TEMPLATE IPS Allergies and Intolerances (IPS Allergies and Intolerances)

Name: IPS Allergies and Intolerances
License: http://creativecommons.org/licenses/by-sa/4.0/

TEMPLATE ID	IPS Allergies and Intolerances
Concept	IPS Allergies and Intolerances
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: 95237740722f9575c47b4ec9cf9c35c6 PARENT:MD5-CAM-1.0.1: 9FC6BA2D63BE451F034CE25153F4E298 Sem Ver: 1.0.0-alpha.21 Original Language: ISO_639-1::en
Language used	en
Citeable Identifier	1013.26.1365
Root archetype id	openEHR-EHR-SECTION.adhoc.v1
IPS Allergies and Intolerances	IPS Allergies and Intolerances: 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 adverse reactions	Global exclusion of adverse reactions: Overall statement of exclusion about all adverse reactions at the time of recording. No known allergies No known medication allergies No known environmental allergies No known food allergies
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 allergies
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.
Adverse reaction risk	Adverse reaction risk: Clinical assessment of the propensity for an individual to experience a harmful or undesirable physiological response if exposed, or re-exposed, to a substance. Substances include, but are not limited to: a therapeutic substance administered correctly at an appropriate dosage for the individual; food; material derived from plants or animals; or venom from insect stings. Optional[{source=openEHR,FHIR}]
Data
Substance	Substance: Identification of a substance, or substance class, that is considered to put the individual at risk of an adverse reaction event. Both an individual substance and a substance class are valid entries in 'Substance'. A substance may be a compound of simpler substances, for example a medicinal product. It is strongly recommended that the 'Substance' is coded with a terminology capable of triggering decision support, where possible. For example: Snomed CT, DM+D, RxNorm, NDFRT, ATC, New Zealand Universal List of Medicines and Australian Medicines Terminology. Free text entry should only be used if there is no appropriate terminology available. Value set: terminology:Allergies%20&%20Intolerances%20-%20IPS?subset=terminology://fhir.hl7.org/ValueSet/$expand?url=http://hl7.org/fhir/uv/ips/ValueSet/allergies-intolerances-uv-ips
Active/inactive status	Active/inactive status: Status about whether the adverse reaction risk statement is active or inactive. Coded Text Active Inactive Text
Verification status	Verification status: Assertion about the certainty of the propensity, or potential future risk, of the identified 'Substance' to cause a reaction. Decision support would typically raise alerts for 'Unconfirmed' and 'Confirmed', and ignore a 'Refuted' reaction. Clinical systems may choose not to display Adverse reaction entries with a 'Refuted' status in the Adverse Reaction List. However, 'Refuted' may be useful for reconciliation of the adverse reaction list or when communicating between systems. Some implementations may choose to make this field mandatory. The free text data type will allow for local variation by enabling other value sets to be applied to this data element in a template - in this situation it is recommended that values should be coded using a terminology. Coded Text Unconfirmed Confirmed Refuted Text
Criticality	Criticality: An indication of the potential for critical system organ damage or life threatening consequence. This can be regarded as a predictive judgement of a 'worst case scenario'. In most contexts 'Low' would be regarded as the default value. Coded Text Low High Indeterminate Text
Category	Category: Category of the identified 'Substance'. This data element has been included because it is currently being captured in some clinical systems. This data can be derived from the Substance where coding systems are used, and is effectively redundant in that situation. Food Medication Environment Biologic
Onset of last reaction	Onset of last reaction: The date and/or time of the onset of the last known occurrence of a reaction event. For example: the actual date and/or time of onset; the interval of time during which the onset occurred; the age of the individual at the time of the onset; or the duration of time since the onset occurred. A partial date is valid, using the DV_DATE_TIME data type, to record only a year.
Onset of first reaction	Onset of first reaction: The onset of the first known occurrence of a reaction event. For example: the actual date and/or time of onset; the interval of time during which the onset occurred; the age of the individual at the time of the onset; or the duration of time since the onset occurred. A partial date is valid, using the DV_DATE_TIME data type, to record only a year. Date/Time Duration Text Interval Interval
Reaction mechanism	Reaction mechanism: Identification of the underlying physiological mechanism for the adverse reaction. Immune-mediated responses have been traditionally regarded as an indicator for escalation of significant future risk. Contemporary knowledge suggests that some reactions previously thought to be immune are actually non-immune and still carry life threatening risk. Immunological testing may provide supporting evidence for the mechanism and causative substance , but no tests are 100% sensitive or specific for a sensitivity. It is acknowledged that most clinicians will NOT be able to distinguish the mechanism of any specific reaction. However this data element is included because many legacy systems have captured this attribute. Allergy Intolerance
Adverse reaction event	Adverse reaction event: Information about a specific adverse reaction event caused by exposure to a specific substance.
Specific substance	Specific substance: The substance considered to be responsible for the specific adverse reaction event. For example: 'Amoxycillin'. Only an individual substance is a valid entry in 'Specific substance'. A substance may be a compound of simpler substances, for example a medicinal product. If the 'Substance' recorded in the archetype in which this archetype is nested is an individual substance and not a substance class, then it may be duplicated in this data element, or this element may be redundant. It is strongly recommended that 'Specific substance' be coded with a terminology, for example: RxNorm, SNOMED CT, DM+D, NDFRT, ICD-9, ICD-10, UNI, ATC or CPT.
Manifestation	Manifestation: Clinical symptoms and/or signs that are observed or associated with the adverse reaction. Manifestation can be expressed as a single word, phrase or brief description. For example: nausea, rash. 'No reaction' may be appropriate where a previous reaction has been noted but the reaction did not re-occur after further exposure. It is preferable that 'Manifestation' should be coded with a terminology, where possible. The values entered here may be used to display on an application screen as part of a list of adverse reactions. Value set: terminology:Allergy%20Reaction%20-%20IPS?subset=terminology://fhir.hl7.org/ValueSet/$expand?url=http://hl7.org/fhir/uv/ips/ValueSet/allergy-reaction-uv-ips
Reaction description	Reaction description: Narrative description about the adverse reaction as a whole, including details of the manifestation if required.
Onset of reaction	Onset of reaction: The date and/or time of the onset of the reaction.
Severity of reaction	Severity of reaction: Clinical assessment of the severity of the reaction event as a whole, potentially considering multiple different manifestations. It is acknowledged that this assessment is very subjective. There may be some some specific practice domains where objective scales have been applied. Objective scales can be included in this model using the 'Reaction details' Cluster. Coded Text Mild Moderate Severe Text
Route of exposure	Route of exposure: The route by which the subject was exposed to the identified 'Specific substance'. Coding of the Route of Exposure with a terminology should be used wherever possible.
Comment	Comment: Additional narrative about the adverse reaction event not captured in other fields.
Comment	Comment: Additional narrative about the propensity for the adverse reaction, not captured in other fields. For example: including reason for flagging a 'Criticality' of 'High risk'; and instructions related to future exposure or administration of the Substance, such as administration within an Intensive Care Unit or under corticosteroid cover.