TEMPLATE Contextual Problem List.v0 (Contextual Problem List.v0)

TEMPLATE IDContextual Problem List.v0
ConceptContextual Problem List.v0
DescriptionThis problem template represents an active list of problems or diagnosis code for the purposes of active patient care.
PurposeThis problem template represents an active list of problems or diagnosis code for the purposes of active patient care.
References
Authorsname: John Meredith; organisation: NHS Wales Informatics Service; email: john.meredith@wales.nhs.uk; date: 2019-09-24
Other Details Languagename: John Meredith; organisation: NHS Wales Informatics Service; email: john.meredith@wales.nhs.uk; date: 2019-09-24
OtherDetails Language Independent{PARENT:MD5-CAM-1.0.1=0CA62AF2B9495CC802003ADD3A0FC2D5, MetaDataSet:Sample Set=Template metadata sample set, MD5-CAM-1.0.1=529a79c38e705005c63cf7dbc0c8a4ac, build_uid=cea9eb88-56ea-4c30-99df-98170cbb7f07}
Keywordsproblem; diagnosis; complication; comorbidity
Language useden
Citeable Identifier1051.57.191
AllOperationalTemplate [rootArchetypeId=openEHR-EHR-COMPOSITION.problem_list.v1, otherContributors=null, tshis=[ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1], code=at0000, itemType=COMPOSITION, level=0, text=Contextual Problem List, description=A persistent and managed list of any combination of diagnoses, problems and/or procedures that may influence clinical decision-making and care provision for the subject of care., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=COMPOSITION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=null, code=null, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=1, text=Other Context, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/context/other_context[at0006]/items[openEHR-EHR-CLUSTER.xds_metadata.v0], code=at0000, itemType=CLUSTER, level=2, text=XDS Metadata, description=Additional composition metadata aligned with IHE-XDS which is not already available from the Reference Model COMPOSITION class., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/context/other_context[at0006]/items[openEHR-EHR-CLUSTER.xds_metadata.v0]/items[at0001], code=at0001, itemType=ELEMENT, level=3, text=Author specialty, description=The speciality of the author/composer of the document., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/context/other_context[at0006]/items[openEHR-EHR-CLUSTER.xds_metadata.v0]/items[at0002], code=at0002, itemType=ELEMENT, level=3, text=Class code, description=A high-level document class code, normally selected from a valueset provided by the IHE-XDS Affinity Domain., comment=For example: Report, Summary, Images, Plan, Patient Preferences, Workflow. These codes are specific to an XDS Affinity Domain., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/context/other_context[at0006]/items[openEHR-EHR-CLUSTER.xds_metadata.v0]/items[at0003], code=at0003, itemType=ELEMENT, level=3, text=Document type, description=The code specifying the precise type of document from the user perspective. Normally selected from a valueset provided by the local IHE-XDS Affinity Domain or national standard., comment=for example: Pulmonary History and Physical, Discharge Summary, Ultrasound Report. These codes are specific to an XDS Affinity Domain., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=Default value: SNOMED-CT::162991000000102::Problems and issues, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/context/other_context[at0006]/items[openEHR-EHR-CLUSTER.xds_metadata.v0]/items[at0004], code=at0004, itemType=ELEMENT, level=3, text=Confidentiality code, description=A term specifying the level of confidentiality of the XDS Document., comment=Coded text is preferred, normally specific to an XDS Affinity Domain., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/context/other_context[at0006]/items[openEHR-EHR-CLUSTER.xds_metadata.v0]/items[at0007], code=at0007, itemType=ELEMENT, level=3, text=Health care facility type, description=A term defining the healthcare facility type., comment=Coded text is preferred. The codes are specific to an XDS Affinity Domain., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/context/other_context[at0006]/items[openEHR-EHR-CLUSTER.xds_metadata.v0]/items[at0011], code=at0011, itemType=ELEMENT, level=3, text=Event code, description=This list of codes represents the main clinical acts., comment=For example: Colonoscopy or appendicectomy., 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=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1], code=at0000, itemType=SECTION, level=1, text=Problems and diagnoses, description=unknown, comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0001], code=at0001, itemType=SECTION, level=2, text=Primary diagnoses, description=*, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0001]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1], code=at0000, itemType=EVALUATION, level=3, text=Primary Diagnosis, description=Details about a single identified health condition, injury, disability or any other issue which impacts on the physical, mental and/or social well-being of an individual., comment=Clear delineation between the scope of a problem versus a diagnosis is not easy to achieve in practice. 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'., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0001]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0001]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=5, text=Problem/Diagnosis name, description=Identification of the problem or diagnosis, by name., comment=Coding of the name of the problem or diagnosis with a terminology is preferred, where possible., 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=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0001]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0077], code=at0077, itemType=ELEMENT, level=5, 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=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0001]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0030], code=at0030, itemType=ELEMENT, level=5, 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=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0001]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v1], code=at0000, itemType=CLUSTER, level=5, text=Problem/Diagnosis qualifier, description=Contextual or temporal qualifier for a specified problem or diagnosis., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0001]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v1]/items[at0003], code=at0003, itemType=ELEMENT, level=6, text=Problem status, description=Category that supports division of problems and diagnoses into Active or Inactive problem lists., comment=The Active/Inactive and Current/Past data elements have similar clinical impact but represent slightly different semantics. Both are actively used in different clinical settings, but usually not together. If a Current/Past qualifier is recorded, then this data element is likely to be redundant. An exception where a condition can be current but inactive is asthma that is not causing acute symptoms., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Active 
