Use to create a framework for recording answers to pre-defined screening questions about diagnostic investigations or groups of investigations. The scope of diagnostic investigations includes all modalities of imaging examinations and the broadest range of laboratory and anatomical pathology tests. In addition, this archetype can also be used to record when other diagnostic tests have been carried out, such as cardiac stress testing, hearing and vision testing, electrocardiography (ECG) and electroencephalography (EEG).
Common use cases include, but are not limited to:
- Patient self-reporting
- Creating a patient profile in a disease registry
- Systematic questioning in any consultation related to patterns of investigation administration
The semantics of this archetype are intentionally loose, and querying this archetype would normally only be useful or safe within the context of each specific template. Each data element would usually be renamed in a template to represent the specific question asked. Where value sets have been proposed for common use cases, these can be adapted to align with local requirements by using the DV_TEXT or the DV_BOOLEAN datatypes choice to match each specific use case.
Utilising this framework within a template can enable documentation of a broad range of question/answer pairs such as:
- Have you ever had your cholesterol level tested? Yes, No, Unknown.
- Have you been tested for rubella antibodies? Yes, No, Unknown.
- Have you ever been screened for sickle cell disease? Yes, No, Unknown.
- When was your last Chest X-ray?
- What was the result of your most recent INR test?
- What were the findings of the electrocardiogram?
- Did the infant pass/fail a Neonatal hearing screen?
The EVENT structure from the reference model can be used to specify whether the questions relate to a point in time or over a period of time. Use a separate instance of this archetype to distinguish between a questionnaire recording information about an investigation or test that has been done at any time in the past and information about an investigation or test done within a specified time interval - for example, the difference between "Have you ever had an INR test?" compared to "Have you had an INR test during the last four weeks?".
The source of the information in a questionnaire response may vary in different contexts but can be specifically identified using the 'Information provider' element in the Reference Model.
This archetype has been designed to be used as a screening tool or to record simple questionnaire-format data for use in situations such as a disease registry. If the screening questionnaire identifies an investigation has been carried out, additional details required for persistence as part of a clinical record can be captured using specific test result archetypes.
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2022-10-21
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2022-10-21
- 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
- Original Namespace: org.openehr
- Original Publisher: openEHR Foundation
- Custodian Namespace: org.openehr
- MD5-CAM-1.0.1: B8C2E96DB0A27622D7007F276769C10E
- Build Uid: 0ecbd966-bc1e-42bd-9fbc-6ed0fd09e94f
- Ip Acknowledgements: This artefact includes content from SNOMED Clinical Terms® (SNOMED CT®) which is copyrighted material of the International Health Terminology Standards Development Organisation (IHTSDO). Where an implementation of this artefact makes use of SNOMED CT content, the implementer must have the appropriate SNOMED CT Affiliate license - for more information contact https://www.snomed.org/snomed-ct/get-snomed or info@snomed.org.
- Revision: 0.0.1-alpha
This data element is intended to provide collection context for the question/answer groups when queried at a later date. It is not expected that this data element will be exposed to the individual, but only stored in data. For example: pre-admission screening, the name of the actual questionnaire or screening for previous investigations.
In a template, the data element would usually be renamed to the specific question asked. The proposed value set can be adapted for local use by using the DV_TEXT or the DV_BOOLEAN datatypes choice to match each specific use case.
Choice of:
Coded Text
Text
Boolean
Use separate instances of this CLUSTER to differentiate between specific investigations or groupings of investigations.
For example: 'Blood gas', Chest Xray', 'ECG'; or 'Hearing test'. Coding of the 'Investigation name' with a terminology is preferred, where possible.
In a template, the data element would usually be renamed to the specific question asked. The proposed value set can be adapted for local use by using the DV_TEXT or the DV_BOOLEAN datatypes choice to match each specific use case.
Choice of:
- Coded Text
- Text
- Boolean
The 'Timing' data element has deliberately been loosely modelled to support the myriad of ways that it can be used in questionnaires to capture when an investigation was carried out. The specific and intended semantics can be further clarified in a template. For example: the actual date and/or time; the start and stop time for the investigation; the interval of time during which the investigation was carried out; the duration of the investigation; the age of the individual at the time of the investigation; or the duration of time since it occurred. A partial date is valid, using the DV_DATE_TIME data type, to record only a year.
Choice of:
Date/Time- Text
Interval of Date/Time
Interval of Duration
Duration
For example: 'All results within normal range', 'Normal', 'Further investigations needed'. This data element is not to contain a representation of the actual results or findings. In that situation, nest an appropriate CLUSTER archetype within the following 'Additional details' SLOT.
