| All | OperationalTemplate [rootArchetypeId=openEHR-EHR-COMPOSITION.encounter.v1, otherContributors=null, tshis=[ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1], code=at0000, itemType=COMPOSITION, level=0, text=Glaucoma pre-assessment, 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=null, code=null, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=1, text=Other Context, description=null, 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]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.xds_metadata.v0], code=at0000, itemType=CLUSTER, level=2, text=XDS Metadata, description=Additional composition metadata aligned with IHE-XDS which is not already available from the Reference Model COMPOSITION class., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.xds_metadata.v0]/items[at0001], code=at0001, itemType=ELEMENT, level=3, text=Author specialty, description=The speciality of the author/composer of the document., 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]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.xds_metadata.v0]/items[at0003], code=at0003, itemType=ELEMENT, level=3, text=Document type, description=The code specifying the precise type of document from the user perspective. Normally selected from a valueset provided by the local IHE-XDS Affinity Domain or national standard., comment=for example: Pulmonary History and Physical, Discharge Summary, Ultrasound Report.
These codes are specific to an XDS Affinity Domain., 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='Situation'], code=at0000, itemType=SECTION, level=1, text=Situation, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Situation']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1], code=at0000, itemType=EVALUATION, level=2, text=Primary problem, description=Details about a single identified health condition, injury, disability or any other issue which impacts on the physical, mental and/or social well-being of an individual., comment=Clear delineation between the scope of a problem versus a diagnosis is not easy to achieve in practice. For the purposes of clinical documentation with this archetype, problem and diagnosis are regarded as a continuum, with increasing levels of detail and supportive evidence usually providing weight towards the label of 'diagnosis'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, 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-SECTION.adhoc.v1 and name/value='Situation']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Situation']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Problem/Diagnosis name, description=Identification of the problem or diagnosis, by name., comment=Coding of the name of the problem or diagnosis 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='Situation']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0003], code=at0003, itemType=ELEMENT, level=4, text=Date/time clinically recognised, description=Estimated or actual date/time the diagnosis or problem was recognised by a healthcare professional., comment=Partial dates are acceptable. If the subject of care is under the age of one year, then the complete date or a minimum of the month and year is necessary to enable accurate age calculations - for example, if used to drive decision support. Data captured/imported as "Age at time of clinical recognition" should be converted to a date using the subject's date of birth., 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-SECTION.adhoc.v1 and name/value='Situation']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0069], code=at0069, itemType=ELEMENT, level=4, text=Comment, description=Additional narrative about the problem or diagnosis not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Situation']/items[openEHR-EHR-OBSERVATION.story.v1], code=at0000, itemType=OBSERVATION, level=2, text=History, description=The subjective clinical history of the subject of care as recorded directly by the subject, or reported to a clinician by the subject or a carer., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, 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='Situation']/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Situation']/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=4, text=Any event, description=Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Situation']/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=5, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Situation']/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=6, text=Story, description=Narrative description of the story or clinical history for the subject of care., 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='Global background'], code=at0000, itemType=SECTION, level=1, text=Global background, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Global background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Allergies'], code=at0000, itemType=SECTION, level=2, text=Allergies, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Global background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Allergies']/items[openEHR-EHR-EVALUATION.adverse_reaction_risk.v1], code=at0000, itemType=EVALUATION, level=3, text=Adverse reaction risk, description=Risk of harmful or undesirable physiological response which is unique to an individual and associated with exposure to a substance., comment=Substances include, but are not limited to: a therapeutic substance administered correctly at an appropriate dosage for the individual; food; material derived from plants or animals; or venom from insect stings., uncommonOntologyItems={source=openEHR,FHIR}, 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-SECTION.adhoc.v1 and name/value='Global background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Allergies']/items[openEHR-EHR-EVALUATION.adverse_reaction_risk.v1]/data[at0001], code=at0001, 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-SECTION.adhoc.v1 and name/value='Global background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Allergies']/items[openEHR-EHR-EVALUATION.adverse_reaction_risk.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=5, text=Substance, description=Identification of a substance, or substance class, that is considered to put the individual at risk of an adverse reaction event., comment=Both an individual substance and a substance class are valid entries in 'Substance'. A substance may be a compound of simpler substances, for example a medicinal product. If the value in 'Substance' is an individual substance, it may be duplicated in 'Specific substance'. It is strongly recommended that both 'Substance' and 'Specific substance' be coded with a terminology capable of triggering decision support, where possible. For example: Snomed CT, DM+D, RxNorm, NDFRT, ATC, New Zealand Universal List of Medicines and Australian Medicines Terminology. Free text entry should only be used if there is no appropriate terminology available., uncommonOntologyItems={source=openEHR,FHIR,DAM}, 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='Global background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Allergies']/items[openEHR-EHR-EVALUATION.adverse_reaction_risk.v1]/protocol[at0042], code=at0042, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, 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='Global background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Allergies']/items[openEHR-EHR-EVALUATION.exclusion_global.v1], code=at0000, itemType=EVALUATION, level=3, text=Exclusion - global, description=An overall statement of exclusion about all Problems/diagnoses, Family history, Medications, Procedures, Adverse reactions or other clinical items that are either not currently present, or have not been present in the past., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, 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-SECTION.adhoc.v1 and name/value='Global background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Allergies']/items[openEHR-EHR-EVALUATION.exclusion_global.v1]/data[at0001], code=at0001, 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-SECTION.adhoc.v1 and name/value='Global background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Allergies']/items[openEHR-EHR-EVALUATION.exclusion_global.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=5, text=Global exclusion of adverse reactions, description=Overall statement of exclusion about all adverse reactions at the time of recording., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=Default value: Patient has no allergies, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Global background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Allergies']/items[openEHR-EHR-EVALUATION.exclusion_global.v1]/data[at0001]/items[at0011], code=at0011, itemType=ELEMENT, level=5, text=Comment, description=Additional comment not covered in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Global background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Family history'], code=at0000, itemType=SECTION, level=2, text=Family history, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Global background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Family history']/items[openEHR-EHR-EVALUATION.family_history.v2], code=at0000, itemType=EVALUATION, level=3, text=Family history, description=Summary information about the significant health-related problems found in family members., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, 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-SECTION.adhoc.v1 and name/value='Global background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Family history']/items[openEHR-EHR-EVALUATION.family_history.v2]/data[at0001], code=at0001, 