ID

24340

Descrizione

Use to enable recording or exchange of an explicit statement that specified health information is not available for inclusion in the health record or record extract at the time of recording. This statement is the third component of a family of statements - statements of positive presence, statements of positive exclusion and statements of absence: - Statements of positive presence indicate that there is relevant health information in the record or extract - for example, EVALUATION.adverse_reaction stating that the patient has an allergy to penicillin or EVALUATION.problem_diagnosis stating that the patient has diabetes. - Equivalent statements about exclusion are used to indicate that it is known that there is no relevant health information in the health record or extract - for example, EVALUATION.exclusion_adverse stating that the patient does not have a known allergy to penicillin or EVALUATION.exclusion_problem_diagnosis stating that the patient is not diabetic; and; - In this context, the EVALUATION.absence could be used to record that there is no health information available about penicillin allergy or the diagnosis of diabetes - it is not known if it is present or excluded, but there is no information that can be provided. This archetype has been developed specifically for the use case where a clinician is preparing an extract from a health record, so that the receiver has explicit and unambiguous understanding of the information available - that which is present, excluded or just not available. It is primarily intended to be used within SLOTS in persistent COMPOSITIONS such as 'Therapeutic precautions', 'Medication list', 'Problem list', or 'Adverse reaction list'. It is also deliberately intended to be statement made by a clinician in the same way that they would record any allergies or diagnoses, and is intended to be quite different to technical use of null flavours in data. Absence statements can only be considered to be current and accurate at the time of recording. This archetype has been designed specifically to avoid the need to use of flags to express negation about any entry within the health record.

Keywords

versioni (2)

1. 08/07/17 08/07/17 - Martin Dugas
2. 30/07/17 30/07/17 - Martin Dugas

Caricato su

30 luglio 2017

DOI

Per favore, per richiedere un accesso.

Licenza