operationaltemplate.ips.v0.opt Maven / Gradle / Ivy
ISO_639-1
en
Heather Leslie
Atomica Informatics
[email protected]
2020-08-17
unmanaged
5b4c02e8097ed021f8e3d6580fe7f5a4
05F3E1D9A0891A37F1DD10A47CCFA472
ISO_639-1::en
ISO_639-1
en
An International Patient Summary (IPS) document is an electronic health record extract containing essential healthcare information about a subject of care. As specified in EN 17269 and ISO/DIS 27269, it is designed for supporting the use case scenario for ‘unplanned, cross border care’, but it is not limited to it. It is intended to be international, i.e., to provide generic solutions for global application beyond a particular region or country.
The IPS dataset is minimal and non-exhaustive; specialty-agnostic and condition-independent; but still clinically relevant.
The IPS document is composed by a set of robust, well-defined and potentially reusable sets of core data items (indicated as IPS library in the figure below). The tight focus of the IPS on unplanned care is in this case not a limitation, but, on the contrary, facilitates their potential re-use beyond the IPS.
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International Patient Summary
International Patient Summary
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openEHR-EHR-CLUSTER\.medication(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.medication(-[a-zA-Z0-9_]+)*\.v1
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openEHR-EHR-CLUSTER.medication.v1
Details about a medication or component of a medication, including strength, form and details of any specific constituents.
Medication
The medication or medication component consists of a number of separate products which are pre-packaged by the manufacturer, for example Canesten Combi.
Combination product
Any other form of expiry date, such as time from production or depending on storage environment, can be inserted using a specific CLUSTER archetype in the Substance Details slot or added as part of the Description.
For example: '2017-05-23'.
The expiry date and/or time of the medication or medication component, as given by the manufacturer or individual preparing the mixture.
Expiry
The strength numerator is usually recorded using mass, volume or arbitrary units. For example: 'mg', 'ml', 'IU'. For a presentation strength of '300 µg/0.3 ml', the strength numerator unit is 'µg'. For a presentation strength of '100 mg/tablet', the strength numerator value is 'mg'.
The unit of the numerator of the strength fraction.
Strength numerator unit
The strength denominator is usually recorded using mass or volume units. For example: 'g', 'ml'. For a presentation strength of '300 µg/0.3 ml', the strength denominator unit is 'ml'. For a presentation strength of '100 mg/tablet', the strength denominator unit is '1'. For this example, the 'Unit of presentation' element is used to record the presentation unit of the medication, 'tablet'.
The unit of the denominator of the strength fraction.
Strength denominator unit
The value of the alternate amount is recorded in the 'Alternate amount' element. For example: for a medication with a strength of '5 mg/ml' and where the Amount is '1 ml', the equivalent amount would be 5 mg and the value recorded in this data element would be 'mg'.
The unit of an equivalent representation of the amount of the medication or medication component.
Alternate amount unit
For example: 'mg', 'ml', 'IU'.
Note: The value of the amount is recorded using the 'Amount' element.
The unit of the amount of medication or medication component.
Amount unit
For example: 'tablet', 'capsule', 'cream', 'infusion fluid' or 'inhalation powder'. Coding of the form with a terminology is preferred, where possible. Medicines catalogues may differentiate between administrable form 'solution for injection' and product form 'powder for solution for injection'. The recorded form will depend on the exact context of use but administrable form is likely to be used in most instances.
The formulation or presentation of the medication or medication component.
Form
Constituent that alone or in combination with one or more other ingredients is considered to fulfil the intended activity of a medicinal product.
Therapeutic
Constituent whose primary function is to modify the activity of an active constituent. An adjuvant constituent itself may or may not be therapeutically active.
Adjuvant
Constituent that is inert in relation to the intended activity of the medicinal product.
Excipient
This element is used for liquid or semisolid medications, or medications intended to be diluted in a liquid before administration. For example: '10 mg/ml', '20 mg/g', '5 %', '10,000 SQ-U/ml'.
The strength of the medication or medication component, as a concentration.
Strength (concentration)
The role of the medication or medication component within a mixture.
Role
For example: 'Zinacef 750 mg powder' or 'cefuroxim'. This item should be coded if possible, using for example, RxNorm, DM+D, Australian Medicines Terminology or FEST. Usage of this element will vary according to context of use. This element may be omitted where the name of the medication is recorded in the parent INSTRUCTION or ACTION archetype, and this archetype is only used to record that the form must be or was 'liquid'.
The name of the medication or medication component.
Name
Narrative description of the medication or medication component where it is not possible to describe this fully using structured elements.
Description
This slot is intended to be used to add details about constituents of the medication or medication component, using nested instances of this archetype. This is not normally required other than where a mixture is being described.
Details of an ingredient or product used to make up a mixed pack, preparation or infusion.
Constituent
For example: '1', '1.5', '1000'.
Note: the associated unit for this amount is recorded using the 'Amount unit' element.
The value of the amount of medication or medication component.
Amount
For example: detailed information about the drug class or intended routes, or additional expiry information.
Additional details about the medication or medication component.
Structured details
For example: 'Paracetamol/codeine' is a Multi-ingredient product, while 'Morphine 60 mg + Haloperidol 2 mg + Midazolam 5 mg' is an Ad-hoc mixture, whose composition is fully specified within the order.
The category of the medication or medication component, with regard to manufacturing or preparation, and the number of ingredients.
Category
The medication or medication component is composed of a mixture of ingredients specified within the order. These are typically prepared by pharmacy or ward personnel to suit individual patients.
Ad-hoc mixture
The medication or medication component consists of a number of active ingredients which are pre-combined into a single form such as a tablet, cream or powder by the manufacturer, for example Paracetamol/codeine.
Multi-ingredient product
The medication or medication component is a manufactured product containing a single active ingredient.
Single-ingredient product
The medication or medication component is an individual ingredient of the medication. This term is used when the archetype is nested within a parent instance of itself, to describe the individual ingredients of a medication.
Ingredient
The unit of the alternate amount is recorded in the 'Alternate amount unit' element. For example: for a medication with a strength of '5 mg/ml' and where the Amount is '1 ml', the equivalent amount would be 5 mg and the value recorded in this data element would be '5'.
The value of an equivalent representation of the amount of the medication or medication component.
Alternate amount
The identifier assigned to the production batch by the manufacturer during production.
Batch ID
For example: 'Abbott'.
The manufacturer of the medication or medication component.
Manufacturer
In some cases, as for liquid or semisolid medications, the denominator of the strength ratio is a physical quantity, for example 2 mg/5 ml. In some of these cases the denominator also reflects the actual volume of the component: 5 ml in the previous example. In this case the 'Strength (concentration)' would be 0.4 mg/ml. In other cases, where the strength involves a denominator which is not a physical quantity, for example 4 mg/tablet, the denominator is expressed as a unitary value '1' with a unit of '1', and 'tablet' is carried in the 'Unit of presentation' element. This arrangement was chosen to align with the approach adopted by the ISO IDMP standard for medication catalogues.
The strength of the medication or medication component, expressed as a ratio.
Strength (presentation)
For example: For a presentation strength of '300 µg/0.3 ml', the strength numerator value is '300'. For a presentation strength of '100 mg/tablet', the strength numerator value is '100'.
The value of the numerator of the strength fraction.
Strength numerator
For example: For a presentation strength of '300 µg/0.3 ml', the strength denominator value is '0.3'. For a presentation strength of '100 mg/tablet', the strength denominator value is '1'.
The value of the denominator of the strength fraction.
Strength denominator
For example: 'tablet', 'capsule', 'puff', 'inhalation'. In most cases, like for tablets and capsules, the unit of presentation is identical to the Form. For some presentations such as inhalers, the Form may be 'inhalation powder', 'inhalation aerosol' or 'inhaler' while the unit of presentation is 'inhalation', 'puff', or 'dose'.
The unit of presentation for a single dose of the medication, for use with the 'Strength denominator unit' element.
Unit of presentation
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at0039
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ELEMENT
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at0026
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DV_TEXT
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true
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1
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ELEMENT
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0
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at0040
value
true
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0
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DV_DURATION
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1
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value
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true
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1
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DURATION
true
true
false
false
1
1
-
PTHMS
true
true
false
false
PT0S
PT24H
false
false
true
false
true
1
CLUSTER
true
false
true
0
at0035
items
true
true
false
false
1
1
ELEMENT
true
true
false
false
0
1
at0036
value
true
true
false
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0
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DV_DURATION
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true
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1
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value
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1
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DURATION
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1
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-
PTHMS
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PT0S
PT24H
ELEMENT
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at0037
value
true
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DV_DURATION
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1
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DURATION
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1
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-
PTHMS
true
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PT0S
PT24H
ELEMENT
true
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false
0
1
at0038
value
true
true
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0
1
DV_COUNT
true
true
false
false
1
1
magnitude
true
true
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1
1
INTEGER
true
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1
1
-
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0
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1
openEHR-EHR-CLUSTER.timing_daily.v1
Structured information about the intended timing of a therapeutic or diagnostic activity within any 24 hour period.
Timing - daily
For example: "4 times per day" or "3 to 4 times per hour".
The frequency as number of times per time period that the activity is to take place.
Frequency
For example: "08:00" or "15:00-16:00".
A specific time or interval of time when the activity should occur.
Specific time
For example: "Every 4 hours" or "Every 4 to 6 hours".
The time interval or minimum and maximum range of an interval between each scheduled activity.
Interval
For example when administering antiparkinson medications.
Is exact timing of the activity critical to effectiveness, or patient safety or wellbeing?
Exact timing critical?
Termed 'PRN' ("pro re nata", latin: "as the situation arises") or 'PN' ("per necessare", latin: "when required") in some cultures.
Record as True if the activity should only occur when the "'As required' criterion" is met.
As required
For example: "for pain".
The condition which triggers an 'As required' activity.
'As required' criterion
For example: "Before each meal", "at bedtime", "in the morning". It is understood that these event names may not equate to the same exact times in different cultures. Coding with a terminology, for example HL7 FHIR Named events, is recommended where appropriate.
The name of the event that triggers the activity to take place.
Event name
For example: "Take morning and evening".
Text description of the daily timing. This element is intended to allow implementers to use the structures for different timings without necessarily specifying the timings in a structured way.
Timing description
For example: "Apply an ice pack on for 20 minutes, off for an hour, repeat".
A cycle of activity where an on-off pattern is required.
On / off cycle
The period of time for which the activity should take place.
On
The period of time for which the activity should NOT take place.
Off
The number of repetitions of the on/off cycle.
Repetitions
A specific, named time event that the activity should occur in relation to.
Specific event
For example: '30 minutes after meal = meal + 30 minutes', '2 hours before bedtime = bedtime -2 hours'.
The period of time before or after the named event when the activity should take place. Negative durations can be used to signify that the activity should take place before the event.
Time offset
false
false
true
false
true
1
openEHR-EHR-CLUSTER.dosage.v1
For example: '2 tablets at 6pm' or '20mg three times per day'. Please note: this cluster allows multiple occurrences to enable representation of a complete set of dose patterns for a single dose direction.
The combination of a medication amount and administration timing for a single day, in the context of a medication order or medication management.
Dosage
For example: 'in the morning', 'at 0600, 1400, 2100'.
Structured details about the timing pattern for a single day.
Daily timing
For example: 'Administer over 10 minutes'.
The period of time over which a single dose of the medication or vaccine should be administered.
Administration duration
For example: '200 ml/h'. Use the text data type to record non- or semi-quantifiable instructions.
The rate at which the medication, such as an infusion, is to be administered.
Administration rate
For example: '10mg/kg/day'. The result of this formula would normally be held in Dose amount/unit or Administration rate/duration. Where clinical measurements such as body weight is used in the dose calculation, a LINK attribute should used to specify which particular measurement has been used.
The formula used to calculate the dose amount or administration rate where this is dependent on some other factor, such as body weight or surface area.
Dose formula
For example: 1, 1.5, 0.125 or 1-2, 12.5-20.5
The value of the amount of medication administered at one time, as a real number, or range of real numbers, and associated with the Dose unit.
Dose amount
For example: 'tablet','mg'. Coding of the dose unit with a terminology is preferred, where possible.
The unit which is associated with the Dose amount.
Dose unit
For example: '1', '2', '3'.
Where multiple dosages are expressed, the 'Pattern sequence' makes the order in which they should be executed explicit. For example: (1) 1 tab in the morning, (2) 2 tab at 2pm, (3) 1 tab at night.
The intended position of this dosage within the overall sequence of dosages.
Dosage sequence
For example, can be used to represent a unit-dose based value such as 'tabs', when the Dose amount is expressed as an SI unit such as 'mg', or where it is required to express the total amount of an infusion as well as the dose amount of the active ingredient.
An alternate representation of the value of the amount of medication administered at one time, as a real number, or range of real numbers, and associated with the Dose unit.
Alternate dose amount
The unit which is associated with the Alternate dose amount.
Alternate dose unit
For example: "Apply ointment to affected area until it glistens". This element is intended to allow implementers to use the structures for increasing/tapering dosages without necessarily specifying the doses in a structured way.
Text description of the dose.
Dose description
CLUSTER
true
true
false
false
0
1
at0140
items
true
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1
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ELEMENT
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0
1
at0147
value
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DV_TEXT
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1
1
ELEMENT
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at0141
value
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0
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DV_TEXT
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1
1
CLUSTER
true
true
false
false
0
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at0142
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
openEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_circle(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.v1
constraint
CLUSTER
true
false
true
0
at0144
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1
constraint
false
false
true
false
true
1
CLUSTER
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false
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0
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at0000
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ELEMENT
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at0002
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value
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DURATION
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PYMWD
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P0D
ELEMENT
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at0014
value
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DV_QUANTITY
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openehr
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1/mo
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366
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0
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1/a
DV_INTERVAL<DV_QUANTITY>
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1
1
upper
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0
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DV_QUANTITY
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1
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openehr
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0
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366
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DV_QUANTITY
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openehr
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1
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31
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ELEMENT
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at0001
value
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DV_DATE
true
true
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1
1
DV_INTERVAL<DV_DATE>
true
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1
1
upper
true
true
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0
1
DV_DATE
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1
1
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DV_DATE
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ELEMENT
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at0003
value
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DV_CODED_TEXT
true
true
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1
1
defining_code
true
true
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1
1
CODE_PHRASE
true
true
false
false
1
1
local
at0007
at0008
at0016
at0017
at0018
at0019
at0020
ELEMENT
true
true
false
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0
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at0004
value
true
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0
1
DV_COUNT
true
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magnitude
true
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1
1
INTEGER
true
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1
1
-
true
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DV_INTERVAL<DV_COUNT>
true
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1
1
upper
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DV_COUNT
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INTEGER
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ELEMENT
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at0021
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DV_TEXT
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CLUSTER
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at0006
items
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ELEMENT
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at0005
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ELEMENT
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at0009
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DURATION
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1
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PYMWD
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1
CLUSTER
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0
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at0010
items
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1
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ELEMENT
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at0011
value
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DURATION
true
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PYMWD
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P0D
ELEMENT
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at0012
value
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DURATION
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ELEMENT
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at0013
value
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INTEGER
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openEHR-EHR-CLUSTER.timing_nondaily.v1
Structured information about the intended timing pattern for a therapeutic or diagnostic activity occurring over days, weeks, months or years.
Timing - non-daily
For example: 'on 12 Jan 2017' or 'on 30 Oct 2017 to 6 Nov 2017'.
The activity should take place on a specific date or a specific range of dates.
Specific date
For example: 'Every 3 weeks'. If necessary, this element can be used to explicity specify that an activity is to take place every single day, by setting it to "1 day".
The interval between repetitions of the activity.
Repetition interval
For example: 'On Monday, Wednesday and Friday'.
The activity should take place on a specific day of the week.
Specific day of week
For example: 'on the 3rd, 13th and 23rd of each month' or 'on the 1st to the 10th of each month'.
The activity should take place on a specific day or interval of days of the month.
Specific day of month
This element is intended for events that can occur at variable dates, such as onset of menstruation, and not for doses or activities that are conditional on a different varable. If required, the event name can be coded using a terminology, which could potentially be used to trigger an application to set a concrete date for the activity.
The name of the event that triggers the activity to take place.
Event name
The activity should take place in relation to a specific named event.
Specific event
The activity should take place on Monday.
Monday
The activity should take place on Tuesday.
Tuesday
For example: '3 days after onset of menstruation = menstrual onset + 3 days', '2 weeks prior to admission= admission -2 weeks'.
The period of time before or after the named event when the activity should take place. Negative durations can be used to signify that the activity should be taken before a known event.
Time offset
For example: 'take for 1 week, omit 2 weeks, repeat 4 times'
A cycle of activity where an on-off pattern is required.
On / off cycle
The period of time for which the activity should take place.
On
The period of time for which the activity should NOT take place.
Off
The number of repetitions of the on/off cycle.
Repetitions
For example: '3 times per week', '2-4 times per month'.
The number of days per time period on which the activity is to take place.
Frequency
The activity should take place on Wednesday.
Wednesday
The activity should take place on Thursday.
Thursday
The activity should take place on Friday.
Friday
The activity should take place on Saturday.
Saturday
The activity should take place on Sunday.
Sunday
For example: 'Use for one week, then stop for two weeks, then repeat'. This element is intended to allow implementers to use the structures for daily timings without necessarily specifying the non-daily timings in a structured way.
Text description of the timing.
Timing description
false
false
true
false
true
0
protocol
true
true
false
false
0
1
ITEM_TREE
true
true
false
false
1
1
at0030
items
true
true
false
false
0
1
ELEMENT
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0
at0103
value
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0
1
DV_IDENTIFIER
true
true
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false
1
1
CLUSTER
true
false
true
0
at0085
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
false
false
true
false
true
1
name
true
true
false
false
1
1
DV_TEXT
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1
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value
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STRING
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1
-
Medication statement
openEHR-EHR-ACTION.medication.v1
This is not limited to activities performed based on medication orders from clinicians, but could also include for example taking over the counter medication.
Any activity related to the planning, scheduling, prescription management, dispensing, administration, cessation and other use of a medication, vaccine, nutritional product or other therapeutic item.
Medication management
A prescription has been issued for the medication.
Prescription issued
The ordered medication has been dispensed, for example from a pharmacy to the patient.
Prescription dispensed
The medication has been taken by, or administered to, the patient for the first time. Although in some settings this significant date may be computable as the first of several administrations, in other settings, such as primary care, specific administration dates are not readily available.
Medication course commenced
The individual medication has been reassessed, for example whether the medication should still be taken. This is not intended to capture review of the medication list.
Medication reassessed
A single administration of the medication has taken place.
Dose administered
The medication course has been completed as planned.
Medication course completed
The prescription has not been dispensed due to a technical or pharamaceutical supply issue.
Prescription supply delayed
The administration of the medication has been suspended until further notice. No further doses should be given until the restart date or conditions have been met. When setting the date/conditions for restart after suspending, a step from ‘Administrations suspended’ and back to 'Medication start date/condition set' should be performed.
Administrations suspended
A prescription has been re-issued for an existing medication order.
Prescription re-issued
Issue of the prescription is awaiting re-authorisation by a clinician.
Prescription re-authorisation pending
The planned course of medication has been cancelled prior to any administration.
Medication course cancelled
The scheduled medication course has been postponed prior to any administration.
Medication course postponed
Administration of the medication has been ceased during the period of the intended course.
Medication course stopped
The time to start the medication, or other starting condition, has been set.
Medication start date/condition set
@ internal @
Tree
An administration of the medication has been withheld and not given. There is no expectation that it will be given later, though the next dose (if any) should be administered according to the original order.
Dose administration omitted
For example: 'Atenolol 100mg' or 'Tenormin tablets 100mg'.
It is strongly recommended that the 'Medication item' is coded with a terminology capable of triggering decision support, where possible. The extent of coding may vary from the simple name of the medication item through to structured details about the actual medication pack used. Free text entry should only be used if there is no appropriate terminology available.
Name of the medication, vaccine or other therapeutic/prescribable item which was the focus of the activity.
Medication item
For example: 'Postponed - Patient not avalable at administration time', 'Cancelled - Adverse reaction'. Note: This is not the reason for the medication instruction, but rather the specific reason that a care step was carried out, and will often be used to document some variance from the original order.
Reason that the pathway step for the identified medication was carried out.
Reason
For example: 'Patient was in radiology department', 'Accidental injection into blood vessel during IM administration'.
Additional narrative about the activity or pathway step not captured in other fields, including details of any variance between the intended action and the action actually performed.
Comment
The sequence number specific to the pathway step being recorded.
Sequence number
@ internal @
Tree
For example: 'Avoid grapefruit' , 'Take at least 2 hours before bedtime', 'Take with food'. May be coded with a terminology when clinically appropriate.
Any guidance, instructions or advice given to the subject of care or personal carer at the time of the pathway step.
Patient guidance
A major change to the order was required, resulting in this order being stopped and a replacement order being started.
Major change to order
The medication order has been changed in a manner which does not require a new instruction/order to be issued, according to local clinical rules.
Minor change to order
Used to compare variance from actual action time where this is not readily calculable from the original instruction.
The datetime at which the medication action was scheduled to occur.
Original scheduled date/time
An administration of a dose of the medication has been delayed but is expected to be given as soon as possible.
Dose administration deferred
Further structured details of the action, possibly specific to a pathway step.
Additional details
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
Comment: This data element allows for multiple occurrences to be defined more explicitly at run-time, if required.
Unique identifier for the medication order.
Order ID
Use this SLOT where the detailed description of the dispensed, authorised or administered item needs to be explicitly stated. For example: the form, strength, any diluents or mixture of ingredients.
Structured details about the medication including strength, form and constituent substances.
Medication details
The original medication order has been re-authorised to allow repeat prescription or dispensing. In some jurisdictions an entirely new order must be issued in these circumstances.
Prescription re-authorised
The medication has been recommended but no steps have been taken to initiate prescribing.
Medication recommended
CLUSTER.dosage is intended to carry details of medication order changes or dose administrations, whilst CLUSTER.medication_supply_amount is intended for details of dispensing-related activity.
Specific details about the amount of the medication item.
Amount
In many jurisdictions, substitution of an ordered item as a generic form or with a different brand name, which has been determined as bioequivalent, is allowed at the point of dispense or supply. In other cases substitution is assumed and the clinician has to explicitly request non-substitution.
Subsitution action taken by the person administering or dispensing the drug.
Substitution
For example: "Generic alternative contains a substance that is not tolerated by the patient." May be coded with a terminology when clinically appropriate
The reason or justification for the substitution action taken.
Substitution reason
A medication was substituted which is bioequivalent to that ordered.
Substitution performed
Although allowed by the medication order a bioequvalent medication was not substituted.
Substitution not performed
Details of body site and administration of the medication.
Administration details
For example: 'left upper arm', 'intravenous catheter right hand'.
Coding of the body site with a terminology is preferred, where possible.
Structured description of the site of administration of the ordered item.
Body site
For example: "On the medial skin surface of the left forearm, from 10 cm to 20 cm distally from the point of the elbow".
Structured description of the site of administration of the medication, vaccine or therapeutic good.
Structured body site
Comment: For example: ' via Z-track injection'; 'via nebuliser'. Coding of the method with a terminology is preferred, where possible.
The technique or device by which the ordered item was, or is to be, administered.
Administration method
Details of the medical device used to assist administration of the medication.
Administration device
Draft prescription has been prepared and is awaiting confirmation from an authorised clinician. May be used where reauthorisations are performed as a batch. This careflow_step may have a status of 'planned' or 'active', reflecting the need to to handle new orders as well as re-authorised orders.
Prescription awaiting authorisation
Comment: For example: 'oral', 'intravenous', or 'topical'. Coding of the route with a terminology is preferred, where possible. Multiple potential routes may be specified.
The route by which the ordered item was, or is to be, administered into the subject's body.
Route
The medication has been physically prepared. For example: preparation of an intravenous mixture.
Medication prepared
Details of the individual performing the double-check can be carried in the Reference Model element "Participation".
The pathway step has been checked by a separate individual.
Double-checked?
The prescription was cancelled prior to being issued.
Prescription cancelled
Prescription has been invalidated or has expired without being fulfilled.
Prescription invalid or expired
The prescription has been fulfilled successfully.
Prescription fulfilled
The medication has been formally authorised for use.
Medication authorised
For example: 2017-10-29
The date/time on which the medication course is set to restart, as per the "Administrations suspended" pathway step.
Restart date/time
For example: "On day 2 after surgery".
The criterion which triggers the medication course to restart, as per the "Administrations suspended" pathway step.
Restart criterion
EVALUATION
true
true
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0
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at0000
data
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1
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ITEM_TREE
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1
at0001
items
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ELEMENT
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1
at0002
name
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DV_CODED_TEXT
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1
1
defining_code
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1
1
CODE_PHRASE
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true
false
false
1
1
local
at0005
value
true
true
false
false
1
1
STRING
true
true
false
false
1
1
-
Global exclusion of medication use
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
-
No known medications
false
false
true
false
true
1
protocol
true
true
false
false
0
1
ITEM_TREE
true
true
false
false
1
1
at0008
items
true
true
false
false
0
1
CLUSTER
true
false
true
0
at0010
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
false
false
true
false
true
0
openEHR-EHR-EVALUATION.exclusion_global.v1
An overall statement of exclusion about all Problems/diagnoses, Family history, Medications, Procedures, Adverse reactions or other clinical items that are either not currently present, or have not been present in the past.
Exclusion - global
@ internal @
Tree
For example: 'No previous diagnoses', 'No known family history', 'No known history of adverse reactions', 'Never taken any medications' or 'No known operations or significant procedures'.
An overall statement of exclusion about all Problems/diagnoses, Family history, Medications, Procedures, Adverse reactions or other clinical items.
