TEMPLATE RESET - Assessment B.v1 (RESET - Assessment B.v1)

TEMPLATE IDRESET - Assessment B.v1
ConceptRESET - Assessment B.v1
DescriptionFor use in RESET Assessment Part B.
PurposeFor use in RESET Assessment Part B.
References
OtherDetails Language Independent{MetaDataSet:Sample Set =Template metadata sample set}
Language useden
Citeable Identifier1051.57.186
AllOperationalTemplate [rootArchetypeId=openEHR-EHR-COMPOSITION.encounter.v1, otherContributors=null, tshis=[ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1], code=at0000, itemType=COMPOSITION, level=0, text=RESET Assessment B (Breathing), 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=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.respiration.v1], code=at0000, itemType=OBSERVATION, level=1, text=Respirations, description=The observed characteristics of spontaneous breathing as would commonly be recorded as part of a 'vital signs' examination., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, 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.respiration.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=2, text=Respiratory Rate, description=Rate of respiration., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=0..200 /min, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.respiration.v1]/data[at0001]/events[at0002]/state[at0022]/items[openEHR-EHR-CLUSTER.inspired_oxygen.v1], code=at0000, itemType=CLUSTER, level=2, text=Inspired oxygen, description=The amount of oxygen being delivered, or to be delivered, to the patient given as a fraction, percentage or indirectly as a flow rate., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.respiration.v1]/data[at0001]/events[at0002]/state[at0022]/items[openEHR-EHR-CLUSTER.inspired_oxygen.v1]/items[at0051], code=at0051, itemType=ELEMENT, level=3, text=Flow rate, description=Oxygen flow rate given to an individual., comment=For example '5 l/min'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=0..50000; 0..50
Units:
  • ml/min
  • l/min
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.respiration.v1]/data[at0001]/events[at0002]/state[at0022]/items[openEHR-EHR-CLUSTER.inspired_oxygen.v1]/items[at0052], code=at0052, itemType=ELEMENT, level=3, text=FiO₂, description=Fraction of oxygen in inspired air., comment=For example: '0.28'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_PROPORTION, bindings=null, values=
  • Unitary
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.breathing_assessment_reset.v0], code=at0000, itemType=OBSERVATION, level=1, text=Breathing assessment RESET, description=Breathing assessment., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, 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.breathing_assessment_reset.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=2, text=Symmetry, description=This is the Symmetry element., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • symmetrical 
  • R < L 
  • L < R 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.breathing_assessment_reset.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0008], code=at0008, itemType=ELEMENT, level=2, text=Volume, description=This is the volume element., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Normal 
  • Shallow 
  • Deep 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.breathing_assessment_reset.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0012], code=at0012, itemType=ELEMENT, level=2, text=Pattern/Effort, description=This is the pattern element., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Normal WOB 
  • Increased WOB + 
  • Increased WOB ++ 
  • Increased WOB +++ 
  • Tiring 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.breathing_evaluation_reset.v0], code=at0000, itemType=CLUSTER, level=1, text=Breathing palpation RESET, description=unknown, 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]/content[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.breathing_evaluation_reset.v0]/items[at0002], code=at0002, itemType=ELEMENT, level=2, text=Right side palpation finding, description=Description of abnormal right side palpation finding as part of breathing evaluation., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Trachea deviated 
  • Chest wall tenderness 
  • Surgical emphysema 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.breathing_evaluation_reset.v0]/items[at0007], code=at0007, itemType=ELEMENT, level=2, text=Left side palpation finding, description=Description of abnormal left side palpation finding as part of breathing evaluation., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Trachea deviated 
  • Chest wall tenderness 
  • Surgical emphysema 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.breathing_evaluation_reset.v0]/items[at0008], code=at0008, itemType=ELEMENT, level=2, text=Right side percussion finding, description=Description of right side percussion finding as part of breathing evaluation., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Normal 
  • Hyper resonant 
  • Dull 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.breathing_evaluation_reset.v0]/items[at0009], code=at0009, itemType=ELEMENT, level=2, text=Left side percussion finding, description=Description of left side percussion finding as part of breathing evaluation., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Normal 
  • Hyper resonant 
  • Dull 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.breathing_evaluation_reset.v0]/items[at0010], code=at0010, itemType=ELEMENT, level=2, text=Right side auscultation air entry finding, description=Description of right side auscultation airway entry finding as part of breathing evaluation., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Good 
  • Reduced + 
  • Reduced ++ 
  • Absent 
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  • Wheeze 
  • Creps 
  • None 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.breathing_evaluation_reset.v0]/items[at0011], code=at0011, itemType=ELEMENT, level=2, text=Left side auscultation air entry finding, description=Description of left side auscultation airway entry finding as part of breathing evaluation., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Good 
  • Reduced + 
  • Reduced ++ 
  • Absent 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.breathing_evaluation_reset.v0]/items[at0013], code=at0013, itemType=ELEMENT, level=2, text=Left side auscultaiton added sounds finding, description=Description of left side auscultation airway entry finding as part of breathing evaluation., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Wheeze 
  • Creps 
  • None 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.conclusion_assess_b_reset.v0], code=at0000, itemType=OBSERVATION, level=1, text=Conclusion Assessment B RESET, description=Conclusion for RESET Assessment B., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, 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.conclusion_assess_b_reset.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=2, text=Assessment B conclusion, description=Describes conclusion of breathing assessment (Part B of RESET assessment)., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Evidence of distress 
  • Failure 
  • Not compromised 
, extendedValues=null]], templateType=normal]