TEMPLATE openEHR-Confirmed Covid-19 infection report.v0 (openEHR-Confirmed Covid-19 infection report.v0)

Name: openEHR-Confirmed Covid-19 infection report.v0
License: http://creativecommons.org/licenses/by-sa/4.0/

TEMPLATE ID	openEHR-Confirmed Covid-19 infection report.v0
Concept	openEHR-Confirmed Covid-19 infection report.v0
Description	To provide an epidemiological report on Confirmed COVID-19 infection, in accordance with WHO guidance (10th March 2020).
Use	To provide an epidemiological report on Confirmed COVID-19 infection, in accordance with WHO guidance (10th March 2020).
Purpose	To provide an epidemiological report on Confirmed COVID-19 infection, in accordance with WHO guidance (10th March 2020).
References
Authors	date: 2020-03-08
Other Details Language	date: 2020-03-08
Other Details (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 Original Namespace: org.openehr Original Publisher: openEHR Foundation Custodian Namespace: org.openehr MD5-CAM-1.0.1: 207a300776d3d5ee14908a60e230839b PARENT:MD5-CAM-1.0.1: 55DB2D45BC470E831EE8C905348471E4
Language used	en
Citeable Identifier	1013.26.271
Root archetype id	openEHR-EHR-COMPOSITION.report.v1
Confirmed Covid-19 infection report	Confirmed Covid-19 infection report: Document to communicate information to others, commonly in response to a request from another party.
Other Context
Country case ID	Country case ID: Identification information about the report.
Status	Status: The status of the entire report. Note: This is not the status of any of the report components. STATUS-NO PARTIAL YES
Patient information	Patient information: Anonymised details of a person.
Birth Sex	Birth Sex: The sex of the person at birth. Male Female Not known
Age	Age: The age of the person. This may be calculated. >=PT0H
Where case diagnosed	Where case diagnosed: Address details aligned with FHIR resource.
Use	Use: The purpose of the address. Temp
Admin Level 1 (Province)	Admin Level 1 (Province): The name of the administrative area (county).
Country	Country: Country - a nation as commonly understood or generally accepted.
Usual place of residency	Usual place of residency: Address details aligned with FHIR resource.
Use	Use: The purpose of the address. Home
Country	Country: Country - a nation as commonly understood or generally accepted.
Reporting	Reporting: A generic section header which should be renamed in a template to suit a specific clinical context.
First test	First test: The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.
Data
First test	First test: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Test name	Test name: Name of the laboratory investigation performed on the specimen(s). 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)'. Terminology: SNOMED-CT 2019-nCoV (novel coronavirus) serology Default value: 2019-nCoV (novel coronavirus) serology
Test reason	Test reason: Description of clinical information available at the time of interpretation of results. This data element may include a link to the original clinical information provided in the test request. Terminology: WHO-COVID-TEST_REASON Contact of a case. Seeking Healthcare due to suspicion of COVID-19. Detected at point of entry. Repatriation. Routine respiratory disease surveillance systems (e.g. influenza). Unknown.
Test diagnosis	Test diagnosis: Single word, phrase or brief description that represents the clinical meaning and significance of the laboratory test result. For example: 'Severe hepatic impairment', 'Salmonella contamination'. Coding of the diagnosis with a terminology is strongly recommended, where possible. This diagnosis should be aligned with the narrative in the 'Conclusion'. Terminology: WHO-COVID-TEST_RESULT The Covid-19 test was positive. The Covid-19 test was negative. The Covid-19 test was inconclusive.
Test reason other	Test reason other: Additional narrative about the test result not captured in other fields.
Clinical status	Clinical status: A generic section header which should be renamed in a template to suit a specific clinical context.
Symptoms	Symptoms: The subjective clinical history of the subject of care as recorded directly by the subject, or reported to a clinician by the subject or a carer.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Story	Story: Narrative description of the story or clinical history for the subject of care.
