archetype (adl_version=1.4) openEHR-EHR-EVALUATION.problem-diagnosis.v1 specialise openEHR-EHR-EVALUATION.problem.v1 concept [at0000.1] -- Diagnosis language original_language = <[ISO_639-1::en]> translations = < ["de"] = < language = <[ISO_639-1::de]> author = < ["name"] = <"Jasmin Buck, Sebastian Garde"> ["organisation"] = <"University of Heidelberg, Central Queensland University"> > > ["pt-br"] = < language = <[ISO_639-1::pt-br]> author = < ["name"] = <"Marco Borges"> ["organisation"] = <"P2D"> ["email"] = <"marco.borges@p2d.com.br"> > accreditation = <"P2D Health Advisor Council"> > > description original_author = < ["name"] = <"Sam Heard"> ["organisation"] = <"Ocean Informatics"> ["email"] = <"sam.heard@oceaninformatics.com"> ["date"] = <"23/04/2006"> > details = < ["de"] = < language = <[ISO_639-1::de]> purpose = <"Zur Dokumentation klinischer Diagnosen mit optionalen diagnostischen Kriterien und Dringlichkeiten. Erfordert kodierten Eintrag der Diagnosen."> use = <"Zur Dokumentation beliebiger früherer oder aktueller Diagnosen - also zur Dokumentation des früheren Verlaufs oder der aktuellen Diagnosen. Kann zur Dokumentation der Diagnosen wechselnder Patienten genutzt werden, also zur Familienanamnese."> keywords = <"früher", "Verlauf", "Familie", "Historie", "Zustand"> misuse = <"Für histologische Diagnosen 'openEHR-EHR-EVALUATION.problem-diagnosis-histological' benutzen."> copyright = <"copyright (c) 2010 openEHR Foundation"> > ["pt-br"] = < language = <[ISO_639-1::pt-br]> purpose = <"Registrar diagnósticos médicos com critérios de diagnóstico opcionais e estadiamento. Requer entrada codificada do diagnóstico."> use = <"Usado para o registo de diagnóstico, presente ou passado - usado para gravar a história passada, bem como diagnósticos atuais. Usado com mudou 'Assunto de cuidado' para gravação de diagnósticos em parentes e assim para a histórico famíliar."> keywords = <"*past(en)", "*history(en)", "*family(en)", "*history(en)", "*condition(en)"> misuse = <"Use 'openEHR-EHR-EVALUATION.problem-diagnosis-histological' para diagnosticos histológicos."> copyright = <"copyright (c) 2010 openEHR Foundation"> > ["en"] = < language = <[ISO_639-1::en]> purpose = <"For recording medical diagnoses with optional diagnostic criteria and staging. Requires coded entry of diagnosis. "> use = <"Used for recording any diagnosis, present or past - so is used for recording past history as well as current diagnoses. Used with changed 'Subject of care' for recording diagnoses in relatives and so for family history."> keywords = <"past", "history", "family", "history", "condition"> misuse = <"Use 'openEHR-EHR-EVALUATION.problem-diagnosis-histological' for histological diagnoses."> copyright = <"copyright (c) 2010 openEHR Foundation"> > > lifecycle_state = <"AuthorDraft"> other_contributors = <> other_details = < ["MD5-CAM-1.0.1"] = <"25DE4AB34DEAEC07427F236A035F33B2"> ["references"] = <""> > definition EVALUATION[at0000.1] matches { -- Diagnóstico data matches { ITEM_TREE[at0001] matches { -- structure items cardinality matches {1..*; ordered} matches { ELEMENT[at0002.1] matches { -- Diagnóstico value matches { DV_CODED_TEXT matches { defining_code matches {[ac0.1]} -- *Any term that 'is_a' diagnosis(en) } } } ELEMENT[at0.32] occurrences matches {0..1} matches { -- Estado value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0.33, -- Provisório at0.34] -- Investigando } } } } ELEMENT[at0003] occurrences matches {0..1} matches { -- Data do início dos sintomas value matches { DV_DATE matches {*} } } ELEMENT[at0004] occurrences matches {0..1} matches { -- Idade no início dos sintomas value matches { DV_DURATION matches { value matches {PYMWDTH} } } } ELEMENT[at0005] occurrences matches {0..1} matches { -- Gravidade value matches { 1|[local::at0006], -- Leve 4|[local::at0007], -- Moderada 7|[local::at0008] -- Severa } } ELEMENT[at0009] occurrences matches {0..1} matches { -- Descrição clínica value matches { DV_TEXT matches {*} } } ELEMENT[at0010] occurrences matches {0..1} matches { -- Data do reconhecimento clínico value matches { DV_DATE matches { value matches {yyyy-??