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Dokumentationsteil für die Hüftsonographie entsprechend der Methode nach Graf

Status
colourBlue
titlefachliche QS
 Dr. Lea Botermann

Kommentar

Dokumentationsteil Hüftsonographie

Mio iconlink
Link

https://www.kbv.de/
media
html/
sp/KBV_PraxisWissenSpezial_SonografieSaeugling.pdf

Hüftbefund Vorhandensein

Typ Kode

Value Set Assoziation required Hüftbefund Typ (Dynamisch)

Konzepte

themen_2856.php
LinkTitleKBV Themenseite: Sonographie der Säuglingshüfte

Hüftbefund Vorhandensein

FHIR®-Mapping: KBV_PR_MIO_CMR_Observation_U3_U4_Hip_Screening_Result.value[x]

Wert: Code

413350009 : { 246090004 = ( 118952005 + 116313000 : { 363698007 = 362908009 } ) , 408729009 = 410605003 , 408731000 Finding finding ( Joint finding (finding) + Finding of hip region (finding) : { Finding site (attribute) = Right hip joint structure (body structure) } ) , Finding context (attribute) = Confirmed present attribute Past 413350009 : { 246090004 = ( 118952005 + 116313000 : { 363698007 = 362908009 } ) , 408729009 = 410516002 , 408731000 Finding finding ( Joint finding (finding) + Finding of hip region (finding) : { Finding site (attribute) = Right hip joint structure (body structure) } ) , Finding context (attribute) = Known absent | attribute Past Hüftvorbefund rechts 413350009 246090004 = ( 118952005 + 116313000 : { 363698007 = 362908009 } ) , 408729009 = 261665006 , 408731000 Finding finding ( Joint finding (finding) + Finding of hip region (finding) : { Finding site (attribute) = Right hip joint structure (body structure) } ) , Finding context (attribute) = Unknown attributeFinding finding ( Joint finding (finding) + Finding of hip region (finding) : { Finding site (attribute) = Left hip joint structure (body structure) } ) , Finding context (attribute) = Confirmed present attribute Past unspecified

SNOMED Clinical Terms

KONZEPT & WIEDERGABENAMECodeBEZEICHNUNG IM CODESYSTEMCodesystem
Hüftsonographischer Vorbefund: ja129125009 : { 363589002 = 241503003 , 408730004 = 398166005 , 408731000 Hüftvorbefund rechts vorhanden = 410588008 }Procedure with explicit context (situation) : { Associated procedure (attribute) = Ultrasound scan of neonatal hip (procedure) , Procedure context (situation) = Performed (qualifier value) , Temporal context (situation) = Past - time unspecified (qualifier value) }SNOMED Clinical TermsHüftvorbefund rechts nicht vorhanden

Hüftsonographischer Vorbefund: nein

129125009 : { 363589002 = 241503003 , 408730004 = 385660001 , 408731000 = 410588008 }Procedure with explicit context (situation) : { Associated procedure (attribute) = Ultrasound scan of neonatal hip (procedure) , Procedure context (situation) = Not done (qualifier value) , Temporal context (situation) = Past - time unspecified (qualifier value) }SNOMED Clinical Terms
Hüftsonographischer Vorbefund: unbekannt129125009 : { 363589002 = 241503003 , 408730004 = 410537005 , 408731000 = 410588008 }Procedure with explicit context (situation) : { Associated procedure (attribute) = Ultrasound scan of neonatal hip (procedure) , Procedure context (situation) = Action status unknown (qualifier value) , Temporal context (situation) = Past - time unspecified (qualifier value) }SNOMED Clinical TermsHüftvorbefund links vorhanden

413350009 : { 246090004 = ( 118952005 + 116313000 : { 363698007 = 362907004 } ) , 408729009 = 410605003 , 408731000 = 410588008 }

Hüftsonographischer Befund in der 4.-5. Lebenswoche129125009 : { 363589002 = 241503003 , 408730004 = 398166005 , 408731000 = 410584005 }Procedure with explicit context (situation) : { Associated procedure (attribute) = Ultrasound scan of neonatal hip (procedure) , Procedure context (situation) =  Performed (qualifier value) , Temporal context (situation) = Current - time specified (qualifier value) }SNOMED Clinical Terms
Hüftvorbefund links nicht vorhanden

413350009 : { 246090004 = ( 118952005 + 116313000 : { 363698007 = 362907004 } ) , 408729009 = 410516002 , 408731000 = 410588008 }

Finding with explicit context (situation) : { Associated finding (attribute) = ( Joint finding (finding) + Finding of hip region (finding) : { Finding site (attribute) = Left hip joint structure (body structure) } ) , Finding context (attribute) = Known absent (qualifier value) , Temporal context (attribute) = Past - time unspecified (qualifier value) }

SNOMED Clinical Terms

Hüftvorbefund links unbekannt

413350009 : { 246090004 = ( 118952005 + 116313000 : { 363698007 = 362907004 } ) , 408729009 = 261665006 , 408731000 = 410588008 }

Finding with explicit context (situation) : { Associated finding (attribute) = ( Joint finding (finding) + Finding of hip region (finding) : { Finding site (attribute) = Left hip joint structure (body structure) } ) , Finding context (attribute) = Unknown (qualifier value) , Temporal context (attribute) = Past - time unspecified (qualifier value) }

SNOMED Clinical Terms

Hüftbefund rechts vorhanden

413350009 : { 246090004 = ( 118952005 + 116313000 : { 363698007 = 362908009 } ) , 408729009 = 410605003 , 408731000 = 410585006 }

Finding with explicit context (situation) : { Associated finding (attribute) = ( Joint finding (finding) + Finding of hip region (finding) : { Finding site (attribute) = Right hip joint structure (body structure) } ) , Finding context (attribute) = Confirmed present (qualifier value) , Temporal context (attribute) = Current - time unspecified (qualifier value) }

