Norwegian openEHR Repository
Name
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.
Keywords
problem
list
diagnosis
diagnoses
procedure
problem list
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.
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:
- statements about the positive presence of problems, diagnoses or previous procedures are recorded using the EVALUATION.problem_diagnosis and/or ACTION.procedure archetypes; OR
- statements about the positive exclusion of problems, diagnoses or previous procedures can be recorded using the specific EVALUATION.exclusion-problem_diagnosis or EVALUATION.exclusion-procedure archetypes - for example: "No significant problems or diagnoses" or "No history of significant operations or procedures"; OR
- statements about no information being available - neither a positive presence of a problem, diagnosis or procedure performed nor a positive exclusion - can be recorded using the EVALUATION.absence archetype.
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 clincial 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.
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:
- statements about the positive presence of problems, diagnoses or previous procedures are recorded using the EVALUATION.problem_diagnosis and/or ACTION.procedure archetypes; OR
- statements about the positive exclusion of problems, diagnoses or previous procedures can be recorded using the specific EVALUATION.exclusion-problem_diagnosis or EVALUATION.exclusion-procedure archetypes - for example: "No significant problems or diagnoses" or "No history of significant operations or procedures"; OR
- statements about no information being available - neither a positive presence of a problem, diagnosis or procedure performed nor a positive exclusion - can be recorded using the EVALUATION.absence archetype.
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 clincial 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.
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].
Archetype Id
openEHR-EHR-COMPOSITION.problem_list.v1
Copyright
© openEHR Foundation
Licencing
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/.
Original Author
Sam Heard
Ocean Informatics, Australia
Ocean Informatics, Australia
Date Originally Authored
2013-02-19
| Language | Details |
|---|---|
| Norwegian Bokmal |
John Tore Valand, Terje Bless
Helse Bergen HF, Helse Nord FIKS
|
| Korean |
Seung-Jong Yu
NOUSCO Co.,Ltd.
|
| Portuguese (Brazil) |
Vladimir Pizzo
Hospital Sirio Libanes, Brazil
|
| Arabic (Syria) |
Mona Saleh
|
archetype (adl_version=1.4; uid=2a5f3d8a-cfa7-40b0-9c2e-442048e342f5) openEHR-EHR-COMPOSITION.problem_list.v1 concept [at0000] -- Problem list language original_language = <[ISO_639-1::en]> translations = < ["nb"] = < language = <[ISO_639-1::nb]> author = < ["name"] = <"John Tore Valand, Terje Bless"> ["organisation"] = <"Helse Bergen HF, Helse Nord FIKS"> > > ["ko"] = < language = <[ISO_639-1::ko]> author = < ["name"] = <"Seung-Jong Yu"> ["organisation"] = <"NOUSCO Co.,Ltd."> ["email"] = <"seungjong.yu@gmail.com"> > accreditation = <"Certified Board of Family Medicine in South Korea"> > ["ar-sy"] = < language = <[ISO_639-1::ar-sy]> author = < ["name"] = <"Mona Saleh"> > > ["pt-br"] = < language = <[ISO_639-1::pt-br]> author = < ["name"] = <"Vladimir Pizzo"> ["organisation"] = <"Hospital Sirio Libanes, Brazil"> ["email"] = <"vladimir.pizzo@hsl.org.br"> > > > description original_author = < ["name"] = <"Sam Heard"> ["organisation"] = <"Ocean Informatics, Australia"> ["email"] = <"sam.heard@oceaninformatics.com"> ["date"] = <"2013-02-19"> > details = < ["ar-sy"] = < language = <[ISO_639-1::ar-sy]> purpose = <"للمحافظة على قائمة مُحكَمة للمشكلات الصحية الحالية المؤثرة التي يُعتَدّ بها للشخص."> use = <"للمشكلات النشطة و غير النشطة - و تُعرف المشكلات غير النشطة بوجود تاريخ البُرْء/الشفاء"> keywords = <"قائمة المشكلات", ...> misuse = <"لا يستخدم للمشكلات قصيرة المدى"> copyright = <"© openEHR Foundation"> > ["en"] = < language = <[ISO_639-1::en]> 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."