Modellbiblioteket openEHR Fork
Name
Procedure
Description
A clinical activity carried out for screening, investigative, diagnostic, curative, therapeutic, evaluative or palliative purposes.
Keywords
procedure
intervention
surgical
medical
clinical
therapeutic
diagnostic
cure
treatment
evaluation
investigation
screening
palliative
therapy
Purpose
To record information about the activities required to carry out a procedure, including the planning, scheduling, performance, suspension, cancellation, documentation and completion.
Use
Use to record information about the activities required to carry out a procedure, including the planning, scheduling, performance, suspension, cancellation, documentation and completion. This is done by the recording of data against specific activities, as defined by the 'Pathway' careflow steps in this archetype.
The scope of this archetype encompasses activities for a broad range of clinical procedures performed for evaluative, investigative, screening, diagnostic, curative, therapeutic or palliative purposes. Examples range from the relatively simple activities, such as insertion of an intravenous cannula, through to complex surgical operations.
Additional structured and detailed information about the procedure can be captured using purpose-specific archetypes inserted into the 'Procedure detail' slot, where required.
Timings related to a procedure can be managed in one of two ways:
- Using the reference model - the time for performance of any pathway step will use the ACTION time attribute for each step.
- Archetyped data elements:
--- the 'Scheduled date/time' data element is intended to record the precise time when the procedure is planned. Note: the corresponding ACTION time attribute for the Scheduled pathway step will record the time that the procedure was scheduled into a system, not the intended date/time on which the procedure is intended to be carried out; and
--- the 'Final end date/time' is intended to record the precise time when the procedure was ended. It can be used to document the complex procedures with multiple components. Note: the corresponding ACTION time attribute for the 'Procedure performed' will document the time each component performed was commenced. This 'Final end date/time' data element will record the date/time of the final active component of the procedure. This will enable a full duration of the active procedure to be calculated.
Within the context of an Operation Report, this archetype will be used to record only what was done during the procedure. Separate archetypes will be used to record the other required components of the Operation Report, including the taking of tissue specimen samples, use of imaging guidance, operation findings, post-operative instructions and plans for follow up.
Within the context of a Problem list or summary, this archetype may be used to represent procedures that have been performed. The EVALUATION.problem_diagnosis will be used to represent the patient's problems and diagnoses.
In practice, many procedures (for example, in ambulatory care) will occur once and not be ordered in advance. The details about the procedure will be added against the pathway step, 'Procedure completed'. In some cases a recurring procedure will be ordered, and in this situation data against the 'Procedure performed' step will be recorded on each occasion, leaving the instruction in the active state. When the last occurrence is recorded the 'Procedure completed' action is recorded showing that this order is now in the completed state.
In other situations, such as secondary care, there may be a formal order for a procedure using a corresponding INSTRUCTION archetype. This ACTION archetype can then be used to record the workflow of when and how the order has been carried out.
Recording information using this ACTION archetype indicates that some sort of activity has actually occurred; this will usually be the procedure itself but may be a failed attempt or another activity such as postponing the procedure. If there is a formal order for the procedure, the state of this order is represented by the Pathway step against which the data is recorded. For example, using this archetype the progressing state of a Gastroscopy order may be recorded through separate entries in the EHR progress notes at each 'Pathway' step:
- record the scheduled Start date/time for the gastroscopy (Procedure scheduled); and
- record that the gastroscopy procedure has been completed, including information about the procedure details (Procedure completed).
Please note that in the openEHR Reference Model there is a 'Time' attribute, which is intended to record the date and time at which each pathway step of the Action was performed. This is the attribute to use to record the start of the procedure (using the 'Procedure performed' pathway step) or the time that the procedure was aborted (using the 'Procedure aborted' pathway step).
The scope of this archetype encompasses activities for a broad range of clinical procedures performed for evaluative, investigative, screening, diagnostic, curative, therapeutic or palliative purposes. Examples range from the relatively simple activities, such as insertion of an intravenous cannula, through to complex surgical operations.
Additional structured and detailed information about the procedure can be captured using purpose-specific archetypes inserted into the 'Procedure detail' slot, where required.
Timings related to a procedure can be managed in one of two ways:
- Using the reference model - the time for performance of any pathway step will use the ACTION time attribute for each step.
- Archetyped data elements:
--- the 'Scheduled date/time' data element is intended to record the precise time when the procedure is planned. Note: the corresponding ACTION time attribute for the Scheduled pathway step will record the time that the procedure was scheduled into a system, not the intended date/time on which the procedure is intended to be carried out; and
--- the 'Final end date/time' is intended to record the precise time when the procedure was ended. It can be used to document the complex procedures with multiple components. Note: the corresponding ACTION time attribute for the 'Procedure performed' will document the time each component performed was commenced. This 'Final end date/time' data element will record the date/time of the final active component of the procedure. This will enable a full duration of the active procedure to be calculated.
Within the context of an Operation Report, this archetype will be used to record only what was done during the procedure. Separate archetypes will be used to record the other required components of the Operation Report, including the taking of tissue specimen samples, use of imaging guidance, operation findings, post-operative instructions and plans for follow up.
Within the context of a Problem list or summary, this archetype may be used to represent procedures that have been performed. The EVALUATION.problem_diagnosis will be used to represent the patient's problems and diagnoses.
In practice, many procedures (for example, in ambulatory care) will occur once and not be ordered in advance. The details about the procedure will be added against the pathway step, 'Procedure completed'. In some cases a recurring procedure will be ordered, and in this situation data against the 'Procedure performed' step will be recorded on each occasion, leaving the instruction in the active state. When the last occurrence is recorded the 'Procedure completed' action is recorded showing that this order is now in the completed state.
In other situations, such as secondary care, there may be a formal order for a procedure using a corresponding INSTRUCTION archetype. This ACTION archetype can then be used to record the workflow of when and how the order has been carried out.
Recording information using this ACTION archetype indicates that some sort of activity has actually occurred; this will usually be the procedure itself but may be a failed attempt or another activity such as postponing the procedure. If there is a formal order for the procedure, the state of this order is represented by the Pathway step against which the data is recorded. For example, using this archetype the progressing state of a Gastroscopy order may be recorded through separate entries in the EHR progress notes at each 'Pathway' step:
- record the scheduled Start date/time for the gastroscopy (Procedure scheduled); and
- record that the gastroscopy procedure has been completed, including information about the procedure details (Procedure completed).
Please note that in the openEHR Reference Model there is a 'Time' attribute, which is intended to record the date and time at which each pathway step of the Action was performed. This is the attribute to use to record the start of the procedure (using the 'Procedure performed' pathway step) or the time that the procedure was aborted (using the 'Procedure aborted' pathway step).
Misuse
Not to be used to record details about the anaesthetic - use a separate ACTION archetype for this purpose.
Not to be used to record details about imaging investigations - use ACTION.imaging_exam for this purpose.
Not to be used to record details about laboratory investigations - use ACTION.laboratory_test for this purpose.
Not to be used to record details about education delivered - use ACTION.health_education for this purpose.
Not to be used to record details about administrative activities - use specific ADMIN archetypes for this purpose.
Not to be used to record details about related activities such as the use of frozen sections taken during an operation, medication administered as part of the procedure or when imaging guidance is used during the procedure - use separate and specific ACTION archetypes within the same template for this purpose .
Not to be used to record a whole operation or procedure report - use a template in which this archetype is only one component of the full report.
Not to be used to record details about imaging investigations - use ACTION.imaging_exam for this purpose.
Not to be used to record details about laboratory investigations - use ACTION.laboratory_test for this purpose.
Not to be used to record details about education delivered - use ACTION.health_education for this purpose.
Not to be used to record details about administrative activities - use specific ADMIN archetypes for this purpose.
Not to be used to record details about related activities such as the use of frozen sections taken during an operation, medication administered as part of the procedure or when imaging guidance is used during the procedure - use separate and specific ACTION archetypes within the same template for this purpose .
Not to be used to record a whole operation or procedure report - use a template in which this archetype is only one component of the full report.
Archetype Id
openEHR-EHR-ACTION.procedure.v1
Copyright
© openEHR Foundation
Licencing
This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/.
Original Author
Heather Leslie
Ocean Informatics, Australia
Ocean Informatics, Australia
Date Originally Authored
To record information about the activities required to carry out a procedure, including the planning, scheduling, performance, suspension, cancellation, documentation and completion.
Language | Details |
---|---|
German |
Kim Sommer, Natalia Strauch
MHH, Medizinische Hochschule Hannover
|
Portuguese (Portugal) |
Ana Garcia Niza
EY
|
Russian |
Art Latyp; Латыпов Артур
RusBITech; РусБИТех, Москва
|
Swedish |
Sofia Lång Janstad, Sofia Janstad, Romi Shweta Pathak
SLL, Karolinska universitetssjukhuset
|
Norwegian Bokmal |
John Tore Valand / Silje Ljosland Bakke
Helse Bergen HF / Nasjonal IKT HF
|
Portuguese (Brazil) |
Osmeire Chamelette Sanzovo
Hospital Sírio Libanês
|
Arabic (Syria) |
Mona Saleh
|
Slovenian, Slovene |
Uroš Rajkovič, Biljana Prinčič
Slovenia
|
Spanish, Castilian |
Pablo Pazos, Julio de Sosa
CaboLabs, Servei Català de la Salut
|
Catalan, Valencian |
Julio de Sosa
Servei Català de la Salut
|
Name | Card | Type | Description |
---|---|---|---|
Procedure name
|
1..1 | DV_TEXT |
Identification of the procedure by name.
Comment
Coding of the specific procedure with a terminology is preferred, where possible.
|
Description
|
0..1 | DV_TEXT |
Narrative description about the procedure, as appropriate for the pathway step.
Comment
For example: description about the performance and findings from the the procedure, the aborted attempt or the cancellation of the procedure.
|
Indication
|
0..* | DV_TEXT |
The clinical or process-related reason for the procedure.
Comment
Coding of the indication with a terminology is preferred, where possible. This data element allows multiple occurrences. For example: 'Failed bowel preparation' or 'Bowel cancer screening'.
|
Method
|
0..* | DV_TEXT |
Identification of specific method or technique for the procedure.
Comment
Use this data element to record simple terms or a narrative description. If the requirements for recording the method require more complex modelling then this can be represented by additional archetypes within the 'Procedure detail' SLOT in this archetype. If the method is included in the 'Procedure name' via precoordinated codes, this data element becomes redundant.
|
Urgency
|
0..1 | DV_TEXT |
Urgency of the procedure.
Comment
Coding with a terminology is preferred, where possible.
|
Body site
|
0..* | DV_TEXT |
Identification of the body site for the procedure.
Comment
Occurrences for this data element are unbounded to allow for clinical scenarios such as removing multiple skin lesions in different places, but where all of the other attributes are identical. Use this data element to record simple terms or 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 'Procedure detail' SLOT in this archetype. If the anatomical location is included in the 'Procedure name' via precoordinated codes, this data element becomes redundant.
|
Procedure detail
|
0..* | Slot (Cluster) |
Structured information about the procedure.
Comment
Use to capture detailed, structured information about anatomical location, method & technique, equipment used, devices implanted, results, findings etc.
Slot
Slot
|
Outcome
|
0..* | DV_TEXT |
Outcome of procedure performed.
Comment
Coding with a terminology is preferred, where possible.
|
Procedural difficulty
|
0..* | DV_TEXT |
Difficulties or issues encountered during performance of the procedure.
Comment
Examples: The patient was agitated, insufficient emptying of the stomach before gastroscopy, a tumour in the bile ducts made it impossible to pass the scope through.
|
Complication
|
0..* | DV_TEXT |
Details about any complication arising from the procedure.
Comment
Use this data element to record simple terms or precoordinated complications. If the requirements for recording complication are more complex then use of a specific CLUSTER archetype within the 'Procedure detail' SLOT in this archetype is advised and this data element becomes redundant. Examples: Hematuria after a kidney biopsy, tissue irritation after insertion of intravenous catheter.
|
Scheduled date/time
|
0..1 | DV_DATE_TIME |
The date and/or time on which the procedure is intended to be performed.
Comment
Only for use in association with the 'Procedure scheduled' pathway step.
DV_DATE_TIME
|
Final end date/time
|
0..1 | DV_DATE_TIME |
The date and/or time when the entire procedure, or the last component of a multicomponent procedure, was finished.
Comment
Only for use in association with the 'Procedure performed' pathway step, and in situations where the procedure is repeated on multiple occasions before being completed or there are multiple components to the whole procedure. This may be the same as the RM time attribute for the 'Procedure completed' pathway step.
DV_DATE_TIME
|
Total duration
|
0..1 | DV_DURATION |
The total amount of time taken to complete the procedure, which may include time spent during the active phase of the procedure plus time during which the procedure was suspended.
Comment
Only for use in association with the 'Procedure completed' pathway steps.
DV_DURATION
|
Multimedia
|
0..* | Slot (Cluster) |
Mulitimedia representation of a performed procedure.
Slot
Slot
|
Procedure type
|
0..1 | DV_TEXT |
The type of procedure.
Comment
This pragmatic data element may be used to support organisation within the user interface.
|
Reason
|
0..* | DV_TEXT |
Reason that the activity or care pathway step for the identified procedure was carried out.
Comment
For example: the reason for the cancellation or suspension of the procedure.
|
Comment
|
0..1 | DV_TEXT |
Additional narrative about the activity or care pathway step not captured in other fields.
|
Name | Card | Type | Description |
---|---|---|---|
Requestor order identifier
|
0..1 |
CHOICE OF
DV_TEXT
DV_IDENTIFIER
|
The local ID assigned to the order by the healthcare provider or organisation requesting the service.
Comment
This is equivalent to Placer Order Number in HL7 v2 specifications.
DV_IDENTIFIER
|
Requestor
|
0..1 | Slot (Cluster) |
Details about the healthcare provider or organisation requesting the service.
Slot
Slot
|
Receiver order identifier
|
0..1 |
CHOICE OF
DV_TEXT
DV_IDENTIFIER
|
The ID assigned to the order by the healthcare provider or organisation receiving the request for service. This is also referred to as Filler Order Identifier.
Comment
This is equivalent to Filler Order Number in HL7 v2 specifications.
DV_IDENTIFIER
|
Receiver
|
0..* | Slot (Cluster) |
Details about the healthcare provider or organisation receiving the request for service.
Slot
Slot
|
Extension
|
0..* | Slot (Cluster) |
Additional information required to capture local content or to align with other reference models/formalisms.
Comment
For example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.
Slot
Slot
|
Careflow Step | Description | Current State |
---|---|---|
Procedure planned | The procedure to be undertaken is planned. | planned |
X - Procedure planned | This pathway step has been deprecated as it was incorrectly associated with 'initial' status - use the new 'Procedure planned' (at0004) pathway step which is correctly associated with 'planned' status. | initial |
Procedure request sent | Request for procedure sent. | planned |
X - Procedure request sent | This pathway step has been deprecated as it was incorrectly associated with 'initial' status - use the new 'Procedure request sent' (at0007) pathway step which is correctly associated with 'planned' status. | initial |
Procedure postponed | The procedure has been postponed. | postponed |
Procedure cancelled | The planned procedure has been cancelled prior to commencement. | cancelled |
Procedure scheduled | The procedure has been scheduled. | scheduled |
Procedure commenced | The procedure, or subprocedure in a multicomponent procedure, has been commenced. | active |
Procedure performed | The procedure, or subprocedure in a multicomponent procedure, has been performed. | active |
Procedure suspended | The procedure has been suspended. | suspended |
Procedure aborted | The procedure has been aborted. | aborted |
Procedure completed | The procedure has been performed and all associated clinical activities completed. | completed |
