TEMPLATE WISDM Cardiovascular Assessment (WISDM Cardiovascular Assessment)

TEMPLATE IDWISDM Cardiovascular Assessment
ConceptWISDM Cardiovascular Assessment
DescriptionTo record a cardiovascular assessment and observations as part of diabetes management of a patient. Comprises part of the diabetes outpatient assessment.
UseTo be used in a secondary care setting as part of the NHS Wales Diabetes Solution (WISDM). May be adapted for use in other clinical specialities.
PurposeTo record a cardiovascular assessment and observations as part of diabetes management of a patient. Comprises part of the diabetes outpatient assessment.
References
Authorsdate: 2018-11-26; name: John Meredith; organisation: NHS Wales Informatics Service; email: john.meredith@wales.nhs.uk
Other Details Languagedate: 2018-11-26; name: John Meredith; organisation: NHS Wales Informatics Service; email: john.meredith@wales.nhs.uk
OtherDetails Language Independent{licence=This work is licensed under the Creative Commons Attribution-ShareAlike 3.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/3.0/., custodian_organisation=openEHR Foundation, PARENT:MD5-CAM-1.0.1=15173A4BF38FA171E47BBE704F3E0940, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=c93d7ebd97aa66799f67f86bcb16b8dc}
Keywordsdiabetes, WISDM, NHS Wales, cardiology, cardiovascular, assessment, observation
Language useden
Citeable Identifier1051.57.198
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supports interpretation of 24 hour ambulatory blood pressure records., 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='Cardiovascular Assessment']/items[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.blood_pressure.v1 and name/value='24 Hour Blood Pressure (Day)']/protocol[at0011], code=at0011, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Protocol, description=List structure., 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='Cardiovascular Assessment']/items[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.blood_pressure.v1 and name/value='24 Hour Blood Pressure (Night)'], code=at0000, itemType=OBSERVATION, level=3, text=24 Hour Blood Pressure (Night), description=The local measurement of arterial blood pressure which is a surrogate for arterial pressure in the systemic circulation. Most commonly, use of the term 'blood pressure' refers to measurement of brachial artery pressure in the upper arm., 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='Cardiovascular Assessment']/items[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.blood_pressure.v1 and name/value='24 Hour Blood Pressure (Night)']/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Data, description=History Structural node., 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='Cardiovascular Assessment']/items[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.blood_pressure.v1 and name/value='24 Hour Blood Pressure (Night)']/data[at0001]/events[at1042], code=at1042, itemType=INTERVAL_EVENT, level=5, text=24 hour average, description=Estimate of the average blood pressure over a 24 hour period., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=INTERVAL_EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Cardiovascular Assessment']/items[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.blood_pressure.v1 and name/value='24 Hour Blood Pressure (Night)']/data[at0001]/events[at1042]/data[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=6, 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='Cardiovascular Assessment']/items[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.blood_pressure.v1 and name/value='24 Hour Blood Pressure (Night)']/data[at0001]/events[at1042]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=7, text=Systolic, description=Peak systemic arterial blood pressure - measured in systolic or contraction phase of the heart cycle., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=0..1000 mm[Hg], extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Cardiovascular Assessment']/items[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.blood_pressure.v1 and name/value='24 Hour Blood Pressure (Night)']/data[at0001]/events[at1042]/data[at0003]/items[at0005], code=at0005, itemType=ELEMENT, level=7, text=Diastolic, description=Minimum systemic arterial blood pressure - measured in the diastolic or relaxation phase of the heart cycle., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=0..1000 mm[Hg], extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Cardiovascular Assessment']/items[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.blood_pressure.v1 and name/value='24 Hour Blood Pressure (Night)']/data[at0001]/events[at1042]/state[at0007], code=at0007, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=6, 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='Cardiovascular Assessment']/items[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.blood_pressure.v1 and name/value='24 Hour Blood Pressure (Night)']/data[at0001]/events[at1042]/state[at0007]/items[at0008], code=at0008, itemType=ELEMENT, level=7, text=Position, description=The position of the subject at the time of measurement., 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='Cardiovascular Assessment']/items[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.blood_pressure.v1 and name/value='24 Hour Blood Pressure (Night)']/data[at0001]/events[at1042]/state[at0007]/items[at1043], code=at1043, itemType=ELEMENT, level=7, text=Sleep status, description=Sleep status - supports interpretation of 24 hour ambulatory blood pressure records., 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='Cardiovascular Assessment']/items[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.blood_pressure.v1 and name/value='24 Hour Blood Pressure (Night)']/protocol[at0011], code=at0011, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Protocol, description=List structure., 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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.pulse.v1 and name/value='Pulse Character'], code=at0000, itemType=OBSERVATION, level=2, text=Pulse Character, description=Record details about the rate and associated attributes for a pulse or heart beat., 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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.pulse.v1 and name/value='Pulse Character']/data[at0002], code=at0002, 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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.pulse.v1 and name/value='Pulse Character']/data[at0002]/events[at0003], code=at0003, 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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.pulse.v1 and name/value='Pulse Character']/data[at0002]/events[at0003]/data[at0001], code=at0001, 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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.pulse.v1 and name/value='Pulse Character']/data[at0002]/events[at0003]/data[at0001]/items[at0005], code=at0005, itemType=ELEMENT, level=6, text=Regular?, description=Is the pulse or heart beat regular?, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Regular 
