ARCHETYPE ID | openEHR-EHR-OBSERVATION.story.v1 |
Concept | Story/History |
Description | The 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. |
Use | Use 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. |
Misuse | Not to be used to record formal assessments by clinicians which would usually be recorded using the EVALUATION class of archetypes. |
Purpose | To 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. |
References | Direct communication with clinicians. |
Copyright | © openEHR Foundation |
Authors | Author name: Heather Leslie Organisation: Ocean Informatics Email: heather.leslie@oceaninformatics.com Date originally authored: 2008-05-15 |
Other Details Language | Author 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=C372CBF8FD903DD4B96B6327ABBBAE1F, build_uid=f147f076-2f91-47cb-a18f-e3b0ae5d0eda, revision=1.3.0} |
Keywords | history, presenting, complaint, story, symptom, health, record, presenting complaint, anamnesis |
Lifecycle | published |
UID | 7e289b5c-e123-4dc0-9aad-548352b64915 |
Language used | en |
Citeable Identifier | 1013.1.68 |
Revision Number | 1.3.0 |
All | Archetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=The 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., archetypeConceptComment=null, otherContributors=Tomas Alme, DIPS ASA, Norway 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=
All not explicitly excluded archetypes, extendedValues=null]], ism_transition=[], context=[], data=[ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=4, text=Story, description=Narrative description of the story or clinical history for the subject of care., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0006], code=at0006, itemType=SLOT, level=4, text=Structured detail, description=Structured detail about the individual's story or patient's history., comment=For example: a specific symptom such as nausea or pain; an event such as a fall off a bicycle; or an issue such as a desire to quit using tobacco., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include: openEHR-EHR-CLUSTER.health_ openEHR-EHR-CLUSTER.issue.v0 and specialisations or openEHR-EHR-CLUSTER.symptom_ All not explicitly excluded archetypes, extendedValues=null]], minIndents={}, termBindingRetrievalErrorMessage=null] |