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","type":"text"}]},{"type":"paragraph","content":[{"text":"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.","type":"text"}]},{"type":"paragraph","content":[{"text":"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.","type":"text"}]},{"type":"heading","attrs":{"level":2},"content":[{"text":"Original language","type":"text"}]},{"type":"paragraph","content":[{"text":"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.","type":"text"}]},{"type":"heading","attrs":{"level":2},"content":[{"text":"Metadata","type":"text"}]},{"type":"paragraph","content":[{"text":"All text should have a full stop or equivalent at the end of the description.","type":"text"}]},{"type":"paragraph","content":[{"text":"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.","type":"text"}]},{"type":"table","attrs":{"layout":"full-width","width":1800.0,"localId":"d737e050-eaa9-4292-a14e-33854c781af6"},"content":[{"type":"tableRow","content":[{"type":"tableHeader","attrs":{"colspan":1,"rowspan":1,"colwidth":[124.0]},"content":[{"type":"paragraph","content":[{"type":"hardBreak"}]}]},{"type":"tableHeader","attrs":{"colspan":1,"rowspan":1,"colwidth":[842.0]},"content":[{"type":"paragraph","content":[{"text":"Description","type":"text"}]}]},{"type":"tableHeader","attrs":{"colspan":1,"rowspan":1,"colwidth":[794.0]},"content":[{"type":"paragraph","content":[{"text":"Example","type":"text"}]}]}]},{"type":"tableRow","content":[{"type":"tableHeader","attrs":{"colspan":1,"rowspan":1,"colwidth":[124.0]},"content":[{"type":"paragraph","content":[{"text":"Concept name","type":"text"}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[842.0]},"content":[{"type":"paragraph","content":[{"text":"Succinct name that encompasses the scope and intent of the archetype. ","type":"text"},{"type":"hardBreak"},{"text":"Sentence case - ","type":"text"},{"text":"with the first letter ","type":"text","marks":[{"type":"textColor","attrs":{"color":"#222222"}}]},{"text":"uppercase","type":"text","marks":[{"type":"link","attrs":{"href":"https://en.wiktionary.org/wiki/uppercase"}}]},{"text":" and subsequent letters ","type":"text","marks":[{"type":"textColor","attrs":{"color":"#222222"}}]},{"text":"lowercase","type":"text","marks":[{"type":"link","attrs":{"href":"https://en.wiktionary.org/wiki/lowercase"}}]},{"text":". E","type":"text"},{"text":"xceptions include ","type":"text","marks":[{"type":"textColor","attrs":{"color":"#222222"}}]},{"text":"proper nouns","type":"text","marks":[{"type":"link","attrs":{"href":"https://en.wiktionary.org/wiki/proper_noun"}}]},{"text":" or ","type":"text","marks":[{"type":"textColor","attrs":{"color":"#222222"}}]},{"text":"acronyms","type":"text","marks":[{"type":"link","attrs":{"href":"https://en.wiktionary.org/wiki/acronym"}}]},{"text":".","type":"text"}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[794.0]},"content":[{"type":"paragraph","content":[{"text":"Blood pressure","type":"text"}]}]}]},{"type":"tableRow","content":[{"type":"tableHeader","attrs":{"colspan":1,"rowspan":1,"colwidth":[124.0]},"content":[{"type":"paragraph","content":[{"type":"hardBreak"}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[842.0]},"content":[{"type":"paragraph","content":[{"text":"INSTRUCTION archetype names will include the word 'order' or equivalent.","type":"text"}]},{"type":"paragraph","content":[{"text":"Corresponding ACTION archetype names will just contain the concept, or a very specific scope for the archetype.","type":"text"}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[794.0]},"content":[{"type":"paragraph","content":[{"text":"INSTRUCTION: \"Service request\" & ACTION: \"Service\"","type":"text"}]},{"type":"paragraph","content":[{"text":"INSTRUCTION: \"Medication order\" & ACTION: \"Medication management\"","type":"text"}]}]}]},{"type":"tableRow","content":[{"type":"tableHeader","attrs":{"colspan":1,"rowspan":1,"colwidth":[124.0]},"content":[{"type":"paragraph"}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[842.0]},"content":[{"type":"paragraph","content":[{"text":"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.","type":"text"}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[794.0]},"content":[{"type":"paragraph","content":[{"text":"“Neurologic