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- 2017-07-10 - 1 Formulär, 1 Item-grupp, 53 Dataelement, 3 Språk
Item-grupp: openEHR-EHR-INSTRUCTION.medication_order.v1.xml
Derived from www.openehr.org . Use to record all aspects of an order of a medication, vaccine, nutritional product or other therapeutic item for an identified individual. It is intended to be used for any type of medication and related order, whether prescribed by a health professional or available for purchase 'over the counter'. The scope of this medication archetype also includes orders for vaccinations, parenteral fluids or other therapeutic goods, such as bandages, nutritional products or other items that are applied or administered to have a therapeutic effect and which have a common pattern for data recording. This archetype is designed to be used in a number of clinical contexts, including but not limited to: - a record in a clinical consultation (COMPOSITION.encounter); - a written prescription by a physician, dentist, nurse practitioner, or other designated health professional for a medication or nutritional product to be dispensed and administered (within a COMPOSITION.prescription); - an item in a current medication list, prescription or drug chart (within COMPOSITION.medication_list); and - an item in a summary document such as transfer of care (COMPOSITION.transfer_summary) or a referral (COMPOSITION.request). In many cases a medication order will be simple – typically for a single medication item with uncomplicated instructions for dispensing and administration. However this archetype is also designed to allow for more complex therapeutic orders. For example: - a reducing dose of prednisolone over a period of weeks; - titration of insulin, with dosing dependent on test results; - multiple medications prescribed simultaneously as part of a single drug regimen, such as a triple therapy for peptic ulcer; and - intravenous administration of medications or nutrition supplements, including parenteral nutrition. The archetype has therefore been designed to allow for a range of complexity, from: - simple narrative instructions for orders like 'furosemide 40mg two tablets in the morning and one at lunch' to ensure compatibility with existing systems; and - the amount of medication is usually represented in terms of a number and corresponding dose unit, however there can alternatively be a narrative statement to ensure compatibility with existing systems and coverage of all clinical scenarios; through to - structured detail for dose, route and timing to represent a fully computable specification. It has also been designed so that a single medication order structure can represent: - complex sequential medication orders using the same preparation strength to be supported within a single order structure; and - multiple medication orders can be chained in circumstances where different medications or preparations need to be given sequentially. This archetype is also suitable for ordering parenteral fluids, in care settings where it is normal practice to make these 'prescribable' items. In other settings a separate 'parenteral fluid order' may be appropriate. SLOTs containing CLUSTER archetypes have been used to represent some of the content for three reasons: - To ensure a core archetype that can be used for all the above use cases, yet allow flexibility where it is required, for example the ‘Preparation details’ SLOT where additional structured detail can be added. A candidate archetype has been suggested for Medications. It is possible that other CLUSTER archetypes may be required in future for other purposes such as complex parenteral nutrition orders; - to support archetype re-use in situations where the content has been identified as being also used in other clinical contexts, in particular the paired ACTION.medication archetype for recording actual dispensing, administration etc; and - to remove less commonly used content from the core archetype framework. Multiple orders can be represented as separate activities within this single archetype instance to carry tightly bound orders of different medications, for example, H. pylori therapy when this is not prescribed as a single pack. It should be noted that these uses subsume both the FHIR Medication Order and Medication Statement use cases. i.e this archetype is a match for both FHIR resources, used in the appropriate context.
- 2017-07-10 - 1 Formulär, 1 Item-grupp, 16 Dataelement, 2 Språk
Item-grupp: openEHR-EHR-OBSERVATION.paced_auditory_serial_addition_test.v1.xml
- 2017-07-09 - 1 Formulär, 1 Item-grupp, 5 Dataelement, 9 Språk
Item-grupp: openEHR-EHR-OBSERVATION.height.v1.xml
Derived from www.openehr.org . To be used for recording the actual height or body length of an individual at any point in time. A statement identifying the physical incompleteness of the body can be recorded in the 'Confounding factors' protocol element, if required. This is the usual archetype to be used for a typical measurement of height or body length, independent of the clinical setting. Can also be used for recording an approximation of height or body length measurement in a clinical scenario where it is not possible to measure an accurate height or length - for example, measuring an uncooperative child. This is not modelled explicitly in the archetype as the openEHR Reference model allows the attribute of Approximation for any Quantity data type. At implementation, for example, an application user interface could allow clinicians to select an appropriately labelled check box adjacent to the Height data field to indicate that the recorded height is an approximation, rather than actual. In general, length measurements are recommended for children under 2 years of age and individuals who cannot stand; height measurements for all others. Ideally, height is measured standing on both feet with weight distributed evenly, heels together and both buttocks and heels in contact with a vertical back board; body length is measured in a fully extended, supine position with the pelvis flat, legs extended and feet flexed. Use to record growth and loss of height. This can currently be modelled by constraining the 'any event' to an interval in a template with associated mathematical function of increase or decrease, as appropriate.
