ARCHETYPE Medical History (openEHR-EHR-SECTION.medical_history.v1)

ARCHETYPE IDopenEHR-EHR-SECTION.medical_history.v1
ConceptMedical History
DescriptionThe current and past medical history of the subject of care, this includes problem/diagnosis and medical or surgical procedures performed.
Purpose To group together information relating to the past medical history of a patient.
References
Copyright© openEHR Foundation
AuthorsAuthor name:
Organisation: National E-Health Transition Authority
Email: clinicalinfo@nehta.gov.au
Date originally authored: 28-Apr-2011
Other Details LanguageAuthor name:
Organisation: National E-Health Transition Authority
Email: clinicalinfo@nehta.gov.au
Date originally authored: 28-Apr-2011
OtherDetails Language Independent{MD5-CAM-1.0.1=CD6667C464F52095CB16437AAF6B915A}
Keywords
LifecycleApprovedCandidate
UID1.2.36.1.2001.1001.100.134.1.0
Language useden
Citeable Identifier1013.1.975
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=The current and past medical history of the subject of care, this includes problem/diagnosis and medical or surgical procedures performed., archetypeConceptComment=Relevant information regarding clinical/health history, family history about a subject of care, and clinical interventions (procedures) previously performed on a subject of care as reported by the subject and/or identified by the healthcare provider. This includes health and family histories and performed clinical interventions which are assessed to be relevant/important for the ongoing management of a subject's current/active problems or diagnoses., otherContributors=, originalLanguage=en, translators=, subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={identities=[], activities=[], credentials=[], state=[], capabilities=[], items=[ResourceSimplifiedHierarchyItem [path=/items[at0003], code=at0003, itemType=SLOT, level=1, text=Problem/Diagnosis, description=The problems and/or diagnoses that form part of the past and current medical history of the subject of care., comment=An account of relevant identified health related problems as reported by a healthcare provider. This can include a disease, condition, injury, poisoning, sign, symptom, abnormal finding, complaint, or other factor influencing health status as assessed by a healthcare provider. This item is repeated for every instance of a problem/diagnosis., uncommonOntologyItems={detail_docref=data_groups/NEHTA-15530-Problem_Diagnosis-Data_Group.xml, dc_id=15530.134.1, spec_id=12}, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=Include:
openEHR-EHR-EVALUATION.problem_diagnosis.v5 and specialisations
Exclude:
All not explicitly included archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002], code=at0002, itemType=SLOT, level=1, text=Exclusion Statement - Problems and Diagnoses, description=Statements that positively assert that the patient does not have the problem or diagnosis., comment=To positively record the absence or exclusion of any problems or diagnoses within the health record., uncommonOntologyItems={detail_docref=data_groups/NEHTA-16138-Exclusion_Statement_Problems_and_Diagnoses-Data_Group.xml, dc_id=16138.134.1, spec_id=103}, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=Include:
openEHR-EHR-EVALUATION.exclusion-problem_diagnosis.v1 and specialisations
Exclude:
All not explicitly included archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0004], code=at0004, itemType=SLOT, level=1, text=Procedure, description=A clinical activity carried out for therapeutic, evaluative, investigative, screening or diagnostic purposes., comment=null, uncommonOntologyItems={detail_docref=data_groups/NEHTA-15514-Procedure-Data_Group.xml, dc_id=15514.134.1, spec_id=45}, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ACTION, bindings=null, values=Include:
openEHR-EHR-ACTION.procedure.v1 and specialisations
Exclude:
All not explicitly included archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0005], code=at0005, itemType=SLOT, level=1, text=Exclusion Statement - Procedures, description=Statements to positively assert that a certain procedure has not been performed on the patient., comment=Assertions that procedures have NOT been performed., uncommonOntologyItems={detail_docref=data_groups/NEHTA-16603-Exclusion_Statement_Procedures-Data_Group.xml, dc_id=16603.134.1, spec_id=125}, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=Include:
openEHR-EHR-EVALUATION.exclusion-procedure.v1 and specialisations
Exclude:
All not explicitly included archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0006], code=at0006, itemType=SLOT, level=1, text=Medical History Item, description=A medical history entry which cannot be categorised into one of the categories such as Procedure and Problem/Diagnosis., comment=null, uncommonOntologyItems={detail_docref=data_groups/NEHTA-16627-Medical_History_Item-Data_Group.xml, dc_id=16627.134.1, spec_id=135}, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=Include:
openEHR-EHR-EVALUATION.medical_history_item.v1 and specialisations
Exclude:
All not explicitly included archetypes, extendedValues=null]], events=[], provider=[], content=[], target=[], contacts=[], protocol=[], other_participations=[], relationships=[], ism_transition=[], description=[], source=[], data=[], context=[], details=[]}, topLevelItems={items=ResourceSimplifiedHierarchyItem [path=ROOT_/items[at0003], code=at0003, itemType=EVALUATION, level=0, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=null, extendedValues=null]}, addHierarchyItemsTo=items, currentHierarchyItemsForAdding=[ResourceSimplifiedHierarchyItem [path=/items[at0003], code=at0003, itemType=SLOT, level=1, text=Problem/Diagnosis, description=The problems and/or diagnoses that form part of the past and current medical history of the subject of care., comment=An account of relevant identified health related problems as reported by a healthcare provider. This can include a disease, condition, injury, poisoning, sign, symptom, abnormal finding, complaint, or other factor influencing health status as assessed by a healthcare provider. This item is repeated for every instance of a problem/diagnosis., uncommonOntologyItems={detail_docref=data_groups/NEHTA-15530-Problem_Diagnosis-Data_Group.xml, dc_id=15530.134.1, spec_id=12}, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=Include:
openEHR-EHR-EVALUATION.problem_diagnosis.v5 and specialisations
Exclude:
All not explicitly included archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002], code=at0002, itemType=SLOT, level=1, text=Exclusion Statement - Problems and Diagnoses, description=Statements that positively assert that the patient does not have the problem or diagnosis., comment=To positively record the absence or exclusion of any problems or diagnoses within the health record., uncommonOntologyItems={detail_docref=data_groups/NEHTA-16138-Exclusion_Statement_Problems_and_Diagnoses-Data_Group.xml, dc_id=16138.134.1, spec_id=103}, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=Include:
openEHR-EHR-EVALUATION.exclusion-problem_diagnosis.v1 and specialisations
Exclude:
All not explicitly included archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0004], code=at0004, itemType=SLOT, level=1, text=Procedure, description=A clinical activity carried out for therapeutic, evaluative, investigative, screening or diagnostic purposes., comment=null, uncommonOntologyItems={detail_docref=data_groups/NEHTA-15514-Procedure-Data_Group.xml, dc_id=15514.134.1, spec_id=45}, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ACTION, bindings=null, values=Include:
openEHR-EHR-ACTION.procedure.v1 and specialisations
Exclude:
All not explicitly included archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0005], code=at0005, itemType=SLOT, level=1, text=Exclusion Statement - Procedures, description=Statements to positively assert that a certain procedure has not been performed on the patient., comment=Assertions that procedures have NOT been performed., uncommonOntologyItems={detail_docref=data_groups/NEHTA-16603-Exclusion_Statement_Procedures-Data_Group.xml, dc_id=16603.134.1, spec_id=125}, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=Include:
openEHR-EHR-EVALUATION.exclusion-procedure.v1 and specialisations
Exclude:
All not explicitly included archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0006], code=at0006, itemType=SLOT, level=1, text=Medical History Item, description=A medical history entry which cannot be categorised into one of the categories such as Procedure and Problem/Diagnosis., comment=null, uncommonOntologyItems={detail_docref=data_groups/NEHTA-16627-Medical_History_Item-Data_Group.xml, dc_id=16627.134.1, spec_id=135}, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=Include:
openEHR-EHR-EVALUATION.medical_history_item.v1 and specialisations
Exclude:
All not explicitly included archetypes, extendedValues=null]], minIndents={}, termBindingRetrievalErrorMessage=null]