undersøkelse. Bruk OBSERVATION.exam og relaterte CLUSTER.exam-arketyper for dette formålet. \r\n\r\nBrukes ikke til registrering av problemer og diagnoser som en del av en persistent problemliste, til dette brukes EVALUATION.problem_diagnosis.\r\n\r\nBrukes ikke til å dokumentere tiltak og resultat i løpet av hele perioden individet er under behandling, da arketypen er beregnet til å dokumentere symptomer og sykdomstegn som et øyeblikksbilde.", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "pt-br" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "pt-br" + }, + "purpose" : "Registrar detalhes sobre um episódio único de um sinal ou sintoma relatado incluindo contexto, mas não detalhes, de episódios prévios se apropriado.", + "keywords" : [ "queixa", "sintoma", "distúrbio", "problema", "desconforto", "queixa atual", "sintoma atual", "sinal" ], + "use" : "Usar para relatar detalhes sobre um episódio único de um sintoma ou sinal reportado em um indivíduo, como reportado pelo indivíduo, parente, cuidador ou outra arte. Deve ser registrado por um clínico como parte de um relato de história clínica como reportado por eles, observado pelo clínico ou registrado pelo próprio como parte de um questionário ou relato pessoal de saúde. Uma história clínica completa ou história pessoal deve conter - com variáveis níves de detalhes - múltiplos episódios de um sinal ou sintoma identificado ou reportado assim como múltiplos sinais/sintomas. \r\n\r\nNo sentido mais puro, sintomas são observações subjetivas de um distúrbio físico ou mental e sinais são observações objetivas dos mesmos, como experimentado por um indivíduo e reportado para o tomador da história pelo mesmo indivíduo ou outra parte. Por esta lógica segue que serão necessários dois arquétipos para registrar a história clínica - um para sintomas e outro para sinais relatados. Na realidade isto é pouco prático pois vai requerer entrada de dados clínicos em cada um destes modelos o que acrescenta problemas significantes aos modeladores e aqueles que coletam o dado. Em adição, frequentemente há uma interposição entre os conceitos clínicos - por exemplo: vômitos ou sangramentos prévios devem ser considerados sintomas ou sinais reportados? Em resposta, este arquétipo foi especificamente desenhado para prover um modelo de informação único que permita o registro de todo o continuum entre sintomas claramente identificáveis e sinais reportados quando do reistro de uma história clínica. \r\n\r\nEste arquétipo pretende ser utilizado como um padrão genérico para todos os sintomas e sinais reportados. O SLOT 'Detalhes específicos' pode ser utilizado para estender o arquétipo e incluir elementos de dados específicos ou adicionais para sinais e sintomas mais complexos. \r\n\r\nEste arquétipo foi desenhado especificamennte para ser utilizado no SLOT 'Detalhe estruturado' com o arquétipo OBSERVATION.story, mas pode também ser utilizado com outros arquétipos OBSERVATION ou CLUSTER e nos SLOTS 'Sinal/sintoma associado' ou 'Episódio prévio' em outras instâncias deste arquétipo CLUSTER.symptom_sign.\r\n\r\nClínicos frequentemente registram a frase 'não significante' em sintomas específicos ou sinais relatados como um método eficiente de indicar que eles perguntaram ao indivíduo e foi relatado como não causador de desconforto ou distúrbio - efetivamente é utilizado mais como 'referido como normal' do que uma exclusão explícita. O elemento de dado 'não significante' tem sido incluído deliberadamente neste arquétipo para permitir aos clínicos registrarem esta mesma informação de uma maneira simples e efetiva num sistema clínico. Pode ser utilizado para dirigir uma interface de usuário, por exemplo se 'não significante' é registrado como verdadeiro então os demais elementos de dados podem ser ocultos na tela de entrada de dados. Esta abordagem pragmática dá suporte à maioria dos requerimentos de registros clínicos com relação a sinais e sintomas relatados. \r\n\r\nEntretanto se houver um imperativo clínico para explicitar o registro de que um Sintoma ou Sinal foi reportado como ausente, por exemplo se for utilizado para orientar suporte à decisão clínica, então pode ser preferível usar o arquétipo CLUSTER.exclusion_symptom_sign. O uso de CLUSTER.exclusion_symptom_sign vai aumentar a complexidade da modelagem de template, implementação e pesquisa. É recomendado que o arquétipo CLUSTER.exclusion_symptom_sign apenas seja considerado se um benefício claro for identificado em situações específicas e não deve ser utilizado rotineiramente para o registro de sinais/sintomas.", + "misuse" : "Não deve ser utilizado para registrar que um sintoma ou sinal foi explicitamente relatado como ausente - utilizar CLUSTER.exclusion_symptom_sign cuidadosamente para fins específicos em que os problemas de registro garantam complexidade adicional e apenas se o 'não significante' neste arquétipo não for específico suficiente para fins de registro.\r\n\r\nNão deve ser utilizado para registrar achados objetivos como parte de um exame físico - utilizar OBSERVATION.exam e arquétipos do tipo CLUSTER relacionados a exame para esta finalidade.\r\n\r\nNão dever ser utilizado para diagnósticos e problemas que fazem parte de uma lista de problemas - utilizar EVALUATION.problem_diagnosis.", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "ar-sy" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "ar-sy" + }, + "purpose" : "*To record detail about a symptom - either self-recorded by an individual or recorded on the behalf of a patient by a clinician. A complete patient history may include varying level of details about a variety of symptoms.(en)", + "keywords" : [ ], + "use" : "*Use to record detailed information about a symptom as told to a clinician by a patient or self-recorded by the individual/patient.\r\n\r\nThis archetype allows a 'nil significant' statement to be explicitly recorded.(en)", + "misuse" : "*Not to be used to record details about pain. Use the specialisation of this archetype - the CLUSTER.symptom-pain instead.\r\n\r\nNot to be used for diagnoses and problems that form part of a persisting Problem List - use EVALUATION.problem_diagnosis.(en)", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "en" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "en" + }, + "purpose" : "To record details about a single episode of a reported symptom or sign including context, but not details, of previous episodes if appropriate.", + "keywords" : [ "complaint", "symptom", "disturbance", "problem", "discomfort", "presenting complaint", "presenting symptom", "sign" ], + "use" : "Use to record details about a single episode of a symptom or reported sign in an individual, as reported by the individual, parent, care-giver or other party. It may be recorded by a clinician as part of a clinical history record as reported to them, observed by the clinician or self-recorded as part of a clinical questionnaire or personal health record. A complete clinical history or patient story may include varying level of details about multiple episodes of an identified symptom or reported sign, as well as multiple symptoms/signs.\r\n\r\nIn the purest sense, symptoms are subjective observations of a physical or mental disturbance and signs are objective observations of the same, as experienced by an individual and reported to the history taker by the same individual or another party. From this logic it follows that we will need two archetypes to record clinical history - one for reported symptoms and another for reported signs. In reality this is impractical as it will require clinical data entry into either one of these models which adds signficant overheads to modellers and those entering data. In addition, there is often overlap in clinical concepts - for example, is previous vomiting or bleeding to be categorised as a symptom or reported sign? In response, this archetype has been specifically designed to proved a single information model that allows for recording of the entire continuum between clearly identifable symptoms and reported signs when recording a clinical history.\r\n\r\nThis archetype has been intended to be used as a generic pattern for all symptoms and reported signs. The 'Specific details' SLOT can be used to extend the archetype to include additional, specific data elements for more complex symptoms or signs. \r\n\r\nThis archetype has been specifically designed to be used in the 'Structured detail' SLOT within the OBSERVATION.story archetype, but can also be used within other OBSERVATION or CLUSTER archetypes and in the 'Associated symptom/sign' or 'Previous episode' SLOT within other instances of this CLUSTER.symptom_sign archetype.\r\n\r\nClinicians frequently record the phrase 'nil significant' against specific symptoms or reported signs as an efficient method to indicate that they asked the individual and it was not reported as causing any discomfort or disturbance - effectively used more like a 'normal statement' rather than an explicit exclusion. The 'Nil significant' data element has been deliberately included in this archetype to allow clinicians to record this same information in a simple and effective way in a clinical system. It can be used to drive a user interface, for example if 'Nil significant' is recorded as true then the remaining data elements can be hidden on a data entry screen. This pragmatic approach supports the majority of simple clinical recording requirements around reported symptoms and signs. \r\n\r\nHowever if there is a clinical imperative to explicitly record that a Symptom or Sign was reported as not present, for example if it will be used to drive clinical decision support, then it would be preferable to use the CLUSTER.exclusion_symptom_sign archetype. The use of CLUSTER.exclusion_symptom_sign will increase the complexity of template modelling, implementation and querying. It is recommended that the CLUSTER.exclusion_symptom_sign archetype only be considered for use if clear benefit can be identified in specific situations, but should not be used for routine symptom/sign recording.", + "misuse" : "Not to be used to record that a symptom or sign was explicitly reported as not present - use CLUSTER.exclusion_symptom_sign carefully for specific purposes where the overheads of recording in this way warrant the additional complexity, and only if the 'Nil significant' in this archetype is not specific enough for recording purposes.\r\n\r\nNot to be used for recording objective findings as part of a physical examination - use OBSERVATION.exam and related examination CLUSTER archetypes for this purpose.\r\n\r\nNot to be used for diagnoses and problems that form part of a persisting Problem List - use EVALUATION.problem_diagnosis.", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + } + } + }, + "parentArchetypeId" : "openEHR-EHR-CLUSTER.symptom_sign-cvid.v0", + "differential" : true, + "archetypeId" : { + "@type" : "ARCHETYPE_HRID", + "value" : "openEHR-EHR-CLUSTER.ovl-symptom_sign-cvid-005.v0" + }, + "definition" : { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "CLUSTER", + "nodeId" : "at0000.1.1", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "items", + "children" : [ { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "nodeId" : "at0001.1.1", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "value", + "children" : [ { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "DV_CODED_TEXT", + "occurrences" : "0..1", + "defaultValue" : { + "@type" : "DV_CODED_TEXT", + "value" : "Pain in throat", + "defining_code" : { + "@type" : "CODE_PHRASE", + "terminology_id" : { + "@type" : "TERMINOLOGY_ID", + "value" : "SNOMED-CT" + }, + "code_string" : "162397003" + } + }, + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : 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{ } + } ] + }, { + "@type" : "TEMPLATE_OVERLAY", + "uid" : "58414310-36c9-46a8-861f-604330913760", + "description" : { + "@type" : "RESOURCE_DESCRIPTION", + "originalAuthor" : { }, + "otherContributors" : [ ], + "ipAcknowledgements" : { }, + "references" : { }, + "conversionDetails" : { }, + "otherDetails" : { + "PARENT:MD5-CAM-1.0.1" : "D52BB4ECB2B0380CB1C0F3A4FBC6BB5C", + "ip_acknowledgements" : "This artefact includes content from SNOMED Clinical Terms® (SNOMED CT®) which is copyrighted material of the International Health Terminology Standards Development Organisation (IHTSDO). Where an implementation of this artefact makes use of SNOMED CT content, the implementer must have the appropriate SNOMED CT Affiliate license - for more information contact http://www.snomed.org/snomed-ct/get-snomedct or info@snomed.org." + }, + "details" : { + "de" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "de" + }, + "purpose" : "Zur Erfassung von Details über eine einzelne Episode eines berichteten Symptoms/Krankheitsanzeichens. Zusammenhänge zu früheren Episoden (ohne Angabe von Details) sollen, wenn angemessen, ebenfalls aufgeführt werden.", + "keywords" : [ "Beschwerde", "Symptom", "Störung", "Problem", "gegenwärtige Beschwerde", "gegenwärtiges Symptom", "Zeichen", "Anzeichen", "Krankheitsanzeichen" ], + "use" : "Zu Verwenden, um Details über eine einzelne Episode eines Symptoms oder eines berichteten Krankheitsanzeichens einer Person zu dokumentieren, wie es von der Person, dem Elternteil, dem Betreuer oder einer anderen Partei berichtet wurde. Es kann von einem Arzt als Teil einer Krankengeschichte dokumentiert werden, oder wie es dem Arzt berichtet wurde/wie er es beobachtet hat, oder als Teil eines selbst aufgezeichneten klinischen Fragebogens oder einer persönlichen Gesundheitsakte. Eine vollständige Krankengeschichte kann mehrere Episoden eines identifizierten Symptoms/Krankheitsanzeichens, mit variierendem Detaillierungsgrad, sowie mehrere Symptome/Krankheitsanzeichen beinhalten.\r\n\r\nSymptome sind subjektive Beobachtungen einer körperlichen oder geistigen Störung und Krankheitsanzeichen sind objektive Beobachtungen dieser Störung, wie sie von einer Person erlebt und dem Dokumentierenden von derselben Person oder einer anderen Partei berichtet werden. Aus dieser Logik folgt, dass zwei Archetypen benötigt werden, um die Krankengeschichte aufzuzeichnen - einen für berichtete Symptome und einen weiteren für berichtete Krankheitsanzeichen. Für die Praxis ist dies ungeeignet, da es die Eingabe klinischer Daten in eines der beiden Modelle erfordert, was den Modellierern und denen, die die Daten eingeben, erheblichen Mehraufwand verursacht. Darüber hinaus gibt es oft Überschneidungen von klinischen Konzepten - z.B. ist vorangegangenes Erbrechen oder sind Blutungen als Symptom oder berichtetes Krankheitsanzeichen zu kategorisieren? Als Antwort darauf wurde dieser Archetyp speziell entwickelt, um ein einziges Informationsmodell zu erproben, das es ermöglicht, das gesamte Spektrum von klar identifizierbaren Symptomen bis hin zu berichteten Krankheitsanzeichen bei der Dokumentation einer Krankengeschichte zu erfassen.\r\n\r\nDieser Archetyp wurde als generisches Muster für alle Symptome und Krankheitsanzeichen entwickelt. Der Slot \"Spezifische Details\" kann verwendet werden, um den Archetyp um zusätzliche, spezifische Datenelemente für komplexere Symptome oder Krankheitsanzeichen zu erweitern. \r\n\r\nDieser Archetyp wurde speziell für die Verwendung im Slot \"Strukturiertes Detail\" innerhalb des Archetyps OBSERVATION.story entwickelt, kann aber auch in anderen OBSERVATION- oder CLUSTER-Archetypen und in den Slots \"Assoziierte Symptome/Krankheitsanzeichen\" oder \"Vorangegangene Episoden\" in anderen Instanzen dieses CLUSTER.symptom_sign Archetyps verwendet werden.\r\n\r\nÄrzte benutzen häufig den Ausdruck \"nicht signifikant\", um festzuhalten, dass sie eine Person bezüglich des Symptoms/Krankheitsanzeichens befragt haben und es nicht berichtet wurde, dass Unannehmlichkeiten oder Störungen vorliegen - es wird also eher wie eine \"normale Aussage\" als wie ein ausdrücklicher Ausschluss verwendet. Das Datenelement \"Nicht signifikant\" wurde bewusst in diesen Archetyp aufgenommen, um Ärzten zu ermöglichen, dieselben Informationen auf einfache und effektive Weise in einem klinischen System zu dokumentieren. Es kann verwendet werden, um eine Benutzeroberfläche zu steuern, z.B. wenn \"Nicht signifikant\" als wahr dokumentiert wird, dann können die restlichen Datenelemente auf einem Dateneingabebildschirm ausgeblendet werden. Dieser pragmatische Ansatz unterstützt die Mehrheit der einfachen Anforderungen an die klinische Aufzeichnung im Bereich der berichteten Symptome/Krankheitsanzeichen. \r\n\r\nWenn es jedoch klinisch zwingend erforderlich ist, explizit zu erfassen, dass ein Symptom oder Krankheitsanzeichen als nicht vorhanden berichtet wurde, z.B. wenn es zur Unterstützung der klinischen Entscheidung verwendet wird, dann wäre es besser, den Archetyp CLUSTER.exclusion_symptom_sign zu verwenden. Die Verwendung von CLUSTER.exclusion_symptom_sign soll die Komplexität der Template-Modellierung, -Implementierung und -Abfrage erhöhen. Es wird empfohlen, den Archetyp CLUSTER.exclusion_symptom_sign nur dann für die Verwendung in Betracht zu ziehen, wenn in bestimmten Situationen ein klarer Nutzen erkennbar ist, aber nicht für die routinemäßige Aufnahme von Symptomen und Krankheitsanzeichen.", + "misuse" : "Nicht zu verwenden, um zu dokumentieren, dass ein Symptom oder ein Krankheitsanzeichen explizit als nicht vorhanden berichtet wurde - verwenden Sie CLUSTER.exclusion_symptom_sign sorgfältig für bestimmte Zwecke, bei denen der durch die Aufzeichnung entstehende Mehraufwand die zusätzliche Komplexität rechtfertigt, und nur dann, wenn das \"Nicht signifikant\" in diesem Archetyp nicht spezifisch genug für den Zweck der Dokumentation ist.\r\n\r\nNicht zur Erfassung objektiver Befunde im Rahmen einer körperlichen Untersuchung verwenden - verwenden Sie zu diesem Zweck OBSERVATION.exam und verwandte Untersuchung-CLUSTER-Archetypen.\r\n\r\nNicht für Diagnosen und Probleme, die Teil einer bestehenden Problemliste sind, verwenden - verwenden Sie EVALUATION.problem_diagnosis.\r\n", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "fi" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "fi" + }, + "purpose" : "*To record details about a single episode of a reported symptom or sign including context, but not details, of previous episodes if appropriate.(en)", + "keywords" : [ "*complaint(en)", "*symptom(en)", "*disturbance(en)", "*problem(en)", "*discomfort(en)", "*presenting complaint(en)", "*presenting symptom(en)", "*sign(en)" ], + "use" : "*Use to record details about a single episode of a symptom or reported sign in an individual, as reported by the individual, parent, care-giver or other party. It may be recorded by a clinician as part of a clinical history record as reported to them, observed by the clinician or self-recorded as part of a clinical questionnaire or personal health record. A complete clinical history or patient story may include varying level of details about multiple episodes of an identified symptom or reported sign, as well as multiple symptoms/signs.\r\n\r\nIn the purest sense, symptoms are subjective observations of a physical or mental disturbance and signs are objective observations of the same, as experienced by an individual and reported to the history taker by the same individual or another party. From this logic it follows that we will need two archetypes to record clinical history - one for reported symptoms and another for reported signs. In reality this is impractical as it will require clinical data entry into either one of these models which adds signficant overheads to modellers and those entering data. In addition, there is often overlap in clinical concepts - for example, is previous vomiting or bleeding to be categorised as a symptom or reported sign? In response, this archetype has been specifically designed to proved a single information model that allows for recording of the entire continuum between clearly identifable symptoms and reported signs when recording a clinical history.\r\n\r\nThis archetype has been intended to be used as a generic pattern for all symptoms and reported signs. The 'Specific details' SLOT can be used to extend the archetype to include additional, specific data elements for more complex symptoms or signs. \r\n\r\nThis archetype has been specifically designed to be used in the 'Structured detail' SLOT within the OBSERVATION.story archetype, but can also be used within other OBSERVATION or CLUSTER archetypes and in the 'Associated symptom/sign' or 'Previous episode' SLOT within other instances of this CLUSTER.symptom_sign archetype.\r\n\r\nClinicians frequently record the phrase 'nil significant' against specific symptoms or reported signs as an efficient method to indicate that they asked the individual and it was not reported as causing any discomfort or disturbance - effectively used more like a 'normal statement' rather than an explicit exclusion. The 'Nil significant' data element has been deliberately included in this archetype to allow clinicians to record this same information in a simple and effective way in a clinical system. It can be used to drive a user interface, for example if 'Nil significant' is recorded as true then the remaining data elements can be hidden on a data entry screen. This pragmatic approach supports the majority of simple clinical recording requirements around reported symptoms and signs. \r\n\r\nHowever if there is a clinical imperative to explicitly record that a Symptom or Sign was reported as not present, for example if it will be used to drive clinical decision support, then it would be preferable to use the CLUSTER.exclusion_symptom_sign archetype. The use of CLUSTER.exclusion_symptom_sign will increase the complexity of template modelling, implementation and querying. It is recommended that the CLUSTER.exclusion_symptom_sign archetype only be considered for use if clear benefit can be identified in specific situations, but should not be used for routine symptom/sign recording.(en)", + "misuse" : "*Not to be used to record that a symptom or sign was explicitly reported as not present - use CLUSTER.exclusion_symptom_sign carefully for specific purposes where the overheads of recording in this way warrant the additional complexity, and only if the 'Nil significant' in this archetype is not specific enough for recording purposes.\r\n\r\nNot to be used for recording objective findings as part of a physical examination - use OBSERVATION.exam and related examination CLUSTER archetypes for this purpose.\r\n\r\nNot to be used for diagnoses and problems that form part of a persisting Problem List - use EVALUATION.problem_diagnosis.(en)", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "sv" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "sv" + }, + "purpose" : "Att registrera ett uppvisat symtom eller tecken ifrån en enskild episod, inklusive kontext, men inte detaljer om tidigare episoder, om det är tillämpligt.", + "keywords" : [ "besvär", "symtom", "störning", "problem", "obehag", "uppvisar besvär", "uppvisar symtom", "tecken" ], + "use" : "Används för att beskriva detaljer för en individs rapporterade symtom eller tecken ifrån en enskild episod, som rapporterats av personen, föräldern, hälso- o sjukvårdspersonal eller annan part. Det kan registreras av hälso- o sjukvårdspersonal som en del av en anamnes som rapporterats till hälso- o sjukvårdspersonalen, observerad av eller registrerats själv av personen som en del av ett kliniskt frågeformulär eller personligt hälsodokument. En komplett anamnes eller patientjournal kan innehålla varierande detaljnivå från flera episoder av ett identifierat symtom eller rapporterade tecken, såväl som multipla symtom och tecken. \r\n\r\nSymtom är subjektiva observationer från en fysisk eller psykisk störning och tecken är objektiva observationer av densamma, upplevda av en individ och rapporteras till journalföraren av samma individ eller annan part. \r\nUr denna logik följer att vi behöver två arketyper för att registrera klinisk anamnes , en för rapporterade symtom och en annan för rapporterade tecken. I verkligheten är detta opraktiskt eftersom det kommer att kräva tillgång till kliniska data i någon av dessa mallar, vilket innebär signifikant merarbete för mallarna och dem som matar in data. Dessutom finns det ofta överlappningar i kliniska koncept, exempevisl är tidigare kräkningar eller blödningar att kategoriserade som ett symtom eller rapporterat tecken? \r\nSom svar har denna arketyp utformats specifikt för att möjliggöra registrering av en sammanhängande enhet mellan tydligt identifierbara symtom och rapporterade tecken vid registrering av en klinisk anamnes.\r\n\r\nAnvänds som en allmän mall för alla symtom och rapporterade tecken. Fältet \"Specifika detaljer\" kan användas för att utöka arketypen för att inkludera ytterligare, specifika datakomponenter för mer komplexa symtom eller tecken. \r\n\r\nArketypen är speciellt utformad för att användas i fältet \"Detaljstruktur\" i OBSERVATION.story-arketypen, men kan även användas inom andra OBSERVATION- eller CLUSTER-arketyper och i \"Associerade symtom och tecken\" eller i fältet \"Tidigare episod\" inom andra exempel av denna CLUSTER.symptom_sign arketypen. Hälso- o sjukvårdspersonal registrerar ofta uttrycket \"Används inte för att dokumentera ett symtom eller tecken\" som uttryckligen rapporteras som inte förekommande. \r\n\r\nAnvänd CLUSTER.exclusion_symptom_sign med försiktighet för specifika ändamål där merarbetet för registreringarna på detta sätt motiverar extra komplexitet och endast om \"Noll signifikanta\" fältet i denna arketyp inte är tillräckligt specifik för syftet för registreringen. Används inte för att dokumentera ett symtom eller tecken som uttryckligen rapporteras som inte förekommande – använd CLUSTER.exclusion_symptom_sign med försiktighet för specifika ändamål där merarbetet för registreringarna på detta sätt motiverar extra komplexitet och endast om \"Noll signifikanta\" fältet i denna arketyp inte är tillräckligt specifik för syftet för registreringen. För specifika symtom eller rapporterade tecken som en effektiv metod för att indikera att individen tillfrågats och det inte rapporterades som obehag eller störning - används mer effektivt som ett \"normalt utlåtande\" snarare än en uttrycklig uteslutning. Det \"Noll signifikanta\" fältet har medvetet inkluderats i denna arketyp för att kliniker kan registrera samma information på ett enkelt och effektivt sätt i ett kliniskt system. Det kan användas för att driva ett användargränssnitt, exempelvis om \"Noll signifikant\" är registrerad som sann kan de återstående fälten döljas på en dataskärm. Denna pragmatiska metod stöder majoriteten av enkla kliniska registreringskrav kring rapporterade symtom och tecken.\r\n\r\nDäremot om det finns en klinisk nödvändighet att uttryckligen registrera att ett symtom eller tecken rapporterades som inte förekommande, exempelvis om det kommer att användas som ett kliniskt beslutsstöd, föredras CLUSTER.exclusion_symptom_sign arketypen. Användningen av CLUSTER.exclusion_symptom_sign ökar komplexiteten i mallutformningen, implementeringen och utfrågningen. Det rekommenderas att CLUSTER.exclusion_symptom_sign arketypen endast beaktas för användning om tydlig fördel kan identifieras i specifika situationer, men ska inte användas för rutinmässigt symtom och tecken registrering.\r\n\r\n\r\n", + "misuse" : "Ska inte användas för att dokumentera ett symtom eller tecken som uttryckligen rapporteras som inte förekommande. Använd CLUSTER.exclusion_symptom_sign med försiktighet för specifika ändamål där merarbetet för registreringarna på detta sätt motiverar extra komplexitet och endast om \"Noll significant\" fältet i denna arketyp inte är tillräckligt specifik för registreringens syfte.\r\n\r\nSka inte användas för att registrera objektiva fynd som en del av en fysisk undersökning . Använd OBSERVATION.exam och relaterad undersökning CLUSTER-arketyper för detta ändamål.\r\n\r\nSka inte användas för diagnoser och problem som ingår i en kvarstående problemlista. Använd då istället EVALUATION.problem_diagnosis.", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "nb" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "nb" + }, + "purpose" : "For å registrere detaljer om en enkeltepisode av et rapportert symptom eller sykdomstegn. Dette kan omfatte kontekst, men ikke detaljer, om tidligere episoder av symptomet/sykdomstegnet.", + "keywords" : [ "lidelse", "plage", "problem", "ubehag", "symptom", "sykdomstegn", "lyte", "skavank" ], + "use" : "For å registrere detaljer om en enkeltepisode av et rapportert symptom eller sykdomstegn hos et individ, som redegjort av personen selv, foreldre, omsorgsperson eller andre parter. Registrering kan skje i forbindelse med opptak av anamnese, eller som en selvregistrering som en del av et klinisk spørreskjema eller personlig journal. \r\nEn fullstendig klinisk anamnese eller pasientanamnese kan inneholde beskrivelser med ulikt detaljnivå om flere episoder knyttet til samme symptom eller sykdomstegn, og vil også kunne inneholde flere ulike symptomer eller sykdomstegn.\r\n\r\nI egentlig forstand er symptomer subjektive opplevelser av en fysisk eller mental forstyrrelse mens sykdomstegn er objektive observasjoner av det samme, som er erfart av et individ og rapportert til en kliniker av individet eller av andre. Fra denne logikken følger at det burde være to arketyper til å registrere klinisk anamnese; en for rapporterte symptomer og en for rapporterte sykdomstegn. I virkeligheten er dette upraktisk og vil kreve registrering av kliniske data i enten den ene eller den andre av disse modellene. I praksis vil dette øke kompleksitet og tidsbruk knyttet til modellering og registrering av data. I tillegg overlapper ofte de kliniske konseptene, for eksempel: Vil tidligere oppkast eller blødning kategoriseres som et symptom eller som et rapportert sykdomstegn?\r\nSom svar på dette er arketypen laget for å tillate registrering av hele kontinuumet mellom tydelig definerte symptomer og rapporterte sykdomstegn når en registrerer en klinisk anamnese.\r\n\r\nArketypen er designet for å gi et generisk rammeverk for alle symptomer og rapporterte sykdomstegn. SLOTet \"Spesifikke detaljer\" kan brukes for å utvide arketypen med ytterligere spesifikke dataelementer for komplekse symptomer eller sykdomstegn.\r\n\r\nArketypen skal settes inn i \"Detaljer\"-SLOTet i OBSERVATION.story-arketypen men kan også brukes i en hvilken som helst OBSERVATION eller CLUSTER-arketype. Arketypen kan også gjenbrukes i andre instanser av CLUSTER.symptom_sign-arketypen i SLOTene \"Assosierte symptomer\" eller \"Tidligere detaljer\".