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Example web template based on Problem diagnosis archetype
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| { | |
| "templateId" : "GW - Problem template", | |
| "version" : "2.3", | |
| "defaultLanguage" : "en", | |
| "languages" : [ "en" ], | |
| "tree" : { | |
| "id" : "gw_-_problem_template", | |
| "name" : "GW - Problem template", | |
| "localizedName" : "GW - Problem template", | |
| "rmType" : "COMPOSITION", | |
| "nodeId" : "openEHR-EHR-COMPOSITION.problem_list.v1", | |
| "min" : 1, | |
| "max" : 1, | |
| "localizedNames" : { | |
| "en" : "GW - Problem template" | |
| }, | |
| "localizedDescriptions" : { | |
| "en" : "A persistent and managed list of any combination of diagnoses, problems and/or procedures that may influence clinical decision-making and care provision for the subject of care." | |
| }, | |
| "aqlPath" : "", | |
| "children" : [ { | |
| "id" : "context", | |
| "rmType" : "EVENT_CONTEXT", | |
| "nodeId" : "", | |
| "min" : 1, | |
| "max" : 1, | |
| "aqlPath" : "/context", | |
| "children" : [ { | |
| "id" : "start_time", | |
| "name" : "Start_time", | |
| "rmType" : "DV_DATE_TIME", | |
| "min" : 1, | |
| "max" : 1, | |
| "aqlPath" : "/context/start_time", | |
| "inputs" : [ { | |
| "type" : "DATETIME" | |
| } ], | |
| "inContext" : true | |
| }, { | |
| "id" : "setting", | |
| "name" : "Setting", | |
| "rmType" : "DV_CODED_TEXT", | |
| "min" : 1, | |
| "max" : 1, | |
| "aqlPath" : "/context/setting", | |
| "inputs" : [ { | |
| "suffix" : "code", | |
| "type" : "TEXT" | |
| }, { | |
| "suffix" : "value", | |
| "type" : "TEXT" | |
| } ], | |
| "inContext" : true | |
| } ] | |
| }, { | |
| "id" : "problem_diagnosis", | |
| "name" : "Problem/Diagnosis", | |
| "localizedName" : "Problem/Diagnosis", | |
| "rmType" : "EVALUATION", | |
| "nodeId" : "openEHR-EHR-EVALUATION.problem_diagnosis.v1", | |
| "min" : 0, | |
| "max" : 1, | |
| "localizedNames" : { | |
| "en" : "Problem/Diagnosis" | |
| }, | |
| "localizedDescriptions" : { | |
| "en" : "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." | |
| }, | |
| "annotations" : { | |
| "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'." | |
| }, | |
| "aqlPath" : "/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1]", | |
| "children" : [ { | |
| "id" : "problem_diagnosis_name", | |
| "name" : "Problem/Diagnosis name", | |
| "localizedName" : "Problem/Diagnosis name", | |
| "rmType" : "DV_TEXT", | |
| "nodeId" : "at0002", | |
| "min" : 1, | |
| "max" : 1, | |
| "localizedNames" : { | |
| "en" : "Problem/Diagnosis name" | |
| }, | |
| "localizedDescriptions" : { | |
| "en" : "Identification of the problem or diagnosis, by name." | |
| }, | |
| "annotations" : { | |
| "comment" : "Coding of the name of the problem or diagnosis with a terminology is preferred, where possible." | |
| }, | |
| "aqlPath" : "/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0002]/value", | |
| "inputs" : [ { | |
| "type" : "TEXT" | |
| } ] | |
| }, { | |
| "id" : "clinical_description", | |
| "name" : "Clinical description", | |
| "localizedName" : "Clinical description", | |
| "rmType" : "DV_TEXT", | |
| "nodeId" : "at0009", | |
| "min" : 0, | |
| "max" : 1, | |
| "localizedNames" : { | |
| "en" : "Clinical description" | |
| }, | |
| "localizedDescriptions" : { | |
| "en" : "Narrative description about the problem or diagnosis." | |
| }, | |
| "annotations" : { | |
| "comment" : "Use to provide background and context, including evolution, episodes or exacerbations, progress and any other relevant details, about the problem or diagnosis." | |
| }, | |
| "aqlPath" : "/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0009]/value", | |
| "inputs" : [ { | |
| "type" : "TEXT" | |
| } ] | |
| }, { | |
| "id" : "body_site", | |
| "name" : "Body site", | |
| "localizedName" : "Body site", | |
| "rmType" : "DV_TEXT", | |
| "nodeId" : "at0012", | |
| "min" : 0, | |
| "max" : -1, | |
| "localizedNames" : { | |
| "en" : "Body site" | |
| }, | |
| "localizedDescriptions" : { | |
| "en" : "Identification of a simple body site for the location of the problem or diagnosis." | |
| }, | |
| "annotations" : { | |
