TEMPLATE Aboriginal and Torres Strait Islander health check - MASTER (Aboriginal and Torres Strait Islander health check - MASTER)

TEMPLATE IDAboriginal and Torres Strait Islander health check - MASTER
ConceptAboriginal and Torres Strait Islander health check - MASTER
DescriptionTo create a MASTER data set appropriate for any Aboriginal and Torres Strait Islander health check, as per MBS items 715 (VR) & 228 (non-VR).
UseThis template incorporates all content for an Aboriginal and Torres Strait Islander health check across all ages. It is intended that this template will be further constrained to be made relevant for each age group.
PurposeTo create a MASTER data set appropriate for any Aboriginal and Torres Strait Islander health check, as per MBS items 715 (VR) & 228 (non-VR).
References
Authorsname: Heather Leslie; organisation: Atomica Informatics; email: heather.leslie@atomicainformatics.com; date: 2020-01-29
Other Details Languagename: Heather Leslie; organisation: Atomica Informatics; email: heather.leslie@atomicainformatics.com; date: 2020-01-29
OtherDetails 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, PARENT:MD5-CAM-1.0.1=44D94C2952391723BB72523E4132FF1C, original_language=ISO_639-1::en, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=9f23e120b2c7a218a348e1bb2189aa0a}
Language useden
Citeable Identifier1013.26.254
AllOperationalTemplate [rootArchetypeId=openEHR-EHR-COMPOSITION.encounter.v1, otherContributors=null, tshis=[ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1], code=at0000, itemType=COMPOSITION, level=0, text=*Aboriginal and Torres Strait Islander health check (MBS 715) - MASTER, description=Interaction, contact or care event between a subject of care and healthcare provider(s)., 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.encounter.v1]/content[openEHR-EHR-EVALUATION.reason_for_encounter.v1], code=at0000, itemType=EVALUATION, level=1, text=Reason for encounter, description=The reason for initiation of any healthcare encounter or contact by the individual who is the subject of care., 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.encounter.v1]/content[openEHR-EHR-EVALUATION.reason_for_encounter.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=2, 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.encounter.v1]/content[openEHR-EHR-EVALUATION.reason_for_encounter.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=3, text=Contact type, description=Identification of the type, or administrative category, of healthcare sought or required by the subject of care., comment=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., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Aboriginal and Torres Strait Islander health check
Default value: Aboriginal and Torres Strait Islander health check, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Consent'], code=at0000, itemType=SECTION, level=1, text=Consent, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Consent']/items[openEHR-EHR-ACTION.informed_consent.v0], code=at0000, itemType=ACTION, level=2, text=Informed consent, description=Record of status and details of informed consent from an individual (or the individual's agent/proxy) for a proposed procedure, trial or other healthcare-related activity (including treatments and investigations), based upon a clear appreciation and understanding of the facts, implications, and possible future consequences by the consenting party., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ACTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Consent']/items[openEHR-EHR-ACTION.informed_consent.v0]/description[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Description, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Consent']/items[openEHR-EHR-ACTION.informed_consent.v0]/description[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Activity, description=Identification of the procedure, clinical trial or healthcare-related activity (including correct side/correct site, where appropriate) against which the consent status and details are recorded., comment=null, uncommonOntologyItems=null, occurencesFormal=1..*, occurencesText=Mandatory, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Aboriginal and Torres Strait Islander health check
  • Sharing of health information with relevant healthcare providers
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Consent']/items[openEHR-EHR-ACTION.informed_consent.v0]/description[at0001]/items[at0036], code=at0036, itemType=ELEMENT, level=4, text=Comment, description=Additional narrative about the informed consent activity, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Consent']/items[openEHR-EHR-ACTION.informed_consent.v0]/protocol[at0024], code=at0024, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Protocol, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening'], code=at0000, itemType=SECTION, level=1, text=History screening, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-OBSERVATION.issue_screening.v0], code=at0000, itemType=OBSERVATION, level=2, text=Current health issue screening, description=A screening questionnaire for issues, worries or concerns affecting an individual., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-OBSERVATION.issue_screening.v0]/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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-OBSERVATION.issue_screening.v0]/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=4, text=Any event, description=Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-OBSERVATION.issue_screening.v0]/data[at0001]/events[at0002]/data[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=5, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-OBSERVATION.issue_screening.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0028], code=at0028, itemType=ELEMENT, level=6, text=Any worries??, description=Presence of any relevant issues., comment=For example: screening if the individual has any issues or concerns about their health and well being., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present  [Issues are present.]
  • Absent  [Issues are not present.]
  • Unknown  [It is not known whether any issues are present or absent.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-OBSERVATION.issue_screening.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0022], code=at0022, itemType=CLUSTER, level=6, text=Specific issue, description=Grouping of data elements related to screening for a single issue., comment=null, uncommonOntologyItems=null, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-OBSERVATION.issue_screening.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0022]/items[at0004], code=at0004, itemType=ELEMENT, level=7, text=Issue name, description=Name of the issue being screened., comment=For example: sleep; mood; diet; or physical activity., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Stressful life events
  • Social connection
  • Mood
  • Mental health
  • Food security
  • Housing stability
  • Safety at home
  • Gambling (self)
  • Gambling (others)
  • Diet
  • Physical activity
  • Weight
  • Vision
  • Hearing
  • Teeth
  • Sexual health
  • Sleep
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-OBSERVATION.issue_screening.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0022]/items[at0005], code=at0005, itemType=ELEMENT, level=7, text=Presence?, description=Presence of the issue., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present  [The specific issue is present.]
  • Absent  [The specific issue is not present.]
  • Unknown  [It is not known whether the issue is present or absent.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-OBSERVATION.issue_screening.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0025], code=at0025, itemType=ELEMENT, level=6, text=Comment, description=Additional narrative about the issues, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-OBSERVATION.issue_screening.v0]/protocol[at0007], code=at0007, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Protocol, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-EVALUATION.issue.v0], code=at0000, itemType=EVALUATION, level=2, text=Health issue, description=A health-related concern or worry identified and described by the individual (or their proxy) about the individual's health, usually related to personal perceptions about their state of health or the identification of external factors that influence or impact upon their health., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-EVALUATION.issue.v0]/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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-EVALUATION.issue.v0]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Issue name, description=The name of the issue or concern as presented by the individual., comment=Coding with an external terminology is optional., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-EVALUATION.issue.v0]/data[at0001]/items[at0003], code=at0003, itemType=ELEMENT, level=4, text=Description, description=Narrative description about the issue., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-EVALUATION.issue.v0]/protocol[at0005], code=at0005, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Protocol, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-OBSERVATION.condition_screening.v0], code=at0000, itemType=OBSERVATION, level=2, text=Condition screening questionnaire, description=An screeing questionnaire for conditions, including problems and diagnoses., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-OBSERVATION.condition_screening.v0]/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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-OBSERVATION.condition_screening.v0]/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=4, text=Any event, description=Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-OBSERVATION.condition_screening.v0]/data[at0001]/events[at0002]/data[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=5, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-OBSERVATION.condition_screening.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0022], code=at0022, itemType=CLUSTER, level=6, text=Specific condition, description=Grouping of data elements related to screening for a single condition., comment=null, uncommonOntologyItems=null, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-OBSERVATION.condition_screening.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0022]/items[at0004], code=at0004, itemType=ELEMENT, level=7, text=Condition name, description=Name of the condition being screened., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Diabetes
  • Hypertension
  • Myocardial infarction
  • Stroke
  • Kidney disease
  • Hearing impairment
  • Epilepsy
  • Asthma
  • COPD
  • Rheumatic heart disease
  • HBV
  • Significant head trauma
  • Mental health
  • Recurrent cough or chest infections
  • Recurrent ear infections/CSOM/(glue ear)/grommets
  • Environmental exposure to tobacco smoke (eg at home, in the car)
  • Acute rheumatic fever/rheumatic heart disease (in high prevalence setting)
  • Growth or development problems
  • Headaches or migraines
  • Pregnancy complications
  • Birth complications
  • Problems after birth
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-OBSERVATION.condition_screening.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0022]/items[at0005], code=at0005, itemType=ELEMENT, level=7, text=Presence?, description=Presence of the condition., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present  [The specific condition is present.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-OBSERVATION.condition_screening.v0]/protocol[at0007], code=at0007, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Protocol, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-OBSERVATION.medication_screening.v0], code=at0000, itemType=OBSERVATION, level=2, text=Medication screening questionnaire, description=Questionnaire screening for use of any medication or type/class of medication., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-OBSERVATION.medication_screening.v0]/data[at0022], code=at0022, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-OBSERVATION.medication_screening.v0]/data[at0022]/events[at0023], code=at0023, itemType=EVENT, level=4, text=Any event, description=Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-OBSERVATION.medication_screening.v0]/data[at0022]/events[at0023]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=5, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-OBSERVATION.medication_screening.v0]/data[at0022]/events[at0023]/data[at0001]/items[at0027], code=at0027, itemType=ELEMENT, level=6, text=Any medication use?, description=Is the individual using any medication at or during the time of the event?, comment=null, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History 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subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-OBSERVATION.symptom_sign_screening.v0]/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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-OBSERVATION.symptom_sign_screening.v0]/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=4, text=Any event, description=Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-OBSERVATION.symptom_sign_screening.v0]/data[at0001]/events[at0002]/data[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=5, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-OBSERVATION.symptom_sign_screening.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0022], code=at0022, itemType=CLUSTER, level=6, text=Specific symptom/sign, description=Grouping of data elements related to screening for a single symptom or sign., comment=null, uncommonOntologyItems=null, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-OBSERVATION.symptom_sign_screening.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0022]/items[at0004], code=at0004, itemType=ELEMENT, level=7, text=Symptom or sign name, description=Name of the symptom or sign being screened., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Depression
  • Anxiety
  • Feeding/eating
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-OBSERVATION.symptom_sign_screening.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0022]/items[at0005], code=at0005, itemType=ELEMENT, level=7, text=Presence?, description=Presence of the symptom or sign., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present  [The specific symptom or sign is present.]
  • Absent  [The specific symptom or sign is not present.]
  • Unknown  [It is not known whether the symptom or sign is present or absent.]
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  • Depression
  • Anxiety
  • Feeding/eating
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-OBSERVATION.symptom_sign.v0 and name/value='Specific symptom/sign']/data[at0190]/events[at0191]/data[at0192]/items[at0002], code=at0002, itemType=ELEMENT, level=6, text=Description, description=Narrative description about the reported symptom or sign., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-OBSERVATION.symptom_sign.v0 and name/value='Specific symptom/sign']/data[at0190]/events[at0191]/data[at0192]/items[at0018], code=at0018, itemType=CLUSTER, level=6, text=Modifying factor, description=Detail about how a specific factor effects the identified symptom or sign during this episode., comment=null, uncommonOntologyItems=null, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-OBSERVATION.symptom_sign.v0 and name/value='Specific symptom/sign']/data[at0190]/events[at0191]/data[at0192]/items[at0165], code=at0165, itemType=CLUSTER, level=6, text=(Precipitating/resolving factor), description=Details about specified factors that are associated with the precipitation or resolution of the symptom or sign., comment=For example: onset of headache occurred one week prior to menstruation; or onset of headache occurred one hour after fall of bicycle., uncommonOntologyItems=null, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-OBSERVATION.symptom_sign.v0 and name/value='Specific symptom/sign']/protocol[at0193], code=at0193, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Protocol, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-OBSERVATION.symptom_sign.v0 and name/value='Other symptom/sign'], code=at0000, itemType=OBSERVATION, level=2, text=Other symptom/sign, description=Reported observation of a physical or mental disturbance in an individual., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-OBSERVATION.symptom_sign.v0 and name/value='Other symptom/sign']/data[at0190], code=at0190, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-OBSERVATION.symptom_sign.v0 and name/value='Other symptom/sign']/data[at0190]/events[at0191], code=at0191, itemType=EVENT, level=4, text=Any event, description=Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-OBSERVATION.symptom_sign.v0 and name/value='Other symptom/sign']/data[at0190]/events[at0191]/data[at0192], code=at0192, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=5, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-OBSERVATION.symptom_sign.v0 and name/value='Other symptom/sign']/data[at0190]/events[at0191]/data[at0192]/items[at0001], code=at0001, itemType=ELEMENT, level=6, text=Symptom/Sign name, description=The name of the reported symptom or sign., comment=Symptom name should be coded with a terminology, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-OBSERVATION.symptom_sign.v0 and name/value='Other symptom/sign']/data[at0190]/events[at0191]/data[at0192]/items[at0002], code=at0002, itemType=ELEMENT, level=6, text=Description, description=Narrative description about the reported symptom or sign., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-OBSERVATION.symptom_sign.v0 and name/value='Other symptom/sign']/data[at0190]/events[at0191]/data[at0192]/items[at0018], code=at0018, itemType=CLUSTER, level=6, text=Modifying factor, description=Detail about how a specific factor effects the identified symptom or sign during this episode., comment=null, uncommonOntologyItems=null, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-OBSERVATION.symptom_sign.v0 and name/value='Other symptom/sign']/data[at0190]/events[at0191]/data[at0192]/items[at0165], code=at0165, itemType=CLUSTER, level=6, text=(Precipitating/resolving factor), description=Details about specified factors that are associated with the precipitation or resolution of the symptom or sign., comment=For example: onset of headache occurred one week prior to menstruation; or onset of headache occurred one hour after fall of bicycle., uncommonOntologyItems=null, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-OBSERVATION.symptom_sign.v0 and name/value='Other symptom/sign']/protocol[at0193], code=at0193, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Protocol, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social context'], code=at0000, itemType=SECTION, level=2, text=Social context, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social context']/items[openEHR-EHR-EVALUATION.social_summary.v1], code=at0000, itemType=EVALUATION, level=3, text=Social summary, description=Summary information about social circumstances or experiences that may have a potential impact on an individual's health., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social context']/items[openEHR-EHR-EVALUATION.social_summary.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social context']/items[openEHR-EHR-EVALUATION.social_summary.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=5, text=Summary, description=Narrative description about social circumstances or experiences that may have a potential impact on an individual's health., comment=May be used to record a narrative summary of the complete social circumstances or experiences or key aspects of the social summary, which will be supported by additional structured data, or to import textual data from existing/legacy clinical systems. Details of specific structured findings can be included using CLUSTER archetypes in the 'Details' slot., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social context']/items[openEHR-EHR-EVALUATION.social_summary.v1]/protocol[at0004], code=at0004, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Protocol, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social context']/items[openEHR-EHR-EVALUATION.social_summary.v1]/protocol[at0004]/items[at0006], code=at0006, itemType=ELEMENT, level=5, text=Last updated, description=The date this social 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social context']/items[openEHR-EHR-EVALUATION.housing_summary.v1], code=at0000, itemType=EVALUATION, level=3, text=Housing summary, description=Summary or persistent information about an individual's current and past housing or accommodation situation., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social context']/items[openEHR-EHR-EVALUATION.housing_summary.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social context']/items[openEHR-EHR-EVALUATION.housing_summary.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=5, text=Description, description=Narrative description about the overall housing situation for the individual., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social context']/items[openEHR-EHR-EVALUATION.housing_summary.v1]/protocol[at0012], code=at0012, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Protocol, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social context']/items[openEHR-EHR-EVALUATION.housing_summary.v1]/protocol[at0012]/items[at0013], code=at0013, itemType=ELEMENT, level=5, text=Last updated, description=Date when the housing summary or associated housing records was 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social context']/items[openEHR-EHR-EVALUATION.living_arrangement.v0], code=at0000, itemType=EVALUATION, level=3, text=Living arrangement summary, description=The circumstances about an individual living alone or with others., comment=This information will provide a sense of the level of support, both physically and emotionally, to which an individual may have access., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social context']/items[openEHR-EHR-EVALUATION.living_arrangement.v0]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social context']/items[openEHR-EHR-EVALUATION.living_arrangement.v0]/data[at0001]/items[at0003], code=at0003, itemType=ELEMENT, level=5, text=Description, description=Narrative description about the living arrangements., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social context']/items[openEHR-EHR-EVALUATION.living_arrangement.v0]/data[at0001]/items[at0004], code=at0004, itemType=ELEMENT, level=5, text=Living arrangement type, description=Single word or phrase that describes if an individual usually resides alone or with others., comment=Coding of the living arrangement with a terminology is preferred, where possible. The value sets for this data element are likely to vary between jurisdictions - it is anticipated that they will usually be set within a use-case specific template. For example: 'lives alone'; 'lives with family'; or 'lives with others'., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social context']/items[openEHR-EHR-EVALUATION.living_arrangement.v0]/data[at0001]/items[at0007], code=at0007, itemType=ELEMENT, level=5, text=Number of household members, description=The number of individuals who are in the household., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social context']/items[openEHR-EHR-EVALUATION.living_arrangement.v0]/protocol[at0002], code=at0002, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Protocol, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social context']/items[openEHR-EHR-EVALUATION.living_arrangement.v0]/protocol[at0002]/items[at0012], code=at0012, itemType=ELEMENT, level=5, text=Last updated, description=The date this 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social context']/items[openEHR-EHR-EVALUATION.support_network.v0], code=at0000, itemType=EVALUATION, level=3, text=Support network summary, description=Group of individuals connected by social interactions, support activities and personal relationships., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social context']/items[openEHR-EHR-EVALUATION.support_network.v0]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social context']/items[openEHR-EHR-EVALUATION.support_network.v0]/data[at0001]/items[at0015], code=at0015, itemType=ELEMENT, level=5, text=Description, description=Narrative description about the social network supporting the individual., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social context']/items[openEHR-EHR-EVALUATION.support_network.v0]/protocol[at0010], code=at0010, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Protocol, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social context']/items[openEHR-EHR-EVALUATION.support_network.v0]/protocol[at0010]/items[at0011], code=at0011, itemType=ELEMENT, level=5, text=Last updated, description=Date when the summary was 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social context']/items[openEHR-EHR-EVALUATION.occupation_summary.v1], code=at0000, itemType=EVALUATION, level=3, text=Occupation summary, description=Summary or persistent information about an individual's current and past jobs and/or roles., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social context']/items[openEHR-EHR-EVALUATION.occupation_summary.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social context']/items[openEHR-EHR-EVALUATION.occupation_summary.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=5, text=Description, description=Narrative description about the entire occupation history of the individual., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social context']/items[openEHR-EHR-EVALUATION.occupation_summary.v1]/data[at0001]/items[at0004], code=at0004, itemType=ELEMENT, level=5, text=Employment status, description=Statement about the individual's current employment., comment=For example: employed; unemployed; or not in labour force. Coding with a terminology is desirable, where possible. Detail about each occupation can be recorded within the CLUSTER.occupation_record archetype., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social context']/items[openEHR-EHR-EVALUATION.occupation_summary.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.occupation_record.v1], code=at0000, itemType=CLUSTER, level=5, text=Occupation record, description=A single job or role carried out by an individual during a specified period of time., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social context']/items[openEHR-EHR-EVALUATION.occupation_summary.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.occupation_record.v1]/items[at0005], code=at0005, itemType=ELEMENT, level=6, text=Job title/role, description=The main job title or the role of the individual., comment=For example: Chief Executive Officer; Carer; or Student. Each of these job titles or roles may be comprised of multiple duties., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social context']/items[openEHR-EHR-EVALUATION.occupation_summary.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.occupation_record.v1]/items[at0016], code=at0016, itemType=ELEMENT, level=6, text=Description, description=Narrative description about the job or role carried out by the individual., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social context']/items[openEHR-EHR-EVALUATION.occupation_summary.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.occupation_record.v1]/items[at0007], code=at0007, itemType=ELEMENT, level=6, text=Date commenced, description=The date when an individual commenced the job or role., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social context']/items[openEHR-EHR-EVALUATION.occupation_summary.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.occupation_record.v1]/items[at0013], code=at0013, itemType=ELEMENT, level=6, text=Full time equivalent, description=The time spent in this job or role relative to full-time., comment=Full time equivalent may also be known as 'FTE'. For example: 0.5; 50 %; or "part time"., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Proportion
    • Unitary
    • Percent
  •  Coded Text
    • Full-time  [The individual carries out this occupation for equal to or more than the amount of time that is officially regarded as 'full-time' for the occupation.]
