ARCHETYPE ID | openEHR-EHR-EVALUATION.adverse_reaction_risk.v2 |
Concept | Adverse reaction risk |
Description | Clinical assessment of the propensity for an individual to experience a harmful or undesirable physiological response if exposed, or re-exposed, to a substance. |
Use | Use to record a clinical assessment of a propensity for an adverse reaction upon future exposure to a specified substance or class of substances including, but not limited to, incipients and excipients in medicinal preparations, biological products, metal salts, and organic chemical compounds. This archetype is intended to provide a single place within the health record to document the propensity for the full range of reactions, from trivial to life-threatening: - immune-mediated: Types I-IV (including allergic reactions and hypersensitivities); or - non-immune-mediated: including pseudo-allergic reactions, side effects, intolerances, and drug toxicities. In clinical practice distinguishing between immune-mediated and non-immune-mediated reactions can be difficult. Identification of the type of reaction is not a proxy for seriousness or risk of harm to the patient. Where a propensity is identified, information or evidence about one or more reaction events can be recorded using the CLUSTER.adverse_reaction_event archetype in the 'Reaction event summary' SLOT. Identification of the severity of the manifestation of the reaction, recorded in the CLUSTER.adverse_reaction_event archetype, can inform the 'Criticality' of the adverse reaction risk. For example, experiencing anaphylaxis on first exposure to a substance would warrant setting a 'Criticality' of 'high', due to the high risk that anaphylaxis is likely to recur on second and subsequent exposures. This archetype has been designed to allow the recording of information about a specific substance (amoxycillin, oysters, or bee sting venom) or, alternatively, a class of substance (e.g. Penicillins). If a class of substance is recorded, identification of the exact substance can be recorded on a per-reaction basis using the CLUSTER.adverse_reaction_event archetype. Use to record information about the positive presence of the risk of an adverse reaction: - to support the direct clinical care of an individual; - as part of a managed adverse reaction or allergy/intolerance list; - to support the exchange of information about the propensity and events related to adverse reactions; - to inform adverse reaction reporting; and - to assist with computerised knowledge-based activities such as clinical decision support and alerts. The risk of an adverse reaction event or manifestation must always propose a causative substance or class of substance. If there is a degree of uncertainty that a specific substance is the cause, the level of uncertainty can be recorded using the ‘Verification status’ data element. If more than one possible substance may have caused a reaction/manifestation, each substance should be recorded using a separate instance of this adverse reaction risk archetype with the ‘Verification status’ set to an initial state of ‘Unconfirmed’ so that adverse reaction checking can be activated in clinical systems. If the substance is later proven not to be causal then the ‘Verification status’ can be modified to ‘Refuted’ - for example, after allergy testing. |
Misuse | Not to be used for recording physiological reactions to physical agents, such as heat, cold, sunlight, vibration, exercise activity, by infectious agents or food contaminants. Use a specific archetype for EVALUATION.problem/diagnosis or CLUSTER.symptom/sign for this purpose. Not to be used to record adverse events, including failures of clinical process, interventions or products. For example: abnormal use, incorrect dosage or maladministration of an agent or substance; mislabelling; harm or injury caused by an intervention or procedure; overdose/poisoning etc. Use a specific archetype for the purpose. Not to be used to record an adverse reaction where the substance is unknown. Use EVALUATION.problem_diagnosis