| TEMPLATE ID | Consultation for AMD assessment |
|---|---|
| Concept | Consultation for AMD assessment |
| Description | Analysis of the consultation in ophtalmology aimed at reach an assessment and therapeutic decision for patients affected with wet AMD. |
| Purpose | Analysis of the consultation in ophtalmology aimed at reach an assessment and therapeutic decision for patients affected with wet AMD. |
| References | |
| Other Details (Language Independent) |
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| Language used | en |
| Citeable Identifier | 1013.26.71 |
| Root archetype id | openEHR-EHR-COMPOSITION.report-result.v0 |
| Result Report | Result Report: Document to communicate information to others about the result of a test or assessment. |
| Other Context | |
| Patient's demographic data | Patient's demographic data: Personal demographics including name(s) , addresse(s) and telecommunication contact details. |
| Patient identifier | Patient identifier: Identifier of individual. |
| Date of Birth | Date of Birth: Individual's date of birth. |
| Patient's gender | Patient's gender: Biological sex of the individual.
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| Reporting professional | Reporting professional: Details of a healthcare professional. |
| Clinician's name | Clinician's name: Personal name compliant with European ISA standard. |
| Family Name | Family Name: A family name is usually shared by members of a family. This attribute also carries prefixes or suffixes which are part of the Family Name, e.g. “de Boer”, “van de Putte”, “von und zu Orlow”. Multiple family names, such as are commonly found in Hispanic countries, are recorded in the single Family Name field so that, for example, Miguel de Cervantes Saavedra's Family Name would be recorded as "de Cervantes Saavedra. |
| Given Name | Given Name: A given name, or multiple given names, are the denominator(s) that identify an individual within a family. These are given to a person by his or her parents at birth or may be legally recognised as 'given names' through a formal process. All given names are ordered in one field so that, for example, the Given Name for Johan Sebastian Bach is 'Johan Sebastian.' |
| Professional Identifier | Professional Identifier: The healthcare worker's profesional identifier. |
| Healthcare provider (PARENT) | Healthcare provider (PARENT): Details of a healthcare provider organisation. |
| Healthcare organisation | Healthcare organisation: The name of the organisation. |
| Healthcare organisation identifier | Healthcare organisation identifier: The unique identifier of the organisation. |
| Diagnostic model | Diagnostic model: Manages any healthcare procedure that generates a diagnostic or a therapeutic decision as a result. |
| Study setting | Study setting: Information of interest about the setting of the current study aimed at later statistical and epidemiologic data mining purposes. |
| Efficiency of healthcare procedure | Efficiency of healthcare procedure: Parameters of interest for an objective study of the efficiency for a specific healthcare procedure. |
| Data | |
| Procedure type | Procedure type: Identifies the type of clinical encounter or healthcare procedure analysed. Specially useful when different types are compared. |
| Description | Description: Narrative description of the clinical encounter or healthcare procedure analysed. |
| Anatomical location | Anatomical location: A physical site on or within the human body. |
| Eye examined | Eye examined: The side of the body on which the identified body site is located. 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.
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| Study date | Study date: Date/time of onset of the encounter or healthcare procedure analysed. |
| Duration of the assessment | Duration of the assessment: Time how long it takes to complete the encounter or healthcare procedure analysed. Units:
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| Diagnostic test analysis | Diagnostic test analysis: Information resulting from the analysis of predetermined diagnostic tests, whose outcomes are aimed at determine the diagnosis and/or treatment for a specific affection. |
| Visual acuity at the study onset | Visual acuity at the study onset: Visual acuity is a measure of the spatial resolution of the visual processing system. |
| Data | |
| Any event | Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time. |
| Data | |
| Per Eye | Per Eye: Details of the visual field test result for each eye. |
| Notation | Notation: Details of a visual acuity result recorded using one of the result notation formats. |
| Metric Snellen | Metric Snellen: The distance test result, recorded in Snellen format expressed in metres, where 6/6 is regarded as normal. Examples: '6/6, '6/12', '6/5'
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| US Snellen | US Snellen: The distance test result, recorded as Snellen visual acuity expressed in feet, where 20/20 is regarded as normal. Examples: '20/20' , '20/40', '20/18'
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| Decimal Snellen | Decimal Snellen: The distance test result,recorded as Sn ellen visual acuity expressed as a decimal ratio, where 1.0 is regarded as normal.
