| ARCHETYPE ID | openEHR-EHR-EVALUATION.reason_for_encounter.v1 |
|---|---|
| Concept | Reason for encounter |
| Description | The reason for initiation of any healthcare encounter or contact by the individual who is the subject of care. |
| Use | Use 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:
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| Misuse | Not 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. |
| Purpose | To record the reason, or reasons, for initiation of any type of healthcare encounter or contact by the individual who is the subject of care. |
| 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. |
| Copyright | © openEHR Foundation |
| Authors | Author name: Heather Leslie Organisation: Atomica Informatics Email: heather.leslie@atomicainformatics.com Date originally authored: 2007-04-19 |
| Other Details Language | Author name: Heather Leslie Organisation: Atomica Informatics Email: heather.leslie@atomicainformatics.com Date originally authored: 2007-04-19 |
| Other Details (Language Independent) |
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| Keywords | presentation, presenting complaint, reason for encounter, reason, chief complaint, visit, reason for visit |
| Lifecycle | published |
| UID | 3d268aac-eeb5-4f95-b1a8-1d4dec5d0ae7 |
| Language used | en |
| Citeable Identifier | 1013.1.290 |
| Revision Number | 1.0.3 |
| data | |
| Contact type | Contact type: Identification of the type, or administrative category, of healthcare sought or required by the subject of care. Coding of the 'Contact type' with a terminology is desirable, where possible. Examples include: pre-employment medical, routine antenatal visit, women's health check, pre-operative assessment, or annual medical check-up. |
| Presenting problem | Presenting problem: Identification of the clinical or social problem motivating the subject of care to seeking healthcare. Coding of the 'Presenting problem' with a terminology is desirable, where possible. Clinical or social reasons for seeking healthcare can include health issues, symptoms or physical signs. Examples: health issues - desire to quit smoking, domestic violence; symptoms - abdominal pain, shortness of breath; physical signs - an altered conscious state. 'Chief complaint' may be used as a valid synonym for 'Presenting problem' in templates. |
| Other contributors | Tomas Alme, DIPS ASA, Norway Nadim Anani, Karolinska Institutet, Sweden Vebjørn Arntzen, Oslo University Hospital, Norway Koray Atalag, University of Auckland, New Zealand Silje Ljosland Bakke, Helse Vest IKT AS, Norway (openEHR Editor) Lars Bitsch-Larsen, Haukeland University hospital, Norway Sergio Carmona, Chile Lisbeth Dahlhaug, Helse Midt - Norge IT, Norway Beatriz de Faria Leão, Brazil Shahla Foozonkhah, Ocean Informatics, Australia Einar Fosse, UNN HF, Norwegian Centre for Integrated Care and Telemedicine, Norway Sebastian Garde, Ocean Informatics, Germany Heather Grain, Llewelyn Grain Informatics, Australia Anne Gunn Haugland, Helse Bergen HF, Norway Andreas Hering, Helse Bergen HF, Haukeland universitetssjukehus, Norway Omer Hotomaroglu, Turkey Lars Ivar Mehlum, Helse Bergen HF, Norway 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 Rose Mari Eikås, Helse Bergen, Norway Ian McNicoll, freshEHR Clinical Informatics, United Kingdom Bjørn Næss, DIPS ASA, Norway Rune Pedersen, Universitetssykehuset i Nord Norge, Norway John Tore Valand, Haukeland Universitetssjukehus, Norway (Editor, Translation Editor) Jon Tysdahl, Furst medlab AS, Norway |
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