archetype (adl_version=1.4; uid=82e79f18-76b9-4b5c-a930-1115eecbc4b7) openEHR-EHR-ACTION.procedure.v1 concept [at0000] -- Procedure language original_language = <[ISO_639-1::en]> translations = < ["de"] = < language = <[ISO_639-1::de]> author = < ["name"] = <"Kim Sommer, Natalia Strauch"> ["organisation"] = <"MHH, Medizinische Hochschule Hannover"> ["email"] = <"sommer.kimkatrin@mh-hannover.de, Strauch.Natalia@mh-hannover.de"> > > ["pt-pt"] = < language = <[ISO_639-1::pt-pt]> author = < ["name"] = <"Ana Garcia Niza"> ["organisation"] = <"EY"> ["email"] = <"ana.niza16@gmail.com"> > accreditation = <"I have no accreditation"> > ["ru"] = < language = <[ISO_639-1::ru]> author = < ["name"] = <"Art Latyp; Латыпов Артур"> ["organisation"] = <"RusBITech; РусБИТех, Москва"> > accreditation = <"hmm"> > ["sv"] = < language = <[ISO_639-1::sv]> author = < ["name"] = <"Sofia Lång Janstad, Sofia Janstad, Romi Shweta Pathak"> ["organisation"] = <"SLL, Karolinska universitetssjukhuset"> ["email"] = <"sofia.lang-janstad@sll.se, romi.pathak@regionstockholm.se"> > > ["nb"] = < language = <[ISO_639-1::nb]> author = < ["name"] = <"John Tore Valand / Silje Ljosland Bakke"> ["organisation"] = <"Helse Bergen HF / Nasjonal IKT HF"> ["email"] = <"john.tore.valand@helse-bergen.no"> > > ["pt-br"] = < language = <[ISO_639-1::pt-br]> author = < ["name"] = <"Osmeire Chamelette Sanzovo"> ["organisation"] = <"Hospital Sírio Libanês"> ["email"] = <"osmeire.acsanzovo@hsl.org.br"> > > ["ar-sy"] = < language = <[ISO_639-1::ar-sy]> author = < ["name"] = <"Mona Saleh"> > > ["sl"] = < language = <[ISO_639-1::sl]> author = < ["name"] = <"Uroš Rajkovič, Biljana Prinčič"> ["organisation"] = <"Slovenia"> > > ["es"] = < language = <[ISO_639-1::es]> author = < ["name"] = <"Pablo Pazos, Julio de Sosa"> ["organisation"] = <"CaboLabs, Servei Català de la Salut"> ["email"] = <"pablo.pazos@cabolabs.com, juliodesosa@catsalut.cat"> ["pablo.pazos@cabolabs.com"] = <"pablo.pazos@cabolabs.com"> > accreditation = <"Computer Engineer"> > ["ca"] = < language = <[ISO_639-1::ca]> author = < ["name"] = <"Julio de Sosa"> ["organisation"] = <"Servei Català de la Salut"> ["email"] = <"juliodesosa@catsalut.cat"> > > > description original_author = < ["name"] = <"Heather Leslie"> ["organisation"] = <"Ocean Informatics, Australia"> ["email"] = <"heather.leslie@oceaninformatics.com"> ["date"] = <"2007-03-12"> > details = < ["de"] = < language = <[ISO_639-1::de]> purpose = <"Zur Erfassung von Informationen über die erforderlichen Aktivitäten zum Ausführen einer Prozedur. Dazu zählen die Planung, Terminierung, Durchführung, Unterbrechung, Stornierung, Dokumentation und Beendigung."> use = <"Verwenden Sie diesen Archetypen zur Erfassung von Informationen über die erforderlichen Aktivitäten zum Ausführen einer Prozedur, einschließlich Planung, Terminierung, Durchführung, Unterbrechung, Stornierung, Dokumentation und Beendigung. Dies geschieht durch die Darstellung von Daten zu bestimmten Aktivitäten durch die \"Pathway\"-Verlaufsschritte. Der Anwendungsbereich dieses Archetyps umfasst Aktivitäten für eine breite Palette von klinischen Prozeduren, die für evaluative, ermittelnde, vorsorgliche, diagnostische, kurative, therapeutische oder palliative Zwecke durchgeführt werden. Die Beispiele reichen von relativ einfachen Aktivitäten wie dem Legen einer intravenösen Kanüle bis hin zu komplexen chirurgischen Eingriffen. Zusätzliche strukturierte und detaillierte Informationen über die Prozedur können bei Bedarf mit Hilfe von zweckmäßigen Archetypen erfasst werden, die in den Slot \"Details zur Prozedur\" eingefügt werden. Zeitpläne, die sich auf eine Prozedur beziehen, können auf zwei Arten verwaltet werden: - Unter Verwendung des Referenzmodells - die Zeit für die Ausführung eines beliebigen \"Pathway\"-Verlaufsschrittes verwendet das Attribut ACTION Zeit für jeden Schritt. - Archetypische Datenelemente: --- das Datenelement \"Geplantes Datum/Uhrzeit\" soll die genaue Zeit erfassen, zu der die Prozedur geplant ist. Hinweis: Das entsprechende Attribut ACTION Zeit für den geplanten \"Pathway\"-Verlaufsschritt erfasst die Zeit, zu der die Prozedur in einem System geplant wurde, nicht das vorgesehene Datum/Uhrzeit, zu der die Prozedur ausgeführt werden soll; und --- das \"Enddatum/-uhrzeit\" soll die genaue Zeit erfassen, zu der die Prozedur beendet wurde. Damit können die komplexen Vorgänge mit mehreren Komponenten dokumentiert werden. Hinweis: Das entsprechende Attribut ACTION Zeit in dem Element \"Prozedur durchgeführt\", dokumentiert den Beginn der einzelnen durchgeführten Komponenten. Das Datenelement \"Enddatum/-uhrzeit\" erfasst das Datum/die Uhrzeit der letzten aktiven Komponente der Prozedur. Dadurch kann die volle Dauer der aktiven Prozedur berechnet werden. Im Rahmen eines Operationsberichts wird dieser Archetyp nur verwendet, um zu erfassen, was während der Operation durchgeführt wurde. Eigenständige Archetypen werden verwendet, um die anderen erforderlichen Komponenten des Operationsberichts zu erfassen, einschließlich der Entnahme von Gewebeproben, der Verwendung von Bildkontrolle, der OP-Befunde, postoperativer Anweisungen und Plänen für die Nachsorge. Im Rahmen einer Problemliste oder Zusammenfassung kann dieser Archetyp verwendet werden, um durchgeführte Prozeduren darzustellen. Der Archetyp EVALUATION.Problem/Diagnose wird verwendet, um die Probleme und Diagnosen des Patienten darzustellen. In der Praxis werden viele Prozeduren (z.B. in der ambulanten Versorgung) einmalig durchgeführt und nicht im Voraus angeordnet. Angaben zur Prozedur werden im Datenelement \"Prozedur beendet\" hinzugefügt. In einigen Fällen wird eine wiederkehrende Prozedur angeordnet. In diesen Fällen werden jeweils Daten mit dem Element \"Prozedur durchgeführt\" erfasst, so dass die Instruktion im aktiven Zustand verbleibt. Wenn das letzte Ereignis erfasst wird, wird die Aktion \"Prozedur beendet\" dokumentiert. Dies zeigt an, dass sich diese Prozedur nun im abgeschlossenen Zustand befindet. In anderen Fällen, wie z.B. in der Sekundärversorgung, kann es eine formelle Anordnung für eine Prozedur mit einem entsprechenden INSTRUCTION-Archetyp geben. Dieser ACTION-Archetyp kann dann verwendet werden, um den Workflow aufzuzeichnen, wann und wie der Auftrag ausgeführt wurde. Die Erfassung von Informationen mit diesem ACTION-Archetyp zeigt an, dass tatsächlich eine Art von Aktivität stattgefunden hat; dies ist in der Regel die Prozedur selbst, kann aber auch ein fehlgeschlagener Versuch oder eine andere Aktivität, wie das Verschieben der Prozedur, sein. Wenn es eine formale Anordnung für die Prozedur gibt, wird der Status dieser Anordnung durch das \"Pathway\" Element, für das Daten erfasst werden, dargestellt. Mit diesem Archetyp kann beispielsweise der Fortschritt einer gastroskopischen Anordnung durch separate Einträge in den \"Pathway\" Elementen erfasst werden: - Erfassung des geplante Startdatum/-zeit für die Gastroskopie (Prozedur geplant (zeitlich)); und - Dokumentation, dass das Gastroskopieverfahren abgeschlossen ist, einschließlich zusätzlicher Angaben zur Prozedur (Prozedur beendet). Bitte beachten Sie, dass es im openEHR-Referenzmodell ein Attribut \"Zeit\" gibt, das dazu dient, das Datum und die Uhrzeit zu erfassen, zu der jeder Verlaufsschritt der Aktion ausgeführt wurde. Dies ist das Attribut, mit dem der Beginn der Prozedur (mit dem Schritt \"Prozedur durchgeführt\") oder die Zeit, zu der die Prozedur abgebrochen wurde (mit dem Schritt \"Prozedur abgebrochen\"), erfasst wird."> keywords = <"Prozedur", "Vorgehen", "Verfahren", "Intervention", "Eingriff", "chirurgisch", "medizinisch", "klinisch", "therapeutisch", "Diagnostik", "diagnostisch", "heilen", "Behandlung", "Bewertung", "Untersuchung", "Früherkennung", "Screening", "palliativ", "Therapie", "Operation"> misuse = <"Nicht zur Erfassung von Angaben zur Anästhesie - verwenden Sie dazu einen separaten ACTION-Archetyp. Nicht zur Erfassung von Angaben über bildgebende Untersuchungen - verwenden Sie dazu den Archetypen ACTION.imaging_exam. Nicht zur Erfassung von Angaben über Laboruntersuchungen - verwenden Sie dazu den Archetypen ACTION.laboratory_test. Nicht zur Erfassung von Angaben über erbrachte Ausbildungen/Schulungen - verwenden Sie dazu den Archetypen ACTION.health_education. Nicht zur Erfassung von Angaben über administrative Aktivitäten - verwenden Sie zu diesem Zweck spezifische ADMIN-Archetypen. Nicht zu verwenden, um Angaben über zusammenhängende Aktivitäten zu erfassen. Beispiele für zusammenhängende Aktivitäten sind: der Einsatz von Gefrierschnitten, die während einer Operation durchgeführt werden; Medikamente, die im Rahmen der Prozedur verabreicht werden oder der Einsatz von Bildkontrolle während der Prozedur. Verwenden Sie zu diesem Zweck eigenständige und spezifische ACTION-Archetypen innerhalb des Templates. Nicht zur Erfassung eines vollständigen Berichts über eine OP- oder eine Prozedur - verwenden Sie ein Template, in der dieser Archetyp nur eine Komponente des Gesamtberichts darstellt."> > ["pt-pt"] = < language = <[ISO_639-1::pt-pt]> purpose = <"Registar informações sobre as atividades necessárias para realizar um procedimento, incluindo planeamento, programação, desempenho, suspensão, cancelamento, documentação e conclusão."> use = <"Use para registar informações sobre as atividades necessárias para realizar um procedimento, incluindo o planeamento, programação, desempenho, suspensão, cancelamento, documentação e conclusão. Isso é feito pelo registo de dados contra atividades específicas, conforme definido pelas etapas de fluxo de cuidado 'Pathway' (caminho) neste arquétipo. O âmbito deste arquétipo engloba atividades para uma ampla gama de procedimentos clínicos realizados para fins de avaliação, investigação, de triagem, diagnósticos, curativos, terapêuticos ou paliativos. Os exemplos vão desde as atividades relativamente simples, como a inserção de uma catéter intravenoso, até operações cirúrgicas complexas. Informações adicionais estruturadas e detalhadas sobre o procedimento podem ser capturadas usando arquétipos específicos inseridos no slot 'Detalhes do procedimento', quando necessário. Os prazos relativos a um procedimento podem ser geridos de duas formas: - Utilizando o modelo de referência - o tempo de execução de qualquer etapa do percurso utilizará o atributo ACTION time para cada etapa. - Elementos de dados arqueados: --- o elemento de dados 'Data/hora programada' destina-se a registar a hora exata em que o procedimento está planeado. Nota: o atributo de tempo ACTION correspondente para a etapa Caminho agendado registará o tempo que o procedimento foi programado num sistema, não a data/ hora prevista em que o procedimento deve ser realizado; e --- A data/hora final destina-se a registar a hora exata em que o procedimento terminou. Ele pode ser usado para documentar os procedimentos complexos com vários componentes. Nota: o atributo de tempo ACTION correspondente para o 'Procedimento executado' documentará o tempo em que cada componente executado foi iniciado. Este elemento de dados 'Data/hora final' registará a data/hora do componente ativo final do procedimento. Isso permitirá calcular a duração total do procedimento ativo. No contexto de um Relatório de Operação, este arquétipo será usado para registar apenas o que foi feito durante o procedimento. Serão utilizados arquétipos separados para registar os outros componentes necessários do Relatório de Operação, incluindo a recolha de amostras de tecido, a utilização de orientação por imagem, os resultados da operação, as instruções pós-operatórias e os planos de acompanhamento. No contexto de uma lista ou resumo de problemas, esse arquétipo pode ser usado para representar procedimentos que foram realizados. O EVALUATION.problem_diagnosis será utilizado para representar os problemas e diagnósticos do doente. Na prática, muitos procedimentos (por exemplo, em cuidados ambulatórios) ocorrerão uma vez e não serão solicitados com antecedência. Os detalhes sobre o procedimento serão adicionados contra a etapa do caminho, 'Procedimento concluído'. Em alguns casos, um procedimento recorrente será ordenado, e nesta situação os dados contra a etapa 'Procedimento executado' serão registados em cada ocasião, deixando a instrução no estado ativo. Quando a última ocorrência é registada, a ação 'Procedimento concluído' é registada mostrando que essa ordem está agora no estado concluído. Noutras situações, como a assistência secundária, pode haver uma ordem formal para um procedimento usando um arquétipo de INSTRUÇÃO correspondente. Este arquétipo ACTION pode então ser usado para registar o fluxo de trabalho de quando e como o pedido foi realizado. Registar informações usando este arquétipo ACTION indica que algum tipo de atividade realmente ocorreu; isso geralmente será o procedimento em si, mas pode ser uma tentativa fracassada ou outra atividade, como adiar o procedimento. Se houver uma ordem formal para o procedimento, o estado dessa ordem é representado pela etapa Pathway (caminho) contra a qual os dados são registados. Por exemplo, usando este arquétipo, o estado de progresso de uma ordem de Gastroscopia pode ser registado por entradas separadas nas notas de progresso do EHR em cada passo do 'Caminho': - registar a data/hora de início prevista para a gastroscopia (procedimento agendado); e - registar que o procedimento de gastroscopia foi concluído, incluindo informações sobre os pormenores do procedimento (procedimento concluído). Por favor, note que no openEHR Reference Model existe um atributo 'Time', que se destina a registar a data e a hora em que cada etapa do caminho da Ação foi executada. Este é o atributo a ser usado para registar o início do procedimento (usando a etapa de caminho 'Procedimento realizado') ou o tempo em que o procedimento foi abortado (usando a etapa de caminho 'Procedimento abortado')."> keywords = <"procedimento(pt)", "intervenção(pt)", "cirúrgico(pt)", "médico(pt)", "clínico(pt)", "terapêutico(pt)", "diagnóstico(pt)", "cura(pt)", "tratamento(pt)", "avaliação(pt)", "investigação(pt)", "rastreio(pt)", "paliativo(pt)", "terapia(pt)"> misuse = <"Não deve ser usado para registar detalhes sobre a anestesia - use um arquétipo ACTION separado para essa finalidade. Não deve ser usado para registar detalhes sobre exames de imagem - use ACTION.imaging_exam para este propósito. Não deve ser usado para registar detalhes sobre testes laboratoriais - use ACTION.laboratory_test para esta finalidade. Não deve ser usado para registar detalhes sobre a educação entregue - use ACTION.health_education para este propósito. Não deve ser usado para registar detalhes sobre atividades administrativas - use arquétipos ADMIN, específicos para essa finalidade. Não deve ser usado para registar detalhes sobre atividades relacionadas, como o uso de amostras congeladas tomadas durante uma operação, medicação administrada como parte do procedimento ou quando a orientação por imagem é usada durante o procedimento - usar arquétipos ACTION separados e específicos dentro do mesmo modelo para esta finalidade. Não deve ser usado para registar toda uma operação ou relatório de procedimento - use um modelo no qual este arquétipo é apenas um componente do relatório completo."> > ["ru"] = < language = <[ISO_639-1::ru]> purpose = <"Для записи сведений об проведенной процедуре"> use = <"Используется для записи подробной информации о процедуре, выполненной пациенту. Информация о действиях, связанных с выполнением процедуры, таких как анестезия или применение лекарств, долдно быть записано в отдельных архетипах типа ДЕЙСТВИЕ"> keywords = <"процедура, выполнение", ...> misuse = <""> copyright = <"© openEHR Foundation"> > ["sv"] = < language = <[ISO_639-1::sv]> purpose = <"Att registrera information om de aktiviteter som krävs för att genomföra en procedur, inklusive planering, schemaläggning, utförande, avstängning, avbokning, dokumentation och slutförande. "> use = <"Används för att registrera information om de aktiviteter som krävs för att genomföra en procedur, inklusive planering, schemaläggning, utförande, avstängning, avbokning, dokumentation och slutförande. Detta görs genom registrering av data mot specifika aktiviteter, som definieras av \"Pathway\" -flödesstegen i denna arketyp. Denna arketyp omfattar aktiviteter för ett brett spektrum av kliniska procedurer som utförs för utvärderande, undersökande, screening, diagnostiska, botande, terapeutiska eller palliativa ändamål. Till exempel kan den användas för allt från relativt enkla aktiviteter, såsom insättning av en intravenös kanyl, till komplexa kirurgiska operationer. Ytterligare strukturerad och detaljerad information om proceduren kan fångas med hjälp av specifika arketyper infogade i rutan 'Procedur detaljer', om så krävs. Tider relaterade till ett förfarande kan hanteras på ett av två sätt: - Med hjälp av referensmodellen - tiden för utförandet av något vägsteg ska använda attributet ACTION time för varje steg. - Archetyped dataelement: --- dataelementet 'Schemalagt datum/tid' är avsett att registrera den exakta tidpunkt då proceduren planeras. Obs! Motsvarande ACTION-tidsattribut för det schemalagda vägsteget registrerar den tid som proceduren planerades i ett system, inte det avsedda datumet/tiden då proceduren är avsedd att genomföras; och --- \"Slutdatum/tid\" är avsedd att registrera den exakta tidpunkt då proceduren avslutades. Den kan användas för att dokumentera komplexa procedurer med flera komponenter. Obs! Motsvarande ACTION-tidsattribut för \"Procedur utförd\" kommer att dokumentera den tid varje komponent som utfördes påbörjades. Det \"Slutliga slutdatum/tid\" -element registrerar datum/tid för den slutliga aktiva komponenten i proceduren. Detta gör det möjligt att beräkna en fullständig varaktighet av det aktiva förfarandet. Inom ramen för en operationsrapport kommer denna arketyp att användas för att bara registrera vad som gjordes under proceduren. Separata arketyper kommer att användas för att registrera de andra nödvändiga komponenterna i operationsrapporten, inklusive att ta prover av vävnadsprover, användning av avbildningsvägledning, funktionsresultat, postoperativa instruktioner och planer för uppföljning. Inom ramen för en problemlista eller sammanfattning kan denna arketyp användas för att representera procedurer som har utförts. EVALUATION.problem_diagnosis kommer att användas för att representera patientens problem och diagnoser. I praktiken kommer många förfaranden (till exempel ambulansvård) att inträffa en gång och inte beställas i förväg. Detaljerna om proceduren kommer att läggas till i steget, \"Procedur slutförd\". I vissa fall kommer ett återkommande förfarande att beställas, och i denna situation registreras data över steget \"Procedur utförd\" vid varje tillfälle och lämnar instruktionen i aktivt tillstånd. När den senaste händelsen registreras registreras åtgärden 'Procedur slutförd' som visar att denna procedur nu är i det färdiga tillståndet. I andra situationer, till exempel sekundärvård, kan det finnas en formell order för ett förfarande med en motsvarande INSTRUKTION-arketyp. Denna ACTION-arketyp kan sedan användas för att registrera arbetsflödet för när och hur proceduren har genomförts. Dokumentation med den här ACTION-arketypen indikerar att någon form av aktivitet faktiskt har inträffat; detta är vanligtvis själva proceduren men kan vara ett misslyckat försök eller en annan aktivitet som att skjuta upp proceduren. Om det finns en formell beställning för proceduren representeras tillståndet för denna beställning av det Pathway-steg mot vilket data registreras. Till exempel, med den här arketypen kan det fortskridande tillståndet för en Gastroskopi-beställning registreras genom separata poster i EHR-framstegsanteckningarna vid varje \"Pathway\" -steg: - registrera schemalagt startdatum/tid för gastroskopi (schemalagd procedur); och - registrera att gastroskopiproceduren har slutförts, inklusive information om proceduruppgifterna (proceduren avslutad). Observera att i openEHR-referensmodellen finns ett attribut 'Time' som är avsett att registrera datum och tidpunkt då varje steg i åtgärden utfördes. Detta är attributet som ska användas för att registrera inledningen av proceduren (med hjälp av steget 'Procedur utfört') eller den tid då proceduren avbröts (med hjälp av steget 'Procedur avbruten'). "> keywords = <"*procedur", "*intervention", "*kirurgi", "*medicinsk", "*klinisk", "*terapeutisk", "*diagnostisk", "*botande", "*behandling", "*utredning", "*undersökning", "*screening", "*palliativ", "*terapi"> misuse = <"Får inte användas för att registrera detaljer om narkos - använd en separat ACTION-arketyp för detta ändamål. Används inte för att registrera detaljer om bild undersökningar - använd ACTION.imaging_exam för detta ändamål. Används inte för att registrera detaljer om laboratorieundersökningar - använd ACTION.laboratory_test för detta ändamål. Används inte för att registrera detaljer om utbildning - använd ACTION.health_education för detta ändamål. Används inte för att registrera detaljer om administrativa aktiviteter - använd specifika ADMIN-arketyper för detta ändamål. Får inte användas för att registrera detaljer om relaterade aktiviteter, såsom användning av frysta snitt som tagits under en operation, läkemedel som administreras som en del av proceduren eller när bildvisningsvägledning används under proceduren - använd separata och specifika ACTION-arketyper inom samma mall för detta syfte. Används inte för att registrera en hel operation eller procedurrapport - använd en mall där den här arketypen bara är en komponent i hela rapporten. "> > ["nb"] = < language = <[ISO_639-1::nb]> purpose = <"For å registrere informasjon om aktiviteter som må gjennomføres for å utføre en klinisk prosedyre, inkludert planlegging, fastsetting av tidspunkt, utførelse, utsettelse, kansellering, dokumentering og fullføring."> use = <"Brukes til å registrere nødvendig informasjon om aktiviteter i gjennomføringen av en klinisk prosedyre. Dette inkluderer planlegging, fastsetting av tidspunkt, utførelse, utsettelse, avlysning, dokumentering og fullføring. Dette gjøres ved å registrere data knyttet til spesifikke aktiviteter som definert i arketypens prosesstrinn (Engelsk: \"Pathway careflow steps\"). Arketypen dekker aktiviteter for et bredt spekter av kliniske prosedyrer utført i evaluerende, undersøkende, diagnostisk, kurativ, terapeutisk eller palliativ hensikt. Eksempler strekker seg fra relativt enkle aktiviteter som innlegging av et intravenøst kateter, til komplekse kirurgiske operasjoner. Strukturert og detaljert tilleggsinformasjon om prosedyren kan registreres ved bruk av spesifikke CLUSTER-arketyper satt inn i \"Prosedyredetaljer\"-SLOTet der dette kreves. Tidsberegning relatert til en prosedyre kan håndteres på en av to måter: -Ved å benytte referansemodellen: Tiden for gjennomføring av et prosesstrinn vil benytte \"time\"-attributtet som ligger implisitt i en ACTION-arketype, for hvert enkelt prosesstrinn. -Dataelementer i arketypen: ---Dataelementet \"Planlagt dato/tid\" skal brukes for å registrere nøyaktig tidspunkt prosedyren er planlagt. Merk: Det korresponderende \"time\"-attributtet for prosesstrinnet \"Fastsatt tidspunkt for prosedyre\" registrerer tidspunktet da prosedyren ble planlagt, ikke dato/tid for når prosedyren er planlagt gjennomført. --- \"Endelig dato/tid\" skal registrere nøyaktig tidspunkt for da prosedyren ble avsluttet. Den kan brukes for å dokumentere komplekse prosedyrer med mange komponenter. Merk: Det korresponderende \"time\"-attributtet for prosesstrinnet \"Prosedyre iverksatt\" dokumenterer tidspunkt for hver gang en komponent er gjennomført eller påbegynt. Dataelementet \"Endelig dato/tid\" registrerer dato/tid for det siste aktive komponenten av prosedyren. Dette åpner for mulighet for utregning av den totale varigheten av den aktive prosedyren. Ved bruk i en operasjonsrapport skal arketypen bare benyttes for å registrere hva som ble utført under prosedyren. Egne arketyper vil bli benyttet for å registrere andre komponenter av operasjonsrapporten, dette inkluderer biopsitakning, bildediagnostisk veiledning, funn under operasjonen, postoperative instruksjoner og videre planer for oppfølging. I en problemliste eller i et problemsammendrag kan denne arketypen benyttes for å gi en oversikt over hvilke prosedyrer som er utført. Arketypen EVALUATION.problem_diagnosis vil benyttes for å gi en oversikt over pasientens problemer og diagnoser. I praksis vil mange prosedyrer (f.eks. i primærhelsetjenesten) utføres én gang, og ikke bestilles i forkant. Detaljene om prosedyren vil da registreres for det aktuelle prosesstrinnet. I noen tilfeller vil en gjentagende prosedyre bli rekvirert, og i en slik situasjon registreres prosesstrinnet \"Prosedyre utført\" i hvert enkelt tilfelle, og instruksjonen forblir i en aktiv tilstand. Når den siste prosedyren i serien er registrert settes prosesstrinnet \"Prosedyre avsluttet\" for å avslutte forordningen. I andre situasjoner, for eksempel i spesialisthelsetjenesten, kan det foreligge en formell rekvisisjon for en prosedyre hvor en motsvarende INSTRUCTION-arketype er benyttet. Denne ACTION-arketypen benyttes da for å registrere arbeidsflyt og når og hvordan prosedyren ble utført. Registrering av informasjon i denne ACTION-arketypen indikerer at en eller annen type aktivitet faktisk er utført; dette vil vanligvis være prosedyren i seg selv, men kan også være et mislykket forsøk eller en annen aktivitet som f.eks. en utsettelse av prosedyren. Finnes det en formell henvisning til en prosedyre, er henvisningens status representert i det prosesstrinnet hvor data er registrert. For eksempel vil gjennomføringen av en gastroskopi lagret i denne arketypen kunne registreres som flere påfølgende oppføringer innen et fremdriftsnotat, en oppføring for hvert prosesstrinn: - registrert planlagt Start dato/tid for gastroskopien (\"Prosedyre planlagt\") - registrert at gastroskopiprosedyren er fullført, inkludert informasjon om prosedyredetaljene (\"Prosedyre avsluttet\"). Legg merke til at det i openEHR referansemodellen er et attributt \"time\" som er tenkt brukt til å registrere dato og tid for når hvert enkelt prosesstrinn i ACTION-arketypen ble utført. Denne attributten skal brukes til å registre da prosedyren startet (ved prosesstrinnet \"Prosedyre iverksatt\"), eller tidspunktet da prosedyren ble avbrutt (ved prosesstrinnet \"Prosedyre avbrutt\")."