ARCHETYPE Clinical evidence (openEHR-EHR-CLUSTER.clinical_evidence.v1)

ARCHETYPE IDopenEHR-EHR-CLUSTER.clinical_evidence.v1
ConceptClinical evidence
DescriptionDetails about findings that support a clinical assertion.
UseUse 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.
MisuseNot 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.
PurposeTo 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
AuthorsAuthor name: Heather Leslie
Organisation: Ocean Informatics
Email: heather.leslie@oceaninformatics.com
Date originally authored: 2015-01-23
Other Details LanguageAuthor 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=231248071BB314B31BE7C3F5AAA40F96, build_uid=b32e5307-b36c-4bde-ac97-36080ad30f35, revision=1.1.0}
Keywordsdiagnosis, evidence, condition, disease, problem, assertion, finding, observation
Lifecyclepublished
UID1a30b06f-887a-4b08-ab42-243bf6757c33
Language useden
Citeable Identifier1013.1.1971
Revision Number1.1.0
AllArchetype [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=Norwegian Bokmål: Silje Ljosland Bakke, Nasjonal IKT HF, silje.ljosland.bakke@nasjonalikt.no
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