ARCHETYPE Medication screening questionnaire (openEHR-EHR-OBSERVATION.medication_screening.v1)

ARCHETYPE IDopenEHR-EHR-OBSERVATION.medication_screening.v1
ConceptMedication screening questionnaire
DescriptionSeries of questions and associated answers used to screen for the use of medications.
UseUse to create a framework for recording answers to pre-defined screening questions about the use of any specified medication or grouping (including classes) of medications. Examples of medications, groupings and classes of medications are 'alendronic acid', 'anti osteoporosis medications' and 'bisphosphonates', respectively. Common use cases include, but are not limited to: - Systematic questioning in any consultation related to patterns of medication usage, for example: --- Do you use paracetamol? Yes, No, Unknown. --- Have you been using any anticoagulants the last four weeks? 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 medication that has been used at any time in the past and information about a medication used within a specified time interval - for example the difference between "Do you use paracetamol?" compared to "Have you been using any anticoagulants during the last four 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 medication it is recommended that clinical system record and persist the specific details about the medication using a relevant medication archetype, for example the OBSERVATION.medication_statement to record a detailed snapshot view about the actual use of a single specified medication.
MisuseNot to be used for recording an order for a medication to be administered or consumed - use INSTRUCTION.medication_order for this purpose. Not to be used for recording the administration, dispensing or consumption of a medication - use ACTION.medication for this purpose. Not to be used for recording a summary of use of a medication over the lifetime of the individual - use EVALUATION.medication_summary for this purpose. Not to be used to record a detailed snapshot view about the actual use of a single specified medication, outside of a screening context. - use OBSERVATION.medication_statement for this purpose. Not to be used to record details about the positive absence of a specific medication or grouping of medication, outside of a screening context. Use EVALUATION.exclusion_specific for this purpose. Not to be used to to create a framework for recording answers to pre-defined screening questions about adverse reactions, use an appropriate archetype for this purpose. 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 the use of any specified medication or grouping of medications.
References
Copyright© openEHR Foundation, Nasjonal IKT HF
AuthorsAuthor name: Silje Ljosland Bakke
Organisation: Nasjonal IKT HF
Email: silje.ljosland.bakke@nasjonalikt.no
Date originally authored: 2018-11-07
Other Details LanguageAuthor name: Silje Ljosland Bakke
Organisation: Nasjonal IKT HF
Email: silje.ljosland.bakke@nasjonalikt.no
Date originally authored: 2018-11-07
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=6CA03E7C2861201510F8F796C64B5F43, build_uid=50972535-e86b-43fe-b395-e61b52101ad7, 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=1.0.0}
Keywordsmedication, screening, questionnaire, drug, treatment
Lifecyclepublished
UID95e92636-812d-472e-aa6a-8e5315a34315
Language useden
Citeable Identifier1013.1.4677
Revision Number1.0.0
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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
Randi Brendberg, Helse Nord RHF, Norway
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
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)
Mikael Nyström, Cambio Healthcare Systems AB, Sweden
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: Kim Sommer, Natalia Strauch, Alina Rehberg, Medizinische Hochschule Hannover, sommer.kimkatrin@mh-hannover.de, Strauch.Natalia@mh-hannover.de, rehberg.alina@mh-hannover.de
Norwegian Bokmål: Silje Ljosland Bakke, John Tore Valand, Helse Vest IKT AS, Helse Bergen, silje.ljosland.bakke@helse-vest-ikt.no, john.tore.valand@helse-bergen.no, john.tore.valand@helse-vest-ikt.no
Dutch: Martijn van Eenennaam, Nedap Healthcare, martijn.vaneenennaam@nedap.com, PhD
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