TEMPLATE Hearing Health Program Nurse Consultation (917053af-7591-41e2-8470-58e0bbc3fc71)

TEMPLATE ID917053af-7591-41e2-8470-58e0bbc3fc71
ConceptHearing Health Program Nurse Consultation
DescriptionTo record a consultation by an ENT nurse in the NT Hearing Health Program
UseUse to record the details of a nursing consultation for the purposes of nursing assessment, sharing of details with remote ENT specialists via teleotology and pre-operative assessment.
PurposeTo record a consultation by an ENT nurse in the NT Hearing Health Program
References
OtherDetails Language Independent{MetaDataSet:Sample Set =MetaDataSet:Sample Set }
Language useden
Citeable Identifier1013.26.502
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  • Pre-surgical Assessment
  • Post-surgical Assessment
  • Teleotology
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  • Year
  • Month
  • Week
  • Day
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  • 1: Trivial  [The symptom is trivial and causes no problems.]
  • 2: Mild  [The symptom does not interfere greatly with day to day activities.]
  • 5: Moderate  [The symptom interferes with day to day activities.]
  • 8: Severe  [The symptom prohibits some key daily activities.]
  • 9: Very severe  [The symptom is almost maximum possible intensity and prohibits any activity.]
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  • 0: Not present  [The symptom is not present.]
  • 1: Trivial  [The symptom is trivial and causes no problems.]
  • 2: Mild  [The symptom does not interfere greatly with day to day activities.]
  • 5: Moderate  [The symptom interferes with day to day activities.]
  • 8: Severe  [The symptom prohibits some key daily activities.]
  • 9: Very severe  [The symptom is almost maximum possible intensity and prohibits any activity.]
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  • Ratio
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  • Constant  [The symptom is constantly present.]
  • Intermittent  [The symptom is present at times and not at others.]
  • Fluctuating  [The symptom varys considerably but is almost always present.]
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  • Gradual  [Over a longer period of time.]
  • Rapid  [Over a short period of time.]
  • Sudden  [Almost immediate.]
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  • Improving  [The symptom has improved over time.]
  • Decreasing  [The symptom is decreasing in intensity over time.]
  • Stable  [The symptom has not changed over time.]
  • Increasing  [The symptom is increasing in intensity over time.]
  • Worsening  [The symptom is getting worse over.]
  • Has resolved  [The symptom has resolved over time.]
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  • Gradual  [Over a longer period of time.]
  • Rapid  [Over a short period of time.]
  • Sudden  [Almost immediate.]
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  • -3: Relieved completely  [The symptom is relieved by this factor.]
  • -2: Made better  [The symptom is made better by this factor.]
  • -1: Somewhat improved  [The symptom is somewhat improved by this factor.]
  • 0: No change  [The symptom is not modified by this factor.]
  • 1: Somewhat worse  [The symptom is made somewhat worse by this factor.]
  • 2: Made worse  [The symptom is made worse by this factor.]
  • 3: Much worse  [The symptom is made much worse by this factor.]
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Either self-recorded or recorded on the behalf of a patient by a clinician., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Clinical History']/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom.v1 and name/value='Reported Hearing Loss']/items[at0035], code=at0035, itemType=ELEMENT, level=3, text=Nil Significant, description=The person has not had any significant experience of the symptom., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Clinical History']/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom.v1 and name/value='Reported Hearing Loss']/items[at0002], code=at0002, itemType=ELEMENT, level=3, text=Clinical Description, description=Description of the symptom., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Clinical History']/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom.v1 and name/value='Reported Hearing Loss']/items[at0028], code=at0028, itemType=ELEMENT, level=3, text=Duration, description=The duration of the symptom since onset., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DURATION, bindings=null, values=Units:
  • Year
  • Month
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Clinical History']/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom-pain.v1 and name/value='Reported Left Ear Pain'], code=at0000.1, itemType=CLUSTER, level=2, text=Reported Left Ear Pain, description=A subjective observation by an individual about pain experienced. Either self-recorded or recorded on the behalf of a patient by a clinician., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Clinical History']/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom-pain.v1 and name/value='Reported Left Ear Pain']/items[at0035], code=at0035, itemType=ELEMENT, level=3, text=Nil Significant, description=The person has not had any significant experience of the symptom., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Clinical History']/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom-pain.v1 and name/value='Reported Left Ear Pain']/items[at0002], code=at0002, itemType=ELEMENT, level=3, text=Clinical Description, description=Description of the symptom., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Clinical History']/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom-pain.v1 and name/value='Reported Left Ear Pain']/items[at0028], code=at0028, itemType=ELEMENT, level=3, text=Duration, description=The duration of the symptom since onset., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DURATION, bindings=null, values=Units:
  • Month
  • Week
  • Day
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  • 1: Trivial  [The symptom is trivial and causes no problems.]
  • 2: Mild  [The symptom does not interfere greatly with day to day activities.]
  • 5: Moderate  [The symptom interferes with day to day activities.]
  • 8: Severe  [The symptom prohibits some key daily activities.]
  • 9: Very severe  [The symptom is almost maximum possible intensity and prohibits any activity.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Clinical History']/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom-pain.v1 and name/value='Reported Right Ear Pain']/items[at0046], code=at0046, itemType=CLUSTER, level=3, text=Current Intensity, description=Measures of the intensity of the symptom at this time., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Clinical History']/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom-pain.v1 and name/value='Reported Right Ear Pain']/items[at0046]/items[at0047], code=at0047, itemType=ELEMENT, level=4, text=Degree, description=The degree the symptom is bothering the patient., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_ORDINAL, bindings=null, values=
  • 0: Not present  [The symptom is not present.]
  • 1: Trivial  [The symptom is trivial and causes no problems.]
  • 2: Mild  [The symptom does not interfere greatly with day to day activities.]
  • 5: Moderate  [The symptom interferes with day to day activities.]
  • 8: Severe  [The symptom prohibits some key daily activities.]
  • 9: Very severe  [The symptom is almost maximum possible intensity and prohibits any activity.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Clinical History']/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom-pain.v1 and name/value='Reported Right Ear Pain']/items[at0046]/items[at0026.1], code=at0026.1, itemType=ELEMENT, level=4, text=Pain Score, description=A score from 0 (not present) to 10 (as bad as it could be)., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=0..10, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Clinical History']/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom-pain.v1 and name/value='Reported Right Ear Pain']/items[at0046]/items[at0150], code=at0150, itemType=ELEMENT, level=4, text=Degree, description=The intensity of the symptom expressed as a proportion., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_PROPORTION, bindings=null, values=
  • Ratio
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Clinical History']/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom-pain.v1 and name/value='Reported Right Ear Pain']/items[at0028], code=at0028, itemType=ELEMENT, level=3, text=Duration, description=The duration of the symptom since onset., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DURATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Clinical History']/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom-pain.v1 and name/value='Reported Right Ear Pain']/items[at0031], code=at0031, itemType=ELEMENT, level=3, text=Number of Occurrences, description=The number of times this symptom has occurred., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Clinical History']/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom-pain.v1 and name/value='Reported Right Ear Pain']/items[at0032], code=at0032, itemType=ELEMENT, level=3, text=Character, description=The character of the symptom., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Clinical History']/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom-pain.v1 and name/value='Reported Right Ear Pain']/items[at0003], code=at0003, itemType=ELEMENT, level=3, text=Variation, description=The variation of the symptom., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Constant  [The symptom is constantly present.]
  • Intermittent  [The symptom is present at times and not at others.]
  • Fluctuating  [The symptom varys considerably but is almost always present.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Clinical History']/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom-pain.v1 and name/value='Reported Right Ear Pain']/items[at0058], code=at0058, itemType=CLUSTER, level=3, text=Previous Episodes, description=Details about previous episodes., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Clinical History']/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom-pain.v1 and name/value='Reported Right Ear Pain']/items[at0058]/items[at0059], code=at0059, itemType=ELEMENT, level=4, text=Any Previous Episodes, description=Have there been any previous episodes of this symptom., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Clinical History']/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom-pain.v1 and name/value='Reported Right Ear Pain']/items[at0058]/items[at0090], code=at0090, itemType=CLUSTER, level=4, text=Previous Episode, description=Details about a specific episode., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Clinical History']/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom-pain.v1 and name/value='Reported Right Ear Pain']/items[at0058]/items[at0090]/items[at0142], code=at0142, itemType=ELEMENT, level=5, text=Date / time of previous episode, description=Date/time of previous episode., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Clinical History']/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom-pain.v1 and name/value='Reported Right Ear Pain']/items[at0058]/items[at0090]/items[at0057], code=at0057, itemType=ELEMENT, level=5, text=Details, description=Details of previous symptoms and comparison to this episode., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Clinical History']/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom-pain.v1 and name/value='Reported Right Ear Pain']/items[at0058]/items[at0090]/items[at0143], code=at0143, itemType=ELEMENT, level=5, text=Comparison, description=How the previous episode compares with this one., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Clinical History']/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom-pain.v1 and name/value='Reported Right Ear Pain']/items[at0058]/items[at0098], code=at0098, itemType=ELEMENT, level=4, text=Number of Previous Episodes, description=Number of previous episodes., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=>=0, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Clinical History']/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom-pain.v1 and name/value='Reported Right Ear Pain']/items[at0033], code=at0033, itemType=CLUSTER, level=3, text=Course, description=Features of the course of the symptom., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Clinical History']/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom-pain.v1 and name/value='Reported Right Ear Pain']/items[at0033]/items[at0008], code=at0008, itemType=ELEMENT, level=4, text=Onset Type, description=The nature of the onset of the symptom., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Gradual  [Over a longer period of time.]
