OpenEHR Base package
0.1.0 - First Draft International flag

OpenEHR Base package, published by openEHR + HL7. This guide is not an authorized publication; it is the continuous build for version 0.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/FHIR/openehr-base-ig/ and changes regularly. See the Directory of published versions

Logical Model: EVALUATION - Detailed Descriptions

Page standards status: Informative Maturity Level: 3

Definitions for the EVALUATION logical model.

Guidance on how to interpret the contents of this table can be foundhere

0. EVALUATION
Definition

Entry type for evaluation statements. Used for all kinds of statements which evaluate other information, such as interpretations of observations, diagnoses, differential diagnoses, hypotheses, risk assessments, goals and plans.


Base definition for all types defined in FHIR type system.

ShortEntry type for evaluation statementsBase for all types and resources
Comments

Should not be used for actionable statements such as medication orders - these are represented using the INSTRUCTION type.

Control0..*
Is Modifierfalse
Logical ModelInstances of this logical model are not marked to be the target of a Reference
2. EVALUATION.name
Definition

This is the term provided via a clinical application or batch process to name this EHR construct: its retention in the EHR faithfully preserves the original label by which this entry was known to end users.

ShortRuntime name of this fragment, used to build runtime paths
Control1..1
Typehttp://openehr.org/fhir/StructureDefinition/DV-TEXT
Is Modifierfalse
4. EVALUATION.archetype-node-id
Definition

Design-time archetype identifier of this node taken from its generating archetype; used to build archetype paths. Always in the form of an at-code, e.g. at0005. This value enables a 'standardised' name for this node to be generated, by referring to the generating archetype local terminology.

ShortDesign-time archetype identifier of this node taken from its generating archetype
Comments

At an archetype root point, the value of this attribute is always the stringified form of the archetype_id found in the archetype_details object.

Control1..1
Typestring
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
6. EVALUATION.uid
Definition

Optional globally unique object identifier for root points of archetyped structures.

ShortOptional globally unique object identifier for root points of archetyped structures
Control0..1
Typehttp://openehr.org/fhir/StructureDefinition/UID-BASED-ID
Is Modifierfalse
8. EVALUATION.links
Definition

Links to other archetyped structures (data whose root object inherits from ARCHETYPED, such as ENTRY, SECTION and so on). Links may be to structures in other compositions.

ShortLinks to other archetyped structures
Control0..*
Typehttp://openehr.org/fhir/StructureDefinition/LINK
Is Modifierfalse
10. EVALUATION.archetype-details
Definition

Details of archetyping used on this node.

ShortDetails of archetyping used on this node
Control0..1
Typehttp://openehr.org/fhir/StructureDefinition/ARCHETYPED
Is Modifierfalse
12. EVALUATION.feeder-audit
Definition

Audit trail from non-openEHR system of original commit of information forming the content of this node, or from a conversion gateway which has synthesised this node.

ShortAudit trail from non-openEHR system of original commit of information forming the content of this node
Control0..1
Typehttp://openehr.org/fhir/StructureDefinition/FEEDER-AUDIT
Is Modifierfalse
14. EVALUATION.language
Definition

Mandatory indicator of the localised language in which this Entry is written. Coded from openEHR Code Set languages.

ShortMandatory indicator of the localised language in which this Entry is written. Coded from openEHR Code Set languages
Control1..1
BindingThe codes SHALL be taken from AllLanguages
(required to http://hl7.org/fhir/ValueSet/all-languages)
Typehttp://openehr.org/fhir/StructureDefinition/CODE-PHRASE
Is Modifierfalse
16. EVALUATION.encoding
Definition

Name of character set in which text values in this Entry are encoded. Coded from openEHR Code Set character sets.

ShortName of character set in which text values in this Entry are encoded
Control1..1
BindingThe codes SHALL be taken from Character Set
(required to https://specifications.openehr.org/fhir/valueset-character_sets)
Typehttp://openehr.org/fhir/StructureDefinition/CODE-PHRASE
Is Modifierfalse
18. EVALUATION.other-participations
Definition

Other participations at ENTRY level.

ShortOther participations at ENTRY level
Control0..*
Typehttp://openehr.org/fhir/StructureDefinition/PARTICIPATION
Is Modifierfalse
20. EVALUATION.workflow-id
Definition

Identifier of externally held workflow engine data for this workflow execution, for this subject of care.