Global exclusion statement
Overall statement of exclusion of all problems or diagnoses at the time of recording.
Global exclusion of problems/diagnoses
Overall statement of exclusion of all significant health-related problems in relatives or family members of the individual at the time of recording.
Global exclusion of family history
Overall statement of exclusion about the use of all medications at the time of recording.
Global exclusion of medication use
Overall statement of exclusion about all procedures at the time of recording.
Global exclusion of procedures
Overall statement of exclusion about all adverse reactions at the time of recording.
Global exclusion of adverse reactions
@ 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
Additional comment not covered in other fields.
Comment
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
1
1
at0002
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
-
No information about medications
false
false
true
false
true
1
protocol
true
true
false
false
0
1
ITEM_TREE
true
true
false
false
1
1
at0003
items
true
true
false
false
0
1
ELEMENT
true
true
false
false
0
1
at0004
value
true
true
false
false
0
1
DV_DATE_TIME
true
true
false
false
1
1
CLUSTER
true
false
true
0
at0006
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
false
false
true
false
true
0
openEHR-EHR-EVALUATION.absence.v2
Statement that specified health information is not available for inclusion in the health record or extract at the time of recording.
Absence of information
@ internal @
Tree
For example: "No information available about adverse reactions"; No information available about problems or diagnoses"; "No information available about previous procedures performed"; or "No information available about medications used".
Positive statement that no information is available.
Absence statement
@ internal @
Tree
The date at which the absence was last updated.
Last updated
For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible.
Description of the reason why there is no information available.
Reason for absence
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
false
false
true
false
true
0
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
true
true
false
false
1
1
at0000
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
-
Allergies & Intolerances
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
1
1
at0002
value
true
true
false
false
0
1
DV_TEXT
true
true
false
false
1
1
ELEMENT
true
true
false
false
0
1
at0063
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
at0127
at0064
at0065
at0067
at0066
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
-
Verification status
ELEMENT
true
true
false
false
0
1
at0101
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
at0102
at0103
at0124
ELEMENT
true
true
false
false
0
1
at0058
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
-
Allergy
Intolerance
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
-
Type
ELEMENT
true
true
false
false
0
1
at0006
value
true
true
false
false
0
1
DV_TEXT
true
true
false
false
1
1
CLUSTER
true
false
true
0
at0009
items
true
true
false
false
1
1
ELEMENT
true
false
true
1
at0011
value
true
true
false
false
0
1
DV_TEXT
true
true
false
false
1
1
ELEMENT
true
true
false
false
0
1
at0027
value
true
true
false
false
0
1
DV_DATE_TIME
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
-
Onset
ELEMENT
true
true
false
false
0
1
at0089
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
at0093
at0092
at0090
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
-
Severity
CLUSTER
true
false
true
0
at0029
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
openEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.symptom_sign(-[a-zA-Z0-9_]+)*\.v1
constraint
CLUSTER
true
false
true
0
at0096
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
openEHR-EHR-CLUSTER\.citation(-[a-zA-Z0-9_]+)*\.v1
constraint
CLUSTER
true
false
true
0
at0119
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
CLUSTER
true
false
true
0
at0041
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
CLUSTER
true
false
true
0
at0116
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
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
-
Reaction
false
false
true
false
true
1
protocol
true
true
false
false
0
1
ITEM_TREE
true
true
false
false
1
1
at0042
items
true
true
false
false
0
1
ELEMENT
true
true
false
false
0
1
at0062
value
true
true
false
false
0
1
DV_DATE_TIME
true
true
false
false
1
1
CLUSTER
true
false
true
0
at0128
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
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
-
Allergy Intolerance
openEHR-EHR-EVALUATION.adverse_reaction_risk.v1
Substances include, but are not limited to: a therapeutic substance administered correctly at an appropriate dosage for the individual; food; material derived from plants or animals; or venom from insect stings.
Risk of harmful or undesirable physiological response which is unique to an individual and associated with exposure to a substance.
openEHR,FHIR
Adverse reaction risk
@ internal @
Tree
Both an individual substance and a substance class are valid entries in 'Substance'. A substance may be a compound of simpler substances, for example a medicinal product. If the value in 'Substance' is an individual substance, it may be duplicated in 'Specific substance'. It is strongly recommended that both 'Substance' and 'Specific substance' be coded with a terminology capable of triggering decision support, where possible. For example: Snomed CT, DM+D, RxNorm, NDFRT, ATC, New Zealand Universal List of Medicines and Australian Medicines Terminology. Free text entry should only be used if there is no appropriate terminology available.
Identification of a substance, or substance class, that is considered to put the individual at risk of an adverse reaction event.
openEHR,FHIR,DAM
Substance
For example: including reason for flagging a 'Criticality' of 'High risk'; and instructions related to future exposure or administration of the Substance, such as administration within an Intensive Care Unit or under corticosteroid cover.
Additional narrative about the propensity for the adverse reaction, not captured in other fields.
openEHR
Comment
Details about each adverse reaction event linked to exposure to the identified 'Substance'.
openEHR,FHIR,DAM
Reaction event
For example: 'Amoxycillin'. Only an individual substance is a valid entry in 'Specific substance'. A substance may be a compound of simpler substances, for example a medicinal product. If the value in 'Substance' is an individual substance and not a substance class, then it may be duplicated in this data element. It is strongly recommended that 'Specific substance' be coded with a terminology capable of triggering decision support, where possible. For example: RxNorm, Snomed CT, DM+D, NDFRT, ICD-9, ICD-10, UNI, ATC and CPT. Free text entry should only be used if there is no appropriate terminology available.
Identification of the substance considered to be responsible for the specific adverse reaction event.
FHIR, openEHR,DAM
Specific substance
Manifestation can be expressed as a single word, phrase or brief description. For example: nausea, rash. 'No reaction'may be appropriate where a previous reaction has been noted but the reaction did not re-occur after further exposure. It is preferable that 'Manifestation' should be coded with a terminology, where possible. The values entered here may be used to display on an application screen as part of a list of adverse reactions, as recommended in the UK NHS CUI guidelines.
Terminologies commonly used include, but are not limited to, SNOMED-CT or ICD10.
Clinical symptoms and/or signs that are observed or associated with the adverse reaction.
FHIR, openEHR,DAM
Manifestation
Narrative description about the adverse reaction as a whole, including details of the manifestation if required.
FHIR, openEHR
Reaction description
Narrative description about exposure to the identified 'Specific substance'.
openEHR
Exposure description
Exposure can be more complicated by more than one exposure events leading to a reaction. Further details about the nature of the exposure can be provided by use of additional archetypes in the 'Exposure details' SLOT or as text in the 'Exposure description'.
Record of the date and/or time of the first exposure to the Substance for this Reaction Event.
FHIR, openEHR,DAM
Initial exposure
Statement about the degree of clinical certainty that the identified 'Specific substance' was the cause of the 'Manifestation' in this reaction event.
FHIR
Certainty
A reasonable level of clinical certainty that the reaction was caused by the identified 'Specific substance'.
openEHR
Likely
The total amount of time the individual was exposed to the identified 'Specific substance'.
openEHR
Duration of exposure
Record of the date and/or time of the onset of the reaction.
openEHR, FHIR, DAM
Onset of reaction
The total amount of time that the manifestation of the adverse reaction persisted.
openEHR
Duration of reaction
May include structured detail about symptoms; the anatomical location of the manifestation; grading, classification or formal severity assessments such as Common Terminology Criteria for Adverse Events; or the Multimedia CLUSTER archetype. [Note: FHIR - These would be extensions as specified in a profile.]
Additional details about the adverse reaction, including anatomical location and Common Toxicity Criteria, can be provided by inclusion of specific archetypes in this SLOT.
FHIR, openEHR
Reaction details
Additional narrative about the adverse reaction event not captured in other fields.
openEHR
Reaction comment
Narrative description about the clinical management provided.
openEHR
Clinical management description
Additional structured details required for reporting to regulatory bodies can be provided by inclusion of specific archetypes in this SLOT.
FHIR, openEHR
Reporting details
@ internal @
Tree
Has the adverse reaction ever been reported to a regulatory body?
openEHR
Reaction reported?
Link to an adverse reaction Report sent to a regulatory body.
openEHR
Adverse reaction report
For example, presenting symptoms, examination findings, diagnosis etc.
[Note: FHIR,DAM: Maps to Sensitivity Test.]
Link to further information about the presentation and findings that exist elsewhere in the health record, including allergy test reports.
FHIR, openEHR, DAM
Supporting clinical record information
For example, the reason for non-reporting.
Narrative about the adverse reaction report or reporting process.
openEHR
Report comment
Immune-mediated responses have been traditionally regarded as an indicator for escalation of significant future risk. Contemporary knowledge suggests that some reactions previously thought to be immune are actually non-immune and still carry life threatening risk.
Immunological testing may provide supporting evidence for the mechanism and causative substance , but no tests are 100% sensitive or specific for a sensitivity.
It is acknowledged that most clinicians will NOT be able to distinguish the mechanism of any specific reaction. However this data element is included because many legacy systems have captured this attribute.
Identification of the underlying physiological mechanism for the adverse reaction.
FHIR, DAM
Reaction mechanism
Immune mediated reaction, including allergic reactions and hypersensitivities.
Immune mediated
A non-immune mediated reaction, which can include pseudo-allergic reactions, side effects, intolerances, drug toxicities (for example, to Gentamicin).
Non-immune mediated
Note: maps to recordedDate in FHIR.
Date when the propensity or the reaction event was updated.
openEHR, FHIR, DAM
Last updated
Decision support would typically raise alerts for 'Suspected', 'Likely', 'Confirmed', and ignore a 'Refuted' reaction. Clinical systems may choose not to display Adverse reaction entries with a
'Refuted' status in the Adverse Reaction List.
However, 'Refuted' may be useful for reconciliation of the adverse reaction list or when communicating between systems
. Some implementations may choose to make this field mandatory.
'Resolved' may be used variably across systems, depending on clinical use and context - there appears to be differing opinion whether this should still be used to raise potential alerts or to display in an Adverse Reaction List. The free text data type will allow for local variation by enabling other value sets to be applied to this data element in a template - in this situation it is recommended that values should be coded using a terminology.
Assertion about the certainty of the propensity, or potential future risk, of the identified 'Substance' to cause a reaction.
FHIR, DAM
Status
A reasonable level of certainty about the propensity for a reaction to the identified 'Substance'.
Likely
A high level of certainty about the propensity for a reaction to the identified 'Substance', which may include clinical evidence by testing or re-challenge.
Confirmed
The propensity for a reaction to the identified 'Substance' has been clinically reassessed or has been disproved with a high level of clinical certainty by re-exposure or deliberate challenge.
Refuted
The previously known reaction to the identified 'Substance' has been clinically reassessed and considered no longer to be an active risk.
Resolved
It is acknowledged that this assessment is very subjective. There may be some some specific practice domains where objective scales have been applied.
Objective scales can be included in this model using the 'Reaction details' Cluster.
Clinical assessment of the severity of the reaction event as a whole, potentially considering multiple different manifestations.
DAM
Severity of reaction
Causes severe physiological effects.
FHIR
Severe
Causes moderate physiological effects.
FHIR
Moderate
Causes mild physiological effects.
FHIR
Mild
A low level of clinical certainty that the reaction was caused by the identified 'Specific substance'.
Suspected
Additional details about exposure to the 'Specific substance', especially in situations where there may have been multiple or cumulative exposures can be provided by inclusion of specific archetypes in this SLOT.
Exposure details
Structured details about reports that have been forwarded to regulatory bodies.
Report summary
This can be regarded as a predictive judgement of a 'worst case scenario'.
In most contexts 'Low' would be regarded as the default value.
An indication of the potential for critical system organ damage or life threatening consequence.
DAM, openEHR
Criticality
Exposure to substance unlikely to result in critical system organ damage or life threatening consequence. Future exposure to the identified 'Substance' should be considered a relative contra-indication in normal clinical circumstances.
Low
Exposure to substance may result in critical organ system damage or life threatening consequence. Future exposure to the identified 'Substance' should be considered an absolute contra-indication in normal clinical circumstances.
High
Coding of the Route of Exposure with a terminology should be used wherever possible.
Identification of the route by which the subject was exposed to the identified 'Specific substance'.
FHIR, DAM
Route of exposure
This SLOT is intended to provide details about the source of information for this particular 'Reaction event'. Details about the source of information for the entire 'Adverse reaction risk' should be recorded using the 'Information Provider' reference model attribute.
Details about the provenance of the information can be provided by inclusion of specific archetypes in this SLOT.
Information source
This date may be be a duplicate of the most recent 'Onset of reaction' date.
Where a textual representation of the date of last occurrence is required e.g 'In Childhood, '10 years ago' the Comment element should be used.
The date and/or time of the onset of the last known occurrence of a reaction event.
IMH
Onset of last reaction
A high level of clinical certainty that the reaction was due to the identified 'Substance', which may include clinical evidence by testing or re-challenge.
Confirmed
Additional structured details about clinical management for this reaction event can be provided by inclusion of specific archetypes in this SLOT.
Clinical management details
This data element has been included because it is currently being captured in some clinical systems. This data can be derived from the Substance where coding systems are used, and is effectively redundant in that situation.
Category of the identified 'Substance'.
Category
Any substance consumed to provide nutritional support for the body, such as peanut or egg.
Food
Any substance administered to achieve a physiological effect.
Medication
Any other substance encountered including venom, latex and other environmental substances.
Other
Unable to assess with information available.
Indeterminate
Date that the report was sent to the regulatory authority.
Date of report
The physiological mechanism could not be determined.
Indeterminate
A low level of clinical certainty about the propensity of a reaction to the identified 'Substance'.
Suspected
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
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
1
1
at0002
name
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
local
at0007
value
true
true
false
false
1
1
STRING
true
true
false
false
1
1
-
Global exclusion of adverse reactions
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
-
No known allergies
No known medication allergies
No known environmental allergies
No known food allergies
false
false
true
false
true
1
protocol
true
true
false
false
0
1
ITEM_TREE
true
true
false
false
1
1
at0008
items
true
true
false
false
0
1
CLUSTER
true
false
true
0
at0010
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
false
false
true
false
true
0
openEHR-EHR-EVALUATION.exclusion_global.v1
An overall statement of exclusion about all Problems/diagnoses, Family history, Medications, Procedures, Adverse reactions or other clinical items that are either not currently present, or have not been present in the past.
Exclusion - global
@ internal @
Tree
For example: 'No previous diagnoses', 'No known family history', 'No known history of adverse reactions', 'Never taken any medications' or 'No known operations or significant procedures'.
An overall statement of exclusion about all Problems/diagnoses, Family history, Medications, Procedures, Adverse reactions or other clinical items.
Global exclusion statement
Overall statement of exclusion of all problems or diagnoses at the time of recording.
Global exclusion of problems/diagnoses
Overall statement of exclusion of all significant health-related problems in relatives or family members of the individual at the time of recording.
Global exclusion of family history
Overall statement of exclusion about the use of all medications at the time of recording.
Global exclusion of medication use
Overall statement of exclusion about all procedures at the time of recording.
Global exclusion of procedures
Overall statement of exclusion about all adverse reactions at the time of recording.
Global exclusion of adverse reactions
@ 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
Additional comment not covered in other fields.
Comment
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
1
1
at0002
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
-
No information about allergies
false
false
true
false
true
1
protocol
true
true
false
false
0
1
ITEM_TREE
true
true
false
false
1
1
at0003
items
true
true
false
false
0
1
ELEMENT
true
true
false
false
0
1
at0004
value
true
true
false
false
0
1
DV_DATE_TIME
true
true
false
false
1
1
CLUSTER
true
false
true
0
at0006
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
false
false
true
false
true
0
openEHR-EHR-EVALUATION.absence.v2
Statement that specified health information is not available for inclusion in the health record or extract at the time of recording.
Absence of information
@ internal @
Tree
For example: "No information available about adverse reactions"; No information available about problems or diagnoses"; "No information available about previous procedures performed"; or "No information available about medications used".
Positive statement that no information is available.
Absence statement
@ internal @
Tree
The date at which the absence was last updated.
Last updated
For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible.
Description of the reason why there is no information available.
Reason for absence
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
false
false
true
false
true
0
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
true
true
false
false
1
1
at0000
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
-
Problem List
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
1
1
at0002
value
true
true
false
false
0
1
DV_TEXT
true
true
false
false
1
1
ELEMENT
true
false
true
0
at0012
value
true
true
false
false
0
1
DV_TEXT
true
true
false
false
1
1
CLUSTER
true
false
true
0
at0039
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
openEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_clock(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.v1
constraint
ELEMENT
true
true
false
false
0
1
at0077
value
true
true
false
false
0
1
DV_DATE_TIME
true
true
false
false
1
1
ELEMENT
true
true
false
false
0
1
at0005
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
at0047
at0048
at0049
DV_TEXT
true
true
false
false
1
1
CLUSTER
true
false
true
0
at0043
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
ELEMENT
true
true
false
false
0
1
at0030
value
true
true
false
false
0
1
DV_DATE_TIME
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
-
Date of abatement
CLUSTER
true
true
false
false
0
1
at0000
items
true
true
false
false
1
1
ELEMENT
true
true
false
false
0
1
at0003
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
at0026
at0027
ELEMENT
true
true
false
false
0
1
at0083
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
at0084
at0097
ELEMENT
true
true
false
false
0
1
at0089
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
at0090
ELEMENT
true
true
false
false
0
1
at0071
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
at0096
false
false
true
false
true
1
openEHR-EHR-CLUSTER.problem_qualifier.v1
Contextual or temporal qualifier for a specified problem or diagnosis.
Problem/Diagnosis qualifier
For example: 'New' will enable clinicians to distinguish a new, acute episode of otitis media that may have arisen soon after a previous diagnosis, to distinguish it from an unresolved or 'Ongoing' diagnosis of chronic otitis media. Treatment of recurring, new and acute, episodes of a condition may differ significantly from the same condition that is not resolving or responding to treatment. In many situations the clinician will not be able to tell, and so indeterminate may be appropriate.
Category of this episode for the identified problem/diagnosis.
Episodicity
The Active/Inactive and Current/Past data elements have similar clinical impact but represent slightly different semantics. Both are actively used in different clinical settings, but usually not together. If a Current/Past qualifier is recorded, then this data element is likely to be redundant. An exception where a condition can be current but inactive is asthma that is not causing acute symptoms.
Category that supports division of problems and diagnoses into Active or Inactive problem lists.
Active/Inactive?
The status is usually determined by a combination of the timing of diagnosis plus level of clinical certainty resulting from diagnostic tests and clinical evidence available. This data element and 'Diagnostic certainty' in EVALUATION.problem_diagnosis are two important axes of the diagnostic process, and valid combinations will need to be presented by software that exposes both data elements, so it is not possible for users to select conflicting combinations.
Preliminary or working diagnoses are intended to represent the single most likely choice out of all differential diagnosis options.
Stage or phase of diagnostic process.
Diagnostic status
The initial diagnosis made, usually associated with a low level of clinical certainty. It may change as test results or advice become available.
Preliminary
Interim diagnosis, based on a reasonable amount of clinical certainty but pending further test results or clinical advice. It may still change as test results or advice become available.
Working
Final substantiated diagnosis, based on a high level of clinical certainty, which may include clinical evidence from test results. It is not expected to change.
Established
The problem or diagnosis is currently active and clinically relevant.
Active
The problem or diagnosis is not completely resolved but is inactive or felt less relevant to the current clinical context.
Inactive
A new occurrence of either a new or existing problem or diagnosis. A flag for 'First occurrence' can be recorded separately to distinguish the first from other occurrences.
New
The issue, problem or diagnosis continues, without new, acute episodes occurring.
Ongoing
The Current/Past and Active/Inactive data elements have similar clinical impact but represent slightly different semantics. Both are actively used in different clinical settings, but usually not together. If an Active/Inactive qualifier is recorded, then this data element is likely to be redundant. An exception where a condition can be current but inactive is asthma that is not causing acute symptoms.
Category that supports division of problems and diagnoses into Current or Past problem lists.
Current/Past?
An issue which ocurred in the past.
Past
An issue occuring at present.
Current
This data element contains a value set commonly used in diagnostic categorisation. In episodic care contexts (commonly secondary care) it is common to categorise/organise diagnoses according to their relationship to the principal diagnosis being addressed during that episode of care. These categories may also be used for clinical coding, reporting and billing purposes. In some countries the diagnostic category may be known as a DRG.
In addition, the free text choice permits use of other local value sets, as required.
Category of the problem or diagnosis within a specified episode of care and/or local care context.
Diagnostic category
The diagnosis determined to be the primary reason for an episode of admitted patient care, an episode of residential care or an attendance at the health care establishment.
Principal diagnosis
A problem or diagnosis that occurs at the same time as the primary problem or diagnosis. May also be known as a comorbid condition.
Secondary diagnosis
It is not possible to determine if this occurrence of the problem or diagnosis is new or ongoing.
Indeterminate
This data element can be an additional qualifier to the 'New' value in the 'Episodicity' value set, that is a condition such as asthma can have recurring new episodes that have periods of resolution in between. However it can be important to identify the first ever episode of asthma from all of the other episodes.
Category of the occurrence for this problem or diagnosis.
Occurrence
Record as True if the problem or diagnosis was present on admission. This data element is a requirement from DRG reporting in some countries.
Was the problem or diagnosis present at admission?
Admission diagnosis?
An unfavorable evolution of a problem or diagnosis.
Complication
Definitions of acute vs chronic will differ for each diagnosis.
Category reflecting the speed of onset and/or duration and persistence of the problem or diagnosis.
Course label
A problem or diagnosis with persistent or long-lasting effects, or that evolves over time.
Chronic
A problem or diagnosis with a rapid onset, a short course, or both.
Acute
For example: tracking the progress of resolution of a middle ear infection.
Phase of healing for an acute problem or diagnosis.
Resolution phase
Problem or diagnosis has completed the normal phases of restoration or healing and can be considered resolved.
Resolved
Problem or diagnosis is progressing satisfactorily through the normal stages of restoration or healing towards resolution.
Resolving
Problem or diagnosis is not progressing satisfactorily through the normal stages of restoration or healing towards resolution.
Not resolving
It is not possible to determine the resolution or healing status of the problem or diagnosis.
Indeterminate
The previously recorded diagnosis has been clinically reassessed or disproved with a high level of clinical certainty. This status is used to correct an error in the health record.
Refuted
For example: the status of a cancer or haematological diagnosis.
Status of the remission of an incurable diagnosis.
Remission status
No ongoing signs or symptoms of the disease have been identified.
In remission
No diminution of the signs or symptoms of the disease have been identified.
Not in remission
It is not possible to determine if there have been diminution of the signs or symptoms of the disease have been identified.
Indeterminate
A problem or diagnosis with an acute exacerbation of a chronic condition.
Acute-on-chronic
This is the first ever occurrence of this problem or diagnosis.
First occurrence
New occurrence of the same problem or diagnosis after a previous episode was resolved.
Recurrence
Problem or diagnosis has deteriorated after a period of temporary improvement.
Relapsed
SNOMED-CT
288526004
SNOMED-CT
106229004
SNOMED-CT
148006
SNOMED-CT
5558000
SNOMED-CT
14657009
SNOMED-CT
410511007
SNOMED-CT
410513005
SNOMED-CT
15240007
SNOMED-CT
8319008
SNOMED-CT
85097005
SNOMED-CT
288524001
ELEMENT
true
true
false
false
0
1
at0073
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
at0074
at0075
at0076
DV_TEXT
true
true
false
false
1
1
false
false
true
false
true
1
protocol
true
true
false
false
0
1
ITEM_TREE
true
true
false
false
1
1
at0032
items
true
true
false
false
0
1
ELEMENT
true
true
false
false
0
1
at0070
value
true
true
false
false
0
1
DV_DATE_TIME
true
true
false
false
1
1
CLUSTER
true
false
true
0
at0071
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
false
false
true
false
true
0
openEHR-EHR-EVALUATION.problem_diagnosis.v1
Clear delineation between the scope of a problem versus a diagnosis is not easy to achieve in practice. For the purposes of clinical documentation with this archetype, problem and diagnosis are regarded as a continuum, with increasing levels of detail and supportive evidence usually providing weight towards the label of 'diagnosis'.
Details about a single identified health condition, injury, disability or any other issue which impacts on the physical, mental and/or social well-being of an individual.
Problem/Diagnosis
@ internal @
structure
Coding of the name of the problem or diagnosis with a terminology is preferred, where possible.
Identification of the problem or diagnosis, by name.
Problem/Diagnosis name
Partial dates are acceptable. If the subject of care is under the age of one year, then the complete date or a minimum of the month and year is necessary to enable accurate age calculations - for example, if used to drive decision support. Data captured/imported as "Age at time of clinical recognition" should be converted to a date using the subject's date of birth.
Estimated or actual date/time the diagnosis or problem was recognised by a healthcare professional.
Date/time clinically recognised
If severity is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant. Note: more specific grading of severity can be recorded using the Specific details SLOT.
An assessment of the overall severity of the problem or diagnosis.
Severity
Use to provide background and context, including evolution, episodes or exacerbations, progress and any other relevant details, about the problem or diagnosis.
Narrative description about the problem or diagnosis.
Clinical description
Coding of the name of the anatomical location with a terminology is preferred, where possible.
Use this data element to record precoordinated anatomical locations. If the requirements for recording the anatomical location are determined at run-time by the application or require more complex modelling such as relative locations then use the CLUSTER.anatomical_location or CLUSTER.relative_location within the 'Structured anatomical location' SLOT in this archetype. Occurrences for this data element are unbounded to allow for clinical scenarios such as describing a rash in multiple locations but where all of the other attributes are identical. If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant.
