archetype (adl_version=1.4) openEHR-EHR-CLUSTER.symptom.v1 concept [at0000] -- Symptom language original_language = <[ISO_639-1::en]> translations = < ["de"] = < language = <[ISO_639-1::de]> author = < ["name"] = <"Jasmin Buck, Sebastian Garde"> ["organisation"] = <"University of Heidelberg, Central Queensland University"> > > > description original_author = < ["name"] = <"NHS archetype project"> ["organisation"] = <"UK NHS, Connecting for Health"> ["date"] = <"20/02/2007"> ["email"] = <"tony.shannon@nhs.net"> > details = < ["de"] = < language = <[ISO_639-1::de]> purpose = <"Ein allgemeiner Archetyp zur Dokumentation von Symptomen und Informationen über diese Symptome. Er erlaubt die Aussage, dass der Patient nicht an diesem Symptom leidet (ohne weitere Informationen) oder auch genauere Aussage als erforderlich. Der Grund, dass eine allgemeine negative oder genauere Aussage gemacht werden kann ist, Fehler bezüglich der Vermehrung negative Aussagen über das Symptom und Einzelheiten zu einem deutlich positivem Symptom zu verhindern."> use = <"Zur Dokumentation von Informationen zu einem Symptom. Die Information kann kodiert oder strukturiert sein, falls dies erforderlich ist, oder aber die Freitextbeschreibung des Symptoms mit Einzelheiten als klinische Beschreibung nutzen. "> keywords = <"Beschwerden", ...> misuse = <"Sollte nur für Symptome benutzt werden."> > ["en"] = < language = <[ISO_639-1::en]> purpose = <"A generic archetype for recording symptoms and information about the symptoms. This archetype allows a statement to be made that the patient does not have this symptom (without any other information) or more detailed statements as required. The reason that a general negative statement can be made or a more detailed statement is to ensure that there is no possibility for error with negative statements about the symptom mixed with details of a symptom that is clearly positive."> use = <"For recording information about symptoms. The information can be coded and structured if required or utilise the free text description of the symptom with detail as clinical description if required."> keywords = <"complaint", ...> misuse = <"This should only be used for symptoms (see the referenced SNOMED termset for an indication of the concepts covered)."> > > lifecycle_state = <"OrganisationDraft"> other_contributors = <"Sam Heard, Ocean Informatics", ...> definition CLUSTER[at0000] matches { -- Symptom items cardinality matches {1..2; unordered} matches { ELEMENT[at0001] matches { -- Symptom value matches { DV_TEXT matches {*} } } ELEMENT[at0035] occurrences matches {0..1} matches { -- Nicht signifikant value matches { DV_BOOLEAN matches { value matches {True} } } } CLUSTER[at0034] occurrences matches {0..1} matches { -- Merkmale items cardinality matches {0..*; unordered} matches { ELEMENT[at0002] occurrences matches {0..1} matches { -- Klinische Beschreibung value matches { DV_TEXT matches {*} } } ELEMENT[at0029] occurrences matches {0..*} matches { -- Lokation im Körper value matches { DV_TEXT matches {*} } } ELEMENT[at0021] occurrences matches {0..1} matches { -- Schwere value matches { 1|[local::at0044], -- geringfügig 2|[local::at0023], -- gelinde 5|[local::at0024], -- mäßig 8|[local::at0025], -- schwer 9|[local::at0045] -- sehr schwerwiegend } } CLUSTER[at0046] occurrences matches {0..1} matches { -- Aktuelle Intensität items cardinality matches {0..*; unordered} matches { ELEMENT[at0047] occurrences matches {0..1} matches { -- Grad value matches { 0|[local::at0022], -- nicht anwesend 1|[local::at0044], -- geringfügig 2|[local::at0023], -- gelinde 5|[local::at0024], -- mäßig 8|[local::at0025], -- schwer 9|[local::at0045] -- sehr schwerwiegend } } ELEMENT[at0026] occurrences matches {0..1} matches { -- Visuelle Analogskala value matches { DV_COUNT matches { magnitude matches {|0..10|} } } } } } ELEMENT[at0028] occurrences matches {0..1} matches { -- Dauer value matches { DV_DURATION matches { value matches {PYMWDTHMS} } } } ELEMENT[at0031] occurrences matches {0..1} matches { -- Anzahl der Vorkommnisse value matches { DV_COUNT matches {*} } } ELEMENT[at0032] occurrences matches {0..1} matches { -- Art value matches { DV_TEXT matches {*} } } ELEMENT[at0003] occurrences matches {0..1} matches { -- Variation value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0004, -- Dauerhaft at0005, -- Zeitweise at0006] -- Variabel } } } } CLUSTER[at0058] occurrences matches {0..1} matches { -- Vorherige Vorfälle items cardinality matches {0..