webtemplate.ips_template.json Maven / Gradle / Ivy
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{
"templateId": "International Patient Summary",
"version": "2.3",
"defaultLanguage": "en",
"languages": [
"en"
],
"tree": {
"id": "international_patient_summary",
"name": "International Patient Summary",
"localizedName": "International Patient Summary",
"rmType": "COMPOSITION",
"nodeId": "openEHR-EHR-COMPOSITION.health_summary.v1",
"min": 1,
"max": 1,
"localizedNames": {
"en": "International Patient Summary"
},
"localizedDescriptions": {
"en": "Generic document containing a summary of health information about an individual."
},
"aqlPath": "",
"children": [
{
"id": "context",
"rmType": "EVENT_CONTEXT",
"nodeId": "",
"min": 1,
"max": 1,
"aqlPath": "/context",
"children": [
{
"id": "start_time",
"name": "Start_time",
"rmType": "DV_DATE_TIME",
"min": 1,
"max": 1,
"aqlPath": "/context/start_time",
"inputs": [
{
"type": "DATETIME"
}
],
"inContext": true
},
{
"id": "setting",
"name": "Setting",
"rmType": "DV_CODED_TEXT",
"min": 1,
"max": 1,
"aqlPath": "/context/setting",
"inputs": [
{
"suffix": "code",
"type": "TEXT"
},
{
"suffix": "value",
"type": "TEXT"
}
],
"inContext": true
}
]
},
{
"id": "medication_summary",
"name": "Medication Summary",
"localizedName": "Medication Summary",
"rmType": "SECTION",
"nodeId": "openEHR-EHR-SECTION.adhoc.v1",
"min": 1,
"max": 1,
"localizedNames": {
"en": "Medication Summary"
},
"localizedDescriptions": {
"en": "A generic section header which should be renamed in a template to suit a specific clinical context."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']",
"children": [
{
"id": "medication_statement",
"name": "Medication statement",
"localizedName": "Medication statement",
"rmType": "ACTION",
"nodeId": "openEHR-EHR-ACTION.medication.v1",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Medication statement"
},
"localizedDescriptions": {
"en": "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."
},
"annotations": {
"comment": "This is not limited to activities performed based on medication orders from clinicians, but could also include for example taking over the counter medication."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']",
"children": [
{
"id": "ism_transition",
"name": "Ism_transition",
"rmType": "ISM_TRANSITION",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/ism_transition",
"children": [
{
"id": "current_state",
"name": "Current_state",
"rmType": "DV_CODED_TEXT",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/ism_transition/current_state",
"inputs": [
{
"suffix": "code",
"type": "CODED_TEXT",
"list": [
{
"value": "530",
"label": "suspended"
},
{
"value": "245",
"label": "active"
},
{
"value": "532",
"label": "completed"
},
{
"value": "526",
"label": "planned"
}
]
}
],
"inContext": true
},
{
"id": "transition",
"name": "Transition",
"rmType": "DV_CODED_TEXT",
"min": 0,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/ism_transition/transition",
"inputs": [
{
"suffix": "code",
"type": "TEXT"
},
{
"suffix": "value",
"type": "TEXT"
}
],
"inContext": true
},
{
"id": "careflow_step",
"name": "Careflow_step",
"rmType": "DV_CODED_TEXT",
"min": 0,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/ism_transition/careflow_step",
"inputs": [
{
"suffix": "code",
"type": "CODED_TEXT",
"list": [
{
"value": "at0109",
"label": "Medication recommended",
"localizedLabels": {
"en": "Medication recommended"
},
"currentStates": [
"526"
]
},
{
"value": "at0006",
"label": "Dose administered",
"localizedLabels": {
"en": "Dose administered"
},
"currentStates": [
"245"
]
},
{
"value": "at0009",
"label": "Administrations suspended",
"localizedLabels": {
"en": "Administrations suspended"
},
"currentStates": [
"530"
]
},
{
"value": "at0007",
"label": "Medication course completed",
"localizedLabels": {
"en": "Medication course completed"
},
"currentStates": [
"532"
]
}
]
}
],
"inContext": true
}
],
"inContext": true
},
{
"id": "medication_item",
"name": "Medication item",
"localizedName": "Medication item",
"rmType": "DV_TEXT",
"nodeId": "at0020",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Medication item"
},
"localizedDescriptions": {
"en": "Name of the medication, vaccine or other therapeutic/prescribable item which was the focus of the activity."
},
"annotations": {
"comment": "For example: 'Atenolol 100mg' or 'Tenormin tablets 100mg'. \nIt 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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[at0020]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "medication",
"name": "Medication",
"localizedName": "Medication",
"rmType": "CLUSTER",
"nodeId": "openEHR-EHR-CLUSTER.medication.v1",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Medication"
},
"localizedDescriptions": {
"en": "Details about a medication or component of a medication, including strength, form and details of any specific constituents."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v1]",
"children": [
{
"id": "name",
"name": "Name",
"localizedName": "Name",
"rmType": "DV_TEXT",
"nodeId": "at0132",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Name"
},
"localizedDescriptions": {
"en": "The name of the medication or medication component."
},
"annotations": {
"comment": "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'."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v1]/items[at0132]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "form",
"name": "Form",
"localizedName": "Form",
"rmType": "DV_TEXT",
"nodeId": "at0071",
"min": 0,
"max": -1,
"localizedNames": {
"en": "Form"
},
"localizedDescriptions": {
"en": "The formulation or presentation of the medication or medication component."
},
"annotations": {
"comment": "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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v1]/items[at0071]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "category",
"name": "Category",
"localizedName": "Category",
"rmType": "DV_CODED_TEXT",
"nodeId": "at0142",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Category"
},
"localizedDescriptions": {
"en": "The category of the medication or medication component, with regard to manufacturing or preparation, and the number of ingredients."
},
"annotations": {
"comment": "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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v1]/items[at0142]/value",
"inputs": [
{
"suffix": "code",
"type": "CODED_TEXT",
"list": [
{
"value": "at0143",
"label": "Ad-hoc mixture",
"localizedLabels": {
"en": "Ad-hoc mixture"
},
"localizedDescriptions": {
"en": "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."
}
},
{
"value": "at0146",
"label": "Ingredient",
"localizedLabels": {
"en": "Ingredient"
},
"localizedDescriptions": {
"en": "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."
}
},
{
"value": "at0144",
"label": "Multi-ingredient product",
"localizedLabels": {
"en": "Multi-ingredient product"
},
"localizedDescriptions": {
"en": "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."
}
},
{
"value": "at0145",
"label": "Single-ingredient product",
"localizedLabels": {
"en": "Single-ingredient product"
},
"localizedDescriptions": {
"en": "The medication or medication component is a manufactured product containing a single active ingredient."
}
},
{
"value": "at0001",
"label": "Combination product",
"localizedLabels": {
"en": "Combination product"
},
"localizedDescriptions": {
"en": "The medication or medication component consists of a number of separate products which are pre-packaged by the manufacturer, for example Canesten Combi."
}
}
],
"listOpen": true
},
{
"suffix": "other",
"type": "TEXT"
}
]
},
{
"id": "strength_presentation",
"name": "Strength (presentation)",
"localizedName": "Strength (presentation)",
"rmType": "CLUSTER",
"nodeId": "at0152",
"min": 0,
"max": 1,
"cardinalities": [
{
"min": 4,
"max": -1,
"ids": [
"strength_numerator",
"strength_numerator_unit",
"strength_denominator",
"strength_denominator_unit"
]
}
],
"localizedNames": {
"en": "Strength (presentation)"
},
"localizedDescriptions": {
"en": "The strength of the medication or medication component, expressed as a ratio."
},
"annotations": {
"comment": "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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v1]/items[at0152]",
"children": [
{
"id": "strength_numerator",
"name": "Strength numerator",
"localizedName": "Strength numerator",
"rmType": "DV_QUANTITY",
"nodeId": "at0153",
"min": 1,
"max": 1,
"localizedNames": {
"en": "Strength numerator"
},
"localizedDescriptions": {
"en": "The value of the numerator of the strength fraction."
},
"annotations": {
"comment": "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'."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v1]/items[at0152]/items[at0153]/value",
"inputs": [
{
"suffix": "magnitude",
"type": "DECIMAL",
"validation": {
"range": {
"minOp": ">=",
"min": 0.0
}
}
},
{
"suffix": "unit",
"type": "CODED_TEXT",
"list": [
{
"value": "1",
"label": "1",
"validation": {
"range": {
"minOp": ">=",
"min": 0.0
}
}
}
]
}
]
},
{
"id": "strength_numerator_unit",
"name": "Strength numerator unit",
"localizedName": "Strength numerator unit",
"rmType": "DV_TEXT",
"nodeId": "at0004",
"min": 1,
"max": 1,
"localizedNames": {
"en": "Strength numerator unit"
},
"localizedDescriptions": {
"en": "The unit of the numerator of the strength fraction."
},
"annotations": {
"comment": "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'."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v1]/items[at0152]/items[at0004]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "strength_denominator",
"name": "Strength denominator",
"localizedName": "Strength denominator",
"rmType": "DV_QUANTITY",
"nodeId": "at0157",
"min": 1,
"max": 1,
"localizedNames": {
"en": "Strength denominator"
},
"localizedDescriptions": {
"en": "The value of the denominator of the strength fraction."
},
"annotations": {
"comment": "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'."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v1]/items[at0152]/items[at0157]/value",
"inputs": [
{
"suffix": "magnitude",
"type": "DECIMAL",
"validation": {
"range": {
"minOp": ">=",
"min": 0.0
}
}
},
{
"suffix": "unit",
"type": "CODED_TEXT",
"list": [
{
"value": "1",
"label": "1",
"validation": {
"range": {
"minOp": ">=",
"min": 0.0
}
}
}
]
}
]
},
{
"id": "strength_denominator_unit",
"name": "Strength denominator unit",
"localizedName": "Strength denominator unit",
"rmType": "DV_TEXT",
"nodeId": "at0005",
"min": 1,
"max": 1,
"localizedNames": {
"en": "Strength denominator unit"
},
"localizedDescriptions": {
"en": "The unit of the denominator of the strength fraction."
},
"annotations": {
"comment": "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'."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v1]/items[at0152]/items[at0005]/value",
"inputs": [
{
"type": "TEXT"
}
]
}
]
},
{
"id": "unit_of_presentation",
"name": "Unit of presentation",
"localizedName": "Unit of presentation",
"rmType": "DV_TEXT",
"nodeId": "at0158",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Unit of presentation"
},
"localizedDescriptions": {
"en": "The unit of presentation for a single dose of the medication, for use with the 'Strength denominator unit' element."
},
"annotations": {
"comment": "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'."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v1]/items[at0158]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "strength_concentration",
"name": "Strength (concentration)",
"localizedName": "Strength (concentration)",
"rmType": "DV_QUANTITY",
"nodeId": "at0115",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Strength (concentration)"
},
"localizedDescriptions": {
"en": "The strength of the medication or medication component, as a concentration."
},
"annotations": {
"comment": "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'."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v1]/items[at0115]/value",
"inputs": [
{
"suffix": "magnitude",
"type": "DECIMAL"
},
{
"suffix": "unit",
"type": "CODED_TEXT"
}
]
},
{
"id": "manufacturer",
"name": "Manufacturer",
"localizedName": "Manufacturer",
"rmType": "DV_TEXT",
"nodeId": "at0151",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Manufacturer"
},
"localizedDescriptions": {
"en": "The manufacturer of the medication or medication component."
},
"annotations": {
"comment": "For example: 'Abbott'."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v1]/items[at0151]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "batch_id",
"name": "Batch ID",
"localizedName": "Batch ID",
"rmType": "ELEMENT",
"nodeId": "at0150",
"min": 0,
"max": -1,
"localizedNames": {
"en": "Batch ID"
},
"localizedDescriptions": {
"en": "The identifier assigned to the production batch by the manufacturer during production."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v1]/items[at0150]",
"children": [
{
"id": "text_value",
"localizedName": "Batch ID",
"rmType": "DV_TEXT",
"nodeId": "",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Batch ID"
},
"localizedDescriptions": {
"en": "The identifier assigned to the production batch by the manufacturer during production."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v1]/items[at0150]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "identifier_value",
"localizedName": "Batch ID",
"rmType": "DV_IDENTIFIER",
"nodeId": "",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Batch ID"
},
"localizedDescriptions": {
"en": "The identifier assigned to the production batch by the manufacturer during production."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v1]/items[at0150]/value",
"inputs": [
{
"suffix": "id",
"type": "TEXT"
},
{
"suffix": "type",
"type": "TEXT"
},
{
"suffix": "issuer",
"type": "TEXT"
},
{
"suffix": "assigner",
"type": "TEXT"
}
]
}
]
},
{
"id": "expiry",
"name": "Expiry",
"localizedName": "Expiry",
"rmType": "DV_DATE_TIME",
"nodeId": "at0003",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Expiry"
},
"localizedDescriptions": {
"en": "The expiry date and/or time of the medication or medication component, as given by the manufacturer or individual preparing the mixture."
},
"annotations": {
"comment": "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.\n For example: '2017-05-23'."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v1]/items[at0003]/value",
"inputs": [
{
"type": "DATETIME"
}
]
},
{
"id": "amount",
"name": "Amount",
"localizedName": "Amount",
"rmType": "DV_QUANTITY",
"nodeId": "at0139",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Amount"
},
"localizedDescriptions": {
"en": "The value of the amount of medication or medication component."
},
"annotations": {
"comment": "For example: '1', '1.5', '1000'. \nNote: the associated unit for this amount is recorded using the 'Amount unit' element."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v1]/items[at0139]/value",
"inputs": [
{
"suffix": "magnitude",
"type": "DECIMAL",
"validation": {
"range": {
"minOp": ">=",
"min": 0.0
}
}
},
{
"suffix": "unit",
"type": "CODED_TEXT",
"list": [
{
"value": "1",
"label": "1",
"validation": {
"range": {
"minOp": ">=",
"min": 0.0
}
}
}
]
}
]
},
{
"id": "amount_unit",
"name": "Amount unit",
"localizedName": "Amount unit",
"rmType": "DV_TEXT",
"nodeId": "at0008",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Amount unit"
},
"localizedDescriptions": {
"en": "The unit of the amount of medication or medication component."
},
"annotations": {
"comment": "For example: 'mg', 'ml', 'IU'.\nNote: The value of the amount is recorded using the 'Amount' element."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v1]/items[at0008]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "alternate_amount",
"name": "Alternate amount",
"localizedName": "Alternate amount",
"rmType": "DV_QUANTITY",
"nodeId": "at0148",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Alternate amount"
},
"localizedDescriptions": {
"en": "The value of an equivalent representation of the amount of the medication or medication component."
},
"annotations": {
"comment": "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'."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v1]/items[at0148]/value",
"inputs": [
{
"suffix": "magnitude",
"type": "DECIMAL",
"validation": {
"range": {
"minOp": ">=",
"min": 0.0
}
}
},
{
"suffix": "unit",
"type": "CODED_TEXT",
"list": [
{
"value": "1",
"label": "1",
"validation": {
"range": {
"minOp": ">=",
"min": 0.0
}
}
}
]
}
]
},
{
"id": "alternate_amount_unit",
"name": "Alternate amount unit",
"localizedName": "Alternate amount unit",
"rmType": "DV_TEXT",
"nodeId": "at0007",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Alternate amount unit"
},
"localizedDescriptions": {
"en": "The unit of an equivalent representation of the amount of the medication or medication component."
},
"annotations": {
"comment": "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'."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v1]/items[at0007]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "role",
"name": "Role",
"localizedName": "Role",
"rmType": "DV_CODED_TEXT",
"nodeId": "at0127",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Role"
},
"localizedDescriptions": {
"en": "The role of the medication or medication component within a mixture."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v1]/items[at0127]/value",
"inputs": [
{
"suffix": "code",
"type": "CODED_TEXT",
"list": [
{
"value": "at0080",
"label": "Therapeutic",
"localizedLabels": {
"en": "Therapeutic"
},
"localizedDescriptions": {
"en": "Constituent that alone or in combination with one or more other ingredients is considered to fulfil the intended activity of a medicinal product."
}
},
{
"value": "at0083",
"label": "Adjuvant",
"localizedLabels": {
"en": "Adjuvant"
},
"localizedDescriptions": {
"en": "Constituent whose primary function is to modify the activity of an active constituent. An adjuvant constituent itself may or may not be therapeutically active."
}
},
{
"value": "at0084",
"label": "Excipient",
"localizedLabels": {
"en": "Excipient"
},
"localizedDescriptions": {
"en": "Constituent that is inert in relation to the intended activity of the medicinal product."
}
}
],
"listOpen": true
},
{
"suffix": "other",
"type": "TEXT"
}
]
},
{
"id": "description",
"name": "Description",
"localizedName": "Description",
"rmType": "DV_TEXT",
"nodeId": "at0133",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Description"
},
"localizedDescriptions": {
"en": "Narrative description of the medication or medication component where it is not possible to describe this fully using structured elements."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v1]/items[at0133]/value",
"inputs": [
{
"type": "TEXT"
}
]
}
]
},
{
"id": "dosage",
"name": "Dosage",
"localizedName": "Dosage",
"rmType": "CLUSTER",
"nodeId": "openEHR-EHR-CLUSTER.dosage.v1",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Dosage"
},
"localizedDescriptions": {
"en": "The combination of a medication amount and administration timing for a single day, in the context of a medication order or medication management."
},
"annotations": {
"comment": "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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v1]",
"children": [
{
"id": "dose_amount",
"name": "Dose amount",
"localizedName": "Dose amount",
"rmType": "ELEMENT",
"nodeId": "at0144",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Dose amount"
},
"localizedDescriptions": {
"en": "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."
},
"annotations": {
"comment": "For example: 1, 1.5, 0.125 or 1-2, 12.5-20.5"
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v1]/items[at0144]",
"children": [
{
"id": "quantity_value",
"localizedName": "Dose amount",
"rmType": "DV_QUANTITY",
"nodeId": "",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Dose amount"
},
"localizedDescriptions": {
"en": "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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v1]/items[at0144]/value",
"inputs": [
{
"suffix": "magnitude",
"type": "DECIMAL",
"validation": {
"range": {
"minOp": ">=",
"min": 0.0
}
}
},
{
"suffix": "unit",
"type": "CODED_TEXT",
"list": [
{
"value": "1",
"label": "1",
"validation": {
"range": {
"minOp": ">=",
"min": 0.0
}
}
}
]
}
]
},
{
"id": "interval_of_quantity_value",
"localizedName": "Dose amount",
"rmType": "DV_INTERVAL",
"nodeId": "",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Dose amount"
},
"localizedDescriptions": {
"en": "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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v1]/items[at0144]/value",
"children": [
{
"id": "upper",
"rmType": "DV_QUANTITY",
"nodeId": "",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v1]/items[at0144]/value/upper",
"inputs": [
{
"suffix": "magnitude",
"type": "DECIMAL",
"validation": {
"range": {
"minOp": ">=",
"min": 0.0
}
}
},
{
"suffix": "unit",
"type": "CODED_TEXT",
"list": [
{
"value": "1",
"label": "1",
"validation": {
"range": {
"minOp": ">=",
"min": 0.0
}
}
}
]
}
]
},
{
"id": "lower",
"rmType": "DV_QUANTITY",
"nodeId": "",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v1]/items[at0144]/value/lower",
"inputs": [
{
"suffix": "magnitude",
"type": "DECIMAL",
"validation": {
"range": {
"minOp": ">=",
"min": 0.0
}
}
},
{
"suffix": "unit",
"type": "CODED_TEXT",
"list": [
{
"value": "1",
"label": "1",
"validation": {
"range": {
"minOp": ">=",
"min": 0.0
}
}
}
]
}
]
}
]
}
]
},
{
"id": "dose_unit",
"name": "Dose unit",
"localizedName": "Dose unit",
"rmType": "DV_TEXT",
"nodeId": "at0145",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Dose unit"
},
"localizedDescriptions": {
"en": "The unit which is associated with the Dose amount."
},
"annotations": {
"comment": "For example: 'tablet','mg'. Coding of the dose unit with a terminology is preferred, where possible."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v1]/items[at0145]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "dose_formula",
"name": "Dose formula",
"localizedName": "Dose formula",
"rmType": "ELEMENT",
"nodeId": "at0135",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Dose formula"
},
"localizedDescriptions": {
"en": "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."
},
"annotations": {
"comment": "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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v1]/items[at0135]",
"children": [
{
"id": "text_value",
"localizedName": "Dose formula",
"rmType": "DV_TEXT",
"nodeId": "",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Dose formula"
},
"localizedDescriptions": {
"en": "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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v1]/items[at0135]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "quantity_value",
"localizedName": "Dose formula",
"rmType": "DV_QUANTITY",
"nodeId": "",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Dose formula"
},
"localizedDescriptions": {
"en": "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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v1]/items[at0135]/value",
"inputs": [
{
"suffix": "magnitude",
"type": "DECIMAL"
},
{
"suffix": "unit",
"type": "TEXT"
}
]
}
]
},
{
"id": "dose_description",
"name": "Dose description",
"localizedName": "Dose description",
"rmType": "DV_TEXT",
"nodeId": "at0178",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Dose description"
},
"localizedDescriptions": {
"en": "Text description of the dose."
},
"annotations": {
"comment": "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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v1]/items[at0178]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "timing_-_daily",
"name": "Timing - daily",
"localizedName": "Timing - daily",
"rmType": "CLUSTER",
"nodeId": "openEHR-EHR-CLUSTER.timing_daily.v1",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Timing - daily"
},
"localizedDescriptions": {
"en": "Structured information about the intended timing of a therapeutic or diagnostic activity within any 24 hour period."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v1]/items[openEHR-EHR-CLUSTER.timing_daily.v1]",
"children": [
{
"id": "frequency",
"name": "Frequency",
"localizedName": "Frequency",
"rmType": "ELEMENT",
"nodeId": "at0003",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Frequency"
},
"localizedDescriptions": {
"en": "The frequency as number of times per time period that the activity is to take place."
},
"annotations": {
"comment": "For example: \"4 times per day\" or \"3 to 4 times per hour\"."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v1]/items[openEHR-EHR-CLUSTER.timing_daily.v1]/items[at0003]",
"children": [
{
"id": "quantity_value",
"localizedName": "Frequency",
"rmType": "DV_QUANTITY",
"nodeId": "",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Frequency"
},
"localizedDescriptions": {
"en": "The frequency as number of times per time period that the activity is to take place."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v1]/items[openEHR-EHR-CLUSTER.timing_daily.v1]/items[at0003]/value",
"inputs": [
{
"suffix": "magnitude",
"type": "DECIMAL"
},
{
"suffix": "unit",
"type": "CODED_TEXT",
"list": [
{
"value": "1/d",
"label": "1/d",
"validation": {
"range": {
"minOp": ">=",
"min": 1.0
},
"precision": {
"minOp": ">=",
"min": 0,
"maxOp": "<=",
"max": 0
}
}
},
{
"value": "1/min",
"label": "1/min",
"validation": {
"range": {
"minOp": ">=",
"min": 1.0
},
"precision": {
"minOp": ">=",
"min": 0,
"maxOp": "<=",
"max": 0
}
}
},
{
"value": "1/s",
"label": "1/s",
"validation": {
"range": {
"minOp": ">=",
"min": 1.0
},
"precision": {
"minOp": ">=",
"min": 0,
"maxOp": "<=",
"max": 0
}
}
},
{
"value": "1/h",
"label": "1/h",
"validation": {
"range": {
"minOp": ">=",
"min": 1.0
},
"precision": {
"minOp": ">=",
"min": 0,
"maxOp": "<=",
"max": 0
}
}
}
]
}
]
},
{
"id": "interval_of_quantity_value",
"localizedName": "Frequency",
"rmType": "DV_INTERVAL",
"nodeId": "",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Frequency"
},
"localizedDescriptions": {
"en": "The frequency as number of times per time period that the activity is to take place."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v1]/items[openEHR-EHR-CLUSTER.timing_daily.v1]/items[at0003]/value",
"children": [
{
"id": "upper",
"rmType": "DV_QUANTITY",
"nodeId": "",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v1]/items[openEHR-EHR-CLUSTER.timing_daily.v1]/items[at0003]/value/upper",
"inputs": [
{
"suffix": "magnitude",
"type": "DECIMAL"
},
{
"suffix": "unit",
"type": "CODED_TEXT",
"list": [
{
"value": "1/d",
"label": "1/d",
"validation": {
"range": {
"minOp": ">=",
"min": 1.0
},
"precision": {
"minOp": ">=",
"min": 0,
"maxOp": "<=",
"max": 0
}
}
},
{
"value": "1/min",
"label": "1/min",
"validation": {
"range": {
"minOp": ">=",
"min": 1.0
},
"precision": {
"minOp": ">=",
"min": 0,
"maxOp": "<=",
"max": 0
}
}
},
{
"value": "1/s",
"label": "1/s",
"validation": {
"range": {
"minOp": ">=",
"min": 1.0
},
"precision": {
"minOp": ">=",
"min": 0,
"maxOp": "<=",
"max": 0
}
}
},
{
"value": "1/h",
"label": "1/h",
"validation": {
"range": {
"minOp": ">=",
"min": 1.0
},
"precision": {
"minOp": ">=",
"min": 0,
"maxOp": "<=",
"max": 0
}
}
}
]
}
]
},
{
"id": "lower",
"rmType": "DV_QUANTITY",
"nodeId": "",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v1]/items[openEHR-EHR-CLUSTER.timing_daily.v1]/items[at0003]/value/lower",
"inputs": [
{
"suffix": "magnitude",
"type": "DECIMAL"
},
{
"suffix": "unit",
"type": "CODED_TEXT",
"list": [
{
"value": "1/d",
"label": "1/d",
"validation": {
"range": {
"minOp": ">=",
"min": 1.0
},
"precision": {
"minOp": ">=",
"min": 0,
"maxOp": "<=",
"max": 0
}
}
},
{
"value": "1/min",
"label": "1/min",
"validation": {
"range": {
"minOp": ">=",
"min": 1.0
},
"precision": {
"minOp": ">=",
"min": 0,
"maxOp": "<=",
"max": 0
}
}
},
{
"value": "1/s",
"label": "1/s",
"validation": {
"range": {
"minOp": ">=",
"min": 1.0
},
"precision": {
"minOp": ">=",
"min": 0,
"maxOp": "<=",
"max": 0
}
}
},
{
"value": "1/h",
"label": "1/h",
"validation": {
"range": {
"minOp": ">=",
"min": 1.0
},
"precision": {
"minOp": ">=",
"min": 0,
"maxOp": "<=",
"max": 0
}
}
}
]
}
]
}
]
}
]
},
{
"id": "interval",
"name": "Interval",
"localizedName": "Interval",
"rmType": "DV_DURATION",
"nodeId": "at0014",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Interval"
},
"localizedDescriptions": {
"en": "The time interval or minimum and maximum range of an interval between each scheduled activity."
},
"annotations": {
"comment": "For example: \"Every 4 hours\" or \"Every 4 to 6 hours\"."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v1]/items[openEHR-EHR-CLUSTER.timing_daily.v1]/items[at0014]/value",
"inputs": [
{
"suffix": "hour",
"type": "INTEGER",
"validation": {
"range": {
"minOp": ">=",
"min": 0,
"maxOp": "<=",
"max": 24
}
}
},
{
"suffix": "minute",
"type": "INTEGER",
"validation": {
"range": {
"minOp": ">=",
"min": 0
}
}
},
{
"suffix": "second",
"type": "INTEGER",
"validation": {
"range": {
"minOp": ">=",
"min": 0
}
}
}
]
},
{
"id": "specific_time",
"name": "Specific time",
"localizedName": "Specific time",
"rmType": "ELEMENT",
"nodeId": "at0004",
"min": 0,
"max": -1,
"localizedNames": {
"en": "Specific time"
},
"localizedDescriptions": {
"en": "A specific time or interval of time when the activity should occur."
},
"annotations": {
"comment": "For example: \"08:00\" or \"15:00-16:00\"."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v1]/items[openEHR-EHR-CLUSTER.timing_daily.v1]/items[at0004]",
"children": [
{
"id": "time_value",
"localizedName": "Specific time",
"rmType": "DV_TIME",
"nodeId": "",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Specific time"
},
"localizedDescriptions": {
"en": "A specific time or interval of time when the activity should occur."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v1]/items[openEHR-EHR-CLUSTER.timing_daily.v1]/items[at0004]/value",
"inputs": [
{
"type": "TIME"
}
]
},
{
"id": "interval_of_time_value",
"localizedName": "Specific time",
"rmType": "DV_INTERVAL",
"nodeId": "",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Specific time"
},
"localizedDescriptions": {
"en": "A specific time or interval of time when the activity should occur."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v1]/items[openEHR-EHR-CLUSTER.timing_daily.v1]/items[at0004]/value",
"children": [
{
"id": "upper",
"rmType": "DV_TIME",
"nodeId": "",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v1]/items[openEHR-EHR-CLUSTER.timing_daily.v1]/items[at0004]/value/upper",
"inputs": [
{
"type": "TIME"
}
]
},
{
"id": "lower",
"rmType": "DV_TIME",
"nodeId": "",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v1]/items[openEHR-EHR-CLUSTER.timing_daily.v1]/items[at0004]/value/lower",
"inputs": [
{
"type": "TIME"
}
]
}
]
}
]
},
{
"id": "timing_description",
"name": "Timing description",
"localizedName": "Timing description",
"rmType": "DV_TEXT",
"nodeId": "at0027",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Timing description"
},
"localizedDescriptions": {
"en": "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."
},
"annotations": {
"comment": "For example: \"Take morning and evening\"."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v1]/items[openEHR-EHR-CLUSTER.timing_daily.v1]/items[at0027]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "exact_timing_critical",
"name": "Exact timing critical?",
"localizedName": "Exact timing critical?",
"rmType": "DV_BOOLEAN",
"nodeId": "at0023",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Exact timing critical?"
},
"localizedDescriptions": {
"en": "Is exact timing of the activity critical to effectiveness, or patient safety or wellbeing?"
},
"annotations": {
"comment": "For example when administering antiparkinson medications."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v1]/items[openEHR-EHR-CLUSTER.timing_daily.v1]/items[at0023]/value",
"inputs": [
{
"type": "BOOLEAN"
}
]
},
{
"id": "as_required",
"name": "As required",
"localizedName": "As required",
"rmType": "DV_BOOLEAN",
"nodeId": "at0024",
"min": 0,
"max": 1,
"localizedNames": {
"en": "As required"
},
"localizedDescriptions": {
"en": "Record as True if the activity should only occur when the \"'As required' criterion\" is met."
},
"annotations": {
"comment": "Termed 'PRN' (\"pro re nata\", latin: \"as the situation arises\") or 'PN' (\"per necessare\", latin: \"when required\") in some cultures."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v1]/items[openEHR-EHR-CLUSTER.timing_daily.v1]/items[at0024]/value",
"inputs": [
{
"type": "BOOLEAN",
"list": [
{
"value": "true",
"label": "true"
}
]
}
]
},
{
"id": "as_required_criterion",
"name": "'As required' criterion",
"localizedName": "'As required' criterion",
"rmType": "DV_TEXT",
"nodeId": "at0025",
"min": 0,
"max": 1,
"localizedNames": {
"en": "'As required' criterion"
},
"localizedDescriptions": {
"en": "The condition which triggers an 'As required' activity."
},
"annotations": {
"comment": "For example: \"for pain\"."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v1]/items[openEHR-EHR-CLUSTER.timing_daily.v1]/items[at0025]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "specific_event",
"name": "Specific event",
"localizedName": "Specific event",
"rmType": "CLUSTER",
"nodeId": "at0039",
"min": 0,
"max": -1,
"localizedNames": {
"en": "Specific event"
},
"localizedDescriptions": {
"en": "A specific, named time event that the activity should occur in relation to."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v1]/items[openEHR-EHR-CLUSTER.timing_daily.v1]/items[at0039]",
"children": [
{
"id": "event_name",
"name": "Event name",
"localizedName": "Event name",
"rmType": "DV_TEXT",
"nodeId": "at0026",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Event name"
},
"localizedDescriptions": {
"en": "The name of the event that triggers the activity to take place."
},
"annotations": {
"comment": "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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v1]/items[openEHR-EHR-CLUSTER.timing_daily.v1]/items[at0039]/items[at0026]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "time_offset",
"name": "Time offset",
"localizedName": "Time offset",
"rmType": "DV_DURATION",
"nodeId": "at0040",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Time offset"
},
"localizedDescriptions": {
"en": "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."
},
"annotations": {
"comment": "For example: '30 minutes after meal = meal + 30 minutes', '2 hours before bedtime = bedtime -2 hours'."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v1]/items[openEHR-EHR-CLUSTER.timing_daily.v1]/items[at0039]/items[at0040]/value",
"inputs": [
{
"suffix": "hour",
"type": "INTEGER",
"validation": {
"range": {
"minOp": ">=",
"min": 0,
"maxOp": "<=",
"max": 24
}
}
},
{
"suffix": "minute",
"type": "INTEGER",
"validation": {
"range": {
"minOp": ">=",
"min": 0
}
}
},
{
"suffix": "second",
"type": "INTEGER",
"validation": {
"range": {
"minOp": ">=",
"min": 0
}
}
}
]
}
]
},
{
"id": "on_off_cycle",
"name": "On / off cycle",
"localizedName": "On / off cycle",
"rmType": "CLUSTER",
"nodeId": "at0035",
"min": 0,
"max": -1,
"localizedNames": {
"en": "On / off cycle"
},
"localizedDescriptions": {
"en": "A cycle of activity where an on-off pattern is required."
