| All | OperationalTemplate [rootArchetypeId=openEHR-EHR-COMPOSITION.encounter.v1, otherContributors=null, tshis=[ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1], code=at0000, itemType=COMPOSITION, level=0, text=AiR_Registre_Reaccions_Adverses v0.4, description=Interaction, contact or care event between a subject of care and healthcare provider(s)., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=COMPOSITION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=null, code=null, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=1, text=Other Context, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.admin_salut.v0], code=at0000, itemType=CLUSTER, level=2, text=Admin Salut, description=*Admin Salut (en), comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.admin_salut.v0]/items[at0005], code=at0005, itemType=CLUSTER, level=3, text=Institució, description=*, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.admin_salut.v0]/items[at0005]/items[at0011], code=at0011, itemType=ELEMENT, level=4, text=Centre d'actuació, description=*, comment=null, 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.encounter.v1]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.admin_salut.v0]/items[at0005]/items[at0012], code=at0012, itemType=ELEMENT, level=4, text=Servei Assistencial (SA) d'actuació, description=*, comment=null, 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.encounter.v1]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.admin_salut.v0]/items[at0005]/items[at0013], code=at0013, itemType=ELEMENT, level=4, text=Unitat Productiva (UP) d'actuació, description=*, comment=null, 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.encounter.v1]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.xds_metadata.v0], code=at0000, itemType=CLUSTER, level=2, text=Metadades XDS, description=Metadades de composició addicionals alineades amb IHE-XDS que ja no estan disponibles a la classe COMPOSITION del model de referència., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.xds_metadata.v0]/items[at0001], code=at0001, itemType=ELEMENT, level=3, text=Especialitat de l'autor, description=Especialitat de l'autor/compositor del document., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= Terminologia: local_terms- Metge/essa
- Dentista
- Dietista i/o Nutricionista
- Farmacèutic
- Fisioterapeuta
- Infermer/a
- Llevadora
- Logopeda
- Optometrista, Podòleg
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/context/other_context[at0001]/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=DV_CODED_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adverse_reaction_list.v0], code=at0000, itemType=SECTION, level=1, text=Detall Reacció adversa, 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.encounter.v1]/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.encounter.v1]/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.encounter.v1]/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=Substance, 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.encounter.v1]/content[openEHR-EHR-SECTION.adverse_reaction_list.v0]/items[openEHR-EHR-EVALUATION.adverse_reaction_risk.v2]/data[at0001]/items[at0130], code=at0130, itemType=ELEMENT, level=4, text=Status, description=Status about whether the adverse reaction risk statement is active or inactive., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Obligatòria, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= Terminologia: local_terms, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adverse_reaction_list.v0]/items[openEHR-EHR-EVALUATION.adverse_reaction_risk.v2]/data[at0001]/items[at0120], code=at0120, itemType=ELEMENT, level=4, text=Category, description=Category of the identified 'Substance'., comment=This data element has been included because it is currently being captured in some clinical systems. This data can be derived from the Substance where coding systems are used, and is effectively redundant in that situation., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Obligatòria, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= Terminologia: local_terms-
-
-
- Propensión a presentar reacciones medicamentosas adversas
Valor per defecte: Propensión a presentar reacciones medicamentosas adversas, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adverse_reaction_list.v0]/items[openEHR-EHR-EVALUATION.adverse_reaction_risk.v2]/data[at0001]/items[openEHR-EHR-CLUSTER.adverse_reaction_event.v1], code=at0000, itemType=CLUSTER, level=4, text=Adverse reaction event, description=Information about a specific adverse reaction event caused by exposure to a specific substance., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adverse_reaction_list.v0]/items[openEHR-EHR-EVALUATION.adverse_reaction_risk.v2]/data[at0001]/items[openEHR-EHR-CLUSTER.adverse_reaction_event.