| All | OperationalTemplate [rootArchetypeId=openEHR-EHR-SECTION.adhoc.v1, otherContributors=null, tshis=[ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.adhoc.v1], code=at0000, itemType=SECTION, level=0, text=Clinical management, description=A generic section header which should be renamed in a template to suit a specific clinical context., 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.adhoc.v1]/items[openEHR-EHR-OBSERVATION.management_screening.v1], code=at0000, itemType=OBSERVATION, level=1, text=Management screening, description=Series of questions and associated answers used to screen for clinical management including, but not limited to treatments, therapies and hospitalisation., comment=The answers may be self-reported., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.management_screening.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.adhoc.v1]/items[openEHR-EHR-OBSERVATION.management_screening.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=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.management_screening.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.adhoc.v1]/items[openEHR-EHR-OBSERVATION.management_screening.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0022], code=at0022, itemType=CLUSTER, level=5, text=Management activity, description=Details about a specific management or treatment activity or grouping of management or treatment activities relevant for the screening purpose., 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.adhoc.v1]/items[openEHR-EHR-OBSERVATION.management_screening.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0022]/items[at0004], code=at0004, itemType=ELEMENT, level=6, text=Management name, description=Name of a specific management or treatment activity or grouping of management or treatment activities., comment=For example:
Admitted to hospital; Admitted to ICU; Use of compression stockings; Daily dressings; ECMO.
Coding of the 'Management name' 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.adhoc.v1]/items[openEHR-EHR-OBSERVATION.management_screening.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0022]/items[at0005], code=at0005, itemType=ELEMENT, level=6, text=Done?, description=Is there a history of the specific management or treatment activity?, comment=In a template, the data element would usually be renamed to the specific question asked. The proposed value set can be adapted for local use by using the DV_TEXT or the DV_BOOLEAN datatypes choice to match each specific use case., 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-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.management_screening.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0022]/items[at0037], code=at0037, itemType=ELEMENT, level=6, text=Start date, description=When the managment or treatment started., comment=The 'Start' data element has deliberately been loosely modelled to support the myriad of ways that it can be used in questionnaires to capture when the management or treatment started. The specific and intended semantics can be further clarified in a template. For example: Date/time for the date when the treatment started. Interval of date/time for a period of time eg. between 1940 and 1942. Text for descriptions like 'Immediately after the operation', or 'Up to one week ago', 'Up to two weeks ago', 'Three weeks ago'. Duration for the individual's age at the onset of duration OR the length of time during which the individual has been under treatment. Interval of Duration for the approximate age of the individual at the time of onset., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.investigation_screening.v1], code=at0000, itemType=OBSERVATION, level=1, text=Diagnostic investigation screening, description=Series of questions and associated answers used to screen whether diagnostic investigations have been carried out., comment=The answers may be self-reported., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.investigation_screening.v1]/data[at0022], code=at0022, 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.adhoc.v1]/items[openEHR-EHR-OBSERVATION.investigation_screening.v1]/data[at0022]/events[at0023], code=at0023, 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=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.investigation_screening.v1]/data[at0022]/events[at0023]/data[at0001], code=at0001, 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.adhoc.v1]/items[openEHR-EHR-OBSERVATION.investigation_screening.v1]/data[at0022]/events[at0023]/data[at0001]/items[at0027], code=at0027, itemType=ELEMENT, level=5, text=Specimen taken?, description=Is there a history of any diagnostic tests or investigations related to the screening purpose?, comment=In a template, the data element would usually be renamed to the specific question asked. The proposed value set can be adapted for local use by using the DV_TEXT or the DV_BOOLEAN datatypes choice to match each specific use case., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.investigation_screening.v1]/data[at0022]/events[at0023]/data[at0001]/items[at0026 and name/value='Laboratory test'], code=at0026, itemType=CLUSTER, level=5, text=Laboratory test, description=Details about a specified investigation or grouping of investigations relevant for the screening purpose., comment=Use separate instances of this CLUSTER to differentiate between specific investigations or groupings of investigations., 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.adhoc.v1]/items[openEHR-EHR-OBSERVATION.investigation_screening.v1]/data[at0022]/events[at0023]/data[at0001]/items[at0026 and name/value='Laboratory test']/items[at0021], code=at0021, itemType=ELEMENT, level=6, text=Test name, description=Name of the diagnostic investigation or grouping of investigations., comment=For example: 'Blood gas', Chest Xray', 'ECG'; or 'Hearing test'.
