ARCHETYPE Differential diagnoses (openEHR-EHR-EVALUATION.differential_diagnoses.v1)

ARCHETYPE IDopenEHR-EHR-EVALUATION.differential_diagnoses.v1
ConceptDifferential diagnoses
DescriptionOne or more possible conditions, problems or diagnoses that may be responsible for a clinical presentation, examination findings and/or test results.
UseTo record details about one or more differential diagnoses that may be responsible for a single clinical presentation, examination findings and/or test results. This archetype has been designed to ensure that all differential diagnoses are recorded using a single model. In a clinical system, it would be expected that each differential diagnosis would be recorded using a separate instance of the 'Per differential' cluster. Each differential diagnosis should be regarded as a temporary diagnostic hypothesis and should only be used in the earliest phases of the diagnostic process. In practice, clinicians may identify a list of one or more differential diagnoses, any one of which may explain the clinical presentation. As more information is gathered from the examination, diagnostic test results, or referrals, the list of differential diagnoses is gradually refined and outliers eliminated until one or more working, provisional, or preliminary diagnosis is determined. If a differential diagnosis is accepted as a likely diagnosis, it is anticipated that it will be formally entered into the health record as a Problem/Diagnosis using the EVALUATION.problem_diagnosis archetype. The CLUSTER.problem_qualifier archetype may be nested within the Problem/Diagnosis archetype to support annotation of the diagnosis as 'working' or 'preliminary'.
MisuseNot to be used to record detailed information about a persistent problem or formal diagnosis - use the EVALUATION.problem_diagnosis for this purpose.
PurposeTo record details about one or more differential diagnoses that may be responsible for a single clinical presentation, examination findings and/or test results.
References
Copyright© openEHR Foundation
AuthorsAuthor name: Sam Heard
Organisation: Ocean Informatics, Australia
Email: Sam.Heard@OceanInformatics.com
Date originally authored: 2004-12-08
Other Details LanguageAuthor name: Sam Heard
Organisation: Ocean Informatics, Australia
Email: Sam.Heard@OceanInformatics.com
Date originally authored: 2004-12-08
OtherDetails Language Independent{licence=This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/., custodian_organisation=openEHR Foundation, references=, current_contact=Heather Leslie, Atomica Informatics, Australia, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=6517C726A8DB05F5413A72470B87A283, build_uid=a2b9615e-9f6e-4e0a-9d31-44603dc05533, revision=1.0.0}
Keywordsdifferential, diagnosis, hypothesis, alternative, diagnostic
Lifecyclepublished
UID5cf481d5-8d87-4a38-9ac8-07be3bb00a52
Language useden
Citeable Identifier1013.1.1670
Revision Number1.0.0
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=One or more possible conditions, problems or diagnoses that may be responsible for a clinical presentation, examination findings and/or test results., archetypeConceptComment=null, otherContributors=Andreas Abildgaard, OUS, Norway
Sanyaolu Ameye, imhtech, Nigeria
Vebjørn Arntzen, Oslo University Hospital, Norway (openEHR Editor)
Astrid Askeland, Dips ASA, Norway
Silje Ljosland Bakke, Helse Vest IKT AS, Norway (openEHR Editor)
Terje Bektesevic Holmlund, UiT Norges arktiske universitet, Norway
SB Bhattacharyya, Sudisa Consultancy Services, India
Fatemeh Chalabianloo, Helse Bergen, Norway
Bjørn Christensen, Helse Bergen HF, Norway
Vegar Dagenborg, OUS, Norway
Einar Engtrø, DIPS AS, Norway
Grant Forrest, Lunaria Ltd, United Kingdom
Mikkel Gaup Grønmo, Helse-Nord, FSE, Norway (openEHR Editor)
Maria G, Norway
Heather Grain, Llewelyn Grain Informatics, Australia
Anne Grimstvedt Kvalvik, Haraldsplass Diakonale sykehus, Norway
Mikkel Johan Gaup Grønmo, Forvaltningssenter EPJ, Helse-Nord, Norway (openEHR Editor)
Joost Holslag, Nedap, Netherlands
Evelyn Hovenga, EJSH Consulting, Australia
Dipak Kalra, United Kingdom
Nils Kolstrup, Skansen Legekontor og Nasjonalt Senter for samhandling og telemedisin, Norway
Jörgen Kuylenstierna, eWeave AB, Sweden
Liv Laugen, ​Oslo University Hospital, Norway, Norway (openEHR Editor)
Heather Leslie, Atomica Informatics, Australia
Pedro Leuschner, Centro Hospitalar do Porto, Portugal
Domingo Liotta, University of Morón, Argentina
Mark Luciani, Bath and North East Somerset, Swindon and Wiltshire Clinical Commisioning Group, United Kingdom
James McClay, University of Nebraska Medical Center, United States
Per Meinich, Helse Sør-Øst RHF, Norway
Svenne Naumann, Finnmarkssykehuset, Norway
Sam Philip, NHS Grampian, United Kingdom
Sidharth Ramesh, Kasturba Medical College, India
Jussara Rotzsch, Hospital Alemão Oswaldo Cruz, Brazil
Benjamin Senst, Germany
Norwegian Review Summary, Nasjonal IKT HF, Norway
Nyree Taylor, Ocean Informatics, Australia
Micaela Thierley, Helse Vest IKT, Norway
Rowan Thomas, St. Vincent's Hospital Melbourne, Australia
Anders Thurin, VGR, Sweden
