| TEMPLATE ID | Consumer Entered Note DCM |
|---|---|
| Concept | Consumer Entered Note DCM |
| Description | A narrative about the subject of care's health and related matters as entered bythe subject of care or their authorised representative. |
| Use | When used by a health care provider, clinical synopsis is used to describe additional information includingclinical interpretation of the condition/tests and subject of care understanding of the health care event,and other relevant clinical details not captured by other structured or unstructured information componentspertinent of that health care event. |
| Misuse | Using when more specialised data components are available. |
| Purpose | A narrative about the subject of care's health and related matters as entered bythe subject of care or their authorised representative. |
| References | |
| Authors | Organisation: Nehta; Authored date: 2011-12-19 |
| Other Details Language | Organisation: Nehta; Authored date: 2011-12-19 |
| Other Details (Language Independent) |
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| Language used | en |
| Citeable Identifier | 1013.26.557 |
| Root archetype id | openEHR-EHR-EVALUATION.clinical_synopsis.v4 |
| Consumer Entered Note | Consumer Entered Note: The clinical synopsis contains summary information or comments about the clinical management of the patient, and the prognosis of diagnoses/ problems identified during the healthcare encounter. It may also include health-related information pertinent to the patient, and a clinical interpretation of relevant investigations and observations performed on the patient (including pathology and diagnostic imaging). Narrative information is captured or entered here by a healthcare provider from the focus of a healthcare provider, carer, subject of care and/or others unrelated to the subject of care. Optional[{detail_docref=data_groups/NEHTA-15513-Clinical_Synopsis-Data_Group.xml, spec_id=10}] Annotations
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| Data | |
| Consumer Note Title | Consumer Note Title: The clinical synopsis title/topic, written in free text. Topic of the clinical description about the subject of care and the health care event/encounter. The topic enables to organise the healthcare provider's description or the subject of care's interpretation of the health event/encounter. The title may be a free text intended to allow a summary title to the description of the issues/problems, management strategies, outcomes/progress and possible prognosis. Examples: 1. My Diabetes: 2. Diagnosis: 3. My Blood Pressure: Optional[{dc_id=16673, detail_docref=data_elements/NEHTA-16673-Clinical_Synopsis_Topic-Data_Element.xml}] Annotations
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| Consumer Note Description | Consumer Note Description: The clinical synopsis, written in free text. Provides concise narrative about the subject of care and the health care event/encounter. It may include the healthcare provider's interpretation (meta-observation) and the subject of care's understanding of the health care event that complements other structured or unstructured information contents captured or communicated about the health event/encounter. The description may include a summary of the issues/problems, management strategies, outcomes/progress and possible prognosis. Examples: 1. Admitted for elective bronchoscopy for assessment of left lingular and bibasal pneumonia. No focal endobronchial pathology identified. No evidence of malignancy and no pathogens isolated on bronchial brushings and washings. 2. 3/52 ago involved in a rear end motor vehicle accident, mid-velocity impact- complaining of neck pain, dizziness, nausea and difficulties concentrating. Disturbed sleep. No spinal cord signs. Optional[{dc_id=15582, detail_docref=data_elements/NEHTA-15582-Clinical_Synopsis_Description-Data_Element.xml}] Annotations
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