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• IG © 2025+ HL7 International / Clinical Interoperability Council. Package hl7.fhir.uv.symptoms#1.0.0-ballot based on FHIR 4.0.1. Generated 2025-12-17 Links: Table of Contents | QA Report | Version History | CC0 | Propose a change ( src )
• hl7.fhir.us.hai: Healthcare Associated Infection Implementation Guide ®© HL7 | CC0 ( src )
• Copyright/Legal: This material contains content from LOINC (http://loinc.org). LOINC is copyright © 1995-2020, Regenstrief Institute, Inc. and the Logical Observation Identifiers Names and Codes (LOINC) Committee and is available at no cost under the license at http://loinc.org/license. LOINC® is a registered United States trademark of Regenstrief Institute, Inc ( src )
• Copyright/Legal: This value set includes content from SNOMED CT, which is copyright © 2002+ International Health Terminology Standards Development Organisation (IHTSDO), and distributed by agreement between IHTSDO and HL7. Implementer use of SNOMED CT is not covered by this agreement ( src )
• Copyright/Legal: © openEHR Foundation. 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/. ( src )
• Copyright/Legal: © openEHR Foundation. This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/. This artefact includes content from SNOMED Clinical Terms® (SNOMED CT®) which is copyrighted material of the International Health Terminology Standards Development Organisation (IHTSDO). Where an implementation of this artefact makes use of SNOMED CT content, the implementer must have the appropriate SNOMED CT Affiliate license - for more information contact http://www.snomed.org/snomed-ct/get-snomed or info@snomed.org. ( src )
• FHIR R4 Symptoms Implementation Guide, published by HL7 International / Clinical Interoperability Council. This guide is not an authorized publication; it is the continuous build for version 1.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-symptoms-ig/ and changes regularly. See the Directory of published versions ( src )
• The HL7 International IPS implementation guides incorporate SNOMED CT®, used by permission of the International Health Terminology Standards Development Organisation, trading as SNOMED International. SNOMED CT was originally created by the College of American Pathologists. SNOMED CT is a registered trademark of the International Health Terminology Standards Development Organisation, all rights reserved. Implementers of SNOMED CT should review usage terms or directly contact SNOMED International: info@snomed.org ( src )
• This material contains content from LOINC (http://loinc.org). LOINC is copyright © 1995-2020, Regenstrief Institute, Inc. and the Logical Observation Identifiers Names and Codes (LOINC) Committee and is available at no cost under the license at http://loinc.org/license. LOINC® is a registered United States trademark of Regenstrief Institute, Inc ( src )
• This material contains content from LOINC. LOINC is copyright © 1995-2020, Regenstrief Institute, Inc. and the Logical Observation Identifiers Names and Codes (LOINC) Committee and is available at no cost under the license. LOINC® is a registered United States trademark of Regenstrief Institute, Inc. Show Usage * LOINC: AffectiveGrade, Observation/AbdominalDiscomfortSymptom... Show 30 more , Observation/AbdominalPainSymptom, Observation/AppetiteFunctionalAssessmentCollection, Observation/AppetiteFunctionalAssessmentScale, Observation/ChestPainSymptom, Observation/ChillSymptomAbsence, Observation/ConstipationSymptom, Observation/CoughSymptom, Observation/DizzinessSymptom, Observation/FaintingSymptomAbsence, Observation/FatigueSymptom, Observation/FeverSymptom, Observation/FeverSymptomAbsence, Observation/HearingLossSymptom, Observation/InitialPainAssessmentCollection, Observation/InitialPainAssessmentScale, Observation/MedicatedAbdominalPainSymptom, Observation/MedicatedPainAssessmentCollection, Observation/MedicatedPainAssessmentScale, Observation/NauseaSymptomAbsence, Observation/RectalBleedingSymptomAbsence, Observation/ShortnessOfBreathPHSymptom, Observation/ShortnessOfBreathSymptom, Observation/UnconsciousnessSymptomAbsence, Observation/UnmedicatedAbdominalPainSymptom, Observation/UnmedicatedPainAssessmentCollection, Observation/UnmedicatedPainAssessmentScale, Observation/WeightLossSymptom, OtherEventCodes, SymptomAbsentObservation and SymptomObservation ( src )
• This material derives from the HL7 Terminology (THO). THO is copyright ©1989+ Health Level Seven International and is made available under the CC0 designation. For more licensing information see: https://terminology.hl7.org/license.html Show Usage * Observation Category Codes: AssessmentScaleCollection, AssessmentScaleObservation... Show 10 more , FunctionalAssessmentCollection, FunctionalAssessmentObservation, Observation/AppetiteFunctionalAssessmentCollection, Observation/AppetiteFunctionalAssessmentScale, Observation/InitialPainAssessmentCollection, Observation/InitialPainAssessmentScale, Observation/MedicatedPainAssessmentCollection, Observation/MedicatedPainAssessmentScale, Observation/UnmedicatedPainAssessmentCollection and Observation/UnmedicatedPainAssessmentScale ( src )
• archetype (adl_version=1.4; rm_release=1.1.0; uid=88c7d677-fa69-498f-aec2-976c53d15a6f) openEHR-EHR-CLUSTER.symptom_sign.v2 concept [at0000] -- Symptom/Sign language original_language = <[ISO_639-1::en]> translations = < ["de"] = < language = <[ISO_639-1::de]> author = < ["name"] = <"Sebastian Garde, Kim Sommer, Natalia Strauch, Alina Rehberg"> ["organisation"] = <"University of Heidelberg, Central Queensland University, Medizinische Hochschule Hannover"> ["email"] = <"Strauch.Natalia@mh-hannover.de, rehberg.alina@mh-hannover.de"> > > ["fi"] = < language = <[ISO_639-1::fi]> author = < ["name"] = <"Kalle Vuorinen"> ["organisation"] = <"Tieto Healthcare & Welfare Oy"> ["email"] = <"kalle.vuorinen@tieto.com"> > > ["sv"] = < language = <[ISO_639-1::sv]> author = < ["name"] = <"Kirsi Poikela; Erik Sundvall, Jörgen Kuylenstierna"> ["organisation"] = <"Tieto Sweden AB; Karolinska Institutet, Karolinska University Hospital, Region Stockholm + Linköping University, Karolinska Institutet + Karolinska University Hospital, Region Stockholm + Linköping University, eWeave AB"> ["email"] = <"ext.kirsi.poikela@tieto.com, erik.sundvall@regionstockholm.se, jorgen.kuylenstierna@solvikshalsan.se"> > > ["nb"] = < language = <[ISO_639-1::nb]> author = < ["name"] = <"Lars Bitsch-Larsen, Silje Ljosland Bakke"> ["organisation"] = <"Haukeland University Hospital of Bergen, Norway, Helse Vest IKT AS"> ["email"] = <"lbla@helse-bergen.no, silje.ljosland.bakke@helse-vest-ikt.no"> > accreditation = <"MD, DEAA, MBA, spec in anesthesia, spec in tropical medicine."> > ["pt-br"] = < language = <[ISO_639-1::pt-br]> author = < ["name"] = <"Vladimir Pizzo"> ["organisation"] = <"Hospital Sirio Libanes - Brazil"> ["email"] = <"vladimir.pizzo@hsl.org.br"> > > ["ar-sy"] = < language = <[ISO_639-1::ar-sy]> author = < ["name"] = <"Mona Saleh"> > > ["nl"] = < language = <[ISO_639-1::nl]> author = < ["name"] = <"Joost Holslag"> ["organisation"] = <"Nedap"> ["email"] = <"joost.holslag@nedap.com"> > accreditation = <"MD"> > > description original_author = < ["name"] = <"Tony Shannon"> ["organisation"] = <"UK NHS, Connecting for Health"> ["email"] = <"tony.shannon@nhs.net"> ["date"] = <"2007-02-20"> > details = < ["de"] = < language = <[ISO_639-1::de]> purpose = <"Zur Darstellung von Details über eine einzelne Episode eines berichteten Symptoms oder Krankheitsanzeichens einschließlich des Kontexts. Details zu früheren Episoden sollen, wenn angemessen, nicht aufgeführt werden."> use = <"Zu Verwenden, um Details über eine einzelne Episode eines Symptoms oder eines berichteten Krankheitsanzeichens einer Person zu dokumentieren, wie es von der Person, dem Elternteil, dem Betreuer oder einer anderen Partei berichtet wurde. Es kann von einem Arzt als Teil einer Krankengeschichte dokumentiert werden, oder wie es dem Arzt berichtet wurde/wie er es beobachtet hat, oder als Teil eines selbst aufgezeichneten klinischen Fragebogens oder einer persönlichen Gesundheitsakte. Eine vollständige Kranken- oder Patientengeschichet kann mehrere Episoden eines identifizierten Symptoms/Krankheitsanzeichens, mit variierendem Detaillierungsgrad, sowie mehrere Symptome/Krankheitsanzeichen beinhalten. Dieser Archetyp wurde entwickelt, um das positive Vorhandensein des Symptoms oder Krankheitsanzeichens als Teil der Anamneseerhebung mit OBSERVATION.story oder in Verbindung mit einer positiven Reaktion auf OBSERVATION.symptom_sign_screening darzustellen. Im reinsten Sinne sind Symptome subjektive Beobachtungen einer körperlichen oder geistigen Störung und Krankheitsanzeichen sind objektive Beobachtungen dieser Störung, wie sie von einer Person erlebt und dem Dokumentierenden von derselben Person oder einer anderen Partei berichtet werden. Aus dieser Logik folgt, dass zwei Archetypen benötigt werden, um die Krankengeschichte aufzuzeichnen - einen für berichtete Symptome und einen weiteren für berichtete Krankheitsanzeichen. Für die Praxis ist dies ungeeignet, da es die Eingabe klinischer Daten in eines der beiden Modelle erfordert, was den Modellierern und denen, die die Daten eingeben, erheblichen Mehraufwand verursacht. Darüber hinaus gibt es oft Überschneidungen von klinischen Konzepten - z.B. ist vorangegangenes Erbrechen oder sind Blutungen als Symptom oder berichtetes Krankheitsanzeichen zu kategorisieren? Als Antwort darauf wurde dieser Archetyp speziell entwickelt, um ein einziges Informationsmodell zu erproben, das es ermöglicht, das gesamte Spektrum von klar identifizierbaren Symptomen bis hin zu berichteten Krankheitsanzeichen bei der Dokumentation einer Krankengeschichte zu erfassen. Dieser Archetyp wurde als generisches Muster für alle Symptome und Krankheitsanzeichen entwickelt. Der Slot \"Spezifische Details\" kann verwendet werden, um den Archetyp um zusätzliche, spezifische Datenelemente für komplexere Symptome oder Krankheitsanzeichen zu erweitern. Dieser Archetyp wurde speziell für die Verwendung im Slot \"Strukturiertes Detail\" innerhalb des Archetyps OBSERVATION.story entwickelt, kann aber auch in anderen OBSERVATION- oder CLUSTER-Archetypen und in den Slots \"Assoziierte Symptome/Krankheitsanzeichen\" oder \"Vorangegangene Episoden\" in anderen Instanzen dieses CLUSTER.symptom_sign Archetyps verwendet werden."> keywords = <"Beschwerde", "Symptom", "Störung", "Problem", "vorlegende Beschwerde", "vorlegendes Symptom", "Zeichen", "Anzeichen", "Krankheitsanzeichen"> misuse = <"Den Archetyp nicht verwenden, um Antworten auf Screening-Fragebögen über das Vorhandensein oder Nichtvorhandensein bestimmter Symptome abzufragen – verwenden Sie für diesen Zweck den Archetyp OBSERVATION.symptom_sign_screening. Dieser CLUSTER.symptom_sign kann jedoch im SLOT „Screening-Details“ im Archetyp OBSERVATION.symptom_sign_screening verschachtelt werden, wenn es notwendig ist, den Fragebogen zu erweitern, indem Details zu Symptomen oder Anzeichen aufgezeichnet werden. Den Archetyp nicht verwenden, um darzustellen, dass ein Symptom oder Anzeichen explizit als nicht vorhanden gemeldet wurde – verwenden Sie CLUSTER.exclusion_symptom_sign mit Bedacht für bestimmte Zwecke, bei denen der Overhead der Aufzeichnung auf diese Weise die zusätzliche Komplexität rechtfertigt. Nicht zur Erfassung objektiver Befunde im Rahmen einer körperlichen Untersuchung verwenden - verwenden Sie zu diesem Zweck OBSERVATION.exam und mit Untersuchung verwandte CLUSTER-Archetypen. Nicht für Diagnosen und Probleme, die Teil einer bestehenden Problemliste sind, verwenden - verwenden Sie EVALUATION.problem_diagnosis. Nicht zur Darstellung einer formalen und wiederholbaren Schweregradskala wie VAS oder NRS verwenden. Verwenden Sie zu diesem Zweck geeignete OBSERVATION-Archetypen."> copyright = <"© openEHR Foundation"> > ["sv"] = < language = <[ISO_639-1::sv]> purpose = <"För att registrera detaljer om en enskild episod av ett rapporterat symptom eller tecken inklusive dess sammanhang, men inte detaljer om tidigare episoder, om så är lämpligt"> use = <"Används för att registrera detaljer om en enskild episod av ett symptom eller rapporterat tecken hos en individ, som det rapporterats av individen, föräldern, vårdgivaren eller annan part. Det kan registreras av en läkare som en del av en journal dokumentation som rapporterats till dem, observerad av läkaren eller självregistrerad som en del av ett kliniskt frågeformulär eller personlig journal. En fullständig klinisk historia eller patientberättelse kan innehålla varierande nivå av detaljer om flera episoder av ett identifierat symptom eller rapporterat tecken, såväl som flera symtom/tecken. Den här arketypen har utformats för att registrera förekomsten av symtomet eller tecknet som en del av historiken med OBSERVATION.story, eller i samband med ett positivt svar vid användningen av OBSERVATION.symptom_sign_screening. I sin renaste mening är symtom subjektiva observationer av en fysisk eller psykisk störning och tecken är objektiva observationer av detsamma, som upplevs av en individ och rapporteras till vårdgivaren för samma individ eller annan part. Av denna logik följer att vi kommer att behöva två arketyper för att registrera den kliniska historiken - en för rapporterade symtom och en annan för rapporterade tecken. I verkligheten är detta opraktiskt eftersom det kommer att kräva inmatning av kliniska data i någon av dessa modeller, vilket lägger till betydande omkostnader för modellerare och de som matar in data. Dessutom finns det ofta en överlappning i mellan olika kliniska begrepp. Är till exempel, tidigare kräkningar eller blödningar att kategoriseras som ett symptom eller rapporterat tecken? Som svar på detta, har denna arketyp utformats specifikt för att tillhandahålla en enda informationsmodell som möjliggör registrering av ett sammanhängande flöde mellan tydligt identifierbara symtom och rapporterade tecken. Denna arketyp är avsedd för att kunna användas som en generisk modell för alla symtom och rapporterade tecken.'Specific details' SLOT kan användas för att utöka arketypen till att inkludera ytterligare, specifika dataelement för mer komplexa symtom eller tecken. Denna arketyp har utformats specifikt för att användas i \"Structured detail\" SLOT inom arketypen OBSERVATION.story, men kan också användas inom andra OBSERVATION eller CLUSTER arketyper och i \"Associated symptom/tecken\" eller \"Previous episode\" SLOT, såväl som även nom andra instanser av denna CLUSTER.symptom_sign-arketyp. "> keywords = <"klagomål", "symptom", "störning", "besvär", "problem", "obehag", "framföra besvär", "framföra symtom", "tecken"> misuse = <"Får inte användas för att registrera svar från screening frågeformulär om närvaro eller frånvaro av specifika symptom.Använd då istället arketypen OBSERVATION.symptom_sign_screening för detta ändamål. Emellertid kan den här CLUSTER.symptom_sign-arketypen vara inkapslad i \"Screening details\" SLOT i arketypen OBSERVATION.symptom_sign_screening om det är nödvändigt att utöka frågeformuläret genom att registrera detaljer om symptom eller tecken. Ska inte användas för att registrera ett specifikt symptom eller tecken som inte är närvarande. Använd istället arketypen CLUSTER.exclusion_symptom_sign på ett noggrant sätt för att motivera det övergripande syftet för denna registrering och därmed den ökade komplexitet. Får inte användas för att registrera objektiva fynd som en del av en fysisk undersökning , Använd istället arketypen OBSERVATION.exam och relaterade undersökningar i CLUSTER-arketyper för detta ändamål. Ska inte användas för diagnoser och problem som ingår i en kvarstående problemlista. Använd istället arketypen EVALUATION.problem_diagnosis. Ska inte användas för att registrera en accepterad och repeterbar svårighetsskala som VAS eller NRS. Använd lämpliga OBSERVATIONSarketyper för detta ändamål."> > ["fi"] = < language = <[ISO_639-1::fi]> purpose = <"*To record details about a single episode of a reported symptom or sign including context, but not details, of previous episodes if appropriate.(en)"> use = <"*Use to record details about a single episode of a symptom or reported sign in an individual, as reported by the individual, parent, care-giver or other party. It may be recorded by a clinician as part of a clinical history record as reported to them, observed by the clinician or self-recorded as part of a clinical questionnaire or personal health record. A complete clinical history or patient story may include varying level of details about multiple episodes of an identified symptom or reported sign, as well as multiple symptoms/signs. This archetype has been designed to record the positive presence of the symptom or sign as part of history taking using OBSERVATION.story, or in conjunction with a positive response to OBSERVATION.symptom_sign_screening. In the purest sense, symptoms are subjective observations of a physical or mental disturbance and signs are objective observations of the same, as experienced by an individual and reported to the history taker by the same individual or another party. From this logic it follows that we will need two archetypes to record clinical history - one for reported symptoms and another for reported signs. In reality this is impractical as it will require clinical data entry into either one of these models which adds signficant overheads to modellers and those entering data. In addition, there is often overlap in clinical concepts - for example, is previous vomiting or bleeding to be categorised as a symptom or reported sign? In response, this archetype has been specifically designed to provide a single information model that allows for recording of the entire continuum between clearly identifiable symptoms and reported signs. This archetype has been intended to be used as a generic pattern for all symptoms and reported signs. The 'Specific details' SLOT can be used to extend the archetype to include additional, specific data elements for more complex symptoms or signs. This archetype has been specifically designed to be used in the 'Structured detail' SLOT within the OBSERVATION.story archetype, but can also be used within other OBSERVATION or CLUSTER archetypes and in the 'Associated symptom/sign' or 'Previous episode' SLOT within other instances of this CLUSTER.symptom_sign archetype. (en)"> keywords = <"*complaint(en)", "*symptom(en)", "*disturbance(en)", "*problem(en)", "*discomfort(en)", "*presenting complaint(en)", "*presenting symptom(en)", "*sign(en)"> misuse = <"*Not to be used to record screening questionnaire responses about the presence or absence of specific symptoms - use the OBSERVATION.symptom_sign_screening archetype for this purpose. However, this CLUSTER.symptom_sign archetype may be nested within the 'Screening details' SLOT in the OBSERVATION.symptom_sign_screening archetype if it is necessary to extend the questionnaire by recording details about symptom or sign. Not to be used to record that a symptom or sign was explicitly reported as not present - use CLUSTER.exclusion_symptom_sign carefully for specific purposes where the overheads of recording in this way warrant the additional complexity. Not to be used for recording objective findings as part of a physical examination - use OBSERVATION.exam and related examination CLUSTER archetypes for this purpose. Not to be used for diagnoses and problems that form part of a persisting Problem List - use EVALUATION.problem_diagnosis. Not to be used to record a formal and repeatable severity scale such as VAS or NRS. Use appropriate OBSERVATION archetypes for this purpose. (en)"> > ["nb"] = < language = <[ISO_639-1::nb]> purpose = <"For å registrere detaljer om en enkeltepisode av et rapportert symptom eller sykdomstegn. Dette kan omfatte kontekst, men ikke detaljer, om tidligere episoder av symptomet/sykdomstegnet."> use = <" For å registrere detaljer om en enkeltepisode av et rapportert symptom eller sykdomstegn hos et individ, som redegjort av personen selv, foreldre, omsorgsperson eller andre parter. Registrering kan skje i forbindelse med opptak av anamnese, eller som en selvregistrering som en del av et klinisk spørreskjema eller personlig journal. En fullstendig klinisk anamnese eller pasientanamnese kan inneholde beskrivelser med ulikt detaljnivå om flere episoder knyttet til samme symptom eller sykdomstegn, og vil også kunne inneholde flere ulike symptomer eller sykdomstegn. Denne arketypen er laget for å registrere positiv tilstedeværelse av et symptom eller sykdomstegn som en del av anamneseopptak ved å bruke OBSERVATION.story-arketypen, eller i sammenheng med et positivt svar i arketypen OBSERVATION.symptom_sign_screening. I egentlig forstand er symptomer subjektive opplevelser av en fysisk eller mental forstyrrelse mens sykdomstegn er objektive observasjoner av det samme, som er erfart av et individ og rapportert til en kliniker av individet eller av andre. Fra denne logikken følger at det burde være to arketyper til å registrere klinisk anamnese; en for rapporterte symptomer og en for rapporterte sykdomstegn. I virkeligheten er dette upraktisk og vil kreve registrering av kliniske data i enten den ene eller den andre av disse modellene. I praksis vil dette øke kompleksitet og tidsbruk knyttet til modellering og registrering av data. I tillegg overlapper ofte de kliniske konseptene, for eksempel: Vil tidligere oppkast eller blødning kategoriseres som et symptom eller som et rapportert sykdomstegn? Som svar på dette er arketypen laget for å tillate registrering av hele kontinuumet mellom tydelig definerte symptomer og rapporterte sykdomstegn. Arketypen er designet for å gi et generisk rammeverk for alle symptomer og rapporterte sykdomstegn. SLOTet \"Spesifikke detaljer\" kan brukes for å utvide arketypen med ytterligere spesifikke dataelementer for komplekse symptomer eller sykdomstegn. Arketypen skal settes inn i \"Detaljer\"-SLOTet i OBSERVATION.story-arketypen men kan også brukes i en hvilken som helst OBSERVATION eller CLUSTER-arketype. Arketypen kan også gjenbrukes i andre instanser av CLUSTER.symptom_sign-arketypen i SLOTene \"Assosierte symptomer\" eller \"Tidligere detaljer\"."