ARCHETYPE Problema/Diagnòstic (openEHR-EHR-EVALUATION.problem_diagnosis.v1)

ARCHETYPE IDopenEHR-EHR-EVALUATION.problem_diagnosis.v1
ConceptProblema/Diagnòstic
DescriptionDetalls sobre una única condició de salut, lesió, discapacitat o qualsevol altre problema identificat que afecti al benestar físic, mental i/o social d'una persona.
UseÚs per registrar detalls sobre un problema de salut o diagnòstic únic identificat.
Misuse*Not to be used to record symptoms as described by the individual - use the CLUSTER.symptom archetype, usually within the OBSERVATION.story archetype. Not to be used to record examination findings - use the family of examination-related CLUSTER archetypes, usually nested within the OBSERVATION.exam archetype. Not to be used to record laboratory test results or related diagnoses, for example pathological diagnoses - use an appropriate archetype from the laboratory family of OBSERVATION archetypes. Not to be used to record imaging examination results or imaging diagnoses - use an appropriate archetype from the imaging family of OBSERVATION archetypes. Not to be used to record 'Differential Diagnoses' - use the EVALUATION.differential_diagnosis archetype. Not to be used to record 'Reason for Encounter' or 'Presenting Complaint' - use the EVALUATION.reason_for_encounter archetype. Not to be used to record procedures - use the ACTION.procedure archetype. Not to be used to record details about pregnancy - use the EVALUATION.pregnancy_bf_status and EVALUATION.pregnancy and related archetypes. Not to be used to record statements about health risk or potential problems - use the EVALUATION.health_risk archetype. Not to be used to record statements about adverse reactions, allergies or intolerances - use the EVALUATION.adverse_reaction archetype. Not to be used for the explicit recording of an absence (or negative presence) of a problem or diagnosis, for example ‘No known problem or diagnoses’ or ‘No known diabetes’. Use the EVALUATION.exclusion-problem_diagnosis archetype to express a positive statement about exclusion of a problem or diagnosis.(en)
PurposePer registrar detalls sobre un únic problema de salut o diagnòstic identificat.
ReferencesProblem/Diagnosis, Draft Archetype [Internet]. National eHealth Transition Authority, NEHTA Clinical Knowledge Manager [cited: 2015-03-12]. Available from: http://dcm.nehta.org.au/ckm/#showArchetype_1013.1.896.

ISO/DIS 13940 Health informatics -- System of concepts to support continuity of care., International Organization for Standardization [Internet]. Available at: http://www.iso.org/iso/catalogue_detail.htm?csnumber=58102 (accessed 2015 -04-09).

Common Terminology Criteria for Adverse Events (CTCAE) [Internet]. National Cancer Institute, USA. Available from: http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm (accessed 2015-07-13).

Weed LL. Medical records that guide and teach. N Engl J Med. 1968 Mar 14;278(11):593-600. PubMed PMID: 5637758. Available from: http://www.nejm.org/doi/full/10.1056/NEJM196803142781105 (accessed 2015-07-13).
AuthorsNom de l'autor: Sam Heard
Organització: Ocean Informatics
Correu electrònic: sam.heard@oceaninformatics.com
Data d'autor original: 2006-04-23
Other Details LanguageNom de l'autor: Sam Heard
Organització: Ocean Informatics
Correu electrònic: sam.heard@oceaninformatics.com
Data d'autor original: 2006-04-23
OtherDetails Language Independent{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=Problem/Diagnosis, Draft Archetype [Internet]. National eHealth Transition Authority, NEHTA Clinical Knowledge Manager [cited: 2015-03-12]. Available from: http://dcm.nehta.org.au/ckm/#showArchetype_1013.1.896. ISO/DIS 13940 Health informatics -- System of concepts to support continuity of care., International Organization for Standardization [Internet]. Available at: http://www.iso.org/iso/catalogue_detail.htm?csnumber=58102 (accessed 2015 -04-09). Common Terminology Criteria for Adverse Events (CTCAE) [Internet]. National Cancer Institute, USA. Available from: http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm (accessed 2015-07-13). Weed LL. Medical records that guide and teach. N Engl J Med. 1968 Mar 14;278(11):593-600. PubMed PMID: 5637758. Available from: http://www.nejm.org/doi/full/10.1056/NEJM196803142781105 (accessed 2015-07-13)., 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=F3BA1A6809F466FF10AB50CC86EC78C5, build_uid=5084c995-e34b-4832-aa41-b43ca3fe7fdf, revision=1.4.1}
Keywords*issue(en), *condition(en), *problem(en), *diagnosis(en), *concern(en), *injury(en), *clinical impression(en)
Lifecyclepublished
UIDcc3a20b3-8928-4c2a-babd-fe9e28987be7
Language usedca
Citeable Identifier1380.146.115
Revision Number1.4.1
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Detalls sobre una única condició de salut, lesió, discapacitat o qualsevol altre problema identificat que afecti al benestar físic, mental i/o social d'una persona., archetypeConceptComment=*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'.(en), otherContributors=Grethe Almenning, Bergen kommune, Norway
