TEMPLATE Clinical context - JM (Clinical context - JM)

Name: Clinical context - JM
License: http://creativecommons.org/licenses/by-sa/4.0/

TEMPLATE ID	Clinical context - JM
Concept	Clinical context - JM
Description	To record a summary of the clinical background comprising past history, current medications and vaccination status.
Purpose	To record a summary of the clinical background comprising past history, current medications and vaccination status.
References
Authors	date: 2022-11-03
Other Details Language	date: 2022-11-03
Other Details (Language Independent)	Licence: This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/. Custodian Organisation: openEHR Foundation Original Namespace: org.openehr Original Publisher: openEHR Foundation Custodian Namespace: org.openehr MD5-CAM-1.0.1: 307d145e6ff039fb77a4e39cf47491cf Sem Ver: 14.0.0 Original Language: ISO_639-1::en PARENT:MD5-CAM-1.0.1: 8FE80F3E80C594AAF99D3BA540A53D73
Language used	en
Citeable Identifier	1013.26.946
Root archetype id	openEHR-EHR-SECTION.adhoc.v1
Clinical context	Clinical context: A generic section header which should be renamed in a template to suit a specific clinical context.
Problem/Diagnosis screening	Problem/Diagnosis screening: Series of questions and associated answers used to screen for issues, problems or diagnoses. The answers may be self-reported.
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
Specific problem or diagnosis	Specific problem or diagnosis: Details about a specific issue, problem or diagnosis or grouping of problems or diagnoses relevant for the screening purpose.
Problem/diagnosis name	Problem/diagnosis name: Identification of an issue, problem or diagnosis, or grouping of issues, problems or diagnoses, by name. Coding of the 'Problem/diagnosis name' with a terminology is preferred, where possible.
Presence?	Presence?: Is there a history of the specific issue, problem or diagnosis? In a template, the data element would usually be renamed to the specific question asked. The proposed value set can be adapted for local use by using the DV_TEXT or the DV_BOOLEAN datatypes choice to match each specific use case. Yes No Unknown
Pregnancy screening	Pregnancy screening: An individual- or self-reported questionnaire about the current pregnancy and associated antenatal care.
Data
Any event	Any event: *
Data
Pregnant?	Pregnant?: Is the individual currently pregnant? Yes Unknown No
Gestation assertion	Gestation assertion: A statement or declaration by a clinician about the estimated or known duration of an active pregnancy at a specific point-in-time, usually based on EDD estimations and used as the basis for clinical decision-making.
Data
Date of measurement	Date of measurement: The date and time of the measurement of gestation.
Data
Gestational age	Gestational age: Estimated duration of an active pregnancy. Commonly this is estimated using the same method used to calculate the agreed or active 'Estimated Date of Delivery (EDD)' - frequently using the onset of the last menstrual period (LMP), or calculated from the measurement of fetal parameters during a pregnancy ultrasound. P0W..P60W Units: Week Day
Trimester	Trimester: Duration of pregnancy grouped into 12-14 week intervals. First trimester Second trimester Third trimester
Vaccinations	Vaccinations: A generic section header which should be renamed in a template to suit a specific clinical context.
Vaccination screening	Vaccination screening: Series of questions and associated answers used to screen for the administration of vaccination. The answers may be self-reported.
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
Specific vaccination	Specific vaccination: Details about a specified vaccine or grouping of vaccines relevant for the screening purpose. Use separate instances of this CLUSTER to differentiate between specific medications or groupings of medication.
(Vaccination name)	(Vaccination name): Name of vaccination or targeted infectious disease. For example: 'alendronic acid', 'anti osteoporosis medications' or 'bisphosphonates'. Coding of the 'Medication name' with a terminology is preferred, where possible.
Vaccinated?	Vaccinated?: Is there a history of use of a specific vaccine or group of vaccines. In a template, the data element would usually be renamed to the specific question asked. The proposed value set can be adapted for local use by using the DV_TEXT or the DV_BOOLEAN datatypes choice to match each specific use case. For example an alternative valueset using the DV_TEXT datatype can be: Currently using [The individual currently uses the specific medication either on a regular basis or as required.] Never used [The individual has never used the specific medication.] Used in the past [The individual has used the specific medication in the past, but isn't currently using it.] Unknown [It is not known whether the individual uses or has used the specific medication.] Yes No Unknown
Vaccination summary	Vaccination summary: Summary of vaccination administration for a single infectious disease or agent, or a group of infectious diseases or agents that are vaccinated simultaneously using a combination vaccine.
Data
Vaccine name	Vaccine name: Name of the vaccine administered. The vaccine name may contain a generic or trade name for a vaccine, the name of a combination vaccine, or a category of vaccine. For example: Measles vaccine; Measles Mumps Rubella (MMR) or 'Measles-containing vaccine'. Coding with an external terminology is preferred, where possible.
Total number of doses	Total number of doses: Total number of vaccine doses administered over the lifetime of the individual. May be manually calculated or extracted from EHR sources. Count>=0 Coded Text Unknown
Date of last dose	Date of last dose: The date when the most recent vaccine was administered. Can be a partial date, for example, only a year.
Protocol
Information source	Information source: Identification of the source of all vaccination information. For example: child health book, clinic record, or parent.
Vaccination status	Vaccination status: Vaccination status of an individual for an identified infectious disease or agent.
Data
Any event	Any event: *
Data
Targeted disease or agent	Targeted disease or agent: Name of the infectious disease or agent targeted by a vaccine. If the 'Vaccine name' is a combination vaccine this data element may contain more than one target disease. Coding with an external terminology is preferred, where possible.
