TEMPLATE Heart Failure Clinic First Visit Summary (Heart Failure Clinic First Visit Summary)

TEMPLATE IDHeart Failure Clinic First Visit Summary
ConceptHeart Failure Clinic First Visit Summary
DescriptionRepresents a clinically-orientated summary of a first visit to a consultant-led heart failure clinic (e.g as a clinic visit record or letter to the GP) but meeting the needs of research / audit and care pathways where possible.
PurposeRepresents a clinically-orientated summary of a first visit to a consultant-led heart failure clinic (e.g as a clinic visit record or letter to the GP) but meeting the needs of research / audit and care pathways where possible.
References
OtherDetails Language Independent{MetaDataSet:Sample Set =Template metadata sample set}
Language useden
Citeable Identifier1013.26.14
AllOperationalTemplate [rootArchetypeId=openEHR-EHR-COMPOSITION.encounter.v1, otherContributors=null, tshis=[ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1], code=at0000, itemType=COMPOSITION, level=0, text=Heart Failure Clinic First Visit Summary, description=Generic encounter or progress note composition., 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.adhoc.v1 and name/value='Risk Factors'], code=at0000, itemType=SECTION, level=1, text=Risk Factors, description=A generic section header., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, 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.adhoc.v1 and name/value='Risk Factors']/items[openEHR-EHR-EVALUATION.tobacco_use_summary.v1], code=at0000, itemType=EVALUATION, level=2, text=Tobacco Use Summary, description=Summary or persisting information about tobacco use or consumption., 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.adhoc.v1 and name/value='Risk Factors']/items[openEHR-EHR-EVALUATION.tobacco_use_summary.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.adhoc.v1 and name/value='Risk Factors']/items[openEHR-EHR-EVALUATION.tobacco_use_summary.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Smoking Status, description=Statement about the individual's current tobacco smoking activity., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Current Smoker 
  • Quitting 
  • Ex-smoker 
  • Never Smoked 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Risk Factors']/items[openEHR-EHR-EVALUATION.tobacco_use_summary.v1]/data[at0001]/items[at0029], code=at0029, itemType=CLUSTER, level=4, text=Smoking Details, description=Details about the pattern of use of a specified form of smoked tobacco., 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.adhoc.v1 and name/value='Risk Factors']/items[openEHR-EHR-EVALUATION.tobacco_use_summary.v1]/data[at0001]/items[at0029]/items[at0028], code=at0028, itemType=ELEMENT, level=5, text=Form, description=Identification of the form of tobacco smoked., comment=The geographical and cultural variation of commonly used forms varies enormously and so this value set should not be specified in this archetype, however coding of the Form with a terminology is desirable, where possible., 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.adhoc.v1 and name/value='Risk Factors']/items[openEHR-EHR-EVALUATION.tobacco_use_summary.v1]/data[at0001]/items[at0029]/items[at0023], code=at0023, itemType=ELEMENT, level=5, text=Typical Smoked Amount, description=Estimate of typical use of the form of smoked tobacco per day - as a whole number, a range or as a term (usually coded)., comment=This data element allows a rough indication of cigarette use to be recorded in a number of formats. For example: 30 a day (quantity) or 5-10 per day (interval of quantity), or select from terminology value set (either a set specified in the template or from a specified external terminology reference set). Please note: the period of time to which this data element is not specified. If exact consumption at specific points in time or averages/maximums over specified intervals of time are required, use the OBSERVATION.tobacco_use archetype., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Quantity>=0
    Units:
    • /d
    • /wk
  •  Interval of QuantityLower constraint: Units:
    • /d
    • /wk
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Risk Factors']/items[openEHR-EHR-EVALUATION.tobacco_use_summary.v1]/data[at0001]/items[at0029]/items[at0030], code=at0030, itemType=ELEMENT, level=5, text=Pattern of Use, description=The typical pattern of use of the form of smoked tobacco., comment=Definitions of 'occasional use' vary widely in research and literature., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Regular, daily use 
  • Occasional use 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Risk Factors']/items[openEHR-EHR-EVALUATION.tobacco_use_summary.v1]/data[at0001]/items[at0029]/items[at0016], code=at0016, itemType=ELEMENT, level=5, text=Date Ceased, description=Date that smoking ceased., comment=Can be a partial date, for example, only a year. May also be known as the 'Quit Date'., 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.adhoc.v1 and name/value='Risk Factors']/items[openEHR-EHR-EVALUATION.tobacco_use_summary.v1]/data[at0001]/items[at0029]/items[at0017], code=at0017, itemType=ELEMENT, level=5, text=Pack Years, description=Estimate of the cumulative amount of cigarettes smoked, measured in pack years., comment=Commonly used in assessment of cigarette use. It is calculated by multiplying the number of packs of cigarettes smoked per day by the number of years the individual has smoked. One pack year equals 365 packs of cigarettes., 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.adhoc.v1 and name/value='Risk Factors']/items[openEHR-EHR-EVALUATION.tobacco_use_summary.v1]/data[at0001]/items[at0033], code=at0033, itemType=ELEMENT, level=4, text=Snuff use status, description=Statement about the individual's current snuff use., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Current snuff user 
  • Former snuff user 
  • Never used snuff 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Risk Factors']/items[openEHR-EHR-EVALUATION.tobacco_use_summary.v1]/data[at0001]/items[at0034], code=at0034, itemType=CLUSTER, level=4, text=Snuff use details, description=Details of the subject's use of snuff., 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.adhoc.v1 and name/value='Risk Factors']/items[openEHR-EHR-EVALUATION.tobacco_use_summary.v1]/data[at0001]/items[at0034]/items[at0039], code=at0039, itemType=ELEMENT, level=5, text=Pattern of Use, description=The subject's pattern of use of snuff., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Regular, daily use 
  • Occasional use 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Risk Factors']/items[openEHR-EHR-EVALUATION.tobacco_use_summary.v1]/data[at0001]/items[at0034]/items[at0035], code=at0035, itemType=ELEMENT, level=5, text=Typical Snuff Consumption (tins), description=The typical use of snuff measured in tins used per week., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  QuantityUnits: /wk
  •  Coded Text
    • 1-3 tins per week 
    • 4-6 tins per week 
    • +7 tins per week 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Risk Factors']/items[openEHR-EHR-EVALUATION.tobacco_use_summary.v1]/data[at0001]/items[at0024], code=at0024, itemType=ELEMENT, level=4, text=Other Tobacco Use, description=Narrative description of other tobacco use, other than smoking., comment=For example chewing tobacco., 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.adhoc.v1 and name/value='Risk Factors']/items[openEHR-EHR-EVALUATION.tobacco_use_summary.v1]/data[at0001]/items[at0019], code=at0019, itemType=ELEMENT, level=4, text=Comment, description=Additional narrative about the toacco use not captured in other fields., comment=For example: stopped smoking or reduced amount on becoming pregnant., 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.adhoc.v1 and name/value='Risk Factors']/items[openEHR-EHR-EVALUATION.tobacco_use_summary.v1]/protocol[at0021]/items[at0022], code=at0022, itemType=ELEMENT, level=3, text=Date Last Updated, description=The date this tobacco use summary 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.adhoc.v1 and name/value='Risk Factors']/items[openEHR-EHR-EVALUATION.alcohol_use_summary.v1], code=at0000, itemType=EVALUATION, level=2, text=Alcohol Use Summary, description=Summary or persisting information about alcohol use or consumption., 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.adhoc.v1 and name/value='Risk Factors']/items[openEHR-EHR-EVALUATION.alcohol_use_summary.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.adhoc.v1 and name/value='Risk Factors']/items[openEHR-EHR-EVALUATION.alcohol_use_summary.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Status, description=Statement about the individual's overall pattern of usage or consumption of alcohol., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Current drinker 
  • Ex-drinker 
  • Lifetime non-drinker 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Risk Factors']/items[openEHR-EHR-EVALUATION.alcohol_use_summary.v1]/data[at0001]/items[at0024], code=at0024, itemType=ELEMENT, level=4, text=Typical Alcohol Consumption, description=Estimate of typical alcohol consumption, in number of standard drinks/units per day - either as a whole number, a range, or as a term, normally coded. Definitions of standard units/drinks vary considerably., comment=This data element allows a rough indication of alcohol consumption to be recorded, for example 5-10 per day. The period of time is not specified. If exact consumption at specific points in time or averages/maximums over specified intervals of time are required, use the OBSERVATION.alcohol_use archetype., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Quantity>=0 /d
  •  Interval of QuantityLower constraint: >=0 /d
    Upper constraint: >=0 /d
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Risk Factors']/items[openEHR-EHR-EVALUATION.alcohol_use_summary.v1]/data[at0001]/items[at0025], code=at0025, itemType=ELEMENT, level=4, text=Form, description=The form or type of alcohol consumed., comment=>> 53527002 | alcoholic beverage |, 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.adhoc.v1 and name/value='Risk Factors']/items[openEHR-EHR-EVALUATION.alcohol_use_summary.v1]/data[at0001]/items[at0027], code=at0027, itemType=ELEMENT, level=4, text=Pattern of Use, description=The typical pattern of the subject's use of alcohol., 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.adhoc.v1 and name/value='Risk Factors']/items[openEHR-EHR-EVALUATION.alcohol_use_summary.v1]/data[at0001]/items[at0026], code=at0026, itemType=ELEMENT, level=4, text=Binge Drinking Pattern, description=The subject's pattern of heavy, episodic drinking., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • None 
  • Less than once per month 
  • Monthly 
  • Weekly 