ShortIdentifier of externally held workflow engine data for this workflow execution, for this subject of care
Control0..1
Typehttp://openehr.org/fhir/StructureDefinition/OBJECT-REF
Is Modifierfalse
22. EVALUATION.subject
Definition

Id of human subject of this ENTRY, e.g.:

  • organ donor
  • foetus
  • a family member
  • another clinically relevant person
ShortId of human subject of this ENTRY, e.g. organ donor, foetus, a family member, or another clinically relevant person
Control1..1
Typehttp://openehr.org/fhir/StructureDefinition/PARTY-PROXY
Is Modifierfalse
24. EVALUATION.provider
Definition

Optional identification of provider of the information in this ENTRY, which might be:

  • the patient
  • a patient agent, e.g. parent, guardian
  • the clinician
  • a device or software

Generally only used when the recorder needs to make it explicit. Otherwise, Composition composer and other participants are assumed.

ShortOptional identification of provider of the information in this ENTRY, which might be the patient, a patient agent, the clinician, a device
Control0..1
Typehttp://openehr.org/fhir/StructureDefinition/PARTY-PROXY
Is Modifierfalse
26. EVALUATION.protocol
Definition

Description of the method (i.e. how) the information in this entry was arrived at. For OBSERVATIONs, this is a description of the method or instrument used. For EVALUATIONs, how the evaluation was arrived at. For INSTRUCTIONs, how to execute the Instruction. This may take the form of references to guidelines, including manually followed and executable; knowledge references such as a paper in Medline; clinical reasons within a larger care process.

ShortDescription of the method (i.e. how) the information in this entry was arrived at
Control0..1
Typehttp://openehr.org/fhir/StructureDefinition/ITEM-STRUCTURE
Is Modifierfalse
28. EVALUATION.guideline-id
Definition

Optional external identifier of guideline creating this Entry if relevant.

ShortOptional external identifier of guideline creating this Entry if relevant
Control0..1
Typehttp://openehr.org/fhir/StructureDefinition/OBJECT-REF
Is Modifierfalse
30. EVALUATION.data
Definition

The data of this evaluation, in the form of a spatial data structure.

ShortThe data of this evaluation, in the form of a spatial data structure
Control1..1
Typehttp://openehr.org/fhir/StructureDefinition/ITEM-STRUCTURE
Is Modifierfalse

Guidance on how to interpret the contents of this table can be foundhere

0. EVALUATION
Definition

Entry type for evaluation statements. Used for all kinds of statements which evaluate other information, such as interpretations of observations, diagnoses, differential diagnoses, hypotheses, risk assessments, goals and plans.

ShortEntry type for evaluation statements
Comments

Should not be used for actionable statements such as medication orders - these are represented using the INSTRUCTION type.

Control0..*
Is Modifierfalse
Logical ModelInstances of this logical model are not marked to be the target of a Reference
2. EVALUATION.data
Definition

The data of this evaluation, in the form of a spatial data structure.

ShortThe data of this evaluation, in the form of a spatial data structure
Control1..1
Typehttp://openehr.org/fhir/StructureDefinition/ITEM-STRUCTURE
Is Modifierfalse

Guidance on how to interpret the contents of this table can be foundhere

0. EVALUATION
Definition

Entry type for evaluation statements. Used for all kinds of statements which evaluate other information, such as interpretations of observations, diagnoses, differential diagnoses, hypotheses, risk assessments, goals and plans.

ShortEntry type for evaluation statements
Comments

Should not be used for actionable statements such as medication orders - these are represented using the INSTRUCTION type.

Control0..*
Is Modifierfalse
Logical ModelInstances of this logical model are not marked to be the target of a Reference
2. EVALUATION.name
Definition

This is the term provided via a clinical application or batch process to name this EHR construct: its retention in the EHR faithfully preserves the original label by which this entry was known to end users.

ShortRuntime name of this fragment, used to build runtime paths
Control1..1
Typehttp://openehr.org/fhir/StructureDefinition/DV-TEXT
Is Modifierfalse
4. EVALUATION.archetype-node-id
Definition

Design-time archetype identifier of this node taken from its generating archetype; used to build archetype paths. Always in the form of an at-code, e.g. at0005. This value enables a 'standardised' name for this node to be generated, by referring to the generating archetype local terminology.

ShortDesign-time archetype identifier of this node taken from its generating archetype
Comments

At an archetype root point, the value of this attribute is always the stringified form of the archetype_id found in the archetype_details object.

Control1..1
Typestring
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
6. EVALUATION.uid
Definition

Optional globally unique object identifier for root points of archetyped structures.

