TEMPLATE CG assessment (CG assessment)

TEMPLATE ID	CG assessment
Concept	CG assessment
Description	Overall assessment of diagnostic tests to identify the slightest sign of progression of chronic glaucoma, and recommend an appropriate therapy accordingly.
Purpose	Overall assessment of diagnostic tests to identify the slightest sign of progression of chronic glaucoma, and recommend an appropriate therapy accordingly.
References
Authors	name: Aitor Eguzkitza; organisation: Universidad Pública de Navarra - Complejo Hospitalario de Navarra; email: aitor.eguzkiza@unavarra.es; date: 2016-07-24
Other Details Language	name: Aitor Eguzkitza; organisation: Universidad Pública de Navarra - Complejo Hospitalario de Navarra; email: aitor.eguzkiza@unavarra.es; date: 2016-07-24
Other Details (Language Independent)	MetaDataSet:Sample Set : Template metadata sample set Copyright: © openEHR Foundation Owner: Aitor Eguzkitza, aitor.eguzkiza@unavarra.es Speciality: Ophthalmology
Language used	en
Citeable Identifier	1013.26.146
Root archetype id	openEHR-EHR-COMPOSITION.report-result.v1
Result Report	Result Report: Document to communicate information to others about the result of a test or assessment.
Other Context
Report ID	Report ID: Identification information about the report.
Status	Status: The status of the entire report. Note: This is not the status of any of the report components.
Image test analysis	Image test analysis: Describes the analysis of image based diagnostic tests, to find clinical findings which can be relevant to decide a diagnosis for a specific disease.
Visual field measurement	Visual field measurement: Results of visual field testing / perimetry.
Data
Any event	Any event: Any measurement event.
Data
Clinical Description	Clinical Description: A term, commonly coded, expressing an overall interpretation of the visual field test. Value set: terminology:Snomed?subset=Findings%20of%20visual%20field&language=en-GB
Additional Comment	Additional Comment: Any additional narrative comment about the visual field test.
State
Confounding Factors	Confounding Factors: Patient circumstances which may affect interpretation of the result.
Fundoscopic examination of eyes	Fundoscopic examination of eyes: Record of clinical findings on fundoscopy of eyes
Data
Any event	Any event: *
Data
Clinical Description	Clinical Description: Descriptive overview of examination findings Value set: terminology:Snomed?subset=Findings%20in%20posterior%20pole%20of%20eye&language=en-GB
Test Result	Test Result: Details of the funduscopic examination test result for each eye.
Side	Side: Determines the eye on which the test was performed.Matches to DICOM Laterality (0020,0060) attribute. Left eye Right eye
Structural description	Structural description: General description of the structures in the eye fundus
Optic Disc	Optic Disc: Description of optic disc
Macula	Macula: Description of macula
Retinal arteries	Retinal arteries: Description of retinal arteries
Retinal veins	Retinal veins: Description of retinal veins
Retinal background	Retinal background: Description of retinal background
Vitreous	Vitreous: Description of vitreous humour
Clinical results	Clinical results: Information of diagnostic interest obtained in the test
Other findings	Other findings: Narrative description of clinical findings not considered in the SLOT
Ophthalmic tomography examination	Ophthalmic tomography examination: Record of clinical findings using optical coherence tomography with ophthalmic purposes.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Clinical description	Clinical description: A term, commonly coded, expressing an overall interpretation of the OCT test. Value set: terminology:Snomed?subset=Findings%20in%20posterior%20pole%20of%20eye&language=en-GB
Test result	Test result: Details of the ophthalmic tomography examination test result for each eye.
Side	Side: Determines the eye on which the test was performed.Matches to DICOM Laterality (0020,0060) attribute. Matches to DICOM Laterality (0020,0060) attribute. Left eye Right eye
Structure analyzed	Structure analyzed: The anatomic structure analyzed in this study. Matches to DICOM Anatomic Region Sequence (0008,2218) attribute. Values permitted are defined by DICOM standard (PS 3.16) inside the table with Context ID 4211 (Ophthalmic OCT Anatomic Structure Imaged). Value set: ac0001
Clinical findings	Clinical findings: Every finding considered clinically relevant, found on posterior chamber of the eye. Value set: ac0002
State
Confounding factors	Confounding factors: Patient circumstances which may affect interpretation of the result.
