ARCHETYPE ID | openEHR-EHR-OBSERVATION.visual_acuity.v0 |
Concept | Visual acuity test result |
Description | Visual acuity is a measure of the spatial resolution of the visual processing system. |
Use | Use to record the results of measurement of visual acuity, for both near and distance testing. The 'Clinical Description' data element can be used to record simple narrative summary or as a means to integrate legacy data. Detailed, structured visual acuity results are preferred and are generally recorded for each eye in turn. Visual acuity may be recorded using a number of different notation formats e.g. Snellen, logMar, EDTRS etc. In some settings the visual acuity result, originally captured using one of the standard notations, is converted to a 'Derived Score' capable of algorithmic conversion to the other notations., with details of the original notation and algorithm employed recorded as part of protocol. Where visual acuity is recorded using coded terms such as 'Visual Acuity 6/6' or 'Jaeger score N1', the 'Clinical Interpretation' element should be used, allowing the result to be captured for each eye. 'Overall Interpretation' should be used where the interpretation applies to both eyes or the test result as a whole. The 'Absent Test Result' element may be used to record circumstances where a test could not be performed or completed. Further details may be recorded under 'Confounding Factors' or 'Additional Comment'. When performing visual acuity testing it is customary to record a series of tests sharing a common charting methodology but with different phases of corrective refraction e.g. Unaided, Usual correction, Best corrected visual acuity etc. Each of these phases should be recorded using a separate Entry record, with the name of the test phase carried in 'Test Name'. Further specific details of the exact correction applied (which may involve applying multiple refractions) may be captured in 'Refractive Correction' and 'Refraction Details' the latter making use of separate Cluster archetypes, one for each eye. |
Misuse | Where details of methodology carried under protocol change between phases of the visual acuity test, a new Entry must be created at run-time. |
Purpose | For recording the results of both near and distance visual acuity testing, normally measured by testing the subject's ability to read a standard test pattern at a defined distance. |
References | Visual Acuity [Internet]. Wikipedia. Available from: http://en.wikipedia.org/wiki/Visual_acuity Aylward W [Internet].Coding Visual Acuity, openEyes Project;2012.Available from http://www.openeyes.org.uk/documents/OpenEyes%20Coding%20Visual%20Acuity.pdf IHE Eye Care Domain. General Eye Evaluation (GEE) [Internet]. IHE; 2012. Available from: http://www.ihe.net/Technical_Framework/upload/IHE_EyeCare_Supp_GEE_Rev1-1_TI_2012-06-29.pdf Royal College of Opthalmologists. Cataract National Dataset for Adults [Internet]. 2011. Available from: http://www.rcophth.ac.uk/page.asp?section=583§ionTitle=Cataract+National+Data+Set+for+Adults Laidlaw D a. H, Tailor V, Shah N, Atamian S, Harcourt C. Validation of a computerised logMAR visual acuity measurement system (COMPlog): comparison with ETDRS and the electronic ETDRS testing algorithm in adults and amblyopic children. Br J Ophthalmol [Internet]. 2008 Feb 1 [cited 2012 Sep 26];92(2):241–4. Available from: http://bjo.bmj.com/content/92/2/241 CfH, UK. Do Once & Share - Glaucoma [Internet]. [cited 2012 Sep 26]. Available from: http://www.doasglaucoma.org/ DICOM Supplement 30 [Internet]. [cited 2012 Sep 26]. Available from: http://medical.nema.org/ Chiang MF, Boland MV, Brewer A, Epley KD, Horton MB, Lim MC, et al. Special Requirements for Electronic Health Record Systems in Ophthalmology. Ophthalmology [Internet]. 2011 Aug [cited 2012 Sep 26];118(8):1681–7. Available from: http://www.aaojournal.org/article/S0161-6420(11)00374-5/abstract Practical Ophthalmology: A Manual for Beginning Residents, 6th Edition [Paperback] American Academy Of Ophthalmology (Author), Fred M. Wilson II (Editor), MD (Editor) |
Copyright | © openEHR Foundation |
Authors | Author name: Ian McNicoll Organisation: Ocean Informatics, UK Email: ian.mcnicoll@oceaninformatics.com Date originally authored: 2012-07-18 |
Other Details Language | Author name: Ian McNicoll Organisation: Ocean Informatics, UK Email: ian.mcnicoll@oceaninformatics.com Date originally authored: 2012-07-18 |
