webtemplate.example.initialassesment.json Maven / Gradle / Ivy
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{
"templateId": "example.initialassesment.v0",
"version": "2.3",
"defaultLanguage": "en",
"languages": [
"en"
],
"tree": {
"id": "initial_assesment",
"name": "Initial Assesment",
"localizedName": "Initial Assesment",
"rmType": "COMPOSITION",
"nodeId": "openEHR-EHR-COMPOSITION.encounter.v1",
"min": 1,
"max": 1,
"localizedNames": {
"en": "Initial Assesment"
},
"localizedDescriptions": {
"en": "Interaction, contact or care event between a subject of care and healthcare provider(s)."
},
"aqlPath": "",
"children": [
{
"id": "context",
"rmType": "EVENT_CONTEXT",
"nodeId": "",
"min": 1,
"max": 1,
"aqlPath": "/context",
"children": [
{
"id": "start_time",
"name": "Start_time",
"rmType": "DV_DATE_TIME",
"min": 0,
"max": 1,
"aqlPath": "/context/start_time",
"inputs": [
{
"type": "DATETIME"
}
],
"inContext": true
},
{
"id": "setting",
"name": "Setting",
"rmType": "DV_CODED_TEXT",
"min": 0,
"max": 1,
"aqlPath": "/context/setting",
"inputs": [
{
"suffix": "code",
"type": "TEXT"
},
{
"suffix": "value",
"type": "TEXT"
}
],
"inContext": true
}
]
},
{
"id": "glasgow_coma_scale_gcs",
"name": "Glasgow Coma Scale (GCS)",
"localizedName": "Glasgow Coma Scale (GCS)",
"rmType": "OBSERVATION",
"nodeId": "openEHR-EHR-OBSERVATION.glasgow_coma_scale.v1",
"min": 0,
"max": -1,
"localizedNames": {
"en": "Glasgow Coma Scale (GCS)"
},
"localizedDescriptions": {
"en": "Fifteen point scale used to assess impairment of consciousness in response to defined stimuli."
},
"annotations": {
"comment": "More correctly known as the Modified Glasgow coma scale."
},
"aqlPath": "/content[openEHR-EHR-OBSERVATION.glasgow_coma_scale.v1]",
"children": [
{
"id": "best_eye_response_e",
"name": "Best eye response (E)",
"localizedName": "Best eye response (E)",
"rmType": "ELEMENT",
"nodeId": "at0009",
"min": 1,
"max": 1,
"localizedNames": {
"en": "Best eye response (E)"
},
"localizedDescriptions": {
"en": "Best response of eyes to test stimulus."
},
"annotations": {
"comment": "Most commonly, the score for eye response will be selected from one of the ordinal values, however if a response cannot be tested, for example if the subject of care cannot physically open their eyes due to other injuries, then the \"Not Applicable\" null flavour should be recorded."
},
"aqlPath": "/content[openEHR-EHR-OBSERVATION.glasgow_coma_scale.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0009]",
"children": [
{
"id": "ordinal_value",
"localizedName": "Best eye response (E)",
"rmType": "DV_ORDINAL",
"nodeId": "",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Best eye response (E)"
},
"localizedDescriptions": {
"en": "Best response of eyes to test stimulus."
},
"aqlPath": "/content[openEHR-EHR-OBSERVATION.glasgow_coma_scale.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0009]/value",
"inputs": [
{
"type": "CODED_TEXT",
"list": [
{
"value": "at0010",
"label": "None",
"localizedLabels": {
"en": "None"
},
"localizedDescriptions": {
"en": "No eye opening at any time, no interfering factor. For example: eyes closed by local swelling."
},
"ordinal": 1
},
{
"value": "at0011",
"label": "To pressure",
"localizedLabels": {
"en": "To pressure"
},
"localizedDescriptions": {
"en": "Eyes opening after finger tip stimulus."
