operationaltemplate.ReSPECT-3.v0.opt Maven / Gradle / Ivy
The newest version!
ISO_639-1
en
Dr Paul Miller
NHS Education Scotland Digital Service (NDS)
[email protected]
Ian McNicoll
published
Template metadata sample set
4b9f18939f8f7944b66f2ef329243865
DE0723367AA22BB716CEC5342B21FF60
0.2.0
3.0.0-published
1.0.0
ISO_639-1::en
ISO_639-1
en
Representing the dataset for capture, reporting and auditing the details of ReSPECT - Recommended Summary Plan for Emergency Care and Treatment.
https://www.resus.org.uk/respect/
Anticipatory Care Plan, ACP, ReSPECT, KIS, Key Information Summary, ECS, Emergency Care Summary, DNACPR, Resuscitation, CPR
Any use that extends the scope or coverage of the template should be checked with the UK Resus council. It may not be appropriate to use it in contexts outside NHS Scotland because of the differing legal frameworks around age of competence and Power of Attorney, so re-use outside of this context should be checked to ensure it meets your needs.
4900f1c5-cc3d-45d6-823c-86718007da57
ReSPECT-3.v0
ReSPECT-3.v0
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openEHR-EHR-CLUSTER.xds_metadata.v0
Additional composition metadata aligned with IHE-XDS which is not already available from the Reference Model COMPOSITION class.
XDS Metadata
The speciality of the author/composer of the document.
Author specialty
For example: Report, Summary, Images, Plan, Patient Preferences, Workflow.
These codes are specific to an XDS Affinity Domain.
A high-level document class code, normally selected from a valueset provided by the IHE-XDS Affinity Domain.
Class code
for example: Pulmonary History and Physical, Discharge Summary, Ultrasound Report.
These codes are specific to an XDS Affinity Domain.
The code specifying the precise type of document from the user perspective. Normally selected from a valueset provided by the local IHE-XDS Affinity Domain or national standard.
Document type
Coded text is preferred, normally specific to an XDS Affinity Domain.
A term specifying the level of confidentiality of the XDS Document.
Confidentiality code
Coded text is preferred. The codes are specific to an XDS Affinity Domain.
A term defining the healthcare facility type.
Health care facility type
For example: Family Practice, Laboratory, Radiology.
Coded text is preferred, normally specific to an XDS Affinity Domain.
The code specifying the clinical specialty where the act that resulted in the document was performed.
Practice setting code
Additional metadata about the document itself, including size, url.
Document_media
For example: Colonoscopy or appendicectomy.
This list of codes represents the main clinical acts.
Event code
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Narrative Summary
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ReSPECT Summary
openEHR-EHR-EVALUATION.clinical_synopsis.v1
Narrative summary or overview about a patient, specifically from the perspective of a healthcare provider, and with or without associated interpretations.
Clinical synopsis
@ internal @
List
The summary, assessment, conclusions or evaluation of the clinical findings.
Synopsis
@ internal @
Tree
For example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.
Additional information required to capture local content or to align with other reference models/formalisms.
Extension
SECTION
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STRING
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Details of other relevant care planning documents and where to find them
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EVALUATION
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Advance planning document
openEHR-EHR-EVALUATION.advance_care_directive.v1
A framework to communicate the preferences of an individual for future medical treatment and care.
Advance care directive
@ internal @
Item tree
Coding of the advance care directive status with a terminology is preferred, where possible.
The status of the advance care directive.
Status
A short text description of the nature of the advance care directive. Coding of the type of directive with a terminology is preferred, where possible. It is expected that this is largely localised to reflect local policy and legislation.
For example, in the Netherlands, advance care directive types include, but are not limited to, 'Treatment prohibition', 'Treatment prohibition with completion of Completed Life', 'Euthanasia request' and 'Declaration of life'.
In the UK, advance care directive types include 'Advance Decision', 'Advance Directive' and 'Advance Statement'.
The type of advance care directive.
Type of directive
May be used to record a narrative overview of the complete advance care directive, which may or may not be supported by structured data. Details of specific structured findings can be included using CLUSTER archetypes in the 'Directive details' slot. This data element may be used to capture legacy data that is not available in a structured format.
Narrative description of the overall advance care directive.
Description
For example: dementia, brain injury, diseases of the central nervous system, and terminal illness. Coding with a terminology is preferred, where possible.
The advance care directive applies to all specified conditions if the individual can no longer make or communicate decisions about their medical treatment and is unlikely to regain the ability to make such decisions. Details of specific decisions that apply to different conditions or situations can be included using CLUSTER archetypes in the 'Directive details' slot.
The conditions or situations in which the individual wishes the advance care directive to apply.
Condition
@ internal @
Item tree
For example, 'John Smith, Lawyer'.
Personal details of a person who witnesses the completion of the advance care directive.
Witness
For example, 'In England and Wales, advance decisions are covered by the Mental Capacity Act. Mandate: https://www.bma.org.uk/advice/employment/ethics/consent/consent-tool-kit/9-advance-decisions'.
