Generated Narrative: Composition example-iv-4a-composition
Profile: Diabetes Composition
Country of Affiliation: AT
status: Final
type: Patient Summary
date: 2025-03-22 11:01:30+0100
author: APS Generator
title: Patient Summary
custodian: Zentrale Anwendung APS
Ramipril 5 mg 1-0-0-0, Start 15.06.2016
Metformin 500 mg 1-0-1-0, Start 09.04.2023
Allergie gegen Benzylpenicillin-Natrium.
Diabettes mellitus Typ 2
Arterielle Hypertonie
Adipositas
Familienanamnese: Vorzeitige koronare Herzerkrankung, Diabetes mellitus
Totalersatz des linken Hüftgelenks
Hüftprothese
Impfung gegen Diphtherie-Pertussis-Poliomyelitis-Tetanus
Glucose im kapillaren Blut 1h postprandial
Hemoglobin A1c/Hemoglobin im Blut: 8.1 %
Kreatinin in Serum: 1.2 mg/dL
Körpergröße: 173 cm
Körpergewicht: 90 kg
BMI: 30.07 (high)
Blutdruck 180 / 80
Herzfrequenz 100
Masernerkrankung in der Kindheit.
Behandlungsplan Vorsorge: Laboruntersuchung
Behandlungsplan Diabetes: Patientenschulung und Ernährungsberatung, Augenuntersuchung
Ehemaliger Raucher, Person
Alkoholische Getränke pro Tag, 1-2 Gläser Wein/Bier
Körperliche Aktivität 2,5h/Wo
Generated Narrative: Patient 001
Profile: AT APS Patient
Anton Testpatient Male, DoB: 1953-11-12 ( Social Security number: 1234121153)
| Marital Status: | Married | ||
| Other Id: | Patient internal identifier/0002 | ||
| Contact Detail | Rotenturmstraße 14 Wien 1010 AUT (home) | ||
Generated Narrative: Practitioner example-iv-4a-practitioner-iv
Profile: AT APS Practitioner
name: Melanie IV Diätologin
address: Praterstern 5 Wien 1020
Generated Narrative: Practitioner example-iv-4a-practitioner-1
Profile: AT APS Practitioner
name: Hanna Hausärztin
address: Treustraße 38 Wien 1200
Generated Narrative: Organization example-iv-4a-organization
Profile: AT APS Organization
name: Zentrale Anwendung APS, BMSGPK
address: Stubenring 1 Wien 1010
Generated Narrative: MedicationStatement example-iv-4a-medication-summary-1
Profile: AT APS MedicationStatement
status: Active
medication: RAMIPRIL 1A TBL 5MG
subject: Anton Testpatient
effective: 2016-11-02 11:00:05+0200 --> (ongoing)
dosage
sequence: 1
text: S:0-0-1-0
route: Orale Einnahme
DoseAndRates
Dose[x] 2 Tablet (Details: elga-medikationmengenart code{TAB} = '{TAB}')
Generated Narrative: MedicationStatement example-iv-4a-medication-summary-2
Profile: AT APS MedicationStatement
status: Active
medication: METFORMIN HEX FTBL 500MG
subject: Anton Testpatient
effective: 2023-03-17 08:00:00+0100 --> (ongoing)
dosage
sequence: 1
text: S:0-0-1-0
route: Orale Einnahme
DoseAndRates
Dose[x] 2 Tablet (Details: elga-medikationmengenart code{TAB} = '{TAB}')
Generated Narrative: AllergyIntolerance example-iv-4a-allergy-1
Profile: AT APS AllergyIntolerance
clinicalStatus: Active
criticality: High Risk
code: Benzylpenicillin-Natrium
patient: Anton Testpatient
asserter: Dr. Hausärztin
Generated Narrative: Condition example-iv-4a-problem-1
Profile: AT APS Condition
clinicalStatus: Active
verificationStatus: Confirmed
category: Problem List Item
code: Arterielle Hypertonie
subject: Anton Testpatient
recordedDate: 2016-11-01 08:30:00+0100
asserter: Dr. Hanna Hausärztin
Generated Narrative: Condition example-iv-4a-problem-2
Profile: AT APS Condition
clinicalStatus: Active
verificationStatus: Confirmed
category: Problem List Item
code: Adipositas
subject: Anton Testpatient
recordedDate: 2016-11-01 08:30:00+0100
asserter: Dr. Hanna Hausärztin
Generated Narrative: Condition example-iv-4a-problem-3
Profile: AT APS Condition
clinicalStatus: Active
verificationStatus: Confirmed
category: Problem List Item
