TEMPLATE CCTA report (CCTA report)

TEMPLATE ID	CCTA report
Concept	CCTA report
Description	Not Specified
Purpose	Not Specified
References
Other Details (Language Independent)	MetaDataSet:Sample Set : Template metadata sample set
Language used	en
Citeable Identifier	1013.26.386
Root archetype id	openEHR-EHR-COMPOSITION.report-result.v1
Result report	Result report: Document to communicate information to others about the result of a test or assessment.
Other Context
Report ID	Report 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.
Organisation	Organisation: A company, an institution, or an association that needs to be represented within the health record.
Name line	Name line: The name by which an organisation is known.
Identifier	Identifier: Identifier associated with the identified organisation.
Role	Role: The role or capacity in which the organisation contributes to the health or social care of the subject of care.
Electronic communication	Electronic communication: Details about a specific type of electronic communication for the organisation.
Medium	Medium: The type of electronic communication or channel. The scope of electronic communication medium includes, but is not limited to use of : a telephone, cellular phone, computer, or pager. Coded Text Mobile (cellular) telephone Telephone (excluding mobile telephone) Email Pager Text
Value	Value: The unique combination of alphanumeric characters, meaningful for the identified medium, for contacting the organisation. For example: area code + landline phone/pager number; country code + mobile phone number; email address; or skype contact name. Text URI
Person	Person: A person who needs to be represented within the health record.
Name line	Name line: The name by which an individual is known as free text or a text composite of one or more structured name components.
Identifier	Identifier: Identifier associated with the identified person.
Identifier #1	Identifier #1: Identifier associated with the identified person.
Role	Role: The role or capacity in which the identified person contributes to the health or social care of the subject of care.
Electronic communication	Electronic communication: Details about a specific type of electronic communication for the person.
Medium	Medium: The type of electronic communication or channel. The scope of electronic communication medium includes, but is not limited to use of : a telephone, cellular phone, computer, or pager. Coded Text Mobile (cellular) telephone Telephone (excluding mobile telephone) Email Pager Text
Type	Type: The purpose or use for the identified medium. Coding with an external terminology is preferred, where possible. Coded Text Business use Personal use Both business and personal use Text
Value	Value: The unique combination of alphanumeric characters, meaningful for the identified medium, for contacting the person. For example: area code + landline phone/pager number; country code + mobile phone number; email address; or skype contact name. Text URI
Birth details	Birth details: Details related to the time and place of birth and additional non-clinical context around the birth.
Date/Time of birth	Date/Time of birth: Date and time of birth.
Place of birth	Place of birth: *
Person #1	Person #1: A person who needs to be represented within the health record.
Name line	Name line: The name by which an individual is known as free text or a text composite of one or more structured name components.
Identifier	Identifier: Identifier associated with the identified person.
Role	Role: The role or capacity in which the identified person contributes to the health or social care of the subject of care.
Electronic communication	Electronic communication: Details about a specific type of electronic communication for the person.
Medium	Medium: The type of electronic communication or channel. The scope of electronic communication medium includes, but is not limited to use of : a telephone, cellular phone, computer, or pager. Coded Text Mobile (cellular) telephone Telephone (excluding mobile telephone) Email Pager Text
Type	Type: The purpose or use for the identified medium. Coding with an external terminology is preferred, where possible. Coded Text Business use Personal use Both business and personal use Text
Value	Value: The unique combination of alphanumeric characters, meaningful for the identified medium, for contacting the person. For example: area code + landline phone/pager number; country code + mobile phone number; email address; or skype contact name. Text URI
Gender	Gender: Details about the gender of an individual.
Data
Administrative gender	Administrative gender: The gender of an individual used for administrative purposes. This element is what most systems today describes as 'Sex' or 'Gender'. For example 'Male', 'Female', 'Other'. This aligns with HL7 FHIR 'Person.gender'. Coding with a terminology is recommended, where possible.
Legal gender	Legal gender: The gender of an individual used for official or legal purposes. For example: identification documents such as birth certificate or passport.
Sex assigned at birth	Sex assigned at birth: The sex of an individual determined by anatomical characteristics observed and registered at birth. For example: 'Male', 'Female', 'Intersex'. Coding with a terminology is recommended, where possible. Use the element 'Comment' or the SLOT 'Details' if needed to register more specific details of the individuals gender.
Gender expression	Gender expression: The expression of the gender by the individual as demonstrated by behaviour, speech, clothes or other external characteristics. For example 'Masculine', 'Feminine', 'Androgynous' or 'Alternating'. Alternatively, a narrative description.
Gender identity	Gender identity: The individual's perception of their own gender. For example: 'male'; 'female'; or 'non-binary'. Coding with a terminology is recommended, where possible.
Preferred pronoun	Preferred pronoun: The pronoun an individual chooses to identify with, and would prefer others to use when talking to or about that individual. For example: 'she'; 'he'; 'they'; or 'ze'. Coding with a terminology is recommended, where possible.
Comment	Comment: Additional narrative about the individual's gender not captured in other data elements.
Protocol
Last updated	Last updated: The date this gender data was last updated.
Ad hoc heading	Ad hoc heading: A generic section header which should be renamed in a template to suit a specific clinical context.
Medication screening questionnaire	Medication screening questionnaire: An individual- or self-reported questionnaire screening for use of any medication or class of medication.
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
Screening purpose	Screening purpose: The reason for overall screening. For example: screening for previous use of a class lof medications, such as bisphosphonates.
Any medication status	Any medication status: Is the individual using any medication? Coded Text Currently used Never used Used in the past Unknown Text
Medication class	Medication class: Details about the use of a specific class of medication. Use another instance of this CLUSTER to represent a subclass of medication.
Class name	Class name: Name of class or subclass of medication. For example: opioid drugs; or NSAIDs.
Class status	Class status: Is the individual using the class of medication? Coded Text Currently used Never used Used in the past Unknown Text
Specific medication	Specific medication: Details about the use of a specific medication.
Medication name	Medication name: Name of medication. For example: Oxycodone.
Medication status	Medication status: Is the individual using the specific medication? Coded Text Currently used Never used Used in the past Unknown Text
Comment	Comment: Additional narrative about the medication use screening, not captured in other fields.
Family history screening questionnaire	Family history screening questionnaire: A screening questionnaire about significant health-related problems found in family members.
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
Screening purpose	Screening purpose: The reason for overall screening. For example: pre-operative screening.
Presence of any problems?	Presence of any problems?: Presence of any relevant problems in the family. Yes No Unknown
Specific problem	Specific problem: Grouping of data elements related to screening for a specific problem.
Problem/diagnosis name	Problem/diagnosis name: Identification of the significant problem or diagnosis in the identified family member. Coding of the family member's problem or diagnosis with a terminology is preferred, where possible.
Present?	Present?: Presence of any relevant specific problem. Yes No Unknown
Specific family member	Specific family member: Details about a specific family member. The data elements in this cluster will relate to the individual identified either by name or by alias. Repeat the use of the cluster for other family members.