Identification of a simple body site for the location of the problem or diagnosis.
Body site
Partial dates are acceptable. If the subject of care is under the age of one year, then the complete date or a minimum of the month and year is necessary to enable accurate age calculations - for example, if used to drive decision support. Data captured/imported as "Age at time of resolution" should be converted to a date using the subject's date of birth.
Estimated or actual date/time of resolution or remission for this problem or diagnosis, as determined by a healthcare professional.
Date/time of resolution
@ internal @
Tree
Use this SLOT to insert the CLUSTER.anatomical_location or CLUSTER.relative_location archetypes if the requirements for recording the anatomical location are determined at run-time by the application or require more complex modelling such as relative locations.
If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, use of this SLOT becomes redundant.
A structured anatomical location for the problem or diagnosis.
Structured body site
May include structured detail about the grading or staging of the diagnosis; diagnostic criteria, classification criteria or formal severity assessments such as Common Terminology Criteria for Adverse Events.
Details that are additionally required to record as unique attributes of this problem or diagnosis.
Specific details
Use status or context qualifiers with care, as they are variably used in practice and interoperability cannot be assured unless usage is clearly defined with the community of use. For example: active status - active, inactive, resolved, in remission; evolution status - initial, interim/working, final; temporal status - current, past; episodicity status - first, new, ongoing; admission status - admission, discharge; or priority status - primary, secondary.
Structured details for location-, domain-, episode- or workflow-specific aspects of the diagnostic process.
Status
The problem or diagnosis does not interfere with normal activity or may cause damage to health if left untreated.
Mild
The problem or diagnosis causes interference with normal activity or will damage health if left untreated.
Moderate
The problem or diagnosis prevents normal activity or will seriously damage health if left untreated.
Severe
Additional narrative about the problem or diagnosis not captured in other fields.
Comment
The date this problem or diagnosis was last updated.
Last updated
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
Narrative description about the course of the problem or diagnosis since onset.
Course description
The level of confidence in the identification of the diagnosis.
Diagnostic certainty
The diagnosis has been identified with a low level of certainty.
Suspected
The diagnosis has been identified with a high level of certainty.
Probable
The diagnosis has been confirmed against recognised criteria.
Confirmed
Data captured/imported as "Age at onset" should be converted to a date using the subject's date of birth.
Estimated or actual date/time that signs or symptoms of the problem/diagnosis were first observed.
Date/time of onset
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
1
1
at0002
name
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
local
at0003
value
true
true
false
false
1
1
STRING
true
true
false
false
1
1
-
Global exclusion of problems/diagnoses
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
-
No known problems
false
false
true
false
true
1
protocol
true
true
false
false
0
1
ITEM_TREE
true
true
false
false
1
1
at0008
items
true
true
false
false
0
1
CLUSTER
true
false
true
0
at0010
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
false
false
true
false
true
0
openEHR-EHR-EVALUATION.exclusion_global.v1
An overall statement of exclusion about all Problems/diagnoses, Family history, Medications, Procedures, Adverse reactions or other clinical items that are either not currently present, or have not been present in the past.
Exclusion - global
@ internal @
Tree
For example: 'No previous diagnoses', 'No known family history', 'No known history of adverse reactions', 'Never taken any medications' or 'No known operations or significant procedures'.
An overall statement of exclusion about all Problems/diagnoses, Family history, Medications, Procedures, Adverse reactions or other clinical items.
Global exclusion statement
Overall statement of exclusion of all problems or diagnoses at the time of recording.
Global exclusion of problems/diagnoses
Overall statement of exclusion of all significant health-related problems in relatives or family members of the individual at the time of recording.
Global exclusion of family history
Overall statement of exclusion about the use of all medications at the time of recording.
Global exclusion of medication use
Overall statement of exclusion about all procedures at the time of recording.
Global exclusion of procedures
Overall statement of exclusion about all adverse reactions at the time of recording.
Global exclusion of adverse reactions
@ 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
Additional comment not covered in other fields.
Comment
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
1
1
at0002
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
-
No information about current problems
false
false
true
false
true
1
protocol
true
true
false
false
0
1
ITEM_TREE
true
true
false
false
1
1
at0003
items
true
true
false
false
0
1
ELEMENT
true
true
false
false
0
1
at0004
value
true
true
false
false
0
1
DV_DATE_TIME
true
true
false
false
1
1
CLUSTER
true
false
true
0
at0006
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
false
false
true
false
true
0
openEHR-EHR-EVALUATION.absence.v2
Statement that specified health information is not available for inclusion in the health record or extract at the time of recording.
Absence of information
@ internal @
Tree
For example: "No information available about adverse reactions"; No information available about problems or diagnoses"; "No information available about previous procedures performed"; or "No information available about medications used".
Positive statement that no information is available.
Absence statement
@ internal @
Tree
The date at which the absence was last updated.
Last updated
For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible.
Description of the reason why there is no information available.
Reason for absence
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
false
false
true
false
true
0
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
true
true
false
false
0
1
at0000
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
-
Immunizations
items
true
true
false
false
0
1
ACTION
true
true
false
false
0
1
at0000
ism_transition
true
true
false
false
1
1
ISM_TRANSITION
true
true
false
false
1
1
at0006
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
245
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
at0006
description
true
true
false
false
1
1
ITEM_TREE
true
true
false
false
1
1
at0017
items
true
true
false
false
0
1
ELEMENT
true
true
false
false
0
1
at0020
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
-
Immunisation item
CLUSTER
true
true
false
false
0
1
at0104
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
openEHR-EHR-CLUSTER\.medication(-[a-zA-Z0-9_]+)*\.v1
constraint
CLUSTER
true
true
false
false
0
1
at0131
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
openEHR-EHR-CLUSTER\.medication_supply_amount(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.medication_supply_amount(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.dosage(-[a-zA-Z0-9_]+)*\.v1
constraint
CLUSTER
true
true
false
false
0
1
at0140
items
true
true
false
false
1
1
ELEMENT
true
true
false
false
0
1
at0147
value
true
true
false
false
0
1
DV_TEXT
true
true
false
false
1
1
ELEMENT
true
true
false
false
0
1
at0141
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
-
Target site
CLUSTER
true
true
false
false
0
1
at0142
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
openEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_circle(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.v1
constraint
CLUSTER
true
false
true
0
at0144
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1
constraint
false
false
true
false
true
1
CLUSTER
true
false
true
0
at0053
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
openEHR-EHR-CLUSTER\.medication_authorisation(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.medication_authorisation(-[a-zA-Z0-9_]+)*\.v1
constraint
ELEMENT
true
true
false
false
0
1
at0025
value
true
true
false
false
0
1
DV_COUNT
true
true
false
false
1
1
false
false
true
false
true
0
protocol
true
true
false
false
0
1
ITEM_TREE
true
true
false
false
1
1
at0030
items
true
true
false
false
0
1
CLUSTER
true
false
true
0
at0085
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
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
-
Immunization statement
openEHR-EHR-ACTION.medication.v1
This is not limited to activities performed based on medication orders from clinicians, but could also include for example taking over the counter medication.
Any activity related to the planning, scheduling, prescription management, dispensing, administration, cessation and other use of a medication, vaccine, nutritional product or other therapeutic item.
Medication management
A prescription has been issued for the medication.
Prescription issued
The ordered medication has been dispensed, for example from a pharmacy to the patient.
Prescription dispensed
The medication has been taken by, or administered to, the patient for the first time. Although in some settings this significant date may be computable as the first of several administrations, in other settings, such as primary care, specific administration dates are not readily available.
Medication course commenced
The individual medication has been reassessed, for example whether the medication should still be taken. This is not intended to capture review of the medication list.
Medication reassessed
A single administration of the medication has taken place.
Dose administered
The medication course has been completed as planned.
Medication course completed
The prescription has not been dispensed due to a technical or pharamaceutical supply issue.
Prescription supply delayed
The administration of the medication has been suspended until further notice. No further doses should be given until the restart date or conditions have been met. When setting the date/conditions for restart after suspending, a step from ‘Administrations suspended’ and back to 'Medication start date/condition set' should be performed.
Administrations suspended
A prescription has been re-issued for an existing medication order.
Prescription re-issued
Issue of the prescription is awaiting re-authorisation by a clinician.
Prescription re-authorisation pending
The planned course of medication has been cancelled prior to any administration.
Medication course cancelled
The scheduled medication course has been postponed prior to any administration.
Medication course postponed
Administration of the medication has been ceased during the period of the intended course.
Medication course stopped
The time to start the medication, or other starting condition, has been set.
Medication start date/condition set
@ internal @
Tree
An administration of the medication has been withheld and not given. There is no expectation that it will be given later, though the next dose (if any) should be administered according to the original order.
Dose administration omitted
For example: 'Atenolol 100mg' or 'Tenormin tablets 100mg'.
It is strongly recommended that the 'Medication item' is coded with a terminology capable of triggering decision support, where possible. The extent of coding may vary from the simple name of the medication item through to structured details about the actual medication pack used. Free text entry should only be used if there is no appropriate terminology available.
Name of the medication, vaccine or other therapeutic/prescribable item which was the focus of the activity.
Medication item
For example: 'Postponed - Patient not avalable at administration time', 'Cancelled - Adverse reaction'. Note: This is not the reason for the medication instruction, but rather the specific reason that a care step was carried out, and will often be used to document some variance from the original order.
Reason that the pathway step for the identified medication was carried out.
Reason
For example: 'Patient was in radiology department', 'Accidental injection into blood vessel during IM administration'.
Additional narrative about the activity or pathway step not captured in other fields, including details of any variance between the intended action and the action actually performed.
Comment
The sequence number specific to the pathway step being recorded.
Sequence number
@ internal @
Tree
For example: 'Avoid grapefruit' , 'Take at least 2 hours before bedtime', 'Take with food'. May be coded with a terminology when clinically appropriate.
Any guidance, instructions or advice given to the subject of care or personal carer at the time of the pathway step.
Patient guidance
A major change to the order was required, resulting in this order being stopped and a replacement order being started.
Major change to order
The medication order has been changed in a manner which does not require a new instruction/order to be issued, according to local clinical rules.
Minor change to order
Used to compare variance from actual action time where this is not readily calculable from the original instruction.
The datetime at which the medication action was scheduled to occur.
Original scheduled date/time
An administration of a dose of the medication has been delayed but is expected to be given as soon as possible.
Dose administration deferred
Further structured details of the action, possibly specific to a pathway step.
Additional details
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
Comment: This data element allows for multiple occurrences to be defined more explicitly at run-time, if required.
Unique identifier for the medication order.
Order ID
Use this SLOT where the detailed description of the dispensed, authorised or administered item needs to be explicitly stated. For example: the form, strength, any diluents or mixture of ingredients.
Structured details about the medication including strength, form and constituent substances.
Medication details
The original medication order has been re-authorised to allow repeat prescription or dispensing. In some jurisdictions an entirely new order must be issued in these circumstances.
Prescription re-authorised
The medication has been recommended but no steps have been taken to initiate prescribing.
Medication recommended
CLUSTER.dosage is intended to carry details of medication order changes or dose administrations, whilst CLUSTER.medication_supply_amount is intended for details of dispensing-related activity.
Specific details about the amount of the medication item.
Amount
In many jurisdictions, substitution of an ordered item as a generic form or with a different brand name, which has been determined as bioequivalent, is allowed at the point of dispense or supply. In other cases substitution is assumed and the clinician has to explicitly request non-substitution.
Subsitution action taken by the person administering or dispensing the drug.
Substitution
For example: "Generic alternative contains a substance that is not tolerated by the patient." May be coded with a terminology when clinically appropriate
The reason or justification for the substitution action taken.
Substitution reason
A medication was substituted which is bioequivalent to that ordered.
Substitution performed
Although allowed by the medication order a bioequvalent medication was not substituted.
Substitution not performed
Details of body site and administration of the medication.
Administration details
For example: 'left upper arm', 'intravenous catheter right hand'.
Coding of the body site with a terminology is preferred, where possible.
Structured description of the site of administration of the ordered item.
Body site
For example: "On the medial skin surface of the left forearm, from 10 cm to 20 cm distally from the point of the elbow".
Structured description of the site of administration of the medication, vaccine or therapeutic good.
Structured body site
Comment: For example: ' via Z-track injection'; 'via nebuliser'. Coding of the method with a terminology is preferred, where possible.
The technique or device by which the ordered item was, or is to be, administered.
Administration method
Details of the medical device used to assist administration of the medication.
Administration device
Draft prescription has been prepared and is awaiting confirmation from an authorised clinician. May be used where reauthorisations are performed as a batch. This careflow_step may have a status of 'planned' or 'active', reflecting the need to to handle new orders as well as re-authorised orders.
Prescription awaiting authorisation
Comment: For example: 'oral', 'intravenous', or 'topical'. Coding of the route with a terminology is preferred, where possible. Multiple potential routes may be specified.
The route by which the ordered item was, or is to be, administered into the subject's body.
Route
The medication has been physically prepared. For example: preparation of an intravenous mixture.
Medication prepared
Details of the individual performing the double-check can be carried in the Reference Model element "Participation".
The pathway step has been checked by a separate individual.
Double-checked?
The prescription was cancelled prior to being issued.
Prescription cancelled
Prescription has been invalidated or has expired without being fulfilled.
Prescription invalid or expired
The prescription has been fulfilled successfully.
Prescription fulfilled
The medication has been formally authorised for use.
Medication authorised
For example: 2017-10-29
The date/time on which the medication course is set to restart, as per the "Administrations suspended" pathway step.
Restart date/time
For example: "On day 2 after surgery".
The criterion which triggers the medication course to restart, as per the "Administrations suspended" pathway step.
Restart criterion
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
1
1
at0002
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
-
No information about immunizations
false
false
true
false
true
1
protocol
true
true
false
false
0
1
ITEM_TREE
true
true
false
false
1
1
at0003
items
true
true
false
false
0
1
ELEMENT
true
true
false
false
0
1
at0004
value
true
true
false
false
0
1
DV_DATE_TIME
true
true
false
false
1
1
CLUSTER
true
false
true
0
at0006
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
false
false
true
false
true
0
openEHR-EHR-EVALUATION.absence.v2
Statement that specified health information is not available for inclusion in the health record or extract at the time of recording.
Absence of information
@ internal @
Tree
For example: "No information available about adverse reactions"; No information available about problems or diagnoses"; "No information available about previous procedures performed"; or "No information available about medications used".
Positive statement that no information is available.
Absence statement
@ internal @
Tree
The date at which the absence was last updated.
Last updated
For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible.
Description of the reason why there is no information available.
Reason for absence
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
false
false
true
false
true
0
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
true
true
false
false
0
1
at0000
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
-
History of Procedures
items
true
true
false
false
0
1
ACTION
true
true
false
false
0
1
at0000
ism_transition
true
true
false
false
1
1
ISM_TRANSITION
true
true
false
false
1
1
at0004
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
526
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
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
-
Preparation
ISM_TRANSITION
true
true
false
false
1
1
at0007
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
526
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
at0007
ISM_TRANSITION
true
true
false
false
1
1
at0038
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
527
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
at0038
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
-
On hold
ISM_TRANSITION
true
true
false
false
1
1
at0039
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
528
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
at0039
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
-
Not done
ISM_TRANSITION
true
true
false
false
1
1
at0068
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
245
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
at0068
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
-
In progress
ISM_TRANSITION
true
true
false
false
1
1
at0041
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
531
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
at0041
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
-
Stopped
ISM_TRANSITION
true
true
false
false
1
1
at0043
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
at0043
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
-
Completed
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
1
1
at0002
value
true
true
false
false
0
1
DV_TEXT
true
true
false
false
1
1
ELEMENT
true
false
true
0
at0063
value
true
true
false
false
0
1
DV_TEXT
true
true
false
false
1
1
CLUSTER
true
false
true
0
at0003
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_clock(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.v1
constraint
CLUSTER
true
false
true
0
at0062
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
1
protocol
true
true
false
false
0
1
ITEM_TREE
true
true
false
false
1
1
at0053
items
true
true
false
false
0
1
CLUSTER
true
true
false
false
0
1
at0055
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
CLUSTER
true
false
true
0
at0057
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
CLUSTER
true
false
true
0
at0064
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
false
false
true
false
true
0
openEHR-EHR-ACTION.procedure.v1
A clinical activity carried out for screening, investigative, diagnostic, curative, therapeutic, evaluative or palliative purposes.
Procedure
@ internal @
Tree
Coding of the specific procedure with a terminology is preferred, where possible.
Identification of the procedure by name.
Procedure name
Use to capture detailed, structured information about anatomical location, method & technique, equipment used, devices implanted, results, findings etc.
Structured information about the procedure.
Procedure detail
The procedure to be undertaken is planned.
Procedure planned
Additional narrative about the activity or care pathway step not captured in other fields.
Comment
Use this data element to record simple terms or precoordinated complications. If the requirements for recording complication are more complex then use of a specific CLUSTER archetype within the 'Procedure detail' SLOT in this archetype is advised and this data element becomes redundant. Examples: Hematuria after a kidney biopsy, tissue irritation after insertion of intravenous catheter.
Details about any complication arising from the procedure.
Complication
Request for procedure sent.
Procedure request sent
For example: the reason for the cancellation or suspension of the procedure.
Reason that the activity or care pathway step for the identified procedure was carried out.
Reason
(Was: The procedure to be undertaken is planned.)
This pathway step has been deprecated as it was incorrectly associated with 'initial' status - use the new 'Procedure planned' (at0004) pathway step which is correctly associated with 'planned' status.
X - Procedure planned
(Was: Request for procedure sent.)
This pathway step has been deprecated as it was incorrectly associated with 'initial' status - use the new 'Procedure request sent' (at0007) pathway step which is correctly associated with 'planned' status.
X - Procedure request sent
The procedure has been scheduled.
Procedure scheduled
The procedure has been postponed.
Procedure postponed
The planned procedure has been cancelled prior to commencement.
Procedure cancelled
The procedure has been suspended.
Procedure suspended
The procedure has been aborted.
Procedure aborted
The procedure has been performed and all associated clinical activities completed.
Procedure completed
The procedure, or subprocedure in a multicomponent procedure, has been performed.
Procedure performed
Coding with a terminology is preferred, where possible.
Outcome of procedure performed.
Outcome
For example: description about the performance and findings from the the procedure, the aborted attempt or the cancellation of the procedure.
Narrative description about the procedure, as appropriate for the pathway step.
Description
@ internal @
Tree
This is equivalent to Placer Order Number in HL7 v2 specifications.
The local ID assigned to the order by the healthcare provider or organisation requesting the service.
Requestor order identifier
Details about the healthcare provider or organisation requesting the service.
Requestor
This is equivalent to Filler Order Number in HL7 v2 specifications.
The ID assigned to the order by the healthcare provider or organisation receiving the request for service. This is also referred to as Filler Order Identifier.
Receiver order identifier
Details about the healthcare provider or organisation receiving the request for service.
Receiver
Coding with a terminology is preferred, where possible.
Urgency of the procedure.
Urgency
Only for use in association with the 'Procedure performed' pathway step, and in situations where the procedure is repeated on multiple occasions before being completed or there are multiple components to the whole procedure. This may be the same as the RM time attribute for the 'Procedure completed' pathway step.
The date and/or time when the entire procedure, or the last component of a multicomponent procedure, was finished.
Final end date/time
Only for use in association with the 'Procedure completed' pathway steps.
The total amount of time taken to complete the procedure, which may include time spent during the active phase of the procedure plus time during which the procedure was suspended.
Total duration
Mulitimedia representation of a performed procedure.
Multimedia
Occurrences for this data element are unbounded to allow for clinical scenarios such as removing multiple skin lesions in different places, but where all of the other attributes are identical. Use this data element to record simple terms or precoordinated anatomical locations. If the requirements for recording the anatomical location are determined at run-time by the application or require more complex modelling such as relative locations then use the CLUSTER.anatomical_location or CLUSTER.relative_location within the 'Procedure detail' SLOT in this archetype. If the anatomical location is included in the 'Procedure name' via precoordinated codes, this data element becomes redundant.
Identification of the body site for the procedure.
Body site
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
Use this data element to record simple terms or a narrative description. If the requirements for recording the method require more complex modelling then this can be represented by additional archetypes within the 'Procedure detail' SLOT in this archetype. If the method is included in the 'Procedure name' via precoordinated codes, this data element becomes redundant.
Identification of specific method or technique for the procedure.
Method
Only for use in association with the 'Procedure scheduled' pathway step.
The date and/or time on which the procedure is intended to be performed.
Scheduled date/time
This pragmatic data element may be used to support organisation within the user interface.
The type of procedure.
Procedure type
The procedure, or subprocedure in a multicomponent procedure, has been commenced.
Procedure commenced
Examples: The patient was agitated, insufficient emptying of the stomach before gastroscopy, a tumour in the bile ducts made it impossible to pass the scope through.
Difficulties or issues encountered during performance of the procedure.
Procedural difficulty
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
1
1
at0002
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
-
No information about past history of procedures
false
false
true
false
true
1
protocol
true
true
false
false
0
1
ITEM_TREE
true
true
false
false
1
1
at0003
items
true
true
false
false
0
1
ELEMENT
true
true
false
false
0
1
at0004
value
true
true
false
false
0
1
DV_DATE_TIME
true
true
false
false
1
1
CLUSTER
true
false
true
0
at0006
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
false
false
true
false
true
0
openEHR-EHR-EVALUATION.absence.v2
Statement that specified health information is not available for inclusion in the health record or extract at the time of recording.
Absence of information
@ internal @
Tree
For example: "No information available about adverse reactions"; No information available about problems or diagnoses"; "No information available about previous procedures performed"; or "No information available about medications used".
Positive statement that no information is available.
Absence statement
@ internal @
Tree
The date at which the absence was last updated.
Last updated
For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible.
Description of the reason why there is no information available.
Reason for absence
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
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
1
1
at0002
name
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
local
at0006
value
true
true
false
false
1
1
STRING
true
true
false
false
1
1
-
Global exclusion of procedures
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
-
No known procedures
false
false
true
false
true
1
protocol
true
true
false
false
0
1
ITEM_TREE
true
true
false
false
1
1
at0008
items
true
true
false
false
0
1
CLUSTER
true
false
true
0
at0010
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
false
false
true
false
true
0
openEHR-EHR-EVALUATION.exclusion_global.v1
An overall statement of exclusion about all Problems/diagnoses, Family history, Medications, Procedures, Adverse reactions or other clinical items that are either not currently present, or have not been present in the past.
Exclusion - global
@ internal @
Tree
For example: 'No previous diagnoses', 'No known family history', 'No known history of adverse reactions', 'Never taken any medications' or 'No known operations or significant procedures'.
An overall statement of exclusion about all Problems/diagnoses, Family history, Medications, Procedures, Adverse reactions or other clinical items.
Global exclusion statement
Overall statement of exclusion of all problems or diagnoses at the time of recording.
Global exclusion of problems/diagnoses
Overall statement of exclusion of all significant health-related problems in relatives or family members of the individual at the time of recording.
Global exclusion of family history
Overall statement of exclusion about the use of all medications at the time of recording.
Global exclusion of medication use
Overall statement of exclusion about all procedures at the time of recording.
Global exclusion of procedures
Overall statement of exclusion about all adverse reactions at the time of recording.
Global exclusion of adverse reactions
@ 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
Additional comment not covered in other fields.
Comment
false
false
true
false
true
0
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
true
true
false
false
0
1
at0000
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
-
Medical Devices
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
CLUSTER
true
false
true
0
at0022
items
true
true
false
false
1
1
ELEMENT
true
true
false
false
0
1
at0007
value
true
true
false
false
0
1
DV_TEXT
true
true
false
false
1
1
ELEMENT
true
true
false
false
0
1
at0012
value
true
true
false
false
0
1
DV_TEXT
true
true
false
false
1
1
CLUSTER
true
false
true
0
at0013
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
openEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1
constraint
CLUSTER
true
true
false
false
0
1
at0000
items
true
true
false
false
1
1
ELEMENT
true
true
false
false
1
1
at0001
value
true
true
false
false
0
1
DV_TEXT
true
true
false
false
1
1
ELEMENT
true
true
false
false
0
1
at0003
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_TEXT
true
true
false
false
1
1
CLUSTER
true
false
true
0
at0009
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
ELEMENT
true
true
false
false
0
1
at0021
value
true
true
false
false
0
1
DV_IDENTIFIER
true
true
false
false
1
1
ELEMENT
true
true
false
false
0
1
at0004
value
true
true
false
false
0
1
DV_TEXT
true
true
false
false
1
1
ELEMENT
true
true
false
false
0
1
at0005
value
true
true
false
false
0
1
DV_DATE_TIME
true
true
false
false
1
1
ELEMENT
true
true
false
false
0
1
at0020
value
true
true
false
false
0
1
DV_TEXT
true
true
false
false
1
1
ELEMENT
true
true
false
false
0
1
at0022
value
true
true
false
false
0
1
DV_TEXT
true
true
false
false
1
1
ELEMENT
true
true
false
false
0
1
at0023
value
true
true
false
false
0
1
DV_TEXT
true
true
false
false
1
1
ELEMENT
true
true
false
false
0
1
at0006
value
true
true
false
false
0
1
DV_TEXT
true
true
false
false
1
1
ELEMENT
true
true
false
false
0
1
at0025
value
true
true
false
false
0
1
DV_TEXT
true
true
false
false
1
1
ELEMENT
true
true
false
false
0
1
at0007
value
true
true
false
false
0
1
DV_DATE_TIME
true
true
false
false
1
1
ELEMENT
true
false
true
0
at0024
value
true
true
false
false
0
1
DV_IDENTIFIER
true
true
false
false
1
1
CLUSTER
true
false
true
0
at0019
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
openEHR-EHR-CLUSTER\.device_details(-[a-zA-Z0-9_]+)*\.v1
constraint
CLUSTER
true
false
true
0
at0018
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1
constraint
CLUSTER
true
false
true
0
at0026
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
CLUSTER
true
false
true
0
at0027
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1
constraint
ELEMENT
true
true
false
false
0
1
at0008
value
true
true
false
false
0
1
DV_TEXT
true
true
false
false
1
1
false
false
true
false
true
1
openEHR-EHR-CLUSTER.device.v1
An instrument, apparatus, implant, material or similar, used in the provision of healthcare. In this context, a medical device includes a broad range of devices which act through a variety of physical, mechanical, thermal or similar means but specifically excludes devices which act through medicinal means such as pharmacological, metabolic or immunological methods. The scope is inclusive of disposable devices as well as durable or persisting devices that require tracking, maintenance activities or regular calibration, recognising that each type of device has specific data recording requirements.
