TEMPLATE Clinical screening - JM (Clinical screening - JM)

TEMPLATE IDClinical screening - JM
ConceptClinical screening - JM
DescriptionNot Specified
PurposeNot Specified
References
Authorsdate: 2022-10-19
Other Details Languagedate: 2022-10-19
Other Details (Language Independent)
  • Licence: This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/.
  • Custodian Organisation: openEHR Foundation
  • Original Namespace: org.openehr
  • Original Publisher: openEHR Foundation
  • Custodian Namespace: org.openehr
  • MD5-CAM-1.0.1: e0aefc322d08ee091480cd34f70802c4
  • Sem Ver: 23.0.0
  • Original Language: ISO_639-1::en
  • PARENT:MD5-CAM-1.0.1: B6D6F0E50537D76A80BB513DD2024B74
Language useden
Citeable Identifier1013.26.936
Root archetype idopenEHR-EHR-SECTION.adhoc.v1
Clinical screeningClinical screening: A generic section header which should be renamed in a template to suit a specific clinical context.
Symptom/sign screeningSymptom/sign screening: Series of questions and associated answers used to screen for symptoms or signs.
The answers may be self-reported.
Data
Any eventAny event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Any symptoms or signs?Any symptoms or signs?: Is there a history of any symptoms or signs relevant for the screening purpose?
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.
  • Yes 
  • No 
  • Unknown 
Onset of illnessOnset of illness: Timing of the inital recognition of any symptom or sign relevant for the screening purpose.
The 'Onset' data element has deliberately been loosely modelled to support the myriad of ways that it can be used in questionnaires to capture the onset of symptoms or signs. The specific and intended semantics can be further clarified in a template. For example: Date/time for the date the symptom 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. Interval of Duration for the approximate age of the individual at the time of onset.
Specific symptom/signSpecific symptom/sign: Details about a specific symptom or sign or grouping of symptoms or signs relatevant for the screening purpose.
Symptom/sign nameSymptom/sign name: Identification of a specific symptom or sign or grouping of symptoms or signs, by name.
Coding of the 'Symptom/sign name' with a terminology is preferred, where possible.
Presence?Presence?: Is there a history of the specific symptom or sign being present?
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.
  • Yes 
  • No 
  • Unknown 
Date of onsetDate of onset: Indication of timing related to the specific symptom or sign.
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 the specific symptom or sign occured. 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 when the specific symptom or sign; the interval of time during which the specific symptom or sign occured; the duration of the specific symptom or sign; the age of the individual at the time of the specific symptom or sign occured; 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.
Body temperatureBody temperature: A measurement of the body temperature, which is a surrogate for the core body temperature of the individual.
Data
Any eventAny event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
TemperatureTemperature: The measured temperature.
0..100; 30..200
Units:
  • °C
  • °F
Neuro examination findingsNeuro examination findings: Findings observed during the physical examination of a subject of care.
Data
Any eventAny event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Muscle power findingMuscle power finding: Findings observed during the physical examination of power in a muscle group or a limb.
Body siteBody site: Identification of the limb or muscle group tested.
  • Right arm (proximal)
  • Right arm (distal)
  • Left arm (proximal)
  • Left arm (distal)
  • Right leg(proximal)
  • Right leg (distal)
  • Left leg (proximal)
  • Left leg (distal)
StrengthStrength: Observed level of power in the identified limb or muscle group.
  •  Text
  •  Ordinal
    • 0: No visible muscle contraction 
    • 1: Visible muscle contraction with no or trace movement 
    • 2: Limb movement, but not against gravity 
    • 3: Movement against gravity but not resistance 
    • 4: Movement against at least some resistance supplied by the examiner 
    • 5: Full strength 
Deep tendon reflex responseDeep tendon reflex response: Findings observed during the physical examination of a single deep tendon reflex.
ReflexReflex: Identification of the deep tendon reflex or group of reflexes being examined.
  • Right arm (proximal)
  • Right arm (distal)
  • Left arm (proximal)
  • Left arm (distal)
  • Right leg(proximal)
  • Right leg (distal)
  • Left leg (proximal)
  • Left leg (distal)
Graded responseGraded response: The elicited reflex response represented as a grade.
  •  Ordinal
    • 0: Absent 
    • 1: Slight 
    • 2: Normal 
    • 3: Brisk 
    • 4: Non-sustained clonus 
    • 5: Sustained clonus 
  •  Text
Muscle tone findingMuscle tone finding: Findings observed during the physical examination of tone in a limb.
Body siteBody site: Identification of the body site examined.
  • Right arm (proximal)
  • Right arm (distal)
  • Left arm (proximal)
  • Left arm (distal)
  • Right leg(proximal)
  • Right leg (distal)
  • Left leg (proximal)
  • Left leg (distal)
Relative toneRelative tone: The muscle tone observed, relative to 'normal' tone.
  •  Coded Text
    • Normal 
    • Increased 
    • Decreased 
  •  Text
Sensory levelSensory level: The most caudal, normally innervated, dermatome level observed in response to light touch, pain or temperature stimuli.
ModalityModality: The type of sensation tested.
  • Pain 
StimulusStimulus: Description of the stimulus used.
For example: testing light touch with cotton wool; or pain using a needle.
  • Pinprick
LevelLevel: The most caudal, normally innervated dermatome tested.
For example: T12 or C5/C6.
Vibration findingVibration finding: The observed response of applying a vibratory stimulus to an identified bony protuberance.
Body siteBody site: Identification of the bony prominence or body site being tested.
  • Ankle
  • Knee
  • Hip
  • Sternum
ResponseResponse: The elicited response to the stimulus.
  • Present 
  • Absent