ARCHETYPE Clinical Synopsis (openEHR-EHR-EVALUATION.clinical_synopsis.v1)

ARCHETYPE IDopenEHR-EHR-EVALUATION.clinical_synopsis.v1
ConceptClinical Synopsis
DescriptionNarrative summary or overview about a patient, specifically from the perspective of a healthcare provider, and with or without associated interpretations.
UseUse to record a narrative, summary view of the patient's health. This unstructured summary may include identified health issues; health care provided; associated interpretation; patient understanding; and enable communication about some of the softer, more subjective aspects of the patient’s experience and journey. Most commonly this summary is likely to be related to a specific health event such as a specific consultation or hospital admission, but may also be used to summarise the patient's health experience over varying time periods. In practice, Clinical Synopsis is a meta observation that will complement the existing structured clinical record, allowing for expression of subtle, subjective or interpretive information about the patient that might not otherwise be obvious through structured data alone, providing balance and context to the EHR record. For example, a Clinical Synopsis can communicate a succinct summary of the patient's hospital admission as one component of a comprehensive and structured Discharge Summary document.
MisuseNot to be used to record specific and structured health information. For example, detailed information about Problems, Diagnoses, and Test Results should be recorded using the specific relevant archetypes EVALUATION.problem, EVALUATION.problem-diagnosis, and laboratory or radiology results in OBSERVATIONs. The Clinical Synopsis may convey some critical and selected numerical results from these structured details when judged important for completeness of the Synopsis but is NOT the primary recording site for them. The term “Clinical Synopsis” can sometimes refer to complex and comprehensive documents, such as a Discharge Summary or a Report. In openEHR these documents should be represented as aggregations of constrained archetypes, that is, a Discharge Summary template or a Report template, comprising a number of separate archetypes, of which this Clinical Synopsis archetype may be one.
PurposeTo manually synthesise and record a narrative summary about a patient, from the perspective of a healthcare provider.
ReferencesClinical Synopsis (Data Specifications) Version 1.0 [Internet]. Sydney, Australia: National E-Health Transition Authority; 2007 Jun 29 [cited 2009 Oct 12]; Available at http://www.nehta.gov.au/DGL/Resources/Downloads/Clinical%20Synopsis%20v1.0.pdf
Copyright© openEHR Foundation
AuthorsAuthor name: Sam Heard
Organisation: Ocean Informatics, Australia
Email: sam.heard@oceaninformatics.com
Date originally authored: 2007-01-09
Other Details LanguageAuthor name: Sam Heard
Organisation: Ocean Informatics, Australia
Email: sam.heard@oceaninformatics.com
Date originally authored: 2007-01-09
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=Clinical Synopsis (Data Specifications) Version 1.0 [Internet]. Sydney, Australia: National E-Health Transition Authority; 2007 Jun 29 [cited 2009 Oct 12]; Available at http://www.nehta.gov.au/DGL/Resources/Downloads/Clinical%20Synopsis%20v1.0.pdf, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=32F9563D428258E02EFA916126110EBF, build_uid=4153b32a-34b0-4fcd-ab26-71b9ca3830c9, revision=1.0.0}
Keywordssummary, conclusion, outline, precis, abstract, assessment, synopsis, epicrisis, comment, note
Lifecyclepublished
UID87e2704b-955b-43bc-b569-755e06dbd3f5
Language useden
Citeable Identifier1013.1.409
Revision Number1.0.0
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Koray Atalag, University of Auckland, New Zealand
Silje Ljosland Bakke, Nasjonal IKT HF, Norway (openEHR Editor)
Maria Beate Nupen, Oslo Universitetssykehus, Norway
Lars Bitsch-Larsen, Haukeland University Hospital, Bergen, Norway
Marco Borges, P2D, Brazil
Rong Chen, Cambio Healthcare Systems, Sweden
Bjørn Christensen, Helse Bergen HF, Norway
Stephen Chu, Queensland Health, Australia
Tamsin Cockayne, Australia
Paul Donaldson, Nursing Informatics Australia, Australia
Shahla Foozonkhah, Iran ministry of health and education, Iran
Bente Gjelsvik, Helse Bergen, Norway
Sam Heard, Ocean Informatics, Australia
Kristian Heldal, Telemark Hospital Trust, Norway
Evelyn Hovenga, EJSH Consulting, Australia
Eugene Igras, IRIS Systems, Inc., Canada
Tom Jarl Jakobsen, Helse Bergen, Norway
Hanne Joensen, Helse Bergen HUS, Norway
Shinji Kobayashi, Kyoto University, Japan
Robert Legan, NEHTA, Australia
Heather Leslie, Ocean Health Systems, Australia (openEHR Editor)
Rikard Lovstrom, Swedish Medical Association, Sweden
Arne Løberg Sæter, DIPS ASA, Norway
Rohan Martin, Ambulance Victoria, Australia
Ian McNicoll, freshEHR Clinical Informatics, United Kingdom
Jeroen Meintjens, Medisch Centrum Alkmaar, Netherlands
Lars Morgan Karlsen, Nordlandssykehuset Bodø, Norway
Bjørn Næss, DIPS ASA, Norway
Rune Pedersen, Universitetssykehuset i Nord Norge, Norway
Tanja Riise, Nasjonal IKT HF, Norway
Arturo Romero, SESCAM, Spain
Thomas Schopf, University Hospital of North-Norway, Norway
John Tore Valand, Helse Bergen, Norway (openEHR Editor), originalLanguage=en, translators=German: Nadim Anani, Health Informatics Centre, Karolinska Institutet, Sweden, fluent in both English and German, Medical Informatics 'MSc' degree from Heidelberg, 2 years professional experience in health informatics, some translation experience, openEHR knowledge.
Swedish: Kirsi Poikela, Tieto Sweden AB, ext.kirsi.poikela@tieto.com
Spanish (Argentina): Dr. Leonardo Der Jachadurian, Bitios.com, Medical Doctor (Internal Medicine Specialist)
Norwegian Bokmål: Ingrid Heitmann, NTNU and OUS, Registered nurse, john.tore.valand@helse-bergen.no
Portuguese (Brazil): Emerson Urushibata, Universidade de São Paulo
Arabic (Syria): Mona Saleh
Farsi: Shahla Foozonkhah, Ocean Informatics, shahla.foozonkhah@oceaninformatics.com
Chinese (PRC): Lin Zhang, BIPH, What goes here?
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