  • Irregular 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.pulse.v1 and name/value='Pulse Character']/data[at0002]/events[at0003]/data[at0001]/items[at1055], code=at1055, itemType=ELEMENT, level=6, text=Irregular type, description=More specific pattern of an irregular pulse or heart beat., comment=Selection of a value from this value set is only valid if 'Irregular' is selected from the 'Regularity' data element., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Regularly Irregular 
  • Irregularly Irregular 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.pulse.v1 and name/value='Pulse Character']/data[at0002]/events[at0003]/data[at0001]/items[at1023], code=at1023, itemType=ELEMENT, level=6, text=Rhythm, description=Specific conclusion about the rhythm of the pulse or heartbeat, drawn from a combination of the heart rate, pattern and other characteristics observed on examination., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: SNOMED-CT
  • Pulse regular 
  • Pulse regularly irregular 
  • Pulse irregularly irregular 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.pulse.v1 and name/value='Carotid Pulse Character'], code=at0000, itemType=OBSERVATION, level=2, text=Carotid Pulse Character, description=Record details about the rate and associated attributes for a pulse or heart beat., 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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.pulse.v1 and name/value='Carotid Pulse Character']/data[at0002], code=at0002, 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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.pulse.v1 and name/value='Carotid Pulse Character']/data[at0002]/events[at0003], code=at0003, 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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.pulse.v1 and name/value='Carotid Pulse Character']/data[at0002]/events[at0003]/data[at0001], code=at0001, 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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.pulse.v1 and name/value='Carotid Pulse Character']/data[at0002]/events[at0003]/data[at0001]/items[at1030], code=at1030, itemType=ELEMENT, level=6, text=Character, description=Description of the character of the pulse or heart beat., comment=Coding with a terminology is desired, where possible. For example: full, thready, bounding, slow rising, or collapsing. Multiple terms may be recorded., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Normal
  • Abnormal
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.pulse.v1 and name/value='Carotid Pulse Character']/data[at0002]/events[at0003]/data[at0001]/items[at1022], code=at1022, itemType=ELEMENT, level=6, text=Clinical description, description=Narrative description about the pulse or heart beat., 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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.pulse.v1 and name/value='Carotid Pulse Character']/data[at0002]/events[at0003]/data[at0001]/items[at1023], code=at1023, itemType=ELEMENT, level=6, text=(Clinical interpretation), description=Single word, phrase or brief description that represents the clinical meaning and significance of the pulse or heart beat findings, including the rhythm., comment=Coding with a terminology is preferred, where possible. For example: Bradycardia, Extrasystoles or Sinus rhythm. Multiple statements are allowed., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: SNOMED-CT
  • Carotid pulse present 
  • Carotid pulse absent 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.pulse.v1 and name/value='Carotid Pulse Character']/protocol[at0010], code=at0010, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Protocol, 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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.pulse.v1 and name/value='Carotid Pulse Character']/protocol[at0010]/items[at1037], code=at1037, itemType=ELEMENT, level=4, text=Body site, description=Body site where the pulse or heart beat were observed., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Coded TextValue set: external
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Carotid bruit'], code=at0000, itemType=OBSERVATION, level=2, text=Carotid bruit, description=Findings observed during the physical examination of a subject of care., 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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Carotid bruit']/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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Carotid bruit']/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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Carotid bruit']/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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Carotid bruit']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam.v1], code=at0000, itemType=CLUSTER, level=6, text=Examination findings, description=Findings observed during the physical examination of a body system or anatomical structure., 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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Carotid bruit']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=7, text=System or structure examined, description=Identification of the examined