Clinical Content
openEHR Templates
Templates are used to create definitions of content such as a particular document or message, required for specific use cases, such as specific screen forms, message types or reports. Typical examples include 'acute care discharge summary', 'GP referral' and radiology report'. A list of the openEHR templates curated by the Clinical Content subcommittee can be found below.
Template Name | Description/Use | Clinical Lead | Status | CKM Link | Git Location | Exemplar Application | Key Words |
---|---|---|---|---|---|---|---|
DENWIS (Dutch-Early-Nurse-Worry-Indicator-Score) v1 | Nurse 'worry' predictor of deteriorating surgical ward patients. Used to record nurse or carer 'worry' linked to routinely measured vital signs to improve prediction of unplanned admission. |
Dr Ian McNicoll | Published v1.0 | DITO Project (In Development) | DENWIS, Deterioration, Early Recognition, Hospital Rapid Response Team, REACT, Open, Intensive Care, Nurses, Worry | ||
DiADeM Assessment.v1 | Use to record DiADeM assessment. The tools have been developed for Clinicians who have a good primary care knowledge of dementia/depression and delirium to enable them to make a diagnosis of Advanced Dementia in a care home setting. |
Dr Ian McNicoll | Published v1.0 | DiADeM | diadem, dementia, screening, assessment | ||
IDCR - Procedures List.v1 | TThe primary intent is to support a continuously curated life-long ‘procedures list', as would be found in a GP system, PHR or other regional/national CDR but this should also be usable for episodic or departmental procedures lists, which are generated at admission to a service e.g hospital admission, and maintained only during that episode of care or for that department. |
Dr Ian McNicoll | Published v1.0 | procedure, surgery, operation, summary, list | |||
IDCR - Adverse Reaction List.v1 | To support a Longitudinal or Episodic allergies/adverse reaction risk list, aligned with AoMRC headings as would be found in a GP system, PHR or Episodic hospital record. |
Dr Paul Miller | Published v1.0 | allergy, adverse reaction, medication, summary, sensitivity | |||
IDCR - Body Measurements Encounter.v0 | The primary purpose is to support a typical face to face contact with a patient during which body measurements such as height, weight, hip circumference, waist circumference and head circumference are taken and recorded, including calculated values such as Body Mass Index and Body Surface Area. The template can also be used for patient-reported body measurements. |
John Meredith | Draft v0.0 | body, measurement, encounter | |||
IDCR - Immunisations List.v0 | The primary intent is to support a continuously curated life-long ‘immunisations list', as would be found in a GP system, PHR or other regional/national CDR but this should also be usable for episodic or departmental immunisations lists, which are generated at admission to a service e.g hospital admission, and maintained only during that episode of care or for that department. The template uses an action archetype to represent the 'procedure performed' aspect of immunisations rather than focussing on the medication aspect which would be more appropriate in an encounter situation. |
Dr Ian McNicoll | Drat v0.0 | immunisation, vaccination, summary, sensitivity | |||
IDCR - Medication Statement List.v1 | The primary intent is to support a continuously curated life-long ‘medication statement list ', as would be found in a GP system, PHR or other regional/national CDR but this should also be usable for episodic or departmental medication lists, which are generated at admission to a service e.g hospital admission, and maintained only during that episode of care or for that department. For clarity, this is NOT intended to be used in a prescribing system for the actual process of prescribing / dispensing, but is a static list of medications the patient is currently using/taking. It is also NOT intended to be used directly for the process of medication reconciliation, which would require some additional metadata. |
Dr Paul Miller | Published v1.0 | medication, medicine, therapy, summary, list | |||