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-SECTION.adhoc.v1 and name/value='Global background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Family history']/items[openEHR-EHR-EVALUATION.family_history.v2]/data[at0001]/items[at0028], code=at0028, itemType=CLUSTER, level=5, text=Per problem, description=Details about the presence of a specific problem or diagnosis in family members., comment=If the problem has a genetic predisposition within families, then only genetic relatives should be considered as part of this data. If the problem has psychosocial or environmental effects then non-genetic family members may also be included., 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='Global background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Family history']/items[openEHR-EHR-EVALUATION.family_history.v2]/data[at0001]/items[at0028]/items[at0029], code=at0029, itemType=ELEMENT, level=6, text=Problem/diagnosis name, description=Identification of the significant problem or diagnosis in the family overall., comment=This is the problem for which aggregated data involving all family members will be collected. Coding of the index problem with a terminology is preferred, where possible., 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='Global background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Family history']/items[openEHR-EHR-EVALUATION.family_history.v2]/data[at0001]/items[at0028]/items[at0030], code=at0030, itemType=ELEMENT, level=6, text=Description, description=Narrative description about occurrence of the problem or diagnosis in family members., 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='Global background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social history'], code=at0000, itemType=SECTION, level=2, text=Social history, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Global background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social history']/items[openEHR-EHR-EVALUATION.tobacco_smoking_summary.v1], code=at0000, itemType=EVALUATION, level=3, text=Tobacco smoking summary, description=Summary or persistent information about the tobacco smoking habits of an individual., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, 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-SECTION.adhoc.v1 and name/value='Global background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social history']/items[openEHR-EHR-EVALUATION.tobacco_smoking_summary.v1]/data[at0001], code=at0001, 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-SECTION.adhoc.v1 and name/value='Global background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social history']/items[openEHR-EHR-EVALUATION.tobacco_smoking_summary.v1]/data[at0001]/items[at0089], code=at0089, itemType=ELEMENT, level=5, text=Overall status, description=Statement about current smoking behaviour for all types of tobacco., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- Never smoked
- Current smoker
- Former smoker
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Global background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social history']/items[openEHR-EHR-EVALUATION.tobacco_smoking_summary.v1]/data[at0001]/items[at0029], code=at0029, itemType=CLUSTER, level=5, text=Per type, description=Details about smoking activity for a specified type of smoked tobacco., 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='Global background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social history']/items[openEHR-EHR-EVALUATION.tobacco_smoking_summary.v1]/data[at0001]/items[at0029]/items[at0095], code=at0095, itemType=ELEMENT, level=6, text=Type, description=The type of tobacco smoked by the individual., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- Cigarettes
- Hand-rolled cigarettes
- Cigars
- Cigarillos
- Pipe
- Waterpipe
- Bidis
- Kreteks
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Global background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social history']/items[openEHR-EHR-EVALUATION.alcohol_consumption_summary.v1], code=at0000, itemType=EVALUATION, level=3, text=Alcohol consumption summary, description=Summary or persistent information about the typical alcohol consumption of an individual., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, 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-SECTION.adhoc.v1 and name/value='Global background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social history']/items[openEHR-EHR-EVALUATION.alcohol_consumption_summary.v1]/data[at0001], code=at0001, 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-SECTION.adhoc.v1 and name/value='Global background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social history']/items[openEHR-EHR-EVALUATION.alcohol_consumption_summary.v1]/data[at0001]/items[at0089], code=at0089, itemType=ELEMENT, level=5, text=Overall status, description=Statement about current consumption for all types of alcohol., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- Current drinker
- Former drinker
- Lifetime non-drinker
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Global background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social history']/items[openEHR-EHR-EVALUATION.occupation_summary.v1], code=at0000, itemType=EVALUATION, level=3, text=Occupation summary, description=Summary or persistent information about an individual's current and past jobs and/or roles., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, 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-SECTION.adhoc.v1 and name/value='Global background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social history']/items[openEHR-EHR-EVALUATION.occupation_summary.v1]/data[at0001], code=at0001, 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-SECTION.adhoc.v1 and name/value='Global background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social history']/items[openEHR-EHR-EVALUATION.occupation_summary.v1]/data[at0001]/items[at0004], code=at0004, itemType=ELEMENT, level=5, text=Employment status, description=Statement about the individual's current employment., comment=For example: employed; unemployed; or not in labour force. Coding with a terminology is desirable, where possible. Detail about each occupation can be recorded within the CLUSTER.occupation_record archetype., 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='Global background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social history']/items[openEHR-EHR-EVALUATION.occupation_summary.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.occupation_record.v1], code=at0000, itemType=CLUSTER, level=5, text=Occupation record, description=A single job or role carried out by an individual during a specified period of time., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Global background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social history']/items[openEHR-EHR-EVALUATION.occupation_summary.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.occupation_record.v1]/items[at0005], code=at0005, itemType=ELEMENT, level=6, text=Job title/role, description=The main job title or the role of the individual., comment=For example: Chief Executive Officer; Carer; or Student. Each of these job titles or roles may be comprised of multiple duties., 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='Global background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social history']/items[openEHR-EHR-EVALUATION.substance_use_summary.v0], code=at0000, itemType=EVALUATION, level=3, text=Substance use summary, description=Summary or persistent information about the typical use of a single addictive, or potentially addictive, substance by an individual., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, 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-SECTION.adhoc.v1 and name/value='Global background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social history']/items[openEHR-EHR-EVALUATION.substance_use_summary.v0]/data[at0001], code=at0001, 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-SECTION.adhoc.v1 and name/value='Global background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social history']/items[openEHR-EHR-EVALUATION.substance_use_summary.v0]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=5, text=Substance name, description=The name of the substance or substance group/class used., comment=Coding with an external terminology is preferred, where possible., 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='Global background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social history']/items[openEHR-EHR-EVALUATION.substance_use_summary.v0]/data[at0001]/items[at0003], code=at0003, itemType=ELEMENT, level=5, text=Overall status, description=Statement about current use of the substance, in all forms and by all routes., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- Never used
- Current user
- Former user
