TEMPLATE GECCO core (GECCO core)

TEMPLATE ID	GECCO core
Concept	GECCO core
Description	To support the systematic collection of scientific data on COVID-19 in Germany.
Use	Basis of the data set are both the ISARIC protocol of the WHO as well as the data concepts of the LEOSS-Register. The purpose of ISARIC is to prevent disease and death from outbreaks of infectious diseases such as COVID-19. ISARIC brings together clinical research networks worldwide to provide the fastest possible research response to an outbreak of an infectious disease. The requirements used in the creation of this template are sourced from the FHIR IG - https://simplifier.net/guide/GermanCoronaConsensusDataSet-ImplementationGuide/Anticoagulation
Purpose	To support the systematic collection of scientific data on COVID-19 in Germany.
References
Authors	name: Heather Leslie; organisation: Atomica Informatics; email: heather.leslie@atomicainformatics.com; date: 2020-07-28
Other Details Language	name: Heather Leslie; organisation: Atomica Informatics; email: heather.leslie@atomicainformatics.com; date: 2020-07-28
Other Details (Language Independent)	MD5-CAM-1.0.1: 091994ba9d0365e8fdef60f775622b35 PARENT:MD5-CAM-1.0.1: 5CB5FECD224DABB2118F808E89A300CE Original Language: ISO_639-1::en
Language used	en
Citeable Identifier	1013.26.372
Root archetype id	openEHR-EHR-COMPOSITION.data_set.v0
German Corona Consensus Data Set (GECCO)	German Corona Consensus Data Set (GECCO): Generic composition to represent a data set for use in research
Anamnesis/Risk factors	Anamnesis/Risk factors: A generic section header which should be renamed in a template to suit a specific clinical context.
Chronic lung disease	Chronic lung disease: An screeing questionnaire for conditions, including problems and diagnoses.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Does the patient suffer from a chronic lung disease?	Does the patient suffer from a chronic lung disease?: Presence of any relevant conditions. Present Absent Unknown
Specific disease	Specific disease: Grouping of data elements related to screening for a single condition.
Disease name	Disease name: Name of the condition being screened. Asthma COPD Fibrosis of lung Pulmonary hypertension Extreme obesity with alveolar hypoventilation Sleep apnea Obstructive sleep apnea syndrome Cystic fibrosis
Presence?	Presence?: Presence of the condition. Present Absent Unknown
Other disease	Other disease: Grouping of data elements related to screening for a single condition.
Disease name	Disease name: Name of the condition being screened.
Presence?	Presence?: Presence of the condition. Present Absent Unknown
Disorders of cardiovascular system	Disorders of cardiovascular system: An screeing questionnaire for conditions, including problems and diagnoses.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Does the patient suffer from a cardiovascular disease?	Does the patient suffer from a cardiovascular disease?: Presence of any relevant conditions. Present Absent Unknown
Specific disease	Specific disease: Grouping of data elements related to screening for a single condition.
Disease name	Disease name: Name of the condition being screened. High blood pressure History of myocardial infarction Cardiac arrhythmia Heart failure Peripheral arterial occlusive disease History of heart revascularization Coronary arteriosclerosis Carotid artery stenosis
Presence?	Presence?: Presence of the condition. Present Absent Unknown
Other disease	Other disease: Grouping of data elements related to screening for a single condition.
Disease name	Disease name: Name of the condition being screened.
Presence?	Presence?: Presence of the condition. Present Absent Unknown
Comment	Comment: Additional narrative about the conditions, not captured in other fields.
Rheumatological/immunological diseases	Rheumatological/immunological diseases: An screeing questionnaire for conditions, including problems and diagnoses.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Does the patient suffer from at least one rheumatological or immunological disease?	Does the patient suffer from at least one rheumatological or immunological disease?: Presence of any relevant conditions. Present Absent Unknown
Specific disease	Specific disease: Grouping of data elements related to screening for a single condition.
Disease name	Disease name: Name of the condition being screened. Inflammatory bowel disease Rheumatic arteritis Disorder of connective tissue Vasculitis Congenital immunodeficiency disease
Presence?	Presence?: Presence of the condition. Present Absent Unknown
Other disease	Other disease: Grouping of data elements related to screening for a single condition.
Disease name	Disease name: Name of the condition being screened.
Presence?	Presence?: Presence of the condition. Present Absent Unknown
Human immunodeficiency virus infection	Human immunodeficiency virus infection: An screeing questionnaire for conditions, including problems and diagnoses.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Is the patient infected with HIV?	Is the patient infected with HIV?: Presence of any relevant conditions. Present Absent Unknown
History of being a tissue or organ transplant recipient	History of being a tissue or organ transplant recipient: An screeing questionnaire for conditions, including problems and diagnoses.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Does the patient have a history of being an organ transplant recipient?	Does the patient have a history of being an organ transplant recipient?: Presence of any relevant conditions. Present Absent Unknown
Specific transplant	Specific transplant: Grouping of data elements related to screening for a single condition.