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=5, text=Specific substance, description=The substance considered to be responsible for the specific adverse reaction event., comment=For example: 'Amoxycillin'. Only an individual substance is a valid entry in 'Specific substance'. A substance may be a compound of simpler substances, for example a medicinal product. If the 'Substance' recorded in the archetype in which this archetype is nested is an individual substance and not a substance class, then it may be duplicated in this data element, or this element may be redundant. It is strongly recommended that 'Specific substance' be coded with a terminology, for example: RxNorm, SNOMED CT, DM+D, NDFRT, ICD-9, ICD-10, UNI, ATC or CPT., 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.encounter.v1]/content[openEHR-EHR-SECTION.adverse_reaction_list.v0]/items[openEHR-EHR-EVALUATION.adverse_reaction_risk.v2]/data[at0001]/items[openEHR-EHR-CLUSTER.adverse_reaction_event.v1]/items[at0002], code=at0002, itemType=ELEMENT, level=5, text=Certainty, description=The degree of clinical certainty that the 'Manifestation' in this reaction event was caused by exposure to the identified 'Specific substance'., comment=The free text data type will allow for local variation by enabling other value sets to be applied to this data element in a template - in this situation it is recommended that values should be coded using a terminology., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Obligatòria, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- Unconfirmed
- Confirmed
- Refuted
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adverse_reaction_list.v0]/items[openEHR-EHR-EVALUATION.adverse_reaction_risk.v2]/data[at0001]/items[openEHR-EHR-CLUSTER.adverse_reaction_event.v1]/items[at0008], code=at0008, itemType=ELEMENT, level=5, text=Onset of reaction, description=The date and/or time of the onset of the reaction., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Obligatòria, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adverse_reaction_list.v0]/items[openEHR-EHR-EVALUATION.adverse_reaction_risk.v2]/data[at0001]/items[openEHR-EHR-CLUSTER.adverse_reaction_event.v1]/items[at0010], code=at0010, itemType=ELEMENT, level=5, text=Severity of reaction, description=Clinical assessment of the severity of the reaction event as a whole, potentially considering multiple different manifestations., comment=It is acknowledged that this assessment is very subjective. There may be some some specific practice domains where objective scales have been applied. Objective scales can be included in this model using the 'Reaction details' Cluster., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Obligatòria, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adverse_reaction_list.v0]/items[openEHR-EHR-EVALUATION.adverse_reaction_risk.v2]/data[at0001]/items[openEHR-EHR-CLUSTER.adverse_reaction_event.v1]/items[openEHR-EHR-CLUSTER.symptom_sign.v2], code=at0000, itemType=CLUSTER, level=5, text=Symptom/Sign, description=Reported observation of a physical or mental disturbance in an individual., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Opcional, repetint, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adverse_reaction_list.v0]/items[openEHR-EHR-EVALUATION.adverse_reaction_risk.v2]/data[at0001]/items[openEHR-EHR-CLUSTER.adverse_reaction_event.v1]/items[openEHR-EHR-CLUSTER.symptom_sign.v2]/items[at0001], code=at0001, itemType=ELEMENT, level=6, text=Symptom/Sign name, description=The name of the reported symptom or sign., comment=Symptom name should be coded with a terminology, where possible., 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.encounter.v1]/content[openEHR-EHR-SECTION.adverse_reaction_list.v0]/items[openEHR-EHR-EVALUATION.adverse_reaction_risk.v2]/data[at0001]/items[openEHR-EHR-CLUSTER.adverse_reaction_event.v1]/items[openEHR-EHR-CLUSTER.symptom_sign.v2]/items[at0180], code=at0180, itemType=ELEMENT, level=6, 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. The Text data type is added as an option, to support other value sets than the ones included in the archetype., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= Terminologia: local_terms-
-
-
-
- Recuperat
- En recuperació
- No recuperat
- Recuperat amb seqüeles
- Mortal
- Desconegut
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adverse_reaction_list.v0]/items[openEHR-EHR-EVALUATION.adverse_reaction_risk.v2]/data[at0001]/items[openEHR-EHR-CLUSTER.adverse_reaction_event.v1]/items[openEHR-EHR-CLUSTER.symptom_sign.v2]/items[at0161], code=at0161, itemType=ELEMENT, level=6, 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., 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.encounter.v1]/content[openEHR-EHR-SECTION.adverse_reaction_list.v0]/items[openEHR-EHR-EVALUATION.adverse_reaction_risk.v2]/data[at0001]/items[at0006], code=at0006, itemType=ELEMENT, level=4, text=Comment, description=Additional narrative about the propensity for the adverse reaction, not captured in other fields., comment=For example: including reason for flagging a 'Criticality' of 'High risk'; and instructions related to future exposure or administration of the Substance, such as administration within an Intensive Care Unit or under corticosteroid cover., 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.encounter.v1]/content[openEHR-EHR-SECTION.adverse_reaction_list.v0]/items[openEHR-EHR-EVALUATION.adverse_reaction_risk.v2]/protocol[at0042], code=at0042, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Protocol, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adverse_reaction_list.v0]/items[openEHR-EHR-EVALUATION.adverse_reaction_risk.v2]/protocol[at0042]/items[at0062], code=at0062, itemType=ELEMENT, level=4, text=Last