Modellbiblioteket openEHR Fork
Name
Problem/Diagnosis
Description
Details about a single identified health condition, injury, disability or any other issue which impacts on the physical, mental and/or social well-being of an individual.
Comment
Clear delineation between the scope of a problem versus a diagnosis is not easy to achieve in practice. For the purposes of clinical documentation with this archetype, problem and diagnosis are regarded as a continuum, with increasing levels of detail and supportive evidence usually providing weight towards the label of 'diagnosis'.
Keywords
issue
condition
problem
diagnosis
concern
injury
clinical impression
Purpose
For recording details about a single, identified health problem or diagnosis.
The intended scope of a health problem is deliberately kept loose in the context of clinical documentation, so as to capture any real or perceived concerns that may adversely affect an individual's wellbeing to any degree. A health problem may be identified by the individual, a carer or a healthcare professional. However, a diagnosis is additionally defined based on objective clinical criteria, and usually determined only by a healthcare professional.
Use
Use for recording details about a single, identified health problem or diagnosis.
Clear definitions that enable differentiation between a 'problem' and a 'diagnosis' are almost impossible in practice - we cannot reliably tell when a problem should be regarded as a diagnosis. When diagnostic or classification criteria are successfully met, then we can confidently call the condition a formal diagnosis, but prior to these conditions being met and while there is supportive evidence available, it can also be valid to use the term 'diagnosis'. The amount of supportive evidence required for the label of diagnosis is not easy to define and in reality probably varies from condition to condition. Many standards committees have grappled with this definitional conundrum for years without clear resolution.
For the purposes of clinical documentation with this archetype, problem and diagnosis are regarded as a continuum, with increasing levels of detail and supportive evidence usually providing weight towards the label of 'diagnosis'. In this archetype it is not neccessary to classify the condition as a 'problem' or 'diagnosis'. The data requirements to support documentation of either are identical, with additional data structure required to support inclusion of the evidence if and when it becomes available. Examples of problems include: the individual's expressed desire to lose weight, but without a formal diagnosis of Obesity; or a relationship problem with a family member. Examples of formal diagnoses would include a cancer that is supported by historical information, examination findings, histopathological findings, radiological findings and meets all requirements for known diagnostic criteria. In practice, most problems or diagnoses do not sit at either end of the problem-diagnosis spectrum, but somewhere in between.
This archetype can be used within many contexts. For example, recording a problem or a clinical diagnosis during a clinical consultation; populating a persistent Problem List; or to provide a summary statement within a Discharge Summary document.
In practice, clinicians use many context-specific qualifiers such as past/present, primary/secondary, active/inactive, admission/discharge etc. The contexts can be location-, specialisation-, episode- or workflow-specific, and these can cause confusion or even potential safety issues if perpetuated in Problem Lists or shared in documents that are outside of the original context. These qualifiers can be archetyped separately and included in the ‘Status’ slot, because their use varies in different settings. It is expected that these will be used mostly within the appropriate context and not shared out of that context without clear understanding of potential consequences. For example, a primary diagnosis to one clinician may be a secondary one to another specialist; an active problem can become inactive (or vice versa) and this can impact the safe use of clinical decision support. In general these qualifiers should be applied locally within the context of the clinical system, and in practice these statuses should be manually curated by clinicians to ensure that lists of Current/Past, Active/Inactive or Primary/Secondary Problems are clinically accurate.
This archetype will be used as a component within the Problem Oriented Medical Record as described by Larry Weed. Additional archetypes, representing clinical concepts such as condition as an overarching organiser for diagnoses etc, will need to be developed to support this approach.
In some situations, it may be assumed that identification of a diagnosis fits only within the expertise of physicians, but this is not the intent for this archetype. Diagnoses can be recorded using this archetype by any healthcare professional.
Clear definitions that enable differentiation between a 'problem' and a 'diagnosis' are almost impossible in practice - we cannot reliably tell when a problem should be regarded as a diagnosis. When diagnostic or classification criteria are successfully met, then we can confidently call the condition a formal diagnosis, but prior to these conditions being met and while there is supportive evidence available, it can also be valid to use the term 'diagnosis'. The amount of supportive evidence required for the label of diagnosis is not easy to define and in reality probably varies from condition to condition. Many standards committees have grappled with this definitional conundrum for years without clear resolution.
For the purposes of clinical documentation with this archetype, problem and diagnosis are regarded as a continuum, with increasing levels of detail and supportive evidence usually providing weight towards the label of 'diagnosis'. In this archetype it is not neccessary to classify the condition as a 'problem' or 'diagnosis'. The data requirements to support documentation of either are identical, with additional data structure required to support inclusion of the evidence if and when it becomes available. Examples of problems include: the individual's expressed desire to lose weight, but without a formal diagnosis of Obesity; or a relationship problem with a family member. Examples of formal diagnoses would include a cancer that is supported by historical information, examination findings, histopathological findings, radiological findings and meets all requirements for known diagnostic criteria. In practice, most problems or diagnoses do not sit at either end of the problem-diagnosis spectrum, but somewhere in between.
This archetype can be used within many contexts. For example, recording a problem or a clinical diagnosis during a clinical consultation; populating a persistent Problem List; or to provide a summary statement within a Discharge Summary document.
In practice, clinicians use many context-specific qualifiers such as past/present, primary/secondary, active/inactive, admission/discharge etc. The contexts can be location-, specialisation-, episode- or workflow-specific, and these can cause confusion or even potential safety issues if perpetuated in Problem Lists or shared in documents that are outside of the original context. These qualifiers can be archetyped separately and included in the ‘Status’ slot, because their use varies in different settings. It is expected that these will be used mostly within the appropriate context and not shared out of that context without clear understanding of potential consequences. For example, a primary diagnosis to one clinician may be a secondary one to another specialist; an active problem can become inactive (or vice versa) and this can impact the safe use of clinical decision support. In general these qualifiers should be applied locally within the context of the clinical system, and in practice these statuses should be manually curated by clinicians to ensure that lists of Current/Past, Active/Inactive or Primary/Secondary Problems are clinically accurate.
This archetype will be used as a component within the Problem Oriented Medical Record as described by Larry Weed. Additional archetypes, representing clinical concepts such as condition as an overarching organiser for diagnoses etc, will need to be developed to support this approach.
In some situations, it may be assumed that identification of a diagnosis fits only within the expertise of physicians, but this is not the intent for this archetype. Diagnoses can be recorded using this archetype by any healthcare professional.
Misuse
Not to be used to record symptoms as described by the individual - use the CLUSTER.symptom archetype, usually within the OBSERVATION.story archetype.
Not to be used to record examination findings - use the family of examination-related CLUSTER archetypes, usually nested within the OBSERVATION.exam archetype.
Not to be used to record laboratory test results or related diagnoses, for example pathological diagnoses - use an appropriate archetype from the laboratory family of OBSERVATION archetypes.
Not to be used to record imaging examination results or imaging diagnoses - use an appropriate archetype from the imaging family of OBSERVATION archetypes.
Not to be used to record 'Differential Diagnoses' - use the EVALUATION.differential_diagnosis archetype.
Not to be used to record 'Reason for Encounter' or 'Presenting Complaint' - use the EVALUATION.reason_for_encounter archetype.
Not to be used to record procedures - use the ACTION.procedure archetype.
Not to be used to record details about pregnancy - use the EVALUATION.pregnancy_bf_status and EVALUATION.pregnancy and related archetypes.
Not to be used to record statements about health risk or potential problems - use the EVALUATION.health_risk archetype.
Not to be used to record statements about adverse reactions, allergies or intolerances - use the EVALUATION.adverse_reaction archetype.
Not to be used for the explicit recording of an absence (or negative presence) of a problem or diagnosis, for example ‘No known problem or diagnoses’ or ‘No known diabetes’. Use the EVALUATION.exclusion-problem_diagnosis archetype to express a positive statement about exclusion of a problem or diagnosis.
Not to be used to record examination findings - use the family of examination-related CLUSTER archetypes, usually nested within the OBSERVATION.exam archetype.
Not to be used to record laboratory test results or related diagnoses, for example pathological diagnoses - use an appropriate archetype from the laboratory family of OBSERVATION archetypes.
Not to be used to record imaging examination results or imaging diagnoses - use an appropriate archetype from the imaging family of OBSERVATION archetypes.
Not to be used to record 'Differential Diagnoses' - use the EVALUATION.differential_diagnosis archetype.
Not to be used to record 'Reason for Encounter' or 'Presenting Complaint' - use the EVALUATION.reason_for_encounter archetype.
Not to be used to record procedures - use the ACTION.procedure archetype.
Not to be used to record details about pregnancy - use the EVALUATION.pregnancy_bf_status and EVALUATION.pregnancy and related archetypes.
Not to be used to record statements about health risk or potential problems - use the EVALUATION.health_risk archetype.
Not to be used to record statements about adverse reactions, allergies or intolerances - use the EVALUATION.adverse_reaction archetype.
Not to be used for the explicit recording of an absence (or negative presence) of a problem or diagnosis, for example ‘No known problem or diagnoses’ or ‘No known diabetes’. Use the EVALUATION.exclusion-problem_diagnosis archetype to express a positive statement about exclusion of a problem or diagnosis.
References
Problem/Diagnosis, Draft Archetype [Internet]. National eHealth Transition Authority, NEHTA Clinical Knowledge Manager [cited: 2015-03-12]. Available from: http://dcm.nehta.org.au/ckm/#showArchetype_1013.1.896.
ISO/DIS 13940 Health informatics -- System of concepts to support continuity of care., International Organization for Standardization [Internet]. Available at: http://www.iso.org/iso/catalogue_detail.htm?csnumber=58102 (accessed 2015 -04-09).
Common Terminology Criteria for Adverse Events (CTCAE) [Internet]. National Cancer Institute, USA. Available from: http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm (accessed 2015-07-13).
Weed LL. Medical records that guide and teach. N Engl J Med. 1968 Mar 14;278(11):593-600. PubMed PMID: 5637758. Available from: http://www.nejm.org/doi/full/10.1056/NEJM196803142781105 (accessed 2015-07-13).
Archetype Id
openEHR-EHR-EVALUATION.problem_diagnosis.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
Sam Heard
Ocean Informatics
Ocean Informatics
Date Originally Authored
For recording details about a single, identified health problem or diagnosis.
The intended scope of a health problem is deliberately kept loose in the context of clinical documentation, so as to capture any real or perceived concerns that may adversely affect an individual's wellbeing to any degree. A health problem may be identified by the individual, a carer or a healthcare professional. However, a diagnosis is additionally defined based on objective clinical criteria, and usually determined only by a healthcare professional.
| Language | Details |
|---|---|
| German |
Aljoscha Kindermann, Jasmin Buck, Sebastian Garde, Natalia Strauch, Alina Rehberg
Universityhospital of Heidelberg, University of Heidelberg, Central Queensland University, Medizinische Hochschule Hannover
|
| Swedish |
Kirsi Poikela
Tieto Sweden AB
|
| Finnish | |
| Korean |
Seung-Jong Yu
InfoClinic Co.,Ltd.
|
| Portuguese (Brazil) |
Adriana Kitajima, Gabriela Alves, Maria Angela Scatena, Marivan Abrahäo
Core Consulting
|
| Arabic (Syria) |
Mona Saleh
|
| Italian |
Cecilia Mascia
CRS4 - Center for advanced studies, research and development in Sardinia, Pula (Cagliari), Italy
|
| Chinese (PRC) |
Lin Zhang
Freelancer
|
| Spanish, Castilian |
Pablo Pazos, Julio de Sosa
CaboLabs, Servei Català de la Salut
|
| Chinese |
Yexuan Cheng
浙江大学
|
| Spanish (Argentina) |
Alan March
Hospital Universitario Austral, Buenos Aires, Argentina
|
| Norwegian Bokmal |
Silje Ljosland Bakke, John Tore Valand, Liv Laugen, Vebjørn Arntzen
Helse Bergen HF, Oslo University Hospital, Norway
|
| Dutch |
Joost Holslag
Nedap
|
| Catalan, Valencian |
Elisa Asensio
|
| Name | Card | Type | Description |
|---|---|---|---|
|
Problem/Diagnosis name
|
1..1 | DV_TEXT |
Identification of the problem or diagnosis, by name.
Comment
Coding of the name of the problem or diagnosis with a terminology is preferred, where possible.
|
|
Variant
|
0..* | DV_TEXT |
Specific variant or subtype of the Diagnosis, if relevant.
Comment
For example: 'acute motor axonal neuropathy' as a variant of Guillain-Barre Syndrome. Coding of the name of the variant with a terminology is preferred, where possible.
|
|
Clinical description
|
0..1 | DV_TEXT |
Narrative description about the problem or diagnosis.
Comment
Use to provide background and context, including evolution, episodes or exacerbations, progress and any other relevant details, about the problem or diagnosis.
|
|
Body site
|
0..* | DV_TEXT |
Identification of a simple body site for the location of the problem or diagnosis.
Comment
Coding of the name of the anatomical location with a terminology is preferred, where possible.
Use this data element to record precoordinated anatomical locations. If the requirements for recording the anatomical location are determined at run-time by the application or require more complex modelling such as relative locations then use the CLUSTER.anatomical_location or CLUSTER.relative_location within the 'Structured anatomical location' SLOT in this archetype. Occurrences for this data element are unbounded to allow for clinical scenarios such as describing a rash in multiple locations but where all of the other attributes are identical. If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant.
|
|
Structured body site
|
0..* | Slot (Cluster) |
A structured anatomical location for the problem or diagnosis.
Comment
Use this SLOT to insert the CLUSTER.anatomical_location or CLUSTER.relative_location archetypes 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.
If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, use of this SLOT becomes redundant.
Slot
Slot
|
|
Cause
|
0..* | DV_TEXT |
A cause, set of causes, or manner of causation of the problem or diagnosis.
Comment
Also known as 'aetiology' or 'etiology'. Coding with an external terminology is preferred, where possible.
|
|
Date/time of onset
|
0..1 | DV_DATE_TIME |
Estimated or actual date/time that signs or symptoms of the problem/diagnosis were first observed.
Comment
Data captured/imported as "Age at onset" should be converted to a date using the subject's date of birth.
DV_DATE_TIME
|
|
Date/time clinically recognised
|
0..1 | DV_DATE_TIME |
Estimated or actual date/time the diagnosis or problem was recognised by a healthcare professional.
Comment
Partial dates are acceptable. If the subject of care is under the age of one year, then the complete date or a minimum of the month and year is necessary to enable accurate age calculations - for example, if used to drive decision support. Data captured/imported as "Age at time of clinical recognition" should be converted to a date using the subject's date of birth.
DV_DATE_TIME
|
|
Severity
|
0..1 |
CHOICE OF
DV_CODED_TEXT
DV_TEXT
|
An assessment of the overall severity of the problem or diagnosis.
Comment
If severity is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant. Note: more specific grading of severity can be recorded using the Specific details SLOT.
Constraint for DV_CODED_TEXT
|
|
Specific details
|
0..* | Slot (Cluster) |
Details that are additionally required to record as unique attributes of this problem or diagnosis.
Comment
May include structured detail about the grading or staging of the diagnosis; diagnostic criteria, classification criteria or formal severity assessments such as Common Terminology Criteria for Adverse Events.
Slot
Slot
|
|
Course description
|
0..1 | DV_TEXT |
Narrative description about the course of the problem or diagnosis since onset.
|
|
Date/time of resolution
|
0..1 | DV_DATE_TIME |
Estimated or actual date/time of resolution or remission for this problem or diagnosis, as determined by a healthcare professional.
Comment
Partial dates are acceptable. If the subject of care is under the age of one year, then the complete date or a minimum of the month and year is necessary to enable accurate age calculations - for example, if used to drive decision support. Data captured/imported as "Age at time of resolution" should be converted to a date using the subject's date of birth.
DV_DATE_TIME
|
|
Status
|
0..* | Slot (Cluster) |
Structured details for location-, domain-, episode- or workflow-specific aspects of the diagnostic process.
Comment
Use status or context qualifiers with care, as they are variably used in practice and interoperability cannot be assured unless usage is clearly defined with the community of use. For example: active status - active, inactive, resolved, in remission; evolution status - initial, interim/working, final; temporal status - current, past; episodicity status - first, new, ongoing; admission status - admission, discharge; or priority status - primary, secondary.
Slot
Slot
|
|
Diagnostic certainty
|
0..1 |
CHOICE OF
DV_CODED_TEXT
DV_TEXT
|
The level of confidence in the identification of the diagnosis.
Comment
If an alternative valueset is required, these values can be added to the DV_TEXT data type in a template.
Constraint for DV_CODED_TEXT
|
|
Comment
|
0..1 | DV_TEXT |
Additional narrative about the problem or diagnosis not captured in other fields.
|
| Name | Card | Type | Description |
|---|---|---|---|
|
Last updated
|
0..1 | DV_DATE_TIME |
The date this problem or diagnosis was last updated.
DV_DATE_TIME
|
|
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
|
archetype (adl_version=1.4; uid=cc3a20b3-8928-4c2a-babd-fe9e28987be7) openEHR-EHR-EVALUATION.problem_diagnosis.v1 concept [at0000] -- Problem/Diagnosis language original_language = <[ISO_639-1::en]> translations = < ["de"] = < language = <[ISO_639-1::de]> author = < ["name"] = <"Aljoscha Kindermann, Jasmin Buck, Sebastian Garde, Natalia Strauch, Alina Rehberg"> ["organisation"] = <"Universityhospital of Heidelberg, University of Heidelberg, Central Queensland University, Medizinische Hochschule Hannover"> ["email"] = <"Strauch.Natalia@mh-hannover.de, rehberg.alina@mh-hannover.de"> > > ["sv"] = < language = <[ISO_639-1::sv]> author = < ["name"] = <"Kirsi Poikela"> ["organisation"] = <"Tieto Sweden AB"> ["email"] = <"ext.kirsi.poikela@tieto.com"> > > ["fi"] = < language = <[ISO_639-1::fi]> author = < > > ["ko"] = < language = <[ISO_639-1::ko]> author = < ["name"] = <"Seung-Jong Yu"> ["organisation"] = <"InfoClinic Co.,Ltd."> ["email"] = <"seungjong.yu@gmail.com"> > accreditation = <"M.D."> > ["pt-br"] = < language = <[ISO_639-1::pt-br]> author = < ["name"] = <"Adriana Kitajima, Gabriela Alves, Maria Angela Scatena, Marivan Abrahäo"> ["organisation"] = <"Core Consulting"> ["email"] = <"contato@coreconsulting.com.br"> > accreditation = <"Hospital Alemão Oswaldo Cruz (HAOC)"> > ["ar-sy"] = < language = <[ISO_639-1::ar-sy]> author = < ["name"] = <"Mona Saleh"> > > ["it"] = < language = <[ISO_639-1::it]> author = < ["name"] = <"Cecilia Mascia"> ["organisation"] = <"CRS4 - Center for advanced studies, research and development in Sardinia, Pula (Cagliari), Italy"> ["email"] = <"cecilia.mascia@crs4.it"> > > ["zh-cn"] = < language = <[ISO_639-1::zh-cn]> author = < ["name"] = <"Lin Zhang"> ["organisation"] = <"Freelancer"> ["email"] = <"linforest@163.com"> > > ["es"] = < language = <[ISO_639-1::es]> author = < ["name"] = <"Pablo Pazos, Julio de Sosa"> ["organisation"] = <"CaboLabs, Servei Català de la Salut"> ["email"] = <"juliodesosa@catsalut.cat"> > accreditation = <"Computer Engineer"> > ["zh"] = < language = <[ISO_639-1::zh]> author = < ["name"] = <"Yexuan Cheng"> ["organisation"] = <"浙江大学"> ["email"] = <"3160100913@zju.edu.cn"> > > ["es-ar"] = < language = <[ISO_639-1::es-ar]> author = < ["name"] = <"Alan March"> ["organisation"] = <"Hospital Universitario Austral, Buenos Aires, Argentina"> ["email"] = <"alandmarch@gmail.com"> > accreditation = <"-"> > ["nb"] = < language = <[ISO_639-1::nb]> author = < ["name"] = <"Silje Ljosland Bakke, John Tore Valand, Liv Laugen, Vebjørn Arntzen"> ["organisation"] = <"Helse Bergen HF, Oslo University Hospital, Norway"> ["email"] = <"liv.laugen@ous-hf.no, varntzen@ous-hf.no"> > > ["nl"] = < language = <[ISO_639-1::nl]> author = < ["name"] = <"Joost Holslag"> ["organisation"] = <"Nedap"> ["email"] = <"joost.holslag@nedap.com"> > accreditation = <"MD"> > ["ca"] = < language = <[ISO_639-1::ca]> author = < ["name"] = <"Elisa Asensio"> ["email"] = <"easensiob@clinic.cat"> > > > description original_author = < ["name"] = <"Sam Heard"> ["organisation"] = <"Ocean Informatics"> ["email"] = <"sam.heard@oceaninformatics.com"> ["date"] = <"2006-04-23"> > details = < ["de"] = < language = <[ISO_639-1::de]> purpose = <"Zur Darstellung von Details über ein einzelnes identifiziertes gesundheitliches Problem oder eine Diagnose. Der angestrebte Anwendungsbereich eines gesundheitlichen Problems wurde im Rahmen der medizinischen Dokumentation bewusst breit gehalten, um die reale und wahrgenommene Beeinträchtigungen, die auf das Wohlbefinden eines Individuums nachteilig auswirken könnten, zu erfassen. Ein gesundheitliches Problem kann durch das Individuum selber, durch einen Betreuer oder eine medizinische Fachkraft festgestellt werden. Im Gegensatz dazu wird eine Diagnose zusätzlich durch objektive klinische Kriterien definiert und wird normalerweise nur durch eine medizinische Fachkraft festgestellt."> use = <"Zur Dokumentation eines einzelnen identifizierten gesundheitlichen Problems bzw. einer Diagnose. Klare Definitionen, welche eine eindeutige Abgrenzung zwischen einem 'Problem' und einer 'Diagnose' zulassen würden, sind in der praktischen Anwendung nahezu unmöglich - wir können nicht verlässlich festlegen, wann ein Problem als Diagnose angesehen werden sollte. Wenn Diagnose- oder Klassifizierungskriterien zutreffen, können wir einen Gesundheitszustand mit Bestimmtheit als Diagnose bezeichnen. Jedoch kann, auch wenn diese Kriterien noch nicht zutreffen, die Bezeichnung 'Diagnose' zutreffend sein. Die Menge an unterstützenden Hinweisen, die für die Bezeichnung 'Diagnose' notwendig ist, ist nicht einfach festzulegen und variiert in Wirklichkeit wohl abhängig vom Gesundheitszustand. Viele Normungsgremien haben sich mit dieser Definitionsproblematik seit Jahren befasst, ohne zu einem eindeutigen Ergebnis zu kommen. Für den Zweck der klinischen Dokumentation im Zuge dieses Archetyps werden Problem und Diagnose als Kontinuum betrachtet, wobei ein zunehmender Detaillierungsgrad und unterstützende Beweise in der Regel dem Label der 'Diagnose' Gewicht verleihen. In diesem Archetyp ist es nicht notwendig eine Zuordnung des Gesundheitszustandes als 'Problem' oder 'Diagnose' vorzunehmen. Die Datenanforderungen zur Unterstützung der beiden sind identisch, wobei eine zusätzliche Datenstruktur erforderlich ist, um die Einbeziehung der Nachweise zu unterstützen, wenn und sobald sie verfügbar sind. Beispiele von Problemen beinhalten: Der vom Individuum geäußerte Wunsch, Gewicht zu verlieren, ohne die formale Diagnose der Fettleibigkeit; oder ein Beziehungsproblem mit einem Familienmitglied. Beispiele formaler Diagnosen beinhalten: Krebs, welcher durch historische Information gestützt wird; Untersuchungsergebnisse; histopathologische Ergebnisse; radiologische Befunde - Diese erfüllen die Anforderungen an diagnostische Kriterien. In der Realität sind Probleme und Diagnosen nicht eindeutig einem der beiden Extreme des Problem-Diagnose-Spektrums zuzuordnen, sondern irgendwo dazwischen. Dieser Archetyp kann in verschiedenen Zusammenhängen verwendet werden. Zum Beispiel: Dokumentation eines Problems oder einer Diagnose während einer klinischen Beratung; Ausfüllen einer persistenten Problemliste; Zusammenfassende Aussage in einem Entlassungsdokument. In der Praxis verwenden Kliniker viele kontextspezifische Merkmale wie Vergangenheit/Gegenwart, Primär/Sekundär, Aktiv/Inaktiv, Aufnahme/Entlassung etc. Die Zusammenhänge können orts-, spezialisierungs-, episoden- oder workflowspezifisch sein, was zu Verwirrung oder gar potenziellen Sicherheitsproblemen führen kann, wenn die Merkmale in Problemlisten fortbestehen oder in Dokumenten geteilt werden, die außerhalb des ursprünglichen Kontextes liegen. Diese Merkmale können separat archetypisiert und in den Slot 'Status' aufgenommen werden, da ihre Verwendung unter verschiedenen Bedingungen variiert. Es wird erwartet, dass diese meist im entsprechenden Kontext verwendet und nicht ohne klares Verständnis der möglichen Folgen aus diesem Kontext heraus geteilt werden. So kann beispielsweise eine Primärdiagnose des einen Arztes eine Sekundärdiagnose für einen anderen Spezialisten darstellen; ein aktives Problem kann inaktiv werden (oder umgekehrt) und dies kann sich auf die sichere Verwendung der klinischen Entscheidungshilfe auswirken. Die Problem/Diagnose Merkmale sollen generell an die Kontexte der lokalen klinischen Systeme angepasst werden und in der Praxis sollte der jeweilige Status von Klinikern manuell kuratiert werden, um sicherzustellen, dass die Listen der aktuellen/vergangenen, aktiven/inaktiven oder primären/sekundären Probleme klinisch korrekt sind. Dieser Archetyp wird als Komponente im Sinne des von Larry Weed beschriebenen 'Problem Oriented Medical Record' verwendet. Zusätzliche Archetypen, die klinische Konzepte wie z.B. die Erkrankung als übergreifender Organisator für Diagnosen usw. repräsentieren, müssen entwickelt werden, um diesen Ansatz zu unterstützen. In einigen Situationen könnte angenommen werden, dass die Identifizierung einer Diagnose nur innerhalb der Expertise von Ärzten liegt, aber das ist nicht die Absicht dieses Archetyps. Diagnosen können mit diesem Archetyp von jedem Angehörigen der Gesundheitsberufe erfasst werden."