TEMPLATE Patient's background for DR screening (4e8f2e3c-e073-4f50-a5fb-2c6778ca5c67)

TEMPLATE ID4e8f2e3c-e073-4f50-a5fb-2c6778ca5c67
ConceptPatient's background for DR screening
DescriptionSet up a background before a follow up process
PurposeSet up a background before a follow up process
References
Authorsname: Aitor Eguzkitza; organisation: Universidad Pública de Navarra - Complejo Hospitalario de Navarra; email: aitor.eguzkiza@unavarra.es; date: 2015-10-19
Other Details Languagename: Aitor Eguzkitza; organisation: Universidad Pública de Navarra - Complejo Hospitalario de Navarra; email: aitor.eguzkiza@unavarra.es; date: 2015-10-19
OtherDetails Language Independent{MetaDataSet:Sample Set =MetaDataSet:Sample Set }
Language useden
Citeable Identifier1013.26.21
AllOperationalTemplate [rootArchetypeId=openEHR-EHR-SECTION.patients_background.v0, otherContributors=José Andonegui, Hospital de Navarra, 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.patients_background.v0], code=at0000, itemType=SECTION, level=0, text=Patients background, description=Clinical information needed from a patient to give context to the responsible physician before register him within a specific service., 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.patients_background.v0]/items[openEHR-EHR-EVALUATION.reason_for_encounter.v1], code=at0000, itemType=EVALUATION, level=1, text=Reason for encounter, description=The reason for initiation of any healthcare encounter or contact by the individual who is the subject of care., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-EVALUATION.reason_for_encounter.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.patients_background.v0]/items[openEHR-EHR-EVALUATION.reason_for_encounter.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=3, text=Contact type, description=Identification of the type, or administrative category, of healthcare sought or required by the subject of care., comment=Coding of the 'Contact type' with a terminology is desirable, where possible. Examples include: pre-employment medical, routine antenatal visit, women's health check, pre-operative assessment, or annual medical check-up., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • DR suspicion established in endocrinology
  • DR suspicion established in primary care review
  • DR suspicion established in a routine ophthalmologic consultation
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-EVALUATION.reason_for_encounter.v1]/data[at0001]/items[at0004], code=at0004, itemType=ELEMENT, level=3, text=Presenting problem, description=Identification of the clinical or social problem motivating the subject of care to seeking healthcare., comment=Coding of the 'Presenting problem' with a terminology is desirable, where possible. Clinical or social reasons for seeking healthcare can include health issues, symptoms or physical signs. Examples: health issues - desire to quit smoking, domestic violence; symptoms - abdominal pain, shortness of breath; physical signs - an altered conscious state. 'Chief complaint' may be used as a valid synonym for 'Presenting problem' in templates., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=Default value: Suspicion of diabetic retinopathy, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.patients_background.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=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.patients_background.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.patients_background.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.patients_background.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.patients_background.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.patients_background.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=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.patients_background.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=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.patients_background.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.patients_background.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0003], code=at0003, itemType=ELEMENT, level=3, text=Date/time clinically recognised, description=Estimated or actual date/time the diagnosis or problem was recognised by a healthcare professional., comment=Partial dates are acceptable. If the subject of care is under the age of one year, then the complete date or a minimum of the month and year is necessary to enable accurate age calculations - for example, if used to drive decision support. Data captured/imported as "Age at time of clinical recognition" 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.patients_background.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0005], code=at0005, itemType=ELEMENT, level=3, text=Severity, description=An assessment of the overall severity of the problem or diagnosis., comment=If severity is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant. Note: more specific grading of severity can be recorded using the Specific details SLOT., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Coded Text
    • Mild  [The problem or diagnosis does not interfere with normal activity or may cause damage to health if left untreated.]
    • Moderate  [The problem or diagnosis causes interference with normal activity or will damage health if left untreated.]
    • Severe  [The problem or diagnosis prevents normal activity or will seriously damage health if left untreated.]
