ID

23536

Descrição

Derived from www.openehr.org . Use to record a narrative, summary view of the patient's health. This unstructured summary may include identified health issues; health care provided; associated interpretation; patient understanding; and enable communication about some of the softer, more subjective aspects of the patient’s experience and journey. Most commonly this summary is likely to be related to a specific health event such as a specific consultation or hospital admission, but may also be used to summarise the patient's health experience over varying time periods. In practice, Clinical Synopsis is a meta observation that will complement the existing structured clinical record, allowing for expression of subtle, subjective or interpretive information about the patient that might not otherwise be obvious through structured data alone, providing balance and context to the EHR record. For example, a Clinical Synopsis can communicate a succinct summary of the patient's hospital admission as one component of a comprehensive and structured Discharge Summary document.

Link

www.openehr.org

Palavras-chave

  1. 08/07/2017 08/07/2017 - Martin Dugas
  2. 08/07/2017 08/07/2017 - Martin Dugas
Transferido a

8 de julho de 2017

DOI

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Licença

Creative Commons BY-NC 3.0

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Clinical Synopsis (EHR Archetype)

openEHR-EHR-EVALUATION.clinical_synopsis.v1

  1. StudyEvent: openEHR-EHR-EVALUATION.clinical_synopsis.v1
    1. openEHR-EHR-EVALUATION.clinical_synopsis.v1
openEHR-EHR-EVALUATION.clinical_synopsis.v1.xml
Descrição

openEHR-EHR-EVALUATION.clinical_synopsis.v1.xml

المختصر السريري
Descrição

ملخص بالرواية أو نظرة عامة عن المريض, خاصة من وجهة نظر مقدم الخدمة الصحية, مع إرفاق أو عدم إرفاق تفسيرات

Tipo de dados

text

Alias
UMLS CUI [1]
C2348629
List
Descrição

List

Tipo de dados

text

Similar models

openEHR-EHR-EVALUATION.clinical_synopsis.v1

  1. StudyEvent: openEHR-EHR-EVALUATION.clinical_synopsis.v1
    1. openEHR-EHR-EVALUATION.clinical_synopsis.v1
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de dados
Alias
Clinical Synopsis
Item
المختصر السريري
text
C2348629 (UMLS CUI [1])
List
Item
text

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