TEMPLATE Test NEWS2 Template (Test NEWS2 Template)

TEMPLATE IDTest NEWS2 Template
ConceptTest NEWS2 Template
DescriptionNot Specified
PurposeNot Specified
References
Authorsname: Ian McNicoll; organisation: freshEHR Clinical Informatics Ltd.; email: ian@freshehr.com; date: 2020-03-23
Other Details Languagename: Ian McNicoll; organisation: freshEHR Clinical Informatics Ltd.; email: ian@freshehr.com; date: 2020-03-23
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=openEHR Foundation, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr}
Language useden
Citeable Identifier1051.57.238
AllOperationalTemplate [rootArchetypeId=openEHR-EHR-COMPOSITION.encounter.v1, otherContributors=null, tshis=[ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1], code=at0000, itemType=COMPOSITION, level=0, text=Test NEWS2 Template, 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], code=at0000, itemType=SECTION, level=1, text=NEWS2, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, 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]/items[openEHR-EHR-OBSERVATION.denwis.v0], code=at0000, itemType=OBSERVATION, level=2, text=DENWIS, description=Dutch Early Nurse Worry Indicator Score (DENWIS), 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]/items[openEHR-EHR-OBSERVATION.denwis.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]/items[openEHR-EHR-OBSERVATION.denwis.v0]/data[at0001]/events[at0002], code=at0002, itemType=POINT_EVENT, level=4, text=Point in time, description=A specific date and/or time 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]/items[openEHR-EHR-OBSERVATION.denwis.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]/items[openEHR-EHR-OBSERVATION.denwis.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0028], code=at0028, itemType=ELEMENT, level=6, text=Q1 Breathing, description=Nurse recorded changes in breathing., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_ORDINAL, bindings=null, values=
  • 0: No change in breathing 
  • 1: Change in breathing 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.denwis.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0062], code=at0062, itemType=ELEMENT, level=6, text=Breathing indicator, description=Nurse recorded the indication that there are changes in breathing., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Coded Text
    • Noisy breathing 
    • Short of breath 
    • Unable to speak full sentences 
    • Use accessory muscles 
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.denwis.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0033], code=at0033, itemType=ELEMENT, level=6, text=Q2 Circulation, description=Nurse recorded changes in circulation., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_ORDINAL, bindings=null, values=
  • 0: No change in circulation 
  • 1: Change in circulation 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.denwis.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0071], code=at0071, itemType=ELEMENT, level=6, text=Circulation indicator, description=Nurse recorded changes in circulation., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Coded Text
    • Colour changes: pale, grey 
    • Sweaty/clammy 
    • Coldness 
    • Impaired perfusion 
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.denwis.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0038], code=at0038, itemType=ELEMENT, level=6, text=Q3 Temperature, description=Nurse recorded changes in temperature., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_ORDINAL, bindings=null, values=
  • 0: No change in temperature 
  • 1: Change in temperature 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.denwis.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0076], code=at0076, itemType=ELEMENT, level=6, text=Temperature indicator, description=Nurse recorded changes in temperature., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Coded Text
    • Rigors 
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.denwis.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0043], code=at0043, itemType=ELEMENT, level=6, text=Q4 Mentation, description=Nurse recorded changes in mentation., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_ORDINAL, bindings=null, values=
  • 0: No change in mentation 
  • 1: Change in mentation 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.denwis.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0078], code=at0078, itemType=ELEMENT, level=6, text=Mentation indicator, description=Nurse recorded changes in mentation., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Text
  •  Coded Text
    • Lethargic 
    • Confused 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.denwis.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0047], code=at0047, itemType=ELEMENT, level=6, text=Q5 Agitation, description=Nurse recorded changes in agitation., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_ORDINAL, bindings=null, values=
  • 0: No agitation 
