| TEMPLATE ID | Hearing Health Program Nurse Consultation |
|---|---|
| Concept | Hearing Health Program Nurse Consultation |
| Description | To record a consultation by an ENT nurse in the NT Hearing Health Program |
| Use | Use to record the details of a nursing consultation for the purposes of nursing assessment, sharing of details with remote ENT specialists via teleotology and pre-operative assessment. |
| Purpose | To record a consultation by an ENT nurse in the NT Hearing Health Program |
| References | |
| Other Details (Language Independent) |
|
| Language used | en |
| Citeable Identifier | 1013.26.502 |
| Root archetype id | openEHR-EHR-COMPOSITION.encounter.v1 |
| ENT Nurse Consultation | ENT Nurse Consultation: Generic encounter or progress note composition. |
| Reason for Encounter | Reason for Encounter: The administrative and/or clinical reason/s for initiation of a healthcare encounter or other service. |
| Reason for Contact | Reason for Contact: Identification of administrative reason for intiation of a healthcare encounter. For example, a clinical consultation, emergency consultation, pre-employment medical, routine antenatal visit, women's health check, pre-operative assessment, or annual medical check-up. Coding of the 'Reason for Contact' with a terminology is desirable, where possible.
Annotations
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| Clinical History | Clinical History: A generic heading for contextual renaming within a template. |
| Presenting History | Presenting History: Narrative description of the clinical history or story. |
| Nil Significant | Nil Significant: The person has not had any significant experience of the symptom. |
| Clinical Description | Clinical Description: Description of the symptom. |
| Duration | Duration: The duration of the symptom since onset. Units:
|
| Number of Occurrences | Number of Occurrences: The number of times this symptom has occurred. |
| Description of Discharge | Description of Discharge: The character of the symptom. |
| Reported Right Ear Discharge | Reported Right Ear Discharge: A subjective observation by an individual about departure from normal function and which may indicate the presence of disease or abnormality. Either self-recorded or recorded on the behalf of a patient by a clinician. |
| Nil Significant | Nil Significant: The person has not had any significant experience of the symptom. |
| Clinical Description | Clinical Description: Description of the symptom. |
| Severity | Severity: The severity of the symptom.
|
| Current Intensity | Current Intensity: Measures of the intensity of the symptom at this time. |
| Degree | Degree: The degree the symptom is bothering the patient.
|
| Visual Analogue Score | Visual Analogue Score: A score from 0 (not present) to 10 (as bad as it could be). 0..10 |
| Degree | Degree: The intensity of the symptom expressed as a proportion.
|
| Duration | Duration: The duration of the symptom since onset. |
| Number of Occurrences | Number of Occurrences: The number of times this symptom has occurred. |
| Character | Character: The character of the symptom. |
| Variation | Variation: The variation of the symptom.
|
| Previous Episodes | Previous Episodes: Details about previous episodes. |
| Any Previous Episodes | Any Previous Episodes: Have there been any previous episodes of this symptom. |
| Previous Episode | Previous Episode: Details about a specific episode. |
| Date / time of previous episode | Date / time of previous episode: Date/time of previous episode. |
| Details | Details: Details of previous symptoms and comparison to this episode. |
| Comparison | Comparison: How the previous episode compares with this one. |
| Number of Previous Episodes | Number of Previous Episodes: Number of previous episodes. >=0 |
| Course | Course: Features of the course of the symptom. |
| Onset Type | Onset Type: The nature of the onset of the symptom.
|
| Onset Description | Onset Description: Activity or situation at and details of onset. |
| Time of Maximum Intensity | Time of Maximum Intensity: The time (and/or date) of maximum intensity of the symptom. |
| Progression | Progression: The progress of the symptom relative to the past.
|
| Cessation | Cessation: The nature of the cessation of the symptom.
|
| Precipitating factors | Precipitating factors: Factors that trigger or bring on the symptom. |
| Precipitating Factor | Precipitating Factor: An event or activity that brings on or triggers the symptom. |
| Modification | Modification: Factors that change the level of intensity of the symptom. |
| Modifying Factor | Modifying Factor: Information about a specific factor that changes the symptom. |
| Factor | Factor: An event or activity that modifies the symptom. |
| Change | Change: An event or activity that makes the symptom worse.
