ARCHETYPE Story/History (openEHR-EHR-OBSERVATION.story.v1)

ARCHETYPE IDopenEHR-EHR-OBSERVATION.story.v1
ConceptStory/History
DescriptionThe subjective clinical history of the subject of care as recorded directly by the subject, or reported to a clinician by the subject or a carer.
UseUse to record a description about subjective health-related observations or impressions from the point of view of the subject of care. When recorded by a clinician within the context of healthcare provision the story can be used for capturing the clinical history, as reported by the subject themselves, a parent, care-giver or other related party. If recorded by the subject, it can be used as an account of their 'story' of symptoms and health experiences, which might be used to share with healthcare providers or to document within their own personal health record. Use: - to record a simple narrative; and/or - as a container archetype to enable recording of a detailed structured history by inclusion of relevant CLUSTER archetypes within the 'Detail' SLOT. For example: CLUSTER.symptom, CLUSTER.issue or CLUSTER.health_event archetypes can be appropriately used in this SLOT. Use to incorporate the narrative descriptions of clinical history captured from existing or legacy clinical systems into an archetyped format, using the 'Story' text data element.
MisuseNot to be used to record formal assessments by clinicians which would usually be recorded using the EVALUATION class of archetypes.
PurposeTo record a narrative description of the clinical history of the subject of care and to provide a framework in which to nest detailed CLUSTER archetypes, each of which will support the narrative with additional structured detail for symptoms, health events and related topics. Use to record detail about the clinical history as reported by an individual, parent, care-giver or other party. It may be recorded by a clinician as part of a clinical history record as reported to them, or self-recorded as part of a clinical questionnaire or personal health record.
ReferencesDirect communication with clinicians.
Copyright© openEHR Foundation
AuthorsAuthor name: Heather Leslie
Organisation: Ocean Informatics
Email: heather.leslie@oceaninformatics.com
Date originally authored: 2008-05-15
Other Details LanguageAuthor name: Heather Leslie
Organisation: Ocean Informatics
Email: heather.leslie@oceaninformatics.com
Date originally authored: 2008-05-15
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=Direct communication with clinicians., current_contact=Heather Leslie, Ocean Informatics, heather.leslie@oceaninformatics.com, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=CF9ADF5EF4D2BC6F8C0BF8FFED32E2A4, build_uid=cd5b730e-cac8-4f01-8abf-e2355c541572, revision=1.1.2}
Keywordshistory, presenting, complaint, story, symptom, health, record, presenting complaint, anamnesis
Lifecyclepublished
UID7e289b5c-e123-4dc0-9aad-548352b64915
Language useden
Citeable Identifier1013.1.68
Revision Number1.1.2
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Nadim Anani, Karolinska Institutet, Sweden
Vebjørn Arntzen, Oslo universitetssykehus HF, Norway (Nasjonal IKT redaktør)
Koray Atalag, University of Auckland, New Zealand
Gustavo Bacelar-Silva, Healthcare Designs, Brazil (openEHR Editor)
Silje Ljosland Bakke, Nasjonal IKT HF, Norway (openEHR Editor)
Lars Bitsch-Larsen, Haukeland University hospital, Norway
Lisbeth Dahlhaug, Helse Midt - Norge IT, Norway
Shahla Foozonkhah, Iran ministry of health and education, Iran
Einar Fosse, National Centre for Integrated Care and Telemedicine, Norway
Sam Heard, Ocean Informatics, Australia
Andreas Hering, Helse Bergen HF, Haukeland universitetssjukehus, Norway
Anca Heyd, DIPS ASA, Norway
Lars Morgan Karlsen, DIPS ASA, Norway
Shinji Kobayashi, Kyoto University, Japan
Heather Leslie, Atomica Informatics, Australia (openEHR Editor)
Hallvard Lærum, Direktoratet for e-helse, Norway
Arne Løberg Sæter, DIPS ASA, Norway
Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (openEHR Editor)
Bjørn Næss, DIPS ASA, Norway
Andrej Orel, Marand d.o.o., Slovenia
Rune Pedersen, Universitetssykehuset i Nord Norge, Norway
Micaela Thierley, Helse Bergen/Haraldsplass sykehus, Norway
John Tore Valand, Haukeland Universitetssjukehus, Norway (Nasjonal IKT redaktør), originalLanguage=en, translators=Korean: Seung-Jong Yu, NOUSCO Co.,Ltd., seungjong.yu@gmail.com, Certified board of Family medicine
Spanish (Argentina): Guillermo Palli
Norwegian Bokmål: Silje Ljosland Bakke, Nasjonal IKT HF
Portuguese (Brazil): Osmeire Chamelette Sanzovo, Hospital Sírio Libanês - SP, osmeire.acsanzovo@hsl.org.br
Arabic (Syria): Mona Saleh
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