TEMPLATE Identification of patients with DR (5360cd56-fbab-4e72-98e3-d98d3b2dbe3b)

TEMPLATE ID5360cd56-fbab-4e72-98e3-d98d3b2dbe3b
ConceptIdentification of patients with DR
DescriptionRegister the clinical decisions relating to the screening of diabetic retinopathy.
PurposeRegister the clinical decisions relating to the screening of diabetic retinopathy.
References
Authorsname: Aitor Eguzkitza; organisation: Universidad Pública de Navarra - Complejo Hospitalario de Navarra; email: aitor.eguzkiza@unavarra.es; date: 2016-07-27
Other Details Languagename: Aitor Eguzkitza; organisation: Universidad Pública de Navarra - Complejo Hospitalario de Navarra; email: aitor.eguzkiza@unavarra.es; date: 2016-07-27
OtherDetails Language Independent{MetaDataSet:Sample Set =MetaDataSet:Sample Set , Copyright=Copyright, Owner=Owner, Speciality=Speciality}
Language useden
Citeable Identifier1013.26.169
AllOperationalTemplate [rootArchetypeId=openEHR-EHR-SECTION.clinical_decision.v0, otherContributors=Jose Andonegui, Complejo hospitalario de Navarra (CHN), jose.andonegui.navarro@cfnavarra.es; Luis Serrano, Universidad Pública de Navarra (UPNA), lserrano@unavarra.es; Jesús D. Trigo, Universidad Pública de Navarra (UPNA), jesusdaniel.trigo@unavarra.es, tshis=[ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.clinical_decision.v0], code=at0000, itemType=SECTION, level=0, text=Clinical decision, description=Defines the process of making a decision about the diagnosis of a specific disease., 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-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.clinical_synopsis.v1], code=at0000, itemType=EVALUATION, level=1, text=Clinical Synopsis, description=Narrative summary or overview about a patient, specifically from the perspective of a healthcare provider, and with or without associated interpretations., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.clinical_synopsis.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=2, 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-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.clinical_synopsis.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=3, text=Synopsis, description=The summary, assessment, conclusions or evaluation of the clinical findings., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1], code=at0000, itemType=EVALUATION, level=1, text=Problem/Diagnosis, description=Details about a single identified health condition, injury, disability or any other issue which impacts on the physical, mental and/or social well-being of an individual., comment=Clear delineation between the scope of a problem versus a diagnosis is not easy to achieve in practice. For the purposes of clinical documentation with this archetype, problem and diagnosis are regarded as a continuum, with increasing levels of detail and supportive evidence usually providing weight towards the label of 'diagnosis'., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=2, 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-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=3, text=Problem/Diagnosis name, description=Identification of the problem or diagnosis, by name., comment=Coding of the name of the problem or diagnosis with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=Default value: Identification of diabetic retinopathy, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0009], code=at0009, itemType=ELEMENT, level=3, text=Clinical description, description=Narrative description about the problem or diagnosis., comment=Use to provide background and context, including evolution, episodes or exacerbations, progress and any other relevant details, about the problem or diagnosis., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=Default value: The patient presents signs of DR., extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0012], code=at0012, itemType=ELEMENT, level=3, text=Body site, description=Identification of a simple body site for the location of the problem or diagnosis., comment=Coding of the name of the anatomical location with a terminology is preferred, where possible. Use this data element to record precoordinated anatomical locations. If the requirements for recording the anatomical location are determined at run-time by the application or require more complex modelling such as relative locations then use the CLUSTER.anatomical_location or CLUSTER.relative_location within the 'Structured anatomical location' SLOT in this archetype. Occurrences for this data element are unbounded to allow for clinical scenarios such as describing a rash in multiple locations but where all of the other attributes are identical. If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=Default value: Eye retina, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0077], code=at0077, itemType=ELEMENT, level=3, text=Date/time of onset, description=Estimated or actual date/time that signs or symptoms of the problem/diagnosis were first observed., comment=Data captured/imported as "Age at onset" should be converted to a date using the subject's date of birth., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.diabetic_retinopathy_classification.v0], code=at0000, itemType=CLUSTER, level=3, text=Classification of Diabetic Retinopathy, description=International clinical disease severity scale for diabetic retinopathy and diabetic macular edema., 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-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.diabetic_retinopathy_classification.v0]/items[at0001], code=at0001, itemType=ELEMENT, level=4, text=Diagnosis of DR, description=Specification of the clinical grade for diabetic retinopathy., 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-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.diabetic_retinopathy_classification.v0]/items[at0014], code=at0014, itemType=ELEMENT, level=4, text=Comments, description=Comments directed to reviewers specialized on classifying DR. It may include test details or issues that provoke uncertainty while classifying the disease. It is useful as feedback channel to improve the quality of the DR classification service., 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-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.diagnostic_criteria_dr.v0], code=at0000, itemType=CLUSTER, level=3, text=Diagnostic criteria DR, description=Findings concerning directly the diagnose of diabetic retinopathy identified during eye fundus study., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.diagnostic_criteria_dr.v0]/items[at0052], code=at0052, itemType=ELEMENT, level=4, text=Patterns of leakage, description=Patterns of leakage, related to the diagnosis of DR, identified in the patient's posterior pole of eye., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • No leakage  [There is not any type of leakage.]