> keywords = <"lidelse", "plage", "problem", "ubehag", "symptom", "sykdomstegn", "lyte", "skavank"> misuse = <"Brukes ikke for å registrere spørreskjema-spørsmål om tilstedeværelsen eller fraværet av spesifikke symptomer eller sykdomstegn. Bruk OBSERVATION.symptom_sign_screening til dette formålet. Imidlertid kan denne CLUSTER.symptom_sign arketypen brukes i SLOTet \"Ytterligere detaljer\" i OBSERVATION.symptom_sign_screening dersom man ønsker å utvide spørreskjemaet med detaljer om et symptom eller sykdomstegn. Brukes ikke til eksplisitt registrering av at et symptom eller sykdomstegn ikke er tilstede. Bruk CLUSTER.exclusion_symptom_sign varsomt da det øker tidsbruk ved registrering og tilfører økt kompleksitet. Brukes ikke til registrering av objektive funn som en del av en fysisk undersøkelse. Bruk OBSERVATION.exam og relaterte CLUSTER.exam-arketyper for dette formålet. Brukes ikke til registrering av problemer og diagnoser som en del av en persistent problemliste, til dette brukes EVALUATION.problem_diagnosis. Brukes ikke til å registrere en formell og repeterbar alvorlighetsgradering som VAS eller NRS. Bruk passende OBSERVATION-arketyper til dette formålet."> copyright = <"© openEHR Foundation"> > ["pt-br"] = < language = <[ISO_639-1::pt-br]> purpose = <"Registrar detalhes sobre um episódio único de um sinal ou sintoma relatado incluindo contexto, mas não detalhes, de episódios prévios se apropriado."> use = <"*Use to record details about a single episode of a symptom or reported sign in an individual, as reported by the individual, parent, care-giver or other party. It may be recorded by a clinician as part of a clinical history record as reported to them, observed by the clinician or self-recorded as part of a clinical questionnaire or personal health record. A complete clinical history or patient story may include varying level of details about multiple episodes of an identified symptom or reported sign, as well as multiple symptoms/signs. This archetype has been designed to record the positive presence of the symptom or sign as part of history taking using OBSERVATION.story, or in conjunction with a positive response to OBSERVATION.symptom_sign_screening. In the purest sense, symptoms are subjective observations of a physical or mental disturbance and signs are objective observations of the same, as experienced by an individual and reported to the history taker by the same individual or another party. From this logic it follows that we will need two archetypes to record clinical history - one for reported symptoms and another for reported signs. In reality this is impractical as it will require clinical data entry into either one of these models which adds signficant overheads to modellers and those entering data. In addition, there is often overlap in clinical concepts - for example, is previous vomiting or bleeding to be categorised as a symptom or reported sign? In response, this archetype has been specifically designed to provide a single information model that allows for recording of the entire continuum between clearly identifiable symptoms and reported signs. This archetype has been intended to be used as a generic pattern for all symptoms and reported signs. The 'Specific details' SLOT can be used to extend the archetype to include additional, specific data elements for more complex symptoms or signs. This archetype has been specifically designed to be used in the 'Structured detail' SLOT within the OBSERVATION.story archetype, but can also be used within other OBSERVATION or CLUSTER archetypes and in the 'Associated symptom/sign' or 'Previous episode' SLOT within other instances of this CLUSTER.symptom_sign archetype. (en)"> keywords = <"queixa", "sintoma", "distúrbio", "problema", "desconforto", "queixa atual", "sintoma atual", "sinal"> misuse = <"*Not to be used to record screening questionnaire responses about the presence or absence of specific symptoms - use the OBSERVATION.symptom_sign_screening archetype for this purpose. However, this CLUSTER.symptom_sign archetype may be nested within the 'Screening details' SLOT in the OBSERVATION.symptom_sign_screening archetype if it is necessary to extend the questionnaire by recording details about symptom or sign. Not to be used to record that a symptom or sign was explicitly reported as not present - use CLUSTER.exclusion_symptom_sign carefully for specific purposes where the overheads of recording in this way warrant the additional complexity. Not to be used for recording objective findings as part of a physical examination - use OBSERVATION.exam and related examination CLUSTER archetypes for this purpose. Not to be used for diagnoses and problems that form part of a persisting Problem List - use EVALUATION.problem_diagnosis. Not to be used to record a formal and repeatable severity scale such as VAS or NRS. Use appropriate OBSERVATION archetypes for this purpose. (en)"> > ["en"] = < language = <[ISO_639-1::en]> purpose = <"To record details about a single episode of a reported symptom or sign including context, but not details, of previous episodes if appropriate."> use = <"Use to record details about a single episode of a symptom or reported sign in an individual, as reported by the individual, parent, care-giver or other party. It may be recorded by a clinician as part of a clinical history record as reported to them, observed by the clinician or self-recorded as part of a clinical questionnaire or personal health record. A complete clinical history or patient story may include varying level of details about multiple episodes of an identified symptom or reported sign, as well as multiple symptoms/signs. This archetype has been designed to record the positive presence of the symptom or sign as part of history taking using OBSERVATION.story, or in conjunction with a positive response to OBSERVATION.symptom_sign_screening. In the purest sense, symptoms are subjective observations of a physical or mental disturbance and signs are objective observations of the same, as experienced by an individual and reported to the history taker by the same individual or another party. From this logic it follows that we will need two archetypes to record clinical history - one for reported symptoms and another for reported signs. In reality this is impractical as it will require clinical data entry into either one of these models which adds signficant overheads to modellers and those entering data. In addition, there is often overlap in clinical concepts - for example, is previous vomiting or bleeding to be categorised as a symptom or reported sign? In response, this archetype has been specifically designed to provide a single information model that allows for recording of the entire continuum between clearly identifiable symptoms and reported signs. This archetype has been intended to be used as a generic pattern for all symptoms and reported signs. The 'Specific details' SLOT can be used to extend the archetype to include additional, specific data elements for more complex symptoms or signs. This archetype has been specifically designed to be used in the 'Structured detail' SLOT within the OBSERVATION.story archetype, but can also be used within other OBSERVATION or CLUSTER archetypes and in the 'Associated symptom/sign' or 'Previous episode' SLOT within other instances of this CLUSTER.symptom_sign archetype."> keywords = <"complaint", "symptom", "disturbance", "problem", "discomfort", "presenting complaint", "presenting symptom", "sign"> misuse = <"Not to be used to record screening questionnaire responses about the presence or absence of specific symptoms - use the OBSERVATION.symptom_sign_screening archetype for this purpose. However, this CLUSTER.symptom_sign archetype may be nested within the 'Screening details' SLOT in the OBSERVATION.symptom_sign_screening archetype if it is necessary to extend the questionnaire by recording details about symptom or sign. Not to be used to record that a symptom or sign was explicitly reported as not present - use CLUSTER.exclusion_symptom_sign carefully for specific purposes where the overheads of recording in this way warrant the additional complexity. Not to be used for recording objective findings as part of a physical examination - use OBSERVATION.exam and related examination CLUSTER archetypes for this purpose. Not to be used for diagnoses and problems that form part of a persisting Problem List - use EVALUATION.problem_diagnosis. Not to be used to record a formal and repeatable severity scale such as VAS or NRS. Use appropriate OBSERVATION archetypes for this purpose."> copyright = <"© openEHR Foundation"> > ["ar-sy"] = < language = <[ISO_639-1::ar-sy]> purpose = <"*To record detail about a symptom - either self-recorded by an individual or recorded on the behalf of a patient by a clinician. A complete patient history may include varying level of details about a variety of symptoms.(en)"> use = <"*Use to record details about a single episode of a symptom or reported sign in an individual, as reported by the individual, parent, care-giver or other party. It may be recorded by a clinician as part of a clinical history record as reported to them, observed by the clinician or self-recorded as part of a clinical questionnaire or personal health record. A complete clinical history or patient story may include varying level of details about multiple episodes of an identified symptom or reported sign, as well as multiple symptoms/signs. This archetype has been designed to record the positive presence of the symptom or sign as part of history taking using OBSERVATION.story, or in conjunction with a positive response to OBSERVATION.symptom_sign_screening. In the purest sense, symptoms are subjective observations of a physical or mental disturbance and signs are objective observations of the same, as experienced by an individual and reported to the history taker by the same individual or another party. From this logic it follows that we will need two archetypes to record clinical history - one for reported symptoms and another for reported signs. In reality this is impractical as it will require clinical data entry into either one of these models which adds signficant overheads to modellers and those entering data. In addition, there is often overlap in clinical concepts - for example, is previous vomiting or bleeding to be categorised as a symptom or reported sign? In response, this archetype has been specifically designed to provide a single information model that allows for recording of the entire continuum between clearly identifiable symptoms and reported signs. This archetype has been intended to be used as a generic pattern for all symptoms and reported signs. The 'Specific details' SLOT can be used to extend the archetype to include additional, specific data elements for more complex symptoms or signs. This archetype has been specifically designed to be used in the 'Structured detail' SLOT within the OBSERVATION.story archetype, but can also be used within other OBSERVATION or CLUSTER archetypes and in the 'Associated symptom/sign' or 'Previous episode' SLOT within other instances of this CLUSTER.symptom_sign archetype. (en)"> misuse = <"*Not to be used to record screening questionnaire responses about the presence or absence of specific symptoms - use the OBSERVATION.symptom_sign_screening archetype for this purpose. However, this CLUSTER.symptom_sign archetype may be nested within the 'Screening details' SLOT in the OBSERVATION.symptom_sign_screening archetype if it is necessary to extend the questionnaire by recording details about symptom or sign. Not to be used to record that a symptom or sign was explicitly reported as not present - use CLUSTER.exclusion_symptom_sign carefully for specific purposes where the overheads of recording in this way warrant the additional complexity. Not to be used for recording objective findings as part of a physical examination - use OBSERVATION.exam and related examination CLUSTER archetypes for this purpose. Not to be used for diagnoses and problems that form part of a persisting Problem List - use EVALUATION.problem_diagnosis. Not to be used to record a formal and repeatable severity scale such as VAS or NRS. Use appropriate OBSERVATION archetypes for this purpose. (en)"> copyright = <"© openEHR Foundation"> > ["nl"] = < language = <[ISO_639-1::nl]> purpose = <"*To record details about a single episode of a reported symptom or sign including context, but not details, of previous episodes if appropriate.(en)"> use = <"*Use to record details about a single episode of a symptom or reported sign in an individual, as reported by the individual, parent, care-giver or other party. It may be recorded by a clinician as part of a clinical history record as reported to them, observed by the clinician or self-recorded as part of a clinical questionnaire or personal health record. A complete clinical history or patient story may include varying level of details about multiple episodes of an identified symptom or reported sign, as well as multiple symptoms/signs. This archetype has been designed to record the positive presence of the symptom or sign as part of history taking using OBSERVATION.story, or in conjunction with a positive response to OBSERVATION.symptom_sign_screening. In the purest sense, symptoms are subjective observations of a physical or mental disturbance and signs are objective observations of the same, as experienced by an individual and reported to the history taker by the same individual or another party. From this logic it follows that we will need two archetypes to record clinical history - one for reported symptoms and another for reported signs. In reality this is impractical as it will require clinical data entry into either one of these models which adds signficant overheads to modellers and those entering data. In addition, there is often overlap in clinical concepts - for example, is previous vomiting or bleeding to be categorised as a symptom or reported sign? In response, this archetype has been specifically designed to provide a single information model that allows for recording of the entire continuum between clearly identifiable symptoms and reported signs. This archetype has been intended to be used as a generic pattern for all symptoms and reported signs. The 'Specific details' SLOT can be used to extend the archetype to include additional, specific data elements for more complex symptoms or signs. This archetype has been specifically designed to be used in the 'Structured detail' SLOT within the OBSERVATION.story archetype, but can also be used within other OBSERVATION or CLUSTER archetypes and in the 'Associated symptom/sign' or 'Previous episode' SLOT within other instances of this CLUSTER.symptom_sign archetype. (en)"> misuse = <"*Not to be used to record screening questionnaire responses about the presence or absence of specific symptoms - use the OBSERVATION.symptom_sign_screening archetype for this purpose. However, this CLUSTER.symptom_sign archetype may be nested within the 'Screening details' SLOT in the OBSERVATION.symptom_sign_screening archetype if it is necessary to extend the questionnaire by recording details about symptom or sign. Not to be used to record that a symptom or sign was explicitly reported as not present - use CLUSTER.exclusion_symptom_sign carefully for specific purposes where the overheads of recording in this way warrant the additional complexity. Not to be used for recording objective findings as part of a physical examination - use OBSERVATION.exam and related examination CLUSTER archetypes for this purpose. Not to be used for diagnoses and problems that form part of a persisting Problem List - use EVALUATION.problem_diagnosis. Not to be used to record a formal and repeatable severity scale such as VAS or NRS. Use appropriate OBSERVATION archetypes for this purpose. (en)"> > > lifecycle_state = <"published"> other_contributors = <"Grethe Almenning, Bergen kommune, Norway", "Tomas Alme, DIPS, Norway", "Erling Are Hole, Helse Bergen, Norway", "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", "Rong Chen, Cambio Healthcare Systems, Sweden", "Stephen Chu, Queensland Health, Australia", "Lisbeth Dahlhaug, Helse Midt - Norge IT, Norway", "Arild Faxvaag, NTNU, Norway", "Kåre Flø, DIPS ASA, Norway", "Einar Fosse, National Centre for Integrated Care and Telemedicine, Norway", "Samuel Frade, Marand, Portugal", "Sebastian Garde, Ocean Informatics, Germany", "Mikkel Gaup Grønmo, FSE, Helse Nord, Norway (Nasjonal IKT redaktør)", "Yves Genevier, Privantis SA, Switzerland", "Gyri Gradek, Senter for medisinsk genetikk og molekylærmedisin, Haukeland Universitetssykehus, Norway", "Heather Grain, Llewelyn Grain Informatics, Australia", "Dag Hanoa, Oslo universitetssykehus, Norway", "Knut Harboe, Stavanger Universitetssjukehus, Norway", "Sam Heard, Ocean Informatics, Australia", "Kristian Heldal, Telemark Hospital Trust, Norway", "Andreas Hering, Helse Bergen HF, Haukeland universitetssjukehus, Norway", "Anca Heyd, DIPS ASA, Norway", "Roar Holm, Helse Vest IKT A/S, Norway", "Evelyn Hovenga, EJSH Consulting, Australia", "Lars Ivar Mehlum, Nasjonal IKT HF, Norway", "Tom Jarl Jakobsen, Helse Bergen, Norway", "Hanne Joensen, Helse Bergen HUS, Norway", "Gunnar Jårvik, Nasjonal IKT HF, Norway", "Lars Karlsen, DIPS ASA, Norway", "Lars Morgan Karlsen, DIPS ASA, Norway", "Goran Karlstrom, County Of Värmland, Sweden", "Shinji Kobayashi, NPO openEHR Japan, Japan", "Nils Kolstrup, Skansen Legekontor og Nasjonalt Senter for samhandling og telemedisin, Norway", "Elisabeth Kvile, Fysioterapiavdelingen, Haukeland Universitets Sykehus, Norway", "Siri Laronningen, Kreftregisteret, Norway", "Sabine Leh, Haukeland University Hospital, Department of Pathology, Norway", "Heather Leslie, Atomica Informatics, Australia (openEHR Editor)", "Hallvard Lærum, Norwegian Directorate of e-health, Norway", "alberto maldonado, UPV, Spain", "Luis Marco Ruiz, Norwegian Center for Integrated Care and Telemedicine, Norway", "Siv Marie Lien, DIPS ASA, Norway", "Ian McNicoll, freshEHR Clinical Informatics, United Kingdom", "Bjoern Naess, DIPS ASA, Norway", "Bjørn Næss, DIPS ASA, Norway", "Andrej Orel, Marand d.o.o., Slovenia", "Anne Pauline Anderssen, Helse Nord RHF, Norway", "Magne Rekdal, DIPS AS, Norway", "Tanja Riise, Nasjonal IKT HF, Norway", "Jussara Rotzsch, Hospital Alemão Oswaldo Cruz, Brazil", "Thomas Schopf, University Hospital of North-Norway, Norway", "Anoop Shah, University College London, United Kingdom", "Hildegunn Siv Aase, Helse Bergen, Norway", "Arild Stangeland, Helse Bergen, Norway", "Norwegian Review Summary, Norwegian Public Hospitals, Norway", "Line Sæle, Nasjonal IKT HF, Norway", "Line Sørensen, Helse Bergen, Norway", "Nils Thomas Songstad, UNN HF, BUK, Barneavdelingen., Norway", "Rowan Thomas, St. Vincent's Hospital Melbourne, Australia", "Lene Thoresen, St. Olavs Hospital, Norway", "Jon Tysdahl, Furst medlab AS, Norway", "Till Uhlig, Nasjonal kompetansetjeneste for revmatologisk rehabilitering, Revmatologisk avd. , Diakonhjemmet Sykehus, Oslo, Norway", "John Tore Valand, Helse Bergen, Norway"> other_details = < ["licence"] = <"This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/."> ["custodian_organisation"] = <"openEHR Foundation"> ["references"] = <"Common Terminology Criteria for Adverse Events (CTCAE) [Internet]. National Cancer Institute, USA. Available from: http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm (accessed 2015-07-13)."> ["current_contact"] = <"Heather Leslie, Ocean Informatics, heather.leslie@oceaninformatics.com"> ["original_namespace"] = <"org.openehr"> ["original_publisher"] = <"openEHR Foundation"> ["custodian_namespace"] = <"org.openehr"> ["MD5-CAM-1.0.1"] = <"BE1FF729C2FD4185A0A51FDE33A48A52"> ["build_uid"] = <"7b321c2c-f295-477d-84ce-6744e5353245"> ["ip_acknowledgements"] = <"This artefact includes content from SNOMED Clinical Terms® (SNOMED CT®) which is copyrighted material of the International Health Terminology Standards Development Organisation (IHTSDO). Where an implementation of this artefact makes use of SNOMED CT content, the implementer must have the appropriate SNOMED CT Affiliate license - for more information contact http://www.snomed.org/snomed-ct/get-snomed or info@snomed.org."> ["revision"] = <"2.1.2"> > definition CLUSTER[at0000] matches { -- Symptom/Sign items cardinality matches {1..*; unordered} matches { ELEMENT[at0001] matches { -- Symptom/Sign name value matches { DV_TEXT matches {*} } } ELEMENT[at0151] occurrences matches {0..*} matches { -- Body site value matches { DV_TEXT matches {*} } } allow_archetype CLUSTER[at0147] occurrences matches {0..*} matches { -- Structured body site include archetype_id/value matches {/openEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_circle(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.v2/} exclude archetype_id/value matches {/.*/} } ELEMENT[at0002] occurrences matches {0..1} matches { -- Description value matches { DV_TEXT matches {*} } } ELEMENT[at0175] occurrences matches {0..1} matches { -- Episodicity value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0176, -- New at0178, -- Ongoing at0177] -- Indeterminate } } } } ELEMENT[at0186] occurrences matches {0..1} matches { -- Occurrence value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0187, -- First occurrence at0188] -- Recurrence } } } } ELEMENT[at0152] occurrences matches {0..1} matches { -- Episode onset value matches { DV_DATE_TIME matches {*} DV_INTERVAL<DV_DATE_TIME> matches {*} } } ELEMENT[at0164] occurrences matches {0..1} matches { -- Onset timing value matches { DV_TEXT matches {*} DV_DURATION matches {*} DV_INTERVAL<DV_DURATION> matches {*} } } ELEMENT[at0200] occurrences matches {0..1} matches { -- Nadir value matches { DV_DATE_TIME matches {*} } } ELEMENT[at0028] occurrences matches {0..1} matches { -- Episode duration value matches { DV_DURATION matches { value matches {|>=PT0S|} } DV_INTERVAL<DV_DURATION> matches { lower matches { DV_DURATION matches { value matches {|>=PT0S|} } } upper matches { DV_DURATION matches { value matches {|>=PT0S|} } } } DV_TEXT matches {*} } } ELEMENT[at0021] occurrences matches {0..1} matches { -- Severity category value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0023, -- Mild at0024, -- Moderate at0025] -- Severe } } DV_TEXT matches {*} } } allow_archetype CLUSTER[at0198] occurrences matches {0..