  • Rapid  [Over a short period of time.]
  • Sudden  [Almost immediate.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Clinical History']/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom-pain.v1 and name/value='Reported Right Ear Pain']/items[at0033]/items[at0060], code=at0060, itemType=ELEMENT, level=4, text=Onset Description, description=Activity or situation at and details of onset., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Clinical History']/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom-pain.v1 and name/value='Reported Right Ear Pain']/items[at0033]/items[at0030], code=at0030, itemType=ELEMENT, level=4, text=Time of Maximum Intensity, description=The time (and/or date) of maximum intensity of the symptom., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Clinical History']/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom-pain.v1 and name/value='Reported Right Ear Pain']/items[at0033]/items[at0037], code=at0037, itemType=ELEMENT, level=4, text=Progression, description=The progress of the symptom relative to the past., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Improving  [The symptom has improved over time.]
  • Decreasing  [The symptom is decreasing in intensity over time.]
  • Stable  [The symptom has not changed over time.]
  • Increasing  [The symptom is increasing in intensity over time.]
  • Worsening  [The symptom is getting worse over.]
  • Has resolved  [The symptom has resolved over time.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Clinical History']/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom-pain.v1 and name/value='Reported Right Ear Pain']/items[at0033]/items[at0011], code=at0011, itemType=ELEMENT, level=4, text=Cessation, description=The nature of the cessation of the symptom., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Gradual  [Over a longer period of time.]
  • Rapid  [Over a short period of time.]
  • Sudden  [Almost immediate.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Clinical History']/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom-pain.v1 and name/value='Reported Right Ear Pain']/items[at0014], code=at0014, itemType=CLUSTER, level=3, text=Precipitating factors, description=Factors that trigger or bring on the symptom., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Clinical History']/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom-pain.v1 and name/value='Reported Right Ear Pain']/items[at0014]/items[at0015], code=at0015, itemType=ELEMENT, level=4, text=Precipitating Factor, description=An event or activity that brings on or triggers the symptom., comment=null, uncommonOntologyItems=null, occurencesFormal=1..*, occurencesText=Mandatory, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Clinical History']/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom-pain.v1 and name/value='Reported Right Ear Pain']/items[at0016], code=at0016, itemType=CLUSTER, level=3, text=Modification, description=Factors that change the level of intensity of the symptom., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Clinical History']/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom-pain.v1 and name/value='Reported Right Ear Pain']/items[at0016]/items[at0018], code=at0018, itemType=CLUSTER, level=4, text=Modifying Factor, description=Information about a specific factor that changes the symptom., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Clinical History']/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom-pain.v1 and name/value='Reported Right Ear Pain']/items[at0016]/items[at0018]/items[at0019], code=at0019, itemType=ELEMENT, level=5, text=Factor, description=An event or activity that modifies the symptom., 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=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Clinical History']/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom-pain.v1 and name/value='Reported Right Ear Pain']/items[at0016]/items[at0018]/items[at0017], code=at0017, itemType=ELEMENT, level=5, text=Change, description=An event or activity that makes the symptom worse., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_ORDINAL, bindings=null, values=
  • -3: Relieved completely  [The symptom is relieved by this factor.]
  • -2: Made better  [The symptom is made better by this factor.]
  • -1: Somewhat improved  [The symptom is somewhat improved by this factor.]
  • 0: No change  [The symptom is not modified by this factor.]
  • 1: Somewhat worse  [The symptom is made somewhat worse by this factor.]
  • 2: Made worse  [The symptom is made worse by this factor.]
  • 3: Much worse  [The symptom is made much worse by this factor.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Clinical History']/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom-pain.v1 and name/value='Reported Right Ear Pain']/items[at0016]/items[at0018]/items[at0056], code=at0056, itemType=ELEMENT, level=5, text=Details, description=Details of the effect., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Clinical History']/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom-pain.v1 and name/value='Reported Right Ear Pain']/items[at0061], code=at0061, itemType=CLUSTER, level=3, text=Features not present, description=Anticipated features which are not present., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Clinical History']/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom-pain.v1 and name/value='Reported Right Ear Pain']/items[at0061]/items[at0062], code=at0062, itemType=ELEMENT, level=4, text=Absent feature, description=A feature that is not present., 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=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Associated Problems'], code=at0000, itemType=SECTION, level=1, text=Associated Problems, description=A generic heading for contextual renaming within a template., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Associated Problems']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=2, text=Other Problem, description=Identification of the problem or diagnosis. Coding of the problem or diagnosis with a terminology is preferred, where possible., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Speech Problems
  • Language Delay
  • Poor School Progress
  • Skin Problems
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Associated Problems']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0009], code=at0009, itemType=ELEMENT, level=2, text=Clinical description, description=Narrative description or comments about clinical aspects of the problem/diagnosis., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Associated Problems']/items[openEHR-EHR-EVALUATION.social_summary.v1], code=at0000, itemType=EVALUATION, level=2, text=Social Summary, description=Summary information about social circumstances or experiences that may have a potential impact on an individual's health., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Associated Problems']/items[openEHR-EHR-EVALUATION.social_summary.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Associated Problems']/items[openEHR-EHR-EVALUATION.social_summary.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Description, description=Narrative summary about social circumstances or experiences that may have a potential impact on an individual's health., comment=May be used to record a narrative summary of the complete social circumstances or experiences or key aspects of the social summary, which will be supported by additioanl structured data. Details of specific structured findings can be included using CLUSTER archetypes in the 'Social Summary Detail' slot., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Actions before Otoscopy'], code=at0000, itemType=SECTION, level=1, text=Actions before Otoscopy, description=A generic heading for contextual renaming within a template., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Actions before Otoscopy']/items[openEHR-EHR-ACTION.procedure.v1 and name/value='Ear Cleaning'], code=at0000, itemType=ACTION, level=2, text=Ear Cleaning, description=A clinical activity carried out for therapeutic, evaluative, investigative, screening or diagnostic purposes., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ACTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Actions before Otoscopy']/items[openEHR-EHR-ACTION.procedure.v1 and name/value='Ear Cleaning']/description[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=3, text=Procedure name, description=The name of the procedure (to be) performed. Coding of the specific procedure with a terminology is preferred, where possible., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=Default value: Ear Cleaned, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Actions before Otoscopy']/items[openEHR-EHR-ACTION.procedure.v1 and name/value='Ear Cleaning']/description[at0001]/items[at0004], code=at0004, itemType=ELEMENT, level=3, text=Description, description=Narrative description about the activity or care pathway step for the identified procedure, for example description about the performance and findings from the the procedure, the failed attempt or the cancellation of the procedure., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Actions before Otoscopy']/items[openEHR-EHR-ACTION.procedure.v1 and name/value='Ear Cleaning']/description[at0001]/items[openEHR-EHR-CLUSTER.ear_cleaning.v1], code=at0000, itemType=CLUSTER, level=3, text=Ear Cleaning Details, description=Details about method for cleaning the external ear canal., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Actions before Otoscopy']/items[openEHR-EHR-ACTION.procedure.v1 and name/value='Ear Cleaning']/description[at0001]/items[openEHR-EHR-CLUSTER.ear_cleaning.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=4, text=Ear Cleaned, description=Identification of the ear being cleaned., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Left Ear  [The left ear was cleaned.]