Coding of the 'Investigation name' 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.adhoc.v1]/items[openEHR-EHR-OBSERVATION.investigation_screening.v1]/data[at0022]/events[at0023]/data[at0001]/items[at0026 and name/value='Laboratory test']/items[at0024], code=at0024, itemType=ELEMENT, level=6, text=Done?, description=Is there a history of the investigation being carried out?, comment=In a template, the data element would usually be renamed to the specific question asked. The proposed value set can be adapted for local use by using the DV_TEXT or the DV_BOOLEAN datatypes choice to match each specific use case., 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-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.investigation_screening.v1]/data[at0022]/events[at0023]/data[at0001]/items[at0026 and name/value='Laboratory test']/items[at0003 and name/value='Date of collection'], code=at0003, itemType=ELEMENT, level=6, text=Date of collection, description=Indication of timing related to the investigation., comment=The 'Timing' data element has deliberately been loosely modelled to support the myriad of ways that it can be used in questionnaires to capture when an investigation was carried out. The specific and intended semantics can be further clarified in a template. For example: the actual date and/or time; the start and stop time for the investigation; the interval of time during which the investigation was carried out; the duration of the investigation; the age of the individual at the time of the investigation; or the duration of time since it occurred. A partial date is valid, using the DV_DATE_TIME data type, to record only a year., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.investigation_screening.v1]/data[at0022]/events[at0023]/data[at0001]/items[at0026 and name/value='Laboratory test']/items[at0003 and name/value='Date sent to laboratory'], code=at0003, itemType=ELEMENT, level=6, text=Date sent to laboratory, description=Indication of timing related to the investigation., comment=The 'Timing' data element has deliberately been loosely modelled to support the myriad of ways that it can be used in questionnaires to capture when an investigation was carried out. The specific and intended semantics can be further clarified in a template. For example: the actual date and/or time; the start and stop time for the investigation; the interval of time during which the investigation was carried out; the duration of the investigation; the age of the individual at the time of the investigation; or the duration of time since it occurred. A partial date is valid, using the DV_DATE_TIME data type, to record only a year., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.investigation_screening.v1]/data[at0022]/events[at0023]/data[at0001]/items[at0026 and name/value='Laboratory test']/items[at0002], code=at0002, itemType=ELEMENT, level=6, text=Conclusion, description=Brief description, summary or interpretation of the investigation outcome., comment=For example: 'All results within normal range', 'Normal', 'Further investigations needed'. This data element is not to contain a representation of the actual results or findings. In that situation, nest an appropriate CLUSTER archetype within the following 'Additional details' SLOT., 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.adhoc.v1]/items[openEHR-EHR-OBSERVATION.investigation_screening.v1]/data[at0022]/events[at0023]/data[at0001]/items[at0026 and name/value='Laboratory test']/items[openEHR-EHR-CLUSTER.laboratory_test_analyte.v1], code=at0000, itemType=CLUSTER, level=6, text=Laboratory analyte result, description=The result of a laboratory test for a single analyte value., 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-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.investigation_screening.v1]/data[at0022]/events[at0023]/data[at0001]/items[at0026 and name/value='Laboratory test']/items[openEHR-EHR-CLUSTER.laboratory_test_analyte.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=7, text=Test result, description=The value of the analyte result., comment=For example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details., uncommonOntologyItems={fhir_mapping=Observation.value[x], hl7v2_mapping=OBX.2, OBX.5, OBX.6, OBX.7, OBX.8}, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values= Quantity Count Duration Proportion Text Coded TextValue set: external
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.investigation_screening.v1]/data[at0022]/events[at0023]/data[at0001]/items[at0026 and name/value='Laboratory test']/items[openEHR-EHR-CLUSTER.laboratory_test_analyte.v1]/items[at0003], code=at0003, itemType=ELEMENT, level=7, text=Comment, description=Additional narrative about the analyte result, not captured in other fields., comment=null, uncommonOntologyItems={fhir_mapping=Observation.note, hl7v2_mapping=NTE.3}, 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.adhoc.v1]/items[openEHR-EHR-OBSERVATION.investigation_screening.v1]/data[at0022]/events[at0023]/data[at0001]/items[at0026 and name/value='Imaging examination'], code=at0026, itemType=CLUSTER, level=5, text=Imaging examination, description=Details about a specified investigation or grouping of investigations relevant for the screening purpose., comment=Use separate instances of this CLUSTER to differentiate between specific investigations or groupings of investigations., 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.adhoc.v1]/items[openEHR-EHR-OBSERVATION.investigation_screening.v1]/data[at0022]/events[at0023]/data[at0001]/items[at0026 and name/value='Imaging examination']/items[at0021], code=at0021, itemType=ELEMENT, level=6, text=Study name, description=Name of the diagnostic investigation or grouping of investigations., comment=For example: 'Blood gas', Chest Xray', 'ECG'; or 'Hearing test'.