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.patients_background.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.patients_background.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=*, 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.patients_background.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=**(es), 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-SECTION.patients_background.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  [**(es)]
  • Proliferative diabetic retinopathy  [**(es)]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.patients_background.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.patients_background.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.patients_background.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0030], code=at0030, itemType=ELEMENT, level=3, text=Date/time of resolution, description=Estimated or actual date/time of resolution or remission for this problem or diagnosis, as determined by a healthcare professional., comment=Partial dates are acceptable. If the subject of care is under the age of one year, then the complete date or a minimum of the month and year is necessary to enable accurate age calculations - for example, if used to drive decision support. Data captured/imported as "Age at time of resolution" 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, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/protocol[at0032]/items[at0070], code=at0070, itemType=ELEMENT, level=2, text=Last updated, description=The date this problem or diagnosis 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-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.v1], code=at0000, itemType=OBSERVATION, level=1, text=Story/History, description=The subjective clinical history of the subject of care as recorded directly by the subject, or reported to a clinician by the subject or a carer., 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-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.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.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=3, text=Any event, description=Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time., 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-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, 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.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=5, text=Story, description=Narrative description of the story or clinical history for the subject of care., 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-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom_sign.v0], code=at0000, itemType=CLUSTER, level=5, text=Symptom/Sign, description=Reported subjective or objective observation of a physical or mental disturbance in an individual., 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.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom_sign.v0]/items[at0001], code=at0001, itemType=ELEMENT, level=6, text=Symptom/Sign name, description=The name of the reported symptom or sign., comment=Symptom name should be coded with a terminology, 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-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom_sign.v0]/items[at0002], code=at0002, itemType=ELEMENT, level=6, text=Description, description=Narrative description about the reported symptom or sign., 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.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom_sign.v0]/items[at0151], code=at0151, itemType=ELEMENT, level=6, text=Body site, description=Simple body site where the symptom or sign was reported., comment=Occurrences of this data element are set to 0..* to allow multiple body sites to be separated out in a template if desired. This allows for representation of clinical scenarios where a symptom or sign needs to be recorded in multiple locations or identifying both the originating and distal site in pain radiation, but where all of the other attributes such as impact and duration are identical. If the requirements for recording the body site 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 Detailed anatomical location' SLOT in this archetype. If the anatomical location is included in the Symptom name via precoordinated codes, this data element becomes redundant. If the anatomical location is recorded using the 'Structured body site' SLOT, then use of this data element is not allowed - record only the simple 'Body site' OR 'Structured body site', but not both., 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.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom_sign.v0]/items[openEHR-EHR-CLUSTER.anatomical_location.v1], code=at0000, itemType=CLUSTER, level=6, 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-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom_sign.v0]/items[openEHR-EHR-CLUSTER.anatomical_location.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=7, 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-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom_sign.v0]/items[openEHR-EHR-CLUSTER.anatomical_location.v1]/items[at0065], code=at0065, itemType=ELEMENT, level=7, 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_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom_sign.v0]/items[openEHR-EHR-CLUSTER.anatomical_location.v1]/items[at0002], code=at0002, itemType=ELEMENT, level=7, 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-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom_sign.v0]/items[openEHR-EHR-CLUSTER.anatomical_location.v1]/items[at0064], code=at0064, itemType=ELEMENT, level=7, 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-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom_sign.v0]/items[openEHR-EHR-CLUSTER.anatomical_location.v1]/items[at0055], code=at0055, itemType=ELEMENT, level=7, 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
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom_sign.v0]/items[openEHR-EHR-CLUSTER.anatomical_location.v1]/items[at0023], code=at0023, itemType=ELEMENT, level=7, text=Description, description=Narrative description that can be used to further refine and support the 'Body site name'., comment=For example: adjacent to the vermilion border; a tattoo covers the bottom half of this area., 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.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom_sign.v0]/items[at0175], code=at0175, itemType=ELEMENT, level=6, text=Episodicity, description=Category of this episode for the identified symptom or sign., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • New  [A new episode of the symptom or sign - either the first ever occurrence or a reoccurrence where the previous episode had completely resolved.]
