| All | OperationalTemplate [rootArchetypeId=openEHR-EHR-SECTION.clinical_decision.v0, otherContributors=Jose Andonegui, Complejo hospitalario de Navarra (CHN), jose.andonegui.navarro@cfnavarra.es; Luis Serrano, Universidad Pública de Navarra (UPNA), lserrano@unavarra.es; Jesús D. Trigo, Universidad Pública de Navarra (UPNA), jesusdaniel.trigo@unavarra.es, tshis=[ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.clinical_decision.v0], code=at0000, itemType=SECTION, level=0, text=Clinical decision, description=Defines the process of making a decision about the diagnosis of a specific disease., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.clinical_synopsis.v1], code=at0000, itemType=EVALUATION, level=1, text=Clinical Synopsis, description=Narrative summary or overview about a patient, specifically from the perspective of a healthcare provider, and with or without associated interpretations., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.clinical_synopsis.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=2, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.clinical_synopsis.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=3, text=Synopsis, description=The summary, assessment, conclusions or evaluation of the clinical findings., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1], code=at0000, itemType=EVALUATION, level=1, text=Problem/Diagnosis, description=Details about a single identified health condition, injury, disability or any other issue which impacts on the physical, mental and/or social well-being of an individual., comment=Clear delineation between the scope of a problem versus a diagnosis is not easy to achieve in practice. For the purposes of clinical documentation with this archetype, problem and diagnosis are regarded as a continuum, with increasing levels of detail and supportive evidence usually providing weight towards the label of 'diagnosis'., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=2, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=3, text=Problem/Diagnosis name, description=Identification of the problem or diagnosis, by name., comment=Coding of the name of the problem or diagnosis with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0009], code=at0009, itemType=ELEMENT, level=3, text=Clinical description, description=Narrative description about the problem or diagnosis., comment=Use to provide background and context, including evolution, episodes or exacerbations, progress and any other relevant details, about the problem or diagnosis., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0012], code=at0012, itemType=ELEMENT, level=3, text=Body site, description=Identification of a simple body site for the location of the problem or diagnosis., comment=Coding of the name of the anatomical location with a terminology is preferred, where possible.
Use this data element to record precoordinated anatomical locations. If the requirements for recording the anatomical location are determined at run-time by the application or require more complex modelling such as relative locations then use the CLUSTER.anatomical_location or CLUSTER.relative_location within the 'Structured anatomical location' SLOT in this archetype. Occurrences for this data element are unbounded to allow for clinical scenarios such as describing a rash in multiple locations but where all of the other attributes are identical. If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant., 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=[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0077], code=at0077, itemType=ELEMENT, level=3, text=Date/time of onset, description=Estimated or actual date/time that signs or symptoms of the problem/diagnosis were first observed., comment=Data captured/imported as "Age at onset" should be converted to a date using the subject's date of birth., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.classification_amd.v0], code=at0000, itemType=CLUSTER, level=3, text=Classification of age related macular degeneration, description=Classifies the condition and argues the diagnostic decision for age-related macular degeneration., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.classification_amd.v0]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=AMD classification, description=Clinical grade determined for age-related macular degeneration., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- No AMD
- Early AMD
- Intermediate AMD
- Dry advanced AMD atrophic
- Exudative or wet AMD
- Ungradable
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.classification_amd.v0]/items[at0004], code=at0004, itemType=ELEMENT, level=4, text=Diagnostic criteria, description=Clinical findings supporting the diagnose or grading., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- Small drusen
- Intermediate drusen
- Numerous intermediate drusen
- Large drusen
- Geographic atrophy
- Geographic atrophy involving foveal center
- Choroidal neovascularization (CNV)
- Serous or hemorragic detachment
- Retinal hard exudates
- Fibrovascular proliferation
- Disciform scar (subretinal fibrosis)
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.classification_amd.v0]/items[at0022], code=at0022, itemType=ELEMENT, level=4, text=Clinical findings, description=Overall findings on the patient considered in the diagnostic classification., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= Value set: ac0001, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.classification_amd.v0]/items[at0003], code=at0003, itemType=ELEMENT, level=4, text=Comments, description=Additional comments that clarify the diagnostic decision made., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.contraindication.v0], code=at0000, itemType=EVALUATION, level=1, text=Contraindication, description=Identification of a treatment, test or procedure which should not be provided to the subject of care, for clinical reasons., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.contraindication.v0]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=2, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.contraindication.v0]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=3, text=Contraindication, description=Identification of a contraindication to a treatment, test or procedure, including a class of medications or vaccines., comment=Coding of the identified 'Contraindication' with a terminology is desirable, where possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=Default value: Contraindication for Intravitreal anti-VEGF therapy, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.contraindication.v0]/data[at0001]/items[at0003], code=at0003, itemType=ELEMENT, level=3, text=Rationale, description=Description of evidence or rationale for the contraindication., comment=Please note: an optional URI link to evidence within the health record is also permitted using Reference Model attributes. As this URI link may not be accessible from a message or by receiving clinical system it is desirable that a narrative description of the rationale should be explicitly stated., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=- Very low VA (below 0.1 in first clinical encounter)
- Healed lesions (Identified signs of previous treatments)
- Multimorbidity (Coexistence of additional alterations on the retina)
- Reaction to anti-VEGF (Suspicion of hypersensitivity to agents used in intravitreal injections)
- No response to treatment (VA decreased below 0.1 three consecutive reviews)
- Morphologic deterioration of the lesion
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.contraindication.v0]/protocol[at0006], code=at0006, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=2, text=Protocol, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.contraindication.v0]/protocol[at0006]/items[at0004], code=at0004, itemType=ELEMENT, level=3, text=Last updated, description=The date this contraindication was last updated., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.contraindication.v0]/protocol[at0006]/items[at0009], code=at0009, itemType=ELEMENT, level=3, text=Review date, description=Date when due for review by a clinician., comment=In some circumstances, contraindications are not intended to be indefinite or lifelong, and this contraindication should be reconsidered in the context of changing clinical circumstances. For example: if a family member is no longer taking immunosuppressive therapy, then live vaccines could safely be administered to the subject of care again and the contraindication is effectively obsolete., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.recommendation.v1], code=at0000, itemType=EVALUATION, level=1, text=Recommendation on the treatment of AMD, description=A suggestion, advice or proposal for clinical management., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.recommendation.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=2, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.recommendation.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=3, text=Recommendation, description=Narrative description of the recommendation., comment=May be coded, using a terminology, if required., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=- Do not treat
- Intravitreal anti-VEGF injection
- High dose Antioxidant Vitamin and Mineral Supplements
- Photodynamic Therapy (PDT)
- Thermal Laser Photocoagulation Surgery
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.recommendation.v1]/data[at0001]/items[at0003], code=at0003, itemType=ELEMENT, level=3, text=Rationale, description=Justifications for the recommendation., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=- Visual acuity decrease with macular fluid
- Macular fluid
- New macular haemorrhage
, extendedValues=null]], templateType=normal] |