| TEMPLATE ID | NT HHIMS ENT Nurse Consultation |
|---|---|
| Concept | NT HHIMS ENT Nurse Consultation |
| Description | To record the details of 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 the details of a consultation by an ENT nurse in the NT Hearing Health Program |
| References | |
| Other Details (Language Independent) |
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| Language used | en |
| Citeable Identifier | 1013.26.531 |
| Root archetype id | openEHR-EHR-COMPOSITION.encounter.v1 |
| ENT Nurse Consultation | ENT Nurse Consultation: Generic encounter or progress note composition.Annotations
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| 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. |
| Patient Story/History | Patient Story/History: The subjective observation by an individual about their health and health issues, as told to a clinician or recorded directly by an individual/patient. Commonly referred to by clinicians as 'Clinical History' or 'History of Presenting Complaint'. |
| Presenting History | Presenting History: Narrative description of the clinical history or story. |
| Reported Ear Discharge | Reported Ear Discharge: A generic cluster heading for contextual renaming within a template. |
| Nil Significant | Nil Significant: The person has not had any significant experience of the symptom. |
| Clinical Description | Clinical Description: Description of the symptom. |
| Body Site | Body Site: Identification of body site. Coding with a pre-coordinated terminology value set is preferred, if possible.
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| Duration | Duration: The duration of the symptom since onset. Units:
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| Number of Occurrences | Number of Occurrences: The number of times this symptom has occurred. |
| Appearance | Appearance: The character of the symptom. |
| Odour | Odour: The character of the symptom. |
| Reported Ear Pain | Reported Ear Pain: A generic cluster heading for contextual renaming within a template. |
| Nil Significant | Nil Significant: The person has not had any significant experience of the symptom. |
| Clinical Description | Clinical Description: Description of the symptom. |
| Body Site | Body Site: Identification of body site. Coding with a pre-coordinated terminology value set is preferred, if possible.
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| Duration | Duration: The duration of the symptom since onset. Units:
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| Precipitating Factor | Precipitating Factor: An event or activity that brings on or triggers the symptom. |
| 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:
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| Character | Character: The character of the symptom. |
| Reported Hearing Loss | Reported Hearing Loss: A generic cluster heading for contextual renaming within a template. |
| Nil Significant | Nil Significant: The person has not had any significant experience of the symptom. |
| Clinical Description | Clinical Description: Description of the symptom. |
| Body Site | Body Site: Identification of body site. Coding with a pre-coordinated terminology value set is preferred, if possible.
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| Duration | Duration: The duration of the symptom since onset. Units:
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| Impact | Impact: The character of the symptom. |
| Variation | Variation: The variation of the symptom.
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| Reported Concerns | Reported Concerns: An issue or concern reported by the subject or caregiver. |
| Concern | Concern: Identification of the issue or concern reported by the subject or caregiver.
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| Description | Description: Narrative description about the identified issue. |
| Risk Factors | Risk Factors: A generic heading for contextual renaming within a template.Annotations
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| Exposure | Exposure: Exposure of the subject to a chemical, physical or biological agent within their environment that has caused, or may possibly cause in the future, a negative impact on health. |
| Data | |
| Agent | Agent: Identification of the chemical, physical or biological agent to which the subject was exposed. For example: passive smoking or industrial noise.
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| Description | Description: Description of the exposure to the identified substance. |
| Ongoing Exposure | Ongoing Exposure: Does the subject remain exposed to the substance to a degree that could be regarded as a potential risk to health? |
| Pregnancy/Early Childhood Risk Factors | Pregnancy/Early Childhood Risk Factors: Record of known risk factors for an identified disease, condition, or other potentially adverse health issue , and/or an evaluation of the likelihood of the subject experiencing it in the future. |
| Risk Factor | Risk Factor: Known risk factor that may contribute to the evaluation of risk.
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| Infant Feeding Summary | Infant Feeding Summary: Summary of early infant feeding activity, particularly focused on breast and formula feeding. |
| Type | Type: The predominant type of feeding for a period of time.
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| Age Commenced | Age Commenced: The age of the infant when the selected type of feeding was commenced. If commenced at birth, which will be recorded as 0 days, weeks or months, then this could be captured or displayed in a system as 'Birth'. >P0Y Units:
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| Social Summary | Social Summary: A generic heading for contextual renaming within a template.Annotations
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| Social Summary | Social Summary: Summary information about social circumstances or experiences that may have a potential impact on an individual's health. |
| Overview | Overview: 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. |
| Household | Household: Summary of the people and pets with whom the subject lives. |
| Description | Description: Narrative description about the household members. For example: a full detailed description of individuals and relatioships; or 'living with spouse, mother-in-law and 4 dependant children'; or 'living with friends'. |
| Children Under 5 years | Children Under 5 years: Number of children under the age of 5 years in the household. |
| Housing | Housing: Summary of the housing or accomodation in which the subject resides. |
| Transient | Transient: Is the subject moving between multiple home environements? |
| Description | Description: Description of the housing or accommodation. |
| Home Environment | Home Environment: Details about the home environment of a subject. |
| Working Refrigerator | Working Refrigerator: Presence of a working refrigerator in the home. For example: required to store medicines adequately, especially in a remote environment or tropical climate. |
| Education and Training | Education and Training: Summary of the educational and training background of the subject. |
| Current School Attendance | Current School Attendance: Description of attendance at primary or secondary school. Only applicable for primary and secondary age children. Reference: METeOR - http://meteor.aihw.gov.au/content/index.phtml/itemId/401809
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| Current Early Childhood Education Attendance | Current Early Childhood Education Attendance: Description of attendance at early childhood education centre.
