open_ehr 0.6.1 → 0.9.0

data/spec/lib/open_ehr/parser/adl/openEHR-EHR-EVALUATION.adverse.v1.adl

@@ -0,0 +1,411 @@
+archetype (adl_version=1.4)
+	openEHR-EHR-EVALUATION.adverse.v1
+
+concept
+	[at0000]	-- Adverse reaction
+language
+	original_language = <[ISO_639-1::en]>
+	translations = <
+		["de"] = <
+			language = <[ISO_639-1::de]>
+			author = <
+				["name"] = <"Jasmin Buck, Sebastian Garde">
+				["organisation"] = <"University of Heidelberg, Central Queensland University">
+			>
+		>
+	>
+description
+	original_author = <
+		["name"] = <"Sam Heard">
+		["organisation"] = <"Ocean Informatics">
+		["date"] = <"23/04/2006">
+		["email"] = <"sam.heard@oceaninformatics.biz">
+	>
+	details = <
+		["de"] = <
+			language = <[ISO_639-1::de]>
+			purpose = <"Zur Dokumentation von Nebenwirkungen auf einen bestimmten Wirkstoff. Die Art dieses Stoffes kann ebenfalls Dokumentiert werden. Fr�herer Aufzeichnungen k�nnen hinzugef�gt werden und auch die Art der Reaktion beim jeweiligen Ereignis.">
+			use = <"">
+			keywords = <"Reaktion", "allergisch", "Allergie", "Intoleranz">
+			misuse = <"Nicht zur Dokumentation keines Verlaufs einer Reaktion auf eine Substanz. F�r diesen Zweck openEHR-EVALUATION.excluded-adverse  benutzen. F�r unbekannte Reaktionen auf beliebige Wirkstoffe openEHR-EVALUATION.excluded benutzen.">
+		>
+		["en"] = <
+			language = <[ISO_639-1::en]>
+			purpose = <"For recording adverse reaction(s) to a particular 'Agent' the type of which may be recorded also. Historical recordings may be added and the type of reaction on each occasion.">
+			use = <"">
+			keywords = <"reaction", "allergic", "allergy", "intolerance">
+			misuse = <"Do not use for recording no history of a reaction to a substance. Use openEHR-EVALUATION.excluded-adverse for this purpose. No known reactions to any agents, use openEHR-EVALUATION.excluded.">
+		>
+	>
+	lifecycle_state = <"AuthorDraft">
+	other_contributors = <"NEHTA data groups (Australia)", "General Practice Computing Group (Australia)">
+
+definition
+	EVALUATION[at0000] matches {	-- Adverse reaction
+		data matches {
+			ITEM_TREE[at0002] matches {	-- structure
+				items cardinality matches {0..*; unordered} matches {
+					ELEMENT[at0003] matches {	-- Agent
+						value matches {
+							DV_TEXT matches {*}
+						}
+					}
+					ELEMENT[at0010] occurrences matches {0..1} matches {	-- Agent category
+						value matches {
+							DV_CODED_TEXT matches {
+								defining_code matches {
+									[local::
+									at0011, 	-- Food
+									at0012, 	-- Animal
+									at0013, 	-- Medication
+									at0014, 	-- Other chemical or substance
+									at0031, 	-- Non-active ingredient of medication
+									at0033, 	-- Imaging dye or media
+									at0034]	-- Environmental
+								}
+							}
+						}
+					}
+					CLUSTER[at0019] occurrences matches {0..*} matches {	-- Exposure and reaction detail
+						items cardinality matches {1..*; unordered} matches {
+							ELEMENT[at0032] occurrences matches {0..1} matches {	-- Specific substance
+								value matches {
+									DV_TEXT matches {*}
+								}
+							}
+							ELEMENT[at0015] occurrences matches {0..1} matches {	-- Reaction category
+								value matches {
+									DV_CODED_TEXT matches {
+										defining_code matches {
+											[local::
+											at0016, 	-- Intolerance
+											at0017, 	-- Sensitivity
+											at0018, 	-- Allergy
+											at0030]	-- No reaction
+										}
+									}
+								}
+							}
+							ELEMENT[at0004] occurrences matches {0..1} matches {	-- Probability of causation
+								value matches {
+									DV_CODED_TEXT matches {
+										defining_code matches {
+											[local::
+											at0005, 	-- Certain/Highly likely
+											at0006, 	-- Probable
+											at0007]	-- Possible
+										}
+									}
+								}
+							}
+							ELEMENT[at0020] occurrences matches {0..1} matches {	-- Date of exposure
+								value matches {
+									DV_DATE_TIME matches {
+										value matches {yyyy-??-??T??:??:??}
+									}
+								}
+							}