> 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: - statements about the positive presence of problems, diagnoses or previous procedures are recorded using the EVALUATION.problem_diagnosis and/or ACTION.procedure archetypes; OR - statements about the positive exclusion of problems, diagnoses or previous procedures can be recorded using the specific EVALUATION.exclusion-problem_diagnosis or EVALUATION.exclusion-procedure archetypes - for example: \"No significant problems or diagnoses\" or \"No history of significant operations or procedures\"; OR - statements about no information being available - neither a positive presence of a problem, diagnosis or procedure performed nor a positive exclusion - can be recorded using the EVALUATION.absence archetype. 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 clincial 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."> keywords = <"problem", "list", "diagnosis", "diagnoses", "procedure", "problem list"> misuse = <""> copyright = <"© openEHR Foundation"> > ["ko"] = < language = <[ISO_639-1::ko]> purpose = <"확인된 진단이나 환자가 겪는 문제 또는 임상의사결정과 환자진료에 영향을 줄 수 있는 이전에 시행된 처치에 대한 영구적으로 관리되는 목록."> use = <"확인된 진단이나 환자가 겪는 문제 또는 임상의사결정과 환자진료에 영향을 줄 수 있는 이전에 시행된 처치에 대한 영구적으로 관리되는 목록을 기록하는데 사용. 이 목록은 교환이나 의사결정을 위한 근거로써 최근의 문제목록 데이터로써 이용될 수 있다. 이 목록은 3가지의 아키타입 종류들로 구성된다. - 문제나 진단 또는 이전에 받은 처치가 있는(positive presence) 경우에 EVALUATION.problem_diagnosis 와/또는 ACTION.procedure 아키타입들을 이용하여 진술문이 기록된다; 또는 - 약물의 이용을 배제하는(positive exclusion) 진술문은 특별한 EVALUATION.exclusion-problem_diagnosis 또는 EVALUATION.exclusion-procedure 아키타입들을 이용하여 진술문이 기록될 수 있다 - 예를 들어, \"중요한 문제들이나 진단들이 없음\" 이나 \"중요한 수술들이나 처치들의 이력이 없음\"; 또는 - 이용가능한 정보가 없는 것(문제나 진단 또는 처치를 받거나 받지 않은 두 경우가 모두 아님)에 대한 진술문이 EVALUATION.absence 아키타입을 이용하여 기록될 수 있다. 이 목록이 의사결정과 교환의 근거로서 정확하고 안전하게 사용되기 위해서는 이 문제목록은 비즈니스 규칙들에 따라 임상시스템에 의해서 자동적으로 관리되기 보다는 이상적으로 기록에 책임이 있는 임상의에 의해 관리되어야 한다."> keywords = <"*문제(ko)", "*목록(ko)", "*진단(ko)", "*처치(ko)"> misuse = <""> copyright = <"© openEHR Foundation"> > ["pt-br"] = < language = <[ISO_639-1::pt-br]> purpose = <"Registrar uma lista permanente e gerenciável de diagnósticos identificados, problemas experimentados pelo indivíduo ou procedimentos previamente realizados, que podem influenciar o processo de tomada de decisão clínica e provisão do cuidado."> use = <"Utilizar como estrutura sugerida para apoiar modelagem consistente da Lista de problemas como uma lista de diagnósticos identificados, problemas vivenciados pelo indivíduo ou procedimentos previamente realizados persistente e gerenciável. Esta lista pode ser utilizada como uma fonte de dados da lista de problemas atuais para troca de informações ou base para suporte à decisão. Esta lista pode ser composta por três tipos de declarações, cada uma representada por arquétipos específicos: - declarações sobre a presença de problemas, diagnósticos ou procedimentos prévios são registradas utilizando arquétipos EVALUATION.problem_diagnosis e/ou ACTION.procedure archetypes; ou - declarações sobre a exclusão de problemas, diagnósticos ou procedimentos prévios podem ser registrados utilizando os arquétipos específicos EVALUATION.exclusion-problem_diagnosis ou EVALUATION.exclusion-procedure - por exemplo: \"Ausência de problemas ou diagnósticos significantes\" ou \"Ausência de história de procedimentos ou operações significantes\"; ou - declarações sobre a ausência de informações disponíveis - nem a afirmação da presença de um problema, diagnóstico ou procedimento realizado nem uma exclusão - pode ser registrado utilizando o arquétipo EVALUATION.absence. Para que esta lista seja acurada e segura para ser utilizada como base para atividades de suporte à decisão e troca de informações, esta Lista de Problemas deve, idealmente, estar sob a responsabilidade de um clínico para o registro de saúde ao invés de gerenciada automaticamente por um sistema clínico baseado apenas em regras de negócio. Num sistema clínico fechado, é esperado que a introdução da informação na Lista de prolemas seja gerenciada através do versionamento deste COMPOSITION e seu conteúdo com a opção de uma trilha de auditoria baseada