| All | OperationalTemplate [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 D, 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-SECTION.adhoc.v1 and name/value='Glasgow Coma Scale'], code=at0000, itemType=SECTION, level=1, text=Glasgow Coma Scale, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Glasgow Coma Scale']/items[openEHR-EHR-OBSERVATION.glasgow_coma_scale.v1], code=at0000, itemType=OBSERVATION, level=2, text=Glasgow coma scale, description=Fifteen point scale used to assess impairment of consciousness in response to defined stimuli. More correctly known as the Modified Glasgow coma scale., 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-SECTION.adhoc.v1 and name/value='Glasgow Coma Scale']/items[openEHR-EHR-OBSERVATION.glasgow_coma_scale.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, description=, 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]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Glasgow Coma Scale']/items[openEHR-EHR-OBSERVATION.glasgow_coma_scale.v1]/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=4, text=Any event, description=Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Glasgow Coma Scale']/items[openEHR-EHR-OBSERVATION.glasgow_coma_scale.v1]/data[at0001]/events[at0002]/data[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=5, text=Data, description=, 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]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Glasgow Coma Scale']/items[openEHR-EHR-OBSERVATION.glasgow_coma_scale.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0009], code=at0009, itemType=ELEMENT, level=6, text=Best eye response (E), description=Best response of eyes to test stimulus., 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., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_ORDINAL, bindings=null, values=- 1: None
- 2: To pressure
- 3: To sound
- 4: Spontaneous
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Glasgow Coma Scale']/items[openEHR-EHR-OBSERVATION.glasgow_coma_scale.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0007], code=at0007, itemType=ELEMENT, level=6, text=Best verbal response (V), description=Best verbal response to test stimulus., 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., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_ORDINAL, bindings=null, values=- 1: None
- 2: Sounds
- 3: Words
- 4: Confused
- 5: Orientated
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Glasgow Coma Scale']/items[openEHR-EHR-OBSERVATION.glasgow_coma_scale.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0008], code=at0008, itemType=ELEMENT, level=6, text=Best motor response (M), description=Best motor response to test stimulus., 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., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_ORDINAL, bindings=null, values=- 1: None
- 2: Extension
- 3: Abnormal flexion
- 4: Normal flexion
- 5: Localising
- 6: Obeys commands
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Glasgow Coma Scale']/items[openEHR-EHR-OBSERVATION.glasgow_coma_scale.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0026], code=at0026, itemType=ELEMENT, level=6, text=Total score, description=The sum of the ordinal scores recorded for each of the three component responses., 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., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=3..15, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Glasgow Coma Scale']/items[openEHR-EHR-OBSERVATION.glasgow_coma_scale.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0030], code=at0030, itemType=ELEMENT, level=6, text=EVM profile, description=Alternative assessment to 'Total Score' where the Eye Verbal Motor profile is expressed as three discrete components., comment=The EMV Score may be automatically derived as a concatenation of the three response data elements and, if so, should be validated by the clinical information system against the individual scores entered by the clinician to ensure there is no conflict or inconsistency. The 'Not applicable' null flavour value should be recorded as 'NT', for 'not tested' as per http://www.glasgowcomascale.org/., 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-SECTION.adhoc.v1 and name/value='Glasgow Coma Scale']/items[openEHR-EHR-OBSERVATION.glasgow_coma_scale.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0037], code=at0037, itemType=ELEMENT, level=6, text=Comment, description=Additional narrative about the measurement of the scale not captured in other fields., comment=Record the reasons for inability to test in the 'Confounding factors' data element., 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]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Glasgow Coma Scale']/items[openEHR-EHR-OBSERVATION.glasgow_coma_scale.v1]/data[at0001]/events[at0002]/state[at0040], code=at0040, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=5, text=State, description=, 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]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Glasgow Coma Scale']/items[openEHR-EHR-OBSERVATION.glasgow_coma_scale.v1]/data[at0001]/events[at0002]/state[at0040]/items[at0041], code=at0041, itemType=ELEMENT, level=6, text=Confounding factors, description=Narrative record of factors that may have contributed to the GCS scores., comment=For example: deafness; aphasia; language issues; use of sedatives; hypothermia; or paralysis, severe facial/eye swelling or tracheal intubation as reasons for inability to record any one of the ordinal E, V or M assessments., 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]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Pupils'], code=at0000, itemType=SECTION, level=1, text=Pupils, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Pupils']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_pupils.v1], code=at0000, itemType=CLUSTER, level=2, text=Examination Findings - Pupils, description=Findings on