TEMPLATE Diagnostic tests in the DR screening service (06dfaaeb-a441-4ce9-afb7-055ec4447415)

TEMPLATE ID06dfaaeb-a441-4ce9-afb7-055ec4447415
ConceptDiagnostic tests in the DR screening service
DescriptionManage the acquisition and validation of diagnostic tests involved in the DR screening service.
PurposeManage the acquisition and validation of diagnostic tests involved in the DR screening service.
References
Authorsname: Aitor Eguzkitza; organisation: Universidad Pública de Navarra - Complejo Hospitalario de Navarra; email: aitor.eguzkiza@unavarra.es; date: 2016-07-25
Other Details Languagename: Aitor Eguzkitza; organisation: Universidad Pública de Navarra - Complejo Hospitalario de Navarra; email: aitor.eguzkiza@unavarra.es; date: 2016-07-25
OtherDetails Language Independent{MetaDataSet:Sample Set =MetaDataSet:Sample Set , Copyright=Copyright, Owner=Owner, Speciality=Speciality}
Language useden
Citeable Identifier1013.26.165
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  • DR screening
  • Monitor the progression of chronic glaucoma
  • Routine eye consultation
  • Other reason
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  •  Text
  •  Identifier
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  •  Text
  •  Identifier
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  • Left  [The left eye was examined.]
  • Right  [The right eye was examined.]
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  •  Coded Text
    • Goldmann  [Goldmann tonometry.]
    • Perkins  [Perkins tonometry.]
    • Tono-Pen  [Tono-Pen tonometry.]
    • Icare (Rebound)  [Icare (Rebound) tonometry.]
    • Dynamic Contour  [Dynamic Contour tonometry.]
    • Ocular Response Analyzer  [Ocular Response Analyzer.]
    • TGDc-01  [A TGDc-01 device was used to perform the test.]
    • Non-contact tonometry  [Non-contact tonometry was used to perfrom the test.]
  •  Text
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For example: <brand name><machine> (XYZ Audiometer); <size> <brand name> <intravenous catheter> (14G Jelco IV catheter); or <brand name/type> <implant>. Coding with a terminology is desirable, where possible, although this may be local and depending on local supplies available., 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.progress_note.v1]/content[openEHR-EHR-SECTION.intraocular_pressure_study.v0]/items[openEHR-EHR-OBSERVATION.intraocular_pressure.v0]/protocol[at0068]/items[openEHR-EHR-CLUSTER.device.v1]/items[at0003], code=at0003, itemType=ELEMENT, level=5, text=Type, description=The category or kind of device., comment=Not applicable if a category is already recorded in 'Device name'. Example: if the 'Device' is named as a 'urinary catheter'; the 'Type' may be recorded as 'indwelling' or 'condom'.Coding with a terminology is desirable, where possible. This may include use of GTIN or EAN numbers., 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.progress_note.v1]/content[openEHR-EHR-SECTION.intraocular_pressure_study.v0]/items[openEHR-EHR-OBSERVATION.intraocular_pressure.v0]/protocol[at0068]/items[openEHR-EHR-CLUSTER.device.v1]/items[at0002], code=at0002, itemType=ELEMENT, level=5, text=Description, description=Narrative description of the medical device., 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.progress_note.v1]/content[openEHR-EHR-SECTION.intraocular_pressure_study.v0]/items[openEHR-EHR-OBSERVATION.intraocular_pressure.v0]/protocol[at0068]/items[openEHR-EHR-CLUSTER.device.v1]/items[at0021], code=at0021, itemType=ELEMENT, level=5, text=Unique device identifier (UDI), description=A numeric or alphanumeric string that is associated with this device within a given system., comment=Often fixed to the device as a barcode., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_IDENTIFIER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.intraocular_pressure_study.v0]/items[openEHR-EHR-OBSERVATION.intraocular_pressure.v0]/protocol[at0068]/items[openEHR-EHR-CLUSTER.device.v1]/items[at0004], code=at0004, itemType=ELEMENT, level=5, text=Manufacturer, description=Name of manufacturer., 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.progress_note.v1]/content[openEHR-EHR-SECTION.intraocular_pressure_study.v0]/items[openEHR-EHR-OBSERVATION.intraocular_pressure.v0]/protocol[at0068]/items[openEHR-EHR-CLUSTER.device.v1]/items[at0005], code=at0005, itemType=ELEMENT, level=5, text=Date of manufacture, description=Date the device was manufactured., 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.progress_note.v1]/content[openEHR-EHR-SECTION.intraocular_pressure_study.v0]/items[openEHR-EHR-OBSERVATION.intraocular_pressure.v0]/protocol[at0068]/items[openEHR-EHR-CLUSTER.device.v1]/items[openEHR-EHR-CLUSTER.device_details.v1], code=at0000, itemType=CLUSTER, level=5, text=Medical device details, description=Specific details that relate to asset management for any medical device that is designed for more than a single use., 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.progress_note.v1]/content[openEHR-EHR-SECTION.intraocular_pressure_study.v0]/items[openEHR-EHR-OBSERVATION.intraocular_pressure.v0]/protocol[at0068]/items[openEHR-EHR-CLUSTER.device.v1]/items[openEHR-EHR-CLUSTER.device_details.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=6, text=Organisation identifier, description=Organisation identifier for device., comment=May be a text string or an IEEE EUI-64 identifier., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Text
  •  Identifier
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[path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.intraocular_pressure_study.v0]/items[openEHR-EHR-OBSERVATION.intraocular_pressure.v0]/protocol[at0068]/items[openEHR-EHR-CLUSTER.device.v1]/items[openEHR-EHR-CLUSTER.device_details.v1]/items[at0024], code=at0024, itemType=ELEMENT, level=6, text=Location, description=Physical location where device is kept., 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.progress_note.v1]/content[openEHR-EHR-SECTION.intraocular_pressure_study.v0]/items[openEHR-EHR-OBSERVATION.intraocular_pressure.v0]/protocol[at0068]/items[openEHR-EHR-CLUSTER.device.v1]/items[openEHR-EHR-CLUSTER.device_details.v1]/items[at0025], code=at0025, itemType=ELEMENT, level=6, text=Network address, description=Network address to contact the device., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_URI, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.intraocular_pressure_study.v0]/items[openEHR-EHR-OBSERVATION.intraocular_pressure.v0]/protocol[at0068]/items[openEHR-EHR-CLUSTER.device.v1]/items[openEHR-EHR-CLUSTER.device_details.v1]/items[at0007], code=at0007, itemType=ELEMENT, level=6, text=Part number, description=The part number of the device., 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.progress_note.v1]/content[openEHR-EHR-SECTION.intraocular_pressure_study.v0]/items[openEHR-EHR-OBSERVATION.intraocular_pressure.v0]/protocol[at0068]/items[openEHR-EHR-CLUSTER.device.v1]/items[openEHR-EHR-CLUSTER.device_details.v1]/items[at0002], code=at0002, itemType=ELEMENT, level=6, text=Manufacturer