Norwegian openEHR Repository
Name
Transfer of care summary
Description
Summary document to support transfer of critical clinical information from the sending healthcare organisation/provider to the receiving healthcare organisation/provider.
Keywords
discharge summary
community
transfer
continuity
discharge
summary
care
Purpose
To share critical clinical information recorded by the sending healthcare organisation/provider to the healthcare organisation/provider who is taking over responsbility for provision of health care for the subject.
Use
Use to provide a summary clinical report about about an episode, or period, of care provided by a healthcare organisation or provider, to support continuity of care as the subject moves under the care or another healthcare organisation or provider, including a return to their original community. This document will typically convey information about events that occurred during the period of care, diagnoses, investigation results, management at discharge and plans for follow-up.
Typical senders of this report will be healthcare providers located within a clinical facility including, but not limited to:
- clinicians providing care during a hospital inpatient admission; and
- clinicians providing acute treatment or assessment as part of an emergency department visit.
Typical recipients of this report will be healthcare providers including, but not limited to:
- the subject's usual primary healthcare provider or health service;
- specialists, residential aged care or rehabilitation facility, welfare or community service provider; and
- all health professionals who need to participate in post-transfer care of the subject.
A discharge summary can be considered as a specific type of transfer of care summary.
Multiple transfer of care summaries may be required to accompany the subject in any single transfer, to ensure that the full breadth of medical, nursing and other care information is shared with the appropriate receiving healthcare providers.
Typical senders of this report will be healthcare providers located within a clinical facility including, but not limited to:
- clinicians providing care during a hospital inpatient admission; and
- clinicians providing acute treatment or assessment as part of an emergency department visit.
Typical recipients of this report will be healthcare providers including, but not limited to:
- the subject's usual primary healthcare provider or health service;
- specialists, residential aged care or rehabilitation facility, welfare or community service provider; and
- all health professionals who need to participate in post-transfer care of the subject.
A discharge summary can be considered as a specific type of transfer of care summary.
Multiple transfer of care summaries may be required to accompany the subject in any single transfer, to ensure that the full breadth of medical, nursing and other care information is shared with the appropriate receiving healthcare providers.
Misuse
Not to be used to represent the notes recorded as part of a single clinical encounters or visits. Use COMPOSITION.encounter for this purpose.
References
Derived from: <http://openehr.org/ckm/#showArchetype_1013.1.1970>
Archetype Id
openEHR-EHR-COMPOSITION.transfer_summary.v0
Copyright
© openEHR Foundation, Nasjonal IKT HF
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
Sistine Barretto-Daniels
Ocean Informatics Pty Ltd
Ocean Informatics Pty Ltd
Date Originally Authored
2012-01-30
| Language | Details |
|---|---|
| Norwegian Bokmal |
John Tore Valand, Terje Bless
Helse Bergen, Helse Nord FIKS
|
archetype (adl_version=1.4; uid=4d806c4a-0f1b-4cb1-9bf6-f08cb7911b07) openEHR-EHR-COMPOSITION.transfer_summary.v0 concept [at0000] -- Transfer of care summary language original_language = <[ISO_639-1::en]> translations = < ["nb"] = < language = <[ISO_639-1::nb]> author = < ["name"] = <"John Tore Valand, Terje Bless"> ["organisation"] = <"Helse Bergen, Helse Nord FIKS"> > > > description original_author = < ["name"] = <"Sistine Barretto-Daniels"> ["organisation"] = <"Ocean Informatics Pty Ltd"> ["email"] = <"Sistine.Barretto-Daniels@oceaninformatics.com"> ["date"] = <"2012-01-30"> > details = < ["en"] = < language = <[ISO_639-1::en]> purpose = <"To share critical clinical information recorded by the sending healthcare organisation/provider to the healthcare organisation/provider who is taking over responsbility for provision of health care for the subject."