| ARCHETYPE ID | openEHR-EHR-COMPOSITION.event_summary.v1 |
|---|---|
| Concept | Event Summary |
| Description | A record, reported by a clinician, of one significant health care event involving the subject of care. |
| Use | An Event Summary may also be used to update a health care provider's local record or to share information, at the discretion of the clinician and with the consent of the individual. |
| Purpose | The aim of an Event Summary is to provide information to an individual's Personally Controlled Electronic Health Record (PCEHR) of significant health care events, at the discretion of the clinician, with the consent of the individual. |
| References | |
| Copyright | © openEHR Foundation |
| Authors | Author name: Organisation: National E-Health Transition Authority Email: clinicalinfo@nehta.gov.au Date originally authored: 08-Sep-2011 |
| Other Details Language | Author name: Organisation: National E-Health Transition Authority Email: clinicalinfo@nehta.gov.au Date originally authored: 08-Sep-2011 |
| Other Details (Language Independent) |
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| Keywords | |
| Lifecycle | OrganisationDraft |
| UID | 1.2.36.1.2001.1001.100.136.1.1 |
| Language used | en |
| Citeable Identifier | 1013.1.986 |
| content | |
| Event Details | Event Details: Summary information concerning the event. Optional[{spec_id=148, detail_docref=sections/NEHTA-16672-Event_Details-Section.xml, dc_id=16672.136.1}] Include: openEHR-EHR-SECTION.event_ Exclude: All not explicitly included archetypes |
| Newly Identified Adverse Reactions | Newly Identified Adverse Reactions: Information about adverse reactions of the patient (including allergies and intolerances), and any relevant reaction details. This includes statements about adverse reactions that need to be positively recorded as absent or excluded. Includes adverse reactions of which the author became aware during the health event. Optional[{dc_id=20113.136.1, detail_docref=sections/NEHTA-20113-Newly_Identified_Adverse_Reactions-Section.xml, spec_id=88}] Include: openEHR-EHR-SECTION.adverse_ Exclude: All not explicitly included archetypes |
| Medications | Medications: Therapeutic Goods which are/were prescribed for the patient or the patient has/had been taking. Optional[{spec_id=86, detail_docref=sections/NEHTA-16146-Medications-Section.xml, dc_id=16146.136.1}] Include: openEHR-EHR-SECTION.medication_ Exclude: All not explicitly included archetypes |
| Diagnoses/Interventions | Diagnoses/Interventions: The current and past medical history of the subject of care which is relevant to the clinical event, this includes problem/diagnosis and medical or surgical procedures performed. This includes diagnoses that were identified at the event which are significant to it, and also any interventions performed during the event or those occurring in the past that are significant to it. Optional[{dc_id=16117.136.1, detail_docref=sections/NEHTA-16117-Diagnoses_Interventions-Section.xml, spec_id=134}] Include: openEHR-EHR-SECTION.medical_ Exclude: All not explicitly included archetypes |
| Administered Immunisations | Administered Immunisations: Information about the immunisation history of the subject of care. Optional[{spec_id=137, detail_docref=sections/NEHTA-16638-Administered_Immunisations-Section.xml, dc_id=16638.136.1}] Include: openEHR-EHR-SECTION.immunisations.v1 and specialisations Exclude: All not explicitly included archetypes |
| Diagnostic Investigations | Diagnostic Investigations: Describes the diagnostic tests or procedures performed on or requested for the subject of care during the healthcare event, that are considered to be relevant to the subject of care’s ongoing care. Optional[{spec_id=91, detail_docref=sections/NEHTA-20117-Diagnostic_Investigations-Section.xml, dc_id=20117.136.1}] Include: openEHR-EHR-SECTION.diagnostic_ Exclude: All not explicitly included archetypes |
| data | |
| Category | |
| null |
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| Other contributors | |
| Translators |