Transplanted organ name	Transplanted organ name: Name of the condition being screened. Heart transplant Lung transplant Liver transplant Kidneys transplant Intestine transplant Skin transplant Cornea transplant Ossicle transplant Heartvalve transplant Blood vessel transplant Cerebral meninges transplant Bone tissue transplant Cartilage tissue transplant Tendon transplant
Presence?	Presence?: Presence of the condition. Present Absent Unknown
Diabetes mellitus	Diabetes mellitus: An screeing questionnaire for conditions, including problems and diagnoses.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Does the patient suffer from diabetes?	Does the patient suffer from diabetes?: Presence of any relevant conditions. Present Absent Unknown
Specific disease	Specific disease: Grouping of data elements related to screening for a single condition.
Disease name	Disease name: Name of the condition being screened. Diabetes mellitus type 1 Diabetes mellitus type 2 Insulin treated type 2 diabetes mellitus Secondary diabetes mellitus
Presence?	Presence?: Presence of the condition. Present Absent Unknown
Malignant neoplastic diseases	Malignant neoplastic diseases: An screeing questionnaire for conditions, including problems and diagnoses.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Does the patient suffer from at least one active tumor or cancer disease?	Does the patient suffer from at least one active tumor or cancer disease?: Presence of any relevant conditions. Present Absent Unknown
Chronic neurological or mental diseases	Chronic neurological or mental diseases: An screeing questionnaire for conditions, including problems and diagnoses.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Does the patient suffer from at least one chronic neurological disease or psychiatric illness? Which one?	Does the patient suffer from at least one chronic neurological disease or psychiatric illness? Which one?: Presence of any relevant conditions. Present Absent Unknown
Specific disease	Specific disease: Grouping of data elements related to screening for a single condition.
Disease name	Disease name: Name of the condition being screened. Parkinson's disease Dementia Multiple sclerosis Combined disorder of muscle and peripheral nerve Epilepsy Migraine History of a cerebrovascular accident with residual deficit History of a cerebrovascular accident without residual deficits Psychotic disorder Depressive disorder Anxiety disorder
Presence?	Presence?: Presence of the condition. Present Absent Unknown
Chronic kidney diseases	Chronic kidney diseases: An screeing questionnaire for conditions, including problems and diagnoses.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Does the patient suffer from chronic kidney disease?	Does the patient suffer from chronic kidney disease?: Presence of any relevant conditions. Present Absent Unknown
Specific disease	Specific disease: Grouping of data elements related to screening for a single condition.
Disease name	Disease name: Name of the condition being screened. With hemodialysis Without hemodialysis
Presence?	Presence?: Presence of the condition. Present Absent Unknown
Gastrointestinal ulcers	Gastrointestinal ulcers: An screeing questionnaire for conditions, including problems and diagnoses.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Specific disease	Specific disease: Grouping of data elements related to screening for a single condition.
Condition name	Condition name: Name of the condition being screened. Gastrointestinal ulcers
Presence?	Presence?: Presence of the condition. Present Absent Unknown
Disease certainty	Disease certainty: Details about a single identified health condition, injury, disability or any other issue which impacts on the physical, mental and/or social well-being of an individual. Clear delineation between the scope of a problem versus a diagnosis is not easy to achieve in practice. For the purposes of clinical documentation with this archetype, problem and diagnosis are regarded as a continuum, with increasing levels of detail and supportive evidence usually providing weight towards the label of 'diagnosis'.
Data
Problem/Diagnosis name	Problem/Diagnosis name: Identification of the problem or diagnosis, by name. Coding of the name of the problem or diagnosis with a terminology is preferred, where possible. Asthma COPD Fibrosis of lung Pulmonary hypertension Extreme obesity with alveolar hypoventilation Sleep apnea Obstructive sleep apnea syndrome Cystic fibrosis High blood pressure History of myocardial infarction Cardiac arrhythmia Heart failure Peripheral arterial occlusive disease History of heart revascularization Coronary arteriosclerosis Carotid artery stenosis Inflammatory bowel disease Rheumatic arteritis Disorder of connective tissue Vasculitis Congenital immunodeficiency disease Heart transplant Lung transplant Liver transplant Kidneys transplant Intestine transplant Skin transplant Cornea transplant Ossicle transplant Heartvalve transplant Blood vessel transplant Cerebral meninges transplant Bone tissue transplant Cartilage tissue transplant Tendon transplant Diabetes mellitus type 1 Diabetes mellitus type 2 Insulin treated type 2 diabetes mellitus Secondary diabetes mellitus Malignant neoplastic disease Parkinson's disease Dementia Multiple sclerosis Combined disorder of muscle and peripheral nerve Epilepsy Migraine Cerebrovascular accident with residual deficit Cerebrovascular accident without residual deficits Psychotic disorder Depressive disorder Anxiety disorder Kidney disease with hemodialysis Kidney disease without hemodialysis Gastrointestinal ulcers
Diagnostic certainty	Diagnostic certainty: The level of confidence in the identification of the diagnosis. Coded Text Suspected Probable Confirmed Text
Protocol
Last updated	Last updated: The date this problem or diagnosis was last updated.
