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Id Issue Status Priority Type Date Assigned To Label
11Verbindung zu ClassCode fehltCancelledNormalFor future consideration2017-10-23 14:14:41
 
For future considerationVerbindung zu ClassCode fehlt
Idch-epr-issue-11
StatusCancelled
PriorityNormal
Last Tracking2017-10-23 14:14:41  by  Johannes Gnaegi
    
Concerns
Value Set
EprDocumentTypeCode (2.16.756.5.30.1.127.3.10.1.27)
/
NameEprDocumentTypeCodeDisplay NameEprDocumentTypeCode
Version2017-06-12 17:44:36StatusDeprecated
Version Label201704.0-stableId2.16.756.5.30.1.127.3.10.1.27
Description
Type of document as per Annex 3  EPRO-FDHA, Chapter 2.11.

The code defines a document’s type (e.g. discharge report, laboratory report). Each document type should be assigned to precisely one document class.
Source Codesystems
2.16.840.1.113883.6.96SNOMED Clinical Termshttp://snomed.info/sct
Values
Level/TypeCodeDisplay NameCodesystemDescription
0-L
371537001
Consent report (record artifact)
preferred: Patienteneinwilligung
preferred: Consentement du patient
preferred: Consenso del paziente
preferred: Patient Consent
2.16.840.1.113883.6.96
0-L
371538006
Advance directive report (record artifact)
preferred: Patientenverfügung
preferred: Directives anticipées du patient
preferred: Direttive anticipate del paziente
preferred: Advance directive report
2.16.840.1.113883.6.96
0-L
371534008
Summary report (record artifact)
preferred: Patient Summary (medizinische Zusammenfassung)
preferred: Résumé du dossier médical
preferred: Patient Summary (riassunto medico)
preferred: Patient Summary
2.16.840.1.113883.6.96
0-L
721912009
Medication summary document (record artifact)
preferred: Medikamentenliste (aktuell)
preferred: Liste des médicaments
preferred: Elenco dei medicamenti
preferred: Medication summary
2.16.840.1.113883.6.96
0-L
440545006
Prescription record (record artifact)
preferred: Rezept
preferred: Ordonnance
preferred: Ricetta medica
preferred: Prescription for Medication
2.16.840.1.113883.6.96
0-L
275670009
Prescription exemption certificate (record artifact)
preferred: Dispensation
preferred: Dispensation
preferred: Dispensazione
preferred: Medication Dispensation
2.16.840.1.113883.6.96
0-L
1221000195109
Medication Comment (record artifact)
preferred: medication comment
preferred: Commentaire sur la médication
preferred: Commento alla terapia farmacologica
preferred: Medication Comment
2.16.840.1.113883.6.96
0-L
721915006
Admission request document (record artifact)
preferred: Zuweisungsschreiben/Einweisungsschreiben
preferred: Demande d'admission
preferred: Richiesta di ricovero/ammissione
preferred: Admission request
2.16.840.1.113883.6.96
0-L
371542009
Admission history and physical report (record artifact)
preferred: Eintrittsbericht
preferred: Rapport d'admission
preferred: Rapporto di ammissione
preferred: Admission report
2.16.840.1.113883.6.96
0-L
721917003
Physician discharge concise summary (record artifact)
preferred: Kurz-Austrittsbericht (ärztlich)
preferred: Avis de sortie
preferred: Rapporto breve d'uscita
preferred: Physician discharge concise summary
2.16.840.1.113883.6.96
0-L
373942005
Discharge summary (record artifact)
preferred: Austrittsbericht (ärztlich)
preferred: Lettre de sortie
preferred: Rapporto/lettera d'uscita
preferred: Discharge summary
2.16.840.1.113883.6.96
0-L
371535009
Transfer summary report (record artifact)
preferred: Verlegungsbericht
preferred: Rapport de transfert
preferred: Rapporto di trasferimento
preferred: Transfer summary report
2.16.840.1.113883.6.96
0-L
278448002
Care plan (qualifier value)
preferred: Pflegeplan (allgemein)
preferred: Plan de soins
preferred: Piano di cura
preferred: Care plan
2.16.840.1.113883.6.96
0-L
5531000179105
Nursing report (record artifact)
preferred: Pflegebericht
preferred: Rapport de soins infirmiers
preferred: Rapporto infermieristico
preferred: Nursing report
2.16.840.1.113883.6.96
0-L
721927009
Referral note (record artifact)
preferred: Konsilauftrag (allgemein)
preferred: Demande de consultation
preferred: Richiesta di consulto
preferred: Referral request
2.16.840.1.113883.6.96
0-L
371530004
Clinical consultation report (record artifact)
preferred: Konsultationsbericht
preferred: Rapport de consultation
preferred: Rapporto di consultazione
preferred: Consultation report
2.16.840.1.113883.6.96
0-L
371525003
Clinical procedure report (record artifact)
preferred: Untersuchungsbefund (allgemein)
preferred: Rapport d'examen
preferred: Risultato d'esame (generale)
preferred: Clinical procedure report
2.16.840.1.113883.6.96
0-L
4241000179101
Laboratory report (record artifact)
preferred: Labor-Befund
preferred: Résultat de laboratoire
preferred: Referto di laboratorio
preferred: Laboratory report
2.16.840.1.113883.6.96
0-L
371528001
