TEMPLATE *CL 7.1 Risk Factor Register (*CL 7.1 Risk Factor Register)

TEMPLATE ID*CL 7.1 Risk Factor Register
Concept*CL 7.1 Risk Factor Register
DescriptionNot Specified
PurposeNot Specified
References
Other Details (Language Independent)
  • MetaDataSet:Sample Set : Template metadata sample set
Language useden
Citeable Identifier1013.26.971
Root archetype idopenEHR-EHR-COMPOSITION.report.v1
Risk Factor RegisterRisk Factor Register: Document to communicate information to others, commonly in response to a request from another party.
Other Context
Report IDReport ID: Identification information about the report.
StatusStatus: The status of the entire report. Note: This is not the status of any of the report components.
Risk of Permanent Hearing LossRisk of Permanent Hearing Loss: A generic heading for contextual renaming within a template.
Risk factorsRisk factors: Details about each possible risk factor.
Risk factorRisk 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

  • HHIMS.Value Set: 7.1-1
PresencePresence: Presence of the risk factor.
  • Present 
  • Indeterminate 
  • Absent 
DescriptionDescription: Narrative description about the risk factor.
Date identifiedDate identified: The date/time that the risk factor was identified.
MitigatedMitigated: 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 evidenceLink to evidence: Identification of the path to the archetype or data node for the evidence of risk.
CommentComment: Additional narrative about the risk factor not captured in other fields.
Risk assessmentRisk assessment: Evaluation of the health risk.
There may be multiple variations on the assessment of risk. The Choice data type allows for recording of the assessment as either free text or value sets (such as low, medium or hig). The proportion data type allows recording of a percentage, a ratio or a fraction. The quantity data type allows recording of a decimal number.
  •  Text
  •  Proportion
  •  QuantityUnits:

Annotations

  • Notes.Authors Note:

    Place health risk assesment here.

Assessment typeAssessment type: Record of whether the risk assessment is a relative or absolute.
  • Relative risk 
  • Absolute risk 

Annotations

  • Notes.Authors Note:

    Please make sure there is an appropriate assesment fof this hearing loss.

CommentComment: Additional narrative about the risk assessment not captured in other fields.
Protocol
Last updatedLast 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 MediaRisk of Otitis Media: A generic heading for contextual renaming within a template.
Risk factorsRisk factors: Details about each possible risk factor.
Risk factorRisk 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

  • HHIMS.Value Set: 7.1-2
PresencePresence: Presence of the risk factor.
  • Present 
  • Indeterminate 
  • Absent 
DescriptionDescription: Narrative description about the risk factor.
Date identifiedDate identified: The date/time that the risk factor was identified.
MitigatedMitigated: 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 evidenceLink to evidence: Identification of the path to the archetype or data node for the evidence of risk.
CommentComment: Additional narrative about the risk factor not captured in other fields.
CommentComment: Additional narrative about the risk assessment not captured in other fields.
Protocol
Last updatedLast 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.
ExposureExposure: A generic heading for contextual renaming within a template.
ExposureExposure: 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
AgentAgent: Identification of the chemical, physical or biological agent to which the subject was exposed.
For example: passive smoking or industrial noise.

Annotations

  • HHIMS.Value Set: 7.1-4
Nil SignificantNil Significant: *
Overall DescriptionOverall Description: Overall description of the exposure to the identified substance.
Ongoing ExposureOngoing Exposure: Does the subject remain exposed to the substance to a degree that could be regarded as a potential risk to health?
Protocol
Date UpdatedDate Updated: The date this exposure summary was last updated.