archetype (adl_version=1.4) openEHR-EHR-OBSERVATION.fundoscopic_examination.v1 concept [at0000] -- Fundoscopic examination of eyes language original_language = <[ISO_639-1::en]> translations = < ["pt-br"] = < language = <[ISO_639-1::pt-br]> author = < ["name"] = <"Marco Borges"> ["organisation"] = <"P2D"> ["email"] = <"marco.borges@p2d.com.br"> > > > description original_author = < ["name"] = <"Heather Leslie"> ["organisation"] = <"Ocean Informatics"> ["email"] = <"heather.leslie@oceaninformatics.com"> ["date"] = <"27/07/2008"> > details = < ["en"] = < language = <[ISO_639-1::en]> purpose = <"To record details about clinical findings on fundoscopy of eyes."> use = <""> misuse = <""> copyright = <"copyright (c) 2010 openEHR Foundation"> > ["pt-br"] = < language = <[ISO_639-1::pt-br]> purpose = <"Para registrar detalhes sobre o resultados clínicos do exame fundoscopia dos olhos."> use = <"*"> misuse = <"*"> copyright = <"copyright (c) 2010 openEHR Foundation"> > > lifecycle_state = <"AuthorDraft"> other_contributors = <> other_details = < ["MD5-CAM-1.0.1"] = <"2A64A8FDB455A13CD40A3237E21FAE06"> ["references"] = <""> > definition OBSERVATION[at0000] matches { -- Exame de fundoscopia data matches { HISTORY[at0001] matches { -- Série de Eventos events cardinality matches {1..*; unordered} matches { EVENT[at0002] occurrences matches {0..1} matches { -- Any event data matches { ITEM_TREE[at0003] matches { -- Tree items cardinality matches {0..*; unordered} matches { ELEMENT[at0008] occurrences matches {0..1} matches { -- Descrição clínica value matches { DV_TEXT matches {*} } } ELEMENT[at0004] occurrences matches {0..1} matches { -- Lado value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0005, -- Esquerdo at0006] -- Direito } } } } CLUSTER[at0007] occurrences matches {0..1} matches { -- Detalhes items cardinality matches {0..*; unordered} matches { ELEMENT[at0010] occurrences matches {0..1} matches { -- Reflexo vermelho value matches { DV_BOOLEAN matches { value matches {True, False} } } } ELEMENT[at0011] occurrences matches {0..1} matches { -- Cristalino value matches { DV_TEXT matches {*} } } ELEMENT[at0012] occurrences matches {0..1} matches { -- Nervo óptico value matches { DV_TEXT matches {*} } } ELEMENT[at0016] occurrences matches {0..1} matches { -- Papiledema value matches { DV_BOOLEAN matches { value matches {True, False} } } } ELEMENT[at0017] occurrences matches {0..1} matches { -- Mácula value matches { DV_TEXT matches {*} } } ELEMENT[at0018] occurrences matches {0..1} matches { -- Artérias da retina value matches { DV_TEXT matches {*} } } ELEMENT[at0019] occurrences matches {0..1} matches { -- Veias da retina value matches { DV_TEXT matches {*} } } ELEMENT[at0020] occurrences matches {0..1} matches { -- Flocos de algodão value matches { DV_BOOLEAN matches { value matches {True, False} } } } ELEMENT[at0021] occurrences matches {0..1} matches { -- Hemorragias retinianas value matches { DV_BOOLEAN matches { value matches {True, False} } } } ELEMENT[at0022] occurrences matches {0..1} matches { -- Fundo da retina value matches { DV_TEXT matches {*} } } ELEMENT[at0023] occurrences matches {0..1} matches { -- Vítreo value matches { DV_TEXT matches {*} } } CLUSTER[at0009] occurrences matches {0..1} matches { -- Visualização items cardinality matches {0..*; unordered} matches { ELEMENT[at0015] occurrences matches {0..1} matches { -- Visibilidade value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0024, -- Totalmente visível at0025, -- Parcialmente visível at0026] -- Não visível } } } } ELEMENT[at0027] occurrences matches {0..1} matches { -- Comentário value matches { DV_TEXT matches {*} } } } } } } } } } state matches { ITEM_TREE[at0013] matches { -- Tree items cardinality matches {0..*; unordered} matches { ELEMENT[at0014] occurrences matches {0..1} matches { -- *Mydriatic used(en) value matches { DV_BOOLEAN matches { value matches {True, False; False} } } } } } } } } } } protocol matches { ITEM_TREE[at0028] matches { -- Tree items cardinality matches {0..*; unordered} matches { ELEMENT[at0029] occurrences matches {0..1} matches { -- Método value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0030, -- Direto at0031] -- Indireto } } } } } } } } ontology term_definitions = < ["en"] = < items = < ["at0000"] = < text = <"Fundoscopic examination of eyes"> description = <"Record of clinical findings on fundoscopy of eyes"> > ["at0001"] = < text = <"Event Series"> description = <"@ internal @"> > ["at0002"] = < text = <"Any event"> description = <"*"> > ["at0003"] = < text = <"Tree"> description = <"@ internal @"> > ["at0004"] = < text = <"Side"> description = <"*"> > ["at0005"] = < text = <"Left"> description = <"*"> > ["at0006"] = < text = <"Right"> description = <"*"> > ["at0007"] = < text = <"Details"> description = <"*"> > ["at0008"] = < text = <"Clinical Description"> description = <"Descriptive overview of examination findings"> > ["at0009"] = < text = <"Visualisation"> description = <"*"> > ["at0010"] = < text = <"Red reflex"> description = <"True if Red Reflex is present"> > ["at0011"] = < text = <"Lens"> description = <"Description of lens"> > ["at0012"] = < text = <"Optic Disc"> description = <"Description of optic disc"> > ["at0013"] = < text = <"Tree"> description = <"@ internal @"> > ["at0014"] = < text = <"Mydriatic used"> description = <"True if mydriatic is used"> > ["at0015"] = < text = <"Ease of Visualisation"> description = <"Description of ease to visualise all the sturctures during fundoscopy"> > ["at0016"] = < text = <"Papilloedema"> description = <"True if papilloedema present"> > ["at0017"] = < text = <"Macula"> description = <"Description of macula"> > ["at0018"] = < text = <"Retinal arteries"> description = <"Description of retinal arteries"> > ["at0019"] = < text = <"Retinal veins"> description = <"Description of retinal veins"> > ["at0020"] = < text = <"'Cotton Wool' artefacts"> description = <"True if 'cotton wool' artefacts are present"> > ["at0021"] = < text = <"Retinal haemorrhages"> description = <"True if retinal haemorrhages are present"> > ["at0022"] = < text = <"Retinal background"> description = <"Description of retinal background"> > ["at0023"] = < text = <"Vitreous"> description = <"Description of vitreous humour"> > ["at0024"] = < text = <"Fully visualised"> description = <"*"> > ["at0025"] = < text = <"Partially visualised"> description = <"*"> > ["at0026"] = < text = <"Not visualised"> description = <"*"> > ["at0027"] = < text = <"Comment"> description = <"Comment, especially if not fully visualised"> > ["at0028"] = < text = <"Tree"> description = <"@ internal @"> > ["at0029"] = < text = <"Method"> description = <"*"> > ["at0030"] = < text = <"Direct"> description = <"*"> > ["at0031"] = < text = <"Indirect"> description = <"*"> > > > ["pt-br"] = < items = < ["at0000"] = < text = <"Exame de fundoscopia"> description = <"Registrar resultados clínicos sobre fundoscopia dos olhos."> > ["at0001"] = < text = <"Série de Eventos"> description = <"@ internal @"> > ["at0002"] = < text = <"Any event"> description = <"*"> > ["at0003"] = < text = <"Tree"> description = <"@ internal @"> > ["at0004"] = < text = <"Lado"> description = <"Lado examinado."> > ["at0005"] = < text = <"Esquerdo"> description = <"Olho esquerdo."> > ["at0006"] = < text = <"Direito"> description = <"Olho direito."> > ["at0007"] = < text = <"Detalhes"> description = <"Detalhes da fundoscopia."> > ["at0008"] = < text = <"Descrição clínica"> description = <"Descição dos achados em fundoscopia."> > ["at0009"] = < text = <"Visualização"> description = <"*"> > ["at0010"] = < text = <"Reflexo vermelho"> description = <"Reflexo vermelho é presente?"> > ["at0011"] = < text = <"Cristalino"> description = <"Descrição dos achados no cristalino."> > ["at0012"] = < text = <"Nervo óptico"> description = <"Descrição dos achados no nervo óptico."> > ["at0013"] = < text = <"Tree"> description = <"@ internal @"> > ["at0014"] = < text = <"*Mydriatic used(en)"> description = <"*True if mydriatic is used(en)"> > ["at0015"] = < text = <"Visibilidade"> description = <"Facilidade de visualizar as estruturas durante fundoscopia."> > ["at0016"] = < text = <"Papiledema"> description = <"Papiledema (inchaço) do nervo óptico é presente?"> > ["at0017"] = < text = <"Mácula"> description = <"Descrição dos achados na mácula."> > ["at0018"] = < text = <"Artérias da retina"> description = <"Descrição dos achados nas artérias da retina."> > ["at0019"] = < text = <"Veias da retina"> description = <"Descrição dos achados nas veias da retina."> > ["at0020"] = < text = <"Flocos de algodão"> description = <"Existem manchas em flocos de algodão?"> > ["at0021"] = < text = <"Hemorragias retinianas"> description = <"Existem hemorragias na retina?"> > ["at0022"] = < text = <"Fundo da retina"> description = <"Descrição dos achados no fundo da retina."> > ["at0023"] = < text = <"Vítreo"> description = <"Descrição dos achados no vítreo."> > ["at0024"] = < text = <"Totalmente visível"> description = <"Facilidade total para visualizar todas as estruturas durante fundoscopia."> > ["at0025"] = < text = <"Parcialmente visível"> description = <"Algumas estruturas são visíveis e outras não."> > ["at0026"] = < text = <"Não visível"> description = <"Estruturas não são visível durante a fundoscopia."> > ["at0027"] = < text = <"Comentário"> description = <"Comentário sobre a fundoscopia."> > ["at0028"] = < text = <"Tree"> description = <"@ internal @"> > ["at0029"] = < text = <"Método"> description = <"Método usado no exame de fundoscopia."> > ["at0030"] = < text = <"Direto"> description = <"*"> > ["at0031"] = < text = <"Indireto"> description = <"*"> > > > >