|
| Details | Details: Details of the effect. |
| Features not present | Features not present: Anticipated features which are not present. |
| Absent feature | Absent feature: A feature that is not present. |
| Reported Hearing Loss | Reported Hearing Loss: A subjective observation by an individual about departure from normal function and which may indicate the presence of disease or abnormality. Either self-recorded or recorded on the behalf of a patient by a clinician. |
| Nil Significant | Nil Significant: The person has not had any significant experience of the symptom. |
| Clinical Description | Clinical Description: Description of the symptom. |
| Duration | Duration: The duration of the symptom since onset. Units:
|
| Reported Left Ear Pain | Reported Left Ear Pain: A subjective observation by an individual about pain experienced. Either self-recorded or recorded on the behalf of a patient by a clinician. |
| Nil Significant | Nil Significant: The person has not had any significant experience of the symptom. |
| Clinical Description | Clinical Description: Description of the symptom. |
| Duration | Duration: The duration of the symptom since onset. Units:
|
| Precipitating factors | Precipitating factors: Factors that trigger or bring on the symptom. |
| Precipitating Factor | Precipitating Factor: An event or activity that brings on or triggers the symptom. |
| Reported Right Ear Pain | Reported Right Ear Pain: A subjective observation by an individual about pain experienced. Either self-recorded or recorded on the behalf of a patient by a clinician. |
| Nil Significant | Nil Significant: The person has not had any significant experience of the symptom. |
| Clinical Description | Clinical Description: Description of the symptom. |
| Severity | Severity: The severity of the symptom.
|
| Current Intensity | Current Intensity: Measures of the intensity of the symptom at this time. |
| Degree | Degree: The degree the symptom is bothering the patient.
|
| Pain Score | Pain Score: A score from 0 (not present) to 10 (as bad as it could be). 0..10 |
| Degree | Degree: The intensity of the symptom expressed as a proportion.
|
| Duration | Duration: The duration of the symptom since onset. |
| Number of Occurrences | Number of Occurrences: The number of times this symptom has occurred. |
| Character | Character: The character of the symptom. |
| Variation | Variation: The variation of the symptom.
|
| Previous Episodes | Previous Episodes: Details about previous episodes. |
| Any Previous Episodes | Any Previous Episodes: Have there been any previous episodes of this symptom. |
| Previous Episode | Previous Episode: Details about a specific episode. |
| Date / time of previous episode | Date / time of previous episode: Date/time of previous episode. |
| Details | Details: Details of previous symptoms and comparison to this episode. |
| Comparison | Comparison: How the previous episode compares with this one. |
| Number of Previous Episodes | Number of Previous Episodes: Number of previous episodes. >=0 |
| Course | Course: Features of the course of the symptom. |
| Onset Type | Onset Type: The nature of the onset of the symptom.
|
| Onset Description | Onset Description: Activity or situation at and details of onset. |
| Time of Maximum Intensity | Time of Maximum Intensity: The time (and/or date) of maximum intensity of the symptom. |
| Progression | Progression: The progress of the symptom relative to the past.
|
| Cessation | Cessation: The nature of the cessation of the symptom.
|
| Precipitating factors | Precipitating factors: Factors that trigger or bring on the symptom. |
| Precipitating Factor | Precipitating Factor: An event or activity that brings on or triggers the symptom. |
| Modification | Modification: Factors that change the level of intensity of the symptom. |
| Modifying Factor | Modifying Factor: Information about a specific factor that changes the symptom. |
| Factor | Factor: An event or activity that modifies the symptom. |
| Change | Change: An event or activity that makes the symptom worse.
|
| Details | Details: Details of the effect. |
| Features not present | Features not present: Anticipated features which are not present. |
| Absent feature | Absent feature: A feature that is not present. |
| Associated Problems | Associated Problems: A generic heading for contextual renaming within a template. |
| Other Problem | Other Problem: Identification of the problem or diagnosis. Coding of the problem or diagnosis with a terminology is preferred, where possible.