updated, description=Date when the propensity or the reaction event was updated., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.medication_list.v0], code=at0000, itemType=SECTION, level=1, text=Detalls medicament, description=Framework for consistent modelling of content within a template for a Medication 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.encounter.v1]/content[openEHR-EHR-SECTION.medication_list.v0]/items[openEHR-EHR-ACTION.medication.v1], code=at0000, itemType=ACTION, level=2, text=Gestió de la medicació, description=Qualsevol activitat relacionada amb la planificació, programació, gestió de prescripció, dispensació, administració, cessament i altre ús d'una medicació, vacuna, producte nutricional o altre article terapèutic., comment=Això no es limita a les activitats realitzades basades en les ordres de medicació dels clínics, sinó que també podria incloure, per exemple, prendre medicació sense prescripció., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ACTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.medication_list.v0]/items[openEHR-EHR-ACTION.medication.v1]/description[at0017], code=at0017, 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.encounter.v1]/content[openEHR-EHR-SECTION.medication_list.v0]/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[at0020], code=at0020, itemType=ELEMENT, level=4, text=Producte de medicació, description=Nom de la medicació, vacuna o altre producte terapèutic/prescriptible el qual era l'objectiu de l'activitat., comment=Per exemple: "Atenol 100mg" o "Tenormin 100mg comprimits".
Es altament recomanable la codificació de "Producte de medicació" amb terminologia capaç de provocar suport per a la decisió, quan sigui possible. L'extensió de la codificació pot variar des del senzill nom de l'element de medicació fins als detalls estructurats sobre l'actual paquet de medicació utilitzat. L'entrada de text lliure només s'ha d'utilitzar si no hi ha disponible una terminologia adequada., 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.encounter.v1]/content[openEHR-EHR-SECTION.medication_list.v0]/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v2], code=at0000, itemType=CLUSTER, level=4, text=Medication details, description=Details about a medication or component of a medication, including strength, form and details of any specific constituents., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.medication_list.v0]/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v2]/items[at0132], code=at0132, itemType=ELEMENT, level=5, text=Name, description=The name of the medication or medication component., comment=For example: 'Zinacef 750 mg powder' or 'cefuroxim'. This item should be coded if possible, using for example, RxNorm, DM+D, Australian Medicines Terminology or FEST. Usage of this element will vary according to context of use. This element may be omitted where the name of the medication is recorded in the parent INSTRUCTION or ACTION archetype, and this archetype is only used to record that the form must be or was 'liquid'., 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.encounter.v1]/content[openEHR-EHR-SECTION.medication_list.v0]/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v2]/items[at0150], code=at0150, itemType=ELEMENT, level=5, text=Batch ID, description=The identifier assigned to the production batch by the manufacturer during production., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Opcional, repetint, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_IDENTIFIER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.medication_list.v0]/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v2]/items[openEHR-EHR-CLUSTER.medication.v2], code=at0000, itemType=CLUSTER, level=5, text=Medication details, description=Details about a medication or component of a medication, including strength, form and details of any specific constituents., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.medication_list.v0]/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v2]/items[openEHR-EHR-CLUSTER.medication.v2]/items[at0132], code=at0132, itemType=ELEMENT, level=6, text=Name, description=The name of the medication or medication component., comment=For example: 'Zinacef 750 mg powder' or 'cefuroxim'. This item should be coded if possible, using for example, RxNorm, DM+D, Australian Medicines Terminology or FEST. Usage of this element will vary according to context of use. This element may be omitted where the name of the medication is recorded in the parent INSTRUCTION or ACTION archetype, and this archetype is only used to record that the form must be or was 'liquid'., 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.encounter.v1]/content[openEHR-EHR-SECTION.medication_list.v0]/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v2], code=at0000, itemType=CLUSTER, level=4, text=Dosage, description=The combination of a medication amount and administration timing for a single day, in the context of a medication order or medication management., comment=For example: '2 tablets at 6pm' or '20 mg three times per day'. Please note: this cluster allows multiple occurrences to enable representation of a complete set of