TEMPLATE Patient admission into the follow-up service for CG (Patient admission into the follow-up service for CG)

TEMPLATE IDPatient admission into the follow-up service for CG
ConceptPatient admission into the follow-up service for CG
DescriptionTo initiate the follow-up service which monitors the development of CG for those patients presenting a medically stable state of glaucoma.
PurposeTo initiate the follow-up service which monitors the development of CG for those patients presenting a medically stable state of glaucoma.
References
Authorsname: Aitor Eguzkitza; organisation: Universidad Pública de Navarra - Complejo Hospitalario de Navarra; email: aitor.eguzkiza@unavarra.es; date: 2016-07-24
Other Details Languagename: Aitor Eguzkitza; organisation: Universidad Pública de Navarra - Complejo Hospitalario de Navarra; email: aitor.eguzkiza@unavarra.es; date: 2016-07-24
OtherDetails Language Independent{MetaDataSet:Sample Set =Template metadata sample set, Copyright=© openEHR Foundation, Owner=Aitor Eguzkitza, aitor.eguzkiza@unavarra.es, Speciality=Ophthalmology}
Language useden
Citeable Identifier1013.26.133
AllOperationalTemplate [rootArchetypeId=openEHR-EHR-COMPOSITION.encounter.v1, otherContributors=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, tshis=[ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1], code=at0000, itemType=COMPOSITION, level=0, text=Encounter, description=Interaction, contact or care event between a subject of care and healthcare provider(s)., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=COMPOSITION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0], code=at0000, itemType=SECTION, level=1, text=Patients background, description=Clinical information needed from a patient to give context to the responsible physician before register him within a specific service., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-EVALUATION.reason_for_encounter.v1], code=at0000, itemType=EVALUATION, level=2, text=Reason for encounter, description=The reason for initiation of any healthcare encounter or contact by the individual who is the subject of care., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-EVALUATION.reason_for_encounter.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-EVALUATION.reason_for_encounter.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Contact type, description=Identification of the type, or administrative category, of healthcare sought or required by the subject of care., comment=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., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • 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
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-EVALUATION.reason_for_encounter.v1]/data[at0001]/items[at0004], code=at0004, itemType=ELEMENT, level=4, text=Presenting problem, description=Identification of the clinical or social problem motivating the subject of care to seeking healthcare., comment=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., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • 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
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.v1], code=at0000, itemType=OBSERVATION, level=2, text=Story/History, description=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., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=4, text=Any event, description=Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=5, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=6, text=Story, description=Narrative description of the story or clinical history for the subject of care., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.risk_factors_in_glaucoma.v0], code=at0000, itemType=CLUSTER, level=6, text=Risk factors in glaucoma, description=Provides a structure to the registration of the risk factors that could affect the development of glaucoma., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.risk_factors_in_glaucoma.v0]/items[at0001], code=at0001, itemType=ELEMENT, level=7, text=Current medications, description=Idenitifcation of all ocular and systemic medications (e.g., corticosteroids), which the patient is currently taking., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.risk_factors_in_glaucoma.v0]/items[at0002], code=at0002, itemType=ELEMENT, level=7, text=Family history, description=Narrative description of the severity and outcome of glaucoma in family members, including history of visual loss from glaucoma., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.risk_factors_in_glaucoma.v0]/items[at0004], code=at0004, itemType=ELEMENT, level=7, text=Ocular trauma, description=Description of any trauma or contusion occurred on the eye., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.risk_factors_in_glaucoma.v0]/items[at0005], code=at0005, itemType=ELEMENT, level=7, text=Refractive surgery, description=A history of prior glaucoma laser or incisional surgical procedures. Some of those procedures are associated with falsely low IOP measurements., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.risk_factors_in_glaucoma.v0]/items[at0006], code=at0006, itemType=ELEMENT, level=7, text=Chronic/severe diseases, description=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., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.risk_factors_in_glaucoma.v0]/items[at0007], code=at0007, itemType=ELEMENT, level=7, text=Vascular, description=Description of vascular disorders related with glaucoma., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.risk_factors_in_glaucoma.v0]/items[at0008], code=at0008, itemType=ELEMENT, level=7, text=Drug allergies, description=Description of known local or systemic intolerance of the patient to ocular or systemic medications., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.intraocular_pressure.v0], code=at0000, itemType=OBSERVATION, level=2, text=Intraocular pressure, description=The local measurement of intraocular pressure, most commonly using a tonometry device., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.intraocular_pressure.v0]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.intraocular_pressure.v0]/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=4, text=Any event, description=Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.intraocular_pressure.v0]/data[at0001]/events[at0002]/data[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=5, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.intraocular_pressure.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0057], code=at0057, itemType=ELEMENT, level=6, text=Eye examined, description=Identification of the eye under examination., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Left 
  • Right 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.intraocular_pressure.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0042], code=at0042, itemType=ELEMENT, level=6, text=Pressure, description=Measured intraocular pressure., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=0..90 mmHg, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.intraocular_pressure.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0065], code=at0065, itemType=ELEMENT, level=6, text=Applanation time, description=The time taken for a non-contact tonometer to flatten the cornea, used to calculate intraocular pressure., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=>=0 millisec, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.intraocular_pressure.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0061], code=at0061, itemType=ELEMENT, level=6, text=Clinical interpretation, description=Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.intraocular_pressure.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0063], code=at0063, itemType=ELEMENT, level=6, text=Comment, description=Additional narrative about the measurement, not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.intraocular_pressure.v0]/data[at0001]/events[at0002]/state[at0007], code=at0007, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=5, text=State, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.intraocular_pressure.v0]/data[at0001]/events[at0002]/state[at0007]/items[at0074], code=at0074, itemType=ELEMENT, level=6, text=Confounding factors, description=Description of any incidental factors related to the state of the subject which may affect clinical interpretation of the measurement., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.intraocular_pressure.v0]/protocol[at0068], code=at0068, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Protocol, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.intraocular_pressure.v0]/protocol[at0068]/items[at0046], code=at0046, itemType=ELEMENT, level=4, text=Tonometry Method, description=Type of tonometery used to measure intracoular pressure., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Coded Text
