Modellbiblioteket openEHR Fork
Name
Reason for encounter
Description
The reason for initiation of any healthcare encounter or contact by the individual who is the subject of care.
Keywords
presentation
presenting complaint
reason for encounter
reason
chief complaint
visit
reason for visit
Purpose
To record the reason, or reasons, for initiation of any type of healthcare encounter or contact by the individual who is the subject of care.
Use
Use to record the reason, or reasons, for initiation of any type of healthcare encounter or contact between a healthcare provider and the individual who is the subject of care. The reason may be for clinical, social or administrative purposes.
Reason for Encounter is a common phrase used in clinical medicine, however the term is often used in two common ways - one that refers to an administrative category for provision of healthcare and the other that reflects clinical or social problems that motivate individuals to seek healthcare.
In an effort to clarify the phrases and intent, this archetype contains two data elements:
- The first, 'Contact type', to document the administrative type of healthcare sought or required - for example the type of consultation, emergency care, pre-operative assessment, routine antenatal visit or elective admission. This data element reflects the administrative category of care provision. Use of the phrase 'Contact type', rather than 'Reason for encounter' or 'Reason for visit' reflects the increasing trend towards alternative methods of healthcare provision that may not result in face-to-face contact between the healthcare provider and patient within a consulting room.
- The second, 'Presenting problem', to document the clinical reasons for healthcare contact. Chief complaint is regarded as a synonym for 'Presenting problem'. These are intended mainly to capture the patient's perceived issues or symptoms which have triggered them to seek healthcare advice, such as desire to quit smoking, stress, shortness of breath, genetic counselling or abdominal pain. Signs such as impaired conscious state may also be captured here, for example by paramedical staff with an unconscious patient.
Reason for Encounter is a common phrase used in clinical medicine, however the term is often used in two common ways - one that refers to an administrative category for provision of healthcare and the other that reflects clinical or social problems that motivate individuals to seek healthcare.
In an effort to clarify the phrases and intent, this archetype contains two data elements:
- The first, 'Contact type', to document the administrative type of healthcare sought or required - for example the type of consultation, emergency care, pre-operative assessment, routine antenatal visit or elective admission. This data element reflects the administrative category of care provision. Use of the phrase 'Contact type', rather than 'Reason for encounter' or 'Reason for visit' reflects the increasing trend towards alternative methods of healthcare provision that may not result in face-to-face contact between the healthcare provider and patient within a consulting room.
- The second, 'Presenting problem', to document the clinical reasons for healthcare contact. Chief complaint is regarded as a synonym for 'Presenting problem'. These are intended mainly to capture the patient's perceived issues or symptoms which have triggered them to seek healthcare advice, such as desire to quit smoking, stress, shortness of breath, genetic counselling or abdominal pain. Signs such as impaired conscious state may also be captured here, for example by paramedical staff with an unconscious patient.
Misuse
Not to be used to record specific details of the patient's story or history of symptoms. Use OBSERVATION.story to capture the narrative and the related nested CLUSTER archetypes for structured content eg CLUSTER.symptom, CLUSTER.event and CLUSTER.issue.
Not to be used to record specific diagnosis details that may be required in addition to a Reason for Encounter. For example, to record a Pre-operative Diagnosis as part of admission for a hospital procedure. Use the EVALUATION.problem_diagnosis archetype for this purpose.
Not to be used to record specific diagnosis details that may be required in addition to a Reason for Encounter. For example, to record a Pre-operative Diagnosis as part of admission for a hospital procedure. Use the EVALUATION.problem_diagnosis archetype for this purpose.
References
openEHR Foundation. openEHR wiki: Reason for Encounter or Chief Complaint [Internet]. 2008 Feb 13 [cited 2012 Jun 17]; Available at http://www.openehr.org/wiki/display/healthmod/Reason+for+encounter+or+Chief+complaint.
Archetype Id
openEHR-EHR-EVALUATION.reason_for_encounter.v1
Copyright
© openEHR Foundation
Licencing
This work is licensed under the Creative Commons Attribution-ShareAlike 3.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/3.0/.
