Type: openEHR TEMPLATE
Purpose: Not Specified
Use: null
Misuse: null
| TEMPLATE ID | *CL 2.1 Hearing Health Summary |
|---|---|
| Concept | *CL 2.1 Hearing Health Summary |
| Description | Not Specified |
| Purpose | Not Specified |
| References | |
| Other Details (Language Independent) |
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| Language used | en |
| Citeable Identifier | 1013.26.791 |
| Root archetype id | openEHR-EHR-COMPOSITION.health_summary.v0 |
| Hearing health summary | Hearing health summary: Generic document containing a summary of health information about an individual. |
| Header | Header: A generic heading for contextual renaming within a template. |
| Informed Consent status (see CL 7.8 Consent template) | Informed Consent status (see CL 7.8 Consent template): A generic heading for contextual renaming within a template. |
| Priority (derived from Admin algorithms) | Priority (derived from Admin algorithms): A generic heading for contextual renaming within a template. |
| Neonatal Hearing Screen status (see CL 2.2 Neonatal Hearing Screen template) | Neonatal Hearing Screen status (see CL 2.2 Neonatal Hearing Screen template): A generic heading for contextual renaming within a template. |
| Last Surgery (derived from all CL 3.3 Operation Note templates) | Last Surgery (derived from all CL 3.3 Operation Note templates): A generic heading for contextual renaming within a template. |
| Aided Device (see CL 7.7 Assisted hearing template) | Aided Device (see CL 7.7 Assisted hearing template): A generic heading for contextual renaming within a template. |
| Service Plan (See CL 8.0 Service Plan) | Service Plan (See CL 8.0 Service Plan): A generic heading for contextual renaming within a template. |
| Recent Results (see CL 3.1.3 Otoscopy Report & CL 3.1.5 Audiometry Report; Risk of hearing loss derived from CL 7.1 Risk Factor Register) | Recent Results (see CL 3.1.3 Otoscopy Report & CL 3.1.5 Audiometry Report; Risk of hearing loss derived from CL 7.1 Risk Factor Register): A generic heading for contextual renaming within a template. |
| Hearing Assessment (limited display only of most recent assessment - Assessment Date, Location, Context, Audiogram graph + data: date, reliability, background noise) | Hearing Assessment (limited display only of most recent assessment - Assessment Date, Location, Context, Audiogram graph + data: date, reliability, background noise): A generic heading for contextual renaming within a template. |
| Audiogram result | Audiogram result: Measurement of hearing acuity using a calibrated hearing test device, and associated clinical interpretation. |
| Data | |
| Any point in time event | Any point in time event: Default, unspecified point in time which may be explicitly defined in a template or at run-time. For example, in a template, this event can be cloned and specifically identified to be the first and/or second test conducted as a part of a comprehensive assessment, such as a Hearing Conservation or Industrial Audiometric Assessment. |
| Data | |
| Test result name | Test result name: Identification of the Audiometry test performed. Coding with an external terminology is preferred, where possible. Applicable tests include: Pure Tone Audiometry; Play Audiometry; Auditory Brainstem Response (for threshold determination); and Visual Reinforcement Orientation Audiometry. Annotations
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| Result details | Result details: The test result measurements and interpretations which can be recorded per ear, or for both ears simultaneously. |
| Test ear | Test ear: Identification of the ear(s) to which the test stimulus is being presented.
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| Hearing threshold interpretation | Hearing threshold interpretation: Interpretation of a series of audiometric measurements for purposes of hearing threshold assessment. |
| Pure tone average | Pure tone average: The average pure tone threshold according to the specified averaging criteria. This calculation is typically determined using air conduction thresholds. -10..120 dB |
| Degree of loss | Degree of loss: Category of the degree of hearing loss derived from the dB threshold values using specified criteria. Coding with a terminology is desirable, where possible. For example: none, mild, moderate, severe and profound. Each of these categories should be clearly defined on the basis of a dB range appropriate for age. |
| Type of loss | Type of loss: Identified type of hearing loss for the test ear, based on all measurements. If there is no degree of loss, then this data element is not applicable.
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| Interpretation | Interpretation: Clinical interpretation of all measurements for the test ear. Coding with a terminology is preferred, where possible. Not to be used for recording the interpretation for both ears when the ears are tested simultaneously - use the data element 'Overall Interpretation' instead. |
| Overall interpretation | Overall interpretation: Overall clinical interpretation of the measurements and related findings using an audiometer. Coding with a terminology is preferred, where possible. This data element is effectively an audiological diagnosis. Binaural test results reflect either the performance for both ears (if equal hearing) or only the better ear (where the hearing is not symmetrical). |
| Protocol | |
| Background noise | Background noise: The amount and nature of noise in the environment that may influence the test results. If testing is conducted in an audiometric booth, this data element is redundant.