body system or anatomical structure., comment=For example: the very generic term "skin", which will likely require additional qualification using one of the 'Body site' data elements, or the complete phrase "skin of right knee". Coding of the system or structure examined with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Value set: external, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Carotid bruit']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam.v1]/items[at0002], code=at0002, itemType=ELEMENT, level=7, text=No abnormality detected, description=Statement that no abnormality was detected (NAD) on physical examination., comment=Record as True if no abnormality was detected on examination. Specific statements about the examination can be included in the 'Clinical Interpretation' data element. If 'No abnormality detected' is selected, then recording of other examination data elements becomes redundant, with the exception of only the 'Clinical interpretation' data element, which may be useful if a normal statement is desired for recording, for example 'Normal skin examination'., 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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Carotid bruit']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam.v1]/items[at0003], code=at0003, itemType=ELEMENT, level=7, text=Clinical description, description=Narrative description of the overall findings observed during the physical 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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Carotid bruit']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam.v1]/items[at0006], code=at0006, itemType=ELEMENT, level=7, text=Clinical interpretation, description=Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings., comment=Coding of the 'Clinical interpretation' with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: SNOMED-CT
  • Carotid bruit present 
  • Carotid bruit absent 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Apex beat'], code=at0000, itemType=OBSERVATION, level=2, text=Apex beat, description=Findings observed during the physical examination of a subject of care., 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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Apex beat']/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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Apex beat']/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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Apex beat']/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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Apex beat']/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=6, text=Description, description=Narrative description of the overall findings observed during a physical examination of a patient., comment=May be used to record a narrative summary of the complete clinical examination or key aspects of clinical examination findings, which will be supported by structured data. Details of specific structured findings can be included using CLUSTER archetypes in the 'Examination Detail' slot. This data element may be used to capture legacy data that is not available in a structured format., 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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Apex beat']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_heart.v0], code=at0000, itemType=CLUSTER, level=6, text=Examination of heart, description=Findings observed during the physical examination of the heart., 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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Apex beat']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_heart.v0]/items[at0002], code=at0002, itemType=ELEMENT, level=7, text=No abnormality detected, description=Statement that no abnormality was detected (NAD) on physical examination., comment=Record as True if no abnormality was detected on examination. Specific statements about the examination can be included in the 'Clinical Interpretation' data element., 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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Apex beat']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_heart.v0]/items[at0003], code=at0003, itemType=ELEMENT, level=7, text=Clinical description, description=Narrative description of the overall findings observed during the physical 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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Apex beat']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_heart.v0]/items[at0009], code=at0009, itemType=ELEMENT, level=7, text=Apex beat location, description=Relative location of the point of maximum impulse on palpation of the chest wall., comment=In adults the 'normal' position is usually described as the left 5th intercostal space, at the midclavicular line., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Normal 
  • Displaced 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Apex beat']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_heart.v0]/items[at0006], code=at0006, itemType=ELEMENT, level=7, text=Clinical interpretation, description=Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: SNOMED-CT
  • Normal character apex beat 
  • Feeble apex beat 