Disease exclusion	Disease exclusion: A statement of exclusion of a specific Problem/diagnosis, Family history, Medication, Procedure, Adverse reaction or other clinical item that is either not currently present, or have not been present in the past.
Data
Problem/diagnosis	Problem/diagnosis: The problem or diagnosis to which the 'Exclusion statement' applies. For example: 'Diabetes', 'COPD' or 'Asthma'. Asthma COPD Fibrosis of lung Pulmonary hypertension Extreme obesity with alveolar hypoventilation Sleep apnea Obstructive sleep apnea syndrome Cystic fibrosis High blood pressure History of myocardial infarction Cardiac arrhythmia Heart failure Peripheral arterial occlusive disease History of heart revascularization Coronary arteriosclerosis Carotid artery stenosis Inflammatory bowel disease Rheumatic arteritis Disorder of connective tissue Vasculitis Congenital immunodeficiency disease Heart transplant Lung transplant Liver transplant Kidneys transplant Intestine transplant Skin transplant Cornea transplant Ossicle transplant Heartvalve transplant Blood vessel transplant Cerebral meninges transplant Bone tissue transplant Cartilage tissue transplant Tendon transplant Diabetes mellitus type 1 Diabetes mellitus type 2 Insulin treated type 2 diabetes mellitus Secondary diabetes mellitus Malignant neoplastic disease Parkinson's disease Dementia Multiple sclerosis Combined disorder of muscle and peripheral nerve Epilepsy Migraine Cerebrovascular accident with residual deficit Cerebrovascular accident without residual deficits Psychotic disorder Depressive disorder Anxiety disorder Kidney disease with hemodialysis Kidney disease without hemodialysis Gastrointestinal ulcers
Comment	Comment: Additional narrative about the Specific Exclusion not captured in other fields.
Active malignant neoplastic disease	Active malignant neoplastic disease: Details about a single identified health condition, injury, disability or any other issue which impacts on the physical, mental and/or social well-being of an individual. Clear delineation between the scope of a problem versus a diagnosis is not easy to achieve in practice. For the purposes of clinical documentation with this archetype, problem and diagnosis are regarded as a continuum, with increasing levels of detail and supportive evidence usually providing weight towards the label of 'diagnosis'.
Data
Problem/Diagnosis name	Problem/Diagnosis name: Identification of the problem or diagnosis, by name. Coding of the name of the problem or diagnosis with a terminology is preferred, where possible.
Problem/Diagnosis qualifier	Problem/Diagnosis qualifier: Contextual or temporal qualifier for a specified problem or diagnosis.
Remission status	Remission status: Status of the remission of an incurable diagnosis. For example: the status of a cancer or haematological diagnosis. In remission Not in remission Indeterminate
Protocol
Last updated	Last updated: The date this problem or diagnosis was last updated.
Travel event	Travel event: Details about a specific trip or travel event.
Data
Specific destination	Specific destination: Details about a single location visited on a trip.
Country	Country: The country visited.
State/region	State/region: The region visited. Different regions within the same country maybe identified if they potentially pose different health risks.
City	City: The city visited. Different cities within the same country or region maybe identified if they potentially pose different health risks.
Travel start date	Travel start date: Date of entry to the identified location.
Travel end date	Travel end date: Date of exit from the identified location.
Tobacco smoking summary	Tobacco smoking summary: Summary or persistent information about the tobacco smoking habits of an individual.
Data
Overall status	Overall status: Statement about current smoking behaviour for all types of tobacco. Never smoked Current smoker Former smoker
Overall comment	Overall comment: Additional narrative about all tobacco smoking that has not been captured in other fields. For example: stopped smoking or reduced amount on becoming pregnant. Heavy tobacco smoker Light tobacco smoker Everyday smoker Some day smoker
Respiratory therapies	Respiratory therapies: An individual- or self-reported questionnaire screening for management or treatment carried out.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Management/treatment activity	Management/treatment activity: Grouping of data elements related to screening for a single management or treatment activity.
Activity name	Activity name: Name of the management or treatment activity being screened. Did oxygen or respiratory therapy already exist before the current illness?
Presence	Presence: The current status of a specific activity. Present Absent Unknown
**Immunisation administration	**Immunisation administration: Any activity related to the planning, scheduling, prescription management, dispensing, administration, cessation and other use of a medication, vaccine, nutritional product or other therapeutic item. This is not limited to activities performed based on medication orders from clinicians, but could also include for example taking over the counter medication.
Description
Medication item	Medication item: Name of the medication, vaccine or other therapeutic/prescribable item which was the focus of the activity. For example: 'Atenolol 100mg' or 'Tenormin tablets 100mg'. It is strongly recommended that the 'Medication item' is coded with a terminology capable of triggering decision support, where possible. The extent of coding may vary from the simple name of the medication item through to structured details about the actual medication pack used. Free text entry should only be used if there is no appropriate terminology available. Influenza Pneumococcal BCG COVID-19
Clinical indication	Clinical indication: The clinical reason for the medication activity. For example: 'Angina' or 'Pain'. Coding of the indication with a terminology is preferred, where possible. This data element allows multiple occurrences. If only an ACTION is used to record a medication indication, this data element can be used without additional consideration. However, if a clinical indication is recorded for both the Medication order INSTRUCTION and this Medication management ACTION, be aware that these indications might not be consistent."