| "comment" : "Coding of the name of the anatomical location with a terminology is preferred, where possible.\r\nUse this data element to record precoordinated anatomical locations. If the requirements for recording the anatomical location are determined at run-time by the application or require more complex modelling such as relative locations then use the CLUSTER.anatomical_location or CLUSTER.relative_location within the 'Structured anatomical location' SLOT in this archetype. Occurrences for this data element are unbounded to allow for clinical scenarios such as describing a rash in multiple locations but where all of the other attributes are identical. If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant. \r\n\r\n" | |
| }, | |
| "aqlPath" : "/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0012]/value", | |
| "inputs" : [ { | |
| "type" : "TEXT" | |
| } ] | |
| }, { | |
| "id" : "date_time_of_onset", | |
| "name" : "Date/time of onset", | |
| "localizedName" : "Date/time of onset", | |
| "rmType" : "DV_DATE_TIME", | |
| "nodeId" : "at0077", | |
| "min" : 0, | |
| "max" : 1, | |
| "localizedNames" : { | |
| "en" : "Date/time of onset" | |
| }, | |
| "localizedDescriptions" : { | |
| "en" : "Estimated or actual date/time that signs or symptoms of the problem/diagnosis were first observed." | |
| }, | |
| "annotations" : { | |
| "comment" : "Data captured/imported as \"Age at onset\" should be converted to a date using the subject's date of birth." | |
| }, | |
| "aqlPath" : "/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0077]/value", | |
| "inputs" : [ { | |
| "type" : "DATETIME" | |
| } ] | |
| }, { | |
| "id" : "date_time_clinically_recognised", | |
| "name" : "Date/time clinically recognised", | |
| "localizedName" : "Date/time clinically recognised", | |
| "rmType" : "DV_DATE_TIME", | |
| "nodeId" : "at0003", | |
| "min" : 0, | |
| "max" : 1, | |
| "localizedNames" : { | |
| "en" : "Date/time clinically recognised" | |
| }, | |
| "localizedDescriptions" : { | |
| "en" : "Estimated or actual date/time the diagnosis or problem was recognised by a healthcare professional." | |
| }, | |
| "annotations" : { | |
| "comment" : "Partial dates are acceptable. If the subject of care is under the age of one year, then the complete date or a minimum of the month and year is necessary to enable accurate age calculations - for example, if used to drive decision support. Data captured/imported as \"Age at time of clinical recognition\" should be converted to a date using the subject's date of birth." | |
| }, | |
| "aqlPath" : "/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0003]/value", | |
| "inputs" : [ { | |
| "type" : "DATETIME" | |
| } ] | |
| }, { | |
| "id" : "severity", | |
| "name" : "Severity", | |
| "localizedName" : "Severity", | |
| "rmType" : "DV_CODED_TEXT", | |
| "nodeId" : "at0005", | |
| "min" : 0, | |
| "max" : 1, | |
| "localizedNames" : { | |
| "en" : "Severity" | |
| }, | |
| "localizedDescriptions" : { | |
| "en" : "An assessment of the overall severity of the problem or diagnosis." | |
| }, | |
| "annotations" : { | |
| "comment" : "If severity is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant. Note: more specific grading of severity can be recorded using the Specific details SLOT." | |
| }, | |
| "aqlPath" : "/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0005]/value", | |
| "inputs" : [ { | |
| "suffix" : "code", | |
| "type" : "CODED_TEXT", | |
| "list" : [ { | |
| "value" : "at0047", | |
| "label" : "Mild", | |
| "localizedLabels" : { | |
| "en" : "Mild" | |
| }, | |
| "localizedDescriptions" : { | |
| "en" : "The problem or diagnosis does not interfere with normal activity or may cause damage to health if left untreated." | |
| } | |
| }, { | |
| "value" : "at0048", | |
| "label" : "Moderate", | |
| "localizedLabels" : { | |
| "en" : "Moderate" | |
| }, | |
| "localizedDescriptions" : { | |
| "en" : "The problem or diagnosis causes interference with normal activity or will damage health if left untreated." | |
| } | |
| }, { | |
| "value" : "at0049", | |
| "label" : "Severe", | |
| "localizedLabels" : { | |
| "en" : "Severe" | |
| }, | |
| "localizedDescriptions" : { | |
| "en" : "The problem or diagnosis prevents normal activity or will seriously damage health if left untreated." | |
| } | |
| } ], | |
| "listOpen" : true | |
| }, { | |
| "suffix" : "other", | |
| "type" : "TEXT" | |
| } ] | |
| }, { | |
| "id" : "course_description", | |
| "name" : "Course description", | |
| "localizedName" : "Course description", | |
| "rmType" : "DV_TEXT", | |
| "nodeId" : "at0072", | |
