Modellbiblioteket openEHR Fork
Name
Request for service
Description
Document sent from one treating healthcare provider or organisation to another, for the purpose of requesting advice, a service or transfer of care.
Keywords
referral request service
Purpose
To request advice, a specified service or transfer of care from a healthcare provider or organisation about the subject of care.
Use
Use as basis for a request for advice, a service or transfer of care from a healthcare provider or organisation about the subject of care. This document will typically include details about the scope and duration of validity of the request, as well as relevant clinical information about the subject. Requests can vary from a simple request for a consultation, seeking recommendation about further action, requesting a specific procedure or diagnostic test, through to full handover of care and clinical responsibility to the receiving healthcare provider.

Use cases include, but are not limited to a request for:
- a consultation, second opinion or management advice from a specialist;
- a diagnostic test;
- home care from visiting nurses;
- transfer of care to a rehabilitation facility;
- for aged care assessment;
- for a medication review by a pharmacist; and
- for provision of physiotherapy or occupational therapy.

Requests may be targeted (identifying a specific healthcare provider or organisation to carry out the request) or untargeted (identifying only the type of care desired).
Misuse
Not to be used to represent the document recorded as part of a single clinical encounter or visit. Use COMPOSITION.encounter for this purpose.

Not to be used to provide a transfer of care summary to another organisation or provider - use COMPOSITION.transfer_summary for this purpose.
References
FHIR ReferralRequest resource: http://hl7-fhir.github.io/referralrequest.html
Archetype Id
openEHR-EHR-COMPOSITION.request.v1
Copyright
© openEHR Foundation
Licencing
This work is licensed under the Creative Commons Attribution-ShareAlike 3.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/3.0/.
Original Author
Dr Ian McNicoll
freshEHR Informatics, UK
Date Originally Authored
To request advice, a specified service or transfer of care from a healthcare provider or organisation about the subject of care.
Language Details
German
Natalia Strauch
Medizinische Hochschule Hannover
Swedish
Lisa Axelsson
Region Östergötland
Norwegian Bokmal
Lars Bitsch-Larsen, John Tore Valand
Haukeland Universitetssjukehus
Arabic (Syria)
Mona Saleh
Dutch
Dennis Valk
Code24 BV
archetype (adl_version=1.4; uid=0942a3f6-3f2d-431c-871c-84bc722f4626)
	openEHR-EHR-COMPOSITION.request.v1

concept
	[at0000]	-- Request for service
language
	original_language = <[ISO_639-1::en]>
	translations = <
		["de"] = <
			language = <[ISO_639-1::de]>
			author = <
				["name"] = <"Natalia Strauch">
				["organisation"] = <"Medizinische Hochschule Hannover">
				["email"] = <"Strauch.Natalia@mh-hannover.de">
			>
		>
		["sv"] = <
			language = <[ISO_639-1::sv]>
			author = <
				["name"] = <"Lisa Axelsson">
				["organisation"] = <"Region Östergötland">
				["email"] = <"lisa.axelsson@regionostergotland.se">
			>
		>
		["nb"] = <
			language = <[ISO_639-1::nb]>
			author = <
				["name"] = <"Lars Bitsch-Larsen, John Tore Valand">
				["organisation"] = <"Haukeland Universitetssjukehus">
			>
		>
		["ar-sy"] = <
			language = <[ISO_639-1::ar-sy]>
			author = <
				["name"] = <"Mona Saleh">
			>
		>
		["nl"] = <
			language = <[ISO_639-1::nl]>
			author = <
				["name"] = <"Dennis Valk">
				["organisation"] = <"Code24 BV">
				["email"] = <"dennis.valk@code24.nl">
			>
			accreditation = <"Code24 BV">
		>
	>
description
	original_author = <
		["name"] = <"Dr Ian McNicoll">
		["organisation"] = <"freshEHR Informatics, UK">
		["email"] = <"ian@freshehr.com">
		["date"] = <"2008-01-08">
	>
	details = <
		["de"] = <
			language = <[ISO_639-1::de]>
			purpose = <"Um eine Beratung, eine bestimmte Dienstleistung oder die Übertragung der Versorgung von einem Gesundheitsdienstleister oder einer Organisation über den Patienten anzufordern.">
			use = <"Verwendung als Grundlage für eine Anfrage für eine Beratung, eine Dienstleistung oder Übertragung der Versorgung von einem Gesundheitsdienstleister oder einer Organisation über den Patienten. Dieses Dokument enthält in der Regel Details zum Anwendungsbereich und zur Dauer der Gültigkeit der Anfrage sowie relevante klinische Informationen zum Patienten. Die Anfragen können von einer einfachen Beratungsanfrage, Einholen von Empfehlungen für weitere Maßnahmen, der Beantragung einer bestimmten Prozedur oder eines diagnostischen Tests bis hin zur vollständigen Übertragung der Versorgungs und der klinischen Verantwortung an den empfangenden Gesundheitsdienstleister variieren.