> keywords = <"Sachverhalt", "Beschwerde", "Problem", "Diagnose", "Befinden", "Verletzung", "Klinisches Bild"> misuse = <"Nicht zur Dokumentation von Symptomen, welche vom Individuum beschrieben werden. Verwenden Sie den Archetyp CLUSTER.symptom, normalerweise innerhalb des OBSERVATION.story Archetyps. Nicht zur Dokumentation von Untersuchungsergebnissen. Verwenden Sie untersuchungsbezogene CLUSTER Archetypen, normalerweise verschachtelt innerhalb des OBSERVATION.exam Archetyps. Nicht zur Dokumentation von Laborergebnissen oder verwandten Diagnosen. Verwenden Sie einen geeigneten Archetyp aus der Familie der Labor-OBSERVATION Archetypen. Nicht zur Dokumentation von Ergebnissen aus bildgebenden Verfahren. Verwenden Sie einen geeigneten Archetyp aus der Famile der Bildgebung-OBSERVATION Archetypen. Nicht zur Dokumentation von Differentialdiagnosen. Verwenden Sie den Archetyp EVALUATION.differential_diagnosis. Nicht zur Dokumentation von 'Grund für Kontakt' oder 'Bestehende Beschwerden'. Verwenden Sie den Archetyp EVALUATION.reason_for_encounter. Nicht zur Dokumentation von Prozeduren. Verwenden Sie den Archetyp ACTION.procedure. Nicht zur Dokumentation von Details über Schwangerschaft. Verwenden Sie die Archetypen EVALUATION.pregnancy_bf_status und EVALUATION.pregnancy sowie verwandte Archetypen. Nicht zur Dokumentation von Aussagen über Gesundheitsrisiken oder potentielle Gesundheitsprobleme. Verwenden Sie den Archetyp EVALUATION.health_risk. Nicht zur Dokumentation von Aussagen über Nebenwirkungen, Allergien oder Intoleranzen. Verwenden Sie den Archetyp EVALUATION.adverse_reaction. Nicht zur Dokumentation einer expliziten Abwesenheit oder Nicht-Anwesenheit eines Problems oder einer Diagnose, wie zum Beispiel 'Kein bekanntes Problem bzw. Diagnose' oder 'Kein Diabetes festgestellt'. Verwenden Sie den Archetyp EVALUATION.exclusion-problem_diagnosis um eine postitive Aussage über den Ausschluss eines Problems oder einer Diagnose zu treffen."> copyright = <"© openEHR Foundation"> > ["fi"] = < language = <[ISO_639-1::fi]> purpose = <"*For recording details about a single, identified health problem or diagnosis. The intended scope of a health problem is deliberately kept loose in the context of clinical documentation, so as to capture any real or perceived concerns that may adversely affect an individual's wellbeing to any degree. A health problem may be identified by the individual, a carer or a healthcare professional. However, a diagnosis is additionally defined based on objective clinical criteria, and usually determined only by a healthcare professional.(en)"> use = <"*Use for recording details about a single, identified health problem or diagnosis. Clear definitions that enable differentiation between a 'problem' and a 'diagnosis' are almost impossible in practice - we cannot reliably tell when a problem should be regarded as a diagnosis. When diagnostic or classification criteria are successfully met, then we can confidently call the condition a formal diagnosis, but prior to these conditions being met and while there is supportive evidence available, it can also be valid to use the term 'diagnosis'. The amount of supportive evidence required for the label of diagnosis is not easy to define and in reality probably varies from condition to condition. Many standards committees have grappled with this definitional conundrum for years without clear resolution. For the purposes of clinical documentation with this archetype, problem and diagnosis are regarded as a continuum, with increasing levels of detail and supportive evidence usually providing weight towards the label of 'diagnosis'. In this archetype it is not neccessary to classify the condition as a 'problem' or 'diagnosis'. The data requirements to support documentation of either are identical, with additional data structure required to support inclusion of the evidence if and when it becomes available. Examples of problems include: the individual's expressed desire to lose weight, but without a formal diagnosis of Obesity; or a relationship problem with a family member. Examples of formal diagnoses would include a cancer that is supported by historical information, examination findings, histopathological findings, radiological findings and meets all requirements for known diagnostic criteria. In practice, most problems or diagnoses do not sit at either end of the problem-diagnosis spectrum, but somewhere in between. This archetype can be used within many contexts. For example, recording a problem or a clinical diagnosis during a clinical consultation; populating a persistent Problem List; or to provide a summary statement within a Discharge Summary document. In practice, clinicians use many context-specific qualifiers such as past/present, primary/secondary, active/inactive, admission/discharge etc. The contexts can be location-, specialisation-, episode- or workflow-specific, and these can cause confusion or even potential safety issues if perpetuated in Problem Lists or shared in documents that are outside of the original context. These qualifiers can be archetyped separately and included in the ‘Status’ slot, because their use varies in different settings. It is expected that these will be used mostly within the appropriate context and not shared out of that context without clear understanding of potential consequences. For example, a primary diagnosis to one clinician may be a secondary one to another specialist; an active problem can become inactive (or vice versa) and this can impact the safe use of clinical decision support. In general these qualifiers should be applied locally within the context of the clinical system, and in practice these statuses should be manually curated by clinicians to ensure that lists of Current/Past, Active/Inactive or Primary/Secondary Problems are clinically accurate. This archetype will be used as a component within the Problem Oriented Medical Record as described by Larry Weed. Additional archetypes, representing clinical concepts such as condition as an overarching organiser for diagnoses etc, will need to be developed to support this approach. In some situations, it may be assumed that identification of a diagnosis fits only within the expertise of physicians, but this is not the intent for this archetype. Diagnoses can be recorded using this archetype by any healthcare professional.(en)"> keywords = <"*issue(en)", "*condition(en)", "*problem(en)", "*diagnosis(en)", "*concern(en)", "*injury(en)", "*clinical impression(en)"> misuse = <"*Not to be used to record symptoms as described by the individual - use the CLUSTER.symptom archetype, usually within the OBSERVATION.story archetype. Not to be used to record examination findings - use the family of examination-related CLUSTER archetypes, usually nested within the OBSERVATION.exam archetype. Not to be used to record laboratory test results or related diagnoses, for example pathological diagnoses - use an appropriate archetype from the laboratory family of OBSERVATION archetypes. Not to be used to record imaging examination results or imaging diagnoses - use an appropriate archetype from the imaging family of OBSERVATION archetypes. Not to be used to record 'Differential Diagnoses' - use the EVALUATION.differential_diagnosis archetype. Not to be used to record 'Reason for Encounter' or 'Presenting Complaint' - use the EVALUATION.reason_for_encounter archetype. Not to be used to record procedures - use the ACTION.procedure archetype. Not to be used to record details about pregnancy - use the EVALUATION.pregnancy_bf_status and EVALUATION.pregnancy and related archetypes. Not to be used to record statements about health risk or potential problems - use the EVALUATION.health_risk archetype. Not to be used to record statements about adverse reactions, allergies or intolerances - use the EVALUATION.adverse_reaction archetype. Not to be used for the explicit recording of an absence (or negative presence) of a problem or diagnosis, for example ‘No known problem or diagnoses’ or ‘No known diabetes’. Use the EVALUATION.exclusion-problem_diagnosis archetype to express a positive statement about exclusion of a problem or diagnosis.(en)"> > ["sv"] = < language = <[ISO_639-1::sv]> purpose = <"Att dokumentera ett enskilt identifierat hälsoproblem eller diagnos. Spännvidden av ett hälsoproblem har avsiktligt gjorts bred, för att kunna fånga upp eventuella verkliga eller upplevda *oroskänslor* som kan inverka negativt på en individs välbefinnande. Ett hälsoproblem kan identifieras av individen, en vårdgivare eller en sjukvårdspersonal. En diagnos definieras däremot baserat på objektiva kliniska kriterier, oftast fastställd endast av sjukvårdspersonal."> use = <"Används för att beskriva ett enskilt identifierat hälsoproblem eller diagnos. Tydliga definitioner som möjliggör en differentiering mellan ett \"problem\" och en \"diagnos\" är nästan omöjliga i praktiken. Vi kan inte på ett tillförlitligt sätt säga när ett problem bör betraktas som en diagnos. När diagnostiska eller klassificeringskriterier är uppfyllda kan vi tryggt kalla tillståndet en formell diagnos. Om det finns stödjande bevis tillgängligt, kan det ändå vara giltigt att använda termen \"diagnos\" trots att dessa villkor ännu inte uppfyllts. Det är inte lätt att definiera mängden stödjande bevis som krävs för diagnosmärkning och i verkligheten varierar det från fall till fall. Många standardkommittéer har brottats med denna definitionsgåta i åratal utan tydlig upplösning. Vid tillämpning av klinisk dokumentation med denna arketyp betraktas problem och diagnoser som ett kontinuum med utrymme för fler detaljer och stödjande bevis som vanligtvis ger stöd för märkningen \"diagnos\". I denna arketyp är det inte nödvändigt att klassificera tillståndet som ett \"problem\" eller \"diagnos\". Kraven för att stödja dokumentation av vardera är identiska, innehållande extra datastruktur som krävs för att stödja inmatning av bevis om och när den blir tillgänglig. Exempel på problem är: individens uttryckliga önskan att gå ner i vikt, men utan en formell diagnos av fetma eller ett relationsproblem med en familjemedlem. Exempel på formella diagnoser skulle omfatta cancer som stöds av anamnes, undersökningsfynd, histopatologiska fynd, radiologiska fynd samt möter alla kända kriteriekrav för diagnostik. I praktiken befinner sig de flesta problem eller diagnoser inte i någon ände av problemet-diagnos spektrumet, utan någonstans däremellan. Denna arketyp kan användas i flera kontexter, exempelvis för dokumentation av ett problem eller en klinisk diagnos under en klinisk konsultation, ifyllnad av en fast problemlista eller för en redogörande sammanfattning i ett utskrivningsdokument. I praktiken använder kliniker många kontext-specifika bestämningar som exempelvis tidigare och nuvarande, primär och sekundär, aktiv och inaktiv, inskrivning och utskrivning etc. Kontexterna kan vara plats-, specialitet-, episod-eller arbetsflödes-specifika. Dessa kan orsaka förvirring eller t.o.m. vara potentiella säkerhetsproblem om de förevigas i problemlistor eller delas i dokument som är utanför den ursprungliga kontexten. Dessa bestämningar kan vara separata i arketyperna och ingår i \"status\"-fältet, eftersom deras användning varierar i olika inställningar. Det förväntas att de huvudsakligen används i en lämplig kontext och inte sprids utanför kontexten utan tydlig förståelse för potentiella konsekvenser. Exempelvis kan en diagnos vara primär för en kliniker och sekundär för en annan specialist, ett aktivt problem kan bli inaktivt (eller vice versa) och detta kan påverka den säkra användningen av kliniskt beslutsstöd. I allmänhet bör dessa bestämningar tillämpas lokalt inom ramen för det kliniska systemet, och i praktiken bör dessa tillstånd ordnas manuellt av kliniker för att säkerställa att listor över nuvarande och tidigare, aktiv och inaktiv eller primärt och sekundärt problem är kliniskt korrekta. Denna arketyp kommer att användas som en komponent inom den problemorienterade patientjournalen som beskrivs av Larry Weed. Ytterligare arketyper, som presenterar kliniska begrepp som villkor som en övergripande organisatör för diagnoser etc. kommer att behöva utvecklas för att stödja denna strategi. I vissa situationer, kan identifiering av en diagnos vara lämplig enbart inom läkarnas expertis, men det är inte avsikten med denna arketyp. Diagnoser kan dokumenteras med hjälp av denna arketyp av vilken som helst sjukvårdspersonal. "> keywords = <"*fråga", "tillstånd", "problem", "diagnos", "oro", "skada", "klinisk tolkning"> misuse = <"Ska inte användas för att dokumentera symtom som beskrivs av individen. Använd CLUSTER. symptom arketypen vanligtvis inom OBSERVATION.story-arketypen för det ändamålet. Ska inte användas för att dokumentera undersökningsfynd. Använda då istället arketyper från den undersökningsrelaterade gruppen CLUSTER- som oftast är inkapslad i Observation Exam-arketypen. Ska inte användas för att dokumentera testresultat från laboratoriet eller till relaterade diagnoser, exempelvis patologiska diagnoser. Använd då istället en lämplig arketyp från laboratoriegruppen OBSERVATION. Ska inte användas för att dokumentera undersökningsfynd genom bildmedia eller bilddiagnostik. Använd då istället en lämplig arketyp från bildmediegruppen OBSERVATION arketyper. Ska inte användas för att dokumentera \"differentialdiagnostik\". Använd då istället EVALUATION.differential_diagnosis-arketypen. Ska inte användas för att dokumentera \"Anledning till Vårdtillfälle\" eller \"Huvudsakligt besvär\". Använd EVALUATION.reason_for_encounter-arketypen till dessa ändamål. Ska inte användas för att dokumentera åtgärder. Använd då istället ACTION.procedure-arketypen. Ska inte användas för att dokumentera uppgifter om graviditet. Använd EVALUATION.pregnancy_bf_status och EVALUATION.pregnancy och relaterade arketyper till dessa ändamål. Ska inte användas för att dokumentera bedömningar om hälsorisker eller potentiella problem. Använd då istället EVALUATION.health_risk-arketypen. Ska inte användas för att dokumentera redogörelser om biverkningar, allergier eller intoleranser. Använd EVALUATION.adverse_reaction-arketyp för dessa ändamål. Ska inte användas för särskild dokumentering av frånvaro (eller negativ närvaro) av ett problem eller en diagnos, exempelvis \"inga kända problem eller diagnoser\" eller \"Ingen känd diabetes\". Använd EVALUATION.exclusion-problem_arketypen för att uttrycka ett positivt utlåtande om uteslutning av ett problem eller diagnos. "> > ["ko"] = < language = <[ISO_639-1::ko]> purpose = <"단일한 확인된 건강 문제 또는 진단에 대한 상세내역을 기록하기 위함. 의도된 건강 문제의 범위는 어느 정도로 개인의 웰빙에 좋지않은 방향으로 영향을 주는 모든 실제 또는 인지된 걱정(concern)를 획득하기 위해 궁극적으로 임상 문서의 문맥에서 느슨하게 유지됨. 건강 문제는 해당 개인, 또는 보호자, 헬스케어 전문가에 의해 확인될 수도 있음. 그러나 진단은 객관적인 임상적 기준에 근거하여 추가적으로 정의되며, 일반적으로 헬스케어 전문가들에 의해서만 결정됨."> use = <"단일한 확인된 건강 문제 또는 진단에 대한 상세내역을 기록하기 위함. '문제(problem)'와 '진단(diagnosis)' 간의 차이를 구분할 수 있는 명확한 정의는 실무에서 거의 불가능함 - 우리는 문제가 언제 진단으로 간주되어야 하는지를 신뢰성있게 구별할 수 없음. 진단 또는 분류 기준이 성공적으로 만족될 때, 우리는 상태(condition)를 정규적인 진단으로 확실하게 말할 수 있지만, 이런 상태를 만족하기 이전에, 지지할 수 있는 증거를 이용가능하다면 '진단'이라는 용어를 또한 사용하는 것이 유효할 수 있음. 진단이라는 표시를 위해 필요한 지지할 수 있는 증거의 양은 정의하기 쉽지 않고 실제로 상태에 따라 다양할 수 있음. 많은 표준 기구는 수 년 동안 명확한 해결책없이 이러한 정의적인 문제로 가득 차 있음. 이 아키타입을 통한 임상 문서의 목적을 위해서, 증가하는 상세내용의 수준과 일반적으로 '진단'의 표시에 대한 무게감을 제공하는 지지할 수 있는 증거를 가지고, 문제와 진단은 연속된 것(a continuum)으로 간주됨. 이 아키타입 내에서 상태를 '문제' 또는 '진단'로 분류할 필요는 없음. 두 가지의 문서화를 보조하기 위한 데이터 요구사항은 동일하며, 증거가 이용가능하거나/이용가능할 때 이 증거의 포함(inclusion)을 지원하는 데 필요한 추가적인 데이터 구조를 가지고 있음. 문제의 예는 다음을 포함함 : 체중을 줄이고 싶다는 개인의 표현, 그러나 비만의 정규적인 진단은 없음. 또는 가정 구성원과의 관계 문제. 정규적인 진단의 예는 과거 정보와 검사 소견, 조직병리학적 소견, 영상의학적 소견에 의해 지지되고 알려진 진단적 기준을 위한 모든 요구사항을 만족하는 암이 포함됨. 실무에서 대부분의 문제와 진단은 문제-진단 스펙트럼의 양 끝에 있지 않지만 그 사이 어딘가에 있음. 이 아키타입은 많은 문맥 내에서 사용될 수 있음. 예를 들어, 임상 자문 동안 문제 또는 임상적 진단를 기록하는 것; 영속적인 문제 목록(persistent Problem List)을 채우는 것; 또는 퇴원 요약 문서(Dischatge Summary document) 내에 요약 문장(summary statement)을 제공하는 것. 실무에서 임상의는 과거/현재(Present/Past), 일차/이차(Primary/Secondary), 활성/비활성(Active/Inactive), 입원/퇴원(Admission/Discharge) 등 많은 문맥-특징적인 한정자(qualifiers)를 사용함. 문맥은 위치-, 세부전공-, 에피소드-, 워크플로우-특징적 이며 이러한 것들은 원래 문맥에서 벗어난 문제 목록에서 유지되거나 문서 내에서 공유된다면 혼란 또는 심어서 잠재적인 안전 이슈를 발생시킬 수 있음. 이러한 한정자의 이용이 잠재적인 결과에 대한 명확한 이해없이 문맥에 따라 다양하기 때문에, 한정자는 구분되어 아키타입화될 수 있고 'Status' slot에 포함될 수 있음. 예를 들어, 어떤 한 임상의의 일차 진단은 다른 전문의에게는 이차 진단일 수 있음; 현재 활성화된(active) 진단은 비활성화될 수 있음 (또는 그 반대) 그리고 이것은 안전한 임상의사결정의 사용에 영향을 줄 수 있음. 일반적으로 이러한 한정자는 임상 시스템의 문맥 내에서 그 부분에서 적용되어야 하고, 실무에서 이러한 상태는, 현재/과거 또는 활성/비활성, 일차/이차 문제의 목록은 임상적으로 정확하다는 것을 보장하기위해서 임상의에 의해 수기로 조정될 수 있음. 이 아키타입은 Larry Weed가 기술한 문제지향의무기록(Problem Oriented Medical Record) 내에서 컴포넌트로 사용될 것임. 상태와 같은 임상 개념을 진단을 위한 포괄적인 구성자(organizer)로 표현하는 추가적인 아키타입은 이러한 접근방식을 지원하기 위해 개발될 필요가 있을 것임. 몇몇 상황에서, 진단의 확인은 임상의의 전문성 안에서만 적용한다는 가정이 될 수 있지만 이것은 이 아카타입이 의도하는 바는 아님. 모든 헬스케어 전문가가 이 아키타입을 이용해 진단을 기록할 수 있음."> keywords = <"이슈", "상태", "진단", "걱정", "상해", "임상소견"> misuse = <"개인에 의해 기술된 증상을 기록하는데 사용하지 않아야 함 - 보통 OBSERVATION.story archetype 내에서 CLUSTER.symptom archetype을 사용해야 함. 검사 소견을 기록하는데 사용하지 않아야 함 - 보통 OBSERVATION.exam archetype 내에 중첩되어, examination-related CLUSTER archetypes 계열을 사용해야 함. 검사실 검사 결과 또는 병리학적 검사와 같은 관련된 진단을 기록하는데 사용하지 않아야 함 - 보통 검사실 계열의 OBSERVATION archetype에서 적당한 archetype을 사용해야 함. 이미지 검사 결과 또는 이미지 진단을 기록하는데 사용하지 않아야 함 - 이미지 계열의 OBSERVATION archetype에서 적당한 archetype을 사용해야 함. '감별 진단'을 기록하는데 사용하지 않아야 함 - EVALUATION.differential_diagnosis archetype을 사용해야 함. '내원의 이유(Reason for Encounter)' 또는 '주호소(Presenting Complaint)'를 기록하는데 사용지 않아야 함 - EVALUATION.reason_for_encounter archetype을 사용해야 함. '처치(procedure)'를 기록하는데 사용하지 않아야 함 - ACTION.procedure archetype를 사용해야 함. 임신에 대한 상세내용을 기록하는데 사용하지 않아야 함 - EVALUATION.pregnancy_bf_status와 EVALUATION.pregnancy 그리고 관련된 archetypes를 사용해야 함. 건강 위험요소(health risk) 및 잠재적인 문제에 대한 진술문을 기록하는데 사용하지 않아야 함 - EVALUATION.health_risk archetype을 사용해야 함. 이상반응(adverse reactions), 알레르기(allergies) 또는 불내성(intolerances)에 대한 진술문을 기록하는데 사용하지 않아야 함 - EVALUATION.adverse_reaction archetype을 사용해야 함. '알려진 문제 또는 진단 없음' 또는 '알려진 당뇨병 없음' 등과 같은 문제와 진단의 부재(absence (or negative presence))을 명시적으로 기록하는데 사용하지 않아야 함 - 문제 또는 진단의 배제(exclusion)에 대한 긍정 진술문(positive statement)을 표현하는데 EVALUATION.exclusion-problem_diagnosis archetype을 사용해야 함."> > ["pt-br"] = < language = <[ISO_639-1::pt-br]> purpose = <"Para gravar detalhes sobre um único problema de saúde ou diagnóstico identificado. O escopo pretendido de um problema de saúde é deliberadamente mantido livre no contexto da documentação clínica, de forma a captar quaisquer preocupações reais ou percebidas que podem afetar adversamente, em qualquer grau, o bem-estar de um indivíduo. Um problema de saúde pode ser identificado pela o indivíduo, um prestador de cuidados ou de um profissional de saúde. No entanto, o diagnóstico é adicionalmente definido com base em critérios clínicos objetivos, e, geralmente, determinado apenas por um profissional de saúde."> use = <"Para gravar detalhes sobre um único problema de saúde ou diagnóstico identificado. Definições claras que permitem a diferenciação entre um \"problema\" e um \"diagnóstico\" são quase impossíveis na prática - não podemos dizer de forma segura quando um problema deve ser considerado como um diagnóstico. Quando o diagnóstico ou os critérios de classificação são cumpridos com sucesso, então com confiança podemos chamar a condição de um diagnóstico formal, mas antes que essas condições sejam cumpridas e enquanto houver evidências para tanto, também pode ser válido usar o termo \"diagnóstico\". A quantidade de evidências de apoio requerida para a indicação de diagnóstico não é fácil de ser definida e na realidade, provavelmente varia de condição para condição. Muitos comitês de padrões têm, por anos, se confrontado com esse dilema de definição sem resolução clara. Este arquétipo pode ser utilizado em muitos contextos. Por exemplo, na gravação de um problema ou um diagnóstico durante uma consulta clínica; preencher uma lista de problema persistente; ou para fornecer uma declaração de resumo de um documento Sumário de Alta. Na prática, os clínicos usam muitos qualificadores de contexto específico, como passado / presente, primário / secundário, ativo / inativo, admissão / alta, etc. Os contextos podem ser: localização, especialização, episódio ou específicos de fluxo de trabalho, e estes podem causar confusão ou até mesmo potenciais problemas de segurança se persistido nas listas de problemas ou compartilhados em documentos que estão fora do contexto original. Estes qualificadores podem ser arquetipados separadamente e incluídos no slot 'Estado', porque seu uso varia em diferentes contextos. Espera-se que estes serão utilizados em sua maioria dentro do contexto apropriado e não compartilhados fora desse contexto, sem compreensão clara das consequências potenciais. Por exemplo, um diagnóstico primário para um clínico pode ser um secundário para outro especialista; um problema ativo pode se tornar inativo (ou vice-versa) e isso pode impactar no uso seguro do apoio à decisão clínica. Em geral, estes qualificadores devem ser aplicados localmente dentro do contexto do sistema clínico e na prática, esses estados devem ser criados manualmente pelos clínicos para assegurar que as listas de problemas: Presente / Passado, ativo / inativo ou primário / secundário são clinicamente precisas. Este arquétipo será usado como um componente dentro do Registro Clínico Orientado à Problemas, tal como descrito por Larry Weed. Arquétipos adicionais, que representam conceitos clínicos, tais como: condição como um organizador abrangente para diagnósticos etc, terão de ser desenvolvidos para apoiar esta abordagem. Em algumas situações, pode ser assumido que a identificação de um diagnóstico só se encaixa dentro da expertise do médico, mas esta não é a intenção para este arquétipo. Os diagnósticos podem ser gravados utilizando esse arquétipo por qualquer profissional de saúde."> keywords = <"caso", "condição", "problema", "diagnóstico", "preocupação", "prejuízo", "impressão clínica"> misuse = <"Não deve ser usado para registrar os sintomas descritos pelo indivíduo, para isso, use o arquétipo CLUSTER.symptom, geralmente dentro do arquétipo OBSERVATION.story. Não deve ser usado para registrar achados do exame, use o CLUSTER da família de arquétipos relacionadas ao exame, geralmente aninhados dentro do arquétipo OBSERVATION.exam. Não deve ser usado para registrar os resultados dos testes de laboratório ou diagnósticos relacionados, por exemplo, em diagnósticos patológicos use um arquétipo apropriado da família de laboratório dos arquétipos OBSERVATION. Não deve ser usado para registrar os resultados dos exames de imagem ou de diagnóstico por imagem, use um arquétipo apropriado a partir da família de imagem dos arquétipos OBSERVATION. Não deve ser usado para gravar 'diagnósticos diferenciais', use o arquétipo EVALUATION.differential_diagnosis. Não deve ser usado para gravar 'Motivo do Encontro \"ou\" queixa apresentada', use o arquétipo EVALUATION.reason_for_encounter. Não deve ser usado para gravar procedimentos, use o arquétipo ACTION.procedure. Não deve ser usado para registrar detalhes sobre a gravidez, use o EVALUATION.pregnancy_bf_status e EVALUATION.pregnancy e os arquétipos relacionados. Não deve ser usado para gravar o estadiamento sobre o risco ou os problemas de saúde potenciais, use o arquétipo risco EVALUATION.health. Não deve ser usado para gravar declarações sobre reações adversas, alergias ou intolerâncias, use o arquétipo EVALUATION.adverse_reaction. Não deve ser usado para a gravação de uma ausência explícita (ou presença negativa) de um problema ou diagnóstico, por exemplo: \"sem problema ou diagnósticos conhecido\" ou \"diabetes não conhecido\". Use o arquétipo EVALUATION.exclusion-problem_diagnosis para expressar uma declaração positiva sobre a exclusão de um problema ou diagnóstico."> copyright = <"© openEHR Foundation"> > ["en"] = < language = <[ISO_639-1::en]> purpose = <"For recording details about a single, identified health problem or diagnosis. The intended scope of a health problem is deliberately kept loose in the context of clinical documentation, so as to capture any real or perceived concerns that may adversely affect an individual's wellbeing to any degree. A health problem may be identified by the individual, a carer or a healthcare professional. However, a diagnosis is additionally defined based on objective clinical criteria, and usually determined only by a healthcare professional."