| 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=Condicionants_Problemes, 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[at0001], code=at0001, itemType=ELEMENT, level=3, text=Data d'autorització del document, description=*, 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]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.admin_salut.v0]/items[at0002], code=at0002, itemType=ELEMENT, level=3, text=Data de creació del document, description=*Date and time when the source document is generated by the supplier system.
(en), 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]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.admin_salut.v0]/items[at0023], code=at0023, itemType=ELEMENT, level=3, text=Data de publicació del document, description=*Date and time when the previously created document is registered in the target database. (en), 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]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.admin_salut.v0]/items[at0003], code=at0003, itemType=ELEMENT, level=3, text=Codificació econòmica, 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[at0004], code=at0004, itemType=ELEMENT, level=3, text=Regió competent, 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], 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.admin_salut.v0]/items[at0007], code=at0007, itemType=CLUSTER, level=3, text=Institució publicadora, 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[at0007]/items[at0014], code=at0014, itemType=ELEMENT, level=4, text=Centre publicador, 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[at0007]/items[at0015], code=at0015, itemType=ELEMENT, level=4, text=SA publicador, 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[at0007]/items[at0016], code=at0016, itemType=ELEMENT, level=4, text=UP publicador, 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[at0010], code=at0010, itemType=CLUSTER, level=3, text=Institució custòdia, 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[at0010]/items[at0017], code=at0017, itemType=ELEMENT, level=4, text=Centre custòdia, 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[at0010]/items[at0018], code=at0018, itemType=ELEMENT, level=4, text=SA custòdia, 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[at0010]/items[at0019], code=at0019, itemType=ELEMENT, level=4, text=UP custòdia, 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[at0009], code=at0009, itemType=CLUSTER, level=3, text=Institució sol·licitant, 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[at0009]/items[at0020], code=at0020, itemType=ELEMENT, level=4, text=Centre sol·licitant, 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[at0009]/items[at0021], code=at0021, itemType=ELEMENT, level=4, text=SA sol·licitant, 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[at0009]/items[at0022], code=at0022, itemType=ELEMENT, level=4, text=UP sol·licitant, 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 and name/value='Metadades XDS'], 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 and name/value='Metadades XDS']/items[at0001], code=at0001, itemType=ELEMENT, level=3, text=Categoria professional, 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_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.xds_metadata.v0 and name/value='Metadades XDS']/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
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.xds_metadata.v0 and name/value='XDS Metadata Professional'], code=at0000, itemType=CLUSTER, level=2, text=XDS Metadata Professional, 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 and name/value='XDS Metadata Professional']/items[at0001], code=at0001, itemType=ELEMENT, level=3, text=Especialitat de la categoria professional, 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_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='DIAGNOSTIC CIM 10 MC'], code=at0000, itemType=EVALUATION, level=1, text=DIAGNOSTIC CIM 10 MC, description=Detalls sobre una única condició de salut, lesió, discapacitat o qualsevol altre problema identificat que afecti al benestar físic, mental i/o social d'una persona., 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), uncommonOntologyItems=null, 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-EVALUATION.problem_diagnosis.v1 and name/value='DIAGNOSTIC CIM 10 MC']/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=2, 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-EVALUATION.problem_diagnosis.v1 and name/value='DIAGNOSTIC CIM 10 MC']/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=3, text=Nom del Problema/Diagnòstic, 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.encounter.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='DIAGNOSTIC CIM 10 MC']/data[at0001]/items[at0012], code=at0012, itemType=ELEMENT, level=3, text=Lateralitat, description=Identificació d'un lloc corporal per la localització del problema o diagnòstic., 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), uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Opcional, repetint, 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-EVALUATION.problem_diagnosis.v1 and name/value='DIAGNOSTIC CIM 10 MC']/data[at0001]/items[at0077], code=at0077, itemType=ELEMENT, level=3, text=Data/hora d'inici, description=Data/hora estimada o real en que es van observar per primera vegada els signes o símptomes del problema/diagnòstic., comment=*Data captured/imported as "Age at onset" 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.encounter.