| ARCHETYPE ID | openEHR-EHR-EVALUATION.exclusion-problem_diagnosis.v1 |
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| Concept | Exclusion of a Problem/Diagnosis |
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| Description | Positive statement/s about problems or diagnoses that need to be recorded as clinically excluded from the health record at a specific point in time. |
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| Use | Use to record positive statement/s about the absence or exclusion of problems or diagnoses within the health record at a specific point in time. For example: to record that the subject has not ever had any significant problems or diagnoses; or that the subject has never been diagnosed with diabetes.
This archetype has specifically been designed to avoid the need to use flags or terminology to express negation about any problems or diagnoses within the health record.
Exclusion statements can only be considered to be current and accurate at the time of recording. For example: recording an exclusion of the previous diagnosis of diabetes during a consultation is only relevant at the time and is effectively obsolete after if the results of a blood glucose test is above diagnostic levels. |
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| Misuse | Not to be used to record exclusion statements about adverse reactions, medications or procedures - use other specific specialisations of the EVALUATION.exclusion archetype for this purpose. |
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| Purpose | To positively record statement/s about problems or diagnoses that need to be clinically excluded from the health record at a specific point in time. |
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| References | Exclusion of Problem/Diagnosis, draft archetype, NEHTA Clinical Knowledge Manager [Internet]. NEHTA. Authored: 02 Mar 2010. Available at:
http://dcm.nehta.org.au/ckm/#showArchetype_1013.1.1304_2(accessed 3 Sept 2013) |
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| Copyright | © openEHR Foundation |
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| Authors | Author name: Heather Leslie
Organisation: Ocean Informatics
Email: heather.leslie@oceaninformatics.com
Date originally authored: 2010-03-02
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| Other Details Language | Author name: Heather Leslie
Organisation: Ocean Informatics
Email: heather.leslie@oceaninformatics.com
Date originally authored: 2010-03-02
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| Other Details (Language Independent) | - References: Exclusion of Problem/Diagnosis, draft archetype, NEHTA Clinical Knowledge Manager [Internet]. NEHTA. Authored: 02 Mar 2010. Available at:
http://dcm.nehta.org.au/ckm/#showArchetype_1013.1.1304_2(accessed 3 Sept 2013)
- Current Contact: Heather Leslie, Ocean Informatics, heather.leslie@oceaninformatics.com
- MD5-CAM-1.0.1: 4C8CAFC70D510CF617DD5B580BFDA8F6
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| Keywords | exclusion, problem, diagnosis |
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| Lifecycle | AuthorDraft |
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| Language used | en |
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| Citeable Identifier | 1013.1.620 |
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| protocol | |
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| Date Last Updated | Date Last Updated: The date at which the exclusion was last clinically asserted, affirmed or confirmed. |
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| data | |
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| Exclusion Statement | Exclusion Statement: A statement about exclusion of use of known problems or diagnoses in the health record.
For example: "No known significant problems or diagnoses"; or "No evidence of" or "Never diagnosed with" (diabetes). |
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| Problem/Diagnosis | Problem/Diagnosis: Identification of the specific problems/diagnoses to which the Exclusion Statement applies.
Coding of the Problem or Diagnosis with a terminology is desirable, where possible.
Choice of:
 Coded Text
Constraint:
Problem or Diagnosis
[All possible problems or diagnoses.]
 Text
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| Comment | Comment: Additional narrative about the Exclusion not captured in other fields. |
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| Other contributors | Sam Heard, Ocean Informatics, Australia
Ian McNicoll, Ocean Informatics, Australia
Stephen Chu, NEHTA, Australia
Stephen Royce, NEHTA, Australia |
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| Translators | |
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