" }], "valueDomain" : [{ "type" : "identifier" }] }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.9.58", "statusCode" : "draft", "effectiveDate" : "2023-11-20T00:00:00", "lastModifiedDate" : "2023-11-27T17:39:29", "type" : "item", "iddisplay" : "notfdok-dataelement2025-58", "shortName" : "aufnahmezeitpunkt", "implementation" : [{ "shortName" : "aufnahmezeitpunkt", "markdown" : "Datum/Zeit der administrativen Aufnahme im Krankenhaus. Dieser Zeitstempel kann durch den Aufnahmeevent vom KIS automatisch vom geliefert werden" }], "inherit" : [{ "ref" : "2.16.840.1.113883.2.6.60.3.2.6.58", "effectiveDate" : "2018-01-25T00:00:00", "prefix" : "aktin-", "datasetId" : "2.16.840.1.113883.2.6.60.3.1.6", "datasetEffectiveDate" : "2018-08-17T00:00:00", "datasetStatusCode" : "final", "datasetVersionLabel" : "v2020.1", "iType" : "item", "iStatusCode" : "final", "iEffectiveDate" : "2018-01-25T00:00:00", "iVersionLabel" : "v2020.1", "iddisplay" : "nap-dataelement2020(1)-58", "refdisplay" : "nap-dataelement2020(1)-58", "localInherit" : "true" }], "name" : [{ "language" : "de-DE", "#text" : "Aufnahmezeitpunkt" }], "synonym" : [{ "language" : "de-DE", "#text" : "B2HIR-Klinikankunft" }], "desc" : [{ "language" : "de-DE", "#text" : "Datum/Zeit der administrativen Aufnahme im Krankenhaus. Dieser Zeitstempel kann durch den Aufnahmeevent vom KIS automatisch vom geliefert werden
" }], "source" : [{ "language" : "de-DE", "#text" : "KIS" }], "relationship" : [{ "type" : "SPEC", "ref" : "2.16.840.1.113883.2.6.60.3.2.1.58", "flexibility" : "2014-01-06T16:43:10", "prefix" : "aktin-", "datasetId" : "2.16.840.1.113883.2.6.60.3.1.1", "datasetEffectiveDate" : "2014-09-15T00:00:00", "datasetStatusCode" : "final", "datasetVersionLabel" : "v2014.1-b", "iType" : "item", "iEffectiveDate" : "2014-01-06T16:43:10", "iStatusCode" : "final", "refdisplay" : "aktin-dataelement2014(1)-58", "name" : [{ "language" : "de-DE", "#text" : "Aufnahmezeitpunkt" }] }], "operationalization" : [{ "language" : "de-DE", "#text" : "Dieser Zeitpunkt kann je nach Prozess in der Notaufnahme vor oder nach der Ersteinschätzung oder dem Arztkontakt erfolgen und stellt damit nicht automatisch den minimalen Zeitstempel einer Episode dar.
In Notaufnahmen gibt es folgende bekannte Prozesse:
1. Aufnahme -> Ersteinschätzung\n -> Arztkontakt
2. Ersteinschätzung -> Aufnahme -> Arztkontakt
3. Ersteinschätzung -> Arztkontakt -> Aufnahme
4. Arztkontakt -> Aufnahme -> Ersteinschätzung
5. Arztkontakt -> Ersteinschätzung -> Aufnahme " }], "valueDomain" : [{ "type" : "datetime", "property" : [{ "timeStampPrecision" : "YMDHM" }] }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.9.20094", "statusCode" : "draft", "effectiveDate" : "2023-11-20T00:00:00", "lastModifiedDate" : "2023-11-27T17:39:29", "type" : "item", "iddisplay" : "notfdok-dataelement2025-20094", "shortName" : "fallnummer", "implementation" : [{ "shortName" : "fallnummer", "markdown" : "Krankenhausinternes Kennzeichen des Behandlungsfalles, vulgo Fallnummer, die zur Zuordnung von Dokumenten zu einem Behandlungsfall innerhalb eines Krankenhauses verwendet wird." }], "inherit" : [{ "ref" : "2.16.840.1.113883.2.6.60.3.2.6.20094", "effectiveDate" : "2018-01-25T00:00:00", "prefix" : "aktin-", "datasetId" : "2.16.840.1.113883.2.6.60.3.1.6", "datasetEffectiveDate" : "2018-08-17T00:00:00", "datasetStatusCode" : "final", "datasetVersionLabel" : "v2020.1", "iType" : "item", "iStatusCode" : "final", "iEffectiveDate" : "2018-01-25T00:00:00", "iVersionLabel" : "v2020.1", "originalId" : "2.16.840.1.113883.2.6.60.3.2.3.20094", "originalStatusCode" : "final", "originalEffectiveDate" : "2017-01-09T12:28:33", "originalPrefix" : "aktin-", "iddisplay" : "nap-dataelement2020(1)-20094", "refdisplay" : "nap-dataelement2020(1)-20094", "localInherit" : "true" }], "name" : [{ "language" : "de-DE", "#text" : "Fallnummer" }], "desc" : [{ "language" : "de-DE", "#text" : "Krankenhausinternes Kennzeichen des Behandlungsfalles, vulgo Fallnummer, die zur Zuordnung von Dokumenten zu einem Behandlungsfall innerhalb eines Krankenhauses verwendet wird.
" }], "relationship" : [{ "type" : "SPEC", "ref" : "2.16.840.1.113883.2.6.60.3.2.3.20094", "flexibility" : "2017-01-09T12:28:33", "prefix" : "aktin-", "datasetId" : "2.16.840.1.113883.2.6.60.3.1.3", "datasetEffectiveDate" : "2015-11-01T00:00:00", "datasetStatusCode" : "final", "datasetVersionLabel" : "v2015.2-b", "iType" : "item", "iEffectiveDate" : "2017-01-09T12:28:33", "iStatusCode" : "final", "refdisplay" : "aktin-dataelement2015(2)-20094", "name" : [{ "language" : "de-DE", "#text" : "Fallnummer" }] }], "valueDomain" : [{ "type" : "identifier" }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.9.20093", "statusCode" : "draft", "effectiveDate" : "2023-11-20T00:00:00", "lastModifiedDate" : "2023-11-27T17:39:29", "type" : "item", "iddisplay" : "notfdok-dataelement2025-20093", "shortName" : "episodennummer", "implementation" : [{ "shortName" : "episodennummer", "markdown" : "Diese Aufenthalts-Identifikation oder Episodennummer wird bei jedem Kontakt eines Patienten mit einer Notaufnahme neu vergeben. Damit können z.B. bei mehreren ambulanten Kontakten eines Patienten mit einer Notaufnahme, die mit einer ambulanten Fallnummer pro Quartal zusammengefasst werden, die einzelnen Episoden in der Notaufnahme identifiziert werden." }], "inherit" : [{ "ref" : "2.16.840.1.113883.2.6.60.3.2.6.20093", "effectiveDate" : "2018-01-25T00:00:00", "prefix" : "aktin-", "datasetId" : "2.16.840.1.113883.2.6.60.3.1.6", "datasetEffectiveDate" : "2018-08-17T00:00:00", "datasetStatusCode" : "final", "datasetVersionLabel" : "v2020.1", "iType" : "item", "iStatusCode" : "final", "iEffectiveDate" : "2018-01-25T00:00:00", "iVersionLabel" : "v2020.1", "originalId" : "2.16.840.1.113883.2.6.60.3.2.3.20093", "originalStatusCode" : "final", "originalEffectiveDate" : "2017-01-09T12:27:56", "originalPrefix" : "aktin-", "iddisplay" : "nap-dataelement2020(1)-20093", "refdisplay" : "nap-dataelement2020(1)-20093", "localInherit" : "true" }], "name" : [{ "language" : "de-DE", "#text" : "Episodennummer" }], "desc" : [{ "language" : "de-DE", "#text" : "Diese Aufenthalts-Identifikation oder Episodennummer wird bei jedem Kontakt eines Patienten mit einer Notaufnahme neu vergeben. Damit können z.B. bei mehreren ambulanten Kontakten eines Patienten mit einer Notaufnahme, die mit einer ambulanten Fallnummer pro Quartal zusammengefasst werden, die einzelnen Episoden in der Notaufnahme identifiziert werden.
" }], "relationship" : [{ "type" : "SPEC", "ref" : "2.16.840.1.113883.2.6.60.3.2.3.20093", "flexibility" : "2017-01-09T12:27:56", "prefix" : "aktin-", "datasetId" : "2.16.840.1.113883.2.6.60.3.1.3", "datasetEffectiveDate" : "2015-11-01T00:00:00", "datasetStatusCode" : "final", "datasetVersionLabel" : "v2015.2-b", "iType" : "item", "iEffectiveDate" : "2017-01-09T12:27:56", "iStatusCode" : "final", "refdisplay" : "aktin-dataelement2015(2)-20093", "name" : [{ "language" : "de-DE", "#text" : "Episodennummer" }] }], "valueDomain" : [{ "type" : "identifier" }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.9.20108", "statusCode" : "draft", "effectiveDate" : "2023-11-20T00:00:00", "lastModifiedDate" : "2023-11-27T17:39:29", "type" : "item", "iddisplay" : "notfdok-dataelement2025-20108", "shortName" : "zuverlegung_aus_einrichtung", "implementation" : [{ "shortName" : "zuverlegung_aus_einrichtung", "markdown" : "Aus welcher Einrichtung kam der Patient" }], "inherit" : [{ "ref" : "2.16.840.1.113883.2.6.60.3.2.6.20108", "effectiveDate" : "2018-08-18T13:07:26", "prefix" : "aktin-", "datasetId" : "2.16.840.1.113883.2.6.60.3.1.6", "datasetEffectiveDate" : "2018-08-17T00:00:00", "datasetStatusCode" : "final", "datasetVersionLabel" : "v2020.1", "iType" : "item", "iStatusCode" : "final", "iEffectiveDate" : "2018-08-18T13:07:26", "iVersionLabel" : "v2020.1", "iddisplay" : "nap-dataelement2020(1)-20108", "refdisplay" : "nap-dataelement2020(1)-20108", "localInherit" : "true" }], "name" : [{ "language" : "de-DE", "#text" : "Zuverlegung aus Einrichtung" }], "desc" : [{ "language" : "de-DE", "#text" : "Aus welcher Einrichtung kam der Patient" }], "source" : [{ "language" : "de-DE", "#text" : "Rettungsdienstprotokoll, Anamnese" }], "rationale" : [{ "language" : "de-DE", "#text" : "Medizinische Implikation bei oder für Isolation. " }], "valueDomain" : [{ "type" : "code", "conceptList" : [{ "id" : "2.16.840.1.113883.2.6.60.3.2.6.20108.20180818130726.0", "concept" : [{ "id" : "2.16.840.1.113883.2.6.60.3.2.6.20108.20180818130726.1", "name" : [{ "language" : "de-DE", "#text" : "Pflegeeinrichtung/-heim" }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.6.20108.20180818130726.2", "name" : [{ "language" : "de-DE", "#text" : "Hospiz" }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.6.20108.20180818130726.3", "name" : [{ "language" : "de-DE", "#text" : "Rehabilitationseinrichtung/-klinik" }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.6.20108.20180818130726.4", "name" : [{ "language" : "de-DE", "#text" : "Krankenhaus (keine Reha-Einrichtung)" }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.6.20108.20180818130726.5", "exception" : "true", "name" : [{ "language" : "de-DE", "#text" : "Sonstige" }] }] }] }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.9.10017", "effectiveDate" : "2023-11-20T00:00:00", "statusCode" : "draft", "lastModifiedDate" : "2024-02-14T10:46:29", "type" : "group", "iddisplay" : "notfdok-dataelement2025-10017", "shortName" : "zuweisung_zur_notaufnahme", "implementation" : [{ "shortName" : "zuweisung_zur_notaufnahme", "markdown" : "Zuweisung" }], "name" : [{ "language" : "de-DE", "lastTranslated" : "2024-02-14T10:46:20", "#text" : "Zuweisung zur Notaufnahme" }], "desc" : [{ "language" : "de-DE", "lastTranslated" : "2024-02-14T10:46:20", "#text" : "Zuweisung" }], "relationship" : [{ "type" : "SPEC", "ref" : "2.16.840.1.113883.2.6.60.3.2.1.10017", "flexibility" : "2014-09-25T00:00:00", "prefix" : "aktin-", "datasetId" : "2.16.840.1.113883.2.6.60.3.1.1", "datasetEffectiveDate" : "2014-09-15T00:00:00", "datasetStatusCode" : "final", "datasetVersionLabel" : "v2014.1-b", "iType" : "group", "iEffectiveDate" : "2014-09-25T00:00:00", "iStatusCode" : "final", "refdisplay" : "aktin-dataelement2014(1)-10017", "name" : [{ "language" : "de-DE", "#text" : "Zuweisung" }] }, { "type" : "SPEC", "ref" : "2.16.840.1.113883.2.6.60.3.2.6.10017", "flexibility" : "2018-01-25T00:00:00", "prefix" : "aktin-", "datasetId" : "2.16.840.1.113883.2.6.60.3.1.6", "datasetEffectiveDate" : "2018-08-17T00:00:00", "datasetStatusCode" : "final", "datasetVersionLabel" : "v2020.1", "iType" : "group", "iEffectiveDate" : "2018-01-25T00:00:00", "iStatusCode" : "final", "iVersionLabel" : "v2020.1", "refdisplay" : "nap-dataelement2020(1)-10017", "name" : [{ "language" : "de-DE", "#text" : "Zuweisung zur Notaufnahme" }] }], "concept" : [{ "id" : "2.16.840.1.113883.2.6.60.3.2.9.22", "effectiveDate" : "2023-11-20T00:00:00", "statusCode" : "draft", "lastModifiedDate" : "2024-02-14T10:46:29", "type" : "item", "iddisplay" : "notfdok-dataelement2025-22", "shortName" : "zuweisung", "implementation" : [{ "shortName" : "zuweisung", "markdown" : "Art der Zuweisung des Patienten. Von welchem medizinischen Fachpersonal ist der Patient ins Krankenhaus geschickt worden?" }], "name" : [{ "language" : "de-DE", "lastTranslated" : "2024-02-14T10:46:29", "#text" : "Zuweisung" }], "synonym" : [{ "language" : "de-DE", "lastTranslated" : "2024-02-14T10:46:29", "#text" : "nokeda_referral" }], "desc" : [{ "language" : "de-DE", "lastTranslated" : "2024-02-14T10:46:29", "#text" : "Art der Zuweisung des Patienten. Von welchem medizinischen Fachpersonal ist der Patient ins Krankenhaus geschickt worden?" }], "comment" : [{ "language" : "de-DE", "lastTranslated" : "2024-02-14T10:46:29", "#text" : "zu 3 = KV-Notfallpraxis am Krankenhaus (Item wird 2014 neu aufgenommen, um in Zukunft die Versorgung durch KV-notfallpraxen auswerten zu können)