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='DIAGNOSTIC CIM 10 MC']/data[at0001]/items[at0003], code=at0003, itemType=ELEMENT, level=3, text=Data/hora del diagnòstic, 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.encounter.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='DIAGNOSTIC CIM 10 MC']/data[at0001]/items[at0005], code=at0005, itemType=ELEMENT, level=3, text=Severitat, 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=CHOICE, bindings=null, values=- Coded Text
- Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='DIAGNOSTIC CIM 10 MC']/data[at0001]/items[openEHR-EHR-CLUSTER.clinical_evidence.v1], code=at0000, itemType=CLUSTER, level=3, text=Clinical evidence, description=Details about findings that support a clinical assertion., 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-EVALUATION.problem_diagnosis.v1 and name/value='DIAGNOSTIC CIM 10 MC']/data[at0001]/items[openEHR-EHR-CLUSTER.clinical_evidence.v1]/items[at0006], code=at0006, itemType=ELEMENT, level=4, text=Date identified, description=The date on which the finding was clinically identified., comment=For example: The date when the finding was made by or made available to the clinician., 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-EVALUATION.problem_diagnosis.v1 and name/value='DIAGNOSTIC CIM 10 MC']/data[at0001]/items[openEHR-EHR-CLUSTER.clinical_evidence.v1]/items[at0023], code=at0023, itemType=ELEMENT, level=4, text=Comment, description=Additional narrative about the finding not captured in other fields., 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.encounter.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='DIAGNOSTIC CIM 10 MC']/data[at0001]/items[openEHR-EHR-CLUSTER.thesaurus_ecap.v0], code=at0000, itemType=CLUSTER, level=3, text=thesaurus_ecap, 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]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='DIAGNOSTIC CIM 10 MC']/data[at0001]/items[openEHR-EHR-CLUSTER.thesaurus_ecap.v0]/items[at0043], code=at0043, itemType=ELEMENT, level=4, text=*DV_CODED_TEXT (en), 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]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='DIAGNOSTIC CIM 10 MC']/data[at0001]/items[openEHR-EHR-CLUSTER.relevance.v0], code=at0000, itemType=CLUSTER, level=3, text=Rellevància, 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]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='DIAGNOSTIC CIM 10 MC']/data[at0001]/items[openEHR-EHR-CLUSTER.relevance.v0]/items[at0043], code=at0043, itemType=ELEMENT, level=4, text=Rellevància del problema o diagnòstic a ECAP, description=És la rellevància per aquell problema de salut pel pacient concret. Condicionarà la prioritat de visualització del diagnòstic en el llistat de diagnòstics del pacient. Tot i que cada codi diagnòstic té una rellevància default assignada en el Centre de Configuració, el professional pot decidir modificar-la pel pacient en qüestió., 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- Molt alta
- Alta
- Mitja
- Baixa
- Sense rellevància
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='DIAGNOSTIC CIM 10 MC']/data[at0001]/items[at0072], code=at0072, itemType=ELEMENT, level=3, text=Descripció del curs, description=Descripció narrativa sobre el curs del problema o diagnòstic des del inici., 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.encounter.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='DIAGNOSTIC CIM 10 MC']/data[at0001]/items[at0030], code=at0030, itemType=ELEMENT, level=3, text=Data/hora de resolució, 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.encounter.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='DIAGNOSTIC CIM 10 MC']/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v2], code=at0000, itemType=CLUSTER, level=3, text=Problem/Diagnosis qualifier, description=Contextual or temporal qualifier for a specified problem or diagnosis., 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-EVALUATION.problem_diagnosis.v1 and name/value='DIAGNOSTIC CIM 10 MC']/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v2]/items[at0060], code=at0060, itemType=ELEMENT, level=4, 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., 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-EVALUATION.problem_diagnosis.v1 and name/value='DIAGNOSTIC CIM 10 MC']/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v2]/items[at0001], code=at0001, itemType=ELEMENT, level=4, 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., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=- Coded Text
- New
- Ongoing
- Indeterminate
- Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='DIAGNOSTIC CIM 10 MC']/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v2]/items[at0071], code=at0071, itemType=ELEMENT, level=4, 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., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=- Coded Text
