ARCHETYPE Substance use summary (openEHR-EHR-EVALUATION.substance_use_summary.v0)

ARCHETYPE IDopenEHR-EHR-EVALUATION.substance_use_summary.v0
ConceptSubstance use summary
DescriptionSummary or persistent information about typical use of a specific substance or class of substances, other than tobacco and alcohol, that may lead to harmful effects on an individual's health or social well-being.
UseUse to record summary or persistent information about typical use of a specific substance or class of substances, other than tobacco and alcohol, that may lead to harmful effects on an individual's health or social well-being. This concept describes a neutral, objective framework for documenting the use of a substance, aside from tobacco or alcohol, without considering the amount or frequency of use. The framework supports the recognition of abuse and dependence but is not limited to these aspects. It avoids terms like 'illegal' or 'misuse' because the legal status of substances can vary by jurisdiction. The model is also useful for noting instances where there might be overuse of a prescribed substance or use beyond its intended medical purpose, such as using laxatives for weight control or beta blockers by athletes to reduce heart rate. This approach allows for a comprehensive and unbiased recording of substance use in medical and health records. This archetype is intended to be used to record information about both current and previous substance use behaviour and can be updated over time. The specific scope of this archetype includes all types of addictive or potential harmful substances, including, but not limited to: recreational drugs; solvents; steroids; caffeine; and therapeutic substances exceeding its appropriate dosage or intent. The exceptions are alcohol consumption, tobacco smoking and smokeless tobacco use, as there are specific archetypes designed for them. The 'Episode' Cluster allows recording of specific details within a specified period of time. If the typical use, pattern or route changes significantly, record the details in a new instance of the Episode' Cluster. Triggers for closing one episode and commencing a new one will largely reflect local data collection preferences, including if the individual: - quits for a significant period of time; or - significantly changes the amount or route of their substance use. Vaping is a complex concept that requires attention to both the behaviour and the substances inhaled. In that context, use this archetype to record amounts of identified ingredients of vaping liquid, such as 'Nicotine', and use EVALUATION.vaping_summary to record the patterns of vaping behaviour. In some cases, both archetypes may be required. Use a separate instance of this archetype to record each substance.
MisuseNot to be used to record summary or persistent information about tobacco use - use EVALUATION.tobacco_smoking_summary or EVALUATION.smokeless_tobacco_summary for this purpose. Not to be used to record summary or persistent information about alcohol use - use EVALUATION.alcohol_use_summary for this purpose. Not to be used to record event-or period-based information about substance use, such as actual daily use or the average use over a specified period of time . Use the OBSERVATION.substance_use archetype for this purpose. Not to be used to record accidental administration of, or exposure to, a substance or medication, overdoses or poisonings, etc. Use an Adverse event archetype for this purpose. Not to be used to record answers to pre-defined screening questions about substance use. Use OBSERVATION.substance_use_screening archetype for this purpose. Not to be used to monitor the use and cumulative dose of a specified prescribed substance which is known to have significant toxic effects or adverse health impacts in long term use, or monitoring the use of an experimental medication in a trial. Use EVALUATION.medication_summary for this purpose. Not to be used for recording information about appropriate medication use under clinical guidance. Use an appropriate medication archetype for this purpose.
PurposeTo record summary or persistent information about typical use of a specific substance or class of substances, other than tobacco and alcohol, that may lead to harmful effects on an individual's health or social well-being.
References
Copyright© Nasjonal IKT HF, openEHR Foundation
AuthorsAuthor name: Heather Leslie
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2020-02-13
Other Details LanguageAuthor name: Heather Leslie
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2020-02-13
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, current_contact=Heather Leslie, Atomica Informatics, heather.leslie@atomicainformatics.com, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=37D164DC7793C12FACEFC4EE76808080, build_uid=34b5a0e4-1a99-4690-9f3f-8da7cc499b02, revision=0.0.1-alpha}
Keywordsdrugs, addiction, abuse, doping, narcotics, performance enhancing, steroids
Lifecyclein_development
UIDab5519ba-22b7-4574-af37-c2a84bc2f24c
Language useden
Citeable Identifier1013.1.354
Revision Number0.0.1-alpha
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Summary or persistent information about typical use of a specific substance or class of substances, other than tobacco and alcohol, that may lead to harmful effects on an individual's health or social well-being., archetypeConceptComment=Substances include, but are not limited to psychostimulants, barbiturates, cannabis, hallucinogens, opioids, GHB, MDMA, sniffing of hydrocarbons, bath salts, anabolic steroids as well as therapeutic substances, for example laxative, exceeding its appropriate dosage or intent., otherContributors=Marit Alice Venheim, Helse Vest IKT, Norway (Nasjonal IKT redaktør)
Vebjørn Arntzen, Oslo University Hospital, Norway (openEHR Editor)
Silje Ljosland Bakke, Helse Vest IKT AS, Norway (openEHR Editor)
SB Bhattacharyya, Bhattacharyyas Clinical Records Research & Informatics LLP, India
Randi Brendberg, Helse Nord RHF, Norway
Hugo Claudio Briceño García, Catsalut, Spain
Clara Calleja Vega, CatSalut. Servei Català de la Salut., Spain
Fatemeh Chalabianloo, Helse Bergen, Norway
