ARCHETYPE Problem/Diagnosis (openEHR-EHR-EVALUATION.problem_diagnosis.v5)

ARCHETYPE IDopenEHR-EHR-EVALUATION.problem_diagnosis.v5
ConceptProblem/Diagnosis
DescriptionAny health care condition which may impact on the physical, mental and/or social well-being of an individual, that may require diagnostic, therapeutic or educational action, and which has been determined by a clinician. A diagnosis is based on scientific evaluation of physical signs, symptoms, history, laboratory tests results, and procedures.
Use Use to record detailed information about problems or diagnoses recognised by a clinician. There are many uses including: recording a Diagnosis during an Encounter; populating a Problem List or a Summary Statement, such as a Discharge Summary. Use to record all problems or diagnoses, including those with context-specific qualifiers such as past/present, primary/secondary, active/inactive etc. These qualifiers can be documented separately and included in the ‘Status’ data group, because their use varies in different settings.
Misuse Not to be used to record 'Differential Diagnoses' - use the Differential Diagnosis DCM. Not to be used to record 'Reason for Encounter' - use the Reason for Encounter DCM. Not to be used to record 'Presenting Complaint' - which is information captured early in the encounter, usually prior to full assessment and will be represented using a separate DCM. Not to be used to record procedures - use the Procedure DCM. Not to be used to record symptoms or signs - these should be recorded as part of a patient story or history. A problem such as 'Chest pain' may masquerade as a symptom, however in this context we are recording it as a problem the person has.
Purpose To record details about a problem or diagnosis by a clinician.
ReferencesNEHTA Clinical data groups - Problem/Diagnosis V2.0 http://www.nehta.gov.au/data-group-library/data-specifications/dgl-problem-diagnosis.

Australian Standard AS 4700.6-2006 Implementation of Health Level Seven version 2.4 - Part 6: Referral, discharge and health record messaging.

CEN/TC 251/WGII prEN 13940-2:2009.3- Health informatics – System of concepts to support Continuity of care – Part 2: Health care process and workflow.

BS_EN_13940-1_2007 - British Standard. Health informatics - System of concepts to support continuity of care - Part 1: Basic concepts.

Swedish National Process model.

IHE Technical Framework Supplement – Patient Plan of Care (PPOC).

