Use to record a relevant context-specific or time-specific qualifier that provides additional detail which is relevant at the time of recording or within the clinical context where a problem or diagnosis is recorded. The qualifier may not be appropriate at another time or in another clinical context.
This archetype is designed to be included in Status SLOT in the EVALUATION.problem_diagnosis archetype. The intent is for the EVALUATION.problem_diagnosis archetype to hold all of the information that applies in all contexts, in contrast to this archetype describing only information that depends on the context of use.
IMPORTANT NOTES FOR IMPLEMENTATION:
- It is not intended or implied that any or all of these qualifiers should be used within the same context or period of time. In contrast to the usual design of archetypes, this archetype has been deliberately designed to collect a number of common qualifiers into one place in an effort to attempt some simple standardisation within a very messy area of clinical practice. It is acknowledged that the data elements contained in this archetype embrace many different, and sometimes even competing, concepts. This has been done mainly to prevent the need for multiple qualifier archetypes, each containing only one or two data elements.
- Some of these data elements are potentially directly conflicting if used simultaneously within the same context, for example it would not make sense to have an 'inactive' problem together with an Episode that is 'ongoing'. As such, these status qualifiers should be used with extreme care as they are variably applied in practice and interoperability cannot be assured unless usage guidelines are clearly defined within the clinical community in which the 'Problem/Diagnosis' and 'Problem/Diagnosis qualifier' archetype pair may be shared.
Full DRG coding will require the DRG-related data elements from this archetype in combination with data elements from other archetypes.
Organisation: freshEHR Clinical Informatics, United Kingdom
Email: ian@freshehr.com
Date originally authored: 2013-05-29
Organisation: freshEHR Clinical Informatics, United Kingdom
Email: ian@freshehr.com
Date originally authored: 2013-05-29
- Licence: This work is licensed under the Creative Commons Attribution-ShareAlike 3.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/3.0/.
- Custodian Organisation: HiGHmed
- References: Derived from:
- Current Contact: Heather Leslie, Atomica Informatics
- Original Namespace: org.highmed
- Original Publisher: HiGHmed
- Custodian Namespace: org.highmed
- MD5-CAM-1.0.1: 9DB3D4FD1ADD7F7FAF421EBB99A4CE75
- Build Uid: 1b972de2-eda5-4eb4-9d57-a0ccca7b60ca
- 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 http://www.snomed.org/snomed-ct/get-snomedct or info@snomed.org.
- Revision: 0.0.1
The status is usually determined by a combination of the timing of diagnosis plus level of clinical certainty resulting from diagnostic tests and clinical evidence available. This data element and 'Diagnostic certainty' in EVALUATION.problem_diagnosis are two important axes of the diagnostic process, and valid combinations will need to be presented by software that exposes both data elements, so it is not possible for users to select conflicting combinations. Preliminary or working diagnoses are intended to represent the single most likely choice out of all differential diagnosis options.
- Preliminary [The initial diagnosis made, usually associated with a low level of clinical certainty. It may change as test results or advice become available.]
[SNOMED-CT::148006 | Preliminary diagnosis] - Working [Interim diagnosis, based on a reasonable amount of clinical certainty but pending further test results or clinical advice. It may still change as test results or advice become available.]
[SNOMED-CT::5558000 | Working diagnosis (contextual qualifier)] - Established [Final substantiated diagnosis, based on a high level of clinical certainty, which may include clinical evidence from test results. It is not expected to change.]
[SNOMED-CT::14657009 | Established diagnosis] - Refuted [The previously recorded diagnosis has been clinically reassessed or disproved with a high level of clinical certainty. This status is used to correct an error in the health record.]
The Current/Past and Active/Inactive data elements have similar clinical impact but represent slightly different semantics. Both are actively used in different clinical settings, but usually not together. If an Active/Inactive qualifier is recorded, then this data element is likely to be redundant. An exception where a condition can be current but inactive is asthma that is not causing acute symptoms.
- Current [An issue occuring at present.]
[SNOMED-CT::15240007 | Current (qualifier value)] - Past [An issue which ocurred in the past.]
[SNOMED-CT::410513005 | In the past]
The Active/Inactive and Current/Past data elements have similar clinical impact but represent slightly different semantics. Both are actively used in different clinical settings, but usually not together. If a Current/Past qualifier is recorded, then this data element is likely to be redundant. An exception where a condition can be current but inactive is asthma that is not causing acute symptoms.
- Active [The problem or diagnosis is currently active and clinically relevant.]
- Inactive [The problem or diagnosis is not completely resolved but is inactive or felt less relevant to the current clinical context.]
For example: tracking the progress of resolution of a middle ear infection.
- Resolving [Problem or diagnosis is progressing satisfactorily through the normal stages of restoration or healing towards resolution.]
- Not resolving [Problem or diagnosis is not progressing satisfactorily through the normal stages of restoration or healing towards resolution.]
- Resolved [Problem or diagnosis has completed the normal phases of restoration or healing and can be considered resolved.]
- Indeterminate [It is not possible to determine the resolution or healing status of the problem or diagnosis.]
- Relapsed [Problem or diagnosis has deteriorated after a period of temporary improvement.]
For example: the status of a cancer or haematological diagnosis.
- In complete remission [No ongoing signs or symptoms of the disease have been identified.]
- Not in remission [No diminution of the signs or symptoms of the disease have been identified.]
- Indeterminate [It is not possible to determine if there have been diminution of the signs or symptoms of the disease have been identified.]
For example: 'New' will enable clinicians to distinguish a new, acute episode of otitis media that may have arisen soon after a previous diagnosis, to distinguish it from an unresolved or 'Ongoing' diagnosis of chronic otitis media. Treatment of recurring, new and acute, episodes of a condition may differ significantly from the same condition that is not resolving or responding to treatment. In many situations the clinician will not be able to tell, and so indeterminate may be appropriate.
