TEMPLATE International Patient Summary (International Patient Summary)

TEMPLATE ID	International Patient Summary
Concept	International Patient Summary
Description	An International Patient Summary (IPS) document is an electronic health record extract containing essential healthcare information about a subject of care. As specified in EN 17269 and ISO/DIS 27269, it is designed for supporting the use case scenario for ‘unplanned, cross border care’, but it is not limited to it. It is intended to be international, i.e., to provide generic solutions for global application beyond a particular region or country. The IPS dataset is minimal and non-exhaustive; specialty-agnostic and condition-independent; but still clinically relevant. The IPS document is composed by a set of robust, well-defined and potentially reusable sets of core data items (indicated as IPS library in the figure below). The tight focus of the IPS on unplanned care is in this case not a limitation, but, on the contrary, facilitates their potential re-use beyond the IPS.
Use	Use this template as an early draft representation of the FHIR IG v1.0.0 - http://www.hl7.org/fhir/uv/ips/STU1/index.html
Purpose	An International Patient Summary (IPS) document is an electronic health record extract containing essential healthcare information about a subject of care. As specified in EN 17269 and ISO/DIS 27269, it is designed for supporting the use case scenario for ‘unplanned, cross border care’, but it is not limited to it. It is intended to be international, i.e., to provide generic solutions for global application beyond a particular region or country. The IPS dataset is minimal and non-exhaustive; specialty-agnostic and condition-independent; but still clinically relevant. The IPS document is composed by a set of robust, well-defined and potentially reusable sets of core data items (indicated as IPS library in the figure below). The tight focus of the IPS on unplanned care is in this case not a limitation, but, on the contrary, facilitates their potential re-use beyond the IPS.
References
Authors	name: Heather Leslie; organisation: Atomica Informatics; email: heather.leslie@atomicainformatics.com; date: 2020-08-17
Other Details Language	name: Heather Leslie; organisation: Atomica Informatics; email: heather.leslie@atomicainformatics.com; date: 2020-08-17
Other Details (Language Independent)	MD5-CAM-1.0.1: 5b4c02e8097ed021f8e3d6580fe7f5a4 PARENT:MD5-CAM-1.0.1: 05F3E1D9A0891A37F1DD10A47CCFA472 Original Language: ISO_639-1::en
Language used	en
Citeable Identifier	1013.26.376
Root archetype id	openEHR-EHR-COMPOSITION.health_summary.v1
International Patient Summary	International Patient Summary: Generic document containing a summary of health information about an individual.
Medication Summary	Medication Summary: A generic section header which should be renamed in a template to suit a specific clinical context.
Medication statement	Medication statement: 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. This is not limited to activities performed based on medication orders from clinicians, but could also include for example taking over the counter medication.
Description
Medication item	Medication item: Name of the medication, vaccine or other therapeutic/prescribable item which was the focus of the activity. 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.
Medication	Medication: Details about a medication or component of a medication, including strength, form and details of any specific constituents.
Name	Name: The name of the medication or medication component. For example: 'Zinacef 750 mg powder' or 'cefuroxim'. This item should be coded if possible, using for example, RxNorm, DM+D, Australian Medicines Terminology or FEST. Usage of this element will vary according to context of use. This element may be omitted where the name of the medication is recorded in the parent INSTRUCTION or ACTION archetype, and this archetype is only used to record that the form must be or was 'liquid'.
Form	Form: The formulation or presentation of the medication or medication component. 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.
Category	Category: The category of the medication or medication component, with regard to manufacturing or preparation, and the number of ingredients. For example: 'Paracetamol/codeine' is a Multi-ingredient product, while 'Morphine 60 mg + Haloperidol 2 mg + Midazolam 5 mg' is an Ad-hoc mixture, whose composition is fully specified within the order. Coded Text Ad-hoc mixture Ingredient Multi-ingredient product Single-ingredient product Combination product Text
Strength (presentation)	Strength (presentation): The strength of the medication or medication component, expressed as a ratio. 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.
Strength numerator	Strength numerator: The value of the numerator of the strength fraction. 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'. >=0 (UCUM: 1)
Strength numerator unit	Strength numerator unit: The unit of the numerator of the strength fraction. 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'.
Strength denominator	Strength denominator: The value of the denominator of the strength fraction. 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'. >=0 (UCUM: 1)
Strength denominator unit	Strength denominator unit: The unit of the denominator of the strength fraction. 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'.
Unit of presentation	Unit of presentation: The unit of presentation for a single dose of the medication, for use with the 'Strength denominator unit' element. 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'.
Strength (concentration)	Strength (concentration): The strength of the medication or medication component, as a concentration. 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'.
Manufacturer	Manufacturer: The manufacturer of the medication or medication component. For example: 'Abbott'.
Batch ID	Batch ID: The identifier assigned to the production batch by the manufacturer during production. Text Identifier
Expiry	Expiry: The expiry date and/or time of the medication or medication component, as given by the manufacturer or individual preparing the mixture. Any other form of expiry date, such as time from production or depending on storage environment, can be inserted using a specific CLUSTER archetype in the Substance Details slot or added as part of the Description. For example: '2017-05-23'.
Amount	Amount: The value of the amount of medication or medication component. For example: '1', '1.5', '1000'. Note: the associated unit for this amount is recorded using the 'Amount unit' element. >=0 (UCUM: 1)
Amount unit	Amount unit: The unit of the amount of medication or medication component. For example: 'mg', 'ml', 'IU'. Note: The value of the amount is recorded using the 'Amount' element.
Alternate amount	Alternate amount: The value of an equivalent representation of the amount of the medication or medication component. The unit of the alternate amount is recorded in the 'Alternate amount unit' element. For example: for a medication with a strength of '5 mg/ml' and where the Amount is '1 ml', the equivalent amount would be 5 mg and the value recorded in this data element would be '5'. >=0 (UCUM: 1)
Alternate amount unit	Alternate amount unit: The unit of an equivalent representation of the amount of the medication or medication component. The value of the alternate amount is recorded in the 'Alternate amount' element. For example: for a medication with a strength of '5 mg/ml' and where the Amount is '1 ml', the equivalent amount would be 5 mg and the value recorded in this data element would be 'mg'.
