OpenEHR Apperta Mirror
Name
Condition screening questionnaire
Description
An individual- or self-reported questionnaire screening for conditions, including problems, diagnoses and pregnancy.
Purpose
To record the responses to an individual- or self-reported questionnaire screening for conditions, including pregnancy.
Use
Use to record the responses to an individual- or self-reported questionnaire screening for conditions, including pregnancy.

Common use cases include, but are not limited to:
- Systematic questioning in any consultation; or
- Specific questioning related to infectious disease surveillance.
Misuse
Not to be used to record details about a specific condition as part of a typical clinical consultation. Use EVALUATION.problem_diagnosis for this purpose.
Archetype Id
openEHR-EHR-OBSERVATION.condition_screening.v0
Copyright
© Apperta 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
Heather Leslie
Atomica Informatics
Date Originally Authored
2020-03-13
Language Details
Norwegian Bokmal
Name Card Type Description
Screening purpose
0..1 DV_TEXT The reason for overall screening.
Comment
For example: pre-operative screening.
Presence of any conditions?
0..1 DV_CODED_TEXT Presence of any relevant conditions.
Constraint for DV_CODED_TEXT
  • Present
    [Conditions are present.]
  • Absent
    [Conditions are not present.]
  • Indeterminate
    [It is not possible to know if any conditions are present or absent.]
Specific condition
0..* CLUSTER Grouping of data elements related to screening for a single condition.
CLUSTER
Condition name
1..1 DV_TEXT Name of the condition being screened.
Presence?
0..1 DV_CODED_TEXT Presence of the condition.
Constraint for DV_CODED_TEXT
  • Present
    [The specific condition is present.]
  • Absent
    [The specific condition is not present.]
  • Indeterminate
    [It is not possible to know if the condition is present or absent.]
Onset
0..1 DV_DATE_TIME The date/time when the condition was first noticed by the individual or diagnosed by a clinician.
Comment
Partial dates are allowed.
Comment
0..1 DV_TEXT Additional narrative about the specific condition, not captured in other fields.
Pregnancy gestation
0..1
CHOICE OF
DV_DURATION
DV_CODED_TEXT
The date/time when any conditions were first noticed.
Comment
Partial dates are allowed.
DV_DURATION
Constraint for DV_CODED_TEXT
  • First trimester
    [Between first day of last period and the end of week 12.]
  • Second trimester
    [Between week 13 and week 28.]
  • Third trimester
    [After week 28.]
Additional details
0..* Slot (Cluster) Additional structured details related to condition screening.
Slot
Slot
Comment
0..1 DV_TEXT Additional narrative about the conditions, not captured in other fields.
Name Card Type Description
Extension
0..* Slot (Cluster) Additional information required to capture local content or to align with other reference models/formalisms.
Comment
For example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.
Slot
Slot
archetype (adl_version=1.4; uid=39d55839-4fb9-493a-bb0c-17478cf1903f)
	openEHR-EHR-OBSERVATION.condition_screening.v0

concept
	[at0000]	-- Condition screening questionnaire
language
	original_language = <[ISO_639-1::en]>
	translations = <
		["nb"] = <
			language = <[ISO_639-1::nb]>
			author = <
			>
		>
	>
description
	original_author = <
		["name"] = <"Heather Leslie">
		["organisation"] = <"Atomica Informatics">
		["email"] = <"heather.leslie@atomicainformatics.com">
		["date"] = <"2020-03-13">
	>
	details = <
		["nb"] = <
			language = <[ISO_639-1::nb]>
			purpose = <"*To record the responses to an individual- or self-reported questionnaire screening for conditions, including pregnancy.(en)">
			use = <"*Use to record the responses to an individual- or self-reported questionnaire screening for conditions, including pregnancy.

Common use cases include, but are not limited to:
- Systematic questioning in any consultation; or
- Specific questioning related to infectious disease surveillance.(en)">
			misuse = <"*Not to be used to record details about a specific condition as part of a typical clinical consultation. Use EVALUATION.problem_diagnosis for this purpose.(en)">
			copyright = <"© Apperta Foundation">
		>
		["en"] = <
			language = <[ISO_639-1::en]>
			purpose = <"To record the responses to an individual- or self-reported questionnaire screening for conditions, including pregnancy.">
			use = <"Use to record the responses to an individual- or self-reported questionnaire screening for conditions, including pregnancy.

Common use cases include, but are not limited to:
- Systematic questioning in any consultation; or
- Specific questioning related to infectious disease surveillance.">
			misuse = <"Not to be used to record details about a specific condition as part of a typical clinical consultation. Use EVALUATION.problem_diagnosis for this purpose.">
			copyright = <"© Apperta Foundation">
		>
	>
	lifecycle_state = <"in_development">
	other_contributors = <"Silje Ljosland Bakke, Helse Vest IKT AS, Norway (openEHR Editor)", "Ian McNicoll, freshEHR Clinical Informatics, UK", "Heather Leslie, Atomica Informatics, Australia (openEHR Editor)">
	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"] = <"Apperta UK">
		["original_namespace"] = <"uk.org.clinicalmodels">
		["original_publisher"] = <"Apperta UK">
		["custodian_namespace"] = <"uk.org.clinicalmodels">
		["MD5-CAM-1.0.1"] = <"AA14DED8BD27EC29A61AD73F44C380F1">
		["build_uid"] = <"6d3625eb-b19e-4fbc-9c3f-83197a286818">
		["revision"] = <"0.0.1-alpha">
	>

definition
	OBSERVATION[at0000] matches {    -- Condition screening questionnaire
		data matches {
			HISTORY[at0001] matches {    -- History
				events cardinality matches {0..*; unordered} matches {
					EVENT[at0002] occurrences matches {0..*} matches {    -- Any event
						data matches {
							ITEM_TREE[at0003] matches {    -- Tree
								items cardinality matches {0..*; unordered} matches {
									ELEMENT[at0034] occurrences matches {0..1} matches {    -- Screening purpose
										value matches {
											DV_TEXT matches {*}
										}
									}
									ELEMENT[at0028] occurrences matches {0..1} matches {    -- Presence of any conditions?
										value matches {
											DV_CODED_TEXT matches {
												defining_code matches {
													[local::
													at0031,    -- Present
													at0032,    -- Absent
													at0033]    -- Indeterminate
												}
											}
										}
									}
									CLUSTER[at0022] occurrences matches {0..*} matches {    -- Specific condition
										items cardinality matches {1..*; unordered} matches {
											ELEMENT[at0004] matches {    -- Condition name
												value matches {
													DV_TEXT matches {*}
												}
											}
											ELEMENT[at0005] occurrences matches {0..1} matches {    -- Presence?
												value matches {
													DV_CODED_TEXT matches {
														defining_code matches {
															[local::
															at0023,    -- Present
															at0024,    -- Absent
															at0027]    -- Indeterminate
														}
													}
												}
											}
											ELEMENT[at0006] occurrences matches {0..1} matches {    -- Onset
												value matches {
													DV_DATE_TIME matches {*}
												}
											}
											ELEMENT[at0035] occurrences matches {0..1} matches {    -- Comment
												value matches {
													DV_TEXT matches {*}
												}
											}
										}
									}
									ELEMENT[at0029] occurrences matches {0..1} matches {    -- Pregnancy gestation
										value matches {
											DV_DURATION matches {*}
											DV_CODED_TEXT matches {
												defining_code matches {
													[local::
													at0036,    -- First trimester
													at0037,    -- Second trimester
													at0038]    -- Third trimester
												}
											}
										}
									}
									allow_archetype CLUSTER[at0026] occurrences matches {0..*} matches {    -- Additional details
										include
											archetype_id/value matches {/.*/}
									}
									ELEMENT[at0025] occurrences matches {0..1} matches {    -- Comment
										value matches {
											DV_TEXT matches {*}
										}
									}
								}
							}
						}
					}
				}
			}
		}
		protocol matches {
			ITEM_TREE[at0007] matches {    -- Item tree
				items cardinality matches {0..*; unordered} matches {
					allow_archetype CLUSTER[at0021] occurrences matches {0..*} matches {    -- Extension
						include
							archetype_id/value matches {/.*/}
					}
				}
			}
		}
	}