Assessment in Neuro-Oncology (NANO) scale.”, and not “Neurologic Assessment in Neuro-Oncology scale (NANO).”","type":"text"}]}]}]},{"type":"tableRow","content":[{"type":"tableHeader","attrs":{"colspan":1,"rowspan":1,"colwidth":[124.0]},"content":[{"type":"paragraph"}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[842.0]},"content":[{"type":"paragraph","content":[{"text":"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.","type":"text"}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[794.0]},"content":[{"type":"blockquote","content":[{"type":"paragraph","content":[{"text":"Obstetric National Early Warning score (ONEWS) ","type":"text"},{"text":"- ","type":"text","marks":[{"type":"annotation","attrs":{"annotationType":"inlineComment","id":"2a5d1d00-8054-4a7b-972f-838bc15ea78f"}}]},{"text":"Sweden ","type":"text","marks":[{"type":"annotation","attrs":{"annotationType":"inlineComment","id":"2a5d1d00-8054-4a7b-972f-838bc15ea78f"}},{"type":"strong"}]},{"text":"- with archetype ID ","type":"text","marks":[{"type":"annotation","attrs":{"annotationType":"inlineComment","id":"2a5d1d00-8054-4a7b-972f-838bc15ea78f"}}]},{"text":"OBSERVATION.","type":"text"},{"text":"onews_se","type":"text","marks":[{"type":"strong"}]}]},{"type":"paragraph","content":[{"text":"Obstetric National Early Warning score (ONEWS) - ","type":"text"},{"text":"Norway ","type":"text","marks":[{"type":"strong"}]},{"text":"- with archetype ID OBSERVATION.","type":"text"},{"text":"onews_no","type":"text","marks":[{"type":"strong"}]}]}]}]}]},{"type":"tableRow","content":[{"type":"tableHeader","attrs":{"colspan":1,"rowspan":1,"colwidth":[124.0]},"content":[{"type":"paragraph","content":[{"text":"Concept description","type":"text"}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[842.0]},"content":[{"type":"paragraph","content":[{"text":"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.","type":"text"}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[794.0]},"content":[{"type":"paragraph","content":[{"text":"\"The local measurement of arterial blood pressure which is a surrogate for arterial pressure in the systemic circulation.\"","type":"text","marks":[{"type":"textColor","attrs":{"color":"#000000"}}]}]}]}]},{"type":"tableRow","content":[{"type":"tableHeader","attrs":{"colspan":1,"rowspan":1,"colwidth":[124.0]},"content":[{"type":"paragraph","content":[{"text":"Purpose","type":"text"}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[842.0]},"content":[{"type":"paragraph","content":[{"text":"Preface with \"To record \"... or similar.","type":"text"}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[794.0]},"content":[{"type":"paragraph","content":[{"text":"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.”","type":"text"},{"type":"hardBreak"}]}]}]},{"type":"tableRow","content":[{"type":"tableHeader","attrs":{"colspan":1,"rowspan":3,"colwidth":[124.0]},"content":[{"type":"paragraph","content":[{"text":"Use","type":"text"}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[842.0]},"content":[{"type":"bulletList","content":[{"type":"listItem","content":[{"type":"paragraph","content":[{"text":"Preface with \"Use to record \"... or similar. Ensure alignment with Purpose if appropriate.","type":"text"}]}]}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[794.0]},"content":[{"type":"paragraph","content":[{"text":"“Use to record all representations of systemic arterial blood pressure measurement, no matter which method or body location is used to record it.”","type":"text"},{"type":"hardBreak"}]}]}]},{"type":"tableRow","content":[{"type":"tableHeader","attrs":{"colspan":1,"rowspan":1,"colwidth":[842.0]},"content":[{"type":"bulletList","content":[{"type":"listItem","content":[{"type":"paragraph","content":[{"text":"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.","type":"text"}]}]}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[794.0]},"content":[{"type":"paragraph","content":[{"text":"\"","type":"text"},{"text":"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.