+							ELEMENT[at0021] occurrences matches {0..1} matches {	-- Duration of the exposure
+								value matches {
+									DV_DURATION matches {
+										value matches {PYMWDTHMS}
+									}
+								}
+							}
+							ELEMENT[at0023] occurrences matches {0..1} matches {	-- Reaction severity
+								value matches {
+									DV_CODED_TEXT matches {
+										defining_code matches {
+											[local::
+											at0024, 	-- Mild
+											at0025, 	-- Disabling
+											at0026]	-- Life threatening
+										}
+									}
+								}
+							}
+							ELEMENT[at0022] matches {	-- Reaction description
+								value matches {
+									DV_TEXT matches {*}
+								}
+							}
+							ELEMENT[at0027] occurrences matches {0..1} matches {	-- Date of onset of reaction
+								value matches {
+									DV_DATE_TIME matches {
+										value matches {yyyy-??-??T??:??:??}
+									}
+								}
+							}
+							ELEMENT[at0028] occurrences matches {0..1} matches {	-- Duration of the reaction
+								value matches {
+									C_DV_QUANTITY <
+										property = <[openehr::128]>
+									>
+								}
+							}
+						}
+					}
+				}
+			}
+		}
+	}
+
+ontology
+	term_definitions = <
+		["de"] = <
+			items = <
+				["at0000"] = <
+					description = <"Zur Dokumentation des Vorhandenseins von sch�dlichen oder unerw�nschten Reaktionen auf einen Wirkstoff oder eine Substanz, einschlie�lich Nahrung, festgestellt von einem Klinikarzt - Vergiftungen und unsachgem��er Gebrauch ausgeschlossen">
+					text = <"Nebenwirkung">
+				>
+				["at0002"] = <
+					description = <"@ internal @">
+					text = <"Structure">
+				>
+				["at0003"] = <
+					description = <"Der Wirkstoff, die Substanz oder die Klasse, welche die Nebenwirkung ausgel�st hat">
+					text = <"Wirkstoff">
+				>
+				["at0004"] = <
+					description = <"Grad an Sicherheit, dass der Wirkstoff der Ausl�ser der Reaktion war">
+					text = <"Wahrscheinlichkeit f�r kausalen Zusammenhang">
+				>
+				["at0005"] = <
+					description = <"Die Reaktion ist laut einem Klinikarzt auf den Wirkstoff zur�ckzuf�hren">
+					text = <"Sicher/ sehr wahrscheinlich">
+				>
+				["at0006"] = <
+					description = <"Die Reaktion ist wahrscheinlich auf den Wirkstoff zur�ckzuf�hren">
+					text = <"Wahrscheinlich">
+				>
+				["at0007"] = <
+					description = <"Die Reaktion ist m�glicherweise auf den Wirkstoff zur�ckzuf�hren">
+					text = <"M�glicherweise">
+				>
+				["at0010"] = <
+					description = <"Die Gruppe des Wirkstoffs">
+					text = <"Wirkstoffgruppe">
+				>
+				["at0011"] = <
+					description = <"Eine Substanz, die als Teil der Ern�hrung zugef�hrt wurde ">
+					text = <"Nahrungsmittel">
+				>
+				["at0012"] = <
+					description = <"Ein lebender Organismus und dessen Gift oder produzierter Stoff">
+					text = <"Tier">
+				>
+				["at0013"] = <
+					description = <"Eine Substanz, die aus medizinischen Gr�nden eingenommen oder verabreicht wurde">
+					text = <"Medikament">
+				>
+				["at0014"] = <
+					description = <"Nicht-medizinische Chemikalie oder Substanz">
+					text = <"Andere Chemikalie oder Substanz">
+				>
+				["at0015"] = <
+					description = <"Die Art der von der Person erfahrenen Reaktion, von einem Klinikarzt ermittelt">
+					text = <"Reaktionsart">
+				>
+				["at0016"] = <
+					description = <"F�hrt zu unerfreulichen Symptomen, die ausreichen um einen Gebrauch in der Zukunft zu vermeiden">
+					text = <"Intoleranz">
+				>
+				["at0017"] = <
+					description = <"F�hrt zu Krankhaftigkeit die eventuell zum Wohle des Patienten behandelt werden muss">
+					text = <"Empfindlichkeit">
+				>
+				["at0018"] = <
+					description = <"F�hrt zu einer IgE Reaktion">
+					text = <"Allergie">
+				>
+				["at0019"] = <
+					description = <"Einzelheiten der von der Person erfahrenen Reaktion">
+					text = <"Exposition und Einzelheiten der Reaktion">
+				>
+				["at0020"] = <
+					description = <"Das Datum (+/- Zeit) wann die Person gegen�ber dem Wirkstoff exponiert wurde">
+					text = <"Datum der Exposition">
