ARCHETYPE ID | openEHR-EHR-OBSERVATION.procedure_screening.v1 |
Concept | Procedure screening questionnaire |
Description | Series of questions and associated answers used to screen for procedures that has been carried out in the past. |
Use | Use 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. |
Misuse | Not 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. |
Purpose | 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. |
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 |
Copyright | © openEHR Foundation |
Authors | Author name: Heather Leslie Organisation: Atomica Informatics Email: heather.leslie@atomicainformatics.com Date originally authored: 2020-03-13 |
Other Details Language | Author 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} |
Keywords | Procedure, surgery, operation, assessment, investigation, questionnaire, screening |
Lifecycle | published |
UID | 7d2adbd4-0ab6-4def-af0a-00c722cc180e |
Language used | en |
Citeable Identifier | 1013.1.4439 |
Revision Number | 1.0.2 |
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