Family member name	Family member name: Name of family member. For example: 'Aunt Susan' or 'Susan Smith'. However, for privacy reasons this may not be appropriate for recording, sharing or public display and in this situation the 'Alias' should be used.
Alias	Alias: An alternative name or label to uniquely identify a family member, without using a personal name which might publicly identify the individual. To be used to assist in distinguishing one individual from multiple family members with identical relationships. For example, the label to distinguish one specific sister from three known sisters might be 'eldest sister' 'sister with the red hair' or 'sister #1'.
Relationship	Relationship: The relationship of the family member to the subject of care. For example: mother, step-father, maternal grandmother, or paternal uncle. Coding of the relationship with a terminology is preferred, where possible and including specification of maternal and paternal as required.
Specific problem	Specific problem: Grouping of data elements about the specific problem relatet to the family member.
Problem/diagnosis name	Problem/diagnosis name: Identification of the significant problem or diagnosis in the identified family member. Coding of the family member's problem or diagnosis with a terminology is preferred, where possible.
Present?	Present?: Presence of any significant problem in the identified family member. Yes No Unknown
Comment	Comment: Additional narrative about the problems, not captured in other fields.
Condition screening questionnaire	Condition screening questionnaire: An screeing questionnaire for conditions, including problems and diagnoses.
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
Screening purpose	Screening purpose: The reason for overall screening. For example: pre-operative screening.
Presence of any conditions?	Presence of any 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.
Presence?	Presence?: Presence of the condition. Present Absent Unknown
Comment	Comment: Additional narrative about the conditions, not captured in other fields.
Ad hoc heading #1	Ad hoc heading #1: 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.
Clinical description	Clinical description: Narrative description about the problem or diagnosis. Use to provide background and context, including evolution, episodes or exacerbations, progress and any other relevant details, about the problem or diagnosis.
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.
Cause	Cause: A cause, set of causes, or manner of causation of the problem or diagnosis. Also known as 'aetiology' or 'etiology'. Coding with an external terminology is preferred, where possible.
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.
Date/time clinically recognised	Date/time clinically recognised: Estimated or actual date/time the diagnosis or problem was recognised 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 clinical recognition" 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
CCTA specific	CCTA specific: The local measurement of arterial blood pressure which is a surrogate for arterial pressure in the systemic circulation.
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])
Course description	Course description: Narrative description about the course of the problem or diagnosis since onset.
Date/time of resolution	Date/time of resolution: 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.
Diagnostic status	Diagnostic status: Stage or phase of diagnostic process. The status is usually determined by a combination of the timing of diagnosis plus level of clinical certainty resulting from diagnostic tests and clinical evidence available. This data element and 'Diagnostic certainty' in EVALUATION.problem_diagnosis are two important axes of the diagnostic process, and valid combinations will need to be presented by software that exposes both data elements, so it is not possible for users to select conflicting combinations. Preliminary or working diagnoses are intended to represent the single most likely choice out of all differential diagnosis options. Preliminary Working Established Refuted
Current/Past?	Current/Past?: Category that supports division of problems and diagnoses into Current or Past problem lists. The Current/Past and Active/Inactive data elements have similar clinical impact but represent slightly different semantics. Both are actively used in different clinical settings, but usually not together. If an Active/Inactive 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. Current Past
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. Not resolving Resolving Resolved Indeterminate 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 Not in remission Indeterminate
Episodicity	Episodicity: Category of this episode for the identified problem/diagnosis. For example: 'New' will enable clinicians to distinguish a new, acute episode of otitis media that may have arisen soon after a previous diagnosis, to distinguish it from an unresolved or 'Ongoing' diagnosis of chronic otitis media. Treatment of recurring, new and acute, episodes of a condition may differ significantly from the same condition that is not resolving or responding to treatment. In many situations the clinician will not be able to tell, and so indeterminate may be appropriate. New Ongoing Indeterminate
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. First occurrence Recurrence
Course label	Course label: Category reflecting the speed of onset and/or duration and persistence of the problem or diagnosis. Definitions of acute vs chronic will differ for each diagnosis. Acute Acute-on-chronic Chronic
Diagnostic category	Diagnostic category: Category of the problem or diagnosis within a specified episode of care and/or local care context. This data element contains a value set commonly used in diagnostic categorisation. In episodic care contexts (commonly secondary care) it is common to categorise/organise diagnoses according to their relationship to the principal diagnosis being addressed during that episode of care. These categories may also be used for clinical coding, reporting and billing purposes. In some countries the diagnostic category may be known as a DRG. In addition, the free text choice permits use of other local value sets, as required. Coded Text Principal diagnosis Secondary diagnosis Complication Text
Admission diagnosis?	Admission diagnosis?: Was the problem or diagnosis present at admission? Record as True if the problem or diagnosis was present on admission. This data element is a requirement from DRG reporting in some countries.
Diagnostic certainty	Diagnostic certainty: The level of confidence in the identification of the diagnosis. If an alternative valueset is required, these values can be added to the DV_TEXT data type in a template. Coded Text Suspected Probable Confirmed Text
Comment	Comment: Additional narrative about the problem or diagnosis not captured in other fields.
Protocol
Last updated	Last updated: The date this problem or diagnosis was last updated.
Problem/Diagnosis #1	Problem/Diagnosis #1: 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.
Clinical description	Clinical description: Narrative description about the problem or diagnosis. Use to provide background and context, including evolution, episodes or exacerbations, progress and any other relevant details, about the problem or diagnosis.
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.
Cause	Cause: A cause, set of causes, or manner of causation of the problem or diagnosis. Also known as 'aetiology' or 'etiology'. Coding with an external terminology is preferred, where possible.
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.
Date/time clinically recognised	Date/time clinically recognised: Estimated or actual date/time the diagnosis or problem was recognised 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 clinical recognition" 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
Course description	Course description: Narrative description about the course of the problem or diagnosis since onset.
Date/time of resolution	Date/time of resolution: 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.