> use = <"Use for recording details about a single, identified health problem or diagnosis. Clear definitions that enable differentiation between a 'problem' and a 'diagnosis' are almost impossible in practice - we cannot reliably tell when a problem should be regarded as a diagnosis. When diagnostic or classification criteria are successfully met, then we can confidently call the condition a formal diagnosis, but prior to these conditions being met and while there is supportive evidence available, it can also be valid to use the term 'diagnosis'. The amount of supportive evidence required for the label of diagnosis is not easy to define and in reality probably varies from condition to condition. Many standards committees have grappled with this definitional conundrum for years without clear resolution. For the purposes of clinical documentation with this archetype, problem and diagnosis are regarded as a continuum, with increasing levels of detail and supportive evidence usually providing weight towards the label of 'diagnosis'. In this archetype it is not neccessary to classify the condition as a 'problem' or 'diagnosis'. The data requirements to support documentation of either are identical, with additional data structure required to support inclusion of the evidence if and when it becomes available. Examples of problems include: the individual's expressed desire to lose weight, but without a formal diagnosis of Obesity; or a relationship problem with a family member. Examples of formal diagnoses would include a cancer that is supported by historical information, examination findings, histopathological findings, radiological findings and meets all requirements for known diagnostic criteria. In practice, most problems or diagnoses do not sit at either end of the problem-diagnosis spectrum, but somewhere in between. This archetype can be used within many contexts. For example, recording a problem or a clinical diagnosis during a clinical consultation; populating a persistent Problem List; or to provide a summary statement within a Discharge Summary document. In practice, clinicians use many context-specific qualifiers such as past/present, primary/secondary, active/inactive, admission/discharge etc. The contexts can be location-, specialisation-, episode- or workflow-specific, and these can cause confusion or even potential safety issues if perpetuated in Problem Lists or shared in documents that are outside of the original context. These qualifiers can be archetyped separately and included in the ‘Status’ slot, because their use varies in different settings. It is expected that these will be used mostly within the appropriate context and not shared out of that context without clear understanding of potential consequences. For example, a primary diagnosis to one clinician may be a secondary one to another specialist; an active problem can become inactive (or vice versa) and this can impact the safe use of clinical decision support. In general these qualifiers should be applied locally within the context of the clinical system, and in practice these statuses should be manually curated by clinicians to ensure that lists of Current/Past, Active/Inactive or Primary/Secondary Problems are clinically accurate. This archetype will be used as a component within the Problem Oriented Medical Record as described by Larry Weed. Additional archetypes, representing clinical concepts such as condition as an overarching organiser for diagnoses etc, will need to be developed to support this approach. In some situations, it may be assumed that identification of a diagnosis fits only within the expertise of physicians, but this is not the intent for this archetype. Diagnoses can be recorded using this archetype by any healthcare professional."> keywords = <"issue", "condition", "problem", "diagnosis", "concern", "injury", "clinical impression"> misuse = <"Not to be used to record symptoms as described by the individual - use the CLUSTER.symptom archetype, usually within the OBSERVATION.story archetype. Not to be used to record examination findings - use the family of examination-related CLUSTER archetypes, usually nested within the OBSERVATION.exam archetype. Not to be used to record laboratory test results or related diagnoses, for example pathological diagnoses - use an appropriate archetype from the laboratory family of OBSERVATION archetypes. Not to be used to record imaging examination results or imaging diagnoses - use an appropriate archetype from the imaging family of OBSERVATION archetypes. Not to be used to record 'Differential Diagnoses' - use the EVALUATION.differential_diagnosis archetype. Not to be used to record 'Reason for Encounter' or 'Presenting Complaint' - use the EVALUATION.reason_for_encounter archetype. Not to be used to record procedures - use the ACTION.procedure archetype. Not to be used to record details about pregnancy - use the EVALUATION.pregnancy_bf_status and EVALUATION.pregnancy and related archetypes. Not to be used to record statements about health risk or potential problems - use the EVALUATION.health_risk archetype. Not to be used to record statements about adverse reactions, allergies or intolerances - use the EVALUATION.adverse_reaction archetype. Not to be used for the explicit recording of an absence (or negative presence) of a problem or diagnosis, for example ‘No known problem or diagnoses’ or ‘No known diabetes’. Use the EVALUATION.exclusion-problem_diagnosis archetype to express a positive statement about exclusion of a problem or diagnosis."> copyright = <"© openEHR Foundation"> > ["ar-sy"] = < language = <[ISO_639-1::ar-sy]> purpose = <"لتسجيل تفاصيل حول قضية أو عقبة تؤثر على السلامة البدنية, العقلية و/أو الاجتماعية لشخص ما"> use = <"يستخدم لتسجيل المعلومات العامة حول المشكلات المتعلقة بالصحة. يحتوي النموذج على معلومات متعددة,و يمكن استخدامه في تسجيل المشكلات الحاضرة و السابقة. و يمكن تحديد المشكلة بواسطة المريض نفسه أو من يقوم بتقديم الرعاية الصحية. بعض الأمثلة تتضمن ما يلي: - بعض الأعراض التي لا تزال تحت الملاحظة و لكنها تمثل تشخيصات مبدأية - الرغبة لفقد الوزن دون تشخيص مؤكد بالسمنة - الرغبة بالإقلاع عن التدخين بواسطة الشخص - مشكلة في العلاقة مع أحد أفراد العائلة"> keywords = <"القضية", "الظرف الصحي", "المشكلة", "العقبة"> misuse = <"لا يستخدم لتسجيل التشخيصات المؤكدة. استخدم بدلا من ذلك النموذج المخصص من هذا النموذج, تقييم.المشكلة - التشخيص"> copyright = <"© openEHR Foundation"> > ["it"] = < language = <[ISO_639-1::it]> purpose = <"Registrare i dettagli di un singolo problema di salute identificato o di una diagnosi. L'ambito previsto di un problema di salute viene deliberatamente lasciato libero nel contesto della documentazione clinica, in modo da catturare qualsiasi preoccupazione reale o percepita che possa influire negativamente sul benessere di un individuo in qualsiasi misura. Un problema di salute può essere identificato dall'individuo, da un caregiver o da un operatore sanitario. Tuttavia, una diagnosi viene definita in aggiunta sulla base di criteri clinici oggettivi e solitamente determinata solo da un professionista sanitario."> use = <"Usato per registrare i dettagli di un singolo problema di salute identificato o di una diagnosi. Definizioni chiare che consentono di distinguere tra un \"problema\" e una \"diagnosi\" sono quasi impossibili nella pratica - non possiamo dire in modo affidabile quando un problema deve essere considerato una diagnosi. Quando i criteri diagnostici o di classificazione sono soddisfatti con successo, allora possiamo tranquillamente definire la condizione come una diagnosi formale, ma prima che queste condizioni siano soddisfatte e mentre ci sono prove di supporto disponibili, può anche essere valido l'uso del termine \"diagnosi\". La quantità delle prove di supporto richieste per la classificazione della diagnosi non è facile da definire e in realtà probabilmente varia da una condizione all'altra. Molti comitati di standardizzazione si sono trovati alle prese con questo enigma di definizione per anni senza una chiara risoluzione. Ai fini della documentazione clinica con questo archetipo, il problema e la diagnosi sono considerati un continuum, con livelli crescenti di dettaglio e prove di supporto che di solito fanno propendere verso all'etichetta di \"diagnosi\". In questo archetipo non è necessario classificare la condizione come \"problema\" o \"diagnosi\". I requisiti dei dati a supporto della documentazione di entrambi sono identici, con una struttura di dati aggiuntivi necessari per supportare l'inclusione dell'evidenza se e quando essa diventa disponibile. Esempi di problemi sono: il desiderio espresso dall'individuo di perdere peso, ma senza una diagnosi formale di obesità; o un problema di relazione con un membro della famiglia. Esempi di diagnosi formali includono un cancro che è supportato da informazioni storiche, risultati di esami, risultati istopatologici, risultati radiologici e soddisfa tutti i requisiti per i criteri diagnostici noti. In pratica, la maggior parte dei problemi o delle diagnosi non si colloca ad una delle due estremità dello spettro diagnostico del problema, ma da qualche parte nel mezzo. Questo archetipo può essere utilizzato in molti contesti. Per esempio, la registrazione di un problema o di una diagnosi clinica durante un consulto clinico; la compilazione di un Elenco dei Problemi persistente; o per fornire una dichiarazione riassuntiva all'interno di un documento di Riepilogo delle dimissioni. In pratica, i clinici usano molte qualificazioni specifiche del contesto, come passato/presente, primario/secondario, attivo/inattivo, ricovero/dimissione, ecc. I contesti possono essere specifici per il luogo, la specializzazione, l'episodio o il flusso di lavoro, e questi possono causare confusione o anche potenziali problemi di sicurezza se vengono riportati in elenchi di problemi o condivisi in documenti che sono al di fuori del contesto originale. Questi qualificatori possono essere archetipizzati separatamente e inclusi nello slot \"Status\", perché il loro uso varia in diverse configurazioni. Ci si aspetta che questi vengano usati per lo più all'interno del contesto appropriato e che non vengano condivisi al di fuori di tale contesto senza una chiara comprensione delle potenziali conseguenze. Per esempio, una diagnosi primaria per un clinico può essere secondaria per un altro specialista; un problema attivo può diventare inattivo (o viceversa) e questo può avere un impatto sull'uso sicuro del supporto decisionale clinico. In generale queste qualificazioni dovrebbero essere applicate localmente nel contesto del sistema clinico, e in pratica questi stati dovrebbero essere gestiti manualmente dai clinici per assicurare che le liste dei problemi attuali/passivi, attivi/inattivi o primari/secondari siano clinicamente accurate. Questo archetipo sarà utilizzato come componente all'interno della cartella clinica orientata ai problemi, come descritto da Larry Weed. Ulteriori archetipi - che rappresentano concetti clinici come la condizione come un organizzatore generale per le diagnosi, ecc. - dovrà essere sviluppato per sostenere questo approccio. In alcune situazioni, si può presumere che l'identificazione di una diagnosi rientri solo nelle competenze dei medici, ma questo non è l'intento di questo archetipo. Le diagnosi possono essere registrate utilizzando questo archetipo da qualsiasi professionista sanitario."> keywords = <"problema, condizione, diagnosi, preoccupazione, lesione, impressione clinica", ...> misuse = <"Da non utilizzare per registrare i sintomi come descritto dall'individuo - utilizzare l'archetipo di CLUSTER.symptom, di solito all'interno dell'archetipo di OBSERVATION.story. Da non utilizzare per registrare i risultati dell'esame - utilizzare la famiglia di archetipi CLUSTER.symptom, di solito annidati all'interno dell'archetipo di OBSERVATION.exam. Da non utilizzare per registrare i risultati di esami di laboratorio o diagnosi correlate, ad esempio diagnosi patologiche - utilizzare un archetipo appropriato della famiglia di archetipi di OBSERVATION.exam. Da non utilizzare per registrare i risultati degli esami di imaging o le diagnosi di imaging - utilizzare un archetipo appropriato della famiglia di archetipi di imaging dell'OBSERVATION. Da non utilizzare per registrare le \"diagnosi differenziali\" - utilizzare l'archetipo EVALUATION.differential_diagnosis. Da non utilizzare per registrare \"Motivo dell'incontro\" o \"Presentazione di un reclamo\" - utilizzare l'archetipo EVALUATION.reason_for_encounter. Da non utilizzare per registrare le procedure - utilizzare l'archetipo ACTION.procedure. Da non utilizzare per registrare i dettagli sulla gravidanza - utilizzare lo stato di EVALUATION.pregnancy_bf_status e EVALUATION.pregnancy e i relativi archetipi. Da non utilizzare per registrare dichiarazioni sul rischio per la salute o su potenziali problemi - utilizzare l'archetipo EVALUATION.health_risk. Da non utilizzare per registrare dichiarazioni su reazioni avverse, allergie o intolleranze - utilizzare l'archetipo EVALUATION.adverse_reaction. Da non utilizzare per la registrazione esplicita di un'assenza (o presenza negativa) di un problema o di una diagnosi, ad esempio \"Nessun problema o diagnosi nota\" o \"Nessun diabete noto\". Utilizzare l'archetipo EVALUATION.exclusion-problem_diagnosis per esprimere una dichiarazione positiva sull'esclusione di un problema o di una diagnosi."> > ["zh-cn"] = < language = <[ISO_639-1::zh-cn]> purpose = <"旨在用于记录关于单个已明确的健康问题或诊断的详情。 在临床文档记录的背景下，健康问题故意保持了宽松的预定适用范围，以便采集任何可能对个人健康产生任何程度不利影响的真实或所感知到的担忧/关注事项（concern）。健康问题可能是由个人（患者本人）、[非正规]照护人员或医疗保健专业人员来确定。然而，诊断则另外还依据客观的临床评判标准进行了定义，且通常仅仅是由医疗保健专业人员来确定。"> use = <"旨在用于记录关于单个已明确的健康问题或诊断的详情。 在实践当中，几乎不可能做出明确的定义来区分“问题”（problem）与“诊断”（diagnosis）——我们无法可靠地判断究竟何时才应该将问题视为诊断。当诊断或分类标准得以成功满足时，我们可以自信地将相应的情况/病情（condition）称为正式的诊断，但在满足此类的评判标准/条件之前，且存在可用的支持性证据之时，也可以有效合理地采用“诊断”一词。诊断标签所需支持性证据的数量并不容易定义，实际上很可能还会因情况而异。多年来，许多标准委员会一直在努力解决这个定义难题，但目前还没有明确的解决办法。 对于利用本原始型的临床文档记录目的来说，在此会将问题与诊断视为统一的连续体系，且由问题到诊断，不断增加的细节水平和支持性证据通常会为“诊断”标签带来更大的权重。在本原始型当中，没有必要将情况/健康状况/病情归类为“问题”还是“诊断”。支持两者文档记录工作的数据需求完全相同，当证据变得可用之时，就需要额外的数据结构来支持收纳相应的证据。关于问题的例子包括：在没有关于肥胖的正式诊断的情况下，个人所表达的关于减肥的愿望；或者是与特定家庭成员的关系问题。关于正式诊断的示例包括拥有历史/病史信息、检查结果、组织病理学发现、放射医学发现支持并满足已知诊断标准所有要求的癌症。在实践当中，大多数的问题或诊断并不处于问题—诊断连续体系的两端，而是介于两者之间。 本原始型可用于很多的上下文背景。例如，在临床就诊咨询/会诊期间对问题或临床诊断的记录；填写持续存在/更新的问题清单；或者是提供出院摘要文档之中总结性陈述。 在实践当中，临床医务人员/临床医生会使用许多上下文特异性的限定词（context-specific qualifier），如过去/现在、主要/次要、现行有效/无效、入院/出院等等。上下文背景可以针对的是位置/场所、专业、服务节段（episode）或工作流，如果将此类的限定词长久存储在问题清单当中，或者是在原始上下文背景之外的文档当中加以共享，则可能会导致混淆/困惑甚至潜在的安全问题。可以单独对此类的限定词进行原始型化，并将其收纳在状态槽位'Status'之中，因为它们的用法在不同的场所环境下会有所不同。期望将此类的限定词/状态主要用于合适的上下文背景，而不是在没有清楚地了解潜在后果的情况下在相应的上下文背景之外共享。例如，一位临床医生的初步诊断可能是另一位专科医生的次要诊断；现行有效的问题可能会变为无效状态（反之亦然），而这种情况可能会影响临床决策支持（CDS）措施的安全使用。一般来说，应该在本地将这些状态应用于相应临床系统的上下文背景，而在实践当中，则应该由临床医务人员/临床医生来手动管理这些状态，以确保当前/过去、现行有效/无效或主要/次要的问题的列表在临床上是准确的。 正如拉里·维德（Larry Weed）所描述的那样，在面向问题的病历（Problem Oriented Medical Record）当中，本原始型将会作为一种组件来使用。为了支持这种方法，需要开发其他原始型，以便将情况/健康状况/病情（condition）之类的临床概念表示为诊断的总体组织手段等。 在某些情况下，可能会假定认为诊断的确定仅仅属于是医生的专长，但这一点并不是本原始型的意图。任何的医疗保健专业人员都可以利用本原始型来记录诊断。"> keywords = <"事宜", "事项", "情况", "健康状况", "病情", "问题", "诊断", "关注事项", "担心事项", "担忧", "损伤", "临床印象"> misuse = <"并非旨在用于记录个人（患者本人）所描述的症状 - 对此，请采用群簇型症状原始型 CLUSTER.symptom 来记录，且通常会将后者放在观察型主观临床病史原始型 OBSERVATION.story 之中。 并非旨在用于记录检查发现/所见 - 对此，请采用与检查相关的群簇型原始型系列，且通常会将后者嵌套在观察型检查原始型 OBSERVATION.exam 当中。 并非旨在用于记录实验室检验结果或相关的诊断，如病理诊断 - 对此，请选用观察型实验室[检验]原始型系列之中合适的原始型。 并非旨在用于记录成像检查结果或成像诊断 - 对此，请选用观察型成像/影像学原始型系列之中合适的原始型。 并非旨在用于记录鉴别诊断（Differential Diagnosis） - 对此，请采用评价型鉴别诊断原始型 EVALUATION.differential_diagnosis。 并非旨在用于记录就医/就诊原因（Reason for Encounter）或当前主诉（Present Complaint） - 对此，请采用评价型就医/就诊原因原始型 EVALUATION.reason_for_encounter。 并非旨在用于记录操作[项目] - 对此，请采用行动型操作[项目]原始型 ACTION.procedure。 并非旨在用于记录关于妊娠的详情 - 对此，请采用评价型妊娠【bf: 哺乳?】状态原始型 EVALUATION.pregnancy_bf_status 和评价型妊娠原始型 EVALUATION.pregnancy 以及相关的原始型。 并非旨在用于记录关于健康风险或潜在问题的陈述 - 对此，请采用评价型健康风险原始型 EVALUATION.health_risk。 并非旨在用于记录关于不良反应、过敏/变态反应或不耐的陈述 - 对此，请采用评价型不良反应原始型 EVALUATION.adverse_reaction。 并非旨在用于明确记录关于并不存在（或否定存在）特定问题或诊断的情况，如“无已知问题或诊断”或“无已知糖尿病”。对此，请采用评价型除外问题/诊断原始型 EVALUATION.exclusion-problem_diagnosis 来表达关于排除特定问题或诊断的明确陈述。 "> > ["es"] = < language = <[ISO_639-1::es]> purpose = <"Este arquetipo se utilizará para registrar un único problema de salud o diagnóstico identificado para el paciente. El alcance del arquetipo se dejó deliberadamente abierto, para poder capturar cualquier inquietud real o percibida que afecte en cualquier grado la salud de un paciente. Independientemente de quién detecte el problema, el diagnóstico debe ser definido basado en criterios clínicos objetivos, determinados por un profesional clínico."> use = <"Este arquetipo se utilizará para registrar un único problema de salud o diagnóstico identificado para el paciente. Las definiciones claras que permitan diferenciar entre un \"problema\" y un \"diagnóstico\" son casi imposibles en la práctica: no podemos decir con certeza cuándo un problema debe considerarse como un diagnóstico. Cuando se cumplen con éxito los criterios de diagnóstico o clasificación, podemos llamar con seguridad a la afección un diagnóstico formal, pero antes de que se cumplan estas condiciones y mientras haya evidencia disponible que lo respalde, también puede ser válido utilizar el término \"diagnóstico\". La cantidad de evidencia que respalda la etiqueta de diagnóstico no es fácil de definir y en realidad probablemente varía de una condición a otra. Muchos comités de normas han lidiado con este enigma de definición durante años sin una resolución clara. A efectos de la documentación clínica con este arquetipo, el problema y el diagnóstico se consideran un continuo, con niveles crecientes de detalle y evidencia de apoyo que generalmente aportan peso a la etiqueta de \"diagnóstico\". En este arquetipo no es necesario clasificar la condición como \"problema\" o \"diagnóstico\". Los requisitos de datos para respaldar la documentación de cualquiera de los dos son idénticos, con una estructura de datos adicional requerida para respaldar la inclusión de la evidencia cuando esté disponible. Ejemplos de problemas incluyen: el deseo expresado por el individuo de perder peso, pero sin un diagnóstico formal de obesidad; o un problema de relación con un miembro de la familia. Ejemplos de diagnósticos formales incluirían un cáncer que esté respaldado por información histórica, hallazgos de exámenes, hallazgos histopatológicos, hallazgos radiológicos y que cumpla con todos los requisitos de los criterios de diagnóstico conocidos. En la práctica, la mayoría de los problemas o diagnósticos no se encuentran en ninguno de los extremos del espectro de diagnóstico de problemas, sino en algún punto intermedio. Este arquetipo se puede utilizar en muchos contextos. Por ejemplo, registrar un problema o un diagnóstico clínico durante una consulta clínica; completar una Lista de Problemas persistente; o para proporcionar un resumen dentro de un Documento de Alta Médica. En la práctica, los médicos utilizan muchos calificadores específicos según el contexto, como pasado/presente, primario/secundario, activo/inactivo, admisión/alta, etc. Los contextos pueden ser específicos de la ubicación, la especialización, el episodio o el flujo de trabajo, y estos pueden causar confusión o incluso posibles problemas de seguridad si se perpetúan en Listas de Problemas o se comparten en documentos que están fuera del contexto original. Estos calificadores se pueden arquetipar por separado e incluir en el hueco \"Estado\", porque su uso varía en diferentes entornos. Se espera que estos se utilicen principalmente dentro del contexto apropiado y no se compartan fuera de ese contexto sin una comprensión clara de las posibles consecuencias. Por ejemplo, un diagnóstico primario para un médico puede ser secundario para otro especialista; un problema activo puede volverse inactivo (o viceversa) y esto puede afectar el uso seguro del apoyo a las decisiones clínicas. En general, estos calificadores deben aplicarse localmente dentro del contexto del sistema clínico y, en la práctica, estos estados deben ser seleccionados manualmente por los médicos para garantizar que las listas de problemas actuales/pasados, activos/inactivos o primarios/secundarios sean clínicamente precisas. Este arquetipo se utilizará como componente dentro del Registro Médico Orientado a Problemas tal como lo describe Larry Weed. Será necesario desarrollar arquetipos adicionales, que representen conceptos clínicos como la condición como organizador general de diagnósticos, etc., para respaldar este enfoque. En algunas situaciones, se puede suponer que la identificación de un diagnóstico sólo se ajusta a la experiencia de los médicos, pero ésta no es la intención de este arquetipo. Cualquier profesional sanitario puede registrar los diagnósticos utilizando este arquetipo."> keywords = <"asunto", "condición", "problema", "diagnóstico", "preocupación", "lesión", "impresión clínica"> misuse = <"No se debe utilizar para registrar síntomas descritos por el paciente; para eso, utilizar el arquetipo CLUSTER.symtom, generalmente dentro del arquetipo OBSERVATION.story. No se debe utilizar para registrar hallazgos; para eso, utilizar arquetipos CLUSTER relacionados con la examinación, usualmente relacionados con el arquetipo OBSERVATION.exam. No se debe utilizar para registrar resultados de pruebas de laboratorio o diagnósticos relacionados, por ejemplo, diagnósticos patológicos; para eso, utilizar un arquetipo apropiado de la familia de arquetipos OBSERVATION de laboratorio. No se debe utilizar para registrar resultados de exámenes de imágenes o diagnósticos de imágenes; para eso, utilizar un arquetipo apropiado de la familia de imágenes de tipo OBSERVATION. No se debe utilizar para registrar 'Diagnósticos Diferenciales'; para eso, utilizar el arquetipo EVALUATION.differential_diagnosis. No se debe utilizar para registrar el motivo de consulta o problema presentado por el paciente; para eso, utilizar el arquetipo EVALUATION.reason_for_encounter. No se debe utilizar para registrar procedimientos; para eso, utilizar el arquetipo ACTION.procedure. No se debe utilizar para registrar detalles sobre el embarazo; para eso, utilizar los arquetipos EVALUATION.pregnancy_bf_status y EVALUATION.pregnancy, o arquetipos relacionados. No se debe utilizar para registrar riesgos o problemas potenciales; para eso, utilizar el arquetipo EVALUATION.health_risk. No se debe utilizar para registrar declaraciones sobre reacciones adversas, alergias o intolerancias; para eso, utilizar el arquetipo EVALUATION.adverse_reaction. No se debe utilizar para el registro explícito de una ausencia (o presencia negativa) de un problema o diagnóstico, por ejemplo, \"No se conocen problemas o diagnósticos\" o \"No se conoce diabetes\". Utilice el arquetipo EVALUATION.exclusion-problem_diagnosis para expresar una afirmación positiva sobre la exclusión de un problema o diagnóstico."> copyright = <"© openEHR Foundation"> > ["zh"] = < language = <[ISO_639-1::zh]> purpose = <"For recording details about a single, identified health problem or diagnosis. The intended scope of a health problem is deliberately kept loose in the context of clinical documentation, so as to capture any real or perceived concerns that may adversely affect an individual's wellbeing to any degree. A health problem may be identified by the individual, a carer or a healthcare professional. However, a diagnosis is additionally defined based on objective clinical criteria, and usually determined only by a healthcare professional."> use = <""> misuse = <""> other_details = < ["notes"] = <"Generated automatically by Adl Designer"> > > ["nb"] = < language = <[ISO_639-1::nb]> purpose = <"For å registrere detaljer om ett identifisert helseproblem eller en diagnose. Omfanget for et helseproblem er med vilje løst definert, for å kunne registrere en reell eller selvoppfattet bekymring som i større eller mindre grad kan påvirke et individs velvære negativt. Et helseproblem kan identifiseres av individet selv, en omsorgsperson eller av helsepersonell. En diagnose er derimot definert basert på objektive kliniske kriterier, og stilles som regel bare av helsepersonell."> use = <"Brukes til å registrere detaljer om ett identifisert helseproblem eller en diagnose. Å klart definere skillet mellom et \"problem\" og en \"diagnose\" er i praksis nesten umulig, og vi kan ikke på en pålitelig måte si når et problem skal ses på som en diagnose. Når diagnostiske- eller klassifikasjonskriterier er innfridd kan vi trygt kalle tilstanden en formell diagnose, men før disse kriteriene er møtt kan det dersom det finnes støttende funn også være riktig å kalle den en diagnose. Mengden støttende funn som kreves for å sette merkelappen \"diagnose\" er ikke lett å definere, og varierer sannsynligvis i praksis fra tilstand til tilstand. Mange standardiseringskomiteer har arbeidet med dette definisjonsproblemet i årevis uten å komme til noen klar konklusjon. Når det gjelder klinisk dokumentasjon med denne arketypen må problemer og diagnoser ses på som deler av et spektrum der økende detaljgrad og mengde støttende funn som regel gir vekt mot merkelappen \"diagnose\". I denne arketypen er det ikke nødvendig å klassifisere tilstanden som enten et problem eller en diagnose. Datastrukturen for å dokumentere dem er identisk, med tilleggsstrukturer som støtter inklusjon av nye funn når eller hvis de blir tilgjengelige. Eksempler på problemer kan være et individs uttrykte ønske om å gå ned i vekt uten en formell diagnose av fedme, eller problemer i forholdet til et familiemedlem. Eksempler på formelle diagnoser kan være en kreftsvulst der diagnosen er støttet av historisk informasjon, undersøkelsesfunn, histologiske funn, radiologiske funn, og som møter alle diagnosekriterier. I praksis er de fleste problemer eller diagnoser ikke i hver sin ende av problem/diagnose-spektrumet, men et sted mellom. Denne arketypen kan brukes i mange sammenhenger. Eksempler kan være å registrere et problem eller en klinisk diagnose under en klinisk konsultasjon, fylle en persistent problemliste, eller for å gi oppsummerende informasjon i en epikrise. I praksis bruker klinikere mange kvalifikatorer som nåværende/tidligere, hoved/bidiagnose, aktiv/inaktiv, innleggelse/utskriving, etc. Sammenhengene kan være steds-, spesialiserings-, episode- eller arbeidsflytspesifikke, og disse kan forårsake forvirring eller til og med mulige sikkerhetsrisikoer dersom de videreføres i problemlister eller deles i dokumenter utenfor sin opprinnelige sammenheng. Disse kvalifikatorene kan arketypes separat og inkluderes i \"Status\"-SLOTet, fordi bruken varierer i ulike settinger. Disse vil sannsynligvis hovedsakelig brukes i passende sammenhenger, og ikke deles utenfor sammenhengen uten en klar forståelse av mulige konsekvenser. For eksempel kan en hoveddiagnose for en kliniker være en bidiagnose for en annen spesialist, et aktivt problem kan bli inaktivt (og omvendt), og dette kan ha innvirkning på sikkerhet og beslutningsstøtte. Generelt burde disse kvalifikatorene brukes lokalt og innenfor kontekst i det kliniske systemet, og i praksis bør de manuelt administreres av klinikere for å sikre at lister over nåværende/tidligere, aktiv/inaktiv eller hoved/bidiagnoser er klinisk presise. Denne arketypen vil bli brukt som en komponent i den problemorienterte journalen som beskrevet av Larry Weed. Tilleggsarketyper som representerer kliniske konsepter som f.eks. \"tilstand\" som en overbygning for diagnoser etc, vil måtte utvikles for å støtte dette. I noen situasjoner antas det at å stille en diagnose ligger fullstendig innenfor legers domene, men dette er ikke hensikten med denne arketypen. Diagnoser kan registreres av alt helsepersonell ved hjelp av denne arketypen."> keywords = <"emne", "problem", "tilstand", "hindring", "diagnose", "helseproblem", "bekymring", "funn", "helsetilstand", "konflikt", "utfordring", "klinisk bilde"> misuse = <"Brukes ikke til å registrere symptomer slik de beskrives av individet. Til dette brukes CLUSTER.symptom-arketypen, som regel innenfor OBSERVATION.story-arketypen. Brukes ikke til å registrere funn ved klinisk undersøkelse. Til dette brukes gruppen av undersøkelsesrelaterte CLUSTER-arketyper, som regel innenfor OBSERVATION.exam-arketypen. Brukes ikke til å registrere laboratoriesvar eller relaterte diagnoser for eksempel patologiske diagnoser. Til dette brukes en passende arketype fra laboratoriefamilien av OBSERVATION-arketyper. Brukes ikke til å registrere billeddiagnostiske svar eller diagnoser. Til dette brukes en passende arketype fra billeddiagnostikkfamilien av OBSERVATION-arketyper. Brukes ikke til å registrere differensialdiagnoser. Til dette brukes EVALUATION.differential_diagnosis-arketypen. Brukes ikke til å registrere kontaktårsak eller klinisk problemstilling ved kontakt. Til dette brukes EVALUATION.reason_for_encounter-arketypen. Brukes ikke til å registrere prosedyrer, til dette brukes ACTION.procedure-arketypen. Brukes ikke til å registrere detaljer om graviditet utover diagnoser. Til dette brukes EVALUATION.pregnancy_bf_status og EVALUATION.pregnancy, samt relaterte arketyper. Brukes ikke til å registrere vurderinger av potensiale og sannsynlighet for fremtidige problemer, diagnoser eller andre uønskede helseeffekter, til dette brukes EVALUATION.health_risk-arketypen. Brukes ikke til å registrere utsagn om uønskede reaksjoner, allergier eller intoleranser - bruk EVALUATION.adverse_reaction-arketypen. Brukes ikke til å registrere et eksplisitt fravær (eller negativ tilstedeværelse) av et problem eller en diagnose, f.eks. \"ingen kjente problemer eller diagnoser\" eller \"ingen kjent diabetes\". Bruk EVALUATION.exclusion-problem_diagnosis for å uttrykke fravær av et problem eller en diagnose. Brukes ikke til å registrere pasientens tilgjengelige ressurser for egenomsorg - bruk egne EVALUATION-arketyper for dette formålet."