TEMPLATE Patient's background and diagnosis of glaucoma (Patient's background and diagnosis of glaucoma)

TEMPLATE ID	Patient's background and diagnosis of glaucoma
Concept	Patient's background and diagnosis of glaucoma
Description	Analyze the previous consultations and diagnostic tests of patients diagnosed with CG who are medically stable.
Purpose	Analyze the previous consultations and diagnostic tests of patients diagnosed with CG who are medically stable.
References
Authors	name: Aitor Eguzkitza; organisation: Universidad Pública de Navarra - Complejo Hospitalario de Navarra; email: aitor.eguzkiza@unavarra.es; date: 2016-07-20
Other Details Language	name: Aitor Eguzkitza; organisation: Universidad Pública de Navarra - Complejo Hospitalario de Navarra; email: aitor.eguzkiza@unavarra.es; date: 2016-07-20
Other Details (Language Independent)	MetaDataSet:Sample Set : Template metadata sample set Copyright: © openEHR Foundation Owner: Aitor Eguzkitza, aitor.eguzkiza@unavarra.es Speciality: Ophthalmology
Language used	en
Citeable Identifier	1013.26.131
Root archetype id	openEHR-EHR-SECTION.patients_background.v0
Patients background	Patients background: Clinical information needed from a patient to give context to the responsible physician before register him within a specific service.
Reason for encounter	Reason for encounter: The reason for initiation of any healthcare encounter or contact by the individual who is the subject of care.
Data
Contact type	Contact type: Identification of the type, or administrative category, of healthcare sought or required by the subject of care. Coding of the 'Contact type' with a terminology is desirable, where possible. Examples include: pre-employment medical, routine antenatal visit, women's health check, pre-operative assessment, or annual medical check-up. Routine eye consultation Ophthalmologic review of an eye condition other than glaucoma Ophthalmologic examination of patient with family history of glaucoma Specialized consultation at the office of an ophthalmologist expert on glaucoma
Presenting problem	Presenting problem: Identification of the clinical or social problem motivating the subject of care to seeking healthcare. Coding of the 'Presenting problem' with a terminology is desirable, where possible. Clinical or social reasons for seeking healthcare can include health issues, symptoms or physical signs. Examples: health issues - desire to quit smoking, domestic violence; symptoms - abdominal pain, shortness of breath; physical signs - an altered conscious state. 'Chief complaint' may be used as a valid synonym for 'Presenting problem' in templates. Established suspicion of glaucoma Confirmed diagnosis of glaucoma Establishment of long-term therapy for CG Post-operation reassessment of glaucoma Identified the need of modifying the treatment of CG
Story/History	Story/History: The subjective clinical history of the subject of care as recorded directly by the subject, or reported to a clinician by the subject or a carer.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Story	Story: Narrative description of the story or clinical history for the subject of care.
Risk factors in glaucoma	Risk factors in glaucoma: Provides a structure to the registration of the risk factors that could affect the development of glaucoma.
Current medications	Current medications: Idenitifcation of all ocular and systemic medications (e.g., corticosteroids), which the patient is currently taking.
Family history	Family history: Narrative description of the severity and outcome of glaucoma in family members, including history of visual loss from glaucoma.
Ocular trauma	Ocular trauma: Description of any trauma or contusion occurred on the eye.
Refractive surgery	Refractive surgery: A history of prior glaucoma laser or incisional surgical procedures. Some of those procedures are associated with falsely low IOP measurements.
Chronic/severe diseases	Chronic/severe diseases: Registers chronic or severe diseases of patients that might affect on the prevalence of glaucoma, such as cardiovascular or respiratory diseases, type 2 diabetes, myopia, or specific genetic mutations.
Vascular	Vascular: Description of vascular disorders related with glaucoma.
Drug allergies	Drug allergies: Description of known local or systemic intolerance of the patient to ocular or systemic medications.