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Global background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social history']/items[openEHR-EHR-EVALUATION.living_arrangement.v0], code=at0000, itemType=EVALUATION, level=3, text=Living arrangement, description=The circumstances about an individual living alone or with others., comment=This information will provide a sense of the level of support, both physically and emotionally, to which an individual may have access., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, 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-SECTION.adhoc.v1 and name/value='Global background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social history']/items[openEHR-EHR-EVALUATION.living_arrangement.v0]/data[at0001], code=at0001, 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-SECTION.adhoc.v1 and name/value='Global background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Social history']/items[openEHR-EHR-EVALUATION.living_arrangement.v0]/data[at0001]/items[at0004], code=at0004, itemType=ELEMENT, level=5, text=Living arrangement, description=Single word or phrase that describes if an individual usually resides alone or with others., comment=Coding of the living arrangement with a terminology is preferred, where possible. The value sets for this data element are likely to vary between jurisdictions - it is anticipated that they will usually be set within a use-case specific template. For example: 'lives alone'; 'lives with family'; or 'lives with others'., 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='Pathway background'], code=at0000, itemType=SECTION, level=1, text=Pathway background, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Pathway background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Systemic diagnoses'], code=at0000, itemType=SECTION, level=2, text=Systemic diagnoses, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Pathway background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Systemic diagnoses']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1], code=at0000, itemType=EVALUATION, level=3, text=Systemic diagnosis, description=Details about a single identified health condition, injury, disability or any other issue which impacts on the physical, mental and/or social well-being of an individual., comment=Clear delineation between the scope of a problem versus a diagnosis is not easy to achieve in practice. For the purposes of clinical documentation with this archetype, problem and diagnosis are regarded as a continuum, with increasing levels of detail and supportive evidence usually providing weight towards the label of 'diagnosis'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, 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-SECTION.adhoc.v1 and name/value='Pathway background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Systemic diagnoses']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001], code=at0001, 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-SECTION.adhoc.v1 and name/value='Pathway background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Systemic diagnoses']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=5, text=Problem/Diagnosis name, description=Identification of the problem or diagnosis, by name., comment=Coding of the name of the problem or diagnosis 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='Pathway background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Systemic diagnoses']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0003], code=at0003, itemType=ELEMENT, level=5, text=Date/time clinically recognised, description=Estimated or actual date/time the diagnosis or problem was recognised by a healthcare professional., comment=Partial dates are acceptable. If the subject of care is under the age of one year, then the complete date or a minimum of the month and year is necessary to enable accurate age calculations - for example, if used to drive decision support. Data captured/imported as "Age at time of clinical recognition" should be converted to a date using the subject's date of birth., 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-SECTION.adhoc.v1 and name/value='Pathway background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Systemic diagnoses']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.anatomical_location.v1], code=at0000, itemType=CLUSTER, level=5, text=Anatomical location, description=A physical site on or within the human body., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Pathway background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Systemic diagnoses']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.anatomical_location.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=6, text=Body site name, description=Identification of a single physical site either on, or within, the human body., comment=This data element is the only mandated data point in this archetype and should be used as the primary data point to record an anatomical location with a commonly used name. It is strongly recommended that 'Body site name' be recorded as specifically as is anatomically possible. For example: record 'upper eyelid' rather than recording 'eyelid' with 'upper' as a qualifier; 'fifth rib' rather than 'rib' with a numeric qualifier. Use the other data elements for laterality, aspect, region and anatomical line to provide more detail.
This data element should be coded with a terminology capable of triggering decision support, where possible - an appropriate termset for use here could comprise individual concepts or a list of precoordinated terms. Free text should be used only if there is no appropriate terminology available.
If body site name is already identified in the parent archetype, then this data element may be redundant. Alternatively, a use case has been identified where the value may be duplicated into this element to support semantic querying using this archetype, rather than the data element within the parent., 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='Pathway background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Systemic diagnoses']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.anatomical_location.v1]/items[at0002], code=at0002, itemType=ELEMENT, level=6, text=Laterality, description=The side of the body on which the identified body site is located., comment=If the identified body site has no laterality, this data element should not have a value.
If the 'Body site name' data element uses pre-coordinated terms that include laterality, then this data element is redundant., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- Left
- Right
- Left and right
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Pathway background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Systemic diagnoses']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0069], code=at0069, itemType=ELEMENT, level=5, text=Comment, description=Additional narrative about the problem or diagnosis not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Pathway background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Surgical history'], code=at0000, itemType=SECTION, level=2, text=Surgical history, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Pathway background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Surgical history']/items[openEHR-EHR-ACTION.procedure.v1], code=at0000, itemType=ACTION, level=3, text=Procedure, description=A clinical activity carried out for screening, investigative, diagnostic, curative, therapeutic, evaluative or palliative purposes., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ACTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Pathway background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Surgical history']/items[openEHR-EHR-ACTION.procedure.v1]/description[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Description, 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='Pathway background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Surgical history']/items[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=5, text=Procedure name, description=Identification of the procedure by name., comment=Coding of the specific procedure 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='Pathway background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Surgical history']/items[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[openEHR-EHR-CLUSTER.anatomical_location.v1], code=at0000, itemType=CLUSTER, level=5, text=Anatomical location, description=A physical site on or within the human body., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Pathway background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Surgical history']/items[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[openEHR-EHR-CLUSTER.anatomical_location.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=6, text=Body site name, description=Identification of a single physical site either on, or within, the human body., comment=This data element is the only mandated data point in this archetype and should be used as the primary data point to record an anatomical location with a commonly used name. It is strongly recommended that 'Body site name' be recorded as specifically as is anatomically possible. For example: record 'upper eyelid' rather than recording 'eyelid' with 'upper' as a qualifier; 'fifth rib' rather than 'rib' with a numeric qualifier. Use the other data elements for laterality, aspect, region and anatomical line to provide more detail.
This data element should be coded with a terminology capable of triggering decision support, where possible - an appropriate termset for use here could comprise individual concepts or a list of precoordinated terms. Free text should be used only if there is no appropriate terminology available.
If body site name is already identified in the parent archetype, then this data element may be redundant. Alternatively, a use case has been identified where the value may be duplicated into this element to support semantic querying using this archetype, rather than the data element within the parent., 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='Pathway background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Surgical history']/items[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[openEHR-EHR-CLUSTER.anatomical_location.v1]/items[at0002], code=at0002, itemType=ELEMENT, level=6, text=Laterality, description=The side of the body on which the identified body site is located., comment=If the identified body site has no laterality, this data element should not have a value.