Pathology report (record artifact)
preferred: Pathologie-Befund
preferred: Rapport de pathologie
preferred: Referto di patologia
preferred: Pathology report
2.16.840.1.113883.6.96
0-L
721631001
Bone marrow pathology biopsy report (record artifact)
preferred: Knochenmark-Biopsie-Befund
preferred: Rapport de la biopsie de la moelle osseuse
preferred: Referto di biopsia del midollo osseoBone marrow Pathology biopsy report
preferred: Bone marrow Pathology biopsy report
2.16.840.1.113883.6.96
0-L
721968000
Cardiac catheterization report (record artifact)
preferred: Herzkatheter-Befund
preferred: Rapport du cathétérisme cardiaque
preferred: Referto di cateterismo cardiaco
preferred: Cardiac catheterization report
2.16.840.1.113883.6.96
0-L
399345000
Adult echocardiography procedure report (record artifact)
preferred: Echokardiographie Befund
preferred: Rapport d'électrocardiographie (ECG)
preferred: Referto di ecocardiografia
preferred: Electrocardiogram report
2.16.840.1.113883.6.96
0-L
4221000179107
Ultrasound imaging report (record artifact)
preferred: Ultraschall-Befund
preferred: Rapport de l'ultrason
preferred: Referto ecografico
preferred: Ultrasound imaging report
2.16.840.1.113883.6.96
0-L
371527006
Radiology report (record artifact)
preferred: Radiologie-Befund
preferred: Rapport de l'examen radiologique
preferred: Referto radiologico
preferred: Radiology report
2.16.840.1.113883.6.96
0-L
721969008
Pulmonary function report (record artifact)
preferred: Lungenfunktions-Befund
preferred: Rapport de l'examen pulmonaire
preferred: Referto spirometrico
preferred: Pulmonary function report
2.16.840.1.113883.6.96
0-L
416779005
Anesthesia record (record artifact)
preferred: Anästhesie-Befund
preferred: Rapport de l'anésthésie
preferred: Referto anestesiologico
preferred: Anaesthesiology report
2.16.840.1.113883.6.96
0-L
371526002
Operative report (record artifact)
preferred: OP-Bericht
preferred: Protocole opératoire
preferred: Referto operatorio
preferred: Operative report
2.16.840.1.113883.6.96
0-L
444561001
Birth certificate (record artifact)
preferred: Geburtsurkunde
preferred: Certificat de naissance
preferred: Cerificato di nascita
preferred: Birth certificate
2.16.840.1.113883.6.96
0-L
307930005
Death certificate (record artifact)
preferred: Todesbescheinigung
preferred: Certificat de décès
preferred: Certificato di morte
preferred: Death certificate
2.16.840.1.113883.6.96
0-L
721599005
Wound care management note (record artifact)
preferred: Wund-Befund
preferred: Rapport sur les blessures
preferred: Rapporto sulle ferite
preferred: Wound report
2.16.840.1.113883.6.96
0-L
371532007
Progress report (record artifact)
preferred: Klinisches Verlaufsblatt
preferred: Note de suite
preferred: Diario clinico
preferred: Progress note
2.16.840.1.113883.6.96
0-L
722091001
Conclusion interpretation document (record artifact)
preferred: Beschlussprotokoll
preferred: Rapport de décision
preferred: Rapporto decisionale
preferred: Conclusion interpretation document
2.16.840.1.113883.6.96
0-L
900000000000471000
Image reference (foundation metadata concept)
preferred: Referenz auf Bilddaten
preferred: Référence d'Image
preferred: Referenza nei dati immagine
preferred: Image reference
2.16.840.1.113883.6.96
0-L
41000179103
Immunization record (record artifact)
preferred: Impfausweis/Impfdossier
preferred: Certificat / carnet de vaccination
preferred: Certificato/libretto di vaccinazione
preferred: Immunization record
2.16.840.1.113883.6.96
0-L
424975005
Record entry (record artifact)
preferred: Anderer EPD Dokumenten-Typ
preferred: Autre type de document DEP
preferred: Altri tipi di documento CIP
preferred: Other EPD-document type
2.16.840.1.113883.6.96
0-L
722160009
Audit trail report (record artifact)
preferred: Journal d'audit
preferred: Audit trail
preferred: Audit trail
preferred: Audit trail
2.16.840.1.113883.6.96
Legenda: Type L=leaf, S=specializable, A=abstract, D=deprecated. NullFlavors to appear in @nullFlavor attribute instead of @code.
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Events
TrackingCancelled2017-10-23 14:14:41: Tracking by Johannes Gnaegi
Description
doppelte Erfassung
TrackingOpen2017-06-15 08:32:44: Tracking by Johannes Gnaegi
Description
Finding:

Die Verbindung der Dokumente zu classcode fehlt

Suggestion:

Das Valueset enthält als Parent jeweils die DocumentClass und als Kind die zugelassenen DocumentTypes dafür. In der Auswahl werden die DocumentClass COdes aber verboten für DocumentTypeCode (falls möglich).

Further explanation:

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Labels
PreviewCodeHTML colorDisplay NameDescription
 
 4 
44genehmigt durch EGM
 
 3 
33Beta
Korrigiert in Betaversion verfügbar
 
 2 
22Betrifft Display Name / Synonym
 
 1 
11Anpassung Verordnung nötig