| TEMPLATE ID | Slovenian National Patient Summary |
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| Concept | Slovenian National Patient Summary |
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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 | 1013.26.572 |
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| Root archetype id | openEHR-EHR-COMPOSITION.report.v1 |
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| PPoP National Patient Summary | PPoP National Patient Summary: Document to communicate information to others, commonly in response to a request from another party. |
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| 1. Allergies and Other Adverse Reactions Section | 1. Allergies and Other Adverse Reactions Section: A generic section header. |
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| Adverse Reaction | Adverse Reaction: A harmful or undesirable, unexpected 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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| 1.8/9 Allergen | 1.8/9 Allergen: Identification of a substance, agent, or a class of substance, that is considered to be responsible for the Adverse Reaction.
Substance/Agent should be coded with a terminology, where possible.
Value set: external |
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| 1.1/2 Allergen Category | 1.1/2 Allergen Category: The category of substance responsible for the adverse reaction. Generally only required where the terminology used to record Substance/Agent cannot determine the Substance Category via inferencing.
e.g. Medication, Foodstuff, Environmental agent
- 1: Drug
- 2: Foodstuff
- 9: Other
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| 1.5 Severity of hypersensitivity | 1.5 Severity of hypersensitivity: The potential seriousness of a future reaction. This represents a clinical judgment about the worst case scenario for a future reaction.
From FHIR AllergyIntolerance Resource
Terminology: SNOMED-CT- Life-threatening
- severe
- heavy
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| 1.3/4 Clinical manifestation | 1.3/4 Clinical manifestation: Clinical manifestation of the Adverse Reaction expressed as a single word, phrase or brief description, e.g. nausea or rash.
Manifestation should be coded with a terminology, 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.
Value set: external |
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| 1.6 Date of occurence | 1.6 Date of occurence: Record of the date and/or time of the onset of the Adverse Reaction. |
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| Date Last Updated | Date Last Updated: The date at which the Adverse Reaction information was most recently updated or verified. |
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| Exclusion of an Adverse Reaction | Exclusion of an Adverse Reaction: Positive statement/s about adverse reactions that need to be recorded as clinically excluded from the health record at a specific point in time. |
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| Exclusion Statement | Exclusion Statement: A statement about exclusion of known adverse reactions in the health record.
For example: "No known adverse reactions"; "No known adverse reaction to" (penicillin).
Default value: No known adverse reactions |
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| Date Last Updated | Date Last Updated: The date at which the exclusion was last clinically asserted, affirmed or confirmed. |
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| Absence of Information | Absence of Information: Positive statement/s about information that is not available within the health record at a specific point in time. |
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| Absence Statement | Absence Statement: Positive statement that no information is available.
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".
Default value: No information available about adverse reactions. |
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| Date Verified | Date Verified: The date at which the information was deemed to be absent. |
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| 2. Diseases and Conditions | 2. Diseases and Conditions: A generic section header. |
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| Problem/Diagnosis | Problem/Diagnosis: An issue or obstacle which adversely impacts on the physical, mental and/or social well-being of an individual. The definition of a problem is deliberately kept rather loose and inclusive of a formal biomedical diagnosis so as to capture any real or perceived concerns that may adversely affect an individual's wellbeing to any degree. |
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| 1.9/10 Diagnosis | 1.9/10 Diagnosis: Identification of the index problem, issue or diagnosis.
Value set: external |
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| 1.11 Date of onset | 1.11 Date of onset: The date / time when the problem was first identified by the individual. |
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| 1.12 Date of Resolution | 1.12 Date of Resolution: The date that the problem resolved or went into remission. |
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| Exclusion of a Problem/Diagnosis | Exclusion of a Problem/Diagnosis: Positive statement/s about problems or diagnoses that need to be recorded as clinically excluded from the health record at a specific point in time. |
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| Exclusion Statement | Exclusion Statement: A statement about exclusion of use of known problems or diagnoses in the health record.
For example: "No known significant problems or diagnoses"; or "No evidence of" or "Never diagnosed with" (diabetes).
Default value: No significant past problems |
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| Date Last Updated | Date Last Updated: The date at which the exclusion was last clinically asserted, affirmed or confirmed. |
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| Absence of Information | Absence of Information: Positive statement/s about information that is not available within the health record at a specific point in time. |
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| Absence Statement | Absence Statement: Positive statement that no information is available.
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".
Default value: No information available about diseases and conditions |
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| Date Verified | Date Verified: The date at which the information was deemed to be absent. |
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| 3. Vaccinations | 3. Vaccinations: A generic section header. |
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| Vaccination | Vaccination: Details of use, administration, dispensing or other care step relating to a vaccination. |
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| 1.13/14 Vaccine Product | 1.13/14 Vaccine Product: The medication or other therapeutic good which was the focus of the action. Use CBZ codes or EPSOS vaccination codes as mapping.
