ARCHETYPE Substance use screening questionnaire (openEHR-EHR-OBSERVATION.substance_use_screening.v1)

ARCHETYPE IDopenEHR-EHR-OBSERVATION.substance_use_screening.v1
ConceptSubstance use screening questionnaire
DescriptionSeries of questions and associated answers to screen for use of any substances or a specific grouping, class or individual substance/s that may harm an individual's health or social well-being.
UseUse to record a framework for documenting answers to pre-defined screening questions about the use of any substances or a specific grouping, class or individual substance/s that may harm an individual's health or social well-being. Substances that fall within the scope of this archetype include harmful or potentially addictive substances, legal and illegal substances, as well as medications that are misused. Misuse may involve administration without clinical supervision, use for non-recommended purposes, or consumption in quantities or frequencies that exceed safe dosages. Examples of substances that may be recorded using this archetype include but are not limited to: - tobacco; - alcohol; - caffeine; - nicotine and other clinically significant components of vaping liquid; - psychostimulants; - barbiturates; - cannabis; - hallucinogens; - opioids; - GHB; - MDMA; - sniffing of hydrocarbons or other solvents; - "bath salts"; and - medication administration, such as a laxative for purposes other than relief of constipation, beta blockers to reduce the heart rate in elite athletes and anabolic steroids in weight lifters. Common use cases include, but are not limited to: - Systematic questioning in any consultation, for example: --- Have you smoked a cigarette during the last week? Yes, No, Unknown. --- When did you last smoke a cigarette? --- Have you ever injected drugs? Yes, No, Unknown. --- Do you use anabolic steroids? Yes, No, Unknown. --- Have you consumed any alcohol during the last 4 hours? 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 data types choice to match each specific use case. The EVENT structure from the reference model can be used to specify whether the questions relate to a 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 substance that has been used at any time in the past and information about a substance used within a specified time interval - for example the difference between "Do you drink alcohol?" compared to "Have you been drinking any alcohol 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 substance, it is recommended that clinical system record and persist the specific details about the substance using a relevant archetype, for example the EVALUATION.alcohol_consumption_summary, EVALUATION.tobacco_smoking_summary, EVALUATION.substance_use_summary, or EVALUATION.health_risk archetypes.
MisuseNot to be used to record the typical frequency or amount of use of any substance. Use the EVALUATION.substance_use_summary or an appropriate substance-specific summary archetype. Not to be used for recording a summary of use of a substance over the lifetime of the individual. Use EVALUATION.substance_use_summary for this purpose. Not to be used for recording a summary of use of tobacco over the lifetime of the individual. Use EVALUATION.smokeless_tobacco_summary or EVALUATION.tobacco_smoking_summary for this purpose. Not to be used for recording a summary of use of alcohol over the lifetime of the individual. Use EVALUATION.alcohol_consumption_summary for this purpose. Not to be used to record information about actual substance use at or during a specified point or interval of time, such as daily or average use over a specified period of time, or a diary of use. Use the OBSERVATION.substance_use archetype for this purpose. Not to be used for recording information about appropriate medication use under clinical supervision, for recommended therapeutic intent and at appropriate dosages. Use an appropriate medication archetype for this purpose.
PurposeTo record a framework for documenting answers to pre-defined screening questions about the use of any substances or a specific grouping, class or individual substance/s that may harm an individual's health or social well-being.
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=E5FBF627824285C690B468E84BB11F53, build_uid=d9cee435-2254-4c79-a4fc-f1747a4a8a11, 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}
Keywordssubstance, screening, questionnaire, drug, addiction, abuse, misuse, dependence, doping, stimulants, sedatives
Lifecyclepublished
UIDd0e8e05e-43e2-48ab-9308-a432f6195478
Language useden
Citeable Identifier1013.1.4903
Revision Number1.0.0
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Vebjørn Arntzen, Oslo University Hospital, Norway (openEHR Editor)
Silje Ljosland Bakke, Helse Vest IKT AS, Norway (openEHR Editor)
Ivar Berge, Oslo University Hospital, Norway (openEHR Editor)
SB Bhattacharyya, Bhattacharyyas Clinical Records Research & Informatics LLP, India
Tara Bonet Chinillach, Catalan Health Service, Spain
Hanne Marte Bårholm, Helse Vest IKT, Norway (openEHR Editor)
Clara Calleja Vega, CatSalut. Servei Català de la Salut., Spain
giovanni delussu, crs4, Italy
Manuela Domingo, hospital general universitario dr. balmis, Spain
Grant Forrest, Lunaria Ltd, United Kingdom
Santiago Frid, Hospital Clínic de Barcelona, Spain
Rosane Gotardo, Systema Ltda., Brazil
Evelyn Hovenga, EJSH Consulting, Australia
Mikkel Johan Gaup Grønmo, Helse Nord IKT, Norway (openEHR Editor)
Mika Kiviaho, Tietoevry, Finland
June Marie Nepstad Knappskog, Helse Nord IKT AS, Norway (openEHR Editor), Norway (openEHR Editor)
Martin Koch, Servei Català de la Salut, Spain
Heidi Koikkalainen, United Kingdom
Bouwe Koopal, ADkwADraat B.V., Netherlands
Ronald Krawec, Alberta Health Services, Canada
Anjali Kulkarni, Karkinos, India
Kanika Kuwelker, Helse Vest IKT, Norway (openEHR Editor)
Jörgen Kuylenstierna, eWeave AB, Sweden
michel laji!, Karolinska Institutet, Sweden
Liv Laugen, ​Oslo University Hospital, Norway, Norway (openEHR Editor)
Darin Leonhardt, PLRI für medizinische Informatik/ Medizinische Hochschule, Germany
Heather Leslie, Atomica Informatics, Australia (openEHR Editor)
Brad Littleton, Big Picture Medical, Australia
Rikard Lovstrom, Karolinska University Hospital, Sweden
Michael Lutz, BITsoft, Germany
Priscila Maranhão, MEDCIDS-FMUP, Portugal
Ian McNicoll, freshEHR Clinical Informatics, United Kingdom
Paul Miller, NES Digital Service, NHS Scotland, United Kingdom
Laura Moral Lopez, Sistema de Salut de Catalunya, Spain
Mikael Nyström, Cambio Healthcare Systems AB, Sweden
Ana Pascual Segura, Catsalut, Spain
Xavier Pastor, Hospital Clínic - University of Barcelona, Spain
Marlene Pérez Colman, Digital Health and Care Wales, United Kingdom
Terje Sagmyr, Helse Vest IKT, Norway (openEHR Editor)
Kritika Sarkar, Karkinos Healthcare, India
Norwegian Review Summary, Norwegian Public Hospitals, Norway
John Tore Valand, Helse Vest IKT, Norway (openEHR Editor)
Marit Alice Venheim, Helse Vest IKT, Norway (openEHR Editor), 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, Marit Alice Venheim, John Tore Valand, Liv Laugen, Vebjørn Arntzen, Helse Vest IKT AS, Helse Bergen, ​Oslo University Hospital, Norway, silje.ljosland.bakke@helse-vest-ikt.no, marit.alice.venheim@helse-vest-ikt.no, john.tore.valand@helse-bergen.no, john.tore.valand@helse-vest-ikt.no, liv.laugen@ous-hf.no, varntzen@ous-hf.no
  • Dutch: Martijn van Eenennaam, Nedap Healthcare, martijn.vaneenennaam@nedap.com, PhD
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