  • Daily 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Risk Factors']/items[openEHR-EHR-EVALUATION.alcohol_use_summary.v1]/data[at0001]/items[at0015], code=at0015, itemType=ELEMENT, level=4, text=Date Commenced, description=Date that any consumption of alcohol commenced., comment=In most situations it is likely that only a partial date will be recorded, for example, only the year of commencement., 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.adhoc.v1 and name/value='Risk Factors']/items[openEHR-EHR-EVALUATION.alcohol_use_summary.v1]/data[at0001]/items[at0016], code=at0016, itemType=ELEMENT, level=4, text=Date Ceased, description=Date that all consumption of alcohol ceased., comment=Can be a partial date, for example, only a year., 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.adhoc.v1 and name/value='Risk Factors']/items[openEHR-EHR-EVALUATION.alcohol_use_summary.v1]/data[at0001]/items[at0019], code=at0019, itemType=ELEMENT, level=4, text=Comment, description=Additional narrative about the alcohol use or consumption pattern 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.adhoc.v1 and name/value='Risk Factors']/items[openEHR-EHR-EVALUATION.alcohol_use_summary.v1]/protocol[at0021], code=at0021, 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.adhoc.v1 and name/value='Risk Factors']/items[openEHR-EHR-EVALUATION.alcohol_use_summary.v1]/protocol[at0021]/items[at0022], code=at0022, itemType=ELEMENT, level=4, text=Date Last Updated, description=The date this alcohol consumption summary 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.adhoc.v1 and name/value='Risk Factors']/items[openEHR-EHR-EVALUATION.alcohol_use_summary.v1]/protocol[at0021]/items[at0033], code=at0033, itemType=ELEMENT, level=4, text=Standard Drink Definition, description=Amount of alcohol defining a standard drink or unit., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=>=0 gm, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='3. Presentation and symptoms'], code=at0000, itemType=SECTION, level=1, text=3. Presentation and symptoms, description=A generic section header., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, 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.adhoc.v1 and name/value='3. Presentation and symptoms']/items[openEHR-EHR-EVALUATION.reason_for_encounter.v1], code=at0000, itemType=EVALUATION, level=2, text=Reason for Encounter, description=Record the administrative and/or clinical reason/s for initiation of a healthcare encounter or contact., 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.adhoc.v1 and name/value='3. Presentation and symptoms']/items[openEHR-EHR-EVALUATION.reason_for_encounter.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=3, text=Nature of Contact, description=Identification of administrative reason for seeking healthcare., comment=For example, a clinical consultation, emergency consultation, pre-employment medical, routine antenatal visit, women's health check, pre-operative assessment, or annual medical check-up. Coding of the Reason for Encounter with a terminology is desirable, where possible., 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.adhoc.v1 and name/value='3. Presentation and symptoms']/items[openEHR-EHR-EVALUATION.reason_for_encounter.v1]/data[at0001]/items[at0004], code=at0004, itemType=ELEMENT, level=3, text=Presenting Problem, description=Identification of the clinical reason for seeking healthcare., comment=Clinical reasons for seeking healthcare can include health issues, symptoms or physical signs. Examples: health issues - desire to quit smoking or to lose weight; symptoms - abdominal pain or shortness of breath; physical signs - an altered conscious state. May also be referred to as Presenting Complaint. Coding of the Presentic Problem with a terminology is desirable, where possible., 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.adhoc.v1 and name/value='3. Presentation and symptoms']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Medical history'], code=at0000, itemType=SECTION, level=2, text=Medical history, description=A generic section header., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, 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.adhoc.v1 and name/value='3. Presentation and symptoms']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Medical history']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Co-morbidity'], code=at0000, itemType=SECTION, level=3, text=Co-morbidity, description=A generic section header., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, 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.adhoc.v1 and name/value='3. Presentation and symptoms']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Medical history']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Co-morbidity']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Co-morbidity, description=Identification of the index problem, issue or diagnosis., 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.adhoc.v1 and name/value='3. Presentation and symptoms']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Medical history']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Co-morbidity']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0003], code=at0003, itemType=ELEMENT, level=4, text=Date of Onset, description=The date / time when the problem was first identified by the individual., 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.adhoc.v1 and name/value='3. Presentation and symptoms']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Medical history']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Co-morbidity']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/protocol[at0032]/items[openEHR-EHR-CLUSTER.problem_status.v1]/items[at0029], code=at0029, itemType=ELEMENT, level=4, text=Certainty, description=The level of confidence in the identification of the problem or diagnosis., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Possible 
  • Equivocal 
  • Probable 
  • Definite 
  • Confirmed 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='3. Presentation and symptoms']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Medical history']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Co-morbidity']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/protocol[at0032]/items[openEHR-EHR-CLUSTER.problem_status.v1]/items[at0004], code=at0004, itemType=ELEMENT, level=4, text=Evolution, description=Records temporal/evidential progress towards identification of the problem or diagnosis, recognising that precise identification may take time to evolve as increasing amounts of evidence become available., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Interim/working assessment 
Default value: Interim/working assessment, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='3. Presentation and symptoms']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Medical history']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Co-morbidity']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/protocol[at0032]/items[openEHR-EHR-CLUSTER.problem_status.v1]/items[at0060], code=at0060, itemType=ELEMENT, level=4, text=Temporal context, description=Temporal context indicator aligned with SNOMEDCT., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Past 
  • Current 
Default value: Current, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='3. Presentation and symptoms']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Medical history']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Co-morbidity']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/protocol[at0032]/items[openEHR-EHR-CLUSTER.problem_status.v1]/items[at0063], code=at0063, itemType=ELEMENT, level=4, text=Episodic care status, description=In episodic care contexts (commonly secondary care) it is common to categorise/ organise problems according to their relationship to the principal problem or diagnosis being addressed during that episode of care. These categories may also be used for clinical coding, reporting and billing purposes., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Primary diagnosis 
  • Primary procedure 
  • Co-morbidity 
  • Complication 
  • Other current problem 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='3. Presentation and symptoms']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Medical history']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Other medical history'], code=at0000, itemType=SECTION, level=3, text=Other medical history, description=A generic section header., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, 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.adhoc.v1 and name/value='3. Presentation and symptoms']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Medical history']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Other medical history']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Past history, description=Identification of the index problem, issue or diagnosis., 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.adhoc.v1 and name/value='3. Presentation and symptoms']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Medical history']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Other medical history']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/protocol[at0032]/items[openEHR-EHR-CLUSTER.problem_status.v1]/items[at0029], code=at0029, itemType=ELEMENT, level=4, text=Certainty, description=The level of confidence in the identification of the problem or diagnosis., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Possible 
  • Equivocal 
  • Probable 
  • Definite 
  • Confirmed 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='3. Presentation and symptoms']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Medical history']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Other medical history']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/protocol[at0032]/items[openEHR-EHR-CLUSTER.problem_status.v1]/items[at0004], code=at0004, itemType=ELEMENT, level=4, text=Evolution, description=Records temporal/evidential progress towards identification of the problem or diagnosis, recognising that precise identification may take time to evolve as increasing amounts of evidence become available., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Interim/working assessment 
Default value: Interim/working assessment, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='3. Presentation and symptoms']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Medical history']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Other medical history']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/protocol[at0032]/items[openEHR-EHR-CLUSTER.problem_status.v1]/items[at0060], code=at0060, itemType=ELEMENT, level=4, text=Temporal context, description=Temporal context indicator aligned with SNOMEDCT., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Past 
  • Current 
Default value: Past, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='3. Presentation and symptoms']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Medical history']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Other medical history']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/protocol[at0032]/items[openEHR-EHR-CLUSTER.problem_status.v1]/items[at0063], code=at0063, itemType=ELEMENT, level=4, text=Episodic care status, description=In episodic care contexts (commonly secondary care) it is common to categorise/ organise problems according to their relationship to the principal problem or diagnosis being addressed during that episode of care. These categories may also be used for clinical coding, reporting and billing purposes., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Primary diagnosis 
  • Primary procedure 
  • Co-morbidity 
  • Complication 
