ARCHETYPE ID | openEHR-EHR-EVALUATION.problem-diagnosis.v1 |
Concept | Diagnosis |
Description | A diagnosis defined by a clinician which is coded in an accepted terminology and may include the stage of the condition and the diagnostic criteria |
Use | Used for recording any diagnosis, present or past - so is used for recording past history as well as current diagnoses. Used with changed 'Subject of care' for recording diagnoses in relatives and so for family history. |
Misuse | Use 'openEHR-EHR-EVALUATION.problem-diagnosis-histological' for histological diagnoses. |
Purpose | For recording medical diagnoses with optional diagnostic criteria and staging. Requires coded entry of diagnosis. |
References | |
Copyright | © openEHR Foundation |
Authors | Author name: Sam Heard Organisation: Ocean Informatics Email: sam.heard@oceaninformatics.com Date originally authored: 23/04/2006 |
Other Details Language | Author name: Sam Heard Organisation: Ocean Informatics Email: sam.heard@oceaninformatics.com Date originally authored: 23/04/2006 |
OtherDetails Language Independent | {references=, MD5-CAM-1.0.1=25DE4AB34DEAEC07427F236A035F33B2} |
Keywords | past, history, family, history, condition |
Lifecycle | Rejected |
Language used | en |
Citeable Identifier | 1013.1.168 |
All | Archetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=A diagnosis defined by a clinician which is coded in an accepted terminology and may include the stage of the condition and the diagnostic criteria, archetypeConceptComment=null, otherContributors=, originalLanguage=en, translators=
Any term that 'is_a' diagnosis [Any term that is a diagnosis in an accepted terminology] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0.32], code=at0.32, itemType=ELEMENT, level=2, text=Status, description=The status of the diagnosis, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0005], code=at0005, itemType=ELEMENT, level=2, text=Severity, description=The severity of the index problem, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=1: Mild [The severity of the index problem is mild, not affecting life or longevity] 4: Moderate [The severity of the index problem is such as to cause significant morbidity] 7: Severe [The severity of the index problem has had a major effect on life and/or longevity] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0009], code=at0009, itemType=ELEMENT, level=2, text=Clinical description, description=Description of the clinical aspects of the problem, 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[at0010], code=at0010, itemType=ELEMENT, level=2, text=Date clinically recognised, description=Date the problem was recognised by clinicians, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE, bindings=null, values=Partial Date, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0037], code=at0037, itemType=ELEMENT, level=2, text=Age when clinically recognised, description=The age when this problem was clinically recognised, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DURATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0011], code=at0011, itemType=CLUSTER, level=2, text=Location, description=Location of the problem in terms of body site, comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=1..2, cardinalityText=Maximum of 2 items , ordered , subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0011]/items[at0012], code=at0012, itemType=ELEMENT, level=3, text=Body site, description=The body site affected, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Constraint: Any term that describes a body site [An anatomical structure with qualifiers] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0011]/items[at0013], code=at0013, itemType=ELEMENT, level=3, text=Location description, description=A free text description of the location - may be in addition to a coded body site, 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[at0014], code=at0014, itemType=CLUSTER, level=2, text=Aetiology, description=Agents or Factors known to have been of aetiological significance, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=1..*, cardinalityText= , subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0014]/items[at0015], code=at0015, itemType=ELEMENT, level=3, text=Agent, description=Microbial or other agent known to have caused this problem, comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0014]/items[at0016], code=at0016, itemType=ELEMENT, level=3, text=Complication of, description=A problem or link to a problem or injury described elsewhere in the EHR, comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
Units:
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0026], code=at0026, itemType=CLUSTER, level=2, text=Related problems, description=Complications that are attributed to this problem, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=1..*, cardinalityText= , subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0026]/items[at0027], code=at0027, itemType=CLUSTER, level=3, text=Related problem, description=A group of characteristics of the problem complicating the index condition in this archetype, 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[at0026]/items[at0027]/items[at0028], code=at0028, itemType=ELEMENT, level=4, text=Related problem, description=Details of the problem as text or coded text or URI, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
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