Archetype content & style guide
Focus
The Editorial focus in archetype design is primarily focused on ensuring that clinical content is expressed clearly and explicitly. Implementation and querying implications are always considered as critical components of archetype design but take a lower priority to representing clinical content accurately and in a way that clinicians can use and understand.
Archetypes define specific clinical concepts, focusing on what the data is. Metadata and element descriptions guide implementers on using archetypes in templates and forms, and is not intended for end users of electronic health records.
Instructions on data capture and interpretation are found in medical guidelines or literature, and can be referenced in the archetype’s Reference section. It can be challenging to differentiate between defining a measurement, and instructions on how to perform the measurement. As an inspiration, see OBSERVATION.head_circumference archetype, which describes “Head circumference” as “The measurement of the longest distance around the head” without detailing the measurement method. This is intentional to avoid serving as a medical textbook and to accommodate local variations. If necessary, users should document measurement methods in designated elements in the archetype's Protocol section.
Original language
All archetypes for upload or federation to the international openEHR CKM should have English (ISO-639-1 "en") as the original language. All translations are done from the original language, and using any language less common than English will likely lead to "chinese whispers" translation; distortion of the original semantics through translations of translations.
Metadata
All text should have a full stop or equivalent at the end of the description.
CKM will flag a style error on upload if the text has extra spaces at the beginning or end of a sentence, or if the text does not end with a full stop or equivalent.
Description | Example | |
|---|---|---|
Concept name | Succinct name that encompasses the scope and intent of the archetype. | 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" | |
| When there is an abbreviation within the name of the archetype, the abbreviation should occur right after the words of which the abbreviation is made. | “Neurologic Assessment in Neuro-Oncology (NANO) scale.”, and not “Neurologic Assessment in Neuro-Oncology scale (NANO).” |
| If the archetype is a local variant, either by country, region or hospital, or a preliminary version made by a project or a vendor in anticipation of a formal review process leading to a published state, it is highly recommended to use a suffix to the archetype name to be able to differentiate from the published archetype. |
|
Concept description | 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." |
Purpose | 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.” |
Use |
| “Use to record all representations of systemic arterial blood pressure measurement, no matter which method or body location is used to record it.” |
| "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." | |
| 'Use to provide a framework in which CLUSTER archetypes can be nested in the 'Examination findings' SLOT to record additional structured physical examination findings." | |
Misuse | Preface with "Not to be used"... or similar, followed by a description of the specific use case the archetype isn’t to be used for. Finish with a separate sentence describing which archetypes to use for the specified use case. If the archetypes to be used haven’t been created yet, make the final sentence “Use a specific archetype for this purpose.” | “Not to be used for recording physiological reactions to physical agents, such as heat, cold, sunlight, vibration, exercise activity, by infectious agents or food contaminants. Use the EVALUATION.problem/diagnosis or CLUSTER.symptom/sign archetypes for this purpose.” “Not to be used to record reactions to transfusions of blood products. Use a specific archetype for this purpose.” |
References
References within published archetypes should be consistent with Citing Medicine, 2nd edition - | |
The National Library of Medicine provides an easy way to ensure consistent formatting through the use of a bibliography tool that can automatically configure citations for a variety of different publications. If the required citation is not found within the PubMed search then the link above will support manual formatting, eg for parts of websites. | |
References to other archetypes or parts of archetypes within CKM can be located on the 'Share with Colleague' tab for each archetype. | http://www.openehr.org/ckm/#showArchetype_1013.1.2741_SHAREWITHCOLLEAGUE |
CKM discontinued | For example: "Derived from: Employment summary, draft archetype [Internet]. Australian Digital Health Agency (NEHTA), ADHA Clinical Knowledge Manager. No longer available." |
Referencing a FHIR artifact |
|
Copyright
Copyright statement |
|
Content copyright
Guideline for communicating external content copyright requirements to users | Include statement describing content copyright, formal copyright statement and access to information about permissions etc by the copyright holders.
|
License
Content Licence |
|
|---|
IP Acknowledgement
SNOMED-CT | Until tooling evolves to allow this to occur through a standard interface, add manually via Notepad or equivalent directly to "other_details = <" section in the archetype ADL:
|
|---|
Data elements
All data element names should be represented in Sentence case - with the first letter uppercase and subsequent letters lowercase. Exceptions include proper nouns or acronyms.
All data element descriptions should have a full stop or equivalent at the end of the description.
Examples and other further explanations about how to use a specific data element should be noted in the “Comment” section of the data element. Use wording like “For example: [example 1]; [example 2]; or [example 3].”
CKM will flag a style error on upload if the data element has extra spaces at the beginning or end of a sentence, or if the description does not end with a full stop or equivalent.
