ARCHETYPE Symptom/Sign (openEHR-EHR-CLUSTER.symptom_sign.v2)

Name: Symptom/Sign
License: http://creativecommons.org/licenses/by-sa/4.0/

ARCHETYPE ID	openEHR-EHR-CLUSTER.symptom_sign.v2
Concept	Symptom/Sign
Description	Reported observation of a physical or mental disturbance in an individual.
Use	Use to record details about a single episode of a symptom or reported sign in an individual, as reported by the individual, parent, care-giver or other party. It may be recorded by a clinician as part of a clinical history record as reported to them, observed by the clinician or self-recorded as part of a clinical questionnaire or personal health record. A complete clinical history or patient story may include varying level of details about multiple episodes of an identified symptom or reported sign, as well as multiple symptoms/signs. This archetype has been designed to record the positive presence of the symptom or sign as part of history taking using OBSERVATION.story, or in conjunction with a positive response to OBSERVATION.symptom_sign_screening. In the purest sense, symptoms are subjective observations of a physical or mental disturbance and signs are objective observations of the same, as experienced by an individual and reported to the history taker by the same individual or another party. From this logic it follows that we will need two archetypes to record clinical history - one for reported symptoms and another for reported signs. In reality this is impractical as it will require clinical data entry into either one of these models which adds signficant overheads to modellers and those entering data. In addition, there is often overlap in clinical concepts - for example, is previous vomiting or bleeding to be categorised as a symptom or reported sign? In response, this archetype has been specifically designed to provide a single information model that allows for recording of the entire continuum between clearly identifiable symptoms and reported signs. This archetype has been intended to be used as a generic pattern for all symptoms and reported signs. The 'Specific details' SLOT can be used to extend the archetype to include additional, specific data elements for more complex symptoms or signs. This archetype has been specifically designed to be used in the 'Structured detail' SLOT within the OBSERVATION.story archetype, but can also be used within other OBSERVATION or CLUSTER archetypes and in the 'Associated symptom/sign' or 'Previous episode' SLOT within other instances of this CLUSTER.symptom_sign archetype.
Misuse	Not to be used to record screening questionnaire responses about the presence or absence of specific symptoms - use the OBSERVATION.symptom_sign_screening archetype for this purpose. However, this CLUSTER.symptom_sign archetype may be nested within the 'Screening details' SLOT in the OBSERVATION.symptom_sign_screening archetype if it is necessary to extend the questionnaire by recording details about symptom or sign. Not to be used to record that a symptom or sign was explicitly reported as not present - use CLUSTER.exclusion_symptom_sign carefully for specific purposes where the overheads of recording in this way warrant the additional complexity. Not to be used for recording objective findings as part of a physical examination - use OBSERVATION.exam and related examination CLUSTER archetypes for this purpose. Not to be used for diagnoses and problems that form part of a persisting Problem List - use EVALUATION.problem_diagnosis. Not to be used to record a formal and repeatable severity scale such as VAS or NRS. Use appropriate OBSERVATION archetypes for this purpose.
Purpose	To record details about a single episode of a reported symptom or sign including context, but not details, of previous episodes if appropriate.
References	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).
Copyright	© openEHR Foundation
Authors	Nom de l'autor: Tony Shannon Organització: UK NHS, Connecting for Health Correu electrònic: tony.shannon@nhs.net Data d'autor original: 2007-02-20
Other Details Language	Nom de l'autor: Tony Shannon Organització: UK NHS, Connecting for Health Correu electrònic: tony.shannon@nhs.net Data d'autor original: 2007-02-20
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 References: 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). 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: BE1FF729C2FD4185A0A51FDE33A48A52 Build Uid: 7b321c2c-f295-477d-84ce-6744e5353245 Ip Acknowledgements: This artefact includes content from SNOMED Clinical Terms® (SNOMED CT®) which is copyrighted material of the International Health Terminology Standards Development Organisation (IHTSDO). Where an implementation of this artefact makes use of SNOMED CT content, the implementer must have the appropriate SNOMED CT Affiliate license - for more information contact http://www.snomed.org/snomed-ct/get-snomed or info@snomed.org. Revision: 2.1.2
Keywords	complaint, symptom, disturbance, problem, discomfort, presenting complaint, presenting symptom, sign
Lifecycle	published
UID	88c7d677-fa69-498f-aec2-976c53d15a6f
Language used	en
Citeable Identifier	1380.146.92
Revision Number	2.1.2
items
Symptom/Sign name	Symptom/Sign name: The name of the reported symptom or sign. Symptom name should be coded with a terminology, where possible.
Body site	Body site: Simple body site where the symptom or sign was reported. Occurrences of this data element are set to 0..* to allow multiple body sites to be separated out in a template if desired. This allows for representation of clinical scenarios where a symptom or sign needs to be recorded in multiple locations or identifying both the originating and distal site in pain radiation, but where all of the other attributes such as impact and duration are identical. If the requirements for recording the body site 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 Detailed anatomical location' SLOT in this archetype. If the anatomical location is included in the Symptom name via precoordinated codes, this data element becomes redundant. If the anatomical location is recorded using the 'Structured body site' SLOT, then use of this data element is not allowed - record only the simple 'Body site' OR 'Structured body site', but not both.
Structured body site	Structured body site: Structured body site where the symptom or sign was reported. If the anatomical location is included in the Symptom name via precoordinated codes, use of this SLOT becomes redundant. If the anatomical location is recorded using the 'Body site' data element, then use of CLUSTER archetypes in this SLOT is not allowed - record only the simple 'Body site' OR 'Structured body site', but not both. Incloure: openEHR-EHR-CLUSTER.anatomical_location.v1 i especialitzacions o openEHR-EHR-CLUSTER.anatomical_location_circle.v1 i especialitzacions o openEHR-EHR-CLUSTER.anatomical_location_relative.v2 i especialitzacions Excloure: Tots no inclouen arquetips explícitament
Description	Description: Narrative description about the reported symptom or sign.
Episodicity	Episodicity: Category of this episode for the identified symptom or sign. at0176::New [A new episode of the symptom or sign - either the first ever occurrence or a reoccurrence where the previous episode had completely resolved.] at0178::Ongoing [This symptom or sign is ongoing, effectively a single, continuous episode.] at0177::Indeterminate [It is not possible to determine if this occurrence of the symptom or sign is new or ongoing.]
Occurrence	Occurrence: Type of occurrence for this symptom or sign? at0187::First occurrence [This is the first ever occurrence of this symptom or sign.] at0188::Recurrence [New occurrence of the same symptom or sign after a previous episode was resolved.]
Episode onset	Episode onset: The onset for this episode of the symptom or sign. While partial dates are permitted, the exact date and time of onset can be recorded, if appropriate. If this symptom or sign is experienced for the first time or is a re-occurrence, this date is used to represent the onset of this episode. If this symptom or sign is ongoing, this data element may be redundant if it has been recorded previously. Elecció de: Date/Time Interval of Date/Time
Onset timing	Onset timing: Timing of the onset and development of the symptom or sign. The type of the onset can be coded with a terminology, if desired. For example: gradual; or sudden. Elecció de: Text Duration Interval of Duration
Nadir	Nadir: Date/time when a monophasic, progressive symptom or sign reached its' maximal intensity or functional impact. For example: the date when neurological signs in Guillain-Barre disease was at its worst.
Episode duration	Episode duration: The duration of this episode of the symptom or sign since initial onset. If 'Date/time of onset' and 'Date/time of resolution' are used in systems, this data element may be calculated, or alternatively, be considered redundant in this scenario. The text data type is used for recording preset duration intervals such as '0-7 days, 1-2 weeks, 2 weeks or more'. Elecció de: Duration >=0 segons Interval of Duration Més baix: >=0 segons Superior: >=0 segons Text
Severity category	Severity category: Category representing the overall severity of the symptom or sign. Defining values such as mild, moderate or severe in such a way that is applicable to multiple symptoms or signs plus allows multiple users to interpret and record them consistently is not easy. Some organisations extend the value set further with inclusion of additional values such as 'Trivial' and 'Very severe', and/or 'Mild-Moderate' and 'Moderate-Severe', adds to the definitional difficulty and may also worsen inter-recorder reliability issues. Use of 'Life-threatening' and 'Fatal' is also often considered as part of this value set, although from a pure point of view it may actually reflect an outcome rather than a severity. In view of the above, keeping to a well-defined but smaller list is preferred and so the mild/moderate/severe value set is offered, however the choice of other text allows for other value sets to be included at this data element in a template. Elecció de: Coded Text at0023::Mild [The intensity of the symptom or sign does not cause interference with normal activity.] [SNOMED-CT::162468002 \| Symptom mild] at0024::Moderate [The intensity of the symptom or sign causes interference with normal activity.] [SNOMED-CT::162469005 \| Symptom moderate] at0025::Severe [The intensity of the symptom or sign causes prevents normal activity.] [SNOMED-CT::162470006 \| Symptom severe] Text
Severity rating	Severity rating: Numerical rating scale representing the overall severity of the symptom or sign. Symptom severity can be rated by the individual by recording a score for example from 0 (ie symptom not present) to 10 (ie symptom is as severe as the individual can imagine). Incloure: openEHR-EHR-CLUSTER.severity_rating_scale.v0 i especialitzacions o openEHR-EHR-CLUSTER.severity_rating_scale.v1 i especialitzacions
Character	Character: Word or short phrase describing the nature of the symptom or sign. For example: pain could be described as 'gnawing', 'burning', or 'like an electric shock'; a headache could be 'throbbing' or 'constant'. Coding with an external terminology is preferred, where possible.