- 2017-07-09 - 1 Formulär, 1 Item-grupp, 6 Dataelement, 10 Språk
Item-grupp: openEHR-EHR-OBSERVATION.body_weight.v1.xml
Derived from www.openehr.org . To be used for recording the actual measurement of body weight, including when the individual is missing a body part due to a congenital cause or after surgical removal. A statement identifying the physical incompleteness of the body can be recorded in the 'Confounding factors' data element, if required. This is the usual archetype to be used for a typical measurement of weight, for example self-measured by the individual at home, a clinician measurement in a clinic/hospital, or a fitness instructor in a gymnasium. Can also be used for recording an approximation of body weight measurement in a clinical scenario where it is not possible to measure accurately body weight - for example, weighing an uncooperative child, or estimating the weight of an unborn fetus (where the 'subject of data' is the Fetus and recording occurs within the mother's health record). This is not modelled explicitly in the archetype as the openEHR Reference model allows the attribute of Approximation for any Quantity data type. At implementation, for example, an application user interface could allow clinicians to select an appropriately labelled check box adjacent to the Weight data field to indicate that the recorded weight is an approximation, rather than actual. To be used for recording weight change, that is, either weight loss or weight gain. This can currently be modelled by constraining the 'any event' to an interval with associated mathematical function of increase or decrease, as appropriate.
- 2017-07-08 - 1 Formulär, 1 Item-grupp, 36 Dataelement, 2 Språk
Item-grupp: openEHR-EHR-EVALUATION.tobacco_smoking_summary.v1.xml
Use to record summary information about the individual's pattern of smoking of tobacco and tobacco-containing products. This archetype is to be used to record information about both current and previous smoking behaviour. The specific scope of this archetype is on documentation about the use of all types of inhaled tobacco smoke because of the associated health risks from direct inhalation of tobacco and associated chemicals. Amount of nicotine and tar, use of filters and additives has been left outside of scope for the core archetype, but could be added into the Episode SLOT if required. Please note that the scope of this archetype does not include unintentional exposure to tobacco smoke (see Misuse). The 'Per type' cluster of data elements allows for recording of specific details and episodes about each type of tobacco smoked and can be repeated once per type. The list of tobacco types listed in the 'Per type' run-time name constraint identifies the type of tobacco. This name constraint can be applied during template modelling or at run-time within a software application. In many situations the individual will only smoke one type of tobacco, such as manufactured cigarettes. If other types of tobacco are smoked, the details will be recorded in another instance of the 'Per type' cluster. The history of waxing and waning of use for each type of tobacco over time can be captured using the repeatable 'Per episode' cluster. This cluster of data elements allows for a very detailed pattern of smoking behaviour to be recorded for each type of tobacco smoked such as daily 'roll-your-own' cigarette smoking, alongside weekly cigar smoking every Friday night and occasional Bidi smoking while on holiday in Bali. Triggers for closing one episode and commencing a new one will largely reflect local data collection preferences, including if the individual: - quits for a significant period of time (which will likely be locally defined); or - significantly changes their amount of use or pattern of their smoking. If only one type of tobacco is smoked, the value for 'Pack years' will be identical to the 'Overall pack years' data element. If more than one type of tobacco is smoked, the calculation for the value for 'Overall pack years' will require a more complex algorithm such as http://smokingpackyears.com/. Use to incorporate the narrative descriptions of tobacco smoking habits within existing or legacy clinical systems into an archetyped format, using the 'Overall description' data element.