openEHR-EHR-EVALUATION.problem_diagnosis.v1.xml
Details about a single identified health condition, injury, disability or any other issue which impacts on the physical, mental and/or social well-being of an individual.
text
@ internal @
Identification of the problem or diagnosis, by name.
Estimated or actual date/time the diagnosis or problem was recognised by a healthcare professional.
datetime
An assessment of the overall severity of the problem or diagnosis.
Narrative description about the problem or diagnosis.
Identification of a simple body site for the location of the problem or diagnosis.
Estimated or actual date/time of resolution or remission for this problem or diagnosis, as determined by a healthcare professional.
A structured anatomical location for the problem or diagnosis.
Details that are additionally required to record as unique attributes of this problem or diagnosis.
Structured details for location-, domain-, episode- or workflow-specific aspects of the diagnostic process.
Additional narrative about the problem or diagnosis not captured in other fields.
The date this problem or diagnosis was last updated.
Additional information required to capture local content or to align with other reference models/formalisms.
Narrative description about the course of the problem or diagnosis since onset.
The level of confidence in the identification of the diagnosis.
Estimated or actual date/time that signs or symptoms of the problem/diagnosis were first observed.