IDCR - Problem List.v1 | The primary intent is to support a continuously curated life-long ‘problem list', as would be found in a GP system, PHR or other regional/national CDR but this should also be usable for episodic or departmental problem lists, which are generated at admission to a service e.g hospital admission, and maintained only during that episode of care or for that department. |
Dr Ian McNicoll | Published v1.0 | problem, condition, diagnosis, issue | |||
IDCR - Vital Signs Encounter.v1 | The primary purpose is to support a typical face to face contact with a patient during which vital signs such as blood pressure, temperature, pulse rate etc are measured and recorded, including overall vital sign scores such as NEWS and Glasgow Coma Scale. The template can also be used for patient-reported vital signs and could be populated via external devices as well. |
Dr Ian McNicoll | Published v1.0 | vitals, observations, encounter | |||
OPENeP - Inpatient Prescription | Ian McNicoll | Published v1.0 | OPENeP | inpatient, patient, prescription, OPENeP, prescribing | |||
OPENeP - Medication Reconciliation | Ian McNicoll | Published v1.0 | OPENeP | inpatient, patient, prescription, OPENeP, prescribing, reconciliation, medication, meds-rec, meds, meds, rec, medicines, admission | |||
OPENeP - Medication on Discharge | Ian McNicoll | Published v1.0 | OPENeP | inpatient, patient, prescription, OPENeP, prescribing, reconciliation, medication, meds-rec, meds, meds, rec, medicines, discharge | |||
OPENeP - Medication on Admission | Ian McNicoll | Published v1.0 | OPENeP | inpatient, patient, prescription, OPENeP, prescribing, reconciliation, medication, meds-rec, meds, meds, rec, medicines, admission | |||
OPENeP - Outpatient Prescription | Ian McNicoll | Published v1.0 | OPENeP | outpatient, patient, prescription, OPENeP, prescribing, medication, meds, medicines, discharge | |||
OPENeP - Pharmacy Review Report | Ian McNicoll | Published v1.0 | OPENeP | pharmacy, review, report, reporting, patient, prescription, OPENeP, prescribing, medication, pharm | |||
OPENeP - Reference Weight | Measurement of body weight of an individual |
Ian McNicoll | Published v1.0 | OPENeP | weight, reference, patient, prescription, OPENeP, prescribing, medication, meds | ||
PROMS - American Orthopaedic Foot and Ankle Society Score (AOFAS) | For the recording of subjective assessment for completion by patient of ankle or hindfoot pain and function. |
Dr Ian McNicoll | Draft | PROMS | PROMS, ankle | ||
PROMS - Ankle Osteoarthritis Score (AOS) questionnaire | For the capture and reporting of the Ankle Osteoarthritis Score (AOS) questionnaire details. |
Dr Ian McNicoll | Draft | PROMS | PROMS, ankle | ||
PROMS - Achilles Tendon Total Rupture Score (ATRS) | For the capture and reporting of patient-reported limitations and difficulties relating to Achilles tendon injury (ATRS = Achilles Tendon Total Rupture Score). |
Dr Ian McNicoll | Draft | PROMS | PROMS, ankle | ||
PROMS - Boston Carpal Tunnel Questionnaire Score (BOSTON) | Use to capture and report Boston Carpal Tunnel Questionnaire (BOSTON) score details. |
Dr Ian McNicoll | Draft | PROMS | PROMS, Carpal, Tunnel | ||
PROMS - Foot and ankle outcome from surgery as reported by patient | For the capture and reporting of patient-reported outcome from foot and ankle surgery as part of a PROM relating to foot and ankle surgery. |
Dr Ian McNicoll | Draft | PROMS | PROMS, foot, ankle | ||
PROMS - Hip outcome questionnaire based on the Non Arthroplasty Hip Surgery Register (NAHSR) of the British Hip Society | For the recording and reporting of patient-reported outcome information following hip operations, based on the questionnaire from the Non Arthroplasty Hip Surgery Register (NAHSR) of the British Hip Society. |
Dr Ian McNicoll | Draft | PROMS | PROMS, hip | ||
PROMS - International Knee Documentation Committee (IKDC) Subjective knee evaluation score | For the recording and reporting of the patient reported results of the Subjective knee evaluation score developed by the International Knee Documentation Committee. |
Dr Ian McNicoll | Draft | PROMS | PROMS, hip | ||
PROMS - Knee injury and Osteoarthritis Outcome Score (KOOS) | For the capture and reporting of details of the Knee injury and Osteoarthritis Outcome Score (KOOS). |
