operationaltemplate.open_eREACT-Care.opt Maven / Gradle / Ivy
The newest version!
ISO_639-1
en
Ian McNicoll
freshEHR Clinical Informatics Ltd.
[email protected]
2020-07-16
unmanaged
61e24713487eb8fc3baa555f8bdbb8bd
706E6DA39FA082EE75E0F0D4E4A87F25
ed2cc0eb-c508-3e66-a7bc-0e3f3e3f196f
Archetype Designer v1.16.3, user=freshehr, repositoryId=open-ereact
ISO_639-1
en
Not Specified
10f9cc8b-006d-48f6-8285-0cbff59c1e17
open_eREACT-Care
open_eREACT-Care
COMPOSITION
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String
-
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content
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Just not themselves
Dehydration
Dizziness
Had a fall
Increased anxiety/agitation
Loss of appetite
Reduced mobility/coordination
Skin changes (colour/puffiness)
Withdrawn
Recently lost consciousness
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Soft signs
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Notes
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Boolean
2007
false
String
- archetype_id/value
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String
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openEHR-EHR-CLUSTER\.health_event(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.issue(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.symptom_sign(-[a-zA-Z0-9_]+)*\.v1
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0
openEHR-EHR-OBSERVATION.story.v1
Story/History
The subjective clinical history of the subject of care as recorded directly by the subject, or reported to a clinician by the subject or a carer.
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 @
Notes
Narrative description of the story or clinical history for the subject of care.
Structured detail
Structured detail about the individual's story or patient's history.
For example: a specific symptom such as nausea or pain; an event such as a fall off a bicycle; or an issue such as a desire to quit using tobacco.
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.
false
false
true
false
false
true
0
name
true
true
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1
1
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DV_TEXT
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false
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value
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1
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STRING
true
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-
Situation
openEHR-EHR-SECTION.adhoc.v1
Situation
A generic section header which should be renamed in a template to suit a specific clinical context.
SECTION
true
true
false
false
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at0000
items
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OBSERVATION
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HISTORY
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EVENT
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ELEMENT
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DV_QUANTITY
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openehr
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state
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Boolean
2007
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String
-
openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1
constraint
CLUSTER
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at0022
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STRING
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Height
openEHR-EHR-OBSERVATION.height.v2
Height
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.
LOINC
[LOINC::8302-2]
OBSERVATION
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HISTORY
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EVENT
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ITEM_TREE
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ELEMENT
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at0004
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DV_QUANTITY
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openehr
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0.0
1000.0
kg
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1
state
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at0008
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at0015
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CLUSTER
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at0020
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Boolean
2007
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String
- archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1
constraint
CLUSTER
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at0027
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- archetype_id/value
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String
-
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STRING
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Weight
openEHR-EHR-OBSERVATION.body_weight.v2
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.
LOINC
[LOINC::29463-7]
OBSERVATION
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HISTORY
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POINT_EVENT
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at0002
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ITEM_TREE
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ELEMENT
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DV_ORDINAL
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local
at0005
2
local
at0006
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local
at0007
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local
at0008
5
local
at0009
6
local
at0010
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local
at0011
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local
at0012
9
local
at0013
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ITEM_TREE
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at0014
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CLUSTER
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at0015
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Boolean
2007
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String
- archetype_id/value
attribute
String
-
.*
constraint
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STRING
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Frailty
openEHR-EHR-OBSERVATION.clinical_frailty_scale.v1
Frailty
An assessment scale used to screen for frailty and to broadly stratify degrees of fitness and frailty in an older adult.
Also known as the Rockwood Clinical Frailty Scale.
History
@ internal @
Any point in time event
Default, unspecified point in time event which may be explicitly defined in a template or at run-time.
Tree
@ internal @
Assessment
Assessed level of frailty.
Very Fit
People who are robust, active, energetic and motivated. These people commonly exercise regularly. They are among the fittest for their age.
Well
People who have no active disease symptoms but are less fit than category 1. Often, they exercise or are very active occasionally, e.g. seasonally.
Managing Well
People whose medical problems are well controlled, but are not regularly active beyond routine walking.
Vulnerable
While not dependent on others for daily help, often symptoms limit activities. A common complaint is being "slowed up", and/or being tired during the day.
Mildly Frail
These people often have more evident slowing, and need help in high order IADLs (finances, transportation, heavy housework, medications). Typically, mild frailty progressively impairs shopping and walking outside alone, meal preparation and housework.
Moderately Frail
People need help with all outside activities and with keeping house. Inside, they often have problems with stairs and need help with bathing and might need minimal assistance (cuing, standby) with dressing.
Severely Frail
Completely dependent for personal care, from whatever cause (physical or cognitive). Even so, they seem stable and not at high risk of dying (within - 6 monts).
Very Severely Frail
Completely dependent, approaching the end of life. Typically, they could not recover even from a minor illness.
Terminally Ill
Approaching the end of life. This category applies to people with a life expectancy <6 months, who are not otherwise evidently frail.
ItemTree
@ internal @
Extension
Additional information required to extend the model with local content or to align with other reference models/formalisms.
For example: local information requirements; or additional metadata to align with FHIR.
SNOMED-CT
[SNOMED-CT::763264000]
SNOMED-CT
[SNOMED-CT::445414007]
EVALUATION
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ITEM_TREE
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ELEMENT
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protocol
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ITEM_TREE
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CLUSTER
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Boolean
2007
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String
- archetype_id/value
attribute
String
-
.*
constraint
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STRING
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Past history
openEHR-EHR-EVALUATION.clinical_synopsis.v1
Past history
Narrative summary or overview about a patient, specifically from the perspective of a healthcare provider, and with or without associated interpretations.
List
@ internal @
Synopsis
The summary, assessment, conclusions or evaluation of the clinical findings.
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.
EVALUATION
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at0000
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at0001
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at0002
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ITEM_TREE
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at0003
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CLUSTER
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at0004
archetype_id/value matches {/.*/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
.*
constraint
false
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true
false
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true
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name
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STRING
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1
-
Medication
openEHR-EHR-EVALUATION.clinical_synopsis.v1
Medication
Narrative summary or overview about a patient, specifically from the perspective of a healthcare provider, and with or without associated interpretations.
List
@ internal @
Synopsis
The summary, assessment, conclusions or evaluation of the clinical findings.
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.
EVALUATION
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at0000
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ITEM_TREE
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at0001
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ELEMENT
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at0002
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CLUSTER
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at0004
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Boolean
2007
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String
- archetype_id/value
attribute
String
-
.*
constraint
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true
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name
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DV_TEXT
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value
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STRING
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1
-
Allergies
openEHR-EHR-EVALUATION.clinical_synopsis.v1
Allergies
Narrative summary or overview about a patient, specifically from the perspective of a healthcare provider, and with or without associated interpretations.
List
@ internal @
Synopsis
The summary, assessment, conclusions or evaluation of the clinical findings.
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.
false
false
true
false
false
true
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STRING
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Background
openEHR-EHR-SECTION.adhoc.v1
Background
A generic section header which should be renamed in a template to suit a specific clinical context.
SECTION
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true
false
false
0
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at0000
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OBSERVATION
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HISTORY
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POINT_EVENT
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ITEM_TREE
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DV_ORDINAL
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local
at0032
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local
at0031
ELEMENT
true
false
false
true
0
at0062
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
at0067
at0068
at0069
at0070
ELEMENT
true
true
false
false
0
1
at0033
value
true
true
false
false
0
1
false
DV_ORDINAL
true
true
false
false
1
1
0
local
at0037
1
local
at0036
ELEMENT
true
false
false
true
0
at0071
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
at0096
at0097
at0098
at0099
ELEMENT
true
true
false
false
0
1
at0038
value
true
true
false
false
0
1
false
DV_ORDINAL
true
true
false
false
1
1
0
local
at0042
1
local
at0105
ELEMENT
true
false
false
true
0
at0076
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
at0100
DV_TEXT
true
true
false
false
1
1
ELEMENT
true
true
false
false
0
1
at0043
value
true
true
false
false
0
1
false
DV_ORDINAL
true
true
false
false
1
1
0
local
at0046
1
local
at0045
ELEMENT
true
false
false
true
0
at0078
value
true
true
false
false
0
1
false
DV_TEXT
true
true
false
false
1
1
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
at0101
at0102
ELEMENT
true
true
false
false
0
1
at0047
value
true
true
false
false
0
1
false
DV_ORDINAL
true
true
false
false
1
1
0
local
at0048
1
local
at0049
ELEMENT
true
false
false
true
0
at0081
value
true
true
false
false
0
1
false
DV_TEXT
true
true
false
false
1
1
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
at0103
at0104
ELEMENT
true
true
false
false
0
1
at0050
value
true
true
false
false
0
1
false
DV_ORDINAL
true
true
false
false
1
1
0
local
at0051
1
local
at0052
ELEMENT
true
false
false
true
0
at0084
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
at0106
at0107
DV_TEXT
true
true
false
false
1
1
ELEMENT
true
true
false
false
0
1
at0053
value
true
true
false
false
0
1
false
DV_ORDINAL
true
true
false
false
1
1
0
local
at0054
1
local
at0055
ELEMENT
true
false
false
true
0
at0087
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
at0108
at0109
DV_TEXT
true
true
false
false
1
1
ELEMENT
true
true
false
false
0
1
at0056
value
true
true
false
false
0
1
false
DV_ORDINAL
true
true
false
false
1
1
0
local
at0057
1
local
at0058
ELEMENT
true
false
false
true
0
at0090
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
at0110
at0111
DV_TEXT
true
true
false
false
1
1
ELEMENT
true
true
false
false
0
1
at0059
value
true
true
false
false
0
1
false
DV_ORDINAL
true
true
false
false
1
1
0
local
at0060
1
local
at0061
ELEMENT
true
false
false
true
0
at0093
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
at0112
at0113
DV_TEXT
true
true
false
false
1
1
ELEMENT
true
true
false
false
0
1
at0027
value
true
true
false
false
0
1
false
DV_TEXT
true
true
false
false
1
1
ELEMENT
true
true
false
false
0
1
at0008
value
true
true
false
false
0
1
false
DV_COUNT
true
true
false
false
1
1
magnitude
true
true
false
false
0
1
false
INTEGER
true
true
false
false
1
1
-
true
true
false
false
0
9
false
false
true
false
false
true
0
state
true
true
false
false
0
1
false
ITEM_TREE
true
true
false
false
1
1
at0006
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
false
false
true
0
at0005
archetype_id/value matches {/.*/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
.*
constraint
false
false
true
false
false
true
0
openEHR-EHR-OBSERVATION.denwis.v0
DENWIS
Dutch Early Nurse Worry Indicator Score (DENWIS)
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 @
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 HL7 or CDISC equivalents.
Tree
@ internal @
Total score
The total score for the four questions.
Q 10 Other comment
Narrative comment.
Q1 Breathing
Nurse recorded changes in breathing.
Change in breathing
Change in breathing.
No change in breathing
No change in breathing.
Q2 Circulation
Nurse recorded changes in circulation.
Change in circulation
Change in circulation.
No change in circulation
No change in circulation.
Q3 Temperature
Nurse recorded changes in temperature.
No change in temperature
No change in temperature.
Q4 Mentation
Nurse recorded changes in mentation.
Change in mentation
Change in mentation.
No change in mentation
No change in mentation.
Q5 Agitation
Nurse recorded changes in agitation.
No agitation
No agitation.
Agitation
Agitation.
Q6 Pain
Nurse recorded changes in pain.
No change in pain
No change in pain.
Change in pain
Change in pain.
Q7 Trajectory
Nurse recorded unexpected trajectory.
No change in trajectory
No change in trajectory.
Change in trajectory
Change in trajectory.
Q8 Patient subjective
Nurse recorded patient indicators.
No subjective patient indicator
No subjective patient indicator.
Subjective patient indicator
Subjective patient indicator.
Q9 Nurse subjective
Nurse recorded subjective observation.
No nurse subjective indicator
No nurse subjective indicator.
Nurse subjective indicator
Nurse subjective indicator.
Breathing indicator
Nurse recorded the indication that there are changes in breathing.
Noisy breathing
Noisy breathing.
Short of breath
Short of breath.
Unable to speak full sentences
Unable to speak in full sentences.
Use accessory muscles
Use accessory muscles.
Circulation indicator
Nurse recorded changes in circulation.
Temperature indicator
Nurse recorded changes in temperature.
Mentation indicator
Nurse recorded changes in mentation.
Agitation indicator
Nurse recorded changes in agitation.
Pain indicator
Nurse recorded changes in pain.
Trajectory indicator
Nurse recorded unexpected trajectory.
Patient indicator
Nurse recorded patient indicators.
Nurse subjective indicator
Nurse recorded subjective observation.
Colour changes: pale, grey
Colour changes: pale, grey.
Sweaty/clammy
Sweaty/clammy.
Coldness
Coldness.
Impaired perfusion
Impaired perfusion.
Rigors
Rigors.
Lethargic
Lethargic.
Confused
Confused.
Restless
Restless.
Anxious
Anxious.
Change in temperature
Change in temperature.
New pain
New pain.
Increasing or consisting pain
Increasing or consisting pain.
No progress
No progress.
Abdominal distension/nausea/bleeding
Abdominal distension/nausea/bleeding.
Not feeling well
Not feeling well.
Feeling of impending doom
Feeling of impending doom.
Change in behaviour
Change in behaviour.
Doesn't look good
Doesn't look good.
SECTION
true
true
false
false
0
1
at0000
items
true
true
false
false
0
1
false
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
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
false
false
true
0
at0006
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
at0007
at0008
at0009
at0010
ELEMENT
true
false
false
true
0
at0011
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
at0012
at0013
at0014
at0015
at0026
at0027
DV_TEXT
true
true
false
false
1
1
ELEMENT
true
false
false
true
0
at0058
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
at0074
at0075
at0076
at0077
at0078
at0079
at0080
at0081
at0082
ELEMENT
true
false
false
true
0
at0083
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
at0090
at0091
at0092
at0093
at0094
at0095
at0096
at0097
ELEMENT
true
false
false
true
0
at0036
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
at0037
at0038
at0039
at0040
at0041
at0042
false
false
true
false
false
true
0
false
false
true
false
false
true
0
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
false
false
true
0
at0005
archetype_id/value matches {/.*/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
.*
constraint
false
false
true
false
false
true
0
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
-
Sepsis screening
openEHR-EHR-OBSERVATION.sepsis_screening_tool.v0
Sepsis screening
Sepsis screening tool for ages 12 plus based on the paper forms developed by The UK Sepsis Trust.
History
@ internal @
Any event
*
Tree
@ internal @
Item tree
@ internal @
Extension
*
Risk factors for sepsis
Used to record details of suspicion of any serious illness from the sepsis screening tool.
Q1: ARE THERE CLUES THAT THE PATIENT MAY BE SERIOUSLY ILL?
Age over 75
Patient is over 75.
Impaired immunity (e.g diabetes, steroids, chemotherapy)
Patient has impaired immunity.
Recent trauma / surgery / invasive procedure
Patient has had recent trauma, surgery or an invasive procedure.
Indwelling lines / IVDU / broken skin
Patient has indwelling lines, IVDU or broken skin.
Likely source of infection
Used to record details of source of any infection from the sepsis screening tool.
Q2: COULD THIS BE DUE TO AN INFECTION?
Respiratory
The likely source of infection is respiratory.
Brain
The likely source of infection is brain.
Urine
The likely source of infection is urine.
Surgical
The likely source of infection is surgical.
Red flag (telephone)
Used to record details of any red flag indicators from the sepsis screening tool.
