ARCHETYPE Global assessment (openEHR-EHR-OBSERVATION.global.v1)

ARCHETYPE IDopenEHR-EHR-OBSERVATION.global.v1
ConceptGlobal assessment
DescriptionGeneral assessment of the whole patient by the clinician.
UseUse in conjunction with Conscious state OBSERVATION.
PurposeTo document an overall impression of the patient as part of examination.
References
Copyrightcopyright (c) 2010 openEHR Foundation
AuthorsAuthor name: Heather Leslie
Organisation: Ocean Informatics
Email: heather.leslie@oceaninformatics.com
Date originally authored: 19/03/2007
Other Details LanguageAuthor name: Heather Leslie
Organisation: Ocean Informatics
Email: heather.leslie@oceaninformatics.com
Date originally authored: 19/03/2007
OtherDetails Language Independent{references=, MD5-CAM-1.0.1=7561ACC34EF2B8E37C10B7CEBF1B85F7}
KeywordsGlobal, General assessment, complexion, appearance, behaviour, hydration, mood
LifecycleAuthorDraft
Language useden
Citeable Identifier1013.1.249
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=General assessment of the whole patient by the clinician., archetypeConceptComment=null, otherContributors=Sam Heard, Ocean Informatics, Australia
Ian McNicoll, Ocean Informatics, UK, originalLanguage=en, translators=, subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={events=[ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=2, text=Any event, description=@ internal @, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=null, extendedValues=null]], context=[], capabilities=[], activities=[], protocol=[], identities=[], source=[], credentials=[], state=[], items=[], contacts=[], target=[], relationships=[], description=[], ism_transition=[], content=[], details=[], other_participations=[], data=[ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0064], code=at0064, itemType=ELEMENT, level=4, text=Normal statements, description=General statements about normal appearance and behaviour., 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=/data[at0001]/events[at0002]/data[at0003]/items[at0067], code=at0067, itemType=ELEMENT, level=4, text=Clinical description, description=General description of the global impression of the patient., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0089], code=at0089, itemType=CLUSTER, level=4, text=Skin complexion, description=Findings related to overall skin appearance., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0089]/items[at0044], code=at0044, itemType=ELEMENT, level=5, text=Complexion, description=Finding of skin complexion., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
  •  Coded Text
    • Pale [Subject appears pale.]
    • Flushed [Subject appears flushed.]
    • Jaundiced [Subject appears jaundiced.]
    • Clammy [Subject's skin feels clammy.]
    • Sweaty [Subject appears sweaty.]
    • Centrally cyanosed [Subject appears centrally cyanosed.]
    • Peripherally cyanosed [Subject appears peripherally cyanosed.]
    • Mottled [Subject's skin appears mottled.]
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0129], code=at0129, itemType=CLUSTER, level=4, text=Sweating and hydration, description=Findings related to sweating and hydration., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0129]/items[at0128], code=at0128, itemType=SLOT, level=5, text=Sweat, description=Detailed findings related to sweat., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.fluid.v1 and specialisations
Exclude:
All not explicitly included archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0129]/items[at0116], code=at0116, itemType=SLOT, level=5, text=Hydration, description=Details of skin hydration., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.hydration.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0065], code=at0065, itemType=CLUSTER, level=4, text=Appearance, description=Findings of general appearance., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0065]/items[at0058], code=at0058, itemType=ELEMENT, level=5, text=Nutrition, description=Description of state of nutrition., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Well nourished [Subject is well-nourished but not overweight.]
  • Under nourished [Subject appears under-nourished.]
  • Cachectic [Subject appears to have general wasting.]
  • Morbidly obese [Subject is overweight to the point of ill health.]
  • Obese [Subject appears overweight.]
  • Anorexic [Subject appears morbidly thin.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0065]/items[at0046], code=at0046, itemType=ELEMENT, level=5, text=Physique, description=Description of physical stature., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Thin [Subject appears thin.]
  • Tall [Subject appears taller than average.]
  • Short [Subject appears smaller than average.]
  • Normal weight for height [Subject appears to have normal weight for height.]
  • Slightly overweight for height [Subject appears slightly overweight for height.]
  • Slightly underweight for height [Subject appears slightly underweight for height.]
  • Overweight for height [Subject appears overweight for height.]
  • Underweight for height [Subject appears underweight for height.]
