| All | OperationalTemplate [rootArchetypeId=openEHR-EHR-COMPOSITION.report.v1, otherContributors=null, tshis=[ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1], code=at0000, itemType=COMPOSITION, level=0, text=Robotic Surgery Radiology Planning Meeting, description=Document to communicate information to others, commonly in response to a request from another party., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=COMPOSITION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.procedure.v1], code=at0000, itemType=ACTION, level=1, text=Proposed procedure, description=A clinical activity carried out for screening, investigative, diagnostic, curative, therapeutic, evaluative or palliative purposes., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ACTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=2, text=Proposed procedure, 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.report.v1]/content[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[openEHR-EHR-CLUSTER.surgical_planning_oc.v0], code=at0000, itemType=CLUSTER, level=2, text=Surgical Planning Details, description=Surgical Planning Details for Prostate Cancer Robotic Surgery Radiology Planning Meeting., 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.report.v1]/content[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[openEHR-EHR-CLUSTER.surgical_planning_oc.v0]/items[at0001], code=at0001, itemType=ELEMENT, level=3, text=MRI predictor of surgical difficulty, description=Details of predictors of surgical difficulty obtained from MRI scan or patient history., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values= Coded Text- Large gland
- Small gland
- Significant median lobe
- Large seminal vesicles
- Narrow pelvis / ethnicity
- Previous laparotomy
- Previous pelvic radiotherapy
- Previous TURP
- Previous prostate ablation
- Hernia repair
 Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[openEHR-EHR-CLUSTER.surgical_planning_oc.v0]/items[at0012], code=at0012, itemType=ELEMENT, level=3, text=Nerve spare right intended, description=Statement of intent whether prostatic neurovascular bundle (right) sparing is proposed., 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.report.v1]/content[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[openEHR-EHR-CLUSTER.surgical_planning_oc.v0]/items[at0013], code=at0013, itemType=ELEMENT, level=3, text=Nerve spare left intended, description=Statement of intent whether prostatic neurovascular bundle (left) sparing is proposed., 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.report.v1]/content[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[openEHR-EHR-CLUSTER.surgical_planning_oc.v0]/items[at0014], code=at0014, itemType=ELEMENT, level=3, text=Lymph node dissection intended, description=Statement of intent whether lymph node dissection is proposed., 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.report.v1]/content[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[openEHR-EHR-CLUSTER.surgical_planning_oc.v0]/items[at0015], code=at0015, itemType=ELEMENT, level=3, text=MRI quality score, description=A subjective score to reflect the quality of the MRI acquired - including whether all required sequences were acquired and whether there is significant artefact. Scored from 1 (poor) to 5 (excellent)., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=1..5, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[openEHR-EHR-CLUSTER.surgical_planning_oc.v0]/items[at0016], code=at0016, itemType=ELEMENT, level=3, text=Grade of difficulty, description=A score to describe the difficulty of the case by considering all the recorded factors. From 1 (easy) to 3 (difficult)., comment=Different sites will use the score for different purposes - eg which operating list the patient goes on, who can do the operation (trainee, experienced consultant etc)., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=1..3, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[openEHR-EHR-CLUSTER.surgical_planning_oc.v0]/items[at0017], code=at0017, itemType=ELEMENT, level=3, text=Department where MRI performed, description=Hospital/department where MRI scan is performed., 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.report.v1]/content[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[at0066], code=at0066, itemType=ELEMENT, level=2, text=Scheduled date/time, description=The date and/or time on which the procedure is intended to be performed., comment=Only for use in association with the 'Procedure scheduled' pathway step., 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.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test.v0], code=at0000, itemType=OBSERVATION, level=1, text=Laboratory test, description=The findings and interpretation of a pathology laboratory test performed on patient-related specimens., comment=This archetype may be used to record a single valued test, but will often be specialised or templated to represent multiple value or 'panel' tests. This archetype also acts as the parent for specialisations appropriate for more specific laboratory tests, e.g. microbiology, histopathology., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.laboratory_test_panel.v0]/items[at0002]/items[at0001], code=at0001, itemType=ELEMENT, level=2, text=Current prostatic specific antigen (PSA) level, description=Actual value of the result. The name of this element is normally replaced in a template or at run-time to relfect the actual analyte e.g. Serum sodium and will often be coded., comment=null, uncommonOntologyItems={fhir_mapping=Observation.result; Observation.name, hl7v2_mapping=OBX.2,OBX.5,OBX.6; OBX-3-observation identifier}, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.exam.v1], code=at0000, itemType=OBSERVATION, level=1, text=Physical examination findings, description=Findings observed during the physical examination of a subject of care., 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.report.