ID

29616

Descripción

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.

Link

http://openehr.org/ckm/

Palabras clave

Versiones (1)
  1. 10/4/18 10/4/18 - Halim Ugurlu
Titular de derechos de autor

openEHR Foundation

Subido en

10 de abril de 2018

DOI

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Licencia

Creative Commons BY-NC 3.0
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openEHR-EHR-CLUSTER.problem_status.v0

Inglés Portugués ( localization.languageCode.BR ) Esloveno

openEHR-EHR-CLUSTER.problem_status.v0

1 formularios  
  1. StudyEvent: openEHR-EHR-CLUSTER.problem_status.v0
    1. openEHR-EHR-CLUSTER.problem_status.v0
openEHR-EHR-CLUSTER.problem_status.v0.xml
Descripción

openEHR-EHR-CLUSTER.problem_status.v0.xml

Alias
UMLS CUI-1
C2735058
UMLS CUI-2
C0449438
Problem/Diagnosis status
Descripción

Qualifiers for a specified problem or diagnosis.

Tipo de datos

text

Alias
UMLS CUI [1,1]
C2735058
UMLS CUI [1,2]
C0449438
UMLS CUI [1,3]
C0011900
Episodicity
Descripción

Category new, recurring and ongoing issues, problems or diagnoses.

Tipo de datos

text

Alias
UMLS CUI [1]
C0566252
Active/Inactive?
Descripción

Category that supports division of problems and diagnoses into Active or Inactive problem lists.

Tipo de datos

text

Alias
UMLS CUI [1]
C0205177
UMLS CUI [2]
C1273827
Diagnostic status
Descripción

Stage or phase of diagnostic process.

Tipo de datos

text

Alias
UMLS CUI [1,1]
C0449438
UMLS CUI [1,2]
C0011900
Current/Past?
Descripción

Category that supports division of problems and diagnoses into Current or Past problem lists.

Tipo de datos

text

Alias
UMLS CUI [1]
C1444635
DRG category
Descripción

In episodic care contexts (commonly secondary care) it is common to categorise/ organise problems according to their relationship to the principal problem or diagnosis being addressed during that episode of care. These categories may also be used for clinical coding, reporting and billing purposes.

Tipo de datos

text

Alias
UMLS CUI [1]
C0011928
First occurrence?
Descripción

Is this the first ever occurrence of this problem or diagnosis?

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C2745955
UMLS CUI [1,2]
C0012634
UMLS CUI [1,3]
C0205435
Present on admission?
Descripción

Was the problem or diagnosis present at admission?

Tipo de datos

boolean

Alias
UMLS CUI [1,1]
C0011900
UMLS CUI [1,2]
C0150312
UMLS CUI [1,3]
C1302393
Course
Descripción

The pattern or evolution of the problem or diagnosis.

Tipo de datos

text

Alias
UMLS CUI [1]
C0449259
Unspecified
Descripción

Unspecified qualifier that will be renamed, data type selected and potential value sets specified in a template.

Tipo de datos

text

Alias
UMLS CUI [1]
C0205370
Resolution status
Descripción

Status of resolution or healing of an acute problem or diagnosis.

Tipo de datos

text

Alias
UMLS CUI [1]
C0449438
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Similar models

openEHR-EHR-CLUSTER.problem_status.v0

1 formularios
  1. StudyEvent: openEHR-EHR-CLUSTER.problem_status.v0
    1. openEHR-EHR-CLUSTER.problem_status.v0
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
Alias
Item Group
openEHR-EHR-CLUSTER.problem_status.v0.xml
C2735058 (UMLS CUI-1)
C0449438 (UMLS CUI-2)
Problem/Diagnosis status
Item
Problem/Diagnosis status
text
C2735058 (UMLS CUI [1,1])
C0449438 (UMLS CUI [1,2])
C0011900 (UMLS CUI [1,3])
Item
Episodicity
text
C0566252 (UMLS CUI [1])
Episodicity
Code List
Episodicity
CL Item
New episode (1)
CL Item
Ongoing episode (2)
CL Item
Indeterminate (3)
Item
Active/Inactive?
text
C0205177 (UMLS CUI [1])
C1273827 (UMLS CUI [2])
Active/Inactive?
Code List
Active/Inactive?
CL Item
Active (1)
CL Item
Inactive (2)
Item
Diagnostic status
text
C0449438 (UMLS CUI [1,1])
C0011900 (UMLS CUI [1,2])
Diagnostic status
Code List
Diagnostic status
CL Item
Preliminary (1)
CL Item
Working (2)
CL Item
Established (3)
CL Item
Refuted (4)
Item
Current/Past?
text
C1444635 (UMLS CUI [1])
Current/Past?
Code List
Current/Past?
CL Item
Current (1)
CL Item
Past (2)
Item
DRG category
text
C0011928 (UMLS CUI [1])
DRG category
Code List
DRG category
CL Item
Principal diagnosis (1)
CL Item
Secondary diagnosis (2)
CL Item
Complication (3)
First occurrence?
Item
First occurrence?
boolean
C2745955 (UMLS CUI [1,1])
C0012634 (UMLS CUI [1,2])
C0205435 (UMLS CUI [1,3])
Present on admission?
Item
Present on admission?
boolean
C0011900 (UMLS CUI [1,1])
C0150312 (UMLS CUI [1,2])
C1302393 (UMLS CUI [1,3])
Item
Course
text
C0449259 (UMLS CUI [1])
Course
Code List
Course
CL Item
Acute (1)
CL Item
Relapsing (2)
CL Item
Chronic (3)
Unspecified
Item
Unspecified
text
C0205370 (UMLS CUI [1])
Item
Resolution status
text
C0449438 (UMLS CUI [1])
Resolution status
Code List
Resolution status
CL Item
Resolved (1)
CL Item
Resolving (2)
CL Item
Not resolving (3)
CL Item
Indeterminate (4)
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