Progression	Progression: Description progression of the symptom or sign at the time of reporting. Occurrences of this data element are set to 0..* to allow multiple types of progression to be separated out in a template if desired - for example, severity or frequency. The Text data type is added as an option, to support other value sets than the ones included in the archetype. Elecció de: Coded Text at0183::Worsening [The severity of the symptom or sign has worsened overall during this episode.] at0182::Unchanged [The severity of the symptom or sign has not changed overall during this episode.] at0181::Improving [The severity of the symptom or sign has improved overall during this episode.] at0184::Resolved [The severity of the symptom or sign has resolved.] Text
Pattern	Pattern: Narrative description about the pattern of the symptom or sign during this episode. For example: pain could be described as constant or intermittent.
Modifying factor	Modifying factor: Detail about how a specific factor effects the identified symptom or sign during this episode.
Factor	Factor: Name of the modifying factor. Examples of modifying factor: lying on multiple pillows, eating or administration of a specific medication.
Factor detail	Factor detail: Structured detail about the factor associated with the identified symptom or sign. Incloure: openEHR-EHR-CLUSTER.health_event.v0 i especialitzacions o openEHR-EHR-CLUSTER.symptom_sign.v1 i especialitzacions o openEHR-EHR-CLUSTER.symptom_sign.v2 i especialitzacions
Effect	Effect: Perceived effect of the modifying factor on the symptom or sign. at0159::Relieves [The factor decreases the severity or impact of the symptom or sign, but does not fully resolve it.] at0156::No effect [The factor has no impact on the symptom or sign.] at0158::Worsens [The factor increases the severity or impact of the symptom or sign.]
Description	Description: Narrative description of the effect of the modifying factor on the symptom or sign.
Precipitating factor	Precipitating factor: Details about specified factors that are associated with the precipitation of the symptom or sign. For example: lying down leads to heartburn; or walking up a hill leads to claudication.
Factor	Factor: Name of the health event, symptom, reported sign or other factor. For example: onset of another symptom; lying down; or walking up a hill.
Factor detail	Factor detail: Structured detail about the factor associated with the identified symptom or sign. Incloure: openEHR-EHR-CLUSTER.health_event.v0 i especialitzacions o openEHR-EHR-CLUSTER.symptom_sign.v1 i especialitzacions o openEHR-EHR-CLUSTER.symptom_sign.v2 i especialitzacions
Time interval	Time interval: The interval of time between the occurrence or onset of the factor and onset of the symptom or sign.
Description	Description: Narrative description about the effect of the factor on the identified symptom or sign.
Resolving factor	Resolving factor: Details about specified factors that are associated with the resolution of the symptom or sign. For example: upright posture stops heartburn; or resting stops claudication.
Factor	Factor: Name of the health event, symptom, reported sign or other factor. For example: upright posture; or resting.
Factor detail	Factor detail: Structured detail about the factor associated with the identified symptom or sign. Incloure: openEHR-EHR-CLUSTER.health_event.v0 i especialitzacions o openEHR-EHR-CLUSTER.symptom_sign.v1 i especialitzacions o openEHR-EHR-CLUSTER.symptom_sign.v2 i especialitzacions
Time interval	Time interval: The interval of time between the occurrence or onset of the factor and resolution of the symptom or sign.
