ARCHETYPE YHSCN - DiADeM assessment (openEHR-EHR-OBSERVATION.yhscn_diadem_assessment.v0)

ARCHETYPE IDopenEHR-EHR-OBSERVATION.yhscn_diadem_assessment.v0
ConceptYHSCN - DiADeM assessment
DescriptionAdditional clinical information used to complete DiADeM assessment.
UseLocal use by Yorkshire and the Humber Clinical Networks for their dementia management programme.
PurposeLocal archetype for Yorkshire and the Humber Clinical Networks Dementia Management. This archetype forms part of the DiADeM (Diagnosing Advanced Dementia Mandate for care home settings) Tool.
References
Copyright© Clinical Models UK
AuthorsAuthor name: Hildegard Franke
Organisation: freshEHR Clinical Informatics Ltd.
Email: hildi@freshehr.com
Date originally authored: 2016-02-26
Other Details LanguageAuthor name: Hildegard Franke
Organisation: freshEHR Clinical Informatics Ltd.
Email: hildi@freshehr.com
Date originally authored: 2016-02-26
OtherDetails Language Independent{licence=This work is licensed under the Creative Commons Attribution-ShareAlike 3.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/3.0/., custodian_organisation=UK Clinical Models, current_contact=Hildegard Franke, freshEHR Clinical Informatics Ltd., original_namespace=uk.org.clinicalmodels, original_publisher=UK Clinical Models, custodian_namespace=uk.org.clinicalmodels, MD5-CAM-1.0.1=6BBC5997C18A320FA8FCE31BF2958A21, build_uid=ea406ef1-20ec-4d84-9ce2-43007ec4c543, revision=0.0.1-alpha}
Keywordsdiadem, dementia
Lifecyclein_development
UIDd85f4081-c34f-4402-84f3-b0ccea5221e0
Language useden
Citeable Identifier1051.32.385
Revision Number0.0.1-alpha
AllArchetype [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 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=
  • True [The patient is no longer fully independent in relation to the basic activities of daily living.]
  • 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=
  • True [History of gradual cognitive decline is confirmed by staff, relatives and medical records.]
  • 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=
  • True [Blood tests screening for other causes are normal.]
  • False [Blood tests indicate other causes.]
  • 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=
  • True [Acute underlying causes to explain confusion have been excluded.]
  • 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=
  • Diagnosis of dementia likely [The assessment indicates that a diagnosis of dementia is likely.]
    [RCD99::XE1Z6]
    [RCDSY_1999::Eu02z]
    [ICD10_1998::F03]
  • Diagnosis of dementia uncertain [The assessment indicates that a diagnosis of dementia is uncertain and may require further assessment.]
    [RCD99::XaaBD]
, extendedValues=null]], credentials=[]}, topLevelItems={data=ResourceSimplifiedHierarchyItem [path=ROOT_/data[at0001]/events[at0002]/data[at0003], code=at0003, itemType=ITEM_TREE, level=2, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=0..1, cardinalityText=optional, subCardinalityFormal=0..*, subCardinalityText=Minimum of 0 items, dataType=ITEM_TREE, bindings=null, values=null, extendedValues=null]}, addHierarchyItemsTo=data, currentHierarchyItemsForAdding=[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 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=
  • True [The patient is no longer fully independent in relation to the basic activities of daily living.]
  • 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=
  • True [History of gradual cognitive decline is confirmed by staff, relatives and medical records.]
  • 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=
  • True [Blood tests screening for other causes are normal.]
  • False [Blood tests indicate other causes.]
  • 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=
  • True [Acute underlying causes to explain confusion have been excluded.]
  • 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=
  • Diagnosis of dementia likely [The assessment indicates that a diagnosis of dementia is likely.]
    [RCD99::XE1Z6]
    [RCDSY_1999::Eu02z]
    [ICD10_1998::F03]
  • 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]