ARCHETYPE Procedure screening questionnaire (openEHR-EHR-OBSERVATION.procedure_screening.v1)

ARCHETYPE IDopenEHR-EHR-OBSERVATION.procedure_screening.v1
ConceptProcedure screening questionnaire
DescriptionSeries of questions and associated answers used to screen for procedures that has been carried out in the past.
UseUse to create a framework for recording answers to pre-defined screening questions about clinical management related to surgical/operative procedures that have been carried out in the past. Common use cases include, but are not limited to: - Specific questioning about previous procedures before admission to a hospital. - Systematic questioning in any consultation, for example: --- Have you ever had an appendectomy? Yes, No, Unknown. --- Have you had a hip or knee replacement in the past twelve months? Yes, No, Unknown. 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 procedure that has been performed at any time in the past and information about a procedure performed within a specified time interval - for example the difference between "Have you ever had any hip or knee surgery?" compared to "Have you had any hip or knee surgery in the last 12 months? 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 process identifies a completed procedure, it is recommended that clinical system record and persist the specific details about the procedure (such as the duration of the procedure) using the ACTION.procedure archetype.
MisuseNot to be used to record details about the presence or absence of a procedure, outside of a screening context. Use ACTION.procedure or EVALUATION.exclusion_specific for these purposes. Not to be used to record non-surgical or non-invasive clinical management. Use OBSERVATION.management_screening for this 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 clinical management related to surgical/operative procedures that have been carried out in the past.
ReferencesAvgrenet fra: Procedure screening questionnaire, Published archetype [Internet]. openEHR Foundation, openEHR Clinical Knowledge Manager [cited: 2023-07-12]. Available from: https://ckm.openehr.org/ckm/archetypes/1013.1.4439
Copyright© openEHR Foundation
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, references=Avgrenet fra: Procedure screening questionnaire, Published archetype [Internet]. openEHR Foundation, openEHR Clinical Knowledge Manager [cited: 2023-07-12]. Available from: https://ckm.openehr.org/ckm/archetypes/1013.1.4439, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=FE52E551D4FDB4B9F5E6E552C7EDC387, build_uid=2e680ac8-6236-4fd6-8220-88b985d5a8f3, 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 https://www.snomed.org/snomed-ct/get-snomed or info@snomed.org., revision=1.0.2}
KeywordsProcedure, surgery, operation, assessment, investigation, questionnaire, screening
Lifecyclepublished
UID7d2adbd4-0ab6-4def-af0a-00c722cc180e
Language useden
Citeable Identifier1013.1.4439
Revision Number1.0.2
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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)
Per Meinich, Helse Sør-Øst RHF, Norway
Mikael Nyström, Cambio Healthcare Systems AB, Sweden
Jussara Rotzsch, Hospital Alemão Oswaldo Cruz, Brazil
Erik Skjemstad, Helse Nord RHF, Norway
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)
Martijn van Eenennaam, Nedap Healthcare, Netherlands
Marit Alice Venheim, Helse Vest IKT, Norway (openEHR Editor)
Ina Wille, Helse-Vest RHF, Norway, originalLanguage=en, translators=
  • German: Nina Schewe, Natalia Strauch, Medizinische Hochschule Hannover, nina.schewe@plri.de, Strauch.Natalia@mh-hannover.de
  • Norwegian Bokmål: Marit Alice Venheim, Silje Ljosland Bakke, John Tore Valand, Helse Vest IKT, Helse Vest IKT AS, Helse Bergen, marit.alice.venheim@helse-vest-ikt.no, silje.ljosland.bakke@helse-vest-ikt.no, john.tore.valand@helse-bergen.no, john.tore.valand@helse-vest-ikt.no
  • Italian:
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