Coding of the 'Investigation name' 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.adhoc.v1]/items[openEHR-EHR-OBSERVATION.investigation_screening.v1]/data[at0022]/events[at0023]/data[at0001]/items[at0026 and name/value='Imaging examination']/items[at0024], code=at0024, itemType=ELEMENT, level=6, text=Done?, description=Is there a history of the investigation being carried out?, comment=In a template, the data element would usually be renamed to the specific question asked. The proposed value set can be adapted for local use by using the DV_TEXT or the DV_BOOLEAN datatypes choice to match each specific use case., 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-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.investigation_screening.v1]/data[at0022]/events[at0023]/data[at0001]/items[at0026 and name/value='Imaging examination']/items[at0003], code=at0003, itemType=ELEMENT, level=6, text=Date of study, description=Indication of timing related to the investigation., comment=The 'Timing' data element has deliberately been loosely modelled to support the myriad of ways that it can be used in questionnaires to capture when an investigation was carried out. The specific and intended semantics can be further clarified in a template. For example: the actual date and/or time; the start and stop time for the investigation; the interval of time during which the investigation was carried out; the duration of the investigation; the age of the individual at the time of the investigation; or the duration of time since it occurred. A partial date is valid, using the DV_DATE_TIME data type, to record only a year., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values= Date/Time- Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.investigation_screening.v1]/data[at0022]/events[at0023]/data[at0001]/items[at0026 and name/value='Imaging examination']/items[at0002 and name/value='Conclusion'], code=at0002, itemType=ELEMENT, level=6, text=Conclusion, description=Brief description, summary or interpretation of the investigation outcome., comment=For example: 'All results within normal range', 'Normal', 'Further investigations needed'. This data element is not to contain a representation of the actual results or findings. In that situation, nest an appropriate CLUSTER archetype within the following 'Additional details' SLOT., 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.adhoc.v1]/items[openEHR-EHR-OBSERVATION.investigation_screening.v1]/data[at0022]/events[at0023]/data[at0001]/items[at0026 and name/value='Imaging examination']/items[at0002 and name/value='Presence?'], code=at0002, itemType=ELEMENT, level=6, text=Presence?, description=Brief description, summary or interpretation of the investigation outcome., comment=For example: 'All results within normal range', 'Normal', 'Further investigations needed'. This data element is not to contain a representation of the actual results or findings. In that situation, nest an appropriate CLUSTER archetype within the following 'Additional details' SLOT., 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.adhoc.v1]/items[openEHR-EHR-OBSERVATION.investigation_screening.v1]/data[at0022]/events[at0023]/data[at0001]/items[at0026 and name/value='Other investigation'], code=at0026, itemType=CLUSTER, level=5, text=Other investigation, description=Details about a specified investigation or grouping of investigations relevant for the screening purpose., comment=Use separate instances of this CLUSTER to differentiate between specific investigations or groupings of investigations., 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.adhoc.v1]/items[openEHR-EHR-OBSERVATION.investigation_screening.v1]/data[at0022]/events[at0023]/data[at0001]/items[at0026 and name/value='Other investigation']/items[at0021], code=at0021, itemType=ELEMENT, level=6, text=Investigation name, description=Name of the diagnostic investigation or grouping of investigations., comment=For example: 'Blood gas', Chest Xray', 'ECG'; or 'Hearing test'.