*; unordered} matches { ELEMENT[at0059] occurrences matches {0..1} matches { -- Frühere Vorfälle value matches { DV_BOOLEAN matches { value matches {True, False} } } } ELEMENT[at0057] occurrences matches {0..1} matches { -- Details über vorherige Symptome value matches { DV_TEXT matches {*} } } } } CLUSTER[at0033] occurrences matches {0..1} matches { -- Verlauf items cardinality matches {0..*; unordered} matches { ELEMENT[at0008] occurrences matches {0..1} matches { -- Art des Eintretens value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0009, -- Graduell at0036, -- rasch at0010] -- Plötzlich } } } } ELEMENT[at0060] occurrences matches {0..1} matches { -- Beschreibung des Auftretens value matches { DV_TEXT matches {*} } } ELEMENT[at0030] occurrences matches {0..1} matches { -- Zeitpunkt der maximalen Stärke value matches { DV_DATE_TIME matches { value matches {yyyy-??-??T??:??:??} } } } ELEMENT[at0037] occurrences matches {0..1} matches { -- Entwicklung value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0038, -- sich bessernd at0039, -- nachlassend at0040, -- stabil at0041, -- zunehmend at0042, -- sich verschlimmernd at0043] -- hat sich gelegt } } } } ELEMENT[at0011] occurrences matches {0..1} matches { -- Ende value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0009, -- Graduell at0036, -- rasch at0010] -- Plötzlich } } } } } } CLUSTER[at0014] occurrences matches {0..1} matches { -- Beschleunigende Faktoren items cardinality matches {1..*; unordered} matches { ELEMENT[at0015] occurrences matches {1..*} matches { -- Beschleunigender Faktor value matches { DV_TEXT matches {*} } } } } CLUSTER[at0016] occurrences matches {0..1} matches { -- Modifizierende Faktoren items cardinality matches {1..*; unordered} matches { CLUSTER[at0018] occurrences matches {0..1} matches { -- Modifizierender Faktor items cardinality matches {1..*; unordered} matches { ELEMENT[at0019] occurrences matches {0..*} matches { -- Faktor value matches { DV_TEXT matches {*} } } ELEMENT[at0017] occurrences matches {0..1} matches { -- Erschwerender Faktor value matches { -3|[local::at0048], -- Komplett gelindert -2|[local::at0049], -- Verbessert -1|[local::at0050], -- Etwas verbessert 0|[local::at0051], -- Keine Veränderung 1|[local::at0052], -- Etwas verschlechtert 2|[local::at0053], -- Verschlechtert 3|[local::at0054] -- Sehr viel verschlechtert } } ELEMENT[at0056] occurrences matches {0..1} matches { -- Details über den Effekt value matches { DV_TEXT matches {*} } } } } } } CLUSTER[at0020] occurrences matches {0..1} matches { -- Assoziierte Symptome items cardinality matches {0..*; unordered} matches { allow_archetype CLUSTER occurrences matches {0..*} matches { include archetype_id/value matches {/symptom\.v1/} archetype_id/value matches {/symptom-pain\.v1/} exclude archetype_id/value matches {/.*/} } } } CLUSTER[at0061] occurrences matches {0..1} matches { -- Nicht vorhandene Merkmale items cardinality matches {0..*; unordered} matches { ELEMENT[at0062] occurrences matches {0..*} matches { -- Nicht vorhandenes Merkmal value matches { DV_TEXT matches {*} } } } } } } } } ontology terminologies_available = <"SNOMED-CT", ...> term_definitions = < ["de"] = < items = < ["at0000"] = < description = <"Ein beim Patienten aufgetretenes Symptom"> text = <"Symptom"> > ["at0001"] = < description = <"das aufgetretene Symptom"> text = <"Symptom"> > ["at0002"] = < description = <"Beschreibung des Symptoms"> text = <"Klinische Beschreibung"> > ["at0003"] = < description = <"die Variationen des Symptoms"> text = <"Variation"> > ["at0004"] = < description = <"das Symptom ist dauerhaft anwesend"> text = <"Dauerhaft"> > ["at0005"] = < description = <"das Symptom ist abwechselnd anwesend und nicht anwesend"> text = <"Zeitweise"> > ["at0006"] = < description = <"das Symptom variiert deutlich, ist aber praktisch ständig