Include:
openEHR-EHR-CLUSTER.imaging_
openEHR-EHR-CLUSTER.organisation.v1 or
openEHR-EHR-CLUSTER.lab_
openEHR-EHR-CLUSTER.lab_
openEHR-EHR-CLUSTER.laboratory_
openEHR-EHR-CLUSTER.lab_
openEHR-EHR-CLUSTER.lab_
openEHR-EHR-CLUSTER.lab_
openEHR-EHR-CLUSTER.lab_
openEHR-EHR-CLUSTER.lab_
openEHR-EHR-CLUSTER.specimen.v1
All not explicitly excluded archetypes
For example: local information requirements; or additional metadata to align with FHIR.
Include:
All not explicitly excluded archetypes
Astrid Askeland, Dips AS, Norway
Silje Ljosland Bakke, Helse Vest IKT AS, Norway (openEHR Editor)
Terje Bektesevic Holmlund, UiT Norges arktiske universitet, Norway
Ivar Berge, Oslo Universitetssykehus, Norway
SB Bhattacharyya, Bhattacharyyas Clinical Records Research & Informatics LLP, India
Randi Brendberg, Helse Nord RHF, Norway
Yexuan Cheng, 浙江大学, China
Are Edvardsen, SKDE, Helse Nord RHF, Norway
Heike Eichele, Regionalt fagmiljø for autimse, ADHD, Tourettes syndrom og narkolepsi Helse Vest, Kronstad DPS, Haukeland universitetssykehus, Bergen, Norway
Alexander Eikrem-Lüthi, Lovisenberg Diakonale Sykehus, Norway
Gunn Elin Blakkisrud, DIPS ASA, Norway
Kåre Flø, DIPS ASA, Norway
Grant Forrest, Lunaria Ltd, United Kingdom
Anca Heyd, DIPS ASA, Norway
Joost Holslag, Nedap, Netherlands
Evelyn Hovenga, EJSH Consulting, Australia
Mikkel Johan Gaup Grønmo, Helse Nord IKT, Norway (Nasjonal IKT redaktør)
Gunnar Jårvik, Helse Vest IKT AS, Norway
Runar Kristiansen, DIPS AS, Norway
Anjali Kulkarni, Karkinos, India
Kanika Kuwelker, Helse Vest IKT, Norway (Nasjonal IKT redaktør)
Jörgen Kuylenstierna, eWeave AB, Sweden
Liv Laugen, Oslo universitetssykehus, Norway (Nasjonal IKT redaktør)
Øygunn Leite Kallevik, Helse Bergen, Norway
Heather Leslie, Atomica Informatics, Australia (openEHR Editor)
Nina Louise Jebsen, Haukeland Universitetssykehus, Norway
Martine Louise Nalum, DIPS AS, Norway
Hanne Marte Bårholm, Helse Vest IKT, Norway (Nasjonal IKT redaktør)
Svenne Naumann, Finnmarkssykehuset, Norway
Terje Nordberg, Helse Bergen, Norway
Mikael Nyström, Cambio Healthcare Systems AB, Sweden
Bjørn Næss, DIPS ASA, Norway
Jussara Rotzsch, Hospital Alemão Oswaldo Cruz, Brazil
Kritika Sarkar, Karkinos Healthcare, India
Ragnhild Schultz, OUS, Norway
Andre Smitt-Ingebretsen, Sørlandet sykehus HF, Norway
Tove Stenquist, Helseforetak, Norway
Frode Stenvik, Helse Sør-Øst, Norway
Natalia Strauch, Medizinische Hochschule Hannover, Germany
Norwegian Review Summary, Norwegian Public Hospitals, Norway
John Tore Valand, Helse Bergen, Norway (openEHR Editor)
Marit Alice Venheim, Helse Vest IKT, Norway (openEHR Editor)
Ina Wille, Helse-Vest RHF, Norway
- German: Natalia Strauch, Darin Leonhardt, Medizinische Hochschule Hannover, PLRI, Strauch.Natalia@mh-hannover.de, leonhardt.darin@mh-hannover.de
- Norwegian Bokmål: Kanika Kuwelker, John Tore Valand, Vebjørn Arntzen, Helse Vest IKT, Helse Bergen, Oslo University Hospital, kanika.kuwelker@helse-vest-ikt.no, john.tore.valand@helse-vest-ikt.no, varntzen@ous-hf.no