ARCHETYPE Problem/Diagnosis (openEHR-EHR-EVALUATION.problem_diagnosis.v0)

ARCHETYPE IDopenEHR-EHR-EVALUATION.problem_diagnosis.v0
ConceptProblem/Diagnosis
DescriptionDetails about a single identified health condition, injury, disability or any other issue which impacts on the physical, mental and/or social well-being of an individual.
UseUse for recording details about a single, identified health problem or diagnosis. Clear definitions that enable differentiation between a 'problem' and a 'diagnosis' are almost impossible in practice - we cannot reliably tell when a problem should be regarded as a diagnosis. When diagnostic or classification criteria are successfully met, then we can confidently call the condition a formal diagnosis, but prior to these conditions being met and while there is supportive evidence available, it can also be valid to use the term 'diagnosis'. The amount of supportive evidence required for the label of diagnosis is not easy to define and in reality probably varies from condition to condition. Many standards committees have grappled with this definitional conundrum for years without clear resolution. For the purposes of clinical documentation with this archetype, problem and diagnosis are regarded as a continuum, with increasing levels of detail and supportive evidence usually providing weight towards the label of 'diagnosis'. In this archetype it is not neccessary to classify the condition as a 'problem' or 'diagnosis'. The data requirements to support documentation of either are identical, with additional data structure required to support inclusion of the evidence if and when it becomes available. Examples of problems include: the individual's expressed desire to lose weight, but without a formal diagnosis of Obesity; or a relationship problem with a family member. Examples of formal diagnoses would include a cancer that is supported by historical information, examination findings, histopathological findings, radiological findings and meets all requirements for known diagnostic criteria. In practice, most problems or diagnoses do not sit at either end of the problem-diagnosis spectrum, but somewhere in between. This archetype can be used within many contexts. For example, recording a problem or a clinical diagnosis during a clinical consultation; populating a persistent Problem List; or to provide a summary statement within a Discharge Summary document. In practice, clinicians use many context-specific qualifiers such as past/present, primary/secondary, active/inactive, admission/discharge etc. The contexts can be location-, specialisation-, episode- or workflow-specific, and these can cause confusion or even potential safety issues if perpetuated in Problem Lists or shared in documents that are outside of the original context. These qualifiers can be archetyped separately and included in the ‘Status’ slot, because their use varies in different settings. It is expected that these will be used mostly within the appropriate context and not shared out of that context without clear understanding of potential consequences. For example, a primary diagnosis to one clinician may be a secondary one to another specialist; an active problem can become inactive (or vice versa) and this can impact the safe use of clinical decision support. In general these qualifiers should be applied locally within the context of the clinical system, and in practice these statuses should be manually curated by clinicians to ensure that lists of Current/Past, Active/Inactive or Primary/Secondary Problems are clinically accurate. This archetype will be used as a component within the Problem Oriented Medical Record as described by Larry Weed. Additional archetypes, representing clinical concepts such as condition as an overarching organiser for diagnoses etc, will need to be developed to support this approach. In some situations, it may be assumed that identification of a diagnosis fits only within the expertise of physicians, but this is not the intent for this archetype. Diagnoses can be recorded using this archetype by any healthcare professional.
MisuseNot to be used to record symptoms as described by the individual - use the CLUSTER.symptom archetype, usually within the OBSERVATION.story archetype. Not to be used to record examination findings - use the family of examination-related CLUSTER archetypes, usually nested within the OBSERVATION.exam archetype. Not to be used to record laboratory test results or related diagnoses, for example pathological diagnoses - use an appropriate archetype from the laboratory family of OBSERVATION archetypes. Not to be used to record imaging examination results or imaging diagnoses - use an appropriate archetype from the imaging family of OBSERVATION archetypes. Not to be used to record 'Differential Diagnoses' - use the EVALUATION.differential_diagnosis archetype. Not to be used to record 'Reason for Encounter' or 'Presenting Complaint' - use the EVALUATION.reason_for_encounter archetype. Not to be used to record procedures - use the ACTION.procedure archetype. Not to be used to record details about pregnancy - use the EVALUATION.pregnancy_bf_status and EVALUATION.pregnancy and related archetypes. Not to be used to record statements about health risk or potential problems - use the EVALUATION.health_risk archetype. Not to be used to record statements about adverse reactions, allergies or intolerances - use the EVALUATION.adverse_reaction archetype. Not to be used for the explicit recording of an absence (or negative presence) of a problem or diagnosis, for example ‘No known problem or diagnoses’ or ‘No known diabetes’. Use the EVALUATION.exclusion-problem_diagnosis archetype to express a positive statement about exclusion of a problem or diagnosis.