Or 'Jehovah's Witnesses believe that the Bible prohibits Christians from accepting blood transfusions. Mandate: https://en.wikipedia.org/wiki/Jehovah%27s_Witnesses_and_blood_transfusions'.
Description of any legislation or other authoritative guidance that apply.
Mandate
For example, 'In the top drawer of the bedside table'.
Information regarding where the advance care directive is stored and how to gain access to it.
Location
Additional narrative about the advance care directive not captured in other fields.
Comment
The individual has an advance care directive.
Present
The individual does not have an advance care directive.
Absent
It is not known whether the individual has an advance care directive.
Unknown
This SLOT should also be used to record details for specific conditions or as per national or other local requirements. For example, in the UK, there may be a specific statement about whether to actively prolong life but only during pregnancy.
Structured details about the advance care directive decisions.
Directive detail
The date/time that marks the beginning of the valid period of time for this advance care directive.
Valid period start
'Valid period end' may often overlap with 'Review due date'. However, they may need to be recorded separately in circumstances where a document has an extended period of validity but requires an interim review. That may be due to changed personal circumstances/events or local policy.
The date/time that marks the conclusion of the valid period of time for this advance care directive.
Valid period end
The date when this advance directive record was last updated. This may not be a formal review but e.g. a typo correction.
Last updated
'Valid period end' may often overlap with 'Review due date'. However, they may need to be recorded separately in circumstances where a document has an extended period of validity but requires an interim review. That may be due to changed personal circumstances/events or local policy.
The date at which the advance care directive is due to be reviewed.
Review due date
Information regarding where the advance care directive is stored and who has a copy of it.
Directive location
For example, 'John Smith, Lawyer'.
Details of a person who has a copy of the advance care directive.
Copy holder
Digital document, image or video representing the advance care directive.
Digital representation
For example: local information requirements; or additional metadata to align with FHIR.
Additional information required to extend the model with local content or to align with other reference models/formalisms.
Extension
SNOMED-CT
410515003
SNOMED-CT
410516002
SNOMED-CT
261665006
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openEHR-EHR-SECTION.adhoc.v1
A generic section header which should be renamed in a template to suit a specific clinical context.
Ad hoc heading
SECTION
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STRING
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-
Legal welfare proxies
items
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ADMIN_ENTRY
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local
at0005
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CLUSTER
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at0042
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String
- archetype_id/value
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C_STRING
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CLUSTER
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at0045
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CLUSTER
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at0040
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Legal welfare proxy in place
openEHR-EHR-ADMIN_ENTRY.legal_authority.v0
A framework to communicate information about legal directives or orders that apply to the individual, for example, a power of attorney or guardianship order.
Legal authority
@ internal @
Item tree
Coding of the type of legal directive or order with a terminology is preferred, where possible. It is expected that this is largely localised to reflect local policy and legislation. For example, 'Welfare Power of Attorney', 'Welfare Guardianship Order' or 'Emergency Detention Order'.
The type of legal directive or order that applies to the individual.
Type
Coding of the legal directive or order status with a terminology is preferred, where possible.
The status of the legal directive or order.
Status
A legal directive or order is present.
Present
A legal directive or order is absent.
Absent
It is not known whether a legal directive or order is present or absent.
Unknown
This data element may be used to capture legacy data that is not available in a structured format.
Narrative description of the legal directive or order that applies to the individual.
Description
Details of a nominated representative who has authority to act and make decisions on behalf of the individual, or who has been appointed to support the individual in decision-making.
Representative
For example, 'Welfare Attorney', 'Substitute Welfare Attorney'. or 'Welfare Guardian'.
Description of the representative's role.
Role
Further information about the representative, including contact details and relationship to the individual.
Representative details
Additional narrative about the legal directive not captured in other fields.
Comment
The date/time that marks the beginning of the valid period of time for this legal directive or order.
Valid period start
The date/time that marks the conclusion of the valid period of time for this legal directive or order.
Valid period end
Information regarding where the legal directive or order certification is stored and who has a copy of it.
Certificate location
Information regarding where the certificate is stored and how to gain access to it.
Location
Details of a person who has a copy of the certificate.
Copy holder
Digital document or image representing the certificate.
Digital representation
For example, 'In Scotland, Welfare Power of Attorneys are covered by the Adults with Incapacity (Scotland) Act 2000. Mandate: http://www.legislation.gov.uk/asp/2000/4/contents'.
Description of any legislation or other authoritative guidance that apply.
Mandate
For example: local information requirements; or additional metadata to align with FHIR.
Additional information required to extend the model with local content or to align with other reference models/formalisms.
Extension
Additional details about the legal directive or order.
Additional details
For example, the court order reference number.
Reference number for the legal directive or order.
Reference number
Details about the authoritative body granting the directive, and/or nominated legal contact for further information about the directive.
Authority
false
false
true
false
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openEHR-EHR-SECTION.ehr_reference.v0
This section indicates that the enclosed information is stored in a different composition/template but is intended to be referenced here.