anwesend"> text = <"Variabel"> > ["at0008"] = < description = <"die Art des Eintretens des Symptoms"> text = <"Art des Eintretens"> > ["at0009"] = < description = <"das Symptom ist allmählich über eine längere Zeitspanne hinweg aufgetaucht"> text = <"Graduell"> > ["at0010"] = < description = <"das Symptom ist sofort aufgetaucht"> text = <"Plötzlich"> > ["at0011"] = < description = <"die Art des Abklingens des Symptoms"> text = <"Ende"> > ["at0014"] = < description = <"Faktoren, die das Symptom auslösen oder bewirken"> text = <"Beschleunigende Faktoren"> > ["at0015"] = < description = <"ein Ereignis oder eine Handlung, die das Symptom auslösen oder bewirken"> text = <"Beschleunigender Faktor"> > ["at0016"] = < description = <"Faktoren, die den Intensitätsgrad des Symptoms verändern"> text = <"Modifizierende Faktoren"> > ["at0017"] = < description = <"ein Ereignis oder eine Handlung, die das Symptom verschlimmern"> text = <"Erschwerender Faktor"> > ["at0018"] = < description = <"Information über einen bestimmten Faktor, der das Symptom verändert"> text = <"Modifizierender Faktor"> > ["at0019"] = < description = <"ein Ereignis oder eine Handlung, die das Symptom verändert"> text = <"Faktor"> > ["at0020"] = < description = <"Symptome, die mit diesem Symptom assoziiert sind"> text = <"Assoziierte Symptome "> > ["at0021"] = < description = <"der Schweregrad des Symptoms"> text = <"Schwere"> > ["at0022"] = < description = <"das Symptom ist nicht anwesend"> text = <"nicht anwesend"> > ["at0023"] = < description = <"das Symptom beeinträchtigt alltägliche Handlungen nicht ernsthaft"> text = <"gelinde"> > ["at0024"] = < description = <"das Symptom beeinträchtigt alltägliche Handlungen"> text = <"mäßig"> > ["at0025"] = < description = <"das Symptom verhindert wichtige alltägliche Handlungen"> text = <"schwer"> > ["at0026"] = < description = <"eine Bewertung von 0 (nicht anwesend) bis 10 (schlimmer geht nicht)"> text = <"Visuelle Analogskala"> > ["at0028"] = < description = <"die Dauer des Symptoms seit dem Beginn"> text = <"Dauer"> > ["at0029"] = < description = <"die Lokationen des Symptoms im Körper"> text = <"Lokation im Körper"> > ["at0030"] = < description = <"Die Zeit (und/oder das Datum) der maximalen Stärke des Symptoms"> text = <"Zeitpunkt der maximalen Stärke"> > ["at0031"] = < description = <"die Anzahl wie oft das Symptom aufgetreten ist"> text = <"Anzahl der Vorkommnisse"> > ["at0032"] = < description = <"die Art des Symptoms"> text = <"Art"> > ["at0033"] = < description = <"Merkmale des Verlaufs des Symptoms"> text = <"Verlauf"> > ["at0034"] = < description = <"die Merkmale des Symptoms"> text = <"Merkmale"> > ["at0035"] = < description = <"die Person hat keine signifikanten Erfahrungen mit dem Symptom"> text = <"Nicht signifikant"> > ["at0036"] = < description = <"über einen kurzen Zeitraum"> text = <"rasch"> > ["at0037"] = < description = <"die Entwicklung des Symptoms im Hinblick auf die Vergangenheit"> text = <"Entwicklung"> > ["at0038"] = < description = <"das Symptom hat sich im Laufe der Zeit gebessert"> text = <"sich bessernd"> > ["at0039"] = < description = <"die Intensität des Symptoms hat im Laufe der Zeit nachgelassen"> text = <"nachlassend"> > ["at0040"] = < description = <"das Symptom hat sich im Laufe der Zeit nicht verändert"> text = <"stabil"> > ["at0041"] = < description = <"die Intensität des Symptoms hat im Laufe der Zeit zugenommen"> text = <"zunehmend"> > ["at0042"] = < description = <"das Symptom hat sich im Laufe der Zeit verschlimmert"> text = <"sich verschlimmernd"> > ["at0043"] = < description = <"das Symptom hat sich im Laufe der Zeit gelegt"> text = <"hat sich gelegt"> > ["at0044"] = < description = <"das Symptom ist geringfügig und verursacht keine Probleme"> text = <"geringfügig"> > ["at0045"] = < description = <"das Symptom hat fast die maximal mögliche Intensität und verhindert jegliche Handlungen"> text = <"sehr schwerwiegend"> > ["at0046"] = < description = <"Messungen der Intensität des Symptoms zum jetzigen Zeitpunkt"> text = <"Aktuelle Intensität"> > ["at0047"] = < description = <"der Grad der Beeinträchtigung des Patienten durch das Symptom"> text = <"Grad"> > ["at0048"] = < description = <"Das Symptom wird durch diesen Faktor gelindert"> text = <"Komplett gelindert"> > ["at0049"] = < description = <"Das Symptom wird durch diesen Faktor verbessert"> text = <"Verbessert"> > ["at0050"] = < description = <"Das Symptom wird durch diesen Faktor etwas verbessert"> text = <"Etwas verbessert"> > ["at0051"] = < description = <"Das Symptom wird durch diesen Faktor nicht verändert"> text = <"Keine Veränderung"> > ["at0052"] = < description = <"Das Symptom wird durch diesen Faktor etwas verschlechtert"> text = <"Etwas verschlechtert"> > ["at0053"] = < description = <"Das Symptom wird durch diesen Faktor verschlechtert"> text = <"Verschlechtert"> > ["at0054"] = < description = <"Das Symptom wird durch diesen Faktor sehr viel verschlechtert"> text = <"Sehr viel verschlechtert"> > ["at0056"] = < description = <"Details über den Effekt"> text = <"Details über den Effekt"> > ["at0057"] = < description = <"Details über vorherige Symptome und Vergleich zu diesem Vorfall"> text = <"Details über vorherige Symptome"> > ["at0058"] = < description = <"Details über vorherige Vorfälle"> text = <"Vorherige Vorfälle"> > ["at0059"] = < description = <"Ist dieses Symptom früher schon einmal aufgetreten"> text = <"Frühere Vorfälle"> > ["at0060"] = < description = <"Taetigkeit oder Situation bei Auftreten des Symptoms und weitere Details"> text = <"Beschreibung des Auftretens"> > ["at0061"] = < description = <"Nicht vorhandene Merkmale"> text = <"Nicht vorhandene Merkmale"> > ["at0062"] = < description = <"Ein nicht vorhandenes Merkmal"> text = <"Nicht vorhandenes Merkmal"> > > > ["en"] = < items = < ["at0000"] = < description = <"A symptom experienced by the patient"> text = <"Symptom"> > ["at0001"] = < description = <"The symptom experienced"> text = <"Symptom"> > ["at0002"] = < description = <"Description of the symptom"> text = <"Clinical description"> > ["at0003"] = < description = <"The variation of the symptom"> text = <"Variation"> > ["at0004"] = < description = <"The symptom is constantly present"> text = <"Constant"> > ["at0005"] = < description = <"The symptom is present at times and not at others"> text = <"Intermittent"> > ["at0006"] = < description = <"The symptom varys considerably but is almost always present"> text = <"Fluctuating"> > ["at0008"] = < description = <"The nature of the onset of the symptom"> text = <"Onset type"> > ["at0009"] = < description = <"Over a longer period of time"> text = <"Gradual"> > ["at0010"] = < description = <"Almost immediate"> text = <"Sudden"> > ["at0011"] = < description = <"The nature of the cessation of the symptom"> text = <"Cessation"> > ["at0014"] = < description = <"Factors that trigger or bring on the symptom"> text = <"Precipitating factors"> > ["at0015"] = < description = <"An event or activity that brings on or triggers the symptom"> text = <"Precipitating factor"> > ["at0016"] = < description = <"Factors that change the level of intensity of the symptom"> text = <"Modification"> > ["at0017"] = < description = <"An event or activity that makes the symptom worse"> text = <"Change"> > ["at0018"] = < description = <"Information about a specific factor that changes the symptom"> text = <"Modifying factor"> > ["at0019"] = < description = <"An event or activity that modifies the symptom"> text = <"Factor"> > ["at0020"] = < description = <"Symptoms associated with this symptom"> text = <"Associated symptoms"> > ["at0021"] = < description = <"The severity of the symptom"> text = <"Severity"> > ["at0022"] = < description = <"the symptom is not present"> text = <"not present"> > ["at0023"] = < description = <"the symptom does not interfere greatly with day to day activities"> text = <"mild"> > ["at0024"] = < description = <"the symptom interferes with day to day activities"> text = <"moderate"> > ["at0025"] = < description = <"the symptom prohibits some key daily activities"> text = <"severe"> > ["at0026"] = < description = <"A score from 0 (not present) to 10 (as bad as it could be)"> text = <"Visual analogue score"> > ["at0028"] = < description = <"The duration of the symptom since onset"> text = <"Duration"> > ["at0029"] = < description = <"The