description: 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.\n\nThis 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.\n\nIn 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.\n\nThis 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. \n\nThis 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.
package_name: hl7.fhir.uv.symptoms
derivation: constraint
name: SymptomSignV2
type: http://openehr.org/fhir/StructureDefinition/CLUSTER
elements:
  items:
    index: 0
    slicing:
      rules: closed
      discriminator:
      - {path: $this, type: profile}
      min: null
      slices:
        at0152:
          match: {}
          schema:
            short: Episode onset
            type: http://openehr.org/fhir/StructureDefinition/ELEMENT
            label: at0152
            index: 12
            elements:
              value:
                index: 13
                slicing:
                  rules: closed
                  discriminator:
                  - {path: $this, type: type}
                  min: null
                  slices:
                    DV_DATE_TIME:
                      match: {}
                      schema: {type: 'http://openehr.org/fhir/StructureDefinition/DV_DATE_TIME', index: 14}
                    DV_INTERVAL:
                      match: {}
                      schema: {type: 'http://openehr.org/fhir/StructureDefinition/DV_INTERVAL', index: 15}
        at0200:
          match: {}
          schema:
            short: Nadir
            type: http://openehr.org/fhir/StructureDefinition/ELEMENT
            label: at0200
            index: 21
            elements:
              value: {type: 'http://openehr.org/fhir/StructureDefinition/DV_DATE_TIME', index: 22}
        at0198:
          match: {}
          schema: {short: Severity rating, type: 'http://openehr.org/fhir/StructureDefinition/CLUSTER', array: true, label: at0198, index: 37}
          min: 0
        at0186:
          match: {}
          schema:
            short: Occurrence
            type: http://openehr.org/fhir/StructureDefinition/ELEMENT
            label: at0186
            index: 10
            elements:
              value:
                type: http://openehr.org/fhir/StructureDefinition/DV_CODED_TEXT
                binding: {strength: required, valueSet: 'http://hl7.org/fhir/uv/symptoms/ValueSet/openEHR-EHR-CLUSTER.symptom-sign.v2.at0186'}
                index: 11
        at0151:
          match: {}
          schema:
            short: Body site
            type: http://openehr.org/fhir/StructureDefinition/ELEMENT
            array: true
            label: at0151
            index: 3
            elements:
              value: {type: 'http://openehr.org/fhir/StructureDefinition/DV_TEXT', index: 4}
        at0189:
          match: {}
          schema:
            short: Character
            type: http://openehr.org/fhir/StructureDefinition/ELEMENT
            array: true
            label: at0189
            index: 38
            elements:
              value: {type: 'http://openehr.org/fhir/StructureDefinition/DV_TEXT', index: 39}
        at0155:
          match: {}
          schema:
            short: Impact
            type: http://openehr.org/fhir/StructureDefinition/ELEMENT
            array: true
            label: at0155
            index: 73
            elements:
              value: {type: 'http://openehr.org/fhir/StructureDefinition/DV_TEXT', index: 74}
        at0153:
          match: {}
          schema: {short: Specific details, type: 'http://openehr.org/fhir/StructureDefinition/CLUSTER', array: true, label: at0153, index: 77}
          min: 0
        at0028:
          match: {}
          schema:
            short: Episode duration
            type: http://openehr.org/fhir/StructureDefinition/ELEMENT
            label: at0028
            index: 23
            elements:
              value:
                index: 24
                slicing:
                  rules: closed
                  discriminator:
                  - {path: $this, type: type}
                  min: null
                  slices:
                    DV_DURATION:
                      match: {}
                      schema:
                        type: http://openehr.org/fhir/StructureDefinition/DV_DURATION
                        index: 25
                        elements:
                          value:
                            minValueQuantity: {code: s, unit: s, value: 0.0, system: 'http://unitsofmeasure.org'}
                            index: 26
                    DV_INTERVAL:
                      match: {}
                      schema:
                        type: http://openehr.org/fhir/StructureDefinition/DV_INTERVAL
                        index: 27
