ARCHETYPE Problem list (openEHR-EHR-SECTION.problem_list.v0)

ARCHETYPE IDopenEHR-EHR-SECTION.problem_list.v0
ConceptProblem list
DescriptionSuggested design pattern for a typical Problem list.
UseUse as a suggested framework or design guidance to support consistent modelling of the Problem list as a persistent and managed list of diagnoses identified, problems experienced by the subject or previous procedures performed. This archetype is intended to be used within the COMPOSITION.problem_list. This list can be comprised of three types of statements, each represented by specific archetypes: - statements about the positive presence of problems, diagnoses or previous procedures are recorded using the EVALUATION.problem_diagnosis and/or ACTION.procedure archetypes; OR - statements about the positive exclusion of problems, diagnoses or previous procedures can be recorded using the specific EVALUATION.exclusion-global archetype - for example:'No significant problems or diagnoses' and/or 'No history of significant operations or procedures'; OR - statements about no information being available - neither a positive presence of a problem, diagnosis or procedure performed nor a positive exclusion - can be recorded using the EVALUATION.absence archetype. While it may be ideal to have only one Problem list for each subject of care, it is more realistic to expect that in a distributed environment there may be multiple Problem lists for a single subject of care, each managed and prioritised for a specific clinician, episode of care or other context. For example, a Problem list for a primary care clinician may be a very different configuration to that which is useful for a specialist surgeon or for reference during a hospital inpatient episode. In primary care it is common to organise the Problem list based on active or inactive problems or diagnoses; specialists may prefer to see their list organised around primary diagnoses which are related to their specific speciality and secondary ones which are not; and an inpatient admission may include additional issues related to immediate nursing priorities that would not be relevant once discharged home - for these purposes there is a Status SLOT in the Problem/Diagnosis archetype, which allow use of an archetype that could support clinical systems to organise Problem lists according to the preference of the clinical users of the system, without perpetuating these contextual status labels to other clinical scenarios or for persistence. In order for this list to be accurate and safe to use as the basis for decision support activities and for exchange, the content of this Problem List should ideally be curated by a clinician responsible for the health record, rather than managed automatically by the clinical system through business rules alone.
PurposeA design pattern for a persistent and managed list of any combination of diagnoses, problems and/or procedures that may influence clinical decision-making and care provision for the individual.
ReferencesDerived from: Problem List, Draft archetype [Internet]. Australian Digital Health Agency, ADHA Clinical Knowledge Manager. Available from: http://dcm.nehta.org.au/ckm/#showArchetype_1013.1.1235 (no longer available).
Copyright© openEHR Foundation
AuthorsAuthor name: Heather Leslie
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2010-07-03
Other Details LanguageAuthor name: Heather Leslie
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2010-07-03
OtherDetails Language Independent{licence=This work is licensed under the Creative Commons Attribution-ShareAlike 3.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/3.0/., custodian_organisation=openEHR Foundation, references=Derived from: Problem List, Draft archetype [Internet]. Australian Digital Health Agency, ADHA Clinical Knowledge Manager. Available from: http://dcm.nehta.org.au/ckm/#showArchetype_1013.1.1235 (no longer available)., current_contact=Heather Leslie, Atomica Informatics, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=4ADA26443C73C24DECB230E301C3791B, build_uid=add67499-c87d-4fc8-a358-e66e8960e794, revision=0.0.1-alpha}
Keywordsproblem, diagnosis, exclusion, absence, known, list, diagnoses, procedure
Lifecyclein_development
UID496598a7-dcfa-45fb-8886-f5b76c2333d9
Language useden
Citeable Identifier1013.1.610
Revision Number0.0.1-alpha
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Vebjoern Arntzen, Oslo university hospital, Norway
Koray Atalag, University of Auckland, New Zealand
Silje Ljosland Bakke, Bergen Hospital Trust, Norway (openEHR Editor)
Sistine Barretto-Daniels, Ocean Informatics, Australia
Lars Bitsch-Larsen, Haukeland University hospital, Norway
Shahla Foozonkhah, Ocean Informatics, Australia
Einar Fosse, National Centre for Integrated Care and Telemedicine, Norway
Sebastian Garde, Ocean Informatics, Germany
Heather Grain, Llewelyn Grain Informatics, Australia
Sam Heard, Ocean Informatics, Australia
Lars Karlsen, DIPS ASA, Norway
Shinji Kobayashi, Kyoto University, Japan
Heather Leslie, Ocean Informatics, Australia (openEHR Editor)
Hallvard Lærum, Oslo University Hospital, Norway
Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (openEHR Editor)
Andrej Orel, Marand d.o.o., Slovenia
Jussara Rotzsch, UNB, Brazil
Rowan Thomas, St. Vincent's Hospital Melbourne, Australia
Heath Frankel, Ocean Informatics, Australia, originalLanguage=en, translators=Spanish (Argentina): Alan March, Hospital Universiatario Austral, Pilar, Buenos Aires, Argentina., alandmarch@gmail.com, MD
Portuguese (Brazil): Adriana Kitajima, Débora Farage, Fernanda Maia, Laíse Figueiredo, Marivan Abrahão, Core Consulting, contato@coreconsulting.com.br, Hospital Alemão Oswaldo Cruz (HAOC)
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