+				>
+				["at0021"] = <
+					description = <"Die Dauer der Exposition gegen�ber dem Wirkstoff">
+					text = <"Dauer der Exposition">
+				>
+				["at0022"] = <
+					description = <"Eine Beschreibung der von einer Person erfahrenen Reaktion auf einen Wirkstoff">
+					text = <"Beschreibung der Reaktion">
+				>
+				["at0023"] = <
+					description = <"Die Klasse der Reaktion f�r zuk�nftige Empfehlungen">
+					text = <"Schweregrad der Reaktion">
+				>
+				["at0024"] = <
+					description = <"Eine Reaktion, die wenig Leiden und keinen Verlust der Arbeitsf�higkeit/ Schulf�higkeit verursacht">
+					text = <"Gelinde">
+				>
+				["at0025"] = <
+					description = <"Eine Reaktion, die Krankheit und/oder den Verlust Funktionen verursacht">
+					text = <"Unf�hig machend">
+				>
+				["at0026"] = <
+					description = <"Eine Reaktion die lebensbedrohlich wahr oder sein kann">
+					text = <"Lebensbedrohlich">
+				>
+				["at0027"] = <
+					description = <"Das Datum, an dem die Reaktion eintrat">
+					text = <"Datum des Beginns der Reaktion">
+				>
+				["at0028"] = <
+					description = <"Die Dauer der Reaktion">
+					text = <"Dauer der Reaktion">
+				>
+				["at0030"] = <
+					description = <"Die Person war ohne Reaktion exponiert">
+					text = <"Keine Reaktion">
+				>
+				["at0031"] = <
+					description = <"Ein nicht-medizinischer Bestandteil des Medikaments, wie Farbstoff, Konservierungsstoff, usw. (Untertyp von andere Chemikalien)">
+					text = <"Inaktiver Bestandteil des Medikaments">
+				>
+				["at0032"] = <
+					description = <"Die charakteristische Substanz, die die Reaktion verursacht, falls verschieden vom Wirkstoff (z.B. Marken oder Teile einer Klasse)">
+					text = <"Charakteristische Substanz">
+				>
+				["at0033"] = <
+					description = <"Zur diagnostischen Bildgebung benutzter Farbstoff oder Medium (Untertyp von anderen Chemikalien)">
+					text = <"Abbildender Farbstoff oder Medium">
+				>
+				["at0034"] = <
+					description = <"Ein in der Umwelt vorhandener Wirkstoff">
+					text = <"Umgebend">
+				>
+			>
+		>
+		["en"] = <
+			items = <
+				["at0000"] = <
+					description = <"Recording the presence of a harmful or undesirable response to an agent or substance including food, as determined by the clinician - excluding poisoning and abnormal use">
+					text = <"Adverse reaction">
+				>
+				["at0002"] = <
+					description = <"@ internal @">
+					text = <"structure">
+				>
+				["at0003"] = <
+					description = <"The agent or substance or class that caused the adverse reaction">
+					text = <"Agent">
+				>
+				["at0004"] = <
+					description = <"Degree of certainty that the agent was the cause of the reaction">
+					text = <"Probability of causation">
+				>
+				["at0005"] = <
+					description = <"A reaction to the agent is deemed to be or have been present by the clinician">
+					text = <"Certain/Highly likely">
+				>
+				["at0006"] = <
+					description = <"The reaction is deemed to be the probable cause of the reaction">
+					text = <"Probable">
+				>
+				["at0007"] = <
+					description = <"The agent is deemed to be a possible cause of the reaction">
+					text = <"Possible">
+				>
+				["at0010"] = <
+					description = <"The category of the agent">
+					text = <"Agent category">
+				>
+				["at0011"] = <
+					description = <"A substance taken as part of the diet">
+					text = <"Food">
+				>
+				["at0012"] = <
+					description = <"A living organism or its venom or produce">
+					text = <"Animal">
+				>
+				["at0013"] = <
+					description = <"A substance taken or applied  for medicinal purposes">
+					text = <"Medication">
+				>
+				["at0014"] = <
+					description = <"Non-medicinal chemicals or substances">
+					text = <"Other chemical or substance">
+				>
+				["at0015"] = <
+					description = <"The type of reaction experience by the person as determined by the clinician">
+					text = <"Reaction category">
+				>
+				["at0016"] = <
+					description = <"Leads to unpleasant symptoms which are sufficient to avoid use in the future">
