ID

23493

Description

Derived from www.openehr.org Use to record details about findings that support a clinical assertion, either as a summary of data available in other (often OBSERVATION class) archetypes, or when the original observational data is not available. This archetype is designed to be nested within a SLOT in the EVALUATION.problem_diagnosis, EVALUATION.adverse_reaction_risk, EVALUATION.health_risk, EVALUATION.contraindication, or similar summary archetypes, where the name of the assertion has already been specified in the EVALUATION, in order to extend its content with this additional and optional dataset. While LINKs within the openEHR Reference Model allow for linkage to data held elsewhere within the health record, this archetype has been developed to make this functionality explicit, and to enable clinical visibility and review of this data, where it may be relevant in a template or specification. The clinical evidence can be entered directly into this archetype as a 'Finding', or a citation can be used to explicitly point to data within the health record.

Lien

www.openehr.org

Mots-clés

  1. 08/07/2017 08/07/2017 - Martin Dugas
  2. 08/07/2017 08/07/2017 - Martin Dugas
Téléchargé le

8 juillet 2017

DOI

Pour une demande vous connecter.

Licence

Creative Commons BY-SA 3.0

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Clinical evidence (EHR archetype)

openEHR-EHR-CLUSTER.clinical_evidence.v1

  1. StudyEvent: openEHR-EHR-CLUSTER.clinical_evidence.v1
    1. openEHR-EHR-CLUSTER.clinical_evidence.v1
openEHR-EHR-CLUSTER.clinical_evidence.v1.xml
Description

openEHR-EHR-CLUSTER.clinical_evidence.v1.xml

Clinical evidence
Description

Details about findings that support a clinical assertion.

Type de données

text

Alias
UMLS CUI [1]
C3887511
Method description
Description

Narrative description of the method used to identify the evidence.

Type de données

text

Finding
Description

Identification of the finding that supports the assertion.

Type de données

text

Finding description
Description

Narrative description of the finding.

Type de données

text

Result
Description

Measurement or value associated with the finding.

Type de données

text

Date identified
Description

The date on which the finding was clinically identified.

Type de données

datetime

Citation
Description

Detailed data available about the evidence held in another part of the health record.

Type de données

text

Multimedia representation
Description

Digital image, video or diagram representing the clinical evidence.

Type de données

text

Method
Description

Type of examination or investigation used to identify the evidence.

Type de données

text

Comment
Description

Additional narrative about the finding not captured in other fields.

Type de données

text

Similar models

openEHR-EHR-CLUSTER.clinical_evidence.v1

  1. StudyEvent: openEHR-EHR-CLUSTER.clinical_evidence.v1
    1. openEHR-EHR-CLUSTER.clinical_evidence.v1
Name
Type
Description | Question | Decode (Coded Value)
Type de données
Alias
Clinical evidence
Item
Clinical evidence
text
C3887511 (UMLS CUI [1])
Method description
Item
Method description
text
Finding
Item
Finding
text
Finding description
Item
Finding description
text
Result
Item
Result
text
Date identified
Item
Date identified
datetime
Citation
Item
Citation
text
Multimedia representation
Item
Multimedia representation
text
Method
Item
Method
text
Comment
Item
Comment
text

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