Q3: ANY RED FLAG PRESENT?
Objective evidence of new or altered mental state
There is objective evidence of new or altered mental state.
Unable to stand / collapsed
The patient is unable to stand or has collapsed.
Unable to catch breath / barely able to speak
The patient is unable to catch their breath and is barely able to speak.
Very fast breathing
The patient has very fast breathing.
Amber flag (telephone)
Used to record details of any amber flag indicators from the sepsis screening tool.
Q4: ANY AMBER FLAG PRESENT?
Behavioural change / reduced activity
The patient has behavioral changes or reduced activity.
Immunosuppressed
The patient is immunosuppressed.
Breathing harder work than normal
The patient is finding it harder to breath than normal.
Reduced urine output
The patient has reduced urine output.
Skin / joint/ wound
The likely source of infection is skin, joint or wound.
Indwelling device
The likely source of infection is an indwelling device.
Skin that is very pale, mottled , ashen or blue
The patient has skin that is very pale, mottled , ashen or blue.
Rash that doesn’t fade when pressed firmly
The patient has a rash that doesn’t fade when pressed firmly.
Recent chemotherapy
The patient has had recent chemotherapy.
Temperature <36°C
The patient has a temperature below 36 degrees Celsius.
Signs of wound infection
The patient has signs of a wound infection.
Under 17 and immunity impaired
The patient is under 17 and has impaired immunity.
999 Flag
*
Slurred speech or confusion
The patient has slurred speech or confusion.
Extreme shivering or muscle pain
The patient has extreme shivering or muscle pain.
Passing no urine (in a day)
The patient is passing no urine (in a day).
Severe breathlessness
The patient has severe breathlessness.
‘I feel I might die’
The patient stated ‘I feel I might die’.
Skin mottled, ashen, blue or very pale
The patient has skin which is mottled, ashen, blue or very pale.
Red flag (acute)
Used to record details of any red flag indicators from the sepsis screening tool.
Q3: ANY RED FLAG PRESENT?
Objective evidence of new or altered mental state
Objective evidence of new or altered mental state
Systolic BP ≤ 90 mmHg (or drop of >40 from normal)
Systolic BP ≤ 90 mmHg (or drop of >40 from normal)
Heart rate ≥ 130 per minute
Heart rate ≥ 130 per minute
Respiratory rate ≥ 25 per minute
Respiratory rate ≥ 25 per minute
Needs O2 to keep SpO2 ≥ 92% (88% in COPD)
Needs O2 to keep SpO2 ≥ 92% (88% in COPD)
Non-blanching rash / mottled / ashen / cyanotic
Non-blanching rash / mottled / ashen / cyanotic
Lactate ≥ 2 mmol/l
Lactate ≥ 2 mmol/l
Recent chemotherapy
Recent chemotherapy
Not passed urine in 18 hours (<0.5ml/kg/hr if catheterised)
Not passed urine in 18 hours (<0.5ml/kg/hr if catheterised)
Amber flag (acute)
Used to record details of any amber flag indicators from the sepsis screening tool.
Q4: ANY AMBER FLAG PRESENT?
Relatives concerned about mental status REQUIRED:
Relatives concerned about mental status REQUIRED:
Acute deterioration in functional ability
Acute deterioration in functional ability
Trauma / surgery / procedure in last 8 weeks
Trauma / surgery / procedure in last 8 weeks
Respiratory rate 21-24
Respiratory rate 21-24
Systolic BP 91-100 mmHg
Systolic BP 91-100 mmHg
Heart rate 91-130 or new dysrhythmia
Heart rate 91-130 or new dysrhythmia
Temperature <36°C
Temperature <36°C
Clinical signs of wound infection
Clinical signs of wound infection
false
false
true
false
false
true
0
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
-
Sepsis
openEHR-EHR-SECTION.adhoc.v1
Sepsis
A generic section header which should be renamed in a template to suit a specific clinical context.
SECTION
true
true
false
false
0
1
at0000
items
true
true
false
false
0
1
false
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
true
false
false
0
1
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
at0004
value
true
true
false
false
0
1
false
DV_TEXT
true
true
false
false
1
1
CLUSTER
true
true
false
false
0
1
at0000.1
items
true
true
false
false
1
1
false
ELEMENT
true
true
false
false
1
1
at0001.1
value
true
true
false
false
0
1
false
DV_CODED_TEXT
true
true
false
false
0
1
defining_code
true
true
false
false
1
1
false
CODE_PHRASE
true
true
false
false
0
1
SNOMED-CT
315642008
CLUSTER
true
false
false
true
0
at0147
archetype_id/value matches {/openEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER.anatomical_location_circle(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.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_circle(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.v1
constraint
archetype_id/value matches {/.*/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
.*
constraint
ELEMENT
true
true
false
false
0
1
at0152
value
true
true
false
false
0
1
false
DV_DATE_TIME
true
true
false
false
1
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
-
Date of onset of first symptoms
ELEMENT
true
true
false
false
0
1
at0028
value
true
true
false
false
0
1
false
DV_DURATION
true
true
false
false
1
1
value
true
true
false
false
1
1
false
DURATION
true
true
false
false
0
1
-
true
false
false
true
PT0H
ELEMENT
true
true
false
false
0
1
at0180
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
at0183
at0182
at0181
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
-
Trend
ELEMENT
true
true
false
false
0
1
at0155
value
true
true
false
false
0
1
false
DV_TEXT
true
true
false
false
1
1
value
true
true
false
false
1
1
false
STRING
true
true
false
false
0
1
-
Normal
Reduced
Severely impaired
CLUSTER
true
false
false
true
0
at0153
archetype_id/value matches {/.*/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
.*
constraint
CLUSTER
true
false
false
true
0
at0146
archetype_id/value matches {/openEHR-EHR-CLUSTER\.symptom_sign(-[a-zA-Z0-9_]+)*\.v1/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.symptom_sign(-[a-zA-Z0-9_]+)*\.v1
constraint
CLUSTER
true
false
false
true
0
at0063
archetype_id/value matches {/openEHR-EHR-CLUSTER\.symptom_sign(-[a-zA-Z0-9_]+)*\.v1/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.symptom_sign(-[a-zA-Z0-9_]+)*\.v1
constraint
ELEMENT
true
true
false
false
0
1
at0.1
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
at0.2
at0.3
at0.4
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
-
First symptoms
openEHR-EHR-CLUSTER.symptom_sign-cvid.v0
First occurrence
This is the first ever occurrence of this symptom or sign.
Recurrence
This is the first ever occurrence of this symptom or sign.
Character
Word or short phrase describing the nature of the symptom or sign.
For example: pain could be described as 'gnawing', 'burning', or 'like an electric shock'; a headache could be 'throbbing' or 'constant'. Coding with an external terminology is preferred, where possible.
First symptoms
Symptoms known to be indicators of suspected Covid-19 infection
Presence
Is the symptom present or not?
Present
The symptom is present.
Absent
The symptom is absent.
Unknown
It is not known if the symptom is present.
Symptom/Sign name
The name of the reported symptom or sign.
Symptom name should be coded with a terminology, where possible.
Symptom/Sign
Reported observation of a physical or mental disturbance in an individual.
Symptom/Sign name
The name of the reported symptom or sign.
Symptom name should be coded with a terminology, where possible.
Description
Narrative description about the reported symptom or sign.
Pattern
Narrative description about the pattern of the symptom or sign during this episode.
For example: pain could be described as constant or intermittent.
Effect
Perceived effect of the modifying factor on the symptom or sign.
Modifying factor
Detail about how a specific factor effects the identified symptom or sign during this episode.
Factor
Name of the modifying factor.
Examples of modifying factor: lying on multiple pillows, eating or administration of a specific medication.
Severity category
Category representing the overall severity of the symptom or sign.
Defining values such as mild, moderate or severe in such a way that is applicable to multiple symptoms or signs plus allows multiple users to interpret and record them consistently is not easy. Some organisations extend the value set further with inclusion of additional values such as 'Trivial' and 'Very severe', and/or 'Mild-Moderate' and 'Moderate-Severe', adds to the definitional difficulty and may also worsen inter-recorder reliability issues. Use of 'Life-threatening' and 'Fatal' is also often considered as part of this value set, although from a pure point of view it may actually reflect an outcome rather than a severity. In view of the above, keeping to a well-defined but smaller list is preferred and so the mild/moderate/severe value set is offered, however the choice of other text allows for other value sets to be included at this data element in a template. Note: more specific grading of severity can be recorded using the 'Specific details' SLOT.
Mild
The intensity of the symptom or sign does not cause interference with normal activity.
Moderate
The intensity of the symptom or sign causes interference with normal activity.
Severe
The intensity of the symptom or sign causes prevents normal activity.
Severity rating
Numerical rating scale representing the overall severity of the symptom or sign.
Symptom severity can be rated by the individual by recording a score from 0 (ie symptom not present) to 10.0 (ie symptom is as severe as the individual can imagine). This score can be represented in the user interface as a visual analogue scale. The data element has occurrences set to 0..* to allow for variations such as 'maximal severity' or 'average severity' to be included in a template.
Duration
The duration of this episode of the symptom or sign since onset.
If 'Date/time of onset' and 'Date/time of resolution' are used in systems, this data element may be calculated, or alternatively, be considered redundant in this scenario.
Number of previous episodes
The number of times this symptom or sign has previously occurred.
Nil significant
The identified symptom or sign was reported as not being present to any significant degree.
Record as True if the subject of care has reported the symptom as not significant. For example: if the individual has never experienced the symptom it is appropriate to record 'nil significant'; or if the individual commonly experiences the symptom, in some circumstances it may be considered appropriate to record 'nil significant' if the individual has experienced no deviation from their 'normal' baseline.
Episode description
Narrative description about the course of the symptom or sign during this episode.
For example: a text description of the immediate onset of the symptom, activities that worsened or relieved the symptom, whether it is improving or worsening and how it resolved over weeks.
Description
Narrative description of the effect of the modifying factor on the symptom or sign.
Description of previous episodes
Narrative description of any or all previous episodes.
For example: frequency/periodicity - per hour, day, week, month, year; and regularity. May include a comparison to this episode.
Associated symptom/sign
Structured details about any associated symptoms or signs that are concurrent.
In linked clinical systems, it is possible that associated symptoms or signs are already recorded within the EHR. Systems can allow the clinician to LINK to relevant associated symptoms/signs. However in a system or message without LINKs to existing data or with a new patient, additional instances of the symptom archetype could be included here to represent associated symptoms/signs.
Previous episodes
Structured details of the symptom or sign during a previous episode.
In linked clinical systems, it is possible that previous episodes are already recorded within the EHR. Systems can allow the clinician to LINK to relevant previous episodes. However in a system or message without LINKs to existing data or with a new patient, additional instances of the symptom archetype could be included here to represent previous episodes. It is recommended that new instances of the Symptom archetype inserted in this SLOT represent one or many previous episodes to this Symptom instance only.
Structured body site
Structured body site where the symptom or sign was reported.
If the anatomical location is included in the Symptom name via precoordinated codes, use of this SLOT becomes redundant. If the anatomical location is recorded using the 'Body site' data element, then use of CLUSTER archetypes in this SLOT is not allowed - record only the simple 'Body site' OR 'Structured body site', but not both.
Body site
Simple body site where the symptom or sign was reported.
Occurrences of this data element are set to 0..* to allow multiple body sites to be separated out in a template if desired. This allows for representation of clinical scenarios where a symptom or sign needs to be recorded in multiple locations or identifying both the originating and distal site in pain radiation, but where all of the other attributes such as impact and duration are identical. If the requirements for recording the body site are determined at run-time by the application or require more complex modelling such as relative locations then use the CLUSTER.anatomical_location or CLUSTER.relative_location within the Detailed anatomical location' SLOT in this archetype.
If the anatomical location is included in the Symptom name via precoordinated codes, this data element becomes redundant. If the anatomical location is recorded using the 'Structured body site' SLOT, then use of this data element is not allowed - record only the simple 'Body site' OR 'Structured body site', but not both.
Date of onset of first symptoms
The onset for this episode of the symptom or sign.
While partial dates are permitted, the exact date and time of onset can be recorded, if appropriate. If this symptom or sign is experienced for the first time or is a re-occurrence, this date is used to represent the onset of this episode. If this symptom or sign is ongoing, this data element may be redundant if it has been recorded previously.
Specific details
Specific data elements that are additionally required to record as unique attributes of the identified symptom or sign.
For example: CTCAE grading.
Factor detail
Structured detail about the factor associated with the identified symptom or sign.
Impact
Description of the impact of this symptom or sign.
Assessment of impact could consider the severity, duration and frequency of the symptom as well as the type of impact including, but not limited to, functional, social and emotional impact. Occurrences of this data element are set to 0..* to allow multiple types of impact to be separated out in a template if desired. Examples for functional impact from hearing loss may include: 'Difficulty Hearing in Quiet Environment'; 'Difficulty Hearing the TV or Radio'; 'Difficulty Hearing Group Conversation'; and 'Difficulty Hearing on Phone'.
No effect
The factor has no impact on the symptom or sign.
Worsens
The factor increases the severity or impact of the symptom or sign.
Relieves
The factor decreases the severity or impact of the symptom or sign, but does not fully resolve it.
Resolution date/time
The timing of the cessation of this episode of the symptom or sign.
If 'Date/time of onset' and 'Duration' are used in systems, this data element may be calculated, or alternatively, considered redundant. While partial dates are permitted, the exact date and time of resolution can be recorded, if appropriate.
Comment
Additional narrative about the symptom or sign not captured in other fields.
Onset type
Description of the onset of the symptom or sign.
The type of the onset can be coded with a terminology, if desired. For example: gradual; or sudden.
Precipitating/resolving factor
Details about specified factors that are associated with the precipitation or resolution of the symptom or sign.
For example: onset of headache occurred one week prior to menstruation; or onset of headache occurred one hour after fall of bicycle.
Precipitating factor
Identification of factors or events that trigger the onset or commencement of the symptom or sign.
Resolving factor
Identification of factors or events that trigger resolution or cessation of the symptom or sign.
Factor
Name of the health event, symptom, reported sign or other factor.
For example: onset of another symptom; onset of menstruation; or fall off bicycle.
Time interval
The interval of time between the occurrence or onset of the factor and onset/resolution of the symptom or sign.
Episodicity
Category of this episode for the identified symptom or sign.
New
A new episode of the symptom or sign - either the first ever occurrence or a reoccurrence where the previous episode had completely resolved.
Indeterminate
It is not possible to determine if this occurrence of the symptom or sign is new or ongoing.
Ongoing
This symptom or sign is ongoing, effectively a single, continuous episode.
Trend
Description progression of the symptom or sign at the time of reporting.
Occurrences of this data element are set to 0..* to allow multiple types of progression to be separated out in a template if desired - for example, severity or frequency.
Improving
The severity of the symptom or sign has improved overall during this episode.
Unchanged
The severity of the symptom or sign has not changed overall during this episode.
Worsening
The severity of the symptom or sign has worsened overall during this episode.
Resolved
The severity of the symptom or sign has resolved.
Description
Narrative description about the effect of the factor on the identified symptom or sign.
First ever?
Is this the first ever occurrence of this symptom or sign?
Record as True if this is the first ever occurrence of this symptom or sign.
