ARCHETYPE Problem/Diagnosis status (openEHR-EHR-CLUSTER.problem_status.v0)

ARCHETYPE IDopenEHR-EHR-CLUSTER.problem_status.v0
ConceptProblem/Diagnosis status
DescriptionContext- or time-specific qualifiers for a specified problem or diagnosis.
UseUse to record context-specific or time-specific qualifiers that can be used to provide additional detail when recording a problem or diagnosis that are relevant at the time of recording or within the clinical context where it is recorded, but which may not be appropriate to assume as appropriate at another time or in another clinical context. This archetype is designed to be included in Status SLOT in the EVALUATION.problem_diagnosis archetype. These status qualifiers should be used with care as they are variably applied in practice and interoperability cannot be assured unless usage guidelines are clearly defined within the clinical community in which the 'Problem/Diagnosis' and 'Problem status' archetype pair may be shared. The 'Unspecified' data element has been added to support addition of other qualifiers that might only be used locally or where the use case has not been clearly established at the time of this archetype being published. As other qualifiers are identified they can be added to this archetype as a backwardly compatible revision.
MisuseNot to be used to represent Differential diagnosis - use the archetype EVALUATION.differential_diagnosis for this purpose.
PurposeTo record clinical context-specific or time-specific status qualifiers for a specified problem or diagnosis.
References
Copyright© openEHR Foundation
AuthorsAuthor name: Dr Ian McNicoll
Organisation: Ocean Informatics, United Kingdom
Email: ian.mcnicoll@oceaninformatics.com
Date originally authored: 2013-05-29
Other Details LanguageAuthor name: Dr Ian McNicoll
Organisation: Ocean Informatics, United Kingdom
Email: ian.mcnicoll@oceaninformatics.com
Date originally authored: 2013-05-29
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, 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}
Keywordsproblem, active, inactive, status, episode, diagnosis
Lifecyclein_development
UID3a666c91-53ba-4e54-8197-8db6e73b5357
Language useden
Citeable Identifier1013.1.1873
Revision Number0.0.1-alpha
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Context- or time-specific qualifiers for a specified problem or diagnosis., archetypeConceptComment=null, otherContributors=Nadim Anani, Karolinska Institutet, Sweden
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), originalLanguage=en, translators=Slovenian: mag. Biljana Prinčič, Marand d.o.o., Ljubljana, Slovenija, biljana.princic@marand.si
, subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={events=[], context=[], capabilities=[], activities=[], protocol=[], identities=[], source=[], credentials=[], state=[], items=[ResourceSimplifiedHierarchyItem [path=/items[at0004], code=at0004, itemType=ELEMENT, level=1, text=Phase, description=Stage or phase of diagnostic process., comment=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., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=[SNOMED-CT::106229004 | Qualifier for type of diagnosis (qualifier value)], values=
  • 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 (contextual qualifier) (qualifier value))
  • 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 (contextual qualifier) (qualifier value))
  • Established [Final substantiated diagnosis, based on all relevant test results and clinical advice. It is not expected to change.]
    [SNOMED-CT::14657009] (Established diagnosis (contextual qualifier) (qualifier value))
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0060], code=at0060, itemType=ELEMENT, level=1, text=Current?, description=Category that supports division of problems and diagnoses into Current or Past problem lists., comment=Aligned with SNOMEDCT., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=[SNOMED-CT::410511007 | Current or past (actual) (qualifier value)], values=
  • Current [An issue which ocurred at present.]
    [SNOMED-CT::15240007] (Current (qualifier value))
  • Past [An issue occuring in the past.]
    [SNOMED-CT::410513005] (In the past (qualifier value))
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0003], code=at0003, itemType=ELEMENT, level=1, text=Active?, description=Category that supports division of problems and diagnoses into Active or Inactive problem lists., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • 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.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0001], code=at0001, itemType=ELEMENT, level=1, text=Episodicity, description=Category new, recurring and ongoing issues, problems or diagnoses., comment=This data element is usually recorded as part of a clinical consultation., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=[SNOMED-CT::288526004 | Episodicities (qualifier value)], values=
  • 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.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0071], code=at0071, itemType=ELEMENT, level=1, text=First ever?, description=Is this the first ever occurrence of this problem or diagnosis?, comment=Record as True if this is the first ever occurrence of this problem or diagnosis., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=Allowed values: {true}, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0077], code=at0077, itemType=ELEMENT, level=1, text=Course, description=The pattern or evolution of the problem or diagnosis., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=[SNOMED-CT::288524001 | Courses (qualifier value)], values=
  • 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 (qualifier value))
  • Chronic [A problem or diagnosis with persistent or long-lasting effects, or that evolves over time.]