-XX} } } } ELEMENT[at0037] occurrences matches {0..1} matches { -- Idade quando reconhecido value matches { DV_DURATION matches {*} } } CLUSTER[at0011] occurrences matches {0..*} matches { -- Localização items cardinality matches {1..2; ordered} matches { ELEMENT[at0012] occurrences matches {0..1} matches { -- Local do corpo value matches { DV_CODED_TEXT matches { defining_code matches {[ac0000]} -- Qualquer termo que descreve a localização do corpo. } } } ELEMENT[at0013] occurrences matches {0..1} matches { -- Descrição value matches { DV_TEXT matches {*} } } } } CLUSTER[at0014] occurrences matches {0..1} matches { -- Etiologia items cardinality matches {1..*; unordered} matches { ELEMENT[at0015] occurrences matches {0..*} matches { -- Agente value matches { DV_TEXT matches {*} } } ELEMENT[at0016] occurrences matches {0..*} matches { -- Complicação da value matches { DV_TEXT matches {*} DV_URI matches {*} } } ELEMENT[at0017] occurrences matches {0..1} matches { -- Descrição value matches { DV_TEXT matches {*} } } } } CLUSTER[at0018] occurrences matches {0..1} matches { -- Ocorrências ou exacerbações items cardinality matches {1..*; ordered} matches { ELEMENT[at0019] occurrences matches {0..1} matches { -- Frequência da ocorrência value matches { C_DV_QUANTITY < property = <[openehr::382]> list = < ["1"] = < units = <"/h"> > ["2"] = < units = <"/d"> > ["3"] = < units = <"/mo"> > ["4"] = < units = <"/wk"> > ["5"] = < units = <"/yr"> > > > } } ELEMENT[at0020] occurrences matches {0..1} matches { -- Data da última ocorrência value matches { DV_DATE matches {*} } } CLUSTER[at0021] occurrences matches {0..*} matches { -- Ocorrências/exacerbações items cardinality matches {1..*; unordered} matches { ELEMENT[at0022] occurrences matches {0..1} matches { -- Descrição Clínica value matches { DV_TEXT matches {*} } } ELEMENT[at0023] occurrences matches {0..1} matches { -- Resultado value matches { DV_TEXT matches {*} } } ELEMENT[at0024] occurrences matches {0..1} matches { -- Data do começo value matches { DV_DATE matches {*} } } ELEMENT[at0036] occurrences matches {0..1} matches { -- Data da resolução value matches { DV_DATE matches {*} } } } } ELEMENT[at0025] occurrences matches {0..1} matches { -- Número de ocorrências value matches { DV_COUNT matches { magnitude matches {|>=1|} } } } } } CLUSTER[at0026] occurrences matches {0..1} matches { -- Problemas relacionados items cardinality matches {1..*; unordered} matches { CLUSTER[at0027] occurrences matches {0..*} matches { -- Grupo de relacionados items cardinality matches {1..*; unordered} matches { ELEMENT[at0028] occurrences matches {0..1} matches { -- Problema relacionado value matches { DV_TEXT matches {*} DV_URI matches {*} } } ELEMENT[at0029] occurrences matches {0..1} matches { -- Descrição clínica value matches { DV_TEXT matches {*} } } } } } } ELEMENT[at0030] occurrences matches {0..1} matches { -- Data da resolução value matches { DV_DATE matches {*} } } ELEMENT[at0031] occurrences matches {0..1} matches { -- Idade na resolução value matches { DV_DURATION matches { value matches {PYMWDTH} } } } CLUSTER[at0.35] occurrences matches {0..1} matches { -- Critério diagnóstico items cardinality matches {1..*; unordered} matches { ELEMENT[at0.36] occurrences matches {0..*} matches { -- Critério value matches { DV_TEXT matches {*} } } } } } } } protocol matches { ITEM_TREE[at0032] matches { -- Tree items cardinality matches {0..*; unordered} matches { CLUSTER[at0033] occurrences matches {0..1} matches { -- Referencias items cardinality matches {1..*; unordered} matches { ELEMENT[at0034] occurrences matches {0..*} matches { -- Referencia value matches { DV_TEXT matches {*} } } ELEMENT[at0035] occurrences matches {0..