TEMPLATE Clinical management - JM (Clinical management - JM)

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

TEMPLATE ID	Clinical management - JM
Concept	Clinical management - JM
Description	Not Specified
Purpose	Not Specified
References
Authors	date: 2023-05-09
Other Details Language	date: 2023-05-09
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: 5277aa858256371da76a293998f03ea4 Sem Ver: 9.0.0 PARENT:MD5-CAM-1.0.1: 8FE80F3E80C594AAF99D3BA540A53D73 Original Language: ISO_639-1::en
Language used	en
Citeable Identifier	1013.26.974
Root archetype id	openEHR-EHR-SECTION.adhoc.v1
Clinical management	Clinical management: A generic section header which should be renamed in a template to suit a specific clinical context.
Management screening	Management screening: Series of questions and associated answers used to screen for clinical management including, but not limited to treatments, therapies and hospitalisation. 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
Management activity	Management activity: Details about a specific management or treatment activity or grouping of management or treatment activities relevant for the screening purpose.
Management name	Management name: Name of a specific management or treatment activity or grouping of management or treatment activities. For example: Admitted to hospital; Admitted to ICU; Use of compression stockings; Daily dressings; ECMO. Coding of the 'Management name' with a terminology is preferred, where possible.
Done?	Done?: Is there a history of the specific management or treatment activity? 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 Unsure
Start date	Start date: Indication of timing related to the management activity. The 'Timing' data element has deliberately been loosely modelled to support the myriad of ways that it can be used in questionnaires to capture when the management activity may have occurred. The specific and intended semantics can be further clarified in a template. For example: the actual point in time when, or interval during which, an activity took place; the start and stop time of an activity; the duration of the activity; the age of the individual at the time of the activity; or the duration of time since the activity occurred. A partial date is valid, using the DV_DATE_TIME data type, to record only a year.
Laboratory test screening	Laboratory test screening: Series of questions and associated answers used to screen whether diagnostic investigations have been carried out. 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
Specimen taken?	Specimen taken?: Is there a history of any diagnostic tests or investigations related to the screening purpose? 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 Unsure
Specific test	Specific test: Details about a specified investigation or grouping of investigations relevant for the screening purpose. Use separate instances of this CLUSTER to differentiate between specific investigations or groupings of investigations.
Test name	Test name: Name of the diagnostic investigation or grouping of investigations. For example: 'Blood gas', Chest Xray', 'ECG'; or 'Hearing test'. Coding of the 'Investigation name' with a terminology is preferred, where possible.
Done?	Done?: Is there a history of the investigation being carried out? 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 Unsure
Type	Type: The method, technique, modality or other more specific identification of the diagnostic investigation. For example: contrast-enhanced mammography, magnification mammography, mammographic digital tomosynthesis,  contrast imaging technique, fluorescence in situ hybridisation, Immunoassay method.
Date/time result reported	Date/time result reported: Indication of timing related to the investigation. The 'Timing' data element has deliberately been loosely modelled to support the myriad of ways that it can be used in questionnaires to capture when an investigation was carried out. The specific and intended semantics can be further clarified in a template. For example: the actual date and/or time; the start and stop time for the investigation; the interval of time during which the investigation was carried out; the duration of the investigation; the age of the individual at the time of the investigation; or the duration of time since it occurred. A partial date is valid, using the DV_DATE_TIME data type, to record only a year.
Conclusion	Conclusion: Brief description, summary or interpretation of the investigation outcome. For example: 'All results within normal range', 'Normal', 'Further investigations needed'. This data element is not to contain a representation of the actual results or findings of laboratory tests. In that situation, nest a CLUSTER archetype carrying the structured result within the following 'Additional details' SLOT, for example the CLUSTER.laboratory_test_analyte archetype.
Specimen collection details	Specimen collection details: A physical sample collected from, or related to, an individual for the purpose of investigation, examination or analysis. For example: Tissue or body fluid.
Specimen type	Specimen type: The type of specimen. For example: Venous blood, bacterial culture, cytology, or tissue sample. Coding of the specimen type with a terminology is preferred, where possible. Optional[{fhir_mapping=Specimen.type}]
Date/time received by laboratory	Date/time received by laboratory: The date and time that the sample was received at the laboratory. Optional[{fhir_mapping=Specimen.receivedTime}]
Date/time collected	Date/time collected: The date and time that collection has been ordered to take place or has taken place. This datetime will be captured primarily in the INSTRUCTION timing, ACTION time or OBSERVATION times. However, as this is a critical piece of information, it can be useful to also associate it directly with the specimen itself.