Medical device
(XYZ Audiometer); (14G Jelco IV catheter); or . Coding with a terminology is desirable, where possible, although this may be local and depending on local supplies available.]]> Identification of the medical device, preferably by a common name, a formal fully descriptive name or, if required, by class or category of device.
Device name
Narrative description of the medical device.
Description
Not applicable if a category is already recorded in 'Device name'.
Example: if the 'Device' is named as a 'urinary catheter'; the 'Type' may be recorded as 'indwelling' or 'condom'.Coding with a terminology is desirable, where possible. This may include use of GTIN or EAN numbers.
The category or kind of device.
Type
Name of manufacturer.
Manufacturer
Date the device was manufactured.
Date of manufacture
The number assigned by the manufacturer which identifies a group of items manufactured at the same time, usually found on the label or packaging material.
Batch/Lot number
This date usually applies only to single use or disposable devices.
Date after which the device/product is no longer fit for use, usually found on the device itself or printed on the accompanying packaging.
Date of expiry
Additional narrative about the device not captured in other fields.
Comment
Further details about specific properties about the medical device.
Properties
Additional structured informations about identified components of the device.
Components
For example: Owner, Contact details, Location, Network address, Date due for replacement, Calibration details etc.
Further details about management and maintenance of the device.
Asset management
Number assigned by the manufacturer which can be found on the device, and should be specific to each device., its label, or accompanying packaging.
Serial number
Often fixed to the device as a barcode.
A numeric or alphanumeric string that is associated with this device within a given system.
Unique device identifier (UDI)
The exact number assigned by the manufacturer, as it appears in the manufacturer's catalogue, device labeling, or accompanying packaging.
Catalogue number
The exact model number assigned by the manufacturer and found on the device label or accompanying packaging.
Model number
Coding of the name of the identifier with a coding system is desirable, if available.
Unspecified identifier, which can be further specified in a template or at run time.
Other identifier
When the medical device is an actual software application, record the version of the software using this data element. When the medical device has multiple software applications embedded within it, record each software component in a separate CLUSTER archetype within the Components SLOT - either as a nested instance of another CLUSTER.device archetype or using a CLUSTER archetype designed specifically for recording software details (but not yet available at time of this archetype development).
Identification of the version of software being used in the medical device.
Software version
Additional information required to capture local context or to align with other reference models/formalisms.
Extension
For example: a technical diagram of a device, or a digital image.
Digital representation of the device.
Multimedia
CLUSTER
true
false
true
0
at0021
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
1
false
false
true
false
true
0
protocol
true
true
false
false
0
1
ITEM_TREE
true
true
false
false
1
1
at0016
items
true
true
false
false
0
1
CLUSTER
true
false
true
0
at0018
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
-
Device use statement
openEHR-EHR-EVALUATION.device_summary.v0
An ongoing and persistent overview about medical devices that have been fitted or implanted.
Medical device summary
@ internal @
Tree
Assertion about the fitting or implanting of devices, as at the date 'Last updated'.
Status
The device type has never been fitted or implanted.
Never
The device type is currently fitted or implanted.
Current
The device type has been fitted or implanted in the past.
Previous
Identification of the specific device, by name.
Device name
Date of fitting or implant of the device.
Start date
Date when the device stopped being used or was removed.
End date
Additional structured detail about the device.
Structured detail
Identification of the body site where the device is fitted/implanted.
Body site
A structured anatomical location of the body site where the device is fitted/implanted.
Structured body site
Narrative description about the device.
Description
Narrative description about the use of the fitted device type.
Description
@ internal @
Tree
The date this summary was last updated.
Last updated
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
Date on which this device should be reviewed.
Next review due
For example: Assisted hearing devices, eyeglasses, contact lens, dental braces, dentures, orthotics or artificial limbs.
Name of the type of medical device.
Device type
Digital image, video or diagram about the device.
Multimedia
Details about each device.
Device details
Commonly, this will be an ACTION archetype that contains the details about the fitting or insertion of the device.
Link to the original data about the fitting or insertion.
URI to original data
false
false
true
false
true
0
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
true
true
false
false
0
1
at0000
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
-
Diagnostic Results
items
true
true
false
false
0
1
OBSERVATION
true
true
false
false
0
1
at0000
data
true
true
false
false
1
1
HISTORY
true
true
false
false
1
1
at0001
events
true
true
false
false
0
1
EVENT
true
false
true
0
at0002
data
true
true
false
false
1
1
ITEM_TREE
true
true
false
false
1
1
at0003
items
true
true
false
false
0
1
ELEMENT
true
true
false
false
1
1
at0005
value
true
true
false
false
0
1
DV_TEXT
true
true
false
false
1
1
CLUSTER
true
true
false
false
0
1
at0000
items
true
true
false
false
1
1
ELEMENT
true
true
false
false
0
1
at0029
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
-
openEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v1
constraint
ELEMENT
true
true
false
false
0
1
at0007
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
-
Method
ELEMENT
true
true
false
false
0
1
at0087
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
-
Body site
CLUSTER
true
false
true
0
at0013
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
openEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_circle(-[a-zA-Z0-9_]+)*\.v1
constraint
CLUSTER
true
false
true
0
at0071
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
CLUSTER
true
false
true
0
at0083
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
CLUSTER
true
false
true
0
at0085
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
openEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v1
constraint
CLUSTER
true
false
true
0
at0068
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
openEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v0
constraint
CLUSTER
true
false
true
0
at0093
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
openEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v1
constraint
CLUSTER
true
false
true
0
at0096
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v0
constraint
false
false
true
false
true
1
openEHR-EHR-CLUSTER.specimen.v1
For example: Tissue or body fluid.
A physical sample collected from, or related to, an individual for the purpose of investigation, examination or analysis.
Specimen
Sometimes called the Accession Identifier. Specimen containers, for example vacuum vials or tissue cassettes, have their own identitiers which may be recorded in the 'Container identifier' element in the 'Specimen container' archetype.
A unique identifier of the specimen, normally assigned by the laboratory.
Specimen.accessionIdentifier
Laboratory specimen identifier
For example: A specific histology slide specimen can have a specific paraffin wax block as its parent specimen.
Unique identifier of the parent specimen, where the specimen is split into sub-samples.
Parent specimen identifier
For example: 'Hepatitis B'; "nerve agent'. Coding of the 'Hazard warning' with a terminology is preferred, where possible.
Identified health risk or biohazard to the collector or laboratory staff due to exposure to, or contact with, the specimen.
Hazard warning
For example: venepuncture, biopsy, resection. Coding of the collection method with a terminology is preferred, where possible. If the collection method is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.
The method of collection used.
Specimen.collection.method
Collection method
For example: 'fasting'; 'full bladder'; 'sterile field'; or special instructions on the handling or immediate processing of the sample, such as 'centrifuge on receipt'. This data element also be used to document any known deviations from collection or handling instructions, for example that the patient had not fasted, even when this had been originally requested. Coding of the 'Sampling context' with a terminology is preferred, where possible.
If this archetype is used within an INSTRUCTION archetype, the context will reflect the intended or desired conditions at sample collection. If this archetype is used for representing an ACTION archetype pathway step which correlates with the collection being performed or completed, the context will be reflecting the conditions that existed at sample collection and this may also be copied to the 'Confounding factors' element of the OBSERVATION.laboratory_test_result archetype.
The context in which the specimen is collected.
Sampling context
Utilise the more detailed archetypes to describe structured or more complex anatomical sites, or to support recording the source site at run-time by the application. If the body site has been fully identified in the 'Source site' data element, this SLOT becomes redundant.
A structured description of the area of the body from where the specimen is collected.
Specimen.collection.sourceSite
Structured source site
This datetime will be captured primarily in the INSTRUCTION timing, ACTION time or OBSERVATION times. However, as this is a critical piece of information, it can be useful to also associate it directly with the specimen itself.
The date and time that collection has been ordered to take place or has taken place.
Collection date/time
For example: Volume, mass, circumference, colour, smell, turbidity. This element can be used to specify the properties of the specimen to be collected, in the context of an INSTRUCTION archetype, or the properties of the specimen which was collected, in the context of an ACTION or OBSERVATION archetype. For example, an INSTRUCTION may request the collection of 20 ml of blood, while the corresponding ACTION records that only 15 ml was collected.
Physical dimensions, mass or non-measurable properties of the specimen.
Specimen.collection.quantity
Physical properties
For example: Venous blood, bacterial culture, cytology, or tissue sample. Coding of the specimen type with a terminology is preferred, where possible.
The type of specimen.
Specimen.type
Specimen type
The date and time that the sample was received at the laboratory.
Specimen.receivedTime
Date/time received
This element is intended to be used to record a judgement about whether or not the specimen quality was good enough for testing, and whether or not testing has been carried out. Coding of the specimen quality issues with a terminology is preferred, where possible.
Information about whether the specimen was adequate for testing.
Adequacy for testing
Coding of the specimen quality issues with a terminology is preferred, where possible.
A specific quality issue with a specimen.
Specimen quality issue
Additional narrative about the specimen not captured in other fields.
Specimen.note
Comment
The specimen was haemolysed.
Haemolysed
The specimen was lipaemic.
Lipaemic
An incorrect additive such as a transport medium or preservative was added to the specimen.
Incorrect additive
The available amount of specimen was insufficient to undertake the examination.
Insufficient amount
The specimen is of sufficient quality to allow reporting.
Satisfactory
The specimen is unsatisfactory but has been analysed.
Unsatisfactory - analysed
The specimen is unsatisfactory and has not been analysed.
Unsatisfactory - not analysed
For example: laboratory outpatient clinic, at home, or hospital ward. This specifies the type of specimen collection location within the healthcare environment. The specimen collection setting may provide additional information relevant to the analysis of the result.
Identification of the physical setting in which the specimen is collected.
Collection setting
For example: Staining or fixation.
Structured details about preparation or processing of the specimen.
Processing details
This element is intended to be used where the specimen has already been collected and the actual collector is known.
Identifier of the person or organisation responsible for collecting the specimen.
Specimen.collection.collector
Specimen collector identifier
The person or organisation responsible for collecting the specimen.
Specimen.collection.collector
Specimen collector details
Narrative description about the collection of the specimen.
Collection description
For example: Number of buckets, jars, vials, tubes, blocks, slides or grids.
The total number of physical units holding this specimen.
Number of containers
For example details about needle biopsies in prostate cancer, where both the request and reporting about the specimen are detailed and specific.
Addtional details related to specific collection methods.
Additional collection details
Details about containers used.
Container details
For example: 'wound on left calf', 'IV cannula right arm', 'right kidney'.
Coding of the name of the source site with a terminology is preferred, where possible. Use this data element to record precoordinated source sites. If the requirements for recording the source site are determined at run-time by the application or require more complex modelling such as relative locations then use the 'Structured source site' SLOT in this archetype. If the source site is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.
Identification of the body site or other location from where the specimen is collected.
Source site
For example: 'Requester ID', 'Archive ID, 'Biobank ID'.
A unique identifier of the specimen, assigned by a party external to the laboratory.
Specimen.identifier
External identifier
The specimen was icteric.
Icteric
An error arose when handling the specimen. For example: Incorrect storage, broken container.
Handling error
The specimen was too old to analyse or to analyse accurately.
Age
The specimen could not be analysed for technical reasons.
Technical failure
Structured details about transport of the specimen.
Transport details
The specimen was clotted.
Clotted
The specimen was labelled incorrectly.
Incorrectly labelled
For example the scanned image of a histopathology slide.
Structured details about a digital representation of the specimen.
Digital representation
ELEMENT
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false
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0
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at0077
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true
true
false
false
0
1
DV_TEXT
true
true
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1
1
value
true
true
false
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1
1
STRING
true
true
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1
1
-
Laboratory
Pathology
CLUSTER
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0
1
at0000
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1
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ELEMENT
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at0024
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DV_TEXT
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1
1
ELEMENT
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true
0
at0001
CLUSTER
true
false
true
0
at0014
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
false
false
true
false
true
1
openEHR-EHR-CLUSTER.laboratory_test_analyte.v1
The result of a laboratory test for a single analyte value.
Laboratory analyte result
For example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details.
The value of the analyte result.
Observation.value[x]
OBX.2, OBX.5, OBX.6, OBX.7, OBX.8
Analyte result
Additional narrative about the analyte result, not captured in other fields.
Observation.note
NTE.3
Comment
For example, 'within normal limits for age and sex'.
Additional advice on the applicability of the reference range to this result or may carry text or coded textual guidance as to whether the result is within the normal range.
Reference range guidance
The values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.
The status of the analyte result value.
Observation.status
OBX.11
Result status
The date and time that the analyte result was issued for the recorded ‘Result status’.
Observation.issued
OBX.19
Result status time
Further detail regarding an individual result.
Analyte result detail
The existence of the test is registered in the Laboratory Information System, but there is nothing yet available.
Registered
This is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.
Partial
Verified early results are available, but not all results are final. This is a sub-category of 'Partial'.
Preliminary
The Test result is complete and verified by an authorised person.
Final
The result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.
Corrected
The result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.
Amended
Subsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.
Appended
The Test Result has been withdrawn following previous Final release.
Entered in error
The result is unavailable because the test was not started or not completed (also sometimes called 'aborted').
Cancelled
The value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies.
The name of the analyte result.
Observation.code
OBX.3
Analyte name
In many jurisdictions the 'Result status' is assumed to include medical validation i.e. a 'final' result will be assumed to be medically validated, but in others this will be recorded and reported separately using this data element.
The date and time that the analyte result was validated in the laboratory by a healthcare practitioner.
Validation time
In some situations, a single Laboratory test result archetype will contain multiple Specimen archetypes and multiple Analyte result archetypes. In these situations, this 'Specimen' data element is needed to be able to connect the results with the correct specimens.
Identification of the specimen used for the analyte result.
Specimen
For example: ''1' '2', '3'. Where multiple analyte results are reported, the 'Analyte result sequence' makes the order in which they were reported explicit.
The intended position of this analyte result within the overall sequence of analyte results.
Analyte result sequence
ELEMENT
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at0057
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DV_TEXT
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name
true
true
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1
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DV_TEXT
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value
true
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1
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STRING
true
true
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1
1
-
Interpretation
CLUSTER
true
false
true
0
at0122
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
CLUSTER
true
true
false
false
0
1
at0000
items
true
true
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1
1
ELEMENT
true
true
false
false
0
1
at0002
value
true
true
false
false
0
1
DV_TEXT
true
true
false
false
1
1
ELEMENT
true
true
false
false
0
1
at0001
value
true
true
false
false
0
1
DV_MULTIMEDIA
true
true
false
false
1
1
media_type
true
true
false
false
1
1
CODE_PHRASE
true
true
false
false
1
1
IANA_media-types
DV_URI
true
true
false
false
1
1
CLUSTER
true
false
true
0
at0012
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
CLUSTER
true
false
true
0
at0011
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
openEHR-EHR-CLUSTER\.device\.v1
constraint
CLUSTER
true
false
true
0
at0013
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
false
false
true
false
true
1
openEHR-EHR-CLUSTER.multimedia_source.v0
A multimedia resource that is generated or acquired during the provision of healthcare.
Multimedia source
The actual content will be captured and stored using the Multimedia data type. For example: RTF or PDF for a document; JPG for an image; MP4 for a video; or WAV for an audio file. If the content is stored elsewhere the external location can be referenced using the URI data type.
Digital representation of the resource.
Content
Name or title of the multimedia resource.
Resource name
The time, date, partial date or period when the resource was generated or authored.
Created
Narrative description about the resource.
Description
Additional narrative about the multimedia source not captured in other fields.
Comment
Identifier for the resource.
Identifier
For example: the camera used to capture an image.
Details about the device used to generate or author the resource.
Source device
Details about the individual or organisation who generated or authored the resource.
Creator
Further details about the multimedia source.
Additional details
false
false
true
false
true
1
state
true
true
false
false
0
1
ITEM_TREE
true
true
false
false
1
1
at0112
items
true
true
false
false
0
1
CLUSTER
true
false
true
0
at0114
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
false
false
true
false
true
0
false
false
true
false
true
1
protocol
true
true
false
false
0
1
ITEM_TREE
true
true
false
false
1
1
at0004
items
true
true
false
false
0
1
CLUSTER
true
true
false
false
0
1
at0017
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
CLUSTER
true
false
true
0
at0110
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1
constraint
CLUSTER
true
false
true
0
at0117
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
false
false
true
false
true
0
openEHR-EHR-OBSERVATION.laboratory_test_result.v1
The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.
Laboratory test result
@ internal @
Event Series
Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Any event
@ internal @
Tree
@ internal @
Tree
A test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'.
Name of the laboratory investigation performed on the specimen(s).
Test name
This slot is intended to carry details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.
The receiving laboratory may either perform the test or refer it to another laboratory. Where a different laboratory is responsible for performing the testing on specific analytes, it would be expected that these details would be carried in the 'Analyte result detail' SLOT within the CLUSTER.laboratory_test_analyte archetype.
Details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.
Receiving laboratory
The 'Distribution list' is for information-only, and that the primary recipient of the report is the person intended to act on the information.
Details of additional clinicians or organisations who require a copy of the test result.
Distribution list
This is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.
Partial
The Test result is complete and verified by an authorised person.
Final
The result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.
Amended
For example: 'Pattern suggests significant renal impairment'. The content of the conclusion will vary, depending on the investigation performed. This conclusion should be aligned with the coded 'Test diagnosis'.
Narrative description of the key findings.
Conclusion
Equivalent to the HL7 Placer Order Identifier.
The local identifier assigned by the requesting clinical system.
Requester order identifier
Assigning an identifier to a request by the Laboratory lnformation System (LIS) enables tracking progress of the request and enables linking results to requests. It also provides a reference to assist with enquiries and it is usually equivalent to the HL7 Filler Order Identifier.
The local identifier assigned to the test order by the order filler, usually by the Laboratory Information System (LIS).
Receiver order identifier
If the specimen type is sufficiently specified with a code in the Test name, then this additional data is not required. Linking results to specific specimens may be recorded using 'Specimen identifier' elements in both the CLUSTER.specimen and the various results CLUSTER archetypes.
Details about the physical substance that has been analysed.
Specimen detail
This identifier is an internal tracking number assigned by the LIS, and it not intended to be the name of the test.
A local identifier assigned by the receiving Laboratory Information System (LIS) to track the test process.
Laboratory internal identifier
The values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.
This element is multiple occurrence to cater for the use cases where statuses for different aspects of the result have been split into several elements.
The status of the laboratory test result as a whole.
Overall test status
The result is unavailable because the test was not started or not completed (also sometimes called 'aborted').
Cancelled
The date and/or time that ‘Overall test status’ was issued.
Overall test status timestamp
This is intended to be a general categorisation and not to capture the organisational name of the laboratory. For example: anatomical pathology, immunology and transfusion medicine, medical microbiology, clinical pharmacology, medical genetics, medical biochemistry. Alternatively more granular sub categories or sub disciplines, such as endocrinology, haematology, and allergology services, may be used. This may assist clinicians in filtering between categories of results. Coding with a terminology is desirable, where possible.
The diagnostic service or discipline that is responsible for the laboratory test result.
Diagnostic service category
Details of the clinician or organisation requesting the laboratory test result.
Requester
In most situations there is one test request and a single corresponding test result, however this repeating cluster allows for the situation where there may be multiple test requests reported using a single test result.
As an example: 'a clinician asks for blood glucose in one request and Urea/electrolytes in a second request, but the lab analyser does both and the lab wishes to report these together'.
Details about the test request.
Test request details
This SLOT may carry an individual analyte, a group, panel or battery of multiple analytes, or a more complex and specific structure.
Results of the test performed on the specimen(s).
Test result
For example: 'Severe hepatic impairment', 'Salmonella contamination'. Coding of the diagnosis with a terminology is strongly recommended, where possible. This diagnosis should be aligned with the narrative in the 'Conclusion'.
Single word, phrase or brief description that represents the clinical meaning and significance of the laboratory test result.
Test diagnosis
This data element may include a link to the original clinical information provided in the test request.
Description of clinical information available at the time of interpretation of results.
Clinical information provided
Additional narrative about the test result not captured in other fields.
Comment
This data element is to be used when the test requested differs from the test actually performed by the laboratory.
Name of the original laboratory test requested.
Original test requested name
The existence of the test is registered in the Laboratory Information System, but there is nothing yet available.
Registered
For example: 'details of ELISA/nephelometry'.
Structured details about the method of analysis, device or interpretation used.
Testing details
True if the test was performed directly at Point-of-Care (POCT).
This indicates whether the test was performed directly at Point-of-Care (POCT) as opposed to a formal result from a laboratory or other service delivery organisation.
Point-of-care test
@ internal @
Tree
'Confounding factors' should be reserved for uncontrolled/unplanned issues of patient state/physiology that might affect interpretation, for example 'recent exercise' or 'recent tobacco smoking'.
Known or required preconditions, such as 'fasting' should be carried in the 'Sampling conditions' element within the CLUSTER.specimen archetype . In some cases preconditions are captured as part of the test name, for example 'Fasting blood glucose'.
Known issues with specimen collection or handling, such as 'prolonged use of tourniquet' or 'sample haemolysed', should be carried in the 'Specimen quality' elements within CLUSTER.specimen archetype.
Coding with a terminology is desirable, where possible.
Issues or circumstances that impact on the accurate interpretation of the measurement or test result.
Confounding factors
For example: Last Normal Menstrual Period (LNMP).
Details of issues or circumstances that impact on the accurate interpretation of the measurement or test result.
Structured confounding factors
The result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.
Corrected
The Test Result has been withdrawn following previous Final release.
Entered in error
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
Multiple formats are allowed but they should represent equivalent clinical content.
Digital image, video or diagram representing the test result.
Multimedia representation
Subsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.
Appended
Verified early results are available, but not all results are final. This is a sub-category of 'Partial'.
Preliminary
Coding with a terminology is desirable, where possible.
Description about the method used to perform the test.
Test method
For example: Anatomical pathology diagnoses consisting of several different axes such as morphology, etiology and function.
A structured or complex diagnosis for the laboratory test.
Structured test diagnosis
OBSERVATION
true
true
false
false
0
1
at0000
data
true
true
false
false
1
1
HISTORY
true
true
false
false
1
1
at0001
events
true
true
false
false
0
1
EVENT
true
false
true
0
at0002
data
true
true
false
false
1
1
ITEM_TREE
true
true
false
false
1
1
at0003
items
true
true
false
false
0
1
ELEMENT
true
true
false
false
1
1
at0004
value
true
true
false
false
0
1
DV_TEXT
true
true
false
false
1
1
ELEMENT
true
true
false
false
0
1
at0005
value
true
true
false
false
0
1
DV_TEXT
true
true
false
false
1
1
ELEMENT
true
true
false
false
0
1
at0055
value
true
true
false
false
0
1
DV_TEXT
true
true
false
false
1
1
CLUSTER
true
false
true
0
at0006
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
openEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1
constraint
ELEMENT
true
true
false
false
0
1
at0007
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
at0009
at0010
at0011
at0012
at0013
ELEMENT
true
true
false
false
0
1
at0008
value
true
true
false
false
0
1
DV_TEXT
true
true
false
false
1
1
CLUSTER
true
true
false
false
0
1
at0000
items
true
true
false
false
1
1
ELEMENT
true
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false
false
0
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at0024
value
true
true
false
false
0
1
DV_TEXT
true
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false
false
1
1
ELEMENT
true
true
false
false
0
1
at0033
value
true
true
false
false
0
1
DV_TEXT
true
true
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false
1
1
CLUSTER
true
false
true
0
at0034
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
openEHR-EHR-CLUSTER\.anatomical_location\.v1
constraint
ELEMENT
true
false
true
0
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
at0035
at0036
at0037
ELEMENT
true
true
false
false
0
1
at0028
value
true
true
false
false
0
1
DV_TEXT
true
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false
false
1
1
CLUSTER
true
false
true
0
at0014
ELEMENT
true
true
false
false
0
1
at0029
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
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1
1
local
at0030
at0031
at0032
DV_TEXT
true
true
false
false
1
1
ELEMENT
true
false
true
0
at0003
value
true
true
false
false
0
1
DV_TEXT
true
true
false
false
1
1
false
false
true
false
true
1
openEHR-EHR-CLUSTER.imaging_finding.v0
A single finding in an imaging examination.
Imaging finding
For example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details.
The presence or absence of the finding.
Observation.value[x]
OBX.2, OBX.5, OBX.6, OBX.7, OBX.8
Presence?
Additional narrative about the finding, not captured in other fields.
Observation.note
NTE.3
Comment
Additional structured detail about the finding.
Structured detail
Coding with an external terminology is strongly recommended.
The name of the finding.
Observation.code
OBX.3
Finding name
Narrative description about the observed clinical finding.
Description
Narrative description about the difference between a previous finding and the finding in this report.
Comparison to previous
The finding is improving compared to previous imaging examinations.
Improving
The finding is unchanged compared to previous imaging examinations.
Unchanged
The finding is worsening compared to previous imaging examinations.
Worsening
Simple description of anatomical location.
Anatomical location
Structured details about the location of the finding.
Structured anatomical location
The finding is observed in the image.
Present
The finding is not observed in the image.
Absent
It is not possible to determine if the finding is present or absent.
Indeterminate
ELEMENT
true
true
false
false
0
1
at0056
value
true
true
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0
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DV_TEXT
true
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ELEMENT
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at0021
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DV_TEXT
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1
1
ELEMENT
true
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true
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at0020
value
true
true
false
false
0
1
DV_TEXT
true
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false
1
1
CLUSTER
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true
false
false
0
1
at0000
items
true
true
false
false
1
1
ELEMENT
true
true
false
false
0
1
at0002
value
true
true
false
false
0
1
DV_TEXT
true
true
false
false
1
1
ELEMENT
true
true
false
false
0
1
at0001
value
true
true
false
false
0
1
DV_MULTIMEDIA
true
true
false
false
1
1
media_type
true
true
false
false
1
1
CODE_PHRASE
true
true
false
false
1
1
IANA_media-types
DV_URI
true
true
false
false
1
1
CLUSTER
true
false
true
0
at0012
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
CLUSTER
true
false
true
0
at0011
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
openEHR-EHR-CLUSTER\.device\.v1
constraint
CLUSTER
true
false
true
0
at0013
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
false
false
true
false
true
1
openEHR-EHR-CLUSTER.multimedia_source.v0
A multimedia resource that is generated or acquired during the provision of healthcare.
Multimedia source
The actual content will be captured and stored using the Multimedia data type. For example: RTF or PDF for a document; JPG for an image; MP4 for a video; or WAV for an audio file. If the content is stored elsewhere the external location can be referenced using the URI data type.
Digital representation of the resource.
Content
Name or title of the multimedia resource.
Resource name
The time, date, partial date or period when the resource was generated or authored.
Created
Narrative description about the resource.
Description
Additional narrative about the multimedia source not captured in other fields.
Comment
Identifier for the resource.
Identifier
For example: the camera used to capture an image.
Details about the device used to generate or author the resource.
Source device
Details about the individual or organisation who generated or authored the resource.
Creator
Further details about the multimedia source.
Additional details
false
false
true
false
true
1
state
true
true
false
false
0
1
ITEM_TREE
true
true
false
false
1
1
at0047
items
true
true
false
false
0
1
false
false
true
false
true
0
false
false
true
false
true
1
protocol
true
true
false
false
0
1
ITEM_TREE
true
true
false
false
1
1
at0025
items
true
true
false
false
0
1
ELEMENT
true
true
false
false
0
1
at0049
value
true
true
false
false
0
1
DV_TEXT
true
true
false
false
1
1
CLUSTER
true
false
true
0
at0041
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
ELEMENT
true
true
false
false
0
1
at0057
value
true
true
false
false
0
1
DV_TEXT
true
true
false
false
1
1
CLUSTER
true
false
true
0
at0026
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
CLUSTER
true
false
true
0
at0027
items
true
true
false
false
1
1
ELEMENT
true
true
false
false
0
1
at0028
value
true
true
false
false
0
1
DV_IDENTIFIER
true
true
false
false
1
1
ELEMENT
true
false
true
0
at0029
value
true
true
false
false
0
1
DV_TEXT
true
true
false
false
1
1
CLUSTER
true
false
true
0
at0030
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
ELEMENT
true
true
false
false
0
1
at0031
value
true
true
false
false
0
1
DV_IDENTIFIER
true
true
false
false
1
1
ELEMENT
true
true
false
false
0
1
at0032
value
true
true
false
false
0
1
DV_URI
true
true
false
false
1
1
ELEMENT
true
true
false
false
0
1
at0033
value
true
true
false
false
0
1
DV_IDENTIFIER
true
true
false
false
1
1
CLUSTER
true
false
true
0
at0034
items
true
true
false
false
1
1
ELEMENT
true
true
false
false
0
1
at0035
value
true
true
false
false
0
1
DV_IDENTIFIER
true
true
false
false
1
1
ELEMENT
true
true
false
false
0
1
at0036
value
true
true
false
false
0
1
DV_IDENTIFIER
true
true
false
false
1
1
ELEMENT
true
true
false
false
0
1
at0037
value
true
true
false
false
0
1
DV_TEXT
true
true
false
false
1
1
ELEMENT
true
true
false
false
0
1
at0038
value
true
true
false
false
0
1
DV_TEXT
true
true
false
false
1
1
ELEMENT
true
true
false
false
0
1
at0039
value
true
true
false
false
0
1
DV_DATE_TIME
true
true
false
false
1
1
ELEMENT
true
true
false
false
0
1
at0040
value
true
true
false
false
0
1
DV_MULTIMEDIA
true
true
false
false
1
1
media_type
true
true
false
false
1
1
CODE_PHRASE
true
true
false
false
1
1
IANA_media-types
application/dicom
image/cgm
image/gif
image/png
image/tiff
image/jpeg
false
false
true
false
true
1
name
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
local
at0053
at0054
false
false
true
false
true
1
CLUSTER
true
false
true
0
at0046
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
false
false
true
false
true
0
openEHR-EHR-OBSERVATION.imaging_exam_result.v0
Record the findings and interpretation of an imaging examination performed.
Imaging examination result
@ internal @
Event Series
Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Any event
@ internal @
Tree
Coding with a terminology, potentially a pre-coordinated term specifying both modality and anatomical location, is desirable where possible. Possible candidate terminologies: LOINC, SNOMED CT or RadLex.
The name of the imaging examination or procedure performed.
Test name
Also known as 'Examination type'. For example: Ultrasound; Computed tomography; or X-ray. Coding with a terminology is desirable, where possible. If the modality is specified by a code in the Examination result name, then this field may be redundant.
Type of equipment that originally acquired the image or series of images.
Modality
Identification of the anatomical site related to a specific finding will be recorded within each instance of CLUSTER.imaging_finding.
Structured detail about the anatomical site related to the entire result.
Structured anatomical site
The status of the examination result as a whole.
Overall result status
Narrative description of the clinical findings.
Findings
No result yet available.
Registered
This is an initial or interim result: data may be missing or verification not been performed.
Interim
The result is complete and verified by the responsible radiologist.
Final
The result has been modified subsequent to being Final, and is complete and verified by the radiologist.
Amended
The result is not available because the examination was not started or completed.
Cancelled / Aborted
This may include a link to the clinical information provided in the original examination request. If other sources of clinical information have been used, this should be clearly stated using this data element.
Description of clinical information available at the time of interpretation of results.
Clinical information provided
This data element has multiple occurrences to allow for more than one diagnoses. Coding with a terminology is preferred, where possible. This data element should be regarded as mutually exclusive to 'Differential diagnoses' - only one of 'Differential diagnoses' OR 'Imaging diagnosis' should be present in the each Imaging examination result.
Single word, phrase or brief description representing the likely condition or diagnosis.
Imaging diagnosis
Also referred to as 'Opinion' or 'Impression'.
Narrative concise, clinically relevant interpretation of all imaging findings, and include a comparison with previous studies where appropriate.
Conclusion
For example: a note that the film was given to the patient.
Additional narrative about the examination not captured in other fields.
Comment
The date and/or time that the result was issued for the recorded 'Examination result status'.
DateTime result issued
@ internal @
Tree
Demographic details about the receiving imaging service performing the imaging test.
Receiving imaging service
Details concerning a single examination requested. Note: Usually there is one examination request for each result, however in some circumstances multiple examination requests may be represented using a single Imaging examination result archetype.
Examination request details
The local identifier assigned to the order by the order requester. Equivalent to the HL7 Placer Order Identifier.
Requester order identifier
Identification of imaging examination or procedure requested, where the examination requested differs from the examination actually performed.
Examination requested name
Details about the clinician or organisation requesting the imaging examination.
Requester
The local identifier assigned to the examination order by the order filler, usually by the Radiology Information System (RIS). Usually equivalent to the HL7 Filler Order Number.
Receiver order identifier
Unique identifier of this study allocated by the imaging service.
DICOM study identifier
The local identifier given to the imaging examination report.
Report identifier
Images referred to, or provided, to assist clinical understanding of the examination. If attached image is in DICOM format, all the fields below should be populated so the values are available to software that does not process DICOM images.
Image details
Unique identifier of this image allocated by the imaging service (often the DICOM image instance UID).
Image identifier
Unique identifier of this series allocated by the imaging service.
DICOM series identifier
The name of the imaging view e.g Lateral or Antero-posterior (AP). Coding using a terminology is desirable, where possible.
View
Description of the subject of care's positon when the image was performed.
Position
Specific date/time the imaging examination was performed.
Image DateTime
An attached or referenced image of a current view.
Image
Additional structured details of technical details and procedure.
Structured technique
Structured details about each imaging finding.
Imaging findings
Digital image or video representing the exam result.
Image 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 or formalisms.
Extension
@ internal @
Tree
Narrative description of factors, not recorded elsewhere, that may influence the examination findings and/or result.
Confounding factors
For example: outline of technique; non-routine alternative or additional imaging; nature and route of administration of contrast agent, radiopharmaceuticals and/or treatments administered; adverse reactions to contrast media.
Narrative description about the technical details and procedure.
Technique
Details about the image being reported.
Reported image
For example: narrative description about progression/worsening of a condition. Structured comparison details will require representation in a separate CLUSTER archetype.
Details about an image being compared to the image being reported.
Comparison image
This data element is redundant if the anatomical site is identified in the 'Test name'.
Simple description about the physical place on, or in, the body that was imaged.
Anatomical site
If there is no availability of previous imaging and/or reports this should also be stated using this data element.
Narrative descripition about the comparison of this image, or series of images, with previous similar examinations.
Comparison with previous
For example: the nature of any limitations and their impact on interpretation.
Narrative description about the quality of the examination.
Imaging quality
This data element has multiple occurrences to allow for more than one differential diagnoses. Coding with a terminology is preferred, where possible. This data element should be regarded as mutually exclusive to 'Imaging diagnosis' - only one of 'Differential diagnoses' OR 'Imaging diagnosis' should be present in each Imaging examination result.
Single word, phrase or brief description representing a possible condition or diagnosis.
Imaging differential diagnosis
This data element has 0..* occurrences to allow for more than one recommendation and associated rationale. Formal orders for additional imaging examination, investigation should be recorded using an INSTRUCTION archetype, such as INSTRUCTION.service_request.
Suggestion for further imaging, investigations and/or referral, and associated rationale.
Recommendation
false
false
true
false
true
0
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
true
true
false
false
0
1
at0000
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
-
Vital Signs
items
true
true
false
false
0
1
OBSERVATION
true
true
false
false
0
1
at0000
data
true
true
false
false
1
1
HISTORY
true
true
false
false
1
1
at0002
events
true
true
false
false
0
1
EVENT
true
false
true
0
at0003
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
1
1
at0004
value
true
true
false
false
0
1
DV_QUANTITY
true
true
false
false
1
1
openehr
124
true
true
false
false
0
1000
kg
true
true
false
false
0
2000
[lb_av]
true
true
false
false
0
1000000
g
false
false
true
false
true
1
state
true
true
false
false
0
1
ITEM_TREE
true
true
false
false
1
1
at0008
items
true
true
false
false
0
1
true
false
true
false
true
0
false
false
true
false
true
1
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
true
false
false
0
1
at0020
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1
constraint
CLUSTER
true
false
true
0
at0027
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
true
false
true
false
true
0
openEHR-EHR-OBSERVATION.body_weight.v2
Measurement of the body weight of an individual.
Body weight
@ internal @
Simple
@ internal @
history
Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Any event
The weight of the individual.
Weight
@ internal @
state structure
Description of the state of dress of the person at the time of weighing.
State of dress
Clothing which may add significantly to weight, including shoes.
Fully clothed, including shoes
Clothing which will not add to weight significantly.
Lightly clothed/underwear
Without any clothes.
Naked
@ internal @
protocol structure
Wearing only a nappy - which may add significantly to weight.
Nappy/diaper
Details about the weighing device.
Device
Additional narrative about the measurement of Body weight, not captured in other fields.
Comment
Record any issues or factors that may impact on the measurement of body weight eg timing in menstrual cycle, timing of recent bowel motion or noting of amputation.
Confounding factors
Usually the first weight, measured soon after birth. This event will only be used once per health record
.
Birth
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
Clothing which may add significantly to weight.
Fully clothed, without shoes
LOINC
29463-7
OBSERVATION
true
true
false
false
0
1
at0000
data
true
true
false
false
1
1
HISTORY
true
true
false
false
1
1
at0001
events
true
true
false
false
0
1
EVENT
true
false
true
0
at0002
data
true
true
false
false
1
1
ITEM_TREE
true
true
false
false
1
1
at0003
items
true
true
false
false
0
1
ELEMENT
true
true
false
false
1
1
at0004
value
true
true
false
false
0
1
DV_QUANTITY
true
true
false
false
1
1
openehr
122
true
true
false
false
0
1000
cm
true
true
false
false
0
250
[in_i]
false
false
true
false
true
1
state
true
true
false
false
0
1
ITEM_TREE
true
true
false
false
1
1
at0013
items
true
true
false
false
0
1
false
false
true
false
true
0
false
false
true
false
true
1
protocol
true
true
false
false
0
1
ITEM_TREE
true
true
false
false
1
1
at0007
items
true
true
false
false
0
1
CLUSTER
true
true
false
false
0
1
at0011
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1
constraint
CLUSTER
true
false
true
0
at0022
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
true
false
true
false
true
0
openEHR-EHR-OBSERVATION.height.v2
Height is measured with the individual in a standing position and body length in a recumbent position.
Height, or body length, is measured from crown of head to sole of foot.
Height/Length
@ internal @
history
Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Any event
@ internal @
Simple
The length of the body from crown of head to sole of foot.
Height/Length
@ internal @
List
Description of the device used to measure height or body length.
Device
@ internal @
Tree
Position of individual when measured.
Position
Height is measured standing on both feet with weight distributed evenly, heels together and both buttocks and heels in contact with a vertical back board.
Standing
Additional narrative about the measurement, not captured in other fields.
Comment
For example: noting of amputation.
Narrative description of any issues or factors that may impact on the measurement.
Confounding factors
Length is measured in a fully extended, recumbent position with the pelvis flat, legs extended and feet flexed.
Lying
Usually the first length measurement, recorded soon after birth. This event will only be used once per health record
.
Birth
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
LOINC
8302-2
OBSERVATION
true
true
false
false
0
1
at0000
data
true
true
false
false
1
1
HISTORY
true
true
false
false
1
1
at0001
events
true
true
false
false
0
1
EVENT
true
false
true
0
at0002
data
true
true
false
false
1
1
ITEM_TREE
true
true
false
false
1
1
at0003
items
true
true
false
false
0
1
ELEMENT
true
true
false
false
0
1
at0004
value
true
true
false
false
0
1
DV_QUANTITY
true
true
false
false
1
1
openehr
382
true
true
false
false
0
200
true
true
false
false
0
0
/min
false
false
true
false
true
0
state
true
true
false
false
0
1
ITEM_TREE
true
true
false
false
1
1
at0022
items
true
true
false
false
0
1
CLUSTER
true
true
false
false
0
1
at0055
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
openEHR-EHR-CLUSTER\.inspired_oxygen(-[a-zA-Z0-9_]+)*\.v1
constraint
CLUSTER
true
true
false
false
0
1
at0037
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
openEHR-EHR-CLUSTER\.level_of_exertion(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.level_of_exertion(-[a-zA-Z0-9_]+)*\.v1
constraint
false
false
true
false
true
0
false
false
true
false
true
1
protocol
true
true
false
false
0
1
ITEM_TREE
true
true
false
false
1
1
at0057
items
true
true
false
false
0
1
CLUSTER
true
false
true
0
at0058
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
false
false
true
false
true
0
openEHR-EHR-OBSERVATION.respiration.v2
The characteristics of spontaneous breathing by an individual.
Respiration
@ internal @
history
Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Any event
@ internal @
List
The frequency of spontaneous breathing.
Rate
The regularity of spontaneous breathing.
Regularity
The breathing pattern is regular.
Regular
The breathing pattern is not regular.
Irregular
Coding with a terminology is preferred, where possible. For example: Normal breathing; Evidence of respiratory distress; Kussmaul's respiration; Cheyne-Stokes respiration; or Apnoeic episodes. Multiple statements are allowed.
Single word, phrase or brief description which represents the clinical meaning and significance of the respiration findings.
Clinical interpretation
The depth of spontaneous breathing.
Depth
Normal depth of breathing.
Normal
Shallow depth of breathing.
Shallow
Deep breathing.
Deep
@ internal @
List
For example: noting respiratory distress, use of accessory muscles or intermittent apnoea; noting characteristics such as stridor, sighing, grunting, groaning, gasping.
Conducting a full respiratory examination, then some of these findings might be more appropriately recorded as part of examination findings.
A narrative description about the spontaneous breathing of the individual.
Clinical description
Variable depth of breathing.
Variable
The individual's level of exertion during, or just prior to, the observation.
Details about physical exertion being undertaken during the examination.
Exertion
Assumed values of 21% oxygen concentration, Fi02 of 0.21 and oxygen flow rate of 0 l/min or 0 ml/min.
Details of the amount of oxygen being delivered to the individual at the time of observation.
Inspired oxygen
For example: level of anxiety, pain, feeding in infants, tracheostomy.
Identification of any issues or incidental factors that may impact on interpretation of the observation.
Confounding factors
@ internal @
Tree
For example: local information requirements or additional metadata to align with FHIR.
Additional information required to capture local context or to align with other reference models/formalisms.
Extension
This data element may be useful in extreme situations where a formal measurement of respiration rate is not possible. For example: a subject is unconscious and distant to the observer, such as trapped in a car or has fallen down a cliff. Presence of respiration can be implied if the 'Rate' >0 breaths/min.
Observation of spontaneous respiration.
Presence
Respiratory movements are observed.
Present
Respiratory movements are not detected on observation.
Not detected
The body position of the individual during the observation.
Body position
The individual was standing, walking or running.
Standing/upright
The individual was sitting (for example, on a bed or chair).
Sitting
The individual was reclining at an approximate angle of 45 degrees, with the legs elevated to the level of the pelvis.
Reclining
The individual was lying on their back.
Lying
Additional narrative about the respirations, not captured in other fields.
Comment
The individual was lying on their front.
Prone
OBSERVATION
true
true
false
false
0
1
at0000
data
true
true
false
false
1
1
HISTORY
true
true
false
false
1
1
at0002
events
true
true
false
false
0
1
EVENT
true
false
true
0
at0003
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
at0004
value
true
true
false
false
0
1
DV_QUANTITY
true
true
false
false
1
1
openehr
382
true
false
false
false
0
1000
true
true
false
false
0
0
/min
false
false
true
false
true
0
state
true
true
false
false
0
1
ITEM_TREE
true
true
false
false
1
1
at0012
items
true
true
false
false
0
1
CLUSTER
true
false
true
0
at1017
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
openEHR-EHR-CLUSTER\.level_of_exertion(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.level_of_exertion(-[a-zA-Z0-9_]+)*\.v0
constraint
false
false
true
false
true
0
false
false
true
false
true
1
protocol
true
true
false
false
0
1
ITEM_TREE
true
true
false
false
1
1
at0010
items
true
true
false
false
0
1
CLUSTER
true
true
false
false
0
1
at1013
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1
constraint
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
CLUSTER
true
false
true
0
at1056
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
false
false
true
false
true
0
openEHR-EHR-OBSERVATION.pulse.v2
The rate and associated attributes for a pulse or heart beat.
Pulse/Heart beat
@ internal @
structure
@ internal @
history
Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Any event
The rate of the pulse or heart beat, measured in beats per minute.
Rate
Regularity of the pulse or heart beat.
Regularity
The pattern is regular.
Regular
The pattern is irregular in a regular pattern,. For example, a dropped beat once every 'n' beats.
Regularly Irregular
The pattern is irregular in a chaotic and unpredictable manner. For example, atrial fibrillation.
Irregularly Irregular
@ internal @
List
@ internal @
List
The body position of the subject during the observation.
Position
The subject was lying flat.
Lying
The subject was sitting (for example on bed or chair).
Sitting
The subject was reclining at an approximate angle of 45 degrees, with the legs elevated to the level of the pelvis.
Reclining
The subject was standing, walking or running.
Standing/upright
It can be implied that the pulse or heart beat is present if Rate >0 /min.
Presence of a pulse or heart beat.
Presence
Details about the device used to measure the pulse rate or heart rate.
Device
Details about physical exertion being undertaken during the examination.
Exertion
For example, presence of a pacemaker, level of anxiety; pain or fever etc.
Narrative description about any incidental factors that may affect interpretation of the physical findings.
Confounding factors
For example, auscultation or electronic monitoring.
Method used to observe the pulse or heart beat.
Method
Narrative description about the pulse or heart beat.
Clinical description
Coding with a terminology is preferred, where possible. For example: Bradycardia, Extrasystoles or Sinus rhythm. Multiple statements are allowed.
Single word, phrase or brief description that represents the clinical meaning and significance of the pulse or heart beat findings, including the rhythm.
Clinical interpretation
A pulse or heart beat can be detected.
Present
A pulse or heart beat cannot be detected.
Not detected
The pattern is irregular.
Irregular
Coding with a terminology is desired, where possible. For example: full, thready, bounding, slow rising, or collapsing. Multiple terms may be recorded.
Description of the character of the pulse or heart beat.
Character
The findings are observed by physical touch of the observer on the subject.
Palpation
The findings are observed with the assistance of a device, such as a stethoscope.
Auscultation
The findings are observed non-invasively using a device such as a pulse oximeter or a stethoscope.
Automatic, non-invasive
Maximum pulse rate or heart rate observed during a period of exertion.
Maximum
Body site where the pulse or heart beat were observed.
Body site
The left radial artery.
Radial Artery - Left
The right radial artery.
Radial Artery - Right
The region of the heart.
Heart
The left carotid artery.
Carotid Artery - Left
The right carotid artery.
Carotid Artery - Right
The left femoral artery.
Femoral Artery - Left
The right femoral artery.
Femoral Artery - Right
An unspecified finger.
Finger
The left brachial artery.
Brachial artery - Left
The right brachial artery.
Brachial artery - Right
The findings are observed invasively using a device such as an arterial catheter.
Automatic, invasive
The lobe of an unspecified ear.
Ear lobe
An unspecified toe.
Toe
Selection of a value from this value set is only valid if 'Irregular' is selected from the 'Regularity' data element.
More specific pattern of an irregular pulse or heart beat.
Irregular type
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
Generic label to allow for any or all statements about the pulse or heart beat.
Clinical interpretation
Specific conclusion about the rhythm of the pulse or heartbeat, drawn from a combination of the heart rate, pattern and other characteristics observed on examination.
Rhythm
Additional narrative about the pulse or heart beat findings not captured in other fields.
Comment
OBSERVATION
true
true
false
false
0
1
at0000
data
true
true
false
false
1
1
HISTORY
true
true
false
false
1
1
at0002
events
true
true
false
false
0
1
EVENT
true
false
true
0
at0003
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
1
1
at0004
value
true
true
false
false
0
1
DV_QUANTITY
true
true
false
false
1
1
true
false
false
false
0
100
true
true
false
false
1
1
Cel
true
false
false
false
30
200
true
true
false
false
1
1
[degF]
false
false
true
false
true
1
state
true
true
false
false
0
1
ITEM_TREE
true
true
false
false
1
1
at0029
items
true
true
false
false
0
1
CLUSTER
true
false
true
0
at0056
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
openEHR-EHR-CLUSTER\.environmental_conditions\.v1|openEHR-EHR-CLUSTER\.environmental_conditions\.v0
constraint
CLUSTER
true
true
false
false
0
1
at0057
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
openEHR-EHR-CLUSTER\.level_of_exertion\.v1|openEHR-EHR-CLUSTER\.level_of_exertion\.v0
constraint
true
false
true
false
true
0
false
false
true
false
true
1
protocol
true
true
false
false
0
1
ITEM_TREE
true
true
false
false
1
1
at0020
items
true
true
false
false
0
1
CLUSTER
true
false
true
0
at0064
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
openEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_relative\.v1
constraint
CLUSTER
true
true
false
false
0
1
at0059
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
openEHR-EHR-CLUSTER\.device\.v1
constraint
CLUSTER
true
false
true
0
at0062
true
false
true
false
true
0
openEHR-EHR-OBSERVATION.body_temperature.v2
A measurement of the body temperature, which is a surrogate for the core body temperature of the individual.
Body temperature
@ internal @
Tree
@ internal @
History
Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Any event
The measured temperature.
Temperature
@ internal @
Protocol
Simple description about the site of measurement.
Location of measurement
Temperature is measured within the mouth.
Mouth
Temperature is measured from within the external auditory canal.
Ear canal
Temperature is measured from the skin of the axilla with the arm positioned down by the side.
Axilla
Temperature measured within the rectum.
Rectum
Temperature is measured within the nasopharynx.
Nasopharynx
Temperature is measured in the urinary bladder.
Urinary bladder
Temperature is measured within the vascular system.
Intravascular
State information about the patient.
State
The degree of exposure of the individual at the time of measurement.
Body exposure
No clothing, bedding or covering.
Naked
The person is covered by a lesser amount of clothing or bedding than deemed appropriate for the environmental circumstances.
Reduced clothing/bedding
The person is covered by an amount of clothing or bedding deemed appropriate for the environmental circumstances.