*} matches { -- Web link value matches { DV_URI matches {*} } } } } } } } } ontology term_definitions = < ["de"] = < items = < ["at0.32"] = < text = <"Status"> description = <"Der Status der Diagnose"> > ["at0.33"] = < text = <"Vorläufig"> description = <"vorläufige, als wahrscheinlich erachtete Diagnose und eine Grundlage zum weiteren Vorgehen"> > ["at0.34"] = < text = <"Wahrscheinlich"> description = <"als sehr wahrscheinlich erachtete, aber noch nicht bestätigte Diagnose"> > ["at0.35"] = < text = <"Diagnostische Merkmale"> description = <"Merkmale, auf die die Diagnose begründet ist"> > ["at0.36"] = < text = <"Merkmale"> description = <"Eine Grundlage für die Diagnose"> > ["at0.37"] = < text = <"Klinische Einstufung"> description = <"Die Einstufung der Erkrankung durch klinische Beurteilung"> > ["at0.38"] = < text = <"Einstufung"> description = <"Die Einstufung der Erkrankung (nicht TNM)"> > ["at0.39"] = < text = <"Tumor"> description = <"Die Ausdehnung des Befalls des lokalen Gewebes"> > ["at0.40"] = < text = <"Tx - Primärtumor nicht beurteilt"> description = <"Keine klinische Beurteilung des Primärtumors erfolgt"> > ["at0.41"] = < text = <"T0 - Kein Primärtumor"> description = <"Kein klinischer Anhalt für einen Primärtumor"> > ["at0.42"] = < text = <"Tis - In-situ_Karzinom"> description = <"Die malignen Zellen sind auf ihre übliche zelluläre Region begrenzt"> > ["at0.43"] = < text = <"Ti - Mikroinvasion (0,5 cm)"> description = <"Mikroskopischer Befall von 5 mm"> > ["at0.44"] = < text = <"T2 - Tumorbefall 1 cm"> description = <"Tumorbefall 1 cm"> > ["at0.45"] = < text = <"T3 - Tumorbefall der gesamten Dicke der Struktur"> description = <"Tumor hat die gesamte Dicke (oder Grenzen) der Struktur befallen"> > ["at0.46"] = < text = <"T5 - Befall angrenzender Strukturen"> description = <"Tumor hat sich über die Struktur hinaus ausgebreitet, in der er entstanden ist"> > ["at0.47"] = < text = <"Knoten"> description = <"Ausdehnung des Befalls regionärer Knoten"> > ["at0.48"] = < text = <"Nx - Regionäre Knoten nicht beurteilt"> description = <"Keine klinische Beurteilung der regionären Knoten erfolgt"> > ["at0.49"] = < text = <"N0 - Keine regionären Knoten befallen"> description = <"Kein klinischer Anhalt für einen Befall der regionären Knoten"> > ["at0.50"] = < text = <"N1 - Regionäre Knoten befallen"> description = <"Klinische Beurteilung deutet darauf hin, dass regionäre Knoten befallen sind"> > ["at0.51"] = < text = <"Metastasen"> description = <"Ausdehnung der Metastasen"> > ["at0.52"] = < text = <"Mx - Metastasen nicht beurteilt"> description = <"Keine klinische Beurteilung der Metastasen"> > ["at0.53"] = < text = <"M0 - keine Fernmetastasen"> description = <"Kein klinischer Anhalt für Fernmetastasen"> > ["at0.54"] = < text = <"M1 - Fernmetastasen"> description = <"Klinischer Anhalt für Fernmetastasen"> > ["at0000"] = < text = <"Problem"> description = <"Ein Problem, ein Zustand oder Sachverhalt definiert von einem Kliniker, der als zusammenfassend für eine Menge von Symptomen oder Anliegen der Person erachtet wird und dieses sinnvoll bezeichnet"> > ["at0000.1"] = < text = <"Diagnose"> description = <"Eine von einem Klinikarzt formulierte Diagnose, kodiert in einer anerkannten Terminologie, einschließlich der Stufe des Zustandes und den diagnostischen Kriterien"> > ["at0001"] = < text = <"Structure"> description = <"@ internal @"> > ["at0002"] = < text = <"Problem"> description = <"Das Problem, der Zustand oder Sachverhalt, der beschrieben wird"> > ["at0002.1"] = < text = <"Diagnose"> description = <"Die angezeigte Diagnose"> > ["at0003"] = < text = <"Datum des ersten Auftretens"> description = <"Das Datum, an dem das Problem begonnen hat, Symptome oder Anzeichen zu verursachen"> > ["at0004"] = < text = <"Alter beim ersten Auftreten"> description = <"Das Alter der Peson zum Zeitpunkt des ersten Auftreten des Problems"> > ["at0005"] = < text = <"Schweregrad"> description = <"Der Schweregrad des Problems"> > ["at0006"] = < text = <"Gelinde"> description = <"Der Schweregrad des Problems ist gelinde, hat keine Auswirkungen auf das Leben oder die Lebensdauer"> > ["at0007"] = < text = <"Mäßig"> description = <"Der Schweregrad des Problems verursacht erhebliche Morbidität"> > ["at0008"] = < text = <"Schwerwiegend"> description = <"Der Schweregrad des Problems hat bedeutende Auswirkungen auf das Leben und/oder die Lebensdauer"> > ["at0009"] = < text = <"Klinische Beschreibung"> description = <"Beschreibung der klinischen Gesichtspunkte des Problems"> > ["at0010"] = < text = <"Datum der klinischen Erkennung"> description = <"Datum, an dem das Problem von einem Kliniker erkannt oder 'diagnostiziert' wurde"> > ["at0011"] = < text = <"Lokalisierung"> description = <"Lage des Problems bezüglich der Körperseiten"> > ["at0012"] = < text = <"Körperstelle"> description = <"Die betroffene Körperstelle"> > ["at0013"] = < text = <"Lagebeschreibung"> description = <"Eine Freitext zur Beschreibung der Lage - kann zusätzlich zu einer codierten Körperseite sein"> > ["at0014"] = < text = <"Ätiologie"> description = <"Erreger oder Faktoren die als ätiologisch signifikant bekannt sind"> > ["at0015"] = < text = <"Erreger"> description = <"Mikrobische oder andere Erreger, die als Verursacher des Problems festgestellt wurden"> > ["at0016"] = < text = <"Komplikation"> description = <"Ein Problem oder ein Hinweis auf ein Problem oder eine Verletzung, an anderer Stelle in der EPA dokumentiert ist"> > ["at0017"] = < text = <"Beschreibung"> description = <"Beschreibung des ätiologischen Verlaufs"> > ["at0018"] = < text = <"Auftreten oder Verschlimmerung"> description = <"Gruppierung von Informationen über individuelle Vorkommen oder Verschlimmerungen"> > ["at0019"] = < text = <"Häufigkeit des Wiederauftritts"> description = <"Die Häufigkeit der individuellen Vorkommen des Problems"> > ["at0020"] = < text = <"Datum des letzten Auftretens"> description = <"Das Datum des letzten Auftreten des Problems"> > ["at0021"] = < text = <"Auftreten/ Verschlimmerung"> description = <"Informationen über einen einzelnen Auftritt oder eine einzelne Verschlimmerung"> > ["at0022"] = < text = <"Klinische Beschreibung"> description = <"Eine Beschreibung der Verschlimmerung oder des Auftretens"> > ["at0023"] = < text = <"Folge"> description = <"Folge des Auftretens oder der Verschlimmerung"> > ["at0024"] = < text = <"Datum des Auftretens"> description = <"Datum des Ausbruchs des Ereignisses oder der Verschlimmerung"> > ["at0025"] = < text = <"Anzahl der Vorkomnisse"> description = <"Anzahl, wie oft das Problem aufgetreten oder ersichtlich war"> > ["at0026"] = < text = <"Verwandte Probleme"> description = <"Komplikationen, die diesem Problem zugeordnet werden können"> > ["at0027"] = < text = <"Verwandtes Problem"> description = <"Eine Gruppe an Kenndaten des Problems, welche die in diesem Archetypen erfassten Gegebenheiten erschweren"> > ["at0028"] = < text = <"Verwandtes Problem"> description = <"Einzelheiten des Problems als Text, kodierter Text oder URI"> > ["at0029"] = < text = <"Klinische Beschreibung"> description = <"Beschreibung des erschwerenden Problems"> > ["at0030"] = < text = <"Datum der Heilung"> description = <"Datum, an dem das Problem behoben wurde oder in Remission überging"> > ["at0031"] = < text = <"Alter bei Heilung"> description = <"Das Alter der Person bei der Behebung des Problems"> > ["at0032"] = < text = <"Tree"> description = <"@ internal @"> > ["at0033"] = < text = <"Hinweis"> description = <"Nützliche Informationen über diesen Zustand"> > ["at0034"] = < text = <"Hinweis"> description = <"Hinweise auf Material über diesen Zustand"> > ["at0035"] = < text = <"Internetverweis"> description = <"Nützliche Informationen im Internet über diesen Zustand"> > ["at0036"] = < text = <"Datum der Behebung"> description = <"Datum, an dem der Auftreten des Problems behoben wurde"> > ["at0037"] = < text = <"*Age when clinically recognised(en)"> description = <"*The age when this problem was clinically recognised(en)"> > > > ["pt-br"] = < items = < ["at0.32"] = < text = <"Estado"> description = <"O estado do diagnóstico."