model name, description=HL7 CDA compatible representation of device manufacture details., comment=May be a simple string or contain simple markup e.g. for Continua PHMR reports: "Pulse Master 2000||584216|69854|2.1|1.1|1.0|" repesenting Model, Unspecified, SerialNumber, PartNumber, HardwareRevision, SoftwareRevision, ProtocolRevision, and ProdSpecGMDN., 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.progress_note.v1]/content[openEHR-EHR-SECTION.intraocular_pressure_study.v0]/items[openEHR-EHR-OBSERVATION.intraocular_pressure.v0]/protocol[at0068]/items[openEHR-EHR-CLUSTER.device.v1]/items[openEHR-EHR-CLUSTER.device_details.v1]/items[at0008], code=at0008, itemType=ELEMENT, level=6, text=Hardware revision, description=The hardware revision number., 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.progress_note.v1]/content[openEHR-EHR-SECTION.intraocular_pressure_study.v0]/items[openEHR-EHR-OBSERVATION.intraocular_pressure.v0]/protocol[at0068]/items[openEHR-EHR-CLUSTER.device.v1]/items[openEHR-EHR-CLUSTER.device_details.v1]/items[at0010], code=at0010, itemType=ELEMENT, level=6, text=Protocol revision, description=The protocol revision number., 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.progress_note.v1]/content[openEHR-EHR-SECTION.intraocular_pressure_study.v0]/items[openEHR-EHR-OBSERVATION.intraocular_pressure.v0]/protocol[at0068]/items[openEHR-EHR-CLUSTER.device.v1]/items[openEHR-EHR-CLUSTER.device_details.v1]/items[at0011], code=at0011, itemType=ELEMENT, level=6, text=Sampling frequency, description=The sampling frequency limits of the device., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Text
  •  Quantity
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  •  Text
  •  Interval of Quantity
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  •  Text
  •  Quantity
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  •  Text
  •  Quantity
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[path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.intraocular_pressure_study.v0]/items[openEHR-EHR-OBSERVATION.intraocular_pressure.v0]/protocol[at0068]/items[openEHR-EHR-CLUSTER.device.v1]/items[openEHR-EHR-CLUSTER.device_details.v1]/items[at0017], code=at0017, itemType=ELEMENT, level=6, text=Date last calibrated, description=Date the device was last calibrated., 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.progress_note.v1]/content[openEHR-EHR-SECTION.intraocular_pressure_study.v0]/items[openEHR-EHR-OBSERVATION.intraocular_pressure.v0]/protocol[at0068]/items[openEHR-EHR-CLUSTER.device.v1]/items[openEHR-EHR-CLUSTER.device_details.v1]/items[at0016], code=at0016, itemType=ELEMENT, level=6, text=Date last serviced, description=The date the device was last serviced., 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.progress_note.v1]/content[openEHR-EHR-SECTION.intraocular_pressure_study.v0]/items[openEHR-EHR-OBSERVATION.intraocular_pressure.v0]/protocol[at0068]/items[openEHR-EHR-CLUSTER.device.v1]/items[at0008], code=at0008, itemType=ELEMENT, level=5, text=Comment, description=Additional narrative about the device 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.progress_note.v1]/content[openEHR-EHR-SECTION.intraocular_pressure_study.v0]/items[openEHR-EHR-OBSERVATION.intraocular_pressure.v0]/protocol[at0068]/items[openEHR-EHR-CLUSTER.corneal_thickness_details.v0], code=at0000, itemType=CLUSTER, level=4, text=Central corneal thickness details, description=Measurement details about of the central corneal thickness., 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.progress_note.v1]/content[openEHR-EHR-SECTION.intraocular_pressure_study.v0]/items[openEHR-EHR-OBSERVATION.intraocular_pressure.v0]/protocol[at0068]/items[openEHR-EHR-CLUSTER.corneal_thickness_details.v0]/items[at0001], code=at0001, itemType=ELEMENT, level=5, text=Central Corneal Thickness (CCT), description=Value measured of the central corneal thickness., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=400..700 um, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.intraocular_pressure_study.v0]/items[openEHR-EHR-OBSERVATION.intraocular_pressure.v0]/protocol[at0068]/items[openEHR-EHR-CLUSTER.corneal_thickness_details.v0]/items[at0002], code=at0002, itemType=ELEMENT, level=5, text=Measurement Method, description=Method used to measure the corneal thickness parameter., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=termset: ac0001, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.intraocular_pressure_study.v0]/items[openEHR-EHR-OBSERVATION.intraocular_pressure.v0]/protocol[at0068]/items[openEHR-EHR-CLUSTER.corneal_thickness_details.v0]/items[at0003], code=at0003, itemType=ELEMENT, level=5, text=Correction parameter, description=Parameter obtained from tables provided by manufacturers, to correct the intraocular pressure value according to the central corneal thickness obtained., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=-7..7 mm[Hg]
Assumed value: 0 mm[Hg], extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0], code=at0000, itemType=SECTION, level=1, text=Clinical image acquisition and validation NMR, description=Manages the acquisition and validation of diagnostic tests based on medical imaging., 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.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-ACTION.imaging_exam.v1], code=at0000, itemType=ACTION, level=2, text=Imaging examination, description=Clinical activity about performing an imaging examination., 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.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-ACTION.imaging_exam.v1]/description[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, 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.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-ACTION.imaging_exam.v1]/description[at0001]/items[at0017], code=at0017, itemType=ELEMENT, level=4, text=Examination name, description=The name of the examination (to be) performed. Coding of the specific procedure with a terminology is preferred, where possible., 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.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-ACTION.imaging_exam.v1]/description[at0001]/items[at0018], code=at0018, itemType=ELEMENT, level=4, text=Description, description=Narrative description about the activity or care pathway step for the identified examination, for example description about the performance and findings from the the examination, the failed attempt or the cancellation of the examination., 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.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-ACTION.imaging_exam.v1]/description[at0001]/items[at0019], code=at0019, itemType=ELEMENT, level=4, text=Reason, description=Reason that the activity or care pathway step for the identified examination was carried out, for example, the reason for the cancellation or suspension of the examination., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • DR screening
