ARCHETYPE Diagnoza (openEHR-EHR-EVALUATION.problem-diagnosis_ra.v0)

ARCHETYPE IDopenEHR-EHR-EVALUATION.problem-diagnosis_ra.v0
ConceptDiagnoza
Description*A diagnosis defined by a clinician which is coded in an accepted terminology and may include the stage of the condition and the diagnostic criteria(en)
Purpose
References
Copyright© openEHR Foundation
AuthorsIme avtorja: Sam Heard
Organizacija: Ocean Informatics
e-Pošta: sam.heard@oceaninformatics.com
Datum izvora: 23/04/2006
Other Details LanguageIme avtorja: Sam Heard
Organizacija: Ocean Informatics
e-Pošta: sam.heard@oceaninformatics.com
Datum izvora: 23/04/2006
OtherDetails Language Independent{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=si.ezdrav, original_namespace=si.ezdrav, original_publisher=si.ezdrav, custodian_namespace=si.ezdrav, MD5-CAM-1.0.1=A0B0D369152EF225A57C42EF2A1CB4BD, build_uid=9731e40b-3085-4cbe-a687-45416a9dd36f, revision=0.0.1-alpha}
Keywords
Lifecyclein_development
UID4eb1ff0b-8687-4659-b402-73e58c0f7b96
Language usedsl
Citeable Identifier1075.67.1529
Revision Number0.0.1-alpha
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=*A diagnosis defined by a clinician which is coded in an accepted terminology and may include the stage of the condition and the diagnostic criteria(en), archetypeConceptComment=null, otherContributors=, originalLanguage=en, translators=German: Jasmin Buck, Sebastian Garde, University of Heidelberg, Central Queensland University
Portuguese (Brazil): Marco Borges, P2D, marco.borges@p2d.com.br, P2D Health Advisor Council
Slovenski: ?
, subjectOfData=brez omejitev, archetypeTranslationTree=null, topLevelToAshis={source=[], state=[], description=[], content=[], provider=[], ism_transition=[], events=[], details=[], identities=[], contacts=[], activities=[], relationships=[], context=[], capabilities=[], other_participations=[], data=[ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0002.1], code=at0002.1, itemType=ELEMENT, level=2, text=*Diagnosis(en), description=*The index diagnosis(en), comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Obvezno, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Omejitev:
šifrant MKB-10
[šifrant MKB-10]

Povezovanje omejitev:
[MKB-10]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0.32], code=at0.32, itemType=ELEMENT, level=2, text=*Status(en), description=*The status of the diagnosis(en), comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • *provisional(en) [*provisional diagnosis considered likely and a basis for proceeding with management(en)]
  • *working(en) [*working diagnosis considered very likely but not yet confirmed(en)]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0003], code=at0003, itemType=ELEMENT, level=2, text=*Date of initial onset(en), description=*The date that the problem began causing symptoms or signs(en), comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0004], code=at0004, itemType=ELEMENT, level=2, text=*Age at initial onset(en), description=*The age of the at the onset of the problem(en), comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DURATION, bindings=null, values=Dovoljene vrednosti: leta, meseci, tedni, dni, ure

, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0005], code=at0005, itemType=ELEMENT, level=2, text=*Severity(en), description=*The severity of the index problem(en), comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=1: *Mild(en) [*The severity of the index problem is mild, not affecting life or longevity(en)]
4: *Moderate(en) [*The severity of the index problem is such as to cause significant morbidity(en)]
7: *Severe(en) [*The severity of the index problem has had a major effect on life and/or longevity(en)]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0009], code=at0009, itemType=ELEMENT, level=2, text=*Clinical description(en), description=*Description of the clinical aspects of the problem(en), comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0010], code=at0010, itemType=ELEMENT, level=2, text=*Date clinically recognised(en), description=*Date the problem was recognised by clinicians(en), comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE, bindings=null, values=Okviren datum, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0037], code=at0037, itemType=ELEMENT, level=2, text=*Age when clinically recognised(en), description=*The age when this problem was clinically recognised(en), comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DURATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0011], code=at0011, itemType=CLUSTER, level=2, text=*Location(en), description=*Location of the problem in terms of body site(en), comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Neobvezen, ponavljam, cardinalityFormal=1..2, cardinalityText=Maximum of 2 items, razvrščen, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0011]/items[at0012], code=at0012, itemType=ELEMENT, level=3, text=*Body site(en), description=*The body site affected(en), comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Omejitev:
*Any term that describes a body site(en)
[*An anatomical structure with qualifiers(en)]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0011]/items[at0013], code=at0013, itemType=ELEMENT, level=3, text=*Location description(en), description=*A free text description of the location - may be in addition to a coded body site(en), comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0014], code=at0014, itemType=CLUSTER, level=2, text=*Aetiology(en), description=*Agents or Factors known to have been of aetiological significance(en), comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0014]/items[at0015], code=at0015, itemType=ELEMENT, level=3, text=*Agent(en), description=*Microbial or other agent known to have caused this problem(en), comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Neobvezen, ponavljam, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0014]/items[at0016], code=at0016, itemType=ELEMENT, level=3, text=*Complication of(en), description=*A problem or link to a problem or injury described elsewhere in the EHR(en), comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Neobvezen, ponavljam, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Izbira:
  •  Besedilo
  •  URI
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0014]/items[at0017], code=at0017, itemType=ELEMENT, level=3, text=*Description(en), description=*Description of aetiological process(en), comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0018], code=at0018, itemType=CLUSTER, level=2, text=*Occurrences or exacerbations(en), description=*Grouping of information about individual occurrences or exacerbations(en), comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=1..*, cardinalityText=razvrščen, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0018]/items[at0019], code=at0019, itemType=ELEMENT, level=3, text=*Frequency of reccurrence(en), description=*The frequency of individual occurrences of the problem(en), comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_QUANTITY, bindings=null, values=Lastnost: Frequency
Enote:
  • /h
  • /d
  • /mo
  • /wk
  • /yr
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0018]/items[at0020], code=at0020, itemType=ELEMENT, level=3, text=*Date of last occurrence(en), description=*The date of the last occurrence or exacerbation(en), comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0018]/items[at0021], code=at0021, itemType=CLUSTER, level=3, text=*Occurence/exacerbation(en), description=*Information about one occurrence or exacerbation(en), comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Neobvezen, ponavljam, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0018]/items[at0021]/items[at0022], code=at0022, itemType=ELEMENT, level=4, text=*Clinical description(en), description=*A description of the exacerbation or occurrence(en), comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0018]/items[at0021]/items[at0023], code=at0023, itemType=ELEMENT, level=4, text=*Outcome(en), description=*Outcome of the occurrence or exacerbation(en), comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0018]/items[at0021]/items[at0024], code=at0024, itemType=ELEMENT, level=4, text=*Date of onset of occurrence(en), description=*Date of onset of occurrence or exacerbation(en), comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0018]/items[at0021]/items[at0036], code=at0036, itemType=ELEMENT, level=4, text=*Date of resolution of occurrence(en), description=*Date of the resolution of the occurrence(en), comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0018]/items[at0025], code=at0025, itemType=ELEMENT, level=3, text=*Number of occurrences(en), description=*Number of times this problem has occurred or been apparent(en), comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=min: >=1

, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0026], code=at0026, itemType=CLUSTER, level=2, text=*Related problems(en), description=*Complications that are attributed to this problem(en), comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0026]/items[at0027], code=at0027, itemType=CLUSTER, level=3, text=*Related problem(en), description=*A group of characteristics of the problem complicating the index condition in this archetype(en), comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Neobvezen, ponavljam, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0026]/items[at0027]/items[at0028], code=at0028, itemType=ELEMENT, level=4, text=*Related problem(en), description=*Details of the problem as text or coded text or URI(en), comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Izbira:
  •  Besedilo
  •  URI
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0026]/items[at0027]/items[at0029], code=at0029, itemType=ELEMENT, level=4, text=*Clinical description(en), description=*Decription of the complicating problem(en), comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0030], code=at0030, itemType=ELEMENT, level=2, text=*Date of resolution(en), description=*The date that the problem resolved or went into remission(en), comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0031], code=at0031, itemType=ELEMENT, level=2, text=*Age at resolution(en), description=*The age of the at the resolution of the problem(en), comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DURATION, bindings=null, values=Dovoljene vrednosti: leta, meseci, tedni, dni, ure

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