Original Author
Heather Leslie
Atomica Informatics
Atomica Informatics
Date Originally Authored
To record the reason, or reasons, for initiation of any type of healthcare encounter or contact by the individual who is the subject of care.
| Language | Details |
|---|---|
| German |
Anneka Sargeant
Medizinische Informatik, UMG
|
| Norwegian Bokmal |
Lars Bitsch-Larsen og John Tore Valand
Haukeland University Hospital
|
| Portuguese (Brazil) |
Fernanda Maia Ewerton
Core Consulting
|
| Spanish, Castilian |
Pablo Pazos
CaboLabs
|
| Name | Card | Type | Description |
|---|---|---|---|
|
Contact type
|
0..* | DV_TEXT |
Identification of the type, or administrative category, of healthcare sought or required by the subject of care.
Comment
Coding of the 'Contact type' with a terminology is desirable, where possible. Examples include: pre-employment medical, routine antenatal visit, women's health check, pre-operative assessment, or annual medical check-up.
|
|
Presenting problem
|
0..* | DV_TEXT |
Identification of the clinical or social problem motivating the subject of care to seeking healthcare.
Comment
Coding of the 'Presenting problem' with a terminology is desirable, where possible. Clinical or social reasons for seeking healthcare can include health issues, symptoms or physical signs. Examples: health issues - desire to quit smoking, domestic violence; symptoms - abdominal pain, shortness of breath; physical signs - an altered conscious state. 'Chief complaint' may be used as a valid synonym for 'Presenting problem' in templates.
|
archetype (adl_version=1.4; uid=3d268aac-eeb5-4f95-b1a8-1d4dec5d0ae7) openEHR-EHR-EVALUATION.reason_for_encounter.v1 concept [at0000] -- Reason for encounter language original_language = <[ISO_639-1::en]> translations = < ["de"] = < language = <[ISO_639-1::de]> author = < ["name"] = <"Anneka Sargeant"> ["organisation"] = <"Medizinische Informatik, UMG"> ["email"] = <"anneka.sargeant@med.uni-goettingen.de"> > > ["nb"] = < language = <[ISO_639-1::nb]> author = < ["name"] = <"Lars Bitsch-Larsen og John Tore Valand"> ["organisation"] = <"Haukeland University Hospital"> > > ["pt-br"] = < language = <[ISO_639-1::pt-br]> author = < ["name"] = <"Fernanda Maia Ewerton"> ["organisation"] = <"Core Consulting"> ["email"] = <"fernanda.maiaewerton@gmail.com"> > accreditation = <"Hospital Alemão Oswaldo Cruz (HAOC)"> > ["es"] = < language = <[ISO_639-1::es]> author = < ["name"] = <"Pablo Pazos"> ["organisation"] = <"CaboLabs"> > accreditation = <"Computer Engineer"> > > description original_author = < ["name"] = <"Heather Leslie"> ["organisation"] = <"Atomica Informatics"> ["email"] = <"heather.leslie@atomicainformatics.com"> ["date"] = <"2007-04-19"> > details = < ["de"] = < language = <[ISO_639-1::de]> purpose = <"Zur Darstellung des Grundes bzw. der Gründe für die Initierung jeglicher Art von Begegnung oder Kontakt zwischen einem Gesundheitsdienstleister und der betreuten Person."> use = <"Zur Darstellung des Grundes oder der Gründe für die Initierung jeglicher Art von Begegnungen oder Kontakten zwischen einem Gesundheitsdienstleister und der betreuten Person aufzuzeichnen. Der Grund kann ein klinischer, sozialer oder administrativer Zwecke sein. \"Grund der Begegnung\" ist eine in der klinischen Medizin gebräuchliche Formulierung. Der Begriff wird jedoch häufig auf zwei Arten verwendet - eine bezieht sich auf eine Verwaltungskategorie für die Gesundheitsversorgung und die andere spiegelt klinische oder soziale Probleme wieder, die Menschen motivieren die Gesundheitsversorgung aufzusuchen. Um die Phrasen und die Absicht zu verdeutlichen, enthält dieser Archetyp zwei Datenelemente: - Der erste Datenelement \"Kontakttyp\", um den administrativen Typ gewünschten oder erforderlichen Gesundheitsversorgung einzuteilen - zum Beispiel die Art des Besuchs wie Notfall, präoperative Einschätzung, routinemäßige vorgeburtliche Visite oder Wahlleistung. Dieses Datenelement spiegelt die administrative Kategorie der