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=2, text=Digital rectal examination, description=Narrative description of the overall findings observed during a physical examination of a patient., comment=May be used to record a narrative summary of the complete clinical examination or key aspects of clinical examination findings, which will be supported by structured data. Details of specific structured findings can be included using CLUSTER archetypes in the 'Examination Detail' slot. This data element may be used to capture legacy data that is not available in a structured format., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.dimensions.v1]/items[at0006], code=at0006, itemType=ELEMENT, level=2, text=Volume of prostate, description=The volume of the part examined., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=Units: ml, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.iief_5.v0], code=at0000, itemType=OBSERVATION, level=1, text=IIEF-5-Score, description=International index of erectile dysfunction (IIEF-5)., 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.report.v1]/content[openEHR-EHR-OBSERVATION.iief_5.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0038], code=at0038, itemType=ELEMENT, level=2, text=IIEF-5 Score, description=The IIEF-5 is administered as a screening instrument for the presence & severity of ED in conjunction with the clinical assessment. The score is the sum of the responses to the five items, so that overall score may range from 1 to 25. A score of 20 or higher indicates a normal degree of erectile functioning. Low scores (10 or less) indicate moderate to severe ED., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=1..25, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.iciq_ui_short.v0], code=at0000, itemType=OBSERVATION, level=1, text=ICIQ-UI Short Form, description=International Consultation on Incontinence (ICIQ) Urinary Incontinence (UI) Short Form., 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.report.v1]/content[openEHR-EHR-OBSERVATION.iciq_ui_short.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0017], code=at0017, itemType=ELEMENT, level=2, text=ICIQ Score, description=Sum of scores for frequency, quantity and interference., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=0..21, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-EVALUATION.clinical_synopsis.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=1, text=Summary, description=The summary, assessment, conclusions or evaluation of the clinical findings., comment=null, 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.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1], code=at0000, itemType=SECTION, level=1, text=Preoperative 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.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.body_mass_index.v1], code=at0000, itemType=OBSERVATION, level=2, text=Body mass index, description=Calculated measurement which compares a person's weight and height., 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.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.body_mass_index.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=3, 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.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.asa_status.v0], code=at0000, itemType=CLUSTER, level=2, text=ASA Physical Status Classification, description=Classification system adopted by the American Society of Anesthesiologists for assessing preoperative physical status., 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.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.asa_status.v0]/items[at0001], code=at0001, itemType=ELEMENT, level=3, text=ASA patient status, description=Assessed pre-operative status of a patient., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- 1 - A normal healthy patient
- 2 - A patient with mild systemic disease
- 3 - A patient with severe systemic disease
- 4 - A patient with severe systemic disease that is a constant threat to life
- 5 - A moribund patient who is not expected to survive without the operation
- 6 - A declared brain-dead patient whose organs are being removed for donor purposes
- 1E - A normal healthy patient (Emergency)
- 2E - A patient with mild systemic disease (Emergency)
- 3E - A patient with severe systemic disease (Emergency)
- 4E - A patient with severe systemic disease that is a constant threat to life (Emergency)
- 5E - A moribund patient who is not expected to survive without the operation (Emergency)
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='PMH'], code=at0000, itemType=SECTION, level=2, text=PMH, 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.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='PMH']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1], code=at0000, itemType=EVALUATION, level=3, text=Problem/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=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='PMH']/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.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='PMH']/items[openEHR-EHR-EVALUATION.exclusion-problem_diagnosis.v0], code=at0000.1, itemType=EVALUATION, level=3, text=Exclusion of a Problem/Diagnosis, description=A statement about problems or diagnoses that have never been noted by the individual or recognised by a clinician., 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.