\r\n\r\nKlinikere registrerer ofte frasen \"Ikke av betydning\" i forbindelse med spesifikke symptomer eller rapporterte tegn for å indikere at det er eksplisitt spurt om det spesifikke symptomet, og at det ble svart at symptomet ikke er tilstede i en slik grad at det påfører pasienten ubehag eller uro. Frasen brukes mer som en normalbeskrivelse enn en eksplisitt eksklusjon. Dataelementet \"Ikke av betydning\" er med hensikt lagt til for å tillate at klinikere enkelt og effektivt kan registrere denne informasjonen i det kliniske systemet. Eksempelvis kan \"Ikke av betydning\" brukes i brukergrensesnittet, er dette registrert som \"Sann\" kan de resterende dataelementene skjules i brukergrensesnittet. Denne pragmatiske tilnærmingen støtter hoveddelen av enkel klinisk journalføring av symptomer og sykdomstegn. \r\n\r\nImidlertid kan det være fordelaktig å bruke arketypen CLUSTER.exclusion_symptom_sign dersom det er klinisk behov for å eksplisitt registrere at et symptom eller sykdomstegn ikke er tilstede, for eksempel dersom dette skal brukes til klinisk beslutningsstøtte. Bruk av CLUSTER.exclusion_symptom_sign vil øke kompleksiteten i templatmodellering, implementasjon og spørring. Det anbefales at CLUSTER.exclusion_symptom_sign kun vurderes brukt dersom man kan identifisere en klar gevinst, men bør ikke brukes for rutineregistreringer av symptomer eller sykdomstegn.", + "misuse" : "Brukes ikke til eksplisitt registrering av at et symptom eller sykdomstegn ikke er tilstede. Bruk CLUSTER.exclusion_symptom_sign varsomt da det øker tidsbruk ved registrering og tilfører økt kompleksitet, og bare når dataelementet \"Ikke av betydning\" i denne arketypen ikke er eksplisitt nok for registreringen.\r\n\r\nBrukes ikke til registrering av objektive funn som en del av en fysisk undersøkelse. Bruk OBSERVATION.exam og relaterte CLUSTER.exam-arketyper for dette formålet. \r\n\r\nBrukes ikke til registrering av problemer og diagnoser som en del av en persistent problemliste, til dette brukes EVALUATION.problem_diagnosis.\r\n\r\nBrukes ikke til å dokumentere tiltak og resultat i løpet av hele perioden individet er under behandling, da arketypen er beregnet til å dokumentere symptomer og sykdomstegn som et øyeblikksbilde.", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "pt-br" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "pt-br" + }, + "purpose" : "Registrar detalhes sobre um episódio único de um sinal ou sintoma relatado incluindo contexto, mas não detalhes, de episódios prévios se apropriado.", + "keywords" : [ "queixa", "sintoma", "distúrbio", "problema", "desconforto", "queixa atual", "sintoma atual", "sinal" ], + "use" : "Usar para relatar detalhes sobre um episódio único de um sintoma ou sinal reportado em um indivíduo, como reportado pelo indivíduo, parente, cuidador ou outra arte. Deve ser registrado por um clínico como parte de um relato de história clínica como reportado por eles, observado pelo clínico ou registrado pelo próprio como parte de um questionário ou relato pessoal de saúde. Uma história clínica completa ou história pessoal deve conter - com variáveis níves de detalhes - múltiplos episódios de um sinal ou sintoma identificado ou reportado assim como múltiplos sinais/sintomas. \r\n\r\nNo sentido mais puro, sintomas são observações subjetivas de um distúrbio físico ou mental e sinais são observações objetivas dos mesmos, como experimentado por um indivíduo e reportado para o tomador da história pelo mesmo indivíduo ou outra parte. Por esta lógica segue que serão necessários dois arquétipos para registrar a história clínica - um para sintomas e outro para sinais relatados. Na realidade isto é pouco prático pois vai requerer entrada de dados clínicos em cada um destes modelos o que acrescenta problemas significantes aos modeladores e aqueles que coletam o dado. Em adição, frequentemente há uma interposição entre os conceitos clínicos - por exemplo: vômitos ou sangramentos prévios devem ser considerados sintomas ou sinais reportados? Em resposta, este arquétipo foi especificamente desenhado para prover um modelo de informação único que permita o registro de todo o continuum entre sintomas claramente identificáveis e sinais reportados quando do reistro de uma história clínica. \r\n\r\nEste arquétipo pretende ser utilizado como um padrão genérico para todos os sintomas e sinais reportados. O SLOT 'Detalhes específicos' pode ser utilizado para estender o arquétipo e incluir elementos de dados específicos ou adicionais para sinais e sintomas mais complexos. \r\n\r\nEste arquétipo foi desenhado especificamennte para ser utilizado no SLOT 'Detalhe estruturado' com o arquétipo OBSERVATION.story, mas pode também ser utilizado com outros arquétipos OBSERVATION ou CLUSTER e nos SLOTS 'Sinal/sintoma associado' ou 'Episódio prévio' em outras instâncias deste arquétipo CLUSTER.symptom_sign.\r\n\r\nClínicos frequentemente registram a frase 'não significante' em sintomas específicos ou sinais relatados como um método eficiente de indicar que eles perguntaram ao indivíduo e foi relatado como não causador de desconforto ou distúrbio - efetivamente é utilizado mais como 'referido como normal' do que uma exclusão explícita. O elemento de dado 'não significante' tem sido incluído deliberadamente neste arquétipo para permitir aos clínicos registrarem esta mesma informação de uma maneira simples e efetiva num sistema clínico. Pode ser utilizado para dirigir uma interface de usuário, por exemplo se 'não significante' é registrado como verdadeiro então os demais elementos de dados podem ser ocultos na tela de entrada de dados. Esta abordagem pragmática dá suporte à maioria dos requerimentos de registros clínicos com relação a sinais e sintomas relatados. \r\n\r\nEntretanto se houver um imperativo clínico para explicitar o registro de que um Sintoma ou Sinal foi reportado como ausente, por exemplo se for utilizado para orientar suporte à decisão clínica, então pode ser preferível usar o arquétipo CLUSTER.exclusion_symptom_sign. O uso de CLUSTER.exclusion_symptom_sign vai aumentar a complexidade da modelagem de template, implementação e pesquisa. É recomendado que o arquétipo CLUSTER.exclusion_symptom_sign apenas seja considerado se um benefício claro for identificado em situações específicas e não deve ser utilizado rotineiramente para o registro de sinais/sintomas.", + "misuse" : "Não deve ser utilizado para registrar que um sintoma ou sinal foi explicitamente relatado como ausente - utilizar CLUSTER.exclusion_symptom_sign cuidadosamente para fins específicos em que os problemas de registro garantam complexidade adicional e apenas se o 'não significante' neste arquétipo não for específico suficiente para fins de registro.\r\n\r\nNão deve ser utilizado para registrar achados objetivos como parte de um exame físico - utilizar OBSERVATION.exam e arquétipos do tipo CLUSTER relacionados a exame para esta finalidade.\r\n\r\nNão dever ser utilizado para diagnósticos e problemas que fazem parte de uma lista de problemas - utilizar EVALUATION.problem_diagnosis.", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "ar-sy" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "ar-sy" + }, + "purpose" : "*To record detail about a symptom - either self-recorded by an individual or recorded on the behalf of a patient by a clinician. A complete patient history may include varying level of details about a variety of symptoms.(en)", + "keywords" : [ ], + "use" : "*Use to record detailed information about a symptom as told to a clinician by a patient or self-recorded by the individual/patient.\r\n\r\nThis archetype allows a 'nil significant' statement to be explicitly recorded.(en)", + "misuse" : "*Not to be used to record details about pain. Use the specialisation of this archetype - the CLUSTER.symptom-pain instead.\r\n\r\nNot to be used for diagnoses and problems that form part of a persisting Problem List - use EVALUATION.problem_diagnosis.(en)", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "en" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "en" + }, + "purpose" : "To record details about a single episode of a reported symptom or sign including context, but not details, of previous episodes if appropriate.", + "keywords" : [ "complaint", "symptom", "disturbance", "problem", "discomfort", "presenting complaint", "presenting symptom", "sign" ], + "use" : "Use to record details about a single episode of a symptom or reported sign in an individual, as reported by the individual, parent, care-giver or other party. It may be recorded by a clinician as part of a clinical history record as reported to them, observed by the clinician or self-recorded as part of a clinical questionnaire or personal health record. A complete clinical history or patient story may include varying level of details about multiple episodes of an identified symptom or reported sign, as well as multiple symptoms/signs.\r\n\r\nIn the purest sense, symptoms are subjective observations of a physical or mental disturbance and signs are objective observations of the same, as experienced by an individual and reported to the history taker by the same individual or another party. From this logic it follows that we will need two archetypes to record clinical history - one for reported symptoms and another for reported signs. In reality this is impractical as it will require clinical data entry into either one of these models which adds signficant overheads to modellers and those entering data. In addition, there is often overlap in clinical concepts - for example, is previous vomiting or bleeding to be categorised as a symptom or reported sign? In response, this archetype has been specifically designed to proved a single information model that allows for recording of the entire continuum between clearly identifable symptoms and reported signs when recording a clinical history.\r\n\r\nThis archetype has been intended to be used as a generic pattern for all symptoms and reported signs. The 'Specific details' SLOT can be used to extend the archetype to include additional, specific data elements for more complex symptoms or signs. \r\n\r\nThis archetype has been specifically designed to be used in the 'Structured detail' SLOT within the OBSERVATION.story archetype, but can also be used within other OBSERVATION or CLUSTER archetypes and in the 'Associated symptom/sign' or 'Previous episode' SLOT within other instances of this CLUSTER.symptom_sign archetype.\r\n\r\nClinicians frequently record the phrase 'nil significant' against specific symptoms or reported signs as an efficient method to indicate that they asked the individual and it was not reported as causing any discomfort or disturbance - effectively used more like a 'normal statement' rather than an explicit exclusion. The 'Nil significant' data element has been deliberately included in this archetype to allow clinicians to record this same information in a simple and effective way in a clinical system. It can be used to drive a user interface, for example if 'Nil significant' is recorded as true then the remaining data elements can be hidden on a data entry screen. This pragmatic approach supports the majority of simple clinical recording requirements around reported symptoms and signs. \r\n\r\nHowever if there is a clinical imperative to explicitly record that a Symptom or Sign was reported as not present, for example if it will be used to drive clinical decision support, then it would be preferable to use the CLUSTER.exclusion_symptom_sign archetype. The use of CLUSTER.exclusion_symptom_sign will increase the complexity of template modelling, implementation and querying. It is recommended that the CLUSTER.exclusion_symptom_sign archetype only be considered for use if clear benefit can be identified in specific situations, but should not be used for routine symptom/sign recording.", + "misuse" : "Not to be used to record that a symptom or sign was explicitly reported as not present - use CLUSTER.exclusion_symptom_sign carefully for specific purposes where the overheads of recording in this way warrant the additional complexity, and only if the 'Nil significant' in this archetype is not specific enough for recording purposes.\r\n\r\nNot to be used for recording objective findings as part of a physical examination - use OBSERVATION.exam and related examination CLUSTER archetypes for this purpose.\r\n\r\nNot to be used for diagnoses and problems that form part of a persisting Problem List - use EVALUATION.problem_diagnosis.", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + } + } + }, + "parentArchetypeId" : 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] + } ] + } ], + "attributeTuples" : [ ] + } ] + } ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "occurrences" : "0..0", + "nodeId" : "at0186.0.1", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "value", + "children" : [ { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "DV_BOOLEAN", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "value", + "children" : [ { + "@type" : "C_BOOLEAN", + "rmTypeName" : "Boolean", + "occurrences" : "1..1", + "constraint" : [ true ] + } ] + } ], + "attributeTuples" : [ ] + } ] + } ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "occurrences" : "0..0", + "nodeId" : "at0152.0.1", + "attributes" : [ ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "occurrences" : "0..0", + "nodeId" : "at0164.0.1", + "attributes" : [ ], + "attributeTuples" : [ ] + }, { + "@type" : 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"ARCHETYPE_TERMINOLOGY", + "conceptCode" : "at0000.1", + "termDefinitions" : { + "ar-sy" : { + "at0000.1.1" : { + "@type" : "ARCHETYPE_TERM", + "code" : "at0000.1.1", + "text" : "Other symptom", + "description" : "*Reported observation of a physical or mental disturbance in an individual.(en)" + } + }, + "en" : { + "at0000.1.1" : { + "@type" : "ARCHETYPE_TERM", + "code" : "at0000.1.1", + "text" : "Other symptom", + "description" : "Symptoms known to be indicators of suspected Covid-19 infection" + } + }, + "de" : { + "at0000.1.1" : { + "@type" : "ARCHETYPE_TERM", + "code" : "at0000.1.1", + "text" : "Other symptom", + "description" : "Festgestellte Beobachtung einer körperlichen oder geistigen Störung bei einer Person." + } + }, + "nb" : { + "at0000.1.1" : { + "@type" : "ARCHETYPE_TERM", + "code" : "at0000.1.1", + "text" : "Other symptom", + "description" : "Rapportert observasjon av fysiske tegn eller beskrivelse av unormale eller ubehagelige fornemmelser i kropp og/eller sinn." + } + 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"terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "ar-sy" + }, + "author" : { + "name" : "Mona Saleh" + }, + "otherDetails" : { } + } ] + }, { + "@type" : "TEMPLATE_OVERLAY", + "uid" : "7e289b5c-e123-4dc0-9aad-548352b64915", + "description" : { + "@type" : "RESOURCE_DESCRIPTION", + "originalAuthor" : { + "date" : "2020-03-08" + }, + "otherContributors" : [ ], + "lifecycleState" : { + "codeString" : "unmanaged" + }, + "ipAcknowledgements" : { }, + "references" : { }, + "conversionDetails" : { }, + "otherDetails" : { + "licence" : "This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/.", + "custodian_organisation" : "openEHR Foundation", + "original_namespace" : "org.openehr", + "original_publisher" : "openEHR Foundation", + "custodian_namespace" : "org.openehr", + "MD5-CAM-1.0.1" : "c0a10fc799e5f7ad58c8536537e84e27", + "PARENT:MD5-CAM-1.0.1" : "D5AC52C70A99C8A90ED0239A76BB61B9" + }, + "details" : { + "es-ar" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "es-ar" + }, + "keywords" : [ ], + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "ko" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "ko" + }, + "keywords" : [ ], + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "nb" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "nb" + }, + "keywords" : [ ], + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "pt-br" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "pt-br" + }, + "keywords" : [ ], + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "ar-sy" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "ar-sy" + }, + "keywords" : [ ], + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "en" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "en" + }, + "keywords" : [ ], + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "it" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "it" + }, + "purpose" : "Registrare una descrizione narrativa della storia clinica del soggetto di cura e fornire un quadro in cui annidare gli archetipi dettagliati di CLUSTER, ognuno dei quali supporterà la narrazione con ulteriori dettagli strutturati per i sintomi, gli eventi sanitari e gli argomenti correlati.\r\n\r\nUsato per registrare i dettagli della storia clinica come riportata da un individuo, da un genitore, da un caregiver o da un altro soggetto. Può essere registrato da un clinico come parte di una storia clinica così come riportata, o autoregistrato come parte di un questionario clinico o di una cartella clinica personale.", + "keywords" : [ "cronologia, presentazione, segnalazione, storia, sintomo, salute, registrazione, presentazione di una lamentela, anamnesi" ], + "use" : "Usato per registrare una descrizione delle osservazioni o impressioni soggettive relative alla salute dal punto di vista del soggetto di cura.\r\n\r\nQuando viene registrata da un clinico nell'ambito dell'assistenza sanitaria, la storia può essere utilizzata per acquisire l'anamnesi clinica, come riportata dal soggetto stesso, da un genitore, da un care-giver o da altre parti correlate. Se registrata dal soggetto, può essere utilizzata come resoconto della sua \"cronologia\" di sintomi ed esperienze di salute, e può essere utilizzata per condividerla con gli operatori sanitari o per documentare all'interno della cartella clinica personale del soggetto.\r\n\r\nUtilizzo:\r\n- per registrare una semplice narrazione; e/o\r\n- come archetipo di contenitore per consentire la registrazione di una storia strutturata e dettagliata includendo i relativi archetipi di CLUSTER all'interno dello SLOT \"Dettaglio\". 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Jedoch kann, auch wenn diese Kriterien noch nicht zutreffen, die Bezeichnung 'Diagnose' zutreffend sein. Die Menge an unterstützenden Hinweisen, die für die Bezeichnung 'Diagnose' notwendig ist, ist nicht einfach festzulegen und variiert in Wirklichkeit wohl abhängig vom Gesundheitszustand. Viele Normungsgremien haben sich mit dieser Definitionsproblematik seit Jahren befasst, ohne zu einem eindeutigen Ergebnis zu kommen.\r\n\r\nFür den Zweck der klinischen Dokumentation im Zuge dieses Archetyps werden Problem und Diagnose als Kontinuum betrachtet, wobei ein zunehmender Detaillierungsgrad und unterstützende Beweise in der Regel dem Label der 'Diagnose' Gewicht verleihen. In diesem Archetyp ist es nicht notwendig eine Zuordnung des Gesundheitszustandes als 'Problem' oder 'Diagnose' vorzunehmen. Die Datenanforderungen zur Unterstützung der beiden sind identisch, wobei eine zusätzliche Datenstruktur erforderlich ist, um die Einbeziehung der Nachweise zu unterstützen, wenn und sobald sie verfügbar sind. Beispiele von Problemen beinhalten: Der vom Individuum geäußerte Wunsch, Gewicht zu verlieren, ohne die formale Diagnose der Fettleibigkeit; oder ein Beziehungsproblem mit einem Familienmitglied. Beispiele formaler Diagnosen beinhalten: Krebs, welcher durch historische Information gestützt wird; Untersuchungsergebnisse; histopathologische Ergebnisse; radiologische Befunde - Diese erfüllen die Anforderungen an diagnostische Kriterien. In der Realität sind Probleme und Diagnosen nicht eindeutig einem der beiden Extreme des Problem-Diagnose-Spektrums zuzuordnen, sondern irgendwo dazwischen.\r\n\r\nDieser Archetyp kann in verschiedenen Zusammenhängen verwendet werden. Zum Beispiel: Dokumentation eines Problems oder einer Diagnose während einer klinischen Beratung; Ausfüllen einer persistenten Problemliste; Zusammenfassende Aussage in einem Entlassungsdokument.\r\n\r\nIn der Praxis verwenden Kliniker viele kontextspezifische Merkmale wie Vergangenheit/Gegenwart, Primär/Sekundär, Aktiv/Inaktiv, Aufnahme/Entlassung etc. Die Zusammenhänge können orts-, spezialisierungs-, episoden- oder workflowspezifisch sein, was zu Verwirrung oder gar potenziellen Sicherheitsproblemen führen kann, wenn die Merkmale in Problemlisten fortbestehen oder in Dokumenten geteilt werden, die außerhalb des ursprünglichen Kontextes liegen. Diese Merkmale können separat archetypisiert und in den Slot 'Status' aufgenommen werden, da ihre Verwendung unter verschiedenen Bedingungen variiert. Es wird erwartet, dass diese meist im entsprechenden Kontext verwendet und nicht ohne klares Verständnis der möglichen Folgen aus diesem Kontext heraus geteilt werden. So kann beispielsweise eine Primärdiagnose des einen Arztes eine Sekundärdiagnose für einen anderen Spezialisten darstellen; ein aktives Problem kann inaktiv werden (oder umgekehrt) und dies kann sich auf die sichere Verwendung der klinischen Entscheidungshilfe auswirken. Die Problem/Diagnose Merkmale sollen generell an die Kontexte der lokalen klinischen Systeme angepasst werden und in der Praxis sollte der jeweilige Status von Klinikern manuell kuratiert werden, um sicherzustellen, dass die Listen der aktuellen/vergangenen, aktiven/inaktiven oder primären/sekundären Probleme klinisch korrekt sind.\r\n\r\nDieser Archetyp wird als Komponente im Sinne des von Larry Weed beschriebenen 'Problem Oriented Medical Record' verwendet. Zusätzliche Archetypen, die klinische Konzepte wie z.B. die Erkrankung als übergreifender Organisator für Diagnosen usw. repräsentieren, müssen entwickelt werden, um diesen Ansatz zu unterstützen.\r\n\r\nIn einigen Situationen könnte angenommen werden, dass die Identifizierung einer Diagnose nur innerhalb der Expertise von Ärzten liegt, aber das ist nicht die Absicht dieses Archetyps. Diagnosen können mit diesem Archetyp von jedem Angehörigen der Gesundheitsberufe erfasst werden.", + "misuse" : "Nicht zur Dokumentation von Symptomen, welche vom Individuum beschrieben werden. Verwenden Sie den Archetyp CLUSTER.symptom, normalerweise innerhalb des OBSERVATION.story Archetyps.\r\n\r\nNicht zur Dokumentation von Untersuchungsergebnissen. Verwenden Sie untersuchungsbezogene CLUSTER Archetypen, normalerweise verschachtelt innerhalb des OBSERVATION.exam Archetyps.\r\n\r\nNicht zur Dokumentation von Laborergebnissen oder verwandten Diagnosen. Verwenden Sie einen geeigneten Archetyp aus der Familie der Labor-OBSERVATION Archetypen.\r\n\r\nNicht zur Dokumentation von Ergebnissen aus bildgebenden Verfahren. Verwenden Sie einen geeigneten Archetyp aus der Famile der Bildgebung-OBSERVATION Archetypen.\r\n\r\nNicht zur Dokumentation von Differentialdiagnosen. Verwenden Sie den Archetyp EVALUATION.differential_diagnosis.\r\n\r\nNicht zur Dokumentation von 'Grund für Kontakt' oder 'Bestehende Beschwerden'. Verwenden Sie den Archetyp EVALUATION.reason_for_encounter.\r\n\r\nNicht zur Dokumentation von Prozeduren. Verwenden Sie den Archetyp ACTION.procedure.\r\n\r\nNicht zur Dokumentation von Details über Schwangerschaft. Verwenden Sie die Archetypen EVALUATION.pregnancy_bf_status und EVALUATION.pregnancy sowie verwandte Archetypen.\r\n\r\nNicht zur Dokumentation von Aussagen über Gesundheitsrisiken oder potentielle Gesundheitsprobleme. Verwenden Sie den Archetyp EVALUATION.health_risk.\r\n\r\nNicht zur Dokumentation von Aussagen über Nebenwirkungen, Allergien oder Intoleranzen. Verwenden Sie den Archetyp EVALUATION.adverse_reaction.\r\n\r\nNicht zur Dokumentation einer expliziten Abwesenheit oder Nicht-Anwesenheit eines Problems oder einer Diagnose, wie zum Beispiel 'Kein bekanntes Problem bzw. Diagnose' oder 'Kein Diabetes festgestellt'. Verwenden Sie den Archetyp EVALUATION.exclusion-problem_diagnosis um eine postitive Aussage über den Ausschluss eines Problems oder einer Diagnose zu treffen.", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "sv" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "sv" + }, + "purpose" : "Att dokumentera ett enskilt identifierat hälsoproblem eller diagnos. Spännvidden av ett hälsoproblem har avsiktligt gjorts bred, för att kunna fånga upp eventuella verkliga eller upplevda *oroskänslor* som kan inverka negativt på en individs välbefinnande. Ett hälsoproblem kan identifieras av individen, en vårdgivare eller en sjukvårdspersonal. En diagnos definieras däremot baserat på objektiva kliniska kriterier, oftast fastställd endast av sjukvårdspersonal.", + "keywords" : [ "*fråga", "tillstånd", "problem", "diagnos", "oro", "skada", "klinisk tolkning" ], + "use" : "Används för att beskriva ett enskilt identifierat hälsoproblem eller diagnos.\r\nTydliga definitioner som möjliggör en differentiering mellan ett \"problem\" och en \"diagnos\" är nästan omöjliga i praktiken. Vi kan inte på ett tillförlitligt sätt säga när ett problem bör betraktas som en diagnos. När diagnostiska eller klassificeringskriterier är uppfyllda kan vi tryggt kalla tillståndet en formell diagnos. \r\n\r\nOm det finns stödjande bevis tillgängligt, kan det ändå vara giltigt att använda termen \"diagnos\" trots att dessa villkor ännu inte uppfyllts. Det är inte lätt att definiera mängden stödjande bevis som krävs för diagnosmärkning och i verkligheten varierar det från fall till fall. Många standardkommittéer har brottats med denna definitionsgåta i åratal utan tydlig upplösning.\r\n\r\nVid tillämpning av klinisk dokumentation med denna arketyp betraktas problem och diagnoser som ett kontinuum med utrymme för fler detaljer och stödjande bevis som vanligtvis ger stöd för märkningen \"diagnos\". I denna arketyp är det inte nödvändigt att klassificera tillståndet som ett \"problem\" eller \"diagnos\". Kraven för att stödja dokumentation av vardera är identiska, innehållande extra datastruktur som krävs för att stödja inmatning av bevis om och när den blir tillgänglig.\r\nExempel på problem är: individens uttryckliga önskan att gå ner i vikt, men utan en formell diagnos av fetma eller ett relationsproblem med en familjemedlem. Exempel på formella diagnoser skulle omfatta cancer som stöds av anamnes, undersökningsfynd, histopatologiska fynd, radiologiska fynd samt möter alla kända kriteriekrav för diagnostik. \r\n\r\nI praktiken befinner sig de flesta problem eller diagnoser inte i någon ände av problemet-diagnos spektrumet, utan någonstans däremellan. \r\nDenna arketyp kan användas i flera kontexter, exempelvis för dokumentation av ett problem eller en klinisk diagnos under en klinisk konsultation, ifyllnad av en fast problemlista eller för en redogörande sammanfattning i ett utskrivningsdokument.\r\n\r\nI praktiken använder kliniker många kontext-specifika bestämningar som exempelvis tidigare och nuvarande, primär och sekundär, aktiv och inaktiv, inskrivning och utskrivning etc. Kontexterna kan vara plats-, specialitet-, episod-eller arbetsflödes-specifika. Dessa kan orsaka förvirring eller t.o.m. vara potentiella säkerhetsproblem om de förevigas i problemlistor eller delas i dokument som är utanför den ursprungliga kontexten.\r\nDessa bestämningar kan vara separata i arketyperna och ingår i \"status\"-fältet, eftersom deras användning varierar i olika inställningar. \r\nDet förväntas att de huvudsakligen används i en lämplig kontext och inte sprids utanför kontexten utan tydlig förståelse för potentiella konsekvenser.\r\nExempelvis kan en diagnos vara primär för en kliniker och sekundär för en annan specialist, ett aktivt problem kan bli inaktivt (eller vice versa) och detta kan påverka den säkra användningen av kliniskt beslutsstöd.\r\n\r\nI allmänhet bör dessa bestämningar tillämpas lokalt inom ramen för det kliniska systemet, och i praktiken bör dessa tillstånd ordnas manuellt av kliniker för att säkerställa att listor över nuvarande och tidigare, aktiv och inaktiv eller primärt och sekundärt problem är kliniskt korrekta.\r\nDenna arketyp kommer att användas som en komponent inom den problemorienterade patientjournalen som beskrivs av Larry Weed. Ytterligare arketyper, som presenterar kliniska begrepp som villkor som en övergripande organisatör för diagnoser etc. kommer att behöva utvecklas för att stödja denna strategi.\r\n\r\nI vissa situationer, kan identifiering av en diagnos vara lämplig enbart inom läkarnas expertis, men det är inte avsikten med denna arketyp. Diagnoser kan dokumenteras med hjälp av denna arketyp av vilken som helst sjukvårdspersonal.\r\n", + "misuse" : "Ska inte användas för att dokumentera symtom som beskrivs av individen. Använd CLUSTER. symptom arketypen vanligtvis inom OBSERVATION.story-arketypen för det ändamålet.\r\n\r\nSka inte användas för att dokumentera undersökningsfynd. Använda då istället arketyper från den undersökningsrelaterade gruppen CLUSTER- som oftast är inkapslad i Observation Exam-arketypen.\r\n\r\nSka inte användas för att dokumentera testresultat från laboratoriet eller till relaterade diagnoser, exempelvis patologiska diagnoser. Använd då istället en lämplig arketyp från laboratoriegruppen OBSERVATION.\r\n\r\nSka inte användas för att dokumentera undersökningsfynd genom bildmedia eller bilddiagnostik. Använd då istället en lämplig arketyp från bildmediegruppen OBSERVATION arketyper.\r\n\r\nSka inte användas för att dokumentera \"differentialdiagnostik\". Använd då istället EVALUATION.differential_diagnosis-arketypen.\r\n\r\nSka inte användas för att dokumentera \"Anledning till Vårdtillfälle\" eller \"Huvudsakligt besvär\". Använd EVALUATION.reason_for_encounter-arketypen till dessa ändamål.\r\n\r\nSka inte användas för att dokumentera åtgärder. Använd då istället ACTION.procedure-arketypen.\r\n\r\nSka inte användas för att dokumentera uppgifter om graviditet. Använd EVALUATION.pregnancy_bf_status och EVALUATION.pregnancy och relaterade arketyper till dessa ändamål.\r\n\r\nSka inte användas för att dokumentera bedömningar om hälsorisker eller potentiella problem. Använd då istället EVALUATION.health_risk-arketypen.\r\n\r\nSka inte användas för att dokumentera redogörelser om biverkningar, allergier eller intoleranser. Använd EVALUATION.adverse_reaction-arketyp för dessa ändamål.\r\n\r\nSka inte användas för särskild dokumentering av frånvaro (eller negativ närvaro) av ett problem eller en diagnos, exempelvis \"inga kända problem eller diagnoser\" eller \"Ingen känd diabetes\". Använd EVALUATION.exclusion-problem_arketypen för att uttrycka ett positivt utlåtande om uteslutning av ett problem eller diagnos. \r\n\r\n", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "es-ar" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "es-ar" + }, + "purpose" : "Para el registro de detalles acerca de un único problema de salud o diagnóstico.