ARCHETYPE Problem/Diagnosis (openEHR-EHR-EVALUATION.problem_diagnosis.v1)

ARCHETYPE IDopenEHR-EHR-EVALUATION.problem_diagnosis.v1
ConceptProblem/Diagnosis
DescriptionAn issue or obstacle which adversely impacts on the physical, mental and/or social well-being of an individual. The definition of a problem is deliberately kept rather loose and inclusive of a formal biomedical diagnosis so as to capture any real or perceived concerns that may adversely affect an individual's wellbeing to any degree.
UseUse for recording any information about general health-related problems, diagnoses and nursing diagnoses. The archetype contains multiple dates, so can record present and/or past problems. A problem can be determined by either the individual themselves or a healthcare provider. Some examples: - A range of symptoms that are under investigation but pre-diagnosis - Desire to lose weight, without formal diagnosis of Obesity - Desire to quit smoking by individual - Relationship problem with family member.
PurposeFor recording details about an issue or obstacle that impacts on the physical, mental and/or social well-being of an individual, including a formal medical diagnosis, nursing diagnosis or problem.
References
Copyright© openEHR Foundation
AuthorsIme avtorja: Ian McNicoll
Organizacija: Ocean Informatics, UK
e-Pošta: ian.mcnicoll@oceaninformatics.com
Datum izvora: 2013-03-06
Other Details LanguageIme avtorja: Ian McNicoll
Organizacija: Ocean Informatics, UK
e-Pošta: ian.mcnicoll@oceaninformatics.com
Datum izvora: 2013-03-06
OtherDetails Language Independent{MD5-CAM-1.0.1=2CD426CD82409C217348260593A062A2}
Keywordsissue, condition, problem, obstacle, diagnosis, nursing diagnosis
LifecycleAuthorDraft
Language useden
Citeable Identifier1075.67.822
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=An issue or obstacle which adversely impacts on the physical, mental and/or social well-being of an individual. The definition of a problem is deliberately kept rather loose and inclusive of a formal biomedical diagnosis so as to capture any real or perceived concerns that may adversely affect an individual's wellbeing to any degree., archetypeConceptComment=null, otherContributors=Koray Atalag, University of Auckland, New Zealand
Steve Bentley, NHS CfH, United Kingdom
Ian Bull, ACT Health, Australia
Sergio Carmona, Chile
Rong Chen, Cambio Healthcare Systems, Sweden
Stephen Chu, NeHTA, Australia
Ed Conley, Cardiff University
Paul Donaldson, Nursing Informatics Australia, Australia
Anneke Goossen, Results 4 Care, Netherlands
Heather Grain, Llewelyn Grain Informatics, Australia
Sam Heard, Ocean Informatics, Australia
Evelyn Hovenga, EJSH Consulting, Australia
Eugene Igras, IRIS Systems, Inc., Canada
Eizen Kimura, Ehime Univ., Japan
Shinji Kobayashi, Ehime University, Japan
Heather Leslie, Ocean Informatics, Australia (Editor)
Rohan Martin, Ambulance Victoria, Australia
Ian McNicoll, Ocean Informatics, United Kingdom (Editor)
Jörg Niggemann, compugroup, Germany
Andrej Orel, Marand d.o.o., Slovenia, originalLanguage=en, translators=German: Jasmin Buck, Sebastian Garde, University of Heidelberg, Central Queensland University
Spanish (Argentina): Alan March, Hospital Universitario Austral, Buenos Aires, Argentina
Portuguese (Brazil): Marco Borges, P2D, marco.borges@p2d.com.br, P2D Health Advisor Council
Arabic (Syria): Mona Saleh
, subjectOfData=brez omejitev, 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], code=at0002, itemType=ELEMENT, level=2, text=Problem/Diagnosis, description=Identification of the index problem, issue or diagnosis., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Obvezno, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0009], code=at0009, itemType=ELEMENT, level=2, text=Description, description=A narrative description of the issue, problem or 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[at0005], code=at0005, itemType=ELEMENT, level=2, text=Severity, description=The assessed overall severity of the index problem., comment= Coding of the severity with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0003], code=at0003, itemType=ELEMENT, level=2, text=Date of Onset, description=The date / time when the problem was first identified by the individual., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=Celoten datum in čas, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0004], code=at0004, itemType=ELEMENT, level=2, text=Age at Onset, description=The age of the individual when the problem was first identified by the individual., 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[at0012], code=at0012, itemType=ELEMENT, level=2, text=Body Site, description=The body site affected., 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[at0039], code=at0039, itemType=SLOT, level=2, text=Body Site Details, description=Details of the body site concerned., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Vključi:
openEHR-EHR-CLUSTER.anatomical_location.v1 in specializacije, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0018], code=at0018, itemType=CLUSTER, level=2, text=Previous Occurrences, description=Grouping of information about individual occurrences or exacerbations., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=1..*, cardinalityText=razvrščen, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0018]/items[at0019], code=at0019, itemType=ELEMENT, level=3, text=Frequency, description=The frequency of individual occurrences of the problem., 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:
  • /min
  • >=0.0 /h
  • >=0.0 /d
  • >=0.0 /wk
  • >=0.0 /mo
  • >=0.0 /yr
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0018]/items[at0020], code=at0020, itemType=ELEMENT, level=3, text=Date of last Occurrence, description=The date / time of the last occurrence of the problem., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=Celoten datum in čas, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0018]/items[at0025], code=at0025, itemType=ELEMENT, level=3, text=Number, description=Number of times this problem has occurred or been apparent., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=min: >=1

, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0018]/items[at0022], code=at0022, itemType=ELEMENT, level=3, text=Description, description=A description of the exacerbation or occurrence., 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[at0027], code=at0027, itemType=CLUSTER, level=2, text=Related Item, description=A group of characteristics of the problem complicating the index problem., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Neobvezen, ponavljam, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0027]/items[at0029], code=at0029, itemType=ELEMENT, level=3, text=Relationship Type, description=The type of relationship that this problem/diagnosis has to the related item., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Caused by [This concept identifies the direct cause or causative agent of a Problem/Diagnosis. The concept includes the idea of ‘complications’, ‘causative agent’ and ‘due to’. Note: Where no causality or sequence of events is known, this relationship type should be left blank.]
  • Following [This value identifies the sequence of events between the related items, but does not assert causality. This can be used for sequelae or late effects. Note: Where no causality or sequence of events is known, this relationship type should be left blank.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0027]/items[at0028], code=at0028, itemType=ELEMENT, level=3, text=Item, description=Identification of a related problem as text,coded text or link within the EHR., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Izbira:
  •  Besedilo
  •  URI
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0027]/items[at0044], code=at0044, itemType=ELEMENT, level=3, text=Description, description=A narrative description of the related item., 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[at0030], code=at0030, itemType=ELEMENT, level=2, text=Date of Resolution, description=The date that the problem resolved or went into remission., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0031], code=at0031, itemType=ELEMENT, level=2, text=Age at Resolution, description=The age of the person at the resolution of the problem., 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[at0042], code=at0042, itemType=SLOT, level=2, text=Diagnostic Criteria, description=The criteria on which the problem/diagnosis is based., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Vključi:
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