archetype (adl_version=1.4) openEHR-EHR-EVALUATION.problem.v1 concept [at0000] -- Problem 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 eines Problems, eines Zustandes oder eines Sachverhalts mit anhaltender Bedeutung für die Gesundheit der Person"> use = <"Zur Dokumentation eines ehemaligen oder aktuellen Problems - also zur Dokumentation ehemaliger Entwicklungen, sowie derzeitiger Probleme. Mit wechselndem 'Subjekt der Daten' zur Dokumentation von Problemen Verwandter, und somit für die Familienanamnese."> keywords = <"Sachverhalt", "Zustand"> misuse = <"Spezialisierungen 'openEHR-EHR-EVALUATION.problem-diagnosis' für medizinische Diagnosen und 'openEHR-EHR-EVALUATION.problem-diagnosis-histological' für histologische Diagnosen benutzen."> copyright = <"copyright (c) 2009 openEHR Foundation"> > ["pt-br"] = < language = <[ISO_639-1::pt-br]> purpose = <"Para registrar detalhes sobre um caso ou obstáculo que tenha impactos sobre o bem estar físico, mental e/ou social de um indivíduo."> use = <"Usado para registrar qualquer informação sobre qualquer problema relacionado a saúde em geral. O Arquétipo contém múltiplas datas, então pode registrar problemas presentes e/ou passados. Um problema pode ser determinado tanto pelo próprio indivíduo como pelo profissional de saúde. Alguns exemplos: - Uma coleção de sintomas que estão sob investigação, mas pré-diagnose - Desejo de perder peso, sem diagnóstico formal de Obesidade - Desejo de parar de fumar pelo indivíduo - Problemas de relacionamento com membro familiar"> keywords = <"caso", "circunstância", "problema", "obstáculo"> misuse = <"Não deve ser usado para registro de diagnósticos formais - usar a especialização deste arquétipo, EVALUATION.problem-diagnosis."> copyright = <"copyright (c) 2009 openEHR Foundation"> > ["en"] = < language = <[ISO_639-1::en]> purpose = <"For recording details about an issue or obstacle that impacts on the physical, mental and/or social well-being of an individual."> use = <"Use for recording any information about general health-related problems. The archetype contains multiple dates, so can record present and/or past problems. A problem can be determined by either the individual themselves or a healthcare provider. Some examples: - A range of symptoms that are under investigation but pre-diagnosis - Desire to lose weight, without formal diagnosis of Obesity - Desire to quit smoking by individual - Relationship problem with family member "> keywords = <"issue", "condition", "problem", "obstacle"> misuse = <"Not to be used for recording formal Diagnoses - use the specialisation of this archetype, EVALUATION.problem-diagnosis. "> copyright = <"copyright (c) 2009 openEHR Foundation"> > > lifecycle_state = <"AuthorDraft"> other_contributors = <> other_details = < ["MD5-CAM-1.0.1"] = <"4A7BAF9ECB8E210E032DAC7C90FBF7D2"> ["references"] = <""> > definition EVALUATION[at0000] matches { -- Problema data matches { ITEM_TREE[at0001] matches { -- structure items cardinality matches {1..*; ordered} matches { ELEMENT[at0002] matches { -- Problema value matches { DV_TEXT matches {*} } } ELEMENT[at0009] occurrences matches {0..1} matches { -- Descrição Clinica value matches { DV_TEXT matches {*} } } ELEMENT[at0003] occurrences matches {0..1} matches { -- Data de começo inicial value matches { DV_DATE matches {*} } } ELEMENT[at0004] occurrences matches {0..1} matches { -- A idade de começo inicial value matches { DV_DURATION matches {*} } } ELEMENT[at0005] occurrences matches {0..1} matches { -- Gravidade value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0006, -- Suave at0007, -- Aguda at0008] -- Crônica } } } } ELEMENT[at0038] occurrences matches {0..1} matches { -- Importância clínica value matches { DV_TEXT matches {*} } } ELEMENT[at0010] occurrences matches {0..1} matches { -- Data do confesso clínico value matches { DV_DATE matches { value matches {yyyy-??-XX} } } } ELEMENT[at0037] occurrences matches {0..1} matches { -- Idade quando confesso clínico 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_TEXT matches {*} } } ELEMENT[at0013] occurrences matches {0..1} matches { -- Descrição de Local value matches { DV_TEXT matches {*} } } } } CLUSTER[at0014] occurrences matches {0..*} 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..1} matches { -- Complicação de 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 de recorrência value matches { C_DV_QUANTITY < > } } ELEMENT[at0020] occurrences matches {0..1} matches { -- Data da última ocorrência value matches { DV_DATE matches {*} } } CLUSTER[at0021] occurrences matches {0..