| TEMPLATE ID | Final classification - JM |
|---|---|
| Concept | Final classification - JM |
| Description | To document the final diagnosis and classification as assigned by the national public health surveillance agency. |
| Purpose | To document the final diagnosis and classification as assigned by the national public health surveillance agency. |
| References | |
| Authors | name: Heather Leslie; organisation: Atomica Informatics; email: heather.leslie@atomicainformatics.com; date: 2024-12-26 |
| Other Details Language | name: Heather Leslie; organisation: Atomica Informatics; email: heather.leslie@atomicainformatics.com; date: 2024-12-26 |
| Other Details (Language Independent) |
|
| Language used | en |
| Citeable Identifier | 1013.26.1047 |
| Root archetype id | openEHR-EHR-SECTION.adhoc.v1 |
| Final classification | Final classification: A generic section header which should be renamed in a template to suit a specific clinical context. |
| Final diagnosis | Final diagnosis: 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. 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'. |
| Data | |
| Diagnosis name | Diagnosis name: Identification of the problem or diagnosis, by name. Coding of the name of the problem or diagnosis with a terminology is preferred, where possible. |
| NSU classification | NSU classification: Classification for an identified infectious disease as part of a disease surveillance investigation. |
| Data | |
| Index disease | Index disease: The name of the infectious disease under investigation. This data element may be redundant if the index disease has been identified elsewhere within a template. |
| Final classification | Final classification: Classification of the likelihood of the 'Index disease' as causal after completion of a case investigation. Not to be used to record the 'Initial classification' at the initiation of a case investigation.
|
| Reason for classification | Reason for classification: The broad category of the reason for the classification. For example: lost to follow-up, child of an infected mother. |
| Epidemiological link | Epidemiological link: Identification of the cause or source of transmission.
|
| Aetiology category | Aetiology category: The category for the cause of infection. For example: imported, import-related, endemic, vaccine-associated, congenital or unknown.
|
| Source country | Source country: Country identified as the (likely or probable) source for an imported or import-related case. |
| Endemic source category | Endemic source category: The category for the source of an endemic case. For example: household contact, community, or unknown. |
| Contribution to death | Contribution to death: Assessment of the relationship between the index disease and the death of the individual.
|
| Comment | Comment: Additional narrative about the classification, not captured in other fields. |