TEMPLATE Core_examinations-v0 (Core_examinations-v0)

TEMPLATE IDCore_examinations-v0
ConceptCore_examinations-v0
DescriptionNot Specified
PurposeNot Specified
References
OtherDetails Language Independent{MetaDataSet:Sample Set =Template metadata sample set}
Language useden
Citeable Identifier1051.57.162
AllOperationalTemplate [rootArchetypeId=openEHR-EHR-COMPOSITION.encounter.v1, otherContributors=null, tshis=[ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1], code=at0000, itemType=COMPOSITION, level=0, text=Core examinations, description=Interaction, contact or care event between a subject of care and healthcare provider(s)., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=COMPOSITION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=null, code=null, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=1, text=Other Context, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.xds_metadata.v0], code=at0000, itemType=CLUSTER, level=2, text=XDS Metadata, description=Additional composition metadata aligned with IHE-XDS which is not already available from the Reference Model COMPOSITION class., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.xds_metadata.v0]/items[at0001], code=at0001, itemType=ELEMENT, level=3, text=Author specialty, description=The speciality of the author/composer of the document., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.xds_metadata.v0]/items[at0002], code=at0002, itemType=ELEMENT, level=3, text=Class code, description=A high-level document class code, normally selected from a valueset provided by the IHE-XDS Affinity Domain., comment=For example: Report, Summary, Images, Plan, Patient Preferences, Workflow. These codes are specific to an XDS Affinity Domain., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.xds_metadata.v0]/items[at0003], code=at0003, itemType=ELEMENT, level=3, text=Document type, description=The code specifying the precise type of document from the user perspective. Normally selected from a valueset provided by the local IHE-XDS Affinity Domain or national standard., comment=for example: Pulmonary History and Physical, Discharge Summary, Ultrasound Report. These codes are specific to an XDS Affinity Domain., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.xds_metadata.v0]/items[at0004], code=at0004, itemType=ELEMENT, level=3, text=Confidentiality code, description=A term specifying the level of confidentiality of the XDS Document., comment=Coded text is preferred, normally specific to an XDS Affinity Domain., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.xds_metadata.v0]/items[at0007], code=at0007, itemType=ELEMENT, level=3, text=Health care facility type, description=A term defining the healthcare facility type., comment=Coded text is preferred. The codes are specific to an XDS Affinity Domain., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.xds_metadata.v0]/items[at0009], code=at0009, itemType=ELEMENT, level=3, text=Practice setting code, description=The code specifying the clinical specialty where the act that resulted in the document was performed., comment=For example: Family Practice, Laboratory, Radiology. Coded text is preferred, normally specific to an XDS Affinity Domain., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.xds_metadata.v0]/items[at0011], code=at0011, itemType=ELEMENT, level=3, text=Event code, description=This list of codes represents the main clinical acts., comment=For example: Colonoscopy or appendicectomy., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.xds_metadata.v0]/items[at0010], code=at0010, itemType=ELEMENT, level=3, text=Document_media, description=Additional metadata about the document itself, including size, url., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_MULTIMEDIA, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.body_weight.v2], code=at0000, itemType=OBSERVATION, level=1, text=Body weight, description=Measurement of the body weight of an individual., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.body_weight.v2]/data[at0002]/events[at0003]/data[at0001]/items[at0004], code=at0004, itemType=ELEMENT, level=2, text=Weight, description=The weight of the individual., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=0..1000; 0..2000
Units:
  • kg
  • [lb_av]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.body_weight.v2]/data[at0002]/events[at0003]/data[at0001]/items[at0024], code=at0024, itemType=ELEMENT, level=2, text=Comment, description=Additional narrative about the measurement of Body weight, not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.body_weight.v2]/data[at0002]/events[at0026]/data[at0001]/items[at0004], code=at0004, itemType=ELEMENT, level=2, text=Birth weight, description=The weight of the individual., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=0..1000; 0..2000
Units:
  • kg
  • [lb_av]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.body_weight.v2]/data[at0002]/events[at0026]/data[at0001]/items[at0024], code=at0024, itemType=ELEMENT, level=2, text=Comment, description=Additional narrative about the measurement of Body weight, not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.height.v1], code=at0000, itemType=OBSERVATION, level=1, text=Height/Length, description=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., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.height.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=2, text=Height/Length, description=The length of the body from crown of head to sole of foot., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=0..1000; 0..250