*} matches { -- Severity rating include archetype_id/value matches {/openEHR-EHR-CLUSTER\.severity_rating_scale(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.severity_rating_scale(-[a-zA-Z0-9_]+)*\.v1/} } ELEMENT[at0189] occurrences matches {0..*} matches { -- Character value matches { DV_TEXT matches {*} } } ELEMENT[at0180] occurrences matches {0..*} matches { -- Progression value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0183, -- Worsening at0182, -- Unchanged at0181, -- Improving at0184] -- Resolved } } DV_TEXT matches {*} } } ELEMENT[at0003] occurrences matches {0..1} matches { -- Pattern value matches { DV_TEXT matches {*} } } CLUSTER[at0018] occurrences matches {0..*} matches { -- Modifying factor items cardinality matches {1..*; unordered} matches { ELEMENT[at0019] occurrences matches {0..1} matches { -- Factor value matches { DV_TEXT matches {*} } } allow_archetype CLUSTER[at0197] occurrences matches {0..1} matches { -- Factor detail include archetype_id/value matches {/openEHR-EHR-CLUSTER\.health_event(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.symptom_sign(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.symptom_sign(-[a-zA-Z0-9_]+)*\.v2/} } ELEMENT[at0017] occurrences matches {0..1} matches { -- Effect value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0159, -- Relieves at0156, -- No effect at0158] -- Worsens } } } } ELEMENT[at0056] occurrences matches {0..1} matches { -- Description value matches { DV_TEXT matches {*} } } } } CLUSTER[at0165] occurrences matches {0..*} matches { -- Precipitating factor items cardinality matches {1..*; unordered} matches { ELEMENT[at0170] occurrences matches {0..1} matches { -- Factor value matches { DV_TEXT matches {*} } } allow_archetype CLUSTER[at0154] occurrences matches {0..*} matches { -- Factor detail include archetype_id/value matches {/openEHR-EHR-CLUSTER\.health_event(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.symptom_sign(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.symptom_sign(-[a-zA-Z0-9_]+)*\.v2/} } ELEMENT[at0171] occurrences matches {0..1} matches { -- Time interval value matches { DV_DURATION matches {*} } } ELEMENT[at0185] occurrences matches {0..1} matches { -- Description value matches { DV_TEXT matches {*} } } } } CLUSTER[at0190] occurrences matches {0..*} matches { -- Resolving factor items cardinality matches {1..*; unordered} matches { ELEMENT[at0193] occurrences matches {0..1} matches { -- Factor value matches { DV_TEXT matches {*} } } allow_archetype CLUSTER[at0194] occurrences matches {0..*} matches { -- Factor detail include archetype_id/value matches {/openEHR-EHR-CLUSTER\.health_event(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.symptom_sign(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.symptom_sign(-[a-zA-Z0-9_]+)*\.v2/} } ELEMENT[at0195] occurrences matches {0..1} matches { -- Time interval value matches { DV_DURATION matches {*} } } ELEMENT[at0196] occurrences matches {0..1} matches { -- Description value matches { DV_TEXT matches {*} } } } } ELEMENT[at0155] occurrences matches {0..*} matches { -- Impact value matches { DV_TEXT matches {*} } } ELEMENT[at0037] occurrences matches {0..1} matches { -- Episode description value matches { DV_TEXT matches {*} } } allow_archetype CLUSTER[at0153] occurrences matches {0..*} matches { -- Specific details include archetype_id/value matches {/.*/} } ELEMENT[at0161] occurrences matches {0..1} matches { -- Resolution date/time value matches { DV_DATE_TIME matches {*} } } ELEMENT[at0057] occurrences matches {0..1} matches { -- Description of previous episodes value matches { DV_TEXT matches {*} } } ELEMENT[at0031] occurrences matches {0..1} matches { -- Number of previous episodes value matches { DV_COUNT matches { magnitude matches {|>=0|} } } } allow_archetype CLUSTER[at0146] occurrences matches {0..*} matches { -- Previous episodes include archetype_id/value matches {/openEHR-EHR-CLUSTER\.symptom_sign(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.symptom_sign(-[a-zA-Z0-9_]+)*\.v2/} } allow_archetype CLUSTER[at0063] occurrences matches {0..*} matches { -- Associated symptom/sign include archetype_id/value matches {/openEHR-EHR-CLUSTER\.symptom_sign(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.symptom_sign(-[a-zA-Z0-9_]+)*\.v2/} } ELEMENT[at0163] occurrences matches {0..1} matches { -- Comment value matches { DV_TEXT matches {*} } } } } ontology terminologies_available = <"SNOMED-CT", ...> term_definitions = < ["ar-sy"] = < items = < ["at0000"] = < text = <"*Symptom/Sign(en)"> description = <"*Reported observation of a physical or mental disturbance in an individual.(en)"> > ["at0001"] = < text = <"*Symptom/Sign name(en)"> description = <"*The name of the reported symptom or sign.(en)"> comment = <"*Symptom name should be coded with a terminology, where possible.(en)"> > ["at0002"] = < text = <"*Description(en)"> description = <"*Narrative description about the reported symptom or sign.(en)"> > ["at0003"] = < text = <"*Pattern(en)"> description = <"*Narrative description about the pattern of the symptom or sign during this episode.(en)"> comment = <"*For example: pain could be described as constant or colicky.(en)"> > ["at0017"] = < text = <"*Effect(en)"> description = <"*Perceived effect of the modifying factor on the symptom or sign.(en)"> > ["at0018"] = < text = <"*Modifying factor(en)"> description = <"*Detail about how a specific factor effects the identified symptom or sign during this episode.(en)"> > ["at0019"] = < text = <"*Factor(en)"> description = <"*Name of the modifying factor.(en)"> comment = <"*Examples of modifying factor: lying on multiple pillows, eating or administration of a specific medication.(en)"> > ["at0021"] = < text = <"*Severity category(en)"> description = <"*Category representing the overall severity of the symptom or sign.(en)"> comment = <"*Defining values such as mild, moderate or severe in such a way that is applicable to multiple symptoms or signs plus allows multiple users to interpret and record them consistently is not easy. Some organisations extend the value set further with inclusion of additional values such as 'Trivial' and 'Very severe', and/or 'Mild-Moderate' and 'Moderate-Severe', adds to the definitional difficulty and may also worsen inter-recorder reliability issues. Use of 'Life-threatening' and 'Fatal' is also often considered as part of this value set, although from a pure point of view it may actually reflect an outcome rather than a severity. In view of the above, keeping to a well-defined but smaller list is preferred and so the mild/moderate/severe value set is offered, however the choice of other text allows for other value sets to be included at this data element in a template. (en)"> > ["at0023"] = < text = <"*Mild(en)"> description = <"*The intensity of the symptom or sign does not cause interference with normal activity.(en)"> > ["at0024"] = < text = <"*Moderate(en)"> description = <"*The intensity of the symptom or sign causes interference with normal activity.(en)"> > ["at0025"] = < text = <"*Severe(en)"> description = <"*The intensity of the symptom or sign causes prevents normal activity.(en)"> > ["at0028"] = < text = <"*Episode duration (en)"> description = <"*The duration of this episode of the symptom or sign since initial onset. (en)"> comment = <"*If 'Date/time of onset' and 'Date/time of resolution' are used in systems, this data element may be calculated, or alternatively, be considered redundant in this scenario. The text data type is used for recording preset duration intervals such as '0-7 days, 1-2 weeks, 2 weeks or more'. (en)"> > ["at0031"] = < text = <"*Number of previous episodes(en)"> description = <"*The number of times this symptom or sign has previously occurred.(en)"> > ["at0037"] = < text = <"*Episode description(en)"> description = <"*Narrative description about the course of the symptom or sign during this episode.(en)"> comment = <"*For example: a text description of the immediate onset of the symptom, activities that worsened or relieved the symptom, whether it is improving or worsening and how it resolved over weeks.(en)"> > ["at0056"] = < text = <"*Description(en)"> description = <"*Narrative description of the effect of the modifying factor on the symptom or sign.(en)"> > ["at0057"] = < text = <"*Description of previous episodes(en)"> description = <"*Narrative description of any or all previous episodes.(en)"> comment = <"*For example: frequency/periodicity - per hour, day, week, month, year; and regularity. May include a comparison to this episode.(en)"> > ["at0063"] = < text = <"*Associated symptom/sign(en)"> description = <"*Structured details about any associated symptoms or signs that are concurrent.(en)"> comment = <"*In linked clinical systems, it is possible that associated symptoms or signs are already recorded within the EHR. Systems can allow the clinician to LINK to relevant associated symptoms/signs. However in a system or message without LINKs to existing data or with a new patient, additional instances of the symptom archetype could be included here to represent associated symptoms/signs.(en)"> > ["at0146"] = < text = <"*Previous episodes(en)"> description = <"*Structured details of the symptom or sign during a previous episode.(en)"> comment = <"*In linked clinical systems, it is possible that previous episodes are already recorded within the EHR. Systems can allow the clinician to LINK to relevant previous episodes. However in a system or message without LINKs to existing data or with a new patient, additional instances of the symptom archetype could be included here to represent previous episodes. It is recommended that new instances of the Symptom archetype inserted in this SLOT represent one or many previous episodes to this Symptom instance only.(en)"> > ["at0147"] = < text = <"*Structured body site(en)"> description = <"*Structured body site where the symptom or sign was reported.(en)"> comment = <"*If the anatomical location is included in the Symptom name via precoordinated codes, use of this SLOT becomes redundant. If the anatomical location is recorded using the 'Body site' data element, then use of CLUSTER archetypes in this SLOT is not allowed - record only the simple 'Body site' OR 'Structured body site', but not both.(en)"> > ["at0151"] = < text = <"*Body site(en)"> description = <"*Simple body site where the symptom or sign was reported.(en)"> comment = <"*Occurrences of this data element are set to 0..* to allow multiple body sites to be separated out in a template if desired. This allows for representation of clinical scenarios where a symptom or sign needs to be recorded in multiple locations or identifying both the originating and distal site in pain radiation, but where all of the other attributes such as impact and duration are identical. If the requirements for recording the body site are determined at run-time by the application or require more complex modelling such as relative locations then use the CLUSTER.anatomical_location or CLUSTER.relative_location within the Detailed anatomical location' SLOT in this archetype. If the anatomical location is included in the Symptom name via precoordinated codes, this data element becomes redundant. If the anatomical location is recorded using the 'Structured body site' SLOT, then use of this data element is not allowed - record only the simple 'Body site' OR 'Structured body site', but not both.(en)"> > ["at0152"] = < text = <"*Onset date/time(en)"> description = <"*The onset for this episode of the symptom or sign.(en)"> comment = <"*While partial dates are permitted, the exact date and time of onset can be recorded, if appropriate. If this is a recurring symptom, this date is used to represent the most recent date or onset of exacerbation, relevant to the clinical presentation. If this is the first instance of this symptom, this date is used to represent the first ever start of symptoms.(en)"> > ["at0153"] = < text = <"*Specific details(en)"> description = <"*Specific data elements that are additionally required to record as unique attributes of the identified symptom or sign.(en)"> comment = <"*For example: CTCAE grading.(en)"> > ["at0154"] = < text = <"*Factor detail(en)"> description = <"*Structured detail about the factor associated with the identified symptom or sign.(en)"> > ["at0155"] = < text = <"*Impact(en)"> description = <"*Description of the impact of this symptom or sign.(en)"> comment = <"*Assessment of impact could consider the severity, duration and frequency of the symptom as well as the type of impact including, but not limited to, functional, social and emotional impact. Occurrences of this data element are set to 0..* to allow multiple types of impact to be separated out in a template if desired. Examples for functional impact from hearing loss may include: 'Difficulty Hearing in Quiet Environment'; 'Difficulty Hearing the TV or Radio'; 'Difficulty Hearing Group Conversation'; and 'Difficulty Hearing on Phone'.(en)"> > ["at0156"] = < text = <"*No effect(en)"> description = <"*Presence of the factor has no impact on the symptom or sign.(en)"> > ["at0158"] = < text = <"*Worsens(en)"> description = <"*Presence of the factor exaccerbates severity or impact of the symptom or sign.(en)"> > ["at0159"] = < text = <"*Relieves(en)"> description = <"*Presence of the factor reduces the severity or impact of the symptom or sign.(en)"> > ["at0161"] = < text = <"*Resolution date/time(en)"> description = <"*The timing of the cessation of this episode of the symptom or sign.(en)"> comment = <"*If 'Date/time of onset' and 'Duration' are used in systems, this data element may be calculated, or alternatively, considered redundant. While partial dates are permitted, the exact date and time of resolution can be recorded, if appropriate.(en)"> > ["at0163"] = < text = <"*Comment(en)"> description = <"*Additional narrative about the symptom or sign not captured in other fields.(en)"> > ["at0164"] = < text = <"*Onset timing (en)"> description = <"*Timing of the onset and development of the symptom or sign. (en)"> comment = <"*The type of the onset can be coded with a terminology, if desired. For example: gradual; or sudden.(en)"> > ["at0165"] = < text = <"*Precipitating factor (en)"> description = <"*Details about specified factors that are associated with the precipitation of the symptom or sign. (en)"> comment = <"*For example: lying down leads to heartburn; or walking up a hill leads to claudication. (en)"> > ["at0170"] = < text = <"*Factor(en)"> description = <"*Name of the health event, symptom, reported sign or other factor.(en)"> comment = <"*For example: onset of another symptom; lying down; or walking up a hill. (en)"> > ["at0171"] = < text = <"*Time interval(en)"> description = <"*The interval of time between the occurrence or onset of the factor and onset of the symptom or sign. (en)"> > ["at0175"] = < text = <"*Episodicity(en)"> description = <"*Category of this epsiode for the identified symptom or sign.(en)"> > ["at0176"] = < text = <"*New(en)"> description = <"*This is the first ever episode of the symptom or sign.(en)"> > ["at0177"] = < text = <"*Reoccurrence(en)"> description = <"*This is a second or subsequent discrete episode of the symptom or sign, where each previous episode has completely resolved.(en)"> > ["at0178"] = < text = <"*Ongoing(en)"> description = <"*This symptom or sign is continuously present, effectively a single, ongoing episode.(en)"> > ["at0180"] = < text = <"*Progression(en)"> description = <"*Description progression of the symptom or sign at the time of reporting.(en)"> comment = <"*Occurrences of this data element are set to 0..* to allow multiple types of progression to be separated out in a template if desired - for example, severity or frequency. The Text data type is added as an option, to support other value sets than the ones included in the archetype. (en)"> > ["at0181"] = < text = <"*Improving(en)"> description = <"*The severity of the symptom or sign has improved overall during this episode.(en)"> > ["at0182"] = < text = <"*Unchanged(en)"> description = <"*The severity of the symptom or sign has not changed overall during this episode.(en)"> > ["at0183"] = < text = <"*Worsening(en)"> description = <"*The severity of the symptom or sign has worsened overall during this episode.(en)"> > ["at0184"] = < text = <"*Resolved(en)"> description = <"*The severity of the symptom or sign has resolved.(en)"> > ["at0185"] = < text = <"*Description(en)"> description = <"*Narrative description about the effect of the factor on the identified symptom or sign.(en)"> > ["at0186"] = < text = <"*Occurrence (en)"> description = <"*Type of occurrence for this symptom or sign? (en)"> > ["at0187"] = < text = <"*First occurrence (en)"> description = <"*This is the first ever occurrence of this symptom or sign. (en)"> > ["at0188"] = < text = <"*Recurrence (en)"> description = <"*This is the first ever occurrence of this symptom or sign. (en)"> > ["at0189"] = < text = <"*Character (en)"> description = <"*Word or short phrase describing the nature of the symptom or sign. (en)"> comment = <"*For example: pain could be described as 'gnawing', 'burning', or 'like an electric shock'; a headache could be 'throbbing' or 'constant'. Coding with an external terminology is preferred, where possible. (en)"> > ["at0190"] = < text = <"*Resolving factor (en)"> description = <"*Details about specified factors that are associated with the resolution of the symptom or sign. (en)"> comment = <"*For example: upright posture stops heartburn; or resting stops claudication. (en)"> > ["at0193"] = < text = <"*Factor(en)"> description = <"*Name of the health event, symptom, reported sign or other factor.(en)"> comment = <"*For example: upright posture; or resting. (en)"> > ["at0194"] = < text = <"*Factor detail(en)"> description = <"*Structured detail about the factor associated with the identified symptom or sign.(en)"> > ["at0195"] = < text = <"*Time interval(en)"> description = <"*The interval of time between the occurrence or onset of the factor and resolution of the symptom or sign. (en)"> > ["at0196"] = < text = <"*Description(en)"> description = <"*Narrative description about the effect of the factor on the identified symptom or sign.(en)"> > ["at0197"] = < text = <"*Factor detail(en)"> description = <"*Structured detail about the factor associated with the identified symptom or sign.(en)"> > ["at0198"] = < text = <"*Severity rating (en)"> description = <"*Numerical rating scale representing the overall severity of the symptom or sign. (en)"> comment = <"*Symptom severity can be rated by the individual by recording a score for example from 0 (ie symptom not present) to 10 (ie symptom is as severe as the individual can imagine). (en)"> > ["at0200"] = < text = <"*Nadir (en)"> description = <"*Date/time when a monophasic, progressive symptom or sign reached its' maximal intensity or functional impact. (en)"> comment = <"*For example: the date when neurological signs in Guillain-Barre disease was at its worst. (en)"> > > > ["en"] = < items = < ["at0000"] = < text = <"Symptom/Sign"> description = <"Reported observation of a physical or mental disturbance in an individual."> > ["at0001"] = < text = <"Symptom/Sign name"> description = <"The name of the reported symptom or sign."> comment = <"Symptom name should be coded with a terminology, where possible."> > ["at0002"] = < text = <"Description"> description = <"Narrative description about the reported symptom or sign."> > ["at0003"] = < text = <"Pattern"> description = <"Narrative description about the pattern of the symptom or sign during this episode."> comment = <"For example: pain could be described as constant or intermittent."> > ["at0017"] = < text = <"Effect"> description = <"Perceived effect of the modifying factor on the symptom or sign."> > ["at0018"] = < text = <"Modifying factor"> description = <"Detail about how a specific factor effects the identified symptom or sign during this episode."> > ["at0019"] = < text = <"Factor"> description = <"Name of the modifying factor."> comment = <"Examples of modifying factor: lying on multiple pillows, eating or administration of a specific medication."> > ["at0021"] = < text = <"Severity category"> description = <"Category representing the overall severity of the symptom or sign."> comment = <"Defining values such as mild, moderate or severe in such a way that is applicable to multiple symptoms or signs plus allows multiple users to interpret and record them consistently is not easy. Some organisations extend the value set further with inclusion of additional values such as 'Trivial' and 'Very severe', and/or 'Mild-Moderate' and 'Moderate-Severe', adds to the definitional difficulty and may also worsen inter-recorder reliability issues. Use of 'Life-threatening' and 'Fatal' is also often considered as part of this value set, although from a pure point of view it may actually reflect an outcome rather than a severity. In view of the above, keeping to a well-defined but smaller list is preferred and so the mild/moderate/severe value set is offered, however the choice of other text allows for other value sets to be included at this data element in a template."