EHR reference
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SECTION
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What I most value
ELEMENT
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What I most fear / wish to avoid
CLUSTER
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at0003
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- archetype_id/value
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C_STRING
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STRING
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What matters to me
openEHR-EHR-EVALUATION.about_me.v0
About me
About me
@ internal @
Item tree
*
Narrative
*
Additional details
false
false
true
false
true
0
SECTION
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false
0
1
at0007
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at0001
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STRING
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Prioritise extending life
Balance extending life with comfort and valued outcomes
Prioritise comfort
name
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1
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DV_TEXT
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1
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STRING
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-
Clinical focus
ELEMENT
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at0003
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DV_TEXT
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STRING
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Clinical guidance on interventions
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false
true
0
protocol
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0
1
ITEM_TREE
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at0004
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CLUSTER
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at0005
Boolean
2007
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String
- archetype_id/value
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C_STRING
-
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constraint
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0
openEHR-EHR-EVALUATION.recommendation.v1
A suggestion, advice or proposal for clinical management.
Recommendation
@ internal @
Tree
May be coded, using a terminology, if required.
Narrative description of the recommendation.
Recommendation
Justifications for the recommendation.
Rationale
@ internal @
Tree
For example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.
Additional information required to capture local content or to align with other reference models/formalisms.
Extension
Useful if multiple types of recommendations are made at the same time, and within the same data set.
The topic or subject of the recommendation.
Topic
EVALUATION
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true
false
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0
1
at0000
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false
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1
1
ITEM_TREE
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1
1
at0001
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ELEMENT
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0
1
at0003
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0
1
DV_CODED_TEXT
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true
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1
1
defining_code
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1
1
CODE_PHRASE
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false
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1
1
local
at0004
at0005
at0022
at0027
ELEMENT
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false
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0
1
at0002
value
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true
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0
1
DV_DATE_TIME
true
true
false
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1
1
false
false
true
false
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0
protocol
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false
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0
1
ITEM_TREE
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1
1
at0010
items
true
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0
1
false
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false
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0
openEHR-EHR-EVALUATION.cpr_decision_uk.v0
The advance recommendation as to whether cardio-pulmonary resuscitation should be undertaken or not. This is generally referred to in UK clinical guidance as the CPR (Cardio-pulmonary resuscitation) decision.
CPR decision
@ internal @
Tree
The date at which the CPR decision was originally taken or last reviewed.
Date of CPR decision
The advance recommendation as to whether cardiopulmonary resuscitation (CPR) should be attempted. In some cases a clear answer may not be available to the recording clinician.
CPR decision
Cardio-pulmonary resuscitation is recommended for adult or child.
CPR attempts recommended adult or child
Cardiopulmonary resuscitation is not recommended for adult or child.
CPR attempts not recommended adult or child.
Is the patient aware of the CPR decision?
Patient awareness of decision
The patient is not aware of the cardiopulmonary resuscitation decision.
Patient not aware of CPR decision
The patient is aware of the cardiopulmonary resucitation decision.
Patient aware of CPR decision
The date at which the CPR decision should be reviewed.
Date for review of CPR decision
@ internal @
Tree
The location of the original CPR document, either a text description or an electronic link.
Location of CPR documentation
Is the informal carer, or carers, aware of the CPR decision?
Informal carer awareness of decision
Has resuscitation been discussed with the patient?
Discussion with patient
Has resuscitation been discussed with the patient's informal carer or carers?
Discussion with informal carer
Resuscitation has been discussed with the patient's informal carer.
Resuscitation discussed with informal carer
Resuscitation has been discussed with the patient.
Resuscitation discussed with patient
Has the physical CPR form been completed?
CPR form completed
The physical CPR form has been completed.
CPR form completed
The physical CPR form has not been completed.
CPR form not completed
Other narrative comment pertinent to the CPR decision.
Comment
There is no clear information on the outcome of the CPR decision.
CPR decision status unknown
Resuscitation has not been discussed with the patient.
Resucitation not discussed with patient
Resuscitation has not been discussed with the patient's informal carer or carers.
Resuscitation not discussed with informal carer
The informal carer is not aware of the do not attempt cardiopulmonary resuscitation clinical decision.
Informal carer not aware of CPR decision
The informal carer is aware of the do not attempt cardiopulmonary resucitation decision.
Informal carer aware of CPR decision
Modified CPR is recommended for child only.
For modified CPR child only
Narrative description of modification where modified CPR for child only has been selected.
Details for Modified CPR child only
The completion status of the CPR form is not known.
CPR form status unknown
SNOMED-CT
450475007
SNOMED-CT
450476008
SNOMED-CT
845151000000104
RCD99
1R00.
RCD99
1R10.
RCD99
9NgV.
READ2
1R0..
READ2
1R1..
READ2
67P1.
READ2
67P0.
