| All | OperationalTemplate [rootArchetypeId=openEHR-EHR-COMPOSITION.data_set.v0, otherContributors=null, tshis=[ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.data_set.v0], code=at0000, itemType=COMPOSITION, level=0, text=GP data set, description=Generic composition to represent a data set for use in research, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=COMPOSITION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.data_set.v0]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Adverse reactions'], code=at0000, itemType=SECTION, level=1, text=Adverse reactions, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.data_set.v0]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Adverse reactions']/items[openEHR-EHR-EVALUATION.adverse_reaction_risk.v1], code=at0000, itemType=EVALUATION, level=2, text=Adverse reaction risk, description=Risk of harmful or undesirable physiological response which is unique to an individual and associated with exposure to a substance., comment=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., uncommonOntologyItems={source=openEHR,FHIR}, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.data_set.v0]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Adverse reactions']/items[openEHR-EHR-EVALUATION.adverse_reaction_risk.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.data_set.v0]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Adverse reactions']/items[openEHR-EHR-EVALUATION.adverse_reaction_risk.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Substance, description=Identification of a substance, or substance class, that is considered to put the individual at risk of an adverse reaction event., comment=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., uncommonOntologyItems={source=openEHR,FHIR,DAM}, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Value set: external, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.data_set.v0]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Adverse reactions']/items[openEHR-EHR-EVALUATION.adverse_reaction_risk.v1]/data[at0001]/items[at0063], code=at0063, itemType=ELEMENT, level=4, text=Status, description=Assertion about the certainty of the propensity, or potential future risk, of the identified 'Substance' to cause a reaction., comment=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., uncommonOntologyItems={source=FHIR, DAM}, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- Suspected
- Likely
- Confirmed
- Resolved
- Refuted
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.data_set.v0]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Adverse reactions']/items[openEHR-EHR-EVALUATION.adverse_reaction_risk.v1]/data[at0001]/items[at0101], code=at0101, itemType=ELEMENT, level=4, text=Criticality, description=An indication of the potential for critical system organ damage or life threatening consequence., comment=This can be regarded as a predictive judgement of a 'worst case scenario'.
In most contexts 'Low' would be regarded as the default value., uncommonOntologyItems={source=DAM, openEHR}, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.data_set.v0]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Adverse reactions']/items[openEHR-EHR-EVALUATION.adverse_reaction_risk.v1]/data[at0001]/items[at0120], code=at0120, itemType=ELEMENT, level=4, text=Category, description=Category of the identified 'Substance'., comment=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., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values= Coded Text Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.data_set.v0]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Adverse reactions']/items[openEHR-EHR-EVALUATION.adverse_reaction_risk.v1]/data[at0001]/items[at0058], code=at0058, itemType=ELEMENT, level=4, text=Reaction mechanism, description=Identification of the underlying physiological mechanism for the adverse reaction., comment=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., uncommonOntologyItems={source=FHIR, DAM}, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- Immune mediated
- Non-immune mediated
- Indeterminate
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.data_set.v0]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Adverse reactions']/items[openEHR-EHR-EVALUATION.adverse_reaction_risk.v1]/data[at0001]/items[at0006], code=at0006, itemType=ELEMENT, level=4, text=Comment, description=Additional narrative about the propensity for the adverse reaction, not captured in other fields., comment=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., uncommonOntologyItems={source=openEHR}, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.data_set.v0]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Adverse reactions']/items[openEHR-EHR-EVALUATION.adverse_reaction_risk.v1]/data[at0001]/items[at0009], code=at0009, itemType=CLUSTER, level=4, text=Reaction event, description=Details about each adverse reaction event linked to exposure to the identified 'Substance'., comment=null, uncommonOntologyItems={source=openEHR,FHIR,DAM}, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.data_set.v0]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Adverse reactions']/items[openEHR-EHR-EVALUATION.adverse_reaction_risk.v1]/data[at0001]/items[at0009]/items[at0021], code=at0021, itemType=ELEMENT, level=5, text=Certainty, description=Statement about the degree of clinical certainty that the identified 'Specific substance' was the cause of the 'Manifestation' in this reaction event., comment=null, uncommonOntologyItems={source=FHIR}, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- Suspected
- Likely
- Confirmed