*} matches { -- Ocorrência/exacerbação 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 da ocorrência value matches { DV_DATE matches {*} } } ELEMENT[at0036] occurrences matches {0..1} matches { -- Data de Resolução da ocorrência 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 { -- Problema relacionado 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 {*} } } } } } protocol matches { ITEM_TREE[at0032] matches { -- Tree(en) items cardinality matches {0..*; unordered} matches { CLUSTER[at0033] occurrences matches {0..1} matches { -- Referências items cardinality matches {1..*; unordered} matches { ELEMENT[at0034] occurrences matches {0..*} matches { -- Referência value matches { DV_TEXT matches {*} } } ELEMENT[at0035] occurrences matches {0..*} matches { -- Web link value matches { DV_URI matches {*} } } } } } } } } ontology term_definitions = < ["de"] = < items = < ["at0000"] = < text = <"*Problem(en)"> description = <"*An issue or obstacle which adversely impacts on the physical, mental and/or social well-being of an individual. The definition of a problem is deliberately kept rather loose so as to capture any real or perceived concerns that may adversely affect an individual's wellbeing to any degree. (en)"> > ["at0001"] = < text = <"Structure"> description = <"@ internal @"> > ["at0002"] = < text = <"*Problem(en)"> description = <"*Identification of the index problem.(en)"> > ["at0003"] = < text = <"*Date of initial onset(en)"> description = <"*The date when the problem was first identified by the individual.(en)"> > ["at0004"] = < text = <"*Age at initial onset(en)"> description = <"*The age of the individual when the problem was first identified by the individual.(en)"> > ["at0005"] = < text = <"*Severity(en)"> description = <"*The assessed overall severity of the index problem.(en)"> > ["at0006"] = < text = <"*Mild(en)"> description = <"*The severity of the index problem is mild, not affecting life or longevity.(en)"> > ["at0007"] = < text = <"*Moderate(en)"> description = <"*The severity of the index problem is such as to cause significant morbidity.(en)"> > ["at0008"] = < text = <"*Severe(en)"> description = <"*The severity of the index problem has had a major effect on life and/or longevity.(en)"> > ["at0009"] = < text = <"*Clinical description(en)"> description = <"*Description of the clinical aspects of the problem.(en)"> > ["at0010"] = < text = <"*Date clinically recognised(en)"> description = <"*Date the problem was recognised by a healthcare provider.(en)"> > ["at0011"] = < text = <"*Location(en)"> description = <"*Location of the problem in terms of body site.(en)"> > ["at0012"] = < text = <"*Body site(en)"> description = <"*The body site affected.(en)"> > ["at0013"] = < text = <"*Location description(en)"> description = <"*Description of the location.(en)"> > ["at0014"] = < text = <"*Aetiology(en)"> description = <"*Agents or Factors known to have been of aetiological significance.(en)"> > ["at0015"] = < text = <"*Agent(en)"> description = <"*Agent or other factor known to have caused this problem.(en)"> > ["at0016"] = < text = <"*Complication of(en)"> description = <"*Identification of a problem, injury or condition as text,coded text or link within the EHR.(en)"> > ["at0017"] = < text = <"*Description(en)"> description = <"*Description of aetiological process.(en)"> > ["at0018"] = < text = <"*Occurrences or exacerbations(en)"> description = <"*Grouping of information about individual occurrences or exacerbations.(en)"> > ["at0019"] = < text = <"*Frequency of reccurrence(en)"> description = <"*The frequency of individual occurrences of the problem.(en)"> > ["at0020"] = < text = <"*Date of last occurrence(en)"> description = <"*The date of the last occurrence of the problem.(en)"> > ["at0021"] = < text = <"*Occurrence/exacerbation(en)"> description = <"*Information about one occurrence or exacerbation.(en)"> > ["at0022"] = < text = <"*Clinical description(en)"> description = <"*A description of the exacerbation or occurrence.(en)"> > ["at0023"] = < text = <"*Outcome(en)"> description = <"*Outcome of the occurrence or exacerbation.(en)"> > ["at0024"] = < text = <"*Date of onset of occurrence(en)"> description = <"*Date of onset of occurrence or exacerbation.(en)"> > ["at0025"] = < text = <"*Number of occurrences(en)"> description = <"*Number of times this problem has occurred or been apparent.