operationaltemplate.NCD.opt Maven / Gradle / Ivy
ISO_639-1
en
2021-11-02
unmanaged
4.2.0
fc63a78f-2f9f-4b87-98d6-373e9ce7823e
34a5825dd988d1ec8092a07af34b2af9
8F3156560D39B12C8362DF26A4C575BD
Archetype Designer v1.23.3, [email protected]@google,
repositoryId=ncd-9v
ISO_639-1
en
Not Specified
4b6e96a6-fcbe-4a10-82d2-b6571ea481fc
NCD
NCD
COMPOSITION
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true
false
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at0000
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DV_CODED_TEXT
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true
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false
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defining_code
true
true
false
false
1
1
false
CODE_PHRASE
true
true
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false
1
1
openehr
433
context
true
true
false
false
0
1
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EVENT_CONTEXT
true
true
false
false
1
1
other_context
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true
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1
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ITEM_TREE
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at0001
items
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0
1
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CLUSTER
true
false
false
true
0
at0002
archetype_id/value matches {/.*/}
Boolean
2007
false
String
-
archetype_id/value
attribute
String
-
.*
constraint
false
false
true
false
false
true
0
content
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OBSERVATION
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data
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1
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ITEM_TREE
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at0001
items
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false
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ELEMENT
true
true
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false
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value
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true
false
false
0
1
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DV_QUANTITY
true
true
false
false
1
1
openehr
127
true
false
false
false
0.0
100.0
true
true
false
false
1
1
Cel
false
false
true
false
false
true
1
state
true
true
false
false
0
1
false
ITEM_TREE
true
true
false
false
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at0029
items
true
true
false
false
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1
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CLUSTER
true
false
false
true
0
at0056
archetype_id/value matches
{/openEHR-EHR-CLUSTER\.environmental_conditions\.v1|openEHR-EHR-CLUSTER\.environmental_conditions\.v0/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.environmental_conditions\.v1|openEHR-EHR-CLUSTER\.environmental_conditions\.v0
constraint
CLUSTER
true
true
false
false
0
1
at0057
archetype_id/value matches
{/openEHR-EHR-CLUSTER\.level_of_exertion\.v1|openEHR-EHR-CLUSTER\.level_of_exertion\.v0/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.level_of_exertion\.v1|openEHR-EHR-CLUSTER\.level_of_exertion\.v0
constraint
true
false
true
false
false
true
0
false
false
true
false
false
true
1
protocol
true
true
false
false
0
1
false
ITEM_TREE
true
true
false
false
1
1
at0020
items
true
true
false
false
0
1
false
CLUSTER
true
false
false
true
0
at0064
archetype_id/value matches
{/openEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_relative\.v1/}
Boolean
2007
false
String
-
archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_relative\.v1
constraint
CLUSTER
true
true
false
false
0
1
at0059
archetype_id/value matches {/openEHR-EHR-CLUSTER\.device\.v1/}
Boolean
2007
false
String
-
archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.device\.v1
constraint
CLUSTER
true
false
false
true
0
at0062
true
false
true
false
false
true
0
openEHR-EHR-OBSERVATION.body_temperature.v2
Body temperature
A measurement of the body temperature, which is a surrogate for the core
body temperature of the individual.
Tree
@ internal @
History
@ internal @
Any event
Default, unspecified point in time or interval event which may be explicitly
defined in a template or at run-time.
Temperature
The measured temperature.
Protocol
@ internal @
Location of measurement
Simple description about the site of measurement.
Mouth
Temperature is measured within the mouth.
Ear canal
Temperature is measured from within the external auditory canal.
Axilla
Temperature is measured from the skin of the axilla with the arm positioned
down by the side.
Rectum
Temperature measured within the rectum.
Nasopharynx
Temperature is measured within the nasopharynx.
Urinary bladder
Temperature is measured in the urinary bladder.
Intravascular
Temperature is measured within the vascular system.
State
State information about the patient.
Body exposure
The degree of exposure of the individual at the time of measurement.
Naked
No clothing, bedding or covering.
Reduced clothing/bedding
The person is covered by a lesser amount of clothing or bedding than deemed
appropriate for the environmental circumstances.
Appropriate clothing/bedding
The person is covered by an amount of clothing or bedding deemed appropriate
for the environmental circumstances.
Increased clothing/bedding
The person is covered by an increased amount of clothing or bedding than
deemed appropriate for the environmental circumstances.
Description of thermal stress
Narrative description of the conditions applied to the subject that might
influence their measured body temperature.
Skin
Temperature is measured from exposed skin.
Vagina
Temperature is measured within the vagina.
Oesophagus
Temperatue is measured within the oesophagus.
Inguinal skin crease
Temperature is measured in the inguinal skin crease between the leg and
abdominal wall.
Environmental conditions
Details about the environmental conditions at the time of temperature
measurement.
Exertion
Details about the exertion of the person at the time of temperature
measurement.
Device
Details about the device used to measure body temperature.
Temple
Temperature is measured at the temple, over the superficial temporal
artery.
Forehead
Temperature is measured on the forehead.
Extension
Additional information required to extend the model with local content or to
align with other reference models or formalisms.
For example: local information requirements; or additional metadata to align
with FHIR.
Comment
Additional comment about the body temperature measurement not captured in
other fields.
Structured measurement location
Structured details about the location of measurement.
Day of menstrual cycle
Current day of the menstrual cycle.
The first day of menstruation is considered to be Day 1 of each menstrual
cycle.
Confounding factors
Additional issues or factors that may impact on the measurement of body
temperature, not captured in other fields.
°C
degrees Celsius
LNC205
[LNC205::8310-5]
SNOMED-CT
[SNOMED-CT::386725007]
OBSERVATION
true
true
false
false
0
1
at0000
data
true
true
false
false
1
1
false
HISTORY
true
true
false
false
1
1
at0001
events
true
true
false
false
0
1
false
EVENT
true
false
false
true
0
at0006
data
true
true
false
false
1
1
false
ITEM_TREE
true
true
false
false
1
1
at0003
items
true
true
false
false
0
1
false
ELEMENT
true
true
false
false
0
1
at0004
value
true
true
false
false
0
1
false
DV_QUANTITY
true
true
false
false
1
1
openehr
125
true
false
false
false
0.0
1000.0
true
true
false
false
0
0
mm[Hg]
ELEMENT
true
true
false
false
0
1
at0005
value
true
true
false
false
0
1
false
DV_QUANTITY
true
true
false
false
1
1
openehr
125
true
false
false
false
0.0
1000.0
true
true
false
false
0
0
mm[Hg]
false
false
true
false
false
true
0
state
true
true
false
false
0
1
false
ITEM_TREE
true
true
false
false
1
1
at0007
items
true
true
false
false
0
1
false
CLUSTER
true
true
false
false
0
1
at1030
archetype_id/value matches
{/openEHR-EHR-CLUSTER\.level_of_exertion(-[a-zA-Z0-9_]+)*\.v1/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.level_of_exertion(-[a-zA-Z0-9_]+)*\.v1
constraint
false
false
true
false
false
true
0
false
false
true
false
false
true
1
protocol
true
true
false
false
0
1
false
ITEM_TREE
true
true
false
false
1
1
at0011
items
true
true
false
false
0
1
false
CLUSTER
true
false
false
true
0
at1057
archetype_id/value matches
{/openEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1/}
Boolean
2007
false
String
-
archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1
constraint
CLUSTER
true
true
false
false
0
1
at1025
archetype_id/value matches
{/openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1/}
Boolean
2007
false
String
-
archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1
constraint
CLUSTER
true
false
false
true
0
at1058
archetype_id/value matches {/.*/}
Boolean
2007
false
String
-
archetype_id/value
attribute
String
-
.*
constraint
false
false
true
false
false
true
0
openEHR-EHR-OBSERVATION.blood_pressure.v2
Blood pressure
The local measurement of arterial blood pressure which is a surrogate for
arterial pressure in the systemic circulation.
Most commonly, use of the term 'blood pressure' refers to measurement of
brachial artery pressure in the upper arm.
History
History Structural node.
blood pressure
@ internal @
Systolic
Peak systemic arterial blood pressure - measured in systolic or contraction
phase of the heart cycle.
Diastolic
Minimum systemic arterial blood pressure - measured in the diastolic or
relaxation phase of the heart cycle.
Any event
Default, unspecified point in time or interval event which may be explicitly
defined in a template or at run-time.
state structure
@ internal @
Position
The position of the individual at the time of measurement.
Tree
List structure.
Cuff size
The size of the cuff used for blood pressure measurement.
Perloff D, Grim C, Flack J, Frohlich ED, Hill M, McDonald M, Morgenstern BZ.
Human blood pressure determination by sphygmomanometry. Circulation 1993;88;2460-2470.
Location of measurement
Simple body site where blood pressure was measured.
Adult Thigh
A cuff used for an adult thigh.
Large Adult
A cuff for adults with larger arms.
Adult
A cuff that is standard for an adult.
Right arm
The right arm of the person.
Left arm
The left arm of the person.
Right thigh
The right thigh of the person.
Left thigh
The left thigh of the person.
Comment
Additional narrative about the measurement, not captured in other fields.
Standing
Standing at the time of blood pressure measurement.