  • Average height [Subject appears to be of average height.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0065]/items[at0042], code=at0042, itemType=ELEMENT, level=5, text=Posture, description=Description of posture., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0011], code=at0011, itemType=CLUSTER, level=4, text=Self care, description=Inspection of patient's hygiene., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0011]/items[at0010], code=at0010, itemType=ELEMENT, level=5, text=Cleanliness, description=Subjective description of cleanliness., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0011]/items[at0012], code=at0012, itemType=ELEMENT, level=5, text=Grooming, description=Subjective description of patient's grooming., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0011]/items[at0014], code=at0014, itemType=ELEMENT, level=5, text=Odour, description=Subjective description of patient's body odour, with respect to self-care., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0011]/items[at0036], code=at0036, itemType=ELEMENT, level=5, text=State of dress, description=Description of patient's state and condition of clothing., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0038], code=at0038, itemType=CLUSTER, level=4, text=Behaviour, description=Description of observed behaviours., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0038]/items[at0103], code=at0103, itemType=ELEMENT, level=5, text=Mood description, description=Description of readily apparent mood disturbance., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0038]/items[at0040], code=at0040, itemType=ELEMENT, level=5, text=Unusual behaviour details, description=Description of observed unusual, abnormal or inappropriate behaviour., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0069], code=at0069, itemType=CLUSTER, level=4, text=Function, description=General aspect of subject's function., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0069]/items[at0062], code=at0062, itemType=ELEMENT, level=5, text=Speech, description=Clinical descripton of speech., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0069]/items[at0045], code=at0045, itemType=ELEMENT, level=5, text=Involuntary movements, description=Clinical description of generalised abnormal body movements., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0069]/items[at0032], code=at0032, itemType=ELEMENT, level=5, text=Handedness, description=Observation of dominant hand., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Left-handed [Subject has left-hand dominance.]
  • Right-handed [Subject has right-hand dominance.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0092], code=at0092, itemType=CLUSTER, level=4, text=Smells of, description=Details of clinically significant smells., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=1..1, cardinalityText=Maximum of 1 item, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0092]/items[at0095], code=at0095, itemType=ELEMENT, level=5, text=Smell, description=The name of the smell., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
  •  Coded Text
    • Smells of alcohol [The subject smells of alcohol.]
    • Smells of ketones [The subject smells of ketones.]
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0092]/items[at0096], code=at0096, itemType=ELEMENT, level=5, text=Description, description=Text description of the smell., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0092]/items[at0098], code=at0098, itemType=ELEMENT, level=5, text=Degree, description=The extent of the smell detected., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=0: Absent [The smell is absent.]
1: Mild [The smell is mild.]
2: Moderate [The smell is moderate.]
3: Marked [The smell is strong.]

Assumed value: 0: Absent
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0092]/items[at0125], code=at0125, itemType=SLOT, level=5, text=Body site, description=Location of the smell., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.anatomical_location.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0105], code=at0105, itemType=SLOT, level=4, text=Obvious abnormality on inspection, description=Details of other obvious abnormalities by simple inspection., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.inspection.v1 and specialisations Or
openEHR-EHR-CLUSTER.gait.v1 and specialisations Or
openEHR-EHR-CLUSTER.issue.v1 and specialisations, extendedValues=null]], provider=[]}, topLevelItems={data=ResourceSimplifiedHierarchyItem [path=ROOT_/data[at0001]/events[at0002]/data[at0003], code=at0003, itemType=ITEM_TREE, level=2, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=1..1, cardinalityText=mandatory, subCardinalityFormal=0..*, subCardinalityText=Minimum of 0 items, dataType=ITEM_TREE, bindings=null, values=null, extendedValues=null]}, addHierarchyItemsTo=data, currentHierarchyItemsForAdding=[ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0064], code=at0064, itemType=ELEMENT, level=4, text=Normal statements, description=General statements about normal appearance and behaviour., 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=/data[at0001]/events[at0002]/data[at0003]/items[at0067], code=at0067, itemType=ELEMENT, level=4, text=Clinical description, description=General description of the global impression of the patient., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0089], code=at0089, itemType=CLUSTER, level=4, text=Skin complexion, description=Findings related to overall skin appearance., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0089]/items[at0044], code=at0044, itemType=ELEMENT, level=5, text=Complexion, description=Finding of skin complexion., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
  •  Coded Text
    • Pale [Subject appears pale.]
    • Flushed [Subject appears flushed.]
    • Jaundiced [Subject appears jaundiced.]
    • Clammy [Subject's skin feels clammy.]
    • Sweaty [Subject appears sweaty.]
    • Centrally cyanosed [Subject appears centrally cyanosed.]
    • Peripherally cyanosed [Subject appears peripherally cyanosed.]
    • Mottled [Subject's skin appears mottled.]