OtherDetails Language Independent | {licence=This work is licensed under the Creative Commons Attribution-ShareAlike 3.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/3.0/., custodian_organisation=openEHR Foundation, references=Visual Acuity [Internet]. Wikipedia. Available from: http://en.wikipedia.org/wiki/Visual_acuity Aylward W [Internet].Coding Visual Acuity, openEyes Project;2012.Available from http://www.openeyes.org.uk/documents/OpenEyes%20Coding%20Visual%20Acuity.pdf IHE Eye Care Domain. General Eye Evaluation (GEE) [Internet]. IHE; 2012. Available from: http://www.ihe.net/Technical_Framework/upload/IHE_EyeCare_Supp_GEE_Rev1-1_TI_2012-06-29.pdf Royal College of Opthalmologists. Cataract National Dataset for Adults [Internet]. 2011. Available from: http://www.rcophth.ac.uk/page.asp?section=583§ionTitle=Cataract+National+Data+Set+for+Adults Laidlaw D a. H, Tailor V, Shah N, Atamian S, Harcourt C. Validation of a computerised logMAR visual acuity measurement system (COMPlog): comparison with ETDRS and the electronic ETDRS testing algorithm in adults and amblyopic children. Br J Ophthalmol [Internet]. 2008 Feb 1 [cited 2012 Sep 26];92(2):241–4. Available from: http://bjo.bmj.com/content/92/2/241 CfH, UK. Do Once & Share - Glaucoma [Internet]. [cited 2012 Sep 26]. Available from: http://www.doasglaucoma.org/ DICOM Supplement 30 [Internet]. [cited 2012 Sep 26]. Available from: http://medical.nema.org/ Chiang MF, Boland MV, Brewer A, Epley KD, Horton MB, Lim MC, et al. Special Requirements for Electronic Health Record Systems in Ophthalmology. Ophthalmology [Internet]. 2011 Aug [cited 2012 Sep 26];118(8):1681–7. Available from: http://www.aaojournal.org/article/S0161-6420(11)00374-5/abstract Practical Ophthalmology: A Manual for Beginning Residents, 6th Edition [Paperback] American Academy Of Ophthalmology (Author), Fred M. Wilson II (Editor), MD (Editor), original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=99E69FA4B68A224E29AD715170A7857D, build_uid=c1c86183-529c-4d08-9904-9a14f7a2a74f, ip_acknowledgements=This artefact includes content from SNOMED Clinical Terms® (SNOMED CT®) which is copyrighted material of the International Health Terminology Standards Development Organisation (IHTSDO). Where an implementation of this artefact makes use of SNOMED CT content, the implementer must have the appropriate SNOMED CT Affiliate license - for more information contact http://www.snomed.org/snomed-ct/get-snomedct or info@snomed.org., revision=0.0.1-alpha} |
Keywords | eye, sight, vision, ophthalmic, visual, refraction |
Lifecycle | in_development |
UID | 93b051f7-c9a6-4728-92aa-13a3af7114d5 |
Language used | en |
Citeable Identifier | 1013.1.1291 |
Revision Number | 0.0.1-alpha |
All | Archetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Visual acuity is a measure of the spatial resolution of the visual processing system., archetypeConceptComment=null, otherContributors=Bill Aylward, openEyes Project, UK Gustavo Bacelar-Silva, Brazil (Editor) Stephen Chu, NeHTA, Australia Alistair Laidlaw, Guys and St Thomas NHS Trust, UK Heather Leslie, Ocean Informatics, Australia Gustavo M Bacelar-Silva, Brazil Mike Mair, Timaru Eye Clinic, New Zealand Ian McNicoll, Ocean Informatics, United Kingdom (Editor), originalLanguage=en, translators=
Units:
openEHR-EHR-CLUSTER.device.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0020]/items[at0092], code=at0092, itemType=ELEMENT, level=2, text=Derived Score Original Notation, description=The original visual acuity result notation from which the Derived Score was calculated., comment=When the visual acuity result is recorded using a Derived Score, this element can be used to record the original notation format, so that it can be displayed using the original notation. , uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
All not explicitly excluded archetypes, extendedValues=null]], ism_transition=[], context=[], data=[ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0134]/data[at0003]/items[at0138], code=at0138, itemType=ELEMENT, level=4, text=Test name, description=The name of the exact visual acuity test performed. This generally represents a broad category of applied refraction. Specific refraction details can be described using 'Refractive Correction'., comment=Details of the exact correction applied, or where multiple corrections should be captured via 'Refractive Correction'., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