If the 'Body site name' data element uses pre-coordinated terms that include laterality, then this data element is redundant., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- Left
- Right
- Left and right
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Pathway background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Eye medications'], code=at0000, itemType=SECTION, level=2, text=Eye medications, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Pathway background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Eye medications']/items[openEHR-EHR-OBSERVATION.medication_statement.v0], code=at0000, itemType=OBSERVATION, level=3, text=Medication statement, description=A snapshot view about the use of a specified medication., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, 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='Pathway background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Eye medications']/items[openEHR-EHR-OBSERVATION.medication_statement.v0]/data[at0001], code=at0001, 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-SECTION.adhoc.v1 and name/value='Pathway background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Eye medications']/items[openEHR-EHR-OBSERVATION.medication_statement.v0]/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=5, 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='Pathway background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Eye medications']/items[openEHR-EHR-OBSERVATION.medication_statement.v0]/data[at0001]/events[at0002]/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='Pathway background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Eye medications']/items[openEHR-EHR-OBSERVATION.medication_statement.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0006], code=at0006, itemType=ELEMENT, level=7, text=Medication item name, description=Name of the medication, vaccine or other therapeutic/prescribable item., comment=It is strongly recommended that the 'Medication item' be coded with a terminology capable of triggering decision support, where possible. The extent of coding may vary from the simple generic or product name of the medication item through to structured details about the actual medication pack to be used. Free text entry should only be used if there is no appropriate terminology available., 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='Pathway background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Eye medications']/items[openEHR-EHR-OBSERVATION.medication_statement.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0008], code=at0008, itemType=ELEMENT, level=7, text=Status, description=The status of use of the medication., comment=For example: the medication is still actively being taken; or a course of antibiotics has been completed., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- Planned
- Scheduled
- Active
- Completed
- Postponed
- Cancelled
- Suspended
- Discontinued
- Unknown
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Pathway background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Eye medications']/items[openEHR-EHR-OBSERVATION.medication_statement.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0018], code=at0018, itemType=ELEMENT, level=7, text=Status reason, description=Reason for the status., comment=For example: abandoned due to adverse reaction; suspended due to pending surgery., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values= Text URI
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Pathway background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Eye medications']/items[openEHR-EHR-OBSERVATION.medication_statement.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0019], code=at0019, itemType=ELEMENT, level=7, text=Status start time, description=The valid start date/time for the Status., 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-SECTION.adhoc.v1 and name/value='Pathway background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Eye medications']/items[openEHR-EHR-OBSERVATION.medication_statement.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0020], code=at0020, itemType=ELEMENT, level=7, text=Status duration, description=The valid duration for the Status., comment=This data element can be combined with either the Status start time or the Status end time, but not both., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DURATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Pathway background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Eye medications']/items[openEHR-EHR-OBSERVATION.medication_statement.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0021], code=at0021, itemType=ELEMENT, level=7, text=Status end time, description=The valid end date/time for the Status., 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-SECTION.adhoc.v1 and name/value='Pathway background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Eye medications']/items[openEHR-EHR-OBSERVATION.medication_statement.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0023], code=at0023, itemType=ELEMENT, level=7, text=Clinical indication, description=The clinical reason for use of the medication item., comment=For example: 'Angina'. Coding of the clinical indication with a terminology is preferred, where possible. This data element allows multiple occurrences., 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='Pathway background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Eye medications']/items[openEHR-EHR-OBSERVATION.medication_statement.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0024], code=at0024, itemType=ELEMENT, level=7, text=First prescribed, description=The date/time when a prescription for the medication was first issued., 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-SECTION.adhoc.v1 and name/value='Pathway background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Eye medications']/items[openEHR-EHR-OBSERVATION.medication_statement.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0025], code=at0025, itemType=ELEMENT, level=7, text=Last prescribed, description=The date/time when a prescription for the medication was last issued., 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-SECTION.adhoc.v1 and name/value='Pathway background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Eye medications']/items[openEHR-EHR-OBSERVATION.medication_statement.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0026], code=at0026, itemType=ELEMENT, level=7, text=Last administered, description=The date/time when the medication was last taken by or administered to the individual., 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-SECTION.adhoc.v1 and name/value='Pathway background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Eye medications']/items[openEHR-EHR-OBSERVATION.medication_statement.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0027], code=at0027, itemType=ELEMENT, level=7, text=Last reviewed, description=The date/time when usage of the medication was last reviewed by a clinician or phamacist., 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-SECTION.adhoc.v1 and name/value='Pathway background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Eye medications']/items[openEHR-EHR-OBSERVATION.medication_statement.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0028], code=at0028, itemType=ELEMENT, level=7, text=Discontinued, description=The date/time when use of the medication was ceased., 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-SECTION.adhoc.v1 and name/value='Pathway background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Eye medications']/items[openEHR-EHR-OBSERVATION.medication_statement.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0029], code=at0029, itemType=ELEMENT, level=7, text=Comment, description=Additional narrative about the medication statement not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Pathway background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Systemic medications'], code=at0000, itemType=SECTION, level=2, text=Systemic medications, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Pathway background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Risks'], code=at0000, itemType=SECTION, level=2, text=Risks, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Pathway background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Risks']/items[openEHR-EHR-EVALUATION.precaution.v1], code=at0000, itemType=EVALUATION, level=3, text=Risk, description=A condition or state of the individual that is clinically significant and unique or idiosyncratic for this individual, and is considered vital information when making treatment decisions., 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-SECTION.adhoc.v1 and name/value='Pathway background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Risks']/items[openEHR-EHR-EVALUATION.precaution.v1]/data[at0001], code=at0001, 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-SECTION.adhoc.v1 and name/value='Pathway background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Risks']/items[openEHR-EHR-EVALUATION.precaution.