Versorgung wider. Die Verwendung des Ausdrucks \"Kontaktart\" anstelle von \"Grund der Begegnung\" oder \"Grund des Besuchs\" spiegelt den zunehmenden Trend zu alternativen Methoden der Gesundheitsversorgung wider, die möglicherweise nicht zu einem persönlichen Kontakt zwischen dem Leistungserbringer und dem Patienten innerhalb eines Behandlungszimmers führen. - Die zweite Datenelement \"Vorstellung einer Beschwerde\", um die klinischen Gründe für den Kontakt im Gesundheitswesen zu dokumentieren. \"Hauptbeschwerde\" gilt als Synonym für \"Vorstellung einer Beschwerde\". Diese sind hauptsächlich dazu bestimmt, die wahrgenommenen Probleme oder Symptome des Patienten zu erfassen, die dazu geführt haben, dass sie Gesundheitsberatung suchen. Beispiele für Probleme oder Symptome sind: \"Wunsch nach Raucherentwöhnung\", wie Stress, Kurzatmigkeit, genetische Beratung oder Bauchschmerzen. Zeichen wie ein gestörter Bewusstseinszustand können hier ebenfalls erfasst werden, beispielsweise durch paramedizinisches Personal im Falle eines bewusstlosen Patienten."> keywords = <"Vorstellung", "vorgestellte Krankheit", "Beschwerde", "Grund", "Begegnung", "Kontakt", "Grund für die Begegnung", "Grund für den Kontakt", "Visite", "Grund der Visite"> misuse = <"Nicht zur Darstellung bestimmter Details der Geschichte des Patienten oder der Geschichte der Symptome aufzuzeichnen. Verwenden Sie hierzu den Archetype OBSERVATION.story, um die Erzählung und die zugehörigen geschachtelten CLUSTER-Archetypen für strukturierten Inhalt zu erfassen, z.B. CLUSTER.symptom, CLUSTER.event und CLUSTER.issue. Nicht zur Darstellung bestimmter Diagnosedetails, die zusätzlich zu einem Grund für die Begegnung erforderlich sein können, verwendet werden. Zum Beispiel um eine präoperative Diagnose im Rahmen einer stationären Aufnahme zu erfassen. Verwenden Sie den Archetyp EVALUATION.problem_diagnosis für diesen Zweck."> > ["nb"] = < language = <[ISO_639-1::nb]> purpose = <"For å registrere årsak eller årsaker til kontakten mellom helsepersonell og individ."> use = <"For å registrere årsak eller årsaker til kontakten mellom helsepersonell og individ. Årsak kan være klinisk, sosial eller administrativ. Kontaktårsak er et vanlig uttrykk som brukes i klinisk medisin, begrepet brukes oftest på to måter - en som refererer til en administrativ kategori for levering av helsetjenester og en som gjenspeiler det kliniske eller sosiale behovet for å søke helsetjenester. Arketypen inneholder to dataelementer: - \"Administrativ kontaktårsak\" brukes for å dokumentere den administrative delen av helsehjelpen som oppsøkes eller behøves, for eksempel konsultasjonstype, øyeblikkelig hjelp, preoperativ vurdering, svangerskapskontroll eller elektiv innleggelse. Dataelementet reflekterer en administrativ kategorisering av helsehjelpen. Valg av ordet kontaktårsak viser at det er en økt trend mot alternative måter for utføring av helsetjenester som ikke må ende opp med ansikt til ansikt kontakt mellom helsepersonell og pasient i konsultasjonsrommet. -\"Klinisk kontaktårsak\" brukes for å dokumentere kliniske årsaker for kontakten. Hovedproblemstilling blir regnet som et synonym for \"Klinisk kontaktårsak\". Formålet er å registrere individets oppfatning av problemer og symptomer som har vært utløsende faktor for at en søker hjelp fra helsevesenet, for eksempel ønske om å slutte å røyke, stress, kortpusthet eller magesmerter. Sykdomstegn som \"nedsatt bevissthet\" kan også registreres her, for eksempel når prehospitalt personell møter en bevisstløs person."> keywords = <"kontaktårsak", "årsak", "besøk", "årsak for besøk", "problemstilling", "konsultasjonsårsak", "innleggelsesårsak", "henvisningsgrunn", "henvisningsårsak", "henvendelse"> misuse = <"Skal ikke benyttes for å registrere spesifikke detaljer om pasientens sykehistorie eller forløp av symptomer. Bruk OBSERVATION.story å registrere den fritekstlige delen og de relaterte nøstede CLUSTER-arketypene for strukturert innhold f.eks CLUSTER.symptom, CLUSTER.event og CLUSTER.issue. Skal ikke benyttes for å registrere bestemte detaljer om diagnoser som kan være nødvendig i tillegg til \"Kontaktårsak\" f.eks innleggelse eller preoperativ diagnose som en del av en innleggelse i sykehus for utførelse av en prosedyre. Bruk EVALUATION.problem_diagnosis for dette formålet."