zu 4 = KV-Notdienst ausserhalb des Krankenhauses (Item wird neu aufgenommen, um in Zukunft die Versorgung duch KV-Notfallpraxen auswerten zu können)
zu 8 =\n Andere (Item wird neu aufgenommen zur Kontrolle der Datenqualität)" }], "relationship" : [{ "type" : "SPEC", "ref" : "2.16.840.1.113883.2.6.60.3.2.2.22", "flexibility" : "2014-01-06T16:43:09", "prefix" : "aktin-", "datasetId" : "2.16.840.1.113883.2.6.60.3.1.2", "datasetEffectiveDate" : "2015-01-15T00:00:00", "datasetStatusCode" : "final", "datasetVersionLabel" : "v2015.1-b", "iType" : "item", "iEffectiveDate" : "2014-01-06T16:43:09", "iStatusCode" : "final", "refdisplay" : "aktin-dataelement2015(1)-22", "name" : [{ "language" : "de-DE", "#text" : "Zuweisung" }] }, { "type" : "SPEC", "ref" : "2.16.840.1.113883.2.6.60.3.2.6.22", "flexibility" : "2018-01-25T00:00:00", "prefix" : "aktin-", "datasetId" : "2.16.840.1.113883.2.6.60.3.1.6", "datasetEffectiveDate" : "2018-08-17T00:00:00", "datasetStatusCode" : "final", "datasetVersionLabel" : "v2020.1", "iType" : "item", "iEffectiveDate" : "2018-01-25T00:00:00", "iStatusCode" : "final", "iVersionLabel" : "v2020.1", "refdisplay" : "nap-dataelement2020(1)-22", "name" : [{ "language" : "de-DE", "#text" : "Zuweisung" }] }], "valueDomain" : [{ "type" : "code", "conceptList" : [{ "id" : "2.16.840.1.113883.2.6.60.3.2.9.22.20231120000000.0", "concept" : [{ "id" : "2.16.840.1.113883.2.6.60.3.2.9.22.20231120000000.0.1", "exception" : "false", "name" : [{ "language" : "de-DE", "lastTranslated" : "2024-02-14T10:46:29", "#text" : "ohne" }], "desc" : [{ "language" : "de-DE", "lastTranslated" : "2024-02-14T10:46:29", "#text" : "Der Patient ist von keinem Arzt ins Krankenhaus geschickt worden" }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.9.22.20231120000000.0.2", "exception" : "false", "name" : [{ "language" : "de-DE", "lastTranslated" : "2024-02-14T10:46:29", "#text" : "Vertragsarzt/Praxis" }], "desc" : [{ "language" : "de-DE", "lastTranslated" : "2024-02-14T10:46:29", "#text" : "Damit sind alle niedergelassenen Ärzte gemeint, keine Treffschärfe bzgl Art der Praxis und des Arztes, es ist nicht die ökonomische Abbildung mit Einweisung und Überweisung differenziert" }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.9.22.20231120000000.0.3", "exception" : "false", "name" : [{ "language" : "de-DE", "lastTranslated" : "2024-02-14T10:46:29", "#text" : "KV-Notfallpraxis am Krankenhaus" }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.9.22.20231120000000.0.4", "exception" : "false", "name" : [{ "language" : "de-DE", "lastTranslated" : "2024-02-14T10:46:29", "#text" : "KV-Notdienst ausserhalb des Krankenhauses" }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.9.22.20231120000000.0.5", "exception" : "false", "name" : [{ "language" : "de-DE", "lastTranslated" : "2024-02-14T10:46:29", "#text" : "Rettungsdienst" }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.9.22.20231120000000.0.6", "exception" : "false", "name" : [{ "language" : "de-DE", "lastTranslated" : "2024-02-14T10:46:29", "#text" : "Notarzt" }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.9.22.20231120000000.0.7", "exception" : "false", "name" : [{ "language" : "de-DE", "lastTranslated" : "2024-02-14T10:46:29", "#text" : "Klinik/Verlegung" }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.9.22.20231120000000.0.8", "exception" : "true", "name" : [{ "language" : "de-DE", "lastTranslated" : "2024-02-14T10:46:29", "#text" : "Andere" }] }] }] }], "valueSet" : [{ "id" : "1.2.276.0.76.11.42", "name" : "referral-setting", "displayName" : "Zuweiser", "effectiveDate" : "2024-02-14T10:48:01", "statusCode" : "draft", "canonicalUri" : "http://aktin.org/fhir/ValueSet/aktin-vs-referral-setting", "versionLabel" : "2024", "lastModifiedDate" : "2024-08-22T11:09:52", "terminologyAssociation" : [{ "conceptId" : "2.16.840.1.113883.2.6.60.3.2.9.22.20231120000000.0", "valueSet" : "1.2.276.0.76.11.42", "flexibility" : "dynamic", "effectiveDate" : "2024-02-14T10:47:10", "valueSetName" : "Zuweiser", "valueSetStatusCode" : "draft", "valueSetVersionLabel" : "2024", "valueSetEffectiveDate" : "2024-02-14T10:48:01" }], "sourceCodeSystem" : [{ "id" : "1.2.276.0.76.5.440", "identifierName" : "Zuweiser", "canonicalUri" : "http://aktin.org/fhir/CodeSystem/aktin-cs-zuweiser", "canonicalUriDSTU2" : "http://aktin.org/fhir/CodeSystem/aktin-cs-zuweiser", "canonicalUriSTU3" : "http://aktin.org/fhir/CodeSystem/aktin-cs-zuweiser", "canonicalUriR4" : "http://aktin.org/fhir/CodeSystem/aktin-cs-zuweiser", "canonicalUriR4B" : "http://aktin.org/fhir/CodeSystem/aktin-cs-zuweiser", "canonicalUriR5" : "http://aktin.org/fhir/CodeSystem/aktin-cs-zuweiser", "context" : "projects/aktin-/zuweiser-1.2.276.0.76.5.440" }, { "id" : "2.16.840.1.113883.6.96", "identifierName" : "SNOMED Clinical Terms", "canonicalUri" : "http://snomed.info/sct", "canonicalUriDSTU2" : "http://snomed.info/sct", "canonicalUriSTU3" : "http://snomed.info/sct", "canonicalUriR4" : "http://snomed.info/sct", "canonicalUriR4B" : "http://snomed.info/sct", "canonicalUriR5" : "http://snomed.info/sct" }], "publishingAuthority" : [{ "name" : "AKTIN e. 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| Bodentransportmittel | ärztlich begleitet | bodengebunden mit NA |
| Bodentransportmittel | nicht-ärztlich begleitet | bodengebunden ohne NA |
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| Ohne | privat/selbst |
| ohne | selbst |
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| KV-Notdienst ausserhalb des Krankenhauses | KV-Dienst |
| Rettungsdienst | RTW |
| Notarzt | NEF |
| Klinik/Verlegung | wird auf Zuverlegung B2HIR Kategorien gemappt |
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Ursprünglich bis 29.09.2017: \n \n \n Beschwerden, die der Patient bei der Vorstellung in der Notaufnahme vorbringt, synonym Grund der Vorstellung.
\n \n " }], "source" : [{ "language" : "de-DE", "#text" : "Patient" }], "comment" : [{ "language" : "de-DE", "#text" : "Die wissenschaftliche Frage ob ärztliche und nicht-ärztliche Erhebung des Vorstellungsgrundes unterschiedlich ist, kann nur durch Erhebung von zwei Datenpunkten bei einem Patienten erhoben werden. Eine zweite Erhebung durch einen Arzt könnte in der Diskussion am 29.09.2017 in Studiensettings (Behringer, Somasundaram, Wrede) sinnvoll, soll aber zunächst\n nicht aufgenommen.
" }], "relationship" : [{ "type" : "SPEC", "ref" : "2.16.840.1.113883.2.6.60.3.2.3.10034", "flexibility" : "2015-11-01T00:00:00", "prefix" : "aktin-", "datasetId" : "2.16.840.1.113883.2.6.60.3.1.3", "datasetEffectiveDate" : "2015-11-01T00:00:00", "datasetStatusCode" : "final", "datasetVersionLabel" : "v2015.2-b", "iType" : "group", "iEffectiveDate" : "2015-11-01T00:00:00", "iStatusCode" : "final", "refdisplay" : "aktin-dataelement2015(2)-10034", "name" : [{ "language" : "de-DE", "#text" : "Beschwerden bei Vorstellung" }] }], "concept" : [{ "id" : "2.16.840.1.113883.2.6.60.3.2.9.36", "statusCode" : "draft", "effectiveDate" : "2023-11-20T00:00:00", "lastModifiedDate" : "2023-11-27T17:39:29", "type" : "item", "iddisplay" : "notfdok-dataelement2025-36", "shortName" : "beschwerden_bei_vorstellung_freitext", "implementation" : [{ "shortName" : "beschwerden_bei_vorstellung_freitext", "markdown" : "Beschwerden, die der Patient bei der Vorstellung in der Notaufnahme vorbringt, synonym Grund der Vorstellung." }], "inherit" : [{ "ref" : "2.16.840.1.113883.2.6.60.3.2.6.36", "effectiveDate" : "2018-01-25T00:00:00", "prefix" : "aktin-", "datasetId" : "2.16.840.1.113883.2.6.60.3.1.6", "datasetEffectiveDate" : "2018-08-17T00:00:00", "datasetStatusCode" : "final", "datasetVersionLabel" : "v2020.1", "iType" : "item", "iStatusCode" : "final", "iEffectiveDate" : "2018-01-25T00:00:00", "iVersionLabel" : "v2020.1", "iddisplay" : "nap-dataelement2020(1)-36", "refdisplay" : "nap-dataelement2020(1)-36", "localInherit" : "true" }], "name" : [{ "language" : "de-DE", "#text" : "Beschwerden bei Vorstellung (Freitext)" }], "desc" : [{ "language" : "de-DE", "#text" : "Beschwerden, die der Patient bei der Vorstellung in der Notaufnahme vorbringt, synonym Grund der Vorstellung." }], "source" : [{ "language" : "de-DE", "#text" : "Patient" }], "comment" : [{ "language" : "de-DE", "#text" : "Konsens der (anwensenden) Sektionsmitglieder: Es soll ein Freitext-Feld geben, damit exakte Informationen über den Zustand des Patienten weitergegeben werden können. Zusätzlich soll ein Feld mit einem kodierten Wert (nach CEDIS) einfügt werden, um ein auswertbares Feld zu bekommen. Dieses soll auch in ein Register übermittelt werden, wobei hierbei\n auch die Information \"nicht erhoben\" oder \"nicht ausgefüllt\" bzw. \"sonstige\" zugelassen wird." }], "relationship" : [{ "type" : "SPEC", "ref" : "2.16.840.1.113883.2.6.60.3.2.1.36", "flexibility" : "2014-01-06T16:43:10", "prefix" : "aktin-", "datasetId" : "2.16.840.1.113883.2.6.60.3.1.1", "datasetEffectiveDate" : "2014-09-15T00:00:00", "datasetStatusCode" : "final", "datasetVersionLabel" : "v2014.1-b", "iType" : "item", "iEffectiveDate" : "2014-01-06T16:43:10", "iStatusCode" : "final", "refdisplay" : "aktin-dataelement2014(1)-36", "name" : [{ "language" : "de-DE", "#text" : "Beschwerden bei Vorstellung (Freitext)" }] }], "valueDomain" : [{ "type" : "string" }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.9.805", "statusCode" : "draft", "effectiveDate" : "2023-11-20T00:00:00", "lastModifiedDate" : "2023-11-27T17:39:29", "type" : "item", "iddisplay" : "notfdok-dataelement2025-805", "shortName" : "beschwerden_bei_vorstellung_cedis", "implementation" : [{ "shortName" : "beschwerden_bei_vorstellung_cedis", "markdown" : "Die Beschwerden, die der Patient bei der Vorstellung in der Notaufnahme nach dem Katalog CEDIS vorbringt. \nVersion CEDIS-PCL Version 5.1" }], "inherit" : [{ "ref" : "2.16.840.1.113883.2.6.60.3.2.6.805", "effectiveDate" : "2018-01-25T00:00:00", "prefix" : "aktin-", "datasetId" : "2.16.840.1.113883.2.6.60.3.1.6", "datasetEffectiveDate" : "2018-08-17T00:00:00", "datasetStatusCode" : "final", "datasetVersionLabel" : "v2020.1", "iType" : "item", "iStatusCode" : "final", "iEffectiveDate" : "2018-01-25T00:00:00", "iVersionLabel" : "v2020.1", "iddisplay" : "nap-dataelement2020(1)-805", "refdisplay" : "nap-dataelement2020(1)-805", "localInherit" : "true" }], "name" : [{ "language" : "de-DE", "#text" : "Beschwerden bei Vorstellung (CEDIS)" }], "synonym" : [{ "language" : "de-DE", "#text" : "nokeda_cedis" }], "desc" : [{ "language" : "de-DE", "#text" : "Die Beschwerden, die der Patient bei der Vorstellung in der Notaufnahme nach dem Katalog CEDIS vorbringt.