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=5, text=Condition, description=Identification, by name, of a condition or state., comment=Coding of the identified 'Condition' with a terminology is desirable, 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='Pathway background']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Risks']/items[openEHR-EHR-EVALUATION.precaution.v1]/data[at0001]/items[at0003], code=at0003, itemType=ELEMENT, level=5, text=Evidence, description=Description of the evidence identified to support the precaution., comment=This data element can be optionally linked to a diagnosis, test result, medication order etc via a URI (as per the Reference Model) in order to provide the rationale or evidence for the precaution assertion. Please note: as this URI link may not be accessible from a message or by receiving clinical system it is desirable that a narrative description of the evidence should also be explicitly 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 and name/value='Assessment'], code=at0000, itemType=SECTION, level=1, text=Assessment, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations'], code=at0000, itemType=SECTION, level=2, text=Observations, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.blood_pressure.v2], code=at0000, itemType=OBSERVATION, level=3, text=Blood pressure, description=The local measurement of arterial blood pressure which is a surrogate for arterial pressure in the systemic circulation., comment=Most commonly, use of the term 'blood pressure' refers to measurement of brachial artery pressure in the upper arm., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, 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='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.blood_pressure.v2]/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='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.blood_pressure.v2]/data[at0001]/events[at0006], code=at0006, itemType=EVENT, level=5, text=Any event, description=Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.blood_pressure.v2]/data[at0001]/events[at0006]/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='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.blood_pressure.v2]/data[at0001]/events[at0006]/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='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.blood_pressure.v2]/data[at0001]/events[at0006]/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='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.blood_pressure.v2]/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='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.blood_pressure.v2]/data[at0001]/events[at1042]/data[at0003 and name/value='blood pressure'], 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='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.blood_pressure.v2]/data[at0001]/events[at1042]/data[at0003 and name/value='blood pressure']/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='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.blood_pressure.v2]/data[at0001]/events[at1042]/data[at0003 and name/value='blood pressure']/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='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.blood_pressure.v2]/data[at0001]/events[at1042]/data[at0003 and name/value='blood pressure']/items[at1006], code=at1006, itemType=ELEMENT, level=7, text=Mean arterial pressure, description=The average arterial pressure that occurs over the entire course of the heart contraction and relaxation 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='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.blood_pressure.v2]/data[at0001]/events[at1042]/data[at0003 and name/value='blood pressure']/items[at1007], code=at1007, itemType=ELEMENT, level=7, text=Pulse pressure, description=The difference between the systolic and diastolic pressure., 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='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.blood_pressure.v2]/data[at0001]/events[at1042]/data[at0003 and name/value='blood pressure']/items[at1059], code=at1059, itemType=ELEMENT, level=7, text=Clinical interpretation, description=Single word, phrase or brief description that represents the clinical meaning and significance of the blood pressure 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='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.blood_pressure.v2]/data[at0001]/events[at1042]/data[at0003 and name/value='blood pressure']/items[at0033], code=at0033, itemType=ELEMENT, level=7, text=Comment, description=Additional narrative about the measurement, not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.blood_pressure.v2]/data[at0001]/events[at1042]/data[at0003 and name/value='blood pressure'], 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='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.blood_pressure.v2]/data[at0001]/events[at1042]/data[at0003 and name/value='blood pressure']/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 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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='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.blood_pressure.v2]/data[at0001]/events[at1042]/data[at0003 and name/value='blood pressure']/items[at1059], code=at1059, itemType=ELEMENT, level=7, text=Clinical interpretation, description=Single word, phrase or brief description that represents the clinical meaning and significance of the blood pressure 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='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.blood_pressure.v2]/data[at0001]/events[at1042]/data[at0003 and name/value='blood pressure']/items[at0033], code=at0033, itemType=ELEMENT, level=7, text=Comment, description=Additional narrative about the measurement, not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.blood_pressure.v2]/data[at0001]/events[at1042]/state[at0007 and name/value='state structure'], 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='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.blood_pressure.v2]/data[at0001]/events[at1042]/state[at0007 and name/value='state structure']/items[at0008], code=at0008, itemType=ELEMENT, level=7, text=Position, description=The position of the individual at the time of measurement., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- Standing
- Sitting
- Reclining
- Lying
- Lying with tilt to left
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.blood_pressure.v2]/data[at0001]/events[at1042]/state[at0007 and name/value='state structure']/items[at1052], code=at1052, itemType=ELEMENT, level=7, text=Confounding factors, description=Comment on and record other incidental factors that may be contributing to the blood pressure measurement. For example, level of anxiety or 'white coat syndrome'; pain or fever; changes in atmospheric pressure etc., 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='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.blood_pressure.v2]/data[at0001]/events[at1042]/state[at0007 and name/value='state structure']/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_CODED_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.blood_pressure.v2]/data[at0001]/events[at1042]/state[at0007 and name/value='state structure']/items[at1005], code=at1005, itemType=ELEMENT, level=7, text=Tilt, description=The craniocaudal tilt of the surface on which the person is lying at the time of measurement., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=-90..90 deg, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.blood_pressure.v2]/data[at0001]/events[at1042]/state[at0007 and name/value='state structure'], 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='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.blood_pressure.v2]/data[at0001]/events[at1042]/state[at0007 and name/value='state structure']/items[at0008], code=at0008, itemType=ELEMENT, level=7, text=Position, description=The position of the individual at the time of measurement., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- Standing
- Sitting
- Reclining
- Lying
- Lying with tilt to left
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.blood_pressure.v2]/data[at0001]/events[at1042]/state[at0007 and name/value='state structure']/items[at1052], code=at1052, itemType=ELEMENT, level=7, text=Confounding factors, description=Comment on and record other incidental factors that may be contributing to the blood pressure measurement. For example, level of anxiety or 'white coat syndrome'; pain or fever; changes in atmospheric pressure etc., 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='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.blood_pressure.v2]/data[at0001]/events[at1042]/state[at0007 and name/value='state structure']/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_CODED_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.blood_pressure.v2]/data[at0001]/events[at1042]/state[at0007 and name/value='state structure']/items[at1005], code=at1005, itemType=ELEMENT, level=7, text=Tilt, description=The craniocaudal tilt of the surface on which the person is lying at the time of measurement., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=-90..90 deg, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.body_weight.v2], code=at0000, itemType=OBSERVATION, level=3, text=Body weight, description=Measurement of the body weight of an individual., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, 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='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.body_weight.v2]/data[at0002], code=at0002, 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-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.body_weight.v2]/data[at0002]/events[at0003], code=at0003, itemType=EVENT, level=5, text=Any event, description=Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.body_weight.v2]/data[at0002]/events[at0003]/data[at0001], code=at0001, 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='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.body_weight.v2]/data[at0002]/events[at0003]/data[at0001]/items[at0004], code=at0004, itemType=ELEMENT, level=7, text=Weight, description=The weight of the individual., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=0..1000 kg, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.pulse_oximetry.v1], code=at0000, itemType=OBSERVATION, level=3, text=Pulse oximetry, description=Blood oxygen and related measurements, measured by pulse oximetry or pulse CO-oximetry., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, 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='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.pulse_oximetry.v1]/data[at0001], code=at0001, 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-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.pulse_oximetry.v1]/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=5, text=Any event, description=Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.pulse_oximetry.v1]/data[at0001]/events[at0002]/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='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.pulse_oximetry.