Role	Role: The role of the medication or medication component within a mixture. Coded Text Therapeutic Adjuvant Excipient Text
Description	Description: Narrative description of the medication or medication component where it is not possible to describe this fully using structured elements.
Dosage	Dosage: The combination of a medication amount and administration timing for a single day, in the context of a medication order or medication management. 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.
Dose amount	Dose amount: 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. For example: 1, 1.5, 0.125 or 1-2, 12.5-20.5 Quantity>=0 (UCUM: 1) Interval of QuantityLower constraint: >=0 (UCUM: 1) Upper constraint: >=0 (UCUM: 1)
Dose unit	Dose unit: The unit which is associated with the Dose amount. For example: 'tablet','mg'. Coding of the dose unit with a terminology is preferred, where possible.
Dose formula	Dose formula: The formula used to calculate the dose amount or administration rate where this is dependent on some other factor, such as body weight or surface area. For example: '10mg/kg/day'. The result of this formula would normally be held in Dose amount/unit or Administration rate/duration. Where clinical measurements such as body weight is used in the dose calculation, a LINK attribute should used to specify which particular measurement has been used. Text Quantity
Dose description	Dose description: Text description of the dose. For example: "Apply ointment to affected area until it glistens". This element is intended to allow implementers to use the structures for increasing/tapering dosages without necessarily specifying the doses in a structured way.
Timing - daily	Timing - daily: Structured information about the intended timing of a therapeutic or diagnostic activity within any 24 hour period.
Frequency	Frequency: The frequency as number of times per time period that the activity is to take place. For example: "4 times per day" or "3 to 4 times per hour". 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
Interval	Interval: The time interval or minimum and maximum range of an interval between each scheduled activity. For example: "Every 4 hours" or "Every 4 to 6 hours". PT0S..PT24H Units: Hour Minute Second
Specific time	Specific time: A specific time or interval of time when the activity should occur. For example: "08:00" or "15:00-16:00". Time Interval of Time
Timing description	Timing description: Text description of the daily timing. This element is intended to allow implementers to use the structures for different timings without necessarily specifying the timings in a structured way. For example: "Take morning and evening".
Exact timing critical?	Exact timing critical?: Is exact timing of the activity critical to effectiveness, or patient safety or wellbeing? For example when administering antiparkinson medications.
As required	As required: Record as True if the activity should only occur when the "'As required' criterion" is met. Termed 'PRN' ("pro re nata", latin: "as the situation arises") or 'PN' ("per necessare", latin: "when required") in some cultures.
'As required' criterion	'As required' criterion: The condition which triggers an 'As required' activity. For example: "for pain".
Specific event	Specific event: A specific, named time event that the activity should occur in relation to.
Event name	Event name: The name of the event that triggers the activity to take place. For example: "Before each meal", "at bedtime", "in the morning". It is understood that these event names may not equate to the same exact times in different cultures. Coding with a terminology, for example HL7 FHIR Named events, is recommended where appropriate.
Time offset	Time offset: The period of time before or after the named event when the activity should take place. Negative durations can be used to signify that the activity should take place before the event. For example: '30 minutes after meal = meal + 30 minutes', '2 hours before bedtime = bedtime -2 hours'. PT0S..PT24H Units: Hour Minute Second
On / off cycle	On / off cycle: A cycle of activity where an on-off pattern is required. For example: "Apply an ice pack on for 20 minutes, off for an hour, repeat".
On	On: The period of time for which the activity should take place. PT0S..PT24H Units: Hour Minute Second
Off	Off: The period of time for which the activity should NOT take place. PT0S..PT24H Units: Hour Minute Second
Repetitions	Repetitions: The number of repetitions of the on/off cycle. >=0
Administration details	Administration details: Details of body site and administration of the medication.
Route	Route: The route by which the ordered item was, or is to be, administered into the subject's body. Comment: For example: 'oral', 'intravenous', or 'topical'. Coding of the route with a terminology is preferred, where possible. Multiple potential routes may be specified.
Body site	Body site: Structured description of the site of administration of the ordered item. For example: 'left upper arm', 'intravenous catheter right hand'. Coding of the body site with a terminology is preferred, where possible.
Timing - non-daily	Timing - non-daily: Structured information about the intended timing pattern for a therapeutic or diagnostic activity occurring over days, weeks, months or years.
Repetition interval	Repetition interval: The interval between repetitions of the activity. For example: 'Every 3 weeks'. If necessary, this element can be used to explicity specify that an activity is to take place every single day, by setting it to "1 day". >P0D Units: Year Month Week Day
Frequency	Frequency: The number of days per time period on which the activity is to take place. For example: '3 times per week', '2-4 times per month'. Quantity1..7; 1..31; 1..366 Units: 1/wk 1/mo 1/a Interval of QuantityLower constraint: 1..7; 1..31; 1..366 Units: 1/wk 1/mo 1/a Upper constraint: 1..7; 1..31; 1..366 Units: 1/wk 1/mo 1/a
Specific date	Specific date: The activity should take place on a specific date or a specific range of dates. For example: 'on 12 Jan 2017' or 'on 30 Oct 2017 to 6 Nov 2017'. Date Interval of Date
Specific day of week	Specific day of week: The activity should take place on a specific day of the week. For example: 'On Monday, Wednesday and Friday'. Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Specific day of month	Specific day of month: The activity should take place on a specific day or interval of days of the month. For example: 'on the 3rd, 13th and 23rd of each month' or 'on the 1st to the 10th of each month'. Count1..31 Interval of CountLower constraint: 1..31 Upper constraint: 1..31
Timing description	Timing description: Text description of the timing. For example: 'Use for one week, then stop for two weeks, then repeat'. This element is intended to allow implementers to use the structures for daily timings without necessarily specifying the non-daily timings in a structured way.
Specific event	Specific event: The activity should take place in relation to a specific named event.
Event name	Event name: The name of the event that triggers the activity to take place. This element is intended for events that can occur at variable dates, such as onset of menstruation, and not for doses or activities that are conditional on a different varable. If required, the event name can be coded using a terminology, which could potentially be used to trigger an application to set a concrete date for the activity.
