archetype (adl_version=1.4) openEHR-EHR-OBSERVATION.global.v1 concept [at0000] -- Global assessment language original_language = <[ISO_639-1::en]> description original_author = < ["name"] = <"Heather Leslie"> ["organisation"] = <"Ocean Informatics"> ["email"] = <"heather.leslie@oceaninformatics.com"> ["date"] = <"19/03/2007"> > details = < ["en"] = < language = <[ISO_639-1::en]> purpose = <"To document an overall impression of the patient as part of examination."> use = <"Use in conjunction with Conscious state OBSERVATION."> keywords = <"Global", "General assessment", "complexion", "appearance", "behaviour", "hydration", "mood"> misuse = <""> copyright = <"copyright (c) 2010 openEHR Foundation"> > > lifecycle_state = <"AuthorDraft"> other_contributors = <"Sam Heard, Ocean Informatics, Australia", "Ian McNicoll, Ocean Informatics, UK"> other_details = < ["MD5-CAM-1.0.1"] = <"7561ACC34EF2B8E37C10B7CEBF1B85F7"> ["references"] = <""> > definition OBSERVATION[at0000] matches { -- Global assessment data matches { HISTORY[at0001] matches { -- Event Series 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[at0064] occurrences matches {0..*} matches { -- Normal statements value matches { DV_TEXT matches {*} } } ELEMENT[at0067] occurrences matches {0..1} matches { -- Clinical description value matches { DV_TEXT matches {*} } } CLUSTER[at0089] occurrences matches {0..1} matches { -- Skin complexion items cardinality matches {1..*; unordered} matches { ELEMENT[at0044] occurrences matches {0..*} matches { -- Complexion value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0111, -- Pale at0118, -- Flushed at0119, -- Jaundiced at0120, -- Clammy at0121, -- Sweaty at0122, -- Centrally cyanosed at0123, -- Peripherally cyanosed at0124] -- Mottled } } DV_TEXT matches {*} } } } } CLUSTER[at0129] occurrences matches {0..1} matches { -- Sweating and hydration items cardinality matches {1..*; unordered} matches { allow_archetype CLUSTER[at0128] occurrences matches {0..1} matches { -- Sweat include archetype_id/value matches {/openEHR-EHR-CLUSTER\.fluid(-[a-zA-Z0-9_]+)*\.v1/} exclude archetype_id/value matches {/.*/} } allow_archetype CLUSTER[at0116] occurrences matches {0..1} matches { -- Hydration include archetype_id/value matches {/openEHR-EHR-CLUSTER\.hydration(-[a-zA-Z0-9_]+)*\.v1/} } } } CLUSTER[at0065] occurrences matches {0..1} matches { -- Appearance items cardinality matches {1..*; unordered} matches { ELEMENT[at0058] occurrences matches {0..1} matches { -- Nutrition value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0059, -- Well nourished at0060, -- Under nourished at0066, -- Cachectic at0056, -- Morbidly obese at0055, -- Obese at0068] -- Anorexic } } } } ELEMENT[at0046] occurrences matches {0..*} matches { -- Physique value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0047, -- Thin at0048, -- Tall at0049, -- Short at0050, -- Normal weight for height at0051, -- Slightly overweight for height at0052, -- Slightly underweight for height at0053, -- Overweight for height at0054, -- Underweight for height at0057] -- Average height } } } } ELEMENT[at0042] occurrences matches {0..1} matches { -- Posture value matches { DV_TEXT matches {*} } } } } CLUSTER[at0011] occurrences matches {0..1} matches { -- Self care items cardinality matches {1..*; unordered} matches { ELEMENT[at0010] occurrences matches {0..1} matches { -- Cleanliness value matches { DV_TEXT matches {*} } } ELEMENT[at0012] occurrences matches {0..1} matches { -- Grooming value matches { DV_TEXT matches {*} } } ELEMENT[at0014] occurrences matches {0..1} matches { -- Odour value matches { DV_TEXT matches {*} } } ELEMENT[at0036] occurrences matches {0..1} matches { -- State of dress value matches { DV_TEXT matches {*} } } } } CLUSTER[at0038] occurrences matches {0..1} matches { -- Behaviour items cardinality matches {1..