location(s) of the symptom in the body"> text = <"Location in body"> > ["at0030"] = < description = <"The time (and/or date) of maximum intensity of the symptom"> text = <"Time of maximum intensity"> > ["at0031"] = < description = <"The number of times this symptom has occurred"> text = <"Number of occurrences"> > ["at0032"] = < description = <"The character of the symptom"> text = <"Character"> > ["at0033"] = < description = <"Features of the course of the symptom"> text = <"Course"> > ["at0034"] = < description = <"The features of the symptom"> text = <"Features"> > ["at0035"] = < description = <"The person has not had any significant experience of the symptom."> text = <"Nil significant"> > ["at0036"] = < description = <"Over a short period of time"> text = <"Rapid"> > ["at0037"] = < description = <"The progress of the symptom relative to the past"> text = <"Progression"> > ["at0038"] = < description = <"The symptom has improved over time"> text = <"improving"> > ["at0039"] = < description = <"The symptom is decreasing in intensity over time"> text = <"decreasing"> > ["at0040"] = < description = <"The symptom has not changed over time"> text = <"stable"> > ["at0041"] = < description = <"The symptom is increasing in intensity over time"> text = <"increasing"> > ["at0042"] = < description = <"The symptom is getting worse over time"> text = <"worsening"> > ["at0043"] = < description = <"The symptom has resolved over time"> text = <"has resolved"> > ["at0044"] = < description = <"the symptom is trivial and causes no problems"> text = <"trivial"> > ["at0045"] = < description = <"the symptom is almost maximum possible intensity and prohibits any activity"> text = <"very severe"> > ["at0046"] = < description = <"Measures of the intensity of the symptom at this time"> text = <"Current intensity"> > ["at0047"] = < description = <"The degree the symptom is bothering the patient"> text = <"Degree"> > ["at0048"] = < description = <"The symptom is relieved by this factor"> text = <"Relieved completely"> > ["at0049"] = < description = <"The symptom is made better by this factor"> text = <"Made better"> > ["at0050"] = < description = <"The symptom is somewhat improved by this factor"> text = <"Somewhat improved"> > ["at0051"] = < description = <"The symptom is not modified by this factor"> text = <"No change"> > ["at0052"] = < description = <"The symptom is made somewhat worse by this factor"> text = <"Somewhat worse"> > ["at0053"] = < description = <"The symptom is made worse by this factor"> text = <"Made worse"> > ["at0054"] = < description = <"The symptom is made much worse by this factor"> text = <"Much worse"> > ["at0056"] = < description = <"Details of the effect"> text = <"Details"> > ["at0057"] = < description = <"Details of previous symptoms and comparison to this episode"> text = <"Details"> > ["at0058"] = < description = <"Details about previous episodes"> text = <"Previous episodes"> > ["at0059"] = < description = <"Have there been any previous episodes of this symptom"> text = <"Any previous episodes"> > ["at0060"] = < description = <"Activity or situation at and details of onset"> text = <"Onset description"> > ["at0061"] = < description = <"*"> text = <"Features not present"> > ["at0062"] = < description = <"A feature that is not present"> text = <"Absent feature"> > > > > term_binding = < ["SNOMED-CT"] = < items = < ["at0000"] = <[SNOMED-CT::19019007]> ["at0002"] = <[SNOMED-CT::162408000]> ["at0014"] = <[SNOMED-CT::57465006]> ["at0015"] = <[SNOMED-CT::57465006]> ["at0016"] = <[SNOMED-CT::68027008]> ["at0021"] = <[SNOMED-CT::162465004]> ["at0023"] = <[SNOMED-CT::162468002]> ["at0024"] = <[SNOMED-CT::162469005]> ["at0025"] = <[SNOMED-CT::162470006]> ["at0026"] = <[SNOMED-CT::273903006]> ["at0028"] = <[SNOMED-CT::162442009]> ["at0029"] = <[SNOMED-CT::91722005]> ["at0033"] = <[SNOMED-CT::260908002]> ["at0038"] = <[SNOMED-CT::385633008]> ["at0039"] = <[SNOMED-CT::260371004]> ["at0040"] = <[SNOMED-CT::58158008]> ["at0041"] = <[SNOMED-CT::260369004]> ["at0042"] = <[SNOMED-CT::230993007]> ["at0043"] = <[SNOMED-CT::370996005]> ["at0044"] = <[SNOMED-CT::162466003]> ["at0045"] = <[SNOMED-CT::162471005]> > > >