> > ["at0.33"] = < text = <"Provisório"> description = <"Diagnóstico provisório considerado provável base para prosseguir com investigação."> > ["at0.34"] = < text = <"Investigando"> description = <"Diagnóstico em investigação considerado muito provável, mas ainda não confirmado."> > ["at0.35"] = < text = <"Critério diagnóstico"> description = <"Critério no qual o diagnóstico é baseado."> > ["at0.36"] = < text = <"Critério"> description = <"Uma base para o diangóstico."> > ["at0.37"] = < text = <"Estadiamento clínico"> description = <"O estágio da doença através da avaliação clínica."> > ["at0.38"] = < text = <"Estágio"> description = <"Estágio da doença (não Tumor, nódulo, metástase)."> > ["at0.39"] = < text = <"Tumor"> description = <"O grau de invasão do tecido local."> > ["at0.40"] = < text = <"Tx - tumor primário não avaliados"> description = <"Sem avaliação clínica do feito do tumor primário."> > ["at0.41"] = < text = <"T0 - sem tumor primário"> description = <"Nenhum tumor primário é evidente clinicamente."> > ["at0.42"] = < text = <"Tis - Carcinoma insitu"> description = <"As células malignas estão limitados à sua região celular habitual."> > ["at0.43"] = < text = <"T1 - Microinvasão (0.5cm)"> description = <"Invasão microscípica de 5mm."> > ["at0.44"] = < text = <"T2 - Tumor invadindo 1 cm"> description = <"T2 - Tumor invadindo 1 cm."> > ["at0.45"] = < text = <"T3 - espessura total da estrutura"> description = <"Tumor invadindo a espessura total (ou fronteiras) da estrutura."> > ["at0.46"] = < text = <"T5 - Invadindo estrutura adjacente"> description = <"Tumor se espalhou para fora da estrutura em que surgiu."> > ["at0.47"] = < text = <"Nódulos"> description = <"Grau de envolvimento dos gânglios regionais."> > ["at0.48"] = < text = <"Nx - os nódulos regionais não avaliados"> description = <"Nenhuma avaliação clínica de nódulos regionais foi realizados."> > ["at0.49"] = < text = <"N0 - sem os nódulos regionais envolvidos"> description = <"Nenhuma evidência clínica de envolvimento nódulo regional."> > ["at0.50"] = < text = <"N1 - Regional nódulos envolvidos"> description = <"A avaliação clínica indica que os nós regionais estão envolvidos."> > ["at0.51"] = < text = <"Metástases"> description = <"Extensão de metástases."> > ["at0.52"] = < text = <"Mx - metástases não avaliadas"> description = <"Nenhuma avaliação clínica de metástases."> > ["at0.53"] = < text = <"M0 - Sem metástases distânte"> description = <"Nenhuma evidência clínica de metástases distantes."> > ["at0.54"] = < text = <"M1 - Metástases distântes"> description = <"Evidência clínica de metástases distantes."> > ["at0000"] = < text = <"Problema"> description = <"Um problema, condição ou questão definida por um médico e é considerado sumativo de uma série de sintomas ou preocupações da pessoa."> > ["at0000.1"] = < text = <"Diagnóstico"> description = <"Um diagnóstico definido por um médico que é codificada em uma terminologia aceita e pode incluir o estágio da doença e os critérios diagnósticos."> > ["at0001"] = < text = <"structure"> description = <"@ internal @"> > ["at0002"] = < text = <"Problema"> description = <"O problema, condição ou questão."> > ["at0002.1"] = < text = <"Diagnóstico"> description = <"O Diagnóstico."> > ["at0003"] = < text = <"Data do início dos sintomas"> description = <"A data em que o problema começou a causar os sinais ou sintomas."> > ["at0004"] = < text = <"Idade no início dos sintomas"> description = <"A idade no início do problema."> > ["at0005"] = < text = <"Gravidade"> description = <"A gravidade do problema."> > ["at0006"] = < text = <"Leve"> description = <"A gravidade do problema é leve."