Organisation: Ocean Informatics, United Kingdom
Email: ian.mcnicoll@oceaninformatics.com
Date originally authored: 2013-05-29
Organisation: Ocean Informatics, United Kingdom
Email: ian.mcnicoll@oceaninformatics.com
Date originally authored: 2013-05-29
- 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
- Original Namespace: com.oceaninformatics
- Original Publisher: Ocean Informatics
- Custodian Namespace: com.oceaninformatics
- MD5-CAM-1.0.1: 5C38661056B310CA29DDF3E67D1F0DC5
- Build Uid: cf128eaa-2cda-4232-b013-7efb8eac92f0
- Revision: 0.0.1-alpha
The phase is usually determined by a combination of the timing of diagnosis plus availability of supporting test results and clinical advice. It can also imply a level of clinical certainty. Terms aligned with SNOMED CT.
- Preliminary [The initial diagnosis made, based on limited available clinical evidence. It may change as test results or advice become available.]
[SNOMED-CT::148006 | Preliminary diagnosis] - Working [Interim diagnosis, based on substantiated clinical evidence but pending further test results or clinical advice. It may still change as test results or advice become available.]
[SNOMED-CT::5558000 | Working diagnosis] - Established [Final substantiated diagnosis, based on all relevant test results and clinical advice. It is not expected to change.]
[SNOMED-CT::14657009 | Established diagnosis]
Aligned with SNOMEDCT.
- Current [An issue which ocurred at present.]
[SNOMED-CT::15240007 | Current] - Past [An issue occuring in the past.]
[SNOMED-CT::410513005 | Past]
- Active [The problem or diagnosis is currently active and clinically relevant.]
- Inactive [The problem or diagnosis is not completely resolved but is inactive or felt less relevant to the current clinical context.]
This data element is usually recorded as part of a clinical consultation.
- New episode [A first occurrence of a new diagnosis or new occurrence of a previous diagnosis. A flag for 'First ever' occurrence can be recorded separately.]
- Ongoing episode [The issue, problem or diagnosis continues, without occurrences of new episodes.]
- Indeterminate [It is not possible to determine if this occurrence of the problem or diagnosis is new or ongoing.]
Record as True if this is the first ever occurrence of this problem or diagnosis.
Allowed values: {true}
- Acute [A problem or diagnosis with a rapid onset, a short course, or both.]
- Relapsing [A recurring problem or diagnosis, with periods of remission in between.]
[SNOMED-CT::255227004 | Recurrent] - Chronic [A problem or diagnosis with persistent or long-lasting effects, or that evolves over time.]
[SNOMED-CT::90734009 | Chronic]
- Principal diagnosis [The diagnosis determined to be chiefly responsible for occasionaing an episode of admitted patient care, an episode of residential care or an attendance at the health care establishment.]
- Secondary diagnosis [A problem or diagnosis that is occurs at the same time as the primary problem or diagnosis. May also be known as a comorbid condition.]
- Complication [An unfavorable evolution of a problem or diagnosis.]
Record as True if the problem or diagnosis was present on admission. Used to support identification of in-admission complications among secondary diagnoses that arise during admission.
Allowed values: {true}
- Resolved [Problem or diagnosis has completed the normal phases of restoration or healing and can be considered resolved.]
- Resolving [Problem or diagnosis is progressing satisfactorily through the normal stages of restoration or healing towards resolution.]
- Not resolving [Problem or diagnosis is not progressing satisfactorily through the normal stages of restoration or healing towards resolution.]
- Indeterminate [It is not possible to determine the resolution or healing status of the problem or diagnosis.]
For example: The boolean data type could be used to signify that the problem/diagnosis can be included in a patient summary; the text data type could be used to categorise in a similar way to 'Current?' or Active?'; and the count data type could be used to assert a priority key or order to problems and diagnoses in a list. If any uses are identified as frequently required, they could be added explicitly to this archetype as an explicit data element.
Choice of:
Text
Boolean
Count
Vebjoern Arntzen, Oslo university hospital, Norway
Koray Atalag, University of Auckland, New Zealand
Silje Ljosland Bakke, National ICT Norway, Norway (openEHR Editor)
Lars Bitsch-Larsen, Haukeland University hospital, Norway
Aitor Eguzkitza, UPNA (Public University of Navarre) - CHN (Complejo Hospitalario de Navarra), Spain
Einar Fosse, National Centre for Integrated Care and Telemedicine, Norway
Heather Grain, Llewelyn Grain Informatics, Australia
Sam Heard, Ocean Informatics, Australia
Lars Karlsen, DIPS ASA, Norway
Shinji Kobayashi, Kyoto University, Japan
Sabine Leh, Haukeland University Hospital, Department of Pathology, Norway
Heather Leslie, Ocean Informatics, Australia (openEHR Editor)
Hugh Leslie, Ocean Informatics, Australia
Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (openEHR Editor)
Andrej Orel, Marand d.o.o., Slovenia
Jussara Rotzsch, UNB, Brazil
Anoop Shah, University College London, United Kingdom
Norwegian Review Summary, Nasjonal IKT, Norway
John Tore Valand, Helse Bergen, Norway (openEHR Editor)