| TEMPLATE ID | openEHR suspected COVID-19 risk assessment.v0 |
|---|---|
| Concept | openEHR suspected COVID-19 risk assessment.v0 |
| Description | To record the information required to evaluate the potential risk of Covid-19 infection, as part of professional screening or self-assessment. This is based on - The current NHS-111 UK self-assessment app at https://111.nhs.uk/covid-19 - A similar risk assessment app developed for pre-hospital admission by DIPS.no - Public Health England COVID-19: investigation and initial clinical management of possible cases https://www.gov.uk/government/publications/wuhan-novel-coronavirus-initial-investigation-of-possible-cases The exact risk factors are subject to continual update as the disease progresses. Note that a critical part of the information, exposure locations, has been left open, so as to allow the list to be updated very regularly and in alignment with local or national policy. We have decided to leave in 'older' questions such as 'Exposure to birds in China' until such time that we get clear professional guidance that these are no longer necessary or useful. |
| Use | To record the information required to evaluate the potential risk of Covid-19 infection, as part of professional screening or self-assessment. This is based on - The current NHS-111 UK self-assessment app at https://111.nhs.uk/covid-19 - A similar risk assessment app developed for pre-hospital admission by DIPS.no - Public Health England COVID-19: investigation and initial clinical management of possible cases https://www.gov.uk/government/publications/wuhan-novel-coronavirus-initial-investigation-of-possible-cases The exact risk factors are subject to continual update as the disease progresses. Note that a critical part of the information, exposure locations, has been left open, so as to allow the list to be updated very regularly and in alignment with local or national policy. |
| Misuse | This assessment is not intended to act directly as part of any public health reporting documentation - further work is being undertaken to support this use-case. Please also be aware that this assessment dataset is likely to be a superset of the questions and criteria required in any single country or setting. You should check the exact requirements for your country and clinical setting and adapt appropriately. For similar reasons we have not embedded any particular guidance or rules on how high / low risk should be estimated - you should follow local guidance. |
| Purpose | To record the information required to evaluate the potential risk of Covid-19 infection, as part of professional screening or self-assessment. This is based on - The current NHS-111 UK self-assessment app at https://111.nhs.uk/covid-19 - A similar risk assessment app developed for pre-hospital admission by DIPS.no - Public Health England COVID-19: investigation and initial clinical management of possible cases https://www.gov.uk/government/publications/wuhan-novel-coronavirus-initial-investigation-of-possible-cases The exact risk factors are subject to continual update as the disease progresses. Note that a critical part of the information, exposure locations, has been left open, so as to allow the list to be updated very regularly and in alignment with local or national policy. We have decided to leave in 'older' questions such as 'Exposure to birds in China' until such time that we get clear professional guidance that these are no longer necessary or useful. |
| References | |
| Authors | name: Ian McNicoll; organisation: freshEHR Clinical Informatics Ltd.; email: ian@freshehr.com; date: 2020-02-27 |
| Other Details Language | name: Ian McNicoll; organisation: freshEHR Clinical Informatics Ltd.; email: ian@freshehr.com; date: 2020-02-27 |
| Other Details (Language Independent) |
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| Keywords | covid-19, risk, screening, triage, coronavirus |
| Language used | en |
| Citeable Identifier | 1246.169.687 |
| Root archetype id | openEHR-EHR-COMPOSITION.encounter.v1 |
| openEHR suspected COVID-19 risk assessment.v0 | openEHR suspected COVID-19 risk assessment.v0: Interaction, contact or care event between a subject of care and healthcare provider(s). |
| Story/History | Story/History: The subjective clinical history of the subject of care as recorded directly by the subject, or reported to a clinician by the subject or a carer. |
| Data | |
| Any event | Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time. |
| Data | |
| Story | Story: Narrative description of the story or clinical history for the subject of care. |
| Symptom/sign screening questionnaire | Symptom/sign screening questionnaire: An individual- or self-reported questionnaire screening for symptoms and signs. |
| Data | |
| Any event | Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time. |
| Data | |
| Screening purpose | Screening purpose: The reason for overall screening. For example: screening for an infectious disease, such as SARS-COV-2.