},
"ordinal": 2
},
{
"value": "at0012",
"label": "To sound",
"localizedLabels": {
"en": "To sound"
},
"localizedDescriptions": {
"en": "Eyes opening after spoken or shouted request. Not to be confused with wakening of a sleeping person."
},
"ordinal": 3
},
{
"value": "at0013",
"label": "Spontaneous",
"localizedLabels": {
"en": "Spontaneous"
},
"localizedDescriptions": {
"en": "Eyes open before stimulus."
},
"ordinal": 4
}
]
}
],
"annotations": {
"comment": "Most commonly, the score for eye response will be selected from one of the ordinal values, however if a response cannot be tested, for example if the subject of care cannot physically open their eyes due to other injuries, then the \"Not Applicable\" null flavour should be recorded."
}
},
{
"id": "coded_text_value",
"localizedName": "Best eye response (E)",
"rmType": "DV_CODED_TEXT",
"nodeId": "",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Best eye response (E)"
},
"localizedDescriptions": {
"en": "Best response of eyes to test stimulus."
},
"aqlPath": "/content[openEHR-EHR-OBSERVATION.glasgow_coma_scale.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0009]/null_flavour",
"inputs": [
{
"suffix": "code",
"type": "CODED_TEXT",
"list": [
{
"value": "273",
"label": "not applicable",
"localizedLabels": {
"en": "not applicable"
}
}
],
"terminology": "openehr"
}
],
"annotations": {
"comment": "Most commonly, the score for eye response will be selected from one of the ordinal values, however if a response cannot be tested, for example if the subject of care cannot physically open their eyes due to other injuries, then the \"Not Applicable\" null flavour should be recorded."
}
}
]
},
{
"id": "best_verbal_response_v",
"name": "Best verbal response (V)",
"localizedName": "Best verbal response (V)",
"rmType": "ELEMENT",
"nodeId": "at0007",
"min": 1,
"max": 1,
"localizedNames": {
"en": "Best verbal response (V)"
},
"localizedDescriptions": {
"en": "Best verbal response to test stimulus."
},
"annotations": {
"comment": "Most commonly, the score for verbal response will be selected from one of the ordinal values, however if a response cannot be tested, for example if the subject of care is intubated, then the \"Not Applicable\" null flavour should be recorded."
},
"aqlPath": "/content[openEHR-EHR-OBSERVATION.glasgow_coma_scale.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0007]",
"children": [
{
"id": "ordinal_value",
"localizedName": "Best verbal response (V)",
"rmType": "DV_ORDINAL",
"nodeId": "",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Best verbal response (V)"
},
"localizedDescriptions": {
"en": "Best verbal response to test stimulus."
},
"aqlPath": "/content[openEHR-EHR-OBSERVATION.glasgow_coma_scale.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0007]/value",
"inputs": [
{
"type": "CODED_TEXT",
"list": [
{
"value": "at0014",
"label": "None",
"localizedLabels": {
"en": "None"
},
"localizedDescriptions": {
"en": "No audible response, no interfering factor. For example: intubation; profound deafness."
},
"ordinal": 1
},
{
"value": "at0015",
"label": "Sounds",
"localizedLabels": {
"en": "Sounds"
},
"localizedDescriptions": {
"en": "Only moans/groans."
},
"ordinal": 2
},
{
"value": "at0016",
"label": "Words",
"localizedLabels": {
"en": "Words"
},
"localizedDescriptions": {
"en": "Intelligible single words."
},
"ordinal": 3
},
{
"value": "at0017",
"label": "Confused",
"localizedLabels": {
"en": "Confused"
},
"localizedDescriptions": {
"en": "Not orientated but communicates coherently."
},
"ordinal": 4
},
{
"value": "at0018",
"label": "Orientated",
"localizedLabels": {
"en": "Orientated"
},
"localizedDescriptions": {
"en": "Correctly gives name, place and date."