  • Other current problem 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='3. Presentation and symptoms']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Medical history']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Other medical history']/items[openEHR-EHR-EVALUATION.exclusion-problem_diagnosis.v1], code=at0000.1, itemType=EVALUATION, level=4, text=Exclusion of a Problem/Diagnosis, description=Positive statement/s about problems or diagnoses that need to be recorded as clinically excluded from the health record at a specific point in time., 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.adhoc.v1 and name/value='3. Presentation and symptoms']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Medical history']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Other medical history']/items[openEHR-EHR-EVALUATION.exclusion-problem_diagnosis.v1]/data[at0001]/items[at0003.1], code=at0003.1, itemType=ELEMENT, level=5, text=Problem/Diagnosis, description=Identification of the specific problems/diagnoses to which the Exclusion Statement applies., comment=Coding of the Problem or Diagnosis with a terminology is desirable, where possible., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Coded TextValue set: ac0.1
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='3. Presentation and symptoms']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Medical history']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Other medical history']/items[openEHR-EHR-EVALUATION.exclusion-problem_diagnosis.v1]/data[at0001]/items[at0007], code=at0007, itemType=ELEMENT, level=5, text=Comment, description=Additional narrative about the Exclusion 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.adhoc.v1 and name/value='3. Presentation and symptoms']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Medical history']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Other medical history']/items[openEHR-EHR-EVALUATION.exclusion-problem_diagnosis.v1]/protocol[at0006], code=at0006, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=5, 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.adhoc.v1 and name/value='3. Presentation and symptoms']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Medical history']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Other medical history']/items[openEHR-EHR-EVALUATION.exclusion-problem_diagnosis.v1]/protocol[at0006]/items[at0004], code=at0004, itemType=ELEMENT, level=6, text=Date Last Updated, description=The date at which the exclusion was last clinically asserted, affirmed or confirmed., 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.adhoc.v1 and name/value='3. Presentation and symptoms']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Medical history']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Other medical history']/items[openEHR-EHR-ACTION.procedure.v1], code=at0000, itemType=ACTION, level=4, text=Procedure undertaken, description=A clinical activity that has been carried out for therapeutic or diagnostic purposes., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ACTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='3. Presentation and symptoms']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Medical history']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Other medical history']/items[openEHR-EHR-ACTION.procedure.v1]/description[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=5, text=Procedure, description=The name of the procedure., 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.adhoc.v1 and name/value='3. Presentation and symptoms']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Medical history']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Allergies and Other Adverse Reactions'], code=at0000, itemType=SECTION, level=3, text=Allergies and Other Adverse Reactions, description=A generic section header., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, 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.adhoc.v1 and name/value='3. Presentation and symptoms']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Medical history']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Allergies and Other Adverse Reactions']/items[openEHR-EHR-EVALUATION.adverse_reaction.v1], code=at0000, itemType=EVALUATION, level=4, text=Adverse Reaction, description=A harmful or undesirable, unexpected effect associated with exposure to any substance or agent, including food, plants, animals, venom from animal stings, or a medication at therapeutic or sub-therapeutic doses., 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.adhoc.v1 and name/value='3. Presentation and symptoms']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Medical history']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Allergies and Other Adverse Reactions']/items[openEHR-EHR-EVALUATION.adverse_reaction.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=5, text=Allergy Agent, description=Identification of a substance, agent, or a class of substance, that is considered to be responsible for the Adverse Reaction., comment=Substance/Agent should be coded with a terminology, where possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, 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.adhoc.v1 and name/value='3. Presentation and symptoms']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Medical history']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Allergies and Other Adverse Reactions']/items[openEHR-EHR-EVALUATION.adverse_reaction.v1]/data[at0001]/items[at0009]/items[at0011], code=at0011, itemType=ELEMENT, level=5, text=Allergy Display Name, description=Clinical manifestation of the Adverse Reaction expressed as a single word, phrase or brief description, e.g. nausea or rash., comment=Manifestation should be coded with a terminology, where possible. The values entered here may be used to display on an application screen as part a list of adverse reactions, as recommended in the NHS CUI guidelines., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, 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.adhoc.v1 and name/value='3. Presentation and symptoms']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Medical history']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Allergies and Other Adverse Reactions']/items[openEHR-EHR-EVALUATION.adverse_reaction.v1]/data[at0001]/items[at0009]/items[at0016], code=at0016, itemType=ELEMENT, level=5, text=Reaction Type, description=The type of Adverse Reaction as determined by the clinician., comment=Coding of the reaction type is preferred, where possible. Examples: Immune mediated - Types I-IV (including allergy and hypersensitivity); Non-immune mediated - including pseudoallergic reaction, side effect, intolerance, drug toxicity, drug-drug interaction, food-drug interaction, drug-disease interaction and idiosyncratic reaction., 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.adhoc.v1 and name/value='3. Presentation and symptoms']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Medical history']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Allergies and Other Adverse Reactions']/items[openEHR-EHR-EVALUATION.adverse_reaction.v1]/data[at0001]/items[at0009]/items[at0027], code=at0027, itemType=ELEMENT, level=5, text=Allergy Onset Date, description=Record of the date and/or time of the onset of the Adverse Reaction., 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.adhoc.v1 and name/value='3. 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  • 0: Not present 
  • 1: Trivial 
  • 2: Mild 
  • 5: Moderate 
  • 8: Severe 
  • 9: Very severe 
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  • 0: Not present 
  • 1: Trivial 
  • 2: Mild 
  • 5: Moderate 
  • 8: Severe 
  • 9: Very severe 
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Presentation and symptoms']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Symptoms']/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom.v1 and name/value='Ankle swelling'], code=at0000, itemType=CLUSTER, level=4, text=Ankle swelling, description=A subjective observation by an individual about departure from normal function and which may indicate the presence of disease or abnormality. Either self-recorded or recorded on the behalf of a patient by a clinician., 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.adhoc.v1 and name/value='3. Presentation and symptoms']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Symptoms']/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom.v1 and name/value='Ankle swelling']/items[at0001], code=at0001, itemType=ELEMENT, level=5, text=Symptom name, description=The symptom experienced., comment=Coding with an external 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=Default value: SNOMEDCT | 423666004 | oedema |, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='3. Presentation and symptoms']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Symptoms']/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom.v1 and name/value='Ankle swelling']/items[at0035], code=at0035, itemType=ELEMENT, level=5, text=Absent, description=The person has not had any significant experience of the symptom., 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.adhoc.v1 and name/value='3. Presentation and symptoms']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Symptoms']/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom.v1 and name/value='Palpitations'], code=at0000, itemType=CLUSTER, level=4, text=Palpitations, description=A subjective observation by an individual about departure from normal function and which may indicate the presence of disease or abnormality. Either self-recorded or recorded on the behalf of a patient by a clinician., 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.adhoc.v1 and name/value='3. Presentation and symptoms']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Symptoms']/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom.v1 and name/value='Palpitations']/items[at0001], code=at0001, itemType=ELEMENT, level=5, text=Symptom name, description=The symptom experienced., comment=Coding with an external 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=Default value: SNOMEDCT | 80313002 | palpitations |, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='3. Presentation and symptoms']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Symptoms']/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom.v1 and name/value='Palpitations']/items[at0035], code=at0035, itemType=ELEMENT, level=5, text=Absent, description=The person has not had any significant experience of the symptom., 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.adhoc.v1 and name/value='3. Presentation and symptoms']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Symptoms']/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom.v1 and name/value='Blackout/Syncope'], code=at0000, itemType=CLUSTER, level=4, text=Blackout/Syncope, description=A subjective observation by an individual about departure from normal function and which may indicate the presence of disease or abnormality. Either self-recorded or recorded on the behalf of a patient by a clinician., 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.adhoc.v1 and name/value='3. Presentation and symptoms']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Symptoms']/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom.v1 and name/value='Blackout/Syncope']/items[at0001], code=at0001, itemType=ELEMENT, level=5, text=Symptom name, description=The symptom experienced., comment=Coding with an external 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=Default value: SNOMEDCT | 271594007 | syncope |, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='3. Presentation and symptoms']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Symptoms']/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom.v1 and name/value='Blackout/Syncope']/items[at0035], code=at0035, itemType=ELEMENT, level=5, text=Absent, description=The person has not had any significant experience of the symptom., 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.adhoc.v1 and name/value='3. Presentation and symptoms']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Symptoms']/items[openEHR-EHR-OBSERVATION.nyha_heart_failure_score.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=3, text=NYHA Class, description=The functional classification of heart failure based on patient symptoms., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_ORDINAL, bindings=null, values=