or CLUSTER.symptom_sign to record as part of the health record until a possible substance is identified. Not to be used to record reactions to transfusions of blood products. Use a specific archetype for this purpose. Not to be used for recording 'alerts'. Use EVALUATION.precaution, EVALUATION.contraindication or related archetypes for this purpose. Not to be used for recording failed therapy. Not to be used for the explicit recording of an absence (or negative presence) of a reaction to 'any substances' or to identified substances, for example ‘No known allergies or adverse reactions’ or ‘No known allergies to Penicillin’. Use the EVALUATION.exclusion_global or EVALUATION.exclusion_specific archetypes to express a positive statement of adverse reaction exclusion. Not to be used for the explicit recording that no information was able to be obtained about the adverse reaction status of a patient. Use the EVALUATION.absence archetype to record that a positive statement that information was not able to be obtained, for example, if a non-cooperative patient refuses to answer questions. |
Purpose | To record the clinical assessment of the propensity for an individual to experience an adverse reaction if exposed, or re-exposed, to a specified substance or class of substances. |
References | Adverse Reaction, draft archetype, Australian Digital Health Agency [Internet]. NEHTA Clinical Knowledge Manager. Authored: 08 Nov 2010. No longer available. Allergy and Intolerance Domain Analysis Model, Release 1, HL7 [Internet]. Publication pending, expected August 2014; Available at http://wiki.hl7.org/images/1/1b/Allergy_and_Intolerance_INFORM_2013_MAY.pdf (accessed 06 July 2014). Allergy, clinical element model, GE/Intermountain Healthcare. Clinical Element Model Search. Available at: http://intermountainhealthcare.org/cem/Pages/Detail.aspx?NCID=520861661&k=allergy (accessed Jan 16, 2012). Edwards IR, Aronson JK. Adverse drug reactions: definitions, diagnosis, and management. Lancet. 2000 Oct 7;356(9237):1255-9. PubMed PMID: 11072960. HL7 FHIR Resource - AllergyIntolerance R1.2.0 STU3 draft [Internet]. Health Level Seven International; [accessed 2020 Jan 17]. Available from: http://hl7.org/fhir/2016Jan/allergyintolerance.html. Horsfield P, Sibeko S. Representation in Electronic Patient Records of Allergic Reactions, Adverse Reactions, and Intolerance of Pharmaceutical Products [Internet]. London, UK: National Health Service; 2006 Sep 07 [cited 2011 Jun 21]; Available at https://svn.connectingforhealth.nhs.uk/svn/public/nhscontentmodels/TRUNK/ref/NPfIT/Allergy_ADR_Intolerance%20v%201.2Final.doc. Long R, Bentley S. SCG Guidance on the Representation of Allergies and Adverse Reaction Information Using NHS Message Templates [Internet]. London, UK: National Health Service; 2008 Apr 30 [cited 2011 Jun 21]; Available at http://www.connectingforhealth.nhs.uk/systemsandservices/data/scg/scg0001.pdf. Microsoft. Design Guidance: Displaying Adverse Drug Reaction Risks [Internet]. 2009 January 28 [cited 2011 Jun 21]; Available at www.mscui.net/DesignGuide/DisplayingAllergies.aspx. Microsoft. Design Guidance: Recording Adverse Drug Reaction Risks [Internet]. 2009 March 27 [cited 2011 Jun 21]; Available at www.mscui.net/DesignGuide/RecordingAllergies.aspx. Mosby. Mosby's Pocket Dictionary of Medicine, Nursing and Health Professions. 6th Edition. USA: Mosby Elsevier; 2010 National E-Health Transition Authority. Adverse Reactions (Data Specifications) Version 1.1 [Internet]. Sydney, Australia: NEHTA; 2008 Feb 29 [cited 2011 Jun 21]; Available at http://www.nehta.gov.au/component/docman/doc_download/453-adverse-reaction-data-specification-v11. Riedl MA, Casillas AM. Adverse drug reactions: types and treatment options. Am Fam Physician. 2003 Nov 1;68(9):1781-90. Review. PubMed PMID: 14620598. Royal Australian College of General Practitioners. Fact Sheet: Allergies & Adverse Reactions (Draft). 2010. Thien FC. Drug hypersensitivity. Med J Aust. 2006 Sep 18;185(6):333-8. Review. PubMed PMID: 16999678. - Uppsala Monitoring Centre (WHO): http://www.who-umc.org/ - European Medicines Agency: http://www.ema.europa.eu/ema/ - DIRECTIVE 2010/84/EU OF THE EUROPEAN PARLIAMENT AND OF THE COUNCIL, of 15 December 2010, amending, as regards pharmacovigilance, Directive 2001/83/EC on the Community code relating to medicinal products for human use: http://ec.europa.eu/health/files/eudralex/vol-1/dir_2010_84/dir_2010_84_en.pdf |
