| ARCHETYPE ID | openEHR-EHR-OBSERVATION.respiration.v2 |
|---|---|
| Concept | Respiration |
| Description | The characteristics of spontaneous breathing by an individual. |
| Use | Use to record the observed and measured characteristics of spontaneous breathing by an individual, including respiratory rate, depth and rhythm. Respirations are commonly recorded as one component of vital signs. |
| Misuse | Not to be used to record the physical examination of the respiratory system - use the physical examination family of archetypes for this purpose, such as CLUSTER.exam-chest or CLUSTER.exam-lung. Not to be used to record other measurements related to breathing - use specific archetypes for the purpose, for example OBSERVATION.pulse_oximetry. Not to be used to record functional assessments of breathing - use specific archetypes for the purpose, for example OBSERVATION.pulmonary_function. Not to be used for recording details about individuals who are undergoing assisted ventilation. |
| Purpose | To record the characteristics of spontaneous breathing by an individual. |
| References | Braun SR. Respiratory Rate and Pattern. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990, Chapter 43 [cited 2019 Sep 26]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK365/. |
| Copyright | © openEHR Foundation |
| Authors | Author name: Ian McNicoll Organisation: freshEHR Clinical Informatics, United Kingdom Email: ian.mcnicoll@freshEHR.com Date originally authored: 2009-07-17 |
| Other Details Language | Author name: Ian McNicoll Organisation: freshEHR Clinical Informatics, United Kingdom Email: ian.mcnicoll@freshEHR.com Date originally authored: 2009-07-17 |
| Other Details (Language Independent) |
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| Keywords | respirations, breathing, breath, resps, respiration |
| Lifecycle | in_development |
| UID | 8dbdb062-2fac-48ce-aa8f-c58686ea1c23 |
| Language used | en |
| Citeable Identifier | 1013.1.2080 |
| Revision Number | 2.0.0-alpha |
| state | |
| Body position | Body position: The body position of the individual during the observation.
|
| Confounding factors | Confounding factors: Identification of any issues or incidental factors that may impact on interpretation of the observation. For example: level of anxiety, pain, feeding in infants, tracheostomy. |
| Inspired oxygen | Inspired oxygen: Details of the amount of oxygen being delivered to the individual at the time of observation. Assumed values of 21% oxygen concentration, Fi02 of 0.21 and oxygen flow rate of 0 l/min or 0 ml/min. Include: openEHR-EHR-CLUSTER.inspired_ |
| Exertion | Exertion: Details about physical exertion being undertaken during the examination. The individual's level of exertion during, or just prior to, the observation. Include: openEHR-EHR-CLUSTER.level_ openEHR-EHR-CLUSTER.level_ |
| events | |
| Any event | Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time. |
| protocol | |
| Extension | Extension: Additional information required to capture local context or to align with other reference models/formalisms. For example: local information requirements or additional metadata to align with FHIR. Include: All not explicitly excluded archetypes |
| data | |
| Presence | Presence: Observation of spontaneous respiration. This data element may be useful in extreme situations where a formal measurement of respiration rate is not possible. For example: a subject is unconscious and distant to the observer, such as trapped in a car or has fallen down a cliff. Presence of respiration can be implied if the 'Rate' >0 breaths/min.
|
| Rate | Rate: The frequency of spontaneous breathing. Units: 0.0..200.0 /min Limit decimal places: 0 |
| Regularity | Regularity: The regularity of spontaneous breathing.
|
| Depth | Depth: The depth of spontaneous breathing.
|
| Clinical description | Clinical description: A narrative description about the spontaneous breathing of the individual. For example: noting respiratory distress, use of accessory muscles or intermittent apnoea; noting characteristics such as stridor, sighing, grunting, groaning, gasping. Conducting a full respiratory examination, then some of these findings might be more appropriately recorded as part of examination findings. |
| Clinical interpretation | Clinical interpretation: Single word, phrase or brief description which represents the clinical meaning and significance of the respiration findings. Coding with a terminology is preferred, where possible. For example: Normal breathing; Evidence of respiratory distress; Kussmaul's respiration; Cheyne-Stokes respiration; or Apnoeic episodes. Multiple statements are allowed. |
| Comment | Comment: Additional narrative about the respirations, not captured in other fields. |
| Other contributors | Karin Aarsheim, Helse Førde, Norway Morten Aas, Diakonhjemmet Sykehus, Norway Tomas Alme, Norway Anne Pauline Anderssen, Helse Nord RHF, Norway Vebjørn Arntzen, Oslo universitetssykehus HF, Norway (Nasjonal IKT redaktør) Silje Ljosland Bakke, Nasjonal IKT HF, Norway (Nasjonal IKT redaktør) Lars Bitsch-Larsen, Haukeland University Hospital, Bergen, Norway Fredrik Borchsenius, Oslo universitetssykehus, Norway Pål Brekke, OUS Rikshospitalet, Norway Marja Buur, Medisch Centrum Alkmaar/ Code24, Netherlands Gregory Caulton, PatientOS Inc., United States Stephen Chu, NeHTA, Australia Einar Fosse, UNN HF, Norwegian Centre for Integrated Care and Telemedicine, Norway Sebastian Garde, Ocean Informatics, Germany Soon Ghee Yap, Singapore Health Services Pte Ltd, Singapore Mikkel Gaup Grønmo, FSE, Helse Nord, Norway (Nasjonal IKT redaktør) Atle Hansen, Universitetssykehuset Nord-Norge, Norway Anne Harbison, CPCER, Australia Sam Heard, Ocean Informatics, Australia Kristian Heldal, Telemark Hospital Trust, Norway Andreas Hering, Helse Bergen HF, Haukeland universitetssjukehus, Norway Erling Are Hole, Helse Bergen, Norway Omer Hotomaroglu, Turkey Sundaresan Jagannathan, Scottish NHS, United Kingdom Tom Jarl Jakobsen, Helse Bergen, Norway Andrew James, University of Toronto, Canada Heather Leslie, Atomica Informatics, Australia (Editor) Rikard Lovstrom, Swedish Medical Association, Sweden Hallvard Lærum, Direktoratet for e-helse, Norway Hildegard McNicoll, freshEHR Clinical Informatics Ltd., UK Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (Editor) Jeroen Meintjens, Medisch Centrum Alkmaar, Netherlands Thomas Schopf, University Hospital of North-Norway, Norway Nils Thomas Songstad, UNN HF, BUK, Barneavdelingen., Norway Arne Løberg Sæter, DIPS ASA, Norway Micaela Thierley, Helse Bergen/Haraldsplass sykehus, Norway Kevin Thon, SKDE, Norway John Tore Valand, Haukeland Universitetssjukehus, Norway (Nasjonal IKT redaktør) Thomas Wilson, Finnmarkssykehuset HF Klinikk Hammerfest, Norway |
| Translators |
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