TEMPLATE DENWIS_Observations (DENWIS_Observations)

TEMPLATE IDDENWIS_Observations
ConceptDENWIS_Observations
DescriptionTo record nurses' 'worry' as a predictor of deteriorating surgical ward patients.
UseTo record nurses' 'worry' as a predictor of deteriorating surgical ward patients.
PurposeTo record nurses' 'worry' as a predictor of deteriorating surgical ward patients.
References
Authorsdate: 2019-11-07; name: Alan Fish; organisation: Apperta UK; email: alan.fish@apperta.org
Other Details Languagedate: 2019-11-07; name: Alan Fish; organisation: Apperta UK; email: alan.fish@apperta.org
OtherDetails Language Independent{licence=This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/., custodian_organisation=Apperta UK, PARENT:MD5-CAM-1.0.1=15173A4BF38FA171E47BBE704F3E0940, original_namespace=org.openehr, original_publisher=Apperta UK, custodian_namespace=org.openehr}
Keywordsobservations, vital, signs, early, warning, score, nurse, dutch
Language useden
Citeable Identifier1051.57.221
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  • 0: No change in breathing  [No change in breathing.]
  • 1: Change in breathing  [Change in breathing.]
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  •  Coded Text
    • Noisy breathing  [Noisy breathing.]
    • Short of breath  [Short of breath.]
    • Unable to speak full sentences  [Unable to speak in full sentences.]
    • Use accessory muscles  [Use accessory muscles.]
  •  Text
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  • 0: No change in circulation  [No change in circulation.]
  • 1: Change in circulation  [Change in circulation.]
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  •  Coded Text
    • Colour changes: pale, grey  [Colour changes: pale, grey.]
    • Sweaty/clammy  [Sweaty/clammy.]
    • Coldness  [Coldness.]
    • Impaired perfusion  [Impaired perfusion.]
  •  Text
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  • 0: No change in temperature  [No change in temperature.]
  • 1: Change in temperature  [Change in temperature.]
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  •  Coded Text
    • Rigors  [Rigors.]
  •  Text
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  • 0: No change in mentation  [No change in mentation.]
  • 1: Change in mentation  [Change in mentation.]
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  •  Text
  •  Coded Text
    • Lethargic  [Lethargic.]
    • Confused  [Confused.]
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  • 0: No agitation  [No agitation.]
  • 1: Agitation  [Agitation.]
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  •  Text
  •  Coded Text
    • Restless  [Restless.]
    • Anxious  [Anxious.]
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  • 0: No change in pain  [No change in pain.]
  • 1: Change in pain  [Change in pain.]
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  •  Coded Text
    • New pain  [New pain.]
    • Increasing or consisting pain  [Increasing or consisting pain.]
  •  Text
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  • 0: No change in trajectory  [No change in trajectory.]
  • 1: Change in trajectory  [Change in trajectory.]
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  •  Coded Text
    • No progress  [No progress.]
    • Abdominal distension/nausea/bleeding  [Abdominal distension/nausea/bleeding.]
  •  Text
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  • 0: No subjective patient indicator  [No subjective patient indicator.]
  • 1: Subjective patient indicator  [Subjective patient indicator.]
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  •  Coded Text
    • Not feeling well  [Not feeling well.]
    • Feeling of impending doom  [Feeling of impending doom.]
  •  Text
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  • 0: No nurse subjective indicator  [No nurse subjective indicator.]
  • 1: Nurse subjective indicator  [Nurse subjective indicator.]
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  •  Coded Text
    • Change in behaviour  [Change in behaviour.]
    • Doesn't look good  [Doesn't look good.]
  •  Text
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of an investigation performed on specimens collected from an individual or related to that individual., 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.laboratory_test_result.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=2, 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-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=3, 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-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, 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-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0005], code=at0005, itemType=ELEMENT, level=5, text=Test name, description=Name of the laboratory investigation performed on the specimen(s)., comment=A test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=Default value: Blood glucose, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.laboratory_test_analyte.v1], code=at0000, itemType=CLUSTER, level=5, text=Laboratory analyte result, description=The result of a laboratory test for a single analyte value., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.laboratory_test_analyte.v1]/items[at0024], code=at0024, itemType=ELEMENT, level=6, text=Analyte name, description=The name of the analyte result., comment=The value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies., uncommonOntologyItems={fhir_mapping=Observation.code, hl7v2_mapping=OBX.3}, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=Default value: Blood glucose, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.laboratory_test_analyte.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=6, text=Analyte result, description=The value of the analyte result., comment=For example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details., uncommonOntologyItems={fhir_mapping=Observation.value[x], hl7v2_mapping=OBX.2, OBX.5, OBX.6, OBX.7, OBX.8}, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=Units: mmol/l, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/state[at0112], code=at0112, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, 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.laboratory_test_result.v1]/protocol[at0004], code=at0004, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=2, 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-OBSERVATION.laboratory_test_result.v1]/protocol[at0004]/items[at0111], code=at0111, itemType=ELEMENT, level=3, text=Point-of-care test, description=This indicates whether the test was performed directly at Point-of-Care (POCT) as opposed to a formal result from a laboratory or other service delivery organisation., comment=True if the test was performed directly at Point-of-Care (POCT)., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=Default value: true, extendedValues=null]], templateType=normal]