Sitting
Sitting (for example on bed or chair) at the time of blood pressure
measurement.
Reclining
Reclining at the time of blood pressure measurement.
Lying
Lying flat at the time of blood pressure measurement.
Tilt
The craniocaudal tilt of the surface on which the person is lying at the
time of measurement.
Mean arterial pressure
The average arterial pressure that occurs over the entire course of the
heart contraction and relaxation cycle.
Pulse pressure
The difference between the systolic and diastolic pressure.
Small Adult
A cuff used for a small adult.
Paediatric/Child
A cuff that is appropriate for a child or adult with a thin arm.
Diastolic endpoint
Record which Korotkoff sound is used for determining diastolic pressure
using auscultative method.
Phase IV
The fourth Korotkoff sound is identified as an abrupt muffling of sounds.
Phase V
The fifth Korotkoff sound is identified by absence of sounds as the cuff
pressure drops below the diastolic blood pressure.
Lying with tilt to left
Lying flat with some lateral tilt, usually angled towards the left side.
Commonly required in the last trimester of pregnancy to relieve aortocaval compression.
Infant
A cuff used for infants.
Neonatal
A cuff used for a neonate, assuming cuff is the appropriate size for
maturity and birthweight of the neonate.
Right wrist
The right wrist of the individual.
Left wrist
The left wrist of the individual.
Device
Details about sphygmomanometer or other device used to measure the blood
pressure.
Right ankle
The right ankle of the individual.
Exertion
Details about physical activity undertaken at the time of blood pressure
measurement.
Left ankle
The left ankle of the individual.
Finger
A finger of the individual.
Method
Method of measurement of blood pressure.
Auscultation
Method of measuring blood pressure externally, using a stethoscope and
Korotkoff sounds.
Palpation
Method of measuring blood pressure externally, using palpation (usually of
the brachial or radial arteries).
Mean arterial pressure formula
Formula used to calculate the Mean Arterial Pressure (if recorded in
data).
Machine
Method of measuring blood pressure externally, using a blood pressure
machine.
Invasive
Method of measuring blood pressure internally ie involving penetration of
the skin and measuring inside blood vessels.
24 hour average
Estimate of the average blood pressure over a 24 hour period.
Sleep status
Sleep status - supports interpretation of 24 hour ambulatory blood pressure
records.
Awake
The individual is fully conscious.
Sleeping
The individual is in the natural state of bodily rest.
Toe
A toe of the individual.
Confounding factors
Comment on and record other incidental factors that may be contributing to
the blood pressure measurement. For example, level of anxiety or 'white coat syndrome'; pain or
fever; changes in atmospheric pressure etc.
Intra-arterial
Invasive measurement via transducer access line within an artery.
Systolic pressure formula
Formula used to calculate the systolic pressure from from mean arterial
pressure (if recorded in data).
Diastolic pressure formula
Formula used to calculate the diastolic pressure from mean arterial pressure
(if recorded in data).
Structured measurement location
Structured anatomical location of where the measurement was taken.
Extension
Additional information required to capture local context or to align with
other reference models/formalisms.
For example: Local hospital departmental infomation or additional metadata to
align with FHIR or CIMI equivalents.
Clinical interpretation
Single word, phrase or brief description that represents the clinical
meaning and significance of the blood pressure measurement.
Dorsum of foot
The individual's dorsum of the foot.
mmHg
millimeters of mercury
SNOMED-CT
[SNOMED-CT(2003)::364090009]
SNOMED-CT
[SNOMED-CT(2003)::271649006]
SNOMED-CT
[SNOMED-CT(2003)::271650006]
SNOMED-CT
[SNOMED-CT(2003)::246153002]
OBSERVATION
true
true
false
false
0
1
at0000
data
true
true
false
false
1
1
false
HISTORY
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true
false
false
1
1
at0002
events
true
true
false
false
0
1
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EVENT
true
false
false
true
0
at0003
data
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false
false
1
1
false
ITEM_TREE
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1
1
at0001
items
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false
false
0
1
false
ELEMENT
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at0004
value
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true
false
false
0
1
false
DV_QUANTITY
true
true
false
false
1
1
openehr
382
true
false
false
false
0.0
1000.0
true
true
false
false
0
0
/min
ELEMENT
true
true
false
false
0
1
at0005
value
true
true
false
false
0
1
false
DV_CODED_TEXT
true
true
false
false
1
1
defining_code
true
true
false
false
1
1
false
CODE_PHRASE
true
true
false
false
1
1
local
at0006
at1028
false
false
true
false
false
true
0
state
true
true
false
false
0
1
false
ITEM_TREE
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true
false
false
1
1
at0012
items
true
true
false
false
0
1
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CLUSTER
true
false
false
true
0
at1017
archetype_id/value matches
{/openEHR-EHR-CLUSTER\.level_of_exertion(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.level_of_exertion(-[a-zA-Z0-9_]+)*\.v0/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.level_of_exertion(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.level_of_exertion(-[a-zA-Z0-9_]+)*\.v0
constraint
false
false
true
false
false
true
0
false
false
true
false
false
true
1
protocol
true
true
false
false
0
1
false
ITEM_TREE
true
true
false
false
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1
at0010
items
true
true
false
false
0
1
false
CLUSTER
true
true
false
false
0
1
at1013
archetype_id/value matches
{/openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1/}
Boolean
2007
false
String
-
archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1
constraint
archetype_id/value matches {/.*/}
Boolean
2007
false
String
-
archetype_id/value
attribute
String
-
.*
constraint
CLUSTER
true
false
false
true
0
at1056
archetype_id/value matches {/.*/}
Boolean
2007
false
String
-
archetype_id/value
attribute
String
-
.*
constraint
false
false
true
false
false
true
0
openEHR-EHR-OBSERVATION.pulse.v2
Pulse/Heart beat
The rate and associated attributes for a pulse or heart beat.
structure
@ internal @
history
@ internal @
Any event
Default, unspecified point in time or interval event which may be explicitly
defined in a template or at run-time.
Rate
The rate of the pulse or heart beat, measured in beats per minute.
Regularity
Regularity of the pulse or heart beat.
Regular
The pattern is regular.
Regularly Irregular
The pattern is irregular in a regular pattern,. For example, a dropped beat
once every 'n' beats.
Irregularly Irregular
The pattern is irregular in a chaotic and unpredictable manner. For example,
atrial fibrillation.
List
@ internal @
List
@ internal @
Position
The body position of the subject during the observation.
Lying
The subject was lying flat.
Sitting
The subject was sitting (for example on bed or chair).
Reclining
The subject was reclining at an approximate angle of 45 degrees, with the
legs elevated to the level of the pelvis.
Standing/upright
The subject was standing, walking or running.
Presence
Presence of a pulse or heart beat.
It can be implied that the pulse or heart beat is present if Rate >0 /min.
Device
Details about the device used to measure the pulse rate or heart rate.
Exertion
Details about physical exertion being undertaken during the examination.
Confounding factors
Narrative description about any incidental factors that may affect
interpretation of the physical findings.
For example, presence of a pacemaker, level of anxiety; pain or fever etc.
Method
Method used to observe the pulse or heart beat.
For example, auscultation or electronic monitoring.
Clinical description
Narrative description about the pulse or heart beat.
Clinical interpretation
Single word, phrase or brief description that represents the clinical
meaning and significance of the pulse or heart beat findings, including the rhythm.
Coding with a terminology is preferred, where possible. For example:
Bradycardia, Extrasystoles or Sinus rhythm. Multiple statements are allowed.
Present
A pulse or heart beat can be detected.
Not detected
A pulse or heart beat cannot be detected.
Irregular
The pattern is irregular.
Character
Description of the character of the pulse or heart beat.
Coding with a terminology is desired, where possible. For example: full,
thready, bounding, slow rising, or collapsing. Multiple terms may be recorded.
Palpation
The findings are observed by physical touch of the observer on the
subject.
Auscultation
The findings are observed with the assistance of a device, such as a
stethoscope.
Automatic, non-invasive
The findings are observed non-invasively using a device such as a pulse
oximeter or a stethoscope.
Maximum
Maximum pulse rate or heart rate observed during a period of exertion.
Body site
Body site where the pulse or heart beat were observed.
Radial Artery - Left
The left radial artery.
Radial Artery - Right
The right radial artery.
Heart
The region of the heart.
Carotid Artery - Left
The left carotid artery.
Carotid Artery - Right
The right carotid artery.
Femoral Artery - Left
The left femoral artery.
Femoral Artery - Right
The right femoral artery.
Finger
An unspecified finger.
Brachial artery - Left
The left brachial artery.
Brachial artery - Right
The right brachial artery.
Automatic, invasive
The findings are observed invasively using a device such as an arterial
catheter.
Ear lobe
The lobe of an unspecified ear.
Toe
An unspecified toe.
Irregular type
More specific pattern of an irregular pulse or heart beat.
Selection of a value from this value set is only valid if 'Irregular' is
selected from the 'Regularity' data element.
Extension
Additional information required to capture local content or to align with
other reference models/formalisms.
For example: local information requirements or additional metadata to align with
FHIR or CIMI equivalents.
Clinical interpretation
Generic label to allow for any or all statements about the pulse or heart
beat.
