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

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!

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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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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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.

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

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

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

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