ISO_639-1 en false 2010-07-03 Heather Leslie Ocean Informatics heather.leslie@oceaninformatics.com Ian McNicoll, Ocean Informatics Heath Frankel, Ocean Informatics in_development 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/. Nasjonal IKT 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). no.nasjonalikt Nasjonal IKT no.nasjonalikt 8F6C801CD6BC5684AF4D88B1C411C91C e0386d5e-f585-41c9-826f-06879fe6ce4d 0.0.1-alpha

ISO_639-1 en To demonstrate a design pattern for representation of a Problem List suitable for use with both episodic and longitudinal recording of problems. problem diagnosis exclusion absence known list 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. © Nasjonal IKT HF

6e584222-912f-417c-a11b-73e0eaa9c467 openEHR-EHR-SECTION.problem_list.v0 1.4 at0000 SECTION true true false false 1 1 at0000 items true true false false 0 1 EVALUATION true false true 0 at0001 archetype_id/value matches {/openEHR-EHR-EVALUATION\.problem_diagnosis(-[a-zA-Z0-9_]+)*\.v1/} Boolean 2007 false String archetype_id/value attribute C_STRING openEHR-EHR-EVALUATION\.problem_diagnosis(-[a-zA-Z0-9_]+)*\.v1 constraint ACTION true false true 0 at0002 archetype_id/value matches {/openEHR-EHR-ACTION\.procedure(-[a-zA-Z0-9_]+)*\.v1/} Boolean 2007 false String archetype_id/value attribute C_STRING openEHR-EHR-ACTION\.procedure(-[a-zA-Z0-9_]+)*\.v1 constraint EVALUATION true false true 0 at0003 archetype_id/value matches {/openEHR-EHR-EVALUATION\.exclusion-problem_diagnosis(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-EVALUATION\.exclusion-procedure(-[a-zA-Z0-9_]+)*\.v1/} Boolean 2007 false String archetype_id/value attribute C_STRING openEHR-EHR-EVALUATION\.exclusion-problem_diagnosis(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-EVALUATION\.exclusion-procedure(-[a-zA-Z0-9_]+)*\.v1 constraint EVALUATION true false true 0 at0004 archetype_id/value matches {/openEHR-EHR-EVALUATION\.absence(-[a-zA-Z0-9_]+)*\.v1/} Boolean 2007 false String archetype_id/value attribute C_STRING openEHR-EHR-EVALUATION\.absence(-[a-zA-Z0-9_]+)*\.v1 constraint false false true false true 1 Problem List Suggested design pattern for including a Problem List in a template. Problems or Diagnoses Details about identified problems or diagnoses. Procedures Details about identified procedures that have been performed. Exclusion Statements Positive statement about the known exclusion of known problems or diagnoses and procedures performed. For example: "No significant problems or diagnoses" or No history of significant operations or procedures". Absent Information Positive statement that no information is available about identification of problems or diagnoses, nor procedures performed. For example: "No information available concerning procedures".