Copyright | © Australian Digital Health Agency, openEHR Foundation, HL7 International, Nasjonal IKT |
Authors | Author name: Heather Leslie Organisation: Atomica Informatics Email: heather.leslie@atomicainformatics.com Date originally authored: 2010-11-08 |
Other Details Language | Author name: Heather Leslie Organisation: Atomica Informatics Email: heather.leslie@atomicainformatics.com Date originally authored: 2010-11-08 |
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, references=Adverse Reaction, draft archetype, Australian Digital Health Agency [Internet]. NEHTA Clinical Knowledge Manager. Authored: 08 Nov 2010. No longer available. Allergy and Intolerance Domain Analysis Model, Release 1, HL7 [Internet]. Publication pending, expected August 2014; Available at http://wiki.hl7.org/images/1/1b/Allergy_and_Intolerance_INFORM_2013_MAY.pdf (accessed 06 July 2014). Allergy, clinical element model, GE/Intermountain Healthcare. Clinical Element Model Search. Available at: http://intermountainhealthcare.org/cem/Pages/Detail.aspx?NCID=520861661&k=allergy (accessed Jan 16, 2012). Edwards IR, Aronson JK. Adverse drug reactions: definitions, diagnosis, and management. Lancet. 2000 Oct 7;356(9237):1255-9. PubMed PMID: 11072960. HL7 FHIR Resource - AllergyIntolerance R1.2.0 STU3 draft [Internet]. Health Level Seven International; [accessed 2020 Jan 17]. Available from: http://hl7.org/fhir/2016Jan/allergyintolerance.html. Horsfield P, Sibeko S. Representation in Electronic Patient Records of Allergic Reactions, Adverse Reactions, and Intolerance of Pharmaceutical Products [Internet]. London, UK: National Health Service; 2006 Sep 07 [cited 2011 Jun 21]; Available at https://svn.connectingforhealth.nhs.uk/svn/public/nhscontentmodels/TRUNK/ref/NPfIT/Allergy_ADR_Intolerance%20v%201.2Final.doc. Long R, Bentley S. SCG Guidance on the Representation of Allergies and Adverse Reaction Information Using NHS Message Templates [Internet]. London, UK: National Health Service; 2008 Apr 30 [cited 2011 Jun 21]; Available at http://www.connectingforhealth.nhs.uk/systemsandservices/data/scg/scg0001.pdf. Microsoft. Design Guidance: Displaying Adverse Drug Reaction Risks [Internet]. 2009 January 28 [cited 2011 Jun 21]; Available at www.mscui.net/DesignGuide/DisplayingAllergies.aspx. Microsoft. Design Guidance: Recording Adverse Drug Reaction Risks [Internet]. 2009 March 27 [cited 2011 Jun 21]; Available at www.mscui.net/DesignGuide/RecordingAllergies.aspx. Mosby. Mosby's Pocket Dictionary of Medicine, Nursing and Health Professions. 6th Edition. USA: Mosby Elsevier; 2010 National E-Health Transition Authority. Adverse Reactions (Data Specifications) Version 1.1 [Internet]. Sydney, Australia: NEHTA; 2008 Feb 29 [cited 2011 Jun 21]; Available at http://www.nehta.gov.au/component/docman/doc_download/453-adverse-reaction-data-specification-v11. Riedl MA, Casillas AM. Adverse drug reactions: types and treatment options. Am Fam Physician. 2003 Nov 1;68(9):1781-90. Review. PubMed PMID: 14620598. Royal Australian College of General Practitioners. Fact Sheet: Allergies & Adverse Reactions (Draft). 2010. Thien FC. Drug hypersensitivity. Med J Aust. 2006 Sep 18;185(6):333-8. Review. PubMed PMID: 16999678. - Uppsala Monitoring Centre (WHO): http://www.who-umc.org/ - European Medicines Agency: http://www.ema.europa.eu/ema/ - DIRECTIVE 2010/84/EU OF THE EUROPEAN PARLIAMENT AND OF THE COUNCIL, of 15 December 2010, amending, as regards pharmacovigilance, Directive 2001/83/EC on the Community code relating to medicinal products for human use: http://ec.europa.eu/health/files/eudralex/vol-1/dir_2010_84/dir_2010_84_en.pdf, current_contact=Heather Leslie, Atomica Informatics, Australia, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=19F2BC4F565422749861B468594E50E7, build_uid=63592b37-306a-4201-a529-181128ace219, revision=2.0.0} |