    • Part-time  [The individual carries out this occupation for less than the amount of time that is officially regarded as 'full-time' for the occupation.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social context']/items[openEHR-EHR-EVALUATION.occupation_summary.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.occupation_record.v1]/items[at0008], code=at0008, itemType=ELEMENT, level=6, text=Date ceased, description=The date when an individual ceased working in a job or role., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social context']/items[openEHR-EHR-EVALUATION.occupation_summary.v1]/protocol[at0007], code=at0007, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Protocol, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social context']/items[openEHR-EHR-EVALUATION.occupation_summary.v1]/protocol[at0007]/items[at0009], code=at0009, itemType=ELEMENT, level=5, text=Last updated, description=Date when the occupation summary or associated occupation records were was updated., comment=At implementation, it is assumed that if an associated occupation record is added or updated then this date will also be updated., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social context']/items[openEHR-EHR-EVALUATION.education_summary.v1], code=at0000, itemType=EVALUATION, level=3, text=Education summary, description=Summary or persistent information about an individual's current and past education or training., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social context']/items[openEHR-EHR-EVALUATION.education_summary.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social context']/items[openEHR-EHR-EVALUATION.education_summary.v1]/data[at0001]/items[at0018], code=at0018, itemType=ELEMENT, level=5, text=Description, description=Narrative description about the overall education or training history of an individual., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social context']/items[openEHR-EHR-EVALUATION.education_summary.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=5, text=Highest level completed, description=Description of highest category of education or training completed., comment=Coding with a terminology is desirable, where possible. For example: the ISCED classification, such as upper secondary vocational education; post-secondary non-tertiary vocational education; Bachelor’s or equivalent level, professional; Doctoral or equivalent level, academic; post-secondary non-tertiary vocational education; or never attended an educational program., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social context']/items[openEHR-EHR-EVALUATION.education_summary.v1]/protocol[at0026], code=at0026, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Protocol, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social context']/items[openEHR-EHR-EVALUATION.education_summary.v1]/protocol[at0026]/items[at0028], code=at0028, itemType=ELEMENT, level=5, text=Last updated, description=The date that this education summary was last updated., comment=At implementation, it is assumed that if an associated education record is added or updated then this date will also be updated., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social context']/items[openEHR-EHR-EVALUATION.gambling_summary.v0], code=at0000, itemType=EVALUATION, level=3, text=Gambling summary, description=Summary about the gambling activity by an individual or the impact of gambling on them by others., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social context']/items[openEHR-EHR-EVALUATION.gambling_summary.v0]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social context']/items[openEHR-EHR-EVALUATION.gambling_summary.v0]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=5, text=Description, description=Narrative description about the individual's gambling activity or the impact of gambling on them by others., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social context']/items[openEHR-EHR-EVALUATION.gambling_summary.v0]/protocol[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Protocol, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social context']/items[openEHR-EHR-EVALUATION.gambling_summary.v0]/protocol[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=5, text=Last updated, description=The date this 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Lifestyle risk factors'], code=at0000, itemType=SECTION, level=2, text=Lifestyle risk factors, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Lifestyle risk factors']/items[openEHR-EHR-EVALUATION.food_nutrition_summary.v0], code=at0000, itemType=EVALUATION, level=3, text=Food and nutrition summary, description=Summary of the nutritional status of an individual, as assessed by a clinician., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History 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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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Lifestyle risk factors']/items[openEHR-EHR-EVALUATION.food_nutrition_summary.v0]/data[at0001]/items[at0013], code=at0013, itemType=ELEMENT, level=5, text=Food security status, description=The current category for secure access to food., comment=The scope of food security includes access to food that is adequate in quantity and nutritional quality; culturally acceptable; safe; and acquired in socially acceptable ways., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Food security  [An absence of any form of food insecurity.]
  • Marginal food security  [Mild food insecurity.]
  • Low food security  [Moderate food insecurity.]
  • Very low food security  [Severe food insecurity.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Lifestyle risk factors']/items[openEHR-EHR-EVALUATION.food_nutrition_summary.v0]/data[at0001]/items[at0020], code=at0020, itemType=ELEMENT, level=5, text=Food security description, description=Narrative description about any difficulties or issues around food security., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Lifestyle risk 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subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Lifestyle risk factors']/items[openEHR-EHR-EVALUATION.physical_activity_summary.v0], code=at0000, itemType=EVALUATION, level=3, text=Physical activity summary, description=A summary of the typical level of physical activity undertaken by the individual., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History 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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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Lifestyle risk factors']/items[openEHR-EHR-EVALUATION.physical_activity_summary.v0]/protocol[at0014], code=at0014, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Protocol, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Lifestyle risk factors']/items[openEHR-EHR-EVALUATION.physical_activity_summary.v0]/protocol[at0014]/items[at0016], code=at0016, itemType=ELEMENT, level=5, text=Last updated, description=The date when the physical activity 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Lifestyle risk factors']/items[openEHR-EHR-EVALUATION.tobacco_smoking_summary.v1 and name/value='Tobacco smoking summary R1'], code=at0000, itemType=EVALUATION, level=3, text=Tobacco smoking summary R1, description=Summary or persistent information about the tobacco smoking habits of an individual., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Lifestyle risk factors']/items[openEHR-EHR-EVALUATION.tobacco_smoking_summary.v1 and name/value='Tobacco smoking summary R1']/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Lifestyle risk factors']/items[openEHR-EHR-EVALUATION.tobacco_smoking_summary.v1 and name/value='Tobacco smoking summary R1']/data[at0001]/items[at0089], code=at0089, itemType=ELEMENT, level=5, text=Overall status, description=Statement about current smoking behaviour for all types of tobacco., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Never smoked  [Individual has never smoked any type of tobacco.]
  • Current smoker  [Individual is a current smoker of tobacco.]
  • Former smoker  [Individual has previously smoked tobacco but is not a current smoker.]
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  • Never smoked  [Individual has never smoked any type of tobacco.]
  • Current smoker  [Individual is a current smoker of tobacco.]
  • Former smoker  [Individual has previously smoked tobacco but is not a current smoker.]
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  • Cigarettes  [Also known as manufactured cigarettes, 'factory made' cigarettes or 'tailor made' cigarettes. Processed tobacco, manufactured into cylinder made of paper or a substance that does not contain tobacco.]
  • Hand-rolled cigarettes  [Also known as "rollies" or "roll-ups". Loose tobacco, hand rolled into a cylinder using cigarette papers.]
  • Cigars  [Also known as "large cigar". Roll of tobacco wrapped within a leaf tobacco or in a substance that contains tobacco.]
  • Pipe  [Loose tobacco placed inside a pipe bowl.]
  • Waterpipe  [Also known as "hookah", "shisha", "narguileh" and "hubble-bubble". Tobacco, often flavoured, is burned then cooled through a basin of water and consumed through a hose and mouthpiece.]
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  •  Coded Text
    • Daily  [Smoking the specified type of tobacco at least once every day.]
    • Non-daily  [Not smoking the specified type of tobacco every day.]
  •  Text
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Units:
  • 1/d
  • 1/wk
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Units:
  • g/d
  • g/wk
  • [oz_av]/d
  • [oz_av]/wk
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This date could be used by decision support guidance to determine if the individual is at risk of relapse, for example in the first 12 months since quitting., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Lifestyle risk factors']/items[openEHR-EHR-EVALUATION.tobacco_smoking_summary.v1 and name/value='Tobacco smoking summary R2']/data[at0001]/items[at0093], code=at0093, itemType=ELEMENT, level=5, text=Overall years of smoking, description=The cumulative number of years that the individual has smoked tobacco., comment=This data element does not take into account the amount of tobacco smoked. It may be used to calculate the 'Smoking index'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=>=0 a, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Lifestyle risk factors']/items[openEHR-EHR-EVALUATION.tobacco_smoking_summary.v1 and name/value='Tobacco smoking summary R2']/data[at0001]/items[at0074], code=at0074, itemType=ELEMENT, level=5, text=Overall pack years, description=Estimate of the cumulative amount for all types of tobacco smoked., comment=The definition of a pack can be recorded in the protocol of this archetype using the 'Pack definition' data element., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=>=0, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Lifestyle risk factors']/items[openEHR-EHR-EVALUATION.tobacco_smoking_summary.v1 and name/value='Tobacco smoking summary R2']/protocol[at0021], code=at0021, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Protocol, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Lifestyle risk factors']/items[openEHR-EHR-EVALUATION.tobacco_smoking_summary.v1 and name/value='Tobacco smoking summary R2']/protocol[at0021]/items[at0022], code=at0022, itemType=ELEMENT, level=5, text=Last updated, description=The date this tobacco smoking 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Lifestyle risk factors']/items[openEHR-EHR-EVALUATION.alcohol_consumption_summary.v1 and name/value='Alcohol consumption summary item R1'], code=at0000, itemType=EVALUATION, level=3, text=Alcohol consumption summary item R1, description=Summary or persistent information about the typical alcohol consumption of an individual., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Lifestyle risk factors']/items[openEHR-EHR-EVALUATION.alcohol_consumption_summary.v1 and name/value='Alcohol consumption summary item R1']/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Lifestyle risk factors']/items[openEHR-EHR-EVALUATION.alcohol_consumption_summary.v1 and name/value='Alcohol consumption summary item R1']/data[at0001]/items[at0089], code=at0089, itemType=ELEMENT, level=5, text=Overall status, description=Statement about current consumption for all types of alcohol., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Current drinker  [Individual is a current consumer of alcohol.]
  • Former drinker  [Individual has previously consumed alcohol but is not a current drinker.]
  • Lifetime non-drinker  [Individual has never consumed alcohol.]
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  • Current drinker  [Individual is a current consumer of alcohol.]
  • Former drinker  [Individual has previously consumed alcohol but is not a current drinker.]
  • Lifetime non-drinker  [Individual has never consumed alcohol.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Lifestyle risk factors']/items[openEHR-EHR-EVALUATION.alcohol_consumption_summary.v1 and name/value='Alcohol consumption summary item R2']/data[at0001]/items[at0043], code=at0043, itemType=ELEMENT, level=5, text=Overall description, description=Narrative summary about the individual's overall alcohol consumption pattern and history., comment=Use this data element to record a narrative description of alcohol drinking habits for this individual or to incorporate unstructured alcohol drinking information from existing or legacy clinical systems into an archetyped format., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Lifestyle risk factors']/items[openEHR-EHR-EVALUATION.alcohol_consumption_summary.v1 and name/value='Alcohol consumption summary item R2']/data[at0001]/items[at0064], code=at0064, itemType=CLUSTER, level=5, text=Per episode, description=Details about a discrete period of time with a consistent pattern of typical consumption., comment=null, uncommonOntologyItems=null, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Lifestyle risk factors']/items[openEHR-EHR-EVALUATION.alcohol_consumption_summary.v1 and name/value='Alcohol consumption summary item R2']/data[at0001]/items[at0064]/items[at0081], code=at0081, itemType=ELEMENT, level=6, text=Episode label, description=Identification of an episode of alcohol consumption - either as a number in a sequence and/or a named event., comment=For example: '2' as the second episode within a sequence of episodes; or 'Pregnancy with twins' if describing the alcohol consumption during a health event such as during a specific pregnancy., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Count>=1
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Lifestyle risk factors']/items[openEHR-EHR-EVALUATION.alcohol_consumption_summary.v1 and name/value='Alcohol consumption summary item R2']/data[at0001]/items[at0064]/items[at0013], code=at0013, itemType=ELEMENT, level=6, text=Episode start date, description=Date when this episode commenced., comment=Can be a partial date, for example, only a year., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Lifestyle risk factors']/items[openEHR-EHR-EVALUATION.alcohol_consumption_summary.v1 and name/value='Alcohol consumption summary item R2']/data[at0001]/items[at0064]/items[at0082], code=at0082, itemType=ELEMENT, level=6, text=Episode end date, description=Date when this episode ceased., comment=Can be a partial date, for example, only a year. This data field will be empty if the episode is current and ongoing., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Lifestyle risk factors']/items[openEHR-EHR-EVALUATION.alcohol_consumption_summary.v1 and name/value='Alcohol consumption summary item R2']/data[at0001]/items[at0064]/items[at0030], code=at0030, itemType=ELEMENT, level=6, text=Pattern, description=The typical pattern of consumption of alcohol., comment=The typical pattern of use can be made more granular by coding with a terminology or a local value set in a template., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Coded Text
    • Daily  [Consuming alcoholic beverage at least once every day.]
    • Non-daily  [Not consuming alcoholic beverage every day.]
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Lifestyle risk factors']/items[openEHR-EHR-EVALUATION.alcohol_consumption_summary.v1 and name/value='Alcohol consumption summary item R2']/data[at0001]/items[at0064]/items[at0097], code=at0097, itemType=ELEMENT, level=6, text=Binge drinking frequency, description=The individual's typical frequency of heavy drinking over a short period of time with the intent of becoming intoxicated., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Quantity0..7; 0..31; 0..365
    Units:
    • 1/wk
    • 1/mo
    • 1/a
  •  Interval of QuantityLower constraint: 0..7; 0..31; 0..365
    Units:
    • 1/wk
    • 1/mo
    • 1/a

    Upper constraint: 0..7; 0..31; 0..365
    Units:
    • 1/wk
    • 1/mo
    • 1/a
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Lifestyle risk factors']/items[openEHR-EHR-EVALUATION.alcohol_consumption_summary.v1 and name/value='Alcohol consumption summary item R2']/data[at0001]/items[at0064]/items[at0113], code=at0113, itemType=ELEMENT, level=6, text=Binge drinking description, description=Narrative description about the individual's typical pattern of binge drinking., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Lifestyle risk factors']/items[openEHR-EHR-EVALUATION.alcohol_consumption_summary.v1 and name/value='Alcohol consumption summary item R2']/data[at0001]/items[at0064]/items[at0110], code=at0110, itemType=ELEMENT, level=6, text=Alcohol free days, description=The number of days where no alcohol was consumed in the specified period., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=0..7; 0..31
Units:
  • 1/wk
  • 1/mo
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Lifestyle risk factors']/items[openEHR-EHR-EVALUATION.alcohol_consumption_summary.v1 and name/value='Alcohol consumption summary item R2']/data[at0001]/items[at0064]/items[at0023], code=at0023, itemType=ELEMENT, level=6, text=Typical consumption (alcohol units), description=Estimate of number of alcohol units consumed in the specified time period., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=>=0; >=0; >=0
Units:
  • 1/d
  • 1/wk
  • 1/mo
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Lifestyle risk factors']/items[openEHR-EHR-EVALUATION.alcohol_consumption_summary.v1 and name/value='Alcohol consumption summary item R2']/data[at0001]/items[at0064]/items[at0025], code=at0025, itemType=ELEMENT, level=6, text=Number of quit attempts, description=Total number of times the individual has attempted to stop consuming alcohol within this episode., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=>=0, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Lifestyle risk factors']/items[openEHR-EHR-EVALUATION.alcohol_consumption_summary.v1 and name/value='Alcohol consumption summary item R2']/data[at0001]/items[at0064]/items[at0087], code=at0087, itemType=ELEMENT, level=6, text=Episode comment, description=Additional narrative about alcohol consumption during the specified episode, not captured in other fields., comment=For example: alcohol consumed as a hangover remedy eg 'hair of the dog'., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Lifestyle risk factors']/items[openEHR-EHR-EVALUATION.alcohol_consumption_summary.v1 and name/value='Alcohol consumption summary item R2']/data[at0001]/items[at0016], code=at0016, itemType=ELEMENT, level=5, text=Overall quit date, description=The date when the individual last ceased consuming alcohol of any type., comment=Can be a partial date, for example, only a year. This date could be used by decision support guidance to determine if the individual is at risk of relapse, for example in the first 12 months since quitting., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Lifestyle risk factors']/items[openEHR-EHR-EVALUATION.alcohol_consumption_summary.v1 and name/value='Alcohol consumption summary item R2']/protocol[at0021], code=at0021, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Protocol, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Lifestyle risk factors']/items[openEHR-EHR-EVALUATION.alcohol_consumption_summary.v1 and name/value='Alcohol consumption summary item R2']/protocol[at0021]/items[at0022], code=at0022, itemType=ELEMENT, level=5, text=Last updated, description=The date this alcohol consumption 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Lifestyle risk factors']/items[openEHR-EHR-EVALUATION.substance_use_summary.v0], code=at0000, itemType=EVALUATION, level=3, text=Substance use summary, description=Summary or persistent information about the typical use of a single addictive, or potentially addictive, substance by an individual., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Lifestyle risk factors']/items[openEHR-EHR-EVALUATION.substance_use_summary.v0]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Lifestyle risk factors']/items[openEHR-EHR-EVALUATION.substance_use_summary.v0]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=5, text=Substance name, description=The name of the substance or substance group/class used., comment=Coding with an external terminology is preferred, where possible., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Lifestyle risk factors']/items[openEHR-EHR-EVALUATION.substance_use_summary.v0]/data[at0001]/items[at0003], code=at0003, itemType=ELEMENT, level=5, text=Overall status, description=Statement about current use of the substance, in all forms and by all routes., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Never used  [The individual has never used the identified substance.]
