ID

23553

Descrição

Allows recording of an assessment of the state of a neonate explicitly as 1, 2, 3, 5 and/or 10 minute events after birth, plus additional events as required. Usual practice is to document the Apgar score at 1 and 5 minutes; further scores can be recorded as clinically indicated. It is possible to record the Apgar score at any time after birth using this archetype. Common clinical practice is to record all 5 parameters plus the total, however this archetype allows any partial information to be recorded, if that is all that is available eg from historical data. If the total is to be calculated, it is necessary for all 5 ordinal values to be recorded. The total is the sum of the five ordinal values (min 0, max 10). It is recognised that mnemonic learning aid for APGAR is commonly taught. For example, in English: A for Appearance (skin color), P for Pulse (heart rate), G for Grimace (reflex irritability), A for Activity (muscle tone), and R for Respiration. As this is not universally applicable for all languages, it is suggested that this mnemonic can be applied by renaming the data elements within templates if desired for a specific clinical scenario.

Palavras-chave

  1. 08/07/2017 08/07/2017 - Martin Dugas
  2. 08/07/2017 08/07/2017 - Martin Dugas
  3. 08/07/2017 08/07/2017 - Martin Dugas
  4. 08/07/2017 08/07/2017 - Martin Dugas
Transferido a

8 de julho de 2017

DOI

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Licença

Creative Commons BY-NC 3.0

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APGAR (EHR Archetype)

  1. StudyEvent: apgarv2
    1. apgarv2
apgarv2.xml
Descrição

apgarv2.xml

Apgar score
Descrição

Clinical score derived from assessment of respiratory effort, heart rate, reflex irritability, muscle tone and skin colour.

Tipo de dados

text

structure
Descrição

@ internal @

Tipo de dados

text

history
Descrição

@ internal @

Tipo de dados

text

1 minute
Descrição

Apgar score 1 minute after birth.

Tipo de dados

text

Heart Rate
Descrição

Recording of the infant's heart rate.

Tipo de dados

text

Absent
Descrição

No heart beat is seen, felt or heard.

Tipo de dados

text

below 100 beats per minute
Descrição

Heart rate less than 100 beats per minute.

Tipo de dados

text

≥100 beats per minute
Descrição

Heart rate greater than or equal to 100 beats per minute.

Tipo de dados

text

Respiratory effort
Descrição

Observation of the infant's respiratory effort.

Tipo de dados

text

Absent
Descrição

No effort to breath.

Tipo de dados

text

Weak or irregular
Descrição

Some effort to breath, moving chest.

Tipo de dados

text

Normal
Descrição

Breathing normally or crying.

Tipo de dados

text

Muscle tone
Descrição

Observation of the infant's muscle tone.

Tipo de dados

text

Limp or flaccid
Descrição

No spontaneous movement.

Tipo de dados

text

Reduced tone
Descrição

Some flexion of extremities.

Tipo de dados

text

Normal tone
Descrição

Normal, vigorous movements.

Tipo de dados

text

Reflex irritability
Descrição

Observation of the response of the infant to an irritant stimulation, for example, suctioning the oropharynx and nares with a soft rubber catheter.

Tipo de dados

text

No response
Descrição

No response to stimulation.

Tipo de dados

text

Reduced response
Descrição

Grimace or feeble cry when stimulated.

Tipo de dados

text

Normal response
Descrição

Grimace, sneeze, cough or pulls away when stimulated.

Tipo de dados

text

Skin colour
Descrição

Observation of the skin colour of the infant.

Tipo de dados

text

Completely blue
Descrição

Body and extremities are blue.

Tipo de dados

text

Body pink; extremities blue
Descrição

Body is pink; extremities are blue.

Tipo de dados

text

Completely pink
Descrição

Body and extremities are pink; no cyanosis.

Tipo de dados

text

Total
Descrição

The sum of the 5 ordinal scores for each component parameter.

Tipo de dados

integer

2 minute
Descrição

Apgar score 2 minutes after birth.

Tipo de dados

text

3 minute
Descrição

Apgar score 3 minutes after birth.

Tipo de dados

text

5 minute
Descrição

Apgar score 5 minutes after birth.

Tipo de dados

text

Tree
Descrição

@ internal @

Tipo de dados

text

Notes on measurement
Descrição

Notes on measurement of the Apgar score.

Tipo de dados

text

10 minute
Descrição

Apgar score 10 minutes after birth.

Tipo de dados

text

Any event
Descrição

Apgar score at any additional time, as required.

Tipo de dados

text

Extension
Descrição

Additional information required to capture local content or to align with other reference models/formalisms.

Tipo de dados

text

Similar models

  1. StudyEvent: apgarv2
    1. apgarv2
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de dados
Alias
Item Group
Apgar score
Item
Apgar score
text
structure
Item
structure
text
history
Item
history
text
1 minute
Item
1 minute
text
Heart Rate
Item
Heart Rate
text
Absent
Item
Absent
text
below 100 beats per minute
Item
below 100 beats per minute
text
≥100 beats per minute
Item
≥100 beats per minute
text
Respiratory effort
Item
Respiratory effort
text
Absent
Item
Absent
text
Weak or irregular
Item
Weak or irregular
text
Normal
Item
Normal
text
Muscle tone
Item
Muscle tone
text
Limp or flaccid
Item
Limp or flaccid
text
Reduced tone
Item
Reduced tone
text
Normal tone
Item
Normal tone
text
Reflex irritability
Item
Reflex irritability
text
No response
Item
No response
text
Reduced response
Item
Reduced response
text
Normal response
Item
Normal response
text
Skin colour
Item
Skin colour
text
Completely blue
Item
Completely blue
text
Body pink; extremities blue
Item
Body pink; extremities blue
text
Completely pink
Item
Completely pink
text
Total
Item
Total
integer
2 minute
Item
2 minute
text
3 minute
Item
3 minute
text
5 minute
Item
5 minute
text
Tree
Item
Tree
text
Notes on measurement
Item
Notes on measurement
text
10 minute
Item
10 minute
text
Any event
Item
Any event
text
Extension
Item
Extension
text

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