| TEMPLATE ID | *CL 7.1 Risk Factor Register |
|---|---|
| Concept | *CL 7.1 Risk Factor Register |
| Description | Not Specified |
| Purpose | Not Specified |
| References | |
| Other Details (Language Independent) |
|
| Language used | en |
| Citeable Identifier | 1013.26.797 |
| Root archetype id | openEHR-EHR-COMPOSITION.report.v1 |
| Risk Factor Register | Risk Factor Register: Document to communicate information to others, commonly in response to a request from another party. |
| Other Context | |
| Report ID | Report ID: Identification information about the report. |
| Status | Status: The status of the entire report. Note: This is not the status of any of the report components. |
| Risk of Permanent Hearing Loss | Risk of Permanent Hearing Loss: A generic heading for contextual renaming within a template. |
| Risk factors | Risk factors: Details about each possible risk factor. |
| Risk factor | Risk factor: Identification of the risk factor, by name. For example: hypertension and hypercholesterolaemia, which may be used as part of the overall assessment for cardiovascular disease; or a genetic marker. Coding of 'Risk factor' with a terminology, where possible. Annotations
|
| Presence | Presence: Presence of the risk factor.
|
| Description | Description: Narrative description about the risk factor. |
| Date identified | Date identified: The date/time that the risk factor was identified. |
| Mitigated | Mitigated: The risk factor has been identified as present, but then subsequently been mitigated by treatment or investigation. Record as True if the risk factor has been treated or investigated and risk from this risk factor is considered to be lessened. For example: an infant given gentamicin in neonatal intensive care is regarded as having a risk of permanent hearing loss. If diagnostic testing shows no evidence of hearing loss in the first year of life, the risk of later hearing loss is considered to be much reduced, but still possible. This data element allows clinicians to say that the risk has been mitigated but should still be considered as a possibility in future. In practice, the risk factor could be maintained in the risk assessment in case it might impact the individual's health at a future time, but flagging that its contribution to risk calculation may not be as great as if it had not been previously treated or investigated. |
| Link to evidence | Link to evidence: Identification of the path to the archetype or data node for the evidence of risk. |
| Comment | Comment: Additional narrative about the risk factor not captured in other fields. |
| Comment | Comment: Additional narrative about the risk assessment not captured in other fields. |
| Protocol | |
| Last updated | Last updated: The date this health risk assessment was last updated. This data element may be thought redundant if the data is recorded and stored using COMPOSITIONs within a closed clinical system. However if this health risk data is extracted from its original COMPOSITION context, for example, to be included in a discharge summary or message then the temporal context is effectively removed if the archetype is used within another COMPOSITION. This 'Last updated' data element has been explicitly added to allow the critical temporal data to be kept alongside the clinical data in all circumstances. It is assumed that the clinical system can copy the date from the COMPOSITION to reduce the need for duplication of data entry by the clincian. |
| Risk of Otitis Media | Risk of Otitis Media: A generic heading for contextual renaming within a template. |
| Risk factors | Risk factors: Details about each possible risk factor. |
| Risk factor | Risk factor: Identification of the risk factor, by name. For example: hypertension and hypercholesterolaemia, which may be used as part of the overall assessment for cardiovascular disease; or a genetic marker. Coding of 'Risk factor' with a terminology, where possible. Annotations
|
| Presence | Presence: Presence of the risk factor.
|
| Description | Description: Narrative description about the risk factor. |
| Date identified | Date identified: The date/time that the risk factor was identified. |
| Mitigated | Mitigated: The risk factor has been identified as present, but then subsequently been mitigated by treatment or investigation. Record as True if the risk factor has been treated or investigated and risk from this risk factor is considered to be lessened. For example: an infant given gentamicin in neonatal intensive care is regarded as having a risk of permanent hearing loss. If diagnostic testing shows no evidence of hearing loss in the first year of life, the risk of later hearing loss is considered to be much reduced, but still possible. This data element allows clinicians to say that the risk has been mitigated but should still be considered as a possibility in future. In practice, the risk factor could be maintained in the risk assessment in case it might impact the individual's health at a future time, but flagging that its contribution to risk calculation may not be as great as if it had not been previously treated or investigated. |
| Link to evidence | Link to evidence: Identification of the path to the archetype or data node for the evidence of risk. |
| Comment | Comment: Additional narrative about the risk factor not captured in other fields. |
| Comment | Comment: Additional narrative about the risk assessment not captured in other fields. |
| Protocol | |
| Last updated | Last updated: The date this health risk assessment was last updated. This data element may be thought redundant if the data is recorded and stored using COMPOSITIONs within a closed clinical system. However if this health risk data is extracted from its original COMPOSITION context, for example, to be included in a discharge summary or message then the temporal context is effectively removed if the archetype is used within another COMPOSITION. This 'Last updated' data element has been explicitly added to allow the critical temporal data to be kept alongside the clinical data in all circumstances. It is assumed that the clinical system can copy the date from the COMPOSITION to reduce the need for duplication of data entry by the clincian. |
| Exposure | Exposure: A generic heading for contextual renaming within a template. |
| 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. Annotations
|
| Nil Significant | Nil Significant: * |
| Overall Description | Overall Description: Overall 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? |
| Protocol | |
| Date Updated | Date Updated: The date this exposure summary was last updated. |