  • 1: Agitation 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.denwis.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0081], code=at0081, itemType=ELEMENT, level=6, text=Agitation indicator, description=Nurse recorded changes in agitation., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Text
  •  Coded Text
    • Restless 
    • Anxious 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.denwis.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0050], code=at0050, itemType=ELEMENT, level=6, text=Q6 Pain, description=Nurse recorded changes in pain., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_ORDINAL, bindings=null, values=
  • 0: No change in pain 
  • 1: Change in pain 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.denwis.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0084], code=at0084, itemType=ELEMENT, level=6, text=Pain indicator, description=Nurse recorded changes in pain., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Coded Text
    • New pain 
    • Increasing or consisting pain 
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.denwis.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0053], code=at0053, itemType=ELEMENT, level=6, text=Q7 Trajectory, description=Nurse recorded unexpected trajectory., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_ORDINAL, bindings=null, values=
  • 0: No change in trajectory 
  • 1: Change in trajectory 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.denwis.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0087], code=at0087, itemType=ELEMENT, level=6, text=Trajectory indicator, description=Nurse recorded unexpected trajectory., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Coded Text
    • No progress 
    • Abdominal distension/nausea/bleeding 
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.denwis.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0056], code=at0056, itemType=ELEMENT, level=6, text=Q8 Patient subjective, description=Nurse recorded patient indicators., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_ORDINAL, bindings=null, values=
  • 0: No subjective patient indicator 
  • 1: Subjective patient indicator 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.denwis.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0090], code=at0090, itemType=ELEMENT, level=6, text=Patient indicator, description=Nurse recorded patient indicators., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Coded Text
    • Not feeling well 
    • Feeling of impending doom 
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.denwis.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0059], code=at0059, itemType=ELEMENT, level=6, text=Q9 Nurse subjective, description=Nurse recorded subjective observation., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_ORDINAL, bindings=null, values=
  • 0: No nurse subjective indicator 
  • 1: Nurse subjective indicator 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.denwis.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0093], code=at0093, itemType=ELEMENT, level=6, text=Nurse subjective indicator, description=Nurse recorded subjective observation., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Coded Text
    • Change in behaviour 
    • Doesn't look good 
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.denwis.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0008], code=at0008, itemType=ELEMENT, level=6, text=Total score, description=The total score for the four questions., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=0..9, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.denwis.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0027], code=at0027, itemType=ELEMENT, level=6, text=Comment, description=Narrative comment., 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]/items[openEHR-EHR-OBSERVATION.body_temperature.v1], code=at0000, itemType=OBSERVATION, level=2, text=Body temperature, description=A measurement of the body temperature, which is a surrogate for the whole body temperature of the person., 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]/items[openEHR-EHR-OBSERVATION.body_temperature.v1]/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]/items[openEHR-EHR-OBSERVATION.body_temperature.v1]/data[at0002]/events[at0003], code=at0003, itemType=EVENT, level=4, text=Any event, description=Any event., 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]/items[openEHR-EHR-OBSERVATION.body_temperature.v1]/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]/items[openEHR-EHR-OBSERVATION.body_temperature.v1]/data[at0002]/events[at0003]/data[at0001]/items[at0004], code=at0004, itemType=ELEMENT, level=6, text=Temperature, description=The measured body temperature (as a surrogate for the whole body)., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=Units:
  • °C
  • °F