  • 1: Class I 
  • 2: Class II 
  • 3: Class III 
  • 4: Class IV 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='3. Presentation and symptoms']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Symptoms']/items[openEHR-EHR-OBSERVATION.nyha_heart_failure_score.v1]/data[at0001]/events[at0002]/state[at0010], code=at0010, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, 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.adhoc.v1 and name/value='3. Presentation and symptoms']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Symptoms']/items[openEHR-EHR-OBSERVATION.nyha_heart_failure_score.v1]/data[at0001]/events[at0002]/state[at0010]/items[at0011], code=at0011, itemType=ELEMENT, level=4, text=Confounding factors, description=Record any issues or factors that may impact on the classification of heart failure symptoms., 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.adhoc.v1 and name/value='4. Physical Exam'], code=at0000, itemType=SECTION, level=1, text=4. Physical Exam, description=A generic section header., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, 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.adhoc.v1 and name/value='4. Physical Exam']/items[openEHR-EHR-OBSERVATION.body_weight.v1]/data[at0002]/events[at0003]/data[at0001]/items[at0004], code=at0004, itemType=ELEMENT, level=2, text=Weight, description=The weight of the individual., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=0..1000 kg, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='4. Physical Exam']/items[openEHR-EHR-OBSERVATION.pulse.v1], code=at0000, itemType=OBSERVATION, level=2, text=Pulse, description=Measurement of the pulse rate, or heart rate, and description of associated characteristics., 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.adhoc.v1 and name/value='4. Physical Exam']/items[openEHR-EHR-OBSERVATION.pulse.v1]/data[at0002]/events[at0003]/data[at0001]/items[at0004], code=at0004, itemType=ELEMENT, level=3, text=(Rate), description=The rate, measured in beats per minute., comment=Run-time name constraints have been specified, in order to simplify the renaming of this data element to Pulse Rate or Heart Rate, as required., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=>=0 /min, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='4. Physical Exam']/items[openEHR-EHR-OBSERVATION.height.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=2, text=Height, description=The length of the body from crown of head to sole of foot., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=0..1000 cm, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='4. Physical Exam']/items[openEHR-EHR-OBSERVATION.blood_pressure.v1], code=at0000, itemType=OBSERVATION, level=2, text=Blood Pressure, description=The local measurement of arterial blood pressure which is a surrogate for arterial. pressure in the systemic circulation. Most commonly, use of the term 'blood pressure' refers to measurement of brachial artery pressure in the upper arm., 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.adhoc.v1 and name/value='4. Physical Exam']/items[openEHR-EHR-OBSERVATION.blood_pressure.v1]/data[at0001]/events[at0006]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=3, text=Systolic Blood Pressure, description=Peak systemic arterial blood pressure - measured in systolic or contraction phase of the heart cycle., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=0..1000 mm[Hg], extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='4. Physical Exam']/items[openEHR-EHR-OBSERVATION.blood_pressure.v1]/data[at0001]/events[at0006]/data[at0003]/items[at0005], code=at0005, itemType=ELEMENT, level=3, text=Diastolic Blood Pressure, description=Minimum systemic arterial blood pressure - measured in the diastolic or relaxation phase of the heart cycle., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=0..1000 mm[Hg], extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='4. Physical Exam']/items[openEHR-EHR-OBSERVATION.exam.v1], code=at0000, itemType=OBSERVATION, level=2, text=Oedema, description=Findings observed during the physical examination of a subject., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, 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.adhoc.v1 and name/value='4. Physical Exam']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.oedema.v1]/items[at0006], code=at0006, itemType=ELEMENT, level=3, text=Degree, description=The degree of oedema., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_ORDINAL, bindings=null, values=
  • 1: Mild + 
  • 2: Moderate ++ 
  • 3: Severe +++ 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='4. Physical Exam']/items[openEHR-EHR-OBSERVATION.indirect_oximetry.v1], code=at0000, itemType=OBSERVATION, level=2, text=Transcutaneous Oxygen saturation, description=Method of monitoring blood gas measurements such as Spo2 and pTCO2 by indirect, currently non-invasive, means., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, 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.adhoc.v1 and name/value='4. Physical Exam']/items[openEHR-EHR-OBSERVATION.indirect_oximetry.v1]/data[at0001]/events[at0002 and name/value='Without oxygen'], code=at0002, itemType=EVENT, level=3, text=Without oxygen, 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.adhoc.v1 and name/value='4. Physical Exam']/items[openEHR-EHR-OBSERVATION.indirect_oximetry.v1]/data[at0001]/events[at0002 and name/value='Without oxygen']/data[at0003]/items[at0006], code=at0006, itemType=ELEMENT, level=4, text=spO2, description=Measured via pulse oximetry, the saturation of oxygen in the peripheral blood., comment=spO2 is defined as the ratio of oxyhaemoglobin (HbO2) to the total concentration of haemoglobin (HbO2 + deoxyhaemoglobin)., 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.adhoc.v1 and name/value='4. Physical Exam']/items[openEHR-EHR-OBSERVATION.indirect_oximetry.v1]/data[at0001]/events[at0002 and name/value='SNOMEDCT::371825009::patient on oxygen'], code=at0002, itemType=EVENT, level=3, text=SNOMEDCT::371825009::patient on oxygen, 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.adhoc.v1 and name/value='4. Physical Exam']/items[openEHR-EHR-OBSERVATION.indirect_oximetry.v1]/data[at0001]/events[at0002 and name/value='SNOMEDCT::371825009::patient on oxygen']/data[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, 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.adhoc.v1 and name/value='4. Physical Exam']/items[openEHR-EHR-OBSERVATION.indirect_oximetry.v1]/data[at0001]/events[at0002 and name/value='SNOMEDCT::371825009::patient on oxygen']/data[at0003]/items[at0006], code=at0006, itemType=ELEMENT, level=5, text=spO2, description=Measured via pulse oximetry, the saturation of oxygen in the peripheral blood., comment=spO2 is defined as the ratio of oxyhaemoglobin (HbO2) to the total concentration of haemoglobin (HbO2 + deoxyhaemoglobin)., 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.adhoc.v1 and name/value='4. Physical Exam']/items[openEHR-EHR-OBSERVATION.indirect_oximetry.v1]/data[at0001]/events[at0002 and name/value='SNOMEDCT::371825009::patient on oxygen']/state[at0014], code=at0014, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, 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.adhoc.v1 and name/value='4. Physical Exam']/items[openEHR-EHR-OBSERVATION.indirect_oximetry.v1]/data[at0001]/events[at0002 and name/value='SNOMEDCT::371825009::patient on oxygen']/state[at0014]/items[openEHR-EHR-CLUSTER.ambient_oxygen.v1], code=at0000, itemType=CLUSTER, level=5, text=Ambient oxygen, description=The amount of oxygen being delivered to the subject at the time of observation. Assumed values of 21% O2, Fi02 of 0.21 and Oxygen flow rate of zero., 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.adhoc.v1 and name/value='4. Physical Exam']/items[openEHR-EHR-OBSERVATION.indirect_oximetry.v1]/data[at0001]/events[at0002 and name/value='SNOMEDCT::371825009::patient on oxygen']/state[at0014]/items[openEHR-EHR-CLUSTER.ambient_oxygen.v1]/items[at0053], code=at0053, itemType=ELEMENT, level=6, text=Percent O2, description=Percentage of inspired oxygen., 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.adhoc.v1 and name/value='5. Blood tests'], code=at0000, itemType=SECTION, level=1, text=5. Blood tests, description=A generic section header., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, 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.adhoc.v1 and name/value='5. Blood tests']/items[openEHR-EHR-OBSERVATION.pathology_test.v1 and name/value='Full blood count'], code=at0000, itemType=OBSERVATION, level=2, text=Full blood count, description=The findings and interpretation of pathology tests performed on patient-related specimens., comment=This archetype may be used to record a single valued test, but will often be specialised or templated to represent multiple value or 'panel' tests. This archetype also acts as the parent for specialisations appropriate for more specific laboratory tests, e.g. microbiology, histopathology., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, 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.adhoc.v1 and name/value='5. Blood tests']/items[openEHR-EHR-OBSERVATION.pathology_test.v1 and name/value='Full blood count']/data[at0001]/events[at0002]/data[at0003]/items[at0005], code=at0005, itemType=ELEMENT, level=3, text=Test Result Name, description=Identification of the pathology test performed, sometimes including specimen type and patient state., comment=A test result may be for a single analyte, or a group of items, including panel tests. Coding with a terminology, potientially a pre-coordinated term including specimen type, is preferred, where possible. May be coded with LOINC or Snomed-CT. Examples include "Glucose", "Urea and Electrolytes", "Swab", “Cortisol (am)” or "Liver Biopsy"., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=Default value: SNOMEDCT| 26604007 | complete blood count |, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='5. Blood tests']/items[openEHR-EHR-OBSERVATION.pathology_test.v1 and name/value='Full blood count']/data[at0001]/events[at0002]/data[at0003]/items[at0073], code=at0073, itemType=ELEMENT, level=3, text=Overall Test Result Status, description=The publication status of the entire pathology test result., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Registered 
