Childrens Community Nursing - Clinical Referral Details
Purpose
To record the Clinical Referral Details
To record the Clinical Referral Details
| Archetype Id | openEHR-EHR-COMPOSITION.report.v3 |
| Template ID | d81f82c9-155a-4a44-9f16-93b33eb50e22 |
| MetaDataSet:UK - England NHS | |
| Acknowledgements | |
| Business Process Level | |
| Care setting | |
| Client group | |
| Clinical Record Element | |
| Copyright | Crown Copyright 2008 |
| Issues | |
| Owner | |
| Sign off | |
| Specialty | |
| User roles |
Report
Sign off {1} [0..1] [+/-] Author [0..1]
Name [0..1]
Date authored [0..1]
[+/-] Submitted by [0..1]
Name [0..1]
Date submitted [0..1]
[+/-] Authenticated by/ Senior professional responsible [0..1]
Name [0..1]
Date authenticated [0..1]
Clinical Referral Details [0..*] Referrer {2} [0..*] Reason {4.1} [0..1]
Name {2.1} [0..1]
Profession {2.1.1} [0..1]
Organisation {2.1.2} [1]
Contact number {2.1.3} [0..1]
Inpatient details {3} [0..*] 
Hospital contact details {3.2} [0..*] Name {3.2.3} [0..1]
Role {3.2.2} [0..1]
Base {3.2.4} [0..1]
Phone no: {3.2.5} [0..1]
Comments {3.2.6} [0..1]
Reason for referral {4} [0..*] My medical history {5} [0..*] Past medical history {5.1} [0..*] 
Documented diagnoses {5.2} [0..1]
Relevant diagnoses {5.3} [0..*] Diagnosis {5.3.1} [1]
Details {5.3.2} [0..1]
Past surgical history {5.4} [0..*] Documented surgical procedures {5.4.1} [0..1]
Surgical procedures {5.4.3} [0..*] Details {5.4.4} [1]
Allergies {5.5} [0..*] Documented allergies {5.5.1} [0..1]
Relevant allergies {5.5.2} [0..*] Allergies {5.5.3} [0..1]
Details {5.5.4} [0..1]
Current Medications {6} [0..*] Documented medications {6.1} [0..1]
Relevant medications {6.2} [0..*] Medication name {6.2.1} [1]
Details {6.2.2} [0..1]
Maintaining a safe environment for me {7} [0..*] 
Ability to maintain own safe environment {7.2} [0..*] Issues {7.2.1} [1]
Influencing factors to safety e.g. nasogastric feeding / infection risks {7.3} [0..*] Issues {7.3.1} [1]
My communication needs {8} [0..*] My breathing / circulation needs {9} [0..*] Pre-existing respiratory / cardiac anomalies {9.2} [0..*] Issues {9.2.1} [1]
Normal breathing pattern / skin colour {9.3} [0..*] Issues {9.3.1} [1]
Ability to maintain core body temperature {9.4} [0..*] Issues {9.4.1} [1]
Intervention / support required to maintain this activity {9.5} [0..*] Issues {9.5.1} [0..1]
My eating and drinking routine e.g. assistance required / level of dependency {10} [0..*] Eating and drinking disorders {10.2} [0..*] Issues {10.2.1} [1]
Type of milk / regime {10.3} [0..*] Issues {10.3.1} [0..1]
My elimination needs {11} [0..*] Pre-existing Renal / Urinary conditions / Bowel Conditions {11.2} [0..*] Issues {11.2.1} [1]
Continence Status (including size of nappies / pads) {11.3} [0..*] Issues {11.3.1} [0..1]
Intervention / support required to maintain this activity {11.4} [0..*] Issues {11.4.1} [0..1]
My rest and sleep - sleep patterns, position and routine {12} [0..*] Regular sleep / rest times / routine {12.2} [0..*] Issues {12.2.1} [0..1]
Intervention / support required to maintain this activity {12.3} [0..*] Issues {12.3.1} [0..1]
My comfort and management of my pain {13} [0..*] [+/-] Awareness and ability to respond to episodes of pain {13.3} [0..1]
Issues {13.3.1} [0..1]
[+/-] Comforters used / Individual strategy {13.2} [0..*]
Issues {13.2.1} [0..*]
My movement and posture needs {14} [0..*] Level of dependency {14.2} [0..*] Issues {14.2.1} [1]
Intervention / support required to maintain this activity {14.3} [0..*] Issues {14.3.1} [0..1]
My education / play needs {15} [0..*] Details of activities enjoyed outside of school {15.3} [0..*] Issues {15.3.1} [0..1]
[+/-] Details of educational support required {15.2} [0..1]
Issues {15.2.1} [0..1]
Intervention / support required to maintain this activity {15.4} [0..*] Issues {15.4.1} [0..1]
My awareness of my own body image {16} [0..*] Factors influencing this {16.2} [0..*] Issues {16.2.1} [1]
Intervention / support required to maintain this activity {16.3} [0..*] Issues {16.3.1} [0..1]
My personal hygiene and skincare needs {17} [0..*] Pre existing skin conditions {17.2} [0..*] Issues {17.2.1} [1]
[+/-] Normal routine to meet hygiene skincare needs {17.3} [0..*]
Issues {17.3.1} [0..1]
[+/-] Intervention / support required to maintain this activity {17.4} [0..1]
Issues {17.4.1} [0..1]
Referral outcome {18} [0..*] 