Rhythm
Specific conclusion about the rhythm of the pulse or heartbeat, drawn from a
combination of the heart rate, pattern and other characteristics observed on examination.
Comment
Additional narrative about the pulse or heart beat findings not captured in
other fields.
OBSERVATION
true
true
false
false
0
1
at0000
data
true
true
false
false
1
1
false
HISTORY
true
true
false
false
1
1
at0001
events
true
true
false
false
0
1
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EVENT
true
false
false
true
0
at0002
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true
true
false
false
1
1
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ITEM_TREE
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at0003
items
true
true
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false
0
1
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ELEMENT
true
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at0004
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true
true
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1
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DV_QUANTITY
true
true
false
false
1
1
openehr
122
true
true
false
false
0.0
1000.0
cm
true
true
false
false
0.0
250.0
[in_i]
false
false
true
false
false
true
1
state
true
true
false
false
0
1
false
ITEM_TREE
true
true
false
false
1
1
at0013
false
false
true
false
false
true
1
protocol
true
true
false
false
0
1
false
ITEM_TREE
true
true
false
false
1
1
at0007
items
true
true
false
false
0
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CLUSTER
true
true
false
false
0
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at0011
archetype_id/value matches
{/openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1/}
Boolean
2007
false
String
-
archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1
constraint
CLUSTER
true
false
false
true
0
at0022
archetype_id/value matches {/.*/}
Boolean
2007
false
String
-
archetype_id/value
attribute
String
-
.*
constraint
true
false
true
false
false
true
0
openEHR-EHR-OBSERVATION.height.v2
Height/Length
Height, or body length, is measured from crown of head to sole of foot.
Height is measured with the individual in a standing position and body length in
a recumbent position.
history
@ internal @
Any event
Default, unspecified point in time or interval event which may be explicitly
defined in a template or at run-time.
Simple
@ internal @
Height/Length
The length of the body from crown of head to sole of foot.
List
@ internal @
Device
Description of the device used to measure height or body length.
Tree
@ internal @
Position
Position of individual when measured.
Standing
Height is measured standing on both feet with weight distributed evenly,
heels together and both buttocks and heels in contact with a vertical back board.
Comment
Additional narrative about the measurement, not captured in other fields.
Confounding factors
Narrative description of any issues or factors that may impact on the
measurement.
For example: noting of amputation.
Lying
Length is measured in a fully extended, recumbent position with the pelvis
flat, legs extended and feet flexed.
Birth
Usually the first length measurement, recorded soon after birth. This event
will only be used once per health record
.
Extension
Additional information required to capture local content or to align with
other reference models/formalisms.
For example: local information requirements or additional metadata to align with
FHIR or CIMI equivalents.
in
inch
LOINC
[LOINC::8302-2]
OBSERVATION
true
true
false
false
0
1
at0000
data
true
true
false
false
1
1
false
HISTORY
true
true
false
false
1
1
at0002
events
true
true
false
false
0
1
false
EVENT
true
false
false
true
0
at0003
data
true
true
false
false
1
1
false
ITEM_TREE
true
true
false
false
1
1
at0001
items
true
true
false
false
0
1
false
ELEMENT
true
true
false
false
1
1
at0004
value
true
true
false
false
0
1
false
DV_QUANTITY
true
true
false
false
1
1
openehr
124
true
true
false
false
0.0
1000.0
kg
true
true
false
false
0.0
2000.0
[lb_av]
true
true
false
false
0.0
1000000.0
g
false
false
true
false
false
true
1
state
true
true
false
false
0
1
false
ITEM_TREE
true
true
false
false
1
1
at0008
false
false
true
false
false
true
1
protocol
true
true
false
false
0
1
false
ITEM_TREE
true
true
false
false
1
1
at0015
items
true
true
false
false
0
1
false
CLUSTER
true
true
false
false
0
1
at0020
archetype_id/value matches
{/openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1/}
Boolean
2007
false
String
-
archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1
constraint
CLUSTER
true
false
false
true
0
at0027
archetype_id/value matches {/.*/}
Boolean
2007
false
String
-
archetype_id/value
attribute
String
-
.*
constraint
true
false
true
false
false
true
0
openEHR-EHR-OBSERVATION.body_weight.v2
Body weight
Measurement of the body weight of an individual.
Simple
@ internal @
history
@ internal @
Any event
Default, unspecified point in time or interval event which may be explicitly
defined in a template or at run-time.
Weight
The weight of the individual.
state structure
@ internal @
State of dress
Description of the state of dress of the person at the time of weighing.
Fully clothed, including shoes
Clothing which may add significantly to weight, including shoes.
Lightly clothed/underwear
Clothing which will not add to weight significantly.
Naked
Without any clothes.
protocol structure
@ internal @
Nappy/diaper
Wearing only a nappy - which may add significantly to weight.
Device
Details about the weighing device.
Comment
Additional narrative about the measurement of Body weight, not captured in
other fields.
Confounding factors
Record any issues or factors that may impact on the measurement of body
weight eg timing in menstrual cycle, timing of recent bowel motion or noting of amputation.
Birth
Usually the first weight, measured soon after birth. This event will only be
used once per health record
.
Extension
Additional information required to capture local content or to align with
other reference models/formalisms.
For example: local information requirements or additional metadata to align with
FHIR or CIMI equivalents.
Fully clothed, without shoes
Clothing which may add significantly to weight.
lbm
pound mass
LOINC
[LOINC::29463-7]
OBSERVATION
true
true
false
false
0
1
at0000
data
true
true
false
false
1
1
false
HISTORY
true
true
false
false
1
1
at0001
events
true
true
false
false
0
1
false
EVENT
true
false
false
true
0
at0010
data
true
true
false
false
1
1
false
ITEM_TREE
true
true
false
false
1
1
at0003
items
true
true
false
false
0
1
false
ELEMENT
true
true
false
false
1
1
at0004
value
true
true
false
false
0
1
false
DV_QUANTITY
true
true
false
false
1
1
openehr
122
true
true
false
false
0.0
500.0
cm
true
false
false
false
0.0
400.0
[in_i]
false
false
true
false
false
true
1
state
true
true
false
false
0
1
false
ITEM_TREE
true
true
false
false
1
1
at0008
false
false
true
false
false
true
1
protocol
true
true
false
false
0
1
false
ITEM_TREE
true
true
false
false
1
1
at0005
items
true
true
false
false
0
1
false
CLUSTER
true
true
false
false
0
1
at0006
archetype_id/value matches
{/openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1/}
Boolean
2007
false
String
-
archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1
constraint
CLUSTER
true
false
false
true
0
at0012
archetype_id/value matches {/.*/}
Boolean
2007
false
String
-
archetype_id/value
attribute
String
-
.*
constraint
false
false
true
false
false
true
0
openEHR-EHR-OBSERVATION.waist_circumference.v1
Waist circumference
The measurement of the distance around the waist.
Event Series
@ internal @
Tree
@ internal @
Waist circumference
The measurement of the circumference of the waist.
Tree
@ internal @
Device
Details about the device used for the measurement.
Comment
Additional narrative about the measurement of waist circumference not
captured in other fields.
Tree
@ internal @
Confounding factors
Narrative description of any issues or factors that may impact on the
measurement.
For example: uncooperative child.
Any event
Default, unspecified point in time or interval event which may be explicitly
defined in a template or at run-time.
Extension
Additional information required to capture local context or to align with
other reference models/formalisms.
For example: Local hospital departmental infomation or additional metadata to
align with FHIR or CIMI equivalents.
Method
The method how the waist circumference was measured.
in
inch
OBSERVATION
true
true
false
false
0
1
at0000
data
true
true
false
false
1
1
false
HISTORY
true
true
false
false
1
1
at0001
events
true
true
false
false
0
1
false
EVENT
true
true
false
false
0
1
at0010
data
true
true
false
false
1
1
false
ITEM_TREE
true
true
false
false
1
1
at0003
items
true
true
false
false
0
1
false
ELEMENT
true
true
false
false
1
1
at0004
value
true
true
false
false
0
1
false
DV_QUANTITY
true
true
false
false
1
1
openehr
122
true
true
false
false
0.0
400.0
true
true
false
false
1
1
cm
true
true
false
false
0.0
150.0
true
true
false
false
1
1
[in_i]
false
false
true
false
false
true
1
state
true
true
false
false
0
1
false
ITEM_TREE
true
true
false
false
1
1
at0008
false
false
true
false
false
true
1
protocol
true
true
false
false
0
1
false
ITEM_TREE
true
true
false
false
1
1
at0005
items
true
true
false
false
0
1
false
CLUSTER
true
true
false
false
0
1
at0006
archetype_id/value matches
{/openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1/}
Boolean
2007
false
String
-
archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1
constraint
CLUSTER
true
false
false
true
0
at0012
archetype_id/value matches {/.*/}
Boolean
2007
false
String
-
archetype_id/value
attribute
String
-
.*
constraint
false
false
true
false
false
true
0
openEHR-EHR-OBSERVATION.hip_circumference.v1
Hip circumference
The measurement of the distance around the hips.
Event Series
@ internal @
Tree
@ internal @
Hip circumference
The measurement of the distance around the widest point of the hip and
buttocks.
The measurement is usually taken at the widest point of the hips/buttocks.
