ARCHETYPE Exclusion (openEHR-EHR-OBSERVATION.exclusion.v0)

ARCHETYPE IDopenEHR-EHR-OBSERVATION.exclusion.v0
ConceptExclusion
DescriptionA positive and explicit statement about exclusion of known current and/or past conditions, treatments or significant aspects of clinical history.
UseUse to enable a clinician, at a specified point of time, to record a clear and unambiguous statement about exclusion of known current and/or past conditions, treatments or significant aspects of clinical history. This approach is used in preference to relying on flags or terminology to express negation. The scope of exclusions should be limited to clinically significant concepts, in particular where it is relevant to patient safety, informing clinical decision-making or medico-legal documentation. It is not intended to encourage recording exclusions of any or all health information. The 'Statement' data element allows for recording of a single statement. Each exclusion should be recorded in a separate instance - for example a separate instance for a statement about medications and another for adverse reactions. Please note that exclusion statements should only be considered to be current and accurate at the time of recording, and should not be assumed to be correct at a later date. For example, it is possible (and appropriate from a medico-legal point of view) for a clinician to record, based on history-taking, that an individual has NO KNOWN history of any adverse reactions (using an exclusion statement) but a few minutes later needing to record evidence of an adverse reaction that occurred in response to administration of penicillin. In future record statements, the individual may have a KNOWN history of the problem or diagnosis recorded in their problem list.
MisuseNot to be used to record the exclusion of a specific problem/diagnosis, medication, procedure, family history, adverse reaction or other clinical item - use the EVALUATION.exclusion_specific archetype for this purpose. Not to be used to record the exclusion of symptoms use the CLUSTER.exclusion_symptom archetype within an appropriate OBSERVATION or CLUSTER archetype. Not to be used to record the absence of information - use the EVALUATION.absence archetype for this purpose.
PurposeTo record a positive and explicit statement about exclusion of known current and/or past conditions, treatments or significant aspects of clinical history.
ReferencesDerived from: Eksklusjonsutsagn - overordnet, Draft archetype [Internet]. Nasjonal IKT, Nasjonal IKT Clinical Knowledge Manager [cited: 2017-03-17]. Available from: http://arketyper.no/ckm/#showArchetype_1078.36.1650

Exclusion statement, Deprecated Archetype [Internet]. openEHR Foundation, openEHR Clinical Knowledge Manager [cited: 2017-02-17]. Available from: http://openehr.org/ckm/#showArchetype_1013.1.617
Copyright© openEHR Foundation
AuthorsAuthor name: Heather Leslie
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2020-08-26
Other Details LanguageAuthor name: Heather Leslie
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2020-08-26
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=Derived from: Eksklusjonsutsagn - overordnet, Draft archetype [Internet]. Nasjonal IKT, Nasjonal IKT Clinical Knowledge Manager [cited: 2017-03-17]. Available from: http://arketyper.no/ckm/#showArchetype_1078.36.1650 Exclusion statement, Deprecated Archetype [Internet]. openEHR Foundation, openEHR Clinical Knowledge Manager [cited: 2017-02-17]. Available from: http://openehr.org/ckm/#showArchetype_1013.1.617, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=46ECA8EB7B7AA37362A3371FD7EEFECF, build_uid=caf12127-db54-4e8c-a962-9bc0c02a0a8d, revision=0.0.1-alpha}
Keywords
Lifecyclein_development
UIDb5264ec4-d65f-4c07-80f6-87bf90df4acd
Language useden
Citeable Identifier1013.1.5154
Revision Number0.0.1-alpha
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