Level/ Typ | Code | Bezeichnung | Codesystem | Designations |
---|
0‑L | BRIEFT | Brieftext | 1.2.40.0.34.5.40 | |
0‑L | 46239-0 | Chief complaint+Reason for visit Narrative | Logical Observation Identifier Names and Codes |  Synonym: Konsultations- oder Überweisungsgrund |
0‑L | 10160-0 | History of Medication use Narrative | Logical Observation Identifier Names and Codes |  Synonym: Aktuelle Medikation, Überwachte Medikamente / Medikationsliste |
0‑L | 48765-2 | Allergies and adverse reactions Document | Logical Observation Identifier Names and Codes |  Synonym: Allergien und Intoleranzen |
0‑S | 10164-2 | History of Present illness Narrative | Logical Observation Identifier Names and Codes |  Synonym: Anamnese |
1‑L | 11348-0 | History of Past illness Narrative | Logical Observation Identifier Names and Codes |  Synonym: Frühere Erkrankungen und Maßnahmen |
1‑L | FachAnamnese | Fachspezifische Anamnese | 1.2.40.0.34.5.40 | |
1‑L | 10162-6 | History of pregnancies Narrative | Logical Observation Identifier Names and Codes |  Synonym: Schwangerschaften |
1‑L | 46264-8 | History of medical device use | Logical Observation Identifier Names and Codes |  Synonym: Medizinische Geräte und Implantate |
1‑L | 47420-5 | Functional status assessment note | Logical Observation Identifier Names and Codes |  Synonym: Beeinträchtigungen |
1‑L | 11369-6 | History of Immunization Narrative | Logical Observation Identifier Names and Codes |  Synonym: Impfungen |
1‑L | 29762-2 | Social history Narrative | Logical Observation Identifier Names and Codes |  Synonym: Lebensstil |
0‑S | 424836000 | Assessment section | SNOMED Clinical Terms |  Synonym: Status, Diagnostik und Befunde |
1‑L | 29545-1 | Physical findings Narrative | Logical Observation Identifier Names and Codes |  Synonym: Status |
1‑L | 8716-3 | Vital signs | Logical Observation Identifier Names and Codes |  Synonym: Vitalparameter |
1‑L | FachDiagnostik | Fachspezifische Diagnostik | 1.2.40.0.34.5.40 | |
1‑L | BEFAUS | Ausstehende Befunde | 1.2.40.0.34.5.40 | |
0‑L | 439401001 | Diagnosis | SNOMED Clinical Terms |  Synonym: Diagnose |
0‑L | 56825-3 | Problem time course | Logical Observation Identifier Names and Codes |  Synonym: Verlauf |
0‑L | 67781-5 | Summarization of encounter note Narrative | Logical Observation Identifier Names and Codes |  Synonym: Zusammenfassende Beurteilung |
0‑S | 29554-3 | Procedure Narrative | Logical Observation Identifier Names and Codes |  Synonym: Durchgeführte Maßnahmen |
1‑L | 87232-5 | Medication administration.brief | Logical Observation Identifier Names and Codes |  Synonym: Dokumentierte Einnahme |
1‑L | 75455-6 | Nurse procedure note | Logical Observation Identifier Names and Codes |  Synonym: Pflegemaßnahmen |
0‑S | 75311-1 | Discharge medications Narrative | Logical Observation Identifier Names and Codes |  Synonym: Empfohlene Medikation |
1‑L | 182838006 | Change of medication | SNOMED Clinical Terms |  Synonym: Änderung der bestehenden Medikation |
1‑L | 275942009 | New medication added | SNOMED Clinical Terms |  Synonym: Zusätzliche Medikation |
0‑S | 59772-4 | Planned procedure Narrative | Logical Observation Identifier Names and Codes |  Synonym: Weitere empfohlene Maßnahmen |
1‑L | 21979-0 | Planned/next follow-up | Logical Observation Identifier Names and Codes |  Synonym: Termine, Kontrollen, Wiederbestellungen |
1‑L | 56447-6 | Deprecated Plan of care note | Logical Observation Identifier Names and Codes |  Synonym: Empfohlene Anordnungen an die weitere Pflege |
1‑L | 59772-4 | Planned procedure Narrative | Logical Observation Identifier Names and Codes |  Synonym: Geplante Untersuchungen |
1‑L | 281131004 | Conservative therapy | SNOMED Clinical Terms |  Synonym: Konservative Therapie |
1‑L | 387713003 | Surgical Procedure | SNOMED Clinical Terms |  Synonym: Chirurgische Therapie |
0‑L | 55752-0 | Clinical information | Logical Observation Identifier Names and Codes |  Synonym: Weitere Informationen |
0‑L | 42348-3 | Advance directives | Logical Observation Identifier Names and Codes |  Synonym: Willenserklärungen und andere juridische Dokumente |
0‑L | ABBEM | Abschließende Bemerkung | 1.2.40.0.34.5.40 | |
0‑L | BEIL | Beilagen | 1.2.40.0.34.5.40 | |
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