|
| Clinical description | Clinical description: Narrative description or comments about clinical aspects of the problem/diagnosis. |
| Social Summary | Social Summary: Summary information about social circumstances or experiences that may have a potential impact on an individual's health. |
| Data | |
| Description | Description: Narrative summary about social circumstances or experiences that may have a potential impact on an individual's health. May be used to record a narrative summary of the complete social circumstances or experiences or key aspects of the social summary, which will be supported by additioanl structured data. Details of specific structured findings can be included using CLUSTER archetypes in the 'Social Summary Detail' slot. |
| Actions before Otoscopy | Actions before Otoscopy: A generic heading for contextual renaming within a template. |
| Ear Cleaning | Ear Cleaning: A clinical activity carried out for therapeutic, evaluative, investigative, screening or diagnostic purposes. |
| Procedure name | Procedure name: The name of the procedure (to be) performed. Coding of the specific procedure with a terminology is preferred, where possible. Default value: Ear Cleaned |
| Description | Description: Narrative description about the activity or care pathway step for the identified procedure, for example description about the performance and findings from the the procedure, the failed attempt or the cancellation of the procedure. |
| Ear Cleaning Details | Ear Cleaning Details: Details about method for cleaning the external ear canal. |
| Ear Cleaned | Ear Cleaned: Identification of the ear being cleaned.
|
| Description | Description: Narrative description of the ear cleaning activity. For example, describing any difficulties encountered and/or the nature of the returned fluid. |
| Method | Method: Method used for ear wash. Coding with a terminology is preferred, if possible. For example: ear wash; suction; instrument; or tissue spears.
|
| Wash Agent | Wash Agent: Substance used for ear wash. Coding with a terminology is preferred, if possible. For example: water, acetic acid or betadine 5%.
|
| Instrument | Instrument: Instrument used to assist cleaning. Coding with a terminology is preferred, if possible. For example Jobson Horne probe, or micro forceps.
|
| Outcome | Outcome: Description of the outcome of ear cleaning. Coding with a terminology is preferred, if possible. For example: attempted, partially completed or successful removal of ear wax, pus or a foreign body. |
| Post-cleaning Multimedia | Post-cleaning Multimedia: Multimedia image or diagram recorded at the conclusion of cleaning of the external auditory canal. Pre-cleaning images or diagrams can be included as part of the examination of CLUSTER.exam_tympanic_membrane archetype. |
| Image of auditory canal/TM | Image of auditory canal/TM: Multimedia representation of the procedure undertaken, for example, a link to a video of the procedure performed or a drawing of the wound/surgery etc. |
| Procedure | Procedure: A clinical activity carried out for therapeutic, evaluative, investigative, screening or diagnostic purposes. |
| Description | |
| Procedure name | Procedure name: The name of the procedure (to be) performed. Coding of the specific procedure with a terminology is preferred, where possible. |
| Description | Description: Narrative description about the activity or care pathway step for the identified procedure, for example description about the performance and findings from the the procedure, the failed attempt or the cancellation of the procedure. |
| Comment | Comment: Additional narrative about the activity or care pathway step not captured in other fields. |
| Examination Findings | Examination Findings: A generic heading for contextual renaming within a template. |
| Ear Examination Findings | Ear Examination Findings: Findings observed during the physical examination of a subject. |
| Examination of External Auditory Canal and Tympanic Membrane | Examination of External Auditory Canal and Tympanic Membrane: Physical examination of the external auditory canal and tympanic membrane by a clinician. |
| Ear Examined | Ear Examined: Identification of the ear under examination.
|
| Clinical Description | Clinical Description: Narrative description of findings observed by a clinician during a physical examination of the external auditory canal and tympanic membrane. Use this data element to provide additional, narrative description of any data elements related to the external auditory canal and tympanic membrane examination as a whole, that are not represented by structured values. For example, the relative size and surface of the auditory canal; increased vascularity of the tympanic membrane; presence of abnormalities not captured in specific structured data elements, such as presence of canal stenosis, exostoses, mastoid bowl/cavity or tumours. |
| Consistency of Wax | Consistency of Wax: Description of the type of wax in the external auditory canal. Presence of hard wax has implications on treatment decisions. Presence of soft wax may be a causative factor in visual occlusion.
|
| State of Wax | State of Wax: Description of the state of the wax observed in the external auditory canal.
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| View of Tympanic Membrane | View of Tympanic Membrane: View of the tympanic membrane.
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| Reason for Occlusion of View | Reason for Occlusion of View: Description of the reason for occlusion to the view of the tympanic membrane. For example, soft wax or foreign body. |
| Tenderness of Canal | Tenderness of Canal: Presence of tenderness in the external auditory canal.
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| Oedema of Canal | Oedema of Canal: Presence of oedema in the external auditory canal.
|
| Erythema of Canal | Erythema of Canal: Presence of erythema or redness in the external auditory canal.