> > ["pt-br"] = < language = <[ISO_639-1::pt-br]> purpose = <"Para gravar a(s) razão(ões) do início de qualquer tipo de contato de saúde entre um profissional de saúde e um paciente. "> use = <"Para gravar a(s) razão(ões) do início de qualquer tipo de contato de saúde entre um profissional de saúde e um paciente. Motivo para o encontro é um frase comum em medicina clínica, entretanto o termo é frequentemente usado de duas maneiras comuns - Uma refere-se à categoria administrativa para provisão de cuidado em saúde e a outra que reflete o gatilho clínico para buscar cuidado em saúde. Num esforço para esclarecer as frases e intenções, este arquétipo contém dois elementos de dados: - O primeiro, \"Motivo para o contato\", para documentar o tipo administrativo de cuidado em saúde procurado ou exigido - por exemplo o tipo de consulta, cuidado emergencial, risco cirúrgico, visita pré-natal de rotina ou adminissão eletiva. Este elemento de dado reflete a categoria administrativa da provisão do cuidado. O uso da frase \"Motivo para o contato\" ao invés de \"Razão para o encontro\" ou \"Razão para visita\" reflete uma tendência crescente em relação a métodos alternativos de provisão de cuidado em saúde que podem não resultar em um contato pessoal entre o profissional de saúde e o paciente dentro de um consultório. - O segundo, \"Problema apresentado\", para documentar as razões clínicas do contato em saúde. O objetivo destes é principalmente para capturar os problemas ou sintomas observados pelo paciente que o levaram a procurar orientação em saúde, como o desejo de parar de fumar, estresse, falta de ar ou dor abdominal. Sinais como estado de consciência alterado também podem ser capturados aqui, por exemplo por paramédicos com pacientes inconscientes. "> keywords = <"apresentação", "queixa apresentada", "motivo para o encontro", "motivo", "queixa principal", "visita", "motivo para a visita"> misuse = <"Não deve ser usado para gravar detalhes específicos e da estória do paciente ou seus sintomas. Use OBSERVATION.story para capturar a narrativa e arquétipos CLUSTER relacionados para conteúdo estruturado p.e. CLUSTER.symptom, CLUSTER.event and CLUSTER.issue. Não deve ser usado para gravar detalhes específicos de diagnósticos que podem ser necessários além do motivo para o encontro p.e. diagnóstico de admissão ou pré-operatório como parte de uma admissão para um procedimento hospitalar. Use EVALUATION.problem_diagnosis (e especializações relacionadas) para este propósito. "> copyright = <"© openEHR Foundation"> > ["en"] = < language = <[ISO_639-1::en]> purpose = <"To record the reason, or reasons, for initiation of any type of healthcare encounter or contact by the individual who is the subject of care."> use = <"Use to record the reason, or reasons, for initiation of any type of healthcare encounter or contact between a healthcare provider and the individual who is the subject of care. The reason may be for clinical, social or administrative purposes. Reason for Encounter is a common phrase used in clinical medicine, however the term is often used in two common ways - one that refers to an administrative category for provision of healthcare and the other that reflects clinical or social problems that motivate individuals to seek healthcare. In an effort to clarify the phrases and intent, this archetype contains two data elements: - The first, 'Contact type', to document the administrative type of healthcare sought or required - for example the type of consultation, emergency care, pre-operative assessment, routine antenatal visit or elective admission. This data element reflects the administrative