ARCHETYPE Precaution (openEHR-EHR-EVALUATION.precaution.v1)

ARCHETYPE IDopenEHR-EHR-EVALUATION.precaution.v1
ConceptPrecaution
DescriptionA condition or state of the individual that is clinically significant and unique or idiosyncratic for this individual, and is considered vital information when making treatment decisions.
UseUse to record a condition or state of the individual that is clinically significant and unique or idiosyncratic for this individual, and which are considered vital information when making treatment decisions. This archetype should be regarded as a critical archetype by any clinical decision support system testing for any relevant therapeutic precautions as a clinician commences a new clinical intervention for an individual. Examples of conditions that warrant creation of a precaution include, but are not limited to: - Immunosuppressed/on immunosuppressive therapy – linked to medication order for chemo or steroids; or diagnosis of leukaemia; - Renal failure – linked to renal function tests and/or a formal diagnosis of renal failure; - Waiting for organ transplant; - Undergoing a regular treatment such as radiation therapy or dialysis; - Transplanted organ or metal implant in situ; - Ongoing investigation or follow up of suspected or verified malignant disease; - Participation in a pharmacological trial; or - Using anticoagulant treatment.
MisuseNot to be used to record a clinical intervention (including, but not limited to, use of a treatment or performance of a test or procedure) that should not be carried out due to the likelihood, or possibility, of harm being caused to an individual. Use the EVALUATION.contraindication for this purpose. Not to be used to record decisions about limitations on the individuals care or future interventions or the individuals preferences of future medical treatment and care. Use EVALUATION.advance_intervention_decisions and EVALUATION.advance_care_directive respectively for this purpose.
PurposeTo record a condition or state of the individual that is clinically significant and unique or idiosyncratic for this individual, and is considered vital information when making treatment decisions.
References
Copyright© openEHR Foundation
AuthorsNom de l'autor: Silje Ljosland Bakke / John Tore Valand
Organització: Helse Vest IKT
Correu electrònic: silje.ljosland.bakke@helse-vest-ikt.no/ john.tore.valand@helse-vest-ikt.no
Data d'autor original: 2016-02-29
Other Details LanguageNom de l'autor: Silje Ljosland Bakke / John Tore Valand
Organització: Helse Vest IKT
Correu electrònic: silje.ljosland.bakke@helse-vest-ikt.no/ john.tore.valand@helse-vest-ikt.no
Data d'autor original: 2016-02-29
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, current_contact=Silje Ljosland Bakke, Helse Vest IKT, silje.ljosland.bakke@helse-vest-ikt.no, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=1F847D0C7A85E138BBBDEA568702B601, build_uid=504c8b10-ac7b-446d-8e1b-2efcc0d0828b, revision=1.1.0}
Keywordsprecaution, prevent, avoid, adverse event, prevention, caution, alert, warning
Lifecyclepublished
UID8e02deb2-7500-4703-81a3-e2bfb22c4bc2
Language useden
Citeable Identifier1380.146.306
Revision Number1.1.0
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=A condition or state of the individual that is clinically significant and unique or idiosyncratic for this individual, and is considered vital information when making treatment decisions., archetypeConceptComment=null, otherContributors=Morten Aas, Oslo Universitetssykehus, Norway
Tomas Alme, DIPS, Norway
Ole Andreas Bjordal, Webmed, Norway
Vebjørn Arntzen, Oslo universitetssykehus HF, Norway (Nasjonal IKT redaktør)
Silje Ljosland Bakke, Nasjonal IKT HF, Norway (openEHR Editor)
Lisbeth Dahlhaug, Helse Midt - Norge IT, Norway
Hildegard Franke, freshEHR Clinical Informatics Ltd., United Kingdom
Heather Grain, Llewelyn Grain Informatics, Australia
Cecilie Graver, Oslo universitetssykehus HF, Norway
Daniel Habashi, PasientSky AS, Norway
Annette Hole Sjøborg, DIPS ASA, Norway
Hilde Hollås, DIPS ASA, Norway
Evelyn Hovenga, EJSH Consulting, Australia
Tom Jarl Jakobsen, Helse Bergen, Norway
Lars Morgan Karlsen, DIPS ASA, Norway
Nils Kolstrup, Skansen Legekontor og Nasjonalt Senter for samhandling og telemedisin, Norway
Heather Leslie, Atomica Informatics, Australia (openEHR Editor)
Siv Marie Lien, DIPS ASA, Norway
Hildegard McNicoll, freshEHR Clinical Informatics Ltd., United Kingdom
Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (openEHR Editor)
Bjørn Næss, DIPS ASA, Norway
Andrej Orel, Marand d.o.o., Slovenia
Rune Pedersen, Universitetssykehuset i Nord Norge, Norway
Vladimir Pizzo, Hospital Sírio Libanês, Brazil
Tanja Riise, Nasjonal IKT HF, Norway
Anoop Shah, University College London, United Kingdom
Arild Stangeland, Helse Bergen, Norway
Norwegian Review Summary, Nasjonal IKT HF, Norway
Nyree Taylor, Ocean Informatics, Australia
Tesfay Teame, OUS, Norway
John Tore Valand, Helse Bergen, Norway, originalLanguage=en, translators=
  • suec: Daniel Hall, Region Östergötland, daniel.hall@regionostergotland.se
  • espanyol (Argentina): Alan March, Hospital Universitario Austral, amarch@cas.austral.edu.ar, MD
  • Bokmål noruec: Silje Ljosland Bakke og John Tore Valand, Helse Vest IKT, silje.ljosland.bakke@helse-vest-ikt.no, john.tore.valand@helse-vest-ikt.no
  • portuguès (Brasil): Débora Farage, Fernanda Maia, Laíse Figueiredo, Core Consulting, contato@coreconsulting.com.br, Hospital Alemão Oswaldo Cruz (HAOC)
