TEMPLATE no.nrua::openEHR-EHR-COMPOSITION.innkomst.kurs.2025_utvalg.v1.2.0 (no.nrua::openEHR-EHR-COMPOSITION.innkomst.kurs.2025_utvalg.v1.2.0)

TEMPLATE IDno.nrua::openEHR-EHR-COMPOSITION.innkomst.kurs.2025_utvalg.v1.2.0
Conceptno.nrua::openEHR-EHR-COMPOSITION.innkomst.kurs.2025_utvalg.v1.2.0
DescriptionFor å bruke i kurs som et utvalg av en generell semistrukturert innkomstjournal.
UseEt forslag til et templat for en generell semistrukturert innkomstjournal. Dette er et utvalg av hele innkomsten. Templatet inneholder felt for: -ANAMNESE • 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.) • Aktuelt/anamnese inkludert symptomer -STATUS PRESENS • Vitale målinger: BT, • Fysiske undersøklesr: Pulm, -RESYMÉ, VURDERING OG TILTAK • Sammendrag/Resymè
PurposeFor å bruke i kurs som et utvalg av 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=13b06235e0a19951df6e84f8617a3473, sem_ver=56.2.0}
KeywordsInnkomst utvalg, kurs
Language usednb
Citeable Identifier1078.60.1245
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  • Ingen utdanning 
  • Grunnskole 
  • Videregående 
  • Universitet/Høyskole <4 år 
  • Universitet/Høyskole ≥4 år 
  • Ukjent 
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  • smerter 
  • nevrologisk symptom 
  • vekttap 
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  • 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=Undersøkelsesfunn gjort 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]], templateType=normal]