READ2
9NgV.
false
false
true
false
true
0
SECTION
true
true
false
false
0
1
at0008
items
true
true
false
false
0
1
EVALUATION
true
true
false
false
0
1
at0000
data
true
true
false
false
1
1
ITEM_TREE
true
true
false
false
1
1
at0001
items
true
true
false
false
0
1
ELEMENT
true
true
false
false
0
1
at0009
value
true
true
false
false
0
1
DV_TEXT
true
true
false
false
1
1
ELEMENT
true
true
false
false
0
1
at0002
value
true
true
false
false
0
1
DV_CODED_TEXT
true
true
false
false
1
1
defining_code
true
true
false
false
1
1
CODE_PHRASE
true
true
false
false
1
1
local
at0003
at0004
name
true
true
false
false
1
1
DV_TEXT
true
true
false
false
1
1
value
true
true
false
false
1
1
STRING
true
true
false
false
1
1
-
Does the person have capacity to participate in making recommendations on this plan?
ELEMENT
true
true
false
false
0
1
at0006
value
true
true
false
false
0
1
DV_TEXT
true
true
false
false
1
1
name
true
true
false
false
1
1
DV_TEXT
true
true
false
false
1
1
value
true
true
false
false
1
1
STRING
true
true
false
false
1
1
-
If no, in what way does this person lack capacity?
CLUSTER
true
false
true
0
at0029
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
false
false
true
false
true
0
protocol
true
true
false
false
0
1
ITEM_TREE
true
true
false
false
1
1
at0023
items
true
true
false
false
0
1
CLUSTER
true
false
true
0
at0024
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
false
false
true
false
true
0
openEHR-EHR-EVALUATION.mental_capacity.v0
The ability of an individual to use and understand information to make a decision or plan.
Mental capacity
@ internal @
Item tree
The individual's mental capacity status.
Status
The individual has sufficient mental capacity to make the decision or plan.
Has capacity
The individual does not have sufficient mental capacity to make the decision or plan.
Does not have capacity
It has not been able to determinate whether the individual has sufficient mental capacity to make decision or plan.
Indeterminate
Narrative description of the individual's mental capacity.
Description
Details of a mental capacity assessment undertaken in relation to the specific decision or plan.
Formal assessment
Description of the specific decision or plan to which the mental capacity status and assessment details relate.
Decision/plan
Details of the person carrying out the mental capacity assessment.
Assessor
Details of a person who has been consulted in relation to the mental capacity assessment.
Person consulted
Additional structured details about the mental capacity assessment.
Assessment details
Additional narrative about the individual's mental capacity or incapacity not captured in other fields.
Comment
@ internal @
Item tree
For example: local information requirements; or additional metadata to align with FHIR.
Additional information required to extend the model with local content or to align with other reference models/formalisms.
Extension
The date/time that marks the conclusion of the valid period of time for this mental capacity assessment.
Valid period end
The date/time that marks the beginning of the valid period of time for this mental capacity assessment.
Valid period start
Structured details about the the individual's mental capacity.
Details
false
false
true
false
true
0
SECTION
true
true
false
false
0
1
at0009
items
true
true
false
false
0
1
ADMIN_ENTRY
true
true
false
false
0
1
at0000
data
true
true
false
false
1
1
ITEM_TREE
true
true
false
false
1
1
at0001
items
true
true
false
false
0
1
CLUSTER
true
true
false
false
0
1
at0012
items
true
true
false
false
1
1
ELEMENT
true
false
true
0
at0002
value
true
true
false
false
0
1
DV_CODED_TEXT
true
true
false
false
1
1
defining_code
true
true
false
false
1
1
CODE_PHRASE
true
true
false
false
1
1
local
at0003
at0004
at0005
at0010
at0011
ELEMENT
true
true
false
false
0
1
at0007
value
true
true
false
false
0
1
DV_TEXT
true
true
false
false
1
1
false
false
true
false
true
1
CLUSTER
true
false
true
0
at0016
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1
constraint
CLUSTER
true
false
true
0
at0015
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
false
false
true
false
true
0
openEHR-EHR-ADMIN_ENTRY.respect_involvement.v0
Details of involvement in making a ReSPECT plan.
ReSPECT involvement
@ internal @
Tree
Details of involvement in making this plan.
Involvement
This person has the mental capacity to participate in making these recommendations. They have been fully involved in making this plan.
A Person has mental capacity
This person does not have the mental capacity to participate in making these recommendations. This plan has been made in accordance with capacity law, including, where applicable, in consultation with their legal proxy, or where no proxy, with relevant family members/friends.
B Person does not have mental capacity
This person is less than 18 (UK except Scotland) / 16 (Scotland) and they have sufficient maturity and understanding to participate in making this plan.
C1 Person less than 18 or 16 with sufficient maturity
Additional implementation guidance: in an electronic format, if someone selects D we could have a line coming up explaining that the only legal reasons for selecting D are:
1. if the physician thinks it would cause the patient physiological or psychological harm
2. if the patient lacks capacity, and it is not practicable or appropriate to contact those close to them.
If C1 or C2 has been selected without selecting C3, please document why involvement of those holding parental responsibility has not been possible.
Description of reason for not selecting Options A, B or C or where C1 or C2 is selected without selecting C3.
Option D
For example in GP Records dated xx/xx/xxxx.
Details of location(s) of full documentation of conversations and decision-making process.
Location of record of discussion
This person is less than 18 (UK except Scotland) / 16 (Scotland) and they do not have sufficient maturity and understanding to participate in this plan. Their views, where known, have been taken into account.
