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Clinical Concept

Comment

Corresponding archetype concept name

NOTE: is linked to the
actual archetype in a CKM instance

Information Provided

Details of each piece of health education information discussed or provided to patient

Information Provided
<ACTION <ACTION.health_education> education >

Social Summary

 

Social Summary
<EVALUATION <EVALUATION.social_summary> summary >

Adverse Reaction List

Adverse Reaction list is made up of multiple Adverse Reaction entries

Adverse Reaction
<EVALUATION <EVALUATION.adverse_reaction> reaction >

Family History List

Family History list is made up of multiple Family History entries

Family History
<EVALUATION <EVALUATION.family_history> history >

Diagnosis
Problem/Diagnosis List
Recent Problem/Diagnosis List

Problem lists, whether current or past are made up of multiple Problem/Diagnosis entries – the same data pattern will be used in all instances

Problem/Diagnosis
<EVALUATION <http://dcm.nehta.org.au/ckm/OKM.html#showArchetype_1013.1.896EVALUATION.problem_diagnosis> diagnosis >

Procedure list

Procedure list is made up of multiple Procedure entries

Procedure
<ACTION <ACTION.procedure> procedure >

Smoking consumption

 

Tobacco use
<OBSERVATION <OBSERVATION.substance_use-tobacco> tobacco >

Alcohol consumption

 

Alcohol consumption
<OBSERVATION <OBSERVATION.substance_use-alcohol> alcohol >

Obstetric Summary

 

Obstetric summary
<EVALUATION <EVALUATION.obstetric_summary> summary >

Pregnancy Summary

An evolving summary of key data about a single pregnancy – either current or past

Pregnancy summary
<EVALUATION <EVALUATION.pregnancy_summary> summary >

Examination Findings

 

Examination Findings
<OBSERVATION <OBSERVATION.exam> exam >
Examination of the uterus
<CLUSTER <CLUSTER.exam-uterus> uterus >
Examination of the fetus
<CLUSTER <CLUSTER.exam-fetus> fetus >

Current Medication List
Medication administered

Medication list is made up of multiple Medication instruction entries

Medication action
<ACTION <ACTION.medication> medication >

Height

 

Height/Length
<OBSERVATION <OBSERVATION.height> height >

Weight

 

Body weight
<OBSERVATION <OBSERVATION.body_weight> weight>

Body Mass Index

 

Body Mass Index
<OBSERVATION <OBSERVATION.body_mass_index> index >

Blood Pressure

 

Blood Pressure
<OBSERVATION <OBSERVATION.blood_pressure> pressure >

Fetal Movements

 

Fetal Movements
<OBSERVATION <OBSERVATION.fetal_movements> movements >

Urinalysis
All Pathology test results

The pattern for urinalysis is identical to the pathology test results, and in some cases will be performed in the lab, so the same pattern will be used

Pathology test result
<OBSERVATION <OBSERVATION.pathology_test> test >

Ultrasound results

 

Imaging examination result
<OBSERVATION <OBSERVATION.imaging_exam> exam >

<strong>Step 3:</strong> CKM Review

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