Intraocular pressure	Intraocular pressure: Value of intraocular pressure in mmHg. Matches to DICOM (0022,000B) attribute. 0..90 mmHg (UCUM: mm[Hg])
Axial length of the eye	Axial length of the eye: Axial length of the eye in mm. Matches to DICOM (0022,0030) attribute. >=0 mm
Horizontal field of view	Horizontal field of view: The horizontal field of view in degrees. Matches to DICOM (0022,000C) attribute. Units: ° (UCUM: deg)
Clinical decision	Clinical decision: Defines the process of making a decision about the diagnosis of a specific disease.
Clinical Synopsis	Clinical Synopsis: Narrative summary or overview about a patient, specifically from the perspective of a healthcare provider, and with or without associated interpretations.
Data
Synopsis	Synopsis: The summary, assessment, conclusions or evaluation of the clinical findings.
Problem/Diagnosis	Problem/Diagnosis: Details about a single identified health condition, injury, disability or any other issue which impacts on the physical, mental and/or social well-being of an individual. Clear delineation between the scope of a problem versus a diagnosis is not easy to achieve in practice. For the purposes of clinical documentation with this archetype, problem and diagnosis are regarded as a continuum, with increasing levels of detail and supportive evidence usually providing weight towards the label of 'diagnosis'.
Data
Problem/Diagnosis name	Problem/Diagnosis name: Identification of the problem or diagnosis, by name. Coding of the name of the problem or diagnosis with a terminology is preferred, where possible.
Clinical description	Clinical description: Narrative description about the problem or diagnosis. Use to provide background and context, including evolution, episodes or exacerbations, progress and any other relevant details, about the problem or diagnosis.
Body site	Body site: Identification of a simple body site for the location of the problem or diagnosis. Coding of the name of the anatomical location with a terminology is preferred, where possible. Use this data element to record precoordinated anatomical locations. If the requirements for recording the anatomical location are determined at run-time by the application or require more complex modelling such as relative locations then use the CLUSTER.anatomical_location or CLUSTER.relative_location within the 'Structured anatomical location' SLOT in this archetype. Occurrences for this data element are unbounded to allow for clinical scenarios such as describing a rash in multiple locations but where all of the other attributes are identical. If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant.
Date/time of onset	Date/time of onset: Estimated or actual date/time that signs or symptoms of the problem/diagnosis were first observed. Data captured/imported as "Age at onset" should be converted to a date using the subject's date of birth.
Classification of glaucoma	Classification of glaucoma: Classifies the type of glaucoma of patients and provides key clinical findings to support the diagnostic decision.
Classification	Classification: Clinical grade determined for glaucoma. Value set: ac0002
Progressive disease	Progressive disease: It is set to true whenever findings are made concerning any glaucomatous activity or progression that could lead to visual loss in the future. Conversely, if it is set to false, it means that the patient is medically stable for now, since the ophthalmologist did not identify clear signs of disease progression. Assumed value: true
Findings in glaucoma	Findings in glaucoma: Clinical findings on eye related with the diagnose of glaucoma.
Anterior segment	Anterior segment: Document the insertion level of the iris root before and during compression dynamic gonioscopy.
Iris root	Iris root: Insertion of iris root. Anterior to Schwalbe Behind Schwalbe Scleral Spur Behind Scleral Spur Cillary Band
Angle recess	Angle recess: Angular width of angle recess. 10..40 ° (UCUM: deg)
Peripheral iris	Peripheral iris: Configuration of the peripheral iris. Steep Regular Queer
Slit thickness	Slit thickness: Ratio of slit thickness of the cornea to the depth of the anterior chamber. Angle closed Angle closure likely (angle 10°) Angle clossure possible (angle 20°) Angle closure unlikely Angle closure very unlikely
Retinal nerve fiber layer	Retinal nerve fiber layer: Findings on RNFL supporting the current study of glaucoma.
