TEMPLATE IDCR - Cancer MDT Output Report.v0 (IDCR - Cancer MDT Output Report.v0)

TEMPLATE IDIDCR - Cancer MDT Output Report.v0
ConceptIDCR - Cancer MDT Output Report.v0
DescriptionNot Specified
PurposeNot Specified
References
OtherDetails Language Independent{MetaDataSet:Sample Set =Template metadata sample set}
Language useden
Citeable Identifier1051.57.52
AllOperationalTemplate [rootArchetypeId=openEHR-EHR-COMPOSITION.report.v1, otherContributors=null, tshis=[ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1], code=at0000, itemType=COMPOSITION, level=0, text=Cancer MDT Output Report, description=Document to communicate information to others, commonly in response to a request from another party., 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=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.referral_details_rcp.v1], code=at0000, itemType=SECTION, level=1, text=Referral details, description=Referral details heading (AoMRC)., 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.report.v1]/content[openEHR-EHR-SECTION.referral_details_rcp.v1]/items[openEHR-EHR-INSTRUCTION.request-referral.v1 and name/value='MDT Referral'], code=at0000.1, itemType=INSTRUCTION, level=2, text=MDT Referral, description=Request for provision of a specified service by another healthcare provider or organisation., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=INSTRUCTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.referral_details_rcp.v1]/items[openEHR-EHR-INSTRUCTION.request-referral.v1 and name/value='MDT Referral']/activities[at0001], code=at0001, itemType=ACTIVITY, level=3, text=Request, description=Current Activity., comment=null, uncommonOntologyItems=null, occurencesFormal=1..*, occurencesText=Mandatory, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ACTIVITY, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.referral_details_rcp.v1]/items[openEHR-EHR-INSTRUCTION.request-referral.v1 and name/value='MDT Referral']/activities[at0001]/description[at0009], code=at0009, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Description, 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.report.v1]/content[openEHR-EHR-SECTION.referral_details_rcp.v1]/items[openEHR-EHR-INSTRUCTION.request-referral.v1 and name/value='MDT Referral']/activities[at0001]/description[at0009]/items[at0121], code=at0121, itemType=ELEMENT, level=5, text=Service requested, description=Identification of the service requested. This is often coded with an external terminology., 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.report.v1]/content[openEHR-EHR-SECTION.referral_details_rcp.v1]/items[openEHR-EHR-INSTRUCTION.request-referral.v1 and name/value='MDT Referral']/activities[at0001]/description[at0009]/items[at0068], code=at0068, itemType=ELEMENT, level=5, text=Urgency, description=Urgency of the request., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Emergency 
  • Urgent 
  • Routine 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.referral_details_rcp.v1]/items[openEHR-EHR-INSTRUCTION.request-referral.v1 and name/value='MDT Referral']/activities[at0001]/description[at0009]/items[at0040], code=at0040, itemType=ELEMENT, level=5, text=Date &/or time service required, description=The date and time that the service should be performed or completed., 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.report.v1]/content[openEHR-EHR-SECTION.referral_details_rcp.v1]/items[openEHR-EHR-INSTRUCTION.request-referral.v1 and name/value='Original referral'], code=at0000.1, itemType=INSTRUCTION, level=2, text=Original referral, description=Request for provision of a specified service by another healthcare provider or organisation., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=INSTRUCTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.referral_details_rcp.v1]/items[openEHR-EHR-INSTRUCTION.request-referral.v1 and name/value='Original referral']/activities[at0001], code=at0001, itemType=ACTIVITY, level=3, text=Request, description=Current Activity., comment=null, uncommonOntologyItems=null, occurencesFormal=1..*, occurencesText=Mandatory, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ACTIVITY, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.referral_details_rcp.v1]/items[openEHR-EHR-INSTRUCTION.request-referral.v1 and name/value='Original referral']/activities[at0001]/description[at0009]/items[at0144], code=at0144, itemType=ELEMENT, level=4, text=Breach date, description=The latest date that is acceptable for the service to be completed., 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.report.v1]/content[openEHR-EHR-SECTION.history_rcp.v1], code=at0000, itemType=SECTION, level=1, text=History, description=History details heading (AoMRC)., 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.report.v1]/content[openEHR-EHR-SECTION.history_rcp.v1]/items[openEHR-EHR-EVALUATION.reason_for_encounter.v1], code=at0000, itemType=EVALUATION, level=2, text=Question for MDT, description=The reason for initiation of any healthcare encounter or contact by the individual who is the subject of care., 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.report.v1]/content[openEHR-EHR-SECTION.history_rcp.v1]/items[openEHR-EHR-EVALUATION.reason_for_encounter.v1]/data[at0001]/items[at0004], code=at0004, itemType=ELEMENT, level=3, text=Question to MDT, 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=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.history_rcp.v1]/items[openEHR-EHR-OBSERVATION.story.v1], code=at0000, itemType=OBSERVATION, level=2, text=Story/History, description=The subjective clinical history of the subject of care as recorded directly by the subject, or reported to a clinician by the subject or a carer., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.history_rcp.v1]/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=3, text=Story, description=Narrative description of the story or clinical history for the subject of care., comment=null, 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.report.v1]/content[openEHR-EHR-SECTION.history_rcp.