ARCHETYPE Informe (openEHR-EHR-COMPOSITION.report-procedure.v1)

ARCHETYPE IDopenEHR-EHR-COMPOSITION.report-procedure.v1
ConceptInforme
DescriptionDocument per comunicar informació a altres persones, normalment en resposta a una sol·licitud procedent d'una altra banda.
Use

*Use as a generic procedure-related archetype to carry information about any stand-alone procedure or operation performed.

It is anticipated that each COMPOSITION.report-procedure archetype will contain at least one ACTION.procedure (or related archetype) but depending on the complexity of the procedure it may contain a variety of other archetypes depending on the nature and complexity of the procedure performed. For example, archetypes to describe the associated anaesthetic or imaging activities carried out during the procedure.

Common use cases are:

  • any procedure that is not recorded as part of a consultation but needs to be carried out recorded as a stand-alone activity;
  • Endoscopy Report; through to a
  • complete Operation Report for an laparotomy or joint replacement.

Record of the anaesthetic used to cover the procedure will be recorded using purpose-specific archetypes. They can be committed to the health record at the same time as the Procedure report, most likely in one of two ways:

  • in a separate Anaesthetic report. This is most likely if the anaesthetic is administered by a separate clinician to the one performing the procedure; or
  • in the same Procedure report as the procedure is recorded. This is most likely if the anaesthetic was administered by the same clinician who performed the procedure.

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)

PurposeArquetip contenidor genèric usat per transmetre informació que s'ha de compartir amb altres.
References
AuthorsNom de l'autor: Heather Leslie
Organització: Ocean Informatics
Correu electrònic: heather.leslie@oceaninformatics.com
Data d'autor original: 2012-12-10
Other Details LanguageNom de l'autor: Heather Leslie
Organització: Ocean Informatics
Correu electrònic: heather.leslie@oceaninformatics.com
Data d'autor original: 2012-12-10
Other Details (Language Independent)
  • 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: 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: 5F29D55EB4B9405B18BE6721E2D54197
  • Build Uid: 35bf5acd-965c-4119-9ebb-ac45ab088931
  • Revision: 1.1.0
Keywordsinforme
Lifecyclepublished
UIDa8d1333d-63ef-4db0-958f-62643d0fa6c5
Language usedca
Citeable Identifier1380.146.261
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 contributorsVebjoern Arntzen, Oslo university hospital, Norway
Silje Ljosland Bakke, Bergen Hospital Trust, Norway (openEHR Editor)
Sistine Barretto-Daniels, Ocean Informatics, Australia
Lars Bitsch-Larsen, Haukeland University hospital, Norway
Heath Frankel, Ocean Informatics, Australia
Heather Grain, Llewelyn Grain Informatics, Australia
Sam Heard, Ocean Informatics, Australia
Lars Karlsen, DIPS ASA, Norway
Sabine Leh, Haukeland University Hospital, Department of Pathology, Norway
Heather Leslie, Ocean Informatics, Australia (openEHR Editor)
Hugh Leslie, Ocean Informatics, Australia
Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (openEHR Editor)
Andrej Orel, Marand d.o.o., Slovenia
Jussara Rotzsch, UNB, Brazil
Translators
  • alemany: Sarah Ballout, MHH-Hannover, ballout.sarah@mh-hannover.de
  • finès:
  • suec: Sofia Lång Janstad, Sofia Janstad, Sajjad Saffari, Henna Haapa Hybinette, Karolinska University Hospital, Stockholm Region, SLSO, Region Stockholm, sofia.lang-janstad@regionstockholm.se, sajjad.saffari-miandoab@regionstockholm.se, henna.haapa-hybinette@regionstockholm.se
  • coreà: Seung-Jong Yu, InfoClinic Co.,Ltd., seungjong.yu@gmail.com, Certified Board of Family Medicine in South Korea
  • portuguès (Brasil): Osmeire Chamelette Sanzovo, Hospital Sírio Libanês - SP, osmeire.acsanzovo@hsl.org.br
  • 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): Laura Moral Lopez, Sistema de Salut de Catalunya, lauramoral@catsalut.cat
  • Bokmål noruec: Vebjørn Arntzen; John Tore Valand, Oslo univeristetsykehus HF; Helse Bergen HF
  • espanyol (Argentina): Alan March, Hospital Universitario Austral - Buenos Aires - Argentina, alandmarch@gmail.com, physician
  • eslovè: ?
  • holandès: Pieter Bos, Jelte Zeilstra, Nedap Healthcare
  • català: Julio de Sosa, Servei Català de la Salut, juliodesosa@catsalut.cat