ontology
	term_definitions = <
		["en"] = <
			items = <
				["at0000"] = <
					text = <"Condition screening questionnaire">
					description = <"An individual- or self-reported questionnaire screening for conditions, including problems, diagnoses and pregnancy.">
				>
				["at0001"] = <
					text = <"History">
					description = <"@ internal @">
				>
				["at0002"] = <
					text = <"Any event">
					description = <"Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.">
				>
				["at0003"] = <
					text = <"Tree">
					description = <"@ internal @">
				>
				["at0004"] = <
					text = <"Condition name">
					description = <"Name of the condition being screened.">
				>
				["at0005"] = <
					text = <"Presence?">
					description = <"Presence of the condition.">
				>
				["at0006"] = <
					text = <"Onset">
					description = <"The date/time when the condition was first noticed by the individual or diagnosed by a clinician.">
					comment = <"Partial dates are allowed.">
				>
				["at0007"] = <
					text = <"Item tree">
					description = <"@ internal @">
				>
				["at0021"] = <
					text = <"Extension">
					description = <"Additional information required to capture local content or to align with other reference models/formalisms.">
					comment = <"For example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.">
				>
				["at0022"] = <
					text = <"Specific condition">
					description = <"Grouping of data elements related to screening for a single condition.">
				>
				["at0023"] = <
					text = <"Present">
					description = <"The specific condition is present.">
				>
				["at0024"] = <
					text = <"Absent">
					description = <"The specific condition is not present.">
				>
				["at0025"] = <
					text = <"Comment">
					description = <"Additional narrative about the conditions, not captured in other fields.">
				>
				["at0026"] = <
					text = <"Additional details">
					description = <"Additional structured details related to condition screening.">
				>
				["at0027"] = <
					text = <"Indeterminate">
					description = <"It is not possible to know if the condition is present or absent.">
				>
				["at0028"] = <
					text = <"Presence of any conditions?">
					description = <"Presence of any relevant conditions.">
				>
				["at0029"] = <
					text = <"Pregnancy gestation">
					description = <"The date/time when any conditions were first noticed.">
					comment = <"Partial dates are allowed.">
				>
				["at0031"] = <
					text = <"Present">
					description = <"Conditions are present.">
				>
				["at0032"] = <
					text = <"Absent">
					description = <"Conditions are not present.">
				>
				["at0033"] = <
					text = <"Indeterminate">
					description = <"It is not possible to know if any conditions are present or absent.">
				>
				["at0034"] = <
					text = <"Screening purpose">
					description = <"The reason for overall screening.">
					comment = <"For example: pre-operative screening.">
				>
				["at0035"] = <
					text = <"Comment">
					description = <"Additional narrative about the specific condition, not captured in other fields.">
				>
				["at0036"] = <
					text = <"First trimester">
					description = <"Between first day of last period and the end of week 12.">
				>
				["at0037"] = <
					text = <"Second trimester">
					description = <"Between week 13 and week 28.">
				>
				["at0038"] = <
					text = <"Third trimester">
					description = <"After week 28.">
				>
			>
		>
		["nb"] = <
			items = <
				["at0000"] = <
					text = <"Spørreskjema for screening av tilstander">
					description = <"*An individual- or self-reported questionnaire screening for conditions, including problems, diagnoses and pregnancy.(en)">
				>
				["at0001"] = <
					text = <"History">
					description = <"@ internal @">
				>
				["at0002"] = <
					text = <"Uspesifikk hendelse">
					description = <"*Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.(en)">
				>
				["at0003"] = <
					text = <"Tree">
					description = <"@ internal @">
				>
				["at0004"] = <
					text = <"Navn på tilstand">
					description = <"*Name of the condition being screened.(en)">
				>
				["at0005"] = <
					text = <"Tilstede?">
					description = <"*Presence of the condition.(en)">
				>
				["at0006"] = <
					text = <"Debut">
					description = <"*The date/time when the condition was first noticed by the individual or diagnosed by a clinician.(en)">
					comment = <"*Partial dates are allowed.(en)">
				>
				["at0007"] = <
					text = <"Item tree">
					description = <"@ internal @">
				>
				["at0021"] = <
					text = <"Tilleggsinformasjon">
					description = <"*Additional information required to capture local content or to align with other reference models/formalisms.(en)">
					comment = <"*For example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.(en)">
				>
				["at0022"] = <
					text = <"Spesifikk tilstand">
					description = <"*Grouping of data elements related to screening for a single condition.(en)">
				>
				["at0023"] = <
					text = <"Tilstede">
					description = <"*The specific condition is present.(en)">
				>
				["at0024"] = <
					text = <"Fraværende">
					description = <"*The specific condition is not present.(en)">
				>
				["at0025"] = <
					text = <"Kommentar">
					description = <"*Additional narrative about the conditions, not captured in other fields.(en)">
				>
				["at0026"] = <
					text = <"Ytterligere detaljer">
					description = <"*Additional structured details related to condition screening.(en)">
				>
				["at0027"] = <
					text = <"Ubestemmelig">
					description = <"*It is not possible to know if the condition is present or absent.(en)">
				>
				["at0028"] = <
					text = <"Er det noen tilstander tilstede?">
					description = <"*Presence of any relevant conditions.(en)">
				>
				["at0029"] = <
					text = <"Tidspunkt i svangerskap">
					description = <"*The date/time when any conditions were first noticed.(en)">
					comment = <"*Partial dates are allowed.(en)">
				>
				["at0031"] = <
					text = <"Tilstede">
					description = <"*Conditions are present.(en)">
				>
				["at0032"] = <
					text = <"Fraværende">
					description = <"*Conditions are not present.(en)">
				>
				["at0033"] = <
					text = <"Ubestemmelig">
					description = <"*It is not possible to know if any conditions are present or absent.(en)">
				>
				["at0034"] = <
					text = <"Formål med screeningen">
					description = <"*The reason for overall screening.(en)">
					comment = <"*For example: pre-operative screening.(en)">
				>
				["at0035"] = <
					text = <"Kommentar">
					description = <"*Additional narrative about the specific condition, not captured in other fields.(en)">
				>
				["at0036"] = <
					text = <"*First trimester(en)">
					description = <"*Between first day of last period and the end of week 12.(en)">
				>
				["at0037"] = <
					text = <"*Second trimester(en)">
					description = <"*Between week 13 and week 28.(en)">
				>
				["at0038"] = <
					text = <"*Third trimester(en)">
					description = <"*After week 28.(en)">
				>
			>
		>
	>