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

To 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.

• 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