    [SNOMED-CT::90734009] (Chronic (qualifier value))
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0063], code=at0063, itemType=ELEMENT, level=1, text=DRG category, description=In episodic care contexts (commonly secondary care) it is common to categorise/ organise problems according to their relationship to the principal problem or diagnosis being addressed during that episode of care. These categories may also be used for clinical coding, reporting and billing purposes., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • 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.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0073], code=at0073, itemType=ELEMENT, level=1, text=Present on admission?, description=Was the problem or diagnosis present at admission?, comment=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., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=Allowed values: {true}, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0083], code=at0083, itemType=ELEMENT, level=1, text=Resolution, description=Phase of resolution or healing of an acute problem or 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=
  • 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.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0082], code=at0082, itemType=ELEMENT, level=1, text=Unspecified, description=Unspecified qualifier that will be renamed, data type selected and potential value sets specified in a template., comment=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., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
  •  Text
  •  Boolean
  •  Count
, extendedValues=null]], contacts=[], target=[], relationships=[], description=[], ism_transition=[], content=[], details=[], other_participations=[], data=[], provider=[]}, topLevelItems={items=ResourceSimplifiedHierarchyItem [path=ROOT_/, code=at0000, itemType=CLUSTER, level=0, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=null, extendedValues=null]}, addHierarchyItemsTo=items, currentHierarchyItemsForAdding=[ResourceSimplifiedHierarchyItem [path=/items[at0004], code=at0004, itemType=ELEMENT, level=1, text=Phase, description=Stage or phase of diagnostic process., comment=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., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=[SNOMED-CT::106229004 | Qualifier for type of diagnosis (qualifier value)], values=
  • 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 (contextual qualifier) (qualifier value))
  • 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 (contextual qualifier) (qualifier value))
  • Established [Final substantiated diagnosis, based on all relevant test results and clinical advice. It is not expected to change.]
    [SNOMED-CT::14657009] (Established diagnosis (contextual qualifier) (qualifier value))
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0060], code=at0060, itemType=ELEMENT, level=1, text=Current?, description=Category that supports division of problems and diagnoses into Current or Past problem lists., comment=Aligned with SNOMEDCT., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=[SNOMED-CT::410511007 | Current or past (actual) (qualifier value)], values=
  • Current [An issue which ocurred at present.]
    [SNOMED-CT::15240007] (Current (qualifier value))
  • Past [An issue occuring in the past.]
    [SNOMED-CT::410513005] (In the past (qualifier value))
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0003], code=at0003, itemType=ELEMENT, level=1, text=Active?, description=Category that supports division of problems and diagnoses into Active or Inactive problem lists., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • 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.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0001], code=at0001, itemType=ELEMENT, level=1, text=Episodicity, description=Category new, recurring and ongoing issues, problems or diagnoses., comment=This data element is usually recorded as part of a clinical consultation., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=[SNOMED-CT::288526004 | Episodicities (qualifier value)], values=
  • 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.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0071], code=at0071, itemType=ELEMENT, level=1, text=First ever?, description=Is this the first ever occurrence of this problem or diagnosis?, comment=Record as True if this is the first ever occurrence of this problem or diagnosis., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=Allowed values: {true}, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0077], code=at0077, itemType=ELEMENT, level=1, text=Course, description=The pattern or evolution of the problem or diagnosis., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=[SNOMED-CT::288524001 | Courses (qualifier value)], values=
  • 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 (qualifier value))
  • Chronic [A problem or diagnosis with persistent or long-lasting effects, or that evolves over time.]
    [SNOMED-CT::90734009] (Chronic (qualifier value))
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0063], code=at0063, itemType=ELEMENT, level=1, text=DRG category, description=In episodic care contexts (commonly secondary care) it is common to categorise/ organise problems according to their relationship to the principal problem or diagnosis being addressed during that episode of care. These categories may also be used for clinical coding, reporting and billing purposes., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • 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.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0073], code=at0073, itemType=ELEMENT, level=1, text=Present on admission?, description=Was the problem or diagnosis present at admission?, comment=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., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=Allowed values: {true}, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0083], code=at0083, itemType=ELEMENT, level=1, text=Resolution, description=Phase of resolution or healing of an acute problem or 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=
  • 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.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0082], code=at0082, itemType=ELEMENT, level=1, text=Unspecified, description=Unspecified qualifier that will be renamed, data type selected and potential value sets specified in a template., comment=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., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
  •  Text
  •  Boolean
  •  Count
, extendedValues=null]], minIndents={}, termBindingRetrievalErrorMessage=null]