ARCHETYPE Problem List (openEHR-EHR-SECTION.problem_list.v1)

ARCHETYPE IDopenEHR-EHR-SECTION.problem_list.v1
ConceptProblem List
DescriptionSuggested design pattern for including a Problem List in a template.
UseUse to support the representation of statements about known problems or diagnoses that have been recorded PLUS to make positive statements about the absence of problems and diagnoses - either general statements of absence or specific statements of absence of a specific problem or diagnosis. The existence of known problems or diagnoses can be persisted in records. Statements about the absence of problems or diagnoses, either general or specific, can only indicate the state of the subject at the time that the information was actually recorded - that is, they are event based. It is not sensible to persist the recording of a positive absence of a problem or diagnosis as it may be recognised at any time and may render any or all previous positive statements of absence obsolete. It is possible to represent both positive statements about identified problems/diagnoses alongside specific positive statements about the absence of identified problems/diagnoses in a template (eg patient has Diabetes, but never had Asthma). However in most use cases either specific statements about the presence of identified problems/diagnoses (eg patient has Diabetes, Glaucoma and Obesity) or general statements about the positive absence of any known problems/diagnoses will be represented (eg No significant past history), but not both. While EVALUATION.problem and it's specialisations, including EVALUATION.problem-diagnosis, and EVALUATION.exclusion-problem_diagnosis have been explicitly included in the slot constraints, other archetypes have not been explicitly excluded. This means that any other archetypes can also be included here, if needed - for example, where structured data is not available or there is a need to provide a synopis, the EVALUATION.clinical_synopsis can be inserted and used.
PurposeTo demonstrate a design pattern for representation of a Problem List.
References
Copyrightcopyright (c) 2010 openEHR foundation
AuthorsAuthor name: Heather Leslie
Organisation: Ocean Informatics
Email: heather.leslie@oceaninformatics.com
Date originally authored: 7/03/2010
Other Details LanguageAuthor name: Heather Leslie
Organisation: Ocean Informatics
Email: heather.leslie@oceaninformatics.com
Date originally authored: 7/03/2010
OtherDetails Language Independent{references=, MD5-CAM-1.0.1=D677F4E1584B93F9E62DDF2546421F7D}
Keywordsproblem, diagnosis, exclusion, absence, known, list
Lifecycle0
Language useden
Citeable Identifier1013.1.610
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openEHR-EHR-EVALUATION.problem.v1 and specialisations Or
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