dose patterns for a single dose direction., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.medication_list.v0]/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v2]/items[at0144], code=at0144, itemType=ELEMENT, level=5, text=Dose, description=The amount of medication administered at one time., comment=For example: 1 mg, 1.5 ml, 0.125 g; or 1-2 ml, 12.5-20.5 mg., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.medication_list.v0]/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v2]/items[openEHR-EHR-CLUSTER.timing_daily.v1], code=at0000, itemType=CLUSTER, level=5, text=Timing - daily, description=Structured information about the intended timing of a therapeutic or diagnostic activity within any 24 hour period., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.medication_list.v0]/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v2]/items[openEHR-EHR-CLUSTER.timing_daily.v1]/items[at0003], code=at0003, itemType=ELEMENT, level=6, text=Frequency, description=The frequency as number of times per time period that the activity is to take place., comment=For example: "4 times per day" or "3 to 4 times per hour"., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=>=1; >=1; >=1; >=1
Unitats:, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.medication_list.v0]/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[at0156], code=at0156, itemType=ELEMENT, level=4, text=Indicació clínica, description=Raó clínica per a l'activitat de medicació., comment=Per exemple: "Angina" o "Dolor". S'afavoreix la codificació de la indicació amb terminologia, quan sigui possible. Aquest element de dades permet múltiples ocurrències. Si només s'utilitza una ACCIÓ per registrar una indicació de medicació, aquest element de dades es pot utilitzar sense consideracions addicionals. No obstant això, si es registra una indicació clínica tant per a la INSTRUCCIÓ de l'ordre de Medicació com per a aquesta ACCIÓ de Gestió de la Medicació, cal tenir present que aquestes indicacions poden no ser consistent., 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.encounter.v1]/content[openEHR-EHR-SECTION.medication_list.v0]/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[at0043], code=at0043, itemType=ELEMENT, level=4, text=Administration date, description=La data/hora a la qual l'acció de medicació va estar programada per ocórrer., comment=Utilitzada per comparar variació d'una acció actual on això no és fàcilment calculable de la instrucció original., 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.encounter.v1]/content[openEHR-EHR-SECTION.medication_list.v0]/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[at0140], code=at0140, itemType=CLUSTER, level=4, text=Detalls de l'administració, description=Detalls de la localització corporal i administració de la medicació., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.medication_list.v0]/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[at0140]/items[at0147], code=at0147, itemType=ELEMENT, level=5, text=Ruta, description=La ruta per la qual el producte ordenat s'administrava o s'administrarà al cos del subjecte., comment=Comenta: Per exemple: "oral", "intravenós", o "tòpica". S'afavoreix la codificació de la ruta amb terminologia, sempre que sigui possible., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= Terminologia: local_terms- Oral
- Intravenosa no especificada
- Intramuscular
- Subcutània
- Tòpica
- Inhalada
- Auricular (ótica)
- Bucal
- Cutània
- Dental
- Endocervical
- Endosinusal
- Endotraqueal
- Epidural
- Extra-amniótica
- Hemodiàlisis
- Intra cos cavernós
- Intra-amniótica
- Intracardíaca
- Intracavernosa
- Intracerebral
- Intracervical
- Intracisternal
- Intracorneal
- Intracoronaria
- Intradèrmica
- Intradiscal (Intraespinal)
- Intrahepàtica
- Intralesional
- Intralinfàtica
- Intramedular (Médula ósea)
- Intrameningeal
- Intraocular
- Intrapericardial
- Intraperitoneal
- Intrapleural
- Intrarterial
- Intrarticular
- Intrasinovial
- Intratecal
- Intratoràcica
- Intratraqueal
- Intratumoral
- Intrauterí
- Intravenosa bolus
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.medication_list.v0]/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[at0140]/items[at0141], code=at0141, itemType=ELEMENT, level=5, text=Localització corporal, description=Descripció estructurada del lloc d'administració del producte ordenat., comment=Per exemple: "braç esquerre superior", "catèter intravenós mà dreta".
S'afavoreix la codificació de la localització corporal amb terminologia, sempre que sigui possible., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= Terminologia: local_terms- Estructura del múscul deltoides dret
- Estructura del múscul deltoides esquerre
- Múscul vast extern de quadríceps dret
- Múscul vast extern de quadríceps esquerre
- Gluti dret
- Gluti esquerre
- Altres
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.medication_list.v0]/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[at0025], code=at0025, itemType=ELEMENT, level=4, text=Xifra de seqüència, description=El número de seqüència específic del pas de la ruta que s'està enregistrant., comment=Per exemple: Número de seqüència de vacuna., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=, extendedValues=null]], templateType=normal] |