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Significant past medical history'], code=at0000, itemType=SECTION, level=2, text=Significant past medical history, description=A generic section header which should be renamed in a template to suit a specific clinical context., 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.report.v1]/content[openEHR-EHR-SECTION.history_rcp.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Significant past medical history']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v0], code=at0000, itemType=EVALUATION, level=3, text=Problem/diagnosis, description=Details about a single identified health condition, injury or 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.report.v1]/content[openEHR-EHR-SECTION.history_rcp.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Significant past medical history']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v0]/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.report.v1]/content[openEHR-EHR-SECTION.history_rcp.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Significant past medical history']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v0]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=5, text=Past medical history, 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.report.v1]/content[openEHR-EHR-SECTION.history_rcp.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Significant past medical history']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v0]/data[at0001]/items[at0077], code=at0077, itemType=ELEMENT, level=5, text=Date of onset, description=Estimated or actual date/time that signs or symptoms of the problem/diagnosis were first observed., 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.report.v1]/content[openEHR-EHR-SECTION.history_rcp.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Significant past medical history']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v0]/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.report.v1]/content[openEHR-EHR-SECTION.history_rcp.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Signifcant factors'], code=at0000, itemType=SECTION, level=2, text=Signifcant factors, description=A generic section header which should be renamed in a template to suit a specific clinical context., 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.report.v1]/content[openEHR-EHR-SECTION.history_rcp.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Signifcant factors']/items[openEHR-EHR-OBSERVATION.lab_test.v1], code=at0000, itemType=OBSERVATION, level=3, text=Laboratory test, description=To record the result of a laboratory test which may be used to record a single valued test but will often be specialised or templated to represent multiple value or 'panel' tests. This archetype also acts as the parent for specialisations appropriate for more specific laboratory tests microbiology, histopathology., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.history_rcp.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Signifcant factors']/items[openEHR-EHR-OBSERVATION.lab_test.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0078], code=at0078, itemType=ELEMENT, level=4, text=Test result, description=The result of the test., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.history_rcp.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Signifcant factors']/items[openEHR-EHR-OBSERVATION.exam.v1], code=at0000, itemType=OBSERVATION, level=3, text=Physical examination findings, description=Findings observed during the physical examination of a subject of care., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.history_rcp.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Signifcant factors']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0006], code=at0006, itemType=ELEMENT, level=4, text=Interpretation, description=Single word, phrase or brief description which represents the clinical meaning and significance of the physical examination findings., comment=Coding with a terminology is preferred, if possible. For example, 'normal examination' or 'tympanic membrane perforation'., 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.report.v1]/content[openEHR-EHR-SECTION.history_rcp.v1]/items[openEHR-EHR-SECTION.investigations_results_rcp.v1], code=at0000, itemType=SECTION, level=2, text=Investigations and results, description=Investigations and results heading (AoMRC)., 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.report.v1]/content[openEHR-EHR-SECTION.history_rcp.v1]/items[openEHR-EHR-SECTION.investigations_results_rcp.v1]/items[openEHR-EHR-OBSERVATION.imaging_exam.v1], code=at0000, itemType=OBSERVATION, level=3, text=Imaging examination result, description=Record the findings and interpretation of an imaging examination, or series of examinations, performed., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.history_rcp.v1]/items[openEHR-EHR-SECTION.investigations_results_rcp.v1]/items[openEHR-EHR-OBSERVATION.imaging_exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=4, text=Examination result name, description=Identification of the imaging examination or procedure performed, typically including modality and anatomical location (including laterality). Coding with a terminology, potientially a pre-coordinated term specifying both modality and anatomical location, is desirable where possible. Possible candidate terminologies: LOINC, SNOMED CT or RadLex., 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.report.v1]/content[openEHR-EHR-SECTION.history_rcp.v1]/items[openEHR-EHR-SECTION.investigations_results_rcp.v1]/items[openEHR-EHR-OBSERVATION.imaging_exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0007], code=at0007, itemType=ELEMENT, level=4, text=Overall result status, description=The status of the examination result as a whole., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Registered 
  • Interim 
  • Final 
  • Amended 
  • Cancelled / Aborted 