SNOMED Clinical Terms

Hüftbefund links vorhanden

413350009 : { 246090004 = ( 118952005 + 116313000 : { 363698007 = 362907004 } ) , 408729009 = 410605003 , 408731000 = 410585006 }

Finding with explicit context (situation) : { Associated finding (attribute) = ( Joint finding (finding) + Finding of hip region (finding) : { Finding site (attribute) = Left hip joint structure (body structure) } ) , Finding context (attribute) = Confirmed present (qualifier value) , Temporal context (attribute) = Current - time unspecified (qualifier value) }

FHIR-Mapping

hüftsonographischer Vorbefund

Linke Hüfte

Hüftlateralität

FHIR®-Mapping: KBV_PR_MIO_CMR_Observation_U3_U4_Hip_Screening_Result.bodySite

Wert: Code

KONZEPT & WIEDERGABENAMECodeBEZEICHNUNG IM CODESYSTEMCodesystem
rechte Hüfte

362906008

Entire right hip joint (body structure)

SNOMED Clinical Terms

linke Hüfte

362905007

Entire left hip joint (body structure)

SNOMED Clinical Terms


Hüftsonographischer Vorbefund

Angaben der Ergebnisse aus einem hüftsonographischen Vorbefund.

Linke Hüfte

FHIR®-Mapping: KBV_PR_MIO_CMR_Observation_U3_U4_Hip_Screening_Result.bodySite

Terminologie Assoziation

FHIR-Mapping
Auszug
Auszug
CodeBEZEICHNUNG IM CODESYSTEMCodesystem
426100003Ultrasound scan of left hip (procedure)SNOMED Clinical Terms
Beta-Winkel (Grad)

Terminologie Assoziation:

CodeBEZEICHNUNG IM CODESYSTEMCodesystem
364501006 : { 704321009 = 241503003 , 246501002 = 278395004 , 246514001 = 259046004 , 718497002 = 91685003 }Hip joint feature (observable entity) : { Characterizes (attribute) = Ultrasound scan of neonatal hip (procedure) , Technique (attribute) = Imaging technique (qualifier value) , Units (attribute) = degrees of arc (qualifier value) , Inherent location (attribute) = Fibrocartilage (body structure) }SNOMED Clinical Terms

Typ Quantität

FHIR-Mapping

FHIR®-Mapping: KBV_PR_MIO_CMR_Observation_U3_U4_Hip_Screening_Result.component:betaWinkel.value[x]

Wert: Quantität (Einheit: Grad)

Alpha-Winkel (Grad)

Terminologie Assoziation:

CodeBEZEICHNUNG IM CODESYSTEMCodesystem
364501006 : { 704321009 = 241503003 , 246501002 = 278395004 , 246514001 = 259046004 , 718497002 = 58823008 }Hip joint feature (observable entity) : { Characterizes (attribute) = Ultrasound scan of neonatal hip (procedure) , Technique (attribute) = Imaging technique (qualifier value) , Units (attribute) = degrees of arc (qualifier value) , Inherent location (attribute) = Structure of acetabular fossa (body structure) }SNOMED Clinical Terms

Typ Quantität

FHIR®-Mapping: KBV_PR_MIO_CMR_Observation_U3_U4_Hip_Screening_Result.component:alphaWinkel.value[x]

Wert: Quantität (Einheit: Grad)FHIR-Mapping

Hüfttyp (nach Graf)

Operationalisation: Automatisierte Erstellung des Hüfttyps basierend auf Angaben für Alpha und Beta Winkel .

Typ Kode

Value Set Assoziation required Hüfttyp nach Graf (Dynamisch)

sind möglich.

FHIR®-Mapping: KBV_PR_MIO_CMR_Observation_U3_U4_Hip_Screening_Result.value[x]:valueCodeableConcept 

Wert: CodeKonzepte

Codesystem
KONZEPT & WIEDERGABENAMECodeBEZEICHNUNG IM CODESYSTEMCodesystem
Ia/Ib

1ab

Graf Ia/Ib

Uheft-valueset-88

IIa

2a

Graf IIa

Uheft-valueset-88

IIc/D

2cd

Graf IIc/D

Uheft-valueset-88

IIIa

3a

Graf IIIa

Uheft-valueset-88

IIIb

3b

Graf IIIb

Uheft-valueset-88

IV

4

Graf IV

Uheft-valueset-88

FHIR-Mapping

Rechte Hüfte



Rechte Hüfte

FHIR®-Mapping: KBV_PR_MIO_CMR_Observation_U3_U4_Hip_Screening_Result.bodySite

Auszug einschließen
6.2.1 Hüftsonographie nach Graf, Phase I
6.2.1 Hüftsonographie nach Graf, Phase I
nopaneltrue


Hüftsonographie 4. bis 5

...

. Lebenswoche

Angaben der Befunde aus der durchgeführten Hüftsonographie.

Linke Hüfte

FHIR®-Mapping: KBV_PR_MIO_CMR_Observation_U3_U4_Hip_Screening_Result.bodySite

Auszug einschließen
6.2.1 Hüftsonographie nach Graf, Phase I
6.2.1 Hüftsonographie nach Graf, Phase I
nopaneltrue


Rechte Hüfte

FHIR®-Mapping: KBV_PR_MIO_CMR_Observation_U3_U4_Hip_Screening_Result.bodySite

Wert: Quantität (Einheit: Grad)

Auszug einschließen
6.2.1 Hüftsonographie nach Graf, Phase I
6.2.1 Hüftsonographie nach Graf, Phase I
nopaneltrue



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Kommentierungen

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