    • Goldmann 
    • Perkins 
    • Tono-Pen 
    • Icare (Rebound) 
    • Dynamic Contour 
    • Ocular Response Analyzer 
    • TGDc-01 
    • Non-contact tonometry 
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.visual_acuity.v1], code=at0000, itemType=OBSERVATION, level=2, text=Visual acuity, description=Visual acuity is a measure of the spatial resolution of the visual processing system., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.visual_acuity.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.visual_acuity.v1]/data[at0001]/events[at0134], code=at0134, itemType=POINT_EVENT, level=4, text=Any event, description=Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=POINT_EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.visual_acuity.v1]/data[at0001]/events[at0134]/data[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=5, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.visual_acuity.v1]/data[at0001]/events[at0134]/data[at0003]/items[at0138], code=at0138, itemType=ELEMENT, level=6, text=Test Name, description=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'., comment=Details of the exact correction applied, or where multiple corrections should be captured via 'Refractive Correction'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Coded Text
    • Pinhole visual acuity 
    • Usual corrected visual acuity 
    • Best corrected visual acuity 
    • Unaided visual acuity 
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.visual_acuity.v1]/data[at0001]/events[at0134]/data[at0003]/items[at0039], code=at0039, itemType=ELEMENT, level=6, text=Description, description=An overall narrative description of the visual acuity test result., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.visual_acuity.v1]/data[at0001]/events[at0134]/data[at0003]/items[at0053], code=at0053, itemType=CLUSTER, level=6, text=Per Eye, description=Details of the visual field test result for each eye., comment=null, uncommonOntologyItems=null, occurencesFormal=0..2, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.visual_acuity.v1]/data[at0001]/events[at0134]/data[at0003]/items[at0053]/items[at0007], code=at0007, itemType=ELEMENT, level=7, text=Eye Examined, description=The eye which is being examined., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Left eye 
  • Right eye 
  • Both eyes simultaneously 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.visual_acuity.v1]/data[at0001]/events[at0134]/data[at0003]/items[at0053]/items[at0055], code=at0055, itemType=ELEMENT, level=7, text=Absent Result, description=Details of a test result which could not be recorded., comment=Details of reasons for an absent test result can be described in Additional Comment or Confounding Factors., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Coded Text
    • Not performed 
    • Not completed 
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.visual_acuity.v1]/data[at0001]/events[at0134]/data[at0003]/items[at0053]/items[at0028], code=at0028, itemType=CLUSTER, level=7, text=Notation, description=Details of a visual acuity result recorded using one of the result notation formats., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.visual_acuity.v1]/data[at0001]/events[at0134]/data[at0003]/items[at0053]/items[at0028]/items[at0056], code=at0056, itemType=ELEMENT, level=8, text=Metric Snellen, description=The distance test result, recorded in Snellen format expressed in metres, where 6/6 is regarded as normal., comment=Examples: '6/6, '6/12', '6/5', uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_PROPORTION, bindings=null, values=
  • Ratio
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.visual_acuity.v1]/data[at0001]/events[at0134]/data[at0003]/items[at0053]/items[at0028]/items[at0009], code=at0009, itemType=ELEMENT, level=8, text=US Snellen, description=The distance test result, recorded as Snellen visual acuity expressed in feet, where 20/20 is regarded as normal., comment=Examples: '20/20' , '20/40', '20/18', uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_PROPORTION, bindings=null, values=
  • Ratio
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.visual_acuity.v1]/data[at0001]/events[at0134]/data[at0003]/items[at0053]/items[at0028]/items[at0057], code=at0057, itemType=ELEMENT, level=8, text=Decimal Snellen, description=The distance test result,recorded as Sn ellen visual acuity expressed as a decimal ratio, where 1.0 is regarded as normal., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_PROPORTION, bindings=null, values=
  • Unitary
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.visual_acuity.v1]/data[at0001]/events[at0134]/data[at0003]/items[at0053]/items[at0028]/items[at0011], code=at0011, itemType=ELEMENT, level=8, text=ETDRS Letters, description=Visual acuity expressed using ETDRS Letters format, with a value of 100 regarded as normal., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=1..120, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.visual_acuity.v1]/data[at0001]/events[at0134]/data[at0003]/items[at0053]/items[at0028]/items[at0046], code=at0046, itemType=ELEMENT, level=8, text=logMar, description=The test result, recorded as logMar visual acuity, where a value of 0 is regarded as normal., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=-0.5..2, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.visual_acuity.v1]/data[at0001]/events[at0134]/data[at0003]/items[at0053]/items[at0028]/items[at0015], code=at0015, itemType=ELEMENT, level=8, text=Low Vision Score, description=Graded scale used when patient has low levels of visual acuity., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_ORDINAL, bindings=null, values=
  • 1: NPL - No perception of light 
  • 2: PL - Perception of light 
  • 3: HM - Hand movement 
  • 4: CF - Count fingers 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.visual_acuity.v1]/data[at0001]/events[at0134]/data[at0003]/items[at0053]/items[at0059], code=at0059, itemType=ELEMENT, level=7, text=Letter Termination Adjustment, description=A line termination adjustment score applied to the visual acuity result., comment=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., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=-10..10
Assumed value: 0, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.visual_acuity.v1]/data[at0001]/events[at0134]/data[at0003]/items[at0053]/items[at0010], code=at0010, itemType=ELEMENT, level=7, text=Derived Score, description=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'., comment=Details of the algorithm used and original result format may be recorded under 'Derived Score Methodology'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=>=0, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.visual_acuity.v1]/data[at0001]/events[at0134]/data[at0003]/items[at0053]/items[at0066], code=at0066, itemType=ELEMENT, level=7, text=Interpretation, description=The test result expressed as a qualitative term, normally coded., comment=Example: 'Visual Acuity 20/20' or 'Jaeger 'J2' score'., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.visual_acuity.v1]/data[at0001]/events[at0134]/data[at0003]/items[at0054], code=at0054, itemType=ELEMENT, level=6, text=Overall Interpretation, description=A term, commonly coded, expressing an overall interpretation of the visual acuity test., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.visual_acuity.v1]/data[at0001]/events[at0134]/data[at0003]/items[at0040], code=at0040, itemType=ELEMENT, level=6, text=Comment, description=Any additional narrative comment about the visual acuity test., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.visual_acuity.v1]/data[at0001]/events[at0134]/state[at0041], code=at0041, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=5, text=State, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.visual_acuity.v1]/data[at0001]/events[at0134]/state[at0041]/items[at0112], code=at0112, itemType=ELEMENT, level=6, text=Confounding Factors, description=Patient circumstances which affect interpretation of the result. Often termed 'reliability' in opthalmological documentation., comment=Examples: 'Patient was confused', 'Low light conditions'., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.visual_acuity.v1]/data[at0001]/events[at0134]/state[at0041]/items[at0042], code=at0042, itemType=ELEMENT, level=6, text=Refractive Correction, description=The specific type(s) of refractive correction applied when measuring visual acuity., comment=Examples: 'No correction : unaided', 'Pinhole'., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Spectacles 