no sistema. Embora o ideal seja ter apenas uma Lista de problemas para cada indivíduo é mais realista esperar que num ambiente compartilhado podem haver múltiplas listas para um sujeito do cuidado, cada uma gerenciada e priorizada por um médico, episódio de cuidado ou outro contexto específico. Por exemplo, uma Lista de problemas de um médico de atenção primária pode ter uma configuração bem diferente daquela que é útil para um cirurgião especialista ou para referência durante um episódio de internação hospitalar. Em atenção primária é comum organizar a Lista de problemas baseada em problemas ou diagnósticos ativos e inativos; especialistas podem preferir ver suas listas organizadas ao redor dos diagnósticos primários que estão relacionados às suas especialidades e secundariamente aqueles que não estão; e uma admissão hospitalar pode incluir aspectos adicionais relacionados a prioridades de enfermagem imediatas que podem não ser relevantes na alta domiciliar - para estes propósitos há um SLOT Status no arquétipo Problem/Diagnosis que permite o uso de um arquétipo que pode suportar sistemas clínicos para organizar as Listas de problemas de acordo com as preferências dos usuários clínicos dos sistemas, sem perpetuar estes rótulos de status contextuais para outros cenários clínicos. Este arquétipo é normalmente gerenciado como uma lista persistente, entretanto há situações em que a lista pode ser utilizada num contexto de cuidado episódico e requeira atributos adicionais como um contexto para permitir um registro acurado. Atualmente o modelo de referência openEHR apenas permite que o contexto seja registrado em arquétipos COMPOSITION baseados em Eventos. Como resultado este arquétipo vem sendo modelado como um Evento ao invés de Persistente, COMPOSITION para permitir a flexibilidade para que alguns sistemas clínicos possam gerenciar de maneira segura as Listas de problemas para episódios de cuidado, enquanto outros escolherão implementar este COMPOSITION para agir de maneira persistente."> keywords = <"lista", "problema", "diagnóstico", "procedimento", "lista de problemas"> misuse = <""> > ["nb"] = < language = <[ISO_639-1::nb]> purpose = <"For å registrere en varig og oppdaterbar liste over diagnoser som er identifisert, problemer som er erfart av individet eller tidligere prosedyrer som er utført som kan ha betydning for kliniske vurderinger og utøvelsen av helsehjelp."> use = <"Brukes som et foreslått rammeverk for å støtte konsistent modellering av en problemliste som en varig og oppdaterbar liste over diagnoser som er identifisert, problemer som er erfart av individet eller tidligere prosedyrer som er utført. Listen kan være kilde for en oppdatert problemliste for utveksling av data eller som basis for beslutningsstøtte. Listen kan bestå av tre typer utsagn representert med spesifikke arketyper: - utsagn om problemer, diagnoser eller tidligere prosedyrer registreres med arketypene EVALUATION.problem_diagnosis (Problem/diagnose) eller ACTION.procedure (Prosedyre). - utsagn om utelukkede problemer, diagnoser eller prosedyrer registreres i arketypene EVALUATION.exclusion-problem_diagnosis eller EVALUATION.exclusion-procedure. For eksempel: \"Ingen betydningsfulle problemer eller diagnoser\" eller \"Har ikke gjennomført noen betydningsfulle operasjonen eller prosedyrer\". - utsagn om at ingen informasjon er tilgjengelig, verken som bekreftede problemer, diagnoser eller prosedyrer eller som utelukkede problemer, diagnoser eller prosedyrer, kan registreres i arketypen EVALUATION.absence. For at denne listen skal være oppdatert og trygg å bruke i beslutningsstøtte og ved utveksling av data, bør problemlisten ideelt sett vedlikeholdes av klinikeren som er pasientansvarlig, i stedet for en automatisk håndtering ved hjelp av forretningslogikk alene. I et lukket klinisk system er det forventet at opphavet til denne problemlisten kan håndteres gjennom versjonering av denne COMPOSITION-arketypen og dens innhold, med opsjon for å også benytte en systembasert endringslogg. Det ideelle ville vært å kun ha en problemliste per pasient, men