> > ["at0023"] = < text = <"Mild"> description = <"The intensity of the symptom or sign does not cause interference with normal activity."> > ["at0024"] = < text = <"Moderate"> description = <"The intensity of the symptom or sign causes interference with normal activity."> > ["at0025"] = < text = <"Severe"> description = <"The intensity of the symptom or sign causes prevents normal activity."> > ["at0028"] = < text = <"Episode duration"> description = <"The duration of this episode of the symptom or sign since initial onset."> comment = <"If 'Date/time of onset' and 'Date/time of resolution' are used in systems, this data element may be calculated, or alternatively, be considered redundant in this scenario. The text data type is used for recording preset duration intervals such as '0-7 days, 1-2 weeks, 2 weeks or more'."> > ["at0031"] = < text = <"Number of previous episodes"> description = <"The number of times this symptom or sign has previously occurred."> > ["at0037"] = < text = <"Episode description"> description = <"Narrative description about the course of the symptom or sign during this episode."> comment = <"For example: a text description of the immediate onset of the symptom, activities that worsened or relieved the symptom, whether it is improving or worsening and how it resolved over weeks."> > ["at0056"] = < text = <"Description"> description = <"Narrative description of the effect of the modifying factor on the symptom or sign."> > ["at0057"] = < text = <"Description of previous episodes"> description = <"Narrative description of any or all previous episodes."> comment = <"For example: frequency/periodicity - per hour, day, week, month, year; and regularity. May include a comparison to this episode."> > ["at0063"] = < text = <"Associated symptom/sign"> description = <"Structured details about any associated symptoms or signs that are concurrent."> comment = <"In linked clinical systems, it is possible that associated symptoms or signs are already recorded within the EHR. Systems can allow the clinician to LINK to relevant associated symptoms/signs. However in a system or message without LINKs to existing data or with a new patient, additional instances of the symptom archetype could be included here to represent associated symptoms/signs."> > ["at0146"] = < text = <"Previous episodes"> description = <"Structured details of the symptom or sign during a previous episode."> comment = <"In linked clinical systems, it is possible that previous episodes are already recorded within the EHR. Systems can allow the clinician to LINK to relevant previous episodes. However in a system or message without LINKs to existing data or with a new patient, additional instances of the symptom archetype could be included here to represent previous episodes. It is recommended that new instances of the Symptom archetype inserted in this SLOT represent one or many previous episodes to this Symptom instance only."> > ["at0147"] = < text = <"Structured body site"> description = <"Structured body site where the symptom or sign was reported."> comment = <"If the anatomical location is included in the Symptom name via precoordinated codes, use of this SLOT becomes redundant. If the anatomical location is recorded using the 'Body site' data element, then use of CLUSTER archetypes in this SLOT is not allowed - record only the simple 'Body site' OR 'Structured body site', but not both."> > ["at0151"] = < text = <"Body site"> description = <"Simple body site where the symptom or sign was reported."> comment = <"Occurrences of this data element are set to 0..* to allow multiple body sites to be separated out in a template if desired. This allows for representation of clinical scenarios where a symptom or sign needs to be recorded in multiple locations or identifying both the originating and distal site in pain radiation, but where all of the other attributes such as impact and duration are identical. If the requirements for recording the body site are determined at run-time by the application or require more complex modelling such as relative locations then use the CLUSTER.anatomical_location or CLUSTER.relative_location within the Detailed anatomical location' SLOT in this archetype. If the anatomical location is included in the Symptom name via precoordinated codes, this data element becomes redundant. If the anatomical location is recorded using the 'Structured body site' SLOT, then use of this data element is not allowed - record only the simple 'Body site' OR 'Structured body site', but not both."> > ["at0152"] = < text = <"Episode onset"> description = <"The onset for this episode of the symptom or sign."> comment = <"While partial dates are permitted, the exact date and time of onset can be recorded, if appropriate. If this symptom or sign is experienced for the first time or is a re-occurrence, this date is used to represent the onset of this episode. If this symptom or sign is ongoing, this data element may be redundant if it has been recorded previously."> > ["at0153"] = < text = <"Specific details"> description = <"Specific data elements that are additionally required to record as unique attributes of the identified symptom or sign."> comment = <"For example: CTCAE grading."> > ["at0154"] = < text = <"Factor detail"> description = <"Structured detail about the factor associated with the identified symptom or sign."> > ["at0155"] = < text = <"Impact"> description = <"Description of the impact of this symptom or sign."> comment = <"Assessment of impact could consider the severity, duration and frequency of the symptom as well as the type of impact including, but not limited to, functional, social and emotional impact. Occurrences of this data element are set to 0..* to allow multiple types of impact to be separated out in a template if desired. Examples for functional impact from hearing loss may include: 'Difficulty Hearing in Quiet Environment'; 'Difficulty Hearing the TV or Radio'; 'Difficulty Hearing Group Conversation'; and 'Difficulty Hearing on Phone'."> > ["at0156"] = < text = <"No effect"> description = <"The factor has no impact on the symptom or sign."> > ["at0158"] = < text = <"Worsens"> description = <"The factor increases the severity or impact of the symptom or sign."> > ["at0159"] = < text = <"Relieves"> description = <"The factor decreases the severity or impact of the symptom or sign, but does not fully resolve it."> > ["at0161"] = < text = <"Resolution date/time"> description = <"The timing of the cessation of this episode of the symptom or sign."> comment = <"If 'Date/time of onset' and 'Duration' are used in systems, this data element may be calculated, or alternatively, considered redundant. While partial dates are permitted, the exact date and time of resolution can be recorded, if appropriate."> > ["at0163"] = < text = <"Comment"> description = <"Additional narrative about the symptom or sign not captured in other fields."> > ["at0164"] = < text = <"Onset timing"> description = <"Timing of the onset and development of the symptom or sign."> comment = <"The type of the onset can be coded with a terminology, if desired. For example: gradual; or sudden."> > ["at0165"] = < text = <"Precipitating factor"> description = <"Details about specified factors that are associated with the precipitation of the symptom or sign."> comment = <"For example: lying down leads to heartburn; or walking up a hill leads to claudication."> > ["at0170"] = < text = <"Factor"> description = <"Name of the health event, symptom, reported sign or other factor."> comment = <"For example: onset of another symptom; lying down; or walking up a hill."> > ["at0171"] = < text = <"Time interval"> description = <"The interval of time between the occurrence or onset of the factor and onset of the symptom or sign."> > ["at0175"] = < text = <"Episodicity"> description = <"Category of this episode for the identified symptom or sign."> > ["at0176"] = < text = <"New"> description = <"A new episode of the symptom or sign - either the first ever occurrence or a reoccurrence where the previous episode had completely resolved."> > ["at0177"] = < text = <"Indeterminate"> description = <"It is not possible to determine if this occurrence of the symptom or sign is new or ongoing."> > ["at0178"] = < text = <"Ongoing"> description = <"This symptom or sign is ongoing, effectively a single, continuous episode."> > ["at0180"] = < text = <"Progression"> description = <"Description progression of the symptom or sign at the time of reporting."> comment = <"Occurrences of this data element are set to 0..* to allow multiple types of progression to be separated out in a template if desired - for example, severity or frequency. The Text data type is added as an option, to support other value sets than the ones included in the archetype."> > ["at0181"] = < text = <"Improving"> description = <"The severity of the symptom or sign has improved overall during this episode."> > ["at0182"] = < text = <"Unchanged"> description = <"The severity of the symptom or sign has not changed overall during this episode."> > ["at0183"] = < text = <"Worsening"> description = <"The severity of the symptom or sign has worsened overall during this episode."> > ["at0184"] = < text = <"Resolved"> description = <"The severity of the symptom or sign has resolved."> > ["at0185"] = < text = <"Description"> description = <"Narrative description about the effect of the factor on the identified symptom or sign."> > ["at0186"] = < text = <"Occurrence"> description = <"Type of occurrence for this symptom or sign?"> > ["at0187"] = < text = <"First occurrence"> description = <"This is the first ever occurrence of this symptom or sign."> > ["at0188"] = < text = <"Recurrence"> description = <"New occurrence of the same symptom or sign after a previous episode was resolved."> > ["at0189"] = < text = <"Character"> description = <"Word or short phrase describing the nature of the symptom or sign."> comment = <"For example: pain could be described as 'gnawing', 'burning', or 'like an electric shock'; a headache could be 'throbbing' or 'constant'. Coding with an external terminology is preferred, where possible."> > ["at0190"] = < text = <"Resolving factor"> description = <"Details about specified factors that are associated with the resolution of the symptom or sign."> comment = <"For example: upright posture stops heartburn; or resting stops claudication."> > ["at0193"] = < text = <"Factor"> description = <"Name of the health event, symptom, reported sign or other factor."> comment = <"For example: upright posture; or resting."> > ["at0194"] = < text = <"Factor detail"> description = <"Structured detail about the factor associated with the identified symptom or sign."> > ["at0195"] = < text = <"Time interval"> description = <"The interval of time between the occurrence or onset of the factor and resolution of the symptom or sign."> > ["at0196"] = < text = <"Description"> description = <"Narrative description about the effect of the factor on the identified symptom or sign."> > ["at0197"] = < text = <"Factor detail"> description = <"Structured detail about the factor associated with the identified symptom or sign."> > ["at0198"] = < text = <"Severity rating"> description = <"Numerical rating scale representing the overall severity of the symptom or sign."> comment = <"Symptom severity can be rated by the individual by recording a score for example from 0 (ie symptom not present) to 10 (ie symptom is as severe as the individual can imagine)."> > ["at0200"] = < text = <"Nadir"> description = <"Date/time when a monophasic, progressive symptom or sign reached its' maximal intensity or functional impact."> comment = <"For example: the date when neurological signs in Guillain-Barre disease was at its worst."> > > > ["de"] = < items = < ["at0000"] = < text = <"Symptom/Krankheitsanzeichen"> description = <"Berichtete Beobachtung einer körperlichen oder psychischen Störung bei einer Person."> > ["at0001"] = < text = <"Name des Symptoms/Krankheitsanzeichens"> description = <"Der Name des berichteten Symptoms/Krankheitsanzeichens."> comment = <"Der Name des Symptoms sollte, wenn möglich, mit einer Terminologie kodiert werden."> > ["at0002"] = < text = <"Beschreibung"> description = <"Beschreibung des festgestellten Symptoms/Krankheitsanzeichens."> > ["at0003"] = < text = <"Muster"> description = <"Beschreibung des Musters des Symptoms/Krankheitsanzeichens während dieser Episode."> comment = <"Zum Beispiel: Schmerzen können als konstant oder periodisch beschrieben werden."> > ["at0017"] = < text = <"Einfluss"> description = <"Wahrgenommene Auswirkung des Faktors auf das Symptom/Krankheitsanzeichen."> > ["at0018"] = < text = <"Einflussfaktor"> description = <"Nähere Informationen zur Art und Weise der Beeinflussung des identifizierten Symptoms/Krankheitsanzeichens durch einen bestimmten Faktor während dieser Episode."> > ["at0019"] = < text = <"Faktor"> description = <"Name des Einflussfaktors."> comment = <"Beispiele für Einflussfaktoren: Liegen auf mehreren Kissen, Essen oder Verabreichung eines bestimmten Medikaments."> > ["at0021"] = < text = <"Schweregrad"> description = <"Kategorie, die den allgemeinen Schweregrad des Symptoms/Krankheitsanzeichens beschreibt."> comment = <"Es ist nicht einfach, Werte wie leicht, mittel oder schwer so zu definieren, dass sie auf mehrere Symptome oder Anzeichen anwendbar sind und von mehreren Benutzern konsistent interpretiert und erfasst werden können. Einige Organisationen erweitern den Wertesatz weiter, indem sie zusätzliche Werte wie z.B. \"trivial\", \"sehr stark\", \"leicht-moderat\" oder \"moderat-schwer\", miteinbeziehen, was die Definitionsschwierigkeiten erhöht und auch die Zuverlässigkeit von Aufzeichnungen von verschiedenen Protokollanten verschlechtern kann. Die Verwendung von „lebensbedrohlich“ und „tödlich“ wird ebenfalls oft als Teil dieses Wertesatzes angesehen, obwohl es rein betrachtet eher ein Ergebnis als einen Schweregrad widerspiegeln kann. In Anbetracht dessen wird die Einhaltung einer gut definierten, aber kürzeren Liste bevorzugt, so dass der Wertesatz \"leicht/moderat/schwer\" angeboten wird. Die Wahl eines anderen Textes wird durch die Aufnahme anderer Wertebereiche für dieses Datenelement im Template ermöglicht."> > ["at0023"] = < text = <"Leicht"> description = <"Die Intensität des Symptoms/Krankheitsanzeichens führt zu keiner Beeinträchtigung der normalen Aktivität."> > ["at0024"] = < text = <"Moderat"> description = <"Die Intensität des Symptoms/Krankheitsanzeichens führt zu einer Beeinträchtigung der normalen Aktivität."> > ["at0025"] = < text = <"Schwer"> description = <"Die Intensität des Symptoms/Krankheitsanzeichens verhindert eine normale Aktivität."> > ["at0028"] = < text = <"Episodendauer"> description = <"Die Dauer dieser Episode des Symptoms oder Anzeichens seit dem ersten Auftreten."> comment = <"Wenn in Systemen \"Beginn der Episode\" und \"Zeitpunkt des Rückgangs\" verwendet werden, kann dieses Datenelement berechnet oder alternativ in diesem Szenario als redundant angesehen werden. Der Datentyp \"Text\" wird zur Darstellung prädefinierten Dauerintervalle wie „0–7 Tage, 1–2 Wochen, 2 Wochen oder mehr“ verwendet."> > ["at0031"] = < text = <"Anzahl vorangegangener Episoden"> description = <"Die Anzahl, wie oft das Symptom/Krankheitsanzeichen bereits aufgetreten ist."> > ["at0037"] = < text = <"Beschreibung der Episode"> description = <"Beschreibung des Verlaufs des Symptoms/Krankheitsanzeichens während dieser Episode."> comment = <"Zum Beispiel: eine Beschreibung des unmittelbaren Auftretens des Symptoms, Aktivitäten, die das Symptom verschlimmert oder gelindert haben, ob es sich verbessert oder verschlechtert hat und wie es über Wochen zurückging."> > ["at0056"] = < text = <"Beschreibung"> description = <"Beschreibung des Einflusses des Faktors auf das Symptom/Krankheitsanzeichen."> > ["at0057"] = < text = <"Beschreibung vorangegangener Episoden"> description = <"Beschreibung einer oder aller früheren Episoden."> comment = <"Zum Beispiel: Häufigkeit/Periodizität - pro Stunde, Tag, Woche, Monat, Jahr; und Regelmäßigkeit. Kann einen Vergleich zu dieser Episode beinhalten."> > ["at0063"] = < text = <"Assoziierte Symptome/Krankheitsanzeichen"> description = <"Strukturierte Details über alle assoziierten Symptome/Krankheitsanzeichen, die gleichzeitig auftreten."> comment = <"In vernetzten klinischen Systemen ist es möglich, dass verbundene Symptome/Krankheitsanzeichen bereits in der elektronischen Gesundheitsakte (engl. Electronic Health Record - EHR) erfasst wurden. Die Systeme können es dem Arzt ermöglichen, auf relevante in Zusammenhang stehende Symptomen/Krankheitsanzeichen zu verweisen. In einem System oder einer Nachricht ohne eine Verlinkung zu bestehenden Daten oder bei einem neuen Patienten können zusätzliche Instanzen des Symptom-Archetyps hier aufgenommen werden, um damit verbundene Symptome/Krankheitsanzeichen darzustellen."> > ["at0146"] = < text = <"Vorangegangene Episoden"> description = <"Strukturierte Details des Symptoms/Befundes während einer früheren Episode."> comment = <"In vernetzten klinischen Systemen ist es möglich, dass vorangegangene Episoden bereits in der elektronischen Gesundheitsakte (engl. Electronic Health Record - EHR) erfasst wurden. Die Systeme können es dem Arzt ermöglichen, auf relevante vorangegangene Episoden zu verweisen. In einem System oder einer Nachricht ohne eine Verlinkung zu bestehenden Daten oder bei einem neuen Patienten können zusätzliche Instanzen des Symptom-Archetyps aufgenommen werden, um frühere Episoden darzustellen. Es wird empfohlen, dass neue Instanzen des Symptom-Archetyps, die in diesen Slot eingefügt werden, eine oder mehrere vorangegangene Episoden dieser Symptom-Instanz darstellen."> > ["at0147"] = < text = <"Spezifische anatomische Lokalisation"> description = <"Spezifische anatomische Lokalisation des Symptoms/Krankheitsanzeichens."> comment = <"Wenn die anatomische Lokalisation über vordefinierte Codes in den Symptomnamen aufgenommen wird, wird die Verwendung dieses Slots überflüssig. Wenn die anatomische Lokalisation mit dem Datenelement \"Anatomische Lokalisation\" erfasst wird, ist die Verwendung von CLUSTER-Archetypen in diesem Slot nicht erlaubt - erfassen Sie entweder die grobe \"Anatomische Lokalisation\" oder die \"Spezifische anatomische Lokalisation\", nicht beides."> > ["at0151"] = < text = <"Anatomische Lokalisation"> description = <"Anatomische Lokalisation des Symptoms/Anzeichens."> comment = <"Das Auftreten dieses Datenelements wird auf 0...* gesetzt, um bei Bedarf mehrere Körperstellen im Template voneinander zu trennen. Dies ermöglicht die Darstellung klinischer Szenarien, in denen ein Symptom/Krankheitsanzeichen an mehreren Stellen erfasst werden muss oder in denen sowohl die ursprüngliche als auch die distale Stelle bei der Schmerzausbreitung identifiziert werden, aber alle anderen Attribute wie Wirkung und Dauer identisch sind. Wenn die Anforderungen an die Erfassung der Lokalisation zur Laufzeit durch die Anwendung festgelegt werden oder komplexere Modellierungen wie z.B. relative Positionen erforderlich sind, verwenden Sie CLUSTER.anatomical_location oder CLUSTER.relative_location innerhalb des Slots \"Spezifische anatomische Lokalisation\" in diesem Archetyp. Wird die anatomische Lokalisation über vordefinierte Codes in den Symptomnamen aufgenommen, wird dieses Datenelement redundant. Wenn die anatomische Lokalisation mit dem Slot \"Spezifische anatomische Lokalisation\" erfasst wird, ist die Verwendung dieses Datenelements nicht erlaubt - erfassen Sie entweder die grobe \"Anatomische Lokalisation\" oder die \"Spezifische anatomische Lokalisation\", nicht beides. "> > ["at0152"] = < text = <"Beginn der Episode"> description = <"Der Beginn der Episode dieses Symptoms/Krankheitsanzeichens."> comment = <"Teil-Datumsangaben sind zulässig, gegebenenfalls kann aber auch das genaue Datum und die genaue Uhrzeit des Beginns erfasst werden. Wenn das Symptom/Krankheitsanzeichen zum ersten Mal auftritt oder ein Wiederauftreten vorliegt, wird dieses Datum verwendet, um den Beginn dieser Episode darzustellen. Wenn das Symptom/Krankheitsanzeichen andauernd ist, kann dieses Datenelement redundant sein, wenn es zuvor bereits erfasst wurde."> > ["at0153"] = < text = <"Spezifische Details"> description = <"Spezifische Datenelemente, die zusätzlich erforderlich sind, um eindeutige Attribute des identifizierten Symptoms/Krankheitsanzeichens zu erfassen."> comment = <"Zum Beispiel: CTCAE Einteilung."> > ["at0154"] = < text = <"Detail zum Faktor"> description = <"Strukturiertes Detail über den Faktor, der mit dem identifizierten Symptom/Krankheitsanzeichen in Verbindung steht."> > ["at0155"] = < text = <"Auswirkungen"> description = <"Beschreibung der Auswirkung des Symptoms/Krankheitsanzeichens."> comment = <"Die Bewertung der Auswirkung könnte die Schwere, Dauer und Häufigkeit des Symptoms sowie die Art der Auswirkungen berücksichtigen, einschließlich (aber nicht beschränkt auf) funktionelle, soziale und emotionale Auswirkungen. Das Auftreten dieses Datenelements wird auf 0...* gesetzt, damit bei Bedarf mehrere Arten von Auswirkungen in einem Template getrennt voneinander erfasst werden können. Beispiele für funktionelle Auswirkungen von Hörverlust können sein: \"Schwierigkeiten beim Hören in ruhiger Umgebung\"; \"Schwierigkeiten beim Hören von TV oder Radio\"; \"Schwierigkeiten beim Hören von Gruppengesprächen\"; und \"Schwierigkeiten beim Hören am Telefon\"."> > ["at0156"] = < text = <"Keinen Einfluss"> description = <"Der Faktor hat keinen Einfluss auf das Symptom/Krankheitsanzeichen."> > ["at0158"] = < text = <"Verschlechterung"> description = <"Der Faktor erhöht den Schweregrad oder die Folgen des Symptoms/Krankheitsanzeichens."> > ["at0159"] = < text = <"Linderung"> description = <"Der Faktor verringert den Schweregrad oder den Einfluss des Symptoms/Krankheitsanzeichens, bringt es aber nicht vollständig zum Abklingen."