Adequacy for testing	Adequacy for testing: Information about whether the specimen was adequate for testing. This element is intended to be used to record a judgement about whether or not the specimen quality was good enough for testing, and whether or not testing has been carried out. Coding of the specimen quality issues with a terminology is preferred, where possible. Satisfactory Unsatisfactory - analysed Unsatisfactory - not analysed
Comment	Comment: Additional narrative about the specimen not captured in other fields. Optional[{fhir_mapping=Specimen.note}]
Comment	Comment: Additional narrative about the diagnostic investigation test not captured in other fields.
Imaging examination screening - JM	Imaging examination screening - JM: Series of questions and associated answers used to screen whether diagnostic investigations have been carried out. 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
Any imaging?	Any imaging?: Is there a history of any diagnostic tests or investigations related to the screening purpose? 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 Unsure
Specific imaging	Specific imaging: Details about a specified investigation or grouping of investigations relevant for the screening purpose. Use separate instances of this CLUSTER to differentiate between specific investigations or groupings of investigations.
Study name	Study name: Name of the diagnostic investigation or grouping of investigations. For example: 'Blood gas', Chest Xray', 'ECG'; or 'Hearing test'. Coding of the 'Investigation name' with a terminology is preferred, where possible.
Done?	Done?: Is there a history of the investigation being carried out? 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 Unsure
Type	Type: The method, technique, modality or other more specific identification of the diagnostic investigation. For example: contrast-enhanced mammography, magnification mammography, mammographic digital tomosynthesis,  contrast imaging technique, fluorescence in situ hybridisation, Immunoassay method.
Date of study	Date of study: Indication of timing related to the investigation. The 'Timing' data element has deliberately been loosely modelled to support the myriad of ways that it can be used in questionnaires to capture when an investigation was carried out. The specific and intended semantics can be further clarified in a template. For example: the actual date and/or time; the start and stop time for the investigation; the interval of time during which the investigation was carried out; the duration of the investigation; the age of the individual at the time of the investigation; or the duration of time since it occurred. A partial date is valid, using the DV_DATE_TIME data type, to record only a year.
Findings	Findings: Brief description, summary or interpretation of the investigation outcome. For example: 'All results within normal range', 'Normal', 'Further investigations needed'. This data element is not to contain a representation of the actual results or findings of laboratory tests. In that situation, nest a CLUSTER archetype carrying the structured result within the following 'Additional details' SLOT, for example the CLUSTER.laboratory_test_analyte archetype.
Comment	Comment: Additional narrative about the diagnostic investigation test not captured in other fields.
Other investigation screening	Other investigation screening: Series of questions and associated answers used to screen whether diagnostic investigations have been carried out. 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
Any other investigations?	Any other investigations?: Is there a history of any diagnostic tests or investigations related to the screening purpose? 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 Unsure
Specific investigation	Specific investigation: Details about a specified investigation or grouping of investigations relevant for the screening purpose. Use separate instances of this CLUSTER to differentiate between specific investigations or groupings of investigations.
Investigation name	Investigation name: Name of the diagnostic investigation or grouping of investigations. For example: 'Blood gas', Chest Xray', 'ECG'; or 'Hearing test'. Coding of the 'Investigation name' with a terminology is preferred, where possible.
Done?	Done?: Is there a history of the investigation being carried out? 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. Coded Text Yes No Unknown Unsure Text Boolean
Type	Type: The method, technique, modality or other more specific identification of the diagnostic investigation. For example: contrast-enhanced mammography, magnification mammography, mammographic digital tomosynthesis,  contrast imaging technique, fluorescence in situ hybridisation, Immunoassay method.
Timing	Timing: Indication of timing related to the investigation. The 'Timing' data element has deliberately been loosely modelled to support the myriad of ways that it can be used in questionnaires to capture when an investigation was carried out. The specific and intended semantics can be further clarified in a template. For example: the actual date and/or time; the start and stop time for the investigation; the interval of time during which the investigation was carried out; the duration of the investigation; the age of the individual at the time of the investigation; or the duration of time since it occurred. A partial date is valid, using the DV_DATE_TIME data type, to record only a year. Date/Time Text Interval of Date/Time Interval of Duration Duration
Conclusion	Conclusion: Brief description, summary or interpretation of the investigation outcome. For example: 'All results within normal range', 'Normal', 'Further investigations needed'. This data element is not to contain a representation of the actual results or findings of laboratory tests. In that situation, nest a CLUSTER archetype carrying the structured result within the following 'Additional details' SLOT, for example the CLUSTER.laboratory_test_analyte archetype.
Comment	Comment: Additional narrative about the diagnostic investigation test not captured in other fields.
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. Completed Not completed Unknown
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. Cured Treatment failure Lost to followup Died Not evaluated
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.
Management notes	Management notes: Narrative summary or overview about a patient, specifically from the perspective of a healthcare provider, and with or without associated interpretations.
Data
Actions taken	Actions taken: The summary, assessment, conclusions or evaluation of the clinical findings.