Beispiele umfassen, ohne darauf beschränkt zu sein, eine Anforderung für:
- eine Beratung, Zweitmeinung oder Managementberatung durch einen Spezialisten;
- ein diagnostischer Test;
- häusliche Pflege durch Krankenschwestern;
- Übergabe der Versorgung an eine Reha-Einrichtung;
- Bewertung der Indikation zur Altenpflege;
- Kontrolle der Medikamente durch einen Apotheker; und
- Bereitstellung von Psychotherapie oder Ergotherapie.

Anforderungen können gezielt (Identifizierung eines bestimmten Gesundheitsdienstleisters oder einer bestimmten Organisation zur Ausführung des Antrags) oder nicht zielgerichtet (Identifizierung nur der Art der gewünschten Leistung) erfolgen.">
			keywords = <"Überweisung", "Anfrage", "Anforderung", "Auftrag", "Leistung">
			misuse = <"Darf nicht zur Darstellung des Dokuments verwendet werden, das im Rahmen einer einzelnen klinischen Begegnung oder einer einzelnen Visite aufgezeichnet wurde. Verwenden Sie dazu COMPOSITION.encounter.

Darf nicht verwendet werden, um eine Zusammenfassung der Leistungsübertragung an eine andere Organisation oder einen anderen Anbieter bereitzustellen - Verwenden Sie COMPOSITION.transfer_summary für diesen Zweck.">
		>
		["sv"] = <
			language = <[ISO_639-1::sv]>
			purpose = <"Att begära rådgivning, en specifik tjänst, eller vårdöverföring mellan vårdgivare eller organisation avseende en patient.">
			use = <"Används som grund för begäran om råd, tjänst eller vårdöverföring avseende en patient, mellan vårdgivare eller organisationer. Dokumentet innehåller vanligtvis detaljer om begärans omfång och giltighetstid tillsammans med relevant klinisk information. En tjänstebegäran kan vara allt från en enkel förfrågan om konsultation, en fråga om rekommenderad vidare vård, en begäran om en specifik procedur eller diagnostisk åtgärd, till en fullständig vårdöverföring mellan vårdgivare.
Användningsområden inkluderar, men är inte begränsade till, att begära:

- konsultation, second opinion eller råd av specialist
- diagnostisk åtgärd
- hemsjukvård
- vårdöverföring till rehabilitering
- bedömning av vårdbehov
- läkemedelsgenomgång med farmaceut
- tillhandahållande av sjukgymnastik eller arbetsterapi

Begäran kan antingen vara riktad till en specifik vårdgivare eller organisation, eller peka ut vilken typ av vård som önskas.
">
			keywords = <"remiss", "remittering", "begäran", "tjänst">
			misuse = <"Ska inte användas för att dokumentera detaljer om ett vårdtillfälle eller ett besök. Använd istället arketypen Vårdtillfälle (COMPOSITION.encounter).

Ska inte användas som epikris vid överflyttning av patient till annan organisation eller vårdgivare. Använd istället arketypen COMPOSITION.transfer_summary.">
		>
		["nb"] = <
			language = <[ISO_639-1::nb]>
			purpose = <"For å spørre om råd, en helsetjeneste, eller ansvarsoverføring for en helsetjenestemottaker.">
			use = <"Brukes som basis for å spørre om råd, en tjeneste eller ansvarsoverføring for en helsetjenestemottaker. Dokumentet vil vanligvis inneholde detaljer om omfang og varighet av forespørselen, sammen med relevant klinisk informasjon. Et forespørselsdokument kan være alt fra en enkel forespørsel om en konsultasjon, forespørsel om anbefalinger om videre behandling, forespørsel om en spesifikk prosedyre eller diagnostisk undersøkelse, til en fullstendig overføring av ansvar mellom helsetjenesteyter. 

