ID

23537

Descrizione

Use to record an overall statement of exclusion about all Problem/diagnosis, Family history, Medications, Procedures, Adverse reactions or other clinical item that are either not currently present, or have not been present in the past. This archetype has been specifically designed to make a clear and unambiguous statement of an overall exclusion of a type of clinical item from the health record. This approach is used in preference to relying on flags or terminology to express negation. Each global statement should be recorded in a separate instance - for example a separate instance for a statement about medications and another for adverse reactions. The 'Global statement' data element allows for recording of a single Global statement. The different Global statements listed in the "Global statement' run-time name constraint identifies the the different global exclusions. This name constraint can be applied during template modelling or at run-time within a software application. Please note that exclusion statements can only be considered to be current and accurate at the point-in-time of recording. It is possible for a record to be able to state that an individual has NO KNOWN history of any problems or diagnoses (using an exclusion statement) at the same consultation as recording the evidence of their first experience of a problem or diagnosis (using the EVALUATION.problem_diagnosis archetype). In future record statements, the individual may have a KNOWN history of the problem or diagnosis recorded in their problem list.

Keywords

versioni (1)

1. 08/07/17 08/07/17 - Martin Dugas

Caricato su

8 luglio 2017

DOI

Per favore, per richiedere un accesso.

Licenza