},
"annotations": {
"comment": "For example: \"Apply an ice pack on for 20 minutes, off for an hour, repeat\"."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v1]/items[openEHR-EHR-CLUSTER.timing_daily.v1]/items[at0035]",
"children": [
{
"id": "on",
"name": "On",
"localizedName": "On",
"rmType": "DV_DURATION",
"nodeId": "at0036",
"min": 0,
"max": 1,
"localizedNames": {
"en": "On"
},
"localizedDescriptions": {
"en": "The period of time for which the activity should take place."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v1]/items[openEHR-EHR-CLUSTER.timing_daily.v1]/items[at0035]/items[at0036]/value",
"inputs": [
{
"suffix": "hour",
"type": "INTEGER",
"validation": {
"range": {
"minOp": ">=",
"min": 0,
"maxOp": "<=",
"max": 24
}
}
},
{
"suffix": "minute",
"type": "INTEGER",
"validation": {
"range": {
"minOp": ">=",
"min": 0
}
}
},
{
"suffix": "second",
"type": "INTEGER",
"validation": {
"range": {
"minOp": ">=",
"min": 0
}
}
}
]
},
{
"id": "off",
"name": "Off",
"localizedName": "Off",
"rmType": "DV_DURATION",
"nodeId": "at0037",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Off"
},
"localizedDescriptions": {
"en": "The period of time for which the activity should NOT take place."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v1]/items[openEHR-EHR-CLUSTER.timing_daily.v1]/items[at0035]/items[at0037]/value",
"inputs": [
{
"suffix": "hour",
"type": "INTEGER",
"validation": {
"range": {
"minOp": ">=",
"min": 0,
"maxOp": "<=",
"max": 24
}
}
},
{
"suffix": "minute",
"type": "INTEGER",
"validation": {
"range": {
"minOp": ">=",
"min": 0
}
}
},
{
"suffix": "second",
"type": "INTEGER",
"validation": {
"range": {
"minOp": ">=",
"min": 0
}
}
}
]
},
{
"id": "repetitions",
"name": "Repetitions",
"localizedName": "Repetitions",
"rmType": "DV_COUNT",
"nodeId": "at0038",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Repetitions"
},
"localizedDescriptions": {
"en": "The number of repetitions of the on/off cycle."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v1]/items[openEHR-EHR-CLUSTER.timing_daily.v1]/items[at0035]/items[at0038]/value",
"inputs": [
{
"type": "INTEGER",
"validation": {
"range": {
"minOp": ">=",
"min": 0
}
}
}
]
}
]
}
]
}
]
},
{
"id": "administration_details",
"name": "Administration details",
"localizedName": "Administration details",
"rmType": "CLUSTER",
"nodeId": "at0140",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Administration details"
},
"localizedDescriptions": {
"en": "Details of body site and administration of the medication."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[at0140]",
"children": [
{
"id": "route",
"name": "Route",
"localizedName": "Route",
"rmType": "DV_TEXT",
"nodeId": "at0147",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Route"
},
"localizedDescriptions": {
"en": "The route by which the ordered item was, or is to be, administered into the subject's body."
},
"annotations": {
"comment": "Comment: For example: 'oral', 'intravenous', or 'topical'. Coding of the route with a terminology is preferred, where possible. Multiple potential routes may be specified."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[at0140]/items[at0147]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "body_site",
"name": "Body site",
"localizedName": "Body site",
"rmType": "DV_TEXT",
"nodeId": "at0141",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Body site"
},
"localizedDescriptions": {
"en": "Structured description of the site of administration of the ordered item."
},
"annotations": {
"comment": "For example: 'left upper arm', 'intravenous catheter right hand'. \nCoding of the body site with a terminology is preferred, where possible."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[at0140]/items[at0141]/value",
"inputs": [
{
"type": "TEXT"
}
]
}
]
},
{
"id": "timing_-_non-daily",
"name": "Timing - non-daily",
"localizedName": "Timing - non-daily",
"rmType": "CLUSTER",
"nodeId": "openEHR-EHR-CLUSTER.timing_nondaily.v1",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Timing - non-daily"
},
"localizedDescriptions": {
"en": "Structured information about the intended timing pattern for a therapeutic or diagnostic activity occurring over days, weeks, months or years."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.timing_nondaily.v1]",
"children": [
{
"id": "repetition_interval",
"name": "Repetition interval",
"localizedName": "Repetition interval",
"rmType": "DV_DURATION",
"nodeId": "at0002",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Repetition interval"
},
"localizedDescriptions": {
"en": "The interval between repetitions of the activity."
},
"annotations": {
"comment": "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\"."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.timing_nondaily.v1]/items[at0002]/value",
"inputs": [
{
"suffix": "year",
"type": "INTEGER",
"validation": {
"range": {
"minOp": ">=",
"min": 0
}
}
},
{
"suffix": "month",
"type": "INTEGER",
"validation": {
"range": {
"minOp": ">=",
"min": 0
}
}
},
{
"suffix": "week",
"type": "INTEGER",
"validation": {
"range": {
"minOp": ">=",
"min": 0
}
}
},
{
"suffix": "day",
"type": "INTEGER",
"validation": {
"range": {
"minOp": ">=",
"min": 0
}
}
}
]
},
{
"id": "frequency",
"name": "Frequency",
"localizedName": "Frequency",
"rmType": "ELEMENT",
"nodeId": "at0014",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Frequency"
},
"localizedDescriptions": {
"en": "The number of days per time period on which the activity is to take place."
},
"annotations": {
"comment": "For example: '3 times per week', '2-4 times per month'."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.timing_nondaily.v1]/items[at0014]",
"children": [
{
"id": "quantity_value",
"localizedName": "Frequency",
"rmType": "DV_QUANTITY",
"nodeId": "",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Frequency"
},
"localizedDescriptions": {
"en": "The number of days per time period on which the activity is to take place."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.timing_nondaily.v1]/items[at0014]/value",
"inputs": [
{
"suffix": "magnitude",
"type": "DECIMAL"
},
{
"suffix": "unit",
"type": "CODED_TEXT",
"list": [
{
"value": "1/wk",
"label": "1/wk",
"validation": {
"range": {
"minOp": ">=",
"min": 1.0,
"maxOp": "<=",
"max": 7.0
},
"precision": {
"minOp": ">=",
"min": 0,
"maxOp": "<=",
"max": 0
}
}
},
{
"value": "1/mo",
"label": "1/mo",
"validation": {
"range": {
"minOp": ">=",
"min": 1.0,
"maxOp": "<=",
"max": 31.0
},
"precision": {
"minOp": ">=",
"min": 0,
"maxOp": "<=",
"max": 0
}
}
},
{
"value": "1/a",
"label": "1/a",
"validation": {
"range": {
"minOp": ">=",
"min": 1.0,
"maxOp": "<=",
"max": 366.0
},
"precision": {
"minOp": ">=",
"min": 0,
"maxOp": "<=",
"max": 0
}
}
}
]
}
]
},
{
"id": "interval_of_quantity_value",
"localizedName": "Frequency",
"rmType": "DV_INTERVAL",
"nodeId": "",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Frequency"
},
"localizedDescriptions": {
"en": "The number of days per time period on which the activity is to take place."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.timing_nondaily.v1]/items[at0014]/value",
"children": [
{
"id": "upper",
"rmType": "DV_QUANTITY",
"nodeId": "",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.timing_nondaily.v1]/items[at0014]/value/upper",
"inputs": [
{
"suffix": "magnitude",
"type": "DECIMAL"
},
{
"suffix": "unit",
"type": "CODED_TEXT",
"list": [
{
"value": "1/wk",
"label": "1/wk",
"validation": {
"range": {
"minOp": ">=",
"min": 1.0,
"maxOp": "<=",
"max": 7.0
},
"precision": {
"minOp": ">=",
"min": 0,
"maxOp": "<=",
"max": 0
}
}
},
{
"value": "1/mo",
"label": "1/mo",
"validation": {
"range": {
"minOp": ">=",
"min": 1.0,
"maxOp": "<=",
"max": 31.0
},
"precision": {
"minOp": ">=",
"min": 0,
"maxOp": "<=",
"max": 0
}
}
},
{
"value": "1/a",
"label": "1/a",
"validation": {
"range": {
"minOp": ">=",
"min": 1.0,
"maxOp": "<=",
"max": 366.0
},
"precision": {
"minOp": ">=",
"min": 0,
"maxOp": "<=",
"max": 0
}
}
}
]
}
]
},
{
"id": "lower",
"rmType": "DV_QUANTITY",
"nodeId": "",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.timing_nondaily.v1]/items[at0014]/value/lower",
"inputs": [
{
"suffix": "magnitude",
"type": "DECIMAL"
},
{
"suffix": "unit",
"type": "CODED_TEXT",
"list": [
{
"value": "1/wk",
"label": "1/wk",
"validation": {
"range": {
"minOp": ">=",
"min": 1.0,
"maxOp": "<=",
"max": 7.0
},
"precision": {
"minOp": ">=",
"min": 0,
"maxOp": "<=",
"max": 0
}
}
},
{
"value": "1/mo",
"label": "1/mo",
"validation": {
"range": {
"minOp": ">=",
"min": 1.0,
"maxOp": "<=",
"max": 31.0
},
"precision": {
"minOp": ">=",
"min": 0,
"maxOp": "<=",
"max": 0
}
}
},
{
"value": "1/a",
"label": "1/a",
"validation": {
"range": {
"minOp": ">=",
"min": 1.0,
"maxOp": "<=",
"max": 366.0
},
"precision": {
"minOp": ">=",
"min": 0,
"maxOp": "<=",
"max": 0
}
}
}
]
}
]
}
]
}
]
},
{
"id": "specific_date",
"name": "Specific date",
"localizedName": "Specific date",
"rmType": "ELEMENT",
"nodeId": "at0001",
"min": 0,
"max": -1,
"localizedNames": {
"en": "Specific date"
},
"localizedDescriptions": {
"en": "The activity should take place on a specific date or a specific range of dates."
},
"annotations": {
"comment": "For example: 'on 12 Jan 2017' or 'on 30 Oct 2017 to 6 Nov 2017'."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.timing_nondaily.v1]/items[at0001]",
"children": [
{
"id": "date_value",
"localizedName": "Specific date",
"rmType": "DV_DATE",
"nodeId": "",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Specific date"
},
"localizedDescriptions": {
"en": "The activity should take place on a specific date or a specific range of dates."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.timing_nondaily.v1]/items[at0001]/value",
"inputs": [
{
"type": "DATE"
}
]
},
{
"id": "interval_of_date_value",
"localizedName": "Specific date",
"rmType": "DV_INTERVAL",
"nodeId": "",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Specific date"
},
"localizedDescriptions": {
"en": "The activity should take place on a specific date or a specific range of dates."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.timing_nondaily.v1]/items[at0001]/value",
"children": [
{
"id": "upper",
"rmType": "DV_DATE",
"nodeId": "",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.timing_nondaily.v1]/items[at0001]/value/upper",
"inputs": [
{
"type": "DATE"
}
]
},
{
"id": "lower",
"rmType": "DV_DATE",
"nodeId": "",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.timing_nondaily.v1]/items[at0001]/value/lower",
"inputs": [
{
"type": "DATE"
}
]
}
]
}
]
},
{
"id": "specific_day_of_week",
"name": "Specific day of week",
"localizedName": "Specific day of week",
"rmType": "DV_CODED_TEXT",
"nodeId": "at0003",
"min": 0,
"max": 7,
"localizedNames": {
"en": "Specific day of week"
},
"localizedDescriptions": {
"en": "The activity should take place on a specific day of the week."
},
"annotations": {
"comment": "For example: 'On Monday, Wednesday and Friday'."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.timing_nondaily.v1]/items[at0003]/value",
"inputs": [
{
"suffix": "code",
"type": "CODED_TEXT",
"list": [
{
"value": "at0007",
"label": "Monday",
"localizedLabels": {
"en": "Monday"
},
"localizedDescriptions": {
"en": "The activity should take place on Monday."
}
},
{
"value": "at0008",
"label": "Tuesday",
"localizedLabels": {
"en": "Tuesday"
},
"localizedDescriptions": {
"en": "The activity should take place on Tuesday."
}
},
{
"value": "at0016",
"label": "Wednesday",
"localizedLabels": {
"en": "Wednesday"
},
"localizedDescriptions": {
"en": "The activity should take place on Wednesday."
}
},
{
"value": "at0017",
"label": "Thursday",
"localizedLabels": {
"en": "Thursday"
},
"localizedDescriptions": {
"en": "The activity should take place on Thursday."
}
},
{
"value": "at0018",
"label": "Friday",
"localizedLabels": {
"en": "Friday"
},
"localizedDescriptions": {
"en": "The activity should take place on Friday."
}
},
{
"value": "at0019",
"label": "Saturday",
"localizedLabels": {
"en": "Saturday"
},
"localizedDescriptions": {
"en": "The activity should take place on Saturday."
}
},
{
"value": "at0020",
"label": "Sunday",
"localizedLabels": {
"en": "Sunday"
},
"localizedDescriptions": {
"en": "The activity should take place on Sunday."
}
}
]
}
]
},
{
"id": "specific_day_of_month",
"name": "Specific day of month",
"localizedName": "Specific day of month",
"rmType": "ELEMENT",
"nodeId": "at0004",
"min": 0,
"max": 31,
"localizedNames": {
"en": "Specific day of month"
},
"localizedDescriptions": {
"en": "The activity should take place on a specific day or interval of days of the month."
},
"annotations": {
"comment": "For example: 'on the 3rd, 13th and 23rd of each month' or 'on the 1st to the 10th of each month'."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.timing_nondaily.v1]/items[at0004]",
"children": [
{
"id": "count_value",
"localizedName": "Specific day of month",
"rmType": "DV_COUNT",
"nodeId": "",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Specific day of month"
},
"localizedDescriptions": {
"en": "The activity should take place on a specific day or interval of days of the month."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.timing_nondaily.v1]/items[at0004]/value",
"inputs": [
{
"type": "INTEGER",
"validation": {
"range": {
"minOp": ">=",
"min": 1,
"maxOp": "<=",
"max": 31
}
}
}
]
},
{
"id": "interval_of_count_value",
"localizedName": "Specific day of month",
"rmType": "DV_INTERVAL",
"nodeId": "",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Specific day of month"
},
"localizedDescriptions": {
"en": "The activity should take place on a specific day or interval of days of the month."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.timing_nondaily.v1]/items[at0004]/value",
"children": [
{
"id": "upper",
"rmType": "DV_COUNT",
"nodeId": "",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.timing_nondaily.v1]/items[at0004]/value/upper",
"inputs": [
{
"type": "INTEGER",
"validation": {
"range": {
"minOp": ">=",
"min": 1,
"maxOp": "<=",
"max": 31
}
}
}
]
},
{
"id": "lower",
"rmType": "DV_COUNT",
"nodeId": "",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.timing_nondaily.v1]/items[at0004]/value/lower",
"inputs": [
{
"type": "INTEGER",
"validation": {
"range": {
"minOp": ">=",
"min": 1,
"maxOp": "<=",
"max": 31
}
}
}
]
}
]
}
]
},
{
"id": "timing_description",
"name": "Timing description",
"localizedName": "Timing description",
"rmType": "DV_TEXT",
"nodeId": "at0021",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Timing description"
},
"localizedDescriptions": {
"en": "Text description of the timing."
},
"annotations": {
"comment": "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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.timing_nondaily.v1]/items[at0021]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "specific_event",
"name": "Specific event",
"localizedName": "Specific event",
"rmType": "CLUSTER",
"nodeId": "at0006",
"min": 0,
"max": -1,
"localizedNames": {
"en": "Specific event"
},
"localizedDescriptions": {
"en": "The activity should take place in relation to a specific named event."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.timing_nondaily.v1]/items[at0006]",
"children": [
{
"id": "event_name",
"name": "Event name",
"localizedName": "Event name",
"rmType": "DV_TEXT",
"nodeId": "at0005",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Event name"
},
"localizedDescriptions": {
"en": "The name of the event that triggers the activity to take place."
},
"annotations": {
"comment": "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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.timing_nondaily.v1]/items[at0006]/items[at0005]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "time_offset",
"name": "Time offset",
"localizedName": "Time offset",
"rmType": "DV_DURATION",
"nodeId": "at0009",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Time offset"
},
"localizedDescriptions": {
"en": "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."
},
"annotations": {
"comment": "For example: '3 days after onset of menstruation = menstrual onset + 3 days', '2 weeks prior to admission= admission -2 weeks'."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.timing_nondaily.v1]/items[at0006]/items[at0009]/value",
"inputs": [
{
"suffix": "year",
"type": "INTEGER",
"validation": {
"range": {
"minOp": ">=",
"min": 0
}
}
},
{
"suffix": "month",
"type": "INTEGER",
"validation": {
"range": {
"minOp": ">=",
"min": 0
}
}
},
{
"suffix": "week",
"type": "INTEGER",
"validation": {
"range": {
"minOp": ">=",
"min": 0
}
}
},
{
"suffix": "day",
"type": "INTEGER",
"validation": {
"range": {
"minOp": ">=",
"min": 0
}
}
}
]
}
]
},
{
"id": "on_off_cycle",
"name": "On / off cycle",
"localizedName": "On / off cycle",
"rmType": "CLUSTER",
"nodeId": "at0010",
"min": 0,
"max": 1,
"localizedNames": {
"en": "On / off cycle"
},
"localizedDescriptions": {
"en": "A cycle of activity where an on-off pattern is required."
},
"annotations": {
"comment": "For example: 'take for 1 week, omit 2 weeks, repeat 4 times'"
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.timing_nondaily.v1]/items[at0010]",
"children": [
{
"id": "on",
"name": "On",
"localizedName": "On",
"rmType": "DV_DURATION",
"nodeId": "at0011",
"min": 0,
"max": 1,
"localizedNames": {
"en": "On"
},
"localizedDescriptions": {
"en": "The period of time for which the activity should take place."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.timing_nondaily.v1]/items[at0010]/items[at0011]/value",
"inputs": [
{
"suffix": "year",
"type": "INTEGER",
"validation": {
"range": {
"minOp": ">=",
"min": 0
}
}
},
{
"suffix": "month",
"type": "INTEGER",
"validation": {
"range": {
"minOp": ">=",
"min": 0
}
}
},
{
"suffix": "week",
"type": "INTEGER",
"validation": {
"range": {
"minOp": ">=",
"min": 0
}
}
},
{
"suffix": "day",
"type": "INTEGER",
"validation": {
"range": {
"minOp": ">=",
"min": 0
}
}
}
]
},
{
"id": "off",
"name": "Off",
"localizedName": "Off",
"rmType": "DV_DURATION",
"nodeId": "at0012",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Off"
},
"localizedDescriptions": {
"en": "The period of time for which the activity should NOT take place."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.timing_nondaily.v1]/items[at0010]/items[at0012]/value",
"inputs": [
{
"suffix": "year",
"type": "INTEGER",
"validation": {
"range": {
"minOp": ">=",
"min": 0
}
}
},
{
"suffix": "month",
"type": "INTEGER",
"validation": {
"range": {
"minOp": ">=",
"min": 0
}
}
},
{
"suffix": "week",
"type": "INTEGER",
"validation": {
"range": {
"minOp": ">=",
"min": 0
}
}
},
{
"suffix": "day",
"type": "INTEGER",
"validation": {
"range": {
"minOp": ">=",
"min": 0
}
}
}
]
},
{
"id": "repetitions",
"name": "Repetitions",
"localizedName": "Repetitions",
"rmType": "DV_COUNT",
"nodeId": "at0013",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Repetitions"
},
"localizedDescriptions": {
"en": "The number of repetitions of the on/off cycle."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/description[at0017]/items[openEHR-EHR-CLUSTER.timing_nondaily.v1]/items[at0010]/items[at0013]/value",
"inputs": [
{
"type": "INTEGER",
"validation": {
"range": {
"minOp": ">=",
"min": 0
}
}
}
]
}
]
}
]
},
{
"id": "order_id",
"name": "Order ID",
"localizedName": "Order ID",
"rmType": "DV_IDENTIFIER",
"nodeId": "at0103",
"min": 0,
"max": -1,
"localizedNames": {
"en": "Order ID"
},
"localizedDescriptions": {
"en": "Unique identifier for the medication order."
},
"annotations": {
"comment": "Comment: This data element allows for multiple occurrences to be defined more explicitly at run-time, if required."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/protocol[at0030]/items[at0103]/value",
"inputs": [
{
"suffix": "id",
"type": "TEXT"
},
{
"suffix": "type",
"type": "TEXT"
},
{
"suffix": "issuer",
"type": "TEXT"
},
{
"suffix": "assigner",
"type": "TEXT"
}
]
},
{
"id": "time",
"name": "Time",
"rmType": "DV_DATE_TIME",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/time",
"inputs": [
{
"type": "DATETIME"
}
],
"inContext": true
},
{
"id": "language",
"name": "Language",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/language",
"inContext": true
},
{
"id": "encoding",
"name": "Encoding",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/encoding",
"inContext": true
},
{
"id": "subject",
"name": "Subject",
"rmType": "PARTY_PROXY",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-ACTION.medication.v1,'Medication statement']/subject",
"inputs": [
{
"suffix": "id",
"type": "TEXT"
},
{
"suffix": "id_scheme",
"type": "TEXT"
},
{
"suffix": "id_namespace",
"type": "TEXT"
},
{
"suffix": "name",
"type": "TEXT"
}
],
"inContext": true
}
]
},
{
"id": "exclusion_-_global",
"name": "Exclusion - global",
"localizedName": "Exclusion - global",
"rmType": "EVALUATION",
"nodeId": "openEHR-EHR-EVALUATION.exclusion_global.v1",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Exclusion - global"
},
"localizedDescriptions": {
"en": "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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-EVALUATION.exclusion_global.v1]",
"children": [
{
"id": "global_exclusion_of_medication_use",
"name": "Global exclusion of medication use",
"localizedName": "Global exclusion of medication use",
"rmType": "DV_TEXT",
"nodeId": "at0002",
"min": 1,
"max": 1,
"localizedNames": {
"en": "Global exclusion of medication use"
},
"localizedDescriptions": {
"en": "Overall statement of exclusion about the use of all medications at the time of recording."
},
"annotations": {
"comment": "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'.",
"FHIR": "AllergyIntolerance.code:absentOrUnknownAllergyIntolerance"
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-EVALUATION.exclusion_global.v1]/data[at0001]/items[at0002,'Global exclusion of medication use']/value",
"inputs": [
{
"type": "TEXT",
"list": [
{
"value": "No known medications",
"label": "No known medications"
}
],
"listOpen": false
}
]
},
{
"id": "language",
"name": "Language",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-EVALUATION.exclusion_global.v1]/language",
"inContext": true
},
{
"id": "encoding",
"name": "Encoding",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-EVALUATION.exclusion_global.v1]/encoding",
"inContext": true
},
{
"id": "subject",
"name": "Subject",
"rmType": "PARTY_PROXY",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-EVALUATION.exclusion_global.v1]/subject",
"inputs": [
{
"suffix": "id",
"type": "TEXT"
},
{
"suffix": "id_scheme",
"type": "TEXT"
},
{
"suffix": "id_namespace",
"type": "TEXT"
},
{
"suffix": "name",
"type": "TEXT"
}
],
"inContext": true
}
]
},
{
"id": "absence_of_information",
"name": "Absence of information",
"localizedName": "Absence of information",
"rmType": "EVALUATION",
"nodeId": "openEHR-EHR-EVALUATION.absence.v2",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Absence of information"
},
"localizedDescriptions": {
"en": "Statement that specified health information is not available for inclusion in the health record or extract at the time of recording."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-EVALUATION.absence.v2]",
"children": [
{
"id": "absence_statement",
"name": "Absence statement",
"localizedName": "Absence statement",
"rmType": "DV_TEXT",
"nodeId": "at0002",
"min": 1,
"max": 1,
"localizedNames": {
"en": "Absence statement"
},
"localizedDescriptions": {
"en": "Positive statement that no information is available."
},
"annotations": {
"comment": "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\".",
"FHIR": "AllergyIntolerance.code:absentOrUnknownAllergyIntolerance"
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-EVALUATION.absence.v2]/data[at0001]/items[at0002]/value",
"inputs": [
{
"type": "TEXT",
"list": [
{
"value": "No information about medications",
"label": "No information about medications"
}
],
"listOpen": false
}
]
},
{
"id": "last_updated",
"name": "Last updated",
"localizedName": "Last updated",
"rmType": "DV_DATE_TIME",
"nodeId": "at0004",
"min": 0,
"max": 1,
"dependsOn": [
"absence_statement"
],
"localizedNames": {
"en": "Last updated"
},
"localizedDescriptions": {
"en": "The date at which the absence was last updated."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-EVALUATION.absence.v2]/protocol[at0003]/items[at0004]/value",
"inputs": [
{
"type": "DATETIME"
}
]
},
{
"id": "language",
"name": "Language",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-EVALUATION.absence.v2]/language",
"inContext": true
},
{
"id": "encoding",
"name": "Encoding",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-EVALUATION.absence.v2]/encoding",
"inContext": true
},
{
"id": "subject",
"name": "Subject",
"rmType": "PARTY_PROXY",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medication Summary']/items[openEHR-EHR-EVALUATION.absence.v2]/subject",
"inputs": [
{
"suffix": "id",
"type": "TEXT"
},
{
"suffix": "id_scheme",
"type": "TEXT"
},
{
"suffix": "id_namespace",
"type": "TEXT"
},
{
"suffix": "name",
"type": "TEXT"
}
],
"inContext": true
}
]
}
]
},
{
"id": "allergies_intolerances",
"name": "Allergies & Intolerances",
"localizedName": "Allergies & Intolerances",
"rmType": "SECTION",
"nodeId": "openEHR-EHR-SECTION.adhoc.v1",
"min": 1,
"max": 1,
"localizedNames": {
"en": "Allergies & Intolerances"
},
"localizedDescriptions": {
"en": "A generic section header which should be renamed in a template to suit a specific clinical context."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Allergies & Intolerances']",
"children": [
{
"id": "allergy_intolerance",
"name": "Allergy Intolerance",
"localizedName": "Allergy Intolerance",
"rmType": "EVALUATION",
"nodeId": "openEHR-EHR-EVALUATION.adverse_reaction_risk.v1",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Allergy Intolerance"
},
"localizedDescriptions": {
"en": "Risk of harmful or undesirable physiological response which is unique to an individual and associated with exposure to a substance."
},
"annotations": {
"comment": "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.",
"source": "openEHR,FHIR;openEHR,FHIR",
"FHIR": "AllergyIntolerance"
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Allergies & Intolerances']/items[openEHR-EHR-EVALUATION.adverse_reaction_risk.v1,'Allergy Intolerance']",
"children": [
{
"id": "substance",
"name": "Substance",
"localizedName": "Substance",
"rmType": "DV_TEXT",
"nodeId": "at0002",
"min": 1,
"max": 1,
"localizedNames": {
"en": "Substance"
},
"localizedDescriptions": {
"en": "Identification of a substance, or substance class, that is considered to put the individual at risk of an adverse reaction event."
},
"annotations": {
"comment": "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.",
"source": "openEHR,FHIR,DAM;openEHR,FHIR,DAM",
"FHIR": "AllergyIntolerance.code:allergyIntoleranceGPSCode"
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Allergies & Intolerances']/items[openEHR-EHR-EVALUATION.adverse_reaction_risk.v1,'Allergy Intolerance']/data[at0001]/items[at0002]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "verification_status",
"name": "Verification status",
"localizedName": "Verification status",
"rmType": "DV_CODED_TEXT",
"nodeId": "at0063",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Verification status"
},
"localizedDescriptions": {
"en": "Assertion about the certainty of the propensity, or potential future risk, of the identified 'Substance' to cause a reaction."
},
"annotations": {
"comment": "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 \n\n\n'Refuted' status in the Adverse Reaction List. \n\nHowever, 'Refuted' may be useful for reconciliation of the adverse reaction list or when communicating between systems\n\n. Some implementations may choose to make this field mandatory.\n '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.",
"source": "FHIR, DAM;FHIR, DAM",
"FHIR": "AllergyIntolerance.clinicalStatus"
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Allergies & Intolerances']/items[openEHR-EHR-EVALUATION.adverse_reaction_risk.v1,'Allergy Intolerance']/data[at0001]/items[at0063,'Verification status']/value",
"inputs": [
{
"suffix": "code",
"type": "CODED_TEXT",
"list": [
{
"value": "at0127",
"label": "Suspected",
"localizedLabels": {
"en": "Suspected"
},
"localizedDescriptions": {
"en": "A low level of clinical certainty about the propensity of a reaction to the identified 'Substance'."
}
},
{
"value": "at0064",
"label": "Likely",
"localizedLabels": {
"en": "Likely"
},
"localizedDescriptions": {
"en": "A reasonable level of certainty about the propensity for a reaction to the identified 'Substance'."
}
},
{
"value": "at0065",
"label": "Confirmed",
"localizedLabels": {
"en": "Confirmed"
},
"localizedDescriptions": {
"en": "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."
}
},
{
"value": "at0067",
"label": "Resolved",
"localizedLabels": {
"en": "Resolved"
},
"localizedDescriptions": {
"en": "The previously known reaction to the identified 'Substance' has been clinically reassessed and considered no longer to be an active risk."
}
},
{
"value": "at0066",
"label": "Refuted",
"localizedLabels": {
"en": "Refuted"
},
"localizedDescriptions": {
"en": "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."
}
}
],
"listOpen": true
},
{
"suffix": "other",
"type": "TEXT"
}
]
},
{
"id": "criticality",
"name": "Criticality",
"localizedName": "Criticality",
"rmType": "DV_CODED_TEXT",
"nodeId": "at0101",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Criticality"
},
"localizedDescriptions": {
"en": "An indication of the potential for critical system organ damage or life threatening consequence."
},
"annotations": {
"comment": "This can be regarded as a predictive judgement of a 'worst case scenario'.\n In most contexts 'Low' would be regarded as the default value.",
"source": "DAM, openEHR;DAM, openEHR"
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Allergies & Intolerances']/items[openEHR-EHR-EVALUATION.adverse_reaction_risk.v1,'Allergy Intolerance']/data[at0001]/items[at0101]/value",
"inputs": [
{
"suffix": "code",
"type": "CODED_TEXT",
"list": [
{
"value": "at0102",
"label": "Low",
"localizedLabels": {
"en": "Low"
},
"localizedDescriptions": {
"en": "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."
}
},
{
"value": "at0103",
"label": "High",
"localizedLabels": {
"en": "High"
},
"localizedDescriptions": {
"en": "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."
}
},
{
"value": "at0124",
"label": "Indeterminate",
"localizedLabels": {
"en": "Indeterminate"
},
"localizedDescriptions": {
"en": "Unable to assess with information available."
}
}
]
}
]
},
{
"id": "type",
"name": "Type",
"localizedName": "Type",
"rmType": "DV_TEXT",
"nodeId": "at0058",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Type"
},
"localizedDescriptions": {
"en": "Identification of the underlying physiological mechanism for the adverse reaction."
},
"annotations": {
"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. \n\nImmunological testing may provide supporting evidence for the mechanism and causative substance , but no tests are 100% sensitive or specific for a sensitivity. \n\nIt 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.",
"source": "FHIR, DAM;FHIR, DAM"
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Allergies & Intolerances']/items[openEHR-EHR-EVALUATION.adverse_reaction_risk.v1,'Allergy Intolerance']/data[at0001]/items[at0058,'Type']/value",
"inputs": [
{
"type": "TEXT",
"list": [
{
"value": "Allergy",
"label": "Allergy"
},
{
"value": "Intolerance",
"label": "Intolerance"
}
],
"listOpen": false
}
]
},
{
"id": "comment",
"name": "Comment",
"localizedName": "Comment",
"rmType": "DV_TEXT",
"nodeId": "at0006",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Comment"
},
"localizedDescriptions": {
"en": "Additional narrative about the propensity for the adverse reaction, not captured in other fields."
},
"annotations": {
"comment": "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.",
"source": "openEHR;openEHR"
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Allergies & Intolerances']/items[openEHR-EHR-EVALUATION.adverse_reaction_risk.v1,'Allergy Intolerance']/data[at0001]/items[at0006]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "reaction",
"name": "Reaction",
"localizedName": "Reaction",
"rmType": "CLUSTER",
"nodeId": "at0009",
"min": 0,
"max": -1,
"localizedNames": {
"en": "Reaction"
},
"localizedDescriptions": {
"en": "Details about each adverse reaction event linked to exposure to the identified 'Substance'."
},
"annotations": {
"source": "openEHR,FHIR,DAM;openEHR,FHIR,DAM"
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Allergies & Intolerances']/items[openEHR-EHR-EVALUATION.adverse_reaction_risk.v1,'Allergy Intolerance']/data[at0001]/items[at0009,'Reaction']",
"children": [
{
"id": "manifestation",
"name": "Manifestation",
"localizedName": "Manifestation",
"rmType": "DV_TEXT",
"nodeId": "at0011",
"min": 1,
"max": -1,
"localizedNames": {
"en": "Manifestation"
},
"localizedDescriptions": {
"en": "Clinical symptoms and/or signs that are observed or associated with the adverse reaction."
},
"annotations": {
"comment": "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.\n\n\n\nTerminologies commonly used include, but are not limited to, SNOMED-CT or ICD10.",
"source": "FHIR, openEHR,DAM;FHIR, openEHR,DAM",
"FHIR": "AllergyIntolerance.reaction.manifestation"
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Allergies & Intolerances']/items[openEHR-EHR-EVALUATION.adverse_reaction_risk.v1,'Allergy Intolerance']/data[at0001]/items[at0009,'Reaction']/items[at0011]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "onset",
"name": "Onset",
"localizedName": "Onset",
"rmType": "DV_DATE_TIME",
"nodeId": "at0027",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Onset"
},
"localizedDescriptions": {
"en": "Record of the date and/or time of the onset of the reaction."
},
"annotations": {
"source": "openEHR, FHIR, DAM;openEHR, FHIR, DAM",
"FHIR": "AllergyIntolerance.reaction.onset"
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Allergies & Intolerances']/items[openEHR-EHR-EVALUATION.adverse_reaction_risk.v1,'Allergy Intolerance']/data[at0001]/items[at0009,'Reaction']/items[at0027,'Onset']/value",
"inputs": [
{
"type": "DATETIME"
}
]
},
{
"id": "severity",
"name": "Severity",
"localizedName": "Severity",
"rmType": "DV_CODED_TEXT",
"nodeId": "at0089",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Severity"
},
"localizedDescriptions": {
"en": "Clinical assessment of the severity of the reaction event as a whole, potentially considering multiple different manifestations."