PurposeFor recording details about a single, identified health problem or diagnosis. The intended scope of a health problem is deliberately kept loose in the context of clinical documentation, so as to capture any real or perceived concerns that may adversely affect an individual's wellbeing to any degree. A health problem may be identified by the individual, a carer or a healthcare professional. However, a diagnosis is additionally defined based on objective clinical criteria, and usually determined only by a healthcare professional.
ReferencesDerived from: <Add reference to original resource here>
Problem/Diagnosis, Draft Archetype [Internet]. National eHealth Transition Authority, NEHTA Clinical Knowledge Manager [cited: 2015-03-12]. Available from: http://dcm.nehta.org.au/ckm/#showArchetype_1013.1.896.

ISO/DIS 13940 Health informatics -- System of concepts to support continuity of care., International Organization for Standardization [Internet]. Available at: http://www.iso.org/iso/catalogue_detail.htm?csnumber=58102 (accessed 2015 -04-09).

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).

Weed LL. Medical records that guide and teach. N Engl J Med. 1968 Mar 14;278(11):593-600. PubMed PMID: 5637758. Available from: http://www.nejm.org/doi/full/10.1056/NEJM196803142781105 (accessed 2015-07-13).
Copyright© openEHR Foundation, HiGHmed
AuthorsAuthor name: Sam Heard
Organisation: Ocean Informatics
Email: sam.heard@oceaninformatics.com
Date originally authored: 2006-04-23
Other Details LanguageAuthor name: Sam Heard
Organisation: Ocean Informatics
Email: sam.heard@oceaninformatics.com
Date originally authored: 2006-04-23
OtherDetails Language Independent{licence=This work is licensed under the Creative Commons Attribution-ShareAlike 3.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/3.0/., custodian_organisation=HiGHmed, references=Derived from: Problem/Diagnosis, Draft Archetype [Internet]. National eHealth Transition Authority, NEHTA Clinical Knowledge Manager [cited: 2015-03-12]. Available from: http://dcm.nehta.org.au/ckm/#showArchetype_1013.1.896. ISO/DIS 13940 Health informatics -- System of concepts to support continuity of care., International Organization for Standardization [Internet]. Available at: http://www.iso.org/iso/catalogue_detail.htm?csnumber=58102 (accessed 2015 -04-09). 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). Weed LL. Medical records that guide and teach. N Engl J Med. 1968 Mar 14;278(11):593-600. PubMed PMID: 5637758. Available from: http://www.nejm.org/doi/full/10.1056/NEJM196803142781105 (accessed 2015-07-13)., current_contact=Heather Leslie, Ocean Informatics, heather.leslie@oceaninformatics.com, original_namespace=org.highmed, original_publisher=HiGHmed, custodian_namespace=org.highmed, MD5-CAM-1.0.1=580FE46292E5A3AF10E4C057770CB301, build_uid=c813f928-8caa-4946-afc7-30938d527ffb, revision=0.0.1-alpha}
Keywordsissue, condition, problem, diagnosis, concern, injury, clinical impression
Lifecyclein_development
UIDd006e820-ca9c-4395-ac9f-3031d3907aba
Language useden
Citeable Identifier867.109.17
Revision Number0.0.1-alpha
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Details about a single identified health condition, injury, disability or any other issue which impacts on the physical, mental and/or social well-being of an individual., archetypeConceptComment=Clear delineation between the scope of a problem versus a diagnosis is not easy to achieve in practice. For the purposes of clinical documentation with this archetype, problem and diagnosis are regarded as a continuum, with increasing levels of detail and supportive evidence usually providing weight towards the label of 'diagnosis'., otherContributors=Tomas Alme, DIPS, Norway
Nadim Anani, Karolinska Institutet, Sweden
Koray Atalag, University of Auckland, New Zealand
Silje Ljosland Bakke, Nasjonal IKT HF, Norway (openEHR Editor)
John Bennett, NEHTA, Australia
Steve Bentley, Allscripts, United Kingdom
Lars Bitsch-Larsen, Haukeland University hospital, Norway
Ian Bull, ACT Health, Australia
Sergio Carmona, Chile
Rong Chen, Cambio Healthcare Systems, Sweden
Stephen Chu, Queensland Health, Australia
Ed Conley, Cardiff University, United Kingdom
Matthew Cordell, NEHTA, Australia
Paul Donaldson, Nursing Informatics Australia, Australia
Gail Easterbrook, Flinders Medical Centre, Australia
Aitor Eguzkitza, UPNA (Public University of Navarre) - CHN (Complejo Hospitalario de Navarra), Spain
David Evans, Queensland Health, Australia
