| TEMPLATE ID | Allergies and Adverse Reactions for HISO 10041.1 |
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| Concept | Allergies and Adverse Reactions for HISO 10041.1 |
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| Description | Not Specified |
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| Purpose | Not Specified |
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| References | |
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| Other Details (Language Independent) | - MetaDataSet:Sample Set : Template metadata sample set
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| Language used | en |
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| Citeable Identifier | 1013.26.546 |
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| Root archetype id | openEHR-EHR-COMPOSITION.adverse_reaction_list_nehta.v1 |
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| Allergies and adverse reactions | Allergies and adverse reactions: A persistent and managed list of adverse reactions experienced by the subject that may influence clinical decision-making and care provision. |
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| Allergies | Allergies: A harmful or undesirable effect associated with exposure to any substance or agent, including food, plants, animals, venom from animal stings, or a medication at therapeutic or sub-therapeutic doses.! |
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| provider | |
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| Data | |
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| Substance/Agent | Substance/Agent: Identification of a substance, agent, or a class of substance, that is considered to be responsible for the Adverse Reaction.
Coding of the Substance/Agent with a terminology is desirable, where possible.
Annotations- Notes.Comment: Whether the allergy is of drug, food or other can be specified here.
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| Reaction Event | Reaction Event: Details about each Adverse Reaction Event. |
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| Specific Substance/Agent | Specific Substance/Agent: Specific identification of the actual Substance/Agent considered to be responsible for the Adverse Reaction event.
Coding of the specific Substance/Agent with a terminology is preferred, where possible. For example, a medication trade name or identification of a specific food. |
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| Manifestation | Manifestation: Clinical manifestation of the Adverse Reaction expressed as a single word, phrase or brief description, e.g. nausea or rash.
Coding with a terminology is preferred, where possible. The values entered here may be used to display on an application screen as part a list of adverse reactions, as recommended in the NHS CUI guidelines. |
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| Reaction Type | Reaction Type: The type of Adverse Reaction as determined by the clinician.
Coding of the reaction type is preferred, where possible. Examples: Immune mediated - Types I-IV (including allergy and hypersensitivity); Non-immune mediated - including pseudoallergic reaction, side effect, intolerance, drug toxicity, drug-drug interaction, food-drug interaction, drug-disease interaction and idiosyncratic reaction. |
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| Reaction Severity | Reaction Severity: Indication of severity. |
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| Status | Status: Whether the reaction is active or resolved.
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| Episodicity | Episodicity: Description of the episodicity of the reaction of any. |
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| Clinical Course | Clinical Course: Description of the clinical course of the reaction |
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| Certainty | Certainty: Degree of certainty, as assessed by a clinician, that the specific Substance/Agent was the cause of the Adverse Reaction.
- Suspected
- Probable
- Confirmed
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| Reaction Description | Reaction Description: Narrative description of the Adverse Reaction. |
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| Onset of Reaction | Onset of Reaction: Record of the date and/or time of the onset of the Adverse Reaction. |
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| Date of Resolution | Date of Resolution: * |
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| Date of Last Reaction | Date of Last Reaction: The date when last reaction occured. |
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| Reaction Comment | Reaction Comment: Additional narrative about the Adverse Reaction event not captured in other fields. |
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| Protocol | |
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| Date Last Verified | Date Last Verified: The most recent date when the reaction has been observed or reported. |
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| Adverse Reactions | Adverse Reactions: A harmful or undesirable effect associated with exposure to any substance or agent, including food, plants, animals, venom from animal stings, or a medication at therapeutic or sub-therapeutic doses.! |
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| provider | |
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| Data | |
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| Substance/Agent | Substance/Agent: Identification of a substance, agent, or a class of substance, that is considered to be responsible for the Adverse Reaction.
Coding of the Substance/Agent with a terminology is desirable, where possible.
Annotations- Notes.Comment: Whether this is an adverse drug reaction or food intolerance can be specified here.
|
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| Reaction Event | Reaction Event: Details about each Adverse Reaction Event. |
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| Specific Substance/Agent | Specific Substance/Agent: Specific identification of the actual Substance/Agent considered to be responsible for the Adverse Reaction event.
Coding of the specific Substance/Agent with a terminology is preferred, where possible. For example, a medication trade name or identification of a specific food. |
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| Manifestation | Manifestation: Clinical manifestation of the Adverse Reaction expressed as a single word, phrase or brief description, e.g. nausea or rash.
Coding with a terminology is preferred, where possible. The values entered here may be used to display on an application screen as part a list of adverse reactions, as recommended in the NHS CUI guidelines. |
|---|
| Reaction Type | Reaction Type: The type of Adverse Reaction as determined by the clinician.
Coding of the reaction type is preferred, where possible. Examples: Immune mediated - Types I-IV (including allergy and hypersensitivity); Non-immune mediated - including pseudoallergic reaction, side effect, intolerance, drug toxicity, drug-drug interaction, food-drug interaction, drug-disease interaction and idiosyncratic reaction. |
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| Reaction Severity | Reaction Severity: Indication of severity. |
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| Status | Status: Whether the reaction is active or resolved.
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| Episodicity | Episodicity: Description of the episodicity of the reaction of any. |
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| Clinical Course | Clinical Course: Description of the clinical course of the reaction |
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| Certainty | Certainty: Degree of certainty, as assessed by a clinician, that the specific Substance/Agent was the cause of the Adverse Reaction.
- Suspected
- Probable
- Confirmed
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| Reaction Description | Reaction Description: Narrative description of the Adverse Reaction. |
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| Onset of Reaction | Onset of Reaction: Record of the date and/or time of the onset of the Adverse Reaction. |
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| Date of Resolution | Date of Resolution: * |
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| Date of Last Reaction | Date of Last Reaction: The date when last reaction occured. |
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| Reaction Comment | Reaction Comment: Additional narrative about the Adverse Reaction event not captured in other fields. |
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| Protocol | |
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| Date Last Verified | Date Last Verified: The most recent date when the reaction has been observed or reported. |
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| Exclusion of an Adverse Reaction (NEHTA) | Exclusion of an Adverse Reaction (NEHTA): Positive statement/s about the absence or exclusion of adverse reactions within the health record at a specific point in time. |
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| Data | |
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| Exclusion Statement | Exclusion Statement: A statement about absence or exclusion of known adverse reactions in the health record.
For example: "No known adverse reactions"; "No known adverse reaction to" (penicillin). |
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| Substance/Agent | Substance/Agent: Identification of a specific substance or agent to which the Exclusion Statement applies.
Coding of the Substance/Agent with a terminology is desirable, where possible.
 Coded Text Value set: ac0.1 Text
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| Absence of Information (NEHTA) | Absence of Information (NEHTA): Statement that there is no relevant information available, neither a positive presence nor a positive exclusion. |
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| Data | |
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| Absence Statement | Absence Statement: Statement explicitly expressing the absence of available information.
Coding with a terminology is desirable, where possible.
For example: "No information available about adverse reactions"; No information available about problems or diagnoses"; "No information available about previous procedures performed"; or "No information available about medications used". |
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