ARCHETYPE Management screening questionnaire (openEHR-EHR-OBSERVATION.management_screening.v1)

Name: Management screening questionnaire
License: http://creativecommons.org/licenses/by-sa/4.0/

ARCHETYPE ID	openEHR-EHR-OBSERVATION.management_screening.v1
Concept	Management screening questionnaire
Description	Series of questions and associated answers used to screen for clinical management including, but not limited to treatments, therapies and hospitalisation.
Use	Use to create a framework for recording answers to pre-defined screening questions about the broad range of clinical management that has been carried out in the past, with the exception of medications or surgical/operative procedures. Common use cases include, but are not limited to: Systematic questioning in any consultation, for example: --- Have you ever been admitted to hospital? --- Have you ever worn compression stockings? --- Have you ever been placed on a ventilator? --- Have you ever been on dialysis? Specific questioning related to disease surveillance. --- Was the patient isolated on admission? Yes, No, Unkown. --- Did the patient receive home oxygen therapy? Yes, No, Unkown. --- Was the patient admitted to ICU? Yes, No, Unkown. The semantics of this archetype are intentionally loose, and querying this archetype would normally only be useful or safe within the context of each specific template. In a template, each data element would usually be renamed to the specific question asked. Where value sets have been proposed for common use cases, these can be adapted for local use by using the DV_TEXT or the DV_BOOLEAN datatypes choice to match each specific use case. The EVENT structure from the reference model can be used to specify whether the questions relate to point in time or over a period of time. Use a separate instance of this archetype to distinguish between a questionnaire recording information about management that has been performed at any time in the past and information about management performed within a specified time interval - for example the difference between "Have you been admitted to hospital?" compared to "Have you been admitted to hospital in the past 4 weeks. The source of the information in a questionnaire response may vary in different contexts but can be specifically identified using the 'Information provider' element in the Reference Model. This archetype has been designed to be used as a screening tool or to record simple questionnaire-format data for use in situations such as a disease registry. If the screening questionnaire identifies the presence of management or treatment, it is recommended that clinical system record and persist the specific details about the management or treatment using archetypes specific for the clinical purpose.
Misuse	Not to be used to record answers to pre-defined screening questions about surgical/operative procedures that have been carried out in the past. Use the OBSERVATION.procedure_screening for this purpose. Not to be used to record answers to pre-defined screening questions about medications that have been used in the past. Use the OBSERVATION.medication_screening for this purpose. Not to be used to record details about a simple selection list where a question may be recorded as either "present" or "indeterminate". Use OBSERVATION.selection_list for this purpose.
Purpose	To create a framework for recording answers to pre-defined screening questions about the broad range of clinical management that has been carried out in the past, with the exception of medications or surgical/operative procedures.
References
Copyright	© openEHR Foundation
Authors	Author name: Heather Leslie Organisation: Atomica Informatics Email: heather.leslie@atomicainformatics.com Date originally authored: 2020-03-13
Other Details Language	Author name: Heather Leslie Organisation: Atomica Informatics Email: heather.leslie@atomicainformatics.com Date originally authored: 2020-03-13
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: EB65BCD42CDD13FD038AF8637097AAFE Build Uid: f924e7d8-3b78-4a37-aed2-eff00d1bbba4 Ip Acknowledgements: This artefact includes content from SNOMED Clinical Terms® (SNOMED CT®) which is copyrighted material of the International Health Terminology Standards Development Organisation (IHTSDO). Where an implementation of this artefact makes use of SNOMED CT content, the implementer must have the appropriate SNOMED CT Affiliate license - for more information contact https://www.snomed.org/snomed-ct/get-snomed or info@snomed.org. Revision: 1.0.3
Keywords	treatment, screening, intervention, questionnaire, care, support, therapy
Lifecycle	deprecated
UID	0c6c23ab-7018-4faf-93dd-c7e717e8569b
Language used	en
Citeable Identifier	1246.145.1088
Revision Number	1.0.3
Archetype Concept Comment	The answers may be self-reported.
protocol
Extension	Extension: Additional information required to extend the model with local content or to align with other reference models or formalisms. For example: local information requirements; or additional metadata to align with FHIR. Include: All not explicitly excluded archetypes
events
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
data
Screening purpose	Screening purpose: The context or reason for screening. This data element is intended to provide collection context for the question/answer groups when queried at a later date. It is not expected that this data element will be exposed to the individual, but only stored in data. For example: pre-admission screening or the name of the actual questionnaire.
Any management?	Any management?: Is there a history of management or treatment activities relevant for the screening purpose? The management or treatment may have been completed or could be ongoing. In a template, the data element would usually be renamed to the specific question asked. The proposed value set can be adapted for local use by using the DV_TEXT or the DV_BOOLEAN datatypes choice to match each specific use case. Choice of: Coded Text at0040::Yes [SNOMED-CT::373066001 \| Yes] at0041::No [SNOMED-CT::373067005 \| No] at0042::Unknown [SNOMED-CT::261665006 \| Unknown] Text Boolean
Description	Description: Narrative description about the history of any management or treatment activities relevant for the screening purpose.
Management activity	Management activity: Details about a specific management or treatment activity or grouping of management or treatment activities relevant for the screening purpose.
