ID

23493

Descrição

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.

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-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
Descrição

openEHR-EHR-CLUSTER.clinical_evidence.v1.xml

Clinical evidence
Descrição

Details about findings that support a clinical assertion.

Tipo de dados

text

Alias
UMLS CUI [1]
C3887511
Method description
Descrição

Narrative description of the method used to identify the evidence.

Tipo de dados

text

Finding
Descrição

Identification of the finding that supports the assertion.

Tipo de dados

text

Finding description
Descrição

Narrative description of the finding.

Tipo de dados

text

Result
Descrição

Measurement or value associated with the finding.

Tipo de dados

text

Date identified
Descrição

The date on which the finding was clinically identified.

Tipo de dados

datetime

Citation
Descrição

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

Tipo de dados

text

Multimedia representation
Descrição

Digital image, video or diagram representing the clinical evidence.

Tipo de dados

text

Method
Descrição

Type of examination or investigation used to identify the evidence.

Tipo de dados

text

Comment
Descrição

Additional narrative about the finding not captured in other fields.

Tipo de dados

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
Tipo
Description | Question | Decode (Coded Value)
Tipo de dados
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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