Appropriate clothing/bedding
The person is covered by an increased amount of clothing or bedding than deemed appropriate for the environmental circumstances.
Increased clothing/bedding
Narrative description of the conditions applied to the subject that might influence their measured body temperature.
Description of thermal stress
Temperature is measured from exposed skin.
Skin
Temperature is measured within the vagina.
Vagina
Temperatue is measured within the oesophagus.
Oesophagus
Temperature is measured in the inguinal skin crease between the leg and abdominal wall.
Inguinal skin crease
Details about the environmental conditions at the time of temperature measurement.
Environmental conditions
Details about the exertion of the person at the time of temperature measurement.
Exertion
Details about the device used to measure body temperature.
Device
Temperature is measured at the temple, over the superficial temporal artery.
Temple
Temperature is measured on the forehead.
Forehead
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 or formalisms.
Extension
Additional comment about the body temperature measurement not captured in other fields.
Comment
Structured details about the location of measurement.
Structured measurement location
The first day of menstruation is considered to be Day 1 of each menstrual cycle.
Current day of the menstrual cycle.
Day of menstrual cycle
Additional issues or factors that may impact on the measurement of body temperature, not captured in other fields.
Confounding factors
LNC205
8310-5
SNOMED-CT
386725007
OBSERVATION
true
true
false
false
0
1
at0000
data
true
true
false
false
1
1
HISTORY
true
true
false
false
1
1
at0001
events
true
true
false
false
0
1
EVENT
true
false
true
0
at0010
data
true
true
false
false
1
1
ITEM_TREE
true
true
false
false
1
1
at0003
items
true
true
false
false
0
1
ELEMENT
true
true
false
false
0
1
at0004
value
true
true
false
false
0
1
DV_QUANTITY
true
true
false
false
1
1
openehr
122
true
true
false
false
0
100
cm
true
true
false
false
0
40
[in_i]
false
false
true
false
true
1
state
true
true
false
false
0
1
ITEM_TREE
true
true
false
false
1
1
at0008
items
true
true
false
false
0
1
false
false
true
false
true
0
false
false
true
false
true
1
protocol
true
true
false
false
0
1
ITEM_TREE
true
true
false
false
1
1
at0005
items
true
true
false
false
0
1
CLUSTER
true
true
false
false
0
1
at0006
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1
constraint
CLUSTER
true
false
true
0
at0012
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
false
false
true
false
true
0
openEHR-EHR-OBSERVATION.head_circumference.v1
The measurement of the longest distance around the head.
Head circumference
@ internal @
Event Series
@ internal @
Tree
The measurement of the longest distance around the head.
Head circumference
@ internal @
Tree
Details about the device used for the measurement.
Device
Additional narrative about the head circumference not captured in other fields.
Comment
@ internal @
Tree
For example: 'uncooperative child','caput & moulding post birth' and 'haematoma'.
Narrative descripiton of any issues or factors that may impact on the measurement.
Confounding factors
Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Any event
The first measurement of head circumference that is recorded soon after birth. This event should only be used once per record.
Birth
For example: Local hospital departmental infomation 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
OBSERVATION
true
true
false
false
0
1
at0000
data
true
true
false
false
1
1
HISTORY
true
true
false
false
1
1
at0001
events
true
true
false
false
0
1
EVENT
true
false
true
0
at0002
data
true
true
false
false
1
1
ITEM_TREE
true
true
false
false
1
1
at0003
items
true
true
false
false
0
1
ELEMENT
true
true
false
false
0
1
at0006
value
true
true
false
false
0
1
DV_PROPORTION
true
true
false
false
1
1
numerator
true
true
false
false
1
1
REAL
true
true
false
false
1
1
-
true
true
false
false
0
100
type
true
true
false
false
1
1
INTEGER
true
true
false
false
1
1
-
2
CLUSTER
true
false
true
0
at0054
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
openEHR-EHR-CLUSTER\.waveform(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.waveform(-[a-zA-Z0-9_]+)*\.v1
constraint
CLUSTER
true
false
true
0
at0060
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1
constraint
false
false
true
false
true
0
state
true
true
false
false
0
1
ITEM_TREE
true
true
false
false
1
1
at0014
items
true
true
false
false
0
1
CLUSTER
true
true
false
false
0
1
at0034
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
openEHR-EHR-CLUSTER\.level_of_exertion(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.level_of_exertion(-[a-zA-Z0-9_]+)*\.v1
constraint
CLUSTER
true
true
false
false
0
1
at0015
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
openEHR-EHR-CLUSTER\.inspired_oxygen(-[a-zA-Z0-9_]+)*\.v1
constraint
false
false
true
false
true
0
false
false
true
false
true
1
protocol
true
true
false
false
0
1
ITEM_TREE
true
true
false
false
1
1
at0007
items
true
true
false
false
0
1
CLUSTER
true
true
false
false
0
1
at0018
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1
constraint
CLUSTER
true
false
true
0
at0059
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
false
false
true
false
true
0
openEHR-EHR-OBSERVATION.pulse_oximetry.v1
Blood oxygen and related measurements, measured by pulse oximetry or pulse CO-oximetry.
Pulse oximetry
@ internal @
Event Series
Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Any event
@ internal @
Tree
SpO₂ is defined as the percentage of oxyhaemoglobin (HbO₂) to the total concentration of haemoglobin (HbO₂ + deoxyhaemoglobin) in peripheral blood.
The saturation of oxygen in the peripheral blood, measured via pulse oximetry.
SpO₂
@ internal @
List
For example: Right index finger, left earlobe. Coding with a terminology is preferred, if possible.
The site of the measurement sensor.
Sensor site
@ internal @
Tree
Assumed values of 21% oxygen concentration, Fi0₂ of 0.21 and oxygen flow rate of 0 l/min or 0 ml/min.
Details of the amount of oxygen available to the subject at the time of observation.
Inspired oxygen
For example, motion, pain, poor perfusion, infant feeding, peripheral hypothermia, sedation.
Comment on and record other incidental factors that may be affect interpretation of the observation.
Confounding factors
Details of the non-invasive oximetry device used.
Oximetry device
Details about physical activity undertaken at the time of measurement.
Exertion
A text comment about the pulse oximetry result.
Comment
The oxygen content of the peripheral blood, calculated based on pulse oximetry and pulse CO-oximetry.
SpOC
The saturation of carboxyhaemoglobin in the peripheral blood, measured via pulse CO-oximetry.
SpCO
The saturation of methaemoglobin in the peripheral blood, measured via pulse CO-oximetry.
SpMet
A waveform reading associated with the oximetry measurement.
Waveform
Coding with a terminology is preferred, if possible. For example, normal oxygen saturation or hypoxaemia.
Single word, phrase or brief description which represents the clinical meaning and significance of the measurements.
Interpretation
e.g. Local hospital departmental infomation or additional metadata to align with HL7 or CDISC equivalents.
Additional information required to capture local context or to align with other reference models/formalisms.
Extension
Details of a series of oximetry readings, other than waveforms, expressed as a multimedia image or series of images. Waveforms should be recorded using the Waveform slot and associated cluster archetype.
Multimedia image
Sensor site relative to the ductus arteriosus in neonates, to determine whether the blood supply to limb of the sensor site is pre- or post-ductal in cases of patent ductus arteriosus.
Pre/post-ductal
The sensor site is pre-ductal.
Pre-ductal
The sensor site is post-ductal.
Post-ductal
Unable to assess whether the sensor site is pre- or post-ductal.
Indeterminate
SNOMED-CT
431314004
SNOMED-CT
16206004
SNOMED-CT
448703006
SNOMED-CT
277923006
LOINC
59408-5
LOINC
20081-6
LOINC
57800-5
LOINC
86904-0
LOINC
2614-6
OBSERVATION
true
true
false
false
0
1
at0000
data
true
true
false
false
1
1
HISTORY
true
true
false
false
1
1
at0001
events
true
true
false
false
0
1
EVENT
true
false
true
0
at0002
data
true
true
false
false
1
1
ITEM_TREE
true
true
false
false
1
1
at0003
items
true
true
false
false
0
1
ELEMENT
true
true
false
false
1
1
at0004
value
true
true
false
false
0
1
DV_QUANTITY
true
true
false
false
1
1
openehr
349
true
false
false
false
0
1000
true
true
false
false
1
1
kg/m2
true
false
false
false
0
1000
true
true
false
false
1
1
[lb_av]/[in_i]2
false
false
true
false
true
1
state
true
true
false
false
0
1
ITEM_TREE
true
true
false
false
1
1
at0014
items
true
true
false
false
0
1
false
false
true
false
true
0
false
false
true
false
true
1
protocol
true
true
false
false
0
1
ITEM_TREE
true
true
false
false
1
1
at0005
items
true
true
false
false
0
1
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-OBSERVATION.body_mass_index.v2
Body Mass Index is a calculated ratio describing how an individual's body weight relates to the weight that is regarded as normal, or desirable, for the individual's height.
Calculated measurement which compares a person's weight and height.
Body mass index
@ internal @
history
Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Any event
@ internal @
Single
Index describing ratio of weight to height.
Body mass index
@ internal @
Tree
The method of entering the body mass index.
Method
Body Mass Index calculated and entered automatically without user intervention.
Automatic entry
Body Mass Index calculated and entered directly by user.
Direct entry
Formula used to derive the body mass index.
Formula
For example: the calculation was made using adjusted weight or height.
Narrative description of any issues or factors that may impact on the calculation.
Confounding factors
Additional narrative about the calculation, not captured in other fields.
Comment
For example: underweight, normal, overweight or obese.
Single word, phrase or brief description that represents the clinical meaning and significance of the body mass index.
Clinical interpretation
@ internal @
Tree
For example: Local hospital departmental infomation 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
SNOMED-CT
60621009
LOINC
39156-5
OBSERVATION
true
true
false
false
0
1
at0000
data
true
true
false
false
1
1
HISTORY
true
true
false
false
1
1
at0001
events
true
true
false
false
0
1
EVENT
true
false
true
0
at0006
data
true
true
false
false
1
1
ITEM_TREE
true
true
false
false
1
1
at0003
items
true
true
false
false
0
1
ELEMENT
true
true
false
false
0
1
at0004
value
true
true
false
false
0
1
DV_QUANTITY
true
true
false
false
1
1
openehr
125
true
false
false
false
0
1000
true
true
false
false
0
0
mm[Hg]
ELEMENT
true
true
false
false
0
1
at0005
value
true
true
false
false
0
1
DV_QUANTITY
true
true
false
false
1
1
openehr
125
true
false
false
false
0
1000
true
true
false
false
0
0
mm[Hg]
false
false
true
false
true
0
state
true
true
false
false
0
1
ITEM_TREE
true
true
false
false
1
1
at0007
items
true
true
false
false
0
1
CLUSTER
true
true
false
false
0
1
at1030
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
openEHR-EHR-CLUSTER\.level_of_exertion(-[a-zA-Z0-9_]+)*\.v1
constraint
false
false
true
false
true
0
false
false
true
false
true
1
protocol
true
true
false
false
0
1
ITEM_TREE
true
true
false
false
1
1
at0011
items
true
true
false
false
0
1
CLUSTER
true
false
true
0
at1057
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
openEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1
constraint
CLUSTER
true
true
false
false
0
1
at1025
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1
constraint
CLUSTER
true
false
true
0
at1058
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
false
false
true
false
true
0
openEHR-EHR-OBSERVATION.blood_pressure.v2
Most commonly, use of the term 'blood pressure' refers to measurement of brachial artery pressure in the upper arm.
The local measurement of arterial blood pressure which is a surrogate for arterial pressure in the systemic circulation.
Blood pressure
History Structural node.
History
@ internal @
blood pressure
Peak systemic arterial blood pressure - measured in systolic or contraction phase of the heart cycle.
Systolic
Minimum systemic arterial blood pressure - measured in the diastolic or relaxation phase of the heart cycle.
Diastolic
Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Any event
@ internal @
state structure
The position of the individual at the time of measurement.
Position
List structure.
Tree
Perloff D, Grim C, Flack J, Frohlich ED, Hill M, McDonald M, Morgenstern BZ. Human blood pressure determination by sphygmomanometry. Circulation 1993;88;2460-2470.
The size of the cuff used for blood pressure measurement.
Cuff size
Simple body site where blood pressure was measured.
Location of measurement
A cuff used for an adult thigh.
Adult Thigh
A cuff for adults with larger arms.
Large Adult
A cuff that is standard for an adult.
Adult
The right arm of the person.
Right arm
The left arm of the person.
Left arm
The right thigh of the person.
Right thigh
The left thigh of the person.
Left thigh
Additional narrative about the measurement, not captured in other fields.
Comment
Standing at the time of blood pressure measurement.
Standing
Sitting (for example on bed or chair) at the time of blood pressure measurement.
Sitting
Reclining at the time of blood pressure measurement.
Reclining
Lying flat at the time of blood pressure measurement.
Lying
The craniocaudal tilt of the surface on which the person is lying at the time of measurement.
Tilt
The average arterial pressure that occurs over the entire course of the heart contraction and relaxation cycle.
Mean arterial pressure
The difference between the systolic and diastolic pressure.
Pulse pressure
A cuff used for a small adult.
Small Adult
A cuff that is appropriate for a child or adult with a thin arm.
Paediatric/Child
Record which Korotkoff sound is used for determining diastolic pressure using auscultative method.
Diastolic endpoint
The fourth Korotkoff sound is identified as an abrupt muffling of sounds.
Phase IV
The fifth Korotkoff sound is identified by absence of sounds as the cuff pressure drops below the diastolic blood pressure.
Phase V
Lying flat with some lateral tilt, usually angled towards the left side. Commonly required in the last trimester of pregnancy to relieve aortocaval compression.
Lying with tilt to left
A cuff used for infants.
Infant
A cuff used for a neonate, assuming cuff is the appropriate size for maturity and birthweight of the neonate.
Neonatal
The right wrist of the individual.
Right wrist
The left wrist of the individual.
Left wrist
Details about sphygmomanometer or other device used to measure the blood pressure.
Device
The right ankle of the individual.
Right ankle
Details about physical activity undertaken at the time of blood pressure measurement.
Exertion
The left ankle of the individual.
Left ankle
A finger of the individual.
Finger
Method of measurement of blood pressure.
Method
Method of measuring blood pressure externally, using a stethoscope and Korotkoff sounds.
Auscultation
Method of measuring blood pressure externally, using palpation (usually of the brachial or radial arteries).
Palpation
Formula used to calculate the Mean Arterial Pressure (if recorded in data).
Mean arterial pressure formula
Method of measuring blood pressure externally, using a blood pressure machine.
Machine
Method of measuring blood pressure internally ie involving penetration of the skin and measuring inside blood vessels.
Invasive
Estimate of the average blood pressure over a 24 hour period.
24 hour average
Sleep status - supports interpretation of 24 hour ambulatory blood pressure records.
Sleep status
The individual is fully conscious.
Awake
The individual is in the natural state of bodily rest.
Sleeping
A toe of the individual.
Toe
Comment on and record other incidental factors that may be contributing to the blood pressure measurement. For example, level of anxiety or 'white coat syndrome'; pain or fever; changes in atmospheric pressure etc.
Confounding factors
Invasive measurement via transducer access line within an artery.
Intra-arterial
Formula used to calculate the systolic pressure from from mean arterial pressure (if recorded in data).
Systolic pressure formula
Formula used to calculate the diastolic pressure from mean arterial pressure (if recorded in data).
Diastolic pressure formula
The individual's dorsum of the foot.
Dorsum of foot
Structured anatomical location of where the measurement was taken.
Structured measurement location
For example: Local hospital departmental infomation 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
Single word, phrase or brief description that represents the clinical meaning and significance of the blood pressure measurement.
Clinical interpretation
SNOMED-CT(2003)
364090009
SNOMED-CT(2003)
271649006
SNOMED-CT(2003)
271650006
SNOMED-CT(2003)
246153002
false
false
true
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true
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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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items
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CLUSTER
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at0039
Boolean
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String
- archetype_id/value
attribute
C_STRING
-
openEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_clock(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.v1
constraint
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Date of abatement
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openEHR-EHR-CLUSTER.problem_qualifier.v1
Contextual or temporal qualifier for a specified problem or diagnosis.
Problem/Diagnosis qualifier
For example: 'New' will enable clinicians to distinguish a new, acute episode of otitis media that may have arisen soon after a previous diagnosis, to distinguish it from an unresolved or 'Ongoing' diagnosis of chronic otitis media. Treatment of recurring, new and acute, episodes of a condition may differ significantly from the same condition that is not resolving or responding to treatment. In many situations the clinician will not be able to tell, and so indeterminate may be appropriate.
Category of this episode for the identified problem/diagnosis.
Episodicity
The Active/Inactive and Current/Past data elements have similar clinical impact but represent slightly different semantics. Both are actively used in different clinical settings, but usually not together. If a Current/Past qualifier is recorded, then this data element is likely to be redundant. An exception where a condition can be current but inactive is asthma that is not causing acute symptoms.
Category that supports division of problems and diagnoses into Active or Inactive problem lists.
Active/Inactive?
The status is usually determined by a combination of the timing of diagnosis plus level of clinical certainty resulting from diagnostic tests and clinical evidence available. This data element and 'Diagnostic certainty' in EVALUATION.problem_diagnosis are two important axes of the diagnostic process, and valid combinations will need to be presented by software that exposes both data elements, so it is not possible for users to select conflicting combinations.
Preliminary or working diagnoses are intended to represent the single most likely choice out of all differential diagnosis options.
Stage or phase of diagnostic process.
Diagnostic status
The initial diagnosis made, usually associated with a low level of clinical certainty. It may change as test results or advice become available.
Preliminary
Interim diagnosis, based on a reasonable amount of clinical certainty but pending further test results or clinical advice. It may still change as test results or advice become available.
Working
Final substantiated diagnosis, based on a high level of clinical certainty, which may include clinical evidence from test results. It is not expected to change.
Established
The problem or diagnosis is currently active and clinically relevant.
Active
The problem or diagnosis is not completely resolved but is inactive or felt less relevant to the current clinical context.
Inactive
A new occurrence of either a new or existing problem or diagnosis. A flag for 'First occurrence' can be recorded separately to distinguish the first from other occurrences.
New
The issue, problem or diagnosis continues, without new, acute episodes occurring.
Ongoing
The Current/Past and Active/Inactive data elements have similar clinical impact but represent slightly different semantics. Both are actively used in different clinical settings, but usually not together. If an Active/Inactive qualifier is recorded, then this data element is likely to be redundant. An exception where a condition can be current but inactive is asthma that is not causing acute symptoms.
Category that supports division of problems and diagnoses into Current or Past problem lists.
Current/Past?
An issue which ocurred in the past.
Past
An issue occuring at present.
Current
This data element contains a value set commonly used in diagnostic categorisation. In episodic care contexts (commonly secondary care) it is common to categorise/organise diagnoses according to their relationship to the principal diagnosis being addressed during that episode of care. These categories may also be used for clinical coding, reporting and billing purposes. In some countries the diagnostic category may be known as a DRG.
In addition, the free text choice permits use of other local value sets, as required.
Category of the problem or diagnosis within a specified episode of care and/or local care context.
Diagnostic category
The diagnosis determined to be the primary reason for an episode of admitted patient care, an episode of residential care or an attendance at the health care establishment.
Principal diagnosis
A problem or diagnosis that occurs at the same time as the primary problem or diagnosis. May also be known as a comorbid condition.
Secondary diagnosis
It is not possible to determine if this occurrence of the problem or diagnosis is new or ongoing.
Indeterminate
This data element can be an additional qualifier to the 'New' value in the 'Episodicity' value set, that is a condition such as asthma can have recurring new episodes that have periods of resolution in between. However it can be important to identify the first ever episode of asthma from all of the other episodes.
Category of the occurrence for this problem or diagnosis.
Occurrence
Record as True if the problem or diagnosis was present on admission. This data element is a requirement from DRG reporting in some countries.
Was the problem or diagnosis present at admission?
Admission diagnosis?
An unfavorable evolution of a problem or diagnosis.
Complication
Definitions of acute vs chronic will differ for each diagnosis.
Category reflecting the speed of onset and/or duration and persistence of the problem or diagnosis.
Course label
A problem or diagnosis with persistent or long-lasting effects, or that evolves over time.
Chronic
A problem or diagnosis with a rapid onset, a short course, or both.
Acute
For example: tracking the progress of resolution of a middle ear infection.
Phase of healing for an acute problem or diagnosis.
Resolution phase
Problem or diagnosis has completed the normal phases of restoration or healing and can be considered resolved.
Resolved
Problem or diagnosis is progressing satisfactorily through the normal stages of restoration or healing towards resolution.
Resolving
Problem or diagnosis is not progressing satisfactorily through the normal stages of restoration or healing towards resolution.
Not resolving
It is not possible to determine the resolution or healing status of the problem or diagnosis.
Indeterminate
The previously recorded diagnosis has been clinically reassessed or disproved with a high level of clinical certainty. This status is used to correct an error in the health record.
Refuted
For example: the status of a cancer or haematological diagnosis.
Status of the remission of an incurable diagnosis.
Remission status
No ongoing signs or symptoms of the disease have been identified.
In remission
No diminution of the signs or symptoms of the disease have been identified.
Not in remission
It is not possible to determine if there have been diminution of the signs or symptoms of the disease have been identified.
Indeterminate
A problem or diagnosis with an acute exacerbation of a chronic condition.
Acute-on-chronic
This is the first ever occurrence of this problem or diagnosis.
First occurrence
New occurrence of the same problem or diagnosis after a previous episode was resolved.
Recurrence
Problem or diagnosis has deteriorated after a period of temporary improvement.
Relapsed
SNOMED-CT
288526004
SNOMED-CT
106229004
SNOMED-CT
148006
SNOMED-CT
5558000
SNOMED-CT
14657009
SNOMED-CT
410511007
SNOMED-CT
410513005
SNOMED-CT
15240007
SNOMED-CT
8319008
SNOMED-CT
85097005
SNOMED-CT
288524001
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at0071
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openEHR-EHR-EVALUATION.problem_diagnosis.v1
Clear delineation between the scope of a problem versus a diagnosis is not easy to achieve in practice. For the purposes of clinical documentation with this archetype, problem and diagnosis are regarded as a continuum, with increasing levels of detail and supportive evidence usually providing weight towards the label of 'diagnosis'.
Details about a single identified health condition, injury, disability or any other issue which impacts on the physical, mental and/or social well-being of an individual.
Problem/Diagnosis
@ internal @
structure
Coding of the name of the problem or diagnosis with a terminology is preferred, where possible.
Identification of the problem or diagnosis, by name.
Problem/Diagnosis name
Partial dates are acceptable. If the subject of care is under the age of one year, then the complete date or a minimum of the month and year is necessary to enable accurate age calculations - for example, if used to drive decision support. Data captured/imported as "Age at time of clinical recognition" should be converted to a date using the subject's date of birth.
Estimated or actual date/time the diagnosis or problem was recognised by a healthcare professional.
Date/time clinically recognised
If severity is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant. Note: more specific grading of severity can be recorded using the Specific details SLOT.
An assessment of the overall severity of the problem or diagnosis.
Severity
Use to provide background and context, including evolution, episodes or exacerbations, progress and any other relevant details, about the problem or diagnosis.
Narrative description about the problem or diagnosis.
Clinical description
Coding of the name of the anatomical location with a terminology is preferred, where possible.
Use this data element to record precoordinated anatomical locations. If the requirements for recording the anatomical location are determined at run-time by the application or require more complex modelling such as relative locations then use the CLUSTER.anatomical_location or CLUSTER.relative_location within the 'Structured anatomical location' SLOT in this archetype. Occurrences for this data element are unbounded to allow for clinical scenarios such as describing a rash in multiple locations but where all of the other attributes are identical. If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant.
Identification of a simple body site for the location of the problem or diagnosis.
Body site
Partial dates are acceptable. If the subject of care is under the age of one year, then the complete date or a minimum of the month and year is necessary to enable accurate age calculations - for example, if used to drive decision support. Data captured/imported as "Age at time of resolution" should be converted to a date using the subject's date of birth.
Estimated or actual date/time of resolution or remission for this problem or diagnosis, as determined by a healthcare professional.
Date/time of resolution
@ internal @
Tree
Use this SLOT to insert the CLUSTER.anatomical_location or CLUSTER.relative_location archetypes if the requirements for recording the anatomical location are determined at run-time by the application or require more complex modelling such as relative locations.
If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, use of this SLOT becomes redundant.
A structured anatomical location for the problem or diagnosis.
Structured body site
May include structured detail about the grading or staging of the diagnosis; diagnostic criteria, classification criteria or formal severity assessments such as Common Terminology Criteria for Adverse Events.
Details that are additionally required to record as unique attributes of this problem or diagnosis.
Specific details
Use status or context qualifiers with care, as they are variably used in practice and interoperability cannot be assured unless usage is clearly defined with the community of use. For example: active status - active, inactive, resolved, in remission; evolution status - initial, interim/working, final; temporal status - current, past; episodicity status - first, new, ongoing; admission status - admission, discharge; or priority status - primary, secondary.
Structured details for location-, domain-, episode- or workflow-specific aspects of the diagnostic process.
Status
The problem or diagnosis does not interfere with normal activity or may cause damage to health if left untreated.
Mild
The problem or diagnosis causes interference with normal activity or will damage health if left untreated.
Moderate
The problem or diagnosis prevents normal activity or will seriously damage health if left untreated.
Severe
Additional narrative about the problem or diagnosis not captured in other fields.
Comment
The date this problem or diagnosis was last updated.
Last updated
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
Narrative description about the course of the problem or diagnosis since onset.
Course description
The level of confidence in the identification of the diagnosis.
