Generated Narrative: StructureDefinition openEHR-EHR-CLUSTER.symptom-sign.v2 Name Flags Card. Type Description & Constraints CLUSTER 0..* CLUSTER Symptom/Sign #xD; Slices for items 1..* ITEM Ordered list of items - `CLUSTER` or `ELEMENT` objects - under this `CLUSTER`. Slice: Unordered, Closed by profile:$this #xD; items:at0001 1..* ELEMENT Symptom/Sign name #xD; value 0..1 DV_TEXT Property representing leaf value object of `ELEMENT`. #xD; items:at0151 0..* ELEMENT Body site #xD; value 0..1 DV_TEXT Property representing leaf value object of `ELEMENT`. #xD; items:at0147 0..* CLUSTER Structured body site #xD; items:at0002 0..1 ELEMENT Description #xD; value 0..1 DV_TEXT Property representing leaf value object of `ELEMENT`. #xD; items:at0175 0..1 ELEMENT Episodicity #xD; value 0..1 DV_CODED_TEXT Property representing leaf value object of `ELEMENT`. Binding: Episodicity ValueSet (required) #xD; items:at0186 0..1 ELEMENT Occurrence #xD; value 0..1 DV_CODED_TEXT Property representing leaf value object of `ELEMENT`. Binding: Occurrence ValueSet (required) #xD; items:at0152 0..1 ELEMENT Episode onset #xD; Slices for value 0..1 DATA_VALUE Property representing leaf value object of `ELEMENT`. Slice: Unordered, Closed by type:$this #xD; value:DV_DATE_TIME 0..1 DV_DATE_TIME Property representing leaf value object of `ELEMENT`. #xD; <a href="StructureDefinition-openEHR-EHR-CLUSTER.symptom-sign.v2-definitions.html#CLUSTER.items:at0152.value:DV_INTERVAL<DV_DATE_TIME>" title="Slice DV_INTERVAL<DV_DATE_TIME>">value:DV_INTERVAL<DV_DATE_TIME> 0..1 DV_INTERVAL<> Property representing leaf value object of `ELEMENT`. #xD; items:at0164 0..1 ELEMENT Onset timing #xD; Slices for value 0..1 DATA_VALUE Property representing leaf value object of `ELEMENT`. Slice: Unordered, Closed by type:$this #xD; value:DV_TEXT 0..1 DV_TEXT Property representing leaf value object of `ELEMENT`. #xD; value:DV_DURATION 0..1 DV_DURATION Property representing leaf value object of `ELEMENT`. #xD; <a href="StructureDefinition-openEHR-EHR-CLUSTER.symptom-sign.v2-definitions.html#CLUSTER.items:at0164.value:DV_INTERVAL<DV_DURATION>" title="Slice DV_INTERVAL<DV_DURATION>">value:DV_INTERVAL<DV_DURATION> 0..1 DV_INTERVAL<> Property representing leaf value object of `ELEMENT`. #xD; items:at0200 0..1 ELEMENT Nadir #xD; value 0..1 DV_DATE_TIME Property representing leaf value object of `ELEMENT`. #xD; items:at0028 0..1 ELEMENT Episode duration #xD; Slices for value 0..1 DATA_VALUE Property representing leaf value object of `ELEMENT`. Slice: Unordered, Closed by type:$this #xD; value:DV_DURATION 0..1 DV_DURATION Property representing leaf value object of `ELEMENT`. #xD; value 1..1 string ISO8601 duration string, including described deviations to support negative values and weeks. #xD; <a href="StructureDefinition-openEHR-EHR-CLUSTER.symptom-sign.v2-definitions.html#CLUSTER.items:at0028.value:DV_INTERVAL<DV_DURATION>" title="Slice DV_INTERVAL<DV_DURATION>">value:DV_INTERVAL<DV_DURATION> 0..1 DV_INTERVAL<> Property representing leaf value object of `ELEMENT`. #xD; <a href="StructureDefinition-openEHR-EHR-CLUSTER.symptom-sign.v2-definitions.html#CLUSTER.items:at0028.value:DV_INTERVAL<DV_DURATION>.lower">lower DV_DURATION #xD; <a href="StructureDefinition-openEHR-EHR-CLUSTER.symptom-sign.v2-definitions.html#CLUSTER.items:at0028.value:DV_INTERVAL<DV_DURATION>.lower.value">value #xD; <a href="StructureDefinition-openEHR-EHR-CLUSTER.symptom-sign.v2-definitions.html#CLUSTER.items:at0028.value:DV_INTERVAL<DV_DURATION>.upper">upper DV_DURATION #xD; <a href="StructureDefinition-openEHR-EHR-CLUSTER.symptom-sign.v2-definitions.html#CLUSTER.items:at0028.value:DV_INTERVAL<DV_DURATION>.upper.value">value #xD; value:DV_TEXT 0..1 DV_TEXT Property representing leaf value object of `ELEMENT`. #xD; items:at0021 0..1 ELEMENT Severity category #xD; Slices for value 0..1 DATA_VALUE Property representing leaf value object of `ELEMENT`. Slice: Unordered, Closed by type:$this #xD; value:DV_CODED_TEXT 0..1 DV_CODED_TEXT Property representing leaf value object of `ELEMENT`. Binding: Severity category ValueSet (required) #xD; value:DV_TEXT 0..1 DV_TEXT Property representing leaf value object of `ELEMENT`. #xD; items:at0198 0..