\"","type":"text","marks":[{"type":"textColor","attrs":{"color":"#000000"}}]}]}]}]},{"type":"tableRow","content":[{"type":"tableHeader","attrs":{"colspan":1,"rowspan":1,"colwidth":[842.0]},"content":[{"type":"bulletList","content":[{"type":"listItem","content":[{"type":"paragraph","content":[{"text":"Explain how SLOTs are intended to be used to expand the concept further.","type":"text"}]}]}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[794.0]},"content":[{"type":"paragraph","content":[{"text":"'Use to provide a framework in which CLUSTER archetypes can be nested in the 'Examination findings' SLOT to record additional structured physical examination findings.\"","type":"text","marks":[{"type":"textColor","attrs":{"color":"#000000"}}]}]}]}]},{"type":"tableRow","content":[{"type":"tableHeader","attrs":{"colspan":1,"rowspan":1,"colwidth":[124.0]},"content":[{"type":"paragraph","content":[{"text":"Misuse","type":"text"}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[842.0]},"content":[{"type":"paragraph","content":[{"text":"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.”","type":"text"}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[794.0]},"content":[{"type":"paragraph","content":[{"text":"“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.”","type":"text"}]},{"type":"paragraph","content":[{"text":"“Not to be used to record reactions to transfusions of blood products. Use a specific archetype for this purpose.”","type":"text"}]}]}]}]},{"type":"heading","attrs":{"level":2},"content":[{"text":"References","type":"text"}]},{"type":"table","attrs":{"layout":"full-width","width":1800.0,"localId":"0f6649a8-e245-4d41-8863-b9123761f694"},"content":[{"type":"tableRow","content":[{"type":"tableHeader","attrs":{"colspan":1,"rowspan":1,"colwidth":[776.0]},"content":[{"type":"paragraph","content":[{"type":"hardBreak"}]}]},{"type":"tableHeader","attrs":{"colspan":1,"rowspan":1,"colwidth":[984.0]},"content":[{"type":"paragraph","content":[{"type":"hardBreak"}]}]}]},{"type":"tableRow","content":[{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[776.0]},"content":[{"type":"paragraph","content":[{"text":"References within published archetypes should be consistent with Citing Medicine, 2nd edition - ","type":"text"},{"type":"hardBreak"},{"text":"The NLM Style Guide for Authors, Editors, and Publishers","type":"text"}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[984.0]},"content":[{"type":"paragraph","content":[{"text":"https://www.ncbi.nlm.nih.gov/books/NBK7256/?amp=&depth=2","type":"text","marks":[{"type":"link","attrs":{"href":"https://www.ncbi.nlm.nih.gov/books/NBK7256/?amp=&depth=2"}}]},{"text":".","type":"text"}]}]}]},{"type":"tableRow","content":[{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[776.0]},"content":[{"type":"paragraph","content":[{"text":"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.","type":"text"}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[984.0]},"content":[{"type":"paragraph","content":[{"text":"https://www.ncbi.nlm.nih.gov/sites/myncbi/","type":"text","marks":[{"type":"link","attrs":{"href":"https://www.ncbi.nlm.nih.gov/sites/myncbi/"}}]}]}]}]},{"type":"tableRow","content":[{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[776.0]},"content":[{"type":"paragraph","content":[{"text":"References to other archetypes or parts of archetypes within CKM can be located on the 'Share with Colleague' tab for each archetype.","type":"text"}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[984.0]},"content":[{"type":"paragraph","content":[{"text":"http://www.openehr.org/ckm/#showArchetype_1013.1.2741_SHAREWITHCOLLEAGUE","type":"text","marks":[{"type":"link","attrs":{"href":"http://www.openehr.org/ckm/#showArchetype_1013.1.2741_SHAREWITHCOLLEAGUE"}}]}]}]}]},{"type":"tableRow","content":[{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[776.0]},"content":[{"type":"paragraph","content":[{"text":"CKM discontinued","type":"text"}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[984.0]},"content":[{"type":"paragraph","content":[{"text":"For example: \"","type":"text"},{"text":"Derived from: Employment summary, draft archetype [Internet]. Australian Digital Health Agency (NEHTA), ADHA Clinical Knowledge Manager. No longer available.