},
"annotations": {
"comment": "It is acknowledged that this assessment is very subjective. There may be some some specific practice domains where objective scales have been applied.\n Objective scales can be included in this model using the 'Reaction details' Cluster.",
"source": "DAM;DAM",
"FHIR": "AllergyIntolerance.reaction.severity"
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Allergies & Intolerances']/items[openEHR-EHR-EVALUATION.adverse_reaction_risk.v1,'Allergy Intolerance']/data[at0001]/items[at0009,'Reaction']/items[at0089,'Severity']/value",
"inputs": [
{
"suffix": "code",
"type": "CODED_TEXT",
"list": [
{
"value": "at0093",
"label": "Mild",
"localizedLabels": {
"en": "Mild"
},
"localizedDescriptions": {
"en": "Causes mild physiological effects."
}
},
{
"value": "at0092",
"label": "Moderate",
"localizedLabels": {
"en": "Moderate"
},
"localizedDescriptions": {
"en": "Causes moderate physiological effects."
}
},
{
"value": "at0090",
"label": "Severe",
"localizedLabels": {
"en": "Severe"
},
"localizedDescriptions": {
"en": "Causes severe physiological effects."
}
}
],
"listOpen": true
},
{
"suffix": "other",
"type": "TEXT"
}
]
}
]
},
{
"id": "last_updated",
"name": "Last updated",
"localizedName": "Last updated",
"rmType": "DV_DATE_TIME",
"nodeId": "at0062",
"min": 0,
"max": 1,
"dependsOn": [
"reaction",
"substance",
"criticality",
"comment",
"verification_status",
"type"
],
"localizedNames": {
"en": "Last updated"
},
"localizedDescriptions": {
"en": "Date when the propensity or the reaction event was updated."
},
"annotations": {
"comment": "Note: maps to recordedDate in FHIR.",
"source": "openEHR, FHIR, DAM;openEHR, FHIR, DAM"
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Allergies & Intolerances']/items[openEHR-EHR-EVALUATION.adverse_reaction_risk.v1,'Allergy Intolerance']/protocol[at0042]/items[at0062]/value",
"inputs": [
{
"type": "DATETIME"
}
]
},
{
"id": "language",
"name": "Language",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Allergies & Intolerances']/items[openEHR-EHR-EVALUATION.adverse_reaction_risk.v1,'Allergy Intolerance']/language",
"inContext": true
},
{
"id": "encoding",
"name": "Encoding",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Allergies & Intolerances']/items[openEHR-EHR-EVALUATION.adverse_reaction_risk.v1,'Allergy Intolerance']/encoding",
"inContext": true
},
{
"id": "subject",
"name": "Subject",
"rmType": "PARTY_PROXY",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Allergies & Intolerances']/items[openEHR-EHR-EVALUATION.adverse_reaction_risk.v1,'Allergy Intolerance']/subject",
"inputs": [
{
"suffix": "id",
"type": "TEXT"
},
{
"suffix": "id_scheme",
"type": "TEXT"
},
{
"suffix": "id_namespace",
"type": "TEXT"
},
{
"suffix": "name",
"type": "TEXT"
}
],
"inContext": true
}
]
},
{
"id": "exclusion_-_global",
"name": "Exclusion - global",
"localizedName": "Exclusion - global",
"rmType": "EVALUATION",
"nodeId": "openEHR-EHR-EVALUATION.exclusion_global.v1",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Exclusion - global"
},
"localizedDescriptions": {
"en": "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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Allergies & Intolerances']/items[openEHR-EHR-EVALUATION.exclusion_global.v1]",
"children": [
{
"id": "global_exclusion_of_adverse_reactions",
"name": "Global exclusion of adverse reactions",
"localizedName": "Global exclusion of adverse reactions",
"rmType": "DV_TEXT",
"nodeId": "at0002",
"min": 1,
"max": 1,
"localizedNames": {
"en": "Global exclusion of adverse reactions"
},
"localizedDescriptions": {
"en": "Overall statement of exclusion about all adverse reactions at the time of recording."
},
"annotations": {
"comment": "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'."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Allergies & Intolerances']/items[openEHR-EHR-EVALUATION.exclusion_global.v1]/data[at0001]/items[at0002,'Global exclusion of adverse reactions']/value",
"inputs": [
{
"type": "TEXT",
"list": [
{
"value": "No known allergies",
"label": "No known allergies"
},
{
"value": "No known medication allergies",
"label": "No known medication allergies"
},
{
"value": "No known environmental allergies",
"label": "No known environmental allergies"
},
{
"value": "No known food allergies",
"label": "No known food allergies"
}
],
"listOpen": false
}
]
},
{
"id": "language",
"name": "Language",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Allergies & Intolerances']/items[openEHR-EHR-EVALUATION.exclusion_global.v1]/language",
"inContext": true
},
{
"id": "encoding",
"name": "Encoding",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Allergies & Intolerances']/items[openEHR-EHR-EVALUATION.exclusion_global.v1]/encoding",
"inContext": true
},
{
"id": "subject",
"name": "Subject",
"rmType": "PARTY_PROXY",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Allergies & Intolerances']/items[openEHR-EHR-EVALUATION.exclusion_global.v1]/subject",
"inputs": [
{
"suffix": "id",
"type": "TEXT"
},
{
"suffix": "id_scheme",
"type": "TEXT"
},
{
"suffix": "id_namespace",
"type": "TEXT"
},
{
"suffix": "name",
"type": "TEXT"
}
],
"inContext": true
}
]
},
{
"id": "absence_of_information",
"name": "Absence of information",
"localizedName": "Absence of information",
"rmType": "EVALUATION",
"nodeId": "openEHR-EHR-EVALUATION.absence.v2",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Absence of information"
},
"localizedDescriptions": {
"en": "Statement that specified health information is not available for inclusion in the health record or extract at the time of recording."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Allergies & Intolerances']/items[openEHR-EHR-EVALUATION.absence.v2]",
"children": [
{
"id": "absence_statement",
"name": "Absence statement",
"localizedName": "Absence statement",
"rmType": "DV_TEXT",
"nodeId": "at0002",
"min": 1,
"max": 1,
"localizedNames": {
"en": "Absence statement"
},
"localizedDescriptions": {
"en": "Positive statement that no information is available."
},
"annotations": {
"comment": "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\"."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Allergies & Intolerances']/items[openEHR-EHR-EVALUATION.absence.v2]/data[at0001]/items[at0002]/value",
"inputs": [
{
"type": "TEXT",
"list": [
{
"value": "No information about allergies",
"label": "No information about allergies"
}
],
"listOpen": false
}
]
},
{
"id": "last_updated",
"name": "Last updated",
"localizedName": "Last updated",
"rmType": "DV_DATE_TIME",
"nodeId": "at0004",
"min": 0,
"max": 1,
"dependsOn": [
"absence_statement"
],
"localizedNames": {
"en": "Last updated"
},
"localizedDescriptions": {
"en": "The date at which the absence was last updated."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Allergies & Intolerances']/items[openEHR-EHR-EVALUATION.absence.v2]/protocol[at0003]/items[at0004]/value",
"inputs": [
{
"type": "DATETIME"
}
]
},
{
"id": "language",
"name": "Language",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Allergies & Intolerances']/items[openEHR-EHR-EVALUATION.absence.v2]/language",
"inContext": true
},
{
"id": "encoding",
"name": "Encoding",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Allergies & Intolerances']/items[openEHR-EHR-EVALUATION.absence.v2]/encoding",
"inContext": true
},
{
"id": "subject",
"name": "Subject",
"rmType": "PARTY_PROXY",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Allergies & Intolerances']/items[openEHR-EHR-EVALUATION.absence.v2]/subject",
"inputs": [
{
"suffix": "id",
"type": "TEXT"
},
{
"suffix": "id_scheme",
"type": "TEXT"
},
{
"suffix": "id_namespace",
"type": "TEXT"
},
{
"suffix": "name",
"type": "TEXT"
}
],
"inContext": true
}
]
}
]
},
{
"id": "problem_list",
"name": "Problem List",
"localizedName": "Problem List",
"rmType": "SECTION",
"nodeId": "openEHR-EHR-SECTION.adhoc.v1",
"min": 1,
"max": 1,
"localizedNames": {
"en": "Problem List"
},
"localizedDescriptions": {
"en": "A generic section header which should be renamed in a template to suit a specific clinical context."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Problem List']",
"children": [
{
"id": "problem_diagnosis",
"name": "Problem/Diagnosis",
"localizedName": "Problem/Diagnosis",
"rmType": "EVALUATION",
"nodeId": "openEHR-EHR-EVALUATION.problem_diagnosis.v1",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Problem/Diagnosis"
},
"localizedDescriptions": {
"en": "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."
},
"annotations": {
"comment": "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'."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Problem List']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]",
"children": [
{
"id": "problem_diagnosis_name",
"name": "Problem/Diagnosis name",
"localizedName": "Problem/Diagnosis name",
"rmType": "DV_TEXT",
"nodeId": "at0002",
"min": 1,
"max": 1,
"localizedNames": {
"en": "Problem/Diagnosis name"
},
"localizedDescriptions": {
"en": "Identification of the problem or diagnosis, by name."
},
"annotations": {
"comment": "Coding of the name of the problem or diagnosis with a terminology is preferred, where possible."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Problem List']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0002]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "body_site",
"name": "Body site",
"localizedName": "Body site",
"rmType": "DV_TEXT",
"nodeId": "at0012",
"min": 0,
"max": -1,
"localizedNames": {
"en": "Body site"
},
"localizedDescriptions": {
"en": "Identification of a simple body site for the location of the problem or diagnosis."
},
"annotations": {
"comment": "Coding of the name of the anatomical location with a terminology is preferred, where possible.\nUse 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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Problem List']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0012]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "date_time_of_onset",
"name": "Date/time of onset",
"localizedName": "Date/time of onset",
"rmType": "DV_DATE_TIME",
"nodeId": "at0077",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Date/time of onset"
},
"localizedDescriptions": {
"en": "Estimated or actual date/time that signs or symptoms of the problem/diagnosis were first observed."
},
"annotations": {
"comment": "Data captured/imported as \"Age at onset\" should be converted to a date using the subject's date of birth."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Problem List']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0077]/value",
"inputs": [
{
"type": "DATETIME"
}
]
},
{
"id": "severity",
"name": "Severity",
"localizedName": "Severity",
"rmType": "DV_CODED_TEXT",
"nodeId": "at0005",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Severity"
},
"localizedDescriptions": {
"en": "An assessment of the overall severity of the problem or diagnosis."
},
"annotations": {
"comment": "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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Problem List']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0005]/value",
"inputs": [
{
"suffix": "code",
"type": "CODED_TEXT",
"list": [
{
"value": "at0047",
"label": "Mild",
"localizedLabels": {
"en": "Mild"
},
"localizedDescriptions": {
"en": "The problem or diagnosis does not interfere with normal activity or may cause damage to health if left untreated."
}
},
{
"value": "at0048",
"label": "Moderate",
"localizedLabels": {
"en": "Moderate"
},
"localizedDescriptions": {
"en": "The problem or diagnosis causes interference with normal activity or will damage health if left untreated."
}
},
{
"value": "at0049",
"label": "Severe",
"localizedLabels": {
"en": "Severe"
},
"localizedDescriptions": {
"en": "The problem or diagnosis prevents normal activity or will seriously damage health if left untreated."
}
}
],
"listOpen": true
},
{
"suffix": "other",
"type": "TEXT"
}
]
},
{
"id": "date_of_abatement",
"name": "Date of abatement",
"localizedName": "Date of abatement",
"rmType": "DV_DATE_TIME",
"nodeId": "at0030",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Date of abatement"
},
"localizedDescriptions": {
"en": "Estimated or actual date/time of resolution or remission for this problem or diagnosis, as determined by a healthcare professional."
},
"annotations": {
"comment": "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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Problem List']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0030,'Date of abatement']/value",
"inputs": [
{
"type": "DATETIME"
}
]
},
{
"id": "problem_diagnosis_qualifier",
"name": "Problem/Diagnosis qualifier",
"localizedName": "Problem/Diagnosis qualifier",
"rmType": "CLUSTER",
"nodeId": "openEHR-EHR-CLUSTER.problem_qualifier.v1",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Problem/Diagnosis qualifier"
},
"localizedDescriptions": {
"en": "Contextual or temporal qualifier for a specified problem or diagnosis."
},
"annotations": {
"FHIR": "Condition.clinicalStatus"
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Problem List']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v1]",
"children": [
{
"id": "active_inactive",
"name": "Active/Inactive?",
"localizedName": "Active/Inactive?",
"rmType": "DV_CODED_TEXT",
"nodeId": "at0003",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Active/Inactive?"
},
"localizedDescriptions": {
"en": "Category that supports division of problems and diagnoses into Active or Inactive problem lists."
},
"annotations": {
"comment": "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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Problem List']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v1]/items[at0003]/value",
"inputs": [
{
"suffix": "code",
"type": "CODED_TEXT",
"list": [
{
"value": "at0026",
"label": "Active",
"localizedLabels": {
"en": "Active"
},
"localizedDescriptions": {
"en": "The problem or diagnosis is currently active and clinically relevant."
}
},
{
"value": "at0027",
"label": "Inactive",
"localizedLabels": {
"en": "Inactive"
},
"localizedDescriptions": {
"en": "The problem or diagnosis is not completely resolved but is inactive or felt less relevant to the current clinical context."
}
}
]
}
]
},
{
"id": "resolution_phase",
"name": "Resolution phase",
"localizedName": "Resolution phase",
"rmType": "DV_CODED_TEXT",
"nodeId": "at0083",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Resolution phase"
},
"localizedDescriptions": {
"en": "Phase of healing for an acute problem or diagnosis."
},
"annotations": {
"comment": "For example: tracking the progress of resolution of a middle ear infection."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Problem List']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v1]/items[at0083]/value",
"inputs": [
{
"suffix": "code",
"type": "CODED_TEXT",
"list": [
{
"value": "at0084",
"label": "Resolved",
"localizedLabels": {
"en": "Resolved"
},
"localizedDescriptions": {
"en": "Problem or diagnosis has completed the normal phases of restoration or healing and can be considered resolved."
}
},
{
"value": "at0097",
"label": "Relapsed",
"localizedLabels": {
"en": "Relapsed"
},
"localizedDescriptions": {
"en": "Problem or diagnosis has deteriorated after a period of temporary improvement."
}
}
]
}
]
},
{
"id": "remission_status",
"name": "Remission status",
"localizedName": "Remission status",
"rmType": "DV_CODED_TEXT",
"nodeId": "at0089",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Remission status"
},
"localizedDescriptions": {
"en": "Status of the remission of an incurable diagnosis."
},
"annotations": {
"comment": "For example: the status of a cancer or haematological diagnosis."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Problem List']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v1]/items[at0089]/value",
"inputs": [
{
"suffix": "code",
"type": "CODED_TEXT",
"list": [
{
"value": "at0090",
"label": "In remission",
"localizedLabels": {
"en": "In remission"
},
"localizedDescriptions": {
"en": "No ongoing signs or symptoms of the disease have been identified."
}
}
]
}
]
},
{
"id": "occurrence",
"name": "Occurrence",
"localizedName": "Occurrence",
"rmType": "DV_CODED_TEXT",
"nodeId": "at0071",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Occurrence"
},
"localizedDescriptions": {
"en": "Category of the occurrence for this problem or diagnosis."
},
"annotations": {
"comment": "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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Problem List']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v1]/items[at0071]/value",
"inputs": [
{
"suffix": "code",
"type": "CODED_TEXT",
"list": [
{
"value": "at0096",
"label": "Recurrence",
"localizedLabels": {
"en": "Recurrence"
},
"localizedDescriptions": {
"en": "New occurrence of the same problem or diagnosis after a previous episode was resolved."
}
}
]
}
]
}
]
},
{
"id": "diagnostic_certainty",
"name": "Diagnostic certainty",
"localizedName": "Diagnostic certainty",
"rmType": "DV_CODED_TEXT",
"nodeId": "at0073",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Diagnostic certainty"
},
"localizedDescriptions": {
"en": "The level of confidence in the identification of the diagnosis."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Problem List']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0073]/value",
"inputs": [
{
"suffix": "code",
"type": "CODED_TEXT",
"list": [
{
"value": "at0074",
"label": "Suspected",
"localizedLabels": {
"en": "Suspected"
},
"localizedDescriptions": {
"en": "The diagnosis has been identified with a low level of certainty."
}
},
{
"value": "at0075",
"label": "Probable",
"localizedLabels": {
"en": "Probable"
},
"localizedDescriptions": {
"en": "The diagnosis has been identified with a high level of certainty."
}
},
{
"value": "at0076",
"label": "Confirmed",
"localizedLabels": {
"en": "Confirmed"
},
"localizedDescriptions": {
"en": "The diagnosis has been confirmed against recognised criteria."
}
}
],
"listOpen": true
},
{
"suffix": "other",
"type": "TEXT"
}
]
},
{
"id": "last_updated",
"name": "Last updated",
"localizedName": "Last updated",
"rmType": "DV_DATE_TIME",
"nodeId": "at0070",
"min": 0,
"max": 1,
"dependsOn": [
"severity",
"problem_diagnosis_name",
"problem_diagnosis_qualifier",
"diagnostic_certainty",
"date_time_of_onset",
"body_site",
"date_of_abatement"
],
"localizedNames": {
"en": "Last updated"
},
"localizedDescriptions": {
"en": "The date this problem or diagnosis was last updated."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Problem List']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/protocol[at0032]/items[at0070]/value",
"inputs": [
{
"type": "DATETIME"
}
]
},
{
"id": "language",
"name": "Language",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Problem List']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/language",
"inContext": true
},
{
"id": "encoding",
"name": "Encoding",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Problem List']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/encoding",
"inContext": true
},
{
"id": "subject",
"name": "Subject",
"rmType": "PARTY_PROXY",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Problem List']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/subject",
"inputs": [
{
"suffix": "id",
"type": "TEXT"
},
{
"suffix": "id_scheme",
"type": "TEXT"
},
{
"suffix": "id_namespace",
"type": "TEXT"
},
{
"suffix": "name",
"type": "TEXT"
}
],
"inContext": true
}
]
},
{
"id": "exclusion_-_global",
"name": "Exclusion - global",
"localizedName": "Exclusion - global",
"rmType": "EVALUATION",
"nodeId": "openEHR-EHR-EVALUATION.exclusion_global.v1",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Exclusion - global"
},
"localizedDescriptions": {
"en": "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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Problem List']/items[openEHR-EHR-EVALUATION.exclusion_global.v1]",
"children": [
{
"id": "global_exclusion_of_problems_diagnoses",
"name": "Global exclusion of problems/diagnoses",
"localizedName": "Global exclusion of problems/diagnoses",
"rmType": "DV_TEXT",
"nodeId": "at0002",
"min": 1,
"max": 1,
"localizedNames": {
"en": "Global exclusion of problems/diagnoses"
},
"localizedDescriptions": {
"en": "Overall statement of exclusion of all problems or diagnoses at the time of recording."
},
"annotations": {
"comment": "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'."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Problem List']/items[openEHR-EHR-EVALUATION.exclusion_global.v1]/data[at0001]/items[at0002,'Global exclusion of problems/diagnoses']/value",
"inputs": [
{
"type": "TEXT",
"list": [
{
"value": "No known problems",
"label": "No known problems"
}
],
"listOpen": false
}
]
},
{
"id": "language",
"name": "Language",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Problem List']/items[openEHR-EHR-EVALUATION.exclusion_global.v1]/language",
"inContext": true
},
{
"id": "encoding",
"name": "Encoding",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Problem List']/items[openEHR-EHR-EVALUATION.exclusion_global.v1]/encoding",
"inContext": true
},
{
"id": "subject",
"name": "Subject",
"rmType": "PARTY_PROXY",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Problem List']/items[openEHR-EHR-EVALUATION.exclusion_global.v1]/subject",
"inputs": [
{
"suffix": "id",
"type": "TEXT"
},
{
"suffix": "id_scheme",
"type": "TEXT"
},
{
"suffix": "id_namespace",
"type": "TEXT"
},
{
"suffix": "name",
"type": "TEXT"
}
],
"inContext": true
}
]
},
{
"id": "absence_of_information",
"name": "Absence of information",
"localizedName": "Absence of information",
"rmType": "EVALUATION",
"nodeId": "openEHR-EHR-EVALUATION.absence.v2",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Absence of information"
},
"localizedDescriptions": {
"en": "Statement that specified health information is not available for inclusion in the health record or extract at the time of recording."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Problem List']/items[openEHR-EHR-EVALUATION.absence.v2]",
"children": [
{
"id": "absence_statement",
"name": "Absence statement",
"localizedName": "Absence statement",
"rmType": "DV_TEXT",
"nodeId": "at0002",
"min": 1,
"max": 1,
"localizedNames": {
"en": "Absence statement"
},
"localizedDescriptions": {
"en": "Positive statement that no information is available."
},
"annotations": {
"comment": "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\"."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Problem List']/items[openEHR-EHR-EVALUATION.absence.v2]/data[at0001]/items[at0002]/value",
"inputs": [
{
"type": "TEXT",
"list": [
{
"value": "No information about current problems",
"label": "No information about current problems"
}
],
"listOpen": false
}
]
},
{
"id": "last_updated",
"name": "Last updated",
"localizedName": "Last updated",
"rmType": "DV_DATE_TIME",
"nodeId": "at0004",
"min": 0,
"max": 1,
"dependsOn": [
"absence_statement"
],
"localizedNames": {
"en": "Last updated"
},
"localizedDescriptions": {
"en": "The date at which the absence was last updated."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Problem List']/items[openEHR-EHR-EVALUATION.absence.v2]/protocol[at0003]/items[at0004]/value",
"inputs": [
{
"type": "DATETIME"
}
]
},
{
"id": "language",
"name": "Language",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Problem List']/items[openEHR-EHR-EVALUATION.absence.v2]/language",
"inContext": true
},
{
"id": "encoding",
"name": "Encoding",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Problem List']/items[openEHR-EHR-EVALUATION.absence.v2]/encoding",
"inContext": true
},
{
"id": "subject",
"name": "Subject",
"rmType": "PARTY_PROXY",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Problem List']/items[openEHR-EHR-EVALUATION.absence.v2]/subject",
"inputs": [
{
"suffix": "id",
"type": "TEXT"
},
{
"suffix": "id_scheme",
"type": "TEXT"
},
{
"suffix": "id_namespace",
"type": "TEXT"
},
{
"suffix": "name",
"type": "TEXT"
}
],
"inContext": true
}
]
}
]
},
{
"id": "immunizations",
"name": "Immunizations",
"localizedName": "Immunizations",
"rmType": "SECTION",
"nodeId": "openEHR-EHR-SECTION.adhoc.v1",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Immunizations"
},
"localizedDescriptions": {
"en": "A generic section header which should be renamed in a template to suit a specific clinical context."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Immunizations']",
"children": [
{
"id": "immunization_statement",
"name": "Immunization statement",
"localizedName": "Immunization statement",
"rmType": "ACTION",
"nodeId": "openEHR-EHR-ACTION.medication.v1",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Immunization statement"
},
"localizedDescriptions": {
"en": "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."
},
"annotations": {
"comment": "This is not limited to activities performed based on medication orders from clinicians, but could also include for example taking over the counter medication."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Immunizations']/items[openEHR-EHR-ACTION.medication.v1,'Immunization statement']",
"children": [
{
"id": "ism_transition",
"name": "Ism_transition",
"rmType": "ISM_TRANSITION",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Immunizations']/items[openEHR-EHR-ACTION.medication.v1,'Immunization statement']/ism_transition",
"children": [
{
"id": "current_state",
"name": "Current_state",
"rmType": "DV_CODED_TEXT",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Immunizations']/items[openEHR-EHR-ACTION.medication.v1,'Immunization statement']/ism_transition/current_state",
"inputs": [
{
"suffix": "code",
"type": "CODED_TEXT",
"list": [
{
"value": "245",
"label": "active"
}
]
}
],
"inContext": true
},
{
"id": "transition",
"name": "Transition",
"rmType": "DV_CODED_TEXT",
"min": 0,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Immunizations']/items[openEHR-EHR-ACTION.medication.v1,'Immunization statement']/ism_transition/transition",
"inputs": [
{
"suffix": "code",
"type": "TEXT"
},
{
"suffix": "value",
"type": "TEXT"
}
],
"inContext": true
},
{
"id": "careflow_step",
"name": "Careflow_step",
"rmType": "DV_CODED_TEXT",
"min": 0,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Immunizations']/items[openEHR-EHR-ACTION.medication.v1,'Immunization statement']/ism_transition/careflow_step",
"inputs": [
{
"suffix": "code",
"type": "CODED_TEXT",
"list": [
{
"value": "at0006",
"label": "Dose administered",
"localizedLabels": {
"en": "Dose administered"
},
"currentStates": [
"245"
]
}
]
}
],
"inContext": true
}
],
"inContext": true
},
{
"id": "immunisation_item",
"name": "Immunisation item",
"localizedName": "Immunisation item",
"rmType": "DV_TEXT",
"nodeId": "at0020",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Immunisation item"
},
"localizedDescriptions": {
"en": "Name of the medication, vaccine or other therapeutic/prescribable item which was the focus of the activity."
},
"annotations": {
"comment": "For example: 'Atenolol 100mg' or 'Tenormin tablets 100mg'. \nIt 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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Immunizations']/items[openEHR-EHR-ACTION.medication.v1,'Immunization statement']/description[at0017]/items[at0020,'Immunisation item']/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "administration_details",
"name": "Administration details",
"localizedName": "Administration details",
"rmType": "CLUSTER",
"nodeId": "at0140",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Administration details"
},
"localizedDescriptions": {
"en": "Details of body site and administration of the medication."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Immunizations']/items[openEHR-EHR-ACTION.medication.v1,'Immunization statement']/description[at0017]/items[at0140]",
"children": [
{
"id": "route",
"name": "Route",
"localizedName": "Route",
"rmType": "DV_TEXT",
"nodeId": "at0147",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Route"
},
"localizedDescriptions": {
"en": "The route by which the ordered item was, or is to be, administered into the subject's body."
},
"annotations": {
"comment": "Comment: For example: 'oral', 'intravenous', or 'topical'. Coding of the route with a terminology is preferred, where possible. Multiple potential routes may be specified."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Immunizations']/items[openEHR-EHR-ACTION.medication.v1,'Immunization statement']/description[at0017]/items[at0140]/items[at0147]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "target_site",
"name": "Target site",
"localizedName": "Target site",
"rmType": "DV_TEXT",
"nodeId": "at0141",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Target site"
},
"localizedDescriptions": {
"en": "Structured description of the site of administration of the ordered item."
},
"annotations": {
"comment": "For example: 'left upper arm', 'intravenous catheter right hand'. \nCoding of the body site with a terminology is preferred, where possible."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Immunizations']/items[openEHR-EHR-ACTION.medication.v1,'Immunization statement']/description[at0017]/items[at0140]/items[at0141,'Target site']/value",
"inputs": [
{
"type": "TEXT"
}
]
}
]
},
{
"id": "sequence_number",
"name": "Sequence number",
"localizedName": "Sequence number",
"rmType": "DV_COUNT",
"nodeId": "at0025",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Sequence number"
},
"localizedDescriptions": {
"en": "The sequence number specific to the pathway step being recorded."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Immunizations']/items[openEHR-EHR-ACTION.medication.v1,'Immunization statement']/description[at0017]/items[at0025]/value",
"inputs": [
{
"type": "INTEGER"
}
]
},
{
"id": "time",
"name": "Time",
"rmType": "DV_DATE_TIME",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Immunizations']/items[openEHR-EHR-ACTION.medication.v1,'Immunization statement']/time",
"inputs": [
{
"type": "DATETIME"
}
],
"inContext": true
},
{
"id": "language",
"name": "Language",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Immunizations']/items[openEHR-EHR-ACTION.medication.v1,'Immunization statement']/language",
"inContext": true
},
{
"id": "encoding",
"name": "Encoding",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Immunizations']/items[openEHR-EHR-ACTION.medication.v1,'Immunization statement']/encoding",
"inContext": true
},
{
"id": "subject",
"name": "Subject",
"rmType": "PARTY_PROXY",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Immunizations']/items[openEHR-EHR-ACTION.medication.v1,'Immunization statement']/subject",
"inputs": [
{
"suffix": "id",
"type": "TEXT"
},
{
"suffix": "id_scheme",
"type": "TEXT"
},
{
"suffix": "id_namespace",
"type": "TEXT"
},
{
"suffix": "name",
"type": "TEXT"
}
],
"inContext": true
}
]
},
{
"id": "absence_of_information",
"name": "Absence of information",
"localizedName": "Absence of information",
"rmType": "EVALUATION",
"nodeId": "openEHR-EHR-EVALUATION.absence.v2",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Absence of information"
},
"localizedDescriptions": {
"en": "Statement that specified health information is not available for inclusion in the health record or extract at the time of recording."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Immunizations']/items[openEHR-EHR-EVALUATION.absence.v2]",
"children": [
{
"id": "absence_statement",
"name": "Absence statement",
"localizedName": "Absence statement",
"rmType": "DV_TEXT",
"nodeId": "at0002",
"min": 1,
"max": 1,
"localizedNames": {
"en": "Absence statement"
},
"localizedDescriptions": {
"en": "Positive statement that no information is available."
},
"annotations": {
"comment": "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\"."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Immunizations']/items[openEHR-EHR-EVALUATION.absence.v2]/data[at0001]/items[at0002]/value",
"inputs": [
{
"type": "TEXT",
"list": [
{
"value": "No information about immunizations",
"label": "No information about immunizations"
}
],
"listOpen": false
}
]
},
{
"id": "last_updated",
"name": "Last updated",
"localizedName": "Last updated",
"rmType": "DV_DATE_TIME",
"nodeId": "at0004",
"min": 0,
"max": 1,
"dependsOn": [
"absence_statement"
],
"localizedNames": {
"en": "Last updated"
},
"localizedDescriptions": {
"en": "The date at which the absence was last updated."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Immunizations']/items[openEHR-EHR-EVALUATION.absence.v2]/protocol[at0003]/items[at0004]/value",
"inputs": [
{
"type": "DATETIME"
}
]
},
{
"id": "language",
"name": "Language",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Immunizations']/items[openEHR-EHR-EVALUATION.absence.v2]/language",
"inContext": true
},
{
"id": "encoding",
"name": "Encoding",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Immunizations']/items[openEHR-EHR-EVALUATION.absence.v2]/encoding",
"inContext": true
},
{
"id": "subject",
"name": "Subject",
"rmType": "PARTY_PROXY",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Immunizations']/items[openEHR-EHR-EVALUATION.absence.v2]/subject",
"inputs": [
{
"suffix": "id",
"type": "TEXT"
},
{
"suffix": "id_scheme",
"type": "TEXT"
},
{
"suffix": "id_namespace",
"type": "TEXT"
},
{
"suffix": "name",
"type": "TEXT"
}
],
"inContext": true
}
]
}
]
},
{
"id": "history_of_procedures",
"name": "History of Procedures",
"localizedName": "History of Procedures",
"rmType": "SECTION",
"nodeId": "openEHR-EHR-SECTION.adhoc.v1",
"min": 0,
"max": 1,
"localizedNames": {
"en": "History of Procedures"
},
"localizedDescriptions": {
"en": "A generic section header which should be renamed in a template to suit a specific clinical context."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'History of Procedures']",
"children": [
{
"id": "procedure",
"name": "Procedure",
"localizedName": "Procedure",
"rmType": "ACTION",
"nodeId": "openEHR-EHR-ACTION.procedure.v1",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Procedure"
},
"localizedDescriptions": {
"en": "A clinical activity carried out for screening, investigative, diagnostic, curative, therapeutic, evaluative or palliative purposes."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'History of Procedures']/items[openEHR-EHR-ACTION.procedure.v1]",
"children": [
{
"id": "ism_transition",
"name": "Ism_transition",
"rmType": "ISM_TRANSITION",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'History of Procedures']/items[openEHR-EHR-ACTION.procedure.v1]/ism_transition",
"children": [
{
"id": "current_state",
"name": "Current_state",
"rmType": "DV_CODED_TEXT",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'History of Procedures']/items[openEHR-EHR-ACTION.procedure.v1]/ism_transition/current_state",
"inputs": [
{
"suffix": "code",
"type": "CODED_TEXT",
"list": [
{
"value": "245",
"label": "active"
},
{
"value": "531",
"label": "aborted"
},
{
"value": "532",
"label": "completed"
},
{
"value": "526",
"label": "planned"
},
{
"value": "527",
"label": "postponed"
},
{
"value": "528",
"label": "cancelled"
}
]
}
],
"inContext": true
},
{
"id": "transition",
"name": "Transition",
"rmType": "DV_CODED_TEXT",
"min": 0,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'History of Procedures']/items[openEHR-EHR-ACTION.procedure.v1]/ism_transition/transition",
"inputs": [
{
"suffix": "code",
"type": "TEXT"
},
{
"suffix": "value",
"type": "TEXT"
}
],
"inContext": true
},
{
"id": "careflow_step",
"name": "Careflow_step",
"rmType": "DV_CODED_TEXT",
"min": 0,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'History of Procedures']/items[openEHR-EHR-ACTION.procedure.v1]/ism_transition/careflow_step",
"inputs": [
{
"suffix": "code",
"type": "CODED_TEXT",
"list": [
{
"value": "at0004",
"label": "Procedure planned",
"localizedLabels": {
"en": "Procedure planned"
},
"currentStates": [
"526"
]
},
{
"value": "at0007",
"label": "Procedure request sent",
"localizedLabels": {
"en": "Procedure request sent"
},
"currentStates": [
"526"
]
},
{
"value": "at0038",
"label": "Procedure postponed",
"localizedLabels": {
"en": "Procedure postponed"
},
"currentStates": [
"527"
]
},
{
"value": "at0039",
"label": "Procedure cancelled",
"localizedLabels": {
"en": "Procedure cancelled"
},
"currentStates": [
"528"
]
},
{
"value": "at0068",
"label": "Procedure commenced",
"localizedLabels": {
"en": "Procedure commenced"
},
"currentStates": [
"245"
]
},
{
"value": "at0041",
"label": "Procedure aborted",
"localizedLabels": {
"en": "Procedure aborted"
},
"currentStates": [
"531"
]
},
{
"value": "at0043",
"label": "Procedure completed",
"localizedLabels": {
"en": "Procedure completed"
},
"currentStates": [
"532"
]
}
]
}
],
"inContext": true
}
],
"inContext": true
},
{
"id": "procedure_name",
"name": "Procedure name",
"localizedName": "Procedure name",
"rmType": "DV_TEXT",
"nodeId": "at0002",
"min": 1,
"max": 1,
"localizedNames": {
"en": "Procedure name"
},
"localizedDescriptions": {
"en": "Identification of the procedure by name."
