ARCHETYPE Problem list (openEHR-EHR-SECTION.problem_list.v0)

Use to provide a framework and design guidance for consistent modelling of content within a template for a Problem list as 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 individual.

This archetype is intended to be used within the COMPOSITION.problem_list or as one component of other COMPOSITION archetypes. For example: complex documents, such as a discharge summary or referral.

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_global archetype - for example: 'No significant problems or diagnoses' and/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.

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, multiple Problem lists for a single individual may coexist, 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; an inpatient admission may include additional issues related to immediate nursing priorities that would not be relevant once discharged home. For these purposes, the CLUSTER.problem_qualifier archetype, nested within the Status SLOT in the Problem/Diagnosis archetype supports the use of qualifiers that will supprt 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.

In order for this list to be accurate and safe to use as the basis for decision support activities and for exchange, the content of 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.

• Licence: This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/.
• Custodian Organisation: openEHR Foundation
• References:
• Current Contact: Heather Leslie, Atomica Informatics
• Original Namespace: org.openehr
• Original Publisher: openEHR Foundation
• Custodian Namespace: org.openehr
• MD5-CAM-1.0.1: 8367D4F2CF2BA5BE59DC4442FD28C085
• Build Uid: 46c18c89-3428-4e56-8aaa-33e4907ea711
• Revision: 0.0.1-alpha

• alemany: Natalia Strauch, Medizinische Hochschule Hannover, Strauch.Natalia@mh-hannover.de
• espanyol (Argentina): Alan March, Hospital Universiatario Austral, Pilar, Buenos Aires, Argentina., alandmarch@gmail.com, MD
• portuguès (Brasil): Adriana Kitajima, Débora Farage, Fernanda Maia, Laíse Figueiredo, Marivan Abrahão, Core Consulting, contato@coreconsulting.com.br, Hospital Alemão Oswaldo Cruz (HAOC)