i en virkelighet med mange ulike systemer er det mer realistisk å forvente at en pasient vil ha flere ulike problemlister, som tas hånd om og prioriteres av klinikere i de ulike kontekstene. For eksempel vil en problemliste i primærhelsetjenesten ha et svært ulikt oppsett fra oppsettet som er nyttig for en spesialist i kirurgi under en innleggelse. I primærhelsetjenesten er det vanlig å organisere problemlisten basert på aktive eller inaktive problemer eller diagnoser. Spesialister kan foretrekke å se listen organisert rundt primærdiagnoser som er relatert til deres spesifikke spesialitet og sekundære som ikke er relatert. Ved en innleggelse kan ytterligere helseproblemer kreve sykepleietiltak som kun er aktuelle der og da, men som ikke er relevant når pasienten skrives ut fra sykehuset. Til dette kan man i arketypen Problem/diagnose legge til en CLUSTER-arketype i «Status» SLOTet. Kliniske systemer kan bruke denne til organisering av problemlisten slik den er foretrukket av klinikerene som bruker systemet. Man unngår dermed å legge til disse kontekstrelaterte merkelappene til andre kliniske scenarier. Denne arketypen er vanligvis organisert som en persistent liste, men det kan være situasjoner hvor listen kan brukes i en episodisk setting og vil trenge ytterligere attributter som kontekst osv. for å sikre presis registrering. OpenEHRs referansemodell tillater for øyeblikket bare at kontekst registreres i Event-baserte COMPOSITION-arketyper. Som resultat av dette er arketypen modellert som en Event heller enn en persistent COMPOSITON for å tillate fleksibilitet slik at de kliniske systemene på en sikker måte kan administrere problemlisten for omsorgsepisoder mens andre vil velge å implementere denne COMPOSITION-arketypen som en persistent arketype."> keywords = <"problem", "liste", "diagnose", "prosedyre", "problemliste"> misuse = <""> > > lifecycle_state = <"published"> other_contributors = <"Nadim Anani, Karolinska Institutet, Sweden", "Anne Pauline Anderssen, Helse Nord RHF, Norway", "Vebjørn Arntzen, Oslo universitetssykehus HF, Norway", "Koray Atalag, University of Auckland, New Zealand", "Silje Ljosland Bakke, Nasjonal IKT HF, Norway (Nasjonal IKT redaktør)", "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", "Kristian Heldal, Telemark Hospital Trust, Norway", "Lars Karlsen, DIPS ASA, Norway", "Lars Morgan Karlsen, DIPS ASA, Norway", "Shinji Kobayashi, Kyoto University, Japan", "Heather Leslie, Ocean Informatics, Australia (openEHR Editor)", "Hallvard Lærum, Oslo Universitetssykehus HF, Norway", "Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (openEHR Editor)", "Andrej Orel, Marand d.o.o., Slovenia", "Jussara Rotzsch, UNB, Brazil", "Line Sæle, Nasjonal IKT HF, Norway", "Rowan Thomas, St. Vincent's Hospital Melbourne, Australia", "Jon Tysdahl, Furst medlab AS, Norway", "John Tore Valand, Haukeland Universitetssjukehus, Norway (Nasjonal IKT redaktør)"> other_details = < ["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"] = <"openEHR Foundation"> ["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]."> ["current_contact"] = <"Heather Leslie, Ocean Informatics, heather.leslie@oceaninformatics.com"> ["original_namespace"] = <"org.openehr"> ["original_publisher"] = <"openEHR Foundation"> ["custodian_namespace"] = <"org.openehr"> ["MD5-CAM-1.0.1"] = <"92511DB5F76BD6F363F676664E27125F"> ["build_uid"] = <"05a4d635-0044-4265-ac9a-40b8cb026e4c"> ["revision"] = <"1.0.0"> > definition COMPOSITION[at0000] matches { -- Problem list category matches { DV_CODED_TEXT matches { defining_code matches {[openehr::433]} } } context matches { EVENT_CONTEXT matches { other_context matches { ITEM_TREE[at0006] matches { -- Tree items cardinality matches {0..*; unordered} matches { allow_archetype CLUSTER[at0008] occurrences matches {0..*} matches { -- Extension include archetype_id/value matches {/.*/} } } } } } } content cardinality matches {1..*; unordered} matches { allow_archetype EVALUATION[at0002] occurrences matches {0..