ARCHETYPE Problem List (openEHR-EHR-SECTION.problem_list.v0)

ARCHETYPE IDopenEHR-EHR-SECTION.problem_list.v0
ConceptProblem List
DescriptionSuggested design pattern for including a Problem List in a template.
UseThis 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 demonstrate a design pattern for representation of a Problem List suitable for use with both episodic and longitudinal recording of problems.
ReferencesDerived from: Problem List (composition), draft archetype, National eHealth Transition Authority [Internet]. NEHTA Clinical Knowledge Manager. Authored: 19 Feb 2013. Available at: http://dcm.nehta.org.au/ckm/#showArchetype_1013.1.1235 (accessed Feb 27, 2012).
Copyright© Nasjonal IKT HF
AuthorsForfatternavn: Heather Leslie
Organisasjon: Ocean Informatics
E-post: heather.leslie@oceaninformatics.com
Opprinnelig skrevet dato: 2010-07-03
Other Details LanguageForfatternavn: Heather Leslie
Organisasjon: Ocean Informatics
E-post: heather.leslie@oceaninformatics.com
Opprinnelig skrevet dato: 2010-07-03
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, references=Derived from: Problem List (composition), draft archetype, National eHealth Transition Authority [Internet]. NEHTA Clinical Knowledge Manager. Authored: 19 Feb 2013. Available at: http://dcm.nehta.org.au/ckm/#showArchetype_1013.1.1235 (accessed Feb 27, 2012)., original_namespace=no.nasjonalikt, original_publisher=Nasjonal IKT, custodian_namespace=no.nasjonalikt, MD5-CAM-1.0.1=8F6C801CD6BC5684AF4D88B1C411C91C, build_uid=e0386d5e-f585-41c9-826f-06879fe6ce4d, revision=0.0.1-alpha}
Keywordsproblem, diagnosis, exclusion, absence, known, list
Lifecyclein_development
UID6e584222-912f-417c-a11b-73e0eaa9c467
Language useden
Citeable Identifier1078.36.695
Revision Number0.0.1-alpha
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openEHR-EHR-EVALUATION.exclusion-problem_diagnosis.v1 og spesialiseringer Eller
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