All | Archetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Additional clinical information used to complete DiADeM assessment., archetypeConceptComment=null, otherContributors=Ian McNicoll, freshEHR Clinical Informatics Ltd., originalLanguage=en, translators=, subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={state=[], content=[], capabilities=[], relationships=[], activities=[], events=[ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002], code=at0002, itemType=POINT_EVENT, level=2, text=Point in time, description=A specific date and/or time which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=POINT_EVENT, bindings=null, values=null, extendedValues=null]], contacts=[], description=[], target=[], context=[], identities=[], protocol=[], other_participations=[], items=[], details=[], provider=[], source=[], ism_transition=[], data=[ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=4, text=Functional impairment, description=The patient is no longer fully independent in relation to basic activities of daily living, washing, dressing, feeding and
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- at0005::False [The patient is fully independent in relation to basic activities of daily living.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0007], code=at0007, itemType=ELEMENT, level=4, text=Corroborating history, description=History of gradual cognitive decline (typically for the last few years) is confirmed by care staff, relatives and medical records., comment=Staff/relatives confirm that in their opinion the patient consistently demonstrates both functional and cognitive
impairment., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- at0011::True [History of gradual cognitive decline is confirmed by staff, relatives and medical records.]
- at0010::False [History of gradual cognitive decline is not confirmed by staff, relatives and medical records.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0008], code=at0008, itemType=ELEMENT, level=4, text=Investigations, description=Dementia screening bloods are normal (where clinically appropriate and patient consents to bloods)., comment=If patient lacks capacity to consent to bloods, a best interest decision must be made and documented accordingly.
NB. If intracranial pathology (e.g. subdural haematoma, cerebral tumour) is suspected, referral for a brain scan may be appropriate. Otherwise where dementia is advanced, differential diagnosis is unlikely to affect patient management & a brain scan is unnecessary., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- at0012::True [Blood tests screening for other causes are normal.]
- at0013::False [Blood tests indicate other causes.]
- at0023::Not done [Blood tests screening for other causes have not been done.]
[RCD99::XaZQq] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0024], code=at0024, itemType=ELEMENT, level=4, text=Reason why bloods not done, description=Narrative statement why screening blood tests have not been done, e.g. patient declined or clinically inappropriate., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0009], code=at0009, itemType=ELEMENT, level=4, text=Exclusion criteria, description=An acute underlying cause to explain confusion i.e. delirium (acute confusional state) has been excluded. Also confirmation whether mood disorder or psychosis is also confirmed or excluded., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- at0014::True [Acute underlying causes to explain confusion have been excluded.]
- at0015::False [There are acute underlying causes to explain confusion.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0022], code=at0022, itemType=ELEMENT, level=4, text=Interpretation, description=The overall interpretation of the assessment, i.e. a coded statement of whether the assessment indicates a likely diagnosis of dementia or not., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- at0029::Diagnosis of dementia likely [The assessment indicates that a diagnosis of dementia is likely.]
[RCD99::XE1Z6] [RCDSY_1999::Eu02z] [ICD10_1998::F03] - at0030::Diagnosis of dementia uncertain [The assessment indicates that a diagnosis of dementia is uncertain and may require further assessment.]
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attending to own continence needs., comment=The requirement of prompting or supervision of staff constitutes a loss of full independence., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- at0006::True [The patient is no longer fully independent in relation to the basic activities of daily living.]
- at0005::False [The patient is fully independent in relation to basic activities of daily living.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0007], code=at0007, itemType=ELEMENT, level=4, text=Corroborating history, description=History of gradual cognitive decline (typically for the last few years) is confirmed by care staff, relatives and medical records., comment=Staff/relatives confirm that in their opinion the patient consistently demonstrates both functional and cognitive
impairment., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- at0011::True [History of gradual cognitive decline is confirmed by staff, relatives and medical records.]
- at0010::False [History of gradual cognitive decline is not confirmed by staff, relatives and medical records.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0008], code=at0008, itemType=ELEMENT, level=4, text=Investigations, description=Dementia screening bloods are normal (where clinically appropriate and patient consents to bloods)., comment=If patient lacks capacity to consent to bloods, a best interest decision must be made and documented accordingly.
NB. If intracranial pathology (e.g. subdural haematoma, cerebral tumour) is suspected, referral for a brain scan may be appropriate. Otherwise where dementia is advanced, differential diagnosis is unlikely to affect patient management & a brain scan is unnecessary., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- at0012::True [Blood tests screening for other causes are normal.]
- at0013::False [Blood tests indicate other causes.]
- at0023::Not done [Blood tests screening for other causes have not been done.]
[RCD99::XaZQq] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0024], code=at0024, itemType=ELEMENT, level=4, text=Reason why bloods not done, description=Narrative statement why screening blood tests have not been done, e.g. patient declined or clinically inappropriate., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0009], code=at0009, itemType=ELEMENT, level=4, text=Exclusion criteria, description=An acute underlying cause to explain confusion i.e. delirium (acute confusional state) has been excluded. Also confirmation whether mood disorder or psychosis is also confirmed or excluded., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- at0014::True [Acute underlying causes to explain confusion have been excluded.]
- at0015::False [There are acute underlying causes to explain confusion.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0022], code=at0022, itemType=ELEMENT, level=4, text=Interpretation, description=The overall interpretation of the assessment, i.e. a coded statement of whether the assessment indicates a likely diagnosis of dementia or not., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- at0029::Diagnosis of dementia likely [The assessment indicates that a diagnosis of dementia is likely.]
[RCD99::XE1Z6] [RCDSY_1999::Eu02z] [ICD10_1998::F03] - at0030::Diagnosis of dementia uncertain [The assessment indicates that a diagnosis of dementia is uncertain and may require further assessment.]
[RCD99::XaaBD] , extendedValues=null]], minIndents={}, termBindingRetrievalErrorMessage=null] |