  • Right Ear  [The right ear was cleaned.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Actions before Otoscopy']/items[openEHR-EHR-ACTION.procedure.v1 and name/value='Ear Cleaning']/description[at0001]/items[openEHR-EHR-CLUSTER.ear_cleaning.v1]/items[at0009], code=at0009, itemType=ELEMENT, level=4, text=Description, description=Narrative description of the ear cleaning activity., comment=For example, describing any difficulties encountered and/or the nature of the returned fluid., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Actions before Otoscopy']/items[openEHR-EHR-ACTION.procedure.v1 and name/value='Ear Cleaning']/description[at0001]/items[openEHR-EHR-CLUSTER.ear_cleaning.v1]/items[at0005], code=at0005, itemType=ELEMENT, level=4, text=Method, description=Method used for ear wash., comment=Coding with a terminology is preferred, if possible. For example: ear wash; suction; instrument; or tissue spears., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Dry mopping
  • Curetting
  • Irrigation
  • Suctioning
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Actions before Otoscopy']/items[openEHR-EHR-ACTION.procedure.v1 and name/value='Ear Cleaning']/description[at0001]/items[openEHR-EHR-CLUSTER.ear_cleaning.v1]/items[at0004], code=at0004, itemType=ELEMENT, level=4, text=Wash Agent, description=Substance used for ear wash., comment=Coding with a terminology is preferred, if possible. For example: water, acetic acid or betadine 5%., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Water
  • Betadine
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Actions before Otoscopy']/items[openEHR-EHR-ACTION.procedure.v1 and name/value='Ear Cleaning']/description[at0001]/items[openEHR-EHR-CLUSTER.ear_cleaning.v1]/items[at0006], code=at0006, itemType=ELEMENT, level=4, text=Instrument, description=Instrument used to assist cleaning., comment=Coding with a terminology is preferred, if possible. For example Jobson Horne probe, or micro forceps., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Tissue Spear
  • Jobson Horne probe
  • Alligator Forceps
  • Syringe
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Actions before Otoscopy']/items[openEHR-EHR-ACTION.procedure.v1 and name/value='Ear Cleaning']/description[at0001]/items[openEHR-EHR-CLUSTER.ear_cleaning.v1]/items[at0007], code=at0007, itemType=ELEMENT, level=4, text=Outcome, description=Description of the outcome of ear cleaning., comment=Coding with a terminology is preferred, if possible. For example: attempted, partially completed or successful removal of ear wax, pus or a foreign body., 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=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Actions before Otoscopy']/items[openEHR-EHR-ACTION.procedure.v1 and name/value='Ear Cleaning']/description[at0001]/items[openEHR-EHR-CLUSTER.ear_cleaning.v1]/items[at0008], code=at0008, itemType=ELEMENT, level=4, text=Post-cleaning Multimedia, description=Multimedia image or diagram recorded at the conclusion of cleaning of the external auditory canal., comment=Pre-cleaning images or diagrams can be included as part of the examination of CLUSTER.exam_tympanic_membrane archetype., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_MULTIMEDIA, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Actions before Otoscopy']/items[openEHR-EHR-ACTION.procedure.v1 and name/value='Ear Cleaning']/description[at0001]/items[at0010], code=at0010, itemType=ELEMENT, level=3, text=Image of auditory canal/TM, description=Multimedia representation of the procedure undertaken, for example, a link to a video of the procedure performed or a drawing of the wound/surgery etc., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_MULTIMEDIA, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Actions before Otoscopy']/items[openEHR-EHR-ACTION.procedure.v1 and name/value='Procedure'], code=at0000, itemType=ACTION, level=2, text=Procedure, description=A clinical activity carried out for therapeutic, evaluative, investigative, screening or diagnostic purposes., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ACTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Actions before Otoscopy']/items[openEHR-EHR-ACTION.procedure.v1 and name/value='Procedure']/description[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Description, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Actions before Otoscopy']/items[openEHR-EHR-ACTION.procedure.v1 and name/value='Procedure']/description[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Procedure name, description=The name of the procedure (to be) performed. Coding of the specific procedure with a terminology is preferred, where possible., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Actions before Otoscopy']/items[openEHR-EHR-ACTION.procedure.v1 and name/value='Procedure']/description[at0001]/items[at0004], code=at0004, itemType=ELEMENT, level=4, text=Description, description=Narrative description about the activity or care pathway step for the identified procedure, for example description about the performance and findings from the the procedure, the failed attempt or the cancellation of the procedure., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Actions before Otoscopy']/items[openEHR-EHR-ACTION.procedure.v1 and name/value='Procedure']/description[at0001]/items[at0009], code=at0009, itemType=ELEMENT, level=4, text=Comment, description=Additional narrative about the activity or care pathway step not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Actions before Otoscopy']/items[openEHR-EHR-ACTION.procedure.v1 and name/value='Procedure']/protocol[at0029], code=at0029, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Protocol, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings'], code=at0000, itemType=SECTION, level=1, text=Examination Findings, description=A generic heading for contextual renaming within a template., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.exam.v1], code=at0000, itemType=OBSERVATION, level=2, text=Ear Examination Findings, description=Findings observed during the physical examination of a subject., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_tympanic_membrane.v1], code=at0000, itemType=CLUSTER, level=3, text=Examination of External Auditory Canal and Tympanic Membrane, description=Physical examination of the external auditory canal and tympanic membrane by a clinician., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_tympanic_membrane.v1]/items[at0097], code=at0097, itemType=ELEMENT, level=4, text=Ear Examined, description=Identification of the ear under examination., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Left  [The left external auditory canal and tympanic membrane.]
  • Right  [The right external auditory canal and tympanic membrane.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_tympanic_membrane.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=4, text=Clinical Description, description=Narrative description of findings observed by a clinician during a physical examination of the external auditory canal and tympanic membrane., comment=Use this data element to provide additional, narrative description of any data elements related to the external auditory canal and tympanic membrane examination as a whole, that are not represented by structured values. For example, the relative size and surface of the auditory canal; increased vascularity of the tympanic membrane; presence of abnormalities not captured in specific structured data elements, such as presence of canal stenosis, exostoses, mastoid bowl/cavity or tumours., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_tympanic_membrane.v1]/items[at0106], code=at0106, itemType=ELEMENT, level=4, text=Consistency of Wax, description=Description of the type of wax in the external auditory canal., comment=Presence of hard wax has implications on treatment decisions. Presence of soft wax may be a causative factor in visual occlusion., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Hard  [The wax is hard.]
  • Soft  [The wax is soft.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_tympanic_membrane.v1]/items[at0109], code=at0109, itemType=ELEMENT, level=4, text=State of Wax, description=Description of the state of the wax observed in the external auditory canal., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Impacted  [Ear wax is tightly packed in the external auditory canal, such that it may be hard to remove or cause difficulty with hearing.]
  • Not impacted  [Ear wax is not tightly packed in the external auditory canal.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_tympanic_membrane.v1]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=View of Tympanic Membrane, description=View of the tympanic membrane., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Full view  [All of the tympanic membrane was visualised.]
  • Partial occlusion  [Part of the tympanic membrane was not clearly visualised, but sufficient to permit a clinical opinion to be formed.]
  • Total occlusion  [None of the tympanic membrane visualised, such that a clinical opinion of the state of the tympanic membrane could not be formed.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_tympanic_membrane.v1]/items[at0006], code=at0006, itemType=ELEMENT, level=4, text=Reason for Occlusion of View, description=Description of the reason for occlusion to the view of the tympanic membrane., comment=For example, soft wax or foreign body., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_tympanic_membrane.v1]/items[at0139], code=at0139, itemType=ELEMENT, level=4, text=Tenderness of Canal, description=Presence of tenderness in the external auditory canal., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present  [Tenderness is noted in the external auditory canal wall.]
  • Absent  [Tenderness is not noted in the external auditory canal wall.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_tympanic_membrane.v1]/items[at0132], code=at0132, itemType=ELEMENT, level=4, text=Oedema of Canal, description=Presence of oedema in the external auditory canal., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present  [Oedema is observed in the external auditory canal wall.]
  • Absent  [Oedema is not observed in the external auditory canal wall.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_tympanic_membrane.v1]/items[at0124], code=at0124, itemType=ELEMENT, level=4, text=Erythema of Canal, description=Presence of erythema or redness in the external auditory canal., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present  [Erythema, or redness, is observed in the wall of the external auditory canal.]
  • Absent  [There is no erythema or redness observed in the wall of the external auditory canal.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_tympanic_membrane.v1]/items[at0143], code=at0143, itemType=ELEMENT, level=4, text=Offensive Odour, description=Presence of any offensive odour originating from the external auditory canal., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present  [An offensive odour is noted as originating from the external auditory canal.]
  • Absent  [No odour is noted as originating from the external auditory canal.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_tympanic_membrane.v1]/items[at0157], code=at0157, itemType=ELEMENT, level=4, text=Discharge Type, description=Type of discharge observed in the external auditory canal or at the tympanic membrane perforation., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Serous  [The discharge appears to consist mostly of clear, watery fluid.]
  • Bloody  [The discharge appears to consist mostly of blood.]
  • Purulent  [The discharge appears to consist mostly of pus.]
  • Mucous  [The discharge appears to consist mostly of a thick, mucoid substance.]
  • Mucopurulent  [The discharge appears to consist of both mucous and pus.]
  • Haemoserous  [The discharge appears to consist of both blood and clear, watery fluid.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_tympanic_membrane.v1]/items[at0151], code=at0151, itemType=ELEMENT, level=4, text=Discharge Amount, description=Amount of discharge observed in the external auditory canal or at the tympanic membrane perforation., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • None  [No discharge is observed in the external auditory canal.]
  • Scant  [A small amount of discharge is observed in the external auditory canal.]
  • Moderate  [A moderate amount of discharge is observed in the external auditory canal.]
  • Profuse  [A profuse amount of discharge is observed in the external auditory canal.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_tympanic_membrane.v1]/items[at0166], code=at0166, itemType=ELEMENT, level=4, text=Ventilation Tube Position, description=Observed position of the ventilation tube (or grommet) in the tympanic membrane or the auditory canal., comment=There is value in identifying the presence of ventilation tubes in all examinations. There is no value in recording the absence of ventilation tubes if they have never been inserted. Note, however, that it is useful to record the extrusion of ventilation tubes if there is a known history of previous ventilation tube insertion., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • In situ  [The ventilation tube is located in situ in the tympanic membrane.]
  • Partially extruded  [The ventilation tube is partially extruded from it's original position in the tympanic membrane.]
  • Extruded - remains in canal  [The ventilation tube has been extruded from the tympanic membrane but is visualised within the external auditory canal.]
  • Extruded - missing  [The ventilation tube has been extruded from the tympanic membrane and is not visualised anywhere within the external auditory canal.]
  • Unknown  [The position of the ventilation tube cannot be determined because the tympanic membrane is obscured and the ventilation tube is not observed within the external auditory canal.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_tympanic_membrane.v1]/items[at0064], code=at0064, itemType=CLUSTER, level=4, text=Abnormal Features, description=Details about abnormal features noted during the examination of the external auditory canal., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_tympanic_membrane.v1]/items[at0064]/items[at0112], code=at0112, itemType=ELEMENT, level=5, text=Polyps, description=Presence of polyp/polyps in the external auditory canal., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present  [Polyps are observed in the external auditory canal.]
