ID

23536

Description

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

Keywords

  1. 7/8/17 7/8/17 - Martin Dugas
  2. 7/8/17 7/8/17 - Martin Dugas
Uploaded on

July 8, 2017

DOI

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License

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
Description

openEHR-EHR-EVALUATION.clinical_synopsis.v1.xml

Clinical Synopsis
Description

Narrative summary or overview about a patient, specifically from the perspective of a healthcare provider, and with or without associated interpretations.

Data type

text

Alias
UMLS CUI [1]
C2348629
List
Description

@ internal @

Data type

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
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Clinical Synopsis
Item
Clinical Synopsis
text
C2348629 (UMLS CUI [1])
List
Item
List
text

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