ARCHETYPE Diagnosis (openEHR-EHR-EVALUATION.problem-diagnosis.v1)

ARCHETYPE IDopenEHR-EHR-EVALUATION.problem-diagnosis.v1
ConceptDiagnosis
DescriptionA diagnosis defined by a clinician which is coded in an accepted terminology and may include the stage of the condition and the diagnostic criteria
UseUsed for recording any diagnosis, present or past - so is used for recording past history as well as current diagnoses. Used with changed 'Subject of care' for recording diagnoses in relatives and so for family history.
MisuseUse 'openEHR-EHR-EVALUATION.problem-diagnosis-histological' for histological diagnoses.
PurposeFor recording medical diagnoses with optional diagnostic criteria and staging. Requires coded entry of diagnosis.
References
Copyrightcopyright (c) 2010 openEHR Foundation
AuthorsAuthor name: Sam Heard
Organisation: Ocean Informatics
Email: sam.heard@oceaninformatics.com
Date originally authored: 23/04/2006
Other Details LanguageAuthor name: Sam Heard
Organisation: Ocean Informatics
Email: sam.heard@oceaninformatics.com
Date originally authored: 23/04/2006
OtherDetails Language Independent{references=, MD5-CAM-1.0.1=25DE4AB34DEAEC07427F236A035F33B2}
Keywordspast, history, family, history, condition
LifecycleAuthorDraft
Language useden
Citeable Identifier1013.1.168
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=A diagnosis defined by a clinician which is coded in an accepted terminology and may include the stage of the condition and the diagnostic criteria, archetypeConceptComment=null, otherContributors=, originalLanguage=en, translators=German: Jasmin Buck, Sebastian Garde, University of Heidelberg, Central Queensland University
Portuguese (Brazil): Marco Borges, P2D, marco.borges@p2d.com.br, P2D Health Advisor Council
, subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={identities=[], activities=[], credentials=[], state=[], capabilities=[], items=[], events=[], provider=[], content=[], target=[], contacts=[], protocol=[ResourceSimplifiedHierarchyItem [path=/protocol[at0032]/items[at0033], code=at0033, itemType=CLUSTER, level=2, text=References, description=Useful information about this condition, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0032]/items[at0033]/items[at0034], code=at0034, itemType=ELEMENT, level=3, text=References, description=Reference to material about this condition, comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0032]/items[at0033]/items[at0035], code=at0035, itemType=ELEMENT, level=3, text=Web link, description=Useful information on the internet about this condition, comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_URI, bindings=null, values=, extendedValues=null]], other_participations=[], relationships=[], ism_transition=[], description=[], source=[], data=[ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0002.1], code=at0002.1, itemType=ELEMENT, level=2, text=Diagnosis, description=The index diagnosis, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Constraint:
Any term that 'is_a' diagnosis
Any term that is a diagnosis in an accepted terminology
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0.32], code=at0.32, itemType=ELEMENT, level=2, text=Status, description=The status of the diagnosis, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • provisional [provisional diagnosis considered likely and a basis for proceeding with management]
  • working [working diagnosis considered very likely but not yet confirmed]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0003], code=at0003, itemType=ELEMENT, level=2, text=Date of initial onset, description=The date that the problem began causing symptoms or signs, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0004], code=at0004, itemType=ELEMENT, level=2, text=Age at initial onset, description=The age of the at the onset of the problem, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DURATION, bindings=null, values=Allowed values: years, months, weeks, days, hours

, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0005], code=at0005, itemType=ELEMENT, level=2, text=Severity, description=The severity of the index problem, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=1: Mild [The severity of the index problem is mild, not affecting life or longevity]
4: Moderate [The severity of the index problem is such as to cause significant morbidity]
7: Severe [The severity of the index problem has had a major effect on life and/or longevity]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0009], code=at0009, itemType=ELEMENT, level=2, text=Clinical description, description=Description of the clinical aspects of the problem, comment=null, 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[at0010], code=at0010, itemType=ELEMENT, level=2, text=Date clinically recognised, description=Date the problem was recognised by clinicians, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE, bindings=null, values=Partial Date, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0037], code=at0037, itemType=ELEMENT, level=2, text=Age when clinically recognised, description=The age when this problem was clinically recognised, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DURATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0011], code=at0011, itemType=CLUSTER, level=2, text=Location, description=Location of the problem in terms of body site, comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=1..2, cardinalityText=Maximum of 2 items, ordered, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0011]/items[at0012], code=at0012, itemType=ELEMENT, level=3, text=Body site, description=The body site affected, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Constraint:
Any term that describes a body site
An anatomical structure with qualifiers
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0011]/items[at0013], code=at0013, itemType=ELEMENT, level=3, text=Location description, description=A free text description of the location - may be in addition to a coded body site, comment=null, 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[at0014], code=at0014, itemType=CLUSTER, level=2, text=Aetiology, description=Agents or Factors known to have been of aetiological significance, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0014]/items[at0015], code=at0015, itemType=ELEMENT, level=3, text=Agent, description=Microbial or other agent known to have caused this problem, comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0014]/items[at0016], code=at0016, itemType=ELEMENT, level=3, text=Complication of, description=A problem or link to a problem or injury described elsewhere in the EHR, comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
  •  Text
  •  URI
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0014]/items[at0017], code=at0017, itemType=ELEMENT, level=3, text=Description, description=Description of aetiological process, comment=null, 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[at0018], code=at0018, itemType=CLUSTER, level=2, text=Occurrences or exacerbations, description=Grouping of information about individual occurrences or exacerbations, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=1..*, cardinalityText=ordered, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0018]/items[at0019], code=at0019, itemType=ELEMENT, level=3, text=Frequency of reccurrence, description=The frequency of individual occurrences of the problem, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_QUANTITY, bindings=null, values=Property: Frequency
Units:
  • /h
  • /d
  • /mo
  • /wk
  • /yr
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0018]/items[at0020], code=at0020, itemType=ELEMENT, level=3, text=Date of last occurrence, description=The date of the last occurrence or exacerbation, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0018]/items[at0021], code=at0021, itemType=CLUSTER, level=3, text=Occurence/exacerbation, description=Information about one occurrence or exacerbation, comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0018]/items[at0021]/items[at0022], code=at0022, itemType=ELEMENT, level=4, text=Clinical description, description=A description of the exacerbation or occurrence, comment=null, 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[at0018]/items[at0021]/items[at0023], code=at0023, itemType=ELEMENT, level=4, text=Outcome, description=Outcome of the occurrence or exacerbation, comment=null, 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[at0018]/items[at0021]/items[at0024], code=at0024, itemType=ELEMENT, level=4, text=Date of onset of occurrence, description=Date of onset of occurrence or exacerbation, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0018]/items[at0021]/items[at0036], code=at0036, itemType=ELEMENT, level=4, text=Date of resolution of occurrence, description=Date of the resolution of the occurrence, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0018]/items[at0025], code=at0025, itemType=ELEMENT, level=3, text=Number of occurrences, description=Number of times this problem has occurred or been apparent, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=min: >=1

, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0026], code=at0026, itemType=CLUSTER, level=2, text=Related problems, description=Complications that are attributed to this problem, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0026]/items[at0027], code=at0027, itemType=CLUSTER, level=3, text=Related problem, description=A group of characteristics of the problem complicating the index condition in this archetype, comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0026]/items[at0027]/items[at0028], code=at0028, itemType=ELEMENT, level=4, text=Related problem, description=Details of the problem as text or coded text or URI, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
  •  Text
  •  URI
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0026]/items[at0027]/items[at0029], code=at0029, itemType=ELEMENT, level=4, text=Clinical description, description=Decription of the complicating problem, comment=null, 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[at0030], code=at0030, itemType=ELEMENT, level=2, text=Date of resolution, description=The date that the problem resolved or went into remission, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0031], code=at0031, itemType=ELEMENT, level=2, text=Age at resolution, description=The age of the at the resolution of the problem, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DURATION, bindings=null, values=Allowed values: years, months, weeks, days, hours

, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0.35], code=at0.35, itemType=CLUSTER, level=2, text=Diagnostic criteria, description=The criteria on which the diagnosis is based, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0.35]/items[at0.36], code=at0.36, itemType=ELEMENT, level=3, text=Criterion, description=A basis for the diagnosis, comment=null, 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={protocol=ResourceSimplifiedHierarchyItem [path=ROOT_/protocol[at0032], code=at0032, 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], 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=1..*, subCardinalityText=ordered, dataType=ITEM_TREE, bindings=null, values=null, extendedValues=null]}, addHierarchyItemsTo=protocol, currentHierarchyItemsForAdding=[ResourceSimplifiedHierarchyItem [path=/protocol[at0032]/items[at0033], code=at0033, itemType=CLUSTER, level=2, text=References, description=Useful information about this condition, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0032]/items[at0033]/items[at0034], code=at0034, itemType=ELEMENT, level=3, text=References, description=Reference to material about this condition, comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0032]/items[at0033]/items[at0035], code=at0035, itemType=ELEMENT, level=3, text=Web link, description=Useful information on the internet about this condition, comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_URI, bindings=null, values=, extendedValues=null]], minIndents={}, termBindingRetrievalErrorMessage=null]