  • Interim 
  • Final 
  • Amended 
  • Cancelled/Aborted 
Default value: Final, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='5. Blood tests']/items[openEHR-EHR-OBSERVATION.pathology_test.v1 and name/value='Full blood count']/data[at0001]/events[at0002]/data[at0003]/items[at0095]/items[at0096 and name/value='SNOMEDCT |38082009 | haemoglobin |'], code=at0096, itemType=CLUSTER, level=3, text=SNOMEDCT |38082009 | haemoglobin |, description=Specific detailed result, including both the value of the result item, and additional information that may be useful for clinical interpretation., comment=Results include whatever specific data items pathology labs report as part of the clinical service; it is not confined to measurements. The result is identified by run-time re-naming of the 'Result group' element or may be fixed in a specialised archetype or template. Coding with a terminology, potentially a pre-coordinated term including specimen type, is preferred where possible for the name. Should be coded with LOINC or SNOMED CT. Examples include: glucose, haemoglobin, phenotype, titre, or scatterplot image. If the test result is for a single analyte, then both the "Test Result Name" and the "Result" item will specify the same test., 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.adhoc.v1 and name/value='5. Blood tests']/items[openEHR-EHR-OBSERVATION.pathology_test.v1 and name/value='Full blood count']/data[at0001]/events[at0002]/data[at0003]/items[at0095]/items[at0096 and name/value='SNOMEDCT |38082009 | haemoglobin |']/items[at0078], code=at0078, itemType=ELEMENT, level=4, text=Result Value, description=Actual value of the result., comment=Most result values will be numerical measurements, but others may be coded concepts, free text, or multimedia images., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='5. Blood tests']/items[openEHR-EHR-OBSERVATION.pathology_test.v1 and name/value='Full blood count']/data[at0001]/events[at0002]/data[at0003]/items[at0095]/items[at0096 and name/value='SNOMEDCT | 767002 | white blood cell count |'], code=at0096, itemType=CLUSTER, level=3, text=SNOMEDCT | 767002 | white blood cell count |, description=Specific detailed result, including both the value of the result item, and additional information that may be useful for clinical interpretation., comment=Results include whatever specific data items pathology labs report as part of the clinical service; it is not confined to measurements. The result is identified by run-time re-naming of the 'Result group' element or may be fixed in a specialised archetype or template. Coding with a terminology, potentially a pre-coordinated term including specimen type, is preferred where possible for the name. Should be coded with LOINC or SNOMED CT. Examples include: glucose, haemoglobin, phenotype, titre, or scatterplot image. If the test result is for a single analyte, then both the "Test Result Name" and the "Result" item will specify the same test., 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.adhoc.v1 and name/value='5. Blood tests']/items[openEHR-EHR-OBSERVATION.pathology_test.v1 and name/value='Full blood count']/data[at0001]/events[at0002]/data[at0003]/items[at0095]/items[at0096 and name/value='SNOMEDCT | 767002 | white blood cell count |']/items[at0078], code=at0078, itemType=ELEMENT, level=4, text=Result Value, description=Actual value of the result., comment=Most result values will be numerical measurements, but others may be coded concepts, free text, or multimedia images., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='5. Blood tests']/items[openEHR-EHR-OBSERVATION.pathology_test.v1 and name/value='HBA1c'], code=at0000, itemType=OBSERVATION, level=2, text=HBA1c, description=The findings and interpretation of pathology tests performed on patient-related specimens., comment=This archetype may be used to record a single valued test, but will often be specialised or templated to represent multiple value or 'panel' tests. This archetype also acts as the parent for specialisations appropriate for more specific laboratory tests, e.g. microbiology, histopathology., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, 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.adhoc.v1 and name/value='5. Blood tests']/items[openEHR-EHR-OBSERVATION.pathology_test.v1 and name/value='HBA1c']/data[at0001]/events[at0002]/data[at0003]/items[at0005], code=at0005, itemType=ELEMENT, level=3, text=Test Result Name, description=Identification of the pathology test performed, sometimes including specimen type and patient state., comment=A test result may be for a single analyte, or a group of items, including panel tests. Coding with a terminology, potientially a pre-coordinated term including specimen type, is preferred, where possible. May be coded with LOINC or Snomed-CT. Examples include "Glucose", "Urea and Electrolytes", "Swab", “Cortisol (am)” or "Liver Biopsy"., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=Default value: SNOMEDCT :: 43396009 :: Hemoglobin A1c measurement, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='5. Blood tests']/items[openEHR-EHR-OBSERVATION.pathology_test.v1 and name/value='HBA1c']/data[at0001]/events[at0002]/data[at0003]/items[at0073], code=at0073, itemType=ELEMENT, level=3, text=Overall Test Result Status, description=The publication status of the entire pathology test result., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Registered 
  • Interim 
  • Final 
  • Amended 
  • Cancelled/Aborted 
Default value: Final, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='5. Blood tests']/items[openEHR-EHR-OBSERVATION.pathology_test.v1 and name/value='HBA1c']/data[at0001]/events[at0002]/data[at0003]/items[at0095]/items[at0096], code=at0096, itemType=CLUSTER, level=3, text=SNOMEDCT :: 43396009 :: Hemoglobin A1c measurement, description=Specific detailed result, including both the value of the result item, and additional information that may be useful for clinical interpretation., comment=Results include whatever specific data items pathology labs report as part of the clinical service; it is not confined to measurements. The result is identified by run-time re-naming of the 'Result group' element or may be fixed in a specialised archetype or template. Coding with a terminology, potentially a pre-coordinated term including specimen type, is preferred where possible for the name. Should be coded with LOINC or SNOMED CT. Examples include: glucose, haemoglobin, phenotype, titre, or scatterplot image. If the test result is for a single analyte, then both the "Test Result Name" and the "Result" item will specify the same test., 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.adhoc.v1 and name/value='5. Blood tests']/items[openEHR-EHR-OBSERVATION.pathology_test.v1 and name/value='HBA1c']/data[at0001]/events[at0002]/data[at0003]/items[at0095]/items[at0096]/items[at0078], code=at0078, itemType=ELEMENT, level=4, text=Result Value, description=Actual value of the result., comment=Most result values will be numerical measurements, but others may be coded concepts, free text, or multimedia images., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='6. Electrocardiography'], code=at0000, itemType=SECTION, level=1, text=6. Electrocardiography, description=A generic section header., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, 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.adhoc.v1 and name/value='6. Electrocardiography']/items[openEHR-EHR-OBSERVATION.ecg.v1]/data[at0001]/events[at0002]/data[at0005]/items[at0006]/items[at0013], code=at0013, itemType=ELEMENT, level=2, text=RR Rate, description=Frequency of electrical ventricular contractions (measured from R wave to R wave) and indicative of the mechanical heart rate., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=>=0 /min, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='6. Electrocardiography']/items[openEHR-EHR-OBSERVATION.ecg.v1]/data[at0001]/events[at0002]/data[at0005]/items[at0006]/items[at0012], code=at0012, itemType=ELEMENT, level=2, text=PR interval, description=Measured interval from onset of P wave to QRS., 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.adhoc.v1 and name/value='6. Electrocardiography']/items[openEHR-EHR-OBSERVATION.ecg.v1]/data[at0001]/events[at0002]/data[at0005]/items[at0006]/items[at0014], code=at0014, itemType=ELEMENT, level=2, text=QRS duration, description=QRS complex duration, measured from its onset to the ST segment onset (J point)., 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.adhoc.v1 and name/value='6. Electrocardiography']/items[openEHR-EHR-OBSERVATION.ecg.v1]/data[at0001]/events[at0002]/data[at0005]/items[at0081], code=at0081, itemType=ELEMENT, level=2, text=Overall interpretation, description=An overall interpretative comment on this recording., 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.adhoc.v1 and name/value='7. Echocardiography'], code=at0000, itemType=SECTION, level=1, text=7. Echocardiography, description=A generic section header., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, 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.adhoc.v1 and name/value='7. Echocardiography']/items[openEHR-EHR-OBSERVATION.imaging_exam.v1], code=at0000, itemType=OBSERVATION, level=2, text=Echocardiography, description=Record the findings and interpretation of an imaging examination, or series of examinations, performed., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, 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.adhoc.v1 and name/value='7. Echocardiography']/items[openEHR-EHR-OBSERVATION.imaging_exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=3, text=Examination result name, description=Identification of the imaging examination or procedure performed, typically including modality and anatomical location (including laterality). Coding with a terminology, potientially a pre-coordinated term specifying both modality and anatomical location, is desirable where possible. Possible candidate terminologies: LOINC, SNOMED CT or RadLex., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=Default value: SNOMEDCT:: 40701008::echocardiography, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='7. Echocardiography']/items[openEHR-EHR-OBSERVATION.imaging_exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0007], code=at0007, itemType=ELEMENT, level=3, text=Overall result status, description=The status of the examination result as a whole., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Registered 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='7. Echocardiography']/items[openEHR-EHR-OBSERVATION.imaging_exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0024], code=at0024, itemType=ELEMENT, level=3, text=DateTime result issued, description=The date and/or time that the result was issued for the recorded 'Examination result status'., 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.adhoc.v1 and name/value='7. Echocardiography']/items[openEHR-EHR-OBSERVATION.imaging_exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0015]/items[at0016 and