  • Current user  [The individual is currently using the identified substance.]
  • Former user  [The individual has previously used the identified substance.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Lifestyle risk factors']/items[openEHR-EHR-EVALUATION.substance_use_summary.v0]/data[at0001]/items[at0007], code=at0007, itemType=ELEMENT, level=5, text=Overall description, description=Narrative summary about use behaviour for the substance., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Lifestyle risk factors']/items[openEHR-EHR-EVALUATION.substance_use_summary.v0]/data[at0001]/items[at0028], code=at0028, itemType=ELEMENT, level=5, text=Overall quit date, description=The date when the individual last ceased all use of the substance., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Lifestyle risk factors']/items[openEHR-EHR-EVALUATION.substance_use_summary.v0]/protocol[at0029], code=at0029, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Protocol, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Lifestyle risk factors']/items[openEHR-EHR-EVALUATION.substance_use_summary.v0]/protocol[at0029]/items[at0031], code=at0031, itemType=ELEMENT, level=5, text=Last updated, description=The date this 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Lifestyle risk factors']/items[openEHR-EHR-EVALUATION.sexual_health_summary.v0], code=at0000, itemType=EVALUATION, level=3, text=Sexual health summary, description=Summary or persistent information about an individual's sexual health and history., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Lifestyle risk factors']/items[openEHR-EHR-EVALUATION.sexual_health_summary.v0]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Lifestyle risk factors']/items[openEHR-EHR-EVALUATION.sexual_health_summary.v0]/data[at0001]/items[at0012], code=at0012, itemType=ELEMENT, level=5, text=Description, description=Narrative description about the sexual health history of an individual., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Lifestyle risk factors']/items[openEHR-EHR-EVALUATION.sexual_health_summary.v0]/data[at0001]/items[at0015], code=at0015, itemType=ELEMENT, level=5, text=Comment, description=Additional narrative about the sexual health history 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Lifestyle risk factors']/items[openEHR-EHR-EVALUATION.sexual_health_summary.v0]/protocol[at0013], code=at0013, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Protocol, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Lifestyle risk factors']/items[openEHR-EHR-EVALUATION.sexual_health_summary.v0]/protocol[at0013]/items[at0004], code=at0004, itemType=ELEMENT, level=5, text=Last updated, description=The date this 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-EVALUATION.contraceptive_summary.v0], code=at0000, itemType=EVALUATION, level=2, text=Contraceptive summary, description=Summary information about a woman's use of contraception during her lifetime., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-EVALUATION.contraceptive_summary.v0]/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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-EVALUATION.contraceptive_summary.v0]/data[at0001]/items[at0089], code=at0089, itemType=ELEMENT, level=4, text=Overall status, description=Statement about current use of any type of contraception., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Current user  [Individual currently uses contraception.]
  • Former user  [Individual has previously used contraception but is not a current user.]
  • Never used  [Individual has never used any type of contraception.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-EVALUATION.contraceptive_summary.v0]/data[at0001]/items[at0043], code=at0043, itemType=ELEMENT, level=4, text=Overall description, description=Narrative summary about the woman's overall use of contraception., comment=Use this data element to record a narrative description only where the structured data does not adequately reflect the use of contraception for this woman or to incorporate unstructured information from existing or legacy clinical systems into an archetyped format., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-EVALUATION.contraceptive_summary.v0]/protocol[at0021], code=at0021, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Protocol, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-EVALUATION.infant_feeding.v0], code=at0000, itemType=EVALUATION, level=2, text=Infant Feeding Summary, description=Summary of early infant feeding activity, particularly focused on breast and formula feeding., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-EVALUATION.infant_feeding.v0]/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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-EVALUATION.infant_feeding.v0]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Description, description=Narrative description about the overall feeding history for the infant., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-EVALUATION.infant_feeding.v0]/data[at0001]/items[at0003], code=at0003, itemType=CLUSTER, level=4, text=Feeding, description=Details about a pattern of feeding., comment=null, uncommonOntologyItems=null, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-EVALUATION.infant_feeding.v0]/data[at0001]/items[at0003]/items[at0006], code=at0006, itemType=ELEMENT, level=5, text=Type, description=The predominant type of feeding for a period of time., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Coded Text
    • Predominantly Breastfed  [Infant was solely breast fed, or the proportion of the volume of milk supplied by breast feeding was significantly greater than the volume from bottled formula.]
    • Predominantly Formula  [Infant was solely fed on bottled formula, or the proportion of the volume of milk supplied by feeding with bottled formula was significantly greater than by breast feeding.]
    • Mixed  [The volume of milk supplied by breast feeding was similar to that supplied as bottled formula.]
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-EVALUATION.infant_feeding.v0]/data[at0001]/items[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=5, text=Age Commenced, description=The age of the infant when the selected type of feeding was commenced., comment=If commenced at birth, which will be recorded as 0 days, weeks or months, then this could be captured or displayed in a system as 'Birth'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DURATION, bindings=null, values=Units:
  • Year
  • Month
  • Week
  • Day
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-EVALUATION.infant_feeding.v0]/data[at0001]/items[at0003]/items[at0005], code=at0005, itemType=ELEMENT, level=5, text=Age Ceased, description=The age of the infant when the selected type of feeding was ceased., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DURATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-EVALUATION.infant_feeding.v0]/data[at0001]/items[at0003]/items[at0009], code=at0009, itemType=ELEMENT, level=5, text=Comment, description=Additional narrative about the feeding activity 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-EVALUATION.infant_feeding.v0]/data[at0001]/items[at0007], code=at0007, itemType=ELEMENT, level=4, text=Total Duration of Breast Feeding, description=The total amount of time that the infant was predominantly breastfed., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DURATION, bindings=null, values=Units:
  • Year
  • Month
  • Week
  • Day
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-EVALUATION.infant_feeding.v0]/data[at0001]/items[at0008], code=at0008, itemType=ELEMENT, level=4, text=Age Commenced Solid Foods, description=The age of the infant when commenced on solid foods., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DURATION, bindings=null, values=Units:
  • Month
  • Week
  • Day
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-EVALUATION.infant_feeding.v0]/data[at0001]/items[at0010], code=at0010, itemType=ELEMENT, level=4, text=Age Weaned, description=The age of the infant when weaned., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DURATION, bindings=null, values=Units:
  • Year
  • Month
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-EVALUATION.exposure.v0], code=at0000, itemType=EVALUATION, level=2, text=Exposure, description=Exposure of the subject to a chemical, physical or biological agent within their environment that has caused, or may possibly cause in the future, a negative impact on health., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-EVALUATION.exposure.v0]/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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-EVALUATION.exposure.v0]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Agent, description=Identification of the chemical, physical or biological agent to which the subject was exposed., comment=For example: passive smoking or industrial noise., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Environmental exposure to tobacco smoke (eg at home, in the car, etc)
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-EVALUATION.exposure.v0]/data[at0001]/items[at0003], code=at0003, itemType=ELEMENT, level=4, text=Description, description=Overall description of the exposure to the identified substance., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-EVALUATION.exposure.v0]/protocol[at0008], code=at0008, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Protocol, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-EVALUATION.exposure.v0]/protocol[at0008]/items[at0009], code=at0009, itemType=ELEMENT, level=4, text=Date Updated, description=The date this exposure 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-EVALUATION.menstrual_cycle_summary.v0], code=at0000, itemType=EVALUATION, level=2, text=Menstruation summary, description=Summary or persistent information about an individual's menstruation history., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-EVALUATION.menstrual_cycle_summary.v0]/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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-EVALUATION.menstrual_cycle_summary.v0]/data[at0001]/items[at0025], code=at0025, itemType=ELEMENT, level=4, text=Overall description, description=Narrative description about the overall pattern of menstruation over the individual's lifetime., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-EVALUATION.menstrual_cycle_summary.v0]/data[at0001]/items[at0010], code=at0010, itemType=CLUSTER, level=4, text=Per episode, description=Details about a typical pattern of menstruation during a specified interval of time., comment=If the pattern of menstruation changes significantly, or other factors significantly interrupt (for example, a full term pregnancy) or influence (for example, changing contraception methods) the menstrual cycle, then it may be useful to record as a new episode ., uncommonOntologyItems=null, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-EVALUATION.menstrual_cycle_summary.v0]/protocol[at0008], code=at0008, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Protocol, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Prevention screening'], code=at0000, itemType=SECTION, level=2, text=Prevention screening, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Prevention screening']/items[openEHR-EHR-OBSERVATION.management_screening.v0], code=at0000, itemType=OBSERVATION, level=3, text=Preventive screening questionnaire, description=An individual- or self-reported questionnaire screening for management or treatment carried out., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Prevention screening']/items[openEHR-EHR-OBSERVATION.management_screening.v0]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Prevention screening']/items[openEHR-EHR-OBSERVATION.management_screening.v0]/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=5, text=Any event, description=Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Prevention screening']/items[openEHR-EHR-OBSERVATION.management_screening.v0]/data[at0001]/events[at0002]/data[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=6, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Prevention screening']/items[openEHR-EHR-OBSERVATION.management_screening.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0022], code=at0022, itemType=CLUSTER, level=7, text=Specific preventive activity, description=Grouping of data elements related to screening for a single management or treatment activity., comment=null, uncommonOntologyItems=null, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Prevention screening']/items[openEHR-EHR-OBSERVATION.management_screening.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0022]/items[at0004], code=at0004, itemType=ELEMENT, level=8, text=Preventive screening name, description=Name of the management or treatment activity being screened., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Breast screening
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Prevention screening']/items[openEHR-EHR-OBSERVATION.management_screening.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0022]/items[at0005], code=at0005, itemType=ELEMENT, level=8, text=Status, description=The current status of a specific activity., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Scheduled  [The specific activity is scheduled.]
  • Completed  [The specific activity has been completed.]
  • Not done  [The specific activity was not carried out.]
  • Unknown  [It is not known whether the activity was carried out.]
  • Declined  [The specific activity has been refused or declined by the individual.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Prevention screening']/items[openEHR-EHR-OBSERVATION.management_screening.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0022]/items[at0006], code=at0006, itemType=ELEMENT, level=8, text=Completed, description=The date/time when the activity was (last) carried out., comment=Partial dates are allowed., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Prevention screening']/items[openEHR-EHR-OBSERVATION.management_screening.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0022]/items[at0037], code=at0037, itemType=ELEMENT, level=8, text=Scheduled, description=The date/time when the activity is (next) due to be carried out., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Prevention screening']/items[openEHR-EHR-OBSERVATION.management_screening.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0022]/items[at0035], code=at0035, itemType=ELEMENT, level=8, text=Comment, description=Additional narrative about the specific management or treatment activity, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Prevention screening']/items[openEHR-EHR-OBSERVATION.management_screening.v0]/protocol[at0007], code=at0007, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Protocol, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Pregnancy/breast feeding status'], code=at0000, itemType=SECTION, level=2, text=Pregnancy/breast feeding status, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Pregnancy/breast feeding status']/items[openEHR-EHR-EVALUATION.precaution.v1], code=at0000, itemType=EVALUATION, level=3, text=Precaution, description=A condition or state of the individual that is clinically significant and unique or idiosyncratic for this individual, and is considered vital information when making treatment decisions., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Pregnancy/breast feeding status']/items[openEHR-EHR-EVALUATION.precaution.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Pregnancy/breast feeding status']/items[openEHR-EHR-EVALUATION.precaution.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=5, text=Condition, description=Identification, by name, of a condition or state., comment=Coding of the identified 'Condition' with a terminology is desirable, where possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Pregnancy
  • Breastfeeding
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Pregnancy/breast feeding status']/items[openEHR-EHR-EVALUATION.precaution.v1]/data[at0001]/items[at0014], code=at0014, itemType=ELEMENT, level=5, text=Status, description=Assertion about the current state of the identified 'Precaution'., comment=Decision support would typically raise alerts for 'Active' and ignore a 'Resolved' or 'Refuted' precaution. Clinical systems may choose not to display Precaution entries with a 'Refuted' status in the Precaution list. However, 'Refuted' may be useful for reconciliation of the Precaution 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. 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=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Active  [The precaution is currently active.]