Time offset	Time offset: The period of time before or after the named event when the activity should take place. Negative durations can be used to signify that the activity should be taken before a known event. For example: '3 days after onset of menstruation = menstrual onset + 3 days', '2 weeks prior to admission= admission -2 weeks'. Units: Year Month Week Day
On / off cycle	On / off cycle: A cycle of activity where an on-off pattern is required. For example: 'take for 1 week, omit 2 weeks, repeat 4 times'
On	On: The period of time for which the activity should take place. >P0D Units: Year Month Week Day
Off	Off: The period of time for which the activity should NOT take place. >P0D Units: Year Month Week Day
Repetitions	Repetitions: The number of repetitions of the on/off cycle. >=0
Protocol
Order ID	Order ID: Unique identifier for the medication order. Comment: This data element allows for multiple occurrences to be defined more explicitly at run-time, if required.
Exclusion - global	Exclusion - global: An overall statement of exclusion about all Problems/diagnoses, Family history, Medications, Procedures, Adverse reactions or other clinical items that are either not currently present, or have not been present in the past.
Data
Global exclusion of medication use	Global exclusion of medication use: Overall statement of exclusion about the use of all medications at the time of recording. No known medications
Absence of information	Absence of information: Statement that specified health information is not available for inclusion in the health record or extract at the time of recording.
Data
Absence statement	Absence statement: Positive statement that no information is available. For example: "No information available about adverse reactions"; No information available about problems or diagnoses"; "No information available about previous procedures performed"; or "No information available about medications used". No information about medications
Protocol
Last updated	Last updated: The date at which the absence was last updated.
Allergies & Intolerances	Allergies & Intolerances: A generic section header which should be renamed in a template to suit a specific clinical context.
Allergy Intolerance	Allergy Intolerance: Risk of harmful or undesirable physiological response which is unique to an individual and associated with exposure to a substance. 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. Optional[{source=openEHR,FHIR}]
Data
Substance	Substance: Identification of a substance, or substance class, that is considered to put the individual at risk of an adverse reaction event. 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. Optional[{source=openEHR,FHIR,DAM}]
Verification status	Verification status: Assertion about the certainty of the propensity, or potential future risk, of the identified 'Substance' to cause a reaction. 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. Optional[{source=FHIR, DAM}] Coded Text Suspected Likely Confirmed Resolved Refuted Text
Criticality	Criticality: An indication of the potential for critical system organ damage or life threatening consequence. This can be regarded as a predictive judgement of a 'worst case scenario'. In most contexts 'Low' would be regarded as the default value. Optional[{source=DAM, openEHR}] Low High Indeterminate
Type	Type: Identification of the underlying physiological mechanism for the adverse reaction. Immune-mediated responses have been traditionally regarded as an indicator for escalation of significant future risk. Contemporary knowledge suggests that some reactions previously thought to be immune are actually non-immune and still carry life threatening risk. Immunological testing may provide supporting evidence for the mechanism and causative substance , but no tests are 100% sensitive or specific for a sensitivity. It is acknowledged that most clinicians will NOT be able to distinguish the mechanism of any specific reaction. However this data element is included because many legacy systems have captured this attribute. Optional[{source=FHIR, DAM}] Allergy Intolerance
Comment	Comment: Additional narrative about the propensity for the adverse reaction, not captured in other fields. 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. Optional[{source=openEHR}]
Reaction	Reaction: Details about each adverse reaction event linked to exposure to the identified 'Substance'. Optional[{source=openEHR,FHIR,DAM}]
Manifestation	Manifestation: Clinical symptoms and/or signs that are observed or associated with the adverse reaction. 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. Optional[{source=FHIR, openEHR,DAM}]
Onset	Onset: Record of the date and/or time of the onset of the reaction. Optional[{source=openEHR, FHIR, DAM}]
Severity	Severity: Clinical assessment of the severity of the reaction event as a whole, potentially considering multiple different manifestations. It is acknowledged that this assessment is very subjective. There may be some some specific practice domains where objective scales have been applied. Objective scales can be included in this model using the 'Reaction details' Cluster. Optional[{source=DAM}] Coded Text Mild Moderate Severe Text
Protocol
Last updated	Last updated: Date when the propensity or the reaction event was updated. Note: maps to recordedDate in FHIR. Optional[{source=openEHR, FHIR, DAM}]
Exclusion - global	Exclusion - global: An overall statement of exclusion about all Problems/diagnoses, Family history, Medications, Procedures, Adverse reactions or other clinical items that are either not currently present, or have not been present in the past.
Data
Global exclusion of adverse reactions	Global exclusion of adverse reactions: Overall statement of exclusion about all adverse reactions at the time of recording. No known allergies No known medication allergies No known environmental allergies No known food allergies
Absence of information	Absence of information: Statement that specified health information is not available for inclusion in the health record or extract at the time of recording.
Data
Absence statement	Absence statement: Positive statement that no information is available. For example: "No information available about adverse reactions"; No information available about problems or diagnoses"; "No information available about previous procedures performed"; or "No information available about medications used". No information about allergies
Protocol
Last updated	Last updated: The date at which the absence was last updated.
Problem List	Problem List: A generic section header which should be renamed in a template to suit a specific clinical context.
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.
Body site	Body site: Identification of a simple body site for the location of the problem or diagnosis. 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.
Date/time of onset	Date/time of onset: Estimated or actual date/time that signs or symptoms of the problem/diagnosis were first observed. Data captured/imported as "Age at onset" should be converted to a date using the subject's date of birth.
Severity	Severity: An assessment of the overall severity of the problem or diagnosis. 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. Coded Text Mild Moderate Severe Text
Date of abatement	Date of abatement: Estimated or actual date/time of resolution or remission for this problem or diagnosis, as determined by a healthcare professional. 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 resolution" should be converted to a date using the subject's date of birth.
Problem/Diagnosis qualifier	Problem/Diagnosis qualifier: Contextual or temporal qualifier for a specified problem or diagnosis.