category of care provision. Use of the phrase 'Contact type', rather than 'Reason for encounter' or 'Reason for visit' reflects the increasing trend towards alternative methods of healthcare provision that may not result in face-to-face contact between the healthcare provider and patient within a consulting room. - The second, 'Presenting problem', to document the clinical reasons for healthcare contact. Chief complaint is regarded as a synonym for 'Presenting problem'. These are intended mainly to capture the patient's perceived issues or symptoms which have triggered them to seek healthcare advice, such as desire to quit smoking, stress, shortness of breath, genetic counselling or abdominal pain. Signs such as impaired conscious state may also be captured here, for example by paramedical staff with an unconscious patient."> keywords = <"presentation", "presenting complaint", "reason for encounter", "reason", "chief complaint", "visit", "reason for visit"> misuse = <"Not to be used to record specific details of the patient's story or history of symptoms. Use OBSERVATION.story to capture the narrative and the related nested CLUSTER archetypes for structured content eg CLUSTER.symptom, CLUSTER.event and CLUSTER.issue. Not to be used to record specific diagnosis details that may be required in addition to a Reason for Encounter. For example, to record a Pre-operative Diagnosis as part of admission for a hospital procedure. Use the EVALUATION.problem_diagnosis archetype for this purpose."> copyright = <"© openEHR Foundation"> > ["es"] = < language = <[ISO_639-1::es]> purpose = <"Registrar los motivos de un paciente para iniciar un encuentro o contacto con un proveedor de salud."> use = <"Utilizar para registrar los motivos de un paciente para iniciar un encuentro o contacto con un proveedor de salud. El motivo tener un propósito clínico, social o administrativo. El arquetipo incluye dos elementos principales: - Motivo de consulta: para registrar el dato administrativo relacionado al tipo de asistencia médica buscada por el paciente. - Problema presentado: para registrar los problemas o síntomas que el paciente percibe, y que lo motivan a buscar asistencia médica. También se pueden registrar datos como el estado de conciencia de un paciente, por ejemplo por personal paramédico atendiendo a un paciente inconsciente."> keywords = <"problema", "síntoma", "razón", "motivo de consulta", "visita", "consulta"> misuse = <"No se debe utilizar para registrar detalles específicos sobre la historia de síntomas del paciente. Para eso utilizar el arquetipo OBSERVATION.story. No debe ser utilizado para registrar diagnósticos. Para eso utilizar el arquetipo EVALUATION.problem_diagnosis."> copyright = <"© openEHR Foundation"> > > lifecycle_state = <"published"> other_contributors = <"Tomas Alme, DIPS ASA, Norway", "Nadim Anani, Karolinska Institutet, Sweden", "Vebjørn Arntzen, Oslo University Hospital, Norway", "Koray Atalag, University of Auckland, New Zealand", "Silje Ljosland Bakke, Helse Vest IKT AS, Norway (openEHR Editor)", "Lars Bitsch-Larsen, Haukeland University hospital, Norway", "Sergio Carmona, Chile", "Lisbeth Dahlhaug, Helse Midt - Norge IT, Norway", "Beatriz de Faria Leão, Brazil", "Shahla Foozonkhah, Ocean Informatics, Australia", "Einar Fosse, UNN HF, Norwegian Centre for Integrated Care and Telemedicine, Norway", "Sebastian Garde, Ocean Informatics, Germany", "Heather Grain, Llewelyn Grain Informatics, Australia", "Anne Gunn Haugland, Helse Bergen HF, Norway", "Andreas Hering, Helse Bergen HF, Haukeland universitetssjukehus, Norway", "Omer Hotomaroglu, Turkey", "Lars Ivar Mehlum, Helse Bergen HF, Norway", "Sundaresan Jagannathan, Scottish NHS, United Kingdom", "Lars Morgan Karlsen, DIPS ASA, Norway", "Heather Leslie, Atomica Informatics, Australia (openEHR Editor)", "Hallvard Lærum, Norwegian Directorate of e-health, Norway", "Rose Mari Eikås, Helse Bergen, Norway", "Ian McNicoll, freshEHR Clinical Informatics, United Kingdom", "Bjørn Næss, DIPS ASA, Norway", "Rune Pedersen, Universitetssykehuset i Nord Norge, Norway", "John Tore Valand, Haukeland Universitetssjukehus, Norway (Editor, Translation Editor)", "Jon Tysdahl, Furst medlab AS, Norway"> other_details = < ["licence"] = <"This work is licensed under the Creative Commons Attribution-ShareAlike 3.