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Symptom/Sign (EHR Archetype) - openEHR-EHR-CLUSTER.symptom_sign.v1

- 2017-07-08 - 1 Formulär, 1 Item-grupp, 32 Dataelement, 1 Språk

Item-grupp: openEHR-EHR-CLUSTER.symptom_sign.v1.xml

Derived from www.openehr.org . Use to record details about a single episode of a symptom or reported sign in an individual, as reported by the individual, parent, care-giver or other party. It may be recorded by a clinician as part of a clinical history record as reported to them, observed by the clinician or self-recorded as part of a clinical questionnaire or personal health record. A complete clinical history or patient story may include varying level of details about multiple episodes of an identified symptom or reported sign, as well as multiple symptoms/signs. In the purest sense, symptoms are subjective observations of a physical or mental disturbance and signs are objective observations of the same, as experienced by an individual and reported to the history taker by the same individual or another party. From this logic it follows that we will need two archetypes to record clinical history - one for reported symptoms and another for reported signs. In reality this is impractical as it will require clinical data entry into either one of these models which adds signficant overheads to modellers and those entering data. In addition, there is often overlap in clinical concepts - for example, is previous vomiting or bleeding to be categorised as a symptom or reported sign? In response, this archetype has been specifically designed to proved a single information model that allows for recording of the entire continuum between clearly identifable symptoms and reported signs when recording a clinical history. This archetype has been intended to be used as a generic pattern for all symptoms and reported signs. The 'Specific details' SLOT can be used to extend the archetype to include additional, specific data elements for more complex symptoms or signs. This archetype has been specifically designed to be used in the 'Structured detail' SLOT within the OBSERVATION.story archetype, but can also be used within other OBSERVATION or CLUSTER archetypes and in the 'Associated symptom/sign' or 'Previous episode' SLOT within other instances of this CLUSTER.symptom_sign archetype. Clinicians frequently record the phrase 'nil significant' against specific symptoms or reported signs as an efficient method to indicate that they asked the individual and it was not reported as causing any discomfort or disturbance - effectively used more like a 'normal statement' rather than an explicit exclusion. The 'Nil significant' data element has been deliberately included in this archetype to allow clinicians to record this same information in a simple and effective way in a clinical system. It can be used to drive a user interface, for example if 'Nil significant' is recorded as true then the remaining data elements can be hidden on a data entry screen. This pragmatic approach supports the majority of simple clinical recording requirements around reported symptoms and signs. However if there is a clinical imperative to explicitly record that a Symptom or Sign was reported as not present, for example if it will be used to drive clinical decision support, then it would be preferable to use the CLUSTER.exclusion_symptom_sign archetype. The use of CLUSTER.exclusion_symptom_sign will increase the complexity of template modelling, implementation and querying. It is recommended that the CLUSTER.exclusion_symptom_sign archetype only be considered for use if clear benefit can be identified in specific situations, but should not be used for routine symptom/sign recording.

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