physical examination of the pupils., 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-SECTION.adhoc.v1 and name/value='Pupils']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_pupils.v1]/items[at0069], code=at0069, itemType=ELEMENT, level=3, text=Description, description=Narrative description of findings observed during a physical examination of the pupil., comment=Use this data element to provide additional, narrative description of any data elements that are represented only by structured values., 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-SECTION.adhoc.v1 and name/value='Pupils']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_pupils.v1]/items[at0071], code=at0071, itemType=ELEMENT, level=3, text=Symmetry, description=An estimate of the equality of the size and shape of the pupils., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Pupils']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_pupils.v1]/items[at0075], code=at0075, itemType=CLUSTER, level=3, text=Per Pupil, description=Physical examination findings of an identified pupil., comment=null, uncommonOntologyItems=null, occurencesFormal=0..2, 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-SECTION.adhoc.v1 and name/value='Pupils']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_pupils.v1]/items[at0075]/items[at0015], code=at0015, itemType=ELEMENT, level=4, text=Pupil Examined, description=Identification of the pupil under examination., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Pupils']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_pupils.v1]/items[at0075]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Measured Size, description=Measured size of the pupil., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=0..30 mm, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Pupils']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_pupils.v1]/items[at0075]/items[at0020], code=at0020, itemType=ELEMENT, level=4, text=Estimated Size, description=A text description of the estimated pupil size., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- Pin-point pupil
- Constricted pupil.
- Normal sized pupil
- Dilated pupil
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Pupils']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_pupils.v1]/items[at0075]/items[at0003], code=at0003, itemType=ELEMENT, level=4, text=Direct Light Reflex, description=Pupil constricts with light shone into that eye., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- Present
- Absent
- Sluggish/slow (-)
- Normal speed (+/-)
- Brisk(+)
- Very brisk (++)
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Pupils']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0006], code=at0006, itemType=ELEMENT, level=2, text=Interpretation, description=Single word, phrase or brief description which represents the clinical meaning and significance of the physical examination findings., comment=Coding with a terminology is preferred, if possible. For example, 'normal examination' or 'tympanic membrane perforation'., 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]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Pupils']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0011], code=at0011, itemType=ELEMENT, level=2, text=Comment, description=Additional narrative about the overall physical examination findings 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-SECTION.adhoc.v1 and name/value='Pupils']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/state[at0009]/items[at0013], code=at0013, itemType=ELEMENT, level=2, text=Position, description=The body position of the subject during the examination., 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-SECTION.adhoc.v1 and name/value='Blood Sugar'], code=at0000, itemType=SECTION, level=1, text=Blood Sugar, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Blood Sugar']/items[openEHR-EHR-OBSERVATION.laboratory_test.v0], code=at0000, itemType=OBSERVATION, level=2, text=Laboratory test, description=The findings and interpretation of a pathology laboratory test performed on patient-related specimens., comment=This archetype may be used to record a single valued test, but will often be specialised or templated to represent multiple value or 'panel' tests. This archetype also acts as the parent for specialisations appropriate for more specific laboratory tests, e.g. microbiology, histopathology., 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-SECTION.adhoc.v1 and name/value='Blood Sugar']/items[openEHR-EHR-OBSERVATION.laboratory_test.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0005], code=at0005, itemType=ELEMENT, level=3, text=Blood Sugar, description=Identification of the pathology test performed, sometimes including specimen type and patient state., comment=A test result may be for a single analyte, or a group of items, including panel tests. Coding with a terminology, potientially a pre-coordinated term including specimen type, is preferred, where possible. May be coded with LOINC or Snomed-CT. Examples include "Glucose", "Urea and Electrolytes", "Swab", “Cortisol (am)” or "Liver Biopsy"., uncommonOntologyItems={fhirmapping=Diagnostic.Reportname, fhirvalueset=reportnames}, occurencesFormal=1..1, occurencesText=Mandatory, 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-SECTION.adhoc.v1 and name/value='Delirium Assessment'], code=at0000, itemType=SECTION, level=1, text=Delirium Assessment, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Delirium Assessment']/items[openEHR-EHR-OBSERVATION.cam_reset.v0], code=at0000, itemType=OBSERVATION, level=2, text=CAM assessment RESET, description=CAM Assessment for RESET., 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-SECTION.adhoc.v1 and name/value='Delirium Assessment']/items[openEHR-EHR-OBSERVATION.cam_reset.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=3, text=F1 (1) Evidence of acute change, description=Feature 1 Acute onset and fluctuating course.
