Seitenhistorie
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U6 dokumentieren (Kindervorsorgeuntersuchungen) | 0. | |
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FHIR®-Mapping: %KBV_PR_MIO_CMR_Composition_U6|KBV_PR_MIO_CMR_Composition_U6.section:untersuchung%untersuchung
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U6 dokumentieren (Kindervorsorgeuntersuchungen) | 0. | |
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Terminologie-Assoziation:
CODE | BEZEICHNUNG IM CODE-SYSTEM | CODE-SYSTEM |
---|---|---|
364528001 | Skin observable (observable entity) | SNOMED CT®, 2021-01-31 |
FHIR®-Mapping:
- %KBV KBV_PR_MIO_CMR_Observation_U5_U9_Physical_Exam_Skin|KBV_PR_MIO_CMR_Observation_U5_U9_Physical_Exam_Skin%
- %KBV KBV_PR_MIO_CMR_Diagnostic_Report_U5_U9_Physical_Exam_Skin|KBV_PR_MIO_CMR_Diagnostic_Report_U5_U9_Physical_Exam_Skin%
Wert: Code
KONZEPT UND WIEDERGABENAME | CODE | BEZEICHNUNG IM CODE-SYSTEM | CODE-SYSTEM |
---|---|---|---|
auffällige Blässe | 267029006 | Pale - symptom (finding) | SNOMED CT®, 2021-01-31 |
Anhalt für Verletzungen (z. B. Hämatome, Petechien, Verbrennungen, Narben) | 781645001 | Injury to skin caused by trauma (finding) | SNOMED CT®, 2021-01-31 |
entzündliche Hautveränderungen | 106076001 : 116676008 = 708039003 | Skin finding (finding) : Associated morphology (attribute) = Inflammatory lesion (morphologic abnormality) | SNOMED CT®, 2021-01-31 |
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SZENARIO | KARDINALITÄT | KONFORMITÄT |
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U6 dokumentieren (Kindervorsorgeuntersuchungen) | 0. | |
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Terminologie-Assoziation:
CODE | BEZEICHNUNG IM CODE-SYSTEM | CODE-SYSTEM |
---|---|---|
364048003 | Respiratory observable (observable entity) | SNOMED CT®, 2021-01-31 |
FHIR®-Mapping:
- %KBV KBV_PR_MIO_CMR_Diagnostic_Report_U6_U7_Physical_Exam_Chest_Lung_Respiratory_Tract|KBV_PR_MIO_CMR_Diagnostic_Report_U6_U7_Physical_Exam_Chest_Lung_Respiratory_Tract%
- %|%
Wert: Code
KONZEPT UND WIEDERGABENAME | CODE | BEZEICHNUNG IM CODE-SYSTEM | CODE-SYSTEM |
---|---|---|---|
Auskultation | 301272007 | Chest auscultation finding (finding) | SNOMED CT®, 2021-01-31 |
Atemgeräusch | 301273002 | Abnormal breath sounds (finding) | SNOMED CT®, 2021-01-31 |
Atemfrequenz | 17077006 | Abnormal respiratory rate (finding) | SNOMED CT®, 2021-01-31 |
Einziehungen | 67909005 | Chest wall retraction (finding) | SNOMED CT®, 2021-01-31 |
Thoraxkonfiguration | 298706004 | Finding of appearance of thorax (finding) | SNOMED CT®, 2021-01-31 |
Mamillenabstand | 423230008 | Wide spaced nipples (finding) | SNOMED CT®, 2021-01-31 |
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SZENARIO | KARDINALITÄT | KONFORMITÄT |
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U6 dokumentieren (Kindervorsorgeuntersuchungen) | 0. | |
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Terminologie-Assoziation:
CODE | BEZEICHNUNG IM CODE-SYSTEM | CODE-SYSTEM |
---|---|---|
364446009 | General characteristics of abdomen (observable entity) | SNOMED CT®, 2021-01-31 |
FHIR®-Mapping:
- %KBV KBV_PR_MIO_CMR_Diagnostic_Report_U5_U6_Physical_Exam_Abdomen_Genitals|KBV_PR_MIO_CMR_Diagnostic_Report_U5_U6_Physical_Exam_Abdomen_Genitals%
- %KBV
- KBV_PR_MIO_CMR_Observation_U5_U6_Physical_Exam_Abdomen_Genitals|KBV_PR_MIO_CMR_Observation_U5_U6_Physical_Exam_Abdomen_Genitals%
Wert: Code
KONZEPT UND WIEDERGABENAME | CODE | BEZEICHNUNG IM CODE-SYSTEM | CODE-SYSTEM |
---|---|---|---|
Anomalien | 822987005 : {116676008 = 49755003 , 363698007 = 818987002} | Finding of abdominopelvic segment of trunk (finding) : {Associated morphology (attribute) = Morphologically abnormal structure (morphologic abnormality) , Finding site (attribute) = Structure of abdominopelvic cavity (body structure) | SNOMED CT®, 2021-01-31 |
