TEMPLATE Guideline (Guideline)

TEMPLATE IDGuideline
ConceptGuideline
DescriptionNot Specified
PurposeNot Specified
References
Other Details (Language Independent)
  • MetaDataSet:MetadataSet: Metadata set
  • Narrative: Useful additional narrative about this template
Language useden
Citeable Identifier1013.26.578
Root archetype idopenEHR-EHR-COMPOSITION.report.v1
Clinical Guidelines for DiabetesClinical Guidelines for Diabetes: Document to communicate information to others, commonly in response to a request from another party.
Other Context
Report IDReport ID: Identification information about the report.
StatusStatus: The status of the entire report. Note: This is not the status of any of the report components.
Blood PressureBlood Pressure: A generic section header.
Blood PressureBlood Pressure: The local measurement of arterial blood pressure which is a surrogate for arterial. pressure in the systemic circulation. Most commonly, use of the term 'blood pressure' refers to measurement of brachial artery pressure in the upper arm.

Annotations

  • Narrative Elements.Related Terms: Hypertension, Cardiovascular Risk
  • Narrative Elements.Rationale: Monitoring for blood pressure is essential for diabetes management. Guidelines for measurement. Diagnosis criteria. Evaluation of risks. Intervention strategy.
DataData: History Structural node.
any eventany event: Default event.
Data
SystolicSystolic: Peak systemic arterial blood pressure - measured in systolic or contraction phase of the heart cycle.
0..1000 mmHg
DiastolicDiastolic: Minimum systemic arterial blood pressure - measured in the diastolic or relaxation phase of the heart cycle.
0..1000 mmHg
Pulse PressurePulse Pressure: The difference between the systolic and diastolic pressure.
0..1000 mmHg
State
PositionPosition: The position of the subject at the time of measurement.
  • Standing 
  • Sitting 
  • Reclining 
  • Lying 
  • Lying with tilt to left 
Assumed value: Sitting
Confounding factorsConfounding factors: Comment on and record other incidental factors that may be contributing to the blood pressure measurement. For example, level of anxiety or 'white coat syndrome'; pain or fever; changes in atmospheric pressure etc.
Sleep statusSleep status: Sleep status - supports interpretation of 24 hour ambulatory blood pressure records.
  • Alert & awake 
  • Sleeping 
Assumed value: Alert & awake
TiltTilt: The craniocaudal tilt of the surface on which the person is lying at the time of measurement.
-90..90 °
Assumed value: 0 °
ProtocolProtocol: List structure.
Cuff sizeCuff size: The size of the cuff used for blood pressure measurement.
Perloff D, Grim C, Flack J, Frohlich ED, Hill M, McDonald M, Morgenstern BZ. Human blood pressure determination by sphygmomanometry. Circulation 1993;88;2460-2470.
  • Adult Thigh 
  • Large Adult 
  • Adult 
  • Small Adult 
  • Paediatric/Child 
  • Infant 
  • Neonatal 
LocationLocation: Body location where blood pressure is measured. Use 'Location of measurement' to select from common sites. Use 'Specific location' to record more specific details or a site that is not in the common set or to refer to an external terminology.
Location of measurementLocation of measurement: Common body sites where blood pressure is recorded.
  • Right arm 
  • Left arm 
  • Right thigh 
  • Left thigh 
  • Right wrist 
  • Left wrist 
  • Right ankle 
  • Left ankle 
  • Finger 
  • Toe 
  • Intra-arterial 
Specific locationSpecific location: Specific details about the body site where blood pressure is recorded.
MethodMethod: Method of measurement of blood pressure.
  • Auscultation 
  • Palpation 
  • Machine 
  • Invasive 
Diastolic endpointDiastolic endpoint: Record which Korotkoff sound is used for determining diastolic pressure using auscultative method.
  • Phase IV 
  • Phase V 
Glucose ToleranceGlucose Tolerance: A generic section header.
Blood glucoseBlood glucose: The concentration of glucose in the blood.

Annotations

  • Narrative Elements.Related Terms: Hyperglycemia, Insulin resistance
  • Narrative Elements.Rationale: Monitoring for glucose tolerance is essential for diabetes management. Measurement procedure. Protocol and criteria for testing, re-testing and diagnosis.
Data
Any eventAny event: *
Data
Test nameTest name: Specific identifier for this lab test. e.g. Full blood count , blood glucose, urine microbiology. May equate to the result name for a single value result. Commonly a coded term e.g from LOINC or SNOMED-CT.
Diagnostic serviceDiagnostic service: The type of high-level diagnostic service e.g. biochemistry, haematology.
Test statusTest status: The status of the lab test as a whole.
  • Interim 
  • Final 
  • Supplementary 
  • Corrected (amended) 
  • Aborted 
  • Never performed 
Blood glucoseBlood glucose: Concentration of blood glucose in the sample.
0
Units:
  • mmol/l
  • mg/dl
Overall interpretationOverall interpretation: An overall interpretative comment on this test.
Multimedia representationMultimedia representation: Representations of the whole test in mutlimedia e.g image, audio, video.
State
DietDiet: Description of when the patient has eaten.
IntakeIntake: Description of calorific intake.
  • Fasting 
  • Post-prandial 
  • Pre-prandial 
  • Random 
Assumed value: Random
DurationDuration: The timing of the specimen in relation to the intake.
Units:
  • Day
  • Hour
  • Minute
  • Second
DescriptionDescription: Description of the intake.
Glucose challengeGlucose challenge: Information about a glucose challenge if relevant.
DoseDose: Dose of glucose.
>=0 gm
RouteRoute: The route of administration of the glucose challenge.
  • Oral 
  • Intravenous 
Assumed value: Oral
TimingTiming: The relationship of the sample to the challenge.
  • Pre-challenge 
  • Post-challenge 
Assumed value: Post-challenge
DurationDuration: The timing of the specimen in relation to the intake.
Units:
  • Day
  • Hour
  • Minute
  • Second
Insulin challengeInsulin challenge: *
DoseDose: Dose of insulin.
>=0 U
RouteRoute: The route of administration of the insulin.
  • Intravenous 
  • Subcutaneous 
Assumed value: Subcutaneous
TimingTiming: The relationship of the sample to the challenge.
  • Pre-challenge 
  • Post-challenge 
Assumed value: Post-challenge
DurationDuration: The timing of the specimen in relation to the intake.
Units:
  • Day
  • Hour
  • Minute
  • Second
EventEvent: An event.
Event nameEvent name: A name for the event.
TimingTiming: The relationship of the sample to the challenge.
  • Pre-challenge 
  • Post-challenge 
Assumed value: Post-challenge
DurationDuration: The timing of the specimen in relation to the intake.
Units:
  • Day
  • Hour
  • Minute
  • Second
Protocol
Test identificationTest identification: Unique identifiers used in delivery of the care process.
Placer order identifierPlacer order identifier: The ID assigned to the order by the order requester. Equivalent to the NEHTA Requester Order Identifier.
Filler order IdentifierFiller order Identifier: The ID assigned to the test order by the order filler, usually by the (LIS) Laboratory Information System. Equivalent to the DICOM Accession Number and NEHTA Laboratory Request Identifier.
Laboratory test result identifierLaboratory test result identifier: The identifier given to the laboratory test result of a pathology investigation.
Datetime result issuedDatetime result issued: The date and/or time that the result was issued for the recorded ‘test status’.
The date and time related to the results status is useful for version control and cumulative results for the report.