Seitenhistorie
...
Code | BEZEICHNUNG IM CODESYSTEM | Codesystem |
|---|---|---|
| 364528001 | Skin observable (observable entity) | SNOMED Clinical Terms |
FHIR®-Mapping:
- KBV_PR_MIO_CMR_Observation_U5_U9_Physical_Exam_Skin
- KBV_PR_MIO_CMR_Diagnostic_Report_U5_U9_Physical_Exam_Skin
Wert: Code
| KONZEPT & WIEDERGABENAME | Code | BEZEICHNUNG IM CODESYSTEM | Codesystem |
|---|---|---|---|
| auffällige Blässe | 267029006 | Pale - symptom (finding) | SNOMED Clinical Terms |
| Anhalt für Verletzungen (z. B. Hämatome, Petechien, Verbrennungen, Narben) | 781645001 | Injury to skin caused by trauma (finding) | SNOMED Clinical Terms |
| entzündliche Hautveränderungen | 106076001 : 116676008 = 708039003 | Skin finding (finding) : Associated morphology (attribute) = Inflammatory lesion (morphologic abnormality) | SNOMED Clinical Terms |
...
CODE | BEZEICHNUNG IM CODESYSTEM | CODESYSTEM |
|---|---|---|
| 364048003 | Respiratory observable (observable entity) | SNOMED Clinical Terms |
FHIR®-Mapping:
- KBV_PR_MIO_CMR_Observation_U8_Physical_Exam_Chest_Lung_Respiratory_Tract
- KBV_PR_MIO_CMR_Diagnostic_Report_U8_Physical_Exam_Chest_Lung_Respiratory_Tract
Wert: Code
| KONZEPT & WIEDERGABENAME | Code | BEZEICHNUNG IM CODESYSTEM | Codesystem |
|---|---|---|---|
| Auskultation | 301272007 | Chest auscultation finding (finding) | SNOMED Clinical Terms |
| Atemgeräusch | 301273002 | Abnormal breath sounds (finding) | SNOMED Clinical Terms |
| Atemfrequenz | 17077006 | Abnormal respiratory rate (finding) | SNOMED Clinical Terms |
| Thoraxkonfiguration | 298706004 | Finding of appearance of thorax (finding) | SNOMED Clinical Terms |
| Mamillenabstand | 423230008 | Wide spaced nipples (finding) | SNOMED Clinical Terms |
| Hinweis auf Rachitis | 404684003 : { 47429007 = 41345002 , 363698007 = 731726001 } | Clinical finding (finding) : { Associated with (attribute) = Rickets (disorder) , Finding site (attribute) = Entire bone of thorax (body structure) } | SNOMED Clinical Terms |
...
| Code | BEZEICHNUNG IM CODESYSTEM | Codesystem |
|---|---|---|
| 364446009 | General characteristics of abdomen (observable entity) | SNOMED Clinical Terms |
FHIR®-Mapping:
- KBV_PR_MIO_CMR_Observation_U8_Physical_Exam_Abdomen_Genitals
- KBV_PR_MIO_CMR_Diagnostic_Report_U8_Physical_Exam_Abdomen_Genitals
Wert: Code
| KONZEPT & WIEDERGABENAME | Code | BEZEICHNUNG IM CODESYSTEM | Codesystem |
|---|---|---|---|
| Hodenhochstand rechts/links | 204878001 | Undescended testicle (disorder) | SNOMED Clinical Terms |
| Hernien | 128545000 | Hernia of abdominal wall (disorder) | SNOMED Clinical Terms |
| Leber- und Milzgröße | 65476007 : { 363698007 = 10200004 } { 363698007 = 62167004 } | Abnormal size (finding) : { Finding site (attribute) = Liver structure (body structure} {Finding site (attribute) = Splenic structure (body structure) } | SNOMED Clinical Terms |
| auffälliger Harnbefund (Mehrfachteststreifen) | 167222005 | Abnormal urinalysis (finding) | SNOMED Clinical Terms |
...
| Code | BEZEICHNUNG IM CODESYSTEM | Codesystem |
|---|---|---|
| 47078008 | Hearing, function (observable entity) | SNOMED Clinical Terms |
FHIR®-Mapping:
- KBV_PR_MIO_CMR_Observation_U8_Physical_Exam_Ears
- KBV_PR_MIO_CMR_Diagnostic_Report_U8_Physical_Exam_Ears
Wert: Code
| KONZEPT & WIEDERGABENAME | Beschreibung | Code | BEZEICHNUNG IM CODESYSTEM | Codesystem |
|---|---|---|---|---|
| Hörtest mittels Screeningaudiometrie: rechts | (Bestimmung der Hörschwelle in Luftleitung mit mindestens 5 Prüffrequenzen) | 134376008 | Hearing test right abnormality (finding) | SNOMED Clinical Terms |
| Hörtest mittels Screeningaudiometrie: links | (Bestimmung der Hörschwelle in Luftleitung mit mindestens 5 Prüffrequenzen) | 134375007 | Hearing test left abnormality (finding) | SNOMED Clinical Terms |
...