Influenza-like symptoms
SNOMED-CT
[SNOMED-CT::418799008]
SNOMED-CT
[SNOMED-CT::418799008]
SNOMED-CT
[SNOMED-CT::162408000]
SNOMED-CT
[SNOMED-CT::162465004]
SNOMED-CT
[SNOMED-CT::162468002]
SNOMED-CT
[SNOMED-CT::162469005]
SNOMED-CT
[SNOMED-CT::162470006]
SNOMED-CT
[SNOMED-CT::162442009]
CLUSTER
true
false
false
true
0
at0000.1
items
true
true
false
false
1
1
false
ELEMENT
true
true
false
false
1
1
at0001.1
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
386661006
49727002
162397003
16001004
64531003
68962001
57676002
84229001
272028008
CLUSTER
true
false
false
true
0
at0147
archetype_id/value matches {/openEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER.anatomical_location_circle(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.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_circle(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[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
at0153
archetype_id/value matches {/.*/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
.*
constraint
CLUSTER
true
false
false
true
0
at0146
archetype_id/value matches {/openEHR-EHR-CLUSTER\.symptom_sign(-[a-zA-Z0-9_]+)*\.v1/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.symptom_sign(-[a-zA-Z0-9_]+)*\.v1
constraint
CLUSTER
true
false
false
true
0
at0063
archetype_id/value matches {/openEHR-EHR-CLUSTER\.symptom_sign(-[a-zA-Z0-9_]+)*\.v1/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.symptom_sign(-[a-zA-Z0-9_]+)*\.v1
constraint
ELEMENT
true
true
false
false
0
1
at0.1
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
at0.2
at0.3
at0.4
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
-
Presence
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
-
Key Covid symptom
openEHR-EHR-CLUSTER.symptom_sign-cvid.v0
First occurrence
This is the first ever occurrence of this symptom or sign.
Recurrence
This is the first ever occurrence of this symptom or sign.
Character
Word or short phrase describing the nature of the symptom or sign.
For example: pain could be described as 'gnawing', 'burning', or 'like an electric shock'; a headache could be 'throbbing' or 'constant'. Coding with an external terminology is preferred, where possible.
Key Covid symptom
Symptoms known to be indicators of suspected Covid-19 infection
Presence
Is the symptom present or not?
Present
The symptom is present.
Absent
The symptom is absent.
Unknown
It is not known if the symptom is present.
Symptom/Sign name
The name of the reported symptom or sign.
Symptom name should be coded with a terminology, where possible.
Symptom/Sign
Reported observation of a physical or mental disturbance in an individual.
Symptom/Sign name
The name of the reported symptom or sign.
Symptom name should be coded with a terminology, where possible.
Description
Narrative description about the reported symptom or sign.
Pattern
Narrative description about the pattern of the symptom or sign during this episode.
For example: pain could be described as constant or intermittent.
Effect
Perceived effect of the modifying factor on the symptom or sign.
Modifying factor
Detail about how a specific factor effects the identified symptom or sign during this episode.
Factor
Name of the modifying factor.
Examples of modifying factor: lying on multiple pillows, eating or administration of a specific medication.
Severity category
Category representing the overall severity of the symptom or sign.
Defining values such as mild, moderate or severe in such a way that is applicable to multiple symptoms or signs plus allows multiple users to interpret and record them consistently is not easy. Some organisations extend the value set further with inclusion of additional values such as 'Trivial' and 'Very severe', and/or 'Mild-Moderate' and 'Moderate-Severe', adds to the definitional difficulty and may also worsen inter-recorder reliability issues. Use of 'Life-threatening' and 'Fatal' is also often considered as part of this value set, although from a pure point of view it may actually reflect an outcome rather than a severity. In view of the above, keeping to a well-defined but smaller list is preferred and so the mild/moderate/severe value set is offered, however the choice of other text allows for other value sets to be included at this data element in a template. Note: more specific grading of severity can be recorded using the 'Specific details' SLOT.
Mild
The intensity of the symptom or sign does not cause interference with normal activity.
Moderate
The intensity of the symptom or sign causes interference with normal activity.
Severe
The intensity of the symptom or sign causes prevents normal activity.
Severity rating
Numerical rating scale representing the overall severity of the symptom or sign.
Symptom severity can be rated by the individual by recording a score from 0 (ie symptom not present) to 10.0 (ie symptom is as severe as the individual can imagine). This score can be represented in the user interface as a visual analogue scale. The data element has occurrences set to 0..* to allow for variations such as 'maximal severity' or 'average severity' to be included in a template.
Duration
The duration of this episode of the symptom or sign since onset.
If 'Date/time of onset' and 'Date/time of resolution' are used in systems, this data element may be calculated, or alternatively, be considered redundant in this scenario.
Number of previous episodes
The number of times this symptom or sign has previously occurred.
Nil significant
The identified symptom or sign was reported as not being present to any significant degree.
Record as True if the subject of care has reported the symptom as not significant. For example: if the individual has never experienced the symptom it is appropriate to record 'nil significant'; or if the individual commonly experiences the symptom, in some circumstances it may be considered appropriate to record 'nil significant' if the individual has experienced no deviation from their 'normal' baseline.
Episode description
Narrative description about the course of the symptom or sign during this episode.
For example: a text description of the immediate onset of the symptom, activities that worsened or relieved the symptom, whether it is improving or worsening and how it resolved over weeks.
Description
Narrative description of the effect of the modifying factor on the symptom or sign.
Description of previous episodes
Narrative description of any or all previous episodes.
For example: frequency/periodicity - per hour, day, week, month, year; and regularity. May include a comparison to this episode.
Associated symptom/sign
Structured details about any associated symptoms or signs that are concurrent.
In linked clinical systems, it is possible that associated symptoms or signs are already recorded within the EHR. Systems can allow the clinician to LINK to relevant associated symptoms/signs. However in a system or message without LINKs to existing data or with a new patient, additional instances of the symptom archetype could be included here to represent associated symptoms/signs.
Previous episodes
Structured details of the symptom or sign during a previous episode.
In linked clinical systems, it is possible that previous episodes are already recorded within the EHR. Systems can allow the clinician to LINK to relevant previous episodes. However in a system or message without LINKs to existing data or with a new patient, additional instances of the symptom archetype could be included here to represent previous episodes. It is recommended that new instances of the Symptom archetype inserted in this SLOT represent one or many previous episodes to this Symptom instance only.
Structured body site
Structured body site where the symptom or sign was reported.
If the anatomical location is included in the Symptom name via precoordinated codes, use of this SLOT becomes redundant. If the anatomical location is recorded using the 'Body site' data element, then use of CLUSTER archetypes in this SLOT is not allowed - record only the simple 'Body site' OR 'Structured body site', but not both.
Body site
Simple body site where the symptom or sign was reported.
Occurrences of this data element are set to 0..* to allow multiple body sites to be separated out in a template if desired. This allows for representation of clinical scenarios where a symptom or sign needs to be recorded in multiple locations or identifying both the originating and distal site in pain radiation, but where all of the other attributes such as impact and duration are identical. If the requirements for recording the body site are determined at run-time by the application or require more complex modelling such as relative locations then use the CLUSTER.anatomical_location or CLUSTER.relative_location within the Detailed anatomical location' SLOT in this archetype.
If the anatomical location is included in the Symptom name via precoordinated codes, this data element becomes redundant. If the anatomical location is recorded using the 'Structured body site' SLOT, then use of this data element is not allowed - record only the simple 'Body site' OR 'Structured body site', but not both.
Episode onset
The onset for this episode of the symptom or sign.
While partial dates are permitted, the exact date and time of onset can be recorded, if appropriate. If this symptom or sign is experienced for the first time or is a re-occurrence, this date is used to represent the onset of this episode. If this symptom or sign is ongoing, this data element may be redundant if it has been recorded previously.
Specific details
Specific data elements that are additionally required to record as unique attributes of the identified symptom or sign.
For example: CTCAE grading.
Factor detail
Structured detail about the factor associated with the identified symptom or sign.
Impact
Description of the impact of this symptom or sign.
Assessment of impact could consider the severity, duration and frequency of the symptom as well as the type of impact including, but not limited to, functional, social and emotional impact. Occurrences of this data element are set to 0..* to allow multiple types of impact to be separated out in a template if desired. Examples for functional impact from hearing loss may include: 'Difficulty Hearing in Quiet Environment'; 'Difficulty Hearing the TV or Radio'; 'Difficulty Hearing Group Conversation'; and 'Difficulty Hearing on Phone'.
No effect
The factor has no impact on the symptom or sign.
Worsens
The factor increases the severity or impact of the symptom or sign.
Relieves
The factor decreases the severity or impact of the symptom or sign, but does not fully resolve it.
Resolution date/time
The timing of the cessation of this episode of the symptom or sign.
If 'Date/time of onset' and 'Duration' are used in systems, this data element may be calculated, or alternatively, considered redundant. While partial dates are permitted, the exact date and time of resolution can be recorded, if appropriate.
Comment
Additional narrative about the symptom or sign not captured in other fields.
Onset type
Description of the onset of the symptom or sign.
The type of the onset can be coded with a terminology, if desired. For example: gradual; or sudden.
Precipitating/resolving factor
Details about specified factors that are associated with the precipitation or resolution of the symptom or sign.
For example: onset of headache occurred one week prior to menstruation; or onset of headache occurred one hour after fall of bicycle.
Precipitating factor
Identification of factors or events that trigger the onset or commencement of the symptom or sign.
Resolving factor
Identification of factors or events that trigger resolution or cessation of the symptom or sign.
Factor
Name of the health event, symptom, reported sign or other factor.
For example: onset of another symptom; onset of menstruation; or fall off bicycle.
Time interval
The interval of time between the occurrence or onset of the factor and onset/resolution of the symptom or sign.
Episodicity
Category of this episode for the identified symptom or sign.
New
A new episode of the symptom or sign - either the first ever occurrence or a reoccurrence where the previous episode had completely resolved.
Indeterminate
It is not possible to determine if this occurrence of the symptom or sign is new or ongoing.
Ongoing
This symptom or sign is ongoing, effectively a single, continuous episode.
Progression
Description progression of the symptom or sign at the time of reporting.
Occurrences of this data element are set to 0..* to allow multiple types of progression to be separated out in a template if desired - for example, severity or frequency.
Improving
The severity of the symptom or sign has improved overall during this episode.
Unchanged
The severity of the symptom or sign has not changed overall during this episode.
Worsening
The severity of the symptom or sign has worsened overall during this episode.
Resolved
The severity of the symptom or sign has resolved.
Description
Narrative description about the effect of the factor on the identified symptom or sign.
First ever?
Is this the first ever occurrence of this symptom or sign?
Record as True if this is the first ever occurrence of this symptom or sign.
Fever
Cough
Sore throat
Ear pain
Runny nose
Muscle aches
Joint pain
Fatigue/malaise
Anosmia (loss of taste/smell)
SNOMED-CT
[SNOMED-CT::418799008]
SNOMED-CT
[SNOMED-CT::418799008]
SNOMED-CT
[SNOMED-CT::162408000]
SNOMED-CT
[SNOMED-CT::162465004]
SNOMED-CT
[SNOMED-CT::162468002]
SNOMED-CT
[SNOMED-CT::162469005]
SNOMED-CT
[SNOMED-CT::162470006]
SNOMED-CT
[SNOMED-CT::162442009]
CLUSTER
true
false
false
true
0
at0000.1
items
true
true
false
false
1
1
false
ELEMENT
true
true
false
false
1
1
at0001.1
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
29857009
267036007
CLUSTER
true
false
false
true
0
at0147
archetype_id/value matches {/openEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER.anatomical_location_circle(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.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_circle(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[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
at0153
archetype_id/value matches {/.*/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
.*
constraint
CLUSTER
true
false
false
true
0
at0146
archetype_id/value matches {/openEHR-EHR-CLUSTER\.symptom_sign(-[a-zA-Z0-9_]+)*\.v1/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.symptom_sign(-[a-zA-Z0-9_]+)*\.v1
constraint
CLUSTER
true
false
false
true
0
at0063
archetype_id/value matches {/openEHR-EHR-CLUSTER\.symptom_sign(-[a-zA-Z0-9_]+)*\.v1/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.symptom_sign(-[a-zA-Z0-9_]+)*\.v1
constraint
ELEMENT
true
true
false
false
0
1
at0.1
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
at0.2
at0.3
at0.4
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
-
Presence
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
-
Chest symptom
openEHR-EHR-CLUSTER.symptom_sign-cvid.v0
First occurrence
This is the first ever occurrence of this symptom or sign.
Recurrence
This is the first ever occurrence of this symptom or sign.
Character
Word or short phrase describing the nature of the symptom or sign.
For example: pain could be described as 'gnawing', 'burning', or 'like an electric shock'; a headache could be 'throbbing' or 'constant'. Coding with an external terminology is preferred, where possible.
Chest symptom
Symptoms known to be indicators of suspected Covid-19 infection
Presence
Is the symptom present or not?
Present
The symptom is present.
Absent
The symptom is absent.
Unknown
It is not known if the symptom is present.
Symptom/Sign name
The name of the reported symptom or sign.
Symptom name should be coded with a terminology, where possible.
Symptom/Sign
Reported observation of a physical or mental disturbance in an individual.
Symptom/Sign name
The name of the reported symptom or sign.
Symptom name should be coded with a terminology, where possible.
Description
Narrative description about the reported symptom or sign.
Pattern
Narrative description about the pattern of the symptom or sign during this episode.
For example: pain could be described as constant or intermittent.
Effect
Perceived effect of the modifying factor on the symptom or sign.
Modifying factor
Detail about how a specific factor effects the identified symptom or sign during this episode.
Factor
Name of the modifying factor.
Examples of modifying factor: lying on multiple pillows, eating or administration of a specific medication.
Severity category
Category representing the overall severity of the symptom or sign.
Defining values such as mild, moderate or severe in such a way that is applicable to multiple symptoms or signs plus allows multiple users to interpret and record them consistently is not easy. Some organisations extend the value set further with inclusion of additional values such as 'Trivial' and 'Very severe', and/or 'Mild-Moderate' and 'Moderate-Severe', adds to the definitional difficulty and may also worsen inter-recorder reliability issues. Use of 'Life-threatening' and 'Fatal' is also often considered as part of this value set, although from a pure point of view it may actually reflect an outcome rather than a severity. In view of the above, keeping to a well-defined but smaller list is preferred and so the mild/moderate/severe value set is offered, however the choice of other text allows for other value sets to be included at this data element in a template. Note: more specific grading of severity can be recorded using the 'Specific details' SLOT.
Mild
The intensity of the symptom or sign does not cause interference with normal activity.
Moderate
The intensity of the symptom or sign causes interference with normal activity.
Severe
The intensity of the symptom or sign causes prevents normal activity.
Severity rating
Numerical rating scale representing the overall severity of the symptom or sign.
Symptom severity can be rated by the individual by recording a score from 0 (ie symptom not present) to 10.0 (ie symptom is as severe as the individual can imagine). This score can be represented in the user interface as a visual analogue scale. The data element has occurrences set to 0..* to allow for variations such as 'maximal severity' or 'average severity' to be included in a template.
Duration
The duration of this episode of the symptom or sign since onset.
If 'Date/time of onset' and 'Date/time of resolution' are used in systems, this data element may be calculated, or alternatively, be considered redundant in this scenario.
Number of previous episodes
The number of times this symptom or sign has previously occurred.
Nil significant
The identified symptom or sign was reported as not being present to any significant degree.
Record as True if the subject of care has reported the symptom as not significant. For example: if the individual has never experienced the symptom it is appropriate to record 'nil significant'; or if the individual commonly experiences the symptom, in some circumstances it may be considered appropriate to record 'nil significant' if the individual has experienced no deviation from their 'normal' baseline.
