TEMPLATE IPS Problem List (IPS Problem List)

Name: IPS Problem List
License: http://creativecommons.org/licenses/by-sa/4.0/

TEMPLATE ID	IPS Problem List
Concept	IPS Problem List
Description	Not Specified
Purpose	Not Specified
References
Authors	date: 2025-02-12
Other Details Language	date: 2025-02-12
Other Details (Language Independent)	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: 2e34bc62f9ec902a0c080e471f920209 PARENT:MD5-CAM-1.0.1: 9FC6BA2D63BE451F034CE25153F4E298 Sem Ver: 1.0.0-alpha.23 Original Language: ISO_639-1::en
Language used	en
Citeable Identifier	1013.26.1363
Root archetype id	openEHR-EHR-SECTION.adhoc.v1
IPS Problem List	IPS Problem List: A generic section header which should be renamed in a template to suit a specific clinical context.
Exclusion - global	Exclusion - global: An overall statement of exclusion about all Problems/diagnoses, Family history, Medications, Procedures, Adverse reactions or other clinical items that are either not currently present, or have not been present in the past.
Data
Global exclusion of problems/diagnoses	Global exclusion of problems/diagnoses: Overall statement of exclusion of all problems or diagnoses at the time of recording. No known problems
Absence of information	Absence of information: Statement that specified health information is not available for inclusion in the health record or extract at the time of recording.
Data
Absence statement	Absence statement: Positive statement that no information is available. For example: "No information available about adverse reactions"; No information available about problems or diagnoses"; "No information available about previous procedures performed"; or "No information available about medications used". No information about current problems
Reason for absence	Reason for absence: Description of the reason why there is no information available. For example: patient is unconscious or refuses to provide information. Coding the reason with a terminology is desirable, if possible.
Problem/Diagnosis	Problem/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
Problem/Diagnosis name	Problem/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. Value set: terminology:Problems%20-%20IPS?subset=terminology://fhir.hl7.org/ValueSet/$expand?url=http://hl7.org/fhir/uv/ips/ValueSet/problems-uv-ips
Body site	Body site: Identification of a simple body site for the location of the problem or diagnosis. Coding of the name of the anatomical location with a terminology is preferred, where possible. Use this data element to record precoordinated anatomical locations. If the requirements for recording the anatomical location are determined at run-time by the application or require more complex modelling such as relative locations then use the CLUSTER.anatomical_location or CLUSTER.relative_location within the 'Structured anatomical location' SLOT in this archetype. Occurrences for this data element are unbounded to allow for clinical scenarios such as describing a rash in multiple locations but where all of the other attributes are identical. If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant. Value set: terminology:SNOMEDCTBodyStructures?subset=terminology://fhir.hl7.org/ValueSet/$expand?url=http://hl7.org/fhir/ValueSet/body-site
Date/time of onset	Date/time of onset: Estimated or actual date/time that signs or symptoms of the problem/diagnosis were first observed. Data captured/imported as "Age at onset" should be converted to a date using the subject's date of birth.
Severity	Severity: An assessment of the overall severity of the problem or diagnosis. If severity is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant. Note: more specific grading of severity can be recorded using the Specific details SLOT. Coded Text Mild Moderate Severe Text
Stage	Stage: Details about findings that support a clinical assertion.
Evidence	Evidence: Identification of an item of clinical evidence by name or type, either as a single result or as a grouping of results. It is recommended that 'Evidence' should be coded with a terminology, where possible. For example: 'Mantoux test', 'AFP level', 'tumour volume', 'genetic tests', 'BRCA1 test', 'histopathology result', 'physical examination finding', 'intraoperative finding', 'FIGO stage', 'symptom', 'tumour grading', 'clinical impression'. For use cases where the evidence is sufficiently identified in 'Result' or 'Structured result', this data element may be redundant and has therefore been made optional.
Result	Result: The result or finding that supports the assertion. For example: '11 mm', '13 µg/L', '2.5 ml' or 'BRCA1 positive'. 'Result' can be coded with a terminology, where appropriate. Text Coded Text
Clinical evidence	Clinical evidence: Details about findings that support a clinical assertion.
Result	Result: The result or finding that supports the assertion. For example: '11 mm', '13 µg/L', '2.5 ml' or 'BRCA1 positive'. 'Result' can be coded with a terminology, where appropriate. Text Coded Text
Date/time of resolution	Date/time of resolution: Estimated or actual date/time of resolution or remission for this problem or diagnosis, as determined by a healthcare professional. Partial dates are acceptable. If the subject of care is under the age of one year, then the complete date or a minimum of the month and year is necessary to enable accurate age calculations - for example, if used to drive decision support. Data captured/imported as "Age at time of resolution" should be converted to a date using the subject's date of birth.
Problem/Diagnosis qualifier	Problem/Diagnosis qualifier: Contextual or temporal qualifier for a specified problem or diagnosis.
Active/Inactive?	Active/Inactive?: Category that supports division of problems and diagnoses into Active or Inactive problem lists. The Active/Inactive and Current/Past data elements have similar clinical impact but represent slightly different semantics. Both are actively used in different clinical settings, but usually not together. If a Current/Past qualifier is recorded, then this data element is likely to be redundant. An exception where a condition can be current but inactive is asthma that is not causing acute symptoms. Active Inactive
Resolution phase	Resolution phase: Phase of healing for an acute problem or diagnosis. For example: tracking the progress of resolution of a middle ear infection. Resolved Relapsed
Remission status	Remission status: Status of the remission of an incurable diagnosis. For example: the status of a cancer or haematological diagnosis. In remission
Occurrence	Occurrence: Category of the occurrence for this problem or diagnosis. This data element can be an additional qualifier to the 'New' value in the 'Episodicity' value set, that is a condition such as asthma can have recurring new episodes that have periods of resolution in between. However it can be important to identify the first ever episode of asthma from all of the other episodes. Recurrence
Diagnostic certainty	Diagnostic certainty: The level of confidence in the identification of the diagnosis. If an alternative valueset is required, these values can be added to the DV_TEXT data type in a template. Coded Text Suspected Probable Confirmed Text
Comment	Comment: Additional narrative about the problem or diagnosis not captured in other fields.