operationaltemplate.aql_example.opt Maven / Gradle / Ivy
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2023-05-12
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aql_example
aql_example
COMPOSITION
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Boolean
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openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1
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openEHR-EHR-OBSERVATION.body_weight.v2
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.
Body weight
Measurement of the body weight of an individual.
lbm
pound mass
LOINC
[LOINC::29463-7]
OBSERVATION
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String
-
openEHR-EHR-CLUSTER\.level_of_exertion(-[a-zA-Z0-9_]+)*\.v1
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openEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1
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openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1
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openEHR-EHR-OBSERVATION.blood_pressure.v2
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.
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.
°
degree
mmHg
millimeters of mercury
SNOMED-CT
[SNOMED-CT(2003)::271649006]
SNOMED-CT
[SNOMED-CT(2003)::271650006]
SNOMED-CT
[SNOMED-CT(2003)::246153002]
SNOMED-CT
[SNOMED-CT(2003)::364090009]
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-
Measurements
openEHR-EHR-SECTION.adhoc.v1
Measurements
A generic section header which should be renamed in a template to suit a specific clinical context.
SECTION
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false
0
0
1/wk
true
true
false
false
0.0
31.0
true
true
false
false
0
0
1/mo
true
true
false
false
0.0
365.0
true
true
false
false
0
0
1/a
DV_INTERVAL<DV_QUANTITY>
true
true
false
false
1
1
lower
true
true
false
false
0
1
false
DV_QUANTITY
true
true
false
false
1
1
true
true
false
false
0.0
7.0
true
true
false
false
0
0
1/wk
true
true
false
false
0.0
31.0
true
true
false
false
0
0
1/mo
true
true
false
false
0.0
365.0
true
true
false
false
0
0
1/a
upper
true
true
false
false
0
1
false
DV_QUANTITY
true
true
false
false
1
1
true
true
false
false
0.0
7.0
true
true
false
false
0
0
1/wk
true
true
false
false
0.0
31.0
true
true
false
false
0
0
1/mo
true
true
false
false
0.0
365.0
true
true
false
false
0
0
1/a
ELEMENT
true
true
false
false
0
1
at0113
value
true
true
false
false
0
1
false
DV_TEXT
true
true
false
false
1
1
ELEMENT
true
true
false
false
0
1
at0110
value
true
true
false
false
0
1
false
DV_QUANTITY
true
true
false
false
1
1
openehr
382
true
false
false
false
0.0
7.0
true
true
false
false
0
0
1/wk
true
false
false
false
0.0
31.0
true
true
false
false
0
0
1/mo
ELEMENT
true
true
false
false
0
1
at0023
value
true
true
false
false
0
1
false
DV_QUANTITY
true
true
false
false
1
1
openehr
382
true
false
false
true
0.0
true
true
false
false
1
1
1/d
true
false
false
true
0.0
true
true
false
false
1
1
1/wk
true
false
false
true
0.0
true
true
false
false
1
1
1/mo
ELEMENT
true
true
false
false
0
1
at0025
value
true
true
false
false
0
1
false
DV_COUNT
true
true
false
false
1
1
magnitude
true
true
false
false
1
1
false
INTEGER
true
true
false
false
1
1
-
true
false
false
true
0
ELEMENT
true
true
false
false
0
1
at0014
value
true
true
false
false
0
1
false
DV_DATE
true
true
false
false
1
1
CLUSTER
true
false
false
true
0
at0026
archetype_id/value matches {/openEHR-EHR-CLUSTER\.cessation_attempts(-[a-zA-Z0-9_]+)*\.v1/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.cessation_attempts(-[a-zA-Z0-9_]+)*\.v1
constraint
ELEMENT
true
true
false
false
0
1
at0087
value
true
true
false
false
0
1
false
DV_TEXT
true
true
false
false
1
1
false
false
true
false
false
true
1
CLUSTER
true
false
false
true
0
at0086
archetype_id/value matches {/.*/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
.*
constraint
ELEMENT
true
true
false
false
0
1
at0016
value
true
true
false
false
0
1
false
DV_DATE
true
true
false
false
1
1
ELEMENT
true
true
false
false
0
1
at0019
value
true
true
false
false
0
1
false
DV_TEXT
true
true
false
false
1
1
false
false
true
false
false
true
0
protocol
true
true
false
false
0
1
false
ITEM_TREE
true
true
false
false
1
1
at0021
items
true
true
false
false
0
1
false
CLUSTER
true
false
false
true
0
at0073