\r\nEl alcance previsto del problema de salud se mantiene deliberadamente poco definido en el contexto de la documentación clínica, de modo tal que pueda representarse cualquier problema, real o percibido, que pueda afectar al bienestar de un individuo en cualquier grado. Un problema de salud puede ser identificado por un individuo, un cuidador, o un profesional de la salud. Para la definición de un diagnóstico se require además de criterios clínicos objetivos, habitualmente determinados por un profesional de la salud.", + "keywords" : [ "asunto", "condición", "problema", "diagnóstico", "preocupación", "lesión", "impresión clínica" ], + "use" : "Utilícese para registrar detalles acerca de un único problema de salud o diagnóstico.\r\n\r\nUna definición clara que permita diferenciar un \"problema\" de un \"diagnóstico\" es casi imposible en la práctica - no podemos determinar en forma confiable cuando un problema debería ser considerado un diagnóstico. Cuando se cumplen con éxito determinados criterios diagnósticos o de clasificación es posible denominar una condición como un diagnóstico formal, pero previo al cumplimiento de dichos criterios y en tanto exista evidencia clínica que lo sustente, también puede ser válido el uso del término \"diagnóstico\". La cantidad de evidencia de apoyo varía de caso en caso. Muchos comités de estándares han lidiado con este problema por años sin lograr una resolución clara.\r\n\r\nA los fines de la documentación clínica mediante este arquetipo, problema y diagnóstico son considerados como un continuo, donde el incremento de los niveles de detalle y sustento en la evidencia inclinan la balanza hacia la etiqueta de \"diagnóstico\". Los requerimientos de datos que sustentan la documentación de ambos son idénticos, siendo necesarias estructuras de datos adicionales para sustentar la inclusión de la evidencia cuando esta exista y se encuentre disponible. Los ejemplos de problemas incluyen: la expresión del deseo de bajar de peso por parte de un individuo sin la existencia de un diagnóstico formal de obesidad, o un problema de relación con un familiar. Los ejemplos de diagnósticos formales incluyen un cáncer fundamentado en información histórica, los hallazgos de un examen, los hallazgos histopatológicos, los hallazgos radiológicos, y que cumplen todos los criterios diagnósticos. En la práctica, la mayoría de los problemas o diagnósticos no se encuentran en los extremos del espectro problema-diagnóstico sino que se ubican en alguna posición intermedia.\r\n\r\nEste arquetipo puede ser utilizado en diversos contextos. Por ejemplo, para registrar un problema o diagnóstico clínico durante una consulta clínica, para la elaboración de una Lista de Problemas persistente, o para proveer una afirmación sumaria dentro de un documento de Resumen de Alta.\r\n\r\nEn la práctica, los clínicos utilizan muchos calificadores dependientes del contexto, tales como pasado/actual, primario/secundario, activo/inactivo, admisión/egreso, etc. Estos contextos pueden ser relativos a la localización, la especialización, el episodio, o a un instancia de un proceso, pudiendo entonces generar confusión o riesgos potenciales de seguridad para el paciente si son incluidos en Listas de Problemas o documentos compartidos que carecen del contexto original. Estos contextos pueden ser arquetipados en forma separada e incluidos en el slot de \"Estado\", dado que su uso varía en diferentes escenarios. Su uso mayormente pretendido debe darse en el contexto apropiado y no debería ser compartido fuera de dicho contexto sin una clara comprensión de sus consecuencias potenciales. Por ejemplo: un diagnóstico primario podría ser un diagnóstico secundario para otro especialista; un problema activo puede tornarse inactivo (o viceversa) e impactar en la seguridad de una decisión clínica. En general, estos calificadores deberían aplicarse localmente dentro del contexto del sistema clínico y en la práctica estos estados deberían ser manualmente mantenidos por clínicos a fin de asegurar que las listas de problemas, actuales o pasados, activos o inactivos o primarios y secundarios, sean clínicamente exactos.\r\n\r\nEste arquetipo será utilizado como un componente del Registro Médico Orientado al Problema descripto por Larry Weed. Se requerirá del desarrollo de arquetipos adicionales para la representación de conceptos clínicos tales como una condición para un organizador general de diagnósticos, etc.\r\n\r\nEn algunas situaciones puede asumirse que la identificación de un diagnóstico solo se ajusta a la experticia del médico, pero no es el propósito de este arquetipo. Los diagnósticos pueden ser registrados mediante este arquetipo por parte de cualquier profesional.\r\n", + "misuse" : "No debe ser utilizado para registrar síntomas tal cual fueron descriptos por el individuo; para ello se debe utilizar el arquetipo CLUSTER.symptom, habitualmente dentro del contexto del arquetipo OBSERVATION.story.\r\n\r\nNo debe ser utilizado para registrar hallazgo de exámenes, para ello se debe utilizar la familia de arquetipos relacionados a exámenes, habitualmente contenidos dentro del arquetipo OBSERVATION.exam.\r\n\r\nNo debe ser utilizado para registrar hallazgos de pruebas de laboratorio o diagnósticos relacionados (como por ejemplo diagnósticos patológicos); para ello se debe utilizar un arquetipo apropiado de la familia de arquetipos del tipo OBSERVATION.\r\n\r\nNo debe ser utilizado para registrar resultados de exámenes por imágenes o diagnósticos imagenológicos; para ello se debe utilizar un arquetipo apropiado de la familia de arquetipos del tipo OBSERVATION.\r\n\r\nNo debe ser utilizado para registrar diagnósticos diferenciales; para ello se debe utilizar el arquetipo EVALUATION.differential_diagnosis.\r\n\r\nNo debe ser utilizado para registrar \"Motivos de Consulta\"; para ello se debe utilizar el arquetipo EVALUATION.reason_for_encounter.\r\n\r\nNo debe ser utilizado para registrar procedimientos; para ello se debe utilizar el arquetipo ACTION.procedure.\r\n\r\nNo debe ser utilizado para registrar detalles acerca del embarazo; para ello se debe utilizar los arquetipos EVALUATION.pregnancy_bf_status, EVALUATION.pregnancy y los arquetipos relacionados.\r\n\r\nNo debe ser utilizado para registrar aseveraciones acerca de riesgos para la salud o problemas potenciales; para ello se debe utilizar el arquetipo EVALUATION.health_risk.\r\n\r\nNo debe ser utilizado para registrar aseveraciones acerca de reacciones adversas, alergias o intolerancias; para ello se debe utilizar el arquetipo EVALUATION.adverse_reaction.\r\n\r\n\r\nNo debe ser utilizado para registrar la ausencia explícita (o presencia negativa) de un problema o diagnóstico (como por ejemplo \"sin diagnósticos o problemas conocidos\" o \"sin diabetes conocida\"); para expresar una aseveración positiva acerca de la exclusión de un problema o diagnóstico se debe utilizar el arquetipo EVALUATION.exclusion-problem_diagnosis.", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "nb" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "nb" + }, + "purpose" : "For å registrere detaljer om ett identifisert helseproblem eller en diagnose.\r\n\r\nOmfanget for et helseproblem er med vilje løst definert, for å kunne registrere en reell eller selvoppfattet bekymring som i større eller mindre grad kan påvirke et individs velvære negativt. Et helseproblem kan identifiseres av individet selv, en omsorgsperson eller av helsepersonell. En diagnose er derimot definert basert på objektive kliniske kriterier, og stilles som regel bare av helsepersonell.", + "keywords" : [ "emne", "problem", "tilstand", "hindring", "diagnose", "helseproblem", "bekymring", "funn", "helsetilstand", "konflikt", "utfordring", "klinisk bilde" ], + "use" : "Brukes til å registrere detaljer om ett identifisert helseproblem eller en diagnose. \r\n\r\nÅ klart definere skillet mellom et \"problem\" og en \"diagnose\" er i praksis nesten umulig, og vi kan ikke på en pålitelig måte si når et problem skal ses på som en diagnose. Når diagnostiske- eller klassifikasjonskriterier er innfridd kan vi trygt kalle tilstanden en formell diagnose, men før disse kriteriene er møtt kan det dersom det finnes støttende funn også være riktig å kalle den en diagnose. Mengden støttende funn som kreves for å sette merkelappen \"diagnose\" er ikke lett å definere, og varierer sannsynligvis i praksis fra tilstand til tilstand. Mange standardiseringskomiteer har arbeidet med dette definisjonsproblemet i årevis uten å komme til noen klar konklusjon.\r\n\r\nNår det gjelder klinisk dokumentasjon med denne arketypen må problemer og diagnoser ses på som deler av et spektrum der økende detaljgrad og mengde støttende funn som regel gir vekt mot merkelappen \"diagnose\". I denne arketypen er det ikke nødvendig å klassifisere tilstanden som enten et problem eller en diagnose. Datastrukturen for å dokumentere dem er identisk, med tilleggsstrukturer som støtter inklusjon av nye funn når eller hvis de blir tilgjengelige. Eksempler på problemer kan være et individs uttrykte ønske om å gå ned i vekt uten en formell diagnose av fedme, eller problemer i forholdet til et familiemedlem. Eksempler på formelle diagnoser kan være en kreftsvulst der diagnosen er støttet av historisk informasjon, undersøkelsesfunn, histologiske funn, radiologiske funn, og som møter alle diagnosekriterier. I praksis er de fleste problemer eller diagnoser ikke i hver sin ende av problem/diagnose-spektrumet, men et sted mellom.\r\n\r\nDenne arketypen kan brukes i mange sammenhenger. Eksempler kan være å registrere et problem eller en klinisk diagnose under en klinisk konsultasjon, fylle en persistent problemliste, eller for å gi oppsummerende informasjon i en epikrise.\r\n\r\nI praksis bruker klinikere mange kvalifikatorer som nåværende/tidligere, hoved/bidiagnose, aktiv/inaktiv, innleggelse/utskriving, etc. Sammenhengene kan være steds-, spesialiserings-, episode- eller arbeidsflytspesifikke, og disse kan forårsake forvirring eller til og med mulige sikkerhetsrisikoer dersom de videreføres i problemlister eller deles i dokumenter utenfor sin opprinnelige sammenheng. Disse kvalifikatorene kan arketypes separat og inkluderes i \"Status\"-SLOTet, fordi bruken varierer i ulike settinger. Disse vil sannsynligvis hovedsakelig brukes i passende sammenhenger, og ikke deles utenfor sammenhengen uten en klar forståelse av mulige konsekvenser. For eksempel kan en hoveddiagnose for en kliniker være en bidiagnose for en annen spesialist, et aktivt problem kan bli inaktivt (og omvendt), og dette kan ha innvirkning på sikkerhet og beslutningsstøtte. Generelt burde disse kvalifikatorene brukes lokalt og innenfor kontekst i det kliniske systemet, og i praksis bør de manuelt administreres av klinikere for å sikre at lister over nåværende/tidligere, aktiv/inaktiv eller hoved/bidiagnoser er klinisk presise.\r\n\r\nDenne arketypen vil bli brukt som en komponent i den problemorienterte journalen som beskrevet av Larry Weed. Tilleggsarketyper som representerer kliniske konsepter som f.eks. \"tilstand\" som en overbygning for diagnoser etc, vil måtte utvikles for å støtte dette.\r\n\r\nI noen situasjoner antas det at å stille en diagnose ligger fullstendig innenfor legers domene, men dette er ikke hensikten med denne arketypen. Diagnoser kan registreres av alt helsepersonell ved hjelp av denne arketypen.", + "misuse" : "Brukes ikke til å registrere symptomer slik de beskrives av individet. Til dette brukes CLUSTER.symptom-arketypen, som regel innenfor OBSERVATION.story-arketypen.\r\n\r\nBrukes ikke til å registrere funn ved klinisk undersøkelse. Til dette brukes gruppen av undersøkelsesrelaterte CLUSTER-arketyper, som regel innenfor OBSERVATION.exam-arketypen.\r\n\r\nBrukes ikke til å registrere laboratoriesvar eller relaterte diagnoser for eksempel patologiske diagnoser. Til dette brukes en passende arketype fra laboratoriefamilien av OBSERVATION-arketyper.\r\n\r\nBrukes ikke til å registrere billeddiagnostiske svar eller diagnoser. Til dette brukes en passende arketype fra billeddiagnostikkfamilien av OBSERVATION-arketyper.\r\n\r\nBrukes ikke til å registrere differensialdiagnoser. Til dette brukes EVALUATION.differential_diagnosis-arketypen.\r\n\r\nBrukes ikke til å registrere kontaktårsak eller klinisk problemstilling ved kontakt. Til dette brukes EVALUATION.reason_for_encounter-arketypen.\r\n\r\nBrukes ikke til å registrere prosedyrer, til dette brukes ACTION.procedure-arketypen.\r\n\r\nBrukes ikke til å registrere detaljer om graviditet utover diagnoser. Til dette brukes EVALUATION.pregnancy_bf_status og EVALUATION.pregnancy, samt relaterte arketyper.\r\n\r\nBrukes ikke til å registrere vurderinger av potensiale og sannsynlighet for fremtidige problemer, diagnoser eller andre uønskede helseeffekter, til dette brukes EVALUATION.health_risk-arketypen.\r\n\r\nBrukes ikke til å registrere utsagn om uønskede reaksjoner, allergier eller intoleranser - bruk EVALUATION.adverse_reaction-arketypen.\r\n\r\nBrukes ikke til å registrere et eksplisitt fravær (eller negativ tilstedeværelse) av et problem eller en diagnose, f.eks. \"ingen kjente problemer eller diagnoser\" eller \"ingen kjent diabetes\". Bruk EVALUATION.exclusion-problem_diagnosis for å uttrykke fravær av et problem eller en diagnose.\r\n\r\nBrukes ikke til å registrere pasientens tilgjengelige ressurser for egenomsorg - bruk egne EVALUATION-arketyper for dette formålet.", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "ko" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "ko" + }, + "purpose" : "단일한 확인된 건강 문제 또는 진단에 대한 상세내역을 기록하기 위함.\r\n\r\n의도된 건강 문제의 범위는 어느 정도로 개인의 웰빙에 좋지않은 방향으로 영향을 주는 모든 실제 또는 인지된 걱정(concern)를 획득하기 위해 궁극적으로 임상 문서의 문맥에서 느슨하게 유지됨. 건강 문제는 해당 개인, 또는 보호자, 헬스케어 전문가에 의해 확인될 수도 있음. 그러나 진단은 객관적인 임상적 기준에 근거하여 추가적으로 정의되며, 일반적으로 헬스케어 전문가들에 의해서만 결정됨.", + "keywords" : [ "이슈", "상태", "진단", "걱정", "상해", "임상소견" ], + "use" : "단일한 확인된 건강 문제 또는 진단에 대한 상세내역을 기록하기 위함.\r\n\r\n'문제(problem)'와 '진단(diagnosis)' 간의 차이를 구분할 수 있는 명확한 정의는 실무에서 거의 불가능함 - 우리는 문제가 언제 진단으로 간주되어야 하는지를 신뢰성있게 구별할 수 없음. 진단 또는 분류 기준이 성공적으로 만족될 때, 우리는 상태(condition)를 정규적인 진단으로 확실하게 말할 수 있지만, 이런 상태를 만족하기 이전에, 지지할 수 있는 증거를 이용가능하다면 '진단'이라는 용어를 또한 사용하는 것이 유효할 수 있음. 진단이라는 표시를 위해 필요한 지지할 수 있는 증거의 양은 정의하기 쉽지 않고 실제로 상태에 따라 다양할 수 있음. 많은 표준 기구는 수 년 동안 명확한 해결책없이 이러한 정의적인 문제로 가득 차 있음. \r\n\r\n이 아키타입을 통한 임상 문서의 목적을 위해서, 증가하는 상세내용의 수준과 일반적으로 '진단'의 표시에 대한 무게감을 제공하는 지지할 수 있는 증거를 가지고, 문제와 진단은 연속된 것(a continuum)으로 간주됨. 이 아키타입 내에서 상태를 '문제' 또는 '진단'로 분류할 필요는 없음. 두 가지의 문서화를 보조하기 위한 데이터 요구사항은 동일하며, 증거가 이용가능하거나/이용가능할 때 이 증거의 포함(inclusion)을 지원하는 데 필요한 추가적인 데이터 구조를 가지고 있음. 문제의 예는 다음을 포함함 : 체중을 줄이고 싶다는 개인의 표현, 그러나 비만의 정규적인 진단은 없음. 또는 가정 구성원과의 관계 문제. 정규적인 진단의 예는 과거 정보와 검사 소견, 조직병리학적 소견, 영상의학적 소견에 의해 지지되고 알려진 진단적 기준을 위한 모든 요구사항을 만족하는 암이 포함됨. 실무에서 대부분의 문제와 진단은 문제-진단 스펙트럼의 양 끝에 있지 않지만 그 사이 어딘가에 있음.\r\n\r\n이 아키타입은 많은 문맥 내에서 사용될 수 있음. 예를 들어, 임상 자문 동안 문제 또는 임상적 진단를 기록하는 것; 영속적인 문제 목록(persistent Problem List)을 채우는 것; 또는 퇴원 요약 문서(Dischatge Summary document) 내에 요약 문장(summary statement)을 제공하는 것.\r\n\r\n실무에서 임상의는 과거/현재(Present/Past), 일차/이차(Primary/Secondary), 활성/비활성(Active/Inactive), 입원/퇴원(Admission/Discharge) 등 많은 문맥-특징적인 한정자(qualifiers)를 사용함. 문맥은 위치-, 세부전공-, 에피소드-, 워크플로우-특징적 이며 이러한 것들은 원래 문맥에서 벗어난 문제 목록에서 유지되거나 문서 내에서 공유된다면 혼란 또는 심어서 잠재적인 안전 이슈를 발생시킬 수 있음. 이러한 한정자의 이용이 잠재적인 결과에 대한 명확한 이해없이 문맥에 따라 다양하기 때문에, 한정자는 구분되어 아키타입화될 수 있고 'Status' slot에 포함될 수 있음. 예를 들어, 어떤 한 임상의의 일차 진단은 다른 전문의에게는 이차 진단일 수 있음; 현재 활성화된(active) 진단은 비활성화될 수 있음 (또는 그 반대) 그리고 이것은 안전한 임상의사결정의 사용에 영향을 줄 수 있음. 일반적으로 이러한 한정자는 임상 시스템의 문맥 내에서 그 부분에서 적용되어야 하고, 실무에서 이러한 상태는, 현재/과거 또는 활성/비활성, 일차/이차 문제의 목록은 임상적으로 정확하다는 것을 보장하기위해서 임상의에 의해 수기로 조정될 수 있음.\r\n\r\n이 아키타입은 Larry Weed가 기술한 문제지향의무기록(Problem Oriented Medical Record) 내에서 컴포넌트로 사용될 것임. 상태와 같은 임상 개념을 진단을 위한 포괄적인 구성자(organizer)로 표현하는 추가적인 아키타입은 이러한 접근방식을 지원하기 위해 개발될 필요가 있을 것임.\r\n\r\n몇몇 상황에서, 진단의 확인은 임상의의 전문성 안에서만 적용한다는 가정이 될 수 있지만 이것은 이 아카타입이 의도하는 바는 아님. 모든 헬스케어 전문가가 이 아키타입을 이용해 진단을 기록할 수 있음.", + "misuse" : "개인에 의해 기술된 증상을 기록하는데 사용하지 않아야 함 - 보통 OBSERVATION.story archetype 내에서 CLUSTER.symptom archetype을 사용해야 함.\r\n\r\n검사 소견을 기록하는데 사용하지 않아야 함 - 보통 OBSERVATION.exam archetype 내에 중첩되어, examination-related CLUSTER archetypes 계열을 사용해야 함.\r\n\r\n검사실 검사 결과 또는 병리학적 검사와 같은 관련된 진단을 기록하는데 사용하지 않아야 함 - 보통 검사실 계열의 OBSERVATION archetype에서 적당한 archetype을 사용해야 함.\r\n\r\n이미지 검사 결과 또는 이미지 진단을 기록하는데 사용하지 않아야 함 - 이미지 계열의 OBSERVATION archetype에서 적당한 archetype을 사용해야 함.\r\n\r\n'감별 진단'을 기록하는데 사용하지 않아야 함 - EVALUATION.differential_diagnosis archetype을 사용해야 함.\r\n\r\n'내원의 이유(Reason for Encounter)' 또는 '주호소(Presenting Complaint)'를 기록하는데 사용지 않아야 함 - EVALUATION.reason_for_encounter archetype을 사용해야 함.\r\n\r\n'처치(procedure)'를 기록하는데 사용하지 않아야 함 - ACTION.procedure archetype를 사용해야 함.\r\n\r\n임신에 대한 상세내용을 기록하는데 사용하지 않아야 함 - EVALUATION.pregnancy_bf_status와 EVALUATION.pregnancy 그리고 관련된 archetypes를 사용해야 함.\r\n\r\n건강 위험요소(health risk) 및 잠재적인 문제에 대한 진술문을 기록하는데 사용하지 않아야 함 - EVALUATION.health_risk archetype을 사용해야 함.\r\n\r\n이상반응(adverse reactions), 알레르기(allergies) 또는 불내성(intolerances)에 대한 진술문을 기록하는데 사용하지 않아야 함 - EVALUATION.adverse_reaction archetype을 사용해야 함.\r\n\r\n'알려진 문제 또는 진단 없음' 또는 '알려진 당뇨병 없음' 등과 같은 문제와 진단의 부재(absence (or negative presence))을 명시적으로 기록하는데 사용하지 않아야 함 - 문제 또는 진단의 배제(exclusion)에 대한 긍정 진술문(positive statement)을 표현하는데 EVALUATION.exclusion-problem_diagnosis archetype을 사용해야 함.", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "pt-br" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "pt-br" + }, + "purpose" : "Para gravar detalhes sobre um único problema de saúde ou diagnóstico identificado.\r\n\r\nO escopo pretendido de um problema de saúde é deliberadamente mantido livre no contexto da documentação clínica, de forma a captar quaisquer preocupações reais ou percebidas que podem afetar adversamente, em qualquer grau, o bem-estar de um indivíduo. Um problema de saúde pode ser identificado pela o indivíduo, um prestador de cuidados ou de um profissional de saúde. No entanto, o diagnóstico é adicionalmente definido com base em critérios clínicos objetivos, e, geralmente, determinado apenas por um profissional de saúde.", + "keywords" : [ "caso", "condição", "problema", "diagnóstico", "preocupação", "prejuízo", "impressão clínica" ], + "use" : "Para gravar detalhes sobre um único problema de saúde ou diagnóstico identificado.\r\n\r\nDefinições claras que permitem a diferenciação entre um \"problema\" e um \"diagnóstico\" são quase impossíveis na prática - não podemos dizer de forma segura quando um problema deve ser considerado como um diagnóstico. Quando o diagnóstico ou os critérios de classificação são cumpridos com sucesso, então com confiança podemos chamar a condição de um diagnóstico formal, mas antes que essas condições sejam cumpridas e enquanto houver evidências para tanto, também pode ser válido usar o termo \"diagnóstico\". A quantidade de evidências de apoio requerida para a indicação de diagnóstico não é fácil de ser definida e na realidade, provavelmente varia de condição para condição. Muitos comitês de padrões têm, por anos, se confrontado com esse dilema de definição sem resolução clara. \r\n\r\nEste arquétipo pode ser utilizado em muitos contextos. Por exemplo, na gravação de um problema ou um diagnóstico durante uma consulta clínica; preencher uma lista de problema persistente; ou para fornecer uma declaração de resumo de um documento Sumário de Alta.\r\n\r\nNa prática, os clínicos usam muitos qualificadores de contexto específico, como passado / presente, primário / secundário, ativo / inativo, admissão / alta, etc. Os contextos podem ser: localização, especialização, episódio ou específicos de fluxo de trabalho, e estes podem causar confusão ou até mesmo potenciais problemas de segurança se persistido nas listas de problemas ou compartilhados em documentos que estão fora do contexto original. Estes qualificadores podem ser arquetipados separadamente e incluídos no slot 'Estado', porque seu uso varia em diferentes contextos. Espera-se que estes serão utilizados em sua maioria dentro do contexto apropriado e não compartilhados fora desse contexto, sem compreensão clara das consequências potenciais. Por exemplo, um diagnóstico primário para um clínico pode ser um secundário para outro especialista; um problema ativo pode se tornar inativo (ou vice-versa) e isso pode impactar no uso seguro do apoio à decisão clínica. Em geral, estes qualificadores devem ser aplicados localmente dentro do contexto do sistema clínico e na prática, esses estados devem ser criados manualmente pelos clínicos para assegurar que as listas de problemas: Presente / Passado, ativo / inativo ou primário / secundário são clinicamente precisas.\r\n\r\nEste arquétipo será usado como um componente dentro do Registro Clínico Orientado à Problemas, tal como descrito por Larry Weed. Arquétipos adicionais, que representam conceitos clínicos, tais como: condição como um organizador abrangente para diagnósticos etc, terão de ser desenvolvidos para apoiar esta abordagem.\r\n\r\nEm algumas situações, pode ser assumido que a identificação de um diagnóstico só se encaixa dentro da expertise do médico, mas esta não é a intenção para este arquétipo. Os diagnósticos podem ser gravados utilizando esse arquétipo por qualquer profissional de saúde.", + "misuse" : "Não deve ser usado para registrar os sintomas descritos pelo indivíduo, para isso, use o arquétipo CLUSTER.symptom, geralmente dentro do arquétipo OBSERVATION.story.\r\n\r\nNão deve ser usado para registrar achados do exame, use o CLUSTER da família de arquétipos relacionadas ao exame, geralmente aninhados dentro do arquétipo OBSERVATION.exam.\r\n\r\nNão deve ser usado para registrar os resultados dos testes de laboratório ou diagnósticos relacionados, por exemplo, em diagnósticos patológicos use um arquétipo apropriado da família de laboratório dos arquétipos OBSERVATION.\r\n\r\nNão deve ser usado para registrar os resultados dos exames de imagem ou de diagnóstico por imagem, use um arquétipo apropriado a partir da família de imagem dos arquétipos OBSERVATION.\r\n\r\nNão deve ser usado para gravar 'diagnósticos diferenciais', use o arquétipo EVALUATION.differential_diagnosis.\r\n\r\nNão deve ser usado para gravar 'Motivo do Encontro \"ou\" queixa apresentada', use o arquétipo EVALUATION.reason_for_encounter.\r\n\r\nNão deve ser usado para gravar procedimentos, use o arquétipo ACTION.procedure.\r\n\r\nNão deve ser usado para registrar detalhes sobre a gravidez, use o EVALUATION.pregnancy_bf_status e EVALUATION.pregnancy e os arquétipos relacionados.\r\n\r\nNão deve ser usado para gravar o estadiamento sobre o risco ou os problemas de saúde potenciais, use o arquétipo risco EVALUATION.health.\r\n\r\nNão deve ser usado para gravar declarações sobre reações adversas, alergias ou intolerâncias, use o arquétipo EVALUATION.adverse_reaction.\r\n\r\nNão deve ser usado para a gravação de uma ausência explícita (ou presença negativa) de um problema ou diagnóstico, por exemplo: \"sem problema ou diagnósticos conhecido\" ou \"diabetes não conhecido\". Use o arquétipo EVALUATION.exclusion-problem_diagnosis para expressar uma declaração positiva sobre a exclusão de um problema ou diagnóstico.", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "ar-sy" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "ar-sy" + }, + "purpose" : "لتسجيل تفاصيل حول قضية أو عقبة تؤثر على السلامة البدنية, العقلية و/أو الاجتماعية لشخص ما", + "keywords" : [ "القضية", "الظرف الصحي", "المشكلة", "العقبة" ], + "use" : "يستخدم لتسجيل المعلومات العامة حول المشكلات المتعلقة بالصحة.\r\nيحتوي النموذج على معلومات متعددة,و يمكن استخدامه في تسجيل المشكلات الحاضرة و السابقة.\r\nو يمكن تحديد المشكلة بواسطة المريض نفسه أو من يقوم بتقديم الرعاية الصحية.\r\nبعض الأمثلة تتضمن ما يلي:\r\n- بعض الأعراض التي لا تزال تحت الملاحظة و لكنها تمثل تشخيصات مبدأية\r\n- الرغبة لفقد الوزن دون تشخيص مؤكد بالسمنة\r\n- الرغبة بالإقلاع عن التدخين بواسطة الشخص\r\n- مشكلة في العلاقة مع أحد أفراد العائلة", + "misuse" : "لا يستخدم لتسجيل التشخيصات المؤكدة. استخدم بدلا من ذلك النموذج المخصص من هذا النموذج, تقييم.المشكلة - التشخيص", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "en" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "en" + }, + "purpose" : "For recording details about a single, identified health problem or diagnosis. \r\n\r\nThe intended scope of a health problem is deliberately kept loose in the context of clinical documentation, so as to capture any real or perceived concerns that may adversely affect an individual's wellbeing to any degree. A health problem may be identified by the individual, a carer or a healthcare professional. However, a diagnosis is additionally defined based on objective clinical criteria, and usually determined only by a healthcare professional.", + "keywords" : [ "issue", "condition", "problem", "diagnosis", "concern", "injury", "clinical impression" ], + "use" : "Use for recording details about a single, identified health problem or diagnosis. \r\n\r\nClear definitions that enable differentiation between a 'problem' and a 'diagnosis' are almost impossible in practice - we cannot reliably tell when a problem should be regarded as a diagnosis. When diagnostic or classification criteria are successfully met, then we can confidently call the condition a formal diagnosis, but prior to these conditions being met and while there is supportive evidence available, it can also be valid to use the term 'diagnosis'. The amount of supportive evidence required for the label of diagnosis is not easy to define and in reality probably varies from condition to condition. Many standards committees have grappled with this definitional conundrum for years without clear resolution.\r\n\r\nFor 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'. In this archetype it is not neccessary to classify the condition as a 'problem' or 'diagnosis'. The data requirements to support documentation of either are identical, with additional data structure required to support inclusion of the evidence if and when it becomes available. Examples of problems include: the individual's expressed desire to lose weight, but without a formal diagnosis of Obesity; or a relationship problem with a family member. Examples of formal diagnoses would include a cancer that is supported by historical information, examination findings, histopathological findings, radiological findings and meets all requirements for known diagnostic criteria. In practice, most problems or diagnoses do not sit at either end of the problem-diagnosis spectrum, but somewhere in between.\r\n\r\nThis archetype can be used within many contexts. For example, recording a problem or a clinical diagnosis during a clinical consultation; populating a persistent Problem List; or to provide a summary statement within a Discharge Summary document.\r\n\r\nIn practice, clinicians use many context-specific qualifiers such as past/present, primary/secondary, active/inactive, admission/discharge etc. The contexts can be location-, specialisation-, episode- or workflow-specific, and these can cause confusion or even potential safety issues if perpetuated in Problem Lists or shared in documents that are outside of the original context. These qualifiers can be archetyped separately and included in the ‘Status’ slot, because their use varies in different settings. It is expected that these will be used mostly within the appropriate context and not shared out of that context without clear understanding of potential consequences. For example, a primary diagnosis to one clinician may be a secondary one to another specialist; an active problem can become inactive (or vice versa) and this can impact the safe use of clinical decision support. In general these qualifiers should be applied locally within the context of the clinical system, and in practice these statuses should be manually curated by clinicians to ensure that lists of Current/Past, Active/Inactive or Primary/Secondary Problems are clinically accurate. \r\n\r\nThis archetype will be used as a component within the Problem Oriented Medical Record as described by Larry Weed. Additional archetypes, representing clinical concepts such as condition as an overarching organiser for diagnoses etc, will need to be developed to support this approach.\r\n\r\nIn some situations, it may be assumed that identification of a diagnosis fits only within the expertise of physicians, but this is not the intent for this archetype. Diagnoses can be recorded using this archetype by any healthcare professional.", + "misuse" : "Not to be used to record symptoms as described by the individual - use the CLUSTER.symptom archetype, usually within the OBSERVATION.story archetype.\r\n\r\nNot to be used to record examination findings - use the family of examination-related CLUSTER archetypes, usually nested within the OBSERVATION.exam archetype.\r\n\r\nNot to be used to record laboratory test results or related diagnoses, for example pathological diagnoses - use an appropriate archetype from the laboratory family of OBSERVATION archetypes.\r\n\r\nNot to be used to record imaging examination results or imaging diagnoses - use an appropriate archetype from the imaging family of OBSERVATION archetypes.\r\n\r\nNot to be used to record 'Differential Diagnoses' - use the EVALUATION.differential_diagnosis archetype.\r\n\r\nNot to be used to record 'Reason for Encounter' or 'Presenting Complaint' - use the EVALUATION.reason_for_encounter archetype.\r\n\r\nNot to be used to record procedures - use the ACTION.procedure archetype.\r\n\r\nNot to be used to record details about pregnancy - use the EVALUATION.pregnancy_bf_status and EVALUATION.pregnancy and related archetypes.\r\n\r\nNot to be used to record statements about health risk or potential problems - use the EVALUATION.health_risk archetype.\r\n\r\nNot to be used to record statements about adverse reactions, allergies or intolerances - use the EVALUATION.adverse_reaction archetype.\r\n\r\nNot to be used for the explicit recording of an absence (or negative presence) of a problem or diagnosis, for example ‘No known problem or diagnoses’ or ‘No known diabetes’. Use the EVALUATION.exclusion-problem_diagnosis archetype to express a positive statement about exclusion of a problem or diagnosis.", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "es" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "es" + }, + "purpose" : "Este arquetipo se utilizará para registrar un único problema de salud o diagnóstico identificado para el paciente.