TEMPLATE Smerteregisteret Behandlerdel 2.2 (117f475a-a5d7-4802-a77b-979e4217185a)

TEMPLATE ID117f475a-a5d7-4802-a77b-979e4217185a
ConceptSmerteregisteret Behandlerdel 2.2
DescriptionNot Specified
PurposeNot Specified
References
Authorsdate: 2018-11-21; name: Silje Ljosland Bakke; organisation: Nasjonal IKT HF; email: silje.ljosland.bakke@nasjonalikt.no
Other Details Languagedate: 2018-11-21; name: Silje Ljosland Bakke; organisation: Nasjonal IKT HF; email: silje.ljosland.bakke@nasjonalikt.no
OtherDetails Language Independent{licence=licence, custodian_organisation=custodian_organisation, PARENT:MD5-CAM-1.0.1=PARENT:MD5-CAM-1.0.1, original_namespace=original_namespace, original_publisher=original_publisher, custodian_namespace=custodian_namespace, MD5-CAM-1.0.1=MD5-CAM-1.0.1}
Language usednb
Citeable Identifier1078.60.789
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  • 0: Nei  [*]
  • 1: Ja  [*]
  • 9: Vet ikke  [*]
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  • Opioider  [F.eks Morfin, Oxynorm, Fentanyl, Metadon, Subutex, Tramadol, Paralgin forte.]
  • Non-opioider  [F.eks Paracet, Nsaids, Cox-2 hemmere.]
  • Ko-analgetika  [F.eks: Lyrica, Neurontin, Sarotex, Noritren, Cymbalta, Efexor, Klonidin, Ketalar, Ketamin og Steroider (brukt i forbindelse med smertebehandling).]
  • Benzodiazepiner  [F.eks: Sobril, Stesolid, Xanor, Vival, Diazepam, Oxazepam.]
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  • 0: Nei  [*]
  • 1: Ja  [*]
  • 9: Vet ikke  [*]
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  • Ingen  [*]
  • Oksygenbehandling  [*]
  • Motgift  [*]
  • Forsterket overvåkning  [*]
  • Intensivbehandling  [*]
  • Resusitering  [*]
  • Respiratorbehandling  [*]
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  • 0: Nei  [*]
  • 1: Ja  [*]
  • 9: Vet ikke  [*]
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  • 0: Nei  [*]
  • 1: Ja  [*]
  • 9: Vet ikke  [*]
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  • 0: Nei  [*]
  • 1: Ja  [*]
  • 9: Vet ikke  [*]
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  • Epidural  [*]
  • Spinal  [*]
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  • Opioider  [*]
  • Lokal anestesi  [*]
  • Ko-analgetika  [*]
  • Annet  [*]
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  • 0: Nei  [*]
  • 1: Ja  [*]
  • 9: Vet ikke  [*]
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  • Intraspinalt/epiduralt hematom  [*]
  • Meningitt  [*]
  • Epidural abscess  [*]
  • Nerveskader  [*]
  • Migrering av kateter fra epiduralt til spinalt  [*]
  • Intravasal injeksjon av lokalanestesi  [*]
  • Postspinal hodepine  [*]
  • Falltendens pga lokalanestesi  [*]
  • Lekkasje av CNF  [*]
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  • Ingen  [*]
  • Operasjon  [*]
  • Antibiotikabehandling  [*]
  • Fjerning av kateter  [*]
  • Bloodpatch  [*]
  • Sengeleie  [*]
  • Fenazon/koffein  [*]
  • Endring av medikament  [*]
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  • 0: Nei  [*]
  • 1: Ja  [*]
  • 9: Vet ikke  [*]
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  • Plexus brachialis blokade  [*]
  • Paravertebral blokade  [*]
  • Intercostal blokade  [*]
  • PECS blokade(Pectoral nerve)  [*]
  • TAP blokade (Transversus abdominis plan)  [*]
  • Femoral blokade  [*]
  • Adduktor kanal blokade  [*]
  • Ischiadicus blokade  [*]
  • Plexus Lumbalis blokade  [*]
  • Fascia iliaca compartment blokade  [*]
  • Serratus plane Block  [*]
  • Annen blokade  [*]
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  • Interscalen  [*]
  • Supraklavikulær  [*]
  • Infraklavikulær  [*]
  • Axillær  [*]
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  • Underkategori 1  [*]
  • Underkategori 2  [*]
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  • Subgluteal  [*]
  • Poplitea  [*]
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  • Singelshot  [*]