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"Genitaler Ausfluss/Läsion" }] }, { "localId" : "64", "code" : "304", "codeSystem" : "1.2.276.0.76.5.439", "displayName" : "Penisschwellung", "level" : "1", "type" : "L", "name" : [{ "language" : "de-DE", "#text" : "Penisschwellung" }] }, { "localId" : "65", "code" : "305", "codeSystem" : "1.2.276.0.76.5.439", "displayName" : "Skrotale Schmerzen und/oder Schwellung", "level" : "1", "type" : "L", "name" : [{ "language" : "de-DE", "#text" : "Skrotale Schmerzen und/oder Schwellung" }] }, { "localId" : "66", "code" : "306", "codeSystem" : "1.2.276.0.76.5.439", "displayName" : "Harnverhalt", "level" : "1", "type" : "L", "name" : [{ "language" : "de-DE", "#text" : "Harnverhalt" }] }, { "localId" : "67", "code" : "307", "codeSystem" : "1.2.276.0.76.5.439", "displayName" : "Beschwerden eines Harnwegsinfektes", "level" : "1", "type" : "L", "name" : [{ "language" : "de-DE", "#text" : "Beschwerden eines Harnwegsinfektes" }] }, { "localId" : "68", "code" : "308", "codeSystem" : "1.2.276.0.76.5.439", "displayName" : "Oligurie", "level" : "1", "type" : "L", "name" : [{ "language" : "de-DE", "#text" : "Oligurie" }] }, { "localId" : "69", "code" : "309", "codeSystem" : "1.2.276.0.76.5.439", "displayName" : "Polyurie", "level" : "1", "type" : "L", "name" : [{ "language" : "de-DE", "#text" : "Polyurie" }] }, { "localId" : "70", "code" : "310", "codeSystem" : "1.2.276.0.76.5.439", "displayName" : "Trauma genital", "level" : "1", "type" : "L", "name" : [{ "language" : "de-DE", "#text" : "Trauma genital" }] }, { "localId" : "71", "code" : "MH", "codeSystem" : "1.2.276.0.76.5.439", "displayName" : "Psychische Verfassung", "level" : "0", "type" : "L", "name" : [{ "language" : "de-DE", "#text" : "Psychische Verfassung" }] }, { "localId" : "72", "code" : "351", "codeSystem" : "1.2.276.0.76.5.439", "displayName" : "Depression/Suizidalität/absichtliche Selbstschädigung", "level" : "1", "type" : "L", "name" : [{ "language" : "de-DE", "#text" : "Depression/Suizidalität/absichtliche Selbstschädigung" }] }, { "localId" : "73", "code" : "352", "codeSystem" : "1.2.276.0.76.5.439", "displayName" : "Angst/situationsbezogene Krise", "level" : "1", "type" : "L", "name" : [{ "language" : "de-DE", "#text" : "Angst/situationsbezogene Krise" }] }, { "localId" : "74", "code" : "353", "codeSystem" : "1.2.276.0.76.5.439", "displayName" : "Halluzinationen/Wahnvorstellungen", "level" : "1", "type" : "L", "name" : [{ "language" : "de-DE", "#text" : "Halluzinationen/Wahnvorstellungen" }] }, { "localId" : "75", "code" : "354", "codeSystem" : "1.2.276.0.76.5.439", "displayName" : "Schlafstörung", "level" : "1", "type" : "L", "name" : [{ "language" : "de-DE", "#text" : "Schlafstörung" }] }, { "localId" : "76", "code" : "355", "codeSystem" : "1.2.276.0.76.5.439", "displayName" : "Gewalttätiges Verhalten/Fremdgefährdung", "level" : "1", "type" : "L", "name" : [{ "language" : "de-DE", "#text" : "Gewalttätiges Verhalten/Fremdgefährdung" }] }, { 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"1.2.276.0.76.5.439", "displayName" : "Krampfanfall", "level" : "1", "type" : "L", "name" : [{ "language" : "de-DE", "#text" : "Krampfanfall" }] }, { "localId" : "87", "code" : "406", "codeSystem" : "1.2.276.0.76.5.439", "displayName" : "Gangstörung/Ataxie", "level" : "1", "type" : "L", "name" : [{ "language" : "de-DE", "#text" : "Gangstörung/Ataxie" }] }, { "localId" : "88", "code" : "407", "codeSystem" : "1.2.276.0.76.5.439", "displayName" : "Kopfverletzung", "level" : "1", "type" : "L", "name" : [{ "language" : "de-DE", "#text" : "Kopfverletzung" }] }, { "localId" : "89", "code" : "408", "codeSystem" : "1.2.276.0.76.5.439", "displayName" : "Zittern", "level" : "1", "type" : "L", "name" : [{ "language" : "de-DE", "#text" : "Zittern" }] }, { "localId" : "90", "code" : "409", "codeSystem" : "1.2.276.0.76.5.439", "displayName" : "Schwäche in den Extremitäten/Symptome eines Schlaganfalls oder TIA", "level" : "1", "type" : "L", "name" : [{ "language" : "de-DE", "#text" : "Schwäche in den 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"Schamlippenschwellung" }] }, { "localId" : "100", "code" : "457", "codeSystem" : "1.2.276.0.76.5.439", "displayName" : "Schwangerschaftsprobleme ≤ 20. 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" }], "rationale" : [{ "language" : "de-DE", "#text" : "Traumaregister, Schlaganfallregister, Medizinische Dokumentation, DGUV-Verfahren, B2HIR, ADSR
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Hierbei werden alle Medikamente recherchiert, die der Patient in der Regel einnimmt. Somit werden alle Medikamente erfragt, die er verordnet bekommen oder als OTC Präparate bezogen hat und derzeit regelmäßig oder bei Bedarf eingenommen werden. Zusätzlich werden bei Verdacht auf eine unerwünschte Arzneimittelwirkung (UAW) oder einen Medikationsfehler (MF) auch die Medikamente erfasst, deren Einnahme ursächlich hierfür sein könnten, deren Einnahmezeitpunkt aber schon länger zurück liegt (z.B. Amiodaron einmalig vor 14 Tagen eingenommen, seitdem Schilddrüsenüberfunktion, da HWZ von Amiodaron 56 Tage; oder Steroide wurden über Jahre bis vor einem Jahr eingenommen - aktuell zwar nicht mehr, aber Befund Deckplatteneinbruch bei Osteoporose; oder Aufnahme wegen Lungenfibrose, vor mehr als 10 Jahren Nitrofurantoin eingenommen, oder Chemotherapie bis vor 2 Wochen – aktuell Stomatitis, etc.).\nHier erfolgt idealerweise die Übernahme vom Bundesmedikationsplan.\nIdealerweise enthält die Medikamentenanamnese also alle Medikamente, die zum Zeitpunkt der Aufnahme eine klinische Wirkung oder ein Interaktionspotential besitzen. Letzter Einnahmezeitpunkt weniger als 4 HWZ des Medikaments oder möglicher Kausalzusammenhang mit UAW/MF.\n\nBeispielhafte Medikamentenanamnese:\n1. Metoprolol 95mg po. 1-0-1\n2. Delix 5mg po. 1-0-0\n3. Torem 10mg po. 1-0-0\n4. Actrapid s.c. 12IE-8IE-10IE\n5. Protaphane s.c. 22:00 12IE\n6. ASS 100mg po 08:00-0-0\n7. Allopurinol 300mg po. 1-0-0\n8. Simvahexal 40mg 0-0-1" }], "name" : [{ "language" : "de-DE", "lastTranslated" : "2023-12-28T16:20:31", "#text" : "Medikamentenanamnese" }], "desc" : [{ "language" : "de-DE", "lastTranslated" : "2023-12-28T16:20:31", "#text" : "Welche Medikamente nimmt der Patient aktuell ein?
\n
Die Medikamentenanamnese findet bei der Erstuntersuchung durch den Arzt statt. Hierbei werden alle Medikamente recherchiert, die der Patient in der Regel einnimmt. Somit werden alle Medikamente erfragt, die er verordnet bekommen oder als OTC Präparate bezogen hat und derzeit regelmäßig oder bei Bedarf eingenommen werden. Zusätzlich werden bei Verdacht auf\n eine unerwünschte Arzneimittelwirkung (UAW) oder einen Medikationsfehler (MF) auch die Medikamente erfasst, deren Einnahme ursächlich hierfür sein könnten, deren Einnahmezeitpunkt aber schon länger zurück liegt (z.B. Amiodaron einmalig vor 14 Tagen eingenommen, seitdem Schilddrüsenüberfunktion, da HWZ von Amiodaron 56 Tage; oder Steroide wurden über Jahre bis vor einem Jahr\n eingenommen - aktuell zwar nicht mehr, aber Befund Deckplatteneinbruch bei Osteoporose; oder Aufnahme wegen Lungenfibrose, vor mehr als 10 Jahren Nitrofurantoin eingenommen, oder Chemotherapie bis vor 2 Wochen – aktuell Stomatitis, etc.).
Hier erfolgt idealerweise die Übernahme vom Bundesmedikationsplan.
Idealerweise enthält die\n Medikamentenanamnese also alle Medikamente, die zum Zeitpunkt der Aufnahme eine klinische Wirkung oder ein Interaktionspotential besitzen. Letzter Einnahmezeitpunkt weniger als 4 HWZ des Medikaments oder möglicher Kausalzusammenhang mit UAW/MF.
\n
Beispielhafte Medikamentenanamnese:
1. Metoprolol 95mg po. 1-0-1
2. Delix 5mg po. 1-0-0
3. Torem 10mg po. 1-0-0
4. Actrapid s.c. 12IE-8IE-10IE
5. Protaphane s.c. 22:00 12IE
6. ASS 100mg po 08:00-0-0
7. \n Allopurinol 300mg po. 1-0-0
8. Simvahexal 40mg 0-0-1
\n
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RKI Surveillance
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\n \n
\n
\n \n
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\n \n
\n
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Kodierung gemäß ISO 3166-1 (ALPHA-2)
Mehrfachauswahl möglich
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Neu = Ja
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| Pflege durch Angehörige | Pflege zu Hause |
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| Pflegedienst | Pflege in Institution |
| Pflegeheim | Pflege in Institution |
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The CCR is only intended for use with alert and stable trauma patients with neck pain
Exclusion Criteria
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INSTRUCTIONS
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Only apply to patients with Glasgow Coma Scale (GCS) 13-15 and at least one of the following:
\n\n
- \n
- Loss of consciousness. \n
- Amnesia to the head injury event. \n
- Witnessed disorientation. \n
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\n
- \n
- Age <16 years. \n
- Blood thinners. \n
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}], "rationale" : [{ "language" : "de-DE", "#text" : "\n
| \n \n CHA₂DS₂-VASc Score\n \n | \n \n \n Risk of ischemic stroke\n \n | \n \n \n Risk of stroke/TIA/systemic embolism\n \n | \n
| \n 0 \n | \n \n 0.2% \n | \n \n 0.3% \n | \n
| \n 1 \n | \n \n 0.6% \n | \n \n 0.9% \n | \n
| \n 2 \n | \n \n 2.2% \n | \n \n 2.9% \n | \n
| \n 3 \n | \n \n 3.2% \n | \n \n 4.6% \n | \n
| \n 4 \n | \n \n 4.8% \n | \n \n 6.7% \n | \n
| \n 5 \n | \n \n 7.2% \n | \n \n 10.0% \n | \n
| \n 6 \n | \n \n 9.7% \n | \n \n 13.6% \n | \n
| \n 7 \n | \n \n 11.2% \n | \n \n 15.7% \n | \n
| \n 8 \n | \n \n 10.8% \n | \n \n 15.2% \n | \n
| \n 9 \n | \n \n 12.2% \n | \n \n 17.4% \n | \n
Möglichst automatisch Befüllen aus
nap-dataelement2020(1)-11
oder
nap-dataelement2020(1)-20143
" }], "valueDomain" : [{ "type" : "code", "conceptList" : [{ "id" : "2.16.840.1.113883.2.6.60.3.2.6.21004.20190813173603.0", "concept" : [{ "id" : "2.16.840.1.113883.2.6.60.3.2.6.21004.20190813173603.3", "name" : [{ "language" : "de-DE", "#text" : "Systolischer Blutdruck < 90 mmHg " }], "synonym" : [{ "language" : "de-DE", "#text" : "1" }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.6.21004.20190813173603.2", "name" : [{ "language" : "de-DE", "#text" : "Diastolischer Blutdruck ≤ 60 mm Hg" }], "synonym" : [{ "language" : "de-DE", "#text" : "1" }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.6.21004.20190813173603.1", "exception" : "true", "name" : [{ "language" : "de-DE", "#text" : "anderer Blutdruck" }], "synonym" : [{ "language" : "de-DE", "#text" : "0" }] }] }] }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.9.21005", "statusCode" : "draft", "effectiveDate" : "2023-11-20T00:00:00", "lastModifiedDate" : "2023-11-27T17:39:29", "type" : "item", "iddisplay" : "notfdok-dataelement2025-21005", 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"2023-11-27T17:39:29", "type" : "item", "iddisplay" : "notfdok-dataelement2025-22041", "shortName" : "klinische_frailty_skala", "implementation" : [{ "shortName" : "klinische_frailty_skala", "markdown" : "Mehrere nationale und internationale Empfehlungen, unter anderem die „Entscheidungen über die Zuteilung von Ressourcen in der Notfall- und der Intensivmedizin im Kontext der COVID-19-Pandemie“ der Deutschen Interdisziplinären Vereinigung für Intensiv- und Notfallmedizin (DIVI) heben klar die Bedeutung der Ver wendung der Clinical Frailty Scale (CFS) / deutsch: Klinischen Frailty Skala hervor. - Ziel ist die Identifizierung von Patien ten mit einem erhöhten Risiko für einen ausbleibenden Behandlungs erfolg, welche nicht von einer intensivmedizinischen Intervention profitieren dürften.\n\nDie CFS (deutsch: Klinische Frailty Skala) kann von allen adäquat geschulten Fachkräften im Gesundheits- oder Pflegedienst durchgeführt werden. Die Skala besteht aus 9 Kategorien. ❯ Fragen Sie den Patienten, Angehörige, Pflegende, betreuende Personen und/oder Heim personal, welche Fähigkeiten die betreffende Person vor ZWEI Wochen hatte. - ❯ Gründen Sie Ihre Einschätzung NICHT auf den Ist-Zustand, in dem sich die be treffende Person in der akuten Erkrankungsphase befindet. ❯ Entscheidungsträger, welche die Klinische Frailty Skala (CFS) verwenden, MÜSSEN die erhobene Kategorie überprüfen, um sicherzustellen, dass diese korrekt ist. ❯ Bedenken Sie, dass die Klinische Frailty Skala nur bei älteren Personen (≥65 Jahren) umfangreich validiert ist. Die Skala ist nicht bei Personen mit stabilen dauerhaften Be hinderungen, wie z.B. frühkindlichen Hirnschädigungen, validiert, da deren Prognose stark von derer älterer Menschen mit progredienten Behinderungen differieren könnte. - ❯ Die Klinische Frailty Skala sollte nicht isoliert verwendet werden; sie ist ein Instrument, welches im Rahmen einer ganzheitlichen Betrachtung und gemeinsamer Entscheidungen eingesetzt werden sollte.\n\n **Klinische Einstufung von Frailty bei Personen mit Demenz** \nDer Schweregrad der Frailty entspricht der Schwe re der Demenz. Typische Symptome einer leichten Demenz sind Vergesslichkeit bezüglich Details jüngster Ereignisse, auch wenn man sich an das Ereignis selbst noch erinnert, sowie das Wiederholen von Fragen und Gesagtem sowie sozialer Rückzug. - Bei mittelgradiger Demenz ist das Kurzzeitgedächtnis stark beeinträchtigt, obwohl die Personen sich augen scheinlich noch gut an Ereignisse der Vergangenheit erinnern können. Die Körperpflege erfolgt selbstständig mit verbaler Unterstützung. - Personen mit schwerer Demenz sind nicht in der Lage, ihre Körperpflege ohne Hilfestellung auszuführen." }], "inherit" : [{ "ref" : "2.16.840.1.113883.2.6.60.3.2.6.22041", "effectiveDate" : "2020-09-07T10:59:43", "prefix" : "aktin-", "datasetId" : "2.16.840.1.113883.2.6.60.3.1.6", "datasetEffectiveDate" : "2018-08-17T00:00:00", "datasetStatusCode" : "final", "datasetVersionLabel" : "v2020.1", "iType" : "item", "iStatusCode" : "final", "iEffectiveDate" : "2020-09-07T10:59:43", "iVersionLabel" : "v2020.1", "iddisplay" : "nap-dataelement2020(1)-22041", "refdisplay" : "nap-dataelement2020(1)-22041", "localInherit" : "true" }], "name" : [{ "language" : "de-DE", "#text" : "Klinische Frailty Skala" }], "desc" : [{ "language" : "de-DE", "#text" : "Mehrere nationale und internationale Empfehlungen, unter anderem die „Entscheidungen über die Zuteilung von Ressourcen in der Notfall- und der Intensivmedizin im Kontext der COVID-19-Pandemie“ der Deutschen Interdisziplinären Vereinigung für Intensiv- und Notfallmedizin (DIVI) heben klar die Bedeutung der Ver wendung der Clinical Frailty Scale (CFS) /\n deutsch: Klinischen Frailty Skala hervor. - Ziel ist die Identifizierung von Patien ten mit einem erhöhten Risiko für einen ausbleibenden Behandlungs erfolg, welche nicht von einer intensivmedizinischen Intervention profitieren dürften. oder
nap-dataelement2020(1)-20143
Die CFS (deutsch: Klinische Frailty Skala) kann von allen adäquat geschulten Fachkräften im Gesundheits-\n oder Pflegedienst durchgeführt werden. Die Skala besteht aus 9 Kategorien. ❯ Fragen Sie den Patienten, Angehörige, Pflegende, betreuende Personen und/oder Heim personal, welche Fähigkeiten die betreffende Person vor ZWEI Wochen hatte. - ❯ Gründen Sie Ihre Einschätzung NICHT auf den Ist-Zustand, in dem sich die be treffende Person in der akuten Erkrankungsphase befindet. ❯\n Entscheidungsträger, welche die Klinische Frailty Skala (CFS) verwenden, MÜSSEN die erhobene Kategorie überprüfen, um sicherzustellen, dass diese korrekt ist. ❯ Bedenken Sie, dass die Klinische Frailty Skala nur bei älteren Personen (≥65 Jahren) umfangreich validiert ist. Die Skala ist nicht bei Personen mit stabilen dauerhaften Be hinderungen, wie z.B. frühkindlichen\n Hirnschädigungen, validiert, da deren Prognose stark von derer älterer Menschen mit progredienten Behinderungen differieren könnte. - ❯ Die Klinische Frailty Skala sollte nicht isoliert verwendet werden; sie ist ein Instrument, welches im Rahmen einer ganzheitlichen Betrachtung und gemeinsamer Entscheidungen eingesetzt werden sollte.