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| Specific symptom/sign | Specific symptom/sign: Grouping of data elements related to screening for a single symptom or sign. |
| Symptom or sign name | Symptom or sign name: Name of the symptom or sign being screened. |
| Presence? | Presence?: Presence of the symptom or sign.
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| Comment | Comment: Additional narrative about the specific symptom or sign, not captured in other fields. |
| Spezifisches Symptom/Krankheitsanzeichen #1 | Spezifisches Symptom/Krankheitsanzeichen #1: Grouping of data elements related to screening for a single symptom or sign. |
| Symptom or sign name | Symptom or sign name: Name of the symptom or sign being screened. |
| Presence? | Presence?: Presence of the symptom or sign.
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| Comment | Comment: Additional narrative about the specific symptom or sign, not captured in other fields. |
| Body temperature | Body temperature: A measurement of the body temperature, which is a surrogate for the core body temperature of the individual. |
| Data | |
| Any event | Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time. |
| Data | |
| Temperature | Temperature: The measured temperature. 0..100 °C |
| State | State: State information about the patient. |
| Confounding factors | Confounding factors: Additional issues or factors that may impact on the measurement of body temperature, not captured in other fields. |
| Travel event | Travel event: Details about travel during an interval of time. |
| Data | |
| Any interval event | Any interval event: Default, unspecified interval event which may be explicitly defined in a template or at run-time. |
| Data | |
| Letzte Reise? | Letzte Reise?: Has the individual travelled during the specified interval? Use the Event to set the relevant interval.
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| Domestic/international | Domestic/international: Was the travel domestic, international, or both?
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| Specific trip | Specific trip: Details about a single trip away from the home base. The trip has a single departure and return date to their home base. A trip may include visiting many individual places, and these details should be recorded in the Specific destination cluster. |
| Specific destination | Specific destination: Details about a single location visited on a trip. |
| Country | Country: The country visited. |
| State/region | State/region: The region visited. Different regions within the same country maybe identified if they potentially pose different health risks. |
| City | City: The city visited. Different cities within the same country or region maybe identified if they potentially pose different health risks. |
| Specific place | Specific place: A specific place visited. For example: airport, cruise ship, conference centre, hotel or sports arena. |
| Date of return | Date of return: The date when the individual returned back to their home base. |
| Gesundheitsbezogener Beruf | Gesundheitsbezogener Beruf: Summary or persistent information about an individual's current and past jobs and/or roles. |
| Data | |
| Occupation record | Occupation record: A single job or role carried out by an individual during a specified period of time. |
| Job title/role | Job title/role: The main job title or the role of the individual. For example: Chief Executive Officer; Carer; or Student. Each of these job titles or roles may be comprised of multiple duties. |
| Einrichtung | Einrichtung: Organisation details aligned with FHIR resource. |
| Name der Einrichtung | Name der Einrichtung: Name associated with the organisation. |
| Address | Address: Address details aligned with FHIR resource. |
| City | City: The name of the city, town, village or other community or delivery center. |
| Country | Country: Country - a nation as commonly understood or generally accepted. |
| Haushalt | Haushalt: The circumstances about an individual living alone or with others. This information will provide a sense of the level of support, both physically and emotionally, to which an individual may have access. |
| Data | |
| Description | Description: Narrative description about the living arrangements. |
| Number of household members | Number of household members: The number of individuals who are in the household. |
| Dwelling | Dwelling: An overview about the properties of a single structure, or a discrete space within a structure, and associated spaces in which an individual lives. The intended scope of dwelling includes, but is not limited to: a building; part of a building; house; apartment; prison; houseboat; mobile home; or vehicle. It can also include the spaces associated with a structure or property, including the basement or yard. |
| Number of bedrooms | Number of bedrooms: The number of bedrooms in the dwelling. |
| Overcrowding screening | Overcrowding screening: Screening to identify when a dwelling is too small for the size and composition of the household living in it. |
| Anzahl der Personen, die in Ihrem Schlafzimmer schlafen | Anzahl der Personen, die in Ihrem Schlafzimmer schlafen: Number of people per bedroom in a dwelling. |
| Health risk assessment | Health risk assessment: Assessment of the potential and likelihood of future adverse health effects as determined by identified risk factors. |
| Data | |
| Health risk | Health risk: Identification of the potential future disease, condition or health issue for which the risk is being assessed, by name. Coding of 'Health risk' with a terminology is preferred, where possible. Free text should be used only if there is no appropriate terminology available. For example: risk of cardiovascular disease, with risk factors of hypertension and hypercholesterolaemia.