  • Infusjon  [*]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-EVALUATION.beh_tilsyn_smerteregisteret.v0]/data[at0001]/items[at0027]/items[at0080]/items[at0108], code=at0108, itemType=ELEMENT, level=5, text=Har det oppstått alvorlige komplikasjoner pga denne behandlingen?, description=Gjelder for all form for medikamentell smertebehandling (iv, sc, po, plaster, PCA, etc). Ved "Ja": Kryss av én eller flere valgmuligheter Ved avkrysning av opioid: Har det oppstått alvorlig respirasjonsdepresjon? Hva er alvorlig respirasjonsdepresjon? Respirasjon < 8/min, comment=OBS! Skal kun krysses av dersom respirasjonsdepresjon har oppstått etter behandling initiert av Smerteteam. Respirasjonsdepresjon i forkant av behandling initiert av Smerteteam skal ikke registreres her., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_ORDINAL, bindings=null, values=
  • 0: Nei  [*]
  • 1: Ja  [*]
  • 9: Vet ikke  [*]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-EVALUATION.beh_tilsyn_smerteregisteret.v0]/data[at0001]/items[at0027]/items[at0080]/items[at0112], code=at0112, itemType=ELEMENT, level=5, text=Hvilke komplikasjoner?, description=*, comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Valgfritt, gjentagende, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Nerveskade  [*]
  • Infeksjon  [*]
  • Intravasal injeksjon av lokalanestesi  [*]
  • Intoksikasjon  [*]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-EVALUATION.beh_tilsyn_smerteregisteret.v0]/data[at0001]/items[at0027]/items[at0080]/items[at0117], code=at0117, itemType=ELEMENT, level=5, text=Hvilke tiltak er iverksatt?, description=*, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Ingen  [*]
  • Operasjon  [*]
  • Antibiotikabehandling  [*]
  • Fjerning av kateter  [*]
  • Endret medisinering og intensivmedisinske tiltak  [*]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-EVALUATION.beh_tilsyn_smerteregisteret.v0]/data[at0001]/items[at0028], code=at0028, itemType=CLUSTER, level=3, text=2. Behandler av smertetilstand, description=En kan krysse av for flere behandlere. Her oppføres hvem som faktisk har vært involvert i pasientbehandlingen og hvor mye ressurser som ble brukt. Antall tilsyn i denne kategorien kan avvike fra antall tilsyn i spørsmål 3 om antall pasienttilsyn. Presisering: Dersom både lege/LIS og sykepleier har vært hos pasient på tilsyn, registreres det som et legetilsyn og et sykepleietilsyn i spørsmål 1, dersom en anser det som nødvendig for pasientbehandlingen at begge to er med. En LIS-lege som følger en overlege pga opplæring registrers ikke som ekstra legetilsyn. I spørsmål 3 telles det derimot kun som 1 tilsyn. Ved vaktromtilsyn skal det ikke registreres tilsyn i spørsmål 3., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Obligatorisk, 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-EVALUATION.beh_tilsyn_smerteregisteret.v0]/data[at0001]/items[at0028]/items[at0123], code=at0123, itemType=ELEMENT, level=4, text=Behandler av smertetilstand, description=*, comment=null, uncommonOntologyItems=null, occurencesFormal=1..*, occurencesText=Obligatorisk, gjentagende, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Lege  [*]
  • Sykepleier  [*]
  • Fysioterapeut  [*]
  • Psykolog  [*]
  • Sosionom  [*]
  • Ambulerende lege  [*]
  • Ambulerende sykepleier  [*]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-EVALUATION.beh_tilsyn_smerteregisteret.v0]/data[at0001]/items[at0028]/items[at0131 and name/value='Antall tilsyn lege'], code=at0131, itemType=ELEMENT, level=4, text=Antall tilsyn lege, description=*, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=1..100, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-EVALUATION.beh_tilsyn_smerteregisteret.v0]/data[at0001]/items[at0028]/items[at0131 and name/value='Antall tilsyn sykepleier'], code=at0131, itemType=ELEMENT, level=4, text=Antall tilsyn sykepleier, description=*, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=1..100, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-EVALUATION.beh_tilsyn_smerteregisteret.v0]/data[at0001]/items[at0028]/items[at0131 and name/value='Antall tilsyn fysioterapeut'], code=at0131, itemType=ELEMENT, level=4, text=Antall tilsyn fysioterapeut, description=*, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=1..100, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-EVALUATION.beh_tilsyn_smerteregisteret.v0]/data[at0001]/items[at0028]/items[at0131 and name/value='Antall tilsyn psykolog'], code=at0131, itemType=ELEMENT, level=4, text=Antall