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.pulse_oximetry.v1], code=at0000, itemType=OBSERVATION, level=2, text=Pulse oximetry, description=Blood oxygen and related measurements, measured by pulse oximetry or pulse CO-oximetry., 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]/items[openEHR-EHR-OBSERVATION.pulse_oximetry.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]/items[openEHR-EHR-OBSERVATION.pulse_oximetry.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]/items[openEHR-EHR-OBSERVATION.pulse_oximetry.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]/items[openEHR-EHR-OBSERVATION.pulse_oximetry.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0006], code=at0006, itemType=ELEMENT, level=6, text=SpO₂, description=The saturation of oxygen in the peripheral blood, measured via pulse oximetry., comment=SpO₂ is defined as the percentage of oxyhaemoglobin (HbO₂) to the total concentration of haemoglobin (HbO₂ + deoxyhaemoglobin) in peripheral blood., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_PROPORTION, bindings=null, values=
  • Percent
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.pulse.v1], code=at0000, itemType=OBSERVATION, level=2, text=Pulse/Heart beat, 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]/items[openEHR-EHR-OBSERVATION.pulse.v1]/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]/items[openEHR-EHR-OBSERVATION.pulse.v1]/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]/items[openEHR-EHR-OBSERVATION.pulse.v1]/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]/items[openEHR-EHR-OBSERVATION.pulse.v1]/data[at0002]/events[at0003]/data[at0001]/items[at0004], code=at0004, itemType=ELEMENT, level=6, text=Pulse Rate, description=The pulse rate, measured in beats per minute., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=>=0 /min, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.pulse.v1]/data[at0002]/events[at1036], code=at1036, itemType=INTERVAL_EVENT, level=4, text=Maximum, description=Maximum pulse rate or heart rate observed during a period of exertion., 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]/items[openEHR-EHR-OBSERVATION.pulse.v1]/data[at0002]/events[at1036]/data[at0001 and name/value='structure'], 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]/items[openEHR-EHR-OBSERVATION.pulse.v1]/data[at0002]/events[at1036]/data[at0001 and name/value='structure']/items[at1005], code=at1005, itemType=ELEMENT, level=6, text=(Presence), description=Presence of a pulse or heart beat., comment=It can be implied that the pulse is present if Rate >0 beats/min., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present 
  • Not detected 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.pulse.v1]/data[at0002]/events[at1036]/data[at0001 and name/value='structure']/items[at0004], code=at0004, itemType=ELEMENT, level=6, text=(Rate), description=The rate, measured in beats per minute., comment=Run-time name constraints have been specified, in order to simplify the renaming of this data element to Pulse Rate or Heart Rate, as required., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=>=0 /min, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.pulse.v1]/data[at0002]/events[at1036]/data[at0001 and name/value='structure']/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]/items[openEHR-EHR-OBSERVATION.pulse.v1]/data[at0002]/events[at1036]/data[at0001 and name/value='structure']/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]/items[openEHR-EHR-OBSERVATION.pulse.v1]/data[at0002]/events[at1036]/data[at0001 and name/value='structure']/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=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.pulse.v1]/data[at0002]/events[at1036]/data[at0001 and name/value='structure']/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]/items[openEHR-EHR-OBSERVATION.pulse.v1]/data[at0002]/events[at1036]/data[at0001 and name/value='structure']/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_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.pulse.v1]/data[at0002]/events[at1036]/data[at0001 and name/value='structure']/items[at1059], code=at1059, itemType=ELEMENT, level=6, text=Comment, description=Additional narrative about the pulse or heart beat 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]/items[openEHR-EHR-OBSERVATION.pulse.v1]/data[at0002]/events[at1036]/data[at0001 and name/value='structure'], 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]/items[openEHR-EHR-OBSERVATION.pulse.v1]/data[at0002]/events[at1036]/data[at0001 and name/value='structure']/items[at1005], code=at1005, itemType=ELEMENT, level=6, text=(Presence), description=Presence of a pulse or heart beat., comment=It can be implied that the pulse is present if Rate >0 beats/min., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present 