Draft | PROMS | PROMS, hip | |||
PROMS - Knee outcome questionnaire | For the recording and reporting of patient-reported outcome information following knee operations. |
Dr Ian McNicoll | Draft | PROMS | PROMS, hip | ||
PROMS - Hip outcome questionnaire based on the Non Arthroplasty Hip Surgery Register (NAHSR) of the British Hip Society | For the recording and reporting of patient-reported outcome information following hip operations, based on the questionnaire from the Non Arthroplasty Hip Surgery Register (NAHSR) of the British Hip Society. |
Dr Ian McNicoll | Draft | PROMS | PROMS, hip | ||
PROMS - Myelopathy Disability Index Questionnaire | For the capture and reporting of details of the Myelopathy Disability Index Questionnaire. |
Dr Ian McNicoll | Draft | PROMS | PROMS, hip | ||
PROMS - Neck Disability Index (NDI) | For the capture and reporting of details of the Neck Disability Index Questionnaire. |
Dr Ian McNicoll | Draft | PROMS | PROMS, hip | ||
PROMS - Non-arthritic hip score (NAHS) | Non-arthritic hip score (NAHS) according to The Non Arthroplasty Hip Surgery Register (NAHSR) of the British Hip Society. |
Dr Ian McNicoll | Draft | PROMS | PROMS, hip | ||
PROMS - Oswestry Low Back Pain Disability Questionnaire (ODI) | For the capture and reporting of details of the Oswestry Low Back Pain Disability Questionnaire. |
Dr Ian McNicoll | Draft | PROMS | PROMS, hip | ||
PROMS - Oxford Hip Questionnaire Score (OHS) | Use to capture and report Oxford Hip Questionnaire (OHS) score details. |
Dr Ian McNicoll | Draft | PROMS | PROMS, hip | ||
PROMS - Oxford Knee Score Activity and Participation Questionnaire (OKS-APQ) | Use to capture and report Oxford Knee Score Activity and Participation Questionnaire (OKS-APQ) score details. |
Dr Ian McNicoll | Draft | PROMS | PROMS, hip | ||
PROMS - Oxford Knee Questionnaire Score (OKS) | Use to capture and report Oxford Knee Questionnaire Score (OKS) score details. |
Dr Ian McNicoll | Draft | PROMS | PROMS, hip | ||
PROMS - Oxford Elbow Questionnaire Score (OSE) | Use to capture and report Oxford Elbow Questionnaire (OSE) score details. |
Dr Ian McNicoll | Draft | PROMS | PROMS, hip | ||
PROMS - Oxford Shoulder Instability Questionnaire Score (OSI) | Use to capture and report Oxford Shoulder Instability Questionnaire (OSI) score details. |
Dr Ian McNicoll | Draft | PROMS | PROMS, hip | ||
PROMS - Oxford Shoulder Questionnaire Score (OSS) | Use to capture and report Oxford Shoulder Questionnaire (OSS) score details. |
Dr Ian McNicoll | Draft | PROMS | PROMS, hip | ||
PROMS - Pain Visual Analogue Scale. | For the capture and reporting of Pain Visual Analogue Scale (VAS) information. |
Dr Ian McNicoll | Draft | PROMS | PROMS, hip | ||
PROMS - Sports Athlete Foot and Ankle Score (SAFAS) | For the capture and reporting of details of the Sports Athlete Foot and Ankle Score (SAFAS). |
Dr Ian McNicoll | Draft | PROMS | PROMS, hip | ||
PROMS - Spine outcome questionnaire | For the recording and reporting of patient-reported outcome information following spine operations. |
Dr Ian McNicoll | Draft | PROMS | PROMS, hip | ||
PROMS - Tegner Activity Level Scale | For the recording and reporting of patient-reported outcome information following knee operations. |
Dr Ian McNicoll | Draft | PROMS | PROMS, hip | ||
PROMS - VISA-A questionnaire | For the capture and reporting of details of the VISA-A questionnaire, an index of the severity of Achilles tendinopathy. |
Dr Ian McNicoll | Draft | PROMS | PROMS, hip | ||
Physical Health App - Self Monitoring | Used to record patient metrics as part of a physical health monitoring tool. |
Dr Ian McNicoll | Published v1.0 | Physical, Health, Monitoring, Self | |||
Physical Health App - Self Monitoring Admin | Used to record procedures and consent as part of a physical health monitoring tool. |
Dr Ian McNicoll | Published v1.0 | Physical, Health, Monitoring, Admin, Self | |||
RESPECT_Form-v0 | Representing the dataset for capture, reporting and auditing the details of the ReSPECT End of life care wishes form. |
Dr Ian McNicoll | Published v1.0 | respect, end of life, wishes, plan, summary |