name/value='Result'], code=at0016, itemType=CLUSTER, level=3, text=Result, description=Specific detailed result, including both the value of the result item and additional information that may be useful for clinical interpretation. Results include whatever specific data items imaging services report as part of the clinical service; it may include measurements. These are often referred to as 'Structured Findings'. The result is identified by run-time re-naming of the 'Result group' element or may be fixed in a specialised archetype or template. Coding with a terminology, potentially a pre-coordinated term including specimen type, is preferred where possible for the name. Should be coded with LOINC or SNOMED CT. Examples include cardiac ejection fraction or bone density., 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.adhoc.v1 and name/value='7. Echocardiography']/items[openEHR-EHR-OBSERVATION.imaging_exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0015]/items[at0016 and name/value='Result']/items[at0017], code=at0017, itemType=ELEMENT, level=4, text=SNOMEDCT:: 250932006::left ventricular end-diastolic cavity size, description=Actual value of the result. Most result values will be numerical measurements, but others may be coded concepts or free text., comment=null, 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.adhoc.v1 and name/value='7. Echocardiography']/items[openEHR-EHR-OBSERVATION.imaging_exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0015]/items[at0016 and name/value='Result #1'], code=at0016, itemType=CLUSTER, level=3, text=Result #1, description=Specific detailed result, including both the value of the result item and additional information that may be useful for clinical interpretation. Results include whatever specific data items imaging services report as part of the clinical service; it may include measurements. These are often referred to as 'Structured Findings'. The result is identified by run-time re-naming of the 'Result group' element or may be fixed in a specialised archetype or template. Coding with a terminology, potentially a pre-coordinated term including specimen type, is preferred where possible for the name. Should be coded with LOINC or SNOMED CT. Examples include cardiac ejection fraction or bone density., 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.adhoc.v1 and name/value='7. Echocardiography']/items[openEHR-EHR-OBSERVATION.imaging_exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0015]/items[at0016 and name/value='Result #1']/items[at0017], code=at0017, itemType=ELEMENT, level=4, text=SNOMEDCT:: 250932006::left ventricular end-diastolic cavity size, description=Actual value of the result. Most result values will be numerical measurements, but others may be coded concepts or free text., comment=null, 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.adhoc.v1 and name/value='7. Echocardiography']/items[openEHR-EHR-OBSERVATION.imaging_exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0020], code=at0020, itemType=ELEMENT, level=3, text=Radiological diagnosis, description=Single word, phrase or brief description representing the 'Conclusion'. Coding with a terminology is preferred, where possible., 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.adhoc.v1 and name/value='8. Other non-invasive Cardiac Imaging'], code=at0000, itemType=SECTION, level=1, text=8. Other non-invasive Cardiac Imaging, description=A generic section header., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, 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.adhoc.v1 and name/value='8. Other non-invasive Cardiac Imaging']/items[openEHR-EHR-OBSERVATION.imaging_exam.v1], code=at0000, itemType=OBSERVATION, level=2, text=Imaging examination result, description=Record the findings and interpretation of an imaging examination, or series of examinations, performed., 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.adhoc.v1 and name/value='8. Other non-invasive Cardiac Imaging']/items[openEHR-EHR-OBSERVATION.imaging_exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=3, text=Examination result name, description=Identification of the imaging examination or procedure performed, typically including modality and anatomical location (including laterality). Coding with a terminology, potientially a pre-coordinated term specifying both modality and anatomical location, is desirable where possible. Possible candidate terminologies: LOINC, SNOMED CT or RadLex., 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.adhoc.v1 and name/value='8. Other non-invasive Cardiac Imaging']/items[openEHR-EHR-OBSERVATION.imaging_exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0024], code=at0024, itemType=ELEMENT, level=3, text=DateTime result issued, description=The date and/or time that the result was issued for the recorded 'Examination result status'., 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.adhoc.v1 and name/value='8. Other non-invasive Cardiac Imaging']/items[openEHR-EHR-OBSERVATION.imaging_exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0020], code=at0020, itemType=ELEMENT, level=3, text=Radiological diagnosis, description=Single word, phrase or brief description representing the 'Conclusion'. Coding with a terminology is preferred, where possible., 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.adhoc.v1 and name/value='9. Lung function'], code=at0000, itemType=SECTION, level=1, text=9. Lung function, description=A generic section header., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, 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.adhoc.v1 and name/value='9. Lung function']/items[openEHR-EHR-OBSERVATION.pulmonary_function.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0127 and name/value='FEV1'], code=at0127, itemType=CLUSTER, level=2, text=FEV1, description=Details of Pulmonary Function Test Results., 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.adhoc.v1 and name/value='9. Lung function']/items[openEHR-EHR-OBSERVATION.pulmonary_function.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0127 and name/value='FEV1']/items[at0052]/items[at0087], code=at0087, itemType=ELEMENT, level=3, text=Test Result Name, description=The name of the pulmonary volume test/parameter., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Forced expiratory volume in 1 sec (FEV1) 
Default value: Forced expiratory volume in 1 sec (FEV1), extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='9. Lung function']/items[openEHR-EHR-OBSERVATION.pulmonary_function.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0127 and name/value='FEV1']/items[at0052]/items[at0054], code=at0054, itemType=ELEMENT, level=3, text=Predicted Result, description=Predicted pulmonary volume test result., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=>=0; >=0
Units:
  • l
  • ml
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='9. Lung function']/items[openEHR-EHR-OBSERVATION.pulmonary_function.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0127 and name/value='FEV1']/items[at0052]/items[at0053], code=at0053, itemType=ELEMENT, level=3, text=Actual Result, description=Actual pulmonary volume test result., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=>=0; >=0
Units:
  • l
  • ml
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='9. Lung function']/items[openEHR-EHR-OBSERVATION.pulmonary_function.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0127 and name/value='FEV1']/items[at0052]/items[at0044], code=at0044, itemType=ELEMENT, level=3, text=Actual/predicted Ratio, description=The ratio of actual to predicted test result., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_PROPORTION, bindings=null, values=
  • Ratio
  • Percent
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='9. Lung function']/items[openEHR-EHR-OBSERVATION.pulmonary_function.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0127 and name/value='FVC'], code=at0127, itemType=CLUSTER, level=2, text=FVC, description=Details of Pulmonary Function Test Results., 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.adhoc.v1 and name/value='9. Lung function']/items[openEHR-EHR-OBSERVATION.pulmonary_function.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0127 and name/value='FVC']/items[at0052]/items[at0087], code=at0087, itemType=ELEMENT, level=3, text=Test Result Name, description=The name of the pulmonary volume test/parameter., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Forced vital capacity (FVC) 
Default value: Forced vital capacity (FVC), extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='9. Lung function']/items[openEHR-EHR-OBSERVATION.pulmonary_function.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0127 and name/value='FVC']/items[at0052]/items[at0054], code=at0054, itemType=ELEMENT, level=3, text=Predicted Result, description=Predicted pulmonary volume test result., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=>=0; >=0
Units:
  • l
  • ml
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='9. Lung function']/items[openEHR-EHR-OBSERVATION.pulmonary_function.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0127 and name/value='FVC']/items[at0052]/items[at0053], code=at0053, itemType=ELEMENT, level=3, text=Actual Result, description=Actual pulmonary volume test result., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=>=0; >=0
Units:
  • l
  • ml
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='9. Lung function']/items[openEHR-EHR-OBSERVATION.pulmonary_function.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0127 and name/value='FVC']/items[at0052]/items[at0044], code=at0044, itemType=ELEMENT, level=3, text=Actual/predicted Ratio, description=The ratio of actual to predicted test result., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_PROPORTION, bindings=null, values=
  • Ratio
  • Percent
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='9. Lung function']/items[openEHR-EHR-OBSERVATION.pulmonary_function.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0127 and name/value='FEV1 / FVC'], code=at0127, itemType=CLUSTER, level=2, text=FEV1 / FVC, description=Details of Pulmonary Function Test Results., 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.adhoc.v1 and name/value='9. Lung function']/items[openEHR-EHR-OBSERVATION.pulmonary_function.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0127 and name/value='FEV1 / FVC']/items[at0055]/items[at0089], code=at0089, itemType=ELEMENT, level=3, text=Test Result Name, description=The nameof the pulmonary ratio test., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • FEV1/FVC ratio (FEV1%FVC) 
Default value: FEV1/FVC ratio (FEV1%FVC), extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='9. Lung function']/items[openEHR-EHR-OBSERVATION.pulmonary_function.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0127 and name/value='FEV1 / FVC']/items[at0055]/items[at0056], code=at0056, itemType=ELEMENT, level=3, text=Actual Result, description=Actual pulmonary test ratio result., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_PROPORTION, bindings=null, values=
  • Ratio
  • Percent