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| Ear Examination Findings | Ear Examination Findings: A generic heading for contextual renaming within a template. |
| Pinna | Pinna: 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 appearance of symmetry of both ears in comparison to one another. The appearance of symmetry required observation of size, shape and position on the head. If asymmetry is found, further details can be recorded in the 'Clinical Description' data elements for each pinna.
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| Per Pinna | Per Pinna: Physical examination findings of an identified pinna. |
| Pinna Examined | Pinna Examined: Identification of the pinna examined.
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| No Abnormality Detected | No Abnormality Detected: Statement that no abnormality was detected on examination. Record as True if no abnormality was detected on examination. |
| 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. |
| Surgical Scar | Surgical Scar: Findings about surgical scars identified on, or related to the identified pinna. The key intent of these data element is to identify the possible existence of significant middle ear surgery where this has not been previously recorded in the subject. This is a not uncommon occurrence in the remote communities managed by NT Hearing Health. |
| Site of Scar | Site of Scar: Identification of the the specific anatomical structure of the pinna or related anatomical region examined. Coding of the System/Stucture with a terminology is desirable, where possible. |
| Scar Description | Scar Description: Narrative description of the scar, including likely aetiology and state of healing. |
| Image | Image: Digital image or video taken, or a diagram drawn, during the physical examination of the body system or anatomical structure. |
| Otoscopy | Otoscopy: Physical examination of the external auditory canal and tympanic membrane by a clinician. |
| Ear Examined | Ear Examined: Identification of the ear under examination.
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| No Abnormality Detected | No Abnormality Detected: Statement that no abnormality was detected (NAD) on examination of the external auditory canal and tympanic membrane. Record as True if no abnormality was detected on examination. Specific statements can be included in the 'Clinical Interpretation' data element. |
| 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; or increased vascularity of the tympanic membrane. |
| 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.
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| 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.
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| 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.
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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?
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| 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.
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| 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.
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| 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.
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| 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.
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| 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.
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| 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 (Valsalva) | Mobility (Valsalva): Description of mobility of the tympanic membrane, usually as determined by pneumatic otoscopy. Occurrences has been set to 0..* to enable multiple methods of observing mobility to be recorded. For example: 'Mobiliy (Pneumatic Otoscopy'; or 'Mobility (Valsalva) with Mobile or Indeterminate as only appropriate value set.
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| Mobility (Pneumatic Otoscopy) | Mobility (Pneumatic Otoscopy): Description of mobility of the tympanic membrane, usually as determined by pneumatic otoscopy. Occurrences has been set to 0..* to enable multiple methods of observing mobility to be recorded. For example: 'Mobiliy (Pneumatic Otoscopy'; or 'Mobility (Valsalva) with Mobile or Indeterminate as only appropriate value set.
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| 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.
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| Pars Flaccida vs Pars Tensa? | Pars Flaccida vs Pars Tensa?: Description of the region of the tympanic membrane perforation. To document explicitly whether the perforation is located 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.
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| Marginal vs Central? | Marginal vs Central?: 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.
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| Edge | Edge: Narrative description of the edge of the perforation. |
| Pre-cleaning Image/Video | Pre-cleaning Image/Video: Image or video taken during the physical examination of the external auditory canal and tympanic membrane. Multiple occurrences allow for pre- and post-cleaning images to be recorded as part of the examination findings. |
| Post-cleaning Image/Video | Post-cleaning Image/Video: Image or video taken during the physical examination of the external auditory canal and tympanic membrane. Multiple occurrences allow for pre- and post-cleaning images to be recorded as part of the examination findings. |
| 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. |
| 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 kg |
| Actions | Actions: 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. |
| 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.
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| 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.
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| 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%.
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| Instrument | Instrument: Instrument used to assist cleaning. Coding with a terminology is preferred, if possible. For example Jobson Horne probe, or micro forceps.
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| 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.
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| Other Procedures | Other Procedures: A generic heading for contextual renaming within a template. |
| Procedure | Procedure: 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. |
| 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. |
| Conclusion | Conclusion: A generic heading for contextual renaming within a template. |
| Nursing Diagnosis | Nursing Diagnosis: Identification of the problem or diagnosis. Coding of the problem or diagnosis with a terminology is preferred, where possible.
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| Nursing Diagnosis | Nursing Diagnosis: Identification of the problem or diagnosis. Coding of the problem or diagnosis with a terminology is preferred, where possible.
