ARCHETYPE Precaution (openEHR-EHR-EVALUATION.precaution.v1)

Name: Precaution
License: http://creativecommons.org/licenses/by-sa/4.0/

ARCHETYPE ID	openEHR-EHR-EVALUATION.precaution.v1
Concept	Precaution
Description	A condition or state of the individual that is clinically significant and unique or idiosyncratic for this individual, and is considered vital information when making treatment decisions.
Use	Use to record a condition or state of the individual that is clinically significant and unique or idiosyncratic for this individual, and which are considered vital information when making treatment decisions. This archetype should be regarded as a critical archetype by any clinical decision support system testing for any relevant therapeutic precautions as a clinician commences a new clinical intervention for an individual. Examples of conditions that warrant creation of a precaution include, but are not limited to: Immunosuppressed/on immunosuppressive therapy – linked to medication order for chemo or steroids; or diagnosis of leukaemia; Renal failure – linked to renal function tests and/or a formal diagnosis of renal failure; Waiting for organ transplant; Undergoing a regular treatment such as radiation therapy or dialysis; Transplanted organ or metal implant in situ; Ongoing investigation or follow up of suspected or verified malignant disease; Participation in a pharmacological trial; or Using anticoagulant treatment.
Misuse	Not to be used to record a clinical intervention (including, but not limited to, use of a treatment or performance of a test or procedure) that should not be carried out due to the likelihood, or possibility, of harm being caused to an individual. Use the EVALUATION.contraindication for this purpose. Not to be used to record decisions about limitations on the individuals care or future interventions or the individuals preferences of future medical treatment and care. Use EVALUATION.advance_intervention_decisions and EVALUATION.advance_care_directive respectively for this purpose.
Purpose	To record a condition or state of the individual that is clinically significant and unique or idiosyncratic for this individual, and is considered vital information when making treatment decisions.
References
Copyright	© openEHR Foundation
Authors	Author name: Silje Ljosland Bakke / John Tore Valand Organisation: Helse Vest IKT Email: silje.ljosland.bakke@helse-vest-ikt.no/ john.tore.valand@helse-vest-ikt.no Date originally authored: 2016-02-29
Other Details Language	Author name: Silje Ljosland Bakke / John Tore Valand Organisation: Helse Vest IKT Email: silje.ljosland.bakke@helse-vest-ikt.no/ john.tore.valand@helse-vest-ikt.no Date originally authored: 2016-02-29
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 Current Contact: Silje Ljosland Bakke, Helse Vest IKT, silje.ljosland.bakke@helse-vest-ikt.no Original Namespace: org.openehr Original Publisher: openEHR Foundation Custodian Namespace: org.openehr MD5-CAM-1.0.1: 1F847D0C7A85E138BBBDEA568702B601 Build Uid: 504c8b10-ac7b-446d-8e1b-2efcc0d0828b Revision: 1.1.0
Keywords	precaution, prevent, avoid, adverse event, prevention, caution, alert, warning
Lifecycle	published
UID	8e02deb2-7500-4703-81a3-e2bfb22c4bc2
Language used	en
Citeable Identifier	1246.145.2759
Revision Number	1.1.0
protocol
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 or CIMI equivalents. Include: All not explicitly excluded archetypes
Valid period start	Valid period start: Date/time after which the 'Condition' is regarded as active. This data element is intended for use when a precaution is identified to start at some time in the future. For example: the commencement date for a pharmaceutical trial.
Valid period end	Valid period end: Date/time after which the 'Condition' is regarded as inactive. This data element is intended for use when a precaution is known to have a definitive end date/time in the future. For example: the cessation date for a pharmaceutical trial.
Review date	Review date: Date when next due for review by a clinician. In circumstances where precautions are not indefinite or life-long, use this data element to record the date/time when this precaution should be reassessed in the context of the clinical circumstances at the time.
Last updated	Last updated: Date when the precaution information was last updated.
data
Condition	Condition: Identification, by name, of a condition or state. Coding of the identified 'Condition' with a terminology is desirable, where possible.