C2 Person less than 18 or 16 without sufficient maturity
This person is less than 18 (UK except Scotland) /16 (Scotland) and those holding parental responsibility have been fully involved in discussing and making this plan.
C3 Person less than 18 or 16 parental decision
The clinician(s) signing this plan is/are confirming that these recommendations have at least one of A, B or C or valid reason for not selecting A,B or C fully documented in clinical record.
Involvement in recommendations
Date when recommendations are made.
Date recommendations made
Name and role of those involved in decision making.
Details of those involved in decision making
Link to record of discussion if held in a remote location.
Link to record of discussion
*
Name and role of those involved in decision making
false
false
true
false
true
0
SECTION
true
true
false
false
0
1
at0010
items
true
true
false
false
0
1
ACTION
true
false
true
0
at0000
ism_transition
true
true
false
false
1
1
ISM_TRANSITION
true
true
false
false
1
1
at0005
current_state
true
true
false
false
1
1
DV_CODED_TEXT
true
true
false
false
1
1
defining_code
true
true
false
false
1
1
CODE_PHRASE
true
true
false
false
1
1
openehr
532
careflow_step
true
true
false
false
0
1
DV_CODED_TEXT
true
true
false
false
1
1
defining_code
true
true
false
false
1
1
CODE_PHRASE
true
true
false
false
1
1
local
at0005
description
true
true
false
false
1
1
ITEM_TREE
true
true
false
false
1
1
at0001
items
true
true
false
false
0
1
ELEMENT
true
true
false
false
0
1
at0011
value
true
true
false
false
0
1
DV_TEXT
true
true
false
false
1
1
value
true
true
false
false
1
1
STRING
true
true
false
false
1
1
-
ReSPECT - clinician signature
ReSPECT - senior responsible clinician signature
CLUSTER
true
false
true
0
at0027
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
CLUSTER
true
false
true
0
at0029
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1
constraint
false
false
true
false
true
0
protocol
true
true
false
false
0
1
ITEM_TREE
true
true
false
false
1
1
at0015
items
true
true
false
false
0
1
CLUSTER
true
false
true
0
at0017
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
CLUSTER
true
false
true
0
at0019
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
false
false
true
false
true
0
name
true
true
false
false
1
1
DV_TEXT
true
true
false
false
1
1
value
true
true
false
false
1
1
STRING
true
true
false
false
1
1
-
Clinician signature
openEHR-EHR-ACTION.service.v0
A general clinical activity carried out for the patient to receive a specified service, advice or care from an expert healthcare provider.
Service
@ internal @
Tree
Service request to healthcare provider is planned.
Service planned
Appointment for a healthcare provider service has been made.
Service scheduled
The healthcare provider has delivered the service.
Service delivered
All service activities have been completed.
Service activity complete
The referral has been ceased before the service has been completed.
Service abandoned
The planned service has been postponed.
Service postponed
The planned service has been cancelled prior to commencement.
Service cancelled
The service has been suspended without completion.
Service suspended
Coding of the specific service name with a terminology is preferred, where possible.
Identification of the clinical service to be/being carried out.
Service name
For example: the reason for the cancellation or suspension of the service.
Reason that the activity or care pathway step for the identified service was carried out.
Reason
Narrative description about the service, as appropriate for the pathway step.
Description
Type of service to be carried out or being carried out.
Service type
@ internal @
Tree
The local ID assigned to the order by the healthcare provider or organisation requesting the service. This is also referred to as Placer Order Identifier.
Requestor identifier
Details about the healthcare provider or organisation requesting the service.
Requestor
The ID assigned to the order by the healthcare provider or organisation receiving the request for referral. This is also referred to as Filler Order Identifier.
Receiver identifier
Details about the healthcare provider or organisation receiving the request for referral.
Receiver
Only for use in association with the 'Service delivered' pathway step. For example: record that this is the 3rd physiotherapy appointment in a planned sequence.
The sequence of the specified clinical service.
Sequence
The referral has expired before the referral episode has been completed.
Service expired
Only for use in association with the 'Service scheduled' pathway step.
The date and/or time on which the service is intended to be performed.
Scheduled date/time
Request for service sent.
Service request sent
Use to capture detailed, structured information about specified aspects of the service.
Structured information about the service.
Service detail
Additional narrative about the activity or care pathway step not captured in other fields.
Comment
Mulitimedia representation of a performed service.