Description	Description: Narrative description about the effect of the factor on the identified symptom or sign.
Impact	Impact: Description of the impact of this symptom or sign. Assessment of impact could consider the severity, duration and frequency of the symptom as well as the type of impact including, but not limited to, functional, social and emotional impact. Occurrences of this data element are set to 0..* to allow multiple types of impact to be separated out in a template if desired. Examples for functional impact from hearing loss may include: 'Difficulty Hearing in Quiet Environment'; 'Difficulty Hearing the TV or Radio'; 'Difficulty Hearing Group Conversation'; and 'Difficulty Hearing on Phone'.
Episode description	Episode description: Narrative description about the course of the symptom or sign during this episode. For example: a text description of the immediate onset of the symptom, activities that worsened or relieved the symptom, whether it is improving or worsening and how it resolved over weeks.
Specific details	Specific details: Specific data elements that are additionally required to record as unique attributes of the identified symptom or sign. For example: CTCAE grading. Incloure: Tots arquetips no exclosos explícitament
Resolution date/time	Resolution date/time: The timing of the cessation of this episode of the symptom or sign. If 'Date/time of onset' and 'Duration' are used in systems, this data element may be calculated, or alternatively, considered redundant. While partial dates are permitted, the exact date and time of resolution can be recorded, if appropriate.
Description of previous episodes	Description of previous episodes: Narrative description of any or all previous episodes. For example: frequency/periodicity - per hour, day, week, month, year; and regularity. May include a comparison to this episode.
Number of previous episodes	Number of previous episodes: The number of times this symptom or sign has previously occurred. min: >=0
Previous episodes	Previous episodes: Structured details of the symptom or sign during a previous episode. In linked clinical systems, it is possible that previous episodes are already recorded within the EHR. Systems can allow the clinician to LINK to relevant previous episodes. However in a system or message without LINKs to existing data or with a new patient, additional instances of the symptom archetype could be included here to represent previous episodes. It is recommended that new instances of the Symptom archetype inserted in this SLOT represent one or many previous episodes to this Symptom instance only. Incloure: openEHR-EHR-CLUSTER.symptom_sign.v1 i especialitzacions o openEHR-EHR-CLUSTER.symptom_sign.v2 i especialitzacions
Associated symptom/sign	Associated symptom/sign: Structured details about any associated symptoms or signs that are concurrent. In linked clinical systems, it is possible that associated symptoms or signs are already recorded within the EHR. Systems can allow the clinician to LINK to relevant associated symptoms/signs. However in a system or message without LINKs to existing data or with a new patient, additional instances of the symptom archetype could be included here to represent associated symptoms/signs. Incloure: openEHR-EHR-CLUSTER.symptom_sign.v1 i especialitzacions o openEHR-EHR-CLUSTER.symptom_sign.v2 i especialitzacions
Comment	Comment: Additional narrative about the symptom or sign not captured in other fields.
