| ARCHETYPE ID | openEHR-EHR-EVALUATION.problem.v1 |
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| Concept | Problem |
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| Description | An issue or obstacle which adversely impacts on the physical, mental and/or social well-being of an individual. The definition of a problem is deliberately kept rather loose so as to capture any real or perceived concerns that may adversely affect an individual's wellbeing to any degree. |
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| Use | Use for recording any information about general health-related problems.
The archetype contains multiple dates, so can record present and/or past problems.
A problem can be determined by either the individual themselves or a healthcare provider.
Some examples: - A range of symptoms that are under investigation but pre-diagnosis
- Desire to lose weight, without formal diagnosis of Obesity
- Desire to quit smoking by individual
- Relationship problem with family member
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| Misuse | Not to be used for recording formal Diagnoses - use the specialisation of this archetype, EVALUATION.problem-diagnosis. |
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| Purpose | For recording details about an issue or obstacle that impacts on the physical, mental and/or social well-being of an individual. |
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| References | |
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| Copyright | copyright (c) 2009 openEHR Foundation |
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| Authors | Author name: Sam Heard
Organisation: Ocean Informatics
Email: sam.heard@oceaninformatics.com
Date originally authored: 23/04/2006
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| Other Details Language | Author name: Sam Heard
Organisation: Ocean Informatics
Email: sam.heard@oceaninformatics.com
Date originally authored: 23/04/2006
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| Other Details (Language Independent) | - References:
- MD5-CAM-1.0.1: 4A7BAF9ECB8E210E032DAC7C90FBF7D2
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| Keywords | issue, condition, problem, obstacle |
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| Lifecycle | AuthorDraft |
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| Language used | en |
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| Citeable Identifier | 1013.1.169 |
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| protocol | |
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| References | References: Useful information about this condition. |
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| Reference | Reference: Reference to material about this condition. |
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| Web link | Web link: Useful information on the internet about this condition. |
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| data | |
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| Problem | Problem: Identification of the index problem. |
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| Clinical description | Clinical description: Description of the clinical aspects of the problem. |
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| Date of initial onset | Date of initial onset: The date when the problem was first identified by the individual. |
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| Age at initial onset | Age at initial onset: The age of the individual when the problem was first identified by the individual. |
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| Severity | Severity: The assessed overall severity of the index problem.
- at0006::Mild [The severity of the index problem is mild, not affecting life or longevity.]
- at0007::Moderate [The severity of the index problem is such as to cause significant morbidity.]
- at0008::Severe [The severity of the index problem has had a major effect on life and/or longevity.]
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| Clinical significance | Clinical significance: Description of the clinical significance of the problem in terms of impact of the problem on the patient. |
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| Date clinically recognised | Date clinically recognised: Date the problem was recognised by a healthcare provider.
Partial Date |
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| Age when clinically recognised | Age when clinically recognised: Age at which the problem was recognised by a healthcare provider. |
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| Location | Location: Location of the problem in terms of body site. |
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| Body site | Body site: The body site affected. |
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| Location description | Location description: Description of the location. |
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| Aetiology | Aetiology: Agents or Factors known to have been of aetiological significance. |
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| Agent | Agent: Agent or other factor known to have caused this problem. |
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| Complication of | Complication of: Identification of a problem, injury or condition as text,coded text or link within the EHR.
Choice of:
 Text
 URI
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| Description | Description: Description of aetiological process. |
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| Occurrences or exacerbations | Occurrences or exacerbations: Grouping of information about individual occurrences or exacerbations. |
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| Frequency of reccurrence | Frequency of reccurrence: The frequency of individual occurrences of the problem. |
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| Date of last occurrence | Date of last occurrence: The date of the last occurrence of the problem. |
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| Occurrence/exacerbation | Occurrence/exacerbation: Information about one occurrence or exacerbation. |
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| Clinical description | Clinical description: A description of the exacerbation or occurrence. |
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| Outcome | Outcome: Outcome of the occurrence or exacerbation. |
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| Date of onset of occurrence | Date of onset of occurrence: Date of onset of occurrence or exacerbation. |
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| Date of resolution of occurrence | Date of resolution of occurrence: Date of the resolution of the occurrence or exacerbation. |
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| Number of occurrences | Number of occurrences: Number of times this problem has occurred or been apparent.
min: >=1
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| Related problems | Related problems: Further problems that are related in some way to the index problem. |
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| Related problem | Related problem: A group of characteristics of the problem complicating the index problem. |
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| Related problem | Related problem: Identification of a related problem as text,coded text or link within the EHR.
Choice of:
- Text
- URI
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| Clinical description | Clinical description: Decription of the related problem. |
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| Date of resolution | Date of resolution: The date that the problem resolved or went into remission. |
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| Age at resolution | Age at resolution: The age of the person at the resolution of the problem. |
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| Other contributors | |
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| 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
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