Hodenhochstand rechts/links | 204878001 | Undescended testicle (disorder) | SNOMED CT®, 2021-01-31 |
Hernien | 128545000 | Hernia of abdominal wall (disorder) | SNOMED CT®, 2021-01-31 |
Leber- und Milzgröße | 65476007 : {363698007 = 10200004}{363698007 = 78961009} | Abnormal size (finding) : {Finding site (attribute) = Liver structure (body structure} {Finding site (attribute) = Splenic structure (body structure)} | SNOMED CT®, 2021-01-31 |
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SZENARIO | KARDINALITÄT | KONFORMITÄT |
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U6 dokumentieren (Kindervorsorgeuntersuchungen) | 0. | |
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Terminologie-Assoziation:
CODE | BEZEICHNUNG IM CODE-SYSTEM | CODE-SYSTEM |
---|---|---|
364066008 | Cardiovascular observable (observable entity) | SNOMED CT®, 2021-01-31 |
FHIR®-Mapping:
- %KBV KBV_PR_MIO_CMR_Diagnostic_Report_U2_U6_Physical_Exam_Heart_Blood_Circulation|KBV_PR_MIO_CMR_Diagnostic_Report_U2_U6_Physical_Exam_Heart_Blood_Circulation%
- %KBV
- KBV_PR_MIO_CMR_Observation_U2_U6_Physical_Exam_Heart_Blood_Circulation|KBV_PR_MIO_CMR_Observation_U2_U6_Physical_Exam_Heart_Blood_Circulation%
Wert: Code
KONZEPT UND WIEDERGABENAME | CODE | BEZEICHNUNG IM CODE-SYSTEM | CODE-SYSTEM |
---|---|---|---|
Herzfrequenz | 361135004 | Abnormal cardiac rate (finding) | SNOMED CT®, 2021-01-31 |
Herzrhythmus | 698247007 | Cardiac arrhythmia (disorder) | SNOMED CT®, 2021-01-31 |
Herztöne | 123824001 | Heart sounds abnormal (finding) | SNOMED CT®, 2021-01-31 |
Herznebengeräusche | 88610006 | Heart murmur (finding) | SNOMED CT®, 2021-01-31 |
Femoralispulse | 50178004 | Abnormal femoral pulse (finding) | SNOMED CT®, 2021-01-31 |
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SZENARIO | KARDINALITÄT | KONFORMITÄT |
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U6 dokumentieren (Kindervorsorgeuntersuchungen) | 0...* | R |
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Terminologie-Assoziation:
CODE | BEZEICHNUNG IM CODE-SYSTEM | CODE-SYSTEM |
---|---|---|
106029005 | Musculoskeletal function (observable entity) | SNOMED CT®, 2021-01-31 |
FHIR®-Mapping:
- %KBV KBV_PR_MIO_CMR_Diagnostic_Report_U6_Physical_Exam_Musculoskeletal_System|KBV_PR_MIO_CMR_Diagnostic_Report_U6_Physical_Exam_Musculoskeletal_System%
- %KBV
- KBV_PR_MIO_CMR_Observation_U6_Physical_Exam_Musculoskeletal_System|KBV_PR_MIO_CMR_Observation_U6_Physical_Exam_Musculoskeletal_System%
Wert: Code
KONZEPT UND WIEDERGABENAME | CODE | BEZEICHNUNG IM CODE-SYSTEM | CODE-SYSTEM |
---|---|---|---|
Asymmetrien | 422949007 | Musculoskeletal asymmetry (finding) | SNOMED CT®, 2021-01-31 |
Schiefhaltung | 43029002 | Abnormal posture (finding) | SNOMED CT®, 2021-01-31 |
Spontanmotorik | 225606002 | Abnormal movement (finding) | SNOMED CT®, 2021-01-31 |
Muskeltonus | 366725004 | Finding of muscle tone (finding) | SNOMED CT®, 2021-01-31 |
passive Beweglichkeit der großen Gelenke | 298180004 | Finding of range of joint movement (finding) | SNOMED CT®, 2021-01-31 |
Muskeleigenreflexe | 366420008 | Peripheral reflex finding (finding) | SNOMED CT®, 2021-01-31 |
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SZENARIO | KARDINALITÄT | KONFORMITÄT |
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U6 dokumentieren (Kindervorsorgeuntersuchungen) | 0. | |
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Terminologie-Assoziation:
CODE | BEZEICHNUNG IM CODE-SYSTEM | CODE-SYSTEM |
---|---|---|
364404000 | Head region observable (observable entity) | SNOMED CT®, 2021-01-31 |
FHIR®-Mapping:
- %KBV KBV_PR_MIO_CMR_Diagnostic_Report_U5_U6_Physical_Exam_Head|KBV_PR_MIO_CMR_Diagnostic_Report_U5_U6_Physical_Exam_Head%
- %KBV
- KBV_PR_MIO_CMR_Observation_U5_U6_Physical_Exam_Head|KBV_PR_MIO_CMR_Observation_U5_U6_Physical_Exam_Head%
Wert: Code
KONZEPT UND WIEDERGABENAME | CODE | BEZEICHNUNG IM CODE-SYSTEM | CODE-SYSTEM |
---|---|---|---|
Fehlhaltung | 111235007 | Musculoskeletal disorder of the neck (disorder) | SNOMED CT®, 2021-01-31 |
Dysmorphiezeichen | 253978002 | Dysmorphic features (finding) | SNOMED CT®, 2021-01-31 |
Schädelnähte | 248387005 | Cranial suture finding (finding) | SNOMED CT®, 2021-01-31 |
Fontanellentonus | 366372002 | Finding of level of fontanelle (finding) | SNOMED CT®, 2021-01-31 |
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SZENARIO | KARDINALITÄT | KONFORMITÄT |
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U6 dokumentieren (Kindervorsorgeuntersuchungen) | 0. | |
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Terminologie-Assoziation:
CODE | BEZEICHNUNG IM CODE-SYSTEM | CODE-SYSTEM |
---|---|---|
271914002 + 364111005 | Ear, nose and throat examination finding (observable entity) + Oral cavity observable (observable entity) | SNOMED CT®, 2021-01-31 |
FHIR®-Mapping:
- %KBV KBV_PR_MIO_CMR_Diagnostic_Report_U6_Physical_Exam_Mouth_Nose|KBV_PR_MIO_CMR_Diagnostic_Report_U6_Physical_Exam_Mouth_Nose%
- %KBV
- KBV_PR_MIO_CMR_Observation_U6_Physical_Exam_Mouth_Nose|KBV_PR_MIO_CMR_Observation_U6_Physical_Exam_Mouth_Nose%
Wert: Code
KONZEPT UND WIEDERGABENAME | CODE | BEZEICHNUNG IM CODE-SYSTEM | CODE-SYSTEM |
---|---|---|---|
Auffälligkeiten an Zähnen und Schleimhäuten | 300255008 | Oral cavity problem (finding) | SNOMED CT®, 2021-01-31 |
Verletzungszeichen | 125593007 | Injury of face (disorder) | SNOMED CT®, 2021-01-31 |
behinderte Nasenatmung | 232209000 | Nasal obstruction (finding) | SNOMED CT®, 2021-01-31 |
fehlender Mundschluss | 367381002 | Weak mouth closure (finding) | SNOMED CT®, 2021-01-31 |
auffälliger Stimmklang (z.B. Heiserkeit und Näseln) | 38160000 | Abnormal voice (finding) | SNOMED CT®, 2021-01-31 |
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SZENARIO | KARDINALITÄT | KONFORMITÄT |
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U6 dokumentieren (Kindervorsorgeuntersuchungen) | 0. | |
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Terminologie-Assoziation:
CODE | BEZEICHNUNG IM CODE-SYSTEM | CODE-SYSTEM |
---|---|---|
414174009 | Eye observable (observable entity) | SNOMED CT®, 2021-01-31 |
FHIR®-Mapping:
- %KBV KBV_PR_MIO_CMR_Diagnostic_Report_U6_Physical_Exam_Eyes|KBV_PR_MIO_CMR_Diagnostic_Report_U6_Physical_Exam_Eyes%
- %KBV KBV_PR_MIO_CMR_Observation_U6_Physical_Exam_Eyes|KBV_PR_MIO_CMR_Observation_U6_Physical_Exam_Eyes%
Wert: Code
KONZEPT UND WIEDERGABENAME | CODE | BEZEICHNUNG IM CODE-SYSTEM | CODE-SYSTEM |
---|---|---|---|
Inspektion: morphologische Auffälligkeiten | 737269000 | Eye appearance abnormal (finding) | SNOMED CT®, 2021-01-31 |
Inspektion: Nystagmus | 307699005 | Nystagmus present (finding) | SNOMED CT®, 2021-01-31 |
Inspektion: Kopffehlhaltung | 34241000119104 | Ocular torticollis (disorder) | SNOMED CT®, 2021-01-31 |
Brückner-Test: Transilluminationsunterschied (z.B. bei Trübung der brechenden Medien, Strabismus, Anisometropie) | 400964006 | Iris transillumination (finding) | SNOMED CT®, 2021-01-31 |
Prüfung der Blickfolge mit einem geräuschlosen, das Kind interessierenden Objekt (z.B. Lichtquelle): Fixationsschwäche rechts/links | 870705000 | Poor visual fixation (finding) | SNOMED CT®, 2021-01-31 |
Pupillenstatus: Vergleich Größe, Form, Lichtreaktion rechts/links | 301937002 | Finding of appearance of pupil (finding) | SNOMED CT®, 2021-01-31 |
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