> > ["at0161"] = < text = <"Zeitpunkt des Rückgangs"> description = <"Der Endzeitpunkt dieser Episode des Symptoms/Krankheitsanzeichens."> comment = <"Wenn in Systemen \"Beginn der Episode\" und \"Dauer\" verwendet werden, kann dieses Datenelement berechnet oder alternativ als redundant betrachtet werden. Teil-Datumsangaben sind zulässig, gegebenenfalls kann aber auch das genaue Datum und die genaue Uhrzeit des Rückgangs erfasst werden."> > ["at0163"] = < text = <"Kommentar"> description = <"Zusätzliche Angaben zu dem Symptom/Krankheitsanzeichen, die nicht in anderen Feldern erfasst wurden."> > ["at0164"] = < text = <"Zeitpunkt des Beginns"> description = <"Zeitpunkt des Beginns und der Entwicklung des Symptoms oder Anzeichens."> comment = <"Es besteht die Möglichkeit die Art des Beginns mit einer Terminologie zu kodieren. Zum Beispiel: schleichend oder plötzlich."> > ["at0165"] = < text = <"Auslösender Faktor"> description = <"Details zu bestimmten Faktoren, die mit der Ausprägung des Symptoms oder Krankheitsanzeichens verbunden sind."> comment = <"Zum Beispiel: Hinlegen führt zu Sodbrennen oder das Gehen bergauf führt zu Claudicatio."> > ["at0170"] = < text = <"Faktor"> description = <"Name des die Gesundheit betreffenden Ereignisses, Symptoms, Krankheitsanzeichens oder eines anderen Faktors."> comment = <"Zum Beispiel: Beginn eines anderen Symptoms, hinlegen oder bergauf gehen."> > ["at0171"] = < text = <"Zeitintervall"> description = <"Das Zeitintervall zwischen dem Auftreten oder Einsetzen des Faktors und dem Einsetzen des Symptoms oder Krankheitsanzeichens."> > ["at0175"] = < text = <"Episode"> description = <"Kategorie dieser Episode für das identifizierte Symptom/Krankheitsanzeichen."> > ["at0176"] = < text = <"Neu"> description = <"Eine neue Episode des Symptoms/Krankheitsanzeichens - entweder das erste Auftreten oder ein Wiederauftreten, bei dem die vorherige Episode vollständig abgeklungen ist."> > ["at0177"] = < text = <"Unbestimmt"> description = <"Es ist nicht möglich zu bestimmen, ob dieses Auftreten des Symptoms/Krankheitsanzeichens neu oder andauernd ist."> > ["at0178"] = < text = <"Andauernd"> description = <"Das Symptom/Krankheitsanzeichen ist andauernd, im Grunde eine einzige, kontinuierliche Episode."> > ["at0180"] = < text = <"Progression"> description = <"Beschreibung der Entwicklung des Symptoms/Krankheitsanzeichens zum Zeitpunkt der Meldung."> comment = <"Das Vorkommen dieses Datenelements wird auf 0..* gesetzt, um zu ermöglichen, dass mehrere Arten der Progression in einem Template auf Wunsch definiert werden können – zum Beispiel Schweregrad oder Häufigkeit. Der Datentyp Text wird als Option hinzugefügt, um andere Wertesätze als die im Archetyp enthaltenen zu unterstützen."> > ["at0181"] = < text = <"Verbesserung"> description = <"Der Schweregrad dieses Symptoms/Krankheitsanzeichens hat sich im Verlauf dieser Episode allgemein verbessert."> > ["at0182"] = < text = <"Unverändert"> description = <"Der Schweregrad dieses Symptoms/Krankheitsanzeichens blieb im Verlauf dieser Episode allgemein unverändert."> > ["at0183"] = < text = <"Verschlechterung"> description = <"Der Schweregrad des Symptoms/Krankheitsanzeichens hat sich im Verlauf dieser Episode allgemein verschlechtert."> > ["at0184"] = < text = <"Vollständiger Rückgang"> description = <"Der Schweregrad dieses Symptoms/Krankheitsanzeichens ist im Verlauf dieser Episode vollständig zurückgegangen."> > ["at0185"] = < text = <"Beschreibung"> description = <"Beschreibung des Einflusses des Faktors auf das identifizierte Symptom/Krankheitsanzeichen."> > ["at0186"] = < text = <"Auftreten"> description = <"Wie ist die Art des Auftretens des Symptoms/Krankheitsanzeichens?"> > ["at0187"] = < text = <"Erstmaliges Auftreten"> description = <"Dies ist das erstmalige Auftreten des Symptoms/Krankheitsanzeichens."> > ["at0188"] = < text = <"Erneutes Auftreten"> description = <"Das Symptom/Krankheitsanzeichen ist in der Vergangenheit bereits aufgetreten."> > ["at0189"] = < text = <"Charakterisierung"> description = <"Wort oder kurzer Satz, mit dem die Art des Symptoms/Krankheitsanzeichens beschrieben wird."> comment = <"Zum Beispiel: Schmerzen können als \"bohrend\", \"brennend\" oder \"wie ein Stromschlag\" beschrieben werden; Kopfschmerzen können \"pochend\" oder \"konstant\" sein. Wenn möglich soll eine Kodierung mit einer externen Terminologie bevorzugt werden."> > ["at0190"] = < text = <"Rückbildender Faktor"> description = <"Details zu bestimmten Faktoren, die mit der Rückbildung des Symptoms oder Krankheitsanzeichens verbunden sind."> comment = <"Zum Beispiel: eine aufrechte Körperhaltung stoppt Sodbrennen oder Ruhepause bei Claudicatio."> > ["at0193"] = < text = <"Faktor"> description = <"Name des die Gesundheit betreffenden Ereignisses, Symptoms, Krankheitsanzeichens oder eines anderen Faktors."> comment = <"Zum Beispiel: aufrechte Körperhaltung oder ruhen."> > ["at0194"] = < text = <"Detail zum Faktor"> description = <"Strukturiertes Detail über den Faktor, der mit dem identifizierten Symptom/Krankheitsanzeichen in Verbindung steht."> > ["at0195"] = < text = <"Zeitintervall"> description = <"Das Zeitintervall zwischen dem Auftreten oder Einsetzen des Faktors und des Rückgangs des Symptoms oder Krankheitsanzeichens."> > ["at0196"] = < text = <"Beschreibung"> description = <"Beschreibung des Einflusses des Faktors auf das identifizierte Symptom/Krankheitsanzeichen."> > ["at0197"] = < text = <"Detail zum Faktor"> description = <"Strukturiertes Detail über den Faktor, der mit dem identifizierten Symptom/Krankheitsanzeichen in Verbindung steht."> > ["at0198"] = < text = <"Schwere-Ratingskala"> description = <"Numerische Bewertungsskala, die den Gesamtschweregrad des Symptoms oder Anzeichens darstellt."> comment = <"Die Schwere der Symptome kann von der Person bewertet werden, indem sie beispielsweise eine Punktzahl von 0 (d. h. kein Symptom vorhanden) bis 10 (d. h. das Symptom ist so schwerwiegend, wie die Person es sich vorstellen kann) aufzeichnet."> > ["at0200"] = < text = <"Tiefpunkt"> description = <"Datum/Uhrzeit, als ein monophasisches, fortschreitendes Symptom oder Zeichen seine maximale Intensität oder funktionelle Auswirkung erreichte."> comment = <"Zum Beispiel: das Datum, an dem die neurologischen Symptome bei der Guillain-Barré-Krankheit am schlimmsten waren."> > > > ["nb"] = < items = < ["at0000"] = < text = <"Symptom/Sykdomstegn"> description = <"Rapportert observasjon av fysiske tegn eller beskrivelse av unormale eller ubehagelige fornemmelser i kropp og/eller sinn."> > ["at0001"] = < 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."> > ["at0002"] = < text = <"Beskrivelse"> description = <"Fritekstbeskrivelse av det rapporterte symptomet eller sykdomstegnet."> comment = <"Eksempel: \"Svimmelhet med rotasjonsfølelse og av og til besvimelsesfølelse. Hurtig bevegelse fra sittende eller liggende til stående stilling virker å være en utløsende faktor. Opptrer typisk flere ganger daglig, og varer i ca et halvt til ett minutt hver gang. Å sette eller legge seg ned virker lindrende.\""> > ["at0003"] = < text = <"Mønster"> description = <"Fritekstbeskrivelse av symptomet eller sykdomstegnet i løpet av denne episoden."> comment = <"For eksempel: Smerte kan beskrives som konstant eller intermitterende. Dette elementet kan brukes til å registrere tekstlige beskrivelser (enten det er fri eller kodet tekst) av den typiske frekvensen og varigheten av symptomanfall under den aktuelle episoden."> > ["at0017"] = < text = <"Effekt"> description = <"Oppfattet effekt av den modifiserende faktoren på symptomet eller sykdomstegnet."> > ["at0018"] = < text = <"Modifiserende faktor"> description = <"Detaljer om hvordan en spesifikk faktor påvirker det identifiserte symptomet eller sykdomstegnet i løpet av denne episoden."> > ["at0019"] = < text = <"Faktor"> description = <"Navn på den modifiserende faktoren."> comment = <"Dette elementet er ment for å dokumentere faktorer, terapeutiske eller andre, som har innvirkning på symptomet. En oversikt over planlagte og utførte tiltak for symptomet eller sykdomstegnet må dokumenteres ved hjelp av andre arketyper. Eksempel på modifiserende faktor: sengeleie med flere puter, spising, eller administrering av et spesifikt legemiddel."> > ["at0021"] = < text = <"Alvorlighetskategori"> description = <"Kategori for å beskrive symptomets eller sykdomstegnets helhetlige alvorlighet."> comment = <"Det er vanskelig å definere verdier som mild, moderat og alvorlig på en slik måte at det kan brukes om flere symptomer, og som samtidig sikrer at tolkning og registrering av verdiene er konsistent. Ved å utvide verdisettet med verdier som \"ubetydelig\" og \"veldig alvorlig\", og/eller \"moderat mild\" og \"moderat alvorlig\" øker kompleksiteten, og påliteligheten i registreringen reduseres. Bruk av verdier som \"Livstruende\" eller \"fatal\" tas ofte med i et slikt verdisett, men disse verdiene gjenspeiler heller resultat enn alvorlighet. I lys av dette foretrekkes en mindre, mer veldefinert liste."> > ["at0023"] = < text = <"Mild"> description = <"Symptomet eller sykdomstegnets intensitet forstyrrer ikke normal aktivitet."> > ["at0024"] = < text = <"Moderat"> description = <"Symptomet eller sykdomstegnet intensitet forstyrrer normal aktivitet."> > ["at0025"] = < text = <"Alvorlig"> description = <"Symptomets eller sykdomstegnets intensitet hindrer normal aktivitet."> > ["at0028"] = < text = <"*Episode duration (en)"> description = <"*The duration of this episode of the symptom or sign since initial onset. (en)"> comment = <"Brukes \"Dato/tid for debut\" og \"Dato/tid for opphør\" i systemer, kan dette dataelementet kalkuleres av systemet eller være overflødig. Tekst-datatypen kan brukes for å registrere forhåndsdefinerte intervaller som \"0-7 dager, 1-2 uker, 2 uker eller mer\"."> > ["at0031"] = < text = <"Antall tidligere episoder"> description = <"Antall ganger symptomet eller sykdomstegnet tidligere har forekommet."> > ["at0037"] = < text = <"Episodebeskrivelse"> description = <"Fritekstbeskrivelse av symptomet eller sykdomstegnets utvikling gjennom denne episoden."> comment = <"For eksempel: Fritekstbeskrivelse av symptomdebuten, aktiviteter som forverret eller forbedret symptomet, om det er i bedring eller forverring og hvordan det ble fullstendig bedret i løpet av uker."> > ["at0056"] = < text = <"Beskrivelse"> description = <"Fritekstbeskrivelse av den modifiserende faktorens effekt på symptomet eller sykdomstegnet."> > ["at0057"] = < text = <"Beskrivelse av tidligere episoder"> description = <"Fritekstbeskrivelse av tidligere episoder."> comment = <"For eksempel: Frekvens/periodisitet - pr. time, dag, uke, måned, år og regularitet. Kan inneholde en sammenligning med denne episoden."> > ["at0063"] = < text = <"Tilknyttede symptomer/sykdomstegn"> description = <"Strukturerte detaljer om ethvert tilknyttet symptom eller sykdomstegn som er tilstede samtidig."> comment = <"I kliniske systemer med mulighet for linking er det mulig at tilknyttede symptomer/sykdomstegn allerede er registrert i det kliniske systemet. Systemet kan tillatte en kliniker å linke til relevante tilknyttede symptomer/sykdomstegn. Tillater ikke systemet linking eller det er en pasient som ikke har noen tilknyttede symptomer registrert, kan man legge til ytterligere instanser av symptom-arketypen for å beskrive de tidligere episodene."> > ["at0146"] = < text = <"Tidligere episoder"> description = <"Strukturerte detaljer om symptomet eller sykdomstegnet i løpet av en tidligere episode."> comment = <"I kliniske systemer med mulighet for linking er det mulig at tidligere episoder allerede er registrert i det kliniske systemet. Systemet kan tillatte en kliniker å linke til relevante tilknyttede symptomer. Tillater ikke systemet linking eller det er en pasient som ikke har noen tilknyttede symptomer registrert, kan man legge til ytterligere instanser av symptom-arketypen for å beskrive de tidligere episodene."> > ["at0147"] = < text = <"Strukturert anatomisk lokalisering"> description = <"Strukturert anatomisk lokalisering hvor symptomet eller sykdomstegnet ble rapportert."> comment = <"Hvis den anatomiske lokaliseringen allerede er satt i elementet \"Navn på symptom/sykdomstegn\" via prekoordinerte koder, blir dette SLOTet overflødig. Er den anatomiske lokaliseringen registrert i dataelementet \"Anatomisk lokalisering\", er bruken av dette SLOTet ikke tillatt. Registrer bare \"Anatomisk lokalisering\" eller \"Strukturert anatomisk lokalisering\", ikke begge."> > ["at0151"] = < text = <"Anatomisk lokalisering"> description = <"Registrering av ett enkelt område på kroppen hvor symptomet eller sykdomstegnet var rapportert."> comment = <"Forekomster for dette dataelementet er satt 0..* for å tillate at flere kroppssted kan trekkes ut i et templat om ønsket. Dette åpner for å representere kliniske scenarier hvor et symptom må registreres flere steder på kroppen eller for å identifisere både opphavssted for smerte og ytterpunkt for utstråling av smerter, og alle andre dataelementer i arketypen som \"Innvirkning\" og \"Varighet\" er like. Om kravet for registrering av kroppsplassering er bestemt i en applikasjon eller krever en mer kompleks modellering som for eksempel relativ lokalisering, bruk arketypen CLUSTER.anatomical_location eller CLUSTER.relative_location i \"Strukturert anatomisk lokalisering\"-SLOTet i denne arketypen. Er den anatomiske lokaliseringen inkludert i \"Navn på symptom/sykdomstegn\" via prekoordinerte koder er dette dataelementet overflødig. Registreres den anatomiske lokaliseringen i SLOTet \"Strukturert anatomisk lokalisering\" er bruken av dette dataelementet ikke tillatt. Registrer enten i \"Anatomisk lokalisering\" eller i \"Strukturert anatomisk lokalisering\", ikke i begge. "> > ["at0152"] = < text = <"Dato/tid for episodens debut"> description = <"Debuttidspunkt for denne episoden av symptomet eller sykdomstegnet."> comment = <"Partielle datoer er tillatt. Nøyaktig tid for symptomets debut kan registreres, dersom relevant. Dersom dette symptomet eller sykdomstegnet oppleves for første gang eller er en ny episode av et tidligere opplevd symptom, kan denne datoen brukes for å representere debuten for denne episoden. Dersom symptomet eller sykdomstegnet opptrer kontinuerlig, kan dette dataelementet være overflødig dersom det er registrert tidligere."> > ["at0153"] = < text = <"Spesifikke detaljer"> description = <"Ekstra dataelementer som er nødvendige for å registrere egenskaper unike for det identifiserte symptomet eller sykdomstegnet."> comment = <"For eksempel: Graderingen \"Common Terminology Criteria for Adverse Events\"."> > ["at0154"] = < text = <"Faktordetaljer"> description = <"Strukturerte detaljer om faktoren som er forbundet med det identifiserte symptomet eller sykdomstegnet."> > ["at0155"] = < text = <"Innvirkning"> description = <"Beskrivelse av symptomet eller sykdomstegnets innvirkning."> comment = <"Bedømmelsen av innvirkning må ta høyde for alvorlighet, varighet og frekvens av symptomet, i tillegg til type innvirkning, for eksempel: funksjonell, sosial og emosjonell innvirkning. Dataelementet er satt til 0..* for å tillate at flere typer innvirkning kan trekkes ut i et templat om ønskelig. For hørselstap vil innvirkning kunne omfatte \"Vansker med å høre i et stille miljø\", \"Vansker med å høre TV eller radio\"; \"Vansker med å høre gruppesamtaler\" og \"Vansker med å høre i telefon\"."> > ["at0156"] = < text = <"Ingen effekt"> description = <"Faktoren har ingen effekt på symptomet eller sykdomstegnet."> > ["at0158"] = < text = <"Forverrer"> description = <"Faktoren øker alvorlighet eller innvirkning av symptomet eller sykdomstegnet."> > ["at0159"] = < text = <"Lindrer"> description = <"Faktoren reduserer alvorligheten eller innvirkning av symptomet eller sykdomstegnet, men får det ikke til å opphøre fullstendig."> > ["at0161"] = < text = <"Dato/tid for opphør"> description = <"Dato/tid for opphør av denne episoden av symptomet eller sykdomstegnet."> comment = <"Brukes \"Dato/tid for debut\" og \"Varighet\" i systemer, kan dette dataelementet kalkuleres av systemet eller være overflødig. Ufullstendig dato er tillatt, nøyaktig dato og tid for opphør kan registreres om ønskelig."> > ["at0163"] = < text = <"Kommentar"> description = <"Ytterligere fritekst om symptomet eller sykdomstegnet som ikke dekkes i andre felt."> > ["at0164"] = < text = <"*Onset timing (en)"> description = <"*Timing of the onset and development of the symptom or sign. (en)"> comment = <"Debuttypen kan kodes med en terminologi om ønsket. For eksempel: Gradvis eller plutselig."> > ["at0165"] = < text = <"Utløsende faktor"> description = <"Detaljer om spesifikke faktorer som utløser symptomet eller sykdomstegnet."> comment = <"For eksempel: Å ligge flatt fører til sure oppstøt, eller å gå opp en bakke fører til beinsmerter."> > ["at0170"] = < text = <"Faktor"> description = <"Navn på helserelatert hendelse, symptom, rapportert sykdomstegn eller annen faktor."> comment = <"For eksempel: Debut av annet symptom, å ligge flatt, eller å gå opp en bakke."> > ["at0171"] = < text = <"Tidsintervall"> description = <"Tidsintervall mellom forekomst eller debut av faktoren og debut av symptomet eller sykdomstegnet."> > ["at0175"] = < text = <"Episodisitet"> description = <"Kategorisering av denne episoden av det identifiserte symptomet eller sykdomstegnet."> > ["at0176"] = < text = <"Nytt"> description = <"En ny episode av symptomet eller sykdomstegnet - enten den første forekomsten eller en ny forekomst der den tidligere episoden var fullstendig opphørt."> > ["at0177"] = < text = <"Ubestemt"> description = <"Det er ikke mulig å bestemme om denne forekomsten av symptomet er ny eller pågående."> > ["at0178"] = < text = <"Kontinuerlig"> description = <"Symptomet eller sykdomstegnet er kontinuerlig tilstedeværende, i praksis en enkelt pågående episode."> > ["at0180"] = < text = <"Progresjon"> description = <"Beskrivelse av symptomets eller sykdomstegnets progresjon ved rapporteringstidspunktet."> comment = <"Dataelementet er definert som 0..* for å tillate at flere typer progresjon trekkes ut i et templat om ønsket. For eksempel: alvorlighet eller frekvens. Tekst-datatypen er lagt til som et alternativ for å støtte andre verdisett enn det som er inkludert i arketypen."> > ["at0181"] = < text = <"Forbedret"> description = <"Symptomet eller sykdomstegnets alvorlighetsgrad er forbedret i løpet av denne episoden."> > ["at0182"] = < text = <"Uendret"> description = <"Symptomet eller sykdomstegnets alvorlighetsgrad er ikke endret i løpet av denne episoden."> > ["at0183"] = < text = <"Forverret"> description = <"Symptomet eller sykdomstegnets alvorighetsgrad har blitt forverret i løpet av denne episoden."> > ["at0184"] = < text = <"Opphørt"> description = <"Symptomet eller sykdomstegnets alvorlighetsgrad er opphørt i løpet av denne episoden."> > ["at0185"] = < text = <"Beskrivelse"> description = <"Fritekstbeskrivelse av faktorens effekt på det identifiserte symptomet eller sykdomstegnet."> > ["at0186"] = < text = <"Forekomst"> description = <"Type forekomst for dette symptomet eller sykdomstegnet."> > ["at0187"] = < text = <"Første forekomst"> description = <"Dette er den første forekomsten av dette symptomet eller sykdomstegnet."> > ["at0188"] = < text = <"Tilbakefall"> description = <"Ny forekomst av det samme symptomet eller sykdomstegnet etter at en tidligere episode var bedret."> > ["at0189"] = < text = <"Karakter"> description = <"Ord eller en kort frase som beskriver symptomets eller sykdomstegnets karakter."> comment = <"For eksempel: Smerte kan beskrives som \"gnagende\", \"brennende\" eller \"som et elektrisk støt\", mens en hodepine kan være \"bankende\" eller \"konstant\". Karakteren bør kodes med en terminologi, der det er mulig."> > ["at0190"] = < text = <"Avsluttende faktor"> description = <"Detaljer om spesifikke faktorer som får symptomet eller sykdomstegnet til å opphøre."> comment = <"For eksempel: vertikal posisjon stopper sure oppstøt, eller hvile får beinsmerter til å gå over."> > ["at0193"] = < text = <"Faktor"> description = <"Navn på helserelatert hendelse, symptom, rapportert sykdomstegn eller annen faktor."> comment = <"For eksempel: vertikal stilling, eller hvile."> > ["at0194"] = < text = <"Faktordetaljer"> description = <"Strukturerte detaljer om faktoren som er forbundet med det identifiserte symptomet eller sykdomstegnet."> > ["at0195"] = < text = <"Tidsintervall"> description = <"Tidsintervall mellom forekomst eller debut av faktoren og opphør av symptomet eller sykdomstegnet."> > ["at0196"] = < text = <"Beskrivelse"> description = <"Fritekstbeskrivelse av faktorens effekt på det identifiserte symptomet eller sykdomstegnet."> > ["at0197"] = < text = <"Faktordetaljer"> description = <"Strukturerte detaljer om faktoren som er forbundet med det identifiserte symptomet eller sykdomstegnet."> > ["at0198"] = < text = <"Gradering av alvorlighet"> description = <"Numerisk graderingsskala som representerer den overordnede alvorligheten til symptomet eller sykdomstegnet."> comment = <"Symptomets alvorlighet graderes av individet ved å registrere en skår for eksempel fra 0 (symptom ikke tilstede) til 10 (symptomet er så alvorlig som individet kan forestille seg)."> > ["at0200"] = < text = <"*Nadir (en)"> description = <"*Date/time when a monophasic, progressive symptom or sign reached its' maximal intensity or functional impact. (en)"> comment = <"*For example: the date when neurological signs in Guillain-Barre disease was at its worst. (en)"> > > > ["fi"] = < items = < ["at0000"] = < text = <"Oire"> description = <"Reported observation of a physical or mental disturbance in an individual.(en)"> > ["at0001"] = < text = <"Oireen nimi"> description = <"The name of the reported symptom or sign.(en)"> comment = <"*Symptom name should be coded with a terminology, where possible.