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| Offensive Odour | Offensive Odour: Presence of any offensive odour originating from the external auditory canal.
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| Discharge Type | Discharge Type: Type of discharge observed in the external auditory canal or at the tympanic membrane perforation.
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| Discharge Amount | Discharge Amount: Amount of discharge observed in the external auditory canal or at the tympanic membrane perforation.
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| Ventilation Tube Position | Ventilation Tube Position: Observed position of the ventilation tube (or grommet) in the tympanic membrane or the auditory canal. There is value in identifying the presence of ventilation tubes in all examinations. There is no value in recording the absence of ventilation tubes if they have never been inserted. Note, however, that it is useful to record the extrusion of ventilation tubes if there is a known history of previous ventilation tube insertion.
|
| Abnormal Features | Abnormal Features: Details about abnormal features noted during the examination of the external auditory canal. |
| Polyps | Polyps: Presence of polyp/polyps in the external auditory canal.
|
| Fungal Spores | Fungal Spores: Presence of fungal spores in the external auditory canal.
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| Foreign Body | Foreign Body: Presence of a foreign body in the external auditory canal.
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| Location of Foreign Body | Location of Foreign Body: Location of the foreign body within the external auditory canal.
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| Tympanic Membrane Details | Tympanic Membrane Details: Details about findings on examination of the tympanic membrane. |
| Membrane Intact? | Membrane Intact?: Is the tympanic membrane intact?
|
| Appearance | Appearance: Category describing the appearance of the tympanic membrane. In most situations, this data element would only be recorded if the tympanic membrane is intact.
|
| Normal Light Reflex | Normal Light Reflex: Presence of a normal light reflex noted. In most situations, this data element would only be recorded if the tympanic membrane is intact. A 'normal' light reflex may be described as : a complete, bright triangular area of reflected light seen in the anteroinferior portion of the tympanic membrane.
|
| Surface Features | Surface Features: Features observed on the surface of the tympanic membrane. Data element has multiple occurrences to enable multiple selections, if required. In most situations, this data element would only be recorded if the tympanic membrane is intact.
|
| Colour | Colour: Description of the overall colour of the tympanic membrane. For example: red, bluish, or yellow. |
| Position of Tympanic Membrane | Position of Tympanic Membrane: Description of the position of the tympanic membrane.
|
| Description of Retraction | Description of Retraction: Description of retraction of the tympanic membrane. |
| Fluid Level Presence | Fluid Level Presence: Presence of a fluid level behind the tympanic membrane.
|
| Fluid Level Description | Fluid Level Description: Narrative description of the fluid level and other related features observed behind the tympanic membrane. For example, presence of bubbles. |
| Mobility | Mobility: Description of mobility of the tympanic membrane, usually as determined by pneumatic otoscopy.
|
| Perforation Details | Perforation Details: Details about the tympanic membrane perforation. |
| Estimation of Size | Estimation of Size: Estimation of the size of the tympanic membrane perforation, based on anatomical landmarks. Many clinicians record perforations between the well defined 'pinhole' and 'subtotal' perforations using a variety of terms with inconsistent usage and definitions, such as small, medium and large. 'Intermediate' has been proposed as a means to minimise inter-clinician variability for documenting the size of all perforations falling between the 'pinhole' and 'subtotal' definitions. If more detail is required, then measurement of the perforation should be recorded.
|
| Region | Region: Description of the region of the tympanic membrane perforation. To document if the perforation is in the Pars flaccida and may be potentially unsafe. If 'Total' or 'Subtotal' is selected in 'Estimation of Size' data element then this data element becomes redundant. Coding with a terminology is preferred, if possible.
|
| Marginal? | Marginal?: Location of the tympanic membrane perforation. To document explicitly whether the perforation is located marginally, and therefore might be clinically unsafe. If 'Total' is selected in 'Estimation of Size' data element then this data element becomes redundant.
|
| Anterior? | Anterior?: Is an anterior perforation present? To document the presence of perf in the anterior portions of the pars tensa can be more difficult to manage. If 'Total' or 'Subtotal' is selected in 'Estimation of Size' data element then this data element becomes redundant.
