| 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:
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 |
| Other Details (Language Independent) |
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| 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 | 1.3.2 |
| events | |
| Any event | Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time. |
| data | |
| Story | Story: Narrative description of the story or clinical history for the subject of care. |
| Structured detail | Structured detail: Structured detail about the individual's story or patient's history. 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. Include: openEHR-EHR-CLUSTER.health_ openEHR-EHR-CLUSTER.issue.v0 and specialisations or openEHR-EHR-CLUSTER.symptom_ |
| protocol | |
| Extension | Extension: Additional information required to capture local content or to align with other reference models/formalisms. For example: Local information requirements or additional metadata to align with FHIR equivalents. Include: All not explicitly excluded archetypes |
| Other contributors | 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) |
| Translators |
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