Value set: ac0.2 |
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| Target | Target: Details of the target for this vaccination. |
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| 1.14/5 Target disease | 1.14/5 Target disease: The disease against which the vaccine is targeted as an ICD-10 code, or disease for which vaccination is declined.
Value set: external |
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| Exclusion of a Medication | Exclusion of a Medication: Statement/s about use of medication that needs to be positively recorded as clinically excluded from the health record ata a specific point in time. |
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| Exclusion Statement | Exclusion Statement: A statement about exclusion of use of medication in the health record.
The statement can support recording that no medications are being taken or that one or more specified medications are not being taken. For example: "Not currently taking any medications"; "Never taken any medications" or "Not currently taking corticosteroids".
Default value: No known previous vaccinations |
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| Absence of Information | Absence of Information: Positive statement/s about information that is not available within the health record at a specific point in time. |
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| Absence Statement | Absence Statement: Positive statement that no information is available.
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".
Default value: No information on vaccination available. |
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| Date Verified | Date Verified: The date at which the information was deemed to be absent. |
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| 4. Surgical procedures | 4. Surgical procedures: A generic section header. |
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| Procedure undertaken | Procedure undertaken: A clinical activity that has been carried out for therapeutic or diagnostic purposes. |
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| 1.17/18 Procedure | 1.17/18 Procedure: The name of the procedure.
Value set: external |
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| 1.20 Anaesthetic complications | 1.20 Anaesthetic complications: Details about any complication arising from the procedure. |
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| Exclusion of a Procedure | Exclusion of a Procedure: Positive statement/s about procedures that need to be recorded as clinically excluded from the health record at a specific point in time. |
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| Exclusion Statement | Exclusion Statement: A statement about exclusion of procedures performed in the health record.
For example: "No known operations or significant procedures" or "No previous" (appendicectomy).
Default value: No significant past surgical procedures. |
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| Absence of Information | Absence of Information: Positive statement/s about information that is not available within the health record at a specific point in time. |
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| Absence Statement | Absence Statement: Positive statement that no information is available.
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".
Default value: No information on surgical procedures available. |
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| Date Verified | Date Verified: The date at which the information was deemed to be absent. |
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| 5. Medical devices and implants | 5. Medical devices and implants: A generic section header. |
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| In-situ device or implant | In-situ device or implant: Details of an in-situ medical device or implant. |
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| 1.21/22 Device name | 1.21/22 Device name: Identification of the device. This is very likely to be a coded field, including pre- or post-coordianted details. |
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| 1.23 Date of Insertion | 1.23 Date of Insertion: The date at which the device was inserted. |
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| Magnetic Resonance (MR) compatibilty | Magnetic Resonance (MR) compatibilty: Information on safe use of the device in the context of Magentic Resonance Imaging. |
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| Comment | Comment: Any other comment about the implant or medical device. |
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| Protocol | |
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| Date last updated | Date last updated: The most recent date at which information about the device or impant was updated or verified as being correct. |
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| Exclusion of a Procedure | Exclusion of a Procedure: Positive statement/s about procedures that need to be recorded as clinically excluded from the health record at a specific point in time. |
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| Exclusion Statement | Exclusion Statement: A statement about exclusion of procedures performed in the health record.
For example: "No known operations or significant procedures" or "No previous" (appendicectomy).
Default value: No history of current medical devices and implants |
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| Date Last Updated | Date Last Updated: The date at which the exclusion was last clinically asserted, affirmed or confirmed. |
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| Absence of Information | Absence of Information: Positive statement/s about information that is not available within the health record at a specific point in time. |
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| Absence Statement | Absence Statement: Positive statement that no information is available.
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".
Default value: No information on medical devices or implants available. |
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| Date Verified | Date Verified: The date at which the information was deemed to be absent. |
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| 6. Treatment Recommendations | 6. Treatment Recommendations: A generic section header. |
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| Recommendation | Recommendation: A suggestion, advice or proposal for current healthcare management or for future action. |
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| 1.24 Treatment Recommendation | 1.24 Treatment Recommendation: Narrative description of the recommendation. |
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| 7. Disability | 7. Disability: A generic section header. |
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| Clinical Synopsis | Clinical Synopsis: Narrative summary or overview about a patient, specifically from the perspective of a healthcare provider, and with or without associated interpretations. |
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| 1.25 Autonomy / Disability | 1.25 Autonomy / Disability: The summary, assessment, conclusions or evaluation of the clinical findings. |
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| 8. Social history | 8. Social history: A generic section header. |
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| Tobacco Use Summary | Tobacco Use Summary: Summary or persisting information about tobacco use or consumption. |
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| Smoking Details | Smoking Details: Details about the pattern of use of a specified form of smoked tobacco. |
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| 1.26 Typical Smoked Amount | 1.26 Typical Smoked Amount: Estimate of typical use of the form of smoked tobacco per day - as a whole number, a range or as a term (usually coded).
