ARCHETYPE Examination of deep tendon reflexes (openEHR-EHR-CLUSTER.exam_tendon_reflexes.v0)

ARCHETYPE IDopenEHR-EHR-CLUSTER.exam_tendon_reflexes.v0
ConceptExamination of deep tendon reflexes
DescriptionFindings observed during the physical examination of deep tendon reflexes in the limbs.
UseUse to record a description of the overall findings observed during the physical examination of deep tendon reflexes. 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_nervous_system archetype, but can also be used within the OBSERVATION.exam and other OBSERVATION or CLUSTER archetypes, where clinically appropriate. 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.
MisuseNot to be used for recording the clinical history about deep tendon reflexes - use specific OBSERVATION and CLUSTER archetypes. For example OBSERVATION.story and CLUSTER.symptom. Not to be used to record the response to Masseter reflex (Jaw jerk). Use CLUSTER.exam_cranial_nerves for this purpose. Not to be used to record the respons to the Plantar reflex (Babinski response/sign). Use CLUSTER.exam.foot for this purpose.
PurposeFor recording a description and clinical interpretation of the findings observed during the physical examination of deep tendon reflexes in the limbs.
References
Copyright© openEHR Foundation
AuthorsAuthor name: Heather Leslie
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2018-09-12
Other Details LanguageAuthor name: Heather Leslie
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2018-09-12
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, Atomica Informatics, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=FC7BFEDDD82A0939EDDC8FC78A4DB367, build_uid=195b369e-9c21-4b82-91d7-853b1b1f5ec0, revision=0.0.2-alpha}
Keywordsexamination, nervous system, reflexes, tendon
Lifecyclein_development
UID52c3c495-8736-4e6d-85b9-613095d12883
Language useden
Citeable Identifier1013.1.3599
Revision Number0.0.2-alpha
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Findings observed during the physical examination of deep tendon reflexes in the limbs., archetypeConceptComment=null, otherContributors=Silje Ljosland Bakke, Nasjonal IKT HF, Norway
Ian McNicoll, freshEHR Clinical Informatics, United Kingdom
John Tore Valand, Haukeland Universitetssjukehus, Norway, originalLanguage=en, translators=, subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={details=[], identities=[], source=[], credentials=[], context=[], description=[], ism_transition=[], events=[], content=[], items=[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. Specific statements about the examination can be included in the 'Clinical Interpretation' data element., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=Allowed values: {true}, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0003], code=at0003, itemType=ELEMENT, level=1, text=Clinical description, description=Narrative description of the overall findings observed during the physical examination., 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[at0012], code=at0012, itemType=CLUSTER, level=1, text=(Per reflex), description=Details per reflex., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Runtime name constraint:
  • Left biceps [Stretch reflex used to test the status of C5 & C6.]
  • Left brachioradialis [Stretch reflex used to test the status of C6. Also known as Supinator jerk.]
  • Left triceps [Stretch reflex used to test the status of C7.]
  • Left patellar [Stretch reflex used to test the status of L4. Also known as Knee jerk.]
  • Left achilles [Stretch reflex used to test the status of S1.]
  • Right biceps [Stretch reflex used to test the status of C5 & C6.]
  • Right brachioradialis [Stretch reflex used to test the status of C6. Also known as Supinator jerk.]
  • Right triceps [Stretch reflex used to test the status of C7.]
  • Right patellar [Stretch reflex used to test the status of L4. Also known as Knee jerk.]
  • Right achilles [Stretch reflex used to test the status of S1.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0012]/items[at0013], code=at0013, itemType=ELEMENT, level=2, text=Response, description=Strength of the reflex response., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Absent [Reflex not evident. May be recorded as '0'.]
  • Equivocal [Reflex possibly present. May be recorded as '+/-'.]
  • Slight [Reflex present but less than normal amplitude, or only seen with reinforcement. May be recorded as '+' or '1+'.]
  • Normal [Reflex present at normal amplitude. May be recorded as '++' or '2+'.]
  • Brisk [Reflex present at greater than normal amplitude. May be recorded as '+++' or '3+'.]
  • Non-sustained clonus [Reflex is repeating but not sustained. May be recorded as '++++' or '4+'.]
  • Sustained clonus [Reflex is repeating and sustained. May be recorded as '+++++' or '5+'.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0012]/items[at0014], code=at0014, itemType=ELEMENT, level=2, text=With recruitment?, description=Record as true if muscle recruitment was used to accentuate the response., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=Allowed values: {true}, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0012]/items[at0015], code=at0015, itemType=ELEMENT, level=2, text=Comment, description=Additional narrative about the reflex response 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[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:
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openEHR-EHR-CLUSTER.exclusion_exam.v1 and specialisations, extendedValues=null]], capabilities=[], other_participations=[], contacts=[], target=[], data=[], relationships=[], state=[], protocol=[], activities=[], provider=[]}, 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=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=null, extendedValues=null]}, addHierarchyItemsTo=items, currentHierarchyItemsForAdding=[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. Specific statements about the examination can be included in the 'Clinical Interpretation' data element., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=Allowed values: {true}, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0003], code=at0003, itemType=ELEMENT, level=1, text=Clinical description, description=Narrative description of the overall findings observed during the physical examination., 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[at0012], code=at0012, itemType=CLUSTER, level=1, text=(Per reflex), description=Details per reflex., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Runtime name constraint:
  • Left biceps [Stretch reflex used to test the status of C5 & C6.]
  • Left brachioradialis [Stretch reflex used to test the status of C6. Also known as Supinator jerk.]
  • Left triceps [Stretch reflex used to test the status of C7.]
  • Left patellar [Stretch reflex used to test the status of L4. Also known as Knee jerk.]
  • Left achilles [Stretch reflex used to test the status of S1.]
  • Right biceps [Stretch reflex used to test the status of C5 & C6.]
  • Right brachioradialis [Stretch reflex used to test the status of C6. Also known as Supinator jerk.]
  • Right triceps [Stretch reflex used to test the status of C7.]
  • Right patellar [Stretch reflex used to test the status of L4. Also known as Knee jerk.]
  • Right achilles [Stretch reflex used to test the status of S1.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0012]/items[at0013], code=at0013, itemType=ELEMENT, level=2, text=Response, description=Strength of the reflex response., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Absent [Reflex not evident. May be recorded as '0'.]
  • Equivocal [Reflex possibly present. May be recorded as '+/-'.]
  • Slight [Reflex present but less than normal amplitude, or only seen with reinforcement. May be recorded as '+' or '1+'.]
  • Normal [Reflex present at normal amplitude. May be recorded as '++' or '2+'.]
  • Brisk [Reflex present at greater than normal amplitude. May be recorded as '+++' or '3+'.]
  • Non-sustained clonus [Reflex is repeating but not sustained. May be recorded as '++++' or '4+'.]
  • Sustained clonus [Reflex is repeating and sustained. May be recorded as '+++++' or '5+'.]
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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]], minIndents={}, termBindingRetrievalErrorMessage=null]