|
| Edge | Edge: Narrative description of the edge of the perforation. |
| Image | Image: Multimedia image taken during the physical examination of the external auditory canal and tympanic membrane. |
| Clinical Interpretation | Clinical Interpretation: Single word, phrase or brief description representing a summary of the examination findings. Coding with a terminology is preferred, if possible. For example, normal examination or chronic otitis media. |
| Comments | Comments: Additional narrative about the physical examination findings of the external auditory canal and tympanic membrane, not captured in other fields. |
| Examination - Pinnae | Examination - Pinnae: Findings observed during the physical examination of each pinna, or the external structure of the ears, and the adjacent periauricular region. |
| Symmetry? | Symmetry?: Description of the symmetry of both ears in comparison to one another.
|
| Per Pinna | Per Pinna: Physical examination findings of an identified pinna. |
| Pinna Examined | Pinna Examined: Identification of the pinna examined.
|
| Clinical Description | Clinical Description: Narrative description of the findings observed during a physical examination of a single identified pinna, including size, shape and position. May be used to record a narrative summary of the complete clinical examination of the body system or anatomical strucutre or key aspects of physical examination findings, which will be further supported by the additional structured data, using CLUSTER archetypes in the 'Examination Detail' slot. This data element may be used to capture legacy data that is not available in a structured format. |
| Post-auricular Scar | Post-auricular Scar: Presence of post-auricular surgical scar observed. |
| Image Representation | Image Representation: Digital image or video taken, or a diagram drawn, during the physical examination of the body system or anatomical structure. |
| Clinical Interpretation | Clinical Interpretation: Single word, phrase or brief description represents the clinical meaning and significance of the physical examination findings. Coding with a terminology is preferred, if possible. For example, normal examination or a specific physical finding. |
| Confounding Factors | Confounding Factors: Description of any incidental factors that may have contributed to the physical examination findings. |
| Body Weight | Body Weight: Measurement of the body weight of an individual. |
| Any event | Any event: Any event. |
| Data | |
| Weight | Weight: The weight of the individual. While recorded as kilogram or pounds, weights can be displayed in systems as grams or as pounds and ounces, as required. Upper limits are set to validate entires based on orders of magnitude eg prevent accidental entry of an extra digit, not to represent possible upper limits of weight. 0..1000; 0..2000 Units:
|
| Comment | Comment: Comment about the measurement of weight. |
| State | |
| State of Dress | State of Dress: Description of the state of dress of the person at the time of weighing.
|
| Pregnant? | Pregnant?: Is the woman pregnant at time of measurement? Assumed value: false |
| Confounding Factors | Confounding Factors: Record any issues or factors that may impact on the measurement of body weight eg timing in menstrual cycle, timing of recent bowel motion or noting of amputation. |
| Protocol | |
| Weight Estimation Formula | Weight Estimation Formula: Formula used to calculate the estimated weight. For example, formula for estimating fetal weight from ultrasound findings. |
| Body Height/Length | Body Height/Length: Body height, or length, is measured from crown of head to sole of foot. Body height is measured with the individual in a standing position and body length in a recumbent position. |
| Data | |
| Any event | Any event: Any timed measurement of body height or length. |
| Data | |
| Height/Length | Height/Length: The length of the body from crown of head to sole of foot. 0..1000; 0..250 Units:
|
| Comment | Comment: Comment about the measurement of body height/length. |
| State | |
| Position | Position: Position of individual when measured.
|
| Confounding factors | Confounding factors: Record any issues or factors that may impact on the measurement of body height or length. For example, uncooperative child making the actual measurement difficult. |
| Presumptive Diagnosis | Presumptive Diagnosis: A generic heading for contextual renaming within a template. |
| Problem/Diagnosis | Problem/Diagnosis: Any health care condition which may impact on the physical, mental and/or social well-being of an individual, that may require diagnostic, therapeutic or educational action, and which has been determined by a clinician. A diagnosis is based on scientific evaluation of physical signs, symptoms, history, laboratory tests results, and procedures. |
| Data | |
| Problem/Diagnosis | Problem/Diagnosis: Identification of the problem or diagnosis. Coding of the problem or diagnosis with a terminology is preferred, where possible.
|
| Differential diagnoses | Differential diagnoses: A set of 1 or more diagnoses considered as reasonable but as yet hypothetical causes of the patients signs and symptoms Set of one or more interim diagnoses that could account for a patient's history, examination findings, measurements and results. In practice, the intent is that as further evidence is gathered differential diagnoses will be eliminated one by one until one diagnosis becomes most likely. |
| Data | |
| Differential | Differential: A group of diagnoses or explanation and likelihoods being considered. |
| Diagnosis | Diagnosis: Identification of diagnosis. It is desirable that this should be coded where possible. |
| Likelihood | Likelihood: The likelihood of this diagnosis being present.