Code | BEZEICHNUNG IM CODESYSTEM | Codesystem |
|---|---|---|
| 364066008 | Cardiovascular observable (observable entity) | SNOMED Clinical Terms |
FHIR®-Mapping:
- KBV_PR_MIO_CMR_Observation_U7_U9_Physical_Exam_Heart_Blood_Circulation
- KBV_PR_MIO_CMR_Diagnostic_Report_U7_U9_Physical_Exam_Heart_Blood_Circulation
Wert: Code
| KONZEPT & WIEDERGABENAME | Code | BEZEICHNUNG IM CODESYSTEM | Codesystem |
|---|---|---|---|
| Herzfrequenz | 361135004 | Abnormal cardiac rate (finding) | SNOMED Clinical Terms |
| Herzrhythmus | 698247007 | Cardiac arrhythmia (disorder) | SNOMED Clinical Terms |
| Herztöne | 123824001 | Heart sounds abnormal (finding) | SNOMED Clinical Terms |
| Herznebengeräusche | 88610006 | Heart murmur (finding) | SNOMED Clinical Terms |
...
| Code | BEZEICHNUNG IM CODESYSTEM | Codesystem |
|---|---|---|
| 106029005 | Musculoskeletal function (observable entity) | SNOMED Clinical Terms |
FHIR®-Mapping:
- KBV_PR_MIO_CMR_Observation_U8_Physical_Exam_Musculoskeletal_System
- KBV_PR_MIO_CMR_Diagnostic_Report_U8_Physical_Exam_Musculoskeletal_System
Wert: Code
| KONZEPT & WIEDERGABENAME | Code | BEZEICHNUNG IM CODESYSTEM | Codesystem |
|---|---|---|---|
| Vorbeugetest | 298380006 | Deformity of spine (finding) | SNOMED Clinical Terms |
| Asymmetrien | 422949007 | Musculoskeletal asymmetry (finding) | SNOMED Clinical Terms |
| Schiefhaltung | 43029002 | Abnormal posture (finding) | SNOMED Clinical Terms |
| Spontanmotorik | 225606002 | Abnormal movement (finding) | SNOMED Clinical Terms |
| passive Beweglichkeit der großen Gelenke | 298180004 | Finding of range of joint movement (finding) | SNOMED Clinical Terms |
| Muskeltonus | 366725004 | Finding of muscle tone (finding) | SNOMED Clinical Terms |
| Muskeleigenreflexe | 366420008 | Peripheral reflex finding (finding) | SNOMED Clinical Terms |
| Hinweis auf Rachitis an den Extremitäten | 404684003 : { 47429007 = 41345002 , 363698007 = 2592007 } | Clinical finding (finding) : { Associated with (attribute) = Rickets (disorder), Finding site (attribute) = All extremities (body structure) } | SNOMED Clinical Terms |
...
CODE | BEZEICHNUNG IM CODESYSTEM | CODESYSTEM |
|---|---|---|
| 271914002+364111005 | Ear, nose and throat examination finding (observable entity) + Oral cavity observable (observable entity) | SNOMED Clinical Terms |
FHIR®-Mapping:
- KBV_PR_MIO_CMR_Observation_U8_U9_Physical_Exam_Mouth_Nose
- KBV_PR_MIO_CMR_Diagnostic_Report_U8_U9_Physical_Exam_Mouth_Nose
Wert: Code
| KONZEPT & WIEDERGABENAME | Code | BEZEICHNUNG IM CODESYSTEM | Codesystem |
|---|---|---|---|
| Auffälligkeiten an Zähnen und Schleimhaut | 300255008 | Oral cavity problem (finding) | SNOMED Clinical Terms |
| Kieferanomalie | 449790007 | Orofacial cleft (disorder) | SNOMED Clinical Terms |
| Verletzungszeichen | 125593007 | Injury of face (disorder) | SNOMED Clinical Terms |
...
CODE | BEZEICHNUNG IM CODESYSTEM | CODESYSTEM |
|---|---|---|
| 414174009 | Eye observable (observable entity) | SNOMED Clinical Terms |
FHIR®-Mapping:
- KBV_PR_MIO_CMR_Observation_U7a_U9_Physical_Exam_Eyes
- KBV_PR_MIO_CMR_Diagnostic_Report_U7a_U9_Physical_Exam_Eyes
Wert: Code
| KONZEPT & WIEDERGABENAME | Code | BEZEICHNUNG IM CODESYSTEM | Codesystem |
|---|---|---|---|
| Inspektion: morphologische Auffälligkeiten (z. B. Ptosis, Leukokorie, Bulbusgrößenauffälligkeiten, Kolobom) | 737269000 | Eye appearance abnormal (finding) | SNOMED Clinical Terms |
| Inspektion: Nystagmus | 307699005 | Nystagmus present (finding) | SNOMED Clinical Terms |
| Hornhautreflexbildchen: auffällig (Strabismus) | 164011009 | On examination - strabismus - squint (finding) | SNOMED Clinical Terms |
| Inspektion: Kopffehlhaltung | 34241000119104 | Ocular torticollis (disorder) | SNOMED Clinical Terms |
| Pupillenstatus: auffällig (Größe, Form, Lichtreaktion rechts/links) | 301937002 | Finding of appearance of pupil (finding) | SNOMED Clinical Terms |
| Stereo-Test (z. B. Lang-Test, Titmus-Test, TNO-Test): auffällig | 252853008 : 363713009 = 263654008 | Stereotests (procedure) : Has interpretation (attribute) = Abnormal (qualifier value) | SNOMED Clinical Terms |
| Sehtest (monokulare Prüfung): Sehschwäche links | 342061000119102 | Amblyopia of left eye (disorder) | SNOMED Clinical Terms |
| Sehtest (monokulare Prüfung): Sehschwäche rechts | 336451000119108 | Amblyopia of right eye (disorder) | SNOMED Clinical Terms |
| Sehtest (monokulare Prüfung): Rechts-Links-Differenz | 3289004 | Anisometropia (disorder) | SNOMED Clinical Terms |
...