Bruksområder kan omfatte, men er ikke begrenset til:
- en konsultasjon, second opinion eller forespørsel om råd fra en spesialist,
- en diagnostisk undersøkelse,
- hjemmebaserte tjenester,
- overføring til rehabilitering,
- vurdering av behov for kommunale tjenester,
- for legemiddelgjennomgang med en farmasøyt,
- for henvisning til fysio- eller ergoterapi.

Forespørselsdokumentet kan ha en spesifikk mottaker (spesifikk helsetjenesteyter eller organisasjon) eller en mer uspesifikk mottaker (ønsket tjenestetype).">
			keywords = <"forespørselsdokument", "forespørsel", "tilsynsforespørsel", "internhenvisning", "eksternhenvisning", "bestilling", "helsetjenester", "medisinske tjenester", "henvisning", "rekvisisjon", "forordning">
			misuse = <"Brukes ikke for å registrere detaljer om en enkel interaksjon, kontakt eller omsorgshendelse mellom et individ og helsepersonell. Bruk arketypen Klinisk kontakt (COMPOSITION.encounter) for dette formålet

Brukes ikke som overflyttingsnotat/epikrise til andre organisasjoner eller tjenesteytere. Bruk Overføringsdokument (COMPOSITION.transfer_summary) for dette formålet.">
		>
		["ar-sy"] = <
			language = <[ISO_639-1::ar-sy]>
			purpose = <"لتوصيل طلب إحالة أو طلب تقديم خدمة إلى من يقوم بتقديمها.">
			use = <"">
			keywords = <"إحالة", "طلب">
			misuse = <"">
			copyright = <"© openEHR Foundation">
		>
		["en"] = <
			language = <[ISO_639-1::en]>
			purpose = <"To request advice, a specified service or transfer of care from a healthcare provider or organisation about the subject of care.">
			use = <"Use as basis for a request for advice, a service or transfer of care from a healthcare provider or organisation about the subject of care. This document will typically include details about the scope and duration of validity of the request, as well as relevant clinical information about the subject. Requests can vary from a simple request for a consultation, seeking recommendation about further action, requesting a specific procedure or diagnostic test, through to full handover of care and clinical responsibility to the receiving healthcare provider.

Use cases include, but are not limited to a request for:
- a consultation, second opinion or management advice from a specialist;
- a diagnostic test;
- home care from visiting nurses;
- transfer of care to a rehabilitation facility;
- for aged care assessment;
- for a medication review by a pharmacist; and
- for provision of physiotherapy or occupational therapy.

Requests may be targeted (identifying a specific healthcare provider or organisation to carry out the request) or untargeted (identifying only the type of care desired).">
			keywords = <"referral", "request", "service">
			misuse = <"Not to be used to represent the document recorded as part of a single clinical encounter or visit. Use COMPOSITION.encounter for this purpose.

Not to be used to provide a transfer of care summary to another organisation or provider - use COMPOSITION.transfer_summary for this purpose.">
			copyright = <"© openEHR Foundation">
		>
		["nl"] = <
			language = <[ISO_639-1::nl]>
			purpose = <"Voor het vragen van advies, een specifieke dienst of overdracht van zorg aan een zorgverlener of organisatie over de onderhavige persoon cq onderwerp van zorg.">
			use = <"Gebruik voor het vragen van advies, een specifieke dienst of overdracht van zorg aan een zorgverlener of organisatie over de onderhavige persoon cq onderwerp van zorg. Dit document zal typisch details omvatten over de scope en geldigheidsduur van het verzoek, als ook relevante klinische informatie over de betreffende persoon cq onderwerp. Verzoeken kunnen variëren van een eenvoudig verzoek voor consultatie, aanbeveling zoeken voor verdere actie, vragen om een specifieke procedure of diagnostische test, tot een volledige overdracht van zorg en klinische verantwoordelijkheid aan de ontvangende zorgaanbieder.

