| ARCHETYPE ID | openEHR-EHR-COMPOSITION.problem_list.v1 |
|---|---|
| Concept | Problem list |
| Description | A persistent and managed list of any combination of diagnoses, problems and/or procedures that may influence clinical decision-making and care provision for the subject of care. |
| Use | Use as a suggested framework to support consistent modelling of the Problem list as a persistent and managed list of diagnoses identified, problems experienced by the subject or previous procedures performed. This list can be utilised as a source of current problem list data for exchange or as the basis for decision support. This list can be comprised of three types of statements, each represented by specific archetypes:
In order for this list to be accurate and safe to use as the basis for decision support activities and for exchange, this Problem List should ideally be curated by a clinician responsible for the health record, rather than managed automatically by the clinical system through business rules alone. In a closed clinical system, it is expected that provenance of this Problem list can be managed through versioning of this COMPOSITION and its contents, with the additional option of a system-based audit trail. While it may be ideal to have only one Problem list for each subject of care, it is more realistic to expect that in a distributed environment there may be multiple Problem lists for a single subject of care, each managed and prioritised for a specific clinician, episode of care or other context. For example, a Problem list for a primary care clinician may be a very different configuration to that which is useful for a specialist surgeon or for reference during a hospital inpatient episode. In primary care it is common to organise the Problem list based on active or inactive problems or diagnoses; specialists may prefer to see their list organised around primary diagnoses which are related to their specific speciality and secondary ones which are not; and an inpatient admission may include additional issues related to immediate nursing priorities that would not be relevant once discharged home - for these purposes there is a Status SLOT in the Problem/Diagnosis archetype, which allow use of an archetype that could support clinical systems to organise Problem lists according to the preference of the clinical users of the system, without perpetuating these contextual status labels to other clinical scenarios or for persistence. This archetype is usually managed as a persistent list, however there are situations where the list may be used within episodic care and require additional attributes such as context etc to enable accurate recording. The openEHR reference model currently only allows context to be recorded within Event-based COMPOSITION archetypes. As a result, this archetype has been modelled as an Event, rather than Persistent, COMPOSITION, to allow for flexibility so that some clinical systems can safely manage Problem lists for episodes of care, while others will choose to implement this COMPOSITION to act in a persistent manner. |
| Purpose | To record a persistent and managed list of diagnoses identified, problems experienced by the subject or previous procedures performed, that may influence clinical decision-making and care provision. |
| References | Problem List, draft archetype [Internet]. National eHealth Transition Authority, NEHTA Clinical Knowledge Manager. Authored: 2013 Feb 19. Available at: http://dcm.nehta.org.au/ckm/#showArchetype_1013.1.1235 [accessed 2015 Apr 28]. |
| Copyright | © openEHR Foundation |
| Authors | Author name: Sam Heard Organisation: Ocean Informatics, Australia Email: sam.heard@oceaninformatics.com Date originally authored: 2013-02-19 |
| Other Details Language | Author name: Sam Heard Organisation: Ocean Informatics, Australia Email: sam.heard@oceaninformatics.com Date originally authored: 2013-02-19 |
| Other Details (Language Independent) |
|
| Keywords | problem, list, diagnosis, diagnoses, procedure, problem list |
| Lifecycle | deprecated |
| UID | 2233cb32-3002-4887-b9f1-40e1c36915ea |
| Language used | en |
| Citeable Identifier | 1246.145.898 |
| Revision Number | 1.0.3 |
| data | |
| Category | |
| null |
|
| content | |
| Problems, diagnoses, concerns or Health issue threads | Problems, diagnoses, concerns or Health issue threads: Detail about identified problems, diagnoses, concerns or health issue threads. Include: openEHR-EHR-EVALUATION.problem_ |
| Procedures | Procedures: Detail about identified procedures that have been performed. Include: openEHR-EHR-ACTION.procedure.v1 and specialisations |
| Exclusion statements | Exclusion statements: Positive statement about the exclusion of known problems or diagnoses and procedures performed. For example: "No significant problems or diagnoses" or "No history of significant operations or procedures". Include: openEHR-EHR-EVALUATION.exclusion-problem_ openEHR-EHR-EVALUATION.exclusion-procedure.v1 and specialisations |
| Absent information | Absent information: Positive statement that no information is available about identification of problems or diagnoses, nor procedures performed. Include: openEHR-EHR-EVALUATION.absence.v1 and specialisations |
| Other | Other: SLOT to contain SECTION archetypes which support alternative modelling patterns for Problem lists in specific clinical scenarios. Include: openEHR-EHR-SECTION.problem_ |
| context | |
| Extension | Extension: Additional information required to capture local context or to align with other reference models/formalisms. For example: Local hospital departmental infomation or additional metadata to align with FHIR or CIMI equivalents. Include: All not explicitly excluded archetypes |
| Other contributors | Nadim Anani, Karolinska Institutet, Sweden Vebjoern Arntzen, Oslo university hospital, Norway Koray Atalag, University of Auckland, New Zealand Silje Ljosland Bakke, Bergen Hospital Trust, Norway (openEHR Editor) Sistine Barretto-Daniels, Ocean Informatics, Australia Lars Bitsch-Larsen, Haukeland University hospital, Norway Shahla Foozonkhah, Ocean Informatics, Australia Einar Fosse, National Centre for Integrated Care and Telemedicine, Norway Sebastian Garde, Ocean Informatics, Germany Heather Grain, Llewelyn Grain Informatics, Australia Sam Heard, Ocean Informatics, Australia Lars Karlsen, DIPS ASA, Norway Shinji Kobayashi, Kyoto University, Japan Heather Leslie, Ocean Informatics, Australia (openEHR Editor) Hallvard Lærum, Oslo University Hospital, Norway Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (openEHR Editor) Andrej Orel, Marand d.o.o., Slovenia Jussara Rotzsch, UNB, Brazil Rowan Thomas, St. Vincent's Hospital Melbourne, Australia |
| Translators |
|