TEMPLATE ID | Clinical Noting NDS Example |
Concept | Clinical Noting NDS Example |
Description | Not Specified |
Purpose | Not Specified |
References | |
Authors | date: 2021-04-10 |
Other Details Language | date: 2021-04-10 |
OtherDetails Language Independent | {original_language=ISO_639-1::en, sem_ver=0.1.0} |
Language used | en |
Citeable Identifier | 1051.57.283 |
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Examples include: pre-employment medical, routine antenatal visit, women's health check, pre-operative assessment, or annual medical check-up., 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.encounter.v1]/content[openEHR-EHR-EVALUATION.reason_for_encounter.v1]/data[at0001]/items[at0004], code=at0004, itemType=ELEMENT, level=3, text=Presenting problem, description=Identification of the clinical or social problem motivating the subject of care to seeking healthcare., comment=Coding of the 'Presenting problem' with a terminology is desirable, where possible. Clinical or social reasons for seeking healthcare can include health issues, symptoms or physical signs. Examples: health issues - desire to quit smoking, domestic violence; symptoms - abdominal pain, shortness of breath; physical signs - an altered conscious state. 'Chief complaint' may be used as a valid synonym for 'Presenting problem' in templates., 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.encounter.v1]/content[openEHR-EHR-EVALUATION.clinical_synopsis.v1], code=at0000, itemType=EVALUATION, level=1, text=Clinical synopsis, description=Narrative summary or overview about a patient, specifically from the perspective of a healthcare provider, and with or without associated interpretations., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-EVALUATION.clinical_synopsis.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=2, 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.encounter.v1]/content[openEHR-EHR-EVALUATION.clinical_synopsis.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=3, text=Synopsis, description=The summary, assessment, conclusions or evaluation of the clinical findings., 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=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1], code=at0000, itemType=EVALUATION, level=1, text=Problem/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=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=2, 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.encounter.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=3, 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.encounter.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0009], code=at0009, itemType=ELEMENT, level=3, 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=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0073], code=at0073, itemType=ELEMENT, level=3, 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=
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