Management name	Management name: Name of a specific management or treatment activity or grouping of management or treatment activities. For example: Admitted to hospital; Admitted to ICU; Use of compression stockings; Daily dressings; ECMO. Coding of the 'Management name' with a terminology is preferred, where possible.
Specific management?	Specific management?: Is there a history of the specific management or treatment activity? In a template, the data element would usually be renamed to the specific question asked. The proposed value set can be adapted for local use by using the DV_TEXT or the DV_BOOLEAN datatypes choice to match each specific use case. Choice of: Coded Text at0023::Yes [SNOMED-CT::373066001 \| Yes] at0024::No [SNOMED-CT::373067005 \| No] at0027::Unknown [SNOMED-CT::261665006 \| Unknown] Text Boolean
Start	Start: When the managment or treatment started. The 'Start' data element has deliberately been loosely modelled to support the myriad of ways that it can be used in questionnaires to capture when the management or treatment started. The specific and intended semantics can be further clarified in a template. For example: Date/time for the date when the treatment started. Interval of date/time for a period of time eg. between 1940 and 1942. Text for descriptions like 'Immediately after the operation', or 'Up to one week ago', 'Up to two weeks ago', 'Three weeks ago'. Duration for the individual's age at the onset of duration OR the length of time during which the individual has been under treatment. Interval of Duration for the approximate age of the individual at the time of onset. Choice of: Date/Time Interval of Date/Time Text Duration Interval of Duration
Stopped	Stopped: When the managment or treatment ceased. The 'Stopped' data element has deliberately been loosely modelled to support the myriad of ways that it can be used in questionnaires to capture when the management or treatment ceased. The specific and intended semantics can be further clarified in a template. For example: Date/time for the date when the treatment stopped. Interval of date/time for a period of time eg. between 1940 and 1942. Text for descriptions like 'Immediately after the operation', or 'Up to one week ago', 'Up to two weeks ago', 'Three weeks ago'. Duration for the individual's age at the onset of duration OR the length of time during which the individual was under treatment. Interval of Duration for the approximate age of the individual at when the management stopped. Choice of: Date/Time Interval of Date/Time Text Duration Interval of Duration
Additional details	Additional details: Structured details or questions about the specific management or treatment activity. For example: hospital where treated. Include: openEHR-EHR-CLUSTER.organisation.v1
Comment	Comment: Additional narrative about a specific management or treatment question, not captured in other fields.
Additional details	Additional details: Structured details or questions about screening for management or treatment. Include: All not explicitly excluded archetypes
Other contributors	Vebjørn Arntzen, Oslo University Hospital, Norway (openEHR Editor) Astrid Askeland, Dips AS, Norway Silje Ljosland Bakke, Helse Vest IKT AS, Norway (openEHR Editor) SB Bhattacharyya, Bhattacharyyas Clinical Records Research & Informatics LLP, India Yexuan Cheng, 浙江大学, China Are Edvardsen, SKDE, Helse Nord RHF, Norway Alexander Eikrem-Lüthi, Lovisenberg Diakonale Sykehus, Norway Kåre Flø, DIPS ASA, Norway Grant Forrest, Lunaria Ltd, United Kingdom Heather Grain, Llewelyn Grain Informatics, Australia Anca Heyd, DIPS ASA, Norway Joost Holslag, Nedap, Netherlands Evelyn Hovenga, EJSH Consulting, Australia Mikkel Johan Gaup Grønmo, Regional forvaltning EPJ, Helse Nord, Norway Gunnar Jårvik, Helse Vest IKT AS, Norway Anjali Kulkarni, Karkinos, India Kanika Kuwelker, Helse Vest IKT, Norway Jörgen Kuylenstierna, eWeave AB, Sweden Liv Laugen, Oslo University Hospital, Norway, Norway Øygunn Leite Kallevik, Helse Bergen, Norway Heather Leslie, Atomica Informatics, Australia (openEHR Editor) Hanne Marte Bårholm, Helse Vest IKT, Norway Per Meinich, Helse Sør-Øst RHF, Norway Mikael Nyström, Cambio Healthcare Systems AB, Sweden Jussara Rotzsch, Hospital Alemão Oswaldo Cruz, Brazil Andre Smitt-Ingebretsen, Sørlandet sykehus HF, Norway Natalia Strauch, Medizinische Hochschule Hannover, Germany Norwegian Review Summary, Norwegian Public Hospitals, Norway John Tore Valand, Helse Bergen, Norway (openEHR Editor) Marit Alice Venheim, Helse Vest IKT, Norway (openEHR Editor) Ina Wille, Helse-Vest RHF, Norway
Translators	German: Natalia Strauch, Nina Schewe, Medizinische Hochschule Hannover, Strauch.Natalia@mh-hannover.de, nina.schewe@plri.de Norwegian Bokmål: Silje Ljosland Bakke, Marit Alice Venheim, John Tore Valand, Liv Laugen, Helse Vest IKT AS, Helse Bergen, Oslo University Hospital, Norway, silje.ljosland.bakke@helse-vest-ikt.no, marit.alice.venheim@helse-vest-ikt.no, john.tore.valand@helse-bergen.no, john.tore.valand@helse-vest-ikt.no, liv.laugen@ous-hf.no Italian: