ARCHETYPE Reason for encounter (openEHR-EHR-EVALUATION.reason_for_encounter.v1)

ARCHETYPE IDopenEHR-EHR-EVALUATION.reason_for_encounter.v1
ConceptReason for encounter
DescriptionThe reason for initiation of any healthcare encounter or contact by the individual who is the subject of care.
UseUse to record the reason, or reasons, for initiation of any type of healthcare encounter or contact between a healthcare provider and the individual who is the subject of care. The reason may be for clinical, social or administrative purposes. Reason for Encounter is a common phrase used in clinical medicine, however the term is often used in two common ways - one that refers to an administrative category for provision of healthcare and the other that reflects clinical or social problems that motivate individuals to seek healthcare. In an effort to clarify the phrases and intent, this archetype contains two data elements: - The first, 'Contact type', to document the administrative type of healthcare sought or required - for example the type of consultation, emergency care, pre-operative assessment, routine antenatal visit or elective admission. This data element reflects the administrative category of care provision. Use of the phrase 'Contact type', rather than 'Reason for encounter' or 'Reason for visit' reflects the increasing trend towards alternative methods of healthcare provision that may not result in face-to-face contact between the healthcare provider and patient within a consulting room. - The second, 'Presenting problem', to document the clinical reasons for healthcare contact. Chief complaint is regarded as a synonym for 'Presenting problem'. These are intended mainly to capture the patient's perceived issues or symptoms which have triggered them to seek healthcare advice, such as desire to quit smoking, stress, shortness of breath, genetic counselling or abdominal pain. Signs such as impaired conscious state may also be captured here, for example by paramedical staff with an unconscious patient.
MisuseNot to be used to record specific details of the patient's story or history of symptoms. Use OBSERVATION.story to capture the narrative and the related nested CLUSTER archetypes for structured content eg CLUSTER.symptom, CLUSTER.event and CLUSTER.issue. Not to be used to record specific diagnosis details that may be required in addition to a Reason for Encounter. For example, to record a Pre-operative Diagnosis as part of admission for a hospital procedure. Use the EVALUATION.problem_diagnosis archetype for this purpose.
PurposeTo record the reason, or reasons, for initiation of any type of healthcare encounter or contact by the individual who is the subject of care.
ReferencesopenEHR Foundation. openEHR wiki: Reason for Encounter or Chief Complaint [Internet]. 2008 Feb 13 [cited 2012 Jun 17]; Available at http://www.openehr.org/wiki/display/healthmod/Reason+for+encounter+or+Chief+complaint.
Copyright© openEHR Foundation
AuthorsAuthor name: Heather Leslie
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2007-04-19
Other Details LanguageAuthor name: Heather Leslie
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2007-04-19
OtherDetails Language Independent{licence=This work is licensed under the Creative Commons Attribution-ShareAlike 3.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/3.0/., custodian_organisation=openEHR Foundation, references=openEHR Foundation. openEHR wiki: Reason for Encounter or Chief Complaint [Internet]. 2008 Feb 13 [cited 2012 Jun 17]; Available at http://www.openehr.org/wiki/display/healthmod/Reason+for+encounter+or+Chief+complaint., current_contact=Heather Leslie, Atomica Informatics, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=90C5F925448956442E23C72D39E87807, build_uid=1a1f289d-216d-42d4-a524-54804ac948e9, revision=1.0.0}
Keywordspresentation, presenting complaint, reason for encounter, reason, chief complaint, visit, reason for visit
Lifecyclepublished
UID3d268aac-eeb5-4f95-b1a8-1d4dec5d0ae7
Language useden
Citeable Identifier1013.1.290
Revision Number1.0.0
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=The reason for initiation of any healthcare encounter or contact by the individual who is the subject of care., archetypeConceptComment=null, otherContributors=Nadim Anani, Karolinska Institutet, Sweden
Vebjørn Arntzen, Oslo University Hospital, Norway
Koray Atalag, University of Auckland, New Zealand
Lars Bitsch-Larsen, Haukeland University hospital, Norway
Sergio Carmona, Chile
Beatriz de Faria Leão, Brazil
Shahla Foozonkhah, Iran ministry of health and education, Iran
Sebastian Garde, Ocean Informatics, Germany
Heather Grain, Llewelyn Grain Informatics, Australia
Omer Hotomaroglu, Turkey
Sundaresan Jagannathan, Scottish NHS, United Kingdom
Lars Morgan Karlsen, DIPS ASA, Norway
Heather Leslie, Atomica Informatics, Australia (openEHR Editor)
Hallvard Lærum, Norwegian Directorate of e-health, Norway
Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (openEHR Editor), originalLanguage=en, translators=Portuguese (Brazil): Fernanda Maia Ewerton, Core Consulting, fernanda.maiaewerton@gmail.com, Hospital Alemão Oswaldo Cruz (HAOC)
Spanish (Spain): Pablo Pazos, CaboLabs, Computer Engineer
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