Active/Inactive?	Active/Inactive?: Category that supports division of problems and diagnoses into Active or Inactive problem lists. 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. Active Inactive
Resolution phase	Resolution phase: Phase of healing for an acute problem or diagnosis. For example: tracking the progress of resolution of a middle ear infection. Resolved Relapsed
Remission status	Remission status: Status of the remission of an incurable diagnosis. For example: the status of a cancer or haematological diagnosis. In remission
Occurrence	Occurrence: Category of the occurrence for this problem or diagnosis. This data element can be an additional qualifier to the 'New' value in the 'Episodicity' value set, that is a condition such as asthma can have recurring new episodes that have periods of resolution in between. However it can be important to identify the first ever episode of asthma from all of the other episodes. Recurrence
Diagnostic certainty	Diagnostic certainty: The level of confidence in the identification of the diagnosis. Coded Text Suspected Probable Confirmed Text
Protocol
Last updated	Last updated: The date this problem or diagnosis was last updated.
Exclusion - global	Exclusion - global: An overall statement of exclusion about all Problems/diagnoses, Family history, Medications, Procedures, Adverse reactions or other clinical items that are either not currently present, or have not been present in the past.
Data
Global exclusion of problems/diagnoses	Global exclusion of problems/diagnoses: Overall statement of exclusion of all problems or diagnoses at the time of recording. No known problems
Absence of information	Absence of information: Statement that specified health information is not available for inclusion in the health record or extract at the time of recording.
Data
Absence statement	Absence statement: Positive statement that no information is available. For example: "No information available about adverse reactions"; No information available about problems or diagnoses"; "No information available about previous procedures performed"; or "No information available about medications used". No information about current problems
Protocol
Last updated	Last updated: The date at which the absence was last updated.
Immunizations	Immunizations: A generic section header which should be renamed in a template to suit a specific clinical context.
Immunization statement	Immunization statement: 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. This is not limited to activities performed based on medication orders from clinicians, but could also include for example taking over the counter medication.
Description
Immunisation item	Immunisation item: Name of the medication, vaccine or other therapeutic/prescribable item which was the focus of the activity. 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.
Administration details	Administration details: Details of body site and administration of the medication.
Route	Route: The route by which the ordered item was, or is to be, administered into the subject's body. Comment: For example: 'oral', 'intravenous', or 'topical'. Coding of the route with a terminology is preferred, where possible. Multiple potential routes may be specified.
Target site	Target site: Structured description of the site of administration of the ordered item. For example: 'left upper arm', 'intravenous catheter right hand'. Coding of the body site with a terminology is preferred, where possible.
Sequence number	Sequence number: The sequence number specific to the pathway step being recorded.
Absence of information	Absence of information: Statement that specified health information is not available for inclusion in the health record or extract at the time of recording.
Data
Absence statement	Absence statement: Positive statement that no information is available. For example: "No information available about adverse reactions"; No information available about problems or diagnoses"; "No information available about previous procedures performed"; or "No information available about medications used". No information about immunizations
Protocol
Last updated	Last updated: The date at which the absence was last updated.
History of Procedures	History of Procedures: A generic section header which should be renamed in a template to suit a specific clinical context.
Procedure	Procedure: A clinical activity carried out for screening, investigative, diagnostic, curative, therapeutic, evaluative or palliative purposes.
Description
Procedure name	Procedure name: Identification of the procedure by name. Coding of the specific procedure with a terminology is preferred, where possible.
Body site	Body site: Identification of the body site for the procedure. Occurrences for this data element are unbounded to allow for clinical scenarios such as removing multiple skin lesions in different places, but where all of the other attributes are identical. Use this data element to record simple terms or 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 'Procedure detail' SLOT in this archetype. If the anatomical location is included in the 'Procedure name' via precoordinated codes, this data element becomes redundant.
Absence of information	Absence of information: Statement that specified health information is not available for inclusion in the health record or extract at the time of recording.
Data
Absence statement	Absence statement: Positive statement that no information is available. For example: "No information available about adverse reactions"; No information available about problems or diagnoses"; "No information available about previous procedures performed"; or "No information available about medications used". No information about past history of procedures
Protocol
Last updated	Last updated: The date at which the absence was last updated.
Exclusion - global	Exclusion - global: An overall statement of exclusion about all Problems/diagnoses, Family history, Medications, Procedures, Adverse reactions or other clinical items that are either not currently present, or have not been present in the past.
Data
Global exclusion of procedures	Global exclusion of procedures: Overall statement of exclusion about all procedures at the time of recording. No known procedures
Medical Devices	Medical Devices: A generic section header which should be renamed in a template to suit a specific clinical context.
Device use statement	Device use statement: An ongoing and persistent overview about medical devices that have been fitted or implanted.
Data
Device details	Device details: Details about each device.
Device name	Device name: Identification of the specific device, by name.
Body site	Body site: Identification of the body site where the device is fitted/implanted.
Medical device	Medical device: An instrument, apparatus, implant, material or similar, used in the provision of healthcare. In this context, a medical device includes a broad range of devices which act through a variety of physical, mechanical, thermal or similar means but specifically excludes devices which act through medicinal means such as pharmacological, metabolic or immunological methods. The scope is inclusive of disposable devices as well as durable or persisting devices that require tracking, maintenance activities or regular calibration, recognising that each type of device has specific data recording requirements.
Device name	Device name: Identification of the medical device, preferably by a common name, a formal fully descriptive name or, if required, by class or category of device. This data element will capture the term, phrase or category used in clinical practice. For example: <brand name><machine> (XYZ Audiometer); <size> <brand name> <intravenous catheter> (14G Jelco IV catheter); or <brand name/type> <implant>. Coding with a terminology is desirable, where possible, although this may be local and depending on local supplies available.
Type	Type: The category or kind of device. Not applicable if a category is already recorded in 'Device name'. Example: if the 'Device' is named as a 'urinary catheter'; the 'Type' may be recorded as 'indwelling' or 'condom'.Coding with a terminology is desirable, where possible. This may include use of GTIN or EAN numbers.
Description	Description: Narrative description of the medical device.
Unique device identifier (UDI)	Unique device identifier (UDI): A numeric or alphanumeric string that is associated with this device within a given system. Often fixed to the device as a barcode.
Manufacturer	Manufacturer: Name of manufacturer.
Date of manufacture	Date of manufacture: Date the device was manufactured.
Serial number	Serial number: Number assigned by the manufacturer which can be found on the device, and should be specific to each device., its label, or accompanying packaging.
