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KONZEPT & WIEDERGABENAMECODEBEZEICHNUNG IM CODESYSTEMCODESYSTEM
(1) Familiäre Belastung (z.B. Diabetes, Hypertonie, Fehlbildungen, genetische Krankheiten, psychische Krankheiten)

416471007

Family history of clinical finding (situation)

SNOMED Clinical Terms

(2) Frühere eigene schwere Erkrankungen (z.B. Herz, Lunge, Leber, Nieren, ZNS, Psyche)

312850006

History of disorder (situation)

SNOMED Clinical Terms

(3) Blutungs-/Thromboseneigung

161460007

History of coagulation defect (situation)

SNOMED Clinical Terms

(4) Allergie, z.B. gegen Medikamente

609328004

Allergic disposition (finding)

SNOMED Clinical Terms

(5) Frühere Bluttransfusionen

161664006

History of blood transfusion (situation)

SNOMED Clinical Terms

(6) Besondere psychische Belastung (z.B. familiäre oder berufliche)

271596009

Mental distress (finding)

SNOMED Clinical Terms

(7) Besondere soziale Belastung (z.B. Integrationsprobleme, wirtschaftliche Probleme)

161152002

Social problem (finding)

SNOMED Clinical Terms

(8) Rhesus-Inkompatibilität (bei vorangegangenen Schwangerschaften)

312850006 : 246090004 = 44795003

History of disorder (situation) : Associated finding (attribute) = Rhesus isoimmunization affecting pregnancy (disorder)

SNOMED Clinical Terms

(9) Diabetes mellitus

73211009

Diabetes mellitus (disorder)

SNOMED Clinical Terms

(10) Adipositas

414916001

Obesity (disorder)

SNOMED Clinical Terms

(11) Kleinwuchs

22033007

237836003

Short stature disorder Fetal growth retardation (disorder)

SNOMED Clinical Terms

(12) Skelettanomalien

8447006

Congenital anomaly of skeletal bone (disorder)

SNOMED Clinical Terms

(13) Schwangere unter 18 Jahren

237240001

Teenage pregnancy (finding)

SNOMED Clinical Terms

(14) Schwangere über 35 Jahren

416413003

Advanced maternal age gravida (finding)

SNOMED Clinical Terms

(15) Vielgebärende (mehr als 4 Kinder)

18656007

Grand multipara (finding)

SNOMED Clinical Terms

(16) Zustand nach Sterilitätsbehandlung

443938003 : { 408731000 = 410513005 , 408730004 = 385658003 , 363589002 = 703145006 , 408732007 = 410604004 }

Procedure carried out on subject (situation) : { Temporal context (attribute) = In the past (qualifier value) , Procedure context (attribute) = Done (qualifier value) , Associated procedure (attribute) = Sterilization procedure (procedure) , Subject relationship context (attribute) = Subject of record (person) }

SNOMED Clinical Terms

(17) Zustand nach Frühgeburt (vor Ende der 37. SSW)

161765003

History of premature delivery (situation)

SNOMED Clinical Terms

(18) Zustand nach Mangelgeburt

726565008

Past history of small for gestational age baby (situation)

SNOMED Clinical Terms

(19) Zustand nach 2 oder mehr Fehlgeburten/Abbrüchen

713651007

History of pregnancy with abortive outcome (situation)

SNOMED Clinical Terms

(20) Totes/geschädigtes Kind in der Anamnese

161743003

History of stillbirth (situation)

SNOMED Clinical Terms

(21) Komplikationen bei vorausgegangenen Entbindungen

417662000 : { 408731000 = 410513005 , 408729009 = 410515003, 246090004=199745000 , 408732007 = 410604004 }

History of clinical finding in subject (situation) : { Temporal context (attribute) = In the past (qualifier value) , Finding context (attribute) = Known present (qualifier value) , Associated finding (attribute) = Complication occurring during labor and delivery (disorder), Subject relationship context (attribute) = Subject of record (person) }

SNOMED Clinical Terms

(22) Komplikationen post partum

417662000 : { 408731000 = 410513005 , 408729009 = 410515003 , 246090004 = 80113008 , 408732007 = 410604004 }

History of clinical finding in subject (situation) : { Temporal context (attribute) = In the past (qualifier value) , Finding context (attribute) = Known present (qualifier value) , Associated finding (attribute) = Complication of the puerperium (disorder) , Subject relationship context (attribute) = Subject of record (person) }

SNOMED Clinical Terms

(23) Zustand nach Sectio

161805006

History of cesarean section (situation)

SNOMED Clinical Terms

(24) Zustand nach anderen Uterusoperationen

272058002 : { 408730004 = 385658003 , 363589002 = 236974004 , 408731000 = 410513005 , 408732007 = 410604004 }

History of past delivery (situation) : { Procedure context (attribute) = Done (qualifier value), Associated procedure (attribute) = Instrumental delivery (procedure) , Temporal context (attribute) = In the past (qualifier value) , Subject relationship context (attribute) = Subject of record (person)}

SNOMED Clinical Terms

(25) Rasche Schwangerschaftsfolge (weniger als 1 Jahr)

60001007 : 263502005 = 424572001

Not pregnant (finding) : Clinical course (attribute) = Clinical course with short duration (qualifier value)

SNOMED Clinical Terms

(26) Andere Besonderheiten

418138009

Patient condition finding (finding)

SNOMED Clinical Terms

Die verwendeten Code-Systeme finden sie hier: Verwendete Code-Systeme, Phase I.

...

In diesem Element können ergänzende Angaben und Erläuterungen zu den einem einzelnen Fragepunkten , abgefragten Punkt gemacht werden.

FHIR®-Mapping: KBV_PR_MIO_MR_Initial_Anamnesis.note

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