},
"ordinal": 5
}
]
}
],
"annotations": {
"comment": "Most commonly, the score for verbal response will be selected from one of the ordinal values, however if a response cannot be tested, for example if the subject of care is intubated, then the \"Not Applicable\" null flavour should be recorded."
}
},
{
"id": "coded_text_value",
"localizedName": "Best verbal response (V)",
"rmType": "DV_CODED_TEXT",
"nodeId": "",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Best verbal response (V)"
},
"localizedDescriptions": {
"en": "Best verbal response to test stimulus."
},
"aqlPath": "/content[openEHR-EHR-OBSERVATION.glasgow_coma_scale.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0007]/null_flavour",
"inputs": [
{
"suffix": "code",
"type": "CODED_TEXT",
"list": [
{
"value": "273",
"label": "not applicable",
"localizedLabels": {
"en": "not applicable"
}
}
],
"terminology": "openehr"
}
],
"annotations": {
"comment": "Most commonly, the score for verbal response will be selected from one of the ordinal values, however if a response cannot be tested, for example if the subject of care is intubated, then the \"Not Applicable\" null flavour should be recorded."
}
}
]
},
{
"id": "best_motor_response_m",
"name": "Best motor response (M)",
"localizedName": "Best motor response (M)",
"rmType": "ELEMENT",
"nodeId": "at0008",
"min": 1,
"max": 1,
"localizedNames": {
"en": "Best motor response (M)"
},
"localizedDescriptions": {
"en": "Best motor response to test stimulus."
},
"annotations": {
"comment": "Most commonly, the score for motor response will be selected from one of the ordinal values, however if a response cannot be tested, for example if the subject of care cannot move their limbs due to injury or paralysis, then the \"Not Applicable\" null flavour should be recorded."
},
"aqlPath": "/content[openEHR-EHR-OBSERVATION.glasgow_coma_scale.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0008]",
"children": [
{
"id": "ordinal_value",
"localizedName": "Best motor response (M)",
"rmType": "DV_ORDINAL",
"nodeId": "",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Best motor response (M)"
},
"localizedDescriptions": {
"en": "Best motor response to test stimulus."
},
"aqlPath": "/content[openEHR-EHR-OBSERVATION.glasgow_coma_scale.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0008]/value",
"inputs": [
{
"type": "CODED_TEXT",
"list": [
{
"value": "at0019",
"label": "None",
"localizedLabels": {
"en": "None"
},
"localizedDescriptions": {
"en": "No movement in arms/legs, no interfering factor. For example: paralysed."
},
"ordinal": 1
},
{
"value": "at0020",
"label": "Extension",
"localizedLabels": {
"en": "Extension"
},
"localizedDescriptions": {
"en": "Decerebrate extension of arms and/or legs in response to stimuli. For example: extends arm at elbow."
},
"ordinal": 2
},
{
"value": "at0021",
"label": "Abnormal flexion",
"localizedLabels": {
"en": "Abnormal flexion"
},
"localizedDescriptions": {
"en": "Slow, decorticate flexion of arms and/or legs. For example: bends arm at elbow, but features predominantly abnormal."
},
"ordinal": 3
},
{
"value": "at0022",
"label": "Normal flexion",
"localizedLabels": {
"en": "Normal flexion"
},
"localizedDescriptions": {
"en": "Rapid flexion in response to stimuli but features predominantly normal. For example: flexion of wrist when supra-orbital pressure applied; pulls part of body away when nailbed pinched."
},
"ordinal": 4
},
{
"value": "at0023",
"label": "Localising",
"localizedLabels": {
"en": "Localising"
},
"localizedDescriptions": {
"en": "Purposeful flexion towards painful stimuli. For example: brings hand above the clavicle when supra-orbital pressure is applied."
},
"ordinal": 5
},
{
"value": "at0024",
"label": "Obeys commands",
"localizedLabels": {
"en": "Obeys commands"
},
"localizedDescriptions": {
"en": "Follows verbal request for movement."