  • Not detected 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.pulse.v1]/data[at0002]/events[at1036]/data[at0001 and name/value='structure']/items[at0004], code=at0004, itemType=ELEMENT, level=6, text=(Rate), description=The rate, measured in beats per minute., comment=Run-time name constraints have been specified, in order to simplify the renaming of this data element to Pulse Rate or Heart Rate, as required., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=>=0 /min, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.pulse.v1]/data[at0002]/events[at1036]/data[at0001 and name/value='structure']/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]/items[openEHR-EHR-OBSERVATION.pulse.v1]/data[at0002]/events[at1036]/data[at0001 and name/value='structure']/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]/items[openEHR-EHR-OBSERVATION.pulse.v1]/data[at0002]/events[at1036]/data[at0001 and name/value='structure']/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=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.pulse.v1]/data[at0002]/events[at1036]/data[at0001 and name/value='structure']/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]/items[openEHR-EHR-OBSERVATION.pulse.v1]/data[at0002]/events[at1036]/data[at0001 and name/value='structure']/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_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.pulse.v1]/data[at0002]/events[at1036]/data[at0001 and name/value='structure']/items[at1059], code=at1059, itemType=ELEMENT, level=6, text=Comment, description=Additional narrative about the pulse or heart beat 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]/items[openEHR-EHR-OBSERVATION.pulse.v1]/data[at0002]/events[at1036]/state[at0012 and name/value='List'], code=at0012, 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]/items[openEHR-EHR-OBSERVATION.pulse.v1]/data[at0002]/events[at1036]/state[at0012 and name/value='List']/items[at0013], code=at0013, itemType=ELEMENT, level=6, text=Position, description=The body position of the subject during the observation., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Standing/upright 
  • Sitting 
  • Reclining 
  • Lying 
Assumed value: Sitting, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.pulse.v1]/data[at0002]/events[at1036]/state[at0012 and name/value='List']/items[at1018], code=at1018, itemType=ELEMENT, level=6, text=Confounding factors, description=Narrative description about any incidental factors that may affect interpretation of the physical findings., comment=For example, presence of a pacemaker, level of anxiety; pain or fever etc., 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]/items[openEHR-EHR-OBSERVATION.pulse.v1]/data[at0002]/events[at1036]/state[at0012 and name/value='List'], code=at0012, 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]/items[openEHR-EHR-OBSERVATION.pulse.v1]/data[at0002]/events[at1036]/state[at0012 and name/value='List']/items[at0013], code=at0013, itemType=ELEMENT, level=6, text=Position, description=The body position of the subject during the observation., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Standing/upright 
  • Sitting 
  • Reclining 
  • Lying 
Assumed value: Sitting, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.pulse.v1]/data[at0002]/events[at1036]/state[at0012 and name/value='List']/items[at1018], code=at1018, itemType=ELEMENT, level=6, text=Confounding factors, description=Narrative description about any incidental factors that may affect interpretation of the physical findings., comment=For example, presence of a pacemaker, level of anxiety; pain or fever etc., 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]/items[openEHR-EHR-OBSERVATION.respiration.v1], code=at0000, itemType=OBSERVATION, level=2, text=Respirations, description=The observed characteristics of spontaneous breathing as would commonly be recorded as part of a 'vital signs' examination., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.respiration.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]/items[openEHR-EHR-OBSERVATION.respiration.v1]/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=4, text=Any event, description=Generic event., 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]/items[openEHR-EHR-OBSERVATION.respiration.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]/items[openEHR-EHR-OBSERVATION.respiration.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=6, text=Rate, description=Rate of respiration., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=0..200 /min, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.acvpu.v0], code=at0000, itemType=OBSERVATION, level=2, text=ACVPU scale, description=Simple scale used as part of an assessment to measure and record an individual's level of consciousness., comment=ACVPU is an acronym for 'Alert', 'Confusion', 'Voice', 'Pain', 'Unresponsive'., 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]/items[openEHR-EHR-OBSERVATION.acvpu.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]/items[openEHR-EHR-OBSERVATION.acvpu.v0]/data[at0001]/events[at0002], code=at0002, itemType=POINT_EVENT, level=4, text=Any point in time event, description=Default, unspecified point in time 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=POINT_EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.acvpu.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]/items[openEHR-EHR-OBSERVATION.acvpu.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=6, text=ACVPU, description=The assessment of the patient's level of consciousness., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Alert 