> keywords = <"prosedyre", "intervensjon", "kirurgisk", "medisinsk", "klinisk", "terapeutisk", "diagnostisk", "behandling", "kur", "evaluering", "undersøkelse", "screening", "palliativ", "terapi", "prognostisk"> misuse = <"Benyttes ikke til å registrere detaljer om administrasjon av legemidler - bruk ACTION.medication til dette formålet. Benyttes ikke til å registrere detaljer om bildediagnostiske undersøkelser - bruk ACTION.imaging_exam til dette formålet. Benyttes ikke til å registrere detaljer om laboratorieundersøkelser - bruk ACTION.laboratory_test til dette formålet. Benyttes ikke til å registrere detaljer om pasientopplæring - bruk ACTION.health_education til dette formålet. Benyttes ikke til å registrere detaljer om administrative aktiviteter - bruk spesifikke ADMIN-arketyper til dette formålet. Benyttes ikke til registrering om relaterte aktiviteter som bruk av frysesnitt tatt under en operasjon, legemidler gitt som del av prosedyren, eller når bildeveiledning er brukt under prosedyren. Bruk separate og spesifikke ACTION-arketyper innen samme templat til dette formålet. Benyttes ikke for å registrere en hel operasjon eller prosedyrerapport - bruk en templat der denne arketypen er kun en komponent av den fullstendige rapporten."> copyright = <"© openEHR Foundation"> > ["pt-br"] = < language = <[ISO_639-1::pt-br]> purpose = <"Para registrar os detalhes sobre um procedimento realizado, incluindo o planejamento, programação , execução, suspensão , cancelamento , documentação e conclusão."> use = <"Use para registrar informações sobre as atividades necessárias para realizar um procedimento , incluindo o planejamento, programação , execução, suspensão , cancelamento , documentação e conclusão. Isto é feito através do registro de dados de atividades específicas , conforme definido neste arquétipo . O escopo deste arquétipo abrange as atividades para uma ampla gama de procedimentos clínicos realizados para avaliação, investigação , triagem , diagnóstico , curativo, terapêutico ou fins paliativos. Os exemplos vão desde as atividades relativamente simples, tais como a inserção de uma cânula intravenosa , através de operações cirúrgicas complexas . Informações adicionais estruturadas e detalhadas sobre o procedimento podem ser capturadas utilizando arquétipos específicos de uso inserido no slot 'Detalhe do Procedimento', onde for necessário. Tempos relacionados a um procedimento podem ser gerenciados de uma de duas maneiras: - Usando o modelo de referência - o prazo para realização de qualquer passo/caminho usará o atributo tempo de ação para cada etapa. - Elementos de dados arquetipados: --- Elemento de dados \"data / hora agendada\" destina-se a registrar o tempo exato em que o procedimento é planejado. Nota: o atributo de tempo de ação correspondente para o passo via Programado irá registrar o tempo que o procedimento foi programado em um sistema, não a data / hora pretendida em que o procedimento se destina a ser realizado; e --- O 'data final / hora' destina-se a registrar o tempo exato em que o processo foi encerrado. Ele pode ser usado para documentar os procedimentos complexos com componentes múltiplos. Nota: o atributo de tempo de ação correspondente para o \"procedimento realizado\" irá documentar o tempo de cada componente realizada foi iniciada. Este elemento de dados 'Data / hora Final' registrará a data / hora do último componente ativo do procedimento. Isto irá permitir uma duração total do processo ativo a ser calculado. Dentro do contexto de um Relatório de Cirurgia, esse arquétipo será usado para gravar apenas o que foi feito durante o procedimento. Arquétipos separados serão utilizados para gravar os outros componentes necessários, incluindo a coleta de amostras de tecidos, utilização de imagens intraoperatórias, achados cirúrgicos, instruções pós-operatória e planos de acompanhamento. Dentro do contexto de uma lista de problemas ou resumo, este arquétipo pode ser usado para representar os procedimentos que têm sido realizados. O EVALUATION.problem_diagnosis será usado para representar os problemas do paciente e diagnósticos. Na prática, muitos procedimentos (por exemplo, um atendimento ambulatorial) ocorrerá uma vez e não será planejado com antecedência. Os detalhes sobre o procedimento serão adicionados ao passo/caminho, «Processo concluído\". Em alguns casos um procedimento recorrente será ordenado, e nesta situação os dados do \"procedimento realizado\" será gravado em cada ocasião, deixando a instrução no estado ativo. Quando a última ocorrência é registrada do \"Procedimento concluído\" a ação é registrada mostrando que essa ordem está agora no estado concluído. Em outras situações, tais como atenção secundária, pode haver uma ordem formal de um procedimento usando um arquétipo instrução correspondente. Este arquétipo ação pode então ser usado para registrar o fluxo de trabalho de quando e como a ordem foi executada. Gravando informações utilizando esse arquétipo AÇÃO indica que algum tipo de atividade realmente ocorreu; este será geralmente o procedimento em si, mas pode ser uma tentativa fracassada ou outra atividade, como o adiamento do procedimento. Se existe uma ordem formal para o procedimento, o estado desta ordem é representado pelo passo Pathway contra a qual os dados são gravados. Por exemplo, usando esse arquétipo do estado progredindo de uma ordem Gastroscopia podem ser registrados através de entradas separadas no progresso EHR observado um passo a cada 'Caminho': - Registrar o início de data / hora programada para a gastroscopia (Procedimento programado); e - Gravar que o procedimento foi concluído gastroscopia, incluindo informações sobre os detalhes de procedimento (processo encerrado). Por favor, note que no Modelo de Referência openEHR há um atributo 'Time', que se destina a registrar a data e hora em que foi realizada a cada passo via da ação. Este é o atributo a ser usado para registar o início do procedimento (usando o \"procedimento realizado 'passo via), ou o tempo que o procedimento foi abortada (usando o\" procedimento abortado' passo via)"> keywords = <"procedimento", "intervenção", "cirúrgico", "médico", "clínico", "terapêutico", "diagnóstico", "cura", "tratamento", "evolução", "investigação", "paliativo", "terapia"> misuse = <"Não deve ser usado para gravar detalhes sobre o anestésico - usar um arquétipo ação separada para esse fim. Não deve ser usado para registrar detalhes sobre as investigações de imagem - use ACTION.imaging_exam para esta finalidade. Não deve ser usado para gravar detalhes sobre investigações laboratoriais - ACTION.laboratory_test usar para essa finalidade. Não deve ser usado para gravar detalhes sobre educação entregues - ACTION.health_education usar para essa finalidade. Não deve ser usado para registrar detalhes sobre as atividades administrativas - usar arquétipos ADMIN específicos para esta finalidade. Não deve ser usado para gravar detalhes sobre as atividades relacionadas, tais como medicação administrada como parte do processo ou quando utilização de imagens para visualização é utilizado durante o procedimento - usar arquétipos ação separados e específicos dentro do mesmo modelo para este fim. Não deve ser usado para gravar uma operação ou procedimento relatório conjunto - usar um modelo em que esse arquétipo é apenas um componente do relatório completo."> copyright = <"© openEHR Foundation"> > ["en"] = < language = <[ISO_639-1::en]> purpose = <"To record information about the activities required to carry out a procedure, including the planning, scheduling, performance, suspension, cancellation, documentation and completion."> use = <"Use to record information about the activities required to carry out a procedure, including the planning, scheduling, performance, suspension, cancellation, documentation and completion. This is done by the recording of data against specific activities, as defined by the 'Pathway' careflow steps in this archetype. The scope of this archetype encompasses activities for a broad range of clinical procedures performed for evaluative, investigative, screening, diagnostic, curative, therapeutic or palliative purposes. Examples range from the relatively simple activities, such as insertion of an intravenous cannula, through to complex surgical operations. Additional structured and detailed information about the procedure can be captured using purpose-specific archetypes inserted into the 'Procedure detail' slot, where required. Timings related to a procedure can be managed in one of two ways: - Using the reference model - the time for performance of any pathway step will use the ACTION time attribute for each step. - Archetyped data elements: --- the 'Scheduled date/time' data element is intended to record the precise time when the procedure is planned. Note: the corresponding ACTION time attribute for the Scheduled pathway step will record the time that the procedure was scheduled into a system, not the intended date/time on which the procedure is intended to be carried out; and --- the 'Final end date/time' is intended to record the precise time when the procedure was ended. It can be used to document the complex procedures with multiple components. Note: the corresponding ACTION time attribute for the 'Procedure performed' will document the time each component performed was commenced. This 'Final end date/time' data element will record the date/time of the final active component of the procedure. This will enable a full duration of the active procedure to be calculated. Within the context of an Operation Report, this archetype will be used to record only what was done during the procedure. Separate archetypes will be used to record the other required components of the Operation Report, including the taking of tissue specimen samples, use of imaging guidance, operation findings, post-operative instructions and plans for follow up. Within the context of a Problem list or summary, this archetype may be used to represent procedures that have been performed. The EVALUATION.problem_diagnosis will be used to represent the patient's problems and diagnoses. In practice, many procedures (for example, in ambulatory care) will occur once and not be ordered in advance. The details about the procedure will be added against the pathway step, 'Procedure completed'. In some cases a recurring procedure will be ordered, and in this situation data against the 'Procedure performed' step will be recorded on each occasion, leaving the instruction in the active state. When the last occurrence is recorded the 'Procedure completed' action is recorded showing that this order is now in the completed state. In other situations, such as secondary care, there may be a formal order for a procedure using a corresponding INSTRUCTION archetype. This ACTION archetype can then be used to record the workflow of when and how the order has been carried out. Recording information using this ACTION archetype indicates that some sort of activity has actually occurred; this will usually be the procedure itself but may be a failed attempt or another activity such as postponing the procedure. If there is a formal order for the procedure, the state of this order is represented by the Pathway step against which the data is recorded. For example, using this archetype the progressing state of a Gastroscopy order may be recorded through separate entries in the EHR progress notes at each 'Pathway' step: - record the scheduled Start date/time for the gastroscopy (Procedure scheduled); and - record that the gastroscopy procedure has been completed, including information about the procedure details (Procedure completed). Please note that in the openEHR Reference Model there is a 'Time' attribute, which is intended to record the date and time at which each pathway step of the Action was performed. This is the attribute to use to record the start of the procedure (using the 'Procedure performed' pathway step) or the time that the procedure was aborted (using the 'Procedure aborted' pathway step)."> keywords = <"procedure", "intervention", "surgical", "medical", "clinical", "therapeutic", "diagnostic", "cure", "treatment", "evaluation", "investigation", "screening", "palliative", "therapy"> misuse = <"Not to be used to record details about the anaesthetic - use a separate ACTION archetype for this purpose. Not to be used to record details about imaging investigations - use ACTION.imaging_exam for this purpose. Not to be used to record details about laboratory investigations - use ACTION.laboratory_test for this purpose. Not to be used to record details about education delivered - use ACTION.health_education for this purpose. Not to be used to record details about administrative activities - use specific ADMIN archetypes for this purpose. Not to be used to record details about related activities such as the use of frozen sections taken during an operation, medication administered as part of the procedure or when imaging guidance is used during the procedure - use separate and specific ACTION archetypes within the same template for this purpose . Not to be used to record a whole operation or procedure report - use a template in which this archetype is only one component of the full report."> copyright = <"© openEHR Foundation"> > ["ar-sy"] = < language = <[ISO_639-1::ar-sy]> purpose = <"لتسجيل تفاصيل حول إجراء طبي تم بالفعل إجراؤه"> use = <"لتسجيل معلومات تفصيلية حول إجراء طبي تم تنفيذه على شخص ما. و ينبغي تسجيل المعلومات حول النشاطات المتعلقة بالنشاطات المتعلقة بالإجراء الطبي, مثل التخدير أو إعطاء الأدوية في نماذج (فعل) منفردة."> keywords = <"الإجراء الطبي", ...> misuse = <""> copyright = <"© openEHR Foundation"> > ["sl"] = < language = <[ISO_639-1::sl]> purpose = <"Za beleženje podrobnosti o izvedeni aktivnosti"> use = <"Za beleženje podrobnosto o izvedeni aktivnosti, ki zadeva posameznega pacienta/subjekt"> keywords = <"aktivnosti", "postopek"> misuse = <"Podrobnosti o aktivnostih povezani z opisano kativnostjo, kot npr. dajanje zdravil, se zabeleži v arhetipih tipa ACTION"> copyright = <"© openEHR Foundation"> > ["es"] = < language = <[ISO_639-1::es]> purpose = <"Registrar información sobre las actividades necesarias para llevar a cabo un procedimiento, incluida la planificación, programación, ejecución, suspensión, cancelación, documentación y finalización."> use = <"Se utiliza para registrar información sobre las actividades requeridas para llevar a cabo un procedimiento, incluyendo planificación, coordinación, ejecución, suspensión, cancelación, documentación y finalización. Esto se hace mediante el registro de los datos sobre actividades específicas, según la definición de los pasos de la vía clínica definida en el arquetipo. El alcance de este arquetipo abarca actividades para una amplia gama de procedimientos clínicos realizados con fines evaluativos, de investigación, cribado, diagnóstico, curativos, terapéuticos o paliativos. Los ejemplos van desde actividades relativamente sencillas, como la inserción de una cánula intravenosa, hasta operaciones quirúrgicas complejas. Se puede capturar información adicional estructurada y detallada sobre el procedimiento utilizando arquetipos específicos insertados en el slot \"Detalle del procedimiento\", cuando sea necesario. Los tiempos relacionados con un procedimiento pueden gestionarse de dos maneras: - Utilizando el modelo de referencia: el tiempo de realización de cualquier etapa del proceso utilizará el atributo de tiempo ACTION de cada etapa. - Elementos de datos arquetipados: --- el elemento de datos \"Fecha/hora prevista\" tiene por objeto registrar el momento preciso en que está previsto realizar el procedimiento. Nota: el atributo de hora ACTION correspondiente a la etapa Scheduled registrará la hora en la que el procedimiento se programó en un sistema, no la fecha/hora prevista en la que se pretende llevar a cabo el procedimiento; y --- la \"Fecha/hora de finalización\" tiene por objeto registrar la hora exacta en que finalizó el procedimiento. Puede utilizarse para documentar los procedimientos complejos con múltiples componentes. Nota: el atributo ACTION time correspondiente al \"Procedimiento realizado\" documentará la hora en que se inició cada componente realizado. Este elemento de datos \"Fecha/hora final\" registrará la fecha/hora del último componente activo del procedimiento. Esto permitirá calcular la duración completa del procedimiento activo. En el contexto de un Informe Quirúrgico, este arquetipo se utilizará para registrar únicamente lo que se hizo durante el procedimiento. Se utilizarán arquetipos separados para registrar los demás componentes necesarios del informe, incluida la toma de muestras de tejido, el uso de la guía por imagen, los resultados de la intervención, las instrucciones postoperatorias y los planes de seguimiento. En el contexto de una lista o resumen de problemas, este arquetipo puede utilizarse para representar los procedimientos que se han realizado. EVALUATION.problem_diagnosis se utilizará para representar los problemas y diagnósticos del paciente. En la práctica, muchos procedimientos (por ejemplo, en atención ambulatoria) tendrán lugar una sola vez y no se solicitarán con antelación. Los detalles sobre el procedimiento se añadirán en el apartado \"Procedimiento realizado\". En algunos casos se pedirá un procedimiento recurrente, y en esta situación los datos contra el apartado \"Procedimiento realizado\" se registrarán en cada ocasión, dejando la instrucción en estado activo. Cuando se registre la última incidencia, se registra la acción \"Procedimiento completado\", lo que indica que esta orden se encuentra ahora en estado completado. En otras situaciones, como la atención secundaria, puede existir una orden formal para un procedimiento utilizando el correspondiente arquetipo INSTRUCTION. Este arquetipo ACTION puede utilizarse para registrar el flujo de trabajo de cuándo y cómo se ha llevado a cabo la orden. El registro de información mediante este arquetipo ACTION indica que se ha producido algún tipo de actividad; normalmente será el procedimiento en sí, pero puede tratarse de un intento fallido u otra actividad, como el aplazamiento del procedimiento. Si existe una orden formal para el procedimiento, el estado de esta orden queda representado por la fase del proceso contra la que se registran los datos. Por ejemplo, utilizando este arquetipo, el estado de progreso de una orden de Gastroscopia puede registrarse mediante entradas separadas en las notas de progreso de la HCE en cada fase: - registrar la fecha/hora de inicio programada para la gastroscopia (Procedimiento programado); y - registrar que el procedimiento de gastroscopia se ha completado, incluyendo información sobre los detalles del procedimiento (Procedimiento completado). Tenga en cuenta que en el Modelo de Referencia openEHR existe un atributo \"Hora\", cuyo objetivo es registrar la fecha y hora en que se completó cada uno de los distintos apartados. Este es el atributo que debe utilizarse para registrar el inicio del procedimiento (utilizando el apartado \"Procedimiento realizado\") o el momento en que se interrumpió el procedimiento (utilizando el apartado \"Procedimiento interrumpido\")."> keywords = <"procedimiento", "intervención", "quirúrgico", "médico", "clínico", "terapéutico", "diagnóstico", "cura", "tratamiento", "evaluación", "investigación", "cribado", "paliativo", "terapia"> misuse = <"No debe utilizarse para registrar detalles acerca de la anestesia; para ello, utilizar un arquetipo ACTION distinto. No debe utilizarse para registrar detalles acerca de estudios por imagen; para ello, utilizar el arquetipo ACTION.imaging_exam. No debe utilizarse para registrar detalles acerca de estudios de laboratorio; para ello, utilizar el arquetipo ACTION.laboratory_test. No debe utilizarse para registrar datos acerca de la educación impartida; para ello, utilizar el arquetipo ACTION.health_education. No debe utilizarse para registrar detalles acerca de actividades administrativas; para ello, utilizar arquetipos ADMIN específicos. No debe utilizarse para registrar detalles acerca de actividades relacionadas, como el uso de secciones congeladas tomadas durante una operación, medicación administrada durante el procedimiento o al hacer uso de la guía por imagen durante el procedimiento; para ello, utilizar arquetipos ACTION por separado y específicos dentro de la misma plantilla. No debe utilizarse para registrar un informe de operación o procedimiento completo: utilizar una plantilla en la que este arquetipo sea sólo un componente del informe completo."