ID

23521

Descrição

Derived from www.openehr.org . Use as a suggested framework to support consistent modelling of the Problem list as a persistent and managed list of diagnoses identified, problems experienced by the subject or previous procedures performed. This list can be utilised as a source of current problem list data for exchange or as the basis for decision support. This list can be comprised of three types of statements, each represented by specific archetypes: - statements about the positive presence of problems, diagnoses or previous procedures are recorded using the EVALUATION.problem_diagnosis and/or ACTION.procedure archetypes; OR - statements about the positive exclusion of problems, diagnoses or previous procedures can be recorded using the specific EVALUATION.exclusion-problem_diagnosis or EVALUATION.exclusion-procedure archetypes - for example: "No significant problems or diagnoses" or "No history of significant operations or procedures"; OR - statements about no information being available - neither a positive presence of a problem, diagnosis or procedure performed nor a positive exclusion - can be recorded using the EVALUATION.absence archetype. In order for this list to be accurate and safe to use as the basis for decision support activities and for exchange, this Problem List should ideally be curated by a clinician responsible for the health record, rather than managed automatically by the clinical system through business rules alone. In a closed clincial system, it is expected that provenance of this Problem list can be managed through versioning of this COMPOSITION and its contents, with the additional option of a system-based audit trail. While it may be ideal to have only one Problem list for each subject of care, it is more realistic to expect that in a distributed environment there may be multiple Problem lists for a single subject of care, each managed and prioritised for a specific clinician, episode of care or other context. For example, a Problem list for a primary care clinician may be a very different configuration to that which is useful for a specialist surgeon or for reference during a hospital inpatient episode. In primary care it is common to organise the Problem list based on active or inactive problems or diagnoses; specialists may prefer to see their list organised around primary diagnoses which are related to their specific speciality and secondary ones which are not; and an inpatient admission may include additional issues related to immediate nursing priorities that would not be relevant once discharged home - for these purposes there is a Status SLOT in the Problem/Diagnosis archetype, which allow use of an archetype that could support clinical systems to organise Problem lists according to the preference of the clinical users of the system, without perpetuating these contextual status labels to other clinical scenarios or for persistence. This archetype is usually managed as a persistent list, however there are situations where the list may be used within episodic care and require additional attributes such as context etc to enable accurate recording. The openEHR reference model currently only allows context to be recorded within Event-based COMPOSITION archetypes. As a result, this archetype has been modelled as an Event, rather than Persistent, COMPOSITION, to allow for flexibility so that some clinical systems can safely manage Problem lists for episodes of care, while others will choose to implement this COMPOSITION to act in a persistent manner.

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www.openehr.org

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Versões (2)

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

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8 luglio 2017

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