  • Resolved  [The previously asserted precaution has been clinically reassessed and considered no longer to be an active risk.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Pregnancy/breast feeding status']/items[openEHR-EHR-EVALUATION.precaution.v1]/protocol[at0006], code=at0006, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Protocol, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Pregnancy/breast feeding status']/items[openEHR-EHR-EVALUATION.obstetric_summary.v1], code=at0000, itemType=EVALUATION, level=3, text=Obstetric summary, description=Summary or persistent information about the numbers of key obstetric events., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Pregnancy/breast feeding status']/items[openEHR-EHR-EVALUATION.obstetric_summary.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Pregnancy/breast feeding status']/items[openEHR-EHR-EVALUATION.obstetric_summary.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=5, text=Gravidity, description=Number of times a woman has been pregnant, current and past, regardless of the pregnancy outcome., comment=Clinical systems might represent this data element by the term 'Gravida' on a clinical form., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=0..100, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Pregnancy/breast feeding status']/items[openEHR-EHR-EVALUATION.obstetric_summary.v1]/data[at0001]/items[at0003], code=at0003, itemType=ELEMENT, level=5, text=Parity, description=Number of times a woman has given birth to a viable baby, regardless of the pregnancy outcome., comment=Parity includes all pregnancies that are carried after the fetus is considered viable, as defined in the 'Definition of viability data' element. Stillbirths, late abortions, and all live births are included in the assessment of Parity. In cases of multiple pregnancies, parity is only increased with birth of the last fetus., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=0..100, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Pregnancy/breast feeding status']/items[openEHR-EHR-EVALUATION.obstetric_summary.v1]/protocol[at0008], code=at0008, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Protocol, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Pregnancy/breast feeding status']/items[openEHR-EHR-EVALUATION.obstetric_summary.v1]/protocol[at0008]/items[at0009], code=at0009, itemType=ELEMENT, level=5, text=Last updated, description=The date this 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Pregnancy/breast feeding status']/items[openEHR-EHR-EVALUATION.estimated_date_delivery.v0], code=at0000, itemType=EVALUATION, level=3, text=Estimated date of delivery, description=Estimated date of delivery for a pregnancy., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Pregnancy/breast feeding status']/items[openEHR-EHR-EVALUATION.estimated_date_delivery.v0]/data[at0002], code=at0002, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Pregnancy/breast feeding status']/items[openEHR-EHR-EVALUATION.estimated_date_delivery.v0]/data[at0002]/items[at0003], code=at0003, itemType=ELEMENT, level=5, text=By date of conception, description=The EDD calculated from a known date of conception., comment=The date of conception will be recorded elsewhere in the health record, for example as part of the record for an IVF procedure., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Pregnancy/breast feeding status']/items[openEHR-EHR-EVALUATION.estimated_date_delivery.v0]/data[at0002]/items[at0004], code=at0004, itemType=ELEMENT, level=5, text=By cycle, description=The EDD estimated from an LNMP and characteristics of the menstrual cycle., comment=The details about the menstrual cycle will be recorded elsewhere in the health record, usually captured using the OBSERVATION.menstruation archetype., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Pregnancy/breast feeding status']/items[openEHR-EHR-EVALUATION.estimated_date_delivery.v0]/data[at0002]/items[at0006], code=at0006, itemType=CLUSTER, level=5, text=By ultrasound, description=Details about an EDD estimated from the findings on a pregnancy ultrasound., comment=Each ultrasound and estimated gestation pair will be captured as a separate instance of this CLUSTER., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Pregnancy/breast feeding status']/items[openEHR-EHR-EVALUATION.estimated_date_delivery.v0]/data[at0002]/items[at0006]/items[at0005], code=at0005, itemType=ELEMENT, level=6, text=Date of ultrasound, description=The date on which the ultrasound was carried out., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Pregnancy/breast feeding status']/items[openEHR-EHR-EVALUATION.estimated_date_delivery.v0]/data[at0002]/items[at0006]/items[at0007], code=at0007, itemType=ELEMENT, level=6, text=Gestation by scan, description=The gestation estimated from the scan., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DURATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Pregnancy/breast feeding status']/items[openEHR-EHR-EVALUATION.estimated_date_delivery.v0]/data[at0002]/items[at0006]/items[at0008], code=at0008, itemType=ELEMENT, level=6, text=Estimated date by ultrasound, description=Details about an EDD estimated from the findings on a pregnancy ultrasound., comment=Only one 'Agreed EDD' is appropriate at any one time. If the agreed EDD needs to be revised then this should be captured in a new revision of this archetype within a health record., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Pregnancy/breast feeding status']/items[openEHR-EHR-EVALUATION.estimated_date_delivery.v0]/data[at0002]/items[at0009], code=at0009, itemType=CLUSTER, level=5, text=Agreed EDD, description=Details about the agreed EDD which is used as the basis for clinical decision-making during the pregnancy., comment=null, uncommonOntologyItems=null, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Pregnancy/breast feeding status']/items[openEHR-EHR-EVALUATION.estimated_date_delivery.v0]/data[at0002]/items[at0009]/items[at0010], code=at0010, itemType=ELEMENT, level=6, text=Agreed date, description=The EDD which is to be used as the basis for clinical decision-making., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Pregnancy/breast feeding status']/items[openEHR-EHR-EVALUATION.estimated_date_delivery.v0]/data[at0002]/items[at0009]/items[at0011], code=at0011, itemType=ELEMENT, level=6, text=Rationale, description=The rationale which explains why the 'Agreed date' has been selected., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Pregnancy/breast feeding status']/items[openEHR-EHR-EVALUATION.estimated_date_delivery.v0]/protocol[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Protocol, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='History screening']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Pregnancy/breast feeding status']/items[openEHR-EHR-EVALUATION.estimated_date_delivery.v0]/protocol[at0001]/items[at0013], code=at0013, itemType=ELEMENT, level=5, text=Last updated, description=The date any EDD 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists'], code=at0000, itemType=SECTION, level=1, text=Persistent lists, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Medical history & current problem list'], code=at0000, itemType=SECTION, level=2, text=Medical history & current 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=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Medical history & current problem list']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1], code=at0000, itemType=EVALUATION, level=3, text=Problem/Diagnosis, description=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., comment=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'., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Medical history & current problem list']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Medical history & current problem list']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=5, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Medical history & current problem list']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0012], code=at0012, itemType=ELEMENT, level=5, 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=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Medical history & current problem list']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.anatomical_location.v1], code=at0000, itemType=CLUSTER, level=5, text=Anatomical location, description=A physical site on or within the human body., comment=null, uncommonOntologyItems=null, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Medical history & current problem list']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.anatomical_location.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=6, text=Body site name, description=Identification of a single physical site either on, or within, the human body., comment=This data element is the only mandated data point in this archetype and should be used as the primary data point to record an anatomical location with a commonly used name. It is strongly recommended that 'Body site name' be recorded as specifically as is anatomically possible. For example: record 'upper eyelid' rather than recording 'eyelid' with 'upper' as a qualifier; 'fifth rib' rather than 'rib' with a numeric qualifier. Use the other data elements for laterality, aspect, region and anatomical line to provide more detail. This data element should be coded with a terminology capable of triggering decision support, where possible - an appropriate termset for use here could comprise individual concepts or a list of precoordinated terms. Free text should be used only if there is no appropriate terminology available. If body site name is already identified in the parent archetype, then this data element may be redundant. Alternatively, a use case has been identified where the value may be duplicated into this element to support semantic querying using this archetype, rather than the data element within the parent., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Medical history & current problem list']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.anatomical_location.v1]/items[at0065], code=at0065, itemType=ELEMENT, level=6, text=Specific site, description=Additional detail using a specific region or a point on, or within, the identified body site., comment=Use to increase precision of identification of the body site, if required. For example, the upper right quadrant or McBurney's point on the abdominal wall or interphalangeal joint of the great toe. If the 'Body site name' data element uses pre-coordinated terms that include the specific site, then this data element is 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Medical history & current problem list']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.anatomical_location.v1]/items[at0002], code=at0002, itemType=ELEMENT, level=6, text=Laterality, description=The side of the body on which the identified body site is located., comment=If the identified body site has no laterality, this data element should not have a value. If the 'Body site name' data element uses pre-coordinated terms that include laterality, then this data element is redundant., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Left  [Left side of the body.]
  • Right  [Right side of the body.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Medical history & current problem list']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0003], code=at0003, itemType=ELEMENT, level=5, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Medical history & current problem list']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0005], code=at0005, itemType=ELEMENT, level=5, 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=CHOICE, bindings=null, values=
  •  Coded Text
    • Mild  [The problem or diagnosis does not interfere with normal activity or may cause damage to health if left untreated.]
    • Moderate  [The problem or diagnosis causes interference with normal activity or will damage health if left untreated.]
    • Severe  [The problem or diagnosis prevents normal activity or will seriously damage health if left untreated.]
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Medical history & current problem list']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0072], code=at0072, itemType=ELEMENT, level=5, text=Course, description=Narrative description about the course of the problem or diagnosis since onset., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Medical history & current problem list']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v1], code=at0000, itemType=CLUSTER, level=5, text=Problem/Diagnosis qualifier, description=Contextual or temporal qualifier for a specified problem or diagnosis., comment=null, uncommonOntologyItems=null, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Medical history & current problem list']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v1]/items[at0003], code=at0003, itemType=ELEMENT, level=6, text=Active/Inactive?, description=Category that supports division of problems and diagnoses into Active or Inactive problem lists., comment=The Active/Inactive and Current/Past data elements have similar clinical impact but represent slightly different semantics. Both are actively used in different clinical settings, but usually not together. If a Current/Past qualifier is recorded, then this data element is likely to be redundant. An exception where a condition can be current but inactive is asthma that is not causing acute symptoms., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Active  [The problem or diagnosis is currently active and clinically relevant.]
  • Inactive  [The problem or diagnosis is not completely resolved but is inactive or felt less relevant to the current clinical context.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Medical history & current problem list']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0069], code=at0069, itemType=ELEMENT, level=5, text=Comment, description=Additional narrative about the problem or diagnosis 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Medical history & current problem list']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/protocol[at0032], code=at0032, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Protocol, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Medical history & current problem list']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/protocol[at0032]/items[at0070], code=at0070, itemType=ELEMENT, level=5, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Medical history & current problem list']/items[openEHR-EHR-ACTION.procedure.v1], code=at0000, itemType=ACTION, level=3, text=Procedure, description=A clinical activity carried out for screening, investigative, diagnostic, curative, therapeutic, evaluative or palliative purposes., comment=null, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Medical history & current problem list']/items[openEHR-EHR-ACTION.procedure.v1]/description[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Description, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Medical history & current problem list']/items[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=5, text=Procedure name, description=Identification of the procedure by name., comment=Coding of the specific procedure 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Medical history & current problem list']/items[openEHR-EHR-ACTION.procedure.v1]/protocol[at0053], code=at0053, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Protocol, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Allergies/Adverse reaction list'], code=at0000, itemType=SECTION, level=2, text=Allergies/Adverse reaction list, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Allergies/Adverse reaction list']/items[openEHR-EHR-EVALUATION.adverse_reaction_risk.v1], code=at0000, itemType=EVALUATION, level=3, text=Adverse reaction risk item, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Allergies/Adverse reaction list']/items[openEHR-EHR-EVALUATION.adverse_reaction_risk.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Allergies/Adverse reaction list']/items[openEHR-EHR-EVALUATION.adverse_reaction_risk.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=5, 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_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Allergies/Adverse reaction list']/items[openEHR-EHR-EVALUATION.adverse_reaction_risk.v1]/data[at0001]/items[at0063], code=at0063, itemType=ELEMENT, level=5, text=Verification 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=CHOICE, bindings=null, values=
  •  Coded Text
    • Suspected  [A low level of clinical certainty about the propensity of a reaction to the identified 'Substance'.]
    • Likely  [A reasonable level of certainty about the propensity for a reaction to the identified 'Substance'.]
    • Confirmed  [A high level of certainty about the propensity for a reaction to the identified 'Substance', which may include clinical evidence by testing or re-challenge.]
    • Resolved  [The previously known reaction to the identified 'Substance' has been clinically reassessed and considered no longer to be an active risk.]
    • Refuted  [The propensity for a reaction to the identified 'Substance' has been clinically reassessed or has been disproved with a high level of clinical certainty by re-exposure or deliberate challenge.]
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Allergies/Adverse reaction list']/items[openEHR-EHR-EVALUATION.adverse_reaction_risk.v1]/data[at0001]/items[at0101], code=at0101, itemType=ELEMENT, level=5, 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=
  • Low  [Exposure to substance unlikely to result in critical system organ damage or life threatening consequence. Future exposure to the identified 'Substance' should be considered a relative contra-indication in normal clinical circumstances.]
  • High  [Exposure to substance may result in critical organ system damage or life threatening consequence. Future exposure to the identified 'Substance' should be considered an absolute contra-indication in normal clinical circumstances.]
  • Indeterminate  [Unable to assess with information available.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Allergies/Adverse reaction list']/items[openEHR-EHR-EVALUATION.adverse_reaction_risk.v1]/data[at0001]/items[at0006], code=at0006, itemType=ELEMENT, level=5, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Allergies/Adverse reaction list']/items[openEHR-EHR-EVALUATION.adverse_reaction_risk.v1]/data[at0001]/items[at0009], code=at0009, itemType=CLUSTER, level=5, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Allergies/Adverse reaction list']/items[openEHR-EHR-EVALUATION.adverse_reaction_risk.v1]/data[at0001]/items[at0009]/items[at0011], code=at0011, itemType=ELEMENT, level=6, 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_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Allergies/Adverse reaction list']/items[openEHR-EHR-EVALUATION.adverse_reaction_risk.v1]/protocol[at0042], code=at0042, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Protocol, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Allergies/Adverse reaction list']/items[openEHR-EHR-EVALUATION.adverse_reaction_risk.v1]/protocol[at0042]/items[at0062], code=at0062, itemType=ELEMENT, level=5, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Immunisation list'], code=at0000, itemType=SECTION, level=2, text=Immunisation list, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Immunisation list']/items[openEHR-EHR-ACTION.medication.v1], code=at0000, itemType=ACTION, level=3, text=Immunisation, 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=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ACTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Immunisation list']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017], code=at0017, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Description, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Immunisation list']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[at0020], code=at0020, itemType=ELEMENT, level=5, text=Immunisation 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=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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Immunisation list']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v1], code=at0000, itemType=CLUSTER, level=5, text=Immunisation detail, description=Details about a medication or component of a medication, including strength, form and details of any specific constituents., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Immunisation list']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v1]/items[at0071], code=at0071, itemType=ELEMENT, level=6, text=Form, description=The formulation or presentation of the medication or medication component., comment=For example: 'tablet', 'capsule', 'cream', 'infusion fluid' or 'inhalation powder'. Coding of the form with a terminology is preferred, where possible. Medicines catalogues may differentiate between administrable form 'solution for injection' and product form 'powder for solution for injection'. The recorded form will depend on the exact context of use but administrable form is likely to be used in most instances., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Immunisation list']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v1]/items[at0152], code=at0152, itemType=CLUSTER, level=6, text=Strength (presentation), description=The strength of the medication or medication component, expressed as a ratio., comment=In some cases, as for liquid or semisolid medications, the denominator of the strength ratio is a physical quantity, for example 2 mg/5 ml. In some of these cases the denominator also reflects the actual volume of the component: 5 ml in the previous example. In this case the 'Strength (concentration)' would be 0.4 mg/ml. In other cases, where the strength involves a denominator which is not a physical quantity, for example 4 mg/tablet, the denominator is expressed as a unitary value '1' with a unit of '1', and 'tablet' is carried in the 'Unit of presentation' element. This arrangement was chosen to align with the approach adopted by the ISO IDMP standard for medication catalogues., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Immunisation list']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v1]/items[at0152]/items[at0153], code=at0153, itemType=ELEMENT, level=7, text=Strength numerator, description=The value of the numerator of the strength fraction., comment=For example: For a presentation strength of '300 µg/0.3 ml', the strength numerator value is '300'. For a presentation strength of '100 mg/tablet', the strength numerator value is '100'., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=>=0 , extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Immunisation list']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v1]/items[at0152]/items[at0004], code=at0004, itemType=ELEMENT, level=7, text=Strength numerator unit, description=The unit of the numerator of the strength fraction., comment=The strength numerator is usually recorded using mass, volume or arbitrary units. For example: 'mg', 'ml', 'IU'. For a presentation strength of '300 µg/0.3 ml', the strength numerator unit is 'µg'. For a presentation strength of '100 mg/tablet', the strength numerator value is 'mg'., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Immunisation list']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v1]/items[at0152]/items[at0157], code=at0157, itemType=ELEMENT, level=7, text=Strength denominator, description=The value of the denominator of the strength fraction., comment=For example: For a presentation strength of '300 µg/0.3 ml', the strength denominator value is '0.3'. For a presentation strength of '100 mg/tablet', the strength denominator value is '1'., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=>=0 , extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Immunisation list']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v1]/items[at0152]/items[at0005], code=at0005, itemType=ELEMENT, level=7, text=Strength denominator unit, description=The unit of the denominator of the strength fraction., comment=The strength denominator is usually recorded using mass or volume units. For example: 'g', 'ml'. For a presentation strength of '300 µg/0.3 ml', the strength denominator unit is 'ml'. For a presentation strength of '100 mg/tablet', the strength denominator unit is '1'. For this example, the 'Unit of presentation' element is used to record the presentation unit of the medication, 'tablet'., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Immunisation list']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v1]/items[at0158], code=at0158, itemType=ELEMENT, level=6, text=Unit of presentation, description=The unit of presentation for a single dose of the medication, for use with the 'Strength denominator unit' element., comment=For example: 'tablet', 'capsule', 'puff', 'inhalation'. In most cases, like for tablets and capsules, the unit of presentation is identical to the Form. For some presentations such as inhalers, the Form may be 'inhalation powder', 'inhalation aerosol' or 'inhaler' while the unit of presentation is 'inhalation', 'puff', or 'dose'., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Immunisation list']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v1]/items[at0115], code=at0115, itemType=ELEMENT, level=6, text=Strength (concentration), description=The strength of the medication or medication component, as a concentration., comment=This element is used for liquid or semisolid medications, or medications intended to be diluted in a liquid before administration. For example: '10 mg/ml', '20 mg/g', '5 %', '10,000 SQ-U/ml'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Immunisation list']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v1], code=at0000, itemType=CLUSTER, level=5, text=Dosage, description=The combination of a medication amount and administration timing for a single day, in the context of a medication order or medication management., comment=For example: '2 tablets at 6pm' or '20mg three times per day'. Please note: this cluster allows multiple occurrences to enable representation of a complete set of dose patterns for a single dose direction., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Immunisation list']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v1]/items[at0144], code=at0144, itemType=ELEMENT, level=6, text=Dose amount, description=The value of the amount of medication administered at one time, as a real number, or range of real numbers, and associated with the Dose unit., comment=For example: 1, 1.5, 0.125 or 1-2, 12.5-20.5, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Quantity>=0