- First occurrence
- Recurrence
- Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='DIAGNOSTIC CIM 10 MC']/data[at0001]/items[at0073], code=at0073, itemType=ELEMENT, level=3, text=Certesa diagnòstica, description=El nivell de confiança en la identificació del diagnòstic., comment=*If an alternative valueset is required, these values can be added to the DV_TEXT data type in a template.(en), uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=- Coded Text
- Sospita
- Probable
- Confirmat
- Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='DIAGNOSTIC CIM 10 MC']/data[at0001]/items[at0069], code=at0069, itemType=ELEMENT, level=3, text=Comentaris, description=Narrativa addicional sobre el problema o diagnòstic no registrada en altres camps., 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.encounter.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='DIAGNOSTIC ATIC'], code=at0000, itemType=EVALUATION, level=1, text=DIAGNOSTIC ATIC, description=Detalls sobre una única condició de salut, lesió, discapacitat o qualsevol altre problema identificat que afecti al benestar físic, mental i/o social d'una persona., 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), uncommonOntologyItems=null, 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-EVALUATION.problem_diagnosis.v1 and name/value='DIAGNOSTIC ATIC']/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=2, 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-EVALUATION.problem_diagnosis.v1 and name/value='DIAGNOSTIC ATIC']/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=3, text=Nom del Problema/Diagnòstic, 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.encounter.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='DIAGNOSTIC ATIC']/data[at0001]/items[at0077], code=at0077, itemType=ELEMENT, level=3, text=Data/hora d'inici, description=Data/hora estimada o real en que es van observar per primera vegada els signes o símptomes del problema/diagnòstic., comment=*Data captured/imported as "Age at onset" 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.encounter.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='DIAGNOSTIC ATIC']/data[at0001]/items[at0003], code=at0003, itemType=ELEMENT, level=3, text=Data/hora del diagnòstic, 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.encounter.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='DIAGNOSTIC ATIC']/data[at0001]/items[openEHR-EHR-CLUSTER.clinical_evidence.v1], code=at0000, itemType=CLUSTER, level=3, text=Clinical evidence, description=Details about findings that support a clinical assertion., 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-EVALUATION.problem_diagnosis.v1 and name/value='DIAGNOSTIC ATIC']/data[at0001]/items[openEHR-EHR-CLUSTER.clinical_evidence.v1]/items[at0006], code=at0006, itemType=ELEMENT, level=4, text=Date identified, description=The date on which the finding was clinically identified., comment=For example: The date when the finding was made by or made available to the clinician., 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-EVALUATION.problem_diagnosis.v1 and name/value='DIAGNOSTIC ATIC']/data[at0001]/items[at0030], code=at0030, itemType=ELEMENT, level=3, text=Data/hora de resolució, 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.encounter.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='DIAGNOSTIC ATIC']/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v2], code=at0000, itemType=CLUSTER, level=3, text=Problem/Diagnosis qualifier, description=Contextual or temporal qualifier for a specified problem or diagnosis., 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-EVALUATION.problem_diagnosis.v1 and name/value='DIAGNOSTIC ATIC']/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v2]/items[at0060], code=at0060, itemType=ELEMENT, level=4, 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., 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-EVALUATION.problem_diagnosis.v1 and name/value='DIAGNOSTIC ATIC']/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v2]/items[at0001], code=at0001, itemType=ELEMENT, level=4, 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., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=- Coded Text
- New
- Ongoing
- Indeterminate
- Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='DIAGNOSTIC ATIC']/data[at0001]/items[at0073], code=at0073, itemType=ELEMENT, level=3, text=Certesa diagnòstica, description=El nivell de confiança en la identificació del diagnòstic., comment=*If an alternative valueset is required, these values can be added to the DV_TEXT data type in a template.(en), uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=- Coded Text
- Sospita
- Probable
- Confirmat
- Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1 and name/value='DIAGNOSTIC ATIC']/data[at0001]/items[at0069], code=at0069, itemType=ELEMENT, level=3, text=Comentaris, description=Narrativa addicional sobre el problema o diagnòstic no registrada en altres camps., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null]], templateType=normal] |