ARCHETYPE Maternal gynaecological problem (openEHR-EHR-EVALUATION.problem_diagnosis-gyn_md.v1)

ARCHETYPE IDopenEHR-EHR-EVALUATION.problem_diagnosis-gyn_md.v1
ConceptMaternal gynaecological problem
DescriptionAny health care condition which may impact on the physical, mental and/or social well-being of an individual, that may require diagnostic, therapeutic or educational action, and which has been determined by a clinician. A diagnosis is based on scientific evaluation of physical signs, symptoms, history, laboratory tests results, and procedures.!
UseUse to record detailed information about problems or diagnoses recognised by a clinician. There are many uses including: recording a diagnosis during an encounter; populating a Problem List or a Summary statement, such as a Discharge Summary. Use to record all problems or diagnoses, including those with context-specific qualifiers such as past/present, primary/secondary, active/inactive etc. These qualifiers can be archetyped separately and included in the ‘Status’ slot, because their use varies in different settings.
MisuseNot to be used for recording the 'Reason for Encounter' or 'Presenting Complaint' - which is information captured early in the encounter, usually prior to full assessment and will be represented using a separate EVALUATION archetype. Not to be used for recording Differential Diagnoses - use the EVALUATION.differential diagnosis archetype.
PurposeTo record details about a problem or diagnosis by a clinician.
ReferencesNEHTA Clinical data groups - Problem/Diagnosis V2.0 http://www.nehta.gov.au/data-group-library/data-specifications/dgl-problem-diagnosis.
Australian Standard AS 4700.6-2006 Implementation of Health Level Seven version 2.4 - Part 6: Referral, discharge and health record messaging.
CEN/TC 251/WGII prEN 13940-2:2009.3- Health informatics – System of concepts to support Continuity of care – Part 2: Health care process and workflow.
BS_EN_13940-1_2007 - British Standard. Health informatics - System of concepts to support continuity of care - Part 1: Basic concepts.
Swedish National Process model.
IHE Technical Framework Supplement – Patient Plan of Care (PPOC).
Royal Australian College of General Practitioners - Fact Sheet: Medical History
Mosby's Pocket Dictionary of Medicine, Nursing and Health Professional, 6th Edition, Mosby Elsevier, 2010
Copyrightcopyright (c) 2010 NEHTA
AuthorsIme avtorja: Sam Heard
Organizacija: Ocean Informatics
e-Pošta: sam.heard@oceaninformatics.com
Datum izvora: 23/04/2006
Other Details LanguageIme avtorja: Sam Heard
Organizacija: Ocean Informatics
e-Pošta: sam.heard@oceaninformatics.com
Datum izvora: 23/04/2006
OtherDetails Language Independent{references=NEHTA Clinical data groups - Problem/Diagnosis V2.0 http://www.nehta.gov.au/data-group-library/data-specifications/dgl-problem-diagnosis. Australian Standard AS 4700.6-2006 Implementation of Health Level Seven version 2.4 - Part 6: Referral, discharge and health record messaging. CEN/TC 251/WGII prEN 13940-2:2009.3- Health informatics – System of concepts to support Continuity of care – Part 2: Health care process and workflow. BS_EN_13940-1_2007 - British Standard. Health informatics - System of concepts to support continuity of care - Part 1: Basic concepts. Swedish National Process model. IHE Technical Framework Supplement – Patient Plan of Care (PPOC). Royal Australian College of General Practitioners - Fact Sheet: Medical History Mosby's Pocket Dictionary of Medicine, Nursing and Health Professional, 6th Edition, Mosby Elsevier, 2010, MD5-CAM-1.0.1=C816F35C61D7B25A525693CE90952F9B}
Keywordsissue, condition, problem, concern, diagnosis, criteria, illness
LifecycleAuthorDraft
Language useden
Citeable Identifier1075.67.1290
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John Bennett, NEHTA, Australia
Steve Bentley, NHS CfH, United Kingdom
Ian Bull, ACT Health, Australia
Sergio Carmona, Chile
Rong Chen, Cambio Healthcare Systems, Sweden
Stephen Chu, NEHTA, Australia (Editor)
Ed Conley, Cardiff University, United Kingdom
Matthew Cordell, NEHTA, Australia
Paul Donaldson, Nursing Informatics Australia, Australia
David Evans, Queensland Health, Australia
Peter Garcia-Webb, Australia
Anneke Goossen, Results4Care, Netherlands
Heather Grain, Llewelyn Grain Consulting, Australia
Evelyn Hovenga, EJSH Consulting, Australia
Eugene Igras, IRIS Systems Inc, Canada
Mary Kelaher, NEHTA, Australia
Eizen Kimura, Ehime University, Japan
Shinji Kobayashi, Ehime University, Japan
Robert L'egan, NEHTA, Australia
Heather Leslie, Ocean Informatics, Australia (Editor)
Hugh Leslie, Ocean Informatics, Australia (Editor)
Rohan Martin, Ambulance Victoria, Australia
David McKillop, NEHTA, Australia
Ian McNicoll, Ocean Informatics UK, United Kingdom
Chris Mitchell, RACGP, Australia
Stewart Morrison, NEHTA, Australia
Jörg Niggeman, Compugroup, Germany
Andrej Orel, Marand d.o.o., Slovenia
Camilla Preeston, Royal Australian College of General Practitioners, Australia
Cathy Richardson, NEHTA, Australia
Kylie Young, The Royal Australian College of General Practitioners, Australia, originalLanguage=en, translators=, subjectOfData=Mother, archetypeTranslationTree=null, topLevelToAshis={source=[], state=[], description=[], content=[], provider=[], ism_transition=[], events=[], details=[], identities=[], contacts=[], activities=[], relationships=[], context=[], capabilities=[], other_participations=[], data=[ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0002.1], code=at0002.1, itemType=ELEMENT, level=2, text=Problem/Diagnosis, description=Identification of the problem or diagnosis. It is desirable that this field should be coded using a terminology, wherever possible., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Obvezno, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Izbira:
  •  Besedilo
  •  Šifriran tekst
    Omejitev:
    New constraint
    [*]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0009], code=at0009, itemType=ELEMENT, level=2, text=Clinical description, description=Narrative description or comments about clinical aspects of the problem/diagnosis., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0010], code=at0010, itemType=ELEMENT, level=2, text=Date of onset, description=Estimated or actual date the problem/diagnosis began in the opinion of the clinician., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0037], code=at0037, itemType=ELEMENT, level=2, text=Age of onset, description=Age of the individual when the clinician assesses that the problem/diagnosis began. May be useful to persist in data in certain situations - for example, the age of onset of breast cancer which might later be used in decision support. or in situations where approximations of age based on calculations are not accurate enough, eg in infants under one year., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DURATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0044], code=at0044, itemType=SLOT, level=2, text=Anatomical location, description=Slot to contain detailed and structured anatomical location details., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Neobvezen, ponavljam, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Vključi:
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, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0018]/items[at0019], code=at0019, itemType=ELEMENT, level=3, text=Frequency, description=The frequency of occurrences or exacerbations of the problem/diagnosis., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_QUANTITY, bindings=null, values=Lastnost: Frequency
Enote:
  • /d
  • /yr
  • /h
  • /wk
  • /mo
  • /min
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