ARCHETYPE Story/History (openEHR-EHR-OBSERVATION.story.v0)

ARCHETYPE IDopenEHR-EHR-OBSERVATION.story.v0
ConceptStory/History
DescriptionThe subjective clinical history of the subject of care as recorded directly by the subject, or reported to a clinician by the subject or a carer.
UseUse to record a description about subjective health-related observations or impressions from the point of view of the subject of care. When recorded by a clinician within the context of healthcare provision the story can be used for capturing the clinical history, as reported by the subject themselves, a parent, care-giver or other related party. If recorded by the subject, it can be used as an account of their 'story' of symptoms and health experiences, which might be used to share with healthcare providers or to document within their own personal health record. Use: - to record a simple narrative; and/or - as a container archetype to enable recording of a detailed structured history by inclusion of relevant CLUSTER archetypes within the 'Detail' SLOT. For example: CLUSTER.symptom, CLUSTER.issue or CLUSTER.health_event archetypes can be appropriately used in this SLOT. Use to incorporate the narrative descriptions of clinical history captured from existing or legacy clinical systems into an archetyped format, using the 'Story' text data element.
MisuseNot to be used to record formal assessments by clincians which would usually be recorded using the EVALUATION class of archetypes.
PurposeTo record a narrative description of the clinical history of the subject of care and to provide a framework in which to nest detailed CLUSTER archetypes, each of which will support the narrative with additional structured detail. Use to record detail about a single symptom as reported by an individual, parent, care-giver or other party. It may be recorded by a clinician as part of a clinical history record as reported to them, or self-recorded as part of a clinical questionnaire or personal health record.
References
Copyright© openEHR Foundation
AuthorsAuthor name: Heather Leslie
Organisation: Ocean Informatics
Email: heather.leslie@oceaninformatics.com
Date originally authored: 2008-05-15
Other Details LanguageAuthor name: Heather Leslie
Organisation: Ocean Informatics
Email: heather.leslie@oceaninformatics.com
Date originally authored: 2008-05-15
OtherDetails Language Independent{licence=Creative Commons Attribution-ShareAlike 4.0 International License, custodian_organisation=Ocean Informatics, current_contact=Heather Leslie, Ocean Informatics, heather.leslie@oceaninformatics.com, original_namespace=com.oceaninformatics, original_publisher=Ocean Informatics, custodian_namespace=com.oceaninformatics, MD5-CAM-1.0.1=F1032E159C7CD6AC450786ADBA80FB87, build_uid=1abaeb86-62d0-4d85-9ee4-85eaa3ecd39e, revision=0.0.1-alpha}
Keywordshistory, presenting, complaint, story
Lifecyclein_development
UIDaf92f877-b7c8-4286-8601-a29327fd929f
Language useden
Citeable Identifier1013.1.68
Revision Number0.0.1-alpha
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=The subjective clinical history of the subject of care as recorded directly by the subject, or reported to a clinician by the subject or a carer., archetypeConceptComment=null, otherContributors=Sam Heard, Ocean Informatics, Australia, originalLanguage=en, translators=Korean: Seung-Jong Yu, NOUSCO Co.,Ltd., seungjong.yu@gmail.com, Certified board of Family medicine
Spanish (Argentina): Guillermo Palli
Arabic (Syria): Mona Saleh
, subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={events=[ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=2, text=Any event, description=Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=null, extendedValues=null]], context=[], capabilities=[], activities=[], protocol=[], identities=[], source=[], credentials=[], state=[], items=[], contacts=[], target=[], relationships=[], description=[], ism_transition=[], content=[], details=[], other_participations=[], data=[ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=4, text=Story, description=Narrative description of the story or clinical history for the subject of care., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0006], code=at0006, itemType=SLOT, level=4, text=Detail, description=Structured detail about the individual's story or patient's history., comment=For example: a specific symptom such as nausea or pain; an event such as a fall off a bicycle; or an issue such as a desire to quit using tobacco., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.symptom.v1 and specialisations Or
openEHR-EHR-CLUSTER.health_event.v1 and specialisations Or
openEHR-EHR-CLUSTER.issue.v1 and specialisations, extendedValues=null]], provider=[]}, topLevelItems={data=ResourceSimplifiedHierarchyItem [path=ROOT_/data[at0001]/events[at0002]/data[at0003], code=at0003, itemType=ITEM_TREE, level=2, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=1..1, cardinalityText=mandatory, subCardinalityFormal=1..*, subCardinalityText=, dataType=ITEM_TREE, bindings=null, values=null, extendedValues=null]}, addHierarchyItemsTo=data, currentHierarchyItemsForAdding=[ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=4, text=Story, description=Narrative description of the story or clinical history for the subject of care., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0006], code=at0006, itemType=SLOT, level=4, text=Detail, description=Structured detail about the individual's story or patient's history., comment=For example: a specific symptom such as nausea or pain; an event such as a fall off a bicycle; or an issue such as a desire to quit using tobacco., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.symptom.v1 and specialisations Or
openEHR-EHR-CLUSTER.health_event.v1 and specialisations Or
openEHR-EHR-CLUSTER.issue.v1 and specialisations, extendedValues=null]], minIndents={}, termBindingRetrievalErrorMessage=null]