                        elements:
                          lower:
                            type: http://openehr.org/fhir/StructureDefinition/DV_DURATION
                            index: 28
                            elements:
                              value:
                                minValueQuantity: {code: s, unit: s, value: 0.0, system: 'http://unitsofmeasure.org'}
                                index: 29
                          upper:
                            type: http://openehr.org/fhir/StructureDefinition/DV_DURATION
                            index: 30
                            elements:
                              value:
                                minValueQuantity: {code: s, unit: s, value: 0.0, system: 'http://unitsofmeasure.org'}
                                index: 31
                    DV_TEXT:
                      match: {}
                      schema: {type: 'http://openehr.org/fhir/StructureDefinition/DV_TEXT', index: 32}
        at0001:
          match: {}
          schema:
            type: http://openehr.org/fhir/StructureDefinition/ELEMENT
            label: at0001
            short: Symptom/Sign name
            index: 1
            elements:
              value: {type: 'http://openehr.org/fhir/StructureDefinition/DV_TEXT', index: 2}
        at0018:
          match: {}
          schema:
            short: Modifying factor
            type: http://openehr.org/fhir/StructureDefinition/CLUSTER
            array: true
            label: at0018
            index: 46
            elements:
              items:
                index: 47
                slicing:
                  rules: closed
                  discriminator:
                  - {path: $this, type: profile}
                  min: null
                  slices:
                    at0019:
                      match: {}
                      schema:
                        short: Factor
                        type: http://openehr.org/fhir/StructureDefinition/ELEMENT
                        label: at0019
                        index: 48
                        elements:
                          value: {type: 'http://openehr.org/fhir/StructureDefinition/DV_TEXT', index: 49}
                    at0197:
                      match: {}
                      schema: {short: Factor detail, type: 'http://openehr.org/fhir/StructureDefinition/CLUSTER', label: at0197, index: 50}
                      min: 0
                      max: 1
                    at0017:
                      match: {}
                      schema:
                        short: Effect
                        type: http://openehr.org/fhir/StructureDefinition/ELEMENT
                        label: at0017
                        index: 51
                        elements:
                          value:
                            type: http://openehr.org/fhir/StructureDefinition/DV_CODED_TEXT
                            binding: {strength: required, valueSet: 'http://hl7.org/fhir/uv/symptoms/ValueSet/openEHR-EHR-CLUSTER.symptom-sign.v2.at0017'}
                            index: 52
                    at0056:
                      match: {}
                      schema:
                        short: Description
                        type: http://openehr.org/fhir/StructureDefinition/ELEMENT
                        label: at0056
                        index: 53
                        elements:
                          value: {type: 'http://openehr.org/fhir/StructureDefinition/DV_TEXT', index: 54}
        at0057:
          match: {}
          schema:
            short: Description of previous episodes
            type: http://openehr.org/fhir/StructureDefinition/ELEMENT
            label: at0057
            index: 80
            elements:
              value: {type: 'http://openehr.org/fhir/StructureDefinition/DV_TEXT', index: 81}
        at0146:
          match: {}
          schema: {short: Previous episodes, type: 'http://openehr.org/fhir/StructureDefinition/CLUSTER', array: true, label: at0146, index: 85}
          min: 0
        at0161:
          match: {}
          schema:
            short: Resolution date/time
            type: http://openehr.org/fhir/StructureDefinition/ELEMENT
            label: at0161
            index: 78
            elements:
              value: {type: 'http://openehr.org/fhir/StructureDefinition/DV_DATE_TIME', index: 79}
        at0165:
          match: {}
          schema:
            short: Precipitating factor
            type: http://openehr.org/fhir/StructureDefinition/CLUSTER
            array: true
            label: at0165
            index: 55
            elements:
              items:
                index: 56
                slicing:
                  rules: closed
