| ARCHETYPE ID | openEHR-EHR-INSTRUCTION.therapeutic_item_order.v1 |
|---|---|
| Concept | Therapeutic item order |
| Description | An order for a therapeutic item, including a medical device, used by the individual or a carer as part of direct provision of healthcare or to mitigate a healthcare risk. |
| Use | Use to record an order for a therapeutic item, including a medical device, used by the individual or a carer as part of direct provision of healthcare or to mitigate a healthcare risk. The scope of this archetype includes, but is not limited to an order for:
This archetype is designed to be used in a number of clinical contexts, including but not limited to:
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| Misuse | Not to be used to record the activities related to carrying out the order for the therapeutic item, such as details about actual administration or application. Use the appropiate ACTION-archetype for this purpose. Not to be used to record the ordering of blood products, which involves a fundamentally different clinical process and is likely to require different supporting information Use the INSTRUCTION.transfusion for this purpose. Not to be used to record the order for insertion of implants or medical devices such as pacemakers and defibrillators. Use the INSTRUCTION.procedure for this purpose. Not to be used to record an order for a medication, vaccine, or nutritional product for an identified individual. Use the INSTRUCTION.medication_order for this purpose. Not to be used to record an order for a therapeutic activity, such as exercise or daily peak flow measurements - use a specific archetype for this purpose. Not to be used to record an order for a medical device or therapeutic item that would be ordered as part of a supply chain, for example, an artificial hip joint used in a total hip replacement procedure. |
| Purpose | To record an order for a therapeutic item, including a medical device, used by the individual or a carer as part of direct provision of healthcare or to mitigate a healthcare risk. |
| References | Medication order, Published Archetype [Internet]. OpenEHR Clinical Knowledge Manager [cited: 2023-05-10]. Available from: https://ckm.openehr.org/ckm/archetypes/1013.1.5946 Standards for medication and medical device records – technical annex [Internet]. RCP London. [cited 2015 Dec 15]. Available from: https://www.rcplondon.ac.uk/projects/outputs/standards-medication-and-medical-device-records-technical-annex |
| Copyright | © openEHR Foundation |
| Authors | Author name: Hanne Marte Bårholm Organisation: Helse Vest IKT Email: hanne.marte.sandal.barholm@helse-vest-ikt.no Date originally authored: 2023-04-20 |
| Other Details Language | Author name: Hanne Marte Bårholm Organisation: Helse Vest IKT Email: hanne.marte.sandal.barholm@helse-vest-ikt.no Date originally authored: 2023-04-20 |
| Other Details (Language Independent) |
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| Keywords | order, prescribe, therapy, therapeutic, otc, therapeutic goods, pharmaceutical, product, treatment, CPOE, assistive device |
| Lifecycle | published |
| UID | eb644d16-2168-4920-bc04-7dd9a132d3d1 |
| Language used | en |
| Citeable Identifier | 1246.145.2712 |
| Revision Number | 1.0.0 |
| activities | |
| Order | Order: Details of the requested order. |
| Item name | Item name: Name of the item ordered. Coding of the therapeutic item name with a terminology is preferred, where possible. |
| Item details | Item details: Structured details about the item. For example: Size and/or model. Include: openEHR-EHR-CLUSTER.device.v1 |
| Body site | Body site: Name of the body site where the item is intended to be used. For example: 'left upper arm', 'left ankle'. Coding of the body site with a terminology is preferred, where possible. |
| Structured body site | Structured body site: Structured description of the body site where the item is intended to be used. Include: openEHR-EHR-CLUSTER.anatomical_ openEHR-EHR-CLUSTER.anatomical_ openEHR-EHR-CLUSTER.anatomical_ |
| Directions | Directions: Narrative description about the intended use of the item. |