  • Inactive 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0001]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v1]/items[at0083], code=at0083, itemType=ELEMENT, level=6, text=Resolution phase, description=Phase of healing for an acute problem or diagnosis., comment=For example: tracking the progress of resolution of a middle ear infection., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Resolved 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0001]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v1]/items[at0063], code=at0063, itemType=ELEMENT, level=6, text=Diagnostic category, description=Category of the problem or diagnosis within a specified episode of care and/or local care context., comment=This data element contains a value set commonly used in diagnostic categorisation. In episodic care contexts (commonly secondary care) it is common to categorise/organise diagnoses according to their relationship to the principal diagnosis being addressed during that episode of care. These categories may also be used for clinical coding, reporting and billing purposes. In some countries the diagnostic category may be known as a DRG. In addition, the free text choice permits use of other local value sets, as required., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Coded TextValue set: external
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0001]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0073], code=at0073, itemType=ELEMENT, level=5, text=Diagnostic certainty, description=The level of confidence in the identification of the diagnosis., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Coded Text
    • Suspected 
    • Probable 
    • Confirmed 
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0001]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0069], code=at0069, itemType=ELEMENT, level=5, text=Comment, description=Additional narrative about the problem or diagnosis not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0001]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/protocol[at0032], code=at0032, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Protocol, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0001]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/protocol[at0032]/items[at0070], code=at0070, itemType=ELEMENT, level=5, text=Last updated, description=The date this problem or diagnosis was last updated., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0001]/items[openEHR-EHR-EVALUATION.absence.v1], code=at0000, itemType=EVALUATION, level=3, text=Absence of information, description=Statement that specified health information is not available for inclusion in the health record or extract at the time of recording., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0001]/items[openEHR-EHR-EVALUATION.absence.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0001]/items[openEHR-EHR-EVALUATION.absence.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=5, text=Absence statement, description=Positive statement that no information is available., comment=For example: "No information available about adverse reactions"; No information available about problems or diagnoses"; "No information available about previous procedures performed"; or "No information available about medications used"., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=Default value: Principle diagnosis not recorded, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0001]/items[openEHR-EHR-EVALUATION.absence.v1]/protocol[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Protocol, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0001]/items[openEHR-EHR-EVALUATION.absence.v1]/protocol[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=5, text=Last updated, description=The date at which the absence was last updated., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0002], code=at0002, itemType=SECTION, level=2, text=Co-morbidities, description=*, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0002]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1], code=at0000, itemType=EVALUATION, level=3, text=Co-morbidities, description=Details about a single identified health condition, injury, disability or any other issue which impacts on the physical, mental and/or social well-being of an individual., comment=Clear delineation between the scope of a problem versus a diagnosis is not easy to achieve in practice. 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'., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0002]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0002]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=5, text=Problem or complication, description=Identification of the problem or diagnosis, by name., comment=Coding of the name of the problem or diagnosis with a terminology is preferred, where possible., 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=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0002]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0077], code=at0077, itemType=ELEMENT, level=5, 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=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0002]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0030], code=at0030, itemType=ELEMENT, level=5, 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=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0002]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v1], code=at0000, itemType=CLUSTER, level=5, text=Problem/Diagnosis qualifier, description=Contextual or temporal qualifier for a specified problem or diagnosis., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0002]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v1]/items[at0003], code=at0003, itemType=ELEMENT, level=6, text=Problem status, description=Category that supports division of problems and diagnoses into Active or Inactive problem lists., comment=The Active/Inactive and Current/Past data elements have similar clinical impact but represent slightly different semantics. Both are actively used in different clinical settings, but usually not together. If a Current/Past qualifier is recorded, then this data element is likely to be redundant. An exception where a condition can be current but inactive is asthma that is not causing acute symptoms., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Active 