Tree
@ internal @
Device
Details about the device used for the measurement.
Comment
Additional narrative about the hip circumference not captured in other
fields.
Tree
@ internal @
Confounding factors
Narrative description of any issues or factors that may impact on the
measurement.
For example: uncooperative child.
Any event
Default, unspecified point in time or interval event which may be explicitly
defined in a template or at run-time.
Extension
Additional information required to capture local context or to align with
other reference models/formalisms.
For example: Local hospital departmental infomation or additional metadata to
align with FHIR or CIMI equivalents.
in
inch
OBSERVATION
true
true
false
false
0
1
at0000
data
true
true
false
false
1
1
false
HISTORY
true
true
false
false
1
1
at0001
events
true
true
false
false
0
1
false
EVENT
true
false
false
true
0
at0002
data
true
true
false
false
1
1
false
ITEM_TREE
true
true
false
false
1
1
at0003
items
true
true
false
false
0
1
false
ELEMENT
true
true
false
false
0
1
at0006
value
true
true
false
false
0
1
false
DV_PROPORTION
true
true
false
false
1
1
numerator
true
true
false
false
1
1
false
REAL
true
true
false
false
1
1
-
true
true
false
false
0.0
100.0
type
true
true
false
false
1
1
false
INTEGER
true
true
false
false
1
1
-
2
CLUSTER
true
false
false
true
0
at0054
archetype_id/value matches
{/openEHR-EHR-CLUSTER\.waveform(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.waveform(-[a-zA-Z0-9_]+)*\.v1/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.waveform(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.waveform(-[a-zA-Z0-9_]+)*\.v1
constraint
CLUSTER
true
false
false
true
0
at0060
archetype_id/value matches
{/openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1
constraint
false
false
true
false
false
true
0
state
true
true
false
false
0
1
false
ITEM_TREE
true
true
false
false
1
1
at0014
items
true
true
false
false
0
1
false
CLUSTER
true
true
false
false
0
1
at0034
archetype_id/value matches
{/openEHR-EHR-CLUSTER\.level_of_exertion(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.level_of_exertion(-[a-zA-Z0-9_]+)*\.v1/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.level_of_exertion(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.level_of_exertion(-[a-zA-Z0-9_]+)*\.v1
constraint
CLUSTER
true
true
false
false
0
1
at0015
archetype_id/value matches
{/openEHR-EHR-CLUSTER\.inspired_oxygen(-[a-zA-Z0-9_]+)*\.v1/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.inspired_oxygen(-[a-zA-Z0-9_]+)*\.v1
constraint
false
false
true
false
false
true
0
false
false
true
false
false
true
1
protocol
true
true
false
false
0
1
false
ITEM_TREE
true
true
false
false
1
1
at0007
items
true
true
false
false
0
1
false
CLUSTER
true
true
false
false
0
1
at0018
archetype_id/value matches
{/openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1/}
Boolean
2007
false
String
-
archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1
constraint
CLUSTER
true
false
false
true
0
at0059
archetype_id/value matches {/.*/}
Boolean
2007
false
String
-
archetype_id/value
attribute
String
-
.*
constraint
false
false
true
false
false
true
0
openEHR-EHR-OBSERVATION.pulse_oximetry.v1
Pulse oximetry
Blood oxygen and related measurements, measured by pulse oximetry or pulse
CO-oximetry.
Event Series
@ internal @
Any event
Default, unspecified point in time or interval event which may be explicitly
defined in a template or at run-time.
Tree
@ internal @
SpO₂
The saturation of oxygen in the peripheral blood, measured via pulse
oximetry.
SpO₂ is defined as the percentage of oxyhaemoglobin (HbO₂) to the total
concentration of haemoglobin (HbO₂ + deoxyhaemoglobin) in peripheral blood.
List
@ internal @
Sensor site
The site of the measurement sensor.
For example: Right index finger, left earlobe. Coding with a terminology is
preferred, if possible.
Tree
@ internal @
Inspired oxygen
Details of the amount of oxygen available to the subject at the time of
observation.
Assumed values of 21% oxygen concentration, Fi0₂ of 0.21 and oxygen flow rate of
0 l/min or 0 ml/min.
Confounding factors
Comment on and record other incidental factors that may be affect
interpretation of the observation.
For example, motion, pain, poor perfusion, infant feeding, peripheral
hypothermia, sedation.
Oximetry device
Details of the non-invasive oximetry device used.
Exertion
Details about physical activity undertaken at the time of measurement.
Comment
A text comment about the pulse oximetry result.
SpOC
The oxygen content of the peripheral blood, calculated based on pulse
oximetry and pulse CO-oximetry.
SpCO
The saturation of carboxyhaemoglobin in the peripheral blood, measured via
pulse CO-oximetry.
SpMet
The saturation of methaemoglobin in the peripheral blood, measured via pulse
CO-oximetry.
Waveform
A waveform reading associated with the oximetry measurement.
Interpretation
Single word, phrase or brief description which represents the clinical
meaning and significance of the measurements.
Coding with a terminology is preferred, if possible. For example, normal oxygen
saturation or hypoxaemia.
Extension
Additional information required to capture local context or to align with
other reference models/formalisms.
e.g. Local hospital departmental infomation or additional metadata to align with
HL7 or CDISC equivalents.
Multimedia image
Details of a series of oximetry readings, other than waveforms, expressed as
a multimedia image or series of images. Waveforms should be recorded using the Waveform slot and
associated cluster archetype.
Pre/post-ductal
Sensor site relative to the ductus arteriosus in neonates, to determine
whether the blood supply to limb of the sensor site is pre- or post-ductal in cases of patent
ductus arteriosus.
Pre-ductal
The sensor site is pre-ductal.
Post-ductal
The sensor site is post-ductal.
Indeterminate
Unable to assess whether the sensor site is pre- or post-ductal.
SNOMED-CT
[SNOMED-CT::431314004]
SNOMED-CT
[SNOMED-CT::16206004]
SNOMED-CT
[SNOMED-CT::448703006]
SNOMED-CT
[SNOMED-CT::277923006]
LOINC
[LOINC::59408-5]
LOINC
[LOINC::20081-6]
LOINC
[LOINC::57800-5]
LOINC
[LOINC::86904-0]
LOINC
[LOINC::2614-6]
OBSERVATION
true
true
false
false
0
1
at0000
data
true
true
false
false
1
1
false
HISTORY
true
true
false
false
1
1
at0001
events
true
true
false
false
0
1
false
EVENT
true
false
false
true
0
at0002
data
true
true
false
false
1
1
false
ITEM_TREE
true
true
false
false
1
1
at0003
items
true
true
false
false
0
1
false
ELEMENT
true
true
false
false
1
1
at0005
value
true
true
false
false
0
1
false
DV_TEXT
true
true
false
false
1
1
CLUSTER
true
false
false
true
0
at0065
archetype_id/value matches
{/openEHR-EHR-CLUSTER\.specimen(-[a-zA-Z0-9_]+)*\.v1/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.specimen(-[a-zA-Z0-9_]+)*\.v1
constraint
CLUSTER
true
true
false
false
0
1
at0000
items
true
true
false
false
1
1
false
ELEMENT
true
true
false
false
0
1
at0001
value
true
true
false
false
0
1
false
DV_QUANTITY
true
true
false
false
1
1
mmol/dl
name
true
true
false
false
1
1
false
DV_TEXT
true
true
false
false
1
1
value
true
true
false
false
1
1
false
STRING
true
true
false
false
1
1
-
Blood Glucose Level
CLUSTER
true
false
false
true
0
at0014
archetype_id/value matches {/.*/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
.*
constraint
false
false
true
false
false
true
1
name
true
true
false
false
1
1
false
DV_TEXT
true
true
false
false
1
1
value
true
true
false
false
1
1
false
STRING
true
true
false
false
1
1
-
Blood Glucose
openEHR-EHR-CLUSTER.laboratory_test_analyte.v1
Blood Glucose
The result of a laboratory test for a single
analyte value.
Blood Glucose Level
The value of the analyte result.
For example '7.3 mmol/l', 'Raised'. The 'Any'
data type will need to be constrained to an appropriate data
type in a specialisation, a template or at run-time to reflect
the actual analyte result. The Quantity data type has reference
model attributes that include flags for normal/abnormal,
reference ranges and approximations - see
https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class
for more details.
Comment
Additional narrative about the analyte
result, not captured in other fields.
Reference range guidance
Additional advice on the applicability of
the reference range to this result or may carry text or coded
textual guidance as to whether the result is within the normal
range.
For example, 'within normal limits for age and
sex'.
Result status
The status of the analyte result value.
The values have been specifically chosen to
match those in the HL7 FHIR Diagnostic report, historically
derived from HL7v2 practice. Other local codes/terms can be used
via the Text 'choice'.
This element allows multiple occurrences to support use cases
where more than one type of status need to be implemented.
Result status time
The date and time that the analyte result
was issued for the recorded ‘Result status’.
Analyte result detail
Further detail regarding an individual
result.
Registered
The existence of the test is registered in
the Laboratory Information System, but there is nothing yet
available.
Partial
This is a partial (e.g. initial, interim or
preliminary) Test Result: data in the Test Result may be
incomplete or unverified.
