ID

23540

Description

Derived from www.openehr.org . Use to record a summary of information about problems or diagnoses found in family members. This information may be used to contribute to the identification of a current health problem, assessment of future risk from familial problems or conditions, or to initiate preventive health activities. Traditionally the scope of family history has been focused on genetic factors or biomarkers as indicators of risk or potential risk. The scope of this archetype includes both recording of problems or diagnoses that have an inheritable origin as well as those that are not directly inheritable but influenced by the domestic setting, including psychosocial or environmental factors. Examples include exposure to toxins in the family environment, domestic violence, sexual abuse, alcoholism and other addictions. Non-genetic family members can include adopted or long term fostered children, those related by marriage, or other unrelated individuals who participate in the regular life and influence of the family. This archetype has been designed to include: - a narrative overview as free text. This will allow family history details from existing systems to be incorporated as non-structured text; and - a detailed area focusing on relevant health details about specific family members, including their medical history and biomarkers. This archetype can be used within many contexts. For example, recording a family history entry within a clinical consultation; populating a Family History List; or to provide a summary statement within a Discharge Summary document. Additional detail about a family member's specific problem, diagnosis or past procedures can be captured using the EVALUATION.problem_diagnosis or the ACTION.procedure archetype and specifying the 'Subject of Care' as the family member, rather than the subject of the health record. This archetype can be used as the basis for a Family Pedigree chart of health problems/diagnoses or to support estimations of risk of a condition based on prevalence in the family history or known biomarkers. It may be necessary to identify each family member specifically and not just by the relationship to the patient. For example, while there will be only one maternal grandmother, there may be many female maternal cousins. This may be required to ensure that a pedigree chart is accurate. It will also enable accurate amendments to the record for each identified family member. If the record is private and will not be shared, for reasons of clarity it may be preferable to record the relative's actual name. If the record, or part of the record, is to be shared, it may be more appropriate for the family member to be identified by a unique label or alias.

Link

www.openehr.org

Keywords

  1. 2017-07-08 2017-07-08 - Martin Dugas
  2. 2017-07-08 2017-07-08 - Martin Dugas
Uploaded on

8 juli 2017

DOI

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License

Creative Commons BY-NC 3.0

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Family History (EHR Archetype)

openEHR-EHR-EVALUATION.family_history.v2

  1. StudyEvent: openEHR-EHR-EVALUATION.family_history.v2
    1. openEHR-EHR-EVALUATION.family_history.v2
openEHR-EHR-EVALUATION.family_history.v2.xml
Description

openEHR-EHR-EVALUATION.family_history.v2.xml

Family history
Description

Summary information about the significant health-related problems found in family members.

Data type

text

Alias
UMLS CUI [1]
C0241889
Tree
Description

@ internal @

Data type

text

Summary
Description

Narrative overview about problems, diagnoses, psychosocial, environmental and genetic markers that have been identified in family members.

Data type

text

Per family member
Description

Details about a specific family member.

Data type

text

Family member name
Description

Name of family member.

Data type

text

Date of birth
Description

Full or partial date of birth of the family member.

Data type

datetime

Alias
UMLS CUI [1]
C2599455
Clinical history
Description

Detail about problems or diagnoses for the family member.

Data type

text

Problem/diagnosis name
Description

Identification of the significant problem or diagnosis in the identified family member.

Data type

text

Age at onset
Description

Estimated or actual age of the family member when the problem/diagnosis was clinically recognised.

Data type

text

Age at death
Description

Exact or estimated age of the family member at death.

Data type

text

Clinical description
Description

Narrative description or comments about clinical aspects of the family member's problem/diagnosis.

Data type

text

Cause of death?
Description

Relationship of the problem/diagnosis to the death of this family member.

Data type

text

Relationship
Description

The relationship of the family member to the subject of care.

Data type

text

Alias
Description

An alternative name or label to uniquely identify a family member, without using a personal name which might publicly identify the individual.

Data type

text

Biomarker description
Description

Description of risk-related biological markers identified in this family member.

Data type

text

Deceased?
Description

Is the family member deceased?

Data type

boolean

Alias
UMLS CUI [1]
C0011065
Biomarkers
Description

Detailed information about measurable indicators of a biological state or condition of the family member.

Data type

text

Tree
Description

@ internal @

Data type

text

Last Updated
Description

The date this family history summary was last updated.

Data type

datetime

Biomarker details
Description

Structured details about biological markers.

Data type

text

Per problem
Description

Details about the presence of a specific problem or diagnosis in family members.

Data type

text

Problem/diagnosis name
Description

Identification of the significant problem or diagnosis in the family overall.

Data type

text

Description
Description

Narrative description about occurrence of the problem or diagnosis in family members.

Data type

text

Extension
Description

Additional information required to capture local content or to align with other reference models/formalisms.

Data type

text

Comment
Description

Additional narrative about the family member not captured in other fields.

Data type

text

Family member details
Description

Structured detail about the identified family member.

Data type

text

Multimedia
Description

Multimedia representation of the family history.

Data type

text

Date of death
Description

Full or partial date of death of the family member.

Data type

datetime

Alias
UMLS CUI [1]
C1148348
Problem details
Description

Structured details about the identified problem or diagnosis.

Data type

text

Biological sex
Description

The family member's biological sex.

Data type

text

Alias
UMLS CUI [1]
C0079399

Similar models

openEHR-EHR-EVALUATION.family_history.v2

  1. StudyEvent: openEHR-EHR-EVALUATION.family_history.v2
    1. openEHR-EHR-EVALUATION.family_history.v2
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Family history
Item
Family history
text
C0241889 (UMLS CUI [1])
Tree
Item
Tree
text
Summary
Item
Summary
text
Per family member
Item
Per family member
text
Family member name
Item
Family member name
text
Date of birth
Item
Date of birth
datetime
C2599455 (UMLS CUI [1])
Clinical history
Item
Clinical history
text
Problem/diagnosis name
Item
Problem/diagnosis name
text
Age at onset
Item
Age at onset
text
Age at death
Item
Age at death
text
Clinical description
Item
Clinical description
text
Item
Cause of death?
text
Code List
Cause of death?
CL Item
Direct cause or closely related (1)
CL Item
Unrelated (2)
CL Item
Indeterminate (3)
Relationship
Item
Relationship
text
Alias
Item
Alias
text
Biomarker description
Item
Biomarker description
text
Deceased
Item
Deceased?
boolean
C0011065 (UMLS CUI [1])
Biomarkers
Item
Biomarkers
text
Tree
Item
Tree
text
Last Updated
Item
Last Updated
datetime
Biomarker details
Item
Biomarker details
text
Per problem
Item
Per problem
text
Problem/diagnosis name
Item
Problem/diagnosis name
text
Description
Item
Description
text
Extension
Item
Extension
text
Comment
Item
Comment
text
Family member details
Item
Family member details
text
Multimedia
Item
Multimedia
text
Date of death
Item
Date of death
datetime
C1148348 (UMLS CUI [1])
Problem details
Item
Problem details
text
Biological sex
Item
Biological sex
text
C0079399 (UMLS CUI [1])

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