- Sem Ver: 36.0.0
- MD5-CAM-1.0.1: 04910cd75f6015e7694df88f23ddd84e
- PARENT:MD5-CAM-1.0.1: 327A8885F97587660404644C3C6053B6
- Original Language: ISO_639-1::en
Per exemple: Medicina Familiar, Laboratori, Radiologia. Es prefereix el text codificat, normalment específic d'un domini d'afinitat XDS.
Text
Coded Text
*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)
*Coding of the name of the problem or diagnosis with a terminology is preferred, where possible.(en)
*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)
Terminologia: local_terms
- Dret
- Esquerra
*Data captured/imported as "Age at onset" should be converted to a date using the subject's date of birth.(en)
*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)
*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)
- Coded Text
- Lleu
- Moderada
- Greu
- Text
For example: The date when the finding was made by or made available to the clinician.
Terminologia: local_terms
- Molt alta
- Alta
- Mitja
- Baixa
- Sense rellevància
*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)
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.
- Current
- Past
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.
- Coded Text
- New
- Ongoing
- Indeterminate
- Text
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.
- Coded Text
- First occurrence
- Recurrence
- Text
*If an alternative valueset is required, these values can be added to the DV_TEXT data type in a template.(en)
- Coded Text
- Sospita
- Probable
- Confirmat
- Text
*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)
*Coding of the name of the problem or diagnosis with a terminology is preferred, where possible.(en)
*Data captured/imported as "Age at onset" should be converted to a date using the subject's date of birth.(en)
*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)
For example: The date when the finding was made by or made available to the clinician.
*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)
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.
- Current
- Past
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.
- Coded Text
- New
- Ongoing
- Indeterminate
- Text
*If an alternative valueset is required, these values can be added to the DV_TEXT data type in a template.(en)
- Coded Text
- Sospita
- Probable
- Confirmat
- Text