- New [A new occurrence of either a new or existing problem or diagnosis. A flag for 'First occurrence' can be recorded separately to distinguish the first from other occurrences.]
- Ongoing [The issue, problem or diagnosis continues, without new, acute episodes occurring.]
- Indeterminate [It is not possible to determine if this occurrence of the problem or diagnosis is new or ongoing.]
This data element can be an additional qualifier to the 'New' value in the 'Episodicity' value set, that is a condition such as asthma can have recurring new episodes that have periods of resolution in between. However it can be important to identify the first ever episode of asthma from all of the other episodes.
- First occurrence [This is the first ever occurrence of this problem or diagnosis.]
- Recurrence [New occurrence of the same problem or diagnosis after a previous episode was resolved.]
Definitions of acute vs chronic will differ for each diagnosis.
- Acute [A problem or diagnosis with a rapid onset, a short course, or both.]
- Acute-on-chronic [A problem or diagnosis with an acute exacerbation of a chronic condition.]
- Chronic [A problem or diagnosis with persistent or long-lasting effects, or that evolves over time.]
This data element contains a value set commonly used in diagnostic categorisation. In episodic care contexts (commonly secondary care) it is common to categorise/organise diagnoses according to their relationship to the principal diagnosis being addressed during that episode of care. These categories may also be used for clinical coding, reporting and billing purposes. In some countries the diagnostic category may be known as a DRG. In addition, the free text choice permits use of other local value sets, as required.
Choice of:
Coded Text- Principal diagnosis [The diagnosis determined to be chiefly responsible for occasionaing an episode of admitted patient care, an episode of residential care or an attendance at the health care establishment.]
[SNOMED-CT::8319008 | Principal diagnosis] - Secondary diagnosis [A problem or diagnosis that is occurs at the same time as the primary problem or diagnosis. May also be known as a comorbid condition.]
[SNOMED-CT::85097005 | Secondary diagnosis (contextual qualifier)] - Complication [An unfavorable evolution of a problem or diagnosis.]
- Principal diagnosis [The diagnosis determined to be chiefly responsible for occasionaing an episode of admitted patient care, an episode of residential care or an attendance at the health care establishment.]
Text
Record as True if the problem or diagnosis was present on admission. This data element is a requirement from DRG reporting in some countries.
Allowed values: {true}
Erling Are Hole, Helse Bergen, Norway
Vebjørn Arntzen, Oslo University Hospital, Norway
Koray Atalag, University of Auckland, New Zealand
Silje Ljosland Bakke, Nasjonal IKT HF, Norway (openEHR Editor)
Malin Berg, DIPS ASA, Norway
Lars Bitsch-Larsen, Haukeland University hospital, Norway
Alexander Davey, HSC NI, United Kingdom
Aitor Eguzkitza, UPNA (Public University of Navarre) - CHN (Complejo Hospitalario de Navarra), Spain
Arild Faxvaag, NTNU, Norway
Shahla Foozonkhah, Iran ministry of health and education, Iran
Einar Fosse, National Centre for Integrated Care and Telemedicine, Norway
Bente Gjelsvik, Helse Bergen, Norway
Heather Grain, Llewelyn Grain Informatics, Australia
Sam Heard, Ocean Informatics, Australia
Andreas Hering, Helse Bergen HF, Haukeland universitetssjukehus, Norway
Anca Heyd, DIPS ASA, Norway
Hilde Hollås, DIPS AS, Norway
Evelyn Hovenga, EJSH Consulting, Australia
Lars Ivar Mehlum, Helse Bergen HF, Norway
Tom Jarl Jakobsen, Helse Bergen, Norway
Lars Morgan Karlsen, DIPS ASA, Norway
Shinji Kobayashi, Kyoto University, Japan
Sabine Leh, Haukeland University Hospital, Department of Pathology, Norway
Heather Leslie, Atomica Informatics, Australia (openEHR Editor)
Hugh Leslie, Ocean Informatics, Australia
Hallvard Lærum, Norwegian Directorate of e-health, Norway
Chunlan Ma, Ocean Informatics, Australia
Luis Marco Ruiz, NST, Spain
Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (openEHR Editor)
Bjørn Næss, DIPS ASA, Norway
Andrej Orel, Marand d.o.o., Slovenia
Jussara Rotzsch, Hospital Alemão Oswaldo Cruz, Brazil
Thomas Schopf, University Hospital of North-Norway, Norway
Anoop Shah, University College London, United Kingdom
Line Silsand, Universitetssykehuset i Nord-Norge, Norway
Line Sæle, Nasjonal IKT HF, Norway
Nyree Taylor, Ocean Informatics, Australia
Richard Townley-O'Neill, Australian Digital Health Agency, Australia
Jon Tysdahl, Furst medlab AS, Norway
Gro-Hilde Ulriksen, Norwegian center for ehealthresearch, Norway
John Tore Valand, Helse Bergen, Norway (openEHR Editor)
- German: Simon Schumacher, HiGHmed, sschuma9@uni-koeln.de
- Norwegian Bokmål: John Tore Valand, Silje Ljosland Bakke, Helse Bergen HF, Nasjonal IKT HF
- Portuguese (Brazil): Marivan Abrahão, Gabriela Alves, Adriana Kitajima e Maria Ângela Scatena, Core Consulting, contato@coreconsulting.com.br, Hospital Alemão Oswaldo Cruz (HAOC)
- Slovenian: mag. Biljana Prinčič, Marand d.o.o., Ljubljana, Slovenija, biljana.princic@marand.si