  • Confusion 
  • Voice 
  • Pain 
  • Unresponsive 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.news2.v0], code=at0000, itemType=OBSERVATION, level=2, text=NEWS2, description=Standardised assessment score used to improve the detection of and response to clinical deterioration in patients with acute illness. This is the second version of the National Early Warning Score, issued by the UK Royal College of Physicians in 2017., 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]/items[openEHR-EHR-OBSERVATION.news2.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]/items[openEHR-EHR-OBSERVATION.news2.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=In most practical situations this event will be constrained to a Point in time event., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, 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]/items[openEHR-EHR-OBSERVATION.news2.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]/items[openEHR-EHR-OBSERVATION.news2.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0006], code=at0006, itemType=ELEMENT, level=6, text=Respiration rate, description=Range category for the respiratory rate measurement., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_ORDINAL, bindings=null, values=
  • 0: 12-20 
  • 1: 9-11 
  • 2: 21-24 
  • 3: <=8 or >=25 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.news2.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0029], code=at0029, itemType=ELEMENT, level=6, text=SpO₂ Scale 1, description=Range category for the oxygen saturation measurement., comment=SpO2 Scale 1 and Scale 2 are variations of the same physiological parameter to be used in different clinical scenarios. Scale 1 will be appropriate for most patients. Do not use Scale 1 in patients with a prescribed oxygen saturation requirement of 88–92%, such as patients with hypercapnic respiratory failure., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_ORDINAL, bindings=null, values=
  • 0: >= 96 
  • 1: 94-95 
  • 2: 92-93 
  • 3: <=91 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.news2.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0047], code=at0047, itemType=ELEMENT, level=6, text=SpO₂ Scale 2, description=Range category for the oxygen saturation measurement only for use in patients with a prescribed oxygen saturation requirement of 88–92%, such as hypercapnic respiratory failure., comment=SpO2 Scale 1 and Scale 2 are variations of the same physiological parameter to be used in different clinical scenarios. Use Scale 2 in patients confirmed to have hypercapnic respiratory failure on blood gas analysis on either a prior, or their current, hospital admission. Use Scale 1 for all other patients., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_ORDINAL, bindings=null, values=
  • 0: 88-92 or >=93 on air 
  • 1: 86-87 or 93-94 on O₂ 
  • 2: 84-85 or 95-96 on O₂ 
  • 3: <=83 or >=97 on O₂ 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.news2.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0034], code=at0034, itemType=ELEMENT, level=6, text=Air or oxygen?, description=Assessment carried out breathing air or supplemental oxygen., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_ORDINAL, bindings=null, values=
  • 0: Air 
  • 2: Oxygen 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.news2.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=6, text=Systolic blood pressure, description=Range category for the systolic blood pressure measurement., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_ORDINAL, bindings=null, values=
  • 0: 111-219 
  • 1: 101-110 
  • 2: 91-100 
  • 3: <=90 or >= 220 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.news2.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0005], code=at0005, itemType=ELEMENT, level=6, text=Pulse, description=Range category for the pulse measurement., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_ORDINAL, bindings=null, values=
  • 0: 51-90 
  • 1: 41-50 or 91-110 
  • 2: 111-130 
  • 3: <=40 or >=131 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.news2.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0008], code=at0008, itemType=ELEMENT, level=6, text=Consciousness, description=Observed category for the ACVPU scale rating of conscious state., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_ORDINAL, bindings=null, values=
  • 0: Alert 
  • 3: Confusion, V, P or U 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.news2.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0007], code=at0007, itemType=ELEMENT, level=6, text=Temperature, description=Range category for the body temperature measurement., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_ORDINAL, bindings=null, values=