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.data_set.v0]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Adverse reactions']/items[openEHR-EHR-EVALUATION.adverse_reaction_risk.v1]/data[at0001]/items[at0009]/items[at0011], code=at0011, itemType=ELEMENT, level=5, text=Manifestation, description=Clinical symptoms and/or signs that are observed or associated with the adverse reaction., comment=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., uncommonOntologyItems={source=FHIR, openEHR,DAM}, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Value set: external, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.data_set.v0]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Adverse reactions']/items[openEHR-EHR-EVALUATION.adverse_reaction_risk.v1]/protocol[at0042]/items[at0062], code=at0062, itemType=ELEMENT, level=3, text=Last updated, description=Date when the propensity or the reaction event was updated., comment=Note: maps to recordedDate in FHIR., uncommonOntologyItems={source=openEHR, FHIR, DAM}, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.data_set.v0]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Adverse reactions']/items[openEHR-EHR-SECTION.adhoc.v1], code=at0000, itemType=SECTION, level=2, text=Empty list options, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.data_set.v0]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Adverse reactions']/items[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-EVALUATION.exclusion_global.v1], code=at0000, itemType=EVALUATION, level=3, text=Explicit exclusion, description=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., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.data_set.v0]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Adverse reactions']/items[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-EVALUATION.exclusion_global.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Global exclusion of adverse reactions, description=Overall statement of exclusion about all adverse reactions at the time of recording., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=- No known allergies or adverse reactions
- No known adverse reactions to any substance
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.data_set.v0]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Adverse reactions']/items[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-EVALUATION.absence.v1], code=at0000, itemType=EVALUATION, level=3, text=No information, description=Statement that specified health information is not available for inclusion in the health record or extract at the time of recording., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.data_set.v0]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Adverse reactions']/items[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-EVALUATION.absence.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Absence statement, description=Positive statement that no information is available., comment=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"., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=- No information about allergies or adverse reactions
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.data_set.v0]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Adverse reactions']/items[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-EVALUATION.absence.v1]/protocol[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=4, text=Last updated, description=The date at which the absence was last updated., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.data_set.v0]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Test results'], code=at0000, itemType=SECTION, level=1, text=Test results, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.data_set.v0]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Test results']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.laboratory_test_analyte.v0]/items[at0001], code=at0001, itemType=ELEMENT, level=2, text=Blood group, description=The value of the analyte result., comment=For example '7.3 mmols/l', 'Raised'., uncommonOntologyItems={fhir_mapping=Observation.result; Observation.name, hl7v2_mapping=OBX.2,OBX.5,OBX.6}, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=- A pos
- A neg
- B pos
- B neg
- AB pos
- AB neg
- O pos
- O neg
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.data_set.v0]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Measurements'], code=at0000, itemType=SECTION, level=1, text=Measurements, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.data_set.v0]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Measurements']/items[openEHR-EHR-OBSERVATION.height.v2]/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=2, text=Height, description=The length of the body from crown of head to sole of foot., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=0..1000; 0..250
Units:, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.data_set.v0]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Problem list'], code=at0000, itemType=SECTION, level=1, text=Problem list, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.data_set.v0]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Problem list']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=2, text=Problem/Diagnosis name, description=Identification of the problem or diagnosis, by name., comment=Coding of the name of the problem or diagnosis with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.data_set.v0]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Problem list']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0012], code=at0012, itemType=ELEMENT, level=2, text=Body site, description=Identification of a simple body site for the location of the problem or diagnosis., comment=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., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.data_set.v0]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Problem list']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0003], code=at0003, itemType=ELEMENT, level=2, text=Date/time clinically recognised, description=Estimated or actual date/time the diagnosis or problem was recognised by a healthcare professional., comment=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., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.data_set.v0]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Problem