  • Contact lenses 
  • Pinhole 
  • Autorefraction 
  • Retinoscopy 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.visual_acuity.v1]/protocol[at0020], code=at0020, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Protocol, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.visual_acuity.v1]/protocol[at0020]/items[at0081], code=at0081, itemType=ELEMENT, level=4, text=Testing Distance, description=The distance at which the subject's visual acuity was measured., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=>=0; >=0; >=0; >=0
Units:
  • ft
  • m
  • cm
  • in
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.visual_acuity.v1]/protocol[at0020]/items[at0023], code=at0023, itemType=ELEMENT, level=4, text=Chart Method, description=The charting method used to measure visual acuity., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • logMar chart 
  • Snellen chart 
  • ETDRS chart 
  • Picture chart 
  • Reduced logMar 
  • Reduced Snellen 
  • Faculty of Ophthalmologists 'N' Score 
  • Jaeger 'J' Score 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.visual_acuity.v1]/protocol[at0020]/items[at0021], code=at0021, itemType=ELEMENT, level=4, text=Chart Optotype, description=The style of chart optotype used to assess visual acuity., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Letter 
  • Orientation 
  • Picture 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.visual_acuity.v1]/protocol[at0020]/items[at0022], code=at0022, itemType=ELEMENT, level=4, text=Chart Scoring Algorithm, description=The alogrithm used to determine the score., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Single letter 
  • Whole line 
  • Last line single letter 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.visual_acuity.v1]/protocol[at0020]/items[at0092], code=at0092, itemType=ELEMENT, level=4, text=Derived Score Original Notation, description=The original visual acuity result notation from which the Derived Score was calculated., comment=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., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • US Snellen 
  • Metric Snellen 
  • Decimal Snellen 
  • ETDRS Letters 
  • Low Vision Score 
  • logMar 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.visual_acuity.v1]/protocol[at0020]/items[at0117], code=at0117, itemType=ELEMENT, level=4, text=Derived Score Algorithm, description=Details of the algorithm used to calculate a derived score., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1], code=at0000, itemType=OBSERVATION, level=2, text=Fundoscopic examination of eyes, description=Record of clinical findings on fundoscopy of eyes, comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=4, text=Any event, description=*, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/data[at0001]/events[at0002]/data[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=5, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0008], code=at0008, itemType=ELEMENT, level=6, text=Clinical Description, description=Descriptive overview of examination findings, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= Value set: external, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0136], code=at0136, itemType=CLUSTER, level=6, text=Test Result, description=Details of the funduscopic examination test result for each eye., comment=null, uncommonOntologyItems=null, occurencesFormal=0..2, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0136]/items[at0004], code=at0004, itemType=ELEMENT, level=7, text=Side, description=Determines the eye on which the test was performed.Matches to DICOM Laterality (0020,0060) attribute., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Left eye 
  • Right eye 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0136]/items[at0051], code=at0051, itemType=CLUSTER, level=7, text=Acquisition details, description=Details about acquisition obtained during the examination of eye fundus, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0136]/items[at0051]/items[at0053], code=at0053, itemType=ELEMENT, level=8, text=Red reflex, description=True if Red Reflex is present, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=Assumed value: false, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0136]/items[at0051]/items[at0054], code=at0054, itemType=ELEMENT, level=8, text=Small pupil, description=True if during the acquisition, pupil diameter is smaller than normal (3,3mm), comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=Assumed value: false, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0136]/items[at0051]/items[at0123], code=at0123, itemType=ELEMENT, level=8, text=High refraction, description=True if the refraction of the eye exceeds the range from -12D to +15D, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=Assumed value: false, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0136]/items[at0051]/items[at0055], code=at0055, itemType=ELEMENT, level=8, text=Cataract artifact, description=True if cataract obstructs the visualization of eye fundus, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=Assumed value: false, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0136]/items[at0051]/items[at0056], code=at0056, itemType=ELEMENT, level=8, text=Shadow artifact, description=True if shadow artifact is present on the border of the image, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=Assumed value: false, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0136]/items[at0051]/items[at0124], code=at0124, itemType=ELEMENT, level=8, text=Uncooperative patient, description=True if patient doesn't collaborate during the image acquisition, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=Assumed value: false, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0136]/items[at0051]/items[at0128], code=at0128, itemType=ELEMENT, level=8, text=Others, description=Other details identified during the acquisition which may affect the results from reviewing the test, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0136]/items[at0051]/items[at0057], code=at0057, itemType=CLUSTER, level=8, text=Visualization, description=Details about image quality related to ease of visualization of structures on eye fundus, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0136]/items[at0051]/items[at0057]/items[at0059], code=at0059, itemType=ELEMENT, level=9, text=Quality, description=Levels quantifying the quality of each acquisition, based in the ease to visualize the structures on the eye fundus, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_ORDINAL, bindings=null, values=