Coding of the 'Investigation name' 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.adhoc.v1]/items[openEHR-EHR-OBSERVATION.investigation_screening.v1]/data[at0022]/events[at0023]/data[at0001]/items[at0026 and name/value='Other investigation']/items[at0024], code=at0024, itemType=ELEMENT, level=6, text=Done?, description=Is there a history of the investigation being carried out?, comment=In a template, the data element would usually be renamed to the specific question asked. The proposed value set can be adapted for local use by using the DV_TEXT or the DV_BOOLEAN datatypes choice to match each specific use case., 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-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.investigation_screening.v1]/data[at0022]/events[at0023]/data[at0001]/items[at0026 and name/value='Other investigation']/items[at0003], code=at0003, itemType=ELEMENT, level=6, text=Timing, description=Indication of timing related to the investigation., comment=The 'Timing' data element has deliberately been loosely modelled to support the myriad of ways that it can be used in questionnaires to capture when an investigation was carried out. The specific and intended semantics can be further clarified in a template. For example: the actual date and/or time; the start and stop time for the investigation; the interval of time during which the investigation was carried out; the duration of the investigation; the age of the individual at the time of the investigation; or the duration of time since it occurred. A partial date is valid, using the DV_DATE_TIME data type, to record only a year., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.investigation_screening.v1]/data[at0022]/events[at0023]/data[at0001]/items[at0026 and name/value='Other investigation']/items[at0002], code=at0002, itemType=ELEMENT, level=6, text=Conclusion, description=Brief description, summary or interpretation of the investigation outcome., comment=For example: 'All results within normal range', 'Normal', 'Further investigations needed'. This data element is not to contain a representation of the actual results or findings. In that situation, nest an appropriate CLUSTER archetype within the following 'Additional details' SLOT., 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.adhoc.v1]/items[openEHR-EHR-OBSERVATION.investigation_screening.v1]/data[at0022]/events[at0023]/data[at0001]/items[openEHR-EHR-CLUSTER.specimen.v1], code=at0000, itemType=CLUSTER, level=5, text=Specimen, description=A physical sample collected from, or related to, an individual for the purpose of investigation, examination or analysis., comment=For example: Tissue or body fluid., 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-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.investigation_screening.v1]/data[at0022]/events[at0023]/data[at0001]/items[openEHR-EHR-CLUSTER.specimen.v1]/items[at0029], code=at0029, itemType=ELEMENT, level=6, text=Specimen type, description=The type of specimen., comment=For example: Venous blood, bacterial culture, cytology, or tissue sample. Coding of the specimen type with a terminology is preferred, where possible., uncommonOntologyItems={fhir_mapping=Specimen.type}, 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.adhoc.v1]/items[openEHR-EHR-OBSERVATION.investigation_screening.v1]/data[at0022]/events[at0023]/data[at0001]/items[openEHR-EHR-CLUSTER.specimen.v1]/items[at0098], code=at0098, itemType=ELEMENT, level=6, text=Specimen number, description=A name or label describing the specimen., comment=Usually only relevant for anatomical pathology samples. For example: 'Sigmoid resection with a piece of bladder wall' or 'Aggregate of multiple skin biopsy fragments'., 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.adhoc.v1]/items[openEHR-EHR-OBSERVATION.investigation_screening.v1]/data[at0022]/events[at0023]/data[at0001]/items[openEHR-EHR-CLUSTER.specimen.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=6, text=Laboratory specimen identifier, description=A unique identifier of the specimen, normally assigned by the laboratory., comment=Sometimes called the Accession Identifier. Specimen containers, for example vacuum vials or tissue cassettes, have their own identitiers which may be recorded in the 'Container identifier' element in the 'Specimen container' archetype., uncommonOntologyItems={fhir_mapping=Specimen.accessionIdentifier}, 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.adhoc.v1]/items[openEHR-EHR-OBSERVATION.investigation_screening.v1]/data[at0022]/events[at0023]/data[at0001]/items[openEHR-EHR-CLUSTER.specimen.v1]/items[at0034], code=at0034, itemType=ELEMENT, level=6, text=Date/time received, description=The date and time that the sample was received at the laboratory., comment=null, uncommonOntologyItems={fhir_mapping=Specimen.receivedTime}, 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.adhoc.v1]/items[openEHR-EHR-OBSERVATION.investigation_screening.v1]/data[at0022]/events[at0023]/data[at0001]/items[openEHR-EHR-CLUSTER.specimen.v1]/items[at0015], code=at0015, itemType=ELEMENT, level=6, text=Date/time collected, description=The date and time that collection has been ordered to take place or has taken place., comment=This datetime will be captured primarily in the INSTRUCTION timing, ACTION time or OBSERVATION times. However, as this is a critical piece of information, it can be useful to also associate it directly with the specimen itself., 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.adhoc.v1]/items[openEHR-EHR-OBSERVATION.investigation_screening.v1]/data[at0022]/events[at0023]/data[at0001]/items[openEHR-EHR-CLUSTER.specimen.v1]/items[at0041], code=at0041, itemType=ELEMENT, level=6, text=Adequacy for testing, description=Information about whether the specimen was adequate for testing., comment=This element is intended to be used to record a judgement about whether or not the specimen quality was good enough for testing, and whether or not testing has been carried out. Coding of the specimen quality issues with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- Satisfactory