* CLUSTER Severity rating #xD; items:at0189 0..* ELEMENT Character #xD; value 0..1 DV_TEXT Property representing leaf value object of `ELEMENT`. #xD; items:at0180 0..* ELEMENT Progression #xD; Slices for value 0..1 DATA_VALUE Property representing leaf value object of `ELEMENT`. Slice: Unordered, Closed by type:$this #xD; value:DV_CODED_TEXT 0..1 DV_CODED_TEXT Property representing leaf value object of `ELEMENT`. Binding: Progression ValueSet (required) #xD; value:DV_TEXT 0..1 DV_TEXT Property representing leaf value object of `ELEMENT`. #xD; items:at0003 0..1 ELEMENT Pattern #xD; value 0..1 DV_TEXT Property representing leaf value object of `ELEMENT`. #xD; items:at0018 0..* CLUSTER Modifying factor #xD; Slices for items 1..* ITEM Ordered list of items - `CLUSTER` or `ELEMENT` objects - under this `CLUSTER`. Slice: Unordered, Closed by profile:$this #xD; items:at0019 0..1 ELEMENT Factor #xD; value 0..1 DV_TEXT Property representing leaf value object of `ELEMENT`. #xD; items:at0197 0..1 CLUSTER Factor detail #xD; items:at0017 0..1 ELEMENT Effect #xD; value 0..1 DV_CODED_TEXT Property representing leaf value object of `ELEMENT`. Binding: Effect ValueSet (required) #xD; items:at0056 0..1 ELEMENT Description #xD; value 0..1 DV_TEXT Property representing leaf value object of `ELEMENT`. #xD; items:at0165 0..* CLUSTER Precipitating factor #xD; Slices for items 1..* ITEM Ordered list of items - `CLUSTER` or `ELEMENT` objects - under this `CLUSTER`. Slice: Unordered, Closed by profile:$this #xD; items:at0170 0..1 ELEMENT Factor #xD; value 0..1 DV_TEXT Property representing leaf value object of `ELEMENT`. #xD; items:at0154 0..* CLUSTER Factor detail #xD; items:at0171 0..1 ELEMENT Time interval #xD; value 0..1 DV_DURATION Property representing leaf value object of `ELEMENT`. #xD; items:at0185 0..1 ELEMENT Description #xD; value 0..1 DV_TEXT Property representing leaf value object of `ELEMENT`. #xD; items:at0190 0..* CLUSTER Resolving factor #xD; Slices for items 1..* ITEM Ordered list of items - `CLUSTER` or `ELEMENT` objects - under this `CLUSTER`. Slice: Unordered, Closed by profile:$this #xD; items:at0193 0..1 ELEMENT Factor #xD; value 0..1 DV_TEXT Property representing leaf value object of `ELEMENT`. #xD; items:at0194 0..* CLUSTER Factor detail #xD; items:at0195 0..1 ELEMENT Time interval #xD; value 0..1 DV_DURATION Property representing leaf value object of `ELEMENT`. #xD; items:at0196 0..1 ELEMENT Description #xD; value 0..1 DV_TEXT Property representing leaf value object of `ELEMENT`. #xD; items:at0155 0..* ELEMENT Impact #xD; value 0..1 DV_TEXT Property representing leaf value object of `ELEMENT`. #xD; items:at0037 0..1 ELEMENT Episode description #xD; value 0..1 DV_TEXT Property representing leaf value object of `ELEMENT`. #xD; items:at0153 0..* CLUSTER Specific details #xD; items:at0161 0..1 ELEMENT Resolution date/time #xD; value 0..1 DV_DATE_TIME Property representing leaf value object of `ELEMENT`. #xD; items:at0057 0..1 ELEMENT Description of previous episodes #xD; value 0..1 DV_TEXT Property representing leaf value object of `ELEMENT`. #xD; items:at0031 0..1 ELEMENT Number of previous episodes #xD; value 0..1 DV_COUNT Property representing leaf value object of `ELEMENT`. #xD; magnitude 1..1 integer #xD; items:at0146 0..* CLUSTER Previous episodes #xD; items:at0063 0..* CLUSTER Associated symptom/sign #xD; items:at0163 0..1 ELEMENT Comment #xD; value 0..1 DV_TEXT Property representing leaf value object of `ELEMENT`. #xD; Documentation for this format