(en)"> > ["at0002"] = < text = <"Kuvaus"> description = <"Narrative description about the reported symptom or sign.(en)"> > ["at0003"] = < text = <"Malli"> description = <"Narrative description about the pattern of the symptom or sign during this episode.(en)"> comment = <"*For example: pain could be described as constant or intermittent.(en)"> > ["at0017"] = < text = <"Vaikutus"> description = <"Perceived effect of the modifying factor on the symptom or sign.(en)"> > ["at0018"] = < text = <"Vaikuttajan kerroin"> description = <"Detail about how a specific factor effects the identified symptom or sign during this episode.(en)"> > ["at0019"] = < text = <"Vaikuttaja"> description = <"Name of the modifying factor.(en)"> comment = <"*Examples of modifying factor: lying on multiple pillows, eating or administration of a specific medication.(en)"> > ["at0021"] = < text = <"Vakavuusasteikko"> description = <"Category representing the overall severity of the symptom or sign.(en)"> comment = <"*Defining values such as mild, moderate or severe in such a way that is applicable to multiple symptoms or signs plus allows multiple users to interpret and record them consistently is not easy. Some organisations extend the value set further with inclusion of additional values such as 'Trivial' and 'Very severe', and/or 'Mild-Moderate' and 'Moderate-Severe', adds to the definitional difficulty and may also worsen inter-recorder reliability issues. Use of 'Life-threatening' and 'Fatal' is also often considered as part of this value set, although from a pure point of view it may actually reflect an outcome rather than a severity. In view of the above, keeping to a well-defined but smaller list is preferred and so the mild/moderate/severe value set is offered, however the choice of other text allows for other value sets to be included at this data element in a template. (en)"> > ["at0023"] = < text = <"Vähäinen"> description = <"The intensity of the symptom or sign does not cause interference with normal activity.(en)"> > ["at0024"] = < text = <"Kohtuullinen"> description = <"The intensity of the symptom or sign causes interference with normal activity.(en)"> > ["at0025"] = < text = <"Vakava"> description = <"The intensity of the symptom or sign causes prevents normal activity.(en)"> > ["at0028"] = < text = <"*Episode duration (en)"> description = <"*The duration of this episode of the symptom or sign since initial onset. (en)"> comment = <"*If 'Date/time of onset' and 'Date/time of resolution' are used in systems, this data element may be calculated, or alternatively, be considered redundant in this scenario. The text data type is used for recording preset duration intervals such as '0-7 days, 1-2 weeks, 2 weeks or more'. (en)"> > ["at0031"] = < text = <"Aikasempien kohtauksien lukumäärä"> description = <"The number of times this symptom or sign has previously occurred.(en)"> > ["at0037"] = < text = <"Kohtauksen kuvaus"> description = <"Narrative description about the course of the symptom or sign during this episode.(en)"> comment = <"*For example: a text description of the immediate onset of the symptom, activities that worsened or relieved the symptom, whether it is improving or worsening and how it resolved over weeks.(en)"> > ["at0056"] = < text = <"Kuvaus"> description = <"Narrative description of the effect of the modifying factor on the symptom or sign.(en)"> > ["at0057"] = < text = <"Edellisen kohtausten kuvaus"> description = <"Narrative description of any or all previous episodes.(en)"> comment = <"*For example: frequency/periodicity - per hour, day, week, month, year; and regularity. May include a comparison to this episode.(en)"> > ["at0063"] = < text = <"Liittyvä oire"> description = <"Structured details about any associated symptoms or signs that are concurrent.(en)"> comment = <"*In linked clinical systems, it is possible that associated symptoms or signs are already recorded within the EHR. Systems can allow the clinician to LINK to relevant associated symptoms/signs. However in a system or message without LINKs to existing data or with a new patient, additional instances of the symptom archetype could be included here to represent associated symptoms/signs.(en)"> > ["at0146"] = < text = <"Edelliset kohtaukset"> description = <"Structured details of the symptom or sign during a previous episode.(en)"> comment = <"*In linked clinical systems, it is possible that previous episodes are already recorded within the EHR. Systems can allow the clinician to LINK to relevant previous episodes. However in a system or message without LINKs to existing data or with a new patient, additional instances of the symptom archetype could be included here to represent previous episodes. It is recommended that new instances of the Symptom archetype inserted in this SLOT represent one or many previous episodes to this Symptom instance only.(en)"> > ["at0147"] = < text = <"Rakenteellinen kehon alue"> description = <"Structured body site where the symptom or sign was reported.(en)"> comment = <"*If the anatomical location is included in the Symptom name via precoordinated codes, use of this SLOT becomes redundant. If the anatomical location is recorded using the 'Body site' data element, then use of CLUSTER archetypes in this SLOT is not allowed - record only the simple 'Body site' OR 'Structured body site', but not both.(en)"> > ["at0151"] = < text = <"Kehon alue"> description = <"Simple body site where the symptom or sign was reported.(en)"> comment = <"*Occurrences of this data element are set to 0..* to allow multiple body sites to be separated out in a template if desired. This allows for representation of clinical scenarios where a symptom or sign needs to be recorded in multiple locations or identifying both the originating and distal site in pain radiation, but where all of the other attributes such as impact and duration are identical. If the requirements for recording the body site are determined at run-time by the application or require more complex modelling such as relative locations then use the CLUSTER.anatomical_location or CLUSTER.relative_location within the Detailed anatomical location' SLOT in this archetype. If the anatomical location is included in the Symptom name via precoordinated codes, this data element becomes redundant. If the anatomical location is recorded using the 'Structured body site' SLOT, then use of this data element is not allowed - record only the simple 'Body site' OR 'Structured body site', but not both.(en)"> > ["at0152"] = < text = <"Kohtauksen alku"> description = <"The onset for this episode of the symptom or sign.(en)"> comment = <"*While partial dates are permitted, the exact date and time of onset can be recorded, if appropriate. If this symptom or sign is experienced for the first time or is a re-occurrence, this date is used to represent the onset of this episode. If this symptom or sign is ongoing, this data element may be redundant if it has been recorded previously.(en)"> > ["at0153"] = < text = <"Ominaistiedot"> description = <"Specific data elements that are additionally required to record as unique attributes of the identified symptom or sign.(en)"> comment = <"*For example: CTCAE grading.(en)"> > ["at0154"] = < text = <"Vaikutustiedot"> description = <"Structured detail about the factor associated with the identified symptom or sign.(en)"> > ["at0155"] = < text = <"Vaikutus"> description = <"Description of the impact of this symptom or sign.(en)"> comment = <"*Assessment of impact could consider the severity, duration and frequency of the symptom as well as the type of impact including, but not limited to, functional, social and emotional impact. Occurrences of this data element are set to 0..* to allow multiple types of impact to be separated out in a template if desired. Examples for functional impact from hearing loss may include: 'Difficulty Hearing in Quiet Environment'; 'Difficulty Hearing the TV or Radio'; 'Difficulty Hearing Group Conversation'; and 'Difficulty Hearing on Phone'.(en)"> > ["at0156"] = < text = <"Ei vaikutusta"> description = <"The factor has no impact on the symptom or sign.(en)"> > ["at0158"] = < text = <"Pahentaa"> description = <"The factor increases the severity or impact of the symptom or sign.(en)"> > ["at0159"] = < text = <"Helpottaa"> description = <"The factor decreases the severity or impact of the symptom or sign, but does not fully resolve it.(en)"> > ["at0161"] = < text = <"Päättymisaika"> description = <"The timing of the cessation of this episode of the symptom or sign.(en)"> comment = <"*If 'Date/time of onset' and 'Duration' are used in systems, this data element may be calculated, or alternatively, considered redundant. While partial dates are permitted, the exact date and time of resolution can be recorded, if appropriate.(en)"> > ["at0163"] = < text = <"Kommentti"> description = <"Additional narrative about the symptom or sign not captured in other fields.(en)"> > ["at0164"] = < text = <"*Onset timing (en)"> description = <"*Timing of the onset and development of the symptom or sign. (en)"> comment = <"*The type of the onset can be coded with a terminology, if desired. For example: gradual; or sudden.(en)"> > ["at0165"] = < text = <"*Precipitating factor (en)"> description = <"*Details about specified factors that are associated with the precipitation of the symptom or sign. (en)"> comment = <"*For example: lying down leads to heartburn; or walking up a hill leads to claudication. (en)"> > ["at0170"] = < text = <"Vaikuttaja"> description = <"Name of the health event, symptom, reported sign or other factor.(en)"> comment = <"*For example: onset of another symptom; lying down; or walking up a hill. (en)"> > ["at0171"] = < text = <"Aikaväli"> description = <"*The interval of time between the occurrence or onset of the factor and onset of the symptom or sign. (en)"> > ["at0175"] = < text = <"Jaksollisuus"> description = <"Category of this episode for the identified symptom or sign.(en)"> > ["at0176"] = < text = <"Uusi"> description = <"A new episode of the symptom or sign - either the first ever occurrence or a reoccurrence where the previous episode had completely resolved.(en)"> > ["at0177"] = < text = <"Epämääräinen"> description = <"It is not possible to determine if this occurrence of the symptom or sign is new or ongoing.(en)"> > ["at0178"] = < text = <"Meneillään oleva"> description = <"This symptom or sign is ongoing, effectively a single, continuous episode.(en)"> > ["at0180"] = < text = <"Progressio"> description = <"Description progression of the symptom or sign at the time of reporting.(en)"> comment = <"*Occurrences of this data element are set to 0..* to allow multiple types of progression to be separated out in a template if desired - for example, severity or frequency. The Text data type is added as an option, to support other value sets than the ones included in the archetype. (en)"> > ["at0181"] = < text = <"Parantuva"> description = <"The severity of the symptom or sign has improved overall during this episode.(en)"> > ["at0182"] = < text = <"Ei muutosta"> description = <"The severity of the symptom or sign has not changed overall during this episode.(en)"> > ["at0183"] = < text = <"Pahentuva"> description = <"The severity of the symptom or sign has worsened overall during this episode.(en)"> > ["at0184"] = < text = <"Ratkaistu"> description = <"The severity of the symptom or sign has resolved.(en)"> > ["at0185"] = < text = <"Kuvaus"> description = <"Narrative description about the effect of the factor on the identified symptom or sign.(en)"> > ["at0186"] = < text = <"*Occurrence (en)"> description = <"*Type of occurrence for this symptom or sign? (en)"> > ["at0187"] = < text = <"*First occurrence (en)"> description = <"*This is the first ever occurrence of this symptom or sign. (en)"> > ["at0188"] = < text = <"*Recurrence (en)"> description = <"*This is the first ever occurrence of this symptom or sign. (en)"> > ["at0189"] = < text = <"*Character (en)"> description = <"*Word or short phrase describing the nature of the symptom or sign. (en)"> comment = <"*For example: pain could be described as 'gnawing', 'burning', or 'like an electric shock'; a headache could be 'throbbing' or 'constant'. Coding with an external terminology is preferred, where possible. (en)"> > ["at0190"] = < text = <"*Resolving factor (en)"> description = <"*Details about specified factors that are associated with the resolution of the symptom or sign. (en)"> comment = <"*For example: upright posture stops heartburn; or resting stops claudication. (en)"> > ["at0193"] = < text = <"Vaikuttaja"> description = <"Name of the health event, symptom, reported sign or other factor.(en)"> comment = <"*For example: upright posture; or resting. (en)"> > ["at0194"] = < text = <"Vaikutustiedot"> description = <"Structured detail about the factor associated with the identified symptom or sign.(en)"> > ["at0195"] = < text = <"Aikaväli"> description = <"*The interval of time between the occurrence or onset of the factor and resolution of the symptom or sign. (en)"> > ["at0196"] = < text = <"Kuvaus"> description = <"Narrative description about the effect of the factor on the identified symptom or sign.(en)"> > ["at0197"] = < text = <"Vaikutustiedot"> description = <"Structured detail about the factor associated with the identified symptom or sign.(en)"> > ["at0198"] = < text = <"*Severity rating (en)"> description = <"*Numerical rating scale representing the overall severity of the symptom or sign. (en)"> comment = <"*Symptom severity can be rated by the individual by recording a score for example from 0 (ie symptom not present) to 10 (ie symptom is as severe as the individual can imagine). (en)"> > ["at0200"] = < text = <"*Nadir (en)"> description = <"*Date/time when a monophasic, progressive symptom or sign reached its' maximal intensity or functional impact. (en)"> comment = <"*For example: the date when neurological signs in Guillain-Barre disease was at its worst. (en)"> > > > ["sv"] = < items = < ["at0000"] = < text = <"Symtom och tecken"> description = <"Rapporterad observation av en fysiskt eller psykiskt störning hos en individ."> > ["at0001"] = < text = <"Namnet på symtomet eller tecknet"> description = <"Namnet på det rapporterade symtomet eller tecknet."> comment = <"Namnet på symtomet ska kodas med en terminologi, om det är möjligt."> > ["at0002"] = < text = <"Beskrivning"> description = <"Sammanfattande beskrivning av rapporterat symtom eller tecken"> > ["at0003"] = < text = <"Mönster för episod"> description = <"Sammanfattande beskrivning av egenart och mönster av symtom eller tecken under denna episod."> comment = <"Exempelvis: smärta som kan beskrivas som konstant eller återkommande."> > ["at0017"] = < text = <"Effekt"> description = <"Upplevd effekt av den modifierande faktorn på symtom eller tecken."> > ["at0018"] = < text = <"Modifierande faktor"> description = <"Beskrivning hur en specifik faktor påverkar aktuellt symtom eller tecken under denna episod."> > ["at0019"] = < text = <"Faktor"> description = <"Namn på den påverkande faktorn."> comment = <"Exempel på påverkande faktor: Ligger på flera kuddar, tillförsel av ett specifikt läkemedel."> > ["at0021"] = < text = <"Svårighetsgrad"> description = <"Gruppering som ger en övergripande bild av svårighetsgraden av symtom eller tecken."> comment = <"Att göra en gradering som mild, måttlig eller svår på ett sådant sätt som är tillämpligt på flera symtom eller tecken samt utformas dem så att flera användare kan tolka och registrera dem på ett konsekvent sätt, är inte lätt. Vissa organisationer utökar alternativen ytterligare genom att inkludera fler steg som \"Obetydlig\" och \"Mycket allvarlig\" och/eller \"Mild-måttlig\" och \"Måttlig-Svår\", vilket ökar definitionssvårigheterna och kan också försämra tillförlitligheten mellan olika bedömare. Användning av \"Livshotande\" och \"Dödlig\" betraktas också ofta som en del av denna skala, även om det mer speglar ett resultat snarare än en en svårighetsgrad. Mot denna bakgrund är det att föredra att hålla sig till en kortare men väldefinierad lista som skalan med mild/måttlig/svår erbjuder. Möjligheten kvarstår dock att kunna inkludera ytterligare värden i detta dataelement i en mall."> > ["at0023"] = < text = <"Mild"> description = <"Intensiteten av symtom eller tecken påverkar inte normal livsföring. "> > ["at0024"] = < text = <"Måttlig"> description = <"Intensiteten av symtom eller tecken påverkar normal livsföring."> > ["at0025"] = < text = <"Svår"> description = <"Intensiteten av symtom eller tecken förhindrar normal livsföring."> > ["at0028"] = < text = <"Episodens längd"> description = <"Varaktigheten av denna episod av symtomet eller tecknet sedan första början."> comment = <"Om \"Datum/tid för start\" och \"Datum/tid för stopp används i IT-system, kan detta dataelement beräknas, eller alternativt betraktas som överflödigt i detta scenario. Textdatatypen används för att fånga förinställda varaktighetsintervall som 0-7 dagar, 1-2 veckor, 2 veckor eller mer. "> > ["at0031"] = < text = <"Antal tidigare inträffade episoder"> description = <"Antalet gånger som detta symtom eller tecken har förekommit tidigare."> > ["at0037"] = < text = <"Beskrivning av episoden"> description = <"Sammanfattande beskrivning av förloppet för symtom eller tecken under denna episod."> comment = <"Exempelvis en textbeskrivning om symtomdebut, aktiviteter som ger symtomförsämring eller förbättring, på vilket sätt som förbättring eller försämring sker och hur det försvinner över tid."> > ["at0056"] = < text = <"Beskrivning"> description = <"Redogörelse av den påverkande faktorns effekt på symtom eller tecken."> > ["at0057"] = < text = <"Beskrivning av tidigare episoder"> description = <"Sammanfattande beskrivning av några eller alla tidigare episoder."> comment = <"Exempelvis frekvens eller periodicitet, per timme, dag, vecka, månad, år och eventuell regelbundenhet. Den kan även innehålla en jämförelse med aktuell episod."> > ["at0063"] = < text = <"Associerade symtom och tecken"> description = <"Strukturerad beskrivning av eventuella samtidiga associerade symtom eller tecken. "> comment = <"I kliniska system med läkningsmöjlighet är det möjligt att assoscierade symtom eller tecken redan har registrerats i journalen. System kan låta klinikern länka till relevanta associerade symtom och tecken.Däremot i ett system eller i meddelanden utan länkningsmöjlighet till befintliga data eller med en ny patient, kan ytterligare fall av Symtom-arketypen ingå för att presentera associerade symtom och tecken."> > ["at0146"] = < text = <"Tidigare episoder"> description = <"Strukturerad beskrivning av symtom eller tecken som inträffat under en tidigare episod."> comment = <"I länkade kliniska system är det möjligt att tidigare episoder redan har registrerats i journalen. System kan låta klinikern länka till relevanta tidigare episoder (med dataypen LINK). Men i ett system eller meddelande utan länkningsmöjlighet till befintlig data eller med en ny patient, kan ytterligare användningsfall av Symtom-arketypen ingå, för att beskriva tidigare episoder. Det rekommenderas att nya exempel med Symtom-arketypen som förs in i detta fält (SLOT) presenterar en eller flera tidigare episoder kopplade till det aktuella symtomexemplet."> > ["at0147"] = < text = <"Strukturerad lokalisation"> description = <"Strukturerad lokalisation av plats på kroppen där symtomen eller tecknet uppvisades."> comment = <"Om den anatomiska platsen ingår i Symtom namnet via kodning blir användningen av detta fält överflödigt. Om den anatomiska platsen beskrivs i fältet \"Lokalisering\" , är det inte tillåtet att använda CLUSTER-arketyper i det här fältet. Dokumentera endast i \"Lokalisering\" ELLER \"Strukturerad lokalisering\", men inte båda fälten. "> > ["at0151"] = < text = <"Lokalisation"> description = <"Lokalisation av platsen på kroppen där symtomet eller tecknet rapporterats."> comment = <"Det här fältet kan repeteras, förekomst 0.. *, för att tillåta att flera platser på kroppen kan anges separat i en mall, om så önskas. Detta möjliggör dokumentation av kliniska användningsfall där ett symtom eller tecken kan förekomma på flera ställen samtidigt eller för att identifiera både start- och slutpunkter för en utstrålande smärta, samtidigt som andra aspekter som svårighetsgrad och varaktighet är identiska. Om kraven för att registrera platsen på kroppen bestäms av applikationen vid körningen, eller om dokumentationskraven för lokalisationen är mer komplex, som att ange den relativa lokalisationen , använd då arketyperna CLUSTER.anatomical_location eller CLUSTER.relative_location i \"Strukturerad lokalisation SLOT\" i den här arketypen. Om den anatomiska platsen ingår i Symtom namnet via kodning blir det här fältet överflödigt. Om den anatomiska platsen beskrivs i fältet \"Strukturerad lokalisation SLOT\" , är det inte tillåtet att använda detta fält. Dokumentera då endast i fältet \"Lokalisation\" ELLER i \"Strukturerad lokalisation\", inte i båda fälten."> > ["at0152"] = < text = <"Episod debut"> description = <"Debut för denna episod av symtomet eller tecknet."> comment = <"Även om partiella datum är tillåtna, kan det exakta datumet och tiden för debuten registreras, om så är lämpligt. Om detta symptom eller tecken upplevs för första gången eller återkommer, används detta datum för att representera början av denna episod. Om detta symptom eller tecken pågår kan detta dataelement vara överflödigt om det har registrerats tidigare. "> > ["at0153"] = < text = <"Specifika detaljer"> description = <"Ytterligare specifika datakomponenter som kan krävas för att fånga unika egenskaper för aktuellt symtom eller tecken."> comment = <"Exempelvis CTCAE-skattning (skattningsskala av svårighetsgraden)."> > ["at0154"] = < text = <"Detaljerad beskrivning av faktor"> description = <"Strukturerad beskrivning om den faktor som är kopplad till aktuellt symtom eller tecken."