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='PMH']/items[openEHR-EHR-EVALUATION.exclusion-problem_diagnosis.v0]/data[at0001]/items[at0002.1], code=at0002.1, itemType=ELEMENT, level=4, text=No relevant past medical history, description=Statement of exclusion of a problem or diagnosis., comment=Use to record a statement about problems or diagnoses that have never been noted by the individual or recognised by a clinician. This statement can support recording general statements such as "No previous/past ..." or " No known ...". Or it can support more exacting statements about a specified object such as "No known history of ..." where the 'Problem/diagnosis' identifies the precise condition., 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.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Drugs'], code=at0000, itemType=SECTION, level=2, text=Drugs, 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.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Drugs']/items[openEHR-EHR-INSTRUCTION.medication_order.v0], code=at0000, itemType=INSTRUCTION, level=3, text=Medication order, description=Instructions for use of a medication, vaccine or other therapeutic item., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=INSTRUCTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Drugs']/items[openEHR-EHR-INSTRUCTION.medication_order.v0]/activities[at0001]/description[at0002]/items[at0070], code=at0070, itemType=ELEMENT, level=4, text=Medication item, description=Identification of the medication, vaccine or other therapeutic item being ordered., 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 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=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.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Drugs']/items[openEHR-EHR-EVALUATION.exclusion-medication.v1], code=at0000.1, itemType=EVALUATION, level=3, text=Exclusion of a Medication, description=Statement/s about use of medication that needs to be positively recorded as clinically excluded from the health record ata a specific point in time., 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.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Drugs']/items[openEHR-EHR-EVALUATION.exclusion-medication.v1]/data[at0001]/items[at0002.1], code=at0002.1, itemType=ELEMENT, level=4, text=No relevant medication, description=A statement about exclusion of use of medication in the health record., comment=The statement can support recording that no medications are being taken or that one or more specified medications are not being taken. For example: "Not currently taking any medications"; "Never taken any medications" or "Not currently taking corticosteroids"., 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.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Previous abdominal surgery'], code=at0000, itemType=SECTION, level=2, text=Previous abdominal surgery, 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.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Previous abdominal surgery']/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.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Previous abdominal surgery']/items[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Previous abdominal 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.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Previous abdominal surgery']/items[openEHR-EHR-EVALUATION.exclusion-procedure.v1], code=at0000.1, itemType=EVALUATION, level=3, text=Exclusion of a Procedure, description=Positive statement/s about procedures that need to be recorded as clinically excluded from the health record at a specific point in time., 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.report.v1]/content[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Previous abdominal surgery']/items[openEHR-EHR-EVALUATION.exclusion-procedure.v1]/data[at0001]/items[at0002.1], code=at0002.1, itemType=ELEMENT, level=4, text=No previous abdominal surgery, description=A statement about exclusion of procedures performed in the health record., comment=For example: "No known operations or significant procedures" or "No previous" (appendicectomy)., 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.report.v1]/content[openEHR-EHR-OBSERVATION.briganti_risk_score.v0], code=at0000, itemType=OBSERVATION, level=1, text=Briganti Risk Score, description=The Briganti risk score is a score for predicting probabilities of survival, recurrence, lymph node involvement, organ-defined involvement, extracapsular extension and seminal invasion., 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.report.v1]/content[openEHR-EHR-OBSERVATION.briganti_risk_score.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.gleason_score.v0], code=at0000, itemType=CLUSTER, level=2, text=Gleason Score, description=Gleason Score (ISUP2005 version) - a prostate cancer grading score ratified by the International Society of Urological Pathologists (ISUP), including Gleason Grade Groups., 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.report.v1]/content[openEHR-EHR-OBSERVATION.briganti_risk_score.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.gleason_score.v0]/items[at0166], code=at0166, itemType=ELEMENT, level=3, text=Primary Gleason grade, description=The primary Gleason grade., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_ORDINAL, bindings=null, values=- 3: Grade 3
- 4: Grade 4
- 5: Grade 5
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.briganti_risk_score.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.gleason_score.v0]/items[at0182], code=at0182, itemType=ELEMENT, level=3, text=Secondary Gleason grade, description=The secondary Gleason grade., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_ORDINAL, bindings=null, values=- 3: Grade 3
- 4: Grade 4
- 5: Grade 5