Multimedia
false
false
true
false
true
0
SECTION
true
true
false
false
0
1
at0011
items
true
true
false
false
0
1
ADMIN_ENTRY
true
true
false
false
0
1
at0000
data
true
true
false
false
1
1
ITEM_TREE
true
true
false
false
1
1
at0001
items
true
true
false
false
0
1
CLUSTER
true
true
false
false
0
1
at0000
items
true
true
false
false
1
1
CLUSTER
true
false
true
0
at0004
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
openEHR-EHR-CLUSTER\.identifier_cc\.v0
constraint
ELEMENT
true
true
false
false
0
1
at0018
value
true
true
false
false
0
1
DV_TEXT
true
true
false
false
1
1
value
true
true
false
false
1
1
STRING
true
true
false
false
1
1
-
ReSPECT Emergency contacts
CLUSTER
true
false
true
0
at0021
items
true
true
false
false
1
1
ELEMENT
true
false
true
0
at0022
value
true
true
false
false
0
1
DV_TEXT
true
true
false
false
1
1
value
true
true
false
false
1
1
STRING
true
true
false
false
1
1
-
Primary emergency contact
true
name
true
true
false
false
1
1
DV_TEXT
true
true
false
false
1
1
value
true
true
false
false
1
1
STRING
true
true
false
false
1
1
-
Role and Relationship
CLUSTER
true
true
false
false
0
1
at0000
items
true
true
false
false
1
1
CLUSTER
true
false
true
0
at0000
items
true
true
false
false
1
1
ELEMENT
true
true
false
false
1
1
at0001
value
true
true
false
false
0
1
DV_CODED_TEXT
true
true
false
false
1
1
defining_code
true
true
false
false
1
1
CODE_PHRASE
true
true
false
false
1
1
local
at0002
ELEMENT
true
true
false
false
0
1
at0009
value
true
true
false
false
0
1
DV_TEXT
true
true
false
false
1
1
name
true
true
false
false
1
1
DV_TEXT
true
true
false
false
1
1
value
true
true
false
false
1
1
STRING
true
true
false
false
1
1
-
Contact name
false
false
true
false
true
1
openEHR-EHR-CLUSTER.name_cc.v0
Name details aligned with FHIR resource.
Name
Identification of the purpose for the name.
Use
The usual name.
Usual
The official name.
Official
A temporary name.
Temp
A nickname.
Nickname
An anonymous name.
Anonymous
An old name.
Old
The maiden name.
Maiden
A text representation of the full name.
Text
Family name or surname.
Family
Given name, not always first and includes middle name(s).
Given
Part of the name that is acquired as a title due to academic, legal, employment or nobility status, etc. and that appears at the start of the name.
Prefix
Part of the name that is acquired as a title due to academic, legal, employment or nobility status, etc. and that appears at the end of the name.
Suffix
The start of the period. The boundary is inclusive.
Valid period start
The end of the period. If the end of the period is missing, it means that the period is ongoing. The start may be in the past, and the end date in the future, which means that period is expected/planned to end at that time.
Valid period end
CLUSTER
true
false
true
0
at0000
items
true
true
false
false
1
1
ELEMENT
true
true
false
false
0
1
at0001
value
true
true
false
false
0
1
DV_CODED_TEXT
true
true
false
false
1
1
defining_code
true
true
false
false
1
1
CODE_PHRASE
true
true
false
false
1
1
local
at0012
ELEMENT
true
true
false
false
0
1
at0002
value
true
true
false
false
0
1
DV_TEXT
true
true
false
false
1
1
name
true
true
false
false
1
1
DV_TEXT
true
true
false
false
1
1
value
true
true
false
false
1
1
STRING
true
true
false
false
1
1
-
Telephone number
false
false
true
false
true
1
name
true
true
false
false
1
1
DV_TEXT
true
true
false
false
1
1
value
true
true
false
false
1
1
STRING
true
true
false
false
1
1
-
Telephone
openEHR-EHR-CLUSTER.telecom_cc.v0
FHIR telecom details.
Telecom
Telecommunications form for contact point - what communications system is required to make use of the contact.
System
The actual contact point details, in a form that is meaningful to the designated communication system (i.e. phone number or email address).
Value
The purpose of the contact point.
Use
Home contact details.
Home
Work contact details.
Work
Temporary contact details.
Temp
Old contact details.
Old
Mobile contact details.
Mobile
Specifies a preferred order in which to use a set of contacts. Contacts are ranked with lower values coming before higher values.
Rank
The start of the period. The boundary is inclusive.
Valid period start
The end of the period. If the end of the period is missing, it means that the period is ongoing. The start may be in the past, and the end date in the future, which means that period is expected/planned to end at that time.
Valid period end
The communication form is phone.
Phone
The communication form is fax.
Fax
The communication form is email.
Email
The communication form is URL.
URL
The communication form is pager.
Pager
The communication is SMS.
SMS
The communication form is other.
Other
CLUSTER
true
false
true
0
at0004
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
openEHR-EHR-CLUSTER\.fhir_address(-[a-zA-Z0-9_]+)*\.v0
constraint
CLUSTER
true
false
true
0
at0010
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
openEHR-EHR-CLUSTER\.fhir_organisation(-[a-zA-Z0-9_]+)*\.v0
constraint
false
false
true
false
true
1
name
true
true
false
false
1
1
DV_TEXT
true
true
false
false
1
1
value
true
true
false
false
1
1
STRING
true
true
false
false
1
1
-
Member
openEHR-EHR-CLUSTER.contact_cc.v0
Contacts for patients and organisations (excluding practitioners).
Contact
Coding with a terminology is desirable where possible.
The relationship between the subject and the contact. This field is only appropriate when the archetype is used for patient contacts, not for organisation contacts.