> > ["ca"] = < language = <[ISO_639-1::ca]> purpose = <"Registrar informació sobre les activitats necessàries per dur a terme un procediment, inclosa la planificació, la programació, l'execució, la suspensió, la cancel·lació, la documentació i la finalització."> use = <"S'utilitza per registrar informació sobre les activitats requerides per dur a terme un procediment, incloent-hi planificació, coordinació, execució, suspensió, cancel·lació, documentació i finalització. Això es fa mitjançant el registre de les dades sobre activitats específiques, segons la definició de les diferents etapes/apartats definit a l'arquetip. L'abast d'aquest arquetip inclou activitats per a una àmplia gamma de procediments clínics realitzats amb fins avaluatius, de recerca, cribratge, diagnòstic, curatius, terapèutics o pal·liatius. Els exemples van des d'activitats relativament senzilles, com ara la inserció d'una cànula intravenosa, fins a operacions quirúrgiques complexes. Es pot capturar informació addicional estructurada i detallada sobre el procediment utilitzant arquetips específics inserits a l'slot \"Detall del procediment\", quan sigui necessari. Els temps relacionats amb un procediment es poden gestionar de dues maneres: - Utilitzant el model de referència: el temps de realització de qualsevol etapa del procés utilitzarà l‟atribut de temps ACTION de cada etapa. - Elements de dades arquetipades: --- l'element de dades \"Data/hora prevista\" té per objecte registrar el moment precís en què està previst fer el procediment. Nota: l'atribut d'hora ACTION corresponent a l'etapa Scheduled registrarà l'hora en què el procediment es va programar en un sistema, no la data/hora prevista en què es vol dur a terme el procediment; i --- la \"Data/hora de finalització\" té per objecte registrar l'hora exacta en què va finalitzar el procediment. Es pot utilitzar per documentar els procediments complexos amb múltiples components. Nota: l'atribut ACTION time corresponent al \"Procediment realitzat\" documentarà l'hora en què es va iniciar cada component realitzat. Aquest element de dades \"Data/hora final\" registrarà la data/hora del darrer component actiu del procediment. Això permetrà calcular la durada completa del procediment actiu. En el context d'un informe quirúrgic, aquest arquetip s'utilitzarà per registrar únicament allò que es va fer durant el procediment. S'utilitzaran arquetips separats per registrar els altres components requerits de l'informe quirúrgic, inclosa la presa de mostres de teixit, l'ús de guia per imatges, les troballes de l'operació, les instruccions postoperatòries i els plans de seguiment. Dins del context d'un llistat o resum de problemes, aquest arquetip es pot fer servir per representar procediments que s'han realitzat. L'AVALUATION.problem_diagnosis s'utilitzarà per representar els problemes i els diagnòstics del pacient. A la pràctica, molts procediments (per exemple, en atenció ambulatòria) es realitzaran una vegada i no se sol·licitaran amb anticipació. Els detalls sobre el procediment s'afegiran a la fase del procés \"Procediment completat\". En alguns casos, s'ordenarà un procediment recurrent i, en aquesta situació, es registraran les dades de la fase 'Procediment realitzat' cada vegada, deixant la instrucció en estat actiu. Quan es registra la darrera ocurrència, es registra l'acció \"Procediment completat\", cosa que mostra que aquesta ordre ara està en estat completat. En altres situacions, com a l'atenció secundària, hi pot haver una ordre formal per a un procediment utilitzant l'arquetip d'INSTRUCTION corresponent. Aquest arquetip de ACTION es pot utilitzar per registrar el flux de treball de quan i com es va dur a terme l'ordre. Registrar informació utilitzant aquest arquetip de ACTION indica que realment ha passat algun tipus d'activitat; En general, aquest serà el procediment en si, però pot ser un intent fallit o una altra activitat, com ara posposar el procediment. Si hi ha una ordre formal per al procediment, l‟estat d‟aquesta ordre està representat per la fase del procés contra la qual es registren les dades. Per exemple, en utilitzar aquest arquetip, l'estat de progrés d'una ordre de gastroscòpia es pot registrar a través d'entrades separades a les notes de progrés de l'HCE a cada fase del procés: - registrar la data/hora d'inici programada per a la gastroscòpia (procediment programat); i - Enregistrar que s'ha completat el procediment de gastroscòpia, inclosa informació sobre els detalls del procediment (Procediment completat). Cal tenir en compte que al model de referència d'openEHR hi ha un atribut de 'Temps', l'objectiu del qual és registrar la data i l'hora en què es va realitzar cada fase del procés de l'Acció. Aquest és l'atribut que s'utilitzarà per registrar l'inici del procediment (usant la fase 'Procediment realitzat') o el moment en què es va avortar el procediment (usant la fase 'Procediment avortat')."> keywords = <"procediment", "intervenció", "quirúrgic", "metge", "clínic", "terapèutic", "diagnòstic", "curar", "tractament", "avaluació", "investigació", "detecció", "pal·liatiu", "teràpia"> misuse = <"No s'ha de fer servir per registrar detalls sobre l'anestèsia; per fer-ho, utilitzar un arquetip ACTION diferent. No s'ha de fer servir per registrar detalls sobre estudis per imatge; per fer-ho, utilitzar l'arquetip ACTION.imaging_exam. No s'ha de fer servir per registrar detalls sobre estudis de laboratori; per fer-ho, utilitzar l'arquetip ACTION.laboratory_test. No s'ha de fer servir per registrar dades sobre l'educació impartida; per fer-ho, utilitzar l'arquetip ACTION.health_education. No s'ha de fer servir per registrar detalls sobre activitats administratives; per això, utilitzar arquetips ADMIN específics. No s'ha de fer servir per registrar detalls sobre activitats relacionades, com l'ús de seccions congelades preses durant una operació, medicació administrada durant el procediment o en fer ús de la guia per imatge durant el procediment; per això, utilitzar arquetips ACTION per separat i específics dins de la mateixa plantilla. No s'ha de fer servir per registrar un informe d'operació o procediment complet: utilitzar una plantilla on aquest arquetip sigui només un component de l'informe complet."> > > lifecycle_state = <"published"> other_contributors = <"Morten Aas, Diakonhjemmet Sykehus, Norway", "Tomas Alme, DIPS, Norway", "Anne Pauline Anderssen, Helse Nord RHF, Norway", "Vebjørn Arntzen, Oslo universitetssykehus HF, Norway (Nasjonal IKT redaktør)", "Koray Atalag, University of Auckland, New Zealand", "Silje Ljosland Bakke, Helse Vest IKT AS, Norway (Nasjonal IKT redaktør)", "Maria Beate Nupen, Oslo Universitetssykehus, Norway", "Lars Bitsch-Larsen, Haukeland University Hospital, Bergen, Norway", "Fredrik Borchsenius, Oslo universitetssykehus, Norway", "Diego Bosca, VeraTech for Health, Spain", "Hanne Marte Bårholm, Helse Vest IKT, Norway (Nasjonal IKT redaktør)", "Rong Chen, Cambio Healthcare Systems, Sweden", "Stephen Chu, NEHTA, Australia (Editor)", "Lisbeth Dahlhaug, Helse Midt - Norge IT, Norway", "Kari Beate Engseth, Finnmarkssykehuset HF + Klinikk Kirkenes, Norway", "David Evans, Queensland Health, Australia", "Shahla Foozonkhah, Iran ministry of health and education, Iran", "Einar Fosse, UNN HF, Norwegian Centre for Integrated Care and Telemedicine, Norway", "Sebastian Garde, Ocean Informatics, Germany", "Jacquie Garton-Smith, Royal Perth Hospital and DoHWA, Australia", "Bente Gjelsvik, Helse Bergen, Norway", "Andrew Goodchild, NEHTA, Australia", "Heather Grain, Llewelyn Grain Informatics, Australia", "Mikkel Johan Gaup Grønmo, Helse Nord IKT, Norway (Nasjonal IKT redaktør)", "Megan Hawkins, Mater Health Services, Australia", "Sam Heard, Ocean Informatics, Australia", "Kristian Heldal, Telemark Hospital Trust, Norway", "Andreas Hering, Helse Bergen HF, Haukeland universitetssjukehus, Norway", "Anca Heyd, DIPS ASA, Norway", "Hilde Hollås, DIPS ASA, Norway", "Lars Morgan Karlsen, Nordlandssykehuset Bodø, Norway", "Mary Kelaher, NEHTA, Australia", "Shinji Kobayashi, Kyoto University, Japan", "Kanika Kuwelker, Helse Vest IKT, Norway (Nasjonal IKT redaktør)", "Liv Laugen, Oslo universitetssykehus, Norway (Nasjonal IKT redaktør)", "Sabine Leh, Helse Bergen, Norway", "Heather Leslie, Atomica Informatics, Australia", "Hugh Leslie, Ocean Informatics, Australia", "Hallvard Lærum, Direktoratet for e-helse, Norway", "Mike Martyn, The Hobart Anaesthetic Group, Australia", "Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (openEHR Editor)", "Lars Ivar Mehlum, Nasjonal IKT HF, Norway", "Chris Mitchell, RACGP, Australia", "Stewart Morrison, NEHTA, Australia", "Maria Beate Nupen-Stieng, Oslo Universitetssykehus, Norway", "Bjørn Næss, DIPS ASA, Norway", "Andrej Orel, Marand d.o.o., Slovenia", "Michael Osborne, Mater Health Services, Australia", "Chris Pearce, Melbourne East GP Network, Australia", "Rune Pedersen, Universitetssykehuset i Nord Norge, Norway", "Norwegian Review Summary, Nasjonal IKT HF, Norway", "Jussara Rotzsch, Hospital Alemão Oswaldo Cruz, Brazil", "Peter Scott, Australia", "Elizabeth Stanick, Hobart Anaesthetic Group, Australia", "Line Sørensen, Helse Bergen, Norway", "John Taylor, NEHTA, Australia", "Micaela Thierley, Helse Vest IKT, Norway", "Rowan Thomas, St. Vincent's Hospital Melbourne, Australia", "Line Thomassen, Helse Bergen, Norway", "Richard Townley-O'Neill, NEHTA, Australia", "John Tore Valand, Helse Vest IKT, Norway (Nasjonal IKT redaktør)", "Marit Alice Venheim, Helse Vest IKT, Norway (Nasjonal IKT redaktør)", "Ørjan Vermeer, Haukeland Universitetssjukehus, Kvinneklinikken, Norway", "Ivar Yrke, DIPS AS, Norway"> other_details = < ["licence"] = <"This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/."> ["custodian_organisation"] = <"openEHR Foundation"> ["current_contact"] = <"Heather Leslie, Atomica Informatics, heather.leslie@atomicainformatics.com"> ["original_namespace"] = <"org.openehr"> ["original_publisher"] = <"openEHR Foundation"> ["custodian_namespace"] = <"org.openehr"> ["MD5-CAM-1.0.1"] = <"A83EF7B3123876997EA6F292C16A246D"> ["build_uid"] = <"00c961dd-1ef5-40b5-84fd-b18486797494"> ["revision"] = <"1.4.6"> > definition ACTION[at0000] matches { -- Procedure ism_transition matches { ISM_TRANSITION[at0004] matches { -- Procedure planned current_state matches { DV_CODED_TEXT matches { defining_code matches { [openehr::526] } } } careflow_step matches { DV_CODED_TEXT matches { defining_code matches { [local::at0004] -- Procedure planned } } } } ISM_TRANSITION[at0034] matches { -- X - Procedure planned current_state matches { DV_CODED_TEXT matches { defining_code matches { [openehr::524] } } } careflow_step matches { DV_CODED_TEXT matches { defining_code matches { [local::at0034] -- X - Procedure planned } } } } ISM_TRANSITION[at0007] matches { -- Procedure request sent current_state matches { DV_CODED_TEXT matches { defining_code matches { [openehr::526] } } } careflow_step matches { DV_CODED_TEXT matches { defining_code matches { [local::at0007] -- Procedure request sent } } } } ISM_TRANSITION[at0035] matches { -- X - Procedure request sent current_state matches { DV_CODED_TEXT matches { defining_code matches { [openehr::524] } } } careflow_step matches { DV_CODED_TEXT matches { defining_code matches { [local::at0035] -- X - Procedure request sent } } } } ISM_TRANSITION[at0038] matches { -- Procedure postponed current_state matches { DV_CODED_TEXT matches { defining_code matches { [openehr::527] } } } careflow_step matches { DV_CODED_TEXT matches { defining_code matches { [local::at0038] -- Procedure postponed } } } } ISM_TRANSITION[at0039] matches { -- Procedure cancelled current_state matches { DV_CODED_TEXT matches { defining_code matches { [openehr::528] } } } careflow_step matches { DV_CODED_TEXT matches { defining_code matches { [local::at0039] -- Procedure cancelled } } } } ISM_TRANSITION[at0036] matches { -- Procedure scheduled current_state matches { DV_CODED_TEXT matches { defining_code matches { [openehr::529] } } } careflow_step matches { DV_CODED_TEXT matches { defining_code matches { [local::at0036] -- Procedure scheduled } } } } ISM_TRANSITION[at0068] matches { -- Procedure commenced current_state matches { DV_CODED_TEXT matches { defining_code matches { [openehr::245] } } } careflow_step matches { DV_CODED_TEXT matches { defining_code matches { [local::at0068] -- Procedure commenced } } } } ISM_TRANSITION[at0047] matches { -- Procedure performed current_state matches { DV_CODED_TEXT matches { defining_code matches { [openehr::245] } } } careflow_step matches { DV_CODED_TEXT matches { defining_code matches { [local::at0047] -- Procedure performed } } } } ISM_TRANSITION[at0040] matches { -- Procedure suspended current_state matches { DV_CODED_TEXT matches { defining_code matches { [openehr::530] } } } careflow_step matches { DV_CODED_TEXT matches { defining_code matches { [local::at0040] -- Procedure suspended } } } } ISM_TRANSITION[at0041] matches { -- Procedure aborted current_state matches { DV_CODED_TEXT matches { defining_code matches { [openehr::531] } } } careflow_step matches { DV_CODED_TEXT matches { defining_code matches { [local::at0041] -- Procedure aborted } } } } ISM_TRANSITION[at0043] matches { -- Procedure completed current_state matches { DV_CODED_TEXT matches { defining_code matches { [openehr::532] } } } careflow_step matches { DV_CODED_TEXT matches { defining_code matches { [local::at0043] -- Procedure completed } } } } } description matches { ITEM_TREE[at0001] matches { -- Tree items cardinality matches {1..*; unordered} matches { ELEMENT[at0002] matches { -- Procedure name value matches { DV_TEXT matches {*} } } ELEMENT[at0049] occurrences matches {0..1} matches { -- Description value matches { DV_TEXT matches {*} } } ELEMENT[at0070] occurrences matches {0..*} matches { -- Indication value matches { DV_TEXT matches {*} } } ELEMENT[at0065] occurrences matches {0..*} matches { -- Method value matches { DV_TEXT matches {*} } } ELEMENT[at0058] occurrences matches {0..1} matches { -- Urgency value matches { DV_TEXT matches {*} } } ELEMENT[at0063] occurrences matches {0..*} matches { -- Body site value matches { DV_TEXT matches {*} } } allow_archetype CLUSTER[at0003] occurrences matches {0..*} matches { -- Procedure detail include archetype_id/value matches {/openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_circle(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.v2/} } ELEMENT[at0048] occurrences matches {0..*} matches { -- Outcome value matches { DV_TEXT matches {*} } } ELEMENT[at0069] occurrences matches {0..*} matches { -- Procedural difficulty value matches { DV_TEXT matches {*} } } ELEMENT[at0006] occurrences matches {0..*} matches { -- Complication value matches { DV_TEXT matches {*} } } ELEMENT[at0066] occurrences matches {0..1} matches { -- Scheduled date/time value matches { DV_DATE_TIME matches {*} } } ELEMENT[at0060] occurrences matches {0..1} matches { -- Final end date/time value matches { DV_DATE_TIME matches {*} } } ELEMENT[at0061] occurrences matches {0..1} matches { -- Total duration value matches { DV_DURATION matches { value matches {|>=PT0S|} } } } allow_archetype CLUSTER[at0062] occurrences matches {0..*} matches { -- Multimedia include archetype_id/value matches {/openEHR-EHR-CLUSTER\.media_file\.v1/} } ELEMENT[at0067] occurrences matches {0..1} matches { -- Procedure type value matches { DV_TEXT matches {*} } } ELEMENT[at0014] occurrences matches {0..*} matches { -- Reason value matches { DV_TEXT matches {*} } } ELEMENT[at0005] occurrences matches {0..1} matches { -- Comment value matches { DV_TEXT matches {*} } } } } } protocol matches { ITEM_TREE[at0053] matches { -- Tree items cardinality matches {0..*; unordered} matches { ELEMENT[at0054] occurrences matches {0..1} matches { -- Requestor order identifier value matches { DV_TEXT matches {*} DV_IDENTIFIER matches {*} } } allow_archetype CLUSTER[at0055] occurrences matches {0..1} matches { -- Requestor include archetype_id/value matches {/.*/} } ELEMENT[at0056] occurrences matches {0..1} matches { -- Receiver order identifier value matches { DV_TEXT matches {*} DV_IDENTIFIER matches {*} } } allow_archetype CLUSTER[at0057] occurrences matches {0..*} matches { -- Receiver include archetype_id/value matches {/.*/} } allow_archetype CLUSTER[at0064] occurrences matches {0..*} matches { -- Extension include archetype_id/value matches {/.*/} } } } } } ontology term_definitions = < ["pt-br"] = < items = < ["at0000"] = < text = <"Procedimento"> description = <"A atividade clínica realizada para rastreamento , investigação , diagnóstico , cura , terapêutica, avaliação ou finalidade paliativos."> > ["at0001"] = < text = <"Tree"> description = <"@ internal @"> > ["at0002"] = < text = <"Nome do procedimento"> description = <"Identificação do procedimento pelo nome."> comment = <"Código do procedimento específico com uma terminologia é preferível , quando possível."> > ["at0003"] = < text = <"Detalhes do Procedimento"> description = <"São as informações estruturadas sobre o procedimento."> comment = <"Use para capturar informações detalhadas , estruturadas sobre a localização anatômica , método e técnica , os equipamentos utilizados , dispositivos implantados , os resultados , as conclusões, etc."> > ["at0004"] = < text = <"*Procedure planned (en)"> description = <"*"> > ["at0005"] = < text = <"Comentários"> description = <"Comentários adicionais sobre a atividade ou etapas não informados em outros campos."> > ["at0006"] = < text = <"Complicações"> description = <"Detalhes sobre alguma complicação decorrente do procedimento"> comment = <"Utilize este elemento de dados para gravar termos simples ou complicações . Se as condições de gravação de complicação são mais complexas, é aconselhado usar de um arquétipo CLUSTER específico dentro do campo \"Detalhes do Procedimento\" neste arquétipo e este elemento de dados torna-se redundante."> > ["at0007"] = < text = <"*Procedure request sent (en)"> description = <"*"> > ["at0014"] = < text = <"Justificativa"> description = <"Razão pela qual a atividade ou cuidado foi identificada para que o procedimento fosse realizado."> comment = <"Por exemplo: o motivo do cancelamento ou suspensão de um procedimento."> > ["at0034"] = < text = <"Plano de procedimento"> description = <"O procedimento a ser realizado é planejado"> > ["at0035"] = < text = <"Procedimento pedido enviado"> description = <"Pedido de procedimento enviado."> > ["at0036"] = < text = <"Procedimento agendado"> description = <"O procedimento foi agendado."> > ["at0038"] = < text = <"Procedimento adiado"> description = <"O procedimento foi adiado."> > ["at0039"] = < text = <"Procedimento cancelado"> description = <"O procedimento planejado foi cancelado antes do início."> > ["at0040"] = < text = <"Procedimento suspenso"> description = <"O procedimento foi suspenso."> > ["at0041"] = < text = <"Procedimento abortado"> description = <"O procedimento foi abortado."> > ["at0043"] = < text = <"Procedimento concluído"> description = <"O procedimento foi realizado e todas as atividades clínicas associadas concluídas."> > ["at0047"] = < text = <"Procedimento realizado"> description = <"O procedimento, ou procedimento secundário no caso de procedimentos sequenciado, foi realizado."> > ["at0048"] = < text = <"Resultado"> description = <"Resultado do procedimento realizado."> comment = <"Utilização de terminologia para a codificação é desejável, quando possível."> > ["at0049"] = < text = <"Descrição"> description = <"Descrição narrativa sobre o procedimento, conforme apropriado para a etapa."> comment = <"Por exemplo : Descrição sobre o desempenho e os resultados do procedimento, a tentativa abortada ou a anulação do procedimento."> > ["at0053"] = < text = <"Tree(en)"> description = <"@ internal @"> > ["at0054"] = < text = <"Identificador do pedido do solicitante"> description = <"O ID local atribuído ao pedido realizado pelo profissional de saúde ou organização solicitando o serviço."> comment = <"Isto é equivalente ao \"Placer Order Number\" nas especificações do HL7 v2."> > ["at0055"] = < text = <"Solicitante"> description = <"Detalhes sobre o profissional ou organização de saúde que solicitou o serviço."> > ["at0056"] = < text = <"Identificador do pedido do destinatário"> description = <"O ID atribuído ao pedido pelo provedor de cuidados de saúde ou organização que recebe o pedido de serviço. Isto é também relacionado ao preenchimento da identificação do pedido."> comment = <"Isto é equivalente ao \"Placer Order Number\" nas especificações do HL7 v2."> > ["at0057"] = < text = <"Destinatário"> description = <"Detalhes sobre o profissional ou organização de saúde que recebeu o requerimento para o serviço."> > ["at0058"] = < text = <"Urgência"> description = <"Urgência do procedimento."> comment = <"Codificação do procedimento é preferível, quando possível."> > ["at0060"] = < text = <"Data final / hora"> description = <"A data e/ou hora , quando todo o processo , ou o último componente de um procedimento de múltiplas etapas , foi finalizada."> comment = <"Apenas para utilização em associação com o \"Procedimento realizado\" da etapa, e em situações em que o procedimento é repetido em várias ocasiões antes de ser concluído ou houver vários componentes para todo o processo. Este pode ser o mesmo que o atributo para o tempo de RM \"Processo concluído\"."> > ["at0061"] = < text = <"Duração Total"> description = <"A quantidade total de tempo necessária para concluir o procedimento, o que pode incluir o tempo gasto durante a fase ativa do procedimento mais o tempo durante o qual o procedimento foi suspenso."> comment = <"Apenas para utilização em associação com o \"Procedimento concluído\"."> > ["at0062"] = < text = <"Multimidia"> description = <"Representação multimídia de um procedimento realizado."