| TEMPLATE ID | Treatment summary - JM |
|---|---|
| Concept | Treatment summary - JM |
| Description | Not Specified |
| Purpose | Not Specified |
| References | |
| Authors | date: 2023-07-19 |
| Other Details Language | date: 2023-07-19 |
| Other Details (Language Independent) |
|
| Language used | en |
| Citeable Identifier | 1013.26.970 |
| Root archetype id | openEHR-EHR-EVALUATION.intervention_summary.v1 |
| Treatment summary | Treatment summary: A summary about a therapeutic activity intended to prevent, diagnose, treat, or manage health conditions, support mental or physical well-being, or address social and environmental factors that influence health outcomes. |
| Data | |
| Treatment name | Treatment name: The name of the intervention. For example: 'Radiotherapy', 'Smoking cessation brief intervention' or 'Appendectomy'. Coding with an external terminology is preferred, where possible. |
| Date treatment stopped | Date treatment stopped: The date/time when the identified intervention was completed, or stopped prior to the completion. For example the date when the last in a series of chemotherapy infusions was administered. |
| Treatment status | Treatment status: The outcome of the intervention based on whether it was delivered as originally intended. This element should only be used when the intervention has ended. "As originally intended" as mentioned in the description of this element may range from the unstated intent of a single clinician responding to an acute situation, to a formal and evidence-based clinical protocol or pathway.
|
| Treatment outcome | Treatment outcome: The outcome of the intervention based on its therapeutic effectiveness. For example: successful, failed, indeterminate. Coding with an external terminology is preferred, where possible.
|
| Date last seen | Date last seen: Date of the most recent contact between the individual and a healthcare provider or service, whether clinical or non-clinical, including formal encounters, consultations, outreach, or other forms of communication. |
| Clinical evidence | Clinical evidence: Details about findings that support a clinical assertion. |
| Test result | Test result: Identification of an item of clinical evidence by name or type, either as a single result or as a grouping of results. It is recommended that 'Evidence' should be coded with a terminology, where possible. For example: 'Mantoux test', 'AFP level', 'tumour volume', 'genetic tests', 'BRCA1 test', 'histopathology result', 'physical examination finding', 'intraoperative finding', 'FIGO stage', 'symptom', 'tumour grading', 'clinical impression'. For use cases where the evidence is sufficiently identified in 'Result' or 'Structured result', this data element may be redundant and has therefore been made optional. |
| Date | Date: The date/time of the result or finding. For example: The date time of a clinical examination. For labs or imaging this is the collection date/time of the specimen or image. |