| ARCHETYPE ID | openEHR-EHR-EVALUATION.exclusion-procedure.v1 |
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| Concept | Exclusion of a Procedure |
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| Description | Positive statement/s about procedures that need to be recorded as clinically excluded from the health record at a specific point in time. |
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| Use | Use to record positive statement/s about the absence or exclusion of procedures performed within the health record at a specific point in time. For example: to record that the patient has not had any operations or significant procedures; or that the patient has not had an appendicectomy, if presenting with abdominal pain.
This archetype has specifically been designed to avoid the need to use flags or terminology to express negation about any procedures performed within the health record.
Exclusion statements can only be considered to be current and accurate at the time of recording. For example: exclusion of appendicectomy during a consultation or emergency room visit for abdominal pain is only relevant at the time of recording and is effectively obsolete if the subsequent diagnosis is appendicitis and an appendicectomy performed. |
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| Misuse | Not to be used to record exclusion statements about adverse reactions, medications, problems or diagnoses - use other specific specialisations of the EVALUATION.exclusion archetype for these purposes. |
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| Purpose | To positively record statement/s about procedures that need to be clinically excluded from the health record at a specific point in time. |
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| References | Exclusion of a Procedure, draft archetype, NEHTA Clinical Knowledge Manager [Internet]. NEHTA. Authored: 02 Mar 2010. Available at:
http://dcm.nehta.org.au/ckm/#showArchetype_1013.1.1312_2 (accessed 3 Sept 2013) |
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| Copyright | © openEHR Foundation |
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| Authors | Author name: Heather Leslie
Organisation: Ocean Informatics
Email: heather.leslie@oceaninformatics.com
Date originally authored: 2010-03-02
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| Other Details Language | Author name: Heather Leslie
Organisation: Ocean Informatics
Email: heather.leslie@oceaninformatics.com
Date originally authored: 2010-03-02
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| Other Details (Language Independent) | - References: Exclusion of a Procedure, draft archetype, NEHTA Clinical Knowledge Manager [Internet]. NEHTA. Authored: 02 Mar 2010. Available at:
http://dcm.nehta.org.au/ckm/#showArchetype_1013.1.1312_2 (accessed 3 Sept 2013)
- Current Contact: Heather Leslie, Ocean Informatics, heather.leslie@oceaninformatics.com
- MD5-CAM-1.0.1: EC8697A3EB07A9B28FD861E7E4037215
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| Keywords | exclusion, procedure, intervention, operation, surgery |
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| Lifecycle | AuthorDraft |
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| Language used | en |
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| Citeable Identifier | 1013.1.1039 |
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| protocol | |
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| Date Last Updated | Date Last Updated: The date at which the exclusion was last clinically asserted, affirmed or confirmed. |
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| data | |
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| Exclusion Statement | Exclusion Statement: A statement about exclusion of procedures performed in the health record.
For example: "No known operations or significant procedures" or "No previous" (appendicectomy). |
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| Procedure | Procedure: Identification of the procedures to which the Exclusion Statement applies.
Coding of the Procedure with a terminology is desirable, where possible.
Choice of:
 Coded Text
Constraint:
Procedures
[All procedures that can be performed.]
 Text
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| Comment | Comment: Additional narrative about the Exclusion not captured in other fields. |
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| Other contributors | Sam Heard, Ocean Informatics, Australia
Ian McNicoll, Ocean Informatics, Australia
Stephen Chu, NEHTA, Australia
Stephen Royce, NEHTA, Australia |
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| Translators | |
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