| ARCHETYPE ID | openEHR-EHR-CLUSTER.symptom.v1 |
|---|---|
| Concept | Symptom |
| Description | A subjective observation by an individual about departure from normal function and which may indicate the presence of disease or abnormality. Either self-recorded or recorded on the behalf of a patient by a clinician. |
| Use | Use to record detailed information about a symptom as told to a clinician by a patient or self-recorded by the individual/patient. This archetype allows a 'nil significant' statement to be explicitly recorded. |
| Misuse | Not to be used to record details about pain. Use the specialisation of this archetype - the CLUSTER.symptom-pain instead. Not to be used for diagnoses and problems that form part of a persisting Problem List - use EVALUATION.problem_diagnosis. |
| Purpose | To record detail about a symptom - either self-recorded by an individual or recorded on the behalf of a patient by a clinician. A complete patient history may include varying level of details about a variety of symptoms. |
| References | |
| Copyright | © openEHR Foundation |
| Authors | Author name: Tony Shannon Organisation: UK NHS, Connecting for Health Email: tony.shannon@nhs.net Date originally authored: 2007-02-20 |
| Other Details Language | Author name: Tony Shannon Organisation: UK NHS, Connecting for Health Email: tony.shannon@nhs.net Date originally authored: 2007-02-20 |
| Other Details (Language Independent) |
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| Keywords | complaint, presenting, symptom |
| Lifecycle | AuthorDraft |
| Language used | en |
| Citeable Identifier | 1013.1.195 |
| items | |
| Symptom name | Symptom name: The symptom experienced. Coding with an external terminology is preferred, where possible. |
| Nil Significant | Nil Significant: The person has not had any significant experience of the symptom. Allowed values: {true} |
| Description | Description: A narrative description of the symptom. |
| Site | Site: The site on the body where the symptom was located. |
| Site Details | Site Details: Details of the location in the body. Include: openEHR-EHR-CLUSTER.anatomical_ Exclude: All not explicitly included archetypes |
| Impact | Impact: The severity of the symptom in its impact on daily living. 1: Trivial [The symptom is trivial and causes no problems.] [SNOMED-CT: 2: Mild [The symptom does not interfere greatly with day to day activities.] [SNOMED-CT: 5: Moderate [The symptom interferes with day to day activities.] [SNOMED-CT: 8: Severe [The symptom prohibits some key daily activities.] [SNOMED-CT: 9: Very severe [The symptom is almost maximum possible intensity and prohibits any activity.] [SNOMED-CT: |
| Intensity | Intensity: Measures of the intensity of the symptom. Assumed to be current intensity unless otherwise specified but may be used to capture e.g. maximal and minimal intensity. |
| Degree | Degree: The degree the symptom is bothering the patient. 0: Not present [The symptom is not present.] 1: Trivial [The symptom is trivial and causes no problems.] [SNOMED-CT: 2: Mild [The symptom does not interfere greatly with day to day activities.] [SNOMED-CT: 5: Moderate [The symptom interferes with day to day activities.] [SNOMED-CT: 8: Severe [The symptom prohibits some key daily activities.] [SNOMED-CT: 9: Very severe [The symptom is almost maximum possible intensity and prohibits any activity.] [SNOMED-CT: |
| Visual Analogue Score | Visual Analogue Score: A score from 0 (not present) to 10 (as bad as it could be). min: >=0; max: <=10 |
| Degree | Degree: The intensity of the symptom expressed as a proportion.
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| Duration | Duration: The duration of the symptom since onset. |
| Number of Occurrences | Number of Occurrences: The number of times this symptom has occurred. |
| Character | Character: The character of the symptom. |
| Variation | Variation: The variation of the symptom.
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| Previous Episodes | Previous Episodes: Details about previous episodes. |
| Any Previous Episodes | Any Previous Episodes: Have there been any previous episodes of this symptom. |
| Previous Episode | Previous Episode: Details about a specific episode. |
| Date / time of previous episode | Date / time of previous episode: Date/time of previous episode. |
| Details | Details: Details of previous symptoms and comparison to this episode. |
| Comparison | Comparison: How the previous episode compares with this one. |
| Details | Details: Structured details of symptoms in previous episodes. Include: openEHR-EHR-CLUSTER.symptom.v1 |
| Number of Previous Episodes | Number of Previous Episodes: Number of previous episodes. min: >=0 |
| Course | Course: Features of the course of the symptom. |
| Onset Type | Onset Type: The nature of the onset of the symptom.
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| Onset Description | Onset Description: Activity or situation at and details of onset. |
| Time of Maximum Intensity | Time of Maximum Intensity: The time (and/or date) of maximum intensity of the symptom. |
| Progression | Progression: The progress of the symptom relative to the past.
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| Cessation | Cessation: The nature of the cessation of the symptom.
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| Precipitating factors | Precipitating factors: Factors that trigger or bring on the symptom. |
| Precipitating Factor | Precipitating Factor: An event or activity that brings on or triggers the symptom. |
| Modification | Modification: Factors that change the level of intensity of the symptom. |
| Modifying Factor | Modifying Factor: Information about a specific factor that changes the symptom. |
| Factor | Factor: An event or activity that modifies the symptom. |
| Change | Change: An event or activity that makes the symptom worse. -3: Relieved completely [The symptom is relieved by this factor.] -2: Made better [The symptom is made better by this factor.] -1: Somewhat improved [The symptom is somewhat improved by this factor.] 0: No change [The symptom is not modified by this factor.] 1: Somewhat worse [The symptom is made somewhat worse by this factor.] 2: Made worse [The symptom is made worse by this factor.] 3: Much worse [The symptom is made much worse by this factor.] |
| Details | Details: Details of the effect. |
| Associated symptoms | Associated symptoms: Associated symptoms. Include: openEHR-EHR-CLUSTER.symptom.v1 and specialisations |
| Features not present | Features not present: Anticipated features which are not present. |
| Absent feature | Absent feature: A feature that is not present. |
| Other contributors | Sam Heard, Ocean Informatics Heather Leslie, Ocean Informatics, Australia (Editor) Ian McNicoll, Ocean Informatics, United Kingdom (Editor) |
| Translators |
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