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.

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-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

Klinisk grunnlag
Description

Grunnlaget for et klinisk utsagn.

Data type

text

Alias
UMLS CUI [1]
C3887511
Metodebeskrivelse
Description

Fritekstbeskrivelse av metoden som ble brukt for å komme fram til funnet.

Data type

text

Funn
Description

Funnet som støtter utsagnet.

Data type

text

Beskrivelse av funn
Description

Fritekstbeskrivelse av funnet.

Data type

text

Resultat
Description

Måling eller verdi knyttet til funnet.

Data type

text

Dato
Description

Datoen da funnet ble klinisk anerkjent.

Data type

datetime

Referanse
Description

Detaljerte data om funnet i andre deler av journalen.

Data type

text

Multimediarepresentasjon
Description

Digitalt bilde, video eller diagram som representerer det kliniske grunnlaget.

Data type

text

Metode
Description

Typen undersøkelse eller utredning som er utført for å komme fram til funnet.

Data type

text

Kommentar
Description

Ytterligere informasjon om funnet, som ikke kan registreres i andre felter.

Data type

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)
Data type
Alias
Clinical evidence
Item
Klinisk grunnlag
text
C3887511 (UMLS CUI [1])
Method description
Item
Metodebeskrivelse
text
Finding
Item
Funn
text
Finding description
Item
Beskrivelse av funn
text
Result
Item
Resultat
text
Date identified
Item
Dato
datetime
Citation
Item
Referanse
text
Multimedia representation
Item
Multimediarepresentasjon
text
Method
Item
Metode
text
Comment
Item
Kommentar
text

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