ID

23535

Beskrivning

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.

Nyckelord

  1. 2017-07-08 2017-07-08 - Martin Dugas
  2. 2017-07-08 2017-07-08 - Martin Dugas
Uppladdad den

8 juli 2017

DOI

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Licens

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
Beskrivning

openEHR-EHR-EVALUATION.clinical_synopsis.v1.xml

Klinische Synopsis
Beskrivning

Zusammenfassung oder Übersicht einer Patientengeschichte, speziell aus der Sicht eines Gesundheitsdienstleisters, evtl. mit dazugehörigen Interpretationen.

Datatyp

text

List
Beskrivning

List

Datatyp

text

Synopsis
Beskrivning

Die Zusammenfassung, Beurteilung, Aussagen or Auswertung des klinischen Befunds.

Datatyp

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
Typ
Description | Question | Decode (Coded Value)
Datatyp
Alias
Clinical Synopsis
Item
Klinische Synopsis
text
List
Item
text
Synopsis
Item
Synopsis
text

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