Tomas Alme, DIPS, Norway
Nadim Anani, Karolinska Institutet, Sweden
Erling Are Hole, Helse Bergen, Norway
Vebjørn Arntzen, Oslo universitetssykehus HF, Norway (Nasjonal IKT redaktør)
Koray Atalag, GALATA-Digital, New Zealand
Silje Ljosland Bakke, Helse Vest IKT AS, Norway (openEHR Editor)
John Bennett, NEHTA, Australia
Steve Bentley, Allscripts, United Kingdom
Lars Bitsch-Larsen, Haukeland University hospital, Norway
Terje Bless, Helse Nord FIKS, Norway
Fredrik Borchsenius, Oslo universitetssykehus, Norway
Ian Bull, ACT Health, Australia
Sergio Carmona, Chile
Rong Chen, Cambio Healthcare Systems, Sweden
Stephen Chu, Queensland Health, Australia
Ed Conley, Cardiff University, United Kingdom
Matthew Cordell, NEHTA, Australia
Inderjit Daphu, Helse Bergen, Norway
Paul Donaldson, Nursing Informatics Australia, Australia
Gail Easterbrook, Flinders Medical Centre, Australia
Aitor Eguzkitza, UPNA (Public University of Navarre) - CHN (Complejo Hospitalario de Navarra), Spain
Tone Engen, Norway
David Evans, Queensland Health, Australia
Arild Faxvaag, NTNU, Norway
Shahla Foozonkhah, Iran ministry of health and education, Iran
Einar Fosse, National Centre for Integrated Care and Telemedicine, Norway
Peter Garcia-Webb, Australia
Sebastian Garde, Ocean Informatics, Germany
Bente Gjelsvik, Helse Bergen, Norway
Andrew Goodchild, NEHTA, Australia
Anneke Goossen, Results 4 Care, Netherlands
Gyri Gradek, Senter for medisinsk genetikk og molekylærmedisin, Haukeland Universitetssykehus, Norway
Heather Grain, Llewelyn Grain Informatics, Australia
Trina Gregory, cpc, Australia
Bjørn Grøva, Diretoratet for e-helse, Norway
Dag Hanoa, Oslo universitetssykehus, Norway
Knut Harboe, Stavanger Universitetssjukehus, Norway
Sam Heard, Ocean Informatics, Australia
Ingrid Heitmann, Oslo universitetssykehus HF, Norway
Kristian Heldal, Telemark Hospital Trust, Norway
Andreas Hering, Helse Bergen HF, Haukeland universitetssjukehus, Norway
Anca Heyd, DIPS ASA, Norway
Hilde Hollås, DIPS AS, Norway
Evelyn Hovenga, EJSH Consulting, Australia
Eugene Igras, IRIS Systems, Inc., Canada
Lars Ivar Mehlum, Helse Bergen HF, Norway
Tom Jarl Jakobsen, Helse Bergen, Norway
Aud Jorunn Mjelstad, Helse Bergen, Norway
Gunnar Jårvik, Nasjonal IKT HF, Norway
Lars Morgan Karlsen, DIPS ASA, Norway
Mary Kelaher, NEHTA, Australia
Eizen Kimura, Ehime Univ., Japan
Shinji Kobayashi, NPO openEHR Japan, Japan
Robert L'egan, NEHTA, Australia
Sabine Leh, Haukeland University Hospital, Department of Pathology, Norway
Heather Leslie, Atomica Informatics, Australia (openEHR Editor)
Hugh Leslie, Ocean Informatics, Australia (Editor)
Hallvard Lærum, Norwegian Directorate of e-health, Norway
Luis Marco Ruiz, NST, Spain
Siv Marie Lien, DIPS ASA, Norway
Rohan Martin, Ambulance Victoria, Australia
David McKillop, NEHTA, Australia
Ian McNicoll, freshEHR Clinical Informatics, United Kingdom
Chris Mitchell, RACGP, Australia
Stewart Morrison, NEHTA, Australia
Jörg Niggemann, compugroup, Germany
Bjørn Næss, DIPS AS, Norway
Mona Oppedal, Helse Bergen, Norway
Andrej Orel, Marand d.o.o., Slovenia
Anne Pauline Anderssen, Helse Nord RHF, Norway
Chris Pearce, Melbourne East GP Network, Australia
Camilla Preeston, Royal Australian College of General Practitioners, Australia
Margaret Prichard, NEHTA, Australia
Jodie Pycroft, Adelaide Northern Division of General Practice Ltd, Australia
Cathy Richardson, NEHTA, Australia
Robyn Richards, NEHTA - Clinical Terminology, Australia
Jussara Rotzsch, Hospital Alemão Oswaldo Cruz, Brazil
Thomas Schopf, University Hospital of North-Norway, Norway
Thilo Schuler, Australia
Anoop Shah, University College London, United Kingdom
Arild Stangeland, Helse Bergen, Norway
Line Sæle, Nasjonal IKT HF, Norway
Line Sørensen, Helse Bergen, Norway
Gordon Tomes, Australian Institute of Health and Welfare, Australia
Richard Townley-O'Neill, NEHTA, Australia
Donna Truran, ACCTI-UoW, Australia
Jon Tysdahl, Furst medlab AS, Norway
John Tore Valand, Helse Vest IKT, Norway (openEHR Editor)
Kylie Young, The Royal Australian College of General Practitioners, Australia, originalLanguage=en, translators=
  • alemany: Aljoscha Kindermann, Jasmin Buck, Sebastian Garde, Natalia Strauch, Alina Rehberg, Universityhospital of Heidelberg, University of Heidelberg, Central Queensland University, Medizinische Hochschule Hannover, Strauch.Natalia@mh-hannover.de, rehberg.alina@mh-hannover.de
  • suec: Kirsi Poikela, Tieto Sweden AB, ext.kirsi.poikela@tieto.com
  • finès:
  • coreà: Seung-Jong Yu, InfoClinic Co.,Ltd., seungjong.yu@gmail.com, M.D.
  • portuguès (Brasil): Adriana Kitajima, Gabriela Alves, Maria Angela Scatena, Marivan Abrahäo, Core Consulting, contato@coreconsulting.com.br, Hospital Alemão Oswaldo Cruz (HAOC)
  • àrab (Síria): Mona Saleh