  • Assessment of wet AMD
  • Monitor the progression of chronic glaucoma
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-ACTION.imaging_exam.v1]/description[at0001]/items[openEHR-EHR-CLUSTER.anatomical_location.v1], code=at0000, itemType=CLUSTER, level=4, text=Anatomical location, description=A physical site on or within the human body., 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.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-ACTION.imaging_exam.v1]/description[at0001]/items[openEHR-EHR-CLUSTER.anatomical_location.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=5, text=Body site name, description=Identification of a single physical site either on, or within, the human body., comment=This data element is the only mandated data point in this archetype and should be used as the primary data point to record an anatomical location with a commonly used name. It is strongly recommended that 'Body site name' be recorded as specifically as is anatomically possible. For example: record 'upper eyelid' rather than recording 'eyelid' with 'upper' as a qualifier; 'fifth rib' rather than 'rib' with a numeric qualifier. Use the other data elements for laterality, aspect, region and anatomical line to provide more detail. This data element should be coded with a terminology capable of triggering decision support, where possible - an appropriate termset for use here could comprise individual concepts or a list of precoordinated terms. Free text should be used only if there is no appropriate terminology available., 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.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-ACTION.imaging_exam.v1]/description[at0001]/items[openEHR-EHR-CLUSTER.anatomical_location.v1]/items[at0065], code=at0065, itemType=ELEMENT, level=5, text=Specific site, description=Additional detail using a specific region or a point on, or within, the identified body site., comment=Use to increase precision of identification of the body site, if required. For example, the upper right quadrant or McBurney's point on the abdominal wall or interphalangeal joint of the great toe. If the 'Body site name' data element uses pre-coordinated terms that include the specific site, then this data element is redundant., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=termset: external, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-ACTION.imaging_exam.v1]/description[at0001]/items[openEHR-EHR-CLUSTER.anatomical_location.v1]/items[at0002], code=at0002, itemType=ELEMENT, level=5, text=Laterality, description=The side of the body on which the identified body site is located., comment=If the identified body site has no laterality, this data element should not have a value. If the 'Body site name' data element uses pre-coordinated terms that include laterality, then this data element is redundant., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Left  [Left side of the body.]
  • Right  [Right side of the body.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-ACTION.imaging_exam.v1]/description[at0001]/items[openEHR-EHR-CLUSTER.anatomical_location.v1]/items[at0064], code=at0064, itemType=ELEMENT, level=5, text=Aspect, description=Qualifying detail about the specific aspect of the identified body site., comment=Use to increase precision of identification of the body site, if required. Common aspects have been included as a value set, which can be extended over time, plus a free text option. Assumes that the body is being described while in the anatomical position. For example: proximal urethra; plantar aspect of the left thumb. Multiple aspects can also be described, if required, by allowing for 0..2 occurrences. For example: a lesion may be on the left anterior/lateral (ie anterolateral) chest wall. If the 'Body site name' data element uses pre-coordinated terms that include the aspect, then this data element is redundant., uncommonOntologyItems=null, occurencesFormal=0..2, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Coded Text
    • Medial  [Towards the midline of the body site.]
    • Lateral  [Towards the side, or edge, of the body site.]
    • Superior  [Above the body site, often meaning towards the head.]
    • Inferior  [Below the body site, often meaning towards the feet.]
    • Anterior  [Towards the front, or ventral surface, of the body site.]
    • Posterior  [Towards the back, or dorsal surface, of the body site.]
    • Proximal  [More central or closer to the point of attachment, and usually describing part of a limb, digit or appendage.]
    • Distal  [More peripheral, or further from the point of attachment, and usually describing part of a limb, digit or appendage.]
    • Palmar  [Towards the palm of the hand.]
    • Plantar  [Towards the sole of the foot.]
    • Mid  [In the middle of the body site.]
    • Oral  [Towards the mouth. Usually used to describe locations within the digestive system.]
    • Anal  [Towards the anus. Usually used to describe locations within the digestive system.]
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-ACTION.imaging_exam.v1]/description[at0001]/items[openEHR-EHR-CLUSTER.anatomical_location.v1]/items[at0055], code=at0055, itemType=ELEMENT, level=5, text=Anatomical Line, description=Additional detail using theoretical lines drawn through anatomical structures used to provide a consistent reference point on the human body., comment=Common anatomical lines have been included as a value set, which can be extended over time, plus a free text option. The additional use of this data element allows for recording of the typical position of the heart's apex beat at 5th intercostal space, left side, and mid-clavicular line. If the 'Body site name' data element uses pre-coordinated terms that include anatomical line, then this data element is redundant., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Coded Text
    • Midline  [Line running vertically which divides the body into left and right portions, passing through the head, spinal cord, and umbilicus. Alternatively it can refer to a line dividing a body part into two equal portions, for example a digit.]
    • Midaxillary line  [Line running vertically down the surface of the body, passing through the apex of the axilla.]
    • Anterior axillary line  [Line running vertically down the surface of the body, passing through the anterior axillary skinfold.]
    • Posterior axillary line  [Line running vertically down the surface of the body, passing through the posterior axillary skinfold.]
    • Mid-clavicular line  [Line running vertically down the surface of the body, parallel to the midline and passing through the midpoint of the clavicle.]
    • Mid-pupillary line  [Line running vertically down the face through the midpoint of the pupil when looking directly forward.]
    • Mid-scapular line  [Line running vertically down the posterior surface of the body, parallel to the midline and passing through the inferior point of the scapula.]
