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Anamnese
Idelgabbr-dataelement(v2)-45Version2017-06-10 15:27:27
StatusDraftVersion Labelv2
Synonym
Aktuelle Anamnese
Description
Die Anamnese enthält die professionelle Erfragung von potenziell medizinisch relevanten Informationen durch Fachpersonal (z.B. einen Arzt) basierend auf den Aussagen des Patienten (Eigenanamnese) oder einer dritten Person (Fremdanamnese) zum aktuellen Konsultationsanlass. Die Anamnese kann sich in mehrere Abschnitte gliedern, z.B.
  • biografische Anamnese, allgemeine Anamnese,
  • vegetative Anamnese,
  • Ernährungsanamnese,
  • Suchtanamnese,
  • psychosoziale Anamnese,
  • Sexualanamnese,
  • Familienanamnese
  • Sozialanamnese
  • Fachspezifische Anamnese
Comment
Nur Freitext.
  • Gutes Beispiel: „Thoraxschmerzen bei leichter Belastung seit zwei Wochen. Vorherige Herzprobleme bekannt.“
  • Schlechtes Beispiel: Kopie sämtlicher Vordiagnosen

LOINC: 10164-2, „History of present illness“
OID 1.2.40.0.34.11.14.2.6

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    Usage (2)
    Busy
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    DatasetPathProject
    Outpatient Report Body / ELGA Basisleitfäden
    Datensatz Fachlicher Inhalt (Sektionen) / ELGA generischer Arztbrief
    Busy
     
     
    DatasetELGA Basis-Dataset
    Id1.2.40.0.34.777.1.1.1Version2017-06-21
    StatusDraftVersion Labelv2
    Description
    Basis Datensätze - Baukasten für ELGA Dokumente
    Usage (1)
    Busy
    TransactionProject
    Dokument erstellen ELGA Repository
    Busy
     
     
    History (282)
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