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/3.0/."> ["custodian_organisation"] = <"openEHR Foundation"> ["references"] = <"openEHR Foundation. openEHR wiki: Reason for Encounter or Chief Complaint [Internet]. 2008 Feb 13 [cited 2012 Jun 17]; Available at http://www.openehr.org/wiki/display/healthmod/Reason+for+encounter+or+Chief+complaint."> ["current_contact"] = <"Heather Leslie, Atomica Informatics<heather.leslie@atomicainformatics.com>"> ["original_namespace"] = <"org.openehr"> ["original_publisher"] = <"openEHR Foundation"> ["custodian_namespace"] = <"org.openehr"> ["MD5-CAM-1.0.1"] = <"8F5F414D89192FFF36DB35A41CBCB740"> ["build_uid"] = <"7b026d2d-41e6-4911-a964-11a9ce4fba26"> ["revision"] = <"1.0.2"> > definition EVALUATION[at0000] matches { -- Reason for encounter data matches { ITEM_TREE[at0001] matches { -- Tree items cardinality matches {0..*; unordered} matches { ELEMENT[at0002] occurrences matches {0..*} matches { -- Contact type value matches { DV_TEXT matches {*} } } ELEMENT[at0004] occurrences matches {0..*} matches { -- Presenting problem value matches { DV_TEXT matches {*} } } } } } } ontology term_definitions = < ["en"] = < items = < ["at0000"] = < text = <"Reason for encounter"> description = <"The reason for initiation of any healthcare encounter or contact by the individual who is the subject of care."> > ["at0001"] = < text = <"Tree"> description = <"@ internal @"> > ["at0002"] = < text = <"Contact type"> description = <"Identification of the type, or administrative category, of healthcare sought or required by the subject of care."> comment = <"Coding of the 'Contact type' with a terminology is desirable, where possible. Examples include: pre-employment medical, routine antenatal visit, women's health check, pre-operative assessment, or annual medical check-up. "> > ["at0004"] = < text = <"Presenting problem"> description = <"Identification of the clinical or social problem motivating the subject of care to seeking healthcare."> comment = <"Coding of the 'Presenting problem' with a terminology is desirable, where possible. Clinical or social reasons for seeking healthcare can include health issues, symptoms or physical signs. Examples: health issues - desire to quit smoking, domestic violence; symptoms - abdominal pain, shortness of breath; physical signs - an altered conscious state. 'Chief complaint' may be used as a valid synonym for 'Presenting problem' in templates. "> > > > ["pt-br"] = < items = < ["at0000"] = < text = <"Motivo para o encontro"> description = <"O motivo de início de qualquer encontro em saúde ou contato pelo indivíduo que é sujeito do cuidado."> > ["at0001"] = < text = <"*Tree(en)"> description = <"*@ internal @"> > ["at0002"] = < text = <"Tipo de contato"> description = <"Identificação do tipo, ou categoria administrativa, ou cuidado em saúde procurado ou exigido pelo sujeito do cuidado."> comment = <"Codificação do \"tipo de contato\" com uma terminologia é desejável, quando possível. Exemplos incluem: Exame pré-admissional, visita pré-natal de rotina, saúde da mulher, risco cirúrgico, ou avaliação médica anual."> > ["at0004"] = < text = <"Problema apresentado"> description = <"Identificação do problema clínico ou social que motiva o sujeito do cuidado a procurar cuidado em saúde."> comment = <" Codificação do \"Problema apresentado\" com uma terminologia é desejável, quando possível. Razões clínicas ou sociais na busca de cuidado em saúde podem incluir problemas de saúde, sintomas ou sinais físicos. Exemplos: problemas de saúde - desejo de parar de fumar, violência doméstica; sintomas - dor abdominal, falta de ar; sinais físicos - um estado de consciência alterado. \"Queixa principal\" pode ser usada como um sinônimo válido para \"Problema apresentado\" nos modelos."