  •  Text
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Assumed value: 0 mm, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-ACTION.imaging_exam.v1]/description[at0001]/items[openEHR-EHR-CLUSTER.mydriasis_application.v0]/items[at0003], code=at0003, itemType=ELEMENT, level=5, text=Mydriatic delivery method, description=The method of delivery if this should be specified (e.g. via a nebuliser or drops)., 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.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-ACTION.imaging_exam.v1]/description[at0001]/items[openEHR-EHR-CLUSTER.mydriasis_application.v0]/items[at0001], code=at0001, itemType=ELEMENT, level=5, text=Mydriatic agent, description=Chemical name of the compound used to apply midriasis., comment=Matches to DICOM (0022,0058) attribute. Values permitted are defined by DICOM standard (PS 3.16) inside the table with Context ID 4208 (Mydriatic agent), uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=termset: external, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-ACTION.imaging_exam.v1]/description[at0001]/items[openEHR-EHR-CLUSTER.mydriasis_application.v0]/items[openEHR-EHR-CLUSTER.medication_supply_amount.v0], code=at0000, itemType=CLUSTER, level=5, text=Medication supply amount, description=Details related to the amount of a medication, vaccine or other therapeutic item to be supplied or supplied to the patient, as part of authorisation, dispensing or administration., 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.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-ACTION.imaging_exam.v1]/description[at0001]/items[openEHR-EHR-CLUSTER.mydriasis_application.v0]/items[openEHR-EHR-CLUSTER.medication_supply_amount.v0]/items[at0161], code=at0161, itemType=ELEMENT, level=6, text=Amount description, description=A narrative representation of the amount The amount of medication, vaccine or therapeutic good intended to be supplied or actually supplied., 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.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-ACTION.imaging_exam.v1]/description[at0001]/items[openEHR-EHR-CLUSTER.mydriasis_application.v0]/items[openEHR-EHR-CLUSTER.medication_supply_amount.v0]/items[at0131], code=at0131, itemType=ELEMENT, level=6, text=Amount, description=The amount of medication, vaccine or therapeutic good intended to be supplied or actually supplied., comment=For example: 1, 1.5, or 0.125., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=>=0 1, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-ACTION.imaging_exam.v1]/description[at0001]/items[openEHR-EHR-CLUSTER.mydriasis_application.v0]/items[openEHR-EHR-CLUSTER.medication_supply_amount.v0]/items[at0147], code=at0147, itemType=ELEMENT, level=6, text=Units, description=The dose unit or pack unit associated with the dispense amount., comment=For example: 'tablets', 'packs', ml'., 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.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-ACTION.imaging_exam.v1]/description[at0001]/items[openEHR-EHR-CLUSTER.mydriasis_application.v0]/items[openEHR-EHR-CLUSTER.medication_supply_amount.v0]/items[at0142], code=at0142, itemType=ELEMENT, level=6, text=Duration of supply, description=The period of time for which the medication should be dispensed or for which a suppy was dispensed., comment=The dispenser is asked to supply sufficient quantity of medication to cover the defined period., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DURATION, bindings=null, values=Units:
  • Year
  • Month
  • Week
  • Day
  • Second
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-ACTION.imaging_exam.v1]/description[at0001]/items[at0020], code=at0020, itemType=ELEMENT, level=4, text=Comment, description=Additional narrative about the activity or care pathway step 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.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-ACTION.imaging_exam.v1]/protocol[at0015], code=at0015, 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.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-ACTION.imaging_exam.v1]/protocol[at0015]/items[at0016], code=at0016, itemType=ELEMENT, level=4, text=Start date/time, description=The start date and/or time for the procedure. This will indicate the scheduled date/time when recorded against the 'Appointment scheduled' care pathway step or the actual Start date/time in the 'Examination performed' step., 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.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1], code=at0000, itemType=OBSERVATION, level=2, text=Fundoscopic examination of eyes, description=Record of clinical findings on fundoscopy of eyes, comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=4, text=Any event, description=*, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/data[at0001]/events[at0002]/data[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=5, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0008], code=at0008, itemType=ELEMENT, level=6, text=Clinical Description, description=Descriptive overview of examination findings, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0136], code=at0136, itemType=CLUSTER, level=6, text=Test Result, description=Details of the funduscopic examination test result for each eye., comment=null, uncommonOntologyItems=null, occurencesFormal=0..2, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0136]/items[at0004], code=at0004, itemType=ELEMENT, level=7, text=Side, description=Determines the eye on which the test was performed.Matches to DICOM Laterality (0020,0060) attribute., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Left eye  [The left eye was examined.]
  • Right eye  [The right eye was examined.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0136]/items[at0051], code=at0051, itemType=CLUSTER, level=7, text=Acquisition details, description=Details about acquisition obtained during the examination of eye fundus, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0136]/items[at0051]/items[at0053], code=at0053, itemType=ELEMENT, level=8, text=Red reflex, description=True if Red Reflex is present, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=Assumed value: false, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0136]/items[at0051]/items[at0054], code=at0054, itemType=ELEMENT, level=8, text=Small pupil, description=True if during the acquisition, pupil diameter is smaller than normal (3,3mm), comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=Assumed value: false, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0136]/items[at0051]/items[at0123], code=at0123, itemType=ELEMENT, level=8, text=High refraction, description=True if the refraction of the eye exceeds the range from -12D to +15D, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=Assumed value: false, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0136]/items[at0051]/items[at0055], code=at0055, itemType=ELEMENT, level=8, text=Cataract artifact, description=True if cataract obstructs the visualization of eye fundus, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=Assumed value: false, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0136]/items[at0051]/items[at0056], code=at0056, itemType=ELEMENT, level=8, text=Shadow artifact, description=True if shadow artifact is present on the border of the image, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=Assumed value: false, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0136]/items[at0051]/items[at0124], code=at0124, itemType=ELEMENT, level=8, text=Uncooperative patient, description=True if patient doesn't collaborate during the image acquisition, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=Assumed value: false, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0136]/items[at0051]/items[at0128], code=at0128, itemType=ELEMENT, level=8, text=Others, description=Other details identified during the acquisition which may affect the results from reviewing the test, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=termset: external, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0136]/items[at0051]/items[at0057], code=at0057, itemType=CLUSTER, level=8, text=Visualization, description=Details about image quality related to ease of visualization of structures on eye fundus, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0136]/items[at0051]/items[at0057]/items[at0059], code=at0059, itemType=ELEMENT, level=9, text=Quality, description=Levels quantifying the quality of each acquisition, based in the ease to visualize the structures on the eye fundus, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_ORDINAL, bindings=null, values=