\"","type":"text","marks":[{"type":"textColor","attrs":{"color":"#000000"}}]}]}]}]},{"type":"tableRow","content":[{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[776.0]},"content":[{"type":"paragraph","content":[{"text":"Referencing a FHIR artifact","type":"text"}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[984.0]},"content":[{"type":"bulletList","content":[{"type":"listItem","content":[{"type":"paragraph","content":[{"text":"Resource ","type":"text","marks":[{"type":"strong"}]},{"text":"- Align with: \" ","type":"text"},{"text":" [Internet]. Health Level Seven International; [cited: ].","type":"text","marks":[{"type":"textColor","attrs":{"color":"#000000"}}]},{"text":" Available from: .\"","type":"text"},{"type":"hardBreak"},{"text":"For example, an R5 Resource - \"AllergyIntolerance, HL7 FHIR Resource [Internet]. Health Level Seven International; [cited: 2024 Feb 05]. Available from: hfps://hl7.org/xir/R5/allergyintolerance.html.”","type":"text"},{"type":"hardBreak"},{"text":"Note: the FHIR website uses a single hyperlink to always access the latest version of a FHIR resource. To create a reference to a particular version of a FHIR resource see the FHIR publication history, where you will be able to locate a URL for the release, and a permanent URL for each resource within the release.","type":"text"}]}]},{"type":"listItem","content":[{"type":"paragraph","content":[{"text":"Profile ","type":"text","marks":[{"type":"strong"}]},{"text":"within an Implementation Guide - Align with “AllergyIntolerance profile, International Patient Summary Implementation Guide, [Internet]. Patient Care Working Group, Health Level Seven International; [cited: 2024 Feb 05]. Available from: hfps://build.xir.org/ig/HL7/xir-ips/StructureDefiniWonAllergyIntolerance-uv-ips.html.”","type":"text"}]}]},{"type":"listItem","content":[{"type":"paragraph","content":[{"text":"Part of an Implementation Guide","type":"text","marks":[{"type":"strong"}]},{"text":" - Align with “Genomic background, Genomics Reporting Implementation Guide [Internet]. Clinical Genomics Working Group, Health Level Seven International; [cited 2024 May 09]. Available from https://build.fhir.org/ig/HL7/genomics-reporting/background.html” ","type":"text"}]}]}]},{"type":"paragraph"}]}]}]},{"type":"heading","attrs":{"level":2},"content":[{"text":"Copyright","type":"text"}]},{"type":"table","attrs":{"layout":"default","width":1800.0,"localId":"4432b1e4-5c06-4d61-99b3-3737a87ff0e3"},"content":[{"type":"tableRow","content":[{"type":"tableCell","attrs":{"colspan":1,"background":"#f0f0f0","rowspan":1,"colwidth":[259.0]},"content":[{"type":"paragraph","content":[{"text":"Copyright statement","type":"text","marks":[{"type":"strong"}]}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[501.0]},"content":[{"type":"blockquote","content":[{"type":"paragraph","content":[{"text":"copyright = <\"© openEHR Foundation\">","type":"text"}]}]}]}]}]},{"type":"heading","attrs":{"level":2},"content":[{"text":"Content copyright","type":"text"}]},{"type":"table","attrs":{"layout":"default","width":1800.0,"localId":"f5ddfcc1-9f36-4719-88a4-ea3aeff64eb2"},"content":[{"type":"tableRow","content":[{"type":"tableCell","attrs":{"colspan":1,"background":"#f0f0f0","rowspan":1,"colwidth":[259.0]},"content":[{"type":"paragraph","content":[{"text":"Guideline for communicating external content copyright requirements to users","type":"text","marks":[{"type":"strong"}]}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[501.0]},"content":[{"type":"paragraph","content":[{"text":"Include statement describing content copyright, formal copyright statement and access to information about permissions etc by the copyright holders. ","type":"text"},{"type":"hardBreak"},{"text":"For example:","type":"text"}]},{"type":"blockquote","content":[{"type":"paragraph","content":[{"text":"While openEHR archetypes are all freely available under an open license, the specific content of this Clinical Frailty Scale archetype is copyright protected. Any use of this archetype within implementations must be in compliance with the terms established by the copyright owners. ","type":"text"}]},{"type":"paragraph","content":[{"text":"Copyright statement: ©2009. Version 1.2_EN. All rights reserved. Geriatric Medicine Research, Dalhousie University, Halifax, Canada. ","type":"text"}]},{"type":"paragraph","content":[{"text":"Copyright information: ","type":"text"},{"text":"https://www.dal.ca/sites/gmr/our-tools/clinical-frailty-scale.html","type":"text","marks":[{"type":"link","attrs":{"href":"https://www.dal.ca/sites/gmr/our-tools/clinical-frailty-scale.html"}}]},{"text":".","type":"text"}]}]}]}]}]},{"type":"heading","attrs":{"level":2},"content":[{"text":"License","type":"text"}]},{"type":"table","attrs":{"layout":"full-width","width":1800.0,"localId":"d6e54b61-162c-45bf-9bc2-b089f28914a9"},"content":[{"type":"tableRow","content":[{"type":"tableHeader","attrs":{"colspan":1,"rowspan":1,"colwidth":[83.0]},"content":[{"type":"paragraph","content":[{"text":"Content Licence","type":"text"}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[1677.0]},"content":[{"type":"blockquote","content":[{"type":"paragraph","content":[{"text":"[\"licence\"] = <“This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit ","type":"text"},{"text":"http://creativecommons.org/licenses/by-sa/4.0/","type":"text","marks":[{"type":"link","attrs":{"href":"http://creativecommons.org/licenses/by-sa/4.0/"}}]},{"text":".”>","type":"text"}]}]}]}]}]},{"type":"heading","attrs":{"level":2},"content":[{"text":"IP Acknowledgement","type":"text"}]},{"type":"table","attrs":{"layout":"wide","width":1800.0,"localId":"2f23db62-aee0-4974-bdf6-e08f54278efe"},"content":[{"type":"tableRow","content":[{"type":"tableHeader","attrs":{"colspan":1,"rowspan":1,"colwidth":[116.0]},"content":[{"type":"paragraph","content":[{"text":"SNOMED-CT","type":"text"}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[844.0]},"content":[{"type":"paragraph","content":[{"text":"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: ","type":"text","marks":[{"type":"textColor","attrs":{"color":"#000000"}}]}]},{"type":"blockquote","content":[{"type":"paragraph","content":[{"text":"[\"ip_acknowledgements\"] = <\"This artefact includes content from SNOMED Clinical Terms® (SNOMED CT®) which is copyrighted material of the International Health Terminology Standards Development Organisation (IHTSDO). Where an implementation of this artefact makes use of SNOMED CT content, the implementer must have the appropriate SNOMED CT Affiliate license - for more information contact ","type":"text","marks":[{"type":"textColor","attrs":{"color":"#000000"}}]},{"text":"http://www.snomed.org/snomed-ct/get-snomedct","type":"text","marks":[{"type":"textColor","attrs":{"color":"#000000"}},{"type":"link","attrs":{"href":"http://www.snomed.org/snomed-ct/get-snomedct"}}]},{"text":" or ","type":"text","marks":[{"type":"textColor","attrs":{"color":"#000000"}}]},{"text":"info@snomed.org","type":"text","marks":[{"type":"textColor","attrs":{"color":"#000000"}},{"type":"link","attrs":{"href":"mailto:info@snomed.org"}}]},{"text":".\">","type":"text","marks":[{"type":"textColor","attrs":{"color":"#000000"}}]}]}]}]}]}]},{"type":"heading","attrs":{"level":2},"content":[{"text":"Data elements","type":"text"}]},{"type":"bulletList","content":[{"type":"listItem","content":[{"type":"paragraph","content":[{"text":"All data element names should be represented in Sentence case - ","type":"text"},{"text":"with the first letter ","type":"text","marks":[{"type":"textColor","attrs":{"color":"#222222"}}]},{"text":"uppercase","type":"text","marks":[{"type":"link","attrs":{"href":"https://en.wiktionary.org/wiki/uppercase"}}]},{"text":" and subsequent ","type":"text","marks":[{"type":"textColor","attrs":{"color":"#222222"}}]},{"text":"letters ","type":"text","marks":[{"type":"annotation","attrs":{"annotationType":"inlineComment","id":"99339fd2-e6c4-42fa-864e-95b3d670c668"}},{"type":"annotation","attrs":{"annotationType":"inlineComment","id":"bffe1557-7151-4872-9a68-2ae2d4b5a7ba"}},{"type":"textColor","attrs":{"color":"#222222"}}]},{"text":"lowercase","type":"text","marks":[{"type":"link","attrs":{"href":"https://en.wiktionary.org/wiki/lowercase"}}]},{"text":". 