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='9. Lung function']/items[openEHR-EHR-OBSERVATION.pulmonary_function.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0127 and name/value='FEV1 / FVC']/items[at0099], code=at0099, itemType=ELEMENT, level=3, text=Interpretation, description=Textual or coded interpretations of the test results., 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.adhoc.v1 and name/value='9. Lung function']/items[openEHR-EHR-OBSERVATION.pulmonary_function.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0130], code=at0130, itemType=ELEMENT, level=2, text=Overall Interpretation, description=Overall clinical interpretation of the measurements and related findings., 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.adhoc.v1 and name/value='Patient and carer concerns'], code=at0000, itemType=SECTION, level=1, text=Patient and carer concerns, description=A generic section header., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, 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.adhoc.v1 and name/value='Patient and carer concerns']/items[openEHR-EHR-EVALUATION.clinical_synopsis.v1], code=at0000, itemType=EVALUATION, level=2, text=Patient and carer concerns 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=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.adhoc.v1 and name/value='Patient and carer concerns']/items[openEHR-EHR-EVALUATION.clinical_synopsis.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=3, 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.adhoc.v1 and name/value='Patient and carer concerns']/items[openEHR-EHR-EVALUATION.advance_decision_refuse_treatment_uk.v1], code=at0000, itemType=EVALUATION, level=2, text=Advance decision to refuse treatment, description=An advance decision to refuse treatment (ADRT) is a decision to refuse a specific treatment, made in advance by a person who has capacity to do so., 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.adhoc.v1 and name/value='Patient and carer concerns']/items[openEHR-EHR-EVALUATION.advance_decision_refuse_treatment_uk.v1]/data[at0001]/items[at0003], code=at0003, itemType=ELEMENT, level=3, text=Decision status, description=The state of the decision to refuse treatment., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Advanced decision to refuse treatment signed 
  • Has advance decision to refuse treatment (Mental Capacity Act 2005) 
  • Has advance decision to refuse life sustaining treatment (Mental Capacity Act 2005) 
  • Advanced directive not signed 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Patient and carer concerns']/items[openEHR-EHR-EVALUATION.advance_decision_refuse_treatment_uk.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=3, text=Date of decision, description=The date at which the DNACPR decision was originally taken or last reviewed., 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.adhoc.v1 and name/value='Patient and carer concerns']/items[openEHR-EHR-EVALUATION.advance_decision_refuse_treatment_uk.v1]/data[at0001]/items[at0012], code=at0012, itemType=ELEMENT, level=3, text=Informal carer awareness of decision, description=Is the informal carer, or carers, aware of the advanced directive?, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Informal carer not aware of advanced directive 
  • Informal carer aware of advanced directive 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Patient and carer concerns']/items[openEHR-EHR-EVALUATION.advance_decision_refuse_treatment_uk.v1]/data[at0001]/items[at0021], code=at0021, itemType=ELEMENT, level=3, text=Comment, description=Other narrative comment pertinent to the advanced directive., 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.adhoc.v1 and name/value='Patient and carer concerns']/items[openEHR-EHR-EVALUATION.advance_decision_refuse_treatment_uk.v1]/protocol[at0010]/items[at0013], code=at0013, itemType=ELEMENT, level=3, text=Discussion with healthcare professional, description=Has the advanced directive been discussed with a healthcare professional?, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Decision to refuse treatment discussed with healthcare professional 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Patient and carer concerns']/items[openEHR-EHR-EVALUATION.advance_decision_refuse_treatment_uk.v1]/protocol[at0010]/items[at0011], code=at0011, itemType=ELEMENT, level=3, text=Location of advance directive documentation, description=The location of the original advanced directive document, either a text description or an electronic link., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Text
  •  URI
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='10. Invasive investigation'], code=at0000, itemType=SECTION, level=1, text=10. Invasive investigation, description=A generic section header., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, 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.adhoc.v1 and name/value='10. Invasive investigation']/items[openEHR-EHR-OBSERVATION.imaging_exam.v1], code=at0000, itemType=OBSERVATION, level=2, text=Coronary angiography, description=Record the findings and interpretation of an imaging examination, or series of examinations, performed., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, 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.adhoc.v1 and name/value='10. Invasive investigation']/items[openEHR-EHR-OBSERVATION.imaging_exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=3, text=Examination result name, description=Identification of the imaging examination or procedure performed, typically including modality and anatomical location (including laterality). Coding with a terminology, potientially a pre-coordinated term specifying both modality and anatomical location, is desirable where possible. Possible candidate terminologies: LOINC, SNOMED CT or RadLex., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=Default value: SNOMEDCT:: 33367005::coronary angiography, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='10. Invasive investigation']/items[openEHR-EHR-OBSERVATION.imaging_exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0007], code=at0007, itemType=ELEMENT, level=3, text=Overall result status, description=The status of the examination result as a whole., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Final 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='10. Invasive investigation']/items[openEHR-EHR-OBSERVATION.imaging_exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0024], code=at0024, itemType=ELEMENT, level=3, text=DateTime result issued, description=The date and/or time that the result was issued for the recorded 'Examination result status'., 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.adhoc.v1 and name/value='10. Invasive investigation']/items[openEHR-EHR-OBSERVATION.imaging_exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0020], code=at0020, itemType=ELEMENT, level=3, text=Radiological diagnosis, description=Single word, phrase or brief description representing the 'Conclusion'. Coding with a terminology is preferred, where possible., 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.adhoc.v1 and name/value='Assessment'], code=at0000, itemType=SECTION, level=1, text=Assessment, description=A generic section header., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, 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.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=2, text=Final diagnosis, description=Identification of the index problem, issue or diagnosis., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, 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.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0003], code=at0003, itemType=ELEMENT, level=2, text=Date of Onset, description=The date / time when the problem was first identified by the individual., 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.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/protocol[at0032]/items[at0035], code=at0035, itemType=ELEMENT, level=2, text=Supporting clinical evidence, description=Useful information on the internet about this condition., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_EHR_URI, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/protocol[at0032]/items[openEHR-EHR-CLUSTER.problem_status.v1]/items[at0029], code=at0029, itemType=ELEMENT, level=2, text=Certainty, description=The level of confidence in the identification of the problem or diagnosis., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Possible 
  • Equivocal 
  • Probable 
  • Definite 
  • Confirmed 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/protocol[at0032]/items[openEHR-EHR-CLUSTER.problem_status.v1]/items[at0004], code=at0004, itemType=ELEMENT, level=2, text=Evolution, description=Records temporal/evidential progress towards identification of the problem or diagnosis, recognising that precise identification may take time to evolve as increasing amounts of evidence become available., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Final assessment 
Default value: Final assessment, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/protocol[at0032]/items[openEHR-EHR-CLUSTER.problem_status.v1]/items[at0060], code=at0060, itemType=ELEMENT, level=2, text=Temporal context, description=Temporal context indicator aligned with SNOMEDCT., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Current 
Default value: Current, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Assessment']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/protocol[at0032]/items[openEHR-EHR-CLUSTER.problem_status.v1]/items[at0063], code=at0063, itemType=ELEMENT, level=2, text=Episodic care status, description=In episodic care contexts (commonly secondary care) it is common to categorise/ organise problems according to their relationship to the principal problem or diagnosis being addressed during that episode of care. These categories may also be used for clinical coding, reporting and billing purposes., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Primary diagnosis 
  • Primary procedure 
  • Co-morbidity 
  • Complication 
