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

Herzfrequenz
Description

Beurteilung der Herzfrequenz des Neubegorenen.

Data type

integer

Alias
UMLS CUI [1]
C0018810
Atemantrieb
Description

Beurteilung des Atemantriebs des Neugeborenen.

Data type

integer

Alias
UMLS CUI [1]
C0425466
Muskeltonus
Description

Beobachtung des Musketonus des Neugeborenen.

Data type

integer

Alias
UMLS CUI [1]
C0026841
Reflexauslösbarkeit
Description

Beobachtung der Antwort des Neugeborens auf eine Reizstimulation, z.B. Absaugen des Oropharynxs und der Nasenlöcher mit einem weichem Gummikatheter.

Data type

text

Alias
UMLS CUI [1]
C1317677
Hautfarbe
Description

Beobachtung der Hautfarbe des Neugeborenen.

Data type

integer

Alias
UMLS CUI [1]
C0475704
Apgar-Score
Description

Klinischer Score, abgeleitet von der Beurteilung des Atemantriebs, Herzfrequenz, Reflexauslösbarkeit, Muskeltonus und Hautfarbe.

Data type

integer

Alias
UMLS CUI [1]
C0003533
1 Minute
Description

Apgar-Score 1 Minute nach Geburt.

Data type

integer

Alias
UMLS CUI [1]
C0426279
2 Minuten
Description

Apgar-Score 2 Minuten nach der Geburt.

Data type

integer

Alias
UMLS CUI [1]
C0489254
3 Minuten
Description

Apgar-Score 3 Minuten nach der Geburt.

Data type

integer

Alias
UMLS CUI [1]
C0003533
5 Minuten
Description

Apgar-Score 5 Minuten nach der Geburt.

Data type

integer

Alias
UMLS CUI [1]
C0489255
10 Minuten
Description

Apgar-Score 10 Minuten nach der Geburt

Data type

integer

Alias
UMLS CUI [1]
C0003533
Beliebiges Ereignis
Description

Apgar-Score zu beliebigen Zeitpunkten, je nach Bedarf.

Data type

integer

Alias
UMLS CUI [1]
C0003533
Anmerkungen zur Messung
Description

Anmerkungen zur Messung des Apgar-Scores.

Data type

text

Alias
UMLS CUI [1]
C1317574
Extension
Description

Extension

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
Herzfrequenz
integer
C0018810 (UMLS CUI [1])
Heart Rate
Code List
Herzfrequenz
CL Item
Kein Herzschlag (0)
CL Item
<100 Schläge pro Minute (1)
CL Item
≥100 Schläge pro Minute (2)
Item
Atemantrieb
integer
C0425466 (UMLS CUI [1])
Respiratory effort
Code List
Atemantrieb
CL Item
Kein Bestreben (0)
CL Item
Schwaches oder unregelmäßiges Bestreben (1)
CL Item
Normal (2)
Item
Muskeltonus
integer
C0026841 (UMLS CUI [1])
Muscle tone
Code List
Muskeltonus
CL Item
Schlaff (0)
CL Item
Reduzierter Tonus (1)
CL Item
Normaler Tonus (2)
Item
Reflexauslösbarkeit
text
C1317677 (UMLS CUI [1])
Reflex irritability
Code List
Reflexauslösbarkeit
CL Item
Keine Reaktion (0)
CL Item
Reduzierte Reaktion (1)
CL Item
Normale Reaktion (2)
Item
Hautfarbe
integer
C0475704 (UMLS CUI [1])
Skin colour
Code List
Hautfarbe
CL Item
Komplett blau (0)
CL Item
Akrozyanotisch (1)
CL Item
Komplett rosig (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 Minuten
integer
C0489254 (UMLS CUI [1])
Apgar score at 3 minute
Item
3 Minuten
integer
C0003533 (UMLS CUI [1])
Apgar score at 5 minute
Item
5 Minuten
integer
C0489255 (UMLS CUI [1])
Apgar score at 10 minute
Item
10 Minuten
integer
C0003533 (UMLS CUI [1])
Apgar score any event
Item
Beliebiges Ereignis
integer
C0003533 (UMLS CUI [1])
Notes on measurement
Item
Anmerkungen zur Messung
text
C1317574 (UMLS CUI [1])
Extension
Item
text
C1546922 (UMLS CUI [1])
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