ARCHETYPE ID | openEHR-EHR-ACTION.service.v1 |
Concept | Service |
Description | A simple health-related service or activity delivered by a clinician, organisation or agency. |
Use | To record details about a simple health-related service or activity delivered by a clinician, organisation or agency. This includes tracking progress from planning, via scheduling and delivery to completion, as well as deviations from the intended care path such as postponement or cancellation. This is achieved by the recording of relevant data elements about specific activities, each of which are described as the 'Pathway' careflow steps in this archetype. The scope of this archetype deliberately encompasses activities for a broad range of clinical services, to act as a non-specific archetype for all non-complex use cases. Examples include, but are not limited to: - self-referral by a patient for a check-up visit to a dentist for preventive care - a series of visits to a physiotherapist for management of a musculoskeletal strain; and - a referral from a requesting healthcare provider, such as a primary care clinician, to a receiving healthcare provider, such as a specialist, for the patient to receive a specific service, advice or care. Additional structured and detailed information about the service can be captured using purpose-specific archetypes inserted into the 'Service detail' slot, where required. This archetype may only be used in two ways: - as a full record of the service that was delivered; or - as a framework to record primarily the state of the requested service, with separate OBSERVATION archetypes used to record the actual test results for the delivered service - for example OBSERVATION.hearing_screening_result. Timings related to service management can be managed in one of two ways: - Using the reference model - the time for performance of any pathway step will use the ACTION time attribute for each step. - Archetyped data elements - the 'Scheduled date/time' data element is intended to record the time when the service was intended to be carried out. Note: the corresponding ACTION time attribute for the Scheduled pathway step will record the time that the clinical activity was scheduled into a system, not the intended date/time on which the activity is intended to be carried out. In practice, some services (for example, in ambulatory care) will occur once and not be ordered in advance. The details about the service will be added against the pathway step, 'Service completed'. In some cases a recurring service will be ordered, and in this situation data against the 'Service delivered' step will be recorded on each occasion, leaving the instruction in the active state. When the last delivery of the service is recorded, the 'Service completed' action is recorded showing that this order is now in the completed state. In other situations, such as secondary care, there may be a formal order for a service using a corresponding INSTRUCTION.request archetype. This ACTION archetype can then be used to record the workflow of when and how the order has been carried out. Recording information using this ACTION archetype indicates that some sort of activity has actually occurred; this will usually be the service delivery itself but may be a failed attempt or another activity such as postponement of the service delivery. If there is a formal order for the service, the state of this order is represented by the Pathway step against which the data is recorded. For example, using this archetype the progressing state of a referral request may be recorded through separate entries in the EHR progress notes at each 'Pathway' step: - record the scheduled Start date/time for the referral (Service scheduled); and - record that the referral has been completed, potentially including information about the service delivered (Service completed). When the activities follow the usual Planned > Scheduled > Active > Completed states, recording a 'Reason' is not usually necessary - rather, it is usually used to record the reason for deviation from the typical care pathway. Please note that in the openEHR Reference Model there is a 'Time' attribute, which is intended to record the date and time at which each pathway step of the Action was performed. This is the attribute to use to record the start of the service (using the 'Service delivered' pathway step) or the time that the service was aborted (using the 'Service abandoned' pathway step). |
Misuse | Not to be used to record data about activities carried out for activities that require a purpose built ACTION archetype because they have very specific data recording or pathway step requirements. For example: ACTION.procedure or ACTION.health_education. |
Purpose | To record details about a simple health-related service or activity delivered by a clinician, organisation or agency. |
References | Derived from: Service, Draft archetype [Internet]. Australian Digital Health Agency (NEHTA), ADHA Clinical Knowledge Manager. Authored: 2015 Dec 21. Available at: http://dcm.nehta.org.au/ckm#showArchetype_1013.1.1395_2 (discontinued) |
Copyright | © openEHR Foundation, Northern Territory Department of Health (Australia) |
Authors | Author name: Heather Leslie Organisation: Atomica Informatics, Australia Email: heather.leslie@atomicainformatics.com Date originally authored: 2015-12-21 |
Other Details Language | Author name: Heather Leslie Organisation: Atomica Informatics, Australia Email: heather.leslie@atomicainformatics.com Date originally authored: 2015-12-21 |
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=Derived from: Service, Draft archetype [Internet]. Australian Digital Health Agency (NEHTA), ADHA Clinical Knowledge Manager. Authored: 2015 Dec 21. Available at: http://dcm.nehta.org.au/ckm#showArchetype_1013.1.1395_2 (discontinued), current_contact=Heather Leslie, Atomica Informatics, Australia |
Keywords | referral, visit, encounter |
Lifecycle | published |
UID | 472b238c-4432-44f0-9847-9990924f6196 |
Language used | en |
Citeable Identifier | 1246.145.840 |
Revision Number | 1.0.1 |
All | Archetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=A simple health-related service or activity delivered by a clinician, organisation or agency., archetypeConceptComment=null, otherContributors=Vebjørn Arntzen, Oslo University Hospital, Norway (openEHR Editor) Silje Ljosland Bakke, Helse Vest IKT AS, Norway (openEHR Editor) Maria Berggren, Region Uppsala, Sweden SB Bhattacharyya, Bhattacharyyas Clinical Records Research & Informatics LLP, India Hanne Marte Bårholm, Helse Vest IKT, Norway (openEHR Editor) Gunn Elin Blakkisrud, DIPS ASA, Norway Kåre Flø, DIPS ASA, Norway Heather Grain, Llewelyn Grain Informatics, Australia Mikkel Johan Gaup Grønmo, Regional forvaltning EPJ, Helse Nord, Norway (openEHR Editor) Evelyn Hovenga, EJSH Consulting, Australia Gunnar Jårvik, Helse Vest IKT AS, Norway Mika Kiviaho, Tietoevry, Finland Kanika Kuwelker, Helse Vest IKT, Norway (openEHR Editor) Liv Laugen, Oslo University Hospital, Norway, Norway (openEHR Editor) Heather Leslie, Atomica Informatics, Australia (openEHR Editor) Mikael Nyström, Cambio Healthcare Systems AB, Sweden Bjørn Næss, DIPS ASA, Norway Marte Rime Bø, Direktoratet for e-helse, Norway Terje Sagmyr, Helse Vest IKT, Norway (openEHR Editor) Andre Smitt-Ingebretsen, Sørlandet sykehus HF, Norway Norwegian Review Summary, Norwegian Public Hospitals, Norway John Tore Valand, Helse Bergen, Norway (openEHR Editor) Marit Alice Venheim, Helse Vest IKT, Norway (openEHR Editor) Ina Wille, Helse-Vest RHF, Norway, originalLanguage=en, translators=
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