  • Other current problem 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan'], code=at0000, itemType=SECTION, level=1, text=Plan, description=A generic section header., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, 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.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Goals'], code=at0000, itemType=SECTION, level=2, text=Goals, description=A generic section header., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, 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.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Goals']/items[openEHR-EHR-EVALUATION.goal.v1 and name/value='Target Systolic BP'], code=at0000, itemType=EVALUATION, level=3, text=Target Systolic BP, description=A future health state that is agreed to by the person., 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.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Goals']/items[openEHR-EHR-EVALUATION.goal.v1 and name/value='Target Systolic BP']/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Goal Name, description=The name of the goal that is to be achieved., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=Default value: Control blood pressure, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Goals']/items[openEHR-EHR-EVALUATION.goal.v1 and name/value='Target Systolic BP']/data[at0001]/items[at0005]/items[at0010], code=at0010, itemType=ELEMENT, level=4, text=Target, description=The name of a specific target., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=Default value: SNOMEDCT::315612005::target systolic blood pressure, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Goals']/items[openEHR-EHR-EVALUATION.goal.v1 and name/value='Target Systolic BP']/data[at0001]/items[at0005]/items[at0007], code=at0007, itemType=ELEMENT, level=4, text=Target measurement, description=The target measurement value or range of values., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=0..200 mm[Hg], extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Goals']/items[openEHR-EHR-EVALUATION.goal.v1 and name/value='Target symptom control'], code=at0000, itemType=EVALUATION, level=3, text=Target symptom control, description=A future health state that is agreed to by the person., 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.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Goals']/items[openEHR-EHR-EVALUATION.goal.v1 and name/value='Target symptom control']/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Goal Name, description=The name of the goal that is to be achieved., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=Default value: Minimise heart failure-related symptoms, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Goals']/items[openEHR-EHR-EVALUATION.goal.v1 and name/value='Target Resting HR'], code=at0000, itemType=EVALUATION, level=3, text=Target Resting HR, description=A future health state that is agreed to by the person., 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.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Goals']/items[openEHR-EHR-EVALUATION.goal.v1 and name/value='Target Resting HR']/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Goal Name, description=The name of the goal that is to be achieved., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=Default value: Control resting heart rate, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Goals']/items[openEHR-EHR-EVALUATION.goal.v1 and name/value='Target Resting HR']/data[at0001]/items[at0005]/items[at0010], code=at0010, itemType=ELEMENT, level=4, text=Target, description=The name of a specific target., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=Default value: SNOMEDCT::428420003::target heart rate, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Goals']/items[openEHR-EHR-EVALUATION.goal.v1 and name/value='Target Resting HR']/data[at0001]/items[at0005]/items[at0007], code=at0007, itemType=ELEMENT, level=4, text=Target measurement, description=The target measurement value or range of values., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Goals']/items[openEHR-EHR-EVALUATION.goal.v1 and name/value='Target Dry Weight'], code=at0000, itemType=EVALUATION, level=3, text=Target Dry Weight, description=A future health state that is agreed to by the person., 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.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Goals']/items[openEHR-EHR-EVALUATION.goal.v1 and name/value='Target Dry Weight']/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Goal Name, description=The name of the goal that is to be achieved., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=Default value: Control dry weight, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Goals']/items[openEHR-EHR-EVALUATION.goal.v1 and name/value='Target Dry Weight']/data[at0001]/items[at0005]/items[at0010], code=at0010, itemType=ELEMENT, level=4, text=Target, description=The name of a specific target., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=Default value: SNOMEDCT::390734006::target weight, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Goals']/items[openEHR-EHR-EVALUATION.goal.v1 and name/value='Target Dry Weight']/data[at0001]/items[at0005]/items[at0007], code=at0007, itemType=ELEMENT, level=4, text=Target measurement, description=The target measurement value or range of values., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=>=0 kg, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Goals']/items[openEHR-EHR-EVALUATION.goal.v1 and name/value='Target HBA1C'], code=at0000, itemType=EVALUATION, level=3, text=Target HBA1C, description=A future health state that is agreed to by the person., 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.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Goals']/items[openEHR-EHR-EVALUATION.goal.v1 and name/value='Target HBA1C']/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Goal Name, description=The name of the goal that is to be achieved., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=Default value: Control HBA1C, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Goals']/items[openEHR-EHR-EVALUATION.goal.v1 and name/value='Target HBA1C']/data[at0001]/items[at0005]/items[at0010], code=at0010, itemType=ELEMENT, level=4, text=Target, description=The name of a specific target., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=Default value: SNOMEDCT::408591000::HBA1c target, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Goals']/items[openEHR-EHR-EVALUATION.goal.v1 and name/value='Target HBA1C']/data[at0001]/items[at0005]/items[at0007], code=at0007, itemType=ELEMENT, level=4, text=Target measurement, description=The target measurement value or range of values., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_PROPORTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Recommended medication'], code=at0000, itemType=SECTION, level=2, text=Recommended medication, description=A generic section header., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, 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.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Recommended medication']/items[openEHR-EHR-INSTRUCTION.medication_order.v1], code=at0000, itemType=INSTRUCTION, level=3, text=Medication order, description=Details of a medicine, vaccine or other therapeutic good with instructions for use., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=INSTRUCTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Recommended medication']/items[openEHR-EHR-INSTRUCTION.medication_order.v1]/activities[at0001], code=at0001, itemType=ACTIVITY, level=4, text=Order, description=The instructions for a particular medicine, vaccine or other therapeutic good including dose and timing., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ACTIVITY, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Recommended medication']/items[openEHR-EHR-INSTRUCTION.medication_order.v1]/activities[at0001]/description[at0002], code=at0002, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=5, text=Description, 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.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Recommended medication']/items[openEHR-EHR-INSTRUCTION.medication_order.v1]/activities[at0001]/description[at0002]/items[at0003], code=at0003, itemType=ELEMENT, level=6, text=Medicine, description=The medicine, vaccine or other therapeutic good being ordered, administered to or used by the subject of care. This item should be coded if possible., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=Default value: Enalapril, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Recommended medication']/items[openEHR-EHR-INSTRUCTION.medication_order.v1]/activities[at0001]/description[at0002]/items[at0009], code=at0009, itemType=ELEMENT, level=6, text=Overall directions, description=A complete narrative description of how much, when and how to use the medicine, vaccine or other therapeutic good., 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.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Recommended medication']/items[openEHR-EHR-INSTRUCTION.medication_order.v1]/activities[at0001]/description[at0002]/items[at0005], code=at0005, itemType=ELEMENT, level=6, text=Dose description, description=The amount and units of the medicine, vaccine or other therapeutic good to be used or administered at one time., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=Default value: 10mg in the morning, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Recommended medication']/items[openEHR-EHR-INSTRUCTION.medication_order.v1]/activities[at0001]/description[at0002]/items[at0035], code=at0035, itemType=ELEMENT, level=6, text=Comment, description=Any additional information that may be needed to ensure the continuity of supply, rationale for current dose and timing, or safe and appropriate use., 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.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Requests'], code=at0000, itemType=SECTION, level=2, text=Requests, description=A generic section header., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, 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.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Requests']/items[openEHR-EHR-INSTRUCTION.request-lab_test.v1], code=at0000.1, itemType=INSTRUCTION, level=3, text=Laboratory Test request, description=Generic request for a laboratory request., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=INSTRUCTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Requests']/items[openEHR-EHR-INSTRUCTION.request-lab_test.v1]/activities[at0001]/description[at0009]/items[at0121], code=at0121, itemType=ELEMENT, level=4, text=Service requested, description=Identification of the service requested. This is often coded with an external terminology., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=Default value: SNOMEDCT::252167001::urea and electrolytes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Requests']/items[openEHR-EHR-INSTRUCTION.request.v1], code=at0000, itemType=INSTRUCTION, level=3, text=Healthcare service request, description=Generic request for a range of different healthcare services e.g referral, lab request, equipment request., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=INSTRUCTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Requests']/items[openEHR-EHR-INSTRUCTION.request.v1]/activities[at0001]/description[at0009], code=at0009, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Description, 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.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Requests']/items[openEHR-EHR-INSTRUCTION.request.v1]/activities[at0001]/description[at0009]/items[at0121], code=at0121, itemType=ELEMENT, level=5, text=Service requested, description=Identification of the service requested. This is often coded with an external terminology., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=Default value: Check potassium levels, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Information given'], code=at0000, itemType=SECTION, level=2, text=Information given, description=A generic section header., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, 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.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Information given']/items[openEHR-EHR-EVALUATION.clinical_synopsis.v1], code=at0000, itemType=EVALUATION, level=3, text=Information given 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=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.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-SECTION.adhoc.v1 and name/value='Information given']/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]], templateType=normal]