This data element allows a rough indication of cigarette use to be recorded in a number of formats. For example: 30 a day (quantity) or 5-10 per day (interval of quantity), or select from terminology value set (either a set specified in the template or from a specified external terminology reference set). Please note: the period of time to which this data element is not specified. If exact consumption at specific points in time or averages/maximums over specified intervals of time are required, use the OBSERVATION.tobacco_use archetype.
>=0
Units: |
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| 1.27 Date Commenced | 1.27 Date Commenced: Date that smoking commenced.
Can be a partial date, for example, only a year. |
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| 1.28 Date Ceased | 1.28 Date Ceased: Date that smoking ceased.
Can be a partial date, for example, only a year. May also be known as the 'Quit Date'. |
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| Alcohol Use Summary | Alcohol Use Summary: Summary or persisting information about alcohol use or consumption. |
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| 1.29 Typical Alcohol Consumption | 1.29 Typical Alcohol Consumption: Estimate of typical alcohol consumption, in number of standard drinks/units per day - either as a whole number, a range, or as a term, normally coded. Definitions of standard units/drinks vary considerably.
This data element allows a rough indication of alcohol consumption to be recorded, for example 5-10 per day. The period of time is not specified. If exact consumption at specific points in time or averages/maximums over specified intervals of time are required, use the OBSERVATION.alcohol_use archetype.
>=0 /d |
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| Date Commenced | Date Commenced: Date that any consumption of alcohol commenced.
In most situations it is likely that only a partial date will be recorded, for example, only the year of commencement. |
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| Date Ceased | Date Ceased: Date that all consumption of alcohol ceased.
Can be a partial date, for example, only a year. |
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| Dietary habits summary | Dietary habits summary: A summary of patient dietary and nutritional habits. |
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| 1.30 Dietary description | 1.30 Dietary description: A description of the patient's current dietary and nutritional habits. |
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| Specific diet | Specific diet: * |
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| 1.31 Date Started | 1.31 Date Started: The date that the diet was started. |
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| 1.32 Date Ended | 1.32 Date Ended: The date that the diet finished. |
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| 9. Pregnancy | 9. Pregnancy: A generic section header. |
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| Pregnancy summary | Pregnancy summary: Recordings related to a single human pregnancy which may include more than one fetus or offspring. |
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| 1.32 Expected date of birth | 1.32 Expected date of birth: The expected date of birth or delivery (EDD). |
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| 10. Physical findings | 10. Physical findings: A generic section header. |
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| Blood Pressure | Blood Pressure: The local measurement of arterial blood pressure which is a surrogate for arterial. pressure in the systemic circulation. Most commonly, use of the term 'blood pressure' refers to measurement of brachial artery pressure in the upper arm. |
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| 1.33 Systolic | 1.33 Systolic: Peak systemic arterial blood pressure - measured in systolic or contraction phase of the heart cycle.
0..1000 mmHg (UCUM: mm[Hg]) |
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| 1.34 Diastolic | 1.34 Diastolic: Minimum systemic arterial blood pressure - measured in the diastolic or relaxation phase of the heart cycle.
0..1000 mmHg (UCUM: mm[Hg]) |
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| 11. Diagnostic Tests | 11. Diagnostic Tests: A generic section header. |
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| Synopsis | Synopsis: The summary, assessment, conclusions or evaluation of the clinical findings. |
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| 12. Medication Summary | 12. Medication Summary: A generic section header. |
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| Medication order | Medication order: Details of a medicine, vaccine or other therapeutic good with instructions for use. |
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| 1.35/36 Product Name | 1.35/36 Product Name: 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.
Value set: ac0001 |
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| 1.43 Pharmaceutical dose form | 1.43 Pharmaceutical dose form: The formulation or presentation of the overall substance.
e.g. "Tab", "Liquid", "Gel". |
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| Ingredient | Ingredient: Detailed Information about an individual ingredient. |
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| 1.36/7 Active ingredient | 1.36/7 Active ingredient: The name of the chemical or medication.
Value set: external |
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| 1.38 Potency | 1.38 Potency: Free text description of the amount which may consist of the amount value and amount dose unit.
Example: 40mg |
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| 1.39 Number of Units per intake | 1.39 Number of Units per intake: The value of the amount of medication as a real number.
Example: 1, 1.5, 0.125
 Quantity>=0 (UCUM: 1) Interval of QuantityLower constraint: >=0 (UCUM: 1)
Upper constraint: >=0 (UCUM: 1)
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| Dose unit | Dose unit: The dose unit of this medication amount.
Example: tab, drop caps
Value set: ac0001 |
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| 1.42 Date of onset of treatment | 1.42 Date of onset of treatment: The date and optional time to begin using the medicine, vaccine or other therapeutic good. |
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| 1.41 Duration of treatment | 1.41 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). |
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| Duration of prior treatment | Duration of prior treatment: The duraton of prior treatment which has already for the same medication prior to this instruction.
e.g To indicate that the patient has already taken 3 days of a 7 day course of treatment.
>=P0Y |
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| 1.40 Frequency of intake | 1.40 Frequency of intake: Complex intervention timing recorded as a parsable syntax.
Formalism |
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