Keywords | reaction, allergy, allergic, adverse, event, effect, sensitivity, intolerance, hypersensitivity, side effect, toxicity, drug, food, agent, substance, immune, non-immune, chemical, anaphylaxis, allergen, medication, supplement, medicine, natural remedies, immunological, non-immunological, risk |
Lifecycle | published |
UID | 6c812c8c-ca00-496a-97dd-6e4916bd1ccf |
Language used | en |
Citeable Identifier | 1246.145.2131 |
Revision Number | 2.0.0 |
All | Archetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Clinical assessment of the propensity for an individual to experience a harmful or undesirable physiological response if exposed, or re-exposed, to a substance., archetypeConceptComment=Substances include, but are not limited to: a therapeutic substance administered correctly at an appropriate dosage for the individual; food; material derived from plants or animals; or venom from insect stings., otherContributors=Fatima Almeida, Critical SW, Portugal Grethe Almenning, Bergen kommune, Norway Magnus Alsaker, Helsedirektoratet, Norway Torunn Apelseth, Helse Bergen, Norway Vebjørn Arntzen, Oslo University Hospital, Norway Bent Asgeir Larsen, Helsedirektoratet, Norway Koray Atalag, University of Auckland, New Zealand Elaine Ayres, US National Institutes of Health, United States Russell B Leftwich MD, United States (openEHR Editor) Silje Ljosland Bakke, Helse Vest IKT AS, Norway (openEHR Editor) John Bennett, NEHTA, Australia Steve Bentley, Allscripts, United Kingdom Sharmila Biswas, Dr Sharmila Biswas GP, Australia Lars Bitsch-Larsen, Haukeland University hospital, Norway Terje Bless, Helse Nord FIKS, Norway Laila Bruun, Oslo universitetssykehus HF, Norway Claire Chalopin, ICCAS, University of Leipzig, Germany Rong Chen, Cambio Healthcare Systems, Sweden Stephen Chu, Queensland Health, Australia Matthew Cordell, NEHTA, Australia Howard Edidin, Edidin Group, Inc, United States Brett Esler, Oridashi, Australia David Evans, Queensland Health, Australia Jerry Fahrni, Kaweah Delta Health Care District, United States Shahla Foozonkhah, Iran ministry of health and education, Iran Einar Fosse, National Centre for Integrated Care and Telemedicine, Norway Joanne Foster, School of Nursing & Midwifery, QLD University of Technology & Nursing Informatics Australia, Australia Sebastian Garde, Ocean Informatics, Germany Jacquie Garton-Smith, Royal Perth Hospital and DoHWA, Australia Sarah Gaunt, NEHTA, Australia Andrew Goodchild, NEHTA, Australia Heather Grain, Llewelyn Grain Informatics, Australia Trina Gregory, cpc, Australia Grahame Grieve, Health Intersections, Australia (Editor) Robert Hausam, Hausam Consulting LLC, United States Sam Heard, Ocean Informatics, Australia Kristian Heldal, Telemark Hospital Trust, Norway Anca Heyd, DIPS ASA, Norway Hilde Hollås, Norway Roar Holm, Helse Vest IKT A/S, Norway Andrew James, University of Toronto, Canada Julie James, Blue Wave Informatics LLP, United Kingdom Tom Jarl Jakobsen, Helse Bergen, Norway Ivor Jones, Queensalnd Helath, Australia Lars Jostein Silihagen, Sopra Steria / Sykehuspartner / Sykehuset Innlandet, Norway Silje Kaada, Helse-Bergen, Avdeling for immunologi og transfusjonsmedisin, Norway Konstantinos Kalliamvakos, Cambio Healthcare Systems, Sweden Lars Karlsen, DIPS ASA, Norway Lars Morgan Karlsen, DIPS ASA, Norway Goran Karlstrom, County Of Värmland, Sweden Mary Kelaher, NEHTA, Australia Diane Kirkham, NEHTA, Australia Shinji Kobayashi, NPO openEHR Japan, Japan Robert L'egan, NEHTA, Australia Jobst Landgrebe, ii4sm, Switzerland Russell Leftwich, Russell B Leftwich MD, United States Fest Legemiddelverket, Statens Legemiddelverk, Norway Heather Leslie, Atomica Informatics, Australia (openEHR Editor) Hugh Leslie, Ocean Informatics, Australia Rikard Lovstrom, Swedish Medical Association, Sweden Hallvard Lærum, Oslo Universitetssykehus HF, Norway Arne Løberg Sæter, DIPS