},
"annotations": {
"comment": "Coding of the specific procedure with a terminology is preferred, where possible."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'History of Procedures']/items[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[at0002]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "body_site",
"name": "Body site",
"localizedName": "Body site",
"rmType": "DV_TEXT",
"nodeId": "at0063",
"min": 0,
"max": -1,
"localizedNames": {
"en": "Body site"
},
"localizedDescriptions": {
"en": "Identification of the body site for the procedure."
},
"annotations": {
"comment": "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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'History of Procedures']/items[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[at0063]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "time",
"name": "Time",
"rmType": "DV_DATE_TIME",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'History of Procedures']/items[openEHR-EHR-ACTION.procedure.v1]/time",
"inputs": [
{
"type": "DATETIME"
}
],
"inContext": true
},
{
"id": "language",
"name": "Language",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'History of Procedures']/items[openEHR-EHR-ACTION.procedure.v1]/language",
"inContext": true
},
{
"id": "encoding",
"name": "Encoding",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'History of Procedures']/items[openEHR-EHR-ACTION.procedure.v1]/encoding",
"inContext": true
},
{
"id": "subject",
"name": "Subject",
"rmType": "PARTY_PROXY",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'History of Procedures']/items[openEHR-EHR-ACTION.procedure.v1]/subject",
"inputs": [
{
"suffix": "id",
"type": "TEXT"
},
{
"suffix": "id_scheme",
"type": "TEXT"
},
{
"suffix": "id_namespace",
"type": "TEXT"
},
{
"suffix": "name",
"type": "TEXT"
}
],
"inContext": true
}
]
},
{
"id": "absence_of_information",
"name": "Absence of information",
"localizedName": "Absence of information",
"rmType": "EVALUATION",
"nodeId": "openEHR-EHR-EVALUATION.absence.v2",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Absence of information"
},
"localizedDescriptions": {
"en": "Statement that specified health information is not available for inclusion in the health record or extract at the time of recording."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'History of Procedures']/items[openEHR-EHR-EVALUATION.absence.v2]",
"children": [
{
"id": "absence_statement",
"name": "Absence statement",
"localizedName": "Absence statement",
"rmType": "DV_TEXT",
"nodeId": "at0002",
"min": 1,
"max": 1,
"localizedNames": {
"en": "Absence statement"
},
"localizedDescriptions": {
"en": "Positive statement that no information is available."
},
"annotations": {
"comment": "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\"."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'History of Procedures']/items[openEHR-EHR-EVALUATION.absence.v2]/data[at0001]/items[at0002]/value",
"inputs": [
{
"type": "TEXT",
"list": [
{
"value": "No information about past history of procedures",
"label": "No information about past history of procedures"
}
],
"listOpen": false
}
]
},
{
"id": "last_updated",
"name": "Last updated",
"localizedName": "Last updated",
"rmType": "DV_DATE_TIME",
"nodeId": "at0004",
"min": 0,
"max": 1,
"dependsOn": [
"absence_statement"
],
"localizedNames": {
"en": "Last updated"
},
"localizedDescriptions": {
"en": "The date at which the absence was last updated."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'History of Procedures']/items[openEHR-EHR-EVALUATION.absence.v2]/protocol[at0003]/items[at0004]/value",
"inputs": [
{
"type": "DATETIME"
}
]
},
{
"id": "language",
"name": "Language",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'History of Procedures']/items[openEHR-EHR-EVALUATION.absence.v2]/language",
"inContext": true
},
{
"id": "encoding",
"name": "Encoding",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'History of Procedures']/items[openEHR-EHR-EVALUATION.absence.v2]/encoding",
"inContext": true
},
{
"id": "subject",
"name": "Subject",
"rmType": "PARTY_PROXY",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'History of Procedures']/items[openEHR-EHR-EVALUATION.absence.v2]/subject",
"inputs": [
{
"suffix": "id",
"type": "TEXT"
},
{
"suffix": "id_scheme",
"type": "TEXT"
},
{
"suffix": "id_namespace",
"type": "TEXT"
},
{
"suffix": "name",
"type": "TEXT"
}
],
"inContext": true
}
]
},
{
"id": "exclusion_-_global",
"name": "Exclusion - global",
"localizedName": "Exclusion - global",
"rmType": "EVALUATION",
"nodeId": "openEHR-EHR-EVALUATION.exclusion_global.v1",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Exclusion - global"
},
"localizedDescriptions": {
"en": "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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'History of Procedures']/items[openEHR-EHR-EVALUATION.exclusion_global.v1]",
"children": [
{
"id": "global_exclusion_of_procedures",
"name": "Global exclusion of procedures",
"localizedName": "Global exclusion of procedures",
"rmType": "DV_TEXT",
"nodeId": "at0002",
"min": 1,
"max": 1,
"localizedNames": {
"en": "Global exclusion of procedures"
},
"localizedDescriptions": {
"en": "Overall statement of exclusion about all procedures at the time of recording."
},
"annotations": {
"comment": "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'."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'History of Procedures']/items[openEHR-EHR-EVALUATION.exclusion_global.v1]/data[at0001]/items[at0002,'Global exclusion of procedures']/value",
"inputs": [
{
"type": "TEXT",
"list": [
{
"value": "No known procedures",
"label": "No known procedures"
}
],
"listOpen": false
}
]
},
{
"id": "language",
"name": "Language",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'History of Procedures']/items[openEHR-EHR-EVALUATION.exclusion_global.v1]/language",
"inContext": true
},
{
"id": "encoding",
"name": "Encoding",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'History of Procedures']/items[openEHR-EHR-EVALUATION.exclusion_global.v1]/encoding",
"inContext": true
},
{
"id": "subject",
"name": "Subject",
"rmType": "PARTY_PROXY",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'History of Procedures']/items[openEHR-EHR-EVALUATION.exclusion_global.v1]/subject",
"inputs": [
{
"suffix": "id",
"type": "TEXT"
},
{
"suffix": "id_scheme",
"type": "TEXT"
},
{
"suffix": "id_namespace",
"type": "TEXT"
},
{
"suffix": "name",
"type": "TEXT"
}
],
"inContext": true
}
]
}
]
},
{
"id": "medical_devices",
"name": "Medical Devices",
"localizedName": "Medical Devices",
"rmType": "SECTION",
"nodeId": "openEHR-EHR-SECTION.adhoc.v1",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Medical Devices"
},
"localizedDescriptions": {
"en": "A generic section header which should be renamed in a template to suit a specific clinical context."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medical Devices']",
"children": [
{
"id": "device_use_statement",
"name": "Device use statement",
"localizedName": "Device use statement",
"rmType": "EVALUATION",
"nodeId": "openEHR-EHR-EVALUATION.device_summary.v0",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Device use statement"
},
"localizedDescriptions": {
"en": "An ongoing and persistent overview about medical devices that have been fitted or implanted."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medical Devices']/items[openEHR-EHR-EVALUATION.device_summary.v0,'Device use statement']",
"children": [
{
"id": "device_details",
"name": "Device details",
"localizedName": "Device details",
"rmType": "CLUSTER",
"nodeId": "at0022",
"min": 0,
"max": -1,
"localizedNames": {
"en": "Device details"
},
"localizedDescriptions": {
"en": "Details about each device."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medical Devices']/items[openEHR-EHR-EVALUATION.device_summary.v0,'Device use statement']/data[at0001]/items[at0022]",
"children": [
{
"id": "device_name",
"name": "Device name",
"localizedName": "Device name",
"rmType": "DV_TEXT",
"nodeId": "at0007",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Device name"
},
"localizedDescriptions": {
"en": "Identification of the specific device, by name."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medical Devices']/items[openEHR-EHR-EVALUATION.device_summary.v0,'Device use statement']/data[at0001]/items[at0022]/items[at0007]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "body_site",
"name": "Body site",
"localizedName": "Body site",
"rmType": "DV_TEXT",
"nodeId": "at0012",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Body site"
},
"localizedDescriptions": {
"en": "Identification of the body site where the device is fitted/implanted."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medical Devices']/items[openEHR-EHR-EVALUATION.device_summary.v0,'Device use statement']/data[at0001]/items[at0022]/items[at0012]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "medical_device",
"name": "Medical device",
"localizedName": "Medical device",
"rmType": "CLUSTER",
"nodeId": "openEHR-EHR-CLUSTER.device.v1",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Medical device"
},
"localizedDescriptions": {
"en": "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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medical Devices']/items[openEHR-EHR-EVALUATION.device_summary.v0,'Device use statement']/data[at0001]/items[at0022]/items[openEHR-EHR-CLUSTER.device.v1]",
"children": [
{
"id": "device_name",
"name": "Device name",
"localizedName": "Device name",
"rmType": "DV_TEXT",
"nodeId": "at0001",
"min": 1,
"max": 1,
"localizedNames": {
"en": "Device name"
},
"localizedDescriptions": {
"en": "Identification of the medical device, preferably by a common name, a formal fully descriptive name or, if required, by class or category of device."
},
"annotations": {
"comment": "This data element will capture the term, phrase or category used in clinical practice. For example: (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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medical Devices']/items[openEHR-EHR-EVALUATION.device_summary.v0,'Device use statement']/data[at0001]/items[at0022]/items[openEHR-EHR-CLUSTER.device.v1]/items[at0001]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "type",
"name": "Type",
"localizedName": "Type",
"rmType": "DV_TEXT",
"nodeId": "at0003",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Type"
},
"localizedDescriptions": {
"en": "The category or kind of device."
},
"annotations": {
"comment": "Not applicable if a category is already recorded in 'Device name'.\n 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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medical Devices']/items[openEHR-EHR-EVALUATION.device_summary.v0,'Device use statement']/data[at0001]/items[at0022]/items[openEHR-EHR-CLUSTER.device.v1]/items[at0003]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "description",
"name": "Description",
"localizedName": "Description",
"rmType": "DV_TEXT",
"nodeId": "at0002",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Description"
},
"localizedDescriptions": {
"en": "Narrative description of the medical device."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medical Devices']/items[openEHR-EHR-EVALUATION.device_summary.v0,'Device use statement']/data[at0001]/items[at0022]/items[openEHR-EHR-CLUSTER.device.v1]/items[at0002]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "unique_device_identifier_udi",
"name": "Unique device identifier (UDI)",
"localizedName": "Unique device identifier (UDI)",
"rmType": "DV_IDENTIFIER",
"nodeId": "at0021",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Unique device identifier (UDI)"
},
"localizedDescriptions": {
"en": "A numeric or alphanumeric string that is associated with this device within a given system."
},
"annotations": {
"comment": "Often fixed to the device as a barcode."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medical Devices']/items[openEHR-EHR-EVALUATION.device_summary.v0,'Device use statement']/data[at0001]/items[at0022]/items[openEHR-EHR-CLUSTER.device.v1]/items[at0021]/value",
"inputs": [
{
"suffix": "id",
"type": "TEXT"
},
{
"suffix": "type",
"type": "TEXT"
},
{
"suffix": "issuer",
"type": "TEXT"
},
{
"suffix": "assigner",
"type": "TEXT"
}
]
},
{
"id": "manufacturer",
"name": "Manufacturer",
"localizedName": "Manufacturer",
"rmType": "DV_TEXT",
"nodeId": "at0004",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Manufacturer"
},
"localizedDescriptions": {
"en": "Name of manufacturer."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medical Devices']/items[openEHR-EHR-EVALUATION.device_summary.v0,'Device use statement']/data[at0001]/items[at0022]/items[openEHR-EHR-CLUSTER.device.v1]/items[at0004]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "date_of_manufacture",
"name": "Date of manufacture",
"localizedName": "Date of manufacture",
"rmType": "DV_DATE_TIME",
"nodeId": "at0005",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Date of manufacture"
},
"localizedDescriptions": {
"en": "Date the device was manufactured."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medical Devices']/items[openEHR-EHR-EVALUATION.device_summary.v0,'Device use statement']/data[at0001]/items[at0022]/items[openEHR-EHR-CLUSTER.device.v1]/items[at0005]/value",
"inputs": [
{
"type": "DATETIME"
}
]
},
{
"id": "serial_number",
"name": "Serial number",
"localizedName": "Serial number",
"rmType": "DV_TEXT",
"nodeId": "at0020",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Serial number"
},
"localizedDescriptions": {
"en": "Number assigned by the manufacturer which can be found on the device, and should be specific to each device., its label, or accompanying packaging."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medical Devices']/items[openEHR-EHR-EVALUATION.device_summary.v0,'Device use statement']/data[at0001]/items[at0022]/items[openEHR-EHR-CLUSTER.device.v1]/items[at0020]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "catalogue_number",
"name": "Catalogue number",
"localizedName": "Catalogue number",
"rmType": "DV_TEXT",
"nodeId": "at0022",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Catalogue number"
},
"localizedDescriptions": {
"en": "The exact number assigned by the manufacturer, as it appears in the manufacturer's catalogue, device labeling, or accompanying packaging."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medical Devices']/items[openEHR-EHR-EVALUATION.device_summary.v0,'Device use statement']/data[at0001]/items[at0022]/items[openEHR-EHR-CLUSTER.device.v1]/items[at0022]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "model_number",
"name": "Model number",
"localizedName": "Model number",
"rmType": "DV_TEXT",
"nodeId": "at0023",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Model number"
},
"localizedDescriptions": {
"en": "The exact model number assigned by the manufacturer and found on the device label or accompanying packaging."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medical Devices']/items[openEHR-EHR-EVALUATION.device_summary.v0,'Device use statement']/data[at0001]/items[at0022]/items[openEHR-EHR-CLUSTER.device.v1]/items[at0023]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "batch_lot_number",
"name": "Batch/Lot number",
"localizedName": "Batch/Lot number",
"rmType": "DV_TEXT",
"nodeId": "at0006",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Batch/Lot number"
},
"localizedDescriptions": {
"en": "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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medical Devices']/items[openEHR-EHR-EVALUATION.device_summary.v0,'Device use statement']/data[at0001]/items[at0022]/items[openEHR-EHR-CLUSTER.device.v1]/items[at0006]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "software_version",
"name": "Software version",
"localizedName": "Software version",
"rmType": "DV_TEXT",
"nodeId": "at0025",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Software version"
},
"localizedDescriptions": {
"en": "Identification of the version of software being used in the medical device."
},
"annotations": {
"comment": "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)."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medical Devices']/items[openEHR-EHR-EVALUATION.device_summary.v0,'Device use statement']/data[at0001]/items[at0022]/items[openEHR-EHR-CLUSTER.device.v1]/items[at0025]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "date_of_expiry",
"name": "Date of expiry",
"localizedName": "Date of expiry",
"rmType": "DV_DATE_TIME",
"nodeId": "at0007",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Date of expiry"
},
"localizedDescriptions": {
"en": "Date after which the device/product is no longer fit for use, usually found on the device itself or printed on the accompanying packaging."
},
"annotations": {
"comment": "This date usually applies only to single use or disposable devices."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medical Devices']/items[openEHR-EHR-EVALUATION.device_summary.v0,'Device use statement']/data[at0001]/items[at0022]/items[openEHR-EHR-CLUSTER.device.v1]/items[at0007]/value",
"inputs": [
{
"type": "DATETIME"
}
]
},
{
"id": "other_identifier",
"name": "Other identifier",
"localizedName": "Other identifier",
"rmType": "DV_IDENTIFIER",
"nodeId": "at0024",
"min": 0,
"max": -1,
"localizedNames": {
"en": "Other identifier"
},
"localizedDescriptions": {
"en": "Unspecified identifier, which can be further specified in a template or at run time."
},
"annotations": {
"comment": "Coding of the name of the identifier with a coding system is desirable, if available."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medical Devices']/items[openEHR-EHR-EVALUATION.device_summary.v0,'Device use statement']/data[at0001]/items[at0022]/items[openEHR-EHR-CLUSTER.device.v1]/items[at0024]/value",
"inputs": [
{
"suffix": "id",
"type": "TEXT"
},
{
"suffix": "type",
"type": "TEXT"
},
{
"suffix": "issuer",
"type": "TEXT"
},
{
"suffix": "assigner",
"type": "TEXT"
}
]
},
{
"id": "comment",
"name": "Comment",
"localizedName": "Comment",
"rmType": "DV_TEXT",
"nodeId": "at0008",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Comment"
},
"localizedDescriptions": {
"en": "Additional narrative about the device not captured in other fields."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medical Devices']/items[openEHR-EHR-EVALUATION.device_summary.v0,'Device use statement']/data[at0001]/items[at0022]/items[openEHR-EHR-CLUSTER.device.v1]/items[at0008]/value",
"inputs": [
{
"type": "TEXT"
}
]
}
]
}
]
},
{
"id": "language",
"name": "Language",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medical Devices']/items[openEHR-EHR-EVALUATION.device_summary.v0,'Device use statement']/language",
"inContext": true
},
{
"id": "encoding",
"name": "Encoding",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medical Devices']/items[openEHR-EHR-EVALUATION.device_summary.v0,'Device use statement']/encoding",
"inContext": true
},
{
"id": "subject",
"name": "Subject",
"rmType": "PARTY_PROXY",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Medical Devices']/items[openEHR-EHR-EVALUATION.device_summary.v0,'Device use statement']/subject",
"inputs": [
{
"suffix": "id",
"type": "TEXT"
},
{
"suffix": "id_scheme",
"type": "TEXT"
},
{
"suffix": "id_namespace",
"type": "TEXT"
},
{
"suffix": "name",
"type": "TEXT"
}
],
"inContext": true
}
]
}
]
},
{
"id": "diagnostic_results",
"name": "Diagnostic Results",
"localizedName": "Diagnostic Results",
"rmType": "SECTION",
"nodeId": "openEHR-EHR-SECTION.adhoc.v1",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Diagnostic Results"
},
"localizedDescriptions": {
"en": "A generic section header which should be renamed in a template to suit a specific clinical context."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']",
"children": [
{
"id": "laboratory_test_result",
"name": "Laboratory test result",
"localizedName": "Laboratory test result",
"rmType": "OBSERVATION",
"nodeId": "openEHR-EHR-OBSERVATION.laboratory_test_result.v1",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Laboratory test result"
},
"localizedDescriptions": {
"en": "The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]",
"children": [
{
"id": "any_event",
"name": "Any event",
"localizedName": "Any event",
"rmType": "EVENT",
"nodeId": "at0002",
"min": 0,
"max": -1,
"localizedNames": {
"en": "Any event"
},
"localizedDescriptions": {
"en": "Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]",
"children": [
{
"id": "test_name",
"name": "Test name",
"localizedName": "Test name",
"rmType": "DV_TEXT",
"nodeId": "at0005",
"min": 1,
"max": 1,
"localizedNames": {
"en": "Test name"
},
"localizedDescriptions": {
"en": "Name of the laboratory investigation performed on the specimen(s)."
},
"annotations": {
"comment": "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)'."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0005]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "specimen",
"name": "Specimen",
"localizedName": "Specimen",
"rmType": "CLUSTER",
"nodeId": "openEHR-EHR-CLUSTER.specimen.v1",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Specimen"
},
"localizedDescriptions": {
"en": "A physical sample collected from, or related to, an individual for the purpose of investigation, examination or analysis."
},
"annotations": {
"comment": "For example: Tissue or body fluid."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.specimen.v1]",
"children": [
{
"id": "specimen_type",
"name": "Specimen type",
"localizedName": "Specimen type",
"rmType": "DV_TEXT",
"nodeId": "at0029",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Specimen type"
},
"localizedDescriptions": {
"en": "The type of specimen."
},
"annotations": {
"comment": "For example: Venous blood, bacterial culture, cytology, or tissue sample. Coding of the specimen type with a terminology is preferred, where possible.",
"fhir_mapping": "Specimen.type;Specimen.type"
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.specimen.v1]/items[at0029]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "method",
"name": "Method",
"localizedName": "Method",
"rmType": "DV_TEXT",
"nodeId": "at0007",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Method"
},
"localizedDescriptions": {
"en": "The method of collection used."
},
"annotations": {
"comment": "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.",
"fhir_mapping": "Specimen.collection.method;Specimen.collection.method"
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.specimen.v1]/items[at0007,'Method']/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "body_site",
"name": "Body site",
"localizedName": "Body site",
"rmType": "DV_TEXT",
"nodeId": "at0087",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Body site"
},
"localizedDescriptions": {
"en": "Identification of the body site or other location from where the specimen is collected."
},
"annotations": {
"comment": "For example: 'wound on left calf', 'IV cannula right arm', 'right kidney'.\nCoding 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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.specimen.v1]/items[at0087,'Body site']/value",
"inputs": [
{
"type": "TEXT"
}
]
}
]
},
{
"id": "diagnostic_service_category",
"name": "Diagnostic service category",
"localizedName": "Diagnostic service category",
"rmType": "DV_TEXT",
"nodeId": "at0077",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Diagnostic service category"
},
"localizedDescriptions": {
"en": "The diagnostic service or discipline that is responsible for the laboratory test result."
},
"annotations": {
"comment": "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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0077]/value",
"inputs": [
{
"type": "TEXT",
"list": [
{
"value": "Laboratory",
"label": "Laboratory"
},
{
"value": "Pathology",
"label": "Pathology"
}
],
"listOpen": false
}
]
},
{
"id": "laboratory_analyte_result",
"name": "Laboratory analyte result",
"localizedName": "Laboratory analyte result",
"rmType": "CLUSTER",
"nodeId": "openEHR-EHR-CLUSTER.laboratory_test_analyte.v1",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Laboratory analyte result"
},
"localizedDescriptions": {
"en": "The result of a laboratory test for a single analyte value."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.laboratory_test_analyte.v1]",
"children": [
{
"id": "analyte_name",
"name": "Analyte name",
"localizedName": "Analyte name",
"rmType": "DV_TEXT",
"nodeId": "at0024",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Analyte name"
},
"localizedDescriptions": {
"en": "The name of the analyte result."
},
"annotations": {
"comment": "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.",
"hl7v2_mapping": "OBX.3;OBX.3",
"fhir_mapping": "Observation.code;Observation.code"
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.laboratory_test_analyte.v1]/items[at0024]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "analyte_result",
"name": "Analyte result",
"localizedName": "Analyte result",
"rmType": "ELEMENT",
"nodeId": "at0001",
"min": 0,
"max": -1,
"localizedNames": {
"en": "Analyte result"
},
"localizedDescriptions": {
"en": "The value of the analyte result."
},
"annotations": {
"comment": "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.",
"hl7v2_mapping": "OBX.2, OBX.5, OBX.6, OBX.7, OBX.8;OBX.2, OBX.5, OBX.6, OBX.7, OBX.8",
"fhir_mapping": "Observation.value[x];Observation.value[x]"
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.laboratory_test_analyte.v1]/items[at0001]",
"children": [
{
"id": "coded_text_value",
"name": "Analyte result",
"localizedName": "Analyte result",
"rmType": "DV_CODED_TEXT",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Analyte result"
},
"localizedDescriptions": {
"en": "The value of the analyte result."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.laboratory_test_analyte.v1]/items[at0001]/Analyte result",
"inputs": [
{
"suffix": "code",
"type": "TEXT"
},
{
"suffix": "value",
"type": "TEXT"
}
],
"inContext": true
},
{
"id": "text_value",
"name": "Analyte result",
"localizedName": "Analyte result",
"rmType": "DV_TEXT",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Analyte result"
},
"localizedDescriptions": {
"en": "The value of the analyte result."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.laboratory_test_analyte.v1]/items[at0001]/Analyte result",
"inputs": [
{
"type": "TEXT"
}
],
"inContext": true
},
{
"id": "multimedia_value",
"name": "Analyte result",
"localizedName": "Analyte result",
"rmType": "DV_MULTIMEDIA",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Analyte result"
},
"localizedDescriptions": {
"en": "The value of the analyte result."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.laboratory_test_analyte.v1]/items[at0001]/Analyte result",
"inputs": [
{
"type": "TEXT"
}
],
"inContext": true
},
{
"id": "parsable_value",
"name": "Analyte result",
"localizedName": "Analyte result",
"rmType": "DV_PARSABLE",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Analyte result"
},
"localizedDescriptions": {
"en": "The value of the analyte result."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.laboratory_test_analyte.v1]/items[at0001]/Analyte result",
"inputs": [
{
"suffix": "value",
"type": "TEXT"
},
{
"suffix": "formalism",
"type": "TEXT"
}
],
"inContext": true
},
{
"id": "state_value",
"name": "Analyte result",
"localizedName": "Analyte result",
"rmType": "DV_STATE",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Analyte result"
},
"localizedDescriptions": {
"en": "The value of the analyte result."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.laboratory_test_analyte.v1]/items[at0001]/Analyte result",
"inputs": [
{
"suffix": "code",
"type": "TEXT"
},
{
"suffix": "value",
"type": "TEXT"
}
],
"inContext": true
},
{
"id": "boolean_value",
"name": "Analyte result",
"localizedName": "Analyte result",
"rmType": "DV_BOOLEAN",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Analyte result"
},
"localizedDescriptions": {
"en": "The value of the analyte result."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.laboratory_test_analyte.v1]/items[at0001]/Analyte result",
"inputs": [
{
"type": "BOOLEAN"
}
],
"inContext": true
},
{
"id": "identifier_value",
"name": "Analyte result",
"localizedName": "Analyte result",
"rmType": "DV_IDENTIFIER",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Analyte result"
},
"localizedDescriptions": {
"en": "The value of the analyte result."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.laboratory_test_analyte.v1]/items[at0001]/Analyte result",
"inputs": [
{
"suffix": "id",
"type": "TEXT"
},
{
"suffix": "type",
"type": "TEXT"
},
{
"suffix": "issuer",
"type": "TEXT"
},
{
"suffix": "assigner",
"type": "TEXT"
}
],
"inContext": true
},
{
"id": "uri_value",
"name": "Analyte result",
"localizedName": "Analyte result",
"rmType": "DV_URI",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Analyte result"
},
"localizedDescriptions": {
"en": "The value of the analyte result."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.laboratory_test_analyte.v1]/items[at0001]/Analyte result",
"inputs": [
{
"type": "TEXT"
}
],
"inContext": true
},
{
"id": "ehr_uri_value",
"name": "Analyte result",
"localizedName": "Analyte result",
"rmType": "DV_EHR_URI",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Analyte result"
},
"localizedDescriptions": {
"en": "The value of the analyte result."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.laboratory_test_analyte.v1]/items[at0001]/Analyte result",
"inputs": [
{
"type": "TEXT"
}
],
"inContext": true
},
{
"id": "duration_value",
"name": "Analyte result",
"localizedName": "Analyte result",
"rmType": "DV_DURATION",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Analyte result"
},
"localizedDescriptions": {
"en": "The value of the analyte result."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.laboratory_test_analyte.v1]/items[at0001]/Analyte result",
"inputs": [
{
"suffix": "year",
"type": "INTEGER",
"validation": {
"range": {
"minOp": ">=",
"min": 0
}
}
},
{
"suffix": "month",
"type": "INTEGER",
"validation": {
"range": {
"minOp": ">=",
"min": 0
}
}
},
{
"suffix": "day",
"type": "INTEGER",
"validation": {
"range": {
"minOp": ">=",
"min": 0
}
}
},
{
"suffix": "week",
"type": "INTEGER",
"validation": {
"range": {
"minOp": ">=",
"min": 0
}
}
},
{
"suffix": "hour",
"type": "INTEGER",
"validation": {
"range": {
"minOp": ">=",
"min": 0
}
}
},
{
"suffix": "minute",
"type": "INTEGER",
"validation": {
"range": {
"minOp": ">=",
"min": 0
}
}
},
{
"suffix": "second",
"type": "INTEGER",
"validation": {
"range": {
"minOp": ">=",
"min": 0
}
}
}
],
"inContext": true
},
{
"id": "quantity_value",
"name": "Analyte result",
"localizedName": "Analyte result",
"rmType": "DV_QUANTITY",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Analyte result"
},
"localizedDescriptions": {
"en": "The value of the analyte result."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.laboratory_test_analyte.v1]/items[at0001]/Analyte result",
"inputs": [
{
"suffix": "magnitude",
"type": "DECIMAL"
},
{
"suffix": "unit",
"type": "TEXT"
}
],
"inContext": true
},
{
"id": "count_value",
"name": "Analyte result",
"localizedName": "Analyte result",
"rmType": "DV_COUNT",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Analyte result"
},
"localizedDescriptions": {
"en": "The value of the analyte result."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.laboratory_test_analyte.v1]/items[at0001]/Analyte result",
"inputs": [
{
"type": "INTEGER"
}
],
"inContext": true
},
{
"id": "proportion_value",
"name": "Analyte result",
"localizedName": "Analyte result",
"rmType": "DV_PROPORTION",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Analyte result"
},
"localizedDescriptions": {
"en": "The value of the analyte result."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.laboratory_test_analyte.v1]/items[at0001]/Analyte result",
"proportionTypes": [
"integer_fraction",
"unitary",
"percent",
"ratio",
"fraction"
],
"inputs": [
{
"suffix": "numerator",
"type": "DECIMAL"
},
{
"suffix": "denominator",
"type": "DECIMAL"
}
],
"inContext": true
},
{
"id": "date_time_value",
"name": "Analyte result",
"localizedName": "Analyte result",
"rmType": "DV_DATE_TIME",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Analyte result"
},
"localizedDescriptions": {
"en": "The value of the analyte result."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.laboratory_test_analyte.v1]/items[at0001]/Analyte result",
"inputs": [
{
"type": "DATETIME"
}
],
"inContext": true
},
{
"id": "date_value",
"name": "Analyte result",
"localizedName": "Analyte result",
"rmType": "DV_DATE",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Analyte result"
},
"localizedDescriptions": {
"en": "The value of the analyte result."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.laboratory_test_analyte.v1]/items[at0001]/Analyte result",
"inputs": [
{
"type": "DATE"
}
],
"inContext": true
},
{
"id": "time_value",
"name": "Analyte result",
"localizedName": "Analyte result",
"rmType": "DV_TIME",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Analyte result"
},
"localizedDescriptions": {
"en": "The value of the analyte result."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.laboratory_test_analyte.v1]/items[at0001]/Analyte result",
"inputs": [
{
"type": "TIME"
}
],
"inContext": true
},
{
"id": "ordinal_value",
"name": "Analyte result",
"localizedName": "Analyte result",
"rmType": "DV_ORDINAL",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Analyte result"
},
"localizedDescriptions": {
"en": "The value of the analyte result."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.laboratory_test_analyte.v1]/items[at0001]/Analyte result",
"inputs": [
{
"type": "CODED_TEXT"
}
],
"inContext": true
}
]
}
]
},
{
"id": "interpretation",
"name": "Interpretation",
"localizedName": "Interpretation",
"rmType": "DV_TEXT",
"nodeId": "at0057",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Interpretation"
},
"localizedDescriptions": {
"en": "Narrative description of the key findings."
},
"annotations": {
"comment": "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'."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0057,'Interpretation']/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "multimedia_source",
"name": "Multimedia source",
"localizedName": "Multimedia source",
"rmType": "CLUSTER",
"nodeId": "openEHR-EHR-CLUSTER.multimedia_source.v0",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Multimedia source"
},
"localizedDescriptions": {
"en": "A multimedia resource that is generated or acquired during the provision of healthcare."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.multimedia_source.v0]",
"children": [
{
"id": "resource_name",
"name": "Resource name",
"localizedName": "Resource name",
"rmType": "DV_TEXT",
"nodeId": "at0002",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Resource name"
},
"localizedDescriptions": {
"en": "Name or title of the multimedia resource."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.multimedia_source.v0]/items[at0002]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "content",
"name": "Content",
"localizedName": "Content",
"rmType": "ELEMENT",
"nodeId": "at0001",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Content"
},
"localizedDescriptions": {
"en": "Digital representation of the resource."
},
"annotations": {
"comment": "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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.multimedia_source.v0]/items[at0001]",
"children": [
{
"id": "multimedia_value",
"localizedName": "Content",
"rmType": "DV_MULTIMEDIA",
"nodeId": "",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Content"
},
"localizedDescriptions": {
"en": "Digital representation of the resource."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.multimedia_source.v0]/items[at0001]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "uri_value",
"localizedName": "Content",
"rmType": "DV_URI",
"nodeId": "",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Content"
},
"localizedDescriptions": {
"en": "Digital representation of the resource."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.multimedia_source.v0]/items[at0001]/value",
"inputs": [
{
"type": "TEXT"
}
]
}
]
}
]
},
{
"id": "time",
"name": "Time",
"rmType": "DV_DATE_TIME",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/time",
"inputs": [
{
"type": "DATETIME"
}
],
"inContext": true
}
]
},
{
"id": "language",
"name": "Language",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/language",
"inContext": true
},
{
"id": "encoding",
"name": "Encoding",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/encoding",
"inContext": true
},
{
"id": "subject",
"name": "Subject",
"rmType": "PARTY_PROXY",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/subject",
"inputs": [
{
"suffix": "id",
"type": "TEXT"
},
{
"suffix": "id_scheme",
"type": "TEXT"
},
{
"suffix": "id_namespace",
"type": "TEXT"
},
{
"suffix": "name",
"type": "TEXT"
}
],
"inContext": true
}
]
},
{
"id": "imaging_examination_result",
"name": "Imaging examination result",
"localizedName": "Imaging examination result",
"rmType": "OBSERVATION",
"nodeId": "openEHR-EHR-OBSERVATION.imaging_exam_result.v0",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Imaging examination result"
},
"localizedDescriptions": {
"en": "Record the findings and interpretation of an imaging examination performed."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]",
"children": [
{
"id": "any_event",
"name": "Any event",
"localizedName": "Any event",
"rmType": "EVENT",
"nodeId": "at0002",
"min": 0,
"max": -1,
"localizedNames": {
"en": "Any event"
},
"localizedDescriptions": {
"en": "Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]",
"children": [
{
"id": "test_name",
"name": "Test name",
"localizedName": "Test name",
"rmType": "DV_TEXT",
"nodeId": "at0004",
"min": 1,
"max": 1,
"localizedNames": {
"en": "Test name"
},
"localizedDescriptions": {
"en": "The name of the imaging examination or procedure performed."