Units:
  • cm
  • in
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.height.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0018], code=at0018, itemType=ELEMENT, level=2, text=Comment, description=Comment about the measurement of body height/length., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.body_mass_index.v2], code=at0000, itemType=OBSERVATION, level=1, text=Body mass index, description=Calculated measurement which compares a person's weight and height., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.body_mass_index.v2]/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=2, text=Body mass index, description=Index describing ratio of weight to height., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=0..1000; 0..1000
Units:
  • kg/m2
  • [lb_av]/[in_i]2
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.body_mass_index.v2]/data[at0001]/events[at0002]/data[at0003]/items[at0012], code=at0012, itemType=ELEMENT, level=2, text=Comment, description=Additional narrative about the calculation, not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.body_surface_area.v0], code=at0000, itemType=OBSERVATION, level=1, text=Body Surface Area, description=Body surface area (BSA) is the measured or calculated surface area of a human body., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.body_surface_area.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=2, text=Body Surface Area, description=The measured or calculated surface area of a human body., comment=For example: '1.81 m2', uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=Units: m2, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.body_surface_area.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0019], code=at0019, itemType=ELEMENT, level=2, text=Comment, description=Any additional comment about the body surface area estimation., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.waist_circumference.v1], code=at0000, itemType=OBSERVATION, level=1, text=Waist circumference, description=The measurement of the distance around the waist., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.waist_circumference.v1]/data[at0001]/events[at0010]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=2, text=Waist circumference, description=The measurement of the circumference of the waist., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=0..500; 0..400
Units:
  • cm
  • [in_i]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.waist_circumference.v1]/data[at0001]/events[at0010]/data[at0003]/items[at0007], code=at0007, itemType=ELEMENT, level=2, text=Comment, description=Additional narrative about the measurement of waist circumference not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.head_circumference.v1], code=at0000, itemType=OBSERVATION, level=1, text=Head circumference, description=The measurement of the longest distance around the head., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.head_circumference.v1]/data[at0001]/events[at0010]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=2, text=Head circumference, description=The measurement of the longest distance around the head., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=0..100; 0..40
Units:
  • cm
  • [in_i]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.head_circumference.v1]/data[at0001]/events[at0010]/data[at0003]/items[at0007], code=at0007, itemType=ELEMENT, level=2, text=Comment, description=Additional narrative about the head circumference not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.head_circumference.v1]/data[at0001]/events[at0011]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=2, text=Head circumference at birth, description=The measurement of the longest distance around the head., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=0..100; 0..40
Units:
  • cm
  • [in_i]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.head_circumference.v1]/data[at0001]/events[at0011]/data[at0003]/items[at0007], code=at0007, itemType=ELEMENT, level=2, text=Comment, description=Additional narrative about the head circumference not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.hip_circumference.v0], code=at0000, itemType=OBSERVATION, level=1, text=Hip circumference, description=The measurement of the distance around the hip, at the widest point., comment=The measurement is usually taken at the widest point of the hips/buttocks., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.hip_circumference.v0]/data[at0001]/events[at0010]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=2, text=Hip circumference, description=The measurement of the distance around the widest point of the hip and buttocks., comment=The measurement is usually taken at the widest point of the hips/buttocks., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=0..400; 0..150
Units:
  • cm
  • [in_i]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.hip_circumference.v0]/data[at0001]/events[at0010]/data[at0003]/items[at0007], code=at0007, itemType=ELEMENT, level=2, text=Comment, description=Additional narrative about the waist circumference not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null]], templateType=normal]