Seitenhistorie
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Code | BEZEICHNUNG IM CODESYSTEM | Codesystem |
|---|---|---|
| 106076001364528001 | Skin finding observable (findingobservable 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 |
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CODE | BEZEICHNUNG IM CODESYSTEM | CODESYSTEM |
|---|---|---|
| 106048009364048003 | Respiratory finding observable (findingobservable entity) | SNOMED Clinical Terms |
FHIR®-Mapping:
- KBV_PR_MIO_CMR_Observation_U7a_and_U9_Physical_Exam_Chest_Lung_Respiratory_Tract
- KBV_PR_MIO_CMR_Diagnostic_Report_U7a_and_U9_Physical_Exam_Chest_Lung_Respiratory_Tract
Wert: Code
| KONZEPT & WIEDERGABENAME | Code | BEZEICHNUNG IM CODESYSTEM | Codesystem | |
|---|---|---|---|---|
| Auskultation | 128254003301272007 | Respiratory Chest auscultation finding (finding) | SNOMED Clinical Terms | |
| Atemgeräusch | 301285005 | 301273002 | Abnormal breath sounds Finding of sound of breathing (finding) | SNOMED Clinical Terms |
| Atemfrequenz | 17077006 | Abnormal respiratory rate (finding) | SNOMED Clinical Terms | |
| Thoraxkonfiguration | 366457002298706004 | Finding of form appearance of thorax thorax (finding) | SNOMED Clinical Terms | |
| Mamillenabstand | 423230008 | Wide spaced nipples (finding) | SNOMED Clinical Terms |
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| Code | BEZEICHNUNG IM CODESYSTEM | Codesystem |
|---|---|---|
| 609624008364446009 | Finding General characteristics of abdomen (findingobservable entity) | SNOMED Clinical Terms |
FHIR®-Mapping:
- KBV_PR_MIO_CMR_Observation_U9_Physical_Exam_Abdomen_Genitals
- KBV_PR_MIO_CMR_Diagnostic_Report_U9_Physical_Exam_Abdomen_Genitals
Wert: Code
| KONZEPT & WIEDERGABENAME | Code | BEZEICHNUNG IM CODESYSTEM | Codesystem | |
|---|---|---|---|---|
| Leber- und Milzgröße | 36760000 | 65476007 : { 363698007 = 10200004 } { 363698007 = 62167004 } | Abnormal size (finding) : { Finding site (attribute) = Liver structure (body structure) } { Finding site (attribute) = Splenic structure (body structure) }Hepatosplenomegaly (disorder) | SNOMED Clinical Terms |
| Hernien | 128545000 | Hernia of abdominal wall (disorder) | SNOMED Clinical Terms |
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Code | BEZEICHNUNG IM CODESYSTEM | Codesystem |
|---|---|---|
| 364066008 | Cardiovascular finding observable (findingobservable 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 | 301113001 | 361135004 | Abnormal cardiac Finding of heart rate (finding) | SNOMED Clinical Terms |
| Herzrhythmus | 301112006 | 698247007 | Cardiac arrhythmia (disorderFinding of heart rhythm (finding) | SNOMED Clinical Terms |
| Herztöne | 301126002123824001 | Finding of heart Heart sounds abnormal (finding) | SNOMED Clinical Terms | |
| Herznebengeräusche | 268934006 | 88610006 | Heart On examination - cardiac murmur (finding) | SNOMED Clinical Terms |
Untersuchung - Bewegungsapparat
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| Code | BEZEICHNUNG IM CODESYSTEM | Codesystem |
|---|---|---|
| 106028002106029005 | Musculoskeletal finding function (findingobservable entity) | SNOMED Clinical Terms |
FHIR®-Mapping:
- KBV_PR_MIO_CMR_Observation_U7a_and_U9_Physical_Exam_Musculoskeletal_System
- KBV_PR_MIO_CMR_Diagnostic_Report_U7a_and_U9_Physical_Exam_Musculoskeletal_System
Wert: Code
| KONZEPT & WIEDERGABENAME | Code | BEZEICHNUNG IM CODESYSTEM | Codesystem |
|---|---|---|---|
| Asymmetrien | 422949007 | Musculoskeletal asymmetry (finding) | SNOMED Clinical Terms |
| Schiefhaltung | 43029002 | Abnormal posture (finding) | SNOMED Clinical Terms |
| passive Beweglichkeit der großen Gelenke | 298180004 | Finding of range of joint movement (finding) | SNOMED Clinical Terms |
| Muskeleigenreflexe | 366420008 | Peripheral reflex finding (finding) | SNOMED Clinical Terms |
| Muskeltonus | 366725004 | Finding of muscle tone (finding) | SNOMED Clinical Terms |
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CODE | BEZEICHNUNG IM CODESYSTEM | CODESYSTEM | ||
|---|---|---|---|---|
| 271914002 + 364111005 | Ear, nose and throat examination finding (observable entity) + Oral cavity observable (observable entity | 301310005 | Finding of face (finding) | 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 | 116337000300255008 | Oral cavity finding problem (finding) | SNOMED Clinical Terms |
| Kieferanomalie | 449790007 | Orofacial cleft (disorder) | SNOMED Clinical Terms |
| Verletzungszeichen | 125593007 | Injury of face (disorder) | SNOMED Clinical Terms |
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CODE | BEZEICHNUNG IM CODESYSTEM | CODESYSTEM |
|---|---|---|
| 308923001414174009 | Eye symptom observable (findingobservable 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 | 737269000 | Eye appearance abnormal (finding) | SNOMED Clinical Terms | ||
| Inspektion: Nystagmus | 307699005 | Nystagmus present (finding) | SNOMED Clinical Terms | Inspektion: Kopffehlhaltung | 301059002 | Neck
| Hornhautreflexbildchen: auffällig (Strabismus) | 164011009 | On examination - strabismus - squint | position finding (finding) | SNOMED Clinical Terms | |
| PupillenstatusInspektion: auffälligKopffehlhaltung | 301937002 | 34241000119104 | Ocular torticollis (disorderFinding of appearance of pupil (finding) | SNOMED Clinical Terms | |
| Pupillenstatus: auffällig | (Strabismus)164011009 | On examination - strabismus - squint 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 |
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