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0006], code=at0006, itemType=ELEMENT, level=7, 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=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.height.v2], code=at0000, itemType=OBSERVATION, level=3, text=Height/Length, description=Height, or body length, is measured from crown of head to sole of foot., comment=Height is measured with the individual in a standing position and body length in a recumbent position., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, 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='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.height.v2]/data[at0001], code=at0001, 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-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.height.v2]/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=5, text=Any event, description=Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.height.v2]/data[at0001]/events[at0002]/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='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.height.v2]/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=7, text=Height/Length, description=The length of the body from crown of head to sole of foot., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=0..1000; 0..250
Units:, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.height.v2]/data[at0001]/events[at0021], code=at0021, itemType=POINT_EVENT, level=5, text=Birth, description=Usually the first length measurement, recorded soon after birth. This event will only be used once per health record
., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=POINT_EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.height.v2]/data[at0001]/events[at0021]/data[at0003 and name/value='Simple'], 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='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.height.v2]/data[at0001]/events[at0021]/data[at0003 and name/value='Simple']/items[at0004], code=at0004, itemType=ELEMENT, level=7, text=Height/Length, description=The length of the body from crown of head to sole of foot., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=0..1000; 0..250
Units:, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.height.v2]/data[at0001]/events[at0021]/data[at0003 and name/value='Simple']/items[at0018], code=at0018, itemType=ELEMENT, level=7, text=Comment, description=Additional narrative about the measurement, not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.height.v2]/data[at0001]/events[at0021]/data[at0003 and name/value='Simple'], 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='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.height.v2]/data[at0001]/events[at0021]/data[at0003 and name/value='Simple']/items[at0004], code=at0004, itemType=ELEMENT, level=7, text=Height/Length, description=The length of the body from crown of head to sole of foot., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=0..1000; 0..250
Units:, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.height.v2]/data[at0001]/events[at0021]/data[at0003 and name/value='Simple']/items[at0018], code=at0018, itemType=ELEMENT, level=7, text=Comment, description=Additional narrative about the measurement, not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.height.v2]/data[at0001]/events[at0021]/state[at0013 and name/value='Tree'], code=at0013, 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='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.height.v2]/data[at0001]/events[at0021]/state[at0013 and name/value='Tree']/items[at0014], code=at0014, itemType=ELEMENT, level=7, text=Position, description=Position of individual when measured., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Assumed value: Standing, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.height.v2]/data[at0001]/events[at0021]/state[at0013 and name/value='Tree']/items[at0019], code=at0019, itemType=ELEMENT, level=7, text=Confounding factors, description=Narrative description of any issues or factors that may impact on the measurement., comment=For example: noting of amputation., 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='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.height.v2]/data[at0001]/events[at0021]/state[at0013 and name/value='Tree'], code=at0013, 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='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.height.v2]/data[at0001]/events[at0021]/state[at0013 and name/value='Tree']/items[at0014], code=at0014, itemType=ELEMENT, level=7, text=Position, description=Position of individual when measured., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Assumed value: Standing, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.height.v2]/data[at0001]/events[at0021]/state[at0013 and name/value='Tree']/items[at0019], code=at0019, itemType=ELEMENT, level=7, text=Confounding factors, description=Narrative description of any issues or factors that may impact on the measurement., comment=For example: noting of amputation., 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='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.pulse.v2], code=at0000, itemType=OBSERVATION, level=3, text=Pulse/Heart beat, description=The rate and associated attributes for a pulse or heart beat., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, 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='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.pulse.v2]/data[at0002], code=at0002, 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-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.pulse.v2]/data[at0002]/events[at0003], code=at0003, itemType=EVENT, level=5, text=Any event, description=Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.pulse.v2]/data[at0002]/events[at0003]/data[at0001], code=at0001, 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='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.pulse.v2]/data[at0002]/events[at0003]/data[at0001]/items[at0004], code=at0004, itemType=ELEMENT, level=7, text=Rate, description=The rate of the pulse or heart beat, 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..1000 /min, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.body_mass_index.v2], code=at0000, itemType=OBSERVATION, level=3, text=Body mass index, description=Calculated measurement which compares a person's weight and height., comment=Body Mass Index is a calculated ratio describing how an individual's body weight relates to the weight that is regarded as normal, or desirable, for the individual's height., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, 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='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.body_mass_index.v2]/data[at0001], code=at0001, 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-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.body_mass_index.v2]/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=5, text=Any event, description=Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.body_mass_index.v2]/data[at0001]/events[at0002]/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='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Observations']/items[openEHR-EHR-OBSERVATION.body_mass_index.v2]/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=7, text=Body mass index, description=Index describing ratio of weight to height., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=0..1000 kg/m2, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Opthalmology exams'], code=at0000, itemType=SECTION, level=2, text=Opthalmology exams, description=A generic section header which should be renamed in a template to suit a specific clinical context., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Opthalmology exams']/items[openEHR-EHR-OBSERVATION.visual_acuity.v0], code=at0000, itemType=OBSERVATION, level=3, text=Visual acuity test result, description=Visual acuity is a measure of the spatial resolution of the visual processing system., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, 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='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Opthalmology exams']/items[openEHR-EHR-OBSERVATION.visual_acuity.v0]/data[at0001], code=at0001, 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-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Opthalmology exams']/items[openEHR-EHR-OBSERVATION.visual_acuity.v0]/data[at0001]/events[at0134], code=at0134, itemType=EVENT, level=5, 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='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Opthalmology exams']/items[openEHR-EHR-OBSERVATION.visual_acuity.v0]/data[at0001]/events[at0134]/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='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Opthalmology exams']/items[openEHR-EHR-OBSERVATION.visual_acuity.v0]/data[at0001]/events[at0134]/data[at0003]/items[at0053], code=at0053, itemType=CLUSTER, level=7, text=Result details, description=Details of the visual field test result for each eye., comment=null, uncommonOntologyItems=null, occurencesFormal=0..2, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Opthalmology exams']/items[openEHR-EHR-OBSERVATION.visual_acuity.v0]/data[at0001]/events[at0134]/data[at0003]/items[at0053]/items[at0007], code=at0007, itemType=ELEMENT, level=8, text=Eye examined, description=The eye which is being examined., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- Left eye