(en)"> > ["at0026"] = < text = <"*Related problems(en)"> description = <"*Further problems that are related in some way to the index problem.(en)"> > ["at0027"] = < text = <"*Related problem(en)"> description = <"*A group of characteristics of the problem complicating the index problem.(en)"> > ["at0028"] = < text = <"*Related problem(en)"> description = <"*Identification of a related problem as text,coded text or link within the EHR.(en)"> > ["at0029"] = < text = <"*Clinical description(en)"> description = <"*Decription of the related problem.(en)"> > ["at0030"] = < text = <"*Date of resolution(en)"> description = <"*The date that the problem resolved or went into remission.(en)"> > ["at0031"] = < text = <"*Age at resolution(en)"> description = <"*The age of the person at the resolution of the problem.(en)"> > ["at0032"] = < text = <"Tree"> description = <"@ internal @"> > ["at0033"] = < text = <"*References(en)"> description = <"*Useful information about this condition.(en)"> > ["at0034"] = < text = <"*Reference(en)"> description = <"*Reference to material about this condition.(en)"> > ["at0035"] = < text = <"*Web link(en)"> description = <"*Useful information on the internet about this condition.(en)"> > ["at0036"] = < text = <"*Date of resolution of occurrence(en)"> description = <"*Date of the resolution of the occurrence or exacerbation.(en)"> > ["at0037"] = < text = <"*Age when clinically recognised(en)"> description = <"*Age at which the problem was recognised by a healthcare provider.(en)"> > ["at0038"] = < text = <"*Clinical significance(en)"> description = <"*Description of the clinical significance of the problem in terms of impact of the problem on the patient.(en)"> > > > ["pt-br"] = < items = < ["at0000"] = < text = <"Problema"> description = <"Um caso ou obstáculo que tenha impactos sobre o bem estar físico, mental e/ou social de um indivíduo"> > ["at0001"] = < text = <"structure"> description = <"@ internal @"> > ["at0002"] = < text = <"Problema"> description = <"Identificação dos indicadores do problema"> > ["at0003"] = < text = <"Data de começo inicial"> description = <"A data de quando o problema foi identificado pela primeira vez pelo indivíduo."> > ["at0004"] = < text = <"A idade de começo inicial"> description = <"A idade do indivíduo quando o problema foi identificado pela primeira vez pelo indivíduo."> > ["at0005"] = < text = <"Gravidade"> description = <"A avaliação global da gravidade dos indicadores problema."> > ["at0006"] = < text = <"Suave"> description = <"A gravidade dos indicadores do problema é suave, não afeta vida ou longevidade."> > ["at0007"] = < text = <"Aguda"> description = <"A gravidade dos indicadores do problema pode causar morbidez significativa."> > ["at0008"] = < text = <"Crônica"> description = <"A gravidade dos indicadores do problema teve um efeito importante sobre a vida e/ou longevidade."> > ["at0009"] = < text = <"Descrição Clinica"> description = <"Descrição dos aspectos clínicos do problema."> > ["at0010"] = < text = <"Data do confesso clínico"> description = <"Data em que o problema foi ouvido pelo profissional de saúde."> > ["at0011"] = < text = <"Localização"> description = <"Localização do problema em termos de local do corpo."> > ["at0012"] = < text = <"Local do corpo"> description = <"O local do corpo afetado."> > ["at0013"] = < text = <"Descrição de Local"> description = <"Descrição do local"> > ["at0014"] = < text = <"Etiologia"> description = <"Agentes ou fatores conhecidos por terem importância etiológica."> > ["at0015"] = < text = <"Agente"> description = <"Agente ou outro fator conhecido por ter causado este problema."> > ["at0016"] = < text = <"Complicação de"> description = <"Identificação de um problema, lesão ou doença como texto, texto codificado ou link dentro do RES."> > ["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 de recorrência"> description = <"A frequência de ocorrências individuais do problema."> > ["at0020"] = < text = <"Data da última ocorrência"> description = <"A data da última ocorrência do problema."> > ["at0021"] = < text = <"Ocorrência/exacerbação"> description = <"Informações sobre uma ocorrência ou exacerbação"> > ["at0022"] = < text = <"Descrição clínica"> description = <"Uma descrição da exacerbação ou ocorrência."> > ["at0023"] = < text = <"Resultado"> description = <"Resultado da ocorrência ou exacerbação."> > ["at0024"] = < text = <"Data do começo da ocorrência"> description = <"Data do começo da ocorrência ou exacerbação."