Diagnostic status	Diagnostic status: Stage or phase of diagnostic process. The status is usually determined by a combination of the timing of diagnosis plus level of clinical certainty resulting from diagnostic tests and clinical evidence available. This data element and 'Diagnostic certainty' in EVALUATION.problem_diagnosis are two important axes of the diagnostic process, and valid combinations will need to be presented by software that exposes both data elements, so it is not possible for users to select conflicting combinations. Preliminary or working diagnoses are intended to represent the single most likely choice out of all differential diagnosis options. Preliminary Working Established Refuted
Current/Past?	Current/Past?: Category that supports division of problems and diagnoses into Current or Past problem lists. The Current/Past and Active/Inactive data elements have similar clinical impact but represent slightly different semantics. Both are actively used in different clinical settings, but usually not together. If an Active/Inactive 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. Current Past
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. Not resolving Resolving Resolved Indeterminate 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 Not in remission Indeterminate
Episodicity	Episodicity: Category of this episode for the identified problem/diagnosis. For example: 'New' will enable clinicians to distinguish a new, acute episode of otitis media that may have arisen soon after a previous diagnosis, to distinguish it from an unresolved or 'Ongoing' diagnosis of chronic otitis media. Treatment of recurring, new and acute, episodes of a condition may differ significantly from the same condition that is not resolving or responding to treatment. In many situations the clinician will not be able to tell, and so indeterminate may be appropriate. New Ongoing Indeterminate
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. First occurrence Recurrence
Course label	Course label: Category reflecting the speed of onset and/or duration and persistence of the problem or diagnosis. Definitions of acute vs chronic will differ for each diagnosis. Acute Acute-on-chronic Chronic
Diagnostic category	Diagnostic category: Category of the problem or diagnosis within a specified episode of care and/or local care context. This data element contains a value set commonly used in diagnostic categorisation. In episodic care contexts (commonly secondary care) it is common to categorise/organise diagnoses according to their relationship to the principal diagnosis being addressed during that episode of care. These categories may also be used for clinical coding, reporting and billing purposes. In some countries the diagnostic category may be known as a DRG. In addition, the free text choice permits use of other local value sets, as required. Coded Text Principal diagnosis Secondary diagnosis Complication Text
Admission diagnosis?	Admission diagnosis?: Was the problem or diagnosis present at admission? Record as True if the problem or diagnosis was present on admission. This data element is a requirement from DRG reporting in some countries.
Diagnostic certainty	Diagnostic certainty: The level of confidence in the identification of the diagnosis. If an alternative valueset is required, these values can be added to the DV_TEXT data type in a template. Coded Text Suspected Probable Confirmed Text
Comment	Comment: Additional narrative about the problem or diagnosis not captured in other fields.
Protocol
Last updated	Last updated: The date this problem or diagnosis was last updated.
Problem/Diagnosis #2	Problem/Diagnosis #2: 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.
Clinical description	Clinical description: Narrative description about the problem or diagnosis. Use to provide background and context, including evolution, episodes or exacerbations, progress and any other relevant details, about the problem or diagnosis.
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.
Cause	Cause: A cause, set of causes, or manner of causation of the problem or diagnosis. Also known as 'aetiology' or 'etiology'. Coding with an external terminology is preferred, where possible.
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.
Date/time clinically recognised	Date/time clinically recognised: Estimated or actual date/time the diagnosis or problem was recognised 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 clinical recognition" 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
Course description	Course description: Narrative description about the course of the problem or diagnosis since onset.
Date/time of resolution	Date/time of resolution: 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.
Diagnostic status	Diagnostic status: Stage or phase of diagnostic process. The status is usually determined by a combination of the timing of diagnosis plus level of clinical certainty resulting from diagnostic tests and clinical evidence available. This data element and 'Diagnostic certainty' in EVALUATION.problem_diagnosis are two important axes of the diagnostic process, and valid combinations will need to be presented by software that exposes both data elements, so it is not possible for users to select conflicting combinations. Preliminary or working diagnoses are intended to represent the single most likely choice out of all differential diagnosis options. Preliminary Working Established Refuted
Current/Past?	Current/Past?: Category that supports division of problems and diagnoses into Current or Past problem lists. The Current/Past and Active/Inactive data elements have similar clinical impact but represent slightly different semantics. Both are actively used in different clinical settings, but usually not together. If an Active/Inactive 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. Current Past
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. Not resolving Resolving Resolved Indeterminate 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 Not in remission Indeterminate
Episodicity	Episodicity: Category of this episode for the identified problem/diagnosis. For example: 'New' will enable clinicians to distinguish a new, acute episode of otitis media that may have arisen soon after a previous diagnosis, to distinguish it from an unresolved or 'Ongoing' diagnosis of chronic otitis media. Treatment of recurring, new and acute, episodes of a condition may differ significantly from the same condition that is not resolving or responding to treatment. In many situations the clinician will not be able to tell, and so indeterminate may be appropriate. New Ongoing Indeterminate
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. First occurrence Recurrence
Course label	Course label: Category reflecting the speed of onset and/or duration and persistence of the problem or diagnosis. Definitions of acute vs chronic will differ for each diagnosis. Acute Acute-on-chronic Chronic
Diagnostic category	Diagnostic category: Category of the problem or diagnosis within a specified episode of care and/or local care context. This data element contains a value set commonly used in diagnostic categorisation. In episodic care contexts (commonly secondary care) it is common to categorise/organise diagnoses according to their relationship to the principal diagnosis being addressed during that episode of care. These categories may also be used for clinical coding, reporting and billing purposes. In some countries the diagnostic category may be known as a DRG. In addition, the free text choice permits use of other local value sets, as required. Coded Text Principal diagnosis Secondary diagnosis Complication Text
Admission diagnosis?	Admission diagnosis?: Was the problem or diagnosis present at admission? Record as True if the problem or diagnosis was present on admission. This data element is a requirement from DRG reporting in some countries.
Diagnostic certainty	Diagnostic certainty: The level of confidence in the identification of the diagnosis. If an alternative valueset is required, these values can be added to the DV_TEXT data type in a template. Coded Text Suspected Probable Confirmed Text
Comment	Comment: Additional narrative about the problem or diagnosis not captured in other fields.
Protocol
Last updated	Last updated: The date this problem or diagnosis was last updated.
Ad hoc heading #2	Ad hoc heading #2: 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.
Clinical description	Clinical description: Narrative description about the problem or diagnosis. Use to provide background and context, including evolution, episodes or exacerbations, progress and any other relevant details, about the problem or diagnosis.
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.
Cause	Cause: A cause, set of causes, or manner of causation of the problem or diagnosis. Also known as 'aetiology' or 'etiology'. Coding with an external terminology is preferred, where possible.
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.
Date/time clinically recognised	Date/time clinically recognised: Estimated or actual date/time the diagnosis or problem was recognised 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 clinical recognition" 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
CCTA specific	CCTA specific: The local measurement of arterial blood pressure which is a surrogate for arterial pressure in the systemic circulation.
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])
Course description	Course description: Narrative description about the course of the problem or diagnosis since onset.
Date/time of resolution	Date/time of resolution: 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.