> > ["at0063"] = < text = <"Localização no corpo"> description = <"Identificação do local no corpo onde será realizado o procedimento."> comment = <"Ocorrências para este elemento de dados são ilimitadas para permitir cenários clínicos, tais como a remoção de lesões da pele em múltiplos locais diferentes , mas em que todos os outros atributos são idênticos . Utilize este elemento de dados para gravar termos simples ou localizações anatômicas padrão. Se as condições de gravação da localização anatômica são determinados em tempo de execução pelo aplicativo ou exigir modelagem mais complexa, como localizações relativas , em seguida, usar o CLUSTER.anatomical_location ou CLUSTER.relative_location dentro do campo \"detalhes do procedimento\" neste arquétipo. Se a localização anatômica estiver incluída no \"Nome do procedimento\" através de códigos padronizados, este elemento de dados torna-se redundante."> > ["at0064"] = < text = <"Extensão"> description = <"Informações adicionais necessárias para capturar o conteúdo local ou para se alinhar com outros modelos / formalismos de referência"> comment = <"Por exemplo : requisitos de informação locais ou metadados adicionais para alinhar com FHIR ou equivalentes CIMI."> > ["at0065"] = < text = <"Método"> description = <"Identificação do método específico ou técnica do procedimento."> comment = <"Utilize este elemento de dados para registrar termos simples ou uma descrição narrativa . Se as condições de registro do método requer uma modelagem mais complexa , então isso pode ser representado por arquétipos adicionais dentro do campo \"Detalhes do procedimento\" deste arquétipo. Se o método está incluído no \"Nome do procedimento\" através de códigos padrão , este elemento de dados torna-se redundante."> > ["at0066"] = < text = <"Agendamento data/hora"> description = <"A data e /ou hora em que o processo está previsto para ocorrer."> comment = <"Apenas para utilização em associação com o \" Procedimento Programado ' para a etapa em curso."> > ["at0067"] = < text = <"Tipo do procedimento"> description = <"O tipo do procedimento."> comment = <"Esse elemento de dados pragmático pode ser usado para apoiar a organização dentro da interface do usuário."> > ["at0068"] = < text = <"Procedimento Iniciou"> description = <"O procedimento, ou procedimento secundário, no caso de procedimentos sequenciados, foi iniciado."> > ["at0069"] = < text = <"*Procedural difficulty(en)"> description = <"*Difficulties or issues encountered during the procedure.(en)"> > ["at0070"] = < text = <"*Indication (en)"> description = <"*The clinical or process-related reason for the procedure. (en)"> comment = <"*Coding of the indication with a terminology is preferred, where possible. This data element allows multiple occurrences. For example: 'Failed bowel preparation' or 'Bowel cancer screening'. (en)"> > > > ["sl"] = < items = < ["at0000"] = < text = <"*Procedure(en)"> description = <"*A clinical activity carried out for screening, investigative, diagnostic, curative, therapeutic, evaluative or palliative purposes.(en)"> > ["at0001"] = < text = <"*Tree(en)"> description = <"*@ internal @(en)"> > ["at0002"] = < text = <"*Procedure name(en)"> description = <"*Identification of the procedure by name.(en)"> comment = <"*Coding of the specific procedure with a terminology is preferred, where possible.(en)"> > ["at0003"] = < text = <"*Procedure detail(en)"> description = <"*Structured information about the procedure. Use to capture detailed, structured information about anatomical location, method & technique, equipment used, devices implanted, results, findings etc.(en)"> > ["at0004"] = < text = <"*Procedure planned (en)"> description = <"*"> > ["at0005"] = < text = <"*Comment(en)"> description = <"*Additional narrative about the activity or care pathway step not captured in other fields.(en)"> > ["at0006"] = < text = <"*Complication(en)"> description = <"*Details about any complication arising from the procedure.(en)"> comment = <"*Use this data element to record simple terms or precoordinated complications. If the requirements for recording complication are more complex then use of a specific CLUSTER archetype within the 'Procedure detail' SLOT in this archetype is advised and this data element becomes redundant. (en)"> > ["at0007"] = < text = <"*Procedure request sent (en)"> description = <"*"> > ["at0014"] = < text = <"*Reason(en)"> description = <"*Reason that the activity or care pathway step for the identified procedure was carried out.(en)"> comment = <"*For example: the reason for the cancellation or suspension of the procedure.(en)"> > ["at0034"] = < text = <"*Procedure planned(en)"> description = <"*The procedure to be undertaken is planned.(en)"> > ["at0035"] = < text = <"*Procedure request sent(en)"> description = <"*Request for procedure sent.(en)"> > ["at0036"] = < text = <"*Procedure scheduled(en)"> description = <"*The procedure has been scheduled.(en)"> > ["at0038"] = < text = <"*Procedure postponed(en)"> description = <"*The procedure has been postponed.(en)"> > ["at0039"] = < text = <"*Procedure cancelled(en)"> description = <"*The planned procedure has been cancelled prior to commencement.(en)"> > ["at0040"] = < text = <"*Procedure suspended(en)"> description = <"*The procedure has been suspended.(en)"> > ["at0041"] = < text = <"*Procedure aborted(en)"> description = <"*The procedure has been aborted.(en)"> > ["at0043"] = < text = <"*Procedure completed(en)"> description = <"*The procedure has been performed and all associated clinical activities completed.(en)"> > ["at0047"] = < text = <"*Procedure performed(en)"> description = <"*The procedure, or subprocedure in a multicomponent procedure, has been performed.(en)"> > ["at0048"] = < text = <"*Outcome(en)"> description = <"*Outcome of procedure performed.(en)"> comment = <"*Coding with a terminology is preferred, where possible.(en)"> > ["at0049"] = < text = <"*Description(en)"> description = <"*Narrative description about the procedure, as appropriate for the pathway step.(en)"> comment = <"*For example: description about the performance and findings from the the procedure, the aborted attempt or the cancellation of the procedure.(en)"> > ["at0053"] = < text = <"*Tree(en)"> description = <"*@ internal @(en)"> > ["at0054"] = < text = <"*Requestor order identifier(en)"> description = <"*The local ID assigned to the order by the healthcare provider or organisation requesting the service.(en)"> comment = <"*This is equivalent to Placer Order Number in HL7 v2 specifications.(en)"> > ["at0055"] = < text = <"Naročnik"> description = <"Kdo je naročil aktivnost, posameznik ali organizacija"> > ["at0056"] = < text = <"*Receiver order identifier(en)"> description = <"*The ID assigned to the order by the healthcare provider or organisation receiving the request for service. This is also referred to as Filler Order Identifier.(en)"> comment = <"*This is equivalent to Filler Order Number in HL7 v2 specifications.(en)"> > ["at0057"] = < text = <"Prejemnik"> description = <"Prejemnik naročila za izvedbo aktivnosti"> > ["at0058"] = < text = <"*Urgency(en)"> description = <"*Urgency of the procedure.(en)"> comment = <"*Coding with a terminology is preferred, where possible.(en)"> > ["at0060"] = < text = <"*Final end date/time(en)"> description = <"*The date and/or time when the entire procedure, or the last component of a multicomponent procedure, was finished.(en)"> comment = <"*Only for use in association with the 'Procedure performed' pathway step, and in situations where the procedure is repeated on multiple occasions before being completed or there are multiple components to the whole procedure. This may be the same as the RM time attribute for the 'Procedure completed' pathway step.(en)"> > ["at0061"] = < text = <"*Total duration(en)"> description = <"*The total amount of time taken to complete the procedure, which may include time spent during the active phase of the procedure plus time during which the procedure was suspended.(en)"> comment = <"*Only for use in association with the 'Procedure completed' pathway steps.(en)"> > ["at0062"] = < text = <"*Multimedia(en)"> description = <"*Mulitimedia representation of a performed procedure.(en)"> > ["at0063"] = < text = <"*Body site(en)"> description = <"*Identification of the body site for the procedure.(en)"> comment = <"*Occurrences for this data element are unbounded to allow for clinical scenarios such as removing multiple skin lesions in different places, but where all of the other attributes are identical. Use this data element to record simple terms or 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 'Procedure detail' SLOT in this archetype. If the anatomical location is included in the 'Procedure name' via precoordinated codes, this data element becomes redundant.(en)"> > ["at0064"] = < text = <"*Extension(en)"> description = <"*Additional information required to capture local content or to align with other reference models/formalisms.(en)"> comment = <"*For example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.(en)"> > ["at0065"] = < text = <"*Method(en)"> description = <"*Identification of specific method or technique for the procedure.(en)"> comment = <"*Use this data element to record simple terms or a narrative description. If the requirements for recording the method require more complex modelling then this can be represented by additional archetypes within the 'Procedure detail' SLOT in this archetype. If the method is included in the 'Procedure name' via precoordinated codes, this data element becomes redundant.(en)"> > ["at0066"] = < text = <"*Scheduled date/time(en)"> description = <"*The date and/or time on which the procedure is intended to be performed.(en)"> comment = <"*Only for use in association with the 'Procedure scheduled' pathway step.(en)"> > ["at0067"] = < text = <"*Procedure type(en)"> description = <"*The type of procedure.(en)"> comment = <"*This pragmatic data element may be used to support organisation within the user interface.(en)"> > ["at0068"] = < text = <"*Procedure commenced(en)"> description = <"*The procedure, or subprocedure in a multicomponent procedure, has been commenced.(en)"> > ["at0069"] = < text = <"*Procedural difficulty(en)"> description = <"*Difficulties or issues encountered during the procedure.(en)"> > ["at0070"] = < text = <"*Indication (en)"> description = <"*The clinical or process-related reason for the procedure. (en)"> comment = <"*Coding of the indication with a terminology is preferred, where possible. This data element allows multiple occurrences. For example: 'Failed bowel preparation' or 'Bowel cancer screening'. (en)"> > > > ["en"] = < items = < ["at0000"] = < text = <"Procedure"> description = <"A clinical activity carried out for screening, investigative, diagnostic, curative, therapeutic, evaluative or palliative purposes."> > ["at0001"] = < text = <"Tree"> description = <"@ internal @"> > ["at0002"] = < text = <"Procedure name"> description = <"Identification of the procedure by name."> comment = <"Coding of the specific procedure with a terminology is preferred, where possible."> > ["at0003"] = < text = <"Procedure detail"> description = <"Structured information about the procedure."> comment = <"Use to capture detailed, structured information about anatomical location, method & technique, equipment used, devices implanted, results, findings etc."> > ["at0004"] = < text = <"Procedure planned"> description = <"The procedure to be undertaken is planned."> > ["at0005"] = < text = <"Comment"> description = <"Additional narrative about the activity or care pathway step not captured in other fields."> > ["at0006"] = < text = <"Complication"> description = <"Details about any complication arising from the procedure."> comment = <"Use this data element to record simple terms or precoordinated complications. If the requirements for recording complication are more complex then use of a specific CLUSTER archetype within the 'Procedure detail' SLOT in this archetype is advised and this data element becomes redundant. Examples: Hematuria after a kidney biopsy, tissue irritation after insertion of intravenous catheter."> > ["at0007"] = < text = <"Procedure request sent"> description = <"Request for procedure sent."> > ["at0014"] = < text = <"Reason"> description = <"Reason that the activity or care pathway step for the identified procedure was carried out."> comment = <"For example: the reason for the cancellation or suspension of the procedure."> > ["at0034"] = < text = <"X - Procedure planned"> description = <"This pathway step has been deprecated as it was incorrectly associated with 'initial' status - use the new 'Procedure planned' (at0004) pathway step which is correctly associated with 'planned' status."> comment = <"(Was: The procedure to be undertaken is planned.)"> > ["at0035"] = < text = <"X - Procedure request sent"> description = <"This pathway step has been deprecated as it was incorrectly associated with 'initial' status - use the new 'Procedure request sent' (at0007) pathway step which is correctly associated with 'planned' status."> comment = <"(Was: Request for procedure sent.)"> > ["at0036"] = < text = <"Procedure scheduled"> description = <"The procedure has been scheduled."> > ["at0038"] = < text = <"Procedure postponed"> description = <"The procedure has been postponed."> > ["at0039"] = < text = <"Procedure cancelled"> description = <"The planned procedure has been cancelled prior to commencement."> > ["at0040"] = < text = <"Procedure suspended"> description = <"The procedure has been suspended."> > ["at0041"] = < text = <"Procedure aborted"> description = <"The procedure has been aborted."> > ["at0043"] = < text = <"Procedure completed"> description = <"The procedure has been performed and all associated clinical activities completed."> > ["at0047"] = < text = <"Procedure performed"> description = <"The procedure, or subprocedure in a multicomponent procedure, has been performed."> > ["at0048"] = < text = <"Outcome"> description = <"Outcome of procedure performed."> comment = <"Coding with a terminology is preferred, where possible."> > ["at0049"] = < text = <"Description"> description = <"Narrative description about the procedure, as appropriate for the pathway step."> comment = <"For example: description about the performance and findings from the the procedure, the aborted attempt or the cancellation of the procedure."> > ["at0053"] = < text = <"Tree"> description = <"@ internal @"> > ["at0054"] = < text = <"Requestor order identifier"> description = <"The local ID assigned to the order by the healthcare provider or organisation requesting the service."> comment = <"This is equivalent to Placer Order Number in HL7 v2 specifications."> > ["at0055"] = < text = <"Requestor"> description = <"Details about the healthcare provider or organisation requesting the service."> > ["at0056"] = < text = <"Receiver order identifier"> description = <"The ID assigned to the order by the healthcare provider or organisation receiving the request for service. This is also referred to as Filler Order Identifier."> comment = <"This is equivalent to Filler Order Number in HL7 v2 specifications."> > ["at0057"] = < text = <"Receiver"> description = <"Details about the healthcare provider or organisation receiving the request for service."> > ["at0058"] = < text = <"Urgency"> description = <"Urgency of the procedure."> comment = <"Coding with a terminology is preferred, where possible."> > ["at0060"] = < text = <"Final end date/time"> description = <"The date and/or time when the entire procedure, or the last component of a multicomponent procedure, was finished."> comment = <"Only for use in association with the 'Procedure performed' pathway step, and in situations where the procedure is repeated on multiple occasions before being completed or there are multiple components to the whole procedure. This may be the same as the RM time attribute for the 'Procedure completed' pathway step."> > ["at0061"] = < text = <"Total duration"> description = <"The total amount of time taken to complete the procedure, which may include time spent during the active phase of the procedure plus time during which the procedure was suspended."> comment = <"Only for use in association with the 'Procedure completed' pathway steps."> > ["at0062"] = < text = <"Multimedia"> description = <"Mulitimedia representation of a performed procedure."> > ["at0063"] = < text = <"Body site"> description = <"Identification of the body site for the procedure."> comment = <"Occurrences for this data element are unbounded to allow for clinical scenarios such as removing multiple skin lesions in different places, but where all of the other attributes are identical. Use this data element to record simple terms or 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 'Procedure detail' SLOT in this archetype. If the anatomical location is included in the 'Procedure name' via precoordinated codes, this data element becomes redundant."> > ["at0064"] = < text = <"Extension"> description = <"Additional information required to capture local content or to align with other reference models/formalisms."> comment = <"For example: local information requirements or additional metadata to align with FHIR or CIMI equivalents."> > ["at0065"] = < text = <"Method"> description = <"Identification of specific method or technique for the procedure."> comment = <"Use this data element to record simple terms or a narrative description. If the requirements for recording the method require more complex modelling then this can be represented by additional archetypes within the 'Procedure detail' SLOT in this archetype. If the method is included in the 'Procedure name' via precoordinated codes, this data element becomes redundant."> > ["at0066"] = < text = <"Scheduled date/time"> description = <"The date and/or time on which the procedure is intended to be performed."> comment = <"Only for use in association with the 'Procedure scheduled' pathway step."> > ["at0067"] = < text = <"Procedure type"> description = <"The type of procedure."> comment = <"This pragmatic data element may be used to support organisation within the user interface."> > ["at0068"] = < text = <"Procedure commenced"> description = <"The procedure, or subprocedure in a multicomponent procedure, has been commenced."> > ["at0069"] = < text = <"Procedural difficulty"> description = <"Difficulties or issues encountered during performance of the procedure."> comment = <"Examples: The patient was agitated, insufficient emptying of the stomach before gastroscopy, a tumour in the bile ducts made it impossible to pass the scope through."> > ["at0070"] = < text = <"Indication"> description = <"The clinical or process-related reason for the procedure."> comment = <"Coding of the indication with a terminology is preferred, where possible. This data element allows multiple occurrences. For example: 'Failed bowel preparation' or 'Bowel cancer screening'."> > > > ["ar-sy"] = < items = < ["at0000"] = < text = <"*Procedure(en)"> description = <"*A clinical activity carried out for screening, investigative, diagnostic, curative, therapeutic, evaluative or palliative purposes.(en)"> > ["at0001"] = < text = <"Tree"> description = <"@ internal @"> > ["at0002"] = < text = <"*Procedure name(en)"> description = <"*Identification of the procedure by name.(en)"> comment = <"*Coding of the specific procedure with a terminology is preferred, where possible.(en)"> > ["at0003"] = < text = <"*Procedure detail(en)"> description = <"*Structured information about the procedure. Use to capture detailed, structured information about anatomical location, method & technique, equipment used, devices implanted, results, findings etc.(en)"> > ["at0004"] = < text = <"*Procedure planned (en)"> description = <"*"> > ["at0005"] = < text = <"*Comment(en)"> description = <"*Additional narrative about the activity or care pathway step not captured in other fields.(en)"> > ["at0006"] = < text = <"*Complication(en)"> description = <"*Details about any complication arising from the procedure.(en)"> comment = <"*Use this data element to record simple terms or precoordinated complications. If the requirements for recording complication are more complex then use of a specific CLUSTER archetype within the 'Procedure detail' SLOT in this archetype is advised and this data element becomes redundant. (en)"> > ["at0007"] = < text = <"*Procedure request sent (en)"> description = <"*"> > ["at0014"] = < text = <"*Reason(en)"> description = <"*Reason that the activity or care pathway step for the identified procedure was carried out.(en)"> comment = <"*For example: the reason for the cancellation or suspension of the procedure.(en)"> > ["at0034"] = < text = <"*Procedure planned(en)"> description = <"*The procedure to be undertaken is planned.(en)"> > ["at0035"] = < text = <"*Procedure request sent(en)"> description = <"*Request for procedure sent.(en)"> > ["at0036"] = < text = <"*Procedure scheduled(en)"> description = <"*The procedure has been scheduled.(en)"> > ["at0038"] = < text = <"*Procedure postponed(en)"> description = <"*The procedure has been postponed.(en)"> > ["at0039"] = < text = <"*Procedure cancelled(en)"> description = <"*The planned procedure has been cancelled prior to commencement.(en)"> > ["at0040"] = < text = <"*Procedure suspended(en)"> description = <"*The procedure has been suspended.(en)"> > ["at0041"] = < text = <"*Procedure aborted(en)"> description = <"*The procedure has been aborted.(en)"> > ["at0043"] = < text = <"*Procedure completed(en)"> description = <"*The procedure has been performed and all associated clinical activities completed.(en)"> > ["at0047"] = < text = <"*Procedure performed(en)"> description = <"*The procedure, or subprocedure in a multicomponent procedure, has been performed.(en)"> > ["at0048"] = < text = <"*Outcome(en)"> description = <"*Outcome of procedure performed.(en)"> comment = <"*Coding with a terminology is preferred, where possible.