ARCHETYPE Informe de resultats (openEHR-EHR-COMPOSITION.report-result.v1)

ARCHETYPE IDopenEHR-EHR-COMPOSITION.report-result.v1
ConceptInforme de resultats
DescriptionDocument per comunicar informació sobre el resultat d'una prova o avaluació.
Use

*Use as a generic archetype to carry information about the result of a stand-alone test or assessment, or a group of related results.

It is anticipated that each COMPOSITION.report-result archetype will contain at least one OBSERVATION archetype that will hold the test results, but depending on the complexity of the test or assessment other archetypes may also be included to provide the complete clinical context.

Common use cases are:

  • one or more specimen-related pathology/laboratory test results;
  • one or more time-related imaging examination test results;
  • an ECG result; or
  • an audiogram hearing assessment.

The main Sections/Content component has been deliberately left unconstrained. This will allow it to be populated with any SECTION or ENTRY archetypes appropriate for the clinical purpose within a template. (en)

MisuseNo s'ha d'utilitzar per a informes que no estiguin relacionats amb els resultats d'una prova o avaluació. Utilitzar el COMPOSITION.report genèric o COMPOSITIONs amb fins específics, segons escaigui. No s'ha d'utilitzar per als resultats de proves o avaluacions que es registren com a part d'una nota de consulta, per exemple, l'escala de coma de Glasgow en el context d'una consulta d'urgències - utilitzeu l'arquetip OBSERVATION.glasgow_coma_scale com a component dins de COMPOSITION.encouter.
PurposeArquetip contenidor genèric per transmetre informació sobre el resultat d'una prova o avaluació.
References
AuthorsNom de l'autor: Heather Leslie
Organització: Ocean Informatics
Correu electrònic: heather.leslie@oceaninformatics.com
Data d'autor original: 2012-12-11
Other Details LanguageNom de l'autor: Heather Leslie
Organització: Ocean Informatics
Correu electrònic: heather.leslie@oceaninformatics.com
Data d'autor original: 2012-12-11
Other Details (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
  • 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: BCC9F9AF2C01FAF0258B8743D079C8E7
  • Build Uid: 8d018ed5-232e-4a45-98e8-00d799383351
  • Revision: 1.1.0
Keywordsinforme, prova, resultat, diagnòstic
Lifecyclepublished
UID91731d1b-67b4-4b14-9d45-255315828bfe
Language usedca
Citeable Identifier1380.146.153
Revision Number1.1.0
context
ID de l'informeID de l'informe: Informació identificativa de l'informe.
EstatEstat: L´estat de tot l´informe. Nota: No és l'estat de cap dels components de l'informe.
*Multiple instances are allowed to represent different aspects or categories of status. (en)
AmpliacióAmpliació: *Additional information required to extend the model with local content or to align with other reference models or formalisms. (en)
*For example: local information requirements; or additional metadata to align with FHIR. (en)
Incloure:
Tots arquetips no exclosos explícitament
*Comment (en)*Comment (en): *A narrative statement concerning the diagnostic report as a whole. (en)
*For example: justification for a change or cancellation, recommended time frame for action, or a recommendation to repeat the investigation. (en)
data
Category
null
  • event
Other contributorsVebjørn Arntzen, Oslo University Hospital, Norway
Koray Atalag, University of Auckland, New Zealand
Silje Ljosland Bakke, Nasjonal IKT HF, Norway (openEHR Editor)
Sistine Barretto-Daniels, Ocean Informatics, Australia
Lars Bitsch-Larsen, Haukeland University hospital, Norway
Einar Fosse, National Centre for Integrated Care and Telemedicine, Norway
Heath Frankel, Ocean Informatics, Australia
Heather Grain, Llewelyn Grain Informatics, Australia
Sam Heard, Ocean Informatics, Australia
Lars Karlsen, DIPS ASA, Norway
Lars Morgan Karlsen, DIPS ASA, Norway
Shinji Kobayashi, Kyoto University, Japan
Heather Leslie, Atomica Informatics, Australia (openEHR Editor)
Hugh Leslie, Ocean Informatics, Australia
Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (openEHR Editor)
Bjoern Naess, DIPS ASA, Norway
Andrej Orel, Marand d.o.o., Slovenia
Translators
  • alemany: Antje Wulff/Sarah Ballout, Peter L. Reichertz Institute for Medical Informatics of TU BS and Hannover Medical School, antje.wulff@plri.de/ballout.sarah@mh-hannover.de
  • suec: Jörgen Kuylenstierna, Manna Vosta, Åsa Skagerhult, Liv Laugen, eWeave AB, Karolinska University Hospital, Region Östergötland, ​Oslo University Hospital, Norway, jorgen.kuylenstierna@solvikshalsan.se, manna.vosta@regionstockholm.se, asa.skagerhult@regionostergotland.se, liv.laugen@ous-hf.no
  • finès:
  • coreà: Seung-Jong Yu, InfoClinic Co.,Ltd., seungjong.yu@gmail.com, Certified Board of Family Medicine in South Korea
  • portuguès (Brasil): Adriana Kitajima, Débora Farage, Fernanda Maia, Laíse Figueiredo, Marivan Abrahão, Core Consulting, contato@coreconsulting.com.br, Hospital Alemão Oswaldo Cruz (HAOC)
  • àrab (Síria): Mona Saleh
  • italià: Francesca Frexia, CRS4 - Center for advanced studies, research and development in Sardinia, Pula (Cagliari), Italy, francesca.frexia@crs4.it
  • xinès (RPC): Lin Zhang, Freelancer, linforest@163.com
  • xinès: Yexuan Cheng, 浙江大学, 3160100913@zju.edu.cn
  • espanyol (Espanya): Clara Calleja Vega, CatSalut. Servei Català de la Salut., ccalleja@catsalut.cat
  • espanyol (Argentina): Alan March, Hospital Universitario Austral - Buenos Aires - Argentina, alandmarch@gmail.com, physician
  • Bokmål noruec: Kristian Berg, Line Silsand, Universitetssykehuset Nord-Norge, kristian.berg@unn.no, line.silsand@unn.no
  • eslovè: ?
  • català: Clara Calleja Vega, CatSalut. Servei Català de la Salut., ccalleja@catsalut.cat
    Altres col·laboradors: TRADCREA
  • holandès: Pieter Bos, Jelte Zeilstra, Nedap Healthcare