|
| Rationale | Rationale: Rationale for this diagnosis being included as a differential. |
| Comment | Comment: Comment on the whole set of differential diagnoses. |
| Protocol | |
| Reference | Reference: Any literary references supporting the diagnoses. |
| Management | Management: A generic heading for contextual renaming within a template. |
| Health education | Health education: Information provided to the patient in any format. |
| Description | |
| Topic | Topic: Topic of information to be provided.
|
| Description | Description: Description of the information provided. |
| Medication action | Medication action: Details of use, administration, dispensing or other care step relating to a medicine, vaccine or other therapeutic good which may arise from an instruction from a clinician. |
| Description | |
| Medicine | Medicine: The medicine, vaccine or other therapeutic good which was the focus of the action. Value set: ac0001 |
| Instructions | Instructions: Any instructions given to the subject of care or carer at the time of the action. |
| Reason | Reason: The reason(s) the specific action or step was carried out. Note: This is not the reason for the medication instruction, rather the specific reason e.g. for administration or for ceasing the medication. |
| Comment | Comment: A comment on the action taken. |
| Sequence number | Sequence number: The sequence number specific to the action being recorded. |
| Brand substituted | Brand substituted: A different brand of the same medicine, vaccine or other therapeutic good was substituted for the one nominated in the order. |
| Protocol | |
| BatchID | BatchID: Assigned by the manufacturer to identify the manufacturing batch of the item. |
| Expiry date | Expiry date: The expiry date of the medicine administered as documented by the manufacturer. |
| Dispensed to | Dispensed to: The name of the person to whom this was dispensed, if not the subject of care. |
| Number of times dispensed | Number of times dispensed: The number of times this order has been dispensed. The sum of this number minus one and the remaining repeats provides the number of repeats on the original order. |
| Remaining repeats | Remaining repeats: The number of times the medicine, vaccine or other therapeutic good may still be dispensed without re-issue of a prescription or order. Note: This is the information required by the subject of care and prescriber. >=0 |
| Claim category | Claim category: The category of reimbursement or subsidy sought for the item. |
| Informed Consent | Informed Consent: Record of status and details of informed consent from a patient (or patient's agent) for a proposed procedure, trial or other healthcare-related activity (including treatments and investigations), based upon a clear appreciation and understanding of the facts, implications, and possible future consequences by the patient or patient's agent. |
| Description | |
| Procedure/Trial/Activity | Procedure/Trial/Activity: Identification of the procedure, clinical trial or healthcare-related activity (including correct side/correct site, where appropriate) against which the consent status and details are recorded. |
| Procedure/Trial/Activity Description | Procedure/Trial/Activity Description: Narrative description of the procedure, clinical trial or healthcare-related activity. |
| Intent | Intent: Description of the intent of the procedure, clinical trial or healthcare-related activity. |
| Consent Description | Consent Description: Narrative description of the informed consent required or recorded prior to performing the proposed procedure, clinical trial or healthcare-related activity. |
| Form of Consent | Form of Consent: Form of the consent sought or provided.
|
| Reason | Reason: Reason that the care pathway step for the identified procedure, clinical trial or healthcare-related activity was carried out. For example, the reason for 'consent refused' or 'consent withdrawn'. |
| Start Date | Start Date: Date, and optional time, when validity of the informed consent becomes active. |
| End Date | End Date: Date, and optional time, when validity of the informed consent ceased. |
| Caveat | Caveat: Details of any qualifications or exemptions to the informed consent. |
| Evidence of Consent | Evidence of Consent: Evidence of consent status. For example, audio of consent being requested or image of written consent obtained. |
| Protocol | |
| Consent Document Used | Consent Document Used: Identification of the consent form or document used. |
| Review Date | Review Date: Date when consent status is due for review. |
| Patient Information | Patient Information: Details about Patient Information made available to the subject or subject's agent. |
| Name | Name: Identification of the information made available. For example, the name of the form. |
| Description | Description: Narrative description of the patient information made available. |
| Multimedia Representation | Multimedia Representation: Digital representation of the Patient Information made available. |
| Plan | Plan: A generic heading for contextual renaming within a template. |
| Referral request | Referral request: Request for provision of a specified service by another healthcare provider or organisation. |
| Request | Request: Current Activity. |
| Description | |
| Service requested | Service requested: Identification of the service requested. This is often coded with an external terminology.
