ARCHETYPE ReSPECT key diagnosis (openEHR-EHR-EVALUATION.problem_diagnosis-respect_principal.v0)

Name: ReSPECT key diagnosis
License: http://creativecommons.org/licenses/by-sa/3.0/

ARCHETYPE ID	openEHR-EHR-EVALUATION.problem_diagnosis-respect_principal.v0
Concept	ReSPECT key diagnosis
Description	One or more key diagnoses leading to the need for a ReSPECT form.
Use	Use for recording details about a single, identified health problem or diagnosis. Clear definitions that enable differentiation between a 'problem' and a 'diagnosis' are almost impossible in practice - we cannot reliably tell when a problem should be regarded as a diagnosis. When diagnostic or classification criteria are successfully met, then we can confidently call the condition a formal diagnosis, but prior to these conditions being met and while there is supportive evidence available, it can also be valid to use the term 'diagnosis'. The amount of supportive evidence required for the label of diagnosis is not easy to define and in reality probably varies from condition to condition. Many standards committees have grappled with this definitional conundrum for years without clear resolution. For the purposes of clinical documentation with this archetype, problem and diagnosis are regarded as a continuum, with increasing levels of detail and supportive evidence usually providing weight towards the label of 'diagnosis'. In this archetype it is not neccessary to classify the condition as a 'problem' or 'diagnosis'. The data requirements to support documentation of either are identical, with additional data structure required to support inclusion of the evidence if and when it becomes available. Examples of problems include: the individual's expressed desire to lose weight, but without a formal diagnosis of Obesity; or a relationship problem with a family member. Examples of formal diagnoses would include a cancer that is supported by historical information, examination findings, histopathological findings, radiological findings and meets all requirements for known diagnostic criteria. In practice, most problems or diagnoses do not sit at either end of the problem-diagnosis spectrum, but somewhere in between. This archetype can be used within many contexts. For example, recording a problem or a clinical diagnosis during a clinical consultation; populating a persistent Problem List; or to provide a summary statement within a Discharge Summary document. In practice, clinicians use many context-specific qualifiers such as past/present, primary/secondary, active/inactive, admission/discharge etc. The contexts can be location-, specialisation-, episode- or workflow-specific, and these can cause confusion or even potential safety issues if perpetuated in Problem Lists or shared in documents that are outside of the original context. These qualifiers can be archetyped separately and included in the ‘Status’ slot, because their use varies in different settings. It is expected that these will be used mostly within the appropriate context and not shared out of that context without clear understanding of potential consequences. For example, a primary diagnosis to one clinician may be a secondary one to another specialist; an active problem can become inactive (or vice versa) and this can impact the safe use of clinical decision support. In general these qualifiers should be applied locally within the context of the clinical system, and in practice these statuses should be manually curated by clinicians to ensure that lists of Current/Past, Active/Inactive or Primary/Secondary Problems are clinically accurate. This archetype will be used as a component within the Problem Oriented Medical Record as described by Larry Weed. Additional archetypes, representing clinical concepts such as condition as an overarching organiser for diagnoses etc, will need to be developed to support this approach. In some situations, it may be assumed that identification of a diagnosis fits only within the expertise of physicians, but this is not the intent for this archetype. Diagnoses can be recorded using this archetype by any healthcare professional.
