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de classificació, description=Un codi de classe documental d'alt nivell, seleccionat normalment d'un conjunt de valors proporcionat pel Domini d'Afinitat IHE-XDS., comment=Per exemple: Informe, Resum, Imatges, Pla, Preferències del pacient, Flux de treball.
Aquests codis són específics de domini d'afinitat XDS., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v2]/context/other_context[at0006]/items[openEHR-EHR-CLUSTER.xds_metadata.v0]/items[at0003], code=at0003, itemType=ELEMENT, level=3, text=Tipus de document, description=Codi que especifica el tipus exacte de document des de la perspectiva de l'usuari. Normalment se selecciona un conjunt de valors proporcionat pel domini d'afinitat local IHE-XDS o la norma nacional., comment=Per exemple: Història i examen físic pulmonar, Resum d'alta, Informe d'ecografia.
Aquests codis són específics de domini d'afinitat XDS., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v2]/context/other_context[at0006]/items[openEHR-EHR-CLUSTER.xds_metadata.v0]/items[at0004], code=at0004, itemType=ELEMENT, level=3, text=Codi de confidencialitat, description=Terme que especifica el nivell de confidencialitat del document XDS., comment=Es prefereix el text codificat, normalment específic d'un domini d'afinitat XDS., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v2]/context/other_context[at0006]/items[openEHR-EHR-CLUSTER.xds_metadata.v0]/items[at0032], code=at0032, itemType=ELEMENT, level=3, text=Tipus de centre sanitari, description=*, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v2]/context/other_context[at0006]/items[openEHR-EHR-CLUSTER.xds_metadata.v0]/items[at0009], code=at0009, itemType=ELEMENT, level=3, text=Codi d´especialitat clínica, description=Codi que especifica l'especialitat clínica on es va realitzar l'acte que va donar lloc al document., comment=Per exemple: Medicina Familiar, Laboratori, Radiologia.
Es prefereix el text codificat, normalment específic d'un domini d'afinitat XDS., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values= Text Coded Text
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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), uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Opcional, repetint, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v2]/content[openEHR-EHR-SECTION.problem_list.v0 and name/value='Diagnosis list']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v2]/content[openEHR-EHR-SECTION.problem_list.v0 and name/value='Diagnosis list']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Diagnosis name, description=Identificació del problema o diagnòstic, pel nom., comment=*Coding of the name of the problem or diagnosis with a terminology is preferred, where possible.(en), uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Obligatòria, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v2]/content[openEHR-EHR-SECTION.problem_list.v0 and name/value='Diagnosis list']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0003], code=at0003, itemType=ELEMENT, level=4, text=Diagnosis Starting Date, description=Data/hora estimada o real en que un professional sanitari va declarar el diagnòstic o problema., 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), uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v2]/content[openEHR-EHR-SECTION.problem_list.v0 and name/value='Diagnosis list']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0005], code=at0005, itemType=ELEMENT, level=4, text=Diagnosis Relevance, description=Una avaluació de la severitat global del problema o diagnòstic., 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), uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v2]/content[openEHR-EHR-SECTION.problem_list.v0 and name/value='Diagnosis list']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0030], code=at0030, itemType=ELEMENT, level=4, text=Diagnosis Ending Date, description=Data/hora estimada o real de resolució o remissió d'aquest problema o diagnòstic, determinada per un professional sanitari., 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), uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v2]/content[openEHR-EHR-SECTION.adverse_reaction_list.v0], code=at0000, itemType=SECTION, level=1, text=Allergy list, description=Framework for consistent modelling of content within a template for an Adverse reaction list., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v2]/content[openEHR-EHR-SECTION.adverse_reaction_list.v0]/items[openEHR-EHR-EVALUATION.adverse_reaction_risk.v2], code=at0000, itemType=EVALUATION, level=2, text=Adverse reaction risk, description=Clinical assessment of the propensity for an individual to experience a harmful or undesirable physiological response if exposed, or re-exposed, to a substance., comment=Substances include, but are not limited to: a therapeutic substance administered correctly at an appropriate dosage for the individual; food; material derived from plants or animals; or venom from insect