Diagnostic certainty
The diagnosis has been identified with a low level of certainty.
Suspected
The diagnosis has been identified with a high level of certainty.
Probable
The diagnosis has been confirmed against recognised criteria.
Confirmed
Data captured/imported as "Age at onset" should be converted to a date using the subject's date of birth.
Estimated or actual date/time that signs or symptoms of the problem/diagnosis were first observed.
Date/time of onset
false
false
true
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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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openEHR-EHR-EVALUATION.pregnancy_summary.v0
Overview or summary record of a pregnancy including the antenatal period, labour, birth and the immediate postnatal period.
Pregnancy summary
@ internal @
Tree
Number of fetuses identified in utero.
Number of babies
Manner in which labour started.
Onset of labour
Onset without intervention.
Spontaneous
Onset through intervention.
Induced
Total duration of all three stages of labour.
Total duration of labor
Coding of the 'Augmentation Method' with a terminology is desirable, where possible.
Method of labour augmentation.
Augmentation method
While most often these details are used to record information about birth of newborn, occasionally they are also useful to record delivery details for
Information about an individual identified baby.
Per baby
Date and time of birth.
Date/Time of birth
Identification might be by the name of the neonate or a label given to a fetus.
Identification of the baby.
Identification
Coding with a terminology is preferred, where possible. Indeterminate is to be used in the situation where is it not possible to tell if the sex is male or female.
Sex of the baby, as determined by observable physical characteristics.
Sex
Weight of the fetus or baby at birth or delivery.
Birthweight
Value set from AIHW.
Method by which the baby was delivered.
Mode of birth
Normal, non-instrumental vaginal delivery.
Unassisted
Vaginal delivery assisted by the use of vacuum extraction.
Vacuum extraction
Vaginal delivery assisted by the use of lift-out forceps.
Lift-out forceps
Vaginal delivery assisted by the use of low forceps.
Low forceps
Extension of the AIHW value set. The clinical context for recording this data element is only presentation at birth, not at any other phase of labour.
Presenting part of the baby at birth or delivery.
Presenting part
The vertext is the presenting part.
Vertex
The breech is the presenting part.
Breech
The fact is the presenting part.
Face
The brow is the presenting part.
Brow
This data element is intended to record estimated gestation based on clinical findings on examination of the fetus/neonate and clinical assessment, not the calculated gestation based on the 'Agreed EDB'.
Estimated gestational age of fetus or baby at birth or delivery, based on clinical examination and evaluation.
Gestational age
Details about complications affecting the baby.
Baby complication
Coding of the 'Complication' with a terminology is desirable, where possible. For example, neonatal hypoglycaemia or hypothermia.
Identification of the complication after birth.
Complication
Date and/or time of onset of the complication.
Date/Time of onset
Narrative description of complication.
Description
Details about pregnancy complications or birth complications affecting the mother.
Maternal complication
Coding of the 'Complication' with a terminology is desirable, where possible. For example, post partum haemorrhage or pre-eclampsia.
Identification of the complication.
Complication
If only a partial date is available, this is acceptable.
Date of onset of complication, as assessed by a clinician.
Date/Time of onset
Narrative description of the maternal complication.
Description
@ internal @
Tree
The date this pregnancy summary was last updated.
Last updated
Narrative description about the whole of pregnancy.
Pregnancy synopsis
For example, record '1' if this neonate is the first born of a multiple birth; record '4' if this neonate is the fourth born of a multiple birth.
Sequential order of each baby in a multiple birth event.
Birth order
Coding of the Pregnancy Outcome with a terminology is desirable, where possible. If individual fetuses have been identified, record this information using the 'Individual Outcome' data element. This data element is not to be recorded if 'Individual Outcome' is recorded.
Outcome of the pregnancy as a whole.
Pregnancy outcome
Coding of the 'Induction Method' with a terminology is desirable, where possible.
Method of labour induction.
Induction method
Reason for induction of labour.
Reason for induction
Vaginal delivery assisted by the use of high forceps.
High forceps
Vaginal delivery assisted by the use of high forceps with rotation.
High forceps with rotation
Surgical delivery by a transverse approach in the lower uterine segment (LUSCS).
Caesarean - lower uterine segment
Surgical delivery by an approach in the upper uterine segment.
Caesarean - upper uterine segment
True, if assisted reproduction was required to achieve the pregnancy.
Was the pregnancy a result of assisted reproductive technology?
Assisted reproduction?
Coding with a terminology is preferred, where possible.
Type of assisted reproductive technology used to achieve pregnancy.
Assisted reproduction type
A foot is the presenting part.
Foot
An arm is the presenting part.
Arm
Narrative description about feeding.
Feeding
No onset of labour.
No labour
Baby appears physically male.
Male
Baby appears physically female.
Female
Sex of the baby has not yet been able to be determined from observation of physical characteristics.
Indeterminate
Narrative description about the condition of the perineum after birth, including injuries and repairs.
Perineum
Estimation of maternal blood loss during birth and immediately post delivery.
Blood Loss
Can be derived direct from the Birth Record documentation, if present.
The sum of the 5 scores for each Apgar component recorded at 1 minute after birth.
Total Apgar at 1 minute
The sum of the 5 scores for each Apgar component recorded at 5 minutes after birth.
Total Apgar at 5 minutes
The sum of the 5 scores for each Apgar component recorded at 10 minutes after birth.
Total Apgar at 10 minutes
Vaginal delivery assisted by the use of vacuum extraction.
Vacuum extraction with rotation
A shoulder is the presenting part.
Shoulder
*
Status
The individual is currently pregnant.
Currently pregnant
The individual has been pregnant in the past.
Previously pregnant
The individual has never been pregnant.
Never pregnant
*
Per pregnancy
*
Pregnancy label
EVALUATION
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false
1
1
ELEMENT
true
true
false
false
0
1
at0004
value
true
true
false
false
0
1
DV_DATE_TIME
true
true
false
false
1
1
CLUSTER
true
true
false
false
0
1
at0006
items
true
true
false
false
1
1
ELEMENT
true
true
false
false
1
1
at0008
value
true
true
false
false
0
1
DV_DATE_TIME
true
true
false
false
1
1
false
false
true
false
true
1
CLUSTER
true
false
true
0
at0009
items
true
true
false
false
1
1
ELEMENT
true
true
false
false
0
1
at0010
value
true
true
false
false
0
1
DV_DATE_TIME
true
true
false
false
1
1
false
false
true
false
true
1
false
false
true
false
true
0
protocol
true
true
false
false
0
1
ITEM_TREE
true
true
false
false
1
1
at0001
items
true
true
false
false
0
1
ELEMENT
true
true
false
false
0
1
at0013
value
true
true
false
false
0
1
DV_DATE_TIME
true
true
false
false
1
1
CLUSTER
true
false
true
0
at0012
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
false
false
true
false
true
0
openEHR-EHR-EVALUATION.estimated_date_delivery.v0
Estimated date of delivery for a pregnancy.
Estimated date of delivery
@ internal @
Item tree
@ internal @
Item tree
The date of conception will be recorded elsewhere in the health record, for example as part of the record for an IVF procedure.
The EDD calculated from a known date of conception.
By date of conception
The details about the menstrual cycle will be recorded elsewhere in the health record, usually captured using the OBSERVATION.menstruation archetype.
The EDD estimated from an LNMP and characteristics of the menstrual cycle.
By cycle
The date on which the ultrasound was carried out.
Date of ultrasound
Each ultrasound and estimated gestation pair will be captured as a separate instance of this CLUSTER.
Details about an EDD estimated from the findings on a pregnancy ultrasound.
By ultrasound
The gestation estimated from the scan.
Gestation by scan
Only one 'Agreed EDD' is appropriate at any one time. If the agreed EDD needs to be revised then this should be captured in a new revision of this archetype within a health record.
Details about an EDD estimated from the findings on a pregnancy ultrasound.
Estimated date by ultrasound
Details about the agreed EDD which is used as the basis for clinical decision-making during the pregnancy.
Agreed EDD
The EDD which is to be used as the basis for clinical decision-making.
Agreed date
The rationale which explains why the 'Agreed date' has been selected.
Rationale
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
The date any EDD was last updated.
Last updated
OBSERVATION
true
true
false
false
0
1
at0000
data
true
true
false
false
1
1
HISTORY
true
true
false
false
1
1
at0001
events
true
true
false
false
0
1
EVENT
true
false
true
0
at0002
data
true
true
false
false
1
1
ITEM_TREE
true
true
false
false
1
1
at0003
items
true
true
false
false
0
1
ELEMENT
true
true
false
false
0
1
at0006
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
-
Not pregnant
false
false
true
false
true
0
false
false
true
false
true
0
protocol
true
true
false
false
0
1
ITEM_TREE
true
true
false
false
1
1
at0004
items
true
true
false
false
0
1
CLUSTER
true
false
true
0
at0005
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
false
false
true
false
true
0
openEHR-EHR-OBSERVATION.exclusion_pregnancy.v0
Statement to explicitly record that a pregnancy was not present.
Exclusion of pregnancy
@ internal @
History
*
Any event
@ internal @
Tree
@ 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 or formalisms.
Extension
An overall statement of exclusion about the state of pregnancy.
Exclusion statement
Justification, rationale or evidence for excluding a pregnancy.
Rationale
For example: post hysterectomy.
Flag to indicate it is not possible for the individual to become pregnant in the future.
Indefinite
false
false
true
false
true
0
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
true
true
false
false
0
1
at0000
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
-
Social History
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
at0089
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
at0006
at0003
at0005
CLUSTER
true
false
true
0
at0086
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
openEHR-EHR-CLUSTER\.change(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.change(-[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
at0021
items
true
true
false
false
0
1
CLUSTER
true
false
true
0
at0073
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
false
false
true
false
true
0
openEHR-EHR-EVALUATION.tobacco_smoking_summary.v1
Summary or persistent information about the tobacco smoking habits of an individual.
Tobacco smoking summary
@ internal @
Tree
Individual is a current smoker of tobacco.
Current smoker
Individual has previously smoked tobacco but is not a current smoker.
Former smoker
Individual has never smoked any type of tobacco.
Never smoked
Can be a partial date, for example, only a year.
Date when this episode commenced.
Episode start date
Can be a partial date, for example, only a year. Definitions for a 'Quit date' vary enormously and can be defined using the 'Quit data definition' data element in the Protocol section of this archetype. This date will be identical to the 'Episode end date' for the most recent episode. This date could be used by decision support guidance to determine if the individual is at risk of relapse, for example in the first 12 months since quitting.
Date when the individual last smoked the specified type of tobacco.
Quit date
Can be a partial date, for example, only a year. For example, this date could represent when the individual commenced smoking every Friday night or at parties.
The date or partial date when the individual first started frequent or regular, but usually non-daily, smoking of tobacco of any type.
Regular smoking commenced
Can be a partial date, for example, only a year. This date could be used by decision support guidance to determine if the individual is at risk of relapse, for example in the first 12 months since quitting.
The date when the individual last ceased using tobacco of any type.
Overall quit date
Commonly used in assessment of cigarette use. It is calculated by multiplying the number of packs of cigarettes smoked per day by the number of years the individual has smoked. One pack year equals 365 packs of cigarettes. Details about how to calculate pack years for other types of tobacco can be found at http://smokingpackyears.com. The definition of a pack can be recorded in the protocol of this archetype using the 'Pack definition' data element.
Estimate of the cumulative amount of tobacco smoked using the specified type of tobacco.
Pack years
For example: stopped smoking or reduced amount on becoming pregnant.
Additional narrative about all tobacco smoking that has not been captured in other fields.
Overall comment
@ internal @
Tree
The date this tobacco smoking summary was last updated.
Last updated
For example: the number of 'sticks' or 'full pipes' per day or per week. This data element is redundant if a value is recorded for 'Typical use(mass)'.
Estimate of number of units of the specified type of tobacco consumed.
Typical use (units)
Total number of times the individual has attempted to stop smoking the specified type of tobacco within this episode.
Number of quit attempts
Additional structured details about the specified episode of tobacco smoking.
Episode details
Details about smoking activity for a specified type of smoked tobacco.
Per type
The typical pattern of smoking for the specified type of tobacco.
Pattern
Use this data element to record a narrative description of the tobacco smoking habits for this individual or to incorporate unstructured tobacco smoking information from existing or legacy clinical systems into an archetyped format.
Narrative summary about the individual's overall tobacco smoking pattern and history.
Overall description
Statement about current smoking behaviour for the specified type of tobacco.
Status
Narrative summary about smoking behaviour for the specified type of tobacco.
Description
Also known as manufactured cigarettes, 'factory made' cigarettes or 'tailor made' cigarettes. Processed tobacco, manufactured into cylinder made of paper or a substance that does not contain tobacco.
Cigarettes
Also known as "rollies" or "roll-ups". Loose tobacco, hand rolled into a cylinder using cigarette papers.
Hand-rolled cigarettes
Also known as "large cigar". Roll of tobacco wrapped within a leaf tobacco or in a substance that contains tobacco.
Cigars
Loose tobacco placed inside a pipe bowl.
Pipe
Individual has previously smoked the specified type of tobacco but is not a current smoker.
Former smoker
Individual is a current smoker of the specified type of tobacco.
Current smoker
Also known as "hookah", "shisha", "narguileh" and "hubble-bubble". Tobacco, often flavoured, is burned then cooled through a basin of water and consumed through a hose and mouthpiece.
Waterpipe
Details about a discrete period of smoking activity for the specified type of tobacco.
Per episode
This data element will typically be used for pipes and hand-rolled cigarettes and is redundant if a value is recorded for 'Typical use (units)'.
Estimate of the weight of loose leaf tobacco smoked.
Typical use (mass)
Also known as mini cigars. Short and narrow cigar.
Cigarillos
Additional narrative about smoking of the specified type of tobacco, not captured in other fields.
Comment
The applied definition for the 'Quit date' data elements used in this archetype.
Quit date definition
Definition may need to be specified per type. For example, the number of units in a pack used for cigarettes may be different to cigars; the mass of loose tobacco in a pack used for hand-rolled cigarettes or pipes.
The definition of the size of pack used as part of the algorithm for calculating 'Pack years' data elements used in this archetype.
Pack definition
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
The definition of a pack can be recorded in the protocol of this archetype using the 'Pack definition' data element.
Estimate of the cumulative amount for all types of tobacco smoked.
Overall pack years
Definition may need to be specified per type. Current smoker definitions vary in different jurisdictions. For example: USA Centre for Disease Control refers to smoking during the past one month and New Zealand Ministry of Health uses 28 days.
The applied definition for the 'Current smoker' value in each of the 'Status' data elements used in this archetype.
Current smoker definition
Definition may need to be specified per type of tobacco. Former smoker definitions vary in different jurisdictions. For example: New Zealand Ministry of Health refers to not having smoked during the past 28 days.
The applied definition for the 'Former smoker' value in each of the 'Status' data elements used in this archetype.
Former smoker definition
Additional structured details about the specified type of tobacco smoking.
Type details
Also known as Beedis. Thin hand-rolled cigarettes filled with tobacco and wrapped in a leaf, often tied with colorful string at one or both ends. They can be flavoured or unflavoured.
Bidis
Definition may need to be specified per type. For example, the definition may not be zero, but less than a specified amount (as units or mass) smoked during a specified time interval.
The applied definition for the 'Never smoked' value in each of the 'Status' data elements used in this archetype.
Never smoked definition
Can be a partial date, for example, only a year.
The date or partial date when the individual first started daily smoking of tobacco of any type.
Daily smoking commenced
For example: '2' as the second episode within a sequence of episodes; or 'Pregnancy with twins' if describing the smoking activity during a health event such as during a specific pregnancy.
Identification of an episode of smoking activity - either as a number in a sequence and/or a named event.
Episode label
Can be a partial date, for example, only a year. This data field will be empty if the episode is current and ongoing.
Date when this episode ceased.
Episode end date
Smoking the specified type of tobacco at least once every day.
Daily
Not smoking the specified type of tobacco every day.
Non-daily
For example: 'stopped smoking for one day or longer with the intention of quitting'.
The applied definition for a Quit attempt used to determine value for the 'Number of quit attempts' data element used in this archetype.
Quit attempt definition
Additional structured details about the overall tobacco smoking behaviour.
Overall details
Additional narrative about tobacco smoking during the specified episode, not captured in other fields.
Episode comment
Also known as clove cigarettes. Cigarettes that contain a mixture of tobacco, cloves and other additives.
Kreteks
Statement about current smoking behaviour for all types of tobacco.
Overall status
Individual has never smoked the specified type of tobacco.
Never smoked
This data element does not take into account the amount of tobacco smoked. It may be used to calculate the 'Smoking index'.
The cumulative number of years that the individual has smoked tobacco.
Overall years of smoking
This parameter is similar to Pack Years but based on units of cigarettes, bidis etc smoked per day, rather than packs.
An indication of the cumulative amount of tobacco smoking exposure.
Smoking index
The type of tobacco smoked by the individual.
Type
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
at0089
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
at0005
at0006
CLUSTER
true
false
true
0
at0064
items
true
true
false
false
1
1
ELEMENT
true
true
false
false
0
1
at0023
value
true
true
false
false
0
1
DV_QUANTITY
true
true
false
false
1
1
openehr
382
true
false
true
0
true
true
false
false
1
1
1/d
true
false
true
0
true
true
false
false
1
1
1/wk
true
false
true
0
true
true
false
false
1
1
1/mo
CLUSTER
true
false
true
0
at0026
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
openEHR-EHR-CLUSTER\.cessation_attempts(-[a-zA-Z0-9_]+)*\.v1
constraint
false
false
true
false
true
1
CLUSTER
true
false
true
0
at0086
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
at0021
items
true
true
false
false
0
1
CLUSTER
true
false
true
0
at0073
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
false
false
true
false
true
0
openEHR-EHR-EVALUATION.alcohol_consumption_summary.v1
Summary or persistent information about the typical alcohol consumption of an individual.
Alcohol consumption summary
@ internal @
Tree
Individual is a current consumer of alcohol.
Current drinker
Individual has previously consumed alcohol but is not a current drinker.
Former drinker
Individual has never consumed alcohol.
Lifetime non-drinker
Can be a partial date, for example, only a year.
Date when this episode commenced.
Episode start date
Can be a partial date, for example, only a year. Definitions for a 'Quit date' vary enormously and can be defined using the 'Quit data definition' data element in the Protocol section of this archetype. This date will be identical to the 'Episode end date' for the most recent episode. This date could be used by decision support guidance to determine if the individual is at risk of relapse, for example in the first 12 months since quitting.
Date when the individual last consumed an alcohol.
Quit date
This data element is recording when a regular pattern of drinking commenced, rather than the first ever taste of alcohol. The first taste could be at a very young age and then no drinking until mid teens. In this case it is the pattern in the mid teens that is clinically significant. To differentiate between patterns of drinking, that has to be recorded in other elements in this archetype, for example in the 'Per episode' section.
The date or partial date when the individual first started frequent or regular, but usually non-daily, consumption of alcohol.
Regular consumption commenced
Can be a partial date, for example, only a year. This date could be used by decision support guidance to determine if the individual is at risk of relapse, for example in the first 12 months since quitting.
The date when the individual last ceased consuming alcohol of any type.
Overall quit date
Additional narrative about all alcohol consumption that has not been captured in other fields.
Overall comment
@ internal @
Tree
The date this alcohol consumption summary was last updated.
Last updated
Estimate of number of alcohol units consumed in the specified time period.
Typical consumption (alcohol units)
Total number of times the individual has attempted to stop consuming alcohol within this episode.
Number of quit attempts
Additional structured details about the specified episode of alcohol consumption.
Episode details
Details about consumption of a specified type of alcohol.
Per type
The typical pattern of use can be made more granular by coding with a terminology or a local value set in a template.
The typical pattern of consumption of alcohol.
Pattern
Use this data element to record a narrative description of alcohol drinking habits for this individual or to incorporate unstructured alcohol drinking information from existing or legacy clinical systems into an archetyped format.
Narrative summary about the individual's overall alcohol consumption pattern and history.
Overall description
Statement about current alcohol drinking behaviour.
Status
Narrative summary about alcohol consumption for the specified type of alcohol.
Description
Individual consumed alcohol during this period.
Current drinker
Details about a discrete period of time with a consistent pattern of typical consumption.
Per episode
Additional narrative about consumption of the specified type of alcohol, not captured in other fields.
Comment
The applied definition for the 'Quit date' data elements used in this archetype.
Quit date definition
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
The applied definition for the 'Current drinker' value in each of the 'Status' data elements used in this archetype.
Current drinker definition
The applied definition for the 'Former drinker' value in each of the 'Status' data elements used in this archetype.
Former drinker definition
Additional structured details about the consumption of the specified alcohol.
Type details
The applied definition for the 'Lifetime non-drinker' value in each of the 'Status' data elements used in this archetype.
Lifetime non-drinker definition
Can be a partial date, for example, only a year.
The date or partial date when the individual first started consuming alcohol on a daily basis.
Daily consumption commenced
For example: '2' as the second episode within a sequence of episodes; or 'Pregnancy with twins' if describing the alcohol consumption during a health event such as during a specific pregnancy.
Identification of an episode of alcohol consumption - either as a number in a sequence and/or a named event.
Episode label
Can be a partial date, for example, only a year. This data field will be empty if the episode is current and ongoing.
Date when this episode ceased.
Episode end date
Consuming alcoholic beverage at least once every day.
Daily
Not consuming alcoholic beverage every day.
Non-daily
For example: 'stopped consuming alcohol for one day or longer with the intention of quitting'.
The applied definition for a Quit attempt used to determine value for the 'Number of quit attempts' data element used in this archetype.
Quit attempt definition
Additional structured details about the overall alcohol consumption.
Overall details
For example: alcohol consumed as a hangover remedy eg 'hair of the dog'.
Additional narrative about alcohol consumption during the specified episode, not captured in other fields.
Episode comment
Statement about current consumption for all types of alcohol.
Overall status
Individual has not consumed alcohol during this episode.
Non-drinker
The individual's typical frequency of heavy drinking over a short period of time with the intent of becoming intoxicated.
Binge drinking frequency
Mass of alcohol defining a standard drink or alcohol unit as used in the 'Typical drinking (alcohol units)' element in this archetype.
Alcohol unit definition (mass)
Use of the coded text option is preferrable when possible. Alternatively, it's possible to use a local valueset or terminologi to record specific types of alcoholic beverages. For example: red or white wine; brandy or whisky; normal or low alcohol beer; or denatured alcohol (methylated spirits) as a specific form of rectified spirits.
The name of the specific type or grouping of alcohol.
Type
The number of days where no alcohol was consumed in the specified period.
Alcohol free days
The definition of an Alcohol unit can be recorded in the Protocol.
Estimate of number of standard drinks of the specified type of alcohol consumed in the specified period.
Typical consumption (alcohol units)
For example: details about binge drinking pattern.
Narrative summary about the individual's overall pattern of alcohol consumption during the specified episode.
Episode description
Narrative description about the individual's typical pattern of binge drinking.
Binge drinking description
This data point is not intended to record an accidental intoxication but to identify when a behaviour pattern of harmful consumption may have commenced.
The date or partial date when the individual became intoxicated for the first time.
Date first intoxicated
Fermented beverage made from grain mash.
Beer
Fermented beverage made from grapes and sometimes other fruits.
Wine
Fermented beverage made from any fruit juice.
Cider
Fermented beverage made from honey, sometimes with various fruits spices, grains or hops.
Mead
Fermented beverage made from 'honey water" of cacti.
Pulque
Fermented beverage made by a distillation process. Usually has an alcohol content >20%. Includes liquers, cocktails and rectified spirits.
Spirits
Wine with added spirits.
Fortified wine
false
false
true
false
true
0
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
true
true
false
false
0
1
at0000
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
-
Plan of Care
items
true
true
false
false
0
1
ACTION
true
true
false
false
0
1
at0000
ism_transition
true
true
false
false
1
1
ISM_TRANSITION
true
true
false
false
1
1
at0003
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
526
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
at0003
ISM_TRANSITION
true
true
false
false
1
1
at0008
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
526
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
at0008
ISM_TRANSITION
true
true
false
false
1
1
at0034
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
527
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
at0034
ISM_TRANSITION
true
true
false
false
1
1
at0033
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
528
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
at0033
ISM_TRANSITION
true
true
false
false
1
1
at0018
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
529
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
at0018
ISM_TRANSITION
true
true
false
false
1
1
at0006
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
245
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
at0006
ISM_TRANSITION
true
true
false
false
1
1
at0020
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
245
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
at0020
ISM_TRANSITION
true
true
false
false
1
1
at0035
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
530
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
at0035
ISM_TRANSITION
true
true
false
false
1
1
at0032
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
531
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
at0032
ISM_TRANSITION
true
true
false
false
1
1
at0010
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
531
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
at0010
ISM_TRANSITION
true
true
false
false
1
1
at0013
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
at0013
description
true
true
false
false
1
1
ITEM_TREE
true
true
false
false
1
1
at0019
items
true
true
false
false
0
1
ELEMENT
true
true
false
false
0
1
at0002
value
true
true
false
false
0
1
DV_TEXT
true
true
false
false
1
1
ELEMENT
true
true
false
false
0
1
at0021
value
true
true
false
false
0
1
DV_TEXT
true
true
false
false
1
1
ELEMENT
true
true
false
false
0
1
at0025
value
true
true
false
false
0
1
DV_TEXT
true
true
false
false
1
1
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
ELEMENT
true
true
false
false
0
1
at0016
value
true
true
false
false
0
1
DV_IDENTIFIER
true
true
false
false
1
1
ELEMENT
true
true
false
false
0
1
at0017
value
true
true
false
false
0
1
DV_DATE_TIME
true
true
false
false
1
1
false
false
true
false
true
0
openEHR-EHR-ACTION.care_plan.v0
Plan or sequence of discrete activities developed to achieve a specified management goal or treatment outcome, carried out by health professionals and/or the patient.