Relationship
Name details for the contact.
Name
Telecoms details for the contact.
Telecoms
Address details for the contact.
Address
Gender details for the contact.
Gender
The contact's gender is male.
Male
The contact's gender is female.
Female
The contact's gender is other.
Other
The contact's gender is unknown.
Unknown
Reference to organisation details for the contact.
Organisation
Date and time when contact detail starts to be valid.
Valid period start
Date and time when contact detail stops being valid.
Valid period end
Indicates a purpose for which the contact can be reached. This field is only appropriate when the archetype is used inside an organisation cluster.
Purpose
CLUSTER
true
false
true
0
at0024
ELEMENT
true
true
false
false
0
1
at0030
value
true
true
false
false
0
1
DV_TEXT
true
true
false
false
1
1
name
true
true
false
false
1
1
DV_TEXT
true
true
false
false
1
1
value
true
true
false
false
1
1
STRING
true
true
false
false
1
1
-
Other details about contact
CLUSTER
true
false
true
0
at0031
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
false
false
true
false
true
1
CLUSTER
true
false
true
0
at0029
false
false
true
false
true
1
openEHR-EHR-CLUSTER.care_team.v0
Care team details aligned with FHIR resource.
Care team
Identifier details for the care team.
Identifier
The current state of the care team.
Status
The current status of the care team is proposed.
Proposed
The current status of the care team is active.
Active
The current status of the care team is suspended.
Suspended
The current status of the care team is inactive.
Inactive
The current status of the care team is entered in error.
Entered in error
Identifies what kind of team. This is to support differentiation between multiple co-existing teams, such as care plan team, episode of care team, longitudinal care team.
Category
The care team category is event.
Event
The care team category is encounter.
Encounter
The care team category is episode.
Episode
The care team category is longitudinal.
Longitudinal
The care team category is condition.
Condition
The care team category is clinicial research.
Clinical research
E.g. the "red" vs. "green" trauma teams.
A label for human use intended to distinguish like teams.
Name
The start of the period. The boundary is inclusive.
Valid period start
The end of the period. If the end of the period is missing, it means that the period is ongoing. The start may be in the past, and the end date in the future, which means that period is expected/planned to end at that time.
Valid period end
Identifies all people and organizations who are expected to be involved in the care team.
Participant
Indicates specific responsibility of an individual within the care team, such as "Primary care physician", "Trained social worker counselor", "Caregiver", etc.
Role
The specific person or organization who is participating/expected to participate in the care team.
Member
The organization of the practitioner.
On behalf of
The start of the period. The boundary is inclusive.
Valid period start
The end of the period. If the end of the period is missing, it means that the period is ongoing. The start may be in the past, and the end date in the future, which means that period is expected/planned to end at that time.
Valid period end
Describes why the care team exists.
Reason
Comments made about the CareTeam.
Note
The organisation responsible for the care team.
Managing organisation
Comments made about the participant.
Note
Any other details about the participant.
Other details
false
false
true
false
true
0
name
true
true
false
false
1
1
DV_TEXT
true
true
false
false
1
1
value
true
true
false
false
1
1
STRING
true
true
false
false
1
1
-
Emergency contacts
openEHR-EHR-ADMIN_ENTRY.care_team.v0
Care team details aligned with FHIR resource. This is an ADMIN ENTRY wrapper archetype to contain the Care team CLUSTER archetype where it has no natural ENTRY level parent.
Care team
@ internal @
Tree
Details of the Care team.
Care team details
false
false
true
false
true
0
SECTION
true
true
false
false
0
1
at0012
items
true
true
false
false
0
1
ACTION
true
false
true
0
at0000
ism_transition
true
true
false
false
1
1
ISM_TRANSITION
true
true
false
false
1
1
at0005
current_state
true
true
false
false
1
1
DV_CODED_TEXT
true
true
false
false
1
1
defining_code
true
true
false
false
1
1
CODE_PHRASE
true
true
false
false
1
1
openehr
532
careflow_step
true
true
false
false
0
1
DV_CODED_TEXT
true
true
false
false
1
1
defining_code
true
true
false
false
1
1
CODE_PHRASE
true
true
false
false
1
1
local
at0005
description
true
true
false
false
1
1
ITEM_TREE
true
true
false
false
1
1
at0001
items
true
true
false
false
0
1
ELEMENT
true
true
false
false
0
1
at0011
value
true
true
false
false
0
1
DV_TEXT
true
true
false
false
1
1
CLUSTER
true
false
true
0
at0027
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
CLUSTER
true
false
true
0
at0029
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1
constraint
false
false
true
false
true
0
protocol
true
true
false
false
0
1
ITEM_TREE
true
true
false
false
1
1
at0015
items
true
true
false
false
0
1
CLUSTER
true
false
true
0
at0017
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
CLUSTER
true
false
true
0
at0019
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
false
false
true
false
true
0
name
true
true
false
false
1
1
DV_TEXT
true
true
false
false
1
1
value
true
true
false
false
1
1
STRING
true
true
false
false
1
1
-
Review of plan
openEHR-EHR-ACTION.service.v0
A general clinical activity carried out for the patient to receive a specified service, advice or care from an expert healthcare provider.
