ID

23558

Description

Derived from www.openehr.org . 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.

Link

www.openehr.org

Keywords

Versions (4)
  1. 7/8/17 7/8/17 - Martin Dugas
  2. 7/8/17 7/8/17 - Martin Dugas
  3. 7/8/17 7/8/17 - Martin Dugas
  4. 7/8/17 7/8/17 - Martin Dugas
Uploaded on

July 8, 2017

DOI

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License

Creative Commons BY-SA 3.0
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APGAR Score (EHR Archetype)

Arabic ( localization.languageCode.SY ) German English Spanish ( localization.languageCode.CL ) Persian Dutch Norwegian Portuguese ( localization.languageCode.BR ) Russian

openEHR-EHR-OBSERVATION.apgar.v1

1 forms  
openEHR-EHR-OBSERVATION.apgar.v1
Description

openEHR-EHR-OBSERVATION.apgar.v1

Heart Rate
Description

Recording of the infant's heart rate.

Data type

integer

Alias
UMLS CUI [1]
C0018810
Respiratory effort
Description

Observation of the infant's respiratory effort.

Data type

integer

Alias
UMLS CUI [1]
C0425466
Muscle tone
Description

Observation of the infant's muscle tone.

Data type

integer

Alias
UMLS CUI [1]
C0026841
Reflex irritability
Description

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

Data type

text

Alias
UMLS CUI [1]
C1317677
Skin colour
Description

Observation of the skin colour of the infant.

Data type

integer

Alias
UMLS CUI [1]
C0475704
Apgar score
Description

Clinical score derived from assessment of respiratory effort, heart rate, reflex irritability, muscle tone and skin colour. The sum of the 5 ordinal scores for each component parameter.

Data type

integer

Alias
UMLS CUI [1]
C0003533
1 minute
Description

Apgar score 1 minute after birth.

Data type

integer

Alias
UMLS CUI [1]
C0426279
2 minute
Description

Apgar score 2 minutes after birth.

Data type

integer

Alias
UMLS CUI [1]
C0489254
3 minute
Description

Apgar score 3 minutes after birth.

Data type

integer

Alias
UMLS CUI [1]
C0003533
5 minute
Description

Apgar score 5 minutes after birth.

Data type

integer

Alias
UMLS CUI [1]
C0489255
10 minute
Description

Apgar score 10 minutes after birth.

Data type

integer

Alias
UMLS CUI [1]
C0003533
Any event
Description

Apgar score at any additional time, as required.

Data type

integer

Alias
UMLS CUI [1]
C0003533
Notes on measurement
Description

Notes on measurement of the Apgar score.

Data type

text

Alias
UMLS CUI [1]
C1317574
Extension
Description

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

Data type

text

Alias
UMLS CUI [1]
C1546922
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Similar models

openEHR-EHR-OBSERVATION.apgar.v1

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item
Heart Rate
integer
C0018810 (UMLS CUI [1])
Heart Rate
Code List
Heart Rate
CL Item
Absent (0)
CL Item
<100 beats per minute (1)
CL Item
≥100 beats per minute (2)
Item
Respiratory effort
integer
C0425466 (UMLS CUI [1])
Respiratory effort
Code List
Respiratory effort
CL Item
Absent (0)
CL Item
Weak or irregular (1)
CL Item
Normal (2)
Item
Muscle tone
integer
C0026841 (UMLS CUI [1])
Muscle tone
Code List
Muscle tone
CL Item
Limp or flaccid (0)
CL Item
Reduced tone (1)
CL Item
Normal tone (2)
Item
Reflex irritability
text
C1317677 (UMLS CUI [1])
Reflex irritability
Code List
Reflex irritability
CL Item
No response (0)
CL Item
Reduced response (1)
CL Item
Normal response (2)
Item
Skin colour
integer
C0475704 (UMLS CUI [1])
Skin colour
Code List
Skin colour
CL Item
Completely blue (0)
CL Item
Body pink; extremities blue (1)
CL Item
Completely pink (2)
Apgar score
Item
Apgar score
integer
C0003533 (UMLS CUI [1])
Apgar score at 1 minute
Item
1 minute
integer
C0426279 (UMLS CUI [1])
Apgar score at 2 minute
Item
2 minute
integer
C0489254 (UMLS CUI [1])
Apgar score at 3 minute
Item
3 minute
integer
C0003533 (UMLS CUI [1])
Apgar score at 5 minute
Item
5 minute
integer
C0489255 (UMLS CUI [1])
Apgar score at 10 minute
Item
10 minute
integer
C0003533 (UMLS CUI [1])
Apgar score any event
Item
Any event
integer
C0003533 (UMLS CUI [1])
Notes on measurement
Item
Notes on measurement
text
C1317574 (UMLS CUI [1])
Extension
Item
Extension
text
C1546922 (UMLS CUI [1])
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