  • Thrusting apex beat 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Palpation for heaves\thrills'], code=at0000, itemType=OBSERVATION, level=2, text=Palpation for heaves\thrills, description=Findings observed during the physical examination of a subject of care., 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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Palpation for heaves\thrills']/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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Palpation for heaves\thrills']/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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Palpation for heaves\thrills']/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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Palpation for heaves\thrills']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam.v1], code=at0000, itemType=CLUSTER, level=6, text=Palpation for heaves\thrills findings, description=Findings observed during the physical examination of a body system or anatomical structure., 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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Palpation for heaves\thrills']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=7, text=System or structure examined, description=Identification of the examined body system or anatomical structure., comment=For example: the very generic term "skin", which will likely require additional qualification using one of the 'Body site' data elements, or the complete phrase "skin of right knee". Coding of the system or structure examined with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Value set: external, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Palpation for heaves\thrills']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam.v1]/items[at0002], code=at0002, itemType=ELEMENT, level=7, text=No abnormality detected, description=Statement that no abnormality was detected (NAD) on physical examination., comment=Record as True if no abnormality was detected on examination. Specific statements about the examination can be included in the 'Clinical Interpretation' data element. If 'No abnormality detected' is selected, then recording of other examination data elements becomes redundant, with the exception of only the 'Clinical interpretation' data element, which may be useful if a normal statement is desired for recording, for example 'Normal skin examination'., 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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Palpation for heaves\thrills']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam.v1]/items[at0003], code=at0003, itemType=ELEMENT, level=7, text=Clinical description, description=Narrative description of the overall findings observed during the physical 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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Palpation for heaves\thrills']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam.v1]/items[at0006], code=at0006, itemType=ELEMENT, level=7, text=Clinical interpretation, description=Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings., comment=Coding of the 'Clinical interpretation' with a terminology is preferred, where possible., 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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.jugular_venous_pressure.v0], code=at0000, itemType=OBSERVATION, level=2, text=Jugular venous pressure, description=The indirectly observed pressure over the venous system via visualization of the internal jugular vein., 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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.jugular_venous_pressure.v0]/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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.jugular_venous_pressure.v0]/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=1..1, occurencesText=Mandatory, 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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.jugular_venous_pressure.v0]/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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.jugular_venous_pressure.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0005], code=at0005, itemType=ELEMENT, level=6, text=JVP presence, description=The JVP is observed as present or absent., 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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.jugular_venous_pressure.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0027], code=at0027, itemType=ELEMENT, level=6, text=Clinical description, description=Narrative description about finding on observation of the jugular venous pressure., 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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.jugular_venous_pressure.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0006], code=at0006, itemType=ELEMENT, level=6, text=Character, description=Description of the character of the jugular wave., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Normal
  • Elevated
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.jugular_venous_pressure.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0028], code=at0028, itemType=ELEMENT, level=6, text=Clinical interpretation, description=Single word, phrase or brief description that represents the clinical meaning and significance of the jugular venous pressure., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: SNOMED-CT
  • Raised jugular venous pressure 
  • Normal jugular venous pressure 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Heart sounds'], code=at0000, itemType=OBSERVATION, level=2, text=Heart sounds, description=Findings observed during the physical examination of a subject of care., 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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Heart sounds']/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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Heart sounds']/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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Heart sounds']/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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Heart sounds']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam.v1], code=at0000, itemType=CLUSTER, level=6, text=Heart Sounds Findings, description=Findings observed during the physical examination of a body system or anatomical structure., 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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Heart sounds']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=7, text=System or structure examined, description=Identification of the examined body system or anatomical structure., comment=For example: the very generic term "skin", which will likely require additional qualification using one of the 'Body site' data elements, or the complete phrase "skin of right knee". Coding of the system or structure examined with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Value set: external, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Heart sounds']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam.v1]/items[at0002], code=at0002, itemType=ELEMENT, level=7, text=No abnormality detected, description=Statement that no abnormality was detected (NAD) on physical examination., comment=Record as True if no abnormality was detected on examination. Specific statements about the examination can be included in the 'Clinical Interpretation' data element. If 'No abnormality detected' is selected, then recording of other examination data elements becomes redundant, with the exception of only the 'Clinical interpretation' data element, which may be useful if a normal statement is desired for recording, for example 'Normal skin examination'., 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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Heart sounds']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam.v1]/items[at0003], code=at0003, itemType=ELEMENT, level=7, text=Clinical description, description=Narrative description of the overall findings observed during the physical 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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Heart sounds']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam.v1]/items[at0006], code=at0006, itemType=ELEMENT, level=7, text=Clinical interpretation, description=Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings., comment=Coding of the 'Clinical interpretation' with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: SNOMED-CT
  • Heart sounds abnormal 
  • Heart sounds normal 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Heart sounds']/data[at0001]/events[at0002]/state[at0009], code=at0009, 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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Heart sounds']/data[at0001]/events[at0002]/state[at0009]/items[at0008], code=at0008, itemType=ELEMENT, level=6, text=Confounding factors, description=Description of any incidental factors that may have contributed to the physical examination findings., 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], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Heart sounds']/data[at0001]/events[at0002]/state[at0009]/items[at0013], code=at0013, itemType=ELEMENT, level=6, 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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Heart murmurs'], code=at0000, itemType=OBSERVATION, level=2, text=Heart murmurs, description=Findings observed during the physical examination of a subject of care., 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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Heart murmurs']/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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Heart murmurs']/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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Heart murmurs']/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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Heart murmurs']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam.v1], code=at0000, itemType=CLUSTER, level=6, text=Heart Murmur Findings, description=Findings observed during the physical examination of a body system or anatomical structure., 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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Heart murmurs']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=7, text=System or structure examined, description=Identification of the examined body system or anatomical structure., comment=For example: the very generic term "skin", which will likely require additional qualification using one of the 'Body site' data elements, or the complete phrase "skin of right knee". Coding of the system or structure examined with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Value set: external, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Heart murmurs']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam.v1]/items[at0002], code=at0002, itemType=ELEMENT, level=7, text=No abnormality detected, description=Statement that no abnormality was detected (NAD) on physical examination., comment=Record as True if no abnormality was detected on examination. Specific statements about the examination can be included in the 'Clinical Interpretation' data element. If 'No abnormality detected' is selected, then recording of other examination data elements becomes redundant, with the exception of only the 'Clinical interpretation' data element, which may be useful if a normal statement is desired for recording, for example 'Normal skin examination'., 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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Heart murmurs']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam.v1]/items[at0003], code=at0003, itemType=ELEMENT, level=7, text=Clinical description, description=Narrative description of the overall findings observed during the physical 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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Heart murmurs']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam.v1]/items[at0006], code=at0006, itemType=ELEMENT, level=7, text=Clinical interpretation, description=Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings., comment=Coding of the 'Clinical interpretation' with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: SNOMED-CT
  • Heart murmur absent 
