TEMPLATE test template respiration (test template respiration)

TEMPLATE IDtest template respiration
Concepttest template respiration
DescriptionNot Specified
PurposeNot Specified
References
Authorsname: Silje Ljosland Bakke; organisation: Helse Vest IKT AS; email: silje.ljosland.bakke@helse-vest-ikt.no; date: 2020-10-12
Other Details Languagename: Silje Ljosland Bakke; organisation: Helse Vest IKT AS; email: silje.ljosland.bakke@helse-vest-ikt.no; date: 2020-10-12
Other Details (Language Independent)
  • Original Language: ISO_639-1::en
Language useden
Citeable Identifier1013.26.990
Root archetype idopenEHR-EHR-OBSERVATION.respiration.v2
test template respirationtest template respiration: The characteristics of spontaneous breathing by an individual.
Data
Any eventAny event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
PresencePresence: Observation of spontaneous respiration.
This data element may be useful in extreme situations where a formal measurement of respiration rate is not possible. For example: a subject is unconscious and distant to the observer, such as trapped in a car or has fallen down a cliff. Presence of respiration can be implied if the 'Rate' >0 breaths/min.
  • Present 
  • Not detected 
RateRate: The frequency of spontaneous breathing.
0..200 /min
RegularityRegularity: The regularity of spontaneous breathing.
  • Regular 
  • Irregular 
DepthDepth: The depth of spontaneous breathing.
  • Normal 
  • Shallow 
  • Deep 
  • Variable 
Clinical descriptionClinical description: A narrative description about the spontaneous breathing of the individual.
For example: noting respiratory distress, use of accessory muscles or intermittent apnoea; noting characteristics such as stridor, sighing, grunting, groaning, gasping. Conducting a full respiratory examination, then some of these findings might be more appropriately recorded as part of examination findings.
Clinical interpretationClinical interpretation: Single word, phrase or brief description which represents the clinical meaning and significance of the respiration findings.
Coding with a terminology is preferred, where possible. For example: Normal breathing; Evidence of respiratory distress; Kussmaul's respiration; Cheyne-Stokes respiration; or Apnoeic episodes. Multiple statements are allowed.
CommentComment: Additional narrative about the respirations, not captured in other fields.
State
Body positionBody position: The body position of the individual during the observation.
  • Standing/upright 
  • Sitting 
  • Reclining 
  • Lying 
  • Prone 
Confounding factorsConfounding factors: Identification of any issues or incidental factors that may impact on interpretation of the observation.
For example: level of anxiety, pain, feeding in infants, tracheostomy.