| ARCHETYPE ID | openEHR-EHR-ADMIN_ENTRY.episode_institution.v0 |
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| Concept | Admission |
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| Description | Administrative details about a period of admitted patient care between a formal or statistical admission and a discharge, characterised by only one type of care from a healthcare institution or service. |
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| Use | To record administrative details about a period of admitted patient care, beginning when a healthcare institution or service assumes medical and/or legal responsibility for the patient, and ending at formal or statistical discharge. This period is defined by a single type of care provided by the institution/service.
Within the context of this archetype, discharge is interpreted broadly, and includes situations that, depending on local rules, may not be considered a discharge, such as death in the institution, or newborns released from care. |
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| Misuse | Not to be used for a single meeting with a patient where the institution does not take formal medical and/or legal responsibility of the patient, such as outpatient visits. At the time of authoring it is not yet determined which archetype should be used for this purpose.
Not to be used for a planned admission to a healthcare institution or service. At the time of authoring it is not yet determined which archetype should be used for this purpose. |
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| Purpose | To record administrative details about a period of admitted patient care between a formal or statistical admission and a discharge, characterised by only one type of care from a healthcare institution or service. |
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| References | |
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| Copyright | © openEHR Foundation |
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| Authors | Author name: Heather Leslie
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2020-03-14
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| Other Details Language | Author name: Heather Leslie
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2020-03-14
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| Other Details (Language Independent) | - Licence: This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/.
- Custodian Organisation: openEHR Foundation
- Original Namespace: org.openehr
- Original Publisher: openEHR Foundation
- Custodian Namespace: org.openehr
- MD5-CAM-1.0.1: 71A668DE9FA7D8F303D4DEE8D5EAA28D
- Build Uid: 40714ef5-9c55-4145-bf44-22e2d11c2444
- Revision: 0.0.1-alpha
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| Keywords | Admission, discharge, separation, visit, stay, hospitalization |
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| Lifecycle | in_development |
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| UID | 8be783ed-7a69-4f43-8816-978891a472df |
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| Language used | en |
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| Citeable Identifier | 1246.145.1083 |
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| Revision Number | 0.0.1-alpha |
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| data | |
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| Admission ID | Admission ID: An identifier for the admission. |
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| Admission date | Admission date: The date or the date-time of the formal or statistical admission to the institution or service. |
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| Reason for admission | Reason for admission: The reason why the individual was admitted to an institution or service.
For example: respite; rehabilitation; or infection isolation.
Diagnosies should be recorded using the EVAL.problem_diagnosis archetype plus the nested CLUSTER.problem_qualifier, if necessary. |
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| Admission category | Admission category: The type of admission.
For example: day surgery; elective surgery or emergency department. |
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| Source category | Source category: The type of residence where the individual resided prior to admission.
For example: hospital, community, or nursing home. 'Admission source' should be coded with a terminology, where possible. |
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| Source | Source: The organisation or address for the individual prior to the admission.
Include:
openEHR-EHR-CLUSTER.organisation.v1 and specialisations or
openEHR-EHR-CLUSTER.address.v1 and specialisations |
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| Referral ID | Referral ID: Identifier of the referral.
Choice of:
 Identifier
 Text
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| Referring clinician | Referring clinician: Details about the clinicians responsible for referring the individual from the Source.
Include:
openEHR-EHR-CLUSTER.person.v1 and specialisations |
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| Medical record number | Medical record number: Identification of the medical record number.
Choice of:
- Identifier
- Text
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| Health insurance category | Health insurance category: The type of health insurance applicable. |
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| Attending unit | Attending unit: The clinical service unit assigned for care of the individual.
For example: Orthopaedic A unit. |
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| Attending clinicians | Attending clinicians: Details about the consultant and attending clinicians responsible for care.
Include:
openEHR-EHR-CLUSTER.person.v1 and specialisations |
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| Physical location | Physical location: The physical location of the individual within the institution or service. |
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| Location onset | Location onset: The date the individual was moved to the internal location.
For example, the date moved to a new ward or bed. |
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| Location category | Location category: The type of location.
For example: Intensive care unit; high dependency unit. |
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| Location | Location: An organisation, physical address or structured address describing where the individual was located while admitted.
For example: 2nd floor, Moorhouse wing, Turnbull building, General Hospital.
Include:
openEHR-EHR-CLUSTER.address.v1 and specialisations or
openEHR-EHR-CLUSTER.organisation.v1 and specialisations |
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| Ward | Ward: The name of the ward within the institution or service where the individual was located. |
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| Room | Room: The name of the room within the institution or service where the individual was located. |
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| Bed | Bed: The name of the bed within the institution or service where the individual was located. |
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| Location end | Location end: The date the individual was moved from the internal location. |
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| Discharge date | Discharge date: The date or date-time of the formal or statistical end of the admission.
For example: transfer of care to home or another institution; or date of death.
Formal recording of the date of death should use CLUSTER.death_details. |
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| Outcome | Outcome: Outcome for the individual following discharge.
For example: recovered/not recovered/death. |
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| Destination category | Destination category: The type of residence where the individual resided following discharge.
For example: home; hospital; nursing home; or rehabilitation hospital. |
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| Destination | Destination: The organisation or address for the individual after the admission.
Include:
openEHR-EHR-CLUSTER.organisation.v1 and specialisations or
openEHR-EHR-CLUSTER.address.v1 and specialisations |
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| Additional details | Additional details: Additional structured details about the admission.
Include:
All not explicitly excluded archetypes |
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| Comment | Comment: Additional narrative about the admission, not captured in other fields. |
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| Other contributors | |
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| Translators | - German: Pascal Biermann, Carl von Ossietzky Universität Oldenburg, pascal.biermann@uni-oldenburg.de
- Norwegian Bokmål: Silje Ljosland Bakke, Mikkel Johan Gaup Grønmo, Vebjørn Arntzen, Martin Milde, Helse Vest IKT AS, Helse Nord IKT, Oslo University Hospital, silje.ljosland.bakke@helse-vest-ikt.no, mikkel.johan.gaup.gronmo@hnikt.no, varntzen@ous-hf.no, martin.milde@helse-vest-ikt.no, Nasjonal IKT
- Italian:
- Catalan: Laura Moral Lopez, Sistema de Salut de Catalunya, lauramoral@catsalut.cat
Other Contributors: Tradcera - Spanish (Spain): Laura Moral Lopez, Sistema de Salut de Catalunya, lauramoral@catsalut.cat
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