Misuse	Not to be used to record symptoms as described by the individual - use the CLUSTER.symptom archetype, usually within the OBSERVATION.story archetype. Not to be used to record examination findings - use the family of examination-related CLUSTER archetypes, usually nested within the OBSERVATION.exam archetype. Not to be used to record laboratory test results or related diagnoses, for example pathological diagnoses - use an appropriate archetype from the laboratory family of OBSERVATION archetypes. Not to be used to record imaging examination results or imaging diagnoses - use an appropriate archetype from the imaging family of OBSERVATION archetypes. Not to be used to record 'Differential Diagnoses' - use the EVALUATION.differential_diagnosis archetype. Not to be used to record 'Reason for Encounter' or 'Presenting Complaint' - use the EVALUATION.reason_for_encounter archetype. Not to be used to record procedures - use the ACTION.procedure archetype. Not to be used to record details about pregnancy - use the EVALUATION.pregnancy_bf_status and EVALUATION.pregnancy and related archetypes. Not to be used to record statements about health risk or potential problems - use the EVALUATION.health_risk archetype. Not to be used to record statements about adverse reactions, allergies or intolerances - use the EVALUATION.adverse_reaction archetype. Not to be used for the explicit recording of an absence (or negative presence) of a problem or diagnosis, for example ‘No known problem or diagnoses’ or ‘No known diabetes’. Use the EVALUATION.exclusion-problem_diagnosis archetype to express a positive statement about exclusion of a problem or diagnosis.
Purpose	For recording details about a single, identified health problem or diagnosis. The intended scope of a health problem is deliberately kept loose in the context of clinical documentation, so as to capture any real or perceived concerns that may adversely affect an individual's wellbeing to any degree. A health problem may be identified by the individual, a carer or a healthcare professional. However, a diagnosis is additionally defined based on objective clinical criteria, and usually determined only by a healthcare professional.
References	Problem/Diagnosis, Draft Archetype [Internet]. National eHealth Transition Authority, NEHTA Clinical Knowledge Manager [cited: 2015-03-12]. Available from: http://dcm.nehta.org.au/ckm/#showArchetype_1013.1.896. ISO/DIS 13940 Health informatics -- System of concepts to support continuity of care., International Organization for Standardization [Internet]. Available at: http://www.iso.org/iso/catalogue_detail.htm?csnumber=58102 (accessed 2015 -04-09). Common Terminology Criteria for Adverse Events (CTCAE) [Internet]. National Cancer Institute, USA. Available from: http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm (accessed 2015-07-13). Weed LL. Medical records that guide and teach. N Engl J Med. 1968 Mar 14;278(11):593-600. PubMed PMID: 5637758. Available from: http://www.nejm.org/doi/full/10.1056/NEJM196803142781105 (accessed 2015-07-13).
Copyright	© openEHR Foundation, Clinical Models UK
Authors	Author name: Sam Heard Organisation: Ocean Informatics Email: sam.heard@oceaninformatics.com Date originally authored: 2006-04-23
Other Details Language	Author name: Sam Heard Organisation: Ocean Informatics Email: sam.heard@oceaninformatics.com Date originally authored: 2006-04-23
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, references=Problem/Diagnosis, Draft Archetype [Internet]. National eHealth Transition Authority, NEHTA Clinical Knowledge Manager [cited: 2015-03-12]. Available from: http://dcm.nehta.org.au/ckm/#showArchetype_1013.1.896. ISO/DIS 13940 Health informatics -- System of concepts to support continuity of care., International Organization for Standardization [Internet]. Available at: http://www.iso.org/iso/catalogue_detail.htm?csnumber=58102 (accessed 2015 -04-09). Common Terminology Criteria for Adverse Events (CTCAE) [Internet]. National Cancer Institute, USA. Available from: http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm (accessed 2015-07-13). Weed LL. Medical records that guide and teach. N Engl J Med. 1968 Mar 14;278(11):593-600. PubMed PMID: 5637758. Available from: http://www.nejm.org/doi/full/10.1056/NEJM196803142781105 (accessed 2015-07-13)., current_contact=Heather Leslie, Ocean Informatics, heather.leslie@oceaninformatics.com, original_namespace=uk.org.clinicalmodels, original_publisher=UK Clinical Models, custodian_namespace=uk.org.clinicalmodels, MD5-CAM-1.0.1=841ADE765D6AC24794D5369F0B1BFD47, build_uid=f99b06d7-ef28-453d-8c80-779e4e995ced, revision=0.0.1-alpha}