- Right eye
- Both eyes simultaneously
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Opthalmology exams']/items[openEHR-EHR-OBSERVATION.visual_acuity.v0]/data[at0001]/events[at0134]/data[at0003]/items[at0053]/items[at0028], code=at0028, itemType=CLUSTER, level=8, text=Notation, description=Details of a visual acuity result recorded using one of the result notation formats., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Opthalmology exams']/items[openEHR-EHR-OBSERVATION.visual_acuity.v0]/data[at0001]/events[at0134]/data[at0003]/items[at0053]/items[at0028]/items[at0056], code=at0056, itemType=ELEMENT, level=9, text=Metric Snellen, description=The distance test result, recorded in Snellen format expressed in metres, where 6/6 is regarded as normal., comment=Examples: '6/6, '6/12', '6/5', uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_PROPORTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Opthalmology exams']/items[openEHR-EHR-OBSERVATION.visual_acuity.v0]/data[at0001]/events[at0134]/data[at0003]/items[at0053]/items[at0028]/items[at0046], code=at0046, itemType=ELEMENT, level=9, text=logMar, description=The test result, recorded as logMar visual acuity, where a value of 0 is regarded as normal., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=-0.5..2, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Opthalmology exams']/items[openEHR-EHR-OBSERVATION.visual_acuity.v0]/data[at0001]/events[at0134]/data[at0003]/items[at0040], code=at0040, itemType=ELEMENT, level=7, text=Comment, description=Any additional narrative comment about the visual acuity test., 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='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Opthalmology exams']/items[openEHR-EHR-OBSERVATION.visual_acuity.v0]/data[at0001]/events[at0134]/data[at0003]/items[openEHR-EHR-CLUSTER.exclusion_exam.v1], code=at0000, itemType=CLUSTER, level=7, text=Exclusion of examination, description=Positive statement to record that a physical examination or clinical test was not performed., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Opthalmology exams']/items[openEHR-EHR-OBSERVATION.visual_acuity.v0]/data[at0001]/events[at0134]/data[at0003]/items[openEHR-EHR-CLUSTER.exclusion_exam.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=8, text=Examination not done, description=Statement to explicity record that the examination was not performed., comment=Record as True if the examination was not performed., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, 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='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Opthalmology exams']/items[openEHR-EHR-OBSERVATION.visual_acuity.v0]/data[at0001]/events[at0134]/data[at0003]/items[openEHR-EHR-CLUSTER.exclusion_exam.v1]/items[at0002], code=at0002, itemType=ELEMENT, level=8, text=Reason, description=Reason for the 'not done' statement., comment=For example: patient factors, equipment factors, time constraints., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=- Unable to assess
- Eye missing
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Opthalmology exams']/items[openEHR-EHR-OBSERVATION.visual_acuity.v0]/data[at0001]/events[at0134]/state[at0041], code=at0041, 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='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Opthalmology exams']/items[openEHR-EHR-OBSERVATION.visual_acuity.v0]/data[at0001]/events[at0134]/state[at0041]/items[at0042], code=at0042, itemType=ELEMENT, level=7, text=Refractive Correction, description=The specific type(s) of refractive correction applied when measuring visual acuity., comment=Examples: 'No correction : unaided', 'Pinhole'., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- Spectacles
- Contact lenses
- Pinhole
- Autorefraction
- Retinoscopy
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Opthalmology exams']/items[openEHR-EHR-OBSERVATION.visual_field_measurement.v0], code=at0000, itemType=OBSERVATION, level=3, text=Visual field measurement, description=Results of visual field testing / perimetry., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, 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='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Opthalmology exams']/items[openEHR-EHR-OBSERVATION.visual_field_measurement.v0]/data[at0001], code=at0001, 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-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Opthalmology exams']/items[openEHR-EHR-OBSERVATION.visual_field_measurement.v0]/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=5, 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='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Opthalmology exams']/items[openEHR-EHR-OBSERVATION.visual_field_measurement.v0]/data[at0001]/events[at0002]/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='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Opthalmology exams']/items[openEHR-EHR-OBSERVATION.visual_field_measurement.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0052], code=at0052, itemType=ELEMENT, level=7, text=Test result name, description=Identification of the visual field test being performed, by name., comment=In DICOM this is defined as a visual field global index (0024,0325)). Values permitted are defined by DICOM standard (PS 3.16) inside the table with Context ID 4257., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- Visual field index
- Visual field loss due to diffuse defect
- Visual field loss due to local defect
- Glaucoma Hemifield Test Analysis (GHT)
- Optical fixation measurements
Assumed value: Glaucoma Hemifield Test Analysis (GHT), extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Opthalmology exams']/items[openEHR-EHR-OBSERVATION.visual_field_measurement.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0005], code=at0005, itemType=ELEMENT, level=7, text=Clinical description, description=Narrative description of the overall findings observed during the test., 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='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Opthalmology exams']/items[openEHR-EHR-OBSERVATION.visual_field_measurement.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0007], code=at0007, itemType=CLUSTER, level=7, text=Test result, description=Details of the visual field test result for each eye., comment=null, uncommonOntologyItems=null, occurencesFormal=0..2, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Opthalmology exams']/items[openEHR-EHR-OBSERVATION.visual_field_measurement.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0007]/items[at0008], code=at0008, itemType=ELEMENT, level=8, text=Eye examined, description=The eye which is being examined., comment=Matches to DICOM Laterality (0020,0060) attribute., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Opthalmology exams']/items[openEHR-EHR-OBSERVATION.visual_field_measurement.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0007]/items[at0164], code=at0164, itemType=ELEMENT, level=8, text=Glaucoma Hemifield Test (GHT), description=A coded intepretation of the Glaucoma Hemifield Test (GHT)., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- Outside normal limits
- Borderline
- General reduction of sensitivity
- Abnormally high sensitivity
- Within normal limits
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Opthalmology exams']/items[openEHR-EHR-OBSERVATION.visual_field_measurement.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0007]/items[at0054], code=at0054, itemType=ELEMENT, level=8, text=Foveal sensitivity measured, description=Whether foveal sensitivity was measured., comment=Matches to DICOM (0024,0086) attribute., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=Assumed value: false, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Opthalmology exams']/items[openEHR-EHR-OBSERVATION.visual_field_measurement.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0007]/items[at0055], code=at0055, itemType=ELEMENT, level=8, text=Foveal sensitivity, description=Foveal Sensitivity is the reciprocal of foveal threshold (1/foveal threshold), in dB., comment=Foveal Threshold is the minimum amount of luminance increment on a uniform background that can be detected by the patient at coordinates 0,0 (relative to the center of the patient’s fixation). Matches to DICOM (0024,0087) attribute., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=-100..100 dB, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Opthalmology exams']/items[openEHR-EHR-OBSERVATION.visual_field_measurement.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0007]/items[at0037], code=at0037, itemType=ELEMENT, level=8, text=Visual Field Index (VFI), description=Visual Field Index result., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_PROPORTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Opthalmology exams']/items[openEHR-EHR-OBSERVATION.visual_field_measurement.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0007]/items[at0034], code=at0034, itemType=ELEMENT, level=8, text=Mean Deviation (MD), description=Weighted average deviation from the age corrected normal field, in dB., comment=Matches to DICOM (0024,0066) attribute., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=-30..10 dB, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Opthalmology exams']/items[openEHR-EHR-OBSERVATION.visual_field_measurement.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0007]/items[at0038], code=at0038, itemType=ELEMENT, level=8, text=Mean Deviation P (MD), description=The P value of the Mean Deviation result., comment=Matches to DICOM (0024,0083) attribute., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_PROPORTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Opthalmology exams']/items[openEHR-EHR-OBSERVATION.visual_field_measurement.