ARCHETYPE Diagnostic investigation screening questionnaire (openEHR-EHR-OBSERVATION.investigation_screening.v1)

ARCHETYPE IDopenEHR-EHR-OBSERVATION.investigation_screening.v1
ConceptDiagnostic investigation screening questionnaire
DescriptionSeries of questions and associated answers used to screen whether diagnostic investigations have been carried out.
UseUse to create a framework for recording answers to pre-defined screening questions about diagnostic investigations or groups of investigations. The scope of diagnostic investigations includes all modalities of imaging examinations and the broadest range of laboratory and anatomical pathology tests. In addition, this archetype can also be used to record when other diagnostic tests have been carried out, such as cardiac stress testing, hearing and vision testing, electrocardiography (ECG) and electroencephalography (EEG). Common use cases include, but are not limited to: - Patient self-reporting - Creating a patient profile in a disease registry - Systematic questioning in any consultation related to patterns of investigation administration 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. Each data element would usually be renamed in a template to represent the specific question asked. Where value sets have been proposed for common use cases, these can be adapted to align with local requirements by using the DV_TEXT or the DV_BOOLEAN datatypes choice to match each specific use case. Utilising this framework within a template can enable documentation of a broad range of question/answer pairs such as: - Have you ever had your cholesterol level tested? Yes, No, Unknown. - Have you been tested for rubella antibodies? Yes, No, Unknown. - Have you ever been screened for sickle cell disease? Yes, No, Unknown. - When was your last Chest X-ray? - What was the result of your most recent INR test? - What were the findings of the electrocardiogram? - Did the infant pass/fail a Neonatal hearing screen? The EVENT structure from the reference model can be used to specify whether the questions relate to a point in time or over a period of time. Use a separate instance of this archetype to distinguish between a questionnaire recording information about an investigation or test that has been done at any time in the past and information about an investigation or test done within a specified time interval - for example, the difference between "Have you ever had an INR test?" compared to "Have you had an INR test during the last four 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 an investigation has been carried out, additional details required for persistence as part of a clinical record can be captured using specific test result archetypes.
MisuseNot to be used for recording an order for an investigation - use INSTRUCTION.service_request for this purpose. Not to be used for recording the progress of activities performed as part of an investigation - use appropriate ACTION archetypes for this purpose. Not to be used to record formal diagnostic test results - use appropriate OBSERVATIONS for this purpose. For example, the OBSERVATION.laboratory_test_result or OBSERVATION.imaging_examination_result.
PurposeTo create a framework for recording answers to pre-defined screening questions about diagnostic investigations or group of investigations, including but not limited to imaging examinations and laboratory tests.
References
Copyright© openEHR Foundation
AuthorsAuthor name: Heather Leslie
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2022-10-21
Other Details LanguageAuthor name: Heather Leslie
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2022-10-21
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=8ACC6E8163347CAB32D6A34B2FE56BDF, build_uid=828dbb29-01dd-400c-a9c4-009cc2f2f707, 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=1.1.2}
Keywordsinvestigation, screening, questionnaire, prevention, imaging, laboratory, pathology, blood, sample, sputum, EMG, ECG, hearing, test, examination, spinal fluid, biopsy, EEG, MRI, CT, X-ray, PET, ultrasound, spirometry
Lifecyclepublished
UID69d2930f-2a17-4c69-b472-785d142d9744
Language useden