Intraocular pressure	Intraocular pressure: The local measurement of intraocular pressure, most commonly using a tonometry device.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Eye examined	Eye examined: Identification of the eye under examination. Left Right
Pressure	Pressure: Measured intraocular pressure. 0..90 mmHg (UCUM: mm[Hg])
Applanation time	Applanation time: The time taken for a non-contact tonometer to flatten the cornea, used to calculate intraocular pressure. >=0 millisec
Clinical interpretation	Clinical interpretation: Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings.
Comment	Comment: Additional narrative about the measurement, not captured in other fields.
State
Confounding factors	Confounding factors: Description of any incidental factors related to the state of the subject which may affect clinical interpretation of the measurement.
Protocol
Tonometry Method	Tonometry Method: Type of tonometery used to measure intracoular pressure. Coded Text Goldmann Perkins Tono-Pen Icare (Rebound) Dynamic Contour Ocular Response Analyzer TGDc-01 Non-contact tonometry Text
Visual acuity	Visual acuity: Visual acuity is a measure of the spatial resolution of the visual processing system.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Test Name	Test Name: The name of the exact visual acuity test performed. This generally represents a broad category of applied refraction. Specific refraction details can be described using 'Refractive Correction'. Details of the exact correction applied, or where multiple corrections should be captured via 'Refractive Correction'. Coded Text Pinhole visual acuity Usual corrected visual acuity Best corrected visual acuity Unaided visual acuity Text
Description	Description: An overall narrative description of the visual acuity test result.
Per Eye	Per Eye: Details of the visual field test result for each eye.
Eye Examined	Eye Examined: The eye which is being examined. Left eye Right eye Both eyes simultaneously
Absent Result	Absent Result: Details of a test result which could not be recorded. Details of reasons for an absent test result can be described in Additional Comment or Confounding Factors. Coded Text Not performed Not completed Text
Notation	Notation: Details of a visual acuity result recorded using one of the result notation formats.
Metric Snellen	Metric Snellen: The distance test result, recorded in Snellen format expressed in metres, where 6/6 is regarded as normal. Examples: '6/6, '6/12', '6/5' Ratio
US Snellen	US Snellen: The distance test result, recorded as Snellen visual acuity expressed in feet, where 20/20 is regarded as normal. Examples: '20/20' , '20/40', '20/18' Ratio
Decimal Snellen	Decimal Snellen: The distance test result,recorded as Sn ellen visual acuity expressed as a decimal ratio, where 1.0 is regarded as normal. Unitary
ETDRS Letters	ETDRS Letters: Visual acuity expressed using ETDRS Letters format, with a value of 100 regarded as normal. 1..120
logMar	logMar: The test result, recorded as logMar visual acuity, where a value of 0 is regarded as normal. -0.5..2
Low Vision Score	Low Vision Score: Graded scale used when patient has low levels of visual acuity. 1: NPL - No perception of light 2: PL - Perception of light 3: HM - Hand movement 4: CF - Count fingers
Letter Termination Adjustment	Letter Termination Adjustment: A line termination adjustment score applied to the visual acuity result. If the patient can read at least half of the chart line the visual acuity terminatin line is recorded as that line, with the number of letters missed on that line recorded as a negative Letter Termination Adjustment score. If the patient can read less than half of a Visual Acuity line, the previous line is recorded as the Visual Acuity result, with the number of letters seen on the following line recorded as a positive 'Letter Termination Adjustment' score. -10..10 Assumed value: 0
Derived Score	Derived Score: Visual acuity expressed as an integer score which is calculated from one or more of the other result notation formats. The original notation should be captured using 'Derived Score Original Notation' format'. Details of the algorithm used and original result format may be recorded under 'Derived Score Methodology'. >=0
Interpretation	Interpretation: The test result expressed as a qualitative term, normally coded. Example: 'Visual Acuity 20/20' or 'Jaeger 'J2' score'.
Overall Interpretation	Overall Interpretation: A term, commonly coded, expressing an overall interpretation of the visual acuity test.
Comment	Comment: Any additional narrative comment about the visual acuity test.
State
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'.