|
| Description of service | Description of service: A detailed narrative description of the service requested. |
| Reason for request | Reason for request: A short description of the reason for the request. This is often coded with an external terminology. |
| Reason description | Reason description: A narrative description explaining the reason for request. |
| Intent | Intent: Stated intent of the request by the referrer. |
| Urgency | Urgency: Urgency of the request.
|
| Date &/or time service required | Date &/or time service required: The date and time that the service should be performed or completed. |
| Latest date service required | Latest date service required: The latest date that is acceptable for the service to be completed. |
| Supplementary information to follow | Supplementary information to follow: True indicates that additional information has been identified and will be forwarded when available eg incomplete pathology test results. |
| Supplementary information expected | Supplementary information expected: Details of the nature of supplementary information that is to follow e.g name of laboratory results. |
| Protocol | |
| Requestor Identifier | Requestor Identifier: The local ID assigned to the order by the healthcare provider or organisation requesting the service. This is also referred to as Placer Order Identifier. |
| Receiver identifier | Receiver identifier: The ID assigned to the order by the healthcare provider or organisation receiving the request for service. This is also referred to as Filler Order Identifier. |
| Request status | Request status: The status of the request for service as indicated by the requester. Status is used to denote whether this is the initial request, or a follow-up request to change or provide supplementary information. |
| Duration | Duration: Length of time the referral is valid. |
| Duration | Duration: Duration for which the referral is valid. |
| Indefinite | Indefinite: If true, referral is for an indefinite period of time. |
| Medication instruction | Medication instruction: Details of a medicine, vaccine or other therapeutic good with instructions for use. |
| Order | Order: The instructions for a particular medicine, vaccine or other therapeutic good including dose and timing. |
| Description | |
| Medicine | Medicine: The medicine, vaccine or other therapeutic good being ordered, administered to or used by the subject of care. This item should be coded if possible. |
| Directions | Directions: A complete narrative description of how much, when and how to use the medicine, vaccine or other therapeutic good. |
| Dose description | Dose description: The amount and units of the medicine, vaccine or other therapeutic good to be used or administered at one time. |
| Timing | Timing: Details of the timing of the use or administration of the medicine, vaccine or other therapeutic good. |
| Timing description | Timing description: The timing of the doses, which may include frequency and details such as relationship to food. |
| PRN | PRN: The timing is dependent within limits on the subject of care's condition or symptoms (e.g. 4hrly p.r.n. means the medicine can be taken as frequently as every four hours if necessary). "Pro re nata" in latin means as circumstances arise. |
| Start criterion | Start criterion: A condition which, when met, requires the start of administration or use. |
| Start date | Start date: The date and optional time to begin using the medicine, vaccine or other therapeutic good. |
| Stop criterion | Stop criterion: A condition which, when met, requires the cessation of administration or use. |
| Stop date | Stop date: The date and optional time to stop using the medicine, vaccine or other therapeutic good. |
| Duration of treatment | Duration of treatment: The length of time for which the medicine, vaccine or other therapeutic good should be used or administered (from the initial dose to the final dose). |
| Number of administrations | Number of administrations: The total number of doses of the medicine, vaccine or other therapeutic good that are to be used or administered (from the initial dose to the final dose). |
| Long-term | Long-term: It is anticipated that the medicine, vaccine or therapeutic good will be re-prescribed or re-dispensed over a period of time. |
| Additional instruction | Additional instruction: An additional statement on how to use the medicine, vaccine or other therapeutic good. |
| Clinical Indication | Clinical Indication: A reason for ordering the medicine, vaccine or other therapeutic good. |
| Comment | Comment: Any additional information that may be needed to ensure the continuity of supply, rationale for current dose and timing, or safe and appropriate use. |
| Dispensing | Dispensing: Information for the dispenser. |
| Number of repeats | Number of repeats: The number of times the expressed quantity of medicine, vaccine or other therapeutic good may be refilled or redispensed without a new prescription. >=0 |
| Minimum interval between repeats | Minimum interval between repeats: The minimum time between repeat dispensing of the medicine, vaccine or therapeutic good. Note: This is specified by the ordering clinician for a specific reason such as safety or best practice. |
| Brand substitution permitted | Brand substitution permitted: Indicates whether or not the substitution of a prescribed medicine with a different brand name of the same medicine, vaccine or other therapeutic good, which has been determined as bioequivalent, is allowed when the medication is dispensed/supplied. |
