ARCHETYPE Diagnostic summary (openEHR-EHR-EVALUATION.diagnostic_summary.v0)

ARCHETYPE IDopenEHR-EHR-EVALUATION.diagnostic_summary.v0
ConceptDiagnostic summary
DescriptionSummary information about examinations, tests or procedures performed with a diagnostic intent.
UseUse to record summary information about examinations, tests or procedures performed with a diagnostic intent. Use cases: Summary information in discharge notes, reporting, clinical synopsis etc.
MisuseNot to be used for recording an instruction for a procedure, test or examination to be perfomerd - use specific INSTRUCTION-archetypes for this purpose. Not to be used for recording the performing of a procedure, test or examination - use specific ACTION-archetypes for this purpose.
PurposeFor recording summary information about examinations, tests or procedures performed with a diagnostic intent.
References
Copyright© Nasjonal IKT HF
AuthorsForfatternavn: John Tore Valand
Organisasjon: Helse Bergen University Hospital
E-post: john.tore.valand@helse-bergen.no
Opprinnelig skrevet dato: 2017-12-22
Other Details LanguageForfatternavn: John Tore Valand
Organisasjon: Helse Bergen University Hospital
E-post: john.tore.valand@helse-bergen.no
Opprinnelig skrevet dato: 2017-12-22
OtherDetails Language Independent{licence=This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/., custodian_organisation=Nasjonal IKT, original_namespace=no.nasjonalikt, original_publisher=Nasjonal IKT, custodian_namespace=no.nasjonalikt, MD5-CAM-1.0.1=33D0C7172828A895C307BA2B13DBDCDF, build_uid=19de7a51-2adb-4aa4-ac31-71d9b1bdf69a, revision=0.0.1-alpha}
Keywordsreport
Lifecyclein_development
UID99b036f6-67ec-4862-a1e6-d554083ae436
Language useden
Citeable Identifier1078.36.2004
Revision Number0.0.1-alpha
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Summary information about examinations, tests or procedures performed with a diagnostic intent., archetypeConceptComment=null, otherContributors=Heather Leslie, Ocean Health Systems, Australia
Ingrid Heitmann, Oslo universitetssykehus HF, Norway
Mikkel Gaup Grønmo, FSE, Helse Nord, Norway
Vebjørn Arntzen, Oslo Univeristy Hospital HF, Norway
Silje Ljosland Bakke, Nasjonal IKT HF, Norway, originalLanguage=en, translators=, subjectOfData=ubegrenset, archetypeTranslationTree=null, topLevelToAshis={items=[], content=[], state=[], other_participations=[], credentials=[], ism_transition=[], contacts=[], description=[], capabilities=[], identities=[], data=[ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=2, text=Test name, description=Name of the examination, test or procedure performed., comment=It is recommended that 'Test name' should be coded with a terminology, where possible., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Valgfritt, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0003], code=at0003, itemType=ELEMENT, level=2, text=Description, description=Narrative description about the examination, test or procedure performed., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Valgfritt, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0004], code=at0004, itemType=CLUSTER, level=2, text=Per test detail, description=Details about each episode of the examination, test or procedure performed., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Valgfritt, gjentagende, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0004]/items[at0005], code=at0005, itemType=ELEMENT, level=3, text=Date of test, description=The date when the examination, test or procedure was performed., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Valgfritt, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0004]/items[at0006], code=at0006, itemType=ELEMENT, level=3, text=Description, description=Narrative description about the episode of the examination, test or procedure performed., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Valgfritt, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0004]/items[at0007], code=at0007, itemType=ELEMENT, level=3, text=Finding, description=Identification of the finding of the Narrative description about the examination, test or procedure performed., comment=For example: Regional lymph node metastasis. It is recommended that 'Finding' should be coded with a terminology, where possible., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Valgfritt, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0004]/items[at0008], code=at0008, itemType=SLOT, level=3, text=Citation, description=Detailed data available about the evidence held in another part of the health record., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Valgfritt, gjentagende, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Inkluder:
Alle ikke eksplisitt ekskluderte arketyper, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0009], code=at0009, itemType=ELEMENT, level=2, text=Comment, description=Additional narrative about the examination, test or procedure not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Valgfritt, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null]], source=[], target=[], context=[], events=[], details=[], protocol=[ResourceSimplifiedHierarchyItem [path=/protocol[at0010]/items[at0011], code=at0011, itemType=SLOT, level=2, text=Cluster, description=Additional information required to capture local content or to align with other reference models/formalisms., comment=For example: local information requirements or additional metadata to align with FHIR or CIMI equivalents., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Valgfritt, gjentagende, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Inkluder:
Alle ikke eksplisitt ekskluderte arketyper, extendedValues=null]], activities=[], provider=[], relationships=[]}, topLevelItems={data=ResourceSimplifiedHierarchyItem [path=ROOT_/data[at0001], code=at0001, itemType=ITEM_TREE, level=0, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Obligatorisk, cardinalityFormal=0..1, cardinalityText=valgfritt, subCardinalityFormal=0..*, subCardinalityText=Minimum 0 oppføringer, dataType=ITEM_TREE, bindings=null, values=null, extendedValues=null], protocol=ResourceSimplifiedHierarchyItem [path=ROOT_/protocol[at0010], code=at0010, itemType=ITEM_TREE, level=0, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Obligatorisk, cardinalityFormal=0..1, cardinalityText=valgfritt, subCardinalityFormal=0..*, subCardinalityText=Minimum 0 oppføringer, dataType=ITEM_TREE, bindings=null, values=null, extendedValues=null]}, addHierarchyItemsTo=protocol, currentHierarchyItemsForAdding=[ResourceSimplifiedHierarchyItem [path=/protocol[at0010]/items[at0011], code=at0011, itemType=SLOT, level=2, text=Cluster, description=Additional information required to capture local content or to align with other reference models/formalisms., comment=For example: local information requirements or additional metadata to align with FHIR or CIMI equivalents., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Valgfritt, gjentagende, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Inkluder:
Alle ikke eksplisitt ekskluderte arketyper, extendedValues=null]], minIndents={}, termBindingRetrievalErrorMessage=null]