+					text = <"Intolerance">
+				>
+				["at0017"] = <
+					description = <"Leads to morbidity which is potentially threatening to the wellbeing of the person">
+					text = <"Sensitivity">
+				>
+				["at0018"] = <
+					description = <"Leads to an IgE mediated reaction">
+					text = <"Allergy">
+				>
+				["at0019"] = <
+					description = <"Details of the reaction experienced by the person">
+					text = <"Exposure and reaction detail">
+				>
+				["at0020"] = <
+					description = <"The date (+/- time) when the person became exposed to the agent">
+					text = <"Date of exposure">
+				>
+				["at0021"] = <
+					description = <"The duration of the exposure to the agent">
+					text = <"Duration of the exposure">
+				>
+				["at0022"] = <
+					description = <"A description of the reaction to this agent as experienced by the person">
+					text = <"Reaction description">
+				>
+				["at0023"] = <
+					description = <"The category of the reaction for future reference">
+					text = <"Reaction severity">
+				>
+				["at0024"] = <
+					description = <"A reaction which causes little distress and no loss of work/school">
+					text = <"Mild">
+				>
+				["at0025"] = <
+					description = <"A reaction which causes morbidity and/or loss of function">
+					text = <"Disabling">
+				>
+				["at0026"] = <
+					description = <"A reaction which was or could be lifethreatening">
+					text = <"Life threatening">
+				>
+				["at0027"] = <
+					description = <"The date the reaction began">
+					text = <"Date of onset of reaction">
+				>
+				["at0028"] = <
+					description = <"The duration of the reaction">
+					text = <"Duration of the reaction">
+				>
+				["at0030"] = <
+					description = <"Person has been exposed with no reaction">
+					text = <"No reaction">
+				>
+				["at0031"] = <
+					description = <"A non-medicinal ingredient of medication such as colouring, preservative, etc (subtype of other chemical)">
+					text = <"Non-active ingredient of medication">
+				>
+				["at0032"] = <
+					description = <"The specific substance that caused the reaction if different from the agent (e.g. brands or members of a class)">
+					text = <"Specific substance">
+				>
+				["at0033"] = <
+					description = <"A dye or media used in diagnostic imaging (subtype of other chemical)">
+					text = <"Imaging dye or media">
+				>
+				["at0034"] = <
+					description = <"An agent present in the environment">
+					text = <"Environmental">
+				>
+			>
+		>
+	>

data/spec/lib/open_ehr/parser/adl/openEHR-EHR-INSTRUCTION.medication.v1.adl

@@ -0,0 +1,88 @@
+archetype (adl_version=1.4)
+	openEHR-EHR-INSTRUCTION.medication.v1
+
+concept
+	[at0000]	-- Medication order
+language
+	original_language = <[ISO_639-1::en]>
+	translations = <
+		["de"] = <
+			language = <[ISO_639-1::de]>
+			author = <
+				["name"] = <"Jasmin Buck, Sebastian Garde">
+				["organisation"] = <"University of Heidelberg, Central Queensland University">
+			>
+		>
+	>
+description
+	original_author = <
+		["name"] = <"Sam Heard">
+		["organisation"] = <"Ocean Informatics">
+		["date"] = <"21/04/2006">
+		["email"] = <"sam.heard@oceaninformatics.biz">
+	>
+	details = <
+		["de"] = <
+			language = <[ISO_639-1::de]>
+			purpose = <"Zur Dokumentation einer Medikationsverordnung, kann mehr als eine Aktivit�t enthalten, aber immer mit der selben Struktur">
+			use = <"Zur Dokumentation von Anweisungen bez�glich eines Medikaments">
+			keywords = <"Verschreibung", "Medikationsverordnung", "Verordnung">
+			misuse = <"Nicht zur Dokumentation der Verabreichung, der Gabe usw. benutzen. F�r diese Dokumentation openEHR-EHR-ACTION.medication benutzen.">
+		>
+		["en"] = <
+			language = <[ISO_639-1::en]>
+			purpose = <"For recording a medication order, which may involve more than one activity, but all have the same structure.">
+			use = <"For recording an instruction about medication.">
+			keywords = <"prescribe", "medication order", "order">
+			misuse = <"Do not use for recording administration, dispensing etc. Use openEHR-EHR-ACTION.medication for these recordings.">
