Capabilities required for a system exchanging symptoms data.

Use to record a positive statement to explicitly record that a symptom or sign was reported as not present. Use to record exlicitly that a symptom or sign was absolutely not present. If this is not absolutely required, consider use of the 'Nil significant' data element within the CLUSTER.symptom_sign archetype. 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, where clinically appropriate.

A logical model showing the elements of a Symptom that have been deemed important and relevant for capture and exchange.

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.

A point in time collection of observations for a patient. This profile is used for exchanging a set of observation data collected through the use of a structured resource (e.g., assessment tool, instrument, or screen) with multiple questions. NOTE: This profile is a universal flavour of the PACIO PFE Personal Functioning and Engagement Collection Observation profile.

An exchange of post-acute care observation for a patient. This profile is used for exchanging an observation for a single question generally included in a structured resource (e.g., assessment tool, instrument, or screen). NOTE: This profile is a universal flavour of the PACIO PFE Personal Functioning and Engagement Single Observation profile.

A collection of observations related to a functional assessment of a patient. This profile is used for exchanging a set of functional data.

A single observation related to a functional assessment of a patient. This profile is used for exchanging an observatoin for a single question.

Used to record the absence of a Symptom as reported by a patient or their caregiver.

Used to record the presence of a Symptom as reported by the patient or a patient's caregiver. The Symptom observation contains all information given about a patient's symptoms.

Information about the specific scale or assessment used to determine the value. This can be either just a code that represents the assessment scale or can be a reference to an Assessment Scale Collection.

Reference to a complete functional assessment collection.

Medication that when taken affecting the factor

Set of codes from LOINC that describe a patient's affective grade

Set of SNOMED codes to describe factors which alleviate the symptom.

Set of SNOMED codes to describe the clinical course of the symptom.

An initial set of Symptom Codes representing the most common symptoms.

ValueSet for Perceived effect of the modifying factor on the symptom or sign.

ValueSet for Category of this episode for the identified symptom or sign.

ValueSet for Identification of the specific symptom to which the Exclusion Statement applies.

Set of SNOMED codes to describe the frequency of experiencing the symptom.

The set of codes from WHO's International Classification of Functioning, Disability, and Health code system.

ValueSet for Type of occurrence for this symptom or sign?

Set of SNOMED codes to describe other events which were occurring at the same time as the symptom.

ValueSet for Description progression of the symptom or sign at the time of reporting.

Set of SNOMED codes to describe the symptom quality.

Set of SNOMED codes to describe the symptom severity.

ValueSet for Category representing the overall severity of the symptom or sign.

Set of codes from SNOMED that describe the speed of onset of a patient's symptom

Set of SNOMED codes to describe the trend of the symptom.

Set of SNOMED codes to describe triggers or factors which exacerbate the symptom.

CodeSystem for Perceived effect of the modifying factor on the symptom or sign.

CodeSystem for Category of this episode for the identified symptom or sign.

CodeSystem for Type of occurrence for this symptom or sign?

CodeSystem for Description progression of the symptom or sign at the time of reporting.

CodeSystem for Category representing the overall severity of the symptom or sign.

A code system that has codes for use in the IG that will eventually be migrated to other code systems such as LOINC or THO.

Abdominal Discomfort

Abdominal pain

Admission to Hospital

Collection of appetite assessment

Rating of appetite loss

Chest pain

Absence of chills

Constipation

Cough

Dizziness

No fainting

Fatigue

Fever

Absence of fever

Hearing Loss

Dose of IV morphine

Collection of rating of abdominal cramping pain

Rating of abdominal cramping pain

Jane Doe - shortness of breath

John Doe - dizziness

Abdominal pain

Collection of rating of abdominal cramping pain

Rating of abdominal cramping pain

Mr. Doe - Oncology

Absense of nausea

Absence of rectal bleeding

Shortness of breath

Shortness of breath

Trish Doe - Public Health

Type 2 Diabetes

No loss of consciousness

Abdominal pain

Collection of rating of abdominal cramping pain

Rating of abdominal cramping pain

Constipation