> > ["at0155"] = < text = <"Påverkan"> description = <"Beskrivning av vilken påverkan detta symptom eller tecken medför."> comment = <"Vid bedömningen av påverkan kan olika faktorer ingå som symtomets svårighetsgrad, varaktighet och frekvens samt typen av påverkan inklusive, men inte begränsat till, funktionell, social och emotionell påverkan. Förekomster av detta dataelement är inställt på 0..* ,vilket tillåter att flera typer av påverkan kan separeras i en mall, om så önskas. Exempel på funktionell påverkan av en hörselnedsättning kan vara: \"Hörselsvårigheter i tyst miljö\", 'Svårigheter att höra TV eller radio, \"Svårigheter att höra gruppsamtal\" och \"Svårigheter att höra på telefon\". "> > ["at0156"] = < text = <"Ingen effekt"> description = <"Faktorn har ingen påverkan på symtom eller tecken."> > ["at0158"] = < text = <"Förvärras"> description = <"Faktorn ökar svårighetsgraden eller effekten av symtom eller tecken. "> > ["at0159"] = < text = <"Lindrar"> description = <"Faktorn minskar svårighetsgraden eller påverkan på symtom eller tecken, men leder inte till fullständig lindring."> > ["at0161"] = < text = <"Upphörande datum/tid"> description = <"Tidpunkten för denna episod när av symtom eller tecken har upphört."> comment = <"Om \"Datum och tidpunkt för start\" och \"Varaktighet\" har använts i systemen, kan detta fält beräknas eller alternativt betraktas som överflödigt. Partiella datum och tidsuppgifter är tillåtna, men om det är möjligt och lämpligt kan exakt datum och tid registreras för symtomfrihet."> > ["at0163"] = < text = <"Kommentar"> description = <"Ytterligare beskrivning av symtom eller tecknen som inte dokumenterats i andra fält."> > ["at0164"] = < text = <"Tidpunkt för start"> description = <"Tidpunkten för starten och utvecklingen av symtomet eller tecknet"> comment = <"Typ av debut kan kodas med en terminologi, om så önskas. Exempelvis: gradvis eller plötslig."> > ["at0165"] = < text = <"Utlösande faktor"> description = <"Beskrivning av specifika faktorer som kan associeras med att symtom eller tecken initieras."> comment = <"Till exempel att ligga ner leder till halsbränna eller att gå uppför en kulle leder till krampsmärta i vaderna (claudicatio)."> > ["at0170"] = < text = <"Faktor"> description = <"Namn på hälsotillståndet, symtom, uppvisat tecken eller annan faktor."> comment = <"Exempelvis: uppkomst av ett annat symptom; lägga sig ner eller gå uppför en kulle."> > ["at0171"] = < text = <"Tidsintervall"> description = <"Tidsintervallet mellan uppkomst av faktorn och start av symtom eller tecken."> > ["at0175"] = < text = <"Förekomst"> description = <"Förekomsten av det angivna symtomet eller tecknet"> > ["at0176"] = < text = <"Ny"> description = <"En ny episod av symtomet eller tecknet, antingen som debutsymtom eller som återfall, där den föregående episoden redan har avslutats ."> > ["at0177"] = < text = <"Obestämd"> description = <"Det är inte möjligt att avgöra om denna förekomst av symtomet eller tecknet är nytt eller pågående."> > ["at0178"] = < text = <"Pågående"> description = <"Detta symptom eller tecken är pågående, registrerat som en enskild sammanhängande episod."> > ["at0180"] = < text = <"Stegvis utveckling"> description = <"Beskrivning av den stegvisa utvecklingen av symtom eller tecken vid tidpunkten för rapportering."> comment = <"Förekomster av detta dataelement är satt till 0..* för att tillåta flera typer av utveckling och kan separeras i en mall om så önskas, till exempel svårighetsgrad eller frekvens. Datatypen Text läggs till som ett alternativ för att stödja andra skalor än de som ingår i arketypen. "> > ["at0181"] = < text = <"förbättras"> description = <"Svårighetsgraden av symtom eller tecken har totalt sett förbättrats under denna episod."> > ["at0182"] = < text = <"oförändrat"> description = <"Svårighetsgraden av symtom eller tecken har totalt sett inte förändrats under denna episod."> > ["at0183"] = < text = <"Försämring"> description = <"Svårighetsgraden av symtom eller tecken har totalt sett förvärrats under denna episod."> > ["at0184"] = < text = <"Gått över"> description = <"Svårighetsgraden av symtom eller tecken har gått över."> > ["at0185"] = < text = <"Beskrivning"> description = <"Beskrivning av effekten av faktorn på identifierat symtom eller tecken."> > ["at0186"] = < text = <"Förekomst"> description = <"Typ av förekomst för detta symtom eller tecken."> > ["at0187"] = < text = <"Första tillfället"> description = <"Detta är det första tillfället någonsin som detta symtom eller tecken uppträder"> > ["at0188"] = < text = <"Upprepning"> description = <"Ny förekomst av samma symtom eller tecken efter att en tidigare episod har avslutats."> > ["at0189"] = < text = <"Egenart"> description = <"Ord eller kort fras som beskriver symtomets (eller tecknets) egenskaper."> comment = <"Exempelvis smärta kan beskrivas som \"gnagande\", \"brännande\" eller \"som en elektrisk stöt\". Huvudvärk kan vara \"bultande\" eller \"konstant\". Kodning med extern terminologi är att föredra, där så är möjligt."> > ["at0190"] = < text = <"Upphävande faktor"> description = <"Detaljer om specificerade faktorer som är associerat med att symtom eller tecken försvinner."> comment = <"Exempelvis att upprätt hållning stoppar halsbrännan eller at en vilopaus upphäver krampsmärta i vaderna (claudicatio)"> > ["at0193"] = < text = <"Faktor"> description = <"Namn på hälsotillståndet, symtom, tecken eller annan faktor."> comment = <"Exempelvis upprätt hållning eller vila."> > ["at0194"] = < text = <"Detaljerad beskrivning av faktor"> description = <"Strukturerad beskrivning av den faktor som är kopplad till aktuellt symtom eller tecken."> > ["at0195"] = < text = <"Tidsintervall"> description = <"Tidsintervallet mellan uppkomsten av faktorn och att symtom eller tecken försvinner."> > ["at0196"] = < text = <"Beskrivning"> description = <"Beskrivning av effekten av faktorn på identifierat symtom eller tecken."> > ["at0197"] = < text = <"Detaljerad beskrivning av faktor"> description = <"Strukturerad beskrivning av den faktor som är kopplad till aktuellt symtom eller tecken."> > ["at0198"] = < text = <"Allvarlighetsgrad"> description = <"Numerisk bedömningsskala som övergripande bild av svårighetsgraden av symtom eller tecken."> comment = <"Symtomets svårighetsgrad kan bedömas av individen själv genom att registrera ett steg på en skala, till exempel från 0 (dvs. symtom saknas) till 10 (dvs. symtomet är så allvarligt som individen kan föreställa sig)"> > ["at0200"] = < text = <"Sämst mående"> description = <"Datum/tid då ett monofasiskt, progressivt symptom eller tecken nådde sin maximala intensitet eller funktionella effekt."> comment = <"Till exempel: det datum då neurologiska tecken vid Guillain-Barres sjukdom var som värst"> > > > ["pt-br"] = < items = < ["at0000"] = < text = <"Sintoma/sinal"> description = <"Observação de um distúrbio físico ou mental relatada em um indivíduo."> > ["at0001"] = < text = <"Nome do sintoma/sinal"> description = <"O nome do sintoma ou sinal relatado."> comment = <"Nome do sintoma deve ser codificado com uma terminologia, se possível."> > ["at0002"] = < text = <"Descrição"> description = <"Descrição narrativa sobre o sintoma ou sinal relatado."> > ["at0003"] = < text = <"Padrão"> description = <"Descrição narrativa sobre o padrão do sintoma ou sinal durante este episódio."> comment = <"Por exemplo: dor pode ser descrita como constante ou intermitente."> > ["at0017"] = < text = <"Efeito"> description = <"Efeito percebido do fator modificador sobre o sintoma ou sinal."> > ["at0018"] = < text = <"Fator modificador"> description = <"Detalhe sobre como um fator específico afeta o sintoma ou sinal identificado durante este episódio."> > ["at0019"] = < text = <"Fator"> description = <"Nome do fator modificador."> comment = <"Exemplos de fatores modificadores: deitar sobre múltiplos travesseiros, comer ou administração de um medicamento específico."> > ["at0021"] = < text = <"Categoria de gravidade"> description = <"Categoria representando a gravidade geral do sintoma ou sinal."> comment = <"*Defining values such as mild, moderate or severe in such a way that is applicable to multiple symptoms or signs plus allows multiple users to interpret and record them consistently is not easy. Some organisations extend the value set further with inclusion of additional values such as 'Trivial' and 'Very severe', and/or 'Mild-Moderate' and 'Moderate-Severe', adds to the definitional difficulty and may also worsen inter-recorder reliability issues. Use of 'Life-threatening' and 'Fatal' is also often considered as part of this value set, although from a pure point of view it may actually reflect an outcome rather than a severity. In view of the above, keeping to a well-defined but smaller list is preferred and so the mild/moderate/severe value set is offered, however the choice of other text allows for other value sets to be included at this data element in a template. (en)"> > ["at0023"] = < text = <"Leve"> description = <"A intensidade do sintoma ou sinal não causa interferência com a atividade normal."> > ["at0024"] = < text = <"Moderada"> description = <"A intensidade do sintoma ou sinal causa interferência com a atividade normal."> > ["at0025"] = < text = <"Grave"> description = <"A intensidade do sintoma ou sinal impede a atividade normal."> > ["at0028"] = < text = <"*Episode duration (en)"> description = <"*The duration of this episode of the symptom or sign since initial onset. (en)"> comment = <"*If 'Date/time of onset' and 'Date/time of resolution' are used in systems, this data element may be calculated, or alternatively, be considered redundant in this scenario. The text data type is used for recording preset duration intervals such as '0-7 days, 1-2 weeks, 2 weeks or more'. (en)"> > ["at0031"] = < text = <"Número de episódios prévios"> description = <"O número de vezes que este sintoma ou sinal cocorreu previamente."> > ["at0037"] = < text = <"Descrição do episódio"> description = <"Descrição narrativa sobre o curso do sintoma ou sinal durante o episódio."> comment = <"Por exemplo: uma descrição em texto do início imediato do sintoma, atividades que pioram ou aliviam o sintoma, se está melhorando ou piorando e como se resolveu ao longo de semanas."> > ["at0056"] = < text = <"Descrição"> description = <"Descrição narrativa do efeito do fato modificador no sintoma ou sinal."> > ["at0057"] = < text = <"Descrição de episódios prévios"> description = <"Descrição narrativa de alguns ou todos os episódios prévios."> comment = <"Por exemplo: frequência/periodicidade - por hora, dia, semana, mês, ano; e regularidade. Pode incluir uma comparação com o episódio atual."> > ["at0063"] = < text = <"Sintoma/sinal associado"> description = <"Detalhes estruturados sobre quaisquer sintomas ou sinais associados que sejam concorrentes."> comment = <"Em sistemas clínicos concatenados, é possível que sintomas ou sinais associados já estejam registrados no PEP. O sistema pode permitir que o clínico relacione com sintomas e sinais associados. Entretanto em um sistema ou mensagem sem este relacionamento com dados existentes ou com um novo paciente, instâncias adicionais do arquétipo de sintoma podem ser incluídas para representar sintomas ou sinais associados."> > ["at0146"] = < text = <"Episódios prévios"> description = <"Detalhes estruturados do sintoma ou sinal durante um episódio prévio."> comment = <"Em sistemas clínicos concatenados, é possível que episódios prévios já etejam registrados no PEP. O sistema pode permitir que o clínico relacione este a episódios relevantes prévios. Entretanto em um sistema ou mensagem sem este relacionamento com dados existentes ou com um novo paciente, instâncias adicionais do arquétipo de sintoma podem ser incluídas para representar episódios prévios. É recomendado que novas instâncias do arquétipo de Sintomas inseridas neste SLOT representem um ou vários episódios prévios relacionados à esta instância."> > ["at0147"] = < text = <"Parte do corpo estruturada"> description = <"Parte do corpo estruturada em que o sintoma ou sinal foi relatado."> comment = <"Se a localização anatômica estiver incluída no nome do Sintoma através de códigos pré-coordenados, a utilização deste SLOT torna-se redundante. Se a localização anatômica for registrada utilizando o elemento de dado 'Parte do corpo', então o uso de arquétipos CLUSTER neste SLOT não é permitido - registre apenas o 'Parte do corpo' simples ou 'Parte do corpo estruturada' mas não ambos."> > ["at0151"] = < text = <"Parte do corpo"> description = <"Parte do corpo em que o sintoma ou sinal foi relatado."> comment = <"Ocorrências deste elemento de dado são ajustadas de 0..* para permitir múltiplas partes do corpo para serem separadas num template se desejado. Isto permite a representação de cenários clínicos em que o sintoma ou sinal precise ser registrado em múltiplas localizações ou identificar tanto local original e local distante de irradiação de dor, mas em que todos os outros atributos como o impacto e duração são idênticos. Se os requerimntos para registro da parte do corpo for determinado em tempo real pela aplicação ou requeira modelagem mais complexa como localizações relativas então utilize CLUSTER.anatomical_location ou CLUSTER.relative_location no SLOT 'Localização anatômica detalhada' neste arquétipo. Se a localização anatômica estiver incluída no nome do Sintoma através de códigos pré-coordenados, este elemento de dado torna-se redundante. Se a localização anatômica for registrada utilizando o SLOT 'Parte do corpo estruturada', então a utilização deste elemento de dado não é permitida - registre apenas o 'Parte do corpo' simples ou 'Parte do corpo estruturada', mas não ambos."> > ["at0152"] = < text = <"Início do episódio"> description = <"O início para este epsiódio de sintoma ou sinal."> comment = <"Datas parciais são permitidas, a data e hora exata do início pode ser registrada, se apropriado. Se este sintoma ou sinal for experimentado pela primeira ou se for uma recorrência, esta data é utilizada para representar o início deste episódio. Se o sintoma ou sinal estiver em curso, este elemento de dado pode ser redundante se já tiver sido registrado anteriormente."> > ["at0153"] = < text = <"Detalhes específicos"> description = <"Elementos de dados específicos que são necessários adicionar para registrar atributos exclusivos do sintoma ou sinal identificado."> comment = <"Por exemplo: graduação CTCAE."> > ["at0154"] = < text = <"Dealhes do fator"> description = <"Detalhe estruturado sobre o fator associado com o sintoma ou sinal identificado."> > ["at0155"] = < text = <"Impacto"> description = <"Descrição do impacto deste sintoma ou sinal."> comment = <"Avaliação do impacto pode considerar a gravidade, duração e frequência do sintoma ou sinal como também o tipo de impacto incluindo, mas limitado a, impacto funcional, social e emocional. Ocorrências deste elemento de dado são setadas para 0..* para permitir múltiplos tipos de impacto para serem separados no template se desejado. Exemplos de impacto funcional para perda auditiva podem incluir: 'Dificuldade de audição em ambiente quieto'; 'Dificuldade para ouvir rádio e TV'; 'Dificuldade de audição para conversa em grupo' e 'Dificuldade de audição ao telefone'."> > ["at0156"] = < text = <"Sem efeito"> description = <"O fator não tem impacto no sintoma ou sinal."> > ["at0158"] = < text = <"Piora"> description = <"O fator aumenta a gravidade ou impacto do sintoma ou sinal."> > ["at0159"] = < text = <"Alivia"> description = <"O fator diminui a gravidade ou impacto do sintoma ou sinal mas não resolve completamente."> > ["at0161"] = < text = <"Data/hora de resolução"> description = <"O momento de cessação deste episódio de sintoma ou sinal."> comment = <"Se 'Data/hora de início' e 'Duração' são utilizados no sistema, este elemento de dado pode ser calculado, ou alternativamente, considerado redundante. Datas parciais são permitidas, a data e hora exatas de resolução podem ser registradas, se apropriado."> > ["at0163"] = < text = <"Comentários"> description = <"Narrativa adicional sobre o sintoma ou sinal não capturada em outros campos."> > ["at0164"] = < text = <"*Onset timing (en)"> description = <"*Timing of the onset and development of the symptom or sign. (en)"> comment = <"O tipo de início pode ser codificado utilizando uma terminologia, se desejado. Por exemplo: gradual; ou súbito."> > ["at0165"] = < text = <"*Precipitating factor (en)"> description = <"*Details about specified factors that are associated with the precipitation of the symptom or sign. (en)"> comment = <"*For example: lying down leads to heartburn; or walking up a hill leads to claudication. (en)"> > ["at0170"] = < text = <"Fator"> description = <"Nome do evento de saúde, sintoma, sinal relatado ou outro fator."> comment = <"*For example: onset of another symptom; lying down; or walking up a hill. (en)"> > ["at0171"] = < text = <"Intervalo de tempo"> description = <"*The interval of time between the occurrence or onset of the factor and onset of the symptom or sign. (en)"> > ["at0175"] = < text = <"Episodicidade"> description = <"Categoria deste episódio para o sintoma ou sinal identificado."> > ["at0176"] = < text = <"Novo"> description = <"Um episódio novo de sintoma ou sinal - tanto para primeira ocorrência como para uma reccorrência quando o episódio prévio estiver completamente resolvido."> > ["at0177"] = < text = <"Indeterminado"> description = <"Não é possível determinar se esta ocorrência de sintoma ou sinal é nova ou em curso."> > ["at0178"] = < text = <"Em curso"> description = <"O sintoma ou sinal está em curso, efetivamente um episódio único e contínuo."> > ["at0180"] = < text = <"Progressão"> description = <"Descrição da progressão do sintoma ou sinal no momento do relato."> comment = <"*Occurrences of this data element are set to 0..* to allow multiple types of progression to be separated out in a template if desired - for example, severity or frequency. The Text data type is added as an option, to support other value sets than the ones included in the archetype. (en)"> > ["at0181"] = < text = <"Melhorando"> description = <"O gravidade do sintoma ou sinal melhorou ao longo deste episódio."> > ["at0182"] = < text = <"Imutável"> description = <"O gravidade do sintoma ou sinal não mudou ao longo deste episódio."> > ["at0183"] = < text = <"Piorando"> description = <"O gravidade do sintoma ou sinal piorou ao longo deste episódio."> > ["at0184"] = < text = <"Resolvido"> description = <"A gravidade do sintoma ou sinal resolveu-se."> > ["at0185"] = < text = <"Descrição"> description = <"Descrição narrativa sobre o efeito do fator no sintoma ou sinal identificado."> > ["at0186"] = < text = <"*Occurrence (en)"> description = <"*Type of occurrence for this symptom or sign? (en)"> > ["at0187"] = < text = <"*First occurrence (en)"> description = <"*This is the first ever occurrence of this symptom or sign. (en)"> > ["at0188"] = < text = <"*Recurrence (en)"> description = <"*This is the first ever occurrence of this symptom or sign. (en)"> > ["at0189"] = < text = <"*Character (en)"> description = <"*Word or short phrase describing the nature of the symptom or sign. (en)"> comment = <"*For example: pain could be described as 'gnawing', 'burning', or 'like an electric shock'; a headache could be 'throbbing' or 'constant'. Coding with an external terminology is preferred, where possible. (en)"> > ["at0190"] = < text = <"*Resolving factor (en)"> description = <"*Details about specified factors that are associated with the resolution of the symptom or sign. (en)"> comment = <"*For example: upright posture stops heartburn; or resting stops claudication. (en)"> > ["at0193"] = < text = <"Fator"> description = <"Nome do evento de saúde, sintoma, sinal relatado ou outro fator."> comment = <"*For example: upright posture; or resting. (en)"> > ["at0194"] = < text = <"Dealhes do fator"> description = <"Detalhe estruturado sobre o fator associado com o sintoma ou sinal identificado."> > ["at0195"] = < text = <"Intervalo de tempo"> description = <"*The interval of time between the occurrence or onset of the factor and resolution of the symptom or sign. (en)"> > ["at0196"] = < text = <"Descrição"> description = <"Descrição narrativa sobre o efeito do fator no sintoma ou sinal identificado."> > ["at0197"] = < text = <"Dealhes do fator"> description = <"Detalhe estruturado sobre o fator associado com o sintoma ou sinal identificado."> > ["at0198"] = < text = <"*Severity rating (en)"> description = <"*Numerical rating scale representing the overall severity of the symptom or sign. (en)"> comment = <"*Symptom severity can be rated by the individual by recording a score for example from 0 (ie symptom not present) to 10 (ie symptom is as severe as the individual can imagine). (en)"> > ["at0200"] = < text = <"*Nadir (en)"> description = <"*Date/time when a monophasic, progressive symptom or sign reached its' maximal intensity or functional impact. (en)"> comment = <"*For example: the date when neurological signs in Guillain-Barre disease was at its worst. (en)"> > > > ["nl"] = < items = < ["at0000"] = < text = <"Symptoom"> description = <"Vastgestelde observatie van een fysieke of mentale afwijking bij een individu."> > ["at0001"] = < text = <"Naam van het symptoom"> description = <"De naam van het vastgelegde symptoom"> > ["at0002"] = < text = <"*Description(en)"> description = <"*Narrative description about the reported symptom or sign.(en)"> > ["at0003"] = < text = <"*Pattern(en)"> description = <"*Narrative description about the pattern of the symptom or sign during this episode.(en)"> > ["at0017"] = < text = <"*Effect(en)"> description = <"*Perceived effect of the modifying factor on the symptom or sign.(en)"> > ["at0018"] = < text = <"*Modifying factor(en)"> description = <"*Detail about how a specific factor effects the identified symptom or sign during this episode.