list']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0005], code=at0005, itemType=ELEMENT, level=2, text=Severity, description=An assessment of the overall severity of the problem or diagnosis., comment=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., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.data_set.v0]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Problem list']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/protocol[at0032]/items[at0070], code=at0070, itemType=ELEMENT, level=2, text=Last updated, description=The date this problem or diagnosis was last updated., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.data_set.v0]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Immunisation'], code=at0000, itemType=SECTION, level=1, text=Immunisation, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.data_set.v0]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Immunisation']/items[openEHR-EHR-EVALUATION.immunisation_summary.v0], code=at0000, itemType=EVALUATION, level=2, text=Immunisation summary, description=Summary of the immunisation status for an identified infectious disease or agent., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.data_set.v0]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Immunisation']/items[openEHR-EHR-EVALUATION.immunisation_summary.v0]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=3, text=Infectious disease or agent, description=Identification of the infectious disease or agent., comment=There may be multiple diseases or agents that are vaccinated together - for example: diptheria, tetanus and pertussis or measles, mumps and rubella., uncommonOntologyItems=null, occurencesFormal=1..*, occurencesText=Mandatory, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.data_set.v0]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Immunisation']/items[openEHR-EHR-EVALUATION.immunisation_summary.v0]/data[at0001]/items[at0003], code=at0003, itemType=ELEMENT, level=3, text=Primary course status, description=Status of the primary course of immunisations., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- Not commenced
- Incomplete
- Complete
- Indeterminate
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.data_set.v0]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Immunisation']/items[openEHR-EHR-EVALUATION.immunisation_summary.v0]/data[at0001]/items[at0008], code=at0008, itemType=ELEMENT, level=3, text=Date primary course completed, description=The date on which the primary (or catch-up) course of vaccines was completed., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.data_set.v0]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Immunisation']/items[openEHR-EHR-EVALUATION.immunisation_summary.v0]/data[at0001]/items[at0009], code=at0009, itemType=ELEMENT, level=3, text=Date of last booster, description=The date of which the last vaccine booster was administered., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.data_set.v0]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Immunisation']/items[openEHR-EHR-EVALUATION.immunisation_summary.v0]/data[at0001]/items[at0010], code=at0010, itemType=ELEMENT, level=3, text=Immunisation status, description=An assertion about whether the immunisation course is up-to-date., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- Immunisation up-to-date
- Immunisation not up-to-date
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.data_set.v0]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Immunisation']/items[openEHR-EHR-EVALUATION.immunisation_summary.v0]/data[at0001]/items[at0016], code=at0016, itemType=ELEMENT, level=3, text=Comment, description=Additional narrative about the immunisation summary for the identified disease or agent, not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.data_set.v0]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Immunisation']/items[openEHR-EHR-EVALUATION.immunisation_summary.v0]/protocol[at0013]/items[at0014], code=at0014, itemType=ELEMENT, level=3, text=Next review due, description=The date at which the immunisation summary should be reviewed and possibly updated., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.data_set.v0]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Immunisation']/items[openEHR-EHR-EVALUATION.immunisation_summary.v0]/protocol[at0013]/items[at0015], code=at0015, itemType=ELEMENT, level=3, text=Last updated, description=The date on which the immunisation summary was last updated., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.data_set.v0]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Immunisation']/items[openEHR-EHR-ACTION.medication.v1], code=at0000, itemType=ACTION, level=2, text=Immunisation administered, description=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., comment=This is not limited to activities performed based on medication orders from clinicians, but could also include for example taking over the counter medication., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ACTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.data_set.v0]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Immunisation']/items[openEHR-EHR-ACTION.medication.v1]/time, code=null, itemType=EXPOSED_RM_ATTRIBUTE, level=3, text=Date administered, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.data_set.v0]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Immunisation']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[at0020], code=at0020, itemType=ELEMENT, level=3, text=Vaccine item, description=Name of the medication, vaccine or other therapeutic/prescribable item which was the focus of the activity., comment=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., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.data_set.v0]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Immunisation']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[at0025], code=at0025, itemType=ELEMENT, level=3, text=Sequence number, description=The sequence number specific to the pathway step being recorded., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=, extendedValues=null]], templateType=normal] |