Seitenhistorie
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| SZENARIO | KARDINALITÄT | KONFORMITÄT |
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| U8 dokumentieren (Kindervorsorgeuntersuchungen) | 0. | |
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| R |
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FHIR®-Mapping: %KBV_PR_MIO_CMR_Composition_U8|KBV_PR_MIO_CMR_Composition_U8.section:untersuchung%untersuchung
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| SZENARIO | KARDINALITÄT | KONFORMITÄT |
|---|---|---|
| U8 dokumentieren (Kindervorsorgeuntersuchungen) | 0. | |
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| .* | R |
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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_Diagnostic_Report_U5_U9_Physical_Exam_Skin|KBV_PR_MIO_CMR_Diagnostic_Report_U5_U9_Physical_Exam_Skin%
- %KBV
- KBV_PR_MIO_CMR_Observation_U5_U9_Physical_Exam_Skin|KBV_PR_MIO_CMR_Observation_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 |
|---|---|---|
| U8 dokumentieren (Kindervorsorgeuntersuchungen) | 0. | |
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| .* | R |
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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_U8_Physical_Exam_Chest_Lung_Respiratory_Tract|KBV_PR_MIO_CMR_Diagnostic_Report_U8_Physical_Exam_Chest_Lung_Respiratory_Tract%
- %KBV
- KBV_PR_MIO_CMR_Observation_U8_Physical_Exam_Chest_Lung_Respiratory_Tract|KBV_PR_MIO_CMR_Observation_U8_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 |
| Thoraxkonfiguration | 298706004 | Finding of appearance of thorax (finding) | SNOMED CT®, 2021-01-31 |
| Mamillenabstand | 423230008 | Wide spaced nipples (finding) | SNOMED CT®, 2021-01-31 |
| 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 CT®, 2021-01-31 |
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| SZENARIO | KARDINALITÄT | KONFORMITÄT |
|---|---|---|
| U8 dokumentieren (Kindervorsorgeuntersuchungen) | 0. | |
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| .* | R |
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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_U8_Physical_Exam_Abdomen_Genitals|KBV_PR_MIO_CMR_Diagnostic_Report_U8_Physical_Exam_Abdomen_Genitals%
- %KBV
- KBV_PR_MIO_CMR_Observation_U8_Physical_Exam_Abdomen_Genitals|KBV_PR_MIO_CMR_Observation_U8_Physical_Exam_Abdomen_Genitals%
Wert: Code
| KONZEPT UND WIEDERGABENAME | CODE | BEZEICHNUNG IM CODE-SYSTEM | CODE-SYSTEM |
|---|---|---|---|
| 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 |
| auffälliger Harnbefund (Mehrfachteststreifen) | 167222005 | Abnormal urinalysis (finding) | SNOMED CT®, 2021-01-31 |
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| SZENARIO | KARDINALITÄT | KONFORMITÄT |
|---|---|---|
| U8 dokumentieren (Kindervorsorgeuntersuchungen) | 0. | |
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| .* | R |
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Terminologie-Assoziation:
| CODE | BEZEICHNUNG IM CODE-SYSTEM | CODE-SYSTEM |
|---|---|---|
| 47078008 | Hearing, function (observable entity) | SNOMED CT®, 2021-01-31 |
FHIR®-Mapping:
- %KBV KBV_PR_MIO_CMR_Diagnostic_Report_U8_Physical_Exam_Ears|KBV_PR_MIO_CMR_Diagnostic_Report_U8_Physical_Exam_Ears%
- %KBV KBV_PR_MIO_CMR_Observation_U8_Physical_Exam_Ears|KBV_PR_MIO_CMR_Observation_U8_Physical_Exam_Ears%
Wert: Code
| KONZEPT UND WIEDERGABENAME | CODE | BEZEICHNUNG IM CODE-SYSTEM | CODE-SYSTEM |
|---|---|---|---|
| Hörtest mittels Screeningaudiometrie: rechts | 134376008 | Hearing test right abnormality (finding) | SNOMED CT®, 2021-01-31 |
| Hörtest mittels Screeningaudiometrie: links | 134375007 | Hearing test left abnormality (finding) | SNOMED CT®, 2021-01-31 |
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| SZENARIO | KARDINALITÄT | KONFORMITÄT |
|---|---|---|
| U8 dokumentieren (Kindervorsorgeuntersuchungen) | 0. | |
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| .* | R |