  • 1: Quality inadequate for any diagnostic purpose  [*]
  • 2: Unable to exclude all emergent findings  [*]
  • 3: Only able to exclude emergent findings  [*]
  • 4: Quality not ideal, but is possible to exclude subtle findings  [*]
  • 5: Ideal quality  [*]
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text=Structural description, description=General description of the structures in the eye fundus, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0136]/items[at0065]/items[at0091], code=at0091, itemType=ELEMENT, level=8, text=Optic Disc, description=Description of optic disc, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0136]/items[at0065]/items[at0090], code=at0090, itemType=ELEMENT, level=8, text=Macula, description=Description of macula, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0136]/items[at0065]/items[at0092], code=at0092, itemType=ELEMENT, level=8, text=Retinal arteries, description=Description of retinal arteries, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0136]/items[at0065]/items[at0093], code=at0093, itemType=ELEMENT, level=8, text=Retinal veins, description=Description of retinal veins, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0136]/items[at0065]/items[at0094], code=at0094, itemType=ELEMENT, level=8, text=Retinal background, description=Description of retinal background, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0136]/items[at0065]/items[at0098], code=at0098, itemType=ELEMENT, level=8, text=Vitreous, description=Description of vitreous humour, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0136]/items[at0066], code=at0066, itemType=CLUSTER, level=7, text=Clinical results, description=Information of diagnostic interest obtained in the test, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0136]/items[at0066]/items[at0126], code=at0126, itemType=ELEMENT, level=8, text=Other findings, description=Narrative description of clinical findings not considered in the SLOT, comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/data[at0001]/events[at0002]/state[at0013], code=at0013, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=5, text=State, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/data[at0001]/events[at0002]/state[at0013]/items[at0014], code=at0014, itemType=ELEMENT, level=6, text=Mydriatic used, description=True if mydriatic is used, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=Assumed value: false, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/protocol[at0028], code=at0028, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Protocol, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/protocol[at0028]/items[at0029], code=at0029, itemType=ELEMENT, level=4, text=Method, description=Method chosen to perform the funduscopic examination, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Direct  [Study performed by direct ophthalmoscopy]
  • Indirect  [Study of eye fundus by indirect ophthalmoscopy method]
  • Contact lens biomicroscopy  [Eye fundus viewing through biomicroscopy lens in contact to patient's eye surface]
  • Non-contact lens biomicroscopy  [Eye fundus viewing through biomicroscopy lens without contact to patient's eye surface]
  • Mydriatic retinography  [Observation of retina through funduscopic images acquired by previous dilatation of patient's pupils]
  • Non-mydriatic retinography  [Observation of retina through funduscopic images acquired without previous dilatation of patient's pupils]
  • Angiography  [Observation of the eye fundus using a fluorescent dye inyected to emphasize the blood vessels in the eye retina]
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The scope is inclusive of disposable devices as well as durable or persisting devices that require tracking, maintenance activities or regular calibration, recognising that each type of device has specific data recording requirements., 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.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/protocol[at0028]/items[openEHR-EHR-CLUSTER.device.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=5, text=Device name, description=Identification of the medical device, preferably by a common name, a formal fully descriptive name or, if required, by class or category of device., comment=This data element will capture the term, phrase or category used in clinical practice. For example: <brand name><machine> (XYZ Audiometer); <size> <brand name> <intravenous catheter> (14G Jelco IV catheter); or <brand name/type> <implant>. Coding with a terminology is desirable, where possible, although this may be local and depending on local supplies available., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=termset: external, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/protocol[at0028]/items[openEHR-EHR-CLUSTER.device.v1]/items[at0003], code=at0003, itemType=ELEMENT, level=5, text=Type, description=The category or kind of device., comment=Not applicable if a category is already recorded in 'Device name'. Example: if the 'Device' is named as a 'urinary catheter'; the 'Type' may be recorded as 'indwelling' or 'condom'.Coding with a terminology is desirable, where possible. This may include use of GTIN or EAN numbers., 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.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/protocol[at0028]/items[openEHR-EHR-CLUSTER.device.v1]/items[at0002], code=at0002, itemType=ELEMENT, level=5, text=Description, description=Narrative description of the medical device., 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.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/protocol[at0028]/items[openEHR-EHR-CLUSTER.device.v1]/items[at0021], code=at0021, itemType=ELEMENT, level=5, text=Unique device identifier (UDI), description=A numeric or alphanumeric string that is associated with this device within a given system., comment=Often fixed to the device as a barcode., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_IDENTIFIER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/protocol[at0028]/items[openEHR-EHR-CLUSTER.device.v1]/items[at0004], code=at0004, itemType=ELEMENT, level=5, text=Manufacturer, description=Name of manufacturer., 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.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/protocol[at0028]/items[openEHR-EHR-CLUSTER.device.v1]/items[at0005], code=at0005, itemType=ELEMENT, level=5, text=Date of manufacture, description=Date the device was manufactured., 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.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/protocol[at0028]/items[openEHR-EHR-CLUSTER.device.v1]/items[at0020], code=at0020, itemType=ELEMENT, level=5, text=Serial number, description=Number assigned by the manufacturer which can be found on the device, and should be specific to each device., its label, or accompanying packaging., 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.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/protocol[at0028]/items[openEHR-EHR-CLUSTER.device.v1]/items[at0022], code=at0022, itemType=ELEMENT, level=5, text=Catalogue number, description=The exact number assigned by the manufacturer, as it appears in the manufacturer's catalogue, device labeling, or accompanying packaging., 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.