  • Absent  [No polyps are observed in the external auditory canal.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_tympanic_membrane.v1]/items[at0064]/items[at0147], code=at0147, itemType=ELEMENT, level=5, text=Fungal Spores, description=Presence of fungal spores in the external auditory canal., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present  [Fungal spores are observed in the external auditory canal.]
  • Absent  [No fungal spores are observed in the external auditory canal.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_tympanic_membrane.v1]/items[at0064]/items[at0159], code=at0159, itemType=ELEMENT, level=5, text=Foreign Body, description=Presence of a foreign body in the external auditory canal., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present  [A foreign body is present in the external auditory canal.]
  • Absent  [A foreign body is present in the external auditory canal.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_tympanic_membrane.v1]/items[at0064]/items[at0163], code=at0163, itemType=ELEMENT, level=5, text=Location of Foreign Body, description=Location of the foreign body within the external auditory canal., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Outer canal  [The foreign body is located in the outer part of the external auditory canal.]
  • Deep canal  [The foreign body is located in the deep, inner part of the external auditory canal.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_tympanic_membrane.v1]/items[at0104], code=at0104, itemType=CLUSTER, level=4, text=Tympanic Membrane Details, description=Details about findings on examination of the tympanic membrane., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_tympanic_membrane.v1]/items[at0104]/items[at0007], code=at0007, itemType=ELEMENT, level=5, text=Membrane Intact?, description=Is the tympanic membrane intact?, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Intact  [The tympanic membrane appears intact.]
  • Perforated  [The tympanic membrane appears perforated.]
  • Indeterminate  [It is not possible to tell if the tympanic membrane is intact or perforated.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_tympanic_membrane.v1]/items[at0104]/items[at0018], code=at0018, itemType=ELEMENT, level=5, text=Appearance, description=Category describing the appearance of the tympanic membrane., comment=In most situations, this data element would only be recorded if the tympanic membrane is intact., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Translucent  [The tympanic membrane appears healthy.]
  • Opaque  [The tympanic membrane appears dull and opaque.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_tympanic_membrane.v1]/items[at0104]/items[at0011], code=at0011, itemType=ELEMENT, level=5, text=Normal Light Reflex, description=Presence of a normal light reflex noted., comment=In most situations, this data element would only be recorded if the tympanic membrane is intact. A 'normal' light reflex may be described as : a complete, bright triangular area of reflected light seen in the anteroinferior portion of the tympanic membrane., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present  [A normal light reflex is visible.]
  • Absent  [A normal light reflex is not visible.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_tympanic_membrane.v1]/items[at0104]/items[at0022], code=at0022, itemType=ELEMENT, level=5, text=Surface Features, description=Features observed on the surface of the tympanic membrane., comment=Data element has multiple occurrences to enable multiple selections, if required. In most situations, this data element would only be recorded if the tympanic membrane is intact., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Blistering present  [Blistering is observed on the surface of the tympanic membrane.]
  • Scarring present  [Scarring is observed on the surface of the tympanic membrane.]
  • Granulation present  [Granulation is observed on the surface of the tympanic membrane.]
  • Thickening present  [Thickening is observed on the surface of the tympanic membrane.]
  • Tympanosclerosis present  [White patches, consistent with tympanosclerosis, are observed on surface of the tympanic membrane.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_tympanic_membrane.v1]/items[at0104]/items[at0028], code=at0028, itemType=ELEMENT, level=5, text=Colour, description=Description of the overall colour of the tympanic membrane., comment=For example: red, bluish, or yellow., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_tympanic_membrane.v1]/items[at0104]/items[at0035], code=at0035, itemType=ELEMENT, level=5, text=Position of Tympanic Membrane, description=Description of the position of the tympanic membrane., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Bulging  [The tympanic membrane appears to be bulging.]
  • Neutral  [The tympanic membrane is in a normal, neutral position - neither bulging or retracted.]
  • Retracted  [The tympanic membrane appears to be retracted.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_tympanic_membrane.v1]/items[at0104]/items[at0040], code=at0040, itemType=ELEMENT, level=5, text=Description of Retraction, description=Description of retraction of the tympanic membrane., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_tympanic_membrane.v1]/items[at0104]/items[at0048], code=at0048, itemType=ELEMENT, level=5, text=Fluid Level Presence, description=Presence of a fluid level behind the tympanic membrane., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present  [A fluid level is observed behind the tympanic membrane.]
  • Absent  [A fluid level is not observed behind the tympanic membrane.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_tympanic_membrane.v1]/items[at0104]/items[at0051], code=at0051, itemType=ELEMENT, level=5, text=Fluid Level Description, description=Narrative description of the fluid level and other related features observed behind the tympanic membrane., comment=For example, presence of bubbles., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_tympanic_membrane.v1]/items[at0104]/items[at0052], code=at0052, itemType=ELEMENT, level=5, text=Mobility, description=Description of mobility of the tympanic membrane, usually as determined by pneumatic otoscopy., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Immobile  [There is minimal or no movement of the tympanic membrane when positive pressure is applied.]
  • Hypomobile  [The tympanic membrane moves with less excursion and in a more sluggish fashion when positive pressure is applied.]
  • Mobile  [The tympanic membrane shows a crisp inward (medial) movement (approx 1mm) with positive pressure.]
  • Hypermobile  [There is exaggerated movement of the tympanic membrane when positive pressure is applied.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_tympanic_membrane.v1]/items[at0104]/items[at0062], code=at0062, itemType=CLUSTER, level=5, text=Perforation Details, description=Details about the tympanic membrane perforation., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_tympanic_membrane.v1]/items[at0104]/items[at0062]/items[at0065], code=at0065, itemType=ELEMENT, level=6, text=Estimation of Size, description=Estimation of the size of the tympanic membrane perforation, based on anatomical landmarks., comment=Many clinicians record perforations between the well defined 'pinhole' and 'subtotal' perforations using a variety of terms with inconsistent usage and definitions, such as small, medium and large. 'Intermediate' has been proposed as a means to minimise inter-clinician variability for documenting the size of all perforations falling between the 'pinhole' and 'subtotal' definitions. If more detail is required, then measurement of the perforation should be recorded., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Pinhole  [A pinhole perforation is present in the tympanic membrane.]
  • Intermediate  [A perforation is present in the tympanic membrane, that is larger than a pinhole but smaller than a subtotal perforation.]
  • Subtotal  [A subtotal perforation is present in the tympanic membrane: the pars tensa is absent but the perforation does not include the annulus.]
  • Total  [A total perforation is present in the tympanic membrane; the tympanic membrane is essentially absent.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_tympanic_membrane.v1]/items[at0104]/items[at0062]/items[at0074], code=at0074, itemType=ELEMENT, level=6, text=Region, description=Description of the region of the tympanic membrane perforation., comment=To document if the perforation is in the Pars flaccida and may be potentially unsafe. If 'Total' or 'Subtotal' is selected in 'Estimation of Size' data element then this data element becomes redundant. Coding with a terminology is preferred, if possible., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Pars flaccida  [The tympanic membrane perforation is located in the pars flaccida.]
  • Pars tensa  [The tympanic membrane perforation is located in the pars tensa.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_tympanic_membrane.v1]/items[at0104]/items[at0062]/items[at0071], code=at0071, itemType=ELEMENT, level=6, text=Marginal?, description=Location of the tympanic membrane perforation., comment=To document explicitly whether the perforation is located marginally, and therefore might be clinically unsafe. If 'Total' is selected in 'Estimation of Size' data element then this data element becomes redundant., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Central  [The perforation is not involving the annulus and is bounded on all sides by the remnant of the tympanic membrane.]
  • Marginal  [The perforation involves the annulus of the tympanic membrane.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_tympanic_membrane.v1]/items[at0104]/items[at0062]/items[at0076], code=at0076, itemType=ELEMENT, level=6, text=Anterior?, description=Is an anterior perforation present?, comment=To document the presence of perf in the anterior portions of the pars tensa can be more difficult to manage. If 'Total' or 'Subtotal' is selected in 'Estimation of Size' data element then this data element becomes redundant., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present  [An anterior perforation is present in the pars tensa.]
  • Absent  [An anterior perforation is not present in the pars tensa.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_tympanic_membrane.v1]/items[at0104]/items[at0062]/items[at0079], code=at0079, itemType=ELEMENT, level=6, text=Edge, description=Narrative description of the edge of the perforation., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_tympanic_membrane.v1]/items[at0172], code=at0172, itemType=ELEMENT, level=4, text=Image, description=Multimedia image taken during the physical examination of the external auditory canal and tympanic membrane., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_MULTIMEDIA, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_tympanic_membrane.v1]/items[at0105], code=at0105, itemType=ELEMENT, level=4, text=Clinical Interpretation, description=Single word, phrase or brief description representing a summary of the examination findings., comment=Coding with a terminology is preferred, if possible. For example, normal examination or chronic otitis media., 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=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_tympanic_membrane.v1]/items[at0173], code=at0173, itemType=ELEMENT, level=4, text=Comments, description=Additional narrative about the physical examination findings of the external auditory canal and tympanic membrane, not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_pinnae.v1], code=at0000, itemType=CLUSTER, level=3, text=Examination - Pinnae, description=Findings observed during the physical examination of each pinna, or the external structure of the ears, and the adjacent periauricular region., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_pinnae.v1]/items[at0006], code=at0006, itemType=ELEMENT, level=4, text=Symmetry?, description=Description of the symmetry of both ears in comparison to one another., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Symmetrical  [The pinnae appear symmetrical - with both pinnae having similar size and shape.]