Keywords	issue, condition, problem, diagnosis, concern, injury, clinical impression
Lifecycle	in_development
UID	fd737070-b1cc-410a-b849-2bf4f42550d5
Language used	en
Citeable Identifier	1051.32.673
Revision Number	0.0.1-alpha
All	Archetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=One or more key diagnoses leading to the need for a ReSPECT form., archetypeConceptComment=null, otherContributors=Tomas Alme, DIPS, Norway Nadim Anani, Karolinska Institutet, Sweden Koray Atalag, University of Auckland, New Zealand Silje Ljosland Bakke, Nasjonal IKT HF, Norway (openEHR Editor) John Bennett, NEHTA, Australia Steve Bentley, Allscripts, United Kingdom Lars Bitsch-Larsen, Haukeland University hospital, Norway Ian Bull, ACT Health, Australia Sergio Carmona, Chile Rong Chen, Cambio Healthcare Systems, Sweden Stephen Chu, Queensland Health, Australia Ed Conley, Cardiff University, United Kingdom Matthew Cordell, NEHTA, Australia Paul Donaldson, Nursing Informatics Australia, Australia Gail Easterbrook, Flinders Medical Centre, Australia Aitor Eguzkitza, UPNA (Public University of Navarre) - CHN (Complejo Hospitalario de Navarra), Spain David Evans, Queensland Health, Australia Shahla Foozonkhah, Iran ministry of health and education, Iran Einar Fosse, National Centre for Integrated Care and Telemedicine, Norway Peter Garcia-Webb, Australia Sebastian Garde, Ocean Informatics, Germany Andrew Goodchild, NEHTA, Australia Anneke Goossen, Results 4 Care, Netherlands Heather Grain, Llewelyn Grain Informatics, Australia Trina Gregory, cpc, Australia Sam Heard, Ocean Informatics, Australia Evelyn Hovenga, EJSH Consulting, Australia Eugene Igras, IRIS Systems, Inc., Canada Lars Karlsen, DIPS ASA, Norway Lars Morgan Karlsen, DIPS ASA, Norway Mary Kelaher, NEHTA, Australia Eizen Kimura, Ehime Univ., Japan Shinji Kobayashi, Kyoto University, Japan Robert L'egan, NEHTA, Australia Sabine Leh, Haukeland University Hospital, Department of Pathology, Norway Heather Leslie, Ocean Health Systems, Australia (openEHR Editor) Hugh Leslie, Ocean Informatics, Australia (Editor) Hallvard Lærum, Oslo University Hospital, Norway Rohan Martin, Ambulance Victoria, Australia David McKillop, NEHTA, Australia Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (openEHR Editor) Chris Mitchell, RACGP, Australia Stewart Morrison, NEHTA, Australia Bjoern Naess, DIPS ASA, Norway Jörg Niggemann, compugroup, Germany Andrej Orel, Marand d.o.o., Slovenia Chris Pearce, Melbourne East GP Network, Australia Camilla Preeston, Royal Australian College of General Practitioners, Australia Margaret Prichard, NEHTA, Australia Jodie Pycroft, Adelaide Northern Division of General Practice Ltd, Australia Cathy Richardson, NEHTA, Australia Robyn Richards, NEHTA - Clinical Terminology, Australia Jussara Rotzsch, UNB, Brazil Thilo Schuler, Australia Anoop Shah, University College London, United Kingdom Norwegian Review Summary, Nasjonal IKT HF, Norway Gordon Tomes, Australian Institute of Health and Welfare, Australia Richard Townley-O'Neill, NEHTA, Australia Donna Truran, ACCTI-UoW, Australia John Tore Valand, Helse Bergen, Norway (openEHR Editor) Kylie Young, The Royal Australian College of General Practitioners, Australia, originalLanguage=en, translators= German: Jasmin Buck, Sebastian Garde, University of Heidelberg, Central Queensland University Spanish (Argentina): Alan March, Hospital Universitario Austral, Buenos Aires, Argentina, alandmarch@gmail.com, - Norwegian Bokmål: Silje Ljosland Bakke, John Tore Valand, Helse Bergen HF Portuguese (Brazil): Adriana Kitajima, Gabriela Alves, Maria Angela Scatena, Marivan Abrahäo, Core Consulting, contato@coreconsulting.com.br, Hospital Alemão Oswaldo Cruz (HAOC) Arabic (Syria): Mona Saleh Spanish (Spain): Pablo Pazos, CaboLabs, Computer Engineer , subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={state=[], content=[], capabilities=[], relationships=[], activities=[], events=[], contacts=[], description=[], target=[], context=[], identities=[], protocol=[ResourceSimplifiedHierarchyItem [path=/protocol[at0032]/items[at0070], code=at0070, itemType=ELEMENT, level=2, text=Last updated, description=The date this problem or diagnosis was last updated., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0032]/items[at0071], code=at0071, itemType=SLOT, level=2, text=Extension, description=Additional information required to capture local content or to align with other reference models/formalisms., comment=For example: local information requirements or additional metadata to align with FHIR or CIMI equivalents., uncommonOntologyItems=null, occurencesFormal=0.., occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:* All not explicitly excluded archetypes, extendedValues=null]], other_participations=[], items=[], details=[], provider=[], source=[], ism_transition=[], data=[ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0002.1], code=at0002.1, itemType=ELEMENT, level=2, text=Key diagnosis, description=The name of the key diagnosis, preferrably coded, e.g. 