| All | OperationalTemplate [rootArchetypeId=openEHR-EHR-COMPOSITION.report-result.v1, 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-COMPOSITION.report-result.v1], code=at0000.1, itemType=COMPOSITION, level=0, text=Result Report, description=Document to communicate information to others about the result of a test or assessment., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=COMPOSITION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=null, code=null, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=1, text=Other Context, description=null, 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.report-result.v1]/context/other_context[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=2, text=Report ID, description=Identification information about the report., 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.report-result.v1]/context/other_context[at0001]/items[at0005], code=at0005, itemType=ELEMENT, level=2, text=Status, description=The status of the entire report. Note: This is not the status of any of the report components., 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.report-result.v1]/content[openEHR-EHR-SECTION.image_test_analysis.v0], code=at0000, itemType=SECTION, level=1, text=Image test analysis, description=Describes the analysis of image based diagnostic tests, to find clinical findings which can be relevant to decide a diagnosis for a specific disease., 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 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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.report-result.v1]/content[openEHR-EHR-SECTION.image_test_analysis.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_CODED_TEXT, bindings=null, values=Value set: external, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report-result.v1]/content[openEHR-EHR-SECTION.image_test_analysis.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.report-result.v1]/content[openEHR-EHR-SECTION.image_test_analysis.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=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report-result.v1]/content[openEHR-EHR-SECTION.image_test_analysis.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0136]/items[at0065], code=at0065, itemType=CLUSTER, level=7, 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.report-result.v1]/content[openEHR-EHR-SECTION.image_test_analysis.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.report-result.v1]/content[openEHR-EHR-SECTION.image_test_analysis.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.report-result.v1]/content[openEHR-EHR-SECTION.image_test_analysis.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.report-result.v1]/content[openEHR-EHR-SECTION.image_test_analysis.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.report-result.v1]/content[openEHR-EHR-SECTION.image_test_analysis.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.report-result.v1]/content[openEHR-EHR-SECTION.image_test_analysis.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.report-result.v1]/content[openEHR-EHR-SECTION.image_test_analysis.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.report-result.v1]/content[openEHR-EHR-SECTION.image_test_analysis.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.report-result.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0], code=at0000, itemType=SECTION, level=1, text=Clinical decision, description=Defines the process of making a decision about the diagnosis of a specific disease., 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.report-result.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.clinical_synopsis.v1], code=at0000, itemType=EVALUATION, level=2, 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-COMPOSITION.report-result.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.clinical_synopsis.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.report-result.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.clinical_synopsis.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Synopsis, description=The summary, assessment, conclusions or evaluation of the clinical findings., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report-result.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1], code=at0000, itemType=EVALUATION, level=2, 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-COMPOSITION.report-result.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.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.report-result.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, 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=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report-result.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0009], code=at0009, itemType=ELEMENT, level=4, 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=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report-result.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0012], code=at0012, itemType=ELEMENT, level=4, 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=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report-result.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0077], code=at0077, itemType=ELEMENT, level=4, 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-COMPOSITION.report-result.v1]/content[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=4, 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-COMPOSITION.report-result.v1]/content[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=5, 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=Value set: ac0001, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report-result.v1]/content[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=5, 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-COMPOSITION.report-result.v1]/content[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=4, 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-COMPOSITION.report-result.v1]/content[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=5, 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
- Neovascular leakage
- Macular leakage
- Focal leakage
- Indeterminate leakage
- Mixed leakage
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report-result.v1]/content[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=5, 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
- Diffuse diabetic macular edema
- Focal diabetic macular edema
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report-result.v1]/content[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=5, 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
- Proliferative diabetic retinopathy
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report-result.v1]/content[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=5, 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-COMPOSITION.report-result.v1]/content[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=5, 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=Value set: ac0001, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report-result.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.exclusion-problem_diagnosis.v0], code=at0000.1, itemType=EVALUATION, level=2, 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-COMPOSITION.report-result.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.exclusion-problem_diagnosis.v0]/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.report-result.v1]/content[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=4, 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-COMPOSITION.report-result.v1]/content[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=4, 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-COMPOSITION.report-result.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.exclusion-problem_diagnosis.v0]/data[at0001]/items[at0007], code=at0007, itemType=ELEMENT, level=4, text=Comment, description=Additional narrative about the Exclusion not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report-result.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.exclusion-problem_diagnosis.v0]/protocol[at0006], code=at0006, 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.report-result.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.exclusion-problem_diagnosis.v0]/protocol[at0006]/items[at0004], code=at0004, itemType=ELEMENT, level=4, 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], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report-result.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.report-result.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.report-result.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.report-result.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.report-result.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.report-result.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.report-result.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.report-result.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.report-result.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.report-result.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=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report-result.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.report-result.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.report-result.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.report-result.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.report-result.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.report-result.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.report-result.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.report-result.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.report-result.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.report-result.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.report-result.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.report-result.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.report-result.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.report-result.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.report-result.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.report-result.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 Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report-result.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.report-result.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.report-result.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.report-result.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.report-result.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.report-result.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.report-result.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.report-result.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] |