},
"ordinal": 6
}
]
}
],
"annotations": {
"comment": "Most commonly, the score for motor response will be selected from one of the ordinal values, however if a response cannot be tested, for example if the subject of care cannot move their limbs due to injury or paralysis, then the \"Not Applicable\" null flavour should be recorded."
}
},
{
"id": "coded_text_value",
"localizedName": "Best motor response (M)",
"rmType": "DV_CODED_TEXT",
"nodeId": "",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Best motor response (M)"
},
"localizedDescriptions": {
"en": "Best motor response to test stimulus."
},
"aqlPath": "/content[openEHR-EHR-OBSERVATION.glasgow_coma_scale.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0008]/null_flavour",
"inputs": [
{
"suffix": "code",
"type": "CODED_TEXT",
"list": [
{
"value": "273",
"label": "not applicable",
"localizedLabels": {
"en": "not applicable"
}
}
],
"terminology": "openehr"
}
],
"annotations": {
"comment": "Most commonly, the score for motor response will be selected from one of the ordinal values, however if a response cannot be tested, for example if the subject of care cannot move their limbs due to injury or paralysis, then the \"Not Applicable\" null flavour should be recorded."
}
}
]
},
{
"id": "total_score",
"name": "Total score",
"localizedName": "Total score",
"rmType": "DV_COUNT",
"nodeId": "at0026",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Total score"
},
"localizedDescriptions": {
"en": "The sum of the ordinal scores recorded for each of the three component responses."
},
"annotations": {
"comment": "The Total Score may be derived as the sum of the three response data elements and, if so, should be validated by the clinical information system against the individual scores entered by the clinician to ensure there is no conflict or inconsistency. Do not report a total score when one or more components are not testable because the score will be artificially low - in this situation record the EVM profile."
},
"aqlPath": "/content[openEHR-EHR-OBSERVATION.glasgow_coma_scale.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0026]/value",
"inputs": [
{
"type": "INTEGER",
"validation": {
"range": {
"minOp": ">=",
"min": 3,
"maxOp": "<=",
"max": 15
}
}
}
]
},
{
"id": "time",
"name": "Time",
"rmType": "DV_DATE_TIME",
"min": 0,
"max": 1,
"aqlPath": "/content[openEHR-EHR-OBSERVATION.glasgow_coma_scale.v1]/data[at0001]/events[at0002]/time",
"inputs": [
{
"type": "DATETIME"
}
],
"inContext": true
},
{
"id": "language",
"name": "Language",
"rmType": "CODE_PHRASE",
"min": 0,
"max": 1,
"aqlPath": "/content[openEHR-EHR-OBSERVATION.glasgow_coma_scale.v1]/language",
"inContext": true
},
{
"id": "encoding",
"name": "Encoding",
"rmType": "CODE_PHRASE",
"min": 0,
"max": 1,
"aqlPath": "/content[openEHR-EHR-OBSERVATION.glasgow_coma_scale.v1]/encoding",
"inContext": true
},
{
"id": "subject",
"name": "Subject",
"rmType": "PARTY_PROXY",
"min": 0,
"max": 1,
"aqlPath": "/content[openEHR-EHR-OBSERVATION.glasgow_coma_scale.v1]/subject",
"inputs": [
{
"suffix": "id",
"type": "TEXT"
},
{
"suffix": "id_scheme",
"type": "TEXT"
},
{
"suffix": "id_namespace",
"type": "TEXT"
},
{
"suffix": "name",
"type": "TEXT"
}
],
"inContext": true
}
]
},
{
"id": "pulse_heart_beat",
"name": "Pulse/Heart beat",
"localizedName": "Pulse/Heart beat",
"rmType": "OBSERVATION",
"nodeId": "openEHR-EHR-OBSERVATION.pulse.v2",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Pulse/Heart beat"
},
"localizedDescriptions": {
"en": "The rate and associated attributes for a pulse or heart beat."