code: Diabetes mellitus Typ 2
subject: Anton Testpatient
recordedDate: 2023-03-17 08:00:00+0100
asserter: Dr. Hanna Hausärztin
Generated Narrative: Condition example-iv-4a-problem-4
Profile: AT APS Condition
clinicalStatus: Active
verificationStatus: Confirmed
category: Problem List Item
code: Familienanamnese: vorzeitige koronare Herzkrankheit
subject: Anton Testpatient
recordedDate: 2022-02-08 08:30:00+0100
asserter: Dr. Hanna Hausärztin
Generated Narrative: Condition example-iv-4a-problem-5
Profile: AT APS Condition
clinicalStatus: Active
verificationStatus: Confirmed
category: Problem List Item
code: Familienanamnese: Diabetes mellitus in der Familie
subject: Anton Testpatient
recordedDate: 2022-02-08 08:30:00+0100
asserter: Dr. Hanna Hausärztin
Generated Narrative: Procedure example-iv-4a-procedure-history-1
Profile: AT APS Procedure
status: Completed
code: Totalersatz des linken Hüftgelenks
subject: Anton Testpatient
performed: 2020-12-23 08:30:00+0100
| Manipulated |
| Hüftprothese |
Generated Narrative: DeviceUseStatement example-iv-4a-medical-deviceUse-Hueftprothese
Profile: AT APS DeviceUseStatement
status: Active
subject: Anton Testpatient
timing: 2020-12-23 08:30:00+0100 --> (ongoing)
device: Implantat: Hüftprothese
bodySite: Gesamtes linkes Hüftgelenk
Generated Narrative: Device example-iv-4a-medical-device-Hueftprothese
Profile: AT APS Device
| Name | Type |
| Hüftprothese | other |
type: Hüftprothese
| Value |
| 123456 |
patient: Anton Testpatient
Generated Narrative: Immunization example-iv-4a-Immunization-1
Profile: AT APS Immunization
status: Completed
vaccineCode: BOOSTRIX POLIO FSPR 0,5ML
patient: Anton Testpatient
occurrence: 2025-01-08 14:31:30+0000
route: Intramuskulär
| Actor |
| Dr. Hanna Hausärztin |
protocolApplied
series: Standardimpfserie
targetDisease: Diphtheria, Pertussis, Poliomyelitis, Tetanus
doseNumber: 1
Generated Narrative: Observation example-iv-4a-diagnostic-result-1
status: Final
category: Laboratory
code: Glucose im kapillaren Blut 1h postprandial
subject: Anton Testpatient
effective: 2023-03-15 08:00:00+0100
performer: Dr. Hanna Hausärztin
value: 250 mg/dL (Details: UCUM codemg/dL = 'mg/dL')
specimen: Blutprobe
Generated Narrative: Observation example-iv-4a-diagnostic-result-2
status: Final
category: Laboratory
code: Hemoglobin A1c/Hemoglobin.total in Blood
effective: 2023-03-16 09:30:00+0100
performer: Amadeus Spital - Labor
value: 8.1 % (Details: UCUM code% = '%')
specimen: Blutprobe
Generated Narrative: Observation example-iv-4a-diagnostic-result-2
status: Final
category: Laboratory
code: Kreatinin in Serum
effective: 2023-03-16 09:30:00+0100
performer: Amadeus Spital - Labor
value: 1.2 mg/dL (Details: UCUM codemg/dL = 'mg/dL')
specimen: Blutprobe
Generated Narrative: Organization example-iv-4a-diagnostic-result-performer-1
Profile: AT APS Organization
name: Amadeus Spital - Labor
telecom: +43.1.3453446.0, fax: +43.1.3453446.4674, info@amadeusspital.at, https://www.amadeusspital.at
address: Währinger Gürtel 18-20 Wien 1090 AUT
Generated Narrative: Specimen example-iv-4a-diagnostic-specimen-1
Profile: AT APS Specimen
status: Unavailable
type: Blutprobe
subject: Anton Testpatient
Generated Narrative: Observation example-iv-4a-vital-sign-1
Profile: AT APS Observation Vital Signs
status: Final
category: Vital Signs
code: Körpergröße
subject: Anton Testpatient
effective: 2020-02-15 08:00:00+0100
performer: Dr. Hanna Hausärztin
value: 173 cm (Details: UCUM codecm = 'cm')
Generated Narrative: Observation example-iv-4a-vital-sign-2
Profile: AT APS Observation Vital Signs
status: Final