  • Inactive 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0002]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v1]/items[at0083], code=at0083, itemType=ELEMENT, level=6, text=Resolution phase, description=Phase of healing for an acute problem or diagnosis., comment=For example: tracking the progress of resolution of a middle ear infection., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Resolved 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0002]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v1]/items[at0063], code=at0063, itemType=ELEMENT, level=6, text=Diagnostic category, description=Category of the problem or diagnosis within a specified episode of care and/or local care context., comment=This data element contains a value set commonly used in diagnostic categorisation. In episodic care contexts (commonly secondary care) it is common to categorise/organise diagnoses according to their relationship to the principal diagnosis being addressed during that episode of care. These categories may also be used for clinical coding, reporting and billing purposes. In some countries the diagnostic category may be known as a DRG. In addition, the free text choice permits use of other local value sets, as required., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Coded TextValue set: external
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0002]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0073], code=at0073, itemType=ELEMENT, level=5, text=Diagnostic certainty, description=The level of confidence in the identification of the diagnosis., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Coded Text
    • Suspected 
    • Probable 
    • Confirmed 
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0002]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0069], code=at0069, itemType=ELEMENT, level=5, text=Comment, description=Additional narrative about the problem or diagnosis not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0002]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/protocol[at0032], code=at0032, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Protocol, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0002]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/protocol[at0032]/items[at0070], code=at0070, itemType=ELEMENT, level=5, text=Last updated, description=The date this problem or diagnosis was last updated., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0002]/items[openEHR-EHR-EVALUATION.absence.v1], code=at0000, itemType=EVALUATION, level=3, text=Absence of information, description=Statement that specified health information is not available for inclusion in the health record or extract at the time of recording., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0002]/items[openEHR-EHR-EVALUATION.absence.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0002]/items[openEHR-EHR-EVALUATION.absence.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=5, text=Absence statement, description=Positive statement that no information is available., comment=For example: "No information available about adverse reactions"; No information available about problems or diagnoses"; "No information available about previous procedures performed"; or "No information available about medications used"., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=Default value: No information for known co-morbidities, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0002]/items[openEHR-EHR-EVALUATION.absence.v1]/protocol[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Protocol, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0002]/items[openEHR-EHR-EVALUATION.absence.v1]/protocol[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=5, text=Last updated, description=The date at which the absence was last updated., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0004], code=at0004, itemType=SECTION, level=2, text=Complications, description=*, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0004]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1], code=at0000, itemType=EVALUATION, level=3, text=Problem or complication, description=Details about a single identified health condition, injury, disability or any other issue which impacts on the physical, mental and/or social well-being of an individual., comment=Clear delineation between the scope of a problem versus a diagnosis is not easy to achieve in practice. 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'., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0004]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0004]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=5, text=Problem or complication, description=Identification of the problem or diagnosis, by name., comment=Coding of the name of the problem or diagnosis with a terminology is preferred, where possible., 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=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0004]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0077], code=at0077, itemType=ELEMENT, level=5, 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=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0004]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0030], code=at0030, itemType=ELEMENT, level=5, 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=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0004]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v1], code=at0000, itemType=CLUSTER, level=5, text=Problem/Diagnosis qualifier, description=Contextual or temporal qualifier for a specified problem or diagnosis., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0004]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v1]/items[at0003], code=at0003, itemType=ELEMENT, level=6, text=Problem status, description=Category that supports division of problems and diagnoses into Active or Inactive problem lists., comment=The Active/Inactive and Current/Past data elements have similar clinical impact but represent slightly different semantics. Both are actively used in different clinical settings, but usually not together. If a Current/Past qualifier is recorded, then this data element is likely to be redundant. An exception where a condition can be current but inactive is asthma that is not causing acute symptoms., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Active 