  • Asymmetrical  [The pinnae appear asymmetrical - with one pinna differing in size and/or shape to the other.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_pinnae.v1]/items[at0009], code=at0009, itemType=CLUSTER, level=4, text=Per Pinna, description=Physical examination findings of an identified pinna., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_pinnae.v1]/items[at0009]/items[at0010], code=at0010, itemType=ELEMENT, level=5, text=Pinna Examined, description=Identification of the pinna examined., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Left pinna  [Examination findings for the left pinna.]
  • Right pinna  [Examination findings for the right pinna.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_pinnae.v1]/items[at0009]/items[at0001], code=at0001, itemType=ELEMENT, level=5, text=Clinical Description, description=Narrative description of the findings observed during a physical examination of a single identified pinna, including size, shape and position., comment=May be used to record a narrative summary of the complete clinical examination of the body system or anatomical strucutre or key aspects of physical examination findings, which will be further supported by the additional structured data, using CLUSTER archetypes in the 'Examination Detail' slot. This data element may be used to capture legacy data that is not available in a structured format., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_pinnae.v1]/items[at0009]/items[at0013], code=at0013, itemType=ELEMENT, level=5, text=Post-auricular Scar, description=Presence of post-auricular surgical scar observed., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_pinnae.v1]/items[at0009]/items[at0005], code=at0005, itemType=ELEMENT, level=5, text=Image Representation, description=Digital image or video taken, or a diagram drawn, during the physical examination of the body system or anatomical structure., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_MULTIMEDIA, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.exam_pinnae.v1]/items[at0009]/items[at0003], code=at0003, itemType=ELEMENT, level=5, text=Clinical Interpretation, description=Single word, phrase or brief description represents the clinical meaning and significance of the physical examination findings., comment=Coding with a terminology is preferred, if possible. For example, normal examination or a specific physical finding., 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=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/data[at0001]/events[at0002]/state[at0009]/items[at0008], code=at0008, itemType=ELEMENT, level=3, text=Confounding Factors, description=Description of any incidental factors that may have contributed to the physical examination findings., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.exam.v1]/protocol[at0007], code=at0007, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Protocol, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.body_weight.v1], code=at0000, itemType=OBSERVATION, level=2, text=Body Weight, description=Measurement of the body weight of an individual., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.body_weight.v1]/data[at0002]/events[at0003], code=at0003, itemType=EVENT, level=3, text=Any event, description=Any event., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.body_weight.v1]/data[at0002]/events[at0003]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.body_weight.v1]/data[at0002]/events[at0003]/data[at0001]/items[at0004], code=at0004, itemType=ELEMENT, level=5, text=Weight, description=The weight of the individual., comment=While recorded as kilogram or pounds, weights can be displayed in systems as grams or as pounds and ounces, as required. Upper limits are set to validate entires based on orders of magnitude eg prevent accidental entry of an extra digit, not to represent possible upper limits of weight., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=0..1000; 0..2000
Units:
  • kg
  • lb
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.body_weight.v1]/data[at0002]/events[at0003]/data[at0001]/items[at0024], code=at0024, itemType=ELEMENT, level=5, text=Comment, description=Comment about the measurement of weight., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.body_weight.v1]/data[at0002]/events[at0003]/state[at0008], code=at0008, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=State, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.body_weight.v1]/data[at0002]/events[at0003]/state[at0008]/items[at0009], code=at0009, itemType=ELEMENT, level=5, text=State of Dress, description=Description of the state of dress of the person at the time of weighing., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Lightly clothed/underwear  [Clothing which will not add to weight significantly.]
  • Naked  [Without any clothes.]
  • Fully clothed, including shoes  [Clothing which may add significantly to weight, including shoes.]
  • Nappy/diaper  [Wearing only a nappy - can add significant weight.]
Assumed value: Lightly clothed/underwear, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.body_weight.v1]/data[at0002]/events[at0003]/state[at0008]/items[at0028], code=at0028, itemType=ELEMENT, level=5, text=Pregnant?, description=Is the woman pregnant at time of measurement?, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=Assumed value: false, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.body_weight.v1]/data[at0002]/events[at0003]/state[at0008]/items[at0025], code=at0025, itemType=ELEMENT, level=5, text=Confounding Factors, description=Record any issues or factors that may impact on the measurement of body weight eg timing in menstrual cycle, timing of recent bowel motion or noting of amputation., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.body_weight.v1]/protocol[at0015], code=at0015, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Protocol, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.body_weight.v1]/protocol[at0015]/items[at0027], code=at0027, itemType=ELEMENT, level=4, text=Weight Estimation Formula, description=Formula used to calculate the estimated weight., comment=For example, formula for estimating fetal weight from ultrasound findings., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.height.v1], code=at0000, itemType=OBSERVATION, level=2, text=Body Height/Length, description=Body height, or length, is measured from crown of head to sole of foot. Body height is measured with the individual in a standing position and body length in a recumbent position., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.height.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.height.v1]/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=4, text=Any event, description=Any timed measurement of body height or length., comment=null, uncommonOntologyItems=null, occurencesFormal=1..*, occurencesText=Mandatory, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.height.v1]/data[at0001]/events[at0002]/data[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=5, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.height.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=6, text=Height/Length, description=The length of the body from crown of head to sole of foot., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=0..1000; 0..250
Units:
  • cm
  • in
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.height.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0018], code=at0018, itemType=ELEMENT, level=6, text=Comment, description=Comment about the measurement of body height/length., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.height.v1]/data[at0001]/events[at0002]/state[at0013], code=at0013, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=5, text=State, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.height.v1]/data[at0001]/events[at0002]/state[at0013]/items[at0014], code=at0014, itemType=ELEMENT, level=6, text=Position, description=Position of individual when measured., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Standing  [Height is measured standing on both feet with weight distributed evenly, heels together and both buttocks and heels in contact with a vertical back board.]
  • Lying  [Length is measured in a fully extended, recumbent position with the legs extended and feet flexed.]
Assumed value: Standing, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.height.v1]/data[at0001]/events[at0002]/state[at0013]/items[at0019], code=at0019, itemType=ELEMENT, level=6, text=Confounding factors, description=Record any issues or factors that may impact on the measurement of body height or length., comment=For example, uncooperative child making the actual measurement difficult., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Examination Findings']/items[openEHR-EHR-OBSERVATION.height.v1]/protocol[at0007], code=at0007, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Protocol, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Presumptive Diagnosis'], code=at0000, itemType=SECTION, level=1, text=Presumptive Diagnosis, description=A generic heading for contextual renaming within a template., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Presumptive Diagnosis']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1], code=at0000, itemType=EVALUATION, level=2, text=Problem/Diagnosis, description=Any health care condition which may impact on the physical, mental and/or social well-being of an individual, that may require diagnostic, therapeutic or educational action, and which has been determined by a clinician. A diagnosis is based on scientific evaluation of physical signs, symptoms, history, laboratory tests results, and procedures., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Presumptive Diagnosis']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Presumptive Diagnosis']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Problem/Diagnosis, description=Identification of the problem or diagnosis. Coding of the problem or diagnosis with a terminology is preferred, where possible., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • AOM
  • AOM with Perforation
  • CSOM (active discharge)
  • CSOM (inactive dry perforation)
  • OME
  • Foreign Body
  • Unsure
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Presumptive Diagnosis']/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/protocol[at0074], code=at0074, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Protocol, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Presumptive Diagnosis']/items[openEHR-EHR-EVALUATION.differential_diagnosis.v1], code=at0000, itemType=EVALUATION, level=2, text=Differential diagnoses, description=A set of 1 or more diagnoses considered as reasonable but as yet hypothetical causes of the patients signs and symptoms Set of one or more interim diagnoses that could account for a patient's history, examination findings, measurements and results. In practice, the intent is that as further evidence is gathered differential diagnoses will be eliminated one by one until one diagnosis becomes most likely., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Presumptive Diagnosis']/items[openEHR-EHR-EVALUATION.differential_diagnosis.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Presumptive Diagnosis']/items[openEHR-EHR-EVALUATION.differential_diagnosis.v1]/data[at0001]/items[at0003], code=at0003, itemType=CLUSTER, level=4, text=Differential, description=A group of diagnoses or explanation and likelihoods being considered., comment=null, uncommonOntologyItems=null, occurencesFormal=1..*, occurencesText=Mandatory, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Presumptive Diagnosis']/items[openEHR-EHR-EVALUATION.differential_diagnosis.v1]/data[at0001]/items[at0003]/items[at0007], code=at0007, itemType=ELEMENT, level=5, text=Diagnosis, description=Identification of diagnosis. It is desirable that this should be coded where possible., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Presumptive Diagnosis']/items[openEHR-EHR-EVALUATION.differential_diagnosis.v1]/data[at0001]/items[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=5, text=Likelihood, description=The likelihood of this diagnosis being present., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Suspected  [Possibly the diagnosis, but without a weight of supportive evidence.]