(en)"> > ["at0049"] = < text = <"*Description(en)"> description = <"*Narrative description about the procedure, as appropriate for the pathway step.(en)"> comment = <"*For example: description about the performance and findings from the the procedure, the aborted attempt or the cancellation of the procedure.(en)"> > ["at0053"] = < text = <"Tree"> description = <"@ internal @"> > ["at0054"] = < text = <"*Requestor order identifier(en)"> description = <"*The local ID assigned to the order by the healthcare provider or organisation requesting the service.(en)"> comment = <"*This is equivalent to Placer Order Number in HL7 v2 specifications.(en)"> > ["at0055"] = < text = <"الطالب"> description = <"تفاصيل حول مقدم الخدمة الصحية أو المؤسسة التي تطلب الخدمة"> > ["at0056"] = < text = <"*Receiver order identifier(en)"> description = <"*The ID assigned to the order by the healthcare provider or organisation receiving the request for service. This is also referred to as Filler Order Identifier.(en)"> comment = <"*This is equivalent to Filler Order Number in HL7 v2 specifications.(en)"> > ["at0057"] = < text = <"المستقبِل"> description = <"تفاصيل حول مقدم الخدمة الصحية أو المؤسسة التي تستقبل طلب الخدمة."> > ["at0058"] = < text = <"*Urgency(en)"> description = <"*Urgency of the procedure.(en)"> comment = <"*Coding with a terminology is preferred, where possible.(en)"> > ["at0060"] = < text = <"*Final end date/time(en)"> description = <"*The date and/or time when the entire procedure, or the last component of a multicomponent procedure, was finished.(en)"> comment = <"*Only for use in association with the 'Procedure performed' pathway step, and in situations where the procedure is repeated on multiple occasions before being completed or there are multiple components to the whole procedure. This may be the same as the RM time attribute for the 'Procedure completed' pathway step.(en)"> > ["at0061"] = < text = <"*Total duration(en)"> description = <"*The total amount of time taken to complete the procedure, which may include time spent during the active phase of the procedure plus time during which the procedure was suspended.(en)"> comment = <"*Only for use in association with the 'Procedure completed' pathway steps.(en)"> > ["at0062"] = < text = <"*Multimedia(en)"> description = <"*Mulitimedia representation of a performed procedure.(en)"> > ["at0063"] = < text = <"*Body site(en)"> description = <"*Identification of the body site for the procedure.(en)"> comment = <"*Occurrences for this data element are unbounded to allow for clinical scenarios such as removing multiple skin lesions in different places, but where all of the other attributes are identical. Use this data element to record simple terms or 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 'Procedure detail' SLOT in this archetype. If the anatomical location is included in the 'Procedure name' via precoordinated codes, this data element becomes redundant.(en)"> > ["at0064"] = < text = <"*Extension(en)"> description = <"*Additional information required to capture local content or to align with other reference models/formalisms.(en)"> comment = <"*For example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.(en)"> > ["at0065"] = < text = <"*Method(en)"> description = <"*Identification of specific method or technique for the procedure.(en)"> comment = <"*Use this data element to record simple terms or a narrative description. If the requirements for recording the method require more complex modelling then this can be represented by additional archetypes within the 'Procedure detail' SLOT in this archetype. If the method is included in the 'Procedure name' via precoordinated codes, this data element becomes redundant.(en)"> > ["at0066"] = < text = <"*Scheduled date/time(en)"> description = <"*The date and/or time on which the procedure is intended to be performed.(en)"> comment = <"*Only for use in association with the 'Procedure scheduled' pathway step.(en)"> > ["at0067"] = < text = <"*Procedure type(en)"> description = <"*The type of procedure.(en)"> comment = <"*This pragmatic data element may be used to support organisation within the user interface.(en)"> > ["at0068"] = < text = <"*Procedure commenced(en)"> description = <"*The procedure, or subprocedure in a multicomponent procedure, has been commenced.(en)"> > ["at0069"] = < text = <"*Procedural difficulty(en)"> description = <"*Difficulties or issues encountered during the procedure.(en)"> > ["at0070"] = < text = <"*Indication (en)"> description = <"*The clinical or process-related reason for the procedure. (en)"> comment = <"*Coding of the indication with a terminology is preferred, where possible. This data element allows multiple occurrences. For example: 'Failed bowel preparation' or 'Bowel cancer screening'. (en)"> > > > ["ru"] = < items = < ["at0000"] = < text = <"*Procedure(en)"> description = <"*A clinical activity carried out for screening, investigative, diagnostic, curative, therapeutic, evaluative or palliative purposes.(en)"> > ["at0001"] = < text = <"*Tree(en)"> description = <"*@ internal @(en)"> > ["at0002"] = < text = <"*Procedure name(en)"> description = <"*Identification of the procedure by name.(en)"> comment = <"*Coding of the specific procedure with a terminology is preferred, where possible.(en)"> > ["at0003"] = < text = <"*Procedure detail(en)"> description = <"*Structured information about the procedure. Use to capture detailed, structured information about anatomical location, method & technique, equipment used, devices implanted, results, findings etc.(en)"> > ["at0004"] = < text = <"*Procedure planned (en)"> description = <"*"> > ["at0005"] = < text = <"*Comment(en)"> description = <"*Additional narrative about the activity or care pathway step not captured in other fields.(en)"> > ["at0006"] = < text = <"*Complication(en)"> description = <"*Details about any complication arising from the procedure.(en)"> comment = <"*Use this data element to record simple terms or precoordinated complications. If the requirements for recording complication are more complex then use of a specific CLUSTER archetype within the 'Procedure detail' SLOT in this archetype is advised and this data element becomes redundant. (en)"> > ["at0007"] = < text = <"*Procedure request sent (en)"> description = <"*"> > ["at0014"] = < text = <"*Reason(en)"> description = <"*Reason that the activity or care pathway step for the identified procedure was carried out.(en)"> comment = <"*For example: the reason for the cancellation or suspension of the procedure.(en)"> > ["at0034"] = < text = <"*Procedure planned(en)"> description = <"*The procedure to be undertaken is planned.(en)"> > ["at0035"] = < text = <"*Procedure request sent(en)"> description = <"*Request for procedure sent.(en)"> > ["at0036"] = < text = <"*Procedure scheduled(en)"> description = <"*The procedure has been scheduled.(en)"> > ["at0038"] = < text = <"*Procedure postponed(en)"> description = <"*The procedure has been postponed.(en)"> > ["at0039"] = < text = <"*Procedure cancelled(en)"> description = <"*The planned procedure has been cancelled prior to commencement.(en)"> > ["at0040"] = < text = <"*Procedure suspended(en)"> description = <"*The procedure has been suspended.(en)"> > ["at0041"] = < text = <"*Procedure aborted(en)"> description = <"*The procedure has been aborted.(en)"> > ["at0043"] = < text = <"*Procedure completed(en)"> description = <"*The procedure has been performed and all associated clinical activities completed.(en)"> > ["at0047"] = < text = <"*Procedure performed(en)"> description = <"*The procedure, or subprocedure in a multicomponent procedure, has been performed.(en)"> > ["at0048"] = < text = <"*Outcome(en)"> description = <"*Outcome of procedure performed.(en)"> comment = <"*Coding with a terminology is preferred, where possible.(en)"> > ["at0049"] = < text = <"*Description(en)"> description = <"*Narrative description about the procedure, as appropriate for the pathway step.(en)"> comment = <"*For example: description about the performance and findings from the the procedure, the aborted attempt or the cancellation of the procedure.(en)"> > ["at0053"] = < text = <"*Tree(en)"> description = <"*@ internal @(en)"> > ["at0054"] = < text = <"*Requestor order identifier(en)"> description = <"*The local ID assigned to the order by the healthcare provider or organisation requesting the service.(en)"> comment = <"*This is equivalent to Placer Order Number in HL7 v2 specifications.(en)"> > ["at0055"] = < text = <"Заказчик"> description = <"Подробности о заказчике (организации), запросившей услугу"> > ["at0056"] = < text = <"*Receiver order identifier(en)"> description = <"*The ID assigned to the order by the healthcare provider or organisation receiving the request for service. This is also referred to as Filler Order Identifier.(en)"> comment = <"*This is equivalent to Filler Order Number in HL7 v2 specifications.(en)"> > ["at0057"] = < text = <"Исполнитель"> description = <"Подробные сведение об организации, получившей заявку на выполнение процедуры"> > ["at0058"] = < text = <"*Urgency(en)"> description = <"*Urgency of the procedure.(en)"> comment = <"*Coding with a terminology is preferred, where possible.(en)"> > ["at0060"] = < text = <"*Final end date/time(en)"> description = <"*The date and/or time when the entire procedure, or the last component of a multicomponent procedure, was finished.(en)"> comment = <"*Only for use in association with the 'Procedure performed' pathway step, and in situations where the procedure is repeated on multiple occasions before being completed or there are multiple components to the whole procedure. This may be the same as the RM time attribute for the 'Procedure completed' pathway step.(en)"> > ["at0061"] = < text = <"*Total duration(en)"> description = <"*The total amount of time taken to complete the procedure, which may include time spent during the active phase of the procedure plus time during which the procedure was suspended.(en)"> comment = <"*Only for use in association with the 'Procedure completed' pathway steps.(en)"> > ["at0062"] = < text = <"*Multimedia(en)"> description = <"*Mulitimedia representation of a performed procedure.(en)"> > ["at0063"] = < text = <"*Body site(en)"> description = <"*Identification of the body site for the procedure.(en)"> comment = <"*Occurrences for this data element are unbounded to allow for clinical scenarios such as removing multiple skin lesions in different places, but where all of the other attributes are identical. Use this data element to record simple terms or 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 'Procedure detail' SLOT in this archetype. If the anatomical location is included in the 'Procedure name' via precoordinated codes, this data element becomes redundant.(en)"> > ["at0064"] = < text = <"*Extension(en)"> description = <"*Additional information required to capture local content or to align with other reference models/formalisms.(en)"> comment = <"*For example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.(en)"> > ["at0065"] = < text = <"*Method(en)"> description = <"*Identification of specific method or technique for the procedure.(en)"> comment = <"*Use this data element to record simple terms or a narrative description. If the requirements for recording the method require more complex modelling then this can be represented by additional archetypes within the 'Procedure detail' SLOT in this archetype. If the method is included in the 'Procedure name' via precoordinated codes, this data element becomes redundant.(en)"> > ["at0066"] = < text = <"*Scheduled date/time(en)"> description = <"*The date and/or time on which the procedure is intended to be performed.(en)"> comment = <"*Only for use in association with the 'Procedure scheduled' pathway step.(en)"> > ["at0067"] = < text = <"*Procedure type(en)"> description = <"*The type of procedure.(en)"> comment = <"*This pragmatic data element may be used to support organisation within the user interface.(en)"> > ["at0068"] = < text = <"*Procedure commenced(en)"> description = <"*The procedure, or subprocedure in a multicomponent procedure, has been commenced.(en)"> > ["at0069"] = < text = <"*Procedural difficulty(en)"> description = <"*Difficulties or issues encountered during the procedure.(en)"> > ["at0070"] = < text = <"*Indication (en)"> description = <"*The clinical or process-related reason for the procedure. (en)"> comment = <"*Coding of the indication with a terminology is preferred, where possible. This data element allows multiple occurrences. For example: 'Failed bowel preparation' or 'Bowel cancer screening'. (en)"> > > > ["nb"] = < items = < ["at0000"] = < text = <"Prosedyre"> description = <"En klinisk aktivitet som er utført i undersøkende, diagnostisk, kurativ, terapeutisk, evaluerende, prognostisk eller palliativ hensikt."> > ["at0001"] = < text = <"Tree"> description = <"@ internal @"> > ["at0002"] = < text = <"Prosedyrenavn"> description = <"Navnet på prosedyren."> comment = <"Det bør om mulig benyttes terminologi for å angi prosedyrenavnet."> > ["at0003"] = < text = <"Prosedyredetaljer"> description = <"Strukturert informasjon om prosedyren."> comment = <"Bruk for å registrere detaljert, strukturert informasjon om anatomisk lokalisering, metode og teknikker, utstyr som ble benyttet, medisinsk utstyr som ble implantert, funn, etc."> > ["at0004"] = < text = <"Prosedyre planlagt"> description = <"Prosedyren er planlagt."> > ["at0005"] = < text = <"Kommentar"> description = <"Ytterligere fritekstbeskrivelse av aktivitet eller prosesstrinn som ikke er registrert i andre felt."> > ["at0006"] = < text = <"Komplikasjon"> description = <"Detaljer om komplikasjoner oppstått under gjennomføring av prosedyren."> comment = <"Bruk dette dataelementet til å registrere enkle termer eller prekoordinerte komplikasjoner. Dersom registreringskravene for komplikasjoner er mer komplekse er det anbefalt å bruke en spesifikk CLUSTER-arketype i SLOTet \"Prosedyredetaljer\" i denne arketypen, og i disse tilfellene blir dette dataelementet overflødig. Eksempler: Hematuri etter nyrebiopsi, vevsirritasjon etter innleggelse av venekateter."> > ["at0007"] = < text = <"Prosedyrerekvisisjon sendt"> description = <"Det er sendt rekvisisjon for prosedyren."> > ["at0014"] = < text = <"Begrunnelse"> description = <"Begrunnelse for at aktiviteten eller prosesstrinnet for den aktuelle prosedyren ble utført."> comment = <"For eksempel grunnen til at prosedyren ble avlyst eller midlertidig stanset."> > ["at0034"] = < text = <"X - Prosedyre planlagt"> description = <"Dette prosesstrinnet er satt ut av bruk, siden det ved en feil hadde statusen \"initial\". Bruk det nye prosesstrinnet \"Prosedyre planlagt\" (at0004) som har den korrekte statusen \"planned\"."> comment = <"(Var: Prosedyren er planlagt.)"> > ["at0035"] = < text = <"X - Prosedyrerekvisisjon sendt"> description = <"Dette prosesstrinnet er satt ut av bruk, siden det ved en feil hadde statusen \"initial\". Bruk det nye prosesstrinnet \"Prosedyre planlagt\" (at0007) som har den korrekte statusen \"planned\"."> comment = <"(Var: Det er sendt rekvisisjon for prosedyren.)"> > ["at0036"] = < text = <"Fastsatt tidspunkt for prosedyre"> description = <"Tidspunkt for prosedyre er fastsatt."> > ["at0038"] = < text = <"Prosedyre utsatt"> description = <"Prosedyren er utsatt."> > ["at0039"] = < text = <"Prosedyre avlyst"> description = <"Den planlagte prosedyren har blitt avlyst før den ble igangsatt."> > ["at0040"] = < text = <"Prosedyre midlertidig stanset"> description = <"Prosedyren er suspendert/ midlertidig stanset."> > ["at0041"] = < text = <"Prosedyre avbrutt"> description = <"Prosedyren har blitt avbrutt."> > ["at0043"] = < text = <"Prosedyre fullført"> description = <"Prosedyren er utført og alle tilknyttede kliniske handlinger er fullførte."> > ["at0047"] = < text = <"Prosedyre utført"> description = <"Prosedyren eller en del av en prosedyre som består av flere delprosedyrer er utført."> > ["at0048"] = < text = <"Resultat"> description = <"Resultatet av den utførte prosedyren."> comment = <"Koding med en terminologi er ønskelig, om mulig."> > ["at0049"] = < text = <"Beskrivelse"> description = <"Fritekstbeskrivelse av prosedyren, tilpasset det aktuelle prosesstrinnet."> comment = <"For eksempel en beskrivelse av utførelsen og funnene fra prosedyren, det avbrutte forsøket, eller avlysningen av prosedyren."> > ["at0053"] = < text = <"Tree"> description = <"@ internal @"> > ["at0054"] = < text = <"Rekvisisjonsidentifikator"> description = <"Den lokale IDen tilordnet rekvisisjonen av helsepersonellet eller organisasjonen som rekvirerer prosedyren."> comment = <"Tilsvarer \"Placer Order Number\" i HL7 v2-spesifikasjonene."> > ["at0055"] = < text = <"Rekvirent"> description = <"Detaljer om helsepersonellet eller organisasjonen som har rekvirert prosedyren."> > ["at0056"] = < text = <"Mottakers rekvisisjonsidentifikator"> description = <"IDen tilordnet rekvisisjonen av helsepersonellet eller organisasjonen som mottar rekvisisjonen."> comment = <"Tilsvarer \"Filler Order Number\" i HL7 v2-spesifikasjonene."> > ["at0057"] = < text = <"Mottaker"> description = <"Detaljer om helsepersonellet eller organisasjonen som mottar prosedyrerekvisisjonen."> > ["at0058"] = < text = <"Hastegrad"> description = <"Prosedyrens hastegrad."> comment = <"Koding med en terminologi er ønskelig, om mulig."> > ["at0060"] = < text = <"Dato/tid for avslutning av prosedyren"> description = <"Datoen og/eller tiden da hele eller den siste av komponentene i en kompleks prosedyre ble avsluttet."> comment = <"Kun for bruk i forbindelse med prosesstrinnet \"Prosedyre utført\" og i situasjoner der prosedyren gjentas flere ganger før den fullføres, eller det finnes flere komponenter i prosedyren. Dette kan være det samme som referansemodellens \"time\"-atributt for prosesssteget \"Prosedyre utført\"."> > ["at0061"] = < text = <"Total varighet"> description = <"Den totale tiden som ble brukt til å fullføre prosedyren. Dette kan omfatte tidsbruk under den aktive fasen av prosedyren, og i tillegg tid da prosedyren var midlertidig stanset."> comment = <"Kun for bruk i forbindelse med prosesstrinnet \"Prosedyre fullført\"."> > ["at0062"] = < text = <"Multimedia"> description = <"Multimediarepresentasjon av en utført prosedyre."> > ["at0063"] = < text = <"Kroppssted"> description = <"Stedet på kroppen der prosedyren er utført."> comment = <"Forekomster for dette dataelementet er satt ubegrenset for å tillate kliniske scenarier som f.eks. å fjerne flere hudlesjoner på forskjellige steder, men der alle de andre attributtene er identiske. Bruk dette dataelementet til å registrere enkle termer eller prekoordinerte anatomiske lokaliseringer. Dersom behovene for registrering av anatomisk lokalisering bestemmes først av applikasjonen eller krever mer kompleks modellering som f.eks. relative lokaliseringer, kan arketypene CLUSTER.anatomical_location eller CLUSTER.relative_location brukes i SLOTet \"Prosedyredetaljer\" i denne arketypen. Dersom den anatomiske lokaliseringen inkluderes som en del av \"Prosedyrenavn\"-elementet ved hjelp av prekoordinerte koder blir dette dataelementet overflødig."> > ["at0064"] = < text = <"Tilleggsinformasjon"> description = <"Ytterligere informasjon som er nødvendig for å sammenstille med andre referansemodeller/formalismer."> comment = <"F.eks. lokale informasjonskrav eller ekstra metadata for å samsvare med FHIR eller CIMI ekvivalenter."> > ["at0065"] = < text = <"Metode"> description = <"Den spesifikke metoden eller teknikken for prosedyren."> comment = <"Bruk dette dataelementet til å registrere enkle termer eller en fritekstlig beskrivelse. Dersom behovene for beskrivelse av metoden krever mer kompleks modellering, kan dette representeres ved hjelp av tilleggsarketyper i SLOTet \"Prosedyredetaljer\" i denne arketypen. Dersom metoden inkluderes som en del av \"Prosedyrenavn\"-elementet ved hjelp av prekoordinerte koder blir dette dataelementet overflødig."> > ["at0066"] = < text = <"Planlagt dato/tid"> description = <"Dato/tid når prosedyren er planlagt utført."> comment = <"Kun til bruk i forbindelse med prosesstrinnet \"Prosedyre planlagt\"."> > ["at0067"] = < text = <"Prosedyretype"> description = <"Typen prosedyre."> comment = <"Dette dataelementet kan brukes til å støtte organisering innenfor brukergrensesnittet."> > ["at0068"] = < text = <"Prosedyre påbegynt"> description = <"Prosedyren eller en del av en prosedyre som består av flere delprosedyrer er påbegynt."> > ["at0069"] = < text = <"Problem ved prosedyre"> description = <"Vanskeligheter eller problemer som det ble støtt på under prosedyren."> comment = <"Eksempler: Pasienten var urolig, magen var ikke skikkelig tømt før gastroskopi, en svulst i gallegangene gjorde det umulig å få skopet gjennom."> > ["at0070"] = < text = <"Indikasjon"> description = <"Den kliniske eller prosessrelaterte årsaken til prosedyren."> comment = <"Koding av indikasjon med en terminologi er foretrukket, om mulig. Dette dataelementet kan repeteres. For eksempel \"Brudd i arm\" eller \"Mislykket tarmtømming\" , \"Tarmkreftscreening\" eller \"Pakkeforløp for kreft\"."> > > > ["es"] = < items = < ["at0000"] = < text = <"Procedimiento"> description = <"Actividad clínica llevada a cabo con fines de cribado, investigación, diagnóstico, curativos, terapéuticos, de evaluación o paliativos."> > ["at0001"] = < text = <"Tree"> description = <"@ internal @"> > ["at0002"] = < text = <"Nombre del procedimiento"> description = <"Identificación del procedimiento por su nombre."> comment = <"Siempre que sea posible, es preferible la codificación del procedimiento específico con una terminología."> > ["at0003"] = < text = <"Detalles del procedimiento"> description = <"Información estructurada sobre el procedimiento."> comment = <"Se utiliza para recopilar información detallada y estructurada sobre la localización anatómica, el método y la técnica, el equipo utilizado, los dispositivos implantados, los resultados, los hallazgos, etc."