ARCHETYPE Pulse/Heart beat (openEHR-EHR-OBSERVATION.pulse.v2)

ARCHETYPE IDopenEHR-EHR-OBSERVATION.pulse.v2
ConceptPulse/Heart beat
DescriptionThe rate and associated attributes for a pulse or heart beat.
UseUse to record the presence or absence of a pulse or heart beat. In practice, the terms 'heart rate' and 'pulse rate' are often used interchangeably, although they may be measured at different body sites. This archetype is intended to be used for either term and the measurement site element is used to differentiate them. Use to record the measurement of the pulse rate, or heart rate, observations about the associated pattern and character, and clinical interpretation of the findings. Measurements such as the maximum pulse or heart rate over an interval of time can be recorded using 'Maximum' event. Others point-in-time or interval events may be specified within a template or at run-time. In development of this archetype, there has been some tension around representation of the regularity of the pulse or heart beat. This archetype represents the relevant data points separately: firstly establishing 'Regular' vs 'Irregular' and then, if 'Irregular', further options of 'Regularly irregular' and 'Irregularly irregular'. In practice, clinical systems could offer users a combination of the values from the 'Regularity' and 'Irregular type' - for example, 'Regular', 'Regularly irregular' and 'Irregularly irregular' drawn from these two data elements. Data could be recorded against both data elements with the assumption that if one of the irregular types are selected, then the 'Irregular' value in the 'Regularity' data element is also automatically selected. In certain situations it is important to be very specific so that a rate observed at a peripheral body site, such as the radial artery, can be differentiated from the rate of the heart. To record a pulse deficit, record the measurements of the mechanical heart rate and a peripheral pulse rate in two instances of this archetype - the difference between these measurments is the pulse deficit. The actual pulse deficit will be recorded in a separate OBSERVATION archetype.
MisuseNot to be used to record the R-R rate in the context of an Electrocardiograph report - use the OBSERVATION.ecg archetype for this purpose. Not to be used to record other details of the full cardiovascular examination or assessment. Other specific CLUSTER archetypes will be used to record characteristics such as apex beat, murmurs and bruits, or auscultatory findings. In particular, this archetype is not intended to record the assessment of peripheral vascular disease, which requires documentation of the presence and strength of each peripheral pulse. A specific CLUSTER archetype will be used to record the general findings on examination of peripheral pulses. Not to be used to record fetal heart rate - use the OBSERVATION.fetal_heart archetype for this purpose. Not to be used to record the pulse deficit - use a specific OBSERVATION archetype for this purpose. Concepts such as Target Heart Rate should be recorded in separate EVALUATION archetypes related to goals and exercise assessment.
PurposeTo record details about the rate and associated attributes for a pulse or heart beat.
ReferencesDirect communication with clinicians.
Copyright© openEHR Foundation
AuthorsAuthor name: Sam Heard
Organisation: Ocean Informatics
Email: sam.heard@oceaninformatics.com
Date originally authored: 2006-03-26
Other Details LanguageAuthor name: Sam Heard
Organisation: Ocean Informatics
Email: sam.heard@oceaninformatics.com
Date originally authored: 2006-03-26
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=Direct communication with clinicians., current_contact=Heather Leslie, Ocean Informatics, heather.leslie@oceaninformatics.com, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=FA62ACCECB4A643E142B1092B1128204, build_uid=64b97a61-b8f8-489d-9bd6-8ca03147e9be, revision=2.0.5}
Keywordsrate, rhythm, beat, pulse, heart, vital, sign
Lifecyclepublished
UID566c355d-9e8f-473d-a80d-90fcd8d61414
Language useden
Citeable Identifier1013.1.4295
Revision Number2.0.5
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=The rate and associated attributes for a pulse or heart beat., archetypeConceptComment=null, otherContributors=Morten Aas, Diakonhjemmet Sykehus, Norway