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0129], code=at0129, itemType=CLUSTER, level=4, text=Sweating and hydration, description=Findings related to sweating and hydration., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0129]/items[at0128], code=at0128, itemType=SLOT, level=5, text=Sweat, description=Detailed findings related to sweat., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.fluid.v1 and specialisations
Exclude:
All not explicitly included archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0129]/items[at0116], code=at0116, itemType=SLOT, level=5, text=Hydration, description=Details of skin hydration., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.hydration.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0065], code=at0065, itemType=CLUSTER, level=4, text=Appearance, description=Findings of general appearance., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0065]/items[at0058], code=at0058, itemType=ELEMENT, level=5, text=Nutrition, description=Description of state of nutrition., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Well nourished [Subject is well-nourished but not overweight.]
  • Under nourished [Subject appears under-nourished.]
  • Cachectic [Subject appears to have general wasting.]
  • Morbidly obese [Subject is overweight to the point of ill health.]
  • Obese [Subject appears overweight.]
  • Anorexic [Subject appears morbidly thin.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0065]/items[at0046], code=at0046, itemType=ELEMENT, level=5, text=Physique, description=Description of physical stature., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Thin [Subject appears thin.]
  • Tall [Subject appears taller than average.]
  • Short [Subject appears smaller than average.]
  • Normal weight for height [Subject appears to have normal weight for height.]
  • Slightly overweight for height [Subject appears slightly overweight for height.]
  • Slightly underweight for height [Subject appears slightly underweight for height.]
  • Overweight for height [Subject appears overweight for height.]
  • Underweight for height [Subject appears underweight for height.]
  • Average height [Subject appears to be of average height.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0065]/items[at0042], code=at0042, itemType=ELEMENT, level=5, text=Posture, description=Description of posture., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0011], code=at0011, itemType=CLUSTER, level=4, text=Self care, description=Inspection of patient's hygiene., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0011]/items[at0010], code=at0010, itemType=ELEMENT, level=5, text=Cleanliness, description=Subjective description of cleanliness., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0011]/items[at0012], code=at0012, itemType=ELEMENT, level=5, text=Grooming, description=Subjective description of patient's grooming., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0011]/items[at0014], code=at0014, itemType=ELEMENT, level=5, text=Odour, description=Subjective description of patient's body odour, with respect to self-care., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0011]/items[at0036], code=at0036, itemType=ELEMENT, level=5, text=State of dress, description=Description of patient's state and condition of clothing., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0038], code=at0038, itemType=CLUSTER, level=4, text=Behaviour, description=Description of observed behaviours., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0038]/items[at0103], code=at0103, itemType=ELEMENT, level=5, text=Mood description, description=Description of readily apparent mood disturbance., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0038]/items[at0040], code=at0040, itemType=ELEMENT, level=5, text=Unusual behaviour details, description=Description of observed unusual, abnormal or inappropriate behaviour., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0069], code=at0069, itemType=CLUSTER, level=4, text=Function, description=General aspect of subject's function., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0069]/items[at0062], code=at0062, itemType=ELEMENT, level=5, text=Speech, description=Clinical descripton of speech., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0069]/items[at0045], code=at0045, itemType=ELEMENT, level=5, text=Involuntary movements, description=Clinical description of generalised abnormal body movements., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0069]/items[at0032], code=at0032, itemType=ELEMENT, level=5, text=Handedness, description=Observation of dominant hand., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Left-handed [Subject has left-hand dominance.]
  • Right-handed [Subject has right-hand dominance.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0092], code=at0092, itemType=CLUSTER, level=4, text=Smells of, description=Details of clinically significant smells., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=1..1, cardinalityText=Maximum of 1 item, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0092]/items[at0095], code=at0095, itemType=ELEMENT, level=5, text=Smell, description=The name of the smell., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
  •  Coded Text
    • Smells of alcohol [The subject smells of alcohol.]
    • Smells of ketones [The subject smells of ketones.]
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0092]/items[at0096], code=at0096, itemType=ELEMENT, level=5, text=Description, description=Text description of the smell., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0092]/items[at0098], code=at0098, itemType=ELEMENT, level=5, text=Degree, description=The extent of the smell detected., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=0: Absent [The smell is absent.]
1: Mild [The smell is mild.]
2: Moderate [The smell is moderate.]
3: Marked [The smell is strong.]

Assumed value: 0: Absent
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openEHR-EHR-CLUSTER.anatomical_location.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0105], code=at0105, itemType=SLOT, level=4, text=Obvious abnormality on inspection, description=Details of other obvious abnormalities by simple inspection., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.inspection.v1 and specialisations Or
openEHR-EHR-CLUSTER.gait.v1 and specialisations Or
openEHR-EHR-CLUSTER.issue.v1 and specialisations, extendedValues=null]], minIndents={}, termBindingRetrievalErrorMessage=null]