*} matches { -- Problems, diagnoses, concerns or Health issue threads include archetype_id/value matches {/openEHR-EHR-EVALUATION\.problem_diagnosis(-[a-zA-Z0-9_]+)*\.v1/} } allow_archetype ACTION[at0003] occurrences matches {0..*} matches { -- Procedures include archetype_id/value matches {/openEHR-EHR-ACTION\.procedure(-[a-zA-Z0-9_]+)*\.v1/} } allow_archetype EVALUATION[at0004] occurrences matches {0..*} matches { -- Exclusion statements include archetype_id/value matches {/openEHR-EHR-EVALUATION\.exclusion-problem_diagnosis(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-EVALUATION\.exclusion-procedure(-[a-zA-Z0-9_]+)*\.v1/} } allow_archetype EVALUATION[at0005] occurrences matches {0..*} matches { -- Absent information include archetype_id/value matches {/openEHR-EHR-EVALUATION\.absence(-[a-zA-Z0-9_]+)*\.v1/} } allow_archetype SECTION[at0007] occurrences matches {0..*} matches { -- Other include archetype_id/value matches {/openEHR-EHR-SECTION\.problem_list(-[a-zA-Z0-9_]+)*\.v1/} } } } ontology term_definitions = < ["ar-sy"] = < items = < ["at0000"] = < text = <"قائمة المشكلات"> description = <"قائمة من المشكلات الصحية الحالية لهذا الشخص."> > ["at0002"] = < text = <"فعل"> description = <"*"> > ["at0003"] = < text = <"*Procedures(en)"> description = <"*Details about identified procedures that have been performed.(en)"> > ["at0004"] = < text = <"*Exclusion statements(en)"> description = <"*Positive statement about the exclusion of known problems or diagnoses and procedures performed.(en)"> comment = <"*For example: \"No significant problems or diagnoses\" or \"No history of significant operations or procedures\".(en)"> > ["at0005"] = < text = <"*Absent Information(en)"> description = <"*Positive statement that no information is available about identification of problems or diagnoses, nor procedures performed.(en)"> > ["at0006"] = < text = <"*Tree(en)"> description = <"*@ internal @(en)"> > ["at0007"] = < text = <"*ENTRY(en)"> description = <"**(en)"> > ["at0008"] = < text = <"*Extension(en)"> description = <"*Additional information required to capture local context or to align with other reference models/formalisms.(en)"> comment = <"*For example: Local hospital departmental infomation or additional metadata to align with FHIR or CIMI equivalents.(en)"> > > > ["en"] = < items = < ["at0000"] = < text = <"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."> > ["at0002"] = < text = <"Problems, diagnoses, concerns or Health issue threads"> description = <"Detail about identified problems, diagnoses, concerns or health issue threads."> > ["at0003"] = < text = <"Procedures"> description = <"Detail about identified procedures that have been performed."> > ["at0004"] = < text = <"Exclusion statements"> description = <"Positive statement about the exclusion of known problems or diagnoses and procedures performed."> comment = <"For example: \"No significant problems or diagnoses\" or \"No history of significant operations or procedures\"."> > ["at0005"] = < text = <"Absent information"> description = <"Positive statement that no information is available about identification of problems or diagnoses, nor procedures performed."> > ["at0006"] = < text = <"Tree"> description = <"@ internal @"> > ["at0007"] = < text = <"Other"> description = <"SLOT to contain SECTION archetypes which support alternative modelling patterns for Problem lists in specific clinical scenarios."> > ["at0008"] = < text = <"Extension"> description = <"Additional information required to capture local context or to align with other reference models/formalisms."> comment = <"For example: Local hospital departmental infomation or additional metadata to align with FHIR or CIMI equivalents."> > > > ["ko"] = < items = < ["at0000"] = < text = <"문제 목록"> description = <"확인된 진단이나 환자가 겪는 문제 또는 임상의사결정과 환자진료에 영향을 줄 수 있는 이전에 시행된 처치에 대한 영구적으로 관리되는 목록."> > ["at0002"] = < text = <"문제 또는 진단"> description = <"확인된 문제 또는 진단에 대한 상세내역"> > ["at0003"] = < text = <"처치"> description = <"시행된 적이 있는 확인된 처치에 대한 상세사항"> > ["at0004"] = < text = <"*Exclusion statements(en)"> description = <"*Positive statement about the exclusion of known problems or diagnoses and procedures performed.