ARCHETYPE Symptom/sign screening questionnaire (openEHR-EHR-OBSERVATION.symptom_sign_screening.v1)

ARCHETYPE IDopenEHR-EHR-OBSERVATION.symptom_sign_screening.v1
ConceptSymptom/sign screening questionnaire
DescriptionSeries of questions and associated answers used to screen for symptoms or signs.
UseUse to create a framework for recording answers to pre-defined screening questions about symptoms or signs. Common use cases include, but are not limited to: - Systematic inquiry in any consultation, for example: --- Do you have headaches? Yes, No, Unknown. --- Have you had dizziness in the past four weeks? Yes, No, Unknown. - Specific questioning related to disease surveillance. The semantics of this archetype are intentionally loose, and querying this archetype would normally only be useful or safe within the context of each specific template. In a template, each data element would usually be renamed to the specific question asked. Where value sets have been proposed for common use cases, these can be adapted for local use by using the DV_TEXT or the DV_BOOLEAN datatypes choice to match each specific use case. The EVENT structure from the reference model can be used to specify whether the questions relate to point in time or over a period of time. Use a separate instance of this archetype to distinguish between a questionnaire recording information about a symptom that has been present at any time in the past and information about a symptom within a specified time interval - for example the difference between ""Are you dizzy now?" compared to "Have you had any dizziness in the past 4 weeks? The source of the information in a questionnaire response may vary in different contexts but can be specifically identified using the 'Information provider' element in the Reference Model. This archetype has been designed to be used as a screening tool or to record simple questionnaire-format data for use in situations such as a disease registry. If the screening questionnaire identifies the presence of a symptom or sign, it is recommended that clinical system record and persist the specific details about the symptom or sign using the CLUSTER.symptom_sign archetype nested within the Additional details SLOT in this archetype.
MisuseNot to be used to record details about the presence or absence of a symptom, outside of a screening context. Use CLUSTER.symptom_sign or CLUSTER.exclusion_symptom_sign for these purposes. Not to be used to record details about a simple selection list where a question may be recorded as either "present" or "indeterminate". Use OBSERVATION.selection_list for this purpose.
PurposeTo create a framework for recording answers to pre-defined screening questions about symptoms or signs.
References
AuthorsAuthor name: Heather Leslie
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2020-03-13
Other Details LanguageAuthor name: Heather Leslie
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2020-03-13
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, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=D0E02DE26104C7DB2CB94198C5B658FE, build_uid=b265bd06-044d-4245-9864-f97e297821c5, ip_acknowledgements=This artefact includes content from SNOMED Clinical Terms® (SNOMED CT®) which is copyrighted material of the International Health Terminology Standards Development Organisation (IHTSDO). Where an implementation of this artefact makes use of SNOMED CT content, the implementer must have the appropriate SNOMED CT Affiliate license - for more information contact http://www.snomed.org/snomed-ct/get-snomedct or info@snomed.org., revision=1.0.0}
Keywordsscreening, questionnaire, complaint, symptom, disturbance, problem, discomfort, sign
Lifecyclepublished
UIDdcae10b9-634e-4fa7-b695-1995af5c89dd
Language useden
Citeable Identifier1013.1.4432
Revision Number1.0.0
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Series of questions and associated answers used to screen for symptoms or signs., archetypeConceptComment=The answers may be self-reported., otherContributors=Dag Aarhus, Vestre Viken HF, Norway
Vebjørn Arntzen, Oslo University Hospital, Norway (openEHR Editor)
Astrid Askeland, Dips AS, Norway
Silje Ljosland Bakke, Helse Vest IKT AS, Norway (openEHR Editor)
SB Bhattacharyya, Bhattacharyyas Clinical Records Research & Informatics LLP, India
Yexuan Cheng, 浙江大学, China
Are Edvardsen, SKDE, Helse Nord RHF, Norway
Alexander Eikrem-Lüthi, Lovisenberg Diakonale Sykehus, Norway
Kåre Flø, DIPS ASA, Norway
Grant Forrest, Lunaria Ltd, United Kingdom
Heather Grain, Llewelyn Grain Informatics, Australia
Anca Heyd, DIPS ASA, Norway
Joost Holslag, Nedap, Netherlands
Evelyn Hovenga, EJSH Consulting, Australia
Mikkel Johan Gaup Grønmo, Regional forvaltning EPJ, Helse Nord, Norway
Gunnar Jårvik, Helse Vest IKT AS, Norway
Anjali Kulkarni, Karkinos, India
Kanika Kuwelker, Helse Vest IKT, Norway
Jörgen Kuylenstierna, eWeave AB, Sweden
Liv Laugen, ​Oslo University Hospital, Norway, Norway
Øygunn Leite Kallevik, Helse Bergen, Norway
Heather Leslie, Atomica Informatics, Australia (openEHR Editor)
Ian McNicoll, freshEHR Clinical Informatics, UK
Per Meinich, Helse Sør-Øst RHF, Norway
Mikael Nyström, Cambio Healthcare Systems AB, Sweden
Vanessa Pereira, Luxembourg Institute of Health (LIH), Portugal
Jussara Rotzsch, Hospital Alemão Oswaldo Cruz, Brazil
Andre Smitt-Ingebretsen, Sørlandet sykehus HF, Norway
Natalia Strauch, Medizinische Hochschule Hannover, Germany
Norwegian Review Summary, Norwegian Public Hospitals, Norway
John Tore Valand, Helse Bergen, Norway (openEHR Editor)
Marit Alice Venheim, Helse Vest IKT, Norway (openEHR Editor)
Ina Wille, Helse-Vest RHF, Norway, originalLanguage=en, translators=German: Sarah Ballout, Natalia Strauch, Medizinische Hochschule Hannover, ballout.sarah@mh-hannover.de, Strauch.Natalia@mh-hannover.de
Finnish:
Swedish: Emma Malm, Erik Sundvall, Karolinska University Hospital, Region Stockholm, Karolinska University Hospital, Region Stockholm + Linköping University, emma.malm@cambio.se, erik.sundvall@regionstockholm.se
Norwegian Bokmål: Marit Alice Venheim, Silje Ljosland Bakke, John Tore Valand, Helse Vest IKT AS, Helse Bergen, marit.alice.venheim@helse-vest-ikt.no, silje.ljosland.bakke@helse-vest-ikt.no, john.tore.valand@helse-vest-ikt.no
Italian:
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