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results for each component parameter and their total sum for the ATRIA stroke risk score.","type":"text"}]}]}]}]},{"type":"tableRow","content":[{"type":"tableHeader","attrs":{"colspan":1,"rowspan":1,"colwidth":[164.0]},"content":[{"type":"paragraph","content":[{"text":"Data element names","type":"text","marks":[{"type":"annotation","attrs":{"annotationType":"inlineComment","id":"d6be53b4-27bc-4bc5-98a1-9b6ce764a175"}}]}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[1089.0]},"content":[{"type":"panel","attrs":{"panelType":"info"},"content":[{"type":"paragraph","content":[{"text":"Proposal","type":"text"}]}]},{"type":"paragraph","content":[{"text":"In a questionnaire type score or scale archetype, data elements should be named as the exact text of the question in the source material.","type":"text"},{"type":"hardBreak"},{"text":"Reasoning:","type":"text"}]},{"type":"bulletList","content":[{"type":"listItem","content":[{"type":"paragraph","content":[{"text":"Making short form names creates an additional modelling burden, and introduces the risk of errors or misunderstandings","type":"text"}]}]},{"type":"listItem","content":[{"type":"paragraph","content":[{"text":"Renaming the elements to the exact question text in templates, creates very long paths to the data elements","type":"text"}]}]},{"type":"listItem","content":[{"type":"paragraph","content":[{"text":"Modifying the element names may deviate from the Intellectual Properties of the source material","type":"text"}]}]},{"type":"listItem","content":[{"type":"paragraph","content":[{"text":"Using the original text makes reviewing easier","type":"text"}]}]}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[507.0]},"content":[{"type":"paragraph"}]}]},{"type":"tableRow","content":[{"type":"tableHeader","attrs":{"colspan":1,"rowspan":1,"colwidth":[164.0]},"content":[{"type":"paragraph","content":[{"text":"Data element descriptions","type":"text","marks":[{"type":"annotation","attrs":{"annotationType":"inlineComment","id":"49c0041c-4f50-4c86-b93b-523fc7189382"}}]}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[1089.0]},"content":[{"type":"panel","attrs":{"panelType":"info"},"content":[{"type":"paragraph","content":[{"text":"Proposal","type":"text"}]}]},{"type":"paragraph","content":[{"text":"Use original descriptions, or leave empty.","type":"text"}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[507.0]},"content":[{"type":"paragraph"}]}]},{"type":"tableRow","content":[{"type":"tableHeader","attrs":{"colspan":1,"rowspan":1,"colwidth":[164.0]},"content":[{"type":"paragraph","content":[{"text":"Total score","type":"text","marks":[{"type":"annotation","attrs":{"annotationType":"inlineComment","id":"5161a89d-f0b0-4fbb-abce-8b3a9bf20178"}}]}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[1089.0]},"content":[{"type":"paragraph","content":[{"text":"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’.","type":"text"}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[507.0]},"content":[{"type":"blockquote","content":[{"type":"paragraph","content":[{"text":"The total sum of each component parameter for the HScore.","type":"text"}]},{"type":"paragraph","content":[{"text":"Calculated ratio.","type":"text"}]}]}]}]},{"type":"tableRow","content":[{"type":"tableHeader","attrs":{"colspan":1,"rowspan":1,"colwidth":[164.0]},"content":[{"type":"paragraph","content":[{"text":"Name of data elements of non-calculcated scales","type":"text"}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[1089.0]},"content":[{"type":"paragraph","content":[{"text":"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’.","type":"text"}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[507.0]},"content":[{"type":"paragraph"}]}]},{"type":"tableRow","content":[{"type":"tableHeader","attrs":{"colspan":1,"rowspan":1,"colwidth":[164.0]},"content":[{"type":"paragraph","content":[{"text":"Clinical interpretation","type":"text"}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[1089.0]},"content":[{"type":"paragraph","content":[{"text":"Only to be added to a score if it is usually part of the formal score/scale representation.","type":"text"}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[507.0]},"content":[{"type":"paragraph"}]}]},{"type":"tableRow","content":[{"type":"tableHeader","attrs":{"colspan":1,"rowspan":1,"colwidth":[164.0]},"content":[{"type":"paragraph","content":[{"text":"Confounding factors","type":"text"}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[1089.0]},"content":[{"type":"paragraph","content":[{"text":"After ","type":"text"},{"text":"discussion (01 