TEMPLATE Follow up (Follow up)

TEMPLATE ID	Follow up
Concept	Follow up
Description	Not Specified
Purpose	Not Specified
References
Other Details (Language Independent)	MetaDataSet:Sample Set : Template metadata sample set
Language used	en
Citeable Identifier	1013.26.391
Root archetype id	openEHR-EHR-COMPOSITION.health_summary.v1
Health summary	Health summary: Generic document containing a summary of health information about an individual.
Service	Service: A general clinical activity carried out for the patient to receive a specified service, advice or care from an expert healthcare provider.
Description
Service name	Service name: Identification of the clinical service to be/being carried out. Coding of the specific service name with a terminology is preferred, where possible.
Service type	Service type: Type of service to be carried out or being carried out.
Description	Description: Narrative description about the service, as appropriate for the pathway step.
Scheduled date/time	Scheduled date/time: The date and/or time on which the service is intended to be performed. Only for use in association with the 'Service scheduled' pathway step.
Sequence	Sequence: The sequence of the specified clinical service. Only for use in association with the 'Service delivered' pathway step. For example: record that this is the 3rd physiotherapy appointment in a planned sequence. >=0
Reason	Reason: Reason that the activity or care pathway step for the identified service was carried out. For example: the reason for the cancellation or suspension of the service.
Comment	Comment: Additional narrative about the activity or care pathway step not captured in other fields.
Protocol
Requestor identifier	Requestor identifier: The local ID assigned to the order by the healthcare provider or organisation requesting the service. This is also referred to as Placer Order Identifier.
Receiver identifier	Receiver identifier: The ID assigned to the order by the healthcare provider or organisation receiving the request for referral. This is also referred to as Filler Order Identifier.
New York Heart Association functional classification	New York Heart Association functional classification: A simple method of classifying the extent of heart failure, as defined by the New York Heart Association.
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
Functional capacity	Functional capacity: Assessment of heart failure based on how a patient with cardiac disease feels during physical activity. Class III and the Class III subtypes, IIIa and IIIb, are intended to be mutually exclusive but are included in this internal code set for completeness. Within a template either the Class III alone or both of the subtypes, IIIa and IIIb, should be set to inactive. Class I Class II Class III Class IIIa Class IIIb Class IV
Objective assessment	Objective assessment: Assessment of heart failure based on evidence of cardiovascular disease and symptoms. Class A Class B Class C Class D
State
Confounding factors	Confounding factors: Narrative description of any issues or factors that may impact on the assessment.
Procedure screening questionnaire	Procedure screening questionnaire: An individual- or self-reported questionnaire screening for investigative, diagnostic, curative, therapeutic, evaluative or palliative procedures which may have been 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
Screening purpose	Screening purpose: The reason for overall screening. For example: screening for post-operative infection.
Any performed?	Any performed?: Were any procedures performed? Coded Text Performed/carried out Unknown Not performed/carried out Text
Specific procedure	Specific procedure: Screening details about a specifed procedure.
Procedure name	Procedure name: Name of the procedure being screened.
Performed?	Performed?: Procedure performed? Coded Text Performed/carried out Not performed/carried out Unknown Text
Date of procedure	Date of procedure: The date the procedure was completed. Can be a partial date, for example, only a year.
Comment	Comment: Additional narrative about the specified procedure, not captured in other fields.
Condition screening questionnaire	Condition screening questionnaire: An individual- or self-reported questionnaire screening for health 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.
Any presence?	Any presence?: Presence of any relevant conditions. Coded Text Present Absent Unknown Text
Specific condition	Specific condition: Screening details about a specified condition or grouping of conditions.
Condition name	Condition name: Name of the condition or group of conditions being screened.
Presence?	Presence?: Presence of the condition. Coded Text Present Absent Unknown Text
Age at diagnosis	Age at diagnosis: The age of the individual when the condition was diagnosed or recognised. Duration Interval of Duration
Duration	Duration: Duration of time since diagnosis.
Comment	Comment: Additional narrative about the specified condition, not captured in other fields.
Management/treatment screening questionnaire	Management/treatment screening questionnaire: An individual- or self-reported questionnaire screening for management or treatment carried out.
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 an infectious disease, such as SARS-COV-2.
Management/treatment activity	Management/treatment activity: Screening details about a specific management or treatment activity.
Activity name	Activity name: Name of the management or treatment activity being screened. For example: hospitalised; admitted to ICU.
Presence?	Presence?: The current status of a specific activity. Coded Text Present Absent Unknown Text
Activity commenced	Activity commenced: The date/time that the activity started. For example: date of admission.
Activity ceased	Activity ceased: The date/time that the activity stopped.
Comment	Comment: Additional narrative about the specified management or treatment activity, not captured in other fields.
Medication screening questionnaire	Medication screening questionnaire: An individual- or self-reported questionnaire screening for use of any specified medication or a grouping 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 usage?	Any usage?: Is the individual using any medication? Coded Text Currently used Never used Used in the past Unknown Text
Specific medication or grouping	Specific medication or grouping: Screening details about a specified medication or grouping of medications. Use separate instances of this CLUSTER to differentiate between specific medications, groupings, or classes of medication.
Medication name	Medication name: Name of medication or grouping of medication. For example: 'oxycodone'; 'narcotic analgesics'; or 'painkillers'.
Usage?	Usage?: Is the individual using the medication? Coded Text Currently used Never used Used in the past Unknown Text
Duration of use	Duration of use: The duration of use of the class or grouping of medications. Duration Interval of Duration
Last dose	Last dose: The date and/or time of administation of the most recent dose of the medication or group of medications. Can be a partial date, for example, only a year.
Comment	Comment: Additional narrative about the specified medication or grouping, not captured in other fields.