OpenEHR Apperta Mirror
Name
Extra examination RESET
Description
Extra examination details in Part E of the RESET assessment.
Purpose
For recording free text additional examination details as part of an unscheduled clinical assessment.
Use
Use for unstructured free text examination details which don't fit into other specific categories, in the context of an unscheduled clinical assessment in emergency care.
Misuse
Not to be used for structured examination details or outside unscheduled clinical assessment in emergency care.
Archetype Id
openEHR-EHR-CLUSTER.extra_examination_reset.v0
Copyright
© Clinical Models UK
Licencing
This work is licensed under the Creative Commons Attribution-ShareAlike 3.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/3.0/.
Original Author
Hildegard Franke
freshEHR Clinical Informatics Ltd.
Date Originally Authored
2016-03-29
Name Card Type Description
Abdominal examination
0..1 DV_TEXT Narrative details of abdominal examination.
Drains, lines and tubes
0..1 DV_TEXT Narrative description of drains, lines and tubes in the patient's body.
Exercise tolerance
0..1 DV_TEXT Narrative description of exercise tolerance.
Care packages / disability
0..1 DV_TEXT Narrative description of care packages and disability.
Frailty assessment
0..1 DV_TEXT Narrative description of frailty assessment.
Escalation status
0..1 DV_TEXT Narrative description of escalation status.
Additional comments/relevant exam
0..1 DV_TEXT Narrative description of any additional comments and relevant exams in the context of Assessment E.
archetype (adl_version=1.4; uid=9131e1f1-fcbb-4100-9ce4-40715c9c581e)
	openEHR-EHR-CLUSTER.extra_examination_reset.v0

concept
	[at0000]	-- Extra examination RESET
language
	original_language = <[ISO_639-1::en]>
description
	original_author = <
		["name"] = <"Hildegard Franke">
		["organisation"] = <"freshEHR Clinical Informatics Ltd.">
		["email"] = <"hildi@freshehr.com">
		["date"] = <"2016-03-29">
	>
	details = <
		["en"] = <
			language = <[ISO_639-1::en]>
			purpose = <"For recording free text additional examination details as part of an unscheduled clinical assessment.">
			use = <"Use for unstructured free text examination details which don't fit into other specific categories, in the context of an unscheduled clinical assessment in emergency care.">
			misuse = <"Not to be used for structured examination details or outside unscheduled clinical assessment in emergency care.">
			copyright = <"© Clinical Models UK">
		>
	>
	lifecycle_state = <"in_development">
	other_contributors = <>
	other_details = <
		["licence"] = <"This work is licensed under the Creative Commons Attribution-ShareAlike 3.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/3.0/.">
		["custodian_organisation"] = <"UK Clinical Models">
		["current_contact"] = <"Hildegard Franke, freshEHR Clinical Informatics Ltd.<hildi@freshehr.com>">
		["original_namespace"] = <"uk.org.clinicalmodels">
		["original_publisher"] = <"UK Clinical Models">
		["custodian_namespace"] = <"uk.org.clinicalmodels">
		["MD5-CAM-1.0.1"] = <"B2B7C70938332A351EC4894AE1579F23">
		["build_uid"] = <"a3df9abd-2028-42ea-ad93-fca99a3573a8">
		["revision"] = <"0.0.1-alpha">
	>

definition
	CLUSTER[at0000] matches {	-- Extra examination RESET
		items cardinality matches {1..*; unordered} matches {
			ELEMENT[at0001] occurrences matches {0..1} matches {	-- Abdominal examination
				value matches {
					DV_TEXT matches {*}
				}
			}
			ELEMENT[at0002] occurrences matches {0..1} matches {	-- Drains, lines and tubes
				value matches {
					DV_TEXT matches {*}
				}
			}
			ELEMENT[at0003] occurrences matches {0..1} matches {	-- Exercise tolerance
				value matches {
					DV_TEXT matches {*}
				}
			}
			ELEMENT[at0004] occurrences matches {0..1} matches {	-- Care packages / disability
				value matches {
					DV_TEXT matches {*}
				}
			}
			ELEMENT[at0005] occurrences matches {0..1} matches {	-- Frailty assessment
				value matches {
					DV_TEXT matches {*}
				}
			}
			ELEMENT[at0006] occurrences matches {0..1} matches {	-- Escalation status
				value matches {
					DV_TEXT matches {*}
				}
			}
			ELEMENT[at0007] occurrences matches {0..1} matches {	-- Additional comments/relevant exam
				value matches {
					DV_TEXT matches {*}
				}
			}
		}
	}


ontology
	term_definitions = <
		["en"] = <
			items = <
				["at0000"] = <
					text = <"Extra examination RESET">
					description = <"Extra examination details in Part E of the RESET assessment.">
				>
				["at0001"] = <
					text = <"Abdominal examination">
					description = <"Narrative details of abdominal examination.">
				>
				["at0002"] = <
					text = <"Drains, lines and tubes">
					description = <"Narrative description of drains, lines and tubes in the patient's body.">
				>
				["at0003"] = <
					text = <"Exercise tolerance">
					description = <"Narrative description of exercise tolerance.">
				>
				["at0004"] = <
					text = <"Care packages / disability">
					description = <"Narrative description of care packages and disability.">
				>
				["at0005"] = <
					text = <"Frailty assessment">
					description = <"Narrative description of frailty assessment.">
				>
				["at0006"] = <
					text = <"Escalation status">
					description = <"Narrative description of escalation status.">
				>
				["at0007"] = <
					text = <"Additional comments/relevant exam">
					description = <"Narrative description of any additional comments and relevant exams in the context of Assessment E.">
				>
			>
		>
	>