  • 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 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0136]/items[at0051]/items[at0057]/items[at0058], code=at0058, itemType=ELEMENT, level=9, text=Comment, description=Comment, especially if not fully visualised, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0136]/items[at0065], code=at0065, itemType=CLUSTER, level=7, text=Structural description, description=General description of the structures in the eye fundus, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0136]/items[at0065]/items[at0091], code=at0091, itemType=ELEMENT, level=8, text=Optic Disc, description=Description of optic disc, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0136]/items[at0065]/items[at0090], code=at0090, itemType=ELEMENT, level=8, text=Macula, description=Description of macula, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0136]/items[at0065]/items[at0092], code=at0092, itemType=ELEMENT, level=8, text=Retinal arteries, description=Description of retinal arteries, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0136]/items[at0065]/items[at0093], code=at0093, itemType=ELEMENT, level=8, text=Retinal veins, description=Description of retinal veins, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0136]/items[at0065]/items[at0094], code=at0094, itemType=ELEMENT, level=8, text=Retinal background, description=Description of retinal background, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0136]/items[at0065]/items[at0098], code=at0098, itemType=ELEMENT, level=8, text=Vitreous, description=Description of vitreous humour, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0136]/items[at0066], code=at0066, itemType=CLUSTER, level=7, text=Clinical results, description=Information of diagnostic interest obtained in the test, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0136]/items[at0066]/items[at0126], code=at0126, itemType=ELEMENT, level=8, text=Other findings, description=Narrative description of clinical findings not considered in the SLOT, comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/data[at0001]/events[at0002]/state[at0013], code=at0013, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=5, text=State, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/data[at0001]/events[at0002]/state[at0013]/items[at0014], code=at0014, itemType=ELEMENT, level=6, text=Mydriatic used, description=True if mydriatic is used, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=Assumed value: false, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/protocol[at0028], code=at0028, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Protocol, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/protocol[at0028]/items[at0029], code=at0029, itemType=ELEMENT, level=4, text=Method, description=Method chosen to perform the funduscopic examination, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Direct 
  • Indirect 
  • Contact lens biomicroscopy 
  • Non-contact lens biomicroscopy 
  • Mydriatic retinography 
  • Non-mydriatic retinography 
  • Angiography 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/protocol[at0028]/items[at0067], code=at0067, itemType=ELEMENT, level=4, text=Field angle, description=Describes the optical acceptance angle of the lens used during the test, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • 30º 
  • 45º 
  • 60º 
  • 100º 
  • 200º 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/protocol[at0028]/items[at0072], code=at0072, itemType=ELEMENT, level=4, text=Attempts, description=Number of attempts before obtaining the acquisition (doesn't compute if test is repeated by a specific recognized technical failure), comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=1..3, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/protocol[at0028]/items[at0073], code=at0073, itemType=CLUSTER, level=4, text=(Subdivision of the retina), description=Subdivision of the retina identifying eye fundus image locations, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/protocol[at0028]/items[at0073]/items[at0074], code=at0074, itemType=ELEMENT, level=5, text=(ETRDS fields), description=Subdivision of the retina based on Diabetic Retinopathy Study fields, comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Study field 1 
  • Study field 2 
  • Study field 3 
  • Study field 4 
  • Study field 5 
  • Study field 6 
  • Study field 7 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/protocol[at0028]/items[at0073]/items[at0082], code=at0082, itemType=ELEMENT, level=5, text=Mosaic and peripherals, description=Division of the retina in quadrants + mosaic obtained from the combination of them, comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Mosaic 
  • Central 
  • Nasal 
  • Temporal 
  • Superior 
  • Inferior 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.ophthalmic_tomography_examination.v0], code=at0000, itemType=OBSERVATION, level=2, text=Ophthalmic tomography examination, description=Record of clinical findings using optical coherence tomography with ophthalmic purposes., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.ophthalmic_tomography_examination.v0]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.ophthalmic_tomography_examination.v0]/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=4, text=Any event, description=Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.ophthalmic_tomography_examination.v0]/data[at0001]/events[at0002]/data[at0008], code=at0008, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=5, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.ophthalmic_tomography_examination.v0]/data[at0001]/events[at0002]/data[at0008]/items[at0038], code=at0038, itemType=ELEMENT, level=6, text=Clinical description, description=A term, commonly coded, expressing an overall interpretation of the OCT test., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= Value set: external, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.ophthalmic_tomography_examination.v0]/data[at0001]/events[at0002]/data[at0008]/items[at0039], code=at0039, itemType=CLUSTER, level=6, text=Test result, description=Details of the ophthalmic tomography examination test result for each eye., comment=null, uncommonOntologyItems=null, occurencesFormal=0..2, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.ophthalmic_tomography_examination.v0]/data[at0001]/events[at0002]/data[at0008]/items[at0039]/items[at0040], code=at0040, itemType=ELEMENT, level=7, text=Side, description=Determines the eye on which the test was performed.Matches to DICOM Laterality (0020,0060) attribute., comment=Matches to DICOM Laterality (0020,0060) attribute., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Left eye 
  • Right eye 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.ophthalmic_tomography_examination.v0]/data[at0001]/events[at0002]/data[at0008]/items[at0039]/items[at0045], code=at0045, itemType=ELEMENT, level=7, text=Structure analyzed, description=The anatomic structure analyzed in this study., comment=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)., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= Value set: ac0001, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.ophthalmic_tomography_examination.v0]/data[at0001]/events[at0002]/data[at0008]/items[at0039]/items[at0090], code=at0090, itemType=CLUSTER, level=7, text=Reference image, description=Information about the image on which the position of OCT acquisitions/slices will be referenced., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.ophthalmic_tomography_examination.v0]/data[at0001]/events[at0002]/data[at0008]/items[at0039]/items[at0090]/items[at0091], code=at0091, itemType=ELEMENT, level=8, text=Acquisition method, description=Ophthalmic photography acquisition method chosen to obtain the reference image., comment=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)., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= Value set: ac0003, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.ophthalmic_tomography_examination.v0]/data[at0001]/events[at0002]/data[at0008]/items[at0039]/items[at0090]/items[at0046], code=at0046, itemType=ELEMENT, level=8, text=Image type, description=Identifies the fundus imaging modalities obtained from the acquisition of the reference image., comment=Corresponds to the value 4 of the DICOM image type attribute (0008,0008)., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • RF 
  • IR 
  • AF 
  • FA 
