| ARCHETYPE ID | openEHR-EHR-OBSERVATION.refractive_error_measurement.v0 |
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| Concept | Refractive error measurement |
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| Description | Measurements of the refractive error of an individual's eyes, which would need to be corrected for light to be appropriately focused on the retina. |
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| Use | Use to record the results and contextual parameters of a measurement of refractive error.
Use to record both subjective and objective measurements of a refractive error.
Use to record both examiner-led subjective refration and autorefractometer-based subjective refraction.
Use to record the result of static retinoscopy, |
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| Misuse | Not to be used to record a spectacle or contact lens prescription.
Not to be used to record the correction used during other tests, such as visual acuity tests.
Not to be used to record the results of an overrefraction, which is a measurement of the residual refractive error while a correction is being used. No appropriate Archetype is available at this time.
Not to be used to record the results of measurements of accomodative capabilty, including dynamic retinoscopy. No appropriate Archetype is available at this time. |
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| Purpose | For recording the results of a measurement of refractive error, which is commonly referred to as performing a refraction. |
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| References | |
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| Copyright | © openEHR Foundation |
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| Authors | Author name: Ian McNicoll
Organisation: Ocean Informatics, UK
Email: ian.mcnicoll@oceaninformatics.com
Date originally authored: 2012-07-18
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| Other Details Language | Author name: Ian McNicoll
Organisation: Ocean Informatics, UK
Email: ian.mcnicoll@oceaninformatics.com
Date originally authored: 2012-07-18
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| Other Details (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:
- Current Contact: Ian McNicoll, Ocean Informatics, UK, ian.mcnicoll@oceaninformatics.com
- Original Namespace: org.openehr
- Original Publisher: openEHR Foundation
- Custodian Namespace: org.openehr
- MD5-CAM-1.0.1: C3FA1DBDEF7F71166FE21F9BEC436AC7
- Build Uid: 6d9cbdbf-8776-4332-8ffb-5cfde3f28805
- 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
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| Keywords | eye, sight, vision, ophthalmic, visual, refraction, refraction |
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| Lifecycle | in_development |
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| UID | 0425d1b2-593c-46b3-ba9e-462bf11a0b1f |
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| Language used | en |
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| Citeable Identifier | 1013.1.8517 |
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| Revision Number | 0.0.1-alpha |
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| data | |
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| Eye examined | Eye examined: Identification of the eye which was tested.
- at0145::Right eye [Assessment of the right eye was performed.]
- at0146::Left eye [Assessment of the left eye was performed.]
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| Sphere | Sphere: The refractive error that is equal in all meridians.
Property: Refractive power
Units: dioptre (UCUM: [diop]) |
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| Cylinder | Cylinder: The refractive error added to the spherical error at the meridian 90° from the cylinder axis, reflecting the degree of cylindrical astigmatism.
Property: Refractive power
Units: dioptre (UCUM: [diop]) |
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| Axis of cylinder | Axis of cylinder: The orientation of the cylinder of the refractive error in degrees.
Property: Angle, plane
Units: ° (UCUM: deg) |
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| Spherical equivalent | Spherical equivalent: The calculated spherical equivalent of the refractive error.
Property: Refractive power
Units: dioptre (UCUM: [diop]) |
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| Interpretation | Interpretation: Interpretation of the results.
Not to be used for information about how the test was performed or patient circumstances affecting result. |
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| Comment | Comment: Any additional narrative comment.
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| Examination not done | Examination not done: Details to explicitly record that this test was not performed.
Include:
openEHR-EHR-CLUSTER.exclusion_exam.v1 and specialisations |
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| state | |
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| Method | Method: The type of method that was used to perform the measurement.
- at0150::Automated objective refractometry [The measurement was performed by automated objective refractomery, commonly refered to as autorefractometry.]
- at0151::Manual subjective refraction [Subjective refraction was performed by a human examiner based on patient feedback.]
- at0152::Automated subjective refraction [Subjective refraction was perfomed in an automated manner based on patient feedback.]
- at0155::Retinoscopy [The measurement was perfomed by retinoscopy.]
- at0235::Direct ophthalmoscope refraction [The refractive error was estimated via a direct ophthalmoscope.]
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| Targeted Distance | Targeted Distance: The (virtual or real) distance between the eye and the object from which the light rays should be focused on the retina if the measured refractive error is corrected. |
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| Targeted Distance category | Targeted Distance category: A categorisation of the targeted distance.
- at0205::Infinity
- at0206::Far
- at0207::Intermediate
- at0208::Near
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| Device Details | Device Details: Details of the device used to measure refraction.
Include:
openEHR-EHR-CLUSTER.device.v1 and specialisations |
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| Confounding Factors | Confounding Factors: Patient circumstances which affect interpretation of the result. Often termed 'reliability' in opthalmological documentation.