Tomas Alme, Norway
Magnus Alvestad, Helse Bergen HF, Norway
Nadim Anani, Karolinska Institutet, Sweden
Anne Pauline Anderssen, Helse Nord RHF, Norway
Vebjørn Arntzen, Oslo universitetssykehus HF, Norway (Nasjonal IKT redaktør)
Koray Atalag, University of Auckland, New Zealand
Gustavo Bacelar-Silva, Healthcare Designs, Brazil (openEHR Editor)
Silje Ljosland Bakke, Nasjonal IKT HF, Norway (Nasjonal IKT redaktør)
Lars Bitsch-Larsen, Haukeland University Hospital, Bergen, Norway
Diego Bosca, IBIME group, Spain
Pål Brekke, OUS Rikshospitalet, Norway
Einar Bugge, UNN HF, Fag- og forskningssenteret, Norway
Rong Chen, Cambio Healthcare Systems, Sweden
Stephen Chu, Queensland Health, Australia
Lisbeth Dahlhaug, Helse Midt - Norge IT, Norway
Angela de Zwart, Orion Health, New Zealand
Graham Denyer, Australian Antarctic Division, Australia
Paul Donaldson, Nursing Informatics Australia, Australia
Shahla Foozonkhah, Ocean Informatics, Australia
Einar Fosse, UNN HF, Norwegian Centre for Integrated Care and Telemedicine, Norway
Sebastian Garde, Ocean Informatics, Germany
John George, HSCIC, United Kingdom
Soon Ghee Yap, Singapore General Hospital, Singapore
Heather Grain, Llewelyn Grain Informatics, Australia
Mikkel Gaup Grønmo, FSE, Helse Nord, Norway (Nasjonal IKT redaktør)
Bjørn Grøva, Diretoratet for e-helse, Norway
Atle Hansen, Universitetssykehuset Nord-Norge, Norway
Sam Heard, Ocean Informatics, Australia
Kristian Heldal, Telemark Hospital Trust, Norway
Andreas Hering, Helse Bergen HF, Haukeland universitetssjukehus, Norway
Erling Are Hole, Helse Bergen, Norway
Evelyn Hovenga, EJSH Consulting, Australia
Eugene Igras, IRIS Systems, Inc., Canada
Tom Jarl Jakobsen, Helse Bergen, Norway
Lars Karlsen, DIPS ASA, Norway
Athanasios Kleontas, Ergobyte Informatics, Greece
Shinji Kobayashi, Kyoto University, Japan
Robert Legan, NEHTA, Australia
Heather Leslie, Ocean Informatics, Australia (openEHR Editor)
Hallvard Lærum, Direktoratet for e-helse, Norway
Rohan Martin, Ambulance Victoria, Australia
Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (openEHR Editor)
Lars Ivar Mehlum, Nasjonal IKT HF, Norway
Jeroen Meintjens, Medisch Centrum Alkmaar, Netherlands
Monica Merchat, Hospital Cardiac Electrophysiology, MS Health Informatics Student, former ICU nurse, former Anesthesia Technician, United States
Bjoern Naess, DIPS ASA, Norway
Andrej Orel, Marand d.o.o., Slovenia
Arturo Romero, SESCAM, Spain
Jussara Rotzsch, UNB, Brazil
Thomas Schopf, University Hospital of North-Norway, Norway
Nils Thomas Songstad, UNN HF, BUK, Barneavdelingen., Norway
Thor-Einar Stemland, Helse Bergen, FOU Seksjon for e-helse, Norway
Arne Løberg Sæter, DIPS ASA, Norway
Jan Inge Sørheim, Helse Bergen, Haukeland uniersitetssjukehus, Norway
Micaela Thierley, Helse Bergen/Haraldsplass sykehus, Norway
Kevin Thon, SKDE, Norway
John Tore Valand, Haukeland Universitetssjukehus, Norway (Nasjonal IKT redaktør), originalLanguage=en, translators=
  • German: Jasmin Buck, Sebastian Garde, Ramona Wellmann, University of Heidelberg, Central Queensland University, Hannover Medical School
  • Russian: Vyacheslav Mavrin, JSC Comsoft
  • Swedish: Erik Sundvall; Åsa Skagerhult, Kirsi Poikela, Region Östergötland, Tieto Sweden AB, asa.skagerhult@regionostergotland.se, ext.kirsi.poikela@tieto.com
  • Finnish: Vesa Peltola, Tieto Finland, vesa.peltola@tieto.com
  • Norwegian Bokmål: Silje Ljosland Bakke, Helse Bergen HF, ., RN
  • Portuguese (Brazil): Osmeire Chamelette Sanzovo, Hospital Sírio Libanês - SP, osmeire.acsanzovo@hsl.org.br
  • Greek: Erasmia Partafylla, Sigmasoft, c.partafylla@sigmasoft.gr
  • Arabic (Syria): Mona Saleh
  • Spanish (Spain): Pablo Pazos, CaboLabs - Health Informatics, pablo.pazos@cabolabs.com
  • Dutch: Joost Holslag, Nedap, joost.holslag@nedap.com, MD
  • Spanish (Colombia): Jose Florez-Arango, MD MS PhD
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  • Standing/upright [The subject was standing, walking or running.]
  • Sitting [The subject was sitting (for example on bed or chair).]
  • Reclining [The subject was reclining at an approximate angle of 45 degrees, with the legs elevated to the level of the pelvis.]