Diagnostic status	Diagnostic status: Stage or phase of diagnostic process. The status is usually determined by a combination of the timing of diagnosis plus level of clinical certainty resulting from diagnostic tests and clinical evidence available. This data element and 'Diagnostic certainty' in EVALUATION.problem_diagnosis are two important axes of the diagnostic process, and valid combinations will need to be presented by software that exposes both data elements, so it is not possible for users to select conflicting combinations. Preliminary or working diagnoses are intended to represent the single most likely choice out of all differential diagnosis options. Preliminary Working Established Refuted
Current/Past?	Current/Past?: Category that supports division of problems and diagnoses into Current or Past problem lists. The Current/Past and Active/Inactive data elements have similar clinical impact but represent slightly different semantics. Both are actively used in different clinical settings, but usually not together. If an Active/Inactive 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. Current Past
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. Not resolving Resolving Resolved Indeterminate 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 Not in remission Indeterminate
Episodicity	Episodicity: Category of this episode for the identified problem/diagnosis. For example: 'New' will enable clinicians to distinguish a new, acute episode of otitis media that may have arisen soon after a previous diagnosis, to distinguish it from an unresolved or 'Ongoing' diagnosis of chronic otitis media. Treatment of recurring, new and acute, episodes of a condition may differ significantly from the same condition that is not resolving or responding to treatment. In many situations the clinician will not be able to tell, and so indeterminate may be appropriate. New Ongoing Indeterminate
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. First occurrence Recurrence
Course label	Course label: Category reflecting the speed of onset and/or duration and persistence of the problem or diagnosis. Definitions of acute vs chronic will differ for each diagnosis. Acute Acute-on-chronic Chronic
Diagnostic category	Diagnostic category: Category of the problem or diagnosis within a specified episode of care and/or local care context. This data element contains a value set commonly used in diagnostic categorisation. In episodic care contexts (commonly secondary care) it is common to categorise/organise diagnoses according to their relationship to the principal diagnosis being addressed during that episode of care. These categories may also be used for clinical coding, reporting and billing purposes. In some countries the diagnostic category may be known as a DRG. In addition, the free text choice permits use of other local value sets, as required. Coded Text Principal diagnosis Secondary diagnosis Complication Text
Admission diagnosis?	Admission diagnosis?: Was the problem or diagnosis present at admission? Record as True if the problem or diagnosis was present on admission. This data element is a requirement from DRG reporting in some countries.
Diagnostic certainty	Diagnostic certainty: The level of confidence in the identification of the diagnosis. If an alternative valueset is required, these values can be added to the DV_TEXT data type in a template. Coded Text Suspected Probable Confirmed Text
Comment	Comment: Additional narrative about the problem or diagnosis not captured in other fields.
Protocol
Last updated	Last updated: The date this problem or diagnosis was last updated.
Problem/Diagnosis #1	Problem/Diagnosis #1: 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.
Clinical description	Clinical description: Narrative description about the problem or diagnosis. Use to provide background and context, including evolution, episodes or exacerbations, progress and any other relevant details, about the problem or diagnosis.
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.
Cause	Cause: A cause, set of causes, or manner of causation of the problem or diagnosis. Also known as 'aetiology' or 'etiology'. Coding with an external terminology is preferred, where possible.
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.
Date/time clinically recognised	Date/time clinically recognised: Estimated or actual date/time the diagnosis or problem was recognised 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 clinical recognition" 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
Course description	Course description: Narrative description about the course of the problem or diagnosis since onset.
Date/time of resolution	Date/time of resolution: 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.
Diagnostic certainty	Diagnostic certainty: The level of confidence in the identification of the diagnosis. If an alternative valueset is required, these values can be added to the DV_TEXT data type in a template. Coded Text Suspected Probable Confirmed Text
Comment	Comment: Additional narrative about the problem or diagnosis not captured in other fields.
Protocol
Last updated	Last updated: The date this problem or diagnosis was last updated.
Problem/Diagnosis #2	Problem/Diagnosis #2: 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.
Clinical description	Clinical description: Narrative description about the problem or diagnosis. Use to provide background and context, including evolution, episodes or exacerbations, progress and any other relevant details, about the problem or diagnosis.
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.
Body site #1	Body site #1: 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.
Cause	Cause: A cause, set of causes, or manner of causation of the problem or diagnosis. Also known as 'aetiology' or 'etiology'. Coding with an external terminology is preferred, where possible.
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.
Date/time clinically recognised	Date/time clinically recognised: Estimated or actual date/time the diagnosis or problem was recognised 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 clinical recognition" 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
Course description	Course description: Narrative description about the course of the problem or diagnosis since onset.
Date/time of resolution	Date/time of resolution: 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.
Diagnostic certainty	Diagnostic certainty: The level of confidence in the identification of the diagnosis. If an alternative valueset is required, these values can be added to the DV_TEXT data type in a template. Coded Text Suspected Probable Confirmed Text
Comment	Comment: Additional narrative about the problem or diagnosis not captured in other fields.
Protocol
Last updated	Last updated: The date this problem or diagnosis was last updated.
Ad hoc heading #3	Ad hoc heading #3: A generic section header which should be renamed in a template to suit a specific clinical context.
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
Overall description	Overall description: Narrative summary about the individual's overall alcohol consumption pattern and history. Use this data element to record a narrative description of alcohol drinking habits for this individual or to incorporate unstructured alcohol drinking information from existing or legacy clinical systems into an archetyped format.
Regular consumption commenced	Regular consumption commenced: The date or partial date when the individual first started frequent or regular, but usually non-daily, consumption of alcohol. This data element is recording when a regular pattern of drinking commenced, rather than the first ever taste of alcohol. The first taste could be at a very young age and then no drinking until mid teens. In this case it is the pattern in the mid teens that is clinically significant. To differentiate between patterns of drinking, that has to be recorded in other elements in this archetype, for example in the 'Per episode' section.
Daily consumption commenced	Daily consumption commenced: The date or partial date when the individual first started consuming alcohol on a daily basis. Can be a partial date, for example, only a year.
Date first intoxicated	Date first intoxicated: The date or partial date when the individual became intoxicated for the first time. This data point is not intended to record an accidental intoxication but to identify when a behaviour pattern of harmful consumption may have commenced.
Per episode	Per episode: Details about a discrete period of time with a consistent pattern of typical consumption.
Status	Status: Statement about current alcohol drinking behaviour. Current drinker Non-drinker
Episode description	Episode description: Narrative summary about the individual's overall pattern of alcohol consumption during the specified episode. For example: details about binge drinking pattern.
Episode label	Episode label: Identification of an episode of alcohol consumption - either as a number in a sequence and/or a named event. For example: '2' as the second episode within a sequence of episodes; or 'Pregnancy with twins' if describing the alcohol consumption during a health event such as during a specific pregnancy. Count>=1 Text
Episode start date	Episode start date: Date when this episode commenced. Can be a partial date, for example, only a year.
Episode end date	Episode end date: Date when this episode ceased. Can be a partial date, for example, only a year. This data field will be empty if the episode is current and ongoing.
Pattern	Pattern: The typical pattern of consumption of alcohol. The typical pattern of use can be made more granular by coding with a terminology or a local value set in a template. Coded Text Daily Non-daily Text
Binge drinking frequency	Binge drinking frequency: The individual's typical frequency of heavy drinking over a short period of time with the intent of becoming intoxicated. Quantity0..7; 0..31; 0..365 Units: 1/wk 1/mo 1/a Interval of QuantityLower constraint: 0..7; 0..31; 0..365 Units: 1/wk 1/mo 1/a Upper constraint: 0..7; 0..31; 0..365 Units: 1/wk 1/mo 1/a
Binge drinking description	Binge drinking description: Narrative description about the individual's typical pattern of binge drinking.