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0007]/items[at0035], code=at0035, itemType=ELEMENT, level=8, text=Pattern Standard Deviation (PSD), description=Average of non-uniform visual field loss or weighted square root of loss variance, in dB., comment=Matches to DICOM (0024,0068) attribute., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=0..25 dB, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Opthalmology exams']/items[openEHR-EHR-OBSERVATION.visual_field_measurement.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0007]/items[at0039], code=at0039, itemType=ELEMENT, level=8, text=Pattern Standard Deviation P (PSD), description=The P value of the Pattern Standard deviation result., comment=Matches to DICOM (0024,0073) attribute., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_PROPORTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Opthalmology exams']/items[openEHR-EHR-OBSERVATION.visual_field_measurement.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0007]/items[at0058], code=at0058, itemType=ELEMENT, level=8, text=Short-Term Fluctuation (SF), description=Average deviation of sensitivity for the repeated test locations, in dB. This is used to determine the consistency of the patient’s responses., comment=Matches to DICOM (0024,0075) attribute., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=Units: dB, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Opthalmology exams']/items[openEHR-EHR-OBSERVATION.visual_field_measurement.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0007]/items[at0059], code=at0059, itemType=ELEMENT, level=8, text=Corrected Pattern Standard Deviation (CPSD), description=Weighted square root of loss variance corrected for short term fluctuation, in dB., comment=Matches to DICOM (0024,0079) attribute., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=Units: dB, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Opthalmology exams']/items[openEHR-EHR-OBSERVATION.visual_field_measurement.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0007]/items[at0027], code=at0027, itemType=ELEMENT, level=8, text=Perimetry test interpretation, description=A coded intepretation of the Visual field test result., comment=Values permitted are defined by DICOM standard (PS 3.16) inside the table with Context ID 4254., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- Outside normal limits
- Borderline
- Abnormally high sensitivity
- General reduction of sensitivity
- Borderline and general reduction in sensitivity
- Within normal limits
Assumed value: Within normal limits, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Opthalmology exams']/items[openEHR-EHR-OBSERVATION.visual_field_measurement.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0007]/items[at0174], code=at0174, itemType=ELEMENT, level=8, text=No test result, description=No visual field test result is available for the eye examined., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Opthalmology exams']/items[openEHR-EHR-OBSERVATION.visual_field_measurement.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0007]/items[at0175], code=at0175, itemType=ELEMENT, level=8, text=Reason for no test result, description=Reason why no visual field test result is available for the eye examined., 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='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Opthalmology exams']/items[openEHR-EHR-OBSERVATION.visual_field_measurement.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0007]/items[at0009], code=at0009, itemType=ELEMENT, level=8, text=Clinical interpretation, description=Clinical interpretation of all measurements for the test eye., comment=Coding 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='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Opthalmology exams']/items[openEHR-EHR-OBSERVATION.visual_field_measurement.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0007]/items[at0173], code=at0173, itemType=ELEMENT, level=8, text=Comment, description=Additional narrative about the visual field testing for the eye examined, not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Opthalmology exams']/items[openEHR-EHR-OBSERVATION.visual_field_measurement.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0025], code=at0025, itemType=ELEMENT, level=7, text=Overall interpretation, description=Overall clinical interpretation of the measurements and related findings of visual field testing., comment=Coding with a terminology is preferred, where possible. This data element is effectively an opthalmological diagnosis., 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='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Opthalmology exams']/items[openEHR-EHR-OBSERVATION.visual_field_measurement.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0024], code=at0024, itemType=ELEMENT, level=7, text=Comment, description=Additional narrative about the overall test results and intepretation not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Opthalmology exams']/items[openEHR-EHR-OBSERVATION.visual_field_measurement.v0]/data[at0001]/events[at0002]/state[at0022], code=at0022, 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='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Opthalmology exams']/items[openEHR-EHR-OBSERVATION.visual_field_measurement.v0]/data[at0001]/events[at0002]/state[at0022]/items[at0048], code=at0048, itemType=ELEMENT, level=7, text=Fixation checked quantity, description=The number of times that the patient’s gaze fixation is checked., comment=Matches to DICOM (0024,0035) attribute., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=0..100, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Opthalmology exams']/items[openEHR-EHR-OBSERVATION.visual_field_measurement.v0]/data[at0001]/events[at0002]/state[at0022]/items[at0049], code=at0049, itemType=ELEMENT, level=7, text=Patient not properly fixated quantity, description=The number of times the patient’s gaze is not properly fixated., comment=Matches to DICOM (0024,0036) attribute., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=0..100, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Opthalmology exams']/items[openEHR-EHR-OBSERVATION.visual_field_measurement.v0]/data[at0001]/events[at0002]/state[at0022]/items[at0056], code=at0056, itemType=ELEMENT, level=7, text=False positives estimate, description=Estimated percentage of all patient responses that occurred at a time when no visual stimulus was present (false positive responses), as percent., comment=Matches to DICOM (0024,0054) attribute., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_PROPORTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Opthalmology exams']/items[openEHR-EHR-OBSERVATION.visual_field_measurement.v0]/data[at0001]/events[at0002]/state[at0022]/items[at0057], code=at0057, itemType=ELEMENT, level=7, text=False negatives estimate, description=Estimated percentage of all stimuli that were not seen by the patient but were previously seen at a lower luminance earlier in the visual field test (false negative responses), as percent. Matches to DICOM (0024,0046) attribute., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_PROPORTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Opthalmology exams']/items[openEHR-EHR-OBSERVATION.visual_field_measurement.v0]/data[at0001]/events[at0002]/state[at0022]/items[at0023], code=at0023, itemType=ELEMENT, level=7, text=Confounding factors, description=Patient circumstances which may affect interpretation of the result., 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='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Opthalmology exams']/items[openEHR-EHR-OBSERVATION.refraction.v0], code=at0000, itemType=OBSERVATION, level=3, text=Refraction assessment, description=Assessment of the refraction required to achieve optimal visual acuity., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, 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='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Opthalmology exams']/items[openEHR-EHR-OBSERVATION.refraction.v0]/data[at0001], code=at0001, 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-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Opthalmology exams']/items[openEHR-EHR-OBSERVATION.refraction.v0]/data[at0001]/events[at0134], code=at0134, itemType=EVENT, level=5, 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='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Opthalmology exams']/items[openEHR-EHR-OBSERVATION.refraction.v0]/data[at0001]/events[at0134]/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='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Opthalmology exams']/items[openEHR-EHR-OBSERVATION.refraction.v0]/data[at0001]/events[at0134]/data[at0003]/items[at0053], code=at0053, itemType=CLUSTER, level=7, text=Result details, description=Details of the refraction result for each eye., comment=null, uncommonOntologyItems=null, occurencesFormal=0..2, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Opthalmology exams']/items[openEHR-EHR-OBSERVATION.refraction.v0]/data[at0001]/events[at0134]/data[at0003]/items[at0053]/items[at0144], code=at0144, itemType=ELEMENT, level=8, text=Test eye, description=Identification of the eye which is being tested., comment=null, uncommonOntologyItems=null, 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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='Assessment']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Opthalmology exams']/items[openEHR-EHR-OBSERVATION.intraocular_pressure.v0]/protocol[at0068]/items[at0046], code=at0046, itemType=ELEMENT, level=5, text=Tonometry method, description=Type of tonometery used to measure intraocular pressure., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values= Coded Text- Goldmann
- Perkins
- Tono-Pen
- Icare (Rebound)
- Dynamic Contour
- Ocular Response Analyzer
- TGDc-01
- Non-contact tonometry
- Text
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