| ARCHETYPE ID | openEHR-EHR-EVALUATION.absence.v2 |
| Concept | Absence of information |
| Description | Statement that specified health information is not available for inclusion in the health record or extract at the time of recording. |
| Use | Use to enable recording or exchange of an explicit statement that specified health information is not available for inclusion in the health record or record extract at the time of recording. This statement is the third component of a family of statements - statements of positive presence, statements of positive exclusion and statements of absence: - Statements of positive presence indicate that there is relevant health information in the record or extract - for example, EVALUATION.adverse_reaction stating that the patient has an allergy to penicillin or EVALUATION.problem_diagnosis stating that the patient has diabetes. - Equivalent statements about exclusion are used to indicate that it is known that there is no relevant health information in the health record or extract - for example, EVALUATION.exclusion_adverse stating that the patient does not have a known allergy to penicillin or EVALUATION.exclusion_problem_diagnosis stating that the patient is not diabetic; and; - In this context, the EVALUATION.absence could be used to record that there is no health information available about penicillin allergy or the diagnosis of diabetes - it is not known if it is present or excluded, but there is no information that can be provided. This archetype has been developed specifically for the use case where a clinician is preparing an extract from a health record, so that the receiver has explicit and unambiguous understanding of the information available - that which is present, excluded or just not available. It is primarily intended to be used within SLOTS in persistent COMPOSITIONS such as 'Therapeutic precautions', 'Medication list', 'Problem list', or 'Adverse reaction list'. It is also deliberately intended to be statement made by a clinician in the same way that they would record any allergies or diagnoses, and is intended to be quite different to technical use of null flavours in data. Absence statements can only be considered to be current and accurate at the time of recording. This archetype has been designed specifically to avoid the need to use of flags to express negation about any entry within the health record. |
| Misuse | Not to be used to record the presence of adverse reactions, medication use, procedures, problems or diagnoses - use specific archetypes for this purpose. Not to be used to record the exclusion of adverse reactions, medication use, procedures, problems or diagnoses - use specific specialisations of the EVALUATION.exclusion archetype for this purpose. |
| Purpose | To enable recording or exchange of an explicit statement by a clinician that specified health information is not available for inclusion in the health record or record extract at the time of recording. |
| References | |
| Copyright | © openEHR Foundation |
| Authors | Author name: Heather Leslie Organisation: Ocean Informatics Email: heather.leslie@oceaninformatics.com Date originally authored: 2013-03-12 |
| Other Details Language | Author name: Heather Leslie Organisation: Ocean Informatics Email: heather.leslie@oceaninformatics.com Date originally authored: 2013-03-12 |
| 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, current_contact=Heather Leslie, Ocean Informatics, heather.leslie@oceaninformatics.com, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=7CD5D4B56F1AAC4BF3DFF1AB6120FCD0, build_uid=ee743f5f-d87c-496d-8fb7-074143be959f, revision=2.0.1} |
| Keywords | absence, information, adverse, reaction, problem, diagnosis, medication, procedure, vaccination, adverse reaction |
| Lifecycle | published |
| UID | f5adea69-7b6c-4f99-968d-a8e33a7e2f63 |
| Language used | en |
| Citeable Identifier | 1013.1.4213 |
| Revision Number | 2.0.1 |
| All | Archetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Statement that specified health information is not available for inclusion in the health record or extract at the time of recording., archetypeConceptComment=null, otherContributors=Vebjørn Arntzen, Oslo University Hospital, Norway Koray Atalag, University of Auckland, New Zealand Gustavo Bacelar-Silva, Healthcare Designs, Brazil (openEHR Editor) Silje Ljosland Bakke, Nasjonal IKT HF, Norway (openEHR Editor) Lars Bitsch-Larsen, Haukeland University hospital, Norway Einar Fosse, National Centre for Integrated Care and Telemedicine, Norway Sebastian Garde, Ocean Informatics, Germany Heather Grain, Llewelyn Grain Informatics, Australia Sam Heard, Ocean Informatics, Australia Lars Karlsen, DIPS ASA, Norway Lars Morgan Karlsen, DIPS ASA, Norway Shinji Kobayashi, Kyoto University, Japan Heather Leslie, Atomica Informatics, Australia (openEHR Editor) Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (openEHR Editor) Andrej Orel, Marand d.o.o., Slovenia Nyree Taylor, Ocean Informatics, Australia Richard Townley-O'Neill, Australian Digital Health Agency, Australia John Tore Valand, Helse Bergen, Norway, originalLanguage=en, translators=
All not explicitly excluded archetypes, extendedValues=null]], ism_transition=[], context=[], data=[ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=2, text=Absence statement, description=Positive statement that no information is available., comment=For example: "No information available about adverse reactions"; No information available about problems or diagnoses"; "No information available about previous procedures performed"; or "No information available about medications used"., 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[at0005], code=at0005, itemType=ELEMENT, level=2, text=Reason for absence, description=Description of the reason why there is no information available., comment=For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null]], activities=[], relationships=[], credentials=[], target=[], source=[], state=[], content=[], contacts=[], capabilities=[]}, topLevelItems={protocol=ResourceSimplifiedHierarchyItem [path=ROOT_/protocol[at0003], code=at0003, 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=1..*, subCardinalityText=, dataType=ITEM_TREE, bindings=null, values=null, extendedValues=null]}, addHierarchyItemsTo=protocol, currentHierarchyItemsForAdding=[ResourceSimplifiedHierarchyItem [path=/protocol[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=2, text=Last updated, description=The date at which the absence 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[at0003]/items[at0006], code=at0006, itemType=SLOT, level=2, text=Extension, description=Additional information required to capture local content or to align with other reference models/formalisms., comment=For example: local information requirements or additional metadata to align with FHIR or CIMI equivalents., 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] |