Alcohol free days	Alcohol free days: The number of days where no alcohol was consumed in the specified period. 0..7; 0..31 Units: 1/wk 1/mo
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
Per type	Per type: Details about consumption of a specified type of alcohol.
Type	Type: The name of the specific type or grouping of alcohol. Use of the coded text option is preferrable when possible. Alternatively, it's possible to use a local valueset or terminologi to record specific types of alcoholic beverages. For example: red or white wine; brandy or whisky; normal or low alcohol beer; or denatured alcohol (methylated spirits) as a specific form of rectified spirits. Text Coded Text Beer Wine Cider Mead Pulque Spirits Fortified wine
Description	Description: Narrative summary about alcohol consumption for the specified type of alcohol.
Typical consumption (alcohol units)	Typical consumption (alcohol units): Estimate of number of standard drinks of the specified type of alcohol consumed in the specified period. The definition of an Alcohol unit can be recorded in the Protocol. >=0; >=0; >=0 Units: 1/d 1/wk 1/mo
Comment	Comment: Additional narrative about consumption of the specified type of alcohol, not captured in other fields.
Number of quit attempts	Number of quit attempts: Total number of times the individual has attempted to stop consuming alcohol within this episode. >=0
Quit date	Quit date: Date when the individual last consumed an alcohol. Can be a partial date, for example, only a year. Definitions for a 'Quit date' vary enormously and can be defined using the 'Quit data definition' data element in the Protocol section of this archetype. This date will be identical to the 'Episode end date' for the most recent episode. This date could be used by decision support guidance to determine if the individual is at risk of relapse, for example in the first 12 months since quitting.
Episode comment	Episode comment: Additional narrative about alcohol consumption during the specified episode, not captured in other fields. For example: alcohol consumed as a hangover remedy eg 'hair of the dog'.
Overall quit date	Overall quit date: The date when the individual last ceased consuming alcohol of any type. Can be a partial date, for example, only a year. This date could be used by decision support guidance to determine if the individual is at risk of relapse, for example in the first 12 months since quitting.
Overall comment	Overall comment: Additional narrative about all alcohol consumption that has not been captured in other fields.
Protocol
Quit date definition	Quit date definition: The applied definition for the 'Quit date' data elements used in this archetype.
Quit attempt definition	Quit attempt definition: The applied definition for a Quit attempt used to determine value for the 'Number of quit attempts' data element used in this archetype. For example: 'stopped consuming alcohol for one day or longer with the intention of quitting'.
Current drinker definition	Current drinker definition: The applied definition for the 'Current drinker' value in each of the 'Status' data elements used in this archetype.
Former drinker definition	Former drinker definition: The applied definition for the 'Former drinker' value in each of the 'Status' data elements used in this archetype.
Lifetime non-drinker definition	Lifetime non-drinker definition: The applied definition for the 'Lifetime non-drinker' value in each of the 'Status' data elements used in this archetype.
Alcohol unit definition (mass)	Alcohol unit definition (mass): Mass of alcohol defining a standard drink or alcohol unit as used in the 'Typical drinking (alcohol units)' element in this archetype. >=0; >=0 Units: g oz (avoirdupois) (UCUM: [oz_av])
Last updated	Last updated: The date this alcohol consumption summary was last updated.
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
Overall description	Overall description: Narrative summary about the individual's overall tobacco smoking pattern and history. Use this data element to record a narrative description of the tobacco smoking habits for this individual or to incorporate unstructured tobacco smoking information from existing or legacy clinical systems into an archetyped format.
Regular smoking commenced	Regular smoking commenced: The date or partial date when the individual first started frequent or regular, but usually non-daily, smoking of tobacco of any type. Can be a partial date, for example, only a year. For example, this date could represent when the individual commenced smoking every Friday night or at parties.
Daily smoking commenced	Daily smoking commenced: The date or partial date when the individual first started daily smoking of tobacco of any type. Can be a partial date, for example, only a year.
Per type	Per type: Details about smoking activity for a specified type of smoked tobacco.
Type	Type: The type of tobacco smoked by the individual. Cigarettes Hand-rolled cigarettes Cigars Cigarillos Pipe Waterpipe Bidis Kreteks
Status	Status: Statement about current smoking behaviour for the specified type of tobacco. Current smoker Former smoker Never smoked
Description	Description: Narrative summary about smoking behaviour for the specified type of tobacco.
Per episode	Per episode: Details about a discrete period of smoking activity for the specified type of tobacco.
Episode label	Episode label: Identification of an episode of smoking activity - either as a number in a sequence and/or a named event. For example: '2' as the second episode within a sequence of episodes; or 'Pregnancy with twins' if describing the smoking activity during a health event such as during a specific pregnancy. Count>=1 Text
Episode start date	Episode start date: Date when this episode commenced. Can be a partial date, for example, only a year.
Episode end date	Episode end date: Date when this episode ceased. Can be a partial date, for example, only a year. This data field will be empty if the episode is current and ongoing.
Pattern	Pattern: The typical pattern of smoking for the specified type of tobacco. Coded Text Daily Non-daily Text
Typical use (units)	Typical use (units): Estimate of number of units of the specified type of tobacco consumed. For example: the number of 'sticks' or 'full pipes' per day or per week. This data element is redundant if a value is recorded for 'Typical use(mass)'. >=0; >=0 Units: 1/d 1/wk
Typical use (mass)	Typical use (mass): Estimate of the weight of loose leaf tobacco smoked. This data element will typically be used for pipes and hand-rolled cigarettes and is redundant if a value is recorded for 'Typical use (units)'. >=0; >=0; >=0; >=0 Units: g/d g/wk [oz_av]/d [oz_av]/wk
Number of quit attempts	Number of quit attempts: Total number of times the individual has attempted to stop smoking the specified type of tobacco within this episode. >=0
Episode comment	Episode comment: Additional narrative about tobacco smoking during the specified episode, not captured in other fields.
Quit date	Quit date: Date when the individual last smoked the specified type of tobacco. Can be a partial date, for example, only a year. Definitions for a 'Quit date' vary enormously and can be defined using the 'Quit data definition' data element in the Protocol section of this archetype. This date will be identical to the 'Episode end date' for the most recent episode. This date could be used by decision support guidance to determine if the individual is at risk of relapse, for example in the first 12 months since quitting.
Pack years	Pack years: Estimate of the cumulative amount of tobacco smoked using the specified type of tobacco. Commonly used in assessment of cigarette use. It is calculated by multiplying the number of packs of cigarettes smoked per day by the number of years the individual has smoked. One pack year equals 365 packs of cigarettes. Details about how to calculate pack years for other types of tobacco can be found at http://smokingpackyears.com. The definition of a pack can be recorded in the protocol of this archetype using the 'Pack definition' data element. >=0
Comment	Comment: Additional narrative about smoking of the specified type of tobacco, not captured in other fields.