Catalogue number	Catalogue number: The exact number assigned by the manufacturer, as it appears in the manufacturer's catalogue, device labeling, or accompanying packaging.
Model number	Model number: The exact model number assigned by the manufacturer and found on the device label or accompanying packaging.
Batch/Lot number	Batch/Lot number: The number assigned by the manufacturer which identifies a group of items manufactured at the same time, usually found on the label or packaging material.
Software version	Software version: Identification of the version of software being used in the medical device. When the medical device is an actual software application, record the version of the software using this data element. When the medical device has multiple software applications embedded within it, record each software component in a separate CLUSTER archetype within the Components SLOT - either as a nested instance of another CLUSTER.device archetype or using a CLUSTER archetype designed specifically for recording software details (but not yet available at time of this archetype development).
Date of expiry	Date of expiry: Date after which the device/product is no longer fit for use, usually found on the device itself or printed on the accompanying packaging. This date usually applies only to single use or disposable devices.
Other identifier	Other identifier: Unspecified identifier, which can be further specified in a template or at run time. Coding of the name of the identifier with a coding system is desirable, if available.
Comment	Comment: Additional narrative about the device not captured in other fields.
Diagnostic Results	Diagnostic Results: A generic section header which should be renamed in a template to suit a specific clinical context.
Laboratory test result	Laboratory test result: 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
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
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)'.
Specimen	Specimen: A physical sample collected from, or related to, an individual for the purpose of investigation, examination or analysis. For example: Tissue or body fluid.
Specimen type	Specimen type: The type of specimen. For example: Venous blood, bacterial culture, cytology, or tissue sample. Coding of the specimen type with a terminology is preferred, where possible. Optional[{fhir_mapping=Specimen.type}]
Method	Method: The method of collection used. For example: venepuncture, biopsy, resection. Coding of the collection method with a terminology is preferred, where possible. If the collection method is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant. Optional[{fhir_mapping=Specimen.collection.method}]
Body site	Body site: Identification of the body site or other location from where the specimen is collected. For example: 'wound on left calf', 'IV cannula right arm', 'right kidney'. Coding of the name of the source site with a terminology is preferred, where possible. Use this data element to record precoordinated source sites. If the requirements for recording the source site are determined at run-time by the application or require more complex modelling such as relative locations then use the 'Structured source site' SLOT in this archetype. If the source site is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.
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. Laboratory Pathology
Laboratory analyte result	Laboratory analyte result: The result of a laboratory test for a single analyte value.
Analyte name	Analyte name: The name of the analyte result. 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. Optional[{fhir_mapping=Observation.code, hl7v2_mapping=OBX.3}]
Interpretation	Interpretation: 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'.
Multimedia source	Multimedia source: A multimedia resource that is generated or acquired during the provision of healthcare.
Resource name	Resource name: Name or title of the multimedia resource.
Content	Content: Digital representation of the resource. The actual content will be captured and stored using the Multimedia data type. For example: RTF or PDF for a document; JPG for an image; MP4 for a video; or WAV for an audio file. If the content is stored elsewhere the external location can be referenced using the URI data type. Multimedia URI
Imaging examination result	Imaging examination result: Record the findings and interpretation of an imaging examination performed.
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
Test name	Test name: The name of the imaging examination or procedure performed. Coding with a terminology, potentially a pre-coordinated term specifying both modality and anatomical location, is desirable where possible. Possible candidate terminologies: LOINC, SNOMED CT or RadLex.
Modality	Modality: Type of equipment that originally acquired the image or series of images. Also known as 'Examination type'. For example: Ultrasound; Computed tomography; or X-ray. Coding with a terminology is desirable, where possible. If the modality is specified by a code in the Examination result name, then this field may be redundant.
Anatomical site	Anatomical site: Simple description about the physical place on, or in, the body that was imaged. This data element is redundant if the anatomical site is identified in the 'Test name'.
Overall result status	Overall result status: The status of the examination result as a whole. Registered Interim Final Amended Cancelled / Aborted
Findings	Findings: Narrative description of the clinical findings.
Imaging finding	Imaging finding: A single finding in an imaging examination.
Finding name	Finding name: The name of the finding. Coding with an external terminology is strongly recommended. Optional[{fhir_mapping=Observation.code, hl7v2_mapping=OBX.3}]
Anatomical location	Anatomical location: Simple description of anatomical location.
Presence?	Presence?: The presence or absence of the finding. 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. Optional[{fhir_mapping=Observation.value[x], hl7v2_mapping=OBX.2, OBX.5, OBX.6, OBX.7, OBX.8}] Present Absent Indeterminate
Description	Description: Narrative description about the observed clinical finding.
Comparison to previous	Comparison to previous: Narrative description about the difference between a previous finding and the finding in this report. Coded Text Improving Unchanged Worsening Text
Comment	Comment: Additional narrative about the finding, not captured in other fields. Optional[{fhir_mapping=Observation.note, hl7v2_mapping=NTE.3}]
Comparison with previous	Comparison with previous: Narrative descripition about the comparison of this image, or series of images, with previous similar examinations. If there is no availability of previous imaging and/or reports this should also be stated using this data element.
Conclusion	Conclusion: Narrative concise, clinically relevant interpretation of all imaging findings, and include a comparison with previous studies where appropriate. Also referred to as 'Opinion' or 'Impression'.
Imaging differential diagnosis	Imaging differential diagnosis: Single word, phrase or brief description representing a possible condition or diagnosis. This data element has multiple occurrences to allow for more than one differential diagnoses. Coding with a terminology is preferred, where possible. This data element should be regarded as mutually exclusive to 'Imaging diagnosis' - only one of 'Differential diagnoses' OR 'Imaging diagnosis' should be present in each Imaging examination result.
Imaging diagnosis	Imaging diagnosis: Single word, phrase or brief description representing the likely condition or diagnosis. This data element has multiple occurrences to allow for more than one diagnoses. Coding with a terminology is preferred, where possible. This data element should be regarded as mutually exclusive to 'Differential diagnoses' - only one of 'Differential diagnoses' OR 'Imaging diagnosis' should be present in the each Imaging examination result.
Multimedia source	Multimedia source: A multimedia resource that is generated or acquired during the provision of healthcare.
Resource name	Resource name: Name or title of the multimedia resource.