| "min" : 0, | |
| "max" : 1, | |
| "localizedNames" : { | |
| "en" : "Course description" | |
| }, | |
| "localizedDescriptions" : { | |
| "en" : "Narrative description about the course of the problem or diagnosis since onset." | |
| }, | |
| "aqlPath" : "/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0072]/value", | |
| "inputs" : [ { | |
| "type" : "TEXT" | |
| } ] | |
| }, { | |
| "id" : "date_time_of_resolution", | |
| "name" : "Date/time of resolution", | |
| "localizedName" : "Date/time of resolution", | |
| "rmType" : "DV_DATE_TIME", | |
| "nodeId" : "at0030", | |
| "min" : 0, | |
| "max" : 1, | |
| "localizedNames" : { | |
| "en" : "Date/time of resolution" | |
| }, | |
| "localizedDescriptions" : { | |
| "en" : "Estimated or actual date/time of resolution or remission for this problem or diagnosis, as determined by a healthcare professional." | |
| }, | |
| "annotations" : { | |
| "comment" : "Partial dates are acceptable. If the subject of care is under the age of one year, then the complete date or a minimum of the month and year is necessary to enable accurate age calculations - for example, if used to drive decision support. Data captured/imported as \"Age at time of resolution\" should be converted to a date using the subject's date of birth.\r\n" | |
| }, | |
| "aqlPath" : "/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0030]/value", | |
| "inputs" : [ { | |
| "type" : "DATETIME" | |
| } ] | |
| }, { | |
| "id" : "problem_diagnosis_qualifier", | |
| "name" : "Problem/Diagnosis qualifier", | |
| "localizedName" : "Problem/Diagnosis qualifier", | |
| "rmType" : "CLUSTER", | |
| "nodeId" : "openEHR-EHR-CLUSTER.problem_qualifier.v1", | |
| "min" : 0, | |
| "max" : 1, | |
| "localizedNames" : { | |
| "en" : "Problem/Diagnosis qualifier" | |
| }, | |
| "localizedDescriptions" : { | |
| "en" : "Contextual or temporal qualifier for a specified problem or diagnosis." | |
| }, | |
| "aqlPath" : "/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v1]", | |
| "children" : [ { | |
| "id" : "diagnostic_status", | |
| "name" : "Diagnostic status", | |
| "localizedName" : "Diagnostic status", | |
| "rmType" : "DV_CODED_TEXT", | |
| "nodeId" : "at0004", | |
| "min" : 0, | |
| "max" : 1, | |
| "localizedNames" : { | |
| "en" : "Diagnostic status" | |
| }, | |
| "localizedDescriptions" : { | |
| "en" : "Stage or phase of diagnostic process." | |
| }, | |
| "annotations" : { | |
| "comment" : "The status is usually determined by a combination of the timing of diagnosis plus level of clinical certainty resulting from diagnostic tests and clinical evidence available. This data element and 'Diagnostic certainty' in EVALUATION.problem_diagnosis are two important axes of the diagnostic process, and valid combinations will need to be presented by software that exposes both data elements, so it is not possible for users to select conflicting combinations. \r\nPreliminary or working diagnoses are intended to represent the single most likely choice out of all differential diagnosis options." | |
| }, | |
| "aqlPath" : "/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v1]/items[at0004]/value", | |
| "inputs" : [ { | |
| "suffix" : "code", | |
| "type" : "CODED_TEXT", | |
| "list" : [ { | |
| "value" : "at0016", | |
| "label" : "Preliminary", | |
| "localizedLabels" : { | |
| "en" : "Preliminary" | |
| }, | |
| "localizedDescriptions" : { | |
| "en" : "The initial diagnosis made, usually associated with a low level of clinical certainty. It may change as test results or advice become available." | |
| }, | |
| "termBindings" : { | |
| "SNOMED-CT" : { | |
| "value" : "[SNOMED-CT::148006]", | |
| "terminologyId" : "SNOMED-CT" | |
| } | |
| } | |
| }, { | |
| "value" : "at0017", | |
| "label" : "Working", | |
| "localizedLabels" : { | |
| "en" : "Working" | |
| }, | |
| "localizedDescriptions" : { | |
| "en" : "Interim diagnosis, based on a reasonable amount of clinical certainty but pending further test results or clinical advice. It may still change as test results or advice become available." | |
| }, | |
| "termBindings" : { | |
| "SNOMED-CT" : { | |
| "value" : "[SNOMED-CT::5558000]", | |
| "terminologyId" : "SNOMED-CT" | |
| } | |
| } | |
| }, { | |
| "value" : "at0018", | |
| "label" : "Established", | |
| "localizedLabels" : { | |
| "en" : "Established" | |
| }, | |
| "localizedDescriptions" : { | |