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/protocol[at0028]/items[openEHR-EHR-CLUSTER.device.v1]/items[at0023], code=at0023, itemType=ELEMENT, level=5, text=Model number, description=The exact model number assigned by the manufacturer and found on the device label or accompanying packaging., 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.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/protocol[at0028]/items[openEHR-EHR-CLUSTER.device.v1]/items[at0006], code=at0006, itemType=ELEMENT, level=5, text=Batch/Lot number, description=The number assigned by the manufacturer which identifies a group of items manufactured at the same time, usually found on the label or packaging material., 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.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/protocol[at0028]/items[openEHR-EHR-CLUSTER.device.v1]/items[at0025], code=at0025, itemType=ELEMENT, level=5, text=Software version, description=Identification of the version of software being used in the medical device., comment=When the medical device is an actual software application, record the version of the software using this data element. When the medical device has multiple software applications embedded within it, record each software component in a separate CLUSTER archetype within the Components SLOT - either as a nested instance of another CLUSTER.device archetype or using a CLUSTER archetype designed specifically for recording software details (but not yet available at time of this archetype development)., 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.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/protocol[at0028]/items[openEHR-EHR-CLUSTER.device.v1]/items[at0007], code=at0007, itemType=ELEMENT, level=5, text=Date of expiry, description=Date after which the device/product is no longer fit for use, usually found on the device itself or printed on the accompanying packaging., comment=This date usually applies only to single use or disposable devices., 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.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/protocol[at0028]/items[openEHR-EHR-CLUSTER.device.v1]/items[at0024], code=at0024, itemType=ELEMENT, level=5, text=Other identifier, description=Unspecified identifier, which can be further specified in a template or at run time., comment=Coding of the name of the identifier with a coding system is desirable, if available., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_IDENTIFIER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/protocol[at0028]/items[openEHR-EHR-CLUSTER.device.v1]/items[openEHR-EHR-CLUSTER.device_details.v1], code=at0000, itemType=CLUSTER, level=5, text=Medical device details, description=Specific details that relate to asset management for any medical device that is designed for more than a single use., 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.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/protocol[at0028]/items[openEHR-EHR-CLUSTER.device.v1]/items[openEHR-EHR-CLUSTER.device_details.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=6, text=Organisation identifier, description=Organisation identifier for device., comment=May be a text string or an IEEE EUI-64 identifier., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Text
  •  Identifier
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/protocol[at0028]/items[openEHR-EHR-CLUSTER.device.v1]/items[openEHR-EHR-CLUSTER.device_details.v1]/items[at0023], code=at0023, itemType=ELEMENT, level=6, text=Owner, description=Organisation responsible for the medical device., 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.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/protocol[at0028]/items[openEHR-EHR-CLUSTER.device.v1]/items[openEHR-EHR-CLUSTER.device_details.v1]/items[at0024], code=at0024, itemType=ELEMENT, level=6, text=Location, description=Physical location where device is kept., 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.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/protocol[at0028]/items[openEHR-EHR-CLUSTER.device.v1]/items[openEHR-EHR-CLUSTER.device_details.v1]/items[at0025], code=at0025, itemType=ELEMENT, level=6, text=Network address, description=Network address to contact the device., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_URI, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/protocol[at0028]/items[openEHR-EHR-CLUSTER.device.v1]/items[openEHR-EHR-CLUSTER.device_details.v1]/items[at0007], code=at0007, itemType=ELEMENT, level=6, text=Part number, description=The part number of the device., 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.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/protocol[at0028]/items[openEHR-EHR-CLUSTER.device.v1]/items[openEHR-EHR-CLUSTER.device_details.v1]/items[at0002], code=at0002, itemType=ELEMENT, level=6, text=Manufacturer model name, description=HL7 CDA compatible representation of device manufacture details., comment=May be a simple string or contain simple markup e.g. for Continua PHMR reports: "Pulse Master 2000||584216|69854|2.1|1.1|1.0|" repesenting Model, Unspecified, SerialNumber, PartNumber, HardwareRevision, SoftwareRevision, ProtocolRevision, and ProdSpecGMDN., 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.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/protocol[at0028]/items[openEHR-EHR-CLUSTER.device.v1]/items[openEHR-EHR-CLUSTER.device_details.v1]/items[at0008], code=at0008, itemType=ELEMENT, level=6, text=Hardware revision, description=The hardware revision number., 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.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/protocol[at0028]/items[openEHR-EHR-CLUSTER.device.v1]/items[openEHR-EHR-CLUSTER.device_details.v1]/items[at0010], code=at0010, itemType=ELEMENT, level=6, text=Protocol revision, description=The protocol revision number., 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.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/protocol[at0028]/items[openEHR-EHR-CLUSTER.device.v1]/items[openEHR-EHR-CLUSTER.device_details.v1]/items[at0011], code=at0011, itemType=ELEMENT, level=6, text=Sampling frequency, description=The sampling frequency limits of the device., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Text
  •  Quantity
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/protocol[at0028]/items[openEHR-EHR-CLUSTER.device.v1]/items[openEHR-EHR-CLUSTER.device_details.v1]/items[at0012], code=at0012, itemType=ELEMENT, level=6, text=Range, description=The range limits of the device., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Text
  •  Interval of Quantity
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/protocol[at0028]/items[openEHR-EHR-CLUSTER.device.v1]/items[openEHR-EHR-CLUSTER.device_details.v1]/items[at0013], code=at0013, itemType=ELEMENT, level=6, text=Accuracy, description=The accuracy limits of the device., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Text
  •  Quantity
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/protocol[at0028]/items[openEHR-EHR-CLUSTER.device.v1]/items[openEHR-EHR-CLUSTER.device_details.v1]/items[at0014], code=at0014, itemType=ELEMENT, level=6, text=Resolution, description=The resolution limits of the device., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Text
  •  Quantity
