Problem as defined by a clinician: Evaluation

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

Comments to Ocean Informatics

Concept

Archetype Id

Structure

A problem, condition or issue defined by a clinician which is deemed summative of a range of symptoms or concerns of the person and a useful label of these.

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

Data

Protocol

Data: TREE

Concept Ordered	Description	Type	Cardinality	Values
Problem	The index problem, condition or issue described	*Text*	mandatory 1..1	Free or coded text
Date of initial onset	The date that the problem began causing symptoms or signs	*Date & Time*	optional 0..1	Partial date yyyy-??-XX
Age at initial onset	The age of the at the onset of the problem	*Quantity*	optional 0..1	Property = TIME Units: mo, (0..36) wk, (0..52) a, (0..200) d, (0..56)
Severity	The severity of the index problem	*Ordinal*	optional 0..1	1, Mild 4, Moderate 7, Severe
Clinical description	Description of the clinical aspects of the problem	*Text*	optional 0..1	Free or coded text
Date clinically recognised	Date the problem was recognised or 'diagnosed' by clinicians	*Date & Time*	optional 0..1	Partial date yyyy-??-XX

Location, Location of the problem in terms of body site. Cluster (0..*, ordered) optional, repeating

Concept	Description	Type	Cardinality	Values
Body site	The body site affected	*Coded text*	optional 0..1	Terminology Any term that describes a body site
Location description	A free text description of the location - may be in addition to a coded body site	*Text*	optional 0..1	Free or coded text

Aetiology, Agents or Factors known to have been of aetiological significance. Cluster (0..*) optional, repeating

Concept	Description	Type	Cardinality	Values
Agent	Microbial or other agent known to have caused this problem	*Text*	optional, repeating 0..*	Free or coded text
Complication of	A problem or link to a problem or injury described elsewhere in the EHR	Text URI - resource identifier	optional 0..1	Free or coded text
Description	Description of aetiological process	*Text*	optional 0..1	Free or coded text

Occurrences or exacerbations, Grouping of information about individual occurrences or exacerbations. Cluster (0..1, ordered) optional

Concept	Description	Type	Cardinality	Values
Frequency of reccurrence	The frequency of individual occurrences of the problem	*Quantity*	optional 0..1	Property = FREQUENCY
Date of last occurrence	The date of the last occurrence of the problem	*Date & Time*	optional 0..1	Date only yyyy-??-??

Occurence/exacerbation, Information about one occurrence or exacerbation. Cluster (0..*) optional, repeating

Concept	Description	Type	Cardinality	Values
Clinical description	A description of the exacerbation or occurrence	*Text*	optional 0..1	Free or coded text
Outcome	Outcome of the occurrence or exacerbation	*Text*	optional 0..1	Free or coded text
Date of onset of occurrence	Date of onset of occurrence or exacerbation	*Date & Time*	optional 0..1	Date only yyyy-??-??
Date of resolution of occurrence	Date of the resolution of the occurrence	*Date & Time*	optional 0..1	Date only yyyy-??-??

Concept	Description	Type	Cardinality	Values
Number of occurrences	Number of times this problem has occurred or been apparent	*Count*	optional 0..1	>= 1

Related problems, Complications that are attributed to this problem. Cluster (0..1) optional

Related problem, A group of characteristics of the problem complicating the index condition in this archetype. Cluster (0..*) optional, repeating

Concept	Description	Type	Cardinality	Values
Related problem	Details of the problem as text or coded text or URI	Text URI - resource identifier *Runtime name constraint:* {Problem, Complication}	optional 0..1	Free or coded text
Clinical description	Decription of the complicating problem	*Text*	optional 0..1	Free or coded text

Concept Ordered	Description	Type	Cardinality	Values
Date of resolution	The date that the problem resolved or went into remission	*Date & Time*	optional 0..1	Date only yyyy-??-??
Age at resolution	The age of the at the resolution of the problem	*Quantity*	optional 0..1	Property = TIME Units: mo, (0..36) wk, (0..52) a, (0..200) d, (0..56)

Protocol: TREE

References, Useful information about this condition. Cluster (0..1) optional

Concept	Description	Type	Cardinality	Values
Reference	Reference to material about this condition	*Text*	optional, repeating 0..*	Free or coded text
Web link	Useful information on the internet about this condition	*URI - resource identifier*	optional, repeating 0..*

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

Problem as defined by a clinician: Evaluation

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