| 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: - 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. |
| 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 |
| 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 |
| 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 | 1.0.2 |
| All | Archetype [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=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, originalLanguage=en, translators=
|