Preliminary
Verified early results are available, but
not all results are final. This is a sub-category of 'Partial'.
Final
The Test result is complete and verified by
an authorised person.
Corrected
The result has been modified subsequent to
being Final, and is complete and verified by an authorised
person. This is a sub-category of 'Amended'.
Amended
The result has been modified subsequent to
being Final, and is complete and verified by an authorised
person, and result data has been changed.
Appended
Subsequent to being final, the report has
been modified by adding new content. The existing content is
unchanged. This is a sub-category of 'Amended'.
Entered in error
The Test Result has been withdrawn following
previous Final release.
Cancelled
The result is unavailable because the test
was not started or not completed (also sometimes called
'aborted').
Analyte name
The name of the analyte result.
The value for this element is normally supplied
in a specialisation, in a template or at run-time to reflect the
actual analyte. For example: 'Serum sodium', 'Haemoglobin'.
Coding with an external terminology is strongly recommended,
such as LOINC, NPU, SNOMED CT, or local lab terminologies.
Validation time
The date and time that the analyte result
was validated in the laboratory by a healthcare practitioner.
In many jurisdictions the 'Result status' is
assumed to include medical validation i.e. a 'final' result will
be assumed to be medically validated, but in others this will be
recorded and reported separately using this data element.
Specimen
Identification of the specimen used for the
analyte result.
In some situations, a single Laboratory test
result archetype will contain multiple Specimen archetypes and
multiple Analyte result archetypes. In these situations, this
'Specimen' data element is needed to be able to connect the
results with the correct specimens.
Analyte result sequence
The intended position of this analyte result
within the overall sequence of analyte results.
For example: '1' '2', '3'. Where multiple
analyte results are reported, the 'Analyte result sequence'
makes the order in which they were reported explicit.
Test method
Description about the method used to perform
the test on this analyte only.
If the test method applies to an entire panel,
the test method can be captured using the 'Test method' data
element within the OBSERVATION.laboratory_test_result
CLUSTER
true
true
false
false
0
1
at0000
items
true
true
false
false
1
1
false
ELEMENT
true
true
false
false
0
1
at0001
value
true
true
false
false
0
1
false
DV_QUANTITY
true
true
false
false
1
1
g/dl
name
true
true
false
false
1
1
false
DV_TEXT
true
true
false
false
1
1
value
true
true
false
false
1
1
false
STRING
true
true
false
false
1
1
-
Haemoglobin
CLUSTER
true
false
false
true
0
at0014
archetype_id/value matches {/.*/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
.*
constraint
false
false
true
false
false
true
1
name
true
true
false
false
1
1
false
DV_TEXT
true
true
false
false
1
1
value
true
true
false
false
1
1
false
STRING
true
true
false
false
1
1
-
Haemoglobin
openEHR-EHR-CLUSTER.laboratory_test_analyte.v1
Haemoglobin
The result of a laboratory test for a single
analyte value.
Haemoglobin
The value of the analyte result.
For example '7.3 mmol/l', 'Raised'. The 'Any'
data type will need to be constrained to an appropriate data
type in a specialisation, a template or at run-time to reflect
the actual analyte result. The Quantity data type has reference
model attributes that include flags for normal/abnormal,
reference ranges and approximations - see
https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class
for more details.
Comment
Additional narrative about the analyte
result, not captured in other fields.
Reference range guidance
Additional advice on the applicability of
the reference range to this result or may carry text or coded
textual guidance as to whether the result is within the normal
range.
For example, 'within normal limits for age and
sex'.
Result status
The status of the analyte result value.
The values have been specifically chosen to
match those in the HL7 FHIR Diagnostic report, historically
derived from HL7v2 practice. Other local codes/terms can be used
via the Text 'choice'.
This element allows multiple occurrences to support use cases
where more than one type of status need to be implemented.
Result status time
The date and time that the analyte result
was issued for the recorded ‘Result status’.
Analyte result detail
Further detail regarding an individual
result.
Registered
The existence of the test is registered in
the Laboratory Information System, but there is nothing yet
available.
Partial
This is a partial (e.g. initial, interim or
preliminary) Test Result: data in the Test Result may be
incomplete or unverified.
Preliminary
Verified early results are available, but
not all results are final. This is a sub-category of 'Partial'.
Final
The Test result is complete and verified by
an authorised person.
Corrected
The result has been modified subsequent to
being Final, and is complete and verified by an authorised
person. This is a sub-category of 'Amended'.
Amended
The result has been modified subsequent to
being Final, and is complete and verified by an authorised
person, and result data has been changed.
Appended
Subsequent to being final, the report has
been modified by adding new content. The existing content is
unchanged. This is a sub-category of 'Amended'.
Entered in error
The Test Result has been withdrawn following
previous Final release.
Cancelled
The result is unavailable because the test
was not started or not completed (also sometimes called
'aborted').
Analyte name
The name of the analyte result.
The value for this element is normally supplied
in a specialisation, in a template or at run-time to reflect the
actual analyte. For example: 'Serum sodium', 'Haemoglobin'.
Coding with an external terminology is strongly recommended,
such as LOINC, NPU, SNOMED CT, or local lab terminologies.
Validation time
The date and time that the analyte result
was validated in the laboratory by a healthcare practitioner.
In many jurisdictions the 'Result status' is
assumed to include medical validation i.e. a 'final' result will
be assumed to be medically validated, but in others this will be
recorded and reported separately using this data element.
Specimen
Identification of the specimen used for the
analyte result.
In some situations, a single Laboratory test
result archetype will contain multiple Specimen archetypes and
multiple Analyte result archetypes. In these situations, this
'Specimen' data element is needed to be able to connect the
results with the correct specimens.
Analyte result sequence
The intended position of this analyte result
within the overall sequence of analyte results.
For example: '1' '2', '3'. Where multiple
analyte results are reported, the 'Analyte result sequence'
makes the order in which they were reported explicit.
Test method
Description about the method used to perform
the test on this analyte only.
If the test method applies to an entire panel,
the test method can be captured using the 'Test method' data
element within the OBSERVATION.laboratory_test_result
CLUSTER
true
true
false
false
0
1
at0000
items
true
true
false
false
1
1
false
ELEMENT
true
true
false
false
0
1
at0001
value
true
true
false
false
0
1
false
DV_QUANTITY
true
true
false
false
1
1
mg/dl
name
true
true
false
false
1
1
false
DV_TEXT
true
true
false
false
1
1
value
true
true
false
false
1
1
false
STRING
true
true
false
false
1
1
-
Cholesterol
CLUSTER
true
false
false
true
0
at0014
archetype_id/value matches {/.*/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
.*
constraint
false
false
true
false
false
true
1
name
true
true
false
false
1
1
false
DV_TEXT
true
true
false
false
1
1
value
true
true
false
false
1
1
false
STRING
true
true
false
false
1
1
-
Cholesterol
openEHR-EHR-CLUSTER.laboratory_test_analyte.v1
Cholesterol
The result of a laboratory test for a single
analyte value.
Cholesterol
The value of the analyte result.
For example '7.3 mmol/l', 'Raised'. The 'Any'
data type will need to be constrained to an appropriate data
type in a specialisation, a template or at run-time to reflect
the actual analyte result. The Quantity data type has reference
model attributes that include flags for normal/abnormal,
reference ranges and approximations - see
https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class
for more details.
Comment
Additional narrative about the analyte
result, not captured in other fields.
Reference range guidance
Additional advice on the applicability of
the reference range to this result or may carry text or coded
textual guidance as to whether the result is within the normal
range.
For example, 'within normal limits for age and
sex'.
Result status
The status of the analyte result value.
The values have been specifically chosen to
match those in the HL7 FHIR Diagnostic report, historically
derived from HL7v2 practice. Other local codes/terms can be used
via the Text 'choice'.
This element allows multiple occurrences to support use cases
where more than one type of status need to be implemented.
Result status time
The date and time that the analyte result
was issued for the recorded ‘Result status’.
Analyte result detail
Further detail regarding an individual
result.
Registered
The existence of the test is registered in
the Laboratory Information System, but there is nothing yet
available.
Partial
This is a partial (e.g. initial, interim or
preliminary) Test Result: data in the Test Result may be
incomplete or unverified.
Preliminary
Verified early results are available, but
not all results are final. This is a sub-category of 'Partial'.
Final
The Test result is complete and verified by
an authorised person.
Corrected
The result has been modified subsequent to
being Final, and is complete and verified by an authorised
person. This is a sub-category of 'Amended'.
Amended
The result has been modified subsequent to
being Final, and is complete and verified by an authorised
person, and result data has been changed.
Appended
Subsequent to being final, the report has
been modified by adding new content. The existing content is
unchanged. This is a sub-category of 'Amended'.
Entered in error
The Test Result has been withdrawn following
previous Final release.
Cancelled
The result is unavailable because the test
was not started or not completed (also sometimes called
'aborted').
Analyte name
The name of the analyte result.
The value for this element is normally supplied
in a specialisation, in a template or at run-time to reflect the
actual analyte. For example: 'Serum sodium', 'Haemoglobin'.
Coding with an external terminology is strongly recommended,
such as LOINC, NPU, SNOMED CT, or local lab terminologies.
Validation time
The date and time that the analyte result
was validated in the laboratory by a healthcare practitioner.