> copyright = <"© openEHR Foundation"> > ["es-ar"] = < language = <[ISO_639-1::es-ar]> purpose = <"Para el registro de detalles acerca de un único problema de salud o diagnóstico. El alcance previsto del problema de salud se mantiene deliberadamente poco definido en el contexto de la documentación clínica, de modo tal que pueda representarse cualquier problema, real o percibido, que pueda afectar al bienestar de un individuo en cualquier grado. Un problema de salud puede ser identificado por un individuo, un cuidador, o un profesional de la salud. Para la definición de un diagnóstico se require además de criterios clínicos objetivos, habitualmente determinados por un profesional de la salud."> use = <"Utilícese para registrar detalles acerca de un único problema de salud o diagnóstico. Una definición clara que permita diferenciar un \"problema\" de un \"diagnóstico\" es casi imposible en la práctica - no podemos determinar en forma confiable cuando un problema debería ser considerado un diagnóstico. Cuando se cumplen con éxito determinados criterios diagnósticos o de clasificación es posible denominar una condición como un diagnóstico formal, pero previo al cumplimiento de dichos criterios y en tanto exista evidencia clínica que lo sustente, también puede ser válido el uso del término \"diagnóstico\". La cantidad de evidencia de apoyo varía de caso en caso. Muchos comités de estándares han lidiado con este problema por años sin lograr una resolución clara. A los fines de la documentación clínica mediante este arquetipo, problema y diagnóstico son considerados como un continuo, donde el incremento de los niveles de detalle y sustento en la evidencia inclinan la balanza hacia la etiqueta de \"diagnóstico\". Los requerimientos de datos que sustentan la documentación de ambos son idénticos, siendo necesarias estructuras de datos adicionales para sustentar la inclusión de la evidencia cuando esta exista y se encuentre disponible. Los ejemplos de problemas incluyen: la expresión del deseo de bajar de peso por parte de un individuo sin la existencia de un diagnóstico formal de obesidad, o un problema de relación con un familiar. Los ejemplos de diagnósticos formales incluyen un cáncer fundamentado en información histórica, los hallazgos de un examen, los hallazgos histopatológicos, los hallazgos radiológicos, y que cumplen todos los criterios diagnósticos. En la práctica, la mayoría de los problemas o diagnósticos no se encuentran en los extremos del espectro problema-diagnóstico sino que se ubican en alguna posición intermedia. Este arquetipo puede ser utilizado en diversos contextos. Por ejemplo, para registrar un problema o diagnóstico clínico durante una consulta clínica, para la elaboración de una Lista de Problemas persistente, o para proveer una afirmación sumaria dentro de un documento de Resumen de Alta. En la práctica, los clínicos utilizan muchos calificadores dependientes del contexto, tales como pasado/actual, primario/secundario, activo/inactivo, admisión/egreso, etc. Estos contextos pueden ser relativos a la localización, la especialización, el episodio, o a un instancia de un proceso, pudiendo entonces generar confusión o riesgos potenciales de seguridad para el paciente si son incluidos en Listas de Problemas o documentos compartidos que carecen del contexto original. Estos contextos pueden ser arquetipados en forma separada e incluidos en el slot de \"Estado\", dado que su uso varía en diferentes escenarios. Su uso mayormente pretendido debe darse en el contexto apropiado y no debería ser compartido fuera de dicho contexto sin una clara comprensión de sus consecuencias potenciales. Por ejemplo: un diagnóstico primario podría ser un diagnóstico secundario para otro especialista; un problema activo puede tornarse inactivo (o viceversa) e impactar en la seguridad de una decisión clínica. En general, estos calificadores deberían aplicarse localmente dentro del contexto del sistema clínico y en la práctica estos estados deberían ser manualmente mantenidos por clínicos a fin de asegurar que las listas de problemas, actuales o pasados, activos o inactivos o primarios y secundarios, sean clínicamente exactos. Este arquetipo será utilizado como un componente del Registro Médico Orientado al Problema descripto por Larry Weed. Se requerirá del desarrollo de arquetipos adicionales para la representación de conceptos clínicos tales como una condición para un organizador general de diagnósticos, etc. En algunas situaciones puede asumirse que la identificación de un diagnóstico solo se ajusta a la experticia del médico, pero no es el propósito de este arquetipo. Los diagnósticos pueden ser registrados mediante este arquetipo por parte de cualquier profesional. "> keywords = <"asunto", "condición", "problema", "diagnóstico", "preocupación", "lesión", "impresión clínica"> misuse = <"No debe ser utilizado para registrar síntomas tal cual fueron descriptos por el individuo; para ello se debe utilizar el arquetipo CLUSTER.symptom, habitualmente dentro del contexto del arquetipo OBSERVATION.story. No debe ser utilizado para registrar hallazgo de exámenes, para ello se debe utilizar la familia de arquetipos relacionados a exámenes, habitualmente contenidos dentro del arquetipo OBSERVATION.exam. No debe ser utilizado para registrar hallazgos de pruebas de laboratorio o diagnósticos relacionados (como por ejemplo diagnósticos patológicos); para ello se debe utilizar un arquetipo apropiado de la familia de arquetipos del tipo OBSERVATION. No debe ser utilizado para registrar resultados de exámenes por imágenes o diagnósticos imagenológicos; para ello se debe utilizar un arquetipo apropiado de la familia de arquetipos del tipo OBSERVATION. No debe ser utilizado para registrar diagnósticos diferenciales; para ello se debe utilizar el arquetipo EVALUATION.differential_diagnosis. No debe ser utilizado para registrar \"Motivos de Consulta\"; para ello se debe utilizar el arquetipo EVALUATION.reason_for_encounter. No debe ser utilizado para registrar procedimientos; para ello se debe utilizar el arquetipo ACTION.procedure. No debe ser utilizado para registrar detalles acerca del embarazo; para ello se debe utilizar los arquetipos EVALUATION.pregnancy_bf_status, EVALUATION.pregnancy y los arquetipos relacionados. No debe ser utilizado para registrar aseveraciones acerca de riesgos para la salud o problemas potenciales; para ello se debe utilizar el arquetipo EVALUATION.health_risk. No debe ser utilizado para registrar aseveraciones acerca de reacciones adversas, alergias o intolerancias; para ello se debe utilizar el arquetipo EVALUATION.adverse_reaction. No debe ser utilizado para registrar la ausencia explícita (o presencia negativa) de un problema o diagnóstico (como por ejemplo \"sin diagnósticos o problemas conocidos\" o \"sin diabetes conocida\"); para expresar una aseveración positiva acerca de la exclusión de un problema o diagnóstico se debe utilizar el arquetipo EVALUATION.exclusion-problem_diagnosis."> copyright = <"© openEHR Foundation"> > ["nl"] = < language = <[ISO_639-1::nl]> purpose = <"*For recording details about a single, identified health problem or diagnosis. The intended scope of a health problem is deliberately kept loose in the context of clinical documentation, so as to capture any real or perceived concerns that may adversely affect an individual's wellbeing to any degree. A health problem may be identified by the individual, a carer or a healthcare professional. However, a diagnosis is additionally defined based on objective clinical criteria, and usually determined only by a healthcare professional.(en)"> use = <"*Use for recording details about a single, identified health problem or diagnosis. Clear definitions that enable differentiation between a 'problem' and a 'diagnosis' are almost impossible in practice - we cannot reliably tell when a problem should be regarded as a diagnosis. When diagnostic or classification criteria are successfully met, then we can confidently call the condition a formal diagnosis, but prior to these conditions being met and while there is supportive evidence available, it can also be valid to use the term 'diagnosis'. The amount of supportive evidence required for the label of diagnosis is not easy to define and in reality probably varies from condition to condition. Many standards committees have grappled with this definitional conundrum for years without clear resolution. For the purposes of clinical documentation with this archetype, problem and diagnosis are regarded as a continuum, with increasing levels of detail and supportive evidence usually providing weight towards the label of 'diagnosis'. In this archetype it is not neccessary to classify the condition as a 'problem' or 'diagnosis'. The data requirements to support documentation of either are identical, with additional data structure required to support inclusion of the evidence if and when it becomes available. Examples of problems include: the individual's expressed desire to lose weight, but without a formal diagnosis of Obesity; or a relationship problem with a family member. Examples of formal diagnoses would include a cancer that is supported by historical information, examination findings, histopathological findings, radiological findings and meets all requirements for known diagnostic criteria. In practice, most problems or diagnoses do not sit at either end of the problem-diagnosis spectrum, but somewhere in between. This archetype can be used within many contexts. For example, recording a problem or a clinical diagnosis during a clinical consultation; populating a persistent Problem List; or to provide a summary statement within a Discharge Summary document. In practice, clinicians use many context-specific qualifiers such as past/present, primary/secondary, active/inactive, admission/discharge etc. The contexts can be location-, specialisation-, episode- or workflow-specific, and these can cause confusion or even potential safety issues if perpetuated in Problem Lists or shared in documents that are outside of the original context. These qualifiers can be archetyped separately and included in the ‘Status’ slot, because their use varies in different settings. It is expected that these will be used mostly within the appropriate context and not shared out of that context without clear understanding of potential consequences. For example, a primary diagnosis to one clinician may be a secondary one to another specialist; an active problem can become inactive (or vice versa) and this can impact the safe use of clinical decision support. In general these qualifiers should be applied locally within the context of the clinical system, and in practice these statuses should be manually curated by clinicians to ensure that lists of Current/Past, Active/Inactive or Primary/Secondary Problems are clinically accurate. This archetype will be used as a component within the Problem Oriented Medical Record as described by Larry Weed. Additional archetypes, representing clinical concepts such as condition as an overarching organiser for diagnoses etc, will need to be developed to support this approach. In some situations, it may be assumed that identification of a diagnosis fits only within the expertise of physicians, but this is not the intent for this archetype. Diagnoses can be recorded using this archetype by any healthcare professional.(en)"> keywords = <"*issue(en)", "*condition(en)", "*problem(en)", "*diagnosis(en)", "*concern(en)", "*injury(en)", "*clinical impression(en)"> misuse = <"*Not to be used to record symptoms as described by the individual - use the CLUSTER.symptom archetype, usually within the OBSERVATION.story archetype. Not to be used to record examination findings - use the family of examination-related CLUSTER archetypes, usually nested within the OBSERVATION.exam archetype. Not to be used to record laboratory test results or related diagnoses, for example pathological diagnoses - use an appropriate archetype from the laboratory family of OBSERVATION archetypes. Not to be used to record imaging examination results or imaging diagnoses - use an appropriate archetype from the imaging family of OBSERVATION archetypes. Not to be used to record 'Differential Diagnoses' - use the EVALUATION.differential_diagnosis archetype. Not to be used to record 'Reason for Encounter' or 'Presenting Complaint' - use the EVALUATION.reason_for_encounter archetype. Not to be used to record procedures - use the ACTION.procedure archetype. Not to be used to record details about pregnancy - use the EVALUATION.pregnancy_bf_status and EVALUATION.pregnancy and related archetypes. Not to be used to record statements about health risk or potential problems - use the EVALUATION.health_risk archetype. Not to be used to record statements about adverse reactions, allergies or intolerances - use the EVALUATION.adverse_reaction archetype. Not to be used for the explicit recording of an absence (or negative presence) of a problem or diagnosis, for example ‘No known problem or diagnoses’ or ‘No known diabetes’. Use the EVALUATION.exclusion-problem_diagnosis archetype to express a positive statement about exclusion of a problem or diagnosis.(en)"> > ["ca"] = < language = <[ISO_639-1::ca]> purpose = <"Per registrar detalls sobre un únic problema de salut o diagnòstic identificat. "> use = <"Ús per registrar detalls sobre un problema de salut o diagnòstic únic identificat."> keywords = <"*issue(en)", "*condition(en)", "*problem(en)", "*diagnosis(en)", "*concern(en)", "*injury(en)", "*clinical impression(en)"> misuse = <"*Not to be used to record symptoms as described by the individual - use the CLUSTER.symptom archetype, usually within the OBSERVATION.story archetype. Not to be used to record examination findings - use the family of examination-related CLUSTER archetypes, usually nested within the OBSERVATION.exam archetype. Not to be used to record laboratory test results or related diagnoses, for example pathological diagnoses - use an appropriate archetype from the laboratory family of OBSERVATION archetypes. Not to be used to record imaging examination results or imaging diagnoses - use an appropriate archetype from the imaging family of OBSERVATION archetypes. Not to be used to record 'Differential Diagnoses' - use the EVALUATION.differential_diagnosis archetype. Not to be used to record 'Reason for Encounter' or 'Presenting Complaint' - use the EVALUATION.reason_for_encounter archetype. Not to be used to record procedures - use the ACTION.procedure archetype. Not to be used to record details about pregnancy - use the EVALUATION.pregnancy_bf_status and EVALUATION.pregnancy and related archetypes. Not to be used to record statements about health risk or potential problems - use the EVALUATION.health_risk archetype. Not to be used to record statements about adverse reactions, allergies or intolerances - use the EVALUATION.adverse_reaction archetype. Not to be used for the explicit recording of an absence (or negative presence) of a problem or diagnosis, for example ‘No known problem or diagnoses’ or ‘No known diabetes’. Use the EVALUATION.exclusion-problem_diagnosis archetype to express a positive statement about exclusion of a problem or diagnosis.(en)"> > > lifecycle_state = <"published"> other_contributors = <"Grethe Almenning, Bergen kommune, Norway", "Tomas Alme, DIPS, Norway", "Nadim Anani, Karolinska Institutet, Sweden", "Erling Are Hole, Helse Bergen, Norway", "Vebjørn Arntzen, Oslo universitetssykehus HF, Norway (Nasjonal IKT redaktør)", "Koray Atalag, GALATA-Digital, New Zealand", "Silje Ljosland Bakke, Helse Vest IKT AS, Norway (openEHR Editor)", "John Bennett, NEHTA, Australia", "Steve Bentley, Allscripts, United Kingdom", "Lars Bitsch-Larsen, Haukeland University hospital, Norway", "Terje Bless, Helse Nord FIKS, Norway", "Fredrik Borchsenius, Oslo universitetssykehus, Norway", "Ian Bull, ACT Health, Australia", "Sergio Carmona, Chile", "Rong Chen, Cambio Healthcare Systems, Sweden", "Stephen Chu, Queensland Health, Australia", "Ed Conley, Cardiff University, United Kingdom", "Matthew Cordell, NEHTA, Australia", "Inderjit Daphu, Helse Bergen, Norway", "Paul Donaldson, Nursing Informatics Australia, Australia", "Gail Easterbrook, Flinders Medical Centre, Australia", "Aitor Eguzkitza, UPNA (Public University of Navarre) - CHN (Complejo Hospitalario de Navarra), Spain", "Tone Engen, Norway", "David Evans, Queensland Health, Australia", "Arild Faxvaag, NTNU, Norway", "Shahla Foozonkhah, Iran ministry of health and education, Iran", "Einar Fosse, National Centre for Integrated Care and Telemedicine, Norway", "Peter Garcia-Webb, Australia", "Sebastian Garde, Ocean Informatics, Germany", "Bente Gjelsvik, Helse Bergen, Norway", "Andrew Goodchild, NEHTA, Australia", "Anneke Goossen, Results 4 Care, Netherlands", "Gyri Gradek, Senter for medisinsk genetikk og molekylærmedisin, Haukeland Universitetssykehus, Norway", "Heather Grain, Llewelyn Grain Informatics, Australia", "Trina Gregory, cpc, Australia", "Bjørn Grøva, Diretoratet for e-helse, Norway", "Dag Hanoa, Oslo universitetssykehus, Norway", "Knut Harboe, Stavanger Universitetssjukehus, Norway", "Sam Heard, Ocean Informatics, Australia", "Ingrid Heitmann, Oslo universitetssykehus HF, Norway", "Kristian Heldal, Telemark Hospital Trust, Norway", "Andreas Hering, Helse Bergen HF, Haukeland universitetssjukehus, Norway", "Anca Heyd, DIPS ASA, Norway", "Hilde Hollås, DIPS AS, Norway", "Evelyn Hovenga, EJSH Consulting, Australia", "Eugene Igras, IRIS Systems, Inc., Canada", "Lars Ivar Mehlum, Helse Bergen HF, Norway", "Tom Jarl Jakobsen, Helse Bergen, Norway", "Aud Jorunn Mjelstad, Helse Bergen, Norway", "Gunnar Jårvik, Nasjonal IKT HF, Norway", "Lars Morgan Karlsen, DIPS ASA, Norway", "Mary Kelaher, NEHTA, Australia", "Eizen Kimura, Ehime Univ., Japan", "Shinji Kobayashi, NPO openEHR Japan, Japan", "Robert L'egan, NEHTA, Australia", "Sabine Leh, Haukeland University Hospital, Department of Pathology, Norway", "Heather Leslie, Atomica Informatics, Australia (openEHR Editor)", "Hugh Leslie, Ocean Informatics, Australia (Editor)", "Hallvard Lærum, Norwegian Directorate of e-health, Norway", "Luis Marco Ruiz, NST, Spain", "Siv Marie Lien, DIPS ASA, Norway", "Rohan Martin, Ambulance Victoria, Australia", "David McKillop, NEHTA, Australia", "Ian McNicoll, freshEHR Clinical Informatics, United Kingdom", "Chris Mitchell, RACGP, Australia", "Stewart Morrison, NEHTA, Australia", "Jörg Niggemann, compugroup, Germany", "Bjørn Næss, DIPS AS, Norway", "Mona Oppedal, Helse Bergen, Norway", "Andrej Orel, Marand d.o.o., Slovenia", "Anne Pauline Anderssen, Helse Nord RHF, Norway", "Chris Pearce, Melbourne East GP Network, Australia", "Camilla Preeston, Royal Australian College of General Practitioners, Australia", "Margaret Prichard, NEHTA, Australia", "Jodie Pycroft, Adelaide Northern Division of General Practice Ltd, Australia", "Cathy Richardson, NEHTA, Australia", "Robyn Richards, NEHTA - Clinical Terminology, Australia", "Jussara Rotzsch, Hospital Alemão Oswaldo Cruz, Brazil", "Thomas Schopf, University Hospital of North-Norway, Norway", "Thilo Schuler, Australia", "Anoop Shah, University College London, United Kingdom", "Arild Stangeland, Helse Bergen, Norway", "Line Sæle, Nasjonal IKT HF, Norway", "Line Sørensen, Helse Bergen, Norway", "Gordon Tomes, Australian Institute of Health and Welfare, Australia", "Richard Townley-O'Neill, NEHTA, Australia", "Donna Truran, ACCTI-UoW, Australia", "Jon Tysdahl, Furst medlab AS, Norway", "John Tore Valand, Helse Vest IKT, Norway (openEHR Editor)", "Kylie Young, The Royal Australian College of General Practitioners, Australia"> 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"> ["references"] = <"Problem/Diagnosis, Draft Archetype [Internet]. National eHealth Transition Authority, NEHTA Clinical Knowledge Manager [cited: 2015-03-12]. Available from: http://dcm.nehta.org.au/ckm/#showArchetype_1013.1.896. ISO/DIS 13940 Health informatics -- System of concepts to support continuity of care., International Organization for Standardization [Internet]. Available at: http://www.iso.org/iso/catalogue_detail.htm?csnumber=58102 (accessed 2015 -04-09). Common Terminology Criteria for Adverse Events (CTCAE) [Internet]. National Cancer Institute, USA. Available from: http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm (accessed 2015-07-13). Weed LL. Medical records that guide and teach. N Engl J Med. 1968 Mar 14;278(11):593-600. PubMed PMID: 5637758. Available from: http://www.nejm.org/doi/full/10.1056/NEJM196803142781105 (accessed 2015-07-13)."> ["current_contact"] = <"Heather Leslie, Ocean Informatics, heather.leslie@oceaninformatics.com"> ["original_namespace"] = <"org.openehr"> ["original_publisher"] = <"openEHR Foundation"> ["custodian_namespace"] = <"org.openehr"> ["MD5-CAM-1.0.1"] = <"F3BA1A6809F466FF10AB50CC86EC78C5"> ["build_uid"] = <"5084c995-e34b-4832-aa41-b43ca3fe7fdf"> ["revision"] = <"1.4.1"> > definition EVALUATION[at0000] matches { -- Problem/Diagnosis data matches { ITEM_TREE[at0001] matches { -- structure items cardinality matches {1..*; unordered} matches { ELEMENT[at0002] matches { -- Problem/Diagnosis name value matches { DV_TEXT matches {*} } } ELEMENT[at0079] occurrences matches {0..*} matches { -- Variant value matches { DV_TEXT matches {*} } } ELEMENT[at0009] occurrences matches {0..1} matches { -- Clinical description value matches { DV_TEXT matches {*} } } ELEMENT[at0012] occurrences matches {0..*} matches { -- Body site value matches { DV_TEXT matches {*} } } allow_archetype CLUSTER[at0039] occurrences matches {0..*} matches { -- Structured body site include archetype_id/value matches {/openEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_circle\.v1|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.v2/} } ELEMENT[at0078] occurrences matches {0..*} matches { -- Cause value matches { DV_TEXT matches {*} } } ELEMENT[at0077] occurrences matches {0..1} matches { -- Date/time of onset value matches { DV_DATE_TIME matches {*} } } ELEMENT[at0003] occurrences matches {0..1} matches { -- Date/time clinically recognised value matches { DV_DATE_TIME matches {*} } } ELEMENT[at0005] occurrences matches {0..1} matches { -- Severity value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0047, -- Mild at0048, -- Moderate at0049] -- Severe } } DV_TEXT matches {*} } } allow_archetype CLUSTER[at0043] occurrences matches {0..*} matches { -- Specific details include archetype_id/value matches {/.*/} } ELEMENT[at0072] occurrences matches {0..1} matches { -- Course description value matches { DV_TEXT matches {*} } } ELEMENT[at0030] occurrences matches {0..1} matches { -- Date/time of resolution value matches { DV_DATE_TIME matches {*} } } allow_archetype CLUSTER[at0046] occurrences matches {0..*} matches { -- Status include archetype_id/value matches {/openEHR-EHR-CLUSTER\.problem_qualifier(-[a-zA-Z0-9_]+)*\.v2/} } ELEMENT[at0073] occurrences matches {0..1} matches { -- Diagnostic certainty value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0074, -- Suspected at0075, -- Probable at0076] -- Confirmed } } DV_TEXT matches {*} } } ELEMENT[at0069] occurrences matches {0..1} matches { -- Comment value matches { DV_TEXT matches {*} } } } } } protocol matches { ITEM_TREE[at0032] matches { -- Tree items cardinality matches {0..*; unordered} matches { ELEMENT[at0070] occurrences matches {0..1} matches { -- Last updated value matches { DV_DATE_TIME matches {*} } } allow_archetype CLUSTER[at0071] occurrences matches {0..*} matches { -- Extension include archetype_id/value matches {/.*/} } } } } } ontology term_definitions = < ["es"] = < items = < ["at0000"] = < text = <"Problema/Diagnóstico"> description = <"Detalles sobre una única condición de salud, lesión, discapacidad o cualquier otro problema identificado que afecte al bienestar físico, mental y/o social de un individuo."> comment = <"En la práctica, no es fácil distinguir claramente entre el alcance de un problema y el de un diagnóstico. A efectos de la documentación clínica con este arquetipo, el problema y el diagnóstico se consideran un continuo, con niveles crecientes de detalle y evidencia de apoyo que generalmente aportan peso a la etiqueta de \"diagnóstico\"."> > ["at0001"] = < text = <"structure"> description = <"@ internal @"> > ["at0002"] = < text = <"Nombre del problema/diagnóstico"> description = <"Identificación del problema o diagnóstico, por nombre."> comment = <"Siempre que sea posible, es preferible codificar el nombre del problema o diagnóstico con una terminología."> > ["at0003"] = < text = <"Fecha/Hora de reconocimiento del problema"> description = <"Fecha/hora estimada o real en que un profesional sanitario reconoció el diagnóstico o el problema."> comment = <"Se aceptan fechas parciales. Si el sujeto atendido es menor de un año, entonces es necesaria la fecha completa o un mínimo del mes y año para permitir cálculos de edad precisos, por ejemplo, si se utiliza para impulsar el apoyo a la toma de decisiones. Los datos registrados/importados, como \"Edad en el momento del reconocimiento clínico\", deben convertirse a una fecha utilizando la fecha de nacimiento del sujeto."> > ["at0005"] = < text = <"Severidad"> description = <"Evaluación de la gravedad global del problema o diagnóstico."> comment = <"Si la gravedad está incluida dentro del nombre del problema/diagnóstico mediante códigos precoordinados, este elemento de datos se vuelve redundante. Nota: Se puede registrar una clasificación de gravedad más específica utilizando el SLOT de detalles específicos."> > ["at0009"] = < text = <"Descripción clínica"> description = <"Descripción narrativa del problema o diagnóstico."> comment = <"Se utiliza para proporcionar antecedentes y contexto, incluida la evolución, los episodios o exacerbaciones, los progresos y cualquier otro detalle pertinente, sobre el problema o el diagnóstico."> > ["at0012"] = < text = <"Zona corporal"> description = <"Identificación de una zona corporal sencilla para la localización del problema o diagnóstico."