  • Likely  [Likely to be the working diagnosis, with good supportive evidence.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Presumptive Diagnosis']/items[openEHR-EHR-EVALUATION.differential_diagnosis.v1]/data[at0001]/items[at0003]/items[at0006], code=at0006, itemType=ELEMENT, level=5, text=Rationale, description=Rationale for this diagnosis being included as a differential., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Presumptive Diagnosis']/items[openEHR-EHR-EVALUATION.differential_diagnosis.v1]/data[at0001]/items[at0005], code=at0005, itemType=ELEMENT, level=4, text=Comment, description=Comment on the whole set of differential diagnoses., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Presumptive Diagnosis']/items[openEHR-EHR-EVALUATION.differential_diagnosis.v1]/protocol[at0013], code=at0013, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Protocol, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Presumptive Diagnosis']/items[openEHR-EHR-EVALUATION.differential_diagnosis.v1]/protocol[at0013]/items[at0014], code=at0014, itemType=ELEMENT, level=4, text=Reference, description=Any literary references supporting the diagnoses., 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=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Management'], code=at0000, itemType=SECTION, level=1, text=Management, description=A generic heading for contextual renaming within a template., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Management']/items[openEHR-EHR-ACTION.health_education.v1], code=at0000, itemType=ACTION, level=2, text=Health education, description=Information provided to the patient in any format., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ACTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Management']/items[openEHR-EHR-ACTION.health_education.v1]/description[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Description, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Management']/items[openEHR-EHR-ACTION.health_education.v1]/description[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Topic, description=Topic of information to be provided., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Dry Ear Precautions
  • ???
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Note: This is not the reason for the medication instruction, rather the specific reason e.g. for administration or for ceasing the medication., 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=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Management']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[at0024], code=at0024, itemType=ELEMENT, level=4, text=Comment, description=A comment on the action taken., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Management']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[at0025], code=at0025, itemType=ELEMENT, level=4, text=Sequence number, description=The sequence number specific to the action being recorded., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Management']/items[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[at0036], code=at0036, itemType=ELEMENT, level=4, text=Brand substituted, description=A different brand of the same medicine, vaccine or other therapeutic good was substituted for the one nominated in the order., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Management']/items[openEHR-EHR-ACTION.medication.v1]/protocol[at0030], code=at0030, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Protocol, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Management']/items[openEHR-EHR-ACTION.medication.v1]/protocol[at0030]/items[at0026], code=at0026, itemType=ELEMENT, level=4, text=BatchID, description=Assigned by the manufacturer to identify the manufacturing batch of the item., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Management']/items[openEHR-EHR-ACTION.medication.v1]/protocol[at0030]/items[at0040], code=at0040, itemType=ELEMENT, level=4, text=Expiry date, description=The expiry date of the medicine administered as documented by the manufacturer., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Management']/items[openEHR-EHR-ACTION.medication.v1]/protocol[at0030]/items[at0031], code=at0031, itemType=ELEMENT, level=4, text=Dispensed to, description=The name of the person to whom this was dispensed, if not the subject of care., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Management']/items[openEHR-EHR-ACTION.medication.v1]/protocol[at0030]/items[at0037], code=at0037, itemType=ELEMENT, level=4, text=Number of times dispensed, description=The number of times this order has been dispensed. The sum of this number minus one and the remaining repeats provides the number of repeats on the original order., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Management']/items[openEHR-EHR-ACTION.medication.v1]/protocol[at0030]/items[at0032], code=at0032, itemType=ELEMENT, level=4, text=Remaining repeats, description=The number of times the medicine, vaccine or other therapeutic good may still be dispensed without re-issue of a prescription or order. Note: This is the information required by the subject of care and prescriber., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=>=0, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Management']/items[openEHR-EHR-ACTION.medication.v1]/protocol[at0030]/items[at0038], code=at0038, itemType=ELEMENT, level=4, text=Claim category, description=The category of reimbursement or subsidy sought for the item., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Management']/items[openEHR-EHR-ACTION.informed_consent.v1], code=at0000, itemType=ACTION, level=2, text=Informed Consent, description=Record of status and details of informed consent from a patient (or patient's agent) for a proposed procedure, trial or other healthcare-related activity (including treatments and investigations), based upon a clear appreciation and understanding of the facts, implications, and possible future consequences by the patient or patient's agent., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ACTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Management']/items[openEHR-EHR-ACTION.informed_consent.v1]/description[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Description, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Management']/items[openEHR-EHR-ACTION.informed_consent.v1]/description[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Procedure/Trial/Activity, description=Identification of the procedure, clinical trial or healthcare-related activity (including correct side/correct site, where appropriate) against which the consent status and details are recorded., comment=null, uncommonOntologyItems=null, occurencesFormal=1..*, occurencesText=Mandatory, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Management']/items[openEHR-EHR-ACTION.informed_consent.v1]/description[at0001]/items[at0030], code=at0030, itemType=ELEMENT, level=4, text=Procedure/Trial/Activity Description, description=Narrative description of the procedure, clinical trial or healthcare-related activity., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Management']/items[openEHR-EHR-ACTION.informed_consent.v1]/description[at0001]/items[at0031], code=at0031, itemType=ELEMENT, level=4, text=Intent, description=Description of the intent of the procedure, clinical trial or healthcare-related activity., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Management']/items[openEHR-EHR-ACTION.informed_consent.v1]/description[at0001]/items[at0011], code=at0011, itemType=ELEMENT, level=4, text=Consent Description, description=Narrative description of the informed consent required or recorded prior to performing the proposed procedure, clinical trial or healthcare-related activity., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Management']/items[openEHR-EHR-ACTION.informed_consent.v1]/description[at0001]/items[at0004], code=at0004, itemType=ELEMENT, level=4, text=Form of Consent, description=Form of the consent sought or provided., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Written  [Format of the consent is written.]
  • Verbal  [Format of the consent is verbal.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Management']/items[openEHR-EHR-ACTION.informed_consent.v1]/description[at0001]/items[at0007], code=at0007, itemType=ELEMENT, level=4, text=Reason, description=Reason that the care pathway step for the identified procedure, clinical trial or healthcare-related activity was carried out., comment=For example, the reason for 'consent refused' or 'consent withdrawn'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Management']/items[openEHR-EHR-ACTION.informed_consent.v1]/description[at0001]/items[at0008], code=at0008, itemType=ELEMENT, level=4, text=Start Date, description=Date, and optional time, when validity of the informed consent becomes active., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Management']/items[openEHR-EHR-ACTION.informed_consent.v1]/description[at0001]/items[at0009], code=at0009, itemType=ELEMENT, level=4, text=End Date, description=Date, and optional time, when validity of the informed consent ceased., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Management']/items[openEHR-EHR-ACTION.informed_consent.v1]/description[at0001]/items[at0010], code=at0010, itemType=ELEMENT, level=4, text=Caveat, description=Details of any qualifications or exemptions to the informed consent., 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=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Management']/items[openEHR-EHR-ACTION.informed_consent.v1]/description[at0001]/items[at0012], code=at0012, itemType=ELEMENT, level=4, text=Evidence of Consent, description=Evidence of consent status., comment=For example, audio of consent being requested or image of written consent obtained., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_MULTIMEDIA, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Management']/items[openEHR-EHR-ACTION.informed_consent.v1]/protocol[at0024], code=at0024, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Protocol, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Management']/items[openEHR-EHR-ACTION.informed_consent.v1]/protocol[at0024]/items[at0025], code=at0025, itemType=ELEMENT, level=4, text=Consent Document Used, description=Identification of the consent form or document used., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Management']/items[openEHR-EHR-ACTION.informed_consent.v1]/protocol[at0024]/items[at0026], code=at0026, itemType=ELEMENT, level=4, text=Review Date, description=Date when consent status is due for review., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Management']/items[openEHR-EHR-ACTION.informed_consent.v1]/protocol[at0024]/items[at0033], code=at0033, itemType=CLUSTER, level=4, text=Patient Information, description=Details about Patient Information made available to the subject or subject's agent., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Management']/items[openEHR-EHR-ACTION.informed_consent.v1]/protocol[at0024]/items[at0033]/items[at0032], code=at0032, itemType=ELEMENT, level=5, text=Name, description=Identification of the information made available., comment=For example, the name of the form., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Management']/items[openEHR-EHR-ACTION.informed_consent.v1]/protocol[at0024]/items[at0033]/items[at0035], code=at0035, itemType=ELEMENT, level=5, text=Description, description=Narrative description of the patient information made available., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Management']/items[openEHR-EHR-ACTION.informed_consent.v1]/protocol[at0024]/items[at0033]/items[at0034], code=at0034, itemType=ELEMENT, level=5, text=Multimedia Representation, description=Digital representation of the Patient Information made available., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_MULTIMEDIA, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan'], code=at0000, itemType=SECTION, level=1, text=Plan, description=A generic heading for contextual renaming within a template., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.request-referral.v1], code=at0000.1, itemType=INSTRUCTION, level=2, text=Referral request, description=Request for provision of a specified service by another healthcare provider or organisation., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=INSTRUCTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.request-referral.v1]/activities[at0001], code=at0001, itemType=ACTIVITY, level=3, text=Request, description=Current Activity., comment=null, uncommonOntologyItems=null, occurencesFormal=1..*, occurencesText=Mandatory, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ACTIVITY, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.request-referral.v1]/activities[at0001]/description[at0009], code=at0009, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Description, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.request-referral.v1]/activities[at0001]/description[at0009]/items[at0121], code=at0121, itemType=ELEMENT, level=5, text=Service requested, description=Identification of the service requested. This is often coded with an external terminology., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • ENT Specialist
  • Primary Care
  • Audiologist
  • ENT Outpatients
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.request-referral.v1]/activities[at0001]/description[at0009]/items[at0135], code=at0135, itemType=ELEMENT, level=5, text=Description of service, description=A detailed narrative description of the service requested., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.request-referral.v1]/activities[at0001]/description[at0009]/items[at0062], code=at0062, itemType=ELEMENT, level=5, text=Reason for request, description=A short description of the reason for the request. This is often coded with an external terminology., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.request-referral.v1]/activities[at0001]/description[at0009]/items[at0064], code=at0064, itemType=ELEMENT, level=5, text=Reason description, description=A narrative description explaining the reason for request., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.request-referral.v1]/activities[at0001]/description[at0009]/items[at0065], code=at0065, itemType=ELEMENT, level=5, text=Intent, description=Stated intent of the request by the referrer., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.request-referral.v1]/activities[at0001]/description[at0009]/items[at0068], code=at0068, itemType=ELEMENT, level=5, text=Urgency, description=Urgency of the request., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Emergency  [The request is an emergency.]