  • Neovascular leakage  [Due to breaking of new vessels created as a result of diabetic retinopathy.]
  • Macular leakage  [Refers to any loss of fluid located in the macula.]
  • Focal leakage  [In diabetic macular oedema, some patients may show progressive leakages in discrete locations (focal) rising from "culprit" microaneurysms.]
  • Indeterminate leakage  [In many patients with diffuse diabetic macular oedema, an“indeterminate” leakage similar to focal ones appears, with little or no correlation to the presence of microaneurysms.]
  • Mixed leakage  [Many patients, with diabetic macular oedema have a mixed pattern of leakage, which may further include ischemic maculopathy.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.diagnostic_criteria_dr.v0]/items[at0045], code=at0045, itemType=ELEMENT, level=4, text=Patterns of macular ischaemia, description=Patterns of ischaemia, related to the diagnosis of DR, identified in the patient's macula., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • No macular edema  [Patient not presenting macular edema.]
  • Diffuse diabetic macular edema  [Patient presenting a diffuse diabetic macular edema.]
  • Focal diabetic macular edema  [Patient presenting a focal diabetic macular edema.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.diagnostic_criteria_dr.v0]/items[at0036], code=at0036, itemType=ELEMENT, level=4, text=Patterns of retinopathy, description=Identifies disorders within the retina from an overall perspective., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Stable diabetic retinopathy  [Patient presenting a stable state of dianetic retinopathy.]
  • Proliferative diabetic retinopathy  [Patient presenting a proliferative state of diabetic retinopathy.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.diagnostic_criteria_dr.v0]/items[at0053], code=at0053, itemType=ELEMENT, level=4, text=Patterns of retinal ischaemia, description=Every sign of narrowing, deformation or anomaly regarding to blood vessels corresponds to this classification (blot haemorrhage, venous beading, intra-retinal microvascular anomalies)., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.diagnostic_criteria_dr.v0]/items[at0060], code=at0060, itemType=ELEMENT, level=4, text=Clinical findings diabetic retinopathy, description=Findings from the posterior chamber of the eye that have been decisive in obtaining a diagnosis for diabetic retinopathy., 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-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.exclusion-problem_diagnosis.v0], code=at0000.1, itemType=EVALUATION, level=1, text=Exclusion of a Problem/Diagnosis, description=A statement about problems or diagnoses that have never been noted by the individual or recognised by a clinician., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.exclusion-problem_diagnosis.v0]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=2, 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-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.exclusion-problem_diagnosis.v0]/data[at0001]/items[at0002.1], code=at0002.1, itemType=ELEMENT, level=3, text=Exclusion statement, description=Statement of exclusion of a problem or diagnosis., comment=Use to record a statement about problems or diagnoses that have never been noted by the individual or recognised by a clinician. This statement can support recording general statements such as "No previous/past ..." or " No known ...". Or it can support more exacting statements about a specified object such as "No known history of ..." where the 'Problem/diagnosis' identifies the precise condition., uncommonOntologyItems=null, occurencesFormal=1..*, occurencesText=Mandatory, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.exclusion-problem_diagnosis.v0]/data[at0001]/items[at0003.1], code=at0003.1, itemType=ELEMENT, level=3, text=Problem/Diagnosis, description=Identification of the specific Problem or Diagnosis to which the 'Exclusion statement' applies., comment=This data element is used to enable exact statements like: 'No past history of diabetes for the individual'. In this example, 'diabetes' would be an example of the 'Problem/Diagnosis' and the rest of the example phrase would be carried in the 'Exclusion statement'. Another possible use case might be 'Exclusion of pregnancy'. Please note: if coordinated phrases such as 'No known pneumonia' is available, then this can be used as an alternative in the 'Exclusion statement' alone., 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-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.exclusion-problem_diagnosis.v0]/data[at0001]/items[at0007], code=at0007, itemType=ELEMENT, level=3, text=Comment, description=Additional narrative about the Exclusion not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.exclusion-problem_diagnosis.v0]/protocol[at0006], code=at0006, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=2, 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-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.exclusion-problem_diagnosis.v0]/protocol[at0006]/items[at0004], code=at0004, itemType=ELEMENT, level=3, text=Last updated, description=The date on which this exclusion was last updated., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null]], templateType=normal]