openEHR-EHR-CLUSTER.problem_status.v0

ID

29616

Descrizione

http://openehr.org/ckm/ Use to record one or more relevant context-specific or time-specific qualifiers that provide additional detail which are relevant at the time of recording a problem or diagnosis, or within the clinical context where it is recorded, but which may not be appropriate at another time or in another clinical context. This archetype is designed to be included in Status SLOT in the EVALUATION.problem_diagnosis archetype. These status qualifiers should be used with care as they are variably applied in practice and interoperability cannot be assured unless usage guidelines are clearly defined within the clinical community in which the 'Problem/Diagnosis' and 'Problem status' archetype pair may be shared. Full DRG coding will require the DRG data elements from this archetype and the equivalent CLUSTER.procedure_status archetype used within the ACTION.procedure archetype, plus attributes about the patient. The 'Unspecified' data element has been added to support addition of other qualifiers that might only be used locally or where the use case has not been clearly established at the time of this archetype being published. As other qualifiers are identified they can be added to this archetype as a backwardly compatible revision.

collegamento

http://openehr.org/ckm/

Keywords

EHR

Medical Records, Problem-Oriented

Routine documentation

10/04/18 10/04/18 - Halim Ugurlu

Titolare del copyright

openEHR Foundation

Caricato su

10 aprile 2018

DOI

Per favore, per richiedere un accesso.

Licenza

Creative Commons BY-NC 3.0

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