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| ETDRS Letters | ETDRS Letters: Visual acuity expressed using ETDRS Letters format, with a value of 100 regarded as normal. 1..120 |
| logMar | logMar: The test result, recorded as logMar visual acuity, where a value of 0 is regarded as normal. -0.5..2 |
| Low Vision Score | Low Vision Score: Graded scale used when patient has low levels of visual acuity.
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| Latest visual acuity measurement | Latest visual acuity measurement: Visual acuity is a measure of the spatial resolution of the visual processing system. |
| Data | |
| Any event | Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time. |
| Data | |
| Per Eye | Per Eye: Details of the visual field test result for each eye. |
| Notation | Notation: Details of a visual acuity result recorded using one of the result notation formats. |
| Metric Snellen | Metric Snellen: The distance test result, recorded in Snellen format expressed in metres, where 6/6 is regarded as normal. Examples: '6/6, '6/12', '6/5'
|
| US Snellen | US Snellen: The distance test result, recorded as Snellen visual acuity expressed in feet, where 20/20 is regarded as normal. Examples: '20/20' , '20/40', '20/18'
|
| Decimal Snellen | Decimal Snellen: The distance test result,recorded as Sn ellen visual acuity expressed as a decimal ratio, where 1.0 is regarded as normal.
|
| ETDRS Letters | ETDRS Letters: Visual acuity expressed using ETDRS Letters format, with a value of 100 regarded as normal. 1..120 |
| logMar | logMar: The test result, recorded as logMar visual acuity, where a value of 0 is regarded as normal. -0.5..2 |
| Low Vision Score | Low Vision Score: Graded scale used when patient has low levels of visual acuity.
|
| Fundoscopic examination of eyes | Fundoscopic examination of eyes: Record of clinical findings on fundoscopy of eyes |
| Data | |
| Any event | Any event: * |
| Data | |
| Test Result | Test Result: Details of the funduscopic examination test result for each eye. |
| Clinical results | Clinical results: Information of diagnostic interest obtained in the test |
| Clinical findings | Clinical findings: Narrative description of clinical findings not considered in the SLOT Value set: terminology:Snomed?subset=Findings%20in%20posterior%20pole%20of%20eye&language=en-GB |
| State | |
| Mydriatic used | Mydriatic used: True if mydriatic is used Assumed value: false |
| Protocol | |
| Method | Method: Method chosen to perform the funduscopic examination
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| Ophthalmic tomography examination | Ophthalmic tomography examination: Record of clinical findings using optical coherence tomography with ophthalmic purposes. |
| Data | |
| Any event | Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time. |
| Data | |
| Test result | Test result: Details of the ophthalmic tomography examination test result for each eye. |
| Structure analyzed | Structure analyzed: The anatomic structure analyzed in this study. Matches to DICOM Anatomic Region Sequence (0008,2218) attribute. Values permitted are defined by DICOM standard (PS 3.16) inside the table with Context ID 4211 (Ophthalmic OCT Anatomic Structure Imaged). Value set: ac0001 |
| Multiframe properties | Multiframe properties: Information about the slices of the retina obtained by OCT the test. |
| Number of frames | Number of frames: Number of slices in the study (from 1 to n). Matches to DICOM (0028,0008) attribute. >=1 |
| OCT slice analysis | OCT slice analysis: Analysis of OCT slices considered relevant in the study. |
| Frame pointer | Frame pointer: Number identifying a frame among the rest in the study, to highlight its relevance on diagnosis. Matches to DICOM (0028,0009) attribute. >=1 |
| OCT slice | OCT slice: Current slice of the retina regarding the image of reference. |
| Comment | Comment: Narrative description of clinically relevant information identifiable on the specific frames selected from the acquisition. |
| Clinical findings | Clinical findings: Every finding considered clinically relevant, found on posterior chamber of the eye. Value set: ac0002 |
| Assessment and therapeutic decision | Assessment and therapeutic decision: Diagnosis and/or therapeutic decisions made as a result of the assessment of the diagnostic tests above. |
| Recommendation on the treatment of AMD | Recommendation on the treatment of AMD: A suggestion, advice or proposal toward application of the appropriate therapy for patients diagnosed with age-related macular degeneration. |
| Data | |
| Therapeutic recommendation | Therapeutic recommendation: Narrative description of the most effective treatment based on a previous assessment of AMD.
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| Rationale | Rationale: Justification for the recommendation.
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