Citeable Identifier1246.145.1960
Revision Number1.1.2
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Series of questions and associated answers used to screen whether diagnostic investigations have been carried out., 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)
Terje Bektesevic Holmlund, UiT Norges arktiske universitet, Norway
Ivar Berge, Oslo Universitetssykehus, Norway
SB Bhattacharyya, Bhattacharyyas Clinical Records Research & Informatics LLP, India
Randi Brendberg, Helse Nord RHF, Norway
Yexuan Cheng, 浙江大学, China
Are Edvardsen, SKDE, Helse Nord RHF, Norway
Heike Eichele, Regionalt fagmiljø for autimse, ADHD, Tourettes syndrom og narkolepsi Helse Vest, Kronstad DPS, Haukeland universitetssykehus, Bergen, Norway
Alexander Eikrem-Lüthi, Lovisenberg Diakonale Sykehus, Norway
Gunn Elin Blakkisrud, DIPS ASA, Norway
Kåre Flø, DIPS ASA, Norway
Grant Forrest, Lunaria Ltd, United Kingdom
Anca Heyd, DIPS ASA, Norway
Joost Holslag, Nedap, Netherlands
Evelyn Hovenga, EJSH Consulting, Australia
Mikkel Johan Gaup Grønmo, Helse Nord IKT, Norway (Nasjonal IKT redaktør)
Gunnar Jårvik, Helse Vest IKT AS, Norway
Runar Kristiansen, DIPS AS, Norway
Anjali Kulkarni, Karkinos, India
Kanika Kuwelker, Helse Vest IKT, Norway (Nasjonal IKT redaktør)
Jörgen Kuylenstierna, eWeave AB, Sweden
Liv Laugen, Oslo universitetssykehus, Norway (Nasjonal IKT redaktør)
Øygunn Leite Kallevik, Helse Bergen, Norway
Heather Leslie, Atomica Informatics, Australia (openEHR Editor)
Nina Louise Jebsen, Haukeland Universitetssykehus, Norway
Martine Louise Nalum, DIPS AS, Norway
Hanne Marte Bårholm, Helse Vest IKT, Norway (Nasjonal IKT redaktør)
Svenne Naumann, Finnmarkssykehuset, Norway
Terje Nordberg, Helse Bergen, Norway
Mikael Nyström, Cambio Healthcare Systems AB, Sweden
Bjørn Næss, DIPS ASA, Norway
Jussara Rotzsch, Hospital Alemão Oswaldo Cruz, Brazil
Kritika Sarkar, Karkinos Healthcare, India
Ragnhild Schultz, OUS, Norway
Andre Smitt-Ingebretsen, Sørlandet sykehus HF, Norway
Tove Stenquist, Helseforetak, Norway
Frode Stenvik, Helse Sør-Øst, 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, Darin Leonhardt, Medizinische Hochschule Hannover, PLRI, Strauch.Natalia@mh-hannover.de, leonhardt.darin@mh-hannover.de
  • Norwegian Bokmål: Kanika Kuwelker, John Tore Valand, Vebjørn Arntzen, Helse Vest IKT, Helse Bergen, Oslo University Hospital, kanika.kuwelker@helse-vest-ikt.no, john.tore.valand@helse-vest-ikt.no, varntzen@ous-hf.no
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, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0022]/events[at0023]/data[at0001]/items[at0043], code=at0043, itemType=ELEMENT, level=4, text=Description, description=Narrative description about the history of any investigations 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[at0022]/events[at0023]/data[at0001]/items[at0026], code=at0026, itemType=CLUSTER, level=4, text=Specific investigation, description=Details about a specified investigation or grouping of investigations relevant for the screening purpose., comment=Use separate instances of this CLUSTER to differentiate between specific investigations or groupings of investigations., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0022]/events[at0023]/data[at0001]/items[at0026]/items[at0021], code=at0021, itemType=ELEMENT, level=5, text=Investigation name, description=Name of the diagnostic investigation or grouping of investigations., comment=For example: 'Blood gas', Chest Xray', 'ECG'; or 'Hearing test'. Coding of the 'Investigation 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[at0022]/events[at0023]/data[at0001]/items[at0026]/items[at0024], code=at0024, itemType=ELEMENT, level=5, text=Done?, description=Is there a history of the investigation being carried out?, 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:
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  •  Text
  •  Interval of Date/Time

  •  Interval of Duration

  •  Duration
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openEHR-EHR-CLUSTER.imaging_exam.v1 and specialisations or
openEHR-EHR-CLUSTER.laboratory_test_analyte.v1 and specialisations or
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