\r\n\r\nEl alcance del arquetipo se dejó deliberadamente abierto, para poder capturar cualquier inquietud real o percibida que afecte en cualquier grado la salud de un paciente. Independientemente de quién detecte el problema, el diagnóstico debe ser definido basado en criterios clínicos objetivos, determinados por un profesional clínico.", + "keywords" : [ "problema", "diagnóstico", "preocupación", "condición", "enfermedad" ], + "use" : "Este arquetipo se utilizará para registrar un único problema de salud o diagnóstico identificado para el paciente.", + "misuse" : "No se debe utilizar para registrar síntomas descritos por el paciente, para eso utilizar el arquetipo CLUSTER.symtom.\r\n\r\nNo se debe utilizar para registrar hallazgos, para eso utilizar arquetipos relacionados con la examinación, usualmente relacionados con el arquetipo OBSERVATION.exam\r\n\r\nNo se debe utilizar para registrar diagnósticos realizados sobre resultados de estudios diagnósticos como laboratorio o imagenología.\r\n\r\nNo se debe utilizar para registrar el motivo de consulta o problema presentado por el paciente, para eso utilizar el arquetipo EVALUATION.reason_for_encounter\r\n\r\nNo se debe utilizar para registrar riesgos o problemas potenciales, para eso utilizar el arquetipo EVALUATION.health_risk\r\n\r\nNo se debe utilizar para registrar la ausencia de un problema, para eso utilizar el arquetipo EVALUATION.exclusion-problem_diagnosis", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "fi" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "fi" + }, + "purpose" : "*For recording details about a single, identified health problem or diagnosis. \r\n\r\nThe intended scope of a health problem is deliberately kept loose in the context of clinical documentation, so as to capture any real or perceived concerns that may adversely affect an individual's wellbeing to any degree. A health problem may be identified by the individual, a carer or a healthcare professional. However, a diagnosis is additionally defined based on objective clinical criteria, and usually determined only by a healthcare professional.(en)", + "keywords" : [ "*issue(en)", "*condition(en)", "*problem(en)", "*diagnosis(en)", "*concern(en)", "*injury(en)", "*clinical impression(en)" ], + "use" : "*Use for recording details about a single, identified health problem or diagnosis. \r\n\r\nClear definitions that enable differentiation between a 'problem' and a 'diagnosis' are almost impossible in practice - we cannot reliably tell when a problem should be regarded as a diagnosis. When diagnostic or classification criteria are successfully met, then we can confidently call the condition a formal diagnosis, but prior to these conditions being met and while there is supportive evidence available, it can also be valid to use the term 'diagnosis'. The amount of supportive evidence required for the label of diagnosis is not easy to define and in reality probably varies from condition to condition. Many standards committees have grappled with this definitional conundrum for years without clear resolution.\r\n\r\nFor 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'. In this archetype it is not neccessary to classify the condition as a 'problem' or 'diagnosis'. The data requirements to support documentation of either are identical, with additional data structure required to support inclusion of the evidence if and when it becomes available. Examples of problems include: the individual's expressed desire to lose weight, but without a formal diagnosis of Obesity; or a relationship problem with a family member. Examples of formal diagnoses would include a cancer that is supported by historical information, examination findings, histopathological findings, radiological findings and meets all requirements for known diagnostic criteria. In practice, most problems or diagnoses do not sit at either end of the problem-diagnosis spectrum, but somewhere in between.\r\n\r\nThis archetype can be used within many contexts. For example, recording a problem or a clinical diagnosis during a clinical consultation; populating a persistent Problem List; or to provide a summary statement within a Discharge Summary document.\r\n\r\nIn practice, clinicians use many context-specific qualifiers such as past/present, primary/secondary, active/inactive, admission/discharge etc. The contexts can be location-, specialisation-, episode- or workflow-specific, and these can cause confusion or even potential safety issues if perpetuated in Problem Lists or shared in documents that are outside of the original context. These qualifiers can be archetyped separately and included in the ‘Status’ slot, because their use varies in different settings. It is expected that these will be used mostly within the appropriate context and not shared out of that context without clear understanding of potential consequences. For example, a primary diagnosis to one clinician may be a secondary one to another specialist; an active problem can become inactive (or vice versa) and this can impact the safe use of clinical decision support. In general these qualifiers should be applied locally within the context of the clinical system, and in practice these statuses should be manually curated by clinicians to ensure that lists of Current/Past, Active/Inactive or Primary/Secondary Problems are clinically accurate. \r\n\r\nThis archetype will be used as a component within the Problem Oriented Medical Record as described by Larry Weed. Additional archetypes, representing clinical concepts such as condition as an overarching organiser for diagnoses etc, will need to be developed to support this approach.\r\n\r\nIn some situations, it may be assumed that identification of a diagnosis fits only within the expertise of physicians, but this is not the intent for this archetype. Diagnoses can be recorded using this archetype by any healthcare professional.(en)", + "misuse" : "*Not to be used to record symptoms as described by the individual - use the CLUSTER.symptom archetype, usually within the OBSERVATION.story archetype.\r\n\r\nNot to be used to record examination findings - use the family of examination-related CLUSTER archetypes, usually nested within the OBSERVATION.exam archetype.\r\n\r\nNot to be used to record laboratory test results or related diagnoses, for example pathological diagnoses - use an appropriate archetype from the laboratory family of OBSERVATION archetypes.\r\n\r\nNot to be used to record imaging examination results or imaging diagnoses - use an appropriate archetype from the imaging family of OBSERVATION archetypes.\r\n\r\nNot to be used to record 'Differential Diagnoses' - use the EVALUATION.differential_diagnosis archetype.\r\n\r\nNot to be used to record 'Reason for Encounter' or 'Presenting Complaint' - use the EVALUATION.reason_for_encounter archetype.\r\n\r\nNot to be used to record procedures - use the ACTION.procedure archetype.\r\n\r\nNot to be used to record details about pregnancy - use the EVALUATION.pregnancy_bf_status and EVALUATION.pregnancy and related archetypes.\r\n\r\nNot to be used to record statements about health risk or potential problems - use the EVALUATION.health_risk archetype.\r\n\r\nNot to be used to record statements about adverse reactions, allergies or intolerances - use the EVALUATION.adverse_reaction archetype.\r\n\r\nNot to be used for the explicit recording of an absence (or negative presence) of a problem or diagnosis, for example ‘No known problem or diagnoses’ or ‘No known diabetes’. Use the EVALUATION.exclusion-problem_diagnosis archetype to express a positive statement about exclusion of a problem or diagnosis.(en)", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "it" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "it" + }, + "purpose" : "Registrare i dettagli di un singolo problema di salute identificato o di una diagnosi. \r\n\r\nL'ambito previsto di un problema di salute viene deliberatamente lasciato libero nel contesto della documentazione clinica, in modo da catturare qualsiasi preoccupazione reale o percepita che possa influire negativamente sul benessere di un individuo in qualsiasi misura. Un problema di salute può essere identificato dall'individuo, da un caregiver o da un operatore sanitario. Tuttavia, una diagnosi viene definita in aggiunta sulla base di criteri clinici oggettivi e solitamente determinata solo da un professionista sanitario.", + "keywords" : [ "problema, condizione, diagnosi, preoccupazione, lesione, impressione clinica" ], + "use" : "Usato per registrare i dettagli di un singolo problema di salute identificato o di una diagnosi. \r\n\r\nDefinizioni chiare che consentono di distinguere tra un \"problema\" e una \"diagnosi\" sono quasi impossibili nella pratica - non possiamo dire in modo affidabile quando un problema deve essere considerato una diagnosi. Quando i criteri diagnostici o di classificazione sono soddisfatti con successo, allora possiamo tranquillamente definire la condizione come una diagnosi formale, ma prima che queste condizioni siano soddisfatte e mentre ci sono prove di supporto disponibili, può anche essere valido l'uso del termine \"diagnosi\". La quantità delle prove di supporto richieste per la classificazione della diagnosi non è facile da definire e in realtà probabilmente varia da una condizione all'altra. Molti comitati di standardizzazione si sono trovati alle prese con questo enigma di definizione per anni senza una chiara risoluzione.\r\n\r\nAi fini della documentazione clinica con questo archetipo, il problema e la diagnosi sono considerati un continuum, con livelli crescenti di dettaglio e prove di supporto che di solito fanno propendere verso all'etichetta di \"diagnosi\". In questo archetipo non è necessario classificare la condizione come \"problema\" o \"diagnosi\". I requisiti dei dati a supporto della documentazione di entrambi sono identici, con una struttura di dati aggiuntivi necessari per supportare l'inclusione dell'evidenza se e quando essa diventa disponibile. Esempi di problemi sono: il desiderio espresso dall'individuo di perdere peso, ma senza una diagnosi formale di obesità; o un problema di relazione con un membro della famiglia. Esempi di diagnosi formali includono un cancro che è supportato da informazioni storiche, risultati di esami, risultati istopatologici, risultati radiologici e soddisfa tutti i requisiti per i criteri diagnostici noti. In pratica, la maggior parte dei problemi o delle diagnosi non si colloca ad una delle due estremità dello spettro diagnostico del problema, ma da qualche parte nel mezzo.\r\n\r\nQuesto archetipo può essere utilizzato in molti contesti. Per esempio, la registrazione di un problema o di una diagnosi clinica durante un consulto clinico; la compilazione di un Elenco dei Problemi persistente; o per fornire una dichiarazione riassuntiva all'interno di un documento di Riepilogo delle dimissioni.\r\n\r\nIn pratica, i clinici usano molte qualificazioni specifiche del contesto, come passato/presente, primario/secondario, attivo/inattivo, ricovero/dimissione, ecc. I contesti possono essere specifici per il luogo, la specializzazione, l'episodio o il flusso di lavoro, e questi possono causare confusione o anche potenziali problemi di sicurezza se vengono riportati in elenchi di problemi o condivisi in documenti che sono al di fuori del contesto originale. Questi qualificatori possono essere archetipizzati separatamente e inclusi nello slot \"Status\", perché il loro uso varia in diverse configurazioni. Ci si aspetta che questi vengano usati per lo più all'interno del contesto appropriato e che non vengano condivisi al di fuori di tale contesto senza una chiara comprensione delle potenziali conseguenze. Per esempio, una diagnosi primaria per un clinico può essere secondaria per un altro specialista; un problema attivo può diventare inattivo (o viceversa) e questo può avere un impatto sull'uso sicuro del supporto decisionale clinico. In generale queste qualificazioni dovrebbero essere applicate localmente nel contesto del sistema clinico, e in pratica questi stati dovrebbero essere gestiti manualmente dai clinici per assicurare che le liste dei problemi attuali/passivi, attivi/inattivi o primari/secondari siano clinicamente accurate. \r\n\r\nQuesto archetipo sarà utilizzato come componente all'interno della cartella clinica orientata ai problemi, come descritto da Larry Weed. Ulteriori archetipi - che rappresentano concetti clinici come la condizione come un organizzatore generale per le diagnosi, ecc. - dovrà essere sviluppato per sostenere questo approccio.\r\n\r\nIn alcune situazioni, si può presumere che l'identificazione di una diagnosi rientri solo nelle competenze dei medici, ma questo non è l'intento di questo archetipo. Le diagnosi possono essere registrate utilizzando questo archetipo da qualsiasi professionista sanitario.", + "misuse" : "Da non utilizzare per registrare i sintomi come descritto dall'individuo - utilizzare l'archetipo di CLUSTER.symptom, di solito all'interno dell'archetipo di OBSERVATION.story.\r\n\r\nDa non utilizzare per registrare i risultati dell'esame - utilizzare la famiglia di archetipi CLUSTER.symptom, di solito annidati all'interno dell'archetipo di OBSERVATION.exam.\r\n\r\nDa non utilizzare per registrare i risultati di esami di laboratorio o diagnosi correlate, ad esempio diagnosi patologiche - utilizzare un archetipo appropriato della famiglia di archetipi di OBSERVATION.exam.\r\n\r\nDa non utilizzare per registrare i risultati degli esami di imaging o le diagnosi di imaging - utilizzare un archetipo appropriato della famiglia di archetipi di imaging dell'OBSERVATION.\r\n\r\nDa non utilizzare per registrare le \"diagnosi differenziali\" - utilizzare l'archetipo EVALUATION.differential_diagnosis.\r\n\r\nDa non utilizzare per registrare \"Motivo dell'incontro\" o \"Presentazione di un reclamo\" - utilizzare l'archetipo EVALUATION.reason_for_encounter.\r\n\r\nDa non utilizzare per registrare le procedure - utilizzare l'archetipo ACTION.procedure.\r\n\r\nDa non utilizzare per registrare i dettagli sulla gravidanza - utilizzare lo stato di EVALUATION.pregnancy_bf_status e EVALUATION.pregnancy e i relativi archetipi.\r\n\r\nDa non utilizzare per registrare dichiarazioni sul rischio per la salute o su potenziali problemi - utilizzare l'archetipo EVALUATION.health_risk.\r\n\r\nDa non utilizzare per registrare dichiarazioni su reazioni avverse, allergie o intolleranze - utilizzare l'archetipo EVALUATION.adverse_reaction.\r\n\r\nDa non utilizzare per la registrazione esplicita di un'assenza (o presenza negativa) di un problema o di una diagnosi, ad esempio \"Nessun problema o diagnosi nota\" o \"Nessun diabete noto\". Utilizzare l'archetipo EVALUATION.exclusion-problem_diagnosis per esprimere una dichiarazione positiva sull'esclusione di un problema o di una diagnosi.", + "originalResourceUri" : { }, + "otherDetails" : { } + } + } + }, + "parentArchetypeId" : "openEHR-EHR-EVALUATION.problem_diagnosis.v1", + "differential" : true, + "archetypeId" : { + "@type" : "ARCHETYPE_HRID", + "value" : "openEHR-EHR-EVALUATION.ovl-problem_diagnosis-001.v1" + }, + "definition" : { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "EVALUATION", + "nodeId" : "at0000.1", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "data", + "children" : [ { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ITEM_TREE", + "nodeId" : "at0001", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "items", + "children" : [ { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "nodeId" : "at0002.1", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "value", + 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Sebastian Garde", + "organisation" : "Universityhospital of Heidelberg, University of Heidelberg, Central Queensland University" + }, + "otherDetails" : { } + }, { + "@type" : "TRANSLATION_DETAILS", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "sv" + }, + "author" : { + "name" : "Kirsi Poikela", + "organisation" : "Tieto Sweden AB", + "email" : "ext.kirsi.poikela@tieto.com" + }, + "otherDetails" : { } + }, { + "@type" : "TRANSLATION_DETAILS", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "es-ar" + }, + "author" : { + "name" : "Alan March", + "organisation" : "Hospital Universitario Austral, Buenos Aires, Argentina", + "email" : "alandmarch@gmail.com" + }, + "accreditation" : "-", + "otherDetails" : { } + }, { + "@type" : "TRANSLATION_DETAILS", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "nb" + }, + "author" : { + "name" : "Silje Ljosland Bakke, John Tore Valand", + 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{ + "@type" : "TRANSLATION_DETAILS", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "es" + }, + "author" : { + "name" : "Pablo Pazos", + "organisation" : "CaboLabs" + }, + "accreditation" : "Computer Engineer", + "otherDetails" : { } + }, { + "@type" : "TRANSLATION_DETAILS", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "fi" + }, + "author" : { }, + "otherDetails" : { } + }, { + "@type" : "TRANSLATION_DETAILS", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "it" + }, + "author" : { + "name" : "Cecilia Mascia", + "organisation" : "CRS4 - Center for advanced studies, research and development in Sardinia, Pula (Cagliari), Italy", + "email" : "cecilia.mascia@crs4.it" + }, + "otherDetails" : { } + } ] + }, { + "@type" : "TEMPLATE_OVERLAY", + "uid" : "343e5c22-301e-45ac-a39a-e84b61ffd78c", + "description" : { + "@type" : "RESOURCE_DESCRIPTION", + "originalAuthor" : { }, + "otherContributors" : [ ], + "ipAcknowledgements" : { }, + "references" : { }, + "conversionDetails" : { }, + "otherDetails" : { + "PARENT:MD5-CAM-1.0.1" : "6467BBA9938EF3141C6611ED2714EE0B" + }, + "details" : { + "de" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "de" + }, + "purpose" : "Zur Darstellung eines klinischen, kontextspezifischen oder zeitspezifischen Attributs für ein spezifisches Problem oder eine spezifische Diagnose.\r\n", + "keywords" : [ "Problem", "Aktiv", "Inaktiv", "Status", "Episode", "Diagnose", "Attribut" ], + "use" : "Zur Darstellung eines kontextspezifischen oder zeitspezifischen Attributs, welches weitere Details liefert, die zum Zeitpunkt der Aufnahme, oder im klinischen Kontext in dem das Problem, oder die Diagnose aufgezeichnet wurde, relevant ist. Das Attribut könnte zu einer anderen Zeit, oder in einem anderen klinischen Kontext, nicht angemessen sein.\r\n\r\nDieser Archetyp wurde entworfen, um in den Status SLOT des EVALUATION.problem_diagnosis Archetyps eingefügt zu werden. Die Absicht des EVALUATION.problem_diagnosis Archetypen ist es alle Informationen zu beinhalten, die in allen Kontexten relevant sein könnten. Dieser Archetyp hingegen soll nur Informationen beschreiben, welche von dem Gebrauchskontext abhängen. \r\n\r\nWICHTIGE ANMERKUNG ZUM IMPLEMENTIEREN DES ARCHETYPEN:\r\n-Es ist weder die Absicht, noch wird impliziert, dass irgendein, oder alle Attribute in dem gleichen Kontext, oder in dem gleichen Zeitraum genutzt werden sollten. Im Gegensatz zu dem üblichen Entwurf von Archetypen, wurde dieser Archetyp absichtlich so gestaltet, dass oft genutzte Attribute an einem Platz gesammelt werden können. Dies gewährleistet eine einfache Standardisierung eines sonst sehr wirren Gebietes der klinischen Praxis. Es ist uns bewusst, dass die Datenelemente in diesem Archetypen viele verschiedene Konzepte, und teilweise auch konkurrierende Konzepte, einschließen. Dies wurde hauptsächlich gemacht um die Notwendigkeit von mehreren, meist nur wenige Elemente beinhaltenden, Attribut-Archetypen zu vermeiden.\r\n-Manche Datenelemente sind unter Umständen widersprüchlich, wenn Sie gleichzeitig in dem selben Kontext genutzt werden. Zum Beispiel würde die Nutzung eines \"inaktiven\" Problems, zusammen mit einer \"anhaltenden\" Episode keinen Sinn ergeben. Aus diesem Grund sollten diese Status Attribute mit hoher Sorgfalt genutzt werden. Sie können zwar variabel angewandt werden, aber in dem praktischen Gebrauch kann die Interoperabilität nur gewährleistet werden, wenn die Richtlinien innerhalb der klinischen Gemeinschaft in welcher das \"Problem/Diagnose\" und \"Problem/Diagnose Attribut\" Archetyp-Paar ausgetauscht wird, klar definiert sind.\r\n\r\nEine komplette DRG Kodierung setzt eine Kombination aus DRG-verwandten Datenelementen dieses Archetypen und von Datenelementen anderer Archetypen voraus. \r\n\r\n", + "misuse" : "Nicht zur Darstellung einer Differenzialdiagnose - nutze den Archetypen EVALUATION.differential_diagnosis für diesen Zweck.\r\n\r\nNicht zur Darstellung der diagnostischen Sicherheit - nutze das \"Diagnostic certainty\" Datenelement innerhalb des EVALUATION.problem/diagnosis Archetypen für diesen Zweck.", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "ko" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "ko" + }, + "purpose" : "특정 문제 또는 진단을 위한 임상 문맥-특징적인 또는 시간-특징적인 한정자(qualifier)를 기록하기 위함.", + "keywords" : [ "문제", "활성", "비활성", "상태", "에피소드", "진단" ], + "use" : "어떤 문제 또는 진단을 기록하는 경우, 임상 문맥을 기록하는 시점 또는 그 안에서 관계되는 추가적인 상세내용을 제공하는 관련된 문맥-특징적인 또는 시간-특징적인 한정자를 기록하는데 사용. 한정자가 다른 시간이나 임상 문맥에서는 부적당할 수도 있음.\r\n\r\n이 아키타입은 EVALUATION.problem_diagnosis archetype 내의 Status SLOT에 포함하도록 설계됨. 의도는 이 아카타입이 사용되는 문맥에 따르는 정보만을 기술하는 것과 반대로 모든 문맥에 적용되는 모든 정보를 포함하는 EVALUATION.problem_diagnosis archetype을 위한 것임.\r\n\r\n구현을 위한 중요 사항:\r\n- 이것은 이 한정자 일부 또는 전부가 같은 문맥 또는 같은 시간의 기간 내에 사용되어야 하는 것을 의도하거나 의미하지 않음. 일반적인 아키타입 설계와 다르게, 이 아카타입은 매우 복잡한 임상 실무 영역 내에서 간단히 표준화하기 위한 노력으로 많은 공통 한정자를 한 곳에 수집하기 위해 의도적으로 설계됨. 이 아키타입에 포함된 데이터 엘리먼트는 많은 상이한 그리고 때때로 심지어 경쟁적인 개념을 포괄하는 것으로 인정됨. 이것은 주로 오직 하나 또는 2개의 데이터 엘리먼트를 포함하는 여러 개의 한정자 아키타입을 필요로 하지 않도록 함. \r\n- 몇몇의 이런 데이터 엘리먼트는 같은 문맥에서 동시에 사용된다면 잠재적으로 직접적으로 충돌하는데, 예를 들어, '진행중'인 어떤 에피소드와 함께 '비활성' 문제를 가지는 것은 이치에 맞지 않음. 이와 같이, 이 상태 한정자는 실무에서 매우 다양하게 적용되는 것처럼 극단적인 진료환경에서 함께 사용되어야 하고, 사용 지침이 'Problem/Diagnosis'와 'Problem/Diagnosis qualifier' archetype 쌍이 공유될 수도 있는 임상 커뮤니티 내에서 명확하게 정의되어야 상호운용성을 보장할 수 있음.\r\n\r\n완전한 DRG 코딩은 다른 아키타입의 데이터 엘리먼트와 조합해서 이 아키타입의 DRG와 관련된 데이터 엘리먼트를 요구할 것임.", + "misuse" : "감별진단을 표현하는데 사용하지 않아야 함 - 이 목적을 위해서는 EVALUATION.differential_diagnosis archetype를 사용해야 함.\r\n\r\n진단의 확실성(certainty)를 표현하기 위해 사용하지 않아야 함 - EVALUATION.problem_diagnosis archetype 내의 'Diagnostic certainty' 데이터 엘리먼트를 사용해야 함.", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "nb" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "nb" + }, + "purpose" : "For å registrere en kontekstspesifikk eller tidsspesifikk kvalifikator for et problem eller en diagnose.", + "keywords" : [ "problem", "aktivt", "inaktivt", "status", "episode", "tilstand", "aktiv", "inaktiv", "remisjon", "kronisk", "akutt" ], + "use" : "Brukes for å registrere en kontekstspesifikk eller tidsspesifikk kvalifikator som gir ytterligere detaljer som er relevante på tidspunktet man registrerer et problem eller en diagnose. Kvalifikatoren er ikke nødvendigvis passende på et annet tidspunkt eller i en annen klinisk sammenheng.\r\n\r\nDenne arketypen skal brukes i SLOTet \"Status\" i arketypen EVALUATION.problem_diagnosis (Problem/diagnose). Intensjonen er at EVALUATION.problem_diagnosis-arketypen skal inneholde all informasjonen som gjelder i alle sammenhenger, i motsetning til denne arketypen som skal inneholde informasjonen som avhenger av brukssammenheng.\r\n\r\nVIKTIG INFORMASJON FOR IMPLEMENTERING:\r\n- Det er ikke meningen eller implisert at alle disse kvalifikatorene skal brukes i den samme sammenhengen eller det samme tidsperioden. I motsetning til den vanlige måten å lage arketyper på, er denne arketypen laget for å samle flere vanlige kvalifikatorer på ett sted for å forsøksvis oppnå et visst nivå av standardisering innenfor et ganske innfløkt område av klinisk praksis. Det erkjennes at dataelementene i denne arketypen omfatter mange forskjellige, og til dels også konkurrerende, konsepter. Dette ble gjort hovedsakelig for å unngå behov for å ha mange arketyper for kvalifikatorer, der hver av dem kun inneholder ett eller to dataelementer.\r\n- Noen av disse dataelementene er potensielt direkte motstridende dersom de brukes samtidig og i den samme sammenhengen. For eksempel gir det ikke mening å ha et \"inaktivt\" problem innenfor en \"pågående\" episode. Av den grunn bør disse kvalifikatorene brukes med stor omhu, siden de i praksis vil brukes for varierende formål, og interoperabilitet kan ikke garanteres med mindre det er definert klare retningslinjer for bruk innenfor de kliniske omstendighetene der \"Problem/diagnose\"- og \"Problem/diagnose-kvalifikatorer\"-arketypeparet brukes.\r\n\r\nFullstendig DRG-koding vil kreve DRG-relaterte dataelementer fra denne arketypen, i kombinasjon med elementer fra andre arketyper.", + "misuse" : "Brukes ikke for å representere differensialdiagnoser. Bruk arketypen EVALUATION.differential_diagnosis for dette formålet.\r\n\r\nBrukes ikke for å representere diagnostisk sikkerhet. Bruk elementet \"Diagnostisk sikkerhet\" i arketypen EVALUATION.problem_diagnosis.", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "pt-br" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "pt-br" + }, + "purpose" : "Para gravar um contexto clínico específico ou qualificador de tempo específico para um problema ou diagnóstico específico.", + "keywords" : [ "problema", "ativo", "inativo", "estado", "episódio", "diagnóstico" ], + "use" : "Use para gravar um qualificador de contexto específico ou tempo específico relevante que forneça detalhes adicionais de ou de e que sejam relevantes no momento do registro de um problema ou diagnóstico, ou dentro do contexto clínico onde é registrado, mas que pode não ser apropriado em outro tempo ou em outro contexto clínico.\r\n\r\nEste arquétipo foi projetado para ser incluído no slot Estado no arquétipo EVALUATION.problem_diagnosis archetype. A intenção é que o arquétipo EVALUATION.problem_diagnosis mantenha todas as informações que se aplicam em todos os contextos, em contraste com esse arquétipo que descreve apenas as informações que dependem do contexto de uso.\r\n\r\nNOTAS IMPORTANTES PARA IMPLEMENTAÇÃO:\r\n- Não é intencional ou implícito que algum ou todos esses qualificadores devam ser usados dentro do mesmo contexto ou período de tempo. Em contraste com o design usual de arquétipos, esse arquétipo foi deliberadamente projetado para coletar uma série de qualificadores comuns em um único lugar, em um esforço para tentar alguma padronização simples dentro de uma área muito confusa da prática clínica. Reconhece-se que os elementos de dados contidos neste arquétipo abrangem muitos conceitos diferentes e às vezes até concorrentes. Isso foi feito principalmente para evitar a necessidade de vários arquétipos de qualificadores, cada um contendo apenas um ou dois elementos de dados.\r\n- Alguns desses elementos de dados são potencialmente conflitantes se usados simultaneamente dentro do mesmo contexto, por exemplo, não faria sentido ter um problema 'inativo' junto com um Episódio 'em andamento'. Assim, esses qualificadores de status devem ser usados com extremo cuidado, pois são aplicados na prática e a interoperabilidade não pode ser assegurada, a menos que as diretrizes de uso estejam claramente definidas na comunidade clínica na qual o par de arquétipos 'Problema / Diagnóstico' e 'Qualificador do Problema / Diagnóstico' pode ser compartilhado.\r\n\r\nA codificação DRG completa vai exigir os elementos de dados DRG deste arquétipo em combinação com elementos de dados de outros arquétipos.", + "misuse" : "Não deve ser usado para representar um diagnóstico diferencial - use o arquétipo EVALUATION.differential_diagnosis para este fim.\r\n\r\nNão deve ser usado para representar certeza diagnóstica - use elemento de dado \"Certeza de diagnóstico\" no arquétipo EVALUATION.problem_diagnosis.", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "en" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "en" + }, + "purpose" : "To record a clinical context-specific or time-specific qualifier for a specified problem or diagnosis.", + "keywords" : [ "problem", "active", "inactive", "status", "episode", "diagnosis" ], + "use" : "Use to record a relevant context-specific or time-specific qualifier that provides additional detail which is relevant at the time of recording or within the clinical context where a problem or diagnosis is recorded. The qualifier may not be appropriate at another time or in another clinical context. \r\n\r\nThis archetype is designed to be included in Status SLOT in the EVALUATION.problem_diagnosis archetype. The intent is for the EVALUATION.problem_diagnosis archetype to hold all of the information that applies in all contexts, in contrast to this archetype describing only information that depends on the context of use.\r\n\r\nIMPORTANT NOTES FOR IMPLEMENTATION: \r\n- It is not intended or implied that any or all of these qualifiers should be used within the same context or period of time. In contrast to the usual design of archetypes, this archetype has been deliberately designed to collect a number of common qualifiers into one place in an effort to attempt some simple standardisation within a very messy area of clinical practice. It is acknowledged that the data elements contained in this archetype embrace many different, and sometimes even competing, concepts. This has been done mainly to prevent the need for multiple qualifier archetypes, each containing only one or two data elements. \r\n- Some of these data elements are potentially directly conflicting if used simultaneously within the same context, for example it would not make sense to have an 'inactive' problem together with an Episode that is 'ongoing'. As such, these status qualifiers should be used with extreme care as they are variably applied in practice and interoperability cannot be assured unless usage guidelines are clearly defined within the clinical community in which the 'Problem/Diagnosis' and 'Problem/Diagnosis qualifier' archetype pair may be shared. \r\n\r\nFull DRG coding will require the DRG-related data elements from this archetype in combination with data elements from other archetypes.", + "misuse" : "Not to be used to represent a differential diagnosis - use the archetype EVALUATION.differential_diagnosis for this purpose.\r\n\r\nNot to be used to represent diagnostic certainty - use the 'Diagnostic certainty' data element within the EVALUATION.problem_diagnosis archetype.", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "sl" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "sl" + }, + "purpose" : "Za zapisovanje različnih statusov, ki se ponavadi uporablja za aplikacijskimi in kliničnimi sporočili, ki so odvisna od definirane vsebine\r\n\r\n", + "keywords" : [ "problem", "aktiven", "ni aktiven" ], + "use" : "Za dodeljevanje pravic EVALUATION.problem_diagnosis.v1 archetype, dodaja informacije za povezovanje. ", + "misuse" : "It should not be assumed that these qualifiers are safely interoperable unless further definition and alignment is agreed between all sharing parties. A problem which has been defined as 'Inactive' during a hospital admission cannot be assumed to be regarded as 'Inactive' in a primary care setting , where a much longer term perspective is being taken. Similarly terms such as Initial, Interim and Final, whilst helpful to the human observer are unlikely to be precisely enough defined to be safely computable e.g. for decision support. ", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "it" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "it" + }, + "purpose" : "Registrare un qualificatore specifico del contesto clinico o temporale per un problema o una diagnosi specifici.", + "keywords" : [ "problema, attivo, inattivo, stato, episodio, diagnosi" ], + "use" : "Usato per registrare un qualificatore specifico del contesto o del tempo che fornisca ulteriori dettagli rilevanti al momento della registrazione o nell'ambito del contesto clinico in cui viene registrato un problema o una diagnosi. Il qualificatore potrebbe non essere appropriato in un altro momento o in un altro contesto clinico.\r\n\r\nQuesto archetipo è progettato per essere incluso in Status SLOT nell'archetipo di EVALUATION.problem_diagnosis. L'intento è che l'archetipo EVALUATION.problem_diagnosis contenga tutte le informazioni che si applicano in tutti i contesti, a differenza di questo archetipo che descrive solo le informazioni che dipendono dal contesto d'uso.\r\n\r\nNOTE IMPORTANTI PER L'IMPLEMENTAZIONE:\r\n- Non è inteso o implicito che uno o tutti questi qualificatori debbano essere utilizzati nello stesso contesto o periodo di tempo. In contrasto con il design abituale degli archetipi, questo archetipo è stato deliberatamente progettato per raccogliere una serie di qualificatori comuni in un unico luogo nel tentativo di tentare una semplice standardizzazione all'interno di un'area molto disordinata della pratica clinica. Si riconosce che i dati contenuti in questo archetipo abbracciano molti concetti diversi, e a volte anche in competizione tra loro. Questo è stato fatto principalmente per evitare la necessità di molteplici archetipi di qualificatori, ognuno dei quali contenente solo uno o due data element.\r\n- Alcuni di questi data element sono potenzialmente in conflitto diretto se utilizzati contemporaneamente all'interno dello stesso contesto, ad esempio non avrebbe senso avere un problema \"inattivo\" insieme ad un Episodio \"in corso\". In quanto tali, questi qualificatori di stato dovrebbero essere utilizzati con estrema cautela in quanto sono applicati in modo variabile nella pratica e l'interoperabilità non può essere garantita a meno che le linee guida di utilizzo non siano chiaramente definite all'interno della comunità clinica in cui la coppia di archetipi \"Problema/Diagnosi\" e \"Qualificatore di problema/diagnosi\" possono essere condivisi.\r\n\r\nLa codifica DRG completa richiederà che i data element relativi al DRG di questo archetipo siano combinati con data element di altri archetipi.", + "misuse" : "Da non utilizzare per rappresentare una diagnosi differenziale - utilizzare a questo scopo l'archetipo EVALUATION.differential_diagnosis.\r\n\r\nDa non utilizzare per rappresentare la certezza diagnostica - utilizzare l'elemento di dati \"Certezza diagnostica\" all'interno dell'archetipo EVALUATION.problem_diagnosis.", + "originalResourceUri" : { }, + "otherDetails" : { } + } + } + }, + "parentArchetypeId" : 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"rmAttributeName" : "defining_code", + "children" : [ { + "@type" : "C_TERMINOLOGY_CODE", + "rmTypeName" : "CODE_PHRASE", + "occurrences" : "1..1", + "terminologyId" : { + "value" : "local" + }, + "constraint" : [ "at0034", "at0035", "at0070" ] + } ] + } ], + "attributeTuples" : [ ] + } ] + } ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "occurrences" : "0..0", + "nodeId" : "at0071.1", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "value", + "children" : [ { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "DV_CODED_TEXT", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "defining_code", + "children" : [ { + "@type" : "C_TERMINOLOGY_CODE", + "rmTypeName" : "CODE_PHRASE", + "occurrences" : "1..1", + "terminologyId" : { + "value" : "local" + }, + "constraint" : [ "at0095", "at0096" ] + } ] + } ], + "attributeTuples" : [ ] + } ] + } ], + "attributeTuples" : [ ] + }, { + "@type" : 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"defining_code", + "children" : [ { + "@type" : "C_TERMINOLOGY_CODE", + "rmTypeName" : "CODE_PHRASE", + "occurrences" : "1..1", + "terminologyId" : { + "value" : "local" + }, + "constraint" : [ "at0064", "at0066", "at0076" ] + } ] + } ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "DV_TEXT", + "attributes" : [ ], + "attributeTuples" : [ ] + } ] + } ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "occurrences" : "0..0", + "nodeId" : "at0073.1", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "value", + "children" : [ { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "DV_BOOLEAN", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "value", + "children" : [ { + "@type" : "C_BOOLEAN", + "rmTypeName" : "Boolean", + "occurrences" : "1..1", + "constraint" : [ true ] + } ] + } ], + "attributeTuples" : [ ] + } ] + } ], + "attributeTuples" : [ ] + } ] + } ], + "attributeTuples" : [ ] + }, + "terminology" : { + "@type" : "ARCHETYPE_TERMINOLOGY", + "conceptCode" : "at0000", + "termDefinitions" : { + "en" : { + "at0000.1" : { + "@type" : "ARCHETYPE_TERM", + "code" : "at0000.1", + "text" : "Status", + "description" : "Contextual or temporal qualifier for a specified problem or diagnosis." + }, + "ac0.6" : { + "@type" : "ARCHETYPE_TERM", + "text" : "(Synthesized)", + "code" : "ac0.6", + "description" : "*" + } + }, + "sl" : { + "ac0.6" : { + "@type" : "ARCHETYPE_TERM", + "text" : "*(Synthesized) (en)", + "code" : "ac0.6", + "description" : "*" + } + }, + "pt-br" : { + "at0000.1" : { + "@type" : "ARCHETYPE_TERM", + "code" : "at0000.1", + "text" : "*Problem/Diagnosis qualifier(en)", + "description" : "*Contextual or temporal qualifier for a specified problem or diagnosis.(en)" + }, + "at0004.1" : { + "@type" : "ARCHETYPE_TERM", + "code" : "at0004.1", + "text" : "*Diagnostic status(en)", + "description" : "*Stage or phase of diagnostic process.(en)", + "comment" : "*The status is usually determined by a combination of the timing of diagnosis plus level of clinical certainty resulting from diagnostic tests and clinical evidence available. This data element and 'Diagnostic certainty' in EVALUATION.problem_diagnosis are two important axes of the diagnostic process, and valid combinations will need to be presented by software that exposes both data elements, so it is not possible for users to select conflicting combinations. \r\nPreliminary or working diagnoses are intended to represent the single most likely choice out of all differential diagnosis options.(en)" + }, + "at0060.1" : { + "@type" : "ARCHETYPE_TERM", + "code" : "at0060.1", + "text" : "*Current/Past?(en)", + "description" : "*Category that supports division of problems and diagnoses into Current or Past problem lists.(en)", + "comment" : "*The Current/Past and Active/Inactive data elements have similar clinical impact but represent slightly different semantics. Both are actively used in different clinical settings, but usually not together. If an Active/Inactive 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.(en)" + }, + "at0003.1" : { + "@type" : "ARCHETYPE_TERM", + "code" : "at0003.1", + "text" : "*Active/Inactive?(en)", + "description" : "*Category that supports division of problems and diagnoses into Active or Inactive problem lists.(en)", + "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.(en)" + }, + "at0083.1" : { + "@type" : "ARCHETYPE_TERM", + "code" : "at0083.1", + "text" : "*Resolution phase(en)", + "description" : "*Phase of healing for an acute problem or diagnosis.(en)", + "comment" : "*For example: tracking the progress of resolution of a middle ear infection.(en)" + }, + "at0089.1" : { + "@type" : "ARCHETYPE_TERM", + "code" : "at0089.1", + "text" : "*Remission status(en)", + "description" : "*Status of the remission of an incurable diagnosis.(en)", + "comment" : "*For example: the status of a cancer or haematological diagnosis.(en)" + }, + "at0001.1" : { + "@type" : "ARCHETYPE_TERM", + "code" : "at0001.1", + "text" : "*Episodicity(en)", + "description" : "*Category of this episode for the identified problem/diagnosis.(en)", + "comment" : "*For example: 'New' will enable clinicians to distinguish a new, acute episode of otitis media that may have arisen soon after a previous diagnosis, to distinguish it from an unresolved or 'Ongoing' diagnosis of chronic otitis media. Treatment of recurring, new and acute, episodes of a condition may differ significantly from the same condition that is not resolving or responding to treatment. In many situations the clinician will not be able to tell, and so indeterminate may be appropriate.(en)" + }, + "at0071.1" : { + "@type" : "ARCHETYPE_TERM", + "code" : "at0071.1", + "text" : "*Occurrence (en)", + "description" : "*Category of the occurrence for this problem or diagnosis. (en)", + "comment" : "*This data element can be an additional qualifier to the 'New' value in the 'Episodicity' value set, that is a condition such as asthma can have recurring new episodes that have periods of resolution in between. However it can be important to identify the first ever episode of asthma from all of the other episodes. (en)" + }, + "at0077.1" : { + "@type" : "ARCHETYPE_TERM", + "code" : "at0077.1", + "text" : "*Course label(en)", + "description" : "*Category reflecting the speed of onset and/or duration and persistence of the problem or diagnosis.(en)", + "comment" : "*Definitions of acute vs chronic will differ for each diagnosis.(en)" + }, + "at0063.1" : { + "@type" : "ARCHETYPE_TERM", + "code" : "at0063.1", + "text" : "*Diagnostic category(en)", + "description" : "*Category of the problem or diagnosis within a specified episode of care and/or local care context.(en)", + "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.\r\nIn addition, the free text choice permits use of other local value sets, as required.(en)" + }, + "at0073.1" : { + "@type" : "ARCHETYPE_TERM", + "code" : "at0073.1", + "text" : "*Admission diagnosis?(en)", + "description" : "*Was the problem or diagnosis present at admission?(en)", + "comment" : "*Record as True if the problem or diagnosis was present on admission. This data element is a requirement from DRG reporting in some countries.(en)" + }, + "ac0.6" : { + "@type" : "ARCHETYPE_TERM", + "text" : "*(Synthesized) (en)", + "code" : "ac0.6", + "description" : "*" + } + }, + "nb" : { + "ac0.6" : { + "@type" : "ARCHETYPE_TERM", + "text" : "*(Synthesized) (en)", + "code" : "ac0.6", + "description" : "*" + } + }, + "ko" : { + "ac0.6" : { + "@type" : "ARCHETYPE_TERM", + "text" : "*(Synthesized) (en)", + "code" : "ac0.6", + "description" : "*" + } + }, + "de" : { + "ac0.6" : { + "@type" : "ARCHETYPE_TERM", + "text" : "*(Synthesized) (en)", + "code" : "ac0.6", + "description" : "*" + } + }, + "it" : { + "ac0.6" : { + "@type" : "ARCHETYPE_TERM", + "text" : "(Synthesized)", + "code" : "ac0.6", + "description" : "*" + } + } + }, + "termBindings" : { + "SNOMED-CT" : { + "at0004.1" : "term:SNOMED-CT::106229004", + "at0060.1" : "term:SNOMED-CT::410511007", + "at0001.1" : "term:SNOMED-CT::288526004", + "at0077.1" : "term:SNOMED-CT::288524001" + } + }, + "terminologyExtracts" : { }, + "valueSets" : { + "ac0.1" : { + "@type" : "VALUE_SET", + "id" : "ac0.1", + "members" : [ "at0017", "at0018", "at0088" ] + }, + "ac0.2" : { + "@type" : "VALUE_SET", + "id" : "ac0.2", + "members" : [ "at0017", "at0088" ] + }, + "ac0.3" : { + "@type" : "VALUE_SET", + "id" : "ac0.3", + "members" : [ "at0017" ] + }, + "ac0.4" : { + "@type" : "VALUE_SET", + "id" : "ac0.4", + "members" : [ "at0017" ] + }, + "ac0.5" : { + "@type" : "VALUE_SET", + "id" : "ac0.5", + "members" : [ "at0017" ] + }, + "ac0.6" : { + "@type" : "VALUE_SET", + "id" : "ac0.6", + "members" : [ "at0017" ] + } + } + }, + "adlVersion" : "1.4", + "buildUid" : "5efb29e7-1fe5-4ea6-a245-de1c6a5dad28", + "rmName" : "openehr", + "rmRelease" : "1.0.3", + "generated" : true, + "otherMetaData" : { }, + "originalLanguage" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "en" + }, + "translations" : [ { + "@type" : "TRANSLATION_DETAILS", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "nb" + }, + "author" : { + "name" : "John Tore Valand, Silje Ljosland Bakke", + "organisation" : "Helse Bergen HF, Nasjonal IKT HF" + }, + "otherDetails" : { } + }, { + "@type" : "TRANSLATION_DETAILS", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "ko" + }, + "author" : { + "name" : "Seung-Jong Yu", + "organisation" : "InfoClinic Co.,Ltd.", + "email" : "seungjong.yu@gmail.com" + }, + "accreditation" : "M.D.", + "otherDetails" : { } + }, { + "@type" : "TRANSLATION_DETAILS", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "pt-br" + }, + "author" : { + "name" : "Marivan Abrahão, Gabriela Alves, Adriana Kitajima e Maria Ângela Scatena", + "organisation" : "Core Consulting", + "email" : "contato@coreconsulting.com.br" + }, + "accreditation" : "Hospital Alemão Oswaldo Cruz (HAOC)", + "otherDetails" : { } + }, { + "@type" : "TRANSLATION_DETAILS", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "sl" + }, + "author" : { + "name" : "mag. Biljana Prinčič", + "organisation" : "Marand d.o.o., Ljubljana, Slovenija", + "email" : "biljana.princic@marand.si" + }, + "otherDetails" : { } + }, { + "@type" : "TRANSLATION_DETAILS", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "de" + }, + "author" : { + "name" : "Simon Schumacher", + "organisation" : "HiGHmed", + "email" : "sschuma9@uni-koeln.de" + }, + "otherDetails" : { } + }, { + "@type" : "TRANSLATION_DETAILS", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "it" + }, + "author" : { + "name" : "Francesca Frexia", + "organisation" : "CRS4 - Center for advanced studies, research and development in Sardinia, Pula (Cagliari), Italy", + "email" : "francesca.frexia@crs4.it" + }, + "otherDetails" : { } + } ] + }, { + "@type" : "TEMPLATE_OVERLAY", + "uid" : "2e6f6ca6-c07b-4900-be1e-497ecd04fc87", + "description" : { + "@type" : "RESOURCE_DESCRIPTION", + "originalAuthor" : { }, + "otherContributors" : [ ], + "ipAcknowledgements" : { }, + "references" : { }, + "conversionDetails" : { }, + "otherDetails" : { + "PARENT:MD5-CAM-1.0.1" : "FF6E51F17D43E5321F2138E98147BAFE" + }, + "details" : { + "en" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "en" + }, + "purpose" : "For the recording of address details aligned with corresponding FHIR resource.", + "keywords" : [ ], + "use" : "Use to record address details aligned with the corresponding FHIR resources.\r\n\r\nThis cluster archetype is intended to be used inside FHIR resource aligned archetypes such as CLUSTER.fhir_contact.v0 and CLUSTER.fhir_practitioner.v0.", + "copyright" : "© Apperta Foundation, openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + } + } + }, + "parentArchetypeId" : "openEHR-EHR-CLUSTER.address_cc.v0", + "differential" : true, + "archetypeId" : { + "@type" : "ARCHETYPE_HRID", + "value" : "openEHR-EHR-CLUSTER.ovl-address_cc-001.v0" + }, + "definition" : { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "CLUSTER", + "nodeId" : "at0000.1", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "items", + "children" : [ { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "occurrences" : "0..0", + "nodeId" : "at0001.1", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "value", + "children" : [ { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "DV_CODED_TEXT", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "defining_code", + "children" : [ { + "@type" : "C_TERMINOLOGY_CODE", + "rmTypeName" : "CODE_PHRASE", + "occurrences" : "1..1", + "terminologyId" : { + "value" : "local" + }, + "constraint" : [ "at0002", "at0003", "at0004", "at0005" ] + } ] + } ], + "attributeTuples" : [ ] + } ] + } ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "occurrences" : "0..0", + "nodeId" : "at0006.1", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "value", + "children" : [ { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "DV_CODED_TEXT", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "defining_code", + "children" : [ { + "@type" : "C_TERMINOLOGY_CODE", + "rmTypeName" : "CODE_PHRASE", + "occurrences" : "1..1", + "terminologyId" : { + "value" : "local" + }, + "constraint" : [ "at0007", "at0008", "at0009" ] + } ] + } ], + "attributeTuples" : [ ] + } ] + } ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "occurrences" : "0..0", + "nodeId" : "at0010.1", + "attributes" : [ ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "occurrences" : "0..0", + "nodeId" : "at0011.1", + "attributes" : [ ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "nodeId" : "at0012.1", + "attributes" : [ ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "occurrences" : "0..0", + "nodeId" : "at0013.1", + "attributes" : [ ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "occurrences" : "0..0", + "nodeId" : "at0014.1", + "attributes" : [ ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "nodeId" : "at0015.1", + "attributes" : [ ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "occurrences" : "0..0", + "nodeId" : "at0016.1", + "attributes" : [ ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "occurrences" : "0..0", + "nodeId" : "at0017.1", + "attributes" : [ ], + "attributeTuples" : [ ] + } ] + } ], + "attributeTuples" : [ ] + }, + "terminology" : { + "@type" : "ARCHETYPE_TERMINOLOGY", + "conceptCode" : "at0000", + "termDefinitions" : { + "en" : { } + }, + "termBindings" : { }, + "terminologyExtracts" : { }, + "valueSets" : { } + }, + "adlVersion" : "1.4", + "buildUid" : "90992ec0-51e5-459b-9b90-107cfb29fe46", + "rmName" : "openehr", + "rmRelease" : "1.0.3", + "generated" : true, + "otherMetaData" : { }, + "originalLanguage" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "en" + }, + "translations" : [ ] + }, { + "@type" : "TEMPLATE_OVERLAY", + "uid" : "ec1f3043-25fd-4630-a858-da4f107fe805", + "description" : { + "@type" : "RESOURCE_DESCRIPTION", + "originalAuthor" : { }, + "otherContributors" : [ ], + "ipAcknowledgements" : { }, + "references" : { }, + "conversionDetails" : { }, + "otherDetails" : { + "PARENT:MD5-CAM-1.0.1" : "AA189406473B39A80DB01615BA770868" + }, + "details" : { + "en" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "en" + }, + "purpose" : "For the recording of organisation details aligned with corresponding FHIR resource.", + "keywords" : [ ], + "use" : "Use to record organisation details aligned with the corresponding FHIR resources.\r\n\r\nThe slots for telecoms, address and contact should be filled with the appropriate FHIR resource-aligned clusters.\r\n\r\nThis cluster archetype is intended to be used inside FHIR resource aligned archetypes such as CLUSTER.fhir_contact.v0 and CLUSTER.fhir_practitioner.v0.", + "copyright" : "© Apperta Foundation, openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + } + } + }, + "parentArchetypeId" : "openEHR-EHR-CLUSTER.organisation_cc.v0", + "differential" : true, + "archetypeId" : { + "@type" : "ARCHETYPE_HRID", + "value" : "openEHR-EHR-CLUSTER.ovl-organisation_cc-001.v0" + }, + "definition" : { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "CLUSTER", + "nodeId" : "at0000.1", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "items", + "children" : [ { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "occurrences" : "0..0", + "nodeId" : "at0010.1", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "value", + "children" : [ { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "DV_BOOLEAN", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "value", + "children" : [ { + "@type" : "C_BOOLEAN", + "rmTypeName" : "BOOLEAN", + "constraint" : [ ] + } ] + } ], + "attributeTuples" : [ ] + } ] + } ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "occurrences" : "0..0", + "nodeId" : "at0011.1", + "attributes" : [ ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "nodeId" : "at0012.1", + "attributes" : [ ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "occurrences" : "0..0", + "nodeId" : "at0013.1", + "attributes" : [ ], + "attributeTuples" : [ ] + }, { + "@type" : "C_ARCHETYPE_ROOT", + "rmTypeName" : "CLUSTER", + "occurrences" : "0..1", + "nodeId" : "at0015.1", + "attributes" : [ ], + "attributeTuples" : [ ], + "archetypeRef" : "openEHR-EHR-CLUSTER.ovl-address_cc-001.v0", + "referenceType" : "archetypeOverlay" + } ] + } ], + "attributeTuples" : [ ] + }, + "terminology" : { + "@type" : "ARCHETYPE_TERMINOLOGY", + "conceptCode" : "at0000", + "termDefinitions" : { + "en" : { + "at0000.1" : { + "@type" : "ARCHETYPE_TERM", + "code" : "at0000.1", + "text" : "Facility", + "description" : "Organisation details aligned with FHIR resource." + }, + "at0012.1" : { + "@type" : "ARCHETYPE_TERM", + "code" : "at0012.1", + "text" : "Facility name", + "description" : "Name associated with the organisation." + } + } + }, + "termBindings" : { }, + "terminologyExtracts" : { }, + "valueSets" : { } + }, + "adlVersion" : "1.4", + "buildUid" : "f520ff83-5512-4d8e-b00d-1716f3f1ef43", + "rmName" : "openehr", + "rmRelease" : "1.0.3", + "generated" : true, + "otherMetaData" : { }, + "originalLanguage" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "en" + }, + "translations" : [ ] + }, { + "@type" : "TEMPLATE_OVERLAY", + "uid" : "99f36a04-b09a-411d-99f6-d9b25341ecfb", + "description" : { + "@type" : "RESOURCE_DESCRIPTION", + "originalAuthor" : { }, + "otherContributors" : [ ], + "ipAcknowledgements" : { }, + "references" : { }, + "conversionDetails" : { }, + "otherDetails" : { + "PARENT:MD5-CAM-1.0.1" : "8A419A318393ABB88CF8188C747918D2" + }, + "details" : { + "nb" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "nb" + }, + "purpose" : "For å registrere detaljert informasjon om en jobb eller rolle individet har, eller har hatt i en spesifisert tidsperiode.", + "keywords" : [ "arbeid", "arbeidstaker", "arbeidsgiver", "arbeidsforhold", "arbeidshistorikk", "jobb", "ansatt", "yrke", "arbeidsløs", "studerer", "student", "elev", "trygdet", "ufør", "arbeidssituasjon", "erverv", "yrkestilknytning", "pensjon", "pensjonist", "attføring", "bransje", "arbeidsledig", "hjemmeværende", "stilling", "profesjon", "frivillig", "vernepliktig", "sektor", "næring", "verv" ], + "use" : "Brukes for å registrere detaljert informasjon om en jobb eller rolle individet har, eller har hatt i en spesifisert tidsperiode.\r\n\r\nArketypen omfatter alle typer arbeid eller aktiviteter individet har eller har hatt. For eksempel: En/et betalt eller ubetalt jobb/arbeid/verv, samt ulike roller som for eksempel pensjonist, hjemmeværende eller student.\r\n\r\nVed å benytte denne arketypen til gjentatte registreringer, vil en få fram en historisk oversikt over nåværende og tidligere arbeidsforhold /roller et individ har eller har hatt.\r\n\r\nEt aktivt, nåværende arbeidsforhold/roller kan bli utledet fra \"Dato for oppstart\" hvis det ikke er registrert noe i \"Dato for opphør\".\r\n\r\nEt individ kan ha mange samtidige arbeidsforhold/rolle, og de kan hver for seg være betalt eller ubetalt. Hvert slik arbeidsforhold registreres i egne instanser av denne arketypen.\r\n\r\nHvis detaljer om et arbeidsforhold/rolle endrer seg vesentlig, som forandring av tittel eller stillingsprosent, registreres dette i egne instanser av denne arketypen.\r\n\r\nArketypen er laget for å benyttes i SLOTet \"Arbeidsepisode\" i arketypen EVALUATION.occupation_summary (Arbeidssammendrag), men kan også brukes innen andre ENTRY- eller CLUSTER-arketyper der det er klinisk relevant.\r\n\r\nDet kan fremstå som å være overlapp, reell eller tilsynelatende, mellom dataelementene i denne arketypen og demografiske opplysninger om sysselsetting/arbeidsforhold andre steder i kliniske systemer. Dataelementene i denne arketypen er laget spesifikt for å støtte kliniske bruksområder, inkludert sykemeldinger eller legeerklæringer.", + "misuse" : "Brukes ikke for å registrere midlertidige endringer eller episoder innen en enkelt arbeidsepisode, som å være i permisjon. Dette er ikke innenfor anvendelsesområdet for denne arketypen, og skal registreres i et personal- eller HR-system.\r\n\r\nBrukes ikke for å beskrive helserisikoer eller eksponering for farlige substanser i arbeidssituasjonen. Til dette brukes henholdsvis arketypene EVALUATION.health_risk (Helserisiko) eller EVALUATION.exposure.\r\n\r\nBrukes ikke for å registrere informasjon om individets inntektskilder eller detaljer om inntekt. Bruk arketypen EVALUATION.income_summary for dette formålet.\r\n\r\nBrukes ikke for å registrere informasjon om arbeid /rolle for et individ på en bestemt dato (for eksempel 16. juni 2014) eller i løpet av en relativ tidsperiode, som for eksempel \"siste 30 dager\". Dette kan utledes fra \"Dato for oppstart\" hvis det ikke er registrert noe i \"Dato for opphør\", og må registreres i en egen OBSERVATION-arketype for dette formålet.", + "copyright" : "© 2010 NEHTA, openEHR Foundation, Nasjonal IKT HF", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "en" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "en" + }, + "purpose" : "To record details about a single job or role carried out by an individual during a specified period of time.", + "keywords" : [ "employment", "employer", "job", "occupation", "work", "profession", "unemployed", "employee", "unemployment", "studying", "employed", "student", "sector", "profession", "volunteer", "vocation", "trade", "worker", "volunteer", "position" ], + "use" : "Use to record details about a single job or role carried out by an individual during a specified period of time. \r\n\r\nThe scope of this archetype is inclusive of all occupations or activities undertaken by an individual. For example: a paid job or employment; unpaid work of any type such as a volunteer position; or roles such as being retired or a student. \r\n\r\nMultiple instances of this archetype captured over time will result in the aggregation of a history of past and present jobs and/or roles.\r\n\r\nAn active, or current occupation may be implied from a 'Date commenced' but no 'Date ceased'. \r\n\r\nAn individual may carry out many simultaneous occupations, each of which may be paid or unpaid. Each occupation should be recorded in a separate instance of this archetype.\r\n\r\nIf occupation attributes change significantly, such as a change of role/title or number of hours, then this should be recorded as a separate instance of this archetype.\r\n\r\nThis archetype has been specifically designed to be used in the 'Occupation episode' SLOT within the EVALUATION.occupation_summary archetype, but can also be used within any other ENTRY or CLUSTER archetypes, where clinically appropriate.\r\n\r\nThere may be some apparent or real overlap between the data elements in this archetype and occupation/employment details that may be stored as demographic details in clinical or administrative systems. These data elements have been designed specifically to support clinical purposes including generation of a medical certificate to a current employer.", + "misuse" : "Not to be used to record temporary changes or episodes within a single occupation record, such as being on leave. This is out of scope for this archetype and should be part of an employer's human relations system.\r\n\r\nNot to be used for detailed descriptions of health risks or exposure to hazardous substances in the workplace. Use the archetypes EVALUATION.health_risk or EVALUATION.exposure for this purpose.\r\n\r\nNot to be used to record information about sources of income or income details for the individual. Use the EVALUATION.income_summary archetype for this purpose.\r\n\r\nNot to be used to record information about the occupation of an individual at a specific point in time (for example, on June 16, 2014) or during a relative interval of time (for example 'in the past 30 days'. Use an appropriate OBSERVATION archetype for this purpose.", + "copyright" : "© Australian Digital Health Agency, openEHR Foundation, Nasjonal IKT HF", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "it" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "it" + }, + "purpose" : "Registrare i dettagli della singola professione svolta o ruolo ricoperto da un individuo durante un determinato periodo di tempo.", + "keywords" : [ "lavoro, impiego, datore di lavoro, occupazione, disoccupazione, professione, disoccupato, occupato, dipendente, impiegato, studente, settore, volontario, vocazione, mestiere, lavoratore, posizione" ], + "use" : "Usato per registrare i dettagli della singola professione svolta o ruolo ricoperto da un individuo durante un determinato periodo di tempo.\r\n\r\nL'ambito di questo archetipo comprende tutte le occupazioni o attività svolte da un individuo. Ad esempio: un lavoro o impiego retribuiti; un qualsiasi lavoro non retribuito, come un'attività di volontariato; o ruoli come essere in pensione o uno studente. \r\n\r\nPiù istanze di questo archetipo catturate nel tempo possono essere aggregate per costruire la storia occupazionale di un individuo, che comprende occupazioni e ruoli passati e presenti.\r\n\r\nÈ possibile dedurre se l'occupazione sia attiva/corrente se è presente una 'Data di inizio' ma non una 'Data di cessazione'.\r\n\r\nUn individuo può avere più occupazioni contemporaneamente, ciascuna delle quali può essere retribuita o meno. Ogni occupazione dovrebbe essere registrata in una istanza separata di questo archetipo. \r\n\r\nSe i dettagli dell'occupazione cambiano significativamente, ad esempio in caso di modifica del ruolo/titolo o numero di ore, questo dovrebbe corrispondere ad un'istanza separata di questo archetipo.\r\n\r\nQuesto archetipo è stato sviluppato per essere usato nello SLOT 'Episodio lavorativo' all'interno dell'archetipo EVALUATION.occupation_summary, ma è possibile utilizzarlo all'interno di altri archetipi di tipo ENTRY o CLUSTER quando clinicamente appropriato. \r\n\r\nCi potrebbe essere una sovrapposizione, apparente o reale, tra i dati all'interno di questo archetipo e i dettegli sull'occupazione/impiego memorizzati come informazioni demografiche all'interno di sistemi clinici o amministrativi. I contenuti sono stati espressamente progettati per supportare l'attività clinica, compresa la generazione di certificati medici per un datore di lavoro.", + "misuse" : "Non utilizzare per memorizzare cambiamenti o episodi temporanei all'interno di un singolo record di occupazione, come ad esempio essere in congedo. Questo non rientra nello scopo dell'archetipo e dovrebbe far parte del sistema di gestione delle risorse umane del datore di lavoro. \r\n\r\nNon utilizzare per descrizioni dettagliate dei rischi per la salute o dell'esposizione a sostanze pericolose nel luogo di lavoro. Utilizzare invece gli archetipi EVALUATION.health_risk o EVALUATION.exposure.\r\n\r\nNon utilizzare per memorizzare informazioni sulle fonti o dettagli del reddito dell'individuo. Per questo scopo, utilizzare l'archetipo EVALUATION.income_summary.\r\n\r\nNon utilizzare per memorizzare informazioni sull'occupazione di un individuo in uno specifico punto nel tempo (ad esempio, il 16 giugno 2014) o durante un intervallo di tempo (ad esempio 'negli ultimi 30 giorni'). Per questo scopo, usare un appropriato archetipo di tipo OBSERVATION. ", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "es" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "es" + }, + "purpose" : "Para registrar detalles sobre un trabajo o rol llevado a cabo por un individuo durante un periodo de tiempo especificado.", + "keywords" : [ "empleo", "empleador", "trabajo", "ocupación", "tarea", "profesión", "desempleado", "empleado", "desempleo", "estudiando", "empleado", "estudiante", "sector", "profesión", "voluntario", "vocación", "comercio", "trabajador", "voluntario", "cargo" ], + "use" : "Usar para registrar detalles sobre un trabajo o rol particular llevado a cabo por un individuo durante un periodo de tiempo especificado.\r\n\r\nEl alcance de este arquetipo incluye todos los empleos o actividades llevadas a cabo por el individuo. Por ejemplo: Un trabajo o empleo pagado; trabajo no remunerado de cualquier tipo como voluntario; o roles tales como estar jubilado o ser estudiante.\r\n\r\nMúltiples instancias de este arquetipo capturadas a lo largo del tiempo resultarán en una agregación de un histórico de trabajos y/o roles presentes o pasados.\r\n\r\nUn trabajo actual puede deducirse de la 'Fecha empezado' pero no de la 'Fecha finalizado'.\r\n\r\nUn individuo puede llevar a cabo muchas ocupaciones al mismo tiempo, las cuales pueden ser remuneradas o no remuneradas. Cada ocupación debería de ser registrada en una instancia separada de este arquetipo.\r\n\r\nSi los atributos de la ocupación cambian significativamente, tales como cambios en el título/rol o el número de horas, éstas se deberían de registrar en una instancia separada de este arquetipo.\r\n\r\nEste arquetipo ha sido específicamente diseñado para ser usado en el SLOT de 'Episodio de ocupación' dentro del arquetipo EVALUATION.occupation_summary, pero también puede ser usado dentro de cualquier otro arquetipo ENTRY o CLUSTER, cuando sea clínicamente apropiado.\r\n\r\nPuede haber una superposición aparente o real entre los elementos de datos en este arquetipo y detalles sobre la ocupación/empleo que puedan haber sido incluidos como detalles demográficos en sistemas clínicos o administrativos. Estos elementos de datos se han diseñado específicamente para dar soporte a propósitos clínicos como puede ser la generación de un certificado médico para el empleador actual.", + "misuse" : "No debe ser usado para registrar cambios temporales o episodios dentro de un único registro ocupacional, tales como estar de baja. Esto está fuera del alcance de este arquetipo y debería ser parte de un sistema de recursos humanos del empleador.\r\n\r\nNo debe ser usado para una descripción detallada de los riesgos de salud o exposición a sustancias nocivas en el lugar de trabajo. Para este propósito use los arquetipos EVALUATION.health_risk o EVALUATION.exposure.\r\n\r\nNo debe ser usado para registrar información sobre fuentes o detalles de ingresos de un individuo. Para este propósito use el arquetipo EVALUATION.income_summary.\r\n\r\nNo debe ser usado para registrar información sobre la ocupación de un individuo en un punto concreto de tiempo (por ejemplo, el 16 de Junio de 2014) o durante un periodo de tiempo relativo (por ejemplo 'durante los últimos 30 días'). Para este propósito use un arquetipo OBSERVATION adecuado.", + "originalResourceUri" : { }, + "otherDetails" : { } + } + } + }, + "parentArchetypeId" : "openEHR-EHR-CLUSTER.occupation_record.v1", + "differential" : true, + "archetypeId" : { + "@type" : "ARCHETYPE_HRID", + "value" : "openEHR-EHR-CLUSTER.ovl-occupation_record-001.v1" + }, + "definition" : { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "CLUSTER", + "nodeId" : "at0000.1", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "items", + "children" : [ { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "nodeId" : "at0005.1", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "value", + "children" : [ { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "DV_TEXT", + "defaultValue" : { + "value" : "Healthcare worker", + "@type" : "DV_TEXT" + }, + "attributes" : [ ], + "attributeTuples" : [ ] + } ] + } ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "occurrences" : "0..0", + "nodeId" : "at0016.1", + "attributes" : [ ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "occurrences" : "0..0", + "nodeId" : "at0007.1", + "attributes" : [ ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "occurrences" : "0..0", + "nodeId" : "at0001.1", + "attributes" : [ ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "occurrences" : "0..0", + "nodeId" : "at0013.1", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "value", + "children" : [ { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "DV_PROPORTION", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "numerator", + "children" : [ { + "@type" : "C_REAL", + "rmTypeName" : "Real", + "occurrences" : "1..1", + "constraint" : [ { + "lower" : 0.0, + "lowerIncluded" : true, + "upperIncluded" : false, + "lowerUnbounded" : false, + "upperUnbounded" : true + } ] + } ] + }, { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "type", + "children" : [ { + "@type" : "C_INTEGER", + "rmTypeName" : "Integer", + "occurrences" : "1..1", + "constraint" : [ { + "lower" : 1, + "upper" : 1, + "lowerIncluded" : true, + "upperIncluded" : true, + "lowerUnbounded" : false, + "upperUnbounded" : false + }, { + "lower" : 2, + "upper" : 2, + "lowerIncluded" : true, + "upperIncluded" : true, + "lowerUnbounded" : false, + "upperUnbounded" : false + } ] + } ] + } ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "DV_CODED_TEXT", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "defining_code", + "children" : [ { + "@type" : "C_TERMINOLOGY_CODE", + "rmTypeName" : "CODE_PHRASE", + "occurrences" : "1..1", + "terminologyId" : { + "value" : "local" + }, + "constraint" : [ "at0020", "at0021" ] + } ] + } ], + "attributeTuples" : [ ] + } ] + } ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "occurrences" : "0..0", + "nodeId" : "at0019.1", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "value", + "children" : [ { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "DV_QUANTITY", + "attributes" : [ ], + "attributeTuples" : [ { + "@type" : "C_ATTRIBUTE_TUPLE", + "members" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "magnitude", + "children" : [ ] + }, { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "units", + "children" : [ ] + }, { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "precision", + "children" : [ ] + } ], + "tuples" : [ { + "@type" : "C_PRIMITIVE_TUPLE", + "members" : [ { + "@type" : "C_REAL", + "constraint" : [ { + "lower" : 0.0, + "lowerIncluded" : true, + "upperIncluded" : false, + "lowerUnbounded" : false, + "upperUnbounded" : true + } ] + }, { + "@type" : "C_STRING", + "constraint" : [ "h/d" ] + }, { + "@type" : "C_INTEGER", + "constraint" : [ { + "lower" : 2, + "upper" : 2, + "lowerIncluded" : true, + "upperIncluded" : true, + "lowerUnbounded" : false, + "upperUnbounded" : false + } ] + } ] + }, { + "@type" : "C_PRIMITIVE_TUPLE", + "members" : [ { + "@type" : "C_REAL", + "constraint" : [ { + "lower" : 0.0, + "lowerIncluded" : true, + "upperIncluded" : false, + "lowerUnbounded" : false, + "upperUnbounded" : true + } ] + }, { + "@type" : "C_STRING", + "constraint" : [ "h/wk" ] + }, { + "@type" : "C_INTEGER", + "constraint" : [ { + "lower" : 2, + "upper" : 2, + "lowerIncluded" : true, + "upperIncluded" : true, + "lowerUnbounded" : false, + "upperUnbounded" : false + } ] + } ] + }, { + "@type" : "C_PRIMITIVE_TUPLE", + "members" : [ { + "@type" : "C_REAL", + "constraint" : [ { + "lower" : 0.0, + "lowerIncluded" : true, + "upperIncluded" : false, + "lowerUnbounded" : false, + "upperUnbounded" : true + } ] + }, { + "@type" : "C_STRING", + "constraint" : [ "h/mo" ] + }, { + "@type" : "C_INTEGER", + "constraint" : [ { + "lower" : 2, + "upper" : 2, + "lowerIncluded" : true, + "upperIncluded" : true, + "lowerUnbounded" : false, + "upperUnbounded" : false + } ] + } ] + }, { + "@type" : "C_PRIMITIVE_TUPLE", + "members" : [ { + "@type" : "C_REAL", + "constraint" : [ { + "lower" : 0.0, + "lowerIncluded" : true, + "upperIncluded" : false, + "lowerUnbounded" : false, + "upperUnbounded" : true + } ] + }, { + "@type" : "C_STRING", + "constraint" : [ "h/a" ] + }, { + "@type" : "C_INTEGER", + "constraint" : [ { + "lower" : 2, + "upper" : 2, + "lowerIncluded" : true, + "upperIncluded" : true, + "lowerUnbounded" : false, + "upperUnbounded" : false + } ] + } ] + }, { + "@type" : "C_PRIMITIVE_TUPLE", + "members" : [ { + "@type" : "C_REAL", + "constraint" : [ { + "lower" : 0.0, + "lowerIncluded" : true, + "upperIncluded" : false, + "lowerUnbounded" : false, + "upperUnbounded" : true + } ] + }, { + "@type" : "C_STRING", + "constraint" : [ "d/wk" ] + }, { + "@type" : "C_INTEGER", + "constraint" : [ { + "lower" : 2, + "upper" : 2, + "lowerIncluded" : true, + "upperIncluded" : true, + "lowerUnbounded" : false, + "upperUnbounded" : false + } ] + } ] + }, { + "@type" : "C_PRIMITIVE_TUPLE", + "members" : [ { + "@type" : "C_REAL", + "constraint" : [ { + "lower" : 0.0, + "lowerIncluded" : true, + "upperIncluded" : false, + "lowerUnbounded" : false, + "upperUnbounded" : true + } ] + }, { + "@type" : "C_STRING", + "constraint" : [ "d/mo" ] + }, { + "@type" : "C_INTEGER", + "constraint" : [ { + "lower" : 2, + "upper" : 2, + "lowerIncluded" : true, + "upperIncluded" : true, + "lowerUnbounded" : false, + "upperUnbounded" : false + } ] + } ] + }, { + "@type" : "C_PRIMITIVE_TUPLE", + "members" : [ { + "@type" : "C_REAL", + "constraint" : [ { + "lower" : 0.0, + "lowerIncluded" : true, + "upperIncluded" : false, + "lowerUnbounded" : false, + "upperUnbounded" : true + } ] + }, { + "@type" : "C_STRING", + "constraint" : [ "wk/mo" ] + }, { + "@type" : "C_INTEGER", + "constraint" : [ { + "lower" : 2, + "upper" : 2, + "lowerIncluded" : true, + "upperIncluded" : true, + "lowerUnbounded" : false, + "upperUnbounded" : false + } ] + } ] + }, { + "@type" : "C_PRIMITIVE_TUPLE", + "members" : [ { + "@type" : "C_REAL", + "constraint" : [ { + "lower" : 0.0, + "lowerIncluded" : true, + "upperIncluded" : false, + "lowerUnbounded" : false, + "upperUnbounded" : true + } ] + }, { + "@type" : "C_STRING", + "constraint" : [ "d/a" ] + }, { + "@type" : "C_INTEGER", + "constraint" : [ { + "lower" : 2, + "upper" : 2, + "lowerIncluded" : true, + "upperIncluded" : true, + "lowerUnbounded" : false, + "upperUnbounded" : false + } ] + } ] + }, { + "@type" : "C_PRIMITIVE_TUPLE", + "members" : [ { + "@type" : "C_REAL", + "constraint" : [ { + "lower" : 0.0, + "lowerIncluded" : true, + "upperIncluded" : false, + "lowerUnbounded" : false, + "upperUnbounded" : true + } ] + }, { + "@type" : "C_STRING", + "constraint" : [ "wk/a" ] + }, { + "@type" : "C_INTEGER", + "constraint" : [ { + "lower" : 2, + "upper" : 2, + "lowerIncluded" : true, + "upperIncluded" : true, + "lowerUnbounded" : false, + "upperUnbounded" : false + } ] + } ] + }, { + "@type" : "C_PRIMITIVE_TUPLE", + "members" : [ { + "@type" : "C_REAL", + "constraint" : [ { + "lower" : 0.0, + "lowerIncluded" : true, + "upperIncluded" : false, + "lowerUnbounded" : false, + "upperUnbounded" : true + } ] + }, { + "@type" : "C_STRING", + "constraint" : [ "mo/a" ] + }, { + "@type" : "C_INTEGER", + "constraint" : [ { + "lower" : 2, + "upper" : 2, + "lowerIncluded" : true, + "upperIncluded" : true, + "lowerUnbounded" : false, + "upperUnbounded" : false + } ] + } ] + } ] + } ] + } ] + } ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "occurrences" : "0..0", + "nodeId" : "at0002.1", + "attributes" : [ ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "occurrences" : "0..0", + "nodeId" : "at0006.1", + "attributes" : [ ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "occurrences" : "0..0", + "nodeId" : "at0008.1", + "attributes" : [ ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "occurrences" : "0..0", + "nodeId" : "at0014.1", + "attributes" : [ ], + "attributeTuples" : [ ] + }, { + "@type" : "C_ARCHETYPE_ROOT", + "rmTypeName" : "CLUSTER", + "occurrences" : "0..1", + "nodeId" : "at0004.1", + "attributes" : [ ], + "attributeTuples" : [ ], + "archetypeRef" : "openEHR-EHR-CLUSTER.ovl-organisation_cc-001.v0", + "referenceType" : "archetypeOverlay" + } ] + } ], + "attributeTuples" : [ ] + }, + "terminology" : { + "@type" : "ARCHETYPE_TERMINOLOGY", + "conceptCode" : "at0000", + "termDefinitions" : { + "en" : { }, + "nb" : { }, + "it" : { }, + "es" : { } + }, + "termBindings" : { }, + "terminologyExtracts" : { }, + "valueSets" : { } + }, + "adlVersion" : "1.4", + "buildUid" : "39a0b4df-30f5-431b-b219-0c4a668893c1", + "rmName" : "openehr", + "rmRelease" : "1.0.3", + "generated" : true, + "otherMetaData" : { }, + "originalLanguage" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "en" + }, + "translations" : [ { + "@type" : "TRANSLATION_DETAILS", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "nb" + }, + "author" : { + "name" : "Silje Ljosland Bakke and Vebjørn Arntzen", + "organisation" : "Nasjonal IKT HF", + "email" : "silje.ljosland.bakke@nasjonalikt.no / varntzen@ous-hf.no" + }, + "otherDetails" : { } + }, { + "@type" : "TRANSLATION_DETAILS", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "it" + }, + "author" : { + "name" : "Cecilia Mascia", + "organisation" : "CRS4 - Center for advanced studies, research and development in Sardinia, Pula (Cagliari), Italy", + "email" : "ceclila.mascia@crs4.it" + }, + "otherDetails" : { } + }, { + "@type" : "TRANSLATION_DETAILS", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "es" + }, + "author" : { + "name" : "Diego Bosca", + "organisation" : "VeraTech for Health", + "email" : "diebosto@veratech.es" + }, + "otherDetails" : { } + } ] + }, { + "@type" : "TEMPLATE_OVERLAY", + "uid" : "08138f06-ccca-416f-b11a-fab61f9761b1", + "description" : { + "@type" : "RESOURCE_DESCRIPTION", + "originalAuthor" : { + "date" : "2020-03-11" + }, + "otherContributors" : [ ], + "lifecycleState" : { + "codeString" : "unmanaged" + }, + "ipAcknowledgements" : { }, + "references" : { }, + "conversionDetails" : { }, + "otherDetails" : { + "licence" : "This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/.", + "custodian_organisation" : "openEHR Foundation", + "original_namespace" : "org.openehr", + "original_publisher" : "openEHR Foundation", + "custodian_namespace" : "org.openehr", + "MD5-CAM-1.0.1" : "0dd6d70762820298bc14b5ee3b12fa25", + "PARENT:MD5-CAM-1.0.1" : "7E6F0883E14EDE591F38805F00280D56" + }, + "details" : { + "nb" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "nb" + }, + "keywords" : [ ], + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "en" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "en" + }, + "keywords" : [ ], + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "it" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "it" + }, + "purpose" : "Registrare un sommario o informazioni persistenti sulle attività lavorative e/o ruoli presenti e passati di un individuo.", + "keywords" : [ "impiego, studio, lavoro, occupazione, badante, ruolo, pensionato, studente, impiegato, datore di lavoro, professione, disoccupazione, occupazione, figlio, disabile" ], + "use" : "Usato per registrare un sommario o informazioni persistenti sulle attività lavorative e/o ruoli presenti e passati di un individuo.\r\n\r\nQuesto archetipo è stato ideato per essere usato come archetipo a sé stante all'interno di un template per la 'Storia sociale' (o simili). L'archetipo intende fornire un sommario di tutte le occupazioni, considerate nel senso più ampio del termine. Per ogni professione o ruolo, usare una istanza separata dell'archetipo CLUSTER.occupation_record all'interno dello SLOT 'Episodio lavorativo'.", + "misuse" : "Non utilizzare per memorizzare dettagli strutturati riguardanti una specifica professione o ruolo. Per questo scopo, usare invece l'archetipo CLUSTER.occupation_record all'interno dello SLOT 'Episodio lavorativo'.\r\n\r\nNon utilizzare per descrizioni dettagliate dei rischi per la salute o dell'esposizione a sostanze pericolose nel luogo di lavoro. Utilizzare invece gli archetipi EVALUATION.health_risk o EVALUATION.exposure.\r\n\r\nNon utilizzare per memorizzare informazioni sulle fonti o dettagli del reddito dell'individuo. Per questo scopo, utilizzare l'archetipo EVALUATION.income_summary.", + "originalResourceUri" : { }, + "otherDetails" : { } + } + } + }, + "parentArchetypeId" : "openEHR-EHR-EVALUATION.occupation_summary.v1", + "differential" : true, + "archetypeId" : { + "@type" : "ARCHETYPE_HRID", + "value" : "openEHR-EHR-EVALUATION.ovl-occupation_summary-001.v1" + }, + "definition" : { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "EVALUATION", + "nodeId" : "at0000.1", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "data", + "children" : [ { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ITEM_TREE", + "nodeId" : "at0001", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "items", + "children" : [ { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "occurrences" : "0..0", + "nodeId" : "at0002.1", + "attributes" : [ ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "occurrences" : "0..0", + "nodeId" : "at0004.1", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "value", + "children" : [ { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "DV_TEXT", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "value", + "children" : [ { + "@type" : "C_STRING", + "rmTypeName" : "STRING", + "constraint" : [ "YES", "NO", "UNKNOWN" ] + } ] + } ], + "attributeTuples" : [ ] + } ] + } ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "occurrences" : "0..0", + "nodeId" : "at0006.1", + "attributes" : [ ], + "attributeTuples" : [ ] + }, { + "@type" : "C_ARCHETYPE_ROOT", + "rmTypeName" : "CLUSTER", + "occurrences" : "0..1", + "nodeId" : "at0003.1", + "attributes" : [ ], + "attributeTuples" : [ ], + "archetypeRef" : "openEHR-EHR-CLUSTER.ovl-occupation_record-001.v1", + "referenceType" : "archetypeOverlay" + }, { + "@type" : "C_ARCHETYPE_ROOT", + "rmTypeName" : "CLUSTER", + "occurrences" : "0..1", + "nodeId" : "at0005.1", + "attributes" : [ ], + "attributeTuples" : [ ], + "archetypeRef" : "openEHR-EHR-CLUSTER.ovl-employment_covid-001.v0", + "referenceType" : "archetypeOverlay" + } ] + } ], + "attributeTuples" : [ ] + } ] + }, { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "protocol", + "children" : [ { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ITEM_TREE", + "nodeId" : "at0007", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "items", + "children" : [ { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "occurrences" : "0..0", + "nodeId" : "at0009.1", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "value", + "children" : [ { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "DV_DATE_TIME", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "value", + "children" : [ { + "@type" : "C_DATE_TIME", + "rmTypeName" : "DATE_TIME", + "constraint" : [ ] + } ] + } ], + "attributeTuples" : [ ] + } ] + } ], + "attributeTuples" : [ ] + } ] + } ], + "attributeTuples" : [ ] + } ] + } ], + "attributeTuples" : [ ] + }, + "terminology" : { + "@type" : "ARCHETYPE_TERMINOLOGY", + "conceptCode" : "at0000", + "termDefinitions" : { + "en" : { + "at0000.1" : { + "@type" : "ARCHETYPE_TERM", + "code" : "at0000.1", + "text" : "Healthcare worker", + "description" : "Summary or persistent information about an individual's current and past jobs and/or roles." + }, + "at0004.1" : { + "@type" : "ARCHETYPE_TERM", + "code" : "at0004.1", + "text" : "Is healthcare worker?", + "description" : "Statement about the individual's current employment.", + "comment" : "For example: employed; unemployed; or not in labour force. Coding with a terminology is desirable, where possible. Detail about each occupation can be recorded within the CLUSTER.occupation_record archetype." + } + }, + "nb" : { }, + "it" : { } + }, + "termBindings" : { }, + "terminologyExtracts" : { }, + "valueSets" : { } + }, + "adlVersion" : "1.4", + "buildUid" : "35709c69-d4e0-33da-9232-b2c62241ee80", + "rmName" : "openehr", + "rmRelease" : "1.0.3", + "generated" : true, + "templateId" : "Healthcare worker fragment", + "otherMetaData" : { }, + "originalLanguage" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "en" + }, + "translations" : [ { + "@type" : "TRANSLATION_DETAILS", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "nb" + }, + "author" : { }, + "otherDetails" : { } + }, { + "@type" : "TRANSLATION_DETAILS", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "it" + }, + "author" : { + "name" : "Cecilia Mascia", + "organisation" : "CRS4 - Center for advanced studies, research and development in Sardinia, Pula (Cagliari), Italy", + "email" : "cecilia.mascia@crs4.it" + }, + "otherDetails" : { } + } ] + }, { + "@type" : "TEMPLATE_OVERLAY", + "uid" : "5dc9a08b-52bc-4432-883b-24464a50f41d", + "description" : { + "@type" : "RESOURCE_DESCRIPTION", + "originalAuthor" : { }, + "otherContributors" : [ ], + "ipAcknowledgements" : { }, + "references" : { }, + "conversionDetails" : { }, + "otherDetails" : { + "PARENT:MD5-CAM-1.0.1" : "3B904FAD4A5459C4CA09D5A9B921CC37" + }, + "details" : { + "en" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "en" + }, + "purpose" : "To record the circumstances about how an individual lives alone or with others.", + "keywords" : [ "alone", "solo", "family", "friends", "others", "household" ], + "use" : "Use to record the circumstances about how an individual lives alone or with others. \r\n\r\nThe intent of this archetype is to provide a sense of the level of day-to-day support, both physically and emotionally, that may be available to an individual in their 'home' setting.\r\n\r\nThe concepts around housing, accommodation and living arrangements are complex and often potentially overlapping. Within this archetype, the intent of the concept of 'household' is to capture information about the group of people (one or more) who live in the same dwelling and share meals or living accommodation. A single dwelling may be considered to contain multiple households if either meals or living space are not shared. In this context households can include varieties of blended families, share housing, group homes, boarding houses, and a single room occupancy.\r\n\r\nThis archetype has been designed to be used within the EVALUATION.housing_summary archetype, but may be used within any other appropriate ENTRY or CLUSTER archetype related to recording social context.", + "misuse" : "Not to be used to record details about the physical structure in which an individual lives - use CLUSTER.dwelling for this purpose.\r\n\r\nNot to be used to record details about the setting in which an individual usually resides - use CLUSTER.accommodation for this purpose.", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + } + } + }, + "parentArchetypeId" : "openEHR-EHR-EVALUATION.living_arrangement.v0", + "differential" : true, + "archetypeId" : { + "@type" : "ARCHETYPE_HRID", + "value" : "openEHR-EHR-EVALUATION.ovl-living_arrangement-001.v0" + }, + "definition" : { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "EVALUATION", + "nodeId" : "at0000.1", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "data", + "children" : [ { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ITEM_TREE", + "nodeId" : "at0001", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "items", + "children" : [ { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "occurrences" : "0..0", + "nodeId" : "at0004.1", + "attributes" : [ ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "occurrences" : "0..0", + "nodeId" : "at0005.1", + "attributes" : [ ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "occurrences" : "0..0", + "nodeId" : "at0006.1", + "attributes" : [ ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "occurrences" : "0..0", + "nodeId" : "at0009.1", + "attributes" : [ ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "occurrences" : "0..0", + "nodeId" : "at0010.1", + "attributes" : [ ], + "attributeTuples" : [ ] + }, { + "@type" : "C_ARCHETYPE_ROOT", + "rmTypeName" : "CLUSTER", + "occurrences" : "0..1", + "nodeId" : "at0008.1", + "attributes" : [ ], + "attributeTuples" : [ ], + "archetypeRef" : "openEHR-EHR-CLUSTER.ovl-dwelling-002.v0", + "referenceType" : "archetypeOverlay" + } ] + } ], + "attributeTuples" : [ ] + } ] + }, { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "protocol", + "children" : [ { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ITEM_TREE", + "nodeId" : "at0002", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "items", + "children" : [ { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "occurrences" : "0..0", + "nodeId" : "at0012.1", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "value", + "children" : [ { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "DV_DATE_TIME", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "value", + "children" : [ { + "@type" : "C_DATE_TIME", + "rmTypeName" : "DATE_TIME", + "constraint" : [ ] + } ] + } ], + "attributeTuples" : [ ] + } ] + } ], + "attributeTuples" : [ ] + } ] + } ], + "attributeTuples" : [ ] + } ] + } ], + "attributeTuples" : [ ] + }, + "terminology" : { + "@type" : "ARCHETYPE_TERMINOLOGY", + "conceptCode" : "at0000", + "termDefinitions" : { + "en" : { + "at0000.1" : { + "@type" : "ARCHETYPE_TERM", + "code" : "at0000.1", + "text" : "Household", + "description" : "The circumstances about an individual living alone or with others.", + "comment" : "This information will provide a sense of the level of support, both physically and emotionally, to which an individual may have access." + } + } + }, + "termBindings" : { }, + "terminologyExtracts" : { }, + "valueSets" : { } + }, + "adlVersion" : "1.4", + "buildUid" : "723aab03-8390-4c37-b0e7-fcf8621ff66b", + "rmName" : "openehr", + "rmRelease" : "1.0.3", + "generated" : true, + "otherMetaData" : { }, + "originalLanguage" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "en" + }, + "translations" : [ ] + }, { + "@type" : "TEMPLATE_OVERLAY", + "uid" : "133d68c4-1f3e-4d9e-ab5e-e7fc7670649a", + "description" : { + "@type" : "RESOURCE_DESCRIPTION", + "originalAuthor" : { }, + "otherContributors" : [ ], + "ipAcknowledgements" : { }, + "references" : { }, + "conversionDetails" : { }, + "otherDetails" : { + "PARENT:MD5-CAM-1.0.1" : "C35F0CD7F5EC0C80B580727E02F8D6CC" + }, + "details" : { + "en" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "en" + }, + "keywords" : [ ], + "originalResourceUri" : { }, + "otherDetails" : { } + } + } + }, + "parentArchetypeId" : "openEHR-EHR-CLUSTER.employment_covid.v0", + "differential" : true, + "archetypeId" : { + "@type" : "ARCHETYPE_HRID", + "value" : "openEHR-EHR-CLUSTER.ovl-employment_covid-001.v0" + }, + "definition" : { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "CLUSTER", + "nodeId" : "at0000.1", + "attributes" : [ ], + "attributeTuples" : [ ] + }, + "terminology" : { + "@type" : "ARCHETYPE_TERMINOLOGY", + "conceptCode" : "at0000", + "termDefinitions" : { + "en" : { } + }, + "termBindings" : { }, + "terminologyExtracts" : { }, + "valueSets" : { } + }, + "adlVersion" : "1.4", + "buildUid" : "118cc0e7-01a2-3067-9c71-1c53baaa25b9", + "rmName" : "openehr", + "rmRelease" : "1.0.3", + "generated" : true, + "otherMetaData" : { }, + "originalLanguage" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "en" + }, + "translations" : [ ] + }, { + "@type" : "TEMPLATE_OVERLAY", + "uid" : "d181e5cf-bd2e-4b95-896d-a6acef9b941d", + "description" : { + "@type" : "RESOURCE_DESCRIPTION", + "originalAuthor" : { }, + "otherContributors" : [ ], + "ipAcknowledgements" : { }, + "references" : { }, + "conversionDetails" : { }, + "otherDetails" : { + "PARENT:MD5-CAM-1.0.1" : "8EF81636931CBD91B3468C1BA5B005EA" + }, + "details" : { + "nb" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "nb" + }, + "purpose" : "For å registrere en oversikt og beskrivelse om egenskapene til en bolig der et individ bor.", + "keywords" : [ "trapper", "soverom", "bad", "tilgjengelighet", "enebolig", "leilighet", "campingvogn", "hytte", "etasje", "rullestol", "areal", "universell utforming", "UU" ], + "use" : "Brukes for å registrere detaljer om egenskapene til en bolig der et individ bor, spesielt ting som kan ha betydning for individets helse og sikkerhet, eller ha innvirkning på ytelse av helsetjenester.\r\n\r\nDenne arketypen er utformet for å registrere attributter til et individs hjem, og vil kunne brukes til:\r\n- å identifisere hjelpemidler som kan være nyttig i boligen\r\n- registrere modifikasjoner og forbedringer for å støtte universell utforming (UU), eller\r\n- bidra til offentlige undersøkelser knyttet til sykdomsutbrudd.\r\n\r\nDenne arketypen er utformet for å brukes i EVALUATION.housing_summary (Boligsammendrag) eller CLUSTER.housing_record (Bolig), men kan også bli brukt i hvilken som helst annen passende ENTRY- eller CLUSTER-arketype.\r\n\r\nDersom det er nødvendig med spesifikke detaljer, kan arketyper legges til i elementet \"Ytterligere detaljer\". \r\n\r\nGrad av overensstemmelse med designprinsipper for universell utforming (UU) bør registreres i en egen arketype, som kan legges til i SLOT'et \"Ytterligere detaljer\".", + "misuse" : "Skal ikke brukes til å registrere detaljer om de sosiale forholdene individet bor under, bruk CLUSTER.living_arrangement til dette.\r\n\r\nSkal ikke brukes til å registrere den fysiske adressen der et individ bor, bruk demografiske arketyper for dette, eller CLUSTER.address (Adresse) dersom det er nødvendig å registrere adressen i den medisinske journalen.