> comment = <"Siempre que sea posible, es preferible codificar el nombre de la ubicación anatómica con una terminología. Utilice este elemento de datos para registrar ubicaciones anatómicas precoordinadas. Si los requisitos para registrar la ubicación anatómica los determina la aplicación en tiempo de ejecución o requieren un modelado más complejo, como ubicaciones relativas, utilice CLUSTER.anatomical_location o CLUSTER.relative_location, dentro del SLOT 'Structured anatomical location', en este arquetipo. Las ocurrencias de este elemento de datos son ilimitadas para permitir escenarios clínicos, como describir una erupción en múltiples ubicaciones pero donde todos los demás atributos son idénticos. Si la ubicación anatómica se incluye en el nombre del problema/diagnóstico mediante códigos precoordinados, este dato será redundante."> > ["at0030"] = < text = <"Fecha/hora de resolución"> description = <"Fecha/hora estimada o real de resolución o remisión de este problema o diagnóstico, determinada por un profesional sanitario."> comment = <"Se aceptan fechas parciales. Si el sujeto atendido es menor de un año, entonces es necesaria la fecha completa o un mínimo del mes y año para permitir cálculos de edad precisos, por ejemplo, si se utiliza para impulsar el apoyo a la toma de decisiones. Los datos registrados/importados como \"Edad en el momento de la resolución\" deben convertirse a una fecha utilizando la fecha de nacimiento del sujeto."> > ["at0032"] = < text = <"Tree"> description = <"@ internal @"> > ["at0039"] = < text = <"Zona corporal estructurada"> description = <"Ubicación anatómica estructurada del problema o diagnóstico."> comment = <"Utilice este SLOT para insertar los arquetipos CLUSTER.anatomical_location o CLUSTER.relative_location si la aplicación determina los requisitos para registrar la ubicación anatómica en tiempo de ejecución o requiere un modelado más complejo, como ubicaciones relativas. Si la ubicación anatómica se incluye en el nombre del problema/diagnóstico mediante códigos precoordinados, el uso de este SLOT se vuelve redundante."> > ["at0043"] = < text = <"Detalles específicos"> description = <"Detalles que es necesario registrar adicionalmente como atributos únicos de este problema o diagnóstico."> comment = <"Puede incluir detalles estructurados sobre la clasificación o estadificación del diagnóstico; criterios de diagnóstico, criterios de clasificación o evaluaciones de gravedad formales, como los Criterios Terminológicos Comunes para Eventos Adversos."> > ["at0046"] = < text = <"Estado"> description = <"Detalles estructurados para aspectos específicos del proceso de diagnóstico de ubicación, dominio, episodio o flujo de trabajo."> comment = <"Utilice los calificadores de estado o contexto con precaución, ya que se utilizan de forma variable en la práctica y no se puede garantizar la interoperabilidad a menos que su uso esté claramente definido con la comunidad de uso. Por ejemplo: estado activo - activo, inactivo, resuelto, en remisión; estado de evolución - inicial, provisional/en curso, final; estado temporal - actual, pasado; estado de episodicidad - primero, nuevo, en curso; estado de admisión - ingreso, alta; o estado de prioridad - primaria, secundaria."> > ["at0047"] = < text = <"Leve"> description = <"El problema o diagnóstico no interfiere con la actividad normal ni puede causar daños a la salud si no se trata."> > ["at0048"] = < text = <"Moderado"> description = <"El problema o diagnóstico interfiere en la actividad normal o perjudica la salud si no se trata."> > ["at0049"] = < text = <"Severo"> description = <"El problema o diagnóstico impide la actividad normal o perjudica gravemente la salud si no se trata."> > ["at0069"] = < text = <"Comentarios"> description = <"Información adicional sobre el problema o el diagnóstico no recogida en otros campos."> > ["at0070"] = < text = <"Última actualización"> description = <"Fecha de la última actualización de este problema o diagnóstico."> > ["at0071"] = < text = <"Ampliación"> description = <"Información adicional necesaria para registrar el contenido local o para alinearse con otros modelos/formalismos de referencia."> comment = <"Por ejemplo: requisitos locales de información o metadatos adicionales para alinearse con los equivalentes de FHIR o CIMI."> > ["at0072"] = < text = <"Progreso"> description = <"Descripción narrativa sobre la evolución del problema o diagnóstico desde su aparición."> > ["at0073"] = < text = <"Certeza diagnóstica"> description = <"Nivel de confianza en la identificación del diagnóstico."> comment = <"Si se necesita un conjunto de valores alternativo, estos valores pueden añadirse al tipo de datos DV_TEXT en una plantilla."> > ["at0074"] = < text = <"Dudoso"> description = <"El diagnóstico se ha identificado con un bajo nivel de certeza."> > ["at0075"] = < text = <"Probable"> description = <"El diagnóstico se ha identificado con un alto nivel de certeza."> > ["at0076"] = < text = <"Confirmado"> description = <"El diagnóstico se ha confirmado con criterios reconocidos."> > ["at0077"] = < text = <"Fecha/hora de inicio"> description = <"Fecha/hora estimada o real en que se observaron por primera vez los signos o síntomas del problema/diagnóstico."> comment = <"Los datos registrados/importados, como \"Edad al inicio\", deben convertirse a una fecha utilizando la fecha de nacimiento del sujeto."> > ["at0078"] = < text = <"Causa"> description = <"Causa, conjunto de causas o manera de causar el problema o diagnóstico."> comment = <"También denominada \"etiología\". Siempre que sea posible, es preferible codificar con una terminología."> > ["at0079"] = < text = <"Variante"> description = <"Variante o subtipo específico del Diagnóstico, si procede."> comment = <"Por ejemplo: \"neuropatía axonal motora aguda\" como variante del síndrome de Guillain-Barré. Siempre que sea posible, es preferible codificar el nombre de la variante con una terminología."> > > > ["es-ar"] = < items = < ["at0000"] = < text = <"Problema/Diagnóstico"> description = <"Detalles acerca de una condición de salud, lesión, incapacidad o cualquier otra cuerstión, univocamente identificadas, que impacta sobre el bienestar físico, mental y/o social de un individuo"> comment = <"La delineación entre el alcance de un problema versus el diagnóstico puede no ser fácil de lograr en la práctica. A los fines de la documentación clínica mediante este arquetipo, problema y diagnóstico son considerados un continuo, donde niveles incrementales de detalles y evidencia de apoyo otorgan mas peso a la etiqueta de \"diagnóstico\"."> > ["at0001"] = < text = <"*structure(en)"> description = <"*@ internal @(en)"> > ["at0002"] = < text = <"Nombre del problema/diagnóstico"> description = <"Identificación del problema o diagnóstico, por nombre."> comment = <"Se prefiere la codificación del nombre del problema o diagnóstico mediante una terminología cuando esto sea posible."> > ["at0003"] = < text = <"Fecha y hora del reconocimiento clínico"> description = <"Fecha y hora estimadas o confirmadas en las cuales el diagnóstico o problema fue reconocido por el profesional de la salud."> comment = <"El uso de fechas parciales es aceptable. Si el sujeto de cuidados tiene menos de un año de edad, se requiere la fecha completa o al menos el año y mes para permitir cálculos adecuados (si por ejemplo se utiliza para guiar un apoyo a la toma de decisiones). Los datos registrados o importados como \"Edad a la aparición\" deberán ser convertidos a una fecha utilizando la fecha de nacimiento del sujeto."> > ["at0005"] = < text = <"Severidad"> description = <"Una evaluación de la severidad general del problema o diagnóstico."> comment = <"Si la severidad del problema o diagnóstico esta incluida en su nombre mediante códigos precoordinados, este dato se torna redundante. Nota: una gradación ,as específica de severidad puede ser registrada utilizando el slot de Detalles específicos."> > ["at0009"] = < text = <"Descripción clínica"> description = <"Descripción narrativa del problema o diagnóstico."> comment = <"Utilizar para proveer trasfondo y contexto, incluyendo evolución, episodios o exacerbaciones, progreso y cualquier otro detalles relevante acerca del problema o diagnóstico."> > ["at0012"] = < text = <"Sitio corporal"> description = <"Identificación de un sitio corporal simple para la localización o el problema."> comment = <"Se prefiere la codificación de la localización anatómica mediante una terminología cuando esto sea posible. Utilícese este dato para registrar localizaciones anatómicas precoordinadas. Si los requerimientos para el registro de una localización anatómica son determinadas en tiempo de ejecución por parte de la aplicación, o se requiere un modelado más complejo tal como una localización relativa, utilícese CLUSTER.anatomical_location or CLUSTER.relative_location dentro del slot \"localización anatómica estructurada\" en este arquetipo. Las ocurrencias de este dato son ilimitadas para así permitir escenarios clínicos tales como la descripción de un rash en múltiples localizaciones pero donde todos los demás atributos son idénticos. Si la localización anatómica esta incluida en el nombre del problema o diagnóstico mediante códigos precoordinados, este dato se torna redundante."> > ["at0030"] = < text = <"Fecha/hora de resolución"> description = <"Fecha y hora estimadas o confirmadas en las cuales este problema o diagnóstico remitió o se resolvió, determinadas de un profesional de la salud."> comment = <"El uso de fechas parciales es aceptable. Si el sujeto de cuidados tiene menos de un año de edad, se requiere la fecha completa o al menos el año y mes para permitir cálculos adecuados (si por ejemplo se utiliza para guiar un apoyo a la toma de decisiones)."> > ["at0032"] = < text = <"*Tree(en)"> description = <"*@ internal @(en)"> > ["at0039"] = < text = <"Sitio corporal estructurado"> description = <"una localización anatómica estructurada para el problema o diagnóstico."> comment = <"Utilícese este slot para insertar los arqeutipos de CLUSTER.anatomical_location o CLUSTER.relative_location si los requerimientos de registro de la localización anatómica son determinados en tiempo de ejecución por la aplicación o se requiere un modelado más complejo tal como localizaciones relativas. Si la localización anatómica está incluida en el nombre del problema o diagnóstico mediante códigos precoordinados, este dato se torna redundante."> > ["at0043"] = < text = <"Detalles específicos"> description = <"Detalles adicionales requeridos para registrar como atributos unívocos del este problema o diagnóstico."> comment = <"Puede incluir detalles estructurados acerca del grado o estadificación del diagnóstico, criterios diagnósticos, criterios de clasificación o una evaluación formal de severidad tal como los Criterios Terminológicos Comunes para Eventos Adversos."> > ["at0046"] = < text = <"Estado"> description = <"Detalles estructurados para los aspectos específicos de localización, dominio, episodio o decurso del proceso diagnóstico."> comment = <"Los calificadores de estado o contexto con cuidado ya que son variables en su utilización y la interoperabilidad no puede ser garantizada excepto en casos en que se encuentren claramente definidos en el seno de la comunidad de uso. Por ejemplo, el estado de actividad (activo, inactivo, resuelto o en remisión), el estado de evolución (inicial, interino o de trabajo, final), el estado temporal (actual, pasado), el estado episódico (primero, inicial, en curso), el estado de admisión (admisión, egreso) o el estado de prioridad (primario, secundario)."> > ["at0047"] = < text = <"Leve"> description = <"El problema o diagnóstico no interfiere con la actividad normal o puede causar daños a la salud si no es tratado."> > ["at0048"] = < text = <"Moderado"> description = <"El problema o diagnóstico interfiere con la actividad normal o puede dañar la salud si no es tratado."> > ["at0049"] = < text = <"Severo"> description = <"El problema o diagnóstico impide la actividad normal o pude dañar seriamente la salud si no es tratado."> > ["at0069"] = < text = <"Comentario"> description = <"Narrativa adicional acerca del problema o diagnóstico que no ha sido consignada en otros campos."> > ["at0070"] = < text = <"Última actualización."> description = <"La fecha de la última actualización de este problema o diagnóstico."> > ["at0071"] = < text = <"Extensión"> description = <"Información adicional requerida para consignar contenidos locales o alinear con otros modelos de referencia o formalismos."> comment = <"Por ejemplo: requerimientos de información local o metadatos adicionales para alineamiento con equivalentes en FHIR o CIMI."> > ["at0072"] = < text = <"Descripción del curso"> description = <"Descripción narrativa del curso del problema o diagnóstico desde su aparición."> > ["at0073"] = < text = <"Certeza diagnóstica"> description = <"El nivel de certeza de la identificación del diagnóstico."> comment = <"*If an alternative valueset is required, these values can be added to the DV_TEXT data type in a template.(en)"> > ["at0074"] = < text = <"Sospechado"> description = <"El diagnóstico ha sido identificado con un bajo nivel de certeza."> > ["at0075"] = < text = <"Probable"> description = <"El diagnóstico ha sido identificado con un alto nivel de certeza."> > ["at0076"] = < text = <"Confirmado"> description = <"El diagnóstico ha sido confirmado en base a criterios reconocidos."> > ["at0077"] = < text = <"Fecha/hora de aparición"> description = <"Fecha y hora estimadas o confirmadas en las cuales los signos o síntomas del problema fueron observados por primera vez."> comment = <"Los datos registrados o importados como \"Edad a la aparición\" deberán ser convertidos a una fecha utilizando la fecha de nacimiento del sujeto."> > ["at0078"] = < text = <"*Cause (en)"> description = <"*A cause, set of causes, or manner of causation of the problem or diagnosis.(en)"> comment = <"*Also known as 'aetiology' or 'etiology'. Coding with an external terminology is preferred, where possible.(en)"> > ["at0079"] = < text = <"*Variant (en)"> description = <"*Specific variant or subtype of the Diagnosis, if relevant. (en)"> comment = <"*For example: 'acute motor axonal neuropathy' as a variant of Guillain-Barre Syndrome. Coding of the name of the variant with a terminology is preferred, where possible. (en)"> > > > ["de"] = < items = < ["at0000"] = < text = <"Problem/Diagnose"> description = <"Angaben über einen einzelnen identifizierten Gesundheitszustand, eine Verletzung, eine Behinderung oder ein Problem, welches das körperliche, geistige und/oder soziale Wohlergehen einer Einzelperson beeinträchtigt."> comment = <"Eine klare Abgrenzung zwischen Problem und Diagnose ist in der Praxis nicht einfach zu erreichen. Für die Zwecke der klinischen Dokumentation mit diesem Archetyp werden Problem und Diagnose als ein Kontinuum betrachtet, mit zunehmendem Detaillierungsgrad und unterstützenden Beweisen, die in der Regel dem Etikett \"Diagnose\" Gewicht verleihen."> > ["at0001"] = < text = <"Structure"> description = <"@ internal @"> > ["at0002"] = < text = <"Name des Problems/ der Diagnose"> description = <"Namentliche Identifikation des Problems oder der Diagnose."> comment = <"Wo möglich, ist die Kodierung des Problems oder der Diagnose über eine Terminologie zu bevorzugen."> > ["at0003"] = < text = <"Datum/Zeitpunkt der klinischen Feststellung"> description = <"Geschätzte oder exakte Zeit (bzw. Datum), zu der die Diagnose oder das Problem von einer medizinischen Fachkraft festgestellt wurde."> comment = <"Unvollständige Datumsangaben sind zulässig. Wenn der Patient unter einem Jahr alt ist, dann ist das vollständige Datum oder ein Minimum von Monat und Jahr notwendig, um genaue Altersberechnungen zu ermöglichen - z.B. wenn es zur Entscheidungsunterstützung verwendet wird. Datumswerte, die als \"Alter zum Zeitpunkt der klinischen Feststellung\" erfasst/importiert werden, sollten anhand des Geburtsdatums der Person in ein Datum umgewandelt werden."> > ["at0005"] = < text = <"Schweregrad"> description = <"Eine Gesamtbeurteilung des Schweregrades des Problems oder der Diagnose."> comment = <"Ist der Schweregrad über vordefinierte Codes im Element \"Name des Problems/ der Diagnose\" enthalten, wird dieses Datenelement überflüssig. Hinweis: Eine spezifischere Einstufung des Schweregrads kann mit Hilfe des SLOTs \"Spezifische Angaben\" angegeben werden."> > ["at0009"] = < text = <"Klinische Beschreibung"> description = <"Beschreibung des Problems oder der Diagnose."> comment = <"Wird verwendet, um Hintergrund und Kontext, einschließlich Entwicklung, Episoden oder Verschlechterungen, Fortschritt und andere relevante Details über das Problem oder die Diagnose zu liefern."> > ["at0012"] = < text = <"Körperstelle"> description = <"Identifikation einer einfachen Körperstelle zur Lokalisierung des Problems oder der Diagnose."> comment = <"Wo dies möglich ist, ist die Kodierung der anatomischen Lokalisation über eine Terminologie zu bevorzugen. Verwenden Sie dieses Datenelement, um vorab präkoordinierte anatomische Lokalisationen zu erfassen. Wenn die Anforderungen an die Erfassung der anatomischen Lokalisation zur Laufzeit durch die Anwendung bestimmt werden oder komplexere Modellierungen, wie z.B. relative Lokalisationen erforderlich sind, dann verwenden Sie in diesem Archetyp den CLUSTER.anatomical_location oder CLUSTER.relative_location innerhalb des SLOT 'Structured anatomical location'. Die Anzahl für dieses Datenelement ist unbegrenzt, um klinische Szenarien wie die Beschreibung eines Hautausschlags an mehreren Stellen zu ermöglichen, wobei jedoch alle anderen Attribute identisch sind. Falls die anatomische Lage über präkoordinierte Codes im Namen des Problems/Diagnose enthalten ist, wird dieses Datenelement überflüssig."> > ["at0030"] = < text = <"Datum/Zeitpunkt der Genesung"> description = <"Geschätzte oder exakte Zeit (bzw. Datum), zu der von einer medizinischen Fachkraft die Genesung oder die Remission des Problems oder der Diagnose festgestellt wurde."> comment = <"Unvollständige Datumsangaben sind zulässig. Wenn der Patient unter einem Jahr alt ist, dann ist das vollständige Datum oder ein Minimum von Monat und Jahr notwendig, um genaue Altersberechnungen zu ermöglichen - z.B. wenn es zur Entscheidungsunterstützung verwendet wird. Datumswerte, die als \"Alter zum Zeitpunkt der Genesung\" erfasst/importiert werden, sollten anhand des Geburtsdatums der Person in ein Datum umgewandelt werden."> > ["at0032"] = < text = <"Tree"> description = <"@ internal @"> > ["at0039"] = < text = <"Anatomische Stelle (strukturiert)"> description = <"Eine strukturierte anatomische Lokalisation des Problems oder der Diagnose."> comment = <"Verwenden Sie diesen SLOT, um die Archetypen CLUSTER.anatomical_location oder CLUSTER.relative_location einzufügen, wenn die Anforderungen für die Aufnahme der anatomischen Position zur Laufzeit der Anwendung bestimmt werden oder komplexere Modellierungen wie z.B. relative Positionen erforderlich sind. Ist die anatomische Lokalisation über präkoordinierte Codes im Namen des Problems/Diagnose enthalten, wird die Verwendung dieses SLOT überflüssig."> > ["at0043"] = < text = <"Spezifische Angaben"> description = <"Zusätzlich benötigte Angaben, welche als eindeutige Merkmale des Problem/der Diagnose erfasst werden sollten."> comment = <"Hier können strukturierte Angaben über die Einstufung oder das Stadium der Diagnose enthalten sein; diagnostische Kriterien, Klassifizierungskriterien oder formale Bewertungen des Schweregrades wie z.B. \"Common Terminology Criteria for Adverse Events\"."> > ["at0046"] = < text = <"Status"> description = <"Strukturierte Angaben zu standort-, domänen-, episoden- oder workflow-spezifischen Aspekten des diagnostischen Prozesses."> comment = <"Verwenden Sie Status- oder Kontext-Merkmale mit Vorsicht, da sie in der Praxis variabel eingesetzt werden und die Interoperabilität nicht gewährleistet werden kann, sofern die Verwendung nicht mit der Nutzungsgemeinschaft klar abgestimmt wird. Beispiel: aktiver Status - aktiv, inaktiv, genesen, in Remission; Entwicklungsstatus - initial, interim/working, final; zeitlicher Status - aktuell, vergangen; Episodenstatus - erstmalig, neu, laufend; Aufnahmestatus - Aufnahme, Entlassung; oder Prioritätsstatus - primär, sekundär."> > ["at0047"] = < text = <"Leicht"> description = <"Das Problem oder die Diagnose beeinträchtigt die normale Aktivität nicht, bzw. verursacht nicht bleibende gesundheitliche Schäden, falls es nicht behandelt wird."> > ["at0048"] = < text = <"Mäßig"> description = <"Das Problem oder die Diagnose beeinträchtigt die normale Aktivität oder verursacht bleibende gesundheitliche Schäden, falls es nicht behandelt wird."> > ["at0049"] = < text = <"Schwer"> description = <"Das Problem oder die Diagnose verhindert die normale Aktivität oder verursacht schwerwiegende gesundheitliche Schäden, falls es nicht behandelt wird."> > ["at0069"] = < text = <"Kommentar"> description = <"Ergänzende Beschreibung des Problems oder der Diagnose, die nicht anderweitig erfasst wurde."> > ["at0070"] = < text = <"Zuletzt aktualisiert"> description = <"Datum der letzten Aktualisierung der Diagnose bzw. des Problems."> > ["at0071"] = < text = <"Erweiterung"> description = <"Zusätzliche Informationen zur Erfassung lokaler Inhalte oder Anpassung an andere Referenzmodelle/Formalismen."> comment = <"Zum Beispiel: Lokaler Informationsbedarf oder zusätzliche Metadaten zur Anpassung an FHIR-Ressourcen oder CIMI-Modelle."> > ["at0072"] = < text = <"Beschreibung des Verlaufs"> description = <"Beschreibung des Problem-/ Diagnoseverlaufs seit Beginn."> > ["at0073"] = < text = <"Diagnostische Sicherheit"> description = <"Grad der Sicherheit, mit der die Diagnose festgestellt wurde."> comment = <"Wenn ein alternativer Wertesatz benötigt wird, können diese Werte in einem Template zum Datentyp DV_TEXT hinzugefügt werden."> > ["at0074"] = < text = <"Vermutet"> description = <"Die Diagnose wurde mit einem niedrigen Grad an Sicherheit gestellt."> > ["at0075"] = < text = <"Wahrscheinlich"> description = <"Die Diagnose wurde mit einem hohen Maß an Sicherheit gestellt."> > ["at0076"] = < text = <"Bestätigt"> description = <"Die Diagnose wurde anhand anerkannter Kriterien bestätigt."> > ["at0077"] = < text = <"Datum/ Zeitpunkt des Auftretens/ der Erstdiagnose"> description = <"Geschätzte oder exakte Zeit (bzw. Datum), zu der die Krankheitsanzeichen oder Symptome zum ersten mal beobachtet wurden."> comment = <"Datumswerte, die als \"Alter zu Beginn\" erfasst/importiert werden, sollten anhand des Geburtsdatums der Person in ein Datum umgewandelt werden."> > ["at0078"] = < text = <"Ursache"> description = <"Die Ursache, eine Reihe von Ursachen oder eine Art und Weise der Verursachung des Problems oder der Diagnose."> comment = <"Auch bekannt als „Ätiologie“. Die Codierung mit einer externen Terminologie wird nach Möglichkeit bevorzugt."> > ["at0079"] = < text = <"Variante"> description = <"Spezifische Variante oder Subtyp der Diagnose, falls relevant."> comment = <"Zum Beispiel: „Akute motorische axonale Neuropathie“ als Variante des Guillain-Barre-Syndroms. Wo möglich, ist die Kodierung des Namens der Variante über eine Terminologie zu bevorzugen."> > > > ["en"] = < items = < ["at0000"] = < text = <"Problem/Diagnosis"> description = <"Details about a single identified health condition, injury, disability or any other issue which impacts on the physical, mental and/or social well-being of an individual."> comment = <"Clear delineation between the scope of a problem versus a diagnosis is not easy to achieve in practice. For the purposes of clinical documentation with this archetype, problem and diagnosis are regarded as a continuum, with increasing levels of detail and supportive evidence usually providing weight towards the label of 'diagnosis'."> > ["at0001"] = < text = <"structure"> description = <"@ internal @"> > ["at0002"] = < text = <"Problem/Diagnosis name"> description = <"Identification of the problem or diagnosis, by name."> comment = <"Coding of the name of the problem or diagnosis with a terminology is preferred, where possible."> > ["at0003"] = < text = <"Date/time clinically recognised"> description = <"Estimated or actual date/time the diagnosis or problem was recognised by a healthcare professional."> comment = <"Partial dates are acceptable. If the subject of care is under the age of one year, then the complete date or a minimum of the month and year is necessary to enable accurate age calculations - for example, if used to drive decision support. Data captured/imported as \"Age at time of clinical recognition\" should be converted to a date using the subject's date of birth."> > ["at0005"] = < text = <"Severity"> description = <"An assessment of the overall severity of the problem or diagnosis."> comment = <"If severity is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant. Note: more specific grading of severity can be recorded using the Specific details SLOT."> > ["at0009"] = < text = <"Clinical description"> description = <"Narrative description about the problem or diagnosis."> comment = <"Use to provide background and context, including evolution, episodes or exacerbations, progress and any other relevant details, about the problem or diagnosis."> > ["at0012"] = < text = <"Body site"> description = <"Identification of a simple body site for the location of the problem or diagnosis."> comment = <"Coding of the name of the anatomical location with a terminology is preferred, where possible. Use this data element to record precoordinated anatomical locations. If the requirements for recording the anatomical location are determined at run-time by the application or require more complex modelling such as relative locations then use the CLUSTER.anatomical_location or CLUSTER.relative_location within the 'Structured anatomical location' SLOT in this archetype. Occurrences for this data element are unbounded to allow for clinical scenarios such as describing a rash in multiple locations but where all of the other attributes are identical. If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant."> > ["at0030"] = < text = <"Date/time of resolution"> description = <"Estimated or actual date/time of resolution or remission for this problem or diagnosis, as determined by a healthcare professional."> comment = <"Partial dates are acceptable. If the subject of care is under the age of one year, then the complete date or a minimum of the month and year is necessary to enable accurate age calculations - for example, if used to drive decision support. Data captured/imported as \"Age at time of resolution\" should be converted to a date using the subject's date of birth. "> > ["at0032"] = < text = <"Tree"> description = <"@ internal @"> > ["at0039"] = < text = <"Structured body site"> description = <"A structured anatomical location for the problem or diagnosis."> comment = <"Use this SLOT to insert the CLUSTER.anatomical_location or CLUSTER.relative_location archetypes 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. If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, use of this SLOT becomes redundant."> > ["at0043"] = < text = <"Specific details"> description = <"Details that are additionally required to record as unique attributes of this problem or diagnosis."> comment = <"May include structured detail about the grading or staging of the diagnosis; diagnostic criteria, classification criteria or formal severity assessments such as Common Terminology Criteria for Adverse Events."