Royal Australian College of General Practitioners - Fact Sheet: Medical History

Mosby's Pocket Dictionary of Medicine, Nursing and Health Professional, 6th Edition, Mosby Elsevier, 2010
Copyright© openEHR Foundation
AuthorsAuthor name: Stephen Chu
Organisation: National E-Health Transition Authority
Email: clinicalinfo@nehta.gov.au
Date originally authored: 2006-04-23
Other Details LanguageAuthor name: Stephen Chu
Organisation: National E-Health Transition Authority
Email: clinicalinfo@nehta.gov.au
Date originally authored: 2006-04-23
OtherDetails Language Independent{licence=This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/., custodian_organisation=Ocean Informatics, references=NEHTA Clinical data groups - Problem/Diagnosis V2.0 http://www.nehta.gov.au/data-group-library/data-specifications/dgl-problem-diagnosis. Australian Standard AS 4700.6-2006 Implementation of Health Level Seven version 2.4 - Part 6: Referral, discharge and health record messaging. CEN/TC 251/WGII prEN 13940-2:2009.3- Health informatics – System of concepts to support Continuity of care – Part 2: Health care process and workflow. BS_EN_13940-1_2007 - British Standard. Health informatics - System of concepts to support continuity of care - Part 1: Basic concepts. Swedish National Process model. IHE Technical Framework Supplement – Patient Plan of Care (PPOC). Royal Australian College of General Practitioners - Fact Sheet: Medical History Mosby's Pocket Dictionary of Medicine, Nursing and Health Professional, 6th Edition, Mosby Elsevier, 2010, original_namespace=com.oceaninformatics, original_publisher=Ocean Informatics, custodian_namespace=com.oceaninformatics, MD5-CAM-1.0.1=14BDC2083962408B228B799BB9CC2E5D, build_uid=233179b6-7139-4ccc-bbce-634f78f432a7, revision=5.0.0-alpha}
Keywordsissue, condition, problem, concern, diagnosis, criteria, illness, disease, disorder
Lifecyclein_development
UID12bb18ad-15e0-490d-99b7-ac51d5e6f4b1
Language useden
Citeable Identifier1013.1.1780
Revision Number5.0.0-alpha
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Any health care condition which may impact on the physical, mental and/or social well-being of an individual, that may require diagnostic, therapeutic or educational action, and which has been determined by a clinician. A diagnosis is based on scientific evaluation of physical signs, symptoms, history, laboratory tests results, and procedures., archetypeConceptComment=An account of relevant identified health related problems as reported by a healthcare provider. This can include a disease, condition, injury, poisoning, sign, symptom, abnormal finding, complaint, or other factor influencing health status as assessed by a healthcare provider., otherContributors=Sam Heard, Ocean Informatics
Koray Atalag, University of Auckland, New Zealand
John Bennett, NEHTA, Australia
Steve Bentley, NHS CfH, United Kingdom
Ian Bull, ACT Health, Australia
Sergio Carmona, Chile
Rong Chen, Cambio Healthcare Systems, Sweden
Stephen Chu, NEHTA, Australia (Editor)
Ed Conley, Cardiff University, United Kingdom
Matthew Cordell, NEHTA, Australia
Paul Donaldson, Nursing Informatics Australia, Australia
Gail Easterbrook, Flinders Medical Centre, Australia
David Evans, Queensland Health, Australia
Peter Garcia-Webb, Australia
Andrew Goodchild, NEHTA, Australia
Anneke Goossen, Results4Care, Netherlands
Heather Grain, Llewelyn Grain Consulting, Australia
Trina Gregory, cpc, Australia
Evelyn Hovenga, EJSH Consulting, Australia
Eugene Igras, IRIS Systems Inc, Canada
Mary Kelaher, NEHTA, Australia
Eizen Kimura, Ehime University, Japan
Shinji Kobayashi, Ehime University, Japan
Robert L'egan, NEHTA, Australia
Heather Leslie, Ocean Informatics, Australia (Editor)
Hugh Leslie, Ocean Informatics, Australia (Editor)
Rohan Martin, Ambulance Victoria, Australia
David McKillop, NEHTA, Australia
Ian McNicoll, Ocean Informatics UK, United Kingdom
Chris Mitchell, RACGP, Australia
Stewart Morrison, NEHTA, Australia
Jörg Niggeman, Compugroup, Germany
Andrej Orel, Marand d.o.o., Slovenia
Chris Pearce, Melbourne East GP Network, Australia
Camilla Preeston, Royal Australian College of General Practitioners, Australia
Margaret Prichard, NEHTA, Australia
Jodie Pycroft, Adelaide Northern Division of General Practice Ltd, Australia
Cathy Richardson, NEHTA, Australia
Robyn Richards, NEHTA - Clinical Terminology, Australia
Thilo Schuler, Australia
Gordon Tomes, Australian Institute of Health and Welfare, Australia
Richard Townley-O'Neill, NEHTA, Australia
Donna Truran, ACCTI-UoW, Australia
Kylie Young, The Royal Australian College of General Practitioners, Australia, originalLanguage=en, translators=, subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={source=[], provider=[], ism_transition=[], other_participations=[], activities=[], protocol=[ResourceSimplifiedHierarchyItem [path=/protocol[at0074]/items[at0075], code=at0075, itemType=ELEMENT, level=2, text=Link to Supporting Clinical Evidence, description=Links to other relevant information, including pathology reports., comment=null, uncommonOntologyItems={detail_docref=data_elements/NEHTA-16546-Link_to_Supporting_Clinical_Evidence-Data_Element.xml, dc_id=16546}, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_URI, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0074]/items[at0076], code=at0076, itemType=SLOT, level=2, text=Status, description=Descriptor for context- or use-case specific label or workflow-related aspect of the diagnostic process which may not be safe to exchange between systems or use in a shared environment., comment=null, uncommonOntologyItems={detail_docref=choices/NEHTA-16625-Status-Choice.xml, dc_id=16625}, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