archetype_id/value matches {/.*/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
.*
constraint
ELEMENT
true
false
false
true
0
at0071
value
true
true
false
false
0
1
false
DV_TEXT
true
true
false
false
1
1
ELEMENT
true
true
false
false
0
1
at0085
value
true
true
false
false
0
1
false
DV_TEXT
true
true
false
false
1
1
ELEMENT
true
false
false
true
0
at0075
value
true
true
false
false
0
1
false
DV_TEXT
true
true
false
false
1
1
ELEMENT
true
false
false
true
0
at0076
value
true
true
false
false
0
1
false
DV_TEXT
true
true
false
false
1
1
ELEMENT
true
false
false
true
0
at0079
value
true
true
false
false
0
1
false
DV_TEXT
true
true
false
false
1
1
ELEMENT
true
true
false
false
0
1
at0104
value
true
true
false
false
0
1
false
DV_QUANTITY
true
true
false
false
1
1
openehr
124
true
false
false
true
0.0
true
true
false
false
0
0
g
true
false
false
true
0.0
true
true
false
false
1
1
[oz_av]
ELEMENT
true
true
false
false
0
1
at0022
value
true
true
false
false
0
1
false
DV_DATE_TIME
true
true
false
false
1
1
false
false
true
false
false
true
0
openEHR-EHR-EVALUATION.alcohol_consumption_summary.v1
Tree
@ internal @
Current drinker
Individual is a current consumer of alcohol.
Former drinker
Individual has previously consumed alcohol but is not a current drinker.
Lifetime non-drinker
Individual has never consumed alcohol.
Episode start date
Date when this episode commenced.
Can be a partial date, for example, only a year.
Quit date
Date when the individual last consumed an alcohol.
Can be a partial date, for example, only a year. Definitions for a 'Quit date' vary enormously and can be defined using the 'Quit data definition' data element in the Protocol section of this archetype. This date will be identical to the 'Episode end date' for the most recent episode. This date could be used by decision support guidance to determine if the individual is at risk of relapse, for example in the first 12 months since quitting.
Regular consumption commenced
The date or partial date when the individual first started frequent or regular, but usually non-daily, consumption of alcohol.
This data element is recording when a regular pattern of drinking commenced, rather than the first ever taste of alcohol. The first taste could be at a very young age and then no drinking until mid teens. In this case it is the pattern in the mid teens that is clinically significant. To differentiate between patterns of drinking, that has to be recorded in other elements in this archetype, for example in the 'Per episode' section.
Overall quit date
The date when the individual last ceased consuming alcohol of any type.
Can be a partial date, for example, only a year. This date could be used by decision support guidance to determine if the individual is at risk of relapse, for example in the first 12 months since quitting.
Overall comment
Additional narrative about all alcohol consumption that has not been captured in other fields.
Tree
@ internal @
Last updated
The date this alcohol consumption summary was last updated.
Typical consumption (alcohol units)
Estimate of number of alcohol units consumed in the specified time period.
Number of quit attempts
Total number of times the individual has attempted to stop consuming alcohol within this episode.
Episode details
Additional structured details about the specified episode of alcohol consumption.
Per type
Details about consumption of a specified type of alcohol.
Pattern
The typical pattern of consumption of alcohol.
The typical pattern of use can be made more granular by coding with a terminology or a local value set in a template.
Overall description
Narrative summary about the individual's overall alcohol consumption pattern and history.
Use this data element to record a narrative description of alcohol drinking habits for this individual or to incorporate unstructured alcohol drinking information from existing or legacy clinical systems into an archetyped format.
Status
Statement about current alcohol drinking behaviour.
Description
Narrative summary about alcohol consumption for the specified type of alcohol.
Current drinker
Individual consumed alcohol during this period.
Per episode
Details about a discrete period of time with a consistent pattern of typical consumption.
Comment
Additional narrative about consumption of the specified type of alcohol, not captured in other fields.
