archetype (adl_version=1.4) openEHR-EHR-EVALUATION.exclusion-procedure.v1 specialise openEHR-EHR-EVALUATION.exclusion.v1 concept [at0000.1] -- Exclusion of a Procedure language original_language = <[ISO_639-1::en]> description original_author = < ["name"] = <"Heather Leslie"> ["organisation"] = <"Ocean Informatics"> ["email"] = <"heather.leslie@oceaninformatics.com"> ["date"] = <"2010-03-02"> > details = < ["en"] = < language = <[ISO_639-1::en]> purpose = <"To positively record statement/s about procedures that need to be clinically excluded from the health record at a specific point in time."> use = <"Use to record positive statement/s about the absence or exclusion of procedures performed within the health record at a specific point in time. For example: to record that the patient has not had any operations or significant procedures; or that the patient has not had an appendicectomy, if presenting with abdominal pain. This archetype has specifically been designed to avoid the need to use flags or terminology to express negation about any procedures performed within the health record. Exclusion statements can only be considered to be current and accurate at the time of recording. For example: exclusion of appendicectomy during a consultation or emergency room visit for abdominal pain is only relevant at the time of recording and is effectively obsolete if the subsequent diagnosis is appendicitis and an appendicectomy performed."> keywords = <"exclusion", "procedure", "intervention", "operation", "surgery"> misuse = <"Not to be used to record exclusion statements about adverse reactions, medications, problems or diagnoses - use other specific specialisations of the EVALUATION.exclusion archetype for these purposes."> copyright = <"© openEHR Foundation"> > > lifecycle_state = <"AuthorDraft"> other_contributors = <"Sam Heard, Ocean Informatics, Australia", "Ian McNicoll, Ocean Informatics, Australia", "Stephen Chu, NEHTA, Australia", "Stephen Royce, NEHTA, Australia"> other_details = < ["current_contact"] = <"Heather Leslie, Ocean Informatics, heather.leslie@oceaninformatics.com"> ["references"] = <"Exclusion of a Procedure, draft archetype, NEHTA Clinical Knowledge Manager [Internet]. NEHTA. Authored: 02 Mar 2010. Available at: http://dcm.nehta.org.au/ckm/#showArchetype_1013.1.1312_2 (accessed 3 Sept 2013)"> ["MD5-CAM-1.0.1"] = <"EC8697A3EB07A9B28FD861E7E4037215"> > definition EVALUATION[at0000.1] matches { -- Exclusion of a Procedure data matches { ITEM_TREE[at0001] matches { -- Tree items cardinality matches {1..*; unordered} matches { ELEMENT[at0002.1] occurrences matches {1..*} matches { -- Exclusion Statement value matches { DV_TEXT matches {*} } } ELEMENT[at0003.1] occurrences matches {0..*} matches { -- Procedure value matches { DV_CODED_TEXT matches { defining_code matches {[ac0.1]} -- Procedures } DV_TEXT matches {*} } } ELEMENT[at0007] occurrences matches {0..1} matches { -- Comment value matches { DV_TEXT matches {*} } } } } } protocol matches { ITEM_TREE[at0006] matches { -- Tree items cardinality matches {0..*; unordered} matches { ELEMENT[at0004] occurrences matches {0..1} matches { -- Date Last Updated value matches { DV_DATE_TIME matches {*} } } } } } } ontology term_definitions = < ["en"] = < items = < ["at0000"] = < text = <"Exclusion Statement"> description = <"Generic, positive statement/s that need to be recorded as clinically excluded from the health record at a specific point in time."> > ["at0000.1"] = < text = <"Exclusion of a Procedure"> description = <"Positive statement/s about procedures that need to be recorded as clinically excluded from the health record at a specific point in time."> > ["at0001"] = < text = <"Tree"> description = <"@ internal @"> > ["at0002"] = < text = <"Exclusion Statement"> description = <"The statement about an exclusion in the health record."> comment = <"Use to capture any information that is needed to be positively recorded as being excluded within the record. The statement can support recording global statements or statements about a specified object. See specialisations for Medications, Adverse Reactions, Problem/Diagnosis and Procedures as common examples that have been explicitly modelled."> > ["at0002.1"] = < text = <"Exclusion Statement"> description = <"A statement about exclusion of procedures performed in the health record."> comment = <"For example: \"No known operations or significant procedures\" or \"No previous\" (appendicectomy)."> > ["at0003"] = < text = <"Specific Object"> description = <"Identification of the specific object/s to which the Exclusion Statement applies."> > ["at0003.1"] = < text = <"Procedure"> description = <"Identification of the procedures to which the Exclusion Statement applies."> comment = <"Coding of the Procedure with a terminology is desirable, where possible."> > ["at0004"] = < text = <"Date Last Updated"> description = <"The date at which the exclusion was last clinically asserted, affirmed or confirmed."> > ["at0006"] = < text = <"Tree"> description = <"@ internal @"> > ["at0007"] = < text = <"Comment"> description = <"Additional narrative about the Exclusion not captured in other fields."> > > > > constraint_definitions = < ["en"] = < items = < ["ac0.1"] = < text = <"Procedures"> description = <"All procedures that can be performed."> > > > >