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/protocol[at0028]/items[openEHR-EHR-CLUSTER.device.v1]/items[openEHR-EHR-CLUSTER.device_details.v1]/items[at0015], code=at0015, itemType=ELEMENT, level=6, text=Regulatory status, description=Whether device is regulated or otherwise., 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.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/protocol[at0028]/items[openEHR-EHR-CLUSTER.device.v1]/items[openEHR-EHR-CLUSTER.device_details.v1]/items[at0022], code=at0022, itemType=ELEMENT, level=6, text=Date last cleaned/sterilized, description=Date the device was last cleaned or sterilized., 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.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/protocol[at0028]/items[openEHR-EHR-CLUSTER.device.v1]/items[openEHR-EHR-CLUSTER.device_details.v1]/items[at0017], code=at0017, itemType=ELEMENT, level=6, text=Date last calibrated, description=Date the device was last calibrated., 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.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/protocol[at0028]/items[openEHR-EHR-CLUSTER.device.v1]/items[openEHR-EHR-CLUSTER.device_details.v1]/items[at0016], code=at0016, itemType=ELEMENT, level=6, text=Date last serviced, description=The date the device was last serviced., 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.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/protocol[at0028]/items[openEHR-EHR-CLUSTER.device.v1]/items[openEHR-EHR-CLUSTER.device_details.v1]/items[at0019], code=at0019, itemType=CLUSTER, level=6, text=Formulae, description=Details about formulae or algorithms used by the device in order to generate results/output., 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.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/protocol[at0028]/items[openEHR-EHR-CLUSTER.device.v1]/items[openEHR-EHR-CLUSTER.device_details.v1]/items[at0019]/items[at0020], code=at0020, itemType=ELEMENT, level=7, text=Formula name, description=Data element which is calculated or derived., 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.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/protocol[at0028]/items[openEHR-EHR-CLUSTER.device.v1]/items[openEHR-EHR-CLUSTER.device_details.v1]/items[at0019]/items[at0021], code=at0021, itemType=ELEMENT, level=7, text=Formula, description=Formula used to calculate or derive the Calculated field., 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.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/protocol[at0028]/items[openEHR-EHR-CLUSTER.device.v1]/items[at0008], code=at0008, itemType=ELEMENT, level=5, text=Comment, description=Additional narrative about the device 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.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/protocol[at0028]/items[at0067], code=at0067, itemType=ELEMENT, level=4, text=Field angle, description=Describes the optical acceptance angle of the lens used during the test, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • 30º  [30º angle used for small pupil (SP) capture (for patients with pupil diameter <3.3mm)]
  • 45º  [45º angle used to acquire eye fundus of normal pupils]
  • 60º  [60º angle used to acquire eye fundus in some DR screening studies]
  • 100º  [Wide angle acquisition]
  • 200º  [Ultra-wide angle acquisition]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/protocol[at0028]/items[at0072], code=at0072, itemType=ELEMENT, level=4, text=Attempts, description=Number of attempts before obtaining the acquisition (doesn't compute if test is repeated by a specific recognized technical failure), comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=1..3, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/protocol[at0028]/items[at0073], code=at0073, itemType=CLUSTER, level=4, text=(Subdivision of the retina), description=Subdivision of the retina identifying eye fundus image locations, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/protocol[at0028]/items[at0073]/items[at0074], code=at0074, itemType=ELEMENT, level=5, text=(ETRDS fields), description=Subdivision of the retina based on Diabetic Retinopathy Study fields, comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Study field 1  [*]
  • Study field 2  [*]
  • Study field 3  [*]
  • Study field 4  [*]
  • Study field 5  [*]
  • Study field 6  [*]
  • Study field 7  [*]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.clinical_image_acquisition.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/protocol[at0028]/items[at0073]/items[at0082], code=at0082, itemType=ELEMENT, level=5, text=Mosaic and peripherals, description=Division of the retina in quadrants + mosaic obtained from the combination of them, comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Mosaic  [Mosaic obtained from combining every peripheral acquisitions and the center one]
  • Central  [Image centered on the macula]
  • Nasal  [Image centered on the optic nerve or papila]
  • Temporal  [Image centered on the temporal quadrant of the retina]
  • Superior  [Image centered on the superior half of the retina]
  • Inferior  [Image centered on the inferior half of the retina]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.next_step_planning.v0], code=at0000, itemType=SECTION, level=1, text=Next step planning, description=Decision-making concerning the planning of next assessment for the diagnostic tests carried out., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.next_step_planning.v0]/items[openEHR-EHR-INSTRUCTION.request-report.v1], code=at0000.1, itemType=INSTRUCTION, level=2, text=Diagnostic report request, description=Request for a diagnostic report involving the study of specific diagnostic tests., 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.progress_note.v1]/content[openEHR-EHR-SECTION.next_step_planning.v0]/items[openEHR-EHR-INSTRUCTION.request-report.v1]/activities[at0001], code=at0001, itemType=ACTIVITY, level=3, text=Request, description=Current Activity., comment=null, uncommonOntologyItems=null, occurencesFormal=1..*, occurencesText=Mandatory, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ACTIVITY, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.next_step_planning.v0]/items[openEHR-EHR-INSTRUCTION.request-report.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.progress_note.v1]/content[openEHR-EHR-SECTION.next_step_planning.v0]/items[openEHR-EHR-INSTRUCTION.request-report.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=
  • Remote screening of DR
  • DR assessment at ophthalmologist's office
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.next_step_planning.v0]/items[openEHR-EHR-INSTRUCTION.request-report.v1]/activities[at0001]/description[at0009]/items[at0135], code=at0135, itemType=ELEMENT, level=5, text=Description of service, description=A detailed narrative description of the service requested., 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.progress_note.v1]/content[openEHR-EHR-SECTION.next_step_planning.v0]/items[openEHR-EHR-INSTRUCTION.request-report.v1]/activities[at0001]/description[at0009]/items[at0062], code=at0062, itemType=ELEMENT, level=5, text=Reason for request, description=A short description of the reason for the request. This is often coded with an external terminology., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Completed the diagnostic tests necessary for assessment
  • Patient presenting dangerously high intraocular pressure
  • Quality of eye fundus images inadequate for remote diagnosis
  • Clinically relevant ophthalmological disorders identified
  • Second opinion needed
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.next_step_planning.v0]/items[openEHR-EHR-INSTRUCTION.request-report.v1]/activities[at0001]/description[at0009]/items[at0064], code=at0064, itemType=ELEMENT, level=5, text=Reason description, description=A narrative description explaining the reason for request., 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.progress_note.v1]/content[openEHR-EHR-SECTION.next_step_planning.v0]/items[openEHR-EHR-INSTRUCTION.request-report.v1]/activities[at0001]/description[at0009]/items[at0065], code=at0065, itemType=ELEMENT, level=5, text=Intent, description=Stated intent of the request by the referrer., 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.progress_note.v1]/content[openEHR-EHR-SECTION.next_step_planning.v0]/items[openEHR-EHR-INSTRUCTION.request-report.v1]/activities[at0001]/description[at0009]/items[at0068], code=at0068, itemType=ELEMENT, level=5, text=Urgency, description=Urgency of the request., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Emergency  [The request is an emergency.]
  • Urgent  [The request is urgent.]