Care Plan
Name of care plan.
Care Plan Name
Need for a care plan has been identified.
Care plan Need Identified
Care plan activities commenced and in progress.
Care Plan Commenced
Care plan components identified and documented.
Care Plan Developed
Care plan duration has passed the 'Expiry Date'.
Care Plan Expired
All activities related to the care plan have been reconciled or completed.
Care Plan Completed
@ internal @
Tree
Identification of care plan.
Care Plan ID
Anticipated date beyond which the care plan can be deemed 'expired'.
Expiry Date
Care plan has been scheduled.
Care Plan Scheduled
@ internal @
Tree
Care plan has been reviewed.
Care Plan Reviewed
Description of activity performed/enacted against the plan.
Description
Reason for activity being performed /enacted against the plan.
Reason
Care plan has been aborted.
Care Plan Aborted
Care plan has been cancelled prior to commencement.
Care Plan Cancelled
Commencement of care plan has been temporarily postponed to a future date.
Care Plan Postponed
Care plan is temporarily suspended but intended to resume at a later date.
Care Plan Suspended
INSTRUCTION
true
true
false
false
0
1
at0000
activities
true
true
false
false
0
1
ACTIVITY
true
false
true
1
at0001
description
true
true
false
false
1
1
ITEM_TREE
true
true
false
false
1
1
at0009
items
true
true
false
false
0
1
ELEMENT
true
true
false
false
1
1
at0121
value
true
true
false
false
0
1
DV_TEXT
true
true
false
false
1
1
ELEMENT
true
true
false
false
0
1
at0148
value
true
true
false
false
0
1
DV_TEXT
true
true
false
false
1
1
ELEMENT
true
true
false
false
0
1
at0135
value
true
true
false
false
0
1
DV_TEXT
true
true
false
false
1
1
ELEMENT
true
false
true
0
at0062
value
true
true
false
false
0
1
DV_TEXT
true
true
false
false
1
1
ELEMENT
true
true
false
false
0
1
at0064
value
true
true
false
false
0
1
DV_TEXT
true
true
false
false
1
1
ELEMENT
true
false
true
0
at0152
value
true
true
false
false
0
1
DV_TEXT
true
true
false
false
1
1
ELEMENT
true
false
true
0
at0065
value
true
true
false
false
0
1
DV_TEXT
true
true
false
false
1
1
ELEMENT
true
true
false
false
0
1
at0068
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
at0136
at0137
at0138
DV_TEXT
true
true
false
false
1
1
ELEMENT
true
true
false
false
0
1
at0040
value
true
true
false
false
0
1
DV_DATE_TIME
true
true
false
false
1
1
DV_INTERVAL<DV_DATE_TIME>
true
true
false
false
1
1
upper
true
true
false
false
0
1
DV_DATE_TIME
true
true
false
false
1
1
lower
true
true
false
false
0
1
DV_DATE_TIME
true
true
false
false
1
1
DV_TEXT
true
true
false
false
1
1
CLUSTER
true
false
true
0
at0151
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
openEHR-EHR-CLUSTER\.service_direction(-[a-zA-Z0-9_]+)*\.v0
constraint
ELEMENT
true
true
false
false
0
1
at0145
value
true
true
false
false
0
1
DV_DATE_TIME
true
true
false
false
1
1
ELEMENT
true
true
false
false
0
1
at0144
value
true
true
false
false
0
1
DV_DATE_TIME
true
true
false
false
1
1
ELEMENT
true
true
false
false
0
1
at0147
value
true
true
false
false
0
1
DV_BOOLEAN
true
true
false
false
1
1
value
true
true
false
false
1
1
BOOLEAN
true
true
false
false
1
1
-
true
false
CLUSTER
true
false
true
0
at0132
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
CLUSTER
true
false
true
0
at0149
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v0
constraint
ELEMENT
true
true
false
false
0
1
at0076
value
true
true
false
false
0
1
DV_BOOLEAN
true
true
false
false
1
1
value
true
true
false
false
1
1
BOOLEAN
true
true
false
false
1
1
-
true
false
ELEMENT
true
true
false
false
0
1
at0078
value
true
true
false
false
0
1
DV_TEXT
true
true
false
false
1
1
CLUSTER
true
false
true
0
at0116
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
ELEMENT
true
true
false
false
0
1
at0150
value
true
true
false
false
0
1
DV_TEXT
true
true
false
false
1
1
false
false
true
false
true
1
false
false
true
false
true
0
protocol
true
true
false
false
0
1
ITEM_TREE
true
true
false
false
1
1
at0008
items
true
true
false
false
0
1
ELEMENT
true
true
false
false
0
1
at0010
value
true
true
false
false
0
1
DV_TEXT
true
true
false
false
1
1
DV_IDENTIFIER
true
true
false
false
1
1
CLUSTER
true
true
false
false
0
1
at0141
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
ELEMENT
true
true
false
false
0
1
at0011
value
true
true
false
false
0
1
DV_TEXT
true
true
false
false
1
1
DV_IDENTIFIER
true
true
false
false
1
1
CLUSTER
true
true
false
false
0
1
at0142
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
ELEMENT
true
true
false
false
0
1
at0127
value
true
true
false
false
0
1
DV_TEXT
true
true
false
false
1
1
CLUSTER
true
false
true
0
at0128
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
openEHR-EHR-CLUSTER\.distribution\.v1
constraint
CLUSTER
true
false
true
0
at0112
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
false
false
true
false
true
1
openEHR-EHR-INSTRUCTION.service_request.v1
Request for a health-related service or activity to be delivered by a clinician, organisation or agency.
Service request
Current Activity.
Current Activity
@ internal @
Tree
@ internal @
Tree
Usually equivalent to the HL7 Placer Order Identifier.
The local identifier assigned by the requesting clinical system.
Requester order identifier
Usually equivalent to the HL7 Filler Order Identifier.
The local identifier assigned to the request by the clinician or organisation receiving the request for service.
Receiver order identifier
This data element allows for recording of the timing for a single service, either as a date and time, a date ranges or a text descriptor which can allow for 'next available. In practice, clinicians will often think in terms of ordering services as approximate timing, for example: review in 3 months, 6 months or 12 months. As clinical systems need more exact parameters to operate on, this '3 months' will usually be converted to an exact date 3 months from the date of recording and stored using this data element. If complex timing or sequences of timings are required, use the CLUSTER.service_direction archetype within the 'Complex timing' SLOT and this data element becomes redundant.
The date/time, or acceptable interval of date/time, for provision of the service.
Service due
Coding of the 'Reason for request' with a coding system is desirable, if available. This data element allows multiple occurrences to enable the user to record a multiple responses, if required. For example: 'manage diabetes complications'.
A short phrase describing the reason for the request.
Reason for request
For example: 'The patient's diabetes has recently become more difficult to stabilise and renal function is deteriorating'.
Narrative description about the reason for request.
Reason description
For example: a referral to a specialist may have the intent of the specialist taking over responsibility for care of the patient, or it may be to provide a second opinion on treatment options. Coding of the 'Intent' with a coding system is desirable, if available. This data element allows multiple occurrences to enable the user to record a multiple responses, if required.
Description of the intent for the request.
Intent
Specific definitions of emergency and urgent will vary between clinical contexts, clinical systems and the nature of the request itself, so have not been defined in this archetype. If explicit timing is required then the Service period should be clearly stated.
Urgency of the request for service.
Urgency
Record as TRUE if additional information has been identified and will be forwarded when available. For example: pending test results.
Supplementary information will be following request.
Supplementary information
Description of the supplementary information.
Information description
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
Language, transport or other personal requirements to support the patient's attendance or participation in provision of the service.
Patient requirements
Coding of the 'Service name' with a coding system is desirable, if available. For example: 'referral' to an endocrinologist for diabetes management.
The name of the single service or activity requested.
Service name
Status is used to denote whether this is the initial request, or a follow-up request to change or provide supplementary information. Coding with a terminology is preferred, where possible.
The status of the request for service as indicated by the requester.
Request status
Details of additional clinicians, organisations or agencies who require copies of any communication.
Distribution list
For example: Specimen details for a laboratory test request, or anatomical location for a procedure request.
Additional detail about the service requested.
Specific details
This data point should be used to describe the named service in more detail, including how it should be delivered, patient concerns and issues that might be encountered in delivering the service.
Narrative description about the service requested.
Description
The request requires immediate attention.
Emergency
The request requires prioritised attention.
Urgent
The request does not require prioritised scheduling.
Routine
Details about the clinician or organisation requesting the service.
Requester
Details about the clinician or organisation receiving the request for service.
Receiver
This date/time is the equivalent to the latest possible date for service delivery or to the date of expiry for this request. For example: a service may be required to be completed before another event, such as scheduled surgery.
The date/time that marks the conclusion of the clinically valid period of time for delivery of this service.
Service period expiry
This date/time is the equivalent to the earliest possible date for service delivery. For example: sometimes a certain amount of time must pass before a service can be performed, for example some procedures can only be performed once the patient has stopped taking medications for a specific amount of time.
The date/time that marks the beginning of the valid period of time for delivery of this service.
Service period start
Record as TRUE to record explicity that the request has no expiry date. For example: commonly required for a referral to a specialist for long-term or lifelong care.
The valid period for this request is open ended and has no date of expiry.
Indefinite?
Coding of the 'Service type' with a coding system is desirable, if available. If the 'Service name' was coded, it is possible for this data point to be derived from the code. For example: biochemistry or microbiology laboratory, ultrasound or CT imaging.
Category of service requested.
Service type
Digital document, image, video or diagram supplied as additional information to support or inform the request.
Supporting information
Additional narrative about the service request not captured in other fields.
Comment
For example: 'hourly vital signs observations for 4 hours, then 4 hourly for 20 hours' or 'every third Wednesday for 3 visits' or .
Details about a complex service request requiring a sequence of timings.
Complex timing
Coding of the clinical indication with a terminology is preferred, where possible. This data element allows multiple occurrences. For example: 'Angina' or 'Type 1 Diabetes mellitus'.
The clinical reason for the ordered service.
Clinical indication
false
false
true
false
true
0
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
true
true
false
false
0
1
at0000
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
-
Functional Status
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
1
1
at0002
value
true
true
false
false
0
1
DV_TEXT
true
true
false
false
1
1
ELEMENT
true
false
true
0
at0012
value
true
true
false
false
0
1
DV_TEXT
true
true
false
false
1
1
CLUSTER
true
false
true
0
at0039
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
openEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_clock(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.v1
constraint
ELEMENT
true
true
false
false
0
1
at0077
value
true
true
false
false
0
1
DV_DATE_TIME
true
true
false
false
1
1
ELEMENT
true
true
false
false
0
1
at0005
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
at0047
at0048
at0049
DV_TEXT
true
true
false
false
1
1
CLUSTER
true
false
true
0
at0043
Boolean
2007
false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
ELEMENT
true
true
false
false
0
1
at0030
value
true
true
false
false
0
1
DV_DATE_TIME
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
-
Date of abatement
CLUSTER
true
true
false
false
0
1
at0000
items
true
true
false
false
1
1
ELEMENT
true
true
false
false
0
1
at0003
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
at0026
at0027
ELEMENT
true
true
false
false
0
1
at0083
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
at0084
at0097
ELEMENT
true
true
false
false
0
1
at0089
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
at0090
ELEMENT
true
true
false
false
0
1
at0071
value
true
true
false
false
0
1
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openEHR-EHR-CLUSTER.problem_qualifier.v1
Contextual or temporal qualifier for a specified problem or diagnosis.
Problem/Diagnosis qualifier
For example: 'New' will enable clinicians to distinguish a new, acute episode of otitis media that may have arisen soon after a previous diagnosis, to distinguish it from an unresolved or 'Ongoing' diagnosis of chronic otitis media. Treatment of recurring, new and acute, episodes of a condition may differ significantly from the same condition that is not resolving or responding to treatment. In many situations the clinician will not be able to tell, and so indeterminate may be appropriate.
Category of this episode for the identified problem/diagnosis.
Episodicity
The Active/Inactive and Current/Past data elements have similar clinical impact but represent slightly different semantics. Both are actively used in different clinical settings, but usually not together. If a Current/Past qualifier is recorded, then this data element is likely to be redundant. An exception where a condition can be current but inactive is asthma that is not causing acute symptoms.
Category that supports division of problems and diagnoses into Active or Inactive problem lists.
Active/Inactive?
The status is usually determined by a combination of the timing of diagnosis plus level of clinical certainty resulting from diagnostic tests and clinical evidence available. This data element and 'Diagnostic certainty' in EVALUATION.problem_diagnosis are two important axes of the diagnostic process, and valid combinations will need to be presented by software that exposes both data elements, so it is not possible for users to select conflicting combinations.
Preliminary or working diagnoses are intended to represent the single most likely choice out of all differential diagnosis options.
Stage or phase of diagnostic process.
Diagnostic status
The initial diagnosis made, usually associated with a low level of clinical certainty. It may change as test results or advice become available.
Preliminary
Interim diagnosis, based on a reasonable amount of clinical certainty but pending further test results or clinical advice. It may still change as test results or advice become available.
Working
Final substantiated diagnosis, based on a high level of clinical certainty, which may include clinical evidence from test results. It is not expected to change.
Established
The problem or diagnosis is currently active and clinically relevant.
Active
The problem or diagnosis is not completely resolved but is inactive or felt less relevant to the current clinical context.
Inactive
A new occurrence of either a new or existing problem or diagnosis. A flag for 'First occurrence' can be recorded separately to distinguish the first from other occurrences.
New
The issue, problem or diagnosis continues, without new, acute episodes occurring.
Ongoing
The Current/Past and Active/Inactive data elements have similar clinical impact but represent slightly different semantics. Both are actively used in different clinical settings, but usually not together. If an Active/Inactive qualifier is recorded, then this data element is likely to be redundant. An exception where a condition can be current but inactive is asthma that is not causing acute symptoms.
Category that supports division of problems and diagnoses into Current or Past problem lists.
Current/Past?
An issue which ocurred in the past.
Past
An issue occuring at present.
Current
This data element contains a value set commonly used in diagnostic categorisation. In episodic care contexts (commonly secondary care) it is common to categorise/organise diagnoses according to their relationship to the principal diagnosis being addressed during that episode of care. These categories may also be used for clinical coding, reporting and billing purposes. In some countries the diagnostic category may be known as a DRG.
In addition, the free text choice permits use of other local value sets, as required.
Category of the problem or diagnosis within a specified episode of care and/or local care context.
Diagnostic category
The diagnosis determined to be the primary reason for an episode of admitted patient care, an episode of residential care or an attendance at the health care establishment.
Principal diagnosis
A problem or diagnosis that occurs at the same time as the primary problem or diagnosis. May also be known as a comorbid condition.
Secondary diagnosis
It is not possible to determine if this occurrence of the problem or diagnosis is new or ongoing.
Indeterminate
This data element can be an additional qualifier to the 'New' value in the 'Episodicity' value set, that is a condition such as asthma can have recurring new episodes that have periods of resolution in between. However it can be important to identify the first ever episode of asthma from all of the other episodes.
Category of the occurrence for this problem or diagnosis.
Occurrence
Record as True if the problem or diagnosis was present on admission. This data element is a requirement from DRG reporting in some countries.
Was the problem or diagnosis present at admission?
Admission diagnosis?
An unfavorable evolution of a problem or diagnosis.
Complication
Definitions of acute vs chronic will differ for each diagnosis.
Category reflecting the speed of onset and/or duration and persistence of the problem or diagnosis.
Course label
A problem or diagnosis with persistent or long-lasting effects, or that evolves over time.
Chronic
A problem or diagnosis with a rapid onset, a short course, or both.
Acute
For example: tracking the progress of resolution of a middle ear infection.
Phase of healing for an acute problem or diagnosis.
Resolution phase
Problem or diagnosis has completed the normal phases of restoration or healing and can be considered resolved.
Resolved
Problem or diagnosis is progressing satisfactorily through the normal stages of restoration or healing towards resolution.
Resolving
Problem or diagnosis is not progressing satisfactorily through the normal stages of restoration or healing towards resolution.
Not resolving
It is not possible to determine the resolution or healing status of the problem or diagnosis.
Indeterminate
The previously recorded diagnosis has been clinically reassessed or disproved with a high level of clinical certainty. This status is used to correct an error in the health record.
Refuted
For example: the status of a cancer or haematological diagnosis.
Status of the remission of an incurable diagnosis.
Remission status
No ongoing signs or symptoms of the disease have been identified.
In remission
No diminution of the signs or symptoms of the disease have been identified.
Not in remission
It is not possible to determine if there have been diminution of the signs or symptoms of the disease have been identified.
Indeterminate
A problem or diagnosis with an acute exacerbation of a chronic condition.
Acute-on-chronic
This is the first ever occurrence of this problem or diagnosis.
First occurrence
New occurrence of the same problem or diagnosis after a previous episode was resolved.
Recurrence
Problem or diagnosis has deteriorated after a period of temporary improvement.
Relapsed
SNOMED-CT
288526004
SNOMED-CT
106229004
SNOMED-CT
148006
SNOMED-CT
5558000
SNOMED-CT
14657009
SNOMED-CT
410511007
SNOMED-CT
410513005
SNOMED-CT
15240007
SNOMED-CT
8319008
SNOMED-CT
85097005
SNOMED-CT
288524001
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openEHR-EHR-EVALUATION.problem_diagnosis.v1
Clear delineation between the scope of a problem versus a diagnosis is not easy to achieve in practice. For the purposes of clinical documentation with this archetype, problem and diagnosis are regarded as a continuum, with increasing levels of detail and supportive evidence usually providing weight towards the label of 'diagnosis'.
Details about a single identified health condition, injury, disability or any other issue which impacts on the physical, mental and/or social well-being of an individual.
Problem/Diagnosis
@ internal @
structure
Coding of the name of the problem or diagnosis with a terminology is preferred, where possible.
Identification of the problem or diagnosis, by name.
Problem/Diagnosis name
Partial dates are acceptable. If the subject of care is under the age of one year, then the complete date or a minimum of the month and year is necessary to enable accurate age calculations - for example, if used to drive decision support. Data captured/imported as "Age at time of clinical recognition" should be converted to a date using the subject's date of birth.
Estimated or actual date/time the diagnosis or problem was recognised by a healthcare professional.
Date/time clinically recognised
If severity is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant. Note: more specific grading of severity can be recorded using the Specific details SLOT.
An assessment of the overall severity of the problem or diagnosis.
Severity
Use to provide background and context, including evolution, episodes or exacerbations, progress and any other relevant details, about the problem or diagnosis.
Narrative description about the problem or diagnosis.
Clinical description
Coding of the name of the anatomical location with a terminology is preferred, where possible.
Use this data element to record precoordinated anatomical locations. If the requirements for recording the anatomical location are determined at run-time by the application or require more complex modelling such as relative locations then use the CLUSTER.anatomical_location or CLUSTER.relative_location within the 'Structured anatomical location' SLOT in this archetype. Occurrences for this data element are unbounded to allow for clinical scenarios such as describing a rash in multiple locations but where all of the other attributes are identical. If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant.
Identification of a simple body site for the location of the problem or diagnosis.
Body site
Partial dates are acceptable. If the subject of care is under the age of one year, then the complete date or a minimum of the month and year is necessary to enable accurate age calculations - for example, if used to drive decision support. Data captured/imported as "Age at time of resolution" should be converted to a date using the subject's date of birth.
Estimated or actual date/time of resolution or remission for this problem or diagnosis, as determined by a healthcare professional.
Date/time of resolution
@ internal @
Tree
Use this SLOT to insert the CLUSTER.anatomical_location or CLUSTER.relative_location archetypes if the requirements for recording the anatomical location are determined at run-time by the application or require more complex modelling such as relative locations.
If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, use of this SLOT becomes redundant.
A structured anatomical location for the problem or diagnosis.
Structured body site
May include structured detail about the grading or staging of the diagnosis; diagnostic criteria, classification criteria or formal severity assessments such as Common Terminology Criteria for Adverse Events.
Details that are additionally required to record as unique attributes of this problem or diagnosis.
Specific details
Use status or context qualifiers with care, as they are variably used in practice and interoperability cannot be assured unless usage is clearly defined with the community of use. For example: active status - active, inactive, resolved, in remission; evolution status - initial, interim/working, final; temporal status - current, past; episodicity status - first, new, ongoing; admission status - admission, discharge; or priority status - primary, secondary.
Structured details for location-, domain-, episode- or workflow-specific aspects of the diagnostic process.
Status
The problem or diagnosis does not interfere with normal activity or may cause damage to health if left untreated.
Mild
The problem or diagnosis causes interference with normal activity or will damage health if left untreated.
Moderate
The problem or diagnosis prevents normal activity or will seriously damage health if left untreated.
Severe
Additional narrative about the problem or diagnosis not captured in other fields.
Comment
The date this problem or diagnosis was last updated.
Last updated
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
Narrative description about the course of the problem or diagnosis since onset.
Course description
The level of confidence in the identification of the diagnosis.
Diagnostic certainty
The diagnosis has been identified with a low level of certainty.
Suspected
The diagnosis has been identified with a high level of certainty.
Probable
The diagnosis has been confirmed against recognised criteria.
Confirmed
Data captured/imported as "Age at onset" should be converted to a date using the subject's date of birth.
Estimated or actual date/time that signs or symptoms of the problem/diagnosis were first observed.
Date/time of onset
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Clinical impression
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
false
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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
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openEHR-EHR-CLUSTER\.multimedia\.v0
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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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false
String
- archetype_id/value
attribute
C_STRING
-
.*
constraint
false
false
true
false
true
0
openEHR-EHR-EVALUATION.limitation_of_treatment.v0
In many countries this is known as the NFR (Not for resuscitation), DNR (Do not resuscitate), DNAR (Do not attempt resuscitation) or DNACPR (Do not attempt cardiopulmonary resuscitation) decision.
Decision/s about limitation of future treatment, determined by a senior clinician.
Limitation of treatment
@ internal @
Tree
Category describing the presence of any limitation of treatment.
Status
For full resuscitation. No limitations on future treatment options have been recorded.
No limitation of treatment
Limitations on future treatment options have been recorded in an advanced care directive or similar.
Limitation of medical treatment
Do not attempt resuscitation. Comfort during the dying process.
Allow natural death
Details about each limitation on treatment
Per limitation
Description about
Type of limitation
Lifesaving emergency procedure involving chest compressions and artificial ventilation.
Cardiopulmonary resuscitation
*
Endotracheal intubation
*
Mechanical ventilation
*
Vasopressor therapy
*
Parenteral or artificial nutrition
*
Dialysis
*
Blood products
*
Antibiotics
*
Intravenous fluids
The decision about whether the identified treatment type is permitted or not.
Decision
The treatment is permitted, if clinically appropriate.
Permitted
The treatment is not permitted.
Not permitted
For example: the types of antibiotics that would be acceptable.
Description about any criteria, caveats or futher clarification about the limitation.
Qualification
Narrative rationale or justification for the limitation of treatment decision/s.
Rationale
Is the patient aware of the limitation of treatment decision/s?
Patient awareness
The patient is aware of the limitation of treatment decision/s.
Patient aware of the decision/s
The patient is not aware of the limitation of treatment decision/s.
Patient not aware of the decision/s
Narrative description about awareness of the treatment decision/s by carers and family.
Carer awareness
Additional narrative about the limitation of treatment decision/s, not captured in other fields.
Comment
@ internal @
Tree
The date when this Limitation of treatment archetype is due for review.
Review date
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 or formalisms.
Extension
*
ELEMENT
SNOMED-CT
304253006
SNOMED-CT
304252001
false
false
true
false
true
0
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
false
false
true
false
true
0
openEHR-EHR-COMPOSITION.health_summary.v1
International Patient Summary
Generic document containing a summary of health information about an individual.
Health summary
@ 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
AllergyIntolerance.code:absentOrUnknownAllergyIntolerance
AllergyIntolerance.code:absentOrUnknownAllergyIntolerance
openEHR,FHIR
AllergyIntolerance
openEHR,FHIR,DAM
AllergyIntolerance.code:allergyIntoleranceGPSCode
DAM, openEHR
openEHR
openEHR, FHIR, DAM
FHIR, DAM
AllergyIntolerance.clinicalStatus
FHIR, DAM
IMH
openEHR,FHIR,DAM
FHIR, openEHR
FHIR, openEHR
FHIR, openEHR,DAM
openEHR, FHIR, DAM
AllergyIntolerance.reaction.onset
FHIR, openEHR,DAM
AllergyIntolerance.reaction.manifestation
FHIR, openEHR,DAM
openEHR
FHIR, DAM
openEHR
openEHR
openEHR
FHIR, openEHR, DAM
openEHR
openEHR
openEHR
FHIR
FHIR, openEHR
openEHR
DAM
AllergyIntolerance.reaction.severity
Condition.clinicalStatus
OBX.3
Observation.code
OBX.2, OBX.5, OBX.6, OBX.7, OBX.8
Observation.value[x]
OBX.11
Observation.status
OBX.19
Observation.issued
NTE.3
Observation.note
Specimen.collection.collector
Specimen.collection.sourceSite
Specimen.collection.quantity
Specimen.type
Specimen.accessionIdentifier
Specimen.identifier
Specimen.receivedTime
Specimen.collection.method
Specimen.collection.collector
Specimen.note
OBX.3
Observation.code
OBX.2, OBX.5, OBX.6, OBX.7, OBX.8
Observation.value[x]
NTE.3
Observation.note
Condition.clinicalStatus
Condition.clinicalStatus
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