Content	Content: Digital representation of the resource. The actual content will be captured and stored using the Multimedia data type. For example: RTF or PDF for a document; JPG for an image; MP4 for a video; or WAV for an audio file. If the content is stored elsewhere the external location can be referenced using the URI data type. Multimedia URI
Protocol
Technique	Technique: Narrative description about the technical details and procedure. For example: outline of technique; non-routine alternative or additional imaging; nature and route of administration of contrast agent, radiopharmaceuticals and/or treatments administered; adverse reactions to contrast media.
Imaging quality	Imaging quality: Narrative description about the quality of the examination. For example: the nature of any limitations and their impact on interpretation.
Examination request details	Examination request details: Details concerning a single examination requested. Note: Usually there is one examination request for each result, however in some circumstances multiple examination requests may be represented using a single Imaging examination result archetype.
Requester order identifier	Requester order identifier: The local identifier assigned to the order by the order requester. Equivalent to the HL7 Placer Order Identifier.
Examination requested name	Examination requested name: Identification of imaging examination or procedure requested, where the examination requested differs from the examination actually performed.
Receiver order identifier	Receiver order identifier: The local identifier assigned to the examination order by the order filler, usually by the Radiology Information System (RIS). Usually equivalent to the HL7 Filler Order Number.
DICOM study identifier	DICOM study identifier: Unique identifier of this study allocated by the imaging service.
Report identifier	Report identifier: The local identifier given to the imaging examination report.
(Image details)	(Image details): Images referred to, or provided, to assist clinical understanding of the examination. If attached image is in DICOM format, all the fields below should be populated so the values are available to software that does not process DICOM images.
Image identifier	Image identifier: Unique identifier of this image allocated by the imaging service (often the DICOM image instance UID).
DICOM series identifier	DICOM series identifier: Unique identifier of this series allocated by the imaging service.
View	View: The name of the imaging view e.g Lateral or Antero-posterior (AP). Coding using a terminology is desirable, where possible.
Position	Position: Description of the subject of care's positon when the image was performed.
Image DateTime	Image DateTime: Specific date/time the imaging examination was performed.
Image	Image: An attached or referenced image of a current view.
Vital Signs	Vital Signs: A generic section header which should be renamed in a template to suit a specific clinical context.
Body weight	Body weight: Measurement of the body weight of an 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
Weight	Weight: The weight of the individual. 0..1000; 0..2000; 0..1000000 Units: kg lbm (UCUM: [lb_av]) g
Height/Length	Height/Length: Height, or body length, is measured from crown of head to sole of foot. Height is measured with the individual in a standing position and body length in a recumbent position.
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
Height/Length	Height/Length: The length of the body from crown of head to sole of foot. 0..1000; 0..250 Units: cm in (UCUM: [in_i])
Respiration	Respiration: The characteristics of spontaneous breathing by an 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
Rate	Rate: The frequency of spontaneous breathing. 0..200 /min
Pulse/Heart beat	Pulse/Heart beat: The rate and associated attributes for a pulse or heart beat.
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
Rate	Rate: The rate of the pulse or heart beat, measured in beats per minute. 0..1000 /min
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 temperature. 0..100; 30..200 Units: °C (UCUM: Cel) °F (UCUM: [degF])
Head circumference	Head circumference: The measurement of the longest distance around the head.
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
Head circumference	Head circumference: The measurement of the longest distance around the head. 0..100; 0..40 Units: cm in (UCUM: [in_i])
Pulse oximetry	Pulse oximetry: Blood oxygen and related measurements, measured by pulse oximetry or pulse CO-oximetry.
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
SpO₂	SpO₂: The saturation of oxygen in the peripheral blood, measured via pulse oximetry. SpO₂ is defined as the percentage of oxyhaemoglobin (HbO₂) to the total concentration of haemoglobin (HbO₂ + deoxyhaemoglobin) in peripheral blood. Percent
Body mass index	Body mass index: Calculated measurement which compares a person's weight and height. 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.
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
Body mass index	Body mass index: Index describing ratio of weight to height. 0..1000; 0..1000 Units: kg/m² (UCUM: kg/m2) [lb_av]/[in_i]2
Blood pressure	Blood pressure: The local measurement of arterial blood pressure which is a surrogate for arterial pressure in the systemic circulation. Most commonly, use of the term 'blood pressure' refers to measurement of brachial artery pressure in the upper arm.
Data	Data: History Structural node.
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
Systolic	Systolic: Peak systemic arterial blood pressure - measured in systolic or contraction phase of the heart cycle. 0..1000 mmHg (UCUM: mm[Hg])
Diastolic	Diastolic: Minimum systemic arterial blood pressure - measured in the diastolic or relaxation phase of the heart cycle. 0..1000 mmHg (UCUM: mm[Hg])
Past History of Illnesses	Past History of Illnesses: A generic section header which should be renamed in a template to suit a specific clinical context.
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.
Body site	Body site: Identification of a simple body site for the location of the problem or diagnosis. 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.
Date/time of onset	Date/time of onset: Estimated or actual date/time that signs or symptoms of the problem/diagnosis were first observed. Data captured/imported as "Age at onset" should be converted to a date using the subject's date of birth.
Severity	Severity: An assessment of the overall severity of the problem or diagnosis. 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. Coded Text Mild Moderate Severe Text
Date of abatement	Date of abatement: Estimated or actual date/time of resolution or remission for this problem or diagnosis, as determined by a healthcare professional. 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 resolution" should be converted to a date using the subject's date of birth.
Problem/Diagnosis qualifier	Problem/Diagnosis qualifier: Contextual or temporal qualifier for a specified problem or diagnosis.
Active/Inactive?	Active/Inactive?: Category that supports division of problems and diagnoses into Active or Inactive problem lists. 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. Active Inactive
Resolution phase	Resolution phase: Phase of healing for an acute problem or diagnosis. For example: tracking the progress of resolution of a middle ear infection. Resolved Relapsed
Remission status	Remission status: Status of the remission of an incurable diagnosis. For example: the status of a cancer or haematological diagnosis. In remission
Occurrence	Occurrence: Category of the occurrence for this problem or diagnosis. This data element can be an additional qualifier to the 'New' value in the 'Episodicity' value set, that is a condition such as asthma can have recurring new episodes that have periods of resolution in between. However it can be important to identify the first ever episode of asthma from all of the other episodes. Recurrence
Diagnostic certainty	Diagnostic certainty: The level of confidence in the identification of the diagnosis. Coded Text Suspected Probable Confirmed Text
Protocol
Last updated	Last updated: The date this problem or diagnosis was last updated.