> > ["at0004"] = < text = <"Procedimiento planificado"> description = <"Se planifica el procedimiento a llevar a cabo."> > ["at0005"] = < text = <"Comentarios"> description = <"Información adicional sobre la actividad o etapa asistencial no recogida en otros campos."> > ["at0006"] = < text = <"Complicación"> description = <"Detalles sobre cualquier complicación derivada del procedimiento."> comment = <"Utilice este elemento de datos para registrar términos sencillos o complicaciones precoordinadas. Si los requisitos para el registro de complicaciones son más complejos, se aconseja utilizar un arquetipo CLUSTER específico dentro del SLOT \"Detalles del procedimiento\" de este arquetipo. Ejemplos: Hematuria tras una biopsia renal, irritación tisular tras la inserción de un catéter intravenoso."> > ["at0007"] = < text = <"Solicitud de procedimiento enviada"> description = <"Solicitud de procedimiento enviada."> > ["at0014"] = < text = <"Motivo"> description = <"Motivo por el que se llevó a cabo la actividad o etapa asistencial para el procedimiento identificado."> comment = <"Por ejemplo: motivo de la cancelación o suspensión del procedimiento."> > ["at0034"] = < text = <"X - Procedimiento planificado"> description = <"Este apartado ha quedado obsoleto, ya que se asociaba incorrectamente con el estado \"inicial\". Utilice el nuevo apartado \"Procedimiento planificado\" (at0004), asociado correctamente con el estado \"planificado\"."> comment = <"(Obsoleto: Se planifica el procedimiento a llevar a cabo.)"> > ["at0035"] = < text = <"X - Solicitud de procedimiento enviada"> description = <"Este apartado ha quedado obsoleto, ya que se asociaba incorrectamente con el estado \"inicial\". Utilice el nuevo apartado \"Solicitud de procedimiento enviada\" (at0004), asociado correctamente con el estado \"planificado\"."> comment = <"(Obsoleto: Solicitud de procedimiento enviada.)"> > ["at0036"] = < text = <"Procedimiento programado"> description = <"Se ha programado el procedimiento."> > ["at0038"] = < text = <"Procedimiento pospuesto"> description = <"El procedimiento se ha pospuesto."> > ["at0039"] = < text = <"Procedimiento cancelado"> description = <"El procedimiento previsto se ha cancelado antes de comenzar."> > ["at0040"] = < text = <"Procedimiento suspendido"> description = <"Se ha suspendido el procedimiento."> > ["at0041"] = < text = <"Procedimiento interrumpido"> description = <"Se ha interrumpido el procedimiento."> > ["at0043"] = < text = <"Procedimiento completado"> description = <"Se ha realizado el procedimiento y se han completado todas las actividades clínicas asociadas."> > ["at0047"] = < text = <"Procedimiento realizado"> description = <"El procedimiento, o subprocedimiento en un procedimiento multicomponente, se ha realizado."> > ["at0048"] = < text = <"Resultado"> description = <"Resultado del procedimiento realizado."> comment = <"Siempre que sea posible, es preferible codificar con una terminología."> > ["at0049"] = < text = <"Descripción"> description = <"Descripción narrativa sobre el procedimiento, según corresponda a la fase del proceso."> comment = <"Por ejemplo: descripción de la realización y los resultados del procedimiento, el intento interrumpido o la cancelación del procedimiento."> > ["at0053"] = < text = <"Tree"> description = <"@ internal @"> > ["at0054"] = < text = <"Identificador de orden del solicitante"> description = <"El ID local asignado a la orden por el proveedor sanitario o la organización que solicita el servicio."> comment = <"Equivalente al Placer Order Number en las especificaciones HL7 v2."> > ["at0055"] = < text = <"Solicitante"> description = <"Datos del profesional sanitario u organización que solicita el servicio."> > ["at0056"] = < text = <"Identificador de orden del receptor"> description = <"El identificador asignado a la orden por el proveedor sanitario o la organización que recibe la solicitud de servicio. También se denomina Identificador de Orden de Cumplimentación."> comment = <"Equivalente al Placer Order Number en las especificaciones HL7 v2."> > ["at0057"] = < text = <"Receptor"> description = <"Datos sobre el proveedor u organización sanitaria que recibe la solicitud de servicio."> > ["at0058"] = < text = <"Urgencia"> description = <"Urgencia del procedimiento."> comment = <"Siempre que sea posible, es preferible codificar con una terminología."> > ["at0060"] = < text = <"Fecha/hora de finalización"> description = <"La fecha y/o la hora en que finalizó todo el procedimiento, o el último componente de un procedimiento multicomponente."> comment = <"Sólo para su uso en asociación con la etapa \"Procedimiento realizado\", y en situaciones en las que el procedimiento se repite en varias ocasiones antes de completarse, o hay varios componentes en todo el procedimiento. Puede ser el mismo que el atributo de tiempo RM de la etapa \"Procedimiento completado\"."> > ["at0061"] = < text = <"Duración"> description = <"Cantidad total de tiempo empleado en completar el procedimiento, que puede incluir el tiempo empleado durante la fase activa del procedimiento más el tiempo durante el cual el procedimiento estuvo suspendido."> comment = <"Sólo para su uso en asociación con la etapa \"Procedimiento completado\"."> > ["at0062"] = < text = <"Multimedia"> description = <"Representación multimedia del procedimiento realizado."> > ["at0063"] = < text = <"Zona corporal"> description = <"Identificación de la zona del cuerpo para el procedimiento."> comment = <"Las ocurrencias de este elemento de datos son ilimitadas para permitir escenarios clínicos como la extirpación de múltiples lesiones cutáneas en diferentes lugares, pero donde todos los demás atributos son idénticos. Utilice este elemento de datos para registrar términos sencillos o localizaciones anatómicas precoordinadas. Si los requisitos para registrar la localización anatómica se determinan en tiempo de ejecución por la aplicación o requieren un modelado más complejo, como localizaciones relativas, utilice CLUSTER.anatomical_location o CLUSTER.relative_location en el SLOT \"Detalles del procedimiento\" de este arquetipo. Si la localización anatómica se incluye en el \"Nombre del procedimiento\" mediante códigos precoordinados, este elemento de datos será redundante."> > ["at0064"] = < text = <"Ampliación"> description = <"Información adicional necesaria para registrar contenido local o para alinearse con otros modelos/formalismos de referencia."> comment = <"Por ejemplo: requisitos de información local o metadatos adicionales para alinearse con los equivalentes de FHIR o CIMI."> > ["at0065"] = < text = <"Método"> description = <"Identificación del método o técnica específicos para el procedimiento."> comment = <"Utilice este elemento de datos para registrar términos sencillos o una descripción narrativa. Si los requisitos para registrar el método requieren una modelización más compleja, ésta puede representarse mediante arquetipos adicionales dentro del SLOT \"Detalle del procedimiento\", de este arquetipo. Si el método se incluye en el \"Nombre del procedimiento\" mediante códigos precoordinados, este elemento de datos será redundante."> > ["at0066"] = < text = <"Fecha/hora programada"> description = <"Fecha y/u hora en que está previsto realizar el procedimiento."> comment = <"Sólo para su uso en asociación con la etapa \"Procedimiento programado\"."> > ["at0067"] = < text = <"Tipo de procedimiento"> description = <"Tipo de procedimiento."> comment = <"Este elemento de datos puede utilizarse para dar soporte a la organización dentro de la interfaz de usuario."> > ["at0068"] = < text = <"Procedimiento iniciado"> description = <"El procedimiento, o subprocedimiento en un procedimiento multicomponente, se ha iniciado."> > ["at0069"] = < text = <"Dificultades del procedimiento"> description = <"Dificultades o problemas encontrados durante la realización del procedimiento."> comment = <"Ejemplos: El paciente estaba agitado, vaciado insuficiente del estómago antes de la gastroscopia, un tumor en las vías biliares impedía el paso del endoscopio."> > ["at0070"] = < text = <"Indicación"> description = <"El motivo, clínico o relacionado con el proceso, del procedimiento."> comment = <"Siempre que sea posible, es preferible codificar la indicación con una terminología. Este elemento de datos permite múltiples ocurrencias. Por ejemplo: \"Preparación intestinal fallida\" o \"Cribado de cáncer de intestino\"."> > > > ["de"] = < items = < ["at0000"] = < text = <"Prozedur"> description = <"Eine klinische Aktivität, die zur Früherkennung, Untersuchung, Diagnose, Heilung, Therapie, Bewertung oder in Hinsicht auf palliative Maßnahmen durchgeführt wird."> > ["at0001"] = < text = <"Tree"> description = <"@ internal @"> > ["at0002"] = < text = <"Name der Prozedur"> description = <"Identifizierung der Prozedur über den Namen."> comment = <"Wenn möglich wird die Kodierung der spezifischen Prozedur mit einer Terminologie bevorzugt."> > ["at0003"] = < text = <"Details zur Prozedur"> description = <"Strukturierte Informationen über die Prozedur."> comment = <"Zur Erfassung detaillierter, strukturierter Informationen über die anatomische Lokalisation, Methode und Technik, verwendetes Equipment, implantierte Geräte, Ergebnisse, Befunde usw."> > ["at0004"] = < text = <"Geplante Prozedur"> description = <"Die Prozedur, die durchgeführt werden soll, ist geplant."> > ["at0005"] = < text = <"Kommentar"> description = <"Zusätzliche Beschreibung der Aktivität oder der \"Pathway\"-Verlaufsschritte, die in anderen Bereichen nicht erfasst wurden."> > ["at0006"] = < text = <"Komplikationen"> description = <"Details zu allen Komplikationen, die sich aus der Prozedur ergeben haben."> comment = <"Verwenden Sie dieses Datenelement, um einfache Begriffe oder präkoordinierte Komplikationen zu erfassen. Wenn die Anforderungen an die Erfassung der Komplikationen komplexer sind, wird die Verwendung eines spezifischen CLUSTER-Archetyps innerhalb des Slots \"Details zur Prozedur\" in diesem Archetyp empfohlen. Dieses Datenelement wird dann redundant. Beispiele: Hämaturie nach einer Nierenbiopsie, Reizungen des Gewebes nach dem Legen eines intravenösen Katheters."> > ["at0007"] = < text = <"Auftrag für Prozedur versendet"> description = <"Der Auftrag für die Prozedur wurde versendet."> > ["at0014"] = < text = <"Grund"> description = <"Grund, warum die angegebene Aktivität für diese Prozedur durchgeführt wurde."> comment = <"Zum Beispiel: der Grund für den Abbruch oder die Unterbrechung der Prozedur."> > ["at0034"] = < text = <"X - Prozedur geplant"> description = <"Dieses Element ist veraltet, da es fälschlicherweise mit dem Status \"initial\" verknüpft war - verwenden Sie das neue Element \"Prozedur geplant\" (at0004), das korrekt mit dem Status \"geplant\" verknüpft ist."> comment = <"(War: Die Prozedur, die durchgeführt werden soll, ist geplant.)"> > ["at0035"] = < text = <"X - Auftrag für Prozedur versendet"> description = <"Dieses Element ist veraltet, da es fälschlicherweise mit dem Status \"initial\" verknüpft war - verwenden Sie das neue Element \"Geplante Prozedur\" (at0007), das korrekt mit dem Status \"geplant\" verknüpft ist."> comment = <"(War: Der Auftrag für die Prozedur wurde versendet.)"> > ["at0036"] = < text = <"geplanter Termin der Prozedur"> description = <"Ein Termin für die Prozedur wurde geplant."> > ["at0038"] = < text = <"Prozedur verschoben"> description = <"Die Prozedur wurde verschoben."> > ["at0039"] = < text = <"Prozedur storniert"> description = <"Die geplante Prozedur wurde vor Beginn storniert."> > ["at0040"] = < text = <"Prozedur unterbrochen"> description = <"Die Prozedur wurde unterbrochen."> > ["at0041"] = < text = <"Prozedur abgebrochen"> description = <"Die Prozedur wurde abgebrochen."> > ["at0043"] = < text = <"Prozedur beendet"> description = <"Die Prozedur wurde durchgeführt und alle damit verbundenen klinischen Aktivitäten wurden beendet."> > ["at0047"] = < text = <"Prozedur durchgeführt"> description = <"Die Prozedur, oder eine Subprozedur in einem mehrstufigen Vorgehen, wurde durchgeführt."> > ["at0048"] = < text = <"Ausgang"> description = <"Ausgang der durchgeführten Prozedur."> comment = <"Wenn möglich wird die Kodierung mit einer Terminologie bevorzugt."> > ["at0049"] = < text = <"Beschreibung"> description = <"Beschreibung der Prozedur, angepasst an den \"Pathway\"-Verlaufsschritt."> comment = <"Zum Beispiel: Beschreibung der Durchführung und der Ergebnisse dieser Prozedur, des abgebrochenen Versuchs oder der Stornierung der Prozedur."> > ["at0053"] = < text = <"Tree"> description = <"@ internal @"> > ["at0054"] = < text = <"Auftragskennung des Antragstellers"> description = <"Die lokale ID, die dem Auftrag vom Gesundheitsdienstleister oder der Organisation, die die Leistung anfordert, zugewiesen wurde."> comment = <"Dies entspricht der \"Placer Order Number\" in den Spezifikationen von HL7 v2."> > ["at0055"] = < text = <"Antragsteller"> description = <"Angaben über den Gesundheitsdienstleister oder die Organisation, die die Leistung anfordert."> > ["at0056"] = < text = <"Auftragskennung des Empfängers"> description = <"Die ID, die dem Auftrag von dem Gesundheitsdienstleister oder der Organisation, die die Leistungsanforderung erhält, zugewiesen wurde. Dies wird auch als \"Filler Order Identifier\" bezeichnet."> comment = <"Dies entspricht der \"Filler Order Number\" in den Spezifikationen von HL7 v2."> > ["at0057"] = < text = <"Empfänger"> description = <"Angaben über den Gesundheitsdienstleister oder die Organisation, die die Leistungsanforderung erhält."> > ["at0058"] = < text = <"Dringlichkeit"> description = <"Dringlichkeit der Prozedur."> comment = <"Wenn möglich wird die Kodierung mit einer Terminologie bevorzugt."> > ["at0060"] = < text = <"Enddatum/-uhrzeit"> description = <"Das Datum und/oder die Uhrzeit, an dem die gesamte Prozedur, oder die letzte Komponente einer mehrstufigen Prozedur, beendet wurde."> comment = <"Nur zur Verwendung in Verbindung mit dem Element \"Prozedur durchgeführt\" und in Situationen, in denen die Prozedur vor dem Abschluss mehrmals wiederholt wird oder die Prozedur sich aus mehreren Komponenten zusammensetzt. Dies kann mit dem RM-Zeitattribut des Elements \"Prozedur beendet\" übereinstimmen."> > ["at0061"] = < text = <"Gesamtdauer"> description = <"Die Gesamtdauer der Prozedur - diese kann sich aus der aktiven Phase und der Phase, in der die Prozedur unterbrochen wurde, ergeben."> comment = <"Nur in Verbindung mit dem Element \"Prozedur beendet\" verwenden."> > ["at0062"] = < text = <"Multimedia"> description = <"Multimediale Darstellung der durchgeführten Prozedur."> > ["at0063"] = < text = <"Körperstelle"> description = <"Anatomische Lokalisation, an der die Prozedur durchgeführt wird."> comment = <"Das Vorkommen dieses Datenelements ist nicht eingeschränkt. Dies ermöglicht die Darstellung von klinischen Situationen, in denen alle Eigenschaften, ausgenommen die anatomische Lokalisation, identisch sind, wie z.B. das Entfernen mehrerer Hautläsionen an verschiedenen Stellen. Verwenden Sie dieses Datenelement, um einfache Begriffe oder präkoordinierte anatomische Lokalisationen aufzunehmen. Wenn die Anforderungen an die Erfassung der anatomischen Lokalisation zur Laufzeit durch die Anwendung festgelegt werden oder komplexere Modellierungen wie z.B. die relative Lokalisation erforderlich sind, verwenden Sie entweder CLUSTER.anatomical_location oder CLUSTER.relative_location innerhalb des Slots \"Details zur Prozedur\" in diesem Archetyp. Wird die anatomische Lokalisation über vordefinierte Codes in den Namen der Prozedur aufgenommen, wird dieses Datenelement redundant."> > ["at0064"] = < text = <"Erweiterung"> description = <"Zusätzliche Informationen, die erforderlich sind, um lokale Inhalte zu erfassen oder mit anderen Referenzmodellen/Formalismen abzugleichen."> comment = <"Zum Beispiel: Lokaler Informationsbedarf oder zusätzliche Metadaten zur Anpassung an FHIR- oder CIMI-Äquivalente."> > ["at0065"] = < text = <"Methode"> description = <"Identifizierung der spezifischen Prozedurmethode oder -technik."> comment = <"Verwenden Sie dieses Datenelement, um einfache Begriffe oder eine Beschreibung zu erfassen. Wenn die Anforderungen an die Erfassung der Methode eine komplexere Modellierung erfordern, kann dies durch zusätzliche Archetypen innerhalb des SLOTs \"Details zur Prozedur\" in diesem Archetyp dargestellt werden. Wird die Methode über vordefinierte Codes in dem Element \"Name der Prozedur\" aufgenommen, wird dieses Datenelement redundant."> > ["at0066"] = < text = <"Geplantes Datum/Uhrzeit"> description = <"Das Datum und/oder die Uhrzeit für die die Prozedur angesetzt ist."> comment = <"Nur für die Verwendung in Verbindung mit dem Element \"geplanter Termin der Prozedur\" ."> > ["at0067"] = < text = <"Art der Prozedur"> description = <"Die Art der Prozedur."> comment = <"Dieses pragmatische Datenelement kann zur Unterstützung der Gliederung für die Benutzeroberfläche verwendet werden."> > ["at0068"] = < text = <"Prozedur begonnen"> description = <"Die Prozedur, oder eine Subprozedur in einem mehrstufigen Vorgehen, wurde begonnen."> > ["at0069"] = < text = <"Schwierigkeiten bei der Durchführung der Prozedur"> description = <"Schwierigkeiten oder Probleme, die während der Durchführung der Prozedur aufgetreten sind."> comment = <"Beispiele: Der Patient war unruhig; unzureichende Entleerung des Magens vor der Gastroskopie; ein Tumor in den Gallengängen machte es unmöglich, den Bereich zu passieren."> > ["at0070"] = < text = <"Indikation"> description = <"Der klinische oder prozessbezogene Grund für die Prozedur."> comment = <"Die Kodierung der Indikation mit einer Terminologie wird nach Möglichkeit bevorzugt. Dieses Datenelement ermöglicht mehrere Vorkommen. Zum Beispiel: \"Fehlgeschlagenen Darmvorbereitung\" oder \"Darmkrebsvorsorge\"."> > > > ["pt-pt"] = < items = < ["at0000"] = < text = <"Procedimento"> description = <"Atividade clínica realizada para fins de rastreio, investigação, diagnóstico, cura, tratamento, avaliação ou cuidados paliativos."> > ["at0001"] = < text = <"Tree"> description = <"@ internal @"> > ["at0002"] = < text = <"Nome do procedimento"> description = <"Identificação do procedimento pelo nome."> comment = <"A codificação do procedimento específico com uma terminologia é preferida, sempre que possível."> > ["at0003"] = < text = <"Detalhe do procedimento"> description = <"Informação estruturada sobre o procedimento."> comment = <"Use para capturar informações detalhadas e estruturadas sobre localização anatómica, método e técnica, equipamentos usados, dispositivos implantados, resultados, descobertas, etc."> > ["at0004"] = < text = <"Procedimento Planeado"> description = <"O procedimento a ser realizado está planeado."> > ["at0005"] = < text = <"Comentário"> description = <"Narrativa adicional sobre a atividade ou etapa do caminho do cuidado não capturada noutros campos."> > ["at0006"] = < text = <"Complicação"> description = <"Detalhes sobre qualquer complicação decorrente do procedimento."> comment = <"Use esse elemento de dados para registar termos simples ou complicações pré-ordenadas. Se os requisitos para a complicação de gravação forem mais complexos, o uso de um arquétipo CLUSTER específico dentro do SLOT 'Detalhe do procedimento' neste arquétipo é recomendado e esse elemento de dados torna-se redundante. Exemplos: Hematúria após biópsia renal, irritação tecidular após inserção de cateter intravenoso."> > ["at0007"] = < text = <"Pedido de procedimento enviado"> description = <"Pedido para o procedimento enviado."> > ["at0014"] = < text = <"Motivo"> description = <"Motivo pelo qual foi realizada a etapa da atividade ou da via de cuidado para o procedimento identificado."> comment = <"Por exemplo: o motivo do cancelamento ou suspensão do procedimento."> > ["at0034"] = < text = <"X - Procedimento planeado"> description = <"Esta etapa de caminho foi preterida, pois foi incorretamente associada ao estado 'inicial' - use a nova etapa de caminho 'Procedimento planeado' (at0004) que está corretamente associada ao estado 'planeado'."> comment = <"(Era: O procedimento a ser realizado está planeado.)"> > ["at0035"] = < text = <"X - Solicitação de procedimento enviada"> description = <"Esta etapa de caminho foi preterida, pois foi incorretamente associada ao estado 'inicial' - use a nova etapa de caminho 'Pedido de procedimento enviado' (at0007) que está corretamente associada ao estado 'planeado'."> comment = <"(Foi: Pedido de procedimento enviado.)"> > ["at0036"] = < text = <"Procedimento programado"> description = <"O procedimento foi agendado."> > ["at0038"] = < text = <"Procedimento Adiado"> description = <"O procedimento foi adiado."> > ["at0039"] = < text = <"Procedimento Cancelado"> description = <"O procedimento previsto foi cancelado antes do início."> > ["at0040"] = < text = <"Procedimento suspenso"> description = <"O procedimento foi suspenso."> > ["at0041"] = < text = <"Procedimento abortado"> description = <"O procedimento foi abortado."> > ["at0043"] = < text = <"Procedimento concluído"> description = <"O procedimento foi realizado e todas as atividades clínicas associadas foram concluídas."> > ["at0047"] = < text = <"Procedimento realizado"> description = <"O procedimento, ou subprocedimento num procedimento com vários componentes, foi realizado."> > ["at0048"] = < text = <"Resultado"> description = <"Resultado do procedimento realizado."> comment = <"A codificação com uma terminologia é preferida, sempre que possível."> > ["at0049"] = < text = <"Descrição"> description = <"Descrição narrativa sobre o procedimento, conforme apropriado para a etapa do caminho."> comment = <"Por exemplo: descrição do desempenho e resultados do procedimento, da tentativa abortada ou do cancelamento do procedimento."> > ["at0053"] = < text = <"Tree"> description = <"@ internal @"> > ["at0054"] = < text = <"Identificador do requerente do pedido"> description = <"O documento de identificação local atribuído ao pedido pelo prestador de cuidados de saúde ou organização que solicita o serviço."