> > ["at0007"] = < text = <"Moderada"> description = <"A gravidade do problema é moderada, podendo causar morbilidade significativa."> > ["at0008"] = < text = <"Severa"> description = <"A gravidade do problema é severa, podendo causar grande impacto na vida ou longevidade."> > ["at0009"] = < text = <"Descrição clínica"> description = <"Descrição dos aspectos clínicos do problema."> > ["at0010"] = < text = <"Data do reconhecimento clínico"> description = <"Data que o problema foi reconhecido por médicos."> > ["at0011"] = < text = <"Localização"> description = <"Local do corpo onde se manifesta o problema."> > ["at0012"] = < text = <"Local do corpo"> description = <"Local do corpo afetado."> > ["at0013"] = < text = <"Descrição"> description = <"Uma descrição em texto livre do local - local do corpo adicional"> > ["at0014"] = < text = <"Etiologia"> description = <"Agentes ou Fatores conhecidos por terem importância etiológica."> > ["at0015"] = < text = <"Agente"> description = <"Micróbio ou outro agente conhecido por ter causado este problema."> > ["at0016"] = < text = <"Complicação da"> description = <"Um problema ou um link para um problema ou lesão descrito no registro eletrônico de saúde."> > ["at0017"] = < text = <"Descrição"> description = <"Descrição do processo etiológico."> > ["at0018"] = < text = <"Ocorrências ou exacerbações"> description = <"Agrupamento de informações sobre ocorrências individuais ou exacerbações."> > ["at0019"] = < text = <"Frequência da ocorrência"> description = <"Frequência da ocorrência de um problema individual."> > ["at0020"] = < text = <"Data da última ocorrência"> description = <"Data da últia ocorrência ou exacerbação."> > ["at0021"] = < text = <"Ocorrências/exacerbações"> description = <"Informação sobre uma ocorrência ou exarcerbação."> > ["at0022"] = < text = <"Descrição Clínica"> description = <"Descrição da ocorrência ou exacerbação."> > ["at0023"] = < text = <"Resultado"> description = <"Resultado da ocorrência ou exacerbação."> > ["at0024"] = < text = <"Data do começo"> description = <"Data do começo da ocorrência ou exacerbação."> > ["at0025"] = < text = <"Número de ocorrências"> description = <"Número de vezes que esse problema ocorreu ou foi aparente."> > ["at0026"] = < text = <"Problemas relacionados"> description = <"Complicações que são atribuídas a este problema."> > ["at0027"] = < text = <"Grupo de relacionados"> description = <"Um grupo de características de complicações a situaçãoao problema índice."> > ["at0028"] = < text = <"Problema relacionado"> description = <"Detalhes do problema como texto, texto codificado ou URL."> > ["at0029"] = < text = <"Descrição clínica"> description = <"Descrição da complicação do problema."> > ["at0030"] = < text = <"Data da resolução"> description = <"A data em que o problema foi resolvido ou entrou em remissão."> > ["at0031"] = < text = <"Idade na resolução"> description = <"Idade na resolução do problema."> > ["at0032"] = < text = <"Tree"> description = <"@ internal @"> > ["at0033"] = < text = <"Referencias"> description = <"Informações úteis sobre esta condição."> > ["at0034"] = < text = <"Referencia"> description = <"Referência a materiais sobre esta condição."> > ["at0035"] = < text = <"Web link"> description = <"Informação útil sobre esta condição encontrada na internet."> > ["at0036"] = < text = <"Data da resolução"> description = <"Data da resolução da ocorrência."> > ["at0037"] = < text = <"Idade quando reconhecido"> description = <"Idade em que o problema foi reconhecido por médicos."