Episode description
Narrative description about the course of the symptom or sign during this episode.
For example: a text description of the immediate onset of the symptom, activities that worsened or relieved the symptom, whether it is improving or worsening and how it resolved over weeks.
Description
Narrative description of the effect of the modifying factor on the symptom or sign.
Description of previous episodes
Narrative description of any or all previous episodes.
For example: frequency/periodicity - per hour, day, week, month, year; and regularity. May include a comparison to this episode.
Associated symptom/sign
Structured details about any associated symptoms or signs that are concurrent.
In linked clinical systems, it is possible that associated symptoms or signs are already recorded within the EHR. Systems can allow the clinician to LINK to relevant associated symptoms/signs. However in a system or message without LINKs to existing data or with a new patient, additional instances of the symptom archetype could be included here to represent associated symptoms/signs.
Previous episodes
Structured details of the symptom or sign during a previous episode.
In linked clinical systems, it is possible that previous episodes are already recorded within the EHR. Systems can allow the clinician to LINK to relevant previous episodes. However in a system or message without LINKs to existing data or with a new patient, additional instances of the symptom archetype could be included here to represent previous episodes. It is recommended that new instances of the Symptom archetype inserted in this SLOT represent one or many previous episodes to this Symptom instance only.
Structured body site
Structured body site where the symptom or sign was reported.
If the anatomical location is included in the Symptom name via precoordinated codes, use of this SLOT becomes redundant. If the anatomical location is recorded using the 'Body site' data element, then use of CLUSTER archetypes in this SLOT is not allowed - record only the simple 'Body site' OR 'Structured body site', but not both.
Body site
Simple body site where the symptom or sign was reported.
Occurrences of this data element are set to 0..* to allow multiple body sites to be separated out in a template if desired. This allows for representation of clinical scenarios where a symptom or sign needs to be recorded in multiple locations or identifying both the originating and distal site in pain radiation, but where all of the other attributes such as impact and duration are identical. If the requirements for recording the body site are determined at run-time by the application or require more complex modelling such as relative locations then use the CLUSTER.anatomical_location or CLUSTER.relative_location within the Detailed anatomical location' SLOT in this archetype.
If the anatomical location is included in the Symptom name via precoordinated codes, this data element becomes redundant. If the anatomical location is recorded using the 'Structured body site' SLOT, then use of this data element is not allowed - record only the simple 'Body site' OR 'Structured body site', but not both.
Episode onset
The onset for this episode of the symptom or sign.
While partial dates are permitted, the exact date and time of onset can be recorded, if appropriate. If this symptom or sign is experienced for the first time or is a re-occurrence, this date is used to represent the onset of this episode. If this symptom or sign is ongoing, this data element may be redundant if it has been recorded previously.
Specific details
Specific data elements that are additionally required to record as unique attributes of the identified symptom or sign.
For example: CTCAE grading.
Factor detail
Structured detail about the factor associated with the identified symptom or sign.
Impact
Description of the impact of this symptom or sign.
Assessment of impact could consider the severity, duration and frequency of the symptom as well as the type of impact including, but not limited to, functional, social and emotional impact. Occurrences of this data element are set to 0..* to allow multiple types of impact to be separated out in a template if desired. Examples for functional impact from hearing loss may include: 'Difficulty Hearing in Quiet Environment'; 'Difficulty Hearing the TV or Radio'; 'Difficulty Hearing Group Conversation'; and 'Difficulty Hearing on Phone'.
No effect
The factor has no impact on the symptom or sign.
Worsens
The factor increases the severity or impact of the symptom or sign.
Relieves
The factor decreases the severity or impact of the symptom or sign, but does not fully resolve it.
Resolution date/time
The timing of the cessation of this episode of the symptom or sign.
If 'Date/time of onset' and 'Duration' are used in systems, this data element may be calculated, or alternatively, considered redundant. While partial dates are permitted, the exact date and time of resolution can be recorded, if appropriate.
Comment
Additional narrative about the symptom or sign not captured in other fields.
Onset type
Description of the onset of the symptom or sign.
The type of the onset can be coded with a terminology, if desired. For example: gradual; or sudden.
Precipitating/resolving factor
Details about specified factors that are associated with the precipitation or resolution of the symptom or sign.
For example: onset of headache occurred one week prior to menstruation; or onset of headache occurred one hour after fall of bicycle.
Precipitating factor
Identification of factors or events that trigger the onset or commencement of the symptom or sign.
Resolving factor
Identification of factors or events that trigger resolution or cessation of the symptom or sign.
Factor
Name of the health event, symptom, reported sign or other factor.
For example: onset of another symptom; onset of menstruation; or fall off bicycle.
Time interval
The interval of time between the occurrence or onset of the factor and onset/resolution of the symptom or sign.
Episodicity
Category of this episode for the identified symptom or sign.
New
A new episode of the symptom or sign - either the first ever occurrence or a reoccurrence where the previous episode had completely resolved.
Indeterminate
It is not possible to determine if this occurrence of the symptom or sign is new or ongoing.
Ongoing
This symptom or sign is ongoing, effectively a single, continuous episode.
Progression
Description progression of the symptom or sign at the time of reporting.
Occurrences of this data element are set to 0..* to allow multiple types of progression to be separated out in a template if desired - for example, severity or frequency.
Improving
The severity of the symptom or sign has improved overall during this episode.
Unchanged
The severity of the symptom or sign has not changed overall during this episode.
Worsening
The severity of the symptom or sign has worsened overall during this episode.
Resolved
The severity of the symptom or sign has resolved.
Description
Narrative description about the effect of the factor on the identified symptom or sign.
First ever?
Is this the first ever occurrence of this symptom or sign?
Record as True if this is the first ever occurrence of this symptom or sign.
Chest pain
Shortness of breath
SNOMED-CT
[SNOMED-CT::418799008]
SNOMED-CT
[SNOMED-CT::418799008]
SNOMED-CT
[SNOMED-CT::162408000]
SNOMED-CT
[SNOMED-CT::162465004]
SNOMED-CT
[SNOMED-CT::162468002]
SNOMED-CT
[SNOMED-CT::162469005]
SNOMED-CT
[SNOMED-CT::162470006]
SNOMED-CT
[SNOMED-CT::162442009]
CLUSTER
true
false
false
true
0
at0000.1
items
true
true
false
false
1
1
false
ELEMENT
true
true
false
false
1
1
at0001.1
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
21522001
62315008
16932000
74474003
CLUSTER
true
false
false
true
0
at0147
archetype_id/value matches {/openEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER.anatomical_location_circle(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.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_circle(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[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
at0153
archetype_id/value matches {/.*/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
.*
constraint
CLUSTER
true
false
false
true
0
at0146
archetype_id/value matches {/openEHR-EHR-CLUSTER\.symptom_sign(-[a-zA-Z0-9_]+)*\.v1/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.symptom_sign(-[a-zA-Z0-9_]+)*\.v1
constraint
CLUSTER
true
false
false
true
0
at0063
archetype_id/value matches {/openEHR-EHR-CLUSTER\.symptom_sign(-[a-zA-Z0-9_]+)*\.v1/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.symptom_sign(-[a-zA-Z0-9_]+)*\.v1
constraint
ELEMENT
true
true
false
false
0
1
at0.1
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
at0.2
at0.3
at0.4
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
-
Presence
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
-
Abdomen symptom
openEHR-EHR-CLUSTER.symptom_sign-cvid.v0
First occurrence
This is the first ever occurrence of this symptom or sign.
Recurrence
This is the first ever occurrence of this symptom or sign.
Character
Word or short phrase describing the nature of the symptom or sign.
For example: pain could be described as 'gnawing', 'burning', or 'like an electric shock'; a headache could be 'throbbing' or 'constant'. Coding with an external terminology is preferred, where possible.
Abdomen symptom
Symptoms known to be indicators of suspected Covid-19 infection
Presence
Is the symptom present or not?
Present
The symptom is present.
Absent
The symptom is absent.
Unknown
It is not known if the symptom is present.
Symptom/Sign name
The name of the reported symptom or sign.
Symptom name should be coded with a terminology, where possible.
Symptom/Sign
Reported observation of a physical or mental disturbance in an individual.
Symptom/Sign name
The name of the reported symptom or sign.
Symptom name should be coded with a terminology, where possible.
Description
Narrative description about the reported symptom or sign.
Pattern
Narrative description about the pattern of the symptom or sign during this episode.
For example: pain could be described as constant or intermittent.
Effect
Perceived effect of the modifying factor on the symptom or sign.
Modifying factor
Detail about how a specific factor effects the identified symptom or sign during this episode.
Factor
Name of the modifying factor.
Examples of modifying factor: lying on multiple pillows, eating or administration of a specific medication.
Severity category
Category representing the overall severity of the symptom or sign.
Defining values such as mild, moderate or severe in such a way that is applicable to multiple symptoms or signs plus allows multiple users to interpret and record them consistently is not easy. Some organisations extend the value set further with inclusion of additional values such as 'Trivial' and 'Very severe', and/or 'Mild-Moderate' and 'Moderate-Severe', adds to the definitional difficulty and may also worsen inter-recorder reliability issues. Use of 'Life-threatening' and 'Fatal' is also often considered as part of this value set, although from a pure point of view it may actually reflect an outcome rather than a severity. In view of the above, keeping to a well-defined but smaller list is preferred and so the mild/moderate/severe value set is offered, however the choice of other text allows for other value sets to be included at this data element in a template. Note: more specific grading of severity can be recorded using the 'Specific details' SLOT.
Mild
The intensity of the symptom or sign does not cause interference with normal activity.
Moderate
The intensity of the symptom or sign causes interference with normal activity.
Severe
The intensity of the symptom or sign causes prevents normal activity.
Severity rating
Numerical rating scale representing the overall severity of the symptom or sign.
Symptom severity can be rated by the individual by recording a score from 0 (ie symptom not present) to 10.0 (ie symptom is as severe as the individual can imagine). This score can be represented in the user interface as a visual analogue scale. The data element has occurrences set to 0..* to allow for variations such as 'maximal severity' or 'average severity' to be included in a template.
Duration
The duration of this episode of the symptom or sign since onset.
If 'Date/time of onset' and 'Date/time of resolution' are used in systems, this data element may be calculated, or alternatively, be considered redundant in this scenario.
Number of previous episodes
The number of times this symptom or sign has previously occurred.
Nil significant
The identified symptom or sign was reported as not being present to any significant degree.
Record as True if the subject of care has reported the symptom as not significant. For example: if the individual has never experienced the symptom it is appropriate to record 'nil significant'; or if the individual commonly experiences the symptom, in some circumstances it may be considered appropriate to record 'nil significant' if the individual has experienced no deviation from their 'normal' baseline.
Episode description
Narrative description about the course of the symptom or sign during this episode.
For example: a text description of the immediate onset of the symptom, activities that worsened or relieved the symptom, whether it is improving or worsening and how it resolved over weeks.
Description
Narrative description of the effect of the modifying factor on the symptom or sign.
Description of previous episodes
Narrative description of any or all previous episodes.
For example: frequency/periodicity - per hour, day, week, month, year; and regularity. May include a comparison to this episode.
Associated symptom/sign
Structured details about any associated symptoms or signs that are concurrent.
In linked clinical systems, it is possible that associated symptoms or signs are already recorded within the EHR. Systems can allow the clinician to LINK to relevant associated symptoms/signs. However in a system or message without LINKs to existing data or with a new patient, additional instances of the symptom archetype could be included here to represent associated symptoms/signs.
Previous episodes
Structured details of the symptom or sign during a previous episode.
In linked clinical systems, it is possible that previous episodes are already recorded within the EHR. Systems can allow the clinician to LINK to relevant previous episodes. However in a system or message without LINKs to existing data or with a new patient, additional instances of the symptom archetype could be included here to represent previous episodes. It is recommended that new instances of the Symptom archetype inserted in this SLOT represent one or many previous episodes to this Symptom instance only.
Structured body site
Structured body site where the symptom or sign was reported.
If the anatomical location is included in the Symptom name via precoordinated codes, use of this SLOT becomes redundant. If the anatomical location is recorded using the 'Body site' data element, then use of CLUSTER archetypes in this SLOT is not allowed - record only the simple 'Body site' OR 'Structured body site', but not both.
Body site
Simple body site where the symptom or sign was reported.
Occurrences of this data element are set to 0..* to allow multiple body sites to be separated out in a template if desired. This allows for representation of clinical scenarios where a symptom or sign needs to be recorded in multiple locations or identifying both the originating and distal site in pain radiation, but where all of the other attributes such as impact and duration are identical. If the requirements for recording the body site are determined at run-time by the application or require more complex modelling such as relative locations then use the CLUSTER.anatomical_location or CLUSTER.relative_location within the Detailed anatomical location' SLOT in this archetype.
If the anatomical location is included in the Symptom name via precoordinated codes, this data element becomes redundant. If the anatomical location is recorded using the 'Structured body site' SLOT, then use of this data element is not allowed - record only the simple 'Body site' OR 'Structured body site', but not both.
Episode onset
The onset for this episode of the symptom or sign.
While partial dates are permitted, the exact date and time of onset can be recorded, if appropriate. If this symptom or sign is experienced for the first time or is a re-occurrence, this date is used to represent the onset of this episode. If this symptom or sign is ongoing, this data element may be redundant if it has been recorded previously.
Specific details
Specific data elements that are additionally required to record as unique attributes of the identified symptom or sign.
For example: CTCAE grading.
Factor detail
Structured detail about the factor associated with the identified symptom or sign.
Impact
Description of the impact of this symptom or sign.
Assessment of impact could consider the severity, duration and frequency of the symptom as well as the type of impact including, but not limited to, functional, social and emotional impact. Occurrences of this data element are set to 0..* to allow multiple types of impact to be separated out in a template if desired. Examples for functional impact from hearing loss may include: 'Difficulty Hearing in Quiet Environment'; 'Difficulty Hearing the TV or Radio'; 'Difficulty Hearing Group Conversation'; and 'Difficulty Hearing on Phone'.
No effect
The factor has no impact on the symptom or sign.
Worsens
The factor increases the severity or impact of the symptom or sign.
Relieves
The factor decreases the severity or impact of the symptom or sign, but does not fully resolve it.
Resolution date/time
The timing of the cessation of this episode of the symptom or sign.
If 'Date/time of onset' and 'Duration' are used in systems, this data element may be calculated, or alternatively, considered redundant. While partial dates are permitted, the exact date and time of resolution can be recorded, if appropriate.
Comment
Additional narrative about the symptom or sign not captured in other fields.
Onset type
Description of the onset of the symptom or sign.
The type of the onset can be coded with a terminology, if desired. For example: gradual; or sudden.
Precipitating/resolving factor
Details about specified factors that are associated with the precipitation or resolution of the symptom or sign.
For example: onset of headache occurred one week prior to menstruation; or onset of headache occurred one hour after fall of bicycle.
Precipitating factor
Identification of factors or events that trigger the onset or commencement of the symptom or sign.
Resolving factor
Identification of factors or events that trigger resolution or cessation of the symptom or sign.
Factor
Name of the health event, symptom, reported sign or other factor.
For example: onset of another symptom; onset of menstruation; or fall off bicycle.
Time interval
The interval of time between the occurrence or onset of the factor and onset/resolution of the symptom or sign.
Episodicity
Category of this episode for the identified symptom or sign.
New
A new episode of the symptom or sign - either the first ever occurrence or a reoccurrence where the previous episode had completely resolved.
Indeterminate
It is not possible to determine if this occurrence of the symptom or sign is new or ongoing.
Ongoing
This symptom or sign is ongoing, effectively a single, continuous episode.
Progression
Description progression of the symptom or sign at the time of reporting.
Occurrences of this data element are set to 0..* to allow multiple types of progression to be separated out in a template if desired - for example, severity or frequency.
Improving
The severity of the symptom or sign has improved overall during this episode.
Unchanged
The severity of the symptom or sign has not changed overall during this episode.
Worsening
The severity of the symptom or sign has worsened overall during this episode.
Resolved
The severity of the symptom or sign has resolved.
Description
Narrative description about the effect of the factor on the identified symptom or sign.
First ever?
Is this the first ever occurrence of this symptom or sign?
Record as True if this is the first ever occurrence of this symptom or sign.
Abdominal pain
Diarrhea
Nausea and vomiting
Bleeding
SNOMED-CT
[SNOMED-CT::418799008]
SNOMED-CT
[SNOMED-CT::418799008]
SNOMED-CT
[SNOMED-CT::162408000]
SNOMED-CT
[SNOMED-CT::162465004]
SNOMED-CT
[SNOMED-CT::162468002]
SNOMED-CT
[SNOMED-CT::162469005]
SNOMED-CT
[SNOMED-CT::162470006]
SNOMED-CT
[SNOMED-CT::162442009]
CLUSTER
true
false
false
true
0
at0000.1
items
true
true
false
false
1
1
false
ELEMENT
true
true
false
false
1
1
at0001.1
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
25064002
91175000
3006004
CLUSTER
true
false
false
true
0
at0147
archetype_id/value matches {/openEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER.anatomical_location_circle(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.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_circle(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[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
at0153
archetype_id/value matches {/.*/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
.*
constraint
CLUSTER
true
false
false
true
0
at0146
archetype_id/value matches {/openEHR-EHR-CLUSTER\.symptom_sign(-[a-zA-Z0-9_]+)*\.v1/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.symptom_sign(-[a-zA-Z0-9_]+)*\.v1
constraint
CLUSTER
true
false
false
true
0
at0063
archetype_id/value matches {/openEHR-EHR-CLUSTER\.symptom_sign(-[a-zA-Z0-9_]+)*\.v1/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.symptom_sign(-[a-zA-Z0-9_]+)*\.v1
constraint
ELEMENT
true
true
false
false
0
1
at0.1
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
at0.2
at0.3
at0.4
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
-
Presence
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
-
Neuro symptom
openEHR-EHR-CLUSTER.symptom_sign-cvid.v0
First occurrence
This is the first ever occurrence of this symptom or sign.
Recurrence
This is the first ever occurrence of this symptom or sign.
Character
Word or short phrase describing the nature of the symptom or sign.
For example: pain could be described as 'gnawing', 'burning', or 'like an electric shock'; a headache could be 'throbbing' or 'constant'. Coding with an external terminology is preferred, where possible.
Neuro symptom
Symptoms known to be indicators of suspected Covid-19 infection
Presence
Is the symptom present or not?
Present
The symptom is present.
Absent
The symptom is absent.
Unknown
It is not known if the symptom is present.
Symptom/Sign name
The name of the reported symptom or sign.
Symptom name should be coded with a terminology, where possible.
Symptom/Sign
Reported observation of a physical or mental disturbance in an individual.
Symptom/Sign name
The name of the reported symptom or sign.
Symptom name should be coded with a terminology, where possible.
Description
Narrative description about the reported symptom or sign.
Pattern
Narrative description about the pattern of the symptom or sign during this episode.
For example: pain could be described as constant or intermittent.
Effect
Perceived effect of the modifying factor on the symptom or sign.
Modifying factor
Detail about how a specific factor effects the identified symptom or sign during this episode.
Factor
Name of the modifying factor.
Examples of modifying factor: lying on multiple pillows, eating or administration of a specific medication.
Severity category
Category representing the overall severity of the symptom or sign.
Defining values such as mild, moderate or severe in such a way that is applicable to multiple symptoms or signs plus allows multiple users to interpret and record them consistently is not easy. Some organisations extend the value set further with inclusion of additional values such as 'Trivial' and 'Very severe', and/or 'Mild-Moderate' and 'Moderate-Severe', adds to the definitional difficulty and may also worsen inter-recorder reliability issues. Use of 'Life-threatening' and 'Fatal' is also often considered as part of this value set, although from a pure point of view it may actually reflect an outcome rather than a severity. In view of the above, keeping to a well-defined but smaller list is preferred and so the mild/moderate/severe value set is offered, however the choice of other text allows for other value sets to be included at this data element in a template. Note: more specific grading of severity can be recorded using the 'Specific details' SLOT.
Mild
The intensity of the symptom or sign does not cause interference with normal activity.
Moderate
The intensity of the symptom or sign causes interference with normal activity.
Severe
The intensity of the symptom or sign causes prevents normal activity.
Severity rating
Numerical rating scale representing the overall severity of the symptom or sign.
Symptom severity can be rated by the individual by recording a score from 0 (ie symptom not present) to 10.0 (ie symptom is as severe as the individual can imagine). This score can be represented in the user interface as a visual analogue scale. The data element has occurrences set to 0..* to allow for variations such as 'maximal severity' or 'average severity' to be included in a template.
Duration
The duration of this episode of the symptom or sign since onset.
If 'Date/time of onset' and 'Date/time of resolution' are used in systems, this data element may be calculated, or alternatively, be considered redundant in this scenario.
Number of previous episodes
The number of times this symptom or sign has previously occurred.
Nil significant
The identified symptom or sign was reported as not being present to any significant degree.
Record as True if the subject of care has reported the symptom as not significant. For example: if the individual has never experienced the symptom it is appropriate to record 'nil significant'; or if the individual commonly experiences the symptom, in some circumstances it may be considered appropriate to record 'nil significant' if the individual has experienced no deviation from their 'normal' baseline.
Episode description
Narrative description about the course of the symptom or sign during this episode.
For example: a text description of the immediate onset of the symptom, activities that worsened or relieved the symptom, whether it is improving or worsening and how it resolved over weeks.
Description
Narrative description of the effect of the modifying factor on the symptom or sign.
Description of previous episodes
Narrative description of any or all previous episodes.
For example: frequency/periodicity - per hour, day, week, month, year; and regularity. May include a comparison to this episode.
Associated symptom/sign
Structured details about any associated symptoms or signs that are concurrent.
In linked clinical systems, it is possible that associated symptoms or signs are already recorded within the EHR. Systems can allow the clinician to LINK to relevant associated symptoms/signs. However in a system or message without LINKs to existing data or with a new patient, additional instances of the symptom archetype could be included here to represent associated symptoms/signs.
Previous episodes
Structured details of the symptom or sign during a previous episode.
In linked clinical systems, it is possible that previous episodes are already recorded within the EHR. Systems can allow the clinician to LINK to relevant previous episodes. However in a system or message without LINKs to existing data or with a new patient, additional instances of the symptom archetype could be included here to represent previous episodes. It is recommended that new instances of the Symptom archetype inserted in this SLOT represent one or many previous episodes to this Symptom instance only.
Structured body site
Structured body site where the symptom or sign was reported.
If the anatomical location is included in the Symptom name via precoordinated codes, use of this SLOT becomes redundant. If the anatomical location is recorded using the 'Body site' data element, then use of CLUSTER archetypes in this SLOT is not allowed - record only the simple 'Body site' OR 'Structured body site', but not both.
Body site
Simple body site where the symptom or sign was reported.
Occurrences of this data element are set to 0..* to allow multiple body sites to be separated out in a template if desired. This allows for representation of clinical scenarios where a symptom or sign needs to be recorded in multiple locations or identifying both the originating and distal site in pain radiation, but where all of the other attributes such as impact and duration are identical. If the requirements for recording the body site are determined at run-time by the application or require more complex modelling such as relative locations then use the CLUSTER.anatomical_location or CLUSTER.relative_location within the Detailed anatomical location' SLOT in this archetype.
If the anatomical location is included in the Symptom name via precoordinated codes, this data element becomes redundant. If the anatomical location is recorded using the 'Structured body site' SLOT, then use of this data element is not allowed - record only the simple 'Body site' OR 'Structured body site', but not both.
Episode onset
The onset for this episode of the symptom or sign.
While partial dates are permitted, the exact date and time of onset can be recorded, if appropriate. If this symptom or sign is experienced for the first time or is a re-occurrence, this date is used to represent the onset of this episode. If this symptom or sign is ongoing, this data element may be redundant if it has been recorded previously.
Specific details
Specific data elements that are additionally required to record as unique attributes of the identified symptom or sign.
For example: CTCAE grading.
Factor detail
Structured detail about the factor associated with the identified symptom or sign.
Impact
Description of the impact of this symptom or sign.
Assessment of impact could consider the severity, duration and frequency of the symptom as well as the type of impact including, but not limited to, functional, social and emotional impact. Occurrences of this data element are set to 0..* to allow multiple types of impact to be separated out in a template if desired. Examples for functional impact from hearing loss may include: 'Difficulty Hearing in Quiet Environment'; 'Difficulty Hearing the TV or Radio'; 'Difficulty Hearing Group Conversation'; and 'Difficulty Hearing on Phone'.
No effect
The factor has no impact on the symptom or sign.
Worsens
The factor increases the severity or impact of the symptom or sign.
Relieves
The factor decreases the severity or impact of the symptom or sign, but does not fully resolve it.
Resolution date/time
The timing of the cessation of this episode of the symptom or sign.
If 'Date/time of onset' and 'Duration' are used in systems, this data element may be calculated, or alternatively, considered redundant. While partial dates are permitted, the exact date and time of resolution can be recorded, if appropriate.
Comment
Additional narrative about the symptom or sign not captured in other fields.
Onset type
Description of the onset of the symptom or sign.
The type of the onset can be coded with a terminology, if desired. For example: gradual; or sudden.
Precipitating/resolving factor
Details about specified factors that are associated with the precipitation or resolution of the symptom or sign.
For example: onset of headache occurred one week prior to menstruation; or onset of headache occurred one hour after fall of bicycle.
Precipitating factor
Identification of factors or events that trigger the onset or commencement of the symptom or sign.
Resolving factor
Identification of factors or events that trigger resolution or cessation of the symptom or sign.
Factor
Name of the health event, symptom, reported sign or other factor.
For example: onset of another symptom; onset of menstruation; or fall off bicycle.
Time interval
The interval of time between the occurrence or onset of the factor and onset/resolution of the symptom or sign.
Episodicity
Category of this episode for the identified symptom or sign.
New
A new episode of the symptom or sign - either the first ever occurrence or a reoccurrence where the previous episode had completely resolved.
Indeterminate
It is not possible to determine if this occurrence of the symptom or sign is new or ongoing.
Ongoing
This symptom or sign is ongoing, effectively a single, continuous episode.
Progression
Description progression of the symptom or sign at the time of reporting.
Occurrences of this data element are set to 0..* to allow multiple types of progression to be separated out in a template if desired - for example, severity or frequency.
Improving
The severity of the symptom or sign has improved overall during this episode.
Unchanged
The severity of the symptom or sign has not changed overall during this episode.
Worsening
The severity of the symptom or sign has worsened overall during this episode.
Resolved
The severity of the symptom or sign has resolved.
Description
Narrative description about the effect of the factor on the identified symptom or sign.
First ever?
Is this the first ever occurrence of this symptom or sign?
Record as True if this is the first ever occurrence of this symptom or sign.
Headache
Seizures
Altered consciousness
SNOMED-CT
[SNOMED-CT::418799008]
SNOMED-CT
[SNOMED-CT::418799008]
SNOMED-CT
[SNOMED-CT::162408000]
SNOMED-CT
[SNOMED-CT::162465004]
SNOMED-CT
[SNOMED-CT::162468002]
SNOMED-CT
[SNOMED-CT::162469005]
SNOMED-CT
[SNOMED-CT::162470006]
SNOMED-CT
[SNOMED-CT::162442009]
CLUSTER
true
false
false
true
0
at0000.1
items
true
true
false
false
1
1
false
ELEMENT
true
true
false
false
1
1
at0001.1
value
true
true
false
false
0
1
false
DV_TEXT
true
true
false
false
1
1
CLUSTER
true
false
false
true
0
at0147
archetype_id/value matches {/openEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER.anatomical_location_circle(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.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_circle(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[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
at0153
archetype_id/value matches {/.*/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
.*
constraint
CLUSTER
true
false
false
true
0
at0146
archetype_id/value matches {/openEHR-EHR-CLUSTER\.symptom_sign(-[a-zA-Z0-9_]+)*\.v1/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.symptom_sign(-[a-zA-Z0-9_]+)*\.v1
constraint
CLUSTER
true
false
false
true
0
at0063
archetype_id/value matches {/openEHR-EHR-CLUSTER\.symptom_sign(-[a-zA-Z0-9_]+)*\.v1/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.symptom_sign(-[a-zA-Z0-9_]+)*\.v1
constraint
ELEMENT
true
true
false
false
0
1
at0.1
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
at0.2
at0.3
at0.4
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
-
Presence
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
-
Other symptom
openEHR-EHR-CLUSTER.symptom_sign-cvid.v0
First occurrence
This is the first ever occurrence of this symptom or sign.
Recurrence
This is the first ever occurrence of this symptom or sign.
Character
Word or short phrase describing the nature of the symptom or sign.
For example: pain could be described as 'gnawing', 'burning', or 'like an electric shock'; a headache could be 'throbbing' or 'constant'. Coding with an external terminology is preferred, where possible.
Other symptom
Symptoms known to be indicators of suspected Covid-19 infection
Presence
Is the symptom present or not?
Present
The symptom is present.
Absent
The symptom is absent.
Unknown
It is not known if the symptom is present.
Symptom/Sign name
The name of the reported symptom or sign.
Symptom name should be coded with a terminology, where possible.
Symptom/Sign
Reported observation of a physical or mental disturbance in an individual.
Symptom/Sign name
The name of the reported symptom or sign.
Symptom name should be coded with a terminology, where possible.
Description
Narrative description about the reported symptom or sign.
Pattern
Narrative description about the pattern of the symptom or sign during this episode.
For example: pain could be described as constant or intermittent.
Effect
Perceived effect of the modifying factor on the symptom or sign.
Modifying factor
Detail about how a specific factor effects the identified symptom or sign during this episode.
Factor
Name of the modifying factor.
Examples of modifying factor: lying on multiple pillows, eating or administration of a specific medication.
Severity category
Category representing the overall severity of the symptom or sign.
Defining values such as mild, moderate or severe in such a way that is applicable to multiple symptoms or signs plus allows multiple users to interpret and record them consistently is not easy. Some organisations extend the value set further with inclusion of additional values such as 'Trivial' and 'Very severe', and/or 'Mild-Moderate' and 'Moderate-Severe', adds to the definitional difficulty and may also worsen inter-recorder reliability issues. Use of 'Life-threatening' and 'Fatal' is also often considered as part of this value set, although from a pure point of view it may actually reflect an outcome rather than a severity. In view of the above, keeping to a well-defined but smaller list is preferred and so the mild/moderate/severe value set is offered, however the choice of other text allows for other value sets to be included at this data element in a template. Note: more specific grading of severity can be recorded using the 'Specific details' SLOT.
Mild
The intensity of the symptom or sign does not cause interference with normal activity.
Moderate
The intensity of the symptom or sign causes interference with normal activity.
Severe
The intensity of the symptom or sign causes prevents normal activity.
Severity rating
Numerical rating scale representing the overall severity of the symptom or sign.
