Manage immunization recommendation and adverse reaction

patient-charting/manage-adverse-reaction/create/PC80-create-adverse-reaction.md

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+#####Use Case ID: UC-PC80
+#####Use Case Name: Create Adverse Reaction
+
+**Level:**                     User Level Goal
+
+**Primary Actors:**            Physician
+
+**Stakeholders:**              Physician, Nurse
+
+**Purpose:**                   The main intent of this use case is to add a adverse reaction of a patient condition.
+
+**Pre Condition:**             Physician must be identified and authenticated.
+
+**Post Condition:**            Adverse Reactioh recorded successfully.
+
+**Frequency of Occurrence:**   High
+__________________________________________________________
+**Main Success Scenario: (Create Adverse Reaction)**
+
+1. User selects a adverse reaction option.
+2. System asks user to specify the type, severity and substance (if known).
+3. User enters the required fields. 
+4. System validates the fields and records the adverse reaction.
+
+__________________________________________________________
+**Alternate Flow:**
+
+1. Repeat step 1-3  from the main success scenario.
+2. If substance is known, associate particular substance with the reaction.
+3. Repeat step 4 from the main success scenario.
+
+________________________________________________________________________
+**Reference Hl7 V3 Interaction Identifiers:**
+[More Details](http://www.hl7.org/implement/standards/product_brief.cfm?product_id=306)
+
+N/A
+_______________________________________________________________
+**Reference CCHIT Criteria:**
+[More Details](https://www.cchit.org/cchit-certified)
+
+FN 05.05, FN 05.13

patient-charting/manage-adverse-reaction/read/PC81-list-adverse-reactions.md

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+#####Use Case ID: UC-PC74
+#####Use Case Name: List Adverse Reactions
+
+**Level:**                     User Level Goal
+
+**Primary Actors:**            Physician
+
+**Stakeholders:**              Physician, Nurse
+
+**Purpose:**                   The main intent of this use case is to display a list of adverse reactions of a patient condition.
+
+**Pre Condition:**             Physician must be identified and authenticated.
+
+**Post Condition:**            Adverse Reactions listed uccessfully.
+
+**Frequency of Occurrence:**   High
+__________________________________________________________
+**Main Success Scenario: (List Adverse Reactions)**
+
+1.	User requests to display list of adverse reactions.
+2.	System asks user to specify the filtering criteria(if any) such as type and severity.
+3.	User enters the filtering criteria.
+4.	System then displays the list of adverse reactions as per criteria.
+
+__________________________________________________________
+**Alternate Flows:**
+
+**Alt-1: List Adverse Reactions in a Patient Chart**
+
+1.	Physician selects [find patients](../../../patient-administration/manage-patient-registry/find-patients.md) option.
+2.	System displays the list of patients.
+3.	Physician navigate to an appropriate patient and then selects view patient's chart option.
+4.	System displays the full patient chart.
+5.	Physician selectes the adverse reaction tab.
+6.	System then displays the patient's adverse reaction list.
+
+________________________________________________________________________
+**Reference Hl7 V3 Interaction Identifiers:**
+[More Details](http://www.hl7.org/implement/standards/product_brief.cfm?product_id=306)
+
+N/A
+_______________________________________________________________
+**Reference CCHIT Criteria:**
+[More Details](https://www.cchit.org/cchit-certified)
+
+FN 05.12

