ARCHETYPE Adverse reaction screening questionnaire (openEHR-EHR-OBSERVATION.adverse_reaction_screening.v1)

ARCHETYPE IDopenEHR-EHR-OBSERVATION.adverse_reaction_screening.v1
ConceptAdverse reaction screening questionnaire
DescriptionSeries of questions and associated answers used to screen for the presence of any previous adverse reactions.
Use

Use to create a framework for recording answers to pre-defined screening questions about past adverse reactions.

This archetype has deliberately been loosely modelled to be inclusive of the broadest range of adverse reactions, including but not limited to allergies, sensitivities, intolerances and side effects which warrant avoiding exposure to the identified substance. Substances include, but are not limited to:

  • Therapeutic substance administered correctly at an appropriate dosage for the individual.
  • Food.
  • Materials derived from plants or animals.
  • Venom from insect stings.

Common use cases include, but are not limited to:

  • Systematic questioning in any consultation, for example:
    --- Allergy to penicilin? Yes, No, Unknown, Unsure.
    --- Reaction to sticking plasters? Yes, No, Unknown, Unsure.
    --- Do you have any food intolerances?
    --- Have you ever had an allergy to dogs?

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.

Use a separate instance of this archetype to distinguish between a questionnaire recording information about an adverse reaction that has occurred at any time in the past and information about an adverse reaction which occurred within a specified time interval - for example the difference between "Do you have any allergies?" compared to "Have you had any reactions to any medications in 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 the presence of an adverse reaction, it is recommended that clinical system record and persist the specific details about the adverse reaction (such as the date of clinical recognition) using the EVALUATION.adverse_reaction_risk archetype or the CLUSTER.adverse_reaction_event.

MisuseNot to be used to record details about the presence or absence of an adverse reaction, outside of a screening context. Use EVALUATION.adverse_reaction_risk, CLUSTER.adverse_reaction_event or EVALUATION.exclusion_specific for these purposes.
PurposeTo create a framework for recording answers to pre-defined screening questions about adverse reactions.
References
Copyright© openEHR Foundation
AuthorsAuthor name: Heather Leslie
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2023-06-26
Other Details LanguageAuthor name: Heather Leslie
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2023-06-26
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: D3A1E58463261BAA824EAFACFFD75704
  • Build Uid: d77294a1-a400-41de-b389-2fda9b22b0a6
  • 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: 1.0.0
KeywordsCondition, state, illness, syndrome, questionnaire, screening, issue, allergy, intolerance
Lifecyclepublished
UIDc691d488-ce79-4653-9a03-403df574b9a5
Language useden
Citeable Identifier1246.145.2660
Revision Number1.0.0
Archetype Concept CommentThe answers may be self-reported.
protocol
ExtensionExtension: 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
data
Screening purposeScreening 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 adverse reactions?Any adverse reactions?: Is there a history of any adverse reactions relevant for the screening purpose?
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:
DescriptionDescription: Narrative description about the history of any adverse reactions relevant for the screening purpose.
Specific adverse reactionSpecific adverse reaction: Details about a specific adverse reaction to an identified substance, or substance class or grouping, relevant for the screening purpose.
Substance nameSubstance name: Identification of a substance, or substance class, that the individual may have had prior reactions to.
Both an individual substance and a substance class are valid entries in 'Substance'. A substance may be a compound of simpler substances, for example a medicinal product.
Presence?Presence?: Is there a history of adverse reactions to the 'Substance name', relevant to the screening purpose?
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:
TimingTiming: Indication of timing related to the adverse reaction.
The 'Timing' data element has deliberately been loosely modelled to support the myriad of ways that it can be used in questionnaires to capture the onset or the timing of an adverse reaction. The specific and intended semantics can be further clarified in a template. For example: – Date/time for the date of onset of an adverse reaction. – Interval of date/time for a period of time, for example between 1940 and 1942. – Text for descriptions such as 'Immediately after the 'bee sting' or 'One week ago'. – Duration for the individual's age at the onset. – Interval of Duration for an approximate age range at onset.
Choice of:
  •  Text
  •  Interval of Duration

  •  Duration
  •  Date/Time
  •  Interval of Date/Time

Additional detailsAdditional details: Structured details or questions about the specific adverse reaction.
For example; hospital where treated.
Include:
openEHR-EHR-CLUSTER.organisation.v1
CommentComment: Additional narrative about the specific adverse reaction question, not captured in other fields.
Additional detailsAdditional details: Structured details or questions about screening for adverse reactions.
Include:
All not explicitly excluded archetypes
events
Any eventAny event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Other contributorsVebjørn Arntzen, Oslo University Hospital, Norway (openEHR Editor)
Silje Ljosland Bakke, Helse Vest IKT AS, Norway (openEHR Editor)
Ivar Berge, Oslo University Hospital, Norway (openEHR Editor)
Hanne Marte Bårholm, Helse Vest IKT, Norway (openEHR Editor)
Fabian Max Bürki, University of Berne, Switzerland
Mona Didriksen, Helse Vest IKT, Norway
Aleksander Furnes, Helse Nord IKT, Norway
Ciprian Gerstenberger, Helse Nord IKT, Norway (openEHR Editor)
Matteus Janicki, Akershus Universitetssykehus, Norway
Anne K Fossum, OUS, Norway
June Marie Nepstad Knappskog, Helse Nord IKT AS, Norway (openEHR Editor)
Martin Koch, Servei Català de la Salut, Spain
Kanika Kuwelker, Helse Vest IKT, Norway (openEHR Editor)
Eli Larsen, UNN, Norway (openEHR Editor)
Liv Laugen, ​Oslo University Hospital, Norway, Norway (openEHR Editor)
Heather Leslie, Atomica Informatics, Australia (openEHR Editor)
Ruth Lochan, Akademiska Sjukhuset Uppsala, Sweden
Jonas Lyshaug, FSE/ HN IKT, Norway
Olha Nikolaieva, University Hospital Basel, Switzerland
Mikael Nyström, Cambio Healthcare Systems AB, Sweden
Marlene Pérez Colman, Digital Health and Care Wales, United Kingdom
Terje Sagmyr, Helse Vest IKT, Norway (openEHR Editor)
Norwegian Review Summary, Norwegian Public Hospitals, Norway
John Tore Valand, Helse Vest IKT, Norway (openEHR Editor)
Marit Alice Venheim, Helse Vest IKT, Norway (openEHR Editor)
Karsten Øvretveit, Helse Vest IKT, Norway (openEHR Editor)
Translators
  • Norwegian Bokmål: June Marie Nepstad Knappskog, Helse Nord IKT AS, Norway (openEHR Editor), june.marie.nepstad.knappskog@hnikt.no