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changes.mady.by.user Dr. Lea Botermann

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changes.mady.by.user Tharsika Keßler

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Code

BEZEICHNUNG IM CODESYSTEM

Codesystem

106076001364528001Skin finding observable (findingobservable entity)SNOMED Clinical Terms

FHIR®-Mapping: 

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KONZEPT & WIEDERGABENAME

CODE

BEZEICHNUNG IM CODESYSTEM

CODESYSTEM

Auskultation

301272007

Chest auscultation finding (finding)

SNOMED Clinical Terms

Atemgeräusch

301273002

Abnormal breath sounds (finding)

SNOMED Clinical Terms

Atemfrequenz

17077006

Abnormal respiratory rate (finding)

SNOMED Clinical Terms

Einziehungen

3779400767909005

Retraction Chest wall retraction (finding)

SNOMED Clinical Terms

Thoraxkonfiguration

298706004

Finding of appearance of thorax (finding)

SNOMED Clinical Terms

Schlüsselbeine

298761006

Finding of clavicle structure (finding)

SNOMED Clinical Terms

...

Hepatosplenomegaly (disorder)
KONZEPT & WIEDERGABENAME

CODE

BEZEICHNUNG IM CODESYSTEM

CODESYSTEM

Anomalien

822987005 : { 116676008 = 21390004 , 363698007 = 818987002 } 

Finding of abdominopelvic segment of trunk (finding) : {Associated morphology (attribute)  = Developmental anomaly (morphologic abnormality) , Finding site (attribute) = Structure of abdominopelvic cavity (body structure) } 

SNOMED Clinical Terms

Nabelveränderungen

249537008

Umbilicus finding (finding)

SNOMED Clinical Terms

Leber- und Milzgröße

36760000

65476007 : { 363698007 = 10200004 , 363698007 = 62167004 }

Abnormal size (finding) : {Finding site (attribute) = Liver structure (body structure) , Finding site (attribute) = Splenic structure (body structure)}

SNOMED Clinical Terms

Hernien

128545000

Hernia of abdominal wall (disorder)

SNOMED Clinical Terms

...

Code

BEZEICHNUNG IM CODESYSTEM

Codesystem

364066008Cardiovascular observable (observable entity)SNOMED Clinical Terms

...

KONZEPT & WIEDERGABENAME

Code

BEZEICHNUNG IM CODESYSTEM

Codesystem

Herzfrequenz

361135004

Abnormal cardiac rate (finding)

SNOMED Clinical Terms

Herzrhythmus

698247007

Cardiac arrhythmia (disorder)

SNOMED Clinical Terms

Herztöne

123824001

Heart sounds abnormal (finding)

SNOMED Clinical Terms

Herznebengeräusche

88610006

Heart murmur (finding)

SNOMED Clinical Terms

Femoralispulse

274723005

50178004Abnormal femoral pulse (findingFemoral bruit present (situation)

SNOMED Clinical Terms


Untersuchung - Ohren

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CodeBEZEICHNUNG IM CODESYSTEMCodesystem
247234006363991003Ear observable (observable entity)SNOMED Clinical Terms

...

KONZEPT & WIEDERGABENAMECodeBEZEICHNUNG IM CODESYSTEMCodesystem
Asymmetrien

422949007

Musculoskeletal asymmetry (finding)

SNOMED Clinical Terms

Schiefhaltung

43029002

Abnormal posture (finding)

SNOMED Clinical Terms

Spontanmotorik

225606002

Abnormal movement (finding)

SNOMED Clinical Terms

Muskeltonus

366725004

Finding of muscle tone (finding)

SNOMED Clinical Terms

Opisthotonus

8652009

Opisthotonus (finding)

SNOMED Clinical Terms

passive Beweglichkeit der großen Gelenke

298180004

Finding of range of joint movement (finding)

SNOMED Clinical Terms

Muskeleigenreflexe

366420008

Peripheral reflex finding (finding)

SNOMED Clinical Terms

Handgreifreflex

366142003299745004 + 299746003

Palmar reflex absent (finding) + Palmar reflex equivocal (finding)

SNOMED Clinical Terms

Moro-Reaktion299742001 + 299743006

Moro reflex absent (finding) + Moro reflex equivocal (finding)

SNOMED Clinical Terms

Saugreflex

299756004299757008 + 299758003

Sucking reflex present absent (finding) + Sucking reflex equivocal (finding)

SNOMED Clinical Terms

klinische Frakturzeichen

404684003 : 116676008 = 72704001

Clinical finding (finding) : Associated morphology (attribute) = Fracture (morphologic abnormality)

SNOMED Clinical Terms

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KONZEPT & WIEDERGABENAMECodeBEZEICHNUNG IM CODESYSTEMCodesystem
Fehlhaltung

70070008

111235007

Musculoskeletal disorder of the neck Torticollis (disorder)

SNOMED Clinical Terms

Dysmorphiezeichen

253978002

Dysmorphic features (finding)

SNOMED Clinical Terms

Schädelnähte

248387005

Cranial suture finding (finding)

SNOMED Clinical Terms

Kephalhämatom

206200000

Cephalhematoma due to birth trauma (disorder)

SNOMED Clinical Terms

Fontanellentonus

366372002

Finding of level of fontanelle (finding)

SNOMED Clinical Terms

Crepitatio capitis

23149001 : 363698007 = 783207002

Bone crepitus (finding) : Finding site (attribute) = Bone and/or joint structure of cranium (body structure)

SNOMED Clinical Terms

lagebedingte Schädelasymmetrie

293291000119108

Acquired postural plagiocephaly (disorder)

SNOMED Clinical Terms

...

CodeBEZEICHNUNG IM CODESYSTEMCodesystem
271914002 + 364111005Ear, nose and throat examination finding (observable entity)  + Oral cavity observable (observable entity301310005Finding of face (finding)SNOMED Clinical Terms

FHIR®-Mapping: 

Wert: Code

KONZEPT & WIEDERGABENAMECodeBEZEICHNUNG IM CODESYSTEMCodesystem
Auffälligkeiten der Schleimhaut und des Kieferkamms

300255008

Oral cavity problem (finding)

SNOMED Clinical Terms

Kiefer- Gaumenanomalie

449790007

Orofacial cleft (disorder)

SNOMED Clinical Terms

Verletzungszeichen

125593007

Injury of face (disorder)

SNOMED Clinical Terms

abnorme Größe der Zunge

366233004

Finding of size of tongue (finding

65476007 : 363698007 = 21974007

Abnormal size (finding) : Finding site (attribute) = Tongue structure (body structure)

SNOMED Clinical Terms

behinderte Nasenatmung

232209000

Nasal obstruction (disorder)

SNOMED Clinical Terms

orofacialer Hypotonus

367381002

Weak mouth closure (finding)

SNOMED Clinical Terms


Untersuchung - Augen

Hinweistext aus der Papierversion des U-Heftes: Inspektion:

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