> > ["at0046"] = < text = <"Status"> description = <"Structured details for location-, domain-, episode- or workflow-specific aspects of the diagnostic process."> comment = <"Use status or context qualifiers with care, as they are variably used in practice and interoperability cannot be assured unless usage is clearly defined with the community of use. For example: active status - active, inactive, resolved, in remission; evolution status - initial, interim/working, final; temporal status - current, past; episodicity status - first, new, ongoing; admission status - admission, discharge; or priority status - primary, secondary."> > ["at0047"] = < text = <"Mild"> description = <"The problem or diagnosis does not interfere with normal activity or may cause damage to health if left untreated."> > ["at0048"] = < text = <"Moderate"> description = <"The problem or diagnosis causes interference with normal activity or will damage health if left untreated."> > ["at0049"] = < text = <"Severe"> description = <"The problem or diagnosis prevents normal activity or will seriously damage health if left untreated."> > ["at0069"] = < text = <"Comment"> description = <"Additional narrative about the problem or diagnosis not captured in other fields."> > ["at0070"] = < text = <"Last updated"> description = <"The date this problem or diagnosis was last updated."> > ["at0071"] = < 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."> > ["at0072"] = < text = <"Course description"> description = <"Narrative description about the course of the problem or diagnosis since onset."> > ["at0073"] = < text = <"Diagnostic certainty"> description = <"The level of confidence in the identification of the diagnosis."> comment = <"If an alternative valueset is required, these values can be added to the DV_TEXT data type in a template."> > ["at0074"] = < text = <"Suspected"> description = <"The diagnosis has been identified with a low level of certainty."> > ["at0075"] = < text = <"Probable"> description = <"The diagnosis has been identified with a high level of certainty."> > ["at0076"] = < text = <"Confirmed"> description = <"The diagnosis has been confirmed against recognised criteria."> > ["at0077"] = < text = <"Date/time of onset"> description = <"Estimated or actual date/time that signs or symptoms of the problem/diagnosis were first observed."> comment = <"Data captured/imported as \"Age at onset\" should be converted to a date using the subject's date of birth."> > ["at0078"] = < text = <"Cause"> description = <"A cause, set of causes, or manner of causation of the problem or diagnosis."> comment = <"Also known as 'aetiology' or 'etiology'. Coding with an external terminology is preferred, where possible."> > ["at0079"] = < text = <"Variant"> description = <"Specific variant or subtype of the Diagnosis, if relevant."> comment = <"For example: 'acute motor axonal neuropathy' as a variant of Guillain-Barre Syndrome. Coding of the name of the variant with a terminology is preferred, where possible. "> > > > ["ar-sy"] = < items = < ["at0000"] = < text = <"*Problem/Diagnosis(en)"> description = <"*Details about a single identified health condition, injury, disability or any other issue which impacts on the physical, mental and/or social well-being of an individual.(en)"> comment = <"*Clear delineation between the scope of a problem versus a diagnosis is not easy to achieve in practice. For the purposes of clinical documentation with this archetype, problem and diagnosis are regarded as a continuum, with increasing levels of detail and supportive evidence usually providing weight towards the label of 'diagnosis'.(en)"> > ["at0001"] = < text = <"*structure(en)"> description = <"*@ internal @(en)"> > ["at0002"] = < text = <"*Problem/Diagnosis name(en)"> description = <"*Identification of the problem or diagnosis, by name.(en)"> comment = <"*Coding of the name of the problem or diagnosis with a terminology is preferred, where possible.(en)"> > ["at0003"] = < text = <"*Date/time clinically recognised(en)"> description = <"*Estimated or actual date/time the diagnosis or problem was recognised by a healthcare professional.(en)"> comment = <"*Partial dates are acceptable. If the subject of care is under the age of one year, then the complete date or a minimum of the month and year is necessary to enable accurate age calculations - for example, if used to drive decision support.(en)"> > ["at0005"] = < text = <"*Severity(en)"> description = <"*An assessment of the overall severity of the problem or diagnosis.(en)"> comment = <"*If severity is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant. Note: more specific grading of severity can be recorded using the Specific details SLOT.(en)"> > ["at0009"] = < text = <"*Clinical description(en)"> description = <"*Narrative description about the problem or diagnosis.(en)"> comment = <"*Use to provide background and context, including evolution, episodes or exacerbations, progress and any other relevant details, about the problem or diagnosis.(en)"> > ["at0012"] = < text = <"*Body site(en)"> description = <"*Identification of a simple body site for the location of the problem or diagnosis.(en)"> comment = <"*Coding of the name of the anatomical location with a terminology is preferred, where possible. Use this data element to record precoordinated anatomical locations. If the requirements for recording the anatomical location are determined at run-time by the application or require more complex modelling such as relative locations then use the CLUSTER.anatomical_location or CLUSTER.relative_location within the 'Structured anatomical location' SLOT in this archetype. Occurrences for this data element are unbounded to allow for clinical scenarios such as describing a rash in multiple locations but where all of the other attributes are identical. If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant.(en)"> > ["at0030"] = < text = <"*Date/time of resolution(en)"> description = <"*Estimated or actual date/time of resolution or remission for this problem or diagnosis, as determined by a healthcare professional.(en)"> comment = <"*Partial dates are acceptable. If the subject of care is under the age of one year, then the complete date or a minimum of the month and year is necessary to enable accurate age calculations - for example, if used to drive decision support.(en)"> > ["at0032"] = < text = <"*Tree(en)"> description = <"*@ internal @(en)"> > ["at0039"] = < text = <"*Structured body site(en)"> description = <"*A structured anatomical location for the problem or diagnosis.(en)"> comment = <"*Use this SLOT to insert the CLUSTER.anatomical_location or CLUSTER.relative_location archetypes 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. If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, use of this SLOT becomes redundant.(en)"> > ["at0043"] = < text = <"*Specific details(en)"> description = <"*Details that are additionally required to record as unique attributes of this problem or diagnosis.(en)"> comment = <"*May include structured detail about the grading or staging of the diagnosis; diagnostic criteria, classification criteria or formal severity assessments such as Common Terminology Criteria for Adverse Events.(en)"> > ["at0046"] = < text = <"*Status(en)"> description = <"*Structured details for location-, domain-, episode- or workflow-specific aspects of the diagnostic process.(en)"> comment = <"*Use status or context qualifiers with care, as they are variably used in practice and interoperability cannot be assured unless usage is clearly defined with the community of use. For example: active status - active, inactive, resolved, in remission; evolution status - initial, interim/working, final; temporal status - current, past; episodicity status - first, new, ongoing; admission status - admission, discharge; or priority status - primary, secondary.(en)"> > ["at0047"] = < text = <"*Mild(en)"> description = <"*The problem or diagnosis does not interfere with normal activity.(en)"> > ["at0048"] = < text = <"*Moderate(en)"> description = <"*The problem or diagnosis causes interference with normal activity.(en)"> > ["at0049"] = < text = <"*Severe(en)"> description = <"*The problem or diagnosis prevents normal activity.(en)"> > ["at0069"] = < text = <"*Comment(en)"> description = <"*Additional narrative about the problem or diagnosis not captured in other fields.(en)"> > ["at0070"] = < text = <"*Last updated(en)"> description = <"*The date this problem or diagnosis was last updated.(en)"> > ["at0071"] = < 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)"> > ["at0072"] = < text = <"*Course description(en)"> description = <"*Narrative description about the course of the problem or diagnosis since onset.(en)"> > ["at0073"] = < text = <"*Diagnostic certainty(en)"> description = <"*The level of confidence in the identification of the diagnosis.(en)"> comment = <"*If an alternative valueset is required, these values can be added to the DV_TEXT data type in a template.(en)"> > ["at0074"] = < text = <"*Suspected(en)"> description = <"*The diagnosis has been identified with a low level of certainty.(en)"> > ["at0075"] = < text = <"*Probable(en)"> description = <"*The diagnosis has been identified with a high level of certainty.(en)"> > ["at0076"] = < text = <"*Confirmed(en)"> description = <"*The diagnosis has been confirmed against recognised criteria.(en)"> > ["at0077"] = < text = <"*Date of onset(en)"> description = <"*Estimated or actual date/time that signs or symptoms of the problem/diagnosis were first observed.(en)"> > ["at0078"] = < text = <"*Cause (en)"> description = <"*A cause, set of causes, or manner of causation of the problem or diagnosis.(en)"> comment = <"*Also known as 'aetiology' or 'etiology'. Coding with an external terminology is preferred, where possible.(en)"> > ["at0079"] = < text = <"*Variant (en)"> description = <"*Specific variant or subtype of the Diagnosis, if relevant. (en)"> comment = <"*For example: 'acute motor axonal neuropathy' as a variant of Guillain-Barre Syndrome. Coding of the name of the variant with a terminology is preferred, where possible. (en)"> > > > ["pt-br"] = < items = < ["at0000"] = < text = <"Problema /Diagnóstico"> description = <"Detalhes sobre uma única condição de saúde identificada, lesões, deficiência ou qualquer outra questão que tenha impacto sobre o bem-estar físico, mental e / ou social de um indivíduo."> comment = <"Delimitação clara entre o âmbito de um problema em comparação a um diagnóstico, não é fácil de se conseguir na prática. Para fins de documentação clínica com este arquétipo, problema e diagnóstico são considerados como uma continuidade, com níveis crescentes de detalhes e evidência de apoio, geralmente fornecendo peso para o rótulo de \"diagnóstico\"."> > ["at0001"] = < text = <"structure"> description = <"@ internal @"> > ["at0002"] = < text = <"Nome do Problema / Diagnóstico"> description = <"Identificação do problema ou diagnóstico, por nome."> comment = <"Quando possível, é preferível usar a codificação do nome do problema ou diagnóstico com uma terminologia."> > ["at0003"] = < text = <"Data / hora da reconhecimento clínico"> description = <"Data / hora, estimada ou real, que o diagnóstico ou o problema foi reconhecido por um profissional de saúde."> comment = <"Datas parciais são aceitáveis. Se o tema do cuidado está com idade inferior a um ano, então a data completa ou no mínimo o mês e o ano são necessários para permitir cálculos de idade precisos, por exemplo, se usado para conduzir apoio à decisão. Os dados capturados / importados como \"Idade no momento do reconhecimento clínico\" deve ser convertida para uma data usando o sujeito data de nascimento."> > ["at0005"] = < text = <"Severidade"> description = <"Uma avaliação global da severidade do problema ou diagnóstico."> comment = <"Se a severidade está incluída no nome do Problema / diagnóstico através de códigos pré-coordenados, este elemento de dados torna-se redundante. Nota: a classificação mais específica da gravidade pode ser gravada utilizando os detalhes específicos SLOT."> > ["at0009"] = < text = <"Descrição clínica"> description = <"Descrição narrativa sobre o problema ou diagnóstico."> comment = <"Usar para fornecer conhecimento e contexto, incluindo evolução, episódios ou exacerbações, progresso e quaisquer outros detalhes relevantes, sobre o problema ou diagnóstico."> > ["at0012"] = < text = <"Local do corpo"> description = <"Simples identificação de um local do corpo para a localização do problema ou diagnóstico."> comment = <"A codificação do nome da localização anatômica com uma terminologia é preferível, quando possível. Utilize este elemento de dados para gravar localizações anatômicas precoordenadas. Se os requisitos para gravar a localização anatômica são determinados em tempo real através da aplicação ou requerem uma modelagem mais complexa, como localizações relativas, em seguida, use o CLUSTER.anatomical_location ou CLUSTER.relative_location dentro do SLOT 'localização anatômica estruturada' neste arquétipo. Ocorrências para este elemento de dados são ilimitadas para permitir cenários clínicos tais como a descrição de uma erupção cutânea em vários locais, mas em que todos os outros atributos são idênticos. Se a localização anatômica é incluída ao nome do Problema / diagnóstico, através de códigos pré-coordenados, este elemento de dados torna-se redundante."> > ["at0030"] = < text = <"Data /tempo de resolução"> description = <"Data / tempo, estimado ou atual, de resolução ou de dispensa desse problema ou diagnóstico, como determinado por um profissional de saúde."> comment = <"Datas parciais são aceitáveis. Se o tema do cuidado está com idade inferior a um ano, então a data completa ou no mínimo o mês e o ano são necessários para permitir cálculos de idade precisos, por exemplo, se usado para conduzir apoio à decisão. Os dados capturados / importados como \"Idade na ocasião da resolução\" deve ser convertida para uma data usando o sujeito data de nascimento."> > ["at0032"] = < text = <"Tree(en)"> description = <"@ internal @"> > ["at0039"] = < text = <"Local estruturado do corpo"> description = <"A localização anatômica estruturada para o problema ou diagnóstico."> comment = <"Use esse SLOT para inserir os arquétipos CLUSTER.anatomical_location ou CLUSTER.relative_location se os requisitos para gravar a localização anatômica são determinados em tempo real através da aplicação ou requer uma modelagem mais complexa, como localizações relativas. Se a localização anatômica está incluída ao nome Problema / diagnóstico, através de códigos pré-coordenados, o uso deste SLOT torna-se redundante."> > ["at0043"] = < text = <"Detalhes específicos"> description = <"Detalhes que são adicionalmente necessários para gravar atributos como únicos deste problema ou diagnóstico."> comment = <"Pode incluir detalhes estruturados sobre a classificação ou a realização do diagnóstico; critérios de diagnóstico, critérios de classificação ou avaliação formal da severidade, como os critérios de terminologia comum para eventos adversos."> > ["at0046"] = < text = <"Estado"> description = <"Detalhes estruturados para localização, domínio, episódio ou aspectos específicos do fluxo de trabalho do processo de diagnóstico."> comment = <"Use o estado ou os qualificadores contexto com cuidado, pois eles são variáveis quando usados na prática e a interoperabilidade não pode ser assegurada, salvo se o uso está claramente definido com a comunidade de uso. Por exemplo: evolução do estado: inicial, inativo, resolvido, em remissão; estado de evolução: inicial, provisório / trabalhando, final; estado temporal: presente, passado; estado do episodio: primeiro, novo, em curso; estado de admissão: admissão, alta; ou estado de prioridade: primário, secundário."> > ["at0047"] = < text = <"Suave"> description = <"O problema ou o diagnóstico não interfere na atividade normal ou causa danos à saúde, se não for tratado."> > ["at0048"] = < text = <"Moderado"> description = <"O problema ou o diagnóstico interfere na atividade normal ou prejudicará a saúde, se não for tratado."> > ["at0049"] = < text = <"Severo"> description = <"O problema ou diagnóstico impede a atividade normal ou causará sérios danos à saúde se não tratado."> > ["at0069"] = < text = <"Comentário"> description = <"Narrativa adicional sobre o problema ou diagnóstico, não capturados em outros campos."> > ["at0070"] = < text = <"Ultima atualização"> description = <"A data este problema ou diagnóstico foi atualizado pela última vez."> > ["at0071"] = < text = <"Extensão"> description = <"Informações adicionais necessárias para capturar o conteúdo local ou para alinhar com outros modelos de referência / formalismos."> comment = <"Por exemplo: requisitos de informação locais ou metadados adicionais para alinhar com FHIR ou CIMI equivalentes."> > ["at0072"] = < text = <"Descrição do curso"> description = <"Descrição narrativa sobre o curso do problema ou diagnóstico, desde o início."> > ["at0073"] = < text = <"Certeza do diagnóstico"> description = <"O nível de confiança da identificação do diagnóstico."> comment = <"*If an alternative valueset is required, these values can be added to the DV_TEXT data type in a template.(en)"> > ["at0074"] = < text = <"Suspeito"> description = <"O diagnóstico foi identificado com um nível baixo de convicção."> > ["at0075"] = < text = <"Provável"> description = <"O diagnóstico foi identificado com um elevado grau de certeza."> > ["at0076"] = < text = <"confirmado"> description = <"O diagnóstico foi confirmado com base em critérios reconhecidos."> > ["at0077"] = < text = <"Data / tempo de início"> description = <"Data / tempo, estimada ou real, que os sinais ou sintomas do problema / diagnóstico foram observados pela primeira vez."> comment = <"Os dados capturados / importados como \"A idade de início\" devem ser convertidos para uma data, usando o sujeito data de nascimento."> > ["at0078"] = < text = <"*Cause (en)"> description = <"*A cause, set of causes, or manner of causation of the problem or diagnosis.(en)"> comment = <"*Also known as 'aetiology' or 'etiology'. Coding with an external terminology is preferred, where possible.(en)"> > ["at0079"] = < text = <"*Variant (en)"> description = <"*Specific variant or subtype of the Diagnosis, if relevant. (en)"> comment = <"*For example: 'acute motor axonal neuropathy' as a variant of Guillain-Barre Syndrome. Coding of the name of the variant with a terminology is preferred, where possible. (en)"> > > > ["nb"] = < items = < ["at0000"] = < text = <"Problem/diagnose"> description = <"Detaljer om én identifisert helsetilstand, skade, funksjonshemming eller annet forhold som påvirker et individs fysiske, mentale og/eller sosiale velvære."> comment = <"Det er i praksis ikke lett å oppnå et klart skille mellom et problem og en diagnose. I klinisk dokumentasjon med denne arketypen ses problem og diagnose som et kontinuum, med økende krav til detaljer og støttende evidens for å underbygge en diagnose."> > ["at0001"] = < text = <"structure"> description = <"@ internal @"> > ["at0002"] = < text = <"Problem/diagnosenavn"> description = <"Identifisering av problemet eller diagnosen ved hjelp av navn."> comment = <"Koding av navnet på problemet eller diagnosen med en terminologi er foretrukket hvis mulig."> > ["at0003"] = < text = <"Dato/tid for klinisk bekreftelse"> description = <"Anslått eller faktisk dato/tid da diagnosen eller problemet ble bekreftet av helsepersonell."> comment = <"Delvise datoer er tillatt. Dersom individet er under ett år gammel, må komplett dato eller som et minimum måned og år oppgis for å muliggjøre presise beregninger av alder, f.eks. ved bruk i beslutningsstøttesystemer. Data registrert eller importert som \"alder ved tidspunkt når diagnosen stilles\" bør konverteres til en dato ved hjelp av individets fødselsdato."> > ["at0005"] = < text = <"Alvorlighetsgrad"> description = <"En vurdering av problemet eller diagnosens overordnede alvorlighetsgrad."> comment = <"Dersom alvorlighetsgrad inkluderes i feltet \"Problem/diagnosenavn\" via prekoordinerte koder blir dette dataelementet overflødig. Merk: Mer spesifikk gradering av alvorlighetsgrad kan registreres ved å bruke SLOTet \"Spesifikke detaljer\""> > ["at0009"] = < text = <"Klinisk beskrivelse"> description = <"Fritekstbeskrivelse av problemet eller diagnosen."> comment = <"Brukes til å gi bakgrunn og kontekst, inkludert utvikling, episoder eller forverringer, fremgang og alle andre relevante detaljer, om problemet eller diagnosen."> > ["at0012"] = < text = <"Anatomisk lokalisering"> description = <"Registrering av et enkelt og usammensatt anatomisk sted der problemet eller diagnosen er lokalisert."> comment = <"Koding av navnet på den anatomiske lokaliseringen ved hjelp av en terminologi er foretrukket når dette er mulig. Bruk dette dataelementet for å registrere prekoordinerte anatomiske lokaliseringer. Dersom behovene for å registrere anatomisk sted bestemmes i applikasjonen eller trenger større grad av kompleksitet som f.eks. relativ lokalisering, er det anbefalt å bruke CLUSTER.anatomical_location eller CLUSTER.relative_location innenfor SLOTet \"Strukturert anatomisk lokalisering\" i denne arketypen. Dette dataelementet kan ha ubegrenset antall forekomster, for å gjøre det mulig å registrere kliniske scenarier som f.eks. å beskrive et utslett som opptrer flere steder på kroppen, men der alle andre attributter er identiske. Dersom den anatomiske lokaliseringen inkluderes i feltet \"Problem/diagnosenavn\" via prekoordinerte koder blir dette dataelementet overflødig."> > ["at0030"] = < text = <"Dato/tid for bedring/remisjon"> description = <"Estimert eller faktisk dato/tid for bedring eller remisjon av det aktuelle problemet eller diagnosen, fastslått av helsepersonell."> comment = <"Delvise datoer er tillatt. Dersom individet er under ett år gammel, må komplett dato eller som et minimum måned og år oppgis for å muliggjøre presise beregninger av alder, f.eks. ved bruk i beslutningsstøttesystemer. Data registrert eller importert som \"alder ved bedring\" bør konverteres til en dato ved hjelp av individets fødselsdato."> > ["at0032"] = < text = <"Tree"> description = <"@ internal @"> > ["at0039"] = < text = <"Strukturert anatomisk lokalisering"> description = <"SLOT som kan inneholde en eller flere detaljerte og strukturerte anatomiske lokaliseringer."> comment = <"Dersom behovene for å registrere anatomisk sted bestemmes i applikasjonen eller trenger større grad av kompleksitet som f.eks. relativ lokalisering, er det anbefalt å bruke CLUSTER.anatomical_location eller CLUSTER.relative_location i dette SLOTet. Dersom den anatomiske lokaliseringen inkluderes i feltet \"Problem/diagnosenavn\" via prekoordinerte koder blir dette dataelementet overflødig."> > ["at0043"] = < text = <"Spesifikke detaljer"> description = <"Detaljer som er nødvendige for å registrere det aktuelle problemet eller diagnosens unike egenskaper."> comment = <"Kan omfatte strukturerte detaljer om klassifisering eller stadier av diagnosen; diagnosiske kriterier, klassifikasjon eller formelle vurderinger av alvorlighetsgrad, som f.eks. Common Terminology Criteria for Adverse Events."> > ["at0046"] = < text = <"Status"> description = <"Strukturerte detaljer for lokalisering-, fagområde-, episode- eller arbeidsflytsspesifikke aspekter av den diagnostiske prosessen."> comment = <"Bruk status eller kontekstkvalifikatorer med omhu, da bruken varierer og interoperabilitet kan ikke garanteres med mindre bruken er klart definert innen miljøet som bruker dem. F.eks. aktiv status - aktiv, inaktiv, løst, i bedring; utviklingsstatus - første, midlertidig, endelig; tidsstatus - nåværende, tidligere; episodisk status - første, ny, pågående; innleggelsesstatus - innleggelse, utskriving; eller prioritetsstatus - primær, sekundær."> > ["at0047"] = < text = <"Mild"> description = <"Problemet eller diagnosen forstyrrer ikke normal aktivitet."> > ["at0048"] = < text = <"Moderat"> description = <"Problemet eller diagnosen forstyrrer normal aktivitet."> > ["at0049"] = < text = <"Alvorlig"> description = <"Problemet eller diagnosen forhindrer normal aktivitet."> > ["at0069"] = < text = <"Kommentar"> description = <"Utdypende fritekst om problemet eller diagnosen, som ikke passer i andre felt."> > ["at0070"] = < text = <"Sist oppdatert"> description = <"Datoen da problemet eller diagnosen sist ble oppdatert."> > ["at0071"] = < text = <"Tilleggsinformasjon"> description = <"Ytterligere informasjon som trengs for å kunne registrere lokalt definert innhold eller for å tilpasse til andre referansemodeller/formalismer."> comment = <"For eksempel lokale informasjonsbehov, eller ytterligere metadata for å kunne tilpasse til tilsvarende konsepter i FHIR."> > ["at0072"] = < text = <"Forløpsbeskrivelse"> description = <"Fritekstbeskrivelse av forløpet av problemet eller diagnosen siden debut."> > ["at0073"] = < text = <"Diagnostisk sikkerhet"> description = <"Grad av sikkerhet i identifikasjonen av diagnosen."> comment = <"Hvis et alternativt verdisett er nødvendig, kan disse verdiene legges til DV_TEXT-datatypen i et templat."> > ["at0074"] = < text = <"Mistenkt"> description = <"Diagnoses er identifisert med en lav grad av sikkerhet."> > ["at0075"] = < text = <"Sannsynlig"> description = <"Diagnosen er identifisert med en stor grad av sikkerhet."> > ["at0076"] = < text = <"Bekreftet"> description = <"Diagnosen er bekreftet opp mot anerkjente kriterier."> > ["at0077"] = < text = <"Dato/ tid for debut"> description = <"Antatt eller faktisk dato/tid da tegn eller symptomer på problemet eller diagnosen først ble observert."> comment = <"Data registrert eller importert som \"alder ved debut\" bør konverteres til en dato ved hjelp av individets fødselsdato."> > ["at0078"] = < text = <"Årsak"> description = <"En årsak, kjede av årsaker til, eller hendelsesforløp forut for problemet eller diagnosen."> comment = <"Også kjent som 'etiologi'. Det anbefales å kode \"Årsak\" med en ekstern terminologi dersom det er mulig."> > ["at0079"] = < text = <"Variant"> description = <"Spesifikk variant eller subtype av diagnose, hvis det er relevant."> comment = <"For eksempel \"akutt motorisk aksonal nevropati\" som en variant av Guillain-Barre Syndrom. Koding av navnet på varianten med en terminologi er foretrukket hvis mulig."> > > > ["sv"] = < items = < ["at0000"] = < text = <"Problem/Diagnos"> description = <"Detaljer av ett enskilt identifierat hälsotillstånd, skada, funktionshinder eller något annat problem som påverkar individens fysiska, psykiska och eller sociala välbefinnande."> comment = <"Det är inte lätt att i praktiken uppnå en tydlig avgränsning mellan ett problem och en diagnos. Vid tillämpning av klinisk dokumentation med denna arketyp betraktas problem och diagnos som ett kontinuum, med plats för fler detaljer och stödjande bevis som vanligtvis ger tyngd till etiketten ”diagnos”."> > ["at0001"] = < text = <"structure"> description = <"@ internal @"> > ["at0002"] = < text = <"Problem/Diagnos namn"> description = <"Identifiering av problemet eller diagnosen efter namn."