- Unsatisfactory - analysed
- Unsatisfactory - not analysed
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1], code=at0000, itemType=OBSERVATION, level=1, text=*Laboratory test result, description=The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.laboratory_test_result.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.adhoc.v1]/items[openEHR-EHR-OBSERVATION.laboratory_test_result.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=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.laboratory_test_result.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.adhoc.v1]/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0005], code=at0005, itemType=ELEMENT, level=5, text=Test name, description=Name of the laboratory investigation performed on the specimen(s)., comment=A test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'., 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.adhoc.v1]/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0075], code=at0075, itemType=ELEMENT, level=5, text=Date/time, description=The date and/or time that ‘Overall test status’ was issued., 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.adhoc.v1]/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.laboratory_test_analyte.v1], code=at0000, itemType=CLUSTER, level=5, text=Laboratory analyte result, description=The result of a laboratory test for a single analyte value., 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-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.laboratory_test_analyte.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=6, text=Test result, description=The value of the analyte result., comment=For example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details., uncommonOntologyItems={fhir_mapping=Observation.value[x], hl7v2_mapping=OBX.2, OBX.5, OBX.6, OBX.7, OBX.8}, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=- Quantity
- Count
- Duration
- Proportion
- Text
- Coded TextValue set: external
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.laboratory_test_analyte.v1]/items[at0003], code=at0003, itemType=ELEMENT, level=6, text=Comment, description=Additional narrative about the analyte result, not captured in other fields., comment=null, uncommonOntologyItems={fhir_mapping=Observation.note, hl7v2_mapping=NTE.3}, 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.adhoc.v1]/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0098], code=at0098, itemType=ELEMENT, level=5, text=Result interpretation, description=Single word, phrase or brief description that represents the clinical meaning and significance of the laboratory test result., comment=For example: 'Severe hepatic impairment', 'Salmonella contamination'. Coding of the diagnosis with a terminology is strongly recommended, where possible. This diagnosis should be aligned with the narrative in the 'Conclusion'., 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.adhoc.v1]/items[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0101], code=at0101, itemType=ELEMENT, level=5, text=Comment, description=Additional narrative about the test result not captured in other fields., 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.adhoc.v1]/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v1], code=at0000, itemType=OBSERVATION, level=1, text=*Imaging examination result, description=The result of an imaging examination performed on an individual, using radiological techniques., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.imaging_exam_result.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.adhoc.v1]/items[openEHR-EHR-OBSERVATION.imaging_exam_result.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=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.imaging_exam_result.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.adhoc.v1]/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=5, text=Study name, description=The name of the imaging examination performed., comment=For example: 'CT abdomen'; 'Doppler ultrasound of renal artery' or 'Plain chest xray'. Coding with a terminology is strongly recommended, preferably a term specifying both modality and anatomical location, where possible. Examples of candidate terminologies are the LOINC Imaging Document Codes, RadLex Playbook or SNOMED-CT. Equivalent to DiagnosticReport.code in FHIR., 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.adhoc.v1]/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0070], code=at0070, itemType=ELEMENT, level=5, text=Study date, description=Date/time when the imaging started., comment=Equivalent to ImagingStudy.started in FHIR., 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.adhoc.v1]/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0008], code=at0008, itemType=ELEMENT, level=5, text=Imaging findings, description=Narrative description or overview of all clinical findings., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-SECTION.adhoc.v1]/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0021], code=at0021, itemType=ELEMENT, level=5, text=Overall impression, description=Narrative concise, clinically relevant interpretation of all imaging findings, and include a comparison with previous studies where appropriate., comment=Also referred to as 'Opinion' or 'Conclusion'. Equivalent to DiagnosticReport.conclusion in FHIR., 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.adhoc.v1]/items[openEHR-EHR-OBSERVATION.imaging_exam_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0023], code=at0023, itemType=ELEMENT, level=5, text=Comment, description=Additional narrative about the examination not captured in other fields., comment=For example: a note that the film was given to the patient. Equivalent to DiagnosticReport.note in FHIR., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null]], templateType=normal] |