ARCHETYPE Absence of Information (NEHTA) (openEHR-EHR-EVALUATION.absence_nehta.v1)

ARCHETYPE IDopenEHR-EHR-EVALUATION.absence_nehta.v1
ConceptAbsence of Information (NEHTA)
DescriptionStatement that there is no relevant information available, neither a positive presence nor a positive exclusion.
UseUse to record an explicit statement that there is no information available in the health record. This does not indicate why there is no information, only that there is neither a positive presence of related information nor a positive statement about known exclusion of information. Absence statements can only be considered to be current and accurate at the time of recording. This archetype has been designed specifically to avoid the need to use of flags to express negation about any item within the health record. Examples of use include: 'No known information about adverse reactions' within a curated, persistent Adverse Reaction List; or 'No known information about significant problems or diagnoses'/'No known information about past procedures or operations' within a curated, persistent, Problem List. The use of null flavours in this situation is not appropriate. This archetype is not usually required in stand-alone clinical systems, where the clinical system can determine when there is no archetyped data recording the positive presence or the positive absence - in this situation the system can simply generate a notification such as 'No known information about xyz'. However in a situation where health information is being exchanged, it becomes important to explicitly represent that there is no information available to the receiving system. So, in a persistent list within a clinical system and if there is no information available - for example if the subject refuses to answer or is unconscious - use this EVALUATION.absent_information to explicitly record the health information that is missing or absent. If it is clinically determined that there is a positive absence of information - for example if the subject has never had an adverse reaction or significant diagnosis - then use the EVALUATION.exclusion family of archetypes. And finally, if it is clinically determined that there is known clinical information that needs to be recorded - then use the appropriate archetypes ie EVALUATION.adverse_reaction or EVALUATION.problem_diagnosis.
MisuseNot to be used to record the exclusion of adverse reactions, medication use, procedures, problems or diagnoses - use specific specialisations of the EVALUATION.exclusion archetype for this purpose.
PurposeTo record an explicit statement that there is no information available in the health record - neither a positive presence or positive exclusion of information.
ReferencesAbsence of Information, draft archetype, openEHR Clinical Knowledge Manager [Internet]. London: openEHR Foundation. Authored: 12 Mar 2013. Available at: http://www.openehr.org/ckm/#showArchetype_1013.1.1427_1 (accessed 14 Mar 2013).
Copyright© openEHR Foundation
AuthorsAuthor name: Heather Leslie
Organisation: Ocean Informatics
Email: heather.leslie@oceaninformatics.com
Date originally authored: 2013-03-12
Other Details LanguageAuthor name: Heather Leslie
Organisation: Ocean Informatics
Email: heather.leslie@oceaninformatics.com
Date originally authored: 2013-03-12
OtherDetails Language Independent{references=Absence of Information, draft archetype, openEHR Clinical Knowledge Manager [Internet]. London: openEHR Foundation. Authored: 12 Mar 2013. Available at: http://www.openehr.org/ckm/#showArchetype_1013.1.1427_1 (accessed 14 Mar 2013)., current_contact=Heather Leslie, Ocean Informatics, heather.leslie@oceaninformatics.com, MD5-CAM-1.0.1=2DB9C32B9F12D4143EB4E279BA6BBEE4}
Keywordsabsence, missing, unknown, absent, information, adverse, reaction, problem, diagnosis, medication, procedure, vaccination, family history
LifecycleCommitteeDraft
Language useden
Citeable Identifier1013.1.1546
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Statement that there is no relevant information available, neither a positive presence nor a positive exclusion., archetypeConceptComment=null, otherContributors=, originalLanguage=en, translators=, subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={identities=[], activities=[], credentials=[], state=[], capabilities=[], items=[], events=[], provider=[], content=[], target=[], contacts=[], protocol=[], other_participations=[], relationships=[], ism_transition=[], description=[], source=[], data=[ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=2, text=Absence Statement, description=Statement explicitly expressing the absence of available information., comment=Coding with a terminology is desirable, where possible. For example: "No information available about adverse reactions"; No information available about problems or diagnoses"; "No information available about previous procedures performed"; or "No information available about medications used"., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null]], context=[], details=[]}, topLevelItems={data=ResourceSimplifiedHierarchyItem [path=ROOT_/data[at0001], code=at0001, itemType=ITEM_TREE, level=0, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=1..1, cardinalityText=mandatory, subCardinalityFormal=0..*, subCardinalityText=Minimum of 0 items, dataType=ITEM_TREE, bindings=null, values=null, extendedValues=null]}, addHierarchyItemsTo=data, currentHierarchyItemsForAdding=[ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=2, text=Absence Statement, description=Statement explicitly expressing the absence of available information., comment=Coding with a terminology is desirable, where possible. For example: "No information available about adverse reactions"; No information available about problems or diagnoses"; "No information available about previous procedures performed"; or "No information available about medications used"., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null]], minIndents={}, termBindingRetrievalErrorMessage=null]