  • italià: Cecilia Mascia, CRS4 - Center for advanced studies, research and development in Sardinia, Pula (Cagliari), Italy, cecilia.mascia@crs4.it
  • xinès (RPC): Lin Zhang, Freelancer, linforest@163.com
  • espanyol (Espanya): Pablo Pazos, Julio de Sosa, CaboLabs, Servei Català de la Salut, juliodesosa@catsalut.cat, Computer Engineer
  • xinès: Yexuan Cheng, 浙江大学, 3160100913@zju.edu.cn
  • espanyol (Argentina): Alan March, Hospital Universitario Austral, Buenos Aires, Argentina, alandmarch@gmail.com, -
  • Bokmål noruec: Silje Ljosland Bakke, John Tore Valand, Liv Laugen, Vebjørn Arntzen, Helse Bergen HF, ​Oslo University Hospital, Norway, liv.laugen@ous-hf.no, varntzen@ous-hf.no
  • holandès: Joost Holslag, Nedap, joost.holslag@nedap.com, MD
  • català: Elisa Asensio, easensiob@clinic.cat
, subjectOfData=sense restriccions, archetypeTranslationTree=null, topLevelToAshis={contacts=[], other_participations=[], description=[], content=[], details=[], items=[], ism_transition=[], events=[], relationships=[], context=[], provider=[], identities=[], target=[], credentials=[], source=[], capabilities=[], data=[ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=2, text=Nom del Problema/Diagnòstic, description=Identificació del problema o diagnòstic, pel nom., comment=*Coding of the name of the problem or diagnosis with a terminology is preferred, where possible.(en), uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Obligatòria, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0079], code=at0079, itemType=ELEMENT, level=2, text=Variant, description=Variant o subtipus específic del Diagnòstic, si escau., comment=*For example: 'acute motor axonal neuropathy' as a variant of Guillain-Barre Syndrome. Coding of the name of the variant with a terminology is preferred, where possible. (en), uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Opcional, repetint, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0009], code=at0009, itemType=ELEMENT, level=2, text=Descripció clínica, description=Descripció narrativa del problema o diagnòstic., comment=*Use to provide background and context, including evolution, episodes or exacerbations, progress and any other relevant details, about the problem or diagnosis.(en), uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Opcional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0012], code=at0012, itemType=ELEMENT, level=2, text=Localització corporal, description=Identificació d'un lloc corporal per la localització del problema o diagnòstic., comment=*Coding of the name of the anatomical location with a terminology is preferred, where possible. Use this data element to record precoordinated anatomical locations. If the requirements for recording the anatomical location are determined at run-time by the application or require more complex modelling such as relative locations then use the CLUSTER.anatomical_location or CLUSTER.relative_location within the 'Structured anatomical location' SLOT in this archetype. Occurrences for this data element are unbounded to allow for clinical scenarios such as describing a rash in multiple locations but where all of the other attributes are identical. If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant.(en), uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Opcional, repetint, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0039], code=at0039, itemType=SLOT, level=2, text=Estructura corporal, description=Una localització anatòmica estructurada per al problema o diagnòstic., comment=*Use this SLOT to insert the CLUSTER.anatomical_location or CLUSTER.relative_location archetypes if the requirements for recording the anatomical location are determined at run-time by the application or require more complex modelling such as relative locations. If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, use of this SLOT becomes redundant.(en), uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Opcional, repetint, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Incloure:
openEHR-EHR-CLUSTER.anatomical_location.v1 i especialitzacions o
openEHR-EHR-CLUSTER.anatomical_location_circle.v1 o
openEHR-EHR-CLUSTER.anatomical_location_relative.v2 i especialitzacions, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0078], code=at0078, itemType=ELEMENT, level=2, text=Causa, description=Una causa, conjunt de causes o el mecanisme causal del problema o diagnòstic., comment=*Also known as 'aetiology' or 'etiology'. Coding with an external terminology is preferred, where possible.(en), uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Opcional, repetint, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0077], code=at0077, itemType=ELEMENT, level=2, text=Data/hora d'inici, description=Data/hora estimada o real en que es van observar per primera vegada els signes o símptomes del problema/diagnòstic., comment=*Data captured/imported as "Age at onset" should be converted to a date using the subject's date of birth.