patient-charting/manage-adverse-reaction/read/PC82-get-adverse-reaction.md

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+#####Use Case ID: UC-PC82
+#####Use Case Name: Get Adverse Reaction
+
+**Level:**                     User Level Goal
+
+**Primary Actors:**            Physician
+
+**Stakeholders:**              Physician, Nurse
+
+**Purpose:**                   The main intent of this use case is to display the details of adverse reaction of a patient condition.
+
+**Pre Condition:**             Physician must be identified and authenticated.
+
+**Post Condition:**            Adverse Reaction details displayed successfully.
+
+**Frequency of Occurrence:**   High
+__________________________________________________________
+**Main Success Scenario: (Get Adverse Reaction)**
+
+1.  User performs the actions in [list adverse reactions usecase](PC81-list-adverse-reactions.md).
+2.	System displays the list of adverse reactions.
+3.	User selects an appropriate adverse reaction and selects view details option.
+4.	System displays the details including the associated agents such as medication of selected adverse reactions.
+
+__________________________________________________________
+**Alternate Flows:**
+
+**Alt-1: Get Adverse Reaction in a Patient Chart**
+
+1.	Physician selects [find patients](../../../patient-administration/manage-patient-registry/find-patients.md) option.
+2.	System displays the list of patients.
+3.	Physician navigate to an appropriate patient and then selects view patient's chart option.
+4.	System displays the full patient chart.
+5.	Physician selectes the adverse reaction tab.
+6.	System then displays the patient's adverse reactions list.
+7.	Repeat step 3 and 4 from the success scenario.
+
+________________________________________________________________________
+**Reference Hl7 V3 Interaction Identifiers:**
+[More Details](http://www.hl7.org/implement/standards/product_brief.cfm?product_id=306)
+
+N/A
+_______________________________________________________________
+**Reference CCHIT Criteria:**
+[More Details](https://www.cchit.org/cchit-certified)
+
+FN 05.12, FN 05.13