  •  Interval of QuantityLower constraint: >=0
    Upper constraint: >=0
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Immunisation list']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v1]/items[at0145], code=at0145, itemType=ELEMENT, level=6, text=Dose unit, description=The unit which is associated with the Dose amount., comment=For example: 'tablet','mg'. Coding of the dose unit with a terminology is preferred, where possible., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Immunisation list']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v1]/items[openEHR-EHR-CLUSTER.timing_daily.v1], code=at0000, itemType=CLUSTER, level=6, text=Timing - daily, description=Structured information about the intended timing of a therapeutic or diagnostic activity within any 24 hour period., comment=null, uncommonOntologyItems=null, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Immunisation list']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v1]/items[openEHR-EHR-CLUSTER.timing_daily.v1]/items[at0003], code=at0003, itemType=ELEMENT, level=7, text=Frequency, description=The frequency as number of times per time period that the activity is to take place., comment=For example: "4 times per day" or "3 to 4 times per hour"., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Quantity>=1; >=1; >=1; >=1
    Units:
    • 1/d
    • 1/min
    • 1/s
    • 1/h
  •  Interval of QuantityLower constraint: >=1; >=1; >=1; >=1
    Units:
    • 1/d
    • 1/min
    • 1/s
    • 1/h

    Upper constraint: >=1; >=1; >=1; >=1
    Units:
    • 1/d
    • 1/min
    • 1/s
    • 1/h
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Immunisation list']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v1]/items[openEHR-EHR-CLUSTER.timing_daily.v1]/items[at0014], code=at0014, itemType=ELEMENT, level=7, text=Interval, description=The time interval or minimum and maximum range of an interval between each scheduled activity., comment=For example: "Every 4 hours" or "Every 4 to 6 hours"., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DURATION, bindings=null, values=Units:
  • Hour
  • Minute
  • Second
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Immunisation list']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v1]/items[openEHR-EHR-CLUSTER.timing_daily.v1]/items[at0024], code=at0024, itemType=ELEMENT, level=7, text=As required, description=Record as True if the activity should only occur when the "'As required' criterion" is met., comment=Termed 'PRN' ("pro re nata", latin: "as the situation arises") or 'PN' ("per necessare", latin: "when required") in some cultures., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Immunisation list']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[at0140], code=at0140, itemType=CLUSTER, level=5, text=Administration details, description=Details of body site and administration of the medication., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Immunisation list']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[at0140]/items[at0147], code=at0147, itemType=ELEMENT, level=6, text=Route of administration, description=The route by which the ordered item was, or is to be, administered into the subject's body., comment=Comment: For example: 'oral', 'intravenous', or 'topical'. Coding of the route with a terminology is preferred, where possible. Multiple potential routes may be specified., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Immunisation list']/items[openEHR-EHR-ACTION.medication.v1]/protocol[at0030], code=at0030, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Protocol, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Regular medication list'], code=at0000, itemType=SECTION, level=2, text=Regular medication list, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Regular medication list']/items[openEHR-EHR-ACTION.medication.v1], code=at0000, itemType=ACTION, level=3, text=Medication management, 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=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ACTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Regular medication list']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017], code=at0017, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Description, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Regular medication list']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[at0020], code=at0020, itemType=ELEMENT, level=5, text=Medication 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Regular medication list']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v1], code=at0000, itemType=CLUSTER, level=5, text=Medication, description=Details about a medication or component of a medication, including strength, form and details of any specific constituents., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Regular medication list']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v1]/items[at0071], code=at0071, itemType=ELEMENT, level=6, text=Form, description=The formulation or presentation of the medication or medication component., comment=For example: 'tablet', 'capsule', 'cream', 'infusion fluid' or 'inhalation powder'. Coding of the form with a terminology is preferred, where possible. Medicines catalogues may differentiate between administrable form 'solution for injection' and product form 'powder for solution for injection'. The recorded form will depend on the exact context of use but administrable form is likely to be used in most instances., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Regular medication list']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v1]/items[at0152], code=at0152, itemType=CLUSTER, level=6, text=Strength (presentation), description=The strength of the medication or medication component, expressed as a ratio., comment=In some cases, as for liquid or semisolid medications, the denominator of the strength ratio is a physical quantity, for example 2 mg/5 ml. In some of these cases the denominator also reflects the actual volume of the component: 5 ml in the previous example. In this case the 'Strength (concentration)' would be 0.4 mg/ml. In other cases, where the strength involves a denominator which is not a physical quantity, for example 4 mg/tablet, the denominator is expressed as a unitary value '1' with a unit of '1', and 'tablet' is carried in the 'Unit of presentation' element. This arrangement was chosen to align with the approach adopted by the ISO IDMP standard for medication catalogues., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Regular medication list']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v1]/items[at0152]/items[at0153], code=at0153, itemType=ELEMENT, level=7, text=Strength numerator, description=The value of the numerator of the strength fraction., comment=For example: For a presentation strength of '300 µg/0.3 ml', the strength numerator value is '300'. For a presentation strength of '100 mg/tablet', the strength numerator value is '100'., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=>=0 , extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Regular medication list']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v1]/items[at0152]/items[at0004], code=at0004, itemType=ELEMENT, level=7, text=Strength numerator unit, description=The unit of the numerator of the strength fraction., comment=The strength numerator is usually recorded using mass, volume or arbitrary units. For example: 'mg', 'ml', 'IU'. For a presentation strength of '300 µg/0.3 ml', the strength numerator unit is 'µg'. For a presentation strength of '100 mg/tablet', the strength numerator value is 'mg'., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Regular medication list']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v1]/items[at0152]/items[at0157], code=at0157, itemType=ELEMENT, level=7, text=Strength denominator, description=The value of the denominator of the strength fraction., comment=For example: For a presentation strength of '300 µg/0.3 ml', the strength denominator value is '0.3'. For a presentation strength of '100 mg/tablet', the strength denominator value is '1'., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=>=0 , extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Regular medication list']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v1]/items[at0152]/items[at0005], code=at0005, itemType=ELEMENT, level=7, text=Strength denominator unit, description=The unit of the denominator of the strength fraction., comment=The strength denominator is usually recorded using mass or volume units. For example: 'g', 'ml'. For a presentation strength of '300 µg/0.3 ml', the strength denominator unit is 'ml'. For a presentation strength of '100 mg/tablet', the strength denominator unit is '1'. For this example, the 'Unit of presentation' element is used to record the presentation unit of the medication, 'tablet'., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Regular medication list']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v1]/items[at0158], code=at0158, itemType=ELEMENT, level=6, text=Unit of presentation, description=The unit of presentation for a single dose of the medication, for use with the 'Strength denominator unit' element., comment=For example: 'tablet', 'capsule', 'puff', 'inhalation'. In most cases, like for tablets and capsules, the unit of presentation is identical to the Form. For some presentations such as inhalers, the Form may be 'inhalation powder', 'inhalation aerosol' or 'inhaler' while the unit of presentation is 'inhalation', 'puff', or 'dose'., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Regular medication list']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v1]/items[at0115], code=at0115, itemType=ELEMENT, level=6, text=Strength (concentration), description=The strength of the medication or medication component, as a concentration., comment=This element is used for liquid or semisolid medications, or medications intended to be diluted in a liquid before administration. For example: '10 mg/ml', '20 mg/g', '5 %', '10,000 SQ-U/ml'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Regular medication list']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v1], code=at0000, itemType=CLUSTER, level=5, text=Dosage, description=The combination of a medication amount and administration timing for a single day, in the context of a medication order or medication management., comment=For example: '2 tablets at 6pm' or '20mg three times per day'. Please note: this cluster allows multiple occurrences to enable representation of a complete set of dose patterns for a single dose direction., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Regular medication list']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v1]/items[at0144], code=at0144, itemType=ELEMENT, level=6, text=Dose amount, description=The value of the amount of medication administered at one time, as a real number, or range of real numbers, and associated with the Dose unit., comment=For example: 1, 1.5, 0.125 or 1-2, 12.5-20.5, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Quantity>=0
  •  Interval of QuantityLower constraint: >=0
    Upper constraint: >=0
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Regular medication list']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v1]/items[at0145], code=at0145, itemType=ELEMENT, level=6, text=Dose unit, description=The unit which is associated with the Dose amount., comment=For example: 'tablet','mg'. Coding of the dose unit with a terminology is preferred, where possible., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Regular medication list']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v1]/items[openEHR-EHR-CLUSTER.timing_daily.v1], code=at0000, itemType=CLUSTER, level=6, text=Timing - daily, description=Structured information about the intended timing of a therapeutic or diagnostic activity within any 24 hour period., comment=null, uncommonOntologyItems=null, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Regular medication list']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v1]/items[openEHR-EHR-CLUSTER.timing_daily.v1]/items[at0003], code=at0003, itemType=ELEMENT, level=7, text=Frequency, description=The frequency as number of times per time period that the activity is to take place., comment=For example: "4 times per day" or "3 to 4 times per hour"., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Quantity>=1; >=1; >=1; >=1
    Units:
    • 1/d
    • 1/min
    • 1/s
    • 1/h
  •  Interval of QuantityLower constraint: >=1; >=1; >=1; >=1
    Units:
    • 1/d
    • 1/min
    • 1/s
    • 1/h

    Upper constraint: >=1; >=1; >=1; >=1
    Units:
    • 1/d
    • 1/min
    • 1/s
    • 1/h
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Regular medication list']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v1]/items[openEHR-EHR-CLUSTER.timing_daily.v1]/items[at0014], code=at0014, itemType=ELEMENT, level=7, text=Interval, description=The time interval or minimum and maximum range of an interval between each scheduled activity., comment=For example: "Every 4 hours" or "Every 4 to 6 hours"., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DURATION, bindings=null, values=Units:
  • Hour
  • Minute
  • Second
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Regular medication list']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v1]/items[openEHR-EHR-CLUSTER.timing_daily.v1]/items[at0024], code=at0024, itemType=ELEMENT, level=7, text=As required, description=Record as True if the activity should only occur when the "'As required' criterion" is met., comment=Termed 'PRN' ("pro re nata", latin: "as the situation arises") or 'PN' ("per necessare", latin: "when required") in some cultures., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Regular medication list']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[at0140], code=at0140, itemType=CLUSTER, level=5, text=Administration details, description=Details of body site and administration of the medication., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Regular medication list']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[at0140]/items[at0147], code=at0147, itemType=ELEMENT, level=6, text=Route of administration, description=The route by which the ordered item was, or is to be, administered into the subject's body., comment=Comment: For example: 'oral', 'intravenous', or 'topical'. Coding of the route with a terminology is preferred, where possible. Multiple potential routes may be specified., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Regular medication list']/items[openEHR-EHR-ACTION.medication.v1]/protocol[at0030], code=at0030, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Protocol, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Family history list'], code=at0000, itemType=SECTION, level=2, text=Family history list, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Family history list']/items[openEHR-EHR-EVALUATION.family_history.v2 and name/value='Family history summary R1'], code=at0000, itemType=EVALUATION, level=3, text=Family history summary R1, description=Summary information about the significant health-related problems found in family members., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Family history list']/items[openEHR-EHR-EVALUATION.family_history.v2 and name/value='Family history summary R1']/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Family history list']/items[openEHR-EHR-EVALUATION.family_history.v2 and name/value='Family history summary R1']/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=5, text=Summary, description=Narrative overview about problems, diagnoses, psychosocial, environmental and genetic markers that have been identified in family members., comment=This field can be used to record a summary or the conclusion of all the findings, for unstructured family history information recorded in clinical records, or to import textual data from existing/legacy clinical systems., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Family history list']/items[openEHR-EHR-EVALUATION.family_history.v2 and name/value='Family history summary R1']/protocol[at0025], code=at0025, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Protocol, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Family history list']/items[openEHR-EHR-EVALUATION.family_history.v2 and name/value='Family history summary R1']/protocol[at0025]/items[at0026], code=at0026, itemType=ELEMENT, level=5, text=Last Updated, description=The date this family history 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Family history list']/items[openEHR-EHR-EVALUATION.family_history.v2 and name/value='Family history summary R2'], code=at0000, itemType=EVALUATION, level=3, text=Family history summary R2, description=Summary information about the significant health-related problems found in family members., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Family history list']/items[openEHR-EHR-EVALUATION.family_history.v2 and name/value='Family history summary R2']/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Family history list']/items[openEHR-EHR-EVALUATION.family_history.v2 and name/value='Family history summary R2']/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=5, text=Summary, description=Narrative overview about problems, diagnoses, psychosocial, environmental and genetic markers that have been identified in family members., comment=This field can be used to record a summary or the conclusion of all the findings, for unstructured family history information recorded in clinical records, or to import textual data from existing/legacy clinical systems., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Family history list']/items[openEHR-EHR-EVALUATION.family_history.v2 and name/value='Family history summary R2']/data[at0001]/items[at0003], code=at0003, itemType=CLUSTER, level=5, text=Per family member, description=Details about a specific family member., comment=The data elements in this cluster will relate to the individual identified either by name or by alias. Repeat the use of the cluster for other family members., uncommonOntologyItems=null, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Family history list']/items[openEHR-EHR-EVALUATION.family_history.v2 and name/value='Family history summary R2']/data[at0001]/items[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=6, text=Family member name, description=Name of family member., comment=For example: 'Aunt Susan' or 'Susan Smith'. However, for privacy reasons this may not be appropriate for recording, sharing or public display and in this situation the 'Alias' should be used., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Family history list']/items[openEHR-EHR-EVALUATION.family_history.v2 and name/value='Family history summary R2']/data[at0001]/items[at0003]/items[at0020], code=at0020, itemType=ELEMENT, level=6, text=Alias, description=An alternative name or label to uniquely identify a family member, without using a personal name which might publicly identify the individual., comment=To be used to assist in distinguishing one individual from multiple family members with identical relationships. For example, the label to distinguish one specific sister from three known sisters might be 'eldest sister' 'sister with the red hair' or 'sister #1'., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Family history list']/items[openEHR-EHR-EVALUATION.family_history.v2 and name/value='Family history summary R2']/data[at0001]/items[at0003]/items[at0016], code=at0016, itemType=ELEMENT, level=6, text=Relationship, description=The relationship of the family member to the subject of care., comment=For example: mother, step-father, maternal grandmother, or paternal uncle. Coding of the relationship with a terminology is preferred, where possible and including specification of maternal and paternal as required., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Family history list']/items[openEHR-EHR-EVALUATION.family_history.v2 and name/value='Family history summary R2']/data[at0001]/items[at0003]/items[at0005], code=at0005, itemType=ELEMENT, level=6, text=Date of birth, description=Full or partial date of birth of the family member., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Family history list']/items[openEHR-EHR-EVALUATION.family_history.v2 and name/value='Family history summary R2']/data[at0001]/items[at0003]/items[at0023], code=at0023, itemType=ELEMENT, level=6, text=Deceased?, description=Is the family member deceased?, comment=Record as 'True' if family member is deceased., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Family history list']/items[openEHR-EHR-EVALUATION.family_history.v2 and name/value='Family history summary R2']/data[at0001]/items[at0003]/items[at0011], code=at0011, itemType=ELEMENT, level=6, text=Age at death, description=Exact or estimated age of the family member at death., comment=Age of death can be useful if the problem/diagnosis which caused their death is being considered as a risk factor for the subject of the health record. For example: death of mother from breast cancer at young age significally increases the risk of breast cancer in a daughter., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DURATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Family history list']/items[openEHR-EHR-EVALUATION.family_history.v2 and name/value='Family history summary R2']/data[at0001]/items[at0003]/items[at0058], code=at0058, itemType=ELEMENT, level=6, text=Date of death, description=Full or partial date of death of the family member., comment=Date of death may be useful in some situations in which the month of death may trigger decision support or identify groupings of disease. For example: environmental allergens triggering respiratory exaccerbations; or events such as Christmas., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Family history list']/items[openEHR-EHR-EVALUATION.family_history.v2 and name/value='Family history summary R2']/data[at0001]/items[at0003]/items[at0008], code=at0008, itemType=CLUSTER, level=6, text=Clinical history, description=Detail about problems or diagnoses for the family member., comment=If more detail is required, suggest using EVALUATION.problem_diagnosis or the ACTION.procedure archetype and specifying the 'Subject of Care' as the family member, rather than the subject of the health record., uncommonOntologyItems=null, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Family history list']/items[openEHR-EHR-EVALUATION.family_history.v2 and name/value='Family history summary R2']/data[at0001]/items[at0003]/items[at0008]/items[at0009], code=at0009, itemType=ELEMENT, level=7, text=Problem/diagnosis name, description=Identification of the significant problem or diagnosis in the identified family member., comment=Coding of the family member's problem or diagnosis with a terminology is preferred, where possible. May link from this data element to a detailed record of a Problem/Diagnosis using the EVALUATION.problem_diagnosis archetype with the Subject of Care set to the family member, not to the patient., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Diabetes
  • Heart disease
  • Cancer
  • Mental health
  • [...]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Family history list']/items[openEHR-EHR-EVALUATION.family_history.v2 and name/value='Family history summary R2']/data[at0001]/items[at0003]/items[at0008]/items[at0012], code=at0012, itemType=ELEMENT, level=7, text=Clinical description, description=Narrative description or comments about clinical aspects of the family member's problem/diagnosis., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Family history list']/items[openEHR-EHR-EVALUATION.family_history.v2 and name/value='Family history summary R2']/data[at0001]/items[at0003]/items[at0008]/items[at0010], code=at0010, itemType=ELEMENT, level=7, text=Age at onset, description=Estimated or actual age of the family member when the problem/diagnosis was clinically recognised., comment=For health problems with multiple occurrences, this describes the first nown occurrence., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DURATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Family history list']/items[openEHR-EHR-EVALUATION.family_history.v2 and name/value='Family history summary R2']/data[at0001]/items[at0003]/items[at0008]/items[at0014], code=at0014, itemType=ELEMENT, level=7, text=Cause of death?, description=Relationship of the problem/diagnosis to the death of this family member., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Coded Text
    • Direct cause or closely related  [The problem or diagnosis was a direct cause or closely related to the direct cause of death.]
    • Unrelated  [The problem or diagnosis was unrelated to the cause of death.]
    • Indeterminate  [It is impossible to determine whether the problem or diagnosis was closely related to the direct cause of death.]