HL7 International / Clinical Interoperability Council
Use to record details about a single episode of a symptom or reported sign in an individual, as reported by the individual, parent, care-giver or other party. It may be recorded by a clinician as part of a clinical history record as reported to them, observed by the clinician or self-recorded as part of a clinical questionnaire or personal health record. A complete clinical history or patient story may include varying level of details about multiple episodes of an identified symptom or reported sign, as well as multiple symptoms/signs. This archetype has been designed to record the positive presence of the symptom or sign as part of history taking using OBSERVATION.story, or in conjunction with a positive response to OBSERVATION.symptom_sign_screening. In the purest sense, symptoms are subjective observations of a physical or mental disturbance and signs are objective observations of the same, as experienced by an individual and reported to the history taker by the same individual or another party. From this logic it follows that we will need two archetypes to record clinical history - one for reported symptoms and another for reported signs. In reality this is impractical as it will require clinical data entry into either one of these models which adds signficant overheads to modellers and those entering data. In addition, there is often overlap in clinical concepts - for example, is previous vomiting or bleeding to be categorised as a symptom or reported sign? In response, this archetype has been specifically designed to provide a single information model that allows for recording of the entire continuum between clearly identifiable symptoms and reported signs. This archetype has been intended to be used as a generic pattern for all symptoms and reported signs. The 'Specific details' SLOT can be used to extend the archetype to include additional, specific data elements for more complex symptoms or signs. This archetype has been specifically designed to be used in the 'Structured detail' SLOT within the OBSERVATION.story archetype, but can also be used within other OBSERVATION or CLUSTER archetypes and in the 'Associated symptom/sign' or 'Previous episode' SLOT within other instances of this CLUSTER.symptom_sign archetype.
To record details about a single episode of a reported symptom or sign including context, but not details, of previous episodes if appropriate. Misuse: Not to be used to record screening questionnaire responses about the presence or absence of specific symptoms - use the OBSERVATION.symptom_sign_screening archetype for this purpose. However, this CLUSTER.symptom_sign archetype may be nested within the 'Screening details' SLOT in the OBSERVATION.symptom_sign_screening archetype if it is necessary to extend the questionnaire by recording details about symptom or sign. Not to be used to record that a symptom or sign was explicitly reported as not present - use CLUSTER.exclusion_symptom_sign carefully for specific purposes where the overheads of recording in this way warrant the additional complexity. Not to be used for recording objective findings as part of a physical examination - use OBSERVATION.exam and related examination CLUSTER archetypes for this purpose. Not to be used for diagnoses and problems that form part of a persisting Problem List - use EVALUATION.problem_diagnosis. Not to be used to record a formal and repeatable severity scale such as VAS or NRS. Use appropriate OBSERVATION archetypes for this purpose.
