ARCHETYPE Fundoscopic examination of eyes (openEHR-EHR-OBSERVATION.fundoscopic_examination.v1)

ARCHETYPE IDopenEHR-EHR-OBSERVATION.fundoscopic_examination.v1
ConceptFundoscopic examination of eyes
DescriptionRecord of clinical findings on fundoscopy of eyes
PurposeTo record details about clinical findings on fundoscopy of eyes.
References
Copyrightcopyright (c) 2010 openEHR Foundation
AuthorsAuthor name: Heather Leslie
Organisation: Ocean Informatics
Email: heather.leslie@oceaninformatics.com
Date originally authored: 27/07/2008
Other Details LanguageAuthor name: Heather Leslie
Organisation: Ocean Informatics
Email: heather.leslie@oceaninformatics.com
Date originally authored: 27/07/2008
Other Details (Language Independent)
  • References:
  • MD5-CAM-1.0.1: 2A64A8FDB455A13CD40A3237E21FAE06
Keywords
LifecycleAuthorDraft
Language useden
Citeable Identifier1013.1.208
state
Mydriatic usedMydriatic used: True if mydriatic is used
Assumed value: false
events
Any eventAny event: *
protocol
MethodMethod: *
  • Direct [*]
  • Indirect [*]
data
Clinical DescriptionClinical Description: Descriptive overview of examination findings
SideSide: *
  • Left [*]
  • Right [*]
DetailsDetails: *
Red reflexRed reflex: True if Red Reflex is present
LensLens: Description of lens
Optic DiscOptic Disc: Description of optic disc
PapilloedemaPapilloedema: True if papilloedema present
MaculaMacula: Description of macula
Retinal arteriesRetinal arteries: Description of retinal arteries
Retinal veinsRetinal veins: Description of retinal veins
'Cotton Wool' artefacts'Cotton Wool' artefacts: True if 'cotton wool' artefacts are present
Retinal haemorrhagesRetinal haemorrhages: True if retinal haemorrhages are present
Retinal backgroundRetinal background: Description of retinal background
VitreousVitreous: Description of vitreous humour
VisualisationVisualisation: *
Ease of VisualisationEase of Visualisation: Description of ease to visualise all the sturctures during fundoscopy
  • Fully visualised [*]
  • Partially visualised [*]
  • Not visualised [*]
CommentComment: Comment, especially if not fully visualised
Other contributors
Translators
  • Portuguese (Brazil): Marco Borges, P2D, marco.borges@p2d.com.br