  • ICGA 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.ophthalmic_tomography_examination.v0]/data[at0001]/events[at0002]/data[at0008]/items[at0039]/items[at0090]/items[at0093], code=at0093, itemType=ELEMENT, level=8, text=Comment, description=Narrative description of clinically relevant information identifiable on the reference image., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.ophthalmic_tomography_examination.v0]/data[at0001]/events[at0002]/data[at0008]/items[at0039]/items[at0090]/items[at0204], code=at0204, itemType=ELEMENT, level=8, text=Reference image, description=Image on which the position of OCT acquisitions/slices will be referenced., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_MULTIMEDIA, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.ophthalmic_tomography_examination.v0]/data[at0001]/events[at0002]/data[at0008]/items[at0039]/items[at0047], code=at0047, itemType=CLUSTER, level=7, text=Multiframe properties, description=Information about the slices of the retina obtained by OCT the test., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.ophthalmic_tomography_examination.v0]/data[at0001]/events[at0002]/data[at0008]/items[at0039]/items[at0047]/items[at0048], code=at0048, itemType=ELEMENT, level=8, text=Number of frames, description=Number of slices in the study (from 1 to n)., comment=Matches to DICOM (0028,0008) attribute., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=>=1, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.ophthalmic_tomography_examination.v0]/data[at0001]/events[at0002]/data[at0008]/items[at0039]/items[at0047]/items[at0277], code=at0277, itemType=CLUSTER, level=8, text=OCT slice analysis, description=Analysis of OCT slices considered relevant in the study., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.ophthalmic_tomography_examination.v0]/data[at0001]/events[at0002]/data[at0008]/items[at0039]/items[at0047]/items[at0277]/items[at0049], code=at0049, itemType=ELEMENT, level=9, text=Frame pointer, description=Number identifying a frame among the rest in the study, to highlight its relevance on diagnosis., comment=Matches to DICOM (0028,0009) attribute., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=>=1, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.ophthalmic_tomography_examination.v0]/data[at0001]/events[at0002]/data[at0008]/items[at0039]/items[at0047]/items[at0277]/items[at0054], code=at0054, itemType=ELEMENT, level=9, text=OCT slice, description=Current slice of the retina regarding the image of reference., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_MULTIMEDIA, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.ophthalmic_tomography_examination.v0]/data[at0001]/events[at0002]/data[at0008]/items[at0039]/items[at0047]/items[at0270], code=at0270, itemType=ELEMENT, level=8, text=Comment, description=Narrative description of clinically relevant information identifiable on the specific frames selected from the acquisition., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.ophthalmic_tomography_examination.v0]/data[at0001]/events[at0002]/data[at0008]/items[at0039]/items[at0055], code=at0055, itemType=CLUSTER, level=7, text=Reports, description=Information about image reports related to the current OCT study., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.ophthalmic_tomography_examination.v0]/data[at0001]/events[at0002]/data[at0008]/items[at0039]/items[at0055]/items[at0056], code=at0056, itemType=ELEMENT, level=8, text=Report type, description=Defines the purpose of the report built from data acquired on the OCT device., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • 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 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.ophthalmic_tomography_examination.v0]/data[at0001]/events[at0002]/data[at0008]/items[at0039]/items[at0055]/items[at0253], code=at0253, itemType=ELEMENT, level=8, text=Report content, description=Which kind of graphs are included in the report., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • 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 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.ophthalmic_tomography_examination.v0]/data[at0001]/events[at0002]/data[at0008]/items[at0039]/items[at0055]/items[at0269], code=at0269, itemType=ELEMENT, level=8, text=Comment, description=Narrative description of clinically relevant information identifiable on the current report., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.ophthalmic_tomography_examination.v0]/data[at0001]/events[at0002]/data[at0008]/items[at0039]/items[at0055]/items[at0088], code=at0088, itemType=ELEMENT, level=8, text=Report, description=Report related to the current OCT study., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_MULTIMEDIA, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.ophthalmic_tomography_examination.v0]/data[at0001]/events[at0002]/data[at0008]/items[at0039]/items[at0186], code=at0186, itemType=CLUSTER, level=7, text=Retinal thickness, description=Information related to retinal thickness measurement., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.ophthalmic_tomography_examination.v0]/data[at0001]/events[at0002]/data[at0008]/items[at0039]/items[at0186]/items[at0272], code=at0272, itemType=ELEMENT, level=8, text=Comment, description=Narrative description of clinically relevant information identifiable on the analysis of ophthalmic thickness measurements., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.ophthalmic_tomography_examination.v0]/data[at0001]/events[at0002]/data[at0008]/items[at0039]/items[at0271], code=at0271, itemType=ELEMENT, level=7, text=Clinical findings, description=Every finding considered clinically relevant, found on posterior chamber of the eye., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= Value set: ac0002, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.ophthalmic_tomography_examination.v0]/data[at0001]/events[at0002]/state[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=5, text=State, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.ophthalmic_tomography_examination.v0]/data[at0001]/events[at0002]/state[at0003]/items[at0115], code=at0115, itemType=ELEMENT, level=6, text=Confounding factors, description=Patient circumstances which may affect interpretation of the result., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.ophthalmic_tomography_examination.v0]/data[at0001]/events[at0002]/state[at0003]/items[at0123], code=at0123, itemType=ELEMENT, level=6, text=Intraocular pressure, description=Value of intraocular pressure in mmHg., comment=Matches to DICOM (0022,000B) attribute., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=0..90 mmHg, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.ophthalmic_tomography_examination.v0]/data[at0001]/events[at0002]/state[at0003]/items[at0124], code=at0124, itemType=ELEMENT, level=6, text=Axial length of the eye, description=Axial length of the eye in mm., comment=Matches to DICOM (0022,0030) attribute., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=>=0 mm, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.ophthalmic_tomography_examination.v0]/data[at0001]/events[at0002]/state[at0003]/items[at0125], code=at0125, itemType=ELEMENT, level=6, text=Horizontal field of view, description=The horizontal field of view in degrees., comment=Matches to DICOM (0022,000C) attribute., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=Units: °, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.ophthalmic_tomography_examination.v0]/data[at0001]/events[at0002]/state[at0003]/items[at0130], code=at0130, itemType=CLUSTER, level=6, text=Contrast/Bolus, description=Information about the contrast agents administered prior to or during the acquisition., comment=Matches to DICOM (0018,0012) attribute., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.ophthalmic_tomography_examination.v0]/data[at0001]/events[at0002]/state[at0003]/items[at0130]/items[at0131], code=at0131, itemType=ELEMENT, level=7, text=Contrast/bolus agent, description=Identification of the contrast agent., comment=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)., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Fluorescein 
  • Indocyanine green 
  • Rose Bengal 
  • Trypan blue 