This feature is usually obtained from a family member or nurse and is shown by positive
responses to the following questions:
1. Is there evidence of an acute change in mental status from the patient’s baseline?, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Delirium Assessment']/items[openEHR-EHR-OBSERVATION.cam_reset.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0005], code=at0005, itemType=ELEMENT, level=3, text=F1 (2) Fluctuating, description=Feature 1 Acute onset and fluctuating course.
This feature is usually obtained from a family member or nurse and is shown by positive
responses to the following questions: 2. Did the (abnormal) behaviour fluctuate during the day, that is, tend to come and go, or
increase or decrease in severity?, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Delirium Assessment']/items[openEHR-EHR-OBSERVATION.cam_reset.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0006], code=at0006, itemType=ELEMENT, level=3, text=F2 (3) Inattention, description=Feature 2 Inattention.
This feature is usually obtained by interacting with the patient, but may also be reported by
family members or staff and is shown by a positive response to the following question:
3. Did the patient have difficulty focusing attention, for example being easily distractible or
having difficulty keeping track of what was being said?, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Delirium Assessment']/items[openEHR-EHR-OBSERVATION.cam_reset.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0007], code=at0007, itemType=ELEMENT, level=3, text=F3 (4) Disorganised thinking, description=Feature 3 Disorganised thinking
. This feature is usually obtained by interacting with the patient, but may also be reported by
family members or staff and is shown by a positive response to the following question:
4. ‘Was the patient’s thinking disorganised or incoherent, such as rambling or irrelevant
conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to
subject?’., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Delirium Assessment']/items[openEHR-EHR-OBSERVATION.cam_reset.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0008], code=at0008, itemType=ELEMENT, level=3, text=F4 (5) Altered level of consciousness, description=Feature 4 Altered level of consciousness.