Quit date definition
The applied definition for the 'Quit date' data elements used in this archetype.
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.
Current drinker definition
The applied definition for the 'Current drinker' value in each of the 'Status' data elements used in this archetype.
Former drinker definition
The applied definition for the 'Former drinker' value in each of the 'Status' data elements used in this archetype.
Type details
Additional structured details about the consumption of the specified alcohol.
Lifetime non-drinker definition
The applied definition for the 'Lifetime non-drinker' value in each of the 'Status' data elements used in this archetype.
Daily consumption commenced
The date or partial date when the individual first started consuming alcohol on a daily basis.
Can be a partial date, for example, only a year.
Episode label
Identification of an episode of alcohol consumption - either as a number in a sequence and/or a named event.
For example: '2' as the second episode within a sequence of episodes; or 'Pregnancy with twins' if describing the alcohol consumption during a health event such as during a specific pregnancy.
Episode end date
Date when this episode ceased.
Can be a partial date, for example, only a year. This data field will be empty if the episode is current and ongoing.
Daily
Consuming alcoholic beverage at least once every day.
Non-daily
Not consuming alcoholic beverage every day.
Quit attempt definition
The applied definition for a Quit attempt used to determine value for the 'Number of quit attempts' data element used in this archetype.
For example: 'stopped consuming alcohol for one day or longer with the intention of quitting'.
Overall details
Additional structured details about the overall alcohol consumption.
Episode comment
Additional narrative about alcohol consumption during the specified episode, not captured in other fields.
For example: alcohol consumed as a hangover remedy eg 'hair of the dog'.
Overall status
Statement about current consumption for all types of alcohol.
Non-drinker
Individual has not consumed alcohol during this episode.
Binge drinking frequency
The individual's typical frequency of heavy drinking over a short period of time with the intent of becoming intoxicated.
Alcohol unit definition (mass)
Mass of alcohol defining a standard drink or alcohol unit as used in the 'Typical drinking (alcohol units)' element in this archetype.
Type
The name of the specific type or grouping of alcohol.
Use of the coded text option is preferrable when possible. Alternatively, it's possible to use a local valueset or terminologi to record specific types of alcoholic beverages. For example: red or white wine; brandy or whisky; normal or low alcohol beer; or denatured alcohol (methylated spirits) as a specific form of rectified spirits.
Alcohol free days
The number of days where no alcohol was consumed in the specified period.
Typical consumption (alcohol units)
Estimate of number of standard drinks of the specified type of alcohol consumed in the specified period.
The definition of an Alcohol unit can be recorded in the Protocol.
Episode description
Narrative summary about the individual's overall pattern of alcohol consumption during the specified episode.
For example: details about binge drinking pattern.
Binge drinking description
Narrative description about the individual's typical pattern of binge drinking.
Date first intoxicated
The date or partial date when the individual became intoxicated for the first time.
This data point is not intended to record an accidental intoxication but to identify when a behaviour pattern of harmful consumption may have commenced.
Beer
Fermented beverage made from grain mash.
Wine
Fermented beverage made from grapes and sometimes other fruits.
Cider
Fermented beverage made from any fruit juice.
Mead
Fermented beverage made from honey, sometimes with various fruits spices, grains or hops.
Pulque
Fermented beverage made from 'honey water" of cacti.
Spirits
Fermented beverage made by a distillation process. Usually has an alcohol content >20%. Includes liquers, cocktails and rectified spirits.
Fortified wine
Wine with added spirits.
Alcohol consumption summary
Summary or persistent information about the typical alcohol consumption of an individual.
oz (avoirdupois)
ounce
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
-
Behavior
openEHR-EHR-SECTION.adhoc.v1
Behavior
A generic section header which should be renamed in a template to suit a specific clinical context.
false
false
true
false
false
true
1
openEHR-EHR-COMPOSITION.report.v1
aql_example
Tree
@ internal @
Report ID
Identification information about the report.
Status
The status of the entire report. Note: This is not the status of any of the report components.
Extension
Additional information required to capture local context or to align with other reference models/formalisms.
For example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.
aql_example
Document to communicate information to others, commonly in response to a request from another party.
items
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