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Family history list']/items[openEHR-EHR-EVALUATION.family_history.v2 and name/value='Family history summary R2']/data[at0001]/items[at0003]/items[at0046], code=at0046, itemType=ELEMENT, level=6, text=Comment, description=Additional narrative about the family member 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Family history list']/items[openEHR-EHR-EVALUATION.family_history.v2 and name/value='Family history summary R2']/protocol[at0025], code=at0025, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Protocol, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Persistent lists']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Family history list']/items[openEHR-EHR-EVALUATION.family_history.v2 and name/value='Family history summary R2']/protocol[at0025]/items[at0026], code=at0026, itemType=ELEMENT, level=5, text=Last Updated, description=The date this family history 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings'], code=at0000, itemType=SECTION, level=1, text=Examination findings, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-OBSERVATION.exam.v1], code=at0000, itemType=OBSERVATION, level=2, text=Physical examination findings, description=Findings observed during the physical examination of a subject of care., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-OBSERVATION.exam.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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=4, text=Any event, description=Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=5, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=6, text=Description, description=Narrative description of the overall findings observed during a physical examination of a patient., comment=May be used to record a narrative summary of the complete clinical examination or key aspects of clinical examination findings, which will be supported by structured data. Details of specific structured findings can be included using CLUSTER archetypes in the 'Examination Detail' slot. This data element may be used to capture legacy data that is not available in a structured format., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam-heart.v0], code=at0000.1, itemType=CLUSTER, level=6, text=Examination of the heart, description=Findings observed during the physical examination of the heart., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam-heart.v0]/items[at0001.1], code=at0001.1, itemType=ELEMENT, level=7, text=System or structure examined, description=Identification of the examined body system or anatomical structure., comment=Coding of the system or structure examined with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Heart  [The heart was examined.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam-heart.v0]/items[at0003], code=at0003, itemType=ELEMENT, level=7, text=Clinical description, description=Narrative description of the overall findings observed during the physical examination., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam-heart.v0]/items[at0.2], code=at0.2, itemType=ELEMENT, level=7, text=Heart sounds description, description=Narrative description of the heart sounds., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam-ear.v0], code=at0000.1, itemType=CLUSTER, level=6, text=Examination of an ear, description=Findings observed during the physical examination of a single ear., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam-ear.v0]/items[at0001.1], code=at0001.1, itemType=ELEMENT, level=7, text=System or structure examined, description=Identification of the examined body system or anatomical structure., comment=Coding of the system or structure examined with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Left ear  [The left ear was examined.]
  • Right ear  [The right ear was examined.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam-ear.v0]/items[at0003], code=at0003, itemType=ELEMENT, level=7, text=Clinical description, description=Narrative description of the overall findings observed during the physical examination., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam-mouth.v0], code=at0000.1, itemType=CLUSTER, level=6, text=Examination of the mouth, description=Findings observed during the physical examination of the mouth as a whole., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam-mouth.v0]/items[at0001.1], code=at0001.1, itemType=ELEMENT, level=7, text=System or structure examined, description=Identification of the examined body system or anatomical structure., comment=Coding of the system or structure examined with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Mouth  [The mouth, as a whole, is examined.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam-mouth.v0]/items[at0003], code=at0003, itemType=ELEMENT, level=7, text=Clinical description, description=Narrative description of the overall findings observed during the physical examination., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam-mouth.v0]/items[at0.3], code=at0.3, itemType=ELEMENT, level=7, text=Dentition description, description=Narrative description about all teeth., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam-eyes.v0], code=at0000.1, itemType=CLUSTER, level=6, text=Examination of both eyes, description=Findings observed during the physical examination of both eyes at the same time., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam-eyes.v0]/items[at0001.1], code=at0001.1, itemType=ELEMENT, level=7, text=System or structure examined, description=Identification of the examined body system or anatomical structure., comment=Coding of the system or structure examined with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Both eyes  [The left and right eyes are examined at the same time.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam-eyes.v0]/items[openEHR-EHR-CLUSTER.exam-eye.v0], code=at0000.1, itemType=CLUSTER, level=7, text=Examination of an eye, description=Findings observed during the physical examination of a single eye., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam-eyes.v0]/items[openEHR-EHR-CLUSTER.exam-eye.v0]/items[at0001.1], code=at0001.1, itemType=ELEMENT, level=8, text=System or structure examined, description=Identification of the examined body system or anatomical structure., comment=Coding of the system or structure examined with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Left eye  [The left eye was examined.]
  • Right eye  [The right eye was examined.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam-eyes.v0]/items[openEHR-EHR-CLUSTER.exam-eye.v0]/items[at0003], code=at0003, itemType=ELEMENT, level=8, text=Clinical description, description=Narrative description of the overall findings observed during the physical examination., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam-eyes.v0]/items[openEHR-EHR-CLUSTER.exam-eye.v0]/items[at0.17], code=at0.17, itemType=ELEMENT, level=8, text=Red reflex, description=Presence of the red reflex., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present  [The red reflex is observed.]
  • Absent  [The red reflex is not present.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam-eyes.v0]/items[at0003], code=at0003, itemType=ELEMENT, level=7, text=Clinical description, description=Narrative description of the overall findings observed during the physical examination., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/state[at0009], code=at0009, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=5, text=State, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/protocol[at0007], code=at0007, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Protocol, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1], code=at0000, itemType=OBSERVATION, level=2, text=Laboratory test result, description=The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=4, text=Any event, description=Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=5, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0005], code=at0005, itemType=ELEMENT, level=6, text=Test name, description=Name of the laboratory investigation performed on the specimen(s)., comment=A test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • POCT Hb
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.laboratory_test_analyte.v1], code=at0000, itemType=CLUSTER, level=6, text=Laboratory analyte result, description=The result of a laboratory test for a single analyte value., comment=null, uncommonOntologyItems=null, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.laboratory_test_analyte.v1]/items[at0024], code=at0024, itemType=ELEMENT, level=7, text=Analyte name, description=The name of the analyte result., comment=The value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies., uncommonOntologyItems={fhir_mapping=Observation.code, hl7v2_mapping=OBX.3}, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Haemoglobin
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.laboratory_test_analyte.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=7, text=Analyte result, description=The value of the analyte result., comment=For example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details., uncommonOntologyItems={fhir_mapping=Observation.value[x], hl7v2_mapping=OBX.2, OBX.5, OBX.6, OBX.7, OBX.8}, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=>=0 g/dl, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0057], code=at0057, itemType=ELEMENT, level=6, text=Conclusion, description=Narrative description of the key findings., comment=For example: 'Pattern suggests significant renal impairment'. The content of the conclusion will vary, depending on the investigation performed. This conclusion should be aligned with the coded 'Test diagnosis'., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/state[at0112], code=at0112, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=5, text=State, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/protocol[at0004], code=at0004, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Protocol, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/protocol[at0004]/items[at0094], code=at0094, itemType=CLUSTER, level=4, text=Test request details, description=Details about the test request., comment=In most situations there is one test request and a single corresponding test result, however this repeating cluster allows for the situation where there may be multiple test requests reported using a single test result. As an example: 'a clinician asks for blood glucose in one request and Urea/electrolytes in a second request, but the lab analyser does both and the lab wishes to report these together'., uncommonOntologyItems=null, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/protocol[at0004]/items[at0111], code=at0111, itemType=ELEMENT, level=4, text=Point-of-care test, description=This indicates whether the test was performed directly at Point-of-Care (POCT) as opposed to a formal result from a laboratory or other service delivery organisation., comment=True if the test was performed directly at Point-of-Care (POCT)., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Measurements'], code=at0000, itemType=SECTION, level=2, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Measurements']/items[openEHR-EHR-OBSERVATION.height.v2], code=at0000, itemType=OBSERVATION, level=3, text=Height/length item, description=Height, or body length, is measured from crown of head to sole of foot., comment=Height is measured with the individual in a standing position and body length in a recumbent position., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Measurements']/items[openEHR-EHR-OBSERVATION.height.v2]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Measurements']/items[openEHR-EHR-OBSERVATION.height.v2]/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=5, text=Any event, description=Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Measurements']/items[openEHR-EHR-OBSERVATION.height.v2]/data[at0001]/events[at0002]/data[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=6, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[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=7, text=Height/Length, 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:
  • cm
  • [in_i]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Measurements']/items[openEHR-EHR-OBSERVATION.height.v2]/data[at0001]/events[at0002]/state[at0013], code=at0013, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=6, text=State, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Measurements']/items[openEHR-EHR-OBSERVATION.height.v2]/protocol[at0007], code=at0007, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Protocol, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Measurements']/items[openEHR-EHR-OBSERVATION.body_weight.v2], code=at0000, itemType=OBSERVATION, level=3, text=Body weight, description=Measurement of the body weight of an individual., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Measurements']/items[openEHR-EHR-OBSERVATION.body_weight.v2]/data[at0002], code=at0002, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Measurements']/items[openEHR-EHR-OBSERVATION.body_weight.v2]/data[at0002]/events[at0003], code=at0003, itemType=EVENT, level=5, text=Any event, description=Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Measurements']/items[openEHR-EHR-OBSERVATION.body_weight.v2]/data[at0002]/events[at0003]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=6, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Measurements']/items[openEHR-EHR-OBSERVATION.body_weight.v2]/data[at0002]/events[at0003]/data[at0001]/items[at0004], code=at0004, itemType=ELEMENT, level=7, text=Weight, description=The weight of the individual., 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..2000; 0..1000000
Units:
  • kg
  • [lb_av]
  • g
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Measurements']/items[openEHR-EHR-OBSERVATION.body_weight.v2]/data[at0002]/events[at0003]/state[at0008], code=at0008, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=6, text=State, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Measurements']/items[openEHR-EHR-OBSERVATION.body_weight.v2]/protocol[at0015], code=at0015, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Protocol, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Measurements']/items[openEHR-EHR-OBSERVATION.waist_circumference.v1], code=at0000, itemType=OBSERVATION, level=3, text=Waist circumference, description=The measurement of the distance around the waist., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Measurements']/items[openEHR-EHR-OBSERVATION.waist_circumference.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Measurements']/items[openEHR-EHR-OBSERVATION.waist_circumference.v1]/data[at0001]/events[at0010], code=at0010, itemType=EVENT, level=5, text=Any event, description=Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Measurements']/items[openEHR-EHR-OBSERVATION.waist_circumference.v1]/data[at0001]/events[at0010]/data[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=6, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Measurements']/items[openEHR-EHR-OBSERVATION.waist_circumference.v1]/data[at0001]/events[at0010]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=7, text=Waist circumference, description=The measurement of the circumference of the waist., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=0..500; 0..400
Units:
  • cm
  • [in_i]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Measurements']/items[openEHR-EHR-OBSERVATION.waist_circumference.v1]/data[at0001]/events[at0010]/state[at0008], code=at0008, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=6, text=State, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Measurements']/items[openEHR-EHR-OBSERVATION.waist_circumference.v1]/protocol[at0005], code=at0005, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Protocol, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Measurements']/items[openEHR-EHR-OBSERVATION.body_mass_index.v2], code=at0000, itemType=OBSERVATION, level=3, text=Body mass index, description=Calculated measurement which compares a person's weight and height., comment=Body Mass Index is a calculated ratio describing how an individual's body weight relates to the weight that is regarded as normal, or desirable, for the individual's height., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Measurements']/items[openEHR-EHR-OBSERVATION.body_mass_index.v2]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Measurements']/items[openEHR-EHR-OBSERVATION.body_mass_index.v2]/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=5, text=Any event, description=Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Measurements']/items[openEHR-EHR-OBSERVATION.body_mass_index.v2]/data[at0001]/events[at0002]/data[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=6, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Measurements']/items[openEHR-EHR-OBSERVATION.body_mass_index.v2]/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=7, text=Body mass index, description=Index describing ratio of weight to height., 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..1000
Units:
  • kg/m2
  • [lb_av]/[in_i]2
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Measurements']/items[openEHR-EHR-OBSERVATION.body_mass_index.v2]/data[at0001]/events[at0002]/state[at0014], code=at0014, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=6, text=State, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Measurements']/items[openEHR-EHR-OBSERVATION.body_mass_index.v2]/protocol[at0005], code=at0005, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Protocol, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Vital signs'], code=at0000, itemType=SECTION, level=2, text=Vital signs, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Vital signs']/items[openEHR-EHR-OBSERVATION.blood_pressure.v2], code=at0000, itemType=OBSERVATION, level=3, text=Blood pressure, description=The local measurement of arterial blood pressure which is a surrogate for arterial pressure in the systemic circulation., comment=Most commonly, use of the term 'blood pressure' refers to measurement of brachial artery pressure in the upper arm., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination 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comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Vital signs']/items[openEHR-EHR-OBSERVATION.blood_pressure.v2]/data[at0001]/events[at0006]/data[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=6, 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 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signs']/items[openEHR-EHR-OBSERVATION.blood_pressure.v2]/data[at0001]/events[at0006]/data[at0003]/items[at0005], code=at0005, itemType=ELEMENT, level=7, text=Diastolic, description=Minimum systemic arterial blood pressure - measured in the diastolic or relaxation phase of the heart cycle., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=0..1000 mm[Hg], extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Vital signs']/items[openEHR-EHR-OBSERVATION.blood_pressure.v2]/data[at0001]/events[at0006]/state[at0007], code=at0007, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=6, text=State, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Vital signs']/items[openEHR-EHR-OBSERVATION.blood_pressure.v2]/protocol[at0011], code=at0011, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Protocol, description=List structure., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 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cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Vital signs']/items[openEHR-EHR-OBSERVATION.respiration.v2]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Vital signs']/items[openEHR-EHR-OBSERVATION.respiration.v2]/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=5, text=Any event, description=Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Vital signs']/items[openEHR-EHR-OBSERVATION.respiration.v2]/data[at0001]/events[at0002]/data[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=6, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Vital signs']/items[openEHR-EHR-OBSERVATION.respiration.v2]/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=7, text=Rate, description=The frequency of spontaneous breathing., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=0..200 /min, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Vital signs']/items[openEHR-EHR-OBSERVATION.respiration.v2]/data[at0001]/events[at0002]/state[at0022], code=at0022, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=6, text=State, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Vital signs']/items[openEHR-EHR-OBSERVATION.respiration.v2]/protocol[at0057], code=at0057, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Protocol, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Vital signs']/items[openEHR-EHR-OBSERVATION.body_temperature.v2], code=at0000, itemType=OBSERVATION, level=3, text=Body temperature, description=A measurement of the body temperature, which is a surrogate for the core body temperature of the individual., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Vital signs']/items[openEHR-EHR-OBSERVATION.body_temperature.v2]/data[at0002], code=at0002, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Vital signs']/items[openEHR-EHR-OBSERVATION.body_temperature.v2]/data[at0002]/events[at0003], code=at0003, itemType=EVENT, level=5, text=Any event, description=Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Vital signs']/items[openEHR-EHR-OBSERVATION.body_temperature.v2]/data[at0002]/events[at0003]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=6, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Vital signs']/items[openEHR-EHR-OBSERVATION.body_temperature.v2]/data[at0002]/events[at0003]/data[at0001]/items[at0004], code=at0004, itemType=ELEMENT, level=7, text=Temperature, description=The measured temperature., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=0..100; 30..200
Units:
  • Cel
  • [degF]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Vital signs']/items[openEHR-EHR-OBSERVATION.body_temperature.v2]/data[at0002]/events[at0003]/state[at0029], code=at0029, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=6, text=State, description=State information about the patient., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination findings']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Vital signs']/items[openEHR-EHR-OBSERVATION.body_temperature.v2]/protocol[at0020], code=at0020, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Protocol, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Risk assessment'], code=at0000, itemType=SECTION, level=1, text=Risk assessment, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Risk assessment']/items[openEHR-EHR-OBSERVATION.au_absolute_cvd_risk.v0], code=at0000, itemType=OBSERVATION, level=2, text=Absolute cardiovascular risk assessment, description=An assessment tool used to calculate the absolute cardiovascular disease risk (CVD) in the next 5 years., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Risk assessment']/items[openEHR-EHR-OBSERVATION.au_absolute_cvd_risk.v0]/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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Risk assessment']/items[openEHR-EHR-OBSERVATION.au_absolute_cvd_risk.v0]/data[at0001]/events[at0002], code=at0002, itemType=POINT_EVENT, level=4, text=Any point in time event, description=Default, unspecified point in time event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=POINT_EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Risk assessment']/items[openEHR-EHR-OBSERVATION.au_absolute_cvd_risk.v0]/data[at0001]/events[at0002]/data[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=5, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Risk assessment']/items[openEHR-EHR-OBSERVATION.au_absolute_cvd_risk.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0029], code=at0029, itemType=ELEMENT, level=6, text=Calculated risk score, description=The calculated risk score., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_PROPORTION, bindings=null, values=
  • Percent