Klinische Einstufung von Frailty bei Personen mit Demenz
Der Schweregrad der Frailty entspricht der Schwe re der Demenz. Typische Symptome einer leichten Demenz sind Vergesslichkeit bezüglich Details jüngster Ereignisse, auch wenn man sich an das Ereignis selbst noch erinnert, sowie das Wiederholen von Fragen und Gesagtem sowie sozialer\n Rückzug. - Bei mittelgradiger Demenz ist das Kurzzeitgedächtnis stark beeinträchtigt, obwohl die Personen sich augen scheinlich noch gut an Ereignisse der Vergangenheit erinnern können. Die Körperpflege erfolgt selbstständig mit verbaler Unterstützung. - Personen mit schwerer Demenz sind nicht in der Lage, ihre Körperpflege ohne Hilfestellung auszuführen.
" }], "source" : [{ "language" : "de-DE", "#text" : "\n https://www.divi.de/images/Dokumente/200331_DGG_Plakat_A4_Clinical_Frailty_Scale_CFS.pdf \n " }], "rationale" : [{ "language" : "de-DE", "#text" : "GECCO-Datensatz" }], "valueDomain" : [{ "type" : "code", "conceptList" : [{ "id" : "2.16.840.1.113883.2.6.60.3.2.6.22041.20200907105943.0", "concept" : [{ "id" : "2.16.840.1.113883.2.6.60.3.2.6.22041.20200907105943.7", "name" : [{ "language" : "de-DE", "#text" : "Sehr fit" }], "synonym" : [{ "language" : "de-DE", "#text" : "1" }], "desc" : [{ "language" : "de-DE", "#text" : "Personen in dieser Kategorie sind robust, aktiv, voller Energie und motiviert. Sie trainieren üblicherweise regelmäßig und sind mit die Fittesten innerhalb ihrer Altersgruppe.
" }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.6.22041.20200907105943.6", "name" : [{ "language" : "de-DE", "#text" : "Durchschnittlich aktiv" }], "synonym" : [{ "language" : "de-DE", "#text" : "2" }], "desc" : [{ "language" : "de-DE", "#text" : "Personen in dieser Kategorie zeigen keine aktiven Krankheitssymptome, sind aber nicht so fit wie Personen in Kategorie 1. Sie sind durchschnittlich aktiv oder zeitweilig sehr aktiv, z.B. saisonal.
" }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.6.22041.20200907105943.5", "name" : [{ "language" : "de-DE", "#text" : "Gut zurechtkommend" }], "synonym" : [{ "language" : "de-DE", "#text" : "3" }], "desc" : [{ "language" : "de-DE", "#text" : "Die Krankheitssymptome dieser Personengruppe sind gut kontrolliert, aber außer Gehen im Rahmen von Alltagsaktivitäten bewegen sie sich nicht regelmäßig.
" }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.6.22041.20200907105943.4", "name" : [{ "language" : "de-DE", "#text" : "Vulnerabel" }], "synonym" : [{ "language" : "de-DE", "#text" : "4" }], "desc" : [{ "language" : "de-DE", "#text" : "Auch wenn sie nicht auf externe Hilfen im Alltag angewiesen sind, sind Personen in dieser Kategorie aufgrund ihrer Krankheitssymptome oft in ihren Aktivitäten eingeschränkt. Häufig klagen sie über Tagesmüdigkeit und/oder berich ten, dass Alltagsaktivitäten mehr Zeit benötigen.
" }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.6.22041.20200907105943.3", "name" : [{ "language" : "de-DE", "#text" : "Geringgradig frail" }], "synonym" : [{ "language" : "de-DE", "#text" : "5" }], "desc" : [{ "language" : "de-DE", "#text" : "Personen in dieser Kategorie sind offensichtlich in ihren Aktivitäten verlangsamt und benötigen Hilfe bei anspruchsvollen Alltagsaktivitä ten, wie finanziellen Angelegenheiten, Transport, schwerer Hausarbeit und im Umgang mit Medika menten. Geringgradige Frailty beeinträchtigt das selbständige Einkaufen, Spazierengehen sowie die\n Essenszubereitung und Haushaltstätigkeiten
" }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.6.22041.20200907105943.2", "name" : [{ "language" : "de-DE", "#text" : "Mittelgradig frail" }], "synonym" : [{ "language" : "de-DE", "#text" : "6" }], "desc" : [{ "language" : "de-DE", "#text" : "Personen in dieser Kategorie benöti gen Hilfe bei allen außerhäuslichen Tätigkeiten und bei der Haus haltsführung. Im Haus haben sie oft Schwierigkeiten mit Treppen, benötigen Hilfe beim Baden/Duschen und eventuell Anleitung oder minimale Unterstützung beim Ankleiden.
" }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.6.22041.20200907105943.1", "name" : [{ "language" : "de-DE", "#text" : "Ausgeprägt frail" }], "synonym" : [{ "language" : "de-DE", "#text" : "7" }], "desc" : [{ "language" : "de-DE", "#text" : "Personen in dieser Kategorie sind aufgrund körperlicher oder kognitiver Einschränkungen bei der Körperpflege komplett auf externe Hilfe angewie sen. Dennoch sind sie gesundheitlich stabil. Die Wahrscheinlichkeit, dass sie innerhalb der nächs ten 6 Monate sterben, ist gering.
" }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.6.22041.20200907105943.10", "name" : [{ "language" : "de-DE", "#text" : "Extrem frail" }], "synonym" : [{ "language" : "de-DE", "#text" : "8" }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.6.22041.20200907105943.8", "name" : [{ "language" : "de-DE", "#text" : "Terminal erkrankt" }], "synonym" : [{ "language" : "de-DE", "#text" : "9" }], "desc" : [{ "language" : "de-DE", "#text" : "Personen in dieser Kategorie haben eine Lebenserwartung <6 Monate. Die Kategorie bezieht sich auf Perso nen, die anderweitig keine Zeichen von Frailty aufweisen.
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- \n
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- \n
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- \n
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- \n
- If imaging is negative consider angiography \n
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Beträgt der Kinn-Hyoid-Abstand weniger als 3 Querfinger?" }], "valueDomain" : [{ "type" : "boolean" }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.9.20716", "statusCode" : "draft", "effectiveDate" : "2023-11-20T00:00:00", "lastModifiedDate" : "2023-11-27T17:39:29", "type" : "item", "iddisplay" : "notfdok-dataelement2025-20716", "shortName" : "mundbodenkehlkopfabstand_unter_2_querfinger", "implementation" : [{ "shortName" : "mundbodenkehlkopfabstand_unter_2_querfinger", "markdown" : "E Evaluate the 3-3-2 rule\nBeträgt der Abstand vom Mundboden zum Kehlkopfeinkerbung unter 2 Querfinger?" }], "inherit" : [{ "ref" : "2.16.840.1.113883.2.6.60.3.2.6.20716", "effectiveDate" : "2019-03-02T12:28:06", "prefix" : "aktin-", "datasetId" : "2.16.840.1.113883.2.6.60.3.1.6", "datasetEffectiveDate" : "2018-08-17T00:00:00", "datasetStatusCode" : "final", "datasetVersionLabel" : "v2020.1", "iType" : "item", "iStatusCode" : "final", "iEffectiveDate" : "2019-03-02T12:28:06", "iVersionLabel" : "v2020.1", "iddisplay" : "nap-dataelement2020(1)-20716", "refdisplay" : "nap-dataelement2020(1)-20716", "localInherit" : "true" }], "name" : [{ "language" : "de-DE", "#text" : "Mundboden-Kehlkopfabstand unter 2 Querfinger" }], "desc" : [{ "language" : "de-DE", "#text" : "E Evaluate the 3-3-2 rule
Beträgt der Abstand vom Mundboden zum Kehlkopfeinkerbung unter 2 Querfinger?" }], "valueDomain" : [{ "type" : "boolean" }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.9.20717", "statusCode" : "draft", "effectiveDate" : "2023-11-20T00:00:00", "lastModifiedDate" : "2023-11-27T17:39:29", "type" : "item", "iddisplay" : "notfdok-dataelement2025-20717", "shortName" : "mallampati_groser_2", "implementation" : [{ "shortName" : "mallampati_groser_2", "markdown" : "M Mallampati" }], "inherit" : [{ "ref" : "2.16.840.1.113883.2.6.60.3.2.6.20717", "effectiveDate" : "2019-03-02T12:31:13", "prefix" : "aktin-", "datasetId" : "2.16.840.1.113883.2.6.60.3.1.6", "datasetEffectiveDate" : "2018-08-17T00:00:00", "datasetStatusCode" : "final", "datasetVersionLabel" : "v2020.1", "iType" : "item", "iStatusCode" : "final", "iEffectiveDate" : "2019-03-02T12:31:13", "iVersionLabel" : "v2020.1", "iddisplay" : "nap-dataelement2020(1)-20717", "refdisplay" : "nap-dataelement2020(1)-20717", "localInherit" : "true" }], "name" : [{ "language" : "de-DE", "#text" : "Mallampati größer 2" }], "desc" : [{ "language" : "de-DE", "#text" : "M Mallampati" }], "operationalization" : [{ "language" : "de-DE", "#text" : "Kann aus Mallampati-Score übernommen werden." }], "valueDomain" : [{ "type" : "boolean" }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.9.20718", "statusCode" : "draft", "effectiveDate" : "2023-11-20T00:00:00", "lastModifiedDate" : "2023-11-27T17:39:29", "type" : "item", "iddisplay" : "notfdok-dataelement2025-20718", "shortName" : "atemwegsobstruktion", "implementation" : [{ "shortName" : "atemwegsobstruktion", "markdown" : "O Obstruction?\nIst der Atemweg obstruiert wie z. B. bei Epiglottitis, Peritonsillarabszeß oder Trauma" }], "inherit" : [{ "ref" : "2.16.840.1.113883.2.6.60.3.2.6.20718", "effectiveDate" : "2019-03-02T12:32:19", "prefix" : "aktin-", "datasetId" : "2.16.840.1.113883.2.6.60.3.1.6", "datasetEffectiveDate" : "2018-08-17T00:00:00", "datasetStatusCode" : "final", "datasetVersionLabel" : "v2020.1", "iType" : "item", "iStatusCode" : "final", "iEffectiveDate" : "2019-03-02T12:32:19", "iVersionLabel" : "v2020.1", "iddisplay" : "nap-dataelement2020(1)-20718", "refdisplay" : "nap-dataelement2020(1)-20718", "localInherit" : "true" }], "name" : [{ "language" : "de-DE", "#text" : "Atemwegsobstruktion" }], "desc" : [{ "language" : "de-DE", "#text" : "O Obstruction?
Ist der Atemweg obstruiert wie z. B. bei Epiglottitis, Peritonsillarabszeß oder Trauma" }], "valueDomain" : [{ "type" : "boolean" }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.9.20719", "statusCode" : "draft", "effectiveDate" : "2023-11-20T00:00:00", "lastModifiedDate" : "2023-11-27T17:39:29", "type" : "item", "iddisplay" : "notfdok-dataelement2025-20719", "shortName" : "eingeschrankte_hwsbeweglichkeit", "implementation" : [{ "shortName" : "eingeschrankte_hwsbeweglichkeit", "markdown" : "N Neck mobility\nIst die Beweglichkeit der HWS eingeschränkt? Dazu gehört auch eine Halsorthese." }], "inherit" : [{ "ref" : "2.16.840.1.113883.2.6.60.3.2.6.20719", "effectiveDate" : "2019-03-02T12:33:18", "prefix" : "aktin-", "datasetId" : "2.16.840.1.113883.2.6.60.3.1.6", "datasetEffectiveDate" : "2018-08-17T00:00:00", "datasetStatusCode" : "final", "datasetVersionLabel" : "v2020.1", "iType" : "item", "iStatusCode" : "final", "iEffectiveDate" : "2019-03-02T12:33:18", "iVersionLabel" : "v2020.1", "iddisplay" : "nap-dataelement2020(1)-20719", "refdisplay" : "nap-dataelement2020(1)-20719", "localInherit" : "true" }], "name" : [{ "language" : "de-DE", "#text" : "Eingeschränkte HWS-Beweglichkeit" }], "desc" : [{ "language" : "de-DE", "#text" : "N Neck mobility
Ist die Beweglichkeit der HWS eingeschränkt? 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Bei Patienten >65 Jahren wird initial Months Backwards Test (MBT) erhoben um Unaufmerksamkeit zu detektieren. Ergibt dieser drei oder mehr Punkte, wird als zweite Stufe der Mental Status Question-naire (MSQ) erhoben. " }], "inherit" : [{ "ref" : "2.16.840.1.113883.2.6.60.3.2.6.20859", "effectiveDate" : "2019-07-28T14:46:51", "prefix" : "aktin-", "datasetId" : "2.16.840.1.113883.2.6.60.3.1.6", "datasetEffectiveDate" : "2018-08-17T00:00:00", "datasetStatusCode" : "final", "datasetVersionLabel" : "v2020.1", "iType" : "group", "iStatusCode" : "final", "iEffectiveDate" : "2019-07-28T14:46:51", "iVersionLabel" : "v2020.1", "iddisplay" : "nap-dataelement2020(1)-20859", "refdisplay" : "nap-dataelement2020(1)-20859", "localInherit" : "true" }], "name" : [{ "language" : "de-DE", "#text" : "mCAM-ED" }], "desc" : [{ "language" : "de-DE", "#text" : "mCAM-ED ist eine Anpassung des CAM für Notaufnahmen. Bei Patienten >65 Jahren wird initial Months Backwards Test (MBT) erhoben um Unaufmerksamkeit zu detektieren. Ergibt dieser drei oder mehr Punkte, wird als zweite Stufe der Mental Status Question- naire (MSQ) erhoben. " }], "source" : [{ "language" : "de-DE", "#text" : "\n https://doi.org/10.1007/s11739-017-1781-y \n " }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.9.114", "statusCode" : "draft", "effectiveDate" : "2023-11-20T00:00:00", "lastModifiedDate" : "2023-11-27T17:39:29", "type" : "item", "iddisplay" : "notfdok-dataelement2025-114", "shortName" : "modified_rankin_skala_score", "implementation" : [{ "shortName" : "modified_rankin_skala_score", "markdown" : "Die Rankin Skala ist eine einfache Ordinalskala, die die funktionelle Einschränkung eines Patienten beschreibt, vor einer Akuterkrankung aber auch als Outcome nach z.B. Rehabilitation. Sie reicht von 0 bis 5 Punkten bei Aufnahme im Krankenhaus. \n\n- Keine Symptome, kann alle gewohnten Aufgaben und Aktivitäten verrichten (0 Punkte) - Keine wesentliche Funktionseinschränkung trotz Symptomen, kann alle gewohnten Aufgaben und Aktivitäten verrichten (1 Punkt) - Geringgradige Funktionseinschränkung, nicht alle früheren Aktivitäten möglich, aber unabhängig im täglichen Leben (2 Punkte) - Mäßiggradige Funktionseinschränkung, bedarf einiger Unterstützung, ist aber ohne Hilfe gehfähig (3 Punkte) - Mittelschwere Funktionseinschränkung, Hilfe zum Gehen und für eigene körperliche Bedürfnisse nötig (4 Punkte) - Schwere Funktionseinschränkung, bettlägrig, inkontinent, kontinuierliche Pflege notwendig (5 Punkte)" }], "inherit" : [{ "ref" : "2.16.840.1.113883.2.6.60.3.2.6.114", "effectiveDate" : "2018-01-25T00:00:00", "prefix" : "aktin-", "datasetId" : "2.16.840.1.113883.2.6.60.3.1.6", "datasetEffectiveDate" : "2018-08-17T00:00:00", "datasetStatusCode" : "final", "datasetVersionLabel" : "v2020.1", "iType" : "item", "iStatusCode" : "final", "iEffectiveDate" : "2018-01-25T00:00:00", "iVersionLabel" : "v2020.1", "iddisplay" : "nap-dataelement2020(1)-114", "refdisplay" : "nap-dataelement2020(1)-114", "localInherit" : "true" }], "name" : [{ "language" : "de-DE", "#text" : "modified Rankin Skala Score" }], "desc" : [{ "language" : "de-DE", "#text" : "Die Rankin Skala ist eine einfache Ordinalskala, die die funktionelle Einschränkung eines Patienten beschreibt, vor einer Akuterkrankung aber auch als Outcome nach z.B. Rehabilitation. Sie reicht von 0 bis 5 Punkten bei Aufnahme im Krankenhaus.