  • Ongoing  [This symptom or sign is ongoing, effectively a single, continuous episode.]
  • Indeterminate  [It is not possible to determine if this occurrence of the symptom or sign is new or ongoing.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom_sign.v0]/items[at0186], code=at0186, itemType=ELEMENT, level=6, text=First ever?, description=Is this the first ever occurrence of this symptom or sign?, comment=Record as True if this is the first ever occurrence of this symptom or sign., 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.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom_sign.v0]/items[at0152], code=at0152, itemType=ELEMENT, level=6, text=Episode onset, description=The onset for this episode of the symptom or sign., comment=While partial dates are permitted, the exact date and time of onset can be recorded, if appropriate. If this symptom or sign is experienced for the first time or is a re-occurrence, this date is used to represent the onset of this episode. If this symptom or sign is ongoing, this data element may be redundant if it has been recorded previously., 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.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom_sign.v0]/items[at0164], code=at0164, itemType=ELEMENT, level=6, text=Onset type, description=Description of the onset of the symptom or sign., comment=The type of the onset can be coded with a terminology, if desired. For example: gradual; or sudden., 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.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom_sign.v0]/items[at0028], code=at0028, itemType=ELEMENT, level=6, text=Duration, description=The duration of this episode of the symptom or sign since onset., comment=If 'Date/time of onset' and 'Date/time of resolution' are used in systems, this data element may be calculated, or alternatively, be considered redundant in this scenario., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DURATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom_sign.v0]/items[at0021], code=at0021, itemType=ELEMENT, level=6, text=Severity category, description=Category representing the overall severity of the symptom or sign., comment=Defining values such as mild, moderate or severe in such a way that is applicable to multiple symptoms or signs plus allows multiple users to interpret and record them consistently is not easy. Some organisations extend the value set further with inclusion of additional values such as 'Trivial' and 'Very severe', and/or 'Mild-Moderate' and 'Moderate-Severe', adds to the definitional difficulty and may also worsen inter-recorder reliability issues. Use of 'Life-threatening' and 'Fatal' is also often considered as part of this value set, although from a pure point of view it may actually reflect an outcome rather than a severity. In view of the above, keeping to a well-defined but smaller list is preferred and so the mild/moderate/severe value set is offered, however the choice of other text allows for other value sets to be included at this data element in a template. Note: more specific grading of severity can be recorded using the 'Specific details' SLOT., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Coded Text
    • Mild  [The intensity of the symptom or sign does not cause interference with normal activity.]
    • Moderate  [The intensity of the symptom or sign causes interference with normal activity.]
    • Severe  [The intensity of the symptom or sign causes prevents normal activity.]
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom_sign.v0]/items[at0026], code=at0026, itemType=ELEMENT, level=6, text=Severity rating, description=Numerical rating scale representing the overall severity of the symptom or sign., comment=Symptom severity can be rated by the individual by recording a score from 0 (ie symptom not present) to 10.0 (ie symptom is as severe as the individual can imagine). This score can be represented in the user interface as a visual analogue scale. The data element has occurrences set to 0..* to allow for variations such as 'maximal severity' or 'average severity' to be included in a template., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=0..10 1, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom_sign.v0]/items[at0180], code=at0180, itemType=ELEMENT, level=6, text=Progression, description=Description progression of the symptom or sign at the time of reporting., comment=Occurrences of this data element are set to 0..* to allow multiple types of progression to be separated out in a template if desired - for example, severity or frequency., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Worsening  [The severity of the symptom or sign has worsened overall during this episode.]
  • Unchanged  [The severity of the symptom or sign has not changed overall during this episode.]
  • Improving  [The severity of the symptom or sign has improved overall during this episode.]