Examples: 'Patient was confused', 'Low light conditions'. |
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| Accommodative state | Accommodative state: The individuals assumed accommodative function during the measurement of refractive error.
Coding with a terminology is recommended. Free text entry should only be permitted if no appropriate coded value is available.
Choice of:
 Coded Text
- at0236::Complete medical cycloplegia [Due to use of cycloplegic eye drops, the ability to accomodate was considered functionally abolished.]
- at0243::Near-complete medical cycloplegia [Due to use of cycloplegic eye drops, the ability to accomodate was considered strongly reduced, but not abolished.]
- at0237::Partial medical cycloplegia [Due to use of cycloplegic eye drops, the ability to accomodate was considered reduced, but not to a complete or near-complete degree.]
- at0238::No medical cycloplegia [Medical cycloplegia was not used.]
- at0239::Accomodation impossible [Accommodation was deemd impossible for other reasons, such as the absence of the natural lens.]
- at0240::Pathological cycloplegia [A reduced abiliy to accommodate was present for pathological reasons.]
 Text
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| Pupil state | Pupil state: Statement describing the condition of the individual's pupils during the measurement.
Comment: The physical examination of the eye will be recorded using the CLUSTER.exam-eye family of archetypes.
Coding with a terminology is recommended. Free text entry should only be permitted if no appropriate coded value is available.
Choice of:
- Coded Text
- at0174::Normal [The pupil is in its natural physiological state without pharmacological intervention or pathological changes.]
- at0175::Medically induced mydriasis [The pupil was dilated due to prior administration of mydriatic agents.]
- at0176::Medically induced miosis [The pupil was constricted due to prior administration of miotic agents.]
- at0177::Pathological Pupil state [The pupil was in an unphysiological state due to disease, trauma, or structural abnormalities.]
- Text
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| Assumed pupil diameter | Assumed pupil diameter: The diameter of the pupil which is assumed to have been present during the measurement of refractive error
Typically based on an observation or measurement of pupil diameter which may be recorded in a separate OBSERVATION.
Property: Length
Units: mm |
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| Assumed vertex distance | Assumed vertex distance: The vertex distance that was assumed or measured as a basis for the measurement of refractive error. |
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| Set interpupillary distance | Set interpupillary distance: The interpupillary distance which was set in the device used to measure the refractive error.
Not an observation or measurement of the tested individual's true interpupillary distance, but rather a recording of the interpupillary distance which was set in the testing device (such as a phoropter) during the measurement of refractive error.
Measurements of Interpupillary distances will be recorded in another archetype.
Property: Length
Units: mm |
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| Autorefractometer details | Autorefractometer details: Detailed information typically only produced by autorefractometers
###Might be better off in a separate CLUSTER Archetype that can be slotted in here#### |
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| Sub-cycle integration method | Sub-cycle integration method: - at0232::Median
- at0233::Typical
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| Optical zone | Optical zone: - at0241::Central Area
- at0242::Expanded Area
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| Sub-cycle results | |
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| Sphere | Sphere: The refractive error that is equal in all meridians.
Property: Refractive power
Units: dioptre (UCUM: [diop]) |
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| Cylinder | Cylinder: The refractive error added to the spherical error at the meridian 90° from the cylinder axis, reflecting the degree of cylindrical astigmatism.
Property: Refractive power
Units: dioptre (UCUM: [diop]) |
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| Axis of cylinder | Axis of cylinder: The orientation of the cylinder of the refractive error in degrees.
Property: Angle, plane
Units: ° (UCUM: deg) |
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| Retinoscopy details | Retinoscopy details: Detailed information typically only produced during retinoscopy.
###Might be better off in a separate CLUSTER Archetype that can be slotted in here#### |
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| By neutralisation point | |
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| Angle of sweep direction | |
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| Angle of streak | |
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| Power of sphere held | |
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| Working distance | |
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| Examiner-led subjective refraction details | Examiner-led subjective refraction details: Detailed information typically only produced during examiner-led subjective refraction.
###Might be better off in a separate CLUSTER Archetype that can be slotted in here#### |
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| Utilized techniques | Utilized techniques: - at0157::Cross-Cylinder
- at0158::Stenopeic slit
- at0159::Duochrome test
- at0160::Correction for room length
- at0161::Binocular balancing
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| events | |
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| Any event | Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time. |
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| protocol | |
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| Extension | Extension: Additional information required to capture local content or to align with other reference models/formalisms.
For example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.
Include:
All not explicitly excluded archetypes |
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| Other contributors | Gustavo M Bacelar-Silva, Brazil
Lars Fuhrmann, Germany |
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| Translators | Norwegian Bokmål: Thomas Baerland, Oslo Universitetssykehus / DIPS ASA, tba@dips.no, ?
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