  • Urgent  [The request is urgent.]
  • Routine  [The request is routine.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.request-referral.v1]/activities[at0001]/description[at0009]/items[at0040], code=at0040, itemType=ELEMENT, level=5, text=Date &/or time service required, description=The date and time that the service should be performed or completed., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.request-referral.v1]/activities[at0001]/description[at0009]/items[at0144], code=at0144, itemType=ELEMENT, level=5, text=Latest date service required, description=The latest date that is acceptable for the service to be completed., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.request-referral.v1]/activities[at0001]/description[at0009]/items[at0076], code=at0076, itemType=ELEMENT, level=5, text=Supplementary information to follow, description=True indicates that additional information has been identified and will be forwarded when available eg incomplete pathology test results., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.request-referral.v1]/activities[at0001]/description[at0009]/items[at0078], code=at0078, itemType=ELEMENT, level=5, text=Supplementary information expected, description=Details of the nature of supplementary information that is to follow e.g name of laboratory results., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.request-referral.v1]/protocol[at0008], code=at0008, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Protocol, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.request-referral.v1]/protocol[at0008]/items[at0010], code=at0010, itemType=ELEMENT, level=4, text=Requestor Identifier, description=The local ID assigned to the order by the healthcare provider or organisation requesting the service. This is also referred to as Placer Order Identifier., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.request-referral.v1]/protocol[at0008]/items[at0011], code=at0011, itemType=ELEMENT, level=4, text=Receiver identifier, description=The ID assigned to the order by the healthcare provider or organisation receiving the request for service. This is also referred to as Filler Order Identifier., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.request-referral.v1]/protocol[at0008]/items[at0127], code=at0127, itemType=ELEMENT, level=4, text=Request status, description=The status of the request for service as indicated by the requester. Status is used to denote whether this is the initial request, or a follow-up request to change or provide supplementary information., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.request-referral.v1]/protocol[at0008]/items[at0.2], code=at0.2, itemType=CLUSTER, level=4, text=Duration, description=Length of time the referral is valid., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.request-referral.v1]/protocol[at0008]/items[at0.2]/items[at0.3], code=at0.3, itemType=ELEMENT, level=5, text=Duration, description=Duration for which the referral is valid., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DURATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.request-referral.v1]/protocol[at0008]/items[at0.2]/items[at0.4], code=at0.4, itemType=ELEMENT, level=5, text=Indefinite, description=If true, referral is for an indefinite period of time., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.medication.v1], code=at0000, itemType=INSTRUCTION, level=2, text=Medication instruction, description=Details of a medicine, vaccine or other therapeutic good with instructions for use., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=INSTRUCTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.medication.v1]/activities[at0001], code=at0001, itemType=ACTIVITY, level=3, text=Order, description=The instructions for a particular medicine, vaccine or other therapeutic good including dose and timing., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ACTIVITY, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.medication.v1]/activities[at0001]/description[at0002], code=at0002, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Description, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.medication.v1]/activities[at0001]/description[at0002]/items[at0003], code=at0003, itemType=ELEMENT, level=5, text=Medicine, description=The medicine, vaccine or other therapeutic good being ordered, administered to or used by the subject of care. This item should be coded if possible., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.medication.v1]/activities[at0001]/description[at0002]/items[at0009], code=at0009, itemType=ELEMENT, level=5, text=Directions, description=A complete narrative description of how much, when and how to use the medicine, vaccine or other therapeutic good., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.medication.v1]/activities[at0001]/description[at0002]/items[at0005], code=at0005, itemType=ELEMENT, level=5, text=Dose description, description=The amount and units of the medicine, vaccine or other therapeutic good to be used or administered at one time., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.medication.v1]/activities[at0001]/description[at0002]/items[at0010], code=at0010, itemType=CLUSTER, level=5, text=Timing, description=Details of the timing of the use or administration of the medicine, vaccine or other therapeutic good., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.medication.v1]/activities[at0001]/description[at0002]/items[at0010]/items[at0008], code=at0008, itemType=ELEMENT, level=6, text=Timing description, description=The timing of the doses, which may include frequency and details such as relationship to food., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.medication.v1]/activities[at0001]/description[at0002]/items[at0010]/items[at0029], code=at0029, itemType=ELEMENT, level=6, text=PRN, description=The timing is dependent within limits on the subject of care's condition or symptoms (e.g. 4hrly p.r.n. means the medicine can be taken as frequently as every four hours if necessary). "Pro re nata" in latin means as circumstances arise., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.medication.v1]/activities[at0001]/description[at0002]/items[at0010]/items[at0011], code=at0011, itemType=ELEMENT, level=6, text=Start criterion, description=A condition which, when met, requires the start of administration or use., 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=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.medication.v1]/activities[at0001]/description[at0002]/items[at0010]/items[at0012], code=at0012, itemType=ELEMENT, level=6, text=Start date, description=The date and optional time to begin using the medicine, vaccine or other therapeutic good., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.medication.v1]/activities[at0001]/description[at0002]/items[at0010]/items[at0016], code=at0016, itemType=ELEMENT, level=6, text=Stop criterion, description=A condition which, when met, requires the cessation of administration or use., 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=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.medication.v1]/activities[at0001]/description[at0002]/items[at0010]/items[at0013], code=at0013, itemType=ELEMENT, level=6, text=Stop date, description=The date and optional time to stop using the medicine, vaccine or other therapeutic good., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.medication.v1]/activities[at0001]/description[at0002]/items[at0010]/items[at0014], code=at0014, itemType=ELEMENT, level=6, text=Duration of treatment, description=The length of time for which the medicine, vaccine or other therapeutic good should be used or administered (from the initial dose to the final dose)., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DURATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.medication.v1]/activities[at0001]/description[at0002]/items[at0010]/items[at0015], code=at0015, itemType=ELEMENT, level=6, text=Number of administrations, description=The total number of doses of the medicine, vaccine or other therapeutic good that are to be used or administered (from the initial dose to the final dose)., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.medication.v1]/activities[at0001]/description[at0002]/items[at0010]/items[at0017], code=at0017, itemType=ELEMENT, level=6, text=Long-term, description=It is anticipated that the medicine, vaccine or therapeutic good will be re-prescribed or re-dispensed over a period of time., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.medication.v1]/activities[at0001]/description[at0002]/items[at0044], code=at0044, itemType=ELEMENT, level=5, text=Additional instruction, description=An additional statement on how to use the medicine, vaccine or other therapeutic good., 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=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.medication.v1]/activities[at0001]/description[at0002]/items[at0018], code=at0018, itemType=ELEMENT, level=5, text=Clinical Indication, description=A reason for ordering the medicine, vaccine or other therapeutic good., 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=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.medication.v1]/activities[at0001]/description[at0002]/items[at0035], code=at0035, itemType=ELEMENT, level=5, text=Comment, description=Any additional information that may be needed to ensure the continuity of supply, rationale for current dose and timing, or safe and appropriate use., 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=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.medication.v1]/activities[at0001]/description[at0002]/items[at0023], code=at0023, itemType=CLUSTER, level=5, text=Dispensing, description=Information for the dispenser., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.medication.v1]/activities[at0001]/description[at0002]/items[at0023]/items[at0025], code=at0025, itemType=ELEMENT, level=6, text=Number of repeats, description=The number of times the expressed quantity of medicine, vaccine or other therapeutic good may be refilled or redispensed without a new prescription., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=>=0, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.medication.v1]/activities[at0001]/description[at0002]/items[at0023]/items[at0046], code=at0046, itemType=ELEMENT, level=6, text=Minimum interval between repeats, description=The minimum time between repeat dispensing of the medicine, vaccine or therapeutic good. Note: This is specified by the ordering clinician for a specific reason such as safety or best practice., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DURATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.medication.v1]/activities[at0001]/description[at0002]/items[at0023]/items[at0026], code=at0026, itemType=ELEMENT, level=6, text=Brand substitution permitted, description=Indicates whether or not the substitution of a prescribed medicine with a different brand name of the same medicine, vaccine or other therapeutic good, which has been determined as bioequivalent, is allowed when the medication is dispensed/supplied., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.medication.v1]/activities[at0001]/description[at0002]/items[at0023]/items[at0028], code=at0028, itemType=ELEMENT, level=6, text=Dispensing instructions, description=Additional instructions to the person dispensing the medicine, vaccine or other therapeutic good., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.medication.v1]/protocol[at0031], code=at0031, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Protocol, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.medication.v1]/protocol[at0031]/items[at0038], code=at0038, itemType=ELEMENT, level=4, text=Indication for authorised use, description=The specific indication for use that is required by an authorising agency to achieve subsidy for or access to the medicine, vaccine or other therapeutic good. This could be a national medication scheme, insurance company or other funding agency., 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=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.medication.v1]/protocol[at0031]/items[at0032], code=at0032, itemType=ELEMENT, level=4, text=Medication Instruction Id, description=An identifier used in an external system and associated with this medication instruction., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_IDENTIFIER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.medication.v1]/protocol[at0031]/items[at0042], code=at0042, itemType=ELEMENT, level=4, text=Concession benefit, description=Indicates the category of subsidy appropriate to the item being prescribed., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.request.v1], code=at0000, itemType=INSTRUCTION, level=2, text=Followup request, description=Request for a range of different healthcare services, for example, a referral, lab request, equipment request., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=INSTRUCTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.request.v1]/activities[at0001], code=at0001, itemType=ACTIVITY, level=3, text=Request, description=Current Activity., comment=null, uncommonOntologyItems=null, occurencesFormal=1..