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Archetype content & style guide

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



Description

Example

Concept name

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"

 

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.

Obstetric National Early Warning score (ONEWS) - Sweden - with archetype ID OBSERVATION.onews_se

Obstetric National Early Warning score (ONEWS) - Norway - with archetype ID OBSERVATION.onews_no

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

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

“Use to record all representations of systemic arterial blood pressure measurement, no matter which method or body location is used to record it.”

  • 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."

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 NLM Style Guide for Authors, Editors, and Publishers

https://www.ncbi.nlm.nih.gov/books/NBK7256/?amp=&depth=2.

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.

https://www.ncbi.nlm.nih.gov/sites/myncbi/

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

  • Resource - Align with: "<Resource name> <release> [Internet]. Health Level Seven International; [cited: <year MON date >]. Available from: <permanent version- or release-specific URL>."
    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.”
    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.

  • Profile 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.”

  • Part of an Implementation Guide - 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”

 

Copyright

Copyright statement

copyright = <"© openEHR Foundation">

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.
For example:

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.

Copyright statement: ©2009. Version 1.2_EN. All rights reserved. Geriatric Medicine Research, Dalhousie University, Halifax, Canada.

Copyright information: https://www.dal.ca/sites/gmr/our-tools/clinical-frailty-scale.html.

License

Content Licence

["licence"] = <“This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/.”>

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: 

["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 http://www.snomed.org/snomed-ct/get-snomedct or info@snomed.org.">

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



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.

  • 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.] 

<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:

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

Clinical description

As per examination archetype pattern.

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

<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.

Digital image, video or diagram representing the findings.

Digital representation of the evidence of consent.

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.

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.

Confounding factors



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

Any event

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.

Any point in time event



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

Extension SLOT

Added to Protocol for every COMPOSITION or ENTRY archet