                  discriminator:
                  - {path: $this, type: profile}
                  min: null
                  slices:
                    at0170:
                      match: {}
                      schema:
                        short: Factor
                        type: http://openehr.org/fhir/StructureDefinition/ELEMENT
                        label: at0170
                        index: 57
                        elements:
                          value: {type: 'http://openehr.org/fhir/StructureDefinition/DV_TEXT', index: 58}
                    at0154:
                      match: {}
                      schema: {short: Factor detail, type: 'http://openehr.org/fhir/StructureDefinition/CLUSTER', array: true, label: at0154, index: 59}
                      min: 0
                    at0171:
                      match: {}
                      schema:
                        short: Time interval
                        type: http://openehr.org/fhir/StructureDefinition/ELEMENT
                        label: at0171
                        index: 60
                        elements:
                          value: {type: 'http://openehr.org/fhir/StructureDefinition/DV_DURATION', index: 61}
                    at0185:
                      match: {}
                      schema:
                        short: Description
                        type: http://openehr.org/fhir/StructureDefinition/ELEMENT
                        label: at0185
                        index: 62
                        elements:
                          value: {type: 'http://openehr.org/fhir/StructureDefinition/DV_TEXT', index: 63}
        at0180:
          match: {}
          schema:
            short: Progression
            type: http://openehr.org/fhir/StructureDefinition/ELEMENT
            array: true
            label: at0180
            index: 40
            elements:
              value:
                index: 41
                slicing:
                  rules: closed
                  discriminator:
                  - {path: $this, type: type}
                  min: null
                  slices:
                    DV_CODED_TEXT:
                      match: {}
                      schema:
                        type: http://openehr.org/fhir/StructureDefinition/DV_CODED_TEXT
                        binding: {strength: required, valueSet: 'http://hl7.org/fhir/uv/symptoms/ValueSet/openEHR-EHR-CLUSTER.symptom-sign.v2.at0180'}
                        index: 42
                    DV_TEXT:
                      match: {}
                      schema: {type: 'http://openehr.org/fhir/StructureDefinition/DV_TEXT', index: 43}
        at0163:
          match: {}
          schema:
            short: Comment
            type: http://openehr.org/fhir/StructureDefinition/ELEMENT
            label: at0163
            index: 87
            elements:
              value: {type: 'http://openehr.org/fhir/StructureDefinition/DV_TEXT', index: 88}
        at0063:
          match: {}
          schema: {short: Associated symptom/sign, type: 'http://openehr.org/fhir/StructureDefinition/CLUSTER', array: true, label: at0063, index: 86}
          min: 0
        at0175:
          match: {}
          schema:
            short: Episodicity
            type: http://openehr.org/fhir/StructureDefinition/ELEMENT
            label: at0175
            index: 8
            elements:
              value:
                type: http://openehr.org/fhir/StructureDefinition/DV_CODED_TEXT
                binding: {strength: required, valueSet: 'http://hl7.org/fhir/uv/symptoms/ValueSet/openEHR-EHR-CLUSTER.symptom-sign.v2.at0175'}
                index: 9
        at0021:
          match: {}
          schema:
            short: Severity category
            type: http://openehr.org/fhir/StructureDefinition/ELEMENT
            label: at0021
            index: 33
            elements:
              value:
                index: 34
                slicing:
                  rules: closed
                  discriminator:
                  - {path: $this, type: type}
                  min: null
                  slices:
                    DV_CODED_TEXT:
                      match: {}
                      schema:
                        type: http://openehr.org/fhir/StructureDefinition/DV_CODED_TEXT
                        binding: {strength: required, valueSet: 'http://hl7.org/fhir/uv/symptoms/ValueSet/openEHR-EHR-CLUSTER.symptom-sign.v2.at0021'}
                        index: 35
                    DV_TEXT:
                      match: {}
                      schema: {type: 'http://openehr.org/fhir/StructureDefinition/DV_TEXT', index: 36}
        at0147:
          match: {}