Parapapillary atrophy	Parapapillary atrophy: Narrative description of diffuse or localized abnormalities of the peripapillary retinal nerve fiber layer, especially at the inferior or superior poles.
RNFL thinning	RNFL thinning: Identification of retinal nerve fiber layer thinning defects. Diffuse thinning Localized defects
Hemorrhages RNFL	Hemorrhages RNFL: Identification of hemorrhages on the peripapillary retinal nerve fiber layer.
Optic disc	Optic disc: Findings on optic disc supporting the current study of glaucoma.
Rim loss pattern	Rim loss pattern: Description of the pattern of neuroretinal rim loss. It may take the form of diffuse thinning, focal narrowing, or localized notching of the optic disc rim, especially at the inferior or superior poles.
Asymmetric rim	Asymmetric rim: Optic disc neural rim asymmetry of the two eyes consistent with loss of neural tissue.
Cupping	Cupping: Identification of progressive thinning of the neuroretinal rim with an associated increase in cupping of the optic disc.
Vessels	Vessels: Description of any positional changes of the vessels at the optic disc with bending, bayoneting or baring of circumlinear vessels.
Hemorrhages optic disc	Hemorrhages optic disc: Identification of hemorrhages on or bordering the optic disc. Assumed value: false
Optic nerve head	Optic nerve head: Description of features in optic nerve head (ONH).
Visual field	Visual field: Findings on visual field supporting the current study of glaucoma.
Visual field defects	Visual field defects: Visual field damage consistent with retinal nerve fiber layer damage. Early glaucomatous loss Moderate glaucomatous loss Advanced glaucomatous loss
Asymmetric loss	Asymmetric loss: Visual field loss in one hemifield that is different from the other hemifield, i.e., across the horizontal midline (in early/moderate cases). Assumed value: false
Comments	Comments: Narrative description of overall findings, inlcuding those not considered above.
Comments	Comments: Additional comments that clarify the diagnostic decision made.
Contraindication	Contraindication: Identification of a treatment, test or procedure which should not be provided to the subject of care, for clinical reasons.
Data
Contraindication	Contraindication: Identification of a contraindication to a treatment, test or procedure, including a class of medications or vaccines. Coding of the identified 'Contraindication' with a terminology is desirable, where possible.
Rationale	Rationale: Description of evidence or rationale for the contraindication. Please note: an optional URI link to evidence within the health record is also permitted using Reference Model attributes. As this URI link may not be accessible from a message or by receiving clinical system it is desirable that a narrative description of the rationale should be explicitly stated.
Protocol
Last updated	Last updated: The date this contraindication was last updated.
Review date	Review date: Date when due for review by a clinician. In some circumstances, contraindications are not intended to be indefinite or lifelong, and this contraindication should be reconsidered in the context of changing clinical circumstances. For example: if a family member is no longer taking immunosuppressive therapy, then live vaccines could safely be administered to the subject of care again and the contraindication is effectively obsolete.
Recommendation	Recommendation: A suggestion, advice or proposal for clinical management.
Data
Recommendation	Recommendation: Narrative description of the recommendation. May be coded, using a terminology, if required. Value set: terminology:Snomed?subset=Glaucoma%20treatments&language=en-GB
Rationale	Rationale: Justifications for the recommendation. Glaucoma stable Visual field loss Progressive excavation of the papilla IOP unstable
Next step planning	Next step planning: Decision-making concerning the planning of next assessment for the diagnostic tests carried out.
Diagnostic report request	Diagnostic report request: Request for a diagnostic report involving the study of specific diagnostic tests.
Request	Request: Current Activity.
Description
Service requested	Service requested: Identification of the service requested. This is often coded with an external terminology. Office assessment of glaucoma Remote assessment of chronic glaucoma
Description of service	Description of service: A detailed narrative description of the service requested.