Voorbeelden bevatten, maar zijn niet gelimiteerd tot een verzoek voor:
- een consultatie, second opinion of management advies van een specialist;
- een diagnostische test;
- thuiszorg uitgevoerd door verpleegkundigen;
- overdracht van zorg aan een rehabilitatie instelling;
- indicatie ouderenzorg;
- controle van medicatie door een apotheker; en
- verlenen van psychotherapie of bezigheidstherapie.

Verzoeken kunnen gericht zijn (richten tot aan specifieke zorgverlener of organisatie om aan het verzoek te voldoen) of globaal geformuleerd (alleen het gewenste type zorg beschrijven).">
			keywords = <"verwijzing", "verzoek", "dienst">
			misuse = <"Niet te gebruiken om het vastgelegde document te presenteren als deel van een enkele klinische ontmoeting (encounter) of bezoek. Gebruik COMPOSITION.encounter voor dit doel.

Niet te gebruiken om een samenvattende zorgoverdracht te leveren aan een andere organisatie of aanbeider. Gebruik COMPOSITION.transfer_summary voor dit doel.">
		>
	>
	lifecycle_state = <"published">
	other_contributors = <"Nadim Anani, Karolinska Institutet, Sweden", "Vebjørn Arntzen, Oslo University Hospital, Norway", "Silje Ljosland Bakke, Nasjonal IKT HF, Norway (openEHR Editor)", "Lars Bitsch-Larsen, Haukeland University hospital, Norway", "Terje Bless, Helse Nord FIKS, Norway", "Shahla Foozonkhah, Iran ministry of health and education, Iran", "Heather Grain, Llewelyn Grain Informatics, Australia", "Bjørn Grøva, Diretoratet for e-helse, Norway", "Kristian Heldal, Telemark Hospital Trust, Norway", "Lars Karlsen, DIPS ASA, Norway", "Lars Morgan Karlsen, DIPS ASA, Norway", "Shinji Kobayashi, Kyoto University, Japan", "Heather Leslie, Atomica Informatics, Australia (openEHR Editor)", "Hallvard Lærum, Oslo Universitetssykehus HF, Norway", "Rose Mari Eikås, Helse Bergen, Norway", "Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (openEHR Editor)", "Bjørn Næss, DIPS ASA, Norway", "Andrej Orel, Marand d.o.o., Slovenia", "Anne Pauline Anderssen, Helse Nord RHF, Norway", "Jussara Rotzsch, Hospital Alemão Oswaldo Cruz, Brazil", "Norwegian Review Summary, Nasjonal IKT HF, Norway", "Line Sæle, Nasjonal IKT HF, Norway", "John Tore Valand, Haukeland Universitetssjukehus, Norway (Nasjonal IKT redaktør)", "Jon Tysdahl, Furst medlab AS, Norway">
	other_details = <
		["licence"] = <"This work is licensed under the Creative Commons Attribution-ShareAlike 3.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/3.0/.">
		["custodian_organisation"] = <"openEHR Foundation">
		["references"] = <"FHIR ReferralRequest resource: http://hl7-fhir.github.io/referralrequest.html">
		["current_contact"] = <"Heather Leslie, Ocean Informatics<heather.leslie@oceaninformatics.com>">
		["original_namespace"] = <"org.openehr">
		["original_publisher"] = <"openEHR Foundation">
		["custodian_namespace"] = <"org.openehr">
		["MD5-CAM-1.0.1"] = <"B8AD0C7EB492491CE6F7968C1AFFB40C">
		["build_uid"] = <"3a928712-c81a-4d9b-82ad-c01857468560">
		["revision"] = <"1.1.3">
	>

definition
	COMPOSITION[at0000] matches {	-- Tjenesteforespørsel
		category matches {
			DV_CODED_TEXT matches {
				defining_code matches {[openehr::433]}
			}
		}
		context matches {
			EVENT_CONTEXT matches {
				other_context matches {
					ITEM_TREE[at0001] matches {	-- Tree
						items cardinality matches {0..*; unordered} matches {
							allow_archetype CLUSTER[at0042] occurrences matches {0..*} matches {	-- Tilleggsinformasjon
								include
									archetype_id/value matches {/.*/}
							}
						}
					}
				}
			}
		}
	}