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Reported observation of a physical or mental disturbance in an individual.
links.exists() implies links.empty().not()
Archetyped valid must satisfy exclusive conditions
is_archetype_root() xor archetype_details .empty()
Archetype node id valid must not be empty
Runtime name of this fragment, used to build runtime paths.
Runtime name of this fragment, used to build runtime paths. 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.
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 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.
Ordered list of items - `CLUSTER` or `ELEMENT` objects - under this `CLUSTER`.
The name of the reported symptom or sign.
Flavour of null value, e.g. `253|unknown|`, `271|no information|`, `272|masked|`, and `273|not applicable|`.
Property representing leaf value object of `ELEMENT`.
Property representing leaf value object of `ELEMENT`. In real data, any concrete subtype of `DATA_VALUE` can be used.
Optional specific reason for null value; if set, `_null_flavour_` must be set.
Optional specific reason for null value; if set, `_null_flavour_` must be set. Null reason may apply only to a minority of clinical data, commonly needed in reporting contexts.
Simple body site where the symptom or sign was reported.
Structured body site where the symptom or sign was reported.
Narrative description about the reported symptom or sign.
Category of this episode for the identified symptom or sign.
Type of occurrence for this symptom or sign?
The onset for this episode of the symptom or sign.
Timing of the onset and development of the symptom or sign.
Date/time when a monophasic, progressive symptom or sign reached its' maximal intensity or functional impact.
The duration of this episode of the symptom or sign since initial onset.
Predefined terminology identifier to indicate it is local to the knowledge resource in which it occurs, e.g. an archetype
Optional normal status indicator of value with respect to normal range for this value.
Optional normal status indicator of value with respect to normal range for this value. Often included by lab, even if the normal range itself is not included. Coded by ordinals in series HHH, HH, H, (nothing), L, LL, LLL; see openEHR terminology group `normal_status`.
Optional tagged other reference ranges for this value in its particular measurement context.
Optional status of magnitude with values: * `"="` : magnitude is a point value * `"<"` : value is < magnitude * `">"` : value is > magnitude * `"<="` : value is <= magnitude * `">="` : value is >= magnitude * `"~"` : value is approximately magnitude If not present, assumed meaning is `"="` .
Accuracy of measurement, expressed either as a half-range percent value (`_accuracy_is_percent_` = `True`) or a half-range quantity.
Accuracy of measurement, expressed either as a half-range percent value (`_accuracy_is_percent_` = `True`) or a half-range quantity. A value of `0` means that accuracy is 100%, i.e. no error. A value of `_unknown_accuracy_value_` means that accuracy was not recorded.
If `True`, indicates that when this object was created, `_accuracy_` was recorded as a percent value; if `False`, as an absolute quantity value.
ISO8601 duration string, including described deviations to support negative values and weeks.
Category representing the overall severity of the symptom or sign.
Numerical rating scale representing the overall severity of the symptom or sign.
Word or short phrase describing the nature of the symptom or sign.
Description progression of the symptom or sign at the time of reporting.
Narrative description about the pattern of the symptom or sign during this episode.
Detail about how a specific factor effects the identified symptom or sign during this episode.
Structured detail about the factor associated with the identified symptom or sign.
Perceived effect of the modifying factor on the symptom or sign.
Narrative description of the effect of the modifying factor on the symptom or sign.
Details about specified factors that are associated with the precipitation of the symptom or sign.
Name of the health event, symptom, reported sign or other factor.
The interval of time between the occurrence or onset of the factor and onset of the symptom or sign.
Narrative description about the effect of the factor on the identified symptom or sign.
Details about specified factors that are associated with the resolution of the symptom or sign.
The interval of time between the occurrence or onset of the factor and resolution of the symptom or sign.
Description of the impact of this symptom or sign.
Narrative description about the course of the symptom or sign during this episode.
Specific data elements that are additionally required to record as unique attributes of the identified symptom or sign.
The timing of the cessation of this episode of the symptom or sign.
Narrative description of any or all previous episodes.
The number of times this symptom or sign has previously occurred.
Structured details of the symptom or sign during a previous episode.
Structured details about any associated symptoms or signs that are concurrent.
Additional narrative about the symptom or sign not captured in other fields.