> comment = <"Kodning av namnet på problemet eller diagnosen med en terminologi är att föredra, om det är tillämpligt."> > ["at0003"] = < text = <"Datum och tid för kliniskt erkänd"> description = <"Uppskattat eller reellt datum coh tid som diagnosen eller problemet erkändes av sjukvårdspersonal."> comment = <"Partiella datum är acceptabla. Om patienten är under ett år, då är det fullständiga datumet eller ett minimum av månad och år nödvändigt för korrekta åldersberäkningar exempelvis om de används för beslutsstöd. Data som registreras och importeras som \"Ålder vid tidpunkten för kliniskt erkännande\" ska omvandlas till ett datum med hjälp av patientens födelsedatum."> > ["at0005"] = < text = <"Svårighetsgrad"> description = <"En bedömning av problemets eller diagnosens totala svårighetsgrad."> comment = <"Om svårighetsgraden har lagts till i Problem- och diagnos-namnet via förkoordinerade koder, blir detta fält överflödigt. Obs: mer specifik gradering av svårighetsgrad kan registreras i fältet ”specifika detaljer.”"> > ["at0009"] = < text = <"Klinisk beskrivning"> description = <"En beskrivning av problemet eller diagnosen."> comment = <"Används för att ge bakgrund och kontext, inklusive utveckling, episoder eller exacerbationer, framsteg och andra relevanta detaljer om problemet eller diagnosen."> > ["at0012"] = < text = <"Anatomisk plats"> description = <"Identifiering av problemets eller diagnosens anatomiska plats."> comment = <"Kodning av den anatomiska platsens namn med en terminologi är att föredra, om det är tillämpligt. Använd det här fältet för att dokumentera förkoordinerade anatomiska platser. Om kraven för att dokumentera den anatomiska platsen bestäms automatiskt av applikationen eller kräver mer komplicerad modellering som exempelvis relativa platser, använd i så fall Cluster.anatomical_location eller cluster. relative_location inom \"Strukturerad anatomisk plats\" - fältet i denna arketyp. I detta fält är det möjligt att dokumentera kliniska scenarier som exempelvis att beskriva ett utslag på flera platser, men där alla andra egenskaper är identiska. Om den anatomiska platsen ingår i problem-och diagnos-namnet via förkoordinerade koder, blir detta fält överflödigt."> > ["at0030"] = < text = <"Datum och tid för upplösning"> description = <"Uppskattat eller reellt datum och tid för upplösning eller remission av detta problem eller diagnos, som fastställts av sjukvårdspersonal."> comment = <"Partiella datum är acceptabla. Om patienten är under ett år är det fullständiga datumet eller ett minimum av månad och år nödvändigt för korrekta åldersberäkningar, exempelvis om de används för beslutsstöd. Data som registreras och importeras som \"Ålder vid tidpunkten för upplösning\" ska konverteras till ett datum med hjälp av patientens födelsedatum."> > ["at0032"] = < text = <"Tree"> description = <"@ internal @"> > ["at0039"] = < text = <"Strukturerad anatomisk plats"> description = <"En strukturerad anatomisk plats för problemet eller diagnosen."> comment = <"Använd det här fältet för att infoga CLUSTER.anatomical_location eller CLUSTER.relative_location-arketyper om den anatomiska platsen bestäms automatiskt av applikationen eller kräver mer komplicerad modellering som exempelvis relativa platser. Om den anatomiska platsen är inkluderad i problem- och diagnos-namnet via förkoordinerade koder, blir detta fält överflödigt."> > ["at0043"] = < text = <"Specifika detaljer"> description = <"Detaljer som krävs för att kunna dokumenteras som unika egenskaper i den här problem eller diagnos arketypen."> comment = <"Fältet kan innehålla strukturerad detalj om klassificering eller stadieindelning av diagnosen diagnostiska kriterier, klassificeringskriterier eller formella bedömningar av svårighetsgrad, såsom gemensamma terminologikriterier för biverkningar."> > ["at0046"] = < text = <"Status"> description = <"Strukturerade detaljer för plats-, domän-, episod-eller arbetsflödes specifika aspekter av diagnosprocessen."> comment = <"Använd status- eller kontextbestämningar med omsorg, pga. varierande användning i praktiken samt pga. att driftskompabilitet inte kan garanteras om inte användningen är tydligt definierad i gruppen exempelvis: Status: Aktiv och inaktiv, utredd och i remission Utvecklingsstatus: Initial, interimistisk preliminär och slutlig Temporal status: Nuvarande och tidigare Episodicitet status: Första, nytt och pågående Inskrivningsstatus: Inskrivning och utskrivning Prioritetsstatus: Primär och sekundär."> > ["at0047"] = < text = <"Mild"> description = <"Problemet eller diagnosen stör inte normal aktivitet eller kan orsaka hälsoskador om den lämnas obehandlad."> > ["at0048"] = < text = <"Medel"> description = <"Problemet eller diagnosen orsakar störningar i normal aktivitet eller kommer att skada hälsan om den lämnas obehandlad."> > ["at0049"] = < text = <"Svår"> description = <"Problemet eller diagnosen förhindrar normal aktivitet eller allvarligt kommer att skada hälsan om den lämnas obehandlad."> > ["at0069"] = < text = <"Kommentar"> description = <"En extra beskrivning av problemet eller diagnosen som inte tagits upp i andra fält."> > ["at0070"] = < text = <"Senast uppdaterad"> description = <"Datumet då problemet eller diagnosen senast uppdaterades."> > ["at0071"] = < text = <"Extra information"> description = <"Ytterligare uppgifter som krävs för att fånga lokalt innehåll eller för anpassning till andra referens modeller och formalismer."> comment = <"Exempelvis: lokala informationskrav eller ytterligare metadata för anpassning till FHIR-eller CIMI -motsvarigheter."> > ["at0072"] = < text = <"Förlopp"> description = <"Beskrivning av problemets eller diagnosen förlopp sedan debuten."> > ["at0073"] = < text = <"Diagnostisk säkerhet"> description = <"Säkerhetsgraden för identifiering av diagnos."> comment = <"*If an alternative valueset is required, these values can be added to the DV_TEXT data type in a template.(en)"> > ["at0074"] = < text = <"Misstänkt"> description = <"Diagnosen har identifierats med en låg grad av säkerhet."> > ["at0075"] = < text = <"Sannolik"> description = <"Diagnosen har identifierats med en hög grad av säkerhet."> > ["at0076"] = < text = <"Bekräftad"> description = <"Diagnosen har bekräftats mot kända kriterier."> > ["at0077"] = < text = <"Datum och tid för debut"> description = <"Uppskattat eller reellt datum och tid när problemets eller diagnosens tecken eller symtom först observerades."> comment = <"Data som dokumenteras och importeras som \"Ålder vid debut\" ska konverteras till ett datum med hjälp av patientens födelsedatum."> > ["at0078"] = < text = <"*Cause (en)"> description = <"*A cause, set of causes, or manner of causation of the problem or diagnosis.(en)"> comment = <"*Also known as 'aetiology' or 'etiology'. Coding with an external terminology is preferred, where possible.(en)"> > ["at0079"] = < text = <"*Variant (en)"> description = <"*Specific variant or subtype of the Diagnosis, if relevant. (en)"> comment = <"*For example: 'acute motor axonal neuropathy' as a variant of Guillain-Barre Syndrome. Coding of the name of the variant with a terminology is preferred, where possible. (en)"> > > > ["ko"] = < items = < ["at0000"] = < text = <"문제/진단"> description = <"한 개인의 신체, 정신 그리고/또는 사회적 웰빙에 영향을 주는 단일한 확인된 건강 성태, 상해, 장애 또는 다른 이슈에 대한 상세내용."> comment = <"실무에서 문제와 진단의 범위 간의 명확한 구분을 하기 쉽지 않음. 이 아키타입을 통한 임상 문서의 목적을 위해서, 증가하는 상세내용의 수준과 일반적으로 '진단'의 표시에 대한 무게감을 제공하는 지지할 수 있는 증거를 가지고, 문제와 진단은 연속된 것(a continuum)으로 간주됨."> > ["at0001"] = < text = <"structure"> description = <"@ internal @"> > ["at0002"] = < text = <"문제/진단명"> description = <"명칭으로 문제 또는 진단의 식별."> comment = <"가능하다면, 용어체계를 통한 문제 또는 진단의 명칭을 코딩하는 것이 좋음."> > ["at0003"] = < text = <"임상적으로 인지된 날짜/시간"> description = <"진단 또는 문가가 헬스케어 전문가에게 인지된 추정 또는 실제 날짜/시간."> comment = <"부분 날짜도 허용됨. 진료의 주체가 한 살 이하이면, 완전한 날짜 또는 달과 년의 하한이 정확한 나이 계산을 위해 필요함 - 예를 들어, 의사결정지원을 사용하는 경우. \\\"임상적으로 인지된 시점의 나이\\\"로 획득/입력된 데이터는 진료의 주체의 생일을 이용해 날짜로 변환되어야 함."> > ["at0005"] = < text = <"중증도"> description = <"문제 또는 진단의 전반적인 중증도 평가."> comment = <"중증도가 선조합코드로 문제/진단 내에 포함된다면, 이 데이터 엘레먼트는 중복이 됨. 주의 : 더 상세한 중증도 등급은 Specific details SLOT을 이용해 기록할 수 있음."> > ["at0009"] = < text = <"임상적 서술"> description = <"문제 또는 진단에 대한 서술 기록."> comment = <"문제와 진단에 대한 진화(evolution)와 에피소드 또는 악화, 경과를 포함한 배경과 문액 그리고 다른 관련된 상세내용을 제공하는데 사용함."> > ["at0012"] = < text = <"신체 위치"> description = <"문제 또는 진단의 위치를 위해 간단한 신체 위치 확인"> comment = <"가능하다면, 용어체계를 통한 해부학적 위치의 명칭을 코딩하는 것이 좋음. 이 데이터 엘리먼트에 선조합된 해부학적 위치를 사용. 해부학적 위치를 기록하기 위한 요구사항이 애플리케이션 실행 때 결정되거나 또는 상대적인 위치와 같은 더 복잡한 모델링을 요구한다면, 이 아키타입의 'Structured anatomical location' SLOT 내의 CLUSTER.anatomical_location 또는 CLUSTER.relative_location를 이용. 이 데이터 엘리먼트을 위한 Occurrences는 여러 위치에 생긴 발진(rash)을 기술하는 것과 같은 임상 시나리오를 허용하는데 제한이 없지만 모든 다른 속성(attributes)은 동일해야 함. 해부학적 위치가 문제/진단명에 선조합코드로 포함된다면 이 데이터 엘리먼트는 중복이 됨."> > ["at0030"] = < text = <"완치 날짜/시간"> description = <"헬스케어 전문가에 의해 결정된 이 문제나 진단의 추정 또는 실제 완치 또는 관해 날짜시간."> comment = <"부분 날짜는 허용됨. 진료의 주체가 한 살 이하면, 완전한 날짜 또는 달과 년의 하한이 정확한 나이 계산을 위해 필요함 - 예를 들어, 의사결정지원을 사용하는 경우. \\\"임상적으로 인지된 시점의 나이\\\"로 획득/입력된 데이터는 진료의 주체의 생일을 이용해 날짜로 변환되어야 함."> > ["at0032"] = < text = <"Tree"> description = <"@ internal @"> > ["at0039"] = < text = <"구조화된 신체 위치"> description = <"문제 또는 진단을 위한 구조화된 해부학적 위치"> comment = <"해부학적 위치를 기록하기 위한 요구사항이 애플리케이션 실행 때 결정되거나 또는 상대적인 위치와 같은 더 복잡한 모델링을 요구한다면, 이 아키타입의 SLOT에 CLUSTER.anatomical_location 또는 CLUSTER.relative_location를 삽입하여 이용 해부학적 위치가 문제/진단명에 선조합코드로 포함된다면 이 슬롯의 사용은 중복이 됨."> > ["at0043"] = < text = <"특정 상세내용"> description = <"이 문제 또는 진단의 유일한 속성으로 기록하는데 필요한 상세내용."> comment = <"진단의 단계(grading 또는 staging)에 대한 구조화된 상세내용을 포함할 수 있음; 진단 기준, 분류 기준 또는 이상 상황(Adverse Events)을 위한 공통 용어체계 기준(Common Terminology Criteria)와 같은 정규적인 중등도 평가."> > ["at0046"] = < text = <"상태"> description = <"진단 과정의 위치-, 도메인-, 에피소드- 또는 워크플로우-특징적인 측면에 대한 구조화된 상세내용."> comment = <"사용법이 사용하는 곳에서 명확히 정의되지 않으면, 실무에서 다양하게 사용되고 상호운용성을 확신할 수 없는 것과 마찬가지로 진료에서 상태 또는 문맥 한정자를 사용. 예를 들어: 활성 상태(active status) - 활성(active), 비활성(inactive), 치료됨(resolved), 관해 상태(in remission); 진화 상태(evolution status) - 초기(initial), 작업중(interim/working), 완료(final); 시간 상태(temporal status) - 현재(current), 과거(past); 에피소드 상태(episodicity status) - 처음(first), 새로(new), 진행중(ongoing); 입퇴원 상태(admission status) - 입원(admission), 퇴원(discharge); 또는 우선순위 상태(priority status) - 일차(primary), 이차(secondary)."> > ["at0047"] = < text = <"경도"> description = <"문제나 진단이 정상 활동을 방해하지 않거나 치료하지 않으면 건강에 해를 일으킬 수 있음."> > ["at0048"] = < text = <"중등도"> description = <"문제나 진단이 정상 활동에 방해가 되거나 치료하지 않으면 건강에 해가 됨."> > ["at0049"] = < text = <"증증도"> description = <"문제나 진단이 정상 활동을 할 수 없게 하거나 치료하지 않으면 건강에 심각한 해가 됨."> > ["at0069"] = < text = <"코멘트"> description = <"다른 필드에서 획득되지 않은 문제 또는 진단에 대한 추가적인 서술내용"> > ["at0070"] = < text = <"최종 업데이트 날짜"> description = <"문제 또는 진단이 최종 업데이트된 날짜."> > ["at0071"] = < text = <"확장"> description = <"로컬 컨텐트를 획득하거나 다른 참조모델/표기형식과 조율하기 위해 필요한 추가적인 정보."> comment = <"예: 로컬 정보 요구사항 또는 FHIR 또는 CIMI의 동등한 것과 조율하기위한 추가적인 메타데이터."> > ["at0072"] = < text = <"경과 서술"> description = <"발병이후 문제 또는 진단의 결과에 대한 서술."> > ["at0073"] = < text = <"진단적 확실성"> description = <"진단을 확인하는 신뢰의 수준."> comment = <"*If an alternative valueset is required, these values can be added to the DV_TEXT data type in a template.(en)"> > ["at0074"] = < text = <"의심"> description = <"진단이 낮은 확신 수준으로 식별됨."> > ["at0075"] = < text = <"추정"> description = <"진단이 높은 확신 수준으로 식별됨."> > ["at0076"] = < text = <"확진"> description = <"진단이 인정된 기준에 대해 확진됨."> > ["at0077"] = < text = <"발병 날짜/시간"> description = <"문제/진단의 증상 또는 징후가 처음 관찰된 추정 또는 실제 날짜/시간."> comment = <"\\\"발병 나이\\\"로 획득/입력된 데이터는 진료의 주체의 생일을 이용해 날짜로 변환되어 함."> > ["at0078"] = < text = <"*Cause (en)"> description = <"*A cause, set of causes, or manner of causation of the problem or diagnosis.(en)"> comment = <"*Also known as 'aetiology' or 'etiology'. Coding with an external terminology is preferred, where possible.(en)"> > ["at0079"] = < text = <"*Variant (en)"> description = <"*Specific variant or subtype of the Diagnosis, if relevant. (en)"> comment = <"*For example: 'acute motor axonal neuropathy' as a variant of Guillain-Barre Syndrome. Coding of the name of the variant with a terminology is preferred, where possible. (en)"> > > > ["fi"] = < items = < ["at0000"] = < text = <"Ongelma/Diagnoosi"> description = <"Yksityiskohdat yksittäisestä tunnistetusta terveystilasta, vammasta, vammasta tai muusta aiheesta, joka vaikuttaa yksilön fyysiseen, henkiseen ja / tai sosiaaliseen hyvinvointiin."> comment = <"*Clear delineation between the scope of a problem versus a diagnosis is not easy to achieve in practice. For the purposes of clinical documentation with this archetype, problem and diagnosis are regarded as a continuum, with increasing levels of detail and supportive evidence usually providing weight towards the label of 'diagnosis'.(en)"> > ["at0001"] = < text = <"structure"> description = <"@ internal @"> > ["at0002"] = < text = <"Ongelman/Diagnoosin nimi"> description = <"Ongelman tai diagnoosin tunnistaminen nimellä."> comment = <"*Coding of the name of the problem or diagnosis with a terminology is preferred, where possible.(en)"> > ["at0003"] = < text = <"Toteamispäivämäärä"> description = <"Arvioitu tai tarkka ajankohta ongelman tai diagnoosin toteamiselle terv.huollon ammattilaisen tekemänä"> comment = <"*Partial dates are acceptable. If the subject of care is under the age of one year, then the complete date or a minimum of the month and year is necessary to enable accurate age calculations - for example, if used to drive decision support. Data captured/imported as \"Age at time of clinical recognition\" should be converted to a date using the subject's date of birth.(en)"> > ["at0005"] = < text = <"Vakavuus"> description = <"Arvioitu vakavuus oireen tai diagnoosin kohdalla"> comment = <"*If severity is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant. Note: more specific grading of severity can be recorded using the Specific details SLOT.(en)"> > ["at0009"] = < text = <"Kliininen kuvaus"> description = <"Ongelman tai diagnoosin vapaamuotoinen selitys"> comment = <"*Use to provide background and context, including evolution, episodes or exacerbations, progress and any other relevant details, about the problem or diagnosis.(en)"> > ["at0012"] = < text = <"Kehonosa"> description = <"Yksinkertaisen vartalokohdan tunnistaminen ongelman tai diagnoosin sijaintia varten."> comment = <"*Coding of the name of the anatomical location with a terminology is preferred, where possible. Use this data element to record precoordinated anatomical locations. If the requirements for recording the anatomical location are determined at run-time by the application or require more complex modelling such as relative locations then use the CLUSTER.anatomical_location or CLUSTER.relative_location within the 'Structured anatomical location' SLOT in this archetype. Occurrences for this data element are unbounded to allow for clinical scenarios such as describing a rash in multiple locations but where all of the other attributes are identical. If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant.(en)"> > ["at0030"] = < text = <"Toteamise pvm"> description = <"ongelman tai diagnoosin arvioitu tai todellinen ratkaisemis- tai loppumispäivämäärä / -aika, jonka on määrittänyt terveydenhuollon ammattilainen."> comment = <"*Partial dates are acceptable. If the subject of care is under the age of one year, then the complete date or a minimum of the month and year is necessary to enable accurate age calculations - for example, if used to drive decision support. Data captured/imported as \"Age at time of resolution\" should be converted to a date using the subject's date of birth.(en)"> > ["at0032"] = < text = <"Tree"> description = <"@ internal @"> > ["at0039"] = < text = <"Anatominen alue"> description = <"Ongelman tai diagnoosin anatominen alue"> comment = <"*Use this SLOT to insert the CLUSTER.anatomical_location or CLUSTER.relative_location archetypes 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. If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, use of this SLOT becomes redundant.(en)"> > ["at0043"] = < text = <"Tarkennettu tieto"> description = <"Tiedot, joita tarvitaan lisäksi tämän ongelman tai diagnoosin yksilöivinä ominaisuuksina tallentamiseksi."> comment = <"*May include structured detail about the grading or staging of the diagnosis; diagnostic criteria, classification criteria or formal severity assessments such as Common Terminology Criteria for Adverse Events.(en)"> > ["at0046"] = < text = <"Status"> description = <"Jäsennellyt yksityiskohdat diagnosointiprosessin sijainti-, alue-, jakso- tai työnkulkukohtaisista näkökohdista."> comment = <"*Use status or context qualifiers with care, as they are variably used in practice and interoperability cannot be assured unless usage is clearly defined with the community of use. For example: active status - active, inactive, resolved, in remission; evolution status - initial, interim/working, final; temporal status - current, past; episodicity status - first, new, ongoing; admission status - admission, discharge; or priority status - primary, secondary.(en)"> > ["at0047"] = < text = <"Vähäinen"> description = <"Ongelma tai diagnoosi ei häiritse normaalia toimintaa tai voi aiheuttaa terveysvaurioita, jos sitä ei hoideta."> > ["at0048"] = < text = <"Kohtalainen"> description = <"Ongelma tai diagnoosi häiritsee normaalia toimintaa tai vahingoittaa terveyttä, jos sitä jätetään hoitamatta."> > ["at0049"] = < text = <"Vakava"> description = <"Ongelma tai diagnoosi estää normaalia toimintaa tai vahingoittaa vakavasti terveyttä, jos sitä jätetään hoitamatta."> > ["at0069"] = < text = <"Kommentti"> description = <"Lisätietoa ongelmasta tai diagnoosista, jota ei voi asettaa edeltäville tietokentille."> > ["at0070"] = < text = <"Viimeksi päivitetty"> description = <"Ongelman tai diagnoosin viimeisin päivityspäivämäärä"> > ["at0071"] = < text = <"Laajennus"> 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.(en)"> > ["at0072"] = < text = <"Ongelman kulku"> description = <"Kuvaus ongelman tai diagnoosin etenemisestä alusta."> > ["at0073"] = < text = <"Diagnoosin varmuus"> description = <"Diagnoosin tunnistamisen luotettavuus"> comment = <"*If an alternative valueset is required, these values can be added to the DV_TEXT data type in a template.(en)"> > ["at0074"] = < text = <"Epäilty"> description = <"Diagnoosi on tunnistettu alhaisella varmuustasolla."> > ["at0075"] = < text = <"Mahdollinen"> description = <"Diagnoosi on tunnistettu erittäin varmuudella."> > ["at0076"] = < text = <"Varmistettu"> description = <"Diagnoosi on vahvistettu tunnustettujen kriteerien perusteella."> > ["at0077"] = < text = <"Alkamis pvm"> description = <"Arvioitu tai todellinen päivämäärä / aika, jolloin ongelman / diagnoosin merkkejä tai oireita havaittiin ensimmäisen kerran."> comment = <"*Data captured/imported as \"Age at onset\" should be converted to a date using the subject's date of birth.(en)"> > ["at0078"] = < text = <"*Cause (en)"> description = <"*A cause, set of causes, or manner of causation of the problem or diagnosis.(en)"> comment = <"*Also known as 'aetiology' or 'etiology'. Coding with an external terminology is preferred, where possible.(en)"> > ["at0079"] = < text = <"*Variant (en)"> description = <"*Specific variant or subtype of the Diagnosis, if relevant. (en)"> comment = <"*For example: 'acute motor axonal neuropathy' as a variant of Guillain-Barre Syndrome. Coding of the name of the variant with a terminology is preferred, where possible. (en)"> > > > ["it"] = < items = < ["at0000"] = < text = <"Problema/Diagnosi"> description = <"Dettagli su una specifica condizione di salute, una lesione, una disabilità o un qualsiasi altro problema individuato su un individuo che abbia un impatto sul benessere fisico, mentale e/o sociale."> comment = <"Nella pratica, non è facile fare una distinzione netta tra gli ambiti dei concetti 'problema' e 'diagnosi'. Ai fini della documentazione clinica con questo archetipo, problema e diagnosi sono considerati un continuum, con livelli crescenti di dettagli ed evidenze a supporto a supporto dell'etichetta 'diagnosi'."> > ["at0001"] = < text = <"structure"> description = <"@ internal @"> > ["at0002"] = < text = <"Nome del problema/diagnosi"> description = <"Nome/identificativo del problema o della diagnosi."> comment = <"Si preferisce, ove possibile, la codifica del problema o diagnosi con una terminologia."> > ["at0003"] = < text = <"Data/ora di riconoscimento clinico"> description = <"Data/ora, stimate o effettive, in cui la diagnosi o il problema sono stati riconosciuti da un operatore sanitario."> comment = <"Sono accettabili le date parziali. Se il soggetto ha età inferiore ad un anno, sono necessari la data completa o almeno il mese e l'anno per permettere un calcolo accurato dell'età - ad esempio, se utilizzato per guidare il supporto decisionale. I dati acquisiti/importati come 'Età al momento del riconoscimento clinico' dovrebbero essere convertiti in una data usando la data di nascita del soggetto."> > ["at0005"] = < text = <"Severità"> description = <"Una valutazione generale della severità del problema o della diagnosi."> comment = <"Se la severità è inclusa nel campo 'Nome del problema/diagnosi' attraverso una codifica prestabilita, questo elemento risulta ridondante. Nota: una classificazione più specifica della severità può essere memorizzata usando lo SLOT 'Dettagli specifici'."> > ["at0009"] = < text = <"Descrizione clinica"> description = <"Descrizione narrativa del problema o della diagnosi."> comment = <"Utilizzare questo campo per fornire il background e il contesto, compresa l'evoluzione, gli episodi o le esacerbazioni, i progressi e qualsiasi altro dettaglio rilevante circa il problema o la diagnosi."> > ["at0012"] = < text = <"Sito corporeo"> description = <"Identificativo di un semplice sito corporeo per per la localizzazione del problema o della diagnosi."> comment = <"Si preferisce, ove possibile, la codifica del sito anatomico con una terminologia. Utilizzare questo campo per memorizzare posizioni anatomiche precoordinate. Se i requisiti per la registrazione della localizzazione sono determinati in fase di esecuzione dell'applicazione (run-time) o se richiedono una modellazione più complessa, come ad esempio le posizioni relative, allora utilizzare gli archetipi CLUSTER.anatomical_location o CLUSTER.relative_location all'interno dello SLOT di questo archetipo 'Dettagli strutturati del sito corporeo'. Questo campo non ha limite sulle occorrenze per essere adattabile a scenari clinici come la descrizione di un'eruzione cutanea che coinvolge più siti corporei, ma dove tutti gli altri attributi sono identici. Se la posizione anatomica è inclusa nel campo 'Nome del problema/diagnosi attraverso una codifica prestabilita, questo elemento risulta ridondante."> > ["at0030"] = < text = <"Data/ora di risoluzione"> description = <"Data/ora, stimate o effettive, della risoluzione o remissione del problema o della diagnosi come determinato da un operatore sanitario."> comment = <"Sono accettabili le date parziali. Se il soggetto ha età inferiore ad un anno, sono necessari la data completa o almeno il mese e l'anno per permettere un calcolo accurato dell'età - ad esempio, se utilizzato per guidare il supporto decisionale. I dati acquisiti/importati come 'Età al momento della risoluzione' dovrebbero essere convertiti in una data usando la data di nascita del soggetto."> > ["at0032"] = < text = <"Tree"> description = <"@ internal @"> > ["at0039"] = < text = <"Dettagli strutturati del sito corporeo"> description = <"Una descrizione strutturata della localizzazione anatomica a cui il problema o la diagnosi si riferiscono."> comment = <"Usare questo SLOT per inserire gli archetipi CLUSTER.anatomical_location o CLUSTER.relative_location se i requisiti per la registrazione della localizzazione sono determinati in fase di esecuzione dell'applicazione (run-time) o se richiedono una modellazione più complessa, come ad esempio per le posizioni relative. Se la posizione anatomica è inclusa nel campo 'Nome del problema/diagnosi attraverso una codifica prestabilita, questo elemento risulta ridondante."> > ["at0043"] = < text = <"Ulteriori dettagli"> description = <"Ulteriori dettagli richiesti per memorizzare attributi specifici del problema o della diagnosi."> comment = <"Può includere dettagli strutturati sulla classificazione o la stadiazione della diagnosi; criteri diagnostici, criteri di classificazione o valutazioni formali della severità, come ad esempio CTCAE - Common Terminology Criteria for Adverse Events."> > ["at0046"] = < text = <"Stato"> description = <"Dettagli strutturati per descrivere aspetti del processo diagnostico specifici in relazione alla localizzazione, dominio, episodio o workflow."> comment = <"L'uso di qualificatori per indicare lo stato o il contesto dovrebbe essere fatto con attenzione, in quanto il loro utilizzo varia nella pratica e l'interoperabilità non può essere garantita a meno che l'utilizzo di quei codici non sia universalmente accettato dalla comunità. Ad esempio: stato attivo - attivo, inattivo, risolto, in remissione; stato evolutivo - iniziale, intermedio/in progressione, finale; stato temporale - attuale, passato; stato di episodicità - primo, nuovo, in corso; stato di ammissione - ammissione, dimissione; o stato di priorità - primario, secondario."> > ["at0047"] = < text = <"Lieve"> description = <"Il problema o la diagnosi non interferiscono con la normale attività o potrebbero causare problemi di salute salute se non trattati."> > ["at0048"] = < text = <"Moderato"> description = <"Il problema o la diagnosi interferiscono con la normale attività o causerebbero problemi di salute se non trattati."> > ["at0049"] = < text = <"Severo"> description = <"Il problema o la diagnosi impediscono la normale attività o causerebbero problemi di salute importanti se non trattati."> > ["at0069"] = < text = <"Commento"> description = <"Informazioni aggiuntive sul problema o diagnosi non catturate in altri campi."> > ["at0070"] = < text = <"Ultimo aggiornamento"> description = <"La data in cui questo record di Problema/Diagnosi è stato aggiornato l'ultima volta."> > ["at0071"] = < text = <"Estensione"> description = <"Informazioni aggiuntive necessarie per registrare specifici contenuti locali o per allinearsi con altri modelli/formalismi di riferimento."> comment = <"Ad esempio: requisiti informativi locali o metadati addizionali per l'allineamento ai corrispondenti modelli FHIR o CIMI."> > ["at0072"] = < text = <"Decorso"> description = <"Descrizione testuale del decorso del problema o della diagnosi a partire dall'insorgenza."> > ["at0073"] = < text = <"Certezza diagnostica"> description = <"Grado di certezza nell'identificazione della diagnosi."> comment = <"*If an alternative valueset is required, these values can be added to the DV_TEXT data type in a template.(en)"> > ["at0074"] = < text = <"Sospetto"> description = <"La diagnosi è identificata con un basso livello di certezza."> > ["at0075"] = < text = <"Probabile"> description = <"La diagnosi è identificata con un alto livello di certezza."> > ["at0076"] = < text = <"Confermato"> description = <"La diagnosi è stata confermata in base a criteri riconosciuti."