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
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
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

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