},
"aqlPath": "/content[openEHR-EHR-OBSERVATION.pulse.v2]",
"children": [
{
"id": "presence",
"name": "Presence",
"localizedName": "Presence",
"rmType": "DV_CODED_TEXT",
"nodeId": "at1005",
"min": 0,
"max": 1,
"localizedNames": {
"en": "Presence"
},
"localizedDescriptions": {
"en": "Presence of a pulse or heart beat."
},
"annotations": {
"comment": "It can be implied that the pulse or heart beat is present if Rate >0 /min."
},
"aqlPath": "/content[openEHR-EHR-OBSERVATION.pulse.v2]/data[at0002]/events[at0003]/data[at0001]/items[at1005]/value",
"inputs": [
{
"suffix": "code",
"type": "CODED_TEXT",
"list": [
{
"value": "at1024",
"label": "Present",
"localizedLabels": {
"en": "Present"
},
"localizedDescriptions": {
"en": "A pulse or heart beat can be detected."
}
},
{
"value": "at1025",
"label": "Not detected",
"localizedLabels": {
"en": "Not detected"
},
"localizedDescriptions": {
"en": "A pulse or heart beat cannot be detected."
}
}
]
}
]
},
{
"id": "time",
"name": "Time",
"rmType": "DV_DATE_TIME",
"min": 0,
"max": 1,
"aqlPath": "/content[openEHR-EHR-OBSERVATION.pulse.v2]/data[at0002]/events[at0003]/time",
"inputs": [
{
"type": "DATETIME"
}
],
"inContext": true
},
{
"id": "language",
"name": "Language",
"rmType": "CODE_PHRASE",
"min": 0,
"max": 1,
"aqlPath": "/content[openEHR-EHR-OBSERVATION.pulse.v2]/language",
"inContext": true
},
{
"id": "encoding",
"name": "Encoding",
"rmType": "CODE_PHRASE",
"min": 0,
"max": 1,
"aqlPath": "/content[openEHR-EHR-OBSERVATION.pulse.v2]/encoding",
"inContext": true
},
{
"id": "subject",
"name": "Subject",
"rmType": "PARTY_PROXY",
"min": 0,
"max": 1,
"aqlPath": "/content[openEHR-EHR-OBSERVATION.pulse.v2]/subject",
"inputs": [
{
"suffix": "id",
"type": "TEXT"
},
{
"suffix": "id_scheme",
"type": "TEXT"
},
{
"suffix": "id_namespace",
"type": "TEXT"
},
{
"suffix": "name",
"type": "TEXT"
}
],
"inContext": true
}
]
},
{
"id": "category",
"rmType": "DV_CODED_TEXT",
"nodeId": "",
"min": 1,
"max": 1,
"aqlPath": "/category",
"inputs": [
{
"suffix": "code",
"type": "CODED_TEXT",
"list": [
{
"value": "433",
"label": "event",
"localizedLabels": {
"en": "event"
}
}
],
"terminology": "openehr"
}
],
"inContext": true
},
{
"id": "language",
"name": "Language",
"rmType": "CODE_PHRASE",
"min": 0,
"max": 1,
"aqlPath": "/language",
"inContext": true
},
{
"id": "territory",
"name": "Territory",
"rmType": "CODE_PHRASE",
"min": 0,
"max": 1,
"aqlPath": "/territory",
"inContext": true
},
{
"id": "composer",
"name": "Composer",
"rmType": "PARTY_PROXY",
"min": 0,
"max": 1,
"aqlPath": "/composer",
"inputs": [
{
"suffix": "id",
"type": "TEXT"
},
{
"suffix": "id_scheme",
"type": "TEXT"
},
{
"suffix": "id_namespace",
"type": "TEXT"
},
{
"suffix": "name",
"type": "TEXT"
}
],
"inContext": true
}
]
}
}
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