Symptom severity can be rated by the individual by recording a score from 0 (ie symptom not present) to 10.0 (ie symptom is as severe as the individual can imagine). This score can be represented in the user interface as a visual analogue scale. The data element has occurrences set to 0..* to allow for variations such as 'maximal severity' or 'average severity' to be included in a template.
Duration
The duration of this episode of the symptom or sign since onset.
If 'Date/time of onset' and 'Date/time of resolution' are used in systems, this data element may be calculated, or alternatively, be considered redundant in this scenario.
Number of previous episodes
The number of times this symptom or sign has previously occurred.
Nil significant
The identified symptom or sign was reported as not being present to any significant degree.
Record as True if the subject of care has reported the symptom as not significant. For example: if the individual has never experienced the symptom it is appropriate to record 'nil significant'; or if the individual commonly experiences the symptom, in some circumstances it may be considered appropriate to record 'nil significant' if the individual has experienced no deviation from their 'normal' baseline.
Episode description
Narrative description about the course of the symptom or sign during this episode.
For example: a text description of the immediate onset of the symptom, activities that worsened or relieved the symptom, whether it is improving or worsening and how it resolved over weeks.
Description
Narrative description of the effect of the modifying factor on the symptom or sign.
Description of previous episodes
Narrative description of any or all previous episodes.
For example: frequency/periodicity - per hour, day, week, month, year; and regularity. May include a comparison to this episode.
Associated symptom/sign
Structured details about any associated symptoms or signs that are concurrent.
In linked clinical systems, it is possible that associated symptoms or signs are already recorded within the EHR. Systems can allow the clinician to LINK to relevant associated symptoms/signs. However in a system or message without LINKs to existing data or with a new patient, additional instances of the symptom archetype could be included here to represent associated symptoms/signs.
Previous episodes
Structured details of the symptom or sign during a previous episode.
In linked clinical systems, it is possible that previous episodes are already recorded within the EHR. Systems can allow the clinician to LINK to relevant previous episodes. However in a system or message without LINKs to existing data or with a new patient, additional instances of the symptom archetype could be included here to represent previous episodes. It is recommended that new instances of the Symptom archetype inserted in this SLOT represent one or many previous episodes to this Symptom instance only.
Structured body site
Structured body site where the symptom or sign was reported.
If the anatomical location is included in the Symptom name via precoordinated codes, use of this SLOT becomes redundant. If the anatomical location is recorded using the 'Body site' data element, then use of CLUSTER archetypes in this SLOT is not allowed - record only the simple 'Body site' OR 'Structured body site', but not both.
Body site
Simple body site where the symptom or sign was reported.
Occurrences of this data element are set to 0..* to allow multiple body sites to be separated out in a template if desired. This allows for representation of clinical scenarios where a symptom or sign needs to be recorded in multiple locations or identifying both the originating and distal site in pain radiation, but where all of the other attributes such as impact and duration are identical. If the requirements for recording the body site are determined at run-time by the application or require more complex modelling such as relative locations then use the CLUSTER.anatomical_location or CLUSTER.relative_location within the Detailed anatomical location' SLOT in this archetype.
If the anatomical location is included in the Symptom name via precoordinated codes, this data element becomes redundant. If the anatomical location is recorded using the 'Structured body site' SLOT, then use of this data element is not allowed - record only the simple 'Body site' OR 'Structured body site', but not both.
Episode onset
The onset for this episode of the symptom or sign.
While partial dates are permitted, the exact date and time of onset can be recorded, if appropriate. If this symptom or sign is experienced for the first time or is a re-occurrence, this date is used to represent the onset of this episode. If this symptom or sign is ongoing, this data element may be redundant if it has been recorded previously.
Specific details
Specific data elements that are additionally required to record as unique attributes of the identified symptom or sign.
For example: CTCAE grading.
Factor detail
Structured detail about the factor associated with the identified symptom or sign.
Impact
Description of the impact of this symptom or sign.
Assessment of impact could consider the severity, duration and frequency of the symptom as well as the type of impact including, but not limited to, functional, social and emotional impact. Occurrences of this data element are set to 0..* to allow multiple types of impact to be separated out in a template if desired. Examples for functional impact from hearing loss may include: 'Difficulty Hearing in Quiet Environment'; 'Difficulty Hearing the TV or Radio'; 'Difficulty Hearing Group Conversation'; and 'Difficulty Hearing on Phone'.
No effect
The factor has no impact on the symptom or sign.
Worsens
The factor increases the severity or impact of the symptom or sign.
Relieves
The factor decreases the severity or impact of the symptom or sign, but does not fully resolve it.
Resolution date/time
The timing of the cessation of this episode of the symptom or sign.
If 'Date/time of onset' and 'Duration' are used in systems, this data element may be calculated, or alternatively, considered redundant. While partial dates are permitted, the exact date and time of resolution can be recorded, if appropriate.
Comment
Additional narrative about the symptom or sign not captured in other fields.
Onset type
Description of the onset of the symptom or sign.
The type of the onset can be coded with a terminology, if desired. For example: gradual; or sudden.
Precipitating/resolving factor
Details about specified factors that are associated with the precipitation or resolution of the symptom or sign.
For example: onset of headache occurred one week prior to menstruation; or onset of headache occurred one hour after fall of bicycle.
Precipitating factor
Identification of factors or events that trigger the onset or commencement of the symptom or sign.
Resolving factor
Identification of factors or events that trigger resolution or cessation of the symptom or sign.
Factor
Name of the health event, symptom, reported sign or other factor.
For example: onset of another symptom; onset of menstruation; or fall off bicycle.
Time interval
The interval of time between the occurrence or onset of the factor and onset/resolution of the symptom or sign.
Episodicity
Category of this episode for the identified symptom or sign.
New
A new episode of the symptom or sign - either the first ever occurrence or a reoccurrence where the previous episode had completely resolved.
Indeterminate
It is not possible to determine if this occurrence of the symptom or sign is new or ongoing.
Ongoing
This symptom or sign is ongoing, effectively a single, continuous episode.
Progression
Description progression of the symptom or sign at the time of reporting.
Occurrences of this data element are set to 0..* to allow multiple types of progression to be separated out in a template if desired - for example, severity or frequency.
Improving
The severity of the symptom or sign has improved overall during this episode.
Unchanged
The severity of the symptom or sign has not changed overall during this episode.
Worsening
The severity of the symptom or sign has worsened overall during this episode.
Resolved
The severity of the symptom or sign has resolved.
Description
Narrative description about the effect of the factor on the identified symptom or sign.
First ever?
Is this the first ever occurrence of this symptom or sign?
Record as True if this is the first ever occurrence of this symptom or sign.
SNOMED-CT
[SNOMED-CT::418799008]
SNOMED-CT
[SNOMED-CT::418799008]
SNOMED-CT
[SNOMED-CT::162408000]
SNOMED-CT
[SNOMED-CT::162465004]
SNOMED-CT
[SNOMED-CT::162468002]
SNOMED-CT
[SNOMED-CT::162469005]
SNOMED-CT
[SNOMED-CT::162470006]
SNOMED-CT
[SNOMED-CT::162442009]
false
false
true
false
false
true
1
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
false
false
true
0
at0008
archetype_id/value matches {/.*/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
.*
constraint
false
false
true
false
false
true
0
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
-
Covid symptoms
openEHR-EHR-OBSERVATION.story.v1
open_eREACT-Care
Covid symptoms
The subjective clinical history of the subject of care as recorded directly by the subject, or reported to a clinician by the subject or a carer.
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 @
Story
Narrative description of the story or clinical history for the subject of care.
Structured detail
Structured detail about the individual's story or patient's history.
For example: a specific symptom such as nausea or pain; an event such as a fall off a bicycle; or an issue such as a desire to quit using tobacco.
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.
EVALUATION
true
true
false
false
0
1
at0000.1
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
at0002.1
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
at0.1
CLUSTER
true
true
false
false
0
1
at0016
items
true
true
false
false
1
1
false
ELEMENT
true
true
false
false
1
1
at0013.1
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
at0.14
ELEMENT
true
true
false
false
0
1
at0017.1
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
at0018
at0019
at0.15
CLUSTER
true
false
false
true
0
at0027.1
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
-
Care home has suspected/confirmed Covid-19
CLUSTER
true
true
false
false
0
1
at0016
items
true
true
false
false
1
1
false
ELEMENT
true
true
false
false
1
1
at0013.1
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
at0.9
ELEMENT
true
true
false
false
0
1
at0017.1
value
true
true
false
false
0
1
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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
at0018
at0019
at0.15
CLUSTER
true
false
false
true
0
at0027.1
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
-
Contact with confirmed case
CLUSTER
true
true
false
false
0
1
at0016
items
true
true
false
false
1
1
false
ELEMENT
true
true
false
false
1
1
at0013.1
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
at0.19
ELEMENT
true
true
false
false
0
1
at0017.1
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
at0018
at0019
at0.15
CLUSTER
true
false
false
true
0
at0027.1
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
-
Other residents/household members unwell
ELEMENT
true
true
false
false
0
1
at0003.1
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
at0.16
at0.17
true
false
true
false
false
true
1
protocol
true
true
false
false
0
1
false
ITEM_TREE
true
true
false
false
1
1
at0010
items
true
true
false
false
0
1
false
CLUSTER
true
false
false
true
0
at0011
archetype_id/value matches {/.*/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
.*
constraint
false
false
true
false
false
true
0
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
-
Covid-19 exposure
openEHR-EHR-EVALUATION.health_risk-covid.v0
open_eREACT-Care
Covid-19 exposure
Assessment of the potential and likelihood of Covid-19 infection as determined by identified risk factors.
Health risk
Identification of the potential future disease, condition or health issue for which the risk is being assessed, by name.
Coding of 'Health risk' with a terminology is preferred, where possible. Free text should be used only if there is no appropriate terminology available. For example: risk of cardiovascular disease, with risk factors of hypertension and hypercholesterolaemia.
COVID-19 Risk assessment
Assessment of risk of COVID-19 infection.
Risk factor
Identification of the risk factor, by name.
For example: hypertension and hypercholesterolaemia, which may be used as part of the overall assessment for cardiovascular disease; or a genetic marker. Coding of
'Risk factor' with a terminology, where possible.
Contact with confirmed Covid-19 case
Contact with confirmed Covid-19 case within 14 days before symptom onset.
Contact with suspected case/ pneumonia case
Contact with suspected case/ pneumonia case within 14 days before symptom onset.
Contact with birds in China
Contact with birds in China in 10 days before symptom onset.
Contact with confirmed human case of Avian flu in China
Contact with confirmed human case of Avian flu in China in 10 days before symptom onset.
Contact with severe, unexplained respiratory disease
Contact with severe, unexplained respiratory disease in 10 days before symptom onset.
Potential contact exposure based on location
Potential contact exposure based on location.
Detail
Structured detail about other aspects of the risk factor assessment.
For example: Prevalence of the risk factor in family members.
Presence
Presence of the risk factor.
Unknown
No information is available for this risk factor.
Risk assessment
Evaluation of the health risk.
There may be multiple variations on the assessment of risk. The Choice data type allows for recording of the assessment as either free text or value sets (such as low, medium or hig). The proportion data type allows recording of a percentage, a ratio or a fraction. The quantity data type allows recording of a decimal number.
Low risk
The risk of the a patient having a Covid-19 infection is assessed to be low.
High risk
The risk of the a patient having a Covid-19 infection is assessed to be high.
Needs admission for respiratory disease
Does the patient require hospital admission with either clinical or radiological evidence of pneumonia, adult respiratory distress syndrome, or influenza like illness?
Other household members are ill
The patient is in a house with other household members who are ill
Household members with travel exposure
Members of the patient's household have travel exposure.
Health risk assessment
Assessment of the potential and likelihood of future adverse health effects as determined by identified risk factors.
structure
@ internal @
Health risk
Identification of the potential future disease, condition or health issue for which the risk is being assessed, by name.
Coding of 'Health risk' with a terminology is preferred, where possible. Free text should be used only if there is no appropriate terminology available. For example: risk of cardiovascular disease, with risk factors of hypertension and hypercholesterolaemia.
Risk assessment
Evaluation of the health risk.
There may be multiple variations on the assessment of risk. The Choice data type allows for recording of the assessment as either free text or value sets (such as low, medium or hig). The proportion data type allows recording of a percentage, a ratio or a fraction. The quantity data type allows recording of a decimal number.
Rationale
Justification for this risk assessment.
Details that may be added to this data element may include information about the population subgroups etc against which the determination of risk is assessed.
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.
Link to evidence
Identification of the path to the archetype or data node for the evidence of risk.
Risk factor
Identification of the risk factor, by name.
For example: hypertension and hypercholesterolaemia, which may be used as part of the overall assessment for cardiovascular disease; or a genetic marker. Coding of
'Risk factor' with a terminology, where possible.
Description
Narrative description about the risk factor.
Comment
Additional narrative about the risk assessment not captured in other fields.
Other household members travel exposure
Details about each possible risk factor.
Presence
Presence of the risk factor.
Present
The risk factor has been identified for this individual.
Absent
The risk factor has not been identified for this individual.
Assessment type
Record of whether the risk assessment is a relative or absolute.
Relative risk
Ratio of probability of a health event or condition occurring compared to a population with similar characteristics eg same age and sex.
Absolute risk
Ratio of probability of a health event or condition occurring compared to the population as a whole.
Time period
The time period during which the predicted health risk is relevant.
That is: the risk of experiencing the identified 'Health risk' in the next <X> years.
Last updated
The date this health risk assessment was last updated.
This data element may be thought redundant if the data is recorded and stored using COMPOSITIONs within a closed clinical system. However if this information is extracted from its original COMPOSITION context, for example, to be included in another document or message then the temporal context is effectively removed. This 'Last updated' data element has been explicitly added to allow the critical temporal data to be kept alongside the clinical data in all circumstances. It is assumed that the clinical system can copy the date from the COMPOSITION to reduce the need for duplication of data entry by the clinician.
Assessment method
Identification of the algorithm or guideline used to make the assessment of risk.
For example: Framingham cardiovascular risk calculator.
Indeterminate
It is not possible to determine if the risk factor is present or absent.
Detail
Structured detail about other aspects of the risk factor assessment.
For example: Prevalence of the risk factor in family members.
Mitigated
The risk factor has been identified as present, but then subsequently been mitigated by treatment or investigation.
Record as True if the risk factor has been treated or investigated and risk from this risk factor is considered to be lessened. For example: an infant given gentamicin in neonatal intensive care is regarded as having a risk of permanent hearing loss. If diagnostic testing shows no evidence of hearing loss in the first year of life, the risk of later hearing loss is considered to be much reduced, but still possible. This data element allows clinicians to say that the risk has been mitigated but should still be considered as a possibility in future. In practice, the risk factor could be maintained in the risk assessment in case it might impact the individual's health at a future time, but flagging that its contribution to risk calculation may not be as great as if it had not been previously treated or investigated.
Date identified
The date/time that the risk factor was identified.
