| ARCHETYPE ID | openEHR-EHR-SECTION.medical_history.v1 |
|---|---|
| Concept | Medical History |
| Description | The 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 |
| Authors | Author name: Organisation: National E-Health Transition Authority Email: clinicalinfo@nehta.gov.au Date originally authored: 28-Apr-2011 |
| Other Details Language | Author name: Organisation: National E-Health Transition Authority Email: clinicalinfo@nehta.gov.au Date originally authored: 28-Apr-2011 |
| Other Details (Language Independent) |
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| Keywords | |
| Lifecycle | ApprovedCandidate |
| UID | 1.2.36.1.2001.1001.100.134.1.0 |
| Language used | en |
| Citeable Identifier | 1013.1.975 |
| Archetype Concept Comment | 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. |
| items | |
| Problem/Diagnosis | Problem/Diagnosis: The problems and/or diagnoses that form part of the past and current medical history of the subject of care. 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. Optional[{dc_id=15530.134.1, detail_docref=data_groups/NEHTA-15530-Problem_Diagnosis-Data_Group.xml, spec_id=12}] Include: openEHR-EHR-EVALUATION.problem_ Exclude: All not explicitly included archetypes |
| Exclusion Statement - Problems and Diagnoses | Exclusion Statement - Problems and Diagnoses: Statements that positively assert that the patient does not have the problem or diagnosis. To positively record the absence or exclusion of any problems or diagnoses within the health record. Optional[{dc_id=16138.134.1, detail_docref=data_groups/NEHTA-16138-Exclusion_Statement_Problems_and_Diagnoses-Data_Group.xml, spec_id=103}] Include: openEHR-EHR-EVALUATION.exclusion-problem_ Exclude: All not explicitly included archetypes |
| Procedure | Procedure: A clinical activity carried out for therapeutic, evaluative, investigative, screening or diagnostic purposes. Optional[{spec_id=45, detail_docref=data_groups/NEHTA-15514-Procedure-Data_Group.xml, dc_id=15514.134.1}] Include: openEHR-EHR-ACTION.procedure.v1 and specialisations Exclude: All not explicitly included archetypes |
| Exclusion Statement - Procedures | Exclusion Statement - Procedures: Statements to positively assert that a certain procedure has not been performed on the patient. Assertions that procedures have NOT been performed. Optional[{dc_id=16603.134.1, detail_docref=data_groups/NEHTA-16603-Exclusion_Statement_Procedures-Data_Group.xml, spec_id=125}] Include: openEHR-EHR-EVALUATION.exclusion-procedure.v1 and specialisations Exclude: All not explicitly included archetypes |
| Medical History Item | Medical History Item: A medical history entry which cannot be categorised into one of the categories such as Procedure and Problem/Diagnosis. Optional[{spec_id=135, detail_docref=data_groups/NEHTA-16627-Medical_History_Item-Data_Group.xml, dc_id=16627.134.1}] Include: openEHR-EHR-EVALUATION.medical_ Exclude: All not explicitly included archetypes |
| Other contributors | |
| Translators |