stings., uncommonOntologyItems={source=openEHR,FHIR}, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v2]/content[openEHR-EHR-SECTION.adverse_reaction_list.v0]/items[openEHR-EHR-EVALUATION.adverse_reaction_risk.v2]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v2]/content[openEHR-EHR-SECTION.adverse_reaction_list.v0]/items[openEHR-EHR-EVALUATION.adverse_reaction_risk.v2]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Allergy name, description=Identification of a substance, or substance class, that is considered to put the individual at risk of an adverse reaction event., comment=Both an individual substance and a substance class are valid entries in 'Substance'. A substance may be a compound of simpler substances, for example a medicinal product. It is strongly recommended that the 'Substance' is coded with a terminology capable of triggering decision support, where possible. For example: Snomed CT, DM+D, RxNorm, NDFRT, ATC, New Zealand Universal List of Medicines and Australian Medicines Terminology. Free text entry should only be used if there is no appropriate terminology available., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Obligatòria, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v2]/content[openEHR-EHR-SECTION.adverse_reaction_list.v0]/items[openEHR-EHR-EVALUATION.adverse_reaction_risk.v2]/data[at0001]/items[at0101], code=at0101, itemType=ELEMENT, level=4, text=Criticality, description=An indication of the potential for critical system organ damage or life threatening consequence., comment=This can be regarded as a predictive judgement of a 'worst case scenario'. In most contexts 'Low' would be regarded as the default value., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=- Coded Text
- Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v2]/content[openEHR-EHR-SECTION.adverse_reaction_list.v0]/items[openEHR-EHR-EVALUATION.adverse_reaction_risk.v2]/data[at0001]/items[at0133], code=at0133, itemType=ELEMENT, level=4, text=Allergy starting date, description=The onset of the first known occurrence of a reaction event., comment=For example: the actual date and/or time of onset; the interval of time during which the onset occurred; the age of the individual at the time of the onset; or the duration of time since the onset occurred. A partial date is valid, using the DV_DATE_TIME data type, to record only a year., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v2]/content[openEHR-EHR-SECTION.problem_list.v0 and name/value='Procedure list'], code=at0000, itemType=SECTION, level=1, text=Procedure list, description=Framework for consistent modelling of content within a template for a Problem list., comment=Intended to be used within the COMPOSITION.problem_list., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v2]/content[openEHR-EHR-SECTION.problem_list.v0 and name/value='Procedure list']/items[openEHR-EHR-ACTION.procedure.v1], code=at0000, itemType=ACTION, level=2, text=Procediment, description=Una activitat clínica duta a terme per a la detecció, investigació, diagnòstic, cura, teràpia, avaluació o amb fins pal·liatius., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Opcional, repetint, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ACTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v2]/content[openEHR-EHR-SECTION.problem_list.v0 and name/value='Procedure list']/items[openEHR-EHR-ACTION.procedure.v1]/description[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Description, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v2]/content[openEHR-EHR-SECTION.problem_list.v0 and name/value='Procedure list']/items[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Procedure Name, description=Identificació del procediment pel nom., comment=Sempre que sigui possible, es prefereix codificar el procediment específic amb una terminologia., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Obligatòria, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v2]/content[openEHR-EHR-SECTION.problem_list.v0 and name/value='Procedure list']/items[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[at0066], code=at0066, itemType=ELEMENT, level=4, text=Procedure Starting Date, description=Data i/o hora en què es pretén fer el procediment., comment=Només per al seu ús en associació amb la fase del procés 'Procediment programat'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v2]/content[openEHR-EHR-SECTION.problem_list.v0 and name/value='Procedure list']/items[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[at0060], code=at0060, itemType=ELEMENT, level=4, text=Procedure Ending Date, description=Data i/o hora en què va finalitzar tot el procediment, o l'últim component d'un procediment multicomponent., comment=Només per a ús en associació amb la fase del procés "Procediment realitzat", i en situacions en què el procediment es repeteix en múltiples ocasions abans de completar-se o hi ha múltiples components a tot el procediment. Pot ser el mateix que l'atribut de temps de RM de la fase del procés 'Procediment completat'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null]], templateType=normal] |