(en)"> comment = <"*For example: \"No significant problems or diagnoses\" or \"No history of significant operations or procedures\".(en)"> > ["at0005"] = < text = <"정보 없음"> description = <"문제나 진단 또는 시행된 처치를 확인하는데 있어서 이용가능한 정보가 없다는 진술문."> > ["at0006"] = < text = <"*Tree(en)"> description = <"*@ internal @(en)"> > ["at0007"] = < text = <"*ENTRY(en)"> description = <"**(en)"> > ["at0008"] = < text = <"*Extension(en)"> description = <"*Additional information required to capture local context or to align with other reference models/formalisms.(en)"> comment = <"*For example: Local hospital departmental infomation or additional metadata to align with FHIR or CIMI equivalents.(en)"> > > > ["pt-br"] = < items = < ["at0000"] = < text = <"Lista de problemas"> description = <"Uma lisa permanente e gerenciável de quaisquer combinações de diagnósticos, problemas e/ou procedimentos que possam influenciar o processo de tomada de decisão clínica e provisão de cuidado ao indivíduo."> > ["at0002"] = < text = <"Problemas, diagnósticos, preocupações ou tópicos relacionados à Saúde"> description = <"Detalhes sobre problemas, diagnósticos, preocupações ou tópicos relacionados à Saúde que foram identificados."> > ["at0003"] = < text = <"Pocedimentos"> description = <"Detalhes sobre procedimentos identificados que tenham sido realizados."> > ["at0004"] = < text = <"Declarações de exclusão"> description = <"Afirmação sobre exclusão de problemas ou diagnósticos conhecidos assim como de procedimentos realizados."> comment = <"Por exemplo: \"Ausência de problemas ou diagnósticos relevantes\" ou \"Ausência de história de cirurgias ou procedimentos relevantes\"."> > ["at0005"] = < text = <"Informação ausente"> description = <"Afirmação de que que não há informação disponível sobre a identificação de problemas ou diagnósticos nem de procedimentos realizados."> > ["at0006"] = < text = <"Tree"> description = <"@ internal @"> > ["at0007"] = < text = <"Outros"> description = <"SLOT para conter arquétipos SECTION que apoiam padrões de modelagem alternativos para Lista de Problemas em cenários clínicos específicos."> > ["at0008"] = < text = <"Extensão"> description = <"Informação adicional necessária para identificar contexto local ou alinhar com outros formalismos/modelos de referência."> comment = <"Por exemplo: informação departamental local de hospital ou metadados para alinhar com equivalentes FHIR ou CIMI."> > > > ["nb"] = < items = < ["at0000"] = < text = <"Problemliste"> description = <"En varig og oppdaterbar liste over en hvilken som helst kombinasjon av diagnoser, problemer og prosedyrer som kan ha betydning for klinisk beslutningsstøtte og utøvelsen av helsehjelp, ved at den kan presenteres i et system for å gi et raskt overblikk over et individs sykehistorie."> > ["at0002"] = < text = <"Problemer, diagnoser eller helseproblemer"> description = <"Detaljer om identifiserte problemer, diagnoser eller helseproblemer."> > ["at0003"] = < text = <"Prosedyrer"> description = <"Detaljer om identifiserte utførte prosedyrer."> > ["at0004"] = < text = <"Eksklusjonsutsagn"> description = <"Eksklusjonsutsagn om problemer, diagnoser og prosedyrer som er utført."> comment = <"For eksempel: \"Ingen betydningsfulle problemer eller diagnoser\" eller \"Har ikke gjennomgått noen betydningsfulle operasjoner eller prosedyrer\"."> > ["at0005"] = < text = <"Fravær av informasjon"> description = <"Utsagn om at ingen informasjon er tilgjengelig om problemer, diagnoser eller utførte prosedyrer."> > ["at0006"] = < text = <"Tree"> description = <"@ internal @"> > ["at0007"] = < text = <"Annet"> description = <"SLOT for ulike SECTION-arketyper som støtter alternative modelleringsmønstre for problemlister i spesifikke kliniske scenarier."> > ["at0008"] = < text = <"Tilleggsinformasjon"> description = <"Ytterligere informasjon som trengs for å kunne registrere lokalt definert innhold eller for å tilpasse til andre referansemodeller/formalismer."> comment = <"For eksempel lokale informasjonsbehov eller ytterligere metadata for å kunne tilpasse til tilsvarende konsepter i FHIR eller CIMI."> > > > >