TEMPLATE GP data set (GP data set)

TEMPLATE ID	GP data set
Concept	GP data set
Description	Not Specified
Purpose	Not Specified
References
Other Details (Language Independent)	MetaDataSet:Sample Set : Template metadata sample set
Language used	en
Citeable Identifier	1013.26.191
Root archetype id	openEHR-EHR-COMPOSITION.data_set.v0
GP data set	GP data set: Generic composition to represent a data set for use in research
Adverse reactions	Adverse reactions: A generic section header which should be renamed in a template to suit a specific clinical context.
Adverse reaction risk	Adverse reaction risk: Risk of harmful or undesirable physiological response which is unique to an individual and associated with exposure 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. If the value in 'Substance' is an individual substance, it may be duplicated in 'Specific substance'. It is strongly recommended that both 'Substance' and 'Specific substance' be 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. Optional[{source=openEHR,FHIR,DAM}] Value set: terminology:SNOMED%20CT?subset=Allery%20&%20adverse%20reactions&language=en-GB
Status	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 'Suspected', 'Likely', '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. 'Resolved' may be used variably across systems, depending on clinical use and context - there appears to be differing opinion whether this should still be used to raise potential alerts or to display in an Adverse Reaction List. 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. Optional[{source=FHIR, DAM}] Suspected Likely Confirmed Resolved Refuted
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. Optional[{source=DAM, openEHR}] Low High Indeterminate
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. Coded Text Food Medication Other Text
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. Optional[{source=FHIR, DAM}] Immune mediated Non-immune mediated Indeterminate
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. Optional[{source=openEHR}]
Reaction event	Reaction event: Details about each adverse reaction event linked to exposure to the identified 'Substance'. Optional[{source=openEHR,FHIR,DAM}]
Certainty	Certainty: Statement about the degree of clinical certainty that the identified 'Specific substance' was the cause of the 'Manifestation' in this reaction event. Optional[{source=FHIR}] Suspected Likely Confirmed
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, as recommended in the UK NHS CUI guidelines. Terminologies commonly used include, but are not limited to, SNOMED-CT or ICD10. Optional[{source=FHIR, openEHR,DAM}] Value set: terminology:SNOMED%20CT?subset=Reaction%20manifestations&language=en-GB
Last updated	Last updated: Date when the propensity or the reaction event was updated. Note: maps to recordedDate in FHIR. Optional[{source=openEHR, FHIR, DAM}]
Empty list options	Empty list options: A generic section header which should be renamed in a template to suit a specific clinical context.
Explicit exclusion	Explicit exclusion: 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.
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 or adverse reactions No known adverse reactions to any substance
No information	No information: Statement that specified health information is not available for inclusion in the health record or extract at the time of recording.
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 or adverse reactions
Last updated	Last updated: The date at which the absence was last updated.
Test results	Test results: A generic section header which should be renamed in a template to suit a specific clinical context.
Blood group	Blood group: The value of the analyte result. For example '7.3 mmols/l', 'Raised'. Optional[{fhir_mapping=Observation.result; Observation.name, hl7v2_mapping=OBX.2,OBX.5,OBX.6}] A pos A neg B pos B neg AB pos AB neg O pos O neg
Measurements	Measurements: A generic section header which should be renamed in a template to suit a specific clinical context.
Height	Height: The length of the body from crown of head to sole of foot. 0..1000; 0..250 Units: cm in (UCUM: [in_i])
Problem list	Problem list: A generic section header which should be renamed in a template to suit a specific clinical context.
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.
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.
Date/time clinically recognised	Date/time clinically recognised: Estimated or actual date/time the diagnosis or problem was recognised 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 clinical recognition" 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. Mild Moderate Severe
Last updated	Last updated: The date this problem or diagnosis was last updated.
Immunisation	Immunisation: A generic section header which should be renamed in a template to suit a specific clinical context.
Immunisation summary	Immunisation summary: Summary of the immunisation status for an identified infectious disease or agent.
Infectious disease or agent	Infectious disease or agent: Identification of the infectious disease or agent. There may be multiple diseases or agents that are vaccinated together - for example: diptheria, tetanus and pertussis or measles, mumps and rubella.
Primary course status	Primary course status: Status of the primary course of immunisations. Not commenced Incomplete Complete Indeterminate
Date primary course completed	Date primary course completed: The date on which the primary (or catch-up) course of vaccines was completed.
Date of last booster	Date of last booster: The date of which the last vaccine booster was administered.
Immunisation status	Immunisation status: An assertion about whether the immunisation course is up-to-date. Immunisation up-to-date Immunisation not up-to-date
Comment	Comment: Additional narrative about the immunisation summary for the identified disease or agent, not captured in other fields.
Next review due	Next review due: The date at which the immunisation summary should be reviewed and possibly updated.
Last updated	Last updated: The date on which the immunisation summary was last updated.
Immunisation administered	Immunisation administered: Any activity related to the planning, scheduling, prescription management, dispensing, administration, cessation and other use of a medication, vaccine, nutritional product or other therapeutic item. This is not limited to activities performed based on medication orders from clinicians, but could also include for example taking over the counter medication.
Date administered
Vaccine item	Vaccine item: Name of the medication, vaccine or other therapeutic/prescribable item which was the focus of the activity. For example: 'Atenolol 100mg' or 'Tenormin tablets 100mg'. It is strongly recommended that the 'Medication item' is coded with a terminology capable of triggering decision support, where possible. The extent of coding may vary from the simple name of the medication item through to structured details about the actual medication pack used. Free text entry should only be used if there is no appropriate terminology available.
Sequence number	Sequence number: The sequence number specific to the pathway step being recorded.