ARCHETYPE Problem/Diagnosis screening questionnaire (openEHR-EHR-OBSERVATION.problem_screening.v0)

ARCHETYPE IDopenEHR-EHR-OBSERVATION.problem_screening.v0
ConceptProblem/Diagnosis screening questionnaire
DescriptionSeries of questions and associated answers used to screen for problems or diagnoses.
UseUse to create a framework for recording answers to pre-defined screening questions about problems or diagnoses. Common use cases include, but are not limited to: - Systematic questioning in any consultation, for example: --- Diagnosed with cancer? Yes, No, Unknown. --- Diagnosed with COVID 19 or Influenza in the past twelve months? Yes, No, Unknown. - Specific questioning related to disease surveillance. 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 'text' 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 a procedure that has been performed at any time in the past and information about a procedure performed within a specified time interval - for example the difference between "Do you have influenza?" compared to "Have you had influenza 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 a problem or diagnosis, it is recommended that clinical system record and persist the specific details about the problem or diagnosis (such as the date of clinical recognition) using the EVALUATION.problem_diagnosis archetype.
MisuseNot to be used to record details about the presence or absence of a problem or diagnosis, outside of a screening context. Use EVALUATION.problem_diagnosis or EVALUATION.exclusion_specific for these purposes. Not to be used to to create a framework for recording answers to pre-defined screening questions about issues, worries or concerns affecting an individual. Use OBSERVATION.issue_screening for this purpose. Not to be used to to create a framework for recording answers to pre-defined screening questions about procedures performed. Use the OBSERVATION.procedure_screening for this purpose. Not to be used to to create a framework for recording answers to pre-defined screening questions about adverse reactions, use OBSERVATION.adverse_reaction_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 problems or diagnoses.
References
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=8E78BEC49EFECE4A42024A2BC661D24A, build_uid=64fd8e20-7af5-4677-8ab5-3b2b8c0b0176, 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 http://www.snomed.org/snomed-ct/get-snomedct or info@snomed.org., revision=0.0.1-alpha}
KeywordsCondition, state, illness, syndrome, questionnaire, screening
Lifecyclein_development
UID522a1a31-1e2a-4b18-ac65-ab1c2d117f00
Language useden
Citeable Identifier1246.145.1090
Revision Number0.0.1-alpha
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Series of questions and associated answers used to screen for problems or diagnoses., archetypeConceptComment=The answers may be self-reported., otherContributors=Vebjørn Arntzen, Oslo University Hospital, Norway (openEHR Editor)
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, Forvaltningssenter EPJ, Helse Nord RHF, Norway (Nasjonal IKT redaktør)
Susanna Jönsson, Region Värmland, Sweden
Jörgen Kuylenstierna, eWeave AB, Sweden
Liv Laugen, ​Oslo University Hospital, Norway, Norway
Heather Leslie, Atomica Informatics, Australia (openEHR Editor)
Ian McNicoll, freshEHR Clinical Informatics, UK
Mikael Nyström, Cambio Healthcare Systems AB, Sweden
Vanessa Pereira, Better - Pathfinder, Portugal
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)
Martijn van Eenennaam, Nedap Healthcare, Netherlands
Marit Alice Venheim, Helse Vest IKT, Norway (openEHR Editor), originalLanguage=en, translators=German: Natalia Strauch, Medizinische Hochschule Hannover, Strauch.Natalia@mh-hannover.de
Norwegian Bokmål: Marit Alice Venheim, Silje Ljosland Bakke, John Tore Valand, Helse Vest IKT, Helse Vest IKT AS, Helse Bergen, marit.alice.venheim@helse-vest-ikt.no, silje.ljosland.bakke@helse-vest-ikt.no, john.tore.valand@helse-bergen.no, john.tore.valand@helse-vest-ikt.no
Dutch: Martijn van Eenennaam, Nedap Healthcare, martijn.vaneenennaam@nedap.com
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