(en), uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Opcional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0003], code=at0003, itemType=ELEMENT, level=2, text=Data/hora del diagnòstic, description=Data/hora estimada o real en que un professional sanitari va declarar el diagnòstic o problema., comment=*Partial dates are acceptable. If the subject of care is under the age of one year, then the complete date or a minimum of the month and year is necessary to enable accurate age calculations - for example, if used to drive decision support. Data captured/imported as "Age at time of clinical recognition" should be converted to a date using the subject's date of birth.(en), uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Opcional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0005], code=at0005, itemType=ELEMENT, level=2, text=Severitat, description=Una avaluació de la severitat global del problema o diagnòstic., comment=*If severity is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant. Note: more specific grading of severity can be recorded using the Specific details SLOT.(en), uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Opcional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Elecció de:
  •  Coded Text
    • Lleu [El problema o diagnòstic no interfereix amb l'activitat normal ni pot causar danys a la salut si no es tracta.]
    • Moderada [El problema o diagnòstic interfereix amb l'activitat normal o pot causar danys a la salut si no es tracta.]
    • Greu [El problema o diagnòstic impedeix l'activitat normal o causarà danys greus a la salut si no es tracta.]
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0043], code=at0043, itemType=SLOT, level=2, text=Detalls específics, description=Detalls que es requereixen addicionalment per registrar atributs únics d'aquest problema o diagnòstic., comment=*May include structured detail about the grading or staging of the diagnosis; diagnostic criteria, classification criteria or formal severity assessments such as Common Terminology Criteria for Adverse Events.(en), uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Opcional, repetint, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Incloure:
Tots arquetips no exclosos explícitament, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0072], code=at0072, itemType=ELEMENT, level=2, text=Descripció del curs, description=Descripció narrativa sobre el curs del problema o diagnòstic des del inici., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Opcional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0030], code=at0030, itemType=ELEMENT, level=2, text=Data/hora de resolució, description=Data/hora estimada o real de resolució o remissió d'aquest problema o diagnòstic, determinada per un professional sanitari., comment=*Partial dates are acceptable. If the subject of care is under the age of one year, then the complete date or a minimum of the month and year is necessary to enable accurate age calculations - for example, if used to drive decision support. Data captured/imported as "Age at time of resolution" should be converted to a date using the subject's date of birth. (en), uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Opcional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0046], code=at0046, itemType=SLOT, level=2, text=Estat, description=Detalls estructurats per a aspectes específics d'ubicació, domini, episodi o flux de treball del procés diagnòstic., comment=*Use status or context qualifiers with care, as they are variably used in practice and interoperability cannot be assured unless usage is clearly defined with the community of use. For example: active status - active, inactive, resolved, in remission; evolution status - initial, interim/working, final; temporal status - current, past; episodicity status - first, new, ongoing; admission status - admission, discharge; or priority status - primary, secondary.(en), uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Opcional, repetint, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Incloure:
openEHR-EHR-CLUSTER.problem_qualifier.v2 i especialitzacions, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0073], code=at0073, itemType=ELEMENT, level=2, text=Certesa diagnòstica, description=El nivell de confiança en la identificació del diagnòstic., comment=*If an alternative valueset is required, these values can be added to the DV_TEXT data type in a template.(en), uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Opcional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Elecció de:
  •  Coded Text
    • Sospita [El diagnòstic s'ha identificat amb un nivell baix de certesa.]
    • Probable [El diagnòstic s'ha identificat amb un nivell alt de certesa.]
    • Confirmat [El diagnòstic s'ha confirmat en base a criteris reconeguts.]
  •  Text
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