Julio de Sosa, Servei Català de la Salut, Spain
Giovanni Delussu, crs4, Italy
Gunn Elin Blakkisrud, DIPS ASA, Norway
Kåre Flø, DIPS ASA, Norway
Astrid Gjelstad, Antidoping Norge, Norway
Rosane Gotardo, Systema Ltda., Brazil
Atle Hansen, Universitetssykehuset Nord-Norge, Norway
Evelyn Hovenga, EJSH Consulting, Australia
Mika Kiviaho, Tietoevry, Finland
Peter Krajci, OUS, Norway
Ronald Krawec, Alberta Health Services, Canada
Anjali Kulkarni, Karkinos, India
Jörgen Kuylenstierna, eWeave AB, Sweden
michel laji!, Karolinska Institutet, Sweden
Liv Laugen, Oslo universitetssykehus, Norway (Nasjonal IKT redaktør)
Heather Leslie, Atomica Informatics, Australia (openEHR Editor)
June Marie Knappskog, Helse Nord IKT AS, Norway (Nasjonal IKT redaktør), Norway
Ian McNicoll, freshEHR Clinical Informatics, United Kingdom
Christine Mikalsen, Helse Nord IKT, Norway
Laura Moral Lopez, Sistema de Salut de Catalunya, Spain
Mikael Nyström, Cambio Healthcare Systems AB, Sweden
Jayashree Panickar, Karolinska Institute, Sweden
Mari Sandlund, Oslo Universitetssykehus, avdeling for teknologi og e-helse, Norway
Benjamin Senst, Germany
Ingrid Skard, DIPS AS, Norway
Norwegian Review Summary, Norwegian Public Hospitals, Norway
Erik Sundvall, Karolinska Institutet + Karolinska University Hospital, Region Stockholm + Linköping University, Sweden
Venkatesh Thoppae, Dedalus, United Kingdom
John Tore Valand, Helse Vest IKT, Norway (Nasjonal IKT redaktør), originalLanguage=en, translators=
  • Norwegian Bokmål: Liv Laugen, Vebjørn Arntzen, ​Oslo University Hospital, Norway, liv.laugen@ous-hf.no, varntzen@ous-hf.no

    • , subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={items=[], description=[], context=[], activities=[], identities=[], capabilities=[], provider=[], protocol=[ResourceSimplifiedHierarchyItem [path=/protocol[at0029]/items[at0031], code=at0031, itemType=ELEMENT, level=2, text=Last updated, description=The date this summary was last updated., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0029]/items[at0032], code=at0032, itemType=SLOT, level=2, text=Extension, description=Additional information required to extend the model with local content or to align with other reference models/formalisms., comment=For example: local information requirements; or additional metadata to align with FHIR., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
    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=Substance name, description=The name of the substance or class of substance., comment=Coding with an external terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, 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=Overall status, description=Statement about current use of the substance, in all forms and by all routes., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
    • Never used [The individual has never used the identified substance.]
    • Current user [The individual is currently using the identified substance.]
    • Former user [The individual has previously used the identified substance.]
    , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0007], code=at0007, itemType=ELEMENT, level=2, text=Overall description, description=Narrative summary about all use of the substance over the lifetime of the individual., comment=This element can also be used to incorporate the narrative descriptions of substance use habits within existing or legacy clinical systems., 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[at0008], code=at0008, itemType=ELEMENT, level=2, text=First ever use, description=Date when the individual first used the substance., comment=Can be a partial date, for example, only a year., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0009], code=at0009, itemType=ELEMENT, level=2, text=Regular use commenced, description=The date when the individual first started frequent or regular, but usually non-daily, use of the substance., comment=Can be a partial date, for example, only a year. For example, this date could represent when the individual commenced using the substance every Friday night or at parties., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0010], code=at0010, itemType=ELEMENT, level=2, text=Daily use commenced, description=The date when the individual first started daily use of the substance., comment=Can be a partial date, for example, only a year., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0012], code=at0012, itemType=CLUSTER, level=2, text=Per episode, description=Details about a period of use of the substance., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0012]/items[at0013], code=at0013, itemType=ELEMENT, level=3, text=Episode label, description=Identification of an episode of substance use - either as a number in a sequence or a named event., comment=For example: '2' as the second episode within a sequence of episodes; 'Life-long'; or 'Pregnancy with twins' if describing the substance use during a health event such as a specific pregnancy., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
    •  Count
      min: >=0

    •  Text
    , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0012]/items[at0014], code=at0014, itemType=ELEMENT, level=3, text=Episode start date, description=Date when this episode commenced., comment=Can be a partial date, for example, only a year., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0012]/items[at0016], code=at0016, itemType=ELEMENT, level=3, text=Specific substance name, description=The name of the specific substance used., comment=This data element may be redundant if the specific substance has been identified in the 'Substance name' data element. However if the 'Substance name' data element is recorded as a grouping or a class, it may be necessary to provide more specificity for a specific episode., 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[at0012]/items[at0017], code=at0017, itemType=ELEMENT, level=3, text=Status, description=Statement about use of the substance during the episode., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
    • Used [The individual used the identified substance during this episode.]
