ARCHETYPE Examination of a pupil (openEHR-EHR-CLUSTER.exam_eye_pupil.v0)

Name: Examination of a pupil
License: http://creativecommons.org/licenses/by-sa/3.0/

ARCHETYPE ID	openEHR-EHR-CLUSTER.exam_eye_pupil.v0
Concept	Examination of a pupil
Description	Findings observed during the physical examination of a pupil.
Use	Use to record a narrative description of the overall findings observed during the physical examination of a pupil. This initial draft archetype consists only of the core examination pattern data elements (as per CLUSTER.exam_pattern) and will likely be expanded further over time as specific clinical requirements are identified. This archetype has been specifically designed to be used in the 'Examination findings' SLOT within the CLUSTER.exam_eye archetype, but can also be used within the OBSERVATION.exam and other OBSERVATION or CLUSTER archetypes, where clinically appropriate - for example, CLUSTER.exam_cranial_nerves. Use to provide a framework in which CLUSTER archetypes can be nested in the 'Examination findings' SLOT to record additional structured physical examination findings. The CLUSTER.exclusion_exam archetype can be nested within the 'Examination not done' SLOT to optionally record explicit details about the examination not being performed. Use to incorporate the narrative descriptions of clinical findings within existing or legacy clinical systems into an archetyped format, using the 'Clinical Description' data element.
Misuse	Not to be used for recording data related to comparison between both pupils - use CLUSTER.exam_eyes for this purpose. Not to be used to record findings of the physical examination of other parts of the eye - use specific purpose-built CLUSTER archetypes for this purpose. For example, CLUSTER.exam_retina. Not to be used for recording the clinical history - use specific OBSERVATION and CLUSTER archetypes. For example OBSERVATION.story and CLUSTER.symptom. Not to be used to record stand-alone clinical observations or measurements or test results - use specific OBSERVATION archetypes. For example OBSERVATION.blood_pressure or OBSERVATION.imaging_exam.
Purpose	For recording a narrative description and clinical interpretation of the findings observed during the physical examination of a single pupil at a time.
References
Copyright	© openEHR Foundation
Authors	Author name: Heather Leslie Organisation: Ocean Informatics Email: heather.leslie@oceaninformatics.com Date originally authored: 2015-07-09
Other Details Language	Author name: Heather Leslie Organisation: Ocean Informatics Email: heather.leslie@oceaninformatics.com Date originally authored: 2015-07-09
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, current_contact=Heather Leslie, Ocean Informatics, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=492AC1B5592E3CAECD4E713A471667A1, build_uid=3d75c631-0dcd-4311-bc46-117fecc764d5, revision=0.0.1}
Keywords	eye, pupil
Lifecycle	rejected
UID	cd7464f8-ef0e-4a29-8c3b-04ded9bdcb8a
Language used	en
Citeable Identifier	1013.1.2168
Revision Number	0.0.1
All	Archetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Findings observed during the physical examination of a pupil., archetypeConceptComment=null, otherContributors=Silje Ljosland Bakke, Bergen Hospital Trust, Norway Ian McNicoll, freshEHR Clinical Informatics, United Kingdom John Tore Valand, Haukeland Universitetssjukehus, Norway Ian McNicoll, freshEHR Informatics, UK, originalLanguage=en, translators=, subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={items=[ResourceSimplifiedHierarchyItem [path=/items[at0001], code=at0001, itemType=ELEMENT, level=1, text=Eye examined, description=Identification of the eye under examination., comment=If the side of eye being examined has previously been identified in another archetype in which this archetype is nested, this data element becomes redundant., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= at0009::Left [The left eye was examined.] at0010::Right [The right eye was examined.] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002], code=at0002, itemType=ELEMENT, level=1, text=No abnormality detected, description=Statement that no abnormality was detected (NAD) on physical examination., comment=Record as True if no abnormality was detected on examination. 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comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= at0012::Circular [The pupil is a normal, circular shape.] at0013::Oval [The pupil is an oval shape.] at0014::Irregular [The pupil is an irregular shape.] at0015::Sectoral abnormality [The pupil has a sectoral abnormality.] at0016::Teardrop [The pupil is a teardrop shape.] at0017::Keyhole [The pupil is a keyhole shape.] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0018], code=at0018, itemType=ELEMENT, level=1, text=Size, description=The size of the pupil., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of: Coded Text at0019::Pinpoint [The pupil is heavily constricted (<= 1mm).] at0020::Constricted [The pupil is constricted, relative to normal (1.5 - 2.5mm).] at0021::Normal [The pupil size is normal (3 - 5mm).] at0022::Dilated [The pupil is dilated, relative to normal (>= 5.5mm).] Quantity Property: Length Units: 0.0..30.0 mm Limit decimal places: 0 , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0023], code=at0023, itemType=ELEMENT, level=1, text=Direct Reflex (DLR), description=Reflex constriction of the identified pupil when light is shone into the same eye., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= at0024::Present [The direct light reflex is present.] at0025::Indeterminate [The presence or absence of the direct light reflex could not be determined.] at0026::Absent [The direct light reflex is absent.] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0027], code=at0027, itemType=ELEMENT, level=1, text=Speed of DLR, description=Subjective estimate of the reactivity of the direct light reflex on stimulus by a light., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= at0028::Sluggish/slow (-) [The reflex is observed to be slow or sluggish, compared to normal.] at0029::Normal speed (+/-) [The reflex is observed to be at or about normal speed.] at0030::Brisk(+) [The reflex is observed to be brisk, compared to normal.] at0031::Very brisk (++) [The reflex is observed to be very brisk (++).] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0032], code=at0032, itemType=ELEMENT, level=1, text=Consensual Reflex (CLR), description=Reflex constriction of the other pupil when light is shone into the identified eye., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= at0033::Present [The consensual light reflex is present.] at0034::Indeterminate [The presence or absence of the consensual light reflex could not be determined.] at0035::Absent [The consensual light reflex is absent.] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0036], code=at0036, itemType=ELEMENT, level=1, text=Speed of CLR, description=Subjective estimate of the reactivity of the consensual light reflex on stimulus by a light., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= at0028::Sluggish/slow (-) [The reflex is observed to be slow or sluggish, compared to normal.] at0029::Normal speed (+/-) [The reflex is observed to be at or about normal speed.] at0030::Brisk(+) [The reflex is observed to be brisk, compared to normal.] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0037], code=at0037, itemType=ELEMENT, level=1, text=Accommodation Reflex (AR), description=Reflex constriction of the pupil, in response to changing focusing on a near or far objects., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= at0038::Present [The accomodation reflex is present.] at0039::Indeterminate [The presence or absence of the accomodation reflex could not be determined.] at0040::Absent [The accommodation reflex is absent.] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0041], code=at0041, itemType=ELEMENT, level=1, text=Speed of AR, description=Subjective estimate of the reactivity of the accodation light reflex on stimulus by a light., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= at0028::Sluggish/slow (-) [The reflex is observed to be slow or sluggish, compared to normal.] at0029::Normal speed (+/-) [The reflex is observed to be at or about normal speed.] at0030::Brisk(+) [The reflex is observed to be brisk, compared to normal.] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0042], code=at0042, itemType=ELEMENT, level=1, text=Relative Afferent Pupillary Defect, description=Finding where the pupils constrict less (therefore appearing to dilate) when a bright light is swung from the unaffected eye to the affected eye., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= at0043::Present [A relative afferent afferent pupillary defect (RAPD) is present.] at0044::Absent [A relative afferent afferent pupillary defect (RAPD) is absent.] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0004], code=at0004, itemType=SLOT, level=1, text=Examination findings, description=Structured details about the physical examination findings., comment=null, 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], ResourceSimplifiedHierarchyItem [path=/items[at0005], code=at0005, itemType=SLOT, level=1, text=Multimedia representation, description=Digital image, video or diagram representing the physical examination findings., comment=null, uncommonOntologyItems=null, occurencesFormal=0.., occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:* openEHR-EHR-CLUSTER.multimedia.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0006], code=at0006, itemType=ELEMENT, level=1, text=Clinical interpretation, description=Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings., comment=null, uncommonOntologyItems=null, occurencesFormal=0.., occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0007], code=at0007, itemType=ELEMENT, level=1, text=Comment, description=Additional narrative about the physical examination findings, not captured in other fields., 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=/items[at0008], code=at0008, itemType=SLOT, level=1, text=Examination not done, description=Details to explicitly record that this examination was not performed., comment=null, uncommonOntologyItems=null, occurencesFormal=0.., occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include: openEHR-EHR-CLUSTER.exclusion_exam.v1 and specialisations, extendedValues=null]], description=[], context=[], activities=[], identities=[], capabilities=[], provider=[], protocol=[], content=[], source=[], credentials=[], events=[], data=[], contacts=[], ism_transition=[], details=[], relationships=[], state=[], target=[], other_participations=[]}, topLevelItems={items=ResourceSimplifiedHierarchyItem [path=ROOT_/, code=at0000, itemType=CLUSTER, level=0, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=1.., cardinalityText= (Cardinality: 1.., unordered), subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=null, extendedValues=null]}, addHierarchyItemsTo=items, currentHierarchyItemsForAdding=[ResourceSimplifiedHierarchyItem [path=/items[at0001], code=at0001, itemType=ELEMENT, level=1, text=Eye examined, description=Identification of the eye under examination., comment=If the side of eye being examined has previously been identified in another archetype in which this archetype is nested, this data element becomes redundant., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= at0009::Left [The left eye was examined.] at0010::Right [The right eye was examined.] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002], code=at0002, itemType=ELEMENT, level=1, text=No abnormality detected, description=Statement that no abnormality was detected (NAD) on physical examination., comment=Record as True if no abnormality was detected on examination. 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comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= at0012::Circular [The pupil is a normal, circular shape.] at0013::Oval [The pupil is an oval shape.] at0014::Irregular [The pupil is an irregular shape.] at0015::Sectoral abnormality [The pupil has a sectoral abnormality.] at0016::Teardrop [The pupil is a teardrop shape.] at0017::Keyhole [The pupil is a keyhole shape.] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0018], code=at0018, itemType=ELEMENT, level=1, text=Size, description=The size of the pupil., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of: Coded Text at0019::Pinpoint [The pupil is heavily constricted (<= 1mm).] at0020::Constricted [The pupil is constricted, relative to normal (1.5 - 2.5mm).] at0021::Normal [The pupil size is normal (3 - 5mm).] at0022::Dilated [The pupil is dilated, relative to normal (>= 5.5mm).] Quantity Property: Length Units: 0.0..30.0 mm Limit decimal places: 0 , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0023], code=at0023, itemType=ELEMENT, level=1, text=Direct Reflex (DLR), description=Reflex constriction of the identified pupil when light is shone into the same eye., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= at0024::Present [The direct light reflex is present.] at0025::Indeterminate [The presence or absence of the direct light reflex could not be determined.] at0026::Absent [The direct light reflex is absent.] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0027], code=at0027, itemType=ELEMENT, level=1, text=Speed of DLR, description=Subjective estimate of the reactivity of the direct light reflex on stimulus by a light., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= at0028::Sluggish/slow (-) [The reflex is observed to be slow or sluggish, compared to normal.] at0029::Normal speed (+/-) [The reflex is observed to be at or about normal speed.] at0030::Brisk(+) [The reflex is observed to be brisk, compared to normal.] at0031::Very brisk (++) [The reflex is observed to be very brisk (++).] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0032], code=at0032, itemType=ELEMENT, level=1, text=Consensual Reflex (CLR), description=Reflex constriction of the other pupil when light is shone into the identified eye., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= at0033::Present [The consensual light reflex is present.] at0034::Indeterminate [The presence or absence of the consensual light reflex could not be determined.] at0035::Absent [The consensual light reflex is absent.] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0036], code=at0036, itemType=ELEMENT, level=1, text=Speed of CLR, description=Subjective estimate of the reactivity of the consensual light reflex on stimulus by a light., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= at0028::Sluggish/slow (-) [The reflex is observed to be slow or sluggish, compared to normal.] at0029::Normal speed (+/-) [The reflex is observed to be at or about normal speed.] at0030::Brisk(+) [The reflex is observed to be brisk, compared to normal.] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0037], code=at0037, itemType=ELEMENT, level=1, text=Accommodation Reflex (AR), description=Reflex constriction of the pupil, in response to changing focusing on a near or far objects., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= at0038::Present [The accomodation reflex is present.] at0039::Indeterminate [The presence or absence of the accomodation reflex could not be determined.] at0040::Absent [The accommodation reflex is absent.] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0041], code=at0041, itemType=ELEMENT, level=1, text=Speed of AR, description=Subjective estimate of the reactivity of the accodation light reflex on stimulus by a light., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= at0028::Sluggish/slow (-) [The reflex is observed to be slow or sluggish, compared to normal.] at0029::Normal speed (+/-) [The reflex is observed to be at or about normal speed.] at0030::Brisk(+) [The reflex is observed to be brisk, compared to normal.] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0042], code=at0042, itemType=ELEMENT, level=1, text=Relative Afferent Pupillary Defect, description=Finding where the pupils constrict less (therefore appearing to dilate) when a bright light is swung from the unaffected eye to the affected eye., 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itemType=SLOT, level=1, text=Multimedia representation, description=Digital image, video or diagram representing the physical examination findings., comment=null, uncommonOntologyItems=null, occurencesFormal=0.., occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:* openEHR-EHR-CLUSTER.multimedia.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0006], code=at0006, itemType=ELEMENT, level=1, text=Clinical interpretation, description=Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings., comment=null, uncommonOntologyItems=null, occurencesFormal=0.., occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, 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extendedValues=null]], minIndents={}, termBindingRetrievalErrorMessage=null]