| "en" : "Final substantiated diagnosis, based on a high level of clinical certainty, which may include clinical evidence from test results. It is not expected to change." | |
| }, | |
| "termBindings" : { | |
| "SNOMED-CT" : { | |
| "value" : "[SNOMED-CT::14657009]", | |
| "terminologyId" : "SNOMED-CT" | |
| } | |
| } | |
| }, { | |
| "value" : "at0088", | |
| "label" : "Refuted", | |
| "localizedLabels" : { | |
| "en" : "Refuted" | |
| }, | |
| "localizedDescriptions" : { | |
| "en" : "The previously recorded diagnosis has been clinically reassessed or disproved with a high level of clinical certainty. This status is used to correct an error in the health record." | |
| } | |
| } ] | |
| } ], | |
| "termBindings" : { | |
| "SNOMED-CT" : { | |
| "value" : "[SNOMED-CT::106229004]", | |
| "terminologyId" : "SNOMED-CT" | |
| } | |
| } | |
| }, { | |
| "id" : "current_past", | |
| "name" : "Current/Past?", | |
| "localizedName" : "Current/Past?", | |
| "rmType" : "DV_CODED_TEXT", | |
| "nodeId" : "at0060", | |
| "min" : 0, | |
| "max" : 1, | |
| "localizedNames" : { | |
| "en" : "Current/Past?" | |
| }, | |
| "localizedDescriptions" : { | |
| "en" : "Category that supports division of problems and diagnoses into Current or Past problem lists." | |
| }, | |
| "annotations" : { | |
| "comment" : "The Current/Past and Active/Inactive data elements have similar clinical impact but represent slightly different semantics. Both are actively used in different clinical settings, but usually not together. If an Active/Inactive qualifier is recorded, then this data element is likely to be redundant. An exception where a condition can be current but inactive is asthma that is not causing acute symptoms." | |
| }, | |
| "aqlPath" : "/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v1]/items[at0060]/value", | |
| "inputs" : [ { | |
| "suffix" : "code", | |
| "type" : "CODED_TEXT", | |
| "list" : [ { | |
| "value" : "at0062", | |
| "label" : "Current", | |
| "localizedLabels" : { | |
| "en" : "Current" | |
| }, | |
| "localizedDescriptions" : { | |
| "en" : "An issue occuring at present." | |
| }, | |
| "termBindings" : { | |
| "SNOMED-CT" : { | |
| "value" : "[SNOMED-CT::15240007]", | |
| "terminologyId" : "SNOMED-CT" | |
| } | |
| } | |
| }, { | |
| "value" : "at0061", | |
| "label" : "Past", | |
| "localizedLabels" : { | |
| "en" : "Past" | |
| }, | |
| "localizedDescriptions" : { | |
| "en" : "An issue which ocurred in the past." | |
| }, | |
| "termBindings" : { | |
| "SNOMED-CT" : { | |
| "value" : "[SNOMED-CT::410513005]", | |
| "terminologyId" : "SNOMED-CT" | |
| } | |
| } | |
| } ] | |
| } ], | |
| "termBindings" : { | |
| "SNOMED-CT" : { | |
| "value" : "[SNOMED-CT::410511007]", | |
| "terminologyId" : "SNOMED-CT" | |
| } | |
| } | |
| }, { | |
| "id" : "active_inactive", | |
| "name" : "Active/Inactive?", | |
| "localizedName" : "Active/Inactive?", | |
| "rmType" : "DV_CODED_TEXT", | |
| "nodeId" : "at0003", | |
| "min" : 0, | |
| "max" : 1, | |
| "localizedNames" : { | |
| "en" : "Active/Inactive?" | |
| }, | |
| "localizedDescriptions" : { | |
| "en" : "Category that supports division of problems and diagnoses into Active or Inactive problem lists." | |
| }, | |
| "annotations" : { | |
| "comment" : "The Active/Inactive and Current/Past data elements have similar clinical impact but represent slightly different semantics. Both are actively used in different clinical settings, but usually not together. If a Current/Past qualifier is recorded, then this data element is likely to be redundant. An exception where a condition can be current but inactive is asthma that is not causing acute symptoms." | |
| }, | |
| "aqlPath" : "/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v1]/items[at0003]/value", | |
| "inputs" : [ { | |
| "suffix" : "code", | |
| "type" : "CODED_TEXT", | |
| "list" : [ { | |
| "value" : "at0026", | |
| "label" : "Active", | |
| "localizedLabels" : { | |
| "en" : "Active" | |
| }, | |
| "localizedDescriptions" : { | |
| "en" : "The problem or diagnosis is currently active and clinically relevant." | |
| } | |
| }, { | |
| "value" : "at0027", | |
| "label" : "Inactive", | |
| "localizedLabels" : { | |
| "en" : "Inactive" | |
| }, | |
| "localizedDescriptions" : { | |
| "en" : "The problem or diagnosis is not completely resolved but is inactive or felt less relevant to the current clinical context." | |
| } | |
| } ] | |
| } ] | |