In many jurisdictions the 'Result status' is
assumed to include medical validation i.e. a 'final' result will
be assumed to be medically validated, but in others this will be
recorded and reported separately using this data element.
Specimen
Identification of the specimen used for the
analyte result.
In some situations, a single Laboratory test
result archetype will contain multiple Specimen archetypes and
multiple Analyte result archetypes. In these situations, this
'Specimen' data element is needed to be able to connect the
results with the correct specimens.
Analyte result sequence
The intended position of this analyte result
within the overall sequence of analyte results.
For example: '1' '2', '3'. Where multiple
analyte results are reported, the 'Analyte result sequence'
makes the order in which they were reported explicit.
Test method
Description about the method used to perform
the test on this analyte only.
If the test method applies to an entire panel,
the test method can be captured using the 'Test method' data
element within the OBSERVATION.laboratory_test_result
CLUSTER
true
true
false
false
0
1
at0000
items
true
true
false
false
1
1
false
ELEMENT
true
true
false
false
0
1
at0001
value
true
true
false
false
0
1
false
DV_QUANTITY
true
true
false
false
1
1
mg/dl
name
true
true
false
false
1
1
false
DV_TEXT
true
true
false
false
1
1
value
true
true
false
false
1
1
false
STRING
true
true
false
false
1
1
-
Uric Acid
CLUSTER
true
false
false
true
0
at0014
archetype_id/value matches {/.*/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
.*
constraint
false
false
true
false
false
true
1
name
true
true
false
false
1
1
false
DV_TEXT
true
true
false
false
1
1
value
true
true
false
false
1
1
false
STRING
true
true
false
false
1
1
-
Uric Acid
openEHR-EHR-CLUSTER.laboratory_test_analyte.v1
Uric Acid
The result of a laboratory test for a single
analyte value.
Uric Acid
The value of the analyte result.
For example '7.3 mmol/l', 'Raised'. The 'Any'
data type will need to be constrained to an appropriate data
type in a specialisation, a template or at run-time to reflect
the actual analyte result. The Quantity data type has reference
model attributes that include flags for normal/abnormal,
reference ranges and approximations - see
https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class
for more details.
Comment
Additional narrative about the analyte
result, not captured in other fields.
Reference range guidance
Additional advice on the applicability of
the reference range to this result or may carry text or coded
textual guidance as to whether the result is within the normal
range.
For example, 'within normal limits for age and
sex'.
Result status
The status of the analyte result value.
The values have been specifically chosen to
match those in the HL7 FHIR Diagnostic report, historically
derived from HL7v2 practice. Other local codes/terms can be used
via the Text 'choice'.
This element allows multiple occurrences to support use cases
where more than one type of status need to be implemented.
Result status time
The date and time that the analyte result
was issued for the recorded ‘Result status’.
Analyte result detail
Further detail regarding an individual
result.
Registered
The existence of the test is registered in
the Laboratory Information System, but there is nothing yet
available.
Partial
This is a partial (e.g. initial, interim or
preliminary) Test Result: data in the Test Result may be
incomplete or unverified.
Preliminary
Verified early results are available, but
not all results are final. This is a sub-category of 'Partial'.
Final
The Test result is complete and verified by
an authorised person.
Corrected
The result has been modified subsequent to
being Final, and is complete and verified by an authorised
person. This is a sub-category of 'Amended'.
Amended
The result has been modified subsequent to
being Final, and is complete and verified by an authorised
person, and result data has been changed.
Appended
Subsequent to being final, the report has
been modified by adding new content. The existing content is
unchanged. This is a sub-category of 'Amended'.
Entered in error
The Test Result has been withdrawn following
previous Final release.
Cancelled
The result is unavailable because the test
was not started or not completed (also sometimes called
'aborted').
Analyte name
The name of the analyte result.
The value for this element is normally supplied
in a specialisation, in a template or at run-time to reflect the
actual analyte. For example: 'Serum sodium', 'Haemoglobin'.
Coding with an external terminology is strongly recommended,
such as LOINC, NPU, SNOMED CT, or local lab terminologies.
Validation time
The date and time that the analyte result
was validated in the laboratory by a healthcare practitioner.
In many jurisdictions the 'Result status' is
assumed to include medical validation i.e. a 'final' result will
be assumed to be medically validated, but in others this will be
recorded and reported separately using this data element.
Specimen
Identification of the specimen used for the
analyte result.
In some situations, a single Laboratory test
result archetype will contain multiple Specimen archetypes and
multiple Analyte result archetypes. In these situations, this
'Specimen' data element is needed to be able to connect the
results with the correct specimens.
Analyte result sequence
The intended position of this analyte result
within the overall sequence of analyte results.
For example: '1' '2', '3'. Where multiple
analyte results are reported, the 'Analyte result sequence'
makes the order in which they were reported explicit.
Test method
Description about the method used to perform
the test on this analyte only.
If the test method applies to an entire panel,
the test method can be captured using the 'Test method' data
element within the OBSERVATION.laboratory_test_result
CLUSTER
true
true
false
false
0
1
at0000
items
true
true
false
false
1
1
false
ELEMENT
true
true
false
false
0
1
at0024
value
true
true
false
false
0
1
false
DV_CODED_TEXT
true
true
false
false
1
1
defining_code
true
true
false
false
1
1
false
CODE_PHRASE
true
true
false
false
0
1
LOINC
882-1
ELEMENT
true
true
false
false
0
1
at0001
value
true
true
false
false
0
1
false
DV_CODED_TEXT
true
true
false
false
1
1
defining_code
true
true
false
false
1
1
false
CODE_PHRASE
true
true
false
false
0
1
SNOMED-CT
278147001
278148006
278149003
278152006
278150003
278153001
278151004
278154007
name
true
true
false
false
1
1
false
DV_TEXT
true
true
false
false
1
1
value
true
true
false
false
1
1
false
STRING
true
true
false
false
1
1
-
Blood Group
CLUSTER
true
false
false
true
0
at0014
archetype_id/value matches {/.*/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
.*
constraint
false
false
true
false
false
true
1
name
true
true
false
false
1
1
false
DV_TEXT
true
true
false
false
1
1
value
true
true
false
false
1
1
false
STRING
true
true
false
false
1
1
-
Blood Group
openEHR-EHR-CLUSTER.laboratory_test_analyte.v1
Blood Group
The result of a laboratory test for a single
analyte value.
Blood Group
The value of the analyte result.
For example '7.3 mmol/l', 'Raised'. The 'Any'
data type will need to be constrained to an appropriate data
type in a specialisation, a template or at run-time to reflect
the actual analyte result. The Quantity data type has reference
model attributes that include flags for normal/abnormal,
reference ranges and approximations - see
https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class
for more details.
Comment
Additional narrative about the analyte
result, not captured in other fields.
Reference range guidance
Additional advice on the applicability of
the reference range to this result or may carry text or coded
textual guidance as to whether the result is within the normal
range.
For example, 'within normal limits for age and
sex'.
Result status
The status of the analyte result value.
The values have been specifically chosen to
match those in the HL7 FHIR Diagnostic report, historically
derived from HL7v2 practice. Other local codes/terms can be used
via the Text 'choice'.
This element allows multiple occurrences to support use cases
where more than one type of status need to be implemented.
Result status time
The date and time that the analyte result
was issued for the recorded ‘Result status’.
Analyte result detail
Further detail regarding an individual
result.
Registered
The existence of the test is registered in
the Laboratory Information System, but there is nothing yet
available.
Partial
This is a partial (e.g. initial, interim or
preliminary) Test Result: data in the Test Result may be
incomplete or unverified.
Preliminary
Verified early results are available, but
not all results are final. This is a sub-category of 'Partial'.
Final
The Test result is complete and verified by
an authorised person.
Corrected
The result has been modified subsequent to
being Final, and is complete and verified by an authorised
person. This is a sub-category of 'Amended'.
Amended
The result has been modified subsequent to
being Final, and is complete and verified by an authorised
person, and result data has been changed.
Appended
Subsequent to being final, the report has
been modified by adding new content. The existing content is
unchanged. This is a sub-category of 'Amended'.
Entered in error
The Test Result has been withdrawn following
previous Final release.
Cancelled
The result is unavailable because the test
was not started or not completed (also sometimes called
'aborted').
Analyte name
The name of the analyte result.
The value for this element is normally supplied
in a specialisation, in a template or at run-time to reflect the
actual analyte. For example: 'Serum sodium', 'Haemoglobin'.
Coding with an external terminology is strongly recommended,
such as LOINC, NPU, SNOMED CT, or local lab terminologies.
Validation time
The date and time that the analyte result
was validated in the laboratory by a healthcare practitioner.
In many jurisdictions the 'Result status' is
assumed to include medical validation i.e. a 'final' result will
be assumed to be medically validated, but in others this will be
recorded and reported separately using this data element.
Specimen
Identification of the specimen used for the
analyte result.
In some situations, a single Laboratory test
result archetype will contain multiple Specimen archetypes and
multiple Analyte result archetypes. In these situations, this
'Specimen' data element is needed to be able to connect the
results with the correct specimens.
Analyte result sequence
The intended position of this analyte result
within the overall sequence of analyte results.
For example: '1' '2', '3'. Where multiple
analyte results are reported, the 'Analyte result sequence'
makes the order in which they were reported explicit.