All not explicitly excluded archetypes, extendedValues=null]], content=[], state=[], description=[], identities=[], data=[ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=2, text=Problem/Diagnosis, description=Identification of the problem or diagnosis., comment=It is preferred that this item be coded from the Problem/Diagnosis Reference Set Value Domain. This item denotes the name of the condition used by the healthcare provider, after assessment, to describe the health problem or diagnosis experienced by the subject of care., uncommonOntologyItems={fsn=Problem/Diagnosis Identification, detail_docref=data_elements/NEHTA-15514-Problem_Diagnosis_Identification-Data_Element.xml, dc_id=15514, coding_preferred=true, value_domain_name=Problem/Diagnosis Reference Set, value_domain_dc_id=16617}, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0009], code=at0009, itemType=ELEMENT, level=2, text=Clinical Description, description=Narrative description or comments about clinical aspects of the problem/diagnosis., comment=Used to provide additional narrative information in relation to a problem/diagnosis., uncommonOntologyItems={detail_docref=data_elements/NEHTA-15597-Clinical_Description-Data_Element.xml, dc_id=15597}, 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[at0082], code=at0082, itemType=ELEMENT, level=2, text=Severity, description=A subjective assessment of the severity of the Problem/Diagnosis as evaluated by the clinician., comment=null, uncommonOntologyItems={detail_docref=data_elements/NEHTA-15531-Severity-Data_Element.xml, dc_id=15531}, 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 of Onset, description=Estimated or actual date the problem/diagnosis began, in the opinion of the clinician., comment=null, uncommonOntologyItems={detail_docref=data_elements/NEHTA-15507-Date_of_Onset-Data_Element.xml, dc_id=15507}, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0037], code=at0037, itemType=ELEMENT, level=2, text=Age at Onset, description=The estimated or actual age of the individual when the clinician assesses that the problem/diagnosis began., comment=May be important in situations where approximations of age based on calculations are not accurate enough, e.g. in infants under one year. It may also be important for assessing clinical implications such as prognosis of condition, e.g. early onset Alzheimer, multiple sclerosis, certain cancers, etc., uncommonOntologyItems={detail_docref=data_elements/NEHTA-16535-Age_at_Onset-Data_Element.xml, dc_id=16535}, 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[at0044], code=at0044, itemType=SLOT, level=2, text=Anatomical Location, description=Slot to contain detailed and structured anatomical location details., comment=null, uncommonOntologyItems={detail_docref=data_groups/NEHTA-16150-Anatomical_Location-Data_Group.xml, dc_id=16150.12.1, spec_id=108}, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.anatomical_location.v1 and specialisations
Exclude:
All not explicitly included archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0018], code=at0018, itemType=CLUSTER, level=2, text=Occurrence Summary, description=Summary information about occurrences or exacerbations., comment=Detailed information about each occurrence or exacerbation is likely to be held in other parts of the health record., uncommonOntologyItems={fsn=Problem/Diagnosis Occurrence Summary, detail_docref=data_groups/NEHTA-16554-Problem_Diagnosis_Occurrence_Summary-Data_Group.xml, dc_id=16554}, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0018]/items[at0025], code=at0025, itemType=ELEMENT, level=3, text=Number, description=Cumulative number of occurrences or exacerbations of the problem/diagnosis., comment=null, uncommonOntologyItems={fsn=Problem/Diagnosis Occurrence Count, detail_docref=data_elements/NEHTA-16555-Problem_Diagnosis_Occurrence_Count-Data_Element.xml, dc_id=16555}, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0018]/items[at0019], code=at0019, itemType=ELEMENT, level=3, text=Frequency, description=The frequency or estimated frequency of occurrences or exacerbations of the problem/diagnosis., comment=null, uncommonOntologyItems={fsn=Problem/Diagnosis Occurrence Frequency, detail_docref=data_elements/NEHTA-16556-Problem_Diagnosis_Occurrence_Frequency-Data_Element.xml, dc_id=16556}, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_QUANTITY, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0018]/items[at0020], code=at0020, itemType=ELEMENT, level=3, text=Latest Occurrence, description=The date of the last occurrence or exacerbation of the problem/diagnosis., comment=null, uncommonOntologyItems={fsn=Problem/Diagnosis Latest Occurrence, detail_docref=data_elements/NEHTA-16557-Problem_Diagnosis_Latest_Occurrence-Data_Element.xml, dc_id=16557}, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0018]/items[at0072], code=at0072, itemType=ELEMENT, level=3, text=Description, description=A narrative description, including outcomes and other key details, about occurrences or exacerbations of the problem/diagnosis., comment=null, uncommonOntologyItems={fsn=Problem/Diagnosis Occurrence Description, detail_docref=data_elements/NEHTA-16558-Problem_Diagnosis_Occurrence_Description-Data_Element.xml, dc_id=16558}, 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[at0073], code=at0073, itemType=ELEMENT, level=3, text=Link to Occurrence Details, description=Link to further information about past occurrences or exacerbations of the problem/diagnosis that exist elsewhere in the health record., comment=null, uncommonOntologyItems={detail_docref=data_elements/NEHTA-10124-Link_to_Occurrence_Details-Data_Element.xml, dc_id=10124}, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_URI, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0026], code=at0026, itemType=CLUSTER, level=2, text=Related