Shahla Foozonkhah, Iran ministry of health and education, Iran
Einar Fosse, National Centre for Integrated Care and Telemedicine, Norway
Peter Garcia-Webb, Australia
Sebastian Garde, Ocean Informatics, Germany
Andrew Goodchild, NEHTA, Australia
Anneke Goossen, Results 4 Care, Netherlands
Heather Grain, Llewelyn Grain Informatics, Australia
Trina Gregory, cpc, Australia
Sam Heard, Ocean Informatics, Australia
Evelyn Hovenga, EJSH Consulting, Australia
Eugene Igras, IRIS Systems, Inc., Canada
Lars Karlsen, DIPS ASA, Norway
Lars Morgan Karlsen, DIPS ASA, Norway
Mary Kelaher, NEHTA, Australia
Eizen Kimura, Ehime Univ., Japan
Shinji Kobayashi, Kyoto University, Japan
Robert L'egan, NEHTA, Australia
Sabine Leh, Haukeland University Hospital, Department of Pathology, Norway
Heather Leslie, Ocean Health Systems, Australia (openEHR Editor)
Hugh Leslie, Ocean Informatics, Australia (Editor)
Hallvard Lærum, Oslo University Hospital, Norway
Rohan Martin, Ambulance Victoria, Australia
David McKillop, NEHTA, Australia
Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (openEHR Editor)
Chris Mitchell, RACGP, Australia
Stewart Morrison, NEHTA, Australia
Bjoern Naess, DIPS ASA, Norway
Jörg Niggemann, compugroup, Germany
Andrej Orel, Marand d.o.o., Slovenia
Chris Pearce, Melbourne East GP Network, Australia
Camilla Preeston, Royal Australian College of General Practitioners, Australia
Margaret Prichard, NEHTA, Australia
Jodie Pycroft, Adelaide Northern Division of General Practice Ltd, Australia
Cathy Richardson, NEHTA, Australia
Robyn Richards, NEHTA - Clinical Terminology, Australia
Jussara Rotzsch, UNB, Brazil
Thilo Schuler, Australia
Anoop Shah, University College London, United Kingdom
Norwegian Review Summary, Nasjonal IKT HF, Norway
Gordon Tomes, Australian Institute of Health and Welfare, Australia
Richard Townley-O'Neill, NEHTA, Australia
Donna Truran, ACCTI-UoW, Australia
John Tore Valand, Helse Bergen, Norway (openEHR Editor)
Kylie Young, The Royal Australian College of General Practitioners, Australia, originalLanguage=en, translators=German: Aljoscha Kindermann, Jasmin Buck, Sebastian Garde, University of Heidelberg, Central Queensland University
Spanish (Argentina): Alan March, Hospital Universitario Austral, Buenos Aires, Argentina, alandmarch@gmail.com, -
Norwegian Bokmål: Silje Ljosland Bakke, John Tore Valand, Helse Bergen HF
Portuguese (Brazil): Adriana Kitajima, Gabriela Alves, Maria Angela Scatena, Marivan Abrahäo, Core Consulting, contato@coreconsulting.com.br, Hospital Alemão Oswaldo Cruz (HAOC)
Arabic (Syria): Mona Saleh
Spanish (Spain): Pablo Pazos, CaboLabs, Computer Engineer
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All not explicitly excluded archetypes, extendedValues=null]], data=[ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=2, text=Problem/Diagnosis name, description=Identification of the problem or diagnosis, by name., comment=Coding of the name of the problem or diagnosis with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0009], code=at0009, itemType=ELEMENT, level=2, text=Clinical description, description=Narrative description about the problem or diagnosis., comment=Use to provide background and context, including evolution, episodes or exacerbations, progress and any other relevant details, about the problem or diagnosis., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0012], code=at0012, itemType=ELEMENT, level=2, text=Body site, description=Identification of a simple body site for the location of the problem or diagnosis., comment=Coding of the name of the anatomical location with a terminology is preferred, where possible. Use this data element to record precoordinated anatomical locations. If the requirements for recording the anatomical location 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 'Structured anatomical location' SLOT in this archetype. Occurrences for this data element are unbounded to allow for clinical scenarios such as describing a rash in multiple locations but where all of the other attributes are identical. If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant. , uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0039], code=at0039, itemType=SLOT, level=2, text=Structured body site, description=A structured anatomical location for the problem or diagnosis., comment=Use this SLOT to insert the CLUSTER.anatomical_location or CLUSTER.relative_location archetypes if the requirements for recording the anatomical location are determined at run-time by the application or require more complex modelling such as relative locations. If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, use of this SLOT becomes redundant. , uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.anatomical_location.v1 and specialisations Or