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Tots arquetips no exclosos explícitament, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0006]/items[at0022], code=at0022, itemType=ELEMENT, level=2, text=Valid period start, description=Date/time after which the 'Condition' is regarded as active., comment=This data element is intended for use when a precaution is identified to start at some time in the future. For example: the commencement date for a pharmaceutical trial., 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=/protocol[at0006]/items[at0024], code=at0024, itemType=ELEMENT, level=2, text=Valid period end, description=Date/time after which the 'Condition' is regarded as inactive., comment=This data element is intended for use when a precaution is known to have a definitive end date/time in the future. For example: the cessation date for a pharmaceutical trial., 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=/protocol[at0006]/items[at0009], code=at0009, itemType=ELEMENT, level=2, text=Review date, description=Date when next due for review by a clinician., comment=In circumstances where precautions are not indefinite or life-long, use this data element to record the date/time when this precaution should be reassessed in the context of the clinical circumstances at the time., 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=/protocol[at0006]/items[at0004], code=at0004, itemType=ELEMENT, level=2, text=Last updated, description=Date when the precaution information was last updated., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Opcional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null]], description=[], items=[], content=[], source=[], identities=[], state=[], data=[ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=2, text=Condition, description=Identification, by name, of a condition or state., comment=Coding of the identified 'Condition' with a terminology is desirable, where possible., 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[at0014], code=at0014, itemType=ELEMENT, level=2, text=Status, description=Assertion about the current state of the identified 'Precaution'., comment=Decision support would typically raise alerts for 'Active' and ignore a 'Resolved' or 'Refuted' precaution. Clinical systems may choose not to display Precaution entries with a 'Refuted' status in the Precaution list. However, 'Refuted' may be useful for reconciliation of the Precaution list or when communicating between systems. Some implementations may choose to make this field mandatory. 'Resolved' may be used variably across systems, depending on clinical use and context. The free text data type will allow for local variation by enabling other value sets to be applied to this data element in a template - in this situation it is recommended that values should be coded using a terminology., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Opcional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Elecció de:
  •  Coded Text
    • Active [The precaution is currently active.]
    • Resolved [The previously asserted precaution has been clinically reassessed and considered no longer to be an active risk.]
    • Refuted [The precaution has been clinically reassessed or has been disproved with a high level of clinical certainty by testing.]
  •  Text
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openEHR-EHR-CLUSTER.clinical_evidence.v1, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0008], code=at0008, itemType=ELEMENT, level=2, text=Comment, description=Additional narrative about the precaution, not captured in other fields., 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]], ism_transition=[], details=[], provider=[], credentials=[]}, topLevelItems={data=ResourceSimplifiedHierarchyItem [path=ROOT_/data[at0001], code=at0001, itemType=ITEM_TREE, level=0, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Obligatòria, cardinalityFormal=0..1, cardinalityText=opcional, subCardinalityFormal=1..*, subCardinalityText=, dataType=ITEM_TREE, bindings=null, values=null, extendedValues=null], protocol=ResourceSimplifiedHierarchyItem [path=ROOT_/protocol[at0006], code=at0006, itemType=ITEM_TREE, level=0, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Obligatòria, cardinalityFormal=0..1, cardinalityText=opcional, subCardinalityFormal=0..*, subCardinalityText=Mínim de 0 elements, dataType=ITEM_TREE, bindings=null, values=null, extendedValues=null]}, addHierarchyItemsTo=protocol, currentHierarchyItemsForAdding=[ResourceSimplifiedHierarchyItem [path=/protocol[at0006]/items[at0020], code=at0020, itemType=SLOT, level=2, 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., 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=/protocol[at0006]/items[at0022], code=at0022, itemType=ELEMENT, level=2, text=Valid period start, description=Date/time after which the 'Condition' is regarded as active., comment=This data element is intended for use when a precaution is identified to start at some time in the future. For example: the commencement date for a pharmaceutical trial., 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=/protocol[at0006]/items[at0024], code=at0024, itemType=ELEMENT, level=2, text=Valid period end, description=Date/time after which the 'Condition' is regarded as inactive., comment=This data element is intended for use when a precaution is known to have a definitive end date/time in the future. For example: the cessation date for a pharmaceutical trial., 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=/protocol[at0006]/items[at0009], code=at0009, itemType=ELEMENT, level=2, text=Review date, description=Date when next due for review by a clinician., comment=In circumstances where precautions are not indefinite or life-long, use this data element to record the date/time when this precaution should be reassessed in the context of the clinical circumstances at the time., 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=/protocol[at0006]/items[at0004], code=at0004, itemType=ELEMENT, level=2, text=Last updated, description=Date when the precaution information was last updated., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Opcional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null]], minIndents={}, termBindingRetrievalErrorMessage=null]