Sequence number	Sequence number: The sequence number specific to the pathway step being recorded. For example: Vaccine sequence number.
**OR Immunization status	**OR Immunization status: Summary of the immunisation status for an identified infectious disease or agent.
Data
Infectious disease or agent	Infectious disease or agent: Identification of the infectious disease or agent. There may be multiple diseases or agents that are vaccinated together - for example: diptheria, tetanus and pertussis or measles, mumps and rubella. Influenza Pneumococcal BCG COVID-19
Immunisation status	Immunisation status: An assertion about whether the immunisation course is up-to-date. Immunisation up-to-date Immunisation not up-to-date
Resuscitation status	Resuscitation status: Anticipatory decisions about the overall intent of care and possible interventions (including treatments, activities, and diagnostic or therapeutic procedures), asserted by a clinician.
Data
CPR decision	CPR decision: Decision about the extent of cardiopulmonary resuscitation (CPR) intervention appropriate for this individual. Full CPR No CPR Unknown
Imaging	Imaging: A generic section header which should be renamed in a template to suit a specific clinical context.
Imaging examination result	Imaging examination result: Record the findings and interpretation of an imaging examination performed.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Test name	Test name: The name of the imaging examination or procedure performed. Coding with a terminology, potentially a pre-coordinated term specifying both modality and anatomical location, is desirable where possible. Possible candidate terminologies: LOINC, SNOMED CT or RadLex. Lung CT Lung radiography Lung ultrasonography
Anatomical site	Anatomical site: Simple description about the physical place on, or in, the body that was imaged. This data element is redundant if the anatomical site is identified in the 'Test name'.
Radiological findings	Radiological findings: Single word, phrase or brief description representing the likely condition or diagnosis. This data element has multiple occurrences to allow for more than one diagnoses. Coding with a terminology is preferred, where possible. This data element should be regarded as mutually exclusive to 'Differential diagnoses' - only one of 'Differential diagnoses' OR 'Imaging diagnosis' should be present in the each Imaging examination result. Undetermined finding COVID-19-characteristic finding Normal finding
Demographics	Demographics: A generic section header which should be renamed in a template to suit a specific clinical context.
Pregnancy	Pregnancy: An screeing questionnaire for conditions, including problems and diagnoses.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Specific condition	Specific condition: Grouping of data elements related to screening for a single condition.
Condition name	Condition name: Name of the condition being screened. Pregnancy
Presence?	Presence?: Presence of the condition. Present Absent Unknown
Gender	Gender: Details about the gender of an individual.
Data
Sex at birth	Sex at birth: The sex of an individual determined by anatomical characteristics observed and registered at birth. For example: 'Male', 'Female', 'Intersex'. Coding with a terminology is recommended, where possible. Use the element 'Comment' or the SLOT 'Details' if needed to register more specific details of the individuals gender.
Frailty score	Frailty score: An assessment scale used to screen for frailty and to broadly stratify degrees of fitness and frailty in an older adult. Also known as the Rockwood Clinical Frailty Scale.
Data
Any point in time event	Any point in time event: Default, unspecified point in time event which may be explicitly defined in a template or at run-time.
Data
Assessment	Assessment: Assessed level of frailty. 1: Very Fit 2: Well 3: Managing Well 4: Vulnerable 5: Mildly Frail 6: Moderately Frail 7: Severely Frail 8: Very Severely Frail 9: Terminally Ill
Body weight	Body weight: Measurement of the body weight of an individual.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Weight	Weight: The weight of the individual. 0..1000; 0..2000; 0..1000000 Units: kg lbm (UCUM: [lb_av]) g
Body height	Body height: Height, or body length, is measured from crown of head to sole of foot. Height is measured with the individual in a standing position and body length in a recumbent position.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Height/Length	Height/Length: The length of the body from crown of head to sole of foot. 0..1000; 0..250 Units: cm in (UCUM: [in_i])
Epidemiological factors	Epidemiological factors: A generic section header which should be renamed in a template to suit a specific clinical context.
Exposure screening questionnaire	Exposure screening questionnaire: A screening questionnaire about potential exposure to a chemical, physical or biological agent which has caused or may cause harm to an individual.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Agent	Agent: The name of the chemical, physical or biological agent to which an individual may have been exposed. Coding of 'Agent' with a terminology is preferred, where possible. Free text should be used only if there is no appropriate terminology available. For example: 2019-nCoV; or HIV. COVID-19
Specific exposure	Specific exposure: Details about each possible specific exposure circumstance.
Exposure situation	Exposure situation: The circumstance of possible exposure. For example: Travel to an 'at risk' location; exposure to infected body fluids; or worked as a dental technician. Coding of 'Exposure situation' with a terminology is preferred, where possible. Did the patient knowingly have contact with a person with probable or proven Covid-19 disease within 14 days before the onset of his/her symptoms?