Test method
Description about the method used to perform
the test on this analyte only.
If the test method applies to an entire panel,
the test method can be captured using the 'Test method' data
element within the OBSERVATION.laboratory_test_result
ABO and Rh group [Type] in Blood
O +ve
O -ve
A +ve
A -ve
B +ve
B -ve
AB +ve
AB -ve
CLUSTER
true
false
false
true
0
at0122
archetype_id/value matches {/.*/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
.*
constraint
CLUSTER
true
false
false
true
0
at0118
archetype_id/value matches
{/openEHR-EHR-CLUSTER\.media_capture(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.media_capture(-[a-zA-Z0-9_]+)*\.v0/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.media_capture(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.media_capture(-[a-zA-Z0-9_]+)*\.v0
constraint
false
false
true
false
false
true
1
state
true
true
false
false
0
1
false
ITEM_TREE
true
true
false
false
1
1
at0112
items
true
true
false
false
0
1
false
CLUSTER
true
false
false
true
0
at0114
archetype_id/value matches {/.*/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
.*
constraint
false
false
true
false
false
true
0
false
false
true
false
false
true
1
protocol
true
true
false
false
0
1
false
ITEM_TREE
true
true
false
false
1
1
at0004
items
true
true
false
false
0
1
false
CLUSTER
true
true
false
false
0
1
at0017
archetype_id/value matches {/.*/}
Boolean
2007
false
String
-
archetype_id/value
attribute
String
-
.*
constraint
CLUSTER
true
false
false
true
0
at0110
archetype_id/value matches
{/openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1/}
Boolean
2007
false
String
-
archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1
constraint
CLUSTER
true
false
false
true
0
at0117
archetype_id/value matches {/.*/}
Boolean
2007
false
String
-
archetype_id/value
attribute
String
-
.*
constraint
false
false
true
false
false
true
0
openEHR-EHR-OBSERVATION.laboratory_test_result.v1
Laboratory test result
The result, including findings and the laboratory's interpretation, of an
investigation performed on specimens collected from an individual or related to that individual.
Event Series
@ internal @
Any event
Default, unspecified point in time or interval event which may be explicitly
defined in a template or at run-time.
Tree
@ internal @
Tree
@ internal @
Test name
Name of the laboratory investigation performed on the specimen(s).
A test result may be for a single analyte, or a group of items, including panel
tests. It is strongly recommended that 'Test name' be coded with a terminology, for example
LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)',
'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include
specimen type and patient state, for example 'Fasting blood glucose' or include other
information, as 'Potassium (PNA blood gas)'.
Receiving laboratory
Details of the laboratory which received the request and has overall
responsibility to manage reporting of the test, even if other labs perform specific aspects.
This slot is intended to carry details of the laboratory which received the
request and has overall responsibility to manage reporting of the test, even if other labs
perform specific aspects.
The receiving laboratory may either perform the test or refer it to another laboratory. Where a
different laboratory is responsible for performing the testing on specific analytes, it would be
expected that these details would be carried in the 'Analyte result detail' SLOT within the
CLUSTER.laboratory_test_analyte archetype.
Distribution list
Details of additional clinicians or organisations who require a copy of the
test result.
The 'Distribution list' is for information-only, and that the primary recipient
of the report is the person intended to act on the information.
Partial
This is a partial (e.g. initial, interim or preliminary) Test Result: data
in the Test Result may be incomplete or unverified.
Final
The Test result is complete and verified by an authorised person.
Amended
The result has been modified subsequent to being Final, and is complete and
verified by the responsible pathologist, and result data has been changed.
Conclusion
Narrative description of the key findings.
For example: 'Pattern suggests significant renal impairment'. The content of the
conclusion will vary, depending on the investigation performed. This conclusion should be
aligned with the coded 'Test diagnosis'.
Requester order identifier
The local identifier assigned by the requesting clinical system.
Equivalent to the HL7 Placer Order Identifier.
Receiver order identifier
The local identifier assigned to the test order by the order filler, usually
by the Laboratory Information System (LIS).
Assigning an identifier to a request by the Laboratory lnformation System (LIS)
enables tracking progress of the request and enables linking results to requests. It also
provides a reference to assist with enquiries and it is usually equivalent to the HL7 Filler
Order Identifier.
Specimen detail
Details about the physical substance that has been analysed.
If the specimen type is sufficiently specified with a code in the Test name,
then this additional data is not required. Linking results to specific specimens may be recorded
using 'Specimen identifier' elements in both the CLUSTER.specimen and the various results
CLUSTER archetypes.
Laboratory internal identifier
A local identifier assigned by the receiving Laboratory Information System
(LIS) to track the test process.
This identifier is an internal tracking number assigned by the LIS, and it not
intended to be the name of the test.
Overall test status
The status of the laboratory test result as a whole.
The values have been specifically chosen to match those in the HL7 FHIR
Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used
via the Text 'choice'.
This element is multiple occurrence to cater for the use cases where statuses for different
aspects of the result have been split into several elements.
Cancelled
The result is unavailable because the test was not started or not completed
(also sometimes called 'aborted').
Overall test status timestamp
The date and/or time that ‘Overall test status’ was issued.
Diagnostic service category
The diagnostic service or discipline that is responsible for the laboratory
test result.
This is intended to be a general categorisation and not to capture the
organisational name of the laboratory. For example: anatomical pathology, immunology and
transfusion medicine, medical microbiology, clinical pharmacology, medical genetics, medical
biochemistry. Alternatively more granular sub categories or sub disciplines, such as
endocrinology, haematology, and allergology services, may be used. This may assist clinicians in
filtering between categories of results. Coding with a terminology is desirable, where possible.
Requester
Details of the clinician or organisation requesting the laboratory test
result.
Test request details
Details about the test request.
In most situations there is one test request and a single corresponding test
result, however this repeating cluster allows for the situation where there may be multiple test
requests reported using a single test result.
As an example: 'a clinician asks for blood glucose in one request and Urea/electrolytes in a
second request, but the lab analyser does both and the lab wishes to report these together'.
Test result
Results of the test performed on the specimen(s).
This SLOT may carry an individual analyte, a group, panel or battery of multiple
analytes, or a more complex and specific structure.
Test diagnosis
Single word, phrase or brief description that represents the clinical
meaning and significance of the laboratory test result.
For example: 'Severe hepatic impairment', 'Salmonella contamination'. Coding of
the diagnosis with a terminology is strongly recommended, where possible. This diagnosis should
be aligned with the narrative in the 'Conclusion'.
Clinical information provided
Description of clinical information available at the time of interpretation
of results.
This data element may include a link to the original clinical information
provided in the test request.
Comment
Additional narrative about the test result not captured in other fields.
Original test requested name
Name of the original laboratory test requested.
This data element is to be used when the test requested differs from the test
actually performed by the laboratory.
Registered
The existence of the test is registered in the Laboratory Information
System, but there is nothing yet available.
Testing details
Structured details about the method of analysis, device or interpretation
used.
For example: 'details of ELISA/nephelometry'.
Point-of-care test
This indicates whether the test was performed directly at Point-of-Care
(POCT) as opposed to a formal result from a laboratory or other service delivery organisation.
True if the test was performed directly at Point-of-Care (POCT).
Tree
@ internal @
Confounding factors
Issues or circumstances that impact on the accurate interpretation of the
measurement or test result.
'Confounding factors' should be reserved for uncontrolled/unplanned issues of
patient state/physiology that might affect interpretation, for example 'recent exercise' or
'recent tobacco smoking'.
Known or required preconditions, such as 'fasting' should be carried in the 'Sampling
conditions' element within the CLUSTER.specimen archetype . In some cases preconditions are
captured as part of the test name, for example 'Fasting blood glucose'.
Known issues with specimen collection or handling, such as 'prolonged use of tourniquet' or
'sample haemolysed', should be carried in the 'Specimen quality' elements within
CLUSTER.specimen archetype.
Coding with a terminology is desirable, where possible.
Structured confounding factors
Details of issues or circumstances that impact on the accurate
interpretation of the measurement or test result.
For example: Last Normal Menstrual Period (LNMP).
Corrected
The result has been modified subsequent to being Final, and is complete and
verified by the responsible pathologist. This is a sub-category of 'Amended'.
Entered in error
The Test Result has been withdrawn following previous Final release.
Extension
Additional information required to capture local content or to align with
other reference models/formalisms.
For example: local information requirements or additional metadata to align with
FHIR or CIMI equivalents.
Multimedia representation
Digital image, video or diagram representing the test result.
Multiple formats are allowed but they should represent equivalent clinical
content.
Appended
Subsequent to being final, the report has been modified by adding new
content. The existing content is unchanged. This is a sub-category of 'Amended'.
Preliminary
Verified early results are available, but not all results are final. This is
a sub-category of 'Partial'.
Test method
Description about the method used to perform the test.
Coding with a terminology is desirable, where possible.
Structured test diagnosis
A structured or complex diagnosis for the laboratory test.
For example: Anatomical pathology diagnoses consisting of several different axes
such as morphology, etiology and function.