Denominator: 4.0..60.0 Integral Assumed value: false , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0134]/data[at0003]/items[at0053]/items[at0028]/items[at0009], code=at0009, itemType=ELEMENT, level=6, text=US Snellen, description=The distance test result, recorded as Snellen visual acuity expressed in feet, where 20/20 is regarded as normal., comment=Examples: '20/20' , '20/40', '20/18', uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_PROPORTION, bindings=[SNOMED-CT:
Denominator: 2.0..200.0 Integral Assumed value: false , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0134]/data[at0003]/items[at0053]/items[at0028]/items[at0057], code=at0057, itemType=ELEMENT, level=6, text=Decimal Snellen, description=The distance test result,recorded as Sn ellen visual acuity expressed as a decimal ratio, where 1.0 is regarded as normal., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_PROPORTION, bindings=[SNOMED-CT:
Integral Assumed value: false , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0134]/data[at0003]/items[at0053]/items[at0028]/items[at0011], code=at0011, itemType=ELEMENT, level=6, text=ETDRS Letters, description=Visual acuity expressed using ETDRS Letters format, with a value of 100 regarded as normal., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=min: >=1; max: <=120 , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0134]/data[at0003]/items[at0053]/items[at0028]/items[at0046], code=at0046, itemType=ELEMENT, level=6, 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=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_QUANTITY, bindings=null, values=Property: Qualified real Units: -0.5..2.0 Limit decimal places: 1, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0134]/data[at0003]/items[at0053]/items[at0028]/items[at0015], code=at0015, itemType=ELEMENT, level=6, text=Low Vision Score, description=Graded scale used when patient has low levels of visual acuity., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=1: NPL - No perception of light [The subject has no perception of light.] 2: PL - Perception of light [The subject can perceive light.] 3: HM - Hand movement [The subject can perceive hand movement.] 4: CF - Count fingers [The subject can count fingers.] [SNOMED-CT: , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0134]/data[at0003]/items[at0053]/items[at0059], code=at0059, itemType=ELEMENT, level=5, text=Letter Termination Adjustment, description=A line termination adjustment score applied to the visual acuity result., comment=If the patient can read at least half of the chart line the visual acuity terminatin line is recorded as that line, with the number of letters missed on that line recorded as a negative Letter Termination Adjustment score. If the patient can read less than half of a Visual Acuity line, the previous line is recorded as the Visual Acuity result, with the number of letters seen on the following line recorded as a positive 'Letter Termination Adjustment' score., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=min: >=-10; max: <=10 <br/>Assumed value0 , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0134]/data[at0003]/items[at0053]/items[at0010], code=at0010, itemType=ELEMENT, level=5, text=Derived Score, description=Visual acuity expressed as an integer score which is calculated from one or more of the other result notation formats. The original notation should be captured using 'Derived Score Original Notation' format'., comment=Details of the algorithm used and original result format may be recorded under 'Derived Score Methodology'., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=min: >=0 , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0134]/data[at0003]/items[at0053]/items[at0066], code=at0066, itemType=ELEMENT, level=5, text=Interpretation, description=Clinical interpretation of all results for the test eye., comment=Example: 'Visual Acuity 20/20' or 'Jaeger 'J2' score'., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=[SNOMED-CT: openEHR-EHR-CLUSTER.exclusion_
openEHR-EHR-CLUSTER.refraction_ openEHR-EHR-CLUSTER.exam_ Units:
openEHR-EHR-CLUSTER.device.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0020]/items[at0092], code=at0092, itemType=ELEMENT, level=2, text=Derived Score Original Notation, description=The original visual acuity result notation from which the Derived Score was calculated., comment=When the visual acuity result is recorded using a Derived Score, this element can be used to record the original notation format, so that it can be displayed using the original notation. , uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
All not explicitly excluded archetypes, extendedValues=null]], minIndents={}, termBindingRetrievalErrorMessage=null] |