Default value: Final, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.history_rcp.v1]/items[openEHR-EHR-SECTION.investigations_results_rcp.v1]/items[openEHR-EHR-OBSERVATION.imaging_exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0021], code=at0021, itemType=ELEMENT, level=4, text=Conclusion, description=Concise and clinically contextualised narrative interpretation of the imaging examination findings., 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.report.v1]/content[openEHR-EHR-SECTION.history_rcp.v1]/items[openEHR-EHR-SECTION.investigations_results_rcp.v1]/items[openEHR-EHR-OBSERVATION.lab_test-histopathology.v1], code=at0000.1, itemType=OBSERVATION, level=3, text=Histopathology, description=Simple histopathology lab test result., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.history_rcp.v1]/items[openEHR-EHR-SECTION.investigations_results_rcp.v1]/items[openEHR-EHR-OBSERVATION.lab_test-histopathology.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0057], code=at0057, itemType=ELEMENT, level=4, text=Overall interpretation, description=An overall interpretative comment on this test., 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.report.v1]/content[openEHR-EHR-SECTION.history_rcp.v1]/items[openEHR-EHR-SECTION.investigations_results_rcp.v1]/items[openEHR-EHR-OBSERVATION.exam.v1], code=at0000, itemType=OBSERVATION, level=3, text=Cystoscopy, description=Findings observed during the physical examination of a subject of care., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.history_rcp.v1]/items[openEHR-EHR-SECTION.investigations_results_rcp.v1]/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=4, text=Description, description=Narrative description of the overall findings observed during a physical examination of a patient., comment=May be used to record a narrative summary of the complete clinical examination or key aspects of clinical examination findings, which will be supported by structured data. Details of specific structured findings can be included using CLUSTER archetypes in the 'Examination Detail' slot. This data element may be used to capture legacy data that is not available in a structured format., 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.report.v1]/content[openEHR-EHR-SECTION.history_rcp.v1]/items[openEHR-EHR-SECTION.assessment_scales_rcp.v1], code=at0000, itemType=SECTION, level=2, text=Assessment scales, description=Assessment scales heading (AoMRC)., 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.report.v1]/content[openEHR-EHR-SECTION.history_rcp.v1]/items[openEHR-EHR-SECTION.assessment_scales_rcp.v1]/items[openEHR-EHR-OBSERVATION.who_performance_status.v0], code=at0000, itemType=OBSERVATION, level=3, text=WHO Performance Status, description=WHO Performance Status Score., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.history_rcp.v1]/items[openEHR-EHR-SECTION.assessment_scales_rcp.v1]/items[openEHR-EHR-OBSERVATION.who_performance_status.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=4, text=Performance Status, description=WHO Performance Status Score., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_ORDINAL, bindings=null, values=
  • 0: Fully active 
  • 1: Ambulatory and light work 
  • 2: Ambulatory and self care only 
  • 3: Limited selfcare 
  • 4: Completely disabled 
  • 5: Dead 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.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.report.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.report.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0001]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v0], code=at0000, itemType=EVALUATION, level=3, text=Problem/diagnosis, description=Details about a single identified health condition, injury or 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.report.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0001]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v0]/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.report.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0001]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v0]/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.report.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0001]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v0]/data[at0001]/items[at0077], code=at0077, itemType=ELEMENT, level=5, text=Date of onset, description=Estimated or actual date/time that signs or symptoms of the problem/diagnosis were first observed., 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.report.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0001]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v0]/data[at0001]/items[openEHR-EHR-CLUSTER.tnm_staging.v1], code=at0000, itemType=CLUSTER, level=5, text=Tumour - TNM Cancer staging, description=A framework for the classification and grading of malignancies using the TNM classification system., 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.report.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0001]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v0]/data[at0001]/items[openEHR-EHR-CLUSTER.tnm_staging.v1]/items[at0002]/items[at0010], code=at0010, itemType=ELEMENT, level=6, text=Clinical staging, description=The overall Clinical staging derived from each T, N and M component e.g T1aM0NX. May include additional TNM descriptors., 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.report.v1]/content[openEHR-EHR-SECTION.problems_and_diagnoses.v1]/items[at0001]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v0]/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.report.v1]/content[openEHR-EHR-SECTION.plan_requested_actions_rcp.v1], code=at0000, itemType=SECTION, level=1, text=Plan and requested actions, description=Plan and requested actions heading (AoMRC), 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.report.v1]/content[openEHR-EHR-SECTION.plan_requested_actions_rcp.v1]/items[openEHR-EHR-EVALUATION.recommendation.v1], code=at0000, itemType=EVALUATION, level=2, text=Recommendation, description=A suggestion, advice or proposal for current healthcare management or for future action., 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.report.v1]/content[openEHR-EHR-SECTION.plan_requested_actions_rcp.v1]/items[openEHR-EHR-EVALUATION.recommendation.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=3, text=Recommendation, description=Narrative description of the recommendation., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null]], templateType=normal]