Page Comparison

Succinct name that encompasses the scope and intent of the archetype.
Sentence case - with the first letter uppercase and subsequent letters lowercase. Exceptions include proper nouns or acronyms.

Blood pressure

INSTRUCTION archetype names will include the word 'order' or equivalent.

Corresponding ACTION archetype names will just contain the concept, or a very specific scope for the archetype.

INSTRUCTION: "Service request" & ACTION: "Service"

INSTRUCTION: "Medication order" & ACTION: "Medication management"

Definition of the 'Concept name'. The intent of the description is to define the concept as clinicians apply it in clinical practice, not the academic or dictionary definition of the concept.

"The local measurement of arterial blood pressure which is a surrogate for arterial pressure in the systemic circulation."

Preface with "To record "... or similar.

COMPOSITION wording needs to be a little different to other clinical content - for example ”a named container for information provided by an individual, to support clear separation of patient generated from clinically genereated health data.”

• Preface with "Use to record "... or similar. Ensure alignment with Purpose if appropriate.

• If the archetype is designed to be used within a family of archetypes, include a statement about which archetypes are intended to be used within internal SLOTS or where the archetype may be nested within other archetypes.

"This archetype has been specifically designed to be used in the 'Examination detail' SLOT within the CLUSTER.exam-mouth, CLUSTER.exam-cranial_nerves or OBSERVATION.exam archetypes, but can also be used within other ENTRY or CLUSTER archetypes, where clinically appropriate."

• Explain how SLOTs are intended to be used to expand the concept further.

'Use to provide a framework in which CLUSTER archetypes can be nested in the 'Examination findings' SLOT to record additional structured physical examination findings."

Preface with "Not to be used"... or similar.

Usually mandatory, as if the actual object of the test or examination is not identified, then any subsequent data is not clearly identified.

The ear(s) to which the test stimulus is being presented.

• Right ear [The test stimuli were presented to the right ear only.] or [The right ear was examined.]

• Left ear [The test stimuli were presented to the left ear only.] or [The left ear was examined.]

• Binaural [The test stimuli were presented to both ears simultaneously in a soundfield.] 

The name and/or code for a particular type of the real world concept the archetype is about. For example lab test, problem/diagnosis or medication.

The intent of the description is to describe the element concept as clinicians apply it in clinical practice, not the academic or dictionary definition of the concept.

Description:

The name of the <XYZ> <...>.

Comment: 

Coding with an external terminology is preferred, where possible.

Coding with an external terminology is optional.

As per examination archetype pattern.

Narrative description of the overall findings observed during the physical examination.

Naming of a data element used to describe a start date for an activity or a duration for an age commenced.

Naming of a data element used to describe a stop date for an activity or a duration for an age ceased.

SLOT to carry the CLUSTER.multimedia archetype until the data type is updated to support all of the additional requirements explicitly modelled in the archetype.

Digital image, video or diagram representing the findings.

Digital representation of the evidence of consent.

Last data element in many archetypes to catch data that may not yet be structured, nor fit into any other general narrative description data element.

May have multiple occurrences, if necessary.

Additional narrative about the <insert appropriate phrase here, for example ‘test results and interpretation’> not captured in other fields.

Additional narrative about the measurement of body weight, not captured in other fields.

(Additional) Issues or factors that may impact on <the measurement of body temperature>, not captured in other fields.

As a default, “Any event” should have “0..*” occurrences, in order to have multiple recordings within one instance of the archetype.

Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.

Default, unspecified point in time event which may be explicitly defined in a template or at run-time.

Added to Protocol for every COMPOSITION or ENTRY archetype to allow for local extensions or potential alignment with other modelling paradigms.

Description:

Additional information required to extend the model with local content or to align with other reference models or formalisms.

Comment: 

For example: local information requirements; or additional metadata to align with FHIR.

ADL:

text = <"Extension">
description = <"Additional information required to extend the model with local content or to align with other reference models or formalisms.">
comment = <"For example: local information requirements; or additional metadata to align with FHIR.">

Some date and datetime elements are intended to allow partial dates, for examples a year only. For these, a comment should be added to specify this.

Comment: 

Can be a partial date, for example, only a year.

The recording of body sites is normally modelled as the combination of a Text element named “Body site” and a SLOT named “Structured body site” for a CLUSTER archetype. The SLOT should normally include one or more of CLUSTER.anatomical_location, CLUSTER.anatomical_location_circle, or CLUSTER.anatomical_location_relative.

Name:

Body site

/

Structured body site

Description:

Simple anatomical location for the identified body structure.

/

Structured details about the anatomical location of the identified body structure.

Comment:

For example: a lymph node group found in the right axilla. Coding of 'Body site' with a terminology, such as SNOMED CT, is desirable.

/

If the anatomical location of the identified body structure is known or it has been identified in the 'Body site' data element, this data element is redundant.