Presence	Presence: Presence of the exposure situation. Present Absent Unknown
Complication	Complication: A generic section header which should be renamed in a template to suit a specific clinical context.
Complication	Complication: An screeing questionnaire for conditions, including problems and diagnoses.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Thromboembolic events	Thromboembolic events: Grouping of data elements related to screening for a single condition.
Complication name	Complication name: Name of the condition being screened. Venous thrombosis Pulmonary embolism Stroke Myocardial infarction
Presence?	Presence?: Presence of the condition. Present Absent Unknown
Infectious disease of lung	Infectious disease of lung: Grouping of data elements related to screening for a single condition.
Complication name	Complication name: Name of the condition being screened. Infectious disease of lung
Presence?	Presence?: Presence of the condition. Present Absent Unknown
Infectious agent in blood stream	Infectious agent in blood stream: Grouping of data elements related to screening for a single condition.
Complication name	Complication name: Name of the condition being screened. Infectious agent in blood stream
Presence?	Presence?: Presence of the condition. Present Absent Unknown
Other	Other: Grouping of data elements related to screening for a single condition.
Complication name	Complication name: Name of the condition being screened.
Presence?	Presence?: Presence of the condition. Present Absent Unknown
Onset of illness/Admission	Onset of illness/Admission: A generic section header which should be renamed in a template to suit a specific clinical context.
Problem/Diagnosis	Problem/Diagnosis: Details about a single identified health condition, injury, disability or any other issue which impacts on the physical, mental and/or social well-being of an individual. Clear delineation between the scope of a problem versus a diagnosis is not easy to achieve in practice. For the purposes of clinical documentation with this archetype, problem and diagnosis are regarded as a continuum, with increasing levels of detail and supportive evidence usually providing weight towards the label of 'diagnosis'.
Data
Problem/Diagnosis name	Problem/Diagnosis name: Identification of the problem or diagnosis, by name. Coding of the name of the problem or diagnosis with a terminology is preferred, where possible. COVID-19
Stage at diagnosis	Stage at diagnosis: Additional narrative about the problem or diagnosis not captured in other fields. Uncomplicated phase Complicated phase Critical phase Recovery phase Dead
Laboratory values	Laboratory values: A generic section header which should be renamed in a template to suit a specific clinical context.
Laboratory value	Laboratory value: The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Test name	Test name: Name of the laboratory investigation performed on the specimen(s). A test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'. CRP Ferritin Bilirubin D-dimer Gamma glutamyl transferase Aspartate aminotransferase Lactate dehydrogenase Cardiac troponin Hemoglobin Creatinine Lactate Leukocytes Lymphocytes Neutrophils Partial thromboplastin time Platelets INR Albumin in serum Antithrombin Procalcitonin Interleukin 6 Natriuretic peptide.B prohormone N-Terminal Fibrinogen
Laboratory analyte result	Laboratory analyte result: The result of a laboratory test for a single analyte value.
Analyte name	Analyte name: The name of the analyte result. The value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies. Optional[{fhir_mapping=Observation.code, hl7v2_mapping=OBX.3}] CRP Ferritin Bilirubin D-dimer Gamma glutamyl transferase Aspartate aminotransferase Lactate dehydrogenase Cardiac troponin Hemoglobin Creatinine Lactate Leukocytes Lymphocytes Neutrophils Partial thromboplastin time Platelets INR Albumin in serum Antithrombin Procalcitonin Interleukin 6 Natriuretic peptide.B prohormone N-Terminal Fibrinogen
SARS-CoV-2-RT-PCR	SARS-CoV-2-RT-PCR: The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Test name	Test name: Name of the laboratory investigation performed on the specimen(s). A test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'. SARS-CoV-2-RT-PCR
Laboratory analyte result	Laboratory analyte result: The result of a laboratory test for a single analyte value.
Analyte name	Analyte name: The name of the analyte result. The value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies. Optional[{fhir_mapping=Observation.code, hl7v2_mapping=OBX.3}] SARS-CoV-2-RT-PCR
SARS-CoV-2 antibodies	SARS-CoV-2 antibodies: The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Test name	Test name: Name of the laboratory investigation performed on the specimen(s). A test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'. SARS-CoV-2 antibodies
Laboratory analyte result	Laboratory analyte result: The result of a laboratory test for a single analyte value.
Analyte name	Analyte name: The name of the analyte result. The value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies. Optional[{fhir_mapping=Observation.code, hl7v2_mapping=OBX.3}] SARS-CoV-2 IgG SARS-CoV-2 IgM
Medication	Medication: A generic section header which should be renamed in a template to suit a specific clinical context.
COVID-19 therapy	COVID-19 therapy: An individual- or self-reported questionnaire screening for use of any medication or class of medication.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Screening purpose	Screening purpose: The reason for overall screening. For example: screening for previous use of a class lof medications, such as bisphosphonates.
Specific medication	Specific medication: Details about the use of a specific medication.