  • Methylene blue 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.ophthalmic_tomography_examination.v0]/data[at0001]/events[at0002]/state[at0003]/items[at0130]/items[at0132], code=at0132, itemType=ELEMENT, level=7, text=Contrast/bolus volume, description=Volume injected in milliliters of diluted contrast agent., comment=Matches to DICOM (0018,1041) attribute., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=>=0 ml, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.ophthalmic_tomography_examination.v0]/data[at0001]/events[at0002]/state[at0003]/items[at0130]/items[at0133], code=at0133, itemType=ELEMENT, level=7, text=Contrast/bolus volume ingredient concentration, description=Milligrams of active ingredient per milliliter of (diluted) agent., comment=Matches to DICOM (0018,1049) attribute., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=>=0 mg/ml, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.visual_field_measurement.v1], code=at0000, itemType=OBSERVATION, level=2, text=Visual field measurement, description=Results of visual field testing / perimetry., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.visual_field_measurement.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.visual_field_measurement.v1]/data[at0001]/events[at0002], code=at0002, itemType=POINT_EVENT, level=4, text=Any event, description=Any measurement event., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=POINT_EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.visual_field_measurement.v1]/data[at0001]/events[at0002]/data[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=5, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.visual_field_measurement.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0005], code=at0005, itemType=ELEMENT, level=6, text=Clinical Description, description=A term, commonly coded, expressing an overall interpretation of the visual field test., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= Value set: external, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.visual_field_measurement.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0007], code=at0007, itemType=CLUSTER, level=6, text=Test Result, description=Details of the visual field test result for each eye., comment=null, uncommonOntologyItems=null, occurencesFormal=0..2, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.visual_field_measurement.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0007]/items[at0008], code=at0008, itemType=ELEMENT, level=7, text=Eye, description=The eye which is being examined., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Left eye 
  • Right eye 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.visual_field_measurement.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0007]/items[at0027], code=at0027, itemType=ELEMENT, level=7, text=Glaucoma Hemifield Test (GHT), description=A coded intepretation of the Glaucoma Hemifield Test (GHT)., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Outside normal limits 
  • Borderline 
  • General reduction of sensitivity 
  • Abnormally high sensitivity 
  • Within normal limits 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.visual_field_measurement.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0007]/items[at0037], code=at0037, itemType=ELEMENT, level=7, text=Visual Field Index, description=Visual Field Index result., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_PROPORTION, bindings=null, values=
  • Percent
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.visual_field_measurement.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0007]/items[at0034], code=at0034, itemType=ELEMENT, level=7, text=Mean deviation, description=The average of deviation in vusual field across all test areas., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=-30..10 dB, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.visual_field_measurement.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0007]/items[at0038], code=at0038, itemType=ELEMENT, level=7, text=Mean deviation P, description=The P value of the Mean Deviation result., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_PROPORTION, bindings=null, values=
  • Percent
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.visual_field_measurement.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0007]/items[at0035], code=at0035, itemType=ELEMENT, level=7, text=Pattern Standard deviation, description=Average of non-uniform visual field loss., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=0..25 dB, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.visual_field_measurement.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0007]/items[at0039], code=at0039, itemType=ELEMENT, level=7, text=Pattern Standard deviation P, description=The P value of the Pattern Standard deviation result., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_PROPORTION, bindings=null, values=
  • Percent
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.visual_field_measurement.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0007]/items[at0009], code=at0009, itemType=ELEMENT, level=7, text=Clinical Interpretation, description=The test result expressed as a qualitative term, normally coded., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.visual_field_measurement.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0007]/items[at0006], code=at0006, itemType=ELEMENT, level=7, text=Image, description=A multimedia representaion of the visual field test., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_MULTIMEDIA, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.visual_field_measurement.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0025], code=at0025, itemType=ELEMENT, level=6, text=Overall Interpretation, description=A term, commonly coded, expressing an overall interpretation of the visual field test., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.visual_field_measurement.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0024], code=at0024, itemType=ELEMENT, level=6, text=Additional Comment, description=Any additional narrative comment about the visual field test., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.visual_field_measurement.v1]/data[at0001]/events[at0002]/state[at0022], code=at0022, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=5, text=State, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.visual_field_measurement.v1]/data[at0001]/events[at0002]/state[at0022]/items[at0023], code=at0023, itemType=ELEMENT, level=6, text=Confounding Factors, description=Patient circumstances which may affect interpretation of the result., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.visual_field_measurement.v1]/protocol[at0010], code=at0010, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Protocol, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.visual_field_measurement.v1]/protocol[at0010]/items[at0011], code=at0011, itemType=ELEMENT, level=4, text=Perimetry Method, description=The method used to record the perimetry result., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Goldman perimetry 
  • Dicon 
  • Henson 
  • Octopus 
  • Humphrey 
  • Frequency Doubling Perimetry (FDP) 
  • FASTPAC automated standard perimetry 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0], code=at0000, itemType=SECTION, level=1, text=Clinical decision, description=Defines the process of making a decision about the diagnosis of a specific disease., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.clinical_synopsis.v1], code=at0000, itemType=EVALUATION, level=2, text=Clinical Synopsis, description=Narrative summary or overview about a patient, specifically from the perspective of a healthcare provider, and with or without associated interpretations., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.clinical_synopsis.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.clinical_synopsis.