> > > > ["en"] = < items = < ["at0.32"] = < text = <"Status"> description = <"The status of the diagnosis"> > ["at0.33"] = < text = <"provisional"> description = <"provisional diagnosis considered likely and a basis for proceeding with management"> > ["at0.34"] = < text = <"working"> description = <"working diagnosis considered very likely but not yet confirmed"> > ["at0.35"] = < text = <"Diagnostic criteria"> description = <"The criteria on which the diagnosis is based"> > ["at0.36"] = < text = <"Criterion"> description = <"A basis for the diagnosis"> > ["at0.37"] = < text = <"Clinical staging"> description = <"The stage of the disease by clinical assessment"> > ["at0.38"] = < text = <"Stage"> description = <"The stage of the disease (not TNM staging)"> > ["at0.39"] = < text = <"Tumour"> description = <"The extent of invasion of local tissue"> > ["at0.40"] = < text = <"Tx - primary tumour not assessed"> description = <"No clinical assessment of the primary tumour made"> > ["at0.41"] = < text = <"T0 - no primary tumour"> description = <"No primary tumour is evident clinically"> > ["at0.42"] = < text = <"Tis - Carcinoma insitu"> description = <"The malignant cells are confined to their usual cellular region"> > ["at0.43"] = < text = <"T1 - Micorinvasion (0.5cm)"> description = <"Microscopic invasion of 5mm"> > ["at0.44"] = < text = <"T2 - Tumour invading 1 cm"> description = <"Tumour invading 1cm"> > ["at0.45"] = < text = <"T3 - Full thickness of structure"> description = <"Tumour invading to full thickness (or border) of structure"> > ["at0.46"] = < text = <"T5 - Invading adjacent structure"> description = <"Tumour has spread outside the structure in which it arose"> > ["at0.47"] = < text = <"Nodes"> description = <"Extent of involvement of regional nodes"> > ["at0.48"] = < text = <"Nx - regional nodes not assessed"> description = <"No clinical assessment of regional nodes made"> > ["at0.49"] = < text = <"N0 - no regional nodes involved"> description = <"No clinical evidence of regional node involvement"> > ["at0.50"] = < text = <"N1 - Regional nodes involved"> description = <"Clinical assessment indicates that regional nodes are involved"> > ["at0.51"] = < text = <"Metastases"> description = <"Extent of metastases"> > ["at0.52"] = < text = <"Mx - metastases not assessed"> description = <"No clinical assessment of metastases"> > ["at0.53"] = < text = <"M0 - No distant metastases"> description = <"No clinical evidence of distanct metastases"> > ["at0.54"] = < text = <"M1 - Distant metastases"> description = <"Clinical evidence of distant metastases"> > ["at0000"] = < text = <"Problem"> description = <"A problem, condition or issue defined by a clinician which is deemed summative of a range of symptoms or concerns of the person and a useful label of these."> > ["at0000.1"] = < text = <"Diagnosis"> description = <"A diagnosis defined by a clinician which is coded in an accepted terminology and may include the stage of the condition and the diagnostic criteria"> > ["at0001"] = < text = <"structure"> description = <"@ internal @"> > ["at0002"] = < text = <"Problem"> description = <"The index problem, condition or issue described"> > ["at0002.1"] = < text = <"Diagnosis"> description = <"The index diagnosis"> > ["at0003"] = < text = <"Date of initial onset"> description = <"The date that the problem began causing symptoms or signs"> > ["at0004"] = < text = <"Age at initial onset"> description = <"The age of the at the onset of the problem"> > ["at0005"] = < text = <"Severity"> description = <"The severity of the index problem"> > ["at0006"] = < text = <"Mild"> description = <"The severity of the index problem is mild, not affecting life or longevity"> > ["at0007"] = < text = <"Moderate"> description = <"The severity of the index problem is such as to cause significant morbidity"> > ["at0008"] = < text = <"Severe"> description = <"The severity of the index problem has had a major effect on life and/or longevity"> > ["at0009"] = < text = <"Clinical description"> description = <"Description of the clinical aspects of the problem"> > ["at0010"] = < text = <"Date clinically recognised"> description = <"Date the problem was recognised by clinicians"> > ["at0011"] = < text = <"Location"> description = <"Location of the problem in terms of body