  • Inactive 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0004]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v1]/items[at0083], code=at0083, itemType=ELEMENT, level=6, text=Resolution phase, description=Phase of healing for an acute problem or diagnosis., comment=For example: tracking the progress of resolution of a middle ear infection., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Resolved 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0004]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v1]/items[at0063], code=at0063, itemType=ELEMENT, level=6, text=Diagnostic category, description=Category of the problem or diagnosis within a specified episode of care and/or local care context., comment=This data element contains a value set commonly used in diagnostic categorisation. In episodic care contexts (commonly secondary care) it is common to categorise/organise diagnoses according to their relationship to the principal diagnosis being addressed during that episode of care. These categories may also be used for clinical coding, reporting and billing purposes. In some countries the diagnostic category may be known as a DRG. In addition, the free text choice permits use of other local value sets, as required., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Coded TextValue set: external
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0004]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0073], code=at0073, itemType=ELEMENT, level=5, text=Diagnostic certainty, description=The level of confidence in the identification of the diagnosis., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Coded Text
    • Suspected 
    • Probable 
    • Confirmed 
  •  Text
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No information available about problems or diagnoses"; "No information available about previous procedures performed"; or "No information available about medications used"., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=Default value: No information for known problems or complications, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0004]/items[openEHR-EHR-EVALUATION.absence.v1]/protocol[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Protocol, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0004]/items[openEHR-EHR-EVALUATION.absence.v1]/protocol[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=5, text=Last updated, description=The date at which the absence was last updated., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0003], code=at0003, itemType=SECTION, level=2, text=Other problems, description=*, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0003]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1], code=at0000, itemType=EVALUATION, level=3, text=Other problems, description=Details about a single identified health condition, injury, disability or any other issue which impacts on the physical, mental and/or social well-being of an individual., comment=Clear delineation between the scope of a problem versus a diagnosis is not easy to achieve in practice. 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'., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0003]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0003]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=5, text=Other problems, description=Identification of the problem or diagnosis, by name., comment=Coding of the name of the problem or diagnosis with a terminology is preferred, where possible., 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=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0003]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0077], code=at0077, itemType=ELEMENT, level=5, 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=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0003]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0030], code=at0030, itemType=ELEMENT, level=5, 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=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0003]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v1], code=at0000, itemType=CLUSTER, level=5, text=Problem/Diagnosis qualifier, description=Contextual or temporal qualifier for a specified problem or diagnosis., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0003]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.problem_qualifier.v1]/items[at0003], code=at0003, itemType=ELEMENT, level=6, text=Problem status, description=Category that supports division of problems and diagnoses into Active or Inactive problem lists., comment=The Active/Inactive and Current/Past data elements have similar clinical impact but represent slightly different semantics. Both are actively used in different clinical settings, but usually not together. If a Current/Past qualifier is recorded, then this data element is likely to be redundant. An exception where a condition can be current but inactive is asthma that is not causing acute symptoms., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Active 
  • Inactive 
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  • Resolved 
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  •  Coded Text
    • Suspected 
    • Probable 
    • Confirmed 
  •  Text
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No information available about problems or diagnoses"; "No information available about previous procedures performed"; or "No information available about medications used"., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=Default value: No information for other problems, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0003]/items[openEHR-EHR-EVALUATION.absence.v1]/protocol[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Protocol, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.problem_list.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0003]/items[openEHR-EHR-EVALUATION.absence.v1]/protocol[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=5, text=Last updated, description=The date at which the absence was last updated., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null]], templateType=normal]