| ARCHETYPE ID | openEHR-EHR-SECTION.problem_list.v0 |
| Concept | Problem list |
| Description | Framework for consistent modelling of content within a template for a Problem list. |
| Use | Use to provide a framework and design guidance for consistent modelling of content within a template for a Problem list as 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. This archetype is intended to be used within the COMPOSITION.problem_list or as one component of other COMPOSITION archetypes. For example: complex documents, such as a discharge summary or referral. 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, multiple Problem lists for a single individual may coexist, 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; an inpatient admission may include additional issues related to immediate nursing priorities that would not be relevant once discharged home. For these purposes, the CLUSTER.problem_qualifier archetype, nested within the Status SLOT in the Problem/Diagnosis archetype supports the use of qualifiers that will supprt 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. |
| Purpose | To provide a framework and design guidance for consistent modelling of content within a template for a Problem list. |
| References | |
| Copyright | © openEHR Foundation |
| Authors | Author name: Heather Leslie Organisation: Atomica Informatics Email: heather.leslie@atomicainformatics.com Date originally authored: 2010-07-03 |
| Other Details Language | Author 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 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=, current_contact=Heather Leslie, Atomica Informatics |
| Keywords | problem, diagnosis, exclusion, absence, known, list, diagnoses, procedure |
| Lifecycle | in_development |
| UID | 496598a7-dcfa-45fb-8886-f5b76c2333d9 |
| Language used | en |
| Citeable Identifier | 1013.1.610 |
| Revision Number | 0.0.1-alpha |
| All | Archetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Framework for consistent modelling of content within a template for a Problem list., archetypeConceptComment=Intended to be used within the COMPOSITION.problem_list., otherContributors=Nadim Anani, Karolinska Institutet, Sweden 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=
openEHR-EHR-EVALUATION.problem_ openEHR-EHR-ACTION.procedure.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0003], code=at0003, itemType=SLOT, level=1, text=Exclusion statement, description=A positive statement about the exclusion of known problems, diagnoses and procedures., comment=For example: "No problems or diagnoses" or No operations or procedures"., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=Include: openEHR-EHR-EVALUATION.exclusion_ openEHR-EHR-EVALUATION.absence.v2 and specialisations, extendedValues=null]], other_participations=[], content=[], state=[], activities=[], data=[], relationships=[], credentials=[]}, topLevelItems={items=ResourceSimplifiedHierarchyItem [path=ROOT_/items[at0001], code=at0001, itemType=EVALUATION, level=0, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=null, extendedValues=null]}, addHierarchyItemsTo=items, currentHierarchyItemsForAdding=[ResourceSimplifiedHierarchyItem [path=/items[at0001], code=at0001, itemType=SLOT, level=1, text=Problems, diagnoses, concerns or health issue threads, description=Positive statements about the presence of problems, diagnoses, concerns or health issue threads., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=Include: openEHR-EHR-EVALUATION.problem_ openEHR-EHR-ACTION.procedure.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0003], code=at0003, itemType=SLOT, level=1, text=Exclusion statement, description=A positive statement about the exclusion of known problems, diagnoses and procedures., comment=For example: "No problems or diagnoses" or No operations or procedures"., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=Include: openEHR-EHR-EVALUATION.exclusion_ openEHR-EHR-EVALUATION.absence.v2 and specialisations, extendedValues=null]], minIndents={}, termBindingRetrievalErrorMessage=null] |