ARCHETYPE Clinical Synopsis (openEHR-EHR-EVALUATION.clinical_synopsis.v4)

ARCHETYPE IDopenEHR-EHR-EVALUATION.clinical_synopsis.v4
ConceptClinical Synopsis
DescriptionThe clinical synopsis contains summary information or comments about the clinical management of the patient, and the prognosis of diagnoses/ problems identified during the healthcare encounter. It may also include health-related information pertinent to the patient, and a clinical interpretation of relevant investigations and observations performed on the patient (including pathology and diagnostic imaging).
UseWhen used by a health care provider, clinical synopsis is used to describe additional information including clinical interpretation of the condition/tests and subject of care understanding of the health care event, and other relevant clinical details not captured by other structured or unstructured information components pertinent of that health care event. When used by the subject of care or a nominated representative (including carer), it is used to provide information such as descriptions of health events, summaries of health issues and assessments of health problems as perceived by the subject of care and/or a nominated representative.
MisuseUsing when more specialised data components are available.
PurposeA clinician-entered clinical synopsis contains summary information or comments about the clinical management of the subject of care, and the prognosis of problems/diagnoses identified during the healthcare encounter. It may also include health-related information pertinent to the subject of care, and a clinical interpretation of relevant investigations and observations performed on the subject of care (including pathology and diagnostic imaging). A subject of care-entered or carer-entered clinical synopsis contains information such as reporting on one or more health events, summaries of health issues and assessments of health problems. Health events include blood pressure measurements, descriptions of instances of adverse reactions to food and reflections on mood.
References
Copyright© openEHR Foundation
AuthorsAuthor name:
Organisation: National E-Health Transition Authority
Email: clinicalinfo@nehta.gov.au
Date originally authored: 24-Dec-2008
Other Details LanguageAuthor name:
Organisation: National E-Health Transition Authority
Email: clinicalinfo@nehta.gov.au
Date originally authored: 24-Dec-2008
OtherDetails Language Independent{MD5-CAM-1.0.1=189F15AAB10956236B0294644DC3D184}
KeywordsClinical Comment, Clinical Note, Clinical Summary, Clinical Management Summary
LifecycleApprovedCandidate
Language useden
Citeable Identifier1013.1.1554
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Stephen Chu, NEHTA
Eleanor Royle, NEHTA
Robert L'egan, NEHTA
Don Stewart, NEHTA
Ning Pan, NEHTA
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