Overall quit date	Overall quit date: The date when the individual last ceased using tobacco of any type. Can be a partial date, for example, only a year. This date could be used by decision support guidance to determine if the individual is at risk of relapse, for example in the first 12 months since quitting.
Overall years of smoking	Overall years of smoking: The cumulative number of years that the individual has smoked tobacco. This data element does not take into account the amount of tobacco smoked. It may be used to calculate the 'Smoking index'. >=0 yr (UCUM: a)
Smoking index	Smoking index: An indication of the cumulative amount of tobacco smoking exposure. This parameter is similar to Pack Years but based on units of cigarettes, bidis etc smoked per day, rather than packs. >=0
Overall pack years	Overall pack years: Estimate of the cumulative amount for all types of tobacco smoked. The definition of a pack can be recorded in the protocol of this archetype using the 'Pack definition' data element. >=0
Overall comment	Overall comment: Additional narrative about all tobacco smoking that has not been captured in other fields. For example: stopped smoking or reduced amount on becoming pregnant.
Protocol
Quit date definition	Quit date definition: The applied definition for the 'Quit date' data elements used in this archetype.
Quit attempt definition	Quit attempt definition: The applied definition for a Quit attempt used to determine value for the 'Number of quit attempts' data element used in this archetype. For example: 'stopped smoking for one day or longer with the intention of quitting'.
Current smoker definition	Current smoker definition: The applied definition for the 'Current smoker' value in each of the 'Status' data elements used in this archetype. Definition may need to be specified per type. Current smoker definitions vary in different jurisdictions. For example: USA Centre for Disease Control refers to smoking during the past one month and New Zealand Ministry of Health uses 28 days.
Former smoker definition	Former smoker definition: The applied definition for the 'Former smoker' value in each of the 'Status' data elements used in this archetype. Definition may need to be specified per type of tobacco. Former smoker definitions vary in different jurisdictions. For example: New Zealand Ministry of Health refers to not having smoked during the past 28 days.
Never smoked definition	Never smoked definition: The applied definition for the 'Never smoked' value in each of the 'Status' data elements used in this archetype. Definition may need to be specified per type. For example, the definition may not be zero, but less than a specified amount (as units or mass) smoked during a specified time interval.
Pack definition	Pack definition: The definition of the size of pack used as part of the algorithm for calculating 'Pack years' data elements used in this archetype. Definition may need to be specified per type. For example, the number of units in a pack used for cigarettes may be different to cigars; the mass of loose tobacco in a pack used for hand-rolled cigarettes or pipes. Count>=0 Quantity>=0; >=0 Units: g oz (avoirdupois) (UCUM: [oz_av])
Last updated	Last updated: The date this tobacco smoking summary was last updated.
Ad hoc heading #4	Ad hoc heading #4: 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
Comment	Comment: Additional narrative about the measurement of Body weight, not captured in other fields.
State
State of dress	State of dress: Description of the state of dress of the person at the time of weighing. Naked Nappy/diaper Lightly clothed/underwear Fully clothed, without shoes Fully clothed, including shoes
Confounding factors	Confounding factors: Record any issues or factors that may impact on the measurement of body weight eg timing in menstrual cycle, timing of recent bowel motion or noting of amputation.
Birth	Birth: Usually the first weight, measured soon after birth. This event will only be used once per health record .
Data
Weight	Weight: The weight of the individual. 0..1000; 0..2000; 0..1000000 Units: kg lbm (UCUM: [lb_av]) g
Comment	Comment: Additional narrative about the measurement of Body weight, not captured in other fields.
State
State of dress	State of dress: Description of the state of dress of the person at the time of weighing. Naked Nappy/diaper Lightly clothed/underwear Fully clothed, without shoes Fully clothed, including shoes
Confounding factors	Confounding factors: Record any issues or factors that may impact on the measurement of body weight eg timing in menstrual cycle, timing of recent bowel motion or noting of amputation.
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])
Comment	Comment: Additional narrative about the measurement, not captured in other fields.
State
Position	Position: Position of individual when measured. Standing Lying Assumed value: Standing
Confounding factors	Confounding factors: Narrative description of any issues or factors that may impact on the measurement. For example: noting of amputation.
Birth	Birth: Usually the first length measurement, recorded soon after birth. This event will only be used once per health record .
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])
Comment	Comment: Additional narrative about the measurement, not captured in other fields.
State
Position	Position: Position of individual when measured. Standing Lying Assumed value: Standing
Confounding factors	Confounding factors: Narrative description of any issues or factors that may impact on the measurement. For example: noting of amputation.
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])
Mean arterial pressure	Mean arterial pressure: The average arterial pressure that occurs over the entire course of the heart contraction and relaxation cycle. 0..1000 mmHg (UCUM: mm[Hg])
Pulse pressure	Pulse pressure: The difference between the systolic and diastolic pressure. 0..1000 mmHg (UCUM: mm[Hg])
Clinical interpretation	Clinical interpretation: Single word, phrase or brief description that represents the clinical meaning and significance of the blood pressure measurement.
Comment	Comment: Additional narrative about the measurement, not captured in other fields.
State
Position	Position: The position of the individual at the time of measurement. Standing Sitting Reclining Lying Lying with tilt to left
Confounding factors	Confounding factors: Comment on and record other incidental factors that may be contributing to the blood pressure measurement. For example, level of anxiety or 'white coat syndrome'; pain or fever; changes in atmospheric pressure etc.
Sleep status	Sleep status: Sleep status - supports interpretation of 24 hour ambulatory blood pressure records. Awake Sleeping
Tilt	Tilt: The craniocaudal tilt of the surface on which the person is lying at the time of measurement. -90..90 ° (UCUM: deg)
24 hour average	24 hour average: Estimate of the average blood pressure over a 24 hour period.
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])
Mean arterial pressure	Mean arterial pressure: The average arterial pressure that occurs over the entire course of the heart contraction and relaxation cycle. 0..1000 mmHg (UCUM: mm[Hg])
Pulse pressure	Pulse pressure: The difference between the systolic and diastolic pressure. 0..1000 mmHg (UCUM: mm[Hg])
Clinical interpretation	Clinical interpretation: Single word, phrase or brief description that represents the clinical meaning and significance of the blood pressure measurement.
Comment	Comment: Additional narrative about the measurement, not captured in other fields.
State
Position	Position: The position of the individual at the time of measurement. Standing Sitting Reclining Lying Lying with tilt to left
Confounding factors	Confounding factors: Comment on and record other incidental factors that may be contributing to the blood pressure measurement. For example, level of anxiety or 'white coat syndrome'; pain or fever; changes in atmospheric pressure etc.
Sleep status	Sleep status: Sleep status - supports interpretation of 24 hour ambulatory blood pressure records. Awake Sleeping
Tilt	Tilt: The craniocaudal tilt of the surface on which the person is lying at the time of measurement. -90..90 ° (UCUM: deg)
Protocol	Protocol: List structure.