- Keine Symptome, kann alle gewohnten Aufgaben und Aktivitäten verrichten (0\n Punkte) - Keine wesentliche Funktionseinschränkung trotz Symptomen, kann alle gewohnten Aufgaben und Aktivitäten verrichten (1 Punkt) - Geringgradige Funktionseinschränkung, nicht alle früheren Aktivitäten möglich, aber unabhängig im täglichen Leben (2 Punkte) - Mäßiggradige Funktionseinschränkung, bedarf einiger Unterstützung, ist aber ohne Hilfe gehfähig (3 Punkte) -\n Mittelschwere Funktionseinschränkung, Hilfe zum Gehen und für eigene körperliche Bedürfnisse nötig (4 Punkte) - Schwere Funktionseinschränkung, bettlägrig, inkontinent, kontinuierliche Pflege notwendig (5 Punkte)
" }], "source" : [{ "language" : "de-DE", "#text" : "Rankin J. zerebral vascular accidents in people over the age of 60: Prognosis. Scott Med J. 1957;2:200-215" }], "rationale" : [{ "language" : "de-DE", "#text" : "ADSR" }], "comment" : [{ "language" : "de-DE", "#text" : "options: 0 = Rankin 0; 1 = Rankin 1; 2 = Rankin 2; 3 = Rankin 3; 4 = Rankin 4; 5 = Rankin 5; 6 = Rankin 6;" }], "relationship" : [{ "type" : "SPEC", "ref" : "2.16.840.1.113883.2.6.60.3.2.1.114", "flexibility" : "2014-01-06T16:43:12", "prefix" : "aktin-", "datasetId" : "2.16.840.1.113883.2.6.60.3.1.1", "datasetEffectiveDate" : "2014-09-15T00:00:00", "datasetStatusCode" : "final", "datasetVersionLabel" : "v2014.1-b", "iType" : "item", "iEffectiveDate" : "2014-01-06T16:43:12", "iStatusCode" : "final", "refdisplay" : "aktin-dataelement2014(1)-114", "name" : [{ "language" : "de-DE", "#text" : "Rankin Skala Score" }] }], "valueDomain" : [{ "type" : "code", "conceptList" : [{ "id" : "2.16.840.1.113883.2.6.60.3.2.6.114.20180125000000.0", "concept" : [{ "id" : "2.16.840.1.113883.2.6.60.3.2.6.114.1", "name" : [{ "language" : "de-DE", "#text" : "keine Symptome" }], "synonym" : [{ "language" : "de-DE", "#text" : "Rankin 0" }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.6.114.2", "name" : [{ "language" : "de-DE", "#text" : "keine wesentliche Funktionseinschränkung" }], "synonym" : [{ "language" : "de-DE", "#text" : "Rankin 1" }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.6.114.3", "name" : [{ "language" : "de-DE", "#text" : "geringgradige Funktionseinschränkung" }], "synonym" : [{ "language" : "de-DE", "#text" : "Rankin 2" }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.6.114.4", "name" : [{ "language" : "de-DE", "#text" : "mäßiggradige Funktionseinschränkung" }], "synonym" : [{ "language" : "de-DE", "#text" : "Rankin 3" }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.6.114.5", "name" : [{ "language" : "de-DE", "#text" : "mittelschwere Funktionseinschränkung" }], "synonym" : [{ "language" : "de-DE", "#text" : "Rankin 4" }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.6.114.6", "name" : [{ "language" : "de-DE", "#text" : "schwere Funktionseinschränkung" }], "synonym" : [{ "language" : "de-DE", "#text" : "Rankin 5" }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.6.114.20180125000000.7", "name" : [{ "language" : "de-DE", "#text" : "Tod" }], "synonym" : [{ "language" : "de-DE", "#text" : "Rankin 6" }] }] }] }], "terminologyAssociation" : [{ "conceptId" : "2.16.840.1.113883.2.6.60.3.2.6.114", "conceptFlexibility" : "2018-01-25T00:00:00", "code" : "75859-9", "codeSystem" : "2.16.840.1.113883.6.1", "displayName" : "Modified rankin scale", "effectiveDate" : "2019-02-10T09:02:09", "codeSystemName" : "Logical Observation Identifier Names and Codes" }, { "conceptId" : "2.16.840.1.113883.2.6.60.3.2.6.114", "conceptFlexibility" : "2018-01-25T00:00:00", "code" : "273729003", "codeSystem" : "2.16.840.1.113883.6.96", "displayName" : "Rankin scale (assessment scale)", "effectiveDate" : "2019-02-10T09:02:09", "codeSystemName" : "SNOMED Clinical Terms" }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.9.20663", "statusCode" : "draft", "effectiveDate" : "2023-11-20T00:00:00", "lastModifiedDate" : "2023-11-27T17:39:29", "type" : "group", "iddisplay" : "notfdok-dataelement2025-20663", "shortName" : "nihssscore", "implementation" : [{ "shortName" : "nihssscore", "markdown" : "Der NIHSS als Score ist hier modelliert, damit der dokumentierte Score standardisiert weitergeben werden kann. Der NIHSS-Score sollte in einem Notaufnahmedokumentationssystem durch Ausfüllen des Befund/Neurostatus erfolgen. Aus diesem sollte der NIHSS-Score automatisch befüllt werden." }], "inherit" : [{ "ref" : "2.16.840.1.113883.2.6.60.3.2.6.20663", "effectiveDate" : "2019-02-10T08:55:13", "prefix" : "aktin-", "datasetId" : "2.16.840.1.113883.2.6.60.3.1.6", "datasetEffectiveDate" : "2018-08-17T00:00:00", "datasetStatusCode" : "final", "datasetVersionLabel" : "v2020.1", "iType" : "group", "iStatusCode" : "final", "iEffectiveDate" : "2019-02-10T08:55:13", "iVersionLabel" : "v2020.1", "iddisplay" : "nap-dataelement2020(1)-20663", "refdisplay" : "nap-dataelement2020(1)-20663", "localInherit" : "true" }], "name" : [{ "language" : "de-DE", "#text" : "NIHSS-Score" }], "desc" : [{ "language" : "de-DE", "#text" : "Der NIHSS als Score ist hier modelliert, damit der dokumentierte Score standardisiert weitergeben werden kann. Der NIHSS-Score sollte in einem Notaufnahmedokumentationssystem durch Ausfüllen des Befund/Neurostatus erfolgen. Aus diesem sollte der NIHSS-Score automatisch befüllt werden." }], "rationale" : [{ "language" : "de-DE", "#text" : "ADSR" }], "relationship" : [{ "type" : "SPEC", "ref" : "2.16.840.1.113883.2.6.60.3.2.6.20567", "flexibility" : "2019-02-07T21:51:30", "prefix" : "aktin-", "datasetId" : "2.16.840.1.113883.2.6.60.3.1.6", "datasetEffectiveDate" : "2018-08-17T00:00:00", "datasetStatusCode" : "final", "datasetVersionLabel" : "v2020.1", "iType" : "group", "iEffectiveDate" : "2019-02-07T21:51:30", "iStatusCode" : "final", "iVersionLabel" : "v2020.1", "refdisplay" : "nap-dataelement2020(1)-20567", "name" : [{ "language" : "de-DE", "#text" : "Neurostatus" }] }], "operationalization" : [{ "language" : "de-DE", "#text" : "Berechnung aus Neurostatus" }], "concept" : [{ "id" : "2.16.840.1.113883.2.6.60.3.2.9.20744", "statusCode" : "draft", "effectiveDate" : "2023-11-20T00:00:00", "lastModifiedDate" : "2023-11-27T17:39:29", "type" : "group", "iddisplay" : "notfdok-dataelement2025-20744", "shortName" : "nihssitems", "implementation" : [{ "shortName" : "nihssitems", "markdown" : "Der Score wird gewöhnlich dazu verwendet, Ergebnisse, Verbesserungen oder Verschlimmerungen eines Schlaganfalls nachzuverfolgen.\n\nFalls ein Arm oder Bein aufgrund von Amputation oder einer anderen Einschränkung nicht getestet werden kann, wird nicht testbar dokumentiert und es werden keine Punkte gezählt." }], "inherit" : [{ "ref" : "2.16.840.1.113883.2.6.60.3.2.6.20744", "effectiveDate" : "2019-05-18T09:23:18", "prefix" : "aktin-", "datasetId" : "2.16.840.1.113883.2.6.60.3.1.6", "datasetEffectiveDate" : "2018-08-17T00:00:00", "datasetStatusCode" : "final", "datasetVersionLabel" : "v2020.1", "iType" : "group", "iStatusCode" : "final", "iEffectiveDate" : "2019-05-18T09:23:18", "iVersionLabel" : "v2020.1", "iddisplay" : "nap-dataelement2020(1)-20744", "refdisplay" : "nap-dataelement2020(1)-20744", "localInherit" : "true", "inheritanceIssues" : "true", "inheritExtraConcepts" : "4", "currentExtraConcepts" : "0" }], "name" : [{ "language" : "de-DE", "#text" : "NIHSS-Items" }], "desc" : [{ "language" : "de-DE", "#text" : "Der Score wird gewöhnlich dazu verwendet, Ergebnisse, Verbesserungen oder Verschlimmerungen eines Schlaganfalls nachzuverfolgen.
Falls ein Arm oder Bein aufgrund von Amputation oder einer anderen Einschränkung nicht getestet werden kann, wird nicht testbar dokumentiert und es werden keine Punkte gezählt.
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| Somnolent | 1 |
| Soporös | 2 |
| Komatös, Schmerzreaktion | 2 |
| Komatös, Dezerebrationszeichen auf Schmerzreiz | 3 |
| Komatös, keine Schmerzreaktion | 3 |
| Örtlich orientiert | |
| Örtlich nicht orientiert | |
| nicht beurteilbar (Koma/Sopor, Aphasie) | |
| nicht zu erheben (mechan. Hindernis, Anarthrie) | |
| Zur Person orientiert | 0 |
| Zur Person nicht orientiert (u.a. Alter) | 1 |
| nicht beurteilbar (Koma/Sopor, Aphasie) | |
| nicht zu erheben (mechan. Hindernis, Anarthrie) | |
| Zur Situation orientiert | |
| Zur Situation nicht orientiert | |
| nicht beurteilbar (Koma/Sopor, Aphasie) | |
| nicht zu erheben (mechan. Hindernis, Anarthrie) | |
| Zur Zeit orientiert | 0 |
| Zur Zeit nicht orientiert (u.a. Monat) | 1 |
| nicht beurteilbar (Koma/Sopor, Aphasie) | 2 |
| nicht zu erheben (mechan. Hindernis, Anarthrie) | 1 |
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11154-22098-2
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\n
| 14688-6 | \n14688-6 | \n
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| 4485-9 | 4485-9 |
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| 76496-9 | 76496-9 |
| 25700-6 | 25700-6 |
| 20393-5 | \n20393-5 | \n
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| 20394-3 | 20394-3 |
| 7852-7 | 7852-7 |
| 7852-7 | 16715-5 |
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| 14955-9 | 5763-8 |
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| 25461-5 | 3719-2 |
| 13965-9 | 13965-9 |
| 13965-9 | 2428-1 |
| 74442-5 | 30552-4 |
| 74442-5 | 62236-5 |
| 15060-7 | 15060-7 |
| 15060-7 | 48138-2 |
| 15060-7 | 57371-7 |
| 32554-8 | 20468-5 |
| 32554-8 | 2999-1 |
| 29775-4 | 29775-4 |
| 29775-4 | 2484-4 |
| 14586-2 | 14586-2 |
| 14586-2 | 1763-2 |
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| 14674-6 | 6879-1 |
| 26515-7 | 13056-7 |
| 26515-7 | 26516-5 |
| 1959-6 | 1962-0 |
| 25433-4 | 25433-4 |
| 25433-4 | 721-1 |
| \n 50556-0\n | \n\n Urinalysis dipstick panel\n | \n\n Logical Observation Identifier Names and Codes\n | \n
| \n 53853004\n | \n\n Urinalysis, reagent strip without microscopy (procedure)\n | \n\n SNOMED Clinical Terms\n | \n
| 2880-3 | 2880-3 |
| 2520-5 | 2520-5 |
| 2520-5 | 27941-4 |
| 26454-9 | 26454-9 |
| 26454-9 | 791-4 |
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| 26465-5 | 805-2 |
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| 26486-1 | 33252-8 |
| 26486-1 | 10329-1 |
| 26486-1 | 26486-1 |
| 76480-3 | 76480-3 |
| 76480-3 | 1746-7 |
| 76480-3 | 2861-3 |
| 76480-3 | 13974-1 |
| 76489-4 | 76489-4 |
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| 76489-4 | 14339-6 |
| 2457-0 | 2457-0 |
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| 11031-2 | 6744-7 |
| 11031-2 | 11031-2 |
| 11031-2 | 13941-0 |
| 15212-4 | 15212-4 |
| 1747-5 | 1747-5 |
| 1747-5 | 43212-0 |
| 1747-5 | 53529-4 |
| 1747-5 | 17820-2 |
| 2529-6 | 2529-6 |
| 2529-6 | 14803-1 |
| 2529-6 | 60017-1 |
| 25386-4 | 12190-5 |
| 25386-4 | 25386-4 |
| 26452-3 | 35063-7 |
| 26452-3 | 40569-6 |
| 26452-3 | 12209-3 |
| 26452-3 | 26452-3 |
| 26455-6 | 23860-0 |
| 26455-6 | 26455-6 |
| 26455-6 | 6741-3 |
| 26466-3 | 26466-3 |
| 26466-3 | 6743-9 |
| 26466-3 | 57845-0 |
| 26493-7 | 21397-5 |
| 26493-7 | 26490-3 |
| 26493-7 | 71689-4 |
| 26493-7 | 26493-7 |
| 26493-7 | 9305-4 |
| 26493-7 | 71697-7 |
| 28543-7 | 35071-0 |
| 28543-7 | 40571-2 |
| 28543-7 | 12179-8 |
| 28543-7 | 28543-7 |
| 2881-1 | 2881-1 |
| 33509-1 | 33509-1 |
| \n 113091000\n | \n\n Magnetic resonance imaging (procedure)\n | \n\n SNOMED Clinical Terms\n | \n
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Rationale? Nötig?" }], "relationship" : [{ "type" : "SPEC", "ref" : "2.16.840.1.113883.2.6.60.3.2.6.20949", "flexibility" : "2019-08-11T17:48:22", "prefix" : "aktin-", "datasetId" : "2.16.840.1.113883.2.6.60.3.1.6", "datasetEffectiveDate" : "2018-08-17T00:00:00", "datasetStatusCode" : "final", "datasetVersionLabel" : "v2020.1", "iType" : "item", "iEffectiveDate" : "2019-08-11T17:48:22", "iStatusCode" : "final", "iVersionLabel" : "v2020.1", "refdisplay" : "nap-dataelement2020(1)-20949", "name" : [{ "language" : "de-DE", "#text" : "Unterbauch" }] }], "valueDomain" : [{ "type" : "code", "conceptList" : [{ "id" : "2.16.840.1.113883.2.6.60.3.2.6.20949.20190811174822.0", "concept" : [{ "id" : "2.16.840.1.113883.2.6.60.3.2.6.20949.20190811174822.1", "name" : [{ "language" : "de-DE", "#text" : "nein" }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.6.20949.20190811174822.2", "name" : [{ "language" : "de-DE", "#text" : "ja" }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.6.20949.20190811174822.3", "name" : [{ "language" : "de-DE", "#text" : "Verdacht auf" }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.6.20949.20190811174822.4", "name" : [{ "language" : "de-DE", "#text" : "nicht beurteilbar" }] }] }] }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.9.20959", "statusCode" : "draft", "effectiveDate" : "2023-11-20T00:00:00", "lastModifiedDate" : "2023-11-27T17:39:29", "type" : "item", "iddisplay" : "notfdok-dataelement2025-20959", "shortName" : "freie_flussigkeit_sonstiges", "implementation" : [{ "shortName" : "freie_flussigkeit_sonstiges", "markdown" : "Optional. 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Wurde in der Arbeitsoberfläche FAST \"ohne pathologischen Befund\" angegeben sind alle Datenfelder des FAST automatisch auf \"Nein\" zu setzen.\n\n |" }], "inherit" : [{ "ref" : "2.16.840.1.113883.2.6.60.3.2.6.20980", "effectiveDate" : "2019-08-11T19:18:37", "prefix" : "aktin-", "datasetId" : "2.16.840.1.113883.2.6.60.3.1.6", "datasetEffectiveDate" : "2018-08-17T00:00:00", "datasetStatusCode" : "final", "datasetVersionLabel" : "v2020.1", "iType" : "item", "iStatusCode" : "final", "iEffectiveDate" : "2019-08-11T19:18:37", "iVersionLabel" : "v2020.1", "iddisplay" : "nap-dataelement2020(1)-20980", "refdisplay" : "nap-dataelement2020(1)-20980", "localInherit" : "true" }], "name" : [{ "language" : "de-DE", "#text" : "E-Fast-Befund" }], "desc" : [{ "language" : "de-DE", "#text" : "\n
\n
\n
\n \n
\n \n \n
\n
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Alle FAST-Parameter mit Nein befundet.