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Risk assessment']/items[openEHR-EHR-OBSERVATION.au_absolute_cvd_risk.v0]/protocol[at0027], code=at0027, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Protocol, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Risk assessment']/items[openEHR-EHR-OBSERVATION.alcohol_audit.v0], code=at0000, itemType=OBSERVATION, level=2, text=Alcohol Use Disorders Identification Test (AUDIT), description=Ten question screening test to identify harmful alcohol consumption., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Risk assessment']/items[openEHR-EHR-OBSERVATION.alcohol_audit.v0]/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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Risk assessment']/items[openEHR-EHR-OBSERVATION.alcohol_audit.v0]/data[at0001]/events[at0002], code=at0002, itemType=POINT_EVENT, level=4, text=Any point in time, description=Default, unspecified point in time event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=POINT_EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Risk assessment']/items[openEHR-EHR-OBSERVATION.alcohol_audit.v0]/data[at0001]/events[at0002]/data[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=5, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Risk assessment']/items[openEHR-EHR-OBSERVATION.alcohol_audit.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0033], code=at0033, itemType=ELEMENT, level=6, text=AUDIT-C total score, description=Total Score calculated from the first 3 questions only., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=0..12, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Risk assessment']/items[openEHR-EHR-OBSERVATION.alcohol_audit.v0]/protocol[at0035], code=at0035, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Protocol, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Risk assessment']/items[openEHR-EHR-OBSERVATION.phq_9.v0], code=at0000, itemType=OBSERVATION, level=2, text=Patient health questionnaire-9 (PHQ-9), description=Screening questionnaire for mental health that can be used by health professionals or self-reported by individuals., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Risk assessment']/items[openEHR-EHR-OBSERVATION.phq_9.v0]/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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Risk assessment']/items[openEHR-EHR-OBSERVATION.phq_9.v0]/data[at0001]/events[at0002], code=at0002, itemType=POINT_EVENT, level=4, text=Point in Time, description=A specific date and/or time which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=POINT_EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Risk assessment']/items[openEHR-EHR-OBSERVATION.phq_9.v0]/data[at0001]/events[at0002]/data[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=5, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Risk assessment']/items[openEHR-EHR-OBSERVATION.phq_9.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0011], code=at0011, itemType=ELEMENT, level=6, text=PHQ-9 score, description=Total Score for all nine questions., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=0..27, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Risk assessment']/items[openEHR-EHR-OBSERVATION.phq_9.v0]/protocol[at0024], code=at0024, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Protocol, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Risk assessment']/items[openEHR-EHR-EVALUATION.health_risk.v1], code=at0000, itemType=EVALUATION, level=2, text=Blood borne virus screening, description=Assessment of the potential and likelihood of future adverse health effects as determined by identified risk factors., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Risk assessment']/items[openEHR-EHR-EVALUATION.health_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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Risk assessment']/items[openEHR-EHR-EVALUATION.health_risk.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Health risk, description=Identification of the potential future disease, condition or health issue for which the risk is being assessed, by name., comment=Coding of 'Health risk' with a terminology is preferred, where possible. Free text should be used only if there is no appropriate terminology available. For example: risk of cardiovascular disease, with risk factors of hypertension and hypercholesterolaemia., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Blood borne virus infection
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Risk assessment']/items[openEHR-EHR-EVALUATION.health_risk.v1]/data[at0001]/items[at0003], code=at0003, itemType=ELEMENT, level=4, text=Risk assessment, description=Evaluation of the health risk., comment=There may be multiple variations on the assessment of risk. The Choice data type allows for recording of the assessment as either free text or value sets (such as low, medium or hig). The proportion data type allows recording of a percentage, a ratio or a fraction. The quantity data type allows recording of a decimal number., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Text
  •  Proportion
  •  QuantityUnits:
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Risk assessment']/items[openEHR-EHR-EVALUATION.health_risk.v1]/data[at0001]/items[at0015], code=at0015, itemType=ELEMENT, level=4, text=Comment, description=Additional narrative about the risk assessment 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Risk assessment']/items[openEHR-EHR-EVALUATION.health_risk.v1]/protocol[at0010], code=at0010, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Protocol, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Risk assessment']/items[openEHR-EHR-EVALUATION.health_risk.v1]/protocol[at0010]/items[at0024], code=at0024, itemType=ELEMENT, level=4, text=Last updated, description=The date this health risk assessment was last updated., comment=This data element may be thought redundant if the data is recorded and stored using COMPOSITIONs within a closed clinical system. However if this information is extracted from its original COMPOSITION context, for example, to be included in another document or message then the temporal context is effectively removed. This 'Last updated' data element has been explicitly added to allow the critical temporal data to be kept alongside the clinical data in all circumstances. It is assumed that the clinical system can copy the date from the COMPOSITION to reduce the need for duplication of data entry by the clinician., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Activities'], code=at0000, itemType=SECTION, level=1, text=Activities, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Activities']/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=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ACTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Activities']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017], code=at0017, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Description, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Activities']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[at0020], code=at0020, itemType=ELEMENT, level=4, text=Immunisation 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=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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Activities']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v1], code=at0000, itemType=CLUSTER, level=4, text=Immunisation detail, description=Details about a medication or component of a medication, including strength, form and details of any specific constituents., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Activities']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v1]/items[at0071], code=at0071, itemType=ELEMENT, level=5, text=Form, description=The formulation or presentation of the medication or medication component., comment=For example: 'tablet', 'capsule', 'cream', 'infusion fluid' or 'inhalation powder'. Coding of the form with a terminology is preferred, where possible. Medicines catalogues may differentiate between administrable form 'solution for injection' and product form 'powder for solution for injection'. The recorded form will depend on the exact context of use but administrable form is likely to be used in most instances., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Activities']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v1]/items[at0152], code=at0152, itemType=CLUSTER, level=5, text=Strength (presentation), description=The strength of the medication or medication component, expressed as a ratio., comment=In some cases, as for liquid or semisolid medications, the denominator of the strength ratio is a physical quantity, for example 2 mg/5 ml. In some of these cases the denominator also reflects the actual volume of the component: 5 ml in the previous example. In this case the 'Strength (concentration)' would be 0.4 mg/ml. In other cases, where the strength involves a denominator which is not a physical quantity, for example 4 mg/tablet, the denominator is expressed as a unitary value '1' with a unit of '1', and 'tablet' is carried in the 'Unit of presentation' element. This arrangement was chosen to align with the approach adopted by the ISO IDMP standard for medication catalogues., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Activities']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v1]/items[at0152]/items[at0153], code=at0153, itemType=ELEMENT, level=6, text=Strength numerator, description=The value of the numerator of the strength fraction., comment=For example: For a presentation strength of '300 µg/0.3 ml', the strength numerator value is '300'. For a presentation strength of '100 mg/tablet', the strength numerator value is '100'., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=>=0 , extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Activities']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v1]/items[at0152]/items[at0004], code=at0004, itemType=ELEMENT, level=6, text=Strength numerator unit, description=The unit of the numerator of the strength fraction., comment=The strength numerator is usually recorded using mass, volume or arbitrary units. For example: 'mg', 'ml', 'IU'. For a presentation strength of '300 µg/0.3 ml', the strength numerator unit is 'µg'. For a presentation strength of '100 mg/tablet', the strength numerator value is 'mg'., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Activities']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v1]/items[at0152]/items[at0157], code=at0157, itemType=ELEMENT, level=6, text=Strength denominator, description=The value of the denominator of the strength fraction., comment=For example: For a presentation strength of '300 µg/0.3 ml', the strength denominator value is '0.3'. For a presentation strength of '100 mg/tablet', the strength denominator value is '1'., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=>=0 , extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Activities']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v1]/items[at0152]/items[at0005], code=at0005, itemType=ELEMENT, level=6, text=Strength denominator unit, description=The unit of the denominator of the strength fraction., comment=The strength denominator is usually recorded using mass or volume units. For example: 'g', 'ml'. For a presentation strength of '300 µg/0.3 ml', the strength denominator unit is 'ml'. For a presentation strength of '100 mg/tablet', the strength denominator unit is '1'. For this example, the 'Unit of presentation' element is used to record the presentation unit of the medication, 'tablet'., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Activities']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v1]/items[at0158], code=at0158, itemType=ELEMENT, level=5, text=Unit of presentation, description=The unit of presentation for a single dose of the medication, for use with the 'Strength denominator unit' element., comment=For example: 'tablet', 'capsule', 'puff', 'inhalation'. In most cases, like for tablets and capsules, the unit of presentation is identical to the Form. For some presentations such as inhalers, the Form may be 'inhalation powder', 'inhalation aerosol' or 'inhaler' while the unit of presentation is 'inhalation', 'puff', or 'dose'., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Activities']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v1]/items[at0115], code=at0115, itemType=ELEMENT, level=5, text=Strength (concentration), description=The strength of the medication or medication component, as a concentration., comment=This element is used for liquid or semisolid medications, or medications intended to be diluted in a liquid before administration. For example: '10 mg/ml', '20 mg/g', '5 %', '10,000 SQ-U/ml'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Activities']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v1], code=at0000, itemType=CLUSTER, level=4, text=Dosage, description=The combination of a medication amount and administration timing for a single day, in the context of a medication order or medication management., comment=For example: '2 tablets at 6pm' or '20mg three times per day'. Please note: this cluster allows multiple occurrences to enable representation of a complete set of dose patterns for a single dose direction., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Activities']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v1]/items[at0144], code=at0144, itemType=ELEMENT, level=5, text=Dose amount, description=The value of the amount of medication administered at one time, as a real number, or range of real numbers, and associated with the Dose unit., comment=For example: 1, 1.5, 0.125 or 1-2, 12.5-20.5, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Quantity>=0
  •  Interval of QuantityLower constraint: >=0
    Upper constraint: >=0
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Activities']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v1]/items[at0145], code=at0145, itemType=ELEMENT, level=5, text=Dose unit, description=The unit which is associated with the Dose amount., comment=For example: 'tablet','mg'. Coding of the dose unit with a terminology is preferred, where possible., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Activities']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v1]/items[openEHR-EHR-CLUSTER.timing_daily.v1], code=at0000, itemType=CLUSTER, level=5, text=Timing - daily, description=Structured information about the intended timing of a therapeutic or diagnostic activity within any 24 hour period., comment=null, uncommonOntologyItems=null, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Activities']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v1]/items[openEHR-EHR-CLUSTER.timing_daily.v1]/items[at0003], code=at0003, itemType=ELEMENT, level=6, text=Frequency, description=The frequency as number of times per time period that the activity is to take place., comment=For example: "4 times per day" or "3 to 4 times per hour"., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Quantity>=1; >=1; >=1; >=1
    Units:
    • 1/d
    • 1/min
    • 1/s
    • 1/h
  •  Interval of QuantityLower constraint: >=1; >=1; >=1; >=1
    Units:
    • 1/d
    • 1/min
    • 1/s
    • 1/h

    Upper constraint: >=1; >=1; >=1; >=1
    Units:
    • 1/d
    • 1/min
    • 1/s
    • 1/h
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Activities']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v1]/items[openEHR-EHR-CLUSTER.timing_daily.v1]/items[at0014], code=at0014, itemType=ELEMENT, level=6, text=Interval, description=The time interval or minimum and maximum range of an interval between each scheduled activity., comment=For example: "Every 4 hours" or "Every 4 to 6 hours"., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DURATION, bindings=null, values=Units:
  • Hour
  • Minute
  • Second
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Activities']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v1]/items[openEHR-EHR-CLUSTER.timing_daily.v1]/items[at0024], code=at0024, itemType=ELEMENT, level=6, text=As required, description=Record as True if the activity should only occur when the "'As required' criterion" is met., comment=Termed 'PRN' ("pro re nata", latin: "as the situation arises") or 'PN' ("per necessare", latin: "when required") in some cultures., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Activities']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[at0140], code=at0140, itemType=CLUSTER, level=4, text=Administration details, description=Details of body site and administration of the medication., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Activities']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[at0140]/items[at0147], code=at0147, itemType=ELEMENT, level=5, text=Route of administration, description=The route by which the ordered item was, or is to be, administered into the subject's body., comment=Comment: For example: 'oral', 'intravenous', or 'topical'. Coding of the route with a terminology is preferred, where possible. Multiple potential routes may be specified., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Activities']/items[openEHR-EHR-ACTION.medication.v1]/protocol[at0030], code=at0030, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Protocol, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Activities']/items[openEHR-EHR-ACTION.health_education.v1], code=at0000, itemType=ACTION, level=2, text=Health education, description=Communication to improve health literacy and life skills., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ACTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Activities']/items[openEHR-EHR-ACTION.health_education.v1]/description[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Description, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Activities']/items[openEHR-EHR-ACTION.health_education.v1]/description[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Topic name, description=Identification of the topic of health education, by name., comment=The 'Topic' could identify a single piece of information or a single skill, or it may be the name of a training course or program that may be delivered over multiple sessions or visits. The name may indicate that the education was transferred to a group or the individual., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Screen use
  • Physical activity and exercise
  • Mental health and wellbeing
  • Carer support
  • Safety/risky behaviours
  • Safe sex/contraception
  • Smoking cessation
  • Substance use/harm minimisation
  • Oral and dental health
  • Healthy eating, including breastfeeding
  • Sugary drinks
  • Physical activity and exercise
  • Screen use
  • Environmental exposure to harmful elements eg tobacco smoke
  • Sun protection
  • Safe sleeping practices
  • Developmental milestones – including language and hearing
  • Parenting advice
  • Care of teeth and gums
  • Mental health and wellbeing
  • Carer support
  • Social support and services
  • [...]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Activities']/items[openEHR-EHR-ACTION.health_education.v1]/protocol[at0021], code=at0021, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Protocol, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Conclusions'], code=at0000, itemType=SECTION, level=1, text=Conclusions, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Conclusions']/items[openEHR-EHR-EVALUATION.clinical_synopsis.v1 and name/value='Clinical notes/synopsis'], code=at0000, itemType=EVALUATION, level=2, text=Clinical notes/synopsis, description=Narrative summary or overview about a patient, specifically from the perspective of a healthcare provider, and with or without associated interpretations., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Conclusions']/items[openEHR-EHR-EVALUATION.clinical_synopsis.v1 and name/value='Clinical notes/synopsis']/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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Conclusions']/items[openEHR-EHR-EVALUATION.clinical_synopsis.v1 and name/value='Clinical notes/synopsis']/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Synopsis, description=The summary, assessment, conclusions or evaluation of the clinical findings., comment=null, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Conclusions']/items[openEHR-EHR-EVALUATION.clinical_synopsis.v1 and name/value='Clinical notes/synopsis']/protocol[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Protocol, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Conclusions']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1], code=at0000, itemType=EVALUATION, level=2, text=Problem/Diagnosis, description=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., comment=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'., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Conclusions']/items[openEHR-EHR-EVALUATION.problem_diagnosis.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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Conclusions']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Conclusions']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0012], code=at0012, itemType=ELEMENT, level=4, 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=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Conclusions']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.anatomical_location.v1], code=at0000, itemType=CLUSTER, level=4, text=Anatomical location, description=A physical site on or within the human body., comment=null, uncommonOntologyItems=null, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Conclusions']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.anatomical_location.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=5, text=Body site name, description=Identification of a single physical site either on, or within, the human body., comment=This data element is the only mandated data point in this archetype and should be used as the primary data point to record an anatomical location with a commonly used name. It is strongly recommended that 'Body site name' be recorded as specifically as is anatomically possible. For example: record 'upper eyelid' rather than recording 'eyelid' with 'upper' as a qualifier; 'fifth rib' rather than 'rib' with a numeric qualifier. Use the other data elements for laterality, aspect, region and anatomical line to provide more detail. This data element should be coded with a terminology capable of triggering decision support, where possible - an appropriate termset for use here could comprise individual concepts or a list of precoordinated terms. Free text should be used only if there is no appropriate terminology available. If body site name is already identified in the parent archetype, then this data element may be redundant. Alternatively, a use case has been identified where the value may be duplicated into this element to support semantic querying using this archetype, rather than the data element within the parent., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Conclusions']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.anatomical_location.v1]/items[at0065], code=at0065, itemType=ELEMENT, level=5, text=Specific site, description=Additional detail using a specific region or a point on, or within, the identified body site., comment=Use to increase precision of identification of the body site, if required. For example, the upper right quadrant or McBurney's point on the abdominal wall or interphalangeal joint of the great toe. If the 'Body site name' data element uses pre-coordinated terms that include the specific site, then this data element is 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Conclusions']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.anatomical_location.v1]/items[at0002], code=at0002, itemType=ELEMENT, level=5, text=Laterality, description=The side of the body on which the identified body site is located., comment=If the identified body site has no laterality, this data element should not have a value. If the 'Body site name' data element uses pre-coordinated terms that include laterality, then this data element is redundant., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Left  [Left side of the body.]
  • Right  [Right side of the body.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Conclusions']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0003], code=at0003, itemType=ELEMENT, level=4, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Conclusions']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0005], code=at0005, itemType=ELEMENT, level=4, 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=CHOICE, bindings=null, values=
  •  Coded Text
    • Mild  [The problem or diagnosis does not interfere with normal activity or may cause damage to health if left untreated.]
    • Moderate  [The problem or diagnosis causes interference with normal activity or will damage health if left untreated.]
    • Severe  [The problem or diagnosis prevents normal activity or will seriously damage health if left untreated.]
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Conclusions']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0072], code=at0072, itemType=ELEMENT, level=4, text=Course, description=Narrative description about the course of the problem or diagnosis since onset., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Conclusions']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v1], code=at0000, itemType=CLUSTER, level=4, text=Problem/Diagnosis qualifier, description=Contextual or temporal qualifier for a specified problem or diagnosis., comment=null, uncommonOntologyItems=null, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Conclusions']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v1]/items[at0003], code=at0003, itemType=ELEMENT, level=5, text=Active/Inactive?, description=Category that supports division of problems and diagnoses into Active or Inactive problem lists., comment=The Active/Inactive and Current/Past data elements have similar clinical impact but represent slightly different semantics. Both are actively used in different clinical settings, but usually not together. If a Current/Past qualifier is recorded, then this data element is likely to be redundant. An exception where a condition can be current but inactive is asthma that is not causing acute symptoms., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Active  [The problem or diagnosis is currently active and clinically relevant.]
