Injury: Evaluation

Generated by the Ocean HTML generator: 25/05/2006

Comments to Ocean Informatics

Concept

Archetype Id

Structure

An injury or illness which is deemed by a clinician to have arisen at least in part from an accident or exposure

Id: openEHR-EHR-EVALUATION.injury.v1
Reference model: EHR
ADL

Data

Protocol

Data: TREE

Concept Ordered	Description	Type	Cardinality	Values
Accident or exposure	The accident, injurious event(s) or exposure that occurred	*Text*	mandatory 1..1	Free or coded text
Date of accident	The date of that the injury occurred or began	*Date & Time*	optional 0..1	Allow all yyyy-??-??T??:??:??
Age at accident	The age at the time of injury or onset of injurous events	*Quantity*	optional 0..1	Property = TIME Units: wk a, (>= 0) d
Description	Description of the accident or exposure	*Text*	optional 0..1	Free or coded text

Injury or illness arising, Details of health problems or diagnoses arising from the injury. Cluster (0..*, ordered) optional, repeating

Concept	Description	Type	Cardinality	Values
Problem	The problem or a link to the problem described elsewhere in the EHR	Text URI - resource identifier	mandatory 1..1	Free or coded text
Date of onset	The date of onset of the injury or illness arising	*Date & Time*	optional 0..1	Allow all yyyy-??-??T??:??:??

Contributing factor, Details of any factors contributing to the illness or injury. Cluster (0..*) optional, repeating

Concept	Description	Type	Cardinality	Values
Factor	The factor that contributed to the cause of the injury	Text URI - resource identifier	optional 0..1	Free or coded text
Description	A description of this factor	*Text*	optional 0..1	Free or coded text
Degree of contribution	The contribution of this factor to the severity of the injury or illness	*Coded text*	optional 0..1	Major Minor

Effect on existing problem, Effect on pre-existing problems. Cluster (0..*) optional, repeating

Concept	Description	Type	Cardinality	Values
Description	The description of the effect on the existing problem	*Text*	optional 0..1	Free or coded text
Category of effect	The category of effect of the injury on the course or progression	*Coded text*	optional 0..1	Permanent aggravation Temporary exacerbation
Date of onset	The date of onset of the effect on an existing problem	*Date & Time*	optional 0..1	Allow all yyyy-??-??T??:??:??
Problem	The problem or a link to the problem described elsewhere in the EHR	Text URI - resource identifier	mandatory 1..1	Free or coded text
Degree of contribution	The contribution of this factor to the severity of the injury or illness	*Coded text*	optional 0..1	Major Minor

Concept Ordered	Description	Type	Cardinality	Values
Intended self harm	Was the injury intentionally self-inflicted	*Boolean*	optional 0..1	True

Insurance information, Details of insurance claims. Cluster (0..*, ordered) optional, repeating

Concept	Description	Type	Cardinality	Values
Insurance company	Details of the insurance company	*Text*	optional 0..1	Free or coded text
Date approved	The date of acceptance/approval of the insurance claim by the insurance company	*Date & Time*	optional 0..1	Partial date yyyy-??-XX
Insurance category	The insurance type that is relevent ot this injury	*Coded text*	optional 0..1	Motor vehicle Workers compensation Personal accident insurance Permanent disability Life insurance Travel insurance Other third party insurance Serving defence forces insurance Veterans insurance
Claim reference	Claim reference number	*Text*	optional 0..1	Free or coded text
Details	Information about the type of cover or restrictions	*Text*	optional 0..1	Free or coded text
Date closed	The date that the claim is finally closed	*Date & Time*	optional 0..1	Partial date yyyy-??-XX

Employer responsible for insurance claim , Details of the employer associated with the claim. Cluster (0..1) optional

Concept	Description	Type	Cardinality	Values
Responsible employer details	Any details about the employer	*Text*	optional 0..1	Free or coded text
Date of commencement	Date employment commenced	*Date & Time*	optional 0..1	Allow all yyyy-??-??T??:??:??
Occupation at time of injury	Occupation class or category	*Text*	optional 0..1	Free or coded text
Job description	Description of the occuption at the time of injury	*Text*	optional 0..1	Free or coded text
Contact	Details of the person managing this claim for the employer	*Text*	optional, repeating 0..*	Free or coded text
Supervisor	The person in the workplace who directly supervises the injured worker	*Text*	optional, repeating 0..*	Free or coded text
Termination date	Date employment ceased	*Date & Time*	optional 0..1	Partial date yyyy-??-XX

Employer not involved in insurance claim, Information about employer(s) not involved in insurance claim. Cluster (0..*) optional, repeating

Concept	Description	Type	Cardinality	Values
Employer details	*	*Coded text*	optional 0..1	Free or coded text
Occupation	Occupation class or category	*Text*	optional 0..1	Free or coded text
Job description	Description of the occuption at the time of injury	*Text*	optional 0..1	Free or coded text
Date of commencement	Date employment commenced	*Date & Time*	optional 0..1	Allow all yyyy-??-??T??:??:??
Contact	Details of the person managing this claim for the employer	*Text*	optional, repeating 0..*	Free or coded text
Supervisor	The person in the workplace who directly supervises the injured worker	*Text*	optional, repeating 0..*	Free or coded text
Termination date	Date employment ceased	*Date & Time*	optional 0..1	Partial date yyyy-??-XX

Supported by the General Practice Computing Group of Australia through funding from the Commonwealth Department of Health and Ageing

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