| Monitoring instruction | Monitoring instruction: Description about monitoring required for use of the item. For example: In ordering a compression bandage, recommend monitoring distal skin status; or for an insulin pump to monitor skin around insertion. |
| Clinical indication | Clinical indication: The clinical reason for use of the ordered item. For example: 'Ankle sprain'. Coding of the clinical indication with a terminology is preferred, where possible. This data element allows multiple occurrences. It is not intended to carry an indication for administrative authorisation purposes. |
| Therapeutic intent | Therapeutic intent: The therapeutic intent of the item. For example: 'pain relief'. Coding of the therapeutic intent with a terminology is preferred, where possible. This data element allows multiple occurrences. |
| Start date/time | Start date/time: Date/time when use of the item should commence. |
| Stop date/time | Stop date/time: Date/time when use of the item should stop. |
| Start criterion | Start criterion: Criteria which triggers commencement of use. For example: 'Start if a movement triggers pain'. This is intended for a general pre-condition which should trigger the whole treatment course to be started, and not for 'as required' administrations of an ongoing order. |
| Stop criterion | Stop criterion: Criteria which triggers cessation of use. For example: 'Stop when a movement is painless''. |
| Additional details | Additional details: Additional structured details about the order not captured in other fields. Include: All not explicitly excluded archetypes |
| Comment | Comment: Additional narrative about the order not captured in other fields. |
| protocol | |
| Order identifier | Order identifier: Unique identifier for the order. This data element allows for multiple occurrences to be defined more explicitly at run-time, if required. |
| Extension | Extension: Additional information required to capture local content or to align with other reference models/formalisms. For example: local information requirements or additional metadata to align with FHIR equivalents Include: All not explicitly excluded archetypes |
| Other contributors | 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 Hugo Claudio Briceño García, Catsalut, Spain Hanne Marte Bårholm, Helse Vest IKT, Norway (openEHR Editor) Clara Calleja Vega, CatSalut. Servei Català de la Salut., Spain Grant Forrest, Lunaria Ltd, United Kingdom Heather Grain, Llewelyn Grain Informatics, Australia Mikkel Johan Gaup Grønmo, Helse Nord IKT, Norway (openEHR Editor) Evelyn Hovenga, EJSH Consulting, Australia Kanika Kuwelker, Helse Vest IKT, Norway (openEHR Editor) Jörgen Kuylenstierna, eWeave AB, Sweden michel laji!, Karolinska Institutet, Sweden Liv Laugen, Oslo University Hospital, Norway, Norway (openEHR Editor) Heather Leslie, Atomica Informatics, Australia (openEHR Editor) Rikard Lovstrom, Swedish Medical Association, Sweden Ian McNicoll, freshEHR Clinical Informatics, United Kingdom Mikael Nyström, Cambio Healthcare Systems AB, Sweden Terje Sagmyr, Helse Vest IKT, Norway (openEHR Editor) Benjamin Senst, Germany Natalia Strauch, Medizinische Hochschule Hannover, Germany 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) Vebjørn Arntzen, Oslo universitetssykehus HF, Norway (Nasjonal IKT redaktør) Silje Ljosland Bakke, Helse Vest IKT AS, Norway (Nasjonal IKT redaktør) Ivar Berge, Oslo Universitetssykehus, Norway Gunn Elin Blakkisrud, DIPS ASA, Norway Hanne Marte Bårholm, Helse Vest IKT, Norway (Nasjonal IKT redaktør) Kåre Flø, DIPS ASA, Norway Mikkel Johan Gaup Grønmo, Helse Nord IKT, Norway (Nasjonal IKT redaktør) Nina Louise Jebsen, Haukeland Universitetssykehus, Norway Kanika Kuwelker, Helse Vest IKT, Norway (Nasjonal IKT redaktør) Liv Laugen, Oslo universitetssykehus, Norway (Nasjonal IKT redaktør) Svenne Naumann, Finnmarkssykehuset, Norway Terje Nordberg, Helse Bergen, Norway Terje Sagmyr, Helse Vest IKT, Norway (Nasjonal IKT redaktør) Ragnhild Schultz, OUS, Norway Andre Smitt-Ingebretsen, Sørlandet sykehus HF, Norway John Tore Valand, Helse Vest IKT, Norway (Nasjonal IKT redaktør) Marit Alice Venheim, Helse Vest IKT, Norway (Nasjonal IKT redaktør) |
| Translators |