| All | OperationalTemplate [rootArchetypeId=openEHR-EHR-SECTION.adhoc.v1, otherContributors=null, tshis=[ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.adhoc.v1], code=at0000, itemType=SECTION, level=0, text=Field investigator classification, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1], code=at0000, itemType=EVALUATION, level=1, text=Field diagnosis, description=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., comment=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'., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=2, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=3, text=Diagnosis name, description=Identification of the problem or diagnosis, by name., comment=Coding of the name of the problem or diagnosis with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-EVALUATION.cause_of_death.v1], code=at0000, itemType=EVALUATION, level=1, text=Cause of death, description=Details about specific diseases, conditions or injuries that caused or contributed to the death of an individual., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-EVALUATION.cause_of_death.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=2, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-EVALUATION.cause_of_death.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=3, text=Immediate cause, description=The disease, condition or injury that directly led to, or occurred closest to, the time of death., comment=It is recommended that 'Direct cause' be coded with an external terminology.
This data element may also be considered as the Cause labelled as 'A' within a death certificate recording a sequence of events leading to death. For example:
Cerebral haemorrhage (as 'Direct cause', A)
- 'due to' Metastasis of the brain ('Antecedent cause B');
- 'due to' Breast cancer (as the earliest 'Antecedent cause C'; or 'Underlying cause')., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-EVALUATION.cause_of_death.v1]/data[at0001]/items[at0003 and name/value='Intermediate cause(s)'], code=at0003, itemType=CLUSTER, level=3, text=Intermediate cause(s), description=Details about one or more diseases, conditions or injuries in the sequence of events preceding death, recorded in order from most recent onset to the earliest onset., comment=In the following example, there would only need to be two instances of this 'Antecedent cause(s)' CLUSTER represented in a template:
- Cerebral haemorrhage (as 'Direct cause', A)
- 'due to' Metastasis of the brain ('Antecedent cause B');
- 'due to' Breast cancer (as the earliest 'Antecedent cause C'; or 'Underlying cause').
If there is more than one 'Antecedent cause', each is represented as a separate instance of this CLUSTER., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-EVALUATION.cause_of_death.v1]/data[at0001]/items[at0003 and name/value='Intermediate cause(s)']/items[at0004], code=at0004, itemType=ELEMENT, level=4, text=Intermediate cause, description=Identification of an antecedent disease, condition or injury that directly contributed to the 'Direct cause'., comment=It is recommended that 'Cause' be coded with an external terminology., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-EVALUATION.cause_of_death.v1]/data[at0001]/items[at0003 and name/value='Underlying cause'], code=at0003, itemType=CLUSTER, level=3, text=Underlying cause, description=Details about one or more diseases, conditions or injuries in the sequence of events preceding death, recorded in order from most recent onset to the earliest onset., comment=In the following example, there would only need to be two instances of this 'Antecedent cause(s)' CLUSTER represented in a template:
- Cerebral haemorrhage (as 'Direct cause', A)
- 'due to' Metastasis of the brain ('Antecedent cause B');
- 'due to' Breast cancer (as the earliest 'Antecedent cause C'; or 'Underlying cause').
If there is more than one 'Antecedent cause', each is represented as a separate instance of this CLUSTER., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-EVALUATION.cause_of_death.v1]/data[at0001]/items[at0003 and name/value='Underlying cause']/items[at0004], code=at0004, itemType=ELEMENT, level=4, text=Underlying cause, description=Identification of an antecedent disease, condition or injury that directly contributed to the 'Direct cause'., comment=It is recommended that 'Cause' be coded with an external terminology., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-EVALUATION.cause_of_death.v1]/data[at0001]/items[at0020], code=at0020, itemType=CLUSTER, level=3, text=Other significant conditions, description=Details about other significant conditions that may have contributed to the death, but without a causal association., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-EVALUATION.cause_of_death.v1]/data[at0001]/items[at0020]/items[at0018], code=at0018, itemType=ELEMENT, level=4, text=Condition, description=Name of a significant condition that may have contributed to the death, but without a causal association., comment=It is recommended that 'Condition' be coded with an external terminology., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-EVALUATION.infectious_investigation_classification.v0], code=at0000, itemType=EVALUATION, level=1, text=Field classification, description=Classification for an identified infectious disease as part of a disease surveillance investigation., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-EVALUATION.infectious_investigation_classification.v0]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=2, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-EVALUATION.infectious_investigation_classification.v0]/data[at0001]/items[at0007], code=at0007, itemType=ELEMENT, level=3, text=Index disease, description=The name of the infectious disease under investigation., comment=This data element may be redundant if the index disease has been identified elsewhere within a template., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-EVALUATION.infectious_investigation_classification.v0]/data[at0001]/items[at0060], code=at0060, itemType=ELEMENT, level=3, text=Final classification, description=Classification of the likelihood of the 'Index disease' as causal after completion of a case investigation., comment=Not to be used to record the 'Initial classification' at the initiation of a case investigation., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- Pending
- Probable
- Laboratory confirmed
- Clinically confirmed
- Discarded
- Inconclusive
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-EVALUATION.infectious_investigation_classification.v0]/data[at0001]/items[at0008], code=at0008, itemType=ELEMENT, level=3, text=Reason for classification, description=The broad category of the reason for the classification., comment=For example: lost to follow-up, child of an infected mother., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-EVALUATION.infectious_investigation_classification.v0]/data[at0001]/items[at0054], code=at0054, itemType=ELEMENT, level=3, text=Epidemiological link, description=Identification of the cause or source of transmission., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values= Text Coded Text- Animal to human transmission
- Exposure to a common source
- Exposure to contaminated food/drinking water
- Environmental exposure
- Laboratory exposure
- Human to human transmission
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-EVALUATION.infectious_investigation_classification.v0]/data[at0001]/items[at0011], code=at0011, itemType=ELEMENT, level=3, text=Aetiology category, description=The category for the cause of infection., comment=For example: imported, import-related, endemic, vaccine-associated, congenital or unknown., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=- Text
- Coded Text
- Imported case
- Import-related case
- Endemic case
- Vaccine-associated case
- Congenital case
- Unknown
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-EVALUATION.infectious_investigation_classification.v0]/data[at0001]/items[at0021], code=at0021, itemType=ELEMENT, level=3, text=Source country, description=Country identified as the (likely or probable) source for an imported or import-related case., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-EVALUATION.infectious_investigation_classification.v0]/data[at0001]/items[at0051], code=at0051, itemType=ELEMENT, level=3, text=Endemic source category, description=The category for the source of an endemic case., comment=For example: household contact, community, or unknown., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-EVALUATION.infectious_investigation_classification.v0]/data[at0001]/items[at0068], code=at0068, itemType=ELEMENT, level=3, text=Contribution to death, description=Assessment of the relationship between the index disease and the death of the individual., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=- Text
- Coded Text
- Related
- Unrelated
- Unknown
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-EVALUATION.infectious_investigation_classification.v0]/data[at0001]/items[at0017], code=at0017, itemType=ELEMENT, level=3, text=Comment, description=Additional narrative about the classification, not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null]], templateType=normal] |