Recording past history (medical and surgical), age, ethnicity

Clinical
1

Hi,
What could be the best archetypes to capture the following:
Past history (medical and surgical)
Age (DoB would do fine as the relevant age can be computed from the record date if this data item is available)
Ethnicity
Thanks!

2

Hello

“Ethnicity” is about to be out for review very soon, probably tomorrow (Monday). You can find the proposed version here: Clinical Knowledge Manager

“Age” is a concept where there are a draft archetype available: Clinical Knowledge Manager
It’s not quite ready for review and publishing yet, but should be very close. Please have a look and evaluate if it fits your requirements. Comments can be placed either here, or in the CKM’s ‘Change request’ or ‘Discussion’ functionality.

Regarding the individual’s past history (medical and surgical), the main archetype is the ‘Story/History’ archetype: Clinical Knowledge Manager. For a narrative free text description, use the ‘Story’ element. If needed, additional information can be documented by nesting other archetypes in the ‘Structured detail’ SLOT, for example ACTION.procedure for past surgeries.

Hope this helps.

Regards,
Vebjørn Arntzen

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3

I’d also add Problem/Diagnosis as an additional option. It largely depends on the context of use.

@johnmeredith wrote a paper on Contextual Problem lists, with an examplar openEHR template

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4

Thanks for the responses. Much appreciated. Problem/Diagnosis is great but date/time of onset is okay only when known. Perhaps a temporal context data like current or past (can be SNOMED coded), current status like ongoing, resolved (again SNOMED coded), and an appropriate one to capture items like social/personal history and some other similar observable entity subtype )(SNOMED again) will be very helpful.

5

Have you looked at the Problem/diagnosis qualifier (Clinical Knowledge Manager) archetype, which plugs into Problem/diagnosis?

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6

I confess that I had not. This one used in combination will work well for past history. Thanks a ton!

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7

Maybe the screening questionnaire archetypes are of interest as well, like this one for procedures:

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8

This is what we’ve been using the problem/diagnosis screening questionnaire to capture this data.

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9

It’s not clear to me what you’re replying to, I’d love to know what you’re currently doing :smile:

We’ve been working on a set of standardised templates to capture some common data patterns across the cancer treatment pathways we’re currently working on. For a admission recording of comorbidities (arguably current additional problems/diagnoses are part of “past history”?) we’ve chosen a combination of the Problem/diagnosis screening questionnnaire and the Precaution archetype: Clinical Knowledge Manager (arketyper.no) (template in Norwegian)

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:laughing:
I was wondering how even though I hit reply it wasn’t showing what to!

I will correct.

We had been using the screening questionnaire to capture the past medical history.
Had some discussions with @heather.leslie and she highlighted the need to think about when we want a survey(Yes/No answers) vs a persistent problem list, which helped to clarify the point.

I’ve updated our templates to use the Problem/Diagnosis archetype in that case.

I will check out the template you’ve shared :pray:

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