Comment
Additional narrative about the risk factor 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
false
POINT_EVENT
true
true
false
false
0
1
at0002
data
true
true
false
false
1
1
false
ITEM_TREE
true
true
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1
1
at0003
items
true
true
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false
0
1
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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_]+)*\.v0|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_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen(-[a-zA-Z0-9_]+)*\.v1
constraint
ELEMENT
true
true
false
false
0
1
at0073
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
at0037
at0120
at0038
at0040
at0115
at0119
at0074
at0116
DV_TEXT
true
true
false
false
1
1
CLUSTER
true
false
false
true
0
at0097
archetype_id/value matches {/openEHR-EHR-CLUSTER\.laboratory_test_analyte(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.laboratory_test_analyte(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.laboratory_test_panel(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.laboratory_test_panel(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.histopathology_findings(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.histopathology_findings(-[a-zA-Z0-9_]+)*\.v1/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.laboratory_test_analyte(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.laboratory_test_analyte(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.laboratory_test_panel(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.laboratory_test_panel(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.histopathology_findings(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.histopathology_findings(-[a-zA-Z0-9_]+)*\.v1
constraint
ELEMENT
true
true
false
false
0
1
at0098
value
true
true
false
false
0
1
false
DV_TEXT
true
true
false
false
1
1
value
true
true
false
false
1
1
false
STRING
true
true
false
false
0
1
-
Positive
Negative
Awaited
Unknown
Not tested
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\.multimedia(-[a-zA-Z0-9_]+)*\.v1/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1
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
at0094
items
true
true
false
false
1
1
false
CLUSTER
true
true
false
false
0
1
at0090
archetype_id/value matches {/.*/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
.*
constraint
CLUSTER
true
false
false
true
0
at0035
archetype_id/value matches {/openEHR-EHR-CLUSTER\.distribution(-[a-zA-Z0-9_]+)*\.v1/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.distribution(-[a-zA-Z0-9_]+)*\.v1
constraint
false
false
true
false
false
true
1
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
name
true
true
false
false
1
1
false
DV_TEXT
true
true
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false
1
1
value
true
true
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1
1
false
STRING
true
true
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1
1
-
Latest Covid-19 test
openEHR-EHR-OBSERVATION.laboratory_test_result.v1
Latest Covid-19 test
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.
EVALUATION
true
true
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0
1
at0000
data
true
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ITEM_TREE
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1
at0001
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ELEMENT
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at0002
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true
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false
DV_TEXT
true
true
false
false
1
1
true
false
true
false
false
true
1
protocol
true
true
false
false
0
1
false
ITEM_TREE
true
true
false
false
1
1
at0003
items
true
true
false
false
0
1
false
CLUSTER
true
false
false
true
0
at0004
archetype_id/value matches {/.*/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
.*
constraint
false
false
true
false
false
true
0
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
-
Covid notes
openEHR-EHR-EVALUATION.clinical_synopsis.v1
Covid notes
Narrative summary or overview about a patient, specifically from the perspective of a healthcare provider, and with or without associated interpretations.
List
@ internal @
Synopsis
The summary, assessment, conclusions or evaluation of the clinical findings.
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.
false
false
true
false
false
true
0
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
-
Covid
openEHR-EHR-SECTION.adhoc.v1
open_eREACT-Care
Covid
A generic section header which should be renamed in a template to suit a specific clinical context.
SECTION
true
true
false
false
0
1
at0000
items
true
true
false
false
0
1
false
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
true
false
false
0
1
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
127
true
true
false
false
1
1
°C
false
false
true
true
false
false
1
1
state
true
true
false
false
0
1
false
ITEM_TREE
true
true
false
false
1
1
at0029
items
true
true
false
false
0
1
false
CLUSTER
true
true
false
false
0
1
at0056
archetype_id/value matches {/openEHR-EHR-CLUSTER\.environmental_conditions\.v1/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.environmental_conditions\.v1
constraint
CLUSTER
true
true
false
false
0
1
at0057
archetype_id/value matches {/openEHR-EHR-CLUSTER\.level_of_exertion\.v1/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.level_of_exertion\.v1
constraint
ELEMENT
true
true
false
false
0
1
at0058
archetype_id/value matches {/openEHR-EHR-ELEMENT\.last_normal_menstrual_period\.v1|openEHR-EHR-ELEMENT\.menstrual_cycle_day\.v1/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
openEHR-EHR-ELEMENT\.last_normal_menstrual_period\.v1|openEHR-EHR-ELEMENT\.menstrual_cycle_day\.v1
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
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
true
false
true
false
false
true
0
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
-
Temperature
openEHR-EHR-OBSERVATION.body_temperature.v1
Temperature
A measurement of the body temperature, which is a surrogate for the whole body temperature of the person.
Tree
@ internal @
History
@ internal @
Any event
Any event.
Temperature
The measured body temperature (as a surrogate for the whole body).
Protocol
@ internal @
Site of measurement
The anatomical site of measurement of the temperature.
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 thermal situation of the person who is having the temperature taken.
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
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.
Menstrual Cycle
Details about the menstrual cycle of a woman.
Device
Details about the device use to measure body temperature.
LNC205
[LNC205::8310-5]
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
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
at0002
events
true
true
false
false
0
1
false
POINT_EVENT
true
true
false
false
0
1
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
0
1
at0004
name
true
true
false
false
1
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
at1026
value
true
true
false
false
1
1
false
STRING
true
true
false
false
1
1
-
Pulse Rate
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
0
0
/min
false
false
true
false
false
true
0
state
true
true
false
false
0
1
false
ITEM_TREE
true
true
false
false
1
1
at0012
items
true
true
false
false
0
1
false
CLUSTER
true
false
false
true
0
at1017
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
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
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
-
Pulse
openEHR-EHR-OBSERVATION.pulse.v1
Pulse
Record details about 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, measured in beats per minute.
Run-time name constraints have been specified, in order to simplify the renaming of this data element to Pulse Rate or Heart Rate, as required.
Regular?
Is the pulse or heart beat regular?
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 is present if Rate >0 beats/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.
Pulse Rate
The pulse rate, measured in beats per minute.
Heart Rate
The heart rate, measured in beats per minute.
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.
Pulse presence
Presence of a pulse.
Heart beat presence
Presence of a heart beat.
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
false
POINT_EVENT
true
true
false
false
0
1
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
at0004
value
true
true
false
false
0
1
false
DV_QUANTITY
true
true
false
false
1
1
openehr
382
true
true
false
false
0.0
200.0
true
true
false
false
0
0
/min
false
false
true
false
false
true
0
state
true
true
false
false
0
1
false
ITEM_TREE
true
true
false
false
1
1
at0022
items
true
true
false
false
0
1
false
CLUSTER
true
true
false
false
0
1
at0055
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
CLUSTER
true
true
false
false
0
1
at0037
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
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
at0057
items
true
true
false
false
0
1
false
CLUSTER
true
false
false
true
0
at0058
archetype_id/value matches {/.*/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
.*
constraint
false
false
true
false
false
true
0
openEHR-EHR-OBSERVATION.respiration.v1
Respirations
The observed characteristics of spontaneous breathing as would commonly be recorded as part of a 'vital signs' examination.
history
@ internal @
Any event
Generic event.
List
@ internal @
Rate
Rate of respiration.
Rhythm
Rhythm of respiration.
Regular
Regular respiration.
Irregular
Irregular respirations.
Clinical interpretation
Respiratory pattern or single word, phrase or brief description which represents the clinical meaning and significance of the measurements.
Kussmaul's respiration
Deep chest breathing with or without a visible gasp.
Depth
Depth of respiration.
Normal
Normal depth of breathing.
Shallow
Shallow depth of breathing.
Deep
Deep breathing.
List
@ internal @
Description
A text description of respirations.
Variable
Variable depth of breathing.
Cheyne-Stokes respiration
Periods of hyperventilation alternating with periods of apnoea.
Ataxic respiration
Breathing of varying tidal volumes and rates.
Apneustic respiration
Deep, gasping inspiration with a pause at full inspiration followed by a brief, insufficient release of breath.
Cluster breathing
Clusters of irregular breaths that alternate with periods of apnoea. Also termed Biot's breathing.
Exertion
Subject's level of exertion at or just prior to the observation being made. Intended only to record exertion only as it might effect respirations and where it would not normally be recorded as part of general clinical observation.
Apnoea
Breathing has ceased.
Prolonged expiratory phase
The respiratory expiratory phase is longer than normal/usual. Associated with obstructive airways disease such as asthma.
Inspired oxygen
Details of the amount of oxygen being delivered 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 contributing to the respirations observation. For example, level of anxiety, pain, feeding in infants, tracheostomy.
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 HL7 or CDISC equivalents.
Tachypnoea
Abnormally rapid breathing.
Bradypnoea
Abnormally slow breathing.
Normal
Normal breathing pattern.
OBSERVATION
true
true
false
false
0
1
at0000
data
true
true
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1
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HISTORY
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at0001
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1
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POINT_EVENT
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1
at0002
data
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1
1
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ITEM_TREE
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1
1
at0003
items
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true
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false
0
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ELEMENT
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1
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at0004
value
true
true
false
false
0
1
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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
at0005
at0015
at0006
at0007
at0008
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
at0009
items
true
true
false
false
0
1
false
CLUSTER
true
false
false
true
0
at0011
archetype_id/value matches {/.*/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
.*
constraint
false
false
true
false
false
true
0
openEHR-EHR-OBSERVATION.acvpu.v0
ACVPU scale
Simple scale used as part of an assessment to measure and record an individual's level of consciousness.
ACVPU is an acronym for 'Alert', 'Confusion', 'Voice', 'Pain', 'Unresponsive'.
Event Series
@ internal @
Any point in time event
Default, unspecified point in time event which may be explicitly defined in a template or at run-time.
Tree
@ internal @
ACVPU
The assessment of the patient's level of consciousness.
Alert
Fully awake. Spontaneous opening of the eyes, responds to voice and have motor function.
Voice
Any verbal, motor or eye response to a voice stimulus.
Pain
Any verbal, motor or eye response to a pain stimulus.
Unresponsive
No response to voice or pain stimuli.
Tree
@ internal @
Extension
Additional information required to capture local content or to align with other reference models/formalisms.
e.g. Local information requirements or additional metadata to align with FHIR or CIMI equivalents.
Tree
@ internal @
Confusion
A new onset or worsening confusion, delirium or any other altered mentation.
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
true
false
false
0
1
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
true
true
false
false
1
1
at0001
events
true
true
false
false
0
1
false
POINT_EVENT
true
true
false
false
0
1
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_ORDINAL
true
true
false
false
1
1
3
local
at0021
1
local
at0019
0
local
at0018
2
local
at0020
3
local
at0064
ELEMENT
true
true
false
false
0
1
at0029
value
true
true
false
false
0
1
false
DV_ORDINAL
true
true
false
false
1
1
3
local
at0033
2
local
at0032
1
local
at0031
0
local
at0030
ELEMENT
true
true
false
false
0
1
at0047
value
true
true
false
false
0
1
false
DV_ORDINAL
true
true
false
false
1
1
3
local
at0061
2
local
at0050
1
local
at0049
0
local
at0048
1
local
at0062
2
local
at0063
3
local
at0051
ELEMENT
true
true
false
false
0
1
at0034
value
true
true
false
false
0
1
false
DV_ORDINAL
true
true
false
false
1
1
0
local
at0036
2
local
at0037
ELEMENT
true
true
false
false
0
1
at0004
value
true
true
false
false
0
1
false
DV_ORDINAL
true
true
false
false
1
1
3
local
at0017
2
local
at0016
1
local
at0015
0
local
at0014
3
local
at0067
ELEMENT
true
true
false
false
0
1
at0005
value
true
true
false
false
0
1
false
DV_ORDINAL
true
true
false
false
1
1
3
local
at0010
1
local
at0012
0
local
at0013
1
local
at0068
2
local
at0011
3
local
at0065
ELEMENT
true
true
false
false
0
1
at0008
value
true
true
false
false
0
1
false
DV_ORDINAL
true
true
false
false
1
1
0
local
at0024
3
local
at0025
ELEMENT
true
true
false
false
0
1
at0007
value
true
true
false
false
0
1
false
DV_ORDINAL
true
true
false
false
1
1
3
local
at0039
1
local
at0023
0
local
at0022
1
local
at0066
2
local
at0038
ELEMENT
true
true
false
false
0
1
at0028
value
true
true
false
false
0
1
false
DV_COUNT
true
true
false
false
1
1
magnitude
true
true
false
false
0
1
false
INTEGER
true
true
false
false
1
1
-
true
true
false
false
0
20
ELEMENT
true
true
false
false
0
1
at0056
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
at0057
at0058
at0059
at0060
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
at0045
items
true
true
false
false
0
1
false
CLUSTER
true
false
false
true
0
at0046
archetype_id/value matches {/.*/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
.*
constraint
false
false
true
false
false
true
0
openEHR-EHR-OBSERVATION.news2.v1
NEWS2 Score
A simple assessment score used to identify clinical deterioration in a patient.
This is the second version of the National Early Warning Score (NEWS), issued by the UK Royal College of Physicians in 2017.
Event Series
@ internal @
Any point in time event
Default, unspecified point in time event which may be explicitly defined in a template or at run-time.
Tree
@ internal @
Systolic blood pressure
Category for the systolic blood pressure measurement.
Pulse
Category for the pulse measurement.
Respiration rate
Category for the respiratory rate measurement.
Temperature
Range category for the body temperature measurement.
Consciousness
Category for the observed conscious state, using the ACVPU scale.
≤40
The pulse measurement is less than/equal to 40 beats/min.
111-130
The pulse measurement is between 111 and 130 beats/min.
41-50
The pulse measurement is between 41 and 50 beats/min.
51-90
The pulse measurement is between 51 and 90 beats/min.
111-219
The systolic blood pressure measurement is between 111 and 219 mmHg.
101-110
The systolic blood pressure measurement is between 101 and 110 mmHg.
91-100
The systolic blood pressure measurement is between 91 and 100 mmHg.
≤90
The systolic blood pressure measurement is less than/equal to 90 mmHg.
12-20
The respiratory rate measurement is between 12 and 20 breaths/min.
9-11
The respiratory rate measurement is between 9 and 11 breaths/min.
21-24
The respiratory rate measurement is between 21 and 24 breaths/min.
≤8
The respiratory rate measurement is less than/equal to 8 breaths/min.
36.1-38.0
The body temperature measurement is between 36.1 and 38.0 degrees Celsius.
35.1-36.0
The body temperature measurement is between 35.1 and 36.0 degrees Celsius.
Alert
The patient is alert or awake; scored as 0 points.
C, V, P or U
The patient is newly confused, responds only to voice or pain, or is unresponsive; scored as 3 points.
Total score
The sum of points assigned for each of the component variables.
The total score may be generated at run-time.
SpO₂ Scale 1
Category for the oxygen saturation measurement.
'SpO₂ Scale 1' and 'SpO₂ Scale 2' are variations of the same physiological variable to be used in different clinical scenarios. Scale 1 will be used for most patients, with the exception of patients with an oxygen saturation target range of 88–92%, such as patients with hypercapnic respiratory failure.
≥96
The oxygen saturation level is greater than/equal to 96%.
94-95
The oxygen saturation level is between 94% and 95%.
92-93
The oxygen saturation level is between 92% and 93%.
≤91
The oxygen saturation level is less than/equal to 91%.
Air or oxygen?
Is the patient receiving supplemental oxygen?
Air
The patient is breathing room air; not receiving supplemental oxygen.
Oxygen
The patient is receiving supplemental oxygen.
≥39.1
The body temperature is greater than/equal to 39.1 degrees Celcius.
≤35.0
The body temperature is less than/equal to 35 degrees Celcius.
Tree
@ internal @
Extension
Additional information required to extend the model with local content or to align with other reference models/formalisms.
For example: local information requirements; or additional metadata to align with FHIR.
SpO₂ Scale 2
Category for the oxygen saturation measurement in patients with a target oxygen saturation range of 88–92%.
'SpO₂ Scale 1' and 'SpO₂ Scale 2' are variations of the same physiological variable to be used in different clinical scenarios. Scale 2 will be used only in patients with an oxygen saturation target range of 88–92%, such as patients with hypercapnic respiratory failure. Otherwise use Scale 1.