Jeremy Tong, NHS, United Kingdom
John Tore Valand, Helse Bergen, Norway (openEHR Editor)
Marit Alice Venheim, Helse Vest IKT, Norway (openEHR Editor), originalLanguage=en, translators=Norwegian Bokmål: Marit Alice Venheim, Vebjørn Arntzen, Helse Vest IKT, Oslo University Hospital, marit.alice.venheim@helse-vest-ikt.no, varntzen@ous-hf.no
, subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={capabilities=[], source=[], description=[], state=[], target=[], details=[], credentials=[], relationships=[], identities=[], provider=[], items=[], activities=[], data=[ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=2, text=Overall description, description=Narrative overview about all of the differential diagnoses identified., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0003], code=at0003, itemType=CLUSTER, level=2, text=Per differential, description=Details about a single differential diagnosis., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=3, text=Diagnosis name, description=Identification of the differential diagnosis, by name., comment=Coding with a terminology is preferred, where possible., 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[at0003]/items[at0005], code=at0005, itemType=ELEMENT, level=3, text=Status, description=Likelihood of the differential diagnosis being responsible for the clinical situation., comment=If using the proposed value set, 'Possible' is considered as the default until each diagnosis is either accepted or excluded. If a diagnosis is regarded as 'Accepted' then it is likely that it will either be manually or automatically added to the health record using the EVALUATION.problem_diagnosis archetype., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
  •  Coded Text
    • Possible [Under investigation; neither accepted as a formal diagnosis, nor excluded.]
    • Accepted [Accepted as a formal diagnosis.]
    • Excluded [Ruled out as a formal diagnosis.]
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0003]/items[at0009], code=at0009, itemType=ELEMENT, level=3, text=Rationale, description=Narrative description about the rationale for the diagnosis being accepted or excluded., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0003]/items[at0010], code=at0010, itemType=SLOT, level=3, text=Clinical evidence, description=Structured details about clinical evidence supporting or excluding the differential diagnosis., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.clinical_evidence.v1, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0003]/items[at0011], code=at0011, itemType=ELEMENT, level=3, text=Order, description=Tag assigned to supporting ordering within a list of differential diagnoses., comment=For example: to prioritise the order of investigation of differential diagnoses., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0003]/items[at0012], code=at0012, itemType=ELEMENT, level=3, text=Comment, description=Additional narrative about the differential diagnosis, not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null]], content=[], ism_transition=[], other_participations=[], context=[], contacts=[], protocol=[ResourceSimplifiedHierarchyItem [path=/protocol[at0013]/items[at0014], code=at0014, itemType=SLOT, level=2, text=Extension, description=Additional information required to extend the model with local content or to align with other reference models or formalisms., comment=For example: local information requirements; or additional metadata to align with FHIR., 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], ResourceSimplifiedHierarchyItem [path=/protocol[at0013]/items[at0015], code=at0015, itemType=ELEMENT, level=2, text=Last updated, description=The date/time the differential diagnoses were 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]], events=[]}, 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=0..1, cardinalityText=optional, subCardinalityFormal=1..*, subCardinalityText=ordered, dataType=ITEM_TREE, bindings=null, values=null, extendedValues=null], protocol=ResourceSimplifiedHierarchyItem [path=ROOT_/protocol[at0013], code=at0013, itemType=ITEM_TREE, level=0, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=0..1, cardinalityText=optional, subCardinalityFormal=0..*, subCardinalityText=Minimum of 0 items, dataType=ITEM_TREE, bindings=null, values=null, extendedValues=null]}, addHierarchyItemsTo=protocol, currentHierarchyItemsForAdding=[ResourceSimplifiedHierarchyItem [path=/protocol[at0013]/items[at0014], code=at0014, itemType=SLOT, level=2, text=Extension, description=Additional information required to extend the model with local content or to align with other reference models or formalisms., comment=For example: local information requirements; or additional metadata to align with FHIR., 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], ResourceSimplifiedHierarchyItem [path=/protocol[at0013]/items[at0015], code=at0015, itemType=ELEMENT, level=2, text=Last updated, description=The date/time the differential diagnoses were 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]], minIndents={}, termBindingRetrievalErrorMessage=null]