+		>
+	>
+	lifecycle_state = <"AuthorDraft">
+	other_contributors = <"NEHTA (Australia) data groups", ...>
+
+definition
+	INSTRUCTION[at0000] matches {	-- Medication order
+		activities cardinality matches {0..*; unordered} matches {
+			ACTIVITY[at0001] occurrences matches {0..*} matches {	-- Medication activity
+				action_archetype_id matches {/medication\.v1/}
+				description matches {
+					allow_archetype ITEM_TREE occurrences matches {0..1} matches {
+						include
+							archetype_id/value matches {/medication\.v1/}
+							archetype_id/value matches {/medication-formulation\.v1/}
+							archetype_id/value matches {/medication-vaccine\.v1/}
+						exclude
+							archetype_id/value matches {/.*/}
+					}
+				}
+			}
+		}
+	}
+
+ontology
+	term_definitions = <
+		["de"] = <
+			items = <
+				["at0000"] = <
+					description = <"Eine von einem Klinikarzt verfasste Verordnung oder Anweisung, die beschreibt welches Medikament wann, f�r wie lange usw. eingenommen werden soll">
+					text = <"Medikationsverordnung">
+				>
+				["at0001"] = <
+					description = <"Informationen �ber die auszuf�hrende Medikationshandlung">
+					text = <"Medikationshandlung">
+				>
+			>
+		>
+		["en"] = <
+			items = <
+				["at0000"] = <
+					description = <"An order or instruction created by a clinician which specifies which medication to take, when, for how long etc.">
+					text = <"Medication order">
+				>
+				["at0001"] = <
+					description = <"Information about the medication action(s) to be carried out">
+					text = <"Medication activity">
+				>
+			>
+		>
+	>

data/spec/lib/open_ehr/parser/adl/openEHR-EHR-INSTRUCTION.referral.v1.adl

@@ -0,0 +1,84 @@
+archetype (adl_version=1.4)
+	openEHR-EHR-INSTRUCTION.referral.v1
+
+concept
+	[at0000]	-- Referral to second provider
+language
+	original_language = <[ISO_639-1::en]>
+	translations = <
+		["de"] = <
+			language = <[ISO_639-1::de]>
+			author = <
+				["name"] = <"Jasmin Buck, Sebastian Garde">
+				["organisation"] = <"University of Heidelberg, Central Queensland University">
+			>
+		>
+	>
+description
+	original_author = <
+		["name"] = <"Sam Heard">
+		["email"] = <"sam.heard@oceaninformatics.biz">
+	>
+	details = <
+		["de"] = <
+			language = <[ISO_639-1::de]>
+			purpose = <"Zur Dokumentation einer Bitte nach Behandlung (�berweisung) durch einen zweiten Gesundheitsdienstleister.">
+			use = <"">
+			keywords = <"�berweisung", "Anfrage", "Anordnung">
+			misuse = <"">
+		>
+		["en"] = <
+			language = <[ISO_639-1::en]>
+			purpose = <"For recording a request for care (referral to) a second health provider">
+			use = <"">
+			keywords = <"refer", "request", "order">
+			misuse = <"">
+		>
+	>
+	lifecycle_state = <"AuthorDraft">
+	other_contributors = <>
+
+definition
+	INSTRUCTION[at0000] matches {	-- Referral to second provider
+		activities cardinality matches {0..*; unordered} matches {
+			ACTIVITY[at0001] occurrences matches {0..1} matches {	-- Refer
+				action_archetype_id matches {/referral\.v1/}
+				description matches {
+					allow_archetype ITEM_TREE occurrences matches {0..1} matches {
+						include
+							archetype_id/value matches {/referral\.v1/}
+						exclude
+							archetype_id/value matches {/.*/}
+					}
+				}
+			}
+		}
+	}
+
+ontology
+	term_definitions = <
+		["de"] = <
+			items = <
+				["at0000"] = <
+					description = <"Eine Bitte nach Gesundheitsdienstleistung von einem Anbieter zu einem zweiten.">
+					text = <"�berweisung zu einem zweiten Gesundheitsdienstleister">
+				>
+				["at0001"] = <
+					description = <"Die Handlung der �berweisung zu einem zweiten Gesundheitsdienstleister">
+					text = <"�berweisung">
+				>
+			>
+		>
+		["en"] = <
+			items = <
+				["at0000"] = <
+					description = <"A request for health care from one provider to a second provider">
+					text = <"Referral to second provider">
+				>
+				["at0001"] = <
+					description = <"The activity of referring to a second health provider">
+					text = <"Refer">
+				>
+			>
+		>
+	>