| ARCHETYPE ID | openEHR-EHR-EVALUATION.exclusion_specific.v1 |
| Concept | Exclusion - specific |
| Description | A statement of exclusion of a specific Problem/diagnosis, Family history, Medication, Procedure, Adverse reaction or other clinical item that is either not currently present, or have not been present in the past. |
| Use | Use to record a statement of exclusion of a specific Problem/diagnosis, Family history, Medication, Procedure, Adverse reaction or other clinical item that is either not currently present, or have not been present in the past. This archetype has been specifically designed to make a clear and unambiguous statement of a specific exclusion of a type of clinical item from the health record. This approach is used in preference to relying on flags or terminology to express negation. The data element 'Excluded concept' allows for recording of a single specific statement. The different specific concepts listed in the "Excluded concept' run-time name constraint identifies the different specific exclusions. This name constraint can be applied during template modelling or at run-time within a software application. Each specific exclusion should be recorded in a separate instance of this archetype. For example: record 'no past history of adverse reaction to penicillin V', 'no past history of adverse reaction to cephalosporins' and 'no known family history of heart disease' in 3 separately constrained instances of this archetype. Please note that exclusion statements can only be considered to be current and accurate at the point-in-time of recording. It is possible for a record to be able to state that an individual has NO KNOWN history of a specific problem or diagnosis (using an exclusion statement) at the same consultation as recording the evidence of their first experience of the same problem or diagnosis (using the EVALUATION.problem_diagnosis archetype). In future record statements, the individual may have a KNOWN history of the problem or diagnosis recorded in their problem list. |
| Misuse | Not to be used to record the exclusion of all problems or diagnoses, medications, procedures, family history, adverse reactions or other clinical items - use the EVALUATION.exclusion_global archetype for this purpose. Not to be used to record the exclusion of any component of a physical examination - use the CLUSTER.exclusion_exam archetype within an appropriate OBSERVATION or CLUSTER archetype. Not to be used to record the exclusion of symptoms use the CLUSTER.exclusion_symptom archetype within an appropriate OBSERVATION or CLUSTER archetype. Not to be used to record the absence of information - use the EVALUATION.absense archetype for this purpose. |
| Purpose | To record a statement of exclusion about a specific Problem/diagnosis, Family history, Medication, Procedure, Adverse reaction or other clinical item that is either not currently present, or have not been present in the past. |
| References | Derived from: Eksklusjonsutsagn - spesifikt, Draft archetype [Internet]. Nasjonal IKT, Nasjonal IKT Clinical Knowledge Manager [sited: 2017-03-17]. Available from: http://arketyper.no/ckm/#showArchetype_1078.36.1653 Exclusion statement, Deprecated Archetype [Internet]. openEHR Foundation, openEHR Clinical Knowledge Manager [cited: 2017-02-17]. Available from: http://openehr.org/ckm/#showArchetype_1013.1.617 |
| Copyright | © Nasjonal IKT HF, openEHR Foundation |
| Authors | Author name: Silje Ljosland Bakke Organisation: Nasjonal IKT HF Email: silje.ljosland.bakke@nasjonalikt.no Date originally authored: 2017-02-17 |
| Other Details Language | Author name: Silje Ljosland Bakke Organisation: Nasjonal IKT HF Email: silje.ljosland.bakke@nasjonalikt.no Date originally authored: 2017-02-17 |
| 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=Derived from: Eksklusjonsutsagn - spesifikt, Draft archetype [Internet]. Nasjonal IKT, Nasjonal IKT Clinical Knowledge Manager [sited: 2017-03-17]. Available from: http://arketyper.no/ckm/#showArchetype_1078.36.1653 Exclusion statement, Deprecated Archetype [Internet]. openEHR Foundation, openEHR Clinical Knowledge Manager [cited: 2017-02-17]. Available from: http://openehr.org/ckm/#showArchetype_1013.1.617, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=FD31B6A3D7C0FE6280E39084A789BA00, build_uid=6297929d-1789-4731-90a8-03a061405761, revision=1.0.2} |
| Keywords | exclusion, negation, rule out, rule-out, r/o, absence |
| Lifecycle | published |
| UID | d99024d9-35e2-4d70-90ac-ec2e5bb8ced2 |
| Language used | en |
| Citeable Identifier | 1013.1.2737 |
| Revision Number | 1.0.2 |
| All | Archetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=A statement of exclusion of a specific Problem/diagnosis, Family history, Medication, Procedure, Adverse reaction or other clinical item that is either not currently present, or have not been present in the past., archetypeConceptComment=null, otherContributors=Tomas Alme, DIPS ASA, Norway Vebjørn Arntzen, Oslo universitetssykehus HF, Norway (Nasjonal IKT editor) Silje Ljosland Bakke, Nasjonal IKT HF, Norway (openEHR Editor) Kristian Berg, Universitetssykehuset Nord Norge, Norway SumanBhusan Bhattacharyya, Sudisa Consultancy Services, India Bjørn Christensen, Helse Bergen HF, Norway Lisbeth Dahlhaug, Helse Midt - Norge IT, Norway Hildegard Franke, freshEHR Clinical Informatics Ltd., United Kingdom Heather Grain, Llewelyn Grain Informatics, Australia Annette Hole Sjøborg, DIPS ASA, Norway Hilde Hollås, DIPS ASA, Norway Evelyn Hovenga, EJSH Consulting, Australia Tom Jarl Jakobsen, Helse Bergen, Norway Hanne Joensen, Helse Bergen HUS, Norway Lars Morgan Karlsen, DIPS ASA, Norway Heather Leslie, Ocean Health Systems, Australia (openEHR Editor) Hallvard Lærum, Direktoratet for e-helse, Norway Siv Marie Lien, DIPS ASA, Norway Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (openEHR Editor) Andrej Orel, Marand d.o.o., Slovenia Vladimir Pizzo, Hospital Sírio Libanês, Brazil Navin Ramachandran, NHS, United Kingdom Arild Stangeland, Helse Bergen, Norway Nyree Taylor, Ocean Informatics, Australia John Tore Valand, Haukeland Universitetssjukehus, Norway (Nasjonal IKT editor), originalLanguage=en, translators=
All not explicitly excluded archetypes, extendedValues=null]], content=[], source=[], credentials=[], events=[], data=[ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=2, text=Exclusion statement, description=A qualifying statement about the exclusion of a Problem/diagnosis, Family history, Medication, Procedure, Adverse reaction or other clinical item., comment=This statement is to be used in conjunction with the 'Excluded concept' data element. For example: this data element can support recording general statements such as "No known history of ..." where the 'Excluded concept' identifies the specific problem, diagnosis, substance, procedure or medication. If the 'Excluded concept' data element is used to record a precoordinated term such as 'No family history of diabetes', this element is redundant., 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=ELEMENT, level=2, text=(Excluded concept), description=Identification of the specific concept which has been excluded., comment=Use this data element in one of two ways. Firstly, exclusion of family history of diabetes can be expressed by using 'Family problem/diagnosis' as the run-time name constraint and 'diabetes' as the value for this data point. Alternatively the value could contain precoordinated terms such as 'No past family history of diabetes'. Coding of the value for 'Excluded concept', either as a simple or precoordinated term, with a terminology is desirable where possible. If a precoordinated term is used with this data element the 'Exclusion statement' becomes redundant., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=Runtime name constraint:
All not explicitly excluded archetypes, extendedValues=null]], minIndents={}, termBindingRetrievalErrorMessage=null] |