Refractive Correction	Refractive Correction: The specific type(s) of refractive correction applied when measuring visual acuity. Examples: 'No correction : unaided', 'Pinhole'. Spectacles Contact lenses Pinhole Autorefraction Retinoscopy
Protocol
Testing Distance	Testing Distance: The distance at which the subject's visual acuity was measured. >=0; >=0; >=0; >=0 Units: ft m cm in
Chart Method	Chart Method: The charting method used to measure visual acuity. logMar chart Snellen chart ETDRS chart Picture chart Reduced logMar Reduced Snellen Faculty of Ophthalmologists 'N' Score Jaeger 'J' Score
Chart Optotype	Chart Optotype: The style of chart optotype used to assess visual acuity. Letter Orientation Picture
Chart Scoring Algorithm	Chart Scoring Algorithm: The alogrithm used to determine the score. Single letter Whole line Last line single letter
Derived Score Original Notation	Derived Score Original Notation: The original visual acuity result notation from which the Derived Score was calculated. When the visual acuity result is recorded using a Derived Score, this element can be used to record the original notation format, so that it can be displayed using the original notation. US Snellen Metric Snellen Decimal Snellen ETDRS Letters Low Vision Score logMar
Derived Score Algorithm	Derived Score Algorithm: Details of the algorithm used to calculate a derived score.
Fundoscopic examination of eyes	Fundoscopic examination of eyes: Record of clinical findings on fundoscopy of eyes
Data
Any event	Any event: *
Data
Clinical Description	Clinical Description: Descriptive overview of examination findings Value set: terminology:Snomed?subset=Findings%20in%20posterior%20pole%20of%20eye&language=en-GB
Test Result	Test Result: Details of the funduscopic examination test result for each eye.
Side	Side: Determines the eye on which the test was performed.Matches to DICOM Laterality (0020,0060) attribute. Left eye Right eye
Acquisition details	Acquisition details: Details about acquisition obtained during the examination of eye fundus
Red reflex	Red reflex: True if Red Reflex is present Assumed value: false
Small pupil	Small pupil: True if during the acquisition, pupil diameter is smaller than normal (3,3mm) Assumed value: false
High refraction	High refraction: True if the refraction of the eye exceeds the range from -12D to +15D Assumed value: false
Cataract artifact	Cataract artifact: True if cataract obstructs the visualization of eye fundus Assumed value: false
Shadow artifact	Shadow artifact: True if shadow artifact is present on the border of the image Assumed value: false
Uncooperative patient	Uncooperative patient: True if patient doesn't collaborate during the image acquisition Assumed value: false
Others	Others: Other details identified during the acquisition which may affect the results from reviewing the test
Visualization	Visualization: Details about image quality related to ease of visualization of structures on eye fundus
Quality	Quality: Levels quantifying the quality of each acquisition, based in the ease to visualize the structures on the eye fundus 1: Quality inadequate for any diagnostic purpose 2: Unable to exclude all emergent findings 3: Only able to exclude emergent findings 4: Quality not ideal, but is possible to exclude subtle findings 5: Ideal quality
Comment	Comment: Comment, especially if not fully visualised
Structural description	Structural description: General description of the structures in the eye fundus
Optic Disc	Optic Disc: Description of optic disc
Macula	Macula: Description of macula
Retinal arteries	Retinal arteries: Description of retinal arteries
Retinal veins	Retinal veins: Description of retinal veins
Retinal background	Retinal background: Description of retinal background
Vitreous	Vitreous: Description of vitreous humour
Clinical results	Clinical results: Information of diagnostic interest obtained in the test
Other findings	Other findings: Narrative description of clinical findings not considered in the SLOT
State
Mydriatic used	Mydriatic used: True if mydriatic is used Assumed value: false
Protocol
Method	Method: Method chosen to perform the funduscopic examination Direct Indirect Contact lens biomicroscopy Non-contact lens biomicroscopy Mydriatic retinography Non-mydriatic retinography Angiography
Field angle	Field angle: Describes the optical acceptance angle of the lens used during the test 30º 45º 60º 100º 200º
Attempts	Attempts: Number of attempts before obtaining the acquisition (doesn't compute if test is repeated by a specific recognized technical failure) 1..3
(Subdivision of the retina)	(Subdivision of the retina): Subdivision of the retina identifying eye fundus image locations
(ETRDS fields)	(ETRDS fields): Subdivision of the retina based on Diabetic Retinopathy Study fields Study field 1 Study field 2 Study field 3 Study field 4 Study field 5 Study field 6 Study field 7
Mosaic and peripherals	Mosaic and peripherals: Division of the retina in quadrants + mosaic obtained from the combination of them Mosaic Central Nasal Temporal Superior Inferior
Ophthalmic tomography examination	Ophthalmic tomography examination: Record of clinical findings using optical coherence tomography with ophthalmic purposes.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Clinical description	Clinical description: A term, commonly coded, expressing an overall interpretation of the OCT test. Value set: terminology:Snomed?subset=Findings%20in%20posterior%20pole%20of%20eye&language=en-GB
Test result	Test result: Details of the ophthalmic tomography examination test result for each eye.
Side	Side: Determines the eye on which the test was performed.Matches to DICOM Laterality (0020,0060) attribute. Matches to DICOM Laterality (0020,0060) attribute. Left eye Right eye
Structure analyzed	Structure analyzed: The anatomic structure analyzed in this study. Matches to DICOM Anatomic Region Sequence (0008,2218) attribute. Values permitted are defined by DICOM standard (PS 3.16) inside the table with Context ID 4211 (Ophthalmic OCT Anatomic Structure Imaged). Value set: ac0001
Reference image	Reference image: Information about the image on which the position of OCT acquisitions/slices will be referenced.
Acquisition method	Acquisition method: Ophthalmic photography acquisition method chosen to obtain the reference image. Matches to DICOM Anatomic Region Sequence (0022,0015) attribute. Values permitted are defined by DICOM standard (PS 3.16) inside the table with Context ID 4202 (Ophthalmic Photography Acquisition Device). Value set: ac0003
Image type	Image type: Identifies the fundus imaging modalities obtained from the acquisition of the reference image. Corresponds to the value 4 of the DICOM image type attribute (0008,0008). RF IR AF FA ICGA
Comment	Comment: Narrative description of clinically relevant information identifiable on the reference image.
Reference image	Reference image: Image on which the position of OCT acquisitions/slices will be referenced.
Multiframe properties	Multiframe properties: Information about the slices of the retina obtained by OCT the test.
Number of frames	Number of frames: Number of slices in the study (from 1 to n). Matches to DICOM (0028,0008) attribute. >=1
OCT slice analysis	OCT slice analysis: Analysis of OCT slices considered relevant in the study.
Frame pointer	Frame pointer: Number identifying a frame among the rest in the study, to highlight its relevance on diagnosis. Matches to DICOM (0028,0009) attribute. >=1
OCT slice	OCT slice: Current slice of the retina regarding the image of reference.
Comment	Comment: Narrative description of clinically relevant information identifiable on the specific frames selected from the acquisition.
Reports	Reports: Information about image reports related to the current OCT study.
Report type	Report type: Defines the purpose of the report built from data acquired on the OCT device. OCT overview Retina exam Retina change 3D view Thickness map exam Thickness map change RNFL thickness exam RNFL thickness change RNFL thickness trend Asymmetry analysis RNFL & asymmetry analysis Posterior pole assessment Other
Report content	Report content: Which kind of graphs are included in the report. Reference image Single OCT scan OCT volume scan Retinal thickness profile Retinal thickness map RNFL thickness profile RNFL thickness map Thickness profile change Thickness map change Periapillary RNFL thickness classification Retinal average thickness Asymmetry OD-OS Hemisphere asymmetry RNFL thickness trend
Comment	Comment: Narrative description of clinically relevant information identifiable on the current report.
Report	Report: Report related to the current OCT study.
Retinal thickness	Retinal thickness: Information related to retinal thickness measurement.
Comment	Comment: Narrative description of clinically relevant information identifiable on the analysis of ophthalmic thickness measurements.
Clinical findings	Clinical findings: Every finding considered clinically relevant, found on posterior chamber of the eye. Value set: ac0002
State
Confounding factors	Confounding factors: Patient circumstances which may affect interpretation of the result.
Intraocular pressure	Intraocular pressure: Value of intraocular pressure in mmHg. Matches to DICOM (0022,000B) attribute. 0..90 mmHg (UCUM: mm[Hg])
Axial length of the eye	Axial length of the eye: Axial length of the eye in mm. Matches to DICOM (0022,0030) attribute. >=0 mm
Horizontal field of view	Horizontal field of view: The horizontal field of view in degrees. Matches to DICOM (0022,000C) attribute. Units: ° (UCUM: deg)
Contrast/Bolus	Contrast/Bolus: Information about the contrast agents administered prior to or during the acquisition. Matches to DICOM (0018,0012) attribute.
Contrast/bolus agent	Contrast/bolus agent: Identification of the contrast agent. Matches to DICOM (0018,0012) attribute. Values permitted are defined by DICOM standard (PS 3.16) inside the table with Context ID 4200 (Ophthalmic Imaging Agent). Fluorescein Indocyanine green Rose Bengal Trypan blue Methylene blue
Contrast/bolus volume	Contrast/bolus volume: Volume injected in milliliters of diluted contrast agent. Matches to DICOM (0018,1041) attribute. >=0 ml
Contrast/bolus volume ingredient concentration	Contrast/bolus volume ingredient concentration: Milligrams of active ingredient per milliliter of (diluted) agent. Matches to DICOM (0018,1049) attribute. >=0 mg/ml
Visual field measurement	Visual field measurement: Results of visual field testing / perimetry.
Data
Any event	Any event: Any measurement event.
Data
Clinical Description	Clinical Description: A term, commonly coded, expressing an overall interpretation of the visual field test. Value set: terminology:Snomed?subset=Findings%20of%20visual%20field&language=en-GB
Test Result	Test Result: Details of the visual field test result for each eye.
Eye	Eye: The eye which is being examined. Left eye Right eye
Glaucoma Hemifield Test (GHT)	Glaucoma Hemifield Test (GHT): A coded intepretation of the Glaucoma Hemifield Test (GHT). Outside normal limits Borderline General reduction of sensitivity Abnormally high sensitivity Within normal limits
Visual Field Index	Visual Field Index: Visual Field Index result. Percent
Mean deviation	Mean deviation: The average of deviation in vusual field across all test areas. -30..10 dB
Mean deviation P	Mean deviation P: The P value of the Mean Deviation result. Percent
Pattern Standard deviation	Pattern Standard deviation: Average of non-uniform visual field loss. 0..25 dB
Pattern Standard deviation P	Pattern Standard deviation P: The P value of the Pattern Standard deviation result. Percent
Clinical Interpretation	Clinical Interpretation: The test result expressed as a qualitative term, normally coded.
Image	Image: A multimedia representaion of the visual field test.
Overall Interpretation	Overall Interpretation: A term, commonly coded, expressing an overall interpretation of the visual field test.
Additional Comment	Additional Comment: Any additional narrative comment about the visual field test.
State
Confounding Factors	Confounding Factors: Patient circumstances which may affect interpretation of the result.
Protocol
Perimetry Method	Perimetry Method: The method used to record the perimetry result. Goldman perimetry Dicon Henson Octopus Humphrey Frequency Doubling Perimetry (FDP) FASTPAC automated standard perimetry
Other contributors	Jose Andonegui, Complejo hospitalario de Navarra (CHN), jose.andonegui.navarro@cfnavarra.es; Luis Serrano, Universidad Pública de Navarra (UPNA), lserrano@unavarra.es; Jesús D. Trigo, Universidad Pública de Navarra (UPNA), jesusdaniel.trigo@unavarra.es