> use = <"Use to provide a summary clinical report about about an episode, or period, of care provided by a healthcare organisation or provider, to support continuity of care as the subject moves under the care or another healthcare organisation or provider, including a return to their original community. This document will typically convey information about events that occurred during the period of care, diagnoses, investigation results, management at discharge and plans for follow-up. Typical senders of this report will be healthcare providers located within a clinical facility including, but not limited to: - clinicians providing care during a hospital inpatient admission; and - clinicians providing acute treatment or assessment as part of an emergency department visit. Typical recipients of this report will be healthcare providers including, but not limited to: - the subject's usual primary healthcare provider or health service; - specialists, residential aged care or rehabilitation facility, welfare or community service provider; and - all health professionals who need to participate in post-transfer care of the subject. A discharge summary can be considered as a specific type of transfer of care summary. Multiple transfer of care summaries may be required to accompany the subject in any single transfer, to ensure that the full breadth of medical, nursing and other care information is shared with the appropriate receiving healthcare providers. "> keywords = <"discharge summary", "community", "transfer", "continuity", "discharge", "summary", "care"> misuse = <"Not to be used to represent the notes recorded as part of a single clinical encounters or visits. Use COMPOSITION.encounter for this purpose."> copyright = <"© openEHR Foundation, Nasjonal IKT HF"> > ["nb"] = < language = <[ISO_639-1::nb]> purpose = <"For å dele viktig klinisk informasjon registrert av avsendende helsetjenesteorganisasjon/utøver til mottakende helsetjenesteorganisasjon/utøver som overtar ansvar for utøvelse av helsetjenester for individet."> use = <"Brukes for å gi et sammendrag av en omsorgsepisode eller -periode for å støtte sammenhengende pasientforløp mellom ulike ytere av helsetjenester, samt tilbakeføring til pasientens opprinnelige omsorgsnivå. Dokumentet vil typisk inneholde informasjon om hendelser i løpet av en omsorgsperiode, diagnoser, resultat av undersøkelser, og videre oppfølging. En typisk avsender av rapporten kan være helsepersonell i en klinisk institusjon: - helsepersonell som yter helsetjenester under et sykehusopphold. - helsepersonell som utfører akutt behandling i forbindelse med et besøk på akuttmottak eller legevakt. En typisk mottaker av rapporten kan være helsepersonell som: - pasientens fastlege, eller dens vanlige yter av primærhelsetjenester. - spesialist, sykehjem, eller rehabiliteringsinstitusjon. - alt helsepersonell som deltar i pasientens omsorg etter overføring. Epikrise er en spesifikk form for sammendrag ved omsorgsoverføring. Det kan være nødvendig at flere sammendrag ved omsorgsoverføring følger pasienten i en enkelt omsorgsoverføring for å sikre at hele bredden av medisinsk-, sykepleie-, og annen omsorgsinformasjon blir delt med aktuell mottakende helsetjenesteyter."> keywords = <"utskrivingsnotat", "overføring", "forløp", "utskriving", "sammendrag", "omsorg"> misuse = <"Skal ikke brukes til å representere data registrert som del av en enkelt omsorgsepisode eller klinisk kontakt. Bruk COMPOSITION.encounter (\"Klinisk kontakt\") til dette formålet."> > > lifecycle_state = <"in_development"> other_contributors = <"Vebjoern Arntzen, Oslo university hospital, Norway", "Silje Ljosland Bakke, Bergen Hospital Trust, Norway (openEHR Editor)", "Lars Bitsch-Larsen, Haukeland University hospital, Norway", "Heather Grain, Llewelyn Grain Informatics, Australia", "Lars Karlsen, DIPS ASA, Norway", "Heather Leslie, Ocean Informatics, Australia (openEHR Editor)", "Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (openEHR Editor)", "Andrej Orel, Marand d.o.o., Slovenia", "Micaela Thierley, Helse Bergen, Norway"> 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"] = <"Nasjonal IKT"> ["references"] = <"Derived from: <http://openehr.org/ckm/#showArchetype_1013.1.1970>"> ["current_contact"] = <"Heather Leslie, Ocean Informatics<heather.leslie@oceaninformatics.com>"> ["original_namespace"] = <"no.nasjonalikt"> ["original_publisher"] = <"Nasjonal IKT"> ["custodian_namespace"] = <"no.nasjonalikt"> ["MD5-CAM-1.0.1"] = <"4CEC5C76364FBB737758D2B9C656BB3C"> ["build_uid"] = <"0894c031-b149-4773-aac2-1943b7591c70"> ["revision"] = <"0.0.1-alpha"> > definition COMPOSITION[at0000] matches { -- Transfer of care summary category matches { DV_CODED_TEXT matches { defining_code matches {[openehr::433]} } } context matches { EVENT_CONTEXT matches { other_context matches { ITEM_TREE[at0001] matches { -- Tree items cardinality matches {0..*; unordered} matches { allow_archetype CLUSTER[at0002] occurrences matches {0..*} matches { -- Extension include archetype_id/value matches {/openEHR-EHR-CLUSTER\.document_entry_metadata(-[a-zA-Z0-9_]+)*\.v1/} } } } } } } } ontology term_definitions = < ["en"] = < items = < ["at0000"] = < text = <"Transfer of care summary"> description = <"Summary document to support transfer of critical clinical information from the sending healthcare organisation/provider to the receiving healthcare organisation/provider."> > ["at0001"] = < text = <"Tree"> description = <"@ internal @"> > ["at0002"] = < 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."> > > > ["nb"] = < items = < ["at0000"] = < text = <"Sammendrag ved omsorgsoverføring"> description = <"Sammendragsdokument for å støtte overføring av kritisk klinisk informasjon fra avgivende helseinstitusjon eller helsetjenesteyter til mottakende helseinstitusjon eller helsetjenesteyter."> > ["at0001"] = < text = <"Tree"> description = <"@ internal @"> > ["at0002"] = < 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."> > > > >