ARCHETYPE Deep tendon reflex response (openEHR-EHR-CLUSTER.deep_tendon_reflex.v0)

ARCHETYPE IDopenEHR-EHR-CLUSTER.deep_tendon_reflex.v0
ConceptDeep tendon reflex response
DescriptionFindings observed during the physical examination of a single deep tendon reflex.
UseUse to record the observed findings during the physical examination of a single deep tendon reflex. This archetype has been specifically designed to be used in the 'Examination detail' SLOT within the OBSERVATION.exam or the CLUSTER.exam-nervous_system archetype. It can also be nested within any other relevant OBSERVATION or Physical examination-related family of CLUSTER archetypes, where clinically appropriate. In clinical scenarios requiring the documentation of more than one deep tendon reflex response, use a separate instance of this archetype for each tendon type, and also for each side in a paired reflex.
MisuseNot to be used to represent superficial reflexes, such as superficial abdominal, sphincteric, and bulbospongiosus reflexes. Use appropriate archetypes for this purpose. Not to be used to represent pathological reflexes, such as Babinski, snout, rooting, or grasp reflexes. Use appropriate archetypes for this purpose.
PurposeTo record the findings observed during the physical examination of a single deep tendon reflex.
References
Copyright© openEHR Foundation
AuthorsAuthor name: Heather Leslie
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2023-05-24
Other Details LanguageAuthor name: Heather Leslie
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2023-05-24
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=C078D48F7C8AB6E4CA55E415B53DC30E, build_uid=a692ca56-c510-4723-a7cf-77e37543a3d4, 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
UID27762887-d4aa-47ef-9e1e-9b1b9c5e734f
Language useden
Citeable Identifier1013.1.6956
Revision Number0.0.1-alpha
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Findings observed during the physical examination of a single deep tendon reflex., 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=, subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={items=[ResourceSimplifiedHierarchyItem [path=/items[at0001], code=at0001, itemType=ELEMENT, level=1, text=Reflex, description=Identification of the deep tendon reflex or group of reflexes being examined., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
  •  Coded Text
    • Right biceps [Testing the C5 and C6 nerve roots.]
    • Left biceps [Testing the C5 and C6 nerve roots.]
    • Right brachioradialis [Testing the C6 nerve root.]
    • Left brachioradialis [Testing the C6 nerve root.]
    • Right triceps [Testing the C7 nerve root.]
    • Left triceps [Testing the C7 nerve root.]
    • Right quadriceps [Also known as patellar or knee jerk. Testing the L4 nerve root.]
    • Left quadriceps [Also known as patellar or knee jerk. Testing the L4 nerve root.]
    • Right achilles [Also known as ankle jerk. Testing the S1 nerve root.]
    • Left achilles [Also known as ankle jerk. Testing the S1 nerve root.]
    • Jaw [Testing the 5th cranial nerve root.]
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0013], code=at0013, itemType=ELEMENT, level=1, text=Relative response, description=The elicited reflex response represented as relative to a 'normal' response., 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
    • Increased [The elicited response appears increased, compared with normal.]
    • Normal [The elicited response is considered within the expected range of responses.]
    • Decreased [The elicited response appears decreased, compared with normal.]
    • Absent [No response can be elicited.]
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0018], code=at0018, itemType=ELEMENT, level=1, text=Graded response, description=The elicited reflex response represented as a grade., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
  •  Ordinal
    0: Absent [Reflex is not evident. May be recorded as '0' or '-'.]
    1: Slight [Reflex is present but less than normal amplitude, or only seen with reinforcement. May be recorded as '+' or '1+'.]
    2: Normal [Reflex is present at normal amplitude. May be recorded as '++' or '2+'.]
    3: Brisk [Reflex is present at greater than normal amplitude. May be recorded as '+++' or '3+'.]
    4: Non-sustained clonus [Reflex is repeating but not sustained. May be recorded as '++++' or '4+'.]
    5: Sustained clonus [Reflex is repeating and sustained. May be recorded as '+++++' or '5+'.]
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0025], code=at0025, itemType=ELEMENT, level=1, text=Augmented response, description=Was the response augmented or reinforced?, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0026], code=at0026, itemType=ELEMENT, level=1, 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]], 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=, 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=Reflex, description=Identification of the deep tendon reflex or group of reflexes being examined., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
  •  Coded Text
    • Right biceps [Testing the C5 and C6 nerve roots.]
    • Left biceps [Testing the C5 and C6 nerve roots.]
    • Right brachioradialis [Testing the C6 nerve root.]
    • Left brachioradialis [Testing the C6 nerve root.]
    • Right triceps [Testing the C7 nerve root.]
    • Left triceps [Testing the C7 nerve root.]
    • Right quadriceps [Also known as patellar or knee jerk. Testing the L4 nerve root.]
    • Left quadriceps [Also known as patellar or knee jerk. Testing the L4 nerve root.]
    • Right achilles [Also known as ankle jerk. Testing the S1 nerve root.]
    • Left achilles [Also known as ankle jerk. Testing the S1 nerve root.]
    • Jaw [Testing the 5th cranial nerve root.]
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0013], code=at0013, itemType=ELEMENT, level=1, text=Relative response, description=The elicited reflex response represented as relative to a 'normal' response., 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
    • Increased [The elicited response appears increased, compared with normal.]
    • Normal [The elicited response is considered within the expected range of responses.]
    • Decreased [The elicited response appears decreased, compared with normal.]
    • Absent [No response can be elicited.]
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0018], code=at0018, itemType=ELEMENT, level=1, text=Graded response, description=The elicited reflex response represented as a grade., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
  •  Ordinal
    0: Absent [Reflex is not evident. May be recorded as '0' or '-'.]
    1: Slight [Reflex is present but less than normal amplitude, or only seen with reinforcement. May be recorded as '+' or '1+'.]
    2: Normal [Reflex is present at normal amplitude. May be recorded as '++' or '2+'.]
    3: Brisk [Reflex is present at greater than normal amplitude. May be recorded as '+++' or '3+'.]
    4: Non-sustained clonus [Reflex is repeating but not sustained. May be recorded as '++++' or '4+'.]
    5: Sustained clonus [Reflex is repeating and sustained. May be recorded as '+++++' or '5+'.]
  •  Text
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