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.briganti_risk_score.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.gleason_score.v0]/items[at0197], code=at0197, itemType=ELEMENT, level=3, text=Total Gleason score, description=The sum of the primary and secondary Gleason grades., comment=The total Gleason score does not take account of the tertiary Gleason grade., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=2..10, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.briganti_risk_score.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.gleason_score.v0]/items[at0265], code=at0265, itemType=ELEMENT, level=3, text=Gleason Grade Group, description=The Gleason Grade Group., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_ORDINAL, bindings=null, values=- 1: Grade Group 1
- 2: Grade Group 2
- 3: Grade Group 3
- 4: Grade Group 4
- 5: Grade Group 5
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.briganti_risk_score.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0029], code=at0029, itemType=ELEMENT, level=2, text=Lymph node involvement probability, description=This number shows, as a percentage, the probability that prostate cancer has spread to the pelvic lymph nodes., 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.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test-histopathology.v0], code=at0000.1, itemType=OBSERVATION, level=1, text=Histopathology test, description=The findings and interpretation of a histopathology test performed on patient-related specimens., 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.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test-histopathology.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0005], code=at0005, itemType=ELEMENT, level=2, text=Biopsy type, description=Identification of the pathology test performed, sometimes including specimen type and patient state., comment=A test result may be for a single analyte, or a group of items, including panel tests. Coding with a terminology, potientially a pre-coordinated term including specimen type, is preferred, where possible. May be coded with LOINC or Snomed-CT. Examples include "Glucose", "Urea and Electrolytes", "Swab", “Cortisol (am)” or "Liver Biopsy"., uncommonOntologyItems={fhirmapping=Diagnostic.Reportname, fhirvalueset=reportnames}, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=- TRUS (targeted)
- TRUS (systematic)
- TRUS (unspecified)
- Transperineal (mapping)
- Transperineal (targeted)
- Transperineal (unspecified)
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test-histopathology.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.tnm_staging_7th-prostate.v1], code=at0000.1, itemType=CLUSTER, level=2, text=Final staging, description=For the classification and grading of prostate cancer using the TNM classification 7th Edition., 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.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test-histopathology.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.tnm_staging_7th-prostate.v1]/items[at0003], code=at0003, itemType=ELEMENT, level=3, text=Primary tumour (T), description=Assessment of the primary tumour., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- TX
- T0
- T1
- T1a
- T1b
- T1c
- T2
- T2a
- T2b
- T2c
- T3
- T3a
- T3b
- T4
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test-histopathology.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.tnm_staging_7th-prostate.v1]/items[at0004], code=at0004, itemType=ELEMENT, level=3, text=Regional lymph nodes (N), description=Assessment of the regional lymph nodes., 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.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test-histopathology.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.tnm_staging_7th-prostate.v1]/items[at0005], code=at0005, itemType=ELEMENT, level=3, text=Distant metastasis (M), description=Assessment of distant metastasis., 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.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test-histopathology.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.gleason_score.v0], code=at0000, itemType=CLUSTER, level=2, text=Gleason Score, description=Gleason Score (ISUP2005 version) - a prostate cancer grading score ratified by the International Society of Urological Pathologists (ISUP), including Gleason Grade Groups., 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.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test-histopathology.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.gleason_score.v0]/items[at0166], code=at0166, itemType=ELEMENT, level=3, text=Primary Gleason grade, description=The primary Gleason grade., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_ORDINAL, bindings=null, values=- 3: Grade 3
- 4: Grade 4
- 5: Grade 5
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test-histopathology.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.gleason_score.v0]/items[at0182], code=at0182, itemType=ELEMENT, level=3, text=Secondary Gleason grade, description=The secondary Gleason grade., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_ORDINAL, bindings=null, values=- 3: Grade 3
- 4: Grade 4
- 5: Grade 5
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test-histopathology.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.gleason_score.v0]/items[at0197], code=at0197, itemType=ELEMENT, level=3, text=Total Gleason score, description=The sum of the primary and secondary Gleason grades., comment=The total Gleason score does not take account of the tertiary Gleason grade., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=2..10, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test-histopathology.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.gleason_score.v0]/items[at0265], code=at0265, itemType=ELEMENT, level=3, text=Gleason Grade Group, description=The Gleason Grade Group., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_ORDINAL, bindings=null, values=- 1: Grade Group 1
- 2: Grade Group 2
- 3: Grade Group 3
- 4: Grade Group 4
- 5: Grade Group 5
, extendedValues=null]], templateType=normal] |