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Bei V.a. mit Sicherheitskennzeichen V
Wurde dies Item beschrieben, sind die Items\n Lungengleiten, Lungenpuls, B-Linien und Lungenpunkt zu beschreiben.
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\n \n \n
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Medizinische Dokumentation." }], "concept" : [{ "id" : "2.16.840.1.113883.2.6.60.3.2.9.20946", "statusCode" : "draft", "effectiveDate" : "2023-11-20T00:00:00", "lastModifiedDate" : "2023-11-27T17:39:29", "type" : "group", "iddisplay" : "notfdok-dataelement2025-20946", "shortName" : "freie_flussigkeit", "implementation" : [{ "shortName" : "freie_flussigkeit", "markdown" : "" }], "inherit" : [{ "ref" : "2.16.840.1.113883.2.6.60.3.2.6.20946", "effectiveDate" : "2019-08-11T17:06:47", "prefix" : "aktin-", "datasetId" : "2.16.840.1.113883.2.6.60.3.1.6", "datasetEffectiveDate" : "2018-08-17T00:00:00", "datasetStatusCode" : "final", "datasetVersionLabel" : "v2020.1", "iType" : "group", "iStatusCode" : "final", "iEffectiveDate" : "2019-08-11T17:06:47", "iVersionLabel" : "v2020.1", "iddisplay" : "nap-dataelement2020(1)-20946", "refdisplay" : "nap-dataelement2020(1)-20946", "localInherit" : "true" }], "name" : [{ "language" : "de-DE", "#text" : "Freie Flüssigkeit" }], "desc" : [{ "language" : "de-DE" }], "rationale" : [{ "language" : "de-DE", "#text" : "\n Focused Assessment with Sonography for Trauma \n
\n
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Gallenblasen-Entfernung (CCE)" }], "inherit" : [{ "ref" : "2.16.840.1.113883.2.6.60.3.2.6.21070", "effectiveDate" : "2019-08-15T07:08:55", "prefix" : "aktin-", "datasetId" : "2.16.840.1.113883.2.6.60.3.1.6", "datasetEffectiveDate" : "2018-08-17T00:00:00", "datasetStatusCode" : "final", "datasetVersionLabel" : "v2020.1", "iType" : "item", "iStatusCode" : "final", "iEffectiveDate" : "2019-08-15T07:08:55", "iVersionLabel" : "v2020.1", "iddisplay" : "nap-dataelement2020(1)-21070", "refdisplay" : "nap-dataelement2020(1)-21070", "localInherit" : "true" }], "name" : [{ "language" : "de-DE", "#text" : "DHC erweitert" }], "desc" : [{ "language" : "de-DE", "#text" : "> 7 mm ohne vor-OP | \n \n \n Medizinische Dokumentation & Konzept der DACH-Arbeitsgruppe Notfallsonographie. \n | \n
> 10 mm bei Z.n. Gallenblasen-Entfernung (CCE)" }], "operationalization" : [{ "language" : "de-DE", "#text" : "Bei Angabe eines Durchmesser-DHC soll dieser Wert automatisch in Verbindung mit dem Wert Gallenblase/Zustand nach Cholecystektomie gesetzt werden:
DHC ist erweitert Wert=ja , wenn:
- wenn DHC-Duchmesser > 7 mm und Z.n. CCE= nein
- wenn DHC-Durchmesser\n > 10 mm und Z.n. CCE=ja
DHC ist erweitert Wert=nein , wenn:
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| RV-Rechtsherzbelastungszeichen-Verhältnis RV:LV >0,6-- | \n
\n " }], "operationalization" : [{ "language" : "de-DE", "#text" : "Automatisches setzen der ICD 10 S27.31 mit der entsprechenden Lateralität." }], "valueDomain" : [{ "type" : "code", "conceptList" : [{ "id" : "2.16.840.1.113883.2.6.60.3.2.6.21039.20190813210912.0", "concept" : [{ "id" : "2.16.840.1.113883.2.6.60.3.2.6.21039.20190813210912.1", "name" : [{ "language" : "de-DE", "#text" : "ja" }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.6.21039.20190813210912.2", "name" : [{ "language" : "de-DE", "#text" : "nein" }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.6.21039.20190813210912.3", "name" : [{ "language" : "de-DE", "#text" : "nicht beurteilbar" }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.6.21039.20190813210912.4", "name" : [{ "language" : "de-DE", "#text" : "Verdacht auf" }] }] }] }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.9.21041", "statusCode" : "draft", "effectiveDate" : "2023-11-20T00:00:00", "lastModifiedDate" : "2023-11-27T17:39:29", "type" : "item", "iddisplay" : "notfdok-dataelement2025-21041", "shortName" : "pneumothorax", "implementation" : [{ "shortName" : "pneumothorax", "markdown" : "Dies hat mit Angabe der Lateralisierung zu erfolgen." }], "inherit" : [{ "ref" : "2.16.840.1.113883.2.6.60.3.2.6.21041", "effectiveDate" : "2019-08-13T21:32:37", "prefix" : "aktin-", "datasetId" : "2.16.840.1.113883.2.6.60.3.1.6", "datasetEffectiveDate" : "2018-08-17T00:00:00", "datasetStatusCode" : "final", "datasetVersionLabel" : "v2020.1", "iType" : "item", "iStatusCode" : "final", "iEffectiveDate" : "2019-08-13T21:32:37", "iVersionLabel" : "v2020.1", "iddisplay" : "nap-dataelement2020(1)-21041", "refdisplay" : "nap-dataelement2020(1)-21041", "localInherit" : "true" }], "name" : [{ "language" : "de-DE", "#text" : "Pneumothorax" }], "desc" : [{ "language" : "de-DE", "#text" : "Dies hat mit Angabe der Lateralisierung zu erfolgen." }], "rationale" : [{ "language" : "de-DE", "#text" : "\n Medizinische Dokumentation & \n Konzept der DACH-Arbeitsgruppe Notfallsonographie. \n " }], "operationalization" : [{ "language" : "de-DE", "#text" : "Automatisch sollte bei ja der ICD J93.9 mit Angabe der Seite übernommen werden (links/rechts/beidseits). Bei V.a. mit Sicherheitskennzeichen V
Wurde dies Item beschrieben, sind die Items\n Lungengleiten, Lungenpuls, B-Linien und Lungenpunkt zu beschreiben.
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Bei V.a. mit Sicherheitskennzeichen V
Wurde dies Item beschrieben, sind die Items\n Lungengleiten, Lungenpuls, B-Linien und Lungenpunkt zu beschreiben.
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nein WENN kein Angiographie dokumentiert
vor Aufnahme WENN Untersuchungszeitpunkt Angiographie < Aufnahmezeitpunkt
direkt im Anschluss an native Bildgebung WENN Untersuchungszeitpunkt Angiographie >=\n Aufnahmezeitpunkt UND Untersuchungszeitpunkt Kopf-CT = Untersuchungszeitpunkt Kontrastmittel
nicht direkt im Anschluss an native Bildgebung aber ≤ 24 h WENN Untersuchungszeitpunkt Angiographie >= Aufnahmezeitpunkt UND Angiographie-Aufnahmezeitpunkt <= 24 h UND Untersuchungszeitpunkt Kopf-CT = Untersuchungszeitpunkt Kontrastmittel
nicht direkt im Anschluss an native Bildgebung aber > 24 h WENN Untersuchungszeitpunkt Angiographie >= Aufnahmezeitpunkt UND Angiographie-Aufnahmezeitpunkt > 24 h UND Untersuchungszeitpunkt Kopf-CT = Untersuchungszeitpunkt Kontrastmittel
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WENN ST-Strecke = STEMI DANN STEMI
WENN ventrikuläre Erregungsausbreitungsstörung = kompletter Linksschenkelblock DANN LSB
WENN ventrikuläre\n Erregungsausbreitungsstörung = kompletter Rechtsschenkelblock DANN RSB
WENN XXXXX DANN NSTEMI
WENN ST-STrecke = ST-Streckensenkung ODER ein Unterpunkt DANN ST-Senkung
WENN T-Welle = präterminale T-Negativierung DANN neg. T
WENN T-Welle = terminale T-Negativierung DANN neg. T
WENN Rhythmus = Sinusrhythmus DANN SR
WENN Rhythmus = Vorhofflimmern DANN VHF
WENN Rhythmus = Vorhofflattern DANN VHF
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Unter dem Begriff „extraglottische Atemwegshilfen“ werden alle Ventilationshilfen subsumiert, die ein Offenhalten der Atemwege zwischen Oropharynx und proximalen Ösophagus gewährleisten, aber außerhalb der Glottis liegen. Neben den unterschiedlichen Larynxmaskentypen umfasst dieser Begriff auch die ösophagealen Verschlusstuben (z.B. Larynxtubus, Combitubus).
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Nach Möglichkeit erfolgt die Dokumentation direkt durch Datenübergabe bei der Alarmierung durch die Leitstelle.
Wenn in diesem Protokoll eine Reanimation dokumentiert wird sollte eine elektronische Dokumentation aktiv zur Eingabe dieses Dokumentationsfeldes auffordern.
\n WENN Typ Entlassung = TOD UND ( \n Thoraxkompression/ \n Beginn ODER Thoraxkompression/Ende) DANN \n \n Todesfestellung\n \n
\n WENN Typ Entlassung <> TOD UND (ENTWEDER \n Thoraxkompression/ \n Beginn ODER Thoraxkompression/Ende) DANN \n \n Reanimation
\n \n WENN Typ Entlassung <> TOD UND (WEDER \n Thoraxkompression/ \n Beginn NOCH Thoraxkompression/Ende) DANN \n \n Notfallteameinsatz ohne Reanimation\n
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Nein WENN kein Beginn Intravenöse Thrombolyse dokumentiert
vor Aufnahme WENN Beginn Intravenöse Thrombolyse < Aufnahmezeitpunkt
im eigenen Haus WENN Aufnahmezeitpunkt <= Beginn Intravenöse Thrombolyse <= Zeitpunkt Patient verlegt\n nach...
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| Kolloid-Gabe während Schockraum-Phase - Schockraum | \n
Optionen: Patient muss isoliert werden / Patient muss nicht isoliert werden
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- Einschätzung der Infektionsgefahr (für Personal und Patienten)
- Dokumentation des Infektionsschutz
- Einhaltung der Hygienerichtlinien
Wildcard für Therapien und Prozeduren
Mehr Informationen finden sich im zugehörigen Datensatz in diesem Projekt.
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| keine Aphasie | nein |
| nichtflüssige Aphasie | ja |
| flüssige Aphasie | ja |
| gemischte Aphasie | ja |
| nicht beurteilbar | nicht\n bestimmbar |
| Ja | Ja |
| Nein | Nein |
| nicht ausgefüllt | nicht\n bestimmbar |
keine Dysarthrie =nein
Dysarthrie, noch zu verstehen = ja
Dys-/Anarthrie = ja
nicht beurteilbar = nicht bestimmbar
nicht möglich = nicht bestimmbar
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| leicht/mäßig gestört | ja |
| stark gestört/nicht möglich | ja |
| leer | nicht bestimmbar |
| wach | wach |
| somnolent | somnolent/soporös |
| soporös | somnolent/soporös |
| komatös, Schmerzreaktion | komatös |
| komatös, Dezerebrationszeichen auf Schmerzreiz | komatös |
| komatös, keine Schmerzreaktion | komatös |
BEFUND nach ABCDE - Als Unterpunkt im Reiter Körperlicher Befund. Ziel ist die Dokumentation adressierter Probleme im Schockraum nach ATLS oder ACiLS-Schema.