ASA, Norway Sarah Mahoney, Australia Luis Marco Ruiz, Norwegian Center for Integrated Care and Telemedicine, Norway Siv Marie Lien, DIPS ASA, Norway Mike Martyn, The Hobart Anaesthetic Group, Australia Lloyd McKenzie, Gordon Point Informatics, Canada David McKillop, NEHTA, Australia Ian McNicoll, freshEHR Clinical Informatics, United Kingdom Chris Mitchell, RACGP, Australia Stewart Morrison, NEHTA, Australia Jörg Niggemann, Compugroup, Germany Bjørn Næss, DIPS ASA, Norway Tom Oniki, Intermountain Healthcare, United States Chris Pearce, Melbourne East GP Network, Australia Rune Pedersen, Universitetssykehuset i Nord Norge, Norway General Practice Computing Group, Australia Camilla Preeston, Royal Australian College of General Practitioners, Australia Margaret Prichard, NEHTA, Australia Jodie Pycroft, Adelaide Northern Division of General Practice Ltd, Australia Cathy Richardson, NEHTA, Australia Robyn Richards, NEHTA - Clinical Terminology, Australia Tanja Riise, Nasjonal IKT HF, Norway Jussara Rotzsch, Hospital Alemão Oswaldo Cruz, Brazil Stefan Sauermann, University of Applied Sciences Technikum Wien, Austria Thomas Schopf, University Hospital of North-Norway, Norway Thilo Schuler, Australia Jason Scott, Plymouth Hospitals NHS Trust, United Kingdom Peter Scott, Medical Objects, Australia Elena Shabanova, UMMSSOft, Russian Federation Anoop Shah, University College London, United Kingdom Elizabeth Stanick, Hobart Anaesthetic Group, Australia Laila Storesund, Haraldsplass diakonale sykehus, Norway Norwegian Review Summary, Norwegian Public Hospitals, Norway Line Sæle, Nasjonal IKT HF, Norway Hwei-Yee Tai, Tan Tock Seng Hospital, Singapore John Taylor, NEHTA, Australia Micaela Thierley, Helse Bergen, Norway Gordon Tomes, Australian Institute of Health and Welfare, Australia John Tore Valand, Haukeland Universitetssjukehus, Norway (Nasjonal IKT redaktør) Richard Townley-O'Neill, Australian Digital Health Agency, Australia Ines Vaz, UFN, Portugal Nils Widnes, Helse-Bergen, Norway Andrew Yap, Australia Kylie Young, The Royal Australian College of General Practitioners, Australia Lin Zhang, Taikang Insurance Group, China, originalLanguage=en, translators=
openEHR-EHR-CLUSTER.adverse_ openEHR-EHR-CLUSTER.adverse_ All not explicitly excluded archetypes, extendedValues=null]]}, topLevelItems={data=ResourceSimplifiedHierarchyItem [path=ROOT_/data[at0001], code=at0001, itemType=ITEM_TREE, level=0, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=0..1, cardinalityText=optional, subCardinalityFormal=1..*, subCardinalityText= , dataType=ITEM_TREE, bindings=null, values=null, extendedValues=null], protocol=ResourceSimplifiedHierarchyItem [path=ROOT_/protocol[at0042], code=at0042, itemType=ITEM_TREE, level=0, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=0..1, cardinalityText=optional, subCardinalityFormal=1..*, subCardinalityText= , dataType=ITEM_TREE, bindings=null, values=null, extendedValues=null]}, addHierarchyItemsTo=protocol, currentHierarchyItemsForAdding=[ResourceSimplifiedHierarchyItem [path=/protocol[at0042]/items[at0062], code=at0062, itemType=ELEMENT, level=2, text=Last updated, description=Date when the propensity or the reaction event was updated., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0042]/items[at0047], code=at0047, itemType=ELEMENT, level=2, text=Supporting clinical record information, description=Link to further information about the presentation and findings that exist elsewhere in the health record, including allergy test reports., comment=For example, presenting symptoms, examination findings, diagnosis etc., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_EHR_URI, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0042]/items[at0128], code=at0128, itemType=SLOT, level=2, text=Extension, description=Additional information required to capture local content or to align with other reference models/formalisms., comment=For example: local information requirements or additional metadata to align with FHIR equivalents., 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] |