Service
@ internal @
Tree
Service request to healthcare provider is planned.
Service planned
Appointment for a healthcare provider service has been made.
Service scheduled
The healthcare provider has delivered the service.
Service delivered
All service activities have been completed.
Service activity complete
The referral has been ceased before the service has been completed.
Service abandoned
The planned service has been postponed.
Service postponed
The planned service has been cancelled prior to commencement.
Service cancelled
The service has been suspended without completion.
Service suspended
Coding of the specific service name with a terminology is preferred, where possible.
Identification of the clinical service to be/being carried out.
Service name
For example: the reason for the cancellation or suspension of the service.
Reason that the activity or care pathway step for the identified service was carried out.
Reason
Narrative description about the service, as appropriate for the pathway step.
Description
Type of service to be carried out or being carried out.
Service type
@ internal @
Tree
The local ID assigned to the order by the healthcare provider or organisation requesting the service. This is also referred to as Placer Order Identifier.
Requestor identifier
Details about the healthcare provider or organisation requesting the service.
Requestor
The ID assigned to the order by the healthcare provider or organisation receiving the request for referral. This is also referred to as Filler Order Identifier.
Receiver identifier
Details about the healthcare provider or organisation receiving the request for referral.
Receiver
Only for use in association with the 'Service delivered' pathway step. For example: record that this is the 3rd physiotherapy appointment in a planned sequence.
The sequence of the specified clinical service.
Sequence
The referral has expired before the referral episode has been completed.
Service expired
Only for use in association with the 'Service scheduled' pathway step.
The date and/or time on which the service is intended to be performed.
Scheduled date/time
Request for service sent.
Service request sent
Use to capture detailed, structured information about specified aspects of the service.
Structured information about the service.
Service detail
Additional narrative about the activity or care pathway step not captured in other fields.
Comment
Mulitimedia representation of a performed service.
Multimedia
false
false
true
false
true
0
false
false
true
false
true
1
openEHR-EHR-SECTION.respect_headings.v0
Top level heading for capturing details of ReSPECT process.
ReSPECT headings
Heading containing summary of relevant information for the ReSPECT process.
2. Shared understanding
Details of personal preferences to guide this ReSPECT plan (where the person has capacity).
3. What matters to me
Summary of clinical recommendations for emergency care and treatment.
4. Clinical recommendations
Details of capacity and representation at the time of completion of the ReSPECT form.
5. Capacity for involvement
Details of those involved and discussions in making the ReSPECT plan.
6. Involvement in making plan
Implementation guidance - Add prompt to UI: The clinical signature is to indicate that the decision-making process has fully complied with relevant capacity and Human Rights legislation.
Details of clinicians involved in making ReSPECT plan.
7. Clinician signatures
Details of emergency contacts for ReSPECT plan.
8. Emergency contacts
Details of review dates and clinician for the confirmation of validity (e.g. for change of condition).
9. Review of Plan
false
false
true
false
true
0
openEHR-EHR-COMPOSITION.report.v1
ReSPECT-3.v0
Document to communicate information to others, commonly in response to a request from another party.
Report
@ internal @
Tree
Identification information about the report.
Report ID
The status of the entire report. Note: This is not the status of any of the report components.
Status
For example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.
Additional information required to capture local context or to align with other reference models/formalisms.
Extension
This description may be useful to display in the UI: Document to communicate relevant patient information and summary recommendations from ReSPECT (Recommended Summary Plan for Emergency Care and Treatment) process.
This description may be useful to display in the UI: Focus on life-sustaining treatment or symptom control according to clinical guidance on specific interventions specified below.
This description may be useful to display in the UI: Clinician's guidance on specific interventions that may or may not be wanted or be clinically appropriate, including being taken or admitted to hospital +/- receiving life support.
This description may be useful to display in the UI: Summary of agreed and realistic clinical recommendations for emergency care and treatment.
value
DV_TEXT
true
true
false
false
1
1
ReSPECT recommendations
[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.respect_headings.v0]/items[at0008]/items[openEHR-EHR-EVALUATION.mental_capacity.v0]/data[at0001]/items[at0009]
value
DV_TEXT
true
true
false
false
1
1
ReSPECT Emergency contacts
[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.respect_headings.v0]/items[at0011]/items[openEHR-EHR-ADMIN_ENTRY.care_team.v0]/data[at0001]/items[openEHR-EHR-CLUSTER.care_team.v0]/items[at0018]
value
DV_TEXT
true
true
false
false
1
1
ReSPECT clinical review
[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.respect_headings.v0]/items[at0012]/items[openEHR-EHR-ACTION.service.v0 and name/value='Review of plan']/description[at0001]/items[at0011]
value
DV_CODED_TEXT
true
true
false
false
1
1
Living will and advance directive record (record artifact)
SNOMED-CT
827701000000106
[openEHR-EHR-COMPOSITION.report.v1]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.xds_metadata.v0]/items[at0003]
encoding
Review date
provider
Review date
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