archetype (adl_version=1.4; uid=3a666c91-53ba-4e54-8197-8db6e73b5357) openEHR-EHR-CLUSTER.problem_status.v0 concept [at0000] -- Problem/Diagnosis status language original_language = <[ISO_639-1::en]> translations = < ["sl"] = < language = <[ISO_639-1::sl]> author = < ["name"] = <"mag. Biljana Prinčič"> ["organisation"] = <"Marand d.o.o., Ljubljana, Slovenija"> ["email"] = <"biljana.princic@marand.si"> > > > description original_author = < ["name"] = <"Dr Ian McNicoll"> ["organisation"] = <"Ocean Informatics, United Kingdom"> ["email"] = <"ian.mcnicoll@oceaninformatics.com"> ["date"] = <"2013-05-29"> > details = < ["sl"] = < language = <[ISO_639-1::sl]> purpose = <"Za zapisovanje različnih statusov, ki se ponavadi uporablja za aplikacijskimi in kliničnimi sporočili, ki so odvisna od definirane vsebine "> use = <"Za dodeljevanje pravic EVALUATION.problem_diagnosis.v1 archetype, dodaja informacije za povezovanje. "> keywords = <"problem", "aktiven", "ni aktiven"> misuse = <"It should not be assumed that these qualifiers are safely interoperable unless further definition and alignment is agreed between all sharing parties. A problem which has been defined as 'Inactive' during a hospital admission cannot be assumed to be regarded as 'Inactive' in a primary care setting , where a much longer term perspective is being taken. Similarly terms such as Initial, Interim and Final, whilst helpful to the human observer are unlikely to be precisely enough defined to be safely computable e.g. for decision support. "> copyright = <"© openEHR Foundation"> > ["en"] = < language = <[ISO_639-1::en]> purpose = <"To record clinical context-specific or time-specific status qualifiers for a specified problem or diagnosis."> use = <"Use to record context-specific or time-specific qualifiers that can be used to provide additional detail when recording a problem or diagnosis that are relevant at the time of recording or within the clinical context where it is recorded, but which may not be appropriate to assume as appropriate at another time or in another clinical context. This archetype is designed to be included in Status SLOT in the EVALUATION.problem_diagnosis archetype. These status qualifiers should be used with care as they are variably applied in practice and interoperability cannot be assured unless usage guidelines are clearly defined within the clinical community in which the 'Problem/Diagnosis' and 'Problem status' archetype pair may be shared. The 'Unspecified' data element has been added to support addition of other qualifiers that might only be used locally or where the use case has not been clearly established at the time of this archetype being published. As other qualifiers are identified they can be added to this archetype as a backwardly compatible revision."> keywords = <"problem", "active", "inactive", "status", "episode", "diagnosis"> misuse = <"Not to be used to represent Differential diagnosis - use the archetype EVALUATION.differential_diagnosis for this purpose."> copyright = <"© openEHR Foundation"> > > lifecycle_state = <"in_development"> other_contributors = <"Nadim Anani, Karolinska Institutet, Sweden", "Vebjoern Arntzen, Oslo university hospital, Norway", "Koray Atalag, University of Auckland, New Zealand", "Silje Ljosland Bakke, National ICT Norway, Norway (openEHR Editor)", "Lars Bitsch-Larsen, Haukeland University hospital, Norway", "Aitor Eguzkitza, UPNA (Public University of Navarre) - CHN (Complejo Hospitalario de Navarra), Spain", "Einar Fosse, National Centre for Integrated Care and Telemedicine, Norway", "Heather Grain, Llewelyn Grain Informatics, Australia", "Sam Heard, Ocean Informatics, Australia", "Lars Karlsen, DIPS ASA, Norway", "Shinji Kobayashi, Kyoto University, Japan", "Sabine Leh, Haukeland University Hospital, Department of Pathology, Norway", "Heather Leslie, Ocean Informatics, Australia (openEHR Editor)", "Hugh Leslie, Ocean Informatics, Australia", "Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (openEHR Editor)", "Andrej Orel, Marand d.o.o., Slovenia", "Jussara Rotzsch, UNB, Brazil", "Anoop Shah, University College London, United Kingdom", "Norwegian Review Summary, Nasjonal IKT, Norway", "John Tore Valand, Helse Bergen, Norway (openEHR Editor)"> other_details = < ["licence"] = <"This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/."> ["custodian_organisation"] = <"Ocean Informatics"> ["original_namespace"] = <"com.oceaninformatics"> ["original_publisher"] = <"Ocean Informatics"> ["custodian_namespace"] = <"com.oceaninformatics"> ["MD5-CAM-1.0.1"] = <"5C38661056B310CA29DDF3E67D1F0DC5"> ["build_uid"] = <"cf128eaa-2cda-4232-b013-7efb8eac92f0"> ["revision"] = <"0.0.1-alpha"> > definition CLUSTER[at0000] matches { -- Problem/Diagnosis status items cardinality matches {1..