Status	Status: Assertion about the current state of the identified 'Precaution'. Decision support would typically raise alerts for 'Active' and ignore a 'Resolved' or 'Refuted' precaution. Clinical systems may choose not to display Precaution entries with a 'Refuted' status in the Precaution list. However, 'Refuted' may be useful for reconciliation of the Precaution list or when communicating between systems. Some implementations may choose to make this field mandatory. 'Resolved' may be used variably across systems, depending on clinical use and context. The free text data type will allow for local variation by enabling other value sets to be applied to this data element in a template - in this situation it is recommended that values should be coded using a terminology. Choice of: Coded Text at0015::Active [The precaution is currently active.] at0018::Resolved [The previously asserted precaution has been clinically reassessed and considered no longer to be an active risk.] at0019::Refuted [The precaution has been clinically reassessed or has been disproved with a high level of clinical certainty by testing.] Text
Evidence	Evidence: Description of the evidence identified to support the precaution. This data element can be optionally linked to a diagnosis, test result, medication order etc via a URI (as per the Reference Model) in order to provide the rationale or evidence for the precaution assertion. Please note: as this URI link may not be accessible from a message or by receiving clinical system it is desirable that a narrative description of the evidence should also be explicitly recorded.
Category	Category: Type of the 'Condition' identified. This data element has been included because it is currently being captured in some clinical systems. This information could be derived when terminology codes are used to represent the condition in clinical systems, and is effectively redundant in that situation.
Additional details	Additional details: Additional structured details about the precaution. For example: clinical evidence supporting the precaution. Include: openEHR-EHR-CLUSTER.clinical_evidence.v1
Comment	Comment: Additional narrative about the precaution, not captured in other fields.
Other contributors	Morten Aas, Oslo Universitetssykehus, Norway Tomas Alme, DIPS, Norway Ole Andreas Bjordal, Webmed, Norway Vebjørn Arntzen, Oslo universitetssykehus HF, Norway (Nasjonal IKT redaktør) Silje Ljosland Bakke, Nasjonal IKT HF, Norway (openEHR Editor) Lisbeth Dahlhaug, Helse Midt - Norge IT, Norway Hildegard Franke, freshEHR Clinical Informatics Ltd., United Kingdom Heather Grain, Llewelyn Grain Informatics, Australia Cecilie Graver, Oslo universitetssykehus HF, Norway Daniel Habashi, PasientSky AS, Norway Annette Hole Sjøborg, DIPS ASA, Norway Hilde Hollås, DIPS ASA, Norway Evelyn Hovenga, EJSH Consulting, Australia Tom Jarl Jakobsen, Helse Bergen, Norway Lars Morgan Karlsen, DIPS ASA, Norway Nils Kolstrup, Skansen Legekontor og Nasjonalt Senter for samhandling og telemedisin, Norway Heather Leslie, Atomica Informatics, Australia (openEHR Editor) Siv Marie Lien, DIPS ASA, Norway Hildegard McNicoll, freshEHR Clinical Informatics Ltd., United Kingdom Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (openEHR Editor) Bjørn Næss, DIPS ASA, Norway Andrej Orel, Marand d.o.o., Slovenia Rune Pedersen, Universitetssykehuset i Nord Norge, Norway Vladimir Pizzo, Hospital Sírio Libanês, Brazil Tanja Riise, Nasjonal IKT HF, Norway Anoop Shah, University College London, United Kingdom Arild Stangeland, Helse Bergen, Norway Norwegian Review Summary, Nasjonal IKT HF, Norway Nyree Taylor, Ocean Informatics, Australia Tesfay Teame, OUS, Norway John Tore Valand, Helse Bergen, Norway
Translators	Swedish: Daniel Hall, Region Östergötland, daniel.hall@regionostergotland.se Spanish (Argentina): Alan March, Hospital Universitario Austral, amarch@cas.austral.edu.ar, MD Norwegian Bokmål: Silje Ljosland Bakke og John Tore Valand, Helse Vest IKT, silje.ljosland.bakke@helse-vest-ikt.no, john.tore.valand@helse-vest-ikt.no Portuguese (Brazil): Débora Farage, Fernanda Maia, Laíse Figueiredo, Core Consulting, contato@coreconsulting.com.br, Hospital Alemão Oswaldo Cruz (HAOC)