\r\n\r\nSkal ikke brukes til å registrere informasjon om boligen som ikke har noe betydning for helse, eller behov for helsetjenester til et individ. For eksempel bør ikke informasjon om dørlåsens kode til bruk for hjemmesykepleietjenesten registreres i denne arketypen.\r\n\r\nSkal ikke brukes for å registrere grad av overenstemmelse med prinsipper for universell utforming.", + "originalResourceUri" : { }, + "otherDetails" : { } + }, + "en" : { + "@type" : "RESOURCE_DESCRIPTION_ITEM", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "en" + }, + "purpose" : "To record an overview and description about aspects about the dwelling where an individual lives.", + "keywords" : [ "stairs", "bedroom", "bathroom", "access" ], + "use" : "Use to record details about the dwelling where an individual lives, particularly where this may have an impact on their health and safety or delivery of healthcare services.\r\n\r\nThis archetype has been designed to be used to record attributes of an individual's home that might be used to:\r\n- contribute to identification of aids/supports that might be useful in the home; \r\n- record modifications or enhancements to support universal access; or\r\n- inform investigations about public health outbreaks.\r\n\r\nThis archetype has been designed to be used within the EVALUATION.housing_summary or CLUSTER.housing_record archetypes, but may be used within any other appropriate ENTRY or CLUSTER archetype. \r\n\r\nIf specific measurements or specific details are required, additional archetypes can be nested within the 'Additional details' SLOT.\r\n\r\nCompliance with Universal design principles should be recorded in a separate archetype, which may be nested within the 'Additional details' SLOT.", + "misuse" : "Not to be used to record details about the social circumstances in which the individual lives - use CLUSTER.living_arrangement for this purpose.\r\n\r\nNot to be used to record the physical address where an individual lives - use demographic archetypes for this purpose, or CLUSTER.address if the individual's address needs to be recorded within the health record.\r\n\r\nNot to be used to record information about the dwelling that does not impact on the health or health care needs of an individual. For example, the security access code for a home nurse visit should not be recorded using this archetype.\r\n\r\nNot to be used to record compliance with Universal design principles.", + "copyright" : "© openEHR Foundation", + "originalResourceUri" : { }, + "otherDetails" : { } + } + } + }, + "parentArchetypeId" : "openEHR-EHR-CLUSTER.dwelling.v0", + "differential" : true, + "archetypeId" : { + "@type" : "ARCHETYPE_HRID", + "value" : "openEHR-EHR-CLUSTER.ovl-dwelling-002.v0" + }, + "definition" : { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "CLUSTER", + "nodeId" : "at0000.1", + "attributes" : [ { + "@type" : "C_ATTRIBUTE", + "rmAttributeName" : "items", + "children" : [ { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "occurrences" : "0..0", + "nodeId" : "at0002.1", + "attributes" : [ ], + "attributeTuples" : [ ] + }, { + "@type" : "C_COMPLEX_OBJECT", + "rmTypeName" : "ELEMENT", + "occurrences" : "0..0", + "nodeId" : "at0001.1", + "attributes" : [ ], + 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"terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "es-ar" + }, + "author" : { + "name" : "Edgardo Vazquez", + "organisation" : "VinculoMedico" + }, + "accreditation" : "Medical Doctor", + "otherDetails" : { } + }, { + "@type" : "TRANSLATION_DETAILS", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "ko" + }, + "author" : { + "name" : "Seung-Jong Yu", + "organisation" : "NOUSCO Co.,Ltd.", + "email" : "seungjong.yu@gmail.com" + }, + "accreditation" : "Certified Board of Family Medicine in South Korea", + "otherDetails" : { } + }, { + "@type" : "TRANSLATION_DETAILS", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "pt-br" + }, + "author" : { + "name" : "Vladimir Pizzo", + "organisation" : "Hospital Sirio Libanes, Brazil", + "email" : "vladimir.pizzo@hsl.org.br" + }, + "otherDetails" : { } + }, { + "@type" : "TRANSLATION_DETAILS", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "ar-sy" + }, + "author" : { + "name" : "Mona Saleh" + }, + "otherDetails" : { } + }, { + "@type" : "TRANSLATION_DETAILS", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "es" + }, + "author" : { + "name" : "Pablo Pazos", + "organisation" : "CaboLabs" + }, + "accreditation" : "Computer Engineer", + "otherDetails" : { } + }, { + "@type" : "TRANSLATION_DETAILS", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "nl" + }, + "author" : { + "name" : "Dennis Valk", + "organisation" : "Code24 BV", + "email" : "dennis.valk@code24.nl" + }, + "accreditation" : "Code24 BV", + "otherDetails" : { } + }, { + "@type" : "TRANSLATION_DETAILS", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "fi" + }, + "author" : { }, + "otherDetails" : { } + }, { + "@type" : "TRANSLATION_DETAILS", + "language" : { + "terminologyId" : { + "value" : "ISO_639-1" + }, + "codeString" : "it" + }, + "author" : { + "name" : "Paolo Anedda", + "organisation" : "Inpeco", + "email" : "paolo.anedda@inpeco.com" + }, + "otherDetails" : { } + } ] +} \ No newline at end of file diff --git a/better-template/src/test/resources/opt_json/adl2/openEHR-EHR-CLUSTER.symptom_sign.v1.0.0.adls b/better-template/src/test/resources/opt_json/adl2/openEHR-EHR-CLUSTER.symptom_sign.v1.0.0.adls new file mode 100644 index 000000000..5388f2bb7 --- /dev/null +++ b/better-template/src/test/resources/opt_json/adl2/openEHR-EHR-CLUSTER.symptom_sign.v1.0.0.adls @@ -0,0 +1,1428 @@ +archetype (adl_version=2.0.6; rm_release=1.0.3; generated; uid=ac33fa64-f61a-4feb-bd29-0e5b1f4710a0) + openEHR-EHR-CLUSTER.symptom_sign.v1.0.0 + +language + original_language = <[ISO_639-1::en]> + translations = < + ["de"] = < + language = <[ISO_639-1::de]> + author = < + ["name"] = <"Jasmin Buck, Sebastian Garde"> + ["organisation"] = <"University of Heidelberg, Central Queensland University"> + > + > + ["nb"] = < + language = <[ISO_639-1::nb]> + author = < + ["name"] = <"Lars Bitsch-Larsen"> + ["organisation"] = <"Haukeland University Hospital of Bergen, Norway"> + ["email"] = <"lbla@helse-bergen.no"> + > + accreditation = <"MD, DEAA, MBA, spec in anesthesia, spec in tropical medicine."> + > + ["ar-sy"] = < + language = <[ISO_639-1::ar-sy]> + author = < + ["name"] = <"Mona Saleh"> + > + > + ["nl"] = < + language = <[ISO_639-1::nl]> + author = < + ["name"] = <"Pieter Bos"> + > + > + > + +description + lifecycle_state = <"unmanaged"> + original_author = < + ["name"] = <"Tony Shannon"> + ["organisation"] = <"UK NHS, Connecting for Health"> + ["email"] = <"tony.shannon@nhs.net"> + ["date"] = <"2007-02-20"> + > + original_namespace = <"org.openehr"> + original_publisher = <"openEHR Foundation"> + custodian_namespace = <"org.openehr"> + custodian_organisation = <"openEHR Foundation"> + copyright = <"© openEHR Foundation"> + licence = <"This work is licensed under the Creative Commons Attribution-ShareAlike 3.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/3.0/."> + details = < + ["ar-sy"] = < + language = <[ISO_639-1::ar-sy]> + purpose = <"*To record detail about a symptom - either self-recorded by an individual or recorded on the behalf of a patient by a clinician. A complete patient history may include varying level of details about a variety of symptoms.(en)"> + use = <"*Use to record detailed information about a symptom as told to a clinician by a patient or self-recorded by the individual/patient. + +This archetype allows a 'nil significant' statement to be explicitly recorded.(en)"> + misuse = <"*Not to be used to record details about pain. Use the specialisation of this archetype - the CLUSTER.symptom-pain instead. + +Not to be used for diagnoses and problems that form part of a persisting Problem List - use EVALUATION.problem_diagnosis.(en)"> + > + ["de"] = < + language = <[ISO_639-1::de]> + purpose = <"*To record detail about a symptom - either self-recorded by an individual or recorded on the behalf of a patient by a clinician. A complete patient history may include varying level of details about a variety of symptoms.(en)"> + use = <"*Use to record detailed information about a symptom as told to a clinician by a patient or self-recorded by the individual/patient. + +This archetype allows a 'nil significant' statement to be explicitly recorded.(en)"> + misuse = <"*Sollte nur für Symptome benutzt werden. (en)"> + > + ["nb"] = < + language = <[ISO_639-1::nb]> + purpose = <"For registrering av detaljer om et symptom - enten registrert av personen selv eller registrert på vegne av pasienten av en klinikker. En fullstendig anamnese kan inkludere forskjellige nivåer av detaljer om forskjellige symptomer."> + use = <"Anvendes til registrering av detaljert informasjon om et symptom som det fortelles til en klinikker eller selv-registrert av personen selv. + +Denne arketype tillater spesifikk registrering av et \"null signifikant\" utsagn."> + keywords = <"klage", "presenterer", "symptom", "problem", "visuell analog skala", "VAS"> + misuse = <"Skal ikke anvendes til registrering av detaljer om smerter. Bruk den spesialiserte -the CLUSTER.symptom-pain arketype istedet. + +Anvendes ikke til diagnoser og problemstillinger der er en del av den eksisterende Problem list - bruk EVALUATION.problem_diagnosis."> + > + ["en"] = < + language = <[ISO_639-1::en]> + purpose = <"To record details about a single episode of a reported symptom or sign including context, but not details, of previous episodes if appropriate."> + use = <"Use to record details about a single episode of a symptom or reported sign in an individual, as reported by the individual, parent, care-giver or other party. It may be recorded by a clinician as part of a clinical history record as reported to them, observed by the clinician or self-recorded as part of a clinical questionnaire or personal health record. A complete clinical history or patient story may include varying level of details about multiple episodes of an identified symptom or reported sign, as well as multiple symptoms/signs. + +In the purest sense, symptoms are subjective observations of a physical or mental disturbance and signs are objective observations of the same, as experienced by an individual and reported to the history taker by the same individual or another party. From this logic it follows that we will need two archetypes to record clinical history - one for reported symptoms and another for reported signs. In reality this is impractical as it will require clinical data entry into either one of these models which adds signficant overheads to modellers and those entering data. In addition, there is often overlap in clinical concepts - for example, is previous vomiting or bleeding to be categorised as a symptom or reported sign? In response, this archetype has been specifically designed to proved a single information model that allows for recording of the entire continuum between clearly identifable symptoms and reported signs when recording a clinical history. + +This archetype has been intended to be used as a generic pattern for all symptoms and reported signs. The 'Specific details' SLOT can be used to extend the archetype to include additional, specific data elements for more complex symptoms or signs. + +This archetype has been specifically designed to be used in the 'Structured detail' SLOT within the OBSERVATION.story archetype, but can also be used within other OBSERVATION or CLUSTER archetypes and in the 'Associated symptom/sign' or 'Previous episode' SLOT within other instances of this CLUSTER.symptom_sign archetype. + +Clinicians frequently record the phrase 'nil significant' against specific symptoms or reported signs as an efficient method to indicate that they asked the individual and it was not reported as causing any discomfort or disturbance - effectively used more like a 'normal statement' rather than an explicit exclusion. The 'Nil significant' data element has been deliberately included in this archetype to allow clinicians to record this same information in a simple and effective way in a clinical system. It can be used to drive a user interface, for example if 'Nil significant' is recorded as true then the remaining data elements can be hidden on a data entry screen. This pragmatic approach supports the majority of simple clinical recording requirements around reported symptoms and signs. + +However if there is a clinical imperative to explicitly record that a Symptom or Sign was reported as not present, for example if it will be used to drive clinical decision support, then it would be preferable to use the CLUSTER.exclusion_symptom_sign archetype. The use of CLUSTER.exclusion_symptom_sign will increase the complexity of template modelling, implementation and querying. It is recommended that the CLUSTER.exclusion_symptom_sign archetype only be considered for use if clear benefit can be identified in specific situations, but should not be used for routine symptom/sign recording."> + keywords = <"complaint", "symptom", "disturbance", "problem", "discomfort", "presenting complaint", "presenting symptom", "sign"> + misuse = <"Not to be used to record that a symptom or sign was explicitly reported as not present - use CLUSTER.exclusion_symptom_sign carefully for specific purposes where the overheads of recording in this way warrant the additional complexity, and only if the 'Nil significant' in this archetype is not specific enough for recording purposes. + +Not to be used for recording objective findings as part of a physical examination - use OBSERVATION.exam and related examination CLUSTER archetypes for this purpose. + +Not to be used for diagnoses and problems that form part of a persisting Problem List - use EVALUATION.problem_diagnosis."> + > + > + other_contributors = <"Tomas Alme, DIPS, Norway", "Vebjoern Arntzen, Oslo university hospital, Norway", "Koray Atalag, University of Auckland, New Zealand", "Silje Ljosland Bakke, National ICT Norway, Norway (openEHR Editor)", "Lars Bitsch-Larsen, Haukeland University hospital, Norway", "Rong Chen, Cambio Healthcare Systems, Sweden", "Stephen Chu, Queensland Health, Australia", "Einar Fosse, National Centre for Integrated Care and Telemedicine, Norway", "Samuel Frade, Marand, Portugal", "Sebastian Garde, Ocean Informatics, Germany", "Yves Genevier, Privantis SA, Switzerland", "Heather Grain, Llewelyn Grain Informatics, Australia", "Sam Heard, Ocean Informatics, Australia", "Evelyn Hovenga, EJSH Consulting, Australia", "Lars Karlsen, DIPS ASA, Norway", "Shinji Kobayashi, Kyoto University, Japan", "Sabine Leh, Haukeland University Hospital, Department of Pathology, Norway", "Heather Leslie, Ocean Informatics, Australia (openEHR Editor)", "Hallvard Lærum, Oslo University Hospital, Norway", "Luis Marco Ruiz, Norwegian Center for Integrated Care and Telemedicine, Norway", "Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (openEHR Editor)", "Bjoern Naess, DIPS ASA, Norway", "Andrej Orel, Marand d.o.o., Slovenia", "Jussara Rotzsch, UNB, Brazil", "Anoop Shah, University College London, United Kingdom", "Norwegian Review Summary, National ICT Norway, Norway", "Rowan Thomas, St. Vincent's Hospital Melbourne, Australia", "John Tore Valand, Helse Bergen, Norway"> + references = < + ["1"] = <"Common Terminology Criteria for Adverse Events (CTCAE) [Internet]. National Cancer Institute, USA. Available from: http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm (accessed 2015-07-13)."> + > + other_details = < + ["current_contact"] = <"Heather Leslie, Ocean Informatics, heather.leslie@oceaninformatics.com"> + ["MD5-CAM-1.0.1"] = <"D99FDDA78E05025ED49B9F7502795394"> + ["build_uid"] = <"f3c119e8-8ec5-4c82-82cd-1a34f30e6bb0"> + > + +definition + CLUSTER[id1] matches { -- Symptom/Sign + items matches { + ELEMENT[id2] matches { -- Symptom/Sign name + value matches { + DV_TEXT[id188] + } + } + ELEMENT[id36] occurrences matches {0..1} matches { -- Nil significant + value matches { + DV_BOOLEAN[id189] matches { + value matches {True} + } + } + } + ELEMENT[id3] occurrences matches {0..1} matches { -- Description + value matches { + DV_TEXT[id190] + } + } + ELEMENT[id152] matches { -- Body site + value matches { + DV_TEXT[id191] + } + } + allow_archetype CLUSTER[id148] matches { -- Structured body site + include + archetype_id/value matches {/openEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_clock(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.v1/} + exclude + archetype_id/value matches {/.*/} + } + ELEMENT[id176] occurrences matches {0..1} matches { -- Episodicity + value matches { + DV_CODED_TEXT[id192] matches { + defining_code matches {[ac1]} -- Episodicity (synthesised) + } + } + } + ELEMENT[id187] occurrences matches {0..1} matches { -- First ever? + value matches { + DV_BOOLEAN[id193] matches { + value matches {True} + } + } + } + ELEMENT[id153] occurrences matches {0..1} matches { -- Episode onset + value matches { + DV_DATE_TIME[id194] + } + } + ELEMENT[id165] occurrences matches {0..1} matches { -- Onset type + value matches { + DV_TEXT[id195] + } + } + ELEMENT[id29] occurrences matches {0..1} matches { -- Duration + value matches { + DV_DURATION[id196] + } + } + ELEMENT[id22] occurrences matches {0..1} matches { -- Severity category + value matches { + DV_CODED_TEXT[id197] matches { + defining_code matches {[ac2]} -- Severity category (synthesised) + } + DV_TEXT[id198] + } + } + ELEMENT[id27] matches { -- Severity rating + value matches { + DV_QUANTITY[id199] matches { + property matches {[at186]} + magnitude matches {|0.0..10.0|} + precision matches {1} + units matches {"1"} + } + } + } + ELEMENT[id181] matches { -- Progression + value matches { + DV_CODED_TEXT[id200] matches { + defining_code matches {[ac3]} -- Progression (synthesised) + } + } + } + ELEMENT[id4] occurrences matches {0..1} matches { -- Pattern + value matches { + DV_TEXT[id201] + } + } + CLUSTER[id19] matches { -- Modifying factor + items matches { + ELEMENT[id20] occurrences matches {0..1} matches { -- Factor + value matches { + DV_TEXT[id202] + } + } + ELEMENT[id18] occurrences matches {0..1} matches { -- Effect + value matches { + DV_CODED_TEXT[id203] matches { + defining_code matches {[ac4]} -- Effect (synthesised) + } + } + } + ELEMENT[id57] occurrences matches {0..1} matches { -- Description + value matches { + DV_TEXT[id204] + } + } + } + } + CLUSTER[id166] matches { -- Precipitating/resolving factor + name matches { + DV_CODED_TEXT[id205] matches { + defining_code matches {[ac5]} -- Precipitating/resolving factor (synthesised) + } + } + items matches { + ELEMENT[id171] occurrences matches {0..1} matches { -- Factor + value matches { + DV_TEXT[id206] + } + } + allow_archetype CLUSTER[id155] matches { -- Factor detail + include + archetype_id/value matches {/openEHR-EHR-CLUSTER\.health_event(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.symptom_sign(-[a-zA-Z0-9_]+)*\.v0/} + } + ELEMENT[id172] occurrences matches {0..1} matches { -- Time interval + value matches { + DV_DURATION[id207] + } + } + ELEMENT[id186] occurrences matches {0..1} matches { -- Description + value matches { + DV_TEXT[id208] + } + } + } + } + ELEMENT[id156] matches { -- Impact + value matches { + DV_TEXT[id209] + } + } + ELEMENT[id38] occurrences matches {0..1} matches { -- Episode description + value matches { + DV_TEXT[id210] + } + } + allow_archetype CLUSTER[id154] matches { -- Specific details + include + archetype_id/value matches {/.*/} + } + ELEMENT[id162] occurrences matches {0..1} matches { -- Resolution date/time + value matches { + DV_DATE_TIME[id211] + } + } + ELEMENT[id58] occurrences matches {0..1} matches { -- Description of previous episodes + value matches { + DV_TEXT[id212] + } + } + ELEMENT[id32] occurrences matches {0..1} matches { -- Number of previous episodes + value matches { + DV_COUNT[id213] matches { + magnitude matches {|>=0|} + } + } + } + allow_archetype CLUSTER[id147] matches { -- Previous episodes + include + archetype_id/value matches {/openEHR-EHR-CLUSTER\.symptom_sign(-[a-zA-Z0-9_]+)*\.v0/} + } + allow_archetype CLUSTER[id64] matches { -- Associated symptom/sign + include + archetype_id/value matches {/openEHR-EHR-CLUSTER\.symptom_sign(-[a-zA-Z0-9_]+)*\.v0/} + } + ELEMENT[id164] occurrences matches {0..1} matches { -- Comment + value matches { + DV_TEXT[id214] + } + } + } + } + +terminology + term_definitions = < + ["nl"] = < + ["id1"] = < + text = <"Symptoom/signaal"> + description = <"Een klacht van een patient of objectief waargenomen kernmerk van een ziekte."> + > + ["id2"] = < + text = <"Naam van Symptoom/signaal"> + description = <"De naam van het symptoom of signaal"> + > + ["id3"] = < + text = <"Beschrijving"> + description = <"Beschrijving over het symptoom of signaal"> + > + ["id4"] = < + text = <"Patroon"> + description = <"Beschrijving over het patroon van het symptoom of signaal tijdens deze episode"> + > + ["id18"] = < + text = <"Effect"> + description = <"*Perceived effect of the modifying factor on the symptom or sign.(en)"> + > + ["id19"] = < + text = <"*Modifying factor(en)"> + description = <"*Detail about how a specific factor effects the identified symptom or sign during this episode.(en)"> + > + ["id20"] = < + text = <"*Factor(en)"> + description = <"*Name of the modifying factor.(en)"> + > + ["id22"] = < + text = <"Ernstcategorie"> + description = <"Een categorie waarbinnen de ernst van dit symptoom of signaal valt"> + > + ["at24"] = < + text = <"Mild"> + description = <"De intensiteit van dit symptoom of signaal levert geen probleem op bij normale activiteiten."> + > + ["at25"] = < + text = <"Middel"> + description = <"De intensiteit van dit symptoom of signaal heeft invloed op normale activiteiten."> + > + ["at26"] = < + text = <"Ernstig"> + description = <"De intensiteit van dit symptoom of signaal maakt normale activiteiten onmogelijk."> + > + ["id27"] = < + text = <"Ernst"> + description = <"Numerieke beoordeelingsschaal van de ernst van het signaal of symptoom"> + > + ["id29"] = < + text = <"Duur"> + description = <"De tijdsduur van het signaal of symptoom sinds het begin"> + > + ["id32"] = < + text = <"Aantal eerdere episodes"> + description = <"Het aantal keer dat dit signaal of symptoom eerder gebeurd is."> + > + ["id36"] = < + text = <"Niet significant"> + description = <"Er is aangegeven dat het signaal of symptoom niet significant aanwezig was"> + > + ["id38"] = < + text = <"*Episode description(en)"> + description = <"*Narrative description about the course of the symptom or sign during this episode.(en)"> + > + ["id57"] = < + text = <"*Description(en)"> + description = <"*Narrative description of the effect of the modifying factor on the symptom or sign.(en)"> + > + ["id58"] = < + text = <"*Description of previous episodes(en)"> + description = <"*Narrative description of any or all previous episodes.(en)"> + > + ["id64"] = < + text = <"*Associated symptom/sign(en)"> + description = <"*Structured details about any associated symptoms or signs that are concurrent.(en)"> + > + ["id147"] = < + text = <"*Previous episodes(en)"> + description = <"*Structured details of the symptom or sign during a previous episode.(en)"> + > + ["id148"] = < + text = <"*Structured body site(en)"> + description = <"*Structured body site where the symptom or sign was reported.(en)"> + > + ["id152"] = < + text = <"*Body site(en)"> + description = <"*Simple body site where the symptom or sign was reported.(en)"> + > + ["id153"] = < + text = <"*Onset date/time(en)"> + description = <"*The onset for this episode of the symptom or sign.(en)"> + > + ["id154"] = < + text = <"*Specific details(en)"> + description = <"*Specific data elements that are additionally required to record as unique attributes of the identified symptom or sign.(en)"> + > + ["id155"] = < + text = <"*Factor detail(en)"> + description = <"*Structured detail about the factor associated with the identified symptom or sign.(en)"> + > + ["id156"] = < + text = <"*Impact(en)"> + description = <"*Description of the impact of this symptom or sign.(en)"> + > + ["at157"] = < + text = <"*No effect(en)"> + description = <"*Presence of the factor has no impact on the symptom or sign.(en)"> + > + ["at159"] = < + text = <"*Worsens(en)"> + description = <"*Presence of the factor exaccerbates severity or impact of the symptom or sign.(en)"> + > + ["at160"] = < + text = <"*Relieves(en)"> + description = <"*Presence of the factor reduces the severity or impact of the symptom or sign.(en)"> + > + ["id162"] = < + text = <"*Resolution date/time(en)"> + description = <"*The timing of the cessation of this episode of the symptom or sign.(en)"> + > + ["id164"] = < + text = <"*Comment(en)"> + description = <"*Additional narrative about the symptom or sign not captured in other fields.(en)"> + > + ["id165"] = < + text = <"*Onset type(en)"> + description = <"*Description of the onset of the symptom or sign.(en)"> + > + ["id166"] = < + text = <"*Precipitating/resolving factor(en)"> + description = <"*Details about a health event, symptom, sign or other factor associated with the onset or cessation of the symptom or sign.(en)"> + > + ["at168"] = < + text = <"*Precipitating factor(en)"> + description = <"*Identification of factors/events associated with onset or commencement of the symptom or sign.(en)"> + > + ["at169"] = < + text = <"*Resolving factor(en)"> + description = <"*Identification of factors/events associated with cessation of the symptom or sign.(en)"> + > + ["id171"] = < + text = <"*Factor(en)"> + description = <"*Name of the health event, symptom, reported sign or other factor.(en)"> + > + ["id172"] = < + text = <"*Time interval(en)"> + description = <"*The interval of time between the occurrence or onset of the factor and onset/resolution of the symptom or sign.(en)"> + > + ["id176"] = < + text = <"*Episodicity(en)"> + description = <"*Category of this epsiode for the identified symptom or sign.(en)"> + > + ["at177"] = < + text = <"*New(en)"> + description = <"*This is the first ever episode of the symptom or sign.(en)"> + > + ["at178"] = < + text = <"*Reoccurrence(en)"> + description = <"*This is a second or subsequent discrete episode of the symptom or sign, where each previous episode has completely resolved.(en)"> + > + ["at179"] = < + text = <"*Ongoing(en)"> + description = <"*This symptom or sign is continuously present, effectively a single, ongoing episode.(en)"> + > + ["id181"] = < + text = <"*Progression(en)"> + description = <"*Description progression of the symptom or sign at the time of reporting.(en)"> + > + ["at182"] = < + text = <"*Improving(en)"> + description = <"*The severity of the symptom or sign has improved overall during this episode.(en)"> + > + ["at183"] = < + text = <"*Unchanged(en)"> + description = <"*The severity of the symptom or sign has not changed overall during this episode.(en)"> + > + ["at184"] = < + text = <"*Worsening(en)"> + description = <"*The severity of the symptom or sign has worsened overall during this episode.(en)"> + > + ["at185"] = < + text = <"*Resolved(en)"> + description = <"*The severity of the symptom or sign has resolved.(en)"> + > + ["id186"] = < + text = <"*Description(en)"> + description = <"*Narrative description about the effect of the factor on the identified symptom or sign.(en)"> + > + ["id187"] = < + text = <"*New element(en)"> + description = <"**(en)"> + > + ["at186"] = < + text = <"*(added by post-parse processor)(en)"> + description = <"*(added by post-parse processor)(en)"> + > + ["ac1"] = < + text = <"*Episodicity(en) (synthesised)"> + description = <"*Category of this epsiode for the identified symptom or sign.(en) (synthesised)"> + > + ["ac2"] = < + text = <"*Severity category(en) (synthesised)"> + description = <"*Category representing the overall severity of the symptom or sign.(en) (synthesised)"> + > + ["ac3"] = < + text = <"*Progression(en) (synthesised)"> + description = <"*Description progression of the symptom or sign at the time of reporting.(en) (synthesised)"> + > + ["ac4"] = < + text = <"*Effect(en) (synthesised)"> + description = <"*Perceived effect of the modifying factor on the symptom or sign.(en) (synthesised)"> + > + ["ac5"] = < + text = <"*Precipitating/resolving factor(en) (synthesised)"> + description = <"*Details about a health event, symptom, sign or other factor associated with the onset or cessation of the symptom or sign.(en) (synthesised)"> + > + > + ["ar-sy"] = < + ["id1"] = < + text = <"*Symptom/Sign(en)"> + description = <"*Reported observation of a physical or mental disturbance in an individual.(en)"> + > + ["id2"] = < + text = <"*Symptom/Sign name(en)"> + description = <"*The name of the reported symptom or sign.(en)"> + > + ["id3"] = < + text = <"*Description(en)"> + description = <"*Narrative description about the reported symptom or sign.(en)"> + > + ["id4"] = < + text = <"*Pattern(en)"> + description = <"*Narrative description about the pattern of the symptom or sign during this episode.(en)"> + > + ["id18"] = < + text = <"*Effect(en)"> + description = <"*Perceived effect of the modifying factor on the symptom or sign.(en)"> + > + ["id19"] = < + text = <"*Modifying factor(en)"> + description = <"*Detail about how a specific factor effects the identified symptom or sign during this episode.(en)"> + > + ["id20"] = < + text = <"*Factor(en)"> + description = <"*Name of the modifying factor.(en)"> + > + ["id22"] = < + text = <"*Severity category(en)"> + description = <"*Category representing the overall severity of the symptom or sign.(en)"> + > + ["at24"] = < + text = <"*Mild(en)"> + description = <"*The intensity of the symptom or sign does not cause interference with normal activity.(en)"> + > + ["at25"] = < + text = <"*Moderate(en)"> + description = <"*The intensity of the symptom or sign causes interference with normal activity.(en)"> + > + ["at26"] = < + text = <"*Severe(en)"> + description = <"*The intensity of the symptom or sign causes prevents normal activity.(en)"> + > + ["id27"] = < + text = <"*Severity rating(en)"> + description = <"*Numerical rating scale representing the overall severity of the symptom or sign.(en)"> + > + ["id29"] = < + text = <"*Duration(en)"> + description = <"*The duration of the symptom or sign since onset.(en)"> + > + ["id32"] = < + text = <"*Number of previous episodes(en)"> + description = <"*The number of times this symptom or sign has previously occurred.(en)"> + > + ["id36"] = < + text = <"*Nil significant(en)"> + description = <"*The identified symptom or sign was reported as not being present to any significant degree.(en)"> + > + ["id38"] = < + text = <"*Episode description(en)"> + description = <"*Narrative description about the course of the symptom or sign during this episode.(en)"> + > + ["id57"] = < + text = <"*Description(en)"> + description = <"*Narrative description of the effect of the modifying factor on the symptom or sign.(en)"> + > + ["id58"] = < + text = <"*Description of previous episodes(en)"> + description = <"*Narrative description of any or all previous episodes.(en)"> + > + ["id64"] = < + text = <"*Associated symptom/sign(en)"> + description = <"*Structured details about any associated symptoms or signs that are concurrent.(en)"> + > + ["id147"] = < + text = <"*Previous episodes(en)"> + description = <"*Structured details of the symptom or sign during a previous episode.(en)"> + > + ["id148"] = < + text = <"*Structured body site(en)"> + description = <"*Structured body site where the symptom or sign was reported.(en)"> + > + ["id152"] = < + text = <"*Body site(en)"> + description = <"*Simple body site where the symptom or sign was reported.(en)"> + > + ["id153"] = < + text = <"*Onset date/time(en)"> + description = <"*The onset for this episode of the symptom or sign.(en)"> + > + ["id154"] = < + text = <"*Specific details(en)"> + description = <"*Specific data elements that are additionally required to record as unique attributes of the identified symptom or sign.(en)"> + > + ["id155"] = < + text = <"*Factor detail(en)"> + description = <"*Structured detail about the factor associated with the identified symptom or sign.(en)"> + > + ["id156"] = < + text = <"*Impact(en)"> + description = <"*Description of the impact of this symptom or sign.(en)"> + > + ["at157"] = < + text = <"*No effect(en)"> + description = <"*Presence of the factor has no impact on the symptom or sign.(en)"> + > + ["at159"] = < + text = <"*Worsens(en)"> + description = <"*Presence of the factor exaccerbates severity or impact of the symptom or sign.(en)"> + > + ["at160"] = < + text = <"*Relieves(en)"> + description = <"*Presence of the factor reduces the severity or impact of the symptom or sign.(en)"> + > + ["id162"] = < + text = <"*Resolution date/time(en)"> + description = <"*The timing of the cessation of this episode of the symptom or sign.(en)"> + > + ["id164"] = < + text = <"*Comment(en)"> + description = <"*Additional narrative about the symptom or sign not captured in other fields.(en)"> + > + ["id165"] = < + text = <"*Onset type(en)"> + description = <"*Description of the onset of the symptom or sign.(en)"> + > + ["id166"] = < + text = <"*Precipitating/resolving factor(en)"> + description = <"*Details about a health event, symptom, sign or other factor associated with the onset or cessation of the symptom or sign.(en)"> + > + ["at168"] = < + text = <"*Precipitating factor(en)"> + description = <"*Identification of factors/events associated with onset or commencement of the symptom or sign.(en)"> + > + ["at169"] = < + text = <"*Resolving factor(en)"> + description = <"*Identification of factors/events associated with cessation of the symptom or sign.(en)"> + > + ["id171"] = < + text = <"*Factor(en)"> + description = <"*Name of the health event, symptom, reported sign or other factor.(en)"> + > + ["id172"] = < + text = <"*Time interval(en)"> + description = <"*The interval of time between the occurrence or onset of the factor and onset/resolution of the symptom or sign.(en)"> + > + ["id176"] = < + text = <"*Episodicity(en)"> + description = <"*Category of this epsiode for the identified symptom or sign.(en)"> + > + ["at177"] = < + text = <"*New(en)"> + description = <"*This is the first ever episode of the symptom or sign.(en)"> + > + ["at178"] = < + text = <"*Reoccurrence(en)"> + description = <"*This is a second or subsequent discrete episode of the symptom or sign, where each previous episode has completely resolved.(en)"> + > + ["at179"] = < + text = <"*Ongoing(en)"> + description = <"*This symptom or sign is continuously present, effectively a single, ongoing episode.(en)"> + > + ["id181"] = < + text = <"*Progression(en)"> + description = <"*Description progression of the symptom or sign at the time of reporting.(en)"> + > + ["at182"] = < + text = <"*Improving(en)"> + description = <"*The severity of the symptom or sign has improved overall during this episode.(en)"> + > + ["at183"] = < + text = <"*Unchanged(en)"> + description = <"*The severity of the symptom or sign has not changed overall during this episode.(en)"> + > + ["at184"] = < + text = <"*Worsening(en)"> + description = <"*The severity of the symptom or sign has worsened overall during this episode.(en)"> + > + ["at185"] = < + text = <"*Resolved(en)"> + description = <"*The severity of the symptom or sign has resolved.(en)"> + > + ["id186"] = < + text = <"*Description(en)"> + description = <"*Narrative description about the effect of the factor on the identified symptom or sign.(en)"> + > + ["id187"] = < + text = <"*New element(en)"> + description = <"**(en)"> + > + ["at186"] = < + text = <"*(added by post-parse processor)(en)"> + description = <"*(added by post-parse processor)(en)"> + > + ["ac1"] = < + text = <"*Episodicity(en) (synthesised)"> + description = <"*Category of this epsiode for the identified symptom or sign.(en) (synthesised)"> + > + ["ac2"] = < + text = <"*Severity category(en) (synthesised)"> + description = <"*Category representing the overall severity of the symptom or sign.(en) (synthesised)"> + > + ["ac3"] = < + text = <"*Progression(en) (synthesised)"> + description = <"*Description progression of the symptom or sign at the time of reporting.(en) (synthesised)"> + > + ["ac4"] = < + text = <"*Effect(en) (synthesised)"> + description = <"*Perceived effect of the modifying factor on the symptom or sign.(en) (synthesised)"> + > + ["ac5"] = < + text = <"*Precipitating/resolving factor(en) (synthesised)"> + description = <"*Details about a health event, symptom, sign or other factor associated with the onset or cessation of the symptom or sign.(en) (synthesised)"> + > + > + ["en"] = < + ["id1"] = < + text = <"Symptom/Sign"> + description = <"Reported observation of a physical or mental disturbance in an individual."> + > + ["id2"] = < + text = <"Symptom/Sign name"> + description = <"The name of the reported symptom or sign."> + > + ["id3"] = < + text = <"Description"> + description = <"Narrative description about the reported symptom or sign."> + > + ["id4"] = < + text = <"Pattern"> + description = <"Narrative description about the pattern of the symptom or sign during this episode."> + > + ["id18"] = < + text = <"Effect"> + description = <"Perceived effect of the modifying factor on the symptom or sign."> + > + ["id19"] = < + text = <"Modifying factor"> + description = <"Detail about how a specific factor effects the identified symptom or sign during this episode."> + > + ["id20"] = < + text = <"Factor"> + description = <"Name of the modifying factor."> + > + ["id22"] = < + text = <"Severity category"> + description = <"Category representing the overall severity of the symptom or sign."> + > + ["at24"] = < + text = <"Mild"> + description = <"The intensity of the symptom or sign does not cause interference with normal activity."> + > + ["at25"] = < + text = <"Moderate"> + description = <"The intensity of the symptom or sign causes interference with normal activity."> + > + ["at26"] = < + text = <"Severe"> + description = <"The intensity of the symptom or sign causes prevents normal activity."> + > + ["id27"] = < + text = <"Severity rating"> + description = <"Numerical rating scale representing the overall severity of the symptom or sign."> + > + ["id29"] = < + text = <"Duration"> + description = <"The duration of this episode of the symptom or sign since onset."> + > + ["id32"] = < + text = <"Number of previous episodes"> + description = <"The number of times this symptom or sign has previously occurred."> + > + ["id36"] = < + text = <"Nil significant"> + description = <"The identified symptom or sign was reported as not being present to any significant degree."> + > + ["id38"] = < + text = <"Episode description"> + description = <"Narrative description about the course of the symptom or sign during this episode."> + > + ["id57"] = < + text = <"Description"> + description = <"Narrative description of the effect of the modifying factor on the symptom or sign."> + > + ["id58"] = < + text = <"Description of previous episodes"> + description = <"Narrative description of any or all previous episodes."> + > + ["id64"] = < + text = <"Associated symptom/sign"> + description = <"Structured details about any associated symptoms or signs that are concurrent."> + > + ["id147"] = < + text = <"Previous episodes"> + description = <"Structured details of the symptom or sign during a previous episode."> + > + ["id148"] = < + text = <"Structured body site"> + description = <"Structured body site where the symptom or sign was reported."> + > + ["id152"] = < + text = <"Body site"> + description = <"Simple body site where the symptom or sign was reported."> + > + ["id153"] = < + text = <"Episode onset"> + description = <"The onset for this episode of the symptom or sign."> + > + ["id154"] = < + text = <"Specific details"> + description = <"Specific data elements that are additionally required to record as unique attributes of the identified symptom or sign."> + > + ["id155"] = < + text = <"Factor detail"> + description = <"Structured detail about the factor associated with the identified symptom or sign."> + > + ["id156"] = < + text = <"Impact"> + description = <"Description of the impact of this symptom or sign."> + > + ["at157"] = < + text = <"No effect"> + description = <"The factor has no impact on the symptom or sign."> + > + ["at159"] = < + text = <"Worsens"> + description = <"The factor increases the severity or impact of the symptom or sign."> + > + ["at160"] = < + text = <"Relieves"> + description = <"The factor decreases the severity or impact of the symptom or sign, but does not fully resolve it."> + > + ["id162"] = < + text = <"Resolution date/time"> + description = <"The timing of the cessation of this episode of the symptom or sign."> + > + ["id164"] = < + text = <"Comment"> + description = <"Additional narrative about the symptom or sign not captured in other fields."> + > + ["id165"] = < + text = <"Onset type"> + description = <"Description of the onset of the symptom or sign."> + > + ["id166"] = < + text = <"Precipitating/resolving factor"> + description = <"Details about specified factors that are associated with the precipitation or resolution of the symptom or sign."> + > + ["at168"] = < + text = <"Precipitating factor"> + description = <"Identification of factors or events that trigger the onset or commencement of the symptom or sign."> + > + ["at169"] = < + text = <"Resolving factor"> + description = <"Identification of factors or events that trigger resolution or cessation of the symptom or sign."> + > + ["id171"] = < + text = <"Factor"> + description = <"Name of the health event, symptom, reported sign or other factor."> + > + ["id172"] = < + text = <"Time interval"> + description = <"The interval of time between the occurrence or onset of the factor and onset/resolution of the symptom or sign."> + > + ["id176"] = < + text = <"Episodicity"> + description = <"Category of this episode for the identified symptom or sign."> + > + ["at177"] = < + text = <"New"> + description = <"A new episode of the symptom or sign - either the first ever occurrence or a reoccurrence where the previous episode had completely resolved."> + > + ["at178"] = < + text = <"Indeterminate"> + description = <"It is not possible to determine if this occurrence of the symptom or sign is new or ongoing."> + > + ["at179"] = < + text = <"Ongoing"> + description = <"This symptom or sign is ongoing, effectively a single, continuous episode."> + > + ["id181"] = < + text = <"Progression"> + description = <"Description progression of the symptom or sign at the time of reporting."> + > + ["at182"] = < + text = <"Improving"> + description = <"The severity of the symptom or sign has improved overall during this episode."> + > + ["at183"] = < + text = <"Unchanged"> + description = <"The severity of the symptom or sign has not changed overall during this episode."> + > + ["at184"] = < + text = <"Worsening"> + description = <"The severity of the symptom or sign has worsened overall during this episode."> + > + ["at185"] = < + text = <"Resolved"> + description = <"The severity of the symptom or sign has resolved."> + > + ["id186"] = < + text = <"Description"> + description = <"Narrative description about the effect of the factor on the identified symptom or sign."> + > + ["id187"] = < + text = <"First ever?"> + description = <"Is this the first ever occurrence of this symptom or sign?"> + > + ["at186"] = < + text = <"(added by post-parse processor)"> + description = <"(added by post-parse processor)"> + > + ["ac1"] = < + text = <"Episodicity (synthesised)"> + description = <"Category of this episode for the identified symptom or sign. (synthesised)"> + > + ["ac2"] = < + text = <"Severity category (synthesised)"> + description = <"Category representing the overall severity of the symptom or sign. (synthesised)"> + > + ["ac3"] = < + text = <"Progression (synthesised)"> + description = <"Description progression of the symptom or sign at the time of reporting. (synthesised)"> + > + ["ac4"] = < + text = <"Effect (synthesised)"> + description = <"Perceived effect of the modifying factor on the symptom or sign. (synthesised)"> + > + ["ac5"] = < + text = <"Precipitating/resolving factor (synthesised)"> + description = <"Details about specified factors that are associated with the precipitation or resolution of the symptom or sign. (synthesised)"> + > + > + ["de"] = < + ["id1"] = < + text = <"*Symptom/Sign(en)"> + description = <"*Reported observation of a physical or mental disturbance in an individual.(en)"> + > + ["id2"] = < + text = <"*Symptom/Sign name(en)"> + description = <"*The name of the reported symptom or sign.(en)"> + > + ["id3"] = < + text = <"*Description(en)"> + description = <"*Narrative description about the reported symptom or sign.(en)"> + > + ["id4"] = < + text = <"*Pattern(en)"> + description = <"*Narrative description about the pattern of the symptom or sign during this episode.(en)"> + > + ["id18"] = < + text = <"*Effect(en)"> + description = <"*Perceived effect of the modifying factor on the symptom or sign.(en)"> + > + ["id19"] = < + text = <"*Modifying factor(en)"> + description = <"*Detail about how a specific factor effects the identified symptom or sign during this episode.(en)"> + > + ["id20"] = < + text = <"*Factor(en)"> + description = <"*Name of the modifying factor.(en)"> + > + ["id22"] = < + text = <"*Severity category(en)"> + description = <"*Category representing the overall severity of the symptom or sign.(en)"> + > + ["at24"] = < + text = <"*Mild(en)"> + description = <"*The intensity of the symptom or sign does not cause interference with normal activity.(en)"> + > + ["at25"] = < + text = <"*Moderate(en)"> + description = <"*The intensity of the symptom or sign causes interference with normal activity.(en)"> + > + ["at26"] = < + text = <"*Severe(en)"> + description = <"*The intensity of the symptom or sign causes prevents normal activity.(en)"> + > + ["id27"] = < + text = <"*Severity rating(en)"> + description = <"*Numerical rating scale representing the overall severity of the symptom or sign.(en)"> + > + ["id29"] = < + text = <"*Duration(en)"> + description = <"*The duration of the symptom or sign since onset.(en)"> + > + ["id32"] = < + text = <"*Number of previous episodes(en)"> + description = <"*The number of times this symptom or sign has previously occurred.(en)"> + > + ["id36"] = < + text = <"*Nil significant(en)"> + description = <"*The identified symptom or sign was reported as not being present to any significant degree.(en)"> + > + ["id38"] = < + text = <"*Episode description(en)"> + description = <"*Narrative description about the course of the symptom or sign during this episode.(en)"> + > + ["id57"] = < + text = <"*Description(en)"> + description = <"*Narrative description of the effect of the modifying factor on the symptom or sign.(en)"> + > + ["id58"] = < + text = <"*Description of previous episodes(en)"> + description = <"*Narrative description of any or all previous episodes.(en)"> + > + ["id64"] = < + text = <"*Associated symptom/sign(en)"> + description = <"*Structured details about any associated symptoms or signs that are concurrent.(en)"> + > + ["id147"] = < + text = <"*Previous episodes(en)"> + description = <"*Structured details of the symptom or sign during a previous episode.(en)"> + > + ["id148"] = < + text = <"*Structured body site(en)"> + description = <"*Structured body site where the symptom or sign was reported.(en)"> + > + ["id152"] = < + text = <"*Body site(en)"> + description = <"*Simple body site where the symptom or sign was reported.(en)"> + > + ["id153"] = < + text = <"*Onset date/time(en)"> + description = <"*The onset for this episode of the symptom or sign.(en)"> + > + ["id154"] = < + text = <"*Specific details(en)"> + description = <"*Specific data elements that are additionally required to record as unique attributes of the identified symptom or sign.(en)"> + > + ["id155"] = < + text = <"*Factor detail(en)"> + description = <"*Structured detail about the factor associated with the identified symptom or sign.(en)"> + > + ["id156"] = < + text = <"*Impact(en)"> + description = <"*Description of the impact of this symptom or sign.(en)"> + > + ["at157"] = < + text = <"*No effect(en)"> + description = <"*Presence of the factor has no impact on the symptom or sign.(en)"> + > + ["at159"] = < + text = <"*Worsens(en)"> + description = <"*Presence of the factor exaccerbates severity or impact of the symptom or sign.(en)"> + > + ["at160"] = < + text = <"*Relieves(en)"> + description = <"*Presence of the factor reduces the severity or impact of the symptom or sign.(en)"> + > + ["id162"] = < + text = <"*Resolution date/time(en)"> + description = <"*The timing of the cessation of this episode of the symptom or sign.(en)"> + > + ["id164"] = < + text = <"*Comment(en)"> + description = <"*Additional narrative about the symptom or sign not captured in other fields.(en)"> + > + ["id165"] = < + text = <"*Onset type(en)"> + description = <"*Description of the onset of the symptom or sign.(en)"> + > + ["id166"] = < + text = <"*Precipitating/resolving factor(en)"> + description = <"*Details about a health event, symptom, sign or other factor associated with the onset or cessation of the symptom or sign.(en)"> + > + ["at168"] = < + text = <"*Precipitating factor(en)"> + description = <"*Identification of factors/events associated with onset or commencement of the symptom or sign.(en)"> + > + ["at169"] = < + text = <"*Resolving factor(en)"> + description = <"*Identification of factors/events associated with cessation of the symptom or sign.(en)"> + > + ["id171"] = < + text = <"*Factor(en)"> + description = <"*Name of the health event, symptom, reported sign or other factor.(en)"> + > + ["id172"] = < + text = <"*Time interval(en)"> + description = <"*The interval of time between the occurrence or onset of the factor and onset/resolution of the symptom or sign.(en)"> + > + ["id176"] = < + text = <"*Episodicity(en)"> + description = <"*Category of this epsiode for the identified symptom or sign.(en)"> + > + ["at177"] = < + text = <"*New(en)"> + description = <"*This is the first ever episode of the symptom or sign.(en)"> + > + ["at178"] = < + text = <"*Reoccurrence(en)"> + description = <"*This is a second or subsequent discrete episode of the symptom or sign, where each previous episode has completely resolved.(en)"> + > + ["at179"] = < + text = <"*Ongoing(en)"> + description = <"*This symptom or sign is continuously present, effectively a single, ongoing episode.(en)"> + > + ["id181"] = < + text = <"*Progression(en)"> + description = <"*Description progression of the symptom or sign at the time of reporting.(en)"> + > + ["at182"] = < + text = <"*Improving(en)"> + description = <"*The severity of the symptom or sign has improved overall during this episode.(en)"> + > + ["at183"] = < + text = <"*Unchanged(en)"> + description = <"*The severity of the symptom or sign has not changed overall during this episode.(en)"> + > + ["at184"] = < + text = <"*Worsening(en)"> + description = <"*The severity of the symptom or sign has worsened overall during this episode.(en)"> + > + ["at185"] = < + text = <"*Resolved(en)"> + description = <"*The severity of the symptom or sign has resolved.(en)"> + > + ["id186"] = < + text = <"*Description(en)"> + description = <"*Narrative description about the effect of the factor on the identified symptom or sign.(en)"> + > + ["id187"] = < + text = <"*New element(en)"> + description = <"**(en)"> + > + ["at186"] = < + text = <"*(added by post-parse processor)(en)"> + description = <"*(added by post-parse processor)(en)"> + > + ["ac1"] = < + text = <"*Episodicity(en) (synthesised)"> + description = <"*Category of this epsiode for the identified symptom or sign.(en) (synthesised)"> + > + ["ac2"] = < + text = <"*Severity category(en) (synthesised)"> + description = <"*Category representing the overall severity of the symptom or sign.(en) (synthesised)"> + > + ["ac3"] = < + text = <"*Progression(en) (synthesised)"> + description = <"*Description progression of the symptom or sign at the time of reporting.(en) (synthesised)"> + > + ["ac4"] = < + text = <"*Effect(en) (synthesised)"> + description = <"*Perceived effect of the modifying factor on the symptom or sign.(en) (synthesised)"> + > + ["ac5"] = < + text = <"*Precipitating/resolving factor(en) (synthesised)"> + description = <"*Details about a health event, symptom, sign or other factor associated with the onset or cessation of the symptom or sign.(en) (synthesised)"> + > + > + ["nb"] = < + ["id1"] = < + text = <"*Symptom/Sign(en)"> + description = <"*Reported observation of a physical or mental disturbance in an individual.(en)"> + > + ["id2"] = < + text = <"*Symptom/Sign name(en)"> + description = <"*The name of the reported symptom or sign.(en)"> + > + ["id3"] = < + text = <"*Description(en)"> + description = <"*Narrative description about the reported symptom or sign.(en)"> + > + ["id4"] = < + text = <"*Pattern(en)"> + description = <"*Narrative description about the pattern of the symptom or sign during this episode.(en)"> + > + ["id18"] = < + text = <"*Effect(en)"> + description = <"*Perceived effect of the modifying factor on the symptom or sign.(en)"> + > + ["id19"] = < + text = <"*Modifying factor(en)"> + description = <"*Detail about how a specific factor effects the identified symptom or sign during this episode.(en)"> + > + ["id20"] = < + text = <"*Factor(en)"> + description = <"*Name of the modifying factor.(en)"> + > + ["id22"] = < + text = <"*Severity category(en)"> + description = <"*Category representing the overall severity of the symptom or sign.(en)"> + > + ["at24"] = < + text = <"*Mild(en)"> + description = <"*The intensity of the symptom or sign does not cause interference with normal activity.(en)"> + > + ["at25"] = < + text = <"*Moderate(en)"> + description = <"*The intensity of the symptom or sign causes interference with normal activity.(en)"> + > + ["at26"] = < + text = <"*Severe(en)"> + description = <"*The intensity of the symptom or sign causes prevents normal activity.(en)"> + > + ["id27"] = < + text = <"*Severity rating(en)"> + description = <"*Numerical rating scale representing the overall severity of the symptom or sign.(en)"> + > + ["id29"] = < + text = <"*Duration(en)"> + description = <"*The duration of the symptom or sign since onset.(en)"> + > + ["id32"] = < + text = <"*Number of previous episodes(en)"> + description = <"*The number of times this symptom or sign has previously occurred.(en)"> + > + ["id36"] = < + text = <"*Nil significant(en)"> + description = <"*The identified symptom or sign was reported as not being present to any significant degree.(en)"> + > + ["id38"] = < + text = <"*Episode description(en)"> + description = <"*Narrative description about the course of the symptom or sign during this episode.(en)"> + > + ["id57"] = < + text = <"*Description(en)"> + description = <"*Narrative description of the effect of the modifying factor on the symptom or sign.(en)"> + > + ["id58"] = < + text = <"*Description of previous episodes(en)"> + description = <"*Narrative description of any or all previous episodes.(en)"> + > + ["id64"] = < + text = <"*Associated symptom/sign(en)"> + description = <"*Structured details about any associated symptoms or signs that are concurrent.(en)"> + > + ["id147"] = < + text = <"*Previous episodes(en)"> + description = <"*Structured details of the symptom or sign during a previous episode.(en)"> + > + ["id148"] = < + text = <"*Structured body site(en)"> + description = <"*Structured body site where the symptom or sign was reported.(en)"> + > + ["id152"] = < + text = <"*Body site(en)"> + description = <"*Simple body site where the symptom or sign was reported.(en)"> + > + ["id153"] = < + text = <"*Onset date/time(en)"> + description = <"*The onset for this episode of the symptom or sign.(en)"> + > + ["id154"] = < + text = <"*Specific details(en)"> + description = <"*Specific data elements that are additionally required to record as unique attributes of the identified symptom or sign.(en)"> + > + ["id155"] = < + text = <"*Factor detail(en)"> + description = <"*Structured detail about the factor associated with the identified symptom or sign.(en)"> + > + ["id156"] = < + text = <"*Impact(en)"> + description = <"*Description of the impact of this symptom or sign.(en)"> + > + ["at157"] = < + text = <"*No effect(en)"> + description = <"*Presence of the factor has no impact on the symptom or sign.(en)"> + > + ["at159"] = < + text = <"*Worsens(en)"> + description = <"*Presence of the factor exaccerbates severity or impact of the symptom or sign.(en)"> + > + ["at160"] = < + text = <"*Relieves(en)"> + description = <"*Presence of the factor reduces the severity or impact of the symptom or sign.(en)"> + > + ["id162"] = < + text = <"*Resolution date/time(en)"> + description = <"*The timing of the cessation of this episode of the symptom or sign.(en)"> + > + ["id164"] = < + text = <"*Comment(en)"> + description = <"*Additional narrative about the symptom or sign not captured in other fields.(en)"> + > + ["id165"] = < + text = <"*Onset type(en)"> + description = <"*Description of the onset of the symptom or sign.(en)"> + > + ["id166"] = < + text = <"*Precipitating/resolving factor(en)"> + description = <"*Details about a health event, symptom, sign or other factor associated with the onset or cessation of the symptom or sign.(en)"> + > + ["at168"] = < + text = <"*Precipitating factor(en)"> + description = <"*Identification of factors/events associated with onset or commencement of the symptom or sign.(en)"> + > + ["at169"] = < + text = <"*Resolving factor(en)"> + description = <"*Identification of factors/events associated with cessation of the symptom or sign.(en)"> + > + ["id171"] = < + text = <"*Factor(en)"> + description = <"*Name of the health event, symptom, reported sign or other factor.(en)"> + > + ["id172"] = < + text = <"*Time interval(en)"> + description = <"*The interval of time between the occurrence or onset of the factor and onset/resolution of the symptom or sign.(en)"> + > + ["id176"] = < + text = <"*Episodicity(en)"> + description = <"*Category of this epsiode for the identified symptom or sign.(en)"> + > + ["at177"] = < + text = <"*New(en)"> + description = <"*This is the first ever episode of the symptom or sign.(en)"> + > + ["at178"] = < + text = <"*Reoccurrence(en)"> + description = <"*This is a second or subsequent discrete episode of the symptom or sign, where each previous episode has completely resolved.(en)"> + > + ["at179"] = < + text = <"*Ongoing(en)"> + description = <"*This symptom or sign is continuously present, effectively a single, ongoing episode.(en)"> + > + ["id181"] = < + text = <"*Progression(en)"> + description = <"*Description progression of the symptom or sign at the time of reporting.(en)"> + > + ["at182"] = < + text = <"*Improving(en)"> + description = <"*The severity of the symptom or sign has improved overall during this episode.(en)"> + > + ["at183"] = < + text = <"*Unchanged(en)"> + description = <"*The severity of the symptom or sign has not changed overall during this episode.(en)"> + > + ["at184"] = < + text = <"*Worsening(en)"> + description = <"*The severity of the symptom or sign has worsened overall during this episode.(en)"> + > + ["at185"] = < + text = <"*Resolved(en)"> + description = <"*The severity of the symptom or sign has resolved.(en)"> + > + ["id186"] = < + text = <"*Description(en)"> + description = <"*Narrative description about the effect of the factor on the identified symptom or sign.(en)"> + > + ["id187"] = < + text = <"*New element(en)"> + description = <"**(en)"> + > + ["at186"] = < + text = <"*(added by post-parse processor)(en)"> + description = <"*(added by post-parse processor)(en)"> + > + ["ac1"] = < + text = <"*Episodicity(en) (synthesised)"> + description = <"*Category of this epsiode for the identified symptom or sign.(en) (synthesised)"> + > + ["ac2"] = < + text = <"*Severity category(en) (synthesised)"> + description = <"*Category representing the overall severity of the symptom or sign.(en) (synthesised)"> + > + ["ac3"] = < + text = <"*Progression(en) (synthesised)"> + description = <"*Description progression of the symptom or sign at the time of reporting.(en) (synthesised)"> + > + ["ac4"] = < + text = <"*Effect(en) (synthesised)"> + description = <"*Perceived effect of the modifying factor on the symptom or sign.(en) (synthesised)"> + > + ["ac5"] = < + text = <"*Precipitating/resolving factor(en) (synthesised)"> + description = <"*Details about a health event, symptom, sign or other factor associated with the onset or cessation of the symptom or sign.(en) (synthesised)"> + > + > + > + term_bindings = < + ["SNOMED-CT"] = < + ["id1"] = + ["id2"] = + ["id3"] = + ["id22"] = + ["at24"] = + ["at25"] = + ["at26"] = + ["id29"] = + > + ["openehr"] = < + ["at186"] = + > + > + value_sets = < + ["ac1"] = < + id = <"ac1"> + members = <"at177", "at179", "at178"> + > + ["ac2"] = < + id = <"ac2"> + members = <"at24", "at25", "at26"> + > + ["ac3"] = < + id = <"ac3"> + members = <"at184", "at183", "at182", "at185"> + > + ["ac4"] = < + id = <"ac4"> + members = <"at160", "at157", "at159"> + > + ["ac5"] = < + id = <"ac5"> + members = <"at168", "at169"> + > + > \ No newline at end of file