| }, { | |
| "id" : "resolution_phase", | |
| "name" : "Resolution phase", | |
| "localizedName" : "Resolution phase", | |
| "rmType" : "DV_CODED_TEXT", | |
| "nodeId" : "at0083", | |
| "min" : 0, | |
| "max" : 1, | |
| "localizedNames" : { | |
| "en" : "Resolution phase" | |
| }, | |
| "localizedDescriptions" : { | |
| "en" : "Phase of healing for an acute problem or diagnosis." | |
| }, | |
| "annotations" : { | |
| "comment" : "For example: tracking the progress of resolution of a middle ear infection." | |
| }, | |
| "aqlPath" : "/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v1]/items[at0083]/value", | |
| "inputs" : [ { | |
| "suffix" : "code", | |
| "type" : "CODED_TEXT", | |
| "list" : [ { | |
| "value" : "at0086", | |
| "label" : "Not resolving", | |
| "localizedLabels" : { | |
| "en" : "Not resolving" | |
| }, | |
| "localizedDescriptions" : { | |
| "en" : "Problem or diagnosis is not progressing satisfactorily through the normal stages of restoration or healing towards resolution." | |
| } | |
| }, { | |
| "value" : "at0085", | |
| "label" : "Resolving", | |
| "localizedLabels" : { | |
| "en" : "Resolving" | |
| }, | |
| "localizedDescriptions" : { | |
| "en" : "Problem or diagnosis is progressing satisfactorily through the normal stages of restoration or healing towards resolution." | |
| } | |
| }, { | |
| "value" : "at0084", | |
| "label" : "Resolved", | |
| "localizedLabels" : { | |
| "en" : "Resolved" | |
| }, | |
| "localizedDescriptions" : { | |
| "en" : "Problem or diagnosis has completed the normal phases of restoration or healing and can be considered resolved." | |
| } | |
| }, { | |
| "value" : "at0087", | |
| "label" : "Indeterminate", | |
| "localizedLabels" : { | |
| "en" : "Indeterminate" | |
| }, | |
| "localizedDescriptions" : { | |
| "en" : "It is not possible to determine the resolution or healing status of the problem or diagnosis." | |
| } | |
| }, { | |
| "value" : "at0097", | |
| "label" : "Relapsed", | |
| "localizedLabels" : { | |
| "en" : "Relapsed" | |
| }, | |
| "localizedDescriptions" : { | |
| "en" : "Problem or diagnosis has deteriorated after a period of temporary improvement." | |
| } | |
| } ] | |
| } ] | |
| }, { | |
| "id" : "remission_status", | |
| "name" : "Remission status", | |
| "localizedName" : "Remission status", | |
| "rmType" : "DV_CODED_TEXT", | |
| "nodeId" : "at0089", | |
| "min" : 0, | |
| "max" : 1, | |
| "localizedNames" : { | |
| "en" : "Remission status" | |
| }, | |
| "localizedDescriptions" : { | |
| "en" : "Status of the remission of an incurable diagnosis." | |
| }, | |
| "annotations" : { | |
| "comment" : "For example: the status of a cancer or haematological diagnosis." | |
| }, | |
| "aqlPath" : "/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v1]/items[at0089]/value", | |
| "inputs" : [ { | |
| "suffix" : "code", | |
| "type" : "CODED_TEXT", | |
| "list" : [ { | |
| "value" : "at0090", | |
| "label" : "In remission", | |
| "localizedLabels" : { | |
| "en" : "In remission" | |
| }, | |
| "localizedDescriptions" : { | |
| "en" : "No ongoing signs or symptoms of the disease have been identified." | |
| } | |
| }, { | |
| "value" : "at0092", | |
| "label" : "Not in remission", | |
| "localizedLabels" : { | |
| "en" : "Not in remission" | |
| }, | |
| "localizedDescriptions" : { | |
| "en" : "No diminution of the signs or symptoms of the disease have been identified." | |
| } | |
| }, { | |
| "value" : "at0093", | |
| "label" : "Indeterminate", | |
| "localizedLabels" : { | |
| "en" : "Indeterminate" | |
| }, | |
| "localizedDescriptions" : { | |
| "en" : "It is not possible to determine if there have been diminution of the signs or symptoms of the disease have been identified." | |
| } | |
| } ] | |
| } ] | |
| }, { | |
| "id" : "episodicity", | |
| "name" : "Episodicity", | |
| "localizedName" : "Episodicity", | |
| "rmType" : "DV_CODED_TEXT", | |
| "nodeId" : "at0001", | |
| "min" : 0, | |
| "max" : 1, | |
| "localizedNames" : { | |
| "en" : "Episodicity" | |
| }, | |
| "localizedDescriptions" : { | |
| "en" : "Category of this episode for the identified problem/diagnosis." | |
| }, | |
| "annotations" : { | |
