TEMPLATE ODL Report Issues (ODL Report Issues)

TEMPLATE IDODL Report Issues
ConceptODL Report Issues
DescriptionReport ODLs that are self-monited by a patient
PurposeReport ODLs that are self-monited by a patient
References
Other Details (Language Independent)
  • MetaDataSet:Sample Set : Template metadata sample set
Language useden
Citeable Identifier1013.26.67
Root archetype idopenEHR-EHR-COMPOSITION.empower_odl.v0
OdlsOdls: Observation of daily living data that is reported by the patient himself while self-monitoring.
Open IssueOpen 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 eventAny 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 personIssue presented by a person: An issue, symptom, or complaint presented to the health provider seeking explanation, education, understanding, investigation or treatment
IssueIssue: The issue as presented by the person
CommentComment: Detailed information about the issue or health problem
MedicationMedication: 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 nameMedication 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.
  •  Text
  •  Coded Text Value set: ac0001
DosageDosage: Any instructions given to the subject of care or carer at the time of the action.
  • as needed
  • regularly
CommentComment: A comment on the action taken.
Problem/diagnosisProblem/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
ProblemProblem: Identification of the problem or diagnosis, by name.
Coding of the name of the problem or diagnosis with a terminology is preferred, where possible.
  • Blurred vision, my glasses are no longer sufficient for reading
  • Digestive disorders (diarrhea, constipation, bloating, spasms, nausea, vomiting)
  • Disturbed sexual function
  • Dizziness
  • Dry mouth
  • Fast heart rate for no apparent reason
  • Frequent urination
  • Itchy skin
  • Muscular cramps (calves, thigh)
  • Pain (head, chest, legs, feet, soles, thighs)
  • Palpitation
  • Restless legs
  • Sleep apnea
  • Snoring
  • Strong sweating
  • Strong thirstiness
  • Tremble
  • Weakness, tiredness, powerlessness
CommentComment: Additional narrative about the problem or diagnosis not captured in other fields.