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

ARCHETYPE IDopenEHR-EHR-CLUSTER.exam-pupil.v0
ConceptExamination of a pupil
DescriptionFindings observed during the physical examination of a pupil in a single eye.
UseUse to record a narrative description and clinical interpretation of the findings observed during the physical examination of a pupil. This archetype has been specifically designed to be used in the 'Examination detail' SLOT within the OBSERVATION.exam, CLUSTER.exam-eye or CLUSTER.exam-cranial_nerves archetypes, but can also be used within other ENTRY or CLUSTER archetypes, where clinically appropriate. 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.
MisuseNot to be used for recording the clinical history - use specific OBSERVATION and CLUSTER archetypes. For example OBSERVATION.story and CLUSTER.symptom_sign.
PurposeTo record a narrative description and clinical interpretation of the findings observed during the physical examination of a pupil.
References
Copyright© openEHR Foundation
AuthorsAuthor name: Heather Leslie
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2015-07-09
Other Details LanguageAuthor name: Heather Leslie
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2015-07-09
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, current_contact=Heather Leslie, Atomica Informatics, Australia, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=9B0118397CA26B21A180B9656B622853, build_uid=6efaea71-b943-43fa-8cdc-a910c7bc8b2a, 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
Lifecyclein_development
UID9549ea5c-a543-4258-a626-46d677eed01b
Language useden
Citeable Identifier1013.1.3882
Revision Number0.0.1-alpha
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Findings observed during the physical examination of a pupil in a single eye., archetypeConceptComment=null, otherContributors=Vebjørn Arntzen, Oslo University Hospital, Norway (openEHR Editor)
Silje Ljosland Bakke, Nasjonal IKT HF, Norway (openEHR Editor)
SB Bhattacharyya, Sudisa Consultancy Services, India
Lisbeth Dahlhaug, Helse Midt - Norge IT, Norway
Shahla Foozonkhah, Iran ministry of health and education, Iran
Hildegard Franke, freshEHR Clinical Informatics Ltd., United Kingdom (openEHR Editor)
Mikkel Gaup Grønmo, FSE, Helse Nord, Norway (Nasjonal IKT redaktør)
Ingrid Heitmann, Oslo universitetssykehus HF, Norway
Hilde Hollås, DIPS ASA, Norway
Evelyn Hovenga, EJSH Consulting, Australia
Lars Ivar Mehlum, Helse Bergen HF, Norway
Sabine Leh, Haukeland University Hospital, Department of Pathology, Norway
Heather Leslie, Atomica Informatics, Australia (openEHR Editor)
Ian McNicoll, freshEHR Clinical Informatics, United Kingdom
Lars Morgan Karlsen, DIPS ASA, Norway
Bjørn Næss, DIPS ASA, Norway
Andrej Orel, Marand d.o.o., Slovenia
Vladimir Pizzo, Hospital Sírio Libanês, Brazil
Jussara Rotzsch, UNB, Brazil
Anoop Shah, University College London, United Kingdom
Line Silsand, Universitetssykehuset i Nord-Norge, Norway
Norwegian Review Summary, Nasjonal IKT HF, Norway
Nyree Taylor, Ocean Informatics, Australia (openEHR Editor)
Rowan Thomas, St. Vincent's Hospital Melbourne, Australia
Jon Tysdahl, Furst medlab AS, Norway
John Tore Valand, Helse Bergen, Norway (openEHR Editor), originalLanguage=en, translators=Norwegian Bokmål: Silje Ljosland Bakke, Nasjonal IKT HF
, subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={identities=[], other_participations=[], credentials=[], description=[], relationships=[], ism_transition=[], activities=[], items=[ResourceSimplifiedHierarchyItem [path=/items[at0001.1], code=at0001.1, itemType=ELEMENT, level=1, text=System or structure examined, description=Identification of the examined body system or anatomical structure., comment=Coding of the system or structure examined with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Left pupil [The left pupil was examined.]
    [SNOMED-CT::16089004] (Structure of pupil of left eye (body structure))
  • Right pupil [The right pupil was examined.]