| "comment" : "For example: 'New' will enable clinicians to distinguish a new, acute episode of otitis media that may have arisen soon after a previous diagnosis, to distinguish it from an unresolved or 'Ongoing' diagnosis of chronic otitis media. Treatment of recurring, new and acute, episodes of a condition may differ significantly from the same condition that is not resolving or responding to treatment. In many situations the clinician will not be able to tell, and so indeterminate may be appropriate." | |
| }, | |
| "aqlPath" : "/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v1]/items[at0001]/value", | |
| "inputs" : [ { | |
| "suffix" : "code", | |
| "type" : "CODED_TEXT", | |
| "list" : [ { | |
| "value" : "at0034", | |
| "label" : "New", | |
| "localizedLabels" : { | |
| "en" : "New" | |
| }, | |
| "localizedDescriptions" : { | |
| "en" : "A new occurrence of either a new or existing problem or diagnosis. A flag for 'First occurrence' can be recorded separately to distinguish the first from other occurrences." | |
| } | |
| }, { | |
| "value" : "at0035", | |
| "label" : "Ongoing", | |
| "localizedLabels" : { | |
| "en" : "Ongoing" | |
| }, | |
| "localizedDescriptions" : { | |
| "en" : "The issue, problem or diagnosis continues, without new, acute episodes occurring." | |
| } | |
| }, { | |
| "value" : "at0070", | |
| "label" : "Indeterminate", | |
| "localizedLabels" : { | |
| "en" : "Indeterminate" | |
| }, | |
| "localizedDescriptions" : { | |
| "en" : "It is not possible to determine if this occurrence of the problem or diagnosis is new or ongoing." | |
| } | |
| } ] | |
| } ], | |
| "termBindings" : { | |
| "SNOMED-CT" : { | |
| "value" : "[SNOMED-CT::288526004]", | |
| "terminologyId" : "SNOMED-CT" | |
| } | |
| } | |
| }, { | |
| "id" : "occurrence", | |
| "name" : "Occurrence", | |
| "localizedName" : "Occurrence", | |
| "rmType" : "DV_CODED_TEXT", | |
| "nodeId" : "at0071", | |
| "min" : 0, | |
| "max" : 1, | |
| "localizedNames" : { | |
| "en" : "Occurrence" | |
| }, | |
| "localizedDescriptions" : { | |
| "en" : "Category of the occurrence for this problem or diagnosis." | |
| }, | |
| "annotations" : { | |
| "comment" : "This data element can be an additional qualifier to the 'New' value in the 'Episodicity' value set, that is a condition such as asthma can have recurring new episodes that have periods of resolution in between. However it can be important to identify the first ever episode of asthma from all of the other episodes." | |
| }, | |
| "aqlPath" : "/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v1]/items[at0071]/value", | |
| "inputs" : [ { | |
| "suffix" : "code", | |
| "type" : "CODED_TEXT", | |
| "list" : [ { | |
| "value" : "at0095", | |
| "label" : "First occurrence", | |
| "localizedLabels" : { | |
| "en" : "First occurrence" | |
| }, | |
| "localizedDescriptions" : { | |
| "en" : "This is the first ever occurrence of this problem or diagnosis." | |
| } | |
| }, { | |
| "value" : "at0096", | |
| "label" : "Recurrence", | |
| "localizedLabels" : { | |
| "en" : "Recurrence" | |
| }, | |
| "localizedDescriptions" : { | |
| "en" : "New occurrence of the same problem or diagnosis after a previous episode was resolved." | |
| } | |
| } ] | |
| } ] | |
| }, { | |
| "id" : "course_label", | |
| "name" : "Course label", | |
| "localizedName" : "Course label", | |
| "rmType" : "DV_CODED_TEXT", | |
| "nodeId" : "at0077", | |
| "min" : 0, | |
| "max" : 1, | |
| "localizedNames" : { | |
| "en" : "Course label" | |
| }, | |
| "localizedDescriptions" : { | |
| "en" : "Category reflecting the speed of onset and/or duration and persistence of the problem or diagnosis." | |
| }, | |
| "annotations" : { | |
| "comment" : "Definitions of acute vs chronic will differ for each diagnosis." | |
| }, | |
| "aqlPath" : "/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v1]/items[at0077]/value", | |
| "inputs" : [ { | |
| "suffix" : "code", | |
| "type" : "CODED_TEXT", | |
| "list" : [ { | |
| "value" : "at0081", | |
| "label" : "Acute", | |
| "localizedLabels" : { | |
| "en" : "Acute" | |
| }, | |
| "localizedDescriptions" : { | |
| "en" : "A problem or diagnosis with a rapid onset, a short course, or both." | |
| } | |
| }, { | |
| "value" : "at0094", | |
| "label" : "Acute-on-chronic", | |
| "localizedLabels" : { | |
| "en" : "Acute-on-chronic" | |
| }, | |
| "localizedDescriptions" : { | |
| "en" : "A problem or diagnosis with an acute exacerbation of a chronic condition." | |
| } | |
| }, { | |
| "value" : "at0079", | |
| "label" : "Chronic", | |
| "localizedLabels" : { | |
| "en" : "Chronic" | |
| }, | |
| "localizedDescriptions" : { | |