Influenza-like symptoms	Influenza-like symptoms: Symptoms known to be indicators of suspected Covid-19 infection
Symptom/Sign name	Symptom/Sign name: The name of the reported symptom or sign. Symptom name should be coded with a terminology, where possible. Terminology: SNOMED-CT Influenza-like symptoms Default value: Influenza-like symptoms
First onset of symptoms	First onset of symptoms: The onset for this episode of the symptom or sign. While partial dates are permitted, the exact date and time of onset can be recorded, if appropriate. If this symptom or sign is experienced for the first time or is a re-occurrence, this date is used to represent the onset of this episode. If this symptom or sign is ongoing, this data element may be redundant if it has been recorded previously.
Has symptoms at specimen time	Has symptoms at specimen time: Is the symptom present or not? Present Absent Unknown
Condition summary	Condition summary: Comorbidity summary_covid
Data
Any underlying conditions?	Any underlying conditions?: * Yes No Unknown
Trimester if pregnant	Trimester if pregnant: * First Second Third
Pregnancy	Pregnancy: *
Condition name	Condition name: * Pregnancy
Status	Status: * Yes No
Post-partum	Post-partum: *
Condition name	Condition name: * Post-partum (<6 weeks)
Status	Status: * Yes No
Immunodeficiency	Immunodeficiency: *
Condition name	Condition name: * Immunodeficiency including HIV
Status	Status: * Yes No
Cardiovascular	Cardiovascular: *
Condition name	Condition name: * Cardiovascular disease including hypertension
Status	Status: * Yes No
Diabetes	Diabetes: *
Condition name	Condition name: * Diabetes
Status	Status: * Yes No
Liver disease	Liver disease: *
Condition name	Condition name: * Liver disease
Status	Status: * Yes No
Renal disease	Renal disease: *
Condition name	Condition name: * Renal disease
Status	Status: * Yes No
Chronic neurological disease	Chronic neurological disease: *
Condition name	Condition name: * Chronic neurological or neuromuscular disease
Status	Status: * Yes No
Malignancy	Malignancy: *
Condition name	Condition name: * Malignancy
Status	Status: * Yes No
Chronic lung disease	Chronic lung disease: *
Condition name	Condition name: * Chronic lung disease
Status	Status: * Yes No
Other condition	Other condition: *
Condition name	Condition name: * Coded Text Pregnancy Post-partum (<6 weeks) Immunodeficiency including HIV Cardiovascular disease including hypertension Diabetes Liver disease Renal disease Chronic neurological or neuromuscular disease Malignancy Chronic lung disease Text
COVID - procedure summary	COVID - procedure summary: A summary of historical procedures and therapies
Data
ICU care	ICU care: *
Procedure name	Procedure name: * ICU care
Status	Status: * Yes No Unknown
Ventilation	Ventilation: *
Procedure name	Procedure name: * Coded Text ICU care Ventilation ECMO Isolation Text
Status	Status: * Yes No Unknown
ECMO	ECMO: *
Procedure name	Procedure name: * ECMO
Status	Status: * Yes No Unknown
Isolation	Isolation: *
Procedure name	Procedure name: * Coded Text ICU care Ventilation ECMO Isolation Text
Status	Status: * Yes No Unknown
Isolation date	Isolation date: *
Protocol
Report phase	Report phase: * Confirmed diagnosis Outcome
Admission	Admission: A generic section header which should be renamed in a template to suit a specific clinical context.
Admission to hospital	Admission to hospital: Covid_19_Admission
Data
Hospital admission status	Hospital admission status: * YES NO UNKNOWN
Date first admitted	Date first admitted: *
Travel	Travel: A generic section header which should be renamed in a template to suit a specific clinical context.
Travel trip history	Travel trip history: Details of a travel trip with respect to exposure to potential risk.
Data
Any event	Any event: *
Data
Recent travel	Recent travel: Has the patient travelled recently? The definition of 'recently' may vary depending on circumstances of the wider patient story and known currnet infection risk. Yes No Unknown
Incubation period	Incubation period: * Default value: P14D
Date of return	Date of return: *
Known contacts	Known contacts: *
Confirmed contact	Confirmed contact: * Yes No Unknown
Contact setting	Contact setting: *
Contact details	Contact details: *
Case identifier	Case identifier: * Text Identifier
Date of first exposure	Date of first exposure: *
Date of last exposure	Date of last exposure: *
Location history	Location history: *
Likely location for exposure	Likely location for exposure: *
Country visited	Country visited: Details of potential exposure to a potentially harmful agent, relating to a specific location, typically an outbreak of infectious disease.