> > ["at0077"] = < text = <"Data/ora di insorgenza"> description = <"Data/ora, stimate o effettive, in cui sono stati per la prima volta osservati i sintomi del problema/diagnosi."> comment = <"I dati acquisiti/importati come 'Età al momento dell'insorgenza' dovrebbero essere convertiti in una data usando la data di nascita del soggetto."> > ["at0078"] = < text = <"*Cause (en)"> description = <"*A cause, set of causes, or manner of causation of the problem or diagnosis.(en)"> comment = <"*Also known as 'aetiology' or 'etiology'. Coding with an external terminology is preferred, where possible.(en)"> > ["at0079"] = < text = <"*Variant (en)"> description = <"*Specific variant or subtype of the Diagnosis, if relevant. (en)"> comment = <"*For example: 'acute motor axonal neuropathy' as a variant of Guillain-Barre Syndrome. Coding of the name of the variant with a terminology is preferred, where possible. (en)"> > > > ["nl"] = < items = < ["at0077"] = < text = <"Datum/tijd van aanvang"> description = <"Geschatte of precieze datum/tijd dat de eerste tekenen of symptomen van het probleem of de diagnose werden opgemerkt."> comment = <"*Data captured/imported as \"Age at onset\" should be converted to a date using the subject's date of birth.(en)"> > ["at0076"] = < text = <"*Confirmed(en)"> description = <"*The diagnosis has been confirmed against recognised criteria.(en)"> > ["at0075"] = < text = <"*Probable(en)"> description = <"*The diagnosis has been identified with a high level of certainty.(en)"> > ["at0074"] = < text = <"*Suspected(en)"> description = <"*The diagnosis has been identified with a low level of certainty.(en)"> > ["at0073"] = < text = <"*Diagnostic certainty(en)"> description = <"*The level of confidence in the identification of the diagnosis.(en)"> comment = <"*If an alternative valueset is required, these values can be added to the DV_TEXT data type in a template.(en)"> > ["at0072"] = < text = <"*Course description(en)"> description = <"*Narrative description about the course of the problem or diagnosis since onset.(en)"> > ["at0071"] = < 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)"> > ["at0070"] = < text = <"*Last updated(en)"> description = <"*The date this problem or diagnosis was last updated.(en)"> > ["at0069"] = < text = <"*Comment(en)"> description = <"*Additional narrative about the problem or diagnosis not captured in other fields.(en)"> > ["at0049"] = < text = <"*Severe(en)"> description = <"*The problem or diagnosis prevents normal activity or will seriously damage health if left untreated.(en)"> > ["at0048"] = < text = <"*Moderate(en)"> description = <"*The problem or diagnosis causes interference with normal activity or will damage health if left untreated.(en)"> > ["at0047"] = < text = <"*Mild(en)"> description = <"*The problem or diagnosis does not interfere with normal activity or may cause damage to health if left untreated.(en)"> > ["at0046"] = < text = <"*Status(en)"> description = <"*Structured details for location-, domain-, episode- or workflow-specific aspects of the diagnostic process.(en)"> comment = <"*Use status or context qualifiers with care, as they are variably used in practice and interoperability cannot be assured unless usage is clearly defined with the community of use. For example: active status - active, inactive, resolved, in remission; evolution status - initial, interim/working, final; temporal status - current, past; episodicity status - first, new, ongoing; admission status - admission, discharge; or priority status - primary, secondary.(en)"> > ["at0043"] = < text = <"*Specific details(en)"> description = <"*Details that are additionally required to record as unique attributes of this problem or diagnosis.(en)"> comment = <"*May include structured detail about the grading or staging of the diagnosis; diagnostic criteria, classification criteria or formal severity assessments such as Common Terminology Criteria for Adverse Events.(en)"> > ["at0039"] = < text = <"*Structured body site(en)"> description = <"*A structured anatomical location for the problem or diagnosis.(en)"> comment = <"*Use this SLOT to insert the CLUSTER.anatomical_location or CLUSTER.relative_location archetypes 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. If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, use of this SLOT becomes redundant.(en)"> > ["at0032"] = < text = <"*Tree(en)"> description = <"*@ internal @(en)"> > ["at0030"] = < text = <"*Date/time of resolution(en)"> description = <"*Estimated or actual date/time of resolution or remission for this problem or diagnosis, as determined by a healthcare professional.(en)"> comment = <"*Partial dates are acceptable. If the subject of care is under the age of one year, then the complete date or a minimum of the month and year is necessary to enable accurate age calculations - for example, if used to drive decision support. Data captured/imported as \"Age at time of resolution\" should be converted to a date using the subject's date of birth.(en)"> > ["at0012"] = < text = <"Lichaamsdeel"> description = <"Identificatie van een eenvoudig lichaamsdeel voor de lokatie van het probleem of de diagnose."> comment = <"*Coding of the name of the anatomical location with a terminology is preferred, where possible. Use this data element to record precoordinated anatomical locations. If the requirements for recording the anatomical location are determined at run-time by the application or require more complex modelling such as relative locations then use the CLUSTER.anatomical_location or CLUSTER.relative_location within the 'Structured anatomical location' SLOT in this archetype. Occurrences for this data element are unbounded to allow for clinical scenarios such as describing a rash in multiple locations but where all of the other attributes are identical. If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant.(en)"> > ["at0009"] = < text = <"Klinische beschrijving"> description = <"Verhalende beschrijving van het probleem of de diagnose."> comment = <"*Use to provide background and context, including evolution, episodes or exacerbations, progress and any other relevant details, about the problem or diagnosis.(en)"> > ["at0005"] = < text = <"*Severity(en)"> description = <"*An assessment of the overall severity of the problem or diagnosis.(en)"> comment = <"*If severity is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant. Note: more specific grading of severity can be recorded using the Specific details SLOT.(en)"> > ["at0003"] = < text = <"Datum/tijd van klinische herkenning"> description = <"Geschatte of werkelijke datum/tijd waarop het probleem of de diagnose is herkend door een zorgprofessional."> comment = <"*Partial dates are acceptable. If the subject of care is under the age of one year, then the complete date or a minimum of the month and year is necessary to enable accurate age calculations - for example, if used to drive decision support. Data captured/imported as \"Age at time of clinical recognition\" should be converted to a date using the subject's date of birth.(en)"> > ["at0002"] = < text = <"Naam van het probleem / de diagnose"> description = <"Identificatie van het probleem of de diagnose bij naam. "> comment = <"*Coding of the name of the problem or diagnosis with a terminology is preferred, where possible.(en)"> > ["at0001"] = < text = <"*structure(en)"> description = <"*@ internal @(en)"> > ["at0000"] = < text = <"Probleem/Diagnose"> description = <"Informatie over een enkele vast te stellen medische aandoening, een letsel, beperking of andere zaak die invloed heeft op de fysieke, mentale en/of het sociale welbevinden van een individu."> comment = <"*Clear delineation between the scope of a problem versus a diagnosis is not easy to achieve in practice. For the purposes of clinical documentation with this archetype, problem and diagnosis are regarded as a continuum, with increasing levels of detail and supportive evidence usually providing weight towards the label of 'diagnosis'.(en)"> > ["at0078"] = < text = <"*Cause (en)"> description = <"*A cause, set of causes, or manner of causation of the problem or diagnosis.(en)"> comment = <"*Also known as 'aetiology' or 'etiology'. Coding with an external terminology is preferred, where possible.(en)"> > ["at0079"] = < text = <"*Variant (en)"> description = <"*Specific variant or subtype of the Diagnosis, if relevant. (en)"> comment = <"*For example: 'acute motor axonal neuropathy' as a variant of Guillain-Barre Syndrome. Coding of the name of the variant with a terminology is preferred, where possible. (en)"> > > > ["zh"] = < items = < ["at0000"] = < text = <"问题/诊断"> description = <"*Details about a single identified health condition, injury, disability or any other issue which impacts the physical, mental and/or social wellbeing of an individual.(en)"> comment = <"*Clear delineation between the scope of a problem versus a diagnosis is not easy to achieve in practice. For the purposes of clinical documentation with this archetype, problem and diagnosis are regarded as a continuum, with increasing levels of detail and supportive evidence usually providing weight towards the label of 'diagnosis'.(en)"> > ["at0001"] = < text = <"structure (en)"> description = <"@ internal @ (en)"> > ["at0002"] = < text = <"问题/诊断名字"> description = <"*Identification of the problem or diagnosis, by name.(en)"> comment = <"*Coding of the name of the problem or diagnosis with a terminology is preferred, where possible.(en)"> > ["at0003"] = < text = <"临床认可的日期/时间"> description = <"*Estimated or actual date/time the diagnosis or problem was recognised by a healthcare professional.(en)"> comment = <"*Partial dates are acceptable. If the subject of care is under the age of one year, then the complete date or a minimum of the month and year is necessary to enable accurate age calculations - for example, if used to drive decision support. Data captured/imported as \"Age at time of clinical recognition\" should be converted to a date using the subject's date of birth.(en)"> > ["at0005"] = < text = <"严重性"> description = <"*An assessment of the overall severity of the problem or diagnosis.(en)"> comment = <"*If severity is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant. Note: more specific grading of severity can be recorded using the Specific details SLOT.(en)"> > ["at0009"] = < text = <"临床描述"> description = <"*Narrative description about the problem or diagnosis.(en)"> comment = <"*Use to provide background and context, including evolution, episodes or exacerbations, progress and any other relevant details, about the problem or diagnosis.(en)"> > ["at0012"] = < text = <"身体位置"> description = <"*Identification of a simple body site for the location of the problem or diagnosis.(en)"> comment = <"*Coding of the name of the anatomical location with a terminology is preferred, where possible. Use this data element to record precoordinated anatomical locations. If the requirements for recording the anatomical location are determined at run-time by the application or require more complex modelling such as relative locations then use the CLUSTER.anatomical_location or CLUSTER.relative_location within the 'Structured anatomical location' SLOT in this archetype. Occurrences for this data element are unbounded to allow for clinical scenarios such as describing a rash in multiple locations but where all of the other attributes are identical. If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant.(en)"> > ["at0030"] = < text = <"解决的日期/时间"> description = <"*Estimated or actual date/time of resolution or remission for this problem or diagnosis, as determined by a healthcare professional.(en)"> comment = <"*Partial dates are acceptable. If the subject of care is under the age of one year, then the complete date or a minimum of the month and year is necessary to enable accurate age calculations - for example, if used to drive decision support. Data captured/imported as \"Age at time of resolution\" should be converted to a date using the subject's date of birth.(en)"> > ["at0032"] = < text = <"Tree (en)"> description = <"@ internal @ (en)"> > ["at0039"] = < text = <"结构化身体位置"> description = <"*A structured anatomical location for the problem or diagnosis.(en)"> comment = <"*Use this SLOT to insert the CLUSTER.anatomical_location or CLUSTER.relative_location archetypes 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. If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, use of this SLOT becomes redundant.(en)"> > ["at0043"] = < text = <"详情"> description = <"*Details that are additionally required to record as unique attributes of this problem or diagnosis.(en)"> comment = <"*May include structured detail about the grading or staging of the diagnosis; diagnostic criteria, classification criteria or formal severity assessments such as Common Terminology Criteria for Adverse Events.(en)"> > ["at0046"] = < text = <"状态"> description = <"描述与位置，域，发作或者工作流程等诊断过程中特定方面相关的结构化细节。"> comment = <"谨慎使用状态或上下文状态符，除非社区明确规定了用法，否则会由于在实际应用中的用法差异而无法保证互操作性。比如：活跃状态-活跃、不活跃、已痊愈、病情缓解；演变状态-初期、临时/演变中、终期；时间状态-当前、过去；发作状态-首次、新发、进行中；入院状态-入院、出院；优先级状态-第一、第二"> > ["at0047"] = < text = <"Mild (en)"> description = <"*The problem or diagnosis does not interfere with normal activity or may cause damage to health if left untreated.(en)"> > ["at0048"] = < text = <"Moderate (en)"> description = <"*The problem or diagnosis causes interference with normal activity or will damage health if left untreated.(en)"> > ["at0049"] = < text = <"Severe (en)"> description = <"*The problem or diagnosis prevents normal activity or will seriously damage health if left untreated.(en)"> > ["at0069"] = < text = <"备注"> description = <"*Additional narrative about the problem or diagnosis not captured in other fields.(en)"> > ["at0070"] = < text = <"最近更新"> description = <"*The date this problem or diagnosis was last updated.(en)"> > ["at0071"] = < text = <"其他"> 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)"> > ["at0072"] = < text = <"过程描述"> description = <"*Narrative description about the course of the problem or diagnosis since onset.(en)"> > ["at0073"] = < text = <"诊断确定性"> description = <"*The level of confidence in the identification of the diagnosis.(en)"> > ["at0074"] = < text = <"*Suspected (en)"> description = <"*The diagnosis has been identified with a low level of certainty.(en)"> > ["at0075"] = < text = <"*Probable (en)"> description = <"*The diagnosis has been identified with a high level of certainty.(en)"> > ["at0076"] = < text = <"*Confirmed (en)"> description = <"*The diagnosis has been confirmed against recognised criteria.(en)"> > ["at0077"] = < text = <"开始日期/时间"> description = <"*Estimated or actual date/time that signs or symptoms of the problem/diagnosis were first observed.(en)"> comment = <"*Data captured/imported as \"Age at onset\" should be converted to a date using the subject's date of birth.(en)"> > ["at0078"] = < text = <"*Cause (en)"> description = <"*A cause, set of causes, or manner of causation of the problem or diagnosis.(en)"> comment = <"*Also known as 'aetiology' or 'etiology'. Coding with an external terminology is preferred, where possible.(en)"> > ["at0079"] = < text = <"*Variant (en)"> description = <"*Specific variant or subtype of the Diagnosis, if relevant. (en)"> comment = <"*For example: 'acute motor axonal neuropathy' as a variant of Guillain-Barre Syndrome. Coding of the name of the variant with a terminology is preferred, where possible. (en)"> > > > ["ca"] = < items = < ["at0000"] = < text = <"Problema/Diagnòstic"> description = <"Detalls sobre una única condició de salut, lesió, discapacitat o qualsevol altre problema identificat que afecti al benestar físic, mental i/o social d'una persona."> comment = <"*Clear delineation between the scope of a problem versus a diagnosis is not easy to achieve in practice. For the purposes of clinical documentation with this archetype, problem and diagnosis are regarded as a continuum, with increasing levels of detail and supportive evidence usually providing weight towards the label of 'diagnosis'.(en)"> > ["at0001"] = < text = <"structure"> description = <"@ internal @"> > ["at0002"] = < text = <"Nom del Problema/Diagnòstic"> description = <"Identificació del problema o diagnòstic, pel nom."> comment = <"*Coding of the name of the problem or diagnosis with a terminology is preferred, where possible.(en)"> > ["at0003"] = < text = <"Data/hora del diagnòstic"> description = <"Data/hora estimada o real en que un professional sanitari va declarar el diagnòstic o problema."> comment = <"*Partial dates are acceptable. If the subject of care is under the age of one year, then the complete date or a minimum of the month and year is necessary to enable accurate age calculations - for example, if used to drive decision support. Data captured/imported as \"Age at time of clinical recognition\" should be converted to a date using the subject's date of birth.(en)"> > ["at0005"] = < text = <"Severitat"> description = <"Una avaluació de la severitat global del problema o diagnòstic."> comment = <"*If severity is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant. Note: more specific grading of severity can be recorded using the Specific details SLOT.(en)"> > ["at0009"] = < text = <"Descripció clínica"> description = <"Descripció narrativa del problema o diagnòstic."> comment = <"*Use to provide background and context, including evolution, episodes or exacerbations, progress and any other relevant details, about the problem or diagnosis.(en)"> > ["at0012"] = < text = <"Localització corporal"> description = <"Identificació d'un lloc corporal per la localització del problema o diagnòstic."> comment = <"*Coding of the name of the anatomical location with a terminology is preferred, where possible. Use this data element to record precoordinated anatomical locations. If the requirements for recording the anatomical location are determined at run-time by the application or require more complex modelling such as relative locations then use the CLUSTER.anatomical_location or CLUSTER.relative_location within the 'Structured anatomical location' SLOT in this archetype. Occurrences for this data element are unbounded to allow for clinical scenarios such as describing a rash in multiple locations but where all of the other attributes are identical. If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant.(en)"> > ["at0030"] = < text = <"Data/hora de resolució"> description = <"Data/hora estimada o real de resolució o remissió d'aquest problema o diagnòstic, determinada per un professional sanitari."> comment = <"*Partial dates are acceptable. If the subject of care is under the age of one year, then the complete date or a minimum of the month and year is necessary to enable accurate age calculations - for example, if used to drive decision support. Data captured/imported as \"Age at time of resolution\" should be converted to a date using the subject's date of birth. (en)"> > ["at0032"] = < text = <"Tree"> description = <"@ internal @"> > ["at0039"] = < text = <"Estructura corporal"> description = <"Una localització anatòmica estructurada per al problema o diagnòstic."> comment = <"*Use this SLOT to insert the CLUSTER.anatomical_location or CLUSTER.relative_location archetypes 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. If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, use of this SLOT becomes redundant.(en)"> > ["at0043"] = < text = <"Detalls específics"> description = <"Detalls que es requereixen addicionalment per registrar atributs únics d'aquest problema o diagnòstic."> comment = <"*May include structured detail about the grading or staging of the diagnosis; diagnostic criteria, classification criteria or formal severity assessments such as Common Terminology Criteria for Adverse Events.(en)"> > ["at0046"] = < text = <"Estat"> description = <"Detalls estructurats per a aspectes específics d'ubicació, domini, episodi o flux de treball del procés diagnòstic."> comment = <"*Use status or context qualifiers with care, as they are variably used in practice and interoperability cannot be assured unless usage is clearly defined with the community of use. For example: active status - active, inactive, resolved, in remission; evolution status - initial, interim/working, final; temporal status - current, past; episodicity status - first, new, ongoing; admission status - admission, discharge; or priority status - primary, secondary.(en)"> > ["at0047"] = < text = <"Lleu"> description = <"El problema o diagnòstic no interfereix amb l'activitat normal ni pot causar danys a la salut si no es tracta."> > ["at0048"] = < text = <"Moderada"> description = <"El problema o diagnòstic interfereix amb l'activitat normal o pot causar danys a la salut si no es tracta."> > ["at0049"] = < text = <"Greu"> description = <"El problema o diagnòstic impedeix l'activitat normal o causarà danys greus a la salut si no es tracta."> > ["at0069"] = < text = <"Comentaris"> description = <"Narrativa addicional sobre el problema o diagnòstic no registrada en altres camps."> > ["at0070"] = < text = <"Darrera actualització"> description = <"La data en que es va actualitzar per última vegada aquest problema o diagnòstic."> > ["at0071"] = < text = <"Extensió"> description = <"Informació addicional necessària per capturar contingut local o per alinear-se amb altres models/formalismes de referència."> comment = <"*For example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.(en)"> > ["at0072"] = < text = <"Descripció del curs"> description = <"Descripció narrativa sobre el curs del problema o diagnòstic des del inici."> > ["at0073"] = < text = <"Certesa diagnòstica"> description = <"El nivell de confiança en la identificació del diagnòstic."> comment = <"*If an alternative valueset is required, these values can be added to the DV_TEXT data type in a template.(en)"> > ["at0074"] = < text = <"Sospita"> description = <"El diagnòstic s'ha identificat amb un nivell baix de certesa."> > ["at0075"] = < text = <"Probable"> description = <"El diagnòstic s'ha identificat amb un nivell alt de certesa."> > ["at0076"] = < text = <"Confirmat"> description = <"El diagnòstic s'ha confirmat en base a criteris reconeguts."> > ["at0077"] = < text = <"Data/hora d'inici"> description = <"Data/hora estimada o real en que es van observar per primera vegada els signes o símptomes del problema/diagnòstic."> comment = <"*Data captured/imported as \"Age at onset\" should be converted to a date using the subject's date of birth.(en)"> > ["at0078"] = < text = <"Causa"> description = <"Una causa, conjunt de causes o el mecanisme causal del problema o diagnòstic."> comment = <"*Also known as 'aetiology' or 'etiology'. Coding with an external terminology is preferred, where possible.(en)"> > ["at0079"] = < text = <"Variant"> description = <"Variant o subtipus específic del Diagnòstic, si escau."> comment = <"*For example: 'acute motor axonal neuropathy' as a variant of Guillain-Barre Syndrome. Coding of the name of the variant with a terminology is preferred, where possible. (en)"> > > > ["zh-cn"] = < items = < ["at0000"] = < text = <"问题/诊断"> description = <"关于单个已明确的健康状况、损伤、残疾或任何其他影响个人身体健康、心理健康和/或社会福祉的问题/事项的详情。"> comment = <"在实践当中，问题与诊断范围的明确区分/划定并非易事。对于利用本原始型的临床文档记录目的来说，在此会将问题与诊断视为统一的连续体系，且由问题到诊断，不断增加的细节水平和支持性证据通常会为“诊断”标签带来更大的权重。"> > ["at0001"] = < text = <"structure"> description = <"@ internal @"> > ["at0002"] = < text = <"问题/诊断名称"> description = <"利用名称对问题或诊断的标识。"> comment = <"尽可能首选采用术语标准对问题或诊断的名称进行编码。"> > ["at0003"] = < text = <"临床认定日期/时间"> description = <"医疗保健专业人员认定当前诊断或问题的估计或实际日期/时间。"> comment = <"可以接受部分型/不完整的日期。如果服务对象未满一周岁，则需要完整的日期或者至少是月份和年份才能准确地计算出年龄 - 比如，在将其用于驱动决策支持之时。应当利用服务/记录对象（患者）的出生日期，将作为临床认定[之时的]年龄（Age at time of clinical recognition）而采集/导入的数据转换成具体的日期。"> > ["at0005"] = < text = <"严重程度"> description = <"对于当前问题或诊断的总体严重程度的评估[结果]。"> comment = <"如果是在问题/诊断名称当中利用了先组[配]式代码（ precoordinated code）来记录严重程度，则本数据元就会变得多余。注意：可以利用特有详情槽位 \"Specific details\" 来记录更为具体的严重程度分级（grading）。"> > ["at0009"] = < text = <"临床描述"> description = <"关于当前问题或诊断的叙述性描述。"> comment = <"用于提供关于问题或诊断的背景和上下文/语境，包括发展演变、片段或恶化、进展和任何其他相关的详情。"> > ["at0012"] = < text = <"身体部位"> description = <"明确的是代表当前问题或诊断所处解剖位置的简单的身体部位。"> comment = <"尽可能首选采用术语标准对解剖位置的名称进行编码。 请利用本数据元记录先组[配]式（ precoordinated）的解剖位置。如果是由应用程序在运行时来确定关于记录解剖位置的要求，或者是需要更为复杂的建模（如相对位置），则请在本原始型的结构化解剖位置槽位 \"Structured anatomical location\" 采用群簇型解剖位置原始型 CLUSTER.anatomical_location 或群簇型相对位置原始型 CLUSTER.relative_location。本数据元的基数/出现次数并不受限制，以便能够适应不同的临床场景，如描述同时拥有多个解剖位置的皮疹但所有其他的特征属性全都相同。如果问题/诊断名称之中是利用先组[配]式代码（ precoordinated code）来记录相应的解剖位置，则本数据元就会变得多余。"> > ["at0030"] = < text = <"解决日期/时间"> description = <"医疗保健专业人员所确定的，当前问题或诊断的估计或实际的解决或缓解日期/时间。"> comment = <"可以接受部分型/不完整的日期。如果服务对象未满一周岁，则需要完整的日期或者至少是月份和年份才能准确地计算出年龄 - 比如，在将其用于驱动决策支持之时。应当利用服务/记录对象（患者）的出生日期，将作为临床认定[之时的]年龄（Age at time of clinical recognition）而采集/导入的数据转换成具体的日期。"> > ["at0032"] = < text = <"Tree"> description = <"@ internal @"> > ["at0039"] = < text = <"结构化身体部位"> description = <"当前问题或诊断的结构化解剖位置。"> comment = <"如果是由应用程序在运行时来确定关于记录解剖位置的要求，或者是需要更为复杂的建模（如相对位置），则请在当前槽位之中采用群簇型解剖位置原始型 CLUSTER.anatomical_location 或群簇型相对位置原始型 CLUSTER.relative_location。 如果问题/诊断名称之中是利用先组[配]式代码（ precoordinated code）来记录相应的解剖位置，则本数据元就会变得多余。"> > ["at0043"] = < text = <"特有详情"> description = <"记录当前问题或诊断特有的特征属性时所额外需要的详细信息。"> comment = <"可能包括关于当前诊断的分级或分期、诊断标准、分类标准或正式的严重程度评估（如不良事件通用术语标准）的结构化详情。"> > ["at0046"] = < text = <"状态"> description = <"关于诊断过程的位置/场所、领域、服务节段/片段（episode）或工作流的特有方面的结构化详细信息。"> comment = <"请谨慎使用状态（status）或上下文/语境（context）限定词，因为它们在实际工作中运用会变化不定，除非与相应的运用社区一起明确定义了用法，否则就无法保证互操作性（interoperability）。例如：有效性状态（现行有效、无效、已解决、缓解中）、演变状态（ 初步、临时/工作、最终）、时间状态（当前、过去/既往）、偶发性（episodicity）状态（首次、新近、持续）、入院状态（入院、出院）或者优先级状态（主要、次要）。"> > ["at0047"] = < text = <"轻度"> description = <"如果不加治疗/处理，当前的问题或诊断并不会干扰患者的正常活动或者可能会对其健康造成损害。"> > ["at0048"] = < text = <"中度"> description = <"如果不加治疗/处理，当前的问题或诊断会干扰患者的正常活动或者会对其健康造成损害。"> > ["at0049"] = < text = <"重度"> description = <"如果不加治疗/处理，当前的问题或诊断会妨碍患者的正常活动或者会对其健康造成严重的损害。"> > ["at0069"] = < text = <"备注"> description = <"其他字段之中并未采集的，关于当前问题或诊断的其他叙述。"> > ["at0070"] = < text = <"最后更新日期"> description = <"最后更新当前问题或诊断时的日期。"> > ["at0071"] = < text = <"扩展"> description = <"采集本地内容或与其他参考模型/形式化体系保持一致时所需的其他信息。"> comment = <"例如：本地信息需求/要求，或者是与 FHIR 或 CIMI 等效项保持一致时所需的其他元数据。"> > ["at0072"] = < text = <"进程描述"> description = <"关于起始/发病以来当前问题或诊断的过程/进程/病程（course）的叙述性描述。"> > ["at0073"] = < text = <"诊断确定性"> description = <"关于确定当前诊断的置信度水平。"> comment = <"如果需要采用其他备选的取值集合，则可以将这些取值添加到模板当中的文本型数据类型 DV_TEXT 。"> > ["at0074"] = < text = <"疑似"> description = <"确定当前诊断时的确定性较低。"> > ["at0075"] = < text = <"很可能"> description = <"确定当前诊断时的确定性较高。"> > ["at0076"] = < text = <"确诊/确认"> description = <"确定当前诊断时依据的是公认的[诊断]标准/评判准则。"> > ["at0077"] = < text = <"起始日期/时间"> description = <"首次观察到/发现当前问题/诊断的症状或体征的估计或实际日期/时间。"> comment = <"应当利用服务/记录对象（患者）的出生日期，将起始/发病年龄（Age at onset）而采集/导入的数据转换成具体的日期。"> > ["at0078"] = < text = <"原因"> description = <"问题或诊断的原因、原因集合（成套/成组的原因）或因果作用方式（manner of causation）。"> comment = <"又称为“病因”（aetiology/etiology）。尽可能首选采用外部术语标准来进行编码。"> > ["at0079"] = < text = <"变体/亚型"> description = <"当前诊断的特定变体/变异类型或亚型/子类型（如果相关/合适）。"> comment = <"例如：“急性运动轴突性神经病”（acute motor axonal neuropathy）就属于是吉兰-巴雷综合征（Guillain-Barre Syndrome）的变体。尽可能首选采用术语标准对变体/亚型的名称进行编码。"> > > > >