TEMPLATE Utvalg_Innkomstjurnal_KursBergen_v2 (Utvalg_Innkomstjurnal_KursBergen_v2)

TEMPLATE IDUtvalg_Innkomstjurnal_KursBergen_v2
ConceptUtvalg_Innkomstjurnal_KursBergen_v2
DescriptionFor å bruke som en generell semistrukturert innkomstjournal.
UseEt forslag til et templat for en generell semistrukturert innkomstjournal. Templatet inneholder felt for: -ANAMNESE • Problemstilling/Kontaktårsak • Sosialanamnese (utdanning, arbeidsstatus inkludert sykemelding, juridisk sivilstatus, samlivsstatus (ikke juridisk), spørsmål om samlivsform og spørsmål om ansvar for barn under 18 eller voksenpersoner over 18 år). Her er det et standardisert verdisett som vil brukes i det interregionale generelle kreftjornalprosjektet.) • Familieanamnese / hereditet • Komorbiditet/Tidligere sykdommer • Aktuelt/anamnese inkludert symptomer • Naturlige funksjoner • Kartlegging av medikamentbruk (arketype kartleggingsspørsmål om legemidler) • Kartlegging av allergier (arketypen kartleggingsspørsmål om problem/diagnose) • Stimulantia (Et standardisert templat for Stimulantia - alkoholbruk, røyk, røykfri tobakk og andre substanser annet enn alkohol og tobakk.) -STATUS PRESENS •Generell beskrivelse, • Vitale målinger: BT, puls, respirasjon, temp, høyde, vekt, • Fysiske undersøklesr: Pupiller. Cavum oris, Collum. Thorax, Cor, Pulm, Columna, Abdomen, Rektaleksplorasjon, Genitalia externa, Kvinnelige genitalia/GU, Ekstremiteter, Orienterende nevrologi, Status localis. -RESYMÉ, VURDERING OG TILTAK • Sammendrag/Resymè • Problem/diagnose med status • Diffrensialdiagnoser • Funn ved supplerende undersøkelser (lab og rad) • Tiltak og videre plan
PurposeFor å bruke som en generell semistrukturert innkomstjournal.
References
Authorsdate: 2024-01-24; name: Liv Laugen; organisation: Oslo universitetssykehus/NRUA; email: liv.laugen@ous-hf.no
Other Details Languagedate: 2024-01-24; name: Liv Laugen; organisation: Oslo universitetssykehus/NRUA; email: liv.laugen@ous-hf.no
OtherDetails Language Independent{PARENT:MD5-CAM-1.0.1=6562F732112B8B3F94790E178F4243A5, original_language=ISO_639-1::nb, MD5-CAM-1.0.1=862b72710ece331c9125005c505d6ea8, sem_ver=53.0.0}
Language usednb
Citeable Identifier1078.60.1138
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  • Screening
  • Sypmptomer
  • Tilfeldig funn v/bildediagnostikk
  • Kontroll
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  • Ugift 
  • Gift//registrert partner 
  • Enke/enkemann/gjenlevende partner 
  • Skilt 
  • Separert 
  • Ukjent 
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  • Ingen utdanning 
  • Grunnskole 
  • Videregående 
  • Universitet/Høyskole <4 år 
  • Universitet/Høyskole ≥4 år 
  • Ukjent 
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[path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Anamnese']/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom_sign.v2]/items[at0001], code=at0001, itemType=ELEMENT, level=7, text=Navn på symptom/sykdomstegn, description=Navnet på det rapporterte symptomet eller sykdomstegnet., comment=Navnet på symptom/sykdomstegn bør kodes med en terminologi om mulig., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Obligatorisk, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= Terminologi: SNOMED-CT
  • smerter 
  • nevrologisk symptom 
  • vekttap 
  • ingen symptomer 
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Å sette eller legge seg ned virker lindrende.", uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Status presens'], code=at0000, itemType=SECTION, level=1, text=Status presens, description=En generisk seksjonsoverskrift som skal gis nytt navn i en templat for å passe i en gitt klinisk kontekst., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Status presens']/items[openEHR-EHR-SECTION.adhoc.v1], code=at0000, itemType=SECTION, level=2, text=Vitale målinger, description=En generisk seksjonsoverskrift som skal gis nytt navn i en templat for å passe i en gitt klinisk kontekst., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Status presens']/items[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.height.v2], code=at0000, itemType=OBSERVATION, level=3, text=Høyde/Lengde, description=Individets høyde eller lengde målt fra isse til fotsåle., comment=Høyde måles stående og lengde liggende., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Status presens']/items[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.height.v2]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Status presens']/items[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.height.v2]/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=5, text=Innkomst, description=Standard, uspesifisert tidspunkt eller tidsintervall som kan defineres mer eksplisitt i et templat eller i en applikasjon., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Status presens']/items[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.height.v2]/data[at0001]/events[at0002]/data[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=6, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Status presens']/items[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.height.v2]/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=7, text=Høyde (cm), description=Høyde/lengde fra isse til fotsåle., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Obligatorisk, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=58..350 cm, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Status presens']/items[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.body_weight.v2], code=at0000, itemType=OBSERVATION, level=3, text=Kroppsvekt, description=Individets kroppsvekt., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Status