| "en" : "A problem or diagnosis with persistent or long-lasting effects, or that evolves over time." | |
| } | |
| } ] | |
| } ], | |
| "termBindings" : { | |
| "SNOMED-CT" : { | |
| "value" : "[SNOMED-CT::288524001]", | |
| "terminologyId" : "SNOMED-CT" | |
| } | |
| } | |
| }, { | |
| "id" : "diagnostic_category", | |
| "name" : "Diagnostic category", | |
| "localizedName" : "Diagnostic category", | |
| "rmType" : "DV_CODED_TEXT", | |
| "nodeId" : "at0063", | |
| "min" : 0, | |
| "max" : -1, | |
| "localizedNames" : { | |
| "en" : "Diagnostic category" | |
| }, | |
| "localizedDescriptions" : { | |
| "en" : "Category of the problem or diagnosis within a specified episode of care and/or local care context." | |
| }, | |
| "annotations" : { | |
| "comment" : "This data element contains a value set commonly used in diagnostic categorisation. In episodic care contexts (commonly secondary care) it is common to categorise/organise diagnoses according to their relationship to the principal diagnosis being addressed during that episode of care. These categories may also be used for clinical coding, reporting and billing purposes. In some countries the diagnostic category may be known as a DRG.\r\n In addition, the free text choice permits use of other local value sets, as required." | |
| }, | |
| "aqlPath" : "/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v1]/items[at0063]/value", | |
| "inputs" : [ { | |
| "suffix" : "code", | |
| "type" : "CODED_TEXT", | |
| "list" : [ { | |
| "value" : "at0064", | |
| "label" : "Principal diagnosis", | |
| "localizedLabels" : { | |
| "en" : "Principal diagnosis" | |
| }, | |
| "localizedDescriptions" : { | |
| "en" : "The diagnosis determined to be chiefly responsible for occasionaing an episode of admitted patient care, an episode of residential care or an attendance at the health care establishment." | |
| }, | |
| "termBindings" : { | |
| "SNOMED-CT" : { | |
| "value" : "[SNOMED-CT::8319008]", | |
| "terminologyId" : "SNOMED-CT" | |
| } | |
| } | |
| }, { | |
| "value" : "at0066", | |
| "label" : "Secondary diagnosis", | |
| "localizedLabels" : { | |
| "en" : "Secondary diagnosis" | |
| }, | |
| "localizedDescriptions" : { | |
| "en" : "A problem or diagnosis that is occurs at the same time as the primary problem or diagnosis. May also be known as a comorbid condition." | |
| }, | |
| "termBindings" : { | |
| "SNOMED-CT" : { | |
| "value" : "[SNOMED-CT::85097005]", | |
| "terminologyId" : "SNOMED-CT" | |
| } | |
| } | |
| }, { | |
| "value" : "at0076", | |
| "label" : "Complication", | |
| "localizedLabels" : { | |
| "en" : "Complication" | |
| }, | |
| "localizedDescriptions" : { | |
| "en" : "An unfavorable evolution of a problem or diagnosis." | |
| } | |
| } ], | |
| "listOpen" : true | |
| }, { | |
| "suffix" : "other", | |
| "type" : "TEXT" | |
| } ] | |
| }, { | |
| "id" : "admission_diagnosis", | |
| "name" : "Admission diagnosis?", | |
| "localizedName" : "Admission diagnosis?", | |
| "rmType" : "DV_BOOLEAN", | |
| "nodeId" : "at0073", | |
| "min" : 0, | |
| "max" : 1, | |
| "localizedNames" : { | |
| "en" : "Admission diagnosis?" | |
| }, | |
| "localizedDescriptions" : { | |
| "en" : "Was the problem or diagnosis present at admission?" | |
| }, | |
| "annotations" : { | |
| "comment" : "Record as True if the problem or diagnosis was present on admission. This data element is a requirement from DRG reporting in some countries." | |
| }, | |
| "aqlPath" : "/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v1]/items[at0073]/value", | |
| "inputs" : [ { | |
| "type" : "BOOLEAN", | |
| "list" : [ { | |
| "value" : "true", | |
| "label" : "true" | |
| } ] | |
| } ] | |
| } ] | |
| }, { | |
| "id" : "diagnostic_certainty", | |
| "name" : "Diagnostic certainty", | |
| "localizedName" : "Diagnostic certainty", | |
| "rmType" : "DV_CODED_TEXT", | |
| "nodeId" : "at0073", | |
| "min" : 0, | |
| "max" : 1, | |
| "localizedNames" : { | |
| "en" : "Diagnostic certainty" | |
| }, | |
| "localizedDescriptions" : { | |
| "en" : "The level of confidence in the identification of the diagnosis." | |
| }, | |
| "aqlPath" : "/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0073]/value", | |
| "inputs" : [ { | |
| "suffix" : "code", | |
| "type" : "CODED_TEXT", | |
| "list" : [ { | |
| "value" : "at0074", | |
| "label" : "Suspected", | |
| "localizedLabels" : { | |