*; unordered} matches { ELEMENT[at0004] occurrences matches {0..1} matches { -- Phase value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0016, -- Preliminary at0017, -- Working at0018] -- Established } } } } ELEMENT[at0060] occurrences matches {0..1} matches { -- Current? value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0062, -- Current at0061] -- Past } } } } ELEMENT[at0003] occurrences matches {0..1} matches { -- Active? value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0026, -- Active at0027] -- Inactive } } } } ELEMENT[at0001] occurrences matches {0..1} matches { -- Episodicity value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0034, -- New episode at0035, -- Ongoing episode at0070] -- Indeterminate } } } } ELEMENT[at0071] occurrences matches {0..1} matches { -- First ever? value matches { DV_BOOLEAN matches { value matches {True} } } } ELEMENT[at0077] occurrences matches {0..1} matches { -- Course value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0081, -- Acute at0078, -- Relapsing at0079] -- Chronic } } } } ELEMENT[at0063] occurrences matches {0..1} matches { -- DRG category value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0064, -- Principal diagnosis at0066, -- Secondary diagnosis at0076] -- Complication } } } } ELEMENT[at0073] occurrences matches {0..1} matches { -- Present on admission? value matches { DV_BOOLEAN matches { value matches {True} } } } ELEMENT[at0083] occurrences matches {0..1} matches { -- Resolution value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0084, -- Resolved at0085, -- Resolving at0086, -- Not resolving at0087] -- Indeterminate } } } } ELEMENT[at0082] occurrences matches {0..*} matches { -- Unspecified value matches { DV_TEXT matches {*} DV_BOOLEAN matches { value matches {True, False} } DV_COUNT matches {*} } } } } ontology terminologies_available = <"SNOMED-CT", ...> term_definitions = < ["en"] = < items = < ["at0000"] = < text = <"Problem/Diagnosis status"> description = <"Context- or time-specific qualifiers for a specified problem or diagnosis."> > ["at0001"] = < text = <"Episodicity"> description = <"Category new, recurring and ongoing issues, problems or diagnoses."> comment = <"This data element is usually recorded as part of a clinical consultation."> > ["at0003"] = < text = <"Active?"> description = <"Category that supports division of problems and diagnoses into Active or Inactive problem lists."> > ["at0004"] = < text = <"Phase"> description = <"Stage or phase of diagnostic process."> comment = <"The phase is usually determined by a combination of the timing of diagnosis plus availability of supporting test results and clinical advice. It can also imply a level of clinical certainty. Terms aligned with SNOMED CT."> > ["at0016"] = < text = <"Preliminary"> description = <"The initial diagnosis made, based on limited available clinical evidence. It may change as test results or advice become available."> > ["at0017"] = < text = <"Working"> description = <"Interim diagnosis, based on substantiated clinical evidence but pending further test results or clinical advice. It may still change as test results or advice become available."> > ["at0018"] = < text = <"Established"> description = <"Final substantiated diagnosis, based on all relevant test results and clinical advice. It is not expected to change."> > ["at0026"] = < text = <"Active"> description = <"The problem or diagnosis is currently active and clinically relevant."> > ["at0027"] = < text = <"Inactive"> description = <"The problem or diagnosis is not completely resolved but is inactive or felt less relevant to the current clinical context."> > ["at0034"] = < text = <"New episode"> description = <"A first occurrence of a new diagnosis or new occurrence of a previous diagnosis. A flag for 'First ever' occurrence can be recorded separately."> > ["at0035"] = < text = <"Ongoing episode"> description = <"The issue, problem or diagnosis continues, without occurrences of new episodes."> > ["at0060"] = < text = <"Current?"> description = <"Category that supports division of problems and diagnoses into Current or Past problem lists."> comment = <"Aligned with SNOMEDCT."> > ["at0061"] = < text = <"Past"> description = <"An issue occuring in the past."> > ["at0062"] = < text = <"Current"> description = <"An issue which ocurred at present."> > ["at0063"] = < text = <"DRG category"> description = <"In episodic care contexts (commonly secondary care) it is common to categorise/ organise problems according to their relationship to the principal problem or diagnosis being addressed during that episode of care. These categories may also be used for clinical coding, reporting and billing purposes."> > ["at0064"] = < text = <"Principal diagnosis"> description = <"The diagnosis determined to be chiefly responsible for occasionaing an episode of admitted patient care, an episode of residential care or an attendance at the health care establishment."> > ["at0066"] = < text = <"Secondary diagnosis"> description = <"A problem or diagnosis that is occurs at the same time as the primary problem or diagnosis. May also be known as a comorbid condition."> > ["at0070"] = < text = <"Indeterminate"> description = <"It is not possible to determine if this occurrence of the problem or diagnosis is new or ongoing."> > ["at0071"] = < text = <"First ever?"> description = <"Is this the first ever occurrence of this problem or diagnosis?"> comment = <"Record as True if this is the first ever occurrence of this problem or diagnosis."> > ["at0073"] = < text = <"Present on admission?"> description = <"Was the problem or diagnosis present at admission?"> comment = <"Record as True if the problem or diagnosis was present on admission. Used to support identification of in-admission complications among secondary diagnoses that arise during admission."> > ["at0076"] = < text = <"Complication"> description = <"An unfavorable evolution of a problem or diagnosis."> > ["at0077"] = < text = <"Course"> description = <"The pattern or evolution of the problem or diagnosis."> > ["at0078"] = < text = <"Relapsing"> description = <"A recurring problem or diagnosis, with periods of remission in between."> > ["at0079"] = < text = <"Chronic"> description = <"A problem or diagnosis with persistent or long-lasting effects, or that evolves over time."> > ["at0081"] = < text = <"Acute"> description = <"A problem or diagnosis with a rapid onset, a short course, or both."> > ["at0082"] = < text = <"Unspecified"> description = <"Unspecified qualifier that will be renamed, data type selected and potential value sets specified in a template."> comment = <"For example: The boolean data type could be used to signify that the problem/diagnosis can be included in a patient summary; the text data type could be used to categorise in a similar way to 'Current?' or Active?'; and the count data type could be used to assert a priority key or order to problems and diagnoses in a list. If any uses are identified as frequently required, they could be added explicitly to this archetype as an explicit data element."> > ["at0083"] = < text = <"Resolution"> description = <"Phase of resolution or healing of an acute problem or diagnosis."> > ["at0084"] = < text = <"Resolved"> description = <"Problem or diagnosis has completed the normal phases of restoration or healing and can be considered resolved."> > ["at0085"] = < text = <"Resolving"> description = <"Problem or diagnosis is progressing satisfactorily through the normal stages of restoration or healing towards resolution."> > ["at0086"] = < text = <"Not resolving"> description = <"Problem or diagnosis is not progressing satisfactorily through the normal stages of restoration or healing towards resolution."> > ["at0087"] = < text = <"Indeterminate"> description = <"It is not possible to determine the resolution or healing status of the problem or diagnosis."> > > > ["sl"] = < items = < ["at0000"] = < text = <"*Problem/Diagnosis status(en)"> description = <"*Context- or time-specific qualifiers for a specified problem or diagnosis.(en)"> > ["at0001"] = < text = <"*Episodicity(en)"> description = <"*Category new, recurring and ongoing issues, problems or diagnoses.(en)"> comment = <"*This data element is usually recorded as part of a clinical consultation.(en)"> > ["at0003"] = < text = <"*Active?(en)"> description = <"*Category that supports division of problems and diagnoses into Active or Inactive problem lists.(en)"> > ["at0004"] = < text = <"*Phase(en)"> description = <"*Stage or phase of diagnostic process.(en)"> comment = <"*The phase is usually determined by a combination of the timing of diagnosis plus availability of supporting test results and clinical advice. It can also imply a level of clinical certainty. Terms aligned with SNOMED CT.(en)"> > ["at0016"] = < text = <"*Preliminary(en)"> description = <"*The initial diagnosis made, based on limited available clinical evidence. It may change as test results or advice become available.(en)"> > ["at0017"] = < text = <"*Working(en)"> description = <"*Interim diagnosis, based on substantiated clinical evidence but pending further test results or clinical advice. It may still change as test results or advice become available.(en)"> > ["at0018"] = < text = <"*Established(en)"> description = <"*Final substantiated diagnosis, based on all relevant test results and clinical advice. It is not expected to change.(en)"> > ["at0026"] = < text = <"Aktiven"> description = <"Problem je trenutno aktiven in klinično relevanten"> > ["at0027"] = < text = <"Ni aktiven"> description = <"Problem trenutno ni aktiven"> > ["at0034"] = < text = <"*New episode(en)"> description = <"*A first occurrence of a new diagnosis or new occurrence of a previous diagnosis. A flag for 'First ever' occurrence can be recorded separately.(en)"> > ["at0035"] = < text = <"*Ongoing episode(en)"> description = <"*The issue, problem or diagnosis continues, without occurrences of new episodes.(en)"> > ["at0060"] = < text = <"*Current?(en)"> description = <"*Category that supports division of problems and diagnoses into Current or Past problem lists.(en)"> comment = <"*Aligned with SNOMEDCT.(en)"> > ["at0061"] = < text = <"*Past(en)"> description = <"*An issue occuring in the past.(en)"> > ["at0062"] = < text = <"*Current(en)"> description = <"*An issue which ocurred at present.(en)"> > ["at0063"] = < text = <"*DRG category(en)"> description = <"*In episodic care contexts (commonly secondary care) it is common to categorise/ organise problems according to their relationship to the principal problem or diagnosis being addressed during that episode of care. These categories may also be used for clinical coding, reporting and billing purposes.(en)"> > ["at0064"] = < text = <"*Principal diagnosis(en)"> description = <"*The diagnosis determined to be chiefly responsible for occasionaing an episode of admitted patient care, an episode of residential care or an attendance at the health care establishment.(en)"> > ["at0066"] = < text = <"*Secondary diagnosis(en)"> description = <"*A problem or diagnosis that is occurs at the same time as the primary problem or diagnosis. May also be known as a comorbid condition.(en)"> > ["at0070"] = < text = <"*Indeterminate(en)"> description = <"*It is not possible to determine if this occurrence of the problem or diagnosis is new or ongoing.(en)"> > ["at0071"] = < text = <"*First ever?(en)"> description = <"*Is this the first ever occurrence of this problem or diagnosis?(en)"> comment = <"*Record as True if this is the first ever occurrence of this problem or diagnosis.(en)"> > ["at0073"] = < text = <"*Present on admission?(en)"> description = <"*Was the problem or diagnosis present at admission?(en)"> comment = <"*Record as True if the problem or diagnosis was present on admission. Used to support identification of in-admission complications among secondary diagnoses that arise during admission.(en)"> > ["at0076"] = < text = <"*Complication(en)"> description = <"*An unfavorable evolution of a problem or diagnosis.(en)"> > ["at0077"] = < text = <"*Course(en)"> description = <"*The pattern or evolution of the problem or diagnosis.(en)"> > ["at0078"] = < text = <"*Relapsing(en)"> description = <"*A recurring problem or diagnosis, with periods of remission in between.(en)"> > ["at0079"] = < text = <"*Chronic(en)"> description = <"*A problem or diagnosis with persistent or long-lasting effects, or that evolves over time.(en)"> > ["at0081"] = < text = <"*Acute(en)"> description = <"*A problem or diagnosis with a rapid onset, a short course, or both.(en)"> > ["at0082"] = < text = <"*Unspecified(en)"> description = <"*Unspecified qualifier that will be renamed, data type selected and potential value sets specified in a template.(en)"> comment = <"*For example: The boolean data type could be used to signify that the problem/diagnosis can be included in a patient summary; the text data type could be used to categorise in a similar way to 'Current?' or Active?'; and the count data type could be used to assert a priority key or order to problems and diagnoses in a list. If any uses are identified as frequently required, they could be added explicitly to this archetype as an explicit data element.(en)"> > ["at0083"] = < text = <"*Resolution(en)"> description = <"*Phase of resolution or healing of an acute problem or diagnosis.(en)"> > ["at0084"] = < text = <"*Resolved(en)"> description = <"*Problem or diagnosis has completed the normal phases of restoration or healing and can be considered resolved.(en)"> > ["at0085"] = < text = <"*Resolving(en)"> description = <"*Problem or diagnosis is progressing satisfactorily through the normal stages of restoration or healing towards resolution.(en)"> > ["at0086"] = < text = <"*Not resolving(en)"> description = <"*Problem or diagnosis is not progressing satisfactorily through the normal stages of restoration or healing towards resolution.(en)"> > ["at0087"] = < text = <"*Indeterminate(en)"> description = <"*It is not possible to determine the resolution or healing status of the problem or diagnosis.(en)"> > > > > term_bindings = < ["SNOMED-CT"] = < items = < ["at0001"] = <[SNOMED-CT::288526004]> ["at0004"] = <[SNOMED-CT::106229004]> ["at0016"] = <[SNOMED-CT::148006]> ["at0017"] = <[SNOMED-CT::5558000]> ["at0018"] = <[SNOMED-CT::14657009]> ["at0060"] = <[SNOMED-CT::410511007]> ["at0061"] = <[SNOMED-CT::410513005]> ["at0062"] = <[SNOMED-CT::15240007]> ["at0077"] = <[SNOMED-CT::288524001]> ["at0078"] = <[SNOMED-CT::255227004]> ["at0079"] = <[SNOMED-CT::90734009]> > > >