> > ["at0025"] = < text = <"Número de ocorrências"> description = <"Número de vezes que este problema ocorreu ou foi aparente."> > ["at0026"] = < text = <"Problemas relacionados"> description = <"Outros problemas que estão relacionados de alguma forma aos indicadores do problema."> > ["at0027"] = < text = <"Problema relacionado"> description = <"Um grupo de características do problema complicando os indicadores do problema."> > ["at0028"] = < text = <"Problema relacionado"> description = <"dentificação textual de um problema relacionado, texto codificado ou link dentro do RES."> > ["at0029"] = < text = <"Descrição clínica"> description = <"Decription do problema relacionado."> > ["at0030"] = < text = <"Data da resolução"> description = <"A data em que o problema resolvido ou entrou em remissão."> > ["at0031"] = < text = <"Idade na resolução"> description = <"A idade da pessoa com a resolução do problema."> > ["at0032"] = < text = <"Tree(en)"> description = <"@ internal @"> > ["at0033"] = < text = <"Referências"> description = <"Informações úteis sobre esta condição"> > ["at0034"] = < text = <"Referência"> description = <"Referência a materiais sobre esta condição."> > ["at0035"] = < text = <"Web link"> description = <"Informações úteis na internet sobre essa condição."> > ["at0036"] = < text = <"Data de Resolução da ocorrência"> description = <"Data da resolução da ocorrência ou exacerbação."> > ["at0037"] = < text = <"Idade quando confesso clínico"> description = <"Idade quando o problema foi ouvido por um profissional de saúde."> > ["at0038"] = < text = <"Importância clínica"> description = <"Descrição do significado clínico do problema em termos de impacto do problema no paciente."> > > > ["en"] = < items = < ["at0000"] = < text = <"Problem"> description = <"An issue or obstacle which adversely impacts on the physical, mental and/or social well-being of an individual. The definition of a problem is deliberately kept rather loose so as to capture any real or perceived concerns that may adversely affect an individual's wellbeing to any degree. "> > ["at0001"] = < text = <"structure"> description = <"@ internal @"> > ["at0002"] = < text = <"Problem"> description = <"Identification of the index problem."> > ["at0003"] = < text = <"Date of initial onset"> description = <"The date when the problem was first identified by the individual."> > ["at0004"] = < text = <"Age at initial onset"> description = <"The age of the individual when the problem was first identified by the individual."> > ["at0005"] = < text = <"Severity"> description = <"The assessed overall 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 a healthcare provider."> > ["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 = <"Description of the location."> > ["at0014"] = < text = <"Aetiology"> description = <"Agents or Factors known to have been of aetiological significance."> > ["at0015"] = < text = <"Agent"> description = <"Agent or other factor known to have caused this problem."> > ["at0016"] = < text = <"Complication of"> description = <"Identification of a problem, injury or condition as text,coded text or link within 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 of the problem."> > ["at0021"] = < text = <"Occurrence/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 = <"Further problems that are related in some way to the index problem."> > ["at0027"] = < text = <"Related problem"> description = <"A group of characteristics of the problem complicating the index problem."> > ["at0028"] = < text = <"Related problem"> description = <"Identification of a related problem as text,coded text or link within the EHR."> > ["at0029"] = < text = <"Clinical description"> description = <"Decription of the related 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 person at the resolution of the problem."> > ["at0032"] = < text = <"Tree"> description = <"@ internal @"> > ["at0033"] = < text = <"References"> description = <"Useful information about this condition."> > ["at0034"] = < text = <"Reference"> 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 or exacerbation."> > ["at0037"] = < text = <"Age when clinically recognised"> description = <"Age at which the problem was recognised by a healthcare provider."> > ["at0038"] = < text = <"Clinical significance"> description = <"Description of the clinical significance of the problem in terms of impact of the problem on the patient."> > > > >