ontology
	term_definitions = <
		["en"] = <
			items = <
				["at0000"] = <
					text = <"Request for service">
					description = <"Document sent from one treating healthcare provider or organisation to another, for the purpose of requesting advice, a service or transfer of care.">
				>
				["at0001"] = <
					text = <"Tree">
					description = <"@ internal @">
				>
				["at0042"] = <
					text = <"Extension">
					description = <"Additional information required to capture local context or to align with other reference models/formalisms.">
					comment = <"For example: Local hospital departmental information or additional metadata to align with FHIR or CIMI equivalents.">
				>
			>
		>
		["ar-sy"] = <
			items = <
				["at0000"] = <
					text = <"*Request for service(en)">
					description = <"*Document sent from one treating healthcare provider or organisation to another, for the purpose of requesting advice, a service or transfer of care.(en)">
				>
				["at0001"] = <
					text = <"*Tree(en)">
					description = <"*@ internal @(en)">
				>
				["at0042"] = <
					text = <"*Extension(en)">
					description = <"*Additional information required to capture local context or to align with other reference models/formalisms.(en)">
					comment = <"*For example: Local hospital departmental information or additional metadata to align with FHIR or CIMI equivalents.(en)">
				>
			>
		>
		["nb"] = <
			items = <
				["at0000"] = <
					text = <"Tjenesteforespørsel">
					description = <"Dokument som sendes fra en helsetjenesteyter til en annen, med hensikt om å forespørre om råd, en tjeneste eller overføring av ansvar.">
				>
				["at0001"] = <
					text = <"Tree">
					description = <"@ internal @">
				>
				["at0042"] = <
					text = <"Tilleggsinformasjon">
					description = <"Ytterligere informasjon som er nødvendig for å registrere lokalt innhold/kontekst, eller for å sammenstille med andre referansemodeller/formalismer.">
					comment = <"F.eks lokale informasjonskrav eller ekstra metadata for å tilpasse med FHIR eller CIMI ekvivalenter.">
				>
			>
		>
		["nl"] = <
			items = <
				["at0000"] = <
					text = <"Verzoek voor een dienst">
					description = <"Document verstuurd van de ene behandelende zorgaanbieder of organisatie naar een andere, met als doel het vragen van advies, een dienst of overdracht van zorg.">
				>
				["at0001"] = <
					text = <"Tree">
					description = <"@ internal @">
				>
				["at0042"] = <
					text = <"Extensie">
					description = <"Aanvullende informatie vereist om de lokale context te vatten of om te verbinden met andere referentie modellen/formalismen.">
					comment = <"Bijvoorbeeld: Informatie van lokale ziekenhuis afdelingen of aanvullende metagegevens verbinden met FHIR of CIMI equivalenten.">
				>
			>
		>
		["sv"] = <
			items = <
				["at0000"] = <
					text = <"Tjänstebegäran">
					description = <"Dokument som skickas från en vårdgivare eller organisation till en annan, i syfte att be om råd, begära en tjänst eller att begära vårdöverföring.">
				>
				["at0001"] = <
					text = <"Tree">
					description = <"@ internal @">
				>
				["at0042"] = <
					text = <"Tilläggsinformation">
					description = <"Plats för att infoga tilläggsinformation som krävs för lokala anpassningar eller anpassning till andra referensmodeller eller formella krav.">
					comment = <"Exempelvis lokala informationskrav eller metadata för anpassning till FHIR- eller CIMI-motsvarigheter.">
				>
			>
		>
		["de"] = <
			items = <
				["at0000"] = <
					text = <"Leistungsanforderung">
					description = <"Das Dokument, das von einem behandelnden Gesundheitsdienstleister oder einer behandelnden Organisation an einen anderen gesendet wird, um Beratung, eine Dienstleistung oder Übertragung der Versorgung anzufordern.">
				>
				["at0001"] = <
					text = <"Tree">
					description = <"@ internal @">
				>
				["at0042"] = <
					text = <"Erweiterung">
					description = <"Zusätzliche Informationen zur Erfassung lokaler Inhalte oder Anpassung an andere Referenzmodelle/Formalismen.">
					comment = <"Zum Beispiel: Lokaler Informationsbedarf oder zusätzliche Metadaten zur Anpassung an FHIR-Ressourcen oder CIMI-Modelle.">
				>
			>
		>
	>