*; unordered} matches { ELEMENT[at0103] occurrences matches {0..1} matches { -- Mood description value matches { DV_TEXT matches {*} } } ELEMENT[at0040] occurrences matches {0..1} matches { -- Unusual behaviour details value matches { DV_TEXT matches {*} } } } } CLUSTER[at0069] occurrences matches {0..1} matches { -- Function items cardinality matches {1..*; unordered} matches { ELEMENT[at0062] occurrences matches {0..1} matches { -- Speech value matches { DV_TEXT matches {*} } } ELEMENT[at0045] occurrences matches {0..1} matches { -- Involuntary movements value matches { DV_TEXT matches {*} } } ELEMENT[at0032] occurrences matches {0..1} matches { -- Handedness value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0033, -- Left-handed at0034] -- Right-handed } } } } } } CLUSTER[at0092] occurrences matches {0..*} matches { -- Smells of items cardinality matches {1; unordered} matches { ELEMENT[at0095] occurrences matches {0..1} matches { -- Smell value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0126, -- Smells of alcohol at0127] -- Smells of ketones } } DV_TEXT matches {*} } } ELEMENT[at0096] occurrences matches {0..1} matches { -- Description value matches { DV_TEXT matches {*} } } ELEMENT[at0098] occurrences matches {0..1} matches { -- Degree value matches { 0|[local::at0099], -- Absent 1|[local::at0100], -- Mild 2|[local::at0101], -- Moderate 3|[local::at0102]; -- Marked 0 -- assumed value } } allow_archetype CLUSTER[at0125] occurrences matches {0..1} matches { -- Body site include archetype_id/value matches {/openEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1/} } } } allow_archetype CLUSTER[at0105] occurrences matches {0..*} matches { -- Obvious abnormality on inspection include archetype_id/value matches {/openEHR-EHR-CLUSTER\.inspection(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.gait(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.issue(-[a-zA-Z0-9_]+)*\.v1/} } } } } } } } } } ontology term_definitions = < ["en"] = < items = < ["at0000"] = < text = <"Global assessment"> description = <"General assessment of the whole patient by the clinician."> > ["at0001"] = < text = <"Event Series"> description = <"@ internal @"> > ["at0002"] = < text = <"Any event"> description = <"@ internal @"> > ["at0003"] = < text = <"Tree"> description = <"@ internal @"> > ["at0010"] = < text = <"Cleanliness"> description = <"Subjective description of cleanliness."> > ["at0011"] = < text = <"Self care"> description = <"Inspection of patient's hygiene."> > ["at0012"] = < text = <"Grooming"> description = <"Subjective description of patient's grooming."> > ["at0014"] = < text = <"Odour"> description = <"Subjective description of patient's body odour, with respect to self-care."> > ["at0032"] = < text = <"Handedness"> description = <"Observation of dominant hand."> > ["at0033"] = < text = <"Left-handed"> description = <"Subject has left-hand dominance."> > ["at0034"] = < text = <"Right-handed"> description = <"Subject has right-hand dominance."> > ["at0036"] = < text = <"State of dress"> description = <"Description of patient's state and condition of clothing."> > ["at0038"] = < text = <"Behaviour"> description = <"Description of observed behaviours."> > ["at0040"] = < text = <"Unusual behaviour details"> description = <"Description of observed unusual, abnormal or inappropriate behaviour."> > ["at0042"] = < text = <"Posture"> description = <"Description of posture."> > ["at0044"] = < text = <"Complexion"> description = <"Finding of skin complexion."> > ["at0045"] = < text = <"Involuntary movements"> description = <"Clinical description of generalised abnormal body movements."> > ["at0046"] = < text = <"Physique"> description = <"Description of physical stature."> > ["at0047"] = < text = <"Thin"> description = <"Subject appears thin."> > ["at0048"] = < text = <"Tall"> description = <"Subject appears taller than average."> > ["at0049"] = < text = <"Short"> description = <"Subject appears smaller than average."> > ["at0050"] = < text = <"Normal weight for height"> description = <"Subject appears to have normal weight for height."