  • Inactive  [The problem or diagnosis is not completely resolved but is inactive or felt less relevant to the current clinical context.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Conclusions']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0069], code=at0069, itemType=ELEMENT, level=4, text=Comment, description=Additional narrative about the problem or diagnosis 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Conclusions']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/protocol[at0032], code=at0032, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Protocol, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Conclusions']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/protocol[at0032]/items[at0070], code=at0070, itemType=ELEMENT, level=4, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Conclusions']/items[openEHR-EHR-EVALUATION.recommendation.v1], code=at0000, itemType=EVALUATION, level=2, text=Recommendation, description=A suggestion, advice or proposal for clinical management., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Conclusions']/items[openEHR-EHR-EVALUATION.recommendation.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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Conclusions']/items[openEHR-EHR-EVALUATION.recommendation.v1]/data[at0001]/items[at0006], code=at0006, itemType=ELEMENT, level=4, text=Topic, description=The topic or subject of the recommendation., comment=Useful if multiple types of recommendations are made at the same time, and within the same data set., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Stressful life events
  • Social connection
  • Food security
  • Housing stability
  • Gambling (self)
  • Gambling (others)
  • Safety at home
  • Mood
  • Mental health
  • Diet
  • Weight
  • Physical activity
  • Screen time
  • Vision
  • Hearing
  • Teeth
  • Sexual health
  • Sleep
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Conclusions']/items[openEHR-EHR-EVALUATION.recommendation.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Recommendation, description=Narrative description of the recommendation., comment=May be coded, using a terminology, if required., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Conclusions']/items[openEHR-EHR-EVALUATION.recommendation.v1]/data[at0001]/items[at0003], code=at0003, itemType=ELEMENT, level=4, text=Rationale, description=Justifications for the recommendation., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Conclusions']/items[openEHR-EHR-EVALUATION.recommendation.v1]/protocol[at0004], code=at0004, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Protocol, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Conclusions']/items[openEHR-EHR-EVALUATION.goal.v1], code=at0000, itemType=EVALUATION, level=2, text=Goal, description=A desired health, or well-being, outcome for the subject of care., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Conclusions']/items[openEHR-EHR-EVALUATION.goal.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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Conclusions']/items[openEHR-EHR-EVALUATION.goal.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Goal name, description=The name of the desired health outcome., comment=For example: reduced blood pressure; 10 kilogram weight loss; or diabetes control., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Conclusions']/items[openEHR-EHR-EVALUATION.goal.v1]/data[at0001]/items[at0012], code=at0012, itemType=ELEMENT, level=4, text=Goal description, description=A narrative description of the goal, including target/s to be achieved if relevant., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Conclusions']/items[openEHR-EHR-EVALUATION.goal.v1]/data[at0001]/items[at0010], code=at0010, itemType=ELEMENT, level=4, text=Clinical indication, description=Name of the problem or diagnosis which is intended to be impacted by achievement of this goal., comment=For example: Hypertension; Obesity; or Diabetes Type 2., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Conclusions']/items[openEHR-EHR-EVALUATION.goal.v1]/data[at0001]/items[at0025], code=at0025, itemType=ELEMENT, level=4, text=Goal start date, description=The anticipated or proposed date for commencing work towards the goal., comment=Note: this date may not be the date of recording of the goal., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Conclusions']/items[openEHR-EHR-EVALUATION.goal.v1]/data[at0001]/items[at0013], code=at0013, itemType=ELEMENT, level=4, text=Goal outcome, description=Single word, phrase or brief description which represents the outcome actually achieved for the goal., comment=Coding with a terminology is preferred, where possible. For example: target weight achieved; poor diabetes control; or successful completion., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Text
  •  Coded Text
    • Achieved  [The proposed goal was realised.]
    • Partially achieved  [The proposed goal was partially realised.]
    • Not achieved  [The proposed goal was not realised and abandoned.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Conclusions']/items[openEHR-EHR-EVALUATION.goal.v1]/data[at0001]/items[at0005], code=at0005, itemType=CLUSTER, level=4, text=Per target, description=Detail about the intended target., comment=Multiple targets are allowed. In some situations, only one target will be required. In some clinical scenarios the goal may require a multifaceted approach with a number of targets contributing to a successful goal outcome. In addition, some goals may require incremental targets to be set sequentially during a period of time., uncommonOntologyItems=null, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Conclusions']/items[openEHR-EHR-EVALUATION.goal.v1]/data[at0001]/items[at0005]/items[at0011], code=at0011, itemType=ELEMENT, level=5, text=Target name, description=Identification of the intended target, by name., comment=For example: systolic blood pressure under 140 mmHg; lose 10 kilograms; or HBA1c in the normal range., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Conclusions']/items[openEHR-EHR-EVALUATION.goal.v1]/data[at0001]/items[at0005]/items[at0024], code=at0024, itemType=ELEMENT, level=5, text=Target description, description=Narrative description about the intended target., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Conclusions']/items[openEHR-EHR-EVALUATION.goal.v1]/protocol[at0026], code=at0026, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Protocol, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Conclusions']/items[openEHR-EHR-EVALUATION.goal.v1]/protocol[at0026]/items[at0029], code=at0029, itemType=ELEMENT, level=4, text=Last updated, description=The date on which the goal 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Conclusions']/items[openEHR-EHR-EVALUATION.clinical_synopsis.v1 and name/value='Patient priorities'], code=at0000, itemType=EVALUATION, level=2, text=Patient priorities, description=Narrative summary or overview about a patient, specifically from the perspective of a healthcare provider, and with or without associated interpretations., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Conclusions']/items[openEHR-EHR-EVALUATION.clinical_synopsis.v1 and name/value='Patient priorities']/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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Conclusions']/items[openEHR-EHR-EVALUATION.clinical_synopsis.v1 and name/value='Patient priorities']/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Synopsis, description=The summary, assessment, conclusions or evaluation of the clinical findings., comment=null, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Conclusions']/items[openEHR-EHR-EVALUATION.clinical_synopsis.v1 and name/value='Patient priorities']/protocol[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Protocol, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan'], code=at0000, itemType=SECTION, level=1, text=Plan, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.service_request.v1 and name/value='Laboratory test'], code=at0000, itemType=INSTRUCTION, level=2, text=Laboratory test, description=Request for a health-related service or activity to be delivered by a clinician, organisation or agency., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=INSTRUCTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.service_request.v1 and name/value='Laboratory test']/activities[at0001], code=at0001, itemType=ACTIVITY, level=3, text=Current Activity, description=Current Activity., comment=null, uncommonOntologyItems=null, occurencesFormal=1..*, occurencesText=Mandatory, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ACTIVITY, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.service_request.v1 and name/value='Laboratory test']/activities[at0001]/description[at0009], code=at0009, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Description, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.service_request.v1 and name/value='Laboratory test']/activities[at0001]/description[at0009]/items[at0121], code=at0121, itemType=ELEMENT, level=5, text=Service name, description=The name of the single service or activity requested., comment=Coding of the 'Service name' with a coding system is desirable, if available. For example: 'referral' to an endocrinologist for diabetes management., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Full blood count
  • HbA1c or blood glucose level
  • Serum lipids
  • Kidney function including eGFR
  • Liver function tests
  • ACR
  • HIV
  • HBV
  • HCV
  • Chlamydia
  • Gonorrhoea
  • Syphilis screening
  • Trichomoniasis
  • Hb
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.service_request.v1 and name/value='Laboratory test']/activities[at0001]/description[at0009]/items[at0152], code=at0152, itemType=ELEMENT, level=5, text=Clinical indication, description=The clinical reason for the ordered service., comment=Coding of the clinical indication with a terminology is preferred, where possible. This data element allows multiple occurrences. For example: 'Angina' or 'Type 1 Diabetes mellitus'., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.service_request.v1 and name/value='Laboratory test']/protocol[at0008], code=at0008, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Protocol, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.service_request.v1 and name/value='Immunisation order'], code=at0000, itemType=INSTRUCTION, level=2, text=Immunisation order, description=Request for a health-related service or activity to be delivered by a clinician, organisation or agency., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=INSTRUCTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.service_request.v1 and name/value='Immunisation order']/activities[at0001], code=at0001, itemType=ACTIVITY, level=3, text=Current Activity, description=Current Activity., comment=null, uncommonOntologyItems=null, occurencesFormal=1..*, occurencesText=Mandatory, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ACTIVITY, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.service_request.v1 and name/value='Immunisation order']/activities[at0001]/description[at0009], code=at0009, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Description, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.service_request.v1 and name/value='Immunisation order']/activities[at0001]/description[at0009]/items[at0121], code=at0121, itemType=ELEMENT, level=5, text=Service name, description=The name of the single service or activity requested., comment=Coding of the 'Service name' with a coding system is desirable, if available. For example: 'referral' to an endocrinologist for diabetes management., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.service_request.v1 and name/value='Immunisation order']/activities[at0001]/description[at0009]/items[at0148], code=at0148, itemType=ELEMENT, level=5, text=Service type, description=Category of service requested., comment=Coding of the 'Service type' with a coding system is desirable, if available. If the 'Service name' was coded, it is possible for this data point to be derived from the code. For example: biochemistry or microbiology laboratory, ultrasound or CT imaging., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.service_request.v1 and name/value='Immunisation order']/activities[at0001]/description[at0009]/items[at0135], code=at0135, itemType=ELEMENT, level=5, text=Description, description=Narrative description about the service requested., comment=This data point should be used to describe the named service in more detail, including how it should be delivered, patient concerns and issues that might be encountered in delivering the service., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.service_request.v1 and name/value='Immunisation order']/activities[at0001]/description[at0009]/items[at0062], code=at0062, itemType=ELEMENT, level=5, text=Reason for request, description=A short phrase describing the reason for the request., comment=Coding of the 'Reason for request' with a coding system is desirable, if available. This data element allows multiple occurrences to enable the user to record a multiple responses, if required. For example: 'manage diabetes complications'., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.service_request.v1 and name/value='Immunisation order']/activities[at0001]/description[at0009]/items[at0064], code=at0064, itemType=ELEMENT, level=5, text=Reason description, description=Narrative description about the reason for request., comment=For example: 'The patient's diabetes has recently become more difficult to stabilise and renal function is deteriorating'., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.service_request.v1 and name/value='Immunisation order']/activities[at0001]/description[at0009]/items[at0152], code=at0152, itemType=ELEMENT, level=5, text=Clinical indication, description=The clinical reason for the ordered service., comment=Coding of the clinical indication with a terminology is preferred, where possible. This data element allows multiple occurrences. For example: 'Angina' or 'Type 1 Diabetes mellitus'., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.service_request.v1 and name/value='Immunisation order']/activities[at0001]/description[at0009]/items[at0065], code=at0065, itemType=ELEMENT, level=5, text=Intent, description=Description of the intent for the request., comment=For example: a referral to a specialist may have the intent of the specialist taking over responsibility for care of the patient, or it may be to provide a second opinion on treatment options. Coding of the 'Intent' with a coding system is desirable, if available. This data element allows multiple occurrences to enable the user to record a multiple responses, if required., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.service_request.v1 and name/value='Immunisation order']/activities[at0001]/description[at0009]/items[at0068], code=at0068, itemType=ELEMENT, level=5, text=Urgency, description=Urgency of the request for service., comment=Specific definitions of emergency and urgent will vary between clinical contexts, clinical systems and the nature of the request itself, so have not been defined in this archetype. If explicit timing is required then the Service period should be clearly stated., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Coded Text
    • Emergency  [The request requires immediate attention.]
    • Urgent  [The request requires prioritised attention.]
    • Routine  [The request does not require prioritised scheduling.]
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.service_request.v1 and name/value='Immunisation order']/activities[at0001]/description[at0009]/items[at0040], code=at0040, itemType=ELEMENT, level=5, text=Service due, description=The date/time, or acceptable interval of date/time, for provision of the service., comment=This data element allows for recording of the timing for a single service, either as a date and time, a date ranges or a text descriptor which can allow for 'next available. 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. If complex timing or sequences of timings are required, use the CLUSTER.service_direction archetype within the 'Complex timing' SLOT and this data element becomes redundant., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Date/Time
  •  Interval of Date/Time
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.service_request.v1 and name/value='Immunisation order']/activities[at0001]/description[at0009]/items[at0145], code=at0145, itemType=ELEMENT, level=5, text=Service period start, description=The date/time that marks the beginning of the valid period of time for delivery of this service., comment=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., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.service_request.v1 and name/value='Immunisation order']/activities[at0001]/description[at0009]/items[at0144], code=at0144, itemType=ELEMENT, level=5, text=Service period expiry, description=The date/time that marks the conclusion of the clinically valid period of time for delivery of this service., comment=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., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.service_request.v1 and name/value='Immunisation order']/activities[at0001]/description[at0009]/items[at0147], code=at0147, itemType=ELEMENT, level=5, text=Indefinite?, description=The valid period for this request is open ended and has no date of expiry., comment=Record as TRUE to record explicity that the request has no expiry date. For example: commonly required for a referral to a specialist for long-term or lifelong care., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.service_request.v1 and name/value='Immunisation order']/activities[at0001]/description[at0009]/items[at0076], code=at0076, itemType=ELEMENT, level=5, text=Supplementary information, description=Supplementary information will be following request., comment=Record as TRUE if additional information has been identified and will be forwarded when available. For example: pending test results., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.service_request.v1 and name/value='Immunisation order']/activities[at0001]/description[at0009]/items[at0078], code=at0078, itemType=ELEMENT, level=5, text=Information description, description=Description of the supplementary information., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.service_request.v1 and name/value='Immunisation order']/activities[at0001]/description[at0009]/items[at0150], code=at0150, itemType=ELEMENT, level=5, text=Comment, description=Additional narrative about the service request 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.service_request.v1 and name/value='Immunisation order']/protocol[at0008], code=at0008, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Protocol, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.service_request.v1 and name/value='Referral'], code=at0000, itemType=INSTRUCTION, level=2, text=Referral, description=Request for a health-related service or activity to be delivered by a clinician, organisation or agency., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=INSTRUCTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.service_request.v1 and name/value='Referral']/activities[at0001], code=at0001, itemType=ACTIVITY, level=3, text=Current Activity, description=Current Activity., comment=null, uncommonOntologyItems=null, occurencesFormal=1..*, occurencesText=Mandatory, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ACTIVITY, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.service_request.v1 and name/value='Referral']/activities[at0001]/description[at0009], code=at0009, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Description, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.service_request.v1 and name/value='Referral']/activities[at0001]/description[at0009]/items[at0121], code=at0121, itemType=ELEMENT, level=5, text=Followup name, description=The name of the single service or activity requested., comment=Coding of the 'Service name' with a coding system is desirable, if available. For example: 'referral' to an endocrinologist for diabetes management., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • GP follow-up
  • GP review of results of investigations
  • Aboriginal health worker/practitioner follow-up
  • Practice nurse follow-up
  • Dentist
  • Medication review
  • Smoking cessation
  • Audiology
  • Dietician
  • Physiotherapist or exercise program
  • Parenting programs/support services
  • Social and emotional wellbeing/mental health
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.service_request.v1 and name/value='Referral']/activities[at0001]/description[at0009]/items[at0148], code=at0148, itemType=ELEMENT, level=5, text=Service type, description=Category of service requested., comment=Coding of the 'Service type' with a coding system is desirable, if available. If the 'Service name' was coded, it is possible for this data point to be derived from the code. For example: biochemistry or microbiology laboratory, ultrasound or CT imaging., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.service_request.v1 and name/value='Referral']/activities[at0001]/description[at0009]/items[at0040], code=at0040, itemType=ELEMENT, level=5, text=Service due, description=The date/time, or acceptable interval of date/time, for provision of the service., comment=This data element allows for recording of the timing for a single service, either as a date and time, a date ranges or a text descriptor which can allow for 'next available. 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. If complex timing or sequences of timings are required, use the CLUSTER.service_direction archetype within the 'Complex timing' SLOT and this data element becomes redundant., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Date/Time
  •  Interval of Date/Time
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.service_request.v1 and name/value='Referral']/protocol[at0008], code=at0008, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Protocol, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.service_request.v1 and name/value='Followup/recall'], code=at0000, itemType=INSTRUCTION, level=2, text=Followup/recall, description=Request for a health-related service or activity to be delivered by a clinician, organisation or agency., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=INSTRUCTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.service_request.v1 and name/value='Followup/recall']/activities[at0001], code=at0001, itemType=ACTIVITY, level=3, text=Current Activity, description=Current Activity., comment=null, uncommonOntologyItems=null, occurencesFormal=1..*, occurencesText=Mandatory, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ACTIVITY, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.service_request.v1 and name/value='Followup/recall']/activities[at0001]/description[at0009], code=at0009, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Description, 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.service_request.v1 and name/value='Followup/recall']/activities[at0001]/description[at0009]/items[at0121], code=at0121, itemType=ELEMENT, level=5, text=Followup name, description=The name of the single service or activity requested., comment=Coding of the 'Service name' with a coding system is desirable, if available. For example: 'referral' to an endocrinologist for diabetes management., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Clinical review
  • Influenza vaccination
  • Asthma plan/cycle of care
  • Diabetes cycle of care
  • Care plan review
  • Cervical screening
  • 715 review
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.service_request.v1 and name/value='Followup/recall']/activities[at0001]/description[at0009]/items[at0148], code=at0148, itemType=ELEMENT, level=5, text=Service type, description=Category of service requested., comment=Coding of the 'Service type' with a coding system is desirable, if available. If the 'Service name' was coded, it is possible for this data point to be derived from the code. For example: biochemistry or microbiology laboratory, ultrasound or CT imaging., 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.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.service_request.v1 and name/value='Followup/recall']/activities[at0001]/description[at0009]/items[at0040], code=at0040, itemType=ELEMENT, level=5, text=Service due, description=The date/time, or acceptable interval of date/time, for provision of the service., comment=This data element allows for recording of the timing for a single service, either as a date and time, a date ranges or a text descriptor which can allow for 'next available. 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. If complex timing or sequences of timings are required, use the CLUSTER.service_direction archetype within the 'Complex timing' SLOT and this data element becomes redundant., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Date/Time
  •  Interval of Date/Time
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.service_request.v1 and name/value='Followup/recall']/protocol[at0008], code=at0008, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Protocol, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null]], templateType=normal]