  • Routine  [The request is routine.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.next_step_planning.v0]/items[openEHR-EHR-INSTRUCTION.request-report.v1]/activities[at0001]/description[at0009]/items[at0040], code=at0040, itemType=ELEMENT, level=5, text=Date &/or time service required, description=The date and time that the service should be performed or completed., 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.progress_note.v1]/content[openEHR-EHR-SECTION.next_step_planning.v0]/items[openEHR-EHR-INSTRUCTION.request-report.v1]/activities[at0001]/description[at0009]/items[at0144], code=at0144, itemType=ELEMENT, level=5, text=Latest date service required, description=The latest date that is acceptable for the service to be completed., 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.progress_note.v1]/content[openEHR-EHR-SECTION.next_step_planning.v0]/items[openEHR-EHR-INSTRUCTION.request-report.v1]/protocol[at0008], code=at0008, 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.progress_note.v1]/content[openEHR-EHR-SECTION.next_step_planning.v0]/items[openEHR-EHR-INSTRUCTION.request-report.v1]/protocol[at0008]/items[at0010], code=at0010, itemType=ELEMENT, level=4, text=Requestor Identifier, description=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., 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.progress_note.v1]/content[openEHR-EHR-SECTION.next_step_planning.v0]/items[openEHR-EHR-INSTRUCTION.request-report.v1]/protocol[at0008]/items[at0011], code=at0011, itemType=ELEMENT, level=4, text=Receiver identifier, description=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., 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.progress_note.v1]/content[openEHR-EHR-SECTION.next_step_planning.v0]/items[openEHR-EHR-INSTRUCTION.request-report.v1]/protocol[at0008]/items[at0127], code=at0127, itemType=ELEMENT, level=4, text=Request status, description=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., 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.progress_note.v1]/content[openEHR-EHR-SECTION.next_step_planning.v0]/items[openEHR-EHR-INSTRUCTION.request.v0], code=at0000, itemType=INSTRUCTION, level=2, text=Service request, description=Request for a health-related service to be supplied by a healthcare provider or agency., comment=For example equipment request., 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.progress_note.v1]/content[openEHR-EHR-SECTION.next_step_planning.v0]/items[openEHR-EHR-INSTRUCTION.request.v0]/activities[at0001], code=at0001, itemType=ACTIVITY, level=3, text=Request, description=Description of the requested service., comment=null, uncommonOntologyItems=null, occurencesFormal=1..*, occurencesText=Mandatory, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ACTIVITY, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.next_step_planning.v0]/items[openEHR-EHR-INSTRUCTION.request.v0]/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.progress_note.v1]/content[openEHR-EHR-SECTION.next_step_planning.v0]/items[openEHR-EHR-INSTRUCTION.request.v0]/activities[at0001]/description[at0009]/items[at0121], code=at0121, itemType=ELEMENT, level=5, text=Service name, description=Identification of the service requested, by name., comment=Coding of the 'Service name' with a coding system is desirable, if available., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Follow-up schedule for patients with suspected DR
  • DR treatment
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.next_step_planning.v0]/items[openEHR-EHR-INSTRUCTION.request.v0]/activities[at0001]/description[at0009]/items[at0148], code=at0148, itemType=ELEMENT, level=5, text=Service type, description=Category of service requested., comment=For example: hospital vs home care delivery., 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.progress_note.v1]/content[openEHR-EHR-SECTION.next_step_planning.v0]/items[openEHR-EHR-INSTRUCTION.request.v0]/activities[at0001]/description[at0009]/items[at0135], code=at0135, itemType=ELEMENT, level=5, text=Description, description=Narrative description of the service requested., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Follow-up comprised by NMR study and IOP measurement
  • DR treatment consisting of scatter PRP laser therapy
  • DR treatment consisting of focal and/or grid laser photocoagulation
  • DR treatment consisting of intravitreal corticosteroids
  • DR treatment consisting of intravitreal anti-VEGF therapy
  • DR treatment consisting of vitrectomy surgery
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.next_step_planning.v0]/items[openEHR-EHR-INSTRUCTION.request.v0]/activities[at0001]/description[at0009]/items[at0062], code=at0062, itemType=ELEMENT, level=5, text=Reason for request, description=A short phrase describing the reason for the request., comment=Coding of the 'Reason for request' with a coding system is desirable, if available., 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.progress_note.v1]/content[openEHR-EHR-SECTION.next_step_planning.v0]/items[openEHR-EHR-INSTRUCTION.request.v0]/activities[at0001]/description[at0009]/items[at0064], code=at0064, itemType=ELEMENT, level=5, text=Reason description, description=Narrative description about the reason for request., 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.progress_note.v1]/content[openEHR-EHR-SECTION.next_step_planning.v0]/items[openEHR-EHR-INSTRUCTION.request.v0]/activities[at0001]/description[at0009]/items[at0065], code=at0065, itemType=ELEMENT, level=5, text=Intent, description=Description of the intent for the request., comment=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., 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.progress_note.v1]/content[openEHR-EHR-SECTION.next_step_planning.v0]/items[openEHR-EHR-INSTRUCTION.request.v0]/activities[at0001]/description[at0009]/items[at0068], code=at0068, itemType=ELEMENT, level=5, text=Urgency, description=Urgency of the request for service., comment=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., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Coded Text
    • Emergency  [The request requires immediate attention.]
    • Urgent  [The request requires prioritised attention.]
    • Routine  [The request does not require prioritised scheduling.]
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.progress_note.v1]/content[openEHR-EHR-SECTION.next_step_planning.v0]/items[openEHR-EHR-INSTRUCTION.request.v0]/activities[at0001]/description[at0009]/items[at0040], code=at0040, itemType=ELEMENT, level=5, text=Service due, description=The date/time, or acceptable interval of date/time, for provision of the service., comment=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., 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.progress_note.v1]/content[openEHR-EHR-SECTION.next_step_planning.v0]/items[openEHR-EHR-INSTRUCTION.request.v0]/activities[at0001]/description[at0009]/items[at0145], code=at0145, itemType=ELEMENT, level=5, text=Service period start, description=The date/time that marks the beginning of the valid period of time for delivery of this service., comment=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., 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.progress_note.v1]/content[openEHR-EHR-SECTION.next_step_planning.v0]/items[openEHR-EHR-INSTRUCTION.request.v0]/activities[at0001]/description[at0009]/items[at0144], code=at0144, itemType=ELEMENT, level=5, text=Service period expiry, description=The date/time that marks the conclusion of the valid period of time for delivery of this service., comment=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., 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.progress_note.v1]/content[openEHR-EHR-SECTION.next_step_planning.v0]/items[openEHR-EHR-INSTRUCTION.request.v0]/activities[at0001]/description[at0009]/items[at0147], code=at0147, itemType=ELEMENT, level=5, text=Indefinite?, description=The valid period for this request is open ended and has no date of expiry., comment=Record as TRUE to record explicity that the request has no expiry date., 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.progress_note.v1]/content[openEHR-EHR-SECTION.next_step_planning.v0]/items[openEHR-EHR-INSTRUCTION.request.v0]/protocol[at0008], code=at0008, 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.progress_note.v1]/content[openEHR-EHR-SECTION.next_step_planning.v0]/items[openEHR-EHR-INSTRUCTION.request.v0]/protocol[at0008]/items[at0010], code=at0010, itemType=ELEMENT, level=4, text=Requestor Identifier, description=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., 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.progress_note.v1]/content[openEHR-EHR-SECTION.next_step_planning.v0]/items[openEHR-EHR-INSTRUCTION.request.v0]/protocol[at0008]/items[at0011], code=at0011, itemType=ELEMENT, level=4, text=Receiver identifier, description=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., 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.progress_note.v1]/content[openEHR-EHR-SECTION.next_step_planning.v0]/items[openEHR-EHR-INSTRUCTION.request.v0]/protocol[at0008]/items[at0127], code=at0127, itemType=ELEMENT, level=4, text=Request status, description=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., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null]], templateType=normal]