  • Resolved  [The severity of the symptom or sign has resolved.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom_sign.v0]/items[at0003], code=at0003, itemType=ELEMENT, level=6, text=Pattern, description=Narrative description about the pattern of the symptom or sign during this episode., comment=For example: pain could be described as constant or intermittent., 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.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom_sign.v0]/items[at0018], code=at0018, itemType=CLUSTER, level=6, text=Modifying factor, description=Detail about how a specific factor effects the identified symptom or sign during this episode., 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.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom_sign.v0]/items[at0018]/items[at0019], code=at0019, itemType=ELEMENT, level=7, text=Factor, description=Name of the modifying factor., comment=Examples of modifying factor: lying on multiple pillows, eating or administration of a specific medication., 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.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom_sign.v0]/items[at0018]/items[at0017], code=at0017, itemType=ELEMENT, level=7, text=Effect, description=Perceived effect of the modifying factor on the symptom or sign., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Relieves  [The factor decreases the severity or impact of the symptom or sign, but does not fully resolve it.]
  • No effect  [The factor has no impact on the symptom or sign.]
  • Worsens  [The factor increases the severity or impact of the symptom or sign.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom_sign.v0]/items[at0018]/items[at0056], code=at0056, itemType=ELEMENT, level=7, text=Description, description=Narrative description of the effect of the modifying factor on the symptom or sign., 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.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom_sign.v0]/items[at0165], code=at0165, itemType=CLUSTER, level=6, text=(Precipitating/resolving factor), description=Details about specified factors that are associated with the precipitation or resolution of the symptom or sign., comment=For example: onset of headache occurred one week prior to menstruation; or onset of headache occurred one hour after fall of bicycle., 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.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom_sign.v0]/items[at0165]/items[at0170], code=at0170, itemType=ELEMENT, level=7, text=Factor, description=Name of the health event, symptom, reported sign or other factor., comment=For example: onset of another symptom; onset of menstruation; or fall off bicycle., 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.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom_sign.v0]/items[at0165]/items[at0171], code=at0171, itemType=ELEMENT, level=7, text=Time interval, description=The interval of time between the occurrence or onset of the factor and onset/resolution of the symptom or sign., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DURATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom_sign.v0]/items[at0165]/items[at0185], code=at0185, itemType=ELEMENT, level=7, text=Description, description=Narrative description about the effect of the factor on the identified symptom or sign., 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.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom_sign.v0]/items[at0155], code=at0155, itemType=ELEMENT, level=6, text=Impact, description=Description of the impact of this symptom or sign., comment=Assessment of impact could consider the severity, duration and frequency of the symptom as well as the type of impact including, but not limited to, functional, social and emotional impact. Occurrences of this data element are set to 0..* to allow multiple types of impact to be separated out in a template if desired. Examples for functional impact from hearing loss may include: 'Difficulty Hearing in Quiet Environment'; 'Difficulty Hearing the TV or Radio'; 'Difficulty Hearing Group Conversation'; and 'Difficulty Hearing on Phone'., 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.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom_sign.v0]/items[at0037], code=at0037, itemType=ELEMENT, level=6, text=Episode description, description=Narrative description about the course of the symptom or sign during this episode., comment=For example: a text description of the immediate onset of the symptom, activities that worsened or relieved the symptom, whether it is improving or worsening and how it resolved over weeks., 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.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom_sign.v0]/items[at0161], code=at0161, itemType=ELEMENT, level=6, text=Resolution date/time, description=The timing of the cessation of this episode of the symptom or sign., comment=If 'Date/time of onset' and 'Duration' are used in systems, this data element may be calculated, or alternatively, considered redundant. While partial dates are permitted, the exact date and time of resolution can be recorded, if appropriate., 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.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom_sign.v0]/items[at0057], code=at0057, itemType=ELEMENT, level=6, text=Description of previous episodes, description=Narrative description of any or all previous episodes., comment=For example: frequency/periodicity - per hour, day, week, month, year; and regularity. May include a comparison to this episode., 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.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom_sign.v0]/items[at0031], code=at0031, itemType=ELEMENT, level=6, text=Number of previous episodes, description=The number of times this symptom or sign has previously occurred., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=>=0, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom_sign.v0]/items[at0163], code=at0163, itemType=ELEMENT, level=6, text=Comment, description=Additional narrative about the symptom or sign 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]], templateType=normal]