Adverse reaction: Evaluation

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© Copyright openEHR Foundation 2007

Concept

Archetype Id

Structure

Recording the presence of a harmful or undesirable response to an agent or substance including food, as determined by the clinician - excluding poisoning and abnormal use

Id: openEHR-EHR-EVALUATION.adverse.v1
Reference model: EHR
ADL, (ADL)

Data

Protocol

Data: TREE

Concept	Description	Type	Cardinality	Values
Agent	The agent or substance or class that caused the adverse reaction	*Text*	mandatory 1..1	Free or coded text
Agent category	The category of the agent	*Coded text*	optional 0..1	Food Animal Medication Other chemical or substance Non-active ingredient of medication Imaging dye or media Environmental

Exposure and reaction detail, Details of the reaction experienced by the person. Cluster (0..*) optional, repeating

Concept	Description	Type	Cardinality	Values
Specific substance	The specific substance that caused the reaction if different from the agent (e.g. brands or members of a class)	*Text*	optional 0..1	Free or coded text
Reaction category	The type of reaction experience by the person as determined by the clinician	*Coded text*	optional 0..1	Intolerance Sensitivity Allergy No reaction
Probability of causation	Degree of certainty that the agent was the cause of the reaction	*Coded text*	optional 0..1	Certain/Highly likely Probable Possible
Date of exposure	The date (+/- time) when the person became exposed to the agent	*Date & Time*	optional 0..1	Allow all yyyy-??-??t??:??:??
Duration of the exposure	The duration of the exposure to the agent	*Duration*	optional 0..1	years, months, weeks, days, hours, minutes, seconds
Reaction severity	The category of the reaction for future reference	*Coded text*	optional 0..1	Mild Disabling Life threatening
Reaction description	A description of the reaction to this agent as experienced by the person	*Text*	mandatory 1..1	Free or coded text
Date of onset of reaction	The date the reaction began	*Date & Time*	optional 0..1	Allow all yyyy-??-??t??:??:??
Duration of the reaction	The duration of the reaction	*Quantity*	optional 0..1	Property = TIME

Generated by the Ocean HTML generator: 13/04/2007

Adverse reaction: Evaluation

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