OBSERVATION
true
true
false
false
0
1
at0000
data
true
true
false
false
1
1
false
HISTORY
true
true
false
false
1
1
at0001
events
true
true
false
false
0
1
false
POINT_EVENT
true
false
false
true
0
at0002
data
true
true
false
false
1
1
false
ITEM_TREE
true
true
false
false
1
1
at0003
items
true
true
false
false
0
1
false
ELEMENT
true
true
false
false
0
1
at0050
value
true
true
false
false
0
1
false
DV_ORDINAL
true
true
false
false
1
1
1
local
at0115
2
local
at0116
3
local
at0117
4
local
at0118
5
local
at0119
6
local
at0120
ELEMENT
true
true
false
false
0
1
at0095
value
true
true
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0
1
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DV_ORDINAL
true
true
false
false
1
1
1
local
at0096
2
local
at0097
3
local
at0098
4
local
at0099
5
local
at0100
6
local
at0101
CLUSTER
true
false
false
true
0
at0182
archetype_id/value matches
{/openEHR-EHR-CLUSTER\.exam_body_fluid(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen(-[a-zA-Z0-9_]+)*\.v0/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.exam_body_fluid(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen(-[a-zA-Z0-9_]+)*\.v0
constraint
CLUSTER
true
false
false
true
0
at0185
archetype_id/value matches
{/openEHR-EHR-CLUSTER\.exclusion_exam(-[a-zA-Z0-9_]+)*\.v1/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.exclusion_exam(-[a-zA-Z0-9_]+)*\.v1
constraint
false
false
true
false
false
true
0
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true
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false
true
1
protocol
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true
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0
1
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ITEM_TREE
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1
1
at0079
items
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true
false
false
0
1
false
CLUSTER
true
true
false
false
0
1
at0180
archetype_id/value matches
{/openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1/}
Boolean
2007
false
String
-
archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1
constraint
CLUSTER
true
true
false
false
0
1
at0183
archetype_id/value matches
{/openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1/}
Boolean
2007
false
String
-
archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1
constraint
CLUSTER
true
false
false
true
0
at0184
archetype_id/value matches {/.*/}
Boolean
2007
false
String
-
archetype_id/value
attribute
String
-
.*
constraint
false
false
true
false
false
true
0
openEHR-EHR-OBSERVATION.urinalysis.v1
Urinalysis
Qualitative and semi-quantitative test array using reagent test strips to
indicate possible abnormalities in a sample of urine, often performed as part of Point of Care
Testing (POCT).
Event Series
@ internal @
Point in Time
A specific date and/or time which may be explicitly defined in a template or
at run-time.
Tree
@ internal @
Comment
Narrative about the urinalysis not captured in other fields.
For example: the freshness or small volume of the urine sample, method of
collection or any problems with testing.
Blood
Detection of blood in urine sample.
Ketones
Detection of ketones in urine sample.
Nitrite
Detection of nitrites in urine sample.
Glucose
Detection of glucose in urine sample.
Urobilinogen
Detection of urobilinogen in urine sample.
Bilirubin
Detection of bilirubin in urine sample.
Leukocytes
Detection of white blood cells in urine sample.
Tree
@ internal @
Protein
Detection of protein in urine sample.
Negative
No protein detected.
Trace
Trace of protein detected.
1+
Amount equivalent to 30mg/dL (or 0.3 g/L) detected.
2+
Amount equivalent to 100mg/dL (or 1.0 g/L) detected.
3+
Amount equivalent to 300mg/dL (or 3.0 g/L) detected.
4+
Amount equivalent to >2000mg/dL (or >20 g/L) detected.
Negative
No blood detected.
Non-haemolysed Trace
Trace of non-haemolysed blood detected.
Non-haemolysed Moderate
Moderate amount of non-haemolysed blood detected.
Haemolysed Trace
Trace of haemolysed blood detected.
1+
Small amount of blood detected.
2+
Moderate amount of blood detected.
3+
Large amount of blood detected.
Negative
No ketones detected.
Trace
Amount equivalent to 5mg/dL (or 0.5 mmol/L) detected.
Small
Amount equivalent to 15mg/dL (or 1.5 mmlol/L) detected.
Moderate
Amount equivalent to 40mg/dL (or 4.0 mmol/L) detected.
Large
Amount equivalent to 80mg/dL (or 8.0 mmol/L) detected.
Large+
Amount equivalent to 160mg/dL (or 16 mmol/L) detected.
Negative
No glucose detected.
Trace
Amount equivalent to 1/10 g/dl (100mg/dL or 5 mmol/L) detected.
1+
Amount equivalent to 1/4 g/dL (250 mg/dL or 15 mmol/L) detected.
2+
Amount equivalent to 1/2 g/dl (500mg/dL or 30 mmol/L) detected.
3+
Amount equivalent to 1 g/dl (1000mg/dL or 60 mmol/L) detected.
4+
Amount equivalent >2 g/dl (>2000mg/dL or >120 mmol/L) detected.
Negative
No bilirubin detected.
1+
Small amount detected.
2+
Moderate amount detected.
3+
Large amount detected.
pH
Measurement of pH in urine sample.
5.0
pH of urine is equivalent to 5.0.
5.5
pH of urine is equivalent to 5.5.
6.0
pH of urine is equivalent to 6.0.
6.5
pH of urine is equivalent to 6.5.
7.0
pH of urine is equivalent to 7.0.
7.5
pH of urine is equivalent to 7.5.
8.0
pH of urine is equivalent to 8.0.
8.5
pH of urine is equivalent to 8.5.
Negative
No leukocytes detected.
Trace
Trace detected.
1+
Small amount detected.
2+
Moderate amount detected.
3+
Large amount detected.
Specific gravity
Measurement of the concentration of substances dissolved (solutes) in the
urine sample relative to distilled water.
1.000
Specific gravity is equivalent to 1.000.
1.005
Specific gravity is equivalent to 1.005.
1.010
Specific gravity is equivalent to 1.010.
1.015
Specific gravity is equivalent to 1.015.
1.020
Specific gravity is equivalent to 1.020.
1.025
Specific gravity is equivalent to 1.025.
1.030
Specific gravity is equivalent to 1.030.
Negative
No nitrites detected.
Positive
Nitrites were detected.
Normal (lower)
Amount equivalent to 0.2 mg/dL detected.
Normal (upper)
Amount equivalent to 1 mg/dL detected.
2 mg/dL
Amount equivalent to 2mg/dL detected.
4 mg/dL
Amount equivalent to 4mg/dL detected.
8 mg/dL
Amount equivalent to 8mg/dL detected.
9.0
pH of urine is equivalent to 9.0.
9.5
pH of urine is equivalent to 9.5.
10.0
pH of urine is equivalent to 10.0.
Reagent Strips
Details about the reagent strips used.
Clinical interpretation
Single word, phrase or brief description represents the clinical meaning and
significance of the urinalysis findings.
Comment: Coding with a terminology is preferred, where possible. For example:
normal urinalysis; mild proteinuria; or trace of blood. Multiple statements are allowed.
Additional details
Additional details about the point of care urinalysis, including macroscopic
appearance or other tests not currently captured in the structured data.
Device
Details about the device used to automatically read the reagent strips.
Extension
Additional information required to capture local content or to align with
other reference models/formalisms.
For example: Local information requirements or additional metadata to align with
FHIR or CIMI equivalents.
Exam not done
Details to explicitly record that urinalysis was not performed.
Use this SLOT and associated CLUSTER archetype if there is an explicit need to
record that the test was not done, for example, if urine could not be obtained from a child even
though it was ordered or neccessary.
Method
Method by which the reagent strips were read.
Manual
The urinalysis results were detemined by a person.
Automatic
The urinalysis results were detemined by a medical device.
false
false
true
false
false
true
1
openEHR-EHR-COMPOSITION.encounter.v1
NCD
NCD
Interaction, contact or care event between a subject of care and healthcare
provider(s).
Tree
@ internal @
Extension
Additional information required to capture local context or to align with other
reference models/formalisms.
e.g. Local hospital departmental infomation or additional metadata to align with FHIR or
CIMI equivalents.
OBX.3
Observation.code
OBX.2, OBX.5, OBX.6, OBX.7, OBX.8
Observation.value[x]
OBX.11
Observation.status
OBX.19
Observation.issued
NTE.3
Observation.note
OBX.3
Observation.code
OBX.2, OBX.5, OBX.6, OBX.7, OBX.8
Observation.value[x]
OBX.11
Observation.status
OBX.19
Observation.issued
NTE.3
Observation.note
OBX.3
Observation.code
OBX.2, OBX.5, OBX.6, OBX.7, OBX.8
Observation.value[x]
OBX.11
Observation.status
OBX.19
Observation.issued
NTE.3
Observation.note
OBX.3
Observation.code
OBX.2, OBX.5, OBX.6, OBX.7, OBX.8
Observation.value[x]
OBX.11
Observation.status
OBX.19
Observation.issued
NTE.3
Observation.note
OBX.3
Observation.code
OBX.2, OBX.5, OBX.6, OBX.7, OBX.8
Observation.value[x]
OBX.11
Observation.status
OBX.19
Observation.issued
NTE.3
Observation.note
value
Blood test
[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0005]
value
ABO and Rh group [Type] in Blood
LOINC
882-1
[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.laboratory_test_analyte.v1,
'Blood Group']/items[at0024]
protocol
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