> > > > ["es"] = < items = < ["at0000"] = < text = <"Motivo de consulta"> description = <"Motivo del paciente por el cual se inició un encuentro clínico o contacto."> > ["at0001"] = < text = <"Tree"> description = <"@ internal @"> > ["at0002"] = < text = <"Tipo de contacto"> description = <"Identificación del tipo o categoría administrativa por la cuál el paciente busca asistencia médica."> comment = <"Es deseable la codificación del 'Tipo de contacto' mediante una terminología. Algunos ejemplos incluyen: control previo al empleo, visita prenatal de rutina, control de salud femenino, evaluación preoperatoria, o control médico anual."> > ["at0004"] = < text = <"Problema presentado"> description = <"Problema o síntoma reportado por el paciente, que da inicio a la consulta médica"> comment = <"Es desable la codificación del 'Problema presentado' mediante una terminología. Motivos clínicos o sociales para buscar atención médica pueden incluir estos problemas, síntomas o signos físicos: deseo de dejar de fumar, violencia doméstica, dolor abdominal, problemas al respirar, alteración del estado de conciencia. En una plantilla, 'Problema principal' puede usarse como sinónimo al 'Problema presentado'."> > > > ["de"] = < items = < ["at0000"] = < text = <"Grund für den Kontakt"> description = <"Der Grund für die Initiierung eines Arztbesuchs durch den Patienten."> > ["at0001"] = < text = <"Tree"> description = <"@ internal @"> > ["at0002"] = < text = <"Kontakt Typ"> description = <"Identifizierung des Typs oder der Verwaltungskategorie des Gesundheitswesens, der von dem Pflegebedürftigen gesucht oder benötigt wird."> comment = <"Die Kodierung des \"Kontakttyps\" sollte, wenn möglich, mit einer Terminologie erfolgen. Beispiele hierfür sind: vorbereitende Untersuchungen, routinemäßiger vorgeburtlicher Vorsorgetermin, Gesundheitscheck für Frauen."> > ["at0004"] = < text = <"Hauptbeschwerde"> description = <"Identifikation des klinischen oder sozialen Problems, welches den Patienten motiviert die medizinische Versorgung aufzusuchen."> comment = <"Die Kodierung der \"Problemdarstellung\" sollte, wenn möglich, mit einer Terminologie erfolgen. Klinische oder soziale Gründe für das Aufsuchen der Gesundheitsversorgung können u.a. Gesundheitsprobleme, Symptome oder andere körperliche Anzeichen sein. Beispiele: Gesundheitsfragen - Wunsch, mit dem Rauchen aufzuhören, häusliche Gewalt; Symptome - Bauchschmerzen, Kurzatmigkeit; körperliche Zeichen - ein veränderter Bewusstseinszustand. \"Hauptbeschwerde\" kann als gültiges Synonym für \"Problemdarstellung\" in den Vorlagen verwendet werden."> > > > ["nb"] = < items = < ["at0000"] = < text = <"Kontaktårsak"> description = <"For å registrere årsaken til kontakt mellom helsepersonell og individet."> > ["at0001"] = < text = <"Tree"> description = <"@ internal @"> > ["at0002"] = < text = <"Administrativ kontaktårsak"> description = <"Type eller administrativ kategori av helsetjenester som er årsak til at individet oppsøker eller behøver helsetjenester."> comment = <"Koding av \"kontaktårsak\" med en terminologi foretrekkes når mulig. Eksempler: Helsesjekk før ansettelse, svangerskapskontroll, gynekologisk undersøkelse, preoperativ undersøkelse eller årlig medisinsk kontroll."> > ["at0004"] = < text = <"Klinisk kontaktårsak"> description = <"Klinisk eller sosial årsak til at individet oppsøker helsevesenet."> comment = <"Koding av \"Klinisk problemstilling\" med en terminologi foretrekkes når mulig. Kliniske årsaker kan omfatte helseproblemer, symptomer, eller fysiske sykdomstegn. Eksempler: Helseproblemer - ønske om å slutte å røyke eller vold i hjemmet, symptomer - magesmerter eller kortpusthet, fysiske sykdomstegn - endret bevissthetsnivå. \"Hovedproblemstilling\" kan bli benyttet som et synonym for \"Klinisk kontaktårsak\" i templater."> > > > >