Vaccination status	Vaccination status: An assertion about whether the individual has received all recommended vaccines for the targeted disease or agent. For example: 'Fully vaccinated', 'Partially vaccinated' and 'Unvaccinated'; or 'Up-to-date' and 'Not up-to-date'.The recommendations will vary for each individual depending on the targeted disease/s or agent/s, age, geographical location and relevant health considerations. Up-to-date Up-to-date for age Not up-to-date
Food and nutrition summary	Food and nutrition summary: Summary of the food and nutritional situation for an individual.
Data
Milk supply	Milk supply: The type of milk available for consumption. Pasteurised Non-pasteurised
Infant clinical context	Infant clinical context: A generic section header which should be renamed in a template to suit a specific clinical context.
Birth summary	Birth summary: Overview or summary record of the pregnancy and birth of an individual.
Data
Birth detail	Birth detail: A subset of persistent or summary information about the pregnancy and birth of an infant, selected for utility of use within both the maternal and infant health records.
Birth outcome	Birth outcome: Outcome of the pregnancy for the identified infant or fetus. Live birth Still birth
Gestational age	Gestational age: The length of the pregnancy at the time of delivery of the infant. The value for this data element will usually, but not always, be identical to the 'Pregnancy duration' data element within the EVALUATION.pregnancy_summary in the maternal record. It may also be derived using the 'Agreed date' data element within the EVALUATION.estimated_date_delivery archetype in the maternal record. Usually estimated by Naegele's rule or by ultrasound scan. P0W..P52W Week
Gestational maturity	Gestational maturity: The estimated gestational maturity of the newborn at, or very near, birth. Usually estimated by physical examination and/or neuromuscular assessment of the newborn. P0W..P52W Week
Birth category by gestation	Birth category by gestation: Category of birth based on the duration of the pregnancy at birth. Pre-term Term Post-term
Adjusted age	Adjusted age: A statement about the age of an individual at a point in time.
Data
Point in time event	Point in time event: Default, unspecified point in time event which may be explicitly defined in a template or at run-time.
Data
Adjusted age	Adjusted age: The age of a premature infant, calculated from their expected due date rather than their actual date of birth. Also known as 'Corrected age'. In most use cases the DV_DURATION data type is used to record the Adjusted age. The DV_QUANTITY data type is used for recording a decimal age in years or mean Julian years (365.25 days), and the DV_TEXT data type is used for recording a textual representation of the individual's age. For example: 'P3M2W', '0,2884615384615385 a_j' or '3 months 2 weeks'. Duration>-P1Y Quantity-1..10; -1..10 Units: yr (UCUM: a) a_j Text
Infant measurements	Infant measurements: 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
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.
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.
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.
Body weight for age	Body weight for age: Details about parameters plotted on a growth chart to allow monitoring of a child's growth over time, relative to a reference population.
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
Growth indicator	Growth indicator: The name of the growth parameter. Weight-for-age
Z-score category	Z-score category: The category or grouping of the Z score. For example: a choice between <-3, <-2, or Normal.
Protocol
Growth reference chart	Growth reference chart: Specifies the standard or syndrome-specific reference charts used to calculate the growth indicator data. For example, for a typical height assessment, 'WHO' might be used, whereas for children diagnosed with Turner Syndrome, the 'Turner' standard would be applicable (see the Royal College of Paediatrics and Child Health API (https://growth.rcpch.ac.uk/).
Length	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
Length	Length: The length of the body from crown of head to sole of foot. 0..1000; 0..250 Units: cm in (UCUM: [in_i])
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.
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.
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.
Body length for age	Body length for age: Details about parameters plotted on a growth chart to allow monitoring of a child's growth over time, relative to a reference population.
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
Growth indicator	Growth indicator: The name of the growth parameter. Length/height-for-age
Z-score category	Z-score category: The category or grouping of the Z score. For example: a choice between <-3, <-2, or Normal.
Head circumference	Head circumference: The measurement of the longest distance around the head.
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
Head circumference	Head circumference: The measurement of the longest distance around the head. 0..100; 0..40 Units: cm in (UCUM: [in_i])
Birth	Birth: The first measurement of head circumference that is recorded soon after birth. This event should only be used once per record.
Data
Head circumference	Head circumference: The measurement of the longest distance around the head. 0..100; 0..40 Units: cm in (UCUM: [in_i])
Comment	Comment: Additional narrative about the head circumference not captured in other fields.
Data
Head circumference	Head circumference: The measurement of the longest distance around the head. 0..100; 0..40 Units: cm in (UCUM: [in_i])
Comment	Comment: Additional narrative about the head circumference not captured in other fields.
State
Confounding factors	Confounding factors: Narrative descripiton of any issues or factors that may impact on the measurement. For example: 'uncooperative child','caput & moulding post birth' and 'haematoma'.
State
Confounding factors	Confounding factors: Narrative descripiton of any issues or factors that may impact on the measurement. For example: 'uncooperative child','caput & moulding post birth' and 'haematoma'.
Head circumference for age	Head circumference for age: Details about parameters plotted on a growth chart to allow monitoring of a child's growth over time, relative to a reference population.
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
Growth indicator	Growth indicator: The name of the growth parameter. Head circumference-for-age
Z-score category	Z-score category: The category or grouping of the Z score. For example: a choice between <-3, <-2, or Normal.
Blood donation summary	Blood donation summary: A summary of donation events made by an individual, for biological products including blood, plasma, stem cells, semen, ova or other human-derived materials.
Data
Per donation event	Per donation event: * May only record date if the blood product is not known.
Donation date	Donation date: *