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Synopsis, description=The summary, assessment, conclusions or evaluation of the clinical findings., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1], code=at0000, itemType=EVALUATION, level=2, text=Problem/Diagnosis, description=Details about a single identified health condition, injury, disability or any other issue which impacts on the physical, mental and/or social well-being of an individual., comment=Clear delineation between the scope of a problem versus a diagnosis is not easy to achieve in practice. For the purposes of clinical documentation with this archetype, problem and diagnosis are regarded as a continuum, with increasing levels of detail and supportive evidence usually providing weight towards the label of 'diagnosis'., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Problem/Diagnosis name, description=Identification of the problem or diagnosis, by name., comment=Coding of the name of the problem or diagnosis with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0009], code=at0009, itemType=ELEMENT, level=4, text=Clinical description, description=Narrative description about the problem or diagnosis., comment=Use to provide background and context, including evolution, episodes or exacerbations, progress and any other relevant details, about the problem or diagnosis., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0012], code=at0012, itemType=ELEMENT, level=4, text=Body site, description=Identification of a simple body site for the location of the problem or diagnosis., comment=Coding of the name of the anatomical location with a terminology is preferred, where possible. Use this data element to record precoordinated anatomical locations. If the requirements for recording the anatomical location are determined at run-time by the application or require more complex modelling such as relative locations then use the CLUSTER.anatomical_location or CLUSTER.relative_location within the 'Structured anatomical location' SLOT in this archetype. Occurrences for this data element are unbounded to allow for clinical scenarios such as describing a rash in multiple locations but where all of the other attributes are identical. If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0077], code=at0077, itemType=ELEMENT, level=4, text=Date/time of onset, description=Estimated or actual date/time that signs or symptoms of the problem/diagnosis were first observed., comment=Data captured/imported as "Age at onset" should be converted to a date using the subject's date of birth., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.classification_glaucoma.v0], code=at0000, itemType=CLUSTER, level=4, text=Classification of glaucoma, description=Classifies the type of glaucoma of patients and provides key clinical findings to support the diagnostic decision., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.classification_glaucoma.v0]/items[at0002], code=at0002, itemType=ELEMENT, level=5, text=Classification, description=Clinical grade determined for glaucoma., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= Value set: ac0002, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.classification_glaucoma.v0]/items[at0024], code=at0024, itemType=ELEMENT, level=5, text=Progressive disease, description=It is set to true whenever findings are made concerning any glaucomatous activity or progression that could lead to visual loss in the future. Conversely, if it is set to false, it means that the patient is medically stable for now, since the ophthalmologist did not identify clear signs of disease progression., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=Assumed value: true, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.classification_glaucoma.v0]/items[openEHR-EHR-CLUSTER.findings_glaucoma.v0], code=at0000, itemType=CLUSTER, level=5, text=Findings in glaucoma, description=Clinical findings on eye related with the diagnose of glaucoma., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.classification_glaucoma.v0]/items[openEHR-EHR-CLUSTER.findings_glaucoma.v0]/items[at0014], code=at0014, itemType=CLUSTER, level=6, text=Anterior segment, description=Document the insertion level of the iris root before and during compression dynamic gonioscopy., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.classification_glaucoma.v0]/items[openEHR-EHR-CLUSTER.findings_glaucoma.v0]/items[at0014]/items[at0015], code=at0015, itemType=ELEMENT, level=7, text=Iris root, description=Insertion of iris root., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Anterior to Schwalbe 
  • Behind Schwalbe 
  • Scleral Spur 
  • Behind Scleral Spur 
  • Cillary Band 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.classification_glaucoma.v0]/items[openEHR-EHR-CLUSTER.findings_glaucoma.v0]/items[at0014]/items[at0021], code=at0021, itemType=ELEMENT, level=7, text=Angle recess, description=Angular width of angle recess., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=10..40 °, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.classification_glaucoma.v0]/items[openEHR-EHR-CLUSTER.findings_glaucoma.v0]/items[at0014]/items[at0022], code=at0022, itemType=ELEMENT, level=7, text=Peripheral iris, description=Configuration of the peripheral iris., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Steep 
  • Regular 
  • Queer 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.classification_glaucoma.v0]/items[openEHR-EHR-CLUSTER.findings_glaucoma.v0]/items[at0014]/items[at0026], code=at0026, itemType=ELEMENT, level=7, text=Slit thickness, description=Ratio of slit thickness of the cornea to the depth of the anterior chamber., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Angle closed 
  • Angle closure likely (angle 10°) 
  • Angle clossure possible (angle 20°) 
  • Angle closure unlikely 
  • Angle closure very unlikely 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.classification_glaucoma.v0]/items[openEHR-EHR-CLUSTER.findings_glaucoma.v0]/items[at0002], code=at0002, itemType=CLUSTER, level=6, text=Retinal nerve fiber layer, description=Findings on RNFL supporting the current study of glaucoma., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.classification_glaucoma.v0]/items[openEHR-EHR-CLUSTER.findings_glaucoma.v0]/items[at0002]/items[at0006], code=at0006, itemType=ELEMENT, level=7, text=Parapapillary atrophy, description=Narrative description of diffuse or localized abnormalities of the peripapillary retinal nerve fiber layer, especially at the inferior or superior poles., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.classification_glaucoma.v0]/items[openEHR-EHR-CLUSTER.findings_glaucoma.v0]/items[at0002]/items[at0040], code=at0040, itemType=ELEMENT, level=7, text=RNFL thinning, description=Identification of retinal nerve fiber layer thinning defects., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Diffuse thinning 
  • Localized defects 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.classification_glaucoma.v0]/items[openEHR-EHR-CLUSTER.findings_glaucoma.v0]/items[at0002]/items[at0048], code=at0048, itemType=ELEMENT, level=7, text=Hemorrhages RNFL, description=Identification of hemorrhages on the peripapillary retinal nerve fiber layer., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.classification_glaucoma.v0]/items[openEHR-EHR-CLUSTER.findings_glaucoma.v0]/items[at0004], code=at0004, itemType=CLUSTER, level=6, text=Optic disc, description=Findings on optic disc supporting the current study of glaucoma., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.classification_glaucoma.v0]/items[openEHR-EHR-CLUSTER.findings_glaucoma.v0]/items[at0004]/items[at0032], code=at0032, itemType=ELEMENT, level=7, text=Rim loss pattern, description=Description of the pattern of neuroretinal rim loss. It may take the form of diffuse thinning, focal narrowing, or localized notching of the optic disc rim, especially at the inferior or superior poles., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.classification_glaucoma.v0]/items[openEHR-EHR-CLUSTER.findings_glaucoma.v0]/items[at0004]/items[at0049], code=at0049, itemType=ELEMENT, level=7, text=Asymmetric rim, description=Optic disc neural rim asymmetry of the two eyes consistent with loss of neural tissue., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.classification_glaucoma.v0]/items[openEHR-EHR-CLUSTER.findings_glaucoma.v0]/items[at0004]/items[at0042], code=at0042, itemType=ELEMENT, level=7, text=Cupping, description=Identification of progressive thinning of the neuroretinal rim with an associated increase in cupping of the optic disc., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.classification_glaucoma.v0]/items[openEHR-EHR-CLUSTER.findings_glaucoma.v0]/items[at0004]/items[at0043], code=at0043, itemType=ELEMENT, level=7, text=Vessels, description=Description of any positional changes of the vessels at the optic disc with bending, bayoneting or baring of circumlinear vessels., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.classification_glaucoma.v0]/items[openEHR-EHR-CLUSTER.findings_glaucoma.v0]/items[at0004]/items[at0005], code=at0005, itemType=ELEMENT, level=7, text=Hemorrhages optic disc, description=Identification of hemorrhages on or bordering the optic disc., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=Assumed value: false, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.classification_glaucoma.v0]/items[openEHR-EHR-CLUSTER.findings_glaucoma.v0]/items[at0004]/items[at0047], code=at0047, itemType=ELEMENT, level=7, text=Optic nerve head, description=Description of features in optic nerve head (ONH)., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.classification_glaucoma.v0]/items[openEHR-EHR-CLUSTER.findings_glaucoma.v0]/items[at0009], code=at0009, itemType=CLUSTER, level=6, text=Visual field, description=Findings on visual field supporting the current study of glaucoma., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.classification_glaucoma.v0]/items[openEHR-EHR-CLUSTER.findings_glaucoma.v0]/items[at0009]/items[at0008], code=at0008, itemType=ELEMENT, level=7, text=Visual field defects, description=Visual field damage consistent with retinal nerve fiber layer damage., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Early glaucomatous loss 
