ARCHETYPE ID | openEHR-EHR-OBSERVATION.nihss.v0 |
Concept | NIH Stroke Scale (NIHSS) |
Description | 15-item neurologic examination stroke scale that provides a quantitative measure of stroke-related neurological deficit. |
Use | Use to record the results of the National Institutes of Health Stroke Score as a quantitative measurement of stroke-related neurologic deficit. The total score is the arithmetic sum of all 15 responses, excluding any untestable responses. |
Purpose | To record the results of the National Institutes of Health Stroke Score as a quantitative measurement of stroke-related neurologic deficit. |
References | NIH Stroke Scale [Internet]. Bethesda, MD: National Institute of Health; [cited 2023 Mar 04]. Available from: https://www.stroke.nih.gov/resources/scale.htm. Validated translation of the NIHSS with cultural adaptation [Internet]. Sykepleien Forskning; [cited 2023 Mar 04]. Available from: https://sykepleien.no/forskning/2020/11/validert-oversettelse-av-nihss-med-kulturell-tilpasning |
Copyright | © openEHR Foundation |
Authors | Author name: Gustavo M Bacelar-Silva Organisation: Healthcare Designs Email: mail@gustavobacelar.com Date originally authored: 2012-05-11 |
Other Details Language | Author name: Gustavo M Bacelar-Silva Organisation: Healthcare Designs Email: mail@gustavobacelar.com Date originally authored: 2012-05-11 |
OtherDetails Language Independent | {licence=This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/., custodian_organisation=openEHR Foundation, references=NIH Stroke Scale [Internet]. Bethesda, MD: National Institute of Health; [cited 2023 Mar 04]. Available from: https://www.stroke.nih.gov/resources/scale.htm.
Validated translation of the NIHSS with cultural adaptation [Internet]. Sykepleien Forskning; [cited 2023 Mar 04]. Available from: https://sykepleien.no/forskning/2020/11/validert-oversettelse-av-nihss-med-kulturell-tilpasning, current_contact=Heather Leslie, Atomica Informatics |
Keywords | scale, neurological, stroke, assessment, examination, NIHSS |
Lifecycle | in_development |
UID | 6359150e-4104-4044-b81d-855ba7c4b643 |
Language used | en |
Citeable Identifier | 1013.1.2041 |
Revision Number | 0.0.1-alpha |
All | Archetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=15-item neurologic examination stroke scale that provides a quantitative measure of stroke-related neurological deficit., archetypeConceptComment=null, otherContributors=Mikkel Johan Gaup Grønmo, Regional forvaltning EPJ, Helse Nord, Norway (openEHR Editor) Gustavo Bacelar-Silva, Healthcare Designs, Portugal Silje Ljosland Bakke, Nasjonal IKT HF, Norway (openEHR Editor) Rong Chen, Cambio Healthcare Systems, Sweden Ricardo Cruz-Correia, Faculty of Medicine of Porto University, Portugal Heather Leslie, Atomica Informatics, Australia (openEHR Editor), originalLanguage=en, translators=
All not explicitly excluded archetypes, extendedValues=null]], ism_transition=[], context=[], data=[ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=4, text=LOC responsiveness, description=Observed level of consciousness of the patient., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=0: Alert [Keenly responsive.] 1: Not alert, but arousable by minor stimulation [Not alert; but arousable by minor stimulation to obey, answer or respond.] 2: Not alert, requires repeated stimulation or strong stimuli. [Not alert; requires repeated stimulation to attend, or is obtunded and requires strong or painful stimulation to make movements.] 3: Reflex reponses only or totally unreponsive [Responds only with reflex motor or autonomic effects, or totally unresponsive, flaccid, and areflexic.] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0009], code=at0009, itemType=ELEMENT, level=4, text=LOC questions, description=The patient is asked the month and his/her age., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=0: Both correct [Patient answered both questions correctly.] 1: One correct [Patient answered one question correctly or is unable to communicate because of a problem not secondary to aphasia.] 2: Neither correct [Patient answered neither question correctly or is comatose or does not comprehend the question.] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0013], code=at0013, itemType=ELEMENT, level=4, text=LOC commands, description=The patient is asked to open and close the eyes and then to grip and release the non-paretic hand., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=0: Both correct [Patient performs both tasks correctly.] 1: One correct [Patient performs one task correctly.] 2: Neither correct [Patient performs neither task correctly.] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0017], code=at0017, itemType=ELEMENT, level=4, text=Horizontal eye movements, description=Horizontal eye movement observation., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=0: Normal [Normal eye movement.] 1: Partial gaze palsy [Gaze is abnormal in one or both eyes, but forced deviation or total gaze paresis is not present.] 2: Forced deviation or total gaze paresis [Forced deviation or total gaze paresis is not overcome by the oculocephalic maneuver.] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0021], code=at0021, itemType=ELEMENT, level=4, text=Visual fields, description=Visual field test observation., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=0: No visual loss [No visual loss detected.] 1: Partial hemianopia [Partial hemianopia or complete quadrantanopia detected.] 2: Complete hemianopia [Complete hemianopia detected.] 3: Bilateral hemianopia [Blindness from any cause, including cortical blindness.] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0026], code=at0026, itemType=ELEMENT, level=4, text=Facial palsy, description=Facial palsy observation., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=0: Normal [Normal symmetrical movements.] 