Country name	Country name: * Text Coded Text
Date left location	Date left location: *
Visited healthcare facilities	Visited healthcare facilities: * Yes No Unknown
Healthcare worker	Healthcare worker: Summary or persistent information about an individual's current and past jobs and/or roles.
Data
Is healthcare worker?	Is healthcare worker?: Statement about the individual's current employment. 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. YES NO UNKNOWN
Occupation record	Occupation record: A single job or role carried out by an individual during a specified period of time.
Job title/role	Job title/role: The main job title or the role of the individual. For example: Chief Executive Officer; Carer; or Student. Each of these job titles or roles may be comprised of multiple duties. Default value: Healthcare worker
Facility	Facility: Organisation details aligned with FHIR resource.
Facility name	Facility name: Name associated with the organisation.
Address	Address: Address details aligned with FHIR resource.
City	City: The name of the city, town, village or other community or delivery center.
Country	Country: Country - a nation as commonly understood or generally accepted.
Outcome	Outcome: A generic section header which should be renamed in a template to suit a specific clinical context.
Symptoms	Symptoms: The subjective clinical history of the subject of care as recorded directly by the subject, or reported to a clinician by the subject or a carer.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Symptoms after test	Symptoms after test: Symptoms known to be indicators of suspected Covid-19 infection
Symptom/Sign name	Symptom/Sign name: The name of the reported symptom or sign. Symptom name should be coded with a terminology, where possible. Terminology: SNOMED-CT Influenza-like symptoms Default value: Influenza-like symptoms
First onset of symptoms	First onset of symptoms: The onset for this episode of the symptom or sign. While partial dates are permitted, the exact date and time of onset can be recorded, if appropriate. If this symptom or sign is experienced for the first time or is a re-occurrence, this date is used to represent the onset of this episode. If this symptom or sign is ongoing, this data element may be redundant if it has been recorded previously.
Developed symptoms after specimen time	Developed symptoms after specimen time: Is the symptom present or not? Present Absent Unknown
Admission to hospital	Admission to hospital: Covid_19_Admission
Data
Hospital admission status	Hospital admission status: * YES NO UNKNOWN
Date first admitted	Date first admitted: *
Outcome procedure summary	Outcome procedure summary: A summary of historical procedures and therapies
Data
ICU care	ICU care: *
Procedure name	Procedure name: * ICU care
Status	Status: * Yes No Unknown
Ventilation	Ventilation: *
Procedure name	Procedure name: * Coded Text ICU care Ventilation ECMO Isolation Text
Status	Status: * Yes No Unknown
ECMO	ECMO: *
Procedure name	Procedure name: * ECMO
Status	Status: * Yes No Unknown
Last test	Last test: The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.
Data
Last test	Last test: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Test name	Test name: Name of the laboratory investigation performed on the specimen(s). 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)'. Terminology: SNOMED-CT 2019-nCoV (novel coronavirus) serology Default value: 2019-nCoV (novel coronavirus) serology
Test reason	Test reason: Description of clinical information available at the time of interpretation of results. This data element may include a link to the original clinical information provided in the test request. Terminology: WHO-COVID-TEST_REASON Contact of a case. Seeking Healthcare due to suspicion of COVID-19. Detected at point of entry. Repatriation. Routine respiratory disease surveillance systems (e.g. influenza). Unknown.
Test diagnosis	Test diagnosis: Single word, phrase or brief description that represents the clinical meaning and significance of the laboratory test result. For example: 'Severe hepatic impairment', 'Salmonella contamination'. Coding of the diagnosis with a terminology is strongly recommended, where possible. This diagnosis should be aligned with the narrative in the 'Conclusion'. Terminology: WHO-COVID-TEST_RESULT The Covid-19 test was positive. The Covid-19 test was negative. The Covid-19 test was inconclusive. The Covid-19 test was unknown.
Test reason other	Test reason other: Additional narrative about the test result not captured in other fields.
COVID outcomes	COVID outcomes: COVID_ outcomes
Data
Health outcome	Health outcome: * Coded Text Recovered/healthy Not recovered Death Unknown Text
Date of release or death	Date of release or death: *
Total number of contacts	Total number of contacts: * Count Coded Text Unknown