tilsyn psykolog, description=*, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=1..100, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-EVALUATION.beh_tilsyn_smerteregisteret.v0]/data[at0001]/items[at0028]/items[at0131 and name/value='Antall tilsyn sosionom'], code=at0131, itemType=ELEMENT, level=4, text=Antall tilsyn sosionom, description=*, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=1..100, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-EVALUATION.beh_tilsyn_smerteregisteret.v0]/data[at0001]/items[at0028]/items[at0131 and name/value='Antall tilsyn ambulerende lege'], code=at0131, itemType=ELEMENT, level=4, text=Antall tilsyn ambulerende lege, description=*, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=1..100, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-EVALUATION.beh_tilsyn_smerteregisteret.v0]/data[at0001]/items[at0028]/items[at0131 and name/value='Antall tilsyn ambulerende sykepleier'], code=at0131, itemType=ELEMENT, level=4, text=Antall tilsyn ambulerende sykepleier, description=*, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=1..100, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-EVALUATION.beh_tilsyn_smerteregisteret.v0]/data[at0001]/items[at0028]/items[at0139], code=at0139, itemType=ELEMENT, level=4, text=Antall pasienttilsyn, description=Antall ganger pasienten har møtt personale fra smerteklinikken., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Obligatorisk, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=>=0, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-EVALUATION.beh_tilsyn_smerteregisteret.v0]/data[at0001]/items[at0028]/items[at0141], code=at0141, itemType=ELEMENT, level=4, text=Total tidsbruk, description=Tidsbruk beregnes ut fra ALLE tilsyn fra ALLE involverte behandlere gjennom hele behandlingsforløpet., comment=Et behandlertilsyn regnes som 1 time. Dette inkluderer: Tilsyn av pasient Tidsbruk forbundet med lesing av journal Kontakt med leg/sykepleier på sengepost Råd gitt på telefon Skriving av journalnotat ol., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Obligatorisk, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DURATION, bindings=null, values=Enheter: Minute, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-EVALUATION.beh_tilsyn_smerteregisteret.v0]/data[at0001]/items[at0149], code=at0149, itemType=ELEMENT, level=3, text=5. Bør pasient følges videre opp for sin smertetilstand etter utskrivelse?, description=*, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_ORDINAL, bindings=null, values=
  • 0: Nei  [*]
  • 1: Ja  [*]
  • 9: Vet ikke  [*]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-EVALUATION.beh_tilsyn_smerteregisteret.v0]/data[at0001]/items[at0151], code=at0151, itemType=ELEMENT, level=3, text=5a. Er det anbefalt videre oppfølging hos fastlege?, description=*, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_ORDINAL, bindings=null, values=
  • 0: Nei  [*]
  • 1: Ja, formidlet via tilsynsnotat/epikrise  [*]
  • 2: Kontaktet direkte skriftlig og/eller muntlig  [*]
  • 3: Usikker  [*]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-EVALUATION.beh_tilsyn_smerteregisteret.v0]/data[at0001]/items[at0152], code=at0152, itemType=ELEMENT, level=3, text=5b. Er det anbefalt videre oppfølging hos annen institusjon, description=*, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_ORDINAL, bindings=null, values=
  • 0: Nei  [*]
  • 1: Ja, formidlet via tilsynsnotat/epikrise  [*]
  • 2: Kontaktet direkte skriftlig og/eller muntlig  [*]
  • 3: Usikker  [*]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-EVALUATION.beh_tilsyn_smerteregisteret.v0]/data[at0001]/items[at0150], code=at0150, itemType=ELEMENT, level=3, text=6. Anbefalt videre oppfølging ved smerteklinikk?, description=*, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_ORDINAL, bindings=null, values=
  • 0: Nei  [*]
  • 1: Ja  [*]
  • 9: Vet ikke  [*]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-EVALUATION.beh_tilsyn_smerteregisteret.v0]/protocol[at0010], code=at0010, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=2, text=Protocol, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null]], templateType=normal]