| ARCHETYPE ID | openEHR-EHR-SECTION.clinical_decision.v0 |
|---|---|
| Concept | Clinical decision |
| Description | Defines the process of making a decision about the diagnosis of a specific disease. |
| Use | All decisions that physicians must take to reach an accurate diagnosis, and thus to adequate therapy, when conduct the clinical evaluation of patients should be included in this archetype. |
| Purpose | Manage the process of reaching a decision about the diagnose regarding a specific disease. |
| References | |
| Copyright | © openEHR Foundation |
| Authors | Author name: Aitor Eguzkitza Organisation: Universidad Pública de Navarra - Complejo Hospitalario de Navarra Email: aitor.eguzkiza@unavarra.es Date originally authored: 2015-06-27 |
| Other Details Language | Author name: Aitor Eguzkitza Organisation: Universidad Pública de Navarra - Complejo Hospitalario de Navarra Email: aitor.eguzkiza@unavarra.es Date originally authored: 2015-06-27 |
| Other Details (Language Independent) |
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| Keywords | decision, diagnose |
| Lifecycle | in_development |
| UID | 99df0ccd-363e-4ba3-a741-55e87a540249 |
| Language used | en |
| Citeable Identifier | 1013.1.1707 |
| Revision Number | 0.0.1-alpha |
| items | |
| Clinical synopsis | Clinical synopsis: Narrative summary or overview about a patient, specifically from the perspective of a healthcare provider, and with or without associated interpretations. Include: openEHR-EHR-EVALUATION.clinical_ Exclude: All not explicitly included archetypes |
| Problem/diagnosis | Problem/diagnosis: An issue or obstacle which adversely impacts on the physical, mental and/or social well-being of an individual. The definition of a problem is deliberately kept rather loose and inclusive of a formal biomedical diagnosis so as to capture any real or perceived concerns that may adversely affect an individual's wellbeing to any degree. Include: openEHR-EHR-EVALUATION.problem_ Exclude: All not explicitly included archetypes |
| Exclusion of a problem/diagnosis | Exclusion of a problem/diagnosis: Positive statement/s about problems or diagnoses that need to be recorded as clinically excluded from the health record at a specific point in time. Include: openEHR-EHR-EVALUATION.exclusion-problem_ Exclude: All not explicitly included archetypes |
| Contraindication | Contraindication: Identification of a treatment, medicine, vaccine or procedure which should not be administered or performed on this subject. Include: openEHR-EHR-EVALUATION.contraindication.v([0-9]+) and specialisations Exclude: All not explicitly included archetypes |
| Recommendation | Recommendation: A suggestion, advice or proposal for current healthcare management or for future action. Include: openEHR-EHR-EVALUATION.recommendation.v([0-9]+) and specialisations Exclude: All not explicitly included archetypes |
| Other contributors | José Andonegui, Hospital de Navarra, jose.andonegui.navarro@cfnavarra.es Luis Serrano, Universidad Pública de Navarra (UPNA), lserrano@unavarra.es Jesús D. Trigo, Universidad Pública de Navarra (UPNA), jesusdaniel.trigo@unavarra.es |
| Translators |