presens']/items[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.body_weight.v2]/data[at0002], code=at0002, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Status presens']/items[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.body_weight.v2]/data[at0002]/events[at0003], code=at0003, itemType=EVENT, level=5, text=Innkomst, description=Standard, uspesifisert tidspunkt eller tidsintervall som kan defineres mer eksplisitt i et templat eller i en applikasjon., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Status presens']/items[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.body_weight.v2]/data[at0002]/events[at0003]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=6, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Status presens']/items[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.body_weight.v2]/data[at0002]/events[at0003]/data[at0001]/items[at0004], code=at0004, itemType=ELEMENT, level=7, text=Vekt, description=Et individs totale kroppsmasse., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Obligatorisk, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=0..500; 0..5000
Enheter:
  • kg
  • g
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Status presens']/items[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.body_weight.v2]/data[at0002]/events[at0003]/state[at0008], code=at0008, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=6, text=State, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Status presens']/items[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.body_weight.v2]/data[at0002]/events[at0003]/state[at0008]/items[at0009], code=at0009, itemType=ELEMENT, level=7, text=Påkledning, description=Beskrivelse av personens påkledning på måletidspunktet., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Naken 
  • Bleie 
  • Lette klær / undertøy 
  • Fullt påkledt, uten sko 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Status presens']/items[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.body_mass_index.v2], code=at0000, itemType=OBSERVATION, level=3, text=Kroppsmasseindeks, description=Beregnet verdi som gjenspeiler individets kroppsmasse på grunnlag av dens høyde og vekt., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Status presens']/items[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.body_mass_index.v2]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Status presens']/items[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.body_mass_index.v2]/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=5, text=Innkomst, description=Standard, uspesifisert tidspunkt eller tidsintervall som kan defineres mer eksplisitt i en template eller i en applikasjon., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Status presens']/items[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.body_mass_index.v2]/data[at0001]/events[at0002]/data[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=6, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Status presens']/items[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.body_mass_index.v2]/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=7, text=Kroppsmasseindeks, description=Indeks som beskriver forholdet mellom vekt og høyde., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Obligatorisk, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=0..1000 kg/m², extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Status presens']/items[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.blood_pressure.v2], code=at0000, itemType=OBSERVATION, level=3, text=Blodtrykk, description=Måling av blodtrykket som uttrykk for det arterielle blodtrykk i det systemiske kretsløp., comment=Vanligvis brukes begrepet "blodtrykk" om måling av brakialt arterietrykk i overarmen., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Status presens']/items[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.blood_pressure.v2]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Data, description=History Structural node., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Status presens']/items[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.blood_pressure.v2]/data[at0001]/events[at0006], code=at0006, itemType=EVENT, level=5, text=Innkomst, description=Standard, uspesifisert tidspunkt eller tidsintervall som kan defineres mer eksplisitt i et templat eller i en applikasjon., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Valgfritt, gjentagende, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Status presens']/items[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.blood_pressure.v2]/data[at0001]/events[at0006]/data[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=6, text=Data, description=*@ internal @(en), comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Status presens']/items[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.blood_pressure.v2]/data[at0001]/events[at0006]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=7, text=Systolisk blodtrykk, description=Maksimalt systemisk arterielt blodtrykk - målt i systolen, det vil si i hjertets kontraksjonsfase., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=0..450 mmHg, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Status presens']/items[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.blood_pressure.v2]/data[at0001]/events[at0006]/data[at0003]/items[at0005], code=at0005, itemType=ELEMENT, level=7, text=Diastolisk blodtrykk, description=Laveste systemiske arterielle blodtrykk - målt i diastolen, det vil si under hjertets relaksasjonsfase., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=0..350 mmHg, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Status presens']/items[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.blood_pressure.v2]/data[at0001]/events[at0006]/state[at0007], code=at0007, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=6, text=State, description=*@ internal @(en), comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Status presens']/items[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.blood_pressure.v2]/data[at0001]/events[at0006]/state[at0007]/items[at0008], code=at0008, itemType=ELEMENT, level=7, text=Stilling, description=Individets posisjon ved tidspunktet for målingen., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Sittende 
