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

ARCHETYPE IDopenEHR-EHR-OBSERVATION.management_screening.v1
ConceptManagement screening questionnaire
DescriptionSeries of questions and associated answers used to screen for clinical management including, but not limited to treatments, therapies and hospitalisation.
UseUse 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.
MisuseNot 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.
PurposeTo 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
AuthorsAuthor name: Heather Leslie
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2020-03-13
Other Details LanguageAuthor name: Heather Leslie
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2020-03-13
OtherDetails 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=9C633F08405F63D544627086044D2B2A, build_uid=389f6de4-cfdc-4cde-94e6-9f81e3a4c6a9, 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-alpha}
Keywordstreatment, screening, intervention, questionnaire, care, support, therapy
Lifecyclein_development
UID0c6c23ab-7018-4faf-93dd-c7e717e8569b
Language useden
Citeable Identifier1246.145.1088
Revision Number1.0.3-alpha
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Series of questions and associated answers used to screen for clinical management including, but not limited to treatments, therapies and hospitalisation., archetypeConceptComment=The answers may be self-reported., otherContributors=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, originalLanguage=en, 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:
, subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={relationships=[], source=[], capabilities=[], activities=[], details=[], context=[], ism_transition=[], other_participations=[], data=[ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0034], code=at0034, itemType=ELEMENT, level=4, text=Screening purpose, description=The context or reason for screening., comment=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., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0039], code=at0039, itemType=ELEMENT, level=4, text=Any management?, description=Is there a history of management or treatment activities relevant for the screening purpose?, comment=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., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0044], code=at0044, itemType=ELEMENT, level=4, text=Description, description=Narrative description about the history of any management or treatment activities relevant for the screening purpose., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0022], code=at0022, itemType=CLUSTER, level=4, text=Management activity, description=Details about a specific management or treatment activity or grouping of management or treatment activities relevant for the screening purpose., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0022]/items[at0004], code=at0004, itemType=ELEMENT, level=5, text=Management name, description=Name of a specific management or treatment activity or grouping of management or treatment activities., comment=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., 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=/data[at0001]/events[at0002]/data[at0003]/items[at0022]/items[at0005], code=at0005, itemType=ELEMENT, level=5, text=Specific management?, description=Is there a history of the specific management or treatment activity?, comment=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., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0022]/items[at0037], code=at0037, itemType=ELEMENT, level=5, text=Timing, description=Indication of timing related to the management activity., comment=The 'Timing' 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 activity may have occurred. The specific and intended semantics can be further clarified in a template. For example: the actual point in time when, or interval during which, an activity took place; the start and stop time of an activity; the duration of the activity; the age of the individual at the time of the activity; or the duration of time since the activity occurred. A partial date is valid, using the DV_DATE_TIME data type, to record only a year., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
  •  Date/Time
  •  Interval of Date/Time

  •  Text
  •  Duration
  •  Interval of Duration

, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0022]/items[at0036], code=at0036, itemType=SLOT, level=5, text=Additional details, description=Structured details or questions about the specific management or treatment activity., comment=For example: hospital where treated., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.organisation.v1, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0022]/items[at0035], code=at0035, itemType=ELEMENT, level=5, text=Comment, description=Additional narrative about a specific management or treatment question, not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0043], code=at0043, itemType=SLOT, level=4, text=Additional details, description=Structured details or questions about screening for management or treatment., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
All not explicitly excluded archetypes, extendedValues=null]], credentials=[], target=[], items=[], content=[], description=[], contacts=[], state=[], events=[ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=2, text=Any event, description=Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=null, extendedValues=null]], provider=[], identities=[], protocol=[ResourceSimplifiedHierarchyItem [path=/protocol[at0007]/items[at0021], code=at0021, itemType=SLOT, level=2, text=Extension, description=Additional information required to extend the model with local content or to align with other reference models or formalisms., comment=For example: local information requirements; or additional metadata to align with FHIR., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
All not explicitly excluded archetypes, extendedValues=null]]}, topLevelItems={data=ResourceSimplifiedHierarchyItem [path=ROOT_/data[at0001]/events[at0002]/data[at0003], code=at0003, itemType=ITEM_TREE, level=2, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=0..1, cardinalityText=optional, subCardinalityFormal=0..*, subCardinalityText=Minimum of 0 items, dataType=ITEM_TREE, bindings=null, values=null, extendedValues=null], protocol=ResourceSimplifiedHierarchyItem [path=ROOT_/protocol[at0007], code=at0007, itemType=ITEM_TREE, level=0, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=0..1, cardinalityText=optional, subCardinalityFormal=0..*, subCardinalityText=Minimum of 0 items, dataType=ITEM_TREE, bindings=null, values=null, extendedValues=null]}, addHierarchyItemsTo=protocol, currentHierarchyItemsForAdding=[ResourceSimplifiedHierarchyItem [path=/protocol[at0007]/items[at0021], code=at0021, itemType=SLOT, level=2, text=Extension, description=Additional information required to extend the model with local content or to align with other reference models or formalisms., comment=For example: local information requirements; or additional metadata to align with FHIR., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
All not explicitly excluded archetypes, extendedValues=null]], minIndents={}, termBindingRetrievalErrorMessage=null]