ARCHETYPE Absence of information (openEHR-EHR-EVALUATION.absence.v1)

ARCHETYPE IDopenEHR-EHR-EVALUATION.absence.v1
ConceptAbsence of information
DescriptionStatement that specified health information is not available for inclusion in the health record or extract at the time of recording.
UseUse to enable recording or exchange of an explicit statement that specified health information is not available for inclusion in the health record or record extract at the time of recording. This statement is the third component of a family of statements - statements of positive presence, statements of positive exclusion and statements of absence: - Statements of positive presence indicate that there is relevant health information in the record or extract - for example, EVALUATION.adverse_reaction stating that the patient has an allergy to penicillin or EVALUATION.problem_diagnosis stating that the patient has diabetes. - Equivalent statements about exclusion are used to indicate that it is known that there is no relevant health information in the health record or extract - for example, EVALUATION.exclusion_adverse stating that the patient does not have a known allergy to penicillin or EVALUATION.exclusion_problem_diagnosis stating that the patient is not diabetic; and; - In this context, the EVALUATION.absence could be used to record that there is no health information available about penicillin allergy or the diagnosis of diabetes - it is not known if it is present or excluded, but there is no information that can be provided. This archetype has been developed specifically for the use case where a clinician is preparing an extract from a health record, so that the receiver has explicit and unambiguous understanding of the information available - that which is present, excluded or just not available. It is primarily intended to be used within SLOTS in persistent COMPOSITIONS such as 'Therapeutic precautions', 'Medication list', 'Problem list', or 'Adverse reaction list'. It is also deliberately intended to be statement made by a clinician in the same way that they would record any allergies or diagnoses, and is intended to be quite different to technical use of null flavours in data. Absence statements can only be considered to be current and accurate at the time of recording. This archetype has been designed specifically to avoid the need to use of flags to express negation about any entry within the health record.
MisuseNot to be used to record the presence of adverse reactions, medication use, procedures, problems or diagnoses - use specific archetypes for this purpose. Not to be used to record the exclusion of adverse reactions, medication use, procedures, problems or diagnoses - use specific specialisations of the EVALUATION.exclusion archetype for this purpose.
PurposeTo enable recording or exchange of an explicit statement by a clinician that specified health information is not available for inclusion in the health record or record extract at the time of recording.
References
Copyright© openEHR Foundation
AuthorsAuthor name: Heather Leslie
Organisation: Ocean Informatics
Email: heather.leslie@oceaninformatics.com
Date originally authored: 2013-03-12
Other Details LanguageAuthor name: Heather Leslie
Organisation: Ocean Informatics
Email: heather.leslie@oceaninformatics.com
Date originally authored: 2013-03-12
OtherDetails Language Independent{licence=This work is licensed under the Creative Commons Attribution-ShareAlike 3.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/3.0/., custodian_organisation=openEHR Foundation, current_contact=Heather Leslie, Ocean Informatics, heather.leslie@oceaninformatics.com, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=FF43E895078FC0D3D3234730AEE4CAEE, build_uid=3500005f-f19a-44bd-856c-655a537837a4, revision=1.0.2-alpha}
Keywordsabsence, information, adverse, reaction, problem, diagnosis, medication, procedure, vaccination, adverse reaction
Lifecyclein_development
UIDd58dadf0-7bf7-4eba-aa68-d923ef309e26
Language useden
Citeable Identifier1013.1.1427
Revision Number1.0.2-alpha
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Statement that specified health information is not available for inclusion in the health record or extract at the time of recording., archetypeConceptComment=null, otherContributors=Vebjoern Arntzen, Oslo university hospital, Norway
Koray Atalag, University of Auckland, New Zealand
Gustavo Bacelar-Silva, Healthcare Designs, Brazil (openEHR Editor)
Silje Ljosland Bakke, Bergen Hospital Trust, Norway (openEHR Editor)
Lars Bitsch-Larsen, Haukeland University hospital, Norway
Einar Fosse, National Centre for Integrated Care and Telemedicine, Norway
Sebastian Garde, Ocean Informatics, Germany
Heather Grain, Llewelyn Grain Informatics, Australia
Sam Heard, Ocean Informatics, Australia
Lars Karlsen, DIPS ASA, Norway
Shinji Kobayashi, Kyoto University, Japan
Heather Leslie, Ocean Informatics, Australia (openEHR Editor)
Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (openEHR Editor)
Andrej Orel, Marand d.o.o., Slovenia
Richard Townley-O'Neill, NEHTA, Australia, originalLanguage=en, translators=Portuguese (Brazil): Vladimir Pizzo, Hospital Sirio Libanes, Brazil, vladimir.pizzo@hsl.org.br
, subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={identities=[], other_participations=[], credentials=[], description=[], relationships=[], ism_transition=[], activities=[], items=[], data=[ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=2, text=Absence statement, description=Positive statement that no information is available., 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"., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0005], code=at0005, itemType=ELEMENT, level=2, text=Reason for absence, description=Narrative description of the reason why there is no information available., comment=For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null]], capabilities=[], state=[], context=[], events=[], source=[], content=[], target=[], details=[], provider=[], protocol=[ResourceSimplifiedHierarchyItem [path=/protocol[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=2, text=Last updated, description=The date at which the absence was last updated., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0003]/items[at0006], code=at0006, itemType=SLOT, level=2, text=Extension, description=Additional information required to capture local content or to align with other reference models/formalisms., comment=For example: local information requirements or additional metadata to align with FHIR or CIMI equivalents., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
All not explicitly excluded archetypes, extendedValues=null]], contacts=[]}, topLevelItems={data=ResourceSimplifiedHierarchyItem [path=ROOT_/data[at0001], code=at0001, itemType=ITEM_TREE, level=0, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=1..1, cardinalityText=mandatory, subCardinalityFormal=1..*, subCardinalityText=, dataType=ITEM_TREE, bindings=null, values=null, extendedValues=null], protocol=ResourceSimplifiedHierarchyItem [path=ROOT_/protocol[at0003], code=at0003, itemType=ITEM_TREE, level=0, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=1..1, cardinalityText=mandatory, subCardinalityFormal=0..*, subCardinalityText=Minimum of 0 items, dataType=ITEM_TREE, bindings=null, values=null, extendedValues=null]}, addHierarchyItemsTo=protocol, currentHierarchyItemsForAdding=[ResourceSimplifiedHierarchyItem [path=/protocol[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=2, text=Last updated, description=The date at which the absence was last updated., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0003]/items[at0006], code=at0006, itemType=SLOT, level=2, text=Extension, description=Additional information required to capture local content or to align with other reference models/formalisms., comment=For example: local information requirements or additional metadata to align with FHIR or CIMI equivalents., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
All not explicitly excluded archetypes, extendedValues=null]], minIndents={}, termBindingRetrievalErrorMessage=null]