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; name: Ian McNicoll; organisation: freshEHR Clinical Informatics; email: ian@freshEHR.com
Other Details Language	date: 2020-03-08; name: Ian McNicoll; organisation: freshEHR Clinical Informatics; email: ian@freshEHR.com
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: d27f459a998a61e2a29c7fe7adf04863 PARENT:MD5-CAM-1.0.1: E3BC8668BB89A4BD43BF551931977A9D Original Language: ISO_639-1::en
Language used	en
Citeable Identifier	1013.26.282
Root archetype id	openEHR-EHR-COMPOSITION.report.v1
Confirmed COVID-19 infection report2	Confirmed COVID-19 infection report2: 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.
Story/History	Story/History: 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.
Symptom/sign screening	Symptom/sign screening: An individual- or self-reported questionnaire screening for symptoms and signs.
Data
At test	At test: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Screening purpose	Screening purpose: The reason for overall screening. For example: screening for an infectious disease, such as SARS-COV-2. Terminology: SNOMED-CT Suspected COVID-19
Specific symptom/sign	Specific symptom/sign: Grouping of data elements related to screening for a single symptom or sign.
Symptom or sign name	Symptom or sign name: Name of the symptom or sign being screened. Terminology: SNOMED-CT Influenza-like symptoms
Has symptoms at specimen time	Has symptoms at specimen time: Presence of the symptom or sign. Present Absent Unknown
Comment	Comment: Additional narrative about the specific symptom or sign, not captured in other fields.
Condition screening	Condition screening: An screeing questionnaire for conditions, including problems and diagnoses.
Data
At testing	At testing: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Screening purpose	Screening purpose: The reason for overall screening. For example: pre-operative screening. Terminology: SNOMED-CT Suspected COVID-19
Any underlying conditions?	Any underlying conditions?: Presence of any relevant conditions. Present Absent Unknown
Specific condition	Specific condition: Grouping of data elements related to screening for a single condition.
Condition name	Condition name: Name of the condition being screened. Pregnancy Post-partum (<6 weeks) Immunodeficiency Cardiovascular disease Diabetes Liver disease Renal disease Chronic neurological disease Malignancy Chronic lung disease
Presence?	Presence?: Presence of the condition. Present Absent
Other condition	Other condition: Grouping of data elements related to screening for a single condition.
Condition name	Condition name: Name of the condition being screened.
Gestation	Gestation: The estimate or known period or duration of the pregnancy or gestational age of the fetus or new born.
Data
Date of measurement	Date of measurement: The date and time of the measurement of gestation.
Data
Trimester if pregnant	Trimester if pregnant: Duration of pregnancy grouped into 12-14 week intervals. First trimester Second trimester Third trimester
Comment	Comment: Clinical comment on gestational or conceptional age.
Procedure screening	Procedure screening: A screening questionnaire about screening, investigative, diagnostic, curative, therapeutic, evaluative or palliative procedures which may have been performed.
Data
At testing	At testing: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Screening purpose	Screening purpose: The reason for overall screening. For example: screening for post-operative infection. Terminology: SNOMED-CT Suspected COVID-19
Specific procedure	Specific procedure: Grouping of data elements related to screening for a single procedure.
Procedure name	Procedure name: Name of the procedure being screened. Ventilation ECMO
Performed?	Performed?: Procedure performed? Performed/carried out Not performed/carried out
Management/treatment screening	Management/treatment screening: An individual- or self-reported questionnaire screening for management or treatment carried out.
Data
At testing	At testing: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Screening purpose	Screening purpose: The reason for overall screening. For example: screening for an infectious disease, such as SARS-COV-2. Terminology: SNOMED-CT Suspected COVID-19
Specific management/treatment activity	Specific management/treatment activity: Grouping of data elements related to screening for a single management or treatment activity.
Activity name	Activity name: Name of the management or treatment activity being screened. Admitted to hospital Admitted to ICU Isolation [...]
Status	Status: The current status of a specific activity. Completed Not done Unknown
Completed	Completed: The date/time when the activity was (last) carried out. Partial dates are allowed.
Scheduled	Scheduled: The date/time when the activity is (next) due to be carried out.
Comment	Comment: Additional narrative about the specific management or treatment activity, not captured in other fields.
Exposure	Exposure: A generic section header which should be renamed in a template to suit a specific clinical context.
