TEMPLATE Suspected Covid-19 Assessment.v0.1 (Suspected Covid-19 Assessment.v0.1)

Name: Suspected Covid-19 Assessment.v0.1
License: http://creativecommons.org/licenses/by-sa/4.0/

TEMPLATE ID	Suspected Covid-19 Assessment.v0.1
Concept	Suspected Covid-19 Assessment.v0.1
Description	To record the information required to evaluate the potential risk of Covid-19 infection, as part of professional screening or self-assessment. This is based on - The current NHS-111 UK self-assessment app at https://111.nhs.uk/covid-19 - A similar risk assessment app developed for pre-hospital admission by DIPS.no - Public Health England COVID-19: investigation and initial clinical management of possible cases https://www.gov.uk/government/publications/wuhan-novel-coronavirus-initial-investigation-of-possible-cases The exact risk factors are subject to continual update as the disease progresses. Note that a critical part of the information, exposure locations, has been left open, so as to allow the list to be updated very regularly and in alignment with local or national policy. We have decided to leave in 'older' questions such as 'Exposure to birds in China' until such time that we get clear professional guidance that these are no longer necessary or useful.
Use	To record the information required to evaluate the potential risk of Covid-19 infection, as part of professional screening or self-assessment. This is based on - The current NHS-111 UK self-assessment app at https://111.nhs.uk/covid-19 - A similar risk assessment app developed for pre-hospital admission by DIPS.no - Public Health England COVID-19: investigation and initial clinical management of possible cases https://www.gov.uk/government/publications/wuhan-novel-coronavirus-initial-investigation-of-possible-cases The exact risk factors are subject to continual update as the disease progresses. Note that a critical part of the information, exposure locations, has been left open, so as to allow the list to be updated very regularly and in alignment with local or national policy.
Misuse	This assessment is not intended to act directly as part of any public health reporting documentation - further work is being undertaken to support this use-case. Please also be aware that this assessment dataset is likely to be a superset of the questions and criteria required in any single country or setting. You should check the exact requirements for your country and clinical setting and adapt appropriately. For similar reasons we have not embedded any particular guidance or rules on how high / low risk should be estimated - you should follow local guidance.
Purpose	To record the information required to evaluate the potential risk of Covid-19 infection, as part of professional screening or self-assessment. This is based on - The current NHS-111 UK self-assessment app at https://111.nhs.uk/covid-19 - A similar risk assessment app developed for pre-hospital admission by DIPS.no - Public Health England COVID-19: investigation and initial clinical management of possible cases https://www.gov.uk/government/publications/wuhan-novel-coronavirus-initial-investigation-of-possible-cases The exact risk factors are subject to continual update as the disease progresses. Note that a critical part of the information, exposure locations, has been left open, so as to allow the list to be updated very regularly and in alignment with local or national policy. We have decided to leave in 'older' questions such as 'Exposure to birds in China' until such time that we get clear professional guidance that these are no longer necessary or useful.
References
Authors	name: Ian McNicoll; organisation: freshEHR Clinical Informatics Ltd.; email: ian@freshehr.com; date: 2020-02-27
Other Details Language	name: Ian McNicoll; organisation: freshEHR Clinical Informatics Ltd.; email: ian@freshehr.com; date: 2020-02-27
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: d1fb926f81506ba236ac56a31d19f283 Build Uid: 7efc32bc-561b-4334-a918-cfed0e233ef2 PARENT:MD5-CAM-1.0.1: 706E6DA39FA082EE75E0F0D4E4A87F25 Sem Ver: 0.1.5.0
Keywords	covid-19, risk, screening, triage, coronavirus
Language used	en
Citeable Identifier	1013.26.280
Root archetype id	openEHR-EHR-COMPOSITION.encounter.v1
Suspected Covid-19 risk assessment	Suspected Covid-19 risk assessment: Interaction, contact or care event between a subject of care and healthcare provider(s).
content
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.
Presence	Presence: Is the symptom present or not? Present Absent Unknown
Cough	Cough: 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 Cough Default value: Cough
Presence	Presence: Is the symptom present or not? Present Absent Unknown
Fever	Fever: 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 Fever Default value: Fever
Presence	Presence: Is the symptom present or not? Present Absent Unknown
Difficulty breathing	Difficulty breathing: 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 Difficulty breathing Default value: Difficulty breathing
Presence	Presence: Is the symptom present or not? Present Absent Unknown
Sore throat	Sore throat: 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 Pain in throat Default value: Pain in throat
Presence	Presence: Is the symptom present or not? Present Absent Unknown
Other symptom	Other symptom: 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.