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| Audiology speech test result | Audiology speech test result: Observations on speech discrimination and speech recognition, and associated clinical interpretation. |
| Data | |
| Any event | Any event: Default, unspecified point in time event which may be explicitly defined in a template or at run-time. |
| Data | |
| Test result name | Test result name: Identification of the audiology speech test performed. For example: AB Word List; Paediatric Speech Intelligibility (PSI); NUCHIPS; HINT; and BKB Sentences.
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| Result details | Result details: The test measurements and interpretations which can be recorded per ear, or for both ears simultaneously. |
| Test ear | Test ear: The ear to which to the speech signal is presented.
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| No test result | No test result: No test result is available for the test ear. Record as True if the clinician was unable to record a result for the test ear or binaural testing in a soundfield, as defined by the 'Test Ear' data element. |
| Clinical interpretation | Clinical interpretation: Clinical interpretation of all responses for the identified test ear. |
| Summary | Summary: Overall clinical interpretation of the responses for both ears. |
| Ear Assessment (limited display only of most recent assessment - Assessment date, Location, Context, plus Ear Diagnosis and Tympanometry Result | Ear Assessment (limited display only of most recent assessment - Assessment date, Location, Context, plus Ear Diagnosis and Tympanometry Result: A generic heading for contextual renaming within a template. |
| Ear Diagnosis (0..2) | Ear Diagnosis (0..2): 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. 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'. |
| Data | |
| Diagnosis | Diagnosis: Identification of the problem or diagnosis, by name. Coding of the name of the problem or diagnosis with a terminology is preferred, where possible. |
| Body site | Body site: Identification of a simple body site for the location of the problem or diagnosis. Coding of the name of the anatomical location with a terminology is preferred, where possible. Use this data element to record precoordinated anatomical locations. If the requirements for recording the anatomical location are determined at run-time by the application or require more complex modelling such as relative locations then use the CLUSTER.anatomical_location or CLUSTER.relative_location within the 'Structured anatomical location' SLOT in this archetype. Occurrences for this data element are unbounded to allow for clinical scenarios such as describing a rash in multiple locations but where all of the other attributes are identical. If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant.
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| Preferred Otoscopy Image | Preferred Otoscopy Image: Details about an multimedia representation of the clinical data. |
| Multimedia resource | Multimedia resource: Multimedia representation of the clinical observation or finding. |
| Date created | Date created: Date/time that the multimedia resource was created. |
| Course | Course: The pattern or evolution of the problem or diagnosis.
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| Resolution | Resolution: Phase of resolution or healing of an acute problem or diagnosis.
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| Grommet status | Grommet status: Unspecified qualifier that will be renamed, data type selected and potential value sets specified in a template. For example: The boolean data type could be used to signify that the problem/diagnosis can be included in a patient summary; the text data type could be used to categorise in a similar way to 'Current?' or Active?'; and the count data type could be used to assert a priority key or order to problems and diagnoses in a list. If any uses are identified as frequently required, they could be added explicitly to this archetype as an explicit data element. |
| Tympanogram Result - 226Hz | Tympanogram Result - 226Hz: Measurement of tympanic membrane movement in response to a 226Hz probe tone and changes in air pressure in the ear canal, and associated clinical interpretation. |
| Baseline | Baseline: Measurement collection recorded as the basis for comparison with following measurement collections that may include other variables of time or patient state. |
| Result details | Result details: The tympanogram test result measurements and interpretations, recorded per ear. |
| Test ear | Test ear: Identification of the ear being tested.
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| No test result | No test result: No test result is available for the test ear. Record as True if the clinician was unable to record a result for the test ear. |
| Tympanogram type | Tympanogram type: Description of the the shape of the tympanogram curve, based on the Jerger categories. If Type B or C subtypes are to be used in an implementation, these should be substituted for the global 'Type B' or 'Type C' classification here. Both 'Type B' and 'Type B - low compliance'/'Type B - high compliance' should not be used in the same implementation. Similarly, both 'Type C' and Types C1-3 should not be used in the same implementation.
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| Comment | Comment: Additional narrative about the test results and intepretation not captured in other fields. |
| Otitis Media Summary (see CL 7.2 Problem List - Otitis Media Diagnosis by query only) | Otitis Media Summary (see CL 7.2 Problem List - Otitis Media Diagnosis by query only): A generic heading for contextual renaming within a template. |
| Service History (See CL 4.0 Consultations) | Service History (See CL 4.0 Consultations): A generic heading for contextual renaming within a template. |