Diagnosis: Evaluation
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Concept

Archetype Id

Structure
A diagnosis defined by a clinician which is coded in an accepted terminology and may include the stage of the condition and the diagnostic criteria Id: openEHR-EHR-EVALUATION.problem-diagnosis.v1
Reference model: EHR
ADL, (ADL)

Data

Protocol
Data: TREE

Concept


Ordered

Description

Type

Cardinality

Values
Diagnosis (specialisation of: Problem) The index diagnosisCoded text
mandatory
1..1		 Terminology
Any term that 'is_a' diagnosis
Status The status of the diagnosisCoded text
optional
0..1		 provisional
working
Date of initial onset The date that the problem began causing symptoms or signsDate & Time
optional
0..1		 Date only
yyyy-??-??
Age at initial onset The age of the at the onset of the problemDuration
optional
0..1		 years, months, weeks, days, hours, minutes, seconds
Severity The severity of the index problemOrdinal
optional
0..1		 1, Mild
4, Moderate
7, Severe
Clinical description Description of the clinical aspects of the problemText
optional
0..1		 Free or coded text
Date clinically recognised Date the problem was recognised by cliniciansDate & Time
optional
0..1		 Partial date
yyyy-??-xx
Location, Location of the problem in terms of body site.       Cluster (0..*, ordered) optional, repeating
 

Concept

Description

Type

Cardinality

Values
Body site The body site affectedCoded text
optional
0..1		 Terminology
Any term that describes a body site
Location description A free text description of the location - may be in addition to a coded body siteText
optional
0..1		 Free or coded text
Aetiology, Agents or Factors known to have been of aetiological significance.       Cluster (0..1) optional
 

Concept

Description

Type

Cardinality

Values
Agent Microbial or other agent known to have caused this problemText
optional, repeating
0..*		 Free or coded text
Complication of A problem or link to a problem or injury described elsewhere in the EHRText
URI - resource identifier
optional, repeating
0..*		 Free or coded text
 
Description Description of aetiological processText
optional
0..1		 Free or coded text
Occurrences or exacerbations, Grouping of information about individual occurrences or exacerbations.       Cluster (0..1, ordered) optional
 

Concept

Description

Type

Cardinality

Values
Frequency of reccurrence The frequency of individual occurrences of the problemQuantity
optional
0..1		  
Date of last occurrence The date of the last occurrence or exacerbationDate & Time
optional
0..1		 Date only
yyyy-??-??
Occurence/exacerbation, Information about one occurrence or exacerbation.       Cluster (0..*) optional, repeating
 

Concept

Description

Type

Cardinality

Values
Clinical description A description of the exacerbation or occurrenceText
optional
0..1		 Free or coded text
Outcome Outcome of the occurrence or exacerbationText
optional
0..1		 Free or coded text
Date of onset of occurrence Date of onset of occurrence or exacerbationDate & Time
optional
0..1		 Date only
yyyy-??-??
Date of resolution of occurrence Date of the resolution of the occurrenceDate & Time
optional
0..1		 Date only
yyyy-??-??

Concept

Description

Type

Cardinality

Values
Number of occurrences Number of times this problem has occurred or been apparentCount
optional
0..1		 >= 1
Related problems, Complications that are attributed to this problem.       Cluster (0..1) optional
 
Related problem, A group of characteristics of the problem complicating the index condition in this archetype.       Cluster (0..*) optional, repeating
 

Concept

Description

Type

Cardinality

Values
Related problem Details of the problem as text or coded text or URIText
URI - resource identifier

Runtime name constraint:
{Problem, Complication}		optional
0..1		 Free or coded text
 
Clinical description Decription of the complicating problemText
optional
0..1		 Free or coded text

Concept


Ordered

Description

Type

Cardinality

Values
Date of resolution The date that the problem resolved or went into remissionDate & Time
optional
0..1		 Date only
yyyy-??-??
Age at resolution The age of the at the resolution of the problemDuration
optional
0..1		 years, months, weeks, days, hours, minutes, seconds
Diagnostic criteria, The criteria on which the diagnosis is based.       Cluster (0..1) optional
 

Concept

Description

Type

Cardinality

Values
Criterion A basis for the diagnosisText
optional, repeating
0..*		 Free or coded text
Clinical staging, The stage of the disease by clinical assessment.       Cluster (0..1, ordered) optional
 

Concept

Description

Type

Cardinality

Values
Stage The stage of the disease (not TNM staging)Text
optional
0..1		 Free or coded text
Tumour The extent of invasion of local tissueOrdinal
optional
0..1		 -1, Tx - primary tumour not assessed
0, T0 - no primary tumour
5, Tis - Carcinoma insitu
10, T1 - Micorinvasion (0.5cm)
20, T2 - Tumour invading 1 cm
30, T3 - Full thickness of structure
40, T5 - Invading adjacent structure
Nodes Extent of involvement of regional nodesOrdinal
optional
0..1		 -1, Nx - regional nodes not assessed
0, N0 - no regional nodes involved
10, N1 - Regional nodes involved
Metastases Extent of metastasesOrdinal
optional
0..1		 -1, Mx - metastases not assessed
0, M0 - No distant metastases
10, M1 - Distant metastases
Protocol: TREE
References, Useful information about this condition.       Cluster (0..1) optional
 

Concept

Description

Type

Cardinality

Values
References Reference to material about this conditionText
optional, repeating
0..*		 Free or coded text
Web link Useful information on the internet about this conditionURI - resource identifier
optional, repeating
0..*		  

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