},
"annotations": {
"comment": "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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0004]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "modality",
"name": "Modality",
"localizedName": "Modality",
"rmType": "DV_TEXT",
"nodeId": "at0005",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Modality"
},
"localizedDescriptions": {
"en": "Type of equipment that originally acquired the image or series of images."
},
"annotations": {
"comment": "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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0005]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "anatomical_site",
"name": "Anatomical site",
"localizedName": "Anatomical site",
"rmType": "DV_TEXT",
"nodeId": "at0055",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Anatomical site"
},
"localizedDescriptions": {
"en": "Simple description about the physical place on, or in, the body that was imaged."
},
"annotations": {
"comment": "This data element is redundant if the anatomical site is identified in the 'Test name'."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0055]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "overall_result_status",
"name": "Overall result status",
"localizedName": "Overall result status",
"rmType": "DV_CODED_TEXT",
"nodeId": "at0007",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Overall result status"
},
"localizedDescriptions": {
"en": "The status of the examination result as a whole."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0007]/value",
"inputs": [
{
"suffix": "code",
"type": "CODED_TEXT",
"list": [
{
"value": "at0009",
"label": "Registered",
"localizedLabels": {
"en": "Registered"
},
"localizedDescriptions": {
"en": "No result yet available."
}
},
{
"value": "at0010",
"label": "Interim",
"localizedLabels": {
"en": "Interim"
},
"localizedDescriptions": {
"en": "This is an initial or interim result: data may be missing or verification not been performed."
}
},
{
"value": "at0011",
"label": "Final",
"localizedLabels": {
"en": "Final"
},
"localizedDescriptions": {
"en": "The result is complete and verified by the responsible radiologist."
}
},
{
"value": "at0012",
"label": "Amended",
"localizedLabels": {
"en": "Amended"
},
"localizedDescriptions": {
"en": "The result has been modified subsequent to being Final, and is complete and verified by the radiologist."
}
},
{
"value": "at0013",
"label": "Cancelled / Aborted",
"localizedLabels": {
"en": "Cancelled / Aborted"
},
"localizedDescriptions": {
"en": "The result is not available because the examination was not started or completed."
}
}
]
}
]
},
{
"id": "findings",
"name": "Findings",
"localizedName": "Findings",
"rmType": "DV_TEXT",
"nodeId": "at0008",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Findings"
},
"localizedDescriptions": {
"en": "Narrative description of the clinical findings."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0008]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "imaging_finding",
"name": "Imaging finding",
"localizedName": "Imaging finding",
"rmType": "CLUSTER",
"nodeId": "openEHR-EHR-CLUSTER.imaging_finding.v0",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Imaging finding"
},
"localizedDescriptions": {
"en": "A single finding in an imaging examination."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_finding.v0]",
"children": [
{
"id": "finding_name",
"name": "Finding name",
"localizedName": "Finding name",
"rmType": "DV_TEXT",
"nodeId": "at0024",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Finding name"
},
"localizedDescriptions": {
"en": "The name of the finding."
},
"annotations": {
"comment": "Coding with an external terminology is strongly recommended.",
"hl7v2_mapping": "OBX.3;OBX.3",
"fhir_mapping": "Observation.code;Observation.code"
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_finding.v0]/items[at0024]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "anatomical_location",
"name": "Anatomical location",
"localizedName": "Anatomical location",
"rmType": "DV_TEXT",
"nodeId": "at0033",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Anatomical location"
},
"localizedDescriptions": {
"en": "Simple description of anatomical location."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_finding.v0]/items[at0033]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "presence",
"name": "Presence?",
"localizedName": "Presence?",
"rmType": "DV_CODED_TEXT",
"nodeId": "at0001",
"min": 0,
"max": -1,
"localizedNames": {
"en": "Presence?"
},
"localizedDescriptions": {
"en": "The presence or absence of the finding."
},
"annotations": {
"comment": "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.",
"hl7v2_mapping": "OBX.2, OBX.5, OBX.6, OBX.7, OBX.8;OBX.2, OBX.5, OBX.6, OBX.7, OBX.8",
"fhir_mapping": "Observation.value[x];Observation.value[x]"
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_finding.v0]/items[at0001]/value",
"inputs": [
{
"suffix": "code",
"type": "CODED_TEXT",
"list": [
{
"value": "at0035",
"label": "Present",
"localizedLabels": {
"en": "Present"
},
"localizedDescriptions": {
"en": "The finding is observed in the image."
}
},
{
"value": "at0036",
"label": "Absent",
"localizedLabels": {
"en": "Absent"
},
"localizedDescriptions": {
"en": "The finding is not observed in the image."
}
},
{
"value": "at0037",
"label": "Indeterminate",
"localizedLabels": {
"en": "Indeterminate"
},
"localizedDescriptions": {
"en": "It is not possible to determine if the finding is present or absent."
}
}
]
}
]
},
{
"id": "description",
"name": "Description",
"localizedName": "Description",
"rmType": "DV_TEXT",
"nodeId": "at0028",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Description"
},
"localizedDescriptions": {
"en": "Narrative description about the observed clinical finding."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_finding.v0]/items[at0028]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "comparison_to_previous",
"name": "Comparison to previous",
"localizedName": "Comparison to previous",
"rmType": "DV_CODED_TEXT",
"nodeId": "at0029",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Comparison to previous"
},
"localizedDescriptions": {
"en": "Narrative description about the difference between a previous finding and the finding in this report."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_finding.v0]/items[at0029]/value",
"inputs": [
{
"suffix": "code",
"type": "CODED_TEXT",
"list": [
{
"value": "at0030",
"label": "Improving",
"localizedLabels": {
"en": "Improving"
},
"localizedDescriptions": {
"en": "The finding is improving compared to previous imaging examinations."
}
},
{
"value": "at0031",
"label": "Unchanged",
"localizedLabels": {
"en": "Unchanged"
},
"localizedDescriptions": {
"en": "The finding is unchanged compared to previous imaging examinations."
}
},
{
"value": "at0032",
"label": "Worsening",
"localizedLabels": {
"en": "Worsening"
},
"localizedDescriptions": {
"en": "The finding is worsening compared to previous imaging examinations."
}
}
],
"listOpen": true
},
{
"suffix": "other",
"type": "TEXT"
}
]
},
{
"id": "comment",
"name": "Comment",
"localizedName": "Comment",
"rmType": "DV_TEXT",
"nodeId": "at0003",
"min": 0,
"max": -1,
"localizedNames": {
"en": "Comment"
},
"localizedDescriptions": {
"en": "Additional narrative about the finding, not captured in other fields."
},
"annotations": {
"hl7v2_mapping": "NTE.3;NTE.3",
"fhir_mapping": "Observation.note;Observation.note"
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_finding.v0]/items[at0003]/value",
"inputs": [
{
"type": "TEXT"
}
]
}
]
},
{
"id": "comparison_with_previous",
"name": "Comparison with previous",
"localizedName": "Comparison with previous",
"rmType": "DV_TEXT",
"nodeId": "at0056",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Comparison with previous"
},
"localizedDescriptions": {
"en": "Narrative descripition about the comparison of this image, or series of images, with previous similar examinations."
},
"annotations": {
"comment": "If there is no availability of previous imaging and/or reports this should also be stated using this data element."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0056]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "conclusion",
"name": "Conclusion",
"localizedName": "Conclusion",
"rmType": "DV_TEXT",
"nodeId": "at0021",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Conclusion"
},
"localizedDescriptions": {
"en": "Narrative concise, clinically relevant interpretation of all imaging findings, and include a comparison with previous studies where appropriate."
},
"annotations": {
"comment": "Also referred to as 'Opinion' or 'Impression'."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0021]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "imaging_differential_diagnosis",
"name": "Imaging differential diagnosis",
"localizedName": "Imaging differential diagnosis",
"rmType": "DV_TEXT",
"nodeId": "at0058",
"min": 0,
"max": -1,
"localizedNames": {
"en": "Imaging differential diagnosis"
},
"localizedDescriptions": {
"en": "Single word, phrase or brief description representing a possible condition or diagnosis."
},
"annotations": {
"comment": "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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0058]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "imaging_diagnosis",
"name": "Imaging diagnosis",
"localizedName": "Imaging diagnosis",
"rmType": "DV_TEXT",
"nodeId": "at0020",
"min": 0,
"max": -1,
"localizedNames": {
"en": "Imaging diagnosis"
},
"localizedDescriptions": {
"en": "Single word, phrase or brief description representing the likely condition or diagnosis."
},
"annotations": {
"comment": "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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0020]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "multimedia_source",
"name": "Multimedia source",
"localizedName": "Multimedia source",
"rmType": "CLUSTER",
"nodeId": "openEHR-EHR-CLUSTER.multimedia_source.v0",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Multimedia source"
},
"localizedDescriptions": {
"en": "A multimedia resource that is generated or acquired during the provision of healthcare."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.multimedia_source.v0]",
"children": [
{
"id": "resource_name",
"name": "Resource name",
"localizedName": "Resource name",
"rmType": "DV_TEXT",
"nodeId": "at0002",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Resource name"
},
"localizedDescriptions": {
"en": "Name or title of the multimedia resource."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.multimedia_source.v0]/items[at0002]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "content",
"name": "Content",
"localizedName": "Content",
"rmType": "ELEMENT",
"nodeId": "at0001",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Content"
},
"localizedDescriptions": {
"en": "Digital representation of the resource."
},
"annotations": {
"comment": "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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.multimedia_source.v0]/items[at0001]",
"children": [
{
"id": "multimedia_value",
"localizedName": "Content",
"rmType": "DV_MULTIMEDIA",
"nodeId": "",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Content"
},
"localizedDescriptions": {
"en": "Digital representation of the resource."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.multimedia_source.v0]/items[at0001]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "uri_value",
"localizedName": "Content",
"rmType": "DV_URI",
"nodeId": "",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Content"
},
"localizedDescriptions": {
"en": "Digital representation of the resource."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.multimedia_source.v0]/items[at0001]/value",
"inputs": [
{
"type": "TEXT"
}
]
}
]
}
]
},
{
"id": "time",
"name": "Time",
"rmType": "DV_DATE_TIME",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/time",
"inputs": [
{
"type": "DATETIME"
}
],
"inContext": true
}
]
},
{
"id": "technique",
"name": "Technique",
"localizedName": "Technique",
"rmType": "DV_TEXT",
"nodeId": "at0049",
"min": 0,
"max": 1,
"dependsOn": [
"any_event"
],
"localizedNames": {
"en": "Technique"
},
"localizedDescriptions": {
"en": "Narrative description about the technical details and procedure."
},
"annotations": {
"comment": "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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[at0049]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "imaging_quality",
"name": "Imaging quality",
"localizedName": "Imaging quality",
"rmType": "DV_TEXT",
"nodeId": "at0057",
"min": 0,
"max": 1,
"dependsOn": [
"any_event"
],
"localizedNames": {
"en": "Imaging quality"
},
"localizedDescriptions": {
"en": "Narrative description about the quality of the examination."
},
"annotations": {
"comment": "For example: the nature of any limitations and their impact on interpretation."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[at0057]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "examination_request_details",
"name": "Examination request details",
"localizedName": "Examination request details",
"rmType": "CLUSTER",
"nodeId": "at0027",
"min": 0,
"max": -1,
"dependsOn": [
"any_event"
],
"localizedNames": {
"en": "Examination request details"
},
"localizedDescriptions": {
"en": "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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[at0027]",
"children": [
{
"id": "requester_order_identifier",
"name": "Requester order identifier",
"localizedName": "Requester order identifier",
"rmType": "DV_IDENTIFIER",
"nodeId": "at0028",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Requester order identifier"
},
"localizedDescriptions": {
"en": "The local identifier assigned to the order by the order requester. Equivalent to the HL7 Placer Order Identifier."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[at0027]/items[at0028]/value",
"inputs": [
{
"suffix": "id",
"type": "TEXT"
},
{
"suffix": "type",
"type": "TEXT"
},
{
"suffix": "issuer",
"type": "TEXT"
},
{
"suffix": "assigner",
"type": "TEXT"
}
]
},
{
"id": "examination_requested_name",
"name": "Examination requested name",
"localizedName": "Examination requested name",
"rmType": "DV_TEXT",
"nodeId": "at0029",
"min": 0,
"max": -1,
"localizedNames": {
"en": "Examination requested name"
},
"localizedDescriptions": {
"en": "Identification of imaging examination or procedure requested, where the examination requested differs from the examination actually performed."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[at0027]/items[at0029]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "receiver_order_identifier",
"name": "Receiver order identifier",
"localizedName": "Receiver order identifier",
"rmType": "DV_IDENTIFIER",
"nodeId": "at0031",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Receiver order identifier"
},
"localizedDescriptions": {
"en": "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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[at0027]/items[at0031]/value",
"inputs": [
{
"suffix": "id",
"type": "TEXT"
},
{
"suffix": "type",
"type": "TEXT"
},
{
"suffix": "issuer",
"type": "TEXT"
},
{
"suffix": "assigner",
"type": "TEXT"
}
]
},
{
"id": "dicom_study_identifier",
"name": "DICOM study identifier",
"localizedName": "DICOM study identifier",
"rmType": "DV_URI",
"nodeId": "at0032",
"min": 0,
"max": 1,
"localizedNames": {
"en": "DICOM study identifier"
},
"localizedDescriptions": {
"en": "Unique identifier of this study allocated by the imaging service."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[at0027]/items[at0032]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "report_identifier",
"name": "Report identifier",
"localizedName": "Report identifier",
"rmType": "DV_IDENTIFIER",
"nodeId": "at0033",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Report identifier"
},
"localizedDescriptions": {
"en": "The local identifier given to the imaging examination report."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[at0027]/items[at0033]/value",
"inputs": [
{
"suffix": "id",
"type": "TEXT"
},
{
"suffix": "type",
"type": "TEXT"
},
{
"suffix": "issuer",
"type": "TEXT"
},
{
"suffix": "assigner",
"type": "TEXT"
}
]
},
{
"id": "reported_image",
"name": "Reported image",
"localizedName": "Reported image",
"rmType": "CLUSTER",
"nodeId": "at0034",
"min": 0,
"max": -1,
"localizedNames": {
"en": "Reported image"
},
"localizedDescriptions": {
"en": "Details about the image being reported."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[at0027]/items[at0034,'Reported image']",
"children": [
{
"id": "image_identifier",
"name": "Image identifier",
"localizedName": "Image identifier",
"rmType": "DV_IDENTIFIER",
"nodeId": "at0035",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Image identifier"
},
"localizedDescriptions": {
"en": "Unique identifier of this image allocated by the imaging service (often the DICOM image instance UID)."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[at0027]/items[at0034,'Reported image']/items[at0035]/value",
"inputs": [
{
"suffix": "id",
"type": "TEXT"
},
{
"suffix": "type",
"type": "TEXT"
},
{
"suffix": "issuer",
"type": "TEXT"
},
{
"suffix": "assigner",
"type": "TEXT"
}
]
},
{
"id": "dicom_series_identifier",
"name": "DICOM series identifier",
"localizedName": "DICOM series identifier",
"rmType": "DV_IDENTIFIER",
"nodeId": "at0036",
"min": 0,
"max": 1,
"localizedNames": {
"en": "DICOM series identifier"
},
"localizedDescriptions": {
"en": "Unique identifier of this series allocated by the imaging service."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[at0027]/items[at0034,'Reported image']/items[at0036]/value",
"inputs": [
{
"suffix": "id",
"type": "TEXT"
},
{
"suffix": "type",
"type": "TEXT"
},
{
"suffix": "issuer",
"type": "TEXT"
},
{
"suffix": "assigner",
"type": "TEXT"
}
]
},
{
"id": "view",
"name": "View",
"localizedName": "View",
"rmType": "DV_TEXT",
"nodeId": "at0037",
"min": 0,
"max": 1,
"localizedNames": {
"en": "View"
},
"localizedDescriptions": {
"en": "The name of the imaging view e.g Lateral or Antero-posterior (AP). Coding using a terminology is desirable, where possible."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[at0027]/items[at0034,'Reported image']/items[at0037]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "position",
"name": "Position",
"localizedName": "Position",
"rmType": "DV_TEXT",
"nodeId": "at0038",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Position"
},
"localizedDescriptions": {
"en": "Description of the subject of care's positon when the image was performed."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[at0027]/items[at0034,'Reported image']/items[at0038]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "image_datetime",
"name": "Image DateTime",
"localizedName": "Image DateTime",
"rmType": "DV_DATE_TIME",
"nodeId": "at0039",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Image DateTime"
},
"localizedDescriptions": {
"en": "Specific date/time the imaging examination was performed."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[at0027]/items[at0034,'Reported image']/items[at0039]/value",
"inputs": [
{
"type": "DATETIME"
}
]
},
{
"id": "image",
"name": "Image",
"localizedName": "Image",
"rmType": "DV_MULTIMEDIA",
"nodeId": "at0040",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Image"
},
"localizedDescriptions": {
"en": "An attached or referenced image of a current view."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[at0027]/items[at0034,'Reported image']/items[at0040]/value",
"inputs": [
{
"type": "TEXT"
}
]
}
]
},
{
"id": "comparison_image",
"name": "Comparison image",
"localizedName": "Comparison image",
"rmType": "CLUSTER",
"nodeId": "at0034",
"min": 0,
"max": -1,
"localizedNames": {
"en": "Comparison image"
},
"localizedDescriptions": {
"en": "Details about an image being compared to the image being reported."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[at0027]/items[at0034,'Comparison image']",
"children": [
{
"id": "image_identifier",
"name": "Image identifier",
"localizedName": "Image identifier",
"rmType": "DV_IDENTIFIER",
"nodeId": "at0035",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Image identifier"
},
"localizedDescriptions": {
"en": "Unique identifier of this image allocated by the imaging service (often the DICOM image instance UID)."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[at0027]/items[at0034,'Comparison image']/items[at0035]/value",
"inputs": [
{
"suffix": "id",
"type": "TEXT"
},
{
"suffix": "type",
"type": "TEXT"
},
{
"suffix": "issuer",
"type": "TEXT"
},
{
"suffix": "assigner",
"type": "TEXT"
}
]
},
{
"id": "dicom_series_identifier",
"name": "DICOM series identifier",
"localizedName": "DICOM series identifier",
"rmType": "DV_IDENTIFIER",
"nodeId": "at0036",
"min": 0,
"max": 1,
"localizedNames": {
"en": "DICOM series identifier"
},
"localizedDescriptions": {
"en": "Unique identifier of this series allocated by the imaging service."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[at0027]/items[at0034,'Comparison image']/items[at0036]/value",
"inputs": [
{
"suffix": "id",
"type": "TEXT"
},
{
"suffix": "type",
"type": "TEXT"
},
{
"suffix": "issuer",
"type": "TEXT"
},
{
"suffix": "assigner",
"type": "TEXT"
}
]
},
{
"id": "view",
"name": "View",
"localizedName": "View",
"rmType": "DV_TEXT",
"nodeId": "at0037",
"min": 0,
"max": 1,
"localizedNames": {
"en": "View"
},
"localizedDescriptions": {
"en": "The name of the imaging view e.g Lateral or Antero-posterior (AP). Coding using a terminology is desirable, where possible."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[at0027]/items[at0034,'Comparison image']/items[at0037]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "position",
"name": "Position",
"localizedName": "Position",
"rmType": "DV_TEXT",
"nodeId": "at0038",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Position"
},
"localizedDescriptions": {
"en": "Description of the subject of care's positon when the image was performed."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[at0027]/items[at0034,'Comparison image']/items[at0038]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "image_datetime",
"name": "Image DateTime",
"localizedName": "Image DateTime",
"rmType": "DV_DATE_TIME",
"nodeId": "at0039",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Image DateTime"
},
"localizedDescriptions": {
"en": "Specific date/time the imaging examination was performed."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[at0027]/items[at0034,'Comparison image']/items[at0039]/value",
"inputs": [
{
"type": "DATETIME"
}
]
},
{
"id": "image",
"name": "Image",
"localizedName": "Image",
"rmType": "DV_MULTIMEDIA",
"nodeId": "at0040",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Image"
},
"localizedDescriptions": {
"en": "An attached or referenced image of a current view."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[at0027]/items[at0034,'Comparison image']/items[at0040]/value",
"inputs": [
{
"type": "TEXT"
}
]
}
]
}
]
},
{
"id": "language",
"name": "Language",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/language",
"inContext": true
},
{
"id": "encoding",
"name": "Encoding",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/encoding",
"inContext": true
},
{
"id": "subject",
"name": "Subject",
"rmType": "PARTY_PROXY",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Diagnostic Results']/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/subject",
"inputs": [
{
"suffix": "id",
"type": "TEXT"
},
{
"suffix": "id_scheme",
"type": "TEXT"
},
{
"suffix": "id_namespace",
"type": "TEXT"
},
{
"suffix": "name",
"type": "TEXT"
}
],
"inContext": true
}
]
}
]
},
{
"id": "vital_signs",
"name": "Vital Signs",
"localizedName": "Vital Signs",
"rmType": "SECTION",
"nodeId": "openEHR-EHR-SECTION.adhoc.v1",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Vital Signs"
},
"localizedDescriptions": {
"en": "A generic section header which should be renamed in a template to suit a specific clinical context."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']",
"children": [
{
"id": "body_weight",
"name": "Body weight",
"localizedName": "Body weight",
"rmType": "OBSERVATION",
"nodeId": "openEHR-EHR-OBSERVATION.body_weight.v2",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Body weight"
},
"localizedDescriptions": {
"en": "Measurement of the body weight of an individual."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.body_weight.v2]",
"children": [
{
"id": "any_event",
"name": "Any event",
"localizedName": "Any event",
"rmType": "EVENT",
"nodeId": "at0003",
"min": 0,
"max": -1,
"localizedNames": {
"en": "Any event"
},
"localizedDescriptions": {
"en": "Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.body_weight.v2]/data[at0002]/events[at0003]",
"children": [
{
"id": "weight",
"name": "Weight",
"localizedName": "Weight",
"rmType": "DV_QUANTITY",
"nodeId": "at0004",
"min": 1,
"max": 1,
"localizedNames": {
"en": "Weight"
},
"localizedDescriptions": {
"en": "The weight of the individual."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.body_weight.v2]/data[at0002]/events[at0003]/data[at0001]/items[at0004]/value",
"inputs": [
{
"suffix": "magnitude",
"type": "DECIMAL"
},
{
"suffix": "unit",
"type": "CODED_TEXT",
"list": [
{
"value": "kg",
"label": "kg",
"validation": {
"range": {
"minOp": ">=",
"min": 0.0,
"maxOp": "<=",
"max": 1000.0
}
}
},
{
"value": "[lb_av]",
"label": "[lb_av]",
"validation": {
"range": {
"minOp": ">=",
"min": 0.0,
"maxOp": "<=",
"max": 2000.0
}
}
},
{
"value": "g",
"label": "g",
"validation": {
"range": {
"minOp": ">=",
"min": 0.0,
"maxOp": "<=",
"max": 1000000.0
}
}
}
]
}
],
"termBindings": {
"LOINC": {
"value": "29463-7",
"terminologyId": "LOINC"
}
}
},
{
"id": "time",
"name": "Time",
"rmType": "DV_DATE_TIME",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.body_weight.v2]/data[at0002]/events[at0003]/time",
"inputs": [
{
"type": "DATETIME"
}
],
"inContext": true
}
]
},
{
"id": "language",
"name": "Language",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.body_weight.v2]/language",
"inContext": true
},
{
"id": "encoding",
"name": "Encoding",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.body_weight.v2]/encoding",
"inContext": true
},
{
"id": "subject",
"name": "Subject",
"rmType": "PARTY_PROXY",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.body_weight.v2]/subject",
"inputs": [
{
"suffix": "id",
"type": "TEXT"
},
{
"suffix": "id_scheme",
"type": "TEXT"
},
{
"suffix": "id_namespace",
"type": "TEXT"
},
{
"suffix": "name",
"type": "TEXT"
}
],
"inContext": true
}
]
},
{
"id": "height_length",
"name": "Height/Length",
"localizedName": "Height/Length",
"rmType": "OBSERVATION",
"nodeId": "openEHR-EHR-OBSERVATION.height.v2",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Height/Length"
},
"localizedDescriptions": {
"en": "Height, or body length, is measured from crown of head to sole of foot."
},
"annotations": {
"comment": "Height is measured with the individual in a standing position and body length in a recumbent position."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.height.v2]",
"children": [
{
"id": "any_event",
"name": "Any event",
"localizedName": "Any event",
"rmType": "EVENT",
"nodeId": "at0002",
"min": 0,
"max": -1,
"localizedNames": {
"en": "Any event"
},
"localizedDescriptions": {
"en": "Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.height.v2]/data[at0001]/events[at0002]",
"children": [
{
"id": "height_length",
"name": "Height/Length",
"localizedName": "Height/Length",
"rmType": "DV_QUANTITY",
"nodeId": "at0004",
"min": 1,
"max": 1,
"localizedNames": {
"en": "Height/Length"
},
"localizedDescriptions": {
"en": "The length of the body from crown of head to sole of foot."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.height.v2]/data[at0001]/events[at0002]/data[at0003]/items[at0004]/value",
"inputs": [
{
"suffix": "magnitude",
"type": "DECIMAL"
},
{
"suffix": "unit",
"type": "CODED_TEXT",
"list": [
{
"value": "cm",
"label": "cm",
"validation": {
"range": {
"minOp": ">=",
"min": 0.0,
"maxOp": "<=",
"max": 1000.0
}
}
},
{
"value": "[in_i]",
"label": "[in_i]",
"validation": {
"range": {
"minOp": ">=",
"min": 0.0,
"maxOp": "<=",
"max": 250.0
}
}
}
]
}
],
"termBindings": {
"LOINC": {
"value": "8302-2",
"terminologyId": "LOINC"
}
}
},
{
"id": "time",
"name": "Time",
"rmType": "DV_DATE_TIME",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.height.v2]/data[at0001]/events[at0002]/time",
"inputs": [
{
"type": "DATETIME"
}
],
"inContext": true
}
]
},
{
"id": "language",
"name": "Language",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.height.v2]/language",
"inContext": true
},
{
"id": "encoding",
"name": "Encoding",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.height.v2]/encoding",
"inContext": true
},
{
"id": "subject",
"name": "Subject",
"rmType": "PARTY_PROXY",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.height.v2]/subject",
"inputs": [
{
"suffix": "id",
"type": "TEXT"
},
{
"suffix": "id_scheme",
"type": "TEXT"
},
{
"suffix": "id_namespace",
"type": "TEXT"
},
{
"suffix": "name",
"type": "TEXT"
}
],
"inContext": true
}
]
},
{
"id": "respiration",
"name": "Respiration",
"localizedName": "Respiration",
"rmType": "OBSERVATION",
"nodeId": "openEHR-EHR-OBSERVATION.respiration.v2",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Respiration"
},
"localizedDescriptions": {
"en": "The characteristics of spontaneous breathing by an individual."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.respiration.v2]",
"children": [
{
"id": "any_event",
"name": "Any event",
"localizedName": "Any event",
"rmType": "EVENT",
"nodeId": "at0002",
"min": 0,
"max": -1,
"localizedNames": {
"en": "Any event"
},
"localizedDescriptions": {
"en": "Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.respiration.v2]/data[at0001]/events[at0002]",
"children": [
{
"id": "rate",
"name": "Rate",
"localizedName": "Rate",
"rmType": "DV_QUANTITY",
"nodeId": "at0004",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Rate"
},
"localizedDescriptions": {
"en": "The frequency of spontaneous breathing."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.respiration.v2]/data[at0001]/events[at0002]/data[at0003]/items[at0004]/value",
"inputs": [
{
"suffix": "magnitude",
"type": "DECIMAL",
"validation": {
"range": {
"minOp": ">=",
"min": 0.0,
"maxOp": "<=",
"max": 200.0
},
"precision": {
"minOp": ">=",
"min": 0,
"maxOp": "<=",
"max": 0
}
}
},
{
"suffix": "unit",
"type": "CODED_TEXT",
"list": [
{
"value": "/min",
"label": "/min",
"validation": {
"range": {
"minOp": ">=",
"min": 0.0,
"maxOp": "<=",
"max": 200.0
},
"precision": {
"minOp": ">=",
"min": 0,
"maxOp": "<=",
"max": 0
}
}
}
]
}
]
},
{
"id": "time",
"name": "Time",
"rmType": "DV_DATE_TIME",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.respiration.v2]/data[at0001]/events[at0002]/time",
"inputs": [
{
"type": "DATETIME"
}
],
"inContext": true
}
]
},
{
"id": "language",
"name": "Language",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.respiration.v2]/language",
"inContext": true
},
{
"id": "encoding",
"name": "Encoding",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.respiration.v2]/encoding",
"inContext": true
},
{
"id": "subject",
"name": "Subject",
"rmType": "PARTY_PROXY",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.respiration.v2]/subject",
"inputs": [
{
"suffix": "id",
"type": "TEXT"
},
{
"suffix": "id_scheme",
"type": "TEXT"
},
{
"suffix": "id_namespace",
"type": "TEXT"
},
{
"suffix": "name",
"type": "TEXT"
}
],
"inContext": true
}
]
},
{
"id": "pulse_heart_beat",
"name": "Pulse/Heart beat",
"localizedName": "Pulse/Heart beat",
"rmType": "OBSERVATION",
"nodeId": "openEHR-EHR-OBSERVATION.pulse.v2",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Pulse/Heart beat"
},
"localizedDescriptions": {
"en": "The rate and associated attributes for a pulse or heart beat."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.pulse.v2]",
"children": [
{
"id": "any_event",
"name": "Any event",
"localizedName": "Any event",
"rmType": "EVENT",
"nodeId": "at0003",
"min": 0,
"max": -1,
"localizedNames": {
"en": "Any event"
},
"localizedDescriptions": {
"en": "Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.pulse.v2]/data[at0002]/events[at0003]",
"children": [
{
"id": "rate",
"name": "Rate",
"localizedName": "Rate",
"rmType": "DV_QUANTITY",
"nodeId": "at0004",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Rate"
},
"localizedDescriptions": {
"en": "The rate of the pulse or heart beat, measured in beats per minute."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.pulse.v2]/data[at0002]/events[at0003]/data[at0001]/items[at0004]/value",
"inputs": [
{
"suffix": "magnitude",
"type": "DECIMAL",
"validation": {
"range": {
"minOp": ">=",
"min": 0.0,
"maxOp": "<",
"max": 1000.0
},
"precision": {
"minOp": ">=",
"min": 0,
"maxOp": "<=",
"max": 0
}
}
},
{
"suffix": "unit",
"type": "CODED_TEXT",
"list": [
{
"value": "/min",
"label": "/min",
"validation": {
"range": {
"minOp": ">=",
"min": 0.0,
"maxOp": "<",
"max": 1000.0
},
"precision": {
"minOp": ">=",
"min": 0,
"maxOp": "<=",
"max": 0
}
}
}
]
}
]
},
{
"id": "time",
"name": "Time",
"rmType": "DV_DATE_TIME",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.pulse.v2]/data[at0002]/events[at0003]/time",
"inputs": [
{
"type": "DATETIME"
}
],
"inContext": true
}
]
},
{
"id": "language",
"name": "Language",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.pulse.v2]/language",
"inContext": true
},
{
"id": "encoding",
"name": "Encoding",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.pulse.v2]/encoding",
"inContext": true
},
{
"id": "subject",
"name": "Subject",
"rmType": "PARTY_PROXY",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.pulse.v2]/subject",
"inputs": [
{
"suffix": "id",
"type": "TEXT"
},
{
"suffix": "id_scheme",
"type": "TEXT"
},
{
"suffix": "id_namespace",
"type": "TEXT"
},
{
"suffix": "name",
"type": "TEXT"
}
],
"inContext": true
}
]
},
{
"id": "body_temperature",
"name": "Body temperature",
"localizedName": "Body temperature",
"rmType": "OBSERVATION",
"nodeId": "openEHR-EHR-OBSERVATION.body_temperature.v2",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Body temperature"
},
"localizedDescriptions": {
"en": "A measurement of the body temperature, which is a surrogate for the core body temperature of the individual."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.body_temperature.v2]",
"children": [
{
"id": "any_event",
"name": "Any event",
"localizedName": "Any event",
"rmType": "EVENT",
"nodeId": "at0003",
"min": 0,
"max": -1,
"localizedNames": {
"en": "Any event"
},
"localizedDescriptions": {
"en": "Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.body_temperature.v2]/data[at0002]/events[at0003]",
"children": [
{
"id": "temperature",
"name": "Temperature",
"localizedName": "Temperature",
"rmType": "DV_QUANTITY",
"nodeId": "at0004",
"min": 1,
"max": 1,
"localizedNames": {
"en": "Temperature"
},
"localizedDescriptions": {
"en": "The measured temperature."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.body_temperature.v2]/data[at0002]/events[at0003]/data[at0001]/items[at0004]/value",
"inputs": [
{
"suffix": "magnitude",
"type": "DECIMAL"
},
{
"suffix": "unit",
"type": "CODED_TEXT",
"list": [
{
"value": "Cel",
"label": "Cel",
"validation": {
"range": {
"minOp": ">=",
"min": 0.0,
"maxOp": "<",
"max": 100.0
},
"precision": {
"minOp": ">=",
"min": 1,
"maxOp": "<=",
"max": 1
}
}
},
{
"value": "[degF]",
"label": "[degF]",
"validation": {
"range": {
"minOp": ">=",
"min": 30.0,
"maxOp": "<",
"max": 200.0
},
"precision": {
"minOp": ">=",
"min": 1,
"maxOp": "<=",
"max": 1
}
}
}
]
}
],
"termBindings": {
"LNC205": {
"value": "8310-5",
"terminologyId": "LNC205"
},
"SNOMED-CT": {
"value": "386725007",
"terminologyId": "SNOMED-CT"
}
}
},
{
"id": "time",
"name": "Time",
"rmType": "DV_DATE_TIME",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.body_temperature.v2]/data[at0002]/events[at0003]/time",
"inputs": [
{
"type": "DATETIME"
}
],
"inContext": true
}
]
},
{
"id": "language",
"name": "Language",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.body_temperature.v2]/language",
"inContext": true
},
{
"id": "encoding",
"name": "Encoding",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.body_temperature.v2]/encoding",
"inContext": true
},
{
"id": "subject",
"name": "Subject",
"rmType": "PARTY_PROXY",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.body_temperature.v2]/subject",
"inputs": [
{
"suffix": "id",
"type": "TEXT"
},
{
"suffix": "id_scheme",
"type": "TEXT"
},
{
"suffix": "id_namespace",
"type": "TEXT"
},
{
"suffix": "name",
"type": "TEXT"
}
],
"inContext": true
}
]
},
{
"id": "head_circumference",
"name": "Head circumference",
"localizedName": "Head circumference",
"rmType": "OBSERVATION",
"nodeId": "openEHR-EHR-OBSERVATION.head_circumference.v1",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Head circumference"
},
"localizedDescriptions": {
"en": "The measurement of the longest distance around the head."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.head_circumference.v1]",
"children": [
{
"id": "any_event",
"name": "Any event",
"localizedName": "Any event",
"rmType": "EVENT",
"nodeId": "at0010",
"min": 0,
"max": -1,
"localizedNames": {
"en": "Any event"
},
"localizedDescriptions": {
"en": "Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.head_circumference.v1]/data[at0001]/events[at0010]",
"children": [
{
"id": "head_circumference",
"name": "Head circumference",
"localizedName": "Head circumference",
"rmType": "DV_QUANTITY",
"nodeId": "at0004",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Head circumference"
},
"localizedDescriptions": {
"en": "The measurement of the longest distance around the head."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.head_circumference.v1]/data[at0001]/events[at0010]/data[at0003]/items[at0004]/value",
"inputs": [
{
"suffix": "magnitude",
"type": "DECIMAL"
},
{
"suffix": "unit",
"type": "CODED_TEXT",
"list": [
{
"value": "cm",
"label": "cm",
"validation": {
"range": {
"minOp": ">=",
"min": 0.0,
"maxOp": "<=",
"max": 100.0
}
}
},
{
"value": "[in_i]",
"label": "[in_i]",
"validation": {
"range": {
"minOp": ">=",
"min": 0.0,
"maxOp": "<=",
"max": 40.0
}
}
}
]
}
]
},
{
"id": "time",
"name": "Time",
"rmType": "DV_DATE_TIME",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.head_circumference.v1]/data[at0001]/events[at0010]/time",
"inputs": [
{
"type": "DATETIME"
}
],
"inContext": true
}
]
},
{
"id": "language",
"name": "Language",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.head_circumference.v1]/language",
"inContext": true
},
{
"id": "encoding",
"name": "Encoding",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.head_circumference.v1]/encoding",
"inContext": true
},
{
"id": "subject",
"name": "Subject",
"rmType": "PARTY_PROXY",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.head_circumference.v1]/subject",
"inputs": [
{
"suffix": "id",
"type": "TEXT"
},
{
"suffix": "id_scheme",
"type": "TEXT"
},
{
"suffix": "id_namespace",
"type": "TEXT"
},
{
"suffix": "name",
"type": "TEXT"
}
],
"inContext": true
}
]
},
{
"id": "pulse_oximetry",
"name": "Pulse oximetry",
"localizedName": "Pulse oximetry",
"rmType": "OBSERVATION",
"nodeId": "openEHR-EHR-OBSERVATION.pulse_oximetry.v1",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Pulse oximetry"
},
"localizedDescriptions": {
"en": "Blood oxygen and related measurements, measured by pulse oximetry or pulse CO-oximetry."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.pulse_oximetry.v1]",
"children": [
{
"id": "any_event",
"name": "Any event",
"localizedName": "Any event",
"rmType": "EVENT",
"nodeId": "at0002",
"min": 0,
"max": -1,
"localizedNames": {
"en": "Any event"
},
"localizedDescriptions": {
"en": "Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.pulse_oximetry.v1]/data[at0001]/events[at0002]",
"children": [
{
"id": "spo",
"name": "SpO₂",
"localizedName": "SpO₂",
"rmType": "DV_PROPORTION",
"nodeId": "at0006",
"min": 0,
"max": 1,
"localizedNames": {
"en": "SpO₂"
},
"localizedDescriptions": {
"en": "The saturation of oxygen in the peripheral blood, measured via pulse oximetry."
},
"annotations": {
"comment": "SpO₂ is defined as the percentage of oxyhaemoglobin (HbO₂) to the total concentration of haemoglobin (HbO₂ + deoxyhaemoglobin) in peripheral blood."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.pulse_oximetry.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0006]/value",
"proportionTypes": [
"percent"
],
"inputs": [
{
"suffix": "numerator",
"type": "DECIMAL",
"validation": {
"range": {
"minOp": ">=",
"min": 0.0,
"maxOp": "<=",
"max": 100.0
}
}
},
{
"suffix": "denominator",
"type": "DECIMAL",
"validation": {
"range": {
"minOp": ">=",
"min": 100.0,
"maxOp": "<=",
"max": 100.0
}
}
}
],
"termBindings": {
"SNOMED-CT": {
"value": "431314004",
"terminologyId": "SNOMED-CT"
},
"LOINC": {
"value": "59408-5",
"terminologyId": "LOINC"
}
}
},
{
"id": "time",
"name": "Time",
"rmType": "DV_DATE_TIME",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.pulse_oximetry.v1]/data[at0001]/events[at0002]/time",
"inputs": [
{
"type": "DATETIME"
}
],
"inContext": true
}
]
},
{
"id": "language",
"name": "Language",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.pulse_oximetry.v1]/language",
"inContext": true
},
{
"id": "encoding",
"name": "Encoding",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.pulse_oximetry.v1]/encoding",
"inContext": true
},
{
"id": "subject",
"name": "Subject",
"rmType": "PARTY_PROXY",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.pulse_oximetry.v1]/subject",
"inputs": [
{
"suffix": "id",
"type": "TEXT"
},
{
"suffix": "id_scheme",
"type": "TEXT"
},
{
"suffix": "id_namespace",
"type": "TEXT"
},
{
"suffix": "name",
"type": "TEXT"
}
],
"inContext": true
}
]
},
{
"id": "body_mass_index",
"name": "Body mass index",
"localizedName": "Body mass index",
"rmType": "OBSERVATION",
"nodeId": "openEHR-EHR-OBSERVATION.body_mass_index.v2",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Body mass index"
},
"localizedDescriptions": {
"en": "Calculated measurement which compares a person's weight and height."
},
"annotations": {
"comment": "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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.body_mass_index.v2]",
"children": [
{
"id": "any_event",
"name": "Any event",
"localizedName": "Any event",
"rmType": "EVENT",
"nodeId": "at0002",
"min": 0,
"max": -1,
"localizedNames": {
"en": "Any event"
},
"localizedDescriptions": {
"en": "Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.body_mass_index.v2]/data[at0001]/events[at0002]",
"children": [
{
"id": "body_mass_index",
"name": "Body mass index",
"localizedName": "Body mass index",
"rmType": "DV_QUANTITY",
"nodeId": "at0004",
"min": 1,
"max": 1,
"localizedNames": {
"en": "Body mass index"
},
"localizedDescriptions": {
"en": "Index describing ratio of weight to height."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.body_mass_index.v2]/data[at0001]/events[at0002]/data[at0003]/items[at0004]/value",
"inputs": [
{
"suffix": "magnitude",
"type": "DECIMAL"
},
{
"suffix": "unit",
"type": "CODED_TEXT",
"list": [
{
"value": "kg/m2",
"label": "kg/m2",
"validation": {
"range": {
"minOp": ">=",
"min": 0.0,
"maxOp": "<",
"max": 1000.0
},
"precision": {
"minOp": ">=",
"min": 1,
"maxOp": "<=",
"max": 1
}
}
},
{
"value": "[lb_av]/[in_i]2",
"label": "[lb_av]/[in_i]2",
"validation": {
"range": {
"minOp": ">=",
"min": 0.0,
"maxOp": "<",
"max": 1000.0
},
"precision": {
"minOp": ">=",
"min": 1,
"maxOp": "<=",
"max": 1
}
}
}
]
}
],
"termBindings": {
"SNOMED-CT": {
"value": "60621009",
"terminologyId": "SNOMED-CT"
},
"LOINC": {
"value": "39156-5",
"terminologyId": "LOINC"
}
}
},
{
"id": "time",
"name": "Time",
"rmType": "DV_DATE_TIME",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.body_mass_index.v2]/data[at0001]/events[at0002]/time",
"inputs": [
{
"type": "DATETIME"
}
],
"inContext": true
}
]
},
{
"id": "language",
"name": "Language",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.body_mass_index.v2]/language",
"inContext": true
},
{
"id": "encoding",
"name": "Encoding",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.body_mass_index.v2]/encoding",
"inContext": true
},
{
"id": "subject",
"name": "Subject",
"rmType": "PARTY_PROXY",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.body_mass_index.v2]/subject",
"inputs": [
{
"suffix": "id",
"type": "TEXT"
},
{
"suffix": "id_scheme",
"type": "TEXT"
},
{
"suffix": "id_namespace",
"type": "TEXT"
},
{
"suffix": "name",
"type": "TEXT"
}
],
"inContext": true
}
]
},
{
"id": "blood_pressure",
"name": "Blood pressure",
"localizedName": "Blood pressure",
"rmType": "OBSERVATION",
"nodeId": "openEHR-EHR-OBSERVATION.blood_pressure.v2",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Blood pressure"
},
"localizedDescriptions": {
"en": "The local measurement of arterial blood pressure which is a surrogate for arterial pressure in the systemic circulation."
},
"annotations": {
"comment": "Most commonly, use of the term 'blood pressure' refers to measurement of brachial artery pressure in the upper arm."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.blood_pressure.v2]",
"children": [
{
"id": "any_event",
"name": "Any event",
"localizedName": "Any event",
"rmType": "EVENT",
"nodeId": "at0006",
"min": 0,
"max": -1,
"localizedNames": {
"en": "Any event"
},
"localizedDescriptions": {
"en": "Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.blood_pressure.v2]/data[at0001]/events[at0006]",
"children": [
{
"id": "systolic",
"name": "Systolic",
"localizedName": "Systolic",
"rmType": "DV_QUANTITY",
"nodeId": "at0004",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Systolic"
},
"localizedDescriptions": {
"en": "Peak systemic arterial blood pressure - measured in systolic or contraction phase of the heart cycle."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.blood_pressure.v2]/data[at0001]/events[at0006]/data[at0003]/items[at0004]/value",
"inputs": [
{
"suffix": "magnitude",
"type": "DECIMAL",
"validation": {
"range": {
"minOp": ">=",
"min": 0.0,
"maxOp": "<",
"max": 1000.0
},
"precision": {
"minOp": ">=",
"min": 0,
"maxOp": "<=",
"max": 0
}
}
},
{
"suffix": "unit",
"type": "CODED_TEXT",
"list": [
{
"value": "mm[Hg]",
"label": "mm[Hg]",
"validation": {
"range": {
"minOp": ">=",
"min": 0.0,
"maxOp": "<",
"max": 1000.0
},
"precision": {
"minOp": ">=",
"min": 0,
"maxOp": "<=",
"max": 0
}
}
}
]
}
],
"termBindings": {
"SNOMED-CT": {
"value": "271649006",
"terminologyId": "SNOMED-CT(2003)"
}
}
},
{
"id": "diastolic",
"name": "Diastolic",
"localizedName": "Diastolic",
"rmType": "DV_QUANTITY",
"nodeId": "at0005",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Diastolic"
},
"localizedDescriptions": {
"en": "Minimum systemic arterial blood pressure - measured in the diastolic or relaxation phase of the heart cycle."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.blood_pressure.v2]/data[at0001]/events[at0006]/data[at0003]/items[at0005]/value",
"inputs": [
{
"suffix": "magnitude",
"type": "DECIMAL",
"validation": {
"range": {
"minOp": ">=",
"min": 0.0,
"maxOp": "<",
"max": 1000.0
},
"precision": {
"minOp": ">=",
"min": 0,
"maxOp": "<=",
"max": 0
}
}
},
{
"suffix": "unit",
"type": "CODED_TEXT",
"list": [
{
"value": "mm[Hg]",
"label": "mm[Hg]",
"validation": {
"range": {
"minOp": ">=",
"min": 0.0,
"maxOp": "<",
"max": 1000.0
},
"precision": {
"minOp": ">=",
"min": 0,
"maxOp": "<=",
"max": 0
}
}
}
]
}
],
"termBindings": {
"SNOMED-CT": {
"value": "271650006",
"terminologyId": "SNOMED-CT(2003)"
}
}
},
{
"id": "time",
"name": "Time",
"rmType": "DV_DATE_TIME",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.blood_pressure.v2]/data[at0001]/events[at0006]/time",
"inputs": [
{
"type": "DATETIME"
}
],
"inContext": true
}
]
},
{
"id": "language",
"name": "Language",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.blood_pressure.v2]/language",
"inContext": true
},
{
"id": "encoding",
"name": "Encoding",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.blood_pressure.v2]/encoding",
"inContext": true
},
{
"id": "subject",
"name": "Subject",
"rmType": "PARTY_PROXY",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Vital Signs']/items[openEHR-EHR-OBSERVATION.blood_pressure.v2]/subject",
"inputs": [
{
"suffix": "id",
"type": "TEXT"
},
{
"suffix": "id_scheme",
"type": "TEXT"
},
{
"suffix": "id_namespace",
"type": "TEXT"
},
{
"suffix": "name",
"type": "TEXT"
}
],
"inContext": true
}
],
"termBindings": {
"SNOMED-CT": {
"value": "364090009",
"terminologyId": "SNOMED-CT(2003)"
}
}
}
]
},
{
"id": "past_history_of_illnesses",
"name": "Past History of Illnesses",
"localizedName": "Past History of Illnesses",
"rmType": "SECTION",
"nodeId": "openEHR-EHR-SECTION.adhoc.v1",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Past History of Illnesses"
},
"localizedDescriptions": {
"en": "A generic section header which should be renamed in a template to suit a specific clinical context."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Past History of Illnesses']",
"children": [
{
"id": "problem_diagnosis",
"name": "Problem/Diagnosis",
"localizedName": "Problem/Diagnosis",
"rmType": "EVALUATION",
"nodeId": "openEHR-EHR-EVALUATION.problem_diagnosis.v1",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Problem/Diagnosis"
},
"localizedDescriptions": {
"en": "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."
},
"annotations": {
"comment": "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'."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Past History of Illnesses']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]",
"children": [
{
"id": "problem_diagnosis_name",
"name": "Problem/Diagnosis name",
"localizedName": "Problem/Diagnosis name",
"rmType": "DV_TEXT",
"nodeId": "at0002",
"min": 1,
"max": 1,
"localizedNames": {
"en": "Problem/Diagnosis name"
},
"localizedDescriptions": {
"en": "Identification of the problem or diagnosis, by name."
},
"annotations": {
"comment": "Coding of the name of the problem or diagnosis with a terminology is preferred, where possible."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Past History of Illnesses']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0002]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "body_site",
"name": "Body site",
"localizedName": "Body site",
"rmType": "DV_TEXT",
"nodeId": "at0012",
"min": 0,
"max": -1,
"localizedNames": {
"en": "Body site"
},
"localizedDescriptions": {
"en": "Identification of a simple body site for the location of the problem or diagnosis."
},
"annotations": {
"comment": "Coding of the name of the anatomical location with a terminology is preferred, where possible.\nUse 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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Past History of Illnesses']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0012]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "date_time_of_onset",
"name": "Date/time of onset",
"localizedName": "Date/time of onset",
"rmType": "DV_DATE_TIME",
"nodeId": "at0077",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Date/time of onset"
},
"localizedDescriptions": {
"en": "Estimated or actual date/time that signs or symptoms of the problem/diagnosis were first observed."
},
"annotations": {
"comment": "Data captured/imported as \"Age at onset\" should be converted to a date using the subject's date of birth."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Past History of Illnesses']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0077]/value",
"inputs": [
{
"type": "DATETIME"
}
]
},
{
"id": "severity",
"name": "Severity",
"localizedName": "Severity",
"rmType": "DV_CODED_TEXT",
"nodeId": "at0005",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Severity"
},
"localizedDescriptions": {
"en": "An assessment of the overall severity of the problem or diagnosis."
},
"annotations": {
"comment": "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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Past History of Illnesses']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0005]/value",
"inputs": [
{
"suffix": "code",
"type": "CODED_TEXT",
"list": [
{
"value": "at0047",
"label": "Mild",
"localizedLabels": {
"en": "Mild"
},
"localizedDescriptions": {
"en": "The problem or diagnosis does not interfere with normal activity or may cause damage to health if left untreated."
}
},
{
"value": "at0048",
"label": "Moderate",
"localizedLabels": {
"en": "Moderate"
},
"localizedDescriptions": {
"en": "The problem or diagnosis causes interference with normal activity or will damage health if left untreated."
}
},
{
"value": "at0049",
"label": "Severe",
"localizedLabels": {
"en": "Severe"
},
"localizedDescriptions": {
"en": "The problem or diagnosis prevents normal activity or will seriously damage health if left untreated."
}
}
],
"listOpen": true
},
{
"suffix": "other",
"type": "TEXT"
}
]
},
{
"id": "date_of_abatement",
"name": "Date of abatement",
"localizedName": "Date of abatement",
"rmType": "DV_DATE_TIME",
"nodeId": "at0030",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Date of abatement"
},
"localizedDescriptions": {
"en": "Estimated or actual date/time of resolution or remission for this problem or diagnosis, as determined by a healthcare professional."
},
"annotations": {
"comment": "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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Past History of Illnesses']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0030,'Date of abatement']/value",
"inputs": [
{
"type": "DATETIME"
}
]
},
{
"id": "problem_diagnosis_qualifier",
"name": "Problem/Diagnosis qualifier",
"localizedName": "Problem/Diagnosis qualifier",
"rmType": "CLUSTER",
"nodeId": "openEHR-EHR-CLUSTER.problem_qualifier.v1",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Problem/Diagnosis qualifier"
},
"localizedDescriptions": {
"en": "Contextual or temporal qualifier for a specified problem or diagnosis."
},
"annotations": {
"FHIR": "Condition.clinicalStatus"
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Past History of Illnesses']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v1]",
"children": [
{
"id": "active_inactive",
"name": "Active/Inactive?",
"localizedName": "Active/Inactive?",
"rmType": "DV_CODED_TEXT",
"nodeId": "at0003",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Active/Inactive?"
},
"localizedDescriptions": {
"en": "Category that supports division of problems and diagnoses into Active or Inactive problem lists."
},
"annotations": {
"comment": "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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Past History of Illnesses']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v1]/items[at0003]/value",
"inputs": [
{
"suffix": "code",
"type": "CODED_TEXT",
"list": [
{
"value": "at0026",
"label": "Active",
"localizedLabels": {
"en": "Active"
},
"localizedDescriptions": {
"en": "The problem or diagnosis is currently active and clinically relevant."
}
},
{
"value": "at0027",
"label": "Inactive",
"localizedLabels": {
"en": "Inactive"
},
"localizedDescriptions": {
"en": "The problem or diagnosis is not completely resolved but is inactive or felt less relevant to the current clinical context."
}
}
]
}
]
},
{
"id": "resolution_phase",
"name": "Resolution phase",
"localizedName": "Resolution phase",
"rmType": "DV_CODED_TEXT",
"nodeId": "at0083",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Resolution phase"
},
"localizedDescriptions": {
"en": "Phase of healing for an acute problem or diagnosis."
},
"annotations": {
"comment": "For example: tracking the progress of resolution of a middle ear infection."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Past History of Illnesses']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v1]/items[at0083]/value",
"inputs": [
{
"suffix": "code",
"type": "CODED_TEXT",
"list": [
{
"value": "at0084",
"label": "Resolved",
"localizedLabels": {
"en": "Resolved"
},
"localizedDescriptions": {
"en": "Problem or diagnosis has completed the normal phases of restoration or healing and can be considered resolved."
}
},
{
"value": "at0097",
"label": "Relapsed",
"localizedLabels": {
"en": "Relapsed"
},
"localizedDescriptions": {
"en": "Problem or diagnosis has deteriorated after a period of temporary improvement."
}
}
]
}
]
},
{
"id": "remission_status",
"name": "Remission status",
"localizedName": "Remission status",
"rmType": "DV_CODED_TEXT",
"nodeId": "at0089",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Remission status"
},
"localizedDescriptions": {
"en": "Status of the remission of an incurable diagnosis."
},
"annotations": {
"comment": "For example: the status of a cancer or haematological diagnosis."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Past History of Illnesses']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v1]/items[at0089]/value",
"inputs": [
{
"suffix": "code",
"type": "CODED_TEXT",
"list": [
{
"value": "at0090",
"label": "In remission",
"localizedLabels": {
"en": "In remission"
},
"localizedDescriptions": {
"en": "No ongoing signs or symptoms of the disease have been identified."
}
}
]
}
]
},
{
"id": "occurrence",
"name": "Occurrence",
"localizedName": "Occurrence",
"rmType": "DV_CODED_TEXT",
"nodeId": "at0071",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Occurrence"
},
"localizedDescriptions": {
"en": "Category of the occurrence for this problem or diagnosis."
},
"annotations": {
"comment": "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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Past History of Illnesses']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v1]/items[at0071]/value",
"inputs": [
{
"suffix": "code",
"type": "CODED_TEXT",
"list": [
{
"value": "at0096",
"label": "Recurrence",
"localizedLabels": {
"en": "Recurrence"
},
"localizedDescriptions": {
"en": "New occurrence of the same problem or diagnosis after a previous episode was resolved."
}
}
]
}
]
}
]
},
{
"id": "diagnostic_certainty",
"name": "Diagnostic certainty",
"localizedName": "Diagnostic certainty",
"rmType": "DV_CODED_TEXT",
"nodeId": "at0073",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Diagnostic certainty"
},
"localizedDescriptions": {
"en": "The level of confidence in the identification of the diagnosis."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Past History of Illnesses']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0073]/value",
"inputs": [
{
"suffix": "code",
"type": "CODED_TEXT",
"list": [
{
"value": "at0074",
"label": "Suspected",
"localizedLabels": {
"en": "Suspected"
},
"localizedDescriptions": {
"en": "The diagnosis has been identified with a low level of certainty."
}
},
{
"value": "at0075",
"label": "Probable",
"localizedLabels": {
"en": "Probable"
},
"localizedDescriptions": {
"en": "The diagnosis has been identified with a high level of certainty."
}
},
{
"value": "at0076",
"label": "Confirmed",
"localizedLabels": {
"en": "Confirmed"
},
"localizedDescriptions": {
"en": "The diagnosis has been confirmed against recognised criteria."
}
}
],
"listOpen": true
},
{
"suffix": "other",
"type": "TEXT"
}
]
},
{
"id": "last_updated",
"name": "Last updated",
"localizedName": "Last updated",
"rmType": "DV_DATE_TIME",
"nodeId": "at0070",
"min": 0,
"max": 1,
"dependsOn": [
"severity",
"problem_diagnosis_name",
"problem_diagnosis_qualifier",
"diagnostic_certainty",
"date_time_of_onset",
"body_site",
"date_of_abatement"
],
"localizedNames": {
"en": "Last updated"
},
"localizedDescriptions": {
"en": "The date this problem or diagnosis was last updated."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Past History of Illnesses']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/protocol[at0032]/items[at0070]/value",
"inputs": [
{
"type": "DATETIME"
}
]
},
{
"id": "language",
"name": "Language",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Past History of Illnesses']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/language",
"inContext": true
},
{
"id": "encoding",
"name": "Encoding",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Past History of Illnesses']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/encoding",
"inContext": true
},
{
"id": "subject",
"name": "Subject",
"rmType": "PARTY_PROXY",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Past History of Illnesses']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/subject",
"inputs": [
{
"suffix": "id",
"type": "TEXT"
},
{
"suffix": "id_scheme",
"type": "TEXT"
},
{
"suffix": "id_namespace",
"type": "TEXT"
},
{
"suffix": "name",
"type": "TEXT"
}
],
"inContext": true
}
]
}
]
},
{
"id": "pregnancy",
"name": "Pregnancy",
"localizedName": "Pregnancy",
"rmType": "SECTION",
"nodeId": "openEHR-EHR-SECTION.adhoc.v1",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Pregnancy"
},
"localizedDescriptions": {
"en": "A generic section header which should be renamed in a template to suit a specific clinical context."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Pregnancy']",
"children": [
{
"id": "pregnancy_summary",
"name": "Pregnancy summary",
"localizedName": "Pregnancy summary",
"rmType": "EVALUATION",
"nodeId": "openEHR-EHR-EVALUATION.pregnancy_summary.v0",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Pregnancy summary"
},
"localizedDescriptions": {
"en": "Overview or summary record of a pregnancy including the antenatal period, labour, birth and the immediate postnatal period."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Pregnancy']/items[openEHR-EHR-EVALUATION.pregnancy_summary.v0]",
"children": [
{
"id": "status",
"name": "Status",
"localizedName": "Status",
"rmType": "DV_CODED_TEXT",
"nodeId": "at0141",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Status"
},
"localizedDescriptions": {
"en": "*"
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Pregnancy']/items[openEHR-EHR-EVALUATION.pregnancy_summary.v0]/data[at0001]/items[at0141]/value",
"inputs": [
{
"suffix": "code",
"type": "CODED_TEXT",
"list": [
{
"value": "at0142",
"label": "Currently pregnant",
"localizedLabels": {
"en": "Currently pregnant"
},
"localizedDescriptions": {
"en": "The individual is currently pregnant."
}
}
]
}
]
},
{
"id": "per_pregnancy",
"name": "Per pregnancy",
"localizedName": "Per pregnancy",
"rmType": "CLUSTER",
"nodeId": "at0145",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Per pregnancy"
},
"localizedDescriptions": {
"en": "*"
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Pregnancy']/items[openEHR-EHR-EVALUATION.pregnancy_summary.v0]/data[at0001]/items[at0145]",
"children": [
{
"id": "pregnancy_outcome",
"name": "Pregnancy outcome",
"localizedName": "Pregnancy outcome",
"rmType": "DV_TEXT",
"nodeId": "at0094",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Pregnancy outcome"
},
"localizedDescriptions": {
"en": "Outcome of the pregnancy as a whole."
},
"annotations": {
"comment": "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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Pregnancy']/items[openEHR-EHR-EVALUATION.pregnancy_summary.v0]/data[at0001]/items[at0145]/items[at0094]/value",
"inputs": [
{
"type": "TEXT"
}
]
}
]
},
{
"id": "language",
"name": "Language",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Pregnancy']/items[openEHR-EHR-EVALUATION.pregnancy_summary.v0]/language",
"inContext": true
},
{
"id": "encoding",
"name": "Encoding",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Pregnancy']/items[openEHR-EHR-EVALUATION.pregnancy_summary.v0]/encoding",
"inContext": true
},
{
"id": "subject",
"name": "Subject",
"rmType": "PARTY_PROXY",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Pregnancy']/items[openEHR-EHR-EVALUATION.pregnancy_summary.v0]/subject",
"inputs": [
{
"suffix": "id",
"type": "TEXT"
},
{
"suffix": "id_scheme",
"type": "TEXT"
},
{
"suffix": "id_namespace",
"type": "TEXT"
},
{
"suffix": "name",
"type": "TEXT"
}
],
"inContext": true
}
]
},
{
"id": "estimated_date_of_delivery",
"name": "Estimated date of delivery",
"localizedName": "Estimated date of delivery",
"rmType": "EVALUATION",
"nodeId": "openEHR-EHR-EVALUATION.estimated_date_delivery.v0",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Estimated date of delivery"
},
"localizedDescriptions": {
"en": "Estimated date of delivery for a pregnancy."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Pregnancy']/items[openEHR-EHR-EVALUATION.estimated_date_delivery.v0]",
"children": [
{
"id": "by_date_of_conception",
"name": "By date of conception",
"localizedName": "By date of conception",
"rmType": "DV_DATE_TIME",
"nodeId": "at0003",
"min": 0,
"max": 1,
"localizedNames": {
"en": "By date of conception"
},
"localizedDescriptions": {
"en": "The EDD calculated from a known date of conception."
},
"annotations": {
"comment": "The date of conception will be recorded elsewhere in the health record, for example as part of the record for an IVF procedure."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Pregnancy']/items[openEHR-EHR-EVALUATION.estimated_date_delivery.v0]/data[at0002]/items[at0003]/value",
"inputs": [
{
"type": "DATETIME"
}
]
},
{
"id": "by_cycle",
"name": "By cycle",
"localizedName": "By cycle",
"rmType": "DV_DATE_TIME",
"nodeId": "at0004",
"min": 0,
"max": 1,
"localizedNames": {
"en": "By cycle"
},
"localizedDescriptions": {
"en": "The EDD estimated from an LNMP and characteristics of the menstrual cycle."
},
"annotations": {
"comment": "The details about the menstrual cycle will be recorded elsewhere in the health record, usually captured using the OBSERVATION.menstruation archetype."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Pregnancy']/items[openEHR-EHR-EVALUATION.estimated_date_delivery.v0]/data[at0002]/items[at0004]/value",
"inputs": [
{
"type": "DATETIME"
}
]
},
{
"id": "by_ultrasound",
"name": "By ultrasound",
"localizedName": "By ultrasound",
"rmType": "CLUSTER",
"nodeId": "at0006",
"min": 0,
"max": 1,
"localizedNames": {
"en": "By ultrasound"
},
"localizedDescriptions": {
"en": "Details about an EDD estimated from the findings on a pregnancy ultrasound."
},
"annotations": {
"comment": "Each ultrasound and estimated gestation pair will be captured as a separate instance of this CLUSTER."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Pregnancy']/items[openEHR-EHR-EVALUATION.estimated_date_delivery.v0]/data[at0002]/items[at0006]",
"children": [
{
"id": "estimated_date_by_ultrasound",
"name": "Estimated date by ultrasound",
"localizedName": "Estimated date by ultrasound",
"rmType": "DV_DATE_TIME",
"nodeId": "at0008",
"min": 1,
"max": 1,
"localizedNames": {
"en": "Estimated date by ultrasound"
},
"localizedDescriptions": {
"en": "Details about an EDD estimated from the findings on a pregnancy ultrasound."
},
"annotations": {
"comment": "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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Pregnancy']/items[openEHR-EHR-EVALUATION.estimated_date_delivery.v0]/data[at0002]/items[at0006]/items[at0008]/value",
"inputs": [
{
"type": "DATETIME"
}
]
}
]
},
{
"id": "agreed_edd",
"name": "Agreed EDD",
"localizedName": "Agreed EDD",
"rmType": "CLUSTER",
"nodeId": "at0009",
"min": 0,
"max": -1,
"localizedNames": {
"en": "Agreed EDD"
},
"localizedDescriptions": {
"en": "Details about the agreed EDD which is used as the basis for clinical decision-making during the pregnancy."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Pregnancy']/items[openEHR-EHR-EVALUATION.estimated_date_delivery.v0]/data[at0002]/items[at0009]",
"children": [
{
"id": "agreed_date",
"name": "Agreed date",
"localizedName": "Agreed date",
"rmType": "DV_DATE_TIME",
"nodeId": "at0010",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Agreed date"
},
"localizedDescriptions": {
"en": "The EDD which is to be used as the basis for clinical decision-making."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Pregnancy']/items[openEHR-EHR-EVALUATION.estimated_date_delivery.v0]/data[at0002]/items[at0009]/items[at0010]/value",
"inputs": [
{
"type": "DATETIME"
}
]
}
]
},
{
"id": "last_updated",
"name": "Last updated",
"localizedName": "Last updated",
"rmType": "DV_DATE_TIME",
"nodeId": "at0013",
"min": 0,
"max": 1,
"dependsOn": [
"by_ultrasound",
"agreed_edd",
"by_cycle",
"by_date_of_conception"
],
"localizedNames": {
"en": "Last updated"
},
"localizedDescriptions": {
"en": "The date any EDD was last updated."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Pregnancy']/items[openEHR-EHR-EVALUATION.estimated_date_delivery.v0]/protocol[at0001]/items[at0013]/value",
"inputs": [
{
"type": "DATETIME"
}
]
},
{
"id": "language",
"name": "Language",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Pregnancy']/items[openEHR-EHR-EVALUATION.estimated_date_delivery.v0]/language",
"inContext": true
},
{
"id": "encoding",
"name": "Encoding",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Pregnancy']/items[openEHR-EHR-EVALUATION.estimated_date_delivery.v0]/encoding",
"inContext": true
},
{
"id": "subject",
"name": "Subject",
"rmType": "PARTY_PROXY",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Pregnancy']/items[openEHR-EHR-EVALUATION.estimated_date_delivery.v0]/subject",
"inputs": [
{
"suffix": "id",
"type": "TEXT"
},
{
"suffix": "id_scheme",
"type": "TEXT"
},
{
"suffix": "id_namespace",
"type": "TEXT"
},
{
"suffix": "name",
"type": "TEXT"
}
],
"inContext": true
}
]
},
{
"id": "exclusion_of_pregnancy",
"name": "Exclusion of pregnancy",
"localizedName": "Exclusion of pregnancy",
"rmType": "OBSERVATION",
"nodeId": "openEHR-EHR-OBSERVATION.exclusion_pregnancy.v0",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Exclusion of pregnancy"
},
"localizedDescriptions": {
"en": "Statement to explicitly record that a pregnancy was not present."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Pregnancy']/items[openEHR-EHR-OBSERVATION.exclusion_pregnancy.v0]",
"children": [
{
"id": "any_event",
"name": "Any event",
"localizedName": "Any event",
"rmType": "EVENT",
"nodeId": "at0002",
"min": 0,
"max": -1,
"localizedNames": {
"en": "Any event"
},
"localizedDescriptions": {
"en": "*"
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Pregnancy']/items[openEHR-EHR-OBSERVATION.exclusion_pregnancy.v0]/data[at0001]/events[at0002]",
"children": [
{
"id": "exclusion_statement",
"name": "Exclusion statement",
"localizedName": "Exclusion statement",
"rmType": "DV_TEXT",
"nodeId": "at0006",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Exclusion statement"
},
"localizedDescriptions": {
"en": "An overall statement of exclusion about the state of pregnancy."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Pregnancy']/items[openEHR-EHR-OBSERVATION.exclusion_pregnancy.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0006]/value",
"inputs": [
{
"type": "TEXT",
"list": [
{
"value": "Not pregnant",
"label": "Not pregnant"
}
],
"listOpen": false
}
]
},
{
"id": "time",
"name": "Time",
"rmType": "DV_DATE_TIME",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Pregnancy']/items[openEHR-EHR-OBSERVATION.exclusion_pregnancy.v0]/data[at0001]/events[at0002]/time",
"inputs": [
{
"type": "DATETIME"
}
],
"inContext": true
}
]
},
{
"id": "language",
"name": "Language",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Pregnancy']/items[openEHR-EHR-OBSERVATION.exclusion_pregnancy.v0]/language",
"inContext": true
},
{
"id": "encoding",
"name": "Encoding",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Pregnancy']/items[openEHR-EHR-OBSERVATION.exclusion_pregnancy.v0]/encoding",
"inContext": true
},
{
"id": "subject",
"name": "Subject",
"rmType": "PARTY_PROXY",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Pregnancy']/items[openEHR-EHR-OBSERVATION.exclusion_pregnancy.v0]/subject",
"inputs": [
{
"suffix": "id",
"type": "TEXT"
},
{
"suffix": "id_scheme",
"type": "TEXT"
},
{
"suffix": "id_namespace",
"type": "TEXT"
},
{
"suffix": "name",
"type": "TEXT"
}
],
"inContext": true
}
]
}
]
},
{
"id": "social_history",
"name": "Social History",
"localizedName": "Social History",
"rmType": "SECTION",
"nodeId": "openEHR-EHR-SECTION.adhoc.v1",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Social History"
},
"localizedDescriptions": {
"en": "A generic section header which should be renamed in a template to suit a specific clinical context."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Social History']",
"children": [
{
"id": "tobacco_smoking_summary",
"name": "Tobacco smoking summary",
"localizedName": "Tobacco smoking summary",
"rmType": "EVALUATION",
"nodeId": "openEHR-EHR-EVALUATION.tobacco_smoking_summary.v1",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Tobacco smoking summary"
},
"localizedDescriptions": {
"en": "Summary or persistent information about the tobacco smoking habits of an individual."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Social History']/items[openEHR-EHR-EVALUATION.tobacco_smoking_summary.v1]",
"children": [
{
"id": "overall_status",
"name": "Overall status",
"localizedName": "Overall status",
"rmType": "DV_CODED_TEXT",
"nodeId": "at0089",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Overall status"
},
"localizedDescriptions": {
"en": "Statement about current smoking behaviour for all types of tobacco."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Social History']/items[openEHR-EHR-EVALUATION.tobacco_smoking_summary.v1]/data[at0001]/items[at0089]/value",
"inputs": [
{
"suffix": "code",
"type": "CODED_TEXT",
"list": [
{
"value": "at0006",
"label": "Never smoked",
"localizedLabels": {
"en": "Never smoked"
},
"localizedDescriptions": {
"en": "Individual has never smoked any type of tobacco."
}
},
{
"value": "at0003",
"label": "Current smoker",
"localizedLabels": {
"en": "Current smoker"
},
"localizedDescriptions": {
"en": "Individual is a current smoker of tobacco."
}
},
{
"value": "at0005",
"label": "Former smoker",
"localizedLabels": {
"en": "Former smoker"
},
"localizedDescriptions": {
"en": "Individual has previously smoked tobacco but is not a current smoker."
}
}
]
}
]
},
{
"id": "language",
"name": "Language",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Social History']/items[openEHR-EHR-EVALUATION.tobacco_smoking_summary.v1]/language",
"inContext": true
},
{
"id": "encoding",
"name": "Encoding",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Social History']/items[openEHR-EHR-EVALUATION.tobacco_smoking_summary.v1]/encoding",
"inContext": true
},
{
"id": "subject",
"name": "Subject",
"rmType": "PARTY_PROXY",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Social History']/items[openEHR-EHR-EVALUATION.tobacco_smoking_summary.v1]/subject",
"inputs": [
{
"suffix": "id",
"type": "TEXT"
},
{
"suffix": "id_scheme",
"type": "TEXT"
},
{
"suffix": "id_namespace",
"type": "TEXT"
},
{
"suffix": "name",
"type": "TEXT"
}
],
"inContext": true
}
]
},
{
"id": "alcohol_consumption_summary",
"name": "Alcohol consumption summary",
"localizedName": "Alcohol consumption summary",
"rmType": "EVALUATION",
"nodeId": "openEHR-EHR-EVALUATION.alcohol_consumption_summary.v1",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Alcohol consumption summary"
},
"localizedDescriptions": {
"en": "Summary or persistent information about the typical alcohol consumption of an individual."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Social History']/items[openEHR-EHR-EVALUATION.alcohol_consumption_summary.v1]",
"children": [
{
"id": "overall_status",
"name": "Overall status",
"localizedName": "Overall status",
"rmType": "DV_CODED_TEXT",
"nodeId": "at0089",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Overall status"
},
"localizedDescriptions": {
"en": "Statement about current consumption for all types of alcohol."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Social History']/items[openEHR-EHR-EVALUATION.alcohol_consumption_summary.v1]/data[at0001]/items[at0089]/value",
"inputs": [
{
"suffix": "code",
"type": "CODED_TEXT",
"list": [
{
"value": "at0003",
"label": "Current drinker",
"localizedLabels": {
"en": "Current drinker"
},
"localizedDescriptions": {
"en": "Individual is a current consumer of alcohol."
}
},
{
"value": "at0005",
"label": "Former drinker",
"localizedLabels": {
"en": "Former drinker"
},
"localizedDescriptions": {
"en": "Individual has previously consumed alcohol but is not a current drinker."
}
},
{
"value": "at0006",
"label": "Lifetime non-drinker",
"localizedLabels": {
"en": "Lifetime non-drinker"
},
"localizedDescriptions": {
"en": "Individual has never consumed alcohol."
}
}
]
}
]
},
{
"id": "per_episode",
"name": "Per episode",
"localizedName": "Per episode",
"rmType": "CLUSTER",
"nodeId": "at0064",
"min": 0,
"max": -1,
"localizedNames": {
"en": "Per episode"
},
"localizedDescriptions": {
"en": "Details about a discrete period of time with a consistent pattern of typical consumption."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Social History']/items[openEHR-EHR-EVALUATION.alcohol_consumption_summary.v1]/data[at0001]/items[at0064]",
"children": [
{
"id": "typical_consumption_alcohol_units",
"name": "Typical consumption (alcohol units)",
"localizedName": "Typical consumption (alcohol units)",
"rmType": "DV_QUANTITY",
"nodeId": "at0023",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Typical consumption (alcohol units)"
},
"localizedDescriptions": {
"en": "Estimate of number of alcohol units consumed in the specified time period."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Social History']/items[openEHR-EHR-EVALUATION.alcohol_consumption_summary.v1]/data[at0001]/items[at0064]/items[at0023]/value",
"inputs": [
{
"suffix": "magnitude",
"type": "DECIMAL"
},
{
"suffix": "unit",
"type": "CODED_TEXT",
"list": [
{
"value": "1/d",
"label": "1/d",
"validation": {
"range": {
"minOp": ">=",
"min": 0.0
},
"precision": {
"minOp": ">=",
"min": 1,
"maxOp": "<=",
"max": 1
}
}
},
{
"value": "1/wk",
"label": "1/wk",
"validation": {
"range": {
"minOp": ">=",
"min": 0.0
},
"precision": {
"minOp": ">=",
"min": 1,
"maxOp": "<=",
"max": 1
}
}
},
{
"value": "1/mo",
"label": "1/mo",
"validation": {
"range": {
"minOp": ">=",
"min": 0.0
},
"precision": {
"minOp": ">=",
"min": 1,
"maxOp": "<=",
"max": 1
}
}
}
]
}
]
}
]
},
{
"id": "language",
"name": "Language",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Social History']/items[openEHR-EHR-EVALUATION.alcohol_consumption_summary.v1]/language",
"inContext": true
},
{
"id": "encoding",
"name": "Encoding",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Social History']/items[openEHR-EHR-EVALUATION.alcohol_consumption_summary.v1]/encoding",
"inContext": true
},
{
"id": "subject",
"name": "Subject",
"rmType": "PARTY_PROXY",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Social History']/items[openEHR-EHR-EVALUATION.alcohol_consumption_summary.v1]/subject",
"inputs": [
{
"suffix": "id",
"type": "TEXT"
},
{
"suffix": "id_scheme",
"type": "TEXT"
},
{
"suffix": "id_namespace",
"type": "TEXT"
},
{
"suffix": "name",
"type": "TEXT"
}
],
"inContext": true
}
]
}
]
},
{
"id": "plan_of_care",
"name": "Plan of Care",
"localizedName": "Plan of Care",
"rmType": "SECTION",
"nodeId": "openEHR-EHR-SECTION.adhoc.v1",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Plan of Care"
},
"localizedDescriptions": {
"en": "A generic section header which should be renamed in a template to suit a specific clinical context."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Plan of Care']",
"children": [
{
"id": "care_plan",
"name": "Care Plan",
"localizedName": "Care Plan",
"rmType": "ACTION",
"nodeId": "openEHR-EHR-ACTION.care_plan.v0",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Care Plan"
},
"localizedDescriptions": {
"en": "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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Plan of Care']/items[openEHR-EHR-ACTION.care_plan.v0]",
"children": [
{
"id": "ism_transition",
"name": "Ism_transition",
"rmType": "ISM_TRANSITION",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Plan of Care']/items[openEHR-EHR-ACTION.care_plan.v0]/ism_transition",
"children": [
{
"id": "current_state",
"name": "Current_state",
"rmType": "DV_CODED_TEXT",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Plan of Care']/items[openEHR-EHR-ACTION.care_plan.v0]/ism_transition/current_state",
"inputs": [
{
"suffix": "code",
"type": "CODED_TEXT",
"list": [
{
"value": "530",
"label": "suspended"
},
{
"value": "245",
"label": "active"
},
{
"value": "531",
"label": "aborted"
},
{
"value": "532",
"label": "completed"
},
{
"value": "526",
"label": "planned"
},
{
"value": "527",
"label": "postponed"
},
{
"value": "528",
"label": "cancelled"
},
{
"value": "529",
"label": "scheduled"
}
]
}
],
"inContext": true
},
{
"id": "transition",
"name": "Transition",
"rmType": "DV_CODED_TEXT",
"min": 0,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Plan of Care']/items[openEHR-EHR-ACTION.care_plan.v0]/ism_transition/transition",
"inputs": [
{
"suffix": "code",
"type": "TEXT"
},
{
"suffix": "value",
"type": "TEXT"
}
],
"inContext": true
},
{
"id": "careflow_step",
"name": "Careflow_step",
"rmType": "DV_CODED_TEXT",
"min": 0,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Plan of Care']/items[openEHR-EHR-ACTION.care_plan.v0]/ism_transition/careflow_step",
"inputs": [
{
"suffix": "code",
"type": "CODED_TEXT",
"list": [
{
"value": "at0003",
"label": "Care plan Need Identified",
"localizedLabels": {
"en": "Care plan Need Identified"
},
"currentStates": [
"526"
]
},
{
"value": "at0008",
"label": "Care Plan Developed",
"localizedLabels": {
"en": "Care Plan Developed"
},
"currentStates": [
"526"
]
},
{
"value": "at0034",
"label": "Care Plan Postponed",
"localizedLabels": {
"en": "Care Plan Postponed"
},
"currentStates": [
"527"
]
},
{
"value": "at0033",
"label": "Care Plan Cancelled",
"localizedLabels": {
"en": "Care Plan Cancelled"
},
"currentStates": [
"528"
]
},
{
"value": "at0018",
"label": "Care Plan Scheduled",
"localizedLabels": {
"en": "Care Plan Scheduled"
},
"currentStates": [
"529"
]
},
{
"value": "at0006",
"label": "Care Plan Commenced",
"localizedLabels": {
"en": "Care Plan Commenced"
},
"currentStates": [
"245"
]
},
{
"value": "at0020",
"label": "Care Plan Reviewed",
"localizedLabels": {
"en": "Care Plan Reviewed"
},
"currentStates": [
"245"
]
},
{
"value": "at0035",
"label": "Care Plan Suspended",
"localizedLabels": {
"en": "Care Plan Suspended"
},
"currentStates": [
"530"
]
},
{
"value": "at0032",
"label": "Care Plan Aborted",
"localizedLabels": {
"en": "Care Plan Aborted"
},
"currentStates": [
"531"
]
},
{
"value": "at0010",
"label": "Care Plan Expired",
"localizedLabels": {
"en": "Care Plan Expired"
},
"currentStates": [
"531"
]
},
{
"value": "at0013",
"label": "Care Plan Completed",
"localizedLabels": {
"en": "Care Plan Completed"
},
"currentStates": [
"532"
]
}
]
}
],
"inContext": true
}
],
"inContext": true
},
{
"id": "care_plan_name",
"name": "Care Plan Name",
"localizedName": "Care Plan Name",
"rmType": "DV_TEXT",
"nodeId": "at0002",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Care Plan Name"
},
"localizedDescriptions": {
"en": "Name of care plan."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Plan of Care']/items[openEHR-EHR-ACTION.care_plan.v0]/description[at0019]/items[at0002]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "description",
"name": "Description",
"localizedName": "Description",
"rmType": "DV_TEXT",
"nodeId": "at0021",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Description"
},
"localizedDescriptions": {
"en": "Description of activity performed/enacted against the plan."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Plan of Care']/items[openEHR-EHR-ACTION.care_plan.v0]/description[at0019]/items[at0021]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "reason",
"name": "Reason",
"localizedName": "Reason",
"rmType": "DV_TEXT",
"nodeId": "at0025",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Reason"
},
"localizedDescriptions": {
"en": "Reason for activity being performed /enacted against the plan."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Plan of Care']/items[openEHR-EHR-ACTION.care_plan.v0]/description[at0019]/items[at0025]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "care_plan_id",
"name": "Care Plan ID",
"localizedName": "Care Plan ID",
"rmType": "DV_IDENTIFIER",
"nodeId": "at0016",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Care Plan ID"
},
"localizedDescriptions": {
"en": "Identification of care plan."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Plan of Care']/items[openEHR-EHR-ACTION.care_plan.v0]/protocol[at0015]/items[at0016]/value",
"inputs": [
{
"suffix": "id",
"type": "TEXT"
},
{
"suffix": "type",
"type": "TEXT"
},
{
"suffix": "issuer",
"type": "TEXT"
},
{
"suffix": "assigner",
"type": "TEXT"
}
]
},
{
"id": "expiry_date",
"name": "Expiry Date",
"localizedName": "Expiry Date",
"rmType": "DV_DATE_TIME",
"nodeId": "at0017",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Expiry Date"
},
"localizedDescriptions": {
"en": "Anticipated date beyond which the care plan can be deemed 'expired'."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Plan of Care']/items[openEHR-EHR-ACTION.care_plan.v0]/protocol[at0015]/items[at0017]/value",
"inputs": [
{
"type": "DATETIME"
}
]
},
{
"id": "time",
"name": "Time",
"rmType": "DV_DATE_TIME",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Plan of Care']/items[openEHR-EHR-ACTION.care_plan.v0]/time",
"inputs": [
{
"type": "DATETIME"
}
],
"inContext": true
},
{
"id": "language",
"name": "Language",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Plan of Care']/items[openEHR-EHR-ACTION.care_plan.v0]/language",
"inContext": true
},
{
"id": "encoding",
"name": "Encoding",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Plan of Care']/items[openEHR-EHR-ACTION.care_plan.v0]/encoding",
"inContext": true
},
{
"id": "subject",
"name": "Subject",
"rmType": "PARTY_PROXY",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Plan of Care']/items[openEHR-EHR-ACTION.care_plan.v0]/subject",
"inputs": [
{
"suffix": "id",
"type": "TEXT"
},
{
"suffix": "id_scheme",
"type": "TEXT"
},
{
"suffix": "id_namespace",
"type": "TEXT"
},
{
"suffix": "name",
"type": "TEXT"
}
],
"inContext": true
}
]
},
{
"id": "service_request",
"name": "Service request",
"localizedName": "Service request",
"rmType": "INSTRUCTION",
"nodeId": "openEHR-EHR-INSTRUCTION.service_request.v1",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Service request"
},
"localizedDescriptions": {
"en": "Request for a health-related service or activity to be delivered by a clinician, organisation or agency."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Plan of Care']/items[openEHR-EHR-INSTRUCTION.service_request.v1]",
"children": [
{
"id": "current_activity",
"name": "Current Activity",
"localizedName": "Current Activity",
"rmType": "ACTIVITY",
"nodeId": "at0001",
"min": 1,
"max": -1,
"localizedNames": {
"en": "Current Activity"
},
"localizedDescriptions": {
"en": "Current Activity."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Plan of Care']/items[openEHR-EHR-INSTRUCTION.service_request.v1]/activities[at0001]",
"children": [
{
"id": "service_name",
"name": "Service name",
"localizedName": "Service name",
"rmType": "DV_TEXT",
"nodeId": "at0121",
"min": 1,
"max": 1,
"localizedNames": {
"en": "Service name"
},
"localizedDescriptions": {
"en": "The name of the single service or activity requested."
},
"annotations": {
"comment": "Coding of the 'Service name' with a coding system is desirable, if available. For example: 'referral' to an endocrinologist for diabetes management."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Plan of Care']/items[openEHR-EHR-INSTRUCTION.service_request.v1]/activities[at0001]/description[at0009]/items[at0121]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "service_type",
"name": "Service type",
"localizedName": "Service type",
"rmType": "DV_TEXT",
"nodeId": "at0148",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Service type"
},
"localizedDescriptions": {
"en": "Category of service requested."
},
"annotations": {
"comment": "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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Plan of Care']/items[openEHR-EHR-INSTRUCTION.service_request.v1]/activities[at0001]/description[at0009]/items[at0148]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "description",
"name": "Description",
"localizedName": "Description",
"rmType": "DV_TEXT",
"nodeId": "at0135",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Description"
},
"localizedDescriptions": {
"en": "Narrative description about the service requested."
},
"annotations": {
"comment": "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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Plan of Care']/items[openEHR-EHR-INSTRUCTION.service_request.v1]/activities[at0001]/description[at0009]/items[at0135]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "reason_for_request",
"name": "Reason for request",
"localizedName": "Reason for request",
"rmType": "DV_TEXT",
"nodeId": "at0062",
"min": 0,
"max": -1,
"localizedNames": {
"en": "Reason for request"
},
"localizedDescriptions": {
"en": "A short phrase describing the reason for the request."
},
"annotations": {
"comment": "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'."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Plan of Care']/items[openEHR-EHR-INSTRUCTION.service_request.v1]/activities[at0001]/description[at0009]/items[at0062]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "reason_description",
"name": "Reason description",
"localizedName": "Reason description",
"rmType": "DV_TEXT",
"nodeId": "at0064",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Reason description"
},
"localizedDescriptions": {
"en": "Narrative description about the reason for request."
},
"annotations": {
"comment": "For example: 'The patient's diabetes has recently become more difficult to stabilise and renal function is deteriorating'."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Plan of Care']/items[openEHR-EHR-INSTRUCTION.service_request.v1]/activities[at0001]/description[at0009]/items[at0064]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "clinical_indication",
"name": "Clinical indication",
"localizedName": "Clinical indication",
"rmType": "DV_TEXT",
"nodeId": "at0152",
"min": 0,
"max": -1,
"localizedNames": {
"en": "Clinical indication"
},
"localizedDescriptions": {
"en": "The clinical reason for the ordered service."
},
"annotations": {
"comment": "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'."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Plan of Care']/items[openEHR-EHR-INSTRUCTION.service_request.v1]/activities[at0001]/description[at0009]/items[at0152]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "intent",
"name": "Intent",
"localizedName": "Intent",
"rmType": "DV_TEXT",
"nodeId": "at0065",
"min": 0,
"max": -1,
"localizedNames": {
"en": "Intent"
},
"localizedDescriptions": {
"en": "Description of the intent for the request."
},
"annotations": {
"comment": "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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Plan of Care']/items[openEHR-EHR-INSTRUCTION.service_request.v1]/activities[at0001]/description[at0009]/items[at0065]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "urgency",
"name": "Urgency",
"localizedName": "Urgency",
"rmType": "DV_CODED_TEXT",
"nodeId": "at0068",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Urgency"
},
"localizedDescriptions": {
"en": "Urgency of the request for service."
},
"annotations": {
"comment": "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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Plan of Care']/items[openEHR-EHR-INSTRUCTION.service_request.v1]/activities[at0001]/description[at0009]/items[at0068]/value",
"inputs": [
{
"suffix": "code",
"type": "CODED_TEXT",
"list": [
{
"value": "at0136",
"label": "Emergency",
"localizedLabels": {
"en": "Emergency"
},
"localizedDescriptions": {
"en": "The request requires immediate attention."
}
},
{
"value": "at0137",
"label": "Urgent",
"localizedLabels": {
"en": "Urgent"
},
"localizedDescriptions": {
"en": "The request requires prioritised attention."
}
},
{
"value": "at0138",
"label": "Routine",
"localizedLabels": {
"en": "Routine"
},
"localizedDescriptions": {
"en": "The request does not require prioritised scheduling."
}
}
],
"listOpen": true
},
{
"suffix": "other",
"type": "TEXT"
}
]
},
{
"id": "service_due",
"name": "Service due",
"localizedName": "Service due",
"rmType": "ELEMENT",
"nodeId": "at0040",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Service due"
},
"localizedDescriptions": {
"en": "The date/time, or acceptable interval of date/time, for provision of the service."
},
"annotations": {
"comment": "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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Plan of Care']/items[openEHR-EHR-INSTRUCTION.service_request.v1]/activities[at0001]/description[at0009]/items[at0040]",
"children": [
{
"id": "date_time_value",
"localizedName": "Service due",
"rmType": "DV_DATE_TIME",
"nodeId": "",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Service due"
},
"localizedDescriptions": {
"en": "The date/time, or acceptable interval of date/time, for provision of the service."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Plan of Care']/items[openEHR-EHR-INSTRUCTION.service_request.v1]/activities[at0001]/description[at0009]/items[at0040]/value",
"inputs": [
{
"type": "DATETIME"
}
]
},
{
"id": "interval_of_date_time_value",
"localizedName": "Service due",
"rmType": "DV_INTERVAL",
"nodeId": "",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Service due"
},
"localizedDescriptions": {
"en": "The date/time, or acceptable interval of date/time, for provision of the service."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Plan of Care']/items[openEHR-EHR-INSTRUCTION.service_request.v1]/activities[at0001]/description[at0009]/items[at0040]/value",
"children": [
{
"id": "upper",
"rmType": "DV_DATE_TIME",
"nodeId": "",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Plan of Care']/items[openEHR-EHR-INSTRUCTION.service_request.v1]/activities[at0001]/description[at0009]/items[at0040]/value/upper",
"inputs": [
{
"type": "DATETIME"
}
]
},
{
"id": "lower",
"rmType": "DV_DATE_TIME",
"nodeId": "",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Plan of Care']/items[openEHR-EHR-INSTRUCTION.service_request.v1]/activities[at0001]/description[at0009]/items[at0040]/value/lower",
"inputs": [
{
"type": "DATETIME"
}
]
}
]
},
{
"id": "text_value",
"localizedName": "Service due",
"rmType": "DV_TEXT",
"nodeId": "",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Service due"
},
"localizedDescriptions": {
"en": "The date/time, or acceptable interval of date/time, for provision of the service."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Plan of Care']/items[openEHR-EHR-INSTRUCTION.service_request.v1]/activities[at0001]/description[at0009]/items[at0040]/value",
"inputs": [
{
"type": "TEXT"
}
]
}
]
},
{
"id": "service_period_start",
"name": "Service period start",
"localizedName": "Service period start",
"rmType": "DV_DATE_TIME",
"nodeId": "at0145",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Service period start"
},
"localizedDescriptions": {
"en": "The date/time that marks the beginning of the valid period of time for delivery of this service."
},
"annotations": {
"comment": "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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Plan of Care']/items[openEHR-EHR-INSTRUCTION.service_request.v1]/activities[at0001]/description[at0009]/items[at0145]/value",
"inputs": [
{
"type": "DATETIME"
}
]
},
{
"id": "service_period_expiry",
"name": "Service period expiry",
"localizedName": "Service period expiry",
"rmType": "DV_DATE_TIME",
"nodeId": "at0144",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Service period expiry"
},
"localizedDescriptions": {
"en": "The date/time that marks the conclusion of the clinically valid period of time for delivery of this service."
},
"annotations": {
"comment": "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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Plan of Care']/items[openEHR-EHR-INSTRUCTION.service_request.v1]/activities[at0001]/description[at0009]/items[at0144]/value",
"inputs": [
{
"type": "DATETIME"
}
]
},
{
"id": "indefinite",
"name": "Indefinite?",
"localizedName": "Indefinite?",
"rmType": "DV_BOOLEAN",
"nodeId": "at0147",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Indefinite?"
},
"localizedDescriptions": {
"en": "The valid period for this request is open ended and has no date of expiry."
},
"annotations": {
"comment": "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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Plan of Care']/items[openEHR-EHR-INSTRUCTION.service_request.v1]/activities[at0001]/description[at0009]/items[at0147]/value",
"inputs": [
{
"type": "BOOLEAN",
"list": [
{
"value": "true",
"label": "true"
}
]
}
]
},
{
"id": "supplementary_information",
"name": "Supplementary information",
"localizedName": "Supplementary information",
"rmType": "DV_BOOLEAN",
"nodeId": "at0076",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Supplementary information"
},
"localizedDescriptions": {
"en": "Supplementary information will be following request."
},
"annotations": {
"comment": "Record as TRUE if additional information has been identified and will be forwarded when available. For example: pending test results."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Plan of Care']/items[openEHR-EHR-INSTRUCTION.service_request.v1]/activities[at0001]/description[at0009]/items[at0076]/value",
"inputs": [
{
"type": "BOOLEAN",
"list": [
{
"value": "true",
"label": "true"
}
]
}
]
},
{
"id": "information_description",
"name": "Information description",
"localizedName": "Information description",
"rmType": "DV_TEXT",
"nodeId": "at0078",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Information description"
},
"localizedDescriptions": {
"en": "Description of the supplementary information."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Plan of Care']/items[openEHR-EHR-INSTRUCTION.service_request.v1]/activities[at0001]/description[at0009]/items[at0078]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "comment",
"name": "Comment",
"localizedName": "Comment",
"rmType": "DV_TEXT",
"nodeId": "at0150",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Comment"
},
"localizedDescriptions": {
"en": "Additional narrative about the service request not captured in other fields."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Plan of Care']/items[openEHR-EHR-INSTRUCTION.service_request.v1]/activities[at0001]/description[at0009]/items[at0150]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "timing",
"name": "Timing",
"rmType": "DV_PARSABLE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Plan of Care']/items[openEHR-EHR-INSTRUCTION.service_request.v1]/activities[at0001]/timing",
"inputs": [
{
"suffix": "value",
"type": "TEXT"
},
{
"suffix": "formalism",
"type": "TEXT"
}
],
"inContext": true
},
{
"id": "action_archetype_id",
"name": "Action_archetype_id",
"rmType": "STRING",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Plan of Care']/items[openEHR-EHR-INSTRUCTION.service_request.v1]/activities[at0001]/action_archetype_id",
"inputs": [
{
"type": "TEXT"
}
],
"inContext": true
}
]
},
{
"id": "requester_order_identifier",
"name": "Requester order identifier",
"localizedName": "Requester order identifier",
"rmType": "ELEMENT",
"nodeId": "at0010",
"min": 0,
"max": 1,
"dependsOn": [
"current_activity"
],
"localizedNames": {
"en": "Requester order identifier"
},
"localizedDescriptions": {
"en": "The local identifier assigned by the requesting clinical system."
},
"annotations": {
"comment": "Usually equivalent to the HL7 Placer Order Identifier."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Plan of Care']/items[openEHR-EHR-INSTRUCTION.service_request.v1]/protocol[at0008]/items[at0010]",
"children": [
{
"id": "text_value",
"localizedName": "Requester order identifier",
"rmType": "DV_TEXT",
"nodeId": "",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Requester order identifier"
},
"localizedDescriptions": {
"en": "The local identifier assigned by the requesting clinical system."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Plan of Care']/items[openEHR-EHR-INSTRUCTION.service_request.v1]/protocol[at0008]/items[at0010]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "identifier_value",
"localizedName": "Requester order identifier",
"rmType": "DV_IDENTIFIER",
"nodeId": "",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Requester order identifier"
},
"localizedDescriptions": {
"en": "The local identifier assigned by the requesting clinical system."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Plan of Care']/items[openEHR-EHR-INSTRUCTION.service_request.v1]/protocol[at0008]/items[at0010]/value",
"inputs": [
{
"suffix": "id",
"type": "TEXT"
},
{
"suffix": "type",
"type": "TEXT"
},
{
"suffix": "issuer",
"type": "TEXT"
},
{
"suffix": "assigner",
"type": "TEXT"
}
]
}
]
},
{
"id": "receiver_order_identifier",
"name": "Receiver order identifier",
"localizedName": "Receiver order identifier",
"rmType": "ELEMENT",
"nodeId": "at0011",
"min": 0,
"max": 1,
"dependsOn": [
"current_activity"
],
"localizedNames": {
"en": "Receiver order identifier"
},
"localizedDescriptions": {
"en": "The local identifier assigned to the request by the clinician or organisation receiving the request for service."
},
"annotations": {
"comment": "Usually equivalent to the HL7 Filler Order Identifier."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Plan of Care']/items[openEHR-EHR-INSTRUCTION.service_request.v1]/protocol[at0008]/items[at0011]",
"children": [
{
"id": "text_value",
"localizedName": "Receiver order identifier",
"rmType": "DV_TEXT",
"nodeId": "",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Receiver order identifier"
},
"localizedDescriptions": {
"en": "The local identifier assigned to the request by the clinician or organisation receiving the request for service."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Plan of Care']/items[openEHR-EHR-INSTRUCTION.service_request.v1]/protocol[at0008]/items[at0011]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "identifier_value",
"localizedName": "Receiver order identifier",
"rmType": "DV_IDENTIFIER",
"nodeId": "",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Receiver order identifier"
},
"localizedDescriptions": {
"en": "The local identifier assigned to the request by the clinician or organisation receiving the request for service."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Plan of Care']/items[openEHR-EHR-INSTRUCTION.service_request.v1]/protocol[at0008]/items[at0011]/value",
"inputs": [
{
"suffix": "id",
"type": "TEXT"
},
{
"suffix": "type",
"type": "TEXT"
},
{
"suffix": "issuer",
"type": "TEXT"
},
{
"suffix": "assigner",
"type": "TEXT"
}
]
}
]
},
{
"id": "request_status",
"name": "Request status",
"localizedName": "Request status",
"rmType": "DV_TEXT",
"nodeId": "at0127",
"min": 0,
"max": 1,
"dependsOn": [
"current_activity"
],
"localizedNames": {
"en": "Request status"
},
"localizedDescriptions": {
"en": "The status of the request for service as indicated by the requester."
},
"annotations": {
"comment": "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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Plan of Care']/items[openEHR-EHR-INSTRUCTION.service_request.v1]/protocol[at0008]/items[at0127]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "expiry_time",
"name": "expiry_time",
"rmType": "DV_DATE_TIME",
"min": 0,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Plan of Care']/items[openEHR-EHR-INSTRUCTION.service_request.v1]/expiry_time",
"inputs": [
{
"type": "DATETIME"
}
]
},
{
"id": "narrative",
"name": "Narrative",
"rmType": "DV_TEXT",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Plan of Care']/items[openEHR-EHR-INSTRUCTION.service_request.v1]/narrative",
"inputs": [
{
"type": "TEXT"
}
],
"inContext": true
},
{
"id": "language",
"name": "Language",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Plan of Care']/items[openEHR-EHR-INSTRUCTION.service_request.v1]/language",
"inContext": true
},
{
"id": "encoding",
"name": "Encoding",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Plan of Care']/items[openEHR-EHR-INSTRUCTION.service_request.v1]/encoding",
"inContext": true
},
{
"id": "subject",
"name": "Subject",
"rmType": "PARTY_PROXY",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Plan of Care']/items[openEHR-EHR-INSTRUCTION.service_request.v1]/subject",
"inputs": [
{
"suffix": "id",
"type": "TEXT"
},
{
"suffix": "id_scheme",
"type": "TEXT"
},
{
"suffix": "id_namespace",
"type": "TEXT"
},
{
"suffix": "name",
"type": "TEXT"
}
],
"inContext": true
}
]
}
]
},
{
"id": "functional_status",
"name": "Functional Status",
"localizedName": "Functional Status",
"rmType": "SECTION",
"nodeId": "openEHR-EHR-SECTION.adhoc.v1",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Functional Status"
},
"localizedDescriptions": {
"en": "A generic section header which should be renamed in a template to suit a specific clinical context."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Functional Status']",
"children": [
{
"id": "problem_diagnosis",
"name": "Problem/Diagnosis",
"localizedName": "Problem/Diagnosis",
"rmType": "EVALUATION",
"nodeId": "openEHR-EHR-EVALUATION.problem_diagnosis.v1",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Problem/Diagnosis"
},
"localizedDescriptions": {
"en": "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."