  • Liggende 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Status presens']/items[openEHR-EHR-OBSERVATION.exam.v1], code=at0000, itemType=OBSERVATION, level=2, text=Fysisk undersøkelse, description=Funn ved fysisk undersøkelse av en helsetjenestemottaker., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Status presens']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Status presens']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=4, text=Innkomst, description=Standard, uspesifisert tidspunkt eller tidsintervall som kan defineres mer eksplisitt i en template eller i en applikasjon., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Status presens']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=5, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Status presens']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=6, text=Overordnet beskrivelse av fysisk undersøkelse, description=Fritekstbeskrivelse av funn ved en klinisk undersøkelse av et individ., comment=Kan anvendes til å registrere en tekstlig sammenfatning av en komplett klinisk undersøkelse eller nøkkelfunn ved den kliniske undersøkelsen, som vil bli understøttet av strukturerte data. Dette dataelementet kan brukes for å fange opp "legacy data" som ikke er tilgjengelig i et strukturert format. Detaljer om spesifikt strukturert funn inkluderes ved å bruke CLUSTER-arketyper i "Examination Detail" SLOT., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Status presens']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam.v2], code=at0000, itemType=CLUSTER, level=6, text=Pulm (lunge), description=Funn ved fysisk undersøkelse av et organsystem eller anatomisk struktur., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Status presens']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam.v2]/items[at0001], code=at0001, itemType=ELEMENT, level=7, text=Pulm (lunge), description=Identifisering av det undersøkte organsystemet eller den anatomiske strukturen., comment=Det anbefales å kode organsystem eller den anatomiske strukturen med en terminologi dersom mulig., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Obligatorisk, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= Terminologi: SNOMED-CT
  • Pulm (lunge) 

Standard verdi: Pulm (lunge), extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Status presens']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam.v2]/items[at0003], code=at0003, itemType=ELEMENT, level=7, text=Klinisk beskrivelse, description=Fritekstbeskrivelse av de overordnede funnene ved den fysiske undersøkelsen., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Resymé, vurdering og tiltak'], code=at0000, itemType=SECTION, level=1, text=Resymé, vurdering og tiltak, description=En generisk seksjonsoverskrift som skal gis nytt navn i en templat for å passe i en gitt klinisk kontekst., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Resymé, vurdering og tiltak']/items[openEHR-EHR-EVALUATION.clinical_synopsis.v1], code=at0000, itemType=EVALUATION, level=2, text=Sammendrag/resymé, description=Fritekstsammendrag eller oversikt om en pasient fra helsepersonellets perspektiv, med eller uten tilhørende fortolkninger., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Resymé, vurdering og tiltak']/items[openEHR-EHR-EVALUATION.clinical_synopsis.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Resymé, vurdering og tiltak']/items[openEHR-EHR-EVALUATION.clinical_synopsis.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Sammendrag/resymé, description=Oppsummering, vurdering, konklusjoner eller evaluering av de kliniske funnene., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Obligatorisk, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Resymé, vurdering og tiltak']/items[openEHR-EHR-OBSERVATION.progress_note.v1], code=at0000, itemType=OBSERVATION, level=2, text=Tiltak og videre plan, description=Fritekstbeskrivelse av et individs helserelaterte hendelser på et spesifikt tidspunkt, sett fra helsepersonellets synsvinkel., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Resymé, vurdering og tiltak']/items[openEHR-EHR-OBSERVATION.progress_note.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Resymé, vurdering og tiltak']/items[openEHR-EHR-OBSERVATION.progress_note.v1]/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=4, text=Innkomst, description=Standard, uspesifisert tidspunkt eller tidsintervall som kan defineres mer eksplisitt i en template eller i en applikasjon., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Resymé, vurdering og tiltak']/items[openEHR-EHR-OBSERVATION.progress_note.v1]/data[at0001]/events[at0002]/data[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=5, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Resymé, vurdering og tiltak']/items[openEHR-EHR-OBSERVATION.progress_note.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=6, text=Tiltak og videre plan, description=Fritekstbeskrivelse av helserelaterte hendelser, status, funn eller oppfatninger på et spesifikt tidspunkt., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null]], templateType=normal]