ShortOptional globally unique object identifier for root points of archetyped structures
Control0..1
Typehttp://openehr.org/fhir/StructureDefinition/UID-BASED-ID
Is Modifierfalse
8. EVALUATION.links
Definition

Links to other archetyped structures (data whose root object inherits from ARCHETYPED, such as ENTRY, SECTION and so on). Links may be to structures in other compositions.

ShortLinks to other archetyped structures
Control0..*
Typehttp://openehr.org/fhir/StructureDefinition/LINK
Is Modifierfalse
10. EVALUATION.archetype-details
Definition

Details of archetyping used on this node.

ShortDetails of archetyping used on this node
Control0..1
Typehttp://openehr.org/fhir/StructureDefinition/ARCHETYPED
Is Modifierfalse
12. EVALUATION.feeder-audit
Definition

Audit trail from non-openEHR system of original commit of information forming the content of this node, or from a conversion gateway which has synthesised this node.

ShortAudit trail from non-openEHR system of original commit of information forming the content of this node
Control0..1
Typehttp://openehr.org/fhir/StructureDefinition/FEEDER-AUDIT
Is Modifierfalse
14. EVALUATION.language
Definition

Mandatory indicator of the localised language in which this Entry is written. Coded from openEHR Code Set languages.

ShortMandatory indicator of the localised language in which this Entry is written. Coded from openEHR Code Set languages
Control1..1
BindingThe codes SHALL be taken from AllLanguages
(required to http://hl7.org/fhir/ValueSet/all-languages)
Typehttp://openehr.org/fhir/StructureDefinition/CODE-PHRASE
Is Modifierfalse
16. EVALUATION.encoding
Definition

Name of character set in which text values in this Entry are encoded. Coded from openEHR Code Set character sets.

ShortName of character set in which text values in this Entry are encoded
Control1..1
BindingThe codes SHALL be taken from Character Set
(required to https://specifications.openehr.org/fhir/valueset-character_sets)
Typehttp://openehr.org/fhir/StructureDefinition/CODE-PHRASE
Is Modifierfalse
18. EVALUATION.other-participations
Definition

Other participations at ENTRY level.

ShortOther participations at ENTRY level
Control0..*
Typehttp://openehr.org/fhir/StructureDefinition/PARTICIPATION
Is Modifierfalse
20. EVALUATION.workflow-id
Definition

Identifier of externally held workflow engine data for this workflow execution, for this subject of care.

ShortIdentifier of externally held workflow engine data for this workflow execution, for this subject of care
Control0..1
Typehttp://openehr.org/fhir/StructureDefinition/OBJECT-REF
Is Modifierfalse
22. EVALUATION.subject
Definition

Id of human subject of this ENTRY, e.g.:

  • organ donor
  • foetus
  • a family member
  • another clinically relevant person
ShortId of human subject of this ENTRY, e.g. organ donor, foetus, a family member, or another clinically relevant person
Control1..1
Typehttp://openehr.org/fhir/StructureDefinition/PARTY-PROXY
Is Modifierfalse
24. EVALUATION.provider
Definition

Optional identification of provider of the information in this ENTRY, which might be:

  • the patient
  • a patient agent, e.g. parent, guardian
  • the clinician
  • a device or software

Generally only used when the recorder needs to make it explicit. Otherwise, Composition composer and other participants are assumed.

ShortOptional identification of provider of the information in this ENTRY, which might be the patient, a patient agent, the clinician, a device
Control0..1
Typehttp://openehr.org/fhir/StructureDefinition/PARTY-PROXY
Is Modifierfalse
26. EVALUATION.protocol
Definition

Description of the method (i.e. how) the information in this entry was arrived at. For OBSERVATIONs, this is a description of the method or instrument used. For EVALUATIONs, how the evaluation was arrived at. For INSTRUCTIONs, how to execute the Instruction. This may take the form of references to guidelines, including manually followed and executable; knowledge references such as a paper in Medline; clinical reasons within a larger care process.

ShortDescription of the method (i.e. how) the information in this entry was arrived at
Control0..1
Typehttp://openehr.org/fhir/StructureDefinition/ITEM-STRUCTURE
Is Modifierfalse
28. EVALUATION.guideline-id
Definition

Optional external identifier of guideline creating this Entry if relevant.

ShortOptional external identifier of guideline creating this Entry if relevant
Control0..1
Typehttp://openehr.org/fhir/StructureDefinition/OBJECT-REF
Is Modifierfalse
30. EVALUATION.data
Definition

The data of this evaluation, in the form of a spatial data structure.

ShortThe data of this evaluation, in the form of a spatial data structure
Control1..1
Typehttp://openehr.org/fhir/StructureDefinition/ITEM-STRUCTURE
Is Modifierfalse