openEHR-EHR-CLUSTER.anatomical_location_clock.v0 and specialisations Or
openEHR-EHR-CLUSTER.anatomical_location_relative.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0077], code=at0077, itemType=ELEMENT, level=2, text=Date/time of onset, description=Estimated or actual date/time that signs or symptoms of the problem/diagnosis were first observed., comment=Data captured/imported as "Age at onset" should be converted to a date using the subject's date of birth., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0003], code=at0003, itemType=ELEMENT, level=2, text=Date/time clinically recognised, description=Estimated or actual date/time the diagnosis or problem was recognised by a healthcare professional., comment=Partial dates are acceptable. If the subject of care is under the age of one year, then the complete date or a minimum of the month and year is necessary to enable accurate age calculations - for example, if used to drive decision support. Data captured/imported as "Age at time of clinical recognition" should be converted to a date using the subject's date of birth., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0005], code=at0005, itemType=ELEMENT, level=2, text=Severity, description=An assessment of the overall severity of the problem or diagnosis., comment=If severity is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant. Note: more specific grading of severity can be recorded using the Specific details SLOT., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
  •  Coded Text
    • Mild [The problem or diagnosis does not interfere with normal activity or may cause damage to health if left untreated.]
    • Moderate [The problem or diagnosis causes interference with normal activity or will damage health if left untreated.]
    • Severe [The problem or diagnosis prevents normal activity or will seriously damage health if left untreated.]
  •  Text
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All not explicitly excluded archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0072], code=at0072, itemType=ELEMENT, level=2, text=Course description, description=Narrative description about the course of the problem or diagnosis since onset., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0030], code=at0030, itemType=ELEMENT, level=2, text=Date/time of resolution, description=Estimated or actual date/time of resolution or remission for this problem or diagnosis, as determined by a healthcare professional., comment=Partial dates are acceptable. If the subject of care is under the age of one year, then the complete date or a minimum of the month and year is necessary to enable accurate age calculations - for example, if used to drive decision support. Data captured/imported as "Age at time of resolution" should be converted to a date using the subject's date of birth. , uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0046], code=at0046, itemType=SLOT, level=2, text=Status, description=Structured details for location-, domain-, episode- or workflow-specific aspects of the diagnostic process., comment=Use status or context qualifiers with care, as they are variably used in practice and interoperability cannot be assured unless usage is clearly defined with the community of use. For example: active status - active, inactive, resolved, in remission; evolution status - initial, interim/working, final; temporal status - current, past; episodicity status - first, new, ongoing; admission status - admission, discharge; or priority status - primary, secondary., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.problem_status.v0 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/items[at0073], code=at0073, itemType=ELEMENT, level=2, text=Diagnostic certainty, description=The level of confidence in the identification of the diagnosis., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
  •  Coded Text
    • Suspected [The diagnosis has been identified with a low level of certainty.]
    • Probable [The diagnosis has been identified with a high level of certainty.]
    • Confirmed [The diagnosis has been confirmed against recognised criteria.]
  •  Text
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