| "en" : "Suspected" | |
| }, | |
| "localizedDescriptions" : { | |
| "en" : "The diagnosis has been identified with a low level of certainty." | |
| } | |
| }, { | |
| "value" : "at0075", | |
| "label" : "Probable", | |
| "localizedLabels" : { | |
| "en" : "Probable" | |
| }, | |
| "localizedDescriptions" : { | |
| "en" : "The diagnosis has been identified with a high level of certainty." | |
| } | |
| }, { | |
| "value" : "at0076", | |
| "label" : "Confirmed", | |
| "localizedLabels" : { | |
| "en" : "Confirmed" | |
| }, | |
| "localizedDescriptions" : { | |
| "en" : "The diagnosis has been confirmed against recognised criteria." | |
| } | |
| } ], | |
| "listOpen" : true | |
| }, { | |
| "suffix" : "other", | |
| "type" : "TEXT" | |
| } ] | |
| }, { | |
| "id" : "comment", | |
| "name" : "Comment", | |
| "localizedName" : "Comment", | |
| "rmType" : "DV_TEXT", | |
| "nodeId" : "at0069", | |
| "min" : 0, | |
| "max" : 1, | |
| "localizedNames" : { | |
| "en" : "Comment" | |
| }, | |
| "localizedDescriptions" : { | |
| "en" : "Additional narrative about the problem or diagnosis not captured in other fields." | |
| }, | |
| "aqlPath" : "/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0069]/value", | |
| "inputs" : [ { | |
| "type" : "TEXT" | |
| } ] | |
| }, { | |
| "id" : "last_updated", | |
| "name" : "Last updated", | |
| "localizedName" : "Last updated", | |
| "rmType" : "DV_DATE_TIME", | |
| "nodeId" : "at0070", | |
| "min" : 0, | |
| "max" : 1, | |
| "dependsOn" : [ "severity", "problem_diagnosis_name", "problem_diagnosis_qualifier", "date_time_of_resolution", "diagnostic_certainty", "date_time_of_onset", "clinical_description", "comment", "body_site", "date_time_clinically_recognised", "course_description" ], | |
| "localizedNames" : { | |
| "en" : "Last updated" | |
| }, | |
| "localizedDescriptions" : { | |
| "en" : "The date this problem or diagnosis was last updated." | |
| }, | |
| "aqlPath" : "/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/protocol[at0032]/items[at0070]/value", | |
| "inputs" : [ { | |
| "type" : "DATETIME" | |
| } ] | |
| }, { | |
| "id" : "language", | |
| "name" : "Language", | |
| "rmType" : "CODE_PHRASE", | |
| "min" : 1, | |
| "max" : 1, | |
| "aqlPath" : "/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/language", | |
| "inContext" : true | |
| }, { | |
| "id" : "encoding", | |
| "name" : "Encoding", | |
| "rmType" : "CODE_PHRASE", | |
| "min" : 1, | |
| "max" : 1, | |
| "aqlPath" : "/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/encoding", | |
| "inContext" : true | |
| }, { | |
| "id" : "subject", | |
| "name" : "Subject", | |
| "rmType" : "PARTY_PROXY", | |
| "min" : 1, | |
| "max" : 1, | |
| "aqlPath" : "/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/subject", | |
| "inputs" : [ { | |
| "suffix" : "id", | |
| "type" : "TEXT" | |
| }, { | |
| "suffix" : "id_scheme", | |
| "type" : "TEXT" | |
| }, { | |
| "suffix" : "id_namespace", | |
| "type" : "TEXT" | |
| }, { | |
| "suffix" : "name", | |
| "type" : "TEXT" | |
| } ], | |
| "inContext" : true | |
| } ] | |
| }, { | |
| "id" : "category", | |
| "rmType" : "DV_CODED_TEXT", | |
| "nodeId" : "", | |
| "min" : 1, | |
| "max" : 1, | |
| "aqlPath" : "/category", | |
| "inputs" : [ { | |
| "suffix" : "code", | |
| "type" : "CODED_TEXT", | |
| "list" : [ { | |
| "value" : "433", | |
| "label" : "event", | |
| "localizedLabels" : { | |
| "en" : "event" | |
| } | |
| } ], | |
| "terminology" : "openehr" | |
| } ], | |
| "inContext" : true | |
| }, { | |
| "id" : "language", | |
| "name" : "Language", | |
| "rmType" : "CODE_PHRASE", | |
| "min" : 1, | |
| "max" : 1, | |
| "aqlPath" : "/language", | |
| "inContext" : true | |
| }, { | |
| "id" : "territory", | |
| "name" : "Territory", | |
| "rmType" : "CODE_PHRASE", | |
| "min" : 1, | |
| "max" : 1, | |
| "aqlPath" : "/territory", | |
| "inContext" : true | |
| }, { | |
| "id" : "composer", | |
| "name" : "Composer", | |
| "rmType" : "PARTY_PROXY", | |
| "min" : 1, | |
| "max" : 1, | |
| "aqlPath" : "/composer", | |
| "inputs" : [ { | |
| "suffix" : "id", | |
| "type" : "TEXT" | |
| }, { | |
| "suffix" : "id_scheme", | |
| "type" : "TEXT" | |
| }, { | |
| "suffix" : "id_namespace", | |
| "type" : "TEXT" | |
| }, { | |
| "suffix" : "name", | |
| "type" : "TEXT" | |
| } ], | |
| "inContext" : true | |
| } ] | |
| } | |
| } |
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