'Bronchial carcinoma'., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0009], code=at0009, itemType=ELEMENT, level=2, text=Clinical description, description=Narrative description about the problem or diagnosis., comment=Use to provide background and context, including evolution, episodes or exacerbations, progress and any other relevant details, about the problem or diagnosis., 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]/items[at0012], code=at0012, itemType=ELEMENT, level=2, text=Body site, description=Identification of a simple body site for the location of the problem or diagnosis., comment=Coding of the name of the anatomical location with a terminology is preferred, where possible. Use this data element to record precoordinated anatomical locations. If the requirements for recording the anatomical location are determined at run-time by the application or require more complex modelling such as relative locations then use the CLUSTER.anatomical_location or CLUSTER.relative_location within the 'Structured anatomical location' SLOT in this archetype. Occurrences for this data element are unbounded to allow for clinical scenarios such as describing a rash in multiple locations but where all of the other attributes are identical. If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant. , uncommonOntologyItems=null, occurencesFormal=0.., occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0039], code=at0039, itemType=SLOT, level=2, text=Structured body site, description=A structured anatomical location for the problem or diagnosis., comment=Use this SLOT to insert the CLUSTER.anatomical_location or CLUSTER.relative_location archetypes if the requirements for recording the anatomical location are determined at run-time by the application or require more complex modelling such as relative locations. If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, use of this SLOT becomes redundant. , uncommonOntologyItems=null, occurencesFormal=0.., occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include: openEHR-EHR-CLUSTER.anatomical_location.v1 and specialisations or openEHR-EHR-CLUSTER.anatomical_location_clock.v0 and specialisations or openEHR-EHR-CLUSTER.anatomical_location_relative.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0077], code=at0077, itemType=ELEMENT, level=2, text=Date/time of onset, description=Estimated or actual date/time that signs or symptoms of the problem/diagnosis were first observed., comment=Data captured/imported as "Age at onset" should be converted to a date using the subject's date of birth., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0003], code=at0003, itemType=ELEMENT, level=2, text=Date/time clinically recognised, description=Estimated or actual date/time the diagnosis or problem was recognised by a healthcare professional., comment=Partial dates are acceptable. If the subject of care is under the age of one year, then the complete date or a minimum of the month and year is necessary to enable accurate age calculations - for example, if used to drive decision support. Data captured/imported as "Age at time of clinical recognition" should be converted to a date using the subject's date of birth., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0005], code=at0005, itemType=ELEMENT, level=2, text=Severity, description=An assessment of the overall severity of the problem or diagnosis., comment=If severity is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant. Note: more specific grading of severity can be recorded using the Specific details SLOT., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of: Coded Text at0047::Mild [The problem or diagnosis does not interfere with normal activity or may cause damage to health if left untreated.] at0048::Moderate [The problem or diagnosis causes interference with normal activity or will damage health if left untreated.] at0049::Severe [The problem or diagnosis prevents normal activity or will seriously damage health if left untreated.] Text , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0043], code=at0043, itemType=SLOT, level=2, text=Specific details, description=Details that are additionally required to record as unique attributes of this problem or diagnosis., comment=May include structured detail about the grading or staging of the diagnosis; diagnostic criteria, classification criteria or formal severity assessments such as Common Terminology Criteria for Adverse Events., uncommonOntologyItems=null, occurencesFormal=0.., occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:* All not explicitly excluded archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0072], code=at0072, itemType=ELEMENT, level=2, text=Course description, description=Narrative description about the course of the problem or diagnosis since onset., 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]/items[at0030], code=at0030, itemType=ELEMENT, level=2, text=Date/time of resolution, description=Estimated or actual date/time of resolution or remission for this problem or diagnosis, as determined by a healthcare professional., comment=Partial dates are acceptable. If the subject of care is under the age of one year, then the complete date or a minimum of the month and year is necessary to enable accurate age calculations - for example, if used to drive decision support. Data captured/imported as "Age at time of resolution" should be converted to a date using the subject's date of birth. , uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0046], code=at0046, itemType=SLOT, level=2, text=Status, description=Structured details for location-, domain-, episode- or workflow-specific aspects of the diagnostic process., comment=Use status or context qualifiers with care, as they are variably used in practice and interoperability cannot be assured unless usage is clearly defined with the community of use. For example: active status - active, inactive, resolved, in remission; evolution status - initial, interim/working, final; temporal status - current, past; episodicity status - first, new, ongoing; admission status - admission, discharge; or priority status - primary, secondary., uncommonOntologyItems=null, occurencesFormal=0.., occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:* openEHR-EHR-CLUSTER.problem_status.v0 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0073], code=at0073, itemType=ELEMENT, level=2, text=Diagnostic certainty, description=The level of confidence in the identification of the diagnosis., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of: Coded Text at0074::Suspected [The diagnosis has been identified with a low level of certainty.] at0075::Probable [The diagnosis has been identified with a high level of certainty.] at0076::Confirmed [The diagnosis has been confirmed against recognised criteria.] Text , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0069], code=at0069, itemType=ELEMENT, level=2, text=Comment, description=Additional narrative about the problem or diagnosis not captured in other fields., 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]], credentials=[]}, topLevelItems={protocol=ResourceSimplifiedHierarchyItem [path=ROOT_/protocol[at0032], code=at0032, itemType=ITEM_TREE, level=0, 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 (Cardinality: 0.., unordered), dataType=ITEM_TREE, bindings=null, values=null, extendedValues=null], data=ResourceSimplifiedHierarchyItem [path=ROOT_/data[at0001], code=at0001, itemType=ITEM_TREE, level=0, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=0..1, cardinalityText=optional, subCardinalityFormal=1.., subCardinalityText= (Cardinality: 1.., unordered), dataType=ITEM_TREE, bindings=null, values=null, extendedValues=null]}, addHierarchyItemsTo=protocol, currentHierarchyItemsForAdding=[ResourceSimplifiedHierarchyItem [path=/protocol[at0032]/items[at0070], code=at0070, itemType=ELEMENT, level=2, text=Last updated, description=The date this problem or diagnosis was last updated., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0032]/items[at0071], code=at0071, itemType=SLOT, level=2, text=Extension, description=Additional information required to capture local content or to align with other reference models/formalisms., comment=For example: local information requirements or additional metadata to align with FHIR or CIMI equivalents., uncommonOntologyItems=null, occurencesFormal=0.., occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:* All not explicitly excluded archetypes, extendedValues=null]], minIndents={}, termBindingRetrievalErrorMessage=null]