  • 0: 36.1-38.0 
  • 1: 35.1-36.0 or 38.1-39.0 
  • 2: >=39.1 
  • 3: <=35.0 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.news2.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0028], code=at0028, itemType=ELEMENT, level=6, text=NEWS2 total score, description=The total sum of ordinal values associated with six relevant NEWS2 physiological parameters, plus the supplemental oxygen weighting score., comment=Total score may be generated at run-time., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=0..20, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.news2.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0056], code=at0056, itemType=ELEMENT, level=6, text=Clinical risk category, description=Overall category representing the urgency and scale of the clinical response required in response to the physiological parameters., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Low 
  • Low-medium 
  • Medium 
  • High 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.news2.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0044], code=at0044, itemType=ELEMENT, level=6, text=Comment, description=Additional narrative about the overall NEWS2 score 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]/items[openEHR-EHR-OBSERVATION.news2.v0]/data[at0001]/events[at0002]/state[at0041], code=at0041, 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]/items[openEHR-EHR-OBSERVATION.news2.v0]/data[at0001]/events[at0002]/state[at0041]/items[openEHR-EHR-CLUSTER.inspired_oxygen.v1], code=at0000, itemType=CLUSTER, level=6, text=Inspired oxygen, description=The amount of oxygen being delivered, or to be delivered, to the patient given as a fraction, percentage or indirectly as a flow rate., comment=null, uncommonOntologyItems=null, occurencesFormal=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]/items[openEHR-EHR-OBSERVATION.news2.v0]/data[at0001]/events[at0002]/state[at0041]/items[openEHR-EHR-CLUSTER.inspired_oxygen.v1]/items[at0051], code=at0051, itemType=ELEMENT, level=7, text=Flow rate, description=Oxygen flow rate given to an individual., comment=For example '5 l/min'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=0..50000; 0..50
Units:
  • ml/min
  • l/min
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.news2.v0]/data[at0001]/events[at0002]/state[at0041]/items[openEHR-EHR-CLUSTER.inspired_oxygen.v1]/items[at0052], code=at0052, itemType=ELEMENT, level=7, text=FiO₂, description=Fraction of oxygen in inspired air., comment=For example: '0.28'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_PROPORTION, bindings=null, values=
  • Unitary
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.news2.v0]/data[at0001]/events[at0002]/state[at0041]/items[openEHR-EHR-CLUSTER.inspired_oxygen.v1]/items[at0053], code=at0053, itemType=ELEMENT, level=7, text=Percent O₂, description=Percentage of oxygen in inspired air., comment=For example: '24 %', uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_PROPORTION, bindings=null, values=
  • Percent
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.news2.v0]/data[at0001]/events[at0002]/state[at0041]/items[openEHR-EHR-CLUSTER.inspired_oxygen.v1]/items[at0057], code=at0057, itemType=ELEMENT, level=7, text=On air, description=The patient is receiving air, equivalent to 21% O₂ or 0.21 FiO₂ and an oxygen flow rate of 0 litres per minute., comment=Where 'On air' is set to true, Flow rate, FiO₂ and Percent O₂ should not be recorded. Conversely 'On air' should be omitted if Flow rate, FiO₂ or Percent O₂ are recorded., 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]/items[openEHR-EHR-OBSERVATION.news2.v0]/data[at0001]/events[at0002]/state[at0041]/items[at0043], code=at0043, itemType=ELEMENT, level=6, text=Confounding factors, description=Record any issues or factors that may impact on the NEWS2 assessment., comment=For example: presence of pain; pregnancy., 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-EVALUATION.cpr_decision_uk.v0], code=at0000, itemType=EVALUATION, level=1, text=CPR decision, description=The advance recommendation as to whether cardio-pulmonary resuscitation should be undertaken or not. This is generally referred to in UK clinical guidance as the CPR (Cardio-pulmonary resuscitation) decision., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-EVALUATION.cpr_decision_uk.v0]/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-EVALUATION.cpr_decision_uk.v0]/data[at0001]/items[at0003], code=at0003, itemType=ELEMENT, level=3, text=CPR decision, description=The advance recommendation as to whether cardiopulmonary resuscitation (CPR) should be attempted. In some cases a clear answer may not be available to the recording clinician., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • CPR attempts recommended adult or child 
  • CPR attempts not recommended adult or child. 