This feature is obtained by observing the patient and is shown by any answer other than
‘alert’ to the following question:
5. Overall, how would you rate this patient’s level of consciousness?, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- Alert (normal)
- Vigilant (hyperalert)
- Lethargic (drowsy/easily aroused)
- Stupor (difficult to arouse)
- Coma (unarousable)
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Delirium Assessment']/items[openEHR-EHR-OBSERVATION.cam_reset.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0014], code=at0014, itemType=ELEMENT, level=3, text=Delirium diagnosis, description=If CAM assessment has Yes for F1 (1), F1 (2), F2 and either Yes for F3 or indicating shifting consciousness for F4, a diagnosis of delirium can be confirmed., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Meningism'], code=at0000, itemType=SECTION, level=1, text=Meningism, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Meningism']/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom_sign.v1], code=at0000, itemType=CLUSTER, level=2, text=Symptom/Sign, description=Reported observation of a physical or mental disturbance in an individual., 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-SECTION.adhoc.v1 and name/value='Meningism']/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom_sign.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=3, text=Meningism, description=The name of the reported symptom or sign., comment=Symptom name should be coded with a terminology, where possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, 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-SECTION.adhoc.v1 and name/value='Meningism']/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom_sign.v1]/items[at0035], code=at0035, itemType=ELEMENT, level=3, text=Nil significant, description=The identified symptom or sign was reported as not being present to any significant degree., comment=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., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='FAST / Other'], code=at0000, itemType=SECTION, level=1, text=FAST / Other, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='FAST / Other']/items[openEHR-EHR-OBSERVATION.story.v1 and name/value='Story/History #1']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom_sign.v1], code=at0000, itemType=CLUSTER, level=2, text=Symptom/Sign, description=Reported observation of a physical or mental disturbance in an individual., 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-SECTION.adhoc.v1 and name/value='FAST / Other']/items[openEHR-EHR-OBSERVATION.story.v1 and name/value='Story/History #1']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom_sign.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=3, text=FAST, description=The name of the reported symptom or sign., comment=Symptom name should be coded with a terminology, where possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, 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-SECTION.adhoc.v1 and name/value='FAST / Other']/items[openEHR-EHR-OBSERVATION.story.v1 and name/value='Story/History #1']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom_sign.v1]/items[at0035], code=at0035, itemType=ELEMENT, level=3, text=Nil significant, description=The identified symptom or sign was reported as not being present to any significant degree., comment=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., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='FAST / Other']/items[openEHR-EHR-OBSERVATION.story.v1 and name/value='Story/History'], code=at0000, itemType=OBSERVATION, level=2, text=Story/History, description=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., 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-SECTION.adhoc.v1 and name/value='FAST / Other']/items[openEHR-EHR-OBSERVATION.story.v1 and name/value='Story/History']/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, description=, 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]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='FAST / Other']/items[openEHR-EHR-OBSERVATION.story.v1 and name/value='Story/History']/data[at0001]/events[at0002], code=at0002, itemType=POINT_EVENT, level=4, text=Any event, description=Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=POINT_EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='FAST / Other']/items[openEHR-EHR-OBSERVATION.story.v1 and name/value='Story/History']/data[at0001]/events[at0002]/data[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=5, text=Data, description=, 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]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='FAST / Other']/items[openEHR-EHR-OBSERVATION.story.v1 and name/value='Story/History']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom_sign.v1], code=at0000, itemType=CLUSTER, level=6, text=Symptom/Sign, description=Reported observation of a physical or mental disturbance in an individual., 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-SECTION.adhoc.v1 and name/value='FAST / Other']/items[openEHR-EHR-OBSERVATION.story.v1 and name/value='Story/History']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom_sign.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=7, text=Other symptom, description=The name of the reported symptom or sign., comment=Symptom name should be coded with a terminology, where possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, 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-SECTION.adhoc.v1 and name/value='FAST / Other']/items[openEHR-EHR-OBSERVATION.story.v1 and name/value='Story/History']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom_sign.v1]/items[at0035], code=at0035, itemType=ELEMENT, level=7, text=Nil significant, description=The identified symptom or sign was reported as not being present to any significant degree., comment=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., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.conclusion_assess_d_reset.v0], code=at0000, itemType=OBSERVATION, level=1, text=Conclusion Assessment D RESET, description=Conclusion of RESET assessment D., 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_d_reset.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=2, text=Assessment D conclusion, description=Describes the conclusion for the delirium assessment (Part D of the RESET assessment section)., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- Global disturbance
- Focal neurology
- Not compromised
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.conclusion_assess_d_reset.v0]/data[at0001]/events[at0002]/state[at0010], code=at0010, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=2, text=State, description=, 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]/content[openEHR-EHR-OBSERVATION.conclusion_assess_d_reset.v0]/data[at0001]/events[at0002]/state[at0010]/items[at0011], code=at0011, itemType=ELEMENT, level=3, text=Confounding factors, description=Record any issues or factors that may impact on the conclusion of Assessment D., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null]], templateType=normal] |