Pregnancy	Pregnancy: A generic section header which should be renamed in a template to suit a specific clinical context.
Pregnancy summary	Pregnancy summary: Overview or summary record of a pregnancy including the antenatal period, labour, birth and the immediate postnatal period.
Data
Status	Status: * Currently pregnant
Per pregnancy	Per pregnancy: *
Pregnancy outcome	Pregnancy outcome: Outcome of the pregnancy as a whole. Coding of the Pregnancy Outcome with a terminology is desirable, where possible. If individual fetuses have been identified, record this information using the 'Individual Outcome' data element. This data element is not to be recorded if 'Individual Outcome' is recorded.
Estimated date of delivery	Estimated date of delivery: Estimated date of delivery for a pregnancy.
Data
By date of conception	By date of conception: The EDD calculated from a known date of conception. The date of conception will be recorded elsewhere in the health record, for example as part of the record for an IVF procedure.
By cycle	By cycle: The EDD estimated from an LNMP and characteristics of the menstrual cycle. The details about the menstrual cycle will be recorded elsewhere in the health record, usually captured using the OBSERVATION.menstruation archetype.
By ultrasound	By ultrasound: Details about an EDD estimated from the findings on a pregnancy ultrasound. Each ultrasound and estimated gestation pair will be captured as a separate instance of this CLUSTER.
Estimated date by ultrasound	Estimated date by ultrasound: Details about an EDD estimated from the findings on a pregnancy ultrasound. 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.
Agreed EDD	Agreed EDD: Details about the agreed EDD which is used as the basis for clinical decision-making during the pregnancy.
Agreed date	Agreed date: The EDD which is to be used as the basis for clinical decision-making.
Protocol
Last updated	Last updated: The date any EDD was last updated.
Exclusion of pregnancy	Exclusion of pregnancy: Statement to explicitly record that a pregnancy was not present.
Data
Any event	Any event: *
Data
Exclusion statement	Exclusion statement: An overall statement of exclusion about the state of pregnancy. Not pregnant
Social History	Social History: A generic section header which should be renamed in a template to suit a specific clinical context.
Tobacco smoking summary	Tobacco smoking summary: Summary or persistent information about the tobacco smoking habits of an individual.
Data
Overall status	Overall status: Statement about current smoking behaviour for all types of tobacco. Never smoked Current smoker Former smoker
Alcohol consumption summary	Alcohol consumption summary: Summary or persistent information about the typical alcohol consumption of an individual.
Data
Overall status	Overall status: Statement about current consumption for all types of alcohol. Current drinker Former drinker Lifetime non-drinker
Per episode	Per episode: Details about a discrete period of time with a consistent pattern of typical consumption.
Typical consumption (alcohol units)	Typical consumption (alcohol units): Estimate of number of alcohol units consumed in the specified time period. >=0; >=0; >=0 Units: 1/d 1/wk 1/mo
Plan of Care	Plan of Care: A generic section header which should be renamed in a template to suit a specific clinical context.
Care Plan	Care Plan: Plan or sequence of discrete activities developed to achieve a specified management goal or treatment outcome, carried out by health professionals and/or the patient.
Description
Care Plan Name	Care Plan Name: Name of care plan.
Description	Description: Description of activity performed/enacted against the plan.
Reason	Reason: Reason for activity being performed /enacted against the plan.
Protocol
Care Plan ID	Care Plan ID: Identification of care plan.
Expiry Date	Expiry Date: Anticipated date beyond which the care plan can be deemed 'expired'.
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.
Service type	Service type: Category of service requested. 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.
Description	Description: Narrative description about the service requested. 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.
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'.
Reason description	Reason description: Narrative description about the reason for request. For example: 'The patient's diabetes has recently become more difficult to stabilise and renal function is deteriorating'.
Clinical indication	Clinical indication: The clinical reason for the ordered service. 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'.
Intent	Intent: Description of the intent for the request. 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.
Urgency	Urgency: Urgency of the request for service. 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. Coded Text Emergency Urgent Routine Text
Service due	Service due: The date/time, or acceptable interval of date/time, for provision of the service. 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. Date/Time Interval of Date/Time Text
Service period start	Service period start: The date/time that marks the beginning of the valid period of time for delivery of this service. 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.
Service period expiry	Service period expiry: The date/time that marks the conclusion of the clinically valid period of time for delivery of this service. 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.
Indefinite?	Indefinite?: The valid period for this request is open ended and has no date of expiry. 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.
Supplementary information	Supplementary information: Supplementary information will be following request. Record as TRUE if additional information has been identified and will be forwarded when available. For example: pending test results.
Information description	Information description: Description of the supplementary information.
Comment	Comment: Additional narrative about the service request not captured in other fields.
Protocol
Requester order identifier	Requester order identifier: The local identifier assigned by the requesting clinical system. Usually equivalent to the HL7 Placer Order Identifier. Text Identifier
Receiver order identifier	Receiver order identifier: The local identifier assigned to the request by the clinician or organisation receiving the request for service. Usually equivalent to the HL7 Filler Order Identifier. Text Identifier
Request status	Request status: The status of the request for service as indicated by the requester. Status is used to denote whether this is the initial request, or a follow-up request to change or provide supplementary information. Coding with a terminology is preferred, where possible.
Functional Status	Functional Status: A generic section header which should be renamed in a template to suit a specific clinical context.
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.
Body site	Body site: Identification of a simple body site for the location of the problem or diagnosis. 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.
Date/time of onset	Date/time of onset: Estimated or actual date/time that signs or symptoms of the problem/diagnosis were first observed. Data captured/imported as "Age at onset" should be converted to a date using the subject's date of birth.
Severity	Severity: An assessment of the overall severity of the problem or diagnosis. 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. Coded Text Mild Moderate Severe Text
Date of abatement	Date of abatement: Estimated or actual date/time of resolution or remission for this problem or diagnosis, as determined by a healthcare professional. 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 resolution" should be converted to a date using the subject's date of birth.