Medication name	Medication name: Name of medication. For example: Oxycodone. Antipyretics Corticosteroids Atazanavir Darunavir Chloroquine phosphate Hydroxychloroquine Ivermectin Lopinavir/ritonavir Ganciclovir Oseltamivir Remdesivir Ribavirin Camostat Favipiravir Convalescent plasma Steroids (> 0.5 mg/kg prednisone equivalents) Steroids (<= 0.5 mg/kg prednisone equivalents) Tocilizumab Sarilumab CNI or mTor inhibitors (e.g. cyclosporin A, tacrolimus, sirolimus, everolimus) Anti-TNF-alpha inhibitors (e.g. adalimumab, etanercept) Il1-receptor antangonists Ruxolitinib Colchicine Interferone (any) 25-Hydroxyvitamin D Zinc
Medication status	Medication status: Is the individual using the specific medication? Coded Text Currently used Never used Used in the past Unknown Text
Comment	Comment: Additional narrative about the medication use screening, not captured in other fields.
ACE inhibitors	ACE inhibitors: An individual- or self-reported questionnaire screening for use of any medication or class of medication.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Screening purpose	Screening purpose: The reason for overall screening. For example: screening for previous use of a class lof medications, such as bisphosphonates.
Medication class	Medication class: Details about the use of a specific class of medication. Use another instance of this CLUSTER to represent a subclass of medication.
Class name	Class name: Name of class or subclass of medication. For example: opioid drugs; or NSAIDs. ACE inhibitors
Class status	Class status: Is the individual using the class of medication? Coded Text Currently used Never used Used in the past Unknown Text
Specific medication	Specific medication: Details about the use of a specific medication.
Medication name	Medication name: Name of medication. For example: Oxycodone. ACE-HEMMER, REIN ACE-Hemmer, rein Captopril Enalapril Lisinopril Perindopril Ramipril Quinapril Benazepril Cilazapril Fosinopril Trandolapril Spirapril Delapril Moexipril Temocapril Zofenopril Imidapril ACE-HEMMER, KOMBINATIONEN ACE-Hemmer und Diuretika Captopril und Diuretika Enalapril und Diuretika Lisinopril und Diuretika Perindopril und Diuretika Ramipril und Diuretika Quinapril und Diuretika Benazepril und Diuretika Cilazapril und Diuretika Fosinopril und Diuretika Delapril und Diuretika Moexipril und Diuretika Zofenopril und Diuretika Captopril und Hydrochlorothiazid Enalapril und Hydrochlorothiazid Lisinopril und Hydrochlorothiazid Ramipril und Hydrochlorothiazid Quinapril und Hydrochlorothiazid Benazepril und Hydrochlorothiazid Cilazapril und Hydrochlorothiazid Fosinopril und Hydrochlorothiazid Moexipril und Hydrochlorothiazid Zofenopril und Hydrochlorothiazid Perindopril und Indapamid Ramipril und Piretanid ACE-Hemmer und Calciumkanalblocker Enalapril und Lercanidipin Lisinopril und Amlodipin Perindopril und Amlodipin Ramipril und Felodipin Enalapril und Nitrendipin Ramipril und Amlodipin Trandolapril und Verapamil Delapril und Manidipin ACE-Hemmer, andere Kombinationen Perindopril, Amlodipin und Indapamid Perindopril und Bisoprolol Ramipril, Amlodipin und Hydrochlorothiazid Perindopril, Bisoprolol und Amlodipin
Medication status	Medication status: Is the individual using the specific medication? Coded Text Currently used Never used Used in the past Unknown Text
Immunoglobulins	Immunoglobulins: An individual- or self-reported questionnaire screening for use of any medication or class of medication.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Screening purpose	Screening purpose: The reason for overall screening. For example: screening for previous use of a class lof medications, such as bisphosphonates.
Medication class	Medication class: Details about the use of a specific class of medication. Use another instance of this CLUSTER to represent a subclass of medication.
Class name	Class name: Name of class or subclass of medication. For example: opioid drugs; or NSAIDs. Immunoglobulins
Class status	Class status: Is the individual using the class of medication? Coded Text Currently used Never used Used in the past Unknown Text
Specific medication	Specific medication: Details about the use of a specific medication.
Medication name	Medication name: Name of medication. For example: Oxycodone. IMMUNGLOBULINE Immunglobuline, normal human Immunglobuline, normal human, zur extravasalen Anwendung Immunglobuline, normal human, zur intravasalen Anwendung Spezifische Immunglobuline Anti-D(rh)-Immunglobulin Tetanus-Immunglobulin Varicella/Zoster-Immunglobulin Hepatitis-B-Immunglobulin Tollwut-Immunglobulin Röteln-Immunglobulin Kuhpocken-Immunglobulin Staphylococcus-Immunglobulin Cytomegalievirus-Immunglobulin Diphtherie-Immunglobulin Hepatitis-A-Immunglobulin FSME-Immunglobulin Pertussis-Immunglobulin Masern-Immunglobulin Mumps-Immunglobulin Palivizumab Motavizumab Raxibacumab Anthrax-Immunglobulin Bezlotoxumab Obiltoxaximab Kombinationen Andere Immunglobuline Nebacumab Andere Immunglobuline
Medication status	Medication status: Is the individual using the specific medication? Coded Text Currently used Never used Used in the past Unknown Text
Anticoagulation	Anticoagulation: An individual- or self-reported questionnaire screening for use of any medication or class of medication.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Screening purpose	Screening purpose: The reason for overall screening. For example: screening for previous use of a class lof medications, such as bisphosphonates.