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| Comment | Comment: An abstract or summary narrative of the assessment, conclusion or evaluation of the clinical findings. |
| Management | Management: A generic heading for contextual renaming within a template. |
| Medication Administered | Medication Administered: A generic heading for contextual renaming within a template. |
| Medicine | Medicine: The medicine, vaccine or other therapeutic good which was the focus of the action. Value set: ac0001 |
| 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. |
| Dose Administered | Dose Administered: Free text description of the amount which may consist of the quantity and dose unit. |
| Comment | Comment: A comment on the action taken. |
| Medication administration | Medication administration: Information about the future or actual administration of medication. |
| Route | Route: The route by which the medication is administered (e.g. oral, sublingual etc). Value set: ac0001 |
| Site | Site: A description of the site of administration.
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| Medication Ceased | Medication Ceased: A generic heading for contextual renaming within a template. |
| Medicine | Medicine: The medicine, vaccine or other therapeutic good which was the focus of the action. Value set: ac0001 |
| 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. |
| Medication Dispensed | Medication Dispensed: A generic heading for contextual renaming within a template. |
| 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. |
| Dose Description | Dose Description: Free text description of the amount which may consist of the quantity and dose unit. |
| Comment | Comment: A comment on the action taken. |
| 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. |
| Health Education Provided | Health Education Provided: A generic heading for contextual renaming within a template. |
| Topic | Topic: Topic of health education information provided.
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| Description | Description: Narrative description of the health education information provided. |
| Method | Method: Method by which the health education information was provided. For example, verbal or written. This is not the same as participation. Material can be exchanged between an educator and a subject in various ways during a face-to-face consultation or via teleconference. In specific situations it may be important to document that writtern fact sheets have been physically handed to the subject, for example regarding the risks of vasectomy. |
| Material Provided | Material Provided: Title or identifier of health education information provided. |
| Link | Link: Internet link to the information provided. |
| Protocol | |
| Interpreter Present | Interpreter Present: Was an interpreter present? Record as True if an Interpreter was present during the health education session. |
| ENT Teleotology Referral Completed | ENT Teleotology Referral Completed: Activity regarding a referral from a clinician, or self-referral by a patient, for the patient to receive a specific service, advice or care from an expert healthcare provider. |
| Description | |
| Referred service | Referred service: Identification of the clinical service to be/being carried out. This is often coded with an external terminology.
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| Description | Description: Description of the service provided. |
| Surgical Discussion | Surgical Discussion: A generic heading for contextual renaming within a template. |
| Surgery Education Provided | Surgery Education Provided: A generic heading for contextual renaming within a template. |
| Description | |
| Topic | Topic: Topic of health education information provided.
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| Method | Method: Method by which the health education information was provided. For example, verbal or written. This is not the same as participation. Material can be exchanged between an educator and a subject in various ways during a face-to-face consultation or via teleconference. In specific situations it may be important to document that writtern fact sheets have been physically handed to the subject, for example regarding the risks of vasectomy. |
| Identification | Identification: Title or identifier of health education information provided. |
| Link | Link: Internet link to the information provided. |
| Protocol | |
| Interpreter Present | Interpreter Present: Was an interpreter present? Record as True if an Interpreter was present during the health education session. |
| Family Opinion | Family Opinion: 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. |
| Plan | Plan: A generic heading for contextual renaming within a template. |
| Recommendation | Recommendation: Narrative description of the recommendation.
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| Rationale | Rationale: Justification for the recommendation. |
| Primary Health Centre Recall | Primary Health Centre Recall: A generic heading for contextual renaming within a template. |
| Follow-up Requested | Follow-up Requested: Identification of the service requested. This is often coded with an external terminology.
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| Reason description | Reason description: A narrative description explaining the reason for request. |
| 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. |
| ENT Teleotology Request | ENT Teleotology Request: A generic heading for contextual renaming within a template. |
| Service requested | Service requested: Identification of the service requested. This is often coded with an external terminology.
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| Description of service | Description of service: A detailed narrative description of the service requested.
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| Reason description | Reason description: A narrative description explaining the reason for request. |
| 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. |
| ENT Nurse Follow-up | ENT Nurse Follow-up: A generic heading for contextual renaming within a template. |
| Service requested | Service requested: Identification of the service requested. This is often coded with an external terminology.
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| Reason description | Reason description: A narrative description explaining the reason for request. |
| 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. |
| Child Hearing Health Coordinator Review | Child Hearing Health Coordinator Review: A generic heading for contextual renaming within a template. |
| Service requested | Service requested: Identification of the service requested. This is often coded with an external terminology.
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| Reason description | Reason description: A narrative description explaining the reason for request. |
| 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. |
| Healthcare service request | Healthcare service request: Request for a range of different healthcare services, for example, a referral, lab request, equipment request.Annotations
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| Service requested | Service requested: Identification of the service requested. This is often coded with an external terminology. |
| Reason description | Reason description: A narrative description explaining the reason for request. |
| 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. |
| Procedure Request | Procedure Request: Request for a procedure to be performed. |
| Procedure requested | Procedure requested: Identification of the service requested. This is often coded with an external terminology. |
| Description of Procedure | Description of Procedure: A detailed narrative description of the service requested. |
| Reason description | Reason description: A narrative description explaining the reason for request. |
| 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. |