Presence	Presence: Is the symptom present or not? Present Absent Unknown
Body temperature	Body temperature: A measurement of the body temperature, which is a surrogate for the core body temperature of the individual.
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
Temperature	Temperature: The measured body temperature (as a surrogate for the core of the body). 0..100 °C (UCUM: Cel)
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
Date of return	Date of return: *
Covid-19 infection risk assessment	Covid-19 infection risk assessment: Assessment of the potential and likelihood of Covid-19 infection as determined by identified risk factors.
Data
Health risk	Health risk: Identification of the potential future disease, condition or health issue for which the risk is being assessed, by name. 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. COVID-19 Risk assessment
Needs admission for resp.disease	Needs admission for resp.disease: Details about each possible risk factor.
Risk factor	Risk factor: Identification of the risk factor, by name. For example: hypertension and hypercholesterolaemia, which may be used as part of the overall assessment for cardiovascular disease; or a genetic marker. Coding of 'Risk factor' with a terminology, where possible. Needs admission for respiratory disease
Presence	Presence: Presence of the risk factor. Present Absent Unknown
Potential locality exposure	Potential locality exposure: Details about each possible risk factor.
Risk factor	Risk factor: Identification of the risk factor, by name. For example: hypertension and hypercholesterolaemia, which may be used as part of the overall assessment for cardiovascular disease; or a genetic marker. Coding of 'Risk factor' with a terminology, where possible. Potential contact exposure based on location
Presence	Presence: Presence of the risk factor. Present Absent Unknown
Location visited	Location visited: Details of potential exposure to a potentially harmful agent, relating to a specific location, typically an outbreak of infectious disease.
(Outbreak location)	(Outbreak location): * Text Coded Text
Contact with confirmed case	Contact with confirmed case: Details about each possible risk factor.
Risk factor	Risk factor: Identification of the risk factor, by name. For example: hypertension and hypercholesterolaemia, which may be used as part of the overall assessment for cardiovascular disease; or a genetic marker. Coding of 'Risk factor' with a terminology, where possible. Contact with confirmed Covid-19 case
Presence	Presence: Presence of the risk factor. Present Absent Unknown
Other household members unwell	Other household members unwell: Details about each possible risk factor.
Risk factor	Risk factor: Identification of the risk factor, by name. For example: hypertension and hypercholesterolaemia, which may be used as part of the overall assessment for cardiovascular disease; or a genetic marker. Coding of 'Risk factor' with a terminology, where possible. Other household members are ill
Presence	Presence: Presence of the risk factor. Present Absent Unknown
Other household members travel exposure	Other household members travel exposure: Details about each possible risk factor.
Risk factor	Risk factor: Identification of the risk factor, by name. For example: hypertension and hypercholesterolaemia, which may be used as part of the overall assessment for cardiovascular disease; or a genetic marker. Coding of 'Risk factor' with a terminology, where possible. Household members with travel exposure
Presence	Presence: Presence of the risk factor. Present Absent Unknown
Contact with suspected pneumonia	Contact with suspected pneumonia: Details about each possible risk factor.
Risk factor	Risk factor: Identification of the risk factor, by name. For example: hypertension and hypercholesterolaemia, which may be used as part of the overall assessment for cardiovascular disease; or a genetic marker. Coding of 'Risk factor' with a terminology, where possible. Contact with suspected case/ pneumonia case
Presence	Presence: Presence of the risk factor. Present Absent Unknown
Contact with severe resp disease	Contact with severe resp disease: Details about each possible risk factor.
Risk factor	Risk factor: Identification of the risk factor, by name. For example: hypertension and hypercholesterolaemia, which may be used as part of the overall assessment for cardiovascular disease; or a genetic marker. Coding of 'Risk factor' with a terminology, where possible. Contact with severe, unexplained respiratory disease
Presence	Presence: Presence of the risk factor. Present Absent Unknown
Contact with birds in China	Contact with birds in China: Details about each possible risk factor.
Risk factor	Risk factor: Identification of the risk factor, by name. For example: hypertension and hypercholesterolaemia, which may be used as part of the overall assessment for cardiovascular disease; or a genetic marker. Coding of 'Risk factor' with a terminology, where possible. Contact with birds in China
Presence	Presence: Presence of the risk factor. Present Absent Unknown
Contact with Avian flu	Contact with Avian flu: Details about each possible risk factor.