*, occurencesText=Mandatory, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ACTIVITY, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.request.v1]/activities[at0001]/timing, code=null, itemType=EXPOSED_RM_ATTRIBUTE, level=4, text=timing, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_PARSABLE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.request.v1]/activities[at0001]/description[at0009], code=at0009, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Description, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.request.v1]/activities[at0001]/description[at0009]/items[at0121], code=at0121, itemType=ELEMENT, level=5, text=Service requested, description=Identification of the service requested. This is often coded with an external terminology., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.request.v1]/activities[at0001]/description[at0009]/items[at0135], code=at0135, itemType=ELEMENT, level=5, text=Description of service, description=A detailed narrative description of the service requested., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.request.v1]/activities[at0001]/description[at0009]/items[at0062], code=at0062, itemType=ELEMENT, level=5, text=Reason for request, description=A short description of the reason for the request. This is often coded with an external terminology., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.request.v1]/activities[at0001]/description[at0009]/items[at0064], code=at0064, itemType=ELEMENT, level=5, text=Reason description, description=A narrative description explaining the reason for request., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.request.v1]/activities[at0001]/description[at0009]/items[at0065], code=at0065, itemType=ELEMENT, level=5, text=Intent, description=Stated intent of the request by the referrer., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.request.v1]/activities[at0001]/description[at0009]/items[at0068], code=at0068, itemType=ELEMENT, level=5, text=Urgency, description=Urgency of the request., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Emergency  [The request is an emergency.]
  • Urgent  [The request is urgent.]
  • Routine  [The request is routine.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.request.v1]/activities[at0001]/description[at0009]/items[at0040], code=at0040, itemType=ELEMENT, level=5, text=Date &/or time service required, description=The date and time that the service should be performed or completed., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.request.v1]/activities[at0001]/description[at0009]/items[at0144], code=at0144, itemType=ELEMENT, level=5, text=Latest date service required, description=The latest date that is acceptable for the service to be completed., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.request.v1]/activities[at0001]/description[at0009]/items[at0076], code=at0076, itemType=ELEMENT, level=5, text=Supplementary information to follow, description=True indicates that additional information has been identified and will be forwarded when available eg incomplete pathology test results., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.request.v1]/activities[at0001]/description[at0009]/items[at0078], code=at0078, itemType=ELEMENT, level=5, text=Supplementary information expected, description=Details of the nature of supplementary information that is to follow e.g name of laboratory results., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.request.v1]/protocol[at0008], code=at0008, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Protocol, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.request.v1]/protocol[at0008]/items[at0010], code=at0010, itemType=ELEMENT, level=4, text=Requestor Identifier, description=The local ID assigned to the order by the healthcare provider or organisation requesting the service. This is also referred to as Placer Order Identifier., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.request.v1]/protocol[at0008]/items[at0011], code=at0011, itemType=ELEMENT, level=4, text=Receiver identifier, description=The ID assigned to the order by the healthcare provider or organisation receiving the request for service. This is also referred to as Filler Order Identifier., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.request.v1]/protocol[at0008]/items[at0127], code=at0127, itemType=ELEMENT, level=4, text=Request status, description=The status of the request for service as indicated by the requester. Status is used to denote whether this is the initial request, or a follow-up request to change or provide supplementary information., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.request-procedure.v1], code=at0000.1, itemType=INSTRUCTION, level=2, text=Procedure request, description=Request for a procedure to be performed., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=INSTRUCTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.request-procedure.v1]/activities[at0001], code=at0001, itemType=ACTIVITY, level=3, text=Request, description=Current Activity., comment=null, uncommonOntologyItems=null, occurencesFormal=1..*, occurencesText=Mandatory, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ACTIVITY, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.request-procedure.v1]/activities[at0001]/description[at0009], code=at0009, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Description, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.request-procedure.v1]/activities[at0001]/description[at0009]/items[at0121], code=at0121, itemType=ELEMENT, level=5, text=Procedure requested, description=Identification of the service requested. This is often coded with an external terminology., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.request-procedure.v1]/activities[at0001]/description[at0009]/items[at0.146], code=at0.146, itemType=ELEMENT, level=5, text=Type of procedure, description=Description about the type of procedure., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.request-procedure.v1]/activities[at0001]/description[at0009]/items[at0135], code=at0135, itemType=ELEMENT, level=5, text=Description of Procedure, description=A detailed narrative description of the service requested., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.request-procedure.v1]/activities[at0001]/description[at0009]/items[at0062], code=at0062, itemType=ELEMENT, level=5, text=Reason for request, description=A short description of the reason for the request or indication. This is often coded with an external terminology., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.request-procedure.v1]/activities[at0001]/description[at0009]/items[at0064], code=at0064, itemType=ELEMENT, level=5, text=Reason description, description=A narrative description explaining the reason for request., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.request-procedure.v1]/activities[at0001]/description[at0009]/items[at0.145], code=at0.145, itemType=ELEMENT, level=5, text=Objective, description=Details about specific objective or goal to be achieved by procedure., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.request-procedure.v1]/activities[at0001]/description[at0009]/items[at0065], code=at0065, itemType=ELEMENT, level=5, text=Intent, description=Intended impact on underlying health condition or issue eg preventive, curative, palliative, adjunct, adjuvant or supportive., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.request-procedure.v1]/activities[at0001]/description[at0009]/items[at0068], code=at0068, itemType=ELEMENT, level=5, text=Urgency, description=Urgency of the request., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Emergency  [The request is an emergency.]
  • Urgent  [The request is urgent.]
  • Routine  [The request is routine.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.request-procedure.v1]/activities[at0001]/description[at0009]/items[at0040], code=at0040, itemType=ELEMENT, level=5, text=Date &/or time service required, description=The date and time that the service should be performed or completed., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.request-procedure.v1]/activities[at0001]/description[at0009]/items[at0144], code=at0144, itemType=ELEMENT, level=5, text=Latest date service required, description=The latest date that is acceptable for the service to be completed., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.request-procedure.v1]/activities[at0001]/description[at0009]/items[at0076], code=at0076, itemType=ELEMENT, level=5, text=Supplementary information to follow, description=True indicates that additional information has been identified and will be forwarded when available eg incomplete pathology test results., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.request-procedure.v1]/activities[at0001]/description[at0009]/items[at0078], code=at0078, itemType=ELEMENT, level=5, text=Supplementary information expected, description=Details of the nature of supplementary information that is to follow e.g name of laboratory results., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.request-procedure.v1]/protocol[at0008], code=at0008, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Protocol, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.request-procedure.v1]/protocol[at0008]/items[at0010], code=at0010, itemType=ELEMENT, level=4, text=Requestor Identifier, description=The local ID assigned to the order by the healthcare provider or organisation requesting the service. This is also referred to as Placer Order Identifier., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.request-procedure.v1]/protocol[at0008]/items[at0011], code=at0011, itemType=ELEMENT, level=4, text=Receiver identifier, description=The ID assigned to the order by the healthcare provider or organisation receiving the request for service. This is also referred to as Filler Order Identifier., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.adhoc.v1 and name/value='Plan']/items[openEHR-EHR-INSTRUCTION.request-procedure.v1]/protocol[at0008]/items[at0127], code=at0127, itemType=ELEMENT, level=4, text=Request status, description=The status of the request for service as indicated by the requester. Status is used to denote whether this is the initial request, or a follow-up request to change or provide supplementary information., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-EVALUATION.clinical_synopsis.v1], code=at0000, itemType=EVALUATION, level=1, text=Clinical Synopsis, description=A narrative summary about a patient, from the perspective of a healthcare provider., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-EVALUATION.clinical_synopsis.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=2, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-EVALUATION.clinical_synopsis.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=3, text=Synopsis, description=An abstract or summary narrative of the assessment, conclusion or evaluation of the clinical findings., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null]], templateType=normal]