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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_U7_U9_Physical_Exam_Heart_Blood_Circulation|KBV_PR_MIO_CMR_Diagnostic_Report_U7_U9_Physical_Exam_Heart_Blood_Circulation%
- %KBV
- KBV_PR_MIO_CMR_Observation_U7_U9_Physical_Exam_Heart_Blood_Circulation|KBV_PR_MIO_CMR_Observation_U7_U9_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 |
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| SZENARIO | KARDINALITÄT | KONFORMITÄT |
|---|---|---|
| U8 dokumentieren (Kindervorsorgeuntersuchungen) | 0. | |
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| .* | 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_U8_Physical_Exam_Musculoskeletal_System|KBV_PR_MIO_CMR_Diagnostic_Report_U8_Physical_Exam_Musculoskeletal_System%
- %KBV
- KBV_PR_MIO_CMR_Observation_U8_Physical_Exam_Musculoskeletal_System|KBV_PR_MIO_CMR_Observation_U8_Physical_Exam_Musculoskeletal_System%
Wert: Code
| KONZEPT UND WIEDERGABENAME | CODE | BEZEICHNUNG IM CODE-SYSTEM | CODE-SYSTEM |
|---|---|---|---|
| Vorbeugetest | 298380006 | Deformity of spine (finding) | SNOMED CT®, 2021-01-31 |
| 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 |
| passive Beweglichkeit der großen Gelenke | 298180004 | Finding of range of joint movement (finding) | SNOMED CT®, 2021-01-31 |
| Muskeltonus | 366725004 | Finding of muscle tone (finding) | SNOMED CT®, 2021-01-31 |
| Muskeleigenreflexe | 366420008 | Peripheral reflex finding (finding) | SNOMED CT®, 2021-01-31 |
| 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 CT®, 2021-01-31 |
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| SZENARIO | KARDINALITÄT | KONFORMITÄT |
|---|---|---|
| U8 dokumentieren (Kindervorsorgeuntersuchungen) | 0. | |
| . | ||
| .* | R |
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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_U8_U9_Physical_Exam_Mouth_Nose|KBV_PR_MIO_CMR_Diagnostic_Report_U8_U9_Physical_Exam_Mouth_Nose%
- %KBV
- KBV_PR_MIO_CMR_Observation_U8_U9_Physical_Exam_Mouth_Nose|KBV_PR_MIO_CMR_Observation_U8_U9_Physical_Exam_Mouth_Nose%
Wert: Code
| KONZEPT UND WIEDERGABENAME | CODE | BEZEICHNUNG IM CODE-SYSTEM | CODE-SYSTEM |
|---|---|---|---|
| Auffälligkeiten an Zähnen und Schleimhaut | 300255008 | Oral cavity problem (finding) | SNOMED CT®, 2021-01-31 |
| Kieferanomalie | 449790007 | Orofacial cleft (disorder) | SNOMED CT®, 2021-01-31 |
| Verletzungszeichen | 125593007 | Injury of face (disorder) | SNOMED CT®, 2021-01-31 |
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| SZENARIO | KARDINALITÄT | KONFORMITÄT |
|---|---|---|
| U8 dokumentieren (Kindervorsorgeuntersuchungen) | 0. | |
| . | ||
| .* | R |
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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_U7a_U9_Physical_Exam_Eyes|KBV_PR_MIO_CMR_Diagnostic_Report_U7a_U9_Physical_Exam_Eyes%
- %KBV
- KBV_PR_MIO_CMR_Observation_U7a_U9_Physical_Exam_Eyes|KBV_PR_MIO_CMR_Observation_U7a_U9_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 |
| Hornhautreflexbildchen: auffällig (Strabismus) | 22066006 | Strabismus (disorder) | SNOMED CT®, 2021-01-31 |
| Inspektion: Kopffehlhaltung | 34241000119104 | Ocular torticollis (disorder) | SNOMED CT®, 2021-01-31 |
| Pupillenstatus: auffällig | 301937002 | Finding of appearance of pupil (finding) | SNOMED CT®, 2021-01-31 |
| Stereo-Test: auffällig | 252853008 : 363713009 = 263654008 | Stereotests (procedure) : Has interpretation (attribute) = Abnormal (qualifier value) | SNOMED CT®, 2021-01-31 |
| Sehtest (monokulare Prüfung): Sehschwäche links | 342061000119102 | Amblyopia of left eye (disorder) | SNOMED CT®, 2021-01-31 |
| Sehtest (monokulare Prüfung): Sehschwäche rechts | 336451000119108 | Amblyopia of right eye (disorder) | SNOMED CT®, 2021-01-31 |
| Sehtest (monokulare Prüfung): Rechts-Links-Differenz | 3289004 | Anisometropia (disorder) | SNOMED CT®, 2021-01-31 |
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