2020)","type":"text","marks":[{"type":"link","attrs":{"href":"https://discourse.openehr.org/t/extra-data-elements-in-archetypes-representing-clinical-scores-and-scales/299/27"}}]},{"text":", 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.","type":"text"}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[507.0]},"content":[{"type":"paragraph","content":[{"type":"hardBreak"}]}]}]},{"type":"tableRow","content":[{"type":"tableHeader","attrs":{"colspan":1,"rowspan":1,"colwidth":[164.0]},"content":[{"type":"paragraph","content":[{"text":"Comment","type":"text"}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[1089.0]},"content":[{"type":"paragraph","content":[{"text":"After ","type":"text"},{"text":"discussion (01 2020)","type":"text","marks":[{"type":"link","attrs":{"href":"https://discourse.openehr.org/t/extra-data-elements-in-archetypes-representing-clinical-scores-and-scales/299/27"}}]},{"text":", 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.","type":"text"}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[507.0]},"content":[{"type":"paragraph","content":[{"type":"hardBreak"}]}]}]},{"type":"tableRow","content":[{"type":"tableHeader","attrs":{"colspan":1,"rowspan":1,"colwidth":[164.0]},"content":[{"type":"paragraph","content":[{"text":"Other elements","type":"text"}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[1089.0]},"content":[{"type":"paragraph","content":[{"text":"After ","type":"text"},{"text":"discussion (01 2020)","type":"text","marks":[{"type":"link","attrs":{"href":"https://discourse.openehr.org/t/extra-data-elements-in-archetypes-representing-clinical-scores-and-scales/299/27"}}]},{"text":", 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.","type":"text"}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[507.0]},"content":[{"type":"paragraph","content":[{"type":"hardBreak"}]}]}]},{"type":"tableRow","content":[{"type":"tableHeader","attrs":{"colspan":1,"rowspan":1,"colwidth":[164.0]},"content":[{"type":"paragraph","content":[{"text":"Events","type":"text"}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[1089.0]},"content":[{"type":"paragraph","content":[{"text":"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).","type":"text","marks":[{"type":"strike"}]}]},{"type":"paragraph","content":[{"text":"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.","type":"text"}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[507.0]},"content":[{"type":"paragraph","content":[{"type":"hardBreak"}]}]}]}]},{"type":"heading","attrs":{"level":2},"content":[{"text":"Editorial style","type":"text"}]},{"type":"table","attrs":{"layout":"full-width","width":1800.0,"localId":"0ec8677c-4751-42f3-8a1a-38c3628f2922"},"content":[{"type":"tableRow","content":[{"type":"tableHeader","attrs":{"colspan":1,"rowspan":1,"colwidth":[106.0]},"content":[{"type":"paragraph","content":[{"type":"hardBreak"}]}]},{"type":"tableHeader","attrs":{"colspan":1,"rowspan":1,"colwidth":[890.0]},"content":[{"type":"paragraph","content":[{"text":"Description","type":"text"}]}]},{"type":"tableHeader","attrs":{"colspan":1,"rowspan":1,"colwidth":[764.0]},"content":[{"type":"paragraph","content":[{"text":"Example","type":"text"}]}]}]},{"type":"tableRow","content":[{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[106.0]},"content":[{"type":"paragraph","content":[{"text":"Dot points","type":"text"}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[890.0]},"content":[{"type":"paragraph","content":[{"text":"If dot points are required within the text, use hyphens ('-') followed by a space and then the subsequent text, not commencing with capitals","type":"text"}]}]},{"type":"tableCell","attrs":{"colspan":1,"rowspan":1,"colwidth":[764.0]},"content":[{"type":"paragraph","content":[{"text":"For example: ","type":"text"},{"type":"hardBreak"},{"text":"Triggers for closing one episode and commencing a new one will largely reflect local data collection preferences, including if the individual: ","type":"text"},{"type":"hardBreak"},{"text":"- quits for a significant period of time (which will likely be locally defined); or ","type":"text"},{"type":"hardBreak"},{"text":"- significantly changes their amount of use or pattern of their usage.","type":"text"}]}]}]}]},{"type":"paragraph","content":[{"type":"hardBreak"}]}],"version":1}