88-92 or ≥93 on air
The oxygen saturation level is between 88% and 92% or greater than/equal to 93% on air.
86-87
The oxygen saturation level is between 86% and 87%.
84-85
The oxygen saturation level is between 84% and 85%.
≥97 on oxygen
The oxygen saturation level is greater than/equal to 97% on supplemental oxygen.
Clinical risk category
Overall category representing the urgency and scale of the clinical response required in response to the physiological variables.
Low
Ward-based response.
Low-medium
Urgent ward-based response.
Medium
Key threshold for urgent response.
High
Urgent or emergency response.
≤83
The oxygen saturation level is less/equal to 83%.
93-94 on oxygen
The oxygen saturation level is between 93% and 94% on supplemental oxygen.
95-96 on oxygen
The oxygen saturation level is between 95% and 96% on supplemental oxygen.
≥25
The respiratory rate measurement is greater than/equal to 25 breaths/min.
≥131
The pulse measurement is greater than/equal to 131 beats/min.
38.1-39.0
The body temperature measurement is between 38.1 and 39.0 degrees Celsius.
≥220
The systolic blood pressure measurement is greater than/equal to 220 mmHg.
91-110
The pulse measurement is between 91 and 110 beats/min.
false
false
true
false
false
true
0
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
-
NEWS2
openEHR-EHR-SECTION.adhoc.v1
open_eREACT-Care
NEWS2
A generic section header which should be renamed in a template to suit a specific clinical context.
false
false
true
false
false
true
0
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
-
Assessment
openEHR-EHR-SECTION.adhoc.v1
open_eREACT-Care
Assessment
A generic section header which should be renamed in a template to suit a specific clinical context.
SECTION
true
true
false
false
0
1
at0000
items
true
true
false
false
0
1
false
EVALUATION
true
true
false
false
0
1
at0000
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
false
false
true
0
at0002
value
true
true
false
false
0
1
false
DV_TEXT
true
true
false
false
1
1
value
true
true
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false
1
1
false
STRING
true
true
false
false
0
1
-
Presumed COVID-19 pathway
111/GP Advice
Ambulance
Keep comfortable
No action required
Enhanced monitoring
Sepsis assessment
true
false
false
true
false
false
true
0
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
false
false
true
0
at0005
archetype_id/value matches {/.*/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
.*
constraint
false
false
true
false
false
true
0
openEHR-EHR-EVALUATION.recommendation.v1
open_eREACT-Care
Recommendation
A suggestion, advice or proposal for clinical management.
Tree
@ internal @
Recommendation
Narrative description of the recommendation.
May be coded, using a terminology, if required.
Rationale
Justifications for the recommendation.
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.
INSTRUCTION
true
false
false
true
0
at0000
activities
true
true
false
false
0
1
false
ACTIVITY
true
false
false
true
1
at0001
description
true
true
false
false
1
1
false
ITEM_TREE
true
true
false
false
1
1
at0009
items
true
true
false
false
0
1
false
ELEMENT
true
true
false
false
1
1
at0121
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
170499009
225368008
ELEMENT
true
false
false
true
0
at0062
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
840544004
840546002
840539006
ELEMENT
true
true
false
false
0
1
at0064
value
true
true
false
false
0
1
false
DV_TEXT
true
true
false
false
1
1
value
true
true
false
false
1
1
false
STRING
true
true
false
false
0
1
-
Symptoms (10 days)
Tested positive
Contact
Following discharge
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
-
Reason for isolation
CLUSTER
true
false
false
true
0
at0151
archetype_id/value matches {/openEHR-EHR-CLUSTER\.service_direction(-[a-zA-Z0-9_]+)*\.v0/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.service_direction(-[a-zA-Z0-9_]+)*\.v0
constraint
ELEMENT
true
true
false
false
0
1
at0145
value
true
true
false
false
0
1
false
DV_DATE_TIME
true
true
false
false
1
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
-
Date isolation due to start
ELEMENT
true
true
false
false
0
1
at0144
value
true
true
false
false
0
1
false
DV_DATE_TIME
true
true
false
false
1
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
-
Date isolation due to end
CLUSTER
true
false
false
true
0
at0132
archetype_id/value matches {/.*/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
.*
constraint
CLUSTER
true
false
false
true
0
at0149
archetype_id/value matches {/openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v0/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v0
constraint
CLUSTER
true
false
false
true
0
at0116
archetype_id/value matches {/.*/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
.*
constraint
false
false
true
false
false
true
1
false
false
true
false
false
true
0
protocol
true
true
false
false
0
1
false
ITEM_TREE
true
true
false
false
1
1
at0008
items
true
true
false
false
0
1
false
CLUSTER
true
true
false
false
0
1
at0141
archetype_id/value matches {/.*/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
.*
constraint
CLUSTER
true
true
false
false
0
1
at0142
archetype_id/value matches {/.*/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
.*
constraint
CLUSTER
true
false
false
true
0
at0128
archetype_id/value matches {/openEHR-EHR-CLUSTER\.distribution\.v1/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.distribution\.v1
constraint
CLUSTER
true
false
false
true
0
at0112
archetype_id/value matches {/.*/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
.*
constraint
false
false
true
false
false
true
1
openEHR-EHR-INSTRUCTION.service_request.v1
open_eREACT-Care
Service request
Request for a health-related service or activity to be delivered by a clinician, organisation or agency.
Current Activity
Current Activity.
Tree
@ internal @
Tree
@ internal @
Requester order identifier
The local identifier assigned by the requesting clinical system.
Usually equivalent to the HL7 Placer Order Identifier.
Receiver order identifier
The local identifier assigned to the request by the clinician or organisation receiving the request for service.
Usually equivalent to the HL7 Filler Order Identifier.
Service due
The date/time, or acceptable interval of date/time, for provision of the service.
This data element allows for recording of the timing for a single service, either as a date and time, a date ranges or a text descriptor which can allow for 'next available. In practice, clinicians will often think in terms of ordering services as approximate timing, for example: review in 3 months, 6 months or 12 months. As clinical systems need more exact parameters to operate on, this '3 months' will usually be converted to an exact date 3 months from the date of recording and stored using this data element. If complex timing or sequences of timings are required, use the CLUSTER.service_direction archetype within the 'Complex timing' SLOT and this data element becomes redundant.
Reason for request
A short phrase describing the reason for the request.
Coding of the 'Reason for request' with a coding system is desirable, if available. This data element allows multiple occurrences to enable the user to record a multiple responses, if required. For example: 'manage diabetes complications'.
Reason for isolation
Narrative description about the reason for request.
For example: 'The patient's diabetes has recently become more difficult to stabilise and renal function is deteriorating'.
Intent
Description of the intent for the request.
For example: a referral to a specialist may have the intent of the specialist taking over responsibility for care of the patient, or it may be to provide a second opinion on treatment options. Coding of the 'Intent' with a coding system is desirable, if available. This data element allows multiple occurrences to enable the user to record a multiple responses, if required.
Urgency
Urgency of the request for service.
Specific definitions of emergency and urgent will vary between clinical contexts, clinical systems and the nature of the request itself, so have not been defined in this archetype. If explicit timing is required then the Service period should be clearly stated.
Supplementary information
Supplementary information will be following request.
Record as TRUE if additional information has been identified and will be forwarded when available. For example: pending test results.
Information description
Description of the supplementary information.
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.
Patient requirements
Language, transport or other personal requirements to support the patient's attendance or participation in provision of the service.
Service name
The name of the single service or activity requested.
Coding of the 'Service name' with a coding system is desirable, if available. For example: 'referral' to an endocrinologist for diabetes management.
Request status
The status of the request for service as indicated by the requester.
Status is used to denote whether this is the initial request, or a follow-up request to change or provide supplementary information. Coding with a terminology is preferred, where possible.
Distribution list
Details of additional clinicians, organisations or agencies who require copies of any communication.
Specific details
Additional detail about the service requested.
For example: Specimen details for a laboratory test request, or anatomical location for a procedure request.
Description
Narrative description about the service requested.
This data point should be used to describe the named service in more detail, including how it should be delivered, patient concerns and issues that might be encountered in delivering the service.
Emergency
The request requires immediate attention.
Urgent
The request requires prioritised attention.
Routine
The request does not require prioritised scheduling.
Requester
Details about the clinician or organisation requesting the service.
Receiver
Details about the clinician or organisation receiving the request for service.
Date isolation due to end
The date/time that marks the conclusion of the clinically valid period of time for delivery of this service.
This date/time is the equivalent to the latest possible date for service delivery or to the date of expiry for this request. For example: a service may be required to be completed before another event, such as scheduled surgery.
Date isolation due to start
The date/time that marks the beginning of the valid period of time for delivery of this service.
This date/time is the equivalent to the earliest possible date for service delivery. For example: sometimes a certain amount of time must pass before a service can be performed, for example some procedures can only be performed once the patient has stopped taking medications for a specific amount of time.
Indefinite?
The valid period for this request is open ended and has no date of expiry.
Record as TRUE to record explicity that the request has no expiry date. For example: commonly required for a referral to a specialist for long-term or lifelong care.
Service type
Category of service requested.
Coding of the 'Service type' with a coding system is desirable, if available. If the 'Service name' was coded, it is possible for this data point to be derived from the code. For example: biochemistry or microbiology laboratory, ultrasound or CT imaging.
Supporting information
Digital document, image, video or diagram supplied as additional information to support or inform the request.
Comment
Additional narrative about the service request not captured in other fields.
Complex timing
Details about a complex service request requiring a sequence of timings.
For example: 'hourly vital signs observations for 4 hours, then 4 hourly for 20 hours' or 'every third Wednesday for 3 visits' or .
Clinical indication
The clinical reason for the ordered service.
Coding of the clinical indication with a terminology is preferred, where possible. This data element allows multiple occurrences. For example: 'Angina' or 'Type 1 Diabetes mellitus'.
Isolation of infection contact
Contact tracing
Suspected disease caused by 2019 novel coronavirus
Exposure to 2019 novel coronavirus
Disease caused by 2019-nCoV
ACTION
true
false
false
true
0
at0000
ism_transition
true
true
false
false
1
1
false
ISM_TRANSITION
true
true
false
false
1
1
at0002
current_state
true
true
false
false
1
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
openehr
526
careflow_step
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
at0002
description
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
0
1
at0011
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
170499009
225368008
ELEMENT
true
true
false
false
0
1
at0013
value
true
true
false
false
0
1
false
DV_TEXT
true
true
false
false
1
1
CLUSTER
true
false
false
true
0
at0027
archetype_id/value matches {/.*/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
.*
constraint
CLUSTER
true
false
false
true
0
at0029
archetype_id/value matches {/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_]+)*\.v1
constraint
false
false
true
false
false
true
0
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
false
false
true
0
at0017
archetype_id/value matches {/.*/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
.*
constraint
CLUSTER
true
false
false
true
0
at0019
archetype_id/value matches {/.*/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
.*
constraint
false
false
true
false
false
true
0
openEHR-EHR-ACTION.service.v0
Service
A general clinical activity carried out for the patient to receive a specified service, advice or care from an expert healthcare provider.
Tree
@ internal @
Service planned
Service request to healthcare provider is planned.
Service scheduled
Appointment for a healthcare provider service has been made.
Service delivered
The healthcare provider has delivered the service.
Service activity complete
All service activities have been completed.
Service abandoned
The referral has been ceased before the service has been completed.
Service postponed
The planned service has been postponed.
Service cancelled
The planned service has been cancelled prior to commencement.
Service suspended
The service has been suspended without completion.
Service name
Identification of the clinical service to be/being carried out.
Coding of the specific service name with a terminology is preferred, where possible.
Reason
Reason that the activity or care pathway step for the identified service was carried out.
For example: the reason for the cancellation or suspension of the service.
Description
Narrative description about the service, as appropriate for the pathway step.
Service type
Type of service to be carried out or being carried out.
Tree
@ internal @
Requestor identifier
The local ID assigned to the order by the healthcare provider or organisation requesting the service. This is also referred to as Placer Order Identifier.
Requestor
Details about the healthcare provider or organisation requesting the service.
Receiver identifier
The ID assigned to the order by the healthcare provider or organisation receiving the request for referral. This is also referred to as Filler Order Identifier.
Receiver
Details about the healthcare provider or organisation receiving the request for referral.
Sequence
The sequence of the specified clinical service.
Only for use in association with the 'Service delivered' pathway step. For example: record that this is the 3rd physiotherapy appointment in a planned sequence.
Service expired
The referral has expired before the referral episode has been completed.
Scheduled date/time
The date and/or time on which the service is intended to be performed.
Only for use in association with the 'Service scheduled' pathway step.
Service request sent
Request for service sent.
Service detail
Structured information about the service.
Use to capture detailed, structured information about specified aspects of the service.
Comment
Additional narrative about the activity or care pathway step not captured in other fields.
Multimedia
Mulitimedia representation of a performed service.
Isolation of infection contact
Contact tracing
false
false
true
false
false
true
0
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
-
Response
openEHR-EHR-SECTION.adhoc.v1
Response
A generic section header which should be renamed in a template to suit a specific clinical context.
false
false
true
false
false
true
0
openEHR-EHR-COMPOSITION.encounter.v1
open_eREACT-Care
open_eREACT-Care
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.
161920001 | Respiratory symptom (finding) |
267045008 | Gastrointestinal symptom (finding) |
308921004 | Neurological symptom (finding) |
value
Influenza-like symptoms
SNOMED-CT
315642008
[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1, 'Assessment']/items[openEHR-EHR-SECTION.adhoc.v1, 'Covid']/items[openEHR-EHR-OBSERVATION.story.v1, 'Covid symptoms']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom_sign-cvid.v0, 'First symptoms']/items[at0001.1]
value
Present
at0.2
[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1, 'Assessment']/items[openEHR-EHR-SECTION.adhoc.v1, 'Covid']/items[openEHR-EHR-OBSERVATION.story.v1, 'Covid symptoms']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom_sign-cvid.v0, 'First symptoms']/items[at0.1]
value
Potential contact exposure based on location
at0.14
[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1, 'Assessment']/items[openEHR-EHR-SECTION.adhoc.v1, 'Covid']/items[openEHR-EHR-EVALUATION.health_risk-covid.v0, 'Covid-19 exposure']/data[at0001]/items[at0016, 'Care home has suspected/confirmed Covid-19']/items[at0013.1]
value
Contact with confirmed Covid-19 case
at0.9
[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1, 'Assessment']/items[openEHR-EHR-SECTION.adhoc.v1, 'Covid']/items[openEHR-EHR-EVALUATION.health_risk-covid.v0, 'Covid-19 exposure']/data[at0001]/items[at0016, 'Contact with confirmed case']/items[at0013.1]
value
Other household members are ill
at0.19
[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1, 'Assessment']/items[openEHR-EHR-SECTION.adhoc.v1, 'Covid']/items[openEHR-EHR-EVALUATION.health_risk-covid.v0, 'Covid-19 exposure']/data[at0001]/items[at0016, 'Other residents/household members unwell']/items[at0013.1]
value
Covid-19 test
[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1, 'Assessment']/items[openEHR-EHR-SECTION.adhoc.v1, 'Covid']/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1, 'Latest Covid-19 test']/data[at0001]/events[at0002]/data[at0003]/items[at0005]
value
0.0
0.0
[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1, 'Assessment']/items[openEHR-EHR-SECTION.adhoc.v1, 'NEWS2']/items[openEHR-EHR-OBSERVATION.pulse_oximetry.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0006]
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