| TEMPLATE ID | Demo with hide-on-form |
|---|---|
| Concept | Demo with hide-on-form |
| Description | To show how hide on form works within templates to not display unwanted structural items. |
| Purpose | To show how hide on form works within templates to not display unwanted structural items. |
| References | |
| Other Details (Language Independent) |
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| Language used | en |
| Citeable Identifier | 1013.26.1 |
| Root archetype id | openEHR-EHR-COMPOSITION.encounter.v1 |
| Encounter | Encounter: Generic encounter or progress note composition |
| SOAP | SOAP: Problem-oriented heading in the record of the problem presented by the patient or client |
| S | S: The subjective findings or story told by the person. |
| History | History: A structure to collect information provided by the person or information provider in relation to the symptoms and difficulties they are presenting to the clinician |
| Story | Story: Information provided about the person |
| Details | Details: * |
| Issue presented by a person | Issue presented by a person: An issue, symptom, or complaint presented to the health provider seeking explanation, education, understanding, investigation or treatment |
| Issue | Issue: The issue as presented by the person |
| Detail | Detail: Detailed information about the issue or health problem |
| Symptom | Symptom: A symptom experienced by the patient |
| Symptom | Symptom: The symptom experienced
|
| Features | Features: The features of the symptom |
| Clinical description | Clinical description: Description of the symptom |
| Severity | Severity: The severity of the symptom
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| Current intensity degree | Current intensity degree: The degree the symptom is bothering the patient
|
| Duration | Duration: The duration of the symptom since onset |
| Character | Character: The character of the symptom |
| Variation | Variation: The variation of the symptom
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| Precipitating factors | Precipitating factors: Factors that trigger or bring on the symptom |
| Precipitating factor | Precipitating factor: An event or activity that brings on or triggers the symptom |
| Modification | Modification: Factors that change the level of intensity of the symptom |
| Modifying factor | Modifying factor: Information about a specific factor that changes the symptom |
| Factor | Factor: An event or activity that modifies the symptom |
| Change | Change: An event or activity that makes the symptom worse
|
| Details | Details: Details of the effect |
| O | O: The objective findings or observations made by the clinician. |
| Blood Pressure | Blood Pressure: The local measurement of arterial blood pressure which is a surrogate for arterial. pressure in the systemic circulation. Most commonly, use of the term 'blood pressure' refers to measurement of brachial artery pressure in the upper arm. |
| Systolic | Systolic: Peak systemic arterial blood pressure - measured in systolic or contraction phase of the heart cycle. 0..1000 mmHg |
| Diastolic | Diastolic: Minimum systemic arterial blood pressure - measured in the diastolic or relaxation phase of the heart cycle. 0..1000 mmHg |
| Comment | Comment: Comment on blood pressure measurement. |
| Position | Position: The position of the subject at the time of measurement.
|
| Cuff size | Cuff size: The size of the cuff used for blood pressure measurement. Perloff D, Grim C, Flack J, Frohlich ED, Hill M, McDonald M, Morgenstern BZ. Human blood pressure determination by sphygmomanometry. Circulation 1993;88;2460-2470.
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| Pulse | Pulse: The mechanical heart rate - usually measured by palpation |
| Findings | Findings: * |
| Rate | Rate: The rate of the heart as beats per minute >=0 /min |
| Rhythm | Rhythm: The rhythm of the heart beat
|
| Body temperature | Body temperature: A measurement of the body temperature, which is a surrogate for the whole body temperature of the person. |
| Temperature | Temperature: The measured body temperature (as a surrogate for the whole body) Units:
|
| Respirations | Respirations: The observed characteristics of spontaneous breathing as would commonly be recorded as part of a 'vital signs' examination. |
| Rate | Rate: Rate of respiration. 0..200 /min |
| Rhythm | Rhythm: Rhythm of respiration.
|
| Depth | Depth: Depth of respiration.
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| Description | Description: A text description of respirations. |
| A | A: The assessment made by the clinician. |
| Diagnosis | Diagnosis: A diagnosis defined by a clinician which is coded in an accepted terminology and may include the stage of the condition and the diagnostic criteria |
| Diagnosis | Diagnosis: The index diagnosis Value set: ac0.1 |
| Status | Status: The status of the diagnosis
|
| P | P: Plans made or procedures carried out. |
| Imaging request | Imaging request: Request for imaging services |
| Imaging activity | Imaging activity: Information about the imaging action(s) to be carried out |
| null | @ internal @ |
| Clinical exam findings | Clinical exam findings: Clinical findings relevant to the imaging investigation |
| Imaging | Imaging: Information about the imaging |
| Imaging procedure | Imaging procedure: The type of imaging |
| Anatomical site | Anatomical site: The anatomical site (or object) for imaging |
| Views | Views: The imaging views |