| ARCHETYPE ID | openEHR-EHR-CLUSTER.clinical_evidence.v1 |
| Concept | Clinical evidence |
| Description | Details about findings that support a clinical assertion. |
| Use | Use to record details about findings that support a clinical assertion, either as a summary of data available in other (often OBSERVATION class) archetypes, or when the original observational data is not available. This archetype is designed to be nested within a SLOT in the EVALUATION.problem_diagnosis, EVALUATION.adverse_reaction_risk, EVALUATION.health_risk, EVALUATION.contraindication, or similar summary archetypes, where the name of the assertion has already been specified in the EVALUATION, in order to extend its content with this additional and optional dataset. While LINKs within the openEHR Reference Model allow for linkage to data held elsewhere within the health record, this archetype has been developed to make this functionality explicit, and to enable clinical visibility and review of this data, where it may be relevant in a template or specification. The clinical evidence can be entered directly into this archetype as a 'Finding', or a citation can be used to explicitly point to data within the health record. |
| Misuse | Not to be used to record summary details about an identified problem or diagnosis - use the EVALUATION.problem_diagnosis for this purpose. Not to be used to record summary details about an identified adverse reaction risk - use the EVALUATION.adverse_reaction_risk for this purpose. Not to be used to record summary details about an identified health risk - use the EVALUATION.health_risk for this purpose. Not to be used to record summary details about an identified contraindication - use the EVALUATION.contraindication for this purpose. |
| Purpose | To record an explicit finding in support of a clinical assertion, such as a problem/diagnosis, adverse reaction risk, health risk assessment, or contraindication. |
| References | |
| Copyright | © openEHR Foundation, Nasjonal IKT HF |
| Authors | Author name: Heather Leslie Organisation: Ocean Informatics Email: heather.leslie@oceaninformatics.com Date originally authored: 2015-01-23 |
| Other Details Language | Author name: Heather Leslie Organisation: Ocean Informatics Email: heather.leslie@oceaninformatics.com Date originally authored: 2015-01-23 |
| OtherDetails Language Independent | {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=93A2363976F764D012E816730DC1C569, build_uid=42c42686-5545-4af1-95b5-d105fa9164a3, revision=1.1.3} |
| Keywords | diagnosis, evidence, condition, disease, problem, assertion, finding, observation |
| Lifecycle | published |
| UID | 1a30b06f-887a-4b08-ab42-243bf6757c33 |
| Language used | en |
| Citeable Identifier | 1013.1.1971 |
| Revision Number | 1.1.3 |
| All | Archetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Details about findings that support a clinical assertion., archetypeConceptComment=null, otherContributors=Morten Aas, Oslo Universitetssykehus, Norway Ole Andreas Bjordal, Webmed, Norway Stein Arne Rimehaug, Sunnaas sykehus, Norway Vebjørn Arntzen, Oslo University Hospital, Norway Silje Ljosland Bakke, Nasjonal IKT HF, Norway (openEHR Editor) Kristian Berg, Universitetssykehuset Nord Norge, Norway SB BHATTACHARYYA, Sudisa Consultancy Services, India SBhusan Bhattacharyya, Sudisa Consultancy Services, India Bjørn Christensen, Helse Bergen HF, Norway Chris Dickson, NHS Digital, United Kingdom Hildegard Franke, freshEHR Clinical Informatics Ltd., United Kingdom Bente Gjelsvik, Helse Bergen, Norway Evelyn Hovenga, EJSH Consulting, Australia Hanne Joensen, Helse Bergen HUS, Norway Siri Larønningen, Kreftregisteret, Norway Heather Leslie, Ocean Informatics, Australia (openEHR Editor) Hallvard Lærum, Direktoratet for e-helse, Norway Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (openEHR Editor) Lars Morgan Karlsen, DIPS ASA, Norway Bjørn Næss, DIPS ASA, Norway Andrej Orel, Marand d.o.o., Slovenia Vladimir Pizzo, Hospital Sírio Libanês, Brazil Navin Ramachandran, NHS, United Kingdom Raymond Simkus, Brookswood Family Practice, Canada Iztok Stotl, UKCLJ, Slovenia Norwegian Review Summary, Nasjonal IKT HF, Norway Nyree Taylor, Ocean Informatics, Australia John Tore Valand, Haukeland Universitetssjukehus, Norway (Nasjonal IKT redaktør) Mette Wam, Esito AS, Norway, originalLanguage=en, translators=
openEHR-EHR-CLUSTER.citation.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0022], code=at0022, itemType=ELEMENT, level=1, text=Method, description=Type of examination or investigation used to identify the evidence., comment=Consider coding 'Method' with a terminology, where possible. For example: Physical examination, Chest x-ray, Histopathology result, Colonoscopy., 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=/items[at0001], code=at0001, itemType=ELEMENT, level=1, text=Method description, description=Narrative description of the method/s used to identify the evidence., 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=/items[at0018], code=at0018, itemType=SLOT, level=1, text=Multimedia representation, description=Digital image, video or diagram representing the clinical evidence., 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.multimedia.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0023], code=at0023, itemType=ELEMENT, level=1, text=Comment, description=Additional narrative about the finding 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]], ism_transition=[], relationships=[], context=[], description=[], state=[], details=[], data=[], content=[], events=[], capabilities=[], contacts=[], activities=[], provider=[]}, topLevelItems={items=ResourceSimplifiedHierarchyItem [path=ROOT_/, code=at0000, itemType=CLUSTER, level=0, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=null, extendedValues=null]}, addHierarchyItemsTo=items, currentHierarchyItemsForAdding=[ResourceSimplifiedHierarchyItem [path=/items[at0003], code=at0003, itemType=ELEMENT, level=1, text=Finding, description=Identification of the finding that supports the assertion., comment=It is recommended that 'Finding' should be coded with a terminology, where possible., 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=/items[at0004], code=at0004, itemType=ELEMENT, level=1, text=Finding description, description=Narrative description of the finding., 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=/items[at0005], code=at0005, itemType=ELEMENT, level=1, text=Result, description=Measurement or value associated with the finding., comment=For example: Mantoux test result., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ANY, bindings=null, values=null, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0006], code=at0006, itemType=ELEMENT, level=1, text=Date identified, description=The date on which the finding was clinically identified., comment=For example: The date when the finding was made by or made available to the clinician., 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=/items[at0007], code=at0007, itemType=SLOT, level=1, text=Citation, description=Detailed data available about the evidence held in another part of the health record., 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.citation.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0022], code=at0022, itemType=ELEMENT, level=1, text=Method, description=Type of examination or investigation used to identify the evidence., comment=Consider coding 'Method' with a terminology, where possible. For example: Physical examination, Chest x-ray, Histopathology result, Colonoscopy., 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=/items[at0001], code=at0001, itemType=ELEMENT, level=1, text=Method description, description=Narrative description of the method/s used to identify the evidence., 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=/items[at0018], code=at0018, itemType=SLOT, level=1, text=Multimedia representation, description=Digital image, video or diagram representing the clinical evidence., 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.multimedia.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0023], code=at0023, itemType=ELEMENT, level=1, text=Comment, description=Additional narrative about the finding 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]], minIndents={}, termBindingRetrievalErrorMessage=null] |