patient-charting/manage-adverse-reaction/readme.md

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+####Description
+--------------
+
+Allergens, including immunizations, and substances are identified and coded (whenever possible) and the list is captured and maintained over time. All pertinent dates, including patient-reported events, are stored and the description of the patient allergy and adverse reaction is modifiable over time.
+
+![image](https://f.cloud.github.com/assets/4283040/1820974/3c4060c4-7117-11e3-92f6-71da534e8e24.png)
+
+####Functional Requirements
+* REQ-1: Create Adverse Reaction
+* REQ-2: List Adverse Reaction
+* REQ-3: Get Adverse Reaction
+* REQ-4: Update Adverse Reaction
+
+_______________________________________________________________
+**Reference Hl7 RMIM:** [More Details](http://www.hl7.org/implement/standards/product_brief.cfm?product_id=306)
+
+N/A
+_______________________________________________________________
+**Reference FHIR Resource:**
+[More Details](http://www.hl7.org/implement/standards/fhir/adversereaction.html)
+
+![image](https://f.cloud.github.com/assets/4283040/1821071/e411ebf0-711d-11e3-946d-a448b6385e0a.png)
+
+_______________________________________________________________
+**Reference CDA Template:** [More Details](http://www.hl7.org/Special/committees/structure/index.cfm)
+
+Section Level Template **"Allergies Section (V2)"**
+_______________________________________________________________
+**Reference OpenEHR Archetypes (Version 1.4):** [More Details](http://www.openehr.org/ckm/)
+
+```
+archetype (adl_version=1.4)
+	openEHR-EHR-COMPOSITION.adverse_reaction_list.v1
+
+concept
+	[at0000]	-- Adverse Reaction List
+language
+	original_language = <[ISO_639-1::en]>
+description
+	original_author = <
+		["name"] = <"Heather Leslie">
+		["organisation"] = <"Ocean Informatics">
+		["email"] = <"heather.leslie@oceaninformatics.com">
+		["date"] = <"2013-03-14">
+	>
+	details = <
+		["en"] = <
+			language = <[ISO_639-1::en]>
+			purpose = <"To record a persistent and managed list of all known adverse reactions experienced by the subject, or statements about positive exclusion or actual absence of information about adverse reactions, that may influence clinical decision-making and care provision.">
+			use = <"Use to record a persistent and managed list of all known adverse reactions (including allergies, hypersensitivities, side effects or intolerances) experienced by the subject, or statements about positive exclusion or actual absence of information about adverse reactions, that may influence clinical decision-making and care provision. 
+
+This list can be utilised as a source of up-to-date adverse reaction data for exchange or as the basis for decision support. 
+
+This list can be comprised of three types of archetype:
+- statements about the positive use of medications are recorded using the EVALUATION.adverse_reaction archetype; OR
+- a statement about the positive exclusion of medication use can be recorded using the specific EVALUATION.exclusion-adverse_reaction archetype - for example: \"No known adverse reactions\"; OR
+- a statement about no information being available - neither a positive and known presence of an adverse reaction nor a positive exclusion - can be recorded using the EVALUATION.absence archetype.
+
+In order for this list to be accurate and safe to use as the basis for decision support activities and for exchange, this list should ideally be curated by a clinician responsible for the health record, rather than managed automatically by the clinical system through business rules alone.">
+			keywords = <"adverse", "reaction", "allergy", "intolerance", "effect", "hypersensitivity", "list", "side">
+			misuse = <"">
+			copyright = <"© openEHR Foundation">
+		>
+	>
+	lifecycle_state = <"CommitteeDraft">
+	other_contributors = <"Ian McNicoll, Ocean Informatics, United Kingdom (Editor)", "Sam Heard, Ocean Informatics, Australia", "Sistine Barretto-Daniels, Ocean Informatics, Australia">
+	other_details = <
+		["current_contact"] = <"Heather Leslie, Ocean Informatics, heather.leslie@oceaninformatics.com">
+		["MD5-CAM-1.0.1"] = <"7C6282FE2D669F7DF0CC7CA4958E4A57">
+	>
+
+definition
+	COMPOSITION[at0000] matches {	-- Adverse Reaction List
+		category matches {
+			DV_CODED_TEXT matches {
+				defining_code matches {[openehr::431]}
+			}
+		}
+		content cardinality matches {1..*; unordered} matches {
+			allow_archetype EVALUATION[at0002] occurrences matches {0..*} matches {	-- Adverse Reactions
+				include
+					archetype_id/value matches {/openEHR-EHR-EVALUATION\.adverse_reaction(-[a-zA-Z0-9_]+)*\.v1/}
+			}
+			allow_archetype EVALUATION[at0003] occurrences matches {0..*} matches {	-- Exclusion Statement
+				include
+					archetype_id/value matches {/openEHR-EHR-EVALUATION\.exclusion-adverse_reaction(-[a-zA-Z0-9_]+)*\.v1/}
+			}
+			allow_archetype EVALUATION[at0004] occurrences matches {0..*} matches {	-- Absent Information
+				include
+					archetype_id/value matches {/openEHR-EHR-EVALUATION\.absence(-[a-zA-Z0-9_]+)*\.v1/}
+			}
+		}
+	}
+
+
+ontology
+	term_definitions = <
+		["en"] = <
+			items = <
+				["at0000"] = <
+					text = <"Adverse Reaction List">
+					description = <"A persistent and managed list of adverse reactions experienced by the subject that may influence clinical decision-making and care provision.">
+				>
+				["at0002"] = <
+					text = <"Adverse Reactions">
+					description = <"Details about known adverse reactions.">
+				>
+				["at0003"] = <
+					text = <"Exclusion Statement">
+					description = <"Positive statement about exclusion of known adverse reactions.">
+					comment = <"For example: \"No known adverse reactions\".">
+				>
+				["at0004"] = <
+					text = <"Absent Information">
+					description = <"Positive statement that no information is available about adverse reactions.">
+				>
+			>
+		>
+	>
+```

patient-charting/manage-adverse-reaction/update/PC83-update-adverse-reaction.md

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+#####Use Case ID: UC-PC83
+#####Use Case Name: Update Adverse Reaction
+
+**Level:**                     User Level Goal
+
+**Primary Actors:**            Physician
+
+**Stakeholders:**              Physician, Nurse
+
+**Purpose:**                   The main intent of this use case is to update adverse reaction of a patient.
+
+**Pre Condition:**             Physician must be identified and authenticated.
+
+**Post Condition:**            Adverse Reaction updated successfully.
+
+**Frequency of Occurrence:**   High
+__________________________________________________________
+**Main Success Scenario: (Update Adverse Reaction)**
+
+1.  User performs the actions in [list adverse reactions usecase](../read/PC81-list-adverse-reactions.md).
+2.	System displays the list of adverse reactions.
+3.	User selects an appropriate adverse reaction.
+4.	System displays the adverse reactions details and asks user to modify desired fields.
+5.	User modifies the reaction details such as type, date/time and severity.
+6.	System validates the changes, creates a modified version of adverse reaction and records the time and user of committed changes.
+
+__________________________________________________________
+**Alternate Flows:**
+
+**Alt-1: Update Adverse Reaction Status**
+
+1.	Repeat step 1 to 5 from the main scenario.
+2.	User modifies the status of the adverse reaction such as activate or de-activate.
+3.	The step 6 in main scenario of events are then executed.
+
+________________________________________________________________________
+**Reference Hl7 V3 Interaction Identifiers:**
+[More Details](http://www.hl7.org/implement/standards/product_brief.cfm?product_id=306)
+
+N/A
+_______________________________________________________________
+**Reference CCHIT Criteria:**
+[More Details](https://www.cchit.org/cchit-certified)
+
+FN 05.01, FN 05.05, FN 05.07, FN 05.12, FN 05.13