Specific medication	Specific medication: Details about the use of a specific medication.
Medication name	Medication name: Name of medication. For example: Oxycodone. Unfractionated heparin Low molecular weight heparin Argatroban Platelet aggregation inhibitor Danaparoid Phenprocoumon Direct oral anticoagulants
Medication status	Medication status: Is the individual using the specific medication? Coded Text Currently used Never used Used in the past Unknown Text
Other (Thrombosis prophylaxis/Therapeutic anticoagulation)	Other (Thrombosis prophylaxis/Therapeutic anticoagulation): Details about the use of a specific medication.
Medication name	Medication name: Name of medication. For example: Oxycodone.
Medication status	Medication status: Is the individual using the specific medication? Coded Text Currently used Never used Used in the past Unknown Text
Outcome at discharge	Outcome at discharge: A generic section header which should be renamed in a template to suit a specific clinical context.
Episode of care - institution	Episode of care - institution: Administrative details about a period of admitted patient care between a formal or statistical admission and a formal or statistical separation, characterised by only one care type of care from a healthcare institution.
Data
Respiratory outcome	Respiratory outcome: Outcome for the individual at the end of the episode. For example: recovered/not recovered/death. On ventilator Not on ventilator
Type of discharge	Type of discharge: The category of destination after discharge. For example: home; hospital; nursing home; or rehabilitation hospital. Alive Admission to hospital Referral to other institution Death Palliative discharge Unknown
Follow-up swab result	Follow-up swab result: The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Test name	Test name: Name of the laboratory investigation performed on the specimen(s). A test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'. SARS-CoV-2-RT-PCR
Comment	Comment: Additional narrative about the test result not captured in other fields.
Study enrollment/Inclusion criteria	Study enrollment/Inclusion criteria: A generic section header which should be renamed in a template to suit a specific clinical context.
Symptoms	Symptoms: A generic section header which should be renamed in a template to suit a specific clinical context.
Symptom/sign screening questionnaire	Symptom/sign screening questionnaire: An individual- or self-reported questionnaire screening for symptoms and signs.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Presence of any symptoms or signs?	Presence of any symptoms or signs?: Presence of any relevant symptoms or signs. Present Absent Unknown
Specific symptom/sign	Specific symptom/sign: Grouping of data elements related to screening for a single symptom or sign.
Symptom or sign name	Symptom or sign name: Name of the symptom or sign being screened. Loss of taste or smell Abdominal pain Clouded consciousness Diarrhea Vomiting Cough Dyspnea Nausea Fever Headache
Presence?	Presence?: Presence of the symptom or sign. Present Absent Unknown
Symptom/Sign	Symptom/Sign: Reported observation of a physical or mental disturbance in an individual.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Symptom/Sign name	Symptom/Sign name: The name of the reported symptom or sign. Symptom name should be coded with a terminology, where possible. Loss of taste or smell Abdominal pain Clouded consciousness Diarrhea Vomiting Cough Dyspnea Nausea Fever Headache
Severity category	Severity category: Category representing the overall severity of the symptom or sign. Defining values such as mild, moderate or severe in such a way that is applicable to multiple symptoms or signs plus allows multiple users to interpret and record them consistently is not easy. Some organisations extend the value set further with inclusion of additional values such as 'Trivial' and 'Very severe', and/or 'Mild-Moderate' and 'Moderate-Severe', adds to the definitional difficulty and may also worsen inter-recorder reliability issues. Use of 'Life-threatening' and 'Fatal' is also often considered as part of this value set, although from a pure point of view it may actually reflect an outcome rather than a severity. In view of the above, keeping to a well-defined but smaller list is preferred and so the mild/moderate/severe value set is offered, however the choice of other text allows for other value sets to be included at this data element in a template. Note: more specific grading of severity can be recorded using the 'Specific details' SLOT. Mild Moderate Severe Life threatening
Therapy	Therapy: A generic section header which should be renamed in a template to suit a specific clinical context.
Management/treatment	Management/treatment: An individual- or self-reported questionnaire screening for management or treatment carried out.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Management/treatment activity	Management/treatment activity: Grouping of data elements related to screening for a single management or treatment activity.
Activity name	Activity name: Name of the management or treatment activity being screened. Dialysis/hemofiltration Apheresis Prone position ECMO therapy Intensive care unit admission
Presence	Presence: The current status of a specific activity. Present Absent Unknown
Ventilation type	Ventilation type: An individual- or self-reported questionnaire screening for management or treatment carried out.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Management/treatment activity	Management/treatment activity: Grouping of data elements related to screening for a single management or treatment activity.