1: Minor paralysis [Flattened nasolabial fold, asymmetry on smiling.] 2: Partial paralysis [Total or near-total paralysis of lower face.] 3: Complete paralysis of one or both sides [Absence of facial movement in the upper and lower face.] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0031], code=at0031, itemType=ELEMENT, level=4, text=Motor - left arm, description=Observation of left arm motor function., comment=Only in the case of amputation or joint fusion at the shoulder, the examiner should record the score as 'UNTESTABLE' and record the reason in the 'Reason left arm untestable' data element. Implementation note: while the UNTESTABLE value has been included in this ordinal to allow for inclusion in user interface picklists, the NIHSS applies no numerical score from this selection to the 'Total score'., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=0: No drift [Limb holds 90 (or 45) degrees for full 10 seconds.] 1: Drift [Limb holds 90 (or 45) degrees, but drifts down before full 10 seconds; does not hit bed or other support.] 2: Some effort against gravity [Limb cannot get to or maintain (if cued) 90 (or 45) degrees, drifts down to bed, but has some effort against gravity.] 3: No effort against gravity [Limb falls.] 4: No movement [There is no observed limb movement.] 0: UNTESTABLE [Amputation or joint fusion at the shoulder.] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0037], code=at0037, itemType=ELEMENT, level=4, text=Reason left arm untestable, description=Narrative description about why the left arm motor function was untestable., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0038], code=at0038, itemType=ELEMENT, level=4, text=Motor - right arm, description=Observation of right arm motor function., comment=Only in the case of amputation or joint fusion at the shoulder, the examiner should record the score as 'UNTESTABLE' and record the reason in the 'Reason right arm untestable' data element. Implementation note: while the UNTESTABLE value has been included in this ordinal to allow for inclusion in user interface picklists, the NIHSS applies no numerical score from this selection to the 'Total score'., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=0: No drift [Limb holds 90 (or 45) degrees for full 10 seconds.] 1: Drift [Limb holds 90 (or 45) degrees, but drifts down before full 10 seconds; does not hit bed or other support.] 2: Some effort against gravity [Limb cannot get to or maintain (if cued) 90 (or 45) degrees, drifts down to bed, but has some effort against gravity.] 3: No effort against gravity [Limb falls.] 4: No movement [There is no observed limb movement.] 0: UNTESTABLE [Amputation or joint fusion at the shoulder.] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0045], code=at0045, itemType=ELEMENT, level=4, text=Reason right arm untestable, description=Narrative description about why the right arm motor function was untestable., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0046], code=at0046, itemType=ELEMENT, level=4, text=Motor - left leg, description=Observation of left leg motor function., comment=Only in the case of amputation or joint fusion at the hip, the examiner should record the score as 'UNTESTABLE' and record the reason in the 'Reason left leg untestable' data element. Implementation note: while the UNTESTABLE value has been included in this ordinal to allow for inclusion in user interface picklists, the NIHSS applies no numerical score from this selection to the 'Total score'., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=0: No drift [Leg holds 30-degree position for full 5 seconds.] 1: Drift [Leg falls by the end of the 5-second period but does not hit the bed.] 2: Some effort against gravity [Leg falls to bed by 5 seconds but has some effort against gravity.] 3: No effort against gravity [Leg falls to bed immediately.] 4: No movement [There is no observed leg movement.] 0: UNTESTABLE [Amputation or joint fusion at the hip.] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0053], code=at0053, itemType=ELEMENT, level=4, text=Reason left leg untestable, description=Narrative description about why the left leg motor function was untestable., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0141], code=at0141, itemType=ELEMENT, level=4, text=Motor - right leg, description=Observation of right leg motor function., comment=Only in the case of amputation or joint fusion at the hip, the examiner should record the score as 'UNTESTABLE' and record the reason in the 'Reason right leg untestable' data element Implementation note: while the UNTESTABLE value has been included in this ordinal to allow for inclusion in user interface picklists, the NIHSS applies no numerical score from this selection to the 'Total score'., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=0: No drift [Leg holds 30-degree position for full 5 seconds.] 1: Drift [Leg falls by the end of the 5-second period but does not hit the bed.] 2: Some effort against gravity [Leg falls to bed by 5 seconds but has some effort against gravity.] 3: No effort against gravity [Leg falls to bed immediately.] 4: No movement [There is no observed leg movement.] 0: UNTESTABLE [Amputation or joint fusion at the hip.] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0060], code=at0060, itemType=ELEMENT, level=4, text=Reason right leg untestable, description=Narrative description about why the right leg motor function was untestable., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0061], code=at0061, itemType=ELEMENT, level=4, text=Limb ataxia, description=Observation of limb ataxia as evidence of a unilateral cerebellar lesion. Only in the case of amputation or joint fusion, the examiner should record the score as untestable (UN)and record the reason in the 'Reason limb ataxia untestable' data element., comment=Only in the case of amputation or joint fusion, the examiner should record the score as 'UNTESTABLE' and record the reason in the 'Reason limb ataxia untestable' data element. Implementation note: while the UNTESTABLE value has been included in this ordinal to allow for inclusion in user interface picklists, the NIHSS applies no numerical score from this selection to the 'Total score'., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=0: Absent [No limb ataxia observed.] 1: Present in one limb [Limb ataxia observed in one limb.] 2: Present in two limbs [Limb ataxia observed in two limbs.] 0: UNTESTABLE [Amputation or joint fusion.] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0066], code=at0066, itemType=ELEMENT, level=4, text=Reason limb ataxia untestable, description=Narrative description about why limb ataxia was untestable., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0067], code=at0067, itemType=ELEMENT, level=4, text=Sensory, description=Observation of sensory loss., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=0: Normal [No sensory loss.] 1: Mild-to-moderate sensory loss [Patient feels pinprick is less sharp or is dull on the affected side; or there is a loss of superficial pain with pinprick, but patient is aware of being touched.] 2: Severe or total sensory loss [Patient is not aware of being touched in the face, arm, and leg.] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0071], code=at0071, itemType=ELEMENT, level=4, text=Language, description=Observation of language capability., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=0: No aphasia [Normal] 1: Mild-to-moderate aphasia [Some obvious loss of fluency or facility of comprehension, without significant limitation on ideas expressed or form of expression.] 2: Severe aphasia [All communication is through fragmentary expression; great need for inference, questioning, and guessing by the listener.] 3: Mute, global aphasia [No usable speech or auditory comprehension.] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0076], code=at0076, itemType=ELEMENT, level=4, text=Speech, description=Observation about speech capability., comment=Only if the patient is intubated or has other physical barriers to producing speech, the examiner should record the score as 'UNTESTABLE' and record the reason in the 'Reason speech untestable' data element. Implementation note: while the UNTESTABLE value has been included in this ordinal to allow for inclusion in user interface picklists, the NIHSS applies no numerical score from this selection to the 'Total score'., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=0: Normal [Normal speech.] 1: Mild-to-moderate dysarthria [Patient slurs at least some words and, at worst, can be understood with some difficulty.] 2: Severe dysarthria [Patient's speech is so slurred as to be unintelligible in the absence of or out of proportion to any dysphasia, or is mute/anarthric.] 0: UNTESTABLE [Intubated or other physical barrier.] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0081], code=at0081, itemType=ELEMENT, level=4, text=Reason speech untestable, description=Narrative description about why speech was untestable., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0082], code=at0082, itemType=ELEMENT, level=4, text=Extinction and inattention, description=Observation of any evidence of extinction or inattention., comment=Also known as 'neglect'., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=0: No abnormality [No abnormality observed.] 1: Inattention, or bilateral extinction in one sensory modality [Visual, tactile, auditory, spatial, or personal inattention, or extinction to bilateral simultaneous stimulation in one of the sensory modalities.] 2: Profound hemi-inattention or extinction to more than one modality [Profound hemi-inattention or extinction to more than one modality; does not recognize own hand or orients to only one side of space.] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0086], code=at0086, itemType=ELEMENT, level=4, text=Total score, description=The total score is the arithmetic sum of all 15 responses, excluding any untestable responses., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=min: >=0; max: <=42 , extendedValues=null]], activities=[], relationships=[], credentials=[], target=[], source=[], state=[], content=[], contacts=[], capabilities=[]}, topLevelItems={protocol=ResourceSimplifiedHierarchyItem [path=ROOT_/protocol[at0092], code=at0092, itemType=ITEM_TREE, level=0, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=0..1, cardinalityText=optional, subCardinalityFormal=0..*, subCardinalityText=Minimum of 0 items , dataType=ITEM_TREE, bindings=null, values=null, extendedValues=null], data=ResourceSimplifiedHierarchyItem [path=ROOT_/data[at0001]/events[at0002]/data[at0003], code=at0003, itemType=ITEM_TREE, level=2, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=0..1, cardinalityText=optional, subCardinalityFormal=0..*, subCardinalityText=Minimum of 0 items , dataType=ITEM_TREE, bindings=null, values=null, extendedValues=null]}, addHierarchyItemsTo=protocol, currentHierarchyItemsForAdding=[ResourceSimplifiedHierarchyItem [path=/protocol[at0092]/items[at0093], code=at0093, itemType=SLOT, level=2, text=Extension, description=Additional information required to extend the model with local content or to align with other reference models or formalisms., comment=For example: local information requirements; or additional metadata to align with FHIR., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include: All not explicitly excluded archetypes, extendedValues=null]], minIndents={}, termBindingRetrievalErrorMessage=null] |