> comment = <"Isto é equivalente ao número de ordem Placer em HL7 v2 especificações."> > ["at0055"] = < text = <"Requerente"> description = <"Detalhes sobre o prestador de cuidados de saúde ou a organização que solicita o serviço."> > ["at0056"] = < text = <"Identificador do destinatário do pedido"> description = <"O ID atribuído à encomenda pelo prestador de cuidados de saúde ou organização que recebe o pedido de serviço. Isto também é referido como Filler Order Identifier."> comment = <"Isso é equivalente ao número Filler Order Identifier nas especificações HL7 v2."> > ["at0057"] = < text = <"Recetor"> description = <"Informações sobre o prestador de cuidados de saúde ou a organização que recebe o pedido de assistência."> > ["at0058"] = < text = <"Urgência"> description = <"Urgência do procedimento."> comment = <"A codificação com uma terminologia é preferida, sempre que possível."> > ["at0060"] = < text = <"Data/hora final"> description = <"A data e/ou hora em que todo o procedimento, ou o último componente de um procedimento com vários componentes, foi concluído."> comment = <"Apenas para utilização em associação com a etapa da via 'Procedimento realizado' e em situações em que o procedimento é repetido em várias ocasiões antes de ser concluído ou há vários componentes em todo o procedimento. Isso pode ser o mesmo que o atributo de tempo RM para a etapa de caminho 'Procedimento concluído'."> > ["at0061"] = < text = <"Duração total"> description = <"O tempo total necessário para concluir o procedimento, que pode incluir o tempo gasto durante a fase ativa do procedimento e o tempo durante o qual o procedimento foi suspenso."> comment = <"Apenas para utilização em associação com as etapas do caminho 'Procedimento concluído'."> > ["at0062"] = < text = <"Multimédia"> description = <"Representação multimédia de um procedimento realizado."> > ["at0063"] = < text = <"Local do corpo"> description = <"Identificação do local do corpo para o procedimento."> comment = <"As ocorrências para este elemento de dados são ilimitadas para permitir cenários clínicos tais como a remoção de lesões de pele múltiplas em lugares diferentes, mas onde todos os outros atributos são idênticos. Use esse elemento de dados para registar termos simples ou localizações anatómicas pré-ordenadas. Se os requisitos para o registo da localização anatómica forem determinados no CLUSTER.anatomical_location ou CLUSTER.relative_location dentro do SLOT 'Detalhe do procedimento' neste arquétipo. Se a localização anatómica for incluída no 'Nome do procedimento' por meio de códigos pré-ordenados, esse elemento de dados ficará redundante."> > ["at0064"] = < text = <"Extensão"> description = <"Informações adicionais necessárias para capturar conteúdo local ou para alinhar com outros modelos/formalismos de referência."> comment = <"Por exemplo: requisitos de informações locais ou metadados adicionais para alinhar com equivalentes FHIR ou CIMI."> > ["at0065"] = < text = <"Método"> description = <"Identificação do método ou técnica específica para o procedimento."> comment = <"Use esse elemento de dados para registar termos simples ou uma descrição narrativa. Se os requisitos para o registo do método exigirem uma modelagem mais complexa, isso pode ser representado por arquétipos adicionais dentro do SLOT 'Detalhes do procedimento' neste arquétipo. Se o método for incluído no 'Nome do procedimento' com códigos pré-ordenados, esse elemento de dados ficará redundante."> > ["at0066"] = < text = <"Data/hora agendada"> description = <"A data e/ou hora em que o procedimento se destina a ser realizado."> comment = <"Apenas para utilização em associação com a etapa de caminho 'Procedimento agendado'."> > ["at0067"] = < text = <"Tipo de procedimento"> description = <"O tipo de procedimento."> comment = <"Este elemento de dados pragmáticos pode ser usado para apoiar a organização dentro da interface do/a utilizador/a."> > ["at0068"] = < text = <"Procedimento iniciado"> description = <"O procedimento, ou subprocedimento num procedimento com vários componentes, foi iniciado."> > ["at0069"] = < text = <"Dificuldade processual"> description = <"Dificuldades ou problemas encontrados durante a execução do procedimento."> comment = <"Exemplos: O doente estava agitado, esvaziamento insuficiente do estômago antes da gastroscopia, um tumor nos ductos biliares impossibilitou a passagem da sonda."> > ["at0070"] = < text = <"indicação"> description = <"A razão clínica ou relacionada ao processo para o procedimento."> comment = <"É preferível codificar a indicação com uma terminologia, sempre que possível. Este elemento de dados permite múltiplas ocorrências. Por exemplo: 'Falha na preparação intestinal' ou 'Rastreio do cancro de intestino'."> > > > ["sv"] = < items = < ["at0000"] = < text = <"Procedur"> description = <"En klinisk aktivitet utförd för screening, undersökande, diagnostiska, botande, terapeutiska, utvärderande eller palliativa ändamål."> > ["at0001"] = < text = <"Tree"> description = <"@ internal @"> > ["at0002"] = < text = <"Namn på procedur"> description = <"Identifiering av procedur med namn."> comment = <"Kodning av den specifika proceduren med en terminologi är att föredra, där det är möjligt."> > ["at0003"] = < text = <"Prodedur detaljer"> description = <"Strukturerad information om proceduren. "> comment = <"Används för att fånga detaljerad, strukturerad information om anatomisk plats, metod & teknik, utrustning som används, implanterade enheter/utrustning, resultat, fynd m.m."> > ["at0004"] = < text = <"Procedur planerad"> description = <"Proceduren som ska genomföras är planerad"> > ["at0005"] = < text = <"Kommentar"> description = <"Ytterligare beskrivning om aktiviteten eller vårdsteget som inte fångas i andra fält."> > ["at0006"] = < text = <"Komplikation"> description = <"Detaljer om eventuella komplikationer som uppstår från proceduren"> comment = <"Använd detta dataelement för att dokumentera enkla termer eller förkoordinerade komplikationer. Om kraven för dokumentation av komplikationen är mer komplexa rekommenderas användning av ett specifikt CLUSTER i öppningen \"Procedur detaljer\", då blir detta dataelement överflödigt. Exempel: Hematuri efter njurbiopsi, vävnadsirritation efter införande av intravenös kateter."> > ["at0007"] = < text = <"Förfrågan om procedur skickad"> description = <"Förfrågan om procedur är skickad "> > ["at0014"] = < text = <"Anledning"> description = <"Anledning att aktivitets- eller vårdsteget för det identifierade förfarandet genomfördes."> comment = <"Till exempel: anledningen till att proceduren pausades eller avbryts."> > ["at0034"] = < text = <"X - Procedur planerad"> description = <"Detta vägsteg har upphört att gälla eftersom det felaktigt var associerat med \"initial\" status - använd det nya \"Procedur planerad\" (at0004) vägsteget som är korrekt associerat med \"planerat\" status. "> comment = <"(Was: The procedure to be undertaken is planned.)(en)"> > ["at0035"] = < text = <"X - Förfrågan om procedur skickad"> description = <"Detta vägsteg har upphört att gälla eftersom det felaktigt var associerat med \"initial\" status - använd det nya \"Procedur förfrågan skickad\" (at0007) vägsteget som är korrekt associerat med \"planerad\" status."> comment = <"(Was: Request for procedure sent.)(en)"> > ["at0036"] = < text = <"Procedur schemalagd"> description = <"Proceduren har blivit schemalagd (bokad) "> > ["at0038"] = < text = <"Procedur uppskjuten"> description = <"Proceduren har skjutits upp "> > ["at0039"] = < text = <"Procedur avbruten"> description = <"Det planerade förfarandet har avbrutits före det påbörjandes."> > ["at0040"] = < text = <"Procedur pausad"> description = <"Proceduren har pausats "> > ["at0041"] = < text = <"Procedur avbruten"> description = <"Proceduren har blivit avbruten "> > ["at0043"] = < text = <"Procedur avslutad"> description = <"Proceduren har utförts och alla tillhörande kliniska aktiviteter har slutförts."> > ["at0047"] = < text = <"Procedur utförd"> description = <"Proceduren, eller delproceduren i ett multikomponentförfarande, har utförts"> > ["at0048"] = < text = <"Resultat"> description = <"Resultat av genomförd procedur "> comment = <"Kodning med en terminologi är att föredra, där det är möjligt."> > ["at0049"] = < text = <"Beskrivning"> description = <"Beskrivning av proceduren, anpassad till det aktuella steget. "> comment = <"Till exempel: beskrivning av utförandet och fyndet från proceduren, det avbrutna försöket eller avslutandet av proceduren."> > ["at0053"] = < text = <"Tree"> description = <"@ internal @"> > ["at0054"] = < text = <"Beställare ID"> description = <"Det lokala ID som tilldelats beställningen av vårdgivaren eller organisationen som begär tjänsten"> comment = <"Detta motsvarar Place Order Number i specifikationerna för HL7 v2"> > ["at0055"] = < text = <"Beställare"> description = <"Detaljer om vårdgivaren eller organisationen som begär tjänsten."> > ["at0056"] = < text = <"Mottagare ID"> description = <"ID som tilldelats beställningen, av vårdgivaren eller organisationen som tar emot begäran om service. Detta kallas också Filler Order Identifier."> comment = <"Detta motsvarar Filler Order Number i specifikationerna för HL7 v2."> > ["at0057"] = < text = <"Mottagare"> description = <"Detaljer om vårdgivaren eller organisationen som tar emot begäran om procedur."> > ["at0058"] = < text = <"Brådskandegrad"> description = <"Brådskandegrad för proceduren."> comment = <"Kodning med en terminologi är att föredra, där det är möjligt."> > ["at0060"] = < text = <"Datum/tid avslut av procedur"> description = <"Datumet och/eller tid då hela proceduren, eller den sista komponenten i ett multikomponentförfarande, avslutades."> comment = <"Kan endast användas i samband med steget \"Procedur utförd\" och i situationer där proceduren upprepas vid flera tillfällen innan den avslutas eller om det finns flera komponenter i hela proceduren. Detta kan vara detsamma som RM-tidsattributet för steget 'Procedur avslutad'."> > ["at0061"] = < text = <"Total duration"> description = <"Den totala tid som krävs för att utföra proceduren, vilket kan inkludera tid som tillbringats under den aktiva fasen av proceduren plus den tid under vilken proceduren pausades."> comment = <"Kan endast användas i samband med steget 'Procedure avslutad'."> > ["at0062"] = < text = <"Multimedia"> description = <"Multimedia representation av en utförd procedur."> > ["at0063"] = < text = <"Kroppsplats"> description = <"Identifiering av kroppsplatsen för proceduren."> comment = <"Förekomsten av detta dataelement är obegränsat för att möjliggöra kliniska scenarier som att ta bort flera hudskador på olika platser, men där alla andra attribut är identiska. Använd detta dataelement för att dokumentera enkla termer eller förkoordinerade anatomiska platser. Om kraven för dokumentation av den anatomiska platsen bestäms vid körning av applikationen eller kräver mer komplex modellering, till exempel relativa platser, använd CLUSTER.anatomical_location eller CLUSTER.relative_location inom öppningen 'Procedur detaljer' i denna arketyp. Om den anatomiska platsen ingår i 'Procedurnamn' via förkoordinerade koder blir detta dataelement överflödigt"> > ["at0064"] = < text = <"Tilläggsinformaiton"> description = <"Ytterligare information som krävs för att fånga lokalt innehåll eller för att anpassa sig till andra referensmodeller/formalismer."> comment = <"Till exempel: lokala informationskrav eller ytterligare metadata för att anpassning till FHIR eller CIMI."> > ["at0065"] = < text = <"Metod"> description = <"Identifiering av specifik metod eller teknik för proceduren."> comment = <"Använd detta dataelement för att dokumentera enkla termer eller en berättande beskrivning. Om kraven för dokumentation av metoden kräver mer komplex modellering kan detta representeras av ytterligare arketyper inom öppningen \"Procedur detalj\" i denna arketyp. Om metoden ingår i 'Procedurnamn' via förkoordinerade koder blir detta dataelement överflödigt."> > ["at0066"] = < text = <"Schemalagt datum/tid"> description = <"Datum och/eller tid då proceduren är tänkt att utföras."> comment = <"Endast för användning i samband med steget \"Procedur schemalagd\"."> > ["at0067"] = < text = <"Typ av procedur"> description = <"Typ av procedur"> comment = <"Detta pragmatiska dataelement kan användas för att stödja en organisation inom användargränssnittet."> > ["at0068"] = < text = <"Procedur påbörjad"> description = <"Proceduren, eller delproceduren i ett flerkomponentförfarande, har påbörjats."> > ["at0069"] = < text = <"Svårigheter med procedur"> description = <"Svårigheter eller problem som uppstår under genomförandet av proceduren."> comment = <"Exempel: Patienten var upprörd, otillräcklig tömning av magen före gastroskopi, en tumör i gallgångarna gjorde det omöjligt att passera genom."> > ["at0070"] = < text = <"Indikation"> description = <"Den kliniska eller processrelaterade orsaken till ingreppet."> comment = <"Kodning av indikationen med en terminologi är att föredra, där det är möjligt. Detta dataelement tillåter flera förekomster. Till exempel: 'Misslyckad tarmberedning' eller 'Screening av tarmcancer'."> > > > ["ca"] = < items = < ["at0000"] = < text = <"Procediment"> description = <"Activitat clínica duta a terme amb fins de cribratge, investigació, diagnòstic, curatius, terapèutics, d'avaluació o pal·liatius."> > ["at0001"] = < text = <"Tree"> description = <"@ internal @"> > ["at0002"] = < text = <"Nom del procediment"> description = <"Identificació del procediment pel nom."> comment = <"Sempre que sigui possible, és preferible la codificació del procediment específic amb una terminologia."> > ["at0003"] = < text = <"Detalls del procediment"> description = <"Informació estructurada sobre el procediment."> comment = <"S'utilitza per recopilar informació detallada i estructurada sobre la localització anatòmica, el mètode i la tècnica, l'equip utilitzat, els dispositius implantats, els resultats, les troballes, etc."> > ["at0004"] = < text = <"Procediment planificat"> description = <"Es planifica el procediment que cal dur a terme."> > ["at0005"] = < text = <"Comentaris"> description = <"Informació addicional sobre l'activitat o l'etapa assistencial no recollida en altres camps."> > ["at0006"] = < text = <"Complicació"> description = <"Detalls sobre qualsevol complicació derivada del procediment."> comment = <"Utilitzeu aquest element de dades per registrar termes senzills o complicacions precoordinades. Si els requisits per al registre de complicacions són més complexos, s'aconsella fer servir un arquetip CLUSTER específic dins del SLOT \"Detalls del procediment\" d'aquest arquetip. Exemples: Hematúria després d'una biòpsia renal, irritació tissular després de la inserció d'un catèter intravenós."> > ["at0007"] = < text = <"Sol·licitud de procediment enviada"> description = <"Sol·licitud de procediment enviada."> > ["at0014"] = < text = <"Motiu"> description = <"Motiu pel qual es va dur a terme l'activitat o etapa assistencial per al procediment identificat."> comment = <"Per exemple: motiu de la cancel·lació o suspensió del procediment."> > ["at0034"] = < text = <"X - Procediment planificat"> description = <"Aquest apartat ha quedat obsolet, ja que s'associava incorrectament amb l'estat inicial. Utilitzeu el nou apartat \"Procediment planificat\" (at0004), associat correctament amb l'estat \"planificat\"."> comment = <"(Obsolet: Es planifica el procediment a dur a terme.)"> > ["at0035"] = < text = <"X - Sol·licitud de procediment enviada"> description = <"Aquest apartat ha quedat obsolet, ja que s'associava incorrectament amb l'estat inicial. Utilitzeu el nou apartat \"Sol·licitud de procediment enviada\" (at0004), associat correctament amb l'estat \"planificat\"."> comment = <"(Obsolet: Sol·licitud de procediment enviada.)"> > ["at0036"] = < text = <"Procediment programat"> description = <"El procediment s'ha programat."> > ["at0038"] = < text = <"Procediment posposat"> description = <"El procediment s'ha posposat."> > ["at0039"] = < text = <"Procediment cancel·lat"> description = <"S'ha cancel·lat el procediment previst abans de començar."> > ["at0040"] = < text = <"Procediment suspès"> description = <"El procediment s'ha suspès."> > ["at0041"] = < text = <"Procediment interromput"> description = <"El procediment s'ha interromput."> > ["at0043"] = < text = <"Procediment completat"> description = <"S'ha fet el procediment i s'han completat totes les activitats clíniques associades."> > ["at0047"] = < text = <"Procediment realitzat"> description = <"El procediment o subprocediment en un procediment multicomponent s'ha realitzat."> > ["at0048"] = < text = <"Resultat"> description = <"Resultat del procediment realitzat."> comment = <"Sempre que sigui possible, és preferible codificar amb una terminologia."> > ["at0049"] = < text = <"Descripció"> description = <"Descripció narrativa del procediment, segons correspongui a la fase del procés."> comment = <"Per exemple: descripció de la realització i resultats del procediment, l'intent interromput o la cancel·lació del procediment."> > ["at0053"] = < text = <"Tree"> description = <"@ internal @"> > ["at0054"] = < text = <"Identificador d'ordre del sol·licitant"> description = <"L'ID local assignat a l'ordre pel proveïdor sanitari o l'organització que sol·licita el servei."> comment = <"Equivalent al Placer Order Number a les especificacions HL7 v2."> > ["at0055"] = < text = <"Sol·licitant"> description = <"Dades del professional sanitari o organització que sol·licita el servei."> > ["at0056"] = < text = <"Identificador d'ordre del receptor"> description = <"L'identificador assignat a l'ordre pel proveïdor sanitari o organització que rep la sol·licitud de servei. També s'anomena identificador d'ordre d'emplenament."> comment = <"Equivalent al Filler Order Number a les especificacions HL7 v2."> > ["at0057"] = < text = <"Receptor"> description = <"Dades sobre el proveïdor o organització sanitària que rep la sol·licitud de servei."> > ["at0058"] = < text = <"Urgència"> description = <"Urgència del procediment."> comment = <"Sempre que sigui possible, és preferible codificar amb una terminologia."> > ["at0060"] = < text = <"Data/hora de finalització"> description = <"Data i/o hora en què va finalitzar tot el procediment, o l'últim component d'un procediment multicomponent."> comment = <"Només per al seu ús en associació amb l'etapa \"Procediment realitzat\", i en situacions en què el procediment es repeteix diverses vegades abans de completar-se, o hi ha diversos components en tot el procediment. Pot ser el mateix que l'atribut de temps RM de l'etapa \"Procediment completat\"."> > ["at0061"] = < text = <"Durada"> description = <"Quantitat total de temps emprat a completar el procediment, que pot incloure el temps emprat durant la fase activa del procediment més el temps durant el qual el procediment va estar suspès."> comment = <"Només per a ús en associació amb l'etapa \"Procediment completat\"."> > ["at0062"] = < text = <"Multimèdia"> description = <"Representació multimèdia del procediment realitzat."> > ["at0063"] = < text = <"Zona corporal"> description = <"Identificació de la zona del cos per al procediment."> comment = <"Les ocurrències d'aquest element de dades són il·limitades per permetre escenaris clínics com l'extirpació de múltiples lesions cutànies a diferents llocs, però on tots els altres atributs són idèntics. Utilitzeu aquest element de dades per registrar termes senzills o localitzacions anatòmiques precoordinades. Si els requisits per registrar la localització anatòmica es determinen en temps d'execució per l'aplicació o requereixen un modelatge més complex, com ara localitzacions relatives, utilitzeu CLUSTER.anatomical_location o CLUSTER.relative_location al SLOT \"Detalls del procediment\" d'aquest arquetip. Si la localització anatòmica s'inclou al “Nom del procediment” mitjançant codis precoordinats, aquest element de dades serà redundant."> > ["at0064"] = < text = <"Ampliació"> description = <"Informació addicional necessària per registrar contingut local o per alinear-se amb altres models/formalismes de referència."> comment = <"Per exemple: requisits d'informació local o metadades addicionals per alinear-se amb els equivalents de FHIR o CIMI."> > ["at0065"] = < text = <"Mètode"> description = <"Identificació del mètode o tècnica específics per al procediment."> comment = <"Utilitzeu aquest element de dades per registrar termes senzills o una descripció narrativa. Si els requisits per registrar el mètode requereixen una modelització més complexa, aquesta es pot representar mitjançant arquetips addicionals dins del SLOT \"Detall del procediment\" d'aquest arquetip. Si el mètode s'inclou al \"Nom del procediment\" mitjançant codis precoordinats, aquest element de dades serà redundant."> > ["at0066"] = < text = <"Data/hora programada"> description = <"Data i/o hora en què està previst fer el procediment."> comment = <"Només per utilitzar-lo en associació amb l'etapa \"Procediment programat\"."> > ["at0067"] = < text = <"Tipus de procediment"> description = <"Tipus de procediment."> comment = <"Aquest element de dades es pot utilitzar per donar suport a l'organització dins la interfície d'usuari."> > ["at0068"] = < text = <"Procediment iniciat"> description = <"El procediment o subprocediment en un procediment multicomponent s'ha iniciat."> > ["at0069"] = < text = <"Dificultats del procediment"> description = <"Dificultats o problemes trobats durant la realització del procediment."> comment = <"Exemples: El pacient estava agitat, buidat insuficient de l'estómac abans de la gastroscòpia, un tumor a les vies biliars impedia el pas de l'endoscopi."> > ["at0070"] = < text = <"Indicació"> description = <"El motiu, clínic o relacionat amb el procés, del procediment."> comment = <"Sempre que sigui possible, és preferible codificar la indicació amb una terminologia. Aquest element de dades permet múltiples ocurrències. Per exemple: \"Preparació intestinal fallida\" o \"Cribat de càncer d'intestí\"."> > > > >