ARCHETYPE Diagnostic investigation screening questionnaire (openEHR-EHR-OBSERVATION.investigation_screening.v0)

ARCHETYPE IDopenEHR-EHR-OBSERVATION.investigation_screening.v0
ConceptDiagnostic investigation screening questionnaire
DescriptionSeries of questions and associated answers used to screen whether diagnostic investigations, either imaging examinations or laboratory tests, have been carried out.
UseUse to create a framework for recording answers to pre-defined screening questions about the use of any specified diagnostic investigation or grouping of investigations. Common use cases include, but are not limited to: - Systematic questioning in any consultation related to patterns of investigation administration, for example: --- Have you ever had your cholesterol level tested? Yes, No, Unknown. --- Have you been tested for rubella antibodies? Yes, No, Unknown. --- Have you ever been screened for sickle cell disease? Yes, No, Unknown. - When was your last Chest X-ray? - When was your most recent INR test? The semantics of this archetype are intentionally loose, and querying this archetype would normally only be useful or safe within the context of each specific template. In a template, each data element would usually be renamed to the specific question asked. Where value sets have been proposed for common use cases, these can be adapted for local use by using the DV_TEXT or the DV_BOOLEAN datatypes choice to match each specific use case. The EVENT structure from the reference model can be used to specify whether the questions relate to a point in time or over a period of time. Use a separate instance of this archetype to distinguish between a questionnaire recording information about a medication that has been used at any time in the past and information about a medication used within a specified time interval - for example the difference between "Have you ever had an INR test?" compared to "Have you had an INR test during the last four weeks?". The source of the information in a questionnaire response may vary in different contexts but can be specifically identified using the 'Information provider' element in the Reference Model. This archetype has been designed to be used as a screening tool or to record simple questionnaire-format data for use in situations such as a disease registry. If the screening questionnaire identifies an investigation has been carried out, it is recommended that the clinical system record and persist the specific details about the investigation using a relevant archetype.
MisuseNot to be used for recording an order for an investigation - use INSTRUCTION.service_request for this purpose. Not to be used for recording the progress of activities performed as part of an investigation - use ACTION.laboratory_test for this purpose. Not to be used to record formal diagnostic test results - use the OBSERVATION.laboratory_test_result or OBSERVATION.imaging_examination_result for this purpose.
PurposeTo create a framework for recording answers to pre-defined screening questions about the use of any specified diagnostic investigation or grouping of investigations.
References
Copyright© openEHR Foundation, Apperta Foundation
AuthorsAuthor name: Heather Leslie
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2022-10-21
Other Details LanguageAuthor name: Heather Leslie
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2022-10-21
OtherDetails Language Independent{licence=This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/., custodian_organisation=Apperta UK, original_namespace=uk.org.clinicalmodels, original_publisher=Apperta UK, custodian_namespace=uk.org.clinicalmodels, MD5-CAM-1.0.1=253D67D92010BEB2F153CC700E4A9575, build_uid=ad2413ca-895a-4cfc-ae99-2e76dbda9fde, ip_acknowledgements=This artefact includes content from SNOMED Clinical Terms® (SNOMED CT®) which is copyrighted material of the International Health Terminology Standards Development Organisation (IHTSDO). Where an implementation of this artefact makes use of SNOMED CT content, the implementer must have the appropriate SNOMED CT Affiliate license - for more information contact https://www.snomed.org/snomed-ct/get-snomed or info@snomed.org., revision=0.0.1-alpha}
Keywordsinvestigation, screening, questionnaire, prevention, imaging, laboratory, pathology, blood, sample, sputum
Lifecyclein_development
UIDaceb6ad0-81a4-4d7f-a66c-c69ca4550503
Language useden
Citeable Identifier1051.32.1201
Revision Number0.0.1-alpha
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Astrid Askeland, Dips AS, Norway
Silje Ljosland Bakke, Helse Vest IKT AS, Norway (openEHR Editor)
SB Bhattacharyya, Bhattacharyyas Clinical Records Research & Informatics LLP, India
Randi Brendberg, Helse Nord RHF, Norway
Yexuan Cheng, 浙江大学, China
Are Edvardsen, SKDE, Helse Nord RHF, Norway
Alexander Eikrem-Lüthi, Lovisenberg Diakonale Sykehus, Norway
Kåre Flø, DIPS ASA, Norway
Grant Forrest, Lunaria Ltd, United Kingdom
Anca Heyd, DIPS ASA, Norway
Joost Holslag, Nedap, Netherlands
Evelyn Hovenga, EJSH Consulting, Australia
Mikkel Johan Gaup Grønmo, Regional forvaltning EPJ, Helse Nord, Norway
Gunnar Jårvik, Helse Vest IKT AS, Norway
Anjali Kulkarni, Karkinos, India
Kanika Kuwelker, Helse Vest IKT, Norway
Jörgen Kuylenstierna, eWeave AB, Sweden
Liv Laugen, ​Oslo University Hospital, Norway, Norway
Øygunn Leite Kallevik, Helse Bergen, Norway
Heather Leslie, Atomica Informatics, Australia (openEHR Editor)
Mikael Nyström, Cambio Healthcare Systems AB, Sweden
Jussara Rotzsch, Hospital Alemão Oswaldo Cruz, Brazil
Andre Smitt-Ingebretsen, Sørlandet sykehus HF, Norway
Natalia Strauch, Medizinische Hochschule Hannover, Germany
Norwegian Review Summary, Norwegian Public Hospitals, Norway
John Tore Valand, Helse Bergen, Norway (openEHR Editor)
Marit Alice Venheim, Helse Vest IKT, Norway (openEHR Editor)
Ina Wille, Helse-Vest RHF, Norway, originalLanguage=en, translators=
  • German: Natalia Strauch, Medizinische Hochschule Hannover, Strauch.Natalia@mh-hannover.de
  • Norwegian Bokmål: Kanika Kuwelker, John Tore Valand, Helse Vest IKT, Helse Bergen, kanika.kuwelker@helse-vest-ikt.no, john.tore.valand@helse-vest-ikt.no
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  •  Text
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  •  Coded Text
    • Positive [The screening test result was positive.]
    • Negative [The screening test result was negative.]
  •  Quantity
  •  Text
  •  Count
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