Reason for request	Reason for request: A short description of the reason for the request. This is often coded with an external terminology. Completed the diagnostic tests necessary for assessment Determine therapy for progressive glaucoma
Reason description	Reason description: A narrative description explaining the reason for request.
Intent	Intent: Stated intent of the request by the referrer.
Urgency	Urgency: Urgency of the request. Emergency Urgent Routine
Date &/or time service required	Date &/or time service required: The date and time that the service should be performed or completed.
Latest date service required	Latest date service required: The latest date that is acceptable for the service to be completed.
Protocol
Requestor Identifier	Requestor Identifier: The local ID assigned to the order by the healthcare provider or organisation requesting the service. This is also referred to as Placer Order Identifier.
Receiver identifier	Receiver identifier: The ID assigned to the order by the healthcare provider or organisation receiving the request for service. This is also referred to as Filler Order Identifier.
Request status	Request status: The status of the request for service as indicated by the requester. Status is used to denote whether this is the initial request, or a follow-up request to change or provide supplementary information.
Service request	Service request: Request for a health-related service to be supplied by a healthcare provider or agency. For example equipment request.
Request	Request: Description of the requested service.
Description
Service name	Service name: Identification of the service requested, by name. Coding of the 'Service name' with a coding system is desirable, if available. Follow-up schedule for chronic glaucoma
Service type	Service type: Category of service requested. For example: hospital vs home care delivery.
Description	Description: Narrative description of the service requested. Follow-up comprised by IOP measurement, VA, NMR, OCT and VF tests
Reason for request	Reason for request: A short phrase describing the reason for the request. Coding of the 'Reason for request' with a coding system is desirable, if available.
Reason description	Reason description: Narrative description about the reason for request.
Intent	Intent: Description of the intent for the request. For example a referral with the intent of having specialist care take over the care of the patient, or advice on how to proceed with an investigation or treatment. This data element allows multiple occurrences to enable multiple choice selection in user interface.
Urgency	Urgency: Urgency of the request for service. Specific definitions of emergency and urgent will vary between clinical contexts, clinical systems and the nature of the request itself, so have not be defined in this archetype. If explicit timing is required then the Service period should be clearly stated. Coded Text Emergency Urgent Routine Text
Service due	Service due: The date/time, or acceptable interval of date/time, for provision of the service. In practice, clinicians will often think in terms of ordering services as approximate timing, for example: review in 3 months, 6 months or 12 months. As clinical systems need more exact parameters to operate on, this '3 months' will usually be converted to an exact date 3 months from the date of recording and stored using this data element.
Service period start	Service period start: The date/time that marks the beginning of the valid period of time for delivery of this service. This date/time is the equivalent to the earliest possible date for service delivery. For example: sometimes a certain amount of time must pass before a service can be performed, for example some procedures can only be performed once the patient has stopped taking medications for a specific amount of time.
Service period expiry	Service period expiry: The date/time that marks the conclusion of the valid period of time for delivery of this service. This date/time is the equivalent to the latest possible date for service delivery or to the date of expiry for this request. For example: a service may be required to be completed before another event, such as scheduled surgery.
Indefinite?	Indefinite?: The valid period for this request is open ended and has no date of expiry. Record as TRUE to record explicity that the request has no expiry date.
Protocol
Requestor Identifier	Requestor Identifier: The local ID assigned to the order by the healthcare provider or organisation requesting the service. This is also referred to as Placer Order Identifier.
Receiver identifier	Receiver identifier: The ID assigned to the order by the healthcare provider or organisation receiving the request for service. This is also referred to as Filler Order Identifier.
Request status	Request status: The status of the request for service as indicated by the requester. Status is used to denote whether this is the initial request, or a follow-up request to change or provide supplementary information.
Other contributors	Jose Andonegui, Complejo hospitalario de Navarra (CHN), jose.andonegui.navarro@cfnavarra.es; Luis Serrano, Universidad Pública de Navarra (UPNA), lserrano@unavarra.es; Jesús D. Trigo, Universidad Pública de Navarra (UPNA), jesusdaniel.trigo@unavarra.es