category: Vital Signs
code: Körpergewicht
subject: Anton Testpatient
effective: 2020-02-15 08:00:00+0100
performer: Dr. Hanna Hausärztin
value: 90 kg (Details: UCUM codekg = 'kg')
Generated Narrative: Observation example-iv-4a-vital-sign-3
Profile: AT APS Observation Vital Signs
status: Final
category: Vital Signs
code: Body Mass Index (BMI) [Verhältnis]
subject: Anton Testpatient
effective: 2020-02-15 08:00:00+0100
performer: Dr. Hanna Hausärztin
value: 30.07 kg/m2 (Details: UCUM codekg/m2 = 'kg/m2')
Generated Narrative: Observation example-iv-4a-vital-sign-4
Profile: AT APS Observation Vital Signs
status: Final
category: Vital Signs
code: Blood pressure panel with all children optional
subject: Anton Testpatient
effective: 2025-03-14 08:00:00+0100
performer: Dr. Hanna Hausärztin
component
code: Systolischer Blutdruck
value: 180 mm[Hg] (Details: UCUM codemm[Hg] = 'mm[Hg]')
component
code: Diastolischer Blutdruck
value: 80 mm[Hg] (Details: UCUM codemm[Hg] = 'mm[Hg]')
Generated Narrative: Observation example-iv-4a-vital-sign-5
Profile: AT APS Observation Vital Signs
status: Final
category: Vital Signs
code: Herzfrequenz
subject: Anton Testpatient
effective: 2025-03-14 08:00:00+0100
performer: Dr. Hanna Hausärztin
value: 100 /min (Details: UCUM code/min = '/min')
Generated Narrative: Condition example-iv-4a-illness-history-1
Profile: AT APS Condition
clinicalStatus: Resolved
verificationStatus: Confirmed
category: Problem List Item
code: Masern
subject: Anton Testpatient
recordedDate: 1960-01-02
asserter: Dr. Hanna Hausärztin
Generated Narrative: Appointment example-iv-4a-careplan-diabetes-eye-exam
status: Proposed
serviceCategory: Überweisung zum Facharzt
serviceType: Diabetes
specialty: Ophthalmology
appointmentType: CHECKUP
reasonReference: Diabetes mellitus Typ 2
description: Augenärztliche Kontrolle auf diabetische Retinopathie
created: 2023-03-17 08:00:00+0100
| Actor | Status |
| Anton Testpatient | Accepted |
requestedPeriod: 2023-03-17 --> 2023-04-17
Generated Narrative: Appointment example-iv-4a-careplan-diabetes-nutrition-training
status: Booked
serviceCategory: Patientenschulung und Ernährungsberatung bei Diabetes mellitus Typ II
serviceType: Diabetes Schulung
appointmentType: ROUTINE
reasonReference: Diabetes mellitus Typ 2
description: Diese Schulung beinhaltet detaillierte Ernährungsinformationten für Diabetes mellitus Typ II Patienten
start: 2023-03-20 08:00:00+0000
end: 2023-03-20 10:00:00+0000
created: 2023-03-17 08:00:00+0100
participant
actor: Anton Testpatient
status: Accepted
participant
actor: Dr. IV Diätologin
status: Accepted
Generated Narrative: Observation example-iv-4a-social-history-1
Profile: AT APS Observation Tobacco Use
status: Final
category: Lebensstil
code: Raucherstatus
subject: Anton Testpatient
effective: 2023-03-15 08:00:00+0100
performer: Dr. Hanna Hausärztin
value: Ehemalig rauchende Person
Generated Narrative: Observation example-iv-4a-social-history-2
Profile: AT APS Observation Alcohol Use
status: Final
category: Lebensstil
code: Alkoholische Getränke pro Tag, 1-2 Gläser Wein/Bier
subject: Anton Testpatient
effective: 2023-03-15 08:00:00+0100
performer: Dr. Hanna Hausärztin
value: 2 Gläser Wein pro Tag (Details: UCUM code/d = '/d')
Generated Narrative: Observation example-iv-4a-social-history-3
Profile: AT APS Observation
status: Final
category: Lebensstil
code: Körperliche Aktivität
subject: Anton Testpatient
effective: 2023-03-15 08:00:00+0100
performer: Dr. Hanna Hausärztin
value: >2.5 Stunden (Details: UCUM codeh = 'h')/1 Woche (Details: UCUM codewk = 'wk')