Cuff size	Cuff size: The size of the cuff used for blood pressure measurement. Perloff D, Grim C, Flack J, Frohlich ED, Hill M, McDonald M, Morgenstern BZ. Human blood pressure determination by sphygmomanometry. Circulation 1993;88;2460-2470. Adult Thigh Large Adult Adult Small Adult Paediatric/Child Infant Neonatal
Location of measurement	Location of measurement: Simple body site where blood pressure was measured. Coded Text Right arm Left arm Right thigh Left thigh Right wrist Left wrist Right ankle Left ankle Finger Toe Dorsum of foot Intra-arterial Text
Method	Method: Method of measurement of blood pressure. Auscultation Palpation Machine Invasive
Mean arterial pressure formula	Mean arterial pressure formula: Formula used to calculate the Mean Arterial Pressure (if recorded in data).
Systolic pressure formula	Systolic pressure formula: Formula used to calculate the systolic pressure from from mean arterial pressure (if recorded in data).
Diastolic pressure formula	Diastolic pressure formula: Formula used to calculate the diastolic pressure from mean arterial pressure (if recorded in data).
Diastolic endpoint	Diastolic endpoint: Record which Korotkoff sound is used for determining diastolic pressure using auscultative method. Phase IV Phase V
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
Presence	Presence: Presence of a pulse or heart beat. It can be implied that the pulse or heart beat is present if Rate >0 /min. Present Not detected
Rate	Rate: The rate of the pulse or heart beat, measured in beats per minute. 0..1000 /min
Regularity	Regularity: Regularity of the pulse or heart beat. Regular Irregular
Irregular type	Irregular type: More specific pattern of an irregular pulse or heart beat. Selection of a value from this value set is only valid if 'Irregular' is selected from the 'Regularity' data element. Regularly Irregular Irregularly Irregular
Character	Character: Description of the character of the pulse or heart beat. Coding with a terminology is desired, where possible. For example: full, thready, bounding, slow rising, or collapsing. Multiple terms may be recorded.
Clinical description	Clinical description: Narrative description about the pulse or heart beat.
(Clinical interpretation)	(Clinical interpretation): Single word, phrase or brief description that represents the clinical meaning and significance of the pulse or heart beat findings, including the rhythm. Coding with a terminology is preferred, where possible. For example: Bradycardia, Extrasystoles or Sinus rhythm. Multiple statements are allowed.
Comment	Comment: Additional narrative about the pulse or heart beat findings not captured in other fields.
State
Position	Position: The body position of the subject during the observation. Standing/upright Sitting Reclining Lying
Confounding factors	Confounding factors: Narrative description about any incidental factors that may affect interpretation of the physical findings. For example, presence of a pacemaker, level of anxiety; pain or fever etc.
Maximum	Maximum: Maximum pulse rate or heart rate observed during a period of exertion.
Data
Presence	Presence: Presence of a pulse or heart beat. It can be implied that the pulse or heart beat is present if Rate >0 /min. Present Not detected
Rate	Rate: The rate of the pulse or heart beat, measured in beats per minute. 0..1000 /min
Regularity	Regularity: Regularity of the pulse or heart beat. Regular Irregular
Irregular type	Irregular type: More specific pattern of an irregular pulse or heart beat. Selection of a value from this value set is only valid if 'Irregular' is selected from the 'Regularity' data element. Regularly Irregular Irregularly Irregular
Character	Character: Description of the character of the pulse or heart beat. Coding with a terminology is desired, where possible. For example: full, thready, bounding, slow rising, or collapsing. Multiple terms may be recorded.
Clinical description	Clinical description: Narrative description about the pulse or heart beat.
(Clinical interpretation)	(Clinical interpretation): Single word, phrase or brief description that represents the clinical meaning and significance of the pulse or heart beat findings, including the rhythm. Coding with a terminology is preferred, where possible. For example: Bradycardia, Extrasystoles or Sinus rhythm. Multiple statements are allowed.
Comment	Comment: Additional narrative about the pulse or heart beat findings not captured in other fields.
State
Position	Position: The body position of the subject during the observation. Standing/upright Sitting Reclining Lying
Confounding factors	Confounding factors: Narrative description about any incidental factors that may affect interpretation of the physical findings. For example, presence of a pacemaker, level of anxiety; pain or fever etc.
Protocol
Method	Method: Method used to observe the pulse or heart beat. For example, auscultation or electronic monitoring. Palpation Auscultation Automatic, non-invasive Automatic, invasive
Body site	Body site: Body site where the pulse or heart beat were observed. Coded Text Radial Artery - Left Radial Artery - Right Heart Carotid Artery - Left Carotid Artery - Right Femoral Artery - Left Femoral Artery - Right Brachial artery - Right Brachial artery - Left Finger Toe Ear lobe Text
Ad hoc heading #5	Ad hoc heading #5: A generic section header which should be renamed in a template to suit a specific clinical context.
Agatston score	Agatston score: An assessment score used to quantify and measure coronary artery calcium, usually as part of a preliminary noncontrast examination for coronary artery and other cardiac structural calcification to estimate risk of cardiovascular diseases.
Data
Any point in time event	Any point in time event: Default, unspecified point in time event which may be explicitly defined in a template or at run-time.
Data
LM	LM: Left main coronary artery calcium score. Units: (UCUM: 1)
LAD	LAD: Left anterior descending artery calcium score. Units: (UCUM: 1)
LCx	LCx: Left circumflex artery calcium score. Units: (UCUM: 1)
RCA	RCA: Right coronary artery calcium score. Units: (UCUM: 1)
Total	Total: The score of all individual calcified lesions in all coronary arteries extending through the z-axis of the heart is summed up to give the total coronary artery calcium score. 0..10000 (UCUM: 1)
Percentile	Percentile: Calcium score percentile based on database representative of the cohort being assessed. This item indicates the percentage of people that have higher score compared to the age, gender, and race matched peers. For example: the total score is at the Xth percentile compared to the same age, gender, and race matched peers. Percent
Risk classification	Risk classification: Overall risk classification based on the total score. Very low Mildly increased Moderately increased Moderate to severely increased
Reaction screening	Reaction screening: An screeing questionnaire for adverse reaction.
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
Screening purpose	Screening purpose: The reason for overall screening. For example: pre-operative screening.
Presence of any reactions?	Presence of any reactions?: Presence of any relevant reactions. Present Absent Unknown
Specific agent	Specific agent: Grouping of data elements related to screening for a single agent.
Agent administered	Agent administered: Name of the agent related to the adverse reaction being screened.
Reaction?	Reaction?: Presence of the reaction. Present Absent Unknown
Comment	Comment: Additional narrative about the reactions, not captured in other fields.
Medication management	Medication management: 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.
Clinical indication	Clinical indication: The clinical reason for the medication activity. For example: 'Angina' or 'Pain'. Coding of the indication with a terminology is preferred, where possible. This data element allows multiple occurrences. If only an ACTION is used to record a medication indication, this data element can be used without additional consideration. However, if a clinical indication is recorded for both the Medication order INSTRUCTION and this Medication management ACTION, be aware that these indications might not be consistent."