          schema: {short: Structured body site, type: 'http://openehr.org/fhir/StructureDefinition/CLUSTER', array: true, label: at0147, index: 5}
          min: 0
        at0002:
          match: {}
          schema:
            short: Description
            type: http://openehr.org/fhir/StructureDefinition/ELEMENT
            label: at0002
            index: 6
            elements:
              value: {type: 'http://openehr.org/fhir/StructureDefinition/DV_TEXT', index: 7}
        at0037:
          match: {}
          schema:
            short: Episode description
            type: http://openehr.org/fhir/StructureDefinition/ELEMENT
            label: at0037
            index: 75
            elements:
              value: {type: 'http://openehr.org/fhir/StructureDefinition/DV_TEXT', index: 76}
        at0031:
          match: {}
          schema:
            short: Number of previous episodes
            type: http://openehr.org/fhir/StructureDefinition/ELEMENT
            label: at0031
            index: 82
            elements:
              value:
                type: http://openehr.org/fhir/StructureDefinition/DV_COUNT
                index: 83
                elements:
                  magnitude: {minValueInteger: 0, index: 84}
        at0003:
          match: {}
          schema:
            short: Pattern
            type: http://openehr.org/fhir/StructureDefinition/ELEMENT
            label: at0003
            index: 44
            elements:
              value: {type: 'http://openehr.org/fhir/StructureDefinition/DV_TEXT', index: 45}
        at0190:
          match: {}
          schema:
            short: Resolving factor
            type: http://openehr.org/fhir/StructureDefinition/CLUSTER
            array: true
            label: at0190
            index: 64
            elements:
              items:
                index: 65
                slicing:
                  rules: closed
                  discriminator:
                  - {path: $this, type: profile}
                  min: null
                  slices:
                    at0193:
                      match: {}
                      schema:
                        short: Factor
                        type: http://openehr.org/fhir/StructureDefinition/ELEMENT
                        label: at0193
                        index: 66
                        elements:
                          value: {type: 'http://openehr.org/fhir/StructureDefinition/DV_TEXT', index: 67}
                    at0194:
                      match: {}
                      schema: {short: Factor detail, type: 'http://openehr.org/fhir/StructureDefinition/CLUSTER', array: true, label: at0194, index: 68}
                      min: 0
                    at0195:
                      match: {}
                      schema:
                        short: Time interval
                        type: http://openehr.org/fhir/StructureDefinition/ELEMENT
                        label: at0195
                        index: 69
                        elements:
                          value: {type: 'http://openehr.org/fhir/StructureDefinition/DV_DURATION', index: 70}
                    at0196:
                      match: {}
                      schema:
                        short: Description
                        type: http://openehr.org/fhir/StructureDefinition/ELEMENT
                        label: at0196
                        index: 71
                        elements:
                          value: {type: 'http://openehr.org/fhir/StructureDefinition/DV_TEXT', index: 72}
        at0164:
          match: {}
          schema:
            short: Onset timing
            type: http://openehr.org/fhir/StructureDefinition/ELEMENT
            label: at0164
            index: 16
            elements:
              value:
                index: 17
                slicing:
                  rules: closed
                  discriminator:
                  - {path: $this, type: type}
                  min: null
                  slices:
                    DV_TEXT:
                      match: {}
                      schema: {type: 'http://openehr.org/fhir/StructureDefinition/DV_TEXT', index: 18}
                    DV_DURATION:
                      match: {}
                      schema: {type: 'http://openehr.org/fhir/StructureDefinition/DV_DURATION', index: 19}
                    DV_INTERVAL:
                      match: {}
                      schema: {type: 'http://openehr.org/fhir/StructureDefinition/DV_INTERVAL', index: 20}
package_version: 1.0.0-ballot
class: logical
kind: logical
url: http://hl7.org/fhir/uv/symptoms/StructureDefinition/openEHR-EHR-CLUSTER.symptom-sign.v2
base: http://openehr.org/fhir/StructureDefinition/CLUSTER
version: 1.0.0-ballot