Ventilation type	Ventilation type: Name of the management or treatment activity being screened. Nasal High-Flow-Oxygen-Therapy Non-invasive ventilation Invasive ventilation (orotracheal) Invasive ventilation (Tracheotomy)
Presence	Presence: The current status of a specific activity. Present Absent Unknown
Vital signs	Vital signs: A generic section header which should be renamed in a template to suit a specific clinical context.
Blood gas analysis	Blood gas analysis: The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Test name	Test name: Name of the laboratory investigation performed on the specimen(s). A test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'. Blood gas analysis
Laboratory analyte result	Laboratory analyte result: The result of a laboratory test for a single analyte value.
Analyte name	Analyte name: The name of the analyte result. The value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies. Optional[{fhir_mapping=Observation.code, hl7v2_mapping=OBX.3}] PaCO2 PaO2 pH
State
Inspired oxygen	Inspired oxygen: The amount of oxygen being delivered, or to be delivered, to the patient given as a fraction, percentage or indirectly as a flow rate.
FiO₂	FiO₂: Fraction of oxygen in inspired air. For example: '0.28'. Unitary
SOFA score	SOFA score: A scoring system to grade and follow the development of organ dysfunction in six vital organ systems. Previously known as "Sepsis related Organ Failure Assessment".
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Cardiovascular system	Cardiovascular system: The mean arterial pressure (MAP), or the need for vasopressors (VP), (dopamine (DA), adrenaline (A), noradrenaline (NA) or dobutamine) are indicators for a possible dysfunction of the cardiovascular system. 0: MAP ≥ 70 mmHg 1: MAP < 70 mmHg 2: DA ≤ 5; Dobutamine 3: DA > 5; NA/A ≤ 0.1 4: NA/A > 0.1
Central nervous system	Central nervous system: The Glasgow Coma Scale (GCS) is an indicator for a possible dysfunction of the central nervous system. 0: GCS 15 1: GCS 13 - 14 2: GCS 10 - 12 3: GCS 6 - 9 4: GCS < 6
Renal function	Renal function: Creatinine concentration and 24 h urine output (UOP) are indicators for a possible dysfunction of the central nervous system. In some localities, creatinine concentration is measured in μmol/L. 0: Creatinine < 1.2 mg/dL 1: Creatinine 1.2-1.9 mg/dL 2: Creatinine 2.0-3.4 mg/dL 3: Creatinine 3.5-4.9 mg/dL or UOP < 500 mL/24h 4: Creatinine ≥ 5.0 mg/dL or UOP < 200 mL/24h
Liver function	Liver function: Bilirubin concentration is an indicator for a possible dysfunction of the central nervous system. In some localities, bilirubin concentration is measured in μmol/L. 0: Bilirubin < 1.2 mg/dL 1: Bilirubin 1.2-1.9 mg/dL 2: Bilirubin 2.0-5.9 mg/dL 3: Bilirubin 6.0-11.9 mg/dL 4: Bilirubin ≥ 12.0 mg/dL
Blood clotting	Blood clotting: Platelets concentration is an indicator for a possible dysfunction of the blood clotting system. 0: Platelets ≥ 150 (x10³/µL) 1: Platelets < 150 (x10³/µL) 2: Platelets < 100 (x10³/µL) 3: Platelets < 50 (x10³/µL) 4: Platelets < 20 (x10³/µL)
Total score	Total score: The total sum of each component parameter for the SOFA score. 0..24
Respiration	Respiration: The characteristics of spontaneous breathing by an individual.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Respiratory rate	Respiratory rate: The frequency of spontaneous breathing. 0..200 /min
Blood pressure	Blood pressure: The local measurement of arterial blood pressure which is a surrogate for arterial pressure in the systemic circulation. Most commonly, use of the term 'blood pressure' refers to measurement of brachial artery pressure in the upper arm.
Data	Data: History Structural node.
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Systolic	Systolic: Peak systemic arterial blood pressure - measured in systolic or contraction phase of the heart cycle. 0..1000 mmHg (UCUM: mm[Hg])
Diastolic	Diastolic: Minimum systemic arterial blood pressure - measured in the diastolic or relaxation phase of the heart cycle. 0..1000 mmHg (UCUM: mm[Hg])
Pulse/Heart beat	Pulse/Heart beat: The rate and associated attributes for a pulse or heart beat.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Heart rate	Heart rate: The rate of the pulse or heart beat, measured in beats per minute. 0..1000 /min
Body temperature	Body temperature: A measurement of the body temperature, which is a surrogate for the core body temperature of the individual.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Temperature	Temperature: The measured temperature. 0..100; 30..200 Units: °C (UCUM: Cel) °F (UCUM: [degF])
Peripheral oxygen saturation	Peripheral oxygen saturation: Blood oxygen and related measurements, measured by pulse oximetry or pulse CO-oximetry.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
SpO₂	SpO₂: The saturation of oxygen in the peripheral blood, measured via pulse oximetry. SpO₂ is defined as the percentage of oxyhaemoglobin (HbO₂) to the total concentration of haemoglobin (HbO₂ + deoxyhaemoglobin) in peripheral blood. Percent