},
"annotations": {
"comment": "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'."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Functional Status']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]",
"children": [
{
"id": "problem_diagnosis_name",
"name": "Problem/Diagnosis name",
"localizedName": "Problem/Diagnosis name",
"rmType": "DV_TEXT",
"nodeId": "at0002",
"min": 1,
"max": 1,
"localizedNames": {
"en": "Problem/Diagnosis name"
},
"localizedDescriptions": {
"en": "Identification of the problem or diagnosis, by name."
},
"annotations": {
"comment": "Coding of the name of the problem or diagnosis with a terminology is preferred, where possible."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Functional Status']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0002]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "body_site",
"name": "Body site",
"localizedName": "Body site",
"rmType": "DV_TEXT",
"nodeId": "at0012",
"min": 0,
"max": -1,
"localizedNames": {
"en": "Body site"
},
"localizedDescriptions": {
"en": "Identification of a simple body site for the location of the problem or diagnosis."
},
"annotations": {
"comment": "Coding of the name of the anatomical location with a terminology is preferred, where possible.\nUse 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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Functional Status']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0012]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "date_time_of_onset",
"name": "Date/time of onset",
"localizedName": "Date/time of onset",
"rmType": "DV_DATE_TIME",
"nodeId": "at0077",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Date/time of onset"
},
"localizedDescriptions": {
"en": "Estimated or actual date/time that signs or symptoms of the problem/diagnosis were first observed."
},
"annotations": {
"comment": "Data captured/imported as \"Age at onset\" should be converted to a date using the subject's date of birth."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Functional Status']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0077]/value",
"inputs": [
{
"type": "DATETIME"
}
]
},
{
"id": "severity",
"name": "Severity",
"localizedName": "Severity",
"rmType": "DV_CODED_TEXT",
"nodeId": "at0005",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Severity"
},
"localizedDescriptions": {
"en": "An assessment of the overall severity of the problem or diagnosis."
},
"annotations": {
"comment": "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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Functional Status']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0005]/value",
"inputs": [
{
"suffix": "code",
"type": "CODED_TEXT",
"list": [
{
"value": "at0047",
"label": "Mild",
"localizedLabels": {
"en": "Mild"
},
"localizedDescriptions": {
"en": "The problem or diagnosis does not interfere with normal activity or may cause damage to health if left untreated."
}
},
{
"value": "at0048",
"label": "Moderate",
"localizedLabels": {
"en": "Moderate"
},
"localizedDescriptions": {
"en": "The problem or diagnosis causes interference with normal activity or will damage health if left untreated."
}
},
{
"value": "at0049",
"label": "Severe",
"localizedLabels": {
"en": "Severe"
},
"localizedDescriptions": {
"en": "The problem or diagnosis prevents normal activity or will seriously damage health if left untreated."
}
}
],
"listOpen": true
},
{
"suffix": "other",
"type": "TEXT"
}
]
},
{
"id": "date_of_abatement",
"name": "Date of abatement",
"localizedName": "Date of abatement",
"rmType": "DV_DATE_TIME",
"nodeId": "at0030",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Date of abatement"
},
"localizedDescriptions": {
"en": "Estimated or actual date/time of resolution or remission for this problem or diagnosis, as determined by a healthcare professional."
},
"annotations": {
"comment": "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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Functional Status']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0030,'Date of abatement']/value",
"inputs": [
{
"type": "DATETIME"
}
]
},
{
"id": "problem_diagnosis_qualifier",
"name": "Problem/Diagnosis qualifier",
"localizedName": "Problem/Diagnosis qualifier",
"rmType": "CLUSTER",
"nodeId": "openEHR-EHR-CLUSTER.problem_qualifier.v1",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Problem/Diagnosis qualifier"
},
"localizedDescriptions": {
"en": "Contextual or temporal qualifier for a specified problem or diagnosis."
},
"annotations": {
"FHIR": "Condition.clinicalStatus"
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Functional Status']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v1]",
"children": [
{
"id": "active_inactive",
"name": "Active/Inactive?",
"localizedName": "Active/Inactive?",
"rmType": "DV_CODED_TEXT",
"nodeId": "at0003",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Active/Inactive?"
},
"localizedDescriptions": {
"en": "Category that supports division of problems and diagnoses into Active or Inactive problem lists."
},
"annotations": {
"comment": "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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Functional Status']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v1]/items[at0003]/value",
"inputs": [
{
"suffix": "code",
"type": "CODED_TEXT",
"list": [
{
"value": "at0026",
"label": "Active",
"localizedLabels": {
"en": "Active"
},
"localizedDescriptions": {
"en": "The problem or diagnosis is currently active and clinically relevant."
}
},
{
"value": "at0027",
"label": "Inactive",
"localizedLabels": {
"en": "Inactive"
},
"localizedDescriptions": {
"en": "The problem or diagnosis is not completely resolved but is inactive or felt less relevant to the current clinical context."
}
}
]
}
]
},
{
"id": "resolution_phase",
"name": "Resolution phase",
"localizedName": "Resolution phase",
"rmType": "DV_CODED_TEXT",
"nodeId": "at0083",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Resolution phase"
},
"localizedDescriptions": {
"en": "Phase of healing for an acute problem or diagnosis."
},
"annotations": {
"comment": "For example: tracking the progress of resolution of a middle ear infection."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Functional Status']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v1]/items[at0083]/value",
"inputs": [
{
"suffix": "code",
"type": "CODED_TEXT",
"list": [
{
"value": "at0084",
"label": "Resolved",
"localizedLabels": {
"en": "Resolved"
},
"localizedDescriptions": {
"en": "Problem or diagnosis has completed the normal phases of restoration or healing and can be considered resolved."
}
},
{
"value": "at0097",
"label": "Relapsed",
"localizedLabels": {
"en": "Relapsed"
},
"localizedDescriptions": {
"en": "Problem or diagnosis has deteriorated after a period of temporary improvement."
}
}
]
}
]
},
{
"id": "remission_status",
"name": "Remission status",
"localizedName": "Remission status",
"rmType": "DV_CODED_TEXT",
"nodeId": "at0089",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Remission status"
},
"localizedDescriptions": {
"en": "Status of the remission of an incurable diagnosis."
},
"annotations": {
"comment": "For example: the status of a cancer or haematological diagnosis."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Functional Status']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v1]/items[at0089]/value",
"inputs": [
{
"suffix": "code",
"type": "CODED_TEXT",
"list": [
{
"value": "at0090",
"label": "In remission",
"localizedLabels": {
"en": "In remission"
},
"localizedDescriptions": {
"en": "No ongoing signs or symptoms of the disease have been identified."
}
}
]
}
]
},
{
"id": "occurrence",
"name": "Occurrence",
"localizedName": "Occurrence",
"rmType": "DV_CODED_TEXT",
"nodeId": "at0071",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Occurrence"
},
"localizedDescriptions": {
"en": "Category of the occurrence for this problem or diagnosis."
},
"annotations": {
"comment": "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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Functional Status']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v1]/items[at0071]/value",
"inputs": [
{
"suffix": "code",
"type": "CODED_TEXT",
"list": [
{
"value": "at0096",
"label": "Recurrence",
"localizedLabels": {
"en": "Recurrence"
},
"localizedDescriptions": {
"en": "New occurrence of the same problem or diagnosis after a previous episode was resolved."
}
}
]
}
]
}
]
},
{
"id": "diagnostic_certainty",
"name": "Diagnostic certainty",
"localizedName": "Diagnostic certainty",
"rmType": "DV_CODED_TEXT",
"nodeId": "at0073",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Diagnostic certainty"
},
"localizedDescriptions": {
"en": "The level of confidence in the identification of the diagnosis."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Functional Status']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0073]/value",
"inputs": [
{
"suffix": "code",
"type": "CODED_TEXT",
"list": [
{
"value": "at0074",
"label": "Suspected",
"localizedLabels": {
"en": "Suspected"
},
"localizedDescriptions": {
"en": "The diagnosis has been identified with a low level of certainty."
}
},
{
"value": "at0075",
"label": "Probable",
"localizedLabels": {
"en": "Probable"
},
"localizedDescriptions": {
"en": "The diagnosis has been identified with a high level of certainty."
}
},
{
"value": "at0076",
"label": "Confirmed",
"localizedLabels": {
"en": "Confirmed"
},
"localizedDescriptions": {
"en": "The diagnosis has been confirmed against recognised criteria."
}
}
],
"listOpen": true
},
{
"suffix": "other",
"type": "TEXT"
}
]
},
{
"id": "last_updated",
"name": "Last updated",
"localizedName": "Last updated",
"rmType": "DV_DATE_TIME",
"nodeId": "at0070",
"min": 0,
"max": 1,
"dependsOn": [
"severity",
"problem_diagnosis_name",
"problem_diagnosis_qualifier",
"diagnostic_certainty",
"date_time_of_onset",
"body_site",
"date_of_abatement"
],
"localizedNames": {
"en": "Last updated"
},
"localizedDescriptions": {
"en": "The date this problem or diagnosis was last updated."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Functional Status']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/protocol[at0032]/items[at0070]/value",
"inputs": [
{
"type": "DATETIME"
}
]
},
{
"id": "language",
"name": "Language",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Functional Status']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/language",
"inContext": true
},
{
"id": "encoding",
"name": "Encoding",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Functional Status']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/encoding",
"inContext": true
},
{
"id": "subject",
"name": "Subject",
"rmType": "PARTY_PROXY",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Functional Status']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/subject",
"inputs": [
{
"suffix": "id",
"type": "TEXT"
},
{
"suffix": "id_scheme",
"type": "TEXT"
},
{
"suffix": "id_namespace",
"type": "TEXT"
},
{
"suffix": "name",
"type": "TEXT"
}
],
"inContext": true
}
]
},
{
"id": "clinical_impression",
"name": "Clinical impression",
"localizedName": "Clinical impression",
"rmType": "EVALUATION",
"nodeId": "openEHR-EHR-EVALUATION.clinical_synopsis.v1",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Clinical impression"
},
"localizedDescriptions": {
"en": "Narrative summary or overview about a patient, specifically from the perspective of a healthcare provider, and with or without associated interpretations."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Functional Status']/items[openEHR-EHR-EVALUATION.clinical_synopsis.v1,'Clinical impression']",
"children": [
{
"id": "impression",
"name": "Impression",
"localizedName": "Impression",
"rmType": "DV_TEXT",
"nodeId": "at0002",
"min": 1,
"max": 1,
"localizedNames": {
"en": "Impression"
},
"localizedDescriptions": {
"en": "The summary, assessment, conclusions or evaluation of the clinical findings."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Functional Status']/items[openEHR-EHR-EVALUATION.clinical_synopsis.v1,'Clinical impression']/data[at0001]/items[at0002,'Impression']/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "language",
"name": "Language",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Functional Status']/items[openEHR-EHR-EVALUATION.clinical_synopsis.v1,'Clinical impression']/language",
"inContext": true
},
{
"id": "encoding",
"name": "Encoding",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Functional Status']/items[openEHR-EHR-EVALUATION.clinical_synopsis.v1,'Clinical impression']/encoding",
"inContext": true
},
{
"id": "subject",
"name": "Subject",
"rmType": "PARTY_PROXY",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Functional Status']/items[openEHR-EHR-EVALUATION.clinical_synopsis.v1,'Clinical impression']/subject",
"inputs": [
{
"suffix": "id",
"type": "TEXT"
},
{
"suffix": "id_scheme",
"type": "TEXT"
},
{
"suffix": "id_namespace",
"type": "TEXT"
},
{
"suffix": "name",
"type": "TEXT"
}
],
"inContext": true
}
]
}
]
},
{
"id": "advanced_directives",
"name": "Advanced Directives",
"localizedName": "Advanced Directives",
"rmType": "SECTION",
"nodeId": "openEHR-EHR-SECTION.adhoc.v1",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Advanced Directives"
},
"localizedDescriptions": {
"en": "A generic section header which should be renamed in a template to suit a specific clinical context."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Advanced Directives']",
"children": [
{
"id": "advance_care_directive",
"name": "Advance care directive",
"localizedName": "Advance care directive",
"rmType": "EVALUATION",
"nodeId": "openEHR-EHR-EVALUATION.advance_care_directive.v1",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Advance care directive"
},
"localizedDescriptions": {
"en": "A framework to communicate the preferences of an individual for future medical treatment and care."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Advanced Directives']/items[openEHR-EHR-EVALUATION.advance_care_directive.v1]",
"children": [
{
"id": "type_of_directive",
"name": "Type of directive",
"localizedName": "Type of directive",
"rmType": "DV_TEXT",
"nodeId": "at0005",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Type of directive"
},
"localizedDescriptions": {
"en": "The type of advance care directive."
},
"annotations": {
"comment": "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.\n\nFor 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'.\n\nIn the UK, advance care directive types include 'Advance Decision', 'Advance Directive' and 'Advance Statement'."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Advanced Directives']/items[openEHR-EHR-EVALUATION.advance_care_directive.v1]/data[at0001]/items[at0005]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "status",
"name": "Status",
"localizedName": "Status",
"rmType": "DV_CODED_TEXT",
"nodeId": "at0004",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Status"
},
"localizedDescriptions": {
"en": "The status of the advance care directive."
},
"annotations": {
"comment": "Coding of the advance care directive status with a terminology is preferred, where possible."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Advanced Directives']/items[openEHR-EHR-EVALUATION.advance_care_directive.v1]/data[at0001]/items[at0004]/value",
"inputs": [
{
"suffix": "code",
"type": "CODED_TEXT",
"list": [
{
"value": "at0044",
"label": "Present",
"localizedLabels": {
"en": "Present"
},
"localizedDescriptions": {
"en": "The individual has an advance care directive."
},
"termBindings": {
"SNOMED-CT": {
"value": "410515003",
"terminologyId": "SNOMED-CT"
}
}
},
{
"value": "at0045",
"label": "Absent",
"localizedLabels": {
"en": "Absent"
},
"localizedDescriptions": {
"en": "The individual does not have an advance care directive."
},
"termBindings": {
"SNOMED-CT": {
"value": "410516002",
"terminologyId": "SNOMED-CT"
}
}
},
{
"value": "at0047",
"label": "Unknown",
"localizedLabels": {
"en": "Unknown"
},
"localizedDescriptions": {
"en": "It is not known whether the individual has an advance care directive."
},
"termBindings": {
"SNOMED-CT": {
"value": "261665006",
"terminologyId": "SNOMED-CT"
}
}
}
],
"listOpen": true
},
{
"suffix": "other",
"type": "TEXT"
}
]
},
{
"id": "description",
"name": "Description",
"localizedName": "Description",
"rmType": "DV_TEXT",
"nodeId": "at0006",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Description"
},
"localizedDescriptions": {
"en": "Narrative description of the overall advance care directive."
},
"annotations": {
"comment": "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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Advanced Directives']/items[openEHR-EHR-EVALUATION.advance_care_directive.v1]/data[at0001]/items[at0006]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "condition",
"name": "Condition",
"localizedName": "Condition",
"rmType": "DV_TEXT",
"nodeId": "at0007",
"min": 0,
"max": -1,
"localizedNames": {
"en": "Condition"
},
"localizedDescriptions": {
"en": "The conditions or situations in which the individual wishes the advance care directive to apply."
},
"annotations": {
"comment": "For example: dementia, brain injury, diseases of the central nervous system, and terminal illness. Coding with a terminology is preferred, where possible.\n\nThe 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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Advanced Directives']/items[openEHR-EHR-EVALUATION.advance_care_directive.v1]/data[at0001]/items[at0007]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "directive_location",
"name": "Directive location",
"localizedName": "Directive location",
"rmType": "CLUSTER",
"nodeId": "at0058",
"min": 0,
"max": -1,
"localizedNames": {
"en": "Directive location"
},
"localizedDescriptions": {
"en": "Information regarding where the advance care directive is stored and who has a copy of it."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Advanced Directives']/items[openEHR-EHR-EVALUATION.advance_care_directive.v1]/data[at0001]/items[at0058]",
"children": [
{
"id": "location",
"name": "Location",
"localizedName": "Location",
"rmType": "DV_TEXT",
"nodeId": "at0030",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Location"
},
"localizedDescriptions": {
"en": "Information regarding where the advance care directive is stored and how to gain access to it."
},
"annotations": {
"comment": "For example, 'In the top drawer of the bedside table'."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Advanced Directives']/items[openEHR-EHR-EVALUATION.advance_care_directive.v1]/data[at0001]/items[at0058]/items[at0030]/value",
"inputs": [
{
"type": "TEXT"
}
]
}
]
},
{
"id": "comment",
"name": "Comment",
"localizedName": "Comment",
"rmType": "DV_TEXT",
"nodeId": "at0038",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Comment"
},
"localizedDescriptions": {
"en": "Additional narrative about the advance care directive not captured in other fields."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Advanced Directives']/items[openEHR-EHR-EVALUATION.advance_care_directive.v1]/data[at0001]/items[at0038]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "valid_period_start",
"name": "Valid period start",
"localizedName": "Valid period start",
"rmType": "DV_DATE_TIME",
"nodeId": "at0053",
"min": 0,
"max": 1,
"dependsOn": [
"condition",
"directive_location",
"type_of_directive",
"description",
"comment",
"status"
],
"localizedNames": {
"en": "Valid period start"
},
"localizedDescriptions": {
"en": "The date/time that marks the beginning of the valid period of time for this advance care directive."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Advanced Directives']/items[openEHR-EHR-EVALUATION.advance_care_directive.v1]/protocol[at0010]/items[at0053]/value",
"inputs": [
{
"type": "DATETIME"
}
]
},
{
"id": "valid_period_end",
"name": "Valid period end",
"localizedName": "Valid period end",
"rmType": "DV_DATE_TIME",
"nodeId": "at0054",
"min": 0,
"max": 1,
"dependsOn": [
"condition",
"directive_location",
"type_of_directive",
"description",
"comment",
"status"
],
"localizedNames": {
"en": "Valid period end"
},
"localizedDescriptions": {
"en": "The date/time that marks the conclusion of the valid period of time for this advance care directive."
},
"annotations": {
"comment": "'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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Advanced Directives']/items[openEHR-EHR-EVALUATION.advance_care_directive.v1]/protocol[at0010]/items[at0054]/value",
"inputs": [
{
"type": "DATETIME"
}
]
},
{
"id": "review_due_date",
"name": "Review due date",
"localizedName": "Review due date",
"rmType": "DV_DATE_TIME",
"nodeId": "at0056",
"min": 0,
"max": 1,
"dependsOn": [
"condition",
"directive_location",
"type_of_directive",
"description",
"comment",
"status"
],
"localizedNames": {
"en": "Review due date"
},
"localizedDescriptions": {
"en": "The date at which the advance care directive is due to be reviewed."
},
"annotations": {
"comment": "'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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Advanced Directives']/items[openEHR-EHR-EVALUATION.advance_care_directive.v1]/protocol[at0010]/items[at0056]/value",
"inputs": [
{
"type": "DATETIME"
}
]
},
{
"id": "last_updated",
"name": "Last updated",
"localizedName": "Last updated",
"rmType": "DV_DATE_TIME",
"nodeId": "at0055",
"min": 0,
"max": 1,
"dependsOn": [
"condition",
"directive_location",
"type_of_directive",
"description",
"comment",
"status"
],
"localizedNames": {
"en": "Last updated"
},
"localizedDescriptions": {
"en": "The date when this advance directive record was last updated. This may not be a formal review but e.g. a typo correction."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Advanced Directives']/items[openEHR-EHR-EVALUATION.advance_care_directive.v1]/protocol[at0010]/items[at0055]/value",
"inputs": [
{
"type": "DATETIME"
}
]
},
{
"id": "mandate",
"name": "Mandate",
"localizedName": "Mandate",
"rmType": "ELEMENT",
"nodeId": "at0027",
"min": 0,
"max": -1,
"dependsOn": [
"condition",
"directive_location",
"type_of_directive",
"description",
"comment",
"status"
],
"localizedNames": {
"en": "Mandate"
},
"localizedDescriptions": {
"en": "Description of any legislation or other authoritative guidance that apply."
},
"annotations": {
"comment": "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'. \n\nOr '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'."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Advanced Directives']/items[openEHR-EHR-EVALUATION.advance_care_directive.v1]/protocol[at0010]/items[at0027]",
"children": [
{
"id": "text_value",
"localizedName": "Mandate",
"rmType": "DV_TEXT",
"nodeId": "",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Mandate"
},
"localizedDescriptions": {
"en": "Description of any legislation or other authoritative guidance that apply."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Advanced Directives']/items[openEHR-EHR-EVALUATION.advance_care_directive.v1]/protocol[at0010]/items[at0027]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "uri_value",
"localizedName": "Mandate",
"rmType": "DV_URI",
"nodeId": "",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Mandate"
},
"localizedDescriptions": {
"en": "Description of any legislation or other authoritative guidance that apply."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Advanced Directives']/items[openEHR-EHR-EVALUATION.advance_care_directive.v1]/protocol[at0010]/items[at0027]/value",
"inputs": [
{
"type": "TEXT"
}
]
}
]
},
{
"id": "language",
"name": "Language",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Advanced Directives']/items[openEHR-EHR-EVALUATION.advance_care_directive.v1]/language",
"inContext": true
},
{
"id": "encoding",
"name": "Encoding",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Advanced Directives']/items[openEHR-EHR-EVALUATION.advance_care_directive.v1]/encoding",
"inContext": true
},
{
"id": "subject",
"name": "Subject",
"rmType": "PARTY_PROXY",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Advanced Directives']/items[openEHR-EHR-EVALUATION.advance_care_directive.v1]/subject",
"inputs": [
{
"suffix": "id",
"type": "TEXT"
},
{
"suffix": "id_scheme",
"type": "TEXT"
},
{
"suffix": "id_namespace",
"type": "TEXT"
},
{
"suffix": "name",
"type": "TEXT"
}
],
"inContext": true
}
]
},
{
"id": "limitation_of_treatment",
"name": "Limitation of treatment",
"localizedName": "Limitation of treatment",
"rmType": "EVALUATION",
"nodeId": "openEHR-EHR-EVALUATION.limitation_of_treatment.v0",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Limitation of treatment"
},
"localizedDescriptions": {
"en": "Decision/s about limitation of future treatment, determined by a senior clinician."
},
"annotations": {
"comment": "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."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Advanced Directives']/items[openEHR-EHR-EVALUATION.limitation_of_treatment.v0]",
"children": [
{
"id": "status",
"name": "Status",
"localizedName": "Status",
"rmType": "DV_CODED_TEXT",
"nodeId": "at0002",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Status"
},
"localizedDescriptions": {
"en": "Category describing the presence of any limitation of treatment."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Advanced Directives']/items[openEHR-EHR-EVALUATION.limitation_of_treatment.v0]/data[at0001]/items[at0002]/value",
"inputs": [
{
"suffix": "code",
"type": "CODED_TEXT",
"list": [
{
"value": "at0003",
"label": "No limitation of treatment",
"localizedLabels": {
"en": "No limitation of treatment"
},
"localizedDescriptions": {
"en": "For full resuscitation. No limitations on future treatment options have been recorded."
},
"termBindings": {
"SNOMED-CT": {
"value": "304253006",
"terminologyId": "SNOMED-CT"
}
}
},
{
"value": "at0004",
"label": "Limitation of medical treatment",
"localizedLabels": {
"en": "Limitation of medical treatment"
},
"localizedDescriptions": {
"en": "Limitations on future treatment options have been recorded in an advanced care directive or similar."
}
},
{
"value": "at0005",
"label": "Allow natural death",
"localizedLabels": {
"en": "Allow natural death"
},
"localizedDescriptions": {
"en": "Do not attempt resuscitation. Comfort during the dying process."
},
"termBindings": {
"SNOMED-CT": {
"value": "304252001",
"terminologyId": "SNOMED-CT"
}
}
}
],
"defaultValue": "at0003"
}
]
},
{
"id": "per_limitation",
"name": "Per limitation",
"localizedName": "Per limitation",
"rmType": "CLUSTER",
"nodeId": "at0006",
"min": 0,
"max": -1,
"localizedNames": {
"en": "Per limitation"
},
"localizedDescriptions": {
"en": "Details about each limitation on treatment"
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Advanced Directives']/items[openEHR-EHR-EVALUATION.limitation_of_treatment.v0]/data[at0001]/items[at0006]",
"children": [
{
"id": "type_of_limitation",
"name": "Type of limitation",
"localizedName": "Type of limitation",
"rmType": "DV_CODED_TEXT",
"nodeId": "at0007",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Type of limitation"
},
"localizedDescriptions": {
"en": "Description about"
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Advanced Directives']/items[openEHR-EHR-EVALUATION.limitation_of_treatment.v0]/data[at0001]/items[at0006]/items[at0007]/value",
"inputs": [
{
"suffix": "code",
"type": "CODED_TEXT",
"list": [
{
"value": "at0008",
"label": "Cardiopulmonary resuscitation",
"localizedLabels": {
"en": "Cardiopulmonary resuscitation"
},
"localizedDescriptions": {
"en": "Lifesaving emergency procedure involving chest compressions and artificial ventilation."
}
},
{
"value": "at0009",
"label": "Endotracheal intubation",
"localizedLabels": {
"en": "Endotracheal intubation"
},
"localizedDescriptions": {
"en": "*"
}
},
{
"value": "at0010",
"label": "Mechanical ventilation",
"localizedLabels": {
"en": "Mechanical ventilation"
},
"localizedDescriptions": {
"en": "*"
}
},
{
"value": "at0011",
"label": "Vasopressor therapy",
"localizedLabels": {
"en": "Vasopressor therapy"
},
"localizedDescriptions": {
"en": "*"
}
},
{
"value": "at0012",
"label": "Parenteral or artificial nutrition",
"localizedLabels": {
"en": "Parenteral or artificial nutrition"
},
"localizedDescriptions": {
"en": "*"
}
},
{
"value": "at0013",
"label": "Dialysis",
"localizedLabels": {
"en": "Dialysis"
},
"localizedDescriptions": {
"en": "*"
}
},
{
"value": "at0014",
"label": "Blood products",
"localizedLabels": {
"en": "Blood products"
},
"localizedDescriptions": {
"en": "*"
}
},
{
"value": "at0015",
"label": "Antibiotics",
"localizedLabels": {
"en": "Antibiotics"
},
"localizedDescriptions": {
"en": "*"
}
},
{
"value": "at0016",
"label": "Intravenous fluids",
"localizedLabels": {
"en": "Intravenous fluids"
},
"localizedDescriptions": {
"en": "*"
}
}
]
}
]
},
{
"id": "decision",
"name": "Decision",
"localizedName": "Decision",
"rmType": "DV_CODED_TEXT",
"nodeId": "at0017",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Decision"
},
"localizedDescriptions": {
"en": "The decision about whether the identified treatment type is permitted or not."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Advanced Directives']/items[openEHR-EHR-EVALUATION.limitation_of_treatment.v0]/data[at0001]/items[at0006]/items[at0017]/value",
"inputs": [
{
"suffix": "code",
"type": "CODED_TEXT",
"list": [
{
"value": "at0018",
"label": "Permitted",
"localizedLabels": {
"en": "Permitted"
},
"localizedDescriptions": {
"en": "The treatment is permitted, if clinically appropriate."
}
},
{
"value": "at0019",
"label": "Not permitted",
"localizedLabels": {
"en": "Not permitted"
},
"localizedDescriptions": {
"en": "The treatment is not permitted."
}
}
]
}
]
},
{
"id": "qualification",
"name": "Qualification",
"localizedName": "Qualification",
"rmType": "DV_TEXT",
"nodeId": "at0020",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Qualification"
},
"localizedDescriptions": {
"en": "Description about any criteria, caveats or futher clarification about the limitation."
},
"annotations": {
"comment": "For example: the types of antibiotics that would be acceptable."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Advanced Directives']/items[openEHR-EHR-EVALUATION.limitation_of_treatment.v0]/data[at0001]/items[at0006]/items[at0020]/value",
"inputs": [
{
"type": "TEXT"
}
]
}
]
},
{
"id": "rationale",
"name": "Rationale",
"localizedName": "Rationale",
"rmType": "DV_TEXT",
"nodeId": "at0021",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Rationale"
},
"localizedDescriptions": {
"en": "Narrative rationale or justification for the limitation of treatment decision/s."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Advanced Directives']/items[openEHR-EHR-EVALUATION.limitation_of_treatment.v0]/data[at0001]/items[at0021]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "patient_awareness",
"name": "Patient awareness",
"localizedName": "Patient awareness",
"rmType": "DV_CODED_TEXT",
"nodeId": "at0022",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Patient awareness"
},
"localizedDescriptions": {
"en": "Is the patient aware of the limitation of treatment decision/s?"
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Advanced Directives']/items[openEHR-EHR-EVALUATION.limitation_of_treatment.v0]/data[at0001]/items[at0022]/value",
"inputs": [
{
"suffix": "code",
"type": "CODED_TEXT",
"list": [
{
"value": "at0024",
"label": "Patient not aware of the decision/s",
"localizedLabels": {
"en": "Patient not aware of the decision/s"
},
"localizedDescriptions": {
"en": "The patient is not aware of the limitation of treatment decision/s."
}
},
{
"value": "at0023",
"label": "Patient aware of the decision/s",
"localizedLabels": {
"en": "Patient aware of the decision/s"
},
"localizedDescriptions": {
"en": "The patient is aware of the limitation of treatment decision/s."
}
}
]
}
]
},
{
"id": "carer_awareness",
"name": "Carer awareness",
"localizedName": "Carer awareness",
"rmType": "DV_TEXT",
"nodeId": "at0025",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Carer awareness"
},
"localizedDescriptions": {
"en": "Narrative description about awareness of the treatment decision/s by carers and family."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Advanced Directives']/items[openEHR-EHR-EVALUATION.limitation_of_treatment.v0]/data[at0001]/items[at0025]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "comment",
"name": "Comment",
"localizedName": "Comment",
"rmType": "DV_TEXT",
"nodeId": "at0026",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Comment"
},
"localizedDescriptions": {
"en": "Additional narrative about the limitation of treatment decision/s, not captured in other fields."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Advanced Directives']/items[openEHR-EHR-EVALUATION.limitation_of_treatment.v0]/data[at0001]/items[at0026]/value",
"inputs": [
{
"type": "TEXT"
}
]
},
{
"id": "element",
"name": "ELEMENT",
"localizedName": "ELEMENT",
"rmType": "DV_DATE_TIME",
"nodeId": "at029",
"min": 0,
"max": 1,
"dependsOn": [
"per_limitation",
"comment",
"carer_awareness",
"rationale",
"status",
"patient_awareness"
],
"localizedNames": {
"en": "ELEMENT"
},
"localizedDescriptions": {
"en": "*"
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Advanced Directives']/items[openEHR-EHR-EVALUATION.limitation_of_treatment.v0]/protocol[at0027]/items[at029]/value",
"inputs": [
{
"type": "DATETIME"
}
]
},
{
"id": "review_date",
"name": "Review date",
"localizedName": "Review date",
"rmType": "DV_DATE_TIME",
"nodeId": "at0030",
"min": 0,
"max": 1,
"dependsOn": [
"per_limitation",
"comment",
"carer_awareness",
"rationale",
"status",
"patient_awareness"
],
"localizedNames": {
"en": "Review date"
},
"localizedDescriptions": {
"en": "The date when this Limitation of treatment archetype is due for review."
},
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Advanced Directives']/items[openEHR-EHR-EVALUATION.limitation_of_treatment.v0]/protocol[at0027]/items[at0030]/value",
"inputs": [
{
"type": "DATETIME"
}
]
},
{
"id": "language",
"name": "Language",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Advanced Directives']/items[openEHR-EHR-EVALUATION.limitation_of_treatment.v0]/language",
"inContext": true
},
{
"id": "encoding",
"name": "Encoding",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Advanced Directives']/items[openEHR-EHR-EVALUATION.limitation_of_treatment.v0]/encoding",
"inContext": true
},
{
"id": "subject",
"name": "Subject",
"rmType": "PARTY_PROXY",
"min": 1,
"max": 1,
"aqlPath": "/content[openEHR-EHR-SECTION.adhoc.v1,'Advanced Directives']/items[openEHR-EHR-EVALUATION.limitation_of_treatment.v0]/subject",
"inputs": [
{
"suffix": "id",
"type": "TEXT"
},
{
"suffix": "id_scheme",
"type": "TEXT"
},
{
"suffix": "id_namespace",
"type": "TEXT"
},
{
"suffix": "name",
"type": "TEXT"
}
],
"inContext": true
}
]
}
]
},
{
"id": "category",
"rmType": "DV_CODED_TEXT",
"nodeId": "",
"min": 1,
"max": 1,
"aqlPath": "/category",
"inputs": [
{
"suffix": "code",
"type": "CODED_TEXT",
"list": [
{
"value": "433",
"label": "event",
"localizedLabels": {
"en": "event"
}
}
],
"terminology": "openehr"
}
],
"inContext": true
},
{
"id": "language",
"name": "Language",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/language",
"inContext": true
},
{
"id": "territory",
"name": "Territory",
"rmType": "CODE_PHRASE",
"min": 1,
"max": 1,
"aqlPath": "/territory",
"inContext": true
},
{
"id": "composer",
"name": "Composer",
"rmType": "PARTY_PROXY",
"min": 1,
"max": 1,
"aqlPath": "/composer",
"inputs": [
{
"suffix": "id",
"type": "TEXT"
},
{
"suffix": "id_scheme",
"type": "TEXT"
},
{
"suffix": "id_namespace",
"type": "TEXT"
},
{
"suffix": "name",
"type": "TEXT"
}
],
"inContext": true
}
]
}
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