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Diagnosen nach DRG-Kodierrichtlinien haben kein Attribut, was in diesem Zusammenhang immer das Attribut gesichert bedeutet." }], "relationship" : [{ "type" : "SPEC", "ref" : "2.16.840.1.113883.2.6.60.3.2.3.20024", "flexibility" : "2016-01-12T19:37:32", "prefix" : "aktin-", "datasetId" : "2.16.840.1.113883.2.6.60.3.1.3", "datasetEffectiveDate" : "2015-11-01T00:00:00", "datasetStatusCode" : "final", "datasetVersionLabel" : "v2015.2-b", "iType" : "item", "iEffectiveDate" : "2016-01-12T19:37:32", "iStatusCode" : "final", "refdisplay" : "aktin-dataelement2015(2)-20024", "name" : [{ "language" : "de-DE", "#text" : "Zusatzkennzeichen" }] }], "valueDomain" : [{ "type" : "code", "conceptList" : [{ "id" : "2.16.840.1.113883.2.6.60.3.2.3.20024.0", "concept" : [{ "id" : "2.16.840.1.113883.2.6.60.3.2.3.20024.1", "exception" : "false", "name" : [{ "language" : "de-DE", "#text" : "Verdachtsdiagnose" }], "synonym" : [{ "language" : "de-DE", "#text" : "V" }], "desc" : [{ "language" : "de-DE" }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.3.20024.2", "exception" : "false", "name" : [{ "language" : "de-DE", "#text" : "ausgeschlossene Diagnose " }], "synonym" : [{ "language" : "de-DE", "#text" : "A" }], "desc" : [{ "language" : "de-DE" }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.3.20024.3", "exception" : "false", "name" : [{ "language" : "de-DE", "#text" : "Zustand nach der Diagnose" }], "synonym" : [{ "language" : "de-DE", "#text" : "Z" }], "desc" : [{ "language" : "de-DE" }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.3.20024.4", "exception" : "false", "name" : [{ "language" : "de-DE", "#text" : "gesicherte Diagnose" }], "synonym" : [{ "language" : "de-DE", "#text" : "G" }], "desc" : [{ "language" : "de-DE" }] }] }] }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.2.20023", "effectiveDate" : "2023-11-20T00:00:00", "statusCode" : "draft", "lastModifiedDate" : "2024-08-08T17:35:46", "type" : "item", "iddisplay" : "aktin-dataelement2015(1)-20023", "shortName" : "fuhrende_abschlussdiagnoseq_sequenznummer", "implementation" : [{ "shortName" : "fuhrende_abschlussdiagnoseq_sequenznummer", "markdown" : "Ist diese Abschlussdiagnose die Hauptdiagnose?\nEine Abschlussdiagnose muss als führende Diagnose und damit Hauptdiagnose gekennzeichnet werden.\n\nFührende Abschlussdiagnose: Sequenznummer = 1\nWeitere Abschlussdiagnosen: Sequenznummer > 1" }], "name" : [{ "language" : "de-DE", "lastTranslated" : "2024-08-08T17:35:34", "#text" : "Führende Abschlussdiagnose? / Sequenznummer" }], "synonym" : [{ "language" : "de-DE", "lastTranslated" : "2024-08-08T17:35:34", "#text" : "nokeda_diagnosis_icd4_rank" }], "desc" : [{ "language" : "de-DE", "lastTranslated" : "2024-08-08T17:35:34", "#text" : "
Ist diese Abschlussdiagnose die Hauptdiagnose?
Eine Abschlussdiagnose muss als führende Diagnose und damit Hauptdiagnose gekennzeichnet werden. \n
Führende Abschlussdiagnose: Sequenznummer = 1
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Mehrfachnennung möglich" }], "valueDomain" : [{ "type" : "code", "conceptList" : [{ "id" : "2.16.840.1.113883.2.6.60.3.2.6.21556.20190925183427.0", "concept" : [{ "id" : "2.16.840.1.113883.2.6.60.3.2.6.21556.20190925183427.6", "name" : [{ "language" : "de-DE", "#text" : "Ebolavirus" }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.6.21556.20190925183427.5", "name" : [{ "language" : "de-DE", "#text" : "Lassa-Virus" }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.6.21556.20190925183427.4", "name" : [{ "language" : "de-DE", "#text" : "Hämorrhagisches Krim-Kongo-Fieber" }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.6.21556.20190925183427.3", "name" : [{ "language" : "de-DE", "#text" : "Yersinia Pestis" }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.6.21556.20190925183427.2", "name" : [{ "language" : "de-DE", "#text" : "SARS-Coronavirus" }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.6.21556.20190925183427.9", "name" : [{ "language" : "de-DE", "#text" : "SARS-CoV-2" }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.6.21556.20190925183427.1", "name" : [{ "language" : "de-DE", "#text" : "MERS-Coronavirus" }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.6.21556.20190925183427.8", "name" : [{ "language" : "de-DE", "#text" : "Hautmilzbrand" }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.6.21556.20190925183427.7", "exception" : "true", "name" : [{ "language" : "de-DE", "#text" : "Sonstige" }] }] }] }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.9.21920", "statusCode" : "draft", "effectiveDate" : "2023-11-20T00:00:00", "lastModifiedDate" : "2023-11-27T17:39:29", "type" : "item", "iddisplay" : "notfdok-dataelement2025-21920", "shortName" : "covid19_verdachtsabklarung", "implementation" : [{ "shortName" : "covid19_verdachtsabklarung", "markdown" : "Ergebnis der COVID-19 Verdachtsabklärung" }], "inherit" : [{ "ref" : "2.16.840.1.113883.2.6.60.3.2.6.21920", "effectiveDate" : "2020-03-27T23:21:26", "prefix" : "aktin-", "datasetId" : "2.16.840.1.113883.2.6.60.3.1.6", "datasetEffectiveDate" : "2018-08-17T00:00:00", "datasetStatusCode" : "final", "datasetVersionLabel" : "v2020.1", "iType" : "item", "iStatusCode" : "final", "iEffectiveDate" : "2020-03-27T23:21:26", "iVersionLabel" : "v2020.1", "iddisplay" : "nap-dataelement2020(1)-21920", "refdisplay" : "nap-dataelement2020(1)-21920", "localInherit" : "true" }], "name" : [{ "language" : "de-DE", "#text" : "COVID-19 Verdachtsabklärung" }], "desc" : [{ "language" : "de-DE", "#text" : "Ergebnis der COVID-19 Verdachtsabklärung" }], "source" : [{ "language" : "de-DE", "#text" : "https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/Massnahmen_Verdachtsfall_Infografik_DINA3.pdf?__blob=publicationFile" }], "operationalization" : [{ "language" : "de-DE", "#text" : "Möglichst automatische Vorbefüllung aber trotzdem noch manuell editierbar:
WENN COVID-19 vereinbare Symptome( Fieber ODER Allgemeine Abgeschlagenheit/Müdigkeit ODER Husten produktiv/unproduktiv ODER Kopf- und Gliederschmerzen ODER Rhinitis ODER passagere Diarrhoe ODER Halsschmerzen ODER\n Geruchs-/Geschmacksstörung) = JA DANN \"Begründeter Verdachtsfall\"
WENN Kontakt zu bestätigtem COVID-19-Fall bis max.14 Tage vor Symptombeginn/Ereigniseintritt UND mindestens ein COVID-19 vereinbare Symptome DANN \"Meldepflichtiger Verdachtsfall\"
WENN Klinische oder radiologische Hinweise auf eine\n virale Pneumonie = JA UND Zusammenhang mit einer Häufung von Pneumonien in Pflegeeinrichtung oder Krankenhaus = JA DANN \"Meldepflichtiger Verdachtsfall\"
Ansonsten \"Kein Verdachtsfall und keine Abklärung\"" }], "valueDomain" : [{ "type" : "code", "conceptList" : [{ "id" : "2.16.840.1.113883.2.6.60.3.2.6.21920.20200327232126.0", "concept" : [{ "id" : "2.16.840.1.113883.2.6.60.3.2.6.21920.20200327232126.3", "name" : [{ "language" : "de-DE", "#text" : "Meldepflichtiger Verdachtsfall" }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.6.21920.20200327232126.2", "name" : [{ "language" : "de-DE", "#text" : "Fall unter differenzialdiagnostischer Abklärung" }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.6.21920.20200327232126.1", "exception" : "true", "name" : [{ "language" : "de-DE", "#text" : "Kein Verdachtsfall und keine Abklärung" }] }] }] }] }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.9.29376", "statusCode" : "draft", "effectiveDate" : "2023-11-20T00:00:00", "lastModifiedDate" : "2023-11-27T17:39:29", "type" : "group", "iddisplay" : "notfdok-dataelement2025-29376", "shortName" : "abgeleitete_informationen_zur_weitergabe", "implementation" : [{ 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In der ZNA vergebene/codierte Diagnosen (ICD-basiert), trunkiert
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"2014-01-06T16:43:10", "prefix" : "aktin-", "datasetId" : "2.16.840.1.113883.2.6.60.3.1.1", "datasetEffectiveDate" : "2014-09-15T00:00:00", "datasetStatusCode" : "final", "datasetVersionLabel" : "v2014.1-b", "iType" : "item", "iEffectiveDate" : "2014-01-06T16:43:10", "iStatusCode" : "final", "refdisplay" : "aktin-dataelement2014(1)-46", "name" : [{ "language" : "de-DE", "#text" : "Procedere" }] }], "valueDomain" : [{ "type" : "text" }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.9.20043", "effectiveDate" : "2023-11-20T00:00:00", "statusCode" : "draft", "lastModifiedDate" : "2023-12-28T16:30:01", "type" : "group", "iddisplay" : "notfdok-dataelement2025-20043", "shortName" : "therapieempfehlung", "implementation" : [{ "shortName" : "therapieempfehlung", "markdown" : "15.01.2016 Aufteilung vonWeiteres Procedere / Therapieempfehlung / Weiterbehandler in Einzelbestandteile zur detaillierten Medikamentendokumentation entsprechend Sektionstreffen vom 30.10.2015" }], "name" : [{ "language" : "de-DE", "lastTranslated" : "2023-12-28T16:29:32", "#text" : "Therapieempfehlung" }], "desc" : [{ "language" : "de-DE", "lastTranslated" : "2023-12-28T16:29:32", "#text" : "15.01.2016 Aufteilung von Weiteres Procedere / Therapieempfehlung /\n Weiterbehandler in Einzelbestandteile zur detaillierten Medikamentendokumentation entsprechend Sektionstreffen vom 30.10.2015" }], "relationship" : [{ "type" : "SPEC", "ref" : "2.16.840.1.113883.2.6.60.3.2.6.20043", "flexibility" : "2018-01-25T00:00:00", "prefix" : "aktin-", "datasetId" : "2.16.840.1.113883.2.6.60.3.1.6", "datasetEffectiveDate" : "2018-08-17T00:00:00", "datasetStatusCode" : "final", "datasetVersionLabel" : "v2020.1", "iEffectiveDate" : "2018-01-25T00:00:00", "iStatusCode" : "final", "iVersionLabel" : "v2020.1", "refdisplay" : "nap-dataelement2020(1)-20043", "name" : [{ "language" : "de-DE", "#text" : "Therapieempfehlung" }] }], "concept" : [{ "id" : "2.16.840.1.113883.2.6.60.3.2.9.20044", "effectiveDate" : "2023-11-20T00:00:00", "statusCode" : "draft", "lastModifiedDate" : "2023-12-28T16:30:01", "type" : "group", "iddisplay" : "notfdok-dataelement2025-20044", "shortName" : "medikamentenverordnung_empfehlung", "implementation" : [{ "shortName" : "medikamentenverordnung_empfehlung", "markdown" : "Mit welcher Medikamentenverordnung oder medikamentösen Therapieempfehlung wird der Patient aus der Notaufnahme entlassen?\n\nHier werden alle Medikamente dokumentiert, die zum Verlegungs- oder Entlassungszeitpunkt aus der Notaufnahme, für die weitere Therapie empfohlen oder verordnet werden. Dies betrifft beispielsweise bei einer internen Verlegung die Medikamentenverordnung für die weiterbehandelnde Station oder im Falle einer ambulanten Versorgung, die Empfehlung für die weitere Medikamententherapie.\nHier erfolgt idealerweise der Ausdruck eines neuen Bundesmedikationsplanes.\n\nBeispielhafte Medikamentenanamnese:\n1. Metoprolol 95mg po. 1-0-1\n2. Delix 5mg po. 1-0-0\n3. Torem 10mg po. 1-0-0\n4. Actrapid s.c. 12IE-8IE-10IE\n5. Protaphane s.c. 22:00 12IE\n6. ASS 100mg po 08:00-0-0\n7. Allopurinol 300mg po. 1-0-0\n8. Simvahexal 40mg 0-0-1\n\n5.01.2016 Aufteilung vonWeiteres Procedere / Therapieempfehlung / Weiterbehandler in Einzelbestandteile zur detaillierten Medikamentendokumentation entsprechend Sektionstreffen vom 30.10.2015" }], "name" : [{ "language" : "de-DE", "lastTranslated" : "2023-12-28T16:29:41", "#text" : "Medikamentenverordnung / Empfehlung " }], "desc" : [{ "language" : "de-DE", "lastTranslated" : "2023-12-28T16:29:41", "#text" : "Mit welcher Medikamentenverordnung oder medikamentösen Therapieempfehlung wird der Patient aus der Notaufnahme entlassen?
\n
Hier werden alle Medikamente dokumentiert, die zum Verlegungs- oder Entlassungszeitpunkt aus der Notaufnahme, für die weitere Therapie empfohlen oder verordnet werden. Dies betrifft beispielsweise bei einer internen Verlegung die Medikamentenverordnung für die weiterbehandelnde Station oder im Falle einer ambulanten Versorgung, die Empfehlung für die\n weitere Medikamententherapie.
Hier erfolgt idealerweise der Ausdruck eines neuen Bundesmedikationsplanes.
\n
Beispielhafte Medikamentenanamnese:
1. Metoprolol 95mg po. 1-0-1
2. Delix 5mg po. 1-0-0
3. Torem 10mg po. 1-0-0
4. Actrapid s.c. 12IE-8IE-10IE
5. Protaphane s.c. 22:00 12IE
6. ASS 100mg po 08:00-0-0
\n 7. Allopurinol 300mg po. 1-0-0
8. Simvahexal 40mg 0-0-1
\n
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Automatische Befüllung aus KIS
1. und 2. Stelle:
\n 1. und 2. Stelle:
01 Krankenhausbehandlung, vollstationär
\n 02 Krankenhausbehandlung, vollstationär mit vorausgegangener vorstationärer Behandlung
\n 03 Krankenhausbehandlung, teilstationär
\n 04 vorstationäre Behandlung ohne anschließende vollstationäre Behandlung
\n 05 Stationäre Entbindung
\n 06 Geburt
\n 07 Wiederaufnahme wegen Komplikationen (Fallpauschale) nach KFPV 2003
\n 08 Stationäre Aufnahme zur Organentnahme
\n 09 frei
\n 3. und 4. Stelle:
\n 01 Normalfall
\n 02 Arbeitsunfall/Berufskrankheit (§ 11 Abs. 5 SGB V)
\n 03 Verkehrsunfall/Sportunfall/Sonstiger Unfall (z.B. § 116 SGB X)
\n 04 Hinweis auf Einwirkung von äußerer Gewalt
\n 05 frei
\n 06 Kriegsbeschädigten-Leiden/BVG-Leiden
\n 07 Notfall
\n Hinweis (zu 3. und 4. Stelle):
\n Bei Zuständigkeitswechsel des Kostenträgers: „21“ bis „27“ anstelle „01“ bis „07“.