    • Not used [The individual has not used the identified substance during this episode.]
    , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0012]/items[at0018], code=at0018, itemType=ELEMENT, level=3, text=Episode description, description=Narrative summary about substance use during the episode., comment=null, 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[at0012]/items[at0019], code=at0019, itemType=ELEMENT, level=3, text=Pattern, description=The typical pattern of frequency of use of the substance., comment=This element is repeatable to allow multiple ways of recording the pattern of use. The typical pattern of use can be made more granular by coding with a terminology or a local value set, or using the quantity data type, in a template., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
    •  Text
    •  Coded Text
      • Daily [Using the substance at least once every day.]
      • Not daily [Not using the substance every day.]
    •  Quantity
      Units:
      • >=0.0 1/d
      • >=0.0 1/wk
      • >=0.0 1/mo
      • >=0.0 1/a
    , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0012]/items[at0023], code=at0023, itemType=ELEMENT, level=3, text=Typical use, description=Typical amount of use., comment=For example: '6 g/wk' or 'irregular pattern of use depending on stress levels, ranging from 1-10 grams per week'., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
    •  Quantity
      Units:
      • >=0.0 mg/d
      • >=0.0 g/d
      • >=0.0 mg/wk
      • >=0.0 g/wk
      • >=0.0 mg/mo
      • >=0.0 g/mo
      • >=0.0 ug/d
      • >=0.0 ug/wk
      • >=0.0 ug/mo
    •  Text
    , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0012]/items[at0036], code=at0036, itemType=ELEMENT, level=3, text=Route, description=The name of the route or form., comment=Coding with an external terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=1..*, occurencesText=Mandatory, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0012]/items[at0015], code=at0015, itemType=ELEMENT, level=3, text=Episode end date, description=Date when this episode ceased., comment=Can be a partial date, for example, only a year. This data field will be empty if the episode is current and ongoing., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0012]/items[at0024], code=at0024, itemType=ELEMENT, level=3, text=Number of quit attempts, description=Total number of times the individual has attempted to stop using the specified substance within this episode., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=min: >=0

    , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0012]/items[at0025], code=at0025, itemType=SLOT, level=3, text=Episode details, description=Additional details about the episode., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
    All not explicitly excluded archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0012]/items[at0026], code=at0026, itemType=ELEMENT, level=3, text=Episode comment, description=Additional narrative about use of the specific substance during this episode, not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0027], code=at0027, itemType=SLOT, level=2, text=Overall details, description=Additional structured details about the overall use of the specified substance., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
    All not explicitly excluded archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0028], code=at0028, itemType=ELEMENT, level=2, text=Overall quit date, description=The date when the individual last used the substance., comment=Can be a partial date, for example, only a year., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0030], code=at0030, itemType=ELEMENT, level=2, text=Overall comment, description=Additional narrative about the overall use of the substance that has not been captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null]], contacts=[], ism_transition=[], details=[], relationships=[], state=[], target=[], other_participations=[]}, topLevelItems={protocol=ResourceSimplifiedHierarchyItem [path=ROOT_/protocol[at0029], code=at0029, itemType=ITEM_TREE, level=0, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=0..1, cardinalityText=optional, subCardinalityFormal=0..*, subCardinalityText=Minimum of 0 items, dataType=ITEM_TREE, bindings=null, values=null, extendedValues=null], data=ResourceSimplifiedHierarchyItem [path=ROOT_/data[at0001], code=at0001, itemType=ITEM_TREE, level=0, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=0..1, cardinalityText=optional, subCardinalityFormal=0..*, subCardinalityText=Minimum of 0 items, dataType=ITEM_TREE, bindings=null, values=null, extendedValues=null]}, addHierarchyItemsTo=protocol, currentHierarchyItemsForAdding=[ResourceSimplifiedHierarchyItem [path=/protocol[at0029]/items[at0031], code=at0031, itemType=ELEMENT, level=2, text=Last updated, description=The date this summary was last updated., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0029]/items[at0032], code=at0032, itemType=SLOT, level=2, text=Extension, description=Additional information required to extend the model with local content or to align with other reference models/formalisms., comment=For example: local information requirements; or additional metadata to align with FHIR., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
    All not explicitly excluded archetypes, extendedValues=null]], minIndents={}, termBindingRetrievalErrorMessage=null]