Entry subtype for all clinical data in the past or present, i.e. which (by the time it is recorded) has already occurred. OBSERVATION data is expressed using the class HISTORY<T>, which guarantees that it is situated in time. OBSERVATION is used for all notionally objective (i.e. measured in some way) observations of phenomena, and patient-reported phenomena, e.g. pain.

Not to be used for recording opinion or future statements of any kind, including instructions, intentions, plans etc.

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.

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.

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.

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

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.

Details of archetyping used on this node.

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.

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

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

Other participations at ENTRY level.

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

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

• organ donor
• foetus
• a family member
• another clinically relevant person

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.

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.

Optional external identifier of guideline creating this Entry if relevant.

The data of this observation, in the form of a history of values which may be of any complexity.

Optional recording of the state of subject of this observation during the observation process, in the form of a separate history of values which may be of any complexity. State may also be recorded within the History of the data attribute.

Entry subtype for all clinical data in the past or present, i.e. which (by the time it is recorded) has already occurred. OBSERVATION data is expressed using the class HISTORY<T>, which guarantees that it is situated in time. OBSERVATION is used for all notionally objective (i.e. measured in some way) observations of phenomena, and patient-reported phenomena, e.g. pain.

Not to be used for recording opinion or future statements of any kind, including instructions, intentions, plans etc.

The data of this observation, in the form of a history of values which may be of any complexity.

Optional recording of the state of subject of this observation during the observation process, in the form of a separate history of values which may be of any complexity. State may also be recorded within the History of the data attribute.

Entry subtype for all clinical data in the past or present, i.e. which (by the time it is recorded) has already occurred. OBSERVATION data is expressed using the class HISTORY<T>, which guarantees that it is situated in time. OBSERVATION is used for all notionally objective (i.e. measured in some way) observations of phenomena, and patient-reported phenomena, e.g. pain.

Not to be used for recording opinion or future statements of any kind, including instructions, intentions, plans etc.

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.

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.

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.

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

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.

Details of archetyping used on this node.

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.

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

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

Other participations at ENTRY level.

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

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

• organ donor
• foetus
• a family member
• another clinically relevant person

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.

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.

Optional external identifier of guideline creating this Entry if relevant.

The data of this observation, in the form of a history of values which may be of any complexity.

Optional recording of the state of subject of this observation during the observation process, in the form of a separate history of values which may be of any complexity. State may also be recorded within the History of the data attribute.