| Dispensing instructions | Dispensing instructions: Additional instructions to the person dispensing the medicine, vaccine or other therapeutic good. |
| Protocol | |
| Indication for authorised use | Indication for authorised use: The specific indication for use that is required by an authorising agency to achieve subsidy for or access to the medicine, vaccine or other therapeutic good. This could be a national medication scheme, insurance company or other funding agency. |
| Medication Instruction Id | Medication Instruction Id: An identifier used in an external system and associated with this medication instruction. |
| Concession benefit | Concession benefit: Indicates the category of subsidy appropriate to the item being prescribed. |
| Followup request | Followup request: Request for a range of different healthcare services, for example, a referral, lab request, equipment request. |
| Request | Request: Current Activity. |
| timing | timing: Annotations
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| Description | |
| Service requested | Service requested: Identification of the service requested. This is often coded with an external terminology. |
| Description of service | Description of service: A detailed narrative description of the service requested. |
| Reason for request | Reason for request: A short description of the reason for the request. This is often coded with an external terminology. |
| Reason description | Reason description: A narrative description explaining the reason for request. |
| Intent | Intent: Stated intent of the request by the referrer. |
| Urgency | Urgency: Urgency of the request.
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| Date &/or time service required | Date &/or time service required: The date and time that the service should be performed or completed. |
| Latest date service required | Latest date service required: The latest date that is acceptable for the service to be completed. |
| Supplementary information to follow | Supplementary information to follow: True indicates that additional information has been identified and will be forwarded when available eg incomplete pathology test results. |
| Supplementary information expected | Supplementary information expected: Details of the nature of supplementary information that is to follow e.g name of laboratory results. |
| Protocol | |
| Requestor Identifier | Requestor Identifier: The local ID assigned to the order by the healthcare provider or organisation requesting the service. This is also referred to as Placer Order Identifier. |
| Receiver identifier | Receiver identifier: The ID assigned to the order by the healthcare provider or organisation receiving the request for service. This is also referred to as Filler Order Identifier. |
| Request status | Request status: The status of the request for service as indicated by the requester. Status is used to denote whether this is the initial request, or a follow-up request to change or provide supplementary information. |
| Procedure request | Procedure request: Request for a procedure to be performed. |
| Request | Request: Current Activity. |
| Description | |
| Procedure requested | Procedure requested: Identification of the service requested. This is often coded with an external terminology. |
| Type of procedure | Type of procedure: Description about the type of procedure. |
| Description of Procedure | Description of Procedure: A detailed narrative description of the service requested. |
| Reason for request | Reason for request: A short description of the reason for the request or indication. This is often coded with an external terminology. |
| Reason description | Reason description: A narrative description explaining the reason for request. |
| Objective | Objective: Details about specific objective or goal to be achieved by procedure. |
| Intent | Intent: Intended impact on underlying health condition or issue eg preventive, curative, palliative, adjunct, adjuvant or supportive. |
| Urgency | Urgency: Urgency of the request.
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| Date &/or time service required | Date &/or time service required: The date and time that the service should be performed or completed. |
| Latest date service required | Latest date service required: The latest date that is acceptable for the service to be completed. |
| Supplementary information to follow | Supplementary information to follow: True indicates that additional information has been identified and will be forwarded when available eg incomplete pathology test results. |
| Supplementary information expected | Supplementary information expected: Details of the nature of supplementary information that is to follow e.g name of laboratory results. |
| Protocol | |
| Requestor Identifier | Requestor Identifier: The local ID assigned to the order by the healthcare provider or organisation requesting the service. This is also referred to as Placer Order Identifier. |
| Receiver identifier | Receiver identifier: The ID assigned to the order by the healthcare provider or organisation receiving the request for service. This is also referred to as Filler Order Identifier. |
| Request status | Request status: The status of the request for service as indicated by the requester. Status is used to denote whether this is the initial request, or a follow-up request to change or provide supplementary information. |
| Clinical Synopsis | Clinical Synopsis: A narrative summary about a patient, from the perspective of a healthcare provider. |
| Data | |
| Synopsis | Synopsis: An abstract or summary narrative of the assessment, conclusion or evaluation of the clinical findings. |