| TEMPLATE ID | Next step in DR screening service |
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| Concept | Next step in DR screening service |
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| Description | To determine the steps to be taken at the transition points between the different stages of the DR screening service. |
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| Purpose | To determine the steps to be taken at the transition points between the different stages of the DR screening service. |
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| References | |
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| Authors | name: Aitor Eguzkitza; organisation: Universidad Pública de Navarra - Complejo Hospitalario de Navarra; email: aitor.eguzkiza@unavarra.es; date: 2016-07-25 |
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| Other Details Language | name: Aitor Eguzkitza; organisation: Universidad Pública de Navarra - Complejo Hospitalario de Navarra; email: aitor.eguzkiza@unavarra.es; date: 2016-07-25 |
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| Other Details (Language Independent) | - MetaDataSet:Sample Set : Template metadata sample set
- Copyright: © openEHR Foundation
- Owner: Aitor Eguzkitza, aitor.eguzkiza@unavarra.es
- Speciality: Ophthalmology
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| Language used | en |
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| Citeable Identifier | 1013.26.164 |
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| Root archetype id | openEHR-EHR-SECTION.next_step_planning.v0 |
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| Next step planning | Next step planning: Decision-making concerning the planning of next assessment for the diagnostic tests carried out. |
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| Diagnostic report request | Diagnostic report request: Request for a diagnostic report involving the study of specific diagnostic tests. |
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| Request | Request: Current Activity. |
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| Description | |
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| Service requested | Service requested: Identification of the service requested. This is often coded with an external terminology.
- Remote screening of DR
- DR assessment at ophthalmologist's office
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| Description of service | Description of service: A detailed narrative description of the service requested. |
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| Reason for request | Reason for request: A short description of the reason for the request. This is often coded with an external terminology.
- Completed the diagnostic tests necessary for assessment
- Patient presenting dangerously high intraocular pressure
- Quality of eye fundus images inadequate for remote diagnosis
- Clinically relevant ophthalmological disorders identified
- Second opinion needed
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| Reason description | Reason description: A narrative description explaining the reason for request. |
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| Intent | Intent: Stated intent of the request by the referrer. |
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| Urgency | Urgency: Urgency of the request.
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| Date &/or time service required | Date &/or time service required: The date and time that the service should be performed or completed. |
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| Latest date service required | Latest date service required: The latest date that is acceptable for the service to be completed. |
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| Protocol | |
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| Requestor Identifier | Requestor Identifier: The local ID assigned to the order by the healthcare provider or organisation requesting the service. This is also referred to as Placer Order Identifier. |
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| Receiver identifier | Receiver identifier: The ID assigned to the order by the healthcare provider or organisation receiving the request for service. This is also referred to as Filler Order Identifier. |
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| Request status | Request status: The status of the request for service as indicated by the requester. Status is used to denote whether this is the initial request, or a follow-up request to change or provide supplementary information. |
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| Service request | Service request: Request for a health-related service to be supplied by a healthcare provider or agency.
For example equipment request. |
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| Request | Request: Description of the requested service. |
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| Description | |
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| Service name | Service name: Identification of the service requested, by name.
Coding of the 'Service name' with a coding system is desirable, if available.
- Follow-up schedule for patients with suspected DR
- DR treatment
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| Service type | Service type: Category of service requested.
For example: hospital vs home care delivery. |
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| Description | Description: Narrative description of the service requested.
- Follow-up comprised by NMR study and IOP measurement
- DR treatment consisting of scatter PRP laser therapy
- DR treatment consisting of focal and/or grid laser photocoagulation
- DR treatment consisting of intravitreal corticosteroids
- DR treatment consisting of intravitreal anti-VEGF therapy
- DR treatment consisting of vitrectomy surgery
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| Reason for request | Reason for request: A short phrase describing the reason for the request.
Coding of the 'Reason for request' with a coding system is desirable, if available. |
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| Reason description | Reason description: Narrative description about the reason for request. |
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| Intent | Intent: Description of the intent for the request.
For example a referral with the intent of having specialist care take over the care of the patient, or advice on how to proceed with an investigation or treatment. This data element allows multiple occurrences to enable multiple choice selection in user interface. |
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| Urgency | Urgency: Urgency of the request for service.
Specific definitions of emergency and urgent will vary between clinical contexts, clinical systems and the nature of the request itself, so have not be defined in this archetype. If explicit timing is required then the Service period should be clearly stated.
 Coded Text Text
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| Service due | Service due: The date/time, or acceptable interval of date/time, for provision of the service.
In practice, clinicians will often think in terms of ordering services as approximate timing, for example: review in 3 months, 6 months or 12 months. As clinical systems need more exact parameters to operate on, this '3 months' will usually be converted to an exact date 3 months from the date of recording and stored using this data element. |
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| Service period start | Service period start: The date/time that marks the beginning of the valid period of time for delivery of this service.
This date/time is the equivalent to the earliest possible date for service delivery. For example: sometimes a certain amount of time must pass before a service can be performed, for example some procedures can only be performed once the patient has stopped taking medications for a specific amount of time. |
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| Service period expiry | Service period expiry: The date/time that marks the conclusion of the valid period of time for delivery of this service.
This date/time is the equivalent to the latest possible date for service delivery or to the date of expiry for this request. For example: a service may be required to be completed before another event, such as scheduled surgery. |
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| Indefinite? | Indefinite?: The valid period for this request is open ended and has no date of expiry.
Record as TRUE to record explicity that the request has no expiry date. |
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| Protocol | |
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| Requestor Identifier | Requestor Identifier: The local ID assigned to the order by the healthcare provider or organisation requesting the service. This is also referred to as Placer Order Identifier. |
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| Receiver identifier | Receiver identifier: The ID assigned to the order by the healthcare provider or organisation receiving the request for service. This is also referred to as Filler Order Identifier. |
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| Request status | Request status: The status of the request for service as indicated by the requester.
Status is used to denote whether this is the initial request, or a follow-up request to change or provide supplementary information. |
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| Other contributors | 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 |
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