Other contributors	Grethe Almenning, Bergen kommune, Norway Tomas Alme, DIPS, Norway Erling Are Hole, Helse Bergen, Norway Vebjørn Arntzen, Oslo University Hospital, Norway Koray Atalag, University of Auckland, New Zealand Silje Ljosland Bakke, Helse Vest IKT AS, Norway (openEHR Editor) Lars Bitsch-Larsen, Haukeland University hospital, Norway Rong Chen, Cambio Healthcare Systems, Sweden Stephen Chu, Queensland Health, Australia Lisbeth Dahlhaug, Helse Midt - Norge IT, Norway Arild Faxvaag, NTNU, Norway Kåre Flø, DIPS ASA, Norway Einar Fosse, National Centre for Integrated Care and Telemedicine, Norway Samuel Frade, Marand, Portugal Sebastian Garde, Ocean Informatics, Germany Mikkel Gaup Grønmo, FSE, Helse Nord, Norway (Nasjonal IKT redaktør) Yves Genevier, Privantis SA, Switzerland Gyri Gradek, Senter for medisinsk genetikk og molekylærmedisin, Haukeland Universitetssykehus, Norway Heather Grain, Llewelyn Grain Informatics, Australia Dag Hanoa, Oslo universitetssykehus, Norway Knut Harboe, Stavanger Universitetssjukehus, Norway Sam Heard, Ocean Informatics, Australia Kristian Heldal, Telemark Hospital Trust, Norway Andreas Hering, Helse Bergen HF, Haukeland universitetssjukehus, Norway Anca Heyd, DIPS ASA, Norway Roar Holm, Helse Vest IKT A/S, Norway Evelyn Hovenga, EJSH Consulting, Australia Lars Ivar Mehlum, Nasjonal IKT HF, Norway Tom Jarl Jakobsen, Helse Bergen, Norway Hanne Joensen, Helse Bergen HUS, Norway Gunnar Jårvik, Nasjonal IKT HF, Norway Lars Karlsen, DIPS ASA, Norway Lars Morgan Karlsen, DIPS ASA, Norway Goran Karlstrom, County Of Värmland, Sweden Shinji Kobayashi, NPO openEHR Japan, Japan Nils Kolstrup, Skansen Legekontor og Nasjonalt Senter for samhandling og telemedisin, Norway Elisabeth Kvile, Fysioterapiavdelingen, Haukeland Universitets Sykehus, Norway Siri Laronningen, Kreftregisteret, Norway Sabine Leh, Haukeland University Hospital, Department of Pathology, Norway Heather Leslie, Atomica Informatics, Australia (openEHR Editor) Hallvard Lærum, Norwegian Directorate of e-health, Norway alberto maldonado, UPV, Spain Luis Marco Ruiz, Norwegian Center for Integrated Care and Telemedicine, Norway Siv Marie Lien, DIPS ASA, Norway Ian McNicoll, freshEHR Clinical Informatics, United Kingdom Bjoern Naess, DIPS ASA, Norway Bjørn Næss, DIPS ASA, Norway Andrej Orel, Marand d.o.o., Slovenia Anne Pauline Anderssen, Helse Nord RHF, Norway Magne Rekdal, DIPS AS, Norway Tanja Riise, Nasjonal IKT HF, Norway Jussara Rotzsch, Hospital Alemão Oswaldo Cruz, Brazil Thomas Schopf, University Hospital of North-Norway, Norway Anoop Shah, University College London, United Kingdom Hildegunn Siv Aase, Helse Bergen, Norway Arild Stangeland, Helse Bergen, Norway Norwegian Review Summary, Norwegian Public Hospitals, Norway Line Sæle, Nasjonal IKT HF, Norway Line Sørensen, Helse Bergen, Norway Nils Thomas Songstad, UNN HF, BUK, Barneavdelingen., Norway Rowan Thomas, St. Vincent's Hospital Melbourne, Australia Lene Thoresen, St. Olavs Hospital, Norway Jon Tysdahl, Furst medlab AS, Norway Till Uhlig, Nasjonal kompetansetjeneste for revmatologisk rehabilitering, Revmatologisk avd. , Diakonhjemmet Sykehus, Oslo, Norway John Tore Valand, Helse Bergen, Norway
Translators	alemany: Sebastian Garde, Kim Sommer, Natalia Strauch, Alina Rehberg, University of Heidelberg, Central Queensland University, Medizinische Hochschule Hannover, Strauch.Natalia@mh-hannover.de, rehberg.alina@mh-hannover.de finès: Kalle Vuorinen, Tieto Healthcare & Welfare Oy, kalle.vuorinen@tieto.com suec: Kirsi Poikela; Erik Sundvall, Jörgen Kuylenstierna, Tieto Sweden AB; Karolinska Institutet, Karolinska University Hospital, Region Stockholm + Linköping University, Karolinska Institutet + Karolinska University Hospital, Region Stockholm + Linköping University, eWeave AB, ext.kirsi.poikela@tieto.com, erik.sundvall@regionstockholm.se, jorgen.kuylenstierna@solvikshalsan.se Bokmål noruec: Lars Bitsch-Larsen, Silje Ljosland Bakke, Haukeland University Hospital of Bergen, Norway, Helse Vest IKT AS, lbla@helse-bergen.no, silje.ljosland.bakke@helse-vest-ikt.no, MD, DEAA, MBA, spec in anesthesia, spec in tropical medicine. portuguès (Brasil): Vladimir Pizzo, Hospital Sirio Libanes - Brazil, vladimir.pizzo@hsl.org.br àrab (Síria): Mona Saleh holandès: Joost Holslag, Nedap, joost.holslag@nedap.com, MD