(en)"> > ["at0019"] = < text = <"*Factor(en)"> description = <"*Name of the modifying factor.(en)"> > ["at0021"] = < text = <"*Severity category(en)"> description = <"*Category representing the overall severity of the symptom or sign.(en)"> comment = <"*Defining values such as mild, moderate or severe in such a way that is applicable to multiple symptoms or signs plus allows multiple users to interpret and record them consistently is not easy. Some organisations extend the value set further with inclusion of additional values such as 'Trivial' and 'Very severe', and/or 'Mild-Moderate' and 'Moderate-Severe', adds to the definitional difficulty and may also worsen inter-recorder reliability issues. Use of 'Life-threatening' and 'Fatal' is also often considered as part of this value set, although from a pure point of view it may actually reflect an outcome rather than a severity. In view of the above, keeping to a well-defined but smaller list is preferred and so the mild/moderate/severe value set is offered, however the choice of other text allows for other value sets to be included at this data element in a template. (en)"> > ["at0023"] = < text = <"*Mild(en)"> description = <"*The intensity of the symptom or sign does not cause interference with normal activity.(en)"> > ["at0024"] = < text = <"*Moderate(en)"> description = <"*The intensity of the symptom or sign causes interference with normal activity.(en)"> > ["at0025"] = < text = <"*Severe(en)"> description = <"*The intensity of the symptom or sign causes prevents normal activity.(en)"> > ["at0028"] = < text = <"*Episode duration (en)"> description = <"*The duration of this episode of the symptom or sign since initial onset. (en)"> comment = <"*If 'Date/time of onset' and 'Date/time of resolution' are used in systems, this data element may be calculated, or alternatively, be considered redundant in this scenario. The text data type is used for recording preset duration intervals such as '0-7 days, 1-2 weeks, 2 weeks or more'. (en)"> > ["at0031"] = < text = <"*Number of previous episodes(en)"> description = <"*The number of times this symptom or sign has previously occurred.(en)"> > ["at0037"] = < text = <"*Episode description(en)"> description = <"*Narrative description about the course of the symptom or sign during this episode.(en)"> > ["at0056"] = < text = <"*Description(en)"> description = <"*Narrative description of the effect of the modifying factor on the symptom or sign.(en)"> > ["at0057"] = < text = <"*Description of previous episodes(en)"> description = <"*Narrative description of any or all previous episodes.(en)"> > ["at0063"] = < text = <"*Associated symptom/sign(en)"> description = <"*Structured details about any associated symptoms or signs that are concurrent.(en)"> > ["at0146"] = < text = <"*Previous episodes(en)"> description = <"*Structured details of the symptom or sign during a previous episode.(en)"> > ["at0147"] = < text = <"*Structured body site(en)"> description = <"*Structured body site where the symptom or sign was reported.(en)"> > ["at0151"] = < text = <"*Body site(en)"> description = <"*Simple body site where the symptom or sign was reported.(en)"> > ["at0152"] = < text = <"*Episode onset(en)"> description = <"*The onset for this episode of the symptom or sign.(en)"> > ["at0153"] = < text = <"*Specific details(en)"> description = <"*Specific data elements that are additionally required to record as unique attributes of the identified symptom or sign.(en)"> > ["at0154"] = < text = <"*Factor detail(en)"> description = <"*Structured detail about the factor associated with the identified symptom or sign.(en)"> > ["at0155"] = < text = <"*Impact(en)"> description = <"*Description of the impact of this symptom or sign.(en)"> > ["at0156"] = < text = <"*No effect(en)"> description = <"*The factor has no impact on the symptom or sign.(en)"> > ["at0158"] = < text = <"*Worsens(en)"> description = <"*The factor increases the severity or impact of the symptom or sign.(en)"> > ["at0159"] = < text = <"*Relieves(en)"> description = <"*The factor decreases the severity or impact of the symptom or sign, but does not fully resolve it.(en)"> > ["at0161"] = < text = <"*Resolution date/time(en)"> description = <"*The timing of the cessation of this episode of the symptom or sign.(en)"> > ["at0163"] = < text = <"*Comment(en)"> description = <"*Additional narrative about the symptom or sign not captured in other fields.(en)"> > ["at0164"] = < text = <"*Onset timing (en)"> description = <"*Timing of the onset and development of the symptom or sign. (en)"> > ["at0165"] = < text = <"*Precipitating factor (en)"> description = <"*Details about specified factors that are associated with the precipitation of the symptom or sign. (en)"> comment = <"*For example: lying down leads to heartburn; or walking up a hill leads to claudication. (en)"> > ["at0170"] = < text = <"*Factor(en)"> description = <"*Name of the health event, symptom, reported sign or other factor.(en)"> comment = <"*For example: onset of another symptom; lying down; or walking up a hill. (en)"> > ["at0171"] = < text = <"*Time interval(en)"> description = <"*The interval of time between the occurrence or onset of the factor and onset of the symptom or sign. (en)"> > ["at0175"] = < text = <"*Episodicity(en)"> description = <"*Category of this episode for the identified symptom or sign.(en)"> > ["at0176"] = < text = <"*New(en)"> description = <"*A new episode of the symptom or sign - either the first ever occurrence or a reoccurrence where the previous episode had completely resolved.(en)"> > ["at0177"] = < text = <"*Indeterminate(en)"> description = <"*It is not possible to determine if this occurrence of the symptom or sign is new or ongoing.(en)"> > ["at0178"] = < text = <"*Ongoing(en)"> description = <"*This symptom or sign is ongoing, effectively a single, continuous episode.(en)"> > ["at0180"] = < text = <"Beloop"> description = <"Beloop van het symptoom op het moment van verslaglegging."> comment = <"*Occurrences of this data element are set to 0..* to allow multiple types of progression to be separated out in a template if desired - for example, severity or frequency. The Text data type is added as an option, to support other value sets than the ones included in the archetype. (en)"> > ["at0181"] = < text = <"Verbeterend"> description = <"*The severity of the symptom or sign has improved overall during this episode.(en)"> > ["at0182"] = < text = <"Onveranderd"> description = <"*The severity of the symptom or sign has not changed overall during this episode.(en)"> > ["at0183"] = < text = <"Verslechtering"> description = <"*The severity of the symptom or sign has worsened overall during this episode.(en)"> > ["at0184"] = < text = <"Hersteld"> description = <"*The severity of the symptom or sign has resolved.(en)"> > ["at0185"] = < text = <"*Description(en)"> description = <"*Narrative description about the effect of the factor on the identified symptom or sign.(en)"> > ["at0186"] = < text = <"*Occurrence(en)"> description = <"*Type of occurrence for this symptom or sign?(en)"> > ["at0187"] = < text = <"*First occurrence(en)"> description = <"*This is the first ever occurrence of this symptom or sign.(en)"> > ["at0188"] = < text = <"*Recurrence(en)"> description = <"*New occurrence of the same symptom or sign after a previous episode was resolved.(en)"> > ["at0189"] = < text = <"*Character(en)"> description = <"*Word or short phrase describing the nature of the symptom or sign.(en)"> > ["at0190"] = < text = <"*Resolving factor (en)"> description = <"*Details about specified factors that are associated with the resolution of the symptom or sign. (en)"> comment = <"*For example: upright posture stops heartburn; or resting stops claudication. (en)"> > ["at0193"] = < text = <"*Factor(en)"> description = <"*Name of the health event, symptom, reported sign or other factor.(en)"> comment = <"*For example: upright posture; or resting. (en)"> > ["at0194"] = < text = <"*Factor detail(en)"> description = <"*Structured detail about the factor associated with the identified symptom or sign.(en)"> > ["at0195"] = < text = <"*Time interval(en)"> description = <"*The interval of time between the occurrence or onset of the factor and resolution of the symptom or sign. (en)"> > ["at0196"] = < text = <"*Description(en)"> description = <"*Narrative description about the effect of the factor on the identified symptom or sign.(en)"> > ["at0197"] = < text = <"*Factor detail(en)"> description = <"*Structured detail about the factor associated with the identified symptom or sign.(en)"> > ["at0198"] = < text = <"*Severity rating (en)"> description = <"*Numerical rating scale representing the overall severity of the symptom or sign. (en)"> comment = <"*Symptom severity can be rated by the individual by recording a score for example from 0 (ie symptom not present) to 10 (ie symptom is as severe as the individual can imagine). (en)"> > ["at0200"] = < text = <"*Nadir (en)"> description = <"*Date/time when a monophasic, progressive symptom or sign reached its' maximal intensity or functional impact. (en)"> comment = <"*For example: the date when neurological signs in Guillain-Barre disease was at its worst. (en)"> > > > > term_bindings = < ["SNOMED-CT"] = < items = < ["at0023"] = <[SNOMED-CT::162468002]> ["at0024"] = <[SNOMED-CT::162469005]> ["at0025"] = <[SNOMED-CT::162470006]> ["at0028"] = <[SNOMED-CT::162434008]> ["at0021"] = <[SNOMED-CT::405162009]> ["at0152"] = <[SNOMED-CT::405795006]> > > > ( src )
• archetype (adl_version=1.4; rm_release=1.1.0; uid=659df819-b8da-4489-9b7e-0a20074f543c) openEHR-EHR-CLUSTER.exclusion_symptom_sign.v0 concept [at0000] -- Exclusion of a symptom or sign language original_language = <[ISO_639-1::en]> translations = < ["nb"] = < language = <[ISO_639-1::nb]> author = < ["name"] = <"Lars Bitsch-Larsen"> ["organisation"] = <"Haukeland University Hospital of Bergen, Norway"> > accreditation = <"MD, DEAA, MBA, spec in anesthesia, spec in tropical medicine."> > > description original_author = < ["name"] = <"Heather Leslie"> ["organisation"] = <"Ocean Informatics"> ["email"] = <"heather.leslie@oceaninformatics.com"> ["date"] = <"2015-06-26"> > details = < ["nb"] = < language = <[ISO_639-1::nb]> purpose = <"Anvendes for registrering av fravær av et spesifikk symptom som definert i \"openEHR-EHR-CLUSTER.symptom.v1 archetype\"."> use = <""> keywords = <"Symptom", "fravær", "eksklusjon"> misuse = <""> copyright = <"© openEHR Foundation"> > ["en"] = < language = <[ISO_639-1::en]> purpose = <"To record a positive statement to explicitly record that a symptom or sign was reported as not present."> use = <"Use to record a positive statement to explicitly record that a symptom or sign was reported as not present. Use to record exlicitly that a symptom or sign was absolutely not present. If this is not absolutely required, consider use of the 'Nil significant' data element within the CLUSTER.symptom_sign archetype. This archetype has been specifically designed to be used in the 'Structured detail' SLOT within the OBSERVATION.story archetype, but can also be used within other OBSERVATION or CLUSTER archetypes, where clinically appropriate."> keywords = <"symptom, absence, exclusion", ...> misuse = <""> copyright = <"© openEHR Foundation"> > > lifecycle_state = <"in_development"> other_contributors = <> 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"> ["current_contact"] = <"Heather Leslie, Ocean Informatics<heather.leslie@oceaninformatics.com>"> ["original_namespace"] = <"org.openehr"> ["original_publisher"] = <"openEHR Foundation"> ["custodian_namespace"] = <"org.openehr"> ["MD5-CAM-1.0.1"] = <"4C7933C02F879864FC54A31737ABEBD3"> ["build_uid"] = <"e1d694db-a6eb-48c3-a4d1-f4fef9f65b75"> ["revision"] = <"0.0.1-alpha"> > definition CLUSTER[at0000] matches { -- Exclusion of a symptom or sign items cardinality matches {1..*; unordered} matches { ELEMENT[at0001] occurrences matches {0..1} matches { -- Exclusion Statement value matches { DV_TEXT matches {*} } } ELEMENT[at0002] occurrences matches {0..1} matches { -- Excluded Symptom value matches { DV_TEXT matches {*} DV_CODED_TEXT matches { defining_code matches {[local::]} } } } } } ontology term_definitions = < ["en"] = < items = < ["at0000"] = < text = <"Exclusion of a symptom or sign"> description = <"Statement to explicitly record that a symptom or signe was reported as not present."> > ["at0001"] = < text = <"Exclusion Statement"> description = <"A statement about the exclusion of known symptoms in the health record."> comment = <"For example: \"No significant symptoms\"."> > ["at0002"] = < text = <"Excluded Symptom"> description = <"Identification of the specific symptom to which the Exclusion Statement applies."> comment = <"Coding of the Symptom with a terminology is desirable, where possible."> > > > ["nb"] = < items = < ["at0000"] = < text = <"*Exclusion of a symptom or sign(en)"> description = <"*Statement to explicitly record that a symptom or signe was reported as not present.(en)"> > ["at0001"] = < text = <"*Exclusion Statement(en)"> description = <"*A statement about the exclusion of known symptoms in the health record.(en)"> comment = <"*For example: \"No significant symptoms\".(en)"> > ["at0002"] = < text = <"*Excluded Symptom(en)"> description = <"*Identification of the specific symptom to which the Exclusion Statement applies.(en)"> comment = <"*Coding of the Symptom with a terminology is desirable, where possible.(en)"> > > > > ( src )

External References

Type	Reference	Content
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web	snomed.info	231107005
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web	snomed.info	6471006
web	snomed.info	55300003
web	snomed.info	24199005
web	snomed.info	255238004
web	snomed.info	255239007
web	snomed.info	307486002
web	snomed.info	27789000
web	snomed.info	70232002
web	snomed.info	5878004
web	snomed.info	445000002
web	snomed.info	27635008
web	snomed.info	36349006
web	snomed.info	73063007
web	snomed.info	279093005
web	snomed.info	279098001
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web	snomed.info	83644001
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web	snomed.info	301371003
web	snomed.info	279095003
web	snomed.info	8708008
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web	snomed.info	103013007
web	snomed.info	71393004
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web	snomed.info	385425000
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web	snomed.info	282260003
web	snomed.info	289123006
web	snomed.info	18949003
web	snomed.info	255710008
web	snomed.info	277773003
web	snomed.info	113011001
web	snomed.info	397578001
web	snomed.info	76067001
web	snomed.info	408797004
web	snomed.info	10904000
web	snomed.info	122546009
web	specifications.openehr.org	CLUSTER
web	specifications.openehr.org	ITEM
web	specifications.openehr.org	ELEMENT
web	specifications.openehr.org	DV_TEXT
web	specifications.openehr.org	DATA_VALUE
web	specifications.openehr.org	DV_CODED_TEXT
web	specifications.openehr.org	DV_DATE_TIME
web	specifications.openehr.org	DV_INTERVAL <>
web	specifications.openehr.org	DV_DURATION
web	specifications.openehr.org	DV_COUNT
web	github.com	FHIR R4 Symptoms Implementation Guide, published by HL7 International / Clinical Interoperability Council. This guide is not an authorized publication; it is the continuous build for version 1.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-symptoms-ig/ and changes regularly. See the Directory of published versions
web	snomed.info	SNOMED CT: 18131002 "Acute fulminating"
web	snomed.info	SNOMED CT: 90734009 "Chronic"
web	snomed.info	SNOMED CT: 255212004 "Acute-on-chronic"
web	snomed.info	SNOMED CT: 279116004 "Affective response to pain"
web	snomed.info	SNOMED CT: 445000002 "Recent air travel (event)"
web	snomed.info	SNOMED CT: 255238004 "Continuous"
web	snomed.info	SNOMED CT: 255239007 "Discontinuous"
web	snomed.info	SNOMED CT: 307486002 "Single event"
web	snomed.info	SNOMED CT: 27789000 "Infrequent"
web	snomed.info	SNOMED CT: 70232002 "Frequent"
web	snomed.info	SNOMED CT: 5878004 "Low frequency"
web	snomed.info	SNOMED CT: 61751001 "Gradual onset"
web	snomed.info	SNOMED CT: 385315009 "Sudden onset"
web	specifications.openehr.org	http://openehr.org/fhir/StructureDefinition/CLUSTER
web	specifications.openehr.org	http://openehr.org/fhir/StructureDefinition/DV-TEXT
web	specifications.openehr.org	http://openehr.org/fhir/StructureDefinition/UID-BASED-ID
web	specifications.openehr.org	http://openehr.org/fhir/StructureDefinition/LINK
web	specifications.openehr.org	http://openehr.org/fhir/StructureDefinition/ARCHETYPED
web	specifications.openehr.org	http://openehr.org/fhir/StructureDefinition/FEEDER-AUDIT
web	specifications.openehr.org	http://openehr.org/fhir/StructureDefinition/ITEM
web	specifications.openehr.org	http://openehr.org/fhir/StructureDefinition/ELEMENT
web	specifications.openehr.org	http://openehr.org/fhir/StructureDefinition/DV-CODED-TEXT
web	specifications.openehr.org	http://openehr.org/fhir/StructureDefinition/DV_TEXT
web	specifications.openehr.org	http://openehr.org/fhir/StructureDefinition/DATA-VALUE
web	specifications.openehr.org	http://openehr.org/fhir/StructureDefinition/DV_CODED_TEXT
web	specifications.openehr.org	Original Source: specifications.openehr.org
web	specifications.openehr.org	UID_BASED_ID
web	specifications.openehr.org	LINK
web	specifications.openehr.org	ARCHETYPED
web	specifications.openehr.org	FEEDER_AUDIT
web	specifications.openehr.org	Exclusion Statement Optional DV_TEXT
web	specifications.openehr.org	Excluded Symptom Optional DV_TEXT
web	specifications.openehr.org	Excluded Symptom Optional DV_CODED_TEXT
web	specifications.openehr.org	http://openehr.org/fhir/StructureDefinition/DV_DATE_TIME
web	specifications.openehr.org	http://openehr.org/fhir/StructureDefinition/DV_INTERVAL < >
web	specifications.openehr.org	http://openehr.org/fhir/StructureDefinition/DV_DURATION
web	specifications.openehr.org	http://openehr.org/fhir/StructureDefinition/CODE-PHRASE
web	specifications.openehr.org	http://openehr.org/fhir/StructureDefinition/DV-INTERVAL
web	specifications.openehr.org	http://openehr.org/fhir/StructureDefinition/REFERENCE-RANGE < http://openehr.org/fhir/StructureDefinition/DV-ORDERED >
web	specifications.openehr.org	http://openehr.org/fhir/StructureDefinition/REFERENCE-RANGE < http://openehr.org/fhir/StructureDefinition/DV-ORDERED >
web	specifications.openehr.org	http://openehr.org/fhir/StructureDefinition/DV_COUNT
web	specifications.openehr.org	http://openehr.org/fhir/StructureDefinition/DV-INTERVAL < http://openehr.org/fhir/StructureDefinition/DV-COUNT >
web	specifications.openehr.org	http://openehr.org/fhir/StructureDefinition/DV-INTERVAL < http://openehr.org/fhir/StructureDefinition/DV-COUNT >
web	specifications.openehr.org	http://openehr.org/fhir/StructureDefinition/REFERENCE-RANGE < http://openehr.org/fhir/StructureDefinition/DV-COUNT >
web	specifications.openehr.org	http://openehr.org/fhir/StructureDefinition/REFERENCE-RANGE < http://openehr.org/fhir/StructureDefinition/DV-COUNT >
web	specifications.openehr.org	CODE_PHRASE
web	specifications.openehr.org	DV_INTERVAL
web	specifications.openehr.org	REFERENCE_RANGE < DV_ORDERED >
web	specifications.openehr.org	REFERENCE_RANGE < DV_ORDERED >
web	specifications.openehr.org	DV_INTERVAL < DV_COUNT >
web	specifications.openehr.org	DV_INTERVAL < DV_COUNT >
web	specifications.openehr.org	REFERENCE_RANGE < DV_COUNT >
web	specifications.openehr.org	REFERENCE_RANGE < DV_COUNT >
web	specifications.openehr.org	Symptom/Sign name Repeating DV_TEXT
web	specifications.openehr.org	Body site Optional, Repeating DV_TEXT
web	specifications.openehr.org	Description Optional DV_TEXT
web	specifications.openehr.org	Episodicity Optional DV_CODED_TEXT
web	specifications.openehr.org	Occurrence Optional DV_CODED_TEXT
web	specifications.openehr.org	Episode onset Optional DV_DATE_TIME
web	specifications.openehr.org	Episode onset Optional DV_INTERVAL
web	specifications.openehr.org	Onset timing Optional DV_TEXT
web	specifications.openehr.org	Onset timing Optional DV_DURATION
web	specifications.openehr.org	Onset timing Optional DV_INTERVAL
web	specifications.openehr.org	Nadir Optional DV_DATE_TIME
web	specifications.openehr.org	Episode duration Optional DV_DURATION
web	specifications.openehr.org	Episode duration Optional DV_INTERVAL
web	specifications.openehr.org	Episode duration Optional DV_TEXT
web	specifications.openehr.org	Severity category Optional DV_CODED_TEXT
web	specifications.openehr.org	Severity category Optional DV_TEXT
web	specifications.openehr.org	Character Optional, Repeating DV_TEXT
web	specifications.openehr.org	Progression Optional, Repeating DV_CODED_TEXT
web	specifications.openehr.org	Progression Optional, Repeating DV_TEXT
web	specifications.openehr.org	Pattern Optional DV_TEXT
web	specifications.openehr.org	Factor Optional DV_TEXT
web	specifications.openehr.org	Effect Optional DV_CODED_TEXT
web	specifications.openehr.org	Time interval Optional DV_DURATION
web	specifications.openehr.org	Impact Optional, Repeating DV_TEXT
web	specifications.openehr.org	Episode description Optional DV_TEXT
web	specifications.openehr.org	Resolution date/time Optional DV_DATE_TIME
web	specifications.openehr.org	Description of previous episodes Optional DV_TEXT
web	specifications.openehr.org	Number of previous episodes Optional DV_COUNT
web	specifications.openehr.org	Comment Optional DV_TEXT
web	snomed.info	44868003
web	snomed.info	231107005
web	snomed.info	394615007
web	snomed.info	225316001
web	snomed.info	7704007
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web	snomed.info	719078002
web	snomed.info	226029000
web	snomed.info	91251008
web	snomed.info	133921002
web	snomed.info	228565006
web	snomed.info	266694003
web	snomed.info	19997007
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Internal Images

../assets/images/001.svg

exclusion_symptom_archetype.png

symptom_archetype.png

tbl-open.png

tree-filter.png