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

ARCHETYPE ID	openEHR-EHR-EVALUATION.problem-diagnosis.v1
Concept	Diagnosis
Description	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
Use	Used 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.
Misuse	Use 'openEHR-EHR-EVALUATION.problem-diagnosis-histological' for histological diagnoses.
Purpose	For recording medical diagnoses with optional diagnostic criteria and staging. Requires coded entry of diagnosis.
References
Copyright	copyright (c) 2010 openEHR Foundation
Authors	Author name: Sam Heard Organisation: Ocean Informatics Email: sam.heard@oceaninformatics.com Date originally authored: 23/04/2006
Other Details Language	Author name: Sam Heard Organisation: Ocean Informatics Email: sam.heard@oceaninformatics.com Date originally authored: 23/04/2006
Other Details (Language Independent)	References: MD5-CAM-1.0.1: 25DE4AB34DEAEC07427F236A035F33B2
Keywords	past, history, family, history, condition
Lifecycle	AuthorDraft
Language used	en
Citeable Identifier	1013.1.168
protocol
References	References: Useful information about this condition
References	References: Reference to material about this condition
Web link	Web link: Useful information on the internet about this condition
data
Diagnosis	Diagnosis: The index diagnosis Constraint: Any term that 'is_a' diagnosis [Any term that is a diagnosis in an accepted terminology]
Status	Status: The status of the diagnosis at0.33::provisional [provisional diagnosis considered likely and a basis for proceeding with management] at0.34::working [working diagnosis considered very likely but not yet confirmed]
Date of initial onset	Date of initial onset: The date that the problem began causing symptoms or signs
Age at initial onset	Age at initial onset: The age of the at the onset of the problem Allowed values: years, months, weeks, days, hours
Severity	Severity: The severity of the index problem 1: at0006::Mild [The severity of the index problem is mild, not affecting life or longevity] 4: at0007::Moderate [The severity of the index problem is such as to cause significant morbidity] 7: at0008::Severe [The severity of the index problem has had a major effect on life and/or longevity]
Clinical description	Clinical description: Description of the clinical aspects of the problem
Date clinically recognised	Date clinically recognised: Date the problem was recognised by clinicians Partial Date
Age when clinically recognised	Age when clinically recognised: The age when this problem was clinically recognised
Location	Location: Location of the problem in terms of body site
Body site	Body site: The body site affected Constraint: Any term that describes a body site [An anatomical structure with qualifiers]
Location description	Location description: A free text description of the location - may be in addition to a coded body site
Aetiology	Aetiology: Agents or Factors known to have been of aetiological significance
Agent	Agent: Microbial or other agent known to have caused this problem
Complication of	Complication of: A problem or link to a problem or injury described elsewhere in the EHR Choice of: Text URI
Description	Description: Description of aetiological process
Occurrences or exacerbations	Occurrences or exacerbations: Grouping of information about individual occurrences or exacerbations
Frequency of reccurrence	Frequency of reccurrence: The frequency of individual occurrences of the problem Property: Frequency Units: /h /d /mo /wk /yr
Date of last occurrence	Date of last occurrence: The date of the last occurrence or exacerbation
Occurence/exacerbation	Occurence/exacerbation: Information about one occurrence or exacerbation
Clinical description	Clinical description: A description of the exacerbation or occurrence
Outcome	Outcome: Outcome of the occurrence or exacerbation
Date of onset of occurrence	Date of onset of occurrence: Date of onset of occurrence or exacerbation
Date of resolution of occurrence	Date of resolution of occurrence: Date of the resolution of the occurrence
Number of occurrences	Number of occurrences: Number of times this problem has occurred or been apparent min: >=1
Related problems	Related problems: Complications that are attributed to this problem
Related problem	Related problem: A group of characteristics of the problem complicating the index condition in this archetype
Related problem	Related problem: Details of the problem as text or coded text or URI Choice of: Text URI
Clinical description	Clinical description: Decription of the complicating problem
Date of resolution	Date of resolution: The date that the problem resolved or went into remission
Age at resolution	Age at resolution: The age of the at the resolution of the problem Allowed values: years, months, weeks, days, hours
Diagnostic criteria	Diagnostic criteria: The criteria on which the diagnosis is based
Criterion	Criterion: A basis for the diagnosis
Other contributors
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