Items, description=Further problems, diagnoses, procedures or events that are related in some way to this problem/diagnosis., comment=null, uncommonOntologyItems={detail_docref=data_groups/NEHTA-16541-Related_Items-Data_Group.xml, dc_id=16541}, 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[at0028], code=at0028, itemType=ELEMENT, level=3, text=Related Item, description=Identification of a related problem, diagnosis, procedure, or event as text, coded text or link within the health record., comment=It is preferred that this item be coded from the Related Item Values Value Domain. This item identifies the relevant health problem experienced by the subject of care, as assessed by the healthcare provider. This element provides a link to one or more established problem(s) or diagnoses., uncommonOntologyItems={detail_docref=data_elements/NEHTA-15562-Related_Item-Data_Element.xml, dc_id=15562, coding_preferred=true, value_domain_name=Related Item Values, value_domain_dc_id=15562}, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0026]/items[at0056], code=at0056, itemType=ELEMENT, level=3, text=Relationship Type, description=The type of relationship that this problem/diagnosis has to the related item., comment=null, uncommonOntologyItems={fsn=Item Relationship Type, detail_docref=data_elements/NEHTA-16560-Item_Relationship_Type-Data_Element.xml, dc_id=16560, value_domain_name=Item Relationship Type Values, value_domain_dc_id=16559}, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Caused by [This concept identifies the direct cause or causative agent of a Problem/Diagnosis. The concept includes the idea of ‘complications’, ‘causative agent’ and ‘due to’. Note: Where no causality or sequence of events is known, this relationship type should be left blank.]
  • Following [This value identifies the sequence of events between the related items, but does not assert causality. This can be used for sequelae or late effects. Note: Where no causality or sequence of events is known, this relationship type should be left blank.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0030], code=at0030, itemType=ELEMENT, level=2, text=Date of Resolution/Remission, description=The date or estimated date that the problem/diagnosis resolved or went into remission, as indicated/identified by the clinician., comment=null, uncommonOntologyItems={detail_docref=data_elements/NEHTA-15510-Date_of_Resolution_Remission-Data_Element.xml, dc_id=15510}, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0031], code=at0031, itemType=ELEMENT, level=2, text=Age at Resolution/Remission, description=The age of the person at the time of resolution or remission of the problem/diagnosis., comment=May be important in situations where approximations of age based on calculations are not accurate enough, eg in infants under one year., uncommonOntologyItems={detail_docref=data_elements/NEHTA-16544-Age_at_Resolution_Remission-Data_Element.xml, dc_id=16544}, 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[at0054], code=at0054, itemType=SLOT, level=2, text=Diagnostic Criteria, description=The criteria on which the problem/diagnosis is based., comment=null, uncommonOntologyItems={detail_docref=choices/NEHTA-16623-Diagnostic_Criteria-Choice.xml, dc_id=16623}, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
All not explicitly excluded archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0055], code=at0055, itemType=SLOT, level=2, text=Clinical Stage/Grade, description=Clinical stage or grade of a problem/diagnosis., comment=null, uncommonOntologyItems={detail_docref=choices/NEHTA-16624-Clinical_Stage_Grade-Choice.xml, dc_id=16624}, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
All not explicitly excluded archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0069], code=at0069, itemType=ELEMENT, level=2, text=Comment, description=Additional narrative about the problem or diagnosis not captured in other fields., comment=null, uncommonOntologyItems={fsn=Problem/Diagnosis Comment, detail_docref=data_elements/NEHTA-16545-Problem_Diagnosis_Comment-Data_Element.xml, dc_id=16545}, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null]], credentials=[], target=[], capabilities=[], items=[], contacts=[], relationships=[], context=[], events=[], details=[]}, topLevelItems={protocol=ResourceSimplifiedHierarchyItem [path=ROOT_/protocol[at0074], code=at0074, 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=, 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=, dataType=ITEM_TREE, bindings=null, values=null, extendedValues=null]}, addHierarchyItemsTo=protocol, currentHierarchyItemsForAdding=[ResourceSimplifiedHierarchyItem [path=/protocol[at0074]/items[at0075], code=at0075, itemType=ELEMENT, level=2, text=Link to Supporting Clinical Evidence, description=Links to other relevant information, including pathology reports., comment=null, uncommonOntologyItems={detail_docref=data_elements/NEHTA-16546-Link_to_Supporting_Clinical_Evidence-Data_Element.xml, dc_id=16546}, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_URI, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0074]/items[at0076], code=at0076, itemType=SLOT, level=2, text=Status, description=Descriptor for context- or use-case specific label or workflow-related aspect of the diagnostic process which may not be safe to exchange between systems or use in a shared environment., comment=null, uncommonOntologyItems={detail_docref=choices/NEHTA-16625-Status-Choice.xml, dc_id=16625}, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
All not explicitly excluded archetypes, extendedValues=null]], minIndents={}, termBindingRetrievalErrorMessage=null]