Infectious exposure investigation	Infectious exposure investigation: Risk assessment for an individual who may have been exposed to an infectious agent.
Data
Infectious agent	Infectious agent: Identification of the organism, material, symptoms or condition to which the individual has been exposed. Terminology: SNOMED-CT SARS-CoV-2
Specific exposure details	Specific exposure details: Details about a single exposure. Multiple exposures can be recorded, using one instance of this cluster per exposure.
Confirmed exposure?	Confirmed exposure?: Has exposure been confirmed? Confirmed Not confirmed
Exposure category	Exposure category: The type of exposure. Travel Occupation Confirmed positive contact Visited healthcare facilities
Date/time of first exposure	Date/time of first exposure: Date and time of exposure. Can be cloned in template and renamed for specific Date/time at onset of exposure and cessation of exposure.
Date/time of last exposure	Date/time of last exposure: Date and time of exposure. Can be cloned in template and renamed for specific Date/time at onset of exposure and cessation of exposure.
Physical location category	Physical location category: Type of location.
Likely location for exposure	Likely location for exposure: Narrative description about the physical location of the exposure.
Activity category	Activity category: The type of activity which resulted in exposure.
Activity description	Activity description: Narrative description about the activity which resulted in exposure.
Duration of exposure	Duration of exposure: The length of time of the exposure. Duration Text
Proximity of contact	Proximity of contact: Closeness of contact. For example: direct contact; shared room; or shared ward.
Case identifier	Case identifier: The identifier used to report the exposure. Text Identifier
Date of notification/report	Date of notification/report: Date/time of notification or report to authorities.
Total number of contacts	Total number of contacts: The total number of exposures to the infectious agent, or total number of infectious contacts.
Occupation	Occupation: 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.
Travel event	Travel event: Details about travel during an interval of time.
Data
Recent travel	Recent travel: Default, unspecified interval event which may be explicitly defined in a template or at run-time.
Data
Recent travel?	Recent travel?: Has the individual travelled during the specified interval? Use the Event to set the relevant interval. Yes No Unknown
Specific trip	Specific trip: Details about a single trip away from the home base. The trip has a single departure and return date to their home base. A trip may include visiting many individual places, and these details should be recorded in the Specific destination cluster.
Specific destination	Specific destination: Details about a single location visited on a trip.
Country	Country: The country visited.
State/region	State/region: The region visited. Different regions within the same country maybe identified if they potentially pose different health risks.
City	City: The city visited. Different cities within the same country or region maybe identified if they potentially pose different health risks.
Date left location	Date left location: Date of exit from the identified location.
Date of return	Date of return: The date when the individual returned back to their home base.
Outcome	Outcome: A generic section header which should be renamed in a template to suit a specific clinical context.
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
Overall test status	Overall test status: The status of the laboratory test result as a whole. The values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'. This element is multiple occurrence to cater for the use cases where statuses for different aspects of the result have been split into several elements. Coded Text Registered Partial Preliminary Final Amended Corrected Appended Cancelled Entered in error Text
Overall test status timestamp	Overall test status timestamp: The date and/or time that ‘Overall test status’ was issued.
Diagnostic service category	Diagnostic service category: The diagnostic service or discipline that is responsible for the laboratory test result. This is intended to be a general categorisation and not to capture the organisational name of the laboratory. For example: anatomical pathology, immunology and transfusion medicine, medical microbiology, clinical pharmacology, medical genetics, medical biochemistry. Alternatively more granular sub categories or sub disciplines, such as endocrinology, haematology, and allergology services, may be used. This may assist clinicians in filtering between categories of results. Coding with a terminology is desirable, where possible.
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 rea	Test rea: Narrative description of the key findings. 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'.
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.
State
Confounding factors	Confounding factors: Issues or circumstances that impact on the accurate interpretation of the measurement or test result. 'Confounding factors' should be reserved for uncontrolled/unplanned issues of patient state/physiology that might affect interpretation, for example 'recent exercise' or 'recent tobacco smoking'. Known or required preconditions, such as 'fasting' should be carried in the 'Sampling conditions' element within the CLUSTER.specimen archetype . In some cases preconditions are captured as part of the test name, for example 'Fasting blood glucose'. Known issues with specimen collection or handling, such as 'prolonged use of tourniquet' or 'sample haemolysed', should be carried in the 'Specimen quality' elements within CLUSTER.specimen archetype. Coding with a terminology is desirable, where possible.