Substitution	Substitution: Subsitution action taken by the person administering or dispensing the drug. In many jurisdictions, substitution of an ordered item as a generic form or with a different brand name, which has been determined as bioequivalent, is allowed at the point of dispense or supply. In other cases substitution is assumed and the clinician has to explicitly request non-substitution. Substitution performed Substitution not performed
Substitution reason	Substitution reason: The reason or justification for the substitution action taken. For example: "Generic alternative contains a substance that is not tolerated by the patient." May be coded with a terminology when clinically appropriate
Original scheduled date/time	Original scheduled date/time: The datetime at which the medication action was scheduled to occur. Used to compare variance from actual action time where this is not readily calculable from the original instruction.
Restart date/time	Restart date/time: The date/time on which the medication course is set to restart, as per the "Administrations suspended" pathway step. For example: 2017-10-29
Restart criterion	Restart criterion: The criterion which triggers the medication course to restart, as per the "Administrations suspended" pathway step. For example: "On day 2 after surgery".
Reason	Reason: Reason that the pathway step for the identified medication was carried out. For example: 'Postponed - Patient not avalable at administration time', 'Cancelled - Adverse reaction'. Note: This is not the reason for the medication instruction, but rather the specific reason that a care step was carried out, and will often be used to document some variance from the original order.
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.
Administration method	Administration method: The technique or device by which the ordered item was, or is to be, administered. Comment: For example: ' via Z-track injection'; 'via nebuliser'. Coding of the method with a terminology is preferred, where possible.
Patient guidance	Patient guidance: Any guidance, instructions or advice given to the subject of care or personal carer at the time of the pathway step. For example: 'Avoid grapefruit' , 'Take at least 2 hours before bedtime', 'Take with food'. May be coded with a terminology when clinically appropriate.
Double-checked?	Double-checked?: The pathway step has been checked by a separate individual. Details of the individual performing the double-check can be carried in the Reference Model element "Participation".
Sequence number	Sequence number: The sequence number specific to the pathway step being recorded. For example: Vaccine sequence number.
Comment	Comment: Additional narrative about the activity or pathway step not captured in other fields, including details of any variance between the intended action and the action actually performed. For example: 'Patient was in radiology department', 'Accidental injection into blood vessel during IM administration'.
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.
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
DateTime result issued	DateTime result issued: The date and/or time that the result was issued for the recorded 'Examination result status'.
Clinical information provided	Clinical information provided: Description of clinical information available at the time of interpretation of results. This may include a link to the clinical information provided in the original examination request. If other sources of clinical information have been used, this should be clearly stated using this data element.
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.
Coronary anatomy	Coronary anatomy: Coronary anatomy
Coronary artery dominance	Coronary artery dominance: * Balanced coronary system Left dominant coronary system Right dominant coronary system
Anomalies	Anomalies: *
Coronary artery stenosis	Coronary artery stenosis: Details of coronary arterial calcific plaque and the situation of stenosis.
Presence of plaque	Presence of plaque: *
Stenosis location	Stenosis location: A standardized approach to coronary segmentation. Proximal RCA (pRCA) Mid RCA (mRCA) Distal RCA (dRCA) PDA-R (R-PDA) Left main (LM) Proximal LAD (pLAD) Mid LAD (mLAD) Distal LAD (dLAD) D1 D2 Proximal LCx (pCx) OM1 Mid and distal LCx (LCx) OM2 PDA-L (L-PDA) PLB-R (R-PLB) Ramus intermedius (RI) PLB-L (L-PLB)
Stenosis severity	Stenosis severity: Quantitative assessment of stenosis severity. 0: Normal 1: Minimal 2: Mild 3: Moderate 4: Severe 5: Occluded
Lesion length	Lesion length: Quantitative assessment of stenosis severity. Discrete Tubular Diffuse
Plaque type	Plaque type: The type of detected plaque.
Modifier	Modifier: To indicate that a study is not fully evaluable or non-diagnostic (N) or to indicate the presence of stents (S), grafts (G), and vulnerable plaque (V). S V N G
Vulnerable plaque assessment	Vulnerable plaque assessment: *
Comment	Comment: To describe uninterpretable segments.
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}]
Imaging finding #1	Imaging finding #1: 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.
Recommendation	Recommendation: Suggestion for further imaging, investigations and/or referral, and associated rationale. This data element has 0..* occurrences to allow for more than one recommendation and associated rationale. Formal orders for additional imaging examination, investigation should be recorded using an INSTRUCTION archetype, such as INSTRUCTION.service_request.
Comment	Comment: Additional narrative about the examination not captured in other fields. For example: a note that the film was given to the patient.
State
Confounding factors	Confounding factors: Narrative description of factors, not recorded elsewhere, that may influence the examination findings and/or result.
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.
Image acquisition details	Image acquisition details: unknown
Scan mode	Scan mode: *
ECG-synchronization	ECG-synchronization: *
Use of duel energy?	Use of duel energy?: *
Scan range	Scan range: * Units: cm
Pitch	Pitch: * Units: (UCUM: 1)
Tube voltage	Tube voltage: * Units: mV
Tube current	Tube current: * Units: A
Dose-length product (DLP)	Dose-length product (DLP): *
CT dose index (CTDI)	CT dose index (CTDI): * Units: Gy
Image reconstruction details	Image reconstruction details: Acquisition details for CCTA
Reconstruction method	Reconstruction method: * iterative analytical
Reconstruction slice	Reconstruction slice: * Units: mm
Reconstruction increment	Reconstruction increment: * Units: mm
Reconstruction filter	Reconstruction filter: *
ECG-pulsing window width	ECG-pulsing window width: *
RR-interval	RR-interval: * Lower constraint: Units: % Upper constraint: Units: %
After R-wave	After R-wave: *
ECG reconstruction phase	ECG reconstruction phase: *
RR-interval	RR-interval: * Units: %
After R-wave	After R-wave: * Units: ms
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.
Reason for encounter	Reason for encounter: The reason for initiation of any healthcare encounter or contact by the individual who is the subject of care.
Data
Contact type	Contact type: Identification of the type, or administrative category, of healthcare sought or required by the subject of care. Coding of the 'Contact type' with a terminology is desirable, where possible. Examples include: pre-employment medical, routine antenatal visit, women's health check, pre-operative assessment, or annual medical check-up.
Presenting problem	Presenting problem: Identification of the clinical or social problem motivating the subject of care to seeking healthcare. Coding of the 'Presenting problem' with a terminology is desirable, where possible. Clinical or social reasons for seeking healthcare can include health issues, symptoms or physical signs. Examples: health issues - desire to quit smoking, domestic violence; symptoms - abdominal pain, shortness of breath; physical signs - an altered conscious state. 'Chief complaint' may be used as a valid synonym for 'Presenting problem' in templates.