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| Spezifischer Risikofaktor | Spezifischer Risikofaktor: Details about each possible risk factor. |
| Risk factor | Risk factor: Identification of the risk factor, by name. For example: hypertension and hypercholesterolaemia, which may be used as part of the overall assessment for cardiovascular disease; or a genetic marker. Coding of 'Risk factor' with a terminology, where possible.
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| Presence | Presence: Presence of the risk factor.
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| Andere Risikofaktoren | Andere Risikofaktoren: Details about each possible risk factor. |
| Risk factor | Risk factor: Identification of the risk factor, by name. For example: hypertension and hypercholesterolaemia, which may be used as part of the overall assessment for cardiovascular disease; or a genetic marker. Coding of 'Risk factor' with a terminology, where possible. |
| Presence | Presence: Presence of the risk factor.
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| Risk assessment | Risk assessment: Evaluation of the health risk. There may be multiple variations on the assessment of risk. The Choice data type allows for recording of the assessment as either free text or value sets (such as low, medium or hig). The proportion data type allows recording of a percentage, a ratio or a fraction. The quantity data type allows recording of a decimal number.
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| Protocol | |
| Last updated | Last updated: The date this health risk assessment was last updated. This data element may be thought redundant if the data is recorded and stored using COMPOSITIONs within a closed clinical system. However if this information is extracted from its original COMPOSITION context, for example, to be included in another document or message then the temporal context is effectively removed. This 'Last updated' data element has been explicitly added to allow the critical temporal data to be kept alongside the clinical data in all circumstances. It is assumed that the clinical system can copy the date from the COMPOSITION to reduce the need for duplication of data entry by the clinician. |
| Assessment method | Assessment method: Identification of the algorithm or guideline used to make the assessment of risk. For example: Framingham cardiovascular risk calculator. |
| Problem/Diagnosis | Problem/Diagnosis: Details about a single identified health condition, injury, disability or any other issue which impacts on the physical, mental and/or social well-being of an individual. Clear delineation between the scope of a problem versus a diagnosis is not easy to achieve in practice. For the purposes of clinical documentation with this archetype, problem and diagnosis are regarded as a continuum, with increasing levels of detail and supportive evidence usually providing weight towards the label of 'diagnosis'. |
| Data | |
| Problem/Diagnosis name | Problem/Diagnosis name: Identification of the problem or diagnosis, by name. Coding of the name of the problem or diagnosis with a terminology is preferred, where possible.
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| Status | Status: Contextual or temporal qualifier for a specified problem or diagnosis. |
| Diagnostic status | Diagnostic status: Stage or phase of diagnostic process. 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.
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| Protocol | |
| Last updated | Last updated: The date this problem or diagnosis was last updated. |
| Service request | Service request: Request for a health-related service or activity to be delivered by a clinician, organisation or agency. |
| Current Activity | Current Activity: Current Activity. |
| Description | |
| Service name | Service name: The name of the single service or activity requested. Coding of the 'Service name' with a coding system is desirable, if available. For example: 'referral' to an endocrinologist for diabetes management.
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| Reason for request | Reason for request: A short phrase describing the reason for the request. Coding of the 'Reason for request' with a coding system is desirable, if available. This data element allows multiple occurrences to enable the user to record a multiple responses, if required. For example: 'manage diabetes complications'.
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