| TEMPLATE ID | ODL Report Issues |
|---|---|
| Concept | ODL Report Issues |
| Description | Report ODLs that are self-monited by a patient |
| Purpose | Report ODLs that are self-monited by a patient |
| References | |
| Other Details (Language Independent) |
|
| Language used | en |
| Citeable Identifier | 1013.26.67 |
| Root archetype id | openEHR-EHR-COMPOSITION.empower_odl.v0 |
| Odls | Odls: Observation of daily living data that is reported by the patient himself while self-monitoring. |
| Open Issue | Open Issue: The subjective clinical history of the subject of care as recorded directly by the subject, or reported to a clinician by the subject or a carer. |
| Data | |
| Any event | Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time. |
| Data | |
| Issue presented by a person | Issue presented by a person: An issue, symptom, or complaint presented to the health provider seeking explanation, education, understanding, investigation or treatment |
| Issue | Issue: The issue as presented by the person |
| Comment | Comment: Detailed information about the issue or health problem |
| Medication | Medication: Details of use, administration, dispensing or other care step relating to a medicine, vaccine or other therapeutic good which may arise from an instruction from a clinician. |
| Description | |
| Medication name | Medication name: The medicine, vaccine or other therapeutic good which was the focus of the action. This element will normally be coded with a medicines terminology but free text may be required in some cases.
|
| Dosage | Dosage: Any instructions given to the subject of care or carer at the time of the action.
|
| Comment | Comment: A comment on the action taken. |
| 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 | Problem: Identification of the problem or diagnosis, by name. Coding of the name of the problem or diagnosis with a terminology is preferred, where possible.
|
| Comment | Comment: Additional narrative about the problem or diagnosis not captured in other fields. |