Risk factor	Risk factor: Identification of the risk factor, by name. For example: hypertension and hypercholesterolaemia, which may be used as part of the overall assessment for cardiovascular disease; or a genetic marker. Coding of 'Risk factor' with a terminology, where possible. Contact with confirmed human case of Avian flu in China
Presence	Presence: Presence of the risk factor. Present Absent Unknown
Other	Other: Details about each possible risk factor.
Risk factor	Risk factor: Identification of the risk factor, by name. For example: hypertension and hypercholesterolaemia, which may be used as part of the overall assessment for cardiovascular disease; or a genetic marker. Coding of 'Risk factor' with a terminology, where possible. Contact with confirmed Covid-19 case Potential contact exposure based on location Contact with suspected case/ pneumonia case Contact with severe, unexplained respiratory disease Contact with birds in China Contact with confirmed human case of Avian flu in China Needs admission for respiratory disease Other household members are ill Household members with travel exposure
Presence	Presence: Presence of the risk factor. Present Absent Unknown
Risk assessment	Risk assessment: Evaluation of the health risk. 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. Low risk High risk
Healthcare worker	Healthcare worker: Summary or persistent information about an individual's current and past jobs and/or roles.
Data
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.
Healthcare worker	Healthcare worker: Addition information for Covid screening on healthcare worker status.
Is healthcare worker?	Is healthcare worker?: * Yes No Unknown
Household	Household: The circumstances about an individual living alone or with others. This information will provide a sense of the level of support, both physically and emotionally, to which an individual may have access.
Data
Description	Description: Narrative description about the living arrangements.
Number of household members	Number of household members: The number of individuals who are in the household.
Dwelling	Dwelling: An overview about the properties of a single structure, or a discrete space within a structure, and associated spaces in which an individual lives. The intended scope of dwelling includes, but is not limited to: a building; part of a building; house; apartment; prison; houseboat; mobile home; or vehicle. It can also include the spaces associated with a structure or property, including the basement or yard.
Number of bedrooms	Number of bedrooms: The number of bedrooms in the dwelling.
Overcrowding screening	Overcrowding screening: Screening to identify when a dwelling is too small for the size and composition of the household living in it.
Number of persons sleeping in your bedroom	Number of persons sleeping in your bedroom: Number of people per bedroom in a dwelling.
Problem/Diagnosis	Problem/Diagnosis: Details about a single identified health condition, injury, disability or any other issue which impacts on the physical, mental and/or social well-being of an individual. Clear delineation between the scope of a problem versus a diagnosis is not easy to achieve in practice. For the purposes of clinical documentation with this archetype, problem and diagnosis are regarded as a continuum, with increasing levels of detail and supportive evidence usually providing weight towards the label of 'diagnosis'.
Data
Problem/Diagnosis name	Problem/Diagnosis name: Identification of the problem or diagnosis, by name. Coding of the name of the problem or diagnosis with a terminology is preferred, where possible. Terminology: SNOMED-CT Suspected disease caused by 2019 novel coronavirus Exposure to 2019 novel coronavirus Disease caused by 2019-nCoV
Status	Status: Contextual or temporal qualifier for a specified problem or diagnosis.
Diagnostic status	Diagnostic status: Stage or phase of diagnostic process. The status is usually determined by a combination of the timing of diagnosis plus level of clinical certainty resulting from diagnostic tests and clinical evidence available. This data element and 'Diagnostic certainty' in EVALUATION.problem_diagnosis are two important axes of the diagnostic process, and valid combinations will need to be presented by software that exposes both data elements, so it is not possible for users to select conflicting combinations. Preliminary or working diagnoses are intended to represent the single most likely choice out of all differential diagnosis options. Working
Protocol
Last updated	Last updated: The date this problem or diagnosis was last updated.
Service request	Service request: Request for a health-related service or activity to be delivered by a clinician, organisation or agency.
Current Activity	Current Activity: Current Activity.
Description
Service name	Service name: The name of the single service or activity requested. Coding of the 'Service name' with a coding system is desirable, if available. For example: 'referral' to an endocrinologist for diabetes management. Terminology: SNOMED-CT Isolation of infection contact Contact tracing
Reason for request	Reason for request: A short phrase describing the reason for the request. 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'. Terminology: SNOMED-CT Suspected disease caused by 2019 novel coronavirus Exposure to 2019 novel coronavirus Disease caused by 2019-nCoV