patient-charting/manage-immunization-recommendation/create/PC73-create-immunization-recommendation.md

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+#####Use Case ID: UC-PC73
+#####Use Case Name: Create Immunization Recommendation
+
+**Level:**                     User Level Goal
+
+**Primary Actors:**            Physician
+
+**Stakeholders:**              Physician, Nurse
+
+**Purpose:**                   The main intent of this use case is to create a immunization recommendation for a patient condition.
+
+**Pre Condition:**             Physician must be identified and authenticated.
+
+**Post Condition:**            Immunization Recommendation recorded successfully.
+
+**Frequency of Occurrence:**   High
+__________________________________________________________
+**Main Success Scenario: (Create Immunization Recommendation)**
+
+1. Physician selects a immunization recommendation option.
+2. System asks user to specify the following information:
+    * Immunization type and dose 
+    * date and time of administration 
+    * route and site
+    * manufacturer
+    * user ID.
+3. Physician enters the required fields and specifies the clinical assesments required for immunization if required.
+4. System validates the fields and records the immunization recommendation.
+
+__________________________________________________________
+**Alternate Flows:**
+
+**Alt-1: Interaction Checking**
+
+1.	Repeat step 1 to 3 from the main scenario.
+2.	Physician review the system response of interaction checking and take actions as: 
+  * In case any allergy interaction reveals, it sort some other alternate immunization and proceed with normal order flow if find no allergy interaction, 
+  * In case absence of any allergy interaction, the physician proceeds with normal flow of immunization recommendation process, 
+  * System will set the immunization recommendation status to active.
+3.	The step 4 in main scenario of events are then executed.
+
+________________________________________________________________________
+**Reference Hl7 V3 Interaction Identifiers:**
+[More Details](http://www.hl7.org/implement/standards/product_brief.cfm?product_id=306)
+
+N/A
+_______________________________________________________________
+**Reference CCHIT Criteria:**
+[More Details](https://www.cchit.org/cchit-certified)
+
+FN 16.02, FN 16.03, IP 15.07

patient-charting/manage-immunization-recommendation/create/PC79-add-comment-to-immunization-recommendation.md

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+#####Use Case ID: UC-PCS79
+#####Use Case Name: Add Comment to Immunization Recommendation
+
+**Level:**                     User Level Goal
+
+**Primary Actors:**            Physician 
+
+**Stakeholders:**              Patient Charting User
+
+**Purpose:**                   The main intent of this use case is to add comment/note to the recommended immunization.
+
+**Pre Condition:**             Physician must be identified and authenticated.  
+
+**Post Condition:**            The comment/note added successfully.    
+
+**Frequency of Occurrence:**   High
+
+**Priority:**                  High
+__________________________________________________________
+**Main Success Scenario: (Add Comment to Immunization Recommendation)**
+
+1.	Physician will select the recommended immunization from the list and will add comment/note to it.
+2.	Physician will save the comment.
+3.	System will associate the comment to particular immunization recommendation.
+
+_______________________________________________________________
+**Reference Hl7 V3 Interaction Identifiers (Domain: Problem List):**
+
+-NA-
+_______________________________________________________________
+**Reference CCHIT Criteria:**
+
+IP 15.05 
+