| TEMPLATE ID | Season's Greetings! |
|---|---|
| Concept | Season's Greetings! |
| Description | This work can only be achieved through collaboration between individuals with a big vision to change healthcare outcomes, one data point at a time. We can't do this without you! |
| Purpose | This work can only be achieved through collaboration between individuals with a big vision to change healthcare outcomes, one data point at a time. We can't do this without you! |
| References | |
| Other Details (Language Independent) |
|
| Language used | en |
| Citeable Identifier | 1013.26.189 |
| Root archetype id | openEHR-EHR-COMPOSITION.notification.v0 |
| Season's Greetings for 2017! | Season's Greetings for 2017!: This is a generic composition used for all sorts of notifications, such as an infection event and surgical site surveillance event. Document to communicate notifications to healthcare providers or be used as triggers for automated business rules. |
| Reason for encounter | Reason for encounter: The reason for initiation of any healthcare encounter or contact by the individual who is the subject of care. |
| This template is: | This template is:: Identification of the type, or administrative category, of healthcare sought or required by the subject of care. Coding of the 'Contact type' with a terminology is desirable, where possible. Examples include: pre-employment medical, routine antenatal visit, women's health check, pre-operative assessment, or annual medical check-up.
|
| Goal | Goal: A desired health, or well-being, outcome for the subject of care. |
| Wishing you | Wishing you: The name of the desired health outcome. For example: reduced blood pressure; 10 kilogram weight loss; or diabetes control.
|
| Clinical indication | Clinical indication: Name of the problem or diagnosis which is intended to be impacted by achievement of this goal. For example: Hypertension; Obesity; or Diabetes Type 2. Terminology: SNOMED-CT
|
| Intended outcome | Intended outcome: Single word, phrase or brief description which represents the outcome actually achieved for the goal. Coding with a terminology is preferred, where possible. For example: target weight achieved; poor diabetes control; or successful completion.
|
| Progress Note | Progress Note: Narrative description of of health-related events at a specific point-in-time about an individual, specifically from the perspective of a healthcare provider. |
| Some stats | Some stats: Narrative description of health-related events, health status, findings, opinions at a specific point-in-time.
|
| Conclusion | Conclusion: Section to record conclusions of an encounter with a patient |
| Diagnosis | 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'. |
| 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.
|
| Status | Status: Unspecified qualifier that will be renamed, data type selected and potential value sets specified in a template. For example: The boolean data type could be used to signify that the problem/diagnosis can be included in a patient summary; the text data type could be used to categorise in a similar way to 'Current?' or Active?'; and the count data type could be used to assert a priority key or order to problems and diagnoses in a list. If any uses are identified as frequently required, they could be added explicitly to this archetype as an explicit data element. Terminology: SNOMED-CT
|
| Final Summary | Final Summary: The summary, assessment, conclusions or evaluation of the clinical findings.
|