    [SNOMED-CT::52378001] (Structure of pupil of right eye (body structure))
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0012], code=at0012, itemType=ELEMENT, level=1, text=Body site, description=Identification of the area of the body under examination., comment=If the body site has been fully identified in the 'System or structure examined' data element, this data element becomes redundant., 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[at0011], code=at0011, itemType=SLOT, level=1, text=Structured body site, description=A structured description of the area of the body under examination., comment=If the body site has been fully identified in the 'System or structure examined' or the 'Body site' data element, this SLOT becomes redundant., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.anatomical_location.v1 and specialisations Or
openEHR-EHR-CLUSTER.anatomical_location_circle.v1 and specialisations Or
openEHR-EHR-CLUSTER.anatomical_location_relative.v1 and specialisations, 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. Specific statements about the examination can be included in the 'Clinical Interpretation' data element. If 'No abnormality detected' is selected, then recording of other examination data elements becomes redundant, with the exception of only the 'Clinical interpretation' data element, which may be useful if a normal statement is desired for recording, for example 'Normal examination'., 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[at0.3], code=at0.3, itemType=ELEMENT, level=1, text=Shape, description=The shape of the pupil., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Circular [The pupil is a normal, circular shape.]
  • Oval [The pupil is an oval shape.]
  • Sectoral abnormality [The pupil is an abnormal, irregular shape.]
  • Teardrop [The pupil is an abnormal, teardrop shape.]
  • Keyhole [The pupil is an abnormal, keyhole shape.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.9], code=at0.9, 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:
  •  Quantity
    Property: Length
    Units:
    • 0.0..20.0 mm
      Limit decimal places: 0
  •  Coded Text
    • Pinpoint [The pupil is heavily constricted (<= 1mm).]
    • Constricted [The pupil is constricted, relative to normal (1.5 - 2.5mm).]
    • Normal [The pupil size is normal (3 - 5mm).]
    • DIlated [The pupil is dilated, relative to normal (>= 5.5mm).]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.14], code=at0.14, itemType=ELEMENT, level=1, text=Direct reflex (DLR), description=Presence of a reflex constriction of the same pupil when light is shone into the identified eye., comment=Also known as 'Direct light reflex' (DLR)., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present [The direct light reflex is present.]
  • Absent [The direct light reflex is not present.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.17], code=at0.17, itemType=ELEMENT, level=1, text=DLR speed, 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=
  • Sluggish (-) [The reflex is observed to be slower than normal.]
  • Normal [The reflex is observed to be at or about the expected normal speed.]
  • Brisk (+) [The reflex is observed to be faster than normal.]
  • Very brisk (++) [The reflex is observed to be much faster than normal.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.22], code=at0.22, itemType=ELEMENT, level=1, text=Consensual reflex (CLR), description=Presence of a reflex constriction of the opposite 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=
  • Present [The consensual light reflex is present.]
  • Absent [The consensual light reflex is absent.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.25], code=at0.25, itemType=ELEMENT, level=1, text=CLR speed, 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=
  • Sluggish (-) [The reflex is observed to be slower than normal.]
  • Normal [The reflex is observed to be at or about the expected normal speed.]
  • Brisk (+) [The reflex is observed to be faster than normal.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.29], code=at0.29, itemType=ELEMENT, level=1, text=Accommodation reflex (AR), description=Presence of a 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=
  • Present [The accommodation reflex is present.]
  • Absent [The accommodation reflex is absent.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.32], code=at0.32, itemType=ELEMENT, level=1, text=AR speed, description=Subjective estimate of the reactivity of the accommodation 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=
  • Sluggish (-) [The reflex is observed to be slower than normal.]
  • Normal [The reflex is observed to be at or about the expected normal speed.]
  • Brisk (+) [The reflex is observed to be faster than normal.]
, 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 Or
openEHR-EHR-CLUSTER.multimedia.v0 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=Coding of the 'Clinical interpretation' with a terminology is preferred, where possible., 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]], data=[], capabilities=[], state=[], context=[], events=[], source=[], content=[], target=[], details=[], provider=[], protocol=[], contacts=[]}, topLevelItems={items=ResourceSimplifiedHierarchyItem [path=ROOT_/, code=at0000.1, 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[at0001.1], code=at0001.1, itemType=ELEMENT, level=1, text=System or structure examined, description=Identification of the examined body system or anatomical structure., comment=Coding of the system or structure examined with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Left pupil [The left pupil was examined.]
    [SNOMED-CT::16089004] (Structure of pupil of left eye (body structure))
  • Right pupil [The right pupil was examined.]
    [SNOMED-CT::52378001] (Structure of pupil of right eye (body structure))
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0012], code=at0012, itemType=ELEMENT, level=1, text=Body site, description=Identification of the area of the body under examination., comment=If the body site has been fully identified in the 'System or structure examined' data element, this data element becomes redundant., 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[at0011], code=at0011, itemType=SLOT, level=1, text=Structured body site, description=A structured description of the area of the body under examination., comment=If the body site has been fully identified in the 'System or structure examined' or the 'Body site' data element, this SLOT becomes redundant., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.anatomical_location.v1 and specialisations Or
openEHR-EHR-CLUSTER.anatomical_location_circle.v1 and specialisations Or
openEHR-EHR-CLUSTER.anatomical_location_relative.v1 and specialisations, 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. Specific statements about the examination can be included in the 'Clinical Interpretation' data element. If 'No abnormality detected' is selected, then recording of other examination data elements becomes redundant, with the exception of only the 'Clinical interpretation' data element, which may be useful if a normal statement is desired for recording, for example 'Normal examination'., 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[at0.3], code=at0.3, itemType=ELEMENT, level=1, text=Shape, description=The shape of the pupil., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Circular [The pupil is a normal, circular shape.]
  • Oval [The pupil is an oval shape.]
  • Sectoral abnormality [The pupil is an abnormal, irregular shape.]
  • Teardrop [The pupil is an abnormal, teardrop shape.]
  • Keyhole [The pupil is an abnormal, keyhole shape.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.9], code=at0.9, 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:
  •  Quantity
    Property: Length
    Units:
    • 0.0..20.0 mm
      Limit decimal places: 0
  •  Coded Text
    • Pinpoint [The pupil is heavily constricted (<= 1mm).]
    • Constricted [The pupil is constricted, relative to normal (1.5 - 2.5mm).]
    • Normal [The pupil size is normal (3 - 5mm).]
    • DIlated [The pupil is dilated, relative to normal (>= 5.5mm).]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.14], code=at0.14, itemType=ELEMENT, level=1, text=Direct reflex (DLR), description=Presence of a reflex constriction of the same pupil when light is shone into the identified eye., comment=Also known as 'Direct light reflex' (DLR)., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present [The direct light reflex is present.]
  • Absent [The direct light reflex is not present.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.17], code=at0.17, itemType=ELEMENT, level=1, text=DLR speed, 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=
  • Sluggish (-) [The reflex is observed to be slower than normal.]
  • Normal [The reflex is observed to be at or about the expected normal speed.]
  • Brisk (+) [The reflex is observed to be faster than normal.]
  • Very brisk (++) [The reflex is observed to be much faster than normal.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.22], code=at0.22, itemType=ELEMENT, level=1, text=Consensual reflex (CLR), description=Presence of a reflex constriction of the opposite 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=
  • Present [The consensual light reflex is present.]
  • Absent [The consensual light reflex is absent.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.25], code=at0.25, itemType=ELEMENT, level=1, text=CLR speed, 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=
  • Sluggish (-) [The reflex is observed to be slower than normal.]
  • Normal [The reflex is observed to be at or about the expected normal speed.]
  • Brisk (+) [The reflex is observed to be faster than normal.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.29], code=at0.29, itemType=ELEMENT, level=1, text=Accommodation reflex (AR), description=Presence of a 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=
  • Present [The accommodation reflex is present.]
  • Absent [The accommodation reflex is absent.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.32], code=at0.32, itemType=ELEMENT, level=1, text=AR speed, description=Subjective estimate of the reactivity of the accommodation 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=
  • Sluggish (-) [The reflex is observed to be slower than normal.]
  • Normal [The reflex is observed to be at or about the expected normal speed.]
  • Brisk (+) [The reflex is observed to be faster than normal.]
, 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 Or
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