ARCHETYPE Problem List (openEHR-EHR-COMPOSITION.problem_list.v1)

ARCHETYPE IDopenEHR-EHR-COMPOSITION.problem_list.v1
ConceptProblem List
DescriptionA persistent and managed list of diagnoses identified or problems experienced by the subject, or procedures performed, that may influence clinical decision-making and care provision.
UseUse to record a persistent and managed list of diagnoses identified or problems experienced by the subject, or previous procedures performed, that may influence clinical decision-making and care provision. This list can be utilised as a source of up-to-date problem list data for exchange or as the basis for decision support. This list can be comprised of three types of archetype: - statements about the positive presence of problems, diagnoses or previous procedures are recorded using the EVALUATION.problem_diagnosis and/or ACTION.procedure archetypes; OR - a statement about the positive exclusion of medication use can be recorded using the specific EVALUATION.exclusion-problem_diagnosis or EVALUATION.exclusion-procedure archetypes - for example: "No significant problems or diagnoses" or No history of significant operations or procedures"; OR - a statement about no information being available - neither a positive presence of a problem, diagnosis or procedure performed nor a positive exclusion - can be recorded using the EVALUATION.absence archetype. In order for this list to be accurate and safe to use as the basis for decision support activities and for exchange, this Problem List should ideally be curated by a clinician responsible for the health record, rather than managed automatically by the clinical system through business rules alone.
PurposeTo record a persistent and managed list of diagnoses identified or problems experienced by the subject, or previous procedures performed, that may influence clinical decision-making and care provision.
References
Copyright© openEHR Foundation
AuthorsIme avtorja: Sam Heard
Organizacija: Ocean Informatics, Australia
e-Pošta: sam.heard@oceaninformatics.com
Datum izvora: 2013-02-19
Other Details LanguageIme avtorja: Sam Heard
Organizacija: Ocean Informatics, Australia
e-Pošta: sam.heard@oceaninformatics.com
Datum izvora: 2013-02-19
OtherDetails Language Independent{current_contact=Heather Leslie, Ocean Informatics, heather.leslie@oceaninformatics.com, MD5-CAM-1.0.1=BFA848F52FAB6BB43DD1E6A9249D11DF}
Keywordsproblem, list, diagnosis, diagnoses, procedure
LifecycleCommitteeDraft
Language useden
Citeable Identifier1075.67.575
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Heather Leslie, Ocean Informatics, Australia
Sistine Barretto-Daniels, Ocean Informatics, Australia, originalLanguage=en, translators=Korean: Seung-Jong Yu, Yonsei FM Clinic, Medical Doctor
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