Childrens Community Nursing - Holistic Assessment
Purpose
To record details of a Holistic Assessment
To record details of a Holistic Assessment
| Archetype Id | openEHR-EHR-COMPOSITION.report.v3 |
| Template ID | 8b419168-3fb2-4659-b49d-eac3fbbe9c45 |
| 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]
Holistic Assessment [0..*] Assessment date {2} [0..*] Date of assessment {2.1} [0..1]
Name of assessor {2.2} [0..1]
Name of assessor {2.2}: Field is expected to reference an externally defined directory service, listing details of the relevant professional"
Designation of assessor {2.3} [0..1]
Maintaining a safe environment for me {3} [0..*] 
Ability to maintain own safe environment {3.2} [0..*] 
Documented {3.2.1} [0..1]
New Issues {3.2.2} [1]
Influencing factors to safety e.g. nasogastric feeding / infection risks {3.3} [0..*] Documented {3.3.1} [0..1]
New Issues {3.3.2} [1]
My communication needs {4} [0..*] Visual {4.2} [0..*] Documented {4.2.1} [0..1]
New Issues {4.2.2} [1]
Auditory {4.3} [0..*] Documented {4.3.1} [0..1]
Auditory {4.3} [0..*] New Issues {4.3.2} [0..*]
[+/-] Speech / Mode of communication {4.4} [0..1]
New Issues {4.4.2} [0..1]
Documented {4.4.1} [0..1]
My breathing / circulation needs {5} [0..*] Pre-existing respiratory / cardiac anomalies {5.2} [0..*] Documented {5.2.1} [0..1]
New Issues {5.2.2} [1]
New Issues {5.2.2}: 410205005 | Respiratory care assessment | AND 408970004 | Circulatory care assessment |
Normal breathing pattern / skin colour {5.3} [0..*] Documented {5.3.1} [0..1]
New Issues {5.3.2} [1]
Ability to maintain core body temperature {5.4} [0..*] Documented {5.4.1} [0..1]
New Issues {5.4.2} [1]
Intervention / support required to maintain this activity {5.5} [0..*] Documented {5.5.1} [0..1]
New Issues {5.5.2} [0..1]
My eating and drinking routine e.g. assistance required / level of dependency {6} [0..*] Eating and drinking disorders {6.2} [0..*] Documented {6.2.1} [0..1]
New Issues {6.2.2} [1]
New Issues {6.2.2}: 410170008 | Nutrition care assessment |
Type of milk / regime {6.3} [0..*] Documented {6.3.1} [0..1]
New Issues {6.3.2} [0..1]
Gastrostomy Type {6.4} [0..1]
Size {6.4.1} [0..1]
Nasogastric tube {6.5} [0..1]
Size {6.5.1} [0..1]
Child's normal Ph reading {6.6} [0..1] [pH]
My eliminating needs {7} [0..*] Pre-existing Renal / Urinary conditions / Bowel Conditions {7.2} [0..*] Documented {7.2.1} [0..1]
New Issues {7.2.2} [1]
New Issues {7.2.2}: 385702002 | Bowel care assessment | AND 385960004 | Bladder care assessment |
Continence Status (including size of nappies / pads) {7.3} [0..*] Documented {7.3.1} [0..1]
New {7.3.2} [0..1]
New Issues {7.3.2} [0..1]
Intervention / support required to maintain this activity {7.4} [0..*] Documented {7.4.1} [0..1]
New Issues {7.4.2} [0..1]
My rest and sleep - sleep patterns, position and routine {8} [0..*] Regular sleep / rest times / routine {8.2} [0..*] Documented {8.2.1} [0..1]
New Issues {8.2.2} [0..1]
Intervention / support required to maintain this activity New Issues {8.3} [0..*] Documented {8.3.1} [0..1]
New Issues {8.3.2} [0..1]
My comfort and management of my pain {9} [0..*] Comforters used / Individual strategy {9.2} [0..*] Documented {9.2.1} [0..1]
New Issues {9.2.2} [1]
[+/-] Awareness and ability to respond to episodes of pain {9.3} [0..1]
Awareness and ability to respond to episodes of pain {9.3}: 410238001 | Pain control assessment |
New Issues {9.3.2} [0..1]
Documented {9.3.1} [0..1]
My movement and posture needs {10} [0..*] Level of dependency {10.2} [0..*] Documented {10.2.1} [0..1]
New Issues {10.2.2} [1]
Intervention / support required to maintain this activity {10.3} [0..*] Documented {10.3.1} [0..1]
New Issues {10.3.2} [0..1]
New Issues {10.3.2}: 398636004 | Physical activity assessment |
My education / play needs {11} [0..*] Details of educational support required {11.2} [0..*] Documented {11.2.1} [0..1]
New Issues {11.2.2} [0..1]
Details of activities enjoyed outside of school {11.3} [0..*] Documented {11.3.1} [0..1]
New {11.3.2} [0..1]
Intervention / support required to maintain this activity {11.4} [0..*] Documented {11.4.1} [0..1]
New Issues {11.4.2} [0..1]
My awareness of my own body image {12} [0..*] Factors influencing this {12.2} [0..*] Documented {12.2.1} [0..1]
New {12.2.2} [1]
New {12.2.2}: 247888008 | Awareness of self |
Intervention / support required to maintain this activity {12.3} [0..*] Documented {12.3.1} [0..1]
New {12.3.2} [0..1]
My personal hygiene and skincare needs {13} [0..*] Pre existing skin conditions {13.2} [0..*] Documented {13.2.1} [0..1]
New {13.2.2} [1]
New {13.2.2}: 410217007 | Personal care assessment |
Normal routine to meet hygiene skincare needs {13.3} [0..*] Documented {13.3.1} [0..1]
New {13.3.2} [0..1]
[+/-] Intervention / support required to maintain this activity {13.4} [0..1]
New {13.4.2} [0..1]
Documented {13.4.1} [0..1]
My prognosis / long term outcome {14} [0..*] Documented {14.1} [0..1]
New Issues {14.1.1} [0..1]
Specific wishes of the family {14.2} [0..*] Documented {14.2.1} [0..1]
New Issues {14.2.2} [0..1]
End of life plan {14.3} [0..*]
End of life plan {14.3}: 395103003 | Final days pathway |
New Issues {14.3.2} [0..1]
Documented {14.3.1} [0..1]