Protocol
Laboratory internal identifier	Laboratory internal identifier: A local identifier assigned by the receiving Laboratory Information System (LIS) to track the test process. This identifier is an internal tracking number assigned by the LIS, and it not intended to be the name of the test. Identifier Text
Test request details	Test request details: Details about the test request. 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'.
Original test requested name	Original test requested name: Name of the original laboratory test requested. This data element is to be used when the test requested differs from the test actually performed by the laboratory.
Requester order identifier	Requester order identifier: The local identifier assigned by the requesting clinical system. Equivalent to the HL7 Placer Order Identifier. Identifier Text
Receiver order identifier	Receiver order identifier: The local identifier assigned to the test order by the order filler, usually by the Laboratory Information System (LIS). Assigning an identifier to a request by the Laboratory lnformation System (LIS) enables tracking progress of the request and enables linking results to requests. It also provides a reference to assist with enquiries and it is usually equivalent to the HL7 Filler Order Identifier. Identifier Text
Point-of-care test	Point-of-care test: 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. True if the test was performed directly at Point-of-Care (POCT).
Test method	Test method: Description about the method used to perform the test. Coding with a terminology is desirable, where possible. Boolean Identifier Multimedia Quantity Count Date/Time Date Time Duration Ordinal Proportion URI Text Coded Text Parsable Interval Interval Interval Interval Interval Interval URI
Post test symptom/sign screening	Post test symptom/sign screening: An individual- or self-reported questionnaire screening for symptoms and signs.
Data
Post testing	Post testing: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Screening purpose	Screening purpose: The reason for overall screening. For example: screening for an infectious disease, such as SARS-COV-2. Terminology: SNOMED-CT Suspected COVID-19
Specific symptom/sign	Specific symptom/sign: Grouping of data elements related to screening for a single symptom or sign.
Symptom or sign name	Symptom or sign name: Name of the symptom or sign being screened. Terminology: SNOMED-CT Influenza-like symptoms
Presence?	Presence?: Presence of the symptom or sign. Present Absent Unknown
Comment	Comment: Additional narrative about the specific symptom or sign, not captured in other fields.
Post test procedure screening	Post test procedure screening: A screening questionnaire about screening, investigative, diagnostic, curative, therapeutic, evaluative or palliative procedures which may have been performed.
Data
Post testing	Post testing: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Screening purpose	Screening purpose: The reason for overall screening. For example: screening for post-operative infection. Terminology: SNOMED-CT Suspected COVID-19
Specific procedure	Specific procedure: Grouping of data elements related to screening for a single procedure.
Procedure name	Procedure name: Name of the procedure being screened. Ventilation ECMO
Performed?	Performed?: Procedure performed? Performed/carried out Not performed/carried out
Post test management/treatment screening	Post test management/treatment screening: An individual- or self-reported questionnaire screening for management or treatment carried out.
Data
At testing	At testing: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Screening purpose	Screening purpose: The reason for overall screening. For example: screening for an infectious disease, such as SARS-COV-2. Terminology: SNOMED-CT Suspected COVID-19
Specific management/treatment activity	Specific management/treatment activity: Grouping of data elements related to screening for a single management or treatment activity.
Activity name	Activity name: Name of the management or treatment activity being screened. Admitted to hospital Admitted to ICU Isolation [...]
Status	Status: The current status of a specific activity. Completed
Date first admitted	Date first admitted: The date/time when the activity was (last) carried out. Partial dates are allowed.
Scheduled	Scheduled: The date/time when the activity is (next) due to be carried out.
Comment	Comment: Additional narrative about the specific management or treatment activity, not captured in other fields.
Episode of care - institution	Episode of care - institution: Administrative details about a period of admitted patient care between a formal or statistical admission and a formal or statistical separation, characterised by only one care type of care from a healthcare institution.
Data
Admission date	Admission date: The date of formal or statistical admission to the institution.
Admitted from	Admitted from: Where the individual was admitted from into the institution. For example: hospital, community, or nursing home. 'Admitted from' should be coded with a terminology, where possible.
Date of release or death	Date of release or death: The date of transfer of care to home or another instituion, or date of death.
Outcome	Outcome: Outcome for the individual at the end of the episode. For example: recovered/not recovered/death. Recovered/healthy Not recovered Death