Problem/Diagnosis qualifier	Problem/Diagnosis qualifier: Contextual or temporal qualifier for a specified problem or diagnosis.
Active/Inactive?	Active/Inactive?: Category that supports division of problems and diagnoses into Active or Inactive problem lists. 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. Active Inactive
Resolution phase	Resolution phase: Phase of healing for an acute problem or diagnosis. For example: tracking the progress of resolution of a middle ear infection. Resolved Relapsed
Remission status	Remission status: Status of the remission of an incurable diagnosis. For example: the status of a cancer or haematological diagnosis. In remission
Occurrence	Occurrence: Category of the occurrence for this problem or diagnosis. This data element can be an additional qualifier to the 'New' value in the 'Episodicity' value set, that is a condition such as asthma can have recurring new episodes that have periods of resolution in between. However it can be important to identify the first ever episode of asthma from all of the other episodes. Recurrence
Diagnostic certainty	Diagnostic certainty: The level of confidence in the identification of the diagnosis. Coded Text Suspected Probable Confirmed Text
Protocol
Last updated	Last updated: The date this problem or diagnosis was last updated.
Clinical impression	Clinical impression: Narrative summary or overview about a patient, specifically from the perspective of a healthcare provider, and with or without associated interpretations.
Data
Impression	Impression: The summary, assessment, conclusions or evaluation of the clinical findings.
Advanced Directives	Advanced Directives: A generic section header which should be renamed in a template to suit a specific clinical context.
Advance care directive	Advance care directive: A framework to communicate the preferences of an individual for future medical treatment and care.
Data
Type of directive	Type of directive: The type of advance care directive. A short text description of the nature of the advance care directive. Coding of the type of directive with a terminology is preferred, where possible. It is expected that this is largely localised to reflect local policy and legislation. For example, in the Netherlands, advance care directive types include, but are not limited to, 'Treatment prohibition', 'Treatment prohibition with completion of Completed Life', 'Euthanasia request' and 'Declaration of life'. In the UK, advance care directive types include 'Advance Decision', 'Advance Directive' and 'Advance Statement'.
Status	Status: The status of the advance care directive. Coding of the advance care directive status with a terminology is preferred, where possible. Coded Text Present Absent Unknown Text
Description	Description: Narrative description of the overall advance care directive. May be used to record a narrative overview of the complete advance care directive, which may or may not be supported by structured data. Details of specific structured findings can be included using CLUSTER archetypes in the 'Directive details' slot. This data element may be used to capture legacy data that is not available in a structured format.
Condition	Condition: The conditions or situations in which the individual wishes the advance care directive to apply. For example: dementia, brain injury, diseases of the central nervous system, and terminal illness. Coding with a terminology is preferred, where possible. The advance care directive applies to all specified conditions if the individual can no longer make or communicate decisions about their medical treatment and is unlikely to regain the ability to make such decisions. Details of specific decisions that apply to different conditions or situations can be included using CLUSTER archetypes in the 'Directive details' slot.
Directive location	Directive location: Information regarding where the advance care directive is stored and who has a copy of it.
Location	Location: Information regarding where the advance care directive is stored and how to gain access to it. For example, 'In the top drawer of the bedside table'.
Comment	Comment: Additional narrative about the advance care directive not captured in other fields.
Protocol
Valid period start	Valid period start: The date/time that marks the beginning of the valid period of time for this advance care directive.
Valid period end	Valid period end: The date/time that marks the conclusion of the valid period of time for this advance care directive. 'Valid period end' may often overlap with 'Review due date'. However, they may need to be recorded separately in circumstances where a document has an extended period of validity but requires an interim review. That may be due to changed personal circumstances/events or local policy.
Review due date	Review due date: The date at which the advance care directive is due to be reviewed. 'Valid period end' may often overlap with 'Review due date'. However, they may need to be recorded separately in circumstances where a document has an extended period of validity but requires an interim review. That may be due to changed personal circumstances/events or local policy.
Last updated	Last updated: The date when this advance directive record was last updated. This may not be a formal review but e.g. a typo correction.
Mandate	Mandate: Description of any legislation or other authoritative guidance that apply. For example, 'In England and Wales, advance decisions are covered by the Mental Capacity Act. Mandate: https://www.bma.org.uk/advice/employment/ethics/consent/consent-tool-kit/9-advance-decisions'. Or 'Jehovah's Witnesses believe that the Bible prohibits Christians from accepting blood transfusions. Mandate: https://en.wikipedia.org/wiki/Jehovah%27s_Witnesses_and_blood_transfusions'. Text URI
Limitation of treatment	Limitation of treatment: Decision/s about limitation of future treatment, determined by a senior clinician. In many countries this is known as the NFR (Not for resuscitation), DNR (Do not resuscitate), DNAR (Do not attempt resuscitation) or DNACPR (Do not attempt cardiopulmonary resuscitation) decision.
Data
Status	Status: Category describing the presence of any limitation of treatment. No limitation of treatment Limitation of medical treatment Allow natural death Assumed value: No limitation of treatment
Per limitation	Per limitation: Details about each limitation on treatment
Type of limitation	Type of limitation: Description about Cardiopulmonary resuscitation Endotracheal intubation Mechanical ventilation Vasopressor therapy Parenteral or artificial nutrition Dialysis Blood products Antibiotics Intravenous fluids
Decision	Decision: The decision about whether the identified treatment type is permitted or not. Permitted Not permitted
Qualification	Qualification: Description about any criteria, caveats or futher clarification about the limitation. For example: the types of antibiotics that would be acceptable.
Rationale	Rationale: Narrative rationale or justification for the limitation of treatment decision/s.
Patient awareness	Patient awareness: Is the patient aware of the limitation of treatment decision/s? Patient not aware of the decision/s Patient aware of the decision/s
Carer awareness	Carer awareness: Narrative description about awareness of the treatment decision/s by carers and family.
Comment	Comment: Additional narrative about the limitation of treatment decision/s, not captured in other fields.
Protocol
ELEMENT	ELEMENT: *
Review date	Review date: The date when this Limitation of treatment archetype is due for review.