operationaltemplate.example_initialassesment.v0.opt Maven / Gradle / Ivy
ISO_639-1
en
Not Specified
Initial
Template metadata sample set
ISO_639-1
en
Not Specified
c26156d5-89a4-4750-8475-663b74eae845
example.initialassesment.v0
example.initialassesment.v0
COMPOSITION
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true
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defining_code
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CODE_PHRASE
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openehr
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context
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EVENT_CONTEXT
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other_context
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at0002
archetype_id/value matches {/.*/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
.*
constraint
false
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false
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true
0
content
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OBSERVATION
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at0000
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HISTORY
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events
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EVENT
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ELEMENT
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at0009
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DV_ORDINAL
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local
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DV_CODED_TEXT
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defining_code
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CODE_PHRASE
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openehr
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ELEMENT
true
true
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at0007
value
true
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DV_ORDINAL
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ELEMENT
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value
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DV_ORDINAL
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DV_CODED_TEXT
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defining_code
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CODE_PHRASE
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openehr
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ELEMENT
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at0026
value
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DV_COUNT
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magnitude
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INTEGER
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-
true
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3
15
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state
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ITEM_TREE
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at0040
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protocol
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ITEM_TREE
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items
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CLUSTER
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at0039
archetype_id/value matches {/.*/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
.*
constraint
false
false
true
false
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true
0
openEHR-EHR-OBSERVATION.glasgow_coma_scale.v1
Glasgow Coma Scale (GCS)
Fifteen point scale used to assess impairment of consciousness in response to defined stimuli.
More correctly known as the Modified Glasgow coma scale.
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 @
Best verbal response (V)
Best verbal response to test stimulus.
Most commonly, the score for verbal response will be selected from one of the ordinal values, however if a response cannot be tested, for example if the subject of care is intubated, then the "Not Applicable" null flavour should be recorded.
Best motor response (M)
Best motor response to test stimulus.
Most commonly, the score for motor response will be selected from one of the ordinal values, however if a response cannot be tested, for example if the subject of care cannot move their limbs due to injury or paralysis, then the "Not Applicable" null flavour should be recorded.
Best eye response (E)
Best response of eyes to test stimulus.
Most commonly, the score for eye response will be selected from one of the ordinal values, however if a response cannot be tested, for example if the subject of care cannot physically open their eyes due to other injuries, then the "Not Applicable" null flavour should be recorded.
None
No eye opening at any time, no interfering factor. For example: eyes closed by local swelling.
To pressure
Eyes opening after finger tip stimulus.
To sound
Eyes opening after spoken or shouted request. Not to be confused with wakening of a sleeping person.
Spontaneous
Eyes open before stimulus.
None
No audible response, no interfering factor. For example: intubation; profound deafness.
Sounds
Only moans/groans.
Words
Intelligible single words.
Confused
Not orientated but communicates coherently.
Orientated
Correctly gives name, place and date.
None
No movement in arms/legs, no interfering factor. For example: paralysed.
Extension
Decerebrate extension of arms and/or legs in response to stimuli. For example: extends arm at elbow.
Abnormal flexion
Slow, decorticate flexion of arms and/or legs. For example: bends arm at elbow, but features predominantly abnormal.
Normal flexion
Rapid flexion in response to stimuli but features predominantly normal. For example: flexion of wrist when supra-orbital pressure applied; pulls part of body away when nailbed pinched.
Localising
Purposeful flexion towards painful stimuli. For example: brings hand above the clavicle when supra-orbital pressure is applied.
Obeys commands
Follows verbal request for movement.
Total score
The sum of the ordinal scores recorded for each of the three component responses.
The Total Score may be derived as the sum of the three response data elements and, if so, should be validated by the clinical information system against the individual scores entered by the clinician to ensure there is no conflict or inconsistency. Do not report a total score when one or more components are not testable because the score will be artificially low - in this situation record the EVM profile.
EVM profile
Alternative assessment to 'Total Score' where the Eye Verbal Motor profile is expressed as three discrete components.
The EMV Score may be automatically derived as a concatenation of the three response data elements and, if so, should be validated by the clinical information system against the individual scores entered by the clinician to ensure there is no conflict or inconsistency. The 'Not applicable' null flavour value should be recorded as 'NT', for 'not tested' as per http://www.glasgowcomascale.org/.
Comment
Additional narrative about the measurement of the scale not captured in other fields.
Record the reasons for inability to test in the 'Confounding factors' data element.
Tree
@ internal @
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.
Tree
@ internal @
Confounding factors
Narrative record of factors that may have contributed to the GCS scores.
For example: deafness; aphasia; language issues; use of sedatives; hypothermia; or paralysis, severe facial/eye swelling or tracheal intubation as reasons for inability to record any one of the ordinal E, V or M assessments.
OBSERVATION
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at0000
data
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HISTORY
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at0002
events
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false
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1
false
EVENT
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true
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0
1
at0003
data
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1
1
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ITEM_TREE
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at0001
items
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ELEMENT
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at1005
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DV_CODED_TEXT
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1
1
defining_code
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1
1
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CODE_PHRASE
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1
1
local
at1024
at1025
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true
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true
0
state
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ITEM_TREE
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at0012
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CLUSTER
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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
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true
false
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true
0
false
false
true
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true
1
protocol
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ITEM_TREE
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at0010
items
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CLUSTER
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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.
false
false
true
false
false
true
0
openEHR-EHR-COMPOSITION.encounter.v1
example.initialassesment.v0
Initial Assesment
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.
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