  • CPR decision status unknown 
  • For modified CPR child only 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-EVALUATION.cpr_decision_uk.v0]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=3, text=Date of CPR decision, description=The date at which the CPR decision was originally taken or last reviewed., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-EVALUATION.advance_care_directive.v0], code=at0000, itemType=EVALUATION, level=1, text=Advance care directive, description=A framework to communicate the preferences of an individual for future medical treatment or end-of-life care., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-EVALUATION.advance_care_directive.v0]/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-EVALUATION.advance_care_directive.v0]/data[at0001]/items[at0005], code=at0005, itemType=ELEMENT, level=3, text=Type of directive, description=The type of advance care directive., comment=A short text description of the nature of the advance care directive. Coding of the type of directive with a terminology is preferred, where possible. It is expected that this is largely localised to reflect local policy and legislation. For example, in the Netherlands, advance care directive types include, but are not limited to, 'Treatment prohibition', 'Treatment prohibition with completion of Completed Life', 'Euthanasia request' and 'Declaration of life'. In the UK, advance care directive types include 'Advance Decision', 'Advance Directive' and 'Advance Statement'., 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-EVALUATION.advance_care_directive.v0]/data[at0001]/items[at0004], code=at0004, itemType=ELEMENT, level=3, text=Status, description=The status of the advance care directive., comment=Coding of the advance care directive status with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Coded Text
    • Present 
    • Absent 
    • Unknown 
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-EVALUATION.advance_care_directive.v0]/data[at0001]/items[at0006], code=at0006, itemType=ELEMENT, level=3, text=Description, description=Narrative description of the overall advance care directive., comment=May be used to record a narrative overview of the complete advance care directive, which may or may not be supported by structured data. Details of specific structured findings can be included using CLUSTER archetypes in the 'Directive details' 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-EVALUATION.advance_care_directive.v0]/data[at0001]/items[at0007], code=at0007, itemType=ELEMENT, level=3, text=Condition, description=The conditions or situations in which the individual wishes the advance care directive to apply., comment=For example: dementia, brain injury, diseases of the central nervous system, and terminal illness. Coding with a terminology is preferred, where possible. The advance care directive applies to all specified conditions if the individual can no longer make or communicate decisions about their medical treatment and is unlikely to regain the ability to make such decisions. Details of specific decisions that apply to different conditions or situations can be included using CLUSTER archetypes in the 'Directive details' slot., 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-EVALUATION.advance_care_directive.v0]/data[at0001]/items[at0058], code=at0058, itemType=CLUSTER, level=3, text=Location details, description=Information regarding where the advance care directive is stored and who has a copy of it., 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-EVALUATION.advance_care_directive.v0]/data[at0001]/items[at0058]/items[at0030], code=at0030, itemType=ELEMENT, level=4, text=Location, description=Information regarding where the advance care directive is stored and how to gain access to it., comment=For example, 'In the top drawer of the bedside table'., 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-EVALUATION.advance_care_directive.v0]/protocol[at0010], code=at0010, 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-EVALUATION.advance_care_directive.v0]/protocol[at0010]/items[at0053], code=at0053, itemType=ELEMENT, level=3, text=Valid period start, description=The date/time that marks the beginning of the valid period of time for this advance care directive., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-EVALUATION.advance_care_directive.v0]/protocol[at0010]/items[at0054], code=at0054, itemType=ELEMENT, level=3, text=Valid period end, description=The date/time that marks the conclusion of the valid period of time for this advance care directive., comment='Valid period end' may often overlap with 'Review due date'. However, they may need to be recorded separately in circumstances where a document has an extended period of validity but requires an interim review. That may be due to changed personal circumstances/events or local policy., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-EVALUATION.advance_care_directive.v0]/protocol[at0010]/items[at0056], code=at0056, itemType=ELEMENT, level=3, text=Review due date, description=The date at which the advance care directive is due to be reviewed., comment='Valid period end' may often overlap with 'Review due date'. However, they may need to be recorded separately in circumstances where a document has an extended period of validity but requires an interim review. That may be due to changed personal circumstances/events or local policy., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-EVALUATION.advance_care_directive.v0]/protocol[at0010]/items[at0055], code=at0055, itemType=ELEMENT, level=3, text=Last updated, description=The date when this advance directive record was last updated. This may not be a formal review but e.g. a typo correction., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-EVALUATION.advance_care_directive.v0]/protocol[at0010]/items[at0027], code=at0027, itemType=ELEMENT, level=3, text=Mandate, description=Description of any legislation or other authoritative guidance that apply., comment=For example, 'In England and Wales, advance decisions are covered by the Mental Capacity Act. Mandate: https://www.bma.org.uk/advice/employment/ethics/consent/consent-tool-kit/9-advance-decisions'. Or 'Jehovah's Witnesses believe that the Bible prohibits Christians from accepting blood transfusions. Mandate: https://en.wikipedia.org/wiki/Jehovah%27s_Witnesses_and_blood_transfusions'., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Text
  •  URI
, extendedValues=null]], templateType=normal]