site"> > ["at0012"] = < text = <"Body site"> description = <"The body site affected"> > ["at0013"] = < text = <"Location description"> description = <"A free text description of the location - may be in addition to a coded body site"> > ["at0014"] = < text = <"Aetiology"> description = <"Agents or Factors known to have been of aetiological significance"> > ["at0015"] = < text = <"Agent"> description = <"Microbial or other agent known to have caused this problem"> > ["at0016"] = < text = <"Complication of"> description = <"A problem or link to a problem or injury described elsewhere in the EHR"> > ["at0017"] = < text = <"Description"> description = <"Description of aetiological process"> > ["at0018"] = < text = <"Occurrences or exacerbations"> description = <"Grouping of information about individual occurrences or exacerbations"> > ["at0019"] = < text = <"Frequency of reccurrence"> description = <"The frequency of individual occurrences of the problem"> > ["at0020"] = < text = <"Date of last occurrence"> description = <"The date of the last occurrence or exacerbation"> > ["at0021"] = < text = <"Occurence/exacerbation"> description = <"Information about one occurrence or exacerbation"> > ["at0022"] = < text = <"Clinical description"> description = <"A description of the exacerbation or occurrence"> > ["at0023"] = < text = <"Outcome"> description = <"Outcome of the occurrence or exacerbation"> > ["at0024"] = < text = <"Date of onset of occurrence"> description = <"Date of onset of occurrence or exacerbation"> > ["at0025"] = < text = <"Number of occurrences"> description = <"Number of times this problem has occurred or been apparent"> > ["at0026"] = < text = <"Related problems"> description = <"Complications that are attributed to this problem"> > ["at0027"] = < text = <"Related problem"> description = <"A group of characteristics of the problem complicating the index condition in this archetype"> > ["at0028"] = < text = <"Related problem"> description = <"Details of the problem as text or coded text or URI"> > ["at0029"] = < text = <"Clinical description"> description = <"Decription of the complicating problem"> > ["at0030"] = < text = <"Date of resolution"> description = <"The date that the problem resolved or went into remission"> > ["at0031"] = < text = <"Age at resolution"> description = <"The age of the at the resolution of the problem"> > ["at0032"] = < text = <"Tree"> description = <"@ internal @"> > ["at0033"] = < text = <"References"> description = <"Useful information about this condition"> > ["at0034"] = < text = <"References"> description = <"Reference to material about this condition"> > ["at0035"] = < text = <"Web link"> description = <"Useful information on the internet about this condition"> > ["at0036"] = < text = <"Date of resolution of occurrence"> description = <"Date of the resolution of the occurrence"> > ["at0037"] = < text = <"Age when clinically recognised"> description = <"The age when this problem was clinically recognised"> > > > > constraint_definitions = < ["de"] = < items = < ["ac0.1"] = < text = <"Beliebiger Ausdruck der eine Diagnose ist"> description = <"Ausdruck, der eine Diagnose in einer anerkannten Terminologie ist"> > ["ac0000"] = < text = <"Beliebiger Ausdruck, der eine Körperstelle beschreibt"> description = <"Eine anatomische Struktur mit Vermerken"> > > > ["pt-br"] = < items = < ["ac0.1"] = < text = <"*Any term that 'is_a' diagnosis(en)"> description = <"*Any term that is a diagnosis in an accepted terminology(en)"> > ["ac0000"] = < text = <"Qualquer termo que descreve a localização do corpo."> description = <"Uma estrutura anatômica qualificada."> > > > ["en"] = < items = < ["ac0.1"] = < text = <"Any term that 'is_a' diagnosis"> description = <"Any term that is a diagnosis in an accepted terminology"> > ["ac0000"] = < text = <"Any term that describes a body site"> description = <"An anatomical structure with qualifiers"> > > > >