Archetype content & style guide

 

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"

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.



Use

  • 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."

Misuse

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



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 resource

Align with: "HL7 FHIR Resource - <resource name> <release> [Internet]. Health Level Seven International; [accessed <date>]. Available from: <permanent version- or release-specific URL>."

For example: "HL7 FHIR Resource - AllergyIntolerance R1.2.0 STU3 draft [Internet]. Health Level Seven International; [accessed 2020 Jan 17]. Available from: http://hl7.org/fhir/2016Jan/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.

Copyright statement

copyright = <"© openEHR Foundation">

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 elements should be represented in Sentence case - with the first letter uppercase and subsequent letters lowercase. Exceptions include proper nouns or acronyms.

All descriptions should have a full stop or equivalent at the end of the description.

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> <...>.

Comment: 

Coding with an external terminology is preferred, where possible.

Coding with an external terminology is optional.

 

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 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.">

 

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: 

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

 

Scores and Scales



Description

Example



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.





Apgar score -  OBSERVATION.apgar
Braden scale - OBSERVATION.braden

Edmonton Symptom Assessment System Revised (ESAS-r) - OBSERVATION.esas_r

HAS-BLED score - OBSERVATION.has_bled
ACVPU score - OBSERVATION.acvpu
ECOG performance status - OBSERVATION.ecog

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



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:
OBSERVATION.grace_admission and OBSERVATION.grace_discharge.

Concept description

Record an explanation of the concept being recorded.

An assessment score used to predict the risk of stroke in patients with atrial fibrillation.

Purpose

Record the reason for using this archetype to record data, not to describe the purpose of the score or scale itself.

To record the results for each component parameter and their total sum for the ATRIA stroke risk score.

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.

Use to record the results for each component parameter and their total sum for the ATRIA stroke risk score.

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’.

The total sum of each component parameter for the HScore.

Calculated 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).



Editorial style



Description

Example



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: 
Triggers for closing one episode and commencing a new one will largely reflect local data collection preferences, including if the individual:
- quits for a significant period of time (which will likely be locally defined); or
- significantly changes their amount of use or pattern of their usage.