| TEMPLATE ID | *CL 2.2 Neonatal Hearing Screen |
|---|---|
| Concept | *CL 2.2 Neonatal Hearing Screen |
| Description | Not Specified |
| Purpose | Not Specified |
| References | |
| Other Details (Language Independent) |
|
| Language used | en |
| Citeable Identifier | 1013.26.798 |
| Root archetype id | openEHR-EHR-COMPOSITION.report-result.v1 |
| Neonatal Hearing Screening Report | Neonatal Hearing Screening Report: Document to communicate information to others about the result of a test or assessment. |
| Other Context | |
| Report ID | Report ID: Identification information about the report. |
| Status | Status: The status of the entire report. Note: This is not the status of any of the report components. |
| Consent | Consent: A generic heading for contextual renaming within a template. |
| Informed Consent | Informed Consent: 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. |
| Description | |
| Procedure/Trial/Activity | Procedure/Trial/Activity: 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.
|
| Interpreter Details | Interpreter Details: Details about an Interpreter involved in, or required to be involved in, a clinical activity. |
| Type of interpreter | Type of interpreter: Identification of the professional background of the interpreter.
|
| Start Date | Start Date: Date, and optional time, when validity of the informed consent becomes active. |
| Risk Factor Register (See CL7.1 Risk Factor Register - Permanent Hearing Loss only) | Risk Factor Register (See CL7.1 Risk Factor Register - Permanent Hearing Loss only): A generic heading for contextual renaming within a template. |
| Screening Outcome | Screening Outcome: A generic heading for contextual renaming within a template. |
| Recommendation | Recommendation: A suggestion, advice or proposal for clinical management. |
| Data | |
| Action | Action: Narrative description of the recommendation. May be coded, using a terminology, if required. |
| Justification | Justification: Justifications for the recommendation. |
| Newborn hearing screen result | Newborn hearing screen result: Record of results of a hearing screening assessment and the screening outcome. |
| Data | |
| Any point in time | Any point in time: Default, unspecified point in time which may be explicitly defined in a template or at run-time. |
| Data | |
| Test result name | Test result name: Identification of the type of screening test performed. Coding with an external terminology is preferred, where possible. Applicable tests using a screening protocol include: Pure Tone Audiometry; Play Audiometry; Auditory Brainstem Response; Automated Auditory Brainstem Response; and Visual Reinforcement Orientation Audiometry.
|
| Exclusion of examination | Exclusion of examination: Positive statement to record that the physical examination, or a specified part of the physical examination, was not performed. |
| Test not done | Test not done: Statement to explicity record that the examination was not performed. Record as True if the examination was not performed. |
| Reason | Reason: Reason for the 'not done' statement. For example: patient factors, equipment factors, time constraints.
|
| Comment | Comment: Additional narrative about the test results and intepretation not captured in other fields. |
| State | |
| Sleep status | Sleep status: The status of the subject during testing.
|
| Confounding factors | Confounding factors: Narrative description of factors, not recorded elsewhere, that may contribute to the screening result. For example: The infant was crying at the time of testing. |
| Service Plan (See CL8 Service Plan) | Service Plan (See CL8 Service Plan): A generic heading for contextual renaming within a template. |