> > ["at0051"] = < text = <"Slightly overweight for height"> description = <"Subject appears slightly overweight for height."> > ["at0052"] = < text = <"Slightly underweight for height"> description = <"Subject appears slightly underweight for height."> > ["at0053"] = < text = <"Overweight for height"> description = <"Subject appears overweight for height."> > ["at0054"] = < text = <"Underweight for height"> description = <"Subject appears underweight for height."> > ["at0055"] = < text = <"Obese"> description = <"Subject appears overweight."> > ["at0056"] = < text = <"Morbidly obese"> description = <"Subject is overweight to the point of ill health."> > ["at0057"] = < text = <"Average height"> description = <"Subject appears to be of average height."> > ["at0058"] = < text = <"Nutrition"> description = <"Description of state of nutrition."> > ["at0059"] = < text = <"Well nourished"> description = <"Subject is well-nourished but not overweight."> > ["at0060"] = < text = <"Under nourished"> description = <"Subject appears under-nourished."> > ["at0062"] = < text = <"Speech"> description = <"Clinical descripton of speech."> > ["at0064"] = < text = <"Normal statements"> description = <"General statements about normal appearance and behaviour."> > ["at0065"] = < text = <"Appearance"> description = <"Findings of general appearance."> > ["at0066"] = < text = <"Cachectic"> description = <"Subject appears to have general wasting."> > ["at0067"] = < text = <"Clinical description"> description = <"General description of the global impression of the patient."> > ["at0068"] = < text = <"Anorexic"> description = <"Subject appears morbidly thin."> > ["at0069"] = < text = <"Function"> description = <"General aspect of subject's function."> > ["at0089"] = < text = <"Skin complexion"> description = <"Findings related to overall skin appearance."> > ["at0092"] = < text = <"Smells of"> description = <"Details of clinically significant smells."> > ["at0095"] = < text = <"Smell"> description = <"The name of the smell."> > ["at0096"] = < text = <"Description"> description = <"Text description of the smell."> > ["at0098"] = < text = <"Degree"> description = <"The extent of the smell detected."> > ["at0099"] = < text = <"Absent"> description = <"The smell is absent."> > ["at0100"] = < text = <"Mild"> description = <"The smell is mild."> > ["at0101"] = < text = <"Moderate"> description = <"The smell is moderate."> > ["at0102"] = < text = <"Marked"> description = <"The smell is strong."> > ["at0103"] = < text = <"Mood description"> description = <"Description of readily apparent mood disturbance."> > ["at0105"] = < text = <"Obvious abnormality on inspection"> description = <"Details of other obvious abnormalities by simple inspection."> > ["at0111"] = < text = <"Pale"> description = <"Subject appears pale."> > ["at0116"] = < text = <"Hydration"> description = <"Details of skin hydration."> > ["at0118"] = < text = <"Flushed"> description = <"Subject appears flushed."> > ["at0119"] = < text = <"Jaundiced"> description = <"Subject appears jaundiced."> > ["at0120"] = < text = <"Clammy"> description = <"Subject's skin feels clammy."> > ["at0121"] = < text = <"Sweaty"> description = <"Subject appears sweaty."> > ["at0122"] = < text = <"Centrally cyanosed"> description = <"Subject appears centrally cyanosed."> > ["at0123"] = < text = <"Peripherally cyanosed"> description = <"Subject appears peripherally cyanosed."> > ["at0124"] = < text = <"Mottled"> description = <"Subject's skin appears mottled."> > ["at0125"] = < text = <"Body site"> description = <"Location of the smell."> > ["at0126"] = < text = <"Smells of alcohol"> description = <"The subject smells of alcohol."> > ["at0127"] = < text = <"Smells of ketones"> description = <"The subject smells of ketones."> > ["at0128"] = < text = <"Sweat"> description = <"Detailed findings related to sweat."> > ["at0129"] = < text = <"Sweating and hydration"> description = <"Findings related to sweating and hydration."> > > > >