ID

23538

Description

Use to record a statement of exclusion of a specific Problem/diagnosis, Family history, Medication, Procedure, Adverse reaction or other clinical item that is either not currently present, or have not been present in the past. This archetype has been specifically designed to make a clear and unambiguous statement of a specific exclusion of a type of clinical item from the health record. This approach is used in preference to relying on flags or terminology to express negation. The data element 'Excluded concept' allows for recording of a single specific statement. The different specific concepts listed in the "Excluded concept' run-time name constraint identifies the different specific exclusions. This name constraint can be applied during template modelling or at run-time within a software application. Each specific exclusion should be recorded in a separate instance of this archetype. For example: record 'no past history of adverse reaction to penicillin V', 'no past history of adverse reaction to cephalosporins' and 'no known family history of heart disease' in 3 separately constrained instances of this archetype. Please note that exclusion statements can only be considered to be current and accurate at the point-in-time of recording. It is possible for a record to be able to state that an individual has NO KNOWN history of a specific problem or diagnosis (using an exclusion statement) at the same consultation as recording the evidence of their first experience of the same problem or diagnosis (using the EVALUATION.problem_diagnosis archetype). In future record statements, the individual may have a KNOWN history of the problem or diagnosis recorded in their problem list.

Keywords

  1. 7/8/17 7/8/17 - Martin Dugas
Uploaded on

July 8, 2017

DOI

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License

Creative Commons BY-NC 3.0

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Exclusion - specific (EHR Archetype)

openEHR-EHR-EVALUATION.exclusion_specific.v1

  1. StudyEvent: openEHR-EHR-EVALUATION.exclusion_specific.v1
    1. openEHR-EHR-EVALUATION.exclusion_specific.v1
openEHR-EHR-EVALUATION.exclusion_specific.v1.xml
Description

openEHR-EHR-EVALUATION.exclusion_specific.v1.xml

Eksklusjonsutsagn - spesifikt
Description

Et utsagn om eksklusjon av en spesifikk problem/diagnose, familiær sykdom, legemiddel, prosedyre, overfølsomhet eller andre kliniske konsepter som ikke er tilstede hos et individ, enten i nåtid eller fortid.

Data type

text

Tree
Description

@ internal @

Data type

text

Eksklusjonsutsagn
Description

Et kvalifiserende utsagn om eksklusjonen av en problem/diagnose, familiær sykdom, legemiddel, prosedyre, overfølsomhet eller andre kliniske konsepter.

Data type

text

Ekskludert konsept
Description

Navngiving av det spesifikke konseptet som ekskluderes.

Data type

text

Tree
Description

@ internal @

Data type

text

Tilleggsinformasjon
Description

Ytterligere informasjon som trengs for å kunne registrere lokalt definert innhold eller for å tilpasse til andre referansemodeller/formalismer.

Data type

text

Kommentar
Description

Ytterligere fritekst om "Spesifikk eksklusjon" som ikke er registrert i andre felt.

Data type

text

Similar models

openEHR-EHR-EVALUATION.exclusion_specific.v1

  1. StudyEvent: openEHR-EHR-EVALUATION.exclusion_specific.v1
    1. openEHR-EHR-EVALUATION.exclusion_specific.v1
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Exclusion - specific
Item
Eksklusjonsutsagn - spesifikt
text
Tree
Item
Tree
text
Exclusion statement
Item
Eksklusjonsutsagn
text
Item
Ekskludert konsept
text
Code List
Ekskludert konsept
CL Item
Substans for overfølsomhetsreaksjon (1)
CL Item
Familiær sykdom (2)
CL Item
Legemiddel (3)
CL Item
Problem/diagnose (4)
CL Item
Prosedyre (5)
Tree
Item
Tree
text
Extension
Item
Tilleggsinformasjon
text
Comment
Item
Kommentar
text

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