  • Lying [The subject was lying flat.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0002]/events[at0003]/state[at0012]/items[at1018], code=at1018, itemType=ELEMENT, level=4, text=Confounding factors, description=Narrative description about any incidental factors that may affect interpretation of the physical findings., comment=For example, presence of a pacemaker, level of anxiety; pain or fever etc., 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=/data[at0002]/events[at0003]/state[at0012]/items[at1017], code=at1017, itemType=SLOT, level=4, text=Exertion, description=Details about physical exertion being undertaken during the examination., 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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  • Present [A pulse or heart beat can be detected.]
  • Not detected [A pulse or heart beat cannot be detected.]
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  • Regular [The pattern is regular.]
  • Irregular [The pattern is irregular.]
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  • Regularly Irregular [The pattern is irregular in a regular pattern,. For example, a dropped beat once every 'n' beats.]
  • Irregularly Irregular [The pattern is irregular in a chaotic and unpredictable manner. For example, atrial fibrillation.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0002]/events[at0003]/data[at0001]/items[at1030], code=at1030, itemType=ELEMENT, level=4, text=Character, description=Description of the character of the pulse or heart beat., comment=Coding with a terminology is desired, where possible. For example: full, thready, bounding, slow rising, or collapsing. Multiple terms may be recorded., 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=/data[at0002]/events[at0003]/data[at0001]/items[at1022], code=at1022, itemType=ELEMENT, level=4, text=Clinical description, description=Narrative description about the pulse or heart beat., 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[at0002]/events[at0003]/data[at0001]/items[at1023], code=at1023, itemType=ELEMENT, level=4, text=(Clinical interpretation), description=Single word, phrase or brief description that represents the clinical meaning and significance of the pulse or heart beat findings, including the rhythm., comment=Coding with a terminology is preferred, where possible. For example: Bradycardia, Extrasystoles or Sinus rhythm. Multiple statements are allowed., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=Runtime name constraint:
  • Clinical interpretation [Generic label to allow for any or all statements about the pulse or heart beat.]
  • Rhythm [Specific conclusion about the rhythm of the pulse or heartbeat, drawn from a combination of the heart rate, pattern and other characteristics observed on examination.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0002]/events[at0003]/data[at0001]/items[at1059], code=at1059, itemType=ELEMENT, level=4, text=Comment, description=Additional narrative about the pulse or heart beat 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]], identities=[], other_participations=[], activities=[], protocol=[ResourceSimplifiedHierarchyItem [path=/protocol[at0010]/items[at1019], code=at1019, itemType=ELEMENT, level=2, text=Method, description=Method used to observe the pulse or heart beat., comment=For example, auscultation or electronic monitoring., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Palpation [The findings are observed by physical touch of the observer on the subject.]
  • Auscultation [The findings are observed with the assistance of a device, such as a stethoscope.]
  • Automatic, non-invasive [The findings are observed non-invasively using a device such as a pulse oximeter or a stethoscope.]
  • Automatic, invasive [The findings are observed invasively using a device such as an arterial catheter.]
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  •  Coded Text
    • Radial Artery - Left [The left radial artery.]
    • Radial Artery - Right [The right radial artery.]
    • Heart [The region of the heart.]
    • Carotid Artery - Left [The left carotid artery.]
    • Carotid Artery - Right [The right carotid artery.]
    • Femoral Artery - Left [The left femoral artery.]
    • Femoral Artery - Right [The right femoral artery.]
    • Brachial artery - Right [The right brachial artery.]
    • Brachial artery - Left [The left brachial artery.]
    • Finger [An unspecified finger.]
    • Toe [An unspecified toe.]
    • Ear lobe [The lobe of an unspecified ear.]
  •  Text
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openEHR-EHR-CLUSTER.device.v1 and specialisations
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  • Palpation [The findings are observed by physical touch of the observer on the subject.]
  • Auscultation [The findings are observed with the assistance of a device, such as a stethoscope.]
  • Automatic, non-invasive [The findings are observed non-invasively using a device such as a pulse oximeter or a stethoscope.]
  • Automatic, invasive [The findings are observed invasively using a device such as an arterial catheter.]
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  •  Coded Text
    • Radial Artery - Left [The left radial artery.]
    • Radial Artery - Right [The right radial artery.]
    • Heart [The region of the heart.]
    • Carotid Artery - Left [The left carotid artery.]
    • Carotid Artery - Right [The right carotid artery.]
    • Femoral Artery - Left [The left femoral artery.]
    • Femoral Artery - Right [The right femoral artery.]
    • Brachial artery - Right [The right brachial artery.]
    • Brachial artery - Left [The left brachial artery.]
    • Finger [An unspecified finger.]
    • Toe [An unspecified toe.]
    • Ear lobe [The lobe of an unspecified ear.]
  •  Text
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openEHR-EHR-CLUSTER.device.v1 and specialisations
Exclude:
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