| TEMPLATE ID | Planning the diagnostic tests to detect and classify DR |
|---|---|
| Concept | Planning the diagnostic tests to detect and classify DR |
| Description | To schedule the diagnostic tests necessary to determine a diagnosis and provide classification for diabetic retinopathy. |
| Purpose | To schedule the diagnostic tests necessary to determine a diagnosis and provide classification for diabetic retinopathy. |
| References | |
| Other Details (Language Independent) |
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| Language used | en |
| Citeable Identifier | 1013.26.160 |
| Root archetype id | openEHR-EHR-SECTION.diagnostic_test_planning.v0 |
| Diagnostic test planning | Diagnostic test planning: Schedules each patient to perform the diagnostic tests necessary to assess a specific disease. |
| Care Plan | Care Plan: Order or instruction for the creation and sequence of activities to achieve a specified management goal or treatment outcome, carried out by health professionals and/or the subject. |
| Activity | Activity: Current Activity. |
| Description | |
| Care Plan Name | Care Plan Name: Identification of the care plan. Default value: Remote screening service for DR |
| Description | Description: Description of the care plan scope, intent and proposed activities. |
| Indication | Indication: Indication for the care plan. For example: a known diagnosis; or a specific goal. Default value: Identified clinical signs leading to DR suspicion. |
| Date of Onset | Date of Onset: Date of onset for the care plan. |
| Comment | Comment: Additional narrative about the care plan order not captured in other fields. |
| Care Plan | Care Plan: Plan or sequence of discrete activities developed to achieve a specified management goal or treatment outcome, carried out by health professionals and/or the patient. |
| Description | |
| Care Plan Name | Care Plan Name: Name of care plan. Default value: Remote screening service for DR |
| Description | Description: Description of activity performed/enacted against the plan. |
| Reason | Reason: Reason for activity being performed /enacted against the plan. |
| Protocol | |
| Care Plan ID | Care Plan ID: Identification of care plan. |
| Expiry Date | Expiry Date: Anticipated date beyond which the care plan can be deemed 'expired'. |
| IOP measurement request | IOP measurement request: Request for provision of a specified service by another healthcare provider or organisation. |
| Request | Request: Current Activity. |
| Description | |
| Service requested | Service requested: Identification of the service requested. This is often coded with an external terminology. Default value: Intraocular pressure measurement |
| Description of service | Description of service: A detailed narrative description of the service requested. Default value: IOP measurements using a non-contact tonometer, adjusted according to the corneal thickness measured by pachimetry. |
| Reason for request | Reason for request: A short description of the reason for the request. This is often coded with an external terminology. Default value: To identify patients with dangerous IOP levels (≥22 mmHg). |
| 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.
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| 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. |
| Supplementary information to follow | Supplementary information to follow: True indicates that additional information has been identified and will be forwarded when available eg incomplete pathology test results. |
| Supplementary information expected | Supplementary information expected: Details of the nature of supplementary information that is to follow e.g name of laboratory results. |
| 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. |
| Duration | Duration: Length of time the referral is valid. |
| Duration | Duration: Duration for which the referral is valid. |
| Indefinite | Indefinite: If true, referral is for an indefinite period of time. |
| Funduscopic examination request | Funduscopic examination request: Generic request for an imaging examination request. |
| Request | Request: Current Activity. |
| Description | |
| Examination requested | Examination requested: Identification of the examination requested. This is often coded with an external terminology. Default value: Examination of eye retina, study specifically focused on macula and papilla |
| Description of examination | Description of examination: A detailed narrative description of the examination requested. Default value: Examination of eye fundus for retinal alterations associated with DR. |
| Acquisition details on eye fundus images | Acquisition details on eye fundus images: Defines specific details about the acquisition of images from eye fundus. |
| Laterality | Laterality: Eye/s from which the eye fundus is examined.
|
| Method | Method: Method chosen to perform the funduscopic examination.
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| Attempts Allowed | Attempts Allowed: Limit on the number of attempts allowed to conduct the acquisition (doesn't compute if test is repeated by a specific recognized technical failure). >=1 Default value: 3 Assumed value: 3 |
| Zone of Retina | Zone of Retina: Anatomical structures from retina in which the study of eye fundus is focused. Value set: ac0001 |
| Study Fields Photographed | Study Fields Photographed: Specifies which fields from a specific subdivision of the retina are photographed in the study of eye fundus. Value set: ac0002 |
| Mosaic | Mosaic: If true, the study includes a mosaic image that combines all eye fundus fields acquired into a single picture. Assumed value: false |
| Reason for request | Reason for request: A short description of the reason for the request. This is often coded with an external terminology. Default value: Suspicion of DR |
| 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.
|
| 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. |
| Supplementary information to follow | Supplementary information to follow: True indicates that additional information has been identified and will be forwarded when available eg incomplete pathology test results. |
| Supplementary information expected | Supplementary information expected: Details of the nature of supplementary information that is to follow e.g name of laboratory results. |
| 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. |