\n Bei Behandlungen im Rahmen von Verträgen zur integrierten Versorgung: „41“ bis „47“ anstelle „01“
\n bis „07“.
\n Im Falle eines Zuständigkeitswechsels des Kostenträgers während einer Behandlung im Rahmen von
\n Verträgen zur integrierten Versorgung ist die Behandlung im Rahmen von Verträgen zur integrierten
\n Versorgung vorrangig anzugeben, wenn der Versicherte seine Teilnahme auch gegenüber der neu
\n zuständigen Krankenkasse erklärt hat.
\n Bei Aufnahme von Patienten in Verbindung mit einem Arbeitsunfall (einschließlich „Wegeunfall“) ist
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Stationäre Aufnahme - Funktion (OP, HKL, etc.) = OP
Stationäre Aufnahme - Überwachung (ITS, IMC, etc.) = ICU/IMC
Stationäre Aufnahme - Normalstation = Sonstiges
Verlegung extern = anderes Krankenhaus
Sonstiges = Sonstiges
intern: Normalstation = RTS
intern: Überwachung = ITS/CPU
intern: OP / Intervention = HKL
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Alternativ manuelle Dokumentation des ersten Patientenkontaktes mit einem Mitarbeiter der Notaufnahme.\nHier ist nicht der Zeitpunkt der Erzeugung des Datensatzes im System gemeint z. 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Hier ist nicht der Zeitpunkt der Erzeugung des Datensatzes im System gemeint z. B. im Rahmen einer\n Vorankündigung oder MANV-Vorbereitung." }], "relationship" : [{ "type" : "ADAPT", "ref" : "2.16.840.1.113883.2.6.60.3.2.2.770", "flexibility" : "2015-01-15T00:00:00", "prefix" : "aktin-", "datasetId" : "2.16.840.1.113883.2.6.60.3.1.2", "datasetEffectiveDate" : "2015-01-15T00:00:00", "datasetStatusCode" : "final", "datasetVersionLabel" : "v2015.1-b", "iType" : "item", "iEffectiveDate" : "2015-01-15T00:00:00", "iStatusCode" : "final", "refdisplay" : "aktin-dataelement2015(1)-770", "name" : [{ "language" : "de-DE", "#text" : "Zeitpunkt der Ersteinschätzung" }] }, { "type" : "ADAPT", "ref" : "2.16.840.1.113883.2.6.60.3.2.6.58", "flexibility" : "2018-01-25T00:00:00", "prefix" : "aktin-", "datasetId" : "2.16.840.1.113883.2.6.60.3.1.6", "datasetEffectiveDate" : "2018-08-17T00:00:00", "datasetStatusCode" : "final", "datasetVersionLabel" : "v2020.1", "iType" : "item", "iEffectiveDate" : "2018-01-25T00:00:00", "iStatusCode" : "final", "iVersionLabel" : "v2020.1", "refdisplay" : "nap-dataelement2020(1)-58", "name" : [{ "language" : "de-DE", "#text" : "Aufnahmezeitpunkt" }] }], "operationalization" : [{ "language" : "de-DE", "#text" : "\n
- \n
- Automatische Befüllung aus Aufnahmezeitpunkt oder Zeitpunkt Ersteinschätzung, was früher war.
- Alternativ: manuelle Dokumentation des ersten Patientenkontaktes mit einem Mitarbeiter der Notaufnahme.
Kein Mapping aus Rohdaten; bei der Datenbereitstellung berechnetes Zeitintervall aus Exportzeitpunkt und nokeda_date/nokeda_hour.
Automatische Berechnung aus Zeitpunkt Export aus EDIS - Aufnahmezeitpunkt
" }], "valueDomain" : [{ "type" : "quantity", "property" : [{ "unit" : "Stunden", "minInclude" : "0", "maxInclude" : "672" }] }], "terminologyAssociation" : [{ "conceptId" : "2.16.840.1.113883.2.6.60.3.2.9.21742", "conceptFlexibility" : "2023-11-20T00:00:00", "code" : "FLN-134", "codeSystem" : "1.2.276.0.76.3.1.195.5.98", "displayName" : "Abgeleitete Informationen über Diagnostik zur Weitergabe - Zeit [in vollen Stunden] vom Beginn der Vorstellung bis zum Export-Zeitpunkt aus dem Primärsystem", "equivalence" : "equal", "effectiveDate" : "2024-08-20T20:09:14", "codeSystemName" : "Kandidaten LOINC Terme" }] }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.9.21739", "effectiveDate" : "2023-11-20T00:00:00", "statusCode" : "draft", "lastModifiedDate" : "2024-02-14T10:24:23", "type" : "group", "iddisplay" : "notfdok-dataelement2025-21739", "shortName" : "datenbereitstellung", "implementation" : [{ "shortName" : "datenbereitstellung" }], "name" : [{ "language" : "de-DE", "lastTranslated" : "2024-02-14T10:23:42", "#text" : "Datenbereitstellung" }], "desc" : [{ "language" : "de-DE" }], "relationship" : [{ "type" : "SPEC", "ref" : "2.16.840.1.113883.2.6.60.3.2.6.21739", "flexibility" : "2020-02-25T11:06:17", "prefix" : "aktin-", "datasetId" : "2.16.840.1.113883.2.6.60.3.1.6", "datasetEffectiveDate" : "2018-08-17T00:00:00", "datasetStatusCode" : "final", "datasetVersionLabel" : "v2020.1", "iType" : "group", "iEffectiveDate" : "2020-02-25T11:06:17", "iStatusCode" : "final", "iVersionLabel" : "v2020.1", "refdisplay" : "nap-dataelement2020(1)-21739", "name" : [{ "language" : "de-DE", "#text" : "Datenbereitstellung" }] }], "concept" : [{ "id" : "2.16.840.1.113883.2.6.60.3.2.9.21738", "effectiveDate" : "2023-11-20T00:00:00", "statusCode" : "draft", "lastModifiedDate" : "2024-02-14T10:24:23", "type" : "item", "iddisplay" : "notfdok-dataelement2025-21738", "shortName" : "name_des_edis", "implementation" : [{ "shortName" : "name_des_edis", "markdown" : "" }], "name" : [{ "language" : "de-DE", "lastTranslated" : "2024-02-14T10:23:51", "#text" : "Name des EDIS" }], "synonym" : [{ "language" : "de-DE", "lastTranslated" : "2024-02-14T10:23:51", "#text" : "nokeda_edis_software" }], "desc" : [{ "language" : "de-DE", "lastTranslated" : "2024-02-14T10:23:51", "#text" : "\n Automatische Berechnung aus Zeitpunkt Export aus EDIS - Aufnahmezeitpunkt
has_multiple_instances = FALSE
\nKein Mapping aus Rohdaten; manuell beschrieben aus der Kenntnis der lokal verwendeten Software; Information zur Software und zum Hersteller bereitstellen, sollte der Hersteller unterschiedliche Produkte anbieten.
\n " }], "valueDomain" : [{ "type" : "string", "property" : [{ "minLength" : "0", "maxLength" : "32" }], "example" : [{ "type" : "neutral", "#text" : "Epias ED" }, { "type" : "neutral", "#text" : "ERPath" }, { "type" : "neutral", "#text" : "e.care" }, { "type" : "neutral", "#text" : "ORBIS Cockpit Notaufnahme" }] }], "terminologyAssociation" : [{ "conceptId" : "2.16.840.1.113883.2.6.60.3.2.9.21738", "conceptFlexibility" : "2023-11-20T00:00:00", "code" : "FLN-135", "codeSystem" : "1.2.276.0.76.3.1.195.5.98", "displayName" : "Abgeleitete Informationen über Diagnostik zur Weitergabe - Name der lokal verwendeten Software zur primären Datenerfassung (EDIS, emergency department information system", "equivalence" : "equal", "effectiveDate" : "2024-08-20T20:10:21", "codeSystemName" : "Kandidaten LOINC Terme" }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.9.21740", "statusCode" : "draft", "effectiveDate" : "2023-11-20T00:00:00", "lastModifiedDate" : "2023-11-27T17:39:29", "type" : "item", "iddisplay" : "notfdok-dataelement2025-21740", "shortName" : "version_des_edis", "implementation" : [{ "shortName" : "version_des_edis", "markdown" : "Versionsnummer und/oder Bezeichnung (nach Herstellerangaben) des EDIS (ggf. KIS)" }], "inherit" : [{ "ref" : "2.16.840.1.113883.2.6.60.3.2.6.21740", "effectiveDate" : "2020-02-25T11:11:36", "prefix" : "aktin-", "datasetId" : "2.16.840.1.113883.2.6.60.3.1.6", "datasetEffectiveDate" : "2018-08-17T00:00:00", "datasetStatusCode" : "final", "datasetVersionLabel" : "v2020.1", "iType" : "item", "iStatusCode" : "final", "iEffectiveDate" : "2020-02-25T11:11:36", "iVersionLabel" : "v2020.1", "iddisplay" : "nap-dataelement2020(1)-21740", "refdisplay" : "nap-dataelement2020(1)-21740", "localInherit" : "true" }], "name" : [{ "language" : "de-DE", "#text" : "Version des EDIS" }], "synonym" : [{ "language" : "de-DE", "#text" : "nokeda_edis_version" }], "desc" : [{ "language" : "de-DE", "#text" : "Versionsnummer und/oder Bezeichnung (nach Herstellerangaben) des EDIS (ggf. KIS)" }], "relationship" : [{ "type" : "SPEC", "ref" : "2.16.840.1.113883.3.1937.777.47.2.43", "flexibility" : "2020-01-09T21:39:03", "prefix" : "nokeda-", "datasetId" : "2.16.840.1.113883.3.1937.777.47.1.1", "datasetEffectiveDate" : "2019-11-07T11:36:25", "datasetStatusCode" : "draft", "iType" : "item", "iEffectiveDate" : "2020-01-09T21:39:03", "iStatusCode" : "draft", "refdisplay" : "nokeda-dataelement-43", "name" : [{ "language" : "de-DE", "#text" : "Version des EDIS" }, { "language" : "en-US", "#text" : "Version EDIS" }] }], "operationalization" : [{ "language" : "de-DE", "#text" : "\n has_multiple_instances = FALSE \n
\n Kein Mapping aus Rohdaten; manuell beschrieben aus der Kenntnis der lokal verwendeten Software-Version; alternativ dynamisches Auslesen falls lokal oder zentral verzeichnet. \n
\n " }], "valueDomain" : [{ "type" : "string", "property" : [{ "minLength" : "0", "maxLength" : "32" }] }], "terminologyAssociation" : [{ "conceptId" : "2.16.840.1.113883.2.6.60.3.2.9.21740", "conceptFlexibility" : "2023-11-20T00:00:00", "code" : "FLN-136", "codeSystem" : "1.2.276.0.76.3.1.195.5.98", "displayName" : "Abgeleitete Informationen über Diagnostik zur Weitergabe - Versionsnummer und/oder Bezeichnung (nach Herstellerangaben) des EDIS (ggf. KIS)", "equivalence" : "equal", "effectiveDate" : "2024-08-20T20:10:59", "codeSystemName" : "Kandidaten LOINC Terme" }] }, { "id" : "2.16.840.1.113883.2.6.60.3.2.9.21741", "statusCode" : "draft", "effectiveDate" : "2023-11-20T00:00:00", "lastModifiedDate" : "2023-11-27T17:39:29", "type" : "item", "iddisplay" : "notfdok-dataelement2025-21741", "shortName" : "zeitpunkt_export_aus_edis", "implementation" : [{ "shortName" : "zeitpunkt_export_aus_edis", "markdown" : "Zeitpunkt wann Datensatz aus dem EDIS an einen weiteren Datennutzer exportiert wurde" }], "inherit" : [{ "ref" : "2.16.840.1.113883.2.6.60.3.2.6.21741", "effectiveDate" : "2020-02-25T11:19:24", "prefix" : "aktin-", "datasetId" : "2.16.840.1.113883.2.6.60.3.1.6", "datasetEffectiveDate" : "2018-08-17T00:00:00", "datasetStatusCode" : "final", "datasetVersionLabel" : "v2020.1", "iType" : "item", "iStatusCode" : "final", "iEffectiveDate" : "2020-02-25T11:19:24", "iVersionLabel" : "v2020.1", "iddisplay" : "nap-dataelement2020(1)-21741", "refdisplay" : "nap-dataelement2020(1)-21741", "localInherit" : "true" }], "name" : [{ "language" : "de-DE", "#text" : "Zeitpunkt Export aus EDIS" }], "desc" : [{ "language" : "de-DE", "#text" : "Zeitpunkt wann Datensatz aus dem EDIS an einen weiteren Datennutzer exportiert wurde" }], "valueDomain" : [{ "type" : "datetime", "property" : [{ "timeStampPrecision" : "YMDHM" }] }], "terminologyAssociation" : [{ "conceptId" : "2.16.840.1.113883.2.6.60.3.2.9.21741", "conceptFlexibility" : "2023-11-20T00:00:00", "code" : "FLN-137", "codeSystem" : "1.2.276.0.76.3.1.195.5.98", "displayName" : "Abgeleitete Informationen über Diagnostik zur Weitergabe - Zeitpunkt wann Datensatz aus dem EDIS an einen weiteren Datennutzer exportiert wurde", "equivalence" : "equal", "effectiveDate" : "2024-08-20T20:11:56", "codeSystemName" : "Kandidaten LOINC Terme" }] }] }], "usage" : [{ "transaction" : [{ "id" : "2.16.840.1.113883.2.6.60.3.4.48", "effectiveDate" : "2024-02-10T11:37:39", "statusCode" : "draft", "versionLabel" : "2024", "type" : "initial", "label" : "nar2025", "lastModifiedDate" : "2025-11-26T21:51:47", "name" : [{ "language" : "de-DE", "lastTranslated" : "2024-02-10T11:37:39", "#text" : "Notaufnahmeregister" }] }, { "id" : "2.16.840.1.113883.2.6.60.3.4.56", "effectiveDate" : "2025-07-30T00:00:00", "statusCode" : "draft", "versionLabel" : "2025.1", "type" : "initial", "label" : "nar2025-2025-07-30", "lastModifiedDate" : "2025-08-15T09:51:08", "name" : [{ "language" : "de-DE", "lastTranslated" : "2024-02-10T11:37:39", "#text" : "NoKeda" }] }, { "id" : "2.16.840.1.113883.2.6.60.3.4.57", "effectiveDate" : "2025-11-12T00:00:00", "statusCode" : "deprecated", "versionLabel" : "2025", "type" : "initial", "label" : "nartrv2025", "lastModifiedDate" : "2026-03-25T11:06:42", "name" : [{ "language" : "de-DE", "lastTranslated" : "2025-11-20T21:25:59", "#text" : "Notaufnahmeregister Transitionsversion" }] }, { "id" : "2.16.840.1.113883.2.6.60.3.4.60", "effectiveDate" : "2026-03-25T00:00:00", "statusCode" : "draft", "versionLabel" : "2026", "type" : "stationary", "label" : "nartrv2026-2", "lastModifiedDate" : "2026-09-21T20:09:55", "name" : [{ "language" : "de-DE", "lastTranslated" : "2025-11-20T21:25:59", "#text" : "Notaufnahmeregister Transitionsversion" }] }] }] }] }