ARCHETYPE Reason for Encounter (openEHR-EHR-EVALUATION.reason_for_encounter.v2)

ARCHETYPE IDopenEHR-EHR-EVALUATION.reason_for_encounter.v2
ConceptReason for Encounter
DescriptionRecord the administrative and/or clinical reason/s for initiation of a healthcare encounter or contact.
UseTo record the reason/s for initiation of any type of healthcare contact between a healthcare provider and a patient, Reason for Encounter is a common phrase used in clinical medicine, however the term is often used in two common ways - one that refers to an administrative category for provision of healthcare and the other that reflects the clinical drive to seek healthcare. In an effort to clarify the phrases and intent, this archetype contains two data elements: - The first, 'Reason for Contact', to document the administrative type of healthcare sought or required - for example the type of consultation, emergency care, pre-operative assessment, routine antenatal visit or elective admission. This data element reflects the administrative category of care provision. Use of the phrase 'Reason for Contact', rather than 'Reason for Encounter' or 'Reason for Visit' reflects the increasing trend towards alternative methods of healthcare provision that may not result in face-to-face contact between the healthcare provider and patient within a consulting room. - The second, 'Presenting Problem', to document the clinical reasons for healthcare contact. These are intended mainly to capture the patient's perceived issues or symptoms which have triggered them to seek healthcare advice, such as desire to quit smoking, stress, shortness of breath or abdominal pain. Signs such as impaired conscious state may also be captured here, for example by paramedical staff with an unconscious patient. Chief Complaint is another phrase in common usage. In effect it is probably a type of Presenting Problem but has not currently been modelled explicitly. As Presenting Problem has occurrences set to unbounded, multiple Presenting Problems can be recorded. Feedback will be sought regarding the need for this to be modelled in it's own right.
MisuseNot to be used to record specific details of the patient's story or history of symptoms. Use OBSERVATION.story to capture the narrative and the related nested CLUSTER archetypes for structured content eg CLUSTER.symptom, CLUSTER.event and CLUSTER.issue. Not to be used to record specific diagnosis details that may be required in addition to a Reason for Encounter eg Admission or Pre-operative Diagnosis as part of admission for a hospital procedure. Use the EVALUATION.problem_diagnosis (and related specialisations) for this purpose.
PurposeTo record the reason/s for initiation of any type of healthcare contact between a healthcare provider and a patient.
ReferencesopenEHR Foundation. openEHR wiki: Reason for Encountrer or Chief Complaint [Internet]. 2008 Feb 13 [cited June 17 2012]; Available at http://www.openehr.org/wiki/display/healthmod/Reason+for+encounter+or+Chief+complaint.
Copyright© openEHR Foundation
AuthorsAuthor name: Heather Leslie
Organisation: Ocean Informatics
Email: heather.leslie@oceaninformatics.com
Date originally authored: 2007-04-19
Other Details LanguageAuthor name: Heather Leslie
Organisation: Ocean Informatics
Email: heather.leslie@oceaninformatics.com
Date originally authored: 2007-04-19
OtherDetails Language Independent{licence=This work is licensed under the Creative Commons Attribution-ShareAlike 3.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/3.0/., custodian_organisation=Ocean Informatics, references=openEHR Foundation. openEHR wiki: Reason for Encountrer or Chief Complaint [Internet]. 2008 Feb 13 [cited June 17 2012]; Available at http://www.openehr.org/wiki/display/healthmod/Reason+for+encounter+or+Chief+complaint., original_namespace=com.oceaninformatics, original_publisher=Ocean Informatics, custodian_namespace=com.oceaninformatics, MD5-CAM-1.0.1=570592F73B222FAF6D060E3558BBE984, build_uid=9c40e26f-c055-4ec2-a6b6-2debf88ea093, revision=2.0.0}
Keywordspresentation, presenting complaint, reason for encounter, reason, chief complaint, visit, reason for visit
Lifecyclepublished
UID3c33042c-3376-4f17-b28c-6152ab6279da
Language useden
Citeable Identifier1013.1.1678
Revision Number2.0.0
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Record the administrative and/or clinical reason/s for initiation of a healthcare encounter or contact., archetypeConceptComment=null, otherContributors=Ian McNicoll, Ocean Informatics, Australia
Sergio Carmona, Chile
Sebastian Garde, Ocean Informatics, Germany
Beatriz de Faria Leão, Brazil
Omer Hotomaroglu, Turkey
Sundaresan Jagannathan, Scottish NHS, United Kingdom, 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=Reason for Contact, description=Identification of administrative reason for seeking healthcare., comment=For example, a clinical consultation, emergency consultation, pre-employment medical, routine antenatal visit, women's health check, pre-operative assessment, or annual medical check-up. Coding of the Reason for Encounter with a terminology is desirable, where possible., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0004], code=at0004, itemType=ELEMENT, level=2, text=Presenting Problem, description=Identification of the clinical reason for seeking healthcare., comment=Clinical reasons for seeking healthcare can include health issues, symptoms or physical signs. Examples: health issues - desire to quit smoking or to lose weight; symptoms - abdominal pain or shortness of breath; physical signs - an altered conscious state. May also be referred to as Presenting Complaint. Coding of the Presentic Problem with a terminology is desirable, where possible., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, 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=Reason for Contact, description=Identification of administrative reason for seeking healthcare., comment=For example, a clinical consultation, emergency consultation, pre-employment medical, routine antenatal visit, women's health check, pre-operative assessment, or annual medical check-up. Coding of the Reason for Encounter with a terminology is desirable, where possible., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0004], code=at0004, itemType=ELEMENT, level=2, text=Presenting Problem, description=Identification of the clinical reason for seeking healthcare., comment=Clinical reasons for seeking healthcare can include health issues, symptoms or physical signs. Examples: health issues - desire to quit smoking or to lose weight; symptoms - abdominal pain or shortness of breath; physical signs - an altered conscious state. May also be referred to as Presenting Complaint. Coding of the Presentic Problem with a terminology is desirable, where possible., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null]], minIndents={}, termBindingRetrievalErrorMessage=null]