  • Observation of heart murmur 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Heart murmurs']/data[at0001]/events[at0002]/state[at0009], code=at0009, 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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Heart murmurs']/data[at0001]/events[at0002]/state[at0009]/items[at0008], code=at0008, itemType=ELEMENT, level=6, text=Confounding factors, description=Description of any incidental factors that may have contributed to the physical examination findings., 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], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Heart murmurs']/data[at0001]/events[at0002]/state[at0009]/items[at0013], code=at0013, itemType=ELEMENT, level=6, 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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Peripheral oedema'], code=at0000, itemType=OBSERVATION, level=2, text=Peripheral oedema, description=Findings observed during the physical examination of a subject of care., 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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Peripheral oedema']/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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Peripheral oedema']/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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Peripheral oedema']/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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Peripheral oedema']/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=6, text=Description, description=Narrative description of the overall findings observed during a physical examination of a patient., comment=May be used to record a narrative summary of the complete clinical examination or key aspects of clinical examination findings, which will be supported by structured data. Details of specific structured findings can be included using CLUSTER archetypes in the 'Examination Detail' slot. This data element may be used to capture legacy data that is not available in a structured format., 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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Peripheral oedema']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam.v1 and name/value='Pedal Oedema Finding'], code=at0000, itemType=CLUSTER, level=6, text=Pedal Oedema Finding, description=Findings observed during the physical examination of a body system or anatomical structure., 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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Peripheral oedema']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam.v1 and name/value='Pedal Oedema Finding']/items[at0001], code=at0001, itemType=ELEMENT, level=7, text=System or structure examined, description=Identification of the examined body system or anatomical structure., comment=For example: the very generic term "skin", which will likely require additional qualification using one of the 'Body site' data elements, or the complete phrase "skin of right knee". Coding of the system or structure examined with a terminology is preferred, 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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Peripheral oedema']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam.v1 and name/value='Pedal Oedema Finding']/items[at0002], code=at0002, itemType=ELEMENT, level=7, text=No abnormality detected, description=Statement that no abnormality was detected (NAD) on physical examination., comment=Record as True if no abnormality was detected on examination. Specific statements about the examination can be included in the 'Clinical Interpretation' data element. If 'No abnormality detected' is selected, then recording of other examination data elements becomes redundant, with the exception of only the 'Clinical interpretation' data element, which may be useful if a normal statement is desired for recording, for example 'Normal skin examination'., 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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Peripheral oedema']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam.v1 and name/value='Pedal Oedema Finding']/items[at0006], code=at0006, itemType=ELEMENT, level=7, text=Clinical interpretation, description=Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings., comment=Coding of the 'Clinical interpretation' with a terminology is preferred, where possible., 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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Peripheral oedema']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam.v1 and name/value='Sacral Oedema Finding'], code=at0000, itemType=CLUSTER, level=6, text=Sacral Oedema Finding, description=Findings observed during the physical examination of a body system or anatomical structure., 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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Peripheral oedema']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam.v1 and name/value='Sacral Oedema Finding']/items[at0001], code=at0001, itemType=ELEMENT, level=7, text=System or structure examined, description=Identification of the examined body system or anatomical structure., comment=For example: the very generic term "skin", which will likely require additional qualification using one of the 'Body site' data elements, or the complete phrase "skin of right knee". Coding of the system or structure examined with a terminology is preferred, 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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Peripheral oedema']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam.v1 and name/value='Sacral Oedema Finding']/items[at0002], code=at0002, itemType=ELEMENT, level=7, text=No abnormality detected, description=Statement that no abnormality was detected (NAD) on physical examination., comment=Record as True if no abnormality was detected on examination. Specific statements about the examination can be included in the 'Clinical Interpretation' data element. If 'No abnormality detected' is selected, then recording of other examination data elements becomes redundant, with the exception of only the 'Clinical interpretation' data element, which may be useful if a normal statement is desired for recording, for example 'Normal skin examination'., 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='Cardiovascular Assessment']/items[openEHR-EHR-OBSERVATION.exam.v1 and name/value='Peripheral oedema']/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam.v1 and name/value='Sacral Oedema Finding']/items[at0006], code=at0006, itemType=ELEMENT, level=7, text=Clinical interpretation, description=Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings., comment=Coding of the 'Clinical interpretation' with a terminology is preferred, where possible., 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]