ARCHETYPE Apgar score (openEHR-EHR-OBSERVATION.apgar.v2)

ARCHETYPE IDopenEHR-EHR-OBSERVATION.apgar.v2
ConceptApgar score
DescriptionA tool to assess the clinical status of the newborn infant immediately after birth and their response to resuscitation.
UseUse to record the results for each component parameter and their total sum for the Apgar score. This archetype has been designed to support the explicit recording of Apgar scores at 1, 2, 3, 5 and/or 10 minute points in time offset from the time of birth, plus additional events as required. Usual practice is to document the Apgar score at 1 and 5 minutes; further scores can be recorded as clinically indicated. It is possible to record the Apgar score at any time after birth using this archetype. Common clinical practice is to record all 5 parameters plus the total, however this archetype allows any partial information to be recorded, if that is all that is available for example from historical data.
PurposeTo record the results for each component parameter and their total sum for the Apgar score.
ReferencesApgar V. A proposal of a New Method of Evaluation of the Newborn Infant. Curr Res Anesth Analg. 1953 Jul-Aug;32(4):260-7.

Apgar V, Holaday DA, James LS, Weisbrod IM, and Berrien C. Evaluation of the newborn infant; second report. J Am Med Assoc. 1958 Dec 13;168(15):1985-8.

Apgar V. The newborn (Apgar) scoring system. Pediatr Clin North Am. 1966 Aug;13(3):645-50.

Whaley LF, Wong DL (1979). Nursing Care of Infants and Children. St. Louis, Toronto, London, The C.V. Mosby Company.
Copyright© openEHR Foundation
AuthorsAuthor name: Sam Heard
Organisation: Ocean Informatics
Email: sam.heard@oceaninformatics.com
Date originally authored: 2004-05-18
Other Details LanguageAuthor name: Sam Heard
Organisation: Ocean Informatics
Email: sam.heard@oceaninformatics.com
Date originally authored: 2004-05-18
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=Apgar V. A proposal of a New Method of Evaluation of the Newborn Infant. Curr Res Anesth Analg. 1953 Jul-Aug;32(4):260-7. Apgar V, Holaday DA, James LS, Weisbrod IM, and Berrien C. Evaluation of the newborn infant; second report. J Am Med Assoc. 1958 Dec 13;168(15):1985-8. Apgar V. The newborn (Apgar) scoring system. Pediatr Clin North Am. 1966 Aug;13(3):645-50. Whaley LF, Wong DL (1979). Nursing Care of Infants and Children. St. Louis, Toronto, London, The C.V. Mosby Company., original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=1D39EEC79BE11592B64E1F7D6F9DF993, build_uid=db82135b-ae5b-47f3-afc4-b6cbacb7b4a8, 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=2.0.0}
Keywordsnewborn, index, score, birth, infant, neonate, assessment
Lifecyclepublished
UID9ebf359c-bfcc-41ab-9353-3ed976cab252
Language useden
Citeable Identifier1013.1.4866
Revision Number2.0.0
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=A tool to assess the clinical status of the newborn infant immediately after birth and their response to resuscitation., archetypeConceptComment=null, otherContributors=Silje Ljosland Bakke, Helse Vest IKT AS, Norway (openEHR Editor)
Paul Donaldson, Nursing Informatics Australia, Australia
Sebastian Garde, Ocean Informatics, Germany
Anneke Goossen, Results 4 Care, Netherlands
Anne Harbison, CPCER, Australia
Sam Heard, Ocean Informatics, Australia
Omer Hotomaroglu, Turkey
Pieter Hummel, Medisch Centrum Alkmaar, Netherlands
Andrew James, University of Toronto, Canada
Heather Leslie, Atomica Informatics, Australia (openEHR Editor)
Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (openEHR Editor), originalLanguage=en, translators=German: Jasmin Buck, Sebastian Garde, Thilo Schuler, University of Heidelberg, Central Queensland University, Ocean Informatics
Russian: Igor Lizunov, i.lizunov@infinnity.ru
Finnish: Vesa Peltola, Tieto Finland
Norwegian Bokmål: Lars Bitsch-Larsen, Haukeland University Hospital, Bergen, Norway, MD, DEAA, specialist in anestesia and intensive care, Tropical medicin & MBA
Portuguese (Brazil): Jussara Rötzsch, OpenEHR Foundation, Medical Doctor, Psychiatrist, Clinical Modeler, OpenEHR Director, Coordinator of WG ehealth infostructure of brazilian e-health program
Arabic (Syria): Mona Saleh
Farsi: Shahla Foozonkhah, Ocean Informatics, Shahla.foozonkhah@oceanInformatics.com
Spanish (Chile): Sergio Carmona
Chinese (PRC): Lin Zhang, BIPH, linforest@163.com
Dutch: Marja Buur, Medisch Centrum Alkmaar, m.buur-krom@mca.nl, Erna Vreeke
, subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={ism_transition=[], context=[], details=[], other_participations=[], description=[], data=[ResourceSimplifiedHierarchyItem [path=/data[at0002]/events[at0003]/data[at0001]/items[at0009], code=at0009, itemType=ELEMENT, level=4, text=Respiratory effort, description=Observation of the infant's respiratory effort., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=[SNOMED-CT::249224006 | Apgar respiratory effort score (observable entity)], values=0: Absent [No effort to breath.]
[LOINC::LA6725-1 | Not breathing]

1: Weak or irregular [Some effort to breath, moving chest.]
[LOINC::LA6726-9 | Weak cry; may sound like whimpering, slow or irregular breathing]

2: Normal [Breathing normally or crying.]
[LOINC::LA6727-7 | Good, strong cry; normal rate and effort of breathing]

, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0002]/events[at0003]/data[at0001]/items[at0005], code=at0005, itemType=ELEMENT, level=4, text=Heart rate, description=Recording of the infant's heart rate., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=[SNOMED-CT::249223000 | Apgar pulse rate score], values=0: Absent [No heart beat is seen, felt or heard.]
[LOINC::LA6716-0 | No heart rate]

1: <100 beats per minute [Heart rate less than 100 beats per minute.]
[LOINC::LA6717-8 | Fewer than 100 beats per minute]

2: ≥100 beats per minute [Heart rate greater than or equal to 100 beats per minute.]
[LOINC::LA6718-6 | At least 100 beats per minute]

, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0002]/events[at0003]/data[at0001]/items[at0013], code=at0013, itemType=ELEMENT, level=4, text=Muscle tone, description=Observation of the infant's muscle tone., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=[SNOMED-CT::249225007 | Apgar activity score], values=0: Limp or flaccid [No spontaneous movement.]
[LOINC::LA6713-7 | Limp; no movement]

1: Reduced tone [Some flexion of extremities.]
[LOINC::LA6714-5 | Some flexion of arms and legs]

2: Normal tone [Normal, vigorous movements.]
[LOINC::LA6715-2 | Active motion]

, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0002]/events[at0003]/data[at0001]/items[at0017], code=at0017, itemType=ELEMENT, level=4, text=Reflex irritability, description=Observation of the response of the infant to an irritant stimulation, for example, suctioning the oropharynx and nares with a soft rubber catheter., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=[SNOMED-CT::249226008 | Apgar grimace score], values=0: No response [No response to stimulation.]
[LOINC::LA6719-4 | No response to airways being suctioned]

1: Reduced response [Grimace or feeble cry when stimulated.]
[LOINC::LA6720-2 | Grimace during suctioning]

2: Normal response [Grimace, sneeze, cough or pulls away when stimulated.]
[LOINC::LA6721-0 | Grimace and pulling away, cough, or sneeze during suctioning]

, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0002]/events[at0003]/data[at0001]/items[at0021], code=at0021, itemType=ELEMENT, level=4, text=Skin colour, description=Observation of the skin colour of the infant., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=[SNOMED-CT::249227004 | Apgar appearance score], values=0: Completely blue [Body and extremities are blue.]
[LOINC::LA6722-8 | The baby's whole body is completely bluish-gray or pale]

1: Body pink; extremities blue [Body is pink; extremities are blue.]
[LOINC::LA6723-6 | Good color in body with bluish hands or feet]

2: Completely pink [Body and extremities are pink; no cyanosis.]
[LOINC::LA6724-4 | Good color all over]

, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0002]/events[at0003]/data[at0001]/items[at0025], code=at0025, itemType=ELEMENT, level=4, text=Total, description=The total sum of each component parameter for the Apgar score., comment=If the total is to be calculated, it is necessary for all 5 component values to be recorded., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=[SNOMED-CT::249228009 | Total apgar score (observable entity)], values=min: >=0; max: <=10

, extendedValues=null]], contacts=[], provider=[], credentials=[], state=[], capabilities=[], activities=[], content=[], items=[], protocol=[ResourceSimplifiedHierarchyItem [path=/protocol[at0029]/items[at0040], code=at0040, 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]], relationships=[], events=[ResourceSimplifiedHierarchyItem [path=/data[at0002]/events[at0003], code=at0003, itemType=POINT_EVENT, level=2, text=1 minute, description=Apgar score 1 minute after birth., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=POINT_EVENT, bindings=[SNOMED-CT::169895004 | Apgar at 1 minute (observable entity)]
[LOINC::48334-7 | 1 minute Apgar panel] (1 minute), values=Offset: 1 minute
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0002]/events[at0026], code=at0026, itemType=POINT_EVENT, level=2, text=2 minute, description=Apgar score 2 minutes after birth., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=POINT_EVENT, bindings=null, values=Offset: 2 minutes
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0002]/events[at0027], code=at0027, itemType=POINT_EVENT, level=2, text=3 minute, description=Apgar score 3 minutes after birth., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=POINT_EVENT, bindings=null, values=Offset: 3 minutes
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0002]/events[at0028], code=at0028, itemType=POINT_EVENT, level=2, text=5 minute, description=Apgar score 5 minutes after birth., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=POINT_EVENT, bindings=[SNOMED-CT::169909004 | Apgar at 5 minutes (observable entity)]
[LOINC::48333-9 | 5 minute Apgar panel] (5 minute), values=Offset: 5 minutes
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0002]/events[at0031], code=at0031, itemType=POINT_EVENT, level=2, text=10 minute, description=Apgar score 10 minutes after birth., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=POINT_EVENT, bindings=[SNOMED-CT::169922007 | Apgar at 10 minutes (observable entity)]
[LOINC::48332-1 | 10 minute Apgar panel] (10 minute), values=Offset: 10 minutes
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0002]/events[at0037], code=at0037, itemType=EVENT, level=2, text=Any event, description=Apgar score at any additional time, as required., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=null, extendedValues=null]], identities=[], source=[], target=[]}, topLevelItems={data=ResourceSimplifiedHierarchyItem [path=ROOT_/data[at0002]/events[at0003]/data[at0001], code=at0001, itemType=ITEM_TREE, level=2, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=0..1, cardinalityText=optional, subCardinalityFormal=1..6, subCardinalityText=Maximum of 6 items, ordered, dataType=ITEM_TREE, bindings=null, values=null, extendedValues=null], protocol=ResourceSimplifiedHierarchyItem [path=ROOT_/protocol[at0029], code=at0029, 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]}, addHierarchyItemsTo=protocol, currentHierarchyItemsForAdding=[ResourceSimplifiedHierarchyItem [path=/protocol[at0029]/items[at0040], code=at0040, 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:
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