Description | Example | |
|---|---|---|
<XYZ> tested/examined | 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.
|
<XYZ> name | 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:
|
Clinical description | As per examination archetype pattern. |
|
<XYZ> commenced | Naming of a data element used to describe a start date for an activity or a duration for an age commenced. | |
<XYZ> ceased | Naming of a data element used to describe a stop date for an activity or a duration for an age ceased. | |
Multimedia representation | 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. |
|
Comment | 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. |
|
Confounding factors |
| |
Any event | As a default, “Any event” should have “0..*” occurrences, in order to have multiple recordings within one instance of the archetype. |
|
Any point in time event |
| |
Extension SLOT | Added to Protocol for every COMPOSITION or ENTRY archetype to allow for local extensions or potential alignment with other modelling paradigms. | Description:
Comment:
ADL:
|
Partial dates and datetimes | 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:
|
Body sites | 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:
Description:
Comment:
|
Repeatable data elements and clusters | Proposal Any data element that is designated as repeatable, such as 1..* or 0..* will be named in the singular. Each instance of the data element is intended to have a single corresponding value. This principle is also applied to repeatable clusters. Add a comment explaining what the purpose is of making the element repeatable. | Name:
Comment:
|
Codeable data elements | Proposal Add a comment reflecting the intended strength of the recommendation to code the element using an external terminology. | Comment:
|
Additional details SLOT | Proposal In most ENTRY archetypes it will be relevant to add an 'Additional details' SLOT to be able to extend its contents using CLUSTER archetypes. |
|
Scores and Scales
Description | Example | |
|---|---|---|
Concept name | Model as the full name of the score or scale. If the name is also used as an acronym, model the name in capitals, including the acronym in brackets. If the most common known name is an acronym, use the acronym as the name. |
|
| If the score or scale is a local variant, either by country, region or hospital, or a preliminary version made by a project or a vendor in anticipation of a formal review process leading to a published state, it is highly recommended to use a suffix to the archetype name to be able to differentiate from the published archetype. |
|
Archetype ID | Same as concept name but without the word 'scale' or 'score' - unless it is necessary to distinguish from another archetypes with a similar name. | See examples above. Also: |
Concept description | Record an explanation of the concept being recorded. |
|
Purpose | Record the reason for using this archetype to record data, not to describe the purpose of the score or scale itself. |
|
Use | Record how the archetype might be used in implementation, not how to perform the assessment. Commence the first sentence with the standard phrase "Use to record..." unless there is a good reason not to do so. Additional information might provide guidance to modellers or implementers about how to utilise the archetype in templates or clinical systems. |
|
Data element names | Proposal In a questionnaire type score or scale archetype, data elements should be named as the exact text of the question in the source material.
|
|
Data element descriptions | Proposal Use original descriptions, or leave empty. |
|
Total score | Naming of the total score or calculated ratio should not contain the name of the score or scale. In this way in a UI could display the heading or grouping of Glasgow Coma Scale or P/F Score with the actual data element named more simply as ‘Total score’ or ‘Ratio’. |
|
Name of data elements of non-calculcated scales | For scales or classifications that do not involve calculating a total score, the scale element(s) should be given the name of the scale or classification as you would expect it to be labelled in a user interface. For example: ‘Modified Rankin scale’, ‘ACVPU’, ‘NYHA Function capacity’ or ‘NYHA Objective assessment’. |
|
Clinical interpretation | Only to be added to a score if it is usually part of the formal score/scale representation. |
|
Confounding factors | After discussion (01 2020), future archetypes will not have 'Confounding factors' modelled explicitly, unless it is a specific component of the published instrument. Use the 'Extension' SLOT to allow a recording of confounding factors for specific use cases or clinical scenarios, if necessary. | |
Comment | After discussion (01 2020), future archetypes will not have an additional 'Comment' modelled explicitly, unless it is a specific component of the published instrument. Use the 'Extension' SLOT to allow a comment for specific use cases or clinical scenarios, if necessary. | |
Other elements | After discussion (01 2020), future archetypes will not have any other elements modelled explicitly, unless they're specific components of the published instrument. Use the 'Extension' SLOT to allow a comment for specific use cases or clinical scenarios, if necessary. | |
Events | If only to be used at a single point in time, set the default event to 'Any point in time event' (0..*) unless it is clinically reasonable to record interval events with multiple records committed over a time period, averages or maximums etc. This is unusual with scores or scales (as opposed to being a common requirement with clinical measurements such as weight or pulse rate). Updated 30 Mar 2023 - Keep 'Any event' unconstrained for scores and scales to allow for outlier use cases where someone might want to record the maximum or minimum score over an interval. More specific constraints, such as changing to a point in time event can be set in the template as required. |
Editorial style
Description | Example | |
|---|---|---|
Dot points | If dot points are required within the text, use hyphens ('-') followed by a space and then the subsequent text, not commencing with capitals | For example: |