  • Moderate glaucomatous loss 
  • Advanced glaucomatous loss 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.classification_glaucoma.v0]/items[openEHR-EHR-CLUSTER.findings_glaucoma.v0]/items[at0009]/items[at0013], code=at0013, itemType=ELEMENT, level=7, text=Asymmetric loss, description=Visual field loss in one hemifield that is different from the other hemifield, i.e., across the horizontal midline (in early/moderate cases)., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=Assumed value: false, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.classification_glaucoma.v0]/items[openEHR-EHR-CLUSTER.findings_glaucoma.v0]/items[at0044], code=at0044, itemType=ELEMENT, level=6, text=Comments, description=Narrative description of overall findings, inlcuding those not considered above., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.classification_glaucoma.v0]/items[at0003], code=at0003, itemType=ELEMENT, level=5, text=Comments, description=Additional comments that clarify the diagnostic decision made., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.contraindication.v0], code=at0000, itemType=EVALUATION, level=2, text=Contraindication, description=Identification of a treatment, test or procedure which should not be provided to the subject of care, for clinical reasons., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.contraindication.v0]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.contraindication.v0]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Contraindication, description=Identification of a contraindication to a treatment, test or procedure, including a class of medications or vaccines., comment=Coding of the identified 'Contraindication' with a terminology is desirable, where possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.contraindication.v0]/data[at0001]/items[at0003], code=at0003, itemType=ELEMENT, level=4, text=Rationale, description=Description of evidence or rationale for the contraindication., comment=Please note: an optional URI link to evidence within the health record is also permitted using Reference Model attributes. As this URI link may not be accessible from a message or by receiving clinical system it is desirable that a narrative description of the rationale should be explicitly stated., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.contraindication.v0]/protocol[at0006], code=at0006, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Protocol, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.contraindication.v0]/protocol[at0006]/items[at0004], code=at0004, itemType=ELEMENT, level=4, text=Last updated, description=The date this contraindication was last updated., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.contraindication.v0]/protocol[at0006]/items[at0009], code=at0009, itemType=ELEMENT, level=4, text=Review date, description=Date when due for review by a clinician., comment=In some circumstances, contraindications are not intended to be indefinite or lifelong, and this contraindication should be reconsidered in the context of changing clinical circumstances. For example: if a family member is no longer taking immunosuppressive therapy, then live vaccines could safely be administered to the subject of care again and the contraindication is effectively obsolete., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.recommendation.v1], code=at0000, itemType=EVALUATION, level=2, text=Recommendation, description=A suggestion, advice or proposal for clinical management., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.recommendation.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.recommendation.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Recommendation, description=Narrative description of the recommendation., comment=May be coded, using a terminology, if required., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= Value set: external, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.recommendation.v1]/data[at0001]/items[at0003], code=at0003, itemType=ELEMENT, level=4, text=Rationale, description=Justifications for the recommendation., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Glaucoma stable
  • Visual field loss
  • Progressive excavation of the papilla
  • IOP unstable
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_admittance.v0], code=at0000, itemType=SECTION, level=1, text=Patient's admittance, description=Decision-making regarding to inscribe or not a patient into a screening process., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_admittance.v0]/items[openEHR-EHR-EVALUATION.long_term_process_enrollment.v0], code=at0000, itemType=EVALUATION, level=2, text=Enrollment in a long-term healthcare process, description=Manages the enrollment of patients in a specific long-term healthcare process., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_admittance.v0]/items[openEHR-EHR-EVALUATION.long_term_process_enrollment.v0]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_admittance.v0]/items[openEHR-EHR-EVALUATION.long_term_process_enrollment.v0]/data[at0001]/items[at0004], code=at0004, itemType=ELEMENT, level=4, text=Healthcare process, description=Identification of the healthcare process about which the enrollment of a specific patient is discussed., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_admittance.v0]/items[openEHR-EHR-EVALUATION.long_term_process_enrollment.v0]/data[at0001]/items[at0005], code=at0005, itemType=ELEMENT, level=4, text=Description, description=Narrative description about the healthcare service to which the patient has been proposed for admittance., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_admittance.v0]/items[openEHR-EHR-EVALUATION.long_term_process_enrollment.v0]/data[at0001]/items[at0012], code=at0012, itemType=ELEMENT, level=4, text=Admittance, description=If true, the patient meets the criteria required to be inscribed in the healthcare process., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=Assumed value: true, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_admittance.v0]/items[openEHR-EHR-EVALUATION.long_term_process_enrollment.v0]/data[at0001]/items[at0010], code=at0010, itemType=ELEMENT, level=4, text=Criteria, description=Narrative description of criteria considered to make a decision with regard to patient's admittance into the healthcare process., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_admittance.v0]/items[openEHR-EHR-EVALUATION.long_term_process_enrollment.v0]/protocol[at0002], code=at0002, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Protocol, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_admittance.v0]/items[openEHR-EHR-EVALUATION.long_term_process_enrollment.v0]/protocol[at0002]/items[at0003], code=at0003, itemType=ELEMENT